7.1 Respiratory Part 2 Flashcards
Pulmonary TB
- Airborne illness spread by droplet nuclei
- Transmission occurs when droplets are inhaled and reach the alveoli
- Most TB is caused by Myobacterium Tuberculosis
- Small amount can be caused by Myobacterium Avium Complex (MAC)
Pathophysiology TB
- Tubercle bacilli is inhaled and multiplies in the alveoli
- Small amounts can enter the blood and spread to other areas of the body (brain, larynx, lymph nodes, lung, spine, bone, kidneys)
- 2-8 weeks macrophages attempt to ingest the bacteria, causing the bacteria to create a shell called granuloma
- When immune system cannot keep the bacteria under control, it multiplies and can travel to different areas such as the lungs, kidneys, brain and bones
Latent TB Infection
- Granulomas is an inactive infection but when broken, becomes active TB
- Can be detected by skin test or IFGA 2-8 weeks after infection
- Immune system can usually stop multiplication of the bacteria
- LTBI is not infectious
TB Disease
- When granuloma break down it becomes active TB disease
- This form is infectious
- Confirmed by M. tb cultures
TB Sites of Disease
- Lungs are most common site
MILIARY TB - TB travels to different areas (Extrapulmonary TB) - Can cause meningitis in the CNS as well as brain/spinal cord
- Extrapulmonary TB is not infectious unless the patient has some form of pulmonary disease already, or it occurs in the oral cavity/larynx.
Risk of Developing TB
- 10% of people who are exposed will develop TB if not treated
- Weakened immune system or HIV can heighten risk of developing TB after exposure
LTBI (Latent TB)
- Bacteria that is alive but inactive (small amounts)
- Non-infectious
- Asymptomatic
- TB skin tests and blood tests can detect LTBI
- Sputum/Cultures show up as negative
- Normal radiograph
- Is not considered a TB case
- Treatment should be considered to prevent TB
TB Disease
- Active bacteria
- Infectious
- Cough/Fever/Chills/Weight loss
- Positive TB Skin and Blood Test
- Radiograph abnormal
- Sputum/Cultures are positive
- Needs treatment
- Respiratory isolation
- TB Case
MDR TB and XDR TB
MDR (Multi-Drug Resistant)
- Resistant to first line drugs such as isoniazid and rifampin
XDR (Extensive-Drug Resistant)
- Resistant to both first line drugs and second line drugs
Primary resistance - Individual contracted a drug resistant TB
Secondary resistance - Individual developed drug resistant TB during drug therapy
TB EVALUATION
TB Symptoms
Patient can either have no symptoms or the following symptoms below
- Prolonged cough for 3+ weeks
- Hemoptysis (spitting blood)
- Chest pain
- Loss of appetite, unexplained weight loss
- Night sweats, fever, fatigue
Extrapulmonary TB Symptoms
Kidneys - Hematuria (blood in urine)
Meningitis - Headache/confusion
Spine - Back pain
Larynx - Hoarseness
- Loss of appetite, unexplained weigh loss, night sweats, fever, fatigue
History/Physical
- Ask about exposure and whether they have vaccine
Skin Test
Skin Test
- Mantoux method (intradermal injection of tuberculin on forearm)
- Assessed in 48-72 hours for size and induration (hardness)
- Look for hardening not redness
- Skin test cannot tell if disease is latent or active when positive result is shown
- Negative means that they do not have latent or active TB
2-step-method
- If first test is positive they are infected
- If first test is negative, another test is given in 1-3 weeks and if positive they are infected, if negative they are not
X-Ray
- Chest X-rays are used to confirm TB
Interferon Gamma Release Assay (IGRA) aka T-Spot Serum Test
- Positive results show that you have TB but cannot distinguish between latent or active
Sputum Culture
- Gold standard for TB screening
- Patient is cultured monthly until 2 consecutive negative cultures are seen
Medical Management TB
- Always treated with 2 or more drugs with direct observation
- Using 1 drug increases chances of bacteria developing resistance
- Treatment is effective when no bacteria is observed in sputum
- Requires long-term treatment and TB is resistant to many medications
- Broad spectrum is not used, only drugs selective for TB
TB Induction Phase
2 months of 4 drugs
- Isoniazid (INH)
- Rifampin
- Pyrazinamide
- Ethambutol
- Most important TB drugs to eliminate extracellular TB (sputum becomes non-infectious)
TB Continuation Phase
- Consists of at least 2 drugs after susceptibility reports
- Isoniazid and Rifampin if no drug resistant bacteria is found
- 4 months for non-drug resistant strains
- 4-7 months for non-drug resistant strains in HIV patients
- Goal is to eliminate intracellular TB
TB Resistant Strains Treatment
Primary drugs
- INH
- Rifampin
- Rifabutin
- Ethambutol
- Pyrazinamide
Secondary Drugs
- Levofloxacin
- Moxifloxacin
- Kanamycin
- Capreomycin
- Amikacin
- Cycloserine
- Ethionamide
- Para-aminosalicylic acid (PAS)
TB Nursing Management
- Airway clearance
- Advocating adherence to treatment
- Promote activity/nutrition
- Prevent transmission
Preventing TB Transmission
- Promote Proper Ventilation
(Primary Control includes opening doors and windows)
(Mechanical Ventilation in hospitals with negative pressure rooms) - Isolation rooms with negative pressure (AII rooms)
- Use N95 mask when entering rooms
- OR should use the same ventilation during treatment
- PPE
- Testing for fitted masks for hospital workers
- Respirators can be used for healthcare workers (not for patients)
- Surgical masks can be worn by patient (not for healthcare workers)
TB Infection Control in Home
- Can be sent home while still infectious
- Make sure there are no young or immunocompromised people at home
- Patient cannot travel unless it is for a healthcare appointment
- Cover mouth when coughing/sneezing
- Healthcare workers should wear respirators when visiting patient homes
Pneumonia (PNA)
- Inflammation of parenchyma caused by bacteria, fungi, or viruses
Pneumonia Types
Community acquired (CAP) - Occurring in community (48 hours or less after hospital admission)
Healthcare-associated (HCAP)
- Pneumonia occurring in non-hospitalized patient who comes in contract with healthcare frequently
Hospital-acquired (HAP)
- Occurs 48 hours or more after admission
Ventilator-associated (VAP)
- Develops 48 hours+ after endotracheal intubation or mechanical ventilation
Pneumonia Prevention
- Pneumococcal vaccine
Recommended for all adults 65+ and 19+ with weak immune systems - Smoking cessations
- Reducing risk of aspiration
- Hand hygiene
Pneumonia Risk Factors
- Age
- Comorbidities
- Alcohol
- Immunosuppression
- Antibiotic therapy
- Poor nutrition
- Aspiration
Pneumonia Manifestations
Bacteria (Pneumococcal)
- Chills/Fever
- Pleuritic chest pain
- Respiratory distress
- Tachypnea
Viral/Mycoplasma/Legionella
- Bradycardia
- Orthopnea
- Crackles
- Increased tactile fremitus
- Purulent sputum
- Respiratory tract infection
- Headache
- Low-grade fever
- Myalgia (muscle aches)
- Rash
- Pharyngitis
Diagnosis of Pneumonia
- Health history and physical exam
- X-ray (in high fowler position
- Sputum/Blood culture
- Bronchoscopy for severe cases
Pneumonia Management
- Antibiotics
- Fluids
- Oxygen (to prevent hypoxia)
- Antipyretics
- Antitussives (cough suppressant)
- Decongestants
- Antihistamines
Nursing Process for Pneumonia
- VS
- Cough frequency/severity
- Secretion odor, color and amount
- Tachypnea, SOB
- Auscultate lungs
- Change in Mental Status
- Fatigue, Edema, Dehydration
- Heart Failure in Older Patients
Pneumonia Complications
After initiation of therapy
- Septic shock
- Respiratory failure
- Atelectasis
- Pleural effusion
- Delirium
Pneumonia Interventions
- O2 via face mask or nasal cannula with humidification (loosens secretions)
- Coughing techniques
- Physiotherapy
- Position change/mobility
- Antibiotics
- Incentive Spirometry
- Adequate hydration
- Education on nutrition and etc
Expected outcomes of Pneumonia
- Improved airway patency
- Conserves energy and slowly increases activity
- Maintains adequate nutrition and hydration
Lung Abscess
- Pus/necrosis of pulmonary parenchyma (alveoli) caused by microbial infection
- Most often caused by pneumonia
- Symptoms include productive cough and febrile (fever) illness
- Pleural friction rub on auscultation
- IV antibiotic therapy for 3+ weeks and then oral antibiotics for 4-12 weeks
NURSING INTERVENTIONS
- Administer IV antibiotic
- Educate deep breathing and coughing
- Encourage high protein diet
Aspiration
- Can cause pneumonia or be a complication of pneumonia
- Risks include flat body position, swallowing disorders, seizures, stroke, LOC, cardiac arrest
SYMPTOMS - Tachycardia, dyspnea, cyanosis, hyper/hypotension
INTERVENTIONS - Elevate HOB, suction while avoiding gag reflex, check tube placement prior to feeding, thickened fluids for patients with trouble swallowing, speech therapy, education.
Pleural Disorders
- Membrane found in the thorax
- Parietal covers inner and Visceral covers outer
- Low protein pleura is usually found in between pleural spaces
Pleural Disorders
Pleurisy - Infection of pleural cavity Pleural Effusion - Buildup of fluid in pleural cavity Empyema - Pus in pleural space Pneumothorax - Air/gas in pleural space Hemothorax - Blood in pleural cavity
Pleurisy
- Inflammation of pleura (both layers)
- Pleuritic pain (pain during respiration) is most common symptom
- Friction rub can be heard on auscultation
- X-ray, sputum analysis and thoracentesis can be used for diagnoses
- Treatment includes analgesia, and splinting when coughing
Pleural Effusion
- Fluid in pleural space
- Can be caused by heart failure, TB, pneumonia, or pulmonary infection
- SYMPTOMS include fever, chills, pleuritic pain and dyspnea
- ASESSMENT - decreased breath sounds and fremitus, dull percussion sound, tracheal deviation
- Same diagnostic as pleurisy
Empyema
- Pus in pleural space from pneumonia or abscess
- Similar manifestations to pneumonia
- Noticeable decreased breath sounds upon auscultation
- Fluid drainage is needed
Pulmonary Emboli
- Obstruction of pulmonary artery by thrombus usually from DVT
- Can lead to ventricular failure and shock due to increased pulmonary arterial pressure and workload of right ventricle.
Pulmonary Emboli Risk Factors
- Trauma
- Surgery
- Pregnancy
- Heart failure
- Hypercoagulability
- Cancer
- Oral Contraceptives
- Immobility
- Venous stasis
(Virchow triad - venous stasis, endothelial damage, hypercoagulability) for venous thrombosis
PE Nursing Assessment
- Dyspnea is the most common symptom
- SOB, pleuritic chest pain during inspiration can also occur
- Low o2, tachypnea, tachycardia, fever, diaphoresis, cough, syncope, and anxiety can also be seen
Prevention of PE
- Exercise to avoid venous stasis
- Early ambulation
- Anti-embolism stocking
- Weight loss
PE diagnosis
- Chest x-ray or CT
Treatment of PE
- Improve respiratory/vascular status
- Anticoagulation therapy (risk of bleeding)
- Thrombolytic therapy
- IVC Filter
- Placed in inferior vena cava to prevent thrombi from reaching pulmonary circulation
Pneumoconioses
- Caused by inhalation of particles such as asbestosis, silicosis, and pneumoconiosis
- Preventable but not treatable
- Best way to counter this reducing exposure with protective gear
- Assess where a patient works and level of exposure
- Provide education on ways to prevent lung injuy
COPD
- Chronic Bronchitis
- Emphysema
- Bronchiectasis (airways widen and become more prone to mucus)
COPD Pathophysiology
- Airflow limitation due to abnormal inflammation response to particles/gas
- Inflammation causes scar tissue which narrows airways and reduces elastic recoil (compliance) of lungs
- Can cause pulmonary hypertension
Chronic Bronchitis
- Cough/Sputum production for 3+ months in 2 consecutive years
- Cilia function is reduced
- Bronchial walls thicken
- Bronchial airways narrow
- Mucus can plug the airways
- Alveoli become fibrosed and damaged, macrophage function also diminishes in the alveoli leaving the patient more susceptible to respiratory infections
Emphysema
- Destruction of alveoli walls leading to decreased surface area (they combine)
- There is increased dead space, air trapping, and impaired oxygen diffusion
- Emphysema causes hypoxemia and increased CO2 buildup
- Increased pulmonary pressure can also cause right-sided heart failure (cor pulmonale)
COPD Risk Factors
- Smoking
- Aging
- Occupational dust, chemicals, pollution
- Infection
- Hereditary (Alpha Antitrypsin Deficiency) can cause early-onset emphysema (20-40 y/o)
COPD Clinical Manifestations
- Chronic Cough
- Sputum Production
- Dyspnea
Can also include barrel chest, clubbed fingers, weight loss (due to dyspnea)
Complications of COPD
- Pneumonia
- Chronic Atelectasis
- Respiratory insufficiency/failure
- Pneumothorax
- Cor Pulmonale
Management of COPD
- Reduce risk factors (smoking cessations) is the most important
- Manage exacerbations
- Provide supplemental oxygen
- Pulmonary rehabilitation
- Pneumococcal vaccine and Influenza vaccine (primary prevention)
Nursing Management of COPD
- Begins with health history and review of diagnostic tests
- Goal is to achieve airway clearance, improve breathing patterns through position, oxygen, medication, smoking cessation, improving activity tolerance, and education on medication such as inhalation mediations.
Smoking Cessation the 5 A’s
Ask - Identify tobacco use at every visit for every patient
Advise - Urge them to quit
Assess - See if they are willing to quit
Assist - Use counseling and pharmacotherapy to help them quit
Arrange - Follow up within a week after they quit
Home Oxygen for COPD Patients
- Do not smoke near oxygen or flammable material
- Caution signs should be placed in front of homes
- Humidity is required during the therapy and must be provided
- Falls is a risk due to length of tubes for oxygen
Surgery for COPD
Bullectomy - Removal of bullae (air spaces in lung larger than 1cm alveoli) Allows improved function of lung tissue due to being less crowded)
Lung Volume Reduction (LVRS) - Remove diseased tissue and also reduces size of overinflated lung. Allows diaphragm to return to normal shape
Lung Transplant - Required for severe damage
COPD Medications
Controlled Medication - Prevent exacerbations (long acting beta agonist, inhaled steroids, anti-cholinergics.
Quick acting - Rescue medication (Short acting beta agonist, short acting anti-cholinergics,
IM/IV/PO steroids, antibiotics when exacerbations are caused by bacterial infection
Albuterol (Proventil, Ventolin, Salbutamol)
- Beta 2 Adrenergic Agonist (Relaxes Bronchial Smooth Muscle)
- Used for asthma, bronchospasm, bronchitis, COPD
- Given either PO or Inhaled
- Do not use in patients with cardiac disease or hypertension
SIDE EFFECTS - Tremor, dizziness, nervousness, restlessness, tachycardia - Wash mouth after using inhaler, and advise them on proper inhaler use
Anticholinergics
- Blocks acetylcholine
- Decreases secretions (respiratory, sweat, saliva)
- Bronchodilation
- Dilated pupils
- Photophobia
- Increases intraocular pressure
- Increased heart rate
- Used during pre-op to reduce secretions, emergency therapy for bradycardia/heart block, Parkinson’s disease, GI/GU disorders, dilate pupils
Nebulizer Therapy
- Aerosolizes medications allowing administration over minutes and smaller particles inhaled deeper into lungs
- Used during difficulty clearing secretions, reduced vital capacity, and unsuccessful with other methods.
NURSING CARE
- Take slow deep breaths through mouth and hold for a few seconds
- Encourage coughing
- Monitor effectiveness of therapy
Bronchiectasis (NOT COPD)
- Chronic irreversible dilation of bronchi and bronchioles
- Caused by airway obstruction, pulmonary infections, diffuse airway injury, genetics, abnormal host defenses.
Bronchiectasis
- Cough, sputum in copious amounts, and clubbing of finger nails
- Management through drainage, physiotherapy, smoking cessations, antibiotics, bronchodilators, and mucolytics.
- Nurses should alleviate and clear pulmonary secretions and teach patients about smoking cessations, drainage, respiratory infections, and conserving energy.
Asthma
- Hyperresponsiveness, edema, and mucus production of airways
- Reversible with or without treatment
- More common in males
- Allergies is the strongest pre-dispositioning factor
Risk Factors of Asthma
- Allergies
- Genetics
- Air pollution, cigarettes, urban residence
- Recurrent viral infections, other allergic diseases (allergic rhinitis)
- House mites, cockroaches, mold, pollen, animal dander, food additives
- Cold and dry air
- Aspirin
- Exercise
Asthma Clinical Manifestations
- Cough, Dyspnea, Wheezing
- Absence of wheezing can mean there is no gas exchange
ACUTE EXACERBATION - Chest tightness
- Dyspnea
- Diaphoresis
- Tachycardia
- Hypoxemia
- Central cyanosis
Asthma Care
- Assess for severity
- Assess how well patient controls their asthma
- These assessments are assessed every encounter
Asthma Treatment
- First assess severity
- This tells us how severe of an intervention we need to use
Asthma Medication
Rescue Medication
- SABA via nebulizer/inhaler or anticholinergics
Control Medication
- LABA, inhaled steroids, leukotriene modifiers
- Mast cell stabilizers
Asthma Nursing Management
- Manage ABC’s
- Supplemental oxygen
- All patients should have a rescue inhaler
- Education on their medication, smoking cessations, triggers
- Teach how to identify and avoid triggers
- How to preform peak flow meter
- How to complete asthma care plan
- When to seek help
Patient education for Asthma
- How to identify/avoid triggers
- Peak flow monitor to assess severity
- How to implement asthma action care plan
EXHALE
- Helped to reduce asthma related hospitalizations
E - Education (Expand access to and delivery of education for asthma self-management) (AS-ME)
X - Xtinguish (Extinguish smoking/second hand smoke)
H - Home Visits (Used to reduce triggers and improve asthma self management)
A - Achievement (Strengthen support systems by improving access/adherence to asthma medications)
L - Linkage (Promoting coordinated care for people with asthma)
E - Environmental Policies
- Smoke free policies
- Clean diesel school buses
- Eliminate exposure to triggers in workplace
