NCSBN–Lesson 8B:Respiratory System Study Guide,100% CORRECT

NCSBN–Lesson 8B:Respiratory System Study Guide Upper Respiratory System Disorders The upper respiratory system consists of the nose, mouth, pharynx and larynx. It allows air flow into and out of the lungs as it warms, humidifies and filters inspired air.This section will review upperrespiratorydisorderssuchasrhinitis,sinusitis,pharyngitis,tonsillitis,peritonsillarabscess, laryngitis, vocal cord paralysis, upper respiratory tract infections and croup syndromes. Rhinitis–UpperRespiratorySystemDisorders Rhinitisisan inflammationofthemucousmembraneofthenosemarkedespeciallyby rhinorrhea,nasalcongestion,itchingandsneezing. • Etiology o Allergicrhinitis(oftencalled"hayfever")iscausedbyexposuretovarious factors,includingenvironmentalallergens,,mold,danderandpollen. o Infectiousrhinitisiscausedbyvirusesorbacteria. • AssessmentFindings o Theclientwillhave ▪ excessivenasaldrainage ▪ congestion ▪ postnasaldripwithsorethroat. o Ifallergiesarethecause,thesymptomscan include ▪ nasalitchiness,sneezingandwatery eyes. o Withviralcauses(commoncold),symptomsinclude ▪ sorethroat ▪ generalmalaise ▪ fever ▪ chills ▪ headache. o Withbacterialcauses ▪ purulentnasaldischarge ▪ Fever • DiagnosticStudies o Thenursewilltakeahistoryofthefindingsandnotethetypeandcolorof drainage. • Management o Thefirststepistodetermineifthecauseisallergic,viralor bacterial. o Theclientcanuseantihistaminesanddecongestantstomanagesymptomsand NSAIDsiftheyhaveaheadache. o Ifthecauseisbacterial,anti-infectivesmaybeprescribed. o Ifthecauseisanallergy,clientsshouldeliminatetheirexposuretotheallergic causes and use desensitization immunizations or treatments. o Intheeventofbothviralorbacterialcauses,encouragefluidintake, rest, gargling with salt water and increased intake of vitamin C and zinc. • NursingInterventions o Administertheprescribedmedicationsforreliefandeducatetheclientabouthow toreduceallergens,propermedicationadministrationandgoodhand-washing technique. Sinusitis–UpperRespiratorySystemDisorders Sinusitisistheinflammationofoneormoreoftheparanasal sinuses. ▪ Etiology o Sinusitiscanbecaused byavirusorbacteria. o Toothinfections,allergicrhinitis,sniffingaerosols/powdersandswimming underwater can often lead to sinusitis. o Structuraldefectsofthenosemayalsocausesinusitis. ▪ AssessmentFindings o Clientswillcomplainofa: ▪ frontalheadache ▪ tendernessovertheaffectedsinus(es),especiallywhenpalpatedorpercussed ▪ purulentnasaldrainageandcongestion. ▪ Theymayalsocomplainoftoothpain,generalmalaiseandfever. ▪ DiagnosticStudies o ChronicsuffersmayrequireanX-rayorCTtoevaluatethefluidbuildupin sinusesandmucousmembrane swelling. ▪ Management o Pharmacologicinterventionsmayinclude: ▪ Nasalsaline,decongestantsandnasalcorticosteroids ▪ Mucolytics,antihistamines,analgesics,antipyreticsandantibiotics o Sinusirrigationcanhelpclearandopensinuscavities. o Clientswithchronicsinusitismaybecandidatesforsurgerytodrainandopenthe sinuses. ▪ NursingInterventions o Administer(andteach)clientsabouttakingprescribedmedicationsand encouragefluidintake(atleastsixtoeight8ounceglassesofnon-carbonated, non-alcoholic beverages daily). o Nasalcleaningtechniquesincludehotshowers,steaminhalationornasal irrigation with saline spray, followed by nose blowing. o Performnasalirrigationasneeded. Pharyngitis–UpperRespiratorySystemDisorders - Pharyngitisisaninflammationofthemucousmembranesof the pharynx. ▪ Etiology o Pharyngitiscanbeaviral,bacterial (including beta-hemolytic strep) or fungal infection. ▪ AssessmentFindings o Clientscomplainofa: ▪ scratchythroatorthroatpainthatissevere,worsenedbyswallowing. ▪ pharynxcanappearredandedematouswithorwithoutpatchywhiteor yellow exudates. ▪ DiagnosticStudies o Throatculturesand/orrapidstrepantigentest. ▪ Management o Pharmacologicinterventionsmayinclude: ▪ Antimicrobialtherapy–penicillinsforstrepthroat(erythromycinif the client is allergic to penicillin) ▪ Antifungaltherapysuchasnystatinforfungal causes ▪ Analgesicssuchasibuprofenortopicalanestheticspraysorlozenges ▪ NursingInterventions o Administerprescribedmedicationsasorderedandencourageincreasedfluid intakeofcool,blandliquidsandgelatin.Avoidcitrusjuicesandcarbonated beverages. o Teachclientstheimportanceoftakingalloftheirprescribedantimicrobialsin order to avoid complications of strep infection. o Managementandnursinginterventionsforpediatricclientsarethesameasfor adult clients. Tonsillitis&Adenoiditis–UpperRespiratorySystemDisorders Tonsillitisandadenoiditisaretheinflammationandinfectionofthetonsils(especiallythe palatine tonsils) and the adenoid tissues. • Etiology o Theacuteformoftheseinfectionsisusuallybacterial ▪ whentheyareinassociationwithpharyngitis,theyareusually viral. • AssessmentFindings o Theclientwillreportasorethroat(thatcanberecurrent),feveranddifficulty swallowing. o Enlargedtonsilsandadenoidsuponinspection;oreven"kissingtonsils" (where they are touching). o Clients often will have foul-smelling breath (halitosis), noisy respirations(snoringloudlyduringsleep)iftheyhaveenlargedadenoidsandrecurrentearinfections. • DiagnosticStudies o Positivethroatculturesforcausativemicrobes. • Management o Anti-infectives,antipyreticsandanalgesicsmaybeprescribed. o Clientswillneedtoincreasetheirfluidsandrestfor recovery. o Ifinfectionsarerecurrent,atonsillectomyand/oradenoidectomymaybe indicated. • NursingInterventions o Administermedicationasprescribed. o Providepostoperativecareaftertonsillectomy/adenoidectomy: ▪ Observeforpostoperativecomplications(hemorrhage,airwayobstruction) ▪ Providepositioningthatallowsforcomfortanddrainageofthemouthand pharynx(prone, head turned to the side) ▪ Maintainicecollarforcomfort ▪ Provideclientandfamily teaching: • Findingsofhemorrhageincludefrequentswallowing • Useofprescribedmouthwashesandpainmedicationsasprescribed • Semi-liquiddiet48-72hours postoperative PediatricTonsillitis–UpperRespiratorySystemDisorders Pediatrictonsillitisisinflammationandinfectionofachild'stonsils(especiallythepalatine tonsils). • Etiology o Pediatrictonsillitiscanbebacterialorviral,inassociationwithpharyngitis. o Itcausesdysphagiaanddifficultybreathingduetoinfectionandinflammationof the tonsils. Palatine tonsils are usually visible during the oral exam. • AssessmentFindings o Assessmentfindingsaresimilartoadultfindings.Thenursewillobserveswollen tonsils(oftencalled"kissingtonsils")sorethroat,halitosis,mouthbreathing (with snoring at night) and fever. • DiagnosticStudies o Mayincludetakingtheclient'shistory,followedbyaphysicalexamandthroat culture. • Management o Antibiotics,fluids,rest,antipyreticsandanalgesicsaretypicallyrequiredfor recovery. o Asurgicalinterventionmaybenecessary(tonsillectomyand/oradenoidectomy) due to: ▪ Repeated(sevenormore)episodesoftonsillitisinone year ▪ Theclienttroublehastrouble breathing ▪ Thepresenceofabscessesorgrowthsonthetonsils o Anadenoidectomymaybedonewithtonsillectomy,ifadenoiditisispresent. • NursingInterventions o Postoptonsillectomy care: ▪ Assessforfrequentswallowingbecausebleedingoftenisthecause. ▪ Assessanyvomitusandplacechildonsidetoavoidaspiration.Provide pain medication as ordered and needed. ▪ Avoidofferingredorbrowncoloredfluids,whichmakestheassessment for bleeding difficult, or acidic fluids that will irritate the throat. ▪ Offersoftfoodsandavoidhighlyseasonedfoods. o Teachingpointsforparents: ▪ Providethechildwithquietactivities. ▪ Monitorforbleeding,suchasindicatedbyfrequentswallowing. ▪ Useantipyreticsandanalgesicsasneededforfeverandpain(butavoid aspirin due to the risk of Reye's syndrome). ▪ Initialdietwillconsistofsoftfoodsand noacidic fluids. ▪ Completerecoverytakes1-2weeks. ▪ Donotallowyourchildtoreturntoschoolforatleast7-10daysand prohibitexerciseorswimmingfor3weeks. PeritonsillarAbscess–UpperRespiratorySystemDisorders