January 28, 2008 N361 RESPIRATORY EXAM STUDY GUIDE *Review Pulmonary Function Studies C. 36, pg. 1214 Upper Respiratory Pathology What are the types and causes of rhinitis? Acute Viral ? aerosol droplets and direct contact Allergic ? seasonal allergies to pollen, dust, dander, and foods Vasomotor ? chronic form w/ intermittent episodes of vascular engorgement; cause unknown Atrophic ? atrophy and sclerosis of nasal mucous membrane; cause unknown What is the treatment for rhinitis including medications? Treatment is symptomatic ? decongestants, antihistamines, throat lozenges, warm salt water gargling, rest, fluids What are the clinical manifestations of influenza? Respiratory ? Coryza (rhinitis or rhinorrhea); Cough (begins as dry cough); Sore throat Systemic ? fever, abrupt onset of chills, headache, malaise, fatigue, muscle aches (myalgias) What are the complications of influenza especially for the elderly? Secondary bacterial infections, sinusitis, otitis media, tracheobronchitis, pneumonia, exacerbation of COPD, Reye?s Syndrome; (complications increase w/ chronic cardiac or pulmonary disease) What are the causative factors of pharyngitis? Viral or bacterial (Group A beta-hemolytic Strep.) What are the clinical differences between bacterial and viral pharyngitis? Viral ? gradual onset, low grade fever, sore throat, mild hoarseness, headache, rhinorrhea Bacterial ? rapid onset, fever 101+, sever sore throat, dysphagia, malaise, arthalgias, myalgias, exudate on tonsils and pharynx What complications can a patient develop from Beta Hemolytic Strep pharyngitis? Peritonsillar abscesses (Quinsy) ? extension of strep to surrounding tissues Acute glomerulonephritis 7-10 days post paryngitis (hematuria, proteinura, edema) Rheumatic fever ? 3-5 weeks post pharyngitis Scarlet fever Sinusitis Otitis media Cervical adenitis What are the clinical manifestations of Sinusitis? What complications? Pain and tenderness over sinuses Especially pain that increases when leaning forward Acute - severe, constant pain Chronic ? dull, constant, intermittent Headache Fever Malaise Nasal congestion Purulent nasal discharge Halitosis Periorbital abscesses Periorbital cellulitis Sinus thrombosis Meningitis Brain abscess Sepsis Hearing loss from edema What is the appropriate treatment and nursing care for epitaxis? Apply pressure 5-10 minutes Ice packs to nose and forehead Sitting position ? leaning forward Topical vasoconstrictors Neo-synephrine Adrenaline Topical chemical cauterization w/ silver nitrate or gel foam Nasal packing Surgery What are the clinical manifestations of acute epiglottis? Painful swallowing of food (odynophagia) Epiglottis red and edematous Dyspnea Decreased O2 sat. Drooling Stridor Why can acute epiglottis be a medical emergency? Airway is threatened due to edema What are the clinical manifestations of diphtheria and pertussis? Diphtheria ? fever, malaise, sore throat, malodorous breath, difficulty eating drinking and breathing; thick grey-white pseudo-rubbery membrane over post pharynx that grows thicker Pertussis (Whooping Cough) ? coryza, sneezing, low fever, mild cough that increases after 1-2 weeks to an audible whoop, coughing spasms may cause vomiting What are the clinical manifestations of nasal trauma? Epitaxis, hematomas (black eyes), bony crepitus, deviated semptum, periorbital edema; assess for leaking CSF What should be included in the plan of care for a patient with nasal packing? Continuously monitory O2 sat; frequently monitor vitals and respiratory rate and pattern; inspect the mouth and oropharynx; elevate the head of the bed; encourage deep, slow breathing trough the mouth; check for blood at the back of the throat and frequent swallowing; report hematemesis; apply cold compresses to the nose; provide for rest; ensure adequate fluid intake; provide frequent oral hygiene What are the causes of laryngeal obstruction? Aspirated food (café coronary), foreign objects, laryngeospasm, edema from inflammation, injury, anaphylactic shock (angioedema) What are the clinical manifestations of laryngeal obstruction? Coughing, gagging, choking, difficulty breathing, dyspnea, painful, use of accessory muscles, inspiratory stridor, asphyxia (laryngeospasm) ? labored respirations, wheezing, stridor, cyanosis What should be the primary concern of the nurse be when caring for a patient with laryngeal obstruction or trauma? Larynx is the most narrow part of URS What are the clinical manifestations of a laryngeal tumor? Hoarseness, subcutaneous emphysema, change in voice, dysphagia, pain with swallowing, inspiratory stridor, hemoptysis, cough, dyspnea, halotisis, palpable lump in the neck, earache What are the priority nursing diagnoses and interventions for a post op total laryngectomy patient? (p.1256-1259) Risk for Ineffective Airway Clearance Risk for Ineffective Breathing Pattern Disturbed Body Image Impaired Verbal Communication Pain Risk for Imbalanced Nutrition Lower Respiratory Pathology What are the various types of pneumonia and who are the most susceptible populations for each type? What are the clinical manifestations of various types of pneumonia? What types of patients are most susceptible to aspiration pneumonia? Emergency surgery or OB, depressed cough or gag reflexes, difficulty swallowing, older surgical clients, clients receiving enteral feedings What are the treatments for pneumonia? Pharmacology (antibiotics, bronchodilators, mucolytics) Oxygen therapy (nasal cannula 2-6 L, simple face mask 40-60%, non-rebreather 100%, venture-mask 24-50%) Respiratory therapy (chest physiotherapy, incentive spirometry, respiratory treatments) Suctioning Artificial ventilation (respiratory failure) What are the clinical manifestations of a lung abscess? Early S&S (2 weeks post-illness) ? productive cough, chills, fever, pleuritic chest pain, malaise, anorexia Later S&S ? temp 103+, copious amounts of foul smelling purulent sputum Diminished lung sounds Crackles near abscess Dull percussion over abscess site What are the most susceptible populations for developing TB? New strains of drug resistant TB (MDR) Elderly population (exposed many years ago) Immunocompromised (HIV/AIDS, chemotherapy) Socioeconomically depressed urban areas (homeless, drug abusers, alcoholics) What are the clinical manifestations of TB? Fatigue, weight loss, anorexia, low grade afternoon fever, night sweats, cough (dry at first, then productive purulent sputum, hemoptysis) What methods are used to screen and diagnosis TB? Skin testing ? intradermal PPD (Mantoux), jet injection TB test, multiple puncture (tine) Sputum (acid-fast smear) ? early morning specimen for 3 consecutive days Chest x-ray Fiberoptic bronchoscopy and bronchial washings How do you interpret TB Skin Tests? Intradermal PPD (purified protein derivative) ? read within 48-72 hours; diameter of induration (raised area) measured Less than 5 mm ? negative response, does not rule out infection 5 to 9 mm ? Positive for people who: Are in close contact with a client with infective TB Have an abnormal chest x-ray Have HIV or are immunocompromised Have an organ transplant Negative for all others 10 to 15 mm ? Positive for people who have other risk factors: Birth in a high-incidence country African American, Hispanic, Asian American in poverty areas Injection drug use Residence in a long-term care facility, correctional institution, residential care setting, homeless shelter Medical risk factors (malnutrition, diabetes, others) Greater than 15 mm ? Positive for all people List medications used to treat TB and their adverse effects? (C. 38, pg. 1288-89) Isoniazid ? peripheral neuropathy; hepatitis Rifampin ? hepatitis; flulike syndrome, fever; colors body fluids including sweat, urine, saliva, tears, and CSF orange-red Pyrazinamide ? hyperuricemia; hepatotoxicity Ethambutol ? optic neuritis Streptomycin ? ototoxicity, vertigo; nephrotoxicity What are the four primary fungal diseases and their causative factors? Histoplasmosis ? found in soil from bird and bat droppings (inhaled) Coccidioidomycosis ? fungus in the SW, Mexico, and C. America Blastomycosis ? south-central and Midwestern states; inhalation of airborne conidia (spores) after disturbance of contaminated soil Aspergillosis - Aspergillus is a fungus (or mold) that is very common in the environment. It is found in soil, on plants and in decaying plant matter. It is also found in household dust, building materials, and even in spices and some foods. What are the primary complications of asbestosis, silicosis, pneumoconiosis, and aspergillosis? Asbestosis ? bronchogenic carcinoma, malignant mesothelioma, pleural plaques Silicosis ? severely dyspneic, productive cough, pulmonary function test with restrictive or fibrotic changes, cor pulmonale Pneumoconiosis (black lung) ? cor pulmonale, pulmonary tuberculosis Aspergillosis ? invades blood vessels causing venous and arterial thrombosis (can cause massive pulmonary hemorrhage) What is the meaning of the term ?disseminating?? Spread or distribute widely What are the causes and clinical manifestations of atelectasis? Obstruction of bronchus Lung compression from pheumothorax, pleural effusion, or tumors Loss of surfactant (inability to maintain open alveoli) Tachycardia, tachypnea, dyspnea, cyanosis, hypoxemia, fever, chest x-ray shows ?airless? lung tissue How can atelectasis best be prevented? Coughing and deep breathing Incentive spirometer Flutter valve Ambulation Encourage fluids What causes pulmonary emboli? Clot that is broken loose from its site and traveled to the pulmonary artery, disrupting blood flow DVT in leg (90-95%) Fat embolism from fracture of femur or liver trauma Bone marrow Amniotic fluid Air or particles from IV line Prolonged immobility What are the clinical manifestations of pulmonary emboli? General ? restlessness, anxiety, diaphoresis Cardiac ? sudden severe chest pain, tachycardia, cardiac gallup (S3 & S4) Respiratory ? dyspnea, tachypnea, hemoptysis, cough, cyanosis, crackles What tests are used to diagnosis pulmonary emboli? Plasma D-dimer ABG Blood coag. studies for a baseline Chest x-ray Electrocardiogram Lung scan Ventilation-Perfusion scan (VP Scan) Pulmonary angiography What is the purpose of a Greenfield filter and where is it placed? To prevent pulmonary emboli. Place in the Inferior Vena Cava. What are the primary causes of pleural effusions? Systemic ? CHF, liver disease, renal disease, connective tissue diseases (RA, SLE) Local ? pneumonia, atelectasis, TB, lung cancer, trauma What are the clinical manifestations of pleural effusions? Large effusion ? dyspnea, pain, diminished breath sounds, dull tone on percussion, limited chest wall movement What is the pre and post procedure care for a thoracentesis? Pre-procedure ? consent form, explain procedure, client sits upright leaning over table tray, instruct client to hold very still, after fluid withdrawn ? send to lab, client may cough harshly as lung expands to fill the space no longer occupied by fluid Post-procedure ? assess respiratory status (VS, RR and character, Pulse Ox., lung sounds, cough: productive?); O2 therapy, assess for pain, monitor for S&S of pnuemothorax, bedrest for about 1 hour PAGE PAGE 8
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