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Respiratory 3

  1. LRS Disorders: Infectious
    1. Pneumonia (illustration)
      1. Definition/etiology
        1. acute infection of lung parenchyma
        2. cause: bacterium, virus, protozoan, mycobacterium, mycoplasma, or rickettsia
        3. pneumonia is the leading cause of death from infectious causes
        4. may affect only a region of lung: lobar pneumonia, bronchopneumonia
        5. may be the result of:
          1. primary infection
          2. secondary to other lung damage
          3. aspiration
      2. Risk factors for pneumonia
        1. pre-existing pulmonary disease
        2. abdominal and thoracic surgery
        3. mechanical ventilation
        4. advanced age
        5. decreased ability to protect airway or cough effectively
        6. artificial airway
        7. chronic illness and debilitation
        8. depressed immune function
        9. cancer
      3. Diagnostics
        1. chest radiograph
        2. sputum culture, sensitivity and microscopic analysis, Gram stain, cytology
        3. ABG as indicated by clinical condition
      4. Management
        1. antimicrobials, depending on pathogen
        2. antipyretic
        3. expectorants
        4. antitussives
        5. supplemental oxygen, as indicated
        6. IV fluids to treat dehydration
      5. Nursing interventions
        1. monitor finger oximeter if hemoglobin levels within normal limits
        2. promote hydration to liquify secretions
        3. teach effective coughing techniques to minimize energy expenditure
        4. suction if necessary
        5. teach the need to continue entire course of antimicrobial therapy which is usually seven to ten days
        6. teach that findings are expected to be less within 48 to 72 hours of initial therapy
  2. Pulmonary tuberculosis (PTB) (illustration)
  3. Etiology
    1. mycobacterium tuberculosis
    2. bacilli lodge in alveoli
    3. pulmonary infiltrates
    4. can spread throughout body via blood
    5. multi-drug resistant PTB is becoming more prevalent
    6. PTB incidence is rising with increasing homelessness and AIDS
  4. Findings
    1. weakness with fatigue
    2. anorexia with weight loss
    3. night sweats
    4. chest pain
    5. productive cough
  5. Diagnostics
  6. sputum and gastric contents, analysis for the presence of acid-fast bacilli
  7. chest x-ray for presence of active or calcified lesions, "coin" lesions
  8. tuberculin testing
    1. tine, mantoux tests
      • checked 48 to 72 hours for induration
      • positive if >10 mm induration in healthy persons
  9. establishes if there is an antibody response to the tubercle bacillus
  10. if positive, indicates prior exposure to bacillus, not an active disease
  11. Management
  12. long-term, six to 24 months, antimicrobial therapy with isoniazid (INH) (Hyzyd) or rifampin (Rifadin), with ethambutol HCL (Etibi) in some cases
  13. bed rest or chair rest until findings abate
  14. surgical resection of involved lung if medication is not effective
  15. high carbohydrate, high protein diet with frequent small meals
  16. Nursing interventions
  17. with active infection, client must be isolated with airborne precautions when in the hospital
  18. teach client
    1. proper techniques to prevent spread of infection: hand washing, etc.
    2. to report bloody sputum
    3. not to use over the counter (OTC) medications without health care provider's approval
    4. importance of taking medications as prescribed
      • adherence to treatment regimen
      • return at scheduled times for lab testing of liver enzymes
      • an increase in B6 to minimize peripheral neuropathies, a common side effect of drug therap
    1. Lung abscess
        1. Localized area of lung infection
        2. Usually follows pneumonia, TB or aspiration
        3. Treatment consists of draining and culturing abscess and antimicrobial therapy
    2. LRS Disorders: Miscellaneous
      1. Pulmonary embolism
        1. Definition/etiology
          1. clot blocks blood from the "bed" of arteries that feed the lung
          2. client is breathing but gases are not exchanged - ventilation without perfusion
          3. hypoxemia results
          4. can be mild or immediately fatal, based on the size and location of clot(s)
          5. usually clot has traveled from deep veins in the leg or pelvis
        2. Diagnostics
          1. ventilation/perfusion (V/P) scan, also called V/Q scan
          2. ABG
          3. EKG
        3. Management
          1. oxygen via mask
          2. anticoagulation - heparin in acute and coumadin for chronic risk
          3. thrombolytics
          4. filter surgically placed in vena cava for long term care
      2. Acute respiratory distress syndrome (ARDS)
        1. Definition/etiology
          1. alveolar capillary membrane becomes more permeable to fluids
          2. increased extravascular lung fluid
          3. pulmonary compliance decreases
          4. intrapulmonary shunt increases
          5. refractory hypoxemia
          6. usually seen after lung injury or massive multi-system organ disease
        2. Findings
          1. restlessness, anxiety
          2. dyspnea
          3. tachycardia
          4. cyanosis
          5. intercostal retractions
        3. Diagnostics
          1. clinical presentation and history of findings
          2. hypoxemiaon ABG despite increasing inspired oxygen level
          3. chest x-ray shows diffuse infiltrates
        4. Management
          1. optimize oxygenation
            1. mechanical ventilation
            2. sedation may be required
            3. paralytic agents may be necessary
          2. antibiotics, as indicated
          3. corticosteroids
        5. Nursing interventions
          1. plan for frequent rest periods
          2. monitor trends in oxygenation status, ABGs, respiratory effort
          3. observe for behavioral changes and vital signs; confusion and hypertension may indicate cerebral hypoxia