Peritonsillarabscess(PTA)isarecognizedcomplicationofacutetonsillitisorpharyngitiswith spreadoftonsillarinfectionintothesurroundingtissue • Etiology o PTAiscausedanuntreatedbacterialtonsillarinfection. • AssessmentFindings o Clientswillhavedifficultyswallowingornoswallowingability. o Thenursewillobserve drooling. o Clientscanalsohaveamarkedtonsillarenlargement,possiblythreateningthe airway. o Clientsoftenpresentwith: ▪ "hotpotato"ormuffledvoice ▪ highfeverandchills ▪ increasedwhitebloodcellcount ▪ facialswelling. • Management o Intravenous(IV)antibioticsarenecessaryforrecoveryandoftentheproviderwill havetodraintheabscess.Apossibleemergencytonsillectomymaybenecessary. • NursingInterventions o Monitorairwaypatencyandresolutionofinfection,andadminister medications asordered.Alsopreparetheclientforsurgeryif needed. Laryngitis–UpperRespiratorySystemDisorders Laryngitisistheinflammationofvocalcordsandsurroundingmucousmembranes. • Etiology o Laryngitisisirritationofthelarynxduetochemical,mechanical,infectiousor allergic causes.Itis commonly seen withupperrespiratoryinfections(URI). o Croupandepiglottitisaretypesoflaryngealinflammationthatcanleadto airway obstruction requiring emergency treatment. • AssessmentFindings o Clientspresentwitha: ▪ hoarsevoice ▪ inflammationofvocalcordsandsurroundingmucousmembranes ▪ fever. o Larynxblockedbyedema,spasmorbothcausingstridor • Management o Clientswillresttheirvoice,treatsymptoms,garglewithwarmsaltwaterand removeall irritants. o Coolormoistairmaybringrelief,nginasteamybathroom,outsidein the cool night air or next to a cool air vaporizer. VocalCordParalysis–UpperRespiratorySystemDisorders Vocalcordparalysisistheinabilityofoneorbothvocalcordstomove. • Etiology o Vocalcordparalysiscanbecausedbyinjury,traumaordiseaseofthelarynx, laryngealnervesorvagusnerve.Itmayresultasacomplicationafter thyroidectomy surgery or endotracheal intubation. o Damagetobothlaryngealnervesmayleadtoairwayobstructionandemergency treatment will be needed! • AssessmentFindings o Theclientwillpresentwithahoarsevoiceanddifficultyswallowing. • DiagnosticStudies o Alaryngoscopywillshowabnormalvocalcordmovement. • Management o Aswallowingevaluationwillbeperformedtoassessforaspirationandvoice therapyisoften necessary. o Surgicalinterventionmaybeneededtoimprovethevoicebychangingthe position of the paralyzed vocal cord. PediatricUpperRespiratoryTractInfections–UpperRespiratorySystemDisorders Pediatricupperrespiratorytractinfection(URI)isoftenduetoan acuteviralnasopharyngitisor the "common cold." • Etiology o Anorganisminvadesthemucousmembranesandcausesedema, vasodilatation, andincreasedmucusproduction.URIsareoftenself-limiting. • AssessmentFindings o Theclientwilloftenpresentwith ▪ nasalcongestion ▪ sneezing ▪ colorednasaldischarge ▪ lowgradefever ▪ cough ▪ irritability. • Management o Medicationsthatmaybeadministeredincludeantipyretics,decongestants(oral or nasal)andanalgesics.Coolmisthumidifierscanalsohelprelievecongestion. Adequate fluids and rest are also necessary for recovery. o Assessforconditionsindicatingcomplications: ▪ Presenceofearache(otitismedia) ▪ Temperatureover101°F(38.3C°) ▪ Refusingtoeat • NursingInterventions o Withinfants,thenursemayneedtosuctionnaresroutinelywithbulb syringe (infantsarenasal breathers). o Reinforcetheneedforgoodhandwashingandstresstheimportanceof maintainingfluidbalance. o AdultURIsaremanagedthesameway. CroupSyndromes–UpperRespiratorySystemDisorders Croup syndromes (including laryngitis, tracheitis and epiglottitis) are airway-blocking infectionsthatincludesubglottal(acutespasmodiccroup)laryngitis(laryngotracheobronchitis (LTB), tracheitis) and supraglottal (epiglottitis). Abuildupofmucusandinflammationnarrowsthe airway. • Etiology o Croupsyndromesare usuallyviralbutoccasionallybacterial,e.g., tracheitis, epiglottitis. o Youngerchildrenareusuallydiagnosedwith"truecroup"(spasmodiccroup) and older children usually diagnosed with tracheitis and epiglottitis. • AssessmentFindings o Classicfindingsare: ▪ "barky"harshcough ▪ stridor ▪ Hoarseness ▪ Fever ▪ purulentsecretions ▪ dyspneaifsevere. o Thechildoftenlooks"sicker"withabacterialinfection o EpiglottitismanifeststhefourDs: ▪ Drooling ▪ Dysphagia ▪ Dysphonia(hoarsevoice) ▪ Distressedinspiratoryefforts • Management o Iftheinfectionisviral,use: ▪ Cool air/mist ▪ Increasefluids ▪ Iftheclientisinpatient,nebulizedracemicepinephrineandinhaled steroids ▪ Antipyretics o Iftheinfectionisbacterial,performthesameinterventionsasabove,withthe additionofantibioticsandpossiblyintubation. o Epiglottitisisamedicalemergency;tracheotomymaybenecessary. • NursingInterventions o Teachtheparentandchildsignsofimpendingairwayobstruction. o Reportincreasedpulse,respirations,retractionsandincreasedrestlessness. o Neverattempttodirectlyvisualizeepiglottiswithatonguedepressor,sinceit couldprecipitatelaryngospasm. LowerRespiratorySystemDisorders–Obstructive Thelowerairwayconsistsofthetrachea,rightandleftmainstembronchi,fivesecondarybronchi and bronchioles. The lower airway's primary function is to facilitate gas exchange. Lower respiratory system disorders include obstructive pulmonary conditions such as pediatric bronchiolitis, aspriation, COPD and asthma. COPD–LowerRespiratorySystemDisorders– Obstructive Chronicobstructivepulmonarydisease(COPD)isachronicirreversibleairwayobstructionwith slowed exhalation. 1. Emphysema–wallsofthealveolienlargeandloseelasticity,trappingairand decreasing capacity for vital gas exchange 2. Chronicbronchitis–achronicinflammatoryresponseinthebronchiolesofthelung 3. Corpulmonale,withrightheartfailure,isalatecomplicationofCOPD-related pulmonary hypertension • Etiology o TheprimarycauseofCOPDisenvironmental,duetosmokingtobacco.About 3%ofemphysemacasesaregenetic(duetoalpha-1antitrypsindeficiency)and occur without tobacco exposure. • AssessmentFindings o Clientswill have: ▪ acoughwithsputumproduction(purulentifacuteinfectionispresent). ▪ Oftenw/edemaandcyanosis(chronicbronchitis). o Theyoftenhavedyspneaonexertion,whichmayoccurwithminimalactivity (oratrestinadvancedstages)andwithacuteexacerbation. o Oftenclientsmustuseaccessorymusclestobreathe,particularlywith severe COPDorrespiratory distress. o Clientswillcomplainofrestlessness,respiratorydifficultyordistress,anxiety andweightlossifbreathingdifficultyinterfereswitheating. o Thenursemayobserveabarrelchest(increasedanterior-posteriordiameter) o Hearrhonchibreathsounds,whichareassociatedwithchronicbronchitis. • DiagnosticStudies o SpirometryandotherpulmonaryfunctiontestsmaybeorderedandachestX- raytaken. o ArterialbloodgaseswillshowanincreasedPaCO2,decreasedPaO2. o Lowoxygensaturation levelswillbeseenwithhigherhematocritlevels. • Management o Toreducetheriskoraidinthereductionofsymptoms,tobaccosmokingcessation orreductionofexposuretotobaccosmokeandotherinhaledenvironmental irritants is recommended. o Pharmacologictreatmentsinclude: ▪ Inhaledbronchodilators–albuterol(beta-adrenergic),ipratropium (anticholinergic) ▪ Inhaledororalcorticosteroids–prednisone(IVduringexacerbations), methylprednisolone ▪ Expectorants–guaifenesin o Supplementaloxygentherapy maybeneeded. o Titrateoxygentothelowestdoseneededtomaintainoxygensaturationaround 90% whether during recommended rest, exercise or sleep. o Apulmonaryrehabilitationexerciseprogrammaybehelpful. o Airwayclearancetechniquessuchaseffectivecoughing,chestphysiotherapy, postural drainage and vibration can be utilized. o Lungvolumereductionsurgeryforemphysemamaybeneeded. • NursingInterventions o Clientandfamilyteachingwillinclude: ▪ Diaphragmaticbreathing ▪ Pursed-lipbreathing ▪ Inspiratorymuscletraining ▪ Controlledcoughing ▪ Pacingofdailyactivities ▪ Physicalconditioning ▪ Eatsmallfrequentmealswithnutritionalsupplements ▪ Avoidtemperatureandhumidityextremes,airpollution,andhigh altitudes o Monitor the client's oxygen saturation both at rest and with activity. Administeroxygenatthelowestdoseneededtomaintainoxygensaturation90%whether during recommended rest, exercise or sleep. o MonitorforcomplicationsofCOPDsuchasrespiratoryinsufficiency,respiratory failure, dysrhythmias, pulmonary infections and cor pulmonale. Asthma–LowerRespiratorySystemDisorders– Obstructive Asthmaisachroniclungdisordermarkedbyrecurrentepisodesofbronchospasm-relatedairway obstruction triggered by hyperreactivity to various stimuli, producing airwaynarrowing and tenacious, thick, excess mucous.Asthma is characterized by remission and exacerbations. Exacerbations are more prevalent during particular seasons, especially with extrinsic and infectious etiologies, i.e., ragweed season or cold or flu season. Asthmaisoneofthemostcommonchronicpediatrichealth problems. • Etiology o Extrinsic=OUTSIDE ▪ Extrinsicasthmaisassociatedwithinflammationandreactivityinresponse to a specific environmental exposure, such as cold air, humidity, allergens and medications. o Intrinsic ▪ Intrinsic etiology includes asthmatic inflammation and reactivity inresponsetophysicalstimuli,suchasarespiratoryinfection,exercise, gastroesophageal reflux-related aspiration or stress. • AssessmentFindings o Duringperiodsofasthmaexacerbation,theclientwillpresent with: ▪ Expiratorywheezing,oftenaudible–wheezingmaydeceaseorstopwith worsening bronchoconstriction as airflow becomes severely limited ▪ SOB ▪ Coughwithsputumproduction ▪ Normalorlowoxygen saturation ▪ Chesttightness ▪ Tachycardia ▪ Useofaccessoryrespiratorymuscleswithrespiratorydistress ▪ HighnormalPaCO2andlownormalPaO2 • DiagnosticStudies o Acute Phase ▪ Physicalexaminationandhistory ▪ Serumstudies–arterialbloodgases ▪ ChestX-ray–hyperinflation,flatteningofdiaphragm WorseningofS/S:Child ▪ Pulmonaryfunctiontests–decreasedFEV1(volumeofairthatcanbe forced out in 1 sec after taking a deep breath), prolonged expiratoryphase, reduced peak expiratory flow rate o ChronicPhase ▪ Peakexpiratoryflowratemonitoringtoguidetherapyandidentifywhen • Fallinpeakflowrates • Feelingtired • Sneezing • Experiencinga stomach-ache • Poor appetite toseekcare ▪ Allergytesting–skinprickorserumRASTtesting,IgEtoidentifyallergic triggers ▪ Pulmonary function tests – bronchial reactivity challenge testing with methacholineorspecificantigentoidentifyseverityofairwayreactivity ▪ Bronchoscopy • Night-timecoughoComplications • Lessrelieffromthe “quick relief” medication • Wheezingandcough that won’t go away ▪ Hypoxemia–lowPaO2 ▪ Hypercapnia–highPaCO2 ▪ Recurrenceofotherrespiratoryinfections ▪ Respiratoryfailure ▪ Absenceofwheezingmaybeanindicationofabsenceofairflow– emergencyrespiratorycareisneededwithpossibleintubation • Management o Pharmacologictherapy: ▪ Long-actingcontrolmedications • Inhaledcorticosteroids(ICS)–fluticasone,beclomethasone • Long-actingbetaagonists(LABA)–salmeterol • Leukotrieneantagonist– montelukast • Anticholinergicinhaler–tiotropium • Mastcellstabilizers–cromolynsodiuminhaler ▪ Short-acting"rescue"medications • Short-actingbetaagonists(SABA)asneeded–albuterolinhaler or nebulizer • Exacerbation – oral (prednisone) or intravenous corticosteroids (methylprednisolone)withtaperingdoseasexacerbationresolves • NursingInterventions o Clientandfamilyteachingwillinclude: ▪ Diaphragmaticbreathing ▪ Pursed-lipbreathing ▪ Inspiratorymuscletraining ▪ Controlledcoughing ▪ Pacingofdailyactivities ▪ Physicalconditioning ▪ Avoidtemperatureandhumidityextremes,airpollutionandhighaltitudes ▪ Smallfrequentmealswithnutritionalsupplements o ThenursewillmonitorforcomplicationsofCOPDwhichincluderespiratory insufficiency, respiratory failure, dysrhythmias, pulmonary infection and cor pulmonale. PediatricAsthma–LowerRespiratorySystemDisorders–Obstructive Thedefinition,pathology,etiologyandmanagementofpediatricasthmaarethesameasinadult asthma. • NursingInterventions o Monitorthechildforrespiratorydistressand/ortheneedfornebulizer treatments. o Placethechildinasemi-tohigh-Fowler's position. o Thenursewillstaywiththechildifpossibleorhavetheparentstayduringacute phase of illness. o Thenursewillmonitorfluidvolumestatus. o Anasthmaactionplanandmedicationadministrationplanmustincludethe school and all caregiver(s). o Helpthechildandfamilyunderstandtheimportanceofcomplyingwith medications and treatments o Thenursewillreviewthecorrectuseofmetered-doseinhaler(MDI)witha spacerandinformationontherisksofoverusing bronchodilators. ▪ Teachtheparentsandchildaboutpeakflowmeteruseforself-evaluation. • Complications o Exercise-inducedbronchospasm:acuteandreversible,usuallystopin20-30 minutes. o Statusasthmaticusisanemergencywhereacuteexacerbationofasthmadoes not respond to standard treatment of bronchodilators and steroids. Mechanical ventilation is usually necessary. PediatricBronchiolitis–LowerRespiratorySystemDisorders–Obstructive Bronchiolitis(tracheobronchitis)istheswellingandmucusbuildupinthebronchioles,usually due to a viral infection. • Etiology o Therespiratorysyncytialvirus(RSV)isthemostcommoncauseofpediatric bronchiolitis.Occasionally,theremaybeabacterialcause. o Theinfectionisrareinchildrenolderthantwoyears. Itisaseasonalevent, which occurs more often in fall and winter months. o The virus spreads via direct contactand enters body via the nose or eye(s), whichleadstoedema,mucusaccumulationandcellulardebristhatobstructthe bronchioles. It can also progress to atelectasis. • AssessmentFindings o BronchiolitisusuallybeginsasmildURIandpresentswithacough,wheezing, SOBordifficultybreathing. o Thenursewillhearlungcracklesandobserveintercostalretractions. o Tachypnea,nasalflaringininfantsandfevermayalsobefindings. • DiagnosticStudies o ChestX-ray,bloodgasesandnasalfluidcultureswillbeperformedtodetermine whichvirusis present. • Management o Appropriatemanagementdependsontheseverityoftheillness. o Incaseswithmildsymptoms,thenursewillprovidefluids,humidificationand rest. o Incaseswherethesymptomsaresevere,theclientwillneedtobehospitalized. ▪ StartIVfluidsalongwithantiviralmedications,possibly bronchodilators,steroidsandmechanicalventilation. ▪ Maintaindropletprecautionsand,ifnecessary,contactprecautions. o Respiratorysyncytialvirusimmuneglobulincanbegiventohigh-riskinfants. • NursingInterventions o AdmiteachchildtoasingleroomorwithanotherRSV-infectedchildren.Teach handwashinganduseofcontactprecautions.Besuretoassesstheclient'sfluid volume status. o Clientandfamilyteachingwillinclude: ▪ Checktheclient'simmunizationschedule;respiratorysyncytialvirus immune globulin (RSV-IVIG) may interfere with immune response ▪ Noadditionalvaccinesforninemonthsafterchildreceivesthese ▪ Donotletanyonesmokeinthehouse,caroranywherenearthechild ▪ Restandbreathingmoistair(usingahumidifier)helpsloosenthesticky mucus AspirationofForeignBody–LowerRespiratorySystemDisorders:Obstructive Aspirationofforeignbodyoccurswhenasubstancebecomeslodgedinachild'sbronchi.The severity is determined by location, substance aspirated and extent of obstruction. • Etiology o Thechildaspiratessolids,liquidsorvegetativematterintoairpassages;thisis mostcommoninolderinfantsandchildrenuptothreeyearsofage. • AssessmentFindings o Suddencoughing,gagging,wheezing,cyanosis,dyspneaandstridor. • DiagnosticStudies o ChestX-ray,fluoroscopyand/orbronchoscopywillbecompleted. • Management o Directlaryngoscopyorbronchoscopytoremoveobject,tobefollowedby supportivetherapy. • NursingInterventions o Thenursewillrecognizesignsofforeignbodyaspirationandadministerback slaps and chest thrusts or perform the Heimlich maneuver for children, as indicated. • Client&FamilyTeaching o Parentscanhelppreventthisbyknowingtheitemsmostlikelytobeaspirated. Thesearereportedtobepeanutbutter,balloons,aluminumtabsfromsodacans and