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Lower Respiratory Tract Disorders

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Involves 3 diseases- Chronic Bronchitis, Asthma, & Emphysema ... Cough in the morning with sputum production is indicative of Chronic Bronchitis ... – PowerPoint PPT presentation

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Title: Lower Respiratory Tract Disorders


1
Lower Respiratory Tract Disorders
Assessment Management of Patients With
2
Lower Respiratory Tract
  • Trachea
  • Bronchi
  • Bronchioles
  • Alveoli
  • Cilia

3
Clinical Manifestations
  • 1. Local Manifestations
  • Cough
  • chronic, paroxysmal, dry , productive
  • Excessive Nasal Secretion
  • Expectoration of Sputum
  • mucoid, purulent, mucopurulent, rusty, hemoptysis
  • Pain
  • pleuritic, intercostal, generalized chest pain
  • Dyspnea- shortness of breath

4
Clinical Manifestations
  • 2. Systemic Manifestations
  • Hypoxemia
  • insufficient oxygenation of the blood
  • cyanosis- bluish, grayish discoloration of skin
    mucous membranes
  • Hypoxia
  • inadequate tissue oxygenation
  • Hypercapnia
  • CO2 in arterial blood above normal limits
  • Hypocapnia
  • CO2 in arterial blood below normal limits
  • Respiratory Failure

5
Assessment of Respiratory System
  • Health History
  • Risk Factors
  • Major Clinical Manifestations
  • Cough
  • Sputum production
  • Chest pain
  • Wheezing
  • Clubbing of the fingers
  • Cyanosis

6
Physical Examination
Assessment of Respiratory System
  • Inspection
  • posture, shape, movement, dimensions of chest,
    flared nostrils, use of accessory muscles, skin
    color, and rate, depth, rhythm of respiration
  • Palpation
  • respiratory excursion, masses, tenderness
  • Percussion
  • flat, dull, resonant, hyperresonant sounds
  • Auscultation
  • breath sounds, voice sounds, crackles, wheezes

7
Crackles
8
Diagnostic Procedures
  • Sputum Studies
  • Methods- standard, saline inhalation, gastric
    washing
  • Arterial Blood Gases
  • measurements of blood pH , arterial O2 CO2
    tensions, acid-base balance
  • Pulse Oximetry
  • Chest X-ray
  • Bronchoscopy
  • Thoracentesis
  • Laryngoscopy

9
  • Lower
  • Respiratory
  • Disorders

10
Pneumonia
  • Inflammation infection of lung- infecting
    organisms typically inhaled- organisms
    transmitted to lower airways and alveoli causing
    inflammation- impairs gas exchange
  • Etiology bacteria, virus, Mycoplasma, fungus,
    or from aspiration or inhalation of chemicals or
    other toxic substances
  • Risk factors cigarette smoking, chronic
    underlying disorders, severe acute illness,
    suppressed immune system, immobility

11
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12
Pneumonia
  • Assessment Questions to ask
  • Have you been experiencing difficulty breathing?
  • Are you having pain? Where?
  • Do you have a cough?
  • Have you been running a fever?
  • Have you been feeling tired?
  • Clinical Manifestations
  • fever, pleuritic chest pain, tachypnea, SOB,
    tachycardia, cough, sputum production- rusty,
    blood-tingled or yellow-green, fatigue, poor
    appetite

13
Pneumonia
  • Diagnostic
  • Sputum and blood cultures, CBC, ABGs, CXR,
    Bronchoscopy
  • Nursing Diagnoses
  • Ineffective airway clearance r/t thick, tenacious
    sputum
  • Ineffective breathing pattern r/t tachypnea,
    chest pain, airway inflammation
  • Impaired gas exchange r/t exudate in alveoli
  • Activity intolerance r/t hypoxemia, fatigue

14
Pneumonia
  • Planning Client Outcomes
  • Maintain open clear airway, normal RR, PO2
    level without supplemental O2, complete physical
    care without frequent rest periods
  • Interventions
  • Improve airway patency- auscultate lung sounds,
    monitor ABGs or pulse oximetry, elevate HOB, C
    DB q 2hrs, ambulate , I/S, O2 as needed
  • Promote fluid intake promote activity
    tolerance
  • Monitor prevent complications

