Respiratory System Part 2

Objectives

• Upper Respiratory Disorders

  • Discuss disease processes affecting the upper respiratory tract.

  • Describe signs and symptoms related to sinuses, pharynx, and larynx disorders.

• Patient Interventions

  • Discuss interventions for patients with respiratory disorders.

  • Explain postoperative care for patients undergoing laryngectomy.

  • Discuss disease processes affecting both upper and lower respiratory tract.

  • Explain the care plan for patients on anti-tubercular medications.

Disorders of the Upper Respiratory System

• Pneumonia

• Pulmonary fibrosis

• Tuberculosis

• Bronchitis

• Emphysema

• Asthma

Upper Airway Disorders

• Epistaxis (Nosebleed)

  • Causes: Primary (aka essential) or secondary, often due to congestion or injury.

  • Signs: Bright red blood from nostrils.

  • Treatment: Apply pressure, use epinephrine, or packing.

  • at risk for anemia and aspiration due to the potential loss of blood and the risk of inhaling blood.

• Deviated Septum

  • Symptoms: Harsh respirations, dyspnea, possibly postnasal drip.

  • Management: Surgery may be necessary.

  • Nursing intervention: aimed at ensuring airway patency and preventing infection.

• Rhinitis

  • Definition: Inflammation of nasal mucosa; can be allergic or non-allergic.

  • Manifestations: Runny nose, nasal congestion, inflamed mucosa, potential low grade fever, purulent nasal discharge, and sneezing.

  • Medications: Antihistamines, Leukotrien inhibitors, and mast cell stabilizers, decongestants, intranasal sprays, and antibiotics (if bacterial).

  • can be caused by infection (viral or bacterial) or allergens.

  • The prensence of an allergen causes histamine release and other mediators from WBCs in the nasal mucosa. The mediators bind to blood vessel receptors, causing capillary leakage, which leads to local edema and swelling.

  • Nursing intervention: encourage rest and increased fluid intake, promote proper disposal of tissue and proper cough etiquette.

  • Adverse reaction to antihistamine is vertigo, hypertension, urinary retention (UTI). Decongestants constrict blood so contraindicated in patients with high blood pressure.

  • Client education: limit exposure to others will prevent and reduce transmission. Use vitamin C and Zinc.

Sinusitis

• Defines as inflammation of the sinuses; often follows rhinitis. Swelling of the mucosa can block the drainage of secretion, which can cause a sinus infection.

• Symptoms: Nasal congestion, headache, facial pain, cough, low-grade fever.

• Diagnostics: CT scan or sinus x-rays, possibly endoscopic sinus cavity lavage or surgery.

• Nursing care: Assess hydration, encourage humidification, and discourage air travel.

• to test if maxillary or frontal you palpate downwards. advise to contact provider for manifestations of a severe headache, neck stiffness and high fever. (bacterial meningitis.)

• Nasal decongestants reduce to reduce swelling of the mucosa.

Influenza (Flu)

• Highly contagious viral infection; prevalent in fall and winter. (offer from August- April)

• Symptoms: Severe headache, chills, fever, cough, fatigue.

• Management: Antivirals (zanamivir, oseltamivir) within 24-48 hours, vaccines for prevention.

• Patient education: Good hygiene practices and annual vaccinations.

• Pandemic influenza refers to a viral infection among animals or birds that has mutated and is becoming highly infectious to humans. 

  • The resulting viral infection has the potential to spread globally, such as H1N1 (“swine flu”) and H5N1 (“avian flu”)

Chronic Obstructive Pulmonary Disease (COPD)

• Characteristics include emphysema and chronic bronchitis; irreversible.

• Emphysema (pink puffer): loss of lung elasticity and hyperinflation of lung tissue. causes destruction of the alveoli, leading to a decreased surface area for gas exchange, carbon dioxide retention (air trapped in the alveoli during expiration), and respiratory acidosis ( decreased O2 and increase CO2) worsened by smoking. PINK

• Chronic bronchitis (blue bloater):Characterized by recurrent or chronic productive cough for a minimum of 3 months a year for at least 2 years. caused by chemical irritants and recurrent lung infections. Smoking is the leading cause of chronic bronchitis. inflammation of the bronchi and bronchioles due to chronic exposure to irritants. BLUE

• Symptoms: Chronic dyspnea, productive cough, hypoxemia, return of respiratory distress.

