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PRELIMS OXYGENATION HANDOUT#3

Disorders and management of patients with diseases of the Upper Respiratory System A. ALL ERGIC RHINITIS (hay fever) - sensitivity to allergens with whitish or clear nasal

discharge; inflammation and irritation of the mucus membranes of the nose Non allergic: changes in temperature, odors, food Allergic: exposure to an irritant or an allergen

B. VIRAL RHINITIS (COMMON COLD)- The term “common cold” often is used when referring to an upper respiratory tract infection that is self-limited and caused by a virus.

Nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise Specifically, the term “cold” refers to an afebrile, infectious, acute inflammation of the

mucous membranes of the nasal cavity. More broadly, the term refers to an acute upper respiratory tract infection, whereas terms

such as “rhinitis,” “pharyngitis,” and “laryngitis” distinguish the sites of the symptoms.

Clinical Manifestations: nasal congestion runny nose sneezing nasal discharge nasal itchiness

tearing watery eyes, “scratchy” or sore throat general malaise low-grade fever

chills headache and muscle

aches.

As the illness progresses, cough usually appears. In some people, viral rhinitis exacerbates the herpes simplex, commonly called a cold sore. The symptoms last from 1 to 2 weeks. If there is significant fever or more severe systemic respiratory symptoms, it is no longer viral rhinitis

but one of the other acute upper respiratory tract infections.

PHARMA MANAGEMENT:o Medication therapy for allergic and non-allergic rhinitis focuses on symptom relief.

Antihistamines are administered for sneezing, itching, and rhinorrhea. Oral decongestant agents are used for nasal obstruction. intranasal corticosteroids may be used for severe congestion Ophthalmic agents are used to relieve irritation, itching, and redness of the eyes.

NURSING MANAGEMENT: Reduce exposure to allergens and irritants, such as dusts, molds, animals, fumes, odors, powders, sprays, and

tobacco smoke. The patient is instructed about the importance of controlling the environment at home and work. Saline nasal or aerosol sprays may be helpful in soothing mucous membranes, softening crusted secretions,

and removing irritants. The nurse instructs the patient in the proper use of and technique for administrating nasal medications.

To achieve maximal relief, the patient is instructed to blow the nose before applying any medication into the nasal cavity.

In the case of infectious rhinitis, the nurse reviews with the patient hand hygiene technique as a measure to prevent transmission of organisms.

6 VIRUSES KNOWN TO CAUSE RHINITIS: Rhinovirus parainfluenza virus coronavirus,

respiratory syncytial virus (RSV)

influenza virus

adenovirus

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C. SINUSITIS: inflammation of mucus membranes in the sinuses which may be followed by infection with a yellowish-green discharge

Pathophysiology:Acute sinusitis is an infection of the paranasal sinuses. It frequently develops as a result of an upper respiratory infection, such as an unresolved viral or bacterial infection, or an exacerbation of allergic rhinitis. Nasal congestion, caused by inflammation, edema, and transudation of fluid, leads to obstruction of the sinus cavities

Focus of Management:∞ treatment with antibiotics, decongestants, antihistamines ∞ surgery to drain and open sinuses ∞ antral irrigation (sinus irrigation)

Clinical Manifestations: facial pain or pressure over the

affected sinus area nasal obstruction fatigue purulent nasal discharge fever headache

ear pain and fullness dental pain cough a decreased sense of smell sore throat eyelid edema facial congestion or fullness

PHARMA MANAGEMENT:o The goals of treatment of acute sinusitis are to treat the infection, shrink the nasal mucosa, and relieve pain.

First-line antibiotics amoxicillin(Amoxil) trimethoprim/sulfamethoxazole (Bactrim, Septra) erythromycin.

Second-line antibiotics Cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), cefprozil (Cefzil) and

amoxicillin clavulanate (Augmentin). Macrolides such as azithromycin (Zithromax), and clarithromycin (Biaxin). Quinolones such as ciprofloxacin (Cipro), levofloxacin (Levaquin) (used with severe penicillin

allergy), and sparfloxacin (Zagam) have also been used.

o The course of treatment is usually 10 to 14 days.

OTHER MEDICATIONS: Use of oral and topical decongestant agents may decrease mucosal swelling of nasal

polyps, thereby improving drainage of the sinuses. Heated mist and saline irrigation may be effective for opening blocked passages. Decongestant agents such as pseudoephedrine (Sudafed, Dimetapp) are effective because

of their vasoconstrictive properties.

o It is important to administer them with the patient’s head tilted back to promote maximal dispersion of the medication.

Guaifenesin (Robitussin, Anti-Tuss), a mucolytic agent, may also be effective in reducing nasal congestion.

NURSING MANAGEMENT: instruct the patient about methods to promote drainage

inhaling steam (steam bath, hot shower, and facial sauna)



increasing fluid intake Applying local heat (hot wet packs).

