RESPIRATORY DISORDERS General Respiratory Anatomy and Physiology 1.

respiratory The system is comprised of the upper airway and lower airway structures. 2. The upper respiratory system filters, moistens and warms air during inspiration. 3. The lower respiratory system enables the exchange of gases to regulate serum PaO2, PaCO2 and Ph. Upper Respiratory A. Nose and sinuses 1. Filters, warms and humidifies air 2. First defense against foreign particles 3. Inhalation for deep breathing is to be done via nose 4. Exhalation is done through the mouth B. Pharynx 1. Behind oral and nasal cavities 2. Nasopharynx a. behind nose b. soft palate, adenoids and eustachian tube 3. Oropharynx a. from soft palate to base of tongue b. palatine tonsils 4. Laryngopharynx a. base of tongue to esophagus b. where food and fluids are separated from air c. bifurcation of larynx and esophagus C. Larynx 1. Between trachea and pharynx 2. Commonly called the voice box 3. Thyroid cartilage - Adam's apple 4. Cricoid cartilage a. contains vocal cords b. the only complete ring in the airway 5. Glottis - opening between vocal cords 6. Epiglottis - covers airway during swallowing III. Lower Respiratory and Other Structures A. Trachea 1. Anterior neck in front of esophagus USJR NURSING MS TEAM 2010 Page 1

2. Carries air to lungs B. Mainstem bronchi 1. Right and left 2. Right is more vertical, so right middle lobe is more likely to receive aspirate into it with the result of aspiraton pneumonia, which is more commonly found in elderly populations C. Conducting airways 1. Lobar bronchi a. surrounded by blood vessels, lymphatics, nerves b. lined with ciliated, columnar epithelial cell c. cilia move mucus or foreign substances up to larger airways 2. Bronchioles a. no cartilage; collapse more easily b. no cilia c. do not participate in gas exchange D. Alveolar ducts and alveoli 1. Lungs contain approximately 300 million alveoli 2. Alveoli surrounded by capillary network 3. Gas exchange area (blood takes O2, gives off CO2) 4. Gas exchange happens at alveolar-capillary membrane (al-cap memb) 5. Held open by surfactant which decreases surface tension to minimize alveolar collapse E. Accessory muscles of respiration 1. Scalene muscles - elevate first two ribs 2. Sternocleidomastoid - raise sternum 3. Trapezius and pectoralis - stabilize shoulders 4. Abdominal muscles - puts power into cough and used most often with chronic respiratory problems and acute severe respiratory distress Physiology Basic gas-exchange unit of the respiratory system is the alveoli. Alveolar stretch receptors respond to inspiration by sending signals to inhibit inspiratory neurons in the brain stem to prevent lung over distention. During expiration stretch receptors stop sending signals to inspiratory neurons and inspiration is ready to start again. Oxygen and carbon dioxide are exchanged across the alveolar capillary membrane by process of diffusion.

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Neural control of respirations is located in the medulla. The respiratory center in the medulla is stimulated by the concentration of carbon dioxide in the blood. Chemoreceptors, a secondary feedback system, located in the carotid arteries and aortic arch respond to hypoxemia. These chemoreceptors also stimulate the medulla. Ph regulation Blood Ph (partial pressure of hydrogen in blood): a decrease in blood Ph stimulates respiration hyperventilation, both through the neurons of the brain's respiratory center and through the chemoreceptors in carotid arteries and aortic arch. Blood PaCO2 (partial pressure of carbon dioxide in arterial blood): an increase in the PaCO2 results in decreased blood Ph, and stimulates respiration as described above. Blood PaO2 (partial pressure of oxygen in arterial blood): a decrease in the PaO2 results in a decreased blood Ph, stimulating respiration as described above. When arterial Ph rises or the arterial PaCO2 falls, hypoventilation occurs. DIAGNOSTIC PROCEDURE Pulmonary Function Test Measures lung volumes, lung mechanics, and diffusion capabilities of the lungs Also includes ventilation tests of forced expiratory volume, vital capacity and maximal voluntary ventilation measures Functional Residual Capacity volume of air that remains in the lungs after a normal quiet exhalation Residual Volume volume of air that remains in the lungs after a forceful exhalation Vital Capacity maximum volume of air that can be exhaled after a maximum exhalation Tidal Volume volume of air inhaled and exhaled with normal quiet breathing Inspiratory Reserve Volume maximum volume that can be inhaled following a normal quiet breathing Expiratory Reserve Volume maximum volume that can be exhaled following a normal quiet breathing Pulse Oximetry Passes a beam of light through the tissues, and a sensor attached to the finger tip, toe, or ear lobe measures the amount of light absorbed by oxygensaturated hemoglobin Non-invasive and continuously monitored Arterial Blood Gas Analysis Measures PaO2, PaCO2, pH, Sa O2, and HCO3 Assesses ventilation and acid-base balance Commonly uses the radial artery Allens test is performed before sample is drawn Pre-heparinized syringe to prevent clotting of specimen Apply pressure to site for 5-10 mins after withdrawing sample Container with ice to prevent hemolysis of the specimen Ventilation Perfusion Scan Assesses lung ventilation and perfusion

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Radioactive gas (ventilation) or radioactive dye (perfusion) is administered and produces an image of the areas to test for ventilation Confirms pulmonary embolism and other blood flow abnormalities Remain still during the procedure Chest X Ray Contraindicated in pregnant women Performed for: Routine screening procedure Pulmonary disease is suspected Monitor status of respiratory disorders Confirm endotracheal or tracheostomy tube placement After traumatic chest injury Teach client to hold his breath and do deep breathing Remove metals from the chest Shield the gonads during the test MANTOUX TEST PPD (Purified Protein Derivative) is used Signifies exposure to Mycobacterium tubercle bacilli Intradermal route of injection (+) Mantoux test is induration of 10 mm or more Induration of 5 mm is considered positive in immunocompromised patients. Reading result 1. Read 48 72 hours 2. Measure induration only 3. Record in millimeters Fluoroscopy Studies the lung and chest in motion A radiopaque (non-iodine) based contrast agent is administered intravenously to help assess the structures assessed Contraindicated in pregnant women Remove all jewelries and underclothes and put on gown Gallium Scans Radioactive gallium citrate taken up by tumors and areas of inflammation after 24-48 hours of injection Painless except for local pain at injection site Client is in supine and may remain dressed but must remove all metal objects Bronchoscopy Direct inspection and observation of the larynx, trachea and bronchi through a flexible or rigid bronchoscope Uses: To collect secretions To determine location or pathologic process To remove aspirated foreign objects To excise lesions Nursing Care before bronchoscopy Informed consent/permit needed Atropine, valium and topical/local anesthetics NPO 6-8 hours to prevent vomiting and aspiration Remove dentures, prostheses, contact lenses to prevent losses of valuables USJR NURSING MS TEAM 2010 Page 4

Nursing Care after bronchoscopy Side-lying position to promote drainage Check for return of gag reflex Watch for signs of bronchial tree perforation (cyanosis, hypotension, tachycardia, arrythmias, hemoptysis, dyspnea) Laryngoscopy Visual examination of the larynx and is used to diagnose laryngeal papillomas, nodules, polyps or cancer Can be performed during bronchoscopy or as a separate procedure 2 approaches: Direct and Indirect Thoracentesis Nursing Care before thoracentesis Secure consent Take initial VS Position: upright leaning on overbed table, feet supported on foot stool Instruct to remain still, avoid coughing during insertion of needle Pressure sensation is felt upon needle insertion Nursing Care after Thoracentesis Turn to the unaffected side for at least 1 hour to prevent leakage of fluid in the thoracic cavity Bed rest until VS are stable to prevent orthostatic hypotension Endoscopic Thoracotomy Alternative to open-lung biopsy and thoracotomy for pleural surface disorders Has 3 incisions: 1 for the insertion, the other 2 for specimen collection Chest tube is inserted to promote lung reexpansion Advantages: reduced anesthesia time, less pain and shortened hospital stay Informed consent is important Uses general anesthesia Chest tube and deep breathing exercises post-operatively SPUTUM EXAM TYPES Sputum culture and sensitivity test to detect actual microorganism causing the infection Sputum test for gross appearance indicate certain diseases AFB staining for diagnosis of TB collected for 3 consecutive days Cytological examination to detect cancer cells 3-day early morning specimen Random sputum collection Early morning sputum specimen is ideal Rinse mouth with water (do not use astringents Use sterile container Collected before the first dose of antimicrobial Instruct not to spit saliva DISTURBANCES OF THE UPPER AIRWAYS LARYNGEAL TUMORS Types: Risk Factors: Glottic 1. Cigarette smoking Supraglottic 2. Chronic laryngitis Subglottic 3. Vocal abuse 4. Alcohol abuse USJR NURSING MS TEAM 2010 Page 5

5. Familial tendency to laryngeal cancer 6. environmental pollutants DIAGNOSTICS

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Laryngoscopy Biopsy Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Chest Radiography Barium Swallow

Clinical Manifestations Supraglottic Glottic Subglottic Localized throat Hoarseness Dyspnea pain Dyspnea Airway obstruction Burning when Anorexia, anemia, Dysphagia drinking hot liquids weight loss Weight loss or acidic beverages hemoptysis (orange juice) hemoptysis halitosis Mass or Lump in the neck Dysphagia Dyspnea Anorexia, anemia, weight loss Medical Management Radiation Chemotherapy Surgery: Subtotal/Total Laryngectomy Subtotal retains voice Total absolute loss of voice Preop Care Postop Care Psychosocial support Care of a client with tracheostomy Effects of total larynectomy Establish patent airway Loss of voice Prevent infection (Cleanse stoma Permanent tracheostomy and tracheostomy at regular Loss of sense of smell basis, Change dressings and ties Inability to: Blow the nose, Sip as necessary) through straw, Whistle, Gargle, Do Establish means of valsalva maneuver (unable to lift communication heavy objects, constipation) Provide psychosocial support Effective means of communication Assist during speech therapy to be used postop Nursing Interventions Suction nose frequently. Promote pain relief. Promote wound drainage. Administer & monitor tube feedings as ordered. Observe stoma/structure lines for signs of infection. Enhance communication. Support client during adaptation to altered physical status Provide client teaching Tracheostomy/laryngectomy and stoma care Avoid swimming Control of dryness and crusting of the tongue. Need for a humidifier at home. Protect stoma while showering. Avoid use of powder, spray, aerosol near tracheostomy Cover stoma when coughing or sneezing. Necessity of installing smoke detectors. EPISTAXIS Causes: Irritation Trauma Foreign bodies Hypertension Rheumatic Heart Disease USJR NURSING MS TEAM 2010 Page 7

