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Respiratory System


        NURS156
      Chapter 28 & 29
                                albuterol
 Kapi’olani Community...
Chapter 28 Lower Respiratory problems

 Acute Bronchitis
 Tuberculosis (pgs 569-575)
 Environmental Lung Diseases
 Lung Ca...
Acute Bronchitis               (p 561)



 Inflammation of bronchi usually d/t infection
 Usually caused by virus (rhino or...
M. tuberculosis

      Caused by Mycobacterium tuberculosis
      Remains one of major causes of
      disability and deat...
TB in the population

   High rates of TB among HIV population
  Why is this population more vulnerable?
                 ...
Tuberculosis

Tuberculosis (TB) - communicable airborne
disease caused by M. tuberculosis droplets inhaled
when someone _c...
manifestations

   Early stages: no sx
   Active stage: fatigue, malaise, anorexia,
   unexplained wt loss, low-grade feve...
Diagnostic tests
 PPD- (+) if induration develops at injection
 site 48 to 72 hours after test
 AFB (acid fest bacilli tes...
First Line TB Drugs
           Isoniazid    side effects:
                        liver toxicity
           Rifampin     a...
Nursing concerns
Preventive isolation
Particulate respirators - masks with special
filters that filter droplet nuclei     ...
Occupational Lung Disease
            (pg 577-578 & 561)

Caused by inhaling dust or chemicals
Longer exposure= greater da...
Lung Cancer
Lung Cancer - affects the epithelium
Four Major Types
 Small cell/Oat cell (SCLC)
NON- Small Cell (NSCLC)
 S...
Statistics
   Leading cause of cancer or related deaths
   Accounts for 28% of all cancer deaths
   Approx. 172,570 new ca...
Etiology
  Cigarette smoking-#1 risk factor!
  Responsible for 80% to 90% of all lung
  cancers
  Tobacco smoke contains 6...
Diagnostic tests

  CXRs
  CT- most effective noninvasive test
  MRI shows same as CT
  Bronchoscopy or sputum studies
  p...
Lung Cancer S/S

Respiration decreased
Symptoms – Dyspnea, hemoptysis, coughing,
wheezing, fatigue, weight loss, SOB,
some...
Lung Cancer- treatment

  Staging - TMN system
Treatment Modalities
  RT - mostly for palliation although may be used in
 ...
Lung Cancer – nursing care
 Preop
   diagnostic tests
   Education...for pre and post op...what to
 expect, deep breathing...
Chapter 29 Obstructive Pulmonary Diseases


Asthma
COPD- Chronic Obstructive Pulmonary Disease
Chronic Bronchitis
Emphysem...
Asthma – Definition

Chronic inflammatory disorder of airways
 Causes airway hyperresponsiveness
  leading to wheezing, bre...
Triggers of Asthma
Allergens: 40% of cases
Exercise
Air Pollutants
Occupational Factors
Respiratory Infection
Nose and Sin...
Pathophysiology            thick tenacious
                           (sticky)mucous
                           edema
o Pr...
Factors Causing
Airway
Obstruction
in Asthma




                  Fig. 29-3
Clinical Manifestations
  Unpredictable and variable
  Expiration may be prolonged (3-4x
  longer)
  Wheezing is unreliabl...
Complications-Status asthmaticus
                                     triggered more
    Status asthmaticus               ...
Complications

 Clinical manifestations of status
 asthmaticus result from
  Increased airway resistance from edema
  Mu...
Complications of status asthmaticus
Complications of status asthmaticus
 Acute cor pulmonale
 Severe respiratory muscle ...
**Red Flags**
• Heart rate >120 bpm
• Respiratory rate >30 bpm
• Pulsus paradoxus
• Wheezes to silent breath sounds
• Spea...
Pulses paradoxus
                           see page 873



Usually during the inspiration phase the
 pulse becomes weaker...
Diagnostic Studies
Detailed history and physical exam
Pulmonary function tests (FEV measuring
how much air u can breath ou...
Drug Therapy
Long-term control medications
  Achieve and maintain control of persistent
  asthma
Quick-relief medications...
Drug Therapy

