Nurs 331 Medical Conditions of The Respiratory, Cardiovascular and Genitourinary Systems

NURS 331 MEDICAL CONDITIONS OF THE
RESPIRATORY, CARDIOVASCULAR AND

GENITOURINARY SYSTEMS
Session One Disorders of the Upper Respiratory system
Lecturer: Dr. Kwadwo Ameyaw Korsah

Contact Information: kakorsah@ug.edu.gh
College of Education
School of Continuing and Distance Education
2014/2015 2016/2017
Session Overview
This session of the course will give you general
idea about the respiratory system its structure as
well as assessment of respiratory function.
Students will also be taken through conditions
that affect the upper respiratory system such as
sinusitis, pharyngitis, tonsillitis, laryngitis and
tracheitis. In addition, students will be taught
how to identify and manage clients with these
conditions.
Dr. Kwadwo Ameyaw Korsah, UG, SON
11/23/16
Slide 2
Session Outline
The key topics to be covered in the session are as
follows:
Topic One Brief overview of anatomy and
physiology
Topic Two Assessment of respiratory function
Topic Three Upper respiratory tract diseases
11/23/16
Slide 3
Topic One
BRIEF ANATOMY AND

PHYSIOLOGY
11/23/16
Slide 4
Brief Anatomy and

Physiology
The respiratory tract extends from the nose to
the alveoli. It includes not only the airconducting passages but also the blood supply.
The main purpose of the respiratory system is
gas exchange, which involves the transfer of
oxygen and carbon dioxide between the
atmosphere and the blood.
The respiratory system is divided into two
major parts:
a. the upper respiratory tract and the
b. lower respiratory tract.
11/23/16
The upper respiratory tract includes
The nose
pharynx
adenoids
tonsils
epiglottis
larynx,
and *trachea*.
11/23/16
Brief Overview of the

Respiratory System Contd.
The upper respiratory tract also includes
the 4 paranasal sinuses. These are frontal,
ethmoid, sphenoid, and maxillary sinuses.
The sinuses are air-filled spaces lined with
mucous membrane that is continuous with
that of the nose.
Their main purpose is to produce mucus
for the nasal cavity and support/promote
vocal resonance/tone.
The sinuses are labelled in the next slide.
11/23/16
Sinuses
11/23/16

Now let us look at the lower respiratory
system.
The lower respiratory tract consists of:
the bronchi,
bronchioles
alveolar ducts
and alveoli
With the exception of the right and left
main-stem bronchi, all lower airway
structures/arrangements are contained
within the lungs.
11/23/16
The respiratory system
11/23/16
10
11/23/16
11
11/23/16
12

The nasal mucosa is responsible for warming
and humidifying the incoming air, and the
hairs and mucus are responsible for filtering
out any particles suspended in it.
This action protects the bronchial tree from
dehydration, contamination, and irritation.
In the upper part of the nose the mucosa
contains olfactory sensory cells that are able
to detect a variety of substances in solution
and are responsible for the sense of smell.
11/23/16
13

The paranasal sinuses are blind-ended
cavities that connect the nasal cavity and
are lined by nasal mucosa.
The middle ear connects with the
nasopharynx through the eustachian
tubes, which are also lined with nasal
mucosa.
The sinuses and the middle ear are prone
to nasal and throat infections which spread
to them through the mucosa.
11/23/16
14

This can be particularly serious when the
infection spreads to the middle ear and
mastoid sinuses. It may cause permanent
hearing loss or spread further into the
meninges.
The pharynx extends from the posterior
portion of the nose to the oesophagus and
larynx. It is divided anatomically according
to location.
These are:
11/23/16
15

1. The nasopharynx near the nose
2. The oropharynx near the mouth and
3. The laryngeal pharynx which is closer to the larynx.
The pharynx is very muscular, and its various
openings can be closed off to permit passage either
of air during inspiration or expiration or food or
drink during swallowing or vomiting. These two
functions never occur at the same time because
food could enter the trachea, block it, and cause
death by asphyxia or cessation of breathing.
11/23/16
16

Normally the pharyngeal openings are
relaxed for respiration and are closed off
by a complex reflex during swallowing or
vomiting. (Read around this function)
With the exception of the nose and the
pharynx, the respiratory tract is lined
throughout with ciliated columnar
epithelium and liberally supplied with
mucus-secreting goblet cells.
11/23/16
17

The mucus secreted by the respiratory
mucosa contains IgA antibodies that
protect the lungs against some of the
infectious agents, and it also traps
particles so they can be carried out of the
respiratory tree in the mucus swept toward
the pharynx by the cilia of the columnar
epithelium.
11/23/16
18

Already noted: Lower respiratory tract is
made up the larynx, the trachea, the
bronchial tree, and the lungs.
Read on the following:
1. Larynx (voice box) as a strong cartilage
tube that forms the upper end of the
trachea.
2. Trachea (windpipe) is a tube that is
strengthened by C-shaped hyaline rings
that keep the airway open.
11/23/16
19

The trachea branches at its inferior end
into the right and left bronchi.
Each primary bronchus divides into
secondary and tertiary bronchi and
bronchioles. All these tubes are also kept
patent by cartilaginous rings. The
bronchioles divide into smaller and smaller
tubes until the smallest, the alveolar
ducts, lead to the alveoli, which form the
mass of the lungs.
11/23/16
20

The lung tissue is very elastic, and the
lungs are always stretched to fill the
thoracic cavity at both sides of the
mediastinum. This creates a negative
(subatmospheric) pressure in the
intrapleural (intrathoracic) space. If air
enters this space, the lungs shrinks to a
considerably smaller size.
11/23/16
21

The right lung is divided into three lobes
(upper, middle, and lower)
the left lung into two lobes (upper and
lower)
The structures of the chest wall
(ribs, pleura, muscles of respiration) are
also essential
11/23/16
22
11/23/16
23
11/23/16
24
Physiology of
Respiration
Ventilation involves inspiration (movement
of air into the lungs) and expiration
(movement of air out of the lungs). Air moves
in and out of the lungs because intrathoracic
pressure changes in relation to pressure at
the airway opening.
Contraction of the diaphragm and intercostal
and scalene muscles increases chest
dimensions, thereby decreasing intrathoracic
pressure.
Gas flows from an area of higher pressure
(atmospheric) to one of lower pressure
(intrathoracic)
11/23/16
25

The bronchial tree dispenses air to the
alveoli of the various lobes and segments
of the lungs.
The bronchial tree provides an extremely
large surface area for gas exchange
between alveolar air and blood.
Read around gas exchange between
alveolar air and blood.
11/23/16
26
Topic Two
ASSESSMENT OF
RESPIRATORY FUNCTION
11/23/16
Slide 27
Assessment of the Respiratory

System
Subjective Data Collection: This involves data
collected from the patient.
Patient with a respiratory disorder may seek health
care for a variety of complaints that include1. Cough
. Type
dry, moist, wet, productive, hoarse, barking, whooping
. Onset
. Duration
. Pattern
activities, time of day, weather
. Severity
effect on Activities of Daily Living
11/23/16
28

System Contd.
Cough with Wheezing:is a
continuous, coarse, whistling sound

produced in the respiratory airways during
breathing.
Associated symptoms
Treatment and effectiveness
11/23/16
29

System Contd.
2. Chest pain
3. Shortness of breath
4. Wheezing without cough
11/23/16
30

System Contd.
Other potential clinical manifestations may
include :
1. Cyanosis
2. Dyspnea
3. Hemoptysis (presence of blood in
sputum)
4. Dysphagia (difficulty swallowing may lead
to aspiration)
11/23/16
31

System Contd.
5. Sputum
amount
color
presence of blood (hemoptysis)
odor
consistency
pattern of production
11/23/16
32

System Contd.
Past Health History
Respiratory infections or diseases
Trauma
Surgery
Chronic conditions of other systems
Tuberculosis
Emphysema : Emphysema is a long-term, progressive
disease of the lungs that primarily causes shortness of
breath.
Lung Cancer
Allergies
Asthma
Etc.
11/23/16
33

System Contd.
Some symptoms may result from a cardiac
disorder or may result from other systemic
disorders or alterations rather than a
respiratory disorder/disease.
Adequate history for a patient with a
respiratory disorder includes a review of
related systems and identification of any
positive findings (symptoms of which the
patient complains) through exploration of
various dimensions.
11/23/16
34

System Contd.
Specific dimensions used to determine
positive findings include:
1. Onset
2. Duration
3. Frequency
4. Alleviating factors
5. Aggravating factors or precipitating
events
6. Associated symptoms and signs
11/23/16
35

