Med-Surg Nursing: Respiratory

***What should you do if Chest Tube gets pulled out of chest wall?

**Cover opening IMMEDIATELY with Vaseline gauze and occlusive dressing** --Monitor for resp. distress, notify MD

Risk Factors: PE

**DVT (90%) --Immobility/reduced mobility --Surgery --Malignancy --Obesity --Oral contraceptives/ hormones --Smoking --Heart failure --Atrial fibrillation --Pregnancy/delivery --Clotting disorders --Central venous catheters --Air or thrombus --Fractured long bones #More than 90% of pulmonary emboli arise from deep vein thrombosis (DVT) in the deep veins of the legs. Risk factors for PE include immobility or reduced mobility, surgery within the last 3 months (especially pelvic and lower extremity surgery), history of DVT, malignancy, obesity, oral contraceptives and hormone therapy, heavy cigarette smoking, prolonged air travel, heart failure, pregnancy, and clotting disorders. Other sites of origin of PE include the right side of the heart (especially with atrial fibrillation), the upper extremities (rare), and the pelvic veins (especially after surgery or childbirth). Upper extremity DVT occasionally occurs in the presence of central venous catheters or cardiac pacing wires. These cases may resolve with the removal of the catheter. Less common causes of PE include fat emboli (from fractured long bones), air emboli (from improperly administered IV therapy), bacterial vegetations, amniotic fluid, and tumors.

Clinical Manifestations PE: Slow or Sudden Onset

**Dyspnea**** --Tachypnea --Crackles --Wheezing --Cough --Hemoptysis --Hypoxemia --decreased PaO2 --decreased O2 sats. --Chest Pain --Tachycardia --Syncope --Change in LOC --Fever

Diagnostics of PE

**Spiral (helical) CT ** w/ IV Contrast --Ventilation/Perfusion Scan if contrast contraindicated (V/Q scan) --^ D-dimer- measures clotting events --Pulmonary angiography --ABG important but not diagnostic --ECG (ST/ T wave changes) --Troponin, BNP elevated: >>>>Associated w/ ^ mortality

************What is the difference between a positive TB and a negative TB skin test?

+TB vs. -TB: (+)TB= This indicates that the body has been infected with the TB bacteria. An infection makes an individual extra sensitive to the tuberculin injection, which causes the test site to grow in diameter. --imm.suppressed (+)= TST greater than or equal to 5mm -- high risk (+)= TST greater than or equal to 10mm -- low risk (+)= TST greater than or equal to 15mm (-)TB= Redness alone at the skin test site usually means you have not been infected with TB bacteria. A firm red bump may mean you have been infected with TB bacteria at some time. The size of the firm bump (not the red area) is measured 2 to 3 days after the test to determine the result Also a false positive may show after already being affected prior to TST. False positive is actually a TB boost. Nursing Implementation for persons with positive TB test: --Person w/ positive tuberculin skin test should have a chest x-ray to assess for the presence of active TB disease --Additional immediate medical workup --Sputum smear and culture for AFB is diagnostic for active disease

Pneumonia Definition and stats

--Acute **infection** of lung caused by **microbial** organism --8th leading cause of death in United States

PE: Evaluation

--Adequate pulmonary tissue perfusion and respiratory function --Adequate C.O. --Increased level of comfort --No recurrence of PE

*******What are asthma triggers?

--Allergens --Exercise --Air pollutants --Occupational Factors --Respiratory Infections --Nose & Sinus problems --Drug additives --Food Additives --GERD --Emotional Stress

***What are the risk factors of pneumonia?

--Altered LOC --Dysphasia --Tube feedings --Noxious substances inhalation --Chronic disease, debilitating illness, HIV --Bed rest, prolonged immobility --Malnutrition --Long term care resident --Alcoholism --Aging

Risk Factors for Pneumonia

--Altered LOC --Dysphasia --Tube feedings --Noxious substances inhalation --Chronic disease, debilitating illness, HIV --Bed rest, prolonged immobility --Malnutrition --Long term care resident --Alcoholism --Aging

Foreign Body

--Aspiration of food or foreign body into upper resp. tract Sx: Stridor, use accessory muscles, intercostal retractions, wheezing, restless, ^HR, cyanosis ***Remove body through route of entry --Watch for complete airway obstruction ***Complete obstruction is medical emergency --Reestablish patent airway via Heimlich, trach., intubation

Risk Factors for Aspiration Pneumonia

--Difficulty swallowing (dysphagia), dysphasia --NG tubes w/ or w/o tube feeding --Decreased LOC --Seizure, anesthesia, head injury, stroke, alcoholism #*Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.

Types of Pneumonia:Medical Care Associated

--HAP (Hospital-acquired pneumonia): Occurring 48 hours or longer after admission in non-intubated patient --VAP (Ventilator-associated pneumonia): Occurring > 48 hours after endotracheal intubation Both associated w/ longer hospital stays, increased costs, sicker patients, and increased risk of morbidity and mortality ##*HAP: Hospital-acquired pneumonia. VAP: Ventilator-associated pneumonia. HCAP: Health care-associated pneumonia: new-onset pneumonia in a patient who (1) was hospitalized in an acute care hospital for ≥2 days within 90 days of the infection; (2) resided in a long-term care facility; (3) received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection; or (4) attended a hospital or hemodialysis clinic.

Factors that could reactive TB

--HIV infection --Contact with an infectious patient --Initiation of an anti-tumour necrosis factor (TNF) treatment (RA treatment) --Dialysis --Organ or hematologic transplantation --Silicosis --Being in prison --Immigrant from high TB burden countries --Being a homeless person --Illicit drug users

***********What diagnostics are used for pneumonia?

--History/Physical examination --Chest x-ray: Consolidation (in the pic provided: Pneumonia as seen on chest X-ray. A: Normal chest X-ray. B: Abnormal chest X-ray with consolidation from pneumonia in the right lung, middle or inferior lobe (white area, left side of image). --Sputum C&S; gram stain Ideally before antibiotic therapy is begun, but don't delay --Pulse oximetry or ABG -- CBC w/ differential, chemistries ^WBC, diff. w/ L shift L shift= ^ in leukocytes (primarily neutrophils (ratio of immature to mature) --Blood cultures (has it spread systemically?) --******X-ray findings are consistent w/airspace opacity, lobar consolidation, or interstitial opacities. --Thoracentesis Obtain fluid samples what is it? Thoracentesis, also known as thoracocentesis or pleural tap, is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia --Bronchoscopy w/ washings A bronchoscope (a thin, tube-like instrument with a light and a lens for viewing) is inserted through the nose or mouth into the lungs. A mild salt solution is washed over the surface of the airways to collect cells, which are then looked at under a microscope. Bronchial washing is used to find infections. --Biologic markers to guide clinical decisions: C-reactive protein (CRP) and Procalcitonin May provide information to guide duration of antibiotic therapy

**TB risk factors

--Homeless --Poverty, poor access to health care --Residents of inner-city neighborhoods --Foreign-born persons --Living or working in institutions (includes health care workers) --IV drug users --Immunosuppression ------------------------------------------------------- TB occurs disproportionately in the poor, the underserved, and minorities. In the United States, persons at risk include the homeless, residents of inner-city neighborhoods, foreign-born persons, those living or working in institutions (long-term care facilities, prisons, shelters, hospitals), IV injecting drug users, persons at poverty level, and those with poor access to health care. Immunosuppression from any etiology (e.g., HIV infection, malignancy, long-term corticosteroid use) increases the risk of active TB infection. The prevalence of TB in the United States is highest in those of Asian descent.

Nursing Diagnosis: TB

--Ineffective breathing pattern --Imbalanced nutrition: Less than body requirements --Noncompliance --Ineffective health maintenance --Activity intolerance

Sinustis: What is it? Symptoms?

--Inflammation/hypertrophy of mucosa --Narrows or blocks sinus exit --Blockage provides rich medium for bacterial growth *******Sx: Pain, purulent nasal drainage, nasal obstruction, congestion, fever, malaise*** --Environmental control of allergens, antibiotics (Bactrim, EES) steroids, decongestants

Safety Precautions: Chest Tubes

--Keep at bedside --Sterile petroleum gauze --Extra drainage system --Bottle sterile water or saline

**What are indications for intubation in an acute asthma attack?

--Life-threatening asthma --Too dyspneic to speak --Perspiring profusely --Drowsy/confused --Require hospital care / ICU --Peak flow is < 25% of personal best --Breath sounds difficult to hear: no wheezing w/ airflow exceptionally limited. Prepare to intubate!!

PE: patient teaching

--Long-term anticoagulant therapy --INR levels --Warfarin dosage corrected --Prevention of complications --Prevention of reoccurrence --Long term management similar to DVT

TB: Infection Can Spread via Lymphatics to Other Organs

--Lungs --Larynx --Kidneys --Meninges --Bones --Adrenal glands --Lymph nodes --Skin

Complications of TB cont.

--Other organ development... --TB of the spine --Pott's disease - Spinal disc and vertebral destruction --CNS TB: bacterial meningitis --Abdominal TB: peritonitis, kidney adrenal or GU tract disease #Because TB can infect organs throughout the body, various acute and long-term complications can result. TB in the spine (Pott's disease) can lead to destruction of the intervertebral disc and adjacent vertebrae. Central nervous system TB can cause severe bacterial meningitis. Abdominal tuberculosis can lead to peritonitis, especially in HIV-positive patients. The kidneys, adrenal glands, lymph nodes, and urogenital tract may also be affected.

Asthma Risk Factors

--Patient related (genetic) --Environment related (pollen) ***Male gender risk factor in children --Obesity

***Asthma Triggers: Allergens

--Pollen --Molds --Fungus --Furry animals --Cockroaches ##Indoor and outdoor allergens are well known to trigger asthma symptoms, but their role in the actual development of asthma is not clear.

Classification of TB

--Primary infection Bacteria are inhaled -->inflammatory reaction. No disease if effective immune response. Encapsulates. --Latent TB infection (LTBI) Infected, but no active disease, NO symptoms, cannot transmit. Granuloma. TREAT! --Active TB disease (Primary/Pulmonary TB) Granuloma break open. Body cannot contain organisms, bacteria replicate, & active TB disease -->results lung destruction #TB can also be classified according to its presentation - primary, latent, or reactivated and whether it is pulmonary or extrapulmonary. Primary infection occurs when the bacteria are inhaled and initiate an inflammatory reaction. The majority of people mount effective immune responses to encapsulate these organisms for the rest of their lives, preventing primary infection from progressing to disease. Latent TB infection (LTBI) is a TB infection in a person who does not have active TB disease. These individuals are asymptomatic and cannot transmit the TB bacteria to others. An estimated 10 to mm million Americans have LTBI, of which 5-10% will develop active TB disease at some point. Therefore treatment of LTBI is important. If the initial immune response is not adequate, the body cannot contain the organisms, the bacteria replicate, and active TB disease results. When active disease develops within the first 2 years of infection, it is termed primary TB. Post-primary, or reactivation TB, is defined as TB disease occurring 2 or more years after the initial infection. Individuals co-infected with HIV are at greatest risk for developing active TB.

***COPD: S/S

--Prolonged expiratory phase --Wheezes --Decreased breath sounds --↑ Anterior-posterior chest diameter (barrel chest)* --Pursed lip breathing --Use of accessory muscles --**Tripod position: pt may sit upright w/ arms supported on a fixed surface such as an over-bed table --**Clubbing of fingers* *Signs of chronic oxygen deprivation #The patient may need to breathe louder than normal for auscultated breath sounds to be heard. (tripod position). The patient may naturally purse lips on expiration, such as those in the neck, to aid with inspiration. Arms supported on a fixed surface such as an over-bed table (orthopenic position)*** need to know for test

***What should you do if Drainage system unit gets damaged/cracked?

--Put end of connective tubing into sterile water to a depth of 2 cm until a new system can be obtained

Complications of Tb: Pleural TB

--Type of extra-pulmonary TB --Results from either primary disease or reactivation of a latent infection --Chest pain, fever, cough, unilateral pleural effusion are common **Pleural effusion: --Bacteria in pleural space --Inflammatory reaction w/ plural exudates of protein-rich fluid **Empyema (Collection of pus)

********What is the nursing care for patients with chest tubes?

--Water seal chamber --Tidaling w/ resps. is normal until lung fully expands --Bubbling will be seen w/ pneumothorax --Check for system leaks --Keep insert site airtight w/ Vaseline gauze dsg. --Keep drain below chest level --Maintain ordered suction/water levels --Monitor/record drainage amt./type --Report>100 ml CT drainage for 2 consecutive hours --Maintain patency (DO NOT STRIP) --Change drainage system prn

****what are the indications for tracheostomy?

-Establish patent airway -Bypass upper airway obstruction -Facilitate removal of secretions -Long-term mechanical ventilation -Oxygen administration -Permit oral intake and speech in patient who requires long-term mechanical ventilation #Most patients who require mechanical ventilation are initially managed with an endotracheal tube, which can be quickly inserted in an emergency. The standard surgical tracheostomy is usually performed in the operating room using general anesthesia. A newer procedure, a percutaneous tracheostomy, can be performed emergently at the bedside using local anesthesia and some sedation/analgesia. ----------------------------------------------- Advantages of Tracheostomy vs. Endotracheal Tube (ETT): --Easier to keep clean --More secure --Better oral/bronchial hygiene ^patient comfort < risk of long-term damage to vocal cords #The tracheostomy tube is shorter in length and slightly wider in diameter than an ET tube, thereby making it easier to keep the tube clean and facilitate better oral and bronchial hygiene. With the use of a tracheostomy (compared to an ET tube), patient comfort may be increased, because no tube is present in the mouth. There is also less risk of long-term damage to vocal cords. A tracheostomy provides a more secure airway and is less likely to be displaced.

