Adult Health Exam 2 PPT Notes:
Exam 2024
Unit 3
Infection or Inflammation of the Lungs PPT:
● Aspiration p. 559-600
○ Etiology
■ Inhalation of foreign material
■ Secretions or stomach contents
○ Pathophysiology
■ Aspiration pneumonia develops after inhalation of colonized oral or
pharyngeal material
■ Acute inflammatory response
■ Blockage if stomach contents
■ Acid gastric juice-destructive to alveoli
○ Prevention
■ Monitor LOC
■ Monitor reflexes and swallowing difficulty
● Impaired gag reflex → risk!
■ HOB elevated
■ Minimal sedatives → b/c you can aspirate if you decrease LOC
■ Enteral tube feeding - confirming location, check residual, avoid if high
risk
● If high risk → avoid bolus feedings
■ Ensure swallow study
■ ETT cuff pressure maintained
● Ensure the cuff is inflated to seal off the airway
● Sleep Apnea (p. 567-568)
○ Neurologic origin
○ Obesity
○ Large uvula
○ Short neck
○ Smoking
○ Enlarged tonsils or adenoids
○ Obstruction by soft palate or tongue
○ Treatment *depends on what is causing sleep apnea*
■ CPAP
■ If tonsils are enlarged or adenoids → surgery
■ Obstruction by soft palate → surgery
○ S/S
■ Loud snoring
1
, ■ Excessive daytime sleepiness
■ Frequent episodes of obstructed breathing during sleep
■ Morning headache
■ Unrefreshing sleep
■ Dry mouth upon awakening
● Pneumonia (p.587 - 596)
○ Types
■ Community-acquired
■ Health care-associated pneumonia
■ Hospital-acquired
■ Ventilator-associated
■ Aspiration
■ Immunocompromised host
○ S/S
■ Chills, fever pleuritic chest pain, tachypnea, and respiratory distress
■ Viral, mycoplasma, or legionella: relative bradycardia
■ Headache, low-grade fever, pleuritic pain, myalgia, rash, and pharyngitis
● Low-temperature elevation - viral
● High-temperature elevation - bacterial
● Pleuritic pain - able to distinguish b/c its accompanied with
respirations whereas cardiac pain is constantly present
■ Orthopnea, crackles, increased tactile fremitus, purulent sputum
● Orthopnea - tripoding position
● Tactile fremitus - mucus and fluids cause a dull vibration
(normal is strong and clear vibrations)
■ Obstruction of bronchioles, decreased gas exchange, increased exudate
■ Cough
○ Diagnostic Tests
■ Sputum Collection
● Nasotracheal suctioning device where you suction and it contains a
sputum trap
○ Need patient to do:
■ Oral hygiene
■ Deep breathing
○ Best first thing in the morning is best!
○ We have 6 hours to start antibiotic after dx w/ pneumonia
■ Chest Xray
■ ABGs if in a lot of respiratory distress
■ Blood culture
■ Bronchoscopy may be used for acute severe infection
2
,● Nursing Diagnosis
○ Activity intolerance r/t imbalance b/w o2 supply and demand
○ Ineffective airway clearance r/t inflammation and presence of secretions
○ Impaired gas exchange r/t decreased functional lung tissue
○ Risk for concussion r/t hypoxia
■ Patient dx w/ pneumonia and has changes in LOC → Hypoxia in the brain
● Monitor for restlessness, agitated, sudden confusion
○ First action to take: check the patient’s pulse ox
○ Nursing Process: Assessment
■ VS
■ Secretions: amount, odor, color
■ Cough: frequency and severity
■ Tachypnea, SOB
■ Inspect and auscultate chest (going to trend them checking if they are
getting better/worse)
■ Changes in mental status, fatigue, edema, dehydration, concomitant heart
failure, especially in older adult patients
○ Nursing Process: Planning
■ Improved airway patency
■ Increased activity as tolerated
● So need to assess what “tolerated” means for the patient
■ Maintenance of proper fluid volume
■ Maintenance of adequate nutrition
■ Understanding of the treatment protocol and preventive measures
■ Absence of complications
○ Medical Mgmt
■ Hydration
■ Oxygenation w/ humidification
■ Antibiotics/ Antivirals
■ Bronchodilators
■ Anti-inflammatories
■ Administration of antibiotic as determined by the results of a culture and
sensitivity
