Med Surg Test 3 (Resp and Renal) - Liberty University

allergic rhinitis

- caused by a particular antigen that causes a reaction to the nasal mucosa

- also affects the conjunctiva

- can be perennial with seasonal exacerbations

- aggravating factors - tobacco smoke, fragrances, air pollutants

- environmental triggers - house dust, feathers, mold spores, animal dander/saliva, and cockroaches

- TYPE 1 HYPERSENSITIVITY

seasonal allergic rhinitis

also known as intermittent; symptoms last less than 4 days a week or 4 weeks out of the year; pollen that depends on cross pollination: trees, grasses, ragweed; high protein counts which happens around the same time for a couple weeks

perennial allergic rhinitis

this is also known as persistent or ANNUAL rhinitis; symptoms are present 4 or more days a week and greater than 4 weeks out of the year; mold and pet dander are examples

presentation of allergic rhinitis

sneezing, nasal/eye itching, watery rhinorrhea (runny nose?), and nasal stuffiness; these are the s/s; this starts when the patient comes in contact with the allergen and IgE and mast cells come into action

treatment for allergic rhinitis

avoid the allergen - dairy might help when the symptoms happen, dust, pets and pollen; symptoms are controlled via drugs; cockroaches cause allergen induced asthma in pediatric patient; dust mites are in 4/5 of human homes so keep bedroom windows closed

allergic rhinitis medication therapy

- antihistamines: first generation agent like Benadryl (diphenhydramine) which can cause a sedative effect, and second generation (which cause minimal sedation) like Loratadine, Fexofenadine, Ceterizine, Levocetirizine; also maintain fluid intake with antihistamine to avoid adverse effects and keep secretions thinned; PG 479, 26.2; first generation is good with itching

intranasal corticosteroids

allergic rhinitis medication; use REGULARLY NOT PRN; discontinue if nasal infection occurs and give Budesonide, Fluticasone, Mometasone, and Triamcinolone; take these medications two weeks prior to exposure peak times and continue throughout the season; these are all anti-inflammatory medications

leukotriene receptor antagonist

another allergic rhinitis medication; monitor liver functions periodically and discontinue if there are elevated; they decrease inflammation and make sure to give on an empty stomach

acute viral rhinitis

acute coryza - common cold; duration is 7-10 days with there being a 3 day early stage (runny nose, sore throat), 3 days intermediate stage, and 3 days of recovery; it is 7-10 days if you have a HEALTHY immune system; the agent normally responsible is adenovirus

acute rhinitis - adenovirus

this is spread by airborne droplet (talking, coughing, breathing, sneezing) and hand contact; can live three days on inanimate objects; this is seen commonly in the winter months; *s/s include: tickling/irritation/dryness of the nose, sneezing, nasal secretions, watery eyes, elevated temperature, general malaise, and headache; if it gets worse then there is thicker secretions; chances are increased with stress, elevations of cortisol, and increased tiredness

acute rhinitis - adenovirus (nursing implications, patient education)

nursing implication: rest, fluids which thins secretions, symptomatic relief and herbal remedies; patient education: pharyngitis, sinusitis, otitis media, tonsillitis, and lung infections can occur; if the patient uses intranasal decongestant spray, stop after 4-5 days to avoid rebound congestion; patient should look for sputum changes, shortness of breath, and chest tightness which can mean that the patient has an infection

e) itchiness/ red blotchy area on skin

which defining clinical symptom are typically present and more pronounced in allergic response v common cold?

a) rhinorrhea

b) epiphora (watery eyes)

c) myalgia

d) sneezing

e) itchiness/ red blotchy area on skin

influenza: how is it spread and s/s

it is a virus (type A and B) that is spread by droplet and inhalation or particles; s/s (presentation) include abrupt onset (hits like a truck), high fever, headache, myalgia, malaise, cough (dry/nonproductive), sore throat, and diffuse crackles and dyspnea are complications from the flu

influenza (general info)

spread by coughing and sneezing by people with the flu and touching objects with influenza virus then touching nose or mouth; symptoms usually subside in 7 days but it is very miserable; most common complication is PNEUMONIA (mainly elderly) and they need ABX to treat

anyone older than 6 months

who should get the flu vaccine?

