The Respiratory System Correlated to the Roy Adaptation Model and Nursing Process

1. The Respiratory SystemCorrelated to the Roy Adaptation Model and Nursing Process Sandy Marks, RN, BSN, MS(HCA) N212 Medical Surgical Nursing 1 Spring 2008

2. Course Packet (2007), p 104 Journey through Roy Adaptation Model(RAM) Roy Adaptation Model ? Patients primarily with alterations in physiological mode ? oxygenation ? respiratory system Respiratory focus will be related to pneumoniaRespiratory focus will be related to pneumonia

3. Objectives - 1 Review the anatomy and physiology of the respiratory system Describe the respiratory changes associated with aging

4. Objectives - 2 Discuss the purpose and interventions (preparation, explanation, procedure, postcare) for the following diagnostic tests: X-rays: chest, bronchogram, CT, lung scan Direct visualization: bronchoscopy Sputum specimen Thoracentesis Pulmonary function tests (PFT) Oximetry Magnetic resonance imaging (MRI) Cultures

5. Objectives - 3 Describe the nursing assessment of the following cardinal signs and symptoms: cough sputum dyspnea Discuss the pathophysiology, nursing assessment, interventions, and evaluation for Pneumonia

6. dscherer.com The Art of Caring Nursing is caring. Remember: we are caring for a family unit, not just the patientNursing is caring. Remember: we are caring for a family unit, not just the patient

7. Respiratory Review Purpose = provide oxygen for tissue metabolism (O2) remove carbon dioxide (CO2) Influences functions of: acid-base balance speech sense of smell fluid balance temperature control Respiratory problems are the 5th leading cause of death in the United States. Can effect young and old.Respiratory problems are the 5th leading cause of death in the United States. Can effect young and old.

8. Chabner, 2007 Review the anatomy and physiology of the respiratory system upper respiratory tract lower respiratory tract divided by trachea (windpipe) bronchi bronchioles alveolar ducts alveoli carina: located at level of manubriosternal junction � or Angle of Louis � it is where the trachea biforcates into R and L main stem bronchi Bronchioles � wrapped by smooth muscles that constrict and dilate in response to stimuli. The narrowing or widening of bronchioles due to contraction and relaxation of muscles determine the diameter of the airways Alveoli: small sacs = the functional units of the lungscarina: located at level of manubriosternal junction � or Angle of Louis � it is where the trachea biforcates into R and L main stem bronchi Bronchioles � wrapped by smooth muscles that constrict and dilate in response to stimuli. The narrowing or widening of bronchioles due to contraction and relaxation of muscles determine the diameter of the airways Alveoli: small sacs = the functional units of the lungs

9. Chabner, 2007 Gas Exchange occurs at alveolar capillary membrane occurs by diffusion Pulmonary edema = excess fluid fills alveoli spaces impairs exchange of O2 and CO2

10. Chabner, 2007 Normal lung tissue 300 million alveoli surface area = tennis court Right bronchus slightly wider shorter more vertical increases problems with intubation aspiration

11. dscherer.com Physiologic changes associated with aging Reference pg. 528 of IGGY, chart 30-1, outlines nursing interventions and rationales Between 1990 and 1990, the total US population increased three-fold, the population of persons = 65 increased ten-fold. As baby-boomers age, this # increases. Proportion of total population = 65 is projected from about 12.5% in 1996 to about 20% by 2040. The oldest old (= 85) = about 12% of the elderly projected to be 18% by 2040. Centenarians increasing faster (57,000 in 1996 to 447,000 in 2040. Health care costs will increase: decrease in younger person creates less financial and social support for the elderly [The Merck Manual of Geriatrics, 2000].Reference pg. 528 of IGGY, chart 30-1, outlines nursing interventions and rationales Between 1990 and 1990, the total US population increased three-fold, the population of persons = 65 increased ten-fold. As baby-boomers age, this # increases. Proportion of total population = 65 is projected from about 12.5% in 1996 to about 20% by 2040. The oldest old (= 85) = about 12% of the elderly projected to be 18% by 2040. Centenarians increasing faster (57,000 in 1996 to 447,000 in 2040. Health care costs will increase: decrease in younger person creates less financial and social support for the elderly [The Merck Manual of Geriatrics, 2000].