Cancer Blood disorders

Nursing Interventions Sit-up, lean forward, head tipped to prevent aspiration of blood Pressure over the soft tissues of the nose for at least 5 minutes Cold compress/ice pack Liquid diet, then soft diet Avoid oral temperature taking Do not blow nose for 2 days after removal of the nasal pack Notify physician if epistaxis is recurrent Medical Management Cauterization of the vessel with application of silver nitrate Nasal pack with Neosenephrine (3-5 days) Avoid petrolatum gauze packing Application of Posterior plug Surgery: Arterial ligation (last resort) SINUSITIS Inflammation of the sinus PANSINUSITIS infection of more than one sinus CAUSES: Clinical Manifestations URTI Pain Cigarette smoking Maxillary: cheek, upper Allergic rhinitis teeth Impaired mucociliary action Frontal: above eyebrows DIAGNOSTIC TOOLS: Ethmoid: in and around the X-ray eyes CT Scan Sphenoid: behind eye, Transillumation test occiput, top of the head General malaise Stuffy nose Headache Post-nasal drip Persistent cough Fever and Chills Nursing Interventions Rest Increase fluid intake Hot wet packs Irrigation of maxillary sinuses with warm NSS Medical Interventions Codeine, avoid ASA it increases the risk of developing nasal polyps Amoxicillin or other anti-infectives: (acute 7 to 10 days; chronic -21 days) Antihistamines or H1 blockers (Loratidine, Diphenhydramine, Brompheniramine) Nasal Decongestants eg. Dimetapp Expectorants and Mucolytic Agents, Antitussives eg. Codeine Surgery Functional Endoscopic Sinus Surgery (FESS) To reestablish sinus ventilation mucociliary clearance Done as outpatient, local anesthesia or general anesthesia Fiberoptic endoscopes are passed through the nasal cavity Complications: bleeding, pain, scar formation, CSF leak, blindness Nasal packing postop Caldwell Luc Surgery (Radical Antrum Surgery) Incision is done and diseased mucous membrane is removed Do not chew on affected side Caution with oral hygiene to prevent trauma to incision Do not wear dentures for 10 days Do not blow nose for 2 weeks after removal of packing Avoid sneezing for 2 weeks after surgery Ethmoidectomy/Sphenoidectomy Osteoplastic flap surgery for frontal sinusitis PHARYNGITIS Could be viral, bacterial or fungal Beta-hemolytic streptococcus is most common

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Risk Groups: alcoholics, smokers, live and work in dusty places, chronic cough, use their voices excessively Clinical Manifestations: sore throat, difficulty swallowing, fever, malaise, cough, elevated WBC Contagious by droplet spread Management Good handwashing Antimicrobials as ordered Bed rest Fluids and saline gargle Analgesics and antipyretics as ordered TONSILLITIS/ADENOIDITIS Clinical Manifestations Sore throat Fever Snoring Dysphagia Mouth-breathing Earache Frequent head colds Bronchitis Foul breath Voice impairment Noisy respiration Draining ears Nursing Interventions Promote rest Increase fluid intake Warm saline gargle Analgesic as ordered Antimicrobial as ordered Surgery: Tonsillectomy/ Adenoidectomy PreOp Care Assess for URTI. Coughing and sneezing postop may cause bleeding Check Prothromin time. Bleeding is a common postop complication Postop Care Prone, head turned to side, or lateral position (awake: semi Fowlers) Oral airway until swallowing reflex returns Monitor for hemorrhage Frequent swallowing Bright red vomitus Increased PR Throat discomfort between 4th to 8th postop day is expected. This is due to sloughing off of mucous membrane at the operative site Stool: black/dark for few days due to swallowed blood Plenty of rest for 2 weeks Avoid colds, overcrowded public places; coughing and sneezing due to URTI may cause bleeding Client Education: Avoid clearing of throat. This may cause bleeding Avoid coughing, sneezing, blowing nose for 1 to 2 weeks 2 to 3 L of fluids/day until mouth odor disappears Avoid hard/scratchy foods until throat is healed Report signs and symptoms of bleeding Promote comfort Ice collar Acetaminophen Avoid administration of ASA (causes bleeding) Foods and fluids Ice-cold fluids Bland foods PERITONSILLAR ABSCESS Extensive swelling of the soft palate and pharyngeal wall USJR NURSING MS TEAM 2010 Page 9

