Chapter 15

1. Chapter 15 Care of Patients with Disorders of the Lower Respiratory System

2. Theory Objectives • Compare and contrast commonalities and differences in nursing care for patients with bronchitis, influenza, pneumonia, empyema, and pleurisy.

3. Theory Objectives (cont.) • List at least three nursing interventions appropriate for care of patients experiencing the following: persistent cough, increased secretions in the respiratory tract, dyspnea, alteration in nutrition and hydration related to respiratory disorder, and fatigue related to hypoxia. • Describe ways a nurse can contribute to prevention and prompt treatment of tuberculosis.

4. Theory Objectives (cont.) • Illustrate the pathophysiologic changes that occur during an asthma attack. • Identify problems that occur with aging that may cause a restrictive pulmonary disorder. • Describe the specifics of nursing care for the patient who has had thoracic surgery and has chest tubes in place.

5. Clinical Practice Objectives • Complete a nursing care plan, including home care, for the patient with chronic obstructive pulmonary disease. • Review nursing interventions for the tracheostomy patient on oxygen therapy. • Teach a patient how to use a peak flowmeter.

6. Clinical Practice Objectives (cont.) • Observe a respiratory therapist (RT) who is responsible for a patient on a mechanical ventilator and identify how RT and nurses work together to deliver safe care.

7. Emerging Infectious Diseases with “Flu-Like” Symptoms • Avian flu • H1N1 • West Nile virus • Severe acute respiratory syndrome (SARS)

8. Health Promotion: Immunization • The Advisory Committee on Immunization Practices (2009) recommends annual influenza vaccination for • People at high risk for influenza-related complications and severe disease, including children ages 6 to 59 months, pregnant women, people aged >50 years, and people of any age with certain chronic medical conditions • People who live with or care for persons at high risk, including household contacts who have frequent contact with people at high risk and who can transmit influenza to those individuals, and health care workers

9. Complementary and Alternative Therapy for the “Flu” • Elderberry juice has been used for centuries as a treatment to ease symptoms of the flu, colds, and sinus infections • Seems to prevent the virus from attaching to cells • Antioxidants in the purple elderberry fruit have an anti-inflammatory effect comparable to aspirin • May explain why the juice produces symptom improvement

10. Complementary and Alternative Therapyfor Pneumonia • Barberry root bark is used against bacteria, fungi, and viruses as well as other organisms and is an alternative treatment for pneumonia • It has antimicrobial action against both gram-positive and gram-negative bacteria • It should not be used during pregnancy as it can cause spontaneous abortion

11. Cultural Considerations: Pneumococcal Vaccine • Routine use of pneumococcal polysaccharide vaccine is not recommended for persons of Alaskan Native or American Indian heritage unless they have underlying medical conditions such as chronic lung, liver, or renal disease • Local public health authorities may consider recommending the vaccine for occurrences of increased risk

12. Nursing Management of Pneumonia • Promote oxygenation • Control elevated temperature • Maintain nutritional and fluid intake • Provide adequate rest • Monitor vital signs and respiratory status • Relieve pain and discomfort • Provide good oral hygiene • Prevent irritation of the lungs by smoke and other irritants • Avoid secondary bacterial infections

13. Pathophysiology of Pneumonia

14. Clinical Cues • The first signs of decreasing oxygenation may be restlessness or confusion • The patient may want to sit upright to allow for better chest excursion • Respiratory rate will increase and later there will be flaring of the nares, then retraction of respiratory muscles if the condition worsens • Cyanosis is a very late sign

15. Elder Care Points • The elderly are more at risk for influenza and pneumonia because of a less efficient immune system, decreased action of cilia, and decreased elasticity and muscle tone • Confusion often is the most obvious sign of atypical pneumonia in the elderly • It may take 6 to 12 weeks after a bout of pneumonia for the older person to be able to resume normal activities without undue fatigue

16. Elder Care Points (cont.) • The very elderly patient may never quite regain the former level of wellness after a serious episode of pneumonia • Teach the elderly to seek medical attention quickly if symptoms of pneumonia occur