inactivated vaccines

given via injection; approved for people 6 months of age or older; can be used in people at increased risk for: people of any age with chronic medical conditions, residents of nursing homes and long term care facilities, immunocompromised, and pregnant woman (after the first trimester)

live attenuated influenza vaccines

administered via nasal spray; given to healthy people ages 2-49; given to only non-pregnant healthy people; this is a weakened but live vaccine; they will more than likely feel malaise and might spike a fever because it is a live virus but they will get over it

contraindications for the flu vaccine

the patient has a history of Guillian-Barre' Syndrome, hypersensitivity to eggs, allergic reaction to prior reactions, and a recent illness (needs to be fever free for 24 hours before they get the flu shot)

symptom management of the flu

general symptom control is having the patient maintain fluid intake, take analgesics and rest; try to prevent a secondary infection; antivirals that are approved: oseltamivir phosphate (Tamiflu), zanamivir (relenza), peramivir (rapivab), and baloxavir marboxil (xofluza); these medications are all neurominidase inhibitors which stop the cell-to-cell replication of the flu

sinusitis

blocked sinus outlet that allows mucous to collect and grow because of swelling; acute happens after upper respiratory infection, allergic rhinitis, swimming and dental treatments; sub acute lasts about 4-8 weeks and chronic is more than 8 weeks, and both are harder to clear and ABX need to be used; the virus enters and slows the cilia, which causes stasis of fluid in the nose which are breeding grounds for bacteria and fungi

acute sinusitis presentation

headache (dependent - bend over and then stand up = headache), purulent nasal drainage, pain over sinus cavities, congestion, malaise, and fever

nursing implications for sinusitis

- warm compresses (opens everything up)

- increased humidity (steam shower to help get everything out)

- push fluids (6 to 8 glasses a day and this thins secretions)

- decongestants/expectorants to help improve swelling

- saline nasal spray (clear passages)

- analgesics for pain relief

- if temperature is greater than 100.4 then notify provider

- antibiotics (must take ALL MEDS)

- 4 to 6 weeks ob ABX for chronic sinusitis (typically Amoxicillin then give a macrolide like Azythromycin and Fluroquinolone

nasal polyps

benign mucous membrane masses that form slowly in response to repeated inflammation of the sinus or nasal mucosa; etiology: recurrent sinus infections, allergies, and the inhalation of irritants like cocaine; they are white and gray in color and are removed endoscopically; the patient might be mouth breathing and have clear but not infected drainage

manifestations of nasal polyps

partial airway obstruction, may see mouth breathing, nasal speech, clear drainage from nares, and the treatment is that they are removed but they tend to reoccur

foreign bodies in the upper respiratory tract

usually seen in children; may cause no symptoms or may cause a local inflammatory reaction and there can be foul smelling and purulent nasal discharge; the foreign body needs to be identified quickly; avoid installing water to flush it out; attempt to grasp or remove; try to get them to sneeze it out; most of the time it is peas, corn legos or cotton; no s/s at first but can lead to the smelly discharge

pharyngitis

acute inflammation of walls of the pharynx; causes: viral 90% of the time, with bacterial and fungal being the other 10%; they will have a sore throat or strep if its bacterial; can happen from the over use of corticosteroids therapy for COPD patients

presentation of pharyngitis

scratchy to painful throat; viral and strep have red edematous pharynx, with or without patchy yellow exudates; swollen lymph nodes; part of viral nodes

nursing implications of pharyngitis

do culture or rapid strep test to determine the cause; ABX if it is strep throat; if candida then treat with nystatin (fungal infection); fluids; saline gargles; tylenol; do not have them take citrus because it is hard on the throat so give jello and warm fluids, and NO ORANGE JUICE

complications of pharyngitis

rheumatic heart disease and acute glomerularnephritis

peritonsillar abscess

this is a complication of acute pharyngitis or tonsillitis due to bacterial invasion; symptoms include asymmetrical swelling of tonsils which THREATEN THE AIRWAY, high fever, leukocytosis, chills, and difficulty swallowing with a sense of fullness in their throat; treatment is IV ABX or excision, drainage or tonsillectomy

head and neck cancer

usually SQUAMOUS CELL in nature, and is slow growing; can involve the paranasal sinuses, oral cavity, nasopharynx, oropharynx, and the larynx; more likely in men; this means the potential loss of voice, permanent disfigurement and social consequences, and it can also effect breathing and eating; the diagnosis is usually late; risk factors include tobacco use and alcohol abuse, as well as long term exposure to harmful chemicals (chemical plant) and HPV

clinical manifestations in head and neck cancer

- mouth ulcers that do not heal

- change in the fit of dentures

- unilateral sore throat (we are bilateral beings so if unilateral then there is a problem)

