Lower Respiratory

cdunbar4's version from 2016-09-24 19:15


Question Answer
Difference between CAP & HAP?CAP= community acquired pneumonia, lower resp. tract infx w/in 1st 2 days of hospitalization. HAP=hosptial/health care assoc. pneumonia occuring 48 hrs or longer after hospital admission & not incubating at time of hospitalization
Organisms associated with CAPstreptococcus, mycoplasma, haemophilus, chlamydia, legionella pneuomniae; respiratory viruses, oral anarobes, moraxella catarrhalis, staph aureus, nocaria, enteric aerobic gram negative, fungi myobacterium TB
Organisms associated with HAPpseudomonas aeruginosa, enterobacte, e. coli, proteus, klebsiella, staph. aureus, strep pneumoniae, oral anaerobes
Red hepatizationmassive dilation of caplillaries & alveoli filled with organisms in lung parenchyma d/t inflammatory mediator arrival
Gray hepatizationblood flow decreases & leukocytes and fibrin consolidate in affected part of lung.
Resolutioncomplete resolution & healing occur if no complications. Exudate is lysed & processed by macrophages. Normal lung tissue is restored & person's gas exchange returns to normal
Patho of pneumoniaaspiration of s. pneumoniae→release of bacterial endotoxin→inflammatory response (neutrophils, mediators; accumulation of fibrinous exudate, RBCs & bacteria→red hepatization & consolidation of lung parenchyma→gray hepatization & fibrin deposits on pleural surfaces; phagocytosis in alveoli
clinical manifestations: onsetsudden fever, shaking, chills, SOB, productive cough of purulent sputum (sometimes rust colored); pleural chest pain
clincical manis: geriatricmay only be confused & hypoxic
clinical manis: physical exambronchial breath sounds, crackels, dullness to percussion, ↑ fremitus
Gradual manifestations..dry cough, fever, h/a, malaise, myalgias, sore throat, n/v, diarrhea
Complications (9)pleurisy, pleural effusion, atelectasis, bateremia, lung abscesses, empyema, pericarditis, meningitis, endocartitis
Diagnostic studieshx, physical exam, & xrays usually enough to make Dx w/o labs; gram stain of sputum; pulse ox, ABGs, CBCs, differential & routine labs, blood cultures
Collaborative Care3L/day of fluids; @ least 1500 kcal/day for energy; VACCINE; AB tx promptly (works w/in 2-3days)
Signs of improvement↓ temp.; ↑ breathing, ↓ chest pain
TherapyO2 for hypoxemia, analgesics for chest pain, anti-pyretics for fever, rest and/or activity to work diaphragm
What kind of health history information would make you suspicious?COPD, lung cancer, smoking, DM, malnutrition, ↓ LOC, immunosuppressed, exposure to chem/toxins, dust, allergens, ETOH
Drug classes that contribute to susceptibility of getting pneumonia?ABs, corticosteroids, chemotherapy (anything that ↓ immunity)
Main goalsclear breath sounds, N breathing patterns, no signs of hypoxia, N chest xray, no complications r/t pneumonia
Nursing Interventions b4 hospitalif sx persist for >7D then seek med care
Nursing Interventions in hospital to prevent pneumoniaside-lying, upright position to ↓RF aspiration, turn & reposition client Q2H to facilitate lung expansion & ↓ pooling of secreations
NI: pulmonary toiletingsplint intercostals b4 coughing
NI: pt with a feeding tuberequires attn to positioning tube to preent aspiration
NI: pt with dysphagianeeds assitance to prev aspiration. check gag reflex. watch narcotic overmedication
Patient and family teaching pointstake every dose of ABs (discuss drug-drug, drug/food interactions & need for rest); may be sev wks b4 usual vigor & well-being returns; teach about vaccines (can get flu shot @ same time in diff. arms); deep breathing exercise for 6-8wks post care


Question Answer
TB can affect what areas of body?lungs, larynx, kidneys, bones, adrenal glands, lymph nodes & meninges
Transmitted viaG + acid fast bacillus-droplets which can remain airborne from minutes to hours.
Types of places that ↑ RF spreading of myobacterium TBLTC, crowded areas, poor areas
PathoMacrophages phagocytose bacteria & release a lytic enzyme that damages lung tissue. A grey/white lesion contains the bacteria (Ghon Focus) which is latent. It can undergo necrosis (granuloma) & if taken up by lymph, it becomes Ghon Complex.
Ghon Tuberclecentral portion, necrosis, liqueactive necrosis, liquid drains into connecting bronchi & produces a cavity
Classification of TB: 0No TB exposure, no Hx of exposure; negative skin test
Classification of TB: 1TB exposure, no infx.; negative skin test; hx of exposure
Classification of TB: 2Latent TB infx.: no disease (significant rxn to skin test, neg. labs, neg. xray, no clinical evidence of TB)
Classification of TB: 3 TB clinically active (TB infx); positive labs, sig. rxn to skin test, positive xray of disease)
Classification of TB: 4TB but not clinically active (no current Dx, hx of previous episode, stable xray, rxn to skin test)
Classification of TB: 5TB suspect (dx pending); person should not be in this class for >3months
Clinical Manis: early stagesusually no sx; ppl w LTBI asymptomatic, but positive skin test
Clinical Manis: systemic symptomsfatigue, malaise, wt. loss (unexplained), low grade fever & night sweats
Clinical Manis: acute symptomschornic cough with blood tinged sputum, high fever, chills, generate flu-like symptoms, pleuritic pain, productive cough
Clinical Manis: miliary TBlarge amount of organisms that can invade bloodstream & spread to all body organs. Secondary to primary Dx or reactivation of latent infx. Always serious and if untreated is almost always fatal!!
Complications of Miliary TBpleural effusion & empyema; TB pneumonia (sim. manis of bact. pneumonia); other organ involvement (meningitis or bone, joints, kidneys, adrenals)
Diagnostic Test: skin testingTST uses purified protein derivative (PPD); Inject 0.1mL PPD intradermally on forearm. Inspected & read 48-72 hours later for presence or absence of induration. If + do NOT get test again. If - means person has developed antibody
Diagnostic Test: chest xrayimportant, but can't make a Dx solely on xray. Other Dx mimic TB. Sugggestive findings: upper lobe infiltrates, cavity infiltrates, lymph node involvement
Diagnostic Test: bacteriologic studiesmicroscopic exam of stained sputum smears for acid-fast bacilli (AFB). 3 consecutive sputum specimens on different days obtained & sent for smear & culture
Diagnostic Test: culturetakes up to 8 wks-can collect from GI washings, CSF or fluid from effusion or abscess
Diagnostic Test: Nucleic acid amplification (NAA)new test results w/in a few hours. Does not replace cultures
Initial phase of drug therapy regimen, option 14-drug regimen consisting of INH, rifampin, pyrazinamide, ethambutol (daily for 56 doses & continuation phase includes INH/rifampin for 126 doses)
Option 2 INH, rifampin, pyrazinamide, ethambutol daily for 14 doses, then 2x wk for 12 doses; continue INH/rifampin for 2x/wk for 36 doses
option 3INH, rifampin, pyrazinamide & ethambutol 3x/wkly for 24 doses, then INH/rifampin 3x/wk for 54 doses
option 4INH, rifampin, ethambutol daily for 56 doses, then INH/rifampin daily for 217 doses
What is DOT?Direct Observational Therapy. Providing TB druggs directly to pts and watching as they swallow meds to ensure adherence.
Which TB drug is usually the only one used for LTBI?INH
Nursing Assessment includes: assess for productive cough, night sweats, afternoon temp. elevation, wt. loss, pleuritic chest pain & crackles over apices of lungs, get sputum from cough in morning
Nursing DiagnosisIneffective breathing pattern r/t ↓ lung capacity
3 main plans/goalscomply with therapeutic regimen; have no recurrence of disease; have normal pulmonary function
Nursing ImplementationTEACH: cover mouth when coughing, wash hands; airborne isolation; medication work-up: chest xray, sputum smear & culture; receive appropriate drug therapy
Evaluationwill have: complete resolution of disease; normal pulmonary function; absence of any complications and no transmission of TB

