Medical and Surgical Nursing

Review
Respiratory System
BY: Jocelyn A. Guzman, Ed.D
Outline of review Concepts
Review of the relevant respiratory
anatomy
Review of the relevant respiratory
physiology
The respiratory assessment
Common laboratory examinations
Outline of review Concepts
Review of the common respiratory
problems and the nursing management
Review of common respiratory diseases
Upper respiratory conditions
Lower respiratory conditions
Respiratory Anatomy &
Physiology
The respiratory system consists of two
main parts- the upper and the lower
tracts
Respiratory Anatomy &
Physiology
The UPPER respiratory system consists
of:
1. nose
2. mouth
3. pharynx
4. larynx
5. trachea
Respiratory Anatomy &
Physiology
The LOWER respiratory system
consists of:
1. Bronchi
2. Bronchioles
3. Respiratory unit alveolar ducts,
alveolar sacs, alveoli
Upper respiratory tract
The Nose
This is the first part of the upper
respiratory system that contains nasal
bones and cartilages
There are numerous hairs called
vibrissae
There are numerous superficial blood
vessels in the nasal mucosa

The Nose
The functions of
the nose are:
1. To filter the air
2. To humidify
the air
3. To aid in
phonation
4. Olfaction
The
pharynx
The pharynx is a
musculo-
membranous tube
that is composed
of three parts
1. Nasopharynx
2. Oropharynx
3. Laryngopharynx
The pharynx
The pharynx functions :
1. As passageway for both air and foods
(in the oropharynx)
2. To protect the lower airway
The larynx
Also called the
voice box
Made of
cartilage and
membranes
and connects
the pharynx to
the trachea
The larynx
Functions of the
larynx:
1. Vocalization
2. Keeps the
patency of the
upper airway
3. Protects the
lower airway
The paranasal sinuses
These are four paired bony cavities that
are lined with nasal mucosa and ciliated
pseudostratified columnar epithelium
Named after their location-
frontal, ethmoidal, sphenoidal and
maxillary
The paranasal sinuses
The function of the sinuses:
Resonating chambers in speech
The Lower Respiratory System
1. Trachea
2. Main bronchus
3. Bronchial tree
4. Lungs- 3R/ 2L
The trachea to the terminal bronchioles
is called the conducting airway
The respiratory bronchioles to the
alveoli is called the respiratory acinus
Trachea
A cartilaginous
tube measures 10-
12 centimeters
Composed of
about 20 C-
shaped cartilages,
incomplete
posteriorly


The trachea
The function of the trachea is to conduct
air towards the lungs
The mucosa is lined up with mucus and
cilia to trap particles and carry them
towards the upper airway
The Bronchus
The right and
left primary
bronchi begin
at the carina
The function is
for air passage
The primary bronchus
RIGHT
BRONCHUS
Wider
Shorter
More Vertical
LEFT BRONCHUS
Narrower
Longer
More horizontal
The bronchioles
The primary bronchus further divides
into secondary, then tertiary then into
bronchioles
The terminal bronchiole is the last part
of the conducting airway
The respiratory Acinus
The respiratory acinus is the chief
respiratory unit
It consists of:
1. Respiratory bronchiole
2. Alveolar duct
3. alveolar sac
4. alveoli

The respiratory Acinus
The function of the respiratory acinus is gas
exchange through the respiratory membrane
The respiratory membrane is composed of
two epithelial cells
1.The type 1 pneumocyte- most abundant,
thin and flat. This is where gas exchange
occurs
2. The type 2 pneumocyte- secretes the lung
surfactant
The respiratory Acinus
A type III pneomocyte is just the
macrophage that ingests foreign
material and acts as an important
defense mechanism
Accessory Structures
The PLEURA
Epithelial serous
membrane lining the
lung parenchyma
Composed of two
parts- the visceral
and parietal pleurae
The space in
between is the
pleural space
containing a minute
amount of fluid for
lubrication
Accessory Structures
The Thoracic cavity
The chest wall
composed of the
sternum and the rib
cage
The cavity is
separated by the
diaphragm, the most
important respiratory
muscle
Accessory Structures
The Mediastinum
The space between
the lungs, which
includes the heart
and pericardium, the
aorta and the vena
cavae.


GENERAL FUNCTIONS OF THE
Respiratory System
Gas exchange through ventilation,
external respiration and cellular
respiration
Oxygen and carbon dioxide transport
The Assessment
HISTORY
Reason for seeking care
Present illness
Previous illness
Family history
Social history

The Assessment
PHYSICAL EXAMINATION
Skin- cyanosis, pallor
Nail clubbing
Cough and sputum production
Inspect-palpate-percuss- auscultate the
thorax
Assessment: LABORATORY
EXAMINATION
1. ABG analysis
2. Sputum analysis
3. PPD Test
4. Pulmonary Function Test
5. Direct visualization- bronchoscopy
6. Indirect visualization- CXR, CT and MRI
7. Pulmonary function test
ABG analysis
This test helps to evaluate gas
exchange in the lungs by measuring the
gas pressures and pH of an arterial
sample
ABG analysis
Pre-test: choose site carefully, perform the Allens
test, secure equipments- 10 mL heparinized syringe,
needle, container with ice
Intra-test: Obtain a 5 mL specimen from the artery
(brachial, femoral and radial)
Post-test: Apply firm pressure for 5 minutes, label
specimen correctly, place in the container with ice
What is the significance of Allens
test????
To assess the adequacy of collateral
circulation
ABG analysis
ABG normal values
PaO2 80-100 mmHg
PaCO2 35-45 mmHg
pH 7.35- 7.45
HCO3 22- 26 mEq/L
O2 Sat 95-100%
Sputum Analysis
This test analyzes the sample of sputum
to diagnose respiratory diseases,
identify organism, and identify abnormal
cells
Sputum Analysis
Pre-test: Encourage to increase fluid intake
Intra-test: rinse mouth with WATER only,
instruct the patient to take 3 deep breaths and
force a deep cough, steam nebulization, collect
early morning sputum
Post-test: provide oral hygiene, label specimen
correctly
PPD (Purified Protein Derivative)
Intradermal
Read after 48-72 hrs
10 mm induration or more = positive
5 mm induration or more = + for HIV patients
Signifies exposure to mycobacterium tubercle
bacilli
POSITIVE PPD TEST
PULMONARY FUNCTION
TESTS
To determine lung volumes and capacities
Volume and capacity tests aid diagnosis in
patient with suspected pulmonary dysfunction
Evaluates ventilatory function
Determines whether obstructive or restrictive
disease
Can be utilized as screening test

