Note
Studied by 6 peopleRespiratory Disorders
I. ATELECTASIS
Atelectasis - is a condition characterized by the collapse of lung tissue, which leads to reduced gas exchange and can result in hypoxemia. A shrunken airless state of the alveoli.
Diagnosis
X-ray or CT scan - shows tracheal deviation or placement away from affected side
Etiology
Primary Atelectasis
Lung tissue remains uninflated as a result of insufficient surfactant production.
Present at birth typically on premature and at-risk infants.
Secondary Atelectasis
Risk for secondary atelectasis increases after surgery
Caused by airway obstruction, lung compression and increased recoil due to diminished surfactants
Surfactants - substances that reduce surface tension in the lungs, helping to keep the alveoli open and facilitating gas exchange.
Airway obstruction may be due to mucus plugs, tumors or exudates.
Exudates - infected fluids, cells, or other substances that are released from blood vessels or through wounds.
Pathophysiologic Processes and Manifestations
Ineffective cough reflex - decrease tidal volume and decreases sigh mechanism - poor alveolar expansion
Increased viscosity of sputum - pooling of secretions
Complete airway obstruction - absorption of oxygen from dependent alveoli and collapse of that portion of lungs
Symptoms
Dyspnea and Tachycardia
Diminished breath sounds from poor air entry causing Hypoxemia
Hyperresonance in percussion
Tracheal deviation - asymmetry of chest wall (from rib fractures) or shifting of mediastinal structures to unaffected side of unaffected chest
Pleuritic pain (sharp pain occurring during inhalation) and Increased RR
Crackles and gurgles
Nursing Interventions for Atelectasis (AICIO)
Antibiotics
Incentive Spirometry (IS) - A patient breathes in as much as air as they can in 10 seconds to expand lungs. A common medical test that measures how much and how quickly you can inhale and exhale air.
CPT - Chest Physical Therapy or vibration of chest to loosen up secretions
IPPB - Intermittent Positive Pressure Breathing (done q 4 hours)
Oxygen if necessary
II. PNEUMOTHORAX
Pneumothorax - it is the accumulation of air in the pleural space, which results in partial or complete lung collapse.
Diagnosis
X-ray or CT scan - shows tracheal deviation or placement away from affected side
Etiology
Tension – air enters but can’t leave pleural space (one-way valve) that has unknown causes
Secondary – air enters the pleural space as a result of trauma or injury to the chest wall, respiratory structures or esophagus
Spontaneous – air enters the pleural space when air-filled blebs (blisters) on the lung surface rupture, specially from smokers
Symptoms of pneumothorax (same with atelectasis but with signs of shock)
In tension pneumothorax, onset is sudden and painful (can affect the heart)
Nursing Interventions for Pneumothorax (NMSACO)
No shortness of breath, no treatment
Monitor V/S, signs of shock, and respiration (changing pattern may indicate worsening situation)
Semi-Fowler’s position
Analgesics as ordered
Chest tube - escape route for air given in worse situation like tension or spontaneous
Maintain sterile dressing at chest tube insertion site
Maintain patency and integrity of closed chest drainage system
Evaluate amount of fluid and breath sounds.
Oxygen if necessary
III. PLEURAL EFFUSION
Pleural Effusion - Refers to an abnormal accumulation of fluid in the pleural cavity. Fluid may be transudate (hydrothorax), exudates (empyema), blood (hemothorax) or chyle (chylothorax).
Chyle - is a milky fluid found in lymph fluid from GI tract.
Etiology (HEHC)
Hydrothorax (Transudative) – results from CHF; other causes are RF, nephrosis and liver failure
Empyema (Exudative) – from infections, malignancies, SLE. May also be caused by direct spread of bacterial pneumonia or trauma-related infections
Hemothorax (Blood) – chest injuries, chest surgery complications, malignancies, blood vessel rupture
Chylothorax (Lymphatic) – chyle buildup coming from lymphatic system trauma, inflammation or malignant infiltration
Pathophysiologic Processes and Manifestations
5 mechanisms
Increase in capillary pressure – failure to shift the blood back towards the heart
Increase in capillary permeability - such as in inflammation
Decrease COP
Increase in intrapleural negative pressure
Impairment in lymphatic drainage of the pleura
Symptoms
Dyspnea
Pleuritic pain
The severity of HEMOTHORAX is determined by volume of fluid:
Minimal (300-500cc) – resolves in 10-14 days as small amounts of blood are naturally absorbed from the pleural space.
