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By: Diana Blum MSNMetropolitan Community College

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Respiratory System

Focuses on the energy required to carry out ADL. When lung tissue is damage and 02 at cellular level is severely decreased the client may not be able to perform any of these functions. Energy conservation tech are most important!

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Nursing Diagnosis

Pain r/t inflammation, tissue damage Ineffective breathing pattern r/t surgical

incision, pleural effusion, decreased lung expansion

Impaired gas exchange r/t alveolar destruction, bronchospasm, air trapping

Ineffective airway clearance r/t weak cough Anxiety r/t hypoxemia Activity intolerance r/t inability to meet 02

needs Decreased cardiac output r/t pump failure (r-

sided) Imbalance nutrition: less than body require r/t

anorexia, dyspnea

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Anatomy

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Apnea

Temporary interruption in the normal breathing pattern in which NO air movement occurs May occur during sleep and at end of life

http://abcnews.go.com/Video/playerIndex?id=2927688

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~pnea

Dyspnea} difficulty breathing or shortness of breath

Orthopnea} difficulty with breathing while in a lying position

Tachypnea} respiratory rate >20 Bradypnea} respiratory rate <12

Other breathing types located in table 30-1

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Data Collection

Past history/Family history: colds, TB, Chronic bronchitis, asthma, cancer, sinus infections, ear infections, pneumonia, COPD, emphysema, allergies, immunizations, diabetes, CAD, TB tine, Smoking history (pack per year history)

Chief complaint: obtain details on subjective complaints r/t respiratory system Cough: Dyspnea: Pain: (chest) :

Look at what meds were taken to attempt relief

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Examination

Ask for subjective info about fatigue, weakness, fever, chills, nasal obstruction, sinus pain, hoarseness, edema, sore throats

Functional assess: General:

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Lung sounds Normal Breath

Sounds             Normal Air Flow

through the Lungs

      Adventitious

sounds Wheezing:

musical, whistling sound

http://www.ed4nurses.com/breathsnds.htm

Rales: crackling sound Expectorate

Rhonchi: bubbling

The sound will be heard throughout inspiration and expiration.

Louder than rales due to larger secretions

Results from air bubbling past secretions in the airways

Interventions: Deep breathing Coughing Hydration (encourage fluids, if no

restriction) Humidify air Mobilize

Friction rub: creaking, leathery sound

End of inspiration and beginning of expiration

Caused by rubbing of inflamed pleural surfaces against lung tissue.

Interventions: Chest x-ray Anti-inflammatory medications

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Lungs sounds continued

Cheyenne Stokes Kussmal’s

Cause: severe brain pathology

Causes: metabolic acidosis, renal failure, diabetic ketoacidosis

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http://micunursing.com/ http://www.med.ucla.edu/wilkes/lungin

tro.htm http://www.rnceus.com/resp/respabn.h

tml

http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/step29e.htm

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Age related changes

Muscle atrophy in pharynx and larynx and change in vocal cords

Loss of lung elasticity Decreased number of alveoli Weaker chest muscles Diminished chest movement Less effective cough Work harder to breath Enlargement of bronchioles More suseptible to lung infections r/t decreased

defense mechanisms Rib cage becomes more rigid and diaphragm

flattens

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Diagnostics

Chest xray Fluoroscopy:

Looks at speed and degree of lung expansion and looks for structural defects

No jewelry on neck or chest, no clothes from waist up except hospital gown

Ventilation/Perfusion Scan: IV or inhaled radioactive med given NPO for 4 hours prior to. Monitor for anaphylaxis Radioactive material is excreted in urine Inform importance of hand washing and if

anyone else handles urine they should glove as well

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Diagnostics continued

Cat scan: Needs to be still With or without contrast Check for iodine allergy IV access

MRI:. Lie flat, mechanical noises NO metal allowed

Pulse oximetry: May be continuous or intermittent Small censor on finger or ear Indicate level of oxygen with result

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Diagnostics continued

PFTs: used to diagnose disease, monitor progression, assesses medications Measures lung volumes and capacities

Total lung capacity, forced expiratory volume, functional residual capacity, inspiratory capacity, vital capacity, forced vital capacity, minute volume, and thoracic gas volume (table 30-2)

A clip is placed on the nose that the patient breathes through a mouth piece to determine mechanics (flow rates of gas in and out of lungs) and diffusion (movement of gas across aveoli/capillary membrane)

ABGs: measures the concentrations of oxygen and carbon dioxide in the arterial blood to determine if exchange is adequate across the alveolar membrane pH: 7.35-7.45 PaCo2: 35-45 PaO2: 80-100 HCO3: 22-26 Sats: 96-100 http://www.youtube.com/watch?v=IBJtQtzN7O8&feature=related http://www.youtube.com/watch?v=Xsr5wF-WDrw&feature=related http://www.youtube.com/watch?v=7s6OGhMfUqI&feature=related http://www.youtube.com/watch?v=LcmjGMWDbXw&feature=related http://www.youtube.com/watch?v=t9x4tB9GOi8&feature=related

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Diagnostics Continued

Bronchoscopy: It allows direct visualization of structures Explain procedure and assess allergies Consent needs to be obtained NPO 6-8 hours prior No smoking days prior dentures removed and document loose teeth Administer sedatives as prescribed (cetacaine)

Atropine may also be given to decrease secretions post procedure:

NPO until gag reflex returns Semi fowler’s position Monitor vitals Monitor for edema, hemoptysis, stridor, asymmetric

movement of chest Report abnormal findings to doctor!http://www.youtube.com/watch?v=DS6MHZCGlJk

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thoracentesis

Removal of pleural fluid for examination or to allow for lung re-expansion Obtain consent Post :

Assess respiratory status Document amount, color of fluid Monitor dressing for bleeding Label specimen bottle and send to labhttp://www.youtube.com/watch?

v=noDxydboLrA&feature=related

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Diagnostics continued

Tuberculin test (A.K.A. TB Tine) Determines past or present exposure to tuberculosis Pre:

Inform the client about intradermal need stick Cleanse skin and inject intradermally into lower anterior

forearm Mark and record site Instruct pt that skin reaction can last 1 week and not to

scratch it. Inform patient they need to return in 48-72 hours for

interpretation of positive or negative response ***Reddness, swelling of 5mm or more is considered positive

A pt with a history of BCG vaccination (foreign born) will always test positive regardless of exposure.

Post: follow up depends on response. If positive pt will be sent for chest x-ray to confirm

active tuberculosis

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Diagnostics Continued

Sputum analysis} the mucous membrane lining in the lower respiratory tract responds to acute inflammation by producing an increase in secretions Specimens are examined for volume, consistency, color,

odor Sputum that is thick, foul smelling, and yellow, green, or

rust colored may indicate bacterial infection Pt needs to expectorate the specimen into a sterile

container after coughing deeply if unable induction may need to be done to obtain

C & S} determines presence of bacteria, id’s specific organism, and appropriate treatment

Acid fast} done to determine the presence of acid fast bacilli including TB. Collection is 3 samples

Cytologic} used to determine the presence of carcinoma or infection. Special collection chamber is needed. Ask facility laboratory.

CBC: Hemoglobin-assess 02 carrying capacity WBCs- assess increase r/t infection

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Breathing exercises

Cough and deep breath (pg. 553) Incentive Spirometry: instruct the pt to use 10 times every

hour awake or with every commercial break if watching t.v. Purse lip breathing: pucker lips like you are going to blow a

kiss, whistle, or blow out a candle. Inhale through the nose and exhale through the pursed lips. Exhalation should last longer than inhalation.

Percussion and vibration Percussion} clapping of cupped palms against chest wall to

dislodge secretions ( only in areas protected by the rib cage) lasts 20-30 secs

Vibration} as pt exhales the therapist creates a shaking movement with the palms

Contraindications for both include: lung ca, bronchospasm, hemorrhage, hemoptysis, increased ICP, chest trauma, PE, pulmonary edema, GERD, anxiety, rib fractures

http://www.youtube.com/watch?v=8rI5y2hyC2c&feature=related

Postural Drainage ( page 555)

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Suctioning Goal} improve to improve oxygen and CO2 exchange by

removing excess mucus with a suction catheter…Follow facility guidelines!

