Respiratory Part 2
Medical Surgical Nursing
Influenza
• AKA
– Flu
• Highly contagious
• Pathogen
– Viral
• Epidemic
– Rapid and extensive spreading infection and
affecting many individuals in an area or a
population at the same time
FYI
• Influenza & its complications (primarily
bacterial pneumonia) are the 8th leading
cause of death in the US.
• @60,000 year
H1N1
• Newly identified
stain
•  Pandemic
–(World-wide
epidemic)
Mode of transmission
• Airborne droplet
• Direct contact
Influenza Statistics
• Incubation period
–Short
• Onset
–Rapid
• Duration
–Up to a week
Influenza: S&S (local)
• Runny nose
• Sore throat
• Cough
– Dry
– Non-productive 
productive
– Substernal burning
Influenza: S&S (systemic)
•
•
•
•
•
Chills & fever
H/A
Malaise
Muscle aches
Fatigue &
weakness
Older adults
• Higher risk of
–Complications
• Pneumonia
• Death
Why are older adult more susceptible
to complications of influenza?
• Cilia
–i
• Chest muscle strength
–i
• Chest wall
– Stiffer
• Cough
– Less effective
Assessment
• S&S
• Vital Signs
IDT
• “Most URI’s are self-limiting”
IDT
• Self-care
• Symptomatic relief
• Prevent
complications
• Prevent spread
Dx test
• Throat swab
– R/O streptococci
• CBC
– WBC normal
• Vial
– WBC increased
• Bacterial
• Chest x-ray
– R/O pneumonia
Flu Vaccine: Is it effective?
• Polyvalent
influenza virus
vaccine
• 85% effective
Flu Vaccine: Who should get it?
•
•
•
•
•
•
•
•
Age >50 years
Nursing home residents
Pg women
Chronically ill
Immunosuppressed
Resp. conditions
Healthcare workers
Fam. members of those
at risk
Flu Vaccine: Who should not get it?
• Allergic to eggs
Small Group Questions
1. What pathogen is assoc. with flu?
2. Identify 5 S&S of the flu
3. What type of isolation would you use for a
client with the flu
4. Mary asks you if she should get the flu
vaccine, how do you respond?
5. What priority nursing diagnosis would you
give for a person with the flu?
Which of the following nursing
interventions is appropriate after a
client has had a bronchoscopy?
A. Report abnormal lab values
B. Lay flat for 8 hours with a sand bag
to the puncture site
C. NPO until gag reflex returns
D. Push fluids
Tuberculosis
• AKA
–TB
Tuberculosis - FYI
• Causes more death than any other
disease. 2 billion world wide, 15
million in the US
Tuberculosis - FYI
• When treated,
about 90% of
those with active
TB survive!
Tuberculosis
• Pathophysiology
– Mycrobacterium
tuberculosis
– Tubercle bacillus
Tuberculosis
Pathophysiology
• Mode of transmission
– Air-borne
•  alveoli
• Multiplies in alveoli
Tuberculosis
• Immune response phase
– Macrophages attack TB
– TB has waxy cell wall that protects it from
macrophages
– Immune system surrounds the infected
macrophages
– Forms a Lesion
– Called a Tubercle
Tuberculosis
• Dormant phase
– Contagious?
• No
– Symptomatic?
• No
– PPD?
• positive
– chest x-ray?
• Negative
Tuberculosis
• Active phase
–If an infected person has a weakened
immune system, 
–the TB escapes and infects the body
Tuberculosis
• 5-10% become active
• Only contagious when
active
• Primarily affect lungs
but…
– Kidneys
– Liver
– Brain
– Bone
Tuberculosis
Etiology
• Assoc. w/
– Poverty
– Malnutrition
– Overcrowding
– Substandard housing
– Inadequate health care
• Elderly
• HIV
• Prison
Tuberculosis: S&S (active phase)
•
•
•
•
NOC sweats
Low grade fever
Wt loss
Chronic productive cough
– Rust colored & thick
• Hemoptysis
• SOB
Tuberculosis: Dx test
• PPD
– Mantoux skin test
– > 10mm in diameter
– induration
– Indicates:
• Latent TB
– Read
• 48-72 after
– Intradermal:
• 15-degrees
Tuberculosis
• Diagnostic tests
– X-ray
– Symptoms
– Acid Fast Bacillus
Tuberculosis: Tx / Rx
• INH
– isonicotinyl hydrazine
– Isoniazid
– Toxic to the liver
• Rifampin
– Turns urine red
Tuberculosis: Prevention
• Clean well ventilated living areas
• Resp. isolation
–Negative pressure room
• If exposed take
–INH
Tuberculosis: complication
•
•
•
•
Malnutrition
S/E of Rx treatment
Multi-drug resistance
Spread of TB infection
Small Group Questions
1.