System Contd.
Other factors to be considered are:
1. Characteristics and course of the
condition
2. Severity and
3. Noting the timing and particular
circumstances under which the
condition/disease occurs.
11/23/16
36

System Contd.
Exploring the Subjective Health History of the
Client
Any risk factors for respiratory disease
smoking
exposure to smoke
history of attempts to quit, methods, results
sedentary lifestyle, immobilization

age
environmental exposure
Dust, chemicals, asbestos, air pollution
obesity
family history of respiratory conditions like asthma
The next part looks at objective data

collection
11/23/16
37

System Contd.
Objective Data Collection: This involves
Physical Examination of the client.
Here the nurse determines the appropriate
systems to be assessed based on the
history obtained and knowledge of
pathophysiology.
Some patients have more complex
symptom involvement than others, and
therefore assessment needs may vary
from patient to patient.
11/23/16
38

System Contd.
General assessment and evaluation of the
integumentary, respiratory, cardiovascular
and gastrointestinal systems are usually
included.
General assessment is significant in every
patient and refers to the examiners
overall impression of the patients state of
health.
11/23/16
39

System Contd.
General assessment: General assessment
of the client includes:
Height
Weight
Vital signs
Age
Nutritional status
General appearance and structure of the
client.
11/23/16
40

System Contd.
Also note any obvious abnormalities. Also
record whether the patient appears to be
comfortable or in distress.
Integumentary
Inspect and palpate the skin noting
warmth, colour, moisture, turgor, lesions
and vascularity.
Inspect the nails noting the presence of or
absence of clubbing as well as other
abnormalities.
11/23/16
41

System Contd.
Clubbing: This is an abnormal
enlargement of the distal phalanges with a
flattening of the curvature of the nail
margin at the cuticle, where the nail meets
the cuticle. It is usually associated with
cyanotic heart diseases or advanced
chronic pulmonary disease but sometimes
occurs in sickle cell anaemia. Clubbing
occurs in all the digits but is most easily
seen in the fingers.
11/23/16
42

System Contd.
Advanced clubbing is obvious, but early
clubbing may be difficult to diagnose. The
nail base angle measures more than 160.
11/23/16
43

System Contd.
Changes in skin colour and nail
characteristics may be related to changes
in oxygenation associated with a
respiratory disorder.
Cardiovascular
Observe the precordium for any heaves,
lifts, or pulsations. Palpate the precordium
for thrills and the epical impulse.
Auscultate the precordium with the bell
and the diaphragm noting the rate,
rhythm, murmurs or other extra sound.
11/23/16
44

System Contd.
Nose and Sinuses:
The nose and sinuses are examined by
inspection and palpation with the use of
simple light source.
A more thorough examination requires
nasal speculum.
External nose is also inspected for lesions,
asymmetry or inflammation.
11/23/16
45

System Contd.
The patient is asked to tilt the head
backward while the examiner gently
pushes the tip of the nose upward to
examine the internal structures of the nose.
The posterior nares (choanae) open into
the nasopharynx, projecting from the
lateral walls of the interior nasal cavities
are the three turbinate bones (conchae).
Adenoids or pharyngeal tonsils are also
located in the roof of the nasopharynx.
11/23/16
46

System Contd.
The nasal mucosa is inspected for:
Colour
Swelling
Exudates
Bleeding
The septum is inspected for deviation,
perforations or bleeding. Slight deviation is
observed in most cases.
11/23/16
47

System Contd.
The frontal and maxillary sinuses are
examined by palpation for tenderness.
Using thumbs, the examiner applies gentle
pressure in an upward fashion at the
supraorbital ridges (frontal sinuses) and in
the cheek area adjacent to the nose
(maxillary sinuses).
Tenderness in the area may suggest
inflammation.
11/23/16
48

System Contd.
Pharynx:
Tongue blade is used to depress the
tongue for adequate visualization of the
pharynx (not always necessary).
Instruct the patient to open mouth wide
and take a deep breath.
This will flatten the posterior tongue and
expose a full view of the anterior and
posterior pillars, tonsils, uvula and
posterior pharynx.
11/23/16
49

System Contd.
Inspect for colour, symmetry, exudates,
ulceration and enlargement.
Trachea:
Position and mobility of the trachea are
usually noted by direct palpation. This is
done by placing the thumb and index
finger of one hand on either side of the
trachea just above the sternal notch.
11/23/16
50

System Contd.
The trachea is highly sensitive, and
palpation too firmly may incite a coughing
or gagging response.
The trachea is normally midline as it
enters the thoracic inlet behind the
sternum but may be deviated by masses
in the neck or mediasternum. Pleural
disorders such as pneumothorax may
result in displacement of the trachea.
11/23/16
51

System Contd.
Surface markings of the lobes of the lung:
(a) anterior, (b) posterior, (c) right lateral
and (d) left lateral.
(UL, upper lobe; ML, middle lobe; LL, lower
lobe).
11/23/16
52
11/23/16
53
11/23/16
54
11/23/16
55

System Contd.
Position/Lighting/Draping
Position
patient should sit upright on the
examination table.
The patient's hands should remain at their
sides.
When the back is examined the patient is
usually asked to move their arms forward
(hug themselves position.
Lighting - adjusted so that it is ideal.
Draping - the chest should be fully exposed.
Exposure time should be minimized.
11/23/16
56

System Contd.
Specifically, the basic steps of the
examination can be remembered with the
mnemonic IPPA:
Inspection
Palpation
Percussion
Auscultation
11/23/16
57

System Contd.
Inspection
Inspect the neck for position of the trachea,
retraction of the sternocleidomastoid or
trapezius muscle, and supraclavicular
retraction during inspiration.
Retraction of the sternocleidomastoid or
trapezius muscles and supraclavicular
retraction indicate respiratory distress and are
referred to as use of accessory muscles.
Trachea should be in the midposition of the
neck. Deviation (may suggest tension
pneumothorax).
11/23/16
58

System Contd.
Inspect the thorax noting symmetry with
movements.
Observe the patient from the side, front,
and back, carefully comparing the
anteroposterior (AP) to transverse (or
lateral) diameter.
In patients with a long history of chronic
obstructive pulmonary disease (COPD),
they may develop barrel chest
11/23/16
59

System Contd.
In the patient with a barrel chest the ribs
lose the 45-degree angle and become
more horizontal; a slight kyphosis of the
thoracic spine develops, and the sternal
angle becomes more prominent.
Elderly patients may also have an increase
of the AP diameter, leading to more barrelchested appearance secondary to
osteoporosis.
Look at the pictures below:
11/23/16
60
11/23/16
61

System Contd.
Read on the following as some of the chest wall
deformities:
Kyphosis
Lordosis
Scoliosis
Barrel Chest
Pectus excavatum
Pectus carinatum
Note the presence or absence of intercostal retractions during

inspiration. The presence of intercostal retractions indicate
respiratory distress and is not seen in normal respiration.
11/23/16
62

System Contd.
Some Chest wall deformities
Kyphosis - curvature of the
spine - anterior-posterior
Scoliosis - curvature of the spine
- lateral
Barrel chest - chest wall
increased anterior-posterior
Pectus excavatum
11/23/16
63

System Contd.
Idiopathic Scoliosis in Children and
Adolescents
Description
Scoliosis is a sideways curvature of the
spine that makes the spine look more like
an "S" or "C" than a straight "I".
11/23/16
64

System Contd.
Scoliosis can cause the bones of the spine
to turn (rotate) so that one shoulder,
scapula (shoulder blade), or hip appears
higher than the other.
The term "idiopathic" means that the
cause of this disorder is not known (in
most cases).
Look at some pictures below:
11/23/16
65

System Contd.
Kyphosis
Pectus
exacavatum
11/23/16
66
Signs of respiratory
distress
Cyanosis - person turns blue