Moderate (500-1000 cc) – fills about 1/3 of the pleural cavity lung compression and signs of hypovolemia
Large (1000 cc or more) – fills half or more of the chest and requires immediate drainage.
Nursing Interventions for Pleural effusion (SAFDDS)
Signs of shock
Analgesics as required
For moderate to large:
Maintain Fluid replacement as ordered and assist with insertion of chest tubes are ordered (maintain patency of tubes).
Small effusion from CHF - needs Diuretics & sodium restriction
Large effusion from cancer - needs Draining tube
Loculated (tb or pneumonia) - needs Surgery
Prepare for surgery if bleeding doesn’t stop.
IV. ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)
ARDS - A sequel of several diseases in which the lungs fill with water, making gas exchange impossible (aka lung failure). Results from unknown cause.
Etiology
Predisposing factors (PNR-STD)
Pneumonia
Near drowning
Reaction to drugs and inhaled gases or Allergic reactions (pulmonary)
Shock infection
Trauma and Burns
Diabetic ketoacidosis
Symptoms:
Crackles and gurgles
Hypoxemia
X-ray result – mass consolidation
ABG Analysis: Respiratory acidosis
Nursing Interventions for ARDS (PMS)
PEEP - Positive End-Expiratory Pressure to improve oxygenation and prevent alveolar collapse
Mechanical ventilator
Steroids as ordered - reduce inflammation
Assess for complication like pneumothorax
Monitor fluid intake
Relieve anxiety
V. PNEUMONIA
Pneumonia - an acute INFECTION of the lung parenchyma varying in severity.
Etiology
Include bacteria, viruses, fungi and protozoa
Lobar pneumonia - partial infection
Bronchopneumonia - diffused infection
Pathophysiology
Organisms enter via the respiratory tract (Staphylococcus and gram-negative bacilli by hematogenous)
Defense system activates (Mucociliary transport, pulmonary macrophagus).
Fails in overwhelming infection and immunosuppression
Invading organisms multiplies releases toxins
Increase in capillary permeability
edema of the lung parenchyma
cellular debris and exudates
if filled, may lead to airless state
Consolidated state
Symptoms (FCRD)
Fever and Malaise
Chills and Cough
Rales and Rhonchi - Pleuritic pain
Dyspnea
Nursing Interventions for pneumonia (ACECHO)
Administer Antibiotics/Antiviral/Antifungi specific for the causative organism, as ordered
Control fever (paracetamol)
Encourage adequate fluid intake
Chest physiotherapy
Provide bronchial Hygiene
Oxygen, as ordered
VI. CHRONIC OBSTRUCTIVE PULMONARY DISEASE
COPD - includes emphysema and chronic bronchitis
Assessment (SWAPLSCVBCCPM)
Sputum production
Crackles and wheezes
Adventitious BS (abnormal breath sounds)
Pursed lip appearance
Alteration in LOC
Alteration in skin color
Voice changes
Barrel chest
Clubbing of fingers
Cyanosis
Polycythemia (blood cancer)
Decreased metabolism
Weakness
Fatigue
Anorexia
Weight loss
Diagnosis
Decreased spo2 (normal: 95-100)
ABG - increase in PACo2 and decreased PAo2
PFT
CXR
Collaborative Management
Rest
Increased oral fluids, 3 liters per day
Good oral care
Diet: calorie, CHON, CHO
O2 therapy not > 3LPM
Avoid smoking, pollutants
CPT, Deep breathing
Bronchial hygiene measures – steam, aerosol, medi mist inhalation
Facilitate removal of secretions, Suction as needed
Pharmacotherapy (BASE)
Bronchodilators
Aminophylline, ventolin, bricanyl, alupent
Antihistamines
diphenhydramine
Steroids
antimicrobials
Expectorants/mucolytic
guaiafenessin/mucosolvan
Antitussives
dextrometorphan, codeine
VII. BRONCIAL ASTHMA
Bronchial Asthma - Bronchial obstruction due to Bronchoconstriction, Hypersecretion of mucous, Bronchial wall inflammation with edema
Triggers or precipitating factor
Inhaled allergens
Dust mites
Pollens
Food allergens
Non allergenic
Viral respiratory infection
Weather changes
Fumes, strong odors
Smoking
Exercise
Drugs-aspirin, NSAIDS
Management goals
Relieve bronchoconstriction
Maintain alveolar ventilation
Reduce airway inflammation/hyperreactivity
Mobilize secretions
Avoid drug toxicity
Pharmacotherapy (ACA)
Adrenergic B 2-agonist
Corticosteroids
Anticholinergic
Supportive Care (HOSP)
Hydration
O2 inhalation
Serial monitoring of ABG’s
Psychosocial support
Asthma is reversible COPD is irreversible
VIII. EMPHYSEMA, BRONCHIECTASIS, BRONCHITIS
Pulmonary Emphysema
Pulmonary Emphysema - a lung disease which involves damage to the air sacs (alveoli) in the lungs. The air sacs are unable to completely deflate (hyperinflation) and are therefore unable to fill with fresh air to ensure adequate oxygen supply to the body, aka “pink puffer”.
