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50 Cards in this Set

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RESPIRATORY SYSTEM
ASSESSMENT: History
– smoking, second hand smoke

– environmental exposure, occupation

– family history of atopic conditions or inherited respiratory diseases (CF)

– medications

– atopic conditions

– respiratory disorders

– infant- term?, maternal history of infection

– exposure to TB or other respiratory infections

– living conditions

– travel

– pets

– effect of symptoms on normal activities

– Vaccination history
-- Flu (yearly)
-- Pneumococcal vaccine 1x (all clients with chronic illnesses of the resp system should have been vaccinated and those over 65)
Respiratory System: Subjective Data
– dyspnea, orthopnea
-- How many pillows do they sleep on or where do they sleep?

– Cough
-- Do they cough when they lay down at night?
--- Might be due to GERD
--- Might be due to sinus draining into throat

– sputum production
-- Check for color of sputum
-- Is there blood in sputum, and HOW MUCH

– hemoptysis

– wheezing

– chest pain

– nasal discharge, sneezing

– watery, itching eyes

- facial pain, headache, teeth pain
-- Teeth pain can actually be a respiratory issue

– change in voice, hoarseness
-- If change in voice or hoarsness lasts for more than two weeks, consult physician
Respiratory System: Objective Data
– respiratory rate
– pulse oximetry
– appearance
-- color of skin, nails
-- nails for clubbing
--- Only see clubbing in chronic respiratory problems, not acute
-- level of apprehension, respiratory effort,
use of accessory muscles, nasal flaring
-- audible wheezing, grunting
Respiratory Assessment: Head
- eyes, nose, mouth breathing, Denny’s lines (darkened eye sacs,
palate, facial tenderness, allergic shiners

- Allergic salute
Respiratory Assessment: Lungs and Chest
- shape and symmetry

- trachea midline

- auscultation

–- quality of air entry

–- crackles
--- Heard in periphery of lungs due to air moving through fluid
--- Heard in inspiration

–- Rhonchi
--- Caused by air passing through secretions in larger bronchioles
--- Can be heard in inspiration and expiration

-- Wheezing
--- Air passing through narrow airway

--Always listen to breath sounds directly on skin, never with shirt on
Rhinitis/ Sinusitis Etiologies
allergies, virus, bacteria (regular sinusitis is bacterial in origin, acute is viral in origin)
Sinusitis treatment
antihistamines, steroid NS, cromolyn NS (mast cell inhibitor)
antibiotics, avoidance of triggers, irrigation
of the sinuses, OR
Sinusitis Education
Avoid sinusitis triggers
Carcinoma of the Larynx Etiology
– increasing in incidence

–> in men than women
–> in people over 60

– associated with smoking, alcohol, chronic laryngitis, vocal abuse, family history
Signs and Symptoms of Carcinoma of the Larynx
– grows slowly due to limited lymphatic supply

– persistent hoarseness with or without ear pain and difficulty swallowing
--hoarse longer than 2 weeks, see a HCP
Diagnosis of Carcinoma of the Larynx
– endoscopy
– biopsy
– CT
Treatment of Larynx Carcinoma
- Surgical resection
–- hemilaryngectomy- 1/2 of larynx removed
–- subtotal laryngectomy- >1/2 removed
–- supraglottic laryngectomy
–- total laryngectomy

- Surgical resection without total removal of the larynx
–- Some voice remains but will be altered
–- Temporary trach, cuffed tube may be used to prevent aspiration
–- Swallowing is a problem, nutrition
–- Aspiration a major concern

- Surgical resection
–- total laryngectomy
--- used in advanced cases
--- larynx and surrounding tissues removed
--- permanent trach
--- permanent loss of voice
–-radical neck dissection
Pre-operative care for Larynx Carcinoma
–Prepare for voice changes, swallowing problems, trach and the care involved, diet changes

– how the patient will communicate

– Lost Cord Club
Post-operative Larynx Carcinoma
– position
-- semi-fowlers, neck flexed
-- up first post-op day

– airway
-- trach tube in 5-10 days for partial, until stoma heals for total
-- extra trach tube available
-- sterile suctioning, oxygen, humidification
-- cuffed tube if on mechanical ventilation then changed to uncuffed
-- watch for dyspnea due to edema, secretions
-- monitor for signs of aspiration

– wound care
-- drain to prevent fluid accumulation
---max 300cc in first 16 hours
-- monitor for air leak
-- monitor for infection

– nutrition
-- NG tube may be used for nutrition or patient may be on hyperalimentation until able to swallow
-- monitor for signs of aspiration
-- adequate fluids to keep secretions thin
-- protein necessary for wound healing