15
Pneumonia
  • Pharmacology
  • Antibiotic therapy based on sputum culture
    sensitivity
  • Levaquin, Tequin, Rocephin, Primaxin, Zithromax,
    Ketek, Zinacef, Cipro, Tetracycline
  • Instruct to finish all antibiotics at prescribed
    intervals
  • Evaluation
  • breathing easier without chest pain
  • temperature normal,
  • activity level increased without frequent rest
    periods

16
Tuberculosis
  • Infectious disease that primarily affects the
    lungs may be transmitted to other parts of the
    body
  • Pulmonary infiltrates accumulate, cavities
    develop, masses of granulated tissue form
    within the lungs
  • Primary infectious agent- Mycobacterium Bacilli
  • Transmitted by inhalation of droplets (talking,
    coughing, sneezing, singing)
  • Risk factors immune system disorder,
    preexisting medical conditions,
    institutionalized, health care workers

17
Pulmonary Tuberculosis
  • Mycobacterium tuberculosis
  • Airborne transmission
  • Tuberculin skin testing
  • Pharmacologic therapy- multi-drug regimens and
    prophylaxis

18
Tuberculosis
  • Assessment
  • Questions to ask - Are you suffering from night
    sweats? Have you lost weight? Have you been
    having low-grade fever? Have you been having SOB
    and coughing up anything from your lungs? Have
    you had chest pain? Where? Have you had weight
    loss?
  • Clinical Manifestations- low-grade fever (late
    afternoon), night sweats, weight loss, anorexia,
    fatigue, chronic productive cough,pleuritic chest
    pain, hemoptysis

19
Tuberculosis
  • Diagnostic
  • Sputum culture- acid-fast bacilli (AFB)
  • Skin testing- PPD
  • CBC- WBC elevated
  • CXR
  • Bronchoscopy
  • Nursing Diagnosis
  • Ineffective airway clearance r/t thick, tenacious
    secretions
  • Ineffective breathing pattern r/t airway
    inflammation

20
Tuberculosis
  • Altered nutrition less than body requirements r/t
    anorexia and fatigue
  • Anxiety r/t social isolation secondary to
    isolation protocols
  • Planning Clients Outcomes
  • Maintain clear airway,normal RR, achieve weight
    gain, anxiety decreased
  • Interventions
  • Maintain respiratory isolation- infectious period
    - diversional activities

21
Tuberculosis
  • Promote airway clearance- bedrest, increase fluid
    intake, high humidity
  • Pharmacology
  • First-line meds- INH, Rifampin, Streptomycin,
    Ehtambutol, Pyrazinamide for 4 months
  • INH and Rifampin continued for an additional 2
    months or up to 12 months.
  • Advocate adherence prevention
  • Monitor and manage potential complications
  • Evaluation
  • Client adheres to isolation precautions, takes
    medication as prescribed

22
Tuberculosis
  • Questions to ask
  • Do you have difficulty breathing- all the time or
    is it caused by exertion?
  • Do you cough frequently and is it productive?
  • Have you had a weight loss?
  • Do you feel tired quite often and are your
    activities impaired by SOB or fatigue?
  • Do you have many respiratory infections? Over
    what period of time?

23
Tuberculosis
  • Nursing Diagnosis
  • Ineffective airway clearance r/t thick, tenacious
    secretion and fatigue
  • Ineffective breathing pattern r/t fatigue and
    obstruction of the bronchial tree
  • Impaired gas exchange r/t increased sputum
    production
  • Activity intolerance r/t hypoxemia fatigue
  • Altered nutrition r/t increased metabolic
    demands, fatigue, anorexia
  • Anxiety r/t inability to breathe effectively

24
Tuberculosis
  • Diagnostics
  • ABGs, CBC, sputum culture, CXR, Pulmonary
    function tests
  • Planning Client Outcomes
  • Effectively clear airway and breathing pattern,
    maintain normal ABGs, increase activity with
    decrease SOB or fatigue, maintain weight, and
    less anxious with episodes of SOB

25
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26
Chronic Obstructive Pulmonary Disease (COPD)
  • A group of chronic, obstructive airflow diseases
    of the lungs. Also known as chronic airflow
    limitation (CAL)
  • Usually progressive irreversible Ciliary
    cleansing mechanism of the respiratory tract is
    affected
  • Involves 3 diseases- Chronic Bronchitis, Asthma,
    Emphysema
  • Risk factors- cigarette smoking, air pollution,
    occupational exposure, infections, allergens,
    stress