Pursed-lip breathing
Accessory muscle use
Diaphragmatic paradox/inconsistencies the diaphragm moves opposite of the
normal direction on inspiration
11/23/16
67
11/23/16
Note the
pursed-lip
breathing
68
11/23/16
69
Palpation
Palpate the thorax generally for
tenderness, muscle mass, and masses.
Assess thoracic expansion (respiratory
excursion) by standing behind the patient,
placing your thumbs on either side of the
spine at approximately the level of the
tenth rib, using your hands to encase the
lateral thorax (rib cage), and instructing
the patient to inhale deeply.
11/23/16
70
Palpation Contd.
Your hands should move with the thorax.
Note symmetry of movement as your
thumbs diverge.
11/23/16
71
Palpation Contd.
Assess Tactile Fremitus:
Fremitus is the palpable vibrations
transmitted to the chest wall as a result of
speech. One has to stand behind the
patient/client, placing the palmer surfaces
of the fingertips on the patients/clients
back.
11/23/16
72
Palpation Contd.
Specifically, place your open palms against the upper
portion of the anterior chest, making sure that the
fingers do not touch the chest wall. Then ask the
patient to repeat the phrase ninety-nine or Mickey
Mouse or another resonant phrase while you
systematically move the palms over the chest from
the central airways to each lungs periphery. You
should feel vibration of equal intensity on both sides
of the chest. Examine the posterior thorax in a similar
manner/fashion. The fremitus/vibrations should be
felt more strongly in the upper chest with little or no
fremitus/vibrations being felt in the lower chest.
11/23/16
Slide 73
Palpation Contd.
If the fremitus is difficult to detect, have
the patient speak louder. Fremitus may
vary with voice pitch and thickness of the
chest wall.
You should also feel the vibrations
transmitted through the airways to the
lung during tactile fremitus.
Increased tactile fremitus suggests
consolidation of the underlying lung
tissues.
11/23/16
74
Palpation contd.
Palpation of the anterior and posterior walls
of the chest can also be done to check for
tenderness and pain around the area.
Consider the pictures below:
11/23/16
75
Assessing chest expansion in expiration (left) and inspiration (right).
Percussion over the anterior chest

Direct percussion of the

76
clavicles for disease
in the
11/23/16
11/23/16
77
Percussion
Do general percussion from side to side
and from apices to bases in posterior,
lateral, and anterior aspects of the chest.
Resonance is the normal percussion tone
in the peripheral lung. If the rib is
percussed, it will elicit a flat tone rather
than resonance.
Hyperresonance is abnormal in an adult
but may be noted in the patient with a
long history of chronic obstructive
pulmonary disease (COPD).
11/23/16
78
Percussion Contd.
Diaphragmatic excursion or expansion may
be percussed to determine the level of the
diaphragm at inspiration and expiration or
movement of the diaphragm.
Ask the patient to inhale deeply and hold
the breath. Deep inspiration normally
moves the diaphragm down.
Percuss along the scapular line until
resonance is placed with dullness.
Mark the point of change.
11/23/16
79
Percussion Contd.
The level of dullness indicates the level of
the diaphragm.
Allow the patient to breathe normally a few
times, and then have the patient exhale as
much as possible and hold. Exhalation
moves the diaphragm upward.
Percuss along the scapular line until
resonance is replaced with dullness.
The level of dullness indicates the upper
level of diaphragmatic movement.
11/23/16
80
Percussion Contd.
Mark this point of change. Measure the
distance between the marks. Repeat on
the opposite side.
Diaphragmatic excursion is usually 3 to 5
cm bilaterally.
11/23/16
81
Auscultation
To assess breath sounds, ask the patient to
breathe in and out slowly and deeply
through the mouth.
Begin at the apex of each lung and zigzag
downward between intercostal spaces .
Listen with the diaphragm portion of the
stethoscope.
Look at the diagram.
11/23/16
82
Auscultation Contd.
Auscultate and note the presence or
absence of any adventitious breath
sounds. Adventitious breath sounds are
abnormal and may include crackles (rales),
wheezes (rhonchi) and pleural friction rubs
(PFRs).
11/23/16
83
Auscultation Contd.
A crackle is a brief, discontinuous sound
heard more frequently on inspiration
(sounds like rubbing hair between the
fingers).
Crackles are caused by the movement of
air through fluid in the airways and alveoli.
Crackle is a common abnormality and may
be found in pneumonia, pulmonary
oedema, and congestive heart failure.
11/23/16
84
Auscultation Contd.
Wheezes are continuous sounds, occur
more frequently in expiration, and have
been described as musical or rumbling.
Wheezes are caused by the passage of air
through constricted bronchi such as in
asthma or in presence of foreign body.
Airway may be constricted because of
secretions, spasms, tumour or swelling.
11/23/16
85
Auscultation Contd.
If wheezes are heard, have the patient cough
and note if wheezes cleared with the cough.
Wheezes that clear with cough are usually
caused by secretions.
In asthma, wheezes may be heard on
inspiration and expiration.
Pleural friction rubs are loud grating and
creaking sounds produced by the rubbing
together of inflamed visceral and parietal
pleura and are heard in late inspiration and
early expiration.
11/23/16
86
Auscultation Contd.
During auscultation, note the following on
inspiration and expiration:
Normal breath sounds
Pitch
Intensity
Quality
Duration
Location
The pictures below indicate auscultatory areas
of the anterior and posterior chest.
11/23/16
87
Auscultation of the anterior and

posterior chest walls
11/23/16
88
Normal Breath Sounds

Bronchial Sounds: These are heard over the
trachea and mainstem bronchi (2nd-4th
intercostal spaces either side of the sternum
anteriorly and 3rd-6th intercostal spaces along
the vertebrae posteriorly). The sounds are
described as tubular and harsh. Also known as
tracheal breath sounds.
Bronchovesicula Sounds: Heard over the
major bronchi below the clavicles in the upper of
the chest anteriorly. Bronchovesicular sounds
heard over the peripheral lung denote pathology.
The sounds are described as medium-pitched
and continuous throughout inspiration and
expiration.
11/23/16
89
Normal Breath sounds

Contd.
Vesicular Sounds: These are also heard
over the peripheral lung. Described as soft
and low- pitched. Best heard on
inspiration.
Diminished: Heard with shallow
breathing; normal in obese patients with
excessive adipose tissue and during
pregnancy. Can also indicate an obstructed
airway, partial or total lung collapse, or
chronic lung disease.
Look at the pictures below showing
summary of percussion of the chest and
also indicating auscultatory and
11/23/16
Slide 90
11/23/16
91
Tactile Fremitus
11/23/16
92
Tactile Fremitus Contd.

Ask the patient to say "ninety-nine"
several times in a normal voice.
Palpate using the ball of your hand.
You should feel the vibrations transmitted
through the airways to the lung.
Increased tactile fremitus suggests
consolidation of the underlying lung
tissues
11/23/16
93
11/23/16
94
11/23/16
95
11/23/16
96
11/23/16
97
Normal auscultatory sound
11/23/16
98
Posterior Chest and Anterior Chest

Posterior Chest
Posterior Chest
Posterior Chest
11/23/16
99
Some Respiratory Diagnostic