Procedure: Use sterile technique for tracheal and clean technique for oral. Administer O2 before inserting catheter WHY? Moisten cath in sterile water and insert through nose or mouth before applying

suction Apply suction as the catheter is withdrawn from the airway Maintain pressure gauge b/w 80-100 mmHg Limit EACH pass to 10 seconds Allow the patient to rest briefly, encourage deep breathing and rinse catheter with

sterile water before each pass. Monitor for patient’s response

If tachycardia or increased respiratory distress develops, stop the procedure immediately and give the patient oxygen as ordered

Document the amount, color, odor, and consistency of the secretions as well as pt status before and after procedure.

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Nasal Cannula: 1-6 liter flow

Simple mask: 6-10 liters/FiO2 35-55%

Partial rebreather: has reservoir bag so patient can rebreath part of inhaled gas: 6-10 liters/ FiO2 35-60%

Non rebreather: non of exhaled gas rebreathed. FiO2 70-100% (venturi mask)

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Monitor O2

Monitor liter flow to make sure it is as prescribed. Assess pt response to therapy (ABGs as ordered)

Maintain sterile water in the humidity reservoir

Clean and replace equipment according to agency policy

NO SMOKING signs need to be posted if not a smoke free facility

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Artificial Airways

Oral: Nasal: Endotracheal Tracheostomy

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Care after thoracic surgery Manage pain with attention to resp status HOB elevated!! VS as per post-op protocol & relate to client’s norms Assess resp closely: rate, rhythm, effort Lung sounds, chest rising and falling with each resp Note absence of cyanosis or dyspnea Maintain patent airway, TCDB, IS q 1 hour while wake,

suction prn Care to chest tube and drainage system 02 responsibilities based on ABGs-02sats IV responsibilities Provide for a safe environment r/t: pain meds Wound assessment and care as ordered Activity progression as ordered and tolerated I&0 q 8 hours to include chest tube Assess lab: h&h, lytes, bun and cr, PT/INR, PTT, CBC

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Chest Tubes

Chest tubes are inserted to drain blood, fluid, or air and allow full expansion of the lungs.

The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has drained from the chest and the lung has fully re-expanded.

When the chest tube is no longer needed, it can be easily removed, usually without the need for medications to sedate or numb the patient. Medications may be used to prevent or treat infection (antibiotics).

http://www.atriummed.com/PDF/ManagingChestDrainage.ppt#438,37,Remove fluid & air

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Tidaling: the middle water seal chamber is observed for expected rise in fluid level with expiration.

Air leak: Suction may be

A gentle bubbling sound is normal to hear with a _____ system

_____ systems have a orange accordion looking object visible when suction is applied

Change the recepticle only when chambers are full using sterile technique

Heimlich Flutter Valve: air and fluid are expelled and not rebreathed in

READ THORACIC SURGERY page 561-562

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Drug Therapy

Corticosteroids: May be given parenteral, oral, inhaler Many SE, masks S/S of infection, cause F&E

imbalances NI: Rinse mouth after each inhaler use, instruct

to not to d/c abruptly, takes up to 10 days to obtain a blood level

Decongestants: NI: monitor pulse, BP, mental status Avoid if HTN, DM or hyperthyroid clients

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Drug Therapy Continued

Bronchodilators: Used for asthma and COPD May be given oral, IV, by Inhalation Does stimulate CNS and cardiac activity Aminophyline, Isuprel, Brethine, Atrovent,

Albuterol NI: Monitor HR, oral hygiene, avoid caffeine

Antitussives: Codeine popular but is a narcotic Dextromethorphan is non-narcotic NI: force fluids

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Drug Therapy Continued Antimicrobials:

Obtain C & S before administration of 1st dose NI: Assess for allergies Instruct on importance of taking all of prescription

Mast Cell Stabilizers:

Does not help after onset of S/S Intal (cromolyn) most common med NI: instruct to use prior to activity

Expectorants: Pill or syrup form Robitussin is a popular OTC NI: assess effectiveness of cough

