Transcript Symptoms

Mononucleosis
 Symptoms
 Viral infection (Epstein-Barr virus) -mimics Strep
in presentation and physical findings
 Referred to as the "kissing disease" for it's
ability to be spread from one person to another
via oral secretions
 Sore throat, swollen lymph nodes, weakness, and
fatigue that persists anywhere from days to weeks.
 Mild hepatitis can also occur with mononucleosis
- Pain right upper quadrant and enlargement of the
liver
Evaluation
 Phsyical will usually reveal Swollen glands
(string of pearls-cervical lymph nodes) and
tonsillitis.
 There may be some mild tenderness over the
spleen and liver.
 Lab studies will include the monospot, CBC, and
throat culture to rule out strep throat.
 A liver profile may show mild elevations in liver
enzymes
Treatment
 Antibiotics are ineffective - Bed rest, liberal
fluid intake, and low doses of
acetaminophen
 Most cases end in 2-3 weeks but medical
follow-up is suggested.
 Complications of Mono include splenic
rupture and Guillain-Barre' syndrome
 Mononucleosis Test or Monospot
 Venipuncture specimen
 The test involves mixing reagents with a drop of
blood on a microscope slide.
 Results of the test are read, usually in less than
one hour, as positive (mono) or negative.
 Because the test may be negative in the early part
of the illness, it must be repeated later if
symptoms persist.
Peritonsillar Abscess
 Symptoms
 Abscess located next to one of the Palatine tonsils
 Complication of bacterial tonsillitis.
 Starts with a sore throat and progresses to difficulty, or
complete inability, in swallowing liquids or saliva.
 Typically, this patient is UNABLE to open their mouth
widely, or swallow water, secondary to swelling.
 Other symptoms, common both to tonsillitis and
peritonsillar abscess, include: fever, chills, and pain upon
swallowing
Evaluation
 Hstory and physical examination.
 Patients UNABLE to open their mouths
OR swallow water are highly suspect for
this problem.
 Oral examination will often show
tremendous swelling about the tonsil,
deviating the uvula to one side.
 Treatment
 Treatment requires an incision of the
abscess, allowing it to drain, so healing can
occur. Antibiotics will likely be prescribed
in follow-up. An ENT specialist is the
expert in the management of this special
situation
Cancers of the Head and Neck
 Fairly common
 Includes cancer of the lips, tongue, mouth,
throat, and larynx.
 Invariably, squamous cell carcinomas occur
with the highest frequency in smokers
 It is rare for nonsmokers to get cancers of
the head and neck
Symptoms
 Persistent hoarse voice, weight loss, difficulty
swallowing, white or dark patches inside of the
mouth, and an unexplained sore to the tongue,
cheek, or lip that does not heal.
 Spreading of this type of cancer is frequently to
regional lymph nodes, before any kind of distant
spread occurs.
 It is extremely uncommon for cancer to spread
beyond the head and neck area, when the disease
is controlled (therapeutically) in that area
Treatment
 Surgery
 Radiation therapy as the initial management
if cancer has spread to lymph nodes
 Chemotherapy has recently been purported
as a method of improving initial cure rates,
when it is given in combination with
radiation therapy prior to surgery
PROBLEMS ASSOCIATED WITH THE
LOWER RESPIRATORY TRACT
 Laryngitis and Voice Strain -Inflammation
of the larynx
 Viral infection in the larynx or secondary to
postnasal drip
 Voice strain can cause mechanical laryngitis
Symptoms
 Hoarse or raspy voice
 May be associated with a sore throat, fever,
posterior nasal drip, or congestion of the
sinuses.
 It should not be accompanied by
difficulty swallowing food or fluids. This
symptom could indicate epiglottitis or
peritonsillar abscess
Evaluation
 History and physical examination
 Direct visual inspection of the throat done
to check for signs of bacterial infection
 In questionable cases, x-rays of the neck
may be useful to diagnose more serious
bacterial upper airway infections. A throat
culture may be needed to exclude the
possibility of strep throat.
Treatment
 Viral laryngitis is self-limiting and disappears by itself in
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approximately 7-10 days.
Avoid talking, smoking, alcohol, hot liquids, frequent
coughing and clearing the throat.
Drink plenty of fluids and use analgesics or lozenges
containing topical anesthetics as ordered.
