Unit V

Third Hand Smoke

"Third-hand" smoke refers to the *cigarette byproducts that cling to smokers' hair and clothing as well as to household fabrics, carpets and surfaces — even after secondhand smoke has cleared*. Doctors coined the term to raise awareness about the danger these invisible tobacco toxins pose to small children, who are especially susceptible because they breathe near, crawl on, play on, touch and mouth contaminated surfaces.

Chronic Bronchitis - Pathophysiology

- *Inflammation of the bronchi and bronchioles* - Hypertrophy and hyper secretion in goblet cells and bronchial mucous glands with increase in size and # - Extension of goblet cells - Increased sputum, congestion - Narrowing of bronchioles and small bronchi Mucus plugs and infection narrows the airways Scaring and stenosis Severe ventilation-perfusion imbalance

Nurses and Smoking

- 15% of Nurses smoke - 28% of LPNs smoke - Smoking varies by educational and socioeconomic background - Smoking varies by specialty with Psychiatric nurses (23%) highest and Pediatrics and oncology nurses lowest (7-8%)

Nursing Interventions

#1 QUIT SMOKING - Airway Management & Monitoring - key to reduce complications. assess hospitalized pt every 2 hrs - Breathing Techniques: use during all activities to reduce stale air in lungs and manage dyspnea, teach when pt. has less dyspnea *diaphragmatic* pt conciously increases movement of the diaphragm, laying on back, breathe thru pursed lips (can be done in diaphragmatic or abdominal breathing) creates resistance and prolongs exhalation and increases airway pressure; delays airway compression and reduces air trapping - Cough Enhancement: controlled coughing, cough in morning, before bedtime, before meals - Oxygen Therapy - as prescribed, assess response, prevent complications - Energy Management - Patient education (disease process, meds, use of inhalers, conservation of energy, activity progression, nutrition, prevention of infection and signs of infection) *airway maintenance is the most important focus of interventions to improve gas exchange*

Manifestations

*Atypical (Viral & Mycoplasma)* - gradual, insidious onset of symptoms - headache, sore throat, muscle soreness, fatigue - dry cough - no fever and chills - scattered wheezes and crackles - little or no consolidation - Infiltrates & WBC

Other Classifications

*Bacterial* - winter/srpring, preceded by upper respirtory; spreads through droplets - *gram positive* (S. pneumoniae, S. aureus, Streptococcus pyogenes) - *Mycoplasma pneumoniae* - *gram negative* (Haemophilus influenzae; Klebsiella, Pseudomonas, Enterobacter, Escherichia, Proteus, P. aeruginosa) - *anaerobic bacteria* (Fusobacterium nucleatum, pigmented Bacteriodes, Peptostreptococcus, microaerophilic Streptococcus)

Smoking and Other Diseases

- *Smoking is a major factor in* coronary heart disease, stroke, and lung disease but also may be related to malignancies in other parts of the body; and *has been linked to* slowed healing of wounds, infertility, and peptic ulcer disease. Recently for the first time, the *Surgeon General includes pneumonia in the list of diseases caused by smoking.*

Diagnostic Tests

*Blood tests (RBC): hemoglobin*: transport of oxygen, a deficiency = hypoxemia; *ABG (arterial blood gas analysis:* gas exchange and perfusion as oxygenation, alveolar ventilation (Pao2 and Paco2), and acid base balance; *blood gas studies* provide info for monitoring treatment results, adjusting oxytherapy, and evaluating the pts responses *Sputum tests* help ID organisms or abnormal cells. *culture and sensitivity analysis* ID bacterial infection and determine which specific antibiotics will be most effective; *cytologic* ID cancer cells, allergies, *eosinophils and curschmanns spirals* are found for allergic asthma *Chest Xray* Eval chest status and establish baseline, performed from the posteroanterior and left lateral; pneumonia, atelectasis, pneumothorax, tumors, pleural fluid, placement of endotracheal tube. *Limitations*: may appear normal even when severe or chronic bronchitis, asthma, or emphysema is present. *CT scan or MRI* soft tissues, can ID lesion or clot, often requires contrast dye; *Determine if pt allergic to dye, iodine, shellfish, kidney function, drugs for type 2 diabetes, metformin - stopped 24 hours before dye is used* *Pulse oximetry* hemoglobin saturation with oxygen, uses infrared light and sensor, 95%-100 ideal, older and dark skin pt have lower normal, pulse ox recorded as Spo2 Sao2, not same as Pao2; causes for low readings: pt movement, hypothermia, low peripheral blood flow, ambient light (solution: cover sensor with glove fingertip), decreased hemoglobin, edema, nail polish; most accurate location is forehead Pulmonary function tests ABGs V/Q scan: a nuclear medicine scan that uses radioactive material (radiopharmaceutical) to examine airflow (ventilation) and blood flow (perfusion) in the lungs. The aim of the scan is to look for evidence of any blood clot in the lungs, called pulmonary embolism Bronchoscopy

Physical Exam

*Inspection:* front and back of thorax pt sitting up; one side of chest to the other, work from top (apex) and move down going side to side, look for discoloration, scars, lesions, masses, spinal curvatures; observe rate, rhythm, and depth of inspirations and symmetry of chest movements, type of breathing, use of accessory muscles - anteroposterior diameter to lateral diameter normal 1:1.5, abnormal 1:1 in pt with emphysema (barrel chest) - Distance of intercostal space normal : one finger breath 2 cm; increased distance in air trapping disorders, emphysema - retractions: areas that get sucked in upon inhalation, appears when pt is working hard in inhale around obstruction *Percussion* - Other indicators respiratory adequacy: skin and mucous membranes, general appearance, and endurance - neck muscles may be enlarged, and patient is very thin

How do you calculate the number of pack years for a smoker?

*Pack years = #packs/day X #years smoking*. If you smoke two packs per day for 10 years, you have a 20 pack-year history

Patient teaching - COPD

*Smoking Cessation #1* - Teach about COPD and when to report symptoms - Adaptive breathing & coughing techniques (pursed lips breathing) - Chest PT and drainage - Relaxation and stress reduction - Avoid contact with others with infections - Importance of medication compliance - Importance of immunizations

Other Classification

*Viral* less severe than bacterial Influenza A Cytomegalovirus *Fungal* - transmitted by inhaling spores Coccidioides immitus & Histoplasma capsulatum Protozoa and helminthes (rare) Pneumocystic carini *Anatomical location (lobular)*

Medications

- *Beta2-Adrenergic Agonists*: Broncholdilators. Short acting and long acting. Short acting for *"rescue" (Proventil, albuterol)* Inhaled. *Long-acting or "prevention" include Serevent and Arcapta.* - *Cholinergic Antagonist: Bronchodilator.* Prevents and Relieves. *(Atrovent & Spiriva*) - *Methylxanthines: (Theophyllin) oral or IV for rapid or long term use* - *Anti-inflamatories/Corticosteroids:* Prevention (QVAR, Advair, Flovent, Prednisone) short term and long term therapy. - *Cromone*: Prevention. (*Tiladel*) - *Leukotriene Modifier*. Prevention. (*Singulair*)

Chronic Bronchitis & Emphysema = COPD - see slide 4 for more info

- *Chronic bronchitis*: excessive mucus secretion in the bronchial tree causes chronic productive cough, "blue bloaters" - *Emphysema* refers to anatomic alterations of the air spaces distal to the conducting airways (alveoli) leading to decreased diffusion capacity. Characterized by *loss of lung elasticity* and *hyperinflation of the lungs*; increased respiratory rate and dyspnea "pink puffer" - see handouts on the portal for illustrations

Stats related to COPD

- 4th leading cause of death in America - Since 2003 women have exceeded men in number of deaths related to COPD! ___smoking______is #1 risk factor for COPD - Approximately 80-90% of COPD deaths are related to smoking - Frequent cause of hospitalization in US - Very costly-directly due to health care costs and indirectly from increased morbidity and mortality

Pulse Oximeter

- < 91% and <86% EMERGENCY < 85% body tissues cannot become oxygenated < 70% is usually life threatening, <80% life threatening in some pt - values are less accurate at lower values

Laboratory Assessment

- ABG values identify abnormal oxygenation, ventilation, acid-base status. Once baseline ABG levels are obtained, pulse ox gauges treatment response - Sputum samples: taken from hospitalized pt with acute respiratory infection WBC count confirms presence of infection - CBC: - Hemoglobin and hematocrit: determine polycythemia (compensatory increase in RBC and iron in chronically hypoxic pt) - Serum electrolytes: examined b/c acidosis can change the value - Serum AAT: taken in pt with family history of COPD - Chest x-ray: used to rule out other lung disease, check progress of pt with respiratory infections or chronic diseases. Advanced emphysema: xray shows hyperinflation and a flattened diaphragm - Pulmonary function test: (PFT): performed before and after the pt inhales a bronchodialater agent. measures lung volume, flow volume curves, and diffusion capacity

Nursing interventions

- Administration of analgesics - Elevation of affected extremity - Cold packs - Monitor for drainage - Proper positioning and alignment - Education about the syndrome and treatment procedures

Emphysema - Consequences

- Air trapping caused by loss of elastic recoil increases collapsibility of terminal airways - Decreased gas exchange causes both pulmonary diffusion and perfusion abnormalities pulmonary artery constriction - Result is increased functional residual capacity, increased compliance, and hypoxia - Silent for Years!: silent chest = serious airflow obstruction or pneumothorax - Hyperinflated lung flattens the diaphragm, weakening the effectiveness of the muscle and pt must use accessory muscles - This increased effort increases the need for oxygen causing "air hunger" sensation. Uncoordinated breathing pattern caused by inhalation starting before exhalation is completed

Non Pharmacological Treatment

- Airway maintenance-keep secretions liquefied and support the patient in clearing airways - Monitoring-Frequent assessments for worsening symptoms or signs of infection - Oxygen therapy-1-4 L/NC or <40% mask to maintain pulse ox > 90% (start low 1-2L) - Teach to conserve energy - Maintain healthy lifestyle-no smoking! - Pulmonary rehab - Last resort-lung transplant (rare) - positioning: upright alleviates dyspnea, increases chest expansion, pt to sit in chair for 1 hr periods 2-3x daily

Patient Teaching

- All family members and close contacts must be tested - Instruct client to cover mouth and nose when coughing or sneezing - Place all tissues in plastic bags - Wear a mask in public - Repeat specimens will be needed every 2-4 weeks once drug therapy is initiated; when results of 3 consecutive sputum cultures are negative, the patient is no longer infectious and may return to former employement - Drugs may cause nausea - Fatigue will decrease over time, offer a positive outcome for treatment if drugs are properly taken - infection control strategies is priority

Changes in Respiratory System Related to Aging

- Alveoli function and area decreases - Lungs residual volume increases - Efficiency of gas exchange decreases - Elasticity decreases - Muscles atrophy, strength decreases - Decrease blood flow through pulmonary circulation - Increase susceptibility to infection - Chest diameter increases and thorax becomes shorter - due to residual volume - Chart 29-1 page 549 text - the sedentary older adult often feels breathless during exercise

Common Manifestations - Chronic Bronchitis

- Asymptomatic for years - productive cough & exertional dyspnea - increasingly progressive cough - copious (abundant) sputum production - chest retractions, wheezing, tachypnea & cyanosis

E-Cigarette

- Battery powered device delivers doses nicotine as well as flavor and sensation of smoking - Smoke free so can be used in bars/restaurants - *Not considered a true nicotine replacement* - *not currently approved method of smoking cessation, safety for the bystander and user has not been established* - Can be harmful (overdose) - Use doubled since 2011

Use of Inhalers (MDI)

- Before use, remove lid and shake - Exhale fully - Place mouthpiece in mouth and as you begin to breath in deeply, press down firmly on the canister - Continue to breath in slowly and deeply - Hold breath for 10 seconds then exhale slowly - Wait at least one minute between puffs

Drug Therapy - same for asthma

- Beta-adrenergic agents Cholinergic antagonists Methylxanthines Corticosteroids NSAIDs Mucolytics Antibiotics Pneumonia and influenza vaccines Pg. 554-555 Chart 30-6

Nutritional Guidelines for COPD

- Breathing muscles of COPD patient use 10 times more calories - Good nutrition helps fight infections - Maintain ideal weight Eat high-fiber foods Limit sodium in your diet Wear your oxygen while eating Avoid overeating and gas forming foods Eat slowly and take small bites Rest before eating Eat high-calorie snacks

Geriatric Considerations

- Bronchodilator therapy-increased side effects *Monitor Theophylline drug levels* Concomitant disease (HF, arrhythmias, HTN, renal failure, anemia) - Client should: frequent rest periods, sit up to eat, liquid supplements, medication routine, frequent medical follow up, flu and pneumonia vaccination

Emphysema - Pathophysiology

- Caused-Recurrent alveolar inflammation Degradation of elastin in distal airways Elastic recoil lost leads to hyperinflation lungs Alveolar walls destroyed, blood vessels density reduced, air spaces enlarge, scaring of the lungs Peripheral bronchioles collapse Leads to air trapping and impaired gas exchange.

Other Diagnostic Assessments

- Chest x-ray: most common, may not show changes until 2 or more days after manifestations are present. Appears as area of increased density. *in older adult, the chest x-ray is essential for early diagnosis because pneumonia manifestations are often vague* - Pulse Oximetry: assess for hypoemia - Transtracheal aspiration (culture): invasive - Bronchoscopy: invasive - Direct needle aspiration: invasive - Thoracentesis: used in pt who have an accompanying pleural effusion

Smoking Health Stats

- Cigarette smoking has been identified as the most important source of preventable morbidity and premature mortality worldwide. - 440,000 Americans die each year from diseases caused by smoking - Smoking is responsible for an estimated one in five U.S. deaths (low) - Smoking costs the U.S. over $150 billion each year in health care costs and lost productivity - You can eat five portions of fruit and vegetables a day and exercise regularly, but healthy behavior means little if you continue to smoke

Respiratory Assessment

- Complete H & P of patient and family - Smoking history-pack-years (# packs smoked per day X # yrs smoked) - Chief complaint and signs/symptoms Dyspnea -Wheezing Cough -Stridor Sputum -Chest pain Hemoptysis -Crackles, gurgles

Physical Exam - Pneumonia

- Complete health history including life style, recent illnesses, vaccination status, swallowing issues, presence of NG tube, tobacco/alcohol use, "street" drugs, recent viral infection, exposure to flu or pneumonia, skin rashes, insect bites, exposure to animals - Findings are based on type (typical or atypical) - Consolidations (Percussion or X-Ray) - Hypoxemia - WBC elevated - Vital signs: fever decreased pulse ox, hypotensive, orthostatic changes result from vasodilation and dehydration, rapid weak pulse = hypoemia, dehydration, impending sepsis, and shock Risk factors:

Pulmonary Circulation

- Deoxygenated blood returns to right atrium - Pulmonary artery-carries deoxygenated blood from heart to lungs - Alveoli/Acinus-capillary gas exchange occurs - Oxygenated blood then travels through the pulmonary veins back to the heart (left atrium) - From left atrium flows to the left ventricle and pumped out the aorta into systemic circulation

Other Clinical Findings

- Flushed face, bright eyes and anxious expression - Chest or pleuritic pain - Myalgia, headache, chills, fever - Cough - Tachycardia, dyspnea, tachypnea - Sputum production (blood tinged) Abnormal lung sounds: crackles with fluid present, diminished breath sounds, wheezing if inflammation of airways, fremitus increased over areas of pneumonia, and percussion dulled fatigued with broken speech

Goals of Treatment

- Identify and treat the cause of acute exacerbation if possible - Optimize lung function by administering bronchodilators and other drugs - Assure adequate oxygenation and secretion clearance - Prevent complications of immobility - Address nutritional needs

Common Nursing Diagnoses for COPD

- Impaired gas exchange R/T alveolar-capillary membrane changes, reduced airway size, ventilatory muscle fatigue, and excessive mucus production - Ineffective breathing pattern R/T airway obstruction, diaphragm flattening, fatigue, and decreased energy - Ineffective airway clearance R/T excessive secretions, fatigue, and ineffective cough - Imbalanced nutrition - Anxiety - Activity intolerance - Potential for pneumonia or respiratory infection

COPD and Nutrition

- Importance of fluid intake - Diet for COPD-patients may have abdominal bloating and feeling of fullness. Teach to pick foods that are easy to chew and not gas forming. Avoid dry foods and milk products. Avoid caffeine. - Eat 4-6 small high calorie, high-protein meals. Include dietary supplements for additional calories and nutrients.

Planned Goals/Expected Outcomes

- Improve oxygenation and reduce carbon dioxide retention - Maintain Spo2 of at least 88% goal is > 90 - Absence of cyanosis - Maintenance of cognitive orientation - Return to pre-hospital level of function - Maintain adequate nutrition and body weight

Quitting Smoking

- In 2003, an estimated 45.9 million adults were former smokers. Of the current 44.5 million smokers, more than 32 million persons reported they wanted to quit smoking completely - The earlier you quit, the greater the health benefit.

Acute Exacerbation COPD

- Increase or change in symptoms usually: cough, sputum or dyspnea - Infection most often the cause - Usually bacterial or viral - Sputum cultures should be done to ensure proper therapy - Antibiotic therapy

Smoking and Lung Disease

- Inhaled smoke leads to *release enzyme elastase protease* from lungs - Smoking is the most common cause of COPD - With as little as *8 pack history lung changes occur without manifestation of the disease* - A *20 pack history lung changes seen on pulmonary function test* - Cigarette smoke contains over *4,800 chemicals, 69 of which are known to cause cancer.*

lab tests

- Lab tests: Sputum, CBC, Blood cultures ABGs, HIV, UA, Electrolytes, BUN and Creatinine - sputum: responsible organ not identified, sputum trap used to obtain samples from ppl who are really ill - CBC: used to see an elevated WBC count which is common EXCEPT in older adults - blood cultures: to see if organism has invaded the blood *from severely ill patients:* - ABGs: arterial blood gases and serum lactate levels: determine baseline arterial oxygen and CO2 and help ID need for supplemental oxygen - BUN: increased as a result of dehydration - high blood sodium levels: hypernatremia, dehydration

Physical Exam/diagnosis - COPD

- Labored breathing - Orthopnea: breathlessness worse when lying down - Rapid shallow respirations - Use of accessory muscles - Dyspnea - Lung assessment-frequently crackles, wheezes more common - Chronic bronchitis: Pale or dusky skin and mucous membranes, CYANOTIC, EXCESSIVE SPUTUM PRODUCTION - Barrel-shaped chest: 1:1 is ABNORMAL - Thin, loss of muscle mass - Digital clubbing, delayed capillary refil, cyanosis, chronically decreased arterial oxygen levels - Chest x-ray: used to rule out other lung disease, check progress of pt with respiratory infections or chronic diseases. Advanced emphysema: xray shows hyperinflation and a flattened diaphragm

Use of Dry Powder Inhaler (DPI)

- Load drug (capsule or disc) - Place lips over mouthpiece and breath in forcefully - Remove device from mouth (never exhale into device) - Do not shake this type of inhaler

Osteoarthritis

- Most common arthritis - Non systemic-progressive deterioration and loss of cartilage - Affects: hips, knees, vertebral column, and hands - Characterized by localized inflammation, pain and loss of function - Primary: unknown cause and Secondary: known cause

Women Greater Risk

- New research: women 25% >risk of developing heart disease than male smokers - Also higher risk for lung cancer by 50%! - Women absorb more carcinogens and toxins - Tobacco companies targeting women worldwide and must be combated - Antismoking programs need female focus and cultural

Nicotine

- Nicotine is an addictive drug, which *when inhaled in cigarette smoke reaches the brain faster than drugs that enter the body intravenously*. Smokers not only become physically addicted to nicotine; *they also link smoking with many social activities, making smoking a difficult habit to break.* *Physically and Psychologically addicting*

Patient Support and Education - nicotine replacement products

- Nicotine replacement products can help *relieve withdrawal symptoms* people experience when they quit smoking. Nicotine patches, nicotine gum and nicotine lozenges are available over-the-counter, and a nicotine nasal spray and inhaler, as well as a non-nicotine pill, are currently available by prescription - Chantix-up to 40% success rate but serious side effects

Disease Processes: Osteoarthritis

- Non-inflammatory, degenerative joint disease (DJD) - Risk factors: joint stress, congenital abnormalities, trauma - Loss of articular cartilage

Risk Factors Community Acquired (CAP)

- Older adults - No history of pneumococcal or flu vaccination - Chronic or other coexisting conditions - Recent exposure to viral or flu infections - History of tobacco or alcohol use

Why is this important?

- Other than health risks; your patients! - Nurses make a big difference in smoking cessation - Nurse-led interventions for smoking cessation increases chance of success by 50%! (dont just give a hand out, go in and talk with the patient multiple times) - Interventions delivered by multiple providers markedly increases cessation rates (Doctors, Nurses etc.)

Who is at Risk for TB?

- People with HIV/AIDS - Close contact with those known to have TB - Immunocompromised patients - Malnourished - Foreign-born from countries with high TB rates (Mexico, Philippines, and Vietnam) - People who work or live in nursing homes, prisons, hospitals - Alcoholics, IV drug users, homeless

Cultural Considerations Smoking

- Prevalence higher among African-Americans, blue-collar workers, and less educated people - High among American Indians and Alaskan Natives - Prevalence has declined in both men and women in the last two decades, but less so in women - This data points out the need for culturally sensitive smoking cessation programs

Smokeless Tobacco

- Primarily a male behavior - Many athletes (1 in 3 baseball players) use >11% high school students in 2012 stated current use Cancer of mouth, throat, cheek, gums, lips, tongue and esophagus - Also heart disease and gum disease

Manifestations and Symptoms

- Related to infectious organism, prior health, extent of infection *Typical* - abrupt onset of fever, shaking chills, cough - Pleuritic chest pain - lung consolidations - hypoxemia - Elevated WBC - Malaise, myalgia, rust colored sputum

Second Hand Smoke

- Secondhand smoke involuntarily inhaled by nonsmokers from other people's cigarettes is classified by the U.S. Environmental Protection Agency as a *known human (Group A) carcinogen*, responsible for approximately 3,000 lung cancer deaths annually in U.S. nonsmokers.

Complications Pneumonia

- Septic shock-Bacteremia: if the organisms move into the bloodstream - Atelectasis (alveolar collapse): fibrin and edema stiffen the lung, reducing compliance and decreasing the cital capacity. Atelectasis further reduces the ability of the lung to oxygenate the blood moving thru it RESULT: arterial oxygen levels fall, causing hypoxemia - Lung abscess, empyema (collection of pus in the pleural cavity): if the infection extends into the pleural cavity - Respiratory failure - Pleural effusion - Pleurisy - Endocarditis/ Pericarditis - Meningitis

Second Hand Smoke

- Smoking by parents is also associated with a wide range of *adverse effects in their children*, including exacerbation of asthma, increased frequency of colds and ear infections, and sudden infant death syndrome. - Secondhand smoke causes an estimated 150,000 to 300,000 cases of lower respiratory tract infections in children less than 18 months of age, resulting in 7,500 to 15,000 annual hospitalizations.

Smoking in Pregnancy

- Smoking in pregnancy accounts for an estimated 20 to 30 percent of low-birth weight babies, up to 14 percent of preterm deliveries, and some 10 percent of all infant deaths - *due to vasoconstriction and lack of oxygen to the fetus*

Assessment

- Subjective data=ask patient about pain and stiffness, Excessive weight gain, occupation, past illness, surgical procedure, and trauma - Objective data= assess for joint edema, tenderness, instability, and deformity, observe the gait (look for limp) HERBERDEN'S NODES= appear on the sides of the distal joints of the fingers BOUCHARD'S NODES= appear on the proximal joints of fingers, these nodes are hard, bony, and cartilaginous

Smoking and Heart Disease

- Surgeon general calls smoking, "the leading preventable cause of disease and deaths in the United States" - Smoking increases the risk of coronary heart disease and is one of the six major modifiable risk factors - Acts by *increasing* atherosclerosis, blood pressure & tendency to clot. It *decreases* exercise tolerance and HDL (good) cholesterol

COPD Management Key Points

- The quality of life decreases as COPD progresses - Treatment does not cure condition - Includes airway maintenance, monitoring, oxygen - therapy and drug therapy - Goal of pharmacotherapy is to relieve symptoms and prevent complications and progression of the disease with minimal side effects

Other manifestations

- Unplanned weight loss; loss of muscle mass in the extremities; enlarged neck muscles; slow moving, slightly stooped posture; sits with forward-bend - Fatigue - Respiratory changes, frequent resp infections - Mood disturbances-anxiety and depression - Cardiac changes-which? = occur as a result of anatomic changes associated with COPD. Asses HR and rythm, swelling of feet and ankles, nail beds, oral mucous membranes - late stage emphysema: pallor, cyanosis, underweight

Emphysema - Consequences gas exchange

- affected by increase work of breathing and loss of alveolar tissue - alveolar enlargement: curves of alveolar walls decrease and less surface area is available for gas exchange - Pt. shows increasing the respiratory rate, ABG values may not show gas exchange problems until the pt has advanced disease - carbon dioxide is produced faster than it can be eliminated resulting in co2 retention and chronic respiratory acidosis - pt with late stage emphysema: low arterial oxygen level (PAO2) b/c difficult for oxygen to move from dead alveoli into the blood

Laboratory Assessment cont

- as COPD worsens: hypoxemia (amt O2 in blood decreases) and hypercarbia (blood CO2 increases) - *Chronic respiratory acidosis results* (Paco2 increase), *metabolic alkalosis* (increased arterial bicarbonate) occurs as compensation - Viewed in labs: on ABGS: increased HCO3, pH remains lower than normal

current and previous drug use

- ask about drugs taken for breathing problems and about drugs taken for other conditions - cough can be a side effect for some antihypertensives - determine over the counter drugs - Blenoxane for chemotherapy and Cordarone for cardiac, causes pulmonary fibrosis - weed and cocaine inhaled causes problems

Biology behind TB from reading

- bacillus multiplies freely when it reaches a susceptible site (bronchi or alveoli) - exudative response occurs causing pneumonitis - with acquired immunity, further growth of bacilli is controlled in most initial lesions. - Only a small percentage of ppl infected with bacillus ever develops active TB

Common Manifestations - Emphysema

- begins in early adulthood - gradual, progressive exertional dyspnea - chronic productive cough, wheezing, recurrent respiratory infection & fatigue - dyspnea (labored) & cyanosis

allergies

- describe specific allergic responses. Do they wheeze, have trouble breathing, cough, sneeze, have rhinitis? - if they do have allergies ask about cause, treatment, and response to treatment

chest pain

- detailed description helps determine cause - continuous or made worse with coughing deep breathing or swallowing - cardiac pain is intense, "crushing" radiates to arm shoulder and neck - pulmonary pain varies, "rubbing" inside, not made worse by touching or pressing over the area

Chief complaint and signs/symptoms

- explore in chronological order - onset, how long it lasts, location, how often, worse over time, what manifestations occur with it, what interventions provide relief and what makes it worse, what treatments have been used - *cough* how long been present, occur at specific time of day, occur with physical activity, does it produce sputum or is it dry tickling or hacking - *sputum producing* *color* (rust-colored: bacterial pneumonia) *consistency* (thin, thick, watery, frothy; mucoid sputum: smokers with chronic bronchitis; frothy pink: pulmonary edema; hemoptysis blood: chronic bronchitis or lung cancer; grossly bloody: TB, pulmonary infarction, ling cancer, or lung abcess) *odor* (foul smelling: lung abcess;) *amount* (normal is 90mL/day, quantify using tsp, tblspn, cup)

effective coughing

- feet on floor - shoulders inward, bend head down, hug a pillow, after 3rd to 5th breath, pt takes deeper breath and bend forward slowly while coughing 2-3x from the same breath. - on return to sitting, pt takes a comfortable deep breath - repeat 2x

diagnostic assessment from reading cont

- foreign born, migrant workers, hospital workers need YEARLY screening - when positive for TB, a chest x-ray is used to detect active TB or old healed lesions. - if active: caseation and inflammation on xray - instruct anyone with manifestations of TB to seek medical attention

Physical Exam/diagnosis - COPD - from reading

- general appearance: low weight for height,stooped posture, slow mobility, loss of muscle mass in extremities with enlarged neck muscles - orthopneic, tripod position - severe activity intolerance: hard to bath and appear dirty - respiratory muscle fatigue: rapid, shallow, abdominal wall sucked in during respirations and accessory muscles used - acute exacerbation: respiratory rate 40-50 breath/min EMERGENCY - emphysema: limited diaphragm excursion b/c diaphragm is flattened; fremitus (chest vibrations) decreased but chest sounds hyperresonate on percussion b/c trapped air; auscultation: reduced breath sounds

TB from reading

- highly communicable disease, most common bacterial infection worldwide, - transmitted via aerosolization by cough, sneeze, laugh, whistle, sing - far more ppl are infected with TB than actually develop active TB

travel and area of living

- histoplasmosis: fungal disease found in central parts of US and Canada - Coccidioidomycosis and Hantavirus: western and southwestern US, Mexico, and Central America

Chronic Bronchitis - Pathophysiology from reading

- inflammation, affects only airways NOT alveoli - chronic inflammation: increase number and size of mucus glands, mucus glands produce large thick mucus, bronchial walls thicken and impair airflow, - Thickening of bronchial walls and mucus: impair airflow, blocks smaller airways and narrows large airways - mucus: provides breeding ground for organisms and leads to chronic infection *chronic bronchitis impairs airflow and gas exchange b/c mucus plugs and infection narrow the airways. Pao2 decreases (hypoxemia) and aerterial carbon dioxide (Paco2) increases (respiratory acidosis)*

*Auscultation*

- info on flow of air thru the trachea and lungs, helps ID fluid, mucus, obstruction - pt upright no shirt, breath deep and slow thru mouth, move side to side down thru intercostal spaces, not quality and intensity of sounds *normal breathing sounds* ID by location, intensity, pitch, and duration; known as bronchial or tubular (harsh hollow over trachea and mainstem bronchi); bronchovesiculr (over branching bronchi) and vesicular (soft rustling sounds in lung tissue over small bronchioles) describe these as normal, increased, diminished, or absent *abnormal bronchial breath sounds* heard at lung edges, atelectasis, tumor, pneumonia *adventitious sounds* additional breath sounds superimposed on normal sounds: *crackle, wheeze, rhonchus, pleural friction rub* *voice sounds* abnormal when loud and distinct b/c sound travels thru solid tissue or liquid (pneumonia, atelectasis, pleural effusion, tumor, abscess)

Two Types of Pneumonia

- lobar pneumonia: with consolidation - solidification, lack of air spaces in a segment or an entire lobe of the lung - bronchopneumonia: diffusely scattered patches around the bronchi. - extent of lung involvement depends on host defense. Bacteria grow quick in immunocompromised ppl. Tissue necrosis results when an abscess forms and perforates the bronchial wall

combination drug therapy interventions

- most effective treatment and prevention of transmission - therapy continues until disease is under control *first line therapy* uses isoniazid (INH) and rifadin (rifampin, RIF); pyrazinamide is added for the first 2 months, Ethambutol (myambutol) is the recommended fourth drug in the first line therapy

diagnostic assessment from reading

- nucleic acid amplification (NAA): results available in less than 2 hours. Use for pt suspected to have TB *blood analysis* by an enzyme linked immunosorbent assay using the QuantiFERON-TB Gold. Test for presence of M. tuberculosis. Results ready in 24 hours, used to determine if symptomatic pt has TB *sputum culture* CONFIRMS DIAGNOSIS - enhanced TB cultures and automated mycobacterial cultures require 1-4 weeks for positive/negative result. After drugs are started, sputum is taken again to assess treatment effectiveness. Cultures are normally negative after 3 months of treatment *The tuberculin test (Mantoux test): most commonly used screening test of TB infection. .01mL of Purified protein derivative is placed intraddermally. *Induration* (swelling, hardness of soft tissue) and readness measuring 10mm or greater in diameter after 72 hours indicates exposure to possible infection with TB *a positive reaction does not mean that active disease is present but indicates exposure to TB or the presence of inactive disease* for the HIV carrier: 5 mm is positive - failure to have a skin response b/c of reduced immune function when infection is present is called *anergy*

emphysema - pathophysiology from my reading

- proteases are present in higher than normal levels, damage the alveoli and small airways by breaking down elastin. Alveolar sacs lose their elasticity and the small airways collapse or narrow. Some alveoli are destroyed and others become large and flabby, with less area for gas exchange - This causes an increased amount of air trapped in the lungs caused by: loss of elastic recoil in alveolar walls, overstratching and enlargement of the alveoli into air-filled spaces called bullae, and collapse of small bronchioles - proteases: destroy and eliminate particulates and organisms inhaled during breathing -

*Palpation*

- respiratory symmetry, ID tenderness, check voal or *tactile fremitus*(vibration); chest expansion: thumbs on spine at 9th rib, extend finger sideways around ribs,upon inhale thumbs should move apart, and movement is up and out - unequal expansion: result of pain, trauma, or air in pleural cavity - slowed movement on one side: respiratory lag, pulmonary problem - *crepitus* air trapped in and under the skin, subQ emphysema; felt as crackling sensation beneath fingertips: document and report to provider if its around a wound site, tracheostomy site, or is pneumothorax is suspected - *tactile (vocal) fremitus* vibration of chest wall when patient speaks, *decreased if* transmission of sound waves from the larynx to the chest wall is slowed when pleural space is filled with air (*pneumothorax*), fluid (*pleural effusion*), or obstructed bronchus . *Increased with* pneumonia and ling abscesses b/c increased density of chest enhances transmission of vibrations

dyspnea (breathless, difficulty breathing)

- subjective - type of onset (slow, abrupt), duration, relieving factors, if wheezing or stridor - *quantify* interfere with ADL and how severely?, after walking one block or one flight of stairs? - *othopnea* shortness of breath when lying down relieved by sitting up - *Paroxysmal nocturnal dyspnea* awakens pt from the sleep from inability to breathe: associated with lung disease and left sided heart failure

Complete H & P of patient and family

- to identify type and severity of breathing problem - use age, gender, and race to determine predicted normal values - respiratory history: smoking history, drug use, travel, and places lived

Nursing Diagnoses Pneumonia ABC airway, breathing, circulation

1.* Impaired gas exchange* related to effects of alveolar-capillary membrane changes *Ineffective airway clearance* related to effects of infection, excessive secretions, fatigue and decreased energy, chest discomfort, and muscle weakness. *Potential for sepsis* related to the presence of microorganisms in a very vascular area Acute pain Deficient fluid volume RT fever, infection

Geriatric Considerations

4th leading cause of death *Nursing home residents at highest risk* Morbidity and mortality higher *Atypical presentation*-most common manifestation is confusion and shortness of breath from hypoxia rather than fever and cough

Computed Tomography (CT)= invasive if dye is used

A narrow x-ray beam produces a 3-D image of the structure being studies Should not be used unnecessarily because of radiation exposure Iodine contrast dye is sometimes used Helps locate injuries to the ligaments, tendons, tumors of the soft tissues, and fractures that are hard to see by other means

Unicompartmental knee arthroplasty

AKA: partial knee replacement Performed when only one to the compartments of the knee is affected

Hip arthroplasty

AKA: total hip replacement Commonly done when arthritis involves the head of the femur and acetabulum There are several variations to the procedure

1. Ventilation - Inspiration

Active process-requires intact nervous system Diaphragm contracts, pulls downward Intercostal muscles contract, elevate ribs Decreased thoracic pressure Results in air flow into the lungs

Nursing Diagnoses-Anemia's

Activity Intolerance Knowledge deficit Anxiety Self-care deficit Altered health maintenance Risk for falls Altered tissue perfusion (peripheral) Altered nutrition, less than body requirements Pain

Evaluation

Activity level Teaching nutrition medications Follow-up care Constipation

Nursing Diagnoses

Acute Pain Risk for Impaired Skin Integrity Risk for Infection Impaired Physical Mobility Risk for Injury Related to Traction Risk for Nutrition Risk for DVT

Venturi Mask

Adaptor located between bottom of mask and O2 sources Delivers precise O2 concentration—best device for chronic lung disease Switch to nasal cannula during mealtimes

Iron Deficiency Anemia Treatment

Anemia is a symptom not a disease; need to find the cause All adults with iron deficiency anemia need to be tested for abnormal bleeding Increase iron intake in diet Oral iron supplements (ferrous sulfate) IM or IV iron for severe deficiency Z-track IM iron injections Vitamin C increases absorption

Modes of transmission

Aspiration Inhalation Circulatory spread

Magnetic Resonance Imaging (MRI)

Assists in diagnosing abnormalities of: Bones and joints Surrounding soft tissue structures Cartilage Synovium Ligaments Tendons Uses magnetism and radio waves to make images of cross sections of the body

Osteoarthritis Diagnosis

Clinical Assessment and history Lab tests: rule out other causes of joint pain Radiographic Assessment CT or MRI

Blood Transfusions

Blood consent-patient education and blood consent Pre-transfusion testing Proper verification procedure Possible Reactions Delayed transfusion complications

Transfusion Times

Blood should be administered over 2-4 hours unless in an emergency Should not be run more than 4 hours-risk for bacterial contamination

IGRAs (Interferon-Gamma Release Assays)

Blood test for TB infection (not disease!) Can diagnose both latent and tuberculosis disease Measures a person's immune reactivity to M. tuberculosis Results available within 24 hours Does not predict who will progress to active disease Used as an aid in diagnosis but not definitive

Structure of Musculoskeletal System

Bones Joints Muscles Ligaments Tendons

Respiratory Processes

Breathing occurs through changes in size of and pressure within chest cavity Ventilation-mechanical process Diffusion of Gases-cellular level Transport-of gases to and from cells Respiratory Regulation-neural and chemical

Gas Exchange Airways

Bronchioles-are less than 1 mm/diameter, pathways only do not participate in gas exchange Alveolar ducts and alveoli-Alveoli surrounded by capillaries; where gas exchange occurs Acinus-structural unit containing bronchiole, alveolar duct, and alveolar sac. Surface contains alveolar-capillary membrane Alveoli are very permeable to oxygen, carbon dioxide, water, and electrolytes

Laboratory tests

Calcium Phosphorus Alkaline phosphatase (ALP) Serum muscle enzymes (CK, LDH, AST, & ALD) Erythrocyte Sedimentation Rate (ESR) ANA C-reactive protein (CRP)

Osteoarthritis

Clinical Manifestations - Pain and stiffness - Joint enlargement or effusions: fluid in synovial joint - Herbeden's nodes (distal) of hand - Bouchard's nodes (proximal) of hand - Atrophy of skeletal muscle, limp - If spine involved radiating pain and muscle spasm

Drug Therpay

Chart 33-7 page 656 text - Usually INH and RIF - Can cause nausea and liver problems - Take at bedtime to prevent nausea - May need antiemetics or take with food *Compliance is very important to avoid drug resistance!!* *strict adherance to the prescribed drug regimen is crucial for suppressing the disease* - well balanced diet, high in iron, protein and vitamins C and D *with current resistant strains of TB emphasize that not taking the drugs as prescribed could lead to an infection that is drug resistant*

Risk Factors & Incidence - Chronic Bronchitis

Chronic Bronchitis prolonged exposure to bronchial irritants More common in women Caucasian Urban (pollution) *cig smoking #1 risk for COPD* - PT with 20 packyear history or longer has early stage COPD with changes in pulmonary function tests genetics: Alpha1-antitrypsin deficiency: AAT inhibits excesive protease activity

Complications

Chronic bronchitis and Emphysema Hypoxemia and acidosis Respiratory infections cor pulmonale (abnormal enlargement of right side of heart) or right heart failure respiratory failure pulmonary hypertension Alveolar blebs and bullae Pneumothorax Cardiac dysrhythmias (atrial fib)

Neurovascular assessment

Circulation checks - CMS=circulation, motion, sensation - Assessment should occur after the trauma and postoperatively - Every 15 -30 minutes for several hours and then every 3-4 hours - Subjective= complaints of numbness or tingling not relieved by flexing the fingers and toes and repositioning the extremity - Objective= cool, pale, cyanotic skin above or below the altered site; edema; greater than 2 second capillary refill time; absent or diminished pulses

Pulmonary TB

Clinical manifestations. * TB should be considered for any pt with:* Cough that will not go away Progressive fatigue anorexia & weight loss low-grade fever night sweats hemoptysis chest pain, chest tightness fever, chills, SOB - early detection epends on subjective findings, slow onset and pt is not aware of problems until the disease is advanced.

Diagnostic findings:

Clinical symptoms & risk - History of TB infection or positive TB testing (Mantoux test/TB skin test or IGRA) - Acid-fast bacillus smear and culture from Sputum specimen. Need three specimens, three mornings. Takes 2-6 wks for results (Isolate) - Chest x-ray

Hazards & Complications of Oxygen Therapy

Combustion Oxygen-induced hypoventilation Hypercarbia—retention of CO2 CO2 narcosis—loss of sensitivity to high levels of CO2 Oxygen toxicity Absorption atelectasis—new onset of crackles/decreased breath sounds Drying of mucous membranes Infection

Home Oxygen Therapy

Criteria for equipment Patient education: Compressed gas in tank or cylinder Liquid oxygen in reservoir Oxygen concentrator

Additional tests

DEXA scan Arthography Tomography Gallium and Thallium scans Indium imaging Arthrocentesis Arthroscopy Electromyography Biopsy Ultrasonography

Geriatric Assessment Findings

Decreased Bone Density Increased Bone Prominence Kyphotic Posture Cartilage Degeneration Decreased ROM Muscle Atrophy, Decreased Strength, and Slowed Movement

Simple Facemask

Delivers O2 up to 40%-60% Minimum of 5 L/min Mask fits securely over nose and mouth Monitor closely for risk of aspiration

T-Piece

Delivers desired FIO2 for tracheostomy, laryngectomy, ET tubes Ensures humidification through creation of mist Mist should be seen during inspiration and expiration

Musculoskeletal Assessment and History

Demographics (age related injury and disease) Family History Past and current health history (accidents) Occupation/Athlete Medications (steroids) Activity level (obesity) Nutrition (lack Calcium)

Iron (Fe) Deficiency Anemia(Microcytic Anemia)

Depleted iron stores Small (microcytic) pale RBCs Causes: blood loss, poor intestinal absorption, or inadequate diet Common in women and elderly

Low-Flow Oxygen Delivery Systems

Does not provide enough flow to meet total oxygen and air volume Nasal cannula (1-6 L) Facemask Simple Partial rebreather Non-rebreather

Nuclear scanning

Done in the nuclear medicine department Use low dosages of radioactive isotopes Consent is needed from the patient Inform the patient that the radioactive isotopes will not affect family or visitors Follow the instructions that are given for any special preparations Push fluids to flush the isotope

Aspiration

Done to obtain a specimen of body fluid Needle inserted under local anesthesia Sterile procedure Arthrocentesis = puncture of the patient's join with a needle and the withdrawal of synovial fluid for diagnostic purposes

Pathophysiology

Ineffective erythropoiesis (RBC formation) Death of erythroid cells Early destruction of circulating erythrocytes B12 or folate deficiency: poor intake or malabsorption

Deep Vein Thrombosis (DVT) and Pulmonary Emboli (PE) Prevention

Early and frequent ambulation are very important Anticoagulants are prescribed Lovenox (Enoxaparin sodium) = is a subcutaneous injection that is given twice daily. Heparin and Coumadin (warfarin sodium)= require frequent laboratory monitoring and have increased bleeding risk.

Critical Thinking Pneumonia

Elderly nursing home male client New disorientation Not eating or drinking VS: T 99, P 110, R 34, BP 96/60 Held morning meds due to not eating (lasix, captopril, vitamin) Nurses is concerned he may have pneumonia or urosepsis What additional assessment data should you obtain? What risk factors for urosepsis? For pneumonia? Should you notify the MD What should you do about his morning medications Should you apply oxygen? If so, how?

Electrographic procedure

Electromyogram Involves insertion of needle electrodes into the skeletal muscles Electrical activities are: Heard Seen on an oscilloscope Recorded on paper

Arthroscopy

Enables direct examination of the joint Used to: Explore joints to determine is a disease

Implementation/Intervention

Energy Management Teaching: Disease Process Anxiety Reduction Self-Care Assistance Health System Guidance

Folic Acid Anemia

Etiology & Risk Factors (develops slowly so may be missed) Three common causes include: poor nutrition, malabsorption, and drugs Clinical Manifestations-similar to B12 deficiency but no neurological symptoms

Pulmonary TB

Etiology-Mycobacterium tuberculosis Transmitted-airborne route, Respiratory isolation Pathophysiology primary Secondary (reinfection)

Implementation/Intervention

Fall precautions Circulatory Care Nutrition Management Pain Management Medication Management (Iron)

Nasal Cannula

Flow rates of 1-6 L/min O2 concentration of 24%-44% (1-6 L/min) Flow rate >6 L/min does not increase O2 because anatomical dead space is full Assess patency of nostrils Assess for changes in respiratory rate and depth

Pulmonary function tests

Forced spirometry (measures flow and volume capacities) Lung volume determination Diffusion capacity

Nursing Diagnoses

Impaired Gas Exchange Ineffective Airway Clearance Deficient Knowledge (Medication regimen) Fatigue Imbalanced Nutrition Social Isolation

Pulmonary Function Tests

Forced vital capacity (FVC). This measures the amount of air you can exhale with force Forced expiratory volume (FEV). This measures the amount of air you can exhale with force in one breath. Peak expiratory flow (PEF). This measures how quickly you can exhale. Total lung capacity (TLC). This measures the amount of air in your lungs after you inhale as deeply as possible. Functional residual capacity (FRC). This measures the amount of air in your lungs at the end of a normal exhaled breath. Residual volume (RV). This measures the amount of air in your lungs after you exhale with force.

Physical Examination

General Musculoskeletal Exam -Observe symmetry and gross deformity -Observe posture, gait, and general mobility Muscles -Assess Muscle Strength Joints and Bones (pain & mobility) Neurovascular assessment (cms checks)

GI Symptoms

Glossitis Cheilosis

Chronic Obstructive Pulmonary Disease (COPD)

Group of diseases characterized by obstruction of airflow - New terminology is CAL or Chronic airflow limitations - Asthma (chronic but transient) - Emphysema (permanent) - Chronic Bronchitis (recurrent productive cough) - Bronchiectasis (irreversible destruction bronchial walls)

Special Considerations TB

HIV-infected persons must be closely monitored for interaction between HIV drugs and TB drugs Children-monitoring by specialist in Pediatric TB is recommended Pregnant women-Many of the drugs can be harmful to the fetus Close contact with drug-resistant TB pt requires 4-month prophylactic treatment

Bone scan= invasive

Helps detect metastatic and inflammatory bone disease Involves IV administration of nuclides (atomic material) 2-3 hours before the test is scheduled No food or fluid restrictions. Encourage drinking water to aid in renal clearance of radioisotope After patient has voided, a scanning camera shows the degree of radionuclide uptake

High-Flow Oxygen Delivery Systems

High-flow—can deliver 24%-100% at 8-15 L/min Venturi mask Face tent Aerosol mask Tracheostomy collar T-piece

Non-Rebreather Mask

Highest O2 level Can deliver FIO2 greater than 90% Used for unstable patients requiring intubation Ensure valves are patent and functional

Folic Acid anemia treatment Medical and Nursing Management

Identify those at risk and improve diet Risks include: older, debilitated patients with poor nutrition; malabsorption such as Crohn's, certain drugs (anticonvulsants), and alcoholism Pharmacologic Treatment-supplements Increase dietary intake foods high in folic acid (organ meats, eggs, cabbage, broccoli, Brussels sprouts)

Nursing diagnoses for total joint replacements

Impaired physical mobility Risk for falls and dislocations Risk for impaired skin integrity Self-care deficit Risk for infection Risk for peripheral neurovascular dysfunction Risk for constipation Knowledge deficit (home care instructions)

Outcome/Planning

Improve Activity Tolerance and endurance Educate: Diet, Disease, Medications Anxiety Control Self-Care (ADLs) Health Promoting Behavior

Vitamin B 12 deficiency treatment

Increase dietary consumption of foods high in B 12 (organ meats, nuts, green leafy vegetables, citrus) Vitamin supplements Vitamin B12 injections Monitor levels for improvement May require potassium supplements

Acute compartment syndrome

Increase in pressure within a muscle Inelastic fascia surrounding muscle creates an enclosed space or compartment Pressure within the space rises from hemorrhage or edema Muscle ischemia and tissue damage occur

hIp fractures: Factors that contribute to hip fractures in the older adult

Increased risk of fall Inability to correct postural imbalance Inadequate tissue to act as shock absorber Underlying skeletal weakness

Follow Up

Instruct the client to receive follow-up care for at least 1 year Provide support such as: American Lung Association (www.lungusa.org) Smoking Cessation Alcoholics Anonymous HIV services

Interventions

Interventions focus on treating and managing air exchange: Cough Enhancement Oxygen Therapy Respiratory Monitoring Drug regimen (depends on type and organism) Smoking cessation if patient is a smoker

Myelogram = invasive

Involves the injection of radiopaque dye into the subarachnoid space at the lumbar spine to x-ray the spinal cord and the vertebral column to detect herniated disk syndrome or spinal tumors Same procedure as a lumbar puncture Notify the physician if the patient has allergies to iodine or seafood Performed on a tilt table Common to have a headache after the procedure

Food Source of Iron, B12, Folic Acid

Iron (liver, red meat, organ meats, kidney beans, whole-wheat, leafy green vegetables, carrots, egg yolks, raisins) B12 (liver, organ meats, dried beans, nuts, green leafy vegetables, citrus fruit, brewer's yeast) Folic Acid (liver, organ meats, eggs, cabbage, broccoli, brussels sprouts)

Geriatric Considerations

Iron deficiency anemia most common in elderly Occult blood loss Deficient diet Confusional states May have B vitamin deficiency Renal failure

Pathophysiology - Iron Deficiency

Iron loss exceeds intake Insufficient iron available for RBC function Decrease in Hgb production Microcytosis (small RBCs) Results in Decrease tissue oxygenation

Knee arthroplasty (total knee replacement)

Knee joint is replaced to restore motion, relieve pain, or correct deformity

Evaluation

Lab values Subjective symptoms decreased Assessment pallor fatigue shortness of breath vital signs

Transtracheal Oxygen Delivery (TTO)

Long-term delivery of O2 directly into lungs Small flexible catheter is passed into trachea through small incision Avoids irritation that nasal prongs cause; is more comfortable Flow rates prescribed for rest, activity

Ventilation or Work of Breathingcan be impacted by:

Lung compliance Surface tension of alveoli Airway resistance

Megaloblastic Anemia

Macrocytic (large) red blood cells Categories: vitamin B12 deficiency folic acid deficiency Causes defective DNA synthesis of RBCs

Manifestations - Megaloblastic Anemia

Macrocytosis Low serum folate or B12 levels Glossitis & diarrhea; possibly N/V, abd pain Weakness, SOB, lemon yellow skin pallor Neurological symptoms (numbness, tingling, muscle weakness, loss of position sense)

Nursing Interventions

Maintain ADLs Alternate activity with rest Weight reduction if obese Check gait enhancers for safety Education about the disease process Education about medications Educations about exercise program (Collaboration with PT and OT)

Expected Outcomes

Maintenance of SaO2 of at least 95% Absence of cyanosis Maintenance of cognitive orientation Return to pre disease state Prevention of complications

Preparation of Blood

Needs special "blood tubing" with filter Runs with Normal Saline to prevent hemolysis and breakdown of RBC's Time of infusion begins when blood reaches the patient Frequent Vital Signs Most reactions will happen within the first 15 minutes

Vitamin B12 Deficiency

May results from a poor intake of foods containing B12 Occurs most often with vegetarian diets and diets lacking dairy products Also small bowel resection, diverticula, or tapeworm may interfere with B12 absorption Pernicious anemia (failure to absorb B12) Paresthesias (tingling extremities and poor balance)

Collaborative Management

Medications General Treat cause Oxygen Oral hygiene Orientation Safety Teaching

Geriatric Considerationsq

Megaloblastic anemia more common in older persons Many are misdiagnosed as dementia checking B12 level should be part of dementia screening Signs and Symptoms: weakness, sore/beefy tongue, pallor, loss appetite, vertigo, numbness and tingling peripherally, jaundiced sclera, wakefulness, paranoia

Total hip replacement

Most commonly replaced joint is the hip More than 80% of hip replacements last > 20 years Performed most often on clients over 60 years of age

Correct Identification

Most important part of the procedure Compare blood label to the patient ID and Blood Band at the bedside with two nurses Stay with the patient the first 15 minutes Can delegate VS but not the first 15 minutes! Start blood at 50 ml/hr. and increase after 15 min.

Extensively drug-resistant TB (XDR TB)

Most serious type of multidrug-resistant tuberculosis (only about 1% cases in US) It is resistant to almost all the TB drugs Also resistant to second-line drugs Few treatment options HIV patients higher risk of mortality Very important continue to take meds Cure is possible in approx. 30% cases Possible quarantine and removal of lung www.cdc.gov/tb

2. Diffusion of Gases

Movement of gases from the alveolar-pulmonary membrane to the pulmonary capillary bed and back Depends on: surface area gas concentration solubility Increases affect gas movement Diffusion inversely affected by membrane thickness & molecular weight.

3. Transport

Movement of oxygen and carbon dioxide trough pulmonary circulation Oxygen transport dependent on: amount of oxygen entering lungs blood flow to alveoli and cells adequacy of diffusion oxygen carrying capacity of blood (Hgb)

Osteoarthritis :Medications

NSAIDS-Ibuprofen and Naproxen Acetaminophen COX2 inhibitors-Celebrex & Mobic* Tramadol-stronger NSAID* Steroid injection Glucosamine & Chondroitin Topical: Precise and Capsaicin *prescription only

Respiratory Regulation

Neural (CNS) Medulla (brainstem) stimulated by increase in CO2, and decrease in O2 pons (apneustic canter) pons (pneumotaxic center) Intact spinal column Chemical Increased carbon dioxide concentration stimulates respiration Increased hydrogen ion concentration (acidosis) stimulates respiration Peripheral chemoreceptors in carotid and aortic bodies

Behavior Change Programs

Nicotine replacement therapies are helpful in quitting when combined with a behavior change program such as the American Lung Association's *Freedom From Smoking (FFS)*, which addresses psychological and behavioral addictions to smoking and strategies for coping with urges to smoke.

Hip precautions

No bending more than 90 degrees No crossing legs past the midline No internal rotation These could lead to dislocation of the joint These precautions must be followed for up to one year

Commonly Used Diagnostic Tests Orthopedic Conditions

Noninvasive Radiography (XRAY, CT, MRI) Radionuclide imaging (Scans) Laboratory

Osteoarthritis

Nonsurgical Management Analgesics (Tylenol, NSAIDS) Rest Positioning Heat/cold therapies Weight control TENS: Transcutaneous electrical nerve stimulation, controversial, alleviates pain CAM therapy (Glucosamine and Chondroitin supplements, cherry juice) Future-Stem cell therapy may prove helpful

Osteoarthritis

Nursing Diagnoses Chronic Pain Impaired Physical Mobility Self-Care Deficit Disturbed body Image Activity Intolerance Ineffective Coping Imbalanced Nutrition (obesity) Knowledge deficit

Pulmonary TB: nursing management

Nursing management Early identification of possible TB patients prevention of transmission preventive drug therapy self care including medication compliance Patient education: worsening symptoms, meds, possible side effects, fatigue Negative airflow rooms, N95 masks (gowns gloves), - well ventialated room with at least 6 exchanges of fresh air per minute

Risk Factors for Hospital Acquired

Older adult Chronic lung disease Surgical procedure/general anesthesia - Gram negative colonization of the oropharnyx and stomach History of debility, dysphagia (trouble swallowing) ,altered consciousness (aspiration) ET, NG, or Trach tubes Poor nutritional status Immunocompromised (disease or medication) Medication that increase gastric pH Mechanical Ventilation

Pre-Op Care Total Hip Arthroplasty

Pre-op teaching regarding procedure and expected post-op recovery Physical therapy: activity and exercise Occupational therapy: help with needed assistive devices and ADL's Autologous blood Cough, deep breath, incentive spirometer Pain control Activity

Joint replacement surgery

Outcomes: Pain reduction Increased function Increased safety

The 7 "P's" of compartment syndrome

Pain Pallor Puffiness Polar temperature Paresthesia Paresis or Paralysis Pulselessness

Nursing Management

Pain control Ice (polar care) Dressing (monitor drainage and change as ordered and PRN) HOB elevated, positioning DVT prevention (SCD's, or ankle pumps) Ambulate early ( within the first 24 hours post op) Respiratory therapy (Incentive spirometer)

Manifestations - Iron deficiency

Pallor, fatigue, weakness Dyspnea, tachycardia, vertigo, Sensitivity to cold Gastrointestinal symptoms (glossitis, pagophagia, stomatitis, cheilosis) Microcytosis, hypochromia Low serum iron levels Pagophagia or PICA-chew on ice, clay or starches

Ventilation - Expiration

Passive process Relaxation of diaphragm & muscles Alveolar pressure above the atmosphere

Hip Fracture

Pathophysiology Intracapsular Extracapsular Intertrochanteric Femoral neck Subtrochanteric

Breathing Exercises

Pg. 563 Chart 30-10 Diaphragmatic or Abdominal Breathing Pursed-Lip Breathing

Pneumonia

Pneumonia - excess fluid in the lungs caused by inflammatory process - caused by infection (bacteria, virus, fungi): organisms penetrate the airway mucosa and multiply inthe alveolar spaces. WBCs migrate to the area of infection causing capillary leak, edema, and exudate. - This fluid collects in and around the alveoli, alveolar walls thicken. - Seriously reduces gas exchange and leads to hypoxemia, interfering with oxygenations and leading to death - Categorized as community-acquired CAP) or hospital acquired (HAP) (nosocomial) 5th leading cause of death in the U.S. Frequent killer of the elderly Major source of disease and death in critically ill patients Can become systemic (sepsis): RBCs and fibrin move into the alveoli and capillary leak spreads the infection to other areas of lung. If organisms move into the blood stream, septicemia results Pneumonitis (similar symptoms) non infectious causes: (inhaled irritants) aspiration of water, food, vomit inflammatory location: interstitial spaces, the alveoli, and often the bronchioles

Home care and patient teaching

Positioning precautions Pain management Incision care Prevention of injury and infection Prevention of DVT

Postoperative care

Prevent DVT Prevent pressure ulcers Prevent other post operative complications (respiratory, falls, infection) Watch for compartment syndrome: A painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues.

Patient Teaching - Pneumonia

Prevention chart 33-4 page 648 text - Know if you are at risk; 65 and above, unless you have a disease that does not allow you to get the vaccine Information about pneumonia (avoid crowds especially if immunosuppressed) - Have influenza and pneumonia vaccine - Medication and treatment compliance - Important follow up with health care provider - Avoid smoking and fumes - Healthy lifestyle, diet, rest - Deep breathing and coughing exercises - Importance of fluids - Balanced diet - Relaxation techniques - Rest & sleep Concept Map page 649 text

Altered Tissue Perfusion

Problems with tissue perfusion (anemia) Anatomy and physiology Blood plasma-55% blood Erythrocytes (HGB) Platelets Leukocytes

Nursing interventions and teaching

Promote healing Facilitate mobility Monitor pain Change dressing as needed Teach medications

Chronic Respiratory Disorders and the Older Adult

Provide rest periods between activities such as bathing, meals, and ambulation Place in upright position for meals to prevent aspiration Encourage fluid intake after the meal to promote increased calorie intake Schedule drugs around routine activities to increase adherence to drug therapy Arrange chairs in strategic locations to allow the patient with dyspnea to stop and rest while walking Urge patient to notify provider promptly for any signs of infection Encourage patient to receive the pneumococcal and influenza vaccines

Partial Rebreather Mask

Provides 60%-75% with flow rate of 6-11 L/min One third exhaled tidal volume with each breath Adjust flow rate to keep reservoir bag inflated

The 7 "P's" of neurovascular function

Pulselessness Paresthesia: an abnormal sensation, typically tingling or pricking ("pins and needles"), caused chiefly by pressure on or damage to peripheral nerves. Paralysis or paresis: a condition of muscular weakness caused by nerve damage or disease; partial paralysis. Polar temperature: Pallor Puffiness (edema) Pain

Oxygen Therapy

Purpose—relieves hypoxemia and hypoxia *Hypoxemia*—low levels of oxygen in the blood *Hypoxia*—decreased tissue oxygenation - *Goal*—use lowest fraction of inspired oxygen for acceptable blood oxygen level without causing harmful side effects *Need for Oxygen is determined b*y ABGs and/or Pulse oximetry - Most often O2 1-4L NC or up to 40% venti mask - Patients with chronic hypercapnia (CO2) require lower O2 rates, usually 1-2L NC but.....

Diagnostic Tests

RBC/CBC Bone marrow examination Gastric analysis Serum B12 & Foliate levels Schilling test

Assessment of the Respiratory System

Respiratory problems very common 5th leading cause of death U.S. Respiratory illnesses may be chronic, acute, or both Disorders going to cover: COPD, Pneumonia, TB, and Anemias

Post-Op Care: total hip arthroplasty

Routine post-op care (VS, pain control) Prevent dislocation (abduction pillow) Keep heels off of the bed Ambulate slowly and often Cough, deep breath, IS every 2 hours Anticipate the need for pain medication Prevent infection Anticipate temporary change in mental status DVT prophylaxis Watch for compartment syndrome

Outcome/Planning

Safety Behavior: Fall Prevention Tissue Perfusion: Peripheral Nutritional Status: Nutrient Intake Pain Control Comfort Level Rest periods Lab values within normal limits

Other Diagnostic Tests

Specimen Sputum Thoracentesis Biopsy Alveolar lavage (bronchoscopy) Endoscopic Thoracotomy Pulmonary Angiography

Lungs

Sponge like, elastic organs located in thoracic cavity Right side has 3 lobes Left side has 2 lobes Diaphragm (muscle of inspiration) Pleura encloses lungs (double walled sac) visceral - adheres to the lung surface Parietal adheres to the thoracic Pleural cavity - has l=pleural fluid in it, when fluid decreases, you hear a rub in the lungs

Preoperative care

Stabilize the medical condition Stabilize the fracture (Buck's traction) Assessment of previous function

Stepped Drug Therapy COPD

Step 1-5 page 551 Chart 30-3 - Control therapy drugs (formerly preventive drugs) used daily regardless of symptoms - Reliever drugs used to actually stop an attach or episode - Different combinations of drugs are used for best response

Management of Blood Transfusion Reaction

Stop transfusion and take down tubing Notify provider Flush with Normal Saline Save blood bag and tubing Observe vitals every 5 minutes and maintain blood pressure Meds: Epinephrine, Antipyretics and Antihistamines

Respiratory Structure Review - Upper respiratory

Structures of the Upper respiratory tract: Nose-filters and humidifies the air Sinuses-air filled cavities, provides resonance during speech Pharynx (throat)-passageway for respiratory and gastrointestinal tracts Larynx (voice box)-cartilage and vocal cords, also contains the epiglottis Glottis and epiglottis-prevents aspiration

Assessment

Subjective =past medical history, significant medical problems. Complaints of pain on one side of the knee with weight bearing, gather information about how the previous treatments have worked Objective= vital signs, weight, blood tests, electrocardiogram (ECG), chest x-ray

Assessment

Subjective=complaint of pain, patient report of a "pop" or "snap" at the time of injury Objective= assessment for soft tissue injury. Affected leg may be shorter, slightly flexed, and externally rotated. Crepitus (grating sound) may be felt or heard. Monitor for signs of shock.

total joint replacement: Knee replacement surgery

Surgery recommended for those ages 50 and older Those with RA or lupus erythematous are not candidates Partial replacement will last 5-25 years Total replacement will last 20-30 years

Biopsy

Surgery with a needle Used to confirm infection or neoplasm

Osteoarthritis

Surgical Management Total Joint Replacement Arthroscopy: is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the joint through a small incision. Osteotomy :the surgical cutting of a bone or removal of a piece of bone. Arthrodesis :surgical immobilization of a joint by fusion of the adjacent bones.

Assessment

Symptom Analysis Pain Joint Stiffness Swelling Deformity Sensory Changes Immobility

Assessment (cont.)

Symptom analysis *Past health history including family*: genetic component - cystic fibrosis, lung cancer, emphysema, allergy linked to asthma. - history of infectious disease, TB, b/c family members may have similar environmental exposures *Occupational history* *Psychosocial history* anxiety due to reduced O2 to the brain, or sensation of not getting enough O2 is frightening. - Encourage pt to express their feelings and fears about manifestations and possible meaning - assess current stress and coping, help pt ID available support systems - assess changes in family roles, social isolation, unemployemnt *Review of systems* - Many times it is difficult to assess if symptoms are normal aging or disease process - Changes associated with aging: many related to heredity and a lifetime of exposure to environmental stimuli - Respiratory disease is a major cause of illness and chronic disability in elderly

Nursing Management - Assessment

Symptoms of anemia Activity tolerance Dietary intake (identify those at risk-elderly) Signs of bleeding Nail beds, mucosa, skin Palpate abdomen Assess for parentheses

Blood transfusion ReactionsFrequent VS

Symptoms: Fever, Pain (back, IV), Bleeding, Rash, Itching, Difficulty Breathing STOP the infusion! Allergic: history of allergies (hives, itching, anaphylaxis) Febrile: history of multiple transfusions (chills, fever, tachycardia, hypotension) Bacterial: contaminated blood products (tachycardia, hypotension, fever, chills, shock) Hemolytic: blood type or RH incompatibility (fever, chills, back pain, apprehension)

Drug Resistant TB

TB that is resistant to at least one first-line anti-TB drug MDR TB (multidrug resistant TB) is resistant to more than one anti-TB drug and at least isonazid (INH) and refampin (RIF) Treatment is complicated Can be life threatening if not compliant

Patient Teaching

Teach the patient: Explain reason physician ordered blood Consent The patient should notify the nurse if they have any chills, dizziness or fever Frequent checking of vitals Approximate length of transfusion

Diagnosis: Ventilation - Pulmonary Volumes

Tidal volume (TV): air displaced, 500 Inspiratory reserve volume (IRV): additional air that can be inhaled, 3100 Expiratory reserve volume (ERV): additional air that can be exhaled, 1000 Residual volume (RV): most affected by COPD, with increases reflecting the trapped stale air remaining in the lungs, amt of air left in lungs after forced exhalation = TOTAL LUNG CAPACITY (TLC)

Structures of the Lower Respiratory Tract

Trachea (windpipe)-located in front of esophagus, Cartilage, carries mucous away from lungs. Main stem bronchi-Right is shorter, wider and more vertical and therefore can be more easily intubated in error Bronchi (lobes (5), segmental, and sub segmental) Bronchioles Alveolar ducts (look like grapes) Alveoli (basic units of gas exchange) Normal lungs contain 300 million alveoli!

Medical management

Traction: Traction is the use of weights, ropes and pulleys to apply force to tissues surrounding a broken bone. It's sometimes used to keep a broken leg in the correct position during the early stages of healing, or to ease the pain of a fracture while a person is waiting for surgery. Pain control Surgical management (prior to surgical intervention Buck's tractions may be applied) Open Reduction and Internal Fixation (ORIF):used to fix broken bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone. This can be done with screws, plates, rods, or pins that are used to hold the broken bone together; used on fractures that do not heal with cast Compression screws Plates Intramedullary rods: is a metal rod forced into the medullary cavity of a bone. IM nails have long been used to treat fractures of long bones of the body. Hemiarthroplasty: s a surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact. May replace all or part of the joint with a prosthesis

Oxygen Delivery Systems

Type used depends on: Oxygen concentration required/achieved Importance of accuracy and control of oxygen concentration Patient comfort Importance of humidity Patient mobility

Alpha1-Antitrypsin Deficiency (AAT)

Uncommon but important risk factor for COPD Special enzyme AAT made by liver and is normally present in the lungs Regulates the enzymes (proteases) that break down inhaled pollutants and microorganisms. AAT prevents the proteases from working on lung structures. Production of normal AAT is dependent on a special gene (recessive)

Ultrasonography

Used to detect: Soft-tissue disorders Masses Fluid accumulation Traumatic joint injury Osteomyelitis Surgical hardware placement Sound waves produce an image No special preparation or post care

Oxygen Therapy

Used to treat Hypoxemia (low blood oxygen) and Hypoxia (low tissue oxygenation) Need for Oxygen is determined by ABGs and/or Pulse oximetry Most often O2 1-4L NC or up to 40% venti mask Patients with chronic hypercapnia (CO2) require lower O2 rates, usually 1-2L NC but..... Non-rebreather mask

Thoracentesis

Used, Pleural effusion, sometimes post surgery. Fluid can be tested for presence of cancer cells etc. *Pleural fluid from pleural space* - to relieve blood vessel or lung compression, respiratory distress caused by cancer, empyema, pleurisy, TB, drugs can be inserted - pre op: tell pt to expect pressure, do no tmove, cough, or deep breath, if pt is sitting then nurse stands in front of pt. - op: assess for shock, pallor, cyanosis, tachypnea, dyspnea - post op: xray, vitals, listen for reduced lungs sounds, pt deep breathes - teach and assess for pneumothorax (partial or complete lung collapse) : 24 hrs, rapid HR, shallow respirations, air hunger, cyanosis, trachea slanted to unaffected side

Bronchoscopy

Used: biopsy, specimen, promote drainage Similar to other endoscopies, requires conscious sedation - Examines the lining of the airway, may take specimens - insertion of tube in airways to the secondary bronchi - verify consent, document allergies, CBC, PLatelet, prothrombin time, electrolytes, NPO 4-8 hrs, methemoglobinemia is adverse effect of numbing spray benzocaine - follow up: monitor until sedation wares off and gag reflex is back, vitals, breath sounds every 15 mins for 2 hrs

Noninvasive Positive-Pressure Ventilation (NPPV)

Uses positive pressure to keep alveoli open, improve gas exchange without airway intubation BiPAP CPAP Delivers set positive airway pressure throughout each cycle of inhalation and exhalation Opens collapsed alveoli Used for atelectasis after surgery or cardiac-induced pulmonary edema; sleep apnea

Blood Transfusion

Vitals taken: before transfusion started At 5 minutes, 10 minutes, 15 minutes then 30 minutes X2 then hourly Observe IV site Watch for fever, chills, itching, rash, headache low back pain, and muscle pain Vital changes: tachycardia, tachypnea, hypotension, and temperature elevation of 1degree Fahrenheit Encourage patient to notify you of any changes Any doubts on reaction stop infusion

Decrease Risk for OAPatient Education

Weight loss Weight bearing exercises (strengthens muscles, tendons, ligaments) Exercise stimulates cartilage growth Exercise helps to control weight

Diagnostic tests

X-ray MRI

Radiographic studies

X-ray Myelogram Nuclear scanning Magnetic resonance imaging (MRI) Computerized axial tomography (CT or CAT scan) Bone scan

*Capnography* and capnometry:

measure amt of carbon dioxide present in exhaled air, which is an indirect measure of arterial carbon dioxide levels; capnometry: sensor changes CO2 level into a color or number analysis; capnography: CO2 level is graphed as a waveform with a number; non invasive, measure partial pressure of end-tital carbon dioxide PETCO2 aka ETCO2; normal value of partial pressure and end-tidal CO2 (PETCO2): 20-40mmHg - changes in PETCO2 reflect changes in breathing effectiveness and gas exchange, occur before hypoxia - use of both pulse ox and PETCO2 give info to direct earl intervention - conditions that increase PETCO2: increased production of CO2 such as inadequate gas exchange (hypoventilation, partial airway obstruction, rebreathing exhaled air) or increase in cellular metabolism (fever, acidosis, heavy exercise) - conditions that decrease PETCO2: reflect poor pulmonary ventilation (pulmonary embolism, apnea, total airway obstruction, tracheal extubation, hyperventilation where CO2 is "blown off"

Anxiety frequently occurs with COPD

see graphic on slide 20

Arterial Blood Gases (ABG's)

see slide 25 for info - squeezing off the ulnar artery

Risk Factors & Incidence - Emphysema

tobacco smoking air pollution underlying respiratory disease age genetics: Alpha1-antitrypsin deficiency: AAT inhibits excesive protease activity white, male, blue-collar workers *cig smoking #1 risk for COPD*PT with 20 packyear history or longer has early stage COPD with changes in pulmonary function tests

XRAY= noninvasive

used as an initial screen Allows observation of : Bone density Alignment Swelling intactness Some joint conditions may be seen Soft tissue is not clearly defined