4 Types of Antiinflammatory Drugs
 Corticosteroids (suppress inflammatory
  response)                       s...
Drug Therapy
 Corticosteroids
 Suppress inflammatory response
  Inhaled
  Systemic form
 Mast cell stabilizers
  Inhibit...
Drug Therapy

 Leukotriene modifiers or inhibitors
  Blocks action of leukotrienes- potent
  bronchoconstrictors          ...
Drug Therapy
3 Types of Bronchodilators
 β2-adrenergic agonists aka rescue drugs
 Methylxanthines – rarely used
 Antich...
Drug Therapy
 Anticholinergic drugs (e.g., ipratropium,
 atrovent)
  Block action of acetylcholine
  Usually used in com...
Patient Teaching
Correct administration of drugs is a major
factor in success
 Inhalation of drugs is preferable to avoid...
Nursing Management
  Nursing Diagnoses
 Ineffective airway clearance
 Anxiety
 Deficient knowledge

Overall Goals
  Mainta...
Collaborative Care
  Desired therapeutic outcomes
   Control or eliminate symptoms
   Attain normal lung function
   Re...
Collaborative Care
     Acute asthma episode
 •    O2 therapy should be started
 •    Treatment depends on severity and
  ...
Collaborative Care
Status asthmaticus
 Most therapeutic measures are the same as for
 acute episode
  ↑ in frequency and...
Nursing Management
Health Promotion

 Teach patient to identify and avoid known
 triggers
 Prompt diagnosis
 Adequate nutr...
COPD - Overview
 increased resistance secondary to bronchial
  edema, ↑ mucous production, destruction of
  cilia, smooth...
COPD - Description
Airflow limitation not fully reversible
 Generally progressive
 Abnormal inflammatory response of lungs...
Chronic Bronchitis
 Presence of chronic productive cough for
 3 or more months in each of 2 successive
 years
  Other cau...
Emphysema

Abnormal permanent enlargement of the
air space distal to the terminal
bronchioles
Destruction of bronchioles w...
Emphysema - Pathophysiology
Two types
  Centrilobular
  Panlobular
COPD - Etiology
Risk factors
 Cigarette smoking
 Occupational chemicals and dust
 Air pollution
 Infection
 Heredity
...
COPD - Cigarette Smoking
 Effects of nicotine
 Carbon monoxide
 Involuntary smoke exposure


 Effects on respiratory tra...
Occupational and Environmental


COPD can develop with intense or
prolonged exposure to
 Dusts, vapors, irritants, or fum...
COPD Risk - Factors

Infection
Heredity - α1-Antitrypsin
           deficiency
Aging
COPD - Pathophysiology
Primary process is inflammation
 Inhalation of noxious particles
 Mediators released cause damage ...
COPD - Pathophysiology
Common characteristics
 Mucus hypersecretion
 Dysfunction of cilia
 Hyperinflation of lungs
 Gas...
COPD - Clinical Manifestations
  Develops slowly
  Diagnosis is considered with
   Cough
   Sputum production
   Dyspne...
COPD - Clinical Manifestations
 Physical examination findings
  Prolonged expiratory phase
  Wheezes
  Decreased breath ...
COPD - Complications

Exacerbations of COPD                     polycythemia

Acute respiratory failure
Peptic ulcer disea...
COPD- Diagnostic Studies

 Diagnosis confirmed by pulmonary
 function tests
 Spirometry—typical findings
 6-minute walk
 ECG
COPD - Collaborative Care
Primary goals of care
 Prevent progression
 Relieve symptoms
 Prevent/treat complications
 P...
COPD- Collaborative Care
 Irritants avoided
 Exacerbations
 Smoking cessation
 Bronchodilators
 corticosteroid therapy
...
COPD - Collaborative Care
 Complications of oxygen therapy
  Combustion     adapted to high CO2 levels
                  ...
COPD - Collaborative Care
Surgical therapy
 Lung volume reduction surgery C-OPD
  Remove 30% of most diseased lung to en...
COPD
Collaborative Care (Cont’d)
 Respiratory and physical therapy
  Aerosol nebulization therapy
  Chest physiotherapy
...
COPD - Collaborative Care
 Vibration
  Facilitates movement of secretions to larger
   airways
  Mild vibration tolerate...
Lower Respiratory Diseases -
            COPD
Nursing Dx
 Impaired gas exchange
 Ineffective airway clearance
 Activity...
Nursing Management - Planning


Goals

 Knowledge and ability to implement
  long-term regimen
 Overall improved quality...
Nursing Management
Nursing Implementation


Ambulatory and Home Care
 Most important aspect is teaching
   Pulmonary reh...
disease for life

  Bronchiectasis -
                               longterm antibiotic
                               the...
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  1. 1. Respiratory System NURS156 Chapter 28 & 29 albuterol Kapi’olani Community College corticosteroids for pretty much every resp
  2. 2. Chapter 28 Lower Respiratory problems Acute Bronchitis Tuberculosis (pgs 569-575) Environmental Lung Diseases Lung Cancer Chest Tubes
  3. 3. Acute Bronchitis (p 561) Inflammation of bronchi usually d/t infection Usually caused by virus (rhino or influenza) Bacterial cause are common: in smokers Acute Exacerbation of Chronic Bronchitis (AECB)- an acute infection along w/chronic bronchitis more sputum from bac supportive care: fluids, rest, meds
  4. 4. M. tuberculosis Caused by Mycobacterium tuberculosis Remains one of major causes of disability and death worldwide In 2006, 9.2 million new cases were diagnosed and 1.7 million died (NIH, 2008). requires 2years of Types of TB include: multi drug therapy -Multidrug-Resistant TB (MDR TB) -Extensively Drug-Resistant TB (XDR TB)
  5. 5. TB in the population High rates of TB among HIV population Why is this population more vulnerable? poor compliance of Emergence of MDR strains treatment What caused this to happen? wrong drugs given because harder to diagnosis when body does not produce antigen immune response
  6. 6. Tuberculosis Tuberculosis (TB) - communicable airborne disease caused by M. tuberculosis droplets inhaled when someone _coughing, sneezing, yelling__ Affects the __ of the lungs first and bacilli not phagocytized wander through the lymphatic system to other parts of the lung and body and lay dormant harbored in granulona to issolate the TB when in body active infection may never happen. must be in active stage to transmit
  7. 7. manifestations Early stages: no sx Active stage: fatigue, malaise, anorexia, unexplained wt loss, low-grade fevers, and night sweats Most common: frequent cough that produces white, frothy sputum Hemoptysis is seen in advanced cases HIV pts may present differently
  8. 8. Diagnostic tests PPD- (+) if induration develops at injection site 48 to 72 hours after test AFB (acid fest bacilli test) CXR to view lesions/scars Lung Scan Bacille Calmette-Guerin Vaccine Sputum culture- confirms diagnosis only way to confirm diagnosis and differenciate bet ween pneumonia
  9. 9. First Line TB Drugs Isoniazid side effects: liver toxicity Rifampin and non viral hepatitis Ethambutol Pyrazinamide DOT, side effects, prevention to active disease directly observed therapy
  10. 10. Nursing concerns Preventive isolation Particulate respirators - masks with special filters that filter droplet nuclei NEGATIVE AIRBORN isolation for details check PRESSURE ROOM!! fundamental text Community Concerns- all contacts with the patient need to be notified and possibly put on medications for prevention → 300mg Isonizid
  11. 11. Occupational Lung Disease (pg 577-578 & 561) Caused by inhaling dust or chemicals Longer exposure= greater damage Occupational/environmental asthma Pneumoconiosis: ‘dust in the lungs’ Chemical pneumonitis: exposure from toxic chemicals Hypersensitivity pneumonitis/extrinsic allergic alveolitis: inhaling antigen cause fibrosis; scaring hardened tissue
  12. 12. Lung Cancer Lung Cancer - affects the epithelium Four Major Types  Small cell/Oat cell (SCLC) NON- Small Cell (NSCLC)  Squamous/Epidermoid  Adenocarcinoma  Large Cell/Undifferentiated  NSCLC are S-L-O-W growing
  13. 13. Statistics Leading cause of cancer or related deaths Accounts for 28% of all cancer deaths Approx. 172,570 new cases are diagnosed each yr 58% of deaths are in men w/African- Americans having the highest rate and Hispanics the lowest Lung cancer now surpassed breast cancer Most common in persons >50 years old w/long hx of cigarette smoking
