management of patient with cheast and lower respiratory tract desorder

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management of patient with cheast and lower respiratory tract desorder

  1. 1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsChapter 23Management of Patients WithChest and Lower RespiratoryTract Disorders
  2. 2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAtelectasis• Collapse or airless condition of alveoli caused byhypoventilation, obstruction to airways, or compression• Causes: bronchial obstruction by secretions due toimpaired cough mechanism or conditions that restrictnormal lung expansion on inspiration• Postoperative patients at high risk• Symptoms: insidious, include cough, sputum production,low-grade fever• Respiratory distress, anxiety, symptoms of hypoxia occurif large areas of lung are affected
  3. 3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAtelectasis (cont’d)• Refer to fig. 23-1
  4. 4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Management• Prevention– Frequent turning, early mobilization– Strategies to improve ventilation: deep breathingexercises at least every 2 hours, incentive spirometer– Strategies to remove secretions: coughing exercises,suctioning, aerosol therapy, chest physiotherapy
  5. 5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Management (cont’d)• Treatment– Strategies to improve ventilation, remove secretions– Treatments: may include PEEP (positive end-expiratory pressure), IPPB (intermittent positive-pressure breathing)– Bronchoscopy may be used to remove obstruction
  6. 6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsRespiratory Infections• Acute tracheobronchitis• Pneumonia– Community-acquired pneumonia– Hospital-acquired pneumonia– Pneumonia in immunocompromised host– Aspiration pneumonia
  7. 7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsDiagnostic Tests• Chest x-ray• Sputum examination
  8. 8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsMedical Treatment of Pneumonia• Supportive treatment includes fluids, oxygen for hypoxia,antipyretics, antitussives, decongestants, antihistamines• Administration of antibiotic therapy determined by gram-stain results• If etiologic agent is not identified, utilize empiricantibiotic therapy• Antibiotics not indicated for viral infections but are usedfor secondary bacterial infection
  9. 9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: Care of the Patient withPneumonia - Assessment• Changes in temperature, pulse• Secretions• Cough• Tachypnea, shortness of breath• Changes in physical assessment, especially inspection,auscultation of chest• Changes in CXR• Changes in mental status, fatigue, dehydration,concomitant heart failure, especially in elderly patients
  10. 10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: Care of the Patient withPneumonia - Diagnoses• Ineffective airway clearance• Activity intolerance• Risk for fluid volume deficient• Imbalanced nutrition• Deficient knowledge
  11. 11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCollaborative Problems• Continuing symptoms after initiation of therapy• Shock• Respiratory failure• Atelectasis• Pleural effusion• Confusion• Superinfection
  12. 12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: Care of the Patient withPneumonia - Planning• Improved airway clearance• Maintenance of proper fluid volume• Maintenance of adequate nutrition• Patient understanding of treatment, prevention• Absence of complications
  13. 13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsImproving Airway Clearance• Encourage hydration; 2 to 3 L a day, unlesscontraindicated• Humidification may be used to loosen secretions– By face mask or with oxygen• Coughing techniques• Chest physiotherapy• Position changes• Oxygen therapy administered to meet patient needs
  14. 14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsOther Interventions• Promoting rest– Encourage rest, avoidance of overexertion– Positioning to promote rest, breathing (Semi-Fowler’s)• Promoting fluid intake– Encourage fluid intake to at least 2 L a day• Maintaining nutrition– Provide nutritionally enriched foods, fluids• Patient teaching
  15. 15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAspiration• Risk factors• Pathophysiology• Prevention:– Elevate HOB– Turn patient to side when vomiting– Prevention of stimulation of gag reflex withsuctioning or other procedures– Assessment, proper administration of tube feeding– Rehabilitation therapy for swallowing
  16. 16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsPleural Conditions• Pleurisy: inflammation of both layers of pleurae– Inflamed surfaces rub together with respirations,cause sharp pain intensified with inspiration• Pleural effusion: collection fluid in pleural space usuallysecondary to another disease process– Large effusions impair lung expansion, causedyspnea