■ Supportive treatment includes fluids, oxygen for hypoxia
■ Medications
● NSAIDS (as MD prescribed), antitussives (Dextromethorphan,
p608), decongestants (Pseudoephedrine, p604), antihistamines
(Hydroxyzine, p750)
○ Nursing Care
■ Face mask or nasal cannula
3
, ■ Coughing techniques
■ Chest physiotherapy
● Percussion
● No postural drainage if they are in acute distress (only when they
stabilize)
■ Position changes
■ Incentive spirometry
■ Nutrition
■ Rest
■ Activity as tolerated
■ Patient teaching
● Take medication as prescribed
● Hand hygiene/ respiratory etiquette
● How to use the incentive spirometer (IS)
● Hydration: what type of fluids they can have (no coffee, tea or
cola b/c diuretics)
● Rest and activity
● Nutrition: high protein diet
■ Self-care
■ Gerontological Considerations
● Classic s/s of pneumonia may be absent or masked
● Complaint is usually over acute confusion or delirium
○ Expected Outcomes
■ Improved airway patency
■ Rests and conserves energy and then slowly increasing activity
■ Maintains adequate hydration, adequate dietary intake
■ Verbalizes increased knowledge about mgmt strategies
■ Complies w/ mgmt strategies
■ Exhibits no complications
○ Complications
■ Respiratory failure → Require intubation
● Tuberculosis (p. 600-605)
○ S/S
■ Insidious
■ Low-grade fever that occurs in the later afternoon
■ Cough; nonproductive or mucopurulent; hemoptysis (Lasting at least 2
weeks)
■ Night sweats (cold), fatigue, unexplained weight loss
■ Malaise
■ Anorexia
4
Exam 2024
Unit 3
Infection or Inflammation of the Lungs PPT:
● Aspiration p. 559-600
○ Etiology
■ Inhalation of foreign material
■ Secretions or stomach contents
○ Pathophysiology
■ Aspiration pneumonia develops after inhalation of colonized oral or
pharyngeal material
■ Acute inflammatory response
■ Blockage if stomach contents
■ Acid gastric juice-destructive to alveoli
○ Prevention
■ Monitor LOC
■ Monitor reflexes and swallowing difficulty
● Impaired gag reflex → risk!
■ HOB elevated
■ Minimal sedatives → b/c you can aspirate if you decrease LOC
■ Enteral tube feeding - confirming location, check residual, avoid if high
risk
● If high risk → avoid bolus feedings
■ Ensure swallow study
■ ETT cuff pressure maintained
● Ensure the cuff is inflated to seal off the airway
● Sleep Apnea (p. 567-568)
○ Neurologic origin
○ Obesity
○ Large uvula
○ Short neck
○ Smoking
○ Enlarged tonsils or adenoids
○ Obstruction by soft palate or tongue
○ Treatment *depends on what is causing sleep apnea*
■ CPAP
■ If tonsils are enlarged or adenoids → surgery
■ Obstruction by soft palate → surgery
○ S/S
■ Loud snoring
1
, ■ Excessive daytime sleepiness
■ Frequent episodes of obstructed breathing during sleep
■ Morning headache
■ Unrefreshing sleep
■ Dry mouth upon awakening
● Pneumonia (p.587 - 596)
○ Types
■ Community-acquired
■ Health care-associated pneumonia
■ Hospital-acquired
■ Ventilator-associated
■ Aspiration
■ Immunocompromised host
○ S/S
■ Chills, fever pleuritic chest pain, tachypnea, and respiratory distress
■ Viral, mycoplasma, or legionella: relative bradycardia
■ Headache, low-grade fever, pleuritic pain, myalgia, rash, and pharyngitis
● Low-temperature elevation - viral
● High-temperature elevation - bacterial
● Pleuritic pain - able to distinguish b/c its accompanied with
respirations whereas cardiac pain is constantly present
■ Orthopnea, crackles, increased tactile fremitus, purulent sputum
● Orthopnea - tripoding position
● Tactile fremitus - mucus and fluids cause a dull vibration
(normal is strong and clear vibrations)
■ Obstruction of bronchioles, decreased gas exchange, increased exudate
■ Cough
○ Diagnostic Tests
■ Sputum Collection
● Nasotracheal suctioning device where you suction and it contains a
sputum trap
○ Need patient to do:
■ Oral hygiene
■ Deep breathing
○ Best first thing in the morning is best!
○ We have 6 hours to start antibiotic after dx w/ pneumonia
■ Chest Xray
■ ABGs if in a lot of respiratory distress
■ Blood culture
■ Bronchoscopy may be used for acute severe infection
2
,● Nursing Diagnosis
○ Activity intolerance r/t imbalance b/w o2 supply and demand
○ Ineffective airway clearance r/t inflammation and presence of secretions
○ Impaired gas exchange r/t decreased functional lung tissue
○ Risk for concussion r/t hypoxia
■ Patient dx w/ pneumonia and has changes in LOC → Hypoxia in the brain
● Monitor for restlessness, agitated, sudden confusion
○ First action to take: check the patient’s pulse ox
○ Nursing Process: Assessment
■ VS
■ Secretions: amount, odor, color
■ Cough: frequency and severity
■ Tachypnea, SOB
■ Inspect and auscultate chest (going to trend them checking if they are
getting better/worse)
■ Changes in mental status, fatigue, edema, dehydration, concomitant heart
failure, especially in older adult patients
○ Nursing Process: Planning
■ Improved airway patency
■ Increased activity as tolerated
● So need to assess what “tolerated” means for the patient
■ Maintenance of proper fluid volume
■ Maintenance of adequate nutrition
■ Understanding of the treatment protocol and preventive measures
■ Absence of complications
○ Medical Mgmt
■ Hydration
■ Oxygenation w/ humidification
■ Antibiotics/ Antivirals
■ Bronchodilators
■ Anti-inflammatories
■ Administration of antibiotic as determined by the results of a culture and
sensitivity
■ Supportive treatment includes fluids, oxygen for hypoxia
■ Medications
● NSAIDS (as MD prescribed), antitussives (Dextromethorphan,
p608), decongestants (Pseudoephedrine, p604), antihistamines
(Hydroxyzine, p750)
○ Nursing Care
■ Face mask or nasal cannula
3
, ■ Coughing techniques
■ Chest physiotherapy
● Percussion
● No postural drainage if they are in acute distress (only when they
stabilize)
■ Position changes
■ Incentive spirometry
■ Nutrition
■ Rest
■ Activity as tolerated
■ Patient teaching
● Take medication as prescribed
● Hand hygiene/ respiratory etiquette
● How to use the incentive spirometer (IS)
● Hydration: what type of fluids they can have (no coffee, tea or
cola b/c diuretics)
● Rest and activity
● Nutrition: high protein diet
■ Self-care
■ Gerontological Considerations
● Classic s/s of pneumonia may be absent or masked
● Complaint is usually over acute confusion or delirium
○ Expected Outcomes
■ Improved airway patency
■ Rests and conserves energy and then slowly increasing activity
■ Maintains adequate hydration, adequate dietary intake
■ Verbalizes increased knowledge about mgmt strategies
■ Complies w/ mgmt strategies
■ Exhibits no complications
○ Complications
■ Respiratory failure → Require intubation
● Tuberculosis (p. 600-605)
○ S/S
■ Insidious
■ Low-grade fever that occurs in the later afternoon
■ Cough; nonproductive or mucopurulent; hemoptysis (Lasting at least 2
weeks)
■ Night sweats (cold), fatigue, unexplained weight loss
■ Malaise
■ Anorexia
4
