PN 132 Day 5 Adult Health Nursing 7 th Ed Foundations of Nursing 7 th Ed.
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Transcript of PN 132 Day 5 Adult Health Nursing 7 th Ed Foundations of Nursing 7 th Ed.
PN 132Day 5
Adult Health Nursing 7th EdFoundations of Nursing 7th Ed
PNEUMONIAEtiology/Pathophysiology -Inflammation of the pulmonary tissue -interstitial spaces -alveoli -bronchioles -Other causes: -oversedation -inadequate ventilation -aspiration
PNEUMONIA
PNEUMONIA -Occurs in any season -most common during winter and early
spring. -People of any age are susceptible -more common in infants and the elderly. -defense mechanisms that are
damaged/altered -vulnerable to contracting pneumonia. -Nosocomial pneumonia
PNEUMONIA-communicable disease -the mode of transmission is dependent on the infecting organism -classified according to the offending
organism.Causes: -bacteria -viruses -fungi -chemicals -mycocplasma
PNEUMONIA -50% of cases are caused by bacteria
and viruses; -96% of bacterial cases are caused by 4 organisms: -Streptococcus pneumoniae -Hemolytic Streptococcus type A -Staphylococcus aureus -Hemophilus influenzae type B.
Aspiration pneumonia -necrotizing pneumonia -pathological changes in the lungs. -aspiration of vomitus: -altered state of consciousness -seizures -alcohol -anesthesia -shock, etc. - foreign body aspiration - toxic materials -gasoline or kerosene.
ASPIRATION PNEUMONIA
CLINICAL MANIFESTATIONS -Various physiological responses -pH of the aspirated substance. -productive and painful cough -consistency and color of the sputum varies. -severe chills, elevated temperature,
increased heart and respiratory rate -Clinical manifestations - dependent on the type of pneumonia.
ASSESSMENTSUBJECTIVE: -onset of symptoms -duration of cough. -fever -night sweats
OBJECTIVE: - Level of consciousness/mental status changes - Vital signs, especially the temperature every 2 hours or as ordered. - Sputum - color, consistency, and amount - Use of accessory muscles - Cyanosis or dyspnea. - Auscultate the lungs -crackles on inspiration/pleural rub.
SPUTUM AND SPUTUM SPECIMEN
DIAGNOSTIC TESTS -Blood and sputum cultures. -Collect the sputum BEFORE the
beginning of antibiotic therapy. -Chest x-ray. -CBC -WBC count with the differential. - ABG test. -Pulmonary function tests (PFT’s) -Pulse oximetry.
Pulse oximetry, pulmonary function test
ABG test
Medical management Medications- -antibiotics: -erythromycin -cephalosporin -tetracycline
- antibiotic depends on the causative organism. -no definitive treatment for viral pneumonia. -analgesics
-antipyretics -expectorants -bronchodilators
Expectorant, Bronchodilator
BRONCHODILATOR
Medical Management -Humidification with humidifier/nebulizer -secretions are tenacious. -Oxygen -O2 saturation is < 91%. -Venturi mask or nasal cannula is used. -Pneumonia vaccine for the most common
bacterial: -streptococcal (or also called Pneumococcal) pneumonia. -recommended for the people at risk -given again after age 65
NURSING INTERVENTIONS -Patient should conserve energy -plan strategies to allow for rest periods. -High Fowler’s position -allows for optimal air exchange. -Position the patient with the good lung down -PaO2 rises when the healthy one is dependent. -Assess the patient’s ability to cough up
secretions. -Assist with: - coughing, suctioning, positioning, liquefying secretions
NURSING INTERVENTIONS -bronchodilators, mucolytics, and expectorants: - dilate the bronchioles - remove secretions. -auscultate the lungs -every 2-4 hours -especially before and after treatments and suctioning -characteristics of the cough and the sputum. -hydration -at least 3 liters per day -oral or IV fluids.
NURSING INTERVENTIONS -at least 1500 cal. per day -small, frequent meals.
Patient and family teaching -deep breathing and coughing techniques. -Good handwashing!!!!!!! -medications -reasons - importance of taking the full course of the prescribed medications -disease process - treatment - possible complications - duration
Teaching -inform his PCP about a change in his health
status - fever despite having taken the full course of antibiotics - change in the color of his sputum - feeling more fatigued - more dyspneic, etc. -balance of exercise and rest. -availability of a Pneumococcal vaccine.
PROGNOSIS -resolves in 2-3 weeks with proper treatment. -most common cause of death from
infectious disease in North America. -Bacterial aspiration pneumonia has a poor
prognosis despite antibiotic therapy -extensive lung damage -resulting lung abscess or empyema.
PLEURISYEtiology/Pathophysiology -inflammation of the visceral and parietal
pleurae. -either a bacterial or viral infection. -occurence: -may occur spontaneously -complication of: -pneumonia -pulmonary infarction -viral infections of the intercostal muscles -pleural trauma -early stages of TB -lung tumor
PLEURISY
CLINICAL MANIFESTATIONS -Sharp, inspiratory pain, -radiating to the shoulder or abdomen of
the affected side -stretching of the inflamed pleur. -If pleural effusion develops -pain subsides -fever and dry cough occur. -Dyspnea, increased temperature
ASSESSMENT
SUBJECTIVE:
-chest pain on inspiration -increased temperature
OBJECTIVE: -assesses the nature of the inspiratory pain with its radiation pattern -vital signs, especially the temperature every 2 -4
hours. -auscultate the lungs -pleural friction rub should be heard -respiratory rate and rhythm -note any dyspnea
DIAGNOSTIC TESTS -Physical exam -presence of a pleural friction rub. -Chest x-ray -not diagnostic unless there is a pleural
effusion.
MEDICAL MANAGEMENT -Injection of an anesthetic block around the
vertebra -blocks the intercostal nerves -relieves the pain -Prescribed medications: -antibiotics -analgesics -antipyretics -oxygen
NERVE BLOCK
NURSING INTERVENTIONS -Position the on the affected side to splint
the chest -Heat or cold may be applied to the area -Effectively cough every 2 hours -Splint the affected side -Signs/symptoms of exacerbation: -purulent sputum -increase in temperature -increased pain
PLEURAL EFFUSION and EMPYEMA
Etiology/Pathophysiology - Pleural effusion -pleural lining is inflamed -fluid can accumulate in the pleural space -secondary problem -occurs when physiological pressure in the
lungs and pleurae is disturbed -alteration of pressure gradients -surface characteristics of capillaries.
Blood and/or purulent drainage in the pleurae
Empyema -pleural fluid becomes infected -may be acute or chronic. -acute empyema -inflammation of the affected area with a thin
layer of fluid -untreated (chronic) -fluid thickens - pleura becomes scarred and fibrosed, losing
its elasticity
CLINICAL MANIFESTATIONS -result of bacterial infection. -persistent fever despite taking antibiotics. -associated with other disease processes: -pancreatitis -CHF -pulmonary edema, etc.
ASSESSMENTSUBJECTIVE: -difficulty breathing, air hunger. -feelings of fear and anxiety related to
decreased levels of oxygen.
OBJECTIVE: -signs and symptoms of respiratory distress -decreased breath sounds.
DIAGNOSTIC TESTS -Chest x-ray. -Thoracentesis -obtain a specimen for C+S -remove excess fluid.
MEDICAL MANAGEMENT -Under normal conditions - intrapleural pressure is below
atmospheric pressure - if intrapleural pressure becomes equal to atmospheric pressure, the lungs will
collapse.
MEDICAL MANAGEMENT Insertion of a chest tube -continuous drainage -medication instillation -prevent the lung from collapsing -a closed system is used Chest tubes are placed in the pleural cavity -drains blood, fluid, or air -re-establishs a negative pressure.
CHEST TUBES -chest or thoracotomy tubes are attached to a
closed, water-seal drainage system.
CHEST TUBE BOTTLES, PLEUROVAC UNIT
CLOSED- SYSTEM, WATER-SEAL DRAINAGE
CHEST TUBE
-If two thoracotomy (chest) tubes are inserted
-one is placed in the anterior chest wall
-removes air from the pleural space
-second tube is inserted through a stab wound in the
posterior chest
- larger in diameter
-removes sero-sanguinous fluid/purulent exudate
from the pleural space.
NURSING INTERVENTIONS -Patient is on bed rest. -Oxygen therapy may -frequent oral care - prevents drying of the mucous membranes. -Deep breathing and coughing every 2 hours. - Auscultate the lungs every 2-4 hours; -Assess the dressing for drainage - color, odor, amount -Ensure the patency of the chest tube system. -keep straight, connections are secured and
coiled loosely.
-Position the patient on the unaffected lung side
-When able to ambulate
-chest tube must be below the level of the chest
-prevent any fluid from draining back into the
pleural cavity
-Document at the end of the shift:
-amount
-color
-consistency of the chest tube drainage
-antibiotics -explain the chest tube insertion procedure to the patient -answer any questions about the patient’s condition and treatments -allay anxiety -practice deep breathing and coughing
with the patient
ATELECTASISEtiology/Pathophysiology -All or part of the lung collapses -Causes hypoventilation -gas exchange is not adequate to meet the
metabolic needs of the body -bronchial obstruction caused by mucous accumulation. -prevents the respiratory exchange of carbon
dioxide and oxygen -common post-op complication -resulting from shallow breathing.
- Accumulation of secretions, a foreign body, or a
tenacious plug -occludes a bronchus. -Compression of lung tissue - emphysema, pneumothorax, or a tumor. -Pathophysiology depends on the site and the degree of occlusion. -Stasis pneumonia -secretions are rich in nutrients for the growth of bacteria -lung damage.
ATELECTASIS
CLINICAL MANIFESTATIONS -Dyspnic -Tachypnic -Pleural friction rub -Restless -Hypertensive -Increased temperture
ASSESSMENTSUBJECTIVE: -Dyspnea -Requires more effort to breathe -Fatigue. -Feeling of air hunger -Anxiety
OBJECTIVE: -Decreased breath sounds -Crackles on auscultation. -Hypertension will be present at first -followed by hypotension. -Respiratory rate -Amount of effort required for breathing. -Level of consciousness (LOC) - hypoxic -may exhibit an altered LOC.
DIAGNOSTIC TESTS -Serial chest x-rays -same area for comparison. -ABG’s -PaO2 may be < 80 mm. Hg. -improves within the first 24 hours. -Pulse oximetry -< 90% because of hypoventilation -Bronchoscopy -bronchial obstruction.
BRONCHOSCOPY
MEDICAL MANAGEMENT -Incentive spirometry -10 times every hour while awake. -Oxygen therapy. -Suctioning may be needed. -Prescription medications: -bronchodilators -antibiotics -mucolytics -Intubation with mechanical ventilation
NURSING INTERVENTIONS -Deep breathe, cough, and change position
every 1-2 hours (DB,C,T) -Analgesics -relieves pain -facilitates ventilatory effort -Give emotional support. -Early ambulation.
PATIENT AND FAMILY TEACHING -Effective deep breathing and coughing
techniques. -Measures for optimal gas exchange: -exercising -changing positions -Medications prescribed -side effects
PNEUMOTHORAXEtiology/Pathophysiology -Collection of air or gas in the pleural space -causes the lung to collapse. -secondary to a ruptured bleb or a severe
coughing spell. -penetrating chest injury -pleural lining is punctured -fractured rib -insertion of a sub-clavian catheter -spontaneous rupture without any obvious
cause
PNEUMOTHORAX -Pleural cavity is penetrated -air enters -normal negative pressure is
interrupted -lung collapses.
PNEUMOTHORAX -Spontaneous pneumothorax -rupture of a bleb -Open pneumothorax -opening through the chest -Tension pneumothorax -blunt chest injury -
PNEUMOTHORAX
CLINICAL MANIFESTATIONS -Recent chest injury. -Decreased breath sounds -affected side. -Sharp, sudden pleuritic chest pain -with shortness of breath. -Diaphoretic -Increased heart and respiratory rate -Lack of chest movements -affected side. -Pneumothorax is from a penetrating injury -sucking sound on inspiration.
Pneumothorax
CLINICAL MANIFESTATIONS -Mediastinum shifts to the unaffected side. -As intrathoracic increases -cardiac output decreases -venous return is decreased -compression on the great vessels
ASSESSMENTSUBJECTIVE: -Recent penetrating chest wound -Severe coughing episode -Shortness of breath (SOB) of sudden
onset. -Feelings of air hunger -Anxiety
•OBJECTIVE: -Frequent vital signs - Change in heart and respiratory rate or heart rhythm -Unequal breath sounds on the right and
left sides -diminished sounds on the affected side. -Sputum -amount, characteristics and
color
DIAGNOSTIC TESTS -Patient’s history. -Chest x-ray. -ABG test.
MEDICAL MANAGEMENT -Thoracotomy -insertion a chest tube -chest tube is then attached to a water-seal
drainage system -Heimlich valve -stopgap measure until chest tube therapy
can be started
HEIMLICH VALVE
NURSING INTERVENTIONS -Patent airway. -Adequate oxygenation. -Chest tube patent. -Chest tube drainage -color , consistency and amount of per shift. -Monitor BP. -High Fowler’s position -promote lung expansion -removal of secretions. -Pain medication -do not depress the respirations.
PATIENT AND FAMILY TEACHING -Explain the rationale for the treatments -before they are implemented -Reinforce the need for ongoing effective
breathing techniques -Limit exposure to people who have infections. -upper resp. infection, influenza -Copious fluid intake -Discourage smoking -Avoid fatigue and strenuous activity. -Report any recurrent s/s to the PCP -fever, chest pain, difficulty breathing, etc.