- lump in the throat

- pain referred to ear (unilateral)

- hoarseness or change in voice

LATE STAGES

- dysphagia or aspiration with swallowing

- pain

- weight loss, anorexia (LOSS OF APPETITE)

- airway obstruction/tracheal deviation/dyspnea

- any smoker that abuses alcohol and has a lump in the throat for more than 2 weeks needs to see a doctor immediately

diagnosis of head and neck cancer

- x rays

- MRI/ CT (GOLDEN STANDARD)

- PET scan

- laryngoscopy (very important, this is light with a scope): they are NPO and monitor post procedure, also do a biopsy

- make sure to do assessment for allergies/cross allergies and renal function

head and neck cancer treatment - radiation

- hypothyroidism can occur after treatment

- FATIGUE

- side effects: xerostomia (dry mouth)

- surgical approach is the number 1 preferred but it depends on the staging of the diagnosis

- avoid lotion 2 hours before treatment

- used prescribed lotions to area if needed

- make sure they avoid exposure to sun and use sunscreen

how to treat xerostomia in the head/neck cancer patient

- pilocarpine hydrochloride to increase saliva production

- increase in fluid intake to increase saliva

- chew sugarless gum/candy to increase saliva

- nonalcoholic rinses

- artificial saliva

- always carry a drink with them if they are PO

side effects of radiation in the head/neck cancer patient

- patients might have irritation, pain, and ulceration

- eat soft foods that are bland

- rinse with water and suck on ice chips

- avoid harsh mouthwashes and spicy food

- 1:1:1 solution of antacid, Benadryl and lidocaine

cordectomy

this is done in the head/neck cancer patient and it is where the cord is removed

laryngectomy

this is done in the head/neck cancer patient; partial or total (breaths through a stoma); lose natural voice; receive a tracheostomy; total laryngectomy includes the removal of the voice box and epiglottis, radial neck dissection, and permanent trach

total laryngectomy

-they will need a nebulizer

- 6-8 glasses of water a day

- breathe through a stoma

- bypasses the nose and the mouth

- can have soft food but mostly have feeding tube

total neck dissection

this is also known as a radical neck dissection; usually is preformed with laryngectomy to decrease lymphatic spread; cranial nerve 11 is cut and causes a shoulder drop (very severe)

modified neck dissection

this is done as an alternative to a radical neck dissection; preserves the nerves and the vessels; limits disfigurement

pre op for head/neck cancer surgery

educate the patient on speech changes, ways to communicate after surgery (communication board), self care of the airway (yankauer at bed side), pain control and oral hygiene; let the patient know that the patient wont be able to communicate

post op for head/neck surgery

-maintain airway (SEMI-FOWLER'S)

- suction PRN

- VS frequently to monitor for hemorrhage and respiratory problems

- monitor for hemorrhage, pain and infection

- assess wound and drains and change the dressing as ordered (serosanguineous is normal, should decrease over the first 24 hours)

- nutrition: parenternal fluids and enteral nutrition possibly, needs calories and protein if on radiation so that tissue repair can happen

- ASPIRATION PRECAUTIONS ALWAYS

- speech therapy

- support the neck

- psychosocial needs of the patient

- PRIORITY - ASPIRATION, AIRWAY, BLEEDING, NUTRITION

- the patient is at risk for bleeding and infections at suture lines

Blom-Singer (indwelling) voice prosthesis

to speak, the patient has to block the stoma with their finger and pushes air up and out of the mouth - speech is made by moving tongue and lips with vibration across the esophagus

patient teaching for head/neck cancer

- clean area around stoma daily

- teach home trach care and G tube care

- scarf, shirt, or handkerchief to shield the stoma if needed

- ABSOLUTELY NO SWIMMING

- humidified air in the hospital, bedside humidifier at home and fluids are encouraged