**Oxygen Delivery Systems: What are the indications for different types?

-Face Tent: Alternative to an aerosol mask for patients who feel claustrophobic -Venturi Mask: Used for patients w/ COPD when accurate FiO2 is essential & CO2 buildup must be kept to minimum -Nasal Cannula -Simple face mask -nonrebreather -partial rebreather -Tracheostomy collar -Humidification

Laryngeal Spasm: Narrowing of airway: Causes/S&S/Treatment

1. Causes: --Inflammation from GERD, complication of intubation, bronchoscopy, allergic reaction 2. S/S's: --Persistent cough ****Inspiratory stridor **Sternal retractions --Acute respiratory distress **Dyspnea --Chest pain **Wheezing 3. Treatment: --Watch carefully after procedures, protect airway: ~~intubation, trach. --Elevate HOB --O2 --Corticosteroids --Intubation --Tracheostomy

**********What are the nursing actions to promote airway clearance and keep a patent airway?Narrowing of airway (Laryngeal Spasm)

1. Causes: Inflammation from GERD, complication of intubation, bronchoscopy, allergic reaction 2. S/S's: Persistent cough Inspiratory stridor Sternal retractions Acute respiratory distress Dyspnea Chest pain Wheezing Treatment: Watch carefully after procedures, protect airway: intubation, trach. Elevate HOB O2 Corticosteroids Intubation Tracheostomy

complications of TB

1.) **Miliary TB --Large numbers of organisms invade the bloodstream & **spread to distant organs **Fatal if untreated --Manifestations progress slowly --Presentation varies depending on organs infected --Fever, cough, hepatomegaly, splenomegaly, and generalized lymphadenopathy #It can occur as a result of primary disease or reactivation of latent infection. Acute symptoms include fever, dyspnea, and cyanosis. Chronic symptoms include the systemic manifestations of weight loss, fever, and gastrointestinal (GI) disturbance. Hepatomegaly, splenomegaly, and generalized lymphadenopathy may be present.

**********What are the indications for chest tubes?

1.) Chest trauma: Mechanisms of injury: --Blunt: Deceleration, acceleration, shearing, and compression injuries Can be life-threatening --Penetrating Open wound through the pleural space 2.) Pneumothorax fluid in pleural space: dyspnea, decreased chest wall movement , absent bowel sounds= CT (chest tube) 3.) Hemothorax blood in pleural space: dyspnea, absent bowel sounds, decrease Hemoglobin, shock= CT, blood or autotransfusion, rapid fluid admin 4.)Tension pneumothorax air in pleural space that does not escape: cyanosis, air hunger, **trach. Deviation, SQ emphysema, neck vein distention= need decompression, CT insert

****Asthma triggers: Gastroesophageal Reflux Disease (GERD)

1.) GERD more common in persons w/ asthma 2.) Reflux triggersbronchoconstriction; cause aspiration 3.) Asthma medications may worsen GERD: •β2 agonists (especially given orally), which are used to treat asthma, relax the lower esophageal sphincter ----------------------------------------------------- #β2 agonists (especially given orally), which are used to treat asthma, relax the lower esophageal sphincter, thus allowing stomach contents to reflux into the esophagus and possibly be aspirated into the lungs.

***Case Study: Tracheostomy PP 44-year-old man was intubated for respiratory distress following occupational exposure to unknown chemical. -Unable to be weaned off ventilator after 3 weeks -Tracheostomy is performed. -Discharged home on ventilator with weaning instructions -Scheduled for home health nursing 1.) What should you teach him and his family about care for the tracheostomy? 2.)What should you explain to him about eating, drinking, and talking? 3.)What are the potential complications of a tracheostomy?

1.) How to properly clean and suction his tracheostomy. 2.) Use of a speaking tracheostomy valve for talking. Eating and drinking can safely be performed as long as he is able to swallow without aspiration. 3.) Aspiration and obstruction

TB: Clinical Manifestations- TB

1.) LTBI - asymptomatic, no active disease 2.)Active pulmonary TB --Takes 2-3 weeks to develop symptoms --Initial dry cough becomes productive, more frequent --Fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats --Dyspnea (unusual) and hemoptysis: Late symptoms, advanced disease #People with LTBI have a positive skin test but are asymptomatic. ----------------------------------------------------- 1.) Can also present more acutely: --High fever --Chills, generalized flulike symptoms --Pleuritic pain --Productive cough --Adventitious breath sounds (crackles) 2.) Extrapulmonary TB manifestations dependent on organs infected #Sometimes TB has a more acute, sudden presentation. The patient may have a high fever, chills, generalized flulike symptoms, pleuritic pain, and a productive cough. Auscultation of the lungs may be normal or reveal crackles, rhonchi, and/or bronchial breath sounds. The clinical manifestations of extrapulmonary TB are dependent on the organs infected. For example, renal TB can cause dysuria and hematuria. Bone and joint TB may cause severe pain. Headaches, vomiting, and lympadenopathy may be present with TB meningitis. ------------------------------------------------- 1.) Immunosuppressed & older adults are less likely to have fever/signs of an infection --Carefully investigate respiratory problems in HIV patients --A change in cognitive function may be the only initial sign of TB in an older person #Immunosuppressed (e.g., HIV-infected) people and older adults are less likely to have fever and other signs of an infection. In patients with HIV, classic manifestations of TB such as fever, cough, and weight loss may be wrongly attributed to P. jiroveci pneumonia (PJP) or other HIV-associated opportunistic diseases. Clinical manifestations of respiratory problems in patients with HIV must be carefully investigated to determine the cause. A change in cognitive function may be the only initial presenting sign of TB in an older person.

***when to d/c a chest tube?

1.) Performed by MD or RN 2.) Chest tubes are removed when lungs are re-expanded/drainage has ceased: --Decreasing amounts of drainage **Lack of air-leak or bubbling in water seal chamber suggests expansion of lung --Tidaling in water seal chamber stops suggests expansion of lung **Verified via CXR**

TB: Case Study: 57-year-old homeless man was transported from shelter for having TB-like symptoms. -He has been coughing regularly and producing mucopurulent sputum. -Chest x-ray and AFB confirm diagnosis of TB. -Isolation and antibiotics started 1.) What is the primary nursing management for him? 2.) What hygiene measures can you teach him to minimize transmission? 3.)What other patient teaching should you do with him? 4.)What can you do to help ensure that he continues medications after discharge?

1.) Place him in airborne isolation, and begin drug therapy. 2.) Cover his nose and mouth with paper tissue every time he coughs, sneezes, or produces sputum. The tissues should be thrown into a paper bag and disposed of with the trash, burned, or flushed down the toilet. Emphasize careful hand washing after handling sputum and soiled tissues. If he needs to be out of the negative-pressure room, the patient must wear a standard isolation mask to prevent exposure to others. 3.) Emphasize the importance of complying with his medication regimen. 4.) Put him in contact with a public health agency to begin DOT.

Structures and Functions of Respiratory System

1.) Primary purpose of respiratory system: --> ****Gas exchange ****O2 & CO2 between atmosphere & blood 2.) Two parts of respiratory system: --Upper respiratory tract --Lower respiratory tract

*****Asthma triggers: Emotional Stress

1.) Psychological factors can worsen the disease process 2.) Extreme emotional expressions: •Crying, laughing, anger, fear •Hyperventilation & hypocapnia, which can cause airway narrowing 3.) Asthma attacks can trigger more panic/ anxiety ------------------------------------------------------- #Extreme emotional expressions (e.g., crying, laughing, anger, fear) can lead to hyperventilation and hypocapnia, which can cause airway narrowing.

Complications of PE

1.) Pulmonary infarction: --Alveolar necrosis and hemorrhage --Abscess --Pleural effusion 2.) Pulmonary hypertension: --Results from hypoxemia associated w/ massive or recurrent emboli --Causes right ventricular hypertrophy

***********What are the diagnostics used for TB?

1.) TB Skin testing: ID administration of tuberculin (Mantoux) --0.1 mL of tuberculin purified protein derivative (PPD) ID dorsal surface of forearm --Read by inspection & palpation @ 48- 72 hours --Presence of induration (not redness; raised hard mass) at injection site indicates development of antibodies secondary to exposure to TB **Reactions ≥15 mm considered (+), needs CXR **Reactions ≥5 mm considered (+) in immunocomp. --Sensitivity remains for life, and individual should not be tested again #The induration is measured, and, based on the size of the induration and the risk factors, an interpretation is made according to standards for determining a positive test reaction. An induration of 15 mm or more is considered positive in all low-risk individuals. Results for patients at higher risk would be considered positive if induration 10 mm or higher. Because the immunocompromised patient may have a decreased response to TST, even smaller induration reactions (≥5 mm) are considered positive. The figure shows a positive tuberculin skin test. This adolescent boy became infected as a result of living with and helping to care for a grandfather whose chronic "smoker's cough" was ultimately discovered to be a manifestation of chronic cavitary tuberculosis. He had a greater than 15-mm induration. The test is administered by injecting 0.1 mL of PPD intradermally on the dorsal surface of the forearm. The test is read by inspection and palpation 48 to 72 hours later for the presence or absence of induration. The indurated area (if present) is measured and recorded in millimeters with 0 for no induration. The reaction occurs 2 to 12 weeks after initial exposure to the organisms. ------------------------------------------ 1.) Tuberculin skin test (TST) Continued... --Two-step testing recommended for health care workers getting repeated testing and those with decreased response to allergens --Repeating TST may boost reaction #Some people who were previously infected with TB may have a waning immune response to the TST. This may result in a false negative result. However, repeating the TST may stimulate (boost) the body's ability to react to tuberculin in future tests. A positive reaction to a subsequent test could then be misinterpreted as a new infection, rather than the result of the boosted reaction to an old infection. To prevent misinterpretation in future testing, a two-step testing process is recommended for initial testing for health care workers (who get repeated testing) and for individuals who have a decreased response to allergens. A previously negative two-step TST ensures that any future positive results can be accurately interpreted as being caused by a new infection. ------------------------------------------------Newer stuff: 2.) Interferon-γ release assays (IGRAs) --Another screening tool for TB --T-SPOT, QuantiFERON-TB **Rapid results (2 hours) --More expensive than Mantoux Interferon-γ release assays (IGRAs) provide another screening tool for TB. These whole blood assays detect INF-γ released from T-cell lymphocytes in response to mycobacterial antigens. Examples of IGRAs include QuantiFERON-TB test and the T-SPOT. Test results are available in a few hours. IGRAs offer several advantages over the TST in that they require only one patient visit, are not subject to reader bias, have no booster phenomenon, and are not affected by prior BCG vaccination. (Bacille-Calmette-Guérin (BCG) vaccine) The cost of an IGRA is substantially higher than the TST. Current guidelines suggest that both tests are viable options and that selection should be based on context and reasons for testing. Neither IGRAs or TST can distinguish between LTBI ((Latent TB infection (LTBI) is a TB infection in a person who does not have active TB disease)) and active TB infection. LTBI can only be diagnosed by excluding active TB. (Post-primary, or reactivation TB, is defined as TB disease occurring 2 or more years after the initial infection. Individuals co-infected with HIV are at greatest risk for developing active TB.) ----------------------------------------------- 3.) Bacteriologic testing= definitive test **Required for diagnosis **Consecutive sputum samples obtained on 3 different days **Sputum examined for--> **acid-fast bacilli (AFB) --Culture results can take up to 8 weeks Treatment is warranted pending culture result --Can also examine samples from other suspected TB sites #The culture to grow the organisms for confirmatory diagnosis can take up to 8 weeks. ----------------------------------------------------- 4.) Chest x-ray: --If skin test is positive --Cannot make diagnosis solely on x-ray --Findings suggestive: Upper lobe infiltrates, cavitary infiltrates, & lymph node involvement

****What is the treatment of hemo/pneumothorax and pleural effusion?

1.) Tension Pneumothorax treatment: NEEDLE DECOMPRESSION- Insertion of large-bore needle into anterior chest wall at 4th or 5th intercostal space Chest tube insertion Releases trapped air 2.) Hemo/pneumothorax treatment: --Depends on severity --May resolve spontaneously Treatment : --Chest tubes (usually)*** --Thoracentesis (needle asp.) --Pleurodesis Procedure causes membranes around lungs to stick together. Prevents buildup of fluid in pleural space #Treatment of a pneumothorax depends on its severity and the nature of the underlying disease. If the patient is stable, and the amount of air and/or fluid accumulated in the intrapleural space is minimal, no treatment may be necessary as the condition may resolve spontaneously. The pleural space can also be aspirated with a large-bore needle. This procedure is called a thoracentesis. The most definitive and common form of treatment of pneumothorax and hemothorax is to insert a chest tube and connect it to water-seal drainage. Repeated spontaneous pneumothorax may need to be treated surgically by a partial pleurectomy, stapling, or pleurodesis to promote adherence of the pleurae to one another. Tension pneumothorax is a medical emergency, requiring urgent needle decompression followed by chest tube insertion to water-seal drainage.

***Asthma triggers: Exercise

1.)Exercise-induced asthma (EIA) or exercise- induced bronchospasm (EIB):****** --Induced/exacerbated by physical exertion --Occurs after vigorous exercise --****Pronounced with exposure to cold air ------------------------------------------------------ #Typically, EIA occurs after vigorous exercise, not during it (e.g., jogging, aerobics, walking briskly, climbing stairs). #Airway obstruction may occur as the result of changes in the airway mucosa caused by hyperventilation that occurs during exercise with either cooling or rewarming of air and capillary leakage in the airway wall.