27
Chronic Bronchitis
  • Inflammation of the bronchi caused by irritants
    or infection
  • hypertrophy hypersecretion of mucous- cause
    increase in sputum production
  • increase mucous- decrease airway lumen size-
    lumen becomes colonized with bacteria.
  • Bronchial wall becomes scarred - leads to
    stenosis airway obstruction
  • Defined as a productive cough that lasts 3 months
    a year for 2 consecutive years with other causes
    excluded.
  • Cough in the morning with sputum production is
    indicative of Chronic Bronchitis

28
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29
Chronic Bronchitis
  • Risk Factors cigarette smoking, exposure to
    pollution, hazardous airborne substances
  • Clinical Manifestations productive cough,
    dyspnea esp. on exertion, wheezing, use of
    accessory muscles to breathe, cyanosis- blue
    bloater, clubbed fingers
  • Interventions
  • Assess patency of airway- suction if cough
    ineffective, RR, accessory muscle use, lung
    sounds, skin color changes, ABGs
  • Encourage high fluid intake instruct in
    effective breathing coughing
  • Monitor oxygen administration aerosol therapy

30
Chronic Bronchitis
  • Encourage to report sputum changes or worsening
    of symptoms
  • Encourage exercise to improve resp. fitness
  • Counsel to avoid respiratory irritants and stop
    smoking
  • Immunize against common flu and pneumonia
  • Pharmacology
  • Antibiotic therapy- Tequin, Levaquin
  • Bronchodilators- Albuterol, Combivent,
    Theophylline
  • Corticosteroids- Prednisone, SoluMedrol

31
Asthma
  • Chronic inflammatory disease of the airways -
    bronchial linings overreact to various stimuli-
    causes episodic smooth muscle spasms that
    severely constrict the airway - thickened
    secretions mucosal edema further block the
    airways.
  • Acute symptoms last from minutes to hours, to
    days and then periods without symptoms
  • Most common chronic disease of childhood
  • Risk Factors allergy, chronic exposure to
    airway irritants of allergens, stress, exertion,
    sinusitis

32
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33
Asthma
  • Clinical Manifestations cough with or without
    sputum production, SOB wheezing, generalized
    chest tightness, expiration requires effort
    becomes prolonged, tachycardia, tachypnea,
    increased restlessness
  • Interventions
  • Immediate care depends on severity of asthma
    symptoms- assess resp. status, ABGs monitoring,
    oxygen therapy
  • Administered prescribed therapy monitor
    response
  • Fluids antibiotics
  • Minimize anxiety
  • Teach preventive measures- exercise

34
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35
Asthma
  • Pharmacology
  • Bronchodilators
  • Beta-agonists- Albuterol, Serevent
  • Xanthines- Theophylline
  • Corticosteroids
  • Prednisone, SoluMedrol
  • Inhalers- Flovent, Vanceril, Beclovent, Advair,
    Azmacort
  • Anticholinergics- Atrovent, Combivent
  • Leukotriene modifiers- Singulair
  • May be treated as outpatient or require
    hospitalization intensive care

36
Emphysema
  • Enlargement of air spaces distal to airways that
    conduct air to the alveoli
  • Enlarged spaces causes breakdown in alveoli
    walls- increases in airway size on inspiration-
    decreases alveolar membrane for gas exchange
  • Small airways collapse on exhalation- air trapped
    in alveolar spaces
  • Theses changes- products destruction of elastin
    in distal airways and alveoli
  • Distinguishing characteristic- airflow limitation
    caused by lack of elastic recoil in the lungs

37
COPD-Emphysema
38
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39
Emphysema
  • No trouble inhaling, but with hyperinflated lungs
    small airways- exhaling becomes more difficult
  • Risk Factors smoking, occupational exposure,
    heredity
  • Most common in fifth decade of life

40
Emphysema
  • Clinical Manifestations SOB on exertion, use of
    accessory muscles to breath, late cough after
    onset of SOB (if productive sputum- scanty
    mucoid), pink puffer, barrel chest (increase in
    anterior-posterior diameter of chest), thin in
    appearance, diminished breath sounds prolonged
    expiration, speaks in short jerky sentences,
    anxious
  • Interventions
  • Improve gas exchange- oxygen therapy
  • Achieve airway clearance- aerosol therapy
  • Encourage adequate hydration
  • Prevent infections- immunizations

41
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42
Emphysema
  • Minimize anxiety
  • Physical therapy
  • Patient teaching
  • Pharmacology
  • Beta-agonists- Albuterol, Theophylline
  • Anticholinergics- Atrovent
  • Antibiotic therapy- Levaquin, Tequin
  • Corticosteroids

43
Emphysema
  • Evaluation
  • Improved gas exchange, achieves airway clearance,
    breathing pattern improved, achieves activity
    tolerance, acquires effective coping mechanisms,
    and adheres to therapeutic program.

