Upper and Lower Respiratory Problems Part 1

NUR 406: Chronic Health, MCSON, Dr. Crouch

what is a nosebleed also called

epistaxis

what are some things a nosebleed (epistaxis) can be caused by

• trauma

• hypertension

• low humidity

• upper respiratory tract infections

• allergies

• sinusitis

• foreign bodies

• chemical irritants (drugs)

• overuse of decongestant nasal sprays

• facial/nasal surgery

• anatomic malformation

• tumors

bleeding time for a nosebleed (epistaxis) may be prolonged if patient is taking NSAIDs/ASA, warfarin, and other _____

anticoagulants

list some nursing management for a nosebleed (epistaxis)

• calm the patient

• place patient in sitting position, leaning slightly forward with head tilted forward

• apply direct pressure by squeezing soft lower portion of nose together for 5-15 minutes

if a nosebleed (epistaxis) does not stop in ___ minutes, seek medical attention

15

medical management for a nosebleed (epistaxis) involves identifying location of bleed. may be difficult in _____ bleeds

posterior

list some medical management for nosebleeds (epistaxis)

• nasal tampon with lidocaine or epinephrine

• cellulose, surgical foam, or other soft sealants may be packed

• thermal cauterization with local or genera anesthesia in severe cases

packing a nose/nostril to stop a nosebleed (epistaxis) can impair _____ - monitor _____!

breathing; vitals

*packing a nose/nostril to stop a nosebleed may be painful!!!

packing a nose/nostril to stop a nosebleed (epistaxis) should be left in for ___ to ___ days

2 to 3

list some discharge teaching for a nosebleed (epistaxis)

• humidifying air

• nasal spray

• sneezing with mouth open

• NSAID use

• avoid vigorous nose blowing, strenuous activity, lifting, and straining for 4 to 6 weeks

what is inflammation of nasal mucosa in response to a specific allergen (seasonal, intermittent, etc.)

allergic rhinitis

list some s/s for allergic rhinitis

• sneezing

• watery eyes and nose

• altered sense of smell

• thin, watery nasal discharge and congestion

• headaches

• postnasal drip leads to cough

list some meds for allergic rhinitis

• antihistamines (diphenhydramine, loratidine, cetirizine)

• decongestants (pseudoephedrine)

• leukotriene receptor antagonists (montelukast)

• corticosteroid sprays (fluticasone)

what does 1 out of 7 adults have

sinusitis

what is inflammation and swelling blocks the openings in the sinuses, causing a buildup of drainage

sinusitis

list some s/s of sinusitis

• rhinosinusitis

• nasal polyps

• foreign bodies

• deviated septum

• tumors can block sinuses

sinusitis usually resolves with no treatment but can develop into a _____ _____

bacterial infection

to prevent sinusitis, reduce _____ that may cause inflammation

allergens

list some meds for sinusitis

• decongestants

• intranasal corticosteroids

• analgesics

• saline nasal spray

• antibiotics if symptoms persist > 1 week

*sinusitis may be acute, subacute, chronic, persistent, and recurrent

persistent reoccurrences for sinusitis may require _____ _____ to relieve blockages

endoscopic surgery

what is a surgically created stoma (opening) in the anterior portion of the trachea

tracheostomy

a tracheostomy may be performed to (what 5 things):

1. establish an airway

2. bypass upper airway obstruction

3. facilitate removal of secretions

4. permit long term mechanical ventilation

5. facilitate weaning from mechanical ventilation

*a tracheostomy can be cuffed Inflated to hold tube in place) or uncuffed (better for long-term chronic patients, allow patients to eat, drink, and speak)

list some care of the patient with a chronic tracheostomy

1. observe/assess site for breakdown

2. cleaning the site and inner cannula

3. tracheal suctioning

how often should the site and inner cannula of a patient with a tracheostomy be cleaned

usually once per day

*if patient cannot protect airway, will need an inflated cuff, but this may cause issues with muscles for swallowing. speech therapists can help determine if a chronic trach patient can be safe to swallow without cuff

*chronic trach patients may wish to have their cuffs deflated, which allows air to flow over their vocal cords. a speaking valve can then be placed over the tracheostomy opening. assess for signs of distress

what is removal of the tracheostomy form the trachea. done after the initial issue had resolved. patient must meet the following:

1. be hemodynamically stable

2. have a stable, intact airway and respiratory drive

3. be able to adequately exchange air and clear secretions (post decannulation, cover site with sterile occlusive dressing and monitor for response)

decannulation

NCLEX QUESTION!

