Respiratory

*Not finished

what are the common causes of sinusitis?

\-result of URI

\-swimming

\-dental procedure

what are the clinical manifestations of acute sinusitis?

feels sick, sinus pain, congestion, fever, malaise, purulent drainage, possible headache

what are the clinical manifestations of chronic sinusitis?

congestion, rarely febrile, facial/dental pain, increased drainage, not easily dx

what are the treatment options for acute sinusitis?

antibiotics for 10-14 days, decongestants, corticosteroids, mucolytics, \*no 1st gen antihistamines\*

what are the treatment options for chronic sinusitis?

difficult to treat, 4-6 wks antibiotics

what is the nursing education for sinusitis?

\-Sleep w/HOB elevated

\-6-8 glasses of water/day

\-nasal saline washes BID

\-hot showers BID

\-warm, damp compresses

\-report 100.4 temp

\-no smoking

what do you want to monitor for sinusitis

fever/symptoms lasting over a week

what diagnostics are there for sinusitis?

nasal culture, CT scan, X-ray, nasal endoscopy

influenza type A is the most common & most virulent

true

when is the peak transmission risk of influenza?

1 day before s/s onset through 5-7 days after becoming ill

How is influenza transmitted

through droplets w/inhaled particles

what are the S/S of influenza?

\-chills, fever

\-myalgias

\-headache

\-cough, sore throat

\-fatigue

Complications of influenza

primary influenza pneumonia or secondary bacterial pneumonia, ear or sinus infx

what are the complications for older adults with the flu

weak and lethargic

Diagnostics for influenza

viral throat culture, rapid-flu test, H&P

what is the key education point for influenza?

prevention with flu shot is the most effective choice; get it in september

what is typical drug treatment for influenza?

\-antivirals: zanamivir (Relenza), oseltamivir (Tamiflu), peramivir (Rapivab)

\-must be started w/in 2 days of sx onset to be effective

what are the risk factors for head & neck cancer?

tobacco products, excess alcohol consumption, age >50, men 2x more likely, sun exposure, radiation to head/neck, asbestos exposure, positive HPV hx, poor oral hygiene

Diagnostics for head and neck cancer

**-indirect pharyngoscopy and laryngoscopy, oral cavity exam**

\-hx & physical, endoscopy, biopsy, CXR, barium swallow

what are the early s/s of head & neck cancer?

\-white or red patch in mouth

\-oral ulcer that does not heal

\-"lump" in the throat

\-voice quality change

\-hoarseness > 2 weeks

\-swelling/lumps in neck

\-coughing up blood

\-throat sore on one side w/ ear pain

what are the later s/s of head & neck cancer?

\-unintentional weight loss

\-difficulty chewing, swallowing, breathing or moving jaw

what are the typical treatments for head & neck cancer?

\-surgical procedures

\-radiation (preferred for early cancer)

\-chemo

\-nutritional therapy

\-physical therapy

\-speech therapy

What surgical procedures are used as treatment for head and neck cancer?

cordectomy, laser surgery, partial/total laryngectomy, lymph node removal, pharyngectomy, tracheostomy; Neck dissection surgery: modified radical neck dissection, radical neck dissection, selective dissection

Anticipated physical/psychosocial needs of a patient with head and neck cancer

\-Communication (assess needs preop- reading/writing ability, offer voice restoration options, hand signals/writing materials)

\-change in body image (plastic collar when showering, can be disfiguring, edema takes weeks to resolve)

\-depression (inability to speak, altered appearance, loss of independence, feelings of hoplessness)

\-Sexuality, support groups

Post-laryngectomy Management Head and Neck cancer: airway

PRIMARY CONCERN immediately postop, humidified oxygen required to keep mucous membranes moist

Post-laryngectomy Management Head and Neck cancer: positioning

keep in semi-Fowler's position at all times to limit edema, prevent suture line tension, promote deep breathing

Post-laryngectomy Management Head and Neck cancer: suctioning

frequent tracheostomy suctioning due to initial serosanguinous drainage, often copious

Post-laryngectomy Management Head and Neck cancer: wound drainage

Jackson-Pratt, Hemovac or both—copious at first, 200 mL/shift not unusual, keep patent & emptied, recorded

Post-laryngectomy Management Head and Neck cancer: nutrition

often have NG tube for feedings later, NPO at first, oral care critical

Post-laryngectomy Management Head and Neck cancer: pain managment

use previously agreed upon tool to communicate, use visual FACES scale to assess

suctioning teaching

ck HR, rhythm, RR, 02 sat before and after suctioning, no more than 3 passes, stop if HR drops 20 bpm or rises 40 bpm from baseline, 02 sat drops below 90%.