  14. 14. Etiology Cigarette smoking-#1 risk factor! Responsible for 80% to 90% of all lung cancers Tobacco smoke contains 60 The smoke is an irritant Ten years after cessation risk of lung cancer mortality is reduced 30% to 50%
  15. 15. Diagnostic tests CXRs CT- most effective noninvasive test MRI shows same as CT Bronchoscopy or sputum studies provide the definitive diagnosis usually by dx too late
  16. 16. Lung Cancer S/S Respiration decreased Symptoms – Dyspnea, hemoptysis, coughing, wheezing, fatigue, weight loss, SOB, sometimes shoulder pain. Paraneoplastic syndrome
  17. 17. Lung Cancer- treatment Staging - TMN system Treatment Modalities RT - mostly for palliation although may be used in conjunction with surgery or chemotherapy Chemotherapy - works best with small cell Surgery: better with non small cell only 25% eligible Laser surgery Resections - Wedge, Segmental, Lobe, Pneumonectomy
  18. 18. Lung Cancer – nursing care Preop diagnostic tests Education...for pre and post op...what to expect, deep breathing for post with practice, inspirometer, chest tube expectations. Postop Monitoring, labs, DB & C, pain management, dressings
  19. 19. Chapter 29 Obstructive Pulmonary Diseases Asthma COPD- Chronic Obstructive Pulmonary Disease Chronic Bronchitis Emphysema Bronchietasis Medications
  20. 20. Asthma – Definition Chronic inflammatory disorder of airways  Causes airway hyperresponsiveness leading to wheezing, breathlessness, chest tightness, and cough Affects about 20 million Americans Women and African Americans have a 30% or greater prevalence
  21. 21. Triggers of Asthma Allergens: 40% of cases Exercise Air Pollutants Occupational Factors Respiratory Infection Nose and Sinus Problems ie. Rhinotic pollops Drugs and Food Additives Gastroesophageal Reflux Disease Emotional Stress
  22. 22. Pathophysiology thick tenacious (sticky)mucous edema o Primary response bronchio spasms Hyper-responsivenes o Inflammatory mediators o Late-phase response
  23. 23. Factors Causing Airway Obstruction in Asthma Fig. 29-3
  24. 24. Clinical Manifestations Unpredictable and variable Expiration may be prolonged (3-4x longer) Wheezing is unreliable to gauge severity Cough variant asthma feeling of suffocation hypoxemia: sx, in rr and pulse, increased CO2, decreased O2, restless, anxious, inappropriate behavior.
  25. 25. Complications-Status asthmaticus triggered more Status asthmaticus easily by viral infections and  Severe, life-threatening attack ingestion of aspirin unresponsive to usual treatment  Patient at risk for respiratory failure  As attack severity ↑, work of breathing ↑, patient tires, and it is harder to overcome the ↑ resistance to breathing  Ultimately the patient deteriorates to hypercapnia (too much CO2) and hypoxemia
  26. 26. Complications Clinical manifestations of status asthmaticus result from  Increased airway resistance from edema  Mucous plugging  Bronchospasm  Respiratory acidosis
  27. 27. Complications of status asthmaticus Complications of status asthmaticus  Acute cor pulmonale  Severe respiratory muscle fatigue leading to respiratory arrest  Death is usually result of respiratory arrest or cardiac failure
  28. 28. **Red Flags** • Heart rate >120 bpm • Respiratory rate >30 bpm • Pulsus paradoxus • Wheezes to silent breath sounds • Speaks in words not sentences • O2 sat <90% • Cant converse • These signs warrant immediate medical intervention to prevent respiratory failure
  29. 29. Pulses paradoxus see page 873 Usually during the inspiration phase the pulse becomes weaker as one inhales and stronger as one exhales. Pulses paradoxus is an exaggeration of this normal variation in pulse. This could also indicate other serious conditions such as: cardiac tamponade, pericarditis, chronic sleep apnea, croup, COPD, and asthma
  30. 30. Diagnostic Studies Detailed history and physical exam Pulmonary function tests (FEV measuring how much air u can breath out in one second) Peak flow monitoring Chest x-ray ABGs Oximetry Allergy testing Blood levels of eosinophils Sputum culture and sensitivity