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? (Select all that apply) 1.       Auscultating breath sounds 2.       Administering medications via metered-dose inhaler 3.       Completing in-depth admission assessment 4.       Checking oxygen saturation using pulse oximetry 5.       Developing nursing care plan 6.       Evaluating the patient’s technique for using MDIs

1, 2, 4

what is an infection of the lung parenchyma

pneumonia

pneumonia is more likely when defense mechanisms become incompetent or overwhelmed

1. tracheostomy, air pollution, smoking, viral URIs, aging, chronic diseases can all impair mechanisms \

2. aspiration, inhalation (bacterial and fungal), hematogenous spread from other source (strep, staph)

which kind of pneumonia is when the patient has not been admitted to a hospital or long-term care in the last 14 day and requires empiric antibiotic therapy.

community acquired therapy (CAP)

what is nosocomial pneumonia (pneumonia in a nonintubated patient that begins 48 hours or longer after admission to hospital and was not present at time of admission)

hospital acquired pneumonia (HAP)

for hospital acquired pneumonia (HAP), treatment can be made difficult due to _____-_____ resistant organisms

multi-drug

what are some risk factors for hospital acquired pneumonia

• immunosuppression

• age

• antibiotic use

• prolonged MV

what kind of pneumonia occurs from abnormal entry of material from mouth or stomach into trachea/lungs

aspiration pneumonia

what are some risk factors for aspiration pneumonia

• decreased LOC

• difficulty swallowing

• NG tubes

which pneumonia is a rare complication of bacterial lung infection; liquefaction/cavitation of lung tissue, often after CAP. Staph, Klebsiella, Strep

necrotizing pneumonia

what are some s/s of necrotizing pneumonia

• immediate respiratory insufficiency and/or failure

• leukopenia

• bleeding into airways

which pneumonia occurs as a result of immunocompromise, HIV/AIDs, malnutrition, radiation/chemo, long-term corticosteroid use

opportunistic pneumonia

what kind of pneumonia nearly only occurs in patients with HIV. Fungal infection, but does not respond to antifungals; trimethoprim/sulfamethoxazole (Bactrim, Septra)

P. jiroveci pneumonia (PIP)

list some manifestations of pneumonia

• cough (may or may not be productive)

• fever

• chills

• dyspnea

• tachypnea

• pleuritic chest pain

• confusion, stupor (older adults)

• hypothermia (older adults)

• fine or coarse crackles

• bronchial breath sounds

• fremitus

list some complications of pneumonia

• atelectasis

• pleurisy

• pleural effusion

• bacteremia

• pneumothorax

• meningitis

• acute respiratory failure

• sepsis/septic shock

• lung abscess (may occur with staph)

what are some planning/goals for pneumonia

• clear breath sounds

• normal breathing pattern

• no signs of hypoxia

• normal chest XR

• absence of complications

what is some implementation for pneumonia

• educate on hand hygiene, proper nutrition, adequate rest, regular exercise

• stop smoking

• avoid individuals with colds, URI; rest and hydrate if patient becomes sick

• place patients who have ALOC in positions to decrease aspiration

• assist unsafe patients with eating and drinking

• turn frequently, encourage coughing and deep breathing

• practice medical asepsis and infection control guidelines

• appropriate antibiotic stewardship

NCLEX QUESTION!

You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to the UAP? 1.       Teaching the patient about the importance of adequate fluid intake and hydration 2.       Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3.       Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4.       Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two to three times in succession

3

what is an infectious disease caused by mycobacterium tuberculosis

tuberculosis

tuberculosis usually involves the _____, but can involve any organ including the brain, kidneys, and bones

lungs

what is the leading cause of mortality in patients with HIV; also strains of MDR TB (resistant to 2 of the first line treatments, either rifampin or isoniazid)

tuberculosis

tuberculosis transmission is _____ and can remain in the air for hours, but does not survive on surfaces for contact transmission

airborne

*likelihood of tuberculosis transmission increases:

1. due to number of organisms expelled

2. if there is a higher concentration (smaller space, limited ventilation)

3. longer length of time exposed

4. immune system of person infected

what are the 4 classifications of tuberculosis

1. primary

2. latent TB infection

3. active TB disease

4. post-primary TB

what classification of tuberculosis occurs when bacteria are inhaled and initiate an inflammatory reaction (doesn’t always progress to active if immune response is adequate). active disease that develops within first 2 years of infection.

primary

what classification of tuberculosis occurs when an individual does not have active, symptomatic TB but does have exposure (AEB: positive TBST, quantiferon gold). bacteria can be activated in future if immune response decreases (immunosuppression, diabetes, pregnancy, poor nutrition, aging, pregnancy, stress, chronic disease, ect.)

latent TB infection

what classification of tuberculosis is symptomatic and occurs when the immune response is not adequate

active TB disease

what classification of tuberculosis is reactivation TB and occurs 2 or more years after initial infection

post-primary TB

what are some clinical manifestations of tuberculosis

• occur 2 to 3 weeks after infection or reactivation

• fever, chills, night sweats

• flu-like symptoms

• pleuritic pain

• productive cough (can be sputum or blood)

• weight loss, loss of appetite

• immunosuppressed individuals may not have fever or signs of infection

• extrapulmonary TB symptoms are dependent on organ involved

list some ways to diagnose tuberculosis

• TB skin test

• interferon release assays

• chest XR

• bacteriologic studies

*drug therapy for active disease is usually a combination of 4 drugs: isoniazid, rifampin, pyrazinamide, and ethambutol. directly observed therapy is utilized. nonadherence is a big factor in emergence of MDR.

*drug therapy for latent disease usually only needs one drug, 9 months of daily isoniazid; 6 months isoniazid or 3 months isoniazid and rifapentine may be used instead

_____-_____-_____ vaccine is given to infants in areas with high risk of tuberculosis; not usually used in US

bacille-calmetter-guerin

NCLEX QUESTION!

When a patient with TB is being prepared for discharge, which statement by the patient indicates a need for further teaching? 1.       “Everyone in my family needs to go and see the doctor for TB testing.” 2.       “I will continue to take my isoniazid until I am feeling completely well.” 3.       “I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.” 4.       “I will change my diet to include more foods rich in iron, protein, and vitamin C.”

2

what is an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs

pulmonary edema

what is a complication of various different heart (CHF) and lung diseases (pneumonia, ARDs)

pulmonary edema

list some other causes for pulmonary edema

• overhydration with IVF

• hypoalbuminemia (nutritional disorders)

• hepatic/renal diseases

• near drowning

• inhaled toxins

• lymph malignancies

• O2 toxicity

treatment for pulmonary edema is to treat _____ cause

underlying

what medication should be administered for pulmonary edema

furosemide (Lasix)

what is elevated pulmonary artery pressure resulting from an increase in resistance of blood flow through pulmonary circulation

pulmonary hypertension

what are the two classifications of pulmonary hypertension

1. primary (idiopathic)

2. secondary (with an apparent cause)

*by the time a patient with pulmonary hypertension becomes symptomatic, the disease is usually in advanced stages

how many groups of pulmonary hypertension are there

5

list the 5 groups of pulmonary hypertension

1. pulmonary artery hypertension attributable to medication, specific diseases, genetic links, or idiopathic

2. R/T left sided heart failure

3. R/T the lungs and hypoxemia

4. related to the cardiovascular system and thromboembolic occlusion

5. multifactorial origins with hematologic or metabolic involvement

list some clinical manifestations of pulmonary hypertension

• most common = dyspnea on exertion and fatigue

• exertional chest pain

• dizziness/syncope

• abnormal heart sounds (S3)

• dyspnea at rest as disease progresses

• right ventricular hypertrophy (as a result of increased workload of the right ventricle called cor pulmonale) and heart failure

list some ways to diagnose pulmonary hypertension

• heart catheterization

• EKG

• chest x-ray

• pulmonary function tests

• CT echocardiogram

list some nursing management for pulmonary hypertension

• early recognition; educate patients to report unexplained shortness of breath, syncope, chest discomfort, and edema of hands and feet

• drug therapy to promote vasodilation of pulmonary blood vessels, reduce right ventricular overload, and reverse remodeling

• diuretics, O2, anticoagulants

what is a common inherited disease characterized by a combination of clinical manifestations along with reversible expiratory airflow limitation

asthma

what are some s/s of asthma

• wheezing

• breathlessness

• chest tightness

• cough

when do s/s of asthma particularly occur

at night and early morning

*asthma is widespread but variable airflow obstruction that is usually reversible

list some risk factors/triggers for asthma

• genetics

• allergens

• air pollutants

• respiratory tract infections

• food and drug additives

• psychological factors

• immune response

• exercise

• occupational factors

• nose and sinus problems

• GERD

list some nursing assessments to gather from a patient with asthma

• health history

• precipitating factors

• what helps the pt personally with symptoms and attacks

• herb and supplement use

• inhaler use

• head to toe assessment

list some nursing planning for pt with asthma

1. minimal symptoms during the day and night

2. acceptable activity levels

3. maintenance of >80% of PEFR (peak expiratory flow rate)

4. few or no adverse effects of therapy

5. no acute exacerbations of asthma

6. adequate knowledge to participate in and carry out the plan of care

what is some nursing implementation for a pt with asthma

health promotion

NCLEX QUESTION!

Which information will the nurse include in the asthma teaching plan for a patient being discharged? 1.       Use inhaled corticosteroid when shortness of breath occurs 2.       Breathe through your nose when using the dry powder inhaler 3.       Hold your breath for 5 seconds after using the inhaler 4.       Tremors are an expected side effect of rapidly acting bronchodilators

4

what is a preventable and treatable disease characterized by persistent airflow limitation that is usually progressive

chronic obstructive pulmonary disease (COPD)

the defining feature of COPD is not fully reversible _____ limitation during forced exhalation

airflow

*chronic obstructive pulmonary disease is loss of elastic recoil and airflow obstruction

chronic obstructive pulmonary disease is associated with an enhanced chronic inflammatory response in the airways and lungs primarily caused by _____ _____ and other noxious particles and gases

cigarette smoking

*COPD exacerbations and other coexisting illnesses or co-morbidities contribute to the overall severity of the disease

what is the destruction of the alveoli and is a pathologic term that explains only one of several structure abnormalities in COPD patients

emphysema

what are some factors that can influence the development and progression of COPD

• smoking

• infection

• asthma

• occupational chemicals/dust

• genetics

• gender

• air pollutants

• aging

*Inflammatory process from inhaled noxious particles -> tissue destruction and disruption of normal repair of lung -> alveoli are irreparably damaged and lungs lose elastic recoil -> air becomes trapped, causing large volumes of residual air -> hypoxemia and hypercapnia occur -> excessive mucous forms -> pulmonary hypertension occurs late

what are some manifestations that may develop slowly for COPD

1.       Chronic cough with/without sputum production

2.       Dyspnea (on exertion in early stages, at rest in later stages)

3.       Wheezing, chest tightness

4.       Fatigue, weight loss, anorexia in later stages

5.       Prolonged respiratory phase, wheezes, decreased breath sounds on auscultation

6.       Barrel chest from chronic air trapping

7.       Pursed lip breathing and accessory muscle use

8.       Edema in ankles if right sided heart involvement

9.       Cyanosis/polycythemia with chronic hypoxemia/hypercapnia

what are some ways to diagnose COPD

1.       History and physical extremely important

2.       spirometry confirms airflow obstruction and determines severity

3.       CXR may show flattened diaphragm because of hyperinflated lungs

4.       ABGs – hypoxia, hypercapnia

5.       Echo – evaluates heart function/workload

6.       Sputum/culture/sensitivity with acute exacerbations, R/O infection

what is some nursing management for COPD

1.       Education on smoking cessation

2.       Drug therapy: Medications are made in stepwise fashion, similar to asthma, based on spirometry results and patient condition/response

1.       Beta-adrenergic agonists, anticholinergic agents, methyxanthines

2.       Long acting bronchodilators (moderate stages)

3.       Short acting bronchodilators (for acute attacks)

4.       Inhaled corticosteroids

5.       Theophylline, roflumilast

6.       Diuretics, if CHF/cor pulmonale involvement

7.       Oxygen

8. nutritional therapy

9. surgical strategies: lung volume reduction surgery

what are some oxygen therapy complications

1.       combustion – smoking with oxygen??

2.       O2 narcosis – patients with chronic hypercapnia can become tolerant for high CO2 levels. Adding in O2 may reduce respiratory drive.

3.       O2 toxicity – results from prolonged exposure to high levels of O2; causes an inflammatory response

4.       Infection – humidity in oxygen can cause bacterial growth

what type of breathing retraining prolongs expiration, preventing alveolar collapse, and gives the patient more control over breathing

combustion

what type of breathing retraining uses the diaphragm instead of accessory muscles to achieve maximum inhalation and slow respiratory rate. watch for signs of increased work of breathing.

diaphragmatic (abdominal) breathing