Inform the patient about the side effects of nasal sprays and about rebound congestion. In the case of rebound congestion, the body’s receptors, which have become dependent on the

decongestant sprays to keep the nasal passages open, close and congestion results after the spray is discontinued.

D. CHRONIC SINUSITIS- is an inflammation of the sinuses that persists for more than 3 weeks in an adult and 2 weeks in a child

PathophysiologyA narrowing or obstruction in the ostia of the frontal, maxillary, and anterior ethmoid sinuses usually causes chronic sinusitis, preventing adequate drainage to the nasal passages. This combined area is known as the osteomeatal complex. Blockage that persists for greater than 3 weeks in an adult may occur because of infection, allergy, or structural abnormalities. This results in stagnant secretions, an ideal medium for infection.

Clinical Manifestations: impaired mucociliary clearance and ventilation cough (because the thick discharge constantly drips backward into the nasopharynx) chronic hoarseness chronic headaches in the periorbital area facial pain.

o These symptoms are generally most pronounced on awakening in the morning. Fatigue and nasal stuffiness are also common. some patients experience a decrease in smell and taste fullness in the ears

PHARMA MANAGEMENT: antimicrobial agents of choice include the following

amoxicillin clavulanate (Augmentin) ampicillin (Ampicin) Clarithromycin (Biaxin)

third-generation cephalosporins such as cefuroxime axetil (Ceftin) cefpodoxime (Vantin) cefprozil (Cefzil)

Quiolones such as: Levofloxacin (Levaquin)

o The course of treatment may be 3 to 4 weeks.o Decongestant agents, antihistamines, saline sprays, and heated mist are also recommended

Nursing Management: Because the patient usually performs care measures for sinusitis at home, nursing management consists

mainly of patient teaching.

TEACHING PATIENTS SELF-CARE: teach the patient how to promote sinus drainage by increasing the environmental humidity (steam bath, hot

shower,and facial sauna)

increasing fluid intake applying local heat (hot wet packs) instructs the patient about the importance of following the medication regimen.

E. TONSILITIS1. Inflammation and/or infection of tonsils 2. Acute form is usually bacterial 3. Treat findings; if culture shows bacteria, use antibiotics

Disorders of Lower Respiratory System (LRS): Obstructive General facts: process in chronic obstructive pulmonary diseases

Block airflow out of lungs Trap air, with impairment of gas exchange Increase the work of breathing

A. Emphysema Destroys alveoli Narrows and collapses small airways Overall lung loses elasticity Traps air As alveolar walls die, there is less surface for vital gas exchange



B. Chronic bronchitis 1. Definition

a. inflammatory response in the lung b. affects few alveoli, mostly airways

2. Findings a. lungs chronically produce fluids b. inflammation and mucus narrow the airways

C.Asthma 1. Definition/etiology

a. reversible obstruction of airways b. inflammation of airways c. airways hypersensitive to variety of stimuli d. bronchospasm is a minor component e. disease waxes and wanes, remissions and exacerbations

2. Findings a. orthopnea , expiratory wheezing b. barrel chest , cyanosis, clubbing of fingers c. distention of neck veins d. edema of extremities e. increased PCO2 and decreased PO2 f. polycythemia

3. Diagnostics a. physical examination with history of findings b. arterial blood gases c. chest x-ray

4. Complications a. hypoxemia b. hypercapnia c. variety of respiratory infections d. cor pulmonale e. dysrhythmias

Pharmacologic Management for obstructive diseases:



Antibiotics and corticosteroids for infection or chronic inflammation Bronchodilators Mucolytics Expectorants Respiratory program: postural drainage, exercise, nebulizer, high protein diet

Nursing interventions common to obstructive diseases Assess client's risk of respiratory failure Assess for degree of respiratory effort for an increased work of breathing or dyspnea Assess oxygenation with pulse oximeter if hemoglobin level is within normal limits Measure arterial blood gases (ABG) to evaluate gas exchange Administer oxygen as indicated If risk of respiratory failure, anticipate ventilation Assist with secretion removal as indicated Pace client activities to reduce oxygen demand Teach diaphragmatic breathing and pursed-lip breathing Position in a high Fowler's to ease breathing effort Provide for nutritional consults as indicated Reinforce the plan for small, frequent high carbohydrate meals Provide referrals for:

a. depression associated with disease b. pulmonary rehabilitation c. stop smoking support groups

For asthma, teach clients that aspirin or peanuts may stuimulate an asthma attack

LRS Disorders: Restrictive In general: these disorders prevent full lung expansion via three mechanisms