- medic alert bracelet - need neck breather

- carbon monoxide/smoke detector installation

- nutritious meals

rib fracture

most common chest injury from trauma; etiology: blow to the chest or a pathological fracture; presentation: pain (especially with inspiration and coughing), splinting or guarding on the affected side, shallow breaths can lead to pneumonia, atelectasis/PNA, bruising on the affected side; TX - decrease the pain to improve ventilation; there is no gas exchange with atelectasis and it comes from the shallow breathing

flail chest

this is an unstable chest wall because of multiple rib fractures; fracture of 2 or more ribs in 2 or more separate locations on the same side can lead to an unstable segment; no longer have stable chest wall to maintain support for ventilation; inspiration: affected side is pulled in; expiration: affected side bulges out; increased workload of breathing

presentation of a flail chest

- rapid, shallow respirations

- tachycardia

- abnormal respiratory movements

diagnosis of a flail chest

evaluate for crepetis near the fractured ribs; chest xray; ABG's

treatment of a flail chest

airway management, oxygen, and pain control

lung cancer

- cigarette smoking is the number 1 risk factor

- primary lung cancer: non small cell is 80% and small cell is 20% (small cell is fast growing)

- common sites for metastasis: liver, brain, bones and the adrenal glands as well the lymph nodes

signs and symptoms of lung cancer

- cough that is persistent and usually productive

- may see hemoptysis but not common

- chest pain that worsens

- hoarseness (laryngeal nerve is impaired)

- dyspnea

- possible wheeze if there is bronchial obstruction

- later can cause anorexia, fatigue, weight loss and n/v

- can be more winded and have fever, chills, blood in spit, and unilateral pain

- usually diagnosed at a later stage

diagnosis of lung cancer

chest x ray, CT being the golden standard, and bronchoscopy in pre and post op care (NPO, meds, take lung tissue)

treatment of lung cancer

- chemotherapy and radiation

- immunotherapy used with patients with tumors that express PD-1

- pain control

- surgery: lobectomy (entire lobe), pneumonectomy (entire lung), segmentectomy (segment of the lobe), or wedge resection

nursing care for the patient with lung cancer

- assess smoking history

- promote adequate nutrition

- encourage high calorie foods

- maintain airway and suction PRN

- high fowlers position

- provide periods of rest

- monitor VS, O2 saturation, monitor for hemorrhage, chest tube and drainage

normal pH

7.35-7.45

PaO2 normal range

80-100 mmHg

PaCO2 normal range

35-45

HCO3 normal range

22-28

acute bronchitis

this is inflammation that involves the bronchi; etiology is usually viral but has the potential to be bacterial; this happens in the LOWER RESPIRATORY TRACT; hallmark is a cough that worsens at night and last about 21 days; mucous is clear or white and they have a low fever

YES

is the lower respiratory tract sterile?

bronchitis - presentation

- lower respiratory issue

- cough

- substernal discomfort with coughing

- wheezing and slight DOE

- low grade fever IF VIRAL

- malaise

- headache

- chest x ray: no consolidation or infiltrates (this differentiates between bacterial and viral bc bacterial will have consolidation)

- inflammation will cause a narrow airway which leads to wheezing

acute bronchitis - nursing implications

- rest

- anti-inflammatory drugs

- encourage fluids: secretions will thin and get easily coughed up

- vaporizer or moisture

- cough suppressor at night

- if bacterial, give ABX

pneumonia

- this acute inflammation in the lungs that produces excess fluid from a microbial organism or aspirated irritants

- inflammatory process: there is edema and exudates in the alveoli

- 8th cause of death in the US

- can be a primary disease or a complication of another condition (aspiration of normal flora, inhalation of airborne microbes, and hematogenous spread)

- classified as community acquired or hospital acquired pneumonia

- the epiglottis closing over the trachea is IMPORTANT because it prevents saliva and food from getting into the STERILE lower lungs

- the invader is hard to clear: COPD patients get ABX prophylactically with simple/complicated issues; they quickly lose their airway which is why we give prophylactically

give the patient oral care q2-4h so they don't get pneumonia

what is something we can do for ICU patients to keep them from having pneumonia?

1) check gastric residual - placement; make sure to give back to the patient since it is their nutrition

2) flush the tube to get gastric residual back into the stomach

3) give the meds

these are the steps to giving medication through an NG tube

PUT TUBE FEEDING ON HOLD - if not, patient at risk for aspiration

what do we need to do with a patient on tube feeding BEFORE we lower the head of the bed?

community acquired pneumonia

- give the patient meds through the PEG tube

- onset is in community or during first two days of the hospital stay

factors that increase risk for PNA

- age (decrease in immune function)

- air pollution

- alcoholism

- decrease in LOC

- tracheal intubation (affecting cough)

- smoking

- malnutrition/poor nutrition

- increase in RT infection

- check gastric residuals because they might aspirate

- diabetics

- altered pharyngeal benefit

- immunocompromised

- bed rest/immobility (turn q2h - more for respiratory to mobilize static secretions and not just blood clots)

hospital acquired pneumonia

- health care associated pneumonia (HCAP)

- ventilator associated pneumonia (VAP)

- high mortality rate

- determine type of PNA so that drug therapy can be initiated

- multi drug resistant organisms is a problem

- acquired 48 hours after or longer after hospital admission

aspiration pneumonia

this is when abnormal secretions or substances enter the lower lungs; mouth or stomach secretions enter lungs; high risk in patients with decreased LOC, decreased swallowing and tube feedings increase the chances so check the gastric residual; do oral care

opportunistic pneumonia

occurs in patients who have suppressed immune systems; highly susceptible to respiratory infections; causative agents: gran negative bacteria, pneumocystis jiroveci, cytomegalovirus, other fungi; transplant, immunocompromised, radiation/chemo, stress can cause this

clinical manifestations of pneumonia

typical

- sudden onset of fever, chills, SOB, productive cough, possibly pleuritic pain, crackles, older adults may only present with confusion or stupor due to decreased gas exchange; most typical

atypical

- gradual onset, dry cough, extra pulmonary manifestations, headache, sore throat, nausea, vomiting, diarrhea, fatigue, and crackles

viral

- chills, fever, dry, nonproductive cough

pleurisy

inflammation of the sac surrounding the lung; sounds like a plural rub

pleural effusion

wide spread vasodilation causing too much space between the sac surrounding the lungs; thoracentesis gets performed to pull fluid

atelectasis

collapsed alveoli with hanging around secretions; cough or deep breath to move surfactant

lung abscess

walled of area of infection; I and D bc they tend to be chronic

empyema

pus in the pleural space

pericarditis

a swelling and irritation of the thin saclike membrane surrounding the heart

meningitis

3 layer membrane around the brain gets infected; bacterial is 100% fatal, get an injection to prevent; increased intracranial pressure is the HALLMARK for this

endocarditis

the inflammation on the valves of the heart

diagnostic studies for pneumonia

- chest x ray: check for consolidation

- give bronchodilators if they are wheezing

- get an accurate history

- physical exam

- sputum culture gram stain (due this prior to ABX and send off within 4 hours of getting it)

- pulse ox and ABG's are always obtained (WILL SEE RESPIRATORY ACIDOSIS, PaCO2 WILL RISE DUE TO FLUID FILLED ALVEOLI)

- labs: leukocytosis (immature WBC)

nursing interventions for pneumonia

- prevent aspiration

- asepsis by good hand washing

- monitor ABGs, oximetry and oxygen

- antipyretics for increased temperature

- TCDB

- limit activity and rest, encourage mobility

- hydration

- nutrition: small and frequent meals

- antibiotic therapy

- monitor complications

- pneumovax recommendations

- influenza

- insentive spirometry

- q2h turning

- chest percussion and vibration can cause release of mucus

tuberculosis

agent: mycobacterium tuberculosis

sites of involvement: primarily in the lung but can involve other body parts

increased risk if they are immunocompromised

seen a resurge of TB in HIV infected patients and multi drug resistant strains

#1 cause of death with HIV and AIDS

not highly contagious in the healthy

mode of transmission of TB

- spread by airborne precautions

- inhale and set up in alveoli

- multiples slowly and spreads via lymph system then spreads to other organs/locations

