Teresa: Clinical Manifestations

Pneumocystis PNA Fever

Opportunistic stabbing or pleuritic chest pain
infection tachypnea
Abrupt onset
Fever Elderly
Tachypnea Weakness
SOB Fatigue
Dry, nonproductive lethargy
cough Confusion
poor appetite without
Respiratory distress classic s & s
Intercostal retractions
 Cyanosis Treatment: Bacterial Pneumonia
Started on Penicillin G
Pneumonia Response between 1 & 2 days
Interdisciplinary care
Prevention Complications of Pneumonia
Pneumococcal vaccine Atelectasis
Influenza vaccine Hypotension & shock
Pleural effusion
Medications Impaired gas exchange
Antibiotics
Bronchodilators
Agents to liquefy mucus Pneumonia: Impaired Gas Exchange
Results in hypoxia
Treatment Earliest sign and symptom of which is
Oxygen therapy a change in the level of consciousness.
Chest physiotherapy
Interventions
Nursing Diagnosis Oxygen by nasal cannula
Ineffective airway clearance Plan for periods of rest during
Ineffective breathing pattern activities of daily
Activity intolerance living.
Theresa Monitor pulse oximetry readings
A 20 year old college student every 4 hours.
Lives in a small dormitory with 30 What oxygen delivery system would
other be most effective for Theresa?
students.
Four weeks into the Spring semester, Nasal Cannula
she was Low flow delivery device
diagnosed with bacterial pneumonia 2 l/min = ~28%
Admitted to the hospital Higher flow rates (>5 l/min) dry nasal
membranes
Teresa: High Priority Intervention Simple Face Mask
Specimens for culture are taken prior Flow rates 6-12 l/min
to beginning the antibiotic Delivers 35-50% O2
Administering prior to cultures may Pt comfort issues (Maybe used for Mr.
make it impossible to determine the Howe if SOB)
actual agent causing the pneumonia.
Non-Rebreathing Mask
Theresa: Bacterial Pneumonia Delivers accurate, high concentrations
Sputume culture results of oxygen
most frequent strain of found in Achieves 60-90% O2 delivery
community
acquired pneumonia
Streptococcus pneumoniae
Oxygen Conserving Cannula Tuberculosis: Signs & Symptoms
Built in oxygen reservoir Fatigue
30-50% O2 delivery Weight loss
Increased comfort Anorexia
pm fever
Nebulizers/Humidifiers Dry cough
02 is drying to mucous membranes Later productive, purelent/blood
Nebulizers tingled
Bubble-through humidifier Night sweats
>4 l/min
Humidifiers Tuberculosis: Interdisciplinary
Heated water Care
Early detection
Tuberculosis Accurate diagnosis
Infection of the lung Effective disease treatment
tissue Preventing spread to others
Mycobacterium
tuberculosisTuberculosis Tuberculin test
Intradermal PPD
Spread through droplet nuclei: (Mantoux) test
Coughing Multiple-puncture
Sneezing (tine) testing
Speaking
TB: Goals of Medication
Tuberculosis: Risk Factors Treatment
Overcrowded, poor living conditions Make the disease noncommunicable
Poor nutritional status to others
Previous infection Reduce symptoms of the disease
Inadequate treatment of Affect a cure in the shortest possible
primary infection leads to multi-drug time
resistant organisms
Close contact to infected person Tuberculosis: Nursing Diagnosis
Immune dysfunction;HIV infection Deficient Knowledge
LTC facilities, Prisons Ineffective Therapeutic Regimem
Elderly Management
Substance abuse Risk for Infection

