Nurs 220- Pulmonary PPT

Dyspnea

• Subjective sensation of uncomfortable breathing

• Orthopnea

  • Dyspnea when a person is lying down

• Paroxysmal nocturnal dyspnea (PSD) 

signs and symptoms of pulmonary disease

dyspnea, cough, abnormal sputum, hemoptysis, abnormal breathing patterns, hypoventilation, hyperventilation, cyanosis, hypoxia, clubbing, pain

cough

• Acute cough

• Chronic cough

hemoptysis

coughing up blood

abnormal breathing pattern

kussmaul respirations (hyperpnea) + cheyne-stokes respiration

hypoventilation

leads to hypercapnia

hyperventilation

leads to hypocapnia

acute bronchitis summary

• Self-limiting inflammation of bronchi; most caused by viruses 

  • Other triggers: pollution, chemical inhalation, smoking, chronic sinusitis and asthma 

  • With the seasons changing comes an increase in viral respiratory illnesses like bronchitis 

    • Patients that are more susceptible to get viral respiratory illnesses will be more likely to get bronchitis 

acute bronchitis symptoms

• *cough, clear/purulent sputum, headache, fever, malaise, dyspnea, chest pain

  • Cough is most common symptom; lasting up to 3 weeks; more frequent at night 

  • Clear mucus cough/ green sputum

    • The green sputum does not always indicate that it has now evolved to a bacterial infection

    • Coughing can lead to chest pain

acute bronchitis diagnosis + tx

• Breath sounds: crackles or wheezes

• Treatment goal–symptoms relief and prevent pneumonia; supportive

  • Cough suppressants, oral fluids, humidifier 

  • Beta 2-agonist inhaler –wheezing or underlying pulmonary condition 

  • Avoid irritants

  • See HCP: fever, dyspnea, or duration greater than 4 weeks 

  • Chest x-ray can be used for dx to look for consolidation

    • To look for patchy white areas in the lungs → pneumonia 

    • Cough suppressants can be prescribed and used/ stronger than OTC 

    • Encourage patients to drink more fluids 

    • Pts with underlying conditions (asthma, COPD) have more intense symptoms → we need albuterol to open up the airways due to the inflammation 

      • AVOID IRRITANTS (like smoking)

    • Can be due to the flu –pts should get prescription for antivirals within 48 hours 

    • Can be persistent –need to encourage patients to see HCP as it might turn into bacterial and they will need antibiotics

Pneumonia

• Acute infection of lung parenchyma 

• Associated with significant morbidity and mortality rates

• Pneumonia and lower respiratory tract infections such as influenza 

  • 4th leading cause of death worldwide in 2019 

• VERY CONCERNING 

Aspiration of normal flora from nasopharynx or oropharynx:

1. something going down the wrong pipe

   1. Unlikely to lead to pneumonia as we usually cough it out

      1. Think about patients who cannot cough: patients with bad gag reflex, neurological problems (stroke, brain injury), patients with problems eating or drinking

      2. Seen often in older patients living in tertiary care facilities (rehab, nursing homes). 

         1. These older patients have comorbidities → high mortality rate

      3. We can also aspirate GI acids (gastric reflux can travel to respiratory tract) 

Inhalation of microbes present in the air

1. coughing, laughing, talking coming from infected patient

   1. TB, covid, flu –droplet/airborne precautions 

Hematogenous spread from primary infection elsewhere in the body

1. comes from another site of infection 

   1. I.e. UTI going into the blood stream and travels to the lungs

Long-term smokers:

1. cilia loses ability to sweep away debris over time the longer that the person smokes

Cough reflex

1. patients who had a stroke lose ability to swallow → lack of cough reflex

Community-acquired pneumonia (CAP)

• Acute infection in patients who have NOT been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms 

• Can be treated at home or hospitalized dependent on the patient’s age, VS, mental status, comorbidities, and condition

• MRSA, legionella (populates within water source)

• Particularly connected with elderly patients 

  • Assessment CURB 65

  • Confusion, BUN greater than 20, RR greater than 30, age greater than 65 

    • Every time you tick yes to each criteria, outcome is not looking great 

Hospital-acquired pneumonia (HAP) or nosocomial pneumonia

• HAP: occurs 48 hours or longer after hospitalization and not present at time of admission 

  • E.coli, assinabacter, clebisella ammonia 

• Ventilator-associated pneumonia (VAP): occurs more than 48 hours after endotracheal intubation 

  • These patients tend to be much more sick → increased mortality rate 

• These are the most common bacterial organisms but pneumonia is MOST commonly caused by the influenza VIRUS