Trach care

position in semi-Fowler's, ck breath sounds & suction if needed before care, set up kit, don sterile gloves to remove inner cannula and replace or clean, clean around faceplate, watch for pressure spots, change tapes (2 nurses), place pre-fenestrated gauze to contain drainage

What can be used to help with voice restoration when a patient is being treated for head and neck cancer?

Electrolarynx—easy to learn, mechanical sound quality \n Transesophageal puncture (TEP)— \n Blom-Singer prosthesis—best speech \n quality, highest patient satisfaction \n Esophageal Speech—takes time to learn, reduced voice quality

lung cancer screening should be done:

annually in adults 55-80 with history of smoking; 30 of smoking > 1 pack/day, currently smoking, quit

risk factors for lung cancer

Smoking risk factor accounts for 80-90%, pollution, asbestos

Non-small-cell lung carcinoma (NSCLC)

85%; SCC, Adenocarcinoma, large-cell carcinoma

small cell carcinoma (SCLC)

15%; very rapid growth, poor prognosis

Early manifestations of lung cancer

persistant cough w/sputum (most common), hemoptysis, dyspnea, wheezing, chest pain

later manifestations of lung cancer

anorexia, n/v, fatigue, wt loss, hoarseness, dysphagia, palpable lymph nodes

what are the diagnostics for pneumonia?

\-history & physical exam

\-CXR

\-thoracentesis and/or bronchoscopy

\-pulse ox

\-ABGs

\-sputum gram stain, C&S

\-blood culture: **always needed before antibiotics started**

\-CBC w/ diff

what are the health promotion strategies for pneumonia prevention?

\-hygiene, nutrition, rest & regular exercise

\-cough or sneeze into elbow

\-avoid cigarette smoke\*\*

\-avoid exposure to URIs & get prompt tx

\-influenza & pneumococcal vaccines

what are the most common S/S of pneumonia?

\-cough: productive or nonproductive

\-green, yellow or rust sputum: based on causative organism

\-fever, chills

\-dyspnea, tachypnea

\-pleuritic chest pain

\-tachycardia

What are the symptoms that are seen in older or debilitated patients with pneumonia?

confusion or stupor, hypothermia

what S/S are seen on physical exam of a pt w/ pneumonia?

\-fine or coarse crackles

\-with consolidation: bronchial breath sounds, egophony, increased fremitus

\-with pleural effusion: dullness to percussion\*\*

What are the complications of pneumonia?

**MDR pathogens (MAJOR problem), atelectasis, pleural effusion, sepsis/septic shock**

\-pleurisy, bacteremia, pneumothorax, acute respiratory failure, lung abscess, empyema

To help prevent atelectasis

teaching is crucial; Incentive spirometer, early ambulation, TCDB

S/S of pleural effusion

progressive dyspnea, cough, sharp pain w/inspiration, decreased or absent breath sounds

Thorocentesis

1-1.2L removed, CXR, monitor pulse ox

Elderly considerations of pneumonia:

pleural effision, atelectasis, sepsis

S/S of sepsis

temp change, clammy/sweaty, shaking, decreased HR and BP, extreme pain, disorientation, rapid breathing

community acquired pneumonia

patients who has not been hospitalized or resided in long term care w/in 14 days onset symptoms \n can be treated at home or hospitalized dependent on pt age,VS, mental status, comorbidities, and condition

hospital acquired pneumonia

Streptococcus pneumonia: most common cause \n 48 hours or longer after hospitalized and not present at time of admission \n VAP: ventilator associated pneumonia, occurs more than 48 hours after endotracheal intubation

empire antibiotic therapy

start treatment before definitive diagnosis based on: \n risk factors, early versus late onset, presentation, underlying medical condition, hemodynamic stability, most likely causative organism

what is nursing education for home care for pneumonia?

\-emphasize need to take full course of antibiotics\*\*

\-adequate rest

\-adequate hydration

\-avoid alcohol & smoking

\-cool mist humidifier or warm bath

\-CXR 6-8 wks later, need to get vaccines

\-will take several weeks to recover

what are risk factors for TB?

\-homeless\*\*

\-foreign-born persons

\-IV drug users\*\*

\-overcrowded living conditions

\-poverty, poor access to healthcare\*\*

\-immunosuppression\*\*

how is TB diagnosed?

\-TB skin test (Mantoux)

\-2-step testing

\-blood testing: detects INF gamma release 

\-CXR: cannot make dx solely on this

\-bacteriologic studies

TB skin test (Mantoux):

induration in 48-72 hours; measure induration & record in mm; positive= greater than 15 mm for **low-risk**, greater than 10 mm for **high-risk**, greater than 5 mm for **immunocompromised**

bacteriologic studies: 

**TB culture is gold standard**\*\*, includes 3 consecutive sputum cultures at 8-24 hr intervals (need at least one in early morning)

What other diagnostic tests besides Mantoux can be done for TB?

Chest x-ray, but sometimes the x-ray appears normal so a diagnosis can not be made solely on this

what are the S/S of pulmonary TB?

\-initial: dry cough that becomes productive

\-late: dyspnea & hemoptysis

\-others: fatigue, malaise, anorexia, low-grade fever, night sweats

what are the drug treatments for active TB?

\-initial: 8 wks-3 mos of isoniazid, rifampin, pyrazinamide, ethambutol 

\-continuation: 18 wks of isoniazid & rifampin

What interprofessional care for TB would be introduced if the pt’s sputum tests positive

restrict visitors/limit public exposure, hand and oral hygiene; for first two weeks

what are the top ADRs to be aware of for TB drugs?

\-isoniazid: hepatitis

\-rifampin: hepatitis, red-orange body fluids

\-pyrazinamide: hepatitis

\-ethambutol: ocular toxicity

what is acute nursing care for TB?

\-airborne isolation: 6-12 air exchanges/hr

\-immediate medical workup: CXR, sputum smear & culture

\-appropriate drug therapy

\-identify & screen close contacts

what is patient education related to TB?

\-monthly sputum cultures, until 2 consecutive cultures are negative= noninfectious

\-teach on minimizing exposure to others

\-notify public health dept

\-smoking cessation

How is TB spread?

airborne droplets (can be suspended in air for minutes to hours)

what are the S/S of lung cancer?

\-most common: pneumonitis, persistent cough w/ sputum

\-hemoptysis, dyspnea, wheezing, chest pain

\-later: anorexia, fatigue, N/V, hoarseness, unilateral paralysis of diaphragm, dysphagia, superior vena cava obstruction, palpable lymph nodes, mediastinal involvement

what are the diagnostics for lung cancer?

\-CXR initial

\-CT scan for further evaluation

\-lung biopsy for definitive dx

\-pleural fluid analysis

\-bone scan: for metastasis

\-CT scans of brain, pelvis, abdomen: for metastasis

\-CBC w/ diff

\-chemistry panel

\-liver, renal & pulmonary fx tests

\-MRI, PET scan: evaluate & stage

when should lung cancer screenings be preformed?

annually for adults 55-80 w/ smoking hx

what is the key point in education related to lung cancer?

SMOKING CESSATION

Nursing Dx for pneumonia

Impaired gas exchange

Impaired breathing

Fluid imbalance

Hyperthermia

Activity intolerance

planning and goals of pneumonia

Clear breath sounds

Normal breathing patterns

No signs of hypoxia

Normal chest x-ray

Normal WBC count

Absence of complications

Lung cancer surgical therapy

Treatment for early stage NSCLC \n survival is related to size of primary tumor, comorbidities \n NOT INDICATED FOR SCLC (bc metastasized)

Chemo therapy for Lung cancer

Primary treatment for SCLC

Treatment of unresectable tumors or adjuvant to surgery in NSCLC

Variety of protocols

Typically a combination of two or more drugs (combination therapy)

Interproffesional care for Active TB

Patients should be taught about adverse/side effects and when to seek medical attention \n Nonviral hepatitis is a major side effect for 3 of 4 first-line drugs; liver function tests should be monitored \n Alternatives are available for those who develop a toxic reaction to primary drugs

Interprofessional care for latent TB

Usually treated with Isoniazid for 6 to 9 months (See Table 27-13) \n HIV patients and those with fibrotic lesions on chest x-ray should take Isoniazid for 9 months \n Alternative 3-month regimen of Isoniazid and rifapentine OR 4 months of rifampin

What is the Bacille-Camette-Guerin (BCG) vaccine?