May arise from acute streptococcal or staphylococcal tonsillitis Clinical Manifestations: drooling, muffled sound, partial obstruction to swallowing Management Surgery if ruptured Antibiotics as ordered Saline or alkaline mouthwashes or gargles RHINITIS Inflammation of nasal mucosa Also called coryza or common cold Classic manifestations: increased nasal drainage, nasal congestion and paroxysmal sneezing Classifications: Acute, Allergic, vasomotor or drug-related Management Humidification Decongestants as ordered Increase oral fluids Symptomatic treatment LARYNGITIS Caused by inflammatory process or vocal abuse or by Gastroesophageal reflux disease Manifestation: Hoarseness of voice Management: Rest of voice Avoid alcohol, caffeine, tobacco Avoid whispering Steroids, antacids and antimicrobials as ordered Outpouchings of mucous membrane lining the nose or paranasal sinuses Causes obstruction to nasal breathing Surgery: Nasal polypectomy (post-op) Humidification Mouth care Nasal packing and ice compress Increase oral fluids Semi- or high Fowlers position DISTURBANCES OF THE LOWER AIRWAYS Asthma Characterized by airway obstruction, inflammation and increased responsiveness to a variety of stimuli Status asthmaticus is a severe life-threatening complication that is refractory to treatment. Trigger Factors Allergens Respiratory infections Exercise Drugs and food additives Emotional stress Clinical Manifestations Wheezing Cough Dyspnea Chest tightness Severely diminished breath sounds Use of accessory muscles Tachycardia Ventricular dysrhythmias Pulsus paradoxus (pulse becomes weaker as one inhales and stronger as one exhales)

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Medical Management Bronchodilators B-adrenergic drugs (metaproterenol, albuterol, isoproterenol, epinephrine, terbutaline) Anticholinergics (ipratropium bromide, atropine) Xanthines (theophylline) Corticosteroids (hydrocortisone, prednisone) Mast-cell stabilizers (cromolyn, nedocromil) Leukotriene modifiers (montelukast, zafirilukast, zileuton) Diagnostics Pulmonary function test ABG Spirometry Sputum specimen Nursing Management Administer medications and monitor closely High fowlers position; slow rhythmic breathing Adequate fluid intake Provide extra humidity If with respiratory acidosis- O2 as prescribed Calm, quiet environment Instruct patient to recognize trigger factors Teach importance of hydration, adequate nutrition and exercise CHRONIC BRONCHITIS CAUSES Cigarette Smoking Respiratory Tract Infection Environmental Pollutants EMPHYSEMA Presence of overdistended, non-functional alveoli which may rupture, resulting to loss of aerating surface CAUSES: Cigarette Smoking Heredity Aging Process

MANAGEMENT Rest to reduce oxygen demands Increase fluid intake to liqeufy mucus Good oral care High calorie, high CHON, low CHO diet Oxygen therapy of 2LPM Avoid smoking, alcohol, pollutants Chest physiotherapy Mucolytics, expectorants, bronchodilators, steroids, antihistamines, antimicrobials as ordered Bronchiectasis Extreme form of bronchitis that causes permanent, abnormal dilation and distortion of bronchi and bronchioles Results from chronic inflammatory changes in the bronchial mucosa USJR NURSING MS TEAM 2010

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C ic l F au lin a e t r

Diagnosis: chest x-ray, bronchogram, CT scan Clinical Manifestations Cough Purulent sputum Hemoptysis Nasal stuffiness fever Clubbing of fingers Fatigue and malaise Management: Same as COPD

Pulmonary Embolism Causes Fat embolism Multiple trauma PVDs Abdominal surgery Immobility hypercoagulability Restlessness Dyspnea Stabbing chest pain Cyanosis Tachycardia Nursing Interventions Oxygen therapy Early ambulation postop Monitor obese patient Do not massage legs Relieve pain Head of bed elevated Heparin (2 weeks) then coumadin (3-6 months) DOs Observe for bleeding Use soft toothbrush, electric razor Evaluate use of contraceptives Dilated pupils Apprehension/fear Diaphoresis Dysrhythmias hypoxia Clinical Manifestations

DONTs Take ASA with Coumadin Restrictive clothings on legs Prolonged sitting/standing Smoking Bruises, constipation contact sports

LUNG CANCER Predisposing Factors Cigarette smoking Asbestosis Emphysema Smoke from burnt wood Types of Lung Cancer Squamous cell Carcinoma with good prognosis Adenocarcinoma with good prognosis Oat cell Carcinoma with poor prognosis Undifferentiated Carcinoma with poor prognosis Warning Signs of Lung Cancer Any change in respiratory pattern Page 12

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Persistent cough Sputum streaked with blood Frank hemoptysis Rust colored or purulent sputum Chest, shoulder, arm pain Recurring pneumonia, pleural effusion, bronchitis Unexplained dyspnea

Nursing Interventions Patent airway Oxygen/Aerosol therapy

Deep breathing Exercises Relief of Pain Protection from infection Adequate nutrition Chest tube managemen

Prevention Quit smoking Early detection/screening Chest x-ray once a year SURGERY Pneumonectomy Position in semi-fowlers, turned slightly on affected side for lung expansion Avoid full side-lying position to prevent mediastinal shift Lobectomy Segmentectomy Wedge Resection removal of entire tumor regardless of segment Decortication stripping off of fibrinous membrane enclosing the lung Thoracoplasty removal of ribs usually after pneumonectomy to reduce the size of the empty thorax thereby prevent mediastinal shift For lobectomy, segmentectomy, wedge resection, decortication, thoracoplasty: Chest tube in place postop Position in semi-Fowlers position or on unaffected side to allow expansion of affected lung

PNEUMONIA - An infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles; edema associated with inflammation stiffens the lung, decreases lung compliance and vital capacity, and causes hypoxemia Major Classification Community Acquired Pneumonia- occur either in the community or 4872 hours before hospitalization Hospital Acquired Pneumonia- also called nosocomial infection, onset of symptoms more than 72 hours after hospitalization Aspiration Pneumonia- pulmonary consequences resulting from the entry of endogenous or exogenous substances into the lower airway. Risk Factors Smoking, Cancer, COPD Aging Immunosuppressed patients Fatigue Prolonged immobility Overexposure to extreme Depressed cough reflex heat or cold USJR NURSING MS TEAM 2010 Page 13

Alcohol intoxication Exposure to polluted air Use of improperly cleaned Malnutrition instruments Clinical Manifestations Increased sputum production and cough Anaerobic- foul-smelling specimen Klebsiella- curant jelly color Staphylococcus- creamy yellow Pseudomonas- green Viral- mucopurulent Consolidated or diffused/patchy appearance on chest x-rays Respiratory acidosis Chest pain, pleural effusion, dullness on percussion, decreased breath sounds, decreased focal fremitus Diagnostics Complete Blood Count Based on history and s/s Dull percussion on affected lung Chest X-Ray Blood culture Sputum examination Arterial Blood Gas (ABG) Management Bedrest Position in Semi-fowlers to facilitate in breathing and lung expansion Early ambulation as tolerated Suction airway using sterile technique Chest physiotherapy Antibiotics as ordered

Atelectasis Collapse of lung at any structural level CAUSES Reduction of Lung Distention Forces Localized Airway Distention Insufficient Pulmonary Surfactant Increased Elastic Recoil Manifestations Tachypnea Hypoxemia Tracheal shift towards the affected side Dullness on percussion Cyanosis Diminished breath sounds Management: Frequent position changes Early ambulation Deep breathing exercises Incentive spirometry Oxygen therapy Tracheal suctioning

Disorders of fluid in pleurae Pleural fluid disorders - all treated with water seal chest drainage systems

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Pneumothorax: air between the pleurae open pneumothorax: hole in the chest wall, communicates with the lung closed pneumothorax: hole in lung, chest wall intact tension pneumothorax - a nursing and medical emergency closed pneumothorax air is forