NUR%20316%20Management%20of%20the%20Diseases%20in%20the%20Respiratory%20System

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NUR 316Management of the Diseases in the
Respiratory System
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Learning objectives

• At the end of this modules, students will be
  able
• Describe the structures and functions of the
  upper and the lower respiratory tracts.
• Discriminate between normal and abnormal
  assessment findings identified by inspection,
  palpation, percussion, and auscultation of the
  respiratory system.
• Recognize and evaluate the major symptoms of
  respiratory dysfunction.
• Identify the diagnostic tests to evaluate
  respiratory function.

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Glossary

• Apnea temporary cessation of breathing.
• Bronchoscopy direct examination of the larynx,
  trachea, and bronchi using an endoscope.
• Dyspnea difficulty/ shortness of breath.
• Hypoxemia decrease in arterial oxygen tension in
  the blood.
• Hypoxia decrease in oxygen supply to the tissue
  and cells.
• Hemoptysis expectoration of blood from the
  respiratory tract.
• Orthopnea inability to breathe easily except in
  an upright position.
• Tachypnea abnormal rapid respiration.

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Anatomy and physiologic

• Respiratory system is responsible for ventilation
  (movement of air in and out of the airways).
• It composes of upper and lower respiratory
  tracts.
• Upper airway warm and filter the inspired air.

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Anatomy and physiologic (cont.)

• Gas exchange delivering oxygen to the tissue
  through the blood steam (inspiration) and
  expelling waste gases, such as carbon dioxide,
  (expiration).

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Anatomy and physiologic (cont.)

• Ventilation is effected by three factors
• Airway pressure the movement of the diagram
  during inspiration create a negative pressure
  which permits ventilation.
• Airway resistance determined by the size/radius
  of airways.
• Compliance is the elasticity and expandability
  of lung and the thoracic cavity. Requires the
  presence of the surfactant.

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Anatomy and physiologic (cont.)

• Pleural
• Covers the lungs.
• Has two layers and fluid to lubricate the lungs
  and thoracic cavity.

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I-Health history

• Elicit a description of the present illness and
  chief complaint, including onset, course,
  duration, location, and precipitating and
  alleviating factors. Cardinal signs and symptoms
  of respiratory dysfunction include-
• Dyspnea
• Orthopnea
• Cough which may be productive or non productive
• Increased sputum, which may be purulent (yellow
  or green),rusty, bloody, or mucoid sputum
• Chest pain
• Wheezing and crackles
• Clubhing of fingers
• Hemoptysis
• Cyanosis (e.g. buccal, peripheral)

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- b-Explore the client's health history for risk
factors associated with respiratory disease
including

• (1) Personal or family history of lung disease
• (2) Smoking (the most significant contributing
  factor in lung disease)
• (3) Occupational or vocational exposure to
  allergens or environmental pollutants
• ( 4) Age-related changes in lung capacity and
  respiratory function
• (5) History of upper respiratory infection
• (6) Postoperative changes resulting in diminished
  respiratory excursion

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Physical examination

• a- Inspection
• (1) observe general appearance, noting body
  size, age, skin quality and color, and posture.
• (2) Inspect configuration and movement of the
  thorax during respiration.
• (3)Assess characteristics of respiration,
  including rate, rhythm, depth and muscles used
  for breathing.
• (4) Note presence of cough and the nature and
  character of sputum (e.g. purulent, bloody)

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• Palpation. Palpate the chest to detect painful
  areas or masses on the chest surface and evaluate
  chest excursion and the presence or absence of
  fremitus (i.e. vibration).
• Percussion. Assess chest sounds to evaluate
  underlying tissues. Resonant sound indicates
  air-filled lung (normal), whereas dull or flat
  sound suggests presence of firm mass (usually
  abnormal). Hyperresonant sound in emphysema.

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• Auscultation. Listen to air movement in lungs to
  detect normal or adventitious breath sounds.
• (1) Vesicular sounds are low-pitched, rustling
  sounds heard over most of lung field, most
  prominently on inspiration. They indicate normal,
  clear lungs.
• (2) Bronchial sounds are high-pitched tubular
  sounds with a slight pause between inspiration
  and expiration. They are normal over large
  airways.
• (3) Bronchovesicular sounds are combination of
  vesicular and bronchial sounds, normally heard
  anterior to the right or left of the sternum and
  posterior between the scapulae inspiration and
  expiration are equal. '
• (4) Adventitious breath sounds are crackles (i.e.
  fine to coarse), wheezes and pleural friction
  rub. https//www.youtube.com/watch?v5JA6D1Mguh0

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Laboratory and diagnostic studies

• Radiographic and scanning studies are done to
  visualize respiratory system structures. The
  studies include
• Chest radiography,
• chest tomography
• Lung scan
• Computed tomography (CT) scan
• Magnetic Resonance Imaging(MRI).

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Bronchoscopy studies are invasive techniques
performed to visualize pulmonary structures and
obtain tissue specimens.
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used to examine thoracic structure
Thoracoscopy
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Thoracentesis involves needle aspiration of
pleural fluid for diagnostic and therapeutic
purposes.
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• Needle biopsy is an invasive technique that
  involves entering the lung or pleura to obtain
  tissue for analysis.
• Pulmonary function test(PFT) it is done to
  measure functional ability of the lung through
  measuring lung volumes and capacities.
• Sputum culture determines the presence of
  pathogenic organisms.
• Arterial blood gas (ABG) studies determine O2 and
  CO2 content and evaluate the body's acid-base
  balance
• Pulse Oximetry Monitoring oxygen saturation of
  hemoglobin (SpO2 or SaO2).
• Incentive spirometer provide visual feedback to
  encourage the patient to maximize lung inflation
  and prevent atelectasis.

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Nursing diagnosis

• Ineffective breathing pattern
• Impaired gas exchange
• Altered tissue perfusion (peripheral)
• Activity intolerance
• Pain
• Anxiety
• Ineffective individual coping
• Knowledge deficit
• Risk for infection

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Implementation

• Assess respiratory status and tissue perfusion,
  including respiratory rate, depth and effort
  level of consciousness lung sounds peripheral
  cyanosis capillary refill time color and
  consistency or sputum and pulse oximetry.
• Improve breathing patterns.
• a. Encourage upright position (semi-Fowler or
  high-Fowler position)
• b. Encourage the client to increase fluid intake
  to at least 2 to 3 liters of fluid each day,
  unless contraindicated as in congestive heart
  failure.
• c. Use of incentive spirometer

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Promote gas exchange

• Administering oxygen therapy.
• Analyze ABG values and pulse oximetry to
  determine need for oxygen therapy.
• Assist in administering nebulizer treatment.
• Encourage effective coughing. Instruct client to
  take three deep breaths in through the nose and
  out through the mouth, and on the third breath
  pull in the abdominal muscles and cough twice
  forcefully with mouth open.
• Encourage the client to lie on the affected side
  to splint the area if there is pain when
  coughing.
• Encourage the client to eliminate or minimize
  exposure to all pulmonary irritants, and advise
  the client to quit smoking.

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• Improve activity tolerance. Encourage client to
  alternate rest with activity to prevent
  overexertion that may exacerbate symptoms and to
  increase activity gradually.
• Provide pain management.
• Assess the client for pain, and exclude other
  potential complications.
• Instruct the client about splinting when the
  client has chest pain,
• Promote infection control measures.
• Instruct the client to avoid crowds or people
  with known colds, flu, or respiratory infection.
• b. Implement standard precautions and droplet or
  airborne precautions as indicated.

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Upper respiratory Tract Infection(URTI)

• URTI follows invasion of the upper respiratory
  organs by microbes.
• Upper respiratory organs include the
• Nose, sinuses, throat
• Common cold is an example of an upper respiratory
  infection.
• Common cold is caused by a virus
• Symptoms- Elevated temperature (fever)
• Runny nose
• Watery eyes
• Treatment of common cold
• Use of antipyretic such as aspirin
• Rest
• Increased fluid intake
• Upper respiratory infections sometimes move down
  into the chest and develop into bronchitis or
  even pneumonia.

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Pneumonia

• Description. Pneumonia is an inflammatory process
  involving the respiratory bronchioles, alveolar
  space and walls, and lobes, caused primarily by
  chemical irritants or by specific bacterial,
  viral, fungal, mycoplasmal, or parasitic
  organisms.
• Pneumonia is the most common cause of death from
  infectious disease in North America and the fifth
  leading cause of death among the elderly.

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Types of pneumonia

• Community Acquire Pneumonia (CAP) occurs either
  in the community setting or within the first 48
  hours of hospitalization. The organisms that most
  frequently cause CAP are Streptococcus pneumonia,
  Haemophilus influenza, and atypical organisms (
  Legionella, Mycoplasma, Chlamydia viral)
• Hospital Acquire Pneumonia (HAP) also known as
  Nasocomial infection Occurring 48 hours or longer
  after admission to the hospital. Bacteria are
  responsible for the majority of HAP infection,
  including Pseudomonas and Enterobacter,
  Staphylococcs aureus and Streptococcus pneumonia.
  

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• Pneumonia in Immunocompromized Host
• E.g. pneumocystic carinii , fungal
  tuberculosis. It is occur most commonly in
  patient with AIDS , nutritional depletion , use
  of broad spectrum antimicrobial agent,
  corticosteroids, chemotherapy, and long term
  life- support technology (mechanical ventilation)
• Aspiration Pneumonia refers to entry of
  endogenous or exogenous substance into the lower
  air way such as gastric content.

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Causes of and contributing

• 1- Smoking and air pollution
• 3- Altered consciousness alcohalizm, head
  injury, seizure, anaesthesia, drug overdose
• 4- Tracheal intubations (endotracheal
  intubations, trachestomy)
• 5- Upper respiratory tract infection
• 6- Chronic diseases chronic lung disease,
  diabetes mellitus, heart disease, uremia, cancer,
• 7- Immunosuppressant
• 8- Malnutrition
• 9- Inhalation or aspiration of noxious substances
• 10- Bed rest and prolonged immobility
• 11- Depress cough reflex

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Pathophysiology.

• Pneumonia often affects both ventilation and
  diffusion . An inflammatory reaction occurs in
  the alveoli, producing an exudates that
  interferes with the diffusion of oxygen and
  carbon dioxide and fill the alveolar air spaces,
  producing lung consolidation
• Areas of the lung are not adequately ventilated
  because of secretions and mucosal edema that
  cause partial occulsion of the bronchi or alveoli
  with a resultant decrease in alvelor oxygen
  tension and bronchospasm may occur.
• Ventilation perfusion mismatching or Impaired
  gas exchange in the alveoli leads to various
  degrees of hypoxia, depending on the amount of
  lung tissue affected.

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Clinical manifestations

• A- Typical pneumonia syndrome is characterized
  by
• Sudden onset fever over 40 C , chills, cough
  productive with Purulent sputum and pleurisy
  chest pain, dullness with consolidation on
  percussion of chest ,dyspnea, respiratory
  grunting, and nasal flaring ,Flushed cheeks
  cyanotic lips and nail beds ,anxiety and
  confusion. In the elderly, the only signs may be
  mental status change and dehydration.
• B- Atypical Pneumonia syndrome is characterized
  by gradual onset, dry cough and extrapulmonary
  manifestations as headach, fatigue, sore throat,
  nausea, vomiting and diarrhea. Crackles are
  heard.

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Laboratory and diagnostic study findings

• Chest radiograph shows density changes, primarily
  in the lower lung fields.
• Sputum culture and sensitivity are positive for a
  specific causative organism.
• While blood cell (WBC) count is elevated in
  pneumonia of bacterial origin WBC count is
  depressed or normal in pneumonia of mycoplasma or
  viral origin.

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Nursing management

• Administer prescribed medications, which may
  include
• Antibiotics (Penicillne, Erthromycine,
  Gentamicine)
• Mucolytics. expectorants, or antitussive agents
  antipyretic
• Promote infection control measures, especially
  droplet precautions as indicated.
• Prevent aspiration pneumonia in a client
  receiving tube feedings. Keep the client in an
  upright position during feedings and for 30
  minutes afterward. Check for residual gastric
  contents if more than 100 mL, stop feeding and
  reevaluate.
• Oxygen administer
• Warm, moist inhalation
• Increase fluid intake

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Complication of pneumonia

• 1- Pleurisy inflammation of pleura
• 2- Pleural effusion accumulation of fluid in
  pleural space
• 3- Empyema accumulation of pus in pleural space
• 4- Atelectasis collapsed, airless alveoli of one
  or part of one lobe may ocurr
• 5- Pericarditis inflammation of pericardium
• 6- Arthritis inflammation of joint
• 7- Meningitis inflammation of brain layer
• 8- Lung abscess

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Chronic obstructive pulmonary disease

• Chronic obstructive pulmonary disease (COPD) is a
  group of disorders associated with persistent or
  recurrent obstruction of air flow, which include
  chronic bronchitis, emphysema, and asthma.
• These conditions frequently overlap.
• Most commonly, bronchitis and emphysema occur
  together.
• Asthma frequently occurs alone without the triad
  of bronchitis, emphysema, and asthma.

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Etiology

• 1-Chronic bronchitis and emphysema. Major causes
  and contributing factors to these disorders,
  which are irreversible, include
• Smoking
• Air pollution
• Occupational exposure to respiratory irritants
• Allergies
• Autoimmunity
• Infection
• Genetic predisposition
• Aging

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• 2- Asthma is a reversible diffuse airway
  obstruction with a possible genetic component. It
  may be extrinsic or intrinsic.
• Extrinsic factors include external agents or
  specific allergens (e.g. dust, foods, mold
  spores, insecticides).
• Intrinsic factors include upper respiratory
  infection, exercise, emotional stress, cold, or
  other nonspecific factors.
• Status asthmatics is a severe and persistent
  asthma that lasts longer than24hours and does not
  respond to conventional therapy.

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Pathophysiology.

• COPD disrupts airway dynamics, resulting in
  obstruction of airflow into or out of the lungs.
• Chronic bronchitis. Hypertrophy and
  hypersecretion in goblet cells and bronchial
  mucus glands leading to increased sputum
  secretion, bronchial congestion, narrowing of
  bronchioles, and small bronchi.

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• Emphysema. Increased size of air spaces (i.e.
  dead space) with loss of elastic recoil of lung
  due to hyperinflation of distal airways causes
  airway obstruction. Destruction of alveolar walls
  and diffuse airway narrowing causing resistance
  to airflow because of loss of supporting
  structure bronchospasm further impede airflow.

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• Asthma. Basic pathologic changes include
• Narrowing of the bronchial airways
• Bronchospasms
• Increased mucosa
• Mucosal edema secondary to inflammation.

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Clinical manifestations

• Chronic bronchitis
• (1) History of productive cough that lasts 3
  months per year for 2 consecutive years
• (2) Persistent cough, known as smoker's cough,
  usually in the winter months
• (3) Persistent sputum production
• (4) Recurrent acute respiratory infections
• (5) "Pink puffer appearance

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• Emphysema
• (1) History of chronic bronchitis
• (2) Slow onset of symptoms (typically over
  several years), which can lead to right sided
  heart failure (i.e. cor pulmonale)
• (3) Progressive dyspnea, initially only on
  exertion and later also at rest
• (4) Progressive cough and increased sputum
  production, use of accessory muscles
• (5) Anorexia with weight loss and profound
  weakness
• (6) Dusky color leading to cyanosis
• (7) Clubbing of fingers

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• Asthma
• (1) Chest tightness and dyspnea
• (2) Cough
• (3) Wheezing
• (4) Expiration more strenuous and prolonged than
  inspiration
• (5) Use of accessory muscles of respiration
  nasal flaring
• (6) Hypoxia with restlessness, anxiety, cyanosis,
  weak pulse, and diaphoresis

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Laboratory and diagnostic study findings

• Chronic bronchitis
• (1) Pulmonary function studies identify decreased
  forced expiratory volume (FEV), decreased forced
  vital capacity (FVC), increased residual volume
  (RV), and total lung capacity (TLC) that is
  normal to slightly increased.
• (2) Chest radiograph shows an enlarged heart with
  a normal or flattened diaphragm.
• (3) ABG studies during the acute phase show
  significantly increased Paco2 and decreased Pa02.
  
• (4) Sputum culture reveals secondary bacterial
  infection with gram-negative or gram-positive
  organisms, such as Diplococcus pneumoniae and
  H.influenzae.

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• b. Emphysema
• (1) Pulmonary function studies identify decreased
  FEV, decreased FVC, increased RV, and increased
  TLC.
• (2) Chest radiograph shows a Flattened diaphragm,
  decreased vascular markings with
  hyperradiolucence, and increased anteroposterior
  (AP) diameter (i.e. "barrel chest").
• (3) ABG studies detect increased PaC02 and
  decreased Pa02
• (4) Blood analysis reveals polycythemia (i.e.
  increased numbers of red blood cells in response
  to hypoxemia).
•  
• C.Asthma.
• (1)-Pulmonary function studies during acute
  episode identify markedly decreased FEV,
  increased RV, and increased TLC in response to
  air trapping. These study values improve after
  treatment.

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Nursing management

• Provide nursing care for the client with chronic
  bronchitis or emphysema.
• a. Administer prescribed medications, which may
  include antibiotics, bronchodilator, mucolytic
  agents, and corticosteroids.
• Antibiotics should be administered at the first
  sign of infection, such as a change in the
  sputum.
• Narcotics, sedatives, and tranquilizers, which
  can further depress respirations, should be
  avoided.

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• Clear airways with postural drainage, percussion
  (i.e. clapping) or vibrating, and suctioning as
  appropriate

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• Promote infection control. Encourage the client
  to obtain influenza and pneumonia vaccines at
  prescribed times.
• Improve breathing patterns. Demonstrate and
  encourage diaphragmatic and purse-lip breathing.
  Have the client take a deep breath and blow out
  against closed lips.

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Provide nursing care for the client with asthma

• Administer prescribed medications, which may
  include
• Adrenergics( Adrenaline),
• Bronchodilators(aminophlline)
• Corticosteroids( Dexamethasone, Solu cortef) for
  acute attack .
• Nebulized aerosol(Ventoline) relive
  bronchospasme.
• Oxygen therapy

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Provide treatment during an acute asthmatic
attack.

• (1) Stay with the client and keep him calm and in
  an upright position.
• (2) Do purse-lip breathing with the client
  encourage relaxation techniques.

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• Implement measures to prevent asthmatic attacks.
  Teach the client the following skills
• (1) Identify and eliminate or minimize exposure
  to pulmonary irritants.
• (2) Remove rugs and curtains from the home
  change air filters frequently keep the home as
  dust free as possible and keep windows closed
  during windy and high pollen days.
• (3) Use an inhaler and take medications as
  prescribed, and notify the physician when not
  gaining complete relief.
• (4) Notify the physician when a respiratory
  infection occurs.
• (5) Obtain influenza and pneumonia vaccines at
  prescribed times.
• (6) Monitor peak expiratory flow rate.

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Pleural effusion

• Description. Pleural effusion is a collection of
  fluid in the pleural space, which is located
  between the visceral and parietal surfaces
• Etiology. Pleural effusion usually results from
  diseases such as neoplastic tumors (of which
  bronchogenic cancer is the most common
  malignancy), congestive heart failure,
  tuberculosis, pneumonia, pulmonary infection, and
  connective tissue disease.
• Pathophysiology. The pleural space contains a
  small amount of lubricating fluid that allows the
  pleural surfaces to move without friction. Excess
  fluid accumulates in the space until it becomes
  clinically evident. The effusion can be composed
  of a clear fluid, or it can be bloody or
  purulent.

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Clinical manifestations

• Large pleural effusion
• (1) Shortness of breath
• (2) Minimal or no breath sounds
• (3) Dull, flat sound when percussed
• (4) Tracheal deviation away from the affected
  side may occur when significant accumulation of
  fluid occurs.
• Small to moderate pleural effusion
• (1) Respiratory difficulty or comprised lung
  expansion may not be evident.
• (2) Dyspnea may not be present.

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Laboratory and diagnostic study findings

• Chest radiograph shows fluid in the pleural
  space.
• Pleural f1uid obtained by thoracentesis and
  treated with an acid-fast bacillus stain may
  reveal tuberculosis or red and white blood cells.
  
• Nursing management.
• Prepare the client for thoracentesis, which is
  performed to remove f1uid, obtain a specimen for
  analysis, and relieve dyspnea.
• Assist the physician with administering
  chemically irritating agents, which may be
  instilled to obliterate the pleural space and
  prevent further accumulation of f1uid.
• Provide pain relief. Position client to decrease
  pain and administer pain medication, as needed .

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Pulmonary Tuberculosis

• Definition
• Pulmonary tuberculosis (T.B) is an infectious
  disease that primarily affects the lung
  parenchyma. It also may be transmitted to the
  other parts of the body including the meninges,
  kidney, bones and lymph nodes.
• The primary infectious agent mycobacterium
  tuberculosis or tubercle bacillus is an acid
  fast, aerobic rod that grows slowly and is
  sensitive to heat and ultraviolet light

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• Transmission
• TB spreads from person to person by airborne
  transmission. An infected person release droplet
  through talking, coughing, sneezing, laughing, or
  singing
• Risk factors for TB
• 1- Close contact with an infected person.
• 2- Recent positive tuberculosis test i.e.
  recently converted from negative to positive skin
  test.
• 3- Large tuberculin reaction (12 mm or more in
  diameter).
• 4- Preexisting medical condition e.g. diabetics,
  malignancy or chronic renal failure,
  hemodialysis, malnourish
• 5- People living in overcrowded homes substandard
  living, with low, income i.e. low socioeconomic
  class.
• 6- Immunocompromised status (e.g. HIV, cancer,
  transplanted organ, high dose of corticosteroids
• 7- Immigration from countries with high prevalent
  TB

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Pathophysiology

• A susceptible person inhales mycobacterium
  bacilli and become infected. The bacteria are
  transmitted through the airways to the alveoli,
  where they are deposited and begin to multiply.
• The bacilli also transported via the lymph system
  and blood stream to other areas of lung other
  area of body (kidney, bone, and cortex).
• The bodys immune system responds initiating an
  inflammatory reaction .Phagocytes engulf many of
  the bacteria and TB specific lymphocytes destroy
  the bacilli and tissue. Granulomas are
  transformed to a fibrous tissue mass, the central
  portion of which is a called Ghon tubercle.
• The material (bacteria and macrophages) becomes
  necrotic, forming a cheesy mass.
• This mass may become calcified and form a
  collagenous scar.

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• Clinical manifestation
• 1-Low grade fever
• 2-Cough may be nonproductive or mucopurulent
  sputum
• 3-Night sweat
• 4-Fatigue
• 5-weight loss
• 6-Hemoptysis

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Assessment and diagnostic studies

• Sputum testing Positive Acid fast bacilli,
  Positive Mycobacterium tuberculosis
• Chest X-ray Active or calcified lesion
• Blood tests WBCS,ESR are increased
•  

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Medical Intervention

• TB is treated primarily with chemotherapeutic
  agent for 6 to 12 months. More than one drug of
  the following are used
• Streptomycine
• Isoniazid(INH)
• Para amino salicylic acid
• Rifampin
• Ethambutol
• Pyrazinamide

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Nursing Intervention

• Maintain patient diet high-carbohydrates,
  protein, vitamin B6C, caloric and fluid intake.
• Provide small frequent meal
• Maintain bed rest
• Instruct the patient to cover nose and mouth when
  sneezing or coughing use of disposable tissue
  papaer to prevent spread of infection
• Provide oral hygiene and hygiene
• Maintain infection control precautions
• Provide adequate air ventilation in room
• The nurse instruct medication, schedule and side
  effect to patient

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• Question?