Transcript Chapter 30

Respiratory
Disorders
Lola Oyedele MSN, RN, CTN
Majuvy L. Sulse MSN, RN, CCRN
LOWER AIRWAY AND
PULMONARY VESSEL
DISORDERS
Pneumonia
SARS
Tuberculosis
Inhalation Anthrax
Chronic Airflow Limitation
Pneumonia
• Excess of fluid in the lungs
resulting from an inflammatory
process
• Inflammation triggered by
infectious organisms and inhalation
of irritants
• Atelectasis
• Hypoxemia
Pneumonia
• Nosocomial or hospital-acquired
• Community acquired
Laboratory Assessment
• Gram stain, culture, and sensitivity
testing of sputum
• Complete blood count
• Arterial blood gas level
• Serum blood, urea nitrogen level
• Electrolytes
• Creatinine
Impaired Gas Exchange
• Interventions include:
– Cough enhancement
– Oxygen therapy
– Respiratory monitoring
Ineffective Airway
Clearance
• Interventions include:
– Help client to cough and deep breathe
at least every 2 hours.
– Administer incentive spirometer—chest
physiotherapy if complicated.
– Prevent dehydration.
(Continued)
Ineffective Airway
Clearance (Continued)
– Monitor intake and output of fluids.
– Use bronchodilators, especially beta2
agonists.
– Inhaled steroids are rarely used.
Potential for Sepsis
• Primary intervention is prescription of
anti-infectives for eradication of
organism causing the infection.
• Drug resistance is a problem, especially
among older people.
• Interventions for aspiration pneumonia
aimed at preventing lung damage and
treating infection.
Severe Acute Respiratory
Syndrome (SARS)
• A virus from a family of virus types
known as “coronaviruses”
• Virus infection of cells of the
respiratory tract, triggering
inflammatory response
• No known effective treatment for this
infection
• Prevention of spread of infection
Pulmonary Tuberculosis
• Highly communicable disease caused by
Mycobacterium tuberculosis
• Most common bacterial infection
• Transmitted via aerosolization
• Initial infection multiplies freely in bronchi
or alveoli
• Secondary TB
• Increase related to the onset of HIV
Assessment
• Diagnosis of TB considered for any client
with a persistent cough or other
compatible symptoms (weight loss,
anorexia, night sweats, hemoptysis,
shortness of breath, fever, or chills)
• Bacillus Calmette-Guerin vaccine within
previous 10 years produces positive skin
test, complicating interpretation of TB
test.
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Clinical Manifestations of
TB
Progressive fatigue
Lethargy
Nausea
Anorexia
Clinical Manifestations
of TB
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Weight loss
Irregular menses
Low-grade fever, night sweats
Cough, mucopurulent sputum, blood
streaks
Diagnostic Assessment
• Manifestation of signs and symptoms
• Positive smear for acid-fast bacillus
• Confirmation of diagnosis by sputum culture
of M. tuberculosis
• Tuberculin test (Mantoux test) purified
protein derivative given intradermally in the
forearm
• Induration of 10 mm or greater diameter
indicative of exposure
(Continued)
Diagnostic Assessment
(Continued)
• Positive reaction does not mean
that active disease is present, but
does indicate exposure to TB or
dormant disease.
Interventions
• Combination drug therapy strict
adherence
• Isoniazid
• Rifampin
• Pyrazinamide
• Ethambutol or streptomycin
• Negative sputum culture indicative of
client no longer being infectious
Health Teaching
• Follow exact drug regimen.
• Proper nutrition must be
maintained.
• Reverse weight loss and severe
lethargy.
• Educate client about the disease.
Lung Abscess
• Localized area of lung destruction
caused by liquefaction necrosis,
usually related to pyogenic bacteria
• Pleuritic chest pain
• Interventions
• Antibiotics
• Drainage of abscess
• Frequent mouth care for Candida albicans
Inhalation Anthrax
• Bacterial infection is caused by the
gram-positive, rod-shaped organism
Bacillus anthracis from contaminated
soil.
• Fatality rate is 100% if untreated.
• Two stages are the prodromal stage and
the fulminant stage.
• Drug therapy includes ciprofloxacin,
doxycycline, and amoxicillin.