12. Alveoli alveolar surface area decreases diffusion capacity decreases elastic recoil decreases bronchioles and alveolar ducts dilate ability to cough decreases airways close early

13. Lungs residual volume increases vital capacity decreases efficiency of oxygen and carbon dioxide exchange decreases elasticity decreases

14. Pharynx and Larynx muscles atrophy vocal cords become slack laryngeal muscles lose elasticity and cartilage

15. Pulmonary Vasculature increased vascular resistance to blood flow through pulmonary vascular system occurs pulmonary capillary blood volume decreases risk of hypoxia increases

16. Exercise Tolerance andMuscle Strength Exercise Tolerance body�s response to hypoxia and hypercapnea decreases Muscle Strength respiratory muscle strength, especially the diaphragm and intercostals, decreases

17. Susceptibility to Infection effectiveness of the cilia increases immunoglobulin A decreases alveolar macrophages are altered

18. Chest Wall anteroposterior (AP) diameter increases thorax becomes shorter progressive kyphoscoliosis occurs chest wall compliance (elasticity) decreases mobility may decrease osteoporosis is possible

19. Summary on effects of aging ? recoil and compliance ? AP diameter ? functional alveoli ? in Pa02 Respiratory defense mechanisms less effective Altered respiratory controls More gradual response to changes in O2 and Co2 levels in blood

20. Diagnostic Tests X-rays: chest, bronchogram, CT, lung scan Direct visualization: bronchoscopy Sputum specimen and Cultures Thoracentesis Pulmonary function tests (PFT) Oximetry Magnetic resonance imaging (MRI)

21. Chest X-Ray Screen, diagnose, evaluate treatment Instructions: Screen for TB, diagnose pneumonia, evaluate tx Common views � AP and Lateral Remove any metal or jewelry between neck and waistScreen for TB, diagnose pneumonia, evaluate tx Common views � AP and Lateral Remove any metal or jewelry between neck and waist

22. Chabner, 2007 X-ray Positions

23. Chest X-Ray (Cont.) The standard chest examination consists of a PA (posterioranterior) and lateral chest x-ray. The films are read together.� The PA exam is viewed as if the patient is standing in front of you with their right side on your left.� The patient is facing towards the left on the lateral view.� To screen (for TB), diagnose (pneumonia, pulmonary edema (CHF); evaluate treatmnet treat to see if pneumonia or pulm edema resolved) http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\radio\images\large\35983598RUL_NODULE.JPG&fzi=1The standard chest examination consists of a PA (posterioranterior) and lateral chest x-ray. The films are read together.� The PA exam is viewed as if the patient is standing in front of you with their right side on your left.� The patient is facing towards the left on the lateral view.� To screen (for TB), diagnose (pneumonia, pulmonary edema (CHF); evaluate treatmnet treat to see if pneumonia or pulm edema resolved) http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\radio\images\large\35983598RUL_NODULE.JPG&fzi=1

24. www.fotosearch.com Bronchogram Slightly oblique

25. Computed Tomography: CT Scan Images in cross-section view Uses contrast agents Instructions: images are shown in cross-section Used to dx px difficult to access by usual x-rays Nursing responsibility-same for x-ray Diagnose problems difficult to access by usual X-rays (mediastinum (area underneath the sternum or breast bone) and pleura, hilum) images are shown in cross-section Used to dx px difficult to access by usual x-rays Nursing responsibility-same for x-ray Diagnose problems difficult to access by usual X-rays (mediastinum (area underneath the sternum or breast bone) and pleura, hilum)

26. www.ucl.ac.uk Lung Scan most to detect emboli no food restrictions breathes radioactive material through a tube for 5 minutes 6 ventilation images taken radioactive injection same 6 images retaken compare images

27. www.diiradiology.com www.washingtonhospital.org Ventilation- air distribution in lungPerfusion- blood supply to & within lung

28. Bronchoscopy Diagnose problems and assess changes in bronchi / bronchioles Performed to remove foreign body, secretions, or to obtain specimens of tissue or mucus for further study Visualization (using fiberoptic tube� bronchoscope- athin flexible fiberoptic telescope) of the tracheobronchila tree via a scope advanced through the mouth or nose into the bronchi Performed to remove foreign body, secretions, or to obtain specimens of tissue or mucus for further study Nursing care: obtain an informed consent Keep NPO for six hours to eight hours before procedure Administer ordered procedure medications (e.g. Valium) to produce sedation and decrease anxiety Inform the client to expect some soreness, dysphagia, hemoptysis after the procedure Advice client to avoid coughing or clearing throat Observe for signs of hemorrhage and /or respiratory distress; keep HOB elevated Monitor VS until stable Do not allow fluids until gag reflex returns Post-op care- keep NPO until gag reflex return and monitor for laryngeal edema; keep HOB elevated Monitor for hemorrhage and pneumothorax The endoscope 1) is inserted through the nose or mouth, then through the trachea 2) and finally into the bronchial tubes 3). During the examination it is possible, without the patient feeling anything, to extract secretion for analysis of� bacteria. Additionally it�s possible to take small�tissue samples with biopsy forceps.During the examination the patient will receive a sedative medicament.Post-op: NPO for 6-12 hours until gag reflex returns Monitor for laryngeal edema; hemorrhage and pneumothorax Keep HOB elevated One type of lung collapse, known medically as a pneumothorax, occurs when air leaks into the area between your lungs and chest wall (pleural space). The pressure of the air against the lung causes it to give way, often leading to mild to severe chest pain and shortness of breath. A pneumothorax can be caused by a chest injury, certain medical treatments, lung disease or a break in an air blister on the lung's surface. A lung collapses in proportion to the amount of air that leaks into your chest cavity. Although the entire lung can collapse, a partial collapse is much more common. A small, uncomplicated pneumothorax may heal on its own in a week or two, but when the pneumothorax is more severe, the excess air is usually removed by inserting a tube or needle between your ribs into the pleural space. If air continues to build up, the increasing pressure can push your heart and blood vessels toward the uncollapsed lung, compressing both your lung and heart. Called a tension pneumothorax, this condition is life-threatening and requires immediate medical care. Visualization (using fiberoptic tube� bronchoscope- athin flexible fiberoptic telescope) of the tracheobronchila tree via a scope advanced through the mouth or nose into the bronchi Performed to remove foreign body, secretions, or to obtain specimens of tissue or mucus for further study Nursing care: obtain an informed consent Keep NPO for six hours to eight hours before procedure Administer ordered procedure medications (e.g. Valium) to produce sedation and decrease anxiety Inform the client to expect some soreness, dysphagia, hemoptysis after the procedure Advice client to avoid coughing or clearing throat Observe for signs of hemorrhage and /or respiratory distress; keep HOB elevated Monitor VS until stable Do not allow fluids until gag reflex returns Post-op care- keep NPO until gag reflex return and monitor for laryngeal edema; keep HOB elevated Monitor for hemorrhage and pneumothorax The endoscope 1) is inserted through the nose or mouth, then through the trachea 2) and finally into the bronchial tubes 3). During the examination it is possible, without the patient feeling anything, to extract secretion for analysis of� bacteria. Additionally it�s possible to take small�tissue samples with biopsy forceps.During the examination the patient will receive a sedative medicament.