Tuberculosis Mr. Howe

Caseation necrosis c/o dyspnea
Inhaled bacteria multiply progressive wt loss
Tubercle is formed for several months
Infected tissue dies Productive cough
 Cheeselike center forms Night sweats
“wringing wet”
If patient has adequate immune Dx: R/O TB
response: What additional questions should you
Scar tissue develops around tubercle ask about Mr. Howe’s cough?
Walls off bacilli
Infected, does not develop TB Assessing Cough
 Inadequate immune response How it feels
TB can develop rapidly How bad it is
Reactivation TB What makes it better or worse
Suppressed immune system due to When it started
Age Amount, color, odor, and consistency
Disease of sputum
Use of immunosuppressive drugs
 Mr. Howe: Post Bronchoscopy
Mr. Howe Complications
Diagnostic test • Aspiration
expected for patient • Infection
Mantoux test • Pneumothorax
Sputum for acid-fast Mr. Howe: Post Bronchoscopy Care
bacillus • NPO until gag reflex
Chest X-ray • Monitor vital signs
History and Physical • Assess for dyspnea, hemoptysis,
Examination & tachycardia
• Notify MD if fever, difficulty
Mantoux Test
breathing
Positive result only indicate exposure
• Semi-Fowler’s position
or has
• Give H2O as first fluid
received BCG immunization
BCG immunization: Eastern Europe • Inform pt of possible
and countries where TB is endemic expectoration of blood tingled
Is not diagnostic for active TB mucus
Give upper 1/3 surface of the forearm
Needle is inserted with bevel up Tuberculosis: Drug Therapy
0.1 ml of purified derivative (PPD)
inserted intradermally) Mr. Howe’s Medication Regime
Read 48-78 hrs • Chemotherapy are all
Induration 1.5 mm or greater is + Hepatotoxic
(HIV or immunosuppressed pts 5 mm or Ethambutol
greater + • optic neuritis
• skin rash
Sputum Studies Rifampicin
Sputum Samples • n/v
• Expectoration tracheal • Thrombocytopenia
suction • turns all bodily secretions a red
• Bronchoscopy orange color (tears, sweat, etc)
Used to INH
• identify infecting organisms • peripheral neuritis (take Vitamin
• Confirm presence of malignant B6 in conjunction to prevent)
cells • hepatotoxicity
• early morning • GI upset
• 15 ml required Streptomycin
• Obtain prior to antibiotics • 8 th cranial nerve damage
• Ask pt to rinse mouth before • routine hearing test
collecting specimen • caution in renal disease