Procedures
CHEST X-RAY FILM (RADIOGRAPH) 1.
Description: provides information regarding
the anatomical location and appearance of
the lungs. 2. Pre-procedure (a). Remove all
jewelry and other metal objects from the
chest area. (b). Assess the clients ability to
inhale and hold breath. (c). Question
females regarding pregnancy or the
possibility of pregnancy. 3. Post-procedure:
Assist the client to dress.
11/23/16
100
Diagnostic Procedures
Contd.
SPUTUM SPECIMEN 1. Description: a specimen obtained
by expectoration or tracheal suctioning to assist in the
identification of organisms or abnormal cells. Obtain an early
morning sterile specimen from suctioning or expectoration .
Obtain 15 ml of sputum. Instruct the client to take several
deep breaths and then cough deeply to obtain sputum.
Always collect the specimen before client begins antibiotic
therapy. 3. Post-procedure a. Transport specimen to
laboratory STAT. b. Assist the client with mouth care.
Example of this is sputum for AFB x 3 for diagnosis of PTB
Note: In children, this may not be possible, therefore gastric
lavage is likely to be done for diagnosis of Pulmonary TB in
children.
11/23/16
101
Contd.
Throat Cultures for group A beta hemolytic
streptococci to diagnose for example
pharyngitis
11/23/16
102
Contd.
A BRONCHOSCOPY is the direct
visualization of the larynx, trachea, and
bronchi with a fibreoptic bronchoscope to
identify lesions, remove foreign bodies and
secretions, obtain tissue for biopsy, and
improve tracheobronchial drainage.
During the test, a catheter brush or biopsy
forceps can be passed to obtain secretions
or tissue for examination for cancer.
11/23/16
103
11/23/16
104
Contd.
A bronchoscope with a tiny camera on the
end which is inserted through the nose (or
mouth) into the lungs. Thus inserted
through the nostril until it passes through
the throat into the trachea and bronchi.
11/23/16
105
Contd.
RELATED NURSING CARE DURING
BRONCHOSCOPIC EXAMINATION
Obtain informed consent.
Maintain NPO status for client from midnight before
the procedure.
Obtain vital signs.
Provide routine preoperative care as ordered.
Bronchoscopy is an invasive procedure requiring
conscious sedation or anesthesia.
Care provided prior to the procedure is similar to that
provided before many minor surgical procedures.
11/23/16
106
Contd.
Provide mouth care just prior to
bronchoscopy. Mouth care reduces oral
microorganisms and the risk of introducing
them into the lungs.
Bring resuscitation and suction equipment to
the bedside.
Laryngospasm and respiratory distress may
occur following the procedure. The anesthetic
suppresses the cough and gag reflexes, and
secretions may be difficult to expectorate.
11/23/16
107
Contd.
COMPUTED TOMOGRAPHY (CT)
CT of the thorax may be performed when
x-rays do not show some areas well, such
as the pleura . It is also done to
differentiate pathologic conditions (such as
tumors, abscesses, and aortic aneurysms),
to identify pleural effusion and enlarged
lymph nodes, and to monitor treatment.
Images are shown in cross section.
11/23/16
108
11/23/16
109
11/23/16
110
Contd.
PULMONARY ANGIOGRAPHY
This test is done to identify pulmonary
emboli, tumors, aneurysms, vascular
changes associated with emphysema, and
pulmonary circulation in which a catheter
(a long, thin, flexible tube) can be inserted
into a vein in the groin or neck and fed
into the pulmonary artery. A specialist then
injects a dye into the arteries of the lungs through
the catheter. The dye helps to highlight any
blockages to blood flow (e.g. blood clots) and the
pictures
lungs taken
by the X-ray
11/23/16
111 machine.
Dr. Kwadwo
Ameyaw Korsah,of
UG, the
SON
Contd.
A catheter is inserted into the brachial or
femoral artery, threaded into the
pulmonary artery, or one of its branches.
Pulmonary angiography involves an
injection of iodine or radiopaque or
contrast material.
11/23/16
112
Contd.
ECG leads are applied to the chest for
cardiac monitoring. That is during a
pulmonary angiography procedure the
patient lies on an X-ray table and are
attached to an electrocardiogram (ECG)
machine.
Images of the lungs are taken.
Findings in many cases may show blood
clots in the lungs.
11/23/16
113
11/23/16
114
Contd.
a. Obtain informed consent b. Assess for allergies to
iodine, seafood, or other radiopaque dyes. c. Maintain
NPO status of client for 8 hours before procedure. d.
Monitor vital signs e. Administer sedation if prescribed f.
Instruct the client to lie still during the procedure.
g. Instruct the client that he or she may feel an urge to
cough, flushing, nausea, or salty taste following
injection of the dye h. Have emergency resuscitation
equipment available
Post-procedure a. Monitor vital signs b. Avoid taking
blood pressures for 24 hours in the extremity used for
injection c. Assess insertion site for bleeding d. Monitor
for delayed reaction to the dye .
11/23/16
115
Contd.
THORACENTESIS 1. Description: removal
of fluid or air from the pleural space via a
transthoracic aspiration or Done to obtain
a specimen of pleural fluid for diagnosis
(and used as a procedure to remove
pleural fluid or instil medication). 2. Preprocedure a. Obtain informed consent b.
Obtain vital signs c. Prepare the client for
ultrasound or chest radiograph, if
prescribed, before procedure.
11/23/16
116
Contd.
d. Note that the client is positioned sitting
upright, with the arms and head supported
by a table at the bedside during the
procedure. e. If the client cannot sit up,
the client is placed lying in bed on the
unaffected side with the head of the bed
elevated 45 degrees f. Instruct the client
not to cough, breath deeply, or move
during the procedure.
11/23/16
117
Contd.
A large-bore needle is inserted through the
chest wall and into the pleural space.
Following the procedure, a chest x-ray is
taken to check for a pneumothorax.
Look at the picture below:
11/23/16
118
THORACENTESIS
11/23/16
119
Contd.
3. Post procedure a. Monitor vital signs b.
Monitor respiratory status c. Apply a
pressure dressing, and assess the
puncture site for bleeding and drainage in
general. d. Monitor for signs of
pneumothorax, air embolism, and
pulmonary oedema
11/23/16
120
Contd.
LUNG BIOPSY 1. Description a. A
percutaneous lung biopsy is performed to
obtain tissue for analysis by culture or
cytological examination b. A needle biopsy
is done to identify pulmonary lesions,
changes in lung tissue, and the cause. It
may be done to obtain tissue to
differentiate benign from malignant
tumours of the lungs. May be done during
a bronchoscopy, or by surgical procedure.
11/23/16
121
Contd.
2. Preprocedure a. Obtain informed consent. b.
Inform the client that a local anaesthetic will be
used but that sensation of pressure during needle
insertion and aspiration may be felt. c. Administer
analgesics and sedatives as prescribed
3. Postprocedure a. Monitor vital signs b. Apply
dressing to the biopsy site and monitor for drainage
or bleeding c. Monitor for signs of respiratory
distress, and notify physician if they occur d.
Monitor for signs of pneumothorax and air emboli,
and notify physician if they occur e. Prepare the
client for chest radiography if prescribed
11/23/16
122
Contd.
Blood Serum Tests:
Full Blood Count- Total & Differential
Erythrocyte Sedimentation Rate (ESR) and
others
11/23/16
123
Contd.
Skin Tests:
Example Tuberculin Skin Testing
(Mantoux)
The mantoux test identifies individuals
infected with mycobacterium tuberculosis.
Using a tuberculin syringe, inject 0.1mL of
intermediate strength purified protein
derivative (PPD) into the inner aspect of
the forearm intradermally.
11/23/16
124
Contd.
Classifying the Reaction
Whether a reaction to the Mantoux
tuberculin skin test is classified as positive
depends on the size of the induration and
the person's risk factors for TB.
11/23/16
125
Contd.
An induration of 5 or more millimeters is
considered a positive reaction for the
following people:

People with HIV infection
Close contacts of people with infectious TB
People with chest x-ray findings
suggestive of previous TB disease
People who inject illicit drugs and whose
HIV status is unknown.
11/23/16
126
Contd.
An induration of 10 or more millimeters
is considered a positive reaction for the
following people:
People born in areas of the world where TB
is common (foreign-born persons)
People who inject illicit drugs but who are
known to be HIV negative
Low-income groups with poor access to
health care.
11/23/16
127
Contd.
People who live in residential facilities (for
example, nursing homes or correctional
facilities)
People with medical conditions that appear
to increase the risk for TB (not including
HIV infection), such as diabetes
Children younger than 4 years old
People in other groups likely to be exposed
to TB, as identified by local public health
officials
11/23/16
128
Contd.
An induration of 15 or more millimeters
is considered a positive reaction for people
with no risk factors for TB.
11/23/16
129
Contd.
Inspect for wheal formation.
Read 48 to 72 hours after injection by
palpating area for the presence of
induration and not erythma.
Measure the width of the induration.
In principle, positive reaction = 10mm or
more of induration (close contact with
some one with TB.
Whereas Doubted Reaction = 5mm to 9mm of
induration. May be repeated 1 week to one month
for some patients.
11/23/16
130
Contd.
False-Positive PPD Reactions
The skin test is a valuable tool, but it is not
perfect.
Sometimes people who are not infected
with M. tuberculosis will have a positive
reaction to the PPD tuberculin skin test.
11/23/16
131
Contd.
This is called a false-positive reaction.
The two most common reasons for false
positive PPD reactions are infection with
nontuberculous mycobacteria
(mycobacteria other than M. tuberculosis)
and vaccination with BCG (bacillus
Calmette-Gurin).
People who have a positive PPD reaction
should be further evaluated for TB
disease, regardless of whether they were
vaccinated with BCG.
11/23/16
132
Contd.
False-Negative Reactions
Some people have a negative reaction to
the tuberculin skin test even though they
have TB infection. These are called falsenegative reactions.
False-negative reactions may be caused
by:
11/23/16
133
Contd.
Anergy
Recent TB infection (within the past 10
weeks)
Very young age (younger than 6 months
old)
Anergy is the inability to react to skin tests
because of a weakened immune system.
Many conditions, such as HIV infection,
cancer, or severe TB disease itself, can
weaken the immune system and cause
11/23/16
134
Contd.
Because of their risk for anergy and their
risk for TB, in selected situations HIVinfected people may be tested for anergy
if they have a negative reaction to the
tuberculin skin test. However, anergy
testing is not recommended as a routine
component of TB screening among HIVinfected persons.
11/23/16
135
Contd.
Another cause of false-negative reactions
is recent TB infection (infection within
the past 10 weeks). It takes 2 to 10 weeks
after TB infection for the body's immune
system to be able to react to tuberculin.
Therefore, after TB has been transmitted,
it takes 2 to 10 weeks before TB infection
can be detected by the tuberculin skin
test.
11/23/16
136
Contd.
For this reason, close contacts of someone
with infectious TB disease who did not
react to the PPD tuberculin skin test should
be retested 10 weeks after the last time
they were in contact with the person who
has TB disease.
11/23/16
137
Contd.
A third cause of false-negative reactions is
very young age. Because their immune
systems are not yet fully developed,
children younger than 6 months old
may have a false-negative reaction to the
tuberculin skin test.
11/23/16
138
Contd.
A false-positive reaction or a falsenegative reaction may occur when the
tuberculin skin test is given incorrectly or
the results are not measured properly.
Any patient with symptoms of TB
should be evaluated for TB disease,
regardless of his or her skin test
reaction. In fact, people with symptoms
of TB should be evaluated for TB disease
right away, at the same time that the
tuberculin skin test is given.
11/23/16
139
Contd.
The symptoms of pulmonary TB disease
include coughing, pain in the chest when
breathing or sputum (The general
symptoms of TB disease (extrapulmonary)
include weight loss, fatigue, malaise,
fever, and night sweats.
11/23/16
140
Giving the Mantoux tuberculin skin

test
11/23/16
141
The induration (raised area) is what is measured.

NOT the erythema (red area).
11/23/16
142
Only the induration is being measured. This is CORRECT.
11/23/16
143
The erythema is being measured. This is INCORRECT.
Classifying the Reaction
11/23/16
144
Contd.
Read on the following:SKIN TEST:
A skin test is an intradermal injection used to assist in diagnosing
various infectious diseases. E.g. Mantoux Skin Test
Determine hypersensitivity or previous reactions to skin tests
ARTERIAL BLOOD GASES:
Measurement of the dissolved oxygen and carbon dioxide in the
arterial blood to reveal the acid-base state and how well the oxygen is
being carried to the body.
PULSE OXIMETRY:
Pulse oximetry is a noninvasive test that registers the oxygen
saturation of the clients hemoglobin.
POSTURAL DRAINAGE: use of the gravity
NURSING CARE: Stop if cyanosis or exhaustion occurs
CONTRAINDICATIONS OF POSTURAL DRAINAGE
11/23/16
145
Topic Three
UPPER RESPIRATORY
TRACT DISEASES
11/23/16
Slide 146
Respiratory Tract
Diseases
Respiratory tract infections are
infectious diseases involving the
respiratory tract. An infection of this
category is normally further classified as
an (1) upper respiratory tract infection
(URI or URTI) or a (2) lower respiratory
tract infection (LRI or LRTI). Lower
respiratory infections, including
pneumonia and bronchitis, tend to cause
severe manifestations, and a far more
serious conditions than upper respiratory
infections, such as the common cold.
11/23/16
147
Respiratory Tract
Diseases contd.
The lower respiratory tract consists of the
trachea (wind pipe), bronchial tubes, the
bronchioles, and the lungs.
Lower respiratory tract infections are
generally more serious than upper
respiratory infections. LRIs are the leading
cause of death among all infectious
diseases.
11/23/16
148
Respiratory Tract
Diseases Contd.
The two most common LRIs are bronchitis
and pneumonia.
Influenza also affects both the upper and
lower respiratory tracts, but more
dangerous strains such as the highly
pernicious H5N1 tend to bind to receptors
deep in the lungs and cause severe
damage.
Influenza, is commonly known as "the flu", is an infectious

disease caused by the influenza virus. Symptoms can be
mild to severe. The most common symptoms include: a high
fever, runny nose, sore throat, muscle pains, headache,
11/23/16
149
coughing, and feeling tired.
-Influenza A Virus
H1N1 -H5N1
What is an upper respiratory

infection?
An upper respiratory tract infection, or
upper respiratory infection, is an infectious
process of any of the components of the
upper airway.
Infection of the specific areas of the upper
respiratory tract can be named specifically.
11/23/16
150
Upper Respiratory Infection

Contd.
Examples of these may include rhinitis
(inflammation of the nasal cavity), sinus
infection (sinusitis or rhinosinusitis) inflammation of the sinuses located
around the nose, common cold
(nasopharyngitis) - inflammation of the
nares, pharynx, hypopharynx, uvula, and
tonsils, pharyngitis (inflammation of the
pharynx, uvula, and tonsils).
11/23/16
151

Contd.
Others may include epiglottitis
(inflammation of the upper portion of the
larynx or the epiglottis), laryngitis
(inflammation of the larynx),
laryngotracheitis (inflammation of the
larynx and the trachea), and ***tracheitis
(inflammation of the trachea some
authorities tend to discuss this under
the lower respiratory tract
infections).
11/23/16
152

Contd.
Majority of upper respiratory infections are
due to self-limited viral infections of the
upper respiratory tract. Occasionally,
bacterial infections may cause upper
respiratory infections.
11/23/16
153

Contd.
Most often, upper respiratory infection is
contagious and can spread from person to
person by inhaling respiratory droplets
from coughing or sneezing. The
transmission can also occur by touching
the nose or mouth by hand or other object
exposed to the virus.
11/23/16
154

Contd.
Upper respiratory infection is generally
caused by the direct invasion of the inner
lining (mucosa or mucus membrane) of
the upper airway by the culprit virus or
bacteria. In order words for the pathogens
(viruses and bacteria) to invade the mucus
membrane of the upper airways, they
have to fight through several physical and
immunologic barriers.
11/23/16
155

Contd.
The hair in the lining of the nose acts as
physical barrier and can potentially trap
the invading organisms. Additionally, the
wet mucus inside the nasal cavity can
engulf the viruses and bacteria that enter
the upper airways. There are also small
hair-like structures (cilia) that line the
trachea which constantly move any
foreign invaders up towards the pharynx
to be eventually swallowed into the
digestive tract and into the stomach.
11/23/16
156

Contd.
In addition to these intense physical
barriers in the upper respiratory tract, the
immune system also does its part to fight
the invasion of the pathogens or microbes
entering the upper airway. Adenoids
(glandlike) and tonsils located in the upper
respiratory tract are a part of the immune
system that help fight infections.
11/23/16
157

Contd.
Through the actions of the specialized
cells, antibodies, and chemicals within
these lymph nodes, invading microbes are
engulfed within them and are eventually
destroyed.
11/23/16
158

Contd.
Despite these defense processes, invading
viruses and bacteria adapt various
mechanisms to resist destruction. They
can sometimes produce toxins to impair
the body's defense system or change their
shape or outer structural proteins to
disguise from being recognized by the
immune systems (change of antigenicity).
Some bacteria may produce adhesion
factors that allow them to stick to the
mucus membrane and hinder their
destruction.
11/23/16
159

Contd.
It is also important to note that different
pathogens have varying ability to
overcome the body's defense system and
cause infections. Some viruses may infect
by much fewer numbers than others.
11/23/16
160

Contd.
Furthermore, different organisms require
varying time of onset from when they
enter the body to when symptoms occur
(incubation time). Some of the common
pathogens for upper respiratory infection
and their respective incubation times are
the following:
rhinoviruses, 1-5 days;
group A streptococci, 1-5 days;
11/23/16
161

Contd.
influenza and parainfluenza viruses, 1-4
days;
respiratory syncytial virus (RSV), 7 days;
pertussis (whooping cough), 7-21 days;
diphtheria,1-10 days; and
Epstein-Barr virus (EBV), 4-6 weeks.
11/23/16
162

Contd.
What are the common clinical
manifestations of upper respiratory
infection?
Generally, the symptoms of upper
respiratory infection result from the toxins
released by the pathogens as well as the
inflammatory response mounted by the
immune system to fight the infection.
11/23/16
163

Contd.
Common symptoms of upper respiratory

infection generally include:
nasal congestion
runny nose (rhinorrhea)
nasal discharge
nasal breathing
sneezing
11/23/16
164

Contd.
sore or scratchy throat

painful swallowing (odynophagia)
cough (from laryngeal swelling etc)
malaise and
fever (more common in children).
11/23/16
165