Acetaminophen can be used for pain or fever, A cool mist
vaporizer can be therapeutic.
Any suspicion of bacterial infection in the throat or sinuses
will require antibiotic treatment.
Any hoarseness of greater than 3 weeks duration
should be evaluated by a physician or ENT specialist
Laryngeal Cancer
 Laryngeal Tumors can initially result in a
hoarse voice, or, in more serious cases, the
total blockage of the airway.
 Slow onset of a hoarse voice occurring
over a period of weeks
 Laryngeal cancer is most commonly seen in
those over 40 years of age who smoke or
"chew" tobacco
Evaluation/Treatment
 Laryngoscopy to visually inspect the vocal cords
 Questionable lesions mandate biopsy
 Treatment for documented laryngeal cancer is
based upon the extent the disease has progressed.
 Surgical removal of part, or all of the larynx, is
often necessary (laryngectomy).
 Radiation therapy has also been used to control
disease that has spread to surrounding tissue.
Laryngectomy Care
 Total neck breather following surgery. CPR -ventilations
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must be made mouth to neck not mouth to mouth.
Immediate post-op. Watch for respiratory obstruction
from swelling of the airway or increased secretions
Post-op patients will be unable to form sounds. Air for
speach no longer comes from the lungs. About 75% of
postlaryngectomy patients learn to use "plosive" speech.
Various mechanical aids are also available
The laryngectomy tube is shorter and thicker than a
tracheostomy tube.
Laryngectomy tube used until the stoma heals.
Observe for crusting: crust can be softened and removed
with petrolatum jelly
Proper room humidification is helpful
INFLUENZA
 Etiology
 Viral upper respiratory infection that commonly affects a
large percentage of children and adults
 Occurs more often in the winter months
 Transmitted through inhalation of particle droplets
 Wide variety of viruses responsible for flu-like illness
 Incubation period 1 to 6 days before onset of symptoms
 Viral upper respiratory infections can lead to pneumonia
and sinusitis
 Children are commonly infected because they transmit
these infections so easily.
 Flu in the elderly patient, more serious, can lead to a
secondary bacterial infection with dehydration
Symptoms
 Fever, chills, runny nose, sore throat,
swollen lymph nodes, frontal headache,
muscle and body aches, joint pains, dry
cough, pleurisy with coughing, and
weakness
 Children and infants can have wheezing,
particularly in a related infection, known as
bronchiolitis
Evaluation
 H&P rule out bacterial infection
 CBC, blood cultures, and Chemogram as
indicated
 Chest x-ray to rule out pneumonia as
indicated
 Urinalysis to rule out UTI may be indicated
Treatment
 Flu is usually nonserious and self-limited
 Observe for signs of dehydration in infants and elderly
 Rest, nutrition, fever control, fluids , avoid alcohol and
caffeine
 Wheezing may require bronchodilators, Cool mist
vaporizer can reduce congestion in children
 Saltwater nose drops followed by suctioning with a bulb
syringe are helpful in infants
 Vaccines against certain viruses (flu shot) have been
quite successful and may be indicated in the elderly,
diabetics, health-care workers, and other high risk
groups.
BRONCHITIS
 Etiology and Symptoms
 Inflammation of the bronchi in the lungs, most often
occurs secondary to a bacterial infection in the airways
 Bronchitis common in the smoking population
 Smokers have difficulty clearing their secretions
(mucus) due to impaired ciliary action and have
diminished immunity against infection.
 Productive cough (in smokers, may be bloody) fever, and
chills, Shortness of breath is seen in more severe cases
 Similar symptoms to pneumonia
 Smokers may develop expiratory wheezes, breathing
OUT more difficult than breathing IN.
Evaluation
 H&P and chest x-ray to rule out pneumonia,
CBC, chemistry and sputum cultures
 Patients with shortness of breath may have
an ABG's to determine if their oxygenation
is acceptable
Treatment
 Oral antibiotics- Some cases (long standing
smokers with COPD) require hospitalization.
 Patients with "wheezing" will require
bronchodilators
 Follow-up chest x-ray for patients not responding
to treatment. The x-ray may reveal a developing
pneumonia.