Pulmonary Empyema
• A collection of pus in the pleural space
• Most common cause: pulmonary infection, lung
abscess, and infected pleural effusion
• Interventions include:
– Emptying the empyema cavity
– Re-expanding the lung
– Controlling the infection
Activity Intolerance
• Interventions to increase activity
level:
– Encourage client to pace activities and
promote self-care.
– Do not rush through morning
activities.
– Gradually increase activity.
– Use supplemental oxygen therapy.
Interventions for Palliation
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Oxygen therapy
Drug therapy
Radiation therapy
Laser therapy
Thoracentesis and pleurodesis
Dyspnea management
Pain management
Chronic Airflow
Limitation
Asthma
Emphysema
Chronic Bronchitis
Chronic Airflow Limitation
• Chronic lung diseases of chronic airflow
limitation include:
– Asthma
– Chronic bronchitis
– Pulmonary emphysema
• Chronic obstructive pulmonary disease includes
emphysema and chronic bronchitis
characterized by bronchospasm and dyspnea.
Asthma
• Intermittent and reversible airflow
obstruction affects only the
airways, not the alveoli.
• Airway obstruction occurs due to
inflammation and airway
hyperresponsiveness.
Aspirin and Other Nonsteroidal
Anti-Inflammatory Drugs
• Incidence of asthma symptoms after
taking aspirin and other nonsteroidal
anti-inflammatory drugs (NSAIDs)
• However, response not a true allergy
• Results from increased production of
leukotriene when other inflammatory
pathways are suppressed
Collaborative Management
• Assessment
• History
• Physical assessment and clinical manifestations:
– No manifestations between attacks
– Audible wheeze and increased respiratory rate
– Use of accessory muscles
– “Barrel chest” from air trapping
Laboratory Assessment
• Assess arterial blood gas level.
• Arterial oxygen level may decrease in
acute asthma attack.
• Arterial carbon dioxide level may
decrease early in the attack and
increase later indicating poor gas
exchange.
(Continued)
Laboratory Assessment
(Continued)
• Atopic asthma with elevated serum
eosinophil count and immunoglobulin
E levels
• Sputum with eosinophils and mucous
plugs with shed epithelial cells
Pulmonary Function Tests
• The most accurate measures for
asthma are pulmonary function
tests using spirometry including:
– Forced vital capacity (FVC)
– Forced expiratory volume in the first
second (FEV1)
– Peak expiratory rate flow (PERF)
– Chest x-rays to rule out other causes
Interventions
• Client education: asthma is often an
intermittent disease; with guided selfcare, clients can co-manage this disease,
increasing symptom-free periods and
decreasing the number and severity of
attacks.
• Peak flow meter can be used twice daily by
client.
• Drug therapy plan is specific.
Drug Therapy
• Pharmacologic management of
asthma can involve the use of:
• Bronchodilators
• Beta2 agonists
• Short-acting beta2 agonists
• Long-acting beta2 agonists
• Cholinergic antagonists
(Continued)
Drug Therapy
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(Continued)
Methylxanthines
Anti-inflammatory agents
Corticosteroids
Inhaled anti-inflammatory agents
Mast cell stabilizers
Monoclonal antibodies
Leukotriene agonists
Other Treatments for
Asthma
• Exercise and activity is a
recommended therapy that
promotes ventilation and perfusion.
• Oxygen therapy is delivered via
mask, nasal cannula, or
endotracheal tube in acute asthma
attack.
Status Asthmaticus
• Status asthmaticus is a severe, lifethreatening acute episode of airway
obstruction that intensifies once it begins
and often does not respond to common
therapy.
• If the condition is not reversed, the client
may develop pneumothorax and cardiac or
respiratory arrest.
• Emergency department treatment is
recommended.
Emphysema
• In pulmonary emphysema, loss of lung
elasticity and hyperinflation of the lung
• Dyspnea and the need for an increased
respiratory rate
• Air trapping, loss of elastic recoil in the
alveolar walls, overstretching and
enlargement of the alveoli into bullae,
and collapse of small airways
(bronchioles)
Classification of Emphysema
• Panlobular: destruction of the entire
alveolus
• Centrilobular: openings occurring in the
bronchioles that allow spaces to develop
as tissue walls break down
• Paraseptal: confined to the alveolar
ducts and alveolar sacs
Chronic Bronchitis
• Inflammation of the bronchi and
bronchioles caused by chronic exposure
to irritants, especially tobacco smoke
• Inflammation, vasodilation, congestion,
mucosal edema, and bronchospasm
• Affects only the airways, not the alveoli
• Production of large amounts of thick
mucus
Complications
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Chronic bronchitis
Hypoxemia and acidosis
Respiratory infections
Cardiac failure, especially cor
pulmonale
• Cardiac dysrhythmias
Physical Assessment and
Clinical Manifestations
• Unplanned weight loss; loss of
muscle mass in the extremities;
enlarged neck muscles; slow moving,
slightly stooped posture; sits with
forward-bend
• Respiratory changes
• Cardiac changes
Laboratory Assessment
• Status of arterial blood gas values for
abnormal oxygenation, ventilation, and
acid-base status
• Sputum samples
• Hemoglobin and hematocrit blood tests
• Serum alpha1-antitrypsin levels drawn
• Chest x-ray
• Pulmonary function test
Impaired Gas Exchange
• Interventions for chronic
obstructive pulmonary disease:
– Airway management
– Monitoring client at least every 2
hours
– Oxygen therapy
– Energy management
Drug Therapy
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Beta-adrenergic agents
Cholinergic antagonists
Methylxanthines
Corticosteroids
Cromolyn sodium/nedocromil
Leukotriene modifiers
Mucolytics
Surgical Management
• Lung transplantation for end-stage
clients
• Preoperative care and testing
• Operative procedure through a
large midline incision or a
transverse anterior thoracotomy
• Postoperative care and close
monitoring for complications
Ineffective Breathing
Pattern
• Interventions for the chronic
obstructive pulmonary disease
client:
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Assessment of client
Assessment of respiratory infection
Pulmonary rehabilitation therapy
Specific breathing techniques
Positioning to help alleviate dyspnea
Exercise conditioning
Energy conservation
Ineffective Airway
Clearance
• Assessment of breath sounds
before and after interventions
• Interventions for compromised
breathing:
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Careful use of drugs
Controlled coughing
Suctioning
Hydration via beverage and humidifier
(Continued)
Ineffective Airway
Clearance (Continued)
– Postural drainage in sitting position
when possible
– Tracheostomy
Imbalanced Nutrition
• Interventions to achieve and
maintain body weight:
– Prevent protein-calorie malnutrition
through dietary consultation.
– Monitor weight, skin condition, and
serum prealbumin levels.
– Address food intolerance, nausea,
early satiety, loss of appetite, and
meal-related dyspnea
Anxiety
• Interventions for increased
anxiety:
– Important to have client understand
that anxiety will worsen symptoms
– Plan ways to deal with anxiety
Health Teaching
• Instruct the client:
– Pursed-lip and diaphragmatic
breathing
– Support of family and friends
– Relaxation therapy
– Professional counseling access
– Complementary and alternative
therapy
Potential for Pneumonia or
Other Respiratory Infections
• Risk is greater for older clients
• Interventions include:
– Avoidance of large crowds
– Pneumonia vaccination
– Yearly influenza vaccine
Cystic Fibrosis
• Genetic disease affecting many organs,
lethally impairing pulmonary function
• Present from birth, first seen in early
childhood (many clients now live to
adulthood)
• Error of chloride transport, producing
mucus with low water content
• Problems in lungs, pancreas, liver, salivary
glands, and testes
Nonpulmonary Manifestations
• Adults: usually smaller and thinner
than average owing to malnutrition
• Abdominal distention
• Gastroesophageal reflux, rectal
prolapse, foul-smelling stools,
steatorrhea
• Vitamin deficiencies
• Diabetes mellitus
Pulmonary Manifestations
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Respiratory infections
Chest congestion
Limited exercise tolerance
Cough and sputum production
Use of accessory muscles
Decreased pulmonary function
Changes in chest x-ray result
Increased anteroposterior diameter of
chest
Exacerbation Therapy
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Avoid mechanical ventilation
Airway clearance
Increased oxygenation
Antibiotic therapy
Heliox (50% oxygen, 50% helium)
therapy
• Bronchodilator and mucolytic therapies
Surgical Therapy
• Lung and/or pancreatic transplantation
do not cure the disease; the genetic
defect in chloride transport and the
thick, sticky mucus remain.
• Transplantation extends life by 10 to 20
years.
• Single-lung transplant as well as doublelung transplantation is possible.
