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Medical Surgical

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Title: Medical Surgical


1
Chpt 27 Disorders of Lower Respiratory Tract
  • Medical Surgical

2
Acute bronchitis PG 374
  • Characterized by inflammation of the mucous
    membranes that line the major bronchi and their
    branches.
  • Most common cause is a viral infection
  • Signs symptoms fever, malaise, and a dry,
    non-productive cough that later becomes
    productive of mucopurulent sputum

3
Acute Bronchitis
  • Acute bronchitis differs from pneumonia in that
    with acute bronchitis there is initially a
    nonproductive cough.
  • They have paroxysmal(sudden violent) attacks of
    coughing and may have wheezing
  • May also have laryngitis and sinusitis.
  • Moist inspiratory crackles may be heard

4
Acute Bronchitis
  • Usually self limiting, lasting for several days
  • Treated with bedrest, antipyretics, expectorants
    and antitussives and lots of fluids
  • If secondary bacterial infection occurs then it
    becomes a serious condition. Has persistent cough
    and thick purulent sputum if secondary infection
    occurs

5
Nursing Care
  • Auscultate breath sounds
  • Monitor vitals
  • Encourage to cough and deep breathe q 2 hrs.
    while awake and to expectorate rather than
    swallow sputum
  • Change damp clothing and linen
  • Offer fluids frequently

6
Prevent Spread
  • Wash hands frequently especially when handling
    soiled tissues
  • cover mouth when sneezing and coughing
  • Discard soiled tissues in a plastic bag
  • Avoid sharing articles

7
Pneumonia PG 374
  • Infalmmatory process affecting bronchioles and
    alveoli
  • Viral pneumonias are most common cause

8
Types of Pneumonia
  • Viral,Bacterial,Radiation,Chemical
  • Aspiration
  • Lobar--confined to one or more lobes
  • bronchopneumonia--patchy and diffuse infection
    scattered thruout both lungs
  • hypostatic--hypoventilation in immobile

9
Pneumonia
  • Organisms that cause pneumonia reach the alveoli
    by inhalation of droplets, aspiration of
    organisms from upper airway, or from bloodstream.
  • When organisms reach alveoli, an intense
    inflammatory reaction occurs. This produces
    exudate which impairs gas exchange .

10
Pneumonia
  • Capillaries surrounding the alveoli become
    engorged and cause the alveoli to collapse
    (atelectasis)
  • If untreated consolidation occurs and the
    infection gets worse causing hypoxemia.
  • Lung tissue gets necrotic and death can occur
    from failure.

11
Complications of Pneumonia
  • CHF
  • empyema-collection of pus in pleural cavity
  • pleurisy-infalmmation of the pleura...major
    complication of pneumonia
  • septicemia-infective microorganisms in the
    blood--can cause endocarditis, pericarditis and
    purulent arthritis
  • atelectasis
  • hypotension and shock

12
Bacterial Pneumonia
  • Onset of bacterial is sudden. he has fever,
    chills, a productive cough, and discomfort in
    chest wall muscle from coughing. Malaise,
    breathing may cause pain and he breathes
    shallowly
  • Classic symptom is rusty colored sputum

13
Viral Pneumonia
  • Differs from bacterial in that blood cultures are
    sterile, sputum may be more copious, chills are
    less common, and pulse and resp rates are
    characteristicly slow.
  • Mortality rate low as less serious than
    bacterial. Mortality rate increases if secondary
    bacterial infection occurs. Wheezing, crackles,
    decreased breath sounds. Nail beds, lips oral
    mucosa may be cyanotic

14
Nursing
  • When he has pneumonia, adequate oxygenation can
    be accomplished by placing him in a semi-fowlers
    position
  • Semi-fowlers increases the amount of air taken in
    with each breath
  • Assess for classic symptoms of chest pain, fever,
    shallow respirations. Assess for signs of Acute
    respiratory failure. Use of accessory muscles of
    respiraton is Ist sign

15
Nursing
  • Auscultate lung sounds and monitor for signs of
    respiratory difficulty
  • assess cough and nature of sputum production
  • Increase fluids
  • Monitor I O, skin turgor and serum electrolytes
  • Monitor pulse oximetry, ABGs and quality of
    breathing

