Respiratory System Part Four

RESPIRATORY SYSTEM PART FOUR 4- Infectious Lung Disorders

Infectious Lung Disorders Pneumonia 

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Definition - acute infection of lung parenchyma - specifically in alveolar sacs Etiology  cause: bacteria, virus, protozoan, mycobacterium, mycoplasma, or rickettsia  may affect only a region of lung: lobar pneumonia, bronchopneumonia  may be primary infection or secondary to other lung damage or caused by aspiration  pneumonia is the leading cause of death from infectious causes

Pneumonia

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Findings  spike in temperature - 101 degrees Fahrenheit or higher  productive sputum - green or yellow  varying degrees of respiratory distress Diagnostics  chest radiograph  sputum culture, sensitivity and microscopic analysis, Gram stain  ABG if indicated by clinical condition  serum elevations of WBC Management  antimicrobials, depending on pathogen  antipyretic; expectorant  IV fluids to prevent dehydration  supplemental oxygen, as indicated

Pneumonia

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Nursing interventions  monitor respiratory and oxygenation status  administer prescribed medications and supplemental oxygen  monitor hemoglobin saturation levels and notify provider if it falls below 90 to 92%  provide positioning that optimizes oxygenation and comfort  encourage fluid intake to liquefy secretions  space activities to avoid fatigue and hypoxia  reinforce teaching of effective coughing  suction when necessary

Pulmonary tuberculosis (PTB) 

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Definition: a chronic infection caused by an acid-fast bacillus, generally transmitted by inhalation or ingestion of infected droplets Etiology  mycobacterium tuberculosis  bacilli lodge in alveoli  pulmonary infiltrates  can spread throughout body via blood  after initial treamtent, may lie dormant for year and later reactivate  multi-drug resistant PTB is becoming more prevalent  TB incidence is rising with increasing homelessness, AIDS, elderly with poor nutrition  considered a communicable disease

Pulmonary tuberculosis (PTB) 

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Findings  early  weakness, fatigue  anorexia, weight loss  chest pain - pleurisy  late  productive cough for purulent sputum  night sweats Diagnostics  sputum and gastric contents analyzed for the presence of acidfast bacilli - definitive way to diagnosis  chest x-ray to determine presence of active or calcified lesions  tuberculin testing - screening test for exposure  Tine, Mantoux tests  Determine antibody response to the tubercle bacillus  indicate prior exposure to bacillus, not necessarily active disease

Pulmonary tuberculosis (PTB) 

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Management  long-term combination antimicrobial therapy with isoniazid (INH) (Hyzyd) or rifampin (Rifadin), with ethambutol HCL (Etibi) in some cases  bed rest until findings subside  surgical resection of involved lung if medication not effective  high carbohydrate, high protein diet - for energy and healing Nursing interventions  with active infection, client must be isolated with airborne precautions when in the hospital  put in a negative airflow  use of special mask when giving care  follow standard precaution guidelines

Pulmonary tuberculosis (PTB)

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reinforce client teaching regarding:  proper techniques to prevent spread of infection: hand washing, etc.  reporting findings of hemorrhage - bloody sputum  not using OTC medications without care provider's approval  importance of taking medications as prescribed assist to report TB cases to proper agencies for follow-up of contacts who might need treatment

Acute / Chronic Lung Disorders Pulmonary embolism  

Definition: blockage of pulmonary by foreign matter with the result of possible infarction in lung Etiology  matter blocks blood from the "bed" of arteries that feed the lung  client is breathing but gases are not exchanged  hypoxemia occurs  can be mild or immediately fatal, based on the size and location of matter  types of embolus  blood clot - has usually traveled from deep veins in the leg or pelvis  fat - from fractured femur, hip  amniotic fluid - post-delivery  primary cause is prolonged immobility  poor hydration and conditions that impair circulation (atrial fibrillation, heart failure) contribute to clot development  with fat embolism occurrences will not occur until at least 24 hours after the initial fracture

Acute / Chronic Lung Disorders 

Findings  "abrupt" onset of dyspnea - classic finding  anxiety, apprehension - feeling of "doom" is expressed by client  cough - productive or nonproductive  tachycardia, tachypnea  cyanosis

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Diagnostics  history of event  ventilation/perfusion (V/P) scan  ABG

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Management  oxygen  anticoagulation therapy (heparin)  thrombolytic therapy  filter surgically placed in vena cava

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Nursing interventions  recognize clients at risk and observe for manifestations  administer oxygen and medications as ordered  reinforce client teaching regarding anticoagulation usage

Acute respiratory distress syndrome (ARDS) 

Definition: associated with pulmonary injury and characterized by noncardiogenic pulmonary hyperexmia, and severe respiratory distress

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Etiology  alveolar capillary membrane becomes more permeable to fluids  increased extravascular lung fluid  pulmonary compliance decreases  intrapulmonary shunt increases  refractory hypoxemia  usually seen after lung injury or massive multi-system organ disease

Acute respiratory distress syndrome (ARDS) 

Findings  restlessness, anxiety  dyspnea  tachycardia  cyanosis

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Diagnostics  clinical presentation  hypoxemia on ABG despite increasing inspired oxygen level  chest radiograph shows diffuse infiltrates

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Management  optimize oxygenation  mechanical ventilation  sedation may be required  corticosteroids

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Nursing interventions  plan for frequent client rest periods  monitor oxygenation status, ABGs, LOC, central of anxiety  observe for changes in vital signs and behavior; confusion and hypertension may indicate cerebral hypoxia

Lung cancer   

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Definition - types of lung cancer SQUAMOUS CELL CARCINOMA Risk factors  Is almost always associated with cigarette smoking  Exposure to environmental carcinogens e.g. uranium, asbestos Characteristics  Accounts for 30-35% of lung cancer cases  Is more common among men  Findings occur earlier because of bronchial obstructive characteristics (arises from bronchial epithelium)  Causes cavitating pulmonary lesions  Usually metastasizes locally Therapy  Life expectancy is better than small cell carcinoma  Surgical resection is often attempted  small-cell (oat cell) carcinoma

SMALL CELL CARCINOMA 

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Risk Factors 

Cigarette smoking

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Environmental carcinogens

Characteristics 

Accounts for 15% to 25% of lung cancers

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Spreads early

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Very malignant form

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Is often associated with endocrine disturbances

Therapy 

Poorest prognosis

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Average survival is less than one year

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adenocarcinoma

ADENOCARCINOMA 

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Risk Factors 

Lung scarring

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Chronic interstitial fibrosis

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NOT related to cigarette smoking

Characteristics 

More common among women

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Accounts for about half of all lung cancers

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Usually located in peripheral section of lungs

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Often no clinical findings until well advanced

Treatment 

Does not respond well to chemotherapy

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Most often, surgical resection is attempted

LARGE CELL CARCINOMA 

Risk Factors  Cigarette smoking  Environmental carcinogens

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Characteristics  Occurs in 15-25% of all lung cancers  Frequently metastases via blood  Usually peripheral rather than central

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Therapy  Usually client not a candidate for surgery due to high frequency of metastasis  Tumors often responds to radiation therapy but frequently recurs

Lung cancer 

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Etiology  prognosis is generally poor, since there are no early findings  most common cancer in U.S. men  largely preventable if smokers stop and nonsmokers do not start Findings - occur late in the disease process  hoarse voice  changes in breathing  persistent cough or change in cough  blood-streaked or bloody sputum  chest pain or tightness in chest wall  recurring pneumonia, pleural effusion  weight loss Diagnostics  medical imaging examinations  cytological sputum analysis  bronchoscopy  biopsy

Lung cancer 

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Management  nonsurgical  chemotherapy  radiation therapy  laser therapy to de-bulk tumor  thoracentesis for effusions and empyema surgical  thoracotomy with  wedge resection  segmental resection  lobectomy  pneumonectomy Nursing interventions  post-operative care  maintain chest drainage system

Lung cancer 

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provide routine post operative care  monitor respiratory status frequently, including breath sounds  review effective cough techniques  reinforce physical therapy exercises to shoulder on affected side  maintain pain control to lower part of pain scale optimize oxygenation by positions of comfort, scheduled care with rest periods provide opportunities for client to talk about cancer; if indicated, refer to support group reinforce client teaching, based on treatment plan and prognosis optimize nutritional status for healing and energy for breathing

Cor Pulmonale

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Definition  right ventricular hypertrophy and subsequent heart failure  cause: heart must pump against great resistance from lung's blood vessels: pulmonary vascular resistance (PVR)

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Etiology  increased PVR results from lung disease, particularly chronic hypoxemia  hypoxemia constricts pulmonary vascular bed, so increases resistance the right ventricle must pump against  often seen with primary pulmonary hypertension

Cor Pulmonale  

Diagnostics cath echocardiogram  chest radiograph  ABG  EKG  Management  treat hypoxemia if possible  if hemoglobin WNL (within normal limits),  monitor oxygenation with finger pulse oximeter  bed rest with commode at bedside  cardiac glycosides (digitalis)  pulmonary artery vasodilator  possibly restricted fluid intake and diuretics  Nursing interventions  monitor oxygenation status  pace activities in clients who tire easily  provide supportive care  monitor skin integrity enter in pulmonary artery 

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Respiratory failure 

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Definition: lungs cannot maintain arterial oxygen levels or eliminate carbon dioxide  clients with chronic lung disease, look for drop from baseline function  this is an emergency  client is continuously hypoxemic Etiology  lung diseases that harden the alveolar-capillary membrane, trap O2 neuro-muscular or musculoskeletal disorders  respiratory drive dulled or blunted  muscles too weak to breathe Findings  PaCO2 > 50 mm Hg, PaO2 < 50 mm Hg 

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classic presentation: the three "H's" - hypoventilation, hypoxemia, hypercapnia

Respiratory failure

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Diagnostics: ABG, history Management  oxygen  mechanical ventilation  treat underlying cause for respiratory failure Nursing interventions  observe for signs of hypoxia and respond to prevent occurrence of respiratory failure  administer medications and oxygen as prescribed (bronchodilators, corticosteroids, antibiotics)  supportive care for emotions, skin integrity, and gastrointestinal / renal function