Primary Pulmonary
Hypertension
• The disorder occurs in the absence of
other lung disorders, and its cause is
unknown although exposure to some drugs
increases the risk.
• The pathologic problem is blood vessel
constriction with increasing vascular
resistance in the lung.
• The heart fails (cor pulmonale).
• Without treatment, death occurs within
2 years.
Interventions
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Warfarin therapy
Calcium channel blockers
Prostacyclin agents
Digoxin and diuretics
Oxygen therapy
Surgical management
Interstitial Pulmonary
Disease
• Affects the alveoli, blood vessels, and
surrounding support tissue of the lungs
rather than the airways
• Restrictive disease: thickened lung
tissue, reduced gas exchange, “stiff”
lungs that do not expand well
• Slow onset of disease
• Dyspnea common
Sarcoidosis
• Granulomatous disorder of unknown cause
that can affect any organ, but the lung
is involved most often
• Autoimmune responses in which the
normally protective T-lymphocytes
increase and damage lung tissue
• Interventions (corticosteroids): lessen
symptoms and prevent fibrosis
Idiopathic Pulmonary
Fibrosis
• Common restrictive lung disease
• Example of excessive wound healing
• Inflammation that continues beyond
normal healing time, causing extensive
fibrosis and scarring
• Mainstays of therapy: corticosteroids,
which slow the fibrotic process and
manage dyspnea
Occupational Pulmonary
Disease
• Can be caused by exposure to
occupational or environmental fumes,
dust, vapors, gases, bacterial or fungal
antigens, or allergens
• Worsened by cigarette smoke
• Interventions: special respirators that
ensure adequate ventilation
Lung Cancer
• A leading cause of cancer deaths
worldwide
• Metastasizes at late-stage diagnosis
• Paraneoplastic syndromes
• Staged to assess size and extent of
disease
• Etiology and genetic risk
(Continued)
Lung Cancer
(Continued)
• Incidence and prevalence make lung
cancer a major health problem.
• Health promotion and illness
prevention is primarily through
education strategies and reduced
tobacco smoking.
Manifestations of Lung
Cancer
• Often nonspecific, appearing late in
the disease process
• Chills, fever, and cough
• Assess sputum
• Breathing pattern
• Palpation
• Percussion
• Auscultation
Surgical Management
• Lobectomy
• Pneumonectomy
• Segmentectomy (wedge resection)
Pulmonary Embolism
• A collection of particulate matter—
solids, liquids, or gases—enters venous
circulation and lodges in the pulmonary
vessels.
• In most people with pulmonary embolism,
a blood clot from a deep vein thrombosis
breaks loose from one of the veins in
the legs or the pelvis.
Etiology
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Prolonged immobilization
Central venous catheters
Surgery
Obesity
Advancing age
Hypercoagulability
History of thromboembolism
Cancer diagnosis
Health Promotion and
Illness Prevention
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Stop smoking.
Reduce weight.
Increase physical activity.
If traveling or sitting for long periods,
get up frequently and drink plenty of
fluids.
• Refrain from massaging or compressing
leg muscles.
Clinical Manifestations
• Assess the client for:
– Respiratory manifestations: dyspnea, tachypnea,
tachycardia, pleuritic chest pain, dry cough,
hemoptysis
– Cardiac manifestations: distended neck veins,
syncope, cyanosis, hypotension, abnormal heart
sounds, abnormal electrocardiogram findings
– Low-grade fever, petechiae, symptoms of flu
Interventions
• Evaluate chest pain
• Auscultate breath sounds
• Encourage good ventilation and relaxation
(Continued)
Interventions
• Monitor the following:
(Continued)
– respiratory pattern
– tissue oxygenation
– symptoms of respiratory failure
– laboratory values
– effects of anticoagulant medications
• Surgery
Decreased Cardiac
Output
• Interventions include:
– Intravenous fluid therapy
– Drug therapy
• Positive inotropic agents
• Vasodilators
Risk for Injury (Bleeding)
• Interventions include:
– Protect client from situations that
could lead to bleeding.
– Closely monitor amount of bleeding.
– Assess often for bleeding,
ecchymoses, petechiae, or purpura.
– Examine all stool, urine, nasogastric
drainage, and vomitus and test for
occult blood.
Anxiety
• Interventions include:
– Oxygen therapy
– Communication
– Drug therapy: anti-anxiety agents