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-Myasthenia gravis
-Poliomyelitis
-Muscular dystrophies
3. Poliomyelitis
a. viral infection
b. if disease strikes the respiratory muscles the result may be respiratory failure
c. may not swallow well
i. may aspirate
ii. may lose protective airway reflexes
4. Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease)
a. affects motor neurons; autonomic, sensory and mental function unchanged
b. manifests as a chronic, progressive irreversible disorder
c. begins usually in distal ends of upper extremities
d. often leads to respiratory failure within two to five years
e. results in ethical issue
i. whether clients want mechanical ventilation
ii. whether nutritional support is desired
iii. if they would rather die when disease becomes this severe
f. results in clients' inability to communicate or physically move from voluntarily
and/or clients lack involuntary reflexes, such as blinking or gag reflex
5. Muscular dystrophies
a. progressive symmetrical wasting of voluntary muscles with no nerve effect
b. as thoracic muscles weaken, breathing becomes more difficult
c. may not swallow well; risk for aspiration with loss of protective airway reflexes
6. Interventions common to musculoskeletal disorders
a. monitor carefully for changes in condition
b. assess regular swallowing and ability to protect the upper airway
c. discuss chances of mechanical ventilation or nutritional support: does client
wish it?
d. assist with coughing and secretion clearance as indicated
e. prevent infection
f. assess for with appropriate referrals for depression that is often associated with
these diseases
g. administer medications specific to the disease condition
h. assist/provide occupational or/and physical rehibilitation as indicated
i. maintain adequate nutrition
j. with terminal disorders, provide for referrals for family
2. LRS Disorders: Infectious
1. Pneumonia (illustration )
3. Definition/etiology
a. acute infection of lung parenchyma
b. cause: bacterium, virus, protozoan, mycobacterium, mycoplasma, or rickettsia
c. pneumonia is the leading cause of death from infectious causes
d. may affect only a region of lung: lobar pneumonia, bronchopneumonia
e. may be the result of:
i. primary infection
ii. secondary to other lung damage
iii. aspiration
4. Risk factors for pneumonia
a. pre-existing pulmonary disease
b. abdominal and thoracic surgery
c. mechanical ventilation
d. advanced age
e. decreased ability to protect airway or cough effectively
f. artificial airway
g. chronic illness and debilitation
h. depressed immune function
i. cancer
5. Diagnostics
a. chest radiograph
b. sputum culture, sensitivity and microscopic analysis, Gram stain, cytology
c. ABG as indicated by clinical condition
6. Management
a. antimicrobials, depending on pathogen
b. antipyretic
c. expectorants
d. antitussives
e. supplemental oxygen, as indicated
f. IV fluids to treat dehydration
7. Nursing interventions
a. monitor finger oximeter if hemoglobin levels within normal limits
b. promote hydration to liquify secretions
c. teach effective coughing techniques to minimize energy expenditure
d. suction if necessary
e. teach the need to continue entire course of antimicrobial therapy which is
usually seven to ten days
f. teach that findings are expected to be less within 48 to 72 hours of initial
therapy
8. Pulmonary tuberculosis (PTB) (illustration )
a. Etiology
i. mycobacterium tuberculosis
ii. bacilli lodge in alveoli
iii. pulmonary infiltrates
iv. can spread throughout body via blood
v. multi-drug resistant PTB is becoming more prevalent
vi. PTB incidence is rising with increasing homelessness and AIDS
b. Findings
i. weakness with fatigue
ii. anorexia with weight loss
iii. night sweats
iv. chest pain
v. productive cough
c. Diagnostics
i. sputum and gastric contents, analysis for the presence of acid-fast
bacilli
ii. chest x-ray for presence of active or calcified lesions, "coin" lesions
iii. tuberculin testing
1. tine, mantoux tests
1. checked 48 to 72 hours for induration
2. positive if >10 mm induration in healthy persons
iv. establishes if there is an antibody response to the tubercle bacillus
v. if positive, indicates prior exposure to bacillus, not an active disease
d. Management
i. long-term, six to 24 months, antimicrobial therapy with isoniazid
(INH) (Hyzyd) or rifampin (Rifadin), with ethambutol HCL (Etibi) in
some cases
ii. bed rest or chair rest until findings abate
iii. surgical resection of involved lung if medication is not effective
iv. high carbohydrate, high protein diet with frequent small meals
e. Nursing interventions
i. with active infection, client must be isolated with airborne
precautions when in the hospital
ii. teach client
1. proper techniques to prevent spread of infection: hand
washing, etc.