***What is the interpretation of ABG's and treatment for abnormal ABG's?

ABG gives information regarding Overall oxygen status: -Acid-base status -Underlying cause of imbalances -Respiratory vs. metabolic -Body's ability to regulate pH -Compensated vs. uncompensated -Arterial puncture -Arterial catheter ---------------------------------------------------- Steps to interpretation of ABGs: -Evaluate pH -Acidosis or alkalosis? pH ^ or decreased -Analyze PaCO2 (Respiratory component) ^ or decreased is respiratory problem -Analyze HCO3 (Metabolic component) ^ or decreased is metabolic problem -Determine if PaCO2 or HCO3 match an alteration in pH (ROME-next slide) -Decide if the body is attempting to compensate for the pH change. -------------------------------------------------------- Possible Diagnostic Findings: Abnormal ABGs compensated respiratory acidosis: -Decreased PaO2, decreased SaO2, ^ PaCO2, polycythemia, pulmonary function tests showing expiratory airflow obstruction ie. (low FEV 1, low FEV 1/FVC, large RV), chest x-ray showing flattened diaphragm and hyperinflation or infiltrates -------------------------------------------------------- Monitor oxygenation status: -Assess breath sounds -Encourage slow deep breathing, coughing, position changes -Administer meds that promote airway patency *Orthopnec position or elevate HOB -Monitor for resp. muscle fatigue -^ fluid intake to liquefy secretions

**ABG case analysis use ROME

ABG results are as follows: pH 7.20 decreased =acidosis PaO2 81 mm Hg PaCO2 58 mm Hg ^ HCO3 25 mEq/L <-- --> decreased pH (acidosis), ^PaCO2 ROME Respiratory acidosis In this case, the decreased pH and decreased HCO3 indicate a metabolic acidosis. The decreased PaCO2 reflects compensation for the acidosis. Metabolic acidosis most commonly occurs in uncontrolled diabetes, but may also be caused by lactic acidosis, starvation, severe diarrhea, renal failure, or shock. Assessment findings may include drowsiness and confusion leading to coma; deep, rapid respirations (compensation); hypotension and arrhythmias; warm, dry, flushed skin; and nausea, vomiting, and abdominal pain. Determination of the underlying cause is necessary to treat the acidosis. Diabetic acidosis is treated with insulin to normalize glucose metabolism, and carbohydrate (glucose) is provided in the case of starvation. Dialysis may be used to treat renal failure, and other underlying causes are treated as appropriate

Adventitious Breath sounds

Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles. -Fine Crackles = rales -Coarse Crackles = rhonchi -Wheezes -Pleural friction rub

************Tracheostomy Safety: Trach dislodgement

Accidental dislodging: 1.)***IMMEDIATELY REPLACE TUBE!!! 2.) Spread tracheostomy opening 3.) Insert obturator into replacement tube: --Lubricated with saline poured over tip --Inserted at 45 degrees to neck --***REMOVE OBTURATOR !!!!!!!!!!!!!!!!! --***HYPEROXYGENATE! --***If insertion is successful, obturator is REMOVED IMMEDIATELY for airflow through the tube. ****IF TUBE CANNOT BE REPLACED*** --Assess level of respiratory distress --Minor dyspnea may be alleviated with semi-Fowler's position, O2 --Severe distress may progress to respiratory arrest. **CALL RRT/Code Blue --Cover stoma w/ sterile dressing & ventilate with bag-valve-mask until help arrives

Pneumonia Definition and Stats

Acute infection of lung caused by microbial organism 8th leading cause of death in United States #However, despite new antimicrobial agents, pneumonia is still common and is associated with significant morbidity and mortality. Pneumonia and influenza are the eighth leading cause of death in the United States, accounting for more than 56,000 deaths annually. The age groups 1 to 4 years old and over 65 years have the highest incidence of death from influenza and pneumonia.

Collaborative Care: Pneumonia: Nutritional Therapy

Adequate hydration Loosen secretions With caution in heart failure Hi-calorie, small, frequent meals #Hydration is important in the supportive treatment of pneumonia to prevent dehydration and loosen secretions. Individualize and carefully monitor fluid intake if the patient has heart failure. If the patient cannot maintain adequate oral intake, IV administration of fluids and electrolytes may become necessary. Weight loss often occurs in patients with pneumonia because of increased metabolic needs and difficulty eating due to shortness of breath and pleuritic pain. Small, frequent meals are easier for dyspneic patients to tolerate. Offer foods high in calories and nutrients.

Risk Factors: Pneumonia

Altered LOC Dysphasia Tube feedings Noxious substances inhalation Chronic disease, debilitating illness, HIV Bed rest, prolonged immobility Malnutrition Long term care resident Alcoholism Aging

Acute Laryngeal Edema: S&S/Causes/treatment

Causes: --Anaphylaxis (allergic reaction) --Inflammation --Injury --Post-extubation S/S's: --Hoarseness --Dyspnea (ominous sign) Action: ***Restore airway immediately! ***Intubate, tracheostomy ***Anaphylaxis: **Epinephrine, adrenal corticosteroids, ice collar (for neck surgeries, injuries).

**********What are the signs and symptoms of active TB?

Assess for: --Productive cough **Early morning is the ideal time to collect sputum specimens for AFB (acid-fast bacilli) --Night sweats --Afternoon temperature elevation --Weight loss --Pleuritic chest pain --Crackles over apexes of lungs #*If the patient has a productive cough, early morning is the ideal time to collect sputum specimens for an acid-fast bacillus smear. The acid-fast stain is a differential stain used to identify acid-fast organisms such as members of the genus Mycobacterium . Acid-fast organisms are characterized by wax-like, nearly impermeable cell walls; they contain mycolic acid and large amounts of fatty acids, waxes, and complex lipids.

More complications: Pneumonia

Atelectasis Collapsed, airless alveoli Usually clears w/ cough, deep breathing Empyema Purulent exudate in pleural cavity Requires antibiotics & drainage of exudate Pneumothorax Air collects in pleural space, lung collapses #Bacteremia is more likely to occur in pneumococcal pneumonia.

metabolic alkalosis

Base bicarbonate excess caused by Prolonged vomiting or gastric suction Gain of HCO3- Ingestion of baking soda Compensatory mechanisms Renal excretion of HCO3- Decreased respiratory rate to increase plasma CO2 (limited) 7.50-92-42-32

Pulmonary Fibrosis

Chronic, progressive inflammation and scar tissue formation in lung connective tissue Inhalation of noxious materials

alteration in acid base balance

Classification of imbalances: Acidosis or alkalosis Respiratory (CO2) or metabolic (HCO3) Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Pulmonary Fibrosis: Clinical manifestations/diagnosis/treatment

Clinical Manifestations: Exertional dyspnea Non-productive cough Inspiratory crackles Clubbing of fingers Diagnosis: CT shows PF (most definitive dx) PFTs show restrictive lung disease Lung biopsy helps differentiate Treatment: steroids, cytotoxic agents, antifibrotic agents, lung transplant Prognosis poor

What is pulmonary embolism (PE)?

Blockage of pulmonary arteries by: --Thrombus --Fat embolus --Air embolus or --Tumor tissue **Obstructs alveolar perfusion --Most commonly affects lower lobes --Mortality rate 30% untreated; treated, 8% --10% w/ massive PE **DIE** in 1st hour

************Know terminology of breath sounds and where normal breath sounds would be auscultated in the chest.

Bronchial --Heard over major airways (trachea) --Abnormally auscultated in pneumonia Bronchovesicular --Heard over mainstem bronchi, either side of trachea Vesicular --Heard over most of lung fields Absent breath sounds --Lobectomy, bronchial obstruction, large atelectasis, pleural effusion (fluid around lung)

Etiology and Pathophysiology of TB

Can be suspended in air for minutes to hours Small droplets, 1 to 5 μm in size NOT spread by touching, sharing food utensils, kissing, or other physical contact Transmission requires close, frequent, or prolonged exposure... Once inhaled, particles lodge in bronchiole and alveolus Local inflammatory reaction occurs Infection is then walled off and further spread is stopped (granulomas) Only 5-10% will develop active TB #The very small droplets, 1 to 5 μm in size, contain M. tuberculosis. Because they are so small, the particles remain airborne indoors for minutes to hours. Factors that influence the likelihood of transmission include (1) number of organisms expelled into the air, (2) concentration of organisms (small spaces with limited ventilation would mean higher concentration), (3) length of time of exposure, and (4) immune system of the exposed person.

*********PE: S&S/treatment

Clinical Manifestations: Slow or sudden onset: **Dyspnea**** --Tachypnea --Crackles --Wheezing --Cough --Hemoptysis --Hypoxemia --decreased PaO2 --decreased O2 sats. --Chest Pain --Tachycardia --Syncope --Change in LOC --Fever --------------------------------------------- Clinical Manifestations of **Massive** PE: ***Abrupt hypotension **Pallor **Severe dyspnea **Hypoxemia **Tachycardia **Right ventricular failure (cor pulmonale) **Mortality rate of massive is 33% ---------------------------------------------- Treatment: Prevention --Prevention is key --TEDs --SCDs --Early ambulation --Prophylactic anticoagulation Treatment: Confirmed PE: Goals of treatment --Prevent further thrombi --Prevent further embolization to pulmonary system --Provide cardiopulmonary support --Supportive care varies according to severity --Oxygen → mechanical ventilation --Pulmonary toilet --Fluids, pressors, diuretics, analgesics #To reduce mortality risk, treatment is begun as soon as PE is suspected. The objectives are to (1) prevent further growth or multiplication of thrombi in the lower extremities, (2) prevent embolization from the upper or lower extremities to the pulmonary vascular system, and (3) provide cardiopulmonary support if indicated. Supportive therapy for the patient's cardiopulmonary status varies according to the severity of the PE. O2 can be given via mask or cannula, and the concentration is determined by ABG analysis. In some situations, endotracheal intubation and mechanical ventilation are necessary to maintain adequate oxygenation. Respiratory measures such as turning, coughing, deep breathing, and incentive spirometry are important to help prevent or treat atelectasis. If manifestations of shock are present, IV fluids are administered followed by vasopressor agents as needed to support perfusion. If heart failure is present, diuretics are used. Pain resulting from pleural irritation or reduced coronary blood flow is treated with opioids (usually morphine).

Asthma triggers: Air Pollutants

Can trigger asthma attacks: -Cigarette or wood smoke -Vehicle exhaust -Concentrated pollution ------------------------------------------------ #In heavily industrialized or densely populated areas, climatic conditions often lead to concentrated pollution in the atmosphere, especially with thermal inversions and stagnant air masses. #Cigarette smoking is associated with an accelerated decline of lung functioning in a person with asthma, increases the severity of the disease, may cause the patient to be less responsive to treatment, and reduces the chance of the asthma being controlled.

respiratory alkalosis

Carbonic acid deficit caused by Hyperventilation "blows off" too much CO2 Anxiety, CNS disorders, mechanical over-ventilation or increase ventilation rate Compensation Rarely occurs when acute Renal compensation if chronic pH 7.55-pO2 85-pCO2 30-HCO3 24

Respiratory Acidosis

Carbonic acid excess caused by Buildup of carbon dioxide (PaCO2) Hypoventilation Respiratory failure Compensation Kidneys conserve HCO3- and secrete H+ into urine (in 24 hrs) Ex.: pH: 7.28decrease- PaO2: 72- PaCO2: 56^- HCO3: 24

************Regarding tracheostomy suctioning: Describe the procedure

Care includes: --Suctioning to remove secretions (patency) --Provision of O2 --Monitoring oxygenation status --Titrating O2 --Cleaning around stoma --Changing securing device --Providing inner cannula care ----------------------------------------------- 1.) Assess need for suctioning: --Breath sounds, ineffective cough, decreased O2 sat. 2.) Obtain suctioning equipment: --STERILE suction catheter kit or inline suction, sterile saline, suction source, goggles, PPE --Suction set at 120-150 mm/Hg w/ tubing OCCLUDED --Wash hands and open kit w/ sterile technique 3.) Apply O2 saturation monitor: --Monitor for hypoxia throughout procedure 4.) High Fowler's position 5.) Hyperoxygenate prior, wash hands, don goggles #1. Assess the need for suctioning q2hr. Indications include coarse crackles or rhonchi over large airways, moist cough, increase in peak inspiratory pressure on mechanical ventilator, and restlessness or agitation if accompanied by decrease in SpO2 or PaO2. Do not suction routinely or if patient is able to clear secretions with cough. 2. If suctioning is indicated, explain procedure to patient. 3. Collect necessary sterile equipment: suction catheter (no larger than half the lumen of the tracheostomy tube), gloves, sterile water, cup, and drape. If a closed tracheal suction system is used, the catheter is enclosed in a plastic sleeve and reused (see Fig. 26-4). No additional equipment is needed. 4. Check suction source and regulator. Adjust suction pressure until the dial reads −120 to −150 mm Hg pressure with tubing occluded. 5. Assess SpO2 and heart rate and rhythm to provide baseline for detecting change during suctioning. 6. Wash hands and put on goggles. 7. Use sterile technique to open package, fill cup with sterile water, put on sterile gloves, and connect catheter to suction tubing. Designate one hand as contaminated for (1) connecting and disconnecting the tubing at the suction catheter, (2) using the resuscitation bag, and (3) operating the suction control. Suction sterile water through the catheter to test the system. 8. Provide preoxygenation for a minimum of 30 seconds by (1) adjusting ventilator to deliver 100% O2, (2) using a reservoir-equipped manual resuscitation bag (MRB) connected to 100% oxygen, or (3) asking the patient to take 5-6 deep breaths while administering oxygen. The method chosen will depend on the patient's underlying disease and acuity of illness. The patient who has had a tracheostomy for an extended period of time and is not acutely ill may be able to tolerate suctioning without use of an MRB or the ventilator. 9. Gently insert catheter without suction to minimize the amount of oxygen removed from the lungs. Insert the catheter to the point where the patient coughs, resistance is met, or 0.5-1.0 cm beyond the length of the artificial airway. Withdraw the catheter 0.5-1.0 cm before applying suction to prevent trauma to the carina. 10. Apply suction intermittently, while withdrawing catheter in a rotating manner. If secretion volume is large, apply suction continuously. Suction should be applied for as short amount of time as possible to minimize decreases in arterial oxygenation levels. 11. Limit suction time to 10 seconds. Discontinue suctioning if heart rate decreases from baseline by 20 beats/min, increases from baseline by 40 beats/min, a dysrhythmia occurs, or SpO2 decreases to less than 90%. 12. After each suction pass, oxygenate for at least 30 seconds with 5-6 breaths by ventilator, MRB, or deep breaths with oxygen. 13. Rinse catheter with sterile water between suction passes. 14. Repeat procedure until airway is clear. Limit insertions of suction catheter to as few as needed. If airway is not clear after 3 suction passes, allow the patient to rest before additional suctioning. 15. Return oxygen concentration to prior setting. 16. Rinse catheter and suction the oropharynx or use mouth suction. 17. Dispose of catheter by wrapping it around fingers of gloved hand and pulling glove over catheter. Discard equipment in proper waste container. 18. Auscultate to assess changes in lung sounds. Record time, amount, and character of secretions and response to suctioning. ------------------------------------------------- Suctioning Continued: --Insert catheter, **WITHOUT suction, the length of the airway (cough) --Apply suction ****intermittently while **withdrawing, no > 10 seconds --After each suctioning pass, monitor O2 sat, oxygenate & clear suction catheter --Suction until lungs clear (auscultate lungs) or O2 saturations improve --Maintain sterility throughout --Red-bag disposal of equipment

**********What are some nursing interventions for pneumonia?

Care of patients with pneumonia: --Frequent pulmonary assessments --Monitor response to treatment --******Prompt initiation of antibiotics --Oxygen therapy --Hydration --Hi-calorie, small, frequent meals --Breathing exercises: IS --Reposition q. 2 hrs --Mobilization Pulmonary Assessments: Inspection, Palpation, percussion, auscultation

*******What is the antibiotic therapy and administration guidelines used for pneumonia?

*****Inpatient: ***Fluoroquinolones : Avelox, Levaquin **Macrolides: EES (erythromycin), Zithromax, Biaxin ***B-Lactam: Amoxicillin, Augmentin, Cefzin, Rocephin ****Outpatient: -Fluoroquinolones -Macrolides -B-Lactams -Doxycycline ------------------------------------------------------ Antibiotic therapy: --Prompt treatment is essential --Antivirals for influenza pneumonia (e.g., ganciclovir [Cytovene], foscarnet [Foscavir], cidofovir [Vistide]) --Repeat chest x-ray (✓for resolution) (obtain x-ray in 6-8 weeks to assess for resolution) In addition to antibiotic therapy: --Supportive care (Individualized to patients needs) --Oxygen therapy for hypoxemia --Analgesics for chest pain --Antipyretics (aspirin or acetaminophen)for significantly elevated temperatures --Individualize rest and activity #Prompt treatment with the appropriate antibiotic almost always cures bacterial and mycoplasmal pneumonia. In uncomplicated cases, the patient responds to drug therapy within 48 to 72 hours. Indications of improvement include decreased temperature, improved breathing, and reduced chest pain. Abnormal physical findings can last more than 7 days. A repeat chest x-ray is obtained in 6-8 weeks to assess for resolution. In addition to antibiotic therapy, supportive measures are individualized to the patient's needs. These may include oxygen therapy to treat hypoxemia, analgesics to relieve the chest pain, and antipyretics such as aspirin or acetaminophen for significantly elevated temperature. ------------------------------------------ --Start w/ empiric antibiotic therapy --Based on likely infecting organism and risk factors for MDR organisms --Minimum 5 days of antibiotic therapy --Should see improvement in 3-5 days --Start w/ IV antibiotics, then switch to oral therapy as soon as patient stable #Once the pneumonia is classified, the health care provider will base empiric therapy on the likely infecting organism. For HAP, VAP, and HCAP, empiric antibiotic therapy is based on whether the patient has risk factors for MDR organisms. The prevalence and resistance patterns of MDR pathogens vary among localities and institutions. Therefore the antibiotic regimen needs to be adapted to the local patterns of antibiotic resistance. Appropriate initial antibiotic therapy for HAP, VAP, and HCAP may also vary markedly according to the hospital site. Multiple regimens exist, but all should include antibiotics that are effective against both resistant gram-negative and gram-positive organisms. Clinical improvement usually occurs between 3 and 5 days. Patients who deteriorate or fail to respond to therapy will require aggressive evaluation to assess for noninfectious etiologies, complications, other coexisting infectious processes, or pneumonia caused by a drug-resistant pathogen. IV antibiotic therapy should be switched to oral therapy as soon as the patient is hemodynamically stable, improving clinically, able to ingest oral medication, and has a normally functioning GI tract. Patients on oral therapy do not need to be observed in the hospital and can be discharged to home. Total treatment time for patients with CAP should be a minimum of 5 days, and the patient should be afebrile for 48 to 72 hours. Longer treatment time may be needed if initial therapy was not active against the identified pathogen or complications occur. ---------------------------------------------------- Guidelines: --***Take full course of antibiotics --✓Drug-drug and drug-food interactions --Adequate rest to recover --Adequate hydration --6-10 glasses H2O/day unless contraindicated --Avoid alcohol and smoking --Cool mist humidifier --Chest x-ray for follow up --Vaccinations

Sleep Apnea: Concerns/Diagnostic/Interventions

****Concerns: --Safety: falling asleep while driving. --Avoid sedatives, alcohol (compound problem) & sleeping on back. --------------------------------------------------- ***Diagnosis: overnight sleep study (polysomnography) --------------------------------------------------- ***Interventions: --Weight loss. --Support groups. --Avoid supine position. --Patients don't breathe as well (tongue falls back) ***CPAP (continuous positive airway pressure):nasal or mask ~~Maintains pressure in alveoli after exhalation. ~~Teaching: mask irritates.May have to add humidifier. ***BIPAP (bi-level PAP-higher pressure during inhalation, lower during exhalation) ***Surgical: excise tonsilar areas, uvular area. ~~Tracheostomy ~~Uvulopalatopharyngoplasty (UVPP) removes obstructing tissue. ~~Overnight stay for surgery & usually home next day

Sleep Apnea: S&S

****S/S's: --Frequent awakening at night (200-400x/night). --Insomnia. --Excessive daytime sleepiness. --Loud snoring (snort-startle-wake up-breath). --Morning headaches (elevated CO2 levels). --Personality changes. --Irritability. --Hypercapnic: elevated CO2 & decreased O2

**********What are the nursing actions for prevention of VAP?

***Adherence to ventilator bundle to prevent VAP ***HOB 45°, ***Excellent mouth care ***Sedation vacation ***PUD & VTE prophylaxis

Manifestations Massive PE

**Abrupt hypotension **Pallor **Severe dyspnea **Hypoxemia **Tachycardia **Right ventricular failure (cor pulmonale) **Mortality rate of massive is 33%

Clinical Manifestations of Asthma: Cough variant

Cough variant asthma • Cough is only symptom • Bronchospasm not severe enough to cause airflow obstruction • Cough may be nonproductive • If productive, secretions may be thick, white, or gelatinous, making removal difficult The cough may be nonproductive. Secretions may be thick, tenacious, white, gelatinous mucus, which makes their removal difficult.

Sleep Apnea: Causes: Definition/causes

Definition: --Air flow cessation for periods of time -------------------------------------------------- Causes: --Anatomical: uvula is abnormal & obstructs airway --Neural: Medulla Oblongata, etc. --Hormonal imbalance: Men more than women (10x) Truncal obesity (waist > hips)

Bronchospasm: Definition/treatment

Definition: --Increased muscle tone with closure of the small airways ------------------------------------------------------- Treatment: --O2, bronchodilators, ^HOB , remove cause (allergic?) --May require airway management (intubation or tracheostomy)

Asthma: Collaborative Care Goals

Desired therapeutic outcomes/goals: Control/eliminate symptoms/exacerbations. Restore normal activities. Attain normal lung function. Reduce side effects of medications.

*******airway protection and conscious sedation?

Endoscopic Examinations: --Bronchoscopy- bronchi visualized via fiber-optic tube --Diagnosis, biopsy specimens **Conscious sedation: -Assess gag reflex post procedure

Types of Pneumonia :Aspiration Pneumonia

Entry of secretions into lower airway Stomach, mouth contents-->trachea/lungs Suppressed gag & cough reflexes Risk factors for aspiration pneumonia Difficulty swallowing (dysphagia), dysphasia NG tubes w/ or w/o tube feeding Decreased LOC Seizure, anesthesia, head injury, stroke, alcoholism Aspirated material triggers inflammatory response Bacterial infection most common Empiric therapy based on Probable causative organism Where infection acquired Severity of illness Aspiration of acid gastric contents initially causes chemical (noninfectious) pneumonitis

metabolic acidosis

Excess carbonic acid or base bicarbonate deficit caused by Ketoacidosis (DKA) Lactic acid accumulation (shock) Severe diarrhea Loss of bicarbonate Kidney disease Kidneys lose ability to reabsorb bicarbonate/secrete hydrogen ions pH 7.25-pO2 88-pCO2 40-HCO3 18

Evaluation: TB

Expected outcomes: --Complete resolution of disease --Normal pulmonary function --Absence of any complications --No transmission of TB

Patient teaching regarding peak flow meter reading in green zones?

GREEN: 80% PFER. Stay on meds

Planning: TB

Goals: --Comply with therapeutic regimen. --Have no recurrence of disease. --Have normal pulmonary function. --Prevent spread of disease. Ultimate goal in the US is eradication: --Screening programs in high-risk groups --Follow-up on (+) TB skin test --Treatment of LTBI decrease (carriers) --Reportable disease --Public health authorities --Identify contacts of patient with TB --Social determinants TB: decrease transmission

Pneumonia: Planning: Goals

Goals: No hypoxia Clear breath sounds Normal breathing patterns Normal chest x-ray No complications related to pneumonia

***ABGs: HCO3 (bicarbonate)

HCO3 is a H+ buffer Manufactured by liver & pancreas & regulated by kidneys Kidneys: Excrete/reabsorb HCO3 to maintain pH In alkaline states, kidneys retain H+ In acid states, kidney excretes H+ Normal = 22-26 Metabolic component of acid-base balance Slower acid/base regulation

Pneumonia: Nursing Implementation: health promotion

Health Promotion: Good health habits Teaching to maintain natural resistance Hygiene, nutrition, rest, regular exercise Cough or sneeze into elbow, not hand Avoid cigarette smoke Prompt treatment of URIs Influenza and pneumococcal vaccination #Good health habits can reduce the risk of pneumonia. It is important to teach individuals to practice good health habits, such as frequent hand washing, proper nutrition, adequate rest, regular exercise, and coughing or sneezing into the elbow rather than hands. Avoidance of cigarette smoke is one of the most important health-promoting behaviors. If possible, people should avoid exposure to people with URIs. If a URI occurs, it requires prompt attention with supportive measures (e.g., rest, fluids). If symptoms persist for longer than 7 days, the person should seek medical care. Encourage those at risk for pneumonia (e.g., the chronically ill, older adult) to obtain both influenza and pneumococcal vaccines.

Adventitious Breath Sounds: Wheezes

High or low pitched musical sounds heard on inspiration or expiration or both Air passages are constricted and air is having trouble passing in and out. Asthma

adventitious breath sound: Fine crackles= rales

High pitched popping sounds heard during inspiration Indicates that there are collapsed alveoli or fluid in the alveoli Pulmonary edema, atelectasis, emphysema

***What is the patient teaching regarding peak flow meter readings of green/yellow/red zones?

Important patient teaching • Measure peak flow at least daily • Daily asthma action plan according to PFER --------------------------------------------------- • GREEN: 80% PFER. Stay on meds** Peak flow results (PEFR): --> Green Zone -Usually 80% to 100% of personal best ***Remain on medications -------------------------------------------------- •YELLOW: 50-80% PEFR. Peak flow results (PEFR): -->Yellow Zone -Usually 50% to 80% of personal best -Indicates caution -Something is triggering asthma ***Use rescue inhaler (Albuterol) --------------------------------------------------- • RED: 0-50% PEFR- Peak flow results (PEFR): Red Zone 50% or less of personal best ***Indicates serious problem ***Definitive action must be taken with health care provider pt teaching: Important patient teaching --Seek medical attention for bronchospasm or when severe side effects occur. **RED ZONE --Demonstrate correct administration of inhaled medications

Types of Pneumonia:Opportunistic Pneumonia

In people w/ weakened immune system Severe protein-calorie malnutrition Immune deficiencies Chemotherapy/radiation recipients Long-term corticosteroid therapy Caused by microorganisms that do not normally cause disease Pneumocystis jiroveci (formerly carinii) and cytomegalovirus (CMV). Liberace had CMV and AIDS. Pneumocystis jiroveci pneumonia (PJP) Most common cause of pneumonia in HIV+ Onset slow and subtle Diffuse bilateral infiltrates to massive consolidation Can be life-threatening Spreads to other organs Treat with trimethoprim/sulfamethoxazole (Bactrim, Septra) IV or orally Cytomegalovirus (CMV) pneumonia Viral pneumonia Herpes virus Most asymptomatic Mild to severe disease Life-threatening in immunosuppressed Treat w/ antiviral medications & high-dose immunoglobulin ganciclovir [Cytovene], foscarnet [Foscavir], cidofovir [Vistide]

ABG results are as follows: pH 7.50 PaO2 85 mm Hg PaCO2 28 mm Hg HCO3 - 24 mEq/L Describe a patient who would have these ABGs, including history, assessment, and treatment.