paper clips. RestrictiveRespiratoryDisorder Restrictive respiratory disorders are caused by irritants, e.g., toxic drugs, radiation and industrial substancesthatcausedamaginginflammationofthealveoliandinterstitialtissueofthelungs.As a result, the lungs become scarred, stiff and noncompliant. RestrictiveRespiratoryInformation–RestrictiveRespiratoryDisorders • Intrapulmonaryrestrictiveconditions–abnormalityoflungs,pleuraorpleuralcavity: o Lungexpansionisrestrictedthroughstiffeningofthelung tissue ▪ pulmonaryfibrosis ▪ pulmonarysarcoidosis o Airorfluidoccupyingthepleuralcavitycauseslungtissuetocollapse ▪ Pneumothorax ▪ Hemothorax ▪ pleuraleffusion ▪ empyema • Extrapulmonaryrestrictiveconditions–lungsarenormal;restrictionoccursthrough respiratory muscle weaknessor external compression of the chest wall: o Neuromuscularconditionsthatcauserespiratorymuscleweakness ▪ spinalcord injury ▪ musculardystrophy ▪ Guillain–Barré ▪ MyastheniaGravis ▪ poliomyelitisamyotrophiclateralsclerosis o Centralnervoussystemconditionsthatimpairtherespiratorycenter ▪ head injury ▪ CNSlesions ▪ opioids PulmonaryFibrosis–RestrictiveRespiratoryDisorders:PulmonaryFibrosis&Sarcoidosis Pulmonaryfibrosisisanintrapulmonaryrestrictive disorderoflungstiffeningwithvarious etiologies. • Etiology o Pulmonaryfibrosishasanidiopathicetiology.Itisachronicprogressive disorder that causes stiffening of the lungs. o Occupationaletiologiesinclude: ▪ Coalworker'spneumoconiosis–riskincreaseswithlengthofexposure to coal dust (> 15 years), intensity of exposure and the silica content of dust ▪ Silicosis–workerswhohaveinhaledsilicadust ▪ Asbestosis–inhalationofasbestosfibers • Diseasemaydevelop15-20yearsafterexposure • Highriskformesothelioma(lungcancerspecifictoasbestos) • AssessmentFindings o Exertionaldyspnea o Nonproductivechroniccough o Chronicinspiratorycrackles(fineorcoarse) o Nailclubbingis possible Sarcoidosis–RestrictiveRespiratoryDisorders-PulmonaryFibrosis&Sarcoidosis Sarcoidosisisanintrapulmonarydisordercharacterizedbytheformationofgranulomasinthelungs,aswellasthe heart,lymphnodes,bonesandskin.Itmayprogresstofibrosisofthe lungs. • Etiology o Unknownetiology;3-4timesmoreprevalentinAfricanAmericans. • AssessmentFindings o Sarcoidosismaybeasymptomatic.Iftheclientissymptomatictheycan experiencedyspnea,coughandchestpain. RestrictiveLungDisease–RestrictiveRespiratoryDisorders:PulmonaryFibrosis&Sarcoidosis Restrictivelungdiseasesrestrictlungexpansion,resultinginadecreasedlungvolume,an increasedworkofbreathingandinadequateventilationand/oroxygenation. • DiagnosticStudies o ChestX-rayandchestCTtoseethepulmonarylymphnodeenlargementand pulmonaryinfiltrates o Pulmonaryfunctiontestsareusedfordiseasestagingandtoguidetreatment decisions o Bronchoscopyorclosedlung biopsy • Management o Corticosteroidtherapyisusedtosuppresstheinflammatoryresponse. o Theclientwillavoidenvironmentalexposuretoinhaledirritants. o Properuseofpersonalprotectiverespiratoryequipmentwithhigh-risk occupations and hobbies. • NursingInterventions o Preventinfectionorexposuretoinfection,includingimmunizationtoprevent influenzaandpneumonia. o Instructtheclienttopaceactivitiestoreduceoxygendemandsanddyspnea. o Administeroxygenasneededforhypoxemiaanddyspnea,particularlyinthe advanced stages of disease. o Reinforcetheneedforsmall,frequentmealsinadvancedstagesand encouragedailyactivitiesandexercisewithinpulmonarytolerance. o Providereferralsfor: ▪ Depressionassociatedwithdisease ▪ Smokingcessationsupportgroups ▪ Pulmonaryrehabilitation ▪ Occupationalrehabilitation CollapsedLung–RestrictiveRespiratoryDisorders Collapsedlungreferstoanumberofdisordersinwhichthe pleuralspaceisabnormallyoccupied by air or fluid, resulting in reduced lung capacity. • Etiology o Typesofcollapsedlung: ▪ Pneumothoraxairinthepleuralspace,causinglung collapse: • Anopenpneumothoraxiswhenairentersthepleuralspace through a hole in the chest wall, e.g., gunshot wound • Aclosedpneumothoraxiswhenairentersthepleuralspace through a hole in the lung tissue, i.e., after lung resection • Atensionpneumothoraxisaclosedpneumothoraxwithrapid accumulation of air in pleural space, increasing pressure o Highpressurecausesmediastinalandtracheal shiftawayfromtheaffectedside,compressingtheheart and preventing adequate cardiac output o Resultsincardiactamponade(andpossiblypulseless electrical activity) – this is an emergency situation • Alltypesofpneumothorax–treatedwithchesttubeinsertion ▪ Pleuraleffusionfluid(transudateorexudate)isfoundinthepleural space. • Itistreatedwithathoracentesisorchesttube. ▪ Hemothoraxbloodisinthepleuralspace. • Itistreatedwithathoracentesisorchesttube. ▪ Empyemapurulentdrainageinthepleuralspace. • Itisusuallyacomplicationofpneumonia,andistreatedwith a chest tube and antibiotics. ▪ Chylothoraxmilky,whitelymphaticfluidinthepleuralspace • Thisconditionistreatedwithathoracentesisorchesttube, pleurodesis or surgery. • AssessmentFindings o Asymmetricalchestmovement o Progressivedyspnea o Diminishedorabsentlungsoundsonaffectedside o Lowoxygensaturationlevels o Fatigueandactivity intolerance o Tachycardia o Restlessness,anxiousness o Chestpain o Progressivecyanosis o Pleuralrub:causedbypleuraleffusionorpneumothorax. • DiagnosticStudies o ChestX-raythatsupportsdiagnosis o Ahighwhitebloodcell(WBC)countwithempyemaclients o Ahemocrit(HCT)/hemoglobin(hGb)countwillbebelowbaselinein hemothorax clients • Management o Thehealthcareteamwillneedtoadjustthetreatmenttothecauseandplacea chestdrainagedeviceappropriately. o Athoracentesis,withorwithoutachestdrainagedevice,willbenecessaryin pleural effusion or hemothorax clients. • NursingInterventions o Positiontheclientforcomfortandtopromoteeaseofbreathing.Monitorthe client'srespiratorystatusandeffortlevel.Administerpainmedicationsasordered. o Maintainandmonitorthechesttubeandclosedchestdrainage system. o Ensure that the chest tube drainage system is closed, has no leaks, all connectionsaretapedorsecuredandtherearenokinksordependentloopsin the tubing. o Monitor volume and characteristics of drainage and notify the surgeon if drainageexceeds100mL/hourand/orsuddenbrightredorfree-flowing drainage. o Keepthecollectiondevicebelowchestlevelorinsertionsiteatalltimes.You should expect the water level to fluctuate with client's respirations (tidaling). o Anocclusivedressingwillpreventairfromenteringpleuralspacethroughthe insertion site (reinforce as necessary). o EnsurethatclienthasappropriatechestX-rays–daily,followingchangestothe chest tube status and when the tube is removed. ChestTubes Trauma, disease or surgery can interrupt the closed negative-pressure system of the lungs, causingalungtocollapseandairorfluidtofillthepleuralcavity.Achesttubeisinsertedanda closed chest drainage system is attached to remove air and/or fluid. • Achestdrainageunit(CDU)hasthreechambers: o Watersealchamber: ▪ Actsasaone-wayvalve ▪ Filled withspecifiedamountofsterilesaline,usuallytothe2cmmark ▪ Tubingshouldstayinfluid ▪ Expectwaterleveltofluctuatewithrespirations (thisiscalledtidaling) ▪ Addwaterasneeded(besuretofirstturnoffsuctiontemporarily) o Suctioncontrolchamber: ▪ Fillwithsterilewatertothe20cmH2O level,orasprescribed. ▪ To start suction, connect tubing on the suction control chamber to a suctionsourceandturnupthepressureuntilgentle,steadybubblingis observedinthechamber. ▪ Addwaterasneeded;besuretofirstturnoffsuction temporarily. o Collectionchamber • Client care: o AssessanddocumentVS o Assessanddocumentbreathsoundsovertheaffectedlungarea. o Assesschestmovementandreportparadoxicalchestmovementandtracheal deviation, which could indicate a tension pneumothorax. o Observechesttubedressingandchangeit,accordingtotheinstitution’spolicy. o Assessthechesttubeinsertionsite,palpatingaroundsiteforanycrepitusor subcutaneousemphysema (soundslike"RiceKrispies"undertheskin). o Assesstubingforpatency–thereshouldbenokinks,dependentloopsorclotsin the tubing. o Makesureallconnectionsaresecurelytapedandthatthechesttubeissecured to the client. o Coilexcesstubingonthemattressnexttotheclientandsecureittothebed. o CDUshouldbeupright andpositionedbelowtheleveloftubeinsertion. o Positiontheclient: ▪ Usesemi-Fowler'stoevacuateairwithpneumothorax. ▪ Usehigh-Fowler'stodrainfluidwithhemothorax. ▪ Repositiontheclientfrequentlyandassistwithambulationorsittingina chair. o Assesspainusingapainintensityratingscale;optimalpainmanagementcan prevent hypoventilation and complications (e.g., atelectasis or pneumonia). o Noteandrecordtheamountandcolorof drainage: ▪ Markthelevelofdrainageattheendofeachshift. ▪ Reportdrainage>100mL/hourand/orchangesincharacter(bright red or free-flowing). • Potentialproblems: o Continuousbubblinginthewatersealchamberindicatesaleakinthesystem; assessthesystemfromtheinsertionsitebacktotheCDU. o Iftidalingdoesnotoccur,determinewhetherthetubingiskinkedorclamped oradependenttubingsectionhasbecomefilledwith fluid. o When there are visible clots in the tubing, squeeze hand-over-hand along thetubingandreleasethetubingbetweensqueezes,avoidingaggressivechesttube manipulation (i.e., no stripping or milking). o Ifthetubingbecomesdisconnectedfromthedrainagesystem,submergethe tube1 to 2 inches (2 to 4 cm) below the surface of a 250 mL bottle of sterilewateror saline solutionuntil a new CDU is set up. o Tensionpneumothoraxfindings: ▪ Severerespiratorydistressorchestpain ▪ Absenceofbreathsoundsontheaffectedside ▪ Hyperresonanceontheaffectedside,withmediastinalshifttotheunaffected side • Removalofachesttube: o Thelunghasfullyexpanded o Noairleak hasdevelopedduringa24to48hourperiod. o <150mLoffluid hasdrained in a24hourperiod. Poliomyelitis–RestrictiveRespiratoryDisorders Poliomyelitisisaviralinfectionthatcanaffectthenervesandcanleadtopartialorfullparalysis. • Etiology o Apoliovirusisspreadbyperson-to-personcontact,contactwithinfected mucusorphlegm fromthenoseormouthand contactwithinfected feces. • AssessmentFindings o Subclinicalinfectionfindings(95%ofcases)rangefromnofindingstomalaise, headache,redthroat,slightfeverandvomiting. o Non-paralyticfindingsinclude: ▪ backpain,diarrhea,fatigue,headache,irritability,legpain,moderate fever, muscle stiffness, rash and neck pain and stiffness. o Paralyticfindingsinclude: ▪ fever,abnormalsensations,bloatedfeelinginabdomen,difficulty breathing, constipation, muscle pain, contraction or spasms, sensitivity to touch and stiff neck and back. o Post-poliosyndromeisacomplicationthatdevelopsinsomepeople,usually30 or more years after the initial infection. ▪ Thecomplicationsmayinclude: • aspirationpneumonia,corpulmonale,kidneystones,urinary tract infection (UTI) and/or shock. • Management o Preventionvia vaccination. MuscularDystrophy–RestrictiveRespiratoryDisorders Muscular dystrophy is a progressive, inherited disorder that causes the wasting of voluntarymuscleswithnonerveeffect.Asthoracicmusclesweaken,breathingbecomesmoredifficult. The client may not swallow well; there is a risk for aspiration with the loss of protective airway reflexes. • NursingInterventions o Neuromusculardisordersoftenaffecttheclient'sbreathing: ▪ Monitorfrequentlyforchangesinrespiratorystatus,suchasrespiratory failure and infection ▪ Regularlyassessswallowingandtheirabilitytoprotecttheupper airway ▪ Discussclientpreferencesformechanicalventilationornutritional support; communicate and advocate for the client's wishes ▪ Assistwithcoughingandsecretionclearanceasindicated ▪ Preventrespiratoryinfectionthroughreductionofriskand immunization (influenza and pneumococcal vaccines) ▪ Assessfordepressionandanxiety,commonwiththesediseases,and provide appropriate referrals ▪ Administermedicationsspecifictothediseasecondition ▪ Provideoccupationalor/andphysicalrehabilitationasindicated ▪ Maintainadequatenutritionand,iftheclient'sswallowingisaffected, utilize appropriate methods to reduce their risk of aspiration Other–RestrictiveRespiratoryDisorders 1. MyastheniaGravis o essofskeletal muscle 2. Guillain-Barre o isaneuromusculardiseasethataffects breathing 3. AmyotrophicLateralSclerosis(ALS) o isadiseaseofthenervecellsinthebrainandspinalcordthatcontrolvoluntary muscle movement. LowerRespiratorySystemDisorders–Infectious Infectiouslowerrespiratorysystemdisordersarecausedbyaninfectiousagentthatentersinto the lower airways. Pneumonia, tuberculosis, abscess and SARS will be discussed in the following section. Pneumonia–LowerRespiratorySystemDisorders:Infectious Pneumonia is a disease of the lungs, primarily caused by infection, characterized by inflammationandconsolidationoflungtissuefollowedbyresolution.Pneumoniais accompanied by fever, chills, coughand difficultybreathing. • Etiology o Community-acquiredpneumonia ▪ iswhentheclientisexposedtoinfectiousorganisms outsideofthe hospital. o Hospital-acquiredpneumonia ▪ issecondarytoinfectiousorganismexposure,i.e.,pseudomonasorrisk factorsassociatedwithahealthcaresetting,occurring48hoursormoreafter admission. o Aspirationpneumonia ▪ isachemicalirritationandinflammationassociatedwithaspirationoffood, stomach contents or normal oral flora. o Opportunisticpneumonia ▪ iscausedbymicroorganismsthatareusuallyharmlessbutthatcanbe pathogenic in individuals with depressed immune function, such asPneumocystiscarinii,cytomegalovirusandLegionnaires'disease. o Pneumoniaistheleadingcauseofdeathfrominfectiouscauses. o Risk factors: ▪ Pre-existingpulmonarydisease ▪ DepressedimmunefunctionsuchasHIV,chemotherapyandother immunosuppressant drugs ▪ Atelectasissecondarytosurgeryorimmobility ▪ Mechanicalventilationorartificialairway ▪ Advancedage,particularlywithchronicillness,frailty ▪ Decreasedabilitytoprotectairway,swallowsafelyorcougheffectively • AssessmentFindings o Fever,chillsandmalaise o SOBwithdecreasedoxygensaturation o Productivecoughwithpurulentsputum o Pleuriticchestpain o Cracklesorrhonchiinaffected lobe(s) o Egophony o whisperedpectoriloquy • Age-relatedFindings o Atypicalpresentationiscommonwitholderclients. ▪ Theymaypresentwithacuteconfusion,whileotherfindingsmaybe less evident. o Ininfantsandyoungchildren ▪ lethargy,crankinessandpoorappetitemayindicateanacuteinfection such as pneumonia. • DiagnosticStudies o AchestX-raywillrevealconsolidationorinfiltratesinaffectedlobes. o Laboratoryresults: ▪ AcompletebloodcountwillshowanincreaseinWBC ▪ Arterialbloodgaseswillindicaterespiratoryacidosis(lowpH,high PaCO2) and hypoxemia (low PaO2) ▪ Sputumculture,sensitivityandmicroscopicanalysis,gramstainand cytology will be used to identify causative organism and appropriate treatment o Whenanorganismisdifficulttoidentify,abronchoscopymaybeperformedto obtain a sputum specimen. • Management o Pharmacologicinterventions: ▪ Antimicrobials(dependsonpathogen)–monitorforsignsofresolving infection ▪ Antipyretic,analgesic–acetaminophenorNSAIDs ▪ Expectorants–guaifenesin ▪ Antitussives–dextromethorphan,codeine o Providerespiratorysupportasneeded,mayincludemechanicalventilationin severecases. • NursingInterventions o Monitorpulseoximetrytitrateoxygenasindicated. o Promotehydrationtoliquefysecretions. o Monitortheclient'srespiratorystatusincludingrate,effortandsignsoffailureor distress. o Teach the client effective coughing techniques to minimize energy expenditure andstresstheimportanceofcompletingtheentirecourseofantimicrobialtherapy. o Clientsshouldexperienceimprovementwithin48-72hoursofinitialtherapy. ▪ Theywillcontacttheirhealthcareprovideriftheyarenotimproving. o Encourageinfluenzaandpneumococcalvaccinesforhigh-riskgroups. PulmonaryTuberculosis–LowerRespiratorySystemDisorders:Infectious Pulmonarytuberculosis(PTB)isachronicinfectioncausedbyanacid-fastbacillus,generally transmittedbyinhalationoringestionofinfecteddroplets. • Etiology o Mycobacteriumtuberculosisisoftendormantandlaterreactivates.Typically, bacillilodgeinthealveolibutcanaffectalmostanyorgan.Theycausepulmonary infiltrates. There is an increase in the prevalence of multi-drug resistant PTB, especially among the homeless and AIDS victims. • AssessmentFindings o common findings: ▪ Fever ▪ Weaknesswithfatigue ▪ anorexiawithweight loss ▪ nightsweats ▪ chestpain o Acoughusuallybeginsdryandprogressestoaproductivecoughwith purulenthemoptysis(coughingupblood). • DiagnosticStudies o Laboratorytests: ▪ Acultureforsputumandgastriccontentswillbeusedtoevaluatefor the presence of acid-fast bacilli ▪ Interferon-gamareleaseassay(IGRA)isabloodtesttomeasureimmune system response o AchestX-raywillshowthepresenceofactiveorcalcifiedlesions("coin"lesions). o Mantouxskintest: ▪ Thetestispositive if>10mminduration inhealthypersons(orif>5 mmindurationinclientswhoareimmunosuppressed)–additionaltests are needed. ▪ False-negativeresponsesarecommoninpeoplewhoare immunosuppressed. • Atwo-stepMantouxisusedforthispopulation(andhealthcare providers). ▪ FalsepositivesmayoccurforthosewhohavereceivedtheBCG vaccine, which is commonly administered outside the U.S. o DiagnosisofTBrequiresallofthefollowing:medicalhistory,physicalexam, TB skin test or blood test, chest X-ray and sputum or other culture. • Management o Long-term(6-24months)antimicrobialtherapywith isoniazid(INH)or rifampin;ethambutolinsomecasesis necessary. o Asurgicalresectionoftheinvolvedlungmaybeneededifmedicationisnot effective. o Ahigh-carbohydrate,high-proteindietwithfrequentsmallmealsis encouraged and activity as tolerated. o TBisareportabledisease.Thenursemustreporttoappropriateagencies;family and close contacts must be tested for disease. • NursingInterventions o Withactiveinfection: ▪ Takeairborneprecautionsandplacetheclientinanegativeairflowroomin the hospital ▪ UseNIOSH-approvedN95particulatefilteringfacepiecerespiratorwhen providing care (visitors can wear surgical masks) ▪ Providetheclientwithasurgicalmaskiftransportis needed ▪ Obtainsputumspecimenearlyinmorning–bestfordefinitive diagnosis o Clientandfamilyteaching includes: ▪ Propertechniquestopreventspreadofinfection,includinghandwashing ▪ Reportbloodysputumtotheheathcareprovider ▪ Donotuseover-the-counter(OTC)medicationswithoutthehealthcare provider's approval due to possible drug interactions ▪ Donotwearsoftcontactlensesiftakingrifampin(cancausereddish- orange discoloration of saliva, sweat, tears, urine and skin) ▪ Importanceoftakingmedicationsasprescribed • Adherencetotreatmentregimen • Returnatscheduledtimesforlabtestingofliverenzymes • AnincreaseinB6(orBcomplex)vitamintominimize peripheral neuropathies (a common side effect of antituberculars) LungAbscess–LowerRespiratorySystemDisorders: Infectious Lungabscessesarealocalizedcollectionofpurulentfluidinthelungwithcavityformation. • Etiology o Lungabscessesareusuallya complicationofpneumonia,TBoraspiration. • Management o Broad-spectrumantimicrobialtreatmentaftercultureoffluid o Percutaneousimagingorsurgicalresectiontodrainabscessmaybenecessaryif the infection does not resolve with pharmacologic treatment SevereAcuteRespiratorySyndrome–LowerRespiratorySystemDisorders:Infectious Severeacuterespiratorysyndrome(SARS)isarespiratoryillnesscausedbythecoronavirus (calledSARS-associatedcoronavirus). • Etiology o TheSARSinfectionisspreadbyclose,person-to-person,directcontact with infectiousmaterial(respiratorysecretionsorcontactwithpersonsorobjects infected with infectious droplets). • AssessmentFindings o Thesyndromebeginswithafever,overallfeelingofdiscomfort,body aches andmildrespiratorysymptoms;drycoughanddyspnea maydeveloplater. o Thelastpandemicoccurredin2003. • DiagnosticStudies o LaboratoryconfirmationofSARS-CoVinfection. • Management o Hospitalizationisnecessaryiftheclientpresentswithradiographicallyconfirmed pneumonia or an acute respiratory distress syndrome of unknown etiology. o Institutecontactandairborneprecautions. o ReportSARScasestotheU.S.CentersforDiseaseControlandPrevention (CDC). o Providesupportivecare.Nospecifictreatmenthasbeenshowntoconsistently improve the outcome of SARS patients. • NursingInterventions o Assesstheclient'stemperatureandmonitorforsignsof pneumonia. o Instructclientstoavoidcontact withthosesuspectedofhavingSARSandto avoidtraveltocountrieswhereanoutbreakofSARSexists. o Practicefrequenthandhygiene. o Clientsshouldwearamasktopreventtransmission. o PPEforstaffwillincludegown,gloves,N95respiratorsandeyeprotection. Lower Respiratory System Disorders – Miscellaneous Thefollowingsectionincludeadditionaldiseasesanddisordersassociatedwiththerespiratory system. PulmonaryEmbolism–LowerRespiratorySystemDisorders:Miscellaneous Apulmonaryembolism(PE)isabloodclotthatpreventsbloodfromperfusingthe"bed"of arteries that feed the lung, resulting in pulmonary infarction and decreased cardiac output; emboli can also be composed of air or fat. • Etiology o Matterblocksbloodfromthe"bed"ofarteriesthatfeedthelung;sincethe clientisbreathingbutnogasesarebeingexchanged, hypoxemiaoccurs. o APEcanbemildorimmediatelyfatal,basedonthesizeandlocationofthe matter. Symptoms develop over a period of minutes and require emergency treatment. o Typesofembolus: ▪ Bloodclothasusuallytraveledfromdeepveinsinthelegor pelvis. ▪ Fat–fromfracturedfemur,hip ▪ Amnioticfluid–post-delivery ▪ Air–frominjectionoflargeairbolusthroughIVorarterialline o AprimarycauseofPEisprolonged immobility. o Poorhydrationandconditionsthatimpaircirculation(e.g.,atrialfibrillationor heart failure) contribute to clot development. o Withafatembolism,findingsoccurabout24hoursaftertheinitialfracture. • AssessmentFindings o Iftheclienthasa smallembolus,theymaybe asymptomatic. o Ifaclienthasalargeembolus: ▪ Suddenonsetofdyspneaandcoughwith lowoxygen saturation ▪ Pleuriticchestpain ▪ Anxiety,apprehension–feelingof"impendingdoom" ▪ Cough–productiveor nonproductive ▪ Tachycardia ▪ Tachypnea • DiagnosticStudies o ChestCTwithcontrast(spiralCT) o D-dimerwillbe elevated o Ventilation/perfusion(V/P)scan(alsocalledV/Qscan) o Respiratoryacidosis–lowPaO2,highPaCO2 o ECG • Management o Preventionisthebesttreatment.Preventiveanticoagulantsarerecommended forpatientswhohavehadorthopedicsurgeryorwhoarebedridden. o Oxygentitratedtocorrecthypoxemia;theclientmayneedamaskorhigh-flow oxygen. o Pharmacologicinterventions: ▪ Anticoagulation: • HeparinIVorLMWHforacutePE • WarfarinforchronicPEtoreduceriskofrecurrence ▪ Thrombolytics(forlargeemboli) o Assesstheclientforpainand anxiety. o Afiltersurgicallyplacedinvenacavamaybeneededforlong-termprevention. • NursingInterventions o Monitortheclientforchangesinrespiratoryandcardiovascularstatus. o Encourageearlyambulationandcompressionstockinguseduringhospitalization to prevent deep vein thrombosis. ARDS–LowerRespiratorySystemDisorders:Miscellaneous Acute respiratory distress syndrome (ARDS) is an unregulated inflammatory response to a significantacuteinjuryorinflammatoryprocessanywhereinthebodythatcausesdamageto the alveolar capillary membrane, resulting in a non-cardiac pulmonary edema. • Etiology o Thealveolarcapillarymembranebecomesmorepermeabletofluids.Asaresult, thereisanincreaseinextravascularlungfluid. Refractoryhypoxemiaisusuallyseenafteralunginjuryorwithamassivemulti- system organ disease. • AssessmentFindings o Restlessness,anxiety–illappearance o Doesnotrespondtooxygentherapy o Tachycardia o Cyanosis(late) o Intercostalretractions,accessorymuscleuse o Assessmentofearlylungsoundsareclear,although coarsecracklesappearlater ▪ Note:InterstitialfibrosisdevelopsinsomepatientswhosurviveARDS • DiagnosticStudies o Clinicalpresentationandhistoryof findings o Arterialbloodgaseswillshowhypoxemiaandrespiratoryacidosisdespite