STUDY GUIDE TEST 1

Rhinitis Definition inflammation of nasal cavities Allergic rhinitis: pollens Acute viral rhinitis: coryza, spread by droplets. Home care: fluids, bedrest, humidification, Echinacea, Vit. C, Zinc, Handwashing. Etiology: Allergen- plant, food: hay fever, complication: otitis media, hearing loss, pneumonia. Virus, bacterial, excessive medication use Transmission: droplet or direct contact (Table 25-3, p. 447, PPE review: Table 25-2, p. 446) Assessment: rhinorrhea, congestion, sore throat (initial symptom if viral), HA, fever Implementation: Pharmocological: OTC medications : Antihistamines, decongestants, nasal steroids, Analgesics, antipyretics, antibiotics (bacterial), desensitization Complemenary/Alternative: Nursing: Deficient Knowledge-

Sinusitis: Definition- inflammation of mucous membranes of one or more sinus cavity Acute- Etiology- bacteria, virus Chronic- Etiology- repeated infections causing mucous membranes to thicken resulting in : h/a, dull aching pain, facial swelling, chronic cough, sleeplessness. Obstruction of drainage Assessment- HA, facial pain, nasal congestion, fever, purulent nasal drainage, tenderness, bad breath Complications: orbital celulitis, meningitis, abscess. Implementation: Medical: Pharmacologic-Broad spectrum antibiotics, analgesics, decongestants, expectorants Surgical: Maxillary Antral Irrigation- under local anesthesia, antral puncture+lavage, outpt. Procedure- irrigated w/saline. Caldwell Luc Procedure- incision under upper lip into maxillary sinus. Infection removed- may have difficulty eating b/c pain and swelling. Ice packs, oral hygiene (Gentle), change dressing prn, limit valsalva maneuver, no coughing or blowing nose, no lifting, situate in semi-fowlers, eat soft foods, use analgesics, increase fluid intake.

Nursing: Post-op (Iggy, Chart 33-1, p. 655) Education: Post-opConservative treatment- Use of meds, comfort measures, humidification, saline irrigations, hot wet packs over sinus, increase fluids

Influenza: Definition: Acute viral resp infection, seasonal Etiology: Virus A, B, C, H1N1 (3-7 day duration, malaise 14 days after) Assessment: Initial- severe HA, myalgia, fever, chills, fatigue 1-2 weeks later- sore throat, cough, rhinorrhea, fatigue Implementation: Acute- Antiviral agents, antihistamines BR, increase fluids Prevention- Immunizations Complications- pneumonia CDC. Seasonal Influenza: complications: bronchitis, pneumonia, worsen COPD. Symptoms begin 2-4 days after exposure and last 5-6 days.

MRSA - transmitted by infection (hands) or colonized carriers (nares). -eradicate with topical agent (bactroban) to nares & oral Ab (Bactrim). -tx. Of infectious patients Vancomycin or Rifampin IV. Alcohol foam can be used for MRSA but can NOT be used for C-diff. -contact/ airborne/ droplet isolation- wearing gloves & gown if direct contact, mask, private room-------dont use shared equipment or do not allow to touch bed or bedstand------clean room items daily with antiseptic. Pts are in negative pressure room. - they might need fit tested masks, that are different than a regular surgical mask. M95 mask

Pneumonia: 8th leading cause of death in US + 3rd leading cause of death in persons >85 y/o. Description- Acute infectious process of bronchioles, alveoli, interstitial spaces Decreasing compliance & causing hypoxemia Pathophysiology: organisms: streptococcus (pneumococcal pneumonia, hemophilous influenza, staphylococcus aureus, pneumocystitis carnii (AIDS).

