NUR 2063 Essentials of Pathophysiology (NUR2063) / Pathophysiology Final Rasmussen Univers, Exams of Nursing

Download NUR 2063 Essentials of Pathophysiology (NUR2063) / Pathophysiology Final Rasmussen Univers and more Exams Nursing in PDF only on Docsity!

Exam 1

Chapter 26: Nursing Assessment: Respiratory System STRUCTURES AND FUNCTIONS OF RESPIRATORY SYSTEM

• The primary purpose of the respiratory system is gas exchange, which involves the transfer of oxygen and carbon dioxide between the atmosphere and the blood.
• The upper respiratory tract includes the nose, pharynx, adenoids, tonsils, epiglottis, larynx, and trachea.
  • The nose warms, cleanses, and humidifies air before it enters lungs.
  • Vibrational sounds originating in the larynx lead to vocalization.
  • The lower respiratory tract consists of the bronchi, bronchioles, alveolar ducts, and alveoli.
  • Gas exchange takes place in the bronchioles.
  • The prior passages are the anatomic dead space, since they are only conducting passageways.
  • Surfactant is a lipoprotein that helps to keep the alveoli open.
  • Contraction of the diaphragm, the major muscle of respiration, results in decreased intrathoracic pressure, allowing air to enter the lungs.

Physiology of Respiration

• Ventilation involves inspiration (movement of air into the lungs) and expiration (movement of air out of the lungs).
• Inspiration is an active process, involving muscle contraction.
• Expiration is a passive process. When elastic recoil is reduced, expiration becomes a more active, labored process.
• In adults, a normal tidal volume (Vt), or volume of air exchanged with each breath, is about 500 ml.
• When compliance, or a measure of the ease of lung expansion, is decreased, the lungs are more difficult to inflate.
• Arterial blood gases (ABGs) are measured to determine oxygenation status and acid-base balance. ABG analysis includes measurement of the PaO 2 , PaCO 2 , acidity (pH), and bicarbonate (HCO 3 – ) in arterial blood.
• Arterial oxygen saturation can be monitored continuously using a pulse oximetry probe on the finger, toe, ear, or bridge of the nose.

Control of Respiration

• The respiratory center in the brainstem medulla responds to chemical and mechanical signals from the body.
• A chemoreceptor is a receptor that responds to a change in the chemical composition (PaCO 2 and pH) of the fluid around it.
• Mechanical receptors are stimulated by a variety of physiologic factors, such as irritants, muscle stretching, and alveolar wall distortion.
• The respiratory defense mechanisms include filtration of air, the mucociliary clearance system, the cough reflex, reflex bronchoconstriction, and alveolar macrophages.

GERONTOLOGIC CONSIDERATIONS: EFFECTS OF AGING ON RESPIRATORY SYSTEM

• Age-related changes in the respiratory system can be divided into alterations in structure, defense mechanisms, and respiratory control.
• There is much variability in the extent of these changes in persons of the same age. The elderly patient who has a significant smoking history, is obese, and is diagnosed with a chronic illness is at greatest risk of adverse outcomes.

ASSESSMENT OF RESPIRATORY SYSTEM

• Use judgment in determining whether all or part of the history and physical examination will be completed based on problems presented by the patient and the degree of respiratory distress. If respiratory distress is severe, only obtain pertinent information and defer a thorough assessment until the patient’s

condition stabilizes.

• A health history for the respiratory system consists of assessment of past health history, medications, surgery or other treatments, family health history, psychosocial history, and a review of systems using functional health patterns.

• Explore and document common signs of respiratory problems (e.g., cough, dyspnea). Describe the course of the patient’s illness, including when it began, the type of symptoms, and factors that alleviate or aggravate these symptoms.
• A cough should be evaluated by the quality of the cough and sputum.
• Vital signs should be obtained prior to the physical examination. During physical examination, the nose, mouth, pharynx, neck, thorax, and lungs should be assessed and the respiratory rate, depth, and rhythm should be observed.
• When listening to the lung sounds, there are three normal breath sounds: vesicular, bronchovesicular, and bronchial.
• Adventitious sounds are extra breath sounds that are abnormal and include crackles, rhonchi, wheezes, and pleural friction rub.

DIAGNOSTIC STUDIES OF RESPIRATORY SYSTEM

• Sputum studies are examined to identify infecting organisms or to confirm a diagnosis.
• Skin tests are performed to test for allergic reactions or exposure to tuberculosis or fungi.
• A chest x-ray is the most commonly used test for assessment of the respiratory system, as well as the progression of disease and response to treatment.
• Bronchoscopy is a procedure in which the bronchi are visualized through a fiberoptic tube. It may be used for diagnostic purposes to obtain biopsy specimens and assess changes resulting from treatment.
• Thoracentesis is the insertion of a large bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space.
• Pulmonary function tests (PFTs) measure lung volumes and airflow.
• The results of PFTs are used to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.
• In the acute setting, PFT parameters are used to determine the need for mechanical ventilation.
• Exercise testing is used in diagnosis, measuring functional capacity and response to treatment, and in determining level of activity tolerance.

