Chapter 23: Management of Patients w/chest & lower respiratory tract Disorders

Question 1

What are some strategies for the prevention of atelectasis?

Answer 1

Change patient’s position frequently, keep upright, encourage early mobilization, deep breathing, coughing, use Incentive Spirometry, pain control, chest percussion, postural drainage, suctioning.

Question 2

What is the treatment of atelectasis?

Answer 2

Improve ventilation, remove secretions.

Question 3

what are the interventions for atelectasis when the cause is bronchial obstruction?

Answer 3

coughing, suctioning, chest physiotherapy, nebulizer treatments, and bronchoscopy.

Question 4

what are the interventions for atelectasis when the cause is lung compression?

Answer 4

Cough, deep breathe, ambulation, thoracentesis, or chest tube.

Question 5

what are the classifications of Pneumonia?

Answer 5

Community Acquired, Hospital Acquired, Health Care Associated, and Ventilator Associated Pneumonias.

Question 6

How often should one use IS?

Answer 6

10 times/hour

Question 7

What are the classifications of Pneumonia

Answer 7

Community Acquired, Hospital Acquired, Health Care Associated, and Ventilator Associated.

Question 8

When and where does CAP occur?

Answer 8

Within the community OR within 48hrs of hospital admission

Question 9

HCAP criteria might include:

Answer 9

PNA occurring in a non-hosp. patient with extended health care contact.

Criteria might include:
Residing in a LTC facility, Antibx Rx, chemo, wound care within 30days of infections, hemodialysis, home infusion therapy, home wound care, OR family members who are infected due to multidrug-resistant bacteria.

Question 10

what is HAP

Answer 10

Hospital Acquired PNA: occurs 48hrs OR longer after admission that did not appear to be incubating at time of admission.

Question 11

what is VAP

Answer 11

Ventilator Associated PNA: a type of HAP that occurs 48hrs or longer after endotracheal intubation.

Question 12

What are the risk factors for infection with Penicillin and Drug resistant pneumococci?

Answer 12

Age > 65, alcoholism, immunosuppression, beta-lactam rx w/in last 3 mos (Cephalosporins), multiple medical comorbidities, exposure to child(ren) in daycare.

Question 13

what are the risk factors for CAP, HAP, HCAP, and VAP

Answer 13

CAP: older adults, patients with COPD, HF, alcoholism, asplenia, diabetes, pts. in LTC, children <5yo, smokers, immunosuppressed people,
HAP/HCAP: Patients with preexisting lung disease, cancer, COPD, homograft transplants, burns, antimicrobial therapy, debilitated people, tracheostomies, alcoholism, immunocompromise, and IV drug use.

Question 14

How; is TB transmitted? What are the risk factors of TB transmission?

Answer 14

TB is a bacteria that is spread via the air and is airborne.
Risk factors for TB transmission include close contact with someone who has active TB, having an immunocompromised status, substance abuse (IV drug use and/or alcoholism), Pre-existing medical conditions or conditions requiring specialized treatments (DM, CRF, dialysis, organ transplant, gastrectomy), institutionalization, immigration from countries with high incidence of TB, Living in crowded, substandard housing.

Question 15

What are the prevention strategies for TB?

Answer 15

1. early identification and Rx of people with active TB: maintain a high index of suspicion, prompt initiation of effective multi anti TB RX.
2. prevention of spread of infectious droplets: initiate AFB isolation, use private room w/neg. pressure, use of respirators.
3. Surveillance for TB transmission: main. surv among health care workers, patients, promptly initiate contact investigations exposed to TB

Question 16

How does TB present?

Answer 16

Insidious s/s: low-grade fever, weight loss, night sweats, anorexia, fatigue, cough: non-productive, productive, hemoptysis, lung sounds: crackles, diminished bronchial sounds, fremitus, epophony

Question 17

How is TB diagnosed? When do you read the PPD

Answer 17

positive skin test, blood test, or sputum culture.
PPD results: 0-4mm not significant, 5+ may be significant in people at risk, 10mm+ is considered significant in people with normal or mildly impaired immunity.
PPD is read 48-72hrs after injection of PPD.

Question 18

What are nursing interventions?

Answer 18

Promoting airway clearance: increase fluid intake, correct positioning.
Promote adherence to Rx regimen: teach med. schedule, S/E, take meds on empty stomach OR 1hr before meals, avoid tyramine and histamine foods:red wine, tuna, aged cheese, soy sauce, yeast extract, avoid alcohol.
Rifampin: makes these drugs LESS effective: beta blockers, OC. digoxin, Warfarin, corticosteroids, oral hypoglycemics, verapamil, theophylline, quinidine. DISCOLORS contact lenses.
Promote activity and adequate nutrition: small, frequent meals, liquid nut. supp., increase act. tol. identify food resources.
Prevent transmission: cover mouth/nose, proper disposal of tissues, hand hygiene

Question 19

What is a delayed hypersensitivity reaction?

Answer 19

an inflammatory reaction that occurs 48-72hrs after exposure to an antigen. This is initiated by mononuclear leukocytes. Monocytes/macrophages and T-cells mediate these reactions, rather than antibodies.

Question 20

What are the precautions for flu, TB, and PNA

Answer 20

Flu: droplet, TB: airborne, PNA: bacterial: droplet

Question 21

What are the presentations and treatments of CAP

Answer 21

CAP: Strep PNA: abrupt onset, toxic appearance, pleuritic chest pain Rx: PCN, amox, cef drugs, macrolide, levofloxacin, vanc, linezolid.
Influenza: insidious onset, assoc. w/URI, fever, aches, chills, productive cough. Rx: doxycylcine, cephalosporin, flouroquinolone
Legionnaires: flu-like, high fever, LOC, h/a, pleuritic pain Rx: azithromycin or fluoroquinolone
Mycoplasma: insid. onset, sore throat, nasal congestion, ear pain, h/a, low grade fever, pleuritic pain, myalgia, diarrhea, rash, pharyngitis Rx: macrolide, doxycycline.
Viral: URI symptoms, GI symptoms Rx: tamiflu relenza
Chlamydial: hoarseness, fever, chills, pharyngitis, rhinitis, non-prod cough. Rx: macrolide or doxycycline

Question 22

What are the presentations and treatments of HAP/HCAP?

Answer 22

Pseudomonas: toxic appearance, fever, chills, prod. cough, bradycardia, leukocytosis Rx: cef, cipro, pipercillin, aminoglycosides, imipenem
Staph PNA: severe hypoxemia, cyanosis, necrot. infect, bacteremia Rx: naficillin, oxacillin, vanc, linezolid
Kleb: rapid tissue necrosis, toxic appear, fever, cough, productive, broncho pna, lung abscess Rx:

Question 23

what are the s/s and Rx for fungal PNA

Answer 23

S/S: cough, hemoptysis, Rx: voriconazole, amphotericin B

Question 24

what are the classic s/s of PNA

Answer 24

sudden onset, shaking, chills, cough, stabbing chest pain, fever, tachycardia, sputum prod. cough, abn. breath sounds

Question 25

What are the supportive Rx for PNA

Answer 25

hydration, supplemental O2, assist with deep breathing, coughing, frequent position changes, early ambulation.

Question 26

how is the presentation different in geriatric patients

Answer 26

Increased difficulty to Dx: gen. deterioration, weakness, abd, symptoms, anorexia, confusion, tachycardia, tachypnea

Question 27

what is atelectasis? What are the causes and clinical manifestations?

Answer 27

Atelectasis: closure or collapse of alveoli. Causes: immobilization, monotonous breathing pattern, blockage: tumor, foreign body, secretions, prolonged supine position, surgical procedures.
S/S: dyspnea, cough, sputum production, tachy, tachypnea, pleural pain, central cyanosis

Question 28

What is part of the assessment for atelectasis?

Answer 28

increased work of breathing and hypoxemia, decreased breath sounds and crackles heard over affected area, SpO2: < 90%, decreased PaO2

Question 29

how is atelectasis managed?

Answer 29

increase ventilation, remove secretions, turn, cough, deep breath, early amb, IS. Second line: nebulizer, suctioning, chest physiotherapy, bronchoscopy, CPPB, PEEP

Question 30

How is the cause of PNA determined by WBC?

Answer 30

Bacterial PNA: high levels of neutrophils: bandemia (70% neutrophils, 10% bands) Viral PNA: normal neutrophil level, high level of lymphocytes

Question 31

What are the diagnoses for pneumonia?

Answer 31

Impaired Airway Clearance, Gas Exchange impairment, Infection, Pain, Activity intolerance, Altered nutrition, fluid volume deficit

Question 32

What is FIO2, PaO2, SaO2, SpO2?

Answer 32

FIO2= fraction of inspired oxygen
PaO2=partial pressure of arterial oxygen (80-100)
SaO2=amount of arterial blood oxygen saturation (93-100)
SpO2=density of hgb in capillaries (pulse ox meas.) (90-100)

Question 33

how do you estimate the amount of oxygen if given FIO2?

Answer 33

RA= 21% NP/NC=3-4% Example:

3L of O2: 3L X 3% +21%= 30% 3L X 4% +21%= 33%

Question 34

how is the predicted PaO2 determined?

Answer 34

FIO2 X 5

Question 35

what factors determine drug used to treat PNA?

Answer 35

Category of PNA, comorbid conditions, diseases prevalent in community at risk, pt. allergies