2.
3.
4.
5.
What type of pathogen is TB?
What is the mode of transmission?
What are the classic S&S of TB ?
How to administer and read a PPD?
If a pt is PPD +, what does that mean?
Small Group Questions
6. What is the standard screening method of
TB?
7. That medications are used to treat TB, what
are their side effects?
8. Where in the US is TB most prevalent?
Why?
COPD - overview
COPD?
– Chronic Obstructive Pulmonary
Disease
– Broad classifications of diseases
COPD
Characteristics
•
•
•
•
•
Airflow limitation
Irreversible
Dyspnea on exertion
Progressive
Abn. inflammatory response of the lungs
to noxious particles or gases
Pathophysiology
• Noxious particles of gas 
• Inflammatory response 
• Narrowing of airway
Pathophysiology
• Inflammation 
• Thickening of the wall of the
pulmonary capillaries
COPD
• Includes
–Emphysema
–Chronic bronchitis
• Does not include
–Asthma
COPD - FYI
• COPD 4th leading cause of death in the US
• 12th leading cause of disability
• Death from COPD is on the rise while death
from heart disease is going down
COPD:
Risk Factors
• Smoking
• Passive smoking
• Occupational
exposure
• Air pollution
COPD risk factors
• #1
– Smoking
• Why is smoking so bad??
– ↓ phagocytes
– ↓ cilia function
– ↑ mucus production
Chronic Bronchitis
• Disease of the airway
• Definition:
– cough + sputum production
– > 3 months
Chronic Bronchitis
Pathophysiology
• Pollutant irritates airway 
• Inflammation
• h secretion of mucus 
• Bronchial walls thicken 
– Lumen narrows
– plugs
Chronic Bronchitis
• Alveoli/bronchioles become
damaged
• ↑ susceptibility to LRI
Emphysema: Pathophysiology
• Affects alveolar membrane
–Destruction of alveolar wall
–Loss of elastic recoil
–Over distended alveoli
Emphysema
Pathophysiology
• Over distended alveoli
–Damage to adjacent pulmonary
capillaries
–Impaired passive expiration
Emphysema
• Damaged pulmonary capillary bed
– h pulmonary pressure 
– h work load for right ventricle 
– Right side heart failure
Emphysema
• Nursing Diagnosis
–Impaired gas exchange
COPD
Compare and contrast
• Chronic Bronchitis is a disease of the
___________?
–Airway
• Emphysema is a disease affecting the
___________?
–Alveoli
C.O.P.D.
• Risk factors, S&S, treatment, Dx, Rx
- same for Chronic Bronchitis & Emphysema
C.O.P.D.
Clinical Manifestation (primary)
1. Cough
2. Sputum production
3. Dyspnea on exertion
(Secondary)
•
•
•
Wt. loss
Resp. infections
Barrel chest
C.O.P.D.
Nrs. Assessment
•
•
•
•
•
•
Risk factors
Past Hx / Family Hx
Pattern of development
Presence of comobidities
Current Tx
Impact
Dx tests
• ABG’s
–Baseline PaO2
• Rule out other diseases
–CT scan
–X-ray
C.O.P.D.
Medical Management
• Risk reduction
– Smoking cessation!
• (The only thing that slows down the
progression of the disease!)
C.O.P.D.
Rx. therapy
Primary
• Bronchodilators
• Corticosteriods
Secondary
• Antibiotics
• Mucolytic agents
• Anti-tussive agents
Bronchodilators
• Action:
–h the size of the lumen
–Relieve bronchospasms
–Reduce airway obstruction
–↑ ventilation
Bronchodilators
• Examples
–Albuterol (Proventil, Ventolin, Volmax)
–Metaproterenol (Alupent)
–Ipratropium bromide (Atrovent)
–Theophylline (Theo-Dur)*
Glucocorticoids
• Action
–Potent anti-inflammatory agent
Corticsteriods
• S/E
– Na+ & H20 retention
– Never D/C abruptly
Glucocorticoids
• Examples
–Prednisone
–Methyprednisone
–Beclovent
C.O.P.D.
Medical Management
• Treatment
–O2
• 2 L/min
–Pulmonary rehab
• Breathing exercises
• Pulmonary hygiene
Small Group Questions
1. What 2 diseases are assoc. with COPD?
2. Describe the pathophysiology of COPD.
3. What effect does smoking have on the resp.
system?
4. Differentiate between chronic bronchitis and
emphysema.
5. What are the 3 main S&S of COPD?
6. What 2 classifications of meds are used to treat
clients with COPD (what are their actions)?
Pneumonia
Pathophysiology
• An inflammatory process in which there
is consolidation
–In the alveolar spaces.
• Gas exchange cannot take place in
consolidated area
Pneumonia
Causative agents
• Viral pneumonia
• Bacterial Pneumonia
– Streptococcus pneumoniae
– Pneumocystis Pneumonia
•
•
•
•
•
Fungal pneumonia
Radiation pneumonia
Chemical pneumonitis
Aspiration pneumonia
Hypostatis pneumonia
Pneumonia FYI
• Most common cause of death from
infectious agents
• 66,000 deaths / year
• $$$
Pneumonia: Progression of events
• Inflammation 
• h Exudate 
• i movement of O2 and CO2

• WBC migrate into the alveoli

• Fill air-containing spaces
• i ventilation
– i Oxygen saturation
Pneumonia: Risk factors
•
•
•
•
•
•
•
•
Immunosuppressant
Smoking
Prolonged immobility
Depressed cough reflex
NPO
ETOH intoxication
Gen. anesthetic or opiod
Advanced age
Pneumonia: S&S TYPICAL
• Onset
– Acute
•
•
•
•
Shaking
Chills
Fever
Cough
– Productive
• Sputum
– Rust-colored
– Purulent
Pneumonia: S&S TYPICAL
• Chest pain
– Sharp
– Localized
• Breath sounds
– Diminished
– Crackles
– Respiratory distress
Pneumonia: S&S ATYPICAL
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•
•
•
•
•
“Walking pneumonia”
Milder symptoms
Fever
H/A
Muscle aches
Malaise
Pneumonia: S&S ATYPICAL
• Cough
– Hacking
– Non-productive
• Self limited
S&S Elderly
• General deterioration
• Weak
• Abd. Symptoms
– Anorexia
• Confusion
• Tachycardia
• Tachypnea
• Do Not C/O
–Cough
–Pain
–Fever
–Sputum
Pneumonia: Dx
• Sputum C&S
• CBC / WBC
–h
• Bacteria
–i
• Viral
• ABG’s
• Pulse oximetry
• Chest x-ray
Pneumonia: Medications
• Primary
– Antibiotics
– Bronchodilators
– Expectorant
Antibiotics
• Action
– Attacks pathogens
• Nursing consideration
– Educate to take all
– Not contagious after 24 hours on meds
Bronchodilators
• Dilate bronchi
• Reduce bronchospasms
• Improve ventilation
Expectorants
• Break up mucus
–i viscosity
• Liquefies mucus 
• Easier to expectorate
• Take with lots of water!
Pneumonia: Medications
• Secondary
–Antibiotics
–Antipyretic
–Analgesic
Pneumonia: Nursing
• Fluids
– 2,500 – 3,000 mL/day
– Humidifier
• Chest physiotherapy
– TCDB
– I.S.
• Assess respiratory status
• Position
– HOB
• Rest
Pneumonia – Nursing Interventions
• O2 per order
• Maintaining nutrition
– Gatorade
– Ensure
• Promoting the patients knowledge
Pneumonia
Prevention
• Vaccine
– Pneumonia
– Flu
• Treat URI
• Avoid irritants
Pneumonia: Small Group Questions
1. Describe the pathophysiology of pneumonia.
2. What is the difference btw typical and atypical
pneumonia?
3. What causes pneumocystis carinii?
4. What lab values are associated with bacterial
pneumonia? / viral pneumonia?
Pneumonia: Small Group Questions
5. What is Nosocomial pneumonia
6. Identify 5 risk factors for developing pneumonia
7. What medications might be administered to treat a
pt. with pneumonia?
8. What nursing education would you give to a patient
with pneumonia?
9. What are the gerontological considerations of caring
for the elderly in regards to pneumonia?
Lung Cancer
Pathophysiology
•
Carcinogen binds to
the DNA and changes
it
•
Abnormal growth
•
Usually develops on
the wall of the
bronchial tree
FYI
• Lung Cancer is the number one
cancer killer in the US
Lung Cancer
Etiology/Contributing factors
•
#1
–
Tobacco Smoke (85%)
–
Second hand smoke
•
Carcinogens
–
Asbestos
–
Uranium
–
Arsenic
–
Nickel
–
Iron oxide
–
Radon
–
Coal dust
Lung Cancer
Clinical manifestations: early
•
Insidious and
asymptomatic
•
until late stages
FYI
– 70% of lung CA have metastasized by the time of
diagnosis
Lung Cancer
S&S: Early
• Objective symptoms
– #1:
• Cough
– #2
• Repeated respiratory
tract infection
– Wheezing
– Dyspnea
Lung Cancer
S&S: Late
•
Hemoptysis
•
Chest pain
•
Wt loss
•
Anemia
•
Anorexia
Lung Cancer
Dx exams/procedures
•
X-ray
•
CT scan
•
Biopsy via
Bronchoscopy
–
cytology
Lung Cancer
Treatment
•
Surgery
–
•
Removal
Chemotherapy
–
•
Metastasis
Radiation
–
To shrink or reduce
symptoms
Lung CA
• Priority Nrs Dx
– Ineffective
breathing
– Ineffective Airway
clearance
– Ineffective Gas
exchange
Assessment
•
•
•
•
Resp assessment
Smoking hx
Lab values
S&S of
complications
Assessment
• S&S of
complications
– Edema
– H/A
– Dizziness
– Vision changes
– Difficulty breathing
– C/O pain
Interventions
• Assess q4hrs
• HOB
• Pulmonary hygiene
– TCDB
– IS
• O2 per order
• Suction PRN
• Emotional support
Secondary Nrs Dx
• Activity intolerance
• Pain
• Grieving
Activity intolerance
• Document response
to activity
– Pulse
– Resp. status
– Fatigue
• Planned rest periods
• Increase activities
gradually
• Enc to remain as
active as possible
• Allow fam. To
provide assist PRN
• Keep frequently
used objects
nearby
Pain
• Assess pain
• Administer
analgesics PRN
PAIN & CANCER
• “For cancer pain, maintain a continuous medication
schedule using opiates, NSAIDs and other drugs as
ordered”
– Addiction is not a concern for the terminal cancer
client; adequate pain relief that does not allow
“breakthrough” pain is vital.
Pain
• Assess pain
• Administer
analgesics PRN
• Alternative pain
relief
–
–
–
–
Massage
Positioning
Distraction
Relaxation
techniques
Pain
• Provide diversion
activities
– TV
– Reading
– Social events
• Allow family to
remain
Grieving
• Spend time with
client & family
• Answer questions
honestly
• Enc. Pt to express
feelings (fear,
anxiety, concerns)
• Assist to understand
the grief process
Grieving
• Enc other support
systems
–
–
–
–
Spiritual
Social groups
Social services
Hospice
• Discuss advanced
directives
– Living will
Lung Cancer
Preventative measures
•
Stop smoking
Small Group Questions
• What is the number one carcinogen of lung
cancer?
• What are the early S&S of lung cancer?
• Who is Lung Cancer diagnosed?
• How is lung cancer usually treated?
• What is one priority nursing diagnosis for a
client with lung cancer? Identify 3 nursing
interventions for this diagnosis