Lung stiffening External compression Muscle weakness

A.Pulmonary fibrosis- lung stiffening 1. Occupational lung diseases

a. coal worker's pneumoconiosis - risk increases with length of exposure to coal dust (>15 years), intensity of exposure, and silica content of dust

b. silicosis: workers who will have inhaled silica dust 2. Asbestosis

a. inhalation of asbestos fibers b. disease may develop 15 to 20 years after exposure

B.Pulmonary sarcoidosis - lung stiffening 1. Etiology

a. unknown origin b. characterized by formation of tubercles, most often in the lungs c. may progress to fibrosis

2. Findings a. dyspnea b. anxiety

3. Diagnostics a. chest x-ray b. biopsy of affected tissue

4. Management a. antitussives b. oxygen therapy c. removal of toxic substances

Nursing interventions common to all types of pulmonary fibrosis Prevent infection or exposure to infection Pace clients' activities to reduce oxygen demands and dyspnea Reinforce the need for small, frequent meals Encourage daily activities within pulmonary tolerance provide referrals for:

depression associated with disease stop smoking support groups occupational rehabilitation

Disorders of fluid in pleurae Pleural fluid disorders - all treated with water seal chest drainage systems

A. Pneumothorax: air between the pleurae



a. open pneumothorax: hole in the chest wall, communicates with the lung b. closed pneumothorax: hole in lung, chest wall intact c. tension pneumothorax - a nursing and medical emergency

closed pneumothorax air is forced into the pleural space with a continued pressure build up shifts mediastinum away from affected side with results of a compressed heart treated with chest tube insertion cardiac and respiratory arrest if not treated

B. Pleural effusion fluid (transudate or exudate) in the pleural space



if small, no treatment if larger, treated with chest tube insertion

Hemothorax blood in the pleural space treated with thoracentesis or chest tube

Empyema purulent drainage in the pleural space often from a chronic condition such as lung cancer treated with chest tube inserton

Chylothorax lymphatic fluid in pleural space treated with thoracentesis or chest tube

Musculoskeletal diseases associated with difficulty breathing A. Guillain-Barre syndrome - follows a viral infection

a. ascending paralysis that may affect muscles of respiration as paralysis ascends b. muscles so weak that client cannot breathe deeply, a nursing and medical emergency c. may progress to respiratory failure d. may require intubation e. mechanical ventilation f. course of illness varies from a few months to years

B. Myasthenia gravis a. sporadic, progressive weakness of skeletal muscle b. cause: lack of acetylcholine with results of a myoneural junction malfunction c. may not be able to chew and swallow well

i. may aspirate ii. may lose protective airway reflexes

d. repeated muscle movements, especially towards days end, can exacerbate acute respiratory failure

C. Poliomyelitis a. viral infection b. if disease strikes the respiratory muscles the result may be respiratory failure c. may not swallow well

i. may aspirate ii. may lose protective airway reflexes

D. Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease) a. affects motor neurons; autonomic, sensory and mental function unchanged b. manifests as a chronic, progressive irreversible disorder c. begins usually in distal ends of upper extremities d. often leads to respiratory failure within two to five years e. results in ethical issue

i. whether clients want mechanical ventilation ii. whether nutritional support is desired



iii. if they would rather die when disease becomes this severe f. results in clients' inability to communicate or physically move from voluntarily and/or clients lack

involuntary reflexes, such as blinking or gag reflex

E. Muscular dystrophies a. progressive symmetrical wasting of voluntary muscles with no nerve effect b. as thoracic muscles weaken, breathing becomes more difficult c. may not swallow well; risk for aspiration with loss of protective airway reflexes

Interventions common to musculoskeletal disorders a. monitor carefully for changes in condition b. assess regular swallowing and ability to protect the upper airway c. discuss chances of mechanical ventilation or nutritional support: does client wish it? d. assist with coughing and secretion clearance as indicated e. prevent infection f. assess for with appropriate referrals for depression that is often associated with these diseases g. administer medications specific to the disease condition h. assist/provide occupational or/and physical rehibilitation as indicated i. maintain adequate nutrition j. with terminal disorders, provide for referrals for family

LRS Disorders: Infectious A. Pneumonia

1. Definition/etiology a. acute infection of lung parenchyma b. cause: bacterium, virus, protozoan, mycobacterium, mycoplasma, or rickettsia c. pneumonia is the leading cause of death from infectious causes d. may affect only a region of lung: lobar pneumonia, bronchopneumonia e. may be the result of:

i. primary infection ii. secondary to other lung damage iii. aspiration

2. Risk factors for pneumonia a. pre-existing pulmonary disease b. abdominal and thoracic surgery c. mechanical ventilation d. advanced age e. decreased ability to protect airway or cough effectively f. artificial airway g. chronic illness and debilitation h. depressed immune function i. cancer

3. Diagnostics a. chest radiograph b. sputum culture, sensitivity and microscopic analysis, Gram stain, cytology c. ABG as indicated by clinical condition

4. Management a. antimicrobials, depending on pathogen b. antipyretic c. expectorants d. antitussives e. supplemental oxygen, as indicated f. IV fluids to treat dehydration



5. Nursing interventions a. monitor finger oximeter if hemoglobin levels within normal limits b. promote hydration to liquify secretions c. teach effective coughing techniques to minimize energy expenditure d. suction if necessary e. teach the need to continue entire course of antimicrobial therapy which is usually seven to ten days f. teach that findings are expected to be less within 48 to 72 hours of initial therapy

B. Pulmonary tuberculosis (PTB) 1. Etiology

a. mycobacterium tuberculosis b. bacilli lodge in alveoli c. pulmonary infiltrates d. can spread throughout body via blood e. multi-drug resistant PTB is becoming more prevalent f. PTB incidence is rising with increasing homelessness and AIDS

2. Findings a. weakness with fatigue b. anorexia with weight loss c. night sweats d. chest pain e. productive cough

3. Diagnostics a. sputum and gastric contents, analysis for the presence of acid-fast bacilli b. chest x-ray for presence of active or calcified lesions, "coin" lesions c. tuberculin testing

i. tine, mantoux tests checked 48 to 72 hours for induration positive if >10 mm induration in healthy persons

d. establishes if there is an antibody response to the tubercle bacillus e. if positive, indicates prior exposure to bacillus, not an active disease

4. Management a. long-term, six to 24 months, antimicrobial therapy with isoniazid (INH) (Hyzyd) or rifampin (Rifadin), with

ethambutol HCL (Etibi) in some cases b. bed rest or chair rest until findings abate c. surgical resection of involved lung if medication is not effective d. high carbohydrate, high protein diet with frequent small meals



5. Nursing interventions a. with active infection, client must be isolated with airborne precautions when in the hospital b. teach client

i. proper techniques to prevent spread of infection: hand washing, etc. ii. to report bloody sputum iii. not to use over the counter (OTC) medications without health care provider's approval iv. importance of taking medications as prescribed

adherence to treatment regimen return at scheduled times for lab testing of liver enzymes an increase in B6 to minimize peripheral neuropathies, a common side effect of drug

therapy

LRS Disorders: Miscellaneous

A. Pulmonary embolism 1. Definition/etiology

a. clot blocks blood from the "bed" of arteries that feed the lung b. client is breathing but gases are not exchanged - ventilation without perfusion c. hypoxemia results d. can be mild or immediately fatal, based on the size and location of clot(s) e. usually clot has traveled from deep veins in the leg or pelvis

2. Diagnostics a. ventilation/perfusion (V/P) scan, also called V/Q scan b. ABG c. EKG

3. Management a. oxygen via mask b. anticoagulation - heparin in acute and coumadin for chronic risk c. thrombolytics d. filter surgically placed in vena cava for long term care

B. Acute respiratory distress syndrome (ARDS) 1. Definition/etiology

a. alveolar capillary membrane becomes more permeable to fluids b. increased extravascular lung fluid c. pulmonary compliance decreases d. intrapulmonary shunt increases e. refractory hypoxemia f. usually seen after lung injury or massive multi-system organ disease

2. Findings a. restlessness, anxiety b. dyspnea c. tachycardia d. cyanosis e. intercostal retractions

3. Diagnostics a. clinical presentation and history of findings b. hypoxemia on ABG despite increasing inspired oxygen level c. chest x-ray shows diffuse infiltrates

4. Management



a. optimize oxygenation i. mechanical ventilation ii. sedation may be required iii. paralytic agents may be necessary

b. antibiotics, as indicated c. corticosteroids

5. Nursing interventions a. plan for frequent rest periods b. monitor trends in oxygenation status, ABGs, respiratory effort c. observe for behavioral changes and vital signs; confusion and hypertension may

indicate cerebral hypoxia

C. Cor pulmonale 1. Definition/etiology

a. right ventricular hypertrophy and subsequent chronic heart failure b. cause: heart must pump against great resistance from lung's blood vessels: called

increased pulmonary vascular resistance (PVR) c. increased PVR results from chronic lung disease d. may be due to primary pulmonary hypertension as well

2. Diagnostics a. pulmonary artery pressure readings via a catheterb. echocardiogram c. chest radiograph d. ABG e. EKG

3. Management a. administer oxygen as ordered b. if hemoglobin within normal limits (WNL), monitor oxygenation with finger or pulse

oximeter c. bed rest, as needed d. monitor effects of medications

i. cardiac glycosides ii. pulmonary artery vasodilator iii. diuretics iv. restricted fluid intake as indicated

e. nursing interventions i. monitor for changes in oxygenation status ii. pace activities in clients who tire easily


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