44
Atelectasis
  • Inadequate ventilation
  • Mucus plugs
  • Pleural effusion
  • Pneumothorax
  • Hemothorax

45
Pleural Effusion
46
Pneumothorax
  • Condition in which air or gas exists in the
    pleural space
  • Normally negative pressure (suction) between the
    visceral and parietal pleura- any injury that
    allows air or positive pressure to enter pleural
    space- prevents the lung from remaining inflated
  • Air in pleural space- increased intrapleural
    pressure- partial or total collapse of the lung
  • Types Simple, Traumatic, or Tension

47
Pneumothorax
48
Pneumothorax Simple (Closed or spontaneous)
  • Air enters the pleural space from the lung in the
    absence of disease
  • Occurs in men ages 20 to 40 result of rupture
    of small blister on the apex of the lung
  • If occurs from trauma or pulmonary disease-
    referred to as secondary or complicated
  • Basic symptoms SOB chest pain

49
Treatment of Simple Pneumothorax
50
Pneumothorax
51
Pneumothorax Traumatic (Open)
  • A hole in the chest wall allows atmospheric air
    to flow into the pleural space
  • Air in the pleural space - increased intrapleural
    pressure- resulting in partial or total collapse
    of the lung
  • Results from a penetrating injury, a therapeutic
    procedure, or insertion of a CVC or pulmonary
    artery catheter
  • A sucking sound audible on inspiration as the
    chest wall rises varying degrees of resp.
    distress

52
Pneumothorax Tension
  • Injury allows air to leak into pleural space
    during inspiration- prevents air from leaking out
    during expiration
  • Each inspiration-amount of air increases- becomes
    trapped to point causing increased thoracic
    pressure- pushes the heart, vena cava, and aorta
    out of position (mediastinum shift)- results in
    poor venous return to heart - leads to poor
    cardiac output
  • Medical emergency- disruption of cardiac output
    respiratory distress

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55
Pneumothorax
  • Etiology
  • Blunt chest trauma (MVAs and falls), penetrating
    traumas (gunshot and knife injuries), rib
    fractures, flail chest
  • Assessment Questions to ask
  • Are you having difficulty breathing?
  • Do you have pain in your chest? Point to your
    pain with one finger.
  • Clinical Manifestations
  • SOB, CP, tachypnea, tachycardia, cyanosis,
    diminished breath sounds, hyper-resonance on
    affected side, neck vein engorgement, paradoxical
    movement of the chest, deviated trachea,
    cardiogenic shock anxiety

56
Pneumothorax
  • Diagnostic
  • ABGs, CXR
  • Nursing Diagnosis
  • Ineffective breathing pattern r/t decreased lung
    expansion
  • Impair gas exchange r/t collapse of an area of
    the lung
  • Anxiety r/t inability to ventilate effectively
  • Planning Client Outcomes
  • RR ABGs within normal limits, client states
    rationale for treatment procedures, client
    rests without behavioral signs of excessive
    anxiety

57
Pneumothorax
  • Nursing Interventions
  • Comprehensive respiratory assessment- airway
    patency, RR, lung sounds, chest rise fall
    symmetrically, ABGs, blood counts, electrolytes,
    cardiac status, urinary output, chest wall
  • Maintain semi-Fowlers position
  • Encourage deep breathing coughing
  • Administer oxygen therapy
  • Medicate for pain as needed
  • Explain all procedures- calm reassure about
    overall treatment condition as needed
  • Encourage use of relaxation techniques
  • Medical- Mechanical Ventilation Chest tubes

58
Chest Tubes
59
Chest Drainage System
  • Inserted after most thoracic cardiac surgeries
  • Consists of chest tube attached to valve
    mechanism- allow air or fluid to drain out of the
    chest cavity
  • Include one, two, and three-bottle systems and
    the one-piece, three chamber, disposable plastic
    systems