In this case, the increased pH and decreased PaCO2 indicate a respiratory alkalosis. The normal HCO3 reflects no compensation for the alkalosis. Respiratory alkalosis most commonly occurs with hypoxemia from acute pulmonary disorders. Anxiety, CNS disorders, and mechanical over-ventilation also increase the ventilation rate, leading to respiratory alkalosis. Assessment findings may include tingling and numbness of the fingers, restlessness, hyperreflexia, tetany, headache, dizziness, confusion, tachycardia, dysrhythmias, nausea, vomiting, and epigastric pain. Determination of the underlying cause is necessary to treat the alkalosis. Having the patient rebreathe into a paper bag can increase CO2 retention and thus decrease the pH. Correction of hypoxemia with oxygen therapy and bronchodilators can also be useful.

Pneumonia: Nursing Diagnoses

Ineffective breathing pattern Ineffective airway clearance Acute pain Activity intolerance Impaired gas exchange

What is TB?

Infectious disease caused by Mycobacterium tuberculosis Lungs most commonly infected 2 Billion people infected worldwide 1/3 of world's population has TB Leading cause of death in patients w/ HIV/AIDs Prevalence is decreasing in the US

Acute Bronchitis

Inflammation of bronchi in lower respiratory tract Occurs after viral infection or URI 10-20 day cough Mucoid, purulent sputum H/A, malaise, SOB, fever CXR is diagnostic Treatment: supportive Fluids, rest, antiinflammatory meds, cough supp.

Pathophysiology of asthma: early phase

Inflammation: early-phase response 30-60 **min. after exposure to allergen Vascular congestion Edema formation Production of thick mucous Bronchial muscle spasm Thickening of airway walls

Antibiotic therapy for pneumonia

Inpatient Fluoroquinolones : Avelox, Levaquin Macrolides: EES (erythromycin), Zithromax, Biaxin B-Lactam: Amoxicillin, Augmentin, Cefzin, Rocephin Outpatient Fluoroquinolones Macrolides B-Lactams Doxycycline

***Droplet Precautions for Tb:

Large, heavy particle Doesn't travel in air current Trans. via conjunctiva, nose , mouth, mucous membranes Reg. surgical mask, gown, glove, goggle, private room Influenza, pneumonia

Complications of Asthma: Life-Threatening

Life-threatening asthma • Too dyspneic to speak • Perspiring profusely • Drowsy/confused • Require hospital care / ICU • Peak flow is < 25% of personal best • Breath sounds difficult to hear: no wheezing w/ airflow exceptionally limited. Prepare to intubate!! The breath sounds may be very difficult to hear, and no wheezing is apparent as the airflow is exceptionally limited. Peak flow is less than 25% of the personal best.

***What is the action and side effects of common LABA medications?

Long-acting β2-Adrenergic Agonist Drugs (LABA) --Long term control of moderate to severe asthma --Taken daily, add to ICS, never used as monotherapy Prevention of symptoms: --Decrease the need for SABAs Salmeterol (Serevent) and formoterol (Foradil)

adventitious breath sounds: pleural friction

Low-pitched grating sound sounds like two pieces of leather rubbing against one another Indicates that the pleura are inflamed Pleuritis

Adventitious Breath Sounds: Course crackles= ronchi

Low-pitched, moist sounds (mucus rolling around) May clear up with coughing heard on inspiration and expiration Bronchial infection, pneumonia

structures and function of respiratory system: Lower Respiratory Tract

Lower Respiratory Tract (past carina) Bronchi R main stem straighter Bronchioles Alveolar ducts Alveoli Lung lobes 2 left 3 right The lower respiratory tract consists of the bronchi, bronchioles, alveolar ducts, and alveoli. With the exception of the right and left mainstem bronchi, all lower airway structures are located inside the lungs. Once air passes the carina, it is in the lower respiratory tract. The right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. For this reason, aspiration is more likely to occur in the right lung than in the left lung. The right lung is divided into three lobes (upper, middle, and lower) and the left lung into two lobes (upper and lower). Carina is where trachea divides into 2 bronchi Alveolar sacs : 1° site of gas exchange in lungs 300 million in each lung

Pneumonia: Etiology

Lung defense mechanisms become incompetent, overwhelmed ↓ Cough/epiglottal reflexes allow aspiration Mucociliary escalator mechanism impaired Pollution Cigarette smoking Upper respiratory infections Tracheal intubation Aging Chronic diseases decreases immune system Leukemia, alcoholism, & diabetes mellitus #Normally, the airway distal to the larynx is sterile because of protective defense mechanisms. These mechanisms include filtration of air, warming and humidification of inspired air, epiglottis closure over the trachea, cough reflex, mucociliary escalator mechanism, secretion of immunoglobulin A, and alveolar macrophages.

***ABGs: PaCO2

Lungs expel CO2 during ventilation, helping maintain pH CO2 carried to lungs by blood Normal = 35-45 Respiratory component of acid/base balance Fast regulation of pH

Clinical Manifestations of Pneumonia

Most common: Cough Fever, shaking chills Dyspnea, tachypnea Pleuritic chest pain Green, yellow, or rust-colored sputum ##The most common presenting symptoms of pneumonia are cough, fever, shaking chills, dyspnea, tachypnea, and pleuritic chest pain. The cough may be or may not be productive. Sputum may appear green, yellow, or even rust-colored (bloody). Viral pneumonia may initially present as influenza, with respiratory symptoms appearing and/or worsening 12 to 36 hours after onset. The older or debilitated patient may not have classic symptoms of pneumonia. Confusion or stupor (possibly related to hypoxia) may be the only finding. Hypothermia, rather than fever, may also be noted with the older patient. Nonspecific clinical manifestations include diaphoresis, anorexia, fatigue, myalgias, headache, and abdominal pain. Nonspecific: Diaphoresis, N/V/D, anorexia, fatigue, myalgia, headache, sore throat, fever Physical examination findings Bronchial breath sounds Fluid within lung transmits sound better Crackles/rhonchi (fluid in small & lg. airway) Change in mentation (older/ debilitated) This manifestation pattern is related to infection with S. pneumoniae and H. influenzae.

The Problem With Pneumonia

Multidrug-resistant (MDR) organisms are major problem in treatment Staphylococcus aureus (MRSA) Gram-negative bacilli Virulence severely limits appropriate antibiotics Risk factors History of antibiotic use Immunosuppression Advanced age Prolonged mechanical ventilation ##A major problem in treating pneumonia today is the development of multidrug-resistant (MDR) organisms. Primary culprits include methicillin-resistant Staphylococcus aureus and gram- negative bacilli. Antibiotic susceptibility tests can identify MDR organisms. The virulence of these organisms can severely limit the available and appropriate antimicrobial therapy. MDR organisms can also increase the morbidity and mortality risks associated with pneumonia. (Chapter 14 discusses MDR organisms.)

**Oxygen Delivery Systems: What are the levels of O2 delivery for each?

Nasal cannula. The fraction of inspired oxygen (FiO2) varies depending on the flow of oxygen in L/min and the rate and depth of the patient's breathing. FiO2: 24% to 38% - Flow: 1 to 2 L FiO2: 30% to 35% - Flow: 3 to 4 L FiO2: 38% to 44% - Flow: 5 to 6 L Face Tent: Delivers oxygen concentrations of 28% to 100% with flow rates from 8 to 12 L/min. Partial and Non-Rebreathing Masks. FiO2: 60% to 100% - Flow: 6 to 15 L Simple Face Mask: FiO2: 35% to 65% - Flow: 8 to 12 L Venturi Mask: Delivers specific, precise O2 concentrations from 24% to 60% FiO2 delivered depends on flow rate and/or entrainment port size Tracheostomy collar: Connects to oxygen source w/ large-bore tubing. Flow rate is usually set at 10 L/min, w/ nebulizer set at the appropriate oxygen concentration Humidification

****Oxygen Delivery Systems: What % O2 is room air?

Normal 80 to 100 on 21% oxygen (room air) The concentration of oxygen on room air is 21%

*******What is the terminology of breath sounds and where adventitious (abnormal) breath sounds would be auscultated in the chest.

Normal breath sounds: ***Bronchial Heard over major airways (trachea) Abnormally auscultated in pneumonia ***Bronchovesicular Heard over mainstem bronchi, either side of trachea ***Vesicular Heard over most of lung fields ***Absent breath sounds Lobectomy, bronchial obstruction, large atelectasis, pleural effusion (fluid around lung) Adventitious breath sounds: *****Wheeze --Narrowed airways --Bronchospasm, asthma, airway obstruction ***Rhonchi --Fluid, secretions in **larger** airways --COPD, cystic fibrosis, pneumonia ***Crackles (rales) --Fluid in **small** airways --Pneumonia, pulmonary edema/fibrosis --Loss of lung volume- atelectasis

structures and function of respiratory system: Upper Respiratory Tract

Nose Mouth Pharynx Epiglottis Larynx Trachea The upper respiratory tract includes the nose, mouth, pharynx, epiglottis, larynx, and trachea. Air enters into the respiratory tract through the nose. The nasal cavity connects with the pharynx, a tubular passageway that is subdivided into three parts: the nasopharynx, the oropharynx, and the laryngopharynx. The nose functions to protect the lower airway by warming and humidifying air and filtering small particles before air enters the lungs. Olfactory nerve endings, located in the roof of the nose, are responsible for the sense of smell. Air moves through the oropharynx to the laryngopharynx. It then travels through the epiglottis to the larynx before moving into the trachea. The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing. This prevents solids and liquids from entering the lungs. The vocal cords are located in the larynx. Vibrational sounds are made during respiration leading to vocalization. Air passes through the glottis, the opening between the vocal cords, and into the trachea. The trachea is a cylindric tube about 5 inches (10 to 12 cm) long and 1 inch (1.5 to 2.5 cm) in diameter. U-shaped cartilages keep the trachea open but allow the adjacent esophagus to expand for swallowing. The trachea bifurcates into the right and left mainstem bronchi at a point called the carina. The carina is located at the level of the manubriosternal junction, also called the angle of Louis. The carina is highly sensitive, and touching it during suctioning causes vigorous coughing.

TB: Factors that influence likelihood of transmission

Number of organisms expelled into air Concentration of organisms (small spaces with limited ventilation -->higher concentration) Length of time of exposure Immune system of the exposed person

*****What is the discharge teaching for a patient with Epistaxis?*****

Nursing Management: --Keep patient quiet --Place in sitting position **Apply direct pressure by pinching soft lower portion of nose for 15 min. --Partially insert gauze into bleeding nostril --Vasoconstrictive agents used locally --Cauterization: ~~Silver nitrate --Anterior packing: ~~Nasal tampon w/ vasoconstrictives like lidocaine, cocaine --Monitor respiratory status --Monitor for aspiration --Monitor LOC --Monitor for infection --Pain management Teach pt: *****Avoid vigorous nose blowing, straining or heavy lifting x 6 weeks ***Avoid ASA containing meds, NSAIDS ***Packing removed by HCP in several days

PE: Nursing interventions & Drug Therapy

Nursing Management: --Bed rest in semi-Fowler's facilitates breathing --Maintain IV --Administer O2, ABGs --Anticoagulants, thrombolytics --Observe for side effects (bleeding) --Monitor PTT, INR --Monitor vitals --Cardiac monitoring --Assess lung sounds --------------------------------------------- Drug Therapy: 1.) Anticoagulation: --Unfractionated IV heparin --Low-molecular-weight heparin (LMWH) ~Lovenox --Warfarin (Coumadin) ~Within 1st 24 hours for 3-6 months. ~Titrate to INR ~Alternative: Eliquis, Pradaxa 2.) Fibrinolytic agents: --Tissue plasminogen activator (tPA) Alteplase (Activase) ##Immediate anticoagulation is required for patients with PE. Subcutaneous administration of low-molecular-weight heparin (LMWH) (e.g., enoxaparin [Lovenox]) has been found to be safer and more effective than unfractionated heparin. It is the recommended choice of treatment for patients with nonmassive PE. Unfractionated intravenous heparin can be as effective but is more difficult to titrate to therapeutic levels. Monitoring the aPTT is not necessary or useful when using LMWH. Warfarin (Coumadin) should be initiated within the first 3 days of heparinization and is typically administered for 3 to 6 months. Fibrinolytic agents, such as tissue plasminogen activator (tPA) or alteplase (Activase), dissolve the pulmonary embolus and the source of the thrombus in the pelvis or deep leg veins, thereby decreasing the likelihood of recurrent emboli. Indications for thrombolytic therapy in PE include hemodynamic instability and right ventricular dysfunction. ----------------------------------------------------- Surgical Therapy: --Pulmonary embolectomy: ~For massive PE ~Has 50% mortality rate ***Rarely used --IVC (inferior vena cava) filter prevents clots in the pulmonary system

Organisms that cause pneumonia reach the lung by what THREE METHODS?

Organisms that cause pneumonia reach the lung by three methods: --Aspiration of normal flora from the nasopharynx or oropharynx. Many organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults. --Inhalation of microbes present in the air. Examples include Mycoplasma pneumoniae and fungal pneumonias. --Hematogenous spread from a primary infection elsewhere in the body. An example is Streptococci and Staphylococcus aureus from infective endocarditis.