Contd.
Other less common symptoms may
include foul breath, poor smelling
sensation (hyposmia), headache,
shortness of breath, sinus pain, itchy and
watery eye (conjunctivitis), nausea,
vomiting, diarrhoea, and body aches.
11/23/16
166

Contd.
The symptoms of upper respiratory
infection usually last between 3-14 days; if
symptoms last longer than 14 days, an
alternative diagnosis can be considered
such as, allergy, pneumonia, or bronchitis
etc.
11/23/16
167

Contd.
Upper respiratory infections in the lower
part of the upper respiratory tract, such
as, laryngotracheitis, are more commonly
featured with dry cough and hoarseness or
loss of voice. Barking or whooping cough,
rib pain (from severe cough) are other
presenting features.
11/23/16
168

Contd.
SINUSITIS
Sinusitis is an inflammation of the sinuses.
Sinuses are air spaces within the bones of the
face. Sinusitis is most often due to an infection
within these spaces. The sinuses are paired air
pockets located within the bones of the face.
Location of sinus
The frontal sinuses, located above the eye in
the centre region of each eyebrow.
11/23/16
169

Contd.
The maxillary sinuses, located within the
cheekbones, just next to either side of the
nose.
The ethmoid sinuses, located between the
eyes, just behind the bridge of the nose.
The sphenoid sinuses, located just behind
the ethmoid sinuses, and behind the eyes.
Having a cold increases the chance of
getting sinusitis.
11/23/16
170
11/23/16
171

Contd.
Pathophysiology
The sinuses are connected with the nose.
They are lined with the same kind of skin
found elsewhere within the respiratory
tract. This skin has tiny little hairs
projecting from it called cilia. The cilia beat
constantly to help move the mucus
produced in the sinuses into the
respiratory tract.
11/23/16
172

Contd.
The beating cilia sweeping the mucus
along the respiratory tract help to clear
the respiratory tract of any debris or of
any organism that may be present. When
the lining of the sinuses is all swollen, the
swelling interferes with the normal flow of
mucus.
11/23/16
173

Contd.
Trapped mucus can then fill the sinuses,
causing an uncomfortable sensation of
pressure and providing an excellent
environment for the growth of infection
causing bacteria.
11/23/16
174
11/23/16
175

Contd.
Types/ Classification
Acute
Sub-acute
Chronic
Allergic
Hyperplasic
11/23/16
176

Contd.
Acute Sinusitis: This is an infection of the air
spaces in the bones of the head which are
connected to the nose, so that infections
in the nose can spread to these spaces.
It usually develops as a result of common
cold, catarrh.
This infection does not occur in children
less than 6 years because their air spaces
are not well developed.
11/23/16
177

Contd.
Causes
Viral origin: which usually last 7- 10 days.
It is precipitated by an early upper
respiratory tract infection.
Bacteria origin: three causative agents
which are Streptococcus pneumoniae,
Haemophilus influenza and Moraxella
catarrhalis which last more than 10 days.
11/23/16
178

Contd.
Clinical Manifestations
Purulent nasal discharge (drainage from
the nose often changes form a clear colour
to a thicker yellowish- green).
General Malaise/ fever
Headache
11/23/16
179

Contd.
Stuffy nose
Pain in jaw or teeth
Pain above and below the eyes, when
patient bends over or when these areas
are tapped lightly.
11/23/16
180

Contd.
Sore throat
Eyelid oedema or facial congestion or
fullness.
In some children, there is upset stomach
due to infected drainage going down back
of the throat and being swallowed
Some patient develop a cough
Decreased sense of smell
11/23/16
181

Contd.
Sub-acute Sinusitis
There is persistent purulent nasal
discharge that last longer than 2 weeks
but less than 4 weeks.
11/23/16
182

Contd.
Chronic Sinusitis
There is a narrowing or obstruction in the
frontal, maxillary and the anterior ethmoid
sinuses (usually causes chronic sinusitis)
preventing adequate drainage to the nasal
passages. Chronic sinusitis may occur
when acute and sub-acute are not
adequately treated.
11/23/16
183

Contd.
Impaired mucociliary clearance and
ventilation
Cough
Chronic hoarseness
Chronic headaches in the peri-orbital area
Facial pain
Fatigue
11/23/16
184

Contd.
Nasal stuffiness/ persistent nasal
congestion
Purulent nasal discharge
Halitosis/sore throat
Anosomia (decreases sense of smell)
Unless complications occur fever is not a
feature of chronic sinusitis.
11/23/16
185

Contd.
Read on other causes:
Fungal invasion: Fungi called Aspergillus
candida or mucorales.
People with weakened immune systems
(including patients with diabetes,
AIDS) and patients on medications that
lowers their immune resistance such as
cancer and transplant patients
11/23/16
186

Contd.
Hyperplasia: Nasal polyps, abnormalities
such as deviated septum.
Allergy: Environmental factors such as
dust or pollution
Second-hand smoke may also be
associated with chronic rhinosinusitis
11/23/16
187

Contd.
Diagnostic Investigations
A careful history and physical examination
are performed
Culture of nose or throat for causative
organisms
Radiographs of sinuses are used to
determine the presence or extent of the
disease.
CT scan
11/23/16
188

Contd.
Treatment
Non Pharmacological Intervention and
Prevention
Medical Intervention
Surgical Intervention
11/23/16
189

Contd.
Non Pharmacological Intervention and
Prevention
The nursing measures are directed
towards drainage. Steam inhalation,
increased fluid intake and local heat
application (hot wet packs) will assist in
promoting drainage.
The nurse teaches the patient the early
signs of a sinus infection and recommends
preventive measures:
11/23/16
190

Contd.
Identify and avoid allergens if allergies are
suspected.
Maintain general health measures so that
the bodys resistance is not lowered, eat
properly, get adequate rest and sleep and
exercise.
Avoid exposure to cigarette smoke, avoid
excessive alcohol intake.
11/23/16
191

Contd.
Avoid others with upper respiratory tract
infections.
Avoid air contaminants (dust, chemical)
where possible.
Report to hospital when there is persistent
nasal discharge.
11/23/16
192

Contd.
Pharmacological or Medical Intervention
Medical management of chronic and acute
sinusitis is almost the same. The goals of
treatment are to control infection, shrinkage
of the nasal mucosa and relief of pain.
The antibiotic of choice:
Amoxicillin(Augmentin) and Ampicillin,
alternatively those allergic to penicillin are
given Sulfathoxazole (Bactrim, Septra,
Erythromycin) as first line of treatment.
11/23/16
193

Contd.
For Example: Amoxicillin, oral;
Adults: 500mg 8hourly for 10 days
Children:
<1yr: 62.5mg 8hourly for 10 days
1-5yrs: 125mg 8 hourly for 10 days
11/23/16
194

Contd.
Cephalosporins such as Cefuroxacin axetil
Quinolone- Levofloxacin(Levaquin)
Oral and Topical decongestants may be
administered: Oral decongestant such as
Drixoral and Dimetapp and Topical
decongestants such as Afrin and Otrivin
Antihistamines eg. cetirizine
Acetaminophen and Ibuprofen can
decrease the pain and headache
11/23/16
195

Contd.
For those with penicillin allergy,
Erythromycin, oral may be given as:
Adults: 500mg 6 hourly for 10 days
Children: 20-50mg/kg BW 6 hourly for 10
days or
Adults: Doxycycline, oral 100mg 12 hourly
for 10 days may be given.
11/23/16
196

Contd.
Paracetamol,oral:
Adults: 500mg-1g, 3 -4 times a day.
Children:
3 months-1yr: 60-120mg, 3-4 times a day.
1-5 years: 120- 250mg, 3-4 times daily.
6-12 years: 250-500mg, 3-4 times a day.
11/23/16
197

Contd.
Surgical Interventions (Read on these)
Most often is done in fungal and chronic
sinusitis when standard medical therapy
fails.
Sinuplasty is used to expand the opening
of the sinuses in a less invasive manner
Ethmoidotomy and ethmoidectomy
11/23/16
198

Contd.
Ethmoidotomy is an opening made for drainage
Ethmoidectomy entails removal of ethmoid tissue
Caldwell-Luc radical antrostomy is done (radical
antrum operation). The procedure is performed
through an incision under the upper lip into the
maxillary sinus to allow dependent drainage from
the maxillary sinus. The incision is closed with
absorbable sutures.
Maxillary antral sinus washout also clears the maxillary
sinus of infectious drainage. The washout is typically
reserved for patients with recurring sinus infectious who
cannot treat the complications with antibiotics.
11/23/16
199

