STUDY GUIDE TEST 1Rhinitis

Definition – inflammation of nasal cavities

Allergic rhinitis: pollens

Acute viral rhinitis: coryza, spread by droplets.

Home care: fluids, bedrest, humidification, Echinacea, Vit. C, Zinc, Handwashing.

Etiology: Allergen- plant, food: hay fever, complication: otitis media, hearing loss, pneumonia.

Virus, bacterial, excessive medication use

Transmission: droplet or direct contact (Table 25-3, p. 447, PPE review: Table 25-2, p. 446)

Assessment: rhinorrhea, congestion, sore throat (initial symptom if viral), HA, fever

Implementation: Pharmocological: OTC medications : Antihistamines, decongestants, nasal steroids,

Analgesics, antipyretics, antibiotics (bacterial), desensitization

Complemenary/Alternative:

Nursing: Deficient Knowledge-

Sinusitis:

Definition- inflammation of mucous membranes of one or more sinus cavity

Acute- Etiology- bacteria, virus

Chronic- Etiology- repeated infections causing mucous membranes to thicken resulting in : h/a, dull aching pain, facial swelling, chronic cough, sleeplessness.

Obstruction of drainage

Assessment- HA, facial pain, nasal congestion, fever, purulent nasal drainage, tenderness, bad breath

Complications: orbital celulitis, meningitis, abscess.

Implementation: Medical: Pharmacologic-Broad spectrum antibiotics, analgesics, decongestants, expectorants

Surgical:

Maxillary Antral Irrigation- under local anesthesia, antral puncture+lavage, outpt. Procedure- irrigated w/saline.

Caldwell Luc Procedure- incision under upper lip into maxillary sinus. Infection removed- may have difficulty eating b/c pain and swelling.

Ice packs, oral hygiene (Gentle), change dressing prn, limit valsalva maneuver, no coughing or blowing nose, no lifting, situate in semi-fowlers, eat soft foods, use analgesics, increase fluid intake.

Nursing: Post-op (Iggy, Chart 33-1, p. 655)

Education: Post-op-

Conservative treatment- Use of meds, comfort measures, humidification, saline irrigations,

hot wet packs over sinus, increase fluids

Influenza:

Definition: Acute viral resp infection, seasonal

Etiology: Virus A, B, C, H1N1 (3-7 day duration, malaise 14 days after)

Assessment: Initial- severe HA, myalgia, fever, chills, fatigue

1-2 weeks later- sore throat, cough, rhinorrhea, fatigue

Implementation: Acute- Antiviral agents, antihistamines

BR, increase fluids

Prevention- Immunizations

Complications- pneumonia CDC. Seasonal Influenza: complications: bronchitis, pneumonia, worsen COPD.

Symptoms begin 2-4 days after exposure and last 5-6 days.

MRSA

- transmitted by infection (hands) or colonized carriers (nares).

-eradicate with topical agent (bactroban) to nares & oral Ab (Bactrim).

-tx. Of infectious patients Vancomycin or Rifampin IV. Alcohol foam can be used for MRSA but can NOT be used for C-diff.

-contact/ airborne/ droplet isolation- wearing gloves & gown if direct contact, mask, private room-------don’t use shared equipment or do not allow to touch bed or bedstand------clean room items daily with antiseptic. Pts are in negative pressure room.

- they might need fit tested masks, that are different than a regular surgical mask. M95 mask

Pneumonia: 8 th leading cause of death in US + 3 rd leading cause of death in persons >85 y/o.

Description- Acute infectious process of bronchioles, alveoli, interstitial spaces

Decreasing compliance & causing hypoxemia

Pathophysiology: organisms: streptococcus (pneumococcal pneumonia, hemophilous influenza, staphylococcus aureus, pneumocystitis carnii (AIDS).

Classification-

Bacterial vs viral: Bacterial- acute onset, chills, fever, productive cough, pleuric chest pain, crackles, tachypnea, tachycardia. VIRAL—sudden, gradual, mild, and flu-like.

Community acquired (CAP) vs hospital acquired (HAP)

Location- bronchopneumonia, lobar

Etiology- Infectious- bacteria, virus, mycoplasma, fungi, protozoa

Non-infectious- toxic gases, chemicals, smoke, aspiration

Risk factors: older, institutionalized, ventilator.

Assessment- (Iggy, Table 33-3, p. 663)

Subjective: Exposure? Risk factors?

Objective: fever (high in bacterial), cough, pleuritic chest pain

VS- tachypnea, tachycardia, BP____low_____

Adventitious lung sounds-

Sputum- hemoptysis, rust, bloody-colored, creamy yellow, green, white, cleareen.

Sputum: pneumococcal- rusty brown, blood tinged. Staph—creamy yellow. Pseudomonas—green.

Diagnostics- sputum C&S, CBC, ABGs, CXR (diffuse patches or consolidation), blood cultures,

Pulse oximetry, electrolytes

White count elevated, pulse ox lowered, check BUN and Na+ for dehydration.

Droplet Precautions- (Table 25-3, p. 447)

Implementation: Medical- oxygen, supportive, nasotracheal suction as needed

Pharmacologic- antimicrobials, bronchodilators, antitussives, mucolytics, expectorants,

Steroids (aspiration pneumonia), nicotine patches, Goldenseal, immunizations

Nursing- Nursing Diagnosis (Iggy, Concept Map, p. 662; Chart 33-6, p. 664; Chart 33-4,

p. 660) & Guidelines for Preventing Health Care Associated Pneumonia (CDC)

Impaired Gas Exchange- Oxygen therapy, monitor respirations, positioning

Ineffective Airway Clearance- Encourage effective coughing techniques, hydration, position pt sitting straight up, incentive spirometer, have suctioning available.

Acute Pain- analgesics---relieve pleuritic pain

Hyperthermia

Deficient Fluid Volume- Manage fluids, monitor sodium, nutrition--- increase fluids 2500-3000 ml/day.

Deficient Knowledge- Use of meds, activity, infection control, S&S to report----explain about pneumonia vaccine.

Health Promotion- Prevention (pneumococcal & influenza vaccine)

Complications: hypoxemia, hypercapnia (Elevated CO2), atelectasis, pleural effusion, empyema, septicemia

Tuberculosis

Description- Highly communicable acute/chronic, bacterial reportable disease; Insidious onset

Can affect lungs or extra-pulmonary organs-----characterized by formation of tubercles. For curable infections, it is the number one cause of death. Highly contagious, can be acute or chronic. Is found in the lngs, joints, kidneys, or pericardium. When cases are known they must be reported to the health department.

Is an indisious disease so people can have it for a while before knowing it, thus spreading it to others.

Transmitted by infected inhaled droplets entering the lungs, and traveling to the small air sacs (Alveoli). ----suspended in the air or on dust particles for long periods. Spread by coughing, talking, singing, laughing. The inflamed area becomes surrounded by collagen, fibroblasts, and lymphocytes. If there is no tx, the site can become necrotic (caseation), and become a cavity….if still continues, can progress into effusion like pericardial effusion.

2-8 weeks after exposure the immune system walls off the infection with macrophages.

Risk Factors- Repeated close contact, foreign born or travel to high risk countries, known HIV+,

Immunosuppressed, high risk health care worker, IV drug users, malnutrition, inadequately treated

Transmission/Pathogenesis

Mycobacterium tuberculosis- acid fast rod, aerobic

Exposure- Transmitted by airborne route (Table 25-3, p. 447): Concern with exposure to

concentration of droplets and close proximity over prolonged period of time

Infected without Active Disease- Usually immune system competent; usually resolution

Infected with Active Disease- Tubercle lesion encapsulated; caseation; calcification ro liquifiecation;

cavitation; may spread to pleura or other organs

Latent TB Infection (LTBI) which may be reactivated later; No symptoms, not appear ill, not infectious, Usually has +PPD w/ normal chest x-ray, sputum culture negative, TST or blood test results usually positive. Inactive, confined tubercle bacilli in the body.

TB disease in Lungs: Active, multiplying tubercle bacilli in the body, TST or blood test results usually positive, Chest X-ray usually abnormal, Sputum smears and cultures may be positive, Symptoms such as cough, fever, weight loss, Often infectious before tx., A case of TB.

Assessment

History: Recent exposure? Travel to other countries? Previous tests? Past tx? Recent BCG vaccine?

Other risk factors?

Early S&S: persistent cough w/ sputum production, low grade fever (In afternoon), fatigue, night sweats, Anorexia, wt loss.

Later S&S: Bloody sputum (hemoptysis), chest pain, SOB

Diagnostics: Tuberculin Skin Test

Purified Pretein Derivative (PPD)(Mantoux): 0.1ml = 5 U tuberculin, intradermal

Read ______48-72______hrs (Evidence Based Practice)

Measure ONLY induration & record in mm

< 5-9 mm (+) >10-14 mm (+) >15 mm (+)

HIV + Travelers/immigrants No known risk

Immunosuppressed IV drug users

Fibrotic changes consistent w/ old TB on chest x-rays

Residents & workers in crowded

living conditions

Ten mm under normal circumstances, and 5mm in immunocompromised pts.

Other diagnostics: Chest x-ray= does not confirm diagnosis

Sputum smear for AFB- early morning specimens on 3 consecutive days

Sputum culture for M. tuberculosis = Confirms diagnosis

Drug susceptibility testing- ensure appropriate treatment & ID drug resistance

Goal- prevent transmission, control symptoms, & prevent progression of disease

Treatment: active disease—6-12 months tx.

-Direct Observation Therapy- If pts not compliant, health care workers go to the residence and MAKE them take their pills. TXs are: Isoniazid, Rifampin, Pyrazinamide, Ethambutaol.

Implementation:

Medical: Pharmacologic-

Infected without Active Disease- Chemoprophylaxis with INH, PZA

Infected with Active Disease- Combination therapy (Iggy, Chart 33-8, p. 671)

Direct Observed Therapy (DOT)

Length of tx

Be aware of multi-drug resistance

BCG (Bacillus of Calmetter & Guerin) vaccination- not widely used in US; Effectiveness is variable

Nursing: Impaired Gas Exchange

Ineffective Airway Clearance

Deficient Knowledge:

Transmission/Prevention behaviors

Transmission-Based Precautions (Infection Control)-

Airborne Precautions- Pt wears mask if must leave room

HANDWASHING!!!

Medication compliance

Follow-up care- Discontinue precautions when have 3 consecutive negative sputum cultures

Follow-up sputum cultures done q2-4 wks during treatment

KNOW to report S&S of toxicity, monitor compliance, stress follow-up, watch out for multiple drug resistance. After three negative cultures, pt is no longer infectious.

Nutrition

Social Isolation- Co-habitants all tested & prophylactically treated

May return to work after negative cultures

Need good ventilation

Fatigue will diminish

Histoplasmosis

Description- Pulmonary & systemic fungal infection from inhalation of spores found in soil contaminated w/ excreta

Caused by Histoplasma Capsulatum organism found in soil, floors or chicken houses, & in bird droppings

Not transmitted from person to person

Patho – inhaled fungi result in development of a lesion in lung parenchyma. Lesion eventually becomes

Fibrotic & calcified. When clacified, no reactivation of disease. May initially extend to lymph nodes, liver,

& spleen.

Assessment- dyspnea, pleuritic chest pain, respiratory illness similar to TB, fever

Diagnostics- skin test, CXR, positive culture

Intervention: no treatment if mild

Medical: Oxygen, TCDB, semifowlers

Pharmacologic: Antifungal drugs: Amphotericin B (Fungizone) x3 months, also Nizoral, Corticosteroids, Antihistamines----may cause nephrotoxic, ototoxic, hypokalemia, seizures, HA, anaphylaxis. -----TEACH to hose down if working in suspicious areas.

Corticosteroids, antihistamines, analgesics

Nursing- preventive: education- hose down if working in areas where organism may be found;

symptom management- education about meds

Pleurisy (Pleuritis) – inflammation of the pleura

Etiology- pneumonia, TB, chest trauma, chest wall infection

Patho- reddened pleura=>exudates=>inflammation=>adherence=>restricted

Expansion=>TV decreased=>atelectasis=>infection=>hypoxia

Assessment- knife-like pain w/ inspiration, pleural friction rub, cough, hypoxemia

Intervention- treat cause

Severe Acute Respiratory Syndrome (SARS)

Etiology- Coronavirus

Patho- inflammation remains in respiratory system

Transmission by airborne route (Table 25-3, p. 447)

Assessment- high fever (>100.4), HA, malaise, dry cough, hypoxia, dyspnea, cyanosis

No diagnostic test

Intervention- No effective treatment; supportive treatment during infection

Preventative activities

Chronic Bronchitis

Description- condition characterized by chronic airway (not alveoli) inflammation Inflammation of large (bronchi) & small (bronchioles) airways r/t continuous exposure

to irritants; thick mucus + thick bronchial walls = impaired airflow and impaired gas exchange = dec. PaO2 and incr. PaCO2

By definition: experience excess mucus production & recurrent productive cough on most days x 3 months/yr for @ least 2 consecutive years

Incidence- 1 out of every 14 people over 45 y/o; usually begins 5th or 6th decade of life; more common in men, urban, disadvantaged

Etiology-smoking, air pollution, chronic resp infections including sinusitis, heredity

Patho- inflammation=>increased mucus production=>hypertrophy of mucous secreting glands=>more mucus secretion to decrease irritiation=>narrowing of structural airways because thickened bronchial walls

Results in mucous plugs, increased airway resistance, hypoxemia, hypercapnia, & resp acidosis.

Ultimately, hypoxia, central cyanosis, & polycythemia

Clinical Manifestations- productive foul smelling chronic cough, early morning cough, grayish-white sputum, inspiratory crackles, dyspnea, orthopnea tachycardia, Later stages: polycythemia, cor pulmonale (hypoxemia, respiratory acidosis, cyanosis, JVD, hepatomegaly, peripheral edema (See Iggy, Chart 32-8, Cor Pulmonale, p. 623)

“Blue Bloater”- color dusky to cyanotic, increased sputum, hypoxia, hypercapnia, acidosis, edematous, exertional dyspnea, digital clubbing, cardiac enlargement, use of accessory muscles, cor pulmonale.

More common in women than men.

Diagnostics: Elevated RBC, Hgb, Hct, WBC

Pulmonary Function Studies (PFS): Increased Residual Volume (IRV), decreased Vital Capacity (VC), Forced Expiratory Volume (FEV)

Sputum cultures

Management- Improve oxygenation & decrease CO2 retention, O2 @ 1-3L/m, effective cough

Meds: Antibiotics, corticosteroids, bronchodilators, anticholinergics, immunizations

Relaxation exercises, meditation, purse-lip breathing, 3-point position, abdominal

Breathing, isometric exercises, breathe in through the nose and exhale slowly through the mouth.

Avoid pulmonary irritants, smoking cessation PG. 624 in IGGY….look at this picture.

Emphysema

Description: Progressive loss of elasticity (loss of stretch and recoil ability) of alveolar sacs, destruction of alveolar walls, collapse of bronchioles & the alveoli become enlarged permanently. Decreasing quality of life. Long term decline in function of lungs; > 50% of patients report being limited in ability to work.

Results in air trapping, hyperinflation of lung, decreased gas exchange, , & retention of CO2, ventilatory dead space flattened diaphragm .

Ultimately, resp alkalosis progressing to resp acidosis

These changes lead to obstructed air passages

“Pink Puffer” S&S: no cyanosis, purse lip breathing, dyspnea, ineffective cough, hyperresonance on chest percussion, orthopneic, barrel chest, exertional dyspnea, prolonged expiratory time, speaks in short jerky sentences, anxious, use of accessory muscles for breathing, thin appearance, leads to right sided heart failure.

Etiology- smoking, air pollution, enzyme deficiencies

Patho- elastin is destroyed by proteases from neutrophils=>loss of elastic recoil (driving force of expiration lost)=>small airways collapse=>overdistended alveoli=>flattened diaphragm=>chest wall springs out=>inspiratory muscles operate at shortened length

Clinical Manifestations- General appearance- position?

Weight- typically lose weight and can become very thin, leading to protein loss, or nutritional imbalances.

Resp- early dyspnea on exertion, progressing to when at rest

Wheezes, crackles, use of accessory muscles, decreased FEV & VC, increased RV;

Decreased breath sounds, increased A-P diameter (barrel chest)

Acid-Base balance- mild hypoxemia with respiratory alkalosis progressing to severe

Hypoxemia with respiratory acidosis, tachycardia

Diagnostics: ABGs, Pulse ox, Chest x-ray, PFS, electrolyte levels

COPD MANAGEMENT: diaphragamatic breathing, pursed lip breathing, controlled cough, O2 therapy, hydration nd humidification, chest physiotherapy & PD (not routinely), surgical management includes lung reduction surgery, and smoke cessation problems.

CHRONICALLY ELEVATED CO2 IS CALLED CO2 NARCOSIS-------KNOW THIS!!!

Medical Management:

Pharmacologic: (See Iggy, Chart 32-5, pp. 616-618)

Stepped therapy

Bronchodilators: key to managing symptoms of COPD

Bronchodilators: give 1st in sequence – why?____________

Beta2 Adrenergics: Short Acting- Albuterol; Salmeterol Methylxanthines: Theophylline [monitor levels; avoid caffeine] Anticholinergics: Ipratropium [blocks parasympathetic system to allow sympathetic system to increase bronchodilation] Combinations: Ipratropium and Albuterol

Anti-inflammatory

Corticosteroids: Prednisone; Fluticasone [monitor for oral fungal infections]

Pneumonia + influenza vaccines should be given to COPD patients

Airway #1

Controlled Cough: Huff coughing

Chest physiotherapy & Postural Drainage (examples shown, Iggy, p. 632)

Suction

Breathing techniques (See Iggy, Chart 32-10, p. 631)

Diaphragmatic Pursed-Lip- Oxygen therapy Remember- Hypoxic drive (LOW ARTERIAL O2 LEVEL) is pts drive to breathe! 1-3 L/NC Hydration & humidification Exercise

Lifestyle: healthy diet; avoid pollutants

Pulmonary Rehab: focus on prevention and coping with dz

Surgical Management:

Lung reduction surgery – research: risk of death in severe lung obstruction?

Lung transplantation increasing #s (severe emphysema)

EDUCATE (See Iggy, Chart 32-6 & 32-7, p. 619; Fig. 32-5, p. 620)

*Metered Dose Inhaler (MDI) w, w/o spacer & Dry Powder Inhaler (DPI)

MDI: need hand-lung coordination; spacers increase delivery

DPI: breath activated/ease of use

Nebulizer: converts drug to mist via face mask or mouthpiece/portable/slower delivery

*Home Care [ wt mngmt; supplements; monitor for infections; when to call doc; schedule rest; prioritize activities; etc. pulm rehap]

Nursing Management: (See Iggy, Chart 32-9, p. 629)

Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Altered Nutrition, < BR Activity Intolerance

Oxygenation/ Oxygen Use

Goal: Use lowest fraction of inspired oxygen (FIO2) to obtain highest level of oxygenation w/out side effects Consider oxygen a medication! Measurement through ABGs & pulse oximetry Room air is 21%

Methods of Delivery (See Iggy, Table 30-1 & 2, p. 575 & 577)

FIO2 Delivered Nursing Care

Nasal Cannula Low flow--- 1-6 L---24-44% Monitor skin integrity

Simple Face Mask Low flow ----40-60% O2---- Careful in pts with n/v…..can aspirate

Partial Rebreather Mask Low flow-----6-11 L of 60-75%---

Nonrebreather Mask Flow Meter----15 L (all the way up) 80-90% O2

Venturi Mask High flow ----55 %=10 L, and 24%=4L

Monitor skin integrity.

Nursing Management (See Iggy, Chart,30-1 Oxygen Therapy only, p. 572, AND Chart 30-2, p. 574

Oxygenation Complications Nursing Care

Combustion No smoking

Suppresses Ventilation

Oxygen Toxicity Look for s&s, if given more thAN 48 HRS, look for nonproductive cough, SOB, chest pain, and crackles. Call MD who will then prob. Check ABG’s. For COPD, if CO2 is greater than 90 will be big cause for concern

Dry Mucous Membranes Mouth care, encourage fluids

Infection Change out equipment per protocol.