Advanced Med Surg Exam 1

- *primary purpose of the respiratory system gas exchange involves the transfer of oxygen and carbon dioxide between the atmosphere and the blood - **where does gas exchange occur? the alveolar sacs - diffusion O2 and CO2 move back and forth across the alveolar-capillary membrane how gas exchange takes place - lower respiratory tract bronchi bronchioles alveolar ducts alveoli - upper respiratory tract nose mouth pharynx adenoids tonsils epiglottis larynx trachea - what does the nose do? warms, cleanses, and humidifies air before it enters the lungs - how does vocalization occur? from vibrational sounds that originate in the larynx - anatomic dead space the passages where the trachea, bronchi, and bronchioles conduct air to the alveoli it is called this because the air is not involved in gas exchange - contraction of the diaphragm (the major muscle of respiration) results in what? decreased intrathoracic pressure, which allows air to enter the lungs - surfactant a lipoprotein that helps to keep the alveoli open, thus preventing alveolar collapse - physiology of respiration oxygenation ventilation inspiration expiration - oxygenation the delivery of oxygen from the atmospheric air to alveolar capillaries and eventual diffusion into the alveoli - ventilation involves inspiration (movement of air into the lungs) and expiration (movement of air out of the lungs) - inspiration breathing in movement of air into the lungs active process involves muscle contration - expiration breathing out movement of air out of the lungs passive process when elastic recoil is reduced, expiration becomes a more active, labored process - compliance are they adapting measure of the ease of expansion of the lungs when decreased, the lungs are harder to inflate ("stiff lungs") - what does it mean when resistance occurs? often indicates some type of impairment to air flow into the lungs, such as narrowed airways or presence of secretions - *why are arterial blood gases important? they are the most effective way to measure oxygen status - ABGs are measured to ... determine oxygenation status, ventilation status, and acid-base balance - arterial oxygen saturation monitoring continuously using a pulse ox. probe applied to a finger, toe, ear, or bridge of nose - CO2 monitoring using transcutaneous carbon dioxide (PtCO2) and end-tidal CO2 (PetCO2) capnography PtCO2 is a noninvasive method of estimating PaCO2 PtCO2 is presented as a graph of expiratory CO2 plotted against time - control of respiration the respiratory center in the medulla in the brainstem responds to chemical and mechanical signals from the body - chemoreceptors respond to changes in the chemical composition (PaCO2 and pH) of the fluid around it - mechanical receptors stimulated by a variety of physiologic factors, such as irritants, muscle stretching, and alveolar wall distortion - respiratory defense mechanisms filtration of air - mucociliary clearance system (movement of mucus) cough reflex: very important; clears the airway by a high-pressure, highvelocity flow of air - reflex of bronchoconstriction: prevent entry of irritants - alveolar macrophages: rapidly phagocytize inhaled foreign particles such as bacteria age-related changes in respiratory system function - can be divided into changes in structure, defense mechanisms, and respiratory control there is much variability in the extent of the changes in persons of the same age the older the patient who has a significant smoking history, is obese, and has a chronic illness is at greatest risk of adverse outcomes - **what do you do before you give a medication? check their levels before you give the medication - diagnostic studies of respiratory system - SpO2 monitoring - ABG analysis - sputum studies: - collected in morning before eating - spontaneous or induced - identify infecting organisms or help confirm a diagnosis - skin tests: - allergies - TB or fungi - bronchoscopy: - bronchi are visualized through a fiberoptic tube - used for diagnostic purposes, obtaining biopsy specimens, and assessing changes resulting from treatment - when patient comes back from procedure you HAVE TO CHECK THE GAG REFLEX BEFORE THEY HAVE ANYTHING TO EAT OR DRINK - lung biopsy: - transbronchial - TTNA - VATS - open biopsy - thoracentesis: - insertion of a large bore needle through the chest wall into the pleural space - gets fluid out of the lungs (assess the lungs sounds when they are done) - also for obtaining specimens for diagnostic evaluation or instilling medication into the pleural space - pulmonary function tests: - measures lung volumes and airflow - spirometry (800-1,000) - can diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators - can also determine the ability to wean and extubate from mechanical ventilation in the acute setting - exercise testing: - used in diagnosis, measuring functional capacity and response to treatment, and determining level of activity tolerance - 6-minute walk test - chest x-ray (good for progression of disease and response to treatment too) - deviated septum - a deflection of the normally straight nasal septum most commonly caused by trauma to the nose - if a nasal fracture is present ... - assess the patient's ability to breathe make sure hemorrhage and leakage of CSF are not present - rhinoplasty - surgical reconstruction of the nose performed for cosmetic reasons or to improve airway function when trauma or developmental deformities result in nasal obstruction - epistaxis - nosebleed variety of causes treat with simple measures first, treat with direct pressure with patient sitting upright if bleeding doesn't stop, apply a vasoconstrictive agent, packing (monitoring respiratory status is critical), or cauterization - allergic rhinitis - inflammation of nasal mucosa - reaction of the nasal mucosa to a specific allergen - classified according to the causative agent and frequency of symptoms - causative agent: seasonal (pollen) or perennial (environmental) allergen - seasonal: caused by allergies to pollens from trees, flowers, grasses, or weeds - perennial: occurs from exposure to environmental allergens such as animal dander, dust mites, molds, and cockroaches - frequency of symptoms: - episodic: sporadic exposure - intermittent: less than 4 days/week or less than 4 weeks/year - persistent: greater than 4 days/week or greater than 4 weeks/year - initial manifestations: sneezing; watery, itchy eyes and nose; thin, watery nasal discharge leading to congestion - management: identify and avoid triggers of allergic reactions - drug therapy: oral H1-antihistamines, corticosteroids, decongestants, and leukotriene receptor antagonists; intranasal antihistamines, anticholinergics, corticosteroids, cromolyn, and decongestants - acute viral rhinopharyngitis - common cold - infection of the upper respiratory tract - caused by more than 200 different viruses - management: rest, oral fluids, proper diet, antipyretics, analgesics, saline spray, gargle, lozenges, antihistamines, decongestant (no more than 3 days to prevent rebound), cough suppressants - chronic illness/immunocompromised: tell about measures to decrease the risk of getting a cold during the cold season - influenza - abrupt onset of systemic symptoms of chills, fever, anorexia, malaise, and generalized myalgia - may be accompanied by headache, cough, rhinorrhea, and sore throat - management: supportive care directed at providing relief of symptoms and preventing pneumonia and other secondary infections - prevention and treatment: - antivirals such as zanamivir (Relenza), oseltamivir (Tamiflu), and peramivir (Rapivab) - inactive and live or attenuated vaccine - nursing considerations: - advocate for the use of the flue vaccine in al patients older than 6 months if age, but especially for those at high risk - healthcare workers should be vaccinated to prevent transmission of flu to high-risk persons - sinusitis - inflammation of sinus mucosa results in blockage and accumulated secretions - develops when the exit from the sinuses is narrowed or blocked by inflammation or swelling of the mucosa - accumulating secretions provide a rich medium for growth of bacteria, viruses, and fungi which can all cause infection - classified as: acute, subacute, or chronic - manifestations: - acute: ◼ typically begin within 1 week of upper resp. infection and last less than 4 weeks ◼ pain/tenderness over the affected sinus, purulent drainage, nasal obstruction, congestion, fever, malaise, headaches, halitosis (bad breath) - chronic: ◼ lasts longer than 12 weeks and is a persistent infection usually associated with allergies and nasal polyps ◼ facial or dental pain, congestion, increased drainage - management: - supportive care, antibiotics (if symptoms worse or greater than 1 week), and the use of ancillary medications to relieve symptoms (oral or topical decongestants, nasal corticosteroids, analgesia, saline spray or irrigation - nasal polyps can cause obstruction and speech distortion, necessitating surgical removal - acute pharyngitis - acute inflammation of pharyngeal walls, tonsils, palate, uvula - manifestations: - range in severity from a scratchy throat to pain so severe that swallowing is difficult - both viral and streptococcal infections appear as a red and edematous pharynx, with or without patchy exudates, so appearance is no always diagnostic - goals: infection control, symptom relief, prevent complications - peritonsillar abscess - complication of acute pharyngitis may threaten the airway if severe treatment: IV antibiotics, needle aspiration, drainage, or surgery - laryngeal polyps - develop on vocal cords because of vocal abuse or irritation most common sign: hoarseness treated conservatively with voice rest and adequate hydration surgical removal may be indicated for large polyps which may cause dyspnea - acute laryngitis - inflammation of larynx (voice box) - main causes: virus - main sign: hoarseness, which may be accompanied by total loss of voice - treatment: - supportive - focused on resting the voice - acetaminophen for throat discomfort - cough suppresants - increasing fluid intake - airway obstruction - medical emergency! - interventions to establish patent airway: - heimlich maneuver - cricothyroidectomy - ET intubation - tracheostomy (surgically created opening in the anterior trachea to establish an airway) - indications for a tracheostomy - bypass an upper airway obstruction facilitate removal of secretions permit long-term mechanical ventilation facilitate weaning from mechanical ventilation nursing care: focuses on maintaining an effective airway, decreasing the risk for aspiration, and promoting verbal communication and self-care management - head and neck cancer - tumors: arise from the mucosal surfaces of the paranasal sinuses, oral cavity, nasopharynx, oropharynx, larynx - early s/s: vary with tumor location - late s/s: difficulty chewing, swallowing, moving the tongue or jaw, and breathing; unintentional weight loss and pain - treatment: based on exact location of tumor, disease stage, patient age and general health, cosmetic and functional considerations, urgency of treatment, and patient choice - stages I and II: potentially curable with single-modality radiation therapy or larynx sparing surgery - stages III and IV: treated with various combinations of surgery (typically involves a total laryngectomy with a permanent tracheostomy), radiation, chemotherapy, and targeted therapy - enteral feedings are used to maintain adequate nutrition after radical neck surgery - nursing care: maintaining an effective airway, decreasing risk for aspiration and infection, promoting adequate nutrition and communication, managing pain, and promoting psychosocial adaptation - acute bronchitis - self-limiting inflammation of bronchi - main symptom: cough, may last up to 3 weeks - diagnosis: based on assessment - breath sounds: crackles or wheezes - treatment goal: symptom relief and prevent pneumonia; supportive - pertussis - highly contagious infection of the respiratory tract - incidence rates are rising in the adult population even though we have improved immunization - treatment: macrolide antibiotics and supportive care - pneumonia - acute infection of lung parenchyma - classification: according to causative microorganisms, such as bacteria, viruses, Mycoplasma, fungi, parasites, and chemicals - community-acquired pneumonia (CAP): acute infection of the lung occurring in patients who have not been hospitalized or lived in a long-term care facility within 14 days of the onset of symptoms - hospital-acquired pneumonia (HAP): begins 48 hours or longer after admission to a hospital and was not present at the time of admission - aspiration pneumonia: the sequelae occurring from abnormal entry of secretions or substances into the lower airway - necrotizing pneumonia: complication of bacterial lung infection and may cause cavitation within the lung parenchyma - opportunistic pneumonia: occurs in certain patients with alter immune responses who are highly susceptible to respiratory infections - classifying pneumonia is important because of the differences in the most likely causative organisms and the choice of antimicrobial therapy - pathophysiologic changes: vary according to the type of offending organism - most trigger an inflammatory response in the lung - complications (develop more often in those with underlying chronic conditions): pleural effusion, abscess, acute respiratory failure - treatment: antibiotics (necessary for bacterial pneumonia), all patients need supportive measures - **nursing diagnoses for pneumonia - IMPAIRED GAS EXCHANGE impaired breathing fluid imbalance hyperthermia activity intolerance - tuberculosis - infectious disease caused by Mycobacterium tuberculosis - etiology and pathophysiology: - gram-positive, aerobic, ACID-FAST BACILLUS (AFB) - spread via airborne droplets - NOT spread by touching, sharing food utensils, kissing, or other physical contact - primary TB infection: - occurs when the bacteria are inhaled - most people mount effective immune responses and do not develop TB - if initial immune response is not adequate, the bacteria replicate and active TB disease results - when active TB develops within the first 2 years of infection, it is called primary TB - latent TB infection (LTBI): - occurs in a person who does not have active TB disease - they have positive skin tests but are asymptomatic - they cannot transmit the TB bacteria to others but can develop active TB disease at some point - reactivation TB (post-primary TB): - TB disease occurring 2+ years after initial infection - if the site of TB is pulmonary or laryngeal the person is infectious and can transmit the disease to others - therapy: - drug therapy for active TB disease: 4 drug regimen used for the initial 3- month phase or longer - LTBI: antitubercular drugs to prevent active disease and decrease the number of TB carriers in the community - TB patients precautions: - placed on airborne precautions - receive appropriate drug therapy - receive an immediate medical workup (chest x-ray, sputum smear, and culture) - teach patients to follow respiratory hygiene measures (covering the nose and mouth with paper tissues every time they cough, sneeze, or produce sputum)