• Risk Factors: Advanced age, smoking, alpha-1 antitrypsin deficiency, Exposure to environmental factors

• Clinical manifestations: Chronic dyspnea, dyspnea upon exertion, productive cough that is most severe upon rising in the morning. Hypoxemia, crackles and wheezes, rapid and shallow respirations, use of accessory. muscles, barrel chest. Hyperresonance on precussion due to trapped air. Irregular breathing pattern, thin extremities, and enlarged neck muscles, dependent edema secondary to right sided heart failure, clubbing of fingers (late stage of disease), pallor and cyanosis of nail bed and mucus membrane (late stage of the disease) decreased oxygen saturation levels (95%-100%) *in older adults with dark colored skin, SaO2 may be lower.

• Nursing Care: Encourage deep breathing and use of incentive spirometry, promote adequate nutrition. Position patient in high fowler’s. Diet of soft high calorie. Encourage hydration.

• Medications: Bronchodilators and anti-inflammatory drugs for managing COPD.

• LABORATORY TESTS:

• Pulmonary function tests

• These tests are used for diagnosis, as well as determining the effectiveness of therapy.

• Comparisons of forced expiratory volume (FEV) to forced vital capacity (FVC) are used to classify COPD as mild to very severe.

• As COPD advances, the FEV-to-FVC ratio decreases. The expected reference range is 100%. For mild COPD, the FEV/FVC ratio is decreased to less than 70%. As the disease progresses to moderate and severe, the ratio decreases to less than 50%.

• Reveals hyperinflation of alveoli and flattened diaphragm in the late stages of emphysema. (19.2)

• It is often not useful for the diagnosis of early or moderate disease. 

• Alpha1 antitrypsin levels

• Used to check for deficiency in AAT, an enzyme produced by the liver that helps regulate other enzymes (which help break down pollutants) from attacking lung tissue.

• Medication: Guaifenesine and dextromethrophan can be taken orally to loosen secretions.

Asthma

• Chronic airway disorder causing intermittent and reversible airflow obstruction of the bronchioles; triggers include allergens and stress. Obstruction occurs wither by inflammation or airway hyperresponsiveness.

• Symptoms: Dyspnea, wheezing, cough, chest tightness.

• Manifestations of asthma includes mucosal edema, bronchoconstriction, and excessive mucus production.

• Nursing care: Inhaler training, peak flow monitoring, and managing acute exacerbations.

• Most commonly characterized by dyspnea on exhalation and expiratory wheezes.

• Status asthmaticus is a severe and unrelenting, life threatning attack that fails to respond to usual treatment and places the patient at risk for respiratory failure. this is a medical emergency.

• Mild intermittent: symptoms occur less than once a week.

• Mild persistent: Symptoms arise more than twice a week but not daily.

• Miderate persistent: Daily symptoms occure in a conjuction with exacerbation twice a weel.

• Severe persistent: Symptoms occur continually, along with freqent exacerbation thay limit physical activity and quality of life.

• Risk factors: older adults that have decreased pulmonary reserves due to physical lung changes that occur with the aging process. Family hx of asthma is also a risk factor. Second hand smoke exposure, environmental allergies, exposure to chemical irritants or dust, and GERD.

• Lab tests: Artera blood gases evaluate O2 during acute attacks. Sputum cultures, bacteria can indicate infeciton.

• Diagnostic procedures: PFTs, are the most accurate tests for diagnosing asthma and severity. FVC is the volume of air exhaled from full inhalation to full exhalation. FEV1 is the volume of air blown out as hard and fast as possible during the fist second of the most forceful exhalation after the greatest full inhalation. Peak expiratory flow rate is the fastest airflow rate reached during exhalation. A decrease in FEV1 by 15% to 20% below the expected value is common in clients who have asthma.

• Medications:

• Medications: Bronchodilators (inhalers). Short acting beta 2 agonists such as albuterol provide rapid relief of acute manifestations and prevent exercise induced asthma. Anticholinergics such as ipratropium block the parasympathetic nervous system. It allows for the sympathetic nervous system effects of increased bronchodilation and decrease pulmonary secretions. These medications are long acting and used to prevent bronchospasms. Methylxanthines, such as theophylline, require close monitoring of blood medication levels due to a narrow therapeutic range. Use only when other treatments are ineffective. Long-acting beta2 agonists, such as salmeterol, primarily are used for asthma attack prevention

• Bronchodilators (inhalers)

  • NURSING ACTIONS

  • ● Albuterol: Watch for tremors and tachycardia.

  • ● Ipratropium: Observe for dry mouth.

  • ● Theophylline: Monitor blood levels for toxicity. Adverse

  • effects include tachycardia, nausea, and diarrhea.

• CLIENT EDUCATION

• ● Ipratropium: Suck on hard candies to help relieve dry mouth; increase fluid intake; and report headache, blurred vision, or palpitations, which can indicate toxicity of ipratropium. Monitor heart rate.