- those infected will always have positive PPD so do x ray to confirm if it is active or not

latent TB

-asymptomatic

- not active TB

- patient does not feel sick

- TB is found in the body, fought off by the immune system

- cannot spread TB

- usually positive PPD

- normal chest x ray

- negative sputum smear

- needs treatment to keep it not active, usually ISONIZID

active TB

- symptomatic

- fatigue

- weight loss and anorexia

- low grade fever

- chills

- night sweats

- cough productive may contain blood

- can be spread to others

- abnormal chest x ray, positive PPD and positive sputum smear

diagnosis of TB

tuberculin skin test - uses PPD best way to diagnose latent TB, occurs 2-12 weeks after infection for positive results, look for induration 48-72 hours after injection, and once positive don't do because it will always be positive; CXR can't diagnose but good to have; bacteriologic studies - early morning smears for 3 days in a row; QUANTIFERON TB - blood test to check for latent and active TB, and results are back within a few hours*; TST - anything +5mm in HIV is positive, and 15 mm for those who are healthy

nursing implications

- most TB is treated on an outpatient basis

- if hospitalized use airborne isolation

- active TB treatment: Isoniazid, Rifampin, Ethambutol, Pyrazinamide (make sure to monitor liver enzymes)

- latent TB: Isoniazid, orally daily for 6-9 months

airborne infection isolation

- done if hospitalized

- negative pressure room

- pt cover mouth with tissue, nose when coughing, sneezing then discard

- hand washing

- if patient leaves the room, need to wear isolation mask

- masks for hospital personnel

- need 3 negative sputum smears for acid fast bacili, effective response to drug therapy and clinically improving signs to diagnose a patient as non infected

-edema

-secretions

- bronchospasm of smooth muscle

what can cause airway obstruction

asthma

- chronic inflammatory disorder of the airways; chronic inflammation in the air way that leads to hyperresponsiveness which leads to smooth muscle spams and limits airflow acutely; usually reversible; mucosal edema and thick secretions can also block the airway; wheezing, chest tightness, cough, and hard to catch their breath; RESULTS ARE AIRWAY OBSTRUCTION

triggers for asthma

- genetics

- obesity

- allergens

- exercise

- air pollutants

- nose and sinus problems

- psychological factors

- occupational factors

- respiratory infections

- drug and food additives

- GERD (acid triggers narrowing)

asthma presentation

- wheezing

- breathlessness

- chest tightness

- cough

- tachypnea

- use of accessory muscles

- sitting upright

- restlessness

- anxiety

- trouble speaking

- decreased breath sounds

- silent chest

- patient can eventually brady down and go into cardiac arrest

4 classifications of asthma

step 1 - intermittent, no more than twice a week

step 2 - mild, symptoms more than twice a week

step 3 - moderate, daily symptoms

step 4 - severe persistent, continuous with frequent exacerbations and limit quality of life

complications of asthma

- status asthmaticus: life threatening asthma attack bc unresponsive to common treatment; dyspnea at rest, speaks about 1 word a breath, usually sitting forward, rr greater than 30, hr greater than 120, use of accessory muscles, agitation, evidence of poor gas exchange; as it progresses, no wheezing is heard, there is bradycardia, and impending respiratory failure; GIVE ALBUTEROL (BETA 2 AGONIST) TO DILATE EVERYTHING BUT IF THEY DO NOT WORK THEN IT LEADS TO THIS PROCESS; O2 demand imbalance which increases the strain on the right side of the heart

diagnosis of asthma

history and physical examination, if they are not in an acute distress; peak flow variability or spirometry; pulmonary function tests; chest x ray can show hyperinflammation

nursing care of patients with asthma

-assessment

- education: avoid triggers, use of inhalers/nebulizers, and cease smoking

- apply oxygen as prescribed

- high fowlers position

- keep the patient calm

- initiate/maintain IV access

- monitor FEFR daily at home

_ drug therapy

long term control medications for asthma

anti-inflammatory drugs: corticosteroids , Leukotrine, Omalizumab

bronchodilators: long acting inhaled beta 2 adrenergic agonist (ALBUTEROL) , long acting oral beta 2 adrenergic agonist, and anticholinergics

quick relief medications for asthma

anti-inflammatory drugs: corticosteroids

bronchodilators: short acting inhaled beta 2 adrenergic agonist like Albuterol, and anticholinergic drugs (inhaled) like Atrovent