Mr. Howe: Bronchoscopy Pyrazinamid

ordered • Heptoxicity
• hyperuricemia
Preparation • monitor uric acid & hepatic
• informed consent function
• NPO after midnight Mr. Howe’s Hospital Care
• Explain procedure, obtain •  Teach handwashing, cover
baseline vs & ABG nose and mouth when coughing,
• Atrpine maybe oredered to dry sneezing
secretions • Droplet Isolation-negative
pressure room
• Special particulate respirator
mask
• Psychosocial support-reinforce
need to take medication
Mr. Howe’s Teaching Plan
• Preventive measures to avoid Why is a chest x-ray ordered post
catching viral infections procedure?
• Taken drugs in combination to
avoid bacterial resistance Assessment: Lower Resp Problems
• Take meds at the same time of • Resp shallow and rapid
day on an empty stomach • Decreased oxygen saturation
• Follow med regimen 6-12 • Skin cyanosis or pallor
months as prescribed • Cyanosis or pallor of lips &
• Adequate nutritional status mucus membranes
• Annual check-up • Tachycardia
• Annual Check-up: liver function • Work hard to inhale & exhale
tests • Restless & anxious
• Notify MD if signs of hepatitis, • Thin compared to height
hepatoxicity, neurotoxicity, & Muscles of neck appear thick
visual changes occur • Arm & leg muscles appear thin
• Clubbed fingers
Thoracentesis • Chest is barrel shaped
• Used to obtain pleural fluid for • Rib space more than a finger
• analysis breath apart
• Needle inserted between ribs
• second and third intercostal Physical Assessment: Lower Resp
spaces Problems
• Fluid withdrawn with syringe • Take vital signs
• or tubing connected to sterile • Monitor O2 sat
vacuum bottle • Assess cognition
• Assess sputum
Pre-Procedure • Assess ability to cough &
• Informed consentexplained & clear airway
signed
• Inform about pressure sensations
that will be experienced during Lab Values: Lower Resp
the procedure
• Baseline vital signs • Elevated RBC, HCT, HGB
• Make sure that a CXR has been • Elevated WBC
• Completed • ABGs
ph <7.35
Thoracentesis: Positioning HCO3 > 24mm Hg
• Lying on theunaffected side with PCO2 > 45 mm HG
the bed elevated 30 – 40 degrees PaO2 < 80 mm Hg
• Sitting on the edge of the bed
with her feet supported and her Interventions: Lower Resp
arms and head on a padded Problems
overbed table. • Upright position
• Straddling a chair with her arms • Chest Physiotherapy
and head resting on the back of • O2 low to maintain resp of 16
the chair. breaths minute
Post Thoracentesis • Pace activities
• Apply pressure to • Administer inhaled drugs
• puncture site • Respiratory therapy
• Assess bleeding &crepitus • Fluid intake at least 3L daily
• Semi-fowlers or puncture site up
• Monitor for blood tingled mucus
Assess for hypoxemia,
• Assess for tachycardia
• Assess breath sounds
Bronchitis Vasoconstriction
• Common in adults Edema
Mucus production
Risk factors:
• Impaired immune defenses Asthma: Patho
• Cigarette smoking Inflammatory mediators released
• Acute bronchitiss Activation of inflammatory cells
• follows a viral URI Bronchoconstriction
• Chronic bronchitis is a Airway edema
component of COPD Impaired mucus clearing
SOB
• Viral, bacterial or inflammatory
trapping of air impairs gas exchange
• Irritants cause increased mucus
• production and mucosal irritation Asthma: Signs & Symptoms
Chest tightness
Acute Bronchitis Cough, dyspnea, sheezing
Bronchitis: Signs & Symptoms Tachycardia, tachypnea,
• Non-productive cough prolonged expiration
• Later becomes productive Fatigue, anxiety apprenhension
• Paroxysmal cough Respiratory failure
• Chest pain Breath sounds may
• Moderate fever improve right before failure
• General malaise
Bronchitis Treatment Asthma: Treatment
• Symptomatic Control symptoms
• Rest Prevent acute attacks
• Increased fluid intake Restore airway patency
Nursing Intervention Restore alveolar ventilation
• teaching Long term control
Medications Anti-infammatory agents
• ASA or tylenol Long acting bronchodialators
• Broad spectrum antibiotic Leukotriene modifiers
• Cough expectorant Quick relief
Short acting adrenergic stimulants
Asthma Anticholinergic drugs
Methylxanthines
• Chronic inflammatory disorder
Administration methods
of the airways
Metered-dose inhaler (MDI)
• Brief (acute asthma fatal)
Dry powder inhaler (DPI)
• Persistent irritation of Nebulizer
theairways
Asthma: Risk Factors Chronic Obstructive Pulmonary
• Allergies Disease
• Family history occupational A collective term used
exposure to refer to chronic
• Respiratory viruses lung disorders
• Exercise in cold air Air flow into or out of
• Emotional stress the lungs is limited
Asthma: Triggers
• Allergens John
• Resp tract infection Emphysema for 25 years
• Exercise H/O smoking
• Inhaled irritants Diagnosis: Bronchitis
• Secondhand smoke John: Cigarette Smoking
• Medications Major causative factor in the
development of
Asthma: Acute/early response respiratory disorders
lung cancer
 cancer of the larynx chronic upper respiratory tract
Emphysema infections
chronic bronchitis complications of other respiratory
disorders
During assessment you note the Obstruction of a pulmonary artery by
presence of a “barrel chest”. a bloodborne substance
“air trapping” in the lungs
Pulmonary Embolism:
Barrel Chest Common Cause:
Deep vein thrombosis
• Slow progressive obstruction of
airways
• Airways narrow Other sources of Pulmonary Emboli
• Resistance to airflow increase Fat Emboli
• Expiration slow and difficult From fractured long bones
• Result: mismatch between Air Emboli
alveolar ventilation and From IVs
• perfusion, leading to impaired Amniotic fluid
gas exchange Tumors