• We must figure out if its viral or bacterial so we can plan proper tx 

  • Also, we must note the comorbidities of the patient

manifestations of pneumonia

Most common

• Cough: productive or non-productive

• Green, yellow, or rust-colored sputum 

• Fever, chills

• Dyspnea, tachypnea 

• Pleuritic chest pain 

Older or debilitated patients: confusion or stupor, hypothermia 

Atelectasis

complication of pneumonia 

Can be developed post anesthesia - which is why spirometer is given

Pleurisy

• inflammation of pleura, complication of pneumonia 

pleural effusion

• Can develop due to pericarditis 

• Fluid builds up in lungs in ADDITION to the already present consolidation

  • Makes gas exchange even worse 

• Complication of pneumonia

pneumothorax

complication of pneumonia

• Many organisms can eat through the lung tissue —> pneumothorax

ARF

complication of pneumonia

•  a leading cause of death in severe pneumonia; ineffective O2 and CO2 exchange 

sepsis/septic shock

complication of pneumonia

• bacteria from alveoli enter the blood stream and lead to shock and MODS 

  • Must monitor pt and assess pt for signs of MODS (like a decrease in urine output 

  • Organs are not getting well-perfused due to hypoxemia 

• Bacteremia is another complication of pneumonia

lung abscess

complication of pneumonia

• Pocket full of pus

• Tx: go in and drain those lung abscess.

• This abscess leads to empyema (pus in lungs)

nursing diagnoses for pneumonia

• Impaired gas exchange

• Impaired breathing

• Fluid imbalance 

• Hyperthermia

• Activity tolerance

covid pna

• Immune cells used as transport throughout the lung tissue

• Ground glass on CXR * 

• Fluid filled alveoli

• ARDS

• Think about extremes of age and comorbidities –these patients have a high risk of getting COVID PNA 

TB

• Infectious disease caused by Mycobacterium tuberculosis

• Can affect other organs such as the brain or the kidneys 

• Spread via airborne particles (talking, coughing)

  • Once organism is inhaled, body tries to wall off that area of infection (this is called TB granuloma) 

• Lungs most commonly infected

• 25% of world’s population has TB

• Prevalence is the United States decreasing except for those with HIV

  • Leading cause of mortality in those with HIV

etiology and patho of TB

• Gram-positive, aerobic, acid-fast bacillus (AFB)

• Spread via airborne droplets (1-5 micrometers) 

  • Can be suspended in air for minutes to hours

  • Humans are only known reservoir for TB 

• Transmission requires close, frequent, or prolonged exposure

  • NOT spread by touching, sharing food utensils, kissing, or other physical contact

  • Number, concentration, length of time for exposure and immunity influence transmission 

• Same process of granuloma will occur in brain or kidneys 

  • Body wants to wall off the area of infection

  • TB granuloma: hallmark sign on chest x-ray and it is very identifiable on chest-ray 

manifestations/ symptoms of pulmonary TB

• Pulmonary TB

  • Takes 2-3 weeks to develop symptoms

    • Usually slow, but can also have acute onset

  • Characteristic initial: dry cough that become productive

  • Other symptoms: fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats 

    • Pt can have acute presentation with high fever, pleuritic chest pain and ARF 

• Remember the immunosuppressed –less likely to have fever & other signs of an infection; with the HIV patient r/o other sources such as PCP/opportunistic diseases

• Granuloma can turn to scar tissue which never functions like normal tissue again

  • Scar tissue interferes with gas exchange 

Late symptoms of TB

• Late symptoms: dyspnea and hemoptysis (coughing up blood)

2 phases of TB tx

• Intensive (8 weeks to 3 months); 4 drugs (below)

• Continuation (18 weeks): 2 drugs (isoniazid and rifampin)

intensive 4-drug regimen specific to TB

• Isoniazid (hepatitis): INH, first line of therapy 

• Rifampin (hepatitis; orange body fluids): first line of therapy 

• Pyrazinamide (hepatitis)

• Ethambutol (ocular toxicity)

multi-drug resistant TB

happens when pts stop taking their antibiotics too early

HIV patients and TB

•  should be taking prophylactic tx for life to avoid getting TB  bc they are immunosuppressed

BCG vaccine

• available in different countries

  • If you test a pt with the BCG vaccine, they will test positive despite not being sick → no point in doing TB screening for these patients

TB questionare

• If you say yes to any, you must get the quantiferon gold test 

• Annual quantiferon blood test is required for many health care facilities