• ● Salmeterol: Use to prevent an asthma attack and not at the onset of an attack. Do not use during acutE exacerbations.

Anti‑inflammatory agents

These medications are for prophylaxis and are used to decrease airway inflammation.

● Corticosteroids, such as fluticasone and prednisone

● Leukotriene antagonists, such as montelukast

● Mast cell stabilizers, such as cromolyn

● Monoclonal antibodies, such as omalizumab

Anti‑inflammatory agents

NURSING ACTIONS

● Watch for decreased immunity function and wound healing.

● Monitor for hyperglycemia.

● Observe for fluid retention and weight gain. This can be common.

● Monitor the throat and mouth for aphthous lesions (canker sores).

● Omalizumab can cause anaphylaxis

Anti‑inflammatory agents

CLIENT EDUCATION

● Use good mouth care and hand washing regimen.

● Do not discontinue medication suddenly.

● Rinse mouth and gargle after inhaled glucocorticoids to minimize dysphonia and candidiasis.

Anti‑inflammatory agents

CLIENT EDUCATION

● Report black, tarry stools.

● Drink plenty of fluids to promote hydration.

● Take prednisone with food.

● Use these medications to prevent asthma, not for the onset of an attack.

● Avoid people who have respiratory infections.

Combination agents (bronchodilator and anti‑inflammatory)

If prescribed separately for inhalation administration at the same time, administer the bronchodilator first in order to increase the absorption of the anti‑inflammatory agent.

● Ipratropium and albuterol

● Fluticasone and salmeterol

Complications of asthma: Respiratory failure

Persistent hypoxemia related to asthma can lead to respiratory failure.

NURSING ACTIONS

● Monitor oxygenation levels and acid-base balance.

● Prepare for intubation and mechanical ventilation.

● Monitor and report inaudible breath sounds, wheezing, retractions, and ineffective cough.

Status asthmaticus

This is a life-threatening episode of airway obstruction that is often unresponsive to common treatment. It involves extreme wheezing, labored breathing, use of accessory muscles, distended neck veins, and creates a risk for cardiac and/or respiratory arrest.

NURSING ACTIONS

● Prepare for emergency intubation.

● Assist with preparing to administer IV fluids, oxygen, bronchodilators, and epinephrine. Assist with initiating systemic steroid therapy.

Nursing Interventions

• Position the client to maximize ventilation (high-Fowler’s).

• Administer oxygen therapy as prescribed.

• Monitor cardiac rate and rhythm for changes during an acute attack (can be irregular, tachycardic, or with PVCs).

• Monitor respiratory rate and rhythm for changes in effort, symmetry, SaO2; auscultate lung sounds.

• Maintain IV access.

• Remain calm and reassuring.

• Provide rest periods for older adult clients who have dyspnea. Design room and walkways with opportunities for rest. Incorporate rest into ADLs.

• Encourage prompt medical attention for infections and appropriate immunizations.

• Administer medications as prescribed.

• Reinforce with the client to perform daily peak flow meter testing. If only able to achieve a reading in the red zone, immediately use the reliever medications and seek emergency care.

Pulmonary Embolism

• Blockage of pulmonary arteries due to blood clots or other substances.

• Symptoms: Sudden chest pain, dyspnea, feelings of doom, tachycardia.

• Diagnostic tests: D-dimer, CT angiography; treatment includes oxygen therapy and anticoagulants.

Acute Respiratory Failure (ARF)

• Defined as inadequate gas exchange; can be caused by various lung diseases. caused by mechanical abnormality of the lung or chest wall, impaired muscle function (diaphragm), or a malfuntion in the respiratory control center of the brain. can result from lack of prefusion to the pulmonary capillary bed (pulmonary embolism) or a condition that alters the gas exchange medium (pulmonary edema, pnemonia)

• Combined failure leads to more profound hypoxemia than either ventilatory failure or oxygenation failure alone.

• Criteria for acute respiratory failure are based on Arterial Bypass Gass (PH O2Sar Po2 PCO2, PHCO3) PH: 7.35- 7.45 O2: 95% PO2: 80%-100% PCO2: 35-45 PHCO3: 22-26

• Symptoms: Altered mental status, hypoxia, respiratory fatigue.

• Management: Maintain airway, monitor patient closely, may require mechanical ventilation.

Acute Respiratory Distress Syndrome (ARDS)

• Results from systemic inflammatory response; characterized by severe respiratory distress and hypoxemia.

• Nursing Actions: Maintain airway patency, monitor vital signs, provide supportive care.