Major symptoms to assess John for: Mrs. Perkins

You should be alert for the following Mrs Perkins is suspected of having a
presenting symptom of COPD? pulmonary embolus.
What diagnostic test confirms this
• Increased dyspnea
diagnosis?
• Sputum production
Pulmonary Embolism
The plasma D-dimer test is highly
Emphysema
specific for the presence of a thrombus.
John is medicated with a bronchodilator
An elevated d-dimer indicates a
to reduce airway obstruction. Assess
thrombus formation and lysis.
for
What assessment data would support
• Dysrhythmias that Mrs. Perkins has experienced a
• Central nervous system pulmonary embolus?
excitement
• Tachycardia Clinical Manifestations of Pulmonary
Embolus
Purse Lip Breathing Sudden, unexplained dyspnea,
Recommended for John to: tachypnea
• Decrease respiratory rate or tachycardia
• Increase alveolar ventilation Cough
• Reduce functional residual Chest pain
capacity Hemoptysis
Sudden changes in mental status
Venturi Mask is prescribed for John (hypoxia)
because:
• Moderate Oxygen Flow Diagnosing Pulmonary Embolism
• Delivers precise, high-flow • Ventilation-Perfusion Scan
• rates • Nuclear imaging test
24%-50% • Determines percentage of each
• Humidification available lung that is functioning normally
• Requires face mask • Pulmonary Angiography

Bronchiectasis
A chronic dilation of the
bronchi caused by:
pulmonary TB infection
Pulmonary Embolism
• Mrs. Perkins pulse oximetry has
• decreased to 90%. What does Pulmonary Embolism
this indicate? • Mrs Perkins PT is 12.9 and PTT
• The normal pulse oximeter is 98. What are your implications
reading is 93% - 100%. for administering heparin to Mrs.
• A reading of 90% indicates Mrs. Perkins?
Perkins has an arterial oxygen • A normal PTT is 39 seconds
level of about 60 • 58-78 is 1.5 to 2 times the
• With a diagnosis of PE, what normal value and is within the
intervention is crucial for Mrs. normal therapeutic range
Perkins? • A PTT of 98 means Mrs
• Institute and maintain bedrest Perkins is not clotting;
• Bedrest reduces metabolic medication should be held.
demands and tissue needs for
oxygen.
Pulmonary Embolism
Management: Pulmonary Emboli The doctor has ordered Coumadin for
• Anticoagulation therapy Mrs. Perkins. PT = 22 PTT = 39 INR =
• Heparin 2.8
• Coumadin for ~6 months What action should you
implement
• Thrombolytic therapy
• Give the Coumadin because the
• Use very cautiously only for
therapeutic INR level is 2-3.
acute, massive PE
• What is the antidote for
• Urokinase, Streptokinase &
Coumadin?
tPA
• Inferior Vena Cava filter
Pulmonary Embolism: Teaching
• Use a soft bristle toothbrush to
Mrs. Perkins
reduce the risk of bleeding
Mrs. Perkins is receiving a heparin
drip. The bag hanging is 20,000 • Avoid aspirin
units/500 ml of • Aspirin is an antiplatlet which
D5W infusing at 22 ml/hr. How many may increase
units of heparin is Mrs Perkins receiving • bleeding tendencies
each hour? • Wear a medic alert band
• Increase fluid intake to 2-3L
Heparin Infusion day (increases fluid
880 units • volume which prevents DVT the
20,000 divided by 500 = 40 units common cause of PE)

If 22 ml are infused per hour, then 880 IVC Filters

units of heparin are infused each hour • Greenfield filter
40 x 22 = 880 • Bird’s nest filter

Heparin Therapy
What nursing interventions should you
implement for
Mrs Perkins receiving Heparin?
• Keep protamine sulfate readily
available
• Assess for overt & covert signs
of bleeding
• Avoid invasive procedures and
injections
• Administer stool softeners as
ordered