 Acetaminophen or aspirin should be used for fever
control
PNEUMONIA
Etiology -Bacterial or viral infection
of the lung tissue
 The most common forms of pneumonia are viral 
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Antibiotics have NO effect on viral infections
Bacterial pneumonia - more severe and require
antibiotics
Pneumococcal pneumonia and streptococcal
pneumonia - rust-colored sputum
Foul smelling green or yellow sputum Pseudomonas pneumonia and lung abscesses
Klebsiella pneumonia - blood tinged sputum
Mycoplasmal pneumonia -neither bacterial nor
viral. Tends to have milder symptoms Produces
whiter colored sputum. Associated with H/A
Smokers, elderly and immunocompromised
(diabetics, cancer patients) are at risk for
SERIOUS pneumonia
Symptoms
 Productive cough, fever, shaking chills and
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extreme fatigue
Examination will usually reveal rales on
asculatation,
WBC over 11,000 cu/ml
Consolidation on the chest x-ray
Crackling rales are likely to be heard anytime
there is fluid in interstitial and alveolar areas.
More severe pneumonia - associated SOB and/or
pleuritic chest pain (pain worse with coughing and
movement
Evaluation
 History and physical examination for evidence of
fever or upper respiratory infection
 A chest x-ray can diagnose pneumonia, and, in
most cases, is necessary for definitive diagnosis.
 CBC, Blood Cultures, Chemogram and sputum
cultures may be indicated
 ABG's for evaluation of oxygenation in those who
are short of breath
Treatment
 Eliminate the organism, support oxygenation, and limit
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activity
Older patients, diabetics, and COPD patients should be
admitted for IV antibiotics.
Any patient SHORT OF BREATH while at rest, or with
evidence for inadequate oxygenation by arterial blood
gas analysis, will require admission to the hospital.
Fatigue /activity intolerance is a common complication
of pneumonia. May continue for weeks.
Pneumovax vaccine - protects against bacterial
pneumonia in those at high risk for infection.
High Risk -over age 65, COPD, HIV, the chronically
debilitated, or those who have had their spleen
removed
ASPIRATION PNEUMONIA
 Etiology and Symptoms
 Results in serious pneumonia, related to the type of
material aspirated.
 Severe pneumonia can result from the aspiration of
stomach acid or petroleum distillates
 Aspiration - passage of foreign materials into the lungs.
 Aspiration pneumonia can become infected secondarily
with bacteria, requiring treatment with an antibiotic.
 Because of the anatomy of the respiratory tree,
aspiration is more likely to affect the Right lung, as the
right mainstem bronchus extends more vertically
downward into the lungs, while the left bronchus is
more horizontal.
Situations associated with a high risk for
aspiration
 Stroke patients (those who cannot swallow well
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and protect their airway)
Unconscious patients
Children playing with toys or food (the "peanut"
or toy aspiration is well known)
Alcohol intoxicated patients
Drowning
Petroleum distillate ingestions (kerosene, gas,
furniture polish, etc.)
Powder aspiration - talcum powder with babies
 Symptoms
 Coughing, shortness of breath, and
wheezing
 Fever is a delayed symptom
 Evaluation
 History to evaluate risk of aspiration, and
physical examination.
 Chest x-ray may show the foreign object or
changes in the lung, indicating a
pneumonia.
 Arterial blood gas analysis will indicate the
patient's overall lung function, including
any need for oxygen therapy
Treatment
 Suction patients who are unable to protect their
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airway
Bronchoscopy may be indicated in cases where a
foreign object must be retrieved (generally
children).
Bronchodilators for wheezing
Antibiotics for bacterial contamination
Respirator for patients who cannot breath on their
own.
Fever control as indicated.
PLEURISY AND PLEURITIS
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Etiology/ Symptoms
Pleura of the lung become inflamed
Resulting chest pain is known as pleurisy
Pain is sharp or "knife-like", and increases in severity
as the patient breathes in
Pleurisy is often one-sided and can radiate pain to the
neck or shoulder.
Movement of the thorax, including bending, stooping,
or even turning in bed can increase pleural pain
Shortness of breath with pleurisy may indicate a more
serious problem such as pulmonary embolism
Pleurisy can easily confused with chest wall pain which is
much less serious. Chest wall pain can sometimes be
distinguished from pleurisy by pressing down
(palpation) on a region of the chest wall which will
reproduce pain in the patient
Causes of pleurisy
 Pneumonia (viral or bacterial)
 Pulmonary Embolism
 Pneumothorax
 Lung cancer
Evaluation
 Chest x-ray to rule out pneumothorax or
pneumonia.