Asthma: What is a peak flow meter?

PEFR: Peak expiratory flow rate Measures how well pt. can exhale/move air Helps to gauge need for bronchodilators

*****What are some asthma treatment goals regarding peak flows and o2 saturations?

PEFR: Peak expiratory flow rate: --Measures how well pt. can exhale/move air --Helps to gauge need for bronchodilators ------------------------------------------------- Acute Asthma Exacerbation: Treatment depends upon severity: • Mild, moderate, severe or life threatening • Severity measured w/ peak flow rates • Correct hypoxia/improve ventilation • **Rescue plan: bronchodilator using SABA • 2-4 puffs albuterol q. 20 min. x 3 for rapid sx control • O2 therapy/pulse oximetry/ABGs in severe cases • ***GOAL: Keep PaO2 of at least 60 mm Hg or O2 saturation greater than 90% ------------------------------------------------------ Severe & Life Threatening Asthma attack treatment: --Correct hypoxemia/improve ventilation --100% O2; Continuous O2 sat. monitoring: **Keep O2 sat. 90% or > or PaO2 of at least 60 mm Hg**** --Continuously nebulized SABA --Inhaled ipratropium (Atrovent) used w/ SABA --IV corticosteroids for pts who do not respond to SABA: ~IV MgSO4 is given as a bronchodilator With peak flow <40%

**ABGs: PaO2

Partial pressure of oxygen dissolved in the arterial blood Oxygen carrying capacity Normal 80 to 100 on 21% oxygen (room air)

Even more complications: Pneumonia

Pericarditis Spread of microorganism to heart Meningitis S. pneumoniae Patient disoriented, confused, or somnolent should have lumbar puncture (LP) Sepsis Acute respiratory failure Leading cause of death Lung damage prevents O2/CO2 exchange

Complications of Pneumonia

Pleurisy Inflammation of pleura Pleural effusion Transudate fluid in pleural space Usually is sterile and reabsorbed in 1 to 2 weeks or may require thoracentesis Absent or distant breath sounds Bacteremia Bacterial infection in the blood #Pleural effusion develops in 40% of hospitalized patients with pneumococcal pneumonia.

Collaborative Care: Pneumonia: pneumococcal vaccine

Pneumococcal vaccine: To prevent S. pneumoniae (pneumococcus) pneumonia Indicated for those at risk Age 65 or older Age 2-64 years w/ long-term health problem or immunosuppression Age 19-64 who smoke or have asthma Live in nursing homes or long-term care facility #Pneumococcal vaccine is used to prevent S. pneumoniae (pneumococcus) pneumonia. Vaccination is recommended for Persons age ≥65 yr Persons age 2-64 yr with long-term health problem (e.g., chronic cardiovascular disease, chronic pulmonary disease, sickle cell disease, diabetes mellitus, alcoholism, cirrhosis, leaks of cerebrospinal fluid, or cochlear implant) or who have a disease or condition that lowers the body's resistance to infection (e.g., Hodgkin's disease, leukemia, lymphoma, kidney failure, multiple myeloma, HIV infection, nephrotic syndrome; those receiving immunosuppressive chemotherapy, radiation therapy, or long-term corticosteroids; asplenia; and after organ or bone marrow transplantation) Persons age 19-64 yr who smoke cigarettes or have asthma Persons living in nursing homes or long-term care facilities. A repeat vaccination in 5 years is recommended for individuals receiving first vaccine before age 65 and for those younger if 5 years have elapsed since last vaccination

*******What are the patient manifestations of hemo/pneumothorax with a chest tube?

Pneumothorax: --Mild tachycardia & dyspnea → severe respiratory distress --movement of chest wall affected side or absent breath sounds affected side --Cough --Chest pain Hemothorax: --Tachycardia --Dyspnea --O2 desaturation --Chest pain --Cough --Absent breath sds. --CXR --Air and fluid in pleural space and lung volume

******Regarding Tracheostomy safety: what equipment do you need to have at bedside? What do you do if trach falls out?

Precautions for tube replacement: ***Tube of equal or smaller size kept at bedside for emergency reinsertion **Obturator kept at bedside for reinsertion **Trach. securing device not changed for at least 24 hours after insertion **First tube change by physician no sooner than 7 days after tracheostomy **Do not to dislodge tracheostomy tube during 1st 5 to 7 days when the stoma is not mature (healed). #The nurse should take care not to dislodge the tracheostomy tube during the first 5 to 7 days when the stoma is not mature (healed).

************what are some nursing interventions to prevent aspiration pneumonia?

Prevent pneumonia in at risk patients --Proper positioning to prevent aspiration --Side-lying, upright for altered LOC patients --Patients w/ tube feedings: HOB 45°, ✓residuals --Reposition every 2 hours --Ambulate ASAP ****Adherence to ventilator bundle to prevent VAP HOB 45°, Excellent mouth care Sedation vacation PUD & VTE prophylaxis #Identifying patients at risk and taking measures to prevent the development of pneumonia are priority interventions. Place the patient with altered consciousness in positions (e.g., side-lying, upright) that will prevent or minimize the risk of aspiration. Turn and reposition the patient at least every 2 hours to facilitate adequate lung expansion and to discourage pooling of secretions. Encourage and assist with ambulation and positioning in a chair. In the intensive care unit, strict adherence to all aspects of the ventilator bundle, a group of interventions aimed at reducing the risk of VAP, has been shown to significantly reduce VAP. Patients who have orogastric or nasogastric tubes are at risk for aspiration pneumonia. Although the feeding tube is small, an interruption in the integrity of the lower esophageal sphincter can allow reflux of gastric contents. To prevent aspiration, elevate the head of the bed 30 to 45 degrees and monitor gastric residual volumes. ----------------------------------------------------- Prevent pneumonia in at risk patients --Elevate head-of-bed 30 degrees and have sit up for all meals --Assist w/ eating, drinking, taking meds prn --Assess for gag reflex --Early mobilization, ambulation --Incentive spirometry --Twice-daily oral hygiene --Chlorhexidine swabs ##Identifying patients at risk and taking measures to prevent the development of pneumonia are priority interventions. Elevate the patient's head-of-bed to at least 30 degrees and have patient sit up for all meals. The patient who has difficulty swallowing needs assistance in eating, drinking, and taking medication to prevent aspiration. Assess for a gag reflex before giving food or fluids in patients who have received local anesthesia to the throat. Early mobilization, the use of an incentive spirometer, and twice-daily oral hygiene with chlorhexidine swabs has been shown to significantly reduce the incidence of pneumonia in postoperative patients. -------------------------------------------------------- Prevent pneumonia in at risk patients --Pain management with any chest/abdominal surgeries --Prevents shallow breathing --Strict medical asepsis --Hand hygiene --Suctioning --Avoid unnecessary antibiotic use ##Identifying patients at risk and taking measures to prevent the development of pneumonia are priority interventions. Treat pain to a comfort level that permits the patient to deep breathe and cough, as well as achieve optimum mobility. Practice strict medical asepsis and adherence to infection control guidelines to reduce the incidence of health care-associated infections. Staff and visitors should wash their hands on entering and leaving the patient's room. Staff must wash or use sanitizing hand gel before and after providing care and on removing gloves. Respiratory devices, which can harbor microorganisms, have been associated with outbreaks of pneumonia. Use strict sterile aseptic technique when suctioning the trachea of a patient and use caution when handling ventilator circuits, tracheostomy tubing, and nebulizer circuits that can become contaminated from patient secretions. Avoid nonprudent use of antibiotics to prevent the development of drug-resistant organisms.

structures and function of respiratory system:

Primary purpose of respiratory system: Gas exchange O2 & CO2 between atmosphere & blood Two parts of respiratory system Upper respiratory tract Lower respiratory tract

Types of Pneumonia:Necrotizing Pneumonia

Rare complication of bacterial pneumonia Lung abscesses Liquefaction, cavitation of lung tissue Often results from CAP Long- term antibiotic therapy/ Surgery Signs and symptoms Immediate respiratory insufficiency/failure Leukopenia Bleeding into airways

practice abg interpretation case: What imbalance is this? pH 7.33 PaO2 47 mm Hg PaCO2 67 mm Hg HCO3 37 mEq/L

Respiratory acidosis, partially compensated pH is low. PaCO2 is high. HCO3 is high. By using the ROME (Respiratory Opposite Metabolic Equal) mnemonic, the respiratory component (PaCO2) is going in the opposite direction as the pH—thus, the patient has respiratory acidosis. Because the HCO3 is elevated, the patient is partially compensating.

**Steps to interpretation of ABGs

STEP 1: is pH↑or ↓? ↓= acidosis ↑= alkalosis This determines 2nd half of your ABG interpretation terminology (Respiratory vs. metabolic) acidosis (Respiratory vs. metabolic) alkalosis Respiratory cause (PaCO2) Opposite directions (pH & PaCO2) Alkalosis ↑ pH ↓ PaCO2 Acidosis ↓ pH ↑ PaCO2 Metabolic cause (HCO3) Equal direction (pH & HCO3) Acidosis ↓ pH ↓ HCO3 Alkalosis ↑ pH ↑ HCO3 In Respiratory conditions, pH + PaCO2 go in Opposite directions (CO2 is resp. part of ABG) RESPIRATORY Alkalosis: ↑ pH, ↓ PaCO2 RESPIRATORY Acidosis: ↓ pH, ↑ PaCO2 In Metabolic conditions, pH + HCO3 go in an Equal (same) direction (HCO2 is metabolic part ABG) METABOLIC Alkalosis: ↑ pH, ↑ HCO3 METABOLIC Acidosis: ↓ pH, ↓ HCO3

Types of Pneumonia: Community-Acquired Pneumonia (CAP)

Seen in patients w/ little or no contact w/ medical settings Treated at home Empiric antibiotic therapy started a.s.a.p. Pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Legionella, Mycoplasma, Chlamydia ##The decision to treat the patient at home or admit them to the hospital is based on several factors such as patient's age, vital signs, mental status, presence of comorbid conditions, and current physiologic condition. Clinicians can use tools such as the CURB-65 scale to supplement clinical judgment. (See Table 27-3.) Empiric antibiotic therapy, the initiation of treatment before a definitive diagnosis or causative agent is confirmed, should be started as soon as possible when CAP is suspected. Empiric antibiotic administration is based on experience and knowledge of drugs known to be effective for the most likely causative agent.

Complications of Asthma: Severe

Severe exacerbations • Respiratory rate >30/min • Dyspnea at rest, feeling suffocation • Cannot speak in complete sentences • Pulse >120/min • Accessory muscle use • Peak expiratory flow rate (PEFR) is 40% of best or <150 L • Usually seen in ED or hospitalized Severe asthma exacerbations occur when the patient is dyspneic at rest and the patient speaks in words, not sentences, because of the difficulty breathing. Accessory muscles in the neck are straining to try to lift the chest wall, and the patient is often agitated. The peak flow (peak expiratory flow rate [PEFR]) is 40% of the personal best or less than 150 L.

****What is the action and side effects of common SABA medications?

Short acting β2-Adrenergic agonists (SABAs) --Rescue medication --Effective for relieving acute bronchospasm Examples: albuterol, Ventolin Onset of action in minutes; duration: 4-8 hours Prevent release of inflammatory mediators Not for long-term use: (tremors, anxiety, tachycardia, palpitations, and nausea) Not in cardiac patients: ^BP, ^HR, dysrhythmias

Clinical manifestations of asthma: signs of hypoxemia

Signs of hypoxemia • ↑ anxiety, restlessness • Difficult to speak in complete sentences • Increased respiratory rate • Inspiratory and expiratory wheezes • Increased pulse and blood pressure • Decreasing O2 sat

***Airborne precautions for TB:

Small particle Suspended in air; air current carried Air handling/ventilation required Transmission via resp. system, private room needed N95 or > fit test mask TB, Chickenpox, measles

Etiology of TB

Spread via airborne droplets when infected person Coughs Speaks Sneezes Sings ♪

Pathophysiology: Pneumonia

Stage 1: Congestion Invading organism provokes immune response in lungs--> Outpouring of fluid to alveoli Organisms multiply, spread to other alveoli Alveolar fluid interferes w/ gas exchange Stage 2: Red hepatization Lung capillary dilation Alveoli fill w/ organisms, neutrophils, RBCs, fibrin Causes lungs to appear red and granular Gas exchange problem Stage 3: Gray hepatization ↓ Blood flow Leukocytes & fibrin consolidate in affected part of lung. Stage 4:Resolution Exudates processed by macrophages Tissue restored Gas exchange returns to normal Complete resolution and healing if no complications

***Oxygen Delivery Systems: What does each type look like?

Standard nasal cannulas Face tent Simple face mask Face mask with reservoir bag Venturi mask High flow method; delivers fixed concentrations O2 Tracheostomy collar Humidification