16
Important Information
  • Review nursing guidelines 27-1 page 377 and care
    of the client with TB page 382 as nursing care is
    same

17
Pleurisy PG 377
  • Acute inflammation of the parietal and visceral
    pleura
  • Respirations become shallow secondary to
    excruciating pain caused by inflamed pleura
    rubbing together. This causes severe, sharp pain.
    Pleura fluid increases because it separates the
    pleura and he develops a dry cough, fatigues
    easily and has shortness of breath. Friction rub
    heard

18
Nursing Care
  • Teach to splint the chest by turning onto the
    affected side. May also splint by using hands or
    a pillow when coughing

19
Pleural effusion PG 377
  • collection of fluid between the visceral and
    parietal pleura
  • Complication of pneumonia, lung cancer, TB,
    pulmonary embolism and CHF
  • Accumulated fluid may be so great that it
    collapses the lung on that side and pressure is
    placed on the heart and other organs

20
Pleural effusion
  • Fever, pain, and dyspnea are the most common
    symptoms. Chest percussion reveals dullness over
    the involved area. May have diminished or absent
    breath sounds. Friction rub may be heard.
  • Thoracentesis sometimes done.

21
Lung abscess PG 378
  • Localized area of pus formation within the lung
    parenchyma. As pus increases, necrosis of the
    tissue occurs. Later the area collapses and
    creates a cavity
  • Signs and symptoms --chills, fever, weight loss,
    chest pain and a productive cough. Sputum may be
    purulent or blood streaked
  • There will be dull or absent breath sounds in the
    area of abscess

22
Surgical Management
  • A lobectomy may be done to remove the abscess and
    surrounding lung tissue
  • Teach to cough and deep breathe and to eat a diet
    high in protein and calories

23
Empyema PG 378
  • Presence of pus in a body cavity..usually refers
    to pus or infected fluid in the pleural cavity
  • Fever chest pain, dyspnea, anorexia and malaise.
    there will be diminished or absent breath sounds
    over area. Appears acutely ill
  • Thoracentesis and chest tube drainage used to
    drain purulent drainage. Following a
    thoracentesis must observe for resp distress

24
Chest Tubes
  • The use of chest tubes is usually necessary to
    drain secretions, air, and blood from the
    thoracic cavity in order to re-expand the lung.
  • Chest tubes are inspected frequently since any
    break in the system could allow air to be drawn
    into the pleural space and collapse the lung

25
Chest Tubes
  • When inspecting chest tubes connected to an
    underwater seal system, the nurse makes sure the
    system is kept below the level of the bed
  • If any break or major leak occurs the nurse
    immediately clamps the chest tube
  • Clamps must be taped to the bed frame when chest
    tubes are inserted to use in an emergency

26
Influenza pg 379
  • Acute respiratory disease caused by virus.
    Transmitted thru respiratory tract
  • Fatalities usually due to secondary bacterial
    infection and complications, especially in
    pregnant women, elderly and debilitated or ones
    with chronic conditions (cardiac, emphysema,
    COPD, diabetes)

27
Nursing Management
  • Prevention and influenza vaccinations recommended
  • Respiratory isolation required
  • Review table 27-2 page 379 for symptoms

28
Pulmonary Tuberculosis Pg 380
  • Bacterial infection disease that primarily
    affects lungs but can affect kidney and other
    organs
  • Tubercle bacilli are gram-positive, rod-shaped,
    acid fast bacteria. It can live in the dark for
    months in particles of dried sputum, exposure to
    direct sunlight, heat and ultraviolet light
    destroys them in a few hours.

29
TB Pathophysiology
  • The microorganism is difficult to kill with
    ordinary disinfectants.
  • Tubercle bacilli are killed by pasteurization, a
    process widely used in preventing the spread of
    TB by milk and milk products.