17. Empyema • Empyema occurs when the fluid within the pleural cavity becomes infected and the exudate becomes thick and purulent • The organisms causing the infection may be staphylococci or streptococci

18. Fungal Infections • Fungal infections are caused by the inhalation of the fungus or spores or by overgrowth of organisms found normally in the body • The most common fungal lung infections are coccidioidomycosis and histoplasmosis

19. Tuberculosis • Tuberculosis is an infectious disease of the lung characterized by lesions within the lung tissue • The lesions may continue to degenerate and become necrotic, or they may heal by fibrosis and calcification • The causative organism is the true tubercle bacillus Mycobacterium tuberculosis

20. Extrapulmonary Tuberculosis • Areas most frequently affected are the bones, meninges, urinary system, and reproductive system • Tuberculosis of the spine, called Pott’s disease, is now quite rare in the United States • The deformity most commonly seen in Pott’s disease is kyphosis, or “hunchback”

21. Bronchiectasis • Chronic respiratory disorder in which one or more bronchi are permanently dilated • Thought to occur as a result of frequent respiratory infections in childhood

22. Cystic Fibrosis • A genetic disease in which there is excessive mucus production because of exocrine gland dysfunction • It occurs most often in Caucasians • The lungs, intestines, sinuses, reproductive tract, sweat glands, and pancreas are all affected • It is diagnosed by history, physical examination, and a positive sweat test

23. Occupational Lung Disorders • Coal dust; dust from hemp, flax, and cotton processing; and exposure to silica in the air all can cause work-related lung disorders • Asbestos exposure may cause a rare cancer of the chest lining, mesothelioma

24. Sarcoidosis • A lung disease characterized by granulomas • It causes fibrotic changes in the lung tissue over time, and the cause is unknown • It affects other tissues in the body as well • A cellular immune response seems to be responsible for the tissue changes

25. Pulmonary Fibrosis • Occurs from severe infection, repeated infection, or inflammation that causes scarring of the lung tissue • The scarring decreases functional lung tissue

26. Tuberculosis • Diagnosis • Tuberculin skin testing • X-Rays and sputum cultures

27. Latent TB Infection (LTBI) • Latent TB infection (LTBI) is the current terminology for an infection with Mycobacterium tuberculosis but no current active disease • LTBI may develop into active TB if the immune system is weakened by a serious illness such as HIV, or when the system is less efficient, as with advanced age

28. Cultural Considerations • American Indian, Alaska Natives, Asian/Pacific Islanders, black non-Hispanics, and Hispanics have a high incidence of tuberculosis • The disease is most prevalent in people over 65 years of age in these groups • For the first few years of residence in the United States, new immigrants from areas where tuberculosis is prevalent have incidence rates similar to those of their former country

29. Directly Observed Therapy • Because of an increase in the incidence of multidrug-resistant TB, directly observed therapy (DOT) is recommended for patients who are known to be at risk of noncompliance with therapy • Visual observation of the ingestion of each required dose of medication for the entire course of treatment • Often a public health nurse administers the medication at a clinic site • Follow-up visits are necessary for 12 months after completion of therapy to monitor for the presence of resistant strains

30. Complementary and Alternative Therapy for Tuberculosis • Vitamin D has been found to be successful in the prevention and treatment of tuberculosis • White blood cells convert vitamin D into an active form that helps make a protein that kills tuberculosis bacteria • Perhaps this is why moving to a sunny climate and a solarium environment helped people with TB years ago

31. Nursing Management of Tuberculosis • Nursing diagnoses • Ineffective breathing pattern related to decreased lung capacity • Noncompliance related to lack of knowledge of disease process and long-term requirements for treatment • Activity intolerance related to fatigue, febrile status, and poor nutritional status • Imbalanced nutrition: less than body requirements related to anorexia, fatigue, and productive cough

32. Nursing Management of Tuberculosis (cont.) • Control infection • Promote immunity • Support

33. Restrictive Pulmonary Disorders • Caused by decreased elasticity or compliance of the lungs, or decreased ability of the chest wall to expand • Disorders of the central nervous system or of the neuromuscular system can cause a restrictive lung disorder

34. Restrictive Pulmonary Disorders (cont.) • Myasthenia gravis and arthritis are examples of extrapulmonary causes of a restrictive disorder • Kyphosis of the spine or severe scoliosis may also hamper lung expansion, though in these muscular/skeletal disorders, the lung tissue remains normal

35. Pleurisy • An inflammation of the pleura • Tuberculosis, pneumonia, neoplasm, and pulmonary infarction all can cause pleurisy • Pleurisy pain is sharp and abrupt in onset and is most evident on inspiration • Pain causes shallow breathing • Pleural friction rub may sometimes be heard

36. Pleural Effusion • A collection of fluid in the pleural space • Transudative • Occurs in noninflammatory conditions • Often a result of congestive heart failure, chronic liver failure, or renal disease • Transudate is a thin fluid containing no protein that passes from cells into interstitial spaces or through a membrane

37. Pleural Effusion (cont.) • Exudative • Thicker, contains cells and other substances, and is slowly discharged from cells into a body space or to the outside of the body • Exudative pleural effusion occurs in an area of inflammation due to the increased capillary permeability characteristic of the inflammatory reaction • Occurs with lung cancer, pulmonary embolism, pancreatic disease, and pulmonary infections

38. Obstructive Pulmonary Disorders • Characterized by problems with moving air into and out of the lungs • Narrowing of the openings in the tracheobronchial tree increases resistance to the flow of air, making it difficult for oxygen to enter, and contributes to air trapping, as exhalation also is difficult • Chronic bronchitis • Asthma • Emphysema • Atelectasis

39. Chronic Obstructive Pulmonary Disease • Etiology and diagnosis • Emphysema • Chronic bronchitis • Treatment • Bronchodilators and anti-inflammatory agents • Smoking cessation • Respiratory rehabilitation programs • Nutrition • Complementary and alternative therapies

40. Complementary and Alternative Therapy for Emphysema • Ginger and cinnamon are aromatic digestives that provide benefit for emphysema patients • Very small doses of Capsicum annum (chili) or garlic can be useful as mucolytic agents

41. Complications of COPD • Cor pulmonale • Acute respiratory failure • Peptic ulcer and gastroesophageal reflux disease • Spontaneous pneumothorax

42. Asthma • Nursing management • Smoking cessation • Psychosocial care • Patient and family teaching

43. Goals of Medical Treatment • Minimize irritation of the air passages and relieve obstruction by secretions, edema, or bronchospasm • Prevent or control infection and allergy • Increase the patient’s tolerance for activity • Determine the best drug combination in the least amount that will control symptoms

44. Peak Flowmeter • The peak flowmeter helps determine the drug dosage needed to control the asthma, predict the effectiveness of therapy, and detect airflow obstruction build-up before it becomes serious and requires hospitalization

45. Patient Teaching • Know your “green zone”—when airflow is normal; your “yellow zone”—when usual airflow has decreased and routine medications should be increased; and your “red zone”—when you need to use rescue medications and call your health care provider

46. The Step System of Asthma Treatment • I. Mild Intermittent • II. Mild Persistent • III. Moderate Persistent • IVa. Severe Persistent • IVb. Severe Persistent, Not Responsive to the Previous Step

47. Audience Response Question 1 On initial admission assessment of a patient with acute exacerbation of COPD, the nurse is likely to expect which sign(s) and symptom(s)? (Select all that apply.) • Tensing of the shoulder muscles • Inability to tolerate sitting up • Flaring of the nostrils • Completes sentences with no effort • Sternal retraction

48. Respiratory Distress • Apply high-flow oxygen and monitor the saturation level with a pulse oximeter • Observe and monitor continuously • Immediately alert the RN and the physician • If there is a history of COPD, the oxygen rate should be changed, as ordered, to a lower flow of 1-3 liters per nasal cannula after the respiratory crisis has been resolved

49. Lung Cancer • Etiology and pathophysiology • Signs and symptoms • Diagnosis • Treatment • Surgery • Chemotherapy • Radiation therapy

50. Pulmonary Vascular Disorders • Pulmonary embolism • Primary pulmonary hypertension • Lung transplantation