2. to report bloody sputum
3. not to use over the counter (OTC) medications without
health care provider's approval
4. importance of taking medications as prescribed
1. adherence to treatment regimen
2. return at scheduled times for lab testing of liver
enzymes
3. an increase in B6 to minimize peripheral
neuropathies, a common side effect of drug
therapy
2. Lung abscess
3. Localized area of lung infection
4. Usually follows pneumonia, TB or aspiration
5. Treatment consists of draining and culturing abscess and antimicrobial therapy
IX. LRS Disorders: Miscellaneous
A. Pulmonary embolism
1. Definition/etiology
a. clot blocks blood from the "bed" of arteries that feed the lung
b. client is breathing but gases are not exchanged - ventilation without perfusion
c. hypoxemia results
d. can be mild or immediately fatal, based on the size and location of clot(s)
e. usually clot has traveled from deep veins in the leg or pelvis
2. Diagnostics
a. ventilation/perfusion (V/P) scan, also called V/Q scan
b. ABG
c. EKG
3. Management
a. oxygen via mask
b. anticoagulation - heparin in acute and coumadin for chronic risk
c. thrombolytics
d. filter surgically placed in vena cava for long term care
B. Acute respiratory distress syndrome (ARDS)
1. Definition/etiology
a. alveolar capillary membrane becomes more permeable to fluids
b. increased extravascular lung fluid
c. pulmonary compliance decreases
d. intrapulmonary shunt increases
e. refractory hypoxemia
f. usually seen after lung injury or massive multi-system organ disease
2. Findings
a. restlessness, anxiety
b. dyspnea
c. tachycardia
d. cyanosis
e. intercostal retractions
3. Diagnostics
a. clinical presentation and history of findings
b. hypoxemia on ABG despite increasing inspired oxygen level
c. chest x-ray shows diffuse infiltrates
4. Management
a. optimize oxygenation
I. mechanical ventilation
II. sedation may be required
III. paralytic agents may be necessary
b. antibiotics, as indicated
c. corticosteroids
5. Nursing interventions
a. plan for frequent rest periods
b. monitor trends in oxygenation status, ABGs, respiratory effort
c. observe for behavioral changes and vital signs; confusion and hypertension
may indicate cerebral hypoxia
C. Lung cancer
1. Definition/etiology
a. types of lung cancer
I. squamous cell carcinoma
II. small-cell (oat cell) carcinoma
III. adenocarcinoma
IV. large cell carcinoma
b. prognosis is generally poor
c. largely preventable if smokers stop and nonsmokers avoid second hand smoke
2. Findings
a. hoarse voice
b. changes in breathing
c. persistent cough or change in cough
d. blood-streaked or bloody sputum
e. chest pain or tightness in chest wall
f. recurring pneumonia, pleural effusion
g. weight loss
3. Diagnostics
a. medical imaging examinations
b. cytological sputum analysis
c. bronchoscopy
d. biopsy
A. Risk factors
1. Is most often associated with cigarette smoking
2. Exposure to environmental carcinogens e.g. uranium, asbestos
B. Characteristics
1. Accounts for 30-35% of lung cancer cases
2. Is more common among men
3. Findings occur earlier because of bronchial obstructive characteristics (arises from
bronchial epithelium)
4. Causes cavitating pulmonary lesions
5. Usually metastasizes locally
C. Therapy
1. Life expectancy is better than small cell carcinoma
2. Surgical resection is often attempted
A. Risk Factors
1. Cigarette smoking
2. Environmental carcinogens
B. Characteristics
1. Accounts for 15% to 25% of lung cancers
2. Spreads early
3. Very malignant form
4. Is often associated with endocrine disturbances
C. Therapy
1. Poorest prognosis
2. Average survival is less than one year
ADENOCARCINOMA
A. Risk Factors
1. Not related to cigarette smoking
2. Lung scarring
3. Chronic interstitial fibrosis
B. Characteristics
1. More common among women
2. Accounts for about half of all lung cancers
3. Usually located in peripheral section of lungs
4. Often no clinical signs or findings until well advanced
C. Treatment
1. Does not respond well to chemotherapy
2. Most often, surgical resection is attempted
A. Risk Factors
1. Cigarette smoking
2. Environmental carcinogens
B. Characteristics
1. Occurs in 15-25% of all lung cancers
2. Frequently metastases via blood
3. Usually peripheral rather than centrally located in the lung lobes
C. Therapy
1. Usually client is not a candidate for surgery due to the high frequency of metastasis
2. Tumors often responds to radiation therapy but frequently recurs
A. Management
A. nonsurgical
A. chemotherapy
B. radiation therapy
C. laser therapy to de-bulk tumor
D. thoracentesis and pleurodesis
B. surgical
A. thoracotomy
A. wedge resection - part of a lobe
B. segmental resection- part of a lobe
C. lobectomy - one or more lobes
D. pneumonectomy - entire right or left lung
B. Nursing interventions
A. post-operative care
A. chest drainage
B. routine post operative care
A. monitor respiratory status frequently
B. teach effective deep breathing and cough techniques
C. refer to physical therapy for exercises for shoulder on
affected side
D. relieve pain
C. optimize oxygenation
D. provide opportunities for the client to talk about cancer; as needed,
refer to support groups
E. teach information as based on treatment plan and prognosis
F. optimize nutritional status
3. Cor pulmonale
A. Definition/etiology
A. right ventricular hypertrophy and subsequent chronic heart failure
B. cause: heart must pump against great resistance from lung's blood vessels:
called increased pulmonary vascular resistance (PVR)