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Drug therapy Continued

Antihistamines: Can be purchased without prescription Dry MM Mild sedation and antiemetic effects Benadryl (1st generation) Claritin (2nd generation) May worsen cough by drying bronchial

secretions Not recommended for clients with asthma NI: Care with operating machinery, being in a

situation where sound judgment is imperative. Avoid alcohol

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Acute Viral Rhinitis

common cold—lasts 2-14 days Inflammation and edema of nasal mm Based on H&P S/S: nasal stuffiness, sneezing, running

nose, ha, sore throat, fatigue, fever Most contagious first 3 days NI: Prevent spread of infection-

handwashing, proper disposal of tissue Rest, fluids to exceed 3000ml Humidifier, antipyretics, analgesics Call MD if T > 101, severe sore throat with white

patches, chest pain, purulent sputum

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Influenza

Several strains and more common in winter Is an acute viral respiratory infection with

fever and aches, chills, ha, cough Complications: bronchitis, pneumonia Spread by droplet/physical contact Incubation 1-3 days, illness lasts 2-8day NI: Rest, fluids, balanced diet, antipyretics,

analgesics, antiviral agents (which must be started 24-48 hours after S/S) Use of immunizations to prevents – 70-90%

effective Go to MD office only if chest pain or increase on

chest congestion.

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Pneumonia Bacteria often pneumococcus which

releases toxins=inflammation=damage Viral, fungal, hypostatic, aspiration,

nosocomial, chemical Classified by location: lobar, bronchial At risk: smokers, altered LOC,

immunosuppressed, chronically ill, tube feeders, trach and ET tube clients

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Pneumonia Diagnosis

H&P C&S of sputum CXR WBC Blood cultures

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S/S

Chills, fever, sweats, chest pain, cough, purulent sputum production, hemoptysis, dyspnea, headache, herpes simplex, leukocytosis (WBC=20,000-30,000), tachycardia, crackles, wheezes, N/V

****Elderly= Complications: Pleurisy, Pleural-

effusion

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NI

HOB > 30-45 degrees, keep warm and dry, VS q 4 h, assess lung sounds, skin color and signs of hypoxia What Is Hypoxia?

FF, I&O q 8 h, freq oral cares, care of expectorations, safety precautions r/t fever, fatigue

TCDB q 2h, measures to mobilize secretions, hi protein diet

Assess fluid and electrolyte balance

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Pleurisy

Inflammation of the pleura Causes: pneumonia, TB, injury S/S abrupt / severe pain. Breathing

and coughing aggravates Tx: analgesics, anti-inflammatory,

antitussives, antimicrobials, heat NI: Assess and Tx pain, Splint with

cough, HOB >, meds as appropriate

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Chest trauma

2 types Penetrating: Non penetrating: S/S: visible trauma, chest pain, Dyspnea,

cough, asymmetric movement, cyanosis, rapid weak pulse decreased blood pressure, tracheal deviation, JVD, bloodshot or bulging eyes

Tx: stablize and prevent further injury, remove clothing to assess injury and observe for other injuries like bleeding. Immediately treat the bleeding cover chest wound and tape on 3 sides

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Pneumothorax Accumulation of air in the pleural cavity

resulting in complete or partial collapse of the lung.

Spontaneous (smokers, blebs) Tension pneumothorax-air entering space > causing

pressure on heart and great vessels Diagnosis: CXR, H&P S/S:dyspnea, tachypnea, tachycardia, restlessness, pain,

anxiety, decreased movement in chest wall, < lung sounds, progressive cyanosis, sucking chest wound with open pneumothorax.

TX: Chest tube insertion to remove air or fluid Closure of open chest wound or tear in structures NI: Fowlers or semi-Fowlers http://video.google.com/videoplay?

docid=1169503917162980359&q=%22chest+tube+%22&total=14&start=0&num=10&so=0&type=search&plindex=1

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Flail Chest

Injury where 2 adjacent ribs on same side are broken into many pieces

Paradoxical movement s/s: dyspnea, cyanosis, tachypnea,

tachycardia Tx: varies

C and DB, pain management, possible intubation/vent, chest x-rays, ABGs, monitor vitals closely, respond promptly to needs

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Pulmonary Embolus Obstruction in pulmonary blood vessel causing

a ventilation-perfusion mismatch resulting in hypoxemia, followed by < CO, bronchial constriction, collapsed alveoli and may result in sudden death

Cause: Diagnosis: H&P, ABGs, VQ scan, EKG S/S: sudden severe chest pain increases on

inspiration, tachypnea, dyspnea, diaphoresis, hemoptysis, abnormal lung sounds, fever, tachycardia

Tx: Anticoagulation: PTT 2-21/2 normal Heparin then oral Coumadin using PT and

INR to regulate doses Therapeutic coumadin range varies per doctor but

most use goal of 2.0-3.0 O2, IV ms, support CV system Surgically may do embolectomy and insert a

vena cava filter

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ARDS Progressive pulmonary disorder FROM A

chest trauma after ___ TO ____HOURS AFTER Also seen with aspiration, prolonged

mechanical ventilation, severe infection and open heart surgery

Involves: pulmonary capillary damage with loss of fluid and interstitial fluid, Impaired alveolar gas exchange and tissue hypoxia due to pulmonary edema, Altered surfactant production, Collapse of alveoli, Atelectasis resulting in labored breathing and ineffective respirations

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ARDS Continued

The damaged tissue of the lungs has increased capillary permeability and fluid accumulates in the tissues of the lungs. The production of pulmonary surfactant < and atelectasis occurs. Lung compliance < meaning the lungs are losing the ability to carry out the process of breathing.

As a result, hypoxia develops. Some clients recover but the scar tissue becomes fibrous and lung fibrosis may progress.

Systemic effects: cardiac dysrhythmia, renal failure, stress ulcers

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Diagnosis and treatment

H&P S/S: > respirations, rapid and shallow, adventitious

lung sounds-crackles, agitation, tachycardia, mental confusion, cyanosis, etc.

CXR-non cardiac pulmonary edema ABGs (hypoxia-respiratory acidosis)> PC02 and <

PO2 Rapid identification of the problem Intubate and place on ventilator with PEEP (keeps

airways open and decreases hypoxia) Maintain patent airway, suction as needed Diuretics to reduce pulmonary edema Steroids

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COPD

5th leading cause of death Asthma, Chronic Bronchitis, Emphysema

Conditions associated with long-term obstruction of airflow both entering and leaving the lungs. Requires effort (energy) to push air out thru obstructed airway

Etiology: Unknown Dx: H&P, Pulmonary Function Tests=

assesses airway dynamics and lung volumes.

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COPD continued

S/S: Marked SOB, Easy fatigability, Pursed lip breathing, Change in speech pattern, Distended neck veins, Clubbing of digits, Intermittent episodes of expiratory wheezing, Chronic cough which becomes productive

Interventions: Maintain an open airway, Relieving bronchospasm, Breathing exercises-pursed lip & diaphragmatic, Postural drainage maneuvers, Diet-6 small meals a day, Avoid underweight or obesity, Avoid intake of ice cold food and drink esp during asthma attach—cold causes gastric distension and inhibits movement of diaphragm, Avoid gas forming foods –cause abd distension and inhibit movement of diaphragm, Avoid sudden temp changes, cover mouth/ nose, Avoid very dry or very humid air, Avoid fatigue, may precipitate attack

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COPD Continued

Practice stress management tech-breathing tech before activity to >>> 02

Avoid crowds during cold and flu season, have decreased resistance to illness

Prevent constipation, causes abd distention Elevate head and shoulders when resting (not just head) to

allow better lung expansion Avoid respiratory irritants: hair sprays, wind, dust Know S/S of infection and when to call MD 02 at 1-3 L/nc only due to reliance on hypoxic drive to

breathe. Elevated C02 levels no longer prompt breathing Immunize: flu and pneumonia Teach!!! Energy conservation tech, STOP SMOKING, assess

use of inhalers Pulmonary Rehab

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COPD Continued

http://www.blinkx.com/video/FullTurnMedia/Understanding_Chronic_Obstructive_Pulmonary_Disease_(COPD_1)~v0tBo7pY8NVCuX62G7fpHaQ

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Asthma

Inflammation of mucosal lining of bronchial tree and spasm of bronchial smooth muscles causing bronchospasms.

Intermittent and reversible KNOW ________ 2 phases

1) triggers-occurs 30-60 min after exposure to trigger and resolves in 30-90 min

2) late phase-begins 5-6 hours after early phase response and this lasts several hours to days. Airways hyper reactive

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Asthma continued

Diagnosis: H&P, PFT and ABG S/S: Dyspnea, productive cough, use

of accessory muscles, audible expiratory wheeze, tachycardia, tachypnea

**__________________—severe persistent bronchospasm with diaphoresis, pulse may become weak, thready—may need ventilator & ICU environment

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Asthma

Treatment: Relievers: in acute stage-Beta 2 receptor

agonists and sometimes anticholinergics Long-term: use Controllers – inhaled

glucocorticoids, leukotriene inhibitors, long-acting Beta 2 receptor agonists, mast cell stabilizer, xanthenes

02 as ordered + COPD Tx listed above Assess VS carefully, Fowler’s, 02, lung sounds,

3000ml/24hours to liquefy secretions Restful environment, have family member stay if

possible Instruct on peek expiratory flow meter (PEFR)—if

PEFR drops 20% call MD

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Emphysema

Affects alveolar walls and lose elasticity Degenerative and nonreversible Alveoli become distended and impairs gas

exchange. Will have VQ mismatch. May experience: Cor Pulmonale – right

sided heart failure, rising C02 with decreasing 02, bullea/blebs

S/S: Dyspnea, use of accessory muscles to breath,

shape of chest wall changes-barrel shaped. Pink-puffer as may have normal ABGs Tend to be thin due to energy required to breath

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Emphysema Continued

Treatment Medications-inhalers to keep airway

open Antidepressants 02 1-3 l/nc Pulmonary Rehab / See above tx COPD Will advise client to stop smoking

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Bronchitis Bronchial tree inflamed with increased

mucous, chronic cough at least 3 months of the year for 2 consecutive years.

Inflammation caused by inhaled irritant often a smoker.

Blue bloater. S/S:

Productive cough Exertional dyspnea Wheezing Develops resp infections readily >>RBC formation SOB, wheezes and crackles TX same as for other COPD

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TB

Mycobacterium tuberculosis Inhaled into lungs Infection: host susceptibility,

virulence, number inhaled Requires prolonged exposure Those at Risk:

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Top 10 countries with TB patientsIndia

China Indonesia Nigeria South Africa Bangladesh Ethiopia Pakistan Philippines Democratic Republic of the Congo

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S/S of TB

Develop gradually Low grade fever-specific pattern Persistent cough Hemoptysis Hoarseness Dyspnea on exertion Night sweats, fatigue, wgt loss

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Screening of TB

Mantoux skin test-0.1cc purified protein derivative (ppd),

ID Read test @ ___ – ____ hrs Palpable swelling 5mm = induration

= + + indicates only exposure and

development of antibodies

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Treatment of TB

+ finding = INH 6-12 months prophylactic. CXR & Sputum for AFB to confirm active TB Active = Isonaizid, Rifampin, Pyrazinamide &

after 3 weeks no longer contagious but requires long term TX

Well balanced nutrition Hydration to liquefy pulmonary secretion Activity as tolerates Hospitalized client:

Airborne & Standard Precautions Isolation room with neg air pressure Doors and windows closed Staff to wear particulate respirator that fits

securely

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Treatment of TB continued Well balanced meals with adequate hydration Instruct: TB is spread by airborne droplets—

protect others by covering mouth when coughing and wash hands often

Keep all clinic appts, continue meds for the prescribed length of time and take all meds

as directed If on isoniazid, avoid foods containing tyramine

(aged cheese, smoked fish) and histamine (tuna and sauerkraut). Meds + these foods will make client ill.

__________ causes body fluids to become red-orange and may stain contact lenses

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Treatment of TB continued Instruct: takes 3 weeks of med

before no longer considered contagious, so if home needs to: Cover mouth and nose when cough/sneeze and wash hands freq, dispose of tissue in a closed bag, avoid close contact with others, sleep alone in bedroom, clean all eating utensils thoroughly and separate

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Surgical treatment of TB

Wedge resection- small triangular resection of tissue

Lobectomy- remove lobe Pneumonectomy-remove entire lung Segmental resection-remove section

of lung Bronchoscopic laser

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Lung Cancer

Malignant growth of tissue occurring in lung tissue

2 major categories: 1.) slow growing are--squamous cell, adenocarcinoma, large cell

2.) (SCLC) small cell lung cancer (oat cell) grows quickly and metastasizes early

Leading cause of CA deaths in the US Cause: cigarette smoking, 2nd hand

smoke, other pollutants DX: H&P, CXR, Bronchoscopy with BX,

CT scan, sputum cytology Scans for mets=bones, liver, brain

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S/S of lung cancer

persistent cough with sputum production, recurrent resp infections, dyspnea, hemoptysis, chest pain, recurring pneumonia, or bronchitis

Anorexia, fatigue, weight loss=late S/S

May develop shoulder or other bone pain= mets

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Treatment of Lung cancer

Radiation Chemotherapy Surgical removal of tumor

Options arrived at after type and staging complete

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