Chapter 27: Nursing Management: Upper Respiratory Problems

PROBLEMS OF NOSE AND PARANASAL SINUSES

• A deviated septum is a deflection of the normally straight nasal septum that is most commonly caused by trauma to the nose or congenital disproportion.
• If a nasal fracture is present, nursing responsibilities including assessing the patient’s ability to breathe and ascertaining that hemorrhage and leakage of cerebrospinal fluid (CSF) is not present.
• Rhinoplasty , the surgical reconstruction of the nose, is performed for cosmetic reasons or to improve airway function when trauma or developmental deformities result in nasal obstruction.
• Epistaxis has a wide variety of causes. Simple measures, including direct pressure with the patient upright, should be tried first. - If bleeding does not stop, application of a vasoconstrictive agent, packing, or cauterization may be warranted. - Monitoring respiratory status is a critical nursing responsibility if the patient has nasal packing.
• Allergic rhinitis is the reaction of the nasal mucosa to a specific allergen.
  • It is classified as either intermittent, with symptoms that are present less than 4 days a week or less than 4 weeks per year, or persistent, with symptoms that are present more than 4 days a week and for more than 4 weeks per year.
  • Specific environmental triggers include pet saliva, dust mites, molds, and cockroaches.
  • Initial manifestations are sneezing; watery, itchy eyes and nose; and thin, watery nasal discharge leading to congestion.
  • The most important step in managing allergic rhinitis involves identifying and avoiding triggers of allergic reactions.

• Medication therapy involves the use of antihistamines, intranasal corticosteroids, and leukotriene receptor antagonists (LTRAs).
• Acute viral rhinitis , also known as common cold, is caused by an adenovirus that invades the upper respiratory tract and often accompanies an acute upper respiratory infection.
• Rest, fluids, proper diet, antipyretics, and analgesics are the recommended management of acute viral

rhinitis.

• During the cold season, advise patients with a chronic illness or a compromised immune status regarding measures to decrease the risk of acquiring a cold.
• In contrast to acute viral rhinitis, the onset of influenza is typically abrupt with systemic symptoms of cough, fever, and myalgia often accompanied by a headache and sore throat.
• Supportive care is directed at preventing pneumonia and other secondary infections and providing relief of symptoms.
• Antivirals such as amantadine (Symmetrel) or rimantadine (Flumadine) are used to prevent and treat influenza. Zanamivir (Relenza) and oseltamivir (Tamiflu) are used to prevent and treat influenza A and B.
• To combat the likelihood of developing influenza, there are two types of flu vaccines available: inactivated; and live, attenuated.
• The nurse should advocate the use of inactivated influenza vaccination in all patients greater than 50 years of age, who are at high risk during routine office visits, or who are hospitalized at the time of discharge.
• Sinusitis develops when the exit from the sinuses is narrowed or blocked by inflammation or swelling of the mucosa. Accumulating secretions provide a rich medium for growth of bacteria, viruses, and fungi, all of which may cause infection.
• Acute sinusitis usually results from an upper respiratory infection, allergic rhinitis, swimming, or dental manipulation. Symptoms include significant pain over the affected sinus, purulent nasal drainage, nasal obstruction, congestion, fever, and malaise.
• Chronic sinusitis lasts longer than 3 weeks and is a persistent infection usually associated with allergies and nasal polyps. Although there may be facial or dental pain, nasal congestion, and increased drainage, severe pain and purulent drainage are often absent.
• Treatment of sinusitis includes supportive care, antibiotics, and the use of ancillary medications to relieve symptoms, including oral or topical decongestants, nasal corticosteroids, and antihistamines.
• Nasal polyps can cause obstruction and speech distortion, necessitating surgical removal.

PROBLEMS OF PHARYNX

• Acute pharyngitis is an acute inflammation of the pharyngeal walls that may include the tonsils, palate, and uvula.
  • Symptoms range in severity from complaints of a ―scratchy throat‖ to pain so severe that swallowing is difficult. Both viral and strep infections appear as a red and edematous pharynx, with or without patchy yellow exudates so appearance is not always diagnostic.
• The goals of nursing management for acute pharyngitis are infection control, symptomatic relief, and prevention of secondary complications.
• Since a peritonsillar abscess—a complication of acute pharyngitis—may threaten the airway, needle aspiration, drainage, or surgery is indicated.

PROBLEMS OF TRACHEA AND LARYNX

• Airway obstruction is a medical emergency. Interventions to reestablish a patent airway include the obstructed airway (Heimlich) maneuver, cricothyroidotomy, endotracheal intubation, and tracheostomy.
• A tracheostomy is the stoma that results from a tracheotomy, or a surgical incision into the trachea for the purpose of establishing an airway.
• Indications for a tracheostomy are to (1) bypass an upper airway obstruction, (2) facilitate removal of secretions, (3) permit long-term mechanical ventilation, and (4) permit oral intake and speech in the patient who requires long-term mechanical ventilation. - A wide variety of tracheostomy tubes are available. While the nurse must provide care specific to the type of tube present, general nursing care for any tracheostomy patient revolves around the diagnoses of ineffective airway clearance, risk for aspiration, impaired verbal communication, and ineffective self-care management.

LARYNGEAL POLYPS

• Polyps on the vocal cords develop as a result of vocal abuse or irritation.

• The most common symptom is hoarseness.
• They are treated conservatively with voice rest and adequate hydration. Surgical removal may be indicated for large polyps, which may cause dyspnea.

HEAD AND NECK CANCER

• This category of tumors arises from the mucosal surfaces of the paranasal sinuses; oral cavity; or nasopharynx, oropharynx, and larynx.
• Early signs and symptoms of head and neck cancer vary with the tumor location. Late stages have easily detectable signs and symptoms, including pain, dysphagia, decreased mobility of the tongue, airway obstruction, and cranial nerve neuropathies.
• Choice of treatment for head and neck cancer is based on medical history, extent of disease, cosmetic considerations, urgency of treatment, and patient choice. - Approximately one third of patients with head and neck cancers have highly confined lesions that are stages I or II at diagnosis. Such patients can undergo radiation therapy or surgery with the goal of cure. - Advanced lesions are treated by a total laryngectomy in which the entire larynx and preepiglottic region is removed and a permanent tracheostomy performed.
• After radical neck surgery, the patient may be unable to take in nutrients through the normal route of ingestion because of swelling, the location of sutures, or difficulty with swallowing. Parenteral fluids will be given for the first 24 to 48 hours.
• Nursing care revolves around the diagnoses of ineffective airway clearance, risk for aspiration, risk for infection, imbalanced nutrition: less than body requirements, pain, impaired verbal communication, and anxiety.

Chapter 28: Nursing Management: Lower Respiratory Problems

LOWER RESPIRATORY TRACT INFECTIONS

ACUTE BRONCHITIS

• Acute bronchitis is an inflammation of the bronchi that usually occurs with a viral upper respiratory infection or in conjunction with chronic obstructive pulmonary disease (COPD).
• It is a self-limiting condition; treatment is supportive.

PERTUSSIS

• It is a highly contagious infection of the lower respiratory tract. Although immunization is available, incidence rates are rising possibly because of waning immunity.
• Pertussis is characterized by a cough that has a ―whooping‖ sound.
• Treatment consists of antibiotics and supportive care.

PNEUMONIA

• Pneumonia is an acute inflammation of the lung parenchyma.
• It can be classified according to the causative microorganism, such as bacteria, viruses, Mycoplasma, fungi, parasites, and chemicals.
• Organisms can reach the lung by three methods: aspiration, inhalation, and homogenous spread from an infection elsewhere in the body.
• A clinically effective way to classify pneumonia:
  • Community-acquired pneumonia is a lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization.
  • Hospital-acquired pneumonia is pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization.
• Aspiration pneumonia refers to the sequelae occurring from abnormal entry of secretions or substances into the lower airway.
• Opportunistic pneumonia occurs in certain patients with altered immune responses who are highly susceptible to respiratory infections.

• There are four characteristic stages of pneumonia: congestion, red hepatization, gray hepatization, and resolution.
• Complications, such as pleural effusion, abscess, and pericarditis, develop more frequently in those with underlying chronic conditions.
• Treatment with antibiotics almost always cures bacterial pneumonia; all patients require supportive measures.
• In the hospital, the nursing role involves identifying the patient at risk and taking measures to prevent the

development of pneumonia. The essential components of nursing care for patients with pneumonia include monitoring physical assessment parameters, facilitating laboratory and diagnostic tests, providing treatment, and monitoring the patient’s response to treatment.

TUBERCULOSIS

• Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, a gram-positive, acid-fast bacillus that is usually spread from person to person via airborne droplets.
• Despite the decline in TB nationwide, there has been a resurgence of TB in those with human immunodeficiency virus (HIV) infection and an emergence of multidrug resistant strains of M. tuberculosis.
• TB can present with a number of complications: the spread of the disease with involvement of many organs simultaneously (military TB), pleural effusion, emphysema, and pneumonia.
• The tuberculin skin test (TST test) using purified protein derivative (PPD) is the best way to screen for a diagnosis M. tuberculosis infection.
• Drug therapy is used to treat an individual with active TB disease. For therapy to be maximally effective, four drugs are used for a 6-month regimen.
• To prevent disease in a TB-infected person with latent TB infection (LTBI), isoniazid (INH) is used alone.
• Patients strongly suspected of having TB should be placed on airborne isolation, receive appropriate drug therapy, and receive an immediate medical workup, including chest x-ray, sputum smear, and culture.
• Nursing care for a patient with TB revolves around the diagnoses of ineffective breathing pattern, imbalanced nutrition, noncompliance, and activity tolerance.

ATYPICALMYCOBACTERIA

• Atypical mycobacteria cause disease that resembles TB, both in manifestations and treatment.
• Disease typically occurs in those who are immunosuppressed or have chronic pulmonary disease.

PULMONARY FUNGAL INFECTIONS

• Infections are found frequently in seriously ill patients being treated with corticosteroids; antineoplastic, immunosuppressive drugs; or multiple antibiotics. They are also found in patients with acquired immunodeficiency syndrome (AIDS) and cystic fibrosis.
• Since these infections are not transmitted from person to person, the patient does not have to be placed in isolation. Antifungal medications are the mainstay of treatment.

NURSING AND COLLABORATIVE MANAGEMENT: LUNG ABSCESS

• A lung abscess is a pus-containing lesion of the lung.
• The causes and pathogenesis of lung abscess are similar to those of pneumonia.
• The onset of a lung abscess is usually insidious, especially if anaerobic organisms are the primary cause. A more acute onset occurs with aerobic organisms.
• Antibiotics given for a prolonged period (up to 2-4 months) are usually the primary method of treatment.

ENVIRONMENTAL LUNG DISEASES

• Environmental or occupational lung diseases are caused or aggravated by workplace or environmental exposure and are preventable.
• Pneumoconiosis is a general term for a group of lung diseases caused by inhalation and retention of dust particles.
• The best approach to management of environmental lung diseases is to try to prevent or decrease environmental and occupational risks.

LUNG CANCER

• Cigarette smoking is the most important risk factor in the development of lung cancer. Smoking is responsible for approximately 80% to 90% of all lung cancers.
• Primary lung cancers are often categorized into two broad subtypes: non–small cell lung cancer (80%) and small cell lung cancer (20%).

• CT scanning is the single most effective noninvasive technique for evaluating lung cancer. Biopsy is necessary for a definitive diagnosis.
• Staging of non–small cell lung cancer is performed according to the TNM staging system. Staging of small cell lung cancer by TNM has not been useful because the cancer is very aggressive and always considered systemic.
• Treatment options are dependent upon the stage of disease.

• Surgical resection is the treatment of choice in non–small cell lung cancer stages I and II, because the disease is potentially curable with resection.
• Radiation therapy may be used as adjuvant therapy after resection or with the intent to cure if the patient is unable to tolerate surgical resection caused by co-morbidities.
• Chemotherapy and targeted therapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery in non–small cell lung cancer.
• The overall goals of nursing management of a patient with lung cancer will include effective breathing patterns, adequate airway clearance, adequate oxygenation of tissues, minimal to no pain, and a realist ic attitude toward treatment and prognosis.

OTHER TYPES OF LUNG TUMORS

• Secondary lung tumors are rare, accounting for only 5% of lung masses. They include chondromas, hamartomas, leiomyomas, and mesotheliomas.
• The lungs are a common site for secondary metastases for a number of cancers.

CHEST TRAUMA AND THORACIC INJURIES PNEUMOTHORAX

• Pneumothorax is air in the pleural space resulting in a partial or complete collapse of the lung. There are several types: - Closed pneumothorax has no associated external wound. The most common form is a spontaneous pneumothorax, which is accumulation of air in the pleural space without an apparent antecedent event. - Open pneumothorax occurs when air enters the pleural space through an opening in the chest wall. Examples include stab or gunshot wounds and surgical thoracotomy. - A tension pneumothorax may be open or closed; there is a rapid accumulation of air in the pleural space causing severely high intrapleural pressures with resultant tension on the heart and great vessels. - Hemothorax is an accumulation of blood in the intrapleural space. Chylothorax is lymphatic fluid in the pleural space caused by a leak in the thoracic duct. Causes of both include trauma, surgical procedures, and malignancy.
• reatment depends on the severity of the pneumothorax and the nature of the underlying disease.

FRACTURED RIBS

• Rib fractures are the most common type of chest injury resulting from blunt trauma.
• Clinical manifestations include pain at the site, especially with inspiration and coughing.
• The main treatment goal is to decrease pain to promote effective breathing. Patients also need to be taught deep breathing, coughing, and use of incentive spirometry.

FLAIL CHEST

• Flail chest results from multiple rib fractures, causing an unstable chest wall. The diagnosis of flail chest is made on the basis of fracture of two or more ribs, in two or more separate locations, causing an unstable segment.
• Initial therapy consists of airway management, adequate ventilation, supplemental oxygen therapy, careful administration of intravenous (IV) solutions, and pain control.
• The definitive therapy is to reexpand the lung and ensure adequate oxygenation.

CHEST TUBES AND PLEURAL DRAINAGE

• The purpose of chest tubes and pleural drainage is to remove the air and fluid from the pleural space and to restore normal intrapleural pressure so that the lungs can reexpand.
• Chest tube malposition is the most common complication.
• Routine monitoring is done by the nurse to evaluate if the chest drainage is successful by observing for tidaling in the water-seal chamber, listening for breath sounds over the lung fields, and measuring the amount of fluid drainage.

CHEST SURGERY

• A thoracotomy, or the surgical opening into the thoracic cavity, is considered major surgery because the incision is large, cutting into bone, muscle, and cartilage. The two types of thoracic incisions are median sternotomy, performed by splitting the sternum, and lateral thoracotomy.
• Video-assisted thoracic surgery (VATS) is a minimally invasive thoracoscopic surgical procedure that in many cases can avoid the impact of a full thoracotomy.

RESTRICTIVE RESPIRATORY DISORDERS

PLEURAL EFFUSION

• Pleural effusion is a collection of fluid in the pleural space. It is not a disease but rather an indication of another disease.
• Pleural effusion is frequently classified as transudative or exudative according to whether the protein content of the effusion is low or high, respectively. A transudate occurs primarily in noninflammatory conditions and is an accumulation of protein-poor, cell- poor fluid. - An exudative effusion is an accumulation of fluid and cells in an area of inflammation. - An empyema is a pleural effusion that contains pus.
• The type of pleural effusion can be determined by a sample of pleural fluid obtained via thoracentesis (a procedure done to remove fluid from the pleural space).
• The main goal of management of pleural effusions is to treat the underlying cause.

PLEURISY

• Pleurisy, or pleuritis, is an inflammation of the pleura. The most common causes are pneumonia, TB, chest trauma, pulmonary infarctions, and neoplasms.
• Treatment of pleurisy is aimed at treating the underlying disease and providing pain relief.

ATELECTASIS

• Atelectasis is a condition of the lungs characterized by collapsed, airless alveoli.
• The most common cause of atelectasis is airway obstruction that results from retained exudates and secretions. This is frequently observed in the postoperative patient.

INTERSTITIAL LUNG DISEASES IDIOPATHIC PULMONARY FIBROSIS

• Idiopathic pulmonary fibrosis is characterized by scar tissue in the connective tissue of the lungs as a sequela to inflammation or irritation.
• The clinical course is variable and the prognosis poor, with a 5-year survival rate of 30% to 50% after diagnosis.
• Although corticosteroids, cytotoxic agents, and antifibrotic agents are used in treating the disease, there is no evidence that their use is effective.

SARCOIDOSIS

• Sarcoidosis is a chronic, multisystem granulomatous disease of unknown cause that primarily affects the lungs. The disease may also involve the skin, eyes, liver, kidney, heart, and lymph nodes.
• The disease is often acute or subacute and self-limiting, but in others it is chronic with remissions and exacerbations.
• Treatment is supportive and aimed at suppressing the inflammatory response.

VASCULAR LUNGDISORDERS PULMONARY EDEMA

• Pulmonary edema is an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs.
• It is considered a medical emergency and may be life-threatening.
• The most common cause of pulmonary edema is left-sided heart failure.

PULMONARY EMBOLISM

• Pulmonary embolism is the blockage of pulmonary arteries by a thrombus, fat, or air emboli, or tumor tissue.
• Most pulmonary embolisms arise from thrombi in the deep veins of the legs.
• The most common risk factors for pulmonary embolism are immobilization, surgery within the last 3 months, stroke, history of deep vein thrombosis, and malignancy.
• Pulmonary infarction (death of lung tissue) and pulmonary hypertension are common complications of pulmonary

embolism.

• It may be diagnosed by spiral CT scan, V/Q scan, and/or pulmonary angiography.
• The objectives of treatment are to prevent further growth or multiplication of thrombi in the lower extremities, prevent embolization from the upper or lower extremities to the pulmonary vascular system, and provide

cardiopulmonary support if indicated.

PULMONARY HYPERTENSION

• Pulmonary hypertension can occur as a primary disease (primary pulmonary hypertension) or as a secondary complication of a respiratory, cardiac, autoimmune, hepatic, or connective tissue disorder (secondary pulmonary hypertension [SPH]).
• Primary pulmonary hypertension is a severe and progressive disease. It is characterized by mean pulmonary arterial pressure greater than 25 mm Hg at rest (normal 12-16 mm Hg) or greater than 30 mm Hg with exercise in the absence of a demonstrable cause.
• Primary pulmonary hypertension is a diagnosis of exclusion. All other conditions must be ruled out.
• Although there is no cure for primary pulmonary, treatment can relieve symptoms, increase quality of life, and prolong life.
• SPH occurs when a primary disease causes a chronic increase in pulmonary artery pressures. Secondary pulmonary hypertension can develop as a result of parenchymal lung disease, left ventricular dysfunction, intracardiac shunts, chronic pulmonary thromboembolism, or systemic connective tissue disease.

COR PULMONALE

• Cor pulmonale is enlargement of the right ventricle resulting from diseases of the lung, thorax, or pulmonary circulation. Pulmonary hypertension is usually a preexisting condition in the individual with cor pulmonale.
• The most common cause of cor pulmonale is COPD.
• The primary management of cor pulmonale is directed at treating the underlying pulmonary problem that precipitated the heart problem.

LUNG TRANSPLANTATION

• There are four types of transplant procedures available: single lung transplant, bilateral lung transplant, heart-lung transplant, and transplant of lobes from living related donor.
• Lung transplant recipients are at high risk for bacterial, viral, fungal, and protozoal infections. Infections are the leading cause of death in the early period after the transplant.
• Immunosuppressive therapy usually includes a three-drug regimen of cyclosporine or tacrolimus, azathioprine (Imuran) or mycophenolate mofetil (CellCept), and prednisone.

Chapter 29: Nursing Management: Obstructive Pulmonary Diseases

ASTHMA

• Asthma is a chronic inflammatory disorder of the airways that results in recurrent episodes of airflow obstruction that it is usually reversible.
• The primary pathophysiologic process in asthma is persistent but variable inflammation of the airways. The airflow is limited because the inflammation results in bronchoconstriction, airway hyperresponsiveness (hyperreactivity), and edema of the airways.
• Although the exact mechanisms that cause asthma remain unknown, often exposure to a trigger, such as an

allergen or irritant, initiates the inflammatory cascade. Respiratory infections are also precipitating factors of an acute asthma attack.

• Common allergens include tree or weed pollen, dust mites, molds, animals, feathers, and cockroaches.
• Asthma that is induced or exacerbated after physical exertion is called exercise-induced asthma.
• Various air pollutants, cigarette or wood smoke, vehicle exhaust, elevated ozone levels, sulfur dioxide,

and nitrogen dioxide can trigger asthma attacks.

• Occupational asthma occurs after exposure to agents of the workplace. These agents are diverse and include wood dusts, laundry detergents, metal salts, chemicals, paints, solvents, and plastics.
• The characteristic clinical manifestations of asthma are wheezing, cough, dyspnea, and chest tightness, particularly at night or early in the morning. Expiration may be prolonged. Examination of the patient during an acute attack usually reveals signs of hypoxemia.
• Asthma can be classified as mild intermittent, mild persistent, moderate persistent, or severe persistent, based upon current impairment of the patient and their risk for exacerbations.
• Severe acute asthma can result in complications such as rib fractures, pneumothorax, pneumomediastinum, atelectasis, and pneumonia.
• A diagnosis of asthma is usually made based upon the presence of various indicators (e.g., clinical manifestations, health history, pulmonary function tests, and peak flow variability).
• The goal of asthma treatment is to achieve and maintain control of the disease. Established guidelines give direction on the classification of severity of asthma at initial diagnosis and help determine which types of medications are best suited to control the asthma symptoms.
• A stepwise approach to drug therapy is based initially on the asthma severity and then on level of control. Persistent asthma requires daily long-term therapy in addition to appropriate medications to manage acute symptoms.
• Medications are divided into two general classifications: (1) long-term–control medications to achieve and maintain control of persistent asthma, and (2) quick-relief medications to treat symptoms and exacerbations.
• Because chronic inflammation is a primary component of asthma, corticosteroids are more effective in improving asthma control than any other long-term drug. Inhaled (ICS) agents, such as Flovent and Pulmicort, are first-line therapy for patients with persistent asthma.
• Orally administered corticosteroids are indicated for acute exacerbations of asthma. Maintenance doses of oral corticosteroids may be necessary to control asthma in a minority of patients with severe chronic asthma.
• Short-acting inhaled β 2 -adrenergic agonists, including Proventil, are the most effective drugs for relieving acute bronchospasm. They are also used for acute exacerbations of asthma.
• Mast cell stabilizers, including Cromolyn, have weak antiinflammatory effects and are less effective than low-dose ICS. They are not used to treat acute bronchospasm but can be effective in exercise-induced asthma.
• The use of leukotriene modifiers can be used successfully as add-on therapy to reduce (not substitute for) the doses of inhaled corticosteroids.
• Methylxanthine (theophylline) preparations are less effective long-term control bronchodilators as compared with β 2 -adrenergic agonists and carry a high incidence of side effects.
• Anticholinergic agents (e.g., ipratropium [Atrovent], tiotropium [Spiriva]) block the bronchoconstricting influence of parasympathetic nervous system.
• The overall goals are that the patient with asthma will have asthma control as evidenced by minimal symptoms during the day and night, acceptable activity levels (including exercise and other physical activity), maintenance greater than 80% of personal best peak expiratory flow rate (PEFR) or forced expiratory volume in 1 second (FEV 1 ), few or no adverse effects of therapy, no recurrent exacerbations of asthma, and adequate knowledge to participate in and carry out management.
• Education remains the cornerstone of asthma management. Your role in preventing asthma attacks or decreasing the severity focuses primarily on teaching the patient and caregiver.
• One of the major factors determining success in asthma management is the correct administration of drugs.
• Inhalation devices include metered-dose inhalers, dry powder inhalers, and nebulizers.
• Teaching should include information about medications, including the name, purpose, dosage, method of administration, schedule, side effects, appropriate action if side effects occur, how to properly use and clean devices, and consequences for breathing if not taking medications as prescribed.
• Several nonprescription combination drugs are available over the counter. An important teaching responsibility is to warn the patient about the dangers associated with nonprescription combination drugs.

• A goal in asthma care is to maximize the ability of the patient to safely manage acute asthma episodes via an asthma action plan developed in conjunction with the health care provider. An important nursing goal during an acute attack is to decrease the patient’s sense of panic.
• Written asthma action plans should be developed together with the patient and family, especially with moderate or severe persistent asthma or a history of severe exacerbations.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

• Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. It is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.
• In addition to cigarette smoke, occupational chemicals, air pollution, severe recurring respiratory infections, and α 1 -antitrypsin deficiency (an autosomal recessive disorder) are risk factors for developing COPD.
• Some degree of emphysema is common in the lungs of the older person caused by changes in the lung structure and the respiratory muscles, even in a nonsmoker.
• The term chronic obstructive pulmonary disease encompasses two types of obstructive airway diseases: chronic bronchitis and emphysema. - Chronic bronchitis is the presence of chronic productive cough for 3 months in each of 2 consecutive years in a patient in whom other causes of chronic cough have been excluded. - Emphysema is an abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
• COPD is characterized by chronic inflammation found in the airways, lung parenchyma (respiratory bronchioles and alveoli), and pulmonary blood vessels.
• The pathogenesis of COPD is complex and involves many mechanisms. The defining features of COPD are irreversible airflow limitation during forced exhalation caused by loss of elastic recoil and airflow obstruction caused by mucus hypersecretion, mucosal edema, and bronchospasm. Gas exchange abnormalities result in hypoxemia and hypercarbia.
• A diagnosis of COPD should be considered in any patient who has symptoms of cough, sputum production, or dyspnea, and/or a history of exposure of risk factors for the disease. An intermittent cough, which is the earliest symptom, usually occurs in the morning with the expectoration of small amounts of sticky mucus resulting from bouts of coughing.
• COPD can be classified as mild, moderate, severe, and very severe, depending on the severity of the obstruction.
• Complications of COPD include the following:
  • Cor pulmonale is hypertrophy of the right side of the heart, with or without heart failure, resulting from pulmonary hypertension and is a late manifestation of chronic pulmonary heart disease.
  • Exacerbations of COPD are signaled by a change in the patient’s usual dyspnea, cough, and/or sputum that is different than the usual daily patterns. These flares require changes in management.
  • Patients with severe COPD who have exacerbations are at risk for the development of respiratory failure.
  • The incidence of peptic ulcer disease is increased in the person with COPD.
  • Anxiety and depression can complicate respiratory compromise and may precipitate dyspnea and hyperventilation.
• The diagnosis of COPD is confirmed by pulmonary function tests.
  • Goals of the diagnostic workup are to confirm the diagnosis of COPD via spirometry, evaluate the severity of the disease, and determine the impact of disease on the patient’s quality of life.
  • When the FEV 1 /FVC ratio is less than 70%, it suggests the presence of obstructive lung disease.
• The primary goals of care for the COPD patient are to prevent disease progression, relieve symptoms and improve exercise tolerance, prevent and treat complications, promote patient participation in care, prevent and treat exacerbations, and improve quality of life and reduce mortality.
• Cessation of cigarette smoking in all stages of COPD is the single most effective and cost-effective intervention to reduce the risk of developing COPD and stop the progression of the disease.
• Although patients with COPD do not respond as dramatically as those with asthma to bronchodilator therapy, a reduction in dyspnea and an increase in FEV 1 are usually achieved with bronchodilator therapy. Presently no drug modifies the decline of lung function with COPD.
• O 2 therapy is frequently used in the treatment of COPD and other problems associated with hypoxemia. Long- term O 2 therapy improves survival, exercise capacity, cognitive performance, and sleep in hypoxemic patients. - O 2 delivery systems are classified as low- or high-flow systems. Most methods of O 2 administration are low-flow devices that deliver O 2 in concentrations that vary with the person’s respiratory pattern. - Dry O 2 has an irritating effect on mucous membranes and dries secretions. Therefore it is important that

O 2 be humidified when administered, either by humidification or nebulization.

• Three different surgical procedures have been used in severe COPD.
  • Lung volume reduction surgery is used to reduce the size of the lungs by removing about 30% of the most diseased lung tissue so the remaining healthy lung tissue can perform better.

• A bullectomy is used for certain patients and can result in improved lung function and reduction in dyspnea.
• In appropriately selected patients with very advanced COPD, lung transplantation improves functional capacity and enhances quality of life.
• Airway clearance techniques include breathing retraining, effective cough techniques, and chest physiotherapy.
• Pursed-lip breathing is a technique that is used to prolong exhalation and thereby prevent bronchiolar collapse and air trapping.
• Effective coughing conserves energy, reduces fatigue, and facilitates removal of secretions. Huff coughing is an effective technique that the patient can be easily taught.
• Chest physiotherapy consists of percussion, vibration, and postural drainage.
• Weight loss and malnutrition are commonly seen in the patient with severe emphysematous COPD. The patient with COPD should try to keep body mass index (BMI) between 21-25 kg/m^2.
• The patient with COPD will require acute intervention for complications such as exacerbations of COPD, pneumonia, cor pulmonale, and acute respiratory failure.
• Pulmonary rehabilitation should be considered for all patients with symptomatic COPD or having functional limitations. The overall goal is to increase the quality of life.
• Walking is by far the best physical exercise for the COPD patient. Also, adequate sleep is extremely important.

OXYGEN THERAPY

• O 2 therapy is frequently used in the treatment of COPD and other problems associated with hypoxemia. Long-term O 2 therapy improves survival, exercise capacity, cognitive performance, and sleep in hypoxemic patients.
• Goals for O 2 therapy are to reduce the work of breathing, maintain the PaO 2 , and/or reduce the workload on the heart, keeping the SaO 2 >90% during rest, sleep, and exertion, or PaO 2 >60 mm Hg.
• O 2 delivery systems are classified as low- or high-flow systems. Most methods of O 2 administration are low-flow devices that deliver O 2 in concentrations that vary with the person’s respiratory pattern.
• Dry O 2 has an irritating effect on mucous membranes and dries secretions. Therefore it is important that O 2 be humidified when administered, either by humidification or nebulization.
• Medical complications associated with oxygen therapy include CO 2 narcosis, oxygen toxicity, infection, and absorption atelectasis. The risk of combustion related injury is also a possibility requiring specific precautions for patient safety.

CYSTIC FIBROSIS

• Cystic fibrosis (CF) is an autosomal-recessive, multisystem disease characterized by altered function of the exocrine glands primarily involving the lungs, pancreas, and sweat glands.
• Initially, CF is an obstructive lung disease caused by the overall obstruction of the airways with mucus. Later, CF also progresses to a restrictive lung disease because of the fibrosis, lung destruction, and thoracic wall changes.
• The major objectives of therapy in CF are to promote clearance of secretions, control infection in the lungs, and provide adequate nutrition.
• Nursing care for the patient with CF revolves around the diagnoses of ineffective airway clearance, impaired gas exchange, ineffective breathing patterns, imbalanced nutrition, and ineffective coping,

BRONCHIECTASIS

• Bronchiectasis is characterized by permanent, abnormal dilation of one or more large bronchi. The pathophysiologic change that results in dilation is destruction of the elastic and muscular structures supporting the bronchial wall.
• The hallmark of bronchiectasis is persistent or recurrent cough with production of large amounts of purulent sputum that may exceed 500 ml/day.
• Bronchiectasis is difficult to treat. Therapy is aimed at treating acute flare-ups and preventing decline in lung function.
• Antibiotics are the mainstay of treatment and are often given empirically, but attempts are made to culture the sputum. Long-term suppressive therapy with antibiotics is reserved for those patients who have symptoms that recur a few days after stopping antibiotics.

• An important nursing goal is to promote drainage and removal of bronchial mucus. Rest, good nutrition, and adequate hydration are also important.

Chapter 30: Nursing Assessment: Hematologic System STRUCTURESAND FUNCTIONS OFHEMATOLOGIC SYSTEM

• Hematology is the study of blood and blood-forming tissues. This includes the bone marrow, blood, spleen, and lymph system.
• Blood cell production (hematopoiesis) occurs within the bone marrow. Bone marrow is the soft material that fills the central core of bones.
• Blood is a type of connective tissue that performs three major functions: transportation, regulation, and protection. There are two major components of blood: plasma and blood cells.
• Plasma is composed primarily of water, but it also contains proteins, electrolytes, gases, nutrients, and waste.
• There are three types of blood cells: erythrocytes (RBCs), leukocytes (WBCs), and thrombocytes (platelets).
• Erythrocytes are primarily composed of a large molecule called hemoglobin. Hemoglobin, a complex protein-iron compound composed of heme (an iron compound) and globin (a simple protein), functions to bind with oxygen and carbon dioxide.
• Leukocytes (WBCs) appear white when separated from blood. There are five different types of leukocytes, each of which has a different function. - Granulocytes: The primary function of the granulocytes is phagocytosis , a process by which WBCs ingest or engulf any unwanted organism and then digest and kill it. The neutrophil is the most common type of granulocyte. - Lymphocytes: The main function of lymphocytes is related to the immune response. Lymphocytes form the basis of the cellular and humoral immune responses. - Monocytes: Monocytes are phagocytic cells. They can ingest small or large masses of matter, such as bacteria, dead cells, tissue debris, and old or defective RBCs.
• The primary function of thrombocytes, or platelets , is to initiate the clotting process by producing an initial platelet plug in the early phases of the clotting process.
• Hemostasis is a term used to describe the blood clotting process. This process is important in minimizing blood loss when various body structures are injured.
• Four components contribute to normal hemostasis: vascular response, platelet plug formation, the development of the fibrin clot on the platelet plug by plasma clotting factors, and the ultimate lysis of the clot.
• The spleen, which is located in the upper left quadrant of the abdomen, has four major functions: hematopoietic, filtration, immunologic, and storage.
• The lymph system—consisting of lymph fluid, lymphatic capillaries, ducts, and lymph nodes—carries fluid from the interstitial spaces to the blood.

GERONTOLOGIC CONSIDERATIONS: EFFECTS OFAGING ON HEMATOLOGIC SYSTEM

• Hemoglobin levels begin to decrease in both men and women after middle age. The osmotic fragility of RBCs is increased in the older person.
• The total WBC count and differential are generally not affected by aging. However, a decrease in humoral antibody response and decrease in T-cell function may occur.

ASSESSMENT OF HEMATOLOGIC SYSTEM

• A health history for the hematopoietic system consists of biographic and demographic data, current health, past health history, past and current use of medications, surgical history, herbal preparations and nutritional supplements, family health history, and review of systems using functional health patterns.
• A complete physical examination is necessary to accurately examine all systems that affect or are affected by the hematologic system, depending on the nature of the patient’s problem, including an assessment of lymph nodes, liver, spleen, and skin.

DIAGNOSTIC STUDIES OF HEMATOLOGIC SYSTEM

• The most direct means of evaluating the hematologic system is through laboratory analysis and other diagnostic studies.

• The complete blood count (CBC) involves several laboratory tests, each of which serves to assess the three major blood cells formed in the bone marrow.

• Erythrocyte sedimentation rate (ESR, or ―sed rate‖) measures the sedimentation or settling of RBCs and is used as a nonspecific measure of many diseases, especially inflammatory conditions.
• The laboratory tests used in evaluating iron metabolism and differentiating anemias include measuring serum levels of iron, total iron-binding capacity (TIBC), serum ferritin, and transferrin saturation.
• Radiologic studies for the hematology system involve primarily the use of computed tomography (CT) or magnetic resonance imaging (MRI) for evaluating the spleen, liver, and lymph nodes.
• Bone marrow examination is important in the evaluation of many hematologic disorders. The examination of the marrow may involve aspiration only or aspiration with biopsy. After a bone marrow aspiration and biopsy, the site must be assessed frequently on the day of the procedure and for several days thereafter. Clients can experience some discomfort or pain and can require a mild analgesic.
• Lymph node biopsy involves obtaining lymph tissue for histologic examination to determine the diagnosis, and to help for planning therapy.
• Testing for specific genetic or chromosomal variations in hematologic conditions is often helpful in assisting in diagnosis and staging. These results also help to determine the treatment options and prognosis.

Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome ACUTE RESPIRATORY FAILURE

• Respiratory failure results when gas exchange, which involves the transfer of oxygen (O 2 ) and carbon dioxide (CO 2 ) between the atmosphere and the blood, is inadequate.
• Respiratory failure is not a disease; it is a condition that occurs as a result of one or more diseases involving the lungs or other body systems. The major threat of respiratory failure is the inability of the lungs to meet the oxygen demands of the tissues.
• Respiratory failure can be classified as hypoxemic or hypercapnic.
  • Hypoxemic respiratory failure is commonly defined as a PaO 2 ≤60 mm Hg when the patient is receiving an inspired O 2 concentration ≥60%. 1 • Disorders that interfere with O 2 transfer into the blood include pneumonia, pulmonary edema, pulmonary emboli, heart failure, shock, and alveolar injury related to inhalation of toxic gases and lung damage related to alveolar stress/ventilator-induced lung injury. 2 •Four physiologic mechanisms may cause hypoxemia and subsequent hypoxemic respiratory failure: V/Q mismatch ; shunt; diffusion limitation; and hypoventilation. 1 o In hypercapnic respiratory failure, or ventilatory failure, the primary problem is insufficient CO 2 removal. 1 ♣ It is commonly defined as a PaCO 2 >45 mm Hg in combination with acidemia (arterial pH <7.35). 2 ♣ Disorders that compromise CO 2 removal include drug overdoses with central nervous system (CNS) depressants, neuromuscular diseases, acute asthma, chronic obstructive pulmonary disease (COPD) exacerbations, and trauma or diseases involving the spinal cord and its role in lung ventilation. 1 • The manifestations of respiratory failure are related to the extent of change in PaO 2 or PaCO 2 , the rapidity of change (acute versus chronic), and the ability to compensate to overcome this change.
    • A change in mental status is frequently the initial indication of respiratory failure.
    • Other early signs include tachycardia, tachypnea, and mild hypertension.
    • A severe morning headache may suggest nighttime hypercapnia.
• Hypoxemia occurs when the amount of O 2 in arterial blood is less than the normal value, and hypoxia occurs when the PaO 2 falls sufficiently to cause signs and symptoms of inadequate oxygenation. - Hypoxemia can lead to hypoxia if not corrected. - Cyanosis is an unreliable indicator of hypoxemia and is a late sign of respiratory failure.

Specific Clinical Manifestations

• The patient may have a rapid, shallow breathing pattern or a respiratory rate that is slower than normal. A change from a rapid rate to a slower rate suggests progression of respiratory muscle fatigue and increased probability of respiratory arrest.
• Other signs that give indicators of the efforts associated with breathing include: