Nursing Management of Lower Respiratory Problems

1. Nursing Management of Lower Respiratory Problems JSB

2. Acute Bronchitis • Inflammation of the bronchi • Supportive treatments • Fluids • Rest • Anti-inflammatory agents • Cough suppressants • Antiviral drugs • Mucolytic medications

3. Pertussis • Highly contagious infection • Whooping cough • Gram-negative bacillus • Symptoms same as bronchitis • Treatment is antibiotics

4. Pneumonia • Acute inflammation of lung caused by microbial organism • Previously, leading cause of death in the United States from infectious disease • Discovery of sulfa drugs and penicillin decreased morbidity and mortality rates. 4

5. Etiology Likely to result when defense mechanisms become incompetent or overwhelmed ↓ Cough and epiglottal reflexes may allow aspiration 5

6. Etiology • Mucociliary mechanism impaired • Pollution • Cigarette smoking • Upper respiratory infections • Tracheal intubation • Aging 6

7. Etiology • Three ways organisms reach lungs: • Aspiration from nasopharynx or oropharynx • Inhalation of microbes such as Mycoplasma pneumoniae • Hematogenous spread from primary infection elsewhere in body 7

8. Types of Pneumonia • Community-acquired pneumonia • Lower respiratory infection of lung • Onset in community or during first 2 days of hospitalization 8

9. Types of Pneumonia • Community-acquired pneumonia • Highest incidence in midwinter • Smoking important risk factor 9

10. Types of Pneumonia • Organisms implicated • Streptococcus pneumoniae • Haemophilus influenzae • Legionella • Mycoplasma • Chlamydia 10

11. Types of Pneumonia • Three-step approach to treatment • Assess ability to treat at home. • Calculate PORT (Pneumonia Patient Outcomes Research Team). • Make clinician decision for inpatient or outpatient. 11

12. Types of Pneumonia • HAP, VAP, HCAP • HAP: Occurring 48 hours or longer after admission and not incubating at time of hospitalization • VAP: Occurring more than 48 hours after endotracheal intubation 12

13. Types of Pneumonia • Risk factors for HAP • Immunosuppressive therapy • General debility • Endotracheal intubation 13

14. Types of Pneumonia • Treatment is based on • Known risk factors • Severity of illness • Early (5 days post admission) or late (more than 5 days post admission) onset • MDR organisms are major problem in treating HCAP. 14

15. Types of Pneumonia • Aspiration pneumonia • Sequelae occurring from abnormal entry of secretions into lower airway 15

16. Types of Pneumonia • Aspiration pneumonia • Usually with history of loss of consciousness • Gag and cough reflexes suppressed • Forms of aspiration pneumonia • Mechanical obstruction • Chemical injury • Bacterial infection 16

17. Types of Pneumonia • Opportunistic pneumonia • Patients at risk • Severe protein-calorie malnutrition • Immune deficiencies • Chemotherapy/radiation recipients • Long-term corticosteroid therapy 17

18. Types of Pneumonia • Causes of opportunistic pneumonia • Bacterial and viral causative agents • Pneumocystis jiroveci (PCP) • Cytomegalovirus • Fungi 18

19. Types of Pneumonia • Clinical manifestations of PCP • Fever • Tachypnea • Tachycardia • Dyspnea • Nonproductive cough • Hypoxemia 19

20. Pathophysiology • Stage 1: Congestion from outpouring of fluid to alveoli • Organisms multiply. • Infection spreads. • Interferes with lung function 20

21. Pathophysiology • Stage 2: Red hepatization • Massive dilation of capillaries • Alveoli fill with organisms, neutrophils, RBCs, and fibrin. • Causes lungs to appear red and granular, similar to liver 21

22. Pathophysiology • Gray hepatization • ↓Blood flow • Leukocyte and fibrin consolidate in affected part of lung. 22

23. Pathophysiology • Resolution • Resolution and healing if no complications • Exudate lysed and processed by macrophages • Tissue restored 23

24. Pathophysiologic Course of Pneumococcal Pneumonia Fig. 28-1. Pathophysiologic course of pneumococcal pneumonia. 24

25. Clinical Manifestations • CAP symptoms • Sudden onset of fever • Shaking chills • Shortness of breath • Cough productive of purulent sputum • Pleuritic chest pain 25

26. Clinical Manifestations • Physical examination findings • Dullness to percussion • ↑ Fremitus • Bronchial breath sounds • Crackles 26

27. Clinical Manifestations • Atypical manifestations • Gradual onset • Dry cough • Extrapulmonary manifestations • Crackles 27

28. Clinical Manifestations • Initial manifestations are highly variable in viral pneumonia. • Primary pneumonia can be caused by influenza viral infection. • Can be a complication of systemic viral disease 28

29. Complications • Pleurisy • Pleural effusion • Usually is sterile and reabsorbed in 1 to 2 weeks or requires thoracentesis 29

30. Complications • Atelectasis • Usually clears with cough and deep breathing • Bacteremia • Bacterial infection in the blood 30

31. Complications • Lung abscess • Seen when caused by S. aureus and gram-negative pneumonias • Empyema • Requires antibiotics and drainage of exudate 31

32. Complications • Pericarditis • Spread of microorganism to heart • Meningitis • Patient who is disoriented, confused, or somnolent should have lumbar puncture. 32

33. Complications • Endocarditis • Microorganisms attack endocardium and heart valves. 33

34. Diagnostic Tests History Physical examination Chest x-ray Gram stain of sputum Sputum culture and sensitivity Pulse oximetry or ABGs 34

35. Diagnostic Tests CBC, differential, chemistries Blood cultures 35

36. Collaborative Care Antibiotic therapy Oxygen for hypoxemia Analgesics for chest pain Antipyretics 36

37. Question • A patient diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? • A. Administer the ordered oral antibiotic STAT. • B. Order the meal tray to be delivered as soon as possible. • C. Obtain a sputum specimen for culture and sensitivity. • D. Have the unlicensed assistive personal weigh the client.

38. Collaborative Care Fluid intake at least 3 L per day Caloric intake at least 1500 per day 38

39. Collaborative Care • Pneumococcal vaccine • Indicated for those at risk • Chronic illness such as heart and lung disease, diabetes mellitus • Recovering from severe illness • 65 or older • In long-term care facility 39

40. Nursing Assessment • History • Lung cancer • COPD • Diabetes mellitus • Debilitating disease • Malnutrition • AIDS 40

41. Nursing Assessment • History • Use of antibiotics, corticosteroids, chemotherapy, or immunosuppressants • Recent abdominal or thoracic surgery • Smoking • Alcoholism • Respiratory infections 41

42. Nursing Assessment Prolonged bed rest Dyspnea Nasal congestion Pain with breathing 42

43. Nursing Assessment Sore throat Muscle ache Fever Restlessness 43

44. Nursing Assessment Splinting affected area Tachypnea Asymmetric chest movements Use of accessory muscles 44

45. Nursing Assessment • Crackles • Green or yellow sputum • Tachycardia • Changes in mental status 45

46. Nursing Assessment Leukocytosis Abnormal ABGs Pleural effusion Pneumothorax on x-ray 46

47. Nursing Diagnoses Ineffective breathing pattern Ineffective airway clearance Acute pain 47

48. Nursing Diagnoses Imbalanced nutrition: Less than body requirements Activity intolerance 48

49. Planning Clear breath sounds Normal breathing patterns No signs of hypoxia Normal chest x-ray No complications related to pneumonia 49

50. Nursing Implementation Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance. Prompt treatment of URIs Strict asepsis 50