29. Sputum Specimen To diagnose; evaluate treatment Specimen: ID organisms or abnormal cells Culture & Sensitivity (C&S) Cytology Gram stains (e.g. Acid Fast Bacilli) Assess presence of abnormal cells Evaluate treatment: TB- AFB stains Acid fast Bacilli - TB Culture and sensitivity; AFB; gram stain, cytology Collected in a sterile container Instruct pt how to produce a good specimen; deep breathe then cough deeply and expectorate (not spit) Sputum specimen Cultre and sensitivity; AFB; gram-stain (+/-); cytology Collect in a sterile container To diagnose bacterial infection, to assess presence of abnormal cells; to evaluate treatment (TB) � AFB stains Instruct pt on how to produce a good specimen; deep breath then cough deeply then expectorate (ex. Pt spits only) Assess presence of abnormal cells Evaluate treatment: TB- AFB stains Acid fast Bacilli - TB Culture and sensitivity; AFB; gram stain, cytology Collected in a sterile container Instruct pt how to produce a good specimen; deep breathe then cough deeply and expectorate (not spit) Sputum specimen Cultre and sensitivity; AFB; gram-stain (+/-); cytology Collect in a sterile container To diagnose bacterial infection, to assess presence of abnormal cells; to evaluate treatment (TB) � AFB stains Instruct pt on how to produce a good specimen; deep breath then cough deeply then expectorate (ex. Pt spits only)