C. increased PVR results from chronic lung disease
D. may be due to primary pulmonary hypertension as well
B. Diagnostics
A. pulmonary artery pressure readings via a catheter (illustration )
B. echocardiogram
C. chest radiograph
D. ABG
E. EKG
C. Management
A. administer oxygen as ordered
B. if hemoglobin within normal limits (WNL), monitor oxygenation with finger or
pulse oximeter
C. bed rest, as needed
D. monitor effects of medications
A. cardiac glycosides
B. pulmonary artery vasodilator
C. diuretics
D. restricted fluid intake as indicated
E. nursing interventions
A. monitor for changes in oxygenation status
B. pace activities in clients who tire easily
4. Respiratory failure
A. Definition: lungs cannot maintain arterial oxygen levels or eliminate carbon dioxide
A. PaCO2 > 50 mm Hg
B. PaO2 < 50 mm Hg
C. clients with chronic lung disease precautions
A. look for drop from baseline function
B. this is a nursing and medical emergency
C. clients are always hypoxemic
B. Etiology
A. lung diseases that harden the alveolar-capillary membrane to trap O2
B. neuro-muscular or musculoskeletal disorders
A. respiratory drive dulled or blunted
B. muscles too weak to breathe
C. Diagnostics: ABG
D. Management
A. oxygen per mask
B. mechanical ventilation
C. monitor for improvement in the underlying cause for the respiratory failure
D. Oxygen is essential for life. So, before all else, keep airways open and ease breathing effort.
E. Clients with chronic lung disease use more oxygen and energy to breathe. This can create a vicious cycle in
which the client works harder, and continually requires more oxygen and more energy.
F. Nursing interventions for clients with chronic lung disease should include pacing of activities, because these
clients have little reserve for exertion.
G. Quality of life for clients can be significantly improved if clients routinely use diaphragmatic breathing and
pursed-lip breathing.
H. Clients with asthma must understand the different types of inhalers and when to use each type. Some rescue
inhalers are for acute dyspnea. Other inhalers are for maintenance or preventative types of drugs.
I. A finger or pulse oximeter reading is simply one element of an assessment. It is not the whole picture.
J. Cyanosis, a late finding, is determined by oxygenation and hemoglobin content.
K. Clients with anemia may be severely hypoxemic and never turn blue, but rather "ashen".
L. Clients with polycythemia may be cyanotic with adequate tissue oxygenation.
M. The serious public health issue of pulmonary TB requires control and reporting of any incidence and recent
contacts that the client had so prophalactic therapy for two to three months can be initiated.
N. When caring for a client after a chest tube insertion, an occlusive dressing is placed around the chest tube
insertion site and the connections of the chest tube system are taped to prevent air leaks at connections. An
occlusive dressing is one that is totally covered, as well as the edges with non-porous tape. This dressing is
typically not changed and not expected to have any drainage on it.
• When caring for a client on a ventilator, if an alarm sounds, first, assess the client. See if the alarm resets or if
the cause is obvious. If the alarm continues to sound and the client develops distress, disconnect the client
from the ventilator, use a manual resuscitation bag to ventilate with 100% oxygen and page or call the
respiratory therapist immediately.
• If the ventilator tube disconnects, the low pressure alarm will sound.
• If the high pressure alarm sounds on the ventilator, the nurse should check for some type of obstruction or
occlusion of the airway: mucous plugs, biting of the tube by the client, tube slips into right main stem
bronchus, or increased secretions.
• To maximize therapeutic effect of inhalers, the key is technique. It is critical to teach clients the right
technique and observe how well they use the inhaler.
• Smoking cessation is critical to reduce the risk and severity of lung disease. Second-hand smoke enhances
the risk of children to develop asthma or other chronic lung diseases.
• Best approach to pulmonary embolus is prevention. The use of intermittent compression stockings prevents
clots in the deep veins.
• Clients with pulmonary TB need intensive community follow up to ensure that they continue with
pharmacological treatment once discharged from the hospital. Clients who stop therapy too soon are the
source for the more deadly multi-drug resistant forms of pulmonary TB.
Acidosis
Alkalosis
Antibiotic
Anticholinergic
Apnea
Auscultation
Bronchodilator
Cheyne-Stokes
COPD
Cor Pulmonale
Corticosteroid
Crackles
Cromolyn sodium
Croup
Hypercapnia
Hyperpnea
Hyperventilation
hypocapnia
Hypoventilation
Hypoxemia
Hypoxia
Influenza
Kussmaul's breathing
Kyphosis
Mucolytic
Nosocomial pneumonia
Pleurodesis
Pneumoconiosis
Scoliosis
Tachypnea
Thoracentesis
Wheezes
• Action of Cilia
• Alveolocapillary membrane
• Alveolus of lungs
• Central venous catheter
• Drainage of lower lobes
• Epiglottis
• Glottis and vocal chords
• Heimlich manuever
• Larynx
• Lungs
• Paranasal Sinuses
• Pneumocystis Carinii Pneumonia
• Pneumothorax
• Postural drainage of lungs
• Respiratory System
• Sternum
• Trachea
• Tubercolosis
• Two views of the nasal cavity