Acute Respiratory Problems

Question 1

What can we do for hospitalized smokers?

Answer 1

Welbutrin: antidepressant that helps ease nicotine withdrawal

Nicotine Patch
-SE = dizziness, sleeping problems, vivid dreams

Question 2

Are cigarette quitting treatments more effective in men or women?

Answer 2

Men b/c women are less likely to quit b/c of weight gain that happens after quitting.

Question 3

Traumatic Problems of the Respiratory System

Answer 3

chest trauma - pneumothorax
epistaxis caused by:
-dry mucous membranes
-substance abuse
-infections (local or systemic)
-HTN
-bleeding disorders
-anticoagulant therapy
-trauma
-high flow O2

Question 4

Tx for nosebleeds

Answer 4

• calm the person
• sit up with head slightly forward
• apply pressure for 5-15min
• seek medical attention if bleeding doesn’t stop

Question 5

Vascular Problems of Respiratory System

Answer 5

PE (leading cause is DVT)
Pulmonary HTN (increased pulmonary pressure d/t pulmonary vascular resistance to blood flow through arteries and arterioles) 
Cor Pulmonale (enlargement of R ventricle secondary to disease of lung, thorax or pulmonary HTN)

Question 6

Pulmonary Edema

Answer 6

abnormal accumulation of fluid in alveoli and interstitial spaces

complication of heart and lung diseases

most common cause = left-sided HF

Question 7

PE: Etiology and Pathophysiology

Answer 7

• blockage of one or more pulmonary arteries by thrombus, fat, or air embolus or tumor tissue
• clot in venous system into pulmonary circulation then lodges in small blood vessel and obstructs alveolar perfusion
• most often affects lower lobes (cause vessels are smaller than in upper lungs)

Question 8

Types of PEs

Answer 8

DVT: deep vein thrombosis
VTE: venous thromboembolism (originates in one place a piece breaks off and travels until it gets stuck)
Saddle Embolus: large thrombus at arterial bifurcation

Question 9

Risk Factors for PE

Answer 9

• immobility or reduced mobility
• surgery w/in 3 months (esp. pelvic or lower extremity)
• history of VTE
• cancer
• obesity
• oral contraceptives/hormone therapy
• smoking
• prolonged air travel
• heart failure
• pregnancy
• clotting disorders

Question 10

Manifestations of PE

Answer 10

depends on type, size, and extent of emboli

• dysnpea (most common manifestation)
• mild-moderate hypoxemia

other symptoms include: tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, tachycardia, syncope, pulmonic heart sound

massive PE symptoms = change in mental status, hypotension, impending doom, death

Question 11

PE Diagnostic Tools

Answer 11

D-Dimer (blood test): normal value <250ng/mL

• elevated w/ clot degradation
• could have false negatives with small PE as it may not be releasing enough to show up on blood work

Spiral (helical) CT scan/CT angiography or CTA:

• most common, requires contrast
• 3D pic of pulmonary vasculature

Ventilation Perfusion (V/Q) scan:

• used if pt cannot have contrast
• 2 components: perfusion scanning with radioisotope injection, ventilation scanning with radioactive gas inhaled

Question 12

Additional tests to look at for PE (not diagnostic)

Answer 12

arterial blood gas
chest x-ray
electrocardiogram (ruling out MI)
troponin levels
b-type natriuretic peptide

Question 13

Drug Therapy for PE

Answer 13

Anticoagulation: stops clot from getting bigger

• heparin: monitor PTT (antidote = protamine sulfate)
• warfarin: monitor PT

Fibrinolytic agents: dissolve clot
-ex) tPA and Alteplase (activase)

Question 14

Drug Therapy Monitoring for PE

Answer 14

monitor for bleeding in unusual places:

• gums
• stool
• hematuria
• hematemesis
• bruising for no reasons
• nose bleeds
• tachycardia and hypotension
• severe HA

monitor CBC (can show bleeding we can’t see)

avoid IM injections
use electric razor

Question 15

Surgical Therapy for PE

Answer 15

Pulmonary embolectomy for massive PE
-when pt is unstable hemodynamically and thrombolytic therapy is contraindicated