60
Purpose of Chest Drainage System
  • Removes air, blood, other fluids from pleural
    space or mediastinal space
  • Facilitates re-expansion of the lungs and restore
    negative pressure in thoracic cavity

61
Indications forChest Drainage System
  • After thoracic cardiac surgery
  • Traumatic injury- Fractured Rib
  • Intrapleural- pneumothorax, hemothorax, pleural
    effusion
  • Mediastinal- cardiac surgery, chest trauma
  • Complication from procedures
  • CVC insertion
  • Lung biopsy

62
Types of Chest Drainage Systems
  • Water-seal
  • Remove air or fluid from pleural space or
    mediastinum
  • Mechanism for collection of drainage
  • One-way mechanism to keep air from getting back
    into the pleural space
  • Water-seal acts one-way valve
  • Allows air to leave pleural space- but not to
    return-maintaining negative pressure

63
Types of Chest Drainage Systems
  • Waterless
  • Valve to regulate suction
  • Valve can be opened for air liquid drainage to
    move out
  • Remain closed to prevent air from entering
    pleural space
  • Autotransfusion
  • Variation of water-seal system
  • Attached container so that blood drained from
    chest can be salvaged for autotransfusion

64
Assessment
Pt with Chest Drainage Systems
  • Respiratory status
  • SS of extended pneumothorax or hemothorax
  • Function of drainage system every 1 hr
  • System below level of patients chest
  • Tube free of kinks, or external obstruction
  • All connections secured
  • Color and amount of drainage
  • Fluctuation of fluid level in water-seal chamber
  • Constant bubbling in water-seal chamber
  • Anxiety level understanding

65
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66
Chest Drainage Systems
  • Nursing Diagnosis
  • Ineffective breathing pattern related to
    decreased lung expansion as evidence by
  • Planning Patient Outcomes
  • Breath sounds are normal
  • Respiration unlabored occur at rate of 16 to 20
    breaths per minute
  • ABG values approaching normal
  • Lung re-expansion seen on chest x-ray film

67
Chest Drainage Systems
  • Nursing Interventions
  • Maintain airtight, patent, functioning chest
    drainage system
  • Re-tape all connections as needed
  • Re-tape or reinforce chest-tube dressing
  • Tubing free of kinks, loops external pressure
  • Place roll towel under chest- protect tubing from
    body weight
  • Encourage cough and deep breathe position
    change frequently
  • Keep occlusive petrolatum jelly dressing at
    bedside

68
Chest Drainage Systems
  • Mark amount of drainage in collection container
    at 1 to 4 hour intervals
  • Check water levels in suction control
    water-seal pressure chambers
  • Notify MD of constant bubbling in water-seal or
    drainage becoming bright red or increases
    suddenly
  • Reassure the patient that staff is nearby- call
    light in reach
  • Documentation for chest drainage systems
  • Assist with chest tube insertion or removal

69
Chest Drainage Systems
  • Evaluation
  • RR ABGs within normal limits
  • Decreased difficulty breathing
  • Chest pain diminished
  • Equal lung sounds
  • Bilateral chest movement
  • Decreased chest tube drainage
  • Client able to verbalize rationale for treatment
    and procedures
  • Client rests without behavioral signs of
    excessive anxiety

70
Older Adult Alert
  • Be concern about any changes in orientation.
    This may be a first indication of pneumonia in
    older adults.
  • Be cautious in fluid administration.
    Overhydration may initiate CHF.
  • Older clients may become confused with multiple
    drug therapies and may not follow the regimen
    correctly. Theses clients may need assistance to
    ensure proper administration. In older clients,
    the thoracic muscles are weaker which may make
    the older adult unable to tolerate the increased
    work of breathing required of COPD.
  • Older adult clients have fewer alveoli than
    younger adults- oxygen exchange will be even more
    impaired in older adult clients with COPD.

71
Older Adult Alert
  • The weaker thoracic muscles in older adults will
    also make coughing more difficult, and thus,
    retained secretions will be a problem in many
    cases.
  • Older adults high risk for infection due to
    decreased immune response. Chest injuries
    evaluated carefully for signs of infection.
    Temperature of 99 degrees F may indicate an
    initial infection.
  • Cough will be impaired due to decreased muscle
    strength- older adults greater risk for
    atelectasis and pneumonia after a chest injury.

72
  • Thank you!
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