  31. 31. Drug Therapy Long-term control medications  Achieve and maintain control of persistent asthma Quick-relief medications  Treat symptoms of exacerbations
  32. 32. Drug Therapy 4 Types of Antiinflammatory Drugs  Corticosteroids (suppress inflammatory response) side effects to steroids:  Mast cell stabilizers lowers immune response and healing time  Leukotriene modifiers round face and thin skin. faster metabolism, and  Monoclonal antibody to IgE appetite high glucose levels
  33. 33. Drug Therapy Corticosteroids Suppress inflammatory response  Inhaled  Systemic form Mast cell stabilizers  Inhibit IgE-mediated release of inflammatory mast cells non-steroidal
  34. 34. Drug Therapy Leukotriene modifiers or inhibitors  Blocks action of leukotrienes- potent bronchoconstrictors add on therapy to induce but not sub for steroids Monoclonal antibody to IgE  ↓ circulating free IgE levels  Prevents IgE from attaching to mast cells, preventing release of chemical mediators
  35. 35. Drug Therapy 3 Types of Bronchodilators  β2-adrenergic agonists aka rescue drugs  Methylxanthines – rarely used  Anticholinergics β-adrenergic agonists (e.g., albuterol, metaproterenol)  Effective for relieving acute bronchospasm  Onset of action in minutes and duration of 4-8 hours  side: tacycard, restlessness
  36. 36. Drug Therapy Anticholinergic drugs (e.g., ipratropium, atrovent)  Block action of acetylcholine  Usually used in combination with a bronchodilator  Most common side effect is dry mouth, headache, nervousnes
  37. 37. Patient Teaching Correct administration of drugs is a major factor in success  Inhalation of drugs is preferable to avoid systemic side effects
  38. 38. Nursing Management Nursing Diagnoses Ineffective airway clearance Anxiety Deficient knowledge Overall Goals  Maintain greater than 80% of PEFR  Have minimal symptoms  Maintain acceptable activity levels
  39. 39. Collaborative Care Desired therapeutic outcomes  Control or eliminate symptoms  Attain normal lung function  Restore normal activities  Reduce or eliminate exacerbations and side effects of medications  Avoid triggers of acute attacks  Premedicate before exercising  Choice of drug therapy depends on symptom severity
  40. 40. Collaborative Care Acute asthma episode • O2 therapy should be started • Treatment depends on severity and response • Inhaled β-adrenergic agonists by metered dose inhaler • Corticosteroids
  41. 41. Collaborative Care Status asthmaticus  Most therapeutic measures are the same as for acute episode  ↑ in frequency and dose of bronchodilators  IV corticosteroids are administered every 4-6 hours  Continuous monitoring  IV fluids - insensible loss of fluids
  42. 42. Nursing Management Health Promotion Teach patient to identify and avoid known triggers Prompt diagnosis Adequate nutrition Adequate sleep Preventive medications Monitoring symptoms
  43. 43. COPD - Overview  increased resistance secondary to bronchial edema, ↑ mucous production, destruction of cilia, smooth muscle contraction, or↓ elastic recoil, or bronchiolar/alveolar wall damage  caused by numerous irritants especially cigarette smoke which is also a risk factor
  44. 44. COPD - Description Airflow limitation not fully reversible  Generally progressive  Abnormal inflammatory response of lungs to noxious particles or gases Includes  Chronic bronchitis  Emphysema
  45. 45. Chronic Bronchitis Presence of chronic productive cough for 3 or more months in each of 2 successive years  Other causes of chronic cough are excluded
  46. 46. Emphysema Abnormal permanent enlargement of the air space distal to the terminal bronchioles Destruction of bronchioles without obvious fibrosis
  47. 47. Emphysema - Pathophysiology Two types  Centrilobular  Panlobular
  48. 48. COPD - Etiology Risk factors  Cigarette smoking  Occupational chemicals and dust  Air pollution  Infection  Heredity  Aging