Percutaneous catheter embolectomy or endovascular u/s delivered thrombolysis

Inferior vena cava (IVC) filter: prevents migration of clots in pulmonary system

Question 16

Nursing Management of PE

Answer 16

prevention:

• SCDs
• ambulation
• anticoagulation

immediate treatment:

• bed rest in semi fowlers
• assess cardiopulmonary status
• O2
• fluids
• medication

pt support for anxiety, dyspnea, fear

education:

• long term anticoagulation therapy
• measures to prevent VTE
• importance of follow ups

Question 17

Acute Bronchitis

Answer 17

self-limiting inflammation of bronchi

most caused by viruses, but can be triggered by pollution, smoking, sinusitis, asthma

symptoms = cough, clear/purulent sputum, HA, fever, malaise, dyspnea, chest pain

Question 18

Acute Bronchitis: Diagnosis and Tx

Answer 18

Diagnosis: based on assessment of breath sounds (crackles or wheezes)

Tx: symptoms relief and prevention of pneumonia

• cough suppressant, oral fluids, humidifier
• beta 2 agonist inhaler
• avoid irritants
• if due to influenza, can take antiviral within 48 hours
• see HCP sx last longer than 4 weeks

Question 19

Flu: Risk Factor

Answer 19

• older than 50
• younger than 3
• chronic cardiac or pulmonary disease
• long-term care facility residents
• hospitalization in past year
• immunocompromised
• pregnant women in 2nd and 3rd trimester
• heath care workers (transmit it to high risk groups)

Question 20

Flu: Subjective/Objective Data

Answer 20

abrupt onset of:

• fever
• HA
• aches
• cough
• sore throat
• fatigue

lung sounds are usually clear

symptoms last about a week (longer for elderly)

Question 21

Flu: Interventions

Answer 21

Prevention: vaccine and sneeze protection
Supportive measures: tx symptoms
Antiviral med (Tamiflu): decreases length and severity of sx by at least 1 day (need to take w/in first 48 hours)

Question 22

Flu: Complication

Answer 22

Secondary Bacterial Pneumonia

• pt starts to improve but then worsens
• tx w/ antibiotics is usually effective

also could get bronchitis, otitis media, sinusitis (can be treated)

Question 23

Pneumonia: Definition

Answer 23

Acute Inflammation of alveolar spaces causing consolidation of lung tissue as alveoli fill with exudate

Gas exchange difficult -> hypoxia and hypercapnia

Can be:
lobar = affects section of lung
bronchopneumonia = affects patches throughout lung

cause can be microbes, chemical (aspiration), fungal

Question 24

3 ways organisms can reach the lung:

Answer 24

1. aspiration (normal flora lives in airway)
2. inhalation: inhaling microbes like black mold
3. hematogenous: spread from one place of the body to another

Question 25

CAP Risk factors

Answer 25

community acquired pneumonia (not in hospital for 14 days of onset of symptoms) - smoking - COPD - flu - long term care facility - HIV - DM

Question 26

MCAP Risk Factors

Answer 26

HAP >48 hours post admission VAP >48 hours after ET tube insertion HCAP - 2 day hospitalization w/in 90 days - - long term care facility resident - IV, chemo, or wound care w/in 30 days (even if it was in your home) - received dialysis in hospital or clinic setting -MDR (multi-drug resistance): huge issue for tx

Question 27

Pneumonia: S/O data

Answer 27

usually bacterial if there is abrupt onset - fever/chills - cough with purulent sputum - crackles or decreased breath sounds if consolidated - pleuritic chest pain (pain with inspiration or coughing, sharp or stabbing) - anorexia - cyanosis = late symptom elderly present w/ lethargy, change in mental status, tachypnea, dehydration, hypothermia

Question 28

Pneumonia: Dx tools

Answer 28

- CBC: leukocytosis with shift to left - chest xray: positive for infiltrate - sputum culture: positive (obtain before starting antibiotics - ABG: indicate hypoxemia