– body image
– communication
-- speech therapy, new techniques available for speech
General information about Obstructive Lung Disease
- Disease state characterized by airflow obstruction

- Increased by 60% over the last decade
Diseases that cause Obstructive Lung Disease
– * chronic bronchitis

– Bronchiectasis
-- Collapse of small areas in the lung

– asthma

– * emphysema
-- Has a problem getting air out of the lungs

– cystic fibrosis
Etiology of Obstructive Lung Disease
– 90% associated with smoking
-- 30x more likely to develop if you smoke

– exposure to inhaled irritants

–recurrent infections

– alpha1-antitrypsin deficiency
-- 3% of COPD, usually
undiagnosed
Obstructive Lung Disease: Chronic Bronchitis
- blue bloater
-- usually are cyanotic

- thickening of the mucous membrane

- increased number of goblet cells

- tissue irritation

- excessive mucous production

- airflow obstruction
Obstructive Lung Disease: Emphysema
- "pink puffer" due to being chronically hypoxic)

- air trapping on expiration

- enlarged air spaces

- loss of elasticity of the airways

- destruction of alveolar septum
Prevention of Obstructive Lung Disease
– smoking cessation

– measures to protect workers with occupational exposure to irritants
-- Wear masks
-- Increase workplace ventilation

– treatment of respiratory infections
Signs and Symptoms of Obstructive Lung Disease
– usually middle age or older

– cyanosis, plethoric in appearance

– barrel shaped chest

– dyspnea and exercise intolerance

– wheezing, crackles, rhonchi

– decreased breath sounds

– prolonged expiration (very common characteristic)

– Orthopnea
-- Breathing difficulty when laying down

– se of accessory muscles for breathing

– cough with sputum esp in the am

– weight loss
-- Eating sometimes can wear them out

– high hematocrit

– cor pulmonale- right heart failure
-- JVD, edema, hepatomegaly
Diagnostic tests for Obstructive Lung Disease
– PFT

– chest x-ray

– ABG
Nursing Concerns for Obstructive Lung Disease
– gas exchange

– airway clearance

– nutrition, hydration

– infection

– activity intolerance

– sleep disturbance

– knowledge deficit
Definition of Pneumonia
- Acute inflammation of the lung tissue which affects gas exchange

- Leading cause of infectious disease in the US
Etiologies of Pneumonia
– bacteria

– virus

– aspiration

– stasis
Types of Pneumonia
– Community acquired pneumonia (CAP)
-- 70% with chronic disease
-- mortality 6-13%

– Hospital acquired pneumonia (HAP)
--mortality 30-70%
--- Hospital infections are more virulent
-- coexisting disease
-- gram negative bacteria with drug resistance
Prevention of Pneumonia
– influenza (flu) vaccination every Oct/Nov

– pneumococcal vaccination

– treatment of upper airway infections/bronchitis

– suctioning

– TCDB, ambulation, spirometer

– hand washing

– respiratory treatments
Signs and Symptoms of Pneumonia
– fever, chills

– altered mental status

– tachypnea, tachycardia

– chest pain

– cough, sputum production

– crackles, decreased breath sounds
Diagnosis of Pneumonia
– chest x-ray

– sputum cultures

– ABG

– WBC
Treatment of Pneumonia
– may or may not be hospitalized

– antibiotics, bronchodilators

– oxygen, respiratory support

– TCDB, activity as tolerated

– suctioning, spirometer, resp treatments

– diet high in protein, calories, fluids

– do not suppress a productive cough
-- Only give cough suppresants during night to allow better sleep

– should improve in 48-72 hrs
-- Clinical presentation will get better before chest x-rays will get better
Tuberculosis: General Information
- Number one cause of infectious disease deaths in the world

- On the increase
–- immigrants from third world countries
–- HIV
–- MDR-TB
Etiology of Tuberculosis
mycobacterium tuberculosis
Pathophysiology of Tuberculosis
– respiratory acquired infection

– body’s reaction depends on susceptibility, size of dose, virulence of the organism

– inflammation occurs within the alveoli and the body’s defense tries to counteract the infection

– T lymphocytes and macrophages wall off the organism producing a firm nodule called a primary tubercle which contains the tubercle bacilli

– material may become calcified or be coughed up leaving a cavity or hole both of which are visible on x-ray

– organism remains in the host for a lifetime and may become active if compromised
-- Only way to get rid of TB is drug therapy for 6-9mos