ClassificationBacterial vs viral: Bacterial- acute onset, chills, fever, productive cough, pleuric chest pain, crackles, tachypnea, tachycardia. VIRALsudden, gradual, mild, and flu-like. Community acquired (CAP) vs hospital acquired (HAP) Location- bronchopneumonia, lobar Etiology- Infectious- bacteria, virus, mycoplasma, fungi, protozoa Non-infectious- toxic gases, chemicals, smoke, aspiration Risk factors: older, institutionalized, ventilator. Assessment- (Iggy, Table 33-3, p. 663) Subjective: Exposure? Risk factors? Objective: fever (high in bacterial), cough, pleuritic chest pain VS- tachypnea, tachycardia, BP____low_____ Adventitious lung soundsSputum- hemoptysis, rust, bloody-colored, creamy yellow, green, white, cleareen. Sputum: pneumococcal- rusty brown, blood tinged. Staphcreamy yellow. Pseudomonasgreen. Diagnostics- sputum C&S, CBC, ABGs, CXR (diffuse patches or consolidation), blood cultures, Pulse oximetry, electrolytes White count elevated, pulse ox lowered, check BUN and Na+ for dehydration. Droplet Precautions- (Table 25-3, p. 447) Implementation: Medical- oxygen, supportive, nasotracheal suction as needed Pharmacologic- antimicrobials, bronchodilators, antitussives, mucolytics, expectorants, Steroids (aspiration pneumonia), nicotine patches, Goldenseal, immunizations Nursing- Nursing Diagnosis (Iggy, Concept Map, p. 662; Chart 33-6, p. 664; Chart 33-4, p. 660) & Guidelines for Preventing Health Care Associated Pneumonia (CDC) Impaired Gas Exchange- Oxygen therapy, monitor respirations, positioning Ineffective Airway Clearance- Encourage effective coughing techniques, hydration, position pt sitting straight up, incentive spirometer, have suctioning available. Acute Pain- analgesics---relieve pleuritic pain Hyperthermia Deficient Fluid Volume- Manage fluids, monitor sodium, nutrition--- increase fluids 2500-3000 ml/day.

Deficient Knowledge- Use of meds, activity, infection control, S&S to report----explain about pneumonia vaccine. Health Promotion- Prevention (pneumococcal & influenza vaccine) Complications: hypoxemia, hypercapnia (Elevated CO2), atelectasis, pleural effusion, empyema, septicemia

Tuberculosis Description- Highly communicable acute/chronic, bacterial reportable disease; Insidious onset Can affect lungs or extra-pulmonary organs-----characterized by formation of tubercles. For curable infections, it is the number one cause of death. Highly contagious, can be acute or chronic. Is found in the lngs, joints, kidneys, or pericardium. When cases are known they must be reported to the health department. Is an indisious disease so people can have it for a while before knowing it, thus spreading it to others. Transmitted by infected inhaled droplets entering the lungs, and traveling to the small air sacs (Alveoli). ---suspended in the air or on dust particles for long periods. Spread by coughing, talking, singing, laughing. The inflamed area becomes surrounded by collagen, fibroblasts, and lymphocytes. If there is no tx, the site can become necrotic (caseation), and become a cavity.if still continues, can progress into effusion like pericardial effusion. 2-8 weeks after exposure the immune system walls off the infection with macrophages. Risk Factors- Repeated close contact, foreign born or travel to high risk countries, known HIV+, Immunosuppressed, high risk health care worker, IV drug users, malnutrition, inadequately treated Transmission/Pathogenesis Mycobacterium tuberculosis- acid fast rod, aerobic Exposure- Transmitted by airborne route (Table 25-3, p. 447): Concern with exposure to concentration of droplets and close proximity over prolonged period of time Infected without Active Disease- Usually immune system competent; usually resolution Infected with Active Disease- Tubercle lesion encapsulated; caseation; calcification ro liquifiecation; cavitation; may spread to pleura or other organs Latent TB Infection (LTBI) which may be reactivated later; No symptoms, not appear ill, not infectious, Usually has +PPD w/ normal chest x-ray, sputum culture negative, TST or blood test results usually positive. Inactive, confined tubercle bacilli in the body. TB disease in Lungs: Active, multiplying tubercle bacilli in the body, TST or blood test results usually positive, Chest X-ray usually abnormal, Sputum smears and cultures may be positive, Symptoms such as cough, fever, weight loss, Often infectious before tx., A case of TB. Assessment History: Recent exposure? Travel to other countries? Previous tests? Past tx? Recent BCG vaccine?

