2.1 Respiratory Flashcards
Define perfusion
Blood flow throughout the lungs
Define defusion
Gas exchange
What does the upper respiratory system do?
Function:
cleansing, filtering, humidifying and warming inhaled air
Nose/sinuses:
nostrils separated by nasal septum
sinuses lighten skull, assist speech
produce mucus that drains to nasal cavities to help trap debris
Pharynx:
nasopharynx: passageway only for air
oropharynx: part of the pharynx that lies between the soft palate and the hyoid bone
Laryngopharynx: where both food and air pass
Upper respiratory system
Larynx
Larynx:
provides airway
routes air, food
contains vocal cords
Upper respiratory system
Trachea
Trachea:
seromucous glands that produce thick mucus
either swallowed or coughed out through mouth
The lower respiratory system
Lungs
Lungs:
elastic connective tissue called stroma
left lung smaller with two lobes
right lung larger with three lobes
The lower respiratory system
Pleura
Pleura:
pleural fluid allows lungs to move over thoracic wall during breathing
The lower respiratory system
Bronchi and Alveoli
Bronchi (larger) and Alveoli (smaller):
respiratory membrane where gas exchange
The lower respiratory system
Rib cage and Intercostal muscles
Rib cage and intercostal muscles:
Protect lungs
Sternum: manubrium, body and xiphoid process
Factors affecting respiration
Oxygen, carbon dioxide, hydrogen ion concentrations
Controlled by?
Oxygen, carbon dioxide, hydrogen ion concentrations:
Controlled by:
Respiratory centers of the medulla oblongata, pons of brain
Chemoreception in medulla and carotid, aortic bodies
Factors affecting respiration
Airway resistance, lung compliance, elasticity?
Airway resistance, lung compliance, elasticity?
Distensibility of lungs
Essential in inspiration
Factors affecting respiration
Alveolar surface tention?
Alveolar surface tension:
Surfactant
Lipoprotein interferes with adhesiveness of water molecules
Helps expand lungs
Factors affecting respiration
Respiratory volume and capacity:
Respiratory volume and capacity:
Pulmonary function test
-total lung capacity (TLC): max inflation
-vital compacity: total amount of air that can be exhaled after max inspiration
Factors affecting respiration
Air pressure
Air pressure:
- inspiration: diaphragm contracting
- expiration: passive, diaphragm relaxes
- intrapulmonary pressure: measured inside the alveoli
- intrapleural pressure: within pleural space
Respiratory assessments
thoracic
Thoracic: Respiratory rate (12-20 bpm) Anteroposterior diameter/transverse diameter ratio Intercostal retraction or bulging Chest expansion Trachea position Lung sounds
Respiratory assessments
Health interview
Health interview: Current manifestations: onset, characteristics course, severity, precipitating, relieving factors History of respiratory or lung conditions Present health status Medical history Family history Risk factors Lifestyle questions: -smoking -environmental exposures -occupational exposures -exercise -recreational drugs
Respiratory assessment
Nasal and sinus assessment
Nasal: Size Shape Color Nasal cavity health Ability to smell
Sinus:
No pain during palpitation
Breath sounds
Breath sound assessment:
Auscultation
Sounds
Crackles: short, discrete, crackling, bubbling (pneumonia, bronchitis, CHF)
Wheezes : continuous, musical sounds ( bronchitis, emphysema, asthma
Friction rubs: loud, dry, creaking sounds (pleural inflammation
Where are vesicular lung sounds heard?
Peripheries of lungs
Where are bronchiolar vascular sounds heard?
Over the bronchi
Each side of sternum
Back between scapula
Where are bronchiolar sounds heard
Closer to the throat, near the manubrium
Diagnostic tests
Sputum: gram stain, C&S, Cytology, acid-fast bacilli (AFB), detect bacterial infections in lungs. collected in A.M.
Chest x-ray
CT scan
MRI
PET scan
Thoracentesis: inserting needle, sample, remove fluid
Endoscopy: laryngoscopy, bronchoscopy, mediastinoscopy
Skin test
Blood test: arterial blood gasses (ABG’s), serology, CBC
Pulmonary function testing
Age related changes in the respiratory system
Decrease in elastic recoil of lungs Loss of skeletal muscle strength in thorax/diaphragm Fibrosis in alveoli Fewer functional capillaries Less effective cough Decrease in pulmonary O2
Patients with pneumonia
Pt with pneumonia
Leading cause of death due to infectious disease in the US
Highest incidence, mortality in older adults
Infectious or noninfectious
**causes by bacteria, viruses, fungal, other pathogens, aspiration of contents, inhalation of toxic material
Patient with pneumonia
Infectiuous classifications
Community acquired: Streptococcus pneumonia (most common) Mycoplasma pneumonia Haemophilus pneumonia Influenzae Chlamydia pneumonia Influenza virus
Nosocomial (hospital acquired): Staphylococcus aureus Gram negative bacterial -Klebsiella pneumonia -Pseudomonas aeruginosa -E coli
Opportunistic:
Pneumocystis
Physiology review of lower respiratory tract
Lower respiratory tract normally sterile
Defense mechanisms:
mucous membranes of nose (sneezing)
reflex closure of epiglottis, bronchial tree
cilia, mucus lining respiratory tract (coughing)
Aging impairs immune responses
Define pneumonia
Pneumonia:
The inflammatory response causes fluid to accumulate in the alveoli and edema to form as alveolar capillaries dilate and allow fluid to leak into interstitial tissues
Pneumonia develops
Four patterns
Four patterns:
Lobar pneumonia- involves the entire lobe of lung
Bronchopneumonia- fluid tends to remain in the bronchia’s and bronchi with less congestion in the alveoli
Interstitial pneumonia- found in the interstitial tissue
Miliary pneumonia- primarily seen in pts who are immunocompromised, typically enters through blood stream
Acute bacterial pneumonia
Acute bacterial pneumonia (quick onset):
Respiratory: cough productive of rust colored or purulent sputum
- Chest aching or pleuritic pain when coughing/breathing
- Limited breathing sounds, fine crackles, rales heard over affected area of lung
- Pleural friction rub may be audible
- Systemic: shaking chills (rigor), fever
Bronchopneumonia (slower onset):
-Insidious onset, low grade fever, cough, scattered crackles
Atypical presentation (older adults): fever, tachypnea, altered mental status, agitation, slight cough, minimal distress
Complications of Acute Bacterial Pneumonia
Typically infection resolves uneventfully
Pleuritis is most common complication
Lung abscess (relatively uncommon):
-Most common etiology
-Aspiration, resultant pneumonia
-At-risk population
Empyema- accumulation of purulent exudate in the pleural cavity.
Manifestations of Infectious Pneumonias
Pneumococcal or lobar pneumonia
Onset?
Respiratory manifestations?
Systemic manifestations?
Pneumococcal or lobar pneumonia
Onset? abrupt
Respiratory manifestations? Cough productive of purulent or rust-colored sputum; pleuritic or aching chest pain; decreased breath sounds and crackles over affected area; possible dyspnea and cyanosis
Systemic manifestations? Chills and fever
Manifestations of Infectious Pneumonias
Bronchopneumonia
Onset?
Respiratory manifestations?
Systemic manifestations?
Bronchopneumonia
Onset? gradual
Respiratory manifestations? Cough, scattered crackles; minimal dyspnea and respiratory distress
Systemic manifestations? Low-grade fever
Manifestations of Infectious Pneumonias
Legionnaire disease
Onset?
Respiratory manifestations?
Systemic manifestations?
Legionnaire disease
Onset? gradual
Respiratory manifestations? Dry cough; dyspnea
Systemic manifestations? Chills and fever; general malaise; headache; confusion; anorexia and diarrhea; myalgias (muscle pain) and arthralgias (joint pain)
Manifestations of Infectious Pneumonias
Primary atypical pneumonia
Onset?
Respiratory manifestations?
Systemic manifestations?
Primary atypical pneumonia
Onset? gradual
Respiratory manifestations? Dry, hacking, nonproductive cough
Systemic manifestations? Fever, headache, myalgias, and arthralgias dominate
Manifestations of Infectious Pneumonias
Viral pneumonia
Onset?