30. Thoracentesis Specimen from pleural fluid Treat pleural effusion Assess for complications Post-Procedure care: These tubes, inserted in your chest during the thoracentesis, will remove air, blood, or fluid from the area around your lungs. Removal of fluid or air from pleural space; performed for diagnostic purposes or to alleviate respiratory distress; a needle biopsy of the pleura may be done No more than 1000 mL of fluid should be removed at the time (may result in sudden fluid shift: pulmonary edema); fluid withdrawn should be sent to the lab for C&S, analysis of glucose, protein and pH Complications include pneumothorax from trauma to the lung and pulmonary edema resulting from sudden fluid shifts Nursing care: Obtain informed consent Ensure a CXR is done before and after the procedure ( to check for pneumothorax) Support the client in the sitting position Inform the client not to cough during the procedure to prevent trauma to the lungs Assess pulse and respirations before, during and after the procedure Obtain specimen of pleural fluid for dx; sometime tx for pleural effusion if excessive amounts Large bore needle into pleural space STAT CXR always after procedure to check for pneumothorax ( d/t possibility of puncturing the visceral pleura) Three different possible positions sitting on side of bed over bedside table chest elevated lying on affected side straddling a chair Effusion without a secure clinical diagnosis (e.g., CHF) or small quantity Thoracentesis is a diagnostic procedure done in patients who have abnormal amounts of fluid accumulation in the pleural space. The procedure is usually done at the bedside under local anesthesia. The needle is placed through the chest wall into the pleural space and fluid is then withdrawn into a syringe. infection and bleeding at site, reaccumulation of pleural fluid, Pneumothorax is a condition in which air gets between your lungs and your chest wall. Pneumothorax is one cause of a collapsed lung � a serious, sometimes life-threatening, condition. Normally, two thin layers of moist tissue (pleura) separate your lungs and chest wall. Any air that leaks through lung tissue into this space (pleural space) will cause the lung tissue to collapse in proportion to the amount of air that enters the pleural cavity. Air can collect in the pleural space for many reasons, including: An injury that damages the chest wall, such as a stab or gunshot wound A broken rib that punctures the lung A procedure or surgery that involves the lung or chest wall Spontaneous pneumothorax, which is thought to be due to the rupture of an air-filled blister on the surface of the lung In many cases, the cause of a pneumothorax can't be determined. People with underlying lung disease, such as asthma or cystic fibrosis, may be at increased risk of pneumothorax. Signs and symptoms of pneumothorax include: Sudden, sharp chest pain Shortness of breath Chest tightness A doctor can confirm a diagnosis of pneumothorax by a chest X-ray. Occasionally, the air leak seals itself. Depending on the severity, a doctor can remove the air from the pleural space with a tube inserted between the ribs and attached to a suction device. Surgery may be needed when suction isn't effective or for recurrent pneumothorax. If air continues to enter the pleural space, tension pneumothorax occurs. The large amount of air may push the center of the chest (mediastinum) toward the other lung, compressing it. This is life-threatening and requires immediate insertion of a chest tube between the ribs to relieve the increased pressure. These tubes, inserted in your chest during the thoracentesis, will remove air, blood, or fluid from the area around your lungs. Removal of fluid or air from pleural space; performed for diagnostic purposes or to alleviate respiratory distress; a needle biopsy of the pleura may be done No more than 1000 mL of fluid should be removed at the time (may result in sudden fluid shift: pulmonary edema); fluid withdrawn should be sent to the lab for C&S, analysis of glucose, protein and pH Complications include pneumothorax from trauma to the lung and pulmonary edema resulting from sudden fluid shifts Nursing care: Obtain informed consent Ensure a CXR is done before and after the procedure ( to check for pneumothorax) Support the client in the sitting position Inform the client not to cough during the procedure to prevent trauma to the lungs Assess pulse and respirations before, during and after the procedure Obtain specimen of pleural fluid for dx; sometime tx for pleural effusion if excessive amounts Large bore needle into pleural space STAT CXR always after procedure to check for pneumothorax ( d/t possibility of puncturing the visceral pleura) Three different possible positions sitting on side of bed over bedside table chest elevated lying on affected side straddling a chair Effusion without a secure clinical diagnosis (e.g., CHF) or small quantity Thoracentesis is a diagnostic procedure done in patients who have abnormal amounts of fluid accumulation in the pleural space. The procedure is usually done at the bedside under local anesthesia. The needle is placed through the chest wall into the pleural space and fluid is then withdrawn into a syringe.

31. Chabner, 2007 Pneumothorax

32. Pulmonary Function Test (PFTs) Evaluate lung function Observe for increased dyspnea or bronchospasm Instructions: Tidal volume, forced inspiratory volume Use of spirometer- to show air movement as pt performs prescribed maneuvers- by RT PFT- Done by RT To evaluate lung function Uses a fancy spirometer, blows hard, fast and as long as possible into the mouthpiece Provide rest after procedure No bronchodilators for 6 hours prior to procedure These are tests that assess your lung function or capacity. They involve taking normal and deep breaths, as well as breathing out as hard as you can into a tube. Occasionally, you will be asked to briefly hold your breath. Your results are adjusted based on your age, gender, race, and height. Pulmonary function tests provide one measure of how well controlled your asthma is. Your physician will use your results, along with your symptoms, to assess the severity of your asthma, as well as your response to treatment. Tidal volume, forced inspiratory volume Use of spirometer- to show air movement as pt performs prescribed maneuvers- by RT PFT- Done by RT To evaluate lung function Uses a fancy spirometer, blows hard, fast and as long as possible into the mouthpiece Provide rest after procedure No bronchodilators for 6 hours prior to procedure These are tests that assess your lung function or capacity. They involve taking normal and deep breaths, as well as breathing out as hard as you can into a tube. Occasionally, you will be asked to briefly hold your breath. Your results are adjusted based on your age, gender, race, and height. Pulmonary function tests provide one measure of how well controlled your asthma is. Your physician will use your results, along with your symptoms, to assess the severity of your asthma, as well as your response to treatment.

33. Pulse Oximetry Measures arterial oxygen saturation Pulse oximetry probe on ears, nose, finger, toes, forehead False readings Intermittent or continuous monitoring Ideal values When to Notify MD Oximetry- which patients do you need to monitor pulse oximetry on? Arterial and venous O2 Sat Device attach t earlobe, finger, or nose, or foot (babies) Continuously monitored in ICU or 24 hours after sx; spot checks in med-surg pts Alteredresults with motion, low perfusion, acrylic nails Notify MD if < 90%, r 92-93% (follow agency protocol or MD specific order if any) IGGY: Medical emerg � 86%; call md if less thatn 91%Oximetry- which patients do you need to monitor pulse oximetry on? Arterial and venous O2 Sat Device attach t earlobe, finger, or nose, or foot (babies) Continuously monitored in ICU or 24 hours after sx; spot checks in med-surg pts Alteredresults with motion, low perfusion, acrylic nails Notify MD if < 90%, r 92-93% (follow agency protocol or MD specific order if any) IGGY: Medical emerg � 86%; call md if less thatn 91%

34. Chabner, 2007 MRI Frontal View White masses = Hodgkin Disease lesions

35. Chabner, 2007 MRI � transverse view � same patient

36. Nursing Assessment:Cardinal Signs and Symptoms of:1. Cough2. Sputum3. Dyspnea

37. Cough � Main Sign of Lung Disease how long present occurs at a specific time (smokers = upon wakening in AM) related to activity productive vs nonproductive congested dry tickling hacking

38. Sputum � normally 3 oz produced/day important symptom associated with coughing Check: duration � long term, short term color � rust colored consistency � thick, thin, watery, frothy odor- foul amount � describe in tsp, or fractions of cup and if increasing (external or internal cause) Pneumococcal pneumonia = underlinedPneumococcal pneumonia = underlined

39. Dyspnea � subjective data (perception) difficulty in breathing or breathlessness Check: onset � slow or abrupt duration - # of hours, time of day relieving factors � position change, med, stop activity wheezing, crackles, rales, or stridor occur with breathlessness Quantify by assessing if interferes with ADL PND or orthopnea PND = paroxysmal nocturnal dyspnea = intermittent dyspnea during sleep orthopnea = SOB when lying down, relieved by sitting up Both indicative of chronic lung disease and left-sided heart failurePND = paroxysmal nocturnal dyspnea = intermittent dyspnea during sleep orthopnea = SOB when lying down, relieved by sitting up Both indicative of chronic lung disease and left-sided heart failure

40. Lung sounds wheezing crackles stridor auscultation � sequence pg. 534, Iggy bronchial = trachea & mainstem bronchi bronchovesicular = branching bronchi vesicular = small bronchiole periphery Incorporate CD of lung sounds hereIncorporate CD of lung sounds here

41. Pneumonia: Case Study Pneumonia is a serious infection causing inflammation to one or both lungs. The air sacs (alveoli) in the lungs fill with fluid and pus, making it difficult for the person affected to breathe. When the air sacs in the lungs' fill it impairs their main function, which is to get oxygen from the air into the bloodstream organism reaches lower resp tract Outpouring of inflammatory exudate and cells WBCs phagocytize the organisms and release enzymes Portions of the lungs fill with exudate and inflammatory cells - consolidation Pneumonia is a serious infection causing inflammation to one or both lungs. The air sacs (alveoli) in the lungs fill with fluid and pus, making it difficult for the person affected to breathe. When the air sacs in the lungs' fill it impairs their main function, which is to get oxygen from the air into the bloodstream organism reaches lower resp tract Outpouring of inflammatory exudate and cells WBCs phagocytize the organisms and release enzymes Portions of the lungs fill with exudate and inflammatory cells - consolidation

42. Course Packet (2007), pgs 115-117 Nursing Student Tools Concept Map � Pneumonia Medical-Surgical Map (Medimap) Nursing Map

43. Pathophysiology Inhalation of pathogens in air droplets Aspiration of infected secretions from the upper respiratory tract Aspiration of infected particles from gastric contents, food, or debris Hematogenous spreadInhalation of pathogens in air droplets Aspiration of infected secretions from the upper respiratory tract Aspiration of infected particles from gastric contents, food, or debris Hematogenous spread

44. Toxic sprinkles anyone?

45. Etiology Cause bacteria (75%) viruses fungi Mycoplasma parasites chemicals What causes pneumonia? Pneumonia can be caused by bacteria, viruses, fungal infections or chemical exposure, sometimes the exact cause of pneumonia is never known. The most common types of pneumonia are as follows: Bacterial pneumonia develops when bacteria that normally live harmlessly in the throat enter the lungs. This usually happens when the body's immune system is weakened in some way. This usually occurs after an upper respiratory infection, such as influenza. The lungs are damaged enough to allow the bacteria to infect the area. Bacterial pneumonia is usually caused by bacteria called either pneumococcus or streptococcus pneumoniae. The pneumonia 'Legionnaire's disease' is caused by the bacterium Legionella pneumophila and is found in faulty air conditioning units of large buildings e.g. hospitals or hotels. The bacteria can survive in warm, moist, air conditioning units and if present can cause an outbreak of the disease. The name comes from an epidemic in 1976, when 29 American Legion members all mysteriously died after staying at the same hotel. However, the disease is usually mild and is treated with antibiotics. Viral pneumonia is caused by simple viral organisms which, are often similar to those responsible for the common cold. Viral pneumonia is also a common complication of other illnesses such as colds, influenza, measles, herpes and chickenpox. Viral pneumonia is usually milder than bacterial pneumonia and lasts a shorter period of time. Mycroplasma pneumonia is caused by a micro-organism of the same name. Mycroplasma pneumonia is spread by close contact with an infected person and is more common in young adults. Some people who are infected with this type of pneumonia may never experience any symptoms. If the infected person is in good health, the illness is not as serious as normal pneumonia and there are rarely any complications. Aspiration pneumonia is caused when bacteria enters into the lungs from the mouth or stomach during vomiting. This type is usually more common in alcoholics. Pneumocystis Carinii Pneumonia (P.C.P.) is caused by a micro-organism that may live harmlessly in normal lungs. P.C.P. often develops as a secondary infection in patients whose immune system is weakened by illnesses such as cancer and HIV. P.C.P. can be the first sign of illness in people with HIV. What are the symptoms of pneumonia? Symptoms of both bacterial and viral pneumonia are similar and usually last about 2 weeks. Symptoms may include any of the following: High temperature. Severe shaking and chills. Cough that worsens over time and is often accompanied by phlegm. Severe chest pain or tightness in the chest. Shortness of breath. Loss of appetite. Tiredness and fatigue. General muscle aches. If you believe you might have pneumonia or have a persistent cough, then you should visit your doctor for further advice. Am I at risk of getting pneumonia? Anyone can get pneumonia, even the young. However, it is more common and more serious if you: Are elderly. Have had your spleen removed. Are an alcoholic. Suffer with asthma, heart conditions, lung diseases or diabetes. Smoke. Have a weak immune system (caused by long term illness such as cancer or HIV). How is pneumonia diagnosed? Your doctor can usually diagnose pneumonia by listening to you breathe with a stethoscope. If he/she suspects you have pneumonia, you will usually be referred to a hospital for a chest X-ray to see how bad the condition is. If the condition is severe the doctor will take a sample of your phlegm to examine under a microscope. The doctor will then try to grow the organism that is causing the infection, to find out which type of pneumonia you have. What treatment is there for pneumonia? If you have bacterial pneumonia your doctor will prescribe antibiotics, if however, you have viral pneumonia it will get better on its own. With both types of pneumonia you should get plenty of bed rest, take painkillers to reduce the fever and drink 8 glasses of juice or water a day. If pneumonia is severe you may need to be hospitalized for treatment. Treatments you receive in hospital may include; supplementary oxygen to help with breathing, physiotherapy to help clear mucus and/or antibiotics given directly into the vein. However, the majority of people with pneumonia will not need to be hospitalized.What causes pneumonia? Pneumonia can be caused by bacteria, viruses, fungal infections or chemical exposure, sometimes the exact cause of pneumonia is never known. The most common types of pneumonia are as follows: Bacterial pneumonia develops when bacteria that normally live harmlessly in the throat enter the lungs. This usually happens when the body's immune system is weakened in some way. This usually occurs after an upper respiratory infection, such as influenza. The lungs are damaged enough to allow the bacteria to infect the area. Bacterial pneumonia is usually caused by bacteria called either pneumococcus or streptococcus pneumoniae. The pneumonia 'Legionnaire's disease' is caused by the bacterium Legionella pneumophila and is found in faulty air conditioning units of large buildings e.g. hospitals or hotels. The bacteria can survive in warm, moist, air conditioning units and if present can cause an outbreak of the disease. The name comes from an epidemic in 1976, when 29 American Legion members all mysteriously died after staying at the same hotel. However, the disease is usually mild and is treated with antibiotics. Viral pneumonia is caused by simple viral organisms which, are often similar to those responsible for the common cold. Viral pneumonia is also a common complication of other illnesses such as colds, influenza, measles, herpes and chickenpox. Viral pneumonia is usually milder than bacterial pneumonia and lasts a shorter period of time. Mycroplasma pneumonia is caused by a micro-organism of the same name. Mycroplasma pneumonia is spread by close contact with an infected person and is more common in young adults. Some people who are infected with this type of pneumonia may never experience any symptoms. If the infected person is in good health, the illness is not as serious as normal pneumonia and there are rarely any complications. Aspiration pneumonia is caused when bacteria enters into the lungs from the mouth or stomach during vomiting. This type is usually more common in alcoholics. Pneumocystis Carinii Pneumonia (P.C.P.) is caused by a micro-organism that may live harmlessly in normal lungs. P.C.P. often develops as a secondary infection in patients whose immune system is weakened by illnesses such as cancer and HIV. P.C.P. can be the first sign of illness in people with HIV. What are the symptoms of pneumonia? Symptoms of both bacterial and viral pneumonia are similar and usually last about 2 weeks. Symptoms may include any of the following: High temperature. Severe shaking and chills. Cough that worsens over time and is often accompanied by phlegm. Severe chest pain or tightness in the chest. Shortness of breath. Loss of appetite. Tiredness and fatigue. General muscle aches. If you believe you might have pneumonia or have a persistent cough, then you should visit your doctor for further advice. Am I at risk of getting pneumonia? Anyone can get pneumonia, even the young. However, it is more common and more serious if you: Are elderly. Have had your spleen removed. Are an alcoholic. Suffer with asthma, heart conditions, lung diseases or diabetes. Smoke. Have a weak immune system (caused by long term illness such as cancer or HIV). How is pneumonia diagnosed? Your doctor can usually diagnose pneumonia by listening to you breathe with a stethoscope. If he/she suspects you have pneumonia, you will usually be referred to a hospital for a chest X-ray to see how bad the condition is. If the condition is severe the doctor will take a sample of your phlegm to examine under a microscope. The doctor will then try to grow the organism that is causing the infection, to find out which type of pneumonia you have. What treatment is there for pneumonia? If you have bacterial pneumonia your doctor will prescribe antibiotics, if however, you have viral pneumonia it will get better on its own. With both types of pneumonia you should get plenty of bed rest, take painkillers to reduce the fever and drink 8 glasses of juice or water a day. If pneumonia is severe you may need to be hospitalized for treatment. Treatments you receive in hospital may include; supplementary oxygen to help with breathing, physiotherapy to help clear mucus and/or antibiotics given directly into the vein. However, the majority of people with pneumonia will not need to be hospitalized.

46. Classifications Community-acquired pneumonia (CAP) Onset in community or during 1st 2 days of hospitalization (Strep. pneumoniae most common) Hospital-acquired Pneumonia (HAP / nosocomial) Occurring 48 hrs or longer after hospitalization Aspiration pneumonia Pneumonia caused by opportunistic organisms Pneumocystis Carinii CAP: Important infection worldwide Most common in the winter months HAP Developing >2 days after arrival in hospital Increased risk in: assisted ventilation pre-existing lung disease aspiration or anyone immunocompromised Aspiration- form aspiration of secretions and substances into lower resp airways from mouth or stomach into trachea dn then to lngs At risk: loss of consciousness: alcoholic, stroke, seizures, anesthesia, coma-where cough and gag reflex depressed Opportunistic- HIV pts. Pneumocystis carinii, cytomegalovirus, fungi � in immunocompormised ptsCAP: Important infection worldwide Most common in the winter months HAP Developing >2 days after arrival in hospital Increased risk in: assisted ventilation pre-existing lung disease aspiration or anyone immunocompromised Aspiration- form aspiration of secretions and substances into lower resp airways from mouth or stomach into trachea dn then to lngs At risk: loss of consciousness: alcoholic, stroke, seizures, anesthesia, coma-where cough and gag reflex depressed Opportunistic- HIV pts. Pneumocystis carinii, cytomegalovirus, fungi � in immunocompormised pts

47. Risk Factors CAP Older adult Chronic/coexisting condition Recent history or exposure to viral or influenza infections History of tobacco or alcohol use HAP Older adult Chronic lung disease ALOC Aspiration ET, Trach, NG / GT Immunocompromised Mechanical ventilation

48. Clinical Manifestations - 1 Fevers, chills, anorexia Pleuritic chest pain SOB Crackles / wheezes Cough, sputum production Tachypnea Insert lung sounds and pneumonia example from Cardionics CDInsert lung sounds and pneumonia example from Cardionics CD

49. Clinical Manifestations - 2 Mycoplasma (Atypical) feeling tired or weak, headaches, sore throat, or diarrhea.  Eventually, most develop a dry cough.� They can, also, develop fever, chills, earaches, chest pain �walking pneumonia� Walking Pneumonia is an infection of the lungs that stems from a bacterial infection (Mycoplasma Pneumonia), mostly affecting people under the age of 40.� The patient may have symptoms lasting from days to weeks.� Once a diagnosis is made, proper treatment is with antibiotics.� It is called "walking Pneumonia" because people do not appear to be very sick, even though they have Pneumonia.  Usually begin with vague symptoms such as feeling tired or weak, headaches, sore throat, or diarrhea.  Eventually, most develop a dry cough.� They can, also, develop fever, chills, earaches, chest pain, enlarged lymph nodes in the neck, and muscle or joint pains.� A few patients may feel short of breath.  Walking Pneumonia is an infection of the lungs that stems from a bacterial infection (Mycoplasma Pneumonia), mostly affecting people under the age of 40.� The patient may have symptoms lasting from days to weeks.� Once a diagnosis is made, proper treatment is with antibiotics.� It is called "walking Pneumonia" because people do not appear to be very sick, even though they have Pneumonia. Usually begin with vague symptoms such as feeling tired or weak, headaches, sore throat, or diarrhea. Eventually, most develop a dry cough.� They can, also, develop fever, chills, earaches, chest pain, enlarged lymph nodes in the neck, and muscle or joint pains.� A few patients may feel short of breath.

