Medsurg I Exam 3

Pneumonia

An infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus

Causes of Pneumonia

• Bacteria (streptococcus pneumoniae, haemophilus influenzae, mycoplasma pneumoniae)

• Viruses (influenza, RSV, coronavirus)

• Fungi (pneumocystis jirovecii, cryptococcus, aspergillus)

• Parasites (ascaris lumbricoides, strongyloides stercoralis, toxoplasma gondii)

Types of Pneumonia

• Aspiration pneumonia

• Community-acquired pneumonia (CAP)

• Hospital-acquired pneumonia (HCAP/HAP/VAP)

• HCAP- healthcare-associated pneumonia

• VAP- ventilator-associated pneumonia

Symptoms of Pneumonia

• Cough with mucus or phlegm

• Fever or chills

• SOB

• chest pain

• fatigue

• nausea and vomiting

• sore throat

• gray/bluish skin (cyanosis)

• muscle aches

Treatments

• Antibiotics

• Antivirals

• Antifungals

• Antiparasitics

• Cough medicine

• Fever reducers/pain relievers

Respiratory Health Promotion and Maintenance

• Minimize exposure to inhalation irritants

• Smoking cessation

• Secondhand smoke

5 As of Smoking Cessation

1. Ask- identify tobacco use

2. Advise- urge the patient to quit

3. Assess- determine readiness to quit

4. Assist- support the quit attempt

5. Arrange- plan follow-up

I PREPARE model for Assessing Particulate Matter Exposure

• I- Investigate potential exposures

• P- Present occupation

• R- Residence

• E- Environmental concerns

• P- Past work

• A- Activities

• R- Referrals and Resources

• E- Educate

Respiratory Diagnostic Assessment (HISTORY)

• Resp history

• Smoking (pack-years)

• Drug use (prescribed and illicit)

• Complementary and integrative therapies

• Allergies

• Travel and geographic area of residence

• Family history and genetic risk

• Current health problems

• PND (paroxysmal nocturnal dyspnea)

Respiratory Diagnostic Assessment (PHYSICAL ASSESSMENT)

• Nose, sinuses

• Pharynx, trachea, larynx

• Lungs and thorax

• Other Indicators: skin and mucous membrane changes, general appearance, endurance

Respiratory Diagnostic Assessment (DIAGNOSTICS)

Laboratory Assessment:

• RBC

• ABG

• Sputum specimens

Imaging Assessment:

• Chest x-rays

• CT

Other noninvasive diagnostic assessments:

• Pulse oximetry

• Capnometry and capnography (assess CO2 levels)

• Pulmonary function tests (PFTs

• Exercise testing

Respiratory Diagnostic Assessment (INVASIVE DIAGNOSTICS)

Endoscopic examinations:

• Bronchoscopy

• Thoracentesis

• Lung biopsy

Oxygen Therapy

• Purpose: to relieve hypoxemia (low levels in blood) and hypoxia (low levels in tissues)

• Goal: Use lowest fraction of inspired oxygen for acceptable blood oxygen level without causing harmful side effects

• ABG analysis for assessment and monitoring

Interventions for Oxygen Therapy

• Recognize oxygen hazards

• Check prescription

• Use humidification if delivered at 4L/min or more

• Check skin for pressure points

• Provide mouth care; lubricate nostrils, face, lips

• Clean cannula, mask

• Collaborate with respiratory therapist

Hazards and Complications of Oxygen Therapy

• Combustion (oxygen makes fire burn faster and hotter)

• Oxygen toxicity

• Absorption atelectasis

• Drying of mucous membranes

• Infection

Oxygen Toxicity

Occurs when a patient receives >50% oxygen for more than 24-48 hours

• oxidative stress → cell damage and death

Nursing Safety Actions:

• track oxygen concentration and duration, use lowest level of O2

• notify provider if PaO2 > 90 mm Hg

• use noninvasive ventilation or mechanical ventilation to reduce FiO2 needs

• titrate oxygen down as soon as possible

Symptoms of Oxygen Toxicity

Early Symptoms:

• Dyspnea

• Nonproductive cough

• Substernal chest pain

• GI upset

• Crackles

Progressive Symptoms:

• Decreased lung compliance

• Decreased vital capacity

• Hypoxemia

• Atelectasis

• Pulmonary edema

• Hemorrhage

• Hyaline membrane formation (ARDS-like)

Absorption Atelectasis

• Nitrogen washes out → oxygen diffuses rapidly into blood → alveoli collapse

• Causes crackles and decreased breath sounds

Drying of Mucous Membranes

When oxygen dries out the mucosa it can lead to:

• Tissue injury

• Crusting

• Increased infection risk

• Discomfort

Nursing Safety Actions for Drying of Mucous Membranes with O2 Therapy

• Humidify oxygen when flow is >4L/min

• Ensure oxygen is bubbling through humidifier water

• For artificial airways, use heated nebulizers

• Maintain sterile water in humidifiers

• Drain condensation from tubing using water traps

• Avoid disconnecting tubing for long periods

Nasal Cannula

• Flow rates of 1-6 L/min

• O2 concentration of 24% to 44%

• Flow rate >6L/min does not increase gas exchange because anatomical dead space is full

• Often used for chronic lung disease or long-term therapy

Simple Facemask

• Delivers O2 up to 40-60% for short-term therapy

• Minimum of 5L/min

• Ensure appropriate fit

Partial Rebreather Mask

• Provides 60-75% with flow rate of 6-11L/min

• Patient rebreathes one third exhaled tidal volume

Non-Rebreather Mask

• Delivers highest O2 level (of the low-flow systems)

• Can deliver FiO2 greater than 90%

• Used for unstable clients who may require intubation

• Ensure valves are patent and functional

High-Flow Nasal Cannula

• 30L/min to 60L/min

• Combination of heat and humidity minimizes damage to mucous membranes

Venturi Mask

• Adaptor location between bottom of mask and O2 sources

• Pulls in a proportional amount of room air for each liter flow of oxygen

T-Piece

• Delivers desired FiO2 to clients with tracheostomy, laryngectomy, ET tube

• Aerosol should appear on exhalation side

Noninvasive Positive-Pressure Ventilation (NPPV)

Use positive pressure to keep alveoli open, improve gas exchange

• CPAP

• Volume-limited or flow-limited

• BiPAP

Transtracheal Oxygen Delivery (TTO)

• Long-term delivery of O2 directly into lungs

• Small flexible catheter is passed into trachea through small incision

• Flow rates prescribed for rest, activity

Tracheostomy Complications

• Tube obstruction

• Tube dislodgement and accidental decannulation

• Pneumothorax

• Subcutaneous emphysema

• Bleeding

• Infection

Patient Teaching for Tracheostomy Care

• Tracheostomy tube care

• Shower shield

• Cover loosely with small cotton cloth during the day

• Increase home humidity

• Wear a medical alert bracelet

• Follow-up

Upper Airway Obstruction

• Interruption in airflow through nose, mouth, pharynx, or larynx

• Can be life-threatening

• Early recognition is crucial in preventing complications such as respiratory arrest

• Causes include tongue edema or occlusion and laryngeal edema

Assessment of Upper Airway Obstruction

• Assess cause of partial or complete obstruction

• S/S: diaphoresis, tachycardia, anxiety, elevated BP, hypoxia, hypercarbia, restlessness, sternal retractions

Interventions for Upper Airway Obstruction

• Assess cause

• Suction

• May require abdominal thrusts for foreign body

• Cricothyroidotomy (opening through cricothyroid membrane), tracheotomy

• Intubation

Obstructive Sleep Apnea (OSA)

A common sleep disorder characterized by repeated interruptions in breathing during sleep due to the relaxation of throat muscles, leading to airway blockage

OSA Etiology and Genetic Risk

• Obstruction by soft palate or tongue

• Obesity

• Large uvula

• Short neck

• Smoking

• Large tonsils or adenoids

• Oropharyngeal edema

OSA Assessment and Cues

• History of persistent daytime sleepiness, snoring, GERD

• Physical Assessment: height and weight, jaw, neck, chin, oral cavity, cardiovascular changes can occur

• Psychosocial Assessment: irritability, personality changes, depression

OSA has the potential for abnormal cardiovascular, metabolic, and neural function due to persistent hypoxia and loss of restorative sleep

OSA Diagnostic Assessment

• STOP-Bang questionnaire and others

• Sleep study at home

• Polysomnography

• Monitoring devices

STOP-BANG Questionnaire

• S- Snoring

• T- Tiredness

• O- Observed Apnea

• P- Pressure (BP)

• B- BMI (>35)

• A- Age (>50)

• N- Neck circumference (>40)

• G- Gender (Male at higher risk)

Polysomnography

An overnight sleep study that records:

• Brain waves (EEG)

• Eye movements

• Muscle activity

• Heart rhythm

• Breathing rate, airflow, resp effort, O2 sat

• Body position, snoring, limb movements

OSA Management

Nonsurgical Management:

• Reducing obstruction

• Changes in sleeping position or weight loss

• Position-fixing devices

• CPAP

• Drug therapy

Surgical Management:

• Considered when patient cannot tolerate CPAP or when it doesn’t improve OSA

Main Goal: improving duration of restorative sleep

Epistaxis (Nosebleed)

• Results from trauma, HTN, blood dyscrasia (any disorder affecting the blood, bone marrow, lymph tissue, or clotting proteins)’

• Often occurs after sneezing or blowing nose

• Usual treatment is packing; cauterization may be necessary

• Posterior nasal bleeding → EMERGENCY

• Assess for resp distress, tolerance of devices

• After tubes or packing removed- use petroleum jelly, nasal saline spray, and teach things to avoid

Asthma

• Chronic respiratory condition causing inflammation and narrowing of the airways, leading to difficulty breathing, wheezing, and coughing (reduces gas exchange)

• Characterized by reversible airway obstruction that occurs intermittently

• Can cause life-threatening airway obstruction and death if severe

Two Main Mechanisms of Asthma

1. Inflammation (obstructs the airway lumen)

2. Airway Hyperresponsiveness (exposure to triggers causes bronchoconstriction)

Most adults with asthma have both inflammation and hyperresponsiveness

Triggers of Asthma

• Allergens (dust, pollen, animal dander

• Respiratory infections

• Exercise

• Cold air

• Air pollutants

• Stress

• Medication (Aspirin and NSAIDs)

• GERD

• Upper resp illness

Symptoms of Asthma

• Wheezing

• SOB

• Chest tightness

• Cough (often nonproductive)

• Increased mucus production

Classification of Asthma (Based on Control)

• Well-Controlled

• Partly-Controlled

• Uncontrolled

Well-Controlled Asthma

• daytime symptoms occur 2 or less days per week,

• nighttime symptoms 2 or less times per month,

• reliever medication used 2 or less times per week

• no limitation of activities

• normal lung function (>80%)

Partly Controlled Asthma

• daytime symptoms occur >2 days per week

• nighttime symptoms 1 or more times per week

• reliever medication used >2 times per week

• some activity limitation

• lung function <80% predicted

Uncontrolled Asthma

• Three or more features of partly controlled asthma present in any week

• Frequent exacerbations or hospitalizations

Drug Therapy for Asthma

• Control therapy drugs (used daily)

• Reliever drugs (used to stop an attack)

• Bronchodilators

• Anti-inflammatory agents

Short-Acting Beta₂ Agonists (SABAs) for Asthma

• Albuterol

• Levalbuterol

• Terbutaline

Provide rapid, short-term relief and are used at the start of an attack or before activity likely to trigger asthma

Long-acting Beta₂ Agonists (LABAs)

• Delivered by inhaler, prevent attacks with longer duration of action

• Not for acute attacks

• Ex. formoterol, salmeterol

• Must never be used alone (have a black box warning for it)

Cholinergic Antagonists (Anticholinergics/ LAMAs)

• Block parasympathetic stimulation → increase bronchodilation and reduce secretions

• Short acting: Ipratropium

• Long acting: Tiotropium

Inhaled Corticosteroids (ICSs)

• Reduce inflammation with fewer systemic side effects (anti-inflammatory)

• Ex. fluticasone, budesonide, mometasone

Chronic Obstructive Pulmonary Disease (COPD)

• A chronic inflammatory lung disease that causes obstructed airflow from the lungs

• Includes conditions such as emphysema and chronic bronchitis

• Primarily caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke

• Advanced disease causes CO2 retention which leads to chronic respiratory acidosis and low PaO2 (hypoxemia)

COPD Risk Factors

• Cigarette smoking is the greatest risk factor

• Alpha₁-antitrypsin deficiency

• Age

• Gender (more common in men)

• Occupational Exposures

Complications of COPD

• Hypoxemia

• Acidosis

• Respiratory infection

• Right-sided HF

• Dysrhythmias

• Respiratory failure

I-PREPARE Model

Assesses environmental exposures for COPD

• I-Investigate potential exposures

• P-Present work history

• R-Residence history

• E-Environmental concerns

• P-Past medical history

• A-Activities (hobbies, lifestyle)

• R-Referrals/resources

• E-Educate patients

Signs and Symptoms of COPD

• Dyspnea

• Chronic cough

• Sputum production

• Recurrent lower respiratory infections

• Fatigue

• Abnormal breathing patterns and breath sounds

• Accessory muscle use

• Barrel chest