Contd.
The drainage fills or blocks the maxillary
sinus activity causing cheek or tooth pain.
Procedure
The washout is done with a special trocar
and cannula under local surface
anaesthesia using saline solution.
11/23/16
200

Contd.
The trocar is directed upwards and
laterally towards the outer canthus.
The sinus is then aspirated and irrigated.
11/23/16
201

Contd.
Pharyngitis and Tonsilitis (Infection of the
throat and tonsils)
This is the inflammation of the pharyngeal wall due
to microbial or mechanical injury. The inflammation
may result from bacterial, viral or fungus invasion.
The throat becomes dry, reddened and painful
especially during swallowing. There is sore throat
and in children fever may be present. Pharyngitis
may occur as secondary outcome of an acute
rhinitis or sinusitis.
11/23/16
202
Inflamed tonsils
11/23/16
203
11/23/16
204
11/23/16
205
11/23/16
206

Contd.
Most sore throats are due to viral
infections and should not be treated
with antibiotics as they subside
within 3-5 days. The tonsils and uvular
may also be inflamed. Examine the mouth
and throat noting enlargement of uvular
and other abnormalities. Encourage
patient to do warm saline/aspirin gaggles.
Encourage intake of fluids and Vitamin C.
Inhalation therapy can be done. Spicy and
citrus fruits should be avoided.
11/23/16
207

Contd.
Liquid diet, fruits or soft diet (agidi with
light soup, tuozafi with ayoyo) is better
tolerated.
However, it is important to diagnose
streptococcal pharyngitis since it may give
rise to abscesses in the throat
(rethropharyngeal and peritonsillar
abscess) as well as complications that
involve organs like kidneys and the heart.
11/23/16
208

Contd.
Streptococcal throat infections require
treatment with antibiotics in order to
reduce the complications noted above.
Symptoms:
Fever
Difficulty in swallowing
Sore throat
Running nose or cough
11/23/16
209

Contd.
Signs:
Reddened throat
Enlarged and reddened tonsils
Palpable tonsillar lymph glands (at the
angle of the mandible).
11/23/16
210

Contd.
Sings of streptococcal pharyngitis are:
Painful enlarged tonsillar lymph gland
Absence of signs suggesting viral
nasopharyngitis (running nose, cough, red
eyes)
Whitish exudates at the back of the throat
as well as whitish tonsillar exudate
Sustained high grade fever
Occasional there is rash of scarlet fever
11/23/16
211

Contd.
Treatment objectives:
To relieve symptoms
To recognise streptococcal throat infection
and treat accordingly
To relieve pain
11/23/16
212

Contd.
Pharmacological Treatment:
In the cases of sore throats without signs
of streptococcal pharyngitis-:
No antibiotics should be given.
Warm salty water for gargle should be
encouraged.
For pain or fever give:
11/23/16
213

Contd.
Paracetamol,oral:
Adults: 500mg-1g, 3 -4 times a day.
Children:
3 months-1yr: 60-120mg, 3-4 times a day.
1-5 years: 120- 250mg, 3-4 times daily.
6-12 years: 250-500mg, 3-4 times a day.
11/23/16
214

Contd.
OR
Adults: Ibuprofen, oral: 200-400mg, 3
times daily
Children: 100-200mg, 3 times daily
In patients with streptococcal pharyngitis
and tonsilitis, it is important to give:
11/23/16
215

Contd.
Amoxicillin, oral:
Adults: 500mg 6hourly for 10 days
Children:
<1yr: 62.5mg 6hourly for 10 days
6-12yrs: 250mg 6hourly for 10 days
Plus
11/23/16
216

Contd.
Benzathine Penicillin, IM:
Adults and Children above 10 yrs: 1.2MU
stat
Children weighing 30kg: 0.9MU stat
Children weighing <30kg: 0.6MU stat
Co-trimoxazole (Septrin) should not be given
in case of acute streptococcal infection.
11/23/16
217

Contd.
If a patient is allergic to penicillin, use
Erythromycin, oral:
Adults: 500mg 6 hourly for 10 days
Children:
0-2 years: 125mg 6 hourly for 10 days
2-8 years: 250mg 6 hourly for 10 days.
A patient with recurrent tonsillitis,
retropharyngeal and peritonsillar abscess
should be referred to an ENT specialist.
11/23/16
218

Contd.
Maintain oral hygiene to refresh the mouth
and reduce dryness and cracking of lips.
Lozenges may be used. Antibiotics may be
given following throat swab for culture and
sensitivity test.
11/23/16
219

Contd.
Laryngitis
Inflammation of the larynx as a result of
voice abuse or exposure to dust,
chemicals, smoke and other pollutants, or
as part of an upper respiratory tract
infection characterized by hoarseness or
loss of voice and coughing.
11/23/16
220
11/23/16
221
11/23/16
222
11/23/16
223

Contd.
Several forms of laryngitis occur in
children that can lead to dangerous
respiratory blockage. These forms include
croup and epiglottitis. Croup is a condition
that causes an inflammation of the upper
airways the voice box (larynx) and
windpipe (trachea). It often leads to a
barking cough or hoarseness, especially
when a child cries.
11/23/16
224

Contd.
Most cases of croup are caused by viruses,
usually parainfluenza virus and sometimes
adenovirus or respiratory syncytial virus
(RSV). Viral croup is most common
and symptoms are most severe in
children 6 months to 3 years old, but can
affect older kids as well. Some children are
more prone to developing croup when they
get a viral upper respiratory infection.
11/23/16
225

Contd.
Causes
Viral infection is the main cause of
laryngitis.
Thyroid inflammation.
Bacterial invasion may be secondary
cause.
Tumour in the neck and chest.
11/23/16
226

Contd.
Exposure to irritating inhalants and
pollutants such as chemical agents,
tobacco, alcohol, dust, smoke, volatile
gases (glue), paint thinner, butane or
intubation.
Trauma.
Overuse of the voice (such as screaming,
singing, shouting, loud speaking) over a
period of time. This results in the oedema
(swelling) of the vocal cords and formation
of nodules or polyps.
11/23/16
227

Contd.
Gastroesophageal Reflux Disease (GERD),
thus acid and digestive juices from
stomach reflux up into the oesophagus.
Pathophysiology
The cause of the infection is almost always
a virus. Bacterial invasion may be
secondary. Laryngitis is usually associated
with allergies, rhinitis or pharyngitis.
11/23/16
228

Contd.
The onset of the infection may be
associated with exposure to sudden
temperature changes like extreme cold,
dietary deficiencies (such as Vitamin C),
malnutrition and an immunosuppressive
state. Laryngitis is common in the cold
season and is easily transmitted.
11/23/16
229

Contd.
Diagnosis
Physical examination determines whether
Respiratory Tract Infection (RTI) is the
cause of the hoarseness. Patient with
hoarseness that last for more than a
month (esp. smokers) will need to see an
ear, nose, throat doctor (otolaryngologist)
for test of the throat and upper airway.
Laryngoscopy is performed to assist in
diagnosis.
11/23/16
230

Contd.
An endoscopic instrument is used in this
examination. This is done to examine the
larynx in order to differentiate
inflammation, polyps, oedema or tumour.
11/23/16
231

Contd.
Hoarseness or aphonia (complete loss of
voice).
Severe cough.
Fever in infants and young children.
Croup (a group of symptoms associated
with inflammation or spasms of the larynx)
in infants.
Runny nose.
11/23/16
232

Contd.
Loss of voice.
Feeling of fullness in the throat and the
neck
Swollen lymph nodes in the neck.
Dyspnoea in children.
Sore throat.
Excessive mucus production.
Tickling sensations in the throat in chronic
cases.
11/23/16
233

Contd.
Management
1) Primary management aims at
preventing the condition from occurring.
Prevention of the causative factors such
as;
Smoking.
Alcohol intake.
Vocal abuse like screaming, shouting,
singing for a long period of time.
Inhalation of poisonous gases.
11/23/16
234

Contd.
2) Secondary management aims at
treating the condition after it has occurred.
i) The patient is asked to rest the voice
and maintain a well humidified
environment.
ii) A daily fluid intake
iii) If the cause of the condition is due to
Gastroesophageal Reflux, it is treated
symptomatically .The clients bed is
elevated at the head side 6-10 inches to
minimize reflux.
11/23/16
235

Contd.
iv) Client is to avoid eating or drinking for
2-3 hours before going to sleep. Avoid
caffeine, alcohol, and tobacco. These are
known to increase gastric secretions.
Respiratory Tract Infection (RTI) should be
well treated with antibiotics if bacterial
infection is suspected.
11/23/16
236

