Medsurg and patho Exam 2

• Hypoventilation


  Air delivered to alveoli is insufficient to provide O2 and remove CO2, resulting in ↑PaCO2 & hypoxemia
• Causes of hypoventilation


  • Drugs such as morphine and barbiturates
  • Morbid obesity
  • Patient in bed in low Fowler's position
  • Administer O2
  • Obstructive sleep apnea
• Hyperventilation


  Increase of air entering alveoli leads to hypocapnia (PaCO2 <35 mm Hg)
• Causes of hyperventilation


  • Pain
  • Fever
  • Sepsis
  • Anxiety
  • Obstructive & restrictive lung diseases
  • High altitude —> mountain climbing
• Aspiration


  Inhalation of foreign material, secretions or stomach contents
• Aspiration pneumonia


  Develops after inhalation of colonized oral or pharyngeal material, causing acute inflammatory response and blockage if stomach contents
• Prevention of aspiration


  • Monitor LOC, reflexes & swallowing difficulty
  • HOB elevated semi Fowler's for continuous feeding
  • Minimal sedatives
  • Enteral tube feeding- confirm location by checking residual
  • Ensure swallow study
  • ETT cuff pressure maintained
• Sleep apnea


  Obstruction of airflow during sleep, leading to frequent episodes of obstructive breathing
• Causes of sleep apnea


  • Neurologic origin
  • Obesity- most common cause
  • Large uvula
  • Short neck
  • Smoking
  • Enlarged tonsils
  • Obstruction by soft palate or tongue
• Signs and symptoms of sleep apnea


  • Loud snoring —> spouse tends to report it
  • Excessive daytime sleepiness
  • Frequent episodes of obstructive breathing during sleep
  • Morning headache
  • Unrefreshing sleep
  • Dry mouth upon awakening
• Diagnosis of sleep apnea

  Sleep study
• Treatments for sleep apnea


  • Nonsurgical: CPAP, weight loss, change sleep position, drug therapy
  • Surgical: Adenoidectomy, uvlectomy, remodeling posterior oropharynx, tracheostomy
• Chronic Obstructive Pulmonary Disease (COPD)


  Preventable & treatable slowly progressive respiratory disease of airflow obstruction involving airways, pulmonary parenchyma, or both

  
• COPD


  • ↓ Lung function (vital capacity & FEV-1)
  • Progressive airflow limitation
  • Inflammation
  • ↑ goblet cells & enlarged submucosal gland (hypersecretion of mucus)
  • Scar tissue formation
  • Alveolar wall destruction
  • Thickening & lining of vessel
• Types of COPD


  • Emphysema: Pink Puffer
  • Chronic Obstructive Bronchitis: Blue bloater
• Emphysema


  Destructive changes of alveolar walls w/o fibrosis, damage is irreversible
• Causes of emphysema


  • Smoking > 70 packs/year
  • Certain occupations (mining, welding, working with or near asbestos)
  • Genetic α 1- Antitrypsin deficiency
• Pathophysiology of emphysema

  Smoking causes alveolar damage, inflammation leads to release of proteolytic enzymes, reduction in pulmonary capillary bed, loss of elastic tissue in lung, air becomes trapped in distal alveoli, loss of alveolar wall & air trapping leads to bullae formation

  
• Clinical manifestations of emphysema


  • Progressive, exertional dyspnea- use of accessory muscles
  • Cough (minimal or absent)
  • Thin, wasted individual hunched forward
  • ↓breath sounds, lack of crackles & rhochi
  • ↓PaCO2 - typically in 80s
  • Chronic morning cough, prolonged expiration
  • Digital clubbing
  • Barrel chest (round chest) from loss of elastic tissue due to chronic hyperinflation—> air trapping
  • Hyperresonance
  • Pursed lip breathing
  • Wheezing
  • Tripod position

  
• Chronic Obstructive Bronchitis

  Chronic or recurrent productive cough > 3 months (> 2+ successive years), persistent, irreversible when paired with emphysema

  
• Causes of chronic obstructive bronchitis


  • Cigarette smoking (90%)
  • Repeated airway infections
  • Genetic predisposition
  • Inhalation of physical or chemical irritants