increasing inspired oxygen level o AchestX-raywillshowdiffuseinfiltrates • Management o Treattheprecipitatingcondition,e.g.,administerantibioticsforsepsis. o Optimizeoxygenationtomaintainsaturation>88%andtocorrectrespiratory acidosis. o MechanicalventilationwithPEEP,possibleextracorporealmembrane oxygenation (ECMO). o Clientsedationmayberequired. o Paralyticagentsmaybenecessary. o Corticosteroidswillbeusedtoreduceinflammation. o Administerantibioticstotreatinfectiouscauses. o Fluidrestrictionmaybeusedtoreducepulmonarymicrovascularpressure,with central venous pressure monitoring to guide therapy. o Utilizenutritionalmanagementviatubefeedingorothermethodwhentheclient is mechanically ventilated. • NursingInterventions o Encourageclientbedrestwithfrequentpositionchanges o Providerangeofmotion exercises o Monitortrendsinoxygenationstatusandarterialbloodgases o Observetheclientforbehavioralchangesandsignsof confusion o Monitorvitalsignsandrespiratory effort o Providecaretotheclientreceivingcorticosteroids o Preventandtreatanycomplications,e.g.,malnutrition,deepveinthrombosis, health care-acquired infections (HAIs), DIC, skin breakdown, inadequate nutrition, GI hemorrhage and pneumothorax o Workwiththeinterdisciplinaryteamwhenitistimetotransfertheclienttoa tertiary care facility ClientCare-SteroidTherapy • Neverdiscontinuemedicationsabruptly–itcouldprecipitateanacutecrisis • Takemedicationwithbreakfast–correspondstobiorhythmsandreducesgastricirritation • Takethehigherdoseinmorningandlowerdosesinevening • Alwaystakemedicationwithamealorasnack • Carryextramedicationduring travel • Contact the health care provider during periods of acute or chronic stress, such as pregnancyorinfections;medicationswillneedtobeadjustedandadditionalinstructions maybe needed • WearMedicAlert®identificationandcarryamedicalcardatalltimes • Avoidotherpeoplewithinfectionsoravoidgoingtocrowdedshoppingmalls,grocery stores, or other venues in times when the cold viruses and influenza are most evident • Encourage weight-bearing exercise and an increase in protein and calcium intake, especiallyforwomen,whowillbeatanincreasedriskforbonelossandosteoporosis when undergoing steroid therapy • WearsunblockwithanSPFof15orhigher;avoiddirectsunlightfrom10amto4pm– due to increased sensitivity to sunlight • Recognizethenormalsignsofinfectionsandunderstandtheimportanceofcontactingthe health care provider at the onset of any sign of infection – steroid use masks the signs of infection • Beawareoftheanticipatedsideeffectsof(long-term)steroidtherapy,including: o Weightgain o Swellingofface,hands, ankles o Skin changes: ▪ Excesshairgrowthonface,hands,arms,back,legs ▪ Easybruising,thinningofskin ▪ Acneoftheface,backandchest(teens andyoungadults) o Moodswingsanddepression o Increaseinbloodsugarlevels–clientmayneedtotakeinsulin Cor Pulmonale – Lower Respiratory System Disorders: Miscellaneous Corpulmonaleisrightheartfailurethatdevelopsduetosustainedlungresistanceinchronic lung disease, i.e., COPD. • Etiology o Theheartmustpump against great resistance to move blood from the right hearttotheleftheart through the lung's blood vessel. o Thisisalsocalled increasedpulmonaryvascular o Thisresultsin right ventricular o hypertrophyandsubsequent chronic heart failure. IncreasedPVRresults fromchroniclungdisease,pulmonaryhypertensionandpulmonaryfibrosis. • AssessmentFindings o Fatigue,tachypnea,exertionaldyspneaandcough o Anginalchestpainduetorightventricularischemiaorpulmonaryartery stretching o Hemoptysis • DiagnosticStudies o PulmonaryarterypressurereadingsviaPAcatheter o Echocardiogram o ChestX-ray o Arterialbloodgases o ECG • Management o Theunderlyinglungdiseasewillbemedicallymanaged.Administeroxygenas orderedtopreventhypoxemiaandmonitortheoxygenationlevelswithapulse oximeter. The client will need frequent rest periods. o Medicationsincludecardiacglycosides,pulmonaryarteryvasodilatorsand diuretics. o Restricttheclient'sfluidintakeas indicated. • NursingInterventions o Monitorclientsforchangesinoxygenationstatusandtheeffectsofthe medications.Paceactivitiesforclientswhotireeasily. AcuteRespiratoryFailure-LowerRespiratorySystemDisorders:Miscellaneous Respiratoryfailureoccurswhenthelungscannotmaintainarterialoxygenlevels oreliminate carbon dioxide, creating the inability to maintain proper oxygenation. • Etiology o Respiratoryfailureiscausedbylungdiseasesthathardenthealveolar-capillary membraneandtrapoxygen.Amultitudeofconditionscancauserespiratory failure, which include neuromuscular and musculoskeletal disorders. • AssessmentFindings o ArterialbloodgaseswillshowaPaCO2>50mmHgandaPaO2<60mmHg o Classicpresentationofthethree"H's"orhypoventilation,hypoxemiaand hypercapnia ▪ Note: Clients with chronic lung disease will often present with a drop in baselinefunction.Theseclientsarealwayshypoxemicandhypercarbic. • DiagnosticStudies o Arterialbloodgases • Management o Emergencycareisnecessaryforclientsinacuterespiratoryfailure. o Administeroxygenviamask,CPAPorintubationandmechanicalventilation. Helptheclientmanageanxiety.Notbeingabletobreatheisscaryandanxiety increases the client's oxygen needs. o Monitorforimprovementintheunderlyingcausefortherespiratoryfailure. • NursingInterventions o Observeforsignsofhypoxiaandrespondtopreventoccurrenceof respiratory failure.Administer medications andoxygenasprescribed andprovide supportive careforemotions,skinintegrity,gastrointestinal(GI)functionandrenalfunction. PediatricRespiratoryFailure-LowerRespiratorySystemDisorders:Miscellaneous Pediatricrespiratoryfailureissimilartoadultrespiratoryfailure,withafewexceptionsin assessment findings and management of the client. • AssessmentFindings o Restlessness,moodchanges o Changesinlevelof consciousness o Increasingratesofrespirationandpulse o Dyspnea o Decreasedplayactivity • Management o Frequentobservationandphysicalexams,withpulseoximeter o Correcthypoxemia,maintainventilationanddeliveroxygen o Monitorforsideeffectsandexpectedoutcomesoftherapy o Ifapneic,rubthetrunkorpatgently–beginCPRifthereisnoresponse Cystic Fibrosis – Lower Respiratory System Disorders: Miscellaneous Cysticfibrosis(CF)isaninheriteddiseasethatcausesthebodytoproduceabnormallythickand sticky mucus. • Etiology o Duetoaninheritedautosomalrecessivetrait,thick,stickymucusbuildsupinthe lungsanddigestivetract(particularlythepancreas). o Mucousglandsproduceathickmucoproteinthataccumulatesinsteadofathin freely flowing secretion, which results in life-threatening lung infections and serious digestion problems. o CFaffectsrespiratory,GIand(male)reproductivesystemsandalsomayaffectthe sweat glands. • AssessmentFindings o GIFindings ▪ Meconiumileus ▪ Steatorrhea ▪ Prolapseof rectum ▪ Failureto grow o RespiratoryFindings ▪ Thicktenaciousmucusthatcausespatchy,atelectasiscough ▪ Barrel-shapedchest ▪ Clubbingoffingersandtoes • DiagnosticStudies o Laboratorytests: ▪ Sweatchloridetest–standarddiagnostictestforCF(highlevelsof sodium and chloride in the patient's sweat is a sign of the disease) ▪ Immunoreactivetrypsinogen(IRT)test–standardnewbornscreeningtest for CF (high level of IRT suggests possible CF and requires further testing) ▪ Stool analysis o Lungfunctiontests o ChestX-rayorCTscantoshowpatchy atelectasis o PossiblyanupperGIandsmallbowelseries • Management o Pharmacologicinterventions: ▪ Bronchodilators ▪ Antibiotics(forPseudomonasaeruginosa,Burkholderia cepacia and Staphylococcus aureus) ▪ DNaseenzymereplacementtherapy–decreasestheviscosityofmucus, making it easier to cough up o Ahigh-protein,high-caloricdietisrecommendedforolderchildrenandadults, with the addition of vitamin supplements, especiallyA, D, E and K. o Yearlyinfluenzavaccineandpneumococcalpolysaccharidevaccine(PPV)are also recommended. • NursingInterventions o Clientandfamilyteachingwillinclude: ▪ Clearingorbringingupmucusorsecretionshouldbedone1-4timeseach day ▪ Drinkplentyoffluids ▪ Avoidsmoke,dust,dirt,fumes,householdchemicals,moldandmildew ▪ Exercise2-3timeseachweek,especiallyswimming,joggingorcycling, but avoid contact or endurance sports ▪ Posturaldrainageusesgravitytohelpmovemucusfromthelungsupto the throat. ▪ Theclientliesorsitsinvariouspositionssothepartofthelungtobe drained is as high as possible. ▪ Percussionorclappingbythecaregiveronthechestwalloverthepartof the lung to be drained helps move the mucus into the larger airways. ▪ Thehandiscuppedasiftoholdwaterbutwiththepalmfacing down. ▪ Thecuppedhandcurvestothechestwallandtrapsacushionofairto soften the clapping. ▪ Generally,eachtreatmentsessioncanlastfor20-40minutes.PD&Pis best done before meals to decrease the chance of vomiting. • Earlymorningandbedtimesareusuallyrecommended BronchopulmonaryDysplasia-LowerRespiratorySystemDisorders:Miscellaneous Bronchopulmonarydysplasia(BPD)isachroniclungconditionthataffectsnewbornbabies whowereeitherputonaventilatorafterbirthand/orwereborn prematurely. • Etiology o Infantsrequiringoxygenand/orlengthymechanicalventilation o Infantssurviving RDS o Lung immaturity o Severerespiratoryorlung infections • Pathophysiology o Mechanicalventilationpressesonlungtissueandthebronchialepitheliumis damaged. The products of inflammation are introduced and the alveolar walls becomethickandfibrotic.Continuedmechanicalventilationaffectsthegrowthof new cells and paralyzes cilia. Lungs develop cystic areas (sacs) and atelectasis occurs (collapsed alveoli). • AssessmentFindings o Tachycardiaandtachypnea o Increasedworkofbreathing(retractionsandnasal flaring) o Pallor o Cyanosiswithactivity o Restlessness • Management o Oxygen(possiblemechanicalventilation) o Pharmacologicinterventionsincludediuretics,bronchodilatorsandanti- inflammatory agents administered in gradually decreasing amounts o Theclient'sdietwillbechangedtoincreasedcalorieformulasandhydration o Providesupplementaloxygenathomeasneeded • NursingInterventions o Providerestperiods. o Observeforfluidoverloadorpulmonary edema. o Provideage-appropriatetoys. o Perform frequent respiratory assessments. Apnea–LowerRespiratorySystemDisorders:Miscellaneous Apneaisthecessationofbreathingforover20 seconds. • Etiology o Prematurity o Foreign-bodyaspiration, drowning or trauma o Incorrectpositioning o Gastroesophagealreflux o Infections o Seizure o Hypoglycemia ▪ Pathophysiology is dependent on the type of apnea. Central apnea is the absence of respiratory effort and air movement. Obstructive apnea presentsrespiratoryeffortbutwithnoairmovement.Mixedapneabegins first as central and then becomes obstructive. • AssessmentFindings o Findingswilldependon etiology. o Theclientmaypresentwithcolorchangesand/orhypotonia(lowmuscletone). o Caregiversoftenreportthatthechildappearedtostopbreathing,changedcoloror became limp – this is an "apparent life-threatening event (ALTE)." • DiagnosticStudies o Avarietyoflaboratorytestswillbeperformed,aswellasachestX-ray, electroencephalogram(EEG),ECG,upperGIseries,esophagealpHprobe,chest movement monitor and a nasal-airflow monitor. • Management o Homeapneamonitoring o Providebasiclifesupport(BLS)trainingtothefamily o Administermedicationsasordered,basedonthetypeofapneaandunderlying condition PediatricRespiratoryDistressSyndrome–LowerRespiratorySystemDisorders: Miscellaneous Pediatricrespiratorydistresssyndromeisusually causedbyalackofaslippery,protectivesubstance called surfactant, which helps the lungs inflate with air and keeps the airsacs from collapsing. • Etiology • Prematureinfants–usuallyduetosurfactantdeficiency • Newborns–birthasphyxia,multiplegestations,diabeticmotherandprolonged rupture of membranes • Olderchildren–traumaanddrowning • Pathophysiology: • Decreaseindevelopmentalqualityofpulmonarysurfactant • Inolderchildren,thesurfactantmaybewashedoutbydrowningorfluid aspiration • Therewillbeanincreaseinalveolarsurfacetension,impairedgas exchange, increased pulmonary resistance and hypoperfusion • AssessmentFindings • Tachypnea,increasedrespiratoryeffort • Paradoxical"seesaw"respirations • Nasalflaring • Substernalretractions • Expiratorygrunt • Deep,gutturalrumblesoundduetoforcedexpirationagainstaclosed glottis • Diseasestates: • Asignofrespiratorydistressinnewborns;alsoseenwithnasal flaring, retractions, cyanosis • Pneumonia,pulmonaryedema,airwayobstruction,croup, epiglottitis • Cyanosis • Hypoxia • DiagnosticStudies • Physical exam • Pulseoximetry reading • Laboratorytests–arterialbloodgas(ABG),glucoseand calcium • AchestX-raywillconfirmadiffusepatternoverbothlungfieldsthatresembles ground glass • Management • Oxygentherapy(possiblemechanicalventilation)andchestphysiotherapyisused to maintain ventilation and oxygenation. • PharmacologicInterventions • Possiblemedicationsincludesurfactant,prophylacticantibiotics,diuretics, inotropes and methylxanthines. • NursingInterventions • Keyprioritiesincludemakingfrequentrespiratoryassessmentsandmaintaining the client's acid-base balance, tissue perfusion and fluid and electrolyte status. • Educatetheparents/caregiverabouttheequipmentbeingusedonthechild. • Thereisaneedformeticulouscareandpositioningofaninfantduetosubtle changes in their oxygenation status. LungCancer-LowerRespiratorySystemDisorders:Miscellaneous Although some types are preventable, lung cancer continues to be the most common cause of cancerdeathsintheUnitedStates.Therearetwotypesoflungcancer:small-cellandnon-smallcell cancer. 80% of lung cancer cases fall under non-small cell. ▪ Etiology& Pathophysiology o Lungcanceriscommonlyaresultoftissuetraumafromtheinhalationof irritants orcarcinogens.Almostalllungcancersoriginatefromtheepitheliumofthelungs. As the epithelial tissue continues to be exposed to irritants or carcinogenics, the cells develop chromosomal changes and become dysplastic. Dysplastic cells turn into neoplastic carcinomas and can start invading deeper tissue. ▪ AssessmentFindings o Adenocarcinomatypicallypresentswithapleuraleffusionandcough.Thistumor grows at a moderate rate. Squamous cell lung cancer will present with an airway obstruction, cough, and sputum production. This tumor grows relatively slow.A largecellcarcinomaisfastgrowingandpresentswithacough,hemoptysis,chest wall pain, pleural effusion, sputum production and pneumonia-induced airway obstruction. Finally, small-cell grows at an alarming rate and presents with multiple findings such as, chest pain, cough, hemoptysis, dyspnea, wheezing, pneumonia-induced airway obstruction, muscle weakness, facial edema, hypokalemia, hyperglycemia and hypertension. ▪ DiagnosticStudies o Diagnosticstudiescanincludeabronchoscopy,sputumanalysis,CTscan and biopsy. ▪ Management o Thereareavarietyoftreatmentmodalitiesforlungcancerdependingonthestage andtypeofthelungcancer.Treatmentsincludebutarenotlimitedtosurgical resection,radiationtherapy,chemotherapy,targetedtherapy,immunotherapy, bronchoscopic laser therapy and radiofrequency ablation. ▪ NursingInterventions o Themosteffectivewaytopreventlungcanceristohelpclientsstopsmokingand decreasetheexposuretoenvironmentalpollutants. o Postoperative care of a client who has had thoracic surgery can be difficult becausetheincisionispainful.Adequatepainmanagementisanursingpriority. Other priorities include monitoring respiratory function (rate, effort, breath sounds), sputum volume and color and chest tube function and drainage. Daily chest X-rays may be ordered. o The nurse will teach the client signs and symptoms to report (hemoptysis, dysphagia,chestpainorhoarseness).Continuetoencouragesmokingcessationto decrease the morbidity and mortality. May also need to plan for home oxygen. Palliativecareshould bediscussed to manage pain and end-of-life careif needed.