Other risk factors? Early S&S: persistent cough w/ sputum production, low grade fever (In afternoon), fatigue, night sweats, Anorexia, wt loss. Later S&S: Bloody sputum (hemoptysis), chest pain, SOB Diagnostics: Tuberculin Skin Test Purified Pretein Derivative (PPD)(Mantoux): 0.1ml = 5 U tuberculin, intradermal Read ______48-72______hrs (Evidence Based Practice) Measure ONLY induration & record in mm < 5-9 mm (+) HIV + Immunosuppressed Fibrotic changes consistent w/ old TB on chest x-rays >10-14 mm (+) Travelers/immigrants IV drug users Residents & workers in crowded living conditions >15 mm (+) No known risk

Ten mm under normal circumstances, and 5mm in immunocompromised pts. Other diagnostics: Chest x-ray= does not confirm diagnosis Sputum smear for AFB- early morning specimens on 3 consecutive days Sputum culture for M. tuberculosis = Confirms diagnosis Drug susceptibility testing- ensure appropriate treatment & ID drug resistance Goal- prevent transmission, control symptoms, & prevent progression of disease Treatment: active disease6-12 months tx. -Direct Observation Therapy- If pts not compliant, health care workers go to the residence and MAKE them take their pills. TXs are: Isoniazid, Rifampin, Pyrazinamide, Ethambutaol.

Implementation: Medical: PharmacologicInfected without Active Disease- Chemoprophylaxis with INH, PZA Infected with Active Disease- Combination therapy (Iggy, Chart 33-8, p. 671) Direct Observed Therapy (DOT) Length of tx Be aware of multi-drug resistance

BCG (Bacillus of Calmetter & Guerin) vaccination- not widely used in US; Effectiveness is variable Nursing: Impaired Gas Exchange Ineffective Airway Clearance Deficient Knowledge: Transmission/Prevention behaviors Transmission-Based Precautions (Infection Control)Airborne Precautions- Pt wears mask if must leave room HANDWASHING!!! Medication compliance Follow-up care- Discontinue precautions when have 3 consecutive negative sputum cultures Follow-up sputum cultures done q2-4 wks during treatment KNOW to report S&S of toxicity, monitor compliance, stress follow-up, watch out for multiple drug resistance. After three negative cultures, pt is no longer infectious. Nutrition Social Isolation- Co-habitants all tested & prophylactically treated May return to work after negative cultures Need good ventilation Fatigue will diminish Histoplasmosis Description- Pulmonary & systemic fungal infection from inhalation of spores found in soil contaminated w/ excreta Caused by Histoplasma Capsulatum organism found in soil, floors or chicken houses, & in bird droppings Not transmitted from person to person Patho inhaled fungi result in development of a lesion in lung parenchyma. Lesion eventually becomes Fibrotic & calcified. When clacified, no reactivation of disease. May initially extend to lymph nodes, liver, & spleen. Assessment- dyspnea, pleuritic chest pain, respiratory illness similar to TB, fever Diagnostics- skin test, CXR, positive culture Intervention: no treatment if mild Medical: Oxygen, TCDB, semifowlers

Pharmacologic: Antifungal drugs: Amphotericin B (Fungizone) x3 months, also Nizoral, Corticosteroids, Antihistamines----may cause nephrotoxic, ototoxic, hypokalemia, seizures, HA, anaphylaxis. -----TEACH to hose down if working in suspicious areas. Corticosteroids, antihistamines, analgesics Nursing- preventive: education- hose down if working in areas where organism may be found; symptom management- education about meds

Pleurisy (Pleuritis) inflammation of the pleura Etiology- pneumonia, TB, chest trauma, chest wall infection Patho- reddened pleura=>exudates=>inflammation=>adherence=>restricted Expansion=>TV decreased=>atelectasis=>infection=>hypoxia Assessment- knife-like pain w/ inspiration, pleural friction rub, cough, hypoxemia Intervention- treat cause

Severe Acute Respiratory Syndrome (SARS) Etiology- Coronavirus Patho- inflammation remains in respiratory system Transmission by airborne route (Table 25-3, p. 447) Assessment- high fever (>100.4), HA, malaise, dry cough, hypoxia, dyspnea, cyanosis No diagnostic test Intervention- No effective treatment; supportive treatment during infection Preventative activities

Chronic Bronchitis Description- condition characterized by chronic airway (not alveoli) inflammation Inflammation of large (bronchi) & small (bronchioles) airways r/t continuous exposure to irritants; thick mucus + thick bronchial walls = impaired airflow and impaired gas exchange = dec. PaO2 and incr. PaCO2 By definition: experience excess mucus production & recurrent productive cough on most days x 3 months/yr for @ least 2 consecutive years Incidence- 1 out of every 14 people over 45 y/o; usually begins 5th or 6th decade of life; more common in men, urban, disadvantaged

Etiology-smoking, air pollution, chronic resp infections including sinusitis, heredity Patho- inflammation=>increased mucus production=>hypertrophy of mucous secreting glands=>more mucus secretion to decrease irritiation=>narrowing of structural airways because thickened bronchial walls Results in mucous plugs, increased airway resistance, hypoxemia, hypercapnia, & resp acidosis. Ultimately, hypoxia, central cyanosis, & polycythemia Clinical Manifestations- productive foul smelling chronic cough, early morning cough, grayish-white sputum, inspiratory crackles, dyspnea, orthopnea tachycardia, Later stages: polycythemia, cor pulmonale (hypoxemia, respiratory acidosis, cyanosis, JVD, hepatomegaly, peripheral edema (See Iggy, Chart 32-8, Cor Pulmonale, p. 623) Blue Bloater- color dusky to cyanotic, increased sputum, hypoxia, hypercapnia, acidosis, edematous, exertional dyspnea, digital clubbing, cardiac enlargement, use of accessory muscles, cor pulmonale. More common in women than men. Diagnostics: Elevated RBC, Hgb, Hct, WBC Pulmonary Function Studies (PFS): Increased Residual Volume (IRV), decreased Vital Capacity (VC), Forced Expiratory Volume (FEV) Sputum cultures Management- Improve oxygenation & decrease CO2 retention, O2 @ 1-3L/m, effective cough Meds: Antibiotics, corticosteroids, bronchodilators, anticholinergics, immunizations Relaxation exercises, meditation, purse-lip breathing, 3-point position, abdominal Breathing, isometric exercises, breathe in through the nose and exhale slowly through the mouth. Avoid pulmonary irritants, smoking cessation PG. 624 in IGGY.look at this picture.

Emphysema Description: Progressive loss of elasticity (loss of stretch and recoil ability) of alveolar sacs, destruction of alveolar walls, collapse of bronchioles & the alveoli become enlarged permanently. Decreasing quality of life. Long term decline in function of lungs; > 50% of patients report being limited in ability to work. Results in air trapping, hyperinflation of lung, decreased gas exchange, , & retention of CO2, ventilatory dead space flattened diaphragm . Ultimately, resp alkalosis progressing to resp acidosis These changes lead to obstructed air passages Pink Puffer S&S: no cyanosis, purse lip breathing, dyspnea, ineffective cough, hyperresonance on chest percussion, orthopneic, barrel chest, exertional dyspnea, prolonged expiratory time, speaks in short jerky sentences, anxious, use of accessory muscles for breathing, thin appearance, leads to right sided heart failure. Etiology- smoking, air pollution, enzyme deficiencies

Patho- elastin is destroyed by proteases from neutrophils=>loss of elastic recoil (driving force of expiration lost)=>small airways collapse=>overdistended alveoli=>flattened diaphragm=>chest wall springs out=>inspiratory muscles operate at shortened length Clinical Manifestations- General appearance- position? Weight- typically lose weight and can become very thin, leading to protein loss, or nutritional imbalances. Resp- early dyspnea on exertion, progressing to when at rest Wheezes, crackles, use of accessory muscles, decreased FEV & VC, increased RV; Decreased breath sounds, increased A-P diameter (barrel chest) Acid-Base balance- mild hypoxemia with respiratory alkalosis progressing to severe Hypoxemia with respiratory acidosis, tachycardia Diagnostics: ABGs, Pulse ox, Chest x-ray, PFS, electrolyte levels COPD MANAGEMENT: diaphragamatic breathing, pursed lip breathing, controlled cough, O2 therapy, hydration nd humidification, chest physiotherapy & PD (not routinely), surgical management includes lung reduction surgery, and smoke cessation problems. CHRONICALLY ELEVATED CO2 IS CALLED CO2 NARCOSIS-------KNOW THIS!!! Medical Management: Pharmacologic: (See Iggy, Chart 32-5, pp. 616-618) Stepped therapy Bronchodilators: key to managing symptoms of COPD Bronchodilators: give 1st in sequence why?____________ Beta2 Adrenergics: Short Acting- Albuterol; Salmeterol Methylxanthines: Theophylline [monitor levels; avoid caffeine] Anticholinergics: Ipratropium [blocks parasympathetic system to allow sympathetic system to increase bronchodilation] Combinations: Ipratropium and Albuterol Anti-inflammatory Airway #1 Controlled Cough: Huff coughing Chest physiotherapy & Postural Drainage (examples shown, Iggy, p. 632) Suction Breathing techniques (See Iggy, Chart 32-10, p. 631) Corticosteroids: Prednisone; Fluticasone [monitor for oral fungal infections]

Pneumonia + influenza vaccines should be given to COPD patients

Diaphragmatic Pursed-Lip- Oxygen therapy Remember- Hypoxic drive (LOW ARTERIAL O2 LEVEL) is pts drive to breathe! 1-3 L/NC Hydration & humidification Exercise

Lifestyle: healthy diet; avoid pollutants Pulmonary Rehab: focus on prevention and coping with dz Surgical Management: Lung reduction surgery research: risk of death in severe lung obstruction? Lung transplantation increasing #s (severe emphysema) EDUCATE (See Iggy, Chart 32-6 & 32-7, p. 619; Fig. 32-5, p. 620) *Metered Dose Inhaler (MDI) w, w/o spacer & Dry Powder Inhaler (DPI) MDI: need hand-lung coordination; spacers increase delivery DPI: breath activated/ease of use Nebulizer: converts drug to mist via face mask or mouthpiece/portable/slower delivery *Home Care [ wt mngmt; supplements; monitor for infections; when to call doc; schedule rest; prioritize activities; etc. pulm rehap] Nursing Management: (See Iggy, Chart 32-9, p. 629) Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Altered Nutrition, < BR Activity Intolerance

Oxygenation/ Oxygen Use Goal: Use lowest fraction of inspired oxygen (FIO2) to obtain highest level of oxygenation w/out side effects Consider oxygen a medication! Measurement through ABGs & pulse oximetry Room air is 21% Methods of Delivery (See Iggy, Table 30-1 & 2, p. 575 & 577) FIO2 Delivered Nasal Cannula Simple Face Mask Low flow--- 1-6 L---24-44% Low flow ----40-60% O2---Nursing Care Monitor skin integrity Careful in pts with n/v..can aspirate

Partial Rebreather Mask Nonrebreather Mask Venturi Mask

Low flow-----6-11 L of 60-75%--Flow Meter----15 L (all the way up) 80-90% O2 High flow ----55 %=10 L, and 24%=4L Monitor skin integrity.

Nursing Management (See Iggy, Chart,30-1 Oxygen Therapy only, p. 572, AND Chart 30-2, p. 574 Oxygenation Complications Combustion Suppresses Ventilation Oxygen Toxicity Look for s&s, if given more thAN 48 HRS, look for nonproductive cough, SOB, chest pain, and crackles. Call MD who will then prob. Check ABGs. For COPD, if CO2 is greater than 90 will be big cause for concern Mouth care, encourage fluids Change out equipment per protocol. Nursing Care No smoking

Dry Mucous Membranes Infection