*********What are signs and symptoms of pneumonia? objective vs. subjective.

Subjective: Past health history: --Lung cancer, COPD, DM, malnutrition, chronic debilitating disease, smoking, EtOH, CVA, alt. LOC --Nutritional intake --Activity, dyspnea, cough --Use of antibiotics, corticosteroids, chemotherapy, or immunosuppressants --Recent abdominal or thoracic surgery? --Recent intubation? --Tube feedings? #Obtain the following important health information from the patient: Past health history: Lung cancer, COPD, diabetes mellitus, chronic debilitating disease, malnutrition, altered consciousness, immunosuppression, exposure to chemical toxins, dust, or allergens Medications: Use of antibiotics; corticosteroids, chemotherapy, or any other immunosuppressants Surgery or other treatments: Recent abdominal or thoracic surgery, splenectomy, endotracheal intubation, or any surgery with general anesthesia; tube feedings ---------------------------------------------- Objective: --Fever --Mental status changes --Restless, lethargic --Tachypnea --Tachycardia --Sputum amount /color Green or yellow Change in color/ consistency --Asymmetric chest movements --Use of accessory muscles --Splinting affected area --Crackles --Friction rub Assess patient's oxygenation status with pulse oximetry (picture). Normal SpO2 values are 94% to 99%. SpO2 is assessed with each routine vital signs check in many inpatient areas. Oximetry is also used during exercise testing and when adjusting flow rates during long-term oxygen therapy. -------------------------------------------- --White = common cold, bronchitis, and viral infection --*****Yellow or green = bacterial infection blood = serious respiratory problems --*****rust colored = TB or pneumococcal pneumonia --Pink frothy = pulmonary edema If no may be r/t upper respiratory irritations or early onset of heart failure --------------------------------------------- Perform a focused physical assessment for the following clinical manifestations: --Generalized: Fever, restlessness or lethargy; splinting of affected area --Respiratory: Tachypnea; pharyngitis; asymmetric chest movements or retraction; decreased excursion; nasal flaring; use of accessory muscles (neck, abdomen)

*********Tracheostomy: what are the speaking and eating safety precautions?

Swallowing Dysfunction W/cuffed Trach: 1.) Inflated cuff --Interferes w/ normal function of muscles used to swallow --***Evaluate risk of aspiration with cuff deflated, or substitute with a cuffless tube --Evaluate ability to swallow w/o aspiration when cuff is deflated: -->Swallowing evaluation: ~~By speech therapy or ~~Endoscopic evaluation -------------------------------------------------------- Speech W/a Trach: 1.)Techniques to promote speech: --***Spontaneously breathing patient may deflate cuff, allowing exhaled air to flow over vocal cords = speech --Tracheostomy tubes/valves have been designed to facilitate speech --Provide patient with writing tools if speaking devices are not used --------------------------------------------- Passy-Muir Speaking Tracheostomy Valve: --The valve is placed over the hub of the tracheostomy tube after the cuff is deflated. --Can be used for ventilated and non-ventilated patients. --One-way valve allows air to enter the lungs during inspiration and redirects air upward over the vocal cords into the mouth during expiration, allowing speech. --Ability to tolerate cuff deflation without aspiration or respiratory distress must be evaluated before speaking valves used --If no aspiration, cuff is deflated and valve is placed over opening ********DO NOT PLACE SPEAKING VALVE WITHOUT DEFLATING CUFF. ******YOUR PATIENT WILL SUFFOCATE!!!!!!!!!!!!!!! Speech and Fenestrated Tubes: --Fenestrated tube has opening on surface of outer cannula to permit airflow over vocal cords to allow: ~~Speech ~~Must have spontaneous breathing through larynx ~~Allows for secretion expectoration w/ tube in place Precautions for Fenestrated Tracheostomy Tubes: --Ability to swallow is determined before use --Monitor for aspiration --Frequently assess for signs of respiratory distress on first use --Requires frequent suctioning --Potential for development of tracheal polyps

Multidrug-resistant TB (MDR-TB)

TB strain resistance to 2 most potent first-line anti-TB drugs INH and rifampin Extensively drug-resistant TB (XDR-TB) Also resistant to fluoroquinolones (Cipro, Levaquin) plus any injectable antibiotic Causes for resistance Incorrect prescribing, nonadherence, lack of case management #Once a strain of M. tuberculosis develops resistance to two of the most potent first-line antituberculosis drugs (e.g., isoniazid [INH], rifampin [Rifadin]), it is defined as multidrug-resistant tuberculosis (MDR-TB). Extensively drug-resistant TB (XDR-TB) occurs when the organism is also resistant to any of the fluoroquinolones plus any injectable antibiotic agent. Resistance results from several problems, including incorrect prescribing, lack of public health case management, and patient nonadherence to the prescribed regimen.

**********Treatment and Precautions of TB

Teach patient to prevent spread: --Cover nose & mouth w/ tissue when coughing, sneezing, or producing sputum --Hand washing after handling sputum-soiled tissues --Red bag trash for tissues --Patient wears mask if outside of negative-pressure room --Identify & screen close contacts #*The tissues should be thrown into a paper bag and disposed of with the trash, burned, or flushed down the toilet. (usually with the TST). If the person has LTBI or active TB disease, he or she should be treated with anti-TB drugs. Identify and screen close contacts of the person with TB. Anyone testing positive for TB infection will undergo further evaluation and needs to be treated for either LTBI or active TB disease. --------------------------------------------------- Ambulatory Home Care: Teaching --Can go home even if cultures are positive --Teach how to minimize exposure to others --Monthly sputum cultures --Ensure that patient can adhere to treatment --Negative cultures are needed to declare the patient not infectious --Teach symptoms of recurrence --Smoking cessation --Notify health department --Instruct about factors that could reactivate TB.. #Patients who have responded clinically are discharged home (even with positive cultures) if their household contacts have already been exposed and the patient is not posing a risk to susceptible persons. The public health nurse will be responsible for follow-up on household contacts and assessment of the patient for compliance. If compliance is an issue, the public health agency may be responsible for DOT. 5% of individuals experience relapses. --------------------------------------------------------

What is used to determine initial treatment of asthma?

The classification system is used at diagnosis to determine the initial treatment. Patients may move to different asthma classifications over the course of their disease. Used to Determine Initial Treatment • Intermittent • Mild persistent • Moderate persistent • Severe persistent

The goal of asthma treatment?

The goal of asthma treatment: Once diagnosed Assess severity of disease Initiate initial treatment with medications Monitor to maintain, control disease

ABG results are as follows: pH 7.20 PaO2 59 mm Hg PaCO2 58 mm Hg HCO3- 24 mEq/L Describe a patient who would have these ABGs, and the treatment.

These ABGs reflect an uncompensated respiratory acidosis with hypoxemia. This could occur with a respiratory infection causing an exacerbation in a patient with COPD. The hypoxemia may be reflected by restlessness, confusion, or stupor. Respiratory and cardiac findings could include rapid, shallow breathing, rhonchi, crackles, diminished breath sounds, increased work of breathing with use of accessory muscles, orthopnea, tachycardia, and arrhythmias. Treatment includes treatment of any underlying respiratory infections, bronchodilator therapy, corticosteroids, hydration therapy, chest PT and postural drainage, breathing exercises, low-flow oxygen therapy, and mechanical ventilation if the patient continues to deteriorate.

***What is the action and side effects of common ICS medications?

Three types of anti-inflammatory drugs (ICS) 1. Corticosteroids 2. Leukotriene modifiers (LTRA) 3. Monoclonal antibody to IgE 1.) Corticosteroid actions: Reduce bronchial hyper-responsiveness Suppresses inflammatory response Decrease mucous production Taken on a fixed schedule Women, especially postmenopausal women, who have asthma and who use corticosteroids should take adequate amounts of calcium and vitamin D and should participate in regular weight-bearing exercise. Inhaled form is used in long-term control Systemic form to control exacerbations & manage persistent asthma Not for acute asthma attack budesonide (Pulmocort), fluticasone (Flovent) Therapeutic effect in 24 hrs Oropharyngeal candidiasis, hoarseness, dry cough Use a spacer to help (next) ICSs are first-line therapy for patients with persistent asthma requiring step 2-6 therapy (see Fig. 29-4). Usually, ICSs must be administered for 1 to 2 weeks before maximum therapeutic effects can be seen. Some ICSs (e.g., fluticasone [Flovent], budesonide [Pulmicort]) begin to have a therapeutic effect in 24 hours. 2.) Leukotriene modifiers or inhibitors (LTRA) Bronchodilator & anti-inflammatory effects Used for prophylactic & maintenance therapy Not indicated for acute attacks Zafirlukast (Accolate), montelukast (Singulair), zileuton (Zyflo) Headaches and nausea most common s/e 3.) Anti IgE IgE elevation= immune system overreaction ↓ circulating free IgE levels Subcutaneous administration every 2 to 4 weeks Xolair The drug has a risk of anaphylaxis, and patients must receive the medication in a health care provider's office, where this emergency can be handled.

Tracheostomy: Definition

Tracheostomy: Stoma (opening) that results from tracheotomy

Tracheotomy: Definition

Tracheotomy: --Surgical incision into the trachea to establish an airway

***********What is the treatment and precautions of TB?

Treatment: Outpatient care** --Hospitalization not necessary for most --Long-term drug therapy used to treat active disease --2 months of the following 4 drugs: Isoniazid (INH) Rifampin Pyrazinamide (PZA) Ethambutol ------------------------------------------------ --TB usually heals without complications except for scarring and residual cavitation within the lung --Significant pulmonary damage may occur in: ~Poorly treated or ~Patients not responding to treatment ------------------------------------------------ Precautions: 1.) Airborne --Small particle --Suspended in air; air current carried --Air handling/ventilation required --Transmission via resp. system, private room needed --N95 or > fit test mask --TB, Chickenpox, measles 1.) Airborne isolation: -Single-occupancy room with 6-12 airflow exchanges/hour --Health care workers wear high-efficiency particulate air (HEPA) masks #Isolation requires a single-occupancy room with negative pressure and airflow of 6 to 12 exchanges per hour. This is a picture of a high-efficiency particulate air (HEPA) mask. Because many different types of HEPA masks are currently available, health care professionals should be "fit tested" each time a different brand or model of mask is used to ensure proper mask size. Otherwise, the CDC recommends that yearly mask "fit testing" is acceptable. To be effective, the mask must be molded to fit tightly around the nose and mouth 2.) Droplet --Large, heavy particle --Doesn't travel in air current --Trans. via conjunctiva, nose , mouth, mucous membranes --Reg. surgical mask, gown, glove, goggle, private room --Influenza, pneumonia

**COPD: patient teaching of non-pharmacological treatments?

Treatment: non-pharmacological --Most important aspect is teaching --Pulmonary rehabilitation... --Activity considerations... --Sexual activity... --Sleep... --Psychosocial considerations... ------------------------------------------------------ Pulmonary rehabilitation: -Includes many disciplines working together to individualize treatment of the patient with chronic respiratory disease -Focus is on strengthening muscles used in ambulation -Increases exercise performance -Improve quality of life ---------------------------------------------------- Activity considerations: -Exercise training energy conservation In upper extremities, it may improve muscle function and reduce dyspnea -Modify ADLs to conserve energy -Alternative methods of hair care, shaving, etc. -Walk 15 to 20 minutes/day, 3x/week w/ gradual increases -Allow adequate rest #Exercise-induced dyspnea should return to baseline within 5 minutes after exercise. Instruct patient to wait 5 minutes after completion of exercise before using the β2-adrenergic agonist to allow a chance to recover. During this time, slow, pursed lip breathing. -------------------------------------------------------- Sexual activity: -Plan when breathing is best. -Use slow, pursed lip breathing. -Refrain from after strenuous activity. -Do not assume dominant position or prolong foreplay. ----------------------------------------------------- Sleep: -Can be difficult because of medications, postnasal drip, or coughing -Nasal saline sprays, decongestants, or nasal steroid inhalers can help. ------------------------------------------------------ Psychosocial considerations: -Lifestyle changes r/t disease -decreased ability to care for self -decreased energy for social activities -Job loss -May feel guilt, depression, anxiety, social isolation, denial, and dependence

compensated vs. uncompensated

Uncompensated - pH is abnormal; either pH and/or HCO3 are abnormal Full/complete compensation - pH remains normal pCO2 and HCO3 are still abnormal One system has been able to fully compensate for the other Partially compensated-pH abnormal Compensating organ system attempts to drive pH to normal level but is not completely successful yet

***********Identify medication treatment for TB and patient teaching regarding administration and side effects of antitubercular meds:

Vaccine: --Bacille Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of the world --In United States, not recommended Can result in positive PPD reaction #Bacille-Calmette-Guérin (BCG) vaccine is a live, attenuated strain of Mycobacterium bovis. The vaccine is given to infants in parts of the world where there is a high prevalence of TB. In the United States, it is typically not recommended because of the low risk of infection, the vaccine's variable effectiveness against adult pulmonary TB, and potential interference with TB skin test reactivity. The BCG vaccine should be considered only for very select individuals who meet specific criteria (e.g., health care workers continually exposed to patients with MDR-TB and infection control precautions are not successful). The BCG vaccination can result in a false-positive TST. IGRA results are not affected. -------------------------------------------------------- Outpatient care** Hospitalization not necessary for most Long-term drug therapy used to treat active disease ****2 months of the following 4 drugs --Isoniazid (INH) --Rifampin --Pyrazinamide (PZA) --Ethambutol #Promoting and monitoring compliance are critical for treatment to be successful. Most patients with TB are treated on an outpatient basis. Many people can continue to work and maintain their lifestyles with few changes. Patients with sputum smear positive TB are generally considered infectious for the first 2 weeks after starting treatment. Advise these patients to restrict visitors, avoid travel on public transportation and trips to public places, and on the importance of good handwashing and oral hygiene. Hospitalization may be needed for the severely ill or debilitated. The mainstay of TB treatment is drug therapy. Promoting and monitoring compliance is critical for treatment to be successful. Because of the growing prevalence of multidrug-resistant TB, it is important to manage the patient with active TB aggressively. Drug therapy is divided into two phases: initial and continuation. In most circumstances, the treatment regimen for patients with previously untreated TB consists of a 2-month initial phase with four drugs (Isoniazid, rifampin [Rifadin], pyrazinamide [PZA], and ethambutol). If drug susceptibility test results indicate that the bacteria are susceptible to all drugs, ethambutol may be discontinued. If PZA cannot be included in the initial phase (due to liver disease, pregnancy, etc.), the remaining three drugs are used for the initial phase. ------------------------------------------------------ cont.. outpatient care: Drug Therapy: **Person is infectious for first 2 weeks after starting treatment if sputum (+)** --Restrict visitors, avoid travel on public transport, to public places, good handwashing /oral hygiene --Directly observed therapy (DOT) **Noncompliance is major factor in multidrug resistance & treatment failures **r/t length of treatment --Requires watching patient swallow drugs --Preferred to ensure adherence ----------------------------------------------------- Side effects: --Patients should be taught SE, & when to seek medical attention **Jaundice --Liver function should be monitored --√ LFTs **Non-viral hepatitis is major side effect of isoniazid, rifampin, & PZA --Monitor for jaundice** **No EtOH! #Teaching patients about the side effects of these drugs and when to seek prompt medical attention is critical. The major side effect of isoniazid, rifampin, and pyrazinamide is nonviral hepatitis. Baseline liver function tests are done at the start of treatment. Monthly monitoring of liver function tests is done if baseline tests are abnormal. Drug alert on Isoniazid - Alcohol may increase hepatotoxicity - instruct patients to avoid drinking alcohol during treatment. If the patient develops a toxic reaction to the primary drugs, other drugs can be used including rifabutin and rifapentine (Priftin). Treatment for drug-resistant TB is guided by sensitivity testing. -------------------------------------------------------- Latent TB infection: Drug Therapy **(+)TB skin test but no active disease **Drug therapy helps prevent TB infection from developing into active disease **LTBI is treated with INH for 6- 9 months HIV(+) patients should take INH for 9 mo. --Alternative: 3-month regimen of INH and rifapentine (Priftin) OR 4 months of rifampin #*Because a person with LTBI has fewer bacteria, treatment is much easier. Usually, only one drug is needed. The 9-month regimen is more effective, but compliance issues may make the 6-month regimen preferable. An alternative 4-month therapy with rifampin may be indicated if the patient is resistant to INH. In people with LTBI, drug therapy helps prevent a TB infection from developing into active TB disease. Because there are fewer bacteria in a person with LTBI, treatment is much easier. Usually, only one drug is needed. The standard treatment regimen for LTBI is 9 months of daily isoniazid (Isoniazid). It is an effective and inexpensive drug that the patient can take orally. The 9-month regimen is more effective, but compliance issues may make the 6-month regimen preferable. For HIV patients and those with fibrotic lesions on chest x-ray, Isoniazid is given for 9 months. An alternative 3-month regimen of Isoniazid and rifapentine (Priftin) may be used for otherwise healthy patients who are not presumed to be infected with drug-resistant bacilli. A 4-month therapy with rifampin may be indicated if the patient is resistant to Isoniazid. Due to severe liver injury and deaths, the CDC does not recommend the combination of rifampin and pyrazinamide for treatment of LTBI.

Allergic Rhinitis: What is it?/S&S/treatment

What is it: --Reaction of nasal mucosa to allergen S&S: --Sneezing, itchy, watery eyes, nasal discharge, nasal congestion --Identify, then avoid triggers Treatment: --Antihistamines, intranasal corticosteroids and leukotriene receptor agonists

**COPD: Signs and symptoms of cor pulmonale?

What is it? --Hypertrophy of right side of heart --Result of pulmonary hypertension --Pressures on right side of the heart must increase to push blood into the lungs --Late manifestation of chronic pulmonary heart disease --RHF -------------------------------------------------------- S/S: **Dyspnea- most common Distended neck veins Hepatomegaly with upper quadrant tenderness Peripheral edema Weight gain

What is Epistaxis? What is it caused by?

What is it? --Nosebleed Causes? --Trauma --Foreign body --Nasal spray --Street drug abuse (cocaine) --Anatomic malformation --Tumors --Conditions that cause prolonged bleeding time

Abnormal Breath Sounds

decreased or absent breath sounds Bronchial over abnormal locations.

*********What does effective treatment for pneumonia look like in your patient?

effective antibiotic treatment looks like: --Effective respiration --SpO2 ≥ 95 --Lungs clear to auscultation --Clear sputum from airway --Pain controlled #Prompt treatment with the appropriate antibiotic almost always cures bacterial and mycoplasmal pneumonia. In uncomplicated cases, the patient responds to drug therapy within 48 to 72 hours. Indications of improvement include decreased temperature, improved breathing, and reduced chest pain. IV antibiotic therapy should be switched to oral therapy as soon as the patient is hemodynamically stable, improving clinically, able to ingest oral medication, and has a normally functioning GI tract. Patients on oral therapy do not need to be observed in the hospital and can be discharged to home.

Collaborative Care: Intermittent and Persistent ASTHMA

o Avoid triggers of acute attacks FIRST • Requires short-term (rescue or reliever) medication • Short-acting β2-adrenergic agonists (SABA): albuterol** • Gold standard & most effective; all asthma types require it • Pre-medicate before exercising • Long-term or controller medication (may be required) • Inhaled corticosteroids (ICSs): (fluticasone [Flovent]) • Most effective class of drugs to treat inflammation • For patients w/ persistent asthma

**COPD: Indications for O2?

oxygen is a drug. too little can cause death and too much can cause severe illness, destruction of tissues and possibly death. must use the least amount of O₂ necessary because of its toxicity ---------------------------------------------------- O2 therapy is used to: --Reduce work of breathing **Maintain PaO2 > 60 --Reduce workload on the heart **Keep O2 st >90% *************titrate it to keep o2 st> 90% or maintain pao2> 60 ------------------------------------------------ Long-term O2 therapy improves: -Survival -Exercise capacity -Cognitive performance -Sleep in hypoxemic patients ---------------------------------------------------- Chronic O2 therapy at home reduces: -Hematocrit -Pulmonary hypertension ------------------------------------------------- O2 is usually administered to treat hypoxemia caused by: (1) respiratory disorders such as COPD, pulmonary hypertension, cor pulmonale, pneumonia, atelectasis, lung cancer, and pulmonary emboli; (2) cardiovascular disorders such as myocardial infarction, dysrhythmias, angina pectoris, and cardiogenic shock; and (3) central nervous system disorders such as overdose of opioids, head injury, and sleep disorders (sleep apnea).

****ABGs: pH

pH (acidity): 7.35-7.45 Measure of H+ ion concentration Blood is normally slightly alkaline at pH 7.35 to 7.45 <7.35 is acidosis >7.45 is alkalosis

Partial Compensation: Example: Partially compensated respiratory acidosis

pH = 7.33 down pCO2 = 55 up (pCO2 is too high) HCO3 = 32 up (keep trying HCO3!)

What imbalance is this? pH 7.60 PaO2 60 mm Hg PaCO2 30 mm Hg HCO3- 22 mEq/L

pH is high. PaCO2 is low. HCO3 is normal. Respiratory opposite. Respiratory alkalosis

What imbalance is this? pH 7.58 PaO2 75 mm Hg PaCO2 35 mm Hg HCO3- 50 mEq/L

pH is high. PaCO2 is normal. HCO3 is high. Metabolic equal. Metabolic alkalosis

practice case 2: ABG interpretation: What imbalance is this? pH 7.18 PaO2 70 mm Hg PaCO2 38 mm Hg HCO3- 15 mEq/L

pH is low. PaCO2 is normal. HCO3 is low. Metabolic equal. Metabolic acidosis

Full Compensation: example respiratory acidosis

pH is normal (fully compensated) pCO2: up or down HCO3: up or down pH: 7.35 (normal) pCO2: 50 (up) HCO3: 33 (up) Saves the day!

****Asthma triggers: Drug additives

• ASA and NSAIDS: Asthma triad:******* -Nasal polyps, asthma & sensitivity to aspirin/ NSAIDs -Sensitivity to salicylates (Found in many foods, beverages & flavorings) -Wheezing develops in about 2 hours • β-Adrenergic blockers (may trigger bronchospasm) Oral and eye drops • ACE inhibitors (cough) worsen asthma symptoms ---------------------------------------------------- #In addition to wheezing, profound rhinorrhea, congestion, and tearing usually occur, and angioedema also can occur. #Although sensitivity to salicylates persists for many years, the nature and severity of the reaction can change over time. #β-Adrenergic blockers in oral form (e.g., metoprolol [Toprol]) or topical eye drops (e.g., timolol) may trigger asthma as the result of bronchospasm. #Angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril [Prinivil]) may produce cough in susceptible individuals, thus making asthma symptoms worse.

***Asthma triggers: Occupational Factors

• Asthma: most common form of occupational lung disease • Exposure to diverse agents • Arrive at work well, but experience a gradual decline • May take months or years of exposure • Agricultural workers, bakers, hospital workers, plastics manufacturing, and beauticians #Occupational asthma is the most common occupational respiratory disorder, with up to 15% of new asthma arising from job-related exposures. #Agricultural workers, bakers, hospital workers, plastics manufacturing, and beauticians are occupations with a high risk.

Diagnostic Studies of Asthma?

• Detailed history & physical exam • Peak flow monitoring/Peak expiratory flow rate (PEFR) • Diagnose, monitor asthma • Spirometry: Pulmonary function tests establish asthma diagnosis • Determine reversibility of bronchoconstriction (using bronchodilators) • CXR (mucoid impaction, atelectasis, pneumothorax) • ABGs • Oximetry- O2 SATS • Allergy testing • Blood levels of eosinophils • Elevated suggests genetic predisposition • Sputum culture and sensitivity • Bacterial infection? • Majority in asthma are viral -Because wheezing and cough are seen with a variety of disorders, this complicates the diagnosis of asthma. These disorders include COPD, pulmonary embolism, GERD, obesity, vocal cord dysfunction, and heart failure. -Pulmonary function tests (i.e., spirometry) can be used to determine the reversibility of bronchoconstriction (using bronchodilators) and thus establish the diagnosis of asthma. -The peak expiratory flow rate (PEFR) measured by the peak flow meter is an aid to diagnose and monitor asthma. -The patient with asthma may show an obstructive pattern with asthma including a decrease in forced vital capacity (FVC), FEV1, PEFR, and FEV1 to FVC ratio (FEV1/FVC). (The normal values for pulmonary function tests are discussed in Chapter 26.) -Chest x-ray is usually normal for asymptomatic patients, but obtained as a baseline, and then to reveal complications of asthma, such as mucoid impaction, pneumothorax, or atelectasis. -ABGs help to provide information about the severity of an attack and the response to therapy. -Oximetry may be measured as a baseline and then to determine the patient's ability to oxygenate during an attack. -Allergy skin testing may be of some value to determine sensitivity to specific allergens. However, a positive skin test does not necessarily mean that the allergen is causing the asthma attack. On the other hand, a negative allergy test does not mean that the asthma is not allergy related. -An elevated serum eosinophil count and elevated serum IgE levels are highly suggestive of atopy (genetic predisposition to develop an allergic response), which may be a risk factor for a person's asthma. -A sputum specimen for culture and sensitivity may be obtained to rule out the presence of bacterial infection; however, the vast majority of asthma exacerbations are viral in nature, and sputum cultures are rarely done on an outpatient basis.

****Asthma triggers: Food Additives

• Food allergies may cause asthma symptoms: • Rare in adults • Oral food challenges determine which foods are triggers --------------------------------------------------- #Avoidance diets are not recommended until an allergy has been demonstrated, usually by oral challenges.

Pathophysiology of asthma: Late phase

• It is characterized by a self-sustaining cycle of inflammation. • Late-phase response (50% of patients)*** • Occurs within 4 to 6 hours after initial attack • Self-sustaining cycle of inflammation • Can be more severe than early phase • Can last for 24 hours or longer • If airway inflammation is not resolved, it may lead to irreversible lung damage • Structural changes in bronchial wall (remodeling)

***Asthma triggers: Respiratory Infections

• Major precipitating factor of an acute asthma attack • Infection causes: ********↑ inflammation & hyper-responsiveness of tracheobronchial system #Viral-induced alterations of epithelial cells, increased inflammatory cell accumulation, edema of airway walls, and exposure of airway nerve endings contribute to altered airway function. #These alterations in airway function may contribute to an exacerbation of asthma.

***Asthma triggers: Nose and sinus problems

• Most patients w/ asthma have history of allergic rhinitis & nasal polyps: -Sinus problems related to inflammation of mucous membranes -Large polyps need to be removed • Treatment improves symptoms • Most patients with asthma have a history of allergic rhinitis, and treatment usually improves the symptoms of asthma.

Goal of asthma treatment

• Once diagnosed • Assess severity of disease • Initiate initial treatment with medications • Monitor to maintain, control disease • Validated questionnaires (e.g., Asthma Control Test [ACT] available at www.asthmacontroltest.com • Life quality issues • Level of control is based on patient's current peak flows or FEV1 • Forced expiratory volume Validated questionnaires (e.g., Asthma Control Test [ACT] available at www.asthmacontroltest.com) can be used to assess quality-of-life issues in asthma patients. The level of control is determined by the patient's current peak flow or Forced expiratory volume (FEV1. In addition, any exacerbations or adverse effects of treatment will determine the level of control.

Clinical Manifestations of asthma?

• Wheezing is unreliable to gauge severity • Severe attacks may have no audible wheezing** • For wheezing to occur, the patient must be able to move enough air to produce the sound • No wheezing may indicate complete airway obstruction** • Shortness of breath • Chest tightness • Variable airflow obstruction • Cough... Many patients with minor attacks wheeze loudly, whereas others with severe attacks do not wheeze. For wheezing to occur, the patient must be able to move enough air to produce the sound.