Live, attenuated strain of Mycobacterium bovis \n Given to infants in parts of world with high prevalence of TB

Why is the BCG vaccine not reccommended in the United States?

low risk of infection except for select individuals \n BCG vaccine can result in false positive

Pneumonia supportive care

o2 for hypoxemia, analgesics for chest pain, antipyretic for fever, adjuvant drugs, individualized rest and activity

Pneumonia clinical manifestations

cough (productive/non-productive); green, yellow, or rust colored sputum; fever, chills, dyspnea, tachycardia, pleuritic chest pain

Pneumonia clinical manifestations in older adults or debilitated patients

confusion/stupor, hypothermia

What appears with a physical examination of pneumonia

fine or course crackles

w/consolidation: bronchial breath sounds, egophony, increased fremitus

w/pleural effusion: dullness to percussion

complications of pneumonia

atelectasis, pleural effusion

Atelectasis Clinical manifestations

Chest pain, Shortness of breath, Lips and skin turning blue, Coughing, Increased HR

Atelectasis nursing managment

incentive spirometer, early ambulation, TCDB

Pleurisy Clinical Manifestations

Abrupt, sharp onset of pain - Worse with inspiration

Pleural friction rub-This is the sound heard over areas where inflamed visceral pleura and parietal pleura rub over one another during inspiration

May sound like a squeaky door, loudest at inspiration

Breathing is shallow and rapid

Plural effusion Clinical manifestation

Dyspnea, Cough; Occasional sharp, non-radiating chest pain that is worse on inhalation

Physical examination may show a decreased movement of chest pain on affected side

Decreased breath sounds over affected area

Dullness to percussion

Cor Pulmonale Clinical Manifestations

Exertional dyspnea, Tachypnea, Cough, Fatigue, Symptoms of right-sided HF, Peripheral edema, Weight gain, Distended neck vein; Full, bounding pulse; Enlarged liver

what is management & treatment of cor pulmonale?

\-long term O2 therapy

\-low sodium diet

\-bronchodilators

\-diuretics

\-vasodilators (if needed)

\-CCBs (if needed)

\-inotropic agents

what are triggers for asthma?

\-allergens

\-irritants: tobacco smoke, air pollutants

\-drugs: beta-blockers, ACE inhibitors

\-exercise

\-nose and sinus problems: allergic rhinitis, chronic sinusitis, viral URIs

Clinical manifestations of asthma

wheezing, coughing, dyspnea, chest tightness, hyperinflation & prolonged expiration due to air trapping

\-decreased/absent breath sounds can occur w/ exhaustion or inability to have enough muscle force for breathing

\-**silent chest**: ominous sign, severe obstruction or impending resp failure

Wheezing may get louder as airflow increases (T/F)

True

what are the diagnostics for asthma?

\-detailed history & physical

\-peak expiratory flow rate (PEFR)\*\*

\-spirometry

\-allergy testing to identify triggers

\-oximetry; ABGs (eosinophils

\-CXR: rules out other disorders

\-sputum culture & sensitivity

what is acute nursing care for asthma?

\-goal: maximize patient's ability to safely manage acute asthma using an action plan

\-plan based on sx & PEFR & when & what to change is needed to gain control 

\-monitor resp & CV systems

\-decrease pt anxiety & sense of panic

what are the health promotion teachings for asthma?

\-weight loss

\-fluid intake of 2-3 L every day

\-good nutrition

\-adequate rest

\-exercise; pretreatment plan if needed

what are drugs used for asthma treatment?

bronchodilators, corticosteroids (oral or inhaled**),** leukotriene modifiers, B-adrenergic agonists (SABA & long acting),

Peak flow results: green zone

80-100% of personal best, remain on medications

Peak flow results: yellow zone

usually 50-80%, indicates caution, something is triggering asthma

Peak flow results: red zone

50% or less of personal best, indicates serious problem, definative action must be taken w/HCP

Complications of asthma

severe and life threatening exacerbations: RR >30/min, dyspnea at rest, feeling suffocated, pulse >120/min, PEFR 40% at best

life-threatening asthma: to dyspneic to speak, perspiring profusly, drowsy/confused, PEFR