  
• Clinical manifestations of chronic obstructive bronchitis


  • Typical patient is overweight due to peripheral edema from right-sided heart failure (cor pulmonale)
  • Commonly associated with emphysema
  • SOB on exertion
  • Excessive sputum
  • Chronic cough (more severe in morning )
  • Edema, hypervolemia
  • Cor pulmonale
  • Cyanosis (late sign)
  • Secondary polycythemia
  • Elevated hemoglobin levels

  
• Diagnostic tests for COPD


  • Chest x-ray
  • History & physical —> determining cause
  • ABGs
  • Pulmonary function test
  • Electrocardiogram
• Medical management of COPD


  • Improve ventilation: Bronchodilators, Corticosteroids, Remove bronchial secretions —> Mucolytics, Pursed lip breathing, Oxygen therapy
  • Improve general health: Prevent weight loss, Nutrition, Promote exercise —> assess activity tolerance with and without use of oxygen
  • Control complications: Hypoxemia/ tissue anoxia, Acidosis, Respiratory infections, Cardiac failure

  
• Patient education for COPD

  • Low Fowler's position to maximize diaphragm breathing
  • Familiarity with prescribed medications' potential side effects
  • S/s if infection
  • Smoking cessation
  • Increase exercise tolerance & prevent further loss of pulmonary function
  • Avoid heat and cold
  • Rest and sleep schedule
• Sarcoidosis


  Interstitial lung disease (not the airways), hypersensitivity response to bacteria, fungi, virus, chemicals in people w/ an inherited or acquired predisposition to the disorder
• Pathophysiology of sarcoidosis

  • Inflammatory response, development of multiple, uniform, noncaseating epithelial granulomas, abnormal T-cell function, affects multiple organs

  
• Clinical manifestations of sarcoidosis


  • Malaise
  • Fatigue
  • Weight loss
  • Fever
  • Dyspnea of insidious onset w/ dry, nonproductive cough
  • Erythema Nodosum, macules, papules, hyperpigmentation & subcutaneous nodules
  • Hepatosplenomegaly
  • Lymphadenopathy
• Diagnostic tests for sarcoidosis


  • Chest x-ray, CT —> bilateral hilar adenopathy
  • Transbronchial biopsy- noncaseating granulomas (definitive diagnosis)
  • Pulmonary function test
  • ABGs
  • Leukemia, anemia
  • ↑eosinophils, elevated sedimentation rate
  • Elevated liver enzymes (when liver involved)
  • ↑calcium (hypercalcemia) - excess vitamin D from macrophages
• Medical management of sarcoidosis


  • Longterm corticosteroids (prednisone)
  • Unwanted effects from long term steroids: Hypoglycemia, Hypokalemia —> low potassium, risk for cardiac dysrhythmias, Immunosuppression —> higher risk for infection, Weight gain
  • Immune modulators: work by targeting specific parts of the immune system to regulate its activity, Reduce inflammation and control symptoms
• Hypersensitivity pneumonitis


  Exposure to allergens causes antigen-antibody complexes to elicit granulomatous inflammation leading to lung tissue injury and diffuse pulmonary fibrosis in upper lobes
• Characteristics of hypersensitivity pneumonitis


  • NONSMOKERS (80-90%)- occupational workers
• Kyphoscoliosis


  Characterized by elevation of scalpels & a corresponding S-shaped spine, limits lung expansion within thorax —> thorax is not symmetrical
• Causes of kyphoscoliosis


  • Idiopathic
  • Neuromuscular - causes from loss of muscle mass or weakness —> muscular dystrophy
  • Congenital
• Pathophysiology of kyphoscoliosis


  • Bone deformity in chest wall resulting from kyphosis and scoliosis, higher deformity in vertebral column, greater compromise of respiratory status, lung volumes compressed leading to atelectasis, mismatch, hypoxemia
• Clinical manifestations of kyphoscoliosis


  • SOB
  • Dyspnea on exertion
  • Rapid, shallow breathing
  • Chest well deformity
  • Ribs protruding backward, flaring on convex side, crowded on concave side
  • Hypoxemia, CO2 retention (late)
• Diagnostic tests for kyphoscoliosis


  • Screening for scoliosis & Kyphoscoliosis in school-aged children
  • PFTs, chest x-ray
• Nursing care for kyphoscoliosis


  • Educate on mobility & chest expansion, pain management
• Medications for kyphoscoliosis

  • Opioids and NSAIDS
• Ankylosing spondylitis


  Chronic & inflammatory disease of the spine, cause unknown