  49. 49. COPD - Cigarette Smoking Effects of nicotine  Carbon monoxide  Involuntary smoke exposure Effects on respiratory tract  Increased mucus production  Hyperplasia of mucus glands  Lost or decreased ciliary activity
  50. 50. Occupational and Environmental COPD can develop with intense or prolonged exposure to  Dusts, vapors, irritants, or fumes  High levels of air pollution  Fumes from indoor heating or cooking with fossil fuels
  51. 51. COPD Risk - Factors Infection Heredity - α1-Antitrypsin deficiency Aging
  52. 52. COPD - Pathophysiology Primary process is inflammation  Inhalation of noxious particles  Mediators released cause damage to lung tissue  Airways inflamed  Parenchyma destroyed Supporting structures of lungs are destroyed Pulmonary vascular changes
  53. 53. COPD - Pathophysiology Common characteristics  Mucus hypersecretion  Dysfunction of cilia  Hyperinflation of lungs  Gas exchange abnormalities  Skeletal muscle wasting
  54. 54. COPD - Clinical Manifestations Develops slowly Diagnosis is considered with  Cough  Sputum production  Dyspnea  Exposure to risk factors  Accessory intercostal muscles  Underweight with adequate caloric intake
  55. 55. COPD - Clinical Manifestations Physical examination findings  Prolonged expiratory phase  Wheezes  Decreased breath sounds  ↑ Anterior-posterior diameter  Fatigue Dx with pulmonary  SOB function test
  56. 56. COPD - Complications Exacerbations of COPD polycythemia Acute respiratory failure Peptic ulcer disease Depression/anxiety Cor pulmonale hypertrophy on R side of heart; late manifestation
  57. 57. COPD- Diagnostic Studies Diagnosis confirmed by pulmonary function tests Spirometry—typical findings 6-minute walk ECG
  58. 58. COPD - Collaborative Care Primary goals of care  Prevent progression  Relieve symptoms  Prevent/treat complications  Promote patient participation  Prevent/treat exacerbations  Improve quality of life and reduce mortality risk
  59. 59. COPD- Collaborative Care Irritants avoided Exacerbations Smoking cessation  Bronchodilators  corticosteroid therapy  O2 therapy pt with COPD do not respond as dramatically as pt with asthma to O2
  60. 60. COPD - Collaborative Care Complications of oxygen therapy  Combustion adapted to high CO2 levels if O2 is given decreases  CO2 narcosis CO2 concentration which decreases reflex to breath  O2 toxicity  Absorption atelectasis  Infection
  61. 61. COPD - Collaborative Care Surgical therapy  Lung volume reduction surgery C-OPD  Remove 30% of most diseased lung to enhance performance of remaining tissue  Bullectomy  Used for emphysema  Large bullae are resected to improve lung function
  62. 62. COPD Collaborative Care (Cont’d) Respiratory and physical therapy  Aerosol nebulization therapy  Chest physiotherapy  Percussion  Vibration  Postural drainage  Pursed-lip breathing slows RR and extends E  Effective coughing
  63. 63. COPD - Collaborative Care Vibration  Facilitates movement of secretions to larger airways  Mild vibration tolerated better than percussion Flutter mucus clearance device  Produces vibration in lungs to loosen mucus for expectoration  Handheld device
  64. 64. Lower Respiratory Diseases - COPD Nursing Dx  Impaired gas exchange  Ineffective airway clearance  Activity intolerance  Anxiety  Risk for infection  Imbalanced nutrition  Sexual dysfunction  Disturbed sleep pattern
  65. 65. Nursing Management - Planning Goals  Knowledge and ability to implement long-term regimen  Overall improved quality of life
  66. 66. Nursing Management Nursing Implementation Ambulatory and Home Care  Most important aspect is teaching  Pulmonary rehabilitation  Activity considerations  Sexual activity  Sleep  Psychosocial considerations
  67. 67. disease for life Bronchiectasis - longterm antibiotic therapy reser ved for worst case pt. ↑ ↑ ↑ mucous production seen in 3 layers → clear, cloudy, purulent; seen in patients who work with fine particles such as flour, aspertame, wheat hallmark- persistent and very productive cough with purulent sputum up to 500ml of mucus

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