– usually pulmonary but can affect other parts of the body (extrapulmonary)

- Do not allow TB tests on people who have TB because it can cause major blisters
Risk factors for Tuberculosis
– HIV, immunosuppression
– homeless
– very young, very old
– living in crowded, unsanitary conditions
– poor nutrition
– ETOH, drug abuse
– From countries where disease is prevalent
Prevention for Tuberculosis
– BCG vaccination

– isolation of infected
persons

– adequate housing and ventilation

– screening high risk persons frequently

– treating persons with positive skin tests with INH for 6 months (HIV 1 year)
-- eradicates the organism
-- concern is for complications associated with drug therapy, risk of noncompliance
Signs and Symptoms of Tuberculosis
– cough, blood streaked sputum

– weight loss

– fever, night sweats

– positive skin test

--indicative of antibodies to the organism
Diagnosis for Tuberculosis
– tuberculin skin testing

– chest x-ray

– sputum smear for AFB

– sputum culture confirms the diagnosis

-- takes 3-6 weeks to get results
Treatment for Tuberculosis
– isolation until symptoms subside, 3 negative smears not infectious

– initial regimen is with 4 drugs

– number can be altered when susceptibility testing is completed

– DOT has increased success of treatment

– Combined drugs in a single tablet improves compliance

– patients can be held against their will for treatment if they do not comply

– lifestyle changes to improve health
Pathophysiology of Tuberculosis
– respiratory acquired infection

– body’s reaction depends on susceptibility, size of dose, virulence of the organism

– inflammation occurs within the alveoli and the body’s defense tries to counteract the infection

– T lymphocytes and macrophages wall off the organism producing a firm nodule called a primary tubercle which contains the tubercle bacilli

– material may become calcified or be coughed up leaving a cavity or hole both of which are visible on x-ray

– organism remains in the host for a lifetime and may become active if compromised
-- Only way to get rid of TB is drug therapy for 6-9mos

– usually pulmonary but can affect other parts of the body (extrapulmonary)

- Do not allow TB tests on people who have TB because it can cause major blisters
Risk factors for Tuberculosis
– HIV, immunosuppression
– homeless
– very young, very old
– living in crowded, unsanitary conditions
– poor nutrition
– ETOH, drug abuse
– From countries where disease is prevalent
Prevention for Tuberculosis
– BCG vaccination

– isolation of infected
persons

– adequate housing and ventilation

– screening high risk persons frequently

– treating persons with positive skin tests with INH for 6 months (HIV 1 year)
-- eradicates the organism
-- concern is for complications associated with drug therapy, risk of noncompliance
Signs and Symptoms of Tuberculosis
– cough, blood streaked sputum

– weight loss

– fever, night sweats

– positive skin test

--indicative of antibodies to the organism
Diagnosis for Tuberculosis
– tuberculin skin testing

– chest x-ray

– sputum smear for AFB

– sputum culture confirms the diagnosis

-- takes 3-6 weeks to get results
Treatment for Tuberculosis
– isolation until symptoms subside, 3 negative smears not infectious

– initial regimen is with 4 drugs

– number can be altered when susceptibility testing is completed

– DOT has increased success of treatment

– Combined drugs in a single tablet improves compliance

– patients can be held against their will for treatment if they do not comply

– lifestyle changes to improve health
Facts about Lung cancer
– Smoking triples your risk of dying from CAD
Lung Cancer PREVENTION
– Don’t start, stop smoking
-- Nicotine replacement, Zyban, hypnosis
-- Average person tries 7-10 times before successful
-- It is never too late to quit

– avoid second hand smoke

– precautions with occupational exposure

– periodic chest x-rays on those at risk have not been found to be helpful with early diagnosis

– CT under study-can detect a 2mm lesion versus a 10mm for xray (no effect on mortality)`
Lung Cancer PATHOLOGY
– most arise from the bronchi

– cell type determines aggressiveness and treatment
Lung Cancer SIGNS AND SYMPTOMS
– * persistent cough unresponsive to treatment

– * hemoptysis

– * dyspnea

– * wheezing

– pain

– fatigue

– weight loss
Lung Cancer DIAGNOSTIC TESTS
– chest x-ray

– sputum cytology

– bronchoscopy and biopsy

– CT and MRI used for diagnosis and staging
Lung Cancer TREATMENT
– patient evaluated with regard to surgical risk, age, pulmonary reserve, co-morbidity

– thoracic surgery
-- pneumonectomy (entire removal of a lung lobe)- no chest tube post-op

- lobectomy/segmental resection, wedge resection - chest tube post-op