Respiratory manifestations?
Systemic manifestations?
Viral pneumonia
Onset? sudden or gradual
Respiratory manifestations? Dry cough
Systemic manifestations? Flulike symptoms
Manifestations of Infectious Pneumonias
Pneumocystis pneumonia
Onset?
Respiratory manifestations?
Systemic manifestations?
Pneumocystis pneumonia
Onset? abrupt
Respiratory manifestations? Dry cough; tachypnea and shortness of breath; significant respiratory distress
Systemic manifestations? Fever
Primary Atypical Pneumonia info, manifestations?
Mycoplasma pneumoniae
College students and military recruits are primary affected population
Primary atypical pneumonia is highly contagious
Called “walking pneumonia”
Mild respiratory manifestations
Pharyngitis or bronchitis
Dry, hacking, nonproductive cough
Systemic manifestations Fever Headache Myalgias Arthralgias
Viral Pneumonia info, manifestations
Mild disease
Affects older adults, people with chronic conditions
Cytomegalovirus (CMV) pneumonia is increasing in immunocompromised people.
Occurs in community epidemics
Influenza and adenovirus
Respiratory
Dry cough
Systemic
Flulike symptoms
Pneumocystis Pneumonia info, manifestation
AIDS and other immunocompromised patients
Pneumocystis jiroveci
Produces patchy involvement throughout the lungs
Alveoli thicken, swell, and fill with fluid
Abrupt onset of symptoms: Fever Tachypnea Shortness of Breath Nonproductive cough
Manifestations of Pneumocystis Pneumonia
Tachypnea, SOB Dry, nonproductive cough Intercostal retractions Cyanosis Fever
Aspiration Pneumonia, risk factors, complications
Risk Factors: Emergency Surgery or Obstetric Procedure, depressed cough reflexes, impaired swallowing, elderly surgical patients, nutrition via NG or Gastric tube, and decreased LOC
Aspiration of gastric contents into lungs
Low p H of gastric contents causes inflammation
Pulmonary edema/respiratory failure can result
Complications:
abscesses
bronchiectasis
gangrene of pulmonary tissue
Interprofessional Care of the Patient with Pneumonia-Diagnosis, tests
Chest x-ray Sputum gram stain Sputum C&S CBC, WBC w/ dif Serology when blood and sputum tests are negative Pulse ox, continuously ABG's Fiberoptic bronchoscopy
Interprofessional Care of the Patient with Pneumonia-Medications
Agents that “break up” mucus
Acetylcysteine
Potassium iodide
Guaifenesin
Broad spectrum antibiotic Macrolide Penicillin Second- or third-generation cephalosporin Fluoroquinolone
Bronchodilators
Sympathomimetic drugs
Methylxanthines
Interprofessional Care of the Patient with Pneumonia-Treatment and Prevention
Immunization
Pneumococcal vaccine
-Pneumococcal Conjugate (PCV13, Prevnar), common used in children
-Pneumococcal Polysaccharide (PPSV23, Pneumovax), given to adults, lifetime one dose.
Influenza vaccine
Treatments Oxygen therapy -For patients who are tachypneic, hypoxemic -Low- or high-flow systems Chest physiotherapy -Percussion -Vibration -Postural drainage
Nursing Care of the Patient with Pneumonia
Diagnoses, outcomes, and interventions
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Activity Intolerance
Continuity of care
Usually treated in the community unless their respiratory status is significantly compromised or risk factors
-Advanced age
-Coexisting heart, kidney, or liver disease are present
The Patient with Tuberculosis
Chronic, recurrent infectious disease usually affecting the lungs
Mycobacterium tuberculosis: Relatively slow-growing, acid-fast organism with a waxy outer capsule
Airborne transmission by droplet nuclei: Suspended in air for hours
Epidemiology of Tuberculosis
Incidence and prevalence
United States
- Incidence fell until the mid-1980s
- Resurgence late 1980s and early 1990s
- Link to H I V/AIDS
- Incidence is now declining
Worldwide
- Continues to be a significant health problem
- An estimated 2 million deaths each year
Risk Factors for Tuberculosis
Characteristics of infected person
Extent of air contamination
Duration of exposure
Susceptibility of host: Those in lower socioeconomic groups, injection drug users, the homeless, and people with alcoholism or H I V infection
Manifestations and Complications of Tuberculosis
Fatigue Weight loss Anorexia Low-grade afternoon fever Dry cough Night sweats Tuberculosis empyema Bronchopleural fistula
Interprofessional Care of the Patient with Tuberculosis
Early detection Accurate diagnosis Effective disease treatment Preventing spread to others Screening -Methods of tuberculin testing -Intradermal P P D (mantoux) test -Multiple-puncture (tine) testing
TB testing
Intradermal injection for tuberculin testing.
The injection causes a local inflammatory response (wheal).
Measurement of induration following tuberculin testing.
The PPD will be administered intradermally on the dorsal aspect of the forearm , causing a wheel to develop approximately 6-10mm in diameter. the patient will have to return to the clinic after 48 to 72 hours to have the test read. The health care professional will measure the diameter of the induration.
Interpretation of Tuberculin Test
Less than 5 millimeter: Negative response, does not rule out infection
5-9 millimeter: Positive for people who are in close contact with someone with T B, are immunocompromised, have an organ transplant
10-15 millimeter: Positive for people who have other risk factors
Greater than 15 millimeter: Positive for all people
TB Diagnosis
A positive tuberculin test alone does not indicate active disease
Sputum smear is microscopically examined for acid-fast bacilli
Positive sputum culture is definitive
Sensitivity testing to determine appropriate drug therapy
Polymerase chain reaction (P C R)-rapid detection of M. tuberculosis D N A
Chest x-ray
Liver function tests
TB Medication
Single-drug therapy: Isoniazid (I N H)
Bacillus Calmette-Guerin (B C G) vaccination
Not widely used in the United States Two-or-more-drugs therapy: Isoniazid Rifampin Pyrazinamide Ethambutol Streptomycin
If a drug-resistant strain of T B: Therapy tailored to that resistance
TB Nursing Care
Health promotion
-Risk to public health
Awareness of TB as reemerging threat
Early diagnosis and appropriate treatment is best for prevention
Focus on infection control and ensuring compliance with prescribed treatment
Diagnoses, outcomes, and interventions
- Deficient Knowledge
- Ineffective Therapeutic Regimen Management
- Risk for Infection
The Patient with a Fungal Infection
Spores are present in the air that everyone breathes.
Normal respiratory and immune defenses prevent infection in most people.
Risk factors
-Inadequate immune system
Pathophysiology of Fungal Infection
Histoplasmosis
- Most common fungal infection in US
- Found in soil and linked to bird and bat droppings
- Histoplasma capsulatum
- Most infections develop into latent asymptomatic disease
- Primary acute histoplasmosis: Mild, self-limiting influenza type illness
- Chronic progressive disease: Older adults in lungs but can involve other organs
Disseminated histoplasmosis
- Oftentimes fatal
- Fever
- Dyspnea
- Cough
- Weight Loss
- Ulcerations of mouth and oropharynx
- Muscle Wasting
- Hepatomegaly
- Splenomegaly
Aspergillosis
Spores are common in the environment; rarely cause disease except in the immunocompromised
Invade blood vessels and produce hyphae that can cause thrombosis
Manifestations
- Dyspnea
- Nonproductive cough
- Pleuritic chest pain
- Chills, fever
- Hemoptysis or massive pulmonary hemorrhage can occur if the organism invades a pulmonary blood vessel
Diagnosis and Treatment of Fungal Infections
Diagnosis
Diagnosis Microscopic examination of sputum specimen Blood cultures Cerebrospinal fluid cultures Chest x-ray
Diagnosis and Treatment of Fungal Infections
Treatments
Treatments Oral itraconazole (Sporanox), a broad-spectrum antifungal agent, is commonly prescribed to treat histoplasmosis
Intravenous amphotericin B
surgery (lobectomy)
Nursing Care of the Patient with a Fungal Infection
Education
-Geographical locations and risk factors (exposure to bird droppings)
Antifungal drugs
-Teach about drug and interactions
Pregnancy and birth control
-Itraconazole is contraindicated during pregnancy and lactation.
Monitor carefully during infusion and therapy
-Amphotericin B is toxic must be monitored closely
The Patient with Obstructive Sleep Apnea
what is it?
Obstructive and Central Sleep Apnea
Obstructive Sleep Apnea: Respiratory drive remains intact but airflow ceases due to occlusion of airway (most common type)
Central sleep apnea rare: Caused by a neurological disorder
The Patient with Obstructive Sleep Apnea
Pathophysiology
Pathophysiology
- Loss of normal pharyngeal muscle tone
- Pharynx collapses during inspiration & tongue pulls against post. pharyngeal wall
- Obstruction causes O2 sat, P O2, and p H to fall, P C O2 to rise
-Asphyxia causes brief arousal from sleep
Restores airway patency and airflow
Episodes can occur hundreds of times a night
Manifestations of Obstructive Sleep Apnea
Loud, cyclic snoring, and restless sleep Excessive daytime sleepiness Irritability Gasping or choking during sleep Morning headache
Later Manifestations:
Depression, intellectual impairment, and impotence
Hypertension
Complications of Obstructive Sleep Apnea Factors
Complications Sleep fragmentation Loss of slow-wave sleep Dysrhythmias Sudden cardiac death Pulmonary hypertension Common in those who are morbidly obese
Obstructive Sleep Apnea and Risk Factors
Risk Factors Male gender Increasing age Obesity Large neck circumference Use of alcohol and C N S depressants
Diagnosis of Sleep Apnea
Overnight sleep study
- Electroencephalogram
- Measurements of ocular activity and muscle tone
- Ventilatory activity and airflow
- Continuous arterial oxygen saturation
- Heart rate
- Transcutaneous arterial P C O2
Treatment of Sleep Apnea
Mild-to-moderate apnea
- Weight reduction
- Abstaining from alcohol
- Improving nasal patency
- Avoiding supine sleeping position
- Nasal continuous positive airway pressure (C P A P) is the treatment of choice for sleep apnea
- Bi P A P ventilator provides less resistance to exhaling
Surgical Intervention for Sleep Apnea
Tonsillectomy
Adenoidectomy
Uvulopalatopharyngoplasty (U P P P)
Tracheostomy
Nursing Care of the Patient with Sleep Apnea
Obstructive sleep apnea is often treated in the home
Education of patient and family
- Equipment use
- Strategies to decrease contributing factors
- Diagnoses, outcomes, and interventions
- Disturbed Sleep Pattern
- Fatigue
- Ineffective Breathing Pattern
- Impaired Gas Exchange
- Risk for Injury
- Risk for Sexual Dysfunction
The Patient with Lung Cancer info
- Leading cause of cancer deaths in United States
- Accounts for 25% of all cancer deaths
- Most people with lung cancer die within 1 year of initial diagnosis
Pathophysiology of Lung Cancer
Vast majority of primary lung lesions are bronchogenic carcinomas.
-Bronchogenic carcinoma further differentiated by cell type
Small-cell carcinomas
-15% of lung cancers
Non-small-cell carcinomas (adenocarcinoma, squamous cell carcinoma, and large cell carcinoma)
-85% of lung cancers
Spread via lymph system to other organs
Types of Lung Cancer
Small-cell (oat cell) carcinoma
Small-cell (oat cell) carcinoma, 15% of all lung cancers
- Central mass
- Aggressive tumor
Types of Lung Cancer
Adenocarcinoma
Adenocarcinoma, 20-40% of all lung cancers
- Peripheral mass
- Early metastasis
Types of Lung Cancer
Squamous cell
Squamous cell, 25-30% of all lung cancers
-Central mass in large bronchi
Types of Lung Cancer
Large cell carcinoma
Large cell carcinoma, 10-15% of all lung cancers
-Peripheral mass larger than adenocarcinoma
Incidence and Risk Factors of Lung Cancer
Populations at risk
- Exposure to tobacco smoke
- Age over 50
- Exposure to ionizing radiation and inhaled irritants
- Exposure to radon
Manifestations of Lung Cancer
Chronic cough Hemoptysis Wheezing SOB Dull, aching chest pain or pleuritic pain Hoarseness and/or dysphagia Weight loss, anorexia Fatigue, weakness Bone pain Clubbing of fingers/toes
Complications and Course of Lung Cancer
Superior vena cava syndrome
-Partial or complete obstruction of superior vena cava
Paraneoplastic syndromes
-Syndrome of inappropriate ADH secretion (SIADH), hyponatremia, edema, Cushing Syndrome, hypercalcemia, venous thrombosis or pulmonary embolism.
Diagnosis of Lung Cancer
Chest x-ray Sputum specimen Bronchoscopy C T scan Cytologic examination, biopsy C B C, liver function, serum electrolytes Tuberculin test Pulmonary function tests, A B G s
Treatment of Lung Cancer
Medications
- Combination chemotherapy treatment of choice for small-cell lung cancer
- Bronchodilators
Surgery
- Only real chance for cure in non-small cell lung cancers
- Most tumors inoperable
Radiation therapy
- Used alone or in combination with surgery or chemotherapy
- Either curative or palliative
- “Debulks” tumors prior to surgery
- Relieve manifestations, complications
- External beam, intraluminal radiation, brachytherapy
Nursing Care of the Patient with Lung Cancer
Diagnoses, outcomes, and interventions
Ineffective Breathing Pattern
Assess respiratory status and oxygenation, pain, elevate HOB, Incentive Spirometer, Cough and Deep Breathe, Suction, Chest Physiotherapy.
Activity Intolerance
Assess physiologic responses to activity, plan rest periods between activities, increase activities gradually, teach energy conserving measures, keep frequently used objects within reach, administer O2 as prescribed, encourage physical activity
Pain
Assess pain, PRN pain meds for comfort or “around the clock” schedule for cancer pain, distraction, massage, positioning, and relaxation techniques.
Anticipatory Grieving
Spend time with patient/family, encourage expression of feelings/concerns, assist in grieving process, identify healthy coping measures, and encourage use of support systems
The Patient with a Laryngeal Tumor
Benign or malignant
- Benign: Papillomas, Nodules, Polyps
- Malignant: Squamous Cell Carcinoma most common
Chronic shouting, projecting, or vocalizing
Cigarette smoking and chronic irritation from industrial pollutants
Pathophysiology and Manifestations of Laryngeal Tumors part 1 or 2
Laryngeal
-Most common malignancy is squamous-cell carcinoma
-Leukoplakia
White, patchy, and precancerous lesions on tongue/mouth
-Erythroplakia
Red, velvety patches thought to represent a later stage
- Initial cancerous lesion, carcinoma in situ (CIS), will develop into squamous-cell cancer if untreated
- Laryngeal cancer can develop in glottis, supraglottis, and subglottis
Pathophysiology and Manifestations of Laryngeal Tumors
part 2 of 2
Pathophysiology and manifestations
Laryngeal cancer
- Cancers of the vocal cords or glottis tend to be well-differentiated, slow-growing
- Metastasis occurs late in illness
- Manifestations
Hoarseness: Change in voice quality
- Cancer of supraglottis (epiglottis, aryepiglottic folds, arytenoid muscles, cartilage, and false vocal cords): Invades locally, metastasizes early
- Subglottic tumors (below vocal cords): Often asymptomatic until enlarging tumor obstructs airway
Risk Factors for Laryngeal Tumors
Tobacco Alcohol Poor nutrition Human papillomavirus infection Exposure to asbestos Race: More common in African Americans
Interprofessional Care of the Patient with a Laryngeal Tumor
Benign tumors may resolve with correction of underlying issue
Early detection of malignant tumors is critical to survival
Diagnosis
- Direct or indirect laryngoscopy when cancer is suspected
- Biopsy
- C T scan, MRI, chest x-ray, & PET
Treatment of Laryngeal Tumors
Benign vocal cord polyps
- Inhaled steroid spray
- Some cases call for surgery
Radiation therapy -Treatment of choice -Preserves voice -Chemoradiotherapy Chemotherapy
- Treats distant metastasis
- Palliation when tumor unresectable
- Cisplatin and 5-fluorouracil
Surgical Intervention for Laryngeal Tumors
Goals
- Remove the malignancy
- Maintain airway patency
- Achieve optimal cosmetic appearance
Laser laryngoscopy (carcinoma in situ, vocal cord polyps, & early vocal cord cancers)
Laryngectomy
- Partial laryngectomy
- —Hemilaryngectomy
- —Vertical partial laryngectomy
- Total
Radical neck dissection
Modified neck dissection
total laryngectomy
Following a total laryngectomy, the patient has a permanent tracheostomy. No connection between the trachea and esophagus remains.
tracheoesophageal prosthesis (T E P)
The tracheoesophageal prosthesis (T E P) allows diversion of air from the trachea through a one-way valve into the esophagus and oropharynx, producing speech when the tracheostomy stoma is occluded. The one-way valve prevents food from entering the trachea.
Post-Surgical Care for the Patient with a Laryngeal Tumor
Speech rehabilitation
Necessary if entire larynx is removed
Techniques
- Tracheoesophageal puncture (TEP) with placement of a one-way shunt valve
- Esophageal speech
- Use of speech generators
Nursing Care of the Patient with a Laryngeal Tumor
Emphasize the need for patients with chronic hoarseness to seek treatment
Health promotion
Prevent tobacco use in children, adolescents, and young adults
Discourage use of alcohol
Nursing Care of the Patient with a Laryngeal Tumor
Diagnoses, outcomes, and interventions
Diagnoses, outcomes, and interventions
- Risk for Impaired Airway Clearance
- Impaired Verbal Communication
- Impaired Swallowing
- Imbalanced Nutrition: Less Than Body Requirements
- Anticipatory Grieving
The Patient with Asthma
what is it?
Asthma
- Chronic inflammatory disorder of airways
- Recurrent episodes of wheezing, breathlessness, chest tightness, coughing
Rare acute cases can be severe enough to cause respiratory failure, death
Pathophysiology of Asthma
Chronic
Subacute
Acute
Chronic inflammatory disorder of airways
Subacute state
- Inflammation quiet
- Inflammatory cells present in airway tissues
Acute episodes
- Widespread airflow obstruction
- Antigen-antibody response
- Inflammatory mediators released
- Bronchoconstriction, airway edema, impaired mucociliar clearance
Triggers for Asthma
Allergens Chemical agents in the workplace Respiratory infections Exercise Emotional stress Pharmacologic -N S A I D s, beta-blockers, sulfites
Responses to Asthma
Acute or early response
Late phase response
Acute or early response
- Inflammatory mediators
- Activation of inflammatory cells
- Stimulation of parasympathetic receptors
- Bronchoconstriction and impaired gas exchange
Late phase response
-4-12 hours after trigger
Manifestations and Complications
Wheezing Breathlessness Chest tightness Coughing Dyspnea Status asthmaticus -Severe, prolonged asthma -Does not respond to treatment
Diagnosis of Asthma
History and manifestations Pulmonary function tests (P F T s) Challenge or bronchial provocation tests A B G s Skin tests
Interprofessional Care of the Patient with Asthma
Disease monitoring
- Peak expiratory flow rate (P E F R)
- Evaluated by traffic signals
Preventative measures
- Avoiding allergens, environmental triggers
- Eliminating tobacco
- Early treatment of respiratory infections
Medications for asthma
Long-term control
- Anti-inflammatory agents
- Long-acting bronchodilators
- Leukotriene modifiers
Quick relief
- Short-acting adrenergic stimulants
- Anticholinergic drugs
- Methylxanthines
Routes of administration
- Metered-dose inhaler (M D I)
- Dry powder inhaler (D P I)
- Nebulizer
Bronchodilators
-Adrenergic stimulants, anticholinergic agents, and methylxanthines
In combination with anti-inflammatory
Anti-inflammatory agents
- Corticosteroids
- Cromolyn sodium and nedocromil
Leukotriene modifiers
- Montelukast, zafirlukast, zileuton
- Reduce need for short-acting bronchodilators
Nursing Care of the Patient with Asthma
Health promotion
- Link between smoking, childhood asthma
- Smoking cessation
Nursing Care of the Patient with Asthma
Diagnoses, outcomes, and interventions
Diagnoses, outcomes, and interventions
- Ineffective Airway Clearance- monitor LOC, assess pulse oximetry, assess cough effort and sputum, raise HOB, administer O2 and nebulizer Tx as ordered
- Ineffective Breathing Pattern-Assess RR, pattern and breath sounds, vital signs, labs, assist with ADL’s, provide rest between scheduled activities, teach pursed lip breathing and relaxation techniques, Administer O2 and bronchodilators/anti-inflammatories as ordered.
- Anxiety-Assess level of anxiety, identify coping skills, provide physical and emotional support, active listening, provide clear instructions, reduce excessive environmental stimuli, relaxation techniques.
- Ineffective Therapeutic Regimen Management-Assess level of understanding about treatment and diagnosis, discuss perceptions of illness, identify problems integrating tx plan into lifestyle, provide verbal and written instructions
The Patient with Chronic Obstructive Pulmonary Disease
Also known as C O P D
Pathophysiology
-Chronic bronchitis and/or emphysema
-Characterized by slow progressive obstruction of airways:
Resistance to airflow increases
Expiration becomes slow or difficult
Mismatch between alveolar ventilation and perfusion
Impaired gas exchange
Pathophysiology of COPD
Chronic bronchitis
Chronic bronchitis
- Inhaled irritants cause chronic inflammation
- Production of thick mucus
- Productive cough lasting 3 or more months in 2 consecutive years
- Narrowing of airways
- Common recurrent infection
Pathophysiology of COPD
Emphysema
Emphysema
- Destruction of the walls of the alveoli
- Enlargement of abnormal air spaces
- Airway collapse
- Loss of alveolar surface area for gas exchange
Manifestations of COPD
COPD is classified according to severity, staged from 0 to 4
Productive cough, often in mornings
Dyspnea with activity, exercise intolerance
Presence of a barrel-shaped chest
Incidence and Risk Factors of C O P D
Fourth leading cause of death in U.S Cigarette smoking Air pollution Occupational exposures Airway infection Familial and genetic factors
Diagnosis of COPD
Pulmonary function tests Ventilation-perfusion scanning Serum alpha1-antitrypsin levels A B G s Pulse oximetry C B C with W B C differential Chest x-ray
Medications for C O P D
- Immunizations against pneumococcal pneumonia and influenza
- Broad-spectrum antibiotics for suspected infection
- Bronchodilators- improves airflow and reduce air trapping
- Corticosteroids when asthma is component
- Alpha1-antitrypsin replacement therapy for those with genetic deficiency
Treatments for C O P D
Smoking cessation Avoidance of airway irritants and allergens Pulmonary hygiene measures Adequate hydration Pulmonary rehabilitation (P R) Pursed Lip Breathing Regular aerobic exercise, if applicable Oxygen -Long-term oxygen therapy Surgery -Lung transplant -Lung reduction surgery
Nursing Care of the Patient with C O P D
Diagnoses, outcomes, and interventions
Diagnoses, outcomes, and interventions
- Ineffective Airway Clearance- assess respiratory status, rate, cough, secretions, oxygen saturation, I/O, mucous membranes, encourage fluid intake of 2500ml/day, elevate HOB, coughing/deep breathing, suction, provide rest periods, oxygen, expectorants/bronchodilators.
- Imbalanced Nutrition: Less Than Body Requirements- assess nutritional status, monitor food intake, provide frequent, small feedings, elevate HOB for meals, provide snacks at bedside, assist with choosing preferred foods, and consult with dietician.
- Compromised Family Coping- Assess family interactions and effects of illness on them, identify coping strengths/weaknesses, provide teaching on COPD, encourage expression of feelings and avoid judgment, encourage family participation in care, family care conferences.
- Decisional Conflict: Smoking- Assess knowledge and understanding, acknowledge concerns and beliefs, listen nonjudgmentally, encourage expression of feelings, assist with creating plan to quit, provide referrals to outside support personal or groups.
