resp disorders 4

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

• 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**

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• contributing facotrs to active TB infection
• advance age
• HIV
• malnutrition
• alcoholism, drug abuser
• other disease- dm, CRF, CA
• genetic predisposition

• 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

• 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

• secondary infection
• reactivation of primary infection
• routine assessment for new evidence of active disease
• PREVENTION IS KEY

• 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

medications

• 1st line
• INH
• Rifamin
• ethambutol
• pyrazinamide
• rifapentine

• ethionamide
• capreomycin
• amikacin
• cycloserine
• levoflaxacin
• gatifloxacin

• 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

• 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

• infection control
• essential
• private resp isolation room
• - negative pressure ventilation
• UV lights- disrupts the DNA in the bacteria
• HEPA filter
• well fitting masks/respirators

• 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

• 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

• 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

• 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

• 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

• non small cell lung cancer
• - squamous cell
• - adenocarcinoma
• - large cell
• Small cell lung cancer

• 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

• 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

• 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

• 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

• 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

• pleural friction rub
• pleural effusions
• fre pna
• finger clubbing
• superior vena cava syndrome

• diagnostic test
• CXR, ct scan, mri
• sputum for cytology
• histological evidence- bronchoscopy, needle biopsy
• TNM classification

• *** 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

• 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

• treatment of nonresectable tumors or adjuvant to surgery
• strong response rate in SCLC, but majority 80% still die from disease

• 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

• preop
• access ability to tolerate surgery and successfully recover- PFT's
• ABG's
• anesthesia- general +/- epidural
• psychological support- fam

• 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

• 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

• 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

• 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

• 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

• 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

• tension pneumothorax- severe dyspnea, tachyapnea, tachycardia, restlessness, and agitation, progressive cyanosis, larygeal and tracheal deviation, PMI shift
• SC emphysema- trach by bedside

• 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

• 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

• 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

• 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

• impaired gas exchange
• ineffect airway clarence
• pain
• impaired physical mobility
• anxiety
• risk for fluid volume imbalance