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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
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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**
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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
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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
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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
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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
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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
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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
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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
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Pulmonary Tuberculosis (TB)
- contributing facotrs to active TB infection
- advance age
- HIV
- malnutrition
- alcoholism, drug abuser
- other disease- dm, CRF, CA
- genetic predisposition
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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
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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
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Pulmonary Tuberculosis (TB)
- secondary infection
- reactivation of primary infection
- routine assessment for new evidence of active disease
- PREVENTION IS KEY
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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
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Pulmonary Tuberculosis (TB)
medications
- 1st line
- INH
- Rifamin
- ethambutol
- pyrazinamide
- rifapentine
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2nd line
- ethionamide
- capreomycin
- amikacin
- cycloserine
- levoflaxacin
- gatifloxacin
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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
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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
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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
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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
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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
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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
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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
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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
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classification and types of lung cancers
- non small cell lung cancer
- - squamous cell
- - adenocarcinoma
- - large cell
- Small cell lung cancer
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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
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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
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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
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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
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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
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Manifestation of lung ca 2
- pleural friction rub
- pleural effusions
- fre pna
- finger clubbing
- superior vena cava syndrome
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lung ca
- diagnostic test
- CXR, ct scan, mri
- sputum for cytology
- histological evidence- bronchoscopy, needle biopsy
- TNM classification
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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
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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
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chemotherapy
- treatment of nonresectable tumors or adjuvant to surgery
- strong response rate in SCLC, but majority 80% still die from disease
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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
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Thoracic surgery
- preop
- access ability to tolerate surgery and successfully recover- PFT's
- ABG's
- anesthesia- general +/- epidural
- psychological support- fam
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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nursing dx
- impaired gas exchange
- ineffect airway clarence
- pain
- impaired physical mobility
- anxiety
- risk for fluid volume imbalance
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