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MedSurge- Respiratory > General Assessment Of Clients With Respiratory Disorders > Flashcards

General Assessment Of Clients With Respiratory Disorders Flashcards

1
Q

Risk Factors for Respiratory disease

A
  • smoking
  • exposure to secondhand smoke
  • personal and family history of lung disease
  • genetic makeup
  • allergens and evironmental pollutants
  • recreational and occupational exposure
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2
Q

Nursing History

A
  • demographic data
  • personal and family history
  • diet history
  • occupational history and socio economic status
  • current health problems
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3
Q

Nursing History:

Age, gender, and race can affect the physical and diagnostic findings related to respiratory function. Many of the diagnostic studies relevant to respiratory disorders (e.g., pulmonary function tests) use these?______________ for determining predicted normal values.

A

Demographic Data

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4
Q

Nursing History:

Personal and Family History

A
  • medical history
  • Smoking history
  • medication use
  • allergies
  • travel and area of residence
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5
Q

Whether the pulmonary problena is acute or chronic, the chief complaint is likely to include _______,_________,_________,_____________.

A
  • cough
  • sputum production
  • chest pain
  • shortness of breath at rest or on exertion
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6
Q

During the interview, the nurse explores the history of the present illness, preferably in chronologic order.
This analysis of the problems) includes the following:

A
  • onset
  • duration
  • location
  • frequency
  • progressing and radiating patterns
  • quality and numbers of symptoms
  • aggravating and relieving factors
  • associated signs and symptoms
  • treatments
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7
Q

Physical Assessment/ Examination

A
  • Assessment of sinuses and nose
  • assessment of pharynx, trachea and larynx
  • assessment of lungs and thorax
  • assessment of normal breath sounds ( adventitious breath sounds)
  • other indicators of respiratory adequacy
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8
Q

Physical Assessment/examination

Other indicator of respiratory adequacy

A
  • cyanosis
  • skin and mucous membrane
  • general appearance
  • endurance
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9
Q

Physical Assessment/examination

Other indicator of respiratory adequacy

A
  • cyanosis
  • skin and mucous membrane
  • general appearance
  • endurance
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10
Q

A skin test to detect if you have been infected with TB bacteria/ Mycobacterium Tubercle Bacilli

A

Skin Test Mantoux Test

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11
Q

A skin test to detect if you have been infected with TB bacteria/ Mycobacterium Tubercle Bacilli

A

Skin Test Mantoux Test

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12
Q

Skin Test Mantoux Test:

Meaning of PPD?
- skin test used to diagnose latent TB Infection

A

Purified Protein Derivative

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13
Q

Skin Test Mantoux Test:

For HIV clients, induration of _______ is considered positive.

a. 3 mm
b. 4 mm
c. 5 mm

A

c. 5 mm

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14
Q

Skin Test Mantoux Test

(1)______ Mantoux test signifies exposure to (2)___________.

For (1)
a. Positive (+)
b. Negative (-)

A
  1. a. Positive
  2. Mycobacterium tubercle bacilli
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15
Q

Skin Test Mantoux Test

  1. Site?
    a. Subcutaneous
    b. Intradermal
    c. Intramascular
  2. read __________ after injection
    a. 49-70hrs
    b. 50-75hrs
    c. 48-72hrs
A
  1. B. Intradermal
  2. C. 48 - 72 hrs
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16
Q

Non invasive method of continuously monitoring the oxygen saturation of hemoglobin.

A

Pulse Oximetry

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17
Q

Pulse Oximetry

Ideal normal pulse oximetry values are:

A

95% - 100%

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18
Q

Throat, nasal and nasopharyngeal ___________ can identify pathogens responsible for respiratory infections

A

Cultures

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19
Q

Done for analysis to identify pathogenic organisms and to determine whether malignant cells are present; also be obtained to assess for hypersensitivity states

A

Sputum examination/studies

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20
Q

Sputum examination/ studies:

Specimen is delivered to the laboratory within

a. 1 hr
b. 2 hrs
c. 3 hrs

A

B. 2 hrs

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21
Q

Sputum examination/studies

What is
1. C & S
2. AFBS

A
  1. Sputum culture and sensitivity analysis
  2. Acid fast bacilli staining
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22
Q

Sputum examination/studies

Procedure:
1. _______ sputum specimen is to be collected.
a. Early morning b. Early evening

  1. Rinse mouth with ________.
    a. Juice b. Plain water
  2. Use Sterile ________.
    a. Can b. Container
A
  1. A. Early morning
  2. B. Plain water
  3. B. Container
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23
Q

Sputum examination/studies

  1. Sputum specimen for C & S is collected before the __________ of antimicrobial.
  2. For AFB staining, collect sputum specimen for__________ mornings.
A
  1. First does
  2. Three consecutive mornings
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24
Q

Are routinely used in patients w/ chronic respiratory disorders.

Evaluates lung function and dysfunction.

useful in screening clients for pulmonary disease even before the onset of signs or symptoms

A

Pulmonary Function Studies/tests

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25
Q

Assess ventilation and acid base balance; assesses oxygenation (partial pressure of arterial oxygen [Pao2]), alveolar ventilation (partial pressure of arterial carbon dioxide [Paco2), and acid-base balance.

A

Arterial Blood Gases

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26
Q

Arterial Blood Gases

Common site for withdrawal of blood specimen

A

Radial artery

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27
Q

Arterial Blood Gases

Done to assess for adequacy of collateral circulation of the hand.

A

Allen’s test

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28
Q

Arterial Blood Gases

  1. ________ pre-heparinized syringe to prevent 2. ____________ of specimen.

1.
a. 5 ml
b.10 ml
c. 15 ml

  1. a. Numb
    b. Clotting
    c. Bleeding
A
  1. B. 10 ml
  2. B. Clotting
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29
Q

Arterial Blood Gases

Container with ______ to prevent hemolysis of the specimen.

a. Ice
B. Hot water

A

A. Ice

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30
Q

Imaging Studies

Performed for clients with respiratory tract disorders to evaluate the present status of the chest and to provide a baseline for comparison with future changes.

A

Chest Xray

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31
Q

Imaging Studies: Chest Xray

Standard chest xray examination are performed from?

A

Posteroanterior and left lateral

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32
Q

Imaging studies:

An imaging method in which the lungs are scanned in successive layers by a narrow beam x-ray; the images produced provide a cross sectional view of the chest; can distinguish fine tissue density

A

Computed Tomogrophy

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33
Q

Imaging studies

Similar to CT except that magnetic fields & radiofrequency signals are used instead of a narrow beam x-ray.

Visualizes soft tissues.

Used to characterize pulmonary nodules.

A

MRI (Magnetic Resonance Imaging)

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34
Q

Imaging Studies:

Studies the lung and chest in motion.

obtaining “live” X-ray images of a living patient

A

Fluoroscopy

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35
Q

Imaging studies:

Commonly used to investigate thromboembolic disease of the lungs.

Involves rapid injection of a radiopaque agent.

A

Pulmonary Angiography

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36
Q

Imaging Studies:

A nuclear scanning test that is most commonly used to detect a blood clot.

Measure blood perfusion through the lungs

Confirm pulmonary embolism or other blood-flow abnormalities.

A

Lung Scan

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37
Q

Imaging Studies: Lung Scan

Remain ________ during the procedure.

a. Standing
b. Still
c. Sitting

A

B. Still

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38
Q

Imaging Studies:

A radiopaque medium is instilled directly into the trachea and bronchi

A

Bronchography

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39
Q

Imaging Studies: Bronchography

Nursing interventions before bronchogram.

A
  • Secure consent
  • Check for allergies to seafoods & iodine & anesthesia
  • NPO for 6-8 hours
    -Pre-op meds: atrophine SO4 & valium, topical anesthesia sprayed; followed by local anesthetic injected into larynx.
  • Have oxygen & antispasmodic agents ready.
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40
Q

Imaging Studies: Bronchography

Nursing Interventions after:

A
  • Side lying position
  • NPO until cough and gag reflexes return
  • Cough & deep breathe client
  • Low grade fever common
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41
Q

Endoscopic Procedures:

The direct inspection & observation of the larynx, trachea & bronchi through a flexible or rigid bronchoscope.

A

Bronchoscopy

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42
Q

Endoscopic Procedures: Bronchoscopy

Diagnostic use:

A
  • to collect secretions
  • to determine location of pathogenic process & collect specimen for biopsy.
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43
Q

Endoscopic Procedures: Bronchoscopy

Therapeutic uses:

A
  • remove foreign object
  • excise lesions
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44
Q

Endoscopic Procedures: Bronchoscopy

Nursing interventions prior to bronchoscopy:

A
  • Informed consent/permit needed
  • Atrophine S04 & valium pre-op;topical anesthesia sprayed followed by local anesthesia injected into larynx
  • NPO 6-8 hrs
  • Remove dentures, prostheses, contact lenses.
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45
Q

Endoscopic Procedures: Bronchoscopy

Nursing Interventions after:

A
  • check for return of cough & gag reflexes before giving fluid.
  • watch for cyanosis, hypotension, tachycardia, arrhytmias, hemoptysis,dyspnea. These signs & symptoms indicate perforation of bronchial tree.
46
Q

Endoscopic Procedures:

A diagnostic procedure in w/c the pleural cavity is examined with an endoscope

A

Thorascopy

47
Q

Endoscopic Procedures:

Aspiration of fluid or air from the pleural space

Used for diamosis or treatment and involves the pleural fluid or air from the pleural space.

A

Thoracentesis

48
Q

Endoscopic Procedures: Thoracentesis

Nursing Interventions before thoracentesis

A
  • secure consent take initial V/S
  • position: upright leaning on over bed table
  • instruct to remain still, avoid coughing during insertion of needle
  • pressure sensation is felt on insertion of needle
49
Q

Endoscopic Procedures: Thoracentesis

Nursing Interventions after:

A
  • Turn on the unaffected side to prevent leakage of fluid in the thoracic cavity
  • Bed rest until VS is stabie
  • Check for the expectoration of blood. Notify physician
  • Monitor VS
50
Q

Endoscopic Procedures:

Performed to obtain tissue for histologic analysis, culture & cytologic examination.

A

Biopsy of Lungs

51
Q

Endoscopic Procedures: Biopsy of Lungs

_________ are used to make a definite diagnosis regarding the type of malignancy, infection, inflammation or lung disease

A

Tissue samples

52
Q

Endoscopic Procedures: Biopsy of Lungs

_________ are used to make a definite diagnosis regarding the type of malignancy, infection, inflammation or lung disease

A

Tissue samples

53
Q

Endoscopic Procedures: Biopsy of Lungs

Biopsy procedures:

A
  • Transbronchoscopic biopsy - done during bronchoscopy
  • Percutaneous needle biopsy - areas not accessible by bronchoscopy
  • Open lung biopsy
54
Q

Endoscopic Procedures:

Removes lymph node tissue to be looked at under a microscope for signs of infection or a disease.

To assess metastasis of cancer.

A

Lymph node biopsy

55
Q

Common Respiratory Interventions

A
  • oxygen theraphy
  • tracheobronchial suctioning
  • bronchial hygiene measures
  • chest physiotheraphy
  • incentive spirometry
  • closed chest drainage ( thoracostomy tube)
56
Q

Common Respiratory Interventions:

Bronchial hygiene measures:

A
  • Suctioning: oropharyngeal, nasopharyngeal
  • Steam inhalation
  • Aerosol inhalation
  • Medimist inhalation
57
Q

Common Respiratory Interventions:

Chest Physiotherapy (CPT):

A
  • postural drainage
  • percussion
  • vibration
58
Q

Common Respiratory Interventions:

Incentive Spirometry:

A
  • Enhance deep inhalation
59
Q

Common Respiratory Interventions:

Closed Chest Drainage (Thoracostomy tube)
Purposes:

A
  • To remove air and/or fluids from the pleural space
  • To reestablish negative pressure and reexpand the lungs
    Types:
    a. Two botle system
    b. Two bottle system
    c. Three bottle system
60
Q

RESPIRATORY DISORDERS:

Infection of the mucous membrane

A

Sinusitis

61
Q

RESPIRATORY DISORDERS: Sinusitis

Causes:

A
  • URTI (Upper respiratory tract infection) / cold
  • Cigarette smoking
  • Allergic rhinitis
62
Q

RESPIRATORY DISORDERS: Sinusitis

Assessment:

A
  • Pain
    -Maxillary: cheek, upper teeth
    - Frontal: above eyebrows
    - Ethmoid: in & around the eyes
    - Sphenoid: behind the eye, occiput, top of the head
  • General malaise
  • Stuffy nose
  • Headache
  • Post-nasal drip
  • fever
63
Q

RESPIRATORY DISORDERS: Sinusitis

Surgical Management:

A
  • Functional Endoscopic Sinus Surgery (FESS)
  • Caldwell-Luc Surgery (Radical Antrum Surgery)
    a. Do not chew on affected side
    b. Caution with oral hygiene to prevent trauma of incision
    c. Do not wear dentures for 10 days
    d. Do not blow nose for 2 weeks after removal of packing
    e. Avoid sneezing for 2 weeks after surgery
  • Ethmoidectomy - surgical procedure in which tissue from the ethmoid sinus cavity is removed. The procedure is usually used to treat chronic sinusitis.
  • Sphenoidotomy/ethmoidotomy-
    Osteoplastic flap surgery for frontal sinusitis
64
Q

RESPIRATORY DISORDERS:

A group of disorders characterized by inflammation & imitation of the mucous membranes of the nose.

Can coexist with other respiratory disorders, such as asthma.

Maybe acute or chronic, nonallergic or allergic.

A

Rhinitis

65
Q

RESPIRATORY DISORDERS: Rhinitis

Seasonal rhinitis occurs during (1)_________ and perennial rhinitis occurs (2)___________.

A
  1. Pollen season
  2. Throughout the year
66
Q

RESPIRATORY DISORDERS: Rhinitis

Causes:

A
  • Changes in temperature or humidity
  • Odors
  • Infection
  • Age
  • Systemic disease
  • Use of OTC drugs & prescribed nasal decongestants
  • Presence of a foreign body
  • Allergic rhinitis
  • Exposure to allergens: food, medications, particles in the outdoor & indoor environment
67
Q

RESPIRATORY DISORDERS: Rhinitis

Clinical Manifestations:

A
  • Rhinorrhea (excessive nasal drainage, runny nose)
  • Nasal congestion, nasal discharge (purulent w/ bacterial rhinitis)
  • Sneezing
  • Pruritus of the nose, roof of the mouth, throat, eyes & ears
  • Headache
68
Q

RESPIRATORY DISORDERS: Rhinitis

Medical Management:

A
  • Antihistamines & corticosteroid nasal sprays
  • Oral decongestant agents - nasal obstruction
69
Q

RESPIRATORY DISORDERS: Rhinitis

Nursing Management:

A
  • Instruct patient w/ allergic rhinitis to avoid or reduce exposure to allergens & irritants
  • Patient education is essential when assisting the patient in the use of all medications
    Instruct patient about the importance of controlling the environment at home and at work
    • For infectious rhinitis, emphasized hand hygiene technique w/ the patient as a measure to prevent transmission of organisms.
    • In elderly and other high risk populations, the nurse reviews the value of receiving an
    influenza vaccination each year to achieve immunity.
70
Q

RESPIRATORY DISORDERS:

Sudden and life threatening deterioration of the gas exchange function of the lungs and indicates failure of the lungs to provide adequate oxygenation or ventilation for the blood.

Defined as a decrease in arterial oxygen tension (Pa02) to less than 50 mmEg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than So mmHg (hypercapnia), w/ an arterial pH of less than 7.35.

A

Acute Respiratory Failure (ARD)

71
Q

RESPIRATORY DISORDERS: Acute Respiratory Failure

Causes:

Ventilator failure mechanisms leading to ARD include:

A
  • Impaired function of the Central Nervous System
  • Neuromuscular dysfunction ( myasthenia gravis, Guillain - Barre syndrome, amyotropic lateral sclerosis, spinal cord trauma)
  • Musculosleletal dysfunction
  • Pulmonary dysfucnction
72
Q

RESPIRATORY DISORDERS: Acute Respiratory Failure

Causes:

Oxygenation failure mechanisms leading to ARD include:

A
  • Pneumonia
    -ARDs
    -Heart failure
  • pulmonary embolism
  • restrictive lung disease
  • COPD
73
Q

RESPIRATORY DISORDERS: Acute Respiratory Failure

Early signs:

A

Restlessness,
fatigue,
headache,
dyspnea,
air hunger,
tachycardia and HPN

74
Q

RESPIRATORY DISORDERS: Acute Respiratory Failure

As hypoxemia progresses, more obvious signs present:

A

Confusion,
lethargy,
tachycardia,
tachypnea,
central cyanosis,
diaphoresis &
finally respiratory arrest

Use of accessory muscles, decreased breath sounds

75
Q

RESPIRATORY DISORDERS: Acute Respiratory Failure

Medical Management:

A
  • assist with intubation and maintaining mechanical ventilation
  • assess the patient’s respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry & VS
  • assess the entire respiratory system and implements strategies to prevent complications.
  • assess the patient’s understanding of the management strategies that are used and initiatives some form of communication to enable the patient to express concerns and needs to the health care team.
76
Q

RESPIRATORY DISORDERS:

A severe form of acute lung injury.

A

Acute Respiratory Distress Syndrome

77
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

Etiologic factors/causes:

A
  • Aspiration (gastric secretions, drowning)
  • Drug ingestion & overdose
  • Polonged inhalaion of high consentration boxygen, smoke, or corrosives
    substances
  • Localized infection (bacterial, fungal, viral pneumonia)
  • Metabolic disorders (pancreatitis, uremia)
  • Shock (any cause)
  • Trauma (pulmonary contusion, multiple fractures, head injury)
  • Major surgery
  • Fat or air embolism
  • Systemic sepsis
  • 02 toxicity
78
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

Clinical Manifestations:

A
  • Increase RR
  • fine crackles
  • dyspnea
  • retractions
  • central cyanosis
  • dry cough
    -fever
  • alteration in LOC
  • ABG’s : decrease Pa02
    increase PaCO2
79
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

Helpful in distinguishing ARDS from hemodynamic pulmonary edema.

A

Plasma brain natriuretic peptide (BNP)

80
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

May be used if the BNP is not conclusive

A

Transthoracic Echocardiography

81
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

The definitive method to distinguish between hemodynamic ( heart failure) and permeability edema

A

Pulmonary artery catheterization

82
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

Medical Management:

A
  • Intubation & mechanical ventilation
  • Circulatory support, adequate fluid volume and nutritional support
  • Supplemental oxygen
    Monitor ABGs, pulse oximetry & bedside pulmonary function testing.
  • PEEP (Posive End Expiratory pressure)
  • Inotropic or vasopressor agents may be required
  • Pulmonary artery pressure catheters
  • Adequate nutritional support
83
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

Medical management:

Critical part in the testiment of ARDS.

A

PEEP ( Positive End Expiratory pressure)

84
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

Medical Management:

Used to monitor the patient’s fluid status & the severe &progressive pulmonary HPN sometimes observed in ARDS.

A

Pulmonary artery pressure catheters

85
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

Medical Management:

Adequate nutrional support

A
  • Patients w/ ARDS require 35-45 kcal/kg/day to meet caloric requirements
  • Enteral feeding
  • Parenteral nutrition
86
Q

RESPIRATORY DISORDERS: Acute Respiratory Distress Syndrome

Nursing Management:

A
  • Close monitoring in the ICU by the nurse
  • 02 thearpy (increase flow 8-10 L/m)
  • Position: semi to high Fowler’s
  • Increase fluid intake (balance with diuretics due to pulmonary edema)
  • Meticulous eye care
  • Frequent assessment of the patient’s status is necessary to evaluate the effectiveness of treatment.
  • Turn patient frequently to improve ventilation & perfusion in the lungs & enhance secretion drainage
  • Reduce patient’s anxiety
  • Provide rest
  • anticipate the patients needs regarding comfort and pain
  • check the patients position to ensure comfortability
87
Q

RESPIRATORY DISORDERS:

Inflammation of the bronchi usually caused by a viral infection.

A

Acute Bronchitis

88
Q

RESPIRATORY DISORDERS: Acute Bronchitis

Causes:

A
  • bacterial & viral infection
  • chemical irritants
  • cigarette smoking
89
Q

RESPIRATORY DISORDERS: Acute Bronchitis

Clinical manifestations:

A
  • wheezing
  • coughing with green or yellow color sputum
  • shortness of breath
  • fever w/ chills (infection)
  • body malaise
  • muscle aches
  • sore throat
  • nasal congestion
90
Q

RESPIRATORY DISORDERS: Acute Bronchitis

Diagnostic findings:

A
  • Chest x-ray
  • Pulmonary function tests
  • ABGs analysis
91
Q

RESPIRATORY DISORDERS: Acute Bronchitis

Treatments:

The goal of treatment for bronchitis is to relieve symptoms and ease breathing

A
  • Paracetamol, ibuprofen for fever, body aches and headaches
  • Increase fluids
  • Rest
  • Breathing in warm moist air
92
Q

RESPIRATORY DISORDERS:

Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi & viruses.

A

Pneumonia

93
Q

RESPIRATORY DISORDERS: pneumonia

Risk Factors:

A
  • Conditions that produce mucus or bronchial obstruction & interfere w/ normal lung drainage ( cancer, cigarette smoking, COPD)
  • Immunosuppressed patients
  • Smoking
  • Prolonged immobility & shallow breathing pattern
  • Depressed cough reflex (due to medications, debilitated state or weak respiratory muscles), aspiration of foreign material into the lung during a period of unconsciousness or abnormal swallowing mechanism
  • NPO status, placement of nasogastric, orogastric or endotracheal tube
  • Supine positioning in patients unable to protect their airway
  • Antibiotic therapy (in very ill people)
  • Alcohol intoxication
  • General anesthetic, sedative, or opiod preparations (promote respiratory depression)
  • Advanced age
  • Respiratory therapy w/ improperly cleaned equipment
  • Transmission of organisms from health care providers
94
Q

RESPIRATORY DISORDERS: pneumonia

Classifacations:

A
  • A. Community Acquired Pneumonia (CAP)
  • B. Hospital Acquired Pneumonia (HAP)/Nosocomial Pneumonia
  • C. Pneumonia in Immunocompromised host
  • D. Aspiration pneumonia
95
Q

RESPIRATORY DISORDERS: pneumonia

Classification:

Occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization.

A

Community Acquired Pneumonia (CAP)

96
Q

RESPIRATORY DISORDERS: pneumonia

Classification: Community Acquired Pneumonia (CAP)

*Causative agents for CAP that requires hospitalization:

A
  • S. pneumonia
  • H. influenza
97
Q

RESPIRATORY DISORDERS: pneumonia
Classification: Community Acquired Pneumonia (CAP)
Causative agents for CAP that requires hospitalization:

*Most common cause of CAP in people younger than 60 years of age; gram positive organism that resides naturally in the upper respiratory tract

A

S. pneumonia

98
Q

RESPIRATORY DISORDERS: pneumonia
Classification: Community Acquired Pneumonia (CAP)
Causative agents for CAP that requires hospitalization:

  • cause a type of CAP that frequently affects elderly people & those w/ comorbid illnesses (COPD, alcoholism, DM)
A

H. influenza

99
Q

RESPIRATORY DISORDERS: pneumonia
Classification:

  • The onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission
A

Hospital Acquired Pneumonia (HAP)/Nosocomial Pneumonia

100
Q

RESPIRATORY DISORDERS: pneumonia
Classification: Hospital Acquired Pneumonia (HAP)/Nosocomial Pneumonia

*Common organism/ causative agents

A
  • enterobacter species,
  • escherechia coli,
  • H. influenza,
  • Klebsiella species,
  • proteus,
  • Serratia marcescens,
  • P aeruginosa,
  • S. aureus,
  • S. pneumonia
101
Q

RESPIRATORY DISORDERS: pneumonia
Classification: Hospital Acquired Pneumonia (HAP)/Nosocomial Pneumonia

Predisposing Factors:

A
  • Sever acute or chronic illness
  • Supine positioning & aspiration
  • Coma
  • Malnutrition
  • Prolonged hospitalization
  • Hypotension
  • Metabolic disorders
102
Q

RESPIRATORY DISORDERS: pneumonia

Classification:

  • Occurs with the use of corticosteroids or other immunosuppressive agents, chemotherapy, nutritional depletion, use of broad spectrumantimicrobial agents, AIDS, genetic immune disorders & long term advanced life-support technology (mechanical ventilation)
A

Pneumonia in Immunocompromised host

103
Q

RESPIRATORY DISORDERS: pneumonia
Classification: Pneumonia in Immunocompromised host

*causative agents:

A
  • pneumocytis pneumonia
  • fungal pneumonias
  • mycobacterium tuberculosis
104
Q

RESPIRATORY DISORDERS: pneumonia
Classification:

Refers to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway.

A

Aspiration pneumonia

105
Q

RESPIRATORY DISORDERS: pneumonia
Classification: Aspiration pneumonia

  • Most common form of aspiration pneumonia is _____________ from aspiration of bacteria that normally reside in the upper airway
A

Bacterial infection

106
Q

RESPIRATORY DISORDERS: pneumonia
Classification: Aspiration pneumonia

*assessment and diagnostic findings

A
  • Physical exam
  • Chest x-ray
  • Blood culture
  • Sputum exam
  • Bronchoscopy
107
Q

RESPIRATORY DISORDERS: pneumonia

  • Medical Management
A
  • Pharmacologic therapy
  • Warm moist inhalations
  • Red rest
    Oxygen therapy — hypoxemia
    Monitor ABGs, pulse oximetry, sputum, chest x-ray, temperature
    Incentive spirometry
108
Q

RESPIRATORY DISORDERS: pneumonia
Medical Management:

  • Pharmacologic therapy
A
  • Antibiotics: azithromycin, clarithromycin or erythromycin
  • Flouroquinolone ( moxifloxacin, gemifloxacin or levofloxacin) -
    outpatients w/ CAP who have cardiopulmonary disease
  • Antihistamines - for sneezing & rhinorrhea
109
Q

RESPIRATORY DISORDERS: pneumonia

  • Nursing Diagnoses:
A
  • Ineffective airway clearance R/T copious tracheobronchial secretions
  • Activity intolerance R/T impaired respiratory function
  • Risk for fluid volume deficit R/T fever and rapid RR
  • Imbalanced nutrition: less than body requirements
  • Knowledge deficit about the treatment regimen & preventive health measures
110
Q

RESPIRATORY DISORDERS: pneumonia

  • Nursing Management
A
  • Improving airway patency
    -Promoting Rest and Conserving Energy
  • Promoting fluid intake
  • maintaing nutrition
  • promoting patient’s knowledge
  • monitoring and managing potential complications
  • promoting home care and community based

MedSurge- Respiratory (1 decks)

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