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Chapter 27 & 28 Lower Respiratory and Obstructive Pulmonary Disease '17

The medical side of the respiratory and lower respiratory system divin...

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Medical Terminology (AHCC 003)

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Chapter 27 Lower Respiratory Problems

Pneumonia Definition: Acute infection of the lung parenchyma. Pneumonia

Etiology Incompetent defense mechanisms or overwhelmed defense mechanisms. Decreased LOC, intubation, air pollution, viral URI, and normal changes that occur with aging. Chronic diseases can also suppress the immune system. Organisms reach the lung by three ways: Aspiration, inhalation, and hematogenous spread. Refer to Table 27. Risk Factors for Pneumonia.

Types of Pneumonia Community-Acquired Pneumonia: acute infection of the lung occurring in clients who have not been hospitalized or resided in a long-term care facility with 14 days of the onset of symptoms.

Hospital-Acquired Pneumonia (nosocomial pneumonia): occurs 48 hours or longer after hospitalization and was not incubating at the time of hospitalization. Ventilator-associated is pneumonia that occurs more than 48 hours after endotracheal intubation.

Aspiration Pneumonia: results from the abnormal entry of materials from the mouth or stomach into the trachea and lungs.

Opportunistic Pneumonia: individuals at a higher risk of developing pneumonia such as individuals with an altered immune response.

Pathophysiology PATHO CHART ON PAGE 505

Clinical Manifestations Cough, fever, shaking, chills, dyspnea, tachypnea, and pleuritic chest pain. Cough may/may not be productive, sputum may be green, yellow, or rust colored. Hypothermia may be assessed on older clients. Rhonchi and crackles may be auscultated.

Complications Pleurisy

Pleural effusion

- Usually is sterile and reabsorbed in 1-2 weeks or requires thoracentesis

Atelectasis

- Usually clears with cough and deep breathing

Pneumothorax

- Air collection in the pleural space, causing lungs to collapse

Lung abscess

- Seen when caused by S. aureus and gram-negative pneumonias

Empyema

- Requires antibiotics and drainage of exudate

Pericarditis - From spread of microorganism

Meningitis

- Patient who is disoriented, confused, or somnolent should have lumbar puncture to evaluate meningitis

Sepsis/septic shock

- Microorganisms🠀 bloodstream

Diagnostic Studies History

Physical exam

Chest x-ray

Gram stain of sputum

Sputum culture and sensitivity

Pulse oximetry or ABGs

CBC, differential

Blood cultures Table 27-4 Diagnostics

Collaborative/Nursing Management

Pneumococcal vaccine: for individuals 65 and older OR younger clients at high risk. (See Table 27 Pneumococcal Vaccines)

Classification Classified according to presentation and whether it is pulmonary or extrapulmonary. Primary infection occurs when the bacteria is inhaled and initiates an inflammatory reaction. Latent TB

infection occurs in a person who does not have active TB disease.

Clinical Manifestations Clients with LTBI have a positive skin test but are asymptomatic. Characteristic pulmonary manifestations are dry cough that frequently becomes productive with mucoid or mucopurulent sputum. Active TB manifests with fatigue, malaise, anorexia, unexplained weight loss, low-grade fever, and night sweats. HIV infected and other immunosuppressed individuals respond differently to TB. Refer to Table 27 for further breakdown of symptoms.

Complications Organ damage due to widespread dissemination of the bacteria. Pleural TB can result from either primary disease or reactivation of a latent infection. Acute pneumonia may result when large amounts of tubercle bacilli are discharged from granulomas into the lung or lymph nodes. Spine complicates may develop, CNS TB may cause severe meningitis.

Diagnostic Studies Tuberculin skin test (Mantoux test), Interferon release assays,

chest x-ray, or bacteriologic (sputum) studies.

Collaborative/Nursing Management

Clients with sputum smear-positive TB are considered infectious for the first 2 weeks after starting treatment. Educate client on restricting visitors and avoid travel on public transportation and trips to public places. Clients who are severely ill or debilitated may require hospitalization. Education regarding hand washing should be provided. Isolate hospitalized client in negative airflow room RN’s do not need a physician order to initiate this

Anti-TB Medications:

Multiple (at least 3) anti TB drugs because have mutated resistant disease (main 2 drugs are liver toxic; monitor AST, ALP, ALT, S/S of liver damage [e. jaundice])

- Should not take ETOH w/ any of these drugs

- Side effects: n/v, anorexia, clients usually noncompliant b/c this makes them sick

- Hepatotoxic. INH is also neurotoxic

Latent TB treated with one drug for 9 months

TB Medications:

Rifampin (RIF)= cause urine, tears, and sweat to be orange

- Use of ETOH or INH increases risk of hepatotoxicity

Isoniazid (INH) = cause peripheral neuropathy🠀 vitamin B6 given to prevent Other meds: pyrazinamide (PZA), ethambutol (EMB), streptomycin.

Refer to Table 27-11/12 Drug Therapy for more details. Ensure you are understanding regarding induction and continuation phase of TB medications and directly observed therapy.

manifestation if a small pneumothorax is present. If there is a large pneumothorax, respiratory distress will be present. Types of Pneumothorax

Spontaneou s

Usually occurs due to rupture of small blebs located on the apex of the lung. Smoking increases this risk along with being tall and thin, male gender, family history, and previous spontaneous pneumothorax.

Iatrogenic Meaning “of or relating to illness caused by medical examination or treatment.”

Can occur due to laceration or puncture of the lung during medical procedures.

Tension Occurs when air enters the pleural space but cannot escape causing increasingly elevated intrapleural pressures 🠀 compression of the lung on the affected side along with pressure on the heart.

Hemothorax Accumulation of blood in the pleural space resulting from injury to the chest wall, diaphragm, lung, blood vessels, or mediastinum.

Chylothorax Presence of lymphatic fluid in the pleural space.

Know treatment management for emergency chest injuries (see Table 27)

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute respiratory distress syndrome

Pleural Effusion Definition: Abnormal collection of fluid in the pleural space. Empyema is the collection of purulent fluid in the pleural space caused by conditions such as pneumothorax. Clinical manifestations include dyspnea, cough, occasional sharp, nonradiating chest pain that is worse on inhalation. Other signs include decreased movement of the chest on one side, dullness on percussion, and diminished breath sounds. Pleural effusion may be seen on an x-ray if the accumulation of fluid is > 250 ml. Treatment involves treating the underlying cause.

Thoracentesis: Aspiration of intrapleural fluid for diagnostic and therapeutic purposes. Client is positioned sitting on the edge of the bed while leaning forward. Thoracentesis needle is inserted into the intercostal space and fluid is aspirated. Usually 1000-1200 mL of pleural fluid is removed at one time. Rapid removal can be dangerous and should be avoided. Observe client for hypotension and pneumothorax. Do not forget to do CXR post-procedure.

Chest Tubes and Drainage Systems

If you have an understanding of the principles of chest tubes and their drainage systems, you will be able to provide better care for the patient requiring this treatment. Merely maintaining an open and oxygenated airway will not result in adequate gas exchange if your patient has partial or complete lung collapse. This life-threatening condition is caused by an excess of fluid and/or air in the pleural space. Under normal circumstances, the intrapleural pressure is below atmospheric pressure and is considered negative pressure (negative pressure in the lungs is similar to a continuous suction on the visceral pleura that keeps the lung expanded to the full space of the chest cavity). However, when the intrapleural pressure is altered by excess air and/or fluid, the lung may collapse. When lung collapse occurs, chest tubes are inserted to the intrapleural space to allow drainage of the problem substance, to restore normal intrapleural pressure, to permit expansion of the lungs, and to promote adequate gas exchange. Chest tubes are attached to a drainage system that is closed to atmospheric pressure.

Review of Respiration

The lungs are protected by 24 ribs, which also shape and support the chest wall. Movement of the chest wall during respiration is generated by the muscles of respiration: the

Expiration

Expiration is a relatively passive process. The diaphragm moves upward and external intercostals relax, decreasing the size of thoracic cage. The pressures within the thoracic cavity become less negative (rise) and air flows out of the lungs. Expiration can be an active process using the accessory muscles during periods of dyspnea when respiration becomes labored.

The Pleural Space

The parietal pleura is a membrane lining the chest cavity. The visceral pleura is a membrane lining the lungs. The space between these two membranes is known as the intrapleural space or pleural space. The pleural space is a potential space between the visceral pleura, the outer lining of the lung, and the parietal pleura, the inner lining of the thoracic cavity. These two surfaces are separated and lubricated by a thin fluid that is produced by the cells of the pleura. Its purpose is to let the surfaces glide smoothly during respirations. Normally the pleural space contains about 50 ml of fluid. The drainage of this space is regulated by the lymphatic circulation.

There are actually three potential spaces in the chest where fluids may collect: right pleural space, left pleural space, and mediastinum. The mediastinum is an extrapleural space that lies between the right and left thoracic cavities. Patients undergoing cardiac surgery often have mediastinal chest tubes placed to drain pericardial wound exudates and blood. If there is no outlet for postoperative mediastinal fluid, its accumulation can lead to excessive pressure that impairs cardiac function.

Normal Chest X-ray Simple Pneumothorax

Collapsed Lung

Tension Pneumothoraxes Mediastinal Shift to Left

Hemothorax

A hemothorax is a collection of blood in the pleural space, maybe from surgery, a traumatic injury, pulmonary embolus, lung malignancy, or complications of anticoagulant therapy. It is frequently found in association with an open pneumothorax and is then called a hemopneumothorax.

Chylothorax A chylothorax is the accumulation of lymphatic fluid in the pleural space caused by chest trauma, an expanding tumor, or surgery on mediastinal structures.

Pleural Effusion Pleural effusion is the accumulation of pathologic quantities of fluid in the intrapleural space. It is a symptom not a disease. Chest x-ray will indicate an abnormality if the effusion is greater than 250 ml. A small excess of fluid or blood will be absorbed by the body over time, and therefore, will not require chest tubes.

Pleural effusions may be transudative or exudative. A transudate occurs in noninflammatory conditions and are usually caused by an increase in hydrostatic pressure associated with CHF or a decrease in oncotic pressure associated with liver or renal disease. The resulting fluid is thin and watery. Some effusions related to CHF can be treated with diuresis - the idea is that decreasing the amount of the water component in the blood will cause the effusion to be re-absorbed. If the effusion is large enough to produce respiratory distress, or tension symptoms, a chest tube should be inserted.

An exudative pleural effusion results from increased capillary permeability during inflammation by diseases such as pulmonary malignancies, pulmonary infections, and pulmonary embolism. The resulting fluid is thicker and contains more protein than transudative effusions.

Fluid or blood is pulled down by gravity and tends to pool in the base and posterior areas of the lung. Pleural chest tubes inserted to drain fluid or blood are usually placed posteriorly near the base of the lungs, in the fourth to sixth intercostal space at the midaxillary line. The patient will be sat up and leaned over a bedside table. The patient may also straddle a chair, with the arms dangling over the back. If the patient is too heavy or weak to straddle the chair or dangle the legs over the side of the bed, simply leaning him all the way forward in the bed, hugging several pillows, may extend the ribs enough for the physician to insert the tube.

Mediastinal chest tubes are usually placed in the central chest during coronary artery bypass surgery, other thoracic surgery, or trauma along the anterior and/or posterior surfaces of the heart to drain blood and other fluids postoperatively.

Insertion of Chest Tubes

The insertion of chest tubes is a sterile procedure, generally performed by a physician with the assistance of a nurse. After handwashing, the nurse will gather the following equipment: several pairs of sterile gloves, sterile drape, betadine solution, vial of 1% lidocaine, alcohol sponge, 10 ml syringe, 22G 1 inch and 22G 5/8th inch needles, sterile forceps and scalpel, one rubber tipped clamp for each chest tube inserted, sterile gauze pads, sterile 4x4s, sturdy elastic tape and scissors, the chest tube, a trocar, suture kit, and the thoracic drainage system with its collection tubes. Most acute care facilities have thoracotomy or chest tube insertion trays. Assemble all this equipment onto a bedside table, preparing with sterile technique. An oxygen source, suction and emergency equipment must be nearby.

The selected chest tube must be of appropriate size. A #16 - 20 French catheter is inserted for air or serous drainage; A #28 to #40 is inserted for serous, thick or purulent drainage. Chest tubes are sized according to French sizing. French sizing refers to the diameter of the tube in millimeters from 8-40 Fr. Chest tubes are sterile, flexible, and nonthrombogenic and are composed of vinyl or silicone. They are typically packaged with an aluminum trocar and measures 20 inches in length (50 cm). The proximal end is fenestrated which means there are several holes along the sides to aspirate drainage from a greater area than just the tip of the tube. Chest tubes also have a radio-opaque line.

Hard to tell from which side the subcutaneous emphysema is coming – both eyes are certainly swollen. Is this patient a little heavy-set, or is that air in her facial tissue? Actually, if her eyes look like that, it is probably the second...

Chest Tube Drainage System

Gravity, positive pressure, and suction are the three basic principles used in closed chest drainage systems. Because gravity causes air and fluid to flow from a higher level to a lower level, the drainage system must always be kept lower than the patient’s chest. Fluid flowing back into the patient may be a source of infection, in addition to reducing capacity for gas exchange. The positive pressure created by the air or fluid in the chest cavity will seek to relieve itself to a lower pressure under water. If suction is added to this system, the subatmospheric pressure is further reduced, promoting air or fluid to move from the higher to the lower pressure more rapidly.

Chest drainage systems contain three basic compartments. In early systems, the three compartments were created in individual bottles, each with its own function. Disposable chest tube drainage systems or units that are used currently, such as the Pleur-evac, are three- compartment systems that utilize the same basic principles as the classic three-bottle system.

1. Drainage collection compartment

The first compartment receives fluid and air from the chest cavity. The fluid stays in this compartment while the air vents to the second compartment. The drainage collection compartment is a reservoir in which drainage can accumulate must be kept below the patient’s chest level to ensure gravity flow. Markings on the compartment indicate the fluid level.

2. Water-seal compartment

The second compartment called the water-seal compartment. The water-seal consists of a tube submerged under 2 cm of water that functions like a one-way valve. If the patient has air in the pleural space, the air enters from the collection compartment and bubbles up through the water in the second compartment. Removing the air from the chest cavity helps reestablish normal negative intrapleural pressure. If air is in the pleural space, there will be intermittent bubbling in the water-seal during expiration and no bubbling during inspiration. (However, in large pleural leaks, the bubbling may be continuous.) During inspiration, the water barrier prevents air from going back into the chest. More air bubbles may be noted when the patient coughs or sneezes. With each respiration, there should be a small water level fluctuation (tidaling) in the water-seal compartment to indicate a patent system. The water should rise with inspiration and fall with expiration, but the opposite occurs during positive-pressure mechanical ventilation. The fluctuation of this fluid will stop when the lung has re-expanded and there is no longer any air in the pleural space. The fluctuation will also stop if the tubing is kinked or clotted, when the suction is not working, or if a dependent loop occurs.

If there is a leak in the tubing, drainage system, or if a chest tube suction port (the openings along the lumen of the tube inside the chest that draw in the air and fluid for drainage) is outside of the chest wall, then air will be sucked in there - instead of being pulled out of the chest. The water-seal compartment will bubble continuously with an air leak. If there is continuous bubbling in the water-seal compartment, assess from the insertion site downward to the collection unit by momentary clamping the tubing, first near the insertion site, then at consecutively lower levels along the tubing. The bubbling in the water-seal compartment will cease when the clamp is placed between the air leak and the water seal. If the air leak stops when the clamp is placed close to the insertion site, the physician should be notified as the patient may

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Chapter 27 & 28 Lower Respiratory and Obstructive Pulmonary Disease '17

Course: Medical Terminology (AHCC 003)

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University: Howard University

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Chapter 27

Lower Respiratory Problems

Pneumonia

Definition: Acute infection of the lung parenchyma.

Pneumonia

Etiology Incompetent defense mechanisms or overwhelmed defense

mechanisms. Decreased LOC, intubation, air pollution, viral URI, and

normal changes that occur with aging. Chronic diseases can also

suppress the immune system. Organisms reach the lung by three ways:

Aspiration, inhalation, and hematogenous spread. Refer to Table 27.1

Risk Factors for Pneumonia.

Types of Pneumonia Community-Acquired Pneumonia: acute infection of the lung

occurring in clients who have not been hospitalized or resided in a

long-term care facility with 14 days of the onset of symptoms.

Hospital-Acquired Pneumonia (nosocomial pneumonia): occurs 48

hours or longer after hospitalization and was not incubating at the time

of hospitalization. Ventilator-associated is pneumonia that occurs

more than 48 hours after endotracheal intubation.

Aspiration Pneumonia: results from the abnormal entry of materials

from the mouth or stomach into the trachea and lungs.

Opportunistic Pneumonia: individuals at a higher risk of developing

pneumonia such as individuals with an altered immune response.

Pathophysiology **PATHO CHART ON PAGE 505**

Clinical Manifestations Cough, fever, shaking, chills, dyspnea, tachypnea, and pleuritic chest

pain. Cough may/may not be productive, sputum may be green,

yellow, or rust colored. Hypothermia may be assessed on older

clients. Rhonchi and crackles may be auscultated.

Complications Pleurisy