MED SURG EXAM TWO STUDY GUIDE

Respiratory System - HAYLEE Explain & discuss assessment findings manifest in lower respiratory disorders (COPD, asthma, pneumonia, tuberculosis), and relate them to underlying pathophysiological processes. COPD consists of emphysema and chronic bronchitis – irreversible. Chronic bronchitis causes structural and inflammation changes. Emphysema damages and enlarges alveoli (air sacs) causing breathlessness. Risk factors: smoking!!!, occupational chemicals and dust, air pollution, infection and some genetic factors (AAT deficiency). Develops slowly, chronic intermittent cough may occur first. Dyspnea is progressive, occurring with exertion. Unable to take a deep breath. Will interfere with ADLs. With advanced COPD, you'll see weight loss despite adequate intake, fatigue, wheezes, adventitious or decreased breath sounds, severe cough leading to fainting/breaking a rib, barrel chest, relief in tripod position, pursed lip breathing, usage of accessory muscles, hypoxemia, blue/red color of skin, retaining CO2 (look at ABGs), edema in the ankles secondary to right sided heart involvement (aka cor pulmonale). Patients with COPD are at a high risk of respiratory failure. Use of beta-adrenergic blockers (atenolol) can improve survival rate and decrease risk of exacerbations. Nurse assessment in acute exacerbation event: increase in dyspnea, sputum volume and purulence, malaise, insomnia, fatigue, depression, confusion, decrease in exercise tolerance, confusion, increase in wheezing, may have a fever. Nursing considerations: if the patient retains CO2, careful monitoring when on oxygen or during surgery and post op is crucial. They might appear to be resting comfortably, but actually aren't. Abdominal surgery can lead to ineffective ventilation and respiratory failure due to the inability to take deep breaths. Diagnostics: spirometry – must confirm obstruction. Pulmonary function test. Chest x-ray will show a flat diaphragm, hyper inflated lungs. Serum and antitrypsin level (genetics), ABGs. 6 minute walk test, COPD assessment test, BODE index. Medications/treatments for COPD exacerbation event: bronchodilators, supplemental oxygen, short acting anticholinergic, corticosteroids, med nursing noninvasive mechanical ventilation (CPAP). Expected SPO2: 90% goal of oxygen therapy Inflammatory Disorder - Asthma A chronic inflammatory response in the lungs, chronic. Usually reversible. Can be severe and life-threatening. When a patient is exposed to a trigger, it leads to inflammation, a bronchospasm and narrowing of airways to make it difficult to breathe. Risk factors: genetics, immune response, allergens, exercise, air pollution, occupational hazards, respiratory tract infections, nose and sinus issues, drug and food allergens/additives, GERD, psychological factors (extreme emotion can cause an episode). Types of triggers: strong odors, pollution, anger, stress, pets, exercise, pollen, bugs, chemicals, cold air, spores, dust and smoke. There are different triggers from person to person. Peak flow meter: used to see where they are at, to plan for their cares. FEV1 – forced expiratory volume for 1 second. Aerochamber: seals the medication in the chamber – helpful when patient is coughing while trying to take medication so they don't lose it. Asthma classifications (Per the lecture, we don't need to know specifics, but we need to be aware of them): Intermittent – symptoms are less than 2 days a week, 0-1 exacerbations per year. No limitations. Persistent mild – Symptoms are greater than 2 days a week, not daily. Exacerbations 2x a year. FEV1 = 80% predicted. Persistent moderate – daily symptoms, night 1/week. SABA usage daily. Some limitations. FEV1 = 60-80% predicted. Persistent severe – symptoms are continuous, nighttime often. SABA several times a day. FEV1 = 80% predicted. Goal of asthma tx: achieve and maintain control. Monitoring the disease and assess at severity. Asthma medications (Meds are the examples mentioned in the lecture). LONG TERM MEDS: Anti-inflammatories (Singulair) such as corticosteroids (inhaled or oral), leukotriene modifiers, Anti-igE. Bronchodilators (Atrovent, Serovent) such as long-acting B2-adrenergic agonists and methylxanthines (rarely used). QUICK RELIEF MEDS: Bronchodilators (Albuterol, Proventil) such as short acting inhaled B2 adrenergic agonists, anticholinergic drugs. Anti- inflammatories (Solumedrol) such as systemic corticosteroids by IV push. Patient education on asthma: Identification and avoidance of known personal triggers. Premedication if triggers can't be avoided and you know prior to exposure. Acute management – ASSESSMENT is crucial. Listen to their lungs, what are their sats, etc. Be aggressive with breathing treatments, medications. Provide a calm environment. Discharge teaching: review their meds, have patient demo the technique. Develop an action plan – when to call doc, when to take meds. Pneumonia: inflammatory response in lungs – something is irritating the lining. Then alveoli fills with fluids and debris, increase production in mucous. Leads to a decrease in gas exchange, air can't get through to the alveoli. Antibiotic medications needed. Diagnostic: CBC draw – elevated WBC, neutrophils, temperature. If it involves a substantial portion of one or more lobes, it's lobar pneumonia. Bronchopneumonia is more common, and it is distributed in a patchy fashion. Community acquired pneumonia is the 6th leading cause of death in people over 65. It is community acquired if happened to patient who has not been hospitalized or residing in a long-term care facility within 14 days of onset. Risk factors: abdominal/thoracic surgery, 65 years old, air pollution, altered LOC, chronic disease, immunosuppressed, LTC resident, smoking, tracheal intubation, URI, NGT, COPD. There is healthcare associated/hospital acquired as well as ventilator associated. Hospital acquired occurs 48 hours or longer after hospital admission. Aspiration pneumonia, opportunistic pneumonia: route of entry. Penicillin resistant pneumonia risk factors: 65 years, alcoholism, immunosuppressed. Enteric gram negative bacteria risk factors: LTC resident, underlying cardiopulmonary disease, recent antibiotics. Pseudomonas risk factors: structural lung disease, corticosteroid treatment, malnutrition, broad spectrum antibiotics 7 days in the last month. Clinical manifestations: elevated WBC, sudden onset of chills, rapidly rising fever, pleuritic chest pain that is aggravated by coughing and deep breathing, low SPO2. Tachypnea, signs of respiratory distress, orthopnea, leaning forward, poor appetite, diaphoresis, easily tired. Diagnostic and assessment findings: recent respiratory infection, physical examination, chest xray, blood culture, sputum examination. Care: vaccinations for patients older than 65, prompt treatment, supportive measures (bronchodilators, corticosteroids) rest but not overdoing it – improved diaphragm movement, chest expansion, mobilizing of secretions. Drug therapy is broad, especially if organism is unknown. Hydration is important, but keep in mind comorbidities (CHF, renal problems). Nursing management and interventions: assess past history, meds. Goal is to reduce the risk of pneumonia by hand washing, nutrition, cough/sneezing in elbows not hands, identifying at risk patients, monitor patient condition while hospitalized. Tuberculosis: infectious, contagious disease caused by mycobacterium tuberculosis. Involves the lungs and is the leading cause of death in patients with HIV. Global issue. Occurs most in the poor, minority and underserved populations. Specific populations at risk: prisons, homeless, people from 3rd world countries, inner city population due to close proximity, IV/drug abusers, immunosuppressed and multi-drug resistant individuals. Latent TB vs. TB disease Latent TB has no symptoms, you don't feel sick. You can't spread TB, but you do have a positive skin and blood test. Normal chest xray and in need of treatment to prevent active TB. Active TB has symptoms present – bad cough longer than 3 weeks, pain in the chest, coughing up blood or sputum, weakness, fatigue, no appetite, chills, fever, sweating at night. Feeling sick, positive TB test, abnormal chest xray and in need of treatment. Diagnostics: skin test, interferon assays, chest xray, sputum collection – 3 separate collections on different days. First thing in the morning. Nursing interventions and management: treated as an outpatient; if there is positive sputum, they are considered infectious for first 2 weeks after starting treatment. Advise them to avoid travel, public transportation, limits visitors. Medications: initial phase – INH, rifampin (Rifadin), pyrazinamide (PZA) ethambutol (Myambutol) given daily for 8 weeks. Continuation phase – INH and rifampin or INH and rifapentine daily for 4-7 months. Patient education and med compliance is crucial – encourage adherence. Screening programs for at-risk populations. Put on airborne precautions, wear proper protection (mask). Sputum should be in a bag and treated as infectious drainage. When transporting the patient, they need to wear a mask. Limit visitors, identify and screen close contacts- have them tested. A negative culture must be done to be deemed not infectious/contagious. Discharge teaching: avoid groups of people – church, public places, etc. Don't share a bed. Ensure adequate ventilation in your home. Spend as much time outdoors as possible. TAKE YOUR MEDS. Be aware of S/S in case of relapse (5%). Notify the health department – they monitor TB cases. Outline the medical, pharmacological and nursing management for persons with oxygenation disorders. See individual disease processes. Identify appropriate nursing diagnoses and therapeutic nursing goals, interventions and evaluations of patients with lower respiratory, obstructive disorders and oxygenation disorders. See individual disease processes.