  17. 17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsPleural Conditions (cont’d)• Empyema: accumulation of thick, purulent fluid in pleuralspace.– Patient usually acutely ill; fluid, fibrin development,loculation impair lung expansion– Resolution is a prolonged process
  18. 18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsPleural Effusion
  19. 19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCausative Factors for Pulmonary Disease• Cigarette smoking• Air pollution
  20. 20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAcute Respiratory Distress Syndrome• Severe form of acute lung injury• Syndrome characterized by sudden, progressivepulmonary edema, increasing bilateral lung infiltrates onCXR, hypoxemia refractory to oxygen therapy, decreasedlung compliance• Symptoms– Rapid onset of severe dyspnea– Hypoxemia that does not respond to supplementaloxygen
  21. 21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsPathophysiology of ARDS
  22. 22. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsManagement of ARDS• Intubation, mechanical ventilation with PEEP to treatprogressive hypoxemia• Positioning: frequent position changes, proning• Nutritional support• General supportive care
  23. 23. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsPulmonary Emboli• Obstruction of pulmonary artery or branch by blood clot,air, fat, amniotic fluid, or septic thrombus– Most thrombus are blood clots from leg veins• Obstructed area has diminished or absent blood flow– Although area is ventilated, no gas exchange occurs• Inflammatory process causes regional blood vessels,bronchioles to constrict, further increasing pulmonaryvascular resistance, pulmonary arterial pressure, rightventricular workload• Ventilation-perfusion imbalance, right ventricular failure,shock occur
  24. 24. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsRisk Factors for Pulmonary Emboli• Venous stasis• Hypercoagulabilty• Venous endothelial disease• Certain disease states: heart disease, trauma,postoperative/postpartum, diabetes mellitus, COPD• Other conditions: pregnancy, obesity, oral contraceptiveuse, constrictive clothing• Previous history of thrombophlebitis
  25. 25. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsPrevention and Treatment of PulmonaryEmboli• Prevention– Exercises to avoid venous stasis– Early ambulation– Anticoagulant therapy– Sequential compression devices (SCDs)• Treatment– Measures to improve respiratory, CV status– Anticoagulation, thrombolytic therapy
  26. 26. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsUmbrella Filter
  27. 27. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestion• Tell whether the following statement is true or false:• Bradypnea is the most common sign for a possiblepulmonary embolism.
  28. 28. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswer• False.• Rationale: Tachypnea, not bradypnea, is the mostcommon sign for a possible pulmonary embolism.
  29. 29. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsPneumoconioses• Occupational lung diseases• Cause of death of 124,846 people in United States (1968to 2000)• Causative agents• Role of nurse as employee advocate• Role of nurse in health education, teaching preventivemeasures• Role of OSHA
  30. 30. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCare of the Patient with Lung Cancer• Prevention, causes• Classification of lung cancer• Treatment– Surgery– Radiation– Chemotherapy• Palliative care
  31. 31. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Care of the Patient with Cancer• Psychological support• Pain• Airway clearance• Fatigue• Dyspnea
  32. 32. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestion• Which of the following is the most common surgery for asmall apparently curable tumor of the lung?A.LobectomyB.PneumonectomyC.SegmentectomyD.Sleeve resection
  33. 33. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswer• A. Lobectomy• Rationale: The most common surgical procedure for asmall, apparently curable tumor of the lung is alobectomy. A pneumonectomy is the removal an entirelung. Segmentectomy is not recommended as curativeresection of lung cancer and is a removal of a segment ofthe lung. A sleeve resection is removal of the cancerouslobes with a segment of the main bronchus resected.
  34. 34. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsChest Trauma• Blunt trauma• Sternal, rib fractures• Flail chest• Pulmonary contusion• Penetrating trauma• Pneumothorax– Spontaneous or simple– Traumatic– Tension pneumothorax
  35. 35. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsFlail Chest
  36. 36. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsOpen Pneumothorax and TensionPneumothorax
  37. 37. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestion• Tell whether the following statement is true or false:• An initial characteristic symptom of a simplepneumothorax is a sudden onset of chest pain.
  38. 38. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswer• True.• Rationale: An initial characteristic symptom of a simplepneumonthorax is a sudden onset of chest pain.

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