resp disorders 4

  1. Pulmonary Tuberculosis (TB)
    this is a bacterial infection that can spread thru the lymph nodes and bloodstream to any organ in the body- it is most often found in the lungs
  2. Pulmonary Tuberculosis (TB)
    • stats
    • about 3 mil deaths a yr world wide
    • infection of the lung parenchyma (pne)
    • - can be transmitted to meninges, kidneys, bones, lymph nodes
    • caused by bacteria- mycobacterium tuberculosis
    • communicable airborne dx- coughing, laughing, sneezing, singing
    • multi-drug resistant- difficult to treat**
  3. Pulmonary Tuberculosis (TB)
    • inc risk
    • medically underserved population
    • malnutrition, poverty, overcrowding
    • HIV/immune compromised
    • personnel and residents LTC, congregated living
    • inc diversity
    • Public health concern for pt and contacts
    • - Tb skin test and CXR
  4. Pulmonary Tuberculosis (TB)
    • patho
    • inhale of mycobacteria bia airway
    • deposited into alveoli and begin to mulitple
    • bacteria transported via blood and lymph system to other parts- kidneys, bones, cerebral cortex
    • body immune- inflamm and phaocytes
    • tissue retn-accumulation of exudate in alveoli causinf broncho pne in initial stage
  5. Pulmonary Tuberculosis (TB)
    • patho- 2
    • initial infection occurs 2-10 weeks post inital exposure
    • granulomas (new tissue masses of live/dead bacilli) surrounded by macrophages- protective wall
    • transform to fibrous tissue- central portion is called the Ghon tubercle
    • the material (bacteria/macrophages) become necrotic- cheesy mass
  6. Pulmonary Tuberculosis (TB)
    • path 3
    • the mass may be calcified and form a collagenous scar
    • at this this point, dx becomes dormant and no progression of active TB
    • Ghon tubercles may contain living bacilli that can be reactivated, even after many years and cause secondary infection
  7. a person living with latent TB infection
    • has no symptoms
    • does not feel sick
    • cannot spread TB bacteria to others
    • usually has a skin test or blood test results
    • - QuantiFERON indicating TB infection
    • has a normal chest xray and a neg sputum smear
    • needs tx for latent TB infection to prevent active TB disease
  8. A person with active TB infection
    • has symptoms that may include
    • fatigue/weakness
    • cough- +/- hemoptysis
    • night sweats
    • weight loss
    • anoerexia
    • chills,
    • low grade fever
    • dyspnea
    • pleuritic chest pain- d/t cough
  9. a person with active tb
    • can
    • usually feels sick
    • may spread to others
    • usually has a skin test or blood test result indicating tb infection
    • have an abnormal chest xray and positive sputum smear or culture (AFB acid fast bacilli)
    • needs tx to treat active TB disease
  10. Pulmonary Tuberculosis (TB)
    • contributing facotrs to active TB infection
    • advance age
    • HIV
    • malnutrition
    • alcoholism, drug abuser
    • other disease- dm, CRF, CA
    • genetic predisposition
  11. Pulmonary Tuberculosis (TB)
    • diagnoses
    • false - if newly infected, elderly, debilitated immunicompromised
    • mantoux test (PPD) pt exposure to TB/measure induration NOT redness
    • CXR
    • sputum for AFB culture and smear
  12. Pulmonary Tuberculosis (TB)
    • mantoux
    • purified protein derivative
    • >/= 5mm- + if HIV, recent close contact, fibrotic changes on cxr consistent with prior tb, organ transplant pt, immunocompromise
    • >/= 10mm- + for all other high risk pts, recent immigrants < 5y from high prevalence countries, drug users, residents/employees of high risk congregate setting, < 4 yrs
    • >/= 15mm- + for all low risk pt- pts with no risk factors
  13. Pulmonary Tuberculosis (TB)
    • secondary infection
    • reactivation of primary infection
    • routine assessment for new evidence of active disease
    • PREVENTION IS KEY
  14. Pulmonary Tuberculosis (TB)
    • management
    • prophylactic therapy
    • IPT (isoniazid preventive therapy)
    • INH 300mg qd x 6-9 months
    • vitamin b d/t peripheral neuropathy/neuritis
    • no pregnant woman
    • to which pts:
    • newly infection, +PPD, - CXR, no signs
    • close contact with TB pt
    • ? inactive TB
    • + skin test, immunocompromised
  15. Pulmonary Tuberculosis (TB)
    medications

    • 1st line
    • INH
    • Rifamin
    • ethambutol
    • pyrazinamide
    • rifapentine
  16. 2nd line
    • ethionamide
    • capreomycin
    • amikacin
    • cycloserine
    • levoflaxacin
    • gatifloxacin
  17. Pulmonary Tuberculosis (TB)
    • management 2
    • resp isolation until results known if hospitalized
    • medications (CDC)
    • - usually 3 + for resistent organism
    • - long term, uninterrupted tx
    • - basic regimen- 2 m INH, Rifampin, Pyrazinamide, Ethambutol qd, then 4 mos INH and Rifampin, vita b6
    • sputum culture to evaluate effectiviness
  18. Pulmonary Tuberculosis (TB)
    • management 3
    • compliance may be an issue
    • - dose changed to 2-3 weeks, go to MD
    • - public health officials monitor
    • side effeft
    • - hepatitis- LFT
    • - peripheral neuropathy/neuritis
    • - GI disturbances
  19. Pulmonary Tuberculosis (TB)
    • infection control
    • essential
    • private resp isolation room
    • - negative pressure ventilation
    • UV lights- disrupts the DNA in the bacteria
    • HEPA filter
    • well fitting masks/respirators
  20. Pulmonary Tuberculosis (TB)
    • two types
    • Extrapulmonary tb
    • - o2 rich areas outside the lunds may become infected (bone plates, meninges, GU, lymph)
    • - manifestation if any, non specific
    • Miliary Tb
    • - widespread dissemination-tiny lesions in lungs mo
    • - more common in HIV
    • - nonspecific manifestation, anorexia, fever
  21. restrictive lung disorder
    • Interstitial lung dx
    • disorders that result in reduce lung volume and expansion
    • causes based on the anatomic structure
    • - intrisic lung dx
    • - extrinsic lung dx
    • - neuromuscular dx
    • xterized by reduced total lung capacity, vital capacity and resting lung volume
  22. restrictive lung disorder
    • intrinsic, extrinsic, neuromuscular
    • intrinsic
    • - dxs that cause inflamm/scarring of lung tissue or results in filling the air space with exudate
    • - dxs that cause it are - idiopathic fibrotic dxs, connective tissue dxs and drug induce lung dx
    • Extrinsic
    • Dx of chest wall, pleura, and respiratory muscles, massive obesity, kyphoscoliosis
    • Neuromuscular
    • CNS, neuromuscular junction or respiratory muschle
  23. restrictive lung disorder
    • manifestation and management
    • manifestation- vary according cause
    • - rapid, shallow resp, sob, dry cough, hemoptysis, d/t vasculitis
    • diagnoses
    • PFT's, CXR, CT, fluroscopy, lung bx
    • management:
    • - wt loss, steriod
    • adequate o2, intubation, trach
    • - patent airway
    • - mostly not reversible
  24. Lung cancer
    • leading cause of cancer deaths in the us among men and eomen
    • ** most preventable
    • - smoking 90%
    • - quitting may dec incidence
    • - second hand smoke contains same carcinogens
    • - others causes- radon gas, asbestos, air pollution
    • no early signs/symptoms
  25. classification and types of lung cancers
    • non small cell lung cancer
    • - squamous cell
    • - adenocarcinoma
    • - large cell
    • Small cell lung cancer
  26. Non Small Cell CA
    • squamos cell
    • survival rates better than small cell
    • Squamous cell CA- 30-35%
    • - bronchial epithlium
    • - slow growing, may result in cavitation
    • - least likely to metastasize
    • - best prognosis
    • - late stages- bulky, may obstruct airway
  27. Non small cell CA
    • adenocarcinoma 25-30%
    • recent increase in woman
    • mostly seen in non smokers
    • intermediate growth rate
    • originate in outer perpherial portions of lung
    • often asymptomatic/fewer sympt than those originated centrally
    • early invasion of lymphatic/blood vessel- worse prognosis to squamous
    • neither chemo or RT inc survival rates
  28. non small cell CA
    • Large cell Ca undifferentiated - 10-20%
    • cell type has lost all evidence of differentiation
    • large bulky tumors in perphery
    • rapid growth, metastasis
    • distortation of trachea
    • surgery often just palliative
  29. small cell CA
    • 20-35%
    • fastest growing
    • originate in major bronchi
    • metastasis- bone, liver, brain, mediastimun, thoracic structures
    • dense cells w/little cytoplasm- 'oat cell'
    • pleural, pericardial effusions, tamponade
  30. Manifestation of lung ca
    • 10% no sympt, found on cxr
    • ** cough or change in chronic cough- most common initial symptoms
    • dyspnea- major problem
    • hemoptysis- erosion of epithelial layer and invasion of blood vessel
    • rust colored sputum
    • pleuritic chest pain
  31. Manifestation of lung ca 2
    • pleural friction rub
    • pleural effusions
    • fre pna
    • finger clubbing
    • superior vena cava syndrome
  32. lung ca
    • diagnostic test
    • CXR, ct scan, mri
    • sputum for cytology
    • histological evidence- bronchoscopy, needle biopsy
    • TNM classification
  33. Lung Ca management
    • *** early detection is key
    • in general, small cell treated with chemo +/-
    • XRT; non small cell with surgery
    • Nsg management
    • - O2, assess lung sound
    • - VS
    • - enough time for adl's activity
  34. Radiation therapy
    • adjunct, palliative therapy
    • potentially curative in locally advanced disease if poor surgical candidate
    • tumor shrinkage, metastatic control
    • 5-6 weeks
    • local effect- esophagitis, pneumonititis, dysphagia
  35. chemotherapy
    • treatment of nonresectable tumors or adjuvant to surgery
    • strong response rate in SCLC, but majority 80% still die from disease
  36. Surgical interventions
    • tx of choice in early stages of non small cell
    • cure possible if localize not mets
    • adjuvant therapy in early stages smal cell but inc risk, no benefit in late stages
    • Aim is to remove tumor completely, while perserving normal tissue
  37. Thoracic surgery
    • preop
    • access ability to tolerate surgery and successfully recover- PFT's
    • ABG's
    • anesthesia- general +/- epidural
    • psychological support- fam
  38. Thoracic surgery
    • pre op teaching
    • assess understanding
    • expect CT and intubation
    • pain control meds- about what they used in the past
    • exercises- legs, arms, and shoulders, breathing
    • T/C/DB, splint incision, IS
  39. Thoracic surgery
    • kinds
    • exploratory thoracotomy- opens thoracic cavity to locate bleeding, or inspect and biopsy lesions
    • lobectomy- removal of love
    • - commonly done than pneumonectomy
    • indications:
    • - lung ca, giant blebs, benign tumors
    • - lung collapses as pleura entered- ct needed
    • - remaining tissue over expands to fill that portion of the thoracic space
  40. Thoracic surgery
    • resection
    • segmental resection- removal of 1+ segments (ie bronchiole and alveoli)
    • - remaining tissue overexpands
    • Wedge resection-
    • - removal of a pie shaped section
    • - well circumscribed benign and malignant, blebs
    • - pulmonary structure and function unchanged
  41. Thoracic surgery
    • pneumonoectomy
    • removal of the entire lung
    • removal of right more dangerous- larger vascular bed
    • thoracic cavity left as an open space
    • phrenic nerve severed to tha side- hemi diaphragm stays elevated, hyperinflation of the opposite lung, shifting of mediastunum and progressive resorbation of air/fluid (3wks-7month) reduces the size of cavity/PPS post pneumonoectomy space
    • space fills with serous flud which consolidates
    • chest tubes clamped if used- bc you dont want it to drain- you want it to consolidate (serous build up) helps to hold up other other side of the lung
  42. Thoracic surgery
    • nursing
    • major goal is to maintain resp and circulatory function
    • pain management
    • monitor for complications
    • - pulmonary edema- resp distress
    • - cardiac dysrhythmias-bc of effect on heart
    • - hemorrhage- tension ptz, mediastinal shift
  43. complication of thoracic surgery
    • hemothorax- SC emphysema- creptitus
    • hypovolemic shock- bc of bleeding
    • thrombophlebitis- PE
    • resp failure- tachyapnea, dysapnea, cyanosis, use of accessory muscles, restlessness, dec PaO2, incr PaCO2, diminished breath sounds, adventitious breath sounds
  44. Complication of thoracic surgery 2
    • tension pneumothorax- severe dyspnea, tachyapnea, tachycardia, restlessness, and agitation, progressive cyanosis, larygeal and tracheal deviation, PMI shift
    • SC emphysema- trach by bedside
  45. complication of thoracic surgery 3
    • bleeding at incision, chest tubes
    • - 500-1000 ml in 1st 24hrs
    • 100-300 ml 1st 2 hours and should decrease
    • bloody first few hours then shoul darken and not rebleed
    • monitor
    • how much
    • clot
    • report accordingly
  46. Thoracic surgery
    • nursing intervention
    • semi fowler- when hemodynamic stable
    • ** if wedge or segmental resection- avoid positioning on operative side
    • ** if lobectemy may be turn to either side
    • ** if pneumonectomy- avoid completly lateral positioning, position q 1h from back to operative side preferred- to make sure enough serous is formed
  47. Thoracic surgery
    • nursing intervention
    • t/c/db- q1-2 hours
    • enc early ambulation 8-12 hours post op
    • maximized pain control, splint incision
    • adequate hydration
    • suction PRN- cautiously
    • gentle turn every 1-2 h
    • maintain CT
    • passive/active ROM of affected arm and shoulder
  48. Thoracic surgery
    • nursing intervention 3
    • passive ROM affected arm and shoulder
    • - start 4 hours after recovery from anesthesia
    • active ROM when ready
    • allow rest period
    • pyschological support
  49. nursing dx
    • impaired gas exchange
    • ineffect airway clarence
    • pain
    • impaired physical mobility
    • anxiety
    • risk for fluid volume imbalance
Author
Prittyrick
ID
327975
Card Set
resp disorders 4
Description
more disease 4 part
Updated