Barrel chest
Bronchiectasis
Bronchiectasis - Permanent abnormal dilatation of bronchi with destruction of muscular and elastic structure of the bronchial wall. Caused by bacterial infection; recurrent lower respiratory tract infections; congenital defects; lung tumors; thick tenacious secretions.
Chronic Bronchitis
Chronic Bronchitis - excessive production of mucus in the bronchi with accompanying persistent cough, aka “blue bloater”.
Hypertrophy/hyperplasia of the mucus secreting glands in the bronchi, decreased ciliary activity, chronic inflammation, and narrowing of the small airways.
Caused by the same factors that cause emphysema.
IX. PULMONARY TUBERCULOSIS (TB)
Classification
Class I: no exposure
Class II: exposure no infection
Class III: disease, clinically active
Class IV: treated, disease not clinically active
Class V: suspect
Client Education
TB is infectious, can be cured with antimicrobial
Transmitted by droplet
Cover mouth, nose when coughing, sneezing or laughing
Wash hands
Wear masks when advised
Take medication religiously as prescribed
Primary anti-TB drugs includes (RIPES)
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin
DO’s
Observe for bleeding
Use soft toothbrush, electric razor
Evaluate use of contraceptives
DON’Ts
Take ASA with coumadin
Restrictive clothing on legs
Prolonged sitting/standing
Smoking
Causes
Fat embolism
Multiple trauma
PVC’s
Abdominal surgery
Immobility
Hypercoagulability
Assessment
Restlessness (hallmark)
Dyspnea
Stabbing chest pain
Cyanosis
Signs of shock
Nursing Interventions for TB (OEDHH)
O2 therapy STAT
Early ambulation post op
Do not massage legs post op
HOB elevated
Heparin (2 wks) then coumadin (3-6) months
X. HISTOPLASMOSIS AND PNEUMOCONIOSIS
Histoplasmosis
Etiologic Factors
Commonly seen in Rural Midwest, Southeastern US
Not spread from human to human
Fungus seen in pigeon, chicken manure
Manifestation
Cough
Fever
Joint pains
Malaise
Diagnosis
CXR
Histoplasmin Skin Test (same PPD)
Management
Amphotericin B
Toxicity: anorexia, chills, fever, nephrotoxicity, headache, adrenal failure
Teach farmers to wet chicken manure before shoveling so that dust does not become airborne
Pneumoconiosis
An occupation-related respiratory disorder caused by prolonged inhalation of high concentration of industrial dust
Etiology
Asbestosis (asbestos)
Silicosis (silicon)
Bagossis (hay dust)
Coal worker’s Pneumoconiosis (black lung)
XI. LUNG CANCER
Refers to malignant tumor growth within the bronchial tissue or lung parenchyma.
Types
Squamous cell – 35 – 50% of all lung cancers.
Adenocarcinoma – 15 – 35% of all lung cancers.
Small cell (oat cell) – 20-25% of all lung cancers
Large cell – 10-15% of all lung cancers
Etiology
Predisposing factors – chronic exposure to pulmonary irritants
Family history of lung cancer
Tend to have poor prognosis, unless it is very well defined and removed by surgery.
Pathophysiology
As the lung tissue experiences irritation, it undergoes a series of changes and eventually gives rise to a tumor.
Metastases can occur, especially when the mother tumor is near areas of lymph drainage.
Some tumors secrete hormones:
ADH – reabsorption of water
ACTH – stimulates adrenal glands to produce steroids
Symptoms
Cough
Wheezing
Shortness of breath
Chest pains
Hoarseness
Dysphagia (compression of esophagus)
Weight loss
Nursing Interventions for Lung Cancer (SCA-ONE)
Prepare the patient for surgery if tumor is small enough to be removed
Prepare patient for planned treatments - chemotherapy / radiation therapy
Analgesics as ordered to control pain
Adequate oxygenation through oxygen therapy or planned activity-rest
Maintain nutritional status
Provide emotional support to the patient and family