30
TB
  • Most commonly transmitted by direct contact with
    a person who has the active disease thru
    inhalation of droplets produced by coughing,
    sneezing, and spitting.
  • Brief contact usually does not result in disease.
  • Bacilli may stay dormant for years and reactivate

31
S/S
  • Symptoms may not appear until the disease is
    advanced. as they develop they are often vague
    and can be overlooked
  • Fatigue, anorexia, weight loss, and a slight
    nonproductive cough are early symptoms
  • Low grade fever, particularly in late afternoon,
    and night sweats are common as it progresses.
    Cough becomes productive of mucopurulent and
    blood-streaked sputum.

32
  • Marked weakness, wasting, hemoptysis and dyspnea
    are common late stage. Chest pain may result from
    spread to pleura
  • Must identify bacteria to diagnose. Cultures of
    sputum ordered. Can do gastric washings to
    retrieve swallowed bacteria.Gastric gavage,
    gastric aspiration and bronchoscopy used.

33
Medications
  • Combined therapy with two or more drugs decrease
    the likelihood of drug resistance, increases the
    action of drugs
  • antibubercular drugs are given for long periods
    and without interruption because healing is slow
    and resistance to drugs is increased by
    interrupted treatment.

34
Drug Regimen for TB table 27-1 pg 382
  • The primary focus of a teaching plan for TB is to
    encourage them to complete the prescribed meds
  • Drug typically used for treatment initially is
    isoniazid. Rifampin, PZA is also given
  • Isoniazid may be given alone initially or a
    combination drug of the three above may be taken
    for...may take meds up to 18 to 24 months

35
Surgical Management
  • surgery may be done if disease is located
    primarily in one section of lung.
  • Segmental resection--one section removed
  • Wedge resection
  • lobectomy
  • pneumonectomy--entire lung

36
Assessment
  • Breath sounds, breathing patterns, and overall
    respiratory status
  • Any pain breathing?
  • Inspect sputum for color, viscosity, amount and
    for signs of blood
  • Review page 382 and 383 for nursing care

37
Teaching
  • Take meds exactly as prescribed and observe time
    intervals between each dose
  • Drugs must be taken for a long time, complete the
    entire series
  • Stress importance of continuous therapy because
    lapses in taking the drugs result in reactivation
    of infection
  • Notify Dr if symptoms worsen or sudden chest pain
    or dyspnea

38
Teaching for TB
  • Drink extra fluids. Take med for fever but if it
    continues call Dr
  • Stop smoking and avoid second hand smoke
  • Eat a balanced but light diet. Call Dr if more
    than a few pounds lost
  • Avoid people with infections
  • follow up care is important!!

39
Obstructive Pulmonary Disease pg. 383
  • COPD is a broad, nonspecific term that describes
    a group of pulmonary disorders with symptoms of
    chronic cough and expectoration, dyspnea, and an
    impaired expiratory air flow.
  • Bronchiecstasis, atelectasis, chronic bronchitis
    and emphysema are COPD disorders.

40
Obstructive Disease
  • Asthma is also an obstructive disorder that is
    more episodic--generally more acute than chronic
  • Sleep apnea syndrome is the cessation of airflow
    in and out of the lungs during sleep. Can be
    caused by obstructive causes

41
Bronchiecstasis pg. 383
  • Chronic disease characterized by irreversible
    dilation of the bronchi and bronchioles and
    chronic infection
  • When clearance of airway is impeded an infection
    can develop in the walls of the bronchus or
    bronchiole. This leads to changes in the
    structure of the wall tissue and results in the
    formation of saccular dilatations which collect
    purulent material

42
S/S
  • Chronic cough with expectoration of copious
    amounts of purulent sputum and possible
    hemoptysis.
  • Cough becomes worse when changing positions. Can
    spit up several ounces of sputum

43
Bronchiectasis
  • When sputum is collected it settles in three
    distinct layers
  • Top layer--frothy and cloudy
  • Middle layer--clear saliva
  • bottom layer--heavy, thick and purulent
  • Also have fatigue, weight loss, anorexia and
    dyspnea

44
Bronchiectasis Nursing Care
  • A major treatment used is postural drainage as it
    helps mobilize and expectorate secretions
  • Performed three times a day in each position
    while he inhales slowly and blows the breath out
    thru the mouth. Usually takes 5 to 15 min.see
    picture pg 385 (used to drain lower lobes) chest
    percussion and vibration also used

45
Atelectasis pg 384
  • Collapse of lung tissue. May involve a small
    portion of lung or entire lung.
  • Symptoms related to size of collapsed area
  • Small areas may have few symptoms. Large areas
    cause cyanosis, fever, pain, dyspnea, increased
    pulse and resp rates and increased pulmonary
    secretions
  • Crackling may be heard but usually absent breath
    sounds in the area

46
Nursing Management
  • Care focus is on prevention. Deep breathing and
    coughing post-op can prevent
  • If it occurs encourage him to cough and deep
    breathe frequently and to use incentive
    spirometer (review guidelines pg. 386)

47
Chronic Bronchitis pg 384
  • Persistence of a chronic cough with excessive
    production of mucus for at least 3 months a year
    for 2 consecutive years
  • Characterized by hypersecretions of mucus by the
    bronchial glands and recurrent or chronic
    respiratory tract infections
  • Secretions remain in lungs and form plugs within
    smaller bronchi can cause necrosis and fibrosis

48
Chronic Bronchitis
  • Earliest symptom is a productive cough of thick
    white mucus, especially when rising in the
    morning and in the evening.
  • Bronchospasm may occur during severe bouts of
    coughing
  • As condition worsens the sputum becomes yellow,
    purulent, copious and after paroxysms of
    coughing, blood streaked

49
Chronic Bronchitis
  • Cyanosis secondary to hypoxemia may be noted,
    especially after coughing.
  • Dyspnea begins with exertion (dyspnea on exertion
    is a common symptom of pulmonary hypertension)
    but leads to dyspnea with minimal activity and
    later at rest

50
Chronic Bronchitis
  • Called the blue bloater as color is dusky and
    cyanotic

51
Medical Management
  • Stop smoking
  • Bronchodilators
  • Increased fluid
  • Well balanced diet Postural drainage
  • steroids
  • change in occupation if exposure to dust and
    chemicals
  • Air filters and antibiotics

52
Nursing
  • Identify ways to eliminate environmental
    irritants
  • Avoid cold air and wind exposure that causes
    bronchospasms
  • Avoid others with resp. infections
  • Get flu and pneumonia immunizations
  • Monitor sputum for signs of infection, teach
    postural drainage
  • Teach how to use inhalers (27-3 pg.387)

53
Pulmonary Emphysema pg. 387
  • Emphysema is a chronic disease characterized by
    abnormal distention of the alveoli
  • Major cause is smoking. Exposure to second hand
    smoke, air pollution, chronic infection and
    allergens also cause it.
  • The alveoli lose elasticity, trapping air that
    normally should be expired

54
Emphysema
  • The walls of the alveoli break down and form one
    large sac
  • Shortness of breath occurs with minimal activity
    (exertional dyspnea) and is often the first
    symptom
  • Breathlessness occurs even with rest
  • Chronic productive cough and inspiration is
    difficult because of barrel chest

55
Emphysema
  • Uses accessory muscles to breathe
  • expiration is prolonged, difficult and has
    wheezing
  • Advanced emphysema pt. Appears drawn, anxious,
    pale and speak in short jerky sentences. They
    lean forward and are short of breath. Neck veins
    distend during inspiration

56
Emphysema
  • In advanced cases memory loss, drowsiness,
    confusion, and loss of judgment may occur
  • CO2 levels may reach toxic levels resulting in
    lethargy, stupor, and eventually coma
  • Will have decreased breath sounds, wheezes and
    crackles. Heart sounds will be diminished

57
Nursing Management
  • Respiratory center is sensitive to the level of
    CO2 in the blood. If level increases slightly,
    the respiratory rate and depth increases to
    eliminate excess. If it is chronically increased
    the resp center becomes insensitive to CO2
  • As long as oxygen is low he breathes, if it
    becomes high he stopsdo not give oxygen over 2-3
    liters

58
Emphysema
  • Safest to give O2 using a nasal cannula
  • If color improves but level of consciousness
    decreases DC O2 as may go into resp arrest
  • Teach to use diaphragm and abdomen to help
    breathe and to use pursed lip breathing
  • Take a deep breath and bend forward at the waist
    while exhaling