Lung Cancer

Question Answer
Factsleading cause of cancer-related deaths in U.S. (28% of all cancer deaths); Approx. 360,000 americans are livign with lung cancer. Survival rates are LOW!
What RF is responsible for 80-90% of all cancer-related deaths??Smoking (over 60 carcinogens in cigarettes)
Other carcinogensasbestos, radon, nickel, iron, iron oxides, uranium, polycyclic aromatic hyrdrocarbons, chromates, arsenic & air pollution
Patho is not well understood. How long takes it take tumors to reach 1 cm in size?8-10 years
Factors to calculation the total cigarette exposuretotal # of cigarettes smoked; age of smoking onset; depth of inhalation; tar & nicotine content; use of unflitered cigarettes
Lung cancers occur primarily in the _________ ______ or beyond & have a perference for the _______ _____ of the lungs.segmental bronchi, upper lobes
Pathologic changes in bronchial systemhypersecretion of mucus, cells desquamate (shed outside layers); reactive hyperplasia of basal cells; metaplasia of N respiratory epithelium to stratified squamous cells
2 primary subtypesnon-small cell carcinoma & small cell carcinoma
S/S usually come late in Dx; Depends on type of primary lung cancer, location & metastatic spread: pneumonitis, persistent cough with sputum, hemptysis, chest pain, dyspnea,
Later manifestationsanorexia, fatigue, n/v, hoarse voice, unilateral paralysis of diaphragm
Types of diagnostic studieschest xray, CT scan, MRI, PET, Dx ID by malignant cells, sputum specimens obtained for cytologic studies (fiberoptic bronchoscope, mediastinoscopy, video-assisted thoracoscopy, pulmonary angiography
staging of non-small cell lung cancer depends on: tumor size, location, degree of invasion, regional lymph node involvement, presence/absence of distant metastases
CC: surgical therapysurgical resection is CI for small cell carcinomas; squamous cell are likely treated with surgery
CC: radiation therapycurative approach with resectable tumor but poor surgery risk; some cells are more radiosensitive than others; used in combo with chemo
CC: chemotherpyTx of nonresctable tumors or adjuvant to surgery in NSCLC with distant metastases; used in combo with multidrug regimen; improved survival rate with NSCLC & SCLC
Nursing Management & Assessment includesAsses the pt. & family's understanding of the diagnostic tests, Dx, Tx options & prognosis. Responding to gaps in knowledge will help them. Assess their level of anxiety.
Plans and goals focus on....effective breathing patterns, airway clearance, oxygenation of tissues, no pain, realistic attitude toward Tx and prognosis
Health Promotion Implementationavoid smoking, smoking cessation programs, support education & smoking policies
Acute Intervention Implementationsupport during dx studies, nut'l eval, comfort, methods to reduce pain, educate indications for hospitalization
Ambulatory & home care interventionsfollow-up carefully for manis of metastasis; educate pt. on s/s of hemoptysis, dysphagia, chest pain, and hoarseness
Expected Outcomesadequate breathing patterns, minimal to no pain, realistic attitude about prognosis


Question Answer
Definition, two types and what events leads you to suspect a pneumothorax?complete or partial collapse of lung as a result of an accumulation of air in the pleural space. Suspected after blunt trauma to the chest wall. Can be closed or open.
Closed pathophysiologyno external wound; usually spontaneous (cased by rupture of small blebs on the visceral pleura); broken ribs can lacerate or puncture lung; excessive pressure used during manual or mechanical ventilation, alveoli or bronchioles can rupture.
Blebresult of airway inflammation, d/t smoking usually.
open pneumothoraxair enters pleural space via opening in chest wall. Ex: gun shot, stab, surgical thoracotomy.
ER tx for open pneumothoraxocclusive dressing, open on 1 side
How does the 3-sided occlusive dressing working to let air out, but not in?Upon inspiration, negative pressure increases, the dressing pulls against wound & prevents air from coming in. during expiration, pressure rises in pleural space, dressing is pushed out, air escapes through wound & from under dressing.
tension pneumothoraxrapid accumulation of air in pleural space can cause high intrapleural pressures. Puts pressure on heart & great vessels
hemothorax aka "hemopneumothorax"accumulation of blood in intrapleural space; usu associated with open pneumothorax
Clinical Manis (if small pneumothorax)mild tachycardia & dyspnea
large pneumothorax manisshallow, rapid RR, dyspnea, and air hunger
Other manischest pain, cought w/ or w/o hemoptysis; no breeath sounds over affected area & hyperresonance may be heard
Manis during a tension pneumothoraxsevere resp. distress, tachycardia & hypoTN; mediastinal displacement occurs & trachea shifts to the unaffected side
CC if amt of air/fluid is minimalno tx, usu resolves spontaneiously or pleural space can be aspirated with large-bore needle
CC open pneumothoraxcover with vented dressing; if object is in, leave it in and apply bulky dressing
CC most common tx: chest tube and connect it to water-seal drainage;
CC surgeryif spontaneous pneumothoraces occur, may need partial pleuralectomy or stapling to promote adherence of pleurae to one another

Section 5

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