Contd.
In severe cases, systemic steroids eg
methylpredinisoline (Medrol) may be
prescribed.
Serve analgesics as prescribed.
11/23/16
237

Contd.
3) Tertiary management aims at
rehabilitation.
i) Resting of the voice.
ii) Long term voice retraining if improper
use of the voice or overuse of the voice is
the main cause of chronic laryngitis.
iii) Retraining learning to use the voice
without straining, forming and projecting
words to use the diaphragm without
shouting.
11/23/16
238

Contd.
Nutrition
Increase intake of warm fluids. Encourage
vitamin C- rich food to improve immunity
and cell regeneration. Vitamin C source
include citrus fruits (oranges, limes,
lemons and grapes and vegetables. Avoid
alcohol intake since it is a major irritant.
11/23/16
239

Contd.
Complications
Sepsis.
Meningitis.
Pretonsillar abscess.
Otitis media.
Sinusitis.
Aspiration pneumonia.
11/23/16
240

Contd.
Tracheitis
The trachea or wind pipe is composed of
smooth muscle with C-shaped rings of
cartilage at regular intervals which serves
as the passage between the larynx and
the bronchi. The cartilaginous rings give
firmness to the wall of the trachea,
preventing it from collapsing. Tracheitis is
the inflammation of the trachea.
11/23/16
241
11/23/16
242
11/23/16
243

Contd.
Incidence
This may occur at all ages from 3 weeks to
13 years, in most of the cases children
below 4 years of age are affected. It is
more serious in children because of their
relatively small size of trachea, which may
block easily.
Types
Bacterial Tracheitis
Acute Tracheitis
11/23/16
244

Contd.
Bacterial Tracheitis
It is a serious life threatening disease
because of its complications due to
severe airway obstruction.

11/23/16
245

Contd.
Aetiology
It is a bacteria disease, however, it usually
follows a viral respiratory infection most
commonly due to parainfluenza 1 & 2 and
less commonly influenza virus. It is
normally a complication or super infection
of viral laryngo-trahceobroncheitis. It is
believed that the virus predisposes the
trachea to bacterial infections by initiating
local mucosal damage.
11/23/16
246

Contd.
It can also begin as a primary infection or
bacterial disease. The hallmark sign of
bacterial tracheitis is the presence of large
volumes of thick purulent secretions. As
the illness progresses, a high fever with
increased respiratory distress from
progressive airway obstruction is seen.
11/23/16
247

Contd.
Causative Organism
The most common pathogen involved is
the staphylococcus aureus followed by
haemophilus influenza type B.
It often follows recent upper viral
respiratory tract infection.

11/23/16
248

Contd.
Signs and Symptoms
Increasing deep or barking croup cough
following a previous upper respiratory
infection.
Crowing sound when inhaling (inspiratory
stridor)
Scratchy feeling in the throat
Chest pains
Fever
11/23/16
249

Contd.
Ear ache
Difficulty in breathing
Headache
Dizziness (light headedness)
Intercostal retractions
Copious tracheal secretions
Necrotic Mucosa forms a pseudo
membrane which worsens the air way
obstructions.
11/23/16
250

Contd.
Diagnosis
By the combination of clinical features and the
presence of large amounts of thick, copious
tracheal secretions.
By visualization of the trachea and the secretions
using endoscopy.
Chest x-ray may show the presence of
pulmonary infiltrates.
Culture of tracheal secretions is also done to
confirm diagnosis.
11/23/16
251

Contd.
Management
The primary collaborative interventions
are directed at maintaining airway
patency, providing antibiotic therapy and
providing psychological support for the
family and child.
Supportive interventions to maintain
airway patency depends on the severity
and clinical progression of the disease.
11/23/16
252

Contd.
Children who have been ill for some time,
those younger than 8 years of age, or
those who show signs of significant airway
obstruction require suctioning of the
purulent secretions.
11/23/16
253

Contd.
Drugs
IV broad-spectrum antibiotics e.g. IV
cefuroxime 100mg/kgbw/day or for
staphylococcus. The therapy should be
continued for 10 14 days.
The fever is also controlled with
antipyretics e.g. suppository paracetamol
125-250mg tid.

11/23/16
254

Contd.
Parental/Support/Participation
Allowing parental participation in the care
of the child is important to the support of
family relationships.
Ensuring the presence of the parents or a
significant other also helps to decrease
anxiety for the child.
Parental education helps parents control
their anxiety and achieve some mastery
over a stressful situation.
11/23/16
255

Contd.
Education concerning the rationale for
interventions and the expected hospital
course is also helpful.
Complications
Pneumonia due to extension of purulent
materials through the tracheobronchial
tree.
Others include sepsis
Toxic shock syndrome
Pneumothorax
11/23/16
256
References
Grossman, S., C. & Porth, C., M. (2014). Porths
Pathophysiology: Concepts of Altered Health States. 9 th
Ed. Lippincott Williams and Wilkins, Philadelphia.
Hinkle, J., L. &Cheever, K., H. (2014)Brunner &
Suddarths Textbook of Medical Surgical Nursing 13 th Ed.
Lippincott Williams and Wilkins, Philadelphia.

Ignatavicius, D., D. &Workman, M., L. (2013). Medical
Surgical Nursing: Patient Centered Collaborative Care.7 th
Ed. Elsevier/Saunders, Philadelphia.

Jones, D., A. & Dumbar, C., F. (2000). Medical Surgical
Nursing: A Conceptual Approach. McGraw Hill, New York.
11/23/16
Slide 257

Nurs 331 Medical Conditions of The Respiratory, Cardiovascular and Genitourinary Systems

Caricato da

Informazioni sul documento

Descrizione originale:

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Nurs 331 Medical Conditions of The Respiratory, Cardiovascular and Genitourinary Systems

Caricato da

Copyright:

Formati disponibili

NURS 331 MEDICAL CONDITIONS OF THE

RESPIRATORY, CARDIOVASCULAR AND

Session One Disorders of the Upper Respiratory system

Lecturer: Dr. Kwadwo Ameyaw Korsah

Dr. Kwadwo Ameyaw Korsah, UG, SON

Dr. Kwadwo Ameyaw Korsah, UG, SON

BRIEF ANATOMY AND

Brief Anatomy and

The upper respiratory tract includes

Dr. Kwadwo Ameyaw Korsah, UG, SON

Brief Overview of the

Dr. Kwadwo Ameyaw Korsah, UG, SON

Brief Overview of the

The respiratory system

Dr. Kwadwo Ameyaw Korsah, UG, SON

Dr. Kwadwo Ameyaw Korsah, UG, SON

Dr. Kwadwo Ameyaw Korsah, UG, SON

Brief Overview of the

Brief Overview of the

Brief Overview of the

Brief Overview of the

Dr. Kwadwo Ameyaw Korsah, UG, SON

Brief Overview of the

Brief Overview of the

Dr. Kwadwo Ameyaw Korsah, UG, SON

Brief Overview of the

Brief Overview of the

Brief Overview of the

Dr. Kwadwo Ameyaw Korsah, UG, SON

Brief Overview of the

Dr. Kwadwo Ameyaw Korsah, UG, SON

Dr. Kwadwo Ameyaw Korsah, UG, SON

Dr. Kwadwo Ameyaw Korsah, UG, SON

Brief Overview of the

Dr. Kwadwo Ameyaw Korsah, UG, SON

Assessment of the Respiratory

Assessment of the Respiratory

Cough with Wheezing:is a

continuous, coarse, whistling sound

Dr. Kwadwo Ameyaw Korsah, UG, SON

Assessment of the Respiratory

Dr. Kwadwo Ameyaw Korsah, UG, SON

Assessment of the Respiratory

Dr. Kwadwo Ameyaw Korsah, UG, SON

Assessment of the Respiratory

Dr. Kwadwo Ameyaw Korsah, UG, SON

Assessment of the Respiratory

Assessment of the Respiratory

Assessment of the Respiratory

Assessment of the Respiratory

Dr. Kwadwo Ameyaw Korsah, UG, SON

Assessment of the Respiratory

sedentary lifestyle, immobilization

Dust, chemicals, asbestos, air pollution

The next part looks at objective data

Assessment of the Respiratory

Assessment of the Respiratory

Dr. Kwadwo Ameyaw Korsah, UG, SON

Assessment of the Respiratory

Assessment of the Respiratory

Assessment of the Respiratory

Assessment of the Respiratory