59
Important Information
  • Review care for obstructive pulmonary disorder
    and patient teaching page 389 390

60
Asthma pg. 390
  • Reversible obstructive disease. Three types
  • allergic asthma--pollen, dust, spores, animal
    dander
  • idiopathic asthma--upper resp infections,
    emotional upsets and exercise
  • mixed asthma--both of above--most common type

61
asthma
  • Acute occurs as a result of increasing airway
    obstruction caused by bronchospasm and
    bronchoconstriction, inflammation and edema of
    lining of bronchi and production of thick mucus
    that can plug airway

62
Asthma
  • Will have interference with gas exchange, poor
    perfusion, possible atelectasis and respiratory
    failure if not treated

63
S/S of Asthma
  • Will have paroxysms of shortness of breath,
    wheezing and coughing and production of thick,
    tenacious sputum
  • Every breath becomes an effort and may have
    sensation of suffocation
  • classic sitting position used--body leaning
    slightly forward and arms at shoulder height

64
Asthma
  • Coughing starts early and is non-productive
    early, but when gets better will expectorate
    large quantities of thick, stringy mucus
  • Skin is pale but if severe will have cyanosis
  • Perspiration is profuse
  • Status asmaticus can be life threatening

65
Medical Management
  • Should use humidified air when he begins to have
    an attack as dehydration of respiratory mucus
    membranes may lead to asthma attacks. The use of
    steam or cool vapor humidifiers help. Push fluids
    to liquify secretions
  • When assessing for bronchial asthma usual
    symptoms found are dyspnea, wheezing and cough

66
Nursing Management
  • Adverse drug effects (epinephrine, aminophyllin
    may cause palpitations, nervousness, trembling,
    pallor and insomnia.
  • Review teaching page 392

67
Cystic Fibrosis pg. 392
  • Cystic Fibrosis (CF) is a multisystem disorder
    that affects infants, children, and young adults.
  • CF results from a defective autosomal recessive
    gene.
  • Inherits from both parents.

68
Cystic Fibrosis
  • Major abnormalities include
  • Faulty transport of sodium and chloride in cells
    lining organs, such as the lungs and pancreas, to
    their outer surfaces.
  • Production of abnormally thick, sticky mucus in
    many organs, especially the lungs and pancreas.
  • Altered electrolyte balance in the sweat glands.

69
Cystic Fibrosis S/S
  • 3 major reasons to suspect CF in children are
    respiratory symptoms, failure to thrive, and
    foul-smelling, bulky, greasy stools.
  • Salty-tasting skin.
  • Frequent resp. infections
  • Finger clubbing is common.
  • Hymoptysis
  • Malabsorption of fats and fat soluble vitamins,
    difficulty gaining weight.
  • Risk of bowel obstruction, cholecystitis, and
    cirrhosis is increased.

70
Medical Management
  • Promoting the removal of the thick sputum through
    postural drainage, chest physical therapy with
    vigorous percussion and vibration, breathing
    exercises, hydration to help thin secretions,
    bronchodilator meds, nebulized mist treatments
    with saline or mucolytic meds and prompt
    treatment of lung infections with antibiotics.

71
Medical Management
  • When the digestive system is involved, clients
    take pancreatic enzyme replacements (Pancrease)
    with meals to aid with digestion and absorption
    of fats.
  • Fat-soluble vitamin supplements
  • High-calorie diet
  • Lung and/or liver transplant

72
Nursing Management
  • Strict adherence to a vigorous pulmonary toilet
  • Chest physical therapy (postural drainage,
    percussion, and vibration) 2-4 x a day
  • Deep breathing and coughing exercises
  • Nebulized treatments
  • Medications
  • New methods, such as high-frequency chest wall
    oscillation through the use of an inflatable vest

73
Pulmonary Hypertension pg. 394
  • Results from heart or lung disease or both.
  • Most common symptoms are dyspnea on exertion and
    weakness and cardiac symptoms ( chest pain,
    fatigue, weakness, distended neck veins,
    orthopnea and peripheral edema.
  • Nursing focus is on identifying symptoms of resp
    distress, and reducing O2 requirements

74
Pulmonary Embolism pg 395
  • Involves the obstruction of one or more pulmonary
    vessels.
  • The blockage is the result of a thrombus that
    forms in the venous system or right side of the
    heart.
  • An embolus is any foreign substance, such as a
    blood clot, air, or particle of fat that travels
    in the venous blood flow to the lungs.