Question 29

Complications of Pneumonia

Answer 29

``` Atelectasis Pleurisy (inflammation of pleura) Pleural effusion (fluid in pleural space) bacteremia (blood infection) pneumothorax meningitis acute respiratory failure sepsis/septic shock ```

Question 30

Pneumonia: Planning/Intervention

Answer 30

Prevention is best (stop smoking, vaccines): In community - nutrition, rest, hygiene, avoid URI exposure, if URI seek medical care after 7 days of persistent sx In hospital - frequent position changes, aseptic technique with suctioning, hand washing, assess for gag reflex to return after procedure where pt is sedated

Question 31

Pneumonia: Nursing Interventions

Answer 31

- monitor VS 4h or as ordered - assess lung sounds, breathing patterns, sputum color and thickness each shift - O2 therapy (humidification when appropriate) - bedrest w/ BRP at first (allow for rest for hypoxia, semi to high fowlers in bed) - hand washing - mouth care - TC & DB - IS (hourly) - Respiratory Therapy (may need nebulizer) - Suctioning PRN - maintain IV access - assess mental status

Question 32

Pneumonia: Medications

Answer 32

Antibiotics (start broad then go narrow): - macrolides: azithromycin (Zithromax) - fluoroquinolones: levofloxacin (Levaquin) - beta-lactams: ceftriaxone (Rocephin) - Antipneumococcal, antipseudomonal beta-lactams: piperacillin/tazobactam (Zosyn) Cough medications: - guaifenesis (robitussin, mucinex) - expectorant (stimulates cough) - antitussive (suppress cough at night so they can rest)

Question 33

TB: Definition and Risk Factors

Answer 33

infectious disease caused by mycobacterium tuberculosis spread via airborne droplets (airborne precautions) transmission requires close, frequent, prolonged exposure - poor, underserved, and minorities - immunosuppressed - foreign-born - living or working in institutions

Question 34

MDR-TB

Answer 34

resistant to 2 of the most potent first line anti-TB drugs causes: - incorrect prescribing (overprescribing) - lack of public health case management - non-adherence - lack of funding for education and prevention

Question 35

TB: Manifestations

Answer 35

takes 2-3 weeks to develop symptoms initial sx: dry cough that becomes productive, fever, malaise, anorexia, weight loss, low-grade fever, night sweats late sx: dyspnea and hemoptysis generalized flu like symptoms *Immunosuppressed and older adults less likely to have fever and other signs of infection

Question 36

TB: Complications

Answer 36

When TB infects other organs, acute and long-term complications may occur - spinal issues - CNS (bacterial meningitis) - abdomen: peritonitis - other organs: kidneys, adrenal glands, lymph nodes and urogenital tract

Question 37

TB: DX tests

Answer 37

TST (tuberculin skin test) - injection in ventral forearm - site inspection for induration in 48-72 hours - induration= palpable, raised, hardened, swollen area (not red) * indicates development of antibodies following exposure to TB Chest x-ray: cannot use alone to make dx Bacteriologic studies: TB culture is gold standard (3 consecutive sputum samples at 8-24 hour intervals) - definitive dx takes up to 6 weeks

Question 38

TB: Drug Therapy

Answer 38

Active TB: Initial drugs (8wk-3months): isoniazid, rifampin, pyrazinamide, ethambutol Continuation (18wks): isoniazid and rifampin *adverse SE = non-viral hepatitis (monitor liver function)

Question 39

MDR-TB: Drug Therapy

Answer 39

sensitivity test determines drugs initial drugs: 5 different ones for at least 6 months continuation: 4 drugs for 18-24 months DOT: direct observation therapy - non-adherence is major factor in NDR-TB - watch pt take drugs - expensive but public health strategy to ensure adherence

Question 40

TB: Nursing Interventions for Acute Care

Answer 40

airborne isolation: - single room w/ 6-12 airflow exchanges/hour - healthcare workers wear HEPA masks (fit tested) - administer drug therapy - teach pt to prevent spread - pt wear mask outside of room - identify and screen close contact Ambulatory care: (may go home even if culture are positive) do monthly sputum cultures two consecutive negative cultures = noninfectious notify public health nurse follow up and DOT