 Those short of breath may require ABG's.
 May need an EKG to exclude the possibility
of angina (angina pain in rare cases can be
pleuritic in nature)
Treatment
 Ventilation/perfusion scanning of the
lung is performed in cases of suspected
pulmonary embolism.
 Treatment is directed at the underlying
cause.
 Narcotic analgesics may be necessary when
pain is severe.
 Anti-inflammatory agents (ibuprofen) can
be helpful in mild to moderate pleurisy
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE (COPD)
 Etiology
 Progressive disease with occasional exacerbations
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requiring hospitalization
Most common chronic respiratory disorder
Spectrum of diseases characterized by limited
airflow and poor oxygenation of the blood.
The two main disease processes are emphysema
and chronic bronchitis.
Chronic asthma, cystic fibrosis, and chronic
bronchiectasis are also COPD
smoking is the leading cause of COPD
 Other causes, cystic fibrosis, alpha-antitrypsinase
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enzyme deficiency (inherited condition), and
chronic exposure to some chemicals/irritants
(asbestos, silica, and coal dust)
Smoking 10 years or more
Inflammation and destruction of the bronchioles
and destruction of the alveolar walls
Increased obstruction to air flow
Hyperinflation of the alveoli
poor oxygenation of the bloodstream
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Continued smoking
Breathing becomes more difficult
Wheezing will develop.
COPD patients also have increased risk of
pulmonary infection (pneumonia and bronchitis)
due to compromised immune system function in
the upper respiratory tree.
 Smokers have a 25 fold increased risk of lung
cancer, and they are also at high risk for heart
disease and stroke through the acceleration of
atherosclerosis in the blood vessels
Symptoms -begin insidiously
 Chronic productive cough
 Barrel chest
 Increasing tolerance of high CO2 levels and
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low O2 levels
Shortness of breath upon exertion
Club fingers
Wheezing
Fever if an infection (bronchitis) is present
Evaluation
 History and physical
 Pulmonary function tests
 Chest x-ray may show changes consistent with emphysema
(lung "disappearing" on the x-ray), scarring, or tumor
 Normally, excessive levels of CO2 stimulate
respirations. However, in the COPD patient, the
Chemoreceptors become insensitive to CO2 and
respond only to hypoxia.
 If too much Oxygen is given to a COPD patient, the
stimulus to breathe is removed and the client may stop
breathing completely.
 Most clients with COPD can tolerate Oxygen at 2 per
N/C at 2-3 l/min, but ABG's need to be monitored
CHRONIC BRONCHITIS
 Etiology
 Prolonged exposure to bronchial irritants
such as smoking
 It is more common in females, whites, and
city dwellers.
 Chronic bronchitis causes inflammation of
the bronchi with enlargement and
hypersecretion of the mucous glands which
causes diffuse airway obstruction
Symptoms of the "Blue Bloater
 Heavy productive cough, particularly at night,
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generally worse in cold, damp weather
Progression
Cough becomes continuous
Dyspnea and wheezing become more severe.
Cyanosis is common secondary to the chronic
hypoxemia, and hypercapnia caused by the airway
obstruction
Generalized edema is also often present, and
this swollen appearance, together with the
cyanosis, gives rise to the phrase "blue bloater"
used to describe these patients.
EMPHYSEMA
Etiology
 Chronic progressive disease
 Enlargement of air spaces - destruction of the alveolar
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walls by enzymes.
Smoking is primary cause but any continuous irritant (coal
dust) can destroy alveoli.
Deficiency of alpha-antitrypisn (an enzyme inhibitor) also
indicated in the development/ progression of emphysema.
Enzymes in the lung destroy elastic structure around
the alveoli; resulting in loss of elasticity, stiffening of
the lungs, and decreased compliance.
The loss of alveolar function diminishes lung recoil (like
an overstretched elastic band) and weakens expiration.
The lung therefore remains partially expanded
following expiration, producing air trapping and a
visible barrel chest over time
Symptoms
 Chronic cough
 Dyspnea - hallmark of emphysema,
worsens over time, may be present even
at rest and is severe on exertion.
 Pursed-lip breathing with prolonged
expiration.
 Barrel chest
 Use of accessory muscles
 Hyperresonance on percussion
 Decreased vocal fremitus on palpation.
 Distant Breath and heart sounds
 Anorexia, Weakness, Decreased muscle, Weight
loss
 The patient remains acyanotic until very late in
the disease because of compensatory
mechanisms. Thus, emphysema patients are
referred to as "pink puffers" as opposed to the
oxygen-starved "blue bloaters" with chronic
bronchitis.
COMMON COMPLICATIONS OF
COPD
 HYPOXEMIA (PaO2 of 55mmHg or less,
with an oxygen saturation of 85% or less
 HYPERCAPNIA (elevated CO2) and
Respiratory acidosis.
 Respiratory infections
 COR PULMONALE (RIGHT
VENTRICULAR HEART FAILURE
Symptoms of Hypoxemia
 Mood changes
 Forgetfulness
 Inability to concentrate
 Later signs are increasing restlessness.
 Cyanosis is a late sign of hypoxemia
HYPERCAPNIA (elevated
CO2) and Respiratory acidosis
 Decreased in oxygen/carbon dioxide exchange
 Rising carbon dioxide levels result in respiratory
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acidosis.
Symptoms of hypercapnia
Increased respiratory rate
SOB
Headache
Confusion
Lethargy
Nausea and Vomiting
Respiratory infections
 Frequent respiratory infections related to:
 Increased production of mucus
 Increased irritability of the bronchial smooth
muscle
 Edema of the respiratory mucosa.
 Many COPD patients are prescribed antibiotics on
a PRN basis and the client self-administer the
antibiotic according to changes in sputum
appearance, which may indicate infection.
COR PULMONALE (RIGHT
VENTRICULAR HEART FAILURE)
 Most frequently associated with chronic bronchitis
 Detection of cor pulmonale (pulmonary heart disease) is
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difficult because its clinical signs are generally masked by
those of COPD.
As COPD progresses, the amount of oxygen in the blood
decreases, which causes major blood vessels in the lung to
constrict.
The body produces more RBC's to attempt to carry more
oxygen.
Leads to polycythemia and increased blood viscosity.
Right side of the heart must pump harder, enlarges and
leads to right-sided heart failure
Symptoms of cor pulmonale
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Increasing dyspnea
Fatigue
Enlarged and tender liver
Warm cyanotic extremities with bounding pulses
Cyanotic lips
Distended neck veins
Right ventricular hypertrophy
Nausea
Dependent edema
Metabolic and respiratory acidosis
TREATMENT FOR COPD
 STOP SMOKING
 BRONCHODILATORs for Wheezing (Proventil
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and Theophylline)
ANTIBIOTICS (in infection)
HOME OXYGEN THERAPY Most clients with
COPD can tolerate Oxygen at 2 per N/C at 2-3
l/min, but ABG's need to be monitored
Steroid medications (Prednisone) for severe cases
to reduce inflammation in bronchial tissue.
Pulmonary disease diet is recommended
RESPIRATORY
EMERGENCIES
 PNEUMOTHORAX Common symptoms of a pneumothorax include
the sudden onset of breathing difficulty,
accompanied by chest pain (pleurisy) that
INCREASES while breathing in. Will also have
diminished lung sounds on the affected side. CXR
will show collapsed lung.
 Treatment Surgical placement of a plastic tube
into the chest cavity to remove the excess air
and restore the negative air pressure within the
pleural space
HEMOTHORAX
 Common symptoms include: chest pain, difficulty in
breathing, and hemorrhagic shock, if the accumulation
of blood in the chest is massive.
 Evaluation includes a chest x-ray which allows
diagnosis and estimation of the hemothorax size. Blood
tests (CBC) to check blood counts will help gauge the
overall extent of blood loss
 Treatment involves placement of a chest tube to remove
the accumulated blood. The chest tube will remain in
place until the bleeding has stopped and the lung
(indicated by x-ray) has adequately re-expanded.
PULMONARY EMBOLISM
 Clot which obstructs perfusion in the lung
 Can result in infarction of a portion of the lung
 Symptoms include a SUDDEN onset of
shortness of breath, pleurisy, elevated pulse and
respirations and Pink frothy sputum
 A nuclear scan of the lung, known as a
ventilation-perfusion scan can diagnose
most pulmonary emboli
 A more specific test is the pulmonary
angiogram
Treatment
 Streptokinase- dissolves clots and heparin -
keeps further clots from forming