75
PE S/S
  • Small area of the lung involved pain,
    tachycardia, and dypnea. Fever, cough and
    blood-streaked sputum may also occur.
  • Larger area severe dyspnea, severe pain,
    cyanosis, tachycardia, restlessness, and shock.
  • Sudden death may follow a massive pulmonary
    infarction when a large embolism occludes a main
    section of the pulmonary artery.

76
PE Medical Management
  • IV heparin
  • IV injection of a thrombolytic drug
  • Complete bed rest, oxygen, analgesics
  • May require surgery pulmonary embolectomy-----

77
Nursing Management PE
  • Patent IV stat
  • Administer vasopressor for TX hypotension
  • Oxygen
  • Continuous EKG monitoring
  • Monitor anticoagulant blood studies

78
Pulmonary Edema pg. 397
  • Accumulation of fluid in alveoli of lungs
  • will have dyspnea, breathlessness, and a feeling
    of suffocation. Cool moist, and cyanotic
    extremities
  • Skin color is cyanotic and gray. Has a productive
    cough of blood tinged frothy fluid.

79
Pulmonary Edema
  • Hallmark symptoms is a cough producing copious
    frothy blood tinged sputum often appearing
    pinkish.

80
Adult respiratory distress syndrome
  • Important to recognize stat
  • Elderly, neuro patients and drug overdose
    increases risk
  • Review factors that precipitate resp. failure
    table 27-4 page 397.

81
Malignant Disorders
  • Review on own

82
Trauma pg 401
  • A client with a chest injury must be observed for
    dyspnea, cyanosis, chest pain, weak and rapid
    pulse, and hypotension---all s/s of respiratory
    distress.

83
Fractured Ribs pg 401
  • Common injury and may be caused by hard fall,
    blow to the chest, MVA, household accidents.
  • Not usually serious unless the sharp end of the
    broken bone tears the lung or thoracic blood
    vessels.
  • If no complications, may return home after
    emergency tx.

84
Fractured Ribs
  • Flail chest occurs when two or more adjacent ribs
    are fractured in multiple places (more than two),
    and the fragments are free-floating.
  • The stability of the chest wall is affected and
    results in a paradoxical chest wall movement.

85
Flail Chest
  • With inspiration the chest expands, but the
    free-floating segments move inward instead of
    outward.
  • With expiration the free-floating segments move
    outward, interfering with exhalation.
  • S/s severe pain on inspiration and expiration
    and obvious trauma

86
Nursing Management
  • Apply the immobilization device
  • Stress the importance of taking deep breaths
    every 1-2 hours
  • Assess for s/s respiratory distress, infection
    and increased pain

87
Blast Injuries pg 402
  • Compression of the chest by an explosion can
    seriously damage the lungs by rupturing the
    alveoli.
  • Death often results from hemorrhage and
    asphyxiation
  • Subcutaneous emphysema (air in SQ tissue) is a
    common finding because the lungs or air passages
    have sustained injury

88
Penetrating Wounds
  • Serious because an opening into the thorax, which
    on inspiration normally is at negative pressure,
    creates continuous and direct communication with
    the outside, which is at positive pressure.
  • An open or penetrating wound permits air to enter
    the thoracic cavity, causing a pneumothorax. If
    not recognized and Txdeath may occur.

89
Penetrating Wounds
  • If the wound is large, a sucking noise may be
    heard as air enters leaves.
  • Depending on the size of the wound, it takes
    seconds to hours before the lung collapses as the
    pressure in the thorax reaches atmospheric
    pressure.
  • Txapplication of a tight pressure dressing over
    the injury site to prevent more air from entering
    the thorax. O2 given until further tx.

90
Thoracic Surgery pg 403
  • Review on own
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