50. Diagnosis Diagnosis ? Physical exam ? crackles, rhonchi / wheezes CXR ? area of increased density (infiltrates / consolidation) Sputum specimen � Gram stain *always obtain both PA & Lateral films For complicated pneumonia- gram stain and ID the infecting organism Rapid Diagnostic studies The infectious agent is the most valuable piece of information in managing a complicated pneumonia. Gram stain - bacteria Acid fast - mycobacteria DFA - Pneumocystis, influenza, legionella PCR - chlamydia, mycoplasma, mycobacteria, legionella, hantavirus EIA - influenza, RSV Treatments: hydration, proper nutrition, support 02; ABX IV, HHN tx, analgesics Treat with abx based on source of infection (com vs hosp acquired;) type of org present; and severity New antibiotics Cephalosporins Macrolides/ketolides Fluoroquinolones Route of administration Oral Intravenous Intramuscular Admission decisions related to :hypoxia, inadequate oral intake, lack of home care support Antibiotic Decision Making: Severity of disease, Microbiology environment, Patient, Host status, Individual considerations *always obtain both PA & Lateral films For complicated pneumonia- gram stain and ID the infecting organism Rapid Diagnostic studies The infectious agent is the most valuable piece of information in managing a complicated pneumonia. Gram stain - bacteria Acid fast - mycobacteria DFA - Pneumocystis, influenza, legionella PCR - chlamydia, mycoplasma, mycobacteria, legionella, hantavirus EIA - influenza, RSV Treatments: hydration, proper nutrition, support 02; ABX IV, HHN tx, analgesics Treat with abx based on source of infection (com vs hosp acquired;) type of org present; and severity New antibiotics Cephalosporins Macrolides/ketolides Fluoroquinolones Route of administration Oral Intravenous Intramuscular Admission decisions related to :hypoxia, inadequate oral intake, lack of home care support Antibiotic Decision Making: Severity of disease, Microbiology environment, Patient, Host status, Individual considerations

51. www.med.wayne.edu CXR- LUL Pneumonia

52. Interventions and Treatment Treatment Antibiotics ? choose based on age, suspected cause & immune status Supportive care ? IV fluids, supplemental oxygen therapy, respiratory monitoring, cough enhancement *may take 6-8 weeks for CXR to normalize

53. Nursing Diagnoses� Impaired gas exchange R/T Pneumonia Pain R/T infection in lung Pneumonia Impaired gas exchange RT inflammatory exudate in alveolar space Pain rt infection in lung Hyperthermia rt infection Anxiety rt dyspneaImpaired gas exchange RT inflammatory exudate in alveolar space Pain rt infection in lung Hyperthermia rt infection Anxiety rt dyspnea

54. Complications Hypoxemia Pleural effusion Atelectasis Pleurisy Pleurisy � inflammation of pleura (pleuritis); common px occurs with Pneumonia Pleural effusion � usually sterile and is absored in 1-2 weeks; but can be aspirated with thoracentesis if too severe Atelectasis � collapsed lung; airless alveoli; on one or part of lobe; clear with good TCDB Which stimulates surfactant � for lung expansion Delayed resolution � results from persistent infection and is seen on x-ray as residual consolidation: in older people, manouished, COPDs, alcoholics Empyema � accumulation of purulent exudate in pleura; infreq; need abx and chest tube drainage Lung abcess � in Staph areus and gram neg pneum; not a common complication Peridarditis � from spread of MO from infected pleura Rheumatic heart disease- endocarditis, pericarditisPleurisy � inflammation of pleura (pleuritis); common px occurs with Pneumonia Pleural effusion � usually sterile and is absored in 1-2 weeks; but can be aspirated with thoracentesis if too severe Atelectasis � collapsed lung; airless alveoli; on one or part of lobe; clear with good TCDB Which stimulates surfactant � for lung expansion Delayed resolution � results from persistent infection and is seen on x-ray as residual consolidation: in older people, manouished, COPDs, alcoholics Empyema � accumulation of purulent exudate in pleura; infreq; need abx and chest tube drainage Lung abcess � in Staph areus and gram neg pneum; not a common complication Peridarditis � from spread of MO from infected pleura Rheumatic heart disease- endocarditis, pericarditis

55. Chabner, 2007 Atelectasis A = obstruction B = accumulation of fluid of air

56. Additional learning resources NANDA approved nursing diagnoses specific to respiratory system: p125 of study packet Skills Lab: Heart and Lung Sounds Trainer Learning Lung Sounds, Cardionics CD Audio-visual material

57. Resources Beers, M. & Berkow, R. (Ed.). (2000). The Merck Manual of Geriatrics (3rd ed.). Whitehouse Station: Merck & Co., Inc. Chabner (2007). The Language of Medicine (8th ed.). St. Louis: Saunders. Ignatavicius, D. & Workman, L. (2006). Medical- Surgical Nursing Critical Thinking for Collaborative Care (5th ed.). St. Louis: Elsevier Saunders. Scherer, D. (2008). Pictures retrieved March 31 and available at dscherer.com

58. dscherer.com