PULMONARY FUNCTION
TESTS
Lung Volumes

1. Tidal volume TV
2. Inspiratory Reserve
Volume- IRV
3. Expiratory Reserve
Volume- ERV
4. Residual volume-
RV

Lung Capacities

1. Inspiratory
Capacity- IC
2. Functional Residual
Capacity- FRC
3. Vital capacity- VC
4. Total Lung
capacity- TLC

PULMONARY FUNCTION
TESTS
Pre-test: Teaching, no smoking for 3 days,
only light meal 4 hours before the test

Intra-test: position sitting, bronchodilator,
nose-clip and mouthpiece, fatigue and
dyspnea during the test

Post-test: adequate rest periods, loosen
tight clothing

LUNG VOLUMES
1. Tidal volume volume of air
inspired or expired with each normal
breath, about 500ml
2. Inspiratory Reserve Volume (IRV)-
extra volume of air than can be
inspired over & beyond the normal
tidal volume, about 3000ml

LUNG VOLUMES
3. Expiratory Reserve Volume (ERV)
-amount of air that can still be expired by
forceful expiration after the end of a
normal tidal expiration
-about 1100ml
4. Residual Volume (RV)
-volume of air still remaining in the lungs
after the most forceful expiration,
averages about 1200ml

Pulmonary Capacities

1. Inspiratory Capacity
-equals TV + IRV, about 3500ml
-amount of air that a person can breathe
beginning at the normal expiratory level &
distending his lungs to maximum amount
2. Functional Residual Capacity
-equals ERV + RV
-about amount of air remaining in the
lungs at the end of normal expiration,
about 2300ml

Pulmonary Capacities
3. Vital Capacity
-equals IRV + TV + ERV or 1C + ERV, about
4600ml
-maximum amount of air that a person can expel
from the lungs after filling the lungs to their
maximum extent & expiring to the maximum
extent
4. Total Lung Capacity
-maximum volume to which the lungs can be
expanded with the greatest possible effort
-volume of air in the lungs at this level is equal
to FRC (2300ml) in young adult

Pulse Oximetry
Non-invasive method of continuously
monitoring the oxygen saturation of
hemoglobin
A sensor or probe is attached to the earlobe,
forehead, fingertip or the bridge of the nose
Bronchoscopy
A direct inspection of the trachea and bronchi
through a flexible fiber-optic or a rigid
bronchoscope
Done to determine location of pathologic
lesions, to remove foreign objects, to collect
tissue specimen and remove
secretions/aspirated materials
Bronchoscopy: NSG Resp.
Pre-test:
Consent
NPO x 6h
Teaching
Remove dentures,
prostheses, contact
lenses

Intra-test:
position supine or sitting
upright in a chair
administer sedative, gag
reflex will be abolished


Post-test:
NPO until gag reflex
returns
position SEMI-fowlers
with head turned to
sides
hoarseness is
temporary
CXR after the procedure
as ordered
keep tracheostomy set
and suction x 24 hours
Watch out for DOB,
hypotension,
tachycardia, cyanosis

Thoracentesis
Pleural fluid aspiration for obtaining a
specimen of pleural fluid for analysis,
relief of lung compression and biopsy
specimen collection
Thoracentesis: NSG Resp.
Pre-test:
Consent
Initial VS
Intra-test:
position the patient sitting
with arms on a table or side-
lying fowlers
instruct not to cough breathe
deeply or move during
insertion of the needle
Post-test:
position unaffected
side to allow lung
expansion of the
affected side
CXR obtained
maintain pressure
dressing
monitor respiratory
status

CHEST X-RAY
Provides information regarding the
anatomic location and appearance of the
lungs
PREPROCEDURE
1.Remove all jewelry and other metal
objects from the chest area
2.Assess the clients ability to inhale and
hold breath
Question females regarding pregnancy or
the possibility of pregnancy

Indirect Visualization
CT scan
Painless, non-invasive, x-ray
procedure
Mechanism: distinguish
density of tissues
MRI SCAN
Painless, non-invasive, no radiation
Creates a magnetic field
Contraindications:
(+) pacemaker
(+) metal prosthesis
Client teaching:
Lie still during the procedure for 60-90 minutes
Earplugs to reduce noise discomfort
Check if the pt. has Claustrophobia
No radiation


Common Respiratory problems
and the common interventions
Dyspnea
Breathing difficulty
Associated with many
conditions- CHF, MG, GBS,
Muscular dystrophy,
obstruction, etc
Dyspnea
General nursing interventions:
1. Fowlers position to promote
maximum lung expansion and promote
comfort. An alternative position is the
ORTHOPNEIC position
2. O2 usually via nasal cannula
3. Provide comfort and distractions
Cough and sputum production
Cough is a protective reflex
Sputum production has many stimuli
Thick, yellow, green or rust-colored bacterial
pneumonia
Profuse, Pink, frothy pulmonary edema
Scant, pink-tinged, mucoid Lung tumor
Cough and sputum production
General nursing Intervention
1. Provide adequate hydration
2. Administer aerosolized solutions
3. advise smoking cessation
4. oral hygiene
Cyanosis
Bluish discoloration of the skin
A LATE indicator of hypoxia
Appears when the unoxygenated hemoglobin
is more than 5 grams/dL
Central cyanosis observe color on the
undersurface of tongue and lips
Peripheral cyanosis observe the nail beds,
earlobes
Cyanosis
Interventions:
Check for airway patency
Positioning
Oxygen therapy
Suctioning
Chest physiotherapy
Check for gas poisoning
Measures to increased hemoglobin

Hemoptysis
Expectoration of blood from the
respiratory tract
Common causes: Pulmo infection, Lung
CA, Bronchiectasis, Pulmo emboli
Bleeding from stomach acidic pH,
coffee ground material

Hemoptysis
Interventions:
Keep patent airway
Determine the cause
Suction and oxygen therapy
Administer Fibrin stabilizers like
aminocaproic acid and tranexamic acid

Epistaxis
Bleeding from the nose caused by rupture
of tiny, distended vessels in the mucus
membrane
Most common site- anterior septum
Causes
1. trauma
2. infection
3. Hypertension
4. blood dyscrasias , nasal tumor, cardio
diseases
Epistaxis
Nursing Interventions
1. Position patient: Upright, leaning forward,
tilted prevents swallowing and aspiration
2. Apply direct pressure. Pinch nose against the
middle septum x 5-10 minutes
3. If unrelieved, administer topical
vasoconstrictors, silver nitrate, gel foams
4. Assist in electrocautery and nasal packing for
posterior bleeding
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections
1. Rhinitis- allergic, non-allergic and
infectious
2. Sinusitis- acute and chronic
3. Pharyngitis- acute and chronic
CONDITIONS OF THE UPPER
AIRWAY
1.RHINITIS
Assessment
findings
Rhinorrhea
Nasal congestion
Nasal itchiness
Sneezing
Headache


CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections
2. sinusitis- Pathophysio:
URTI, Cigarette smoking, Allergic
Rhinitis inflammation edema of te
mucous membranes hypersecration
of mucus infection
Assessment:
Pain
Maxillary: Cheek & upper
teeth
Frontal: above eyebrows
Ethmoid: in & around eyes
Sphenoid: behind eye,
occiput, top of head
General malaise
Stuffy nose
Headache
Post nasal drip
Persistent cough
fever

NSG resp:
Rest
Increase OFI
Hot wet packs
Codeine, avoid ASA D/T increase devt of
nasal polyps
Anti-inffectives
Nasal decongestant for 72 hrs
Irrigation of maxillary sinus w/ warm NSS

CONDITIONS OF THE UPPER
AIRWAY
3. PHARYNGITIS- Assessment findings

Fiery-red pharyngeal membrane
White-purple flecked exudates
Enlarged and tender cervical lymph nodes
Fever malaise ,sore throat
Difficulty swallowing
Cough may be absent


CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections- Laboratory
tests
1. CBC
2. Culture
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections: Nursing
Interventions
1. Maintain Patent Airway
Increase fluid intake to loosen secretions
Utilize room vaporizers or steam inhalation
Administer medications to relieve nasal
congestion

CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections: Nursing
Interventions
2. Promote comfort
Administer prescribed analgesics
Administer topical analgesics
Warm gargles for the relief of sore
throat
Provide oral hygiene

CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections: Nursing
Interventions
3. Promote communication
Instruct patient to refrain from speaking
as much as possible
Provide writing materials

CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections: Nursing
Interventions
4. Administer prescribed antibiotics
Monitor for possible complications like
meningitis, otitis media, abscess
formation
5. Assist in surgical intervention
Tonsillitis
Infection and inflammation of the tonsils
Most common organism- Group A- beta
hemolytic streptococcus (GABS)
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
ASSESSMENT FINDINGS
Sore throat and mouth breathing
Fever
Difficulty swallowing
Enlarged, reddish tonsils
Foul-smelling breath
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
Laboratory test
1. CBC
2. throat culture
NSG intervention
Rest
Increase OFI
Warm saline gargle
Analgesic as ordered
Antimicrobials
Surgery is indicated if + recurrence of 5-
6 times in a year

NURSING INTERVENTION for
tonsillectomy
1. Pre-operative care
Consent
Assess for URTI. Coughing & sneezing
post op may cause bleeding and
septicemia
Check PTT
2. POST-operative care
Position: Most
comfortable is PRONE,
with head turned to side
or lateral
(awake: semi-fowlers)
Maintain oral airway,
until gag reflex returns
Monitor for hemorrhage
Frequent swallowing
Bright red vomitus
Increase PR
Promote comfort
Ice collar
Acetaminophen
No ASA
Foods/fluids
Ice cold
Bland diet

Teachings:
Avoid clearing of throat, coughing,
sneezing, blowing of nose for 1-2 weeks
2-3 L of fluid until mouth odor
disappears
Report S/Sx of bleeding
Throat discomfort b/n 4-8 days is
expected
Avoid crowded places

CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
NURSING INTERVENTION for
tonsillectomy
2. POST-operative care
Apply ICE collar to the neck to reduce
edema
Advise patient to refrain from talking and
coughing
Ice chips are given when there is no
bleeding and gag reflex returns

Laryngeal Cancer
A malignant tumor of the larynx
More frequent in men
50-70 years old
RISK FACTORS
1. Smoking
2. Alcohol
3. Exposure to chemicals
4. Straining of voice
5. chronic laryngitis
6. Deficiency of Riboflavin
7. family history

Laryngeal Cancer
Growth can be anywhere in the larynx
1. Supraglottic- above the vocal cords
2. glottic- vocal cord area
3. infraglottic- below the vocal cords

Most tumors are found in the glottic area
Laryngeal Cancer
ASSESSMENT FINDINGS
Hoarseness of more than TWO weeks
duration
Cough and sore throat
Burning and pain in the throat especially
after consuming HOT liquids and citrus
foods
Neck lump
Dysphagia, dyspnea, foul breath, CLAD
Laryngeal Cancer
LABORATORY FINDINGS
1. Indirect laryngoscopy
2. direct laryngoscopy
3. Biopsy
4. CT and MRI

Most commonly- squamous carcinoma
Laryngeal Cancer
MEDICAL MANAGEMENT
Radiation therapy
Chemotherapy
Surgery
Partial laryngectomy
Supraglottic laryngectomy
Hemilaryngectomy
Total laryngectomy
absolute loss of voice
Permanent
tracheostomy
Loss of sense of smell
Inability to blow, sip
soup or star, whistle,
gargle, do valsalva
manuever (lift heavy
objects, constipation)
NR: establish means of
communication


Laryngeal Cancer
NURSING MANAGEMENT: PRE-operative
1. Provide the patient pre-operative
teachings
Clarify misconceptions
Tell that the natural voice will be lost
Teach communication alternatives
Collaborate with other team members

Laryngeal Cancer
NURSING MANAGEMENT
2. reduce patient ANXIETY
Provide opportunities for patient and family
members to ask questions
Referrals to previous patients with
laryngeal cancers and cancer groups

Laryngeal Cancer
NURSING MANAGEMENT: POST-op
3. Maintain PATENT Airway
Position patient: Semi or High Fowlers
Suction secretions
Encourage to deep breath, turn and cough
Prevent infection
Tracheostomy care
Psychological support

Laryngeal Cancer
NURSING MANAGEMENT: POST-op
4. Administer care of the laryngectomy
tube
Suction as needed
Cleanse the stoma with saline
Administer humidified oxygen
Laryngectomy tube is usually removed
within 3-6 weeks after surgery


Laryngeal Cancer
NURSING MANAGEMENT: POST-op
5. Promote alternative communication
methods
Call bell or hand bell
Magic Slate
Hand signals
Collaborate with speech therapist




Laryngeal Cancer
NURSING MANAGEMENT: POST-op
6. Promote adequate Nutrition
NPO after operation
No foods or drinks per orem for 10 days
IVF, TPN are alternative nutrition routes
Start oral feedings with thick liquids, avoid
sweet foods



Laryngeal Cancer
NURSING MANAGEMENT: POST-op
7. Promote positive body image and self-
esteem
Encourage verbalization of feelings
Allow independence in self-care

Laryngeal Cancer
NURSING MANAGEMENT: POST-op
8. Monitor for COMPLICATIONS
Respiratory Distress
Suction
Coughing and deep breathing
Humidified oxygen
Alert the surgeon


Laryngeal Cancer
NURSING MANAGEMENT: POST-op
8. Monitor for Complications
Hemorrhage
Monitor for bleeding
Monitor vital signs
Apply direct pressure over the bleeding
artery
Summon assistance and alert the surgeon



Laryngeal Cancer
NURSING MANAGEMENT: POST-op
8. Monitor for COMPLICATIONS
Wound infection and breakdown
Monitor for increased temperature,
purulent drainage and increased
redness/tenderness
Administer antibiotics
Clean and change dressing OD



Laryngeal Cancer
NURSING MANAGEMENT: HOME CARE
Humidification system at home is needed
AVOID swimming
Cover the stoma with hands or plastic bib
over the opening
Advise beauty salons to avoid hair sprays,
powders and loose hair near the opening
Oral hygiene frequently

Acute Respiratory Failure

Sudden and life-threatening
deterioration of the gas-exchange
function of the lungs
Occurs when the lungs no longer meet
the bodys metabolic needs
Acute Respiratory Failure
Defined clinically as:
1. PaO2 of less than 50 mmHg
2. PaCO2 of greater than 5o mmHg
3. Arterial pH of less than 7.35

Acute Respiratory Failure
CAUSES
CNS depression- head trauma, sedatives
CVS diseases- MI, CHF, pulmonary emboli
Airway irritants- smoke, fumes
Endocrine and metabolic disorders-
myxedema, metabolic alkalosis
Thoracic abnormalities- chest trauma,
pneumothorax

Acute Respiratory Failure
PATHOPHYSIOLOGY
Decreased Respiratory Drive
Brain injury, sedatives, metabolic
disorders impair the normal response
of the brain to normal respiratory
stimulation
Acute Respiratory Failure
PATHOPHYSIOLOGY
Dysfunction of the chest wall
Dystrophy, MS disorders, peripheral
nerve disorders disrupt the impulse
transmission from the nerve to the
diaphragm abnormal ventilation
Acute Respiratory Failure
PATHOPHYSIOLOGY
Dysfunction of the Lung Parenchyma
Pleural effusion, hemothorax,
pneumothorax, obstruction interfere
ventilation prevent lung expansion
Acute Respiratory Failure
ASSESSMENT FINDINGS
Restlessness
dyspnea
Cyanosis
Altered respiration
Altered mentation
Tachycardia
Cardiac arrhythmias
Respiratory arrest
Acute Respiratory Failure
DIAGNOSTIC FINDINGS
Pulmonary function test
ABG - pH below 7.35
CXR- pulmonary infiltrates
ECG- arrhythmias
Acute Respiratory Failure
MEDICAL TREATMENT
Intubation
Mechanical ventilation
Antibiotics
Steroids
Bronchodilators

Acute Respiratory Failure
NURSING INTERVENTIONS
1. Maintain patent airway
2. Administer O2 to maintain Pa02 at
more than 50 mmHg
3. Suction airways as required
4. Monitor serum electrolyte levels
5. Administer care of patient on
mechanical ventilation
COPD
These are group of disorders
associated with recurrent or
persistent obstruction of air passage
and airflow, usually irreversible.
COPD
The most common cause of COPD is
cigarette smoking. Asthma, Chronic
bronchitis, Emphysema and
Bronchiectasis are the common
disorders.
COPD
The general pathophysiology:
In COPD there is airflow limitation
that is both progressive and
associated with abnormal
inflammatory response of the lungs
to stimuli, usually smoke, particles
and dust
ASTHMA
The acute episode of airway
obstruction is characterized by
airway hyperactivity to various
stimuli that results in recurrent
wheezing brought about by edema
and bronchospasm
Asthma Pathophysiology
Immunologic/allergic reaction results in
histamine release, which produces
three main airway responses
a. Edema of mucous membranes
b. Spasm of the smooth muscle of
bronchi and bronchioles
c. Accumulation of tenacious secretions
Asthma Assessment Findings
Assessment findings
1. Family history of allergies
2. Client history of eczema

Asthma Assessment Findings
3.Respiratory distress
slow onset of
shortness of breath
expiratory wheeze
prolonged expiratory
phase
air trapping (barrel
chest if chronic)
use of accessory
muscles
irritability (from
hypoxia)
Diaphoresis
Cough
Anxiety
weak pulse
Diaphoresis
change in sensorium
if severe attack

inspiratory retractions
prolonged I:E ratio
5. Cardiovascular symptoms:
tachycardia, ECG changes,
hypertension, decreased cardiac
contractility, pulsus paradoxus
6. CNS manifestations: anxiety,
restlessness, fear and disorientation
Emphysema
There is progressive and irreversible
alveolocapillary destruction with
abnormal alveolar enlargement
causing alveolar wall destruction. The
result is INCREASED lung compliance,
DECREASED oxygen diffusion and
INCREASED airway resistance!
Emphysema
These changes
cause a state of
carbon dioxide
retention,
hypoxia, and
respiratory
acidosis.
Emphysema
Cigarette smoking
Heredity, Bronchial asthma
Aging process


Disequilibrium between
ELASTASE & ANTIELASTASE (alpha-1-antitrypsin)


Destruction of distal airways and alveoli
Overdistention of ALVEOLI
Hyper-inflated and pale lungs

Air traping, decreased gas exchange and Retention of CO2


Hypoxia Respiratory acidosis

Emphysema Assessment
1. Anorexia, fatigue, weight
loss
2. Feeling of breathlessness,
cough, sputum production,
flaring of the nostrils, use of
accessory muscles of
respiration, increased rate and
depth of breathing, dyspnea
Emphysema Assessment
3. Decreased respiratory
excursion, resonance to hyper-
resonance, decreased breath
sounds with prolonged expiration,
normal or decreased fremitus
4. Diagnostic tests: pCO2
elevated or normal; PO2 normal
or slightly decreased
Chronic bronchitis
Chronic inflammation of the
bronchial air passageway
characterized by the presence of
cough and sputum production for at
least 3 months in each 2 consecutive
years.
Excessive production of mucus in
the bronchi with accompanying
persistent cough.


Chronic Bronchitis
pathophysiology
Characteristic changes include
hypertrophy/ hyperplasia of the
mucus-secreting glands in the
bronchi, decreased ciliary
activity, chronic inflammation,
and narrowing of the small
airways.
Chronic Bronchitis Assessment
I. Productive (copious) cough,
dyspnea on exertion, use of
accessory muscles of respiration,
scattered rales and rhonchi
2. Feeling of epigastric fullness,
cyanosis, distended neck veins,
ankle edema
3. Diagnostic tests: increased pCO2
decreased PO2
Bronchiectasis
Permanent abnormal
dilation of the bronchi
with destruction of
muscular and elastic
structure of the bronchial
wall


BRONCHIAL TUBE
Bronchiectasis
Caused by bacterial infection;
recurrent lower respiratory
tract infections; congenital
defects (altered bronchial
structures); lung tumors
Bronchiectasis
1. Chronic cough with production of
mucopurulent sputum, hemoptysis,
exertional dyspnea, wheezing
2. Anorexia, fatigue, weight loss
3. Diagnostic tests
a. Bronchoscopy reveals sources and
sites of secretions
b. Possible elevation of WBC
COPD Management
Independent and Collaborative
Management
1. Rest-To reduce oxygen
demands of tissues
2. Increase fluid intake-To liquefy
mucus secretions
3. Good oral care-To remove
sputum and prevent infection
COPD Management
Independent and Collaborative Management
4. Diet:
High caloric diet provides source of
energy
High protein diet helps maintain integrity
of alveolar walls
Moderate fats
Low carbohydrate diet limits carbon
dioxide production (natural end product).
The client has difficulty exhaling carbon
dioxide.
COPD Management
Independent and Collaborative
Management
5. O2 therapy 1 to 3 lpm (2 lpm is
safest)
Do not give high concentration
of oxygen. The drive for
breathing may be depressed.
COPD Management
Independent and Collaborative
Management
6. Avoid cigarette smoking, alcohol,
and environmental pollutants-These
inhibit mucociliary function.
7. CPT percussion, vibration,
postural drainage
COPD Management
Independent and Collaborative
Management
8. Bronchial hygiene measures
Steam inhalation
Aerosol inhalation
Medimist inhalation
COPD Management
Pharmacotherapy
1. Expectorants (guaifenesin)/ mucolytic
(mucomyst/mucosolvan)
2. Antitussives
Dextrometorphan
Codeine
Observe for drowsiness
Avoid activities that involve mental alertness, e.g
driving, operating electrical machines
Cause decrease peristalsis thereby constipation
COPD Management
Pharmacotherapy
3. Bronchodilators
Aminophylline (Theophylline)
Ventolin (Salbutamol)
Bricanyl (Terbutaline)
Alupent (Metaproterenol)
Observe for tachycardia
COPD Management
Pharmacotherapy
4. Antihistamine
Benadryl (Diphenhydramine)
Observe for drowsiness
5. Steroids
Anti-inflammatory effect
6. Antimicrobials
Flail Chest

Complication of chest trauma
occurring when 3 or more
adjacent ribs are fractured at
two or more sites, resulting in
free-floating rib segments.
Flail Chest
Chest wall is no longer able
to provide the bony structure
necessary to maintain
adequate ventilation;
consequently
the flail portion and
underlying tissue move
paradoxically (in opposition)
to the rest of the chest cage
and lungs.

Flail Chest
The flail portion is sucked in on
inspiration and bulges out on
expiration.
Result is hypoxia, hypercapnea, and
increased retained secretions.
Caused by trauma (sternal rib
fracture with possible costochondral
separations).
Flail Chest: PATHOPHYSIOLOGY
During inspiration, as the chest expands,
the detached part of the rib segment (flail
segment) moves in a paradoxical
manner
The chest is pulled INWARD during
inspiration, reducing the amount of air that
can be drawn into the lungs
The chest bulges OUTWARD during
expiration because the intrathoracic
pressure exceeds atmospheric pressure.
The patient has impaired exhalation
Flail Chest
This paradoxical action will lead to:
Increased dead space
Reduced alveolar ventilation
Decreased lung compliance
Hypoxemia and respiratory acidosis
Hypotension, inadequate tissue
perfusion can also follow
Flail Chest: Assessment
1. Severe dyspnea; rapid, shallow, grunty
breathing; paradoxical chest motion. The
chest will move INWARDS on inhalation
and OUTWARDS on exhalation.
2. Cyanosis, possible neck vein distension,
tachycardia, hypotension
3. Diagnostic tests
a. PO2 decreased
b. pCO2 elevated
c. pH decreased
Nursing interventions
1. Maintain an open airway: suction
secretions, blood from nose, throat, mouth,
and via endotracheal tube; note changes in
amount, color, and characteristics.
2. Monitor mechanical ventilation
3. Encourage turning, coughing, and deep
breathing.
4. Monitor for signs of shock: HYPOTENSION,
TACHYCARDIA
Flail Chest
Medical management:
SUPPORTIVE
1. Internal stabilization with a
volume-cycled ventilator
2. Drug therapy (narcotics,
sedatives)
Pneumothorax
Partial or complete collapse
of the lung due to an
accumulation of air or fluid in
the pleural space
Pneumothorax

Types
a. Spontaneous pneumothorax: the
most common type of closed
pneumothorax; air accumulates
within the pleural space without an
obvious cause. Rupture of a small
bleb on the visceral pleura most
frequently produces this type of
pneumothorax.
Pneumothorax

Types
b. Open pneumothorax: air enters the
pleural space through an opening in
the chest wall; usually caused by
stabbing or gunshot wound.
Pneumothorax
Types
c. Tension pneumothorax: air enters
the pleural space with each
inspiration but cannot escape;
causes increased intrathoracic
pressure and shifting of the
mediastinal contents to the
unaffected side (mediastinal shift).
Pneumothorax

Assessment findings
1. Sudden sharp pain in the
chest, dyspnea, diminished or
absent breath sounds on
affected side, tracheal shift to
the opposite side (tension
pneumothorax accompanied by
mediastinal shift)
2. Weak, rapid pulse; anxiety;
diaphoresis
Pneumothorax

Assessment findings
3. Diagnostic tests
a. Chest x-ray reveals area and
degree of pneumothorax
b. pCO2 elevated
c. pH decreased
Pneumothorax
Nursing interventions
1. High-fowlers
2. Pain mngt.
3. O2 therapy
4. CXray
5. ABG
6. Thoracentesis
7. Monitor for shock

Thoracentesis: NR
Aspiration of fluid / air from the pleural space
NR Before:
Consent
Initial VS
Upright leaning on overbed table
Remain still, no coughing or deep breathing
during insertion
NR AFTER:
Position to unaffected side to prevent leakage in
the thoracic cavity
Bed rest until VS are stable
Notify Dr. for expectoration of blood

T H O R A C E N T E S I S
Chest Thoracostomy Tube (CTT)
Removes air / fluids from the pleural
space
Reestablishes negative pressure &
reexpands the lungs
TYPES:
1-bottle system
Drainage bottle and water seal
Keep 2-3 ft below the level of the chest
Air vent should be open to air
intermittent fluctuation

2-bottle system
Not connected to suction
1
st
bottle drainage
2
nd
bottle water-seal; intermittent
fluctuation
Connected to suction
1
st
drainage & water seal, immerse tip 2-
3 cm of NSS; intermittent fluctuation
2
nd
suction; 10-20 cm of of sterile NSS;
continuous bubbling
3- bottle system
1
st
drainage bottle
2
nd
water seal; immerse tip 2-3 cm of
NSS; intermittent fluctuation
3
rd
suction bottle; tip @ 10-20 cm of of
sterile NSS; continuous bubbling
Nsg resp.
Encourage DBE, coughing
exercises
Turn to sides
Ambulate
ROM of arms
Mark the amount of drainage at
regular intervals
Avoid milking or clamping to
prevent tension pneumonthorax
if not ordered
If + continuous
bubbling @ water seal
indicates air leak
check the connection
tube, clamp
+ absence of
fluctuation
Check for
obstruction kinks,
milk towards
thetube as ordered
No obstruction
CXray -
reexpansion
Removal of CTT: NR
Prepare
Petroleum gauze
Suture removal kit
Sterile gauze
Adhesive tape
Semi-fowlers
Instruct to do valsalva maneuver as CTT is
being removed
Cxray
Assess for subcutaneous emphysema, respi.
distress
Pleural Effusion
Defined broadly as a
collection of fluid in
the pleural space
A symptom, not a
disease; may be
produced by
numerous
conditions
Pleural Effusion
General Classification
Transudative effusion:
accumulation of protein-poor,
cell-poor fluid

Exudative effusion:
accumulation of protein rich
fluid
Pleural Effusion
Assessment findings
1. Dyspnea, dullness over affected
area upon percussion, absent or
decreased breath sounds over
affected area, pleural pain, dry cough,
pleural friction rub
2. Pallor, fatigue, fever, and night
sweats (with empyema)
Pleural Effusion
Assessment findings
3. Diagnostic tests
a. Chest x-ray positive if greater than
250 cc pleural fluid
b. Pleural biopsy may reveal
bronchogenic carcinoma
c. Thoracentesis may contain blood if
cause is cancer, pulmonary infarction,
or tuberculosis; positive for specific
organism in empyema.

Pleural Effusion
Nursing interventions: In general:
1. Assist with repeated thoracentesis.
2. Administer narcotics/sedatives as
ordered to decrease pain.
3. Assist with instillation of medication
into pleural space (reposition client every
15 minutes to distribute the drug within
the pleurae).
4. Place client in high-Fowlers position to
promote ventilation.
Atelectasis
Collapse of part or all of a lung due
to bronchial obstruction
May be caused by
intrabronchial obstruction
tumors, bronchospasm
foreign bodies
extrabronchial compression (tumors,
enlarged lymph nodes); or
endobronchial disease (bronchogenic
carcinoma, inflammatory structures)

Atelectasis
Assessment findings
1. Signs and symptoms may be absent
depending upon degree of collapse
and rapidity with which bronchial
obstruction occurs
2. Dyspnea, decreased breath sounds
on affected side, decreased respiratory
excursion, dullness to flatness upon
percussion over affected area
Atelectasis
Assessment findings
3. Cyanosis, tachycardia,
tachypnea, elevated temperature,
weakness, pain over affected area
Atelectasis
Assessment findings
4. Diagnostic tests
a. Bronchoscopy: may or may not
reveal an obstruction
b. Chest x-ray shows diminished size
of affected lung and lack of radiance
over atelectatic area
c. pO2 decreased
Pleural Effusion
Medical management
1. Identification and treatment of the
Underlying cause
2. Thoracentesis
3. Drug therapy
a. Antibiotics: either systemic or inserted
directly into pleural space
b. Fibrinolytic enzymes: trypsin,
streptokinase- to decrease thickness of
pus and dissolve fibrin clots
4. Closed chest drainage
5. Surgery: open drainage
Pneumonia
An inflammation of the alveolar spaces
of the lung, resulting in consolidation
of lung tissue as the alveoli fill with
exudates
The various types of pneumonias are
classified according to the offending
organism.
Pneumonia can also be classified as
COMMUNITY Acquired Pneumonia
(CAP) and HOSPITAL acquired
pneumonia (HAP)

Pneumonia
PATHOPHYSIOLOGIC FINDINGS ARE:
HYPERTROPHY OF MUCOUS
MEMBRANE
Increased sputum production
Wheezing
Dyspnea
Cough
Rales/Crackles
Ronchi
Pneumonia
PATHOPHYSIOLOGIC FINDINGS ARE:
INCREASED CAPILLARY
PERMEABILITY
Increased Fluid Exudation
Consolidation-tissue that solidifies as a
result of collapsed alveoli
Hypoxemia
Pneumonia
PATHOPHYSIOLOGIC FINDINGS ARE:
INFLAMMATION OF THE PLEURA
Chest pain
Pleural effusion
Dullness
Decreased Breath sounds
Increased tactile fremitus
Pneumonia
PATHOPHYSIOLOGIC FINDINGS ARE:
HYPOVENTILATION
Decreased Chest expansion
Respiratory acidosis
Depressed PROTECTIVE MECHANISM
Increased WBC (leukocytosis)
Increased RR and Fever
Pneumonia
Assessment findings
Cough with greenish to rust-colored
sputum production
rapid, shallow respirations with an
expiratory grunt
nasal flaring; intercostal rib retraction;
use of accessory muscles of respiration
Fine rales or crackles (early) progressing
to coarse rales or crackles (later).
Tactile fremitus is INCREASED!
Pneumonia
Assessment findings
Fever, chills, chest pain,
weakness, generalized malaise
Tachycardia, cyanosis, profuse
perspiration, abdominal
distension
Rapid shallow breathing
Pneumonia
Diagnostic tests
a. Chest x-ray shows consolidation over
affected areas
b. WBC increased
c. pO2 decreased
d. Sputum specimen- culture reveal
particular causative organism
1. Facilitate adequate ventilation.
a. Place client in Fowlers position.
B. Administer oxygen as needed and assess
its effectiveness.
c. Turn and reposition frequently clients who
are immobilized/obtunded.
d. Administer analgesics as ordered to relieve
pain associated with breathing
e. Auscultate breath sounds every 24 hours.
f. Monitor ABGs.
Nursing interventions
2. Facilitate removal of secretions
general hydration
deep breathing and coughing
Suctioning
Expectorants
aerosol treatments via nebulizer,
humidification of inhaled air
chest physical therapy
3. Observe color,
characteristics of sputum
and report any changes;
encourage client to perform
good oral hygiene after
expectoration.
4. Provide adequate rest and
relief/control of pain.
a. Provide bed rest with
limited physical activity.
b. Limit visits and minimize
conversations
.
c. Plan for
uninterrupted rest
periods.
d. Institute nursing
care in blocks to
ensure periods of
rest.
e. Maintain pleasant
and restful
environment
5. Administer antibiotics as ordered.
Monitor effects and possible toxicity.
6. Prevent transmission (respiratory
isolation may be required for clients
with staphylococcal pneumonia).
7. Control fever and chills: monitor
temperature and administer
antipyretics as ordered, maintain
increased fluid intake, provide frequent
clothing and linen changes.
8. Provide client teaching and discharge
planning concerning prevention of recurrence.
a. Medication regimen/antibiotic therapy
b. Need for adequate rest,
c. Need to continue deep breathing and coughing
d. Availability of vaccines
e. Techniques that prevent transmission (use of
tissues when coughing, adequate disposal of
secretions)
f. Avoidance of persons with known respiratory
infections
g. Need to report signs and symptoms of respiratory
infection


Lung Cancer
Primary pulmonary tumors arise from the
bronchial epithelium and are therefore
referred to as bronchogenic carcinomas.

FACTORS:
Possibly caused by inhaled carcinogens
(primarily cigarette smoke but also
asbestos, nickel, iron oxides, air silicone
pollution; preexisting pulmonary disorders
PTB, COPD)


Assessment findings
Persistent cough (may be productive
or blood tinged)
chest pain
dyspnea
unilateral wheezing, friction rub,
possible unilateral paralysis of the
diaphragm
Fatigue, anorexia, nausea, vomiting,
pallor
Diagnostic tests
a. Chest x-ray may show presence of tumor or
evidence of metastasis to surrounding
structures
b. Sputum for cytology reveals malignant
cells
c. Bronchoscopy: biopsy reveals malignancy
d. Thoracentesis: pleural fluid contains
malignant cells
e. Biopsy of lymph nodes may reveal
metastasis
NSG responsibility
1. Provide support and guidance to
client as needed.
2. Provide relief/control of pain.
3. Administer medications as ordered
and monitor effects/side effects.
4. Control nausea: administer
medications as ordered, provide good
oral hygiene, provide small and more
frequent feedings.
5. Provide nursing care for a client with
a thoracotomy.
6. Provide client teaching and discharge
planning concerning
a. Disease process, diagnostic and
therapeutic interventions
b. Side effects of radiation and
chemotherapy
c. Realistic information about prognosis
Medical management
1. Radiation therapy
2. Chemotherapy: usually includes
cyclophosphamide, methotrexate,
vincristine, doxorubicin, and
procarbazine; concurrently in some
combination
3. Surgery: when entire tumor can be
removed
Predisposing factors
Cigarette smoking
Asbestosis
Emphysema
Smoke from burnt wood
Types
Squamous cell Ca- with good prognosis
Adenocarcinoma- with good prognosis
Oat cell Ca- with good prognosis
Undifferentiated Ca- with poor prognosis
Nursing Interventions
Patent airway
O2 / Aerosol therapy
Deep breathing exercises
Relief of pain
Protection from infection
Adequate nutrition
Chest tube management
Surgery
Pneumonectomy=Removal of a lung (either
left or right)
NR:
Semi-fowlers, turned slightly on affected
side for lung expansion
Avoid full side lying to prevent mediastinal
shift
No CTT


Lobectomy=Removal of a lobe.
Segmentectomy=Removal of a
segment.
Wedge resection=Removal of the
entire tumor regardless of the segment.
Decortication=Stripping off of fibrinous
membrane enclosing the lung
Thoracoplasty=Removal of rib/s.
Usually done after pneumonectomy, to
reduce the size of the empty thorax
thereby prevent mediastinal shift.

NR:
+ CTT
care w/ a
CTT
Semi-
fowlers
Unaffected
side for
expansion
of affected
lung


Pulmonary Embolism
This refers to the obstruction of the
pulmonary artery or one of its branches by
a blood clot (thrombus) that originates
somewhere in the venous system or in the
right side of the heart.
Most commonly, pulmonary embolism is
due to a clot or thrombus from the deep
veins of the lower legs.

Pulmonary Embolism
Causes
Fat embolism. Air embolism
Multiple trauma
PVDs
Abdominal surgery
Immobility
Hypercoagulability
PATHOPHYSIOLOGY
The thrombus that travels from any part of
the venous system obstructs either
completely or partially. Then the lungs will
have inadequate blood supply, with
resultant increase in dead space in the
lungs
Gas exchange will be impaired or absent
in the involved area
Pulmonary Embolism
PATHOPHYSIOLOGY
The regional pulmonary vasculature
will constrict causing increased
resistance, increased pulmonary
arterial pressure and then increase
workload of the right side of the
heart.
Pulmonary Embolism
PATHOPHYSIOLOGY
When the work of the right side of
the heart exceeds its capacity, right
ventricular failure will result, leading
to a decrease in cardiac output
followed by decreased systemic
perfusion and eventually, SHOCK
Assessment
Restlessness (cardinal initial sign)
Dyspnea
Stabbing chest pain with petecchial rash
Cyanosis
Tachycardia
Dilated pupils
Apprehension/ fear
Diaphoresis
Dysrhythmias
Hypoxia

Pulmonary Embolism
Diagnostic Tests:
Ventilation-perfusion scan
Pulmonary arteriography
CXR
ECG
ABG
Pulmonary Embolism
Nursing Interventions
Oxygen therapy STAT
Early ambulation postop
Monitor obese patient
Do not massage legs
Relieve pain- analgesics
HOB elevated
Heparin (2 weeks) then Coumadin (3-6
months)
Patient Teaching for prevention
Active leg exercises to avoid venous stasis
Early ambulation
Use of elastic compression stockings
Avoidance of leg-crossing and sitting for
prolonged periods
Drink fluids
Stop smoking
avoid contact sports, constipation
Observe for bleeding
Use soft bristled toothbrush
Evaluate use of contraceptives to physician

Surgical Aspect of Respiratory
Care
Thoracic Surgery
a. Exploratory thoracotomy: anterior or
posterolateral incision through the fourth,
fifth, sixth, or seventh intercostal spaces
to expose and examine the pleura and
lung
Surgical Aspect of Respiratory
Care
Thoracic Surgery
b. Lobectomy: removal of one lobe of a
lung; treatment for bronchiectasis,
bronchogenic carcinoma,
emphysematous blebs, lung abscesses
Surgical Aspect of Respiratory
Care
Thoracic Surgery
c. Pneumonectomy: removal of an
entire lung; most commonly done as
treatment for bronchogenic carcinoma
Surgical Aspect of Respiratory
Care
Thoracic Surgery
d. Segmental resection: removal of one
or more segments of lung; most often
done as treatment for bronchiectasis
Surgical Aspect of Respiratory
Care
Thoracic Surgery
e. Wedge resection: removal of lesions
that occupy only part of a segment of
lung tissue; for excision of small
nodules or to obtain a biopsy
Surgical Aspect of Respiratory
Care
Nursing interventions: PREOPERATIVE
1. Provide routine pre-op care.
2. Perform a complete physical assessment of
the lungs to obtain baseline data.
3. Explain expected post-op measures: care
of incision site, oxygen, suctioning, chest
tubes (except if pneumonectomy performed)
Surgical Aspect of Respiratory
Care
Nursing interventions: PREOPERATIVE
4. Teach client adequate splinting of
incision with hands or pillow for turning,
coughing, and deep breathing.
5. Demonstrate ROM exercises for affected
side.
6. Provide chest physical therapy to help
remove secretions.
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
1. Provide routine post-op care.
2. Promote adequate ventilation.
a. Perform complete physical assessment
of lungs and compare with pre-op findings.
b. Auscultate lung fields every 12 hours.
c. Encourage turning, coughing, and deep
breathing every 12 hours after pain relief
obtained.
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
2. Promote adequate ventilation.
d. Perform tracheobronchial suctioning if
needed.
e. Assess for proper maintenance of chest
drainage system (except after pneumonectomy).
f. Monitor ABGs and report significant changes.
g. Place client in semi-Fowlers position
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
If pneumonectomy is performed, follow
surgeons orders about positioning,
often on back or OPERATIVE SIDE
If Lobectomy, patient is usually
positioned on the UNOPERATIVE SIDE
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
3. Provide pain relief.
a. Administer narcotics/analgesics prior to
turning, coughing, and deep breathing.
b. Assist with splinting while turning,
coughing, deep breathing.
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
4. Provide client teaching and discharge
planning concerning
a. Need to continue with coughing/deep
breathing for 68 weeks post-op and to
continue ROM exercises
b. Importance of adequate rest with
gradual increases in activity levels
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
4. Provide client teaching and discharge planning
concerning
c. High-protein diet with inclusion of adequate
fluids
d. Chest physical therapy
e. Good oral hygiene
f. Need to avoid persons with known upper
respiratory infection
g. Adverse signs and symptoms
h. Avoidance of crowds and poorly ventilated
areas.
Tuberculosis
Reportable, communicable disease

Classification of TB
Class 0 no exposure
Class 1 - +exposure; - infection
Class 2 - +infection; - disease (no
clinical evidence of active TB)
Class 3 - +disease, clinically active
Class 4 - + disease; not clinically active
Class 5 suspected; dx pending
Infectious, may be cured by medication
Airborne special mask
Cover nose & mouth when coughing,
sneezing & laughing
Hand hygiene
May lie dormant for many years &
reactivated during stress


Mantoux (PPD)
ID @ forearm
Read in 48-72 hrs
10mm = positive
5 mm = + for pts. w/ HIV
Tine / multiple
puncture test
Read in 48-72 hrs
Screening test only
Positive reaction is
verified by PPD

Nsg Responsibility
Notify health department
INH
Not recommended >35 y/o
who are at low risk
tuberculostatic
<35 y/o 6-9 mos therapy
SE: peripheral neuritis,
hepatotoxic
Admin. Vit B6
Monitor ALT (SGPT), AST
(SGOT)


Streptomycin
SE: ototoxic,
nephrotoxic
Report signs of
deafness
Monitor UO, BUN,
Creatinine
Rifampicin
SE: red orange
secretions,
hepatotoxic, n&v,
thrombocytopenia
tuberculocidal
Ethambutol
SE: optic neuritis, skin rash
Opthalmologic exam @ regular
basis
PZA
SE: most hepatotoxic
Highly specific to mycobacterium
tubercle
Take anti-TB drugs in
combination to prevent
resistance
Take on empty stomach
Pts are not infectious after 2
weeks of treatment
Evaluate drugs effectiveness
through sputum culture
Avoid excessive exposure
to dust & silicone
Must take full course of
meds
Good nutrition
Evaluate household
contacts
Histoplasmosis
Systemic fungal disease by inhalation of dust
contaminated by histoplasma capsulatum
Etiology:
Pigeon / chicken manure
Not spread from human to human
S/SX
Cough
Fever
Joint pain
Malaise
Sometimes asymptomatic

Dx:
CXray
Histoplasmin skin test (like PPD)
Mngt:
Amphoteracin B
Nephrotoxic, adrenal failure, headache, fever &
chills
Wet down chicken manure before shoveling
so fungal spores will not become airborne
Exam!!!!
1. A client with AIDS & PTB which
management will be prescribed?
A. INH, Rifampicin
B. ethambutol, PZA, INH
C. INH, Rifampicin, PZA, Ethambutol
D. etham, ciprofloxacin, streptomycin,
INH
Ans: C
A 21-day course of tx is required to
identify the sensitivity of TB organism to
meds.
Ethambutol & streptomycin are not
given together for this pt.
THANK YOU!!