Management of Patients With Chest and Lower Respiratory Tract Disorders

1. Management of Patients With Chest and Lower Respiratory Tract Disorders

2. Atelectasis • Collapse or airless condition of alveoli caused by hypoventilation, obstruction to airways, or compression • Causes: bronchial obstruction by secretions due to impaired cough mechanism or conditions that restrict normal lung expansion on inspiration • Postoperative patients at high risk • Symptoms: insidious, include cough, sputum production, low-grade fever • Respiratory distress, anxiety, symptoms of hypoxia occur if large areas of lung are affected

3. Nursing Management • Prevention • Frequent turning, early mobilization • Strategies to improve ventilation: deep breathing exercises at least every 2 hours, incentive spirometer • Strategies to remove secretions: coughing exercises, suctioning, aerosol therapy, chest physiotherapy

4. Nursing Management (cont’d) • Treatment • Strategies to improve ventilation, remove secretions • Treatments: may include PEEP (positive end-expiratory pressure), IPPB (intermittent positive-pressure breathing) • Bronchoscopy may be used to remove obstruction

5. Respiratory Infections • Acute tracheobronchitis • Pneumonia • Community-acquired pneumonia • Hospital-acquired pneumonia • Pneumonia in immunocompromised host • Aspiration pneumonia

7. Risk Factors • Cancer, smoking, COPD (produce mucus, or obstruct bronchus • Immunocompromised pt • Prolonged immobility and shallow breathing • Depressed cough reflex, aspiration of foreign material

8. Alcoholism GA, sedative Advance age Respiratory therapy with improperly cleaned equipment Transmission of organisms from staff of health care.

9. Clinical Manifestation • Sudden onset of chills, rapid raising fever (38.5 – 40.5o) • Pleuritic chest pain increase with deep breathing and coughing • Tachypnea ( 25 – 45b\m) • Rapid bounding pulse • In sever cases cheeks flushed and the lips with nail beds become cyanosed.

10. Orthopnea Decrease appetite, fatigue Purulent sputum Crackles, increased tactile fermitus, dullness on percussion, bronchial breathing sounds, egophony and whispered pectoriloquy.

11. Diagnostic Tests • Chest x-ray • Sputum examination

13. Medical Treatment of Pneumonia • Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, antihistamines • Administration of antibiotic therapy determined by gram-stain results • If etiologic agent is not identified, utilize empiric antibiotic therapy • Antibiotics not indicated for viral infections but are used for secondary bacterial infection

14. Nursing Process: Care of the Patient with Pneumonia - Assessment • Changes in temperature, pulse • Secretions • Cough • Tachypnea, shortness of breath • Changes in physical assessment, especially inspection, auscultation of chest • Changes in CXR • Changes in mental status, fatigue, dehydration, concomitant heart failure, especially in elderly patients

15. Nursing Process: Care of the Patient with Pneumonia - Diagnoses • Ineffective airway clearance • Activity intolerance • Risk for fluid volume deficient • Imbalanced nutrition • Deficient knowledge

16. Collaborative Problems • Continuing symptoms after initiation of therapy • Shock • Respiratory failure • Atelectasis • Pleural effusion • Confusion • Superinfection

17. Nursing Process: Care of the Patient with Pneumonia - Planning • Improved airway clearance • Maintenance of proper fluid volume • Maintenance of adequate nutrition • Patient understanding of treatment, prevention • Absence of complications

18. Improving Airway Clearance • Encourage hydration; 2 to 3 L a day, unless contraindicated • Humidification may be used to loosen secretions • By face mask or with oxygen • Coughing techniques • Chest physiotherapy • Position changes • Oxygen therapy administered to meet patient needs

19. Other Interventions • Promoting rest • Encourage rest, avoidance of overexertion • Positioning to promote rest, breathing (Semi-Fowler’s) • Promoting fluid intake • Encourage fluid intake to at least 2 L a day • Maintaining nutrition • Provide nutritionally enriched foods, fluids • Patient teaching

20. Aspiration • Risk factors • Pathophysiology • Prevention: • Elevate HOB • Turn patient to side when vomiting • Prevention of stimulation of gag reflex with suctioning or other procedures • Assessment, proper administration of tube feeding • Rehabilitation therapy for swallowing

21. Pleural Conditions • Pleurisy: inflammation of both layers of pleurae • Inflamed surfaces rub together with respirations, cause sharp pain intensified with inspiration • Pleural effusion: collection fluid in pleural space usually secondary to another disease process • Large effusions impair lung expansion, cause dyspnea

22. Pleural Conditions (cont’d) • Empyema: accumulation of thick, purulent fluid in pleural space. • Patient usually acutely ill; fluid, fibrin development, loculation impair lung expansion • Resolution is a prolonged process

23. Pleural Effusion

24. Causative Factors for Pulmonary Disease • Cigarette smoking • Air pollution

25. Acute Respiratory Distress Syndrome • Severe form of acute lung injury • Syndrome characterized by sudden, progressive pulmonary edema, increasing bilateral lung infiltrates on CXR, hypoxemia refractory to oxygen therapy, decreased lung compliance • Symptoms • Rapid onset of severe dyspnea • Hypoxemia that does not respond to supplemental oxygen

26. Pathophysiology of ARDS

27. Management of ARDS • Intubation, mechanical ventilation with PEEP to treat progressive hypoxemia • Positioning: frequent position changes, proning • Nutritional support • General supportive care

28. Pulmonary Emboli • Obstruction of pulmonary artery or branch by blood clot, air, fat, amniotic fluid, or septic thrombus • Most thrombus are blood clots from leg veins • Obstructed area has diminished or absent blood flow • Although area is ventilated, no gas exchange occurs • Inflammatory process causes regional blood vessels, bronchioles to constrict, further increasing pulmonary vascular resistance, pulmonary arterial pressure, right ventricular workload • Ventilation-perfusion imbalance, right ventricular failure, shock occur

29. Risk Factors for Pulmonary Emboli • Venous stasis • Hypercoagulabilty • Venous endothelial disease • Certain disease states: heart disease, trauma, postoperative/postpartum, diabetes mellitus, COPD • Other conditions: pregnancy, obesity, oral contraceptive use, constrictive clothing • Previous history of thrombophlebitis

30. Thromboembolism P. Vessel

31. Prevention and Treatment of Pulmonary Emboli • Prevention • Exercises to avoid venous stasis • Early ambulation • Anticoagulant therapy • Sequential compression devices (SCDs) • Treatment • Measures to improve respiratory, CV status • Anticoagulation, thrombolytic therapy

32. Umbrella Filter

33. Pneumoconioses • Occupational lung diseases • Cause of death of 124,846 people in United States (1968 to 2000) • Causative agents • Role of nurse as employee advocate • Role of nurse in health education, teaching preventive measures • Role of OSHA

34. Care of the Patient with Lung Cancer • Prevention, causes • Classification of lung cancer • Treatment • Surgery • Radiation • Chemotherapy • Palliative care

35. Nursing Care of the Patient with Cancer • Psychological support • Pain • Airway clearance • Fatigue • Dyspnea

36. Chest Trauma • Blunt trauma • Sternal, rib fractures • Flail chest • Pulmonary contusion • Penetrating trauma • Pneumothorax • Spontaneous or simple • Traumatic • Tension pneumothorax

37. Flail Chest

38. Open Pneumothorax and Tension Pneumothorax

39. Management of Patients With Chronic Pulmonary Disease

40. COPD: • Chronic Obstructive Pulmonary Disease • A disease state characterized by airflow limitation that is not full reversible (GOLD). • COPD is the currently is 4th leading cause of death and the 12th leading cause of disability. • COPD includes diseases that cause airflow obstruction (emphysema, chronic bronchitis) or a combination of these disorders. • Asthma is now considered a separate disorder but can coexist with COPD.

41. Pathophysiology of COPD • Airflow limitation is progressive and is associated with abnormal inflammatory response of the lungs to noxious agents. • Inflammatory response occurs throughout the airways, lung parenchyma, and pulmonary vasculature. • Scar tissue and narrowing occurs in airways. • Substances activated by chronic inflammation damage the parenchyma. • Inflammatory response causes changes in pulmonary vasculature.

42. COPD

43. Chronic Obstructive Pulmonary Disease • Risk Factors • Cigarette smoking • Air pollution • Occupational exposures • Airway infection • Familial and genetic factors

44. Chronic Bronchitis • The presence of a cough and sputum production for at least 3 months in each of 2 consecutive years. • Irritation of airways results in inflammation and hypersecretion of mucous. • Mucous-secreting glands and goblet cells increase in number. • Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucous may plug airways. • Alveoli become damaged, fibrosed, and alveolar macrophage function diminishes. • The patient is more susceptible to respiratory infections.

45. Pathophysiology of Chronic Bronchitis

46. Emphysema: • Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli. • Decreased alveolar surface area causes an increase in “dead space” and impaired oxygen diffusion. • Reduction of the pulmonary capillary bed increases pulmonary vascular resistance and pulmonary artery pressures. • Hypoxemia result of these pathologic changes. • Increased pulmonary artery pressure may cause right-sided heart failure (corpulmonale).

47. Changes in Alveolar Structure with Emphysema

49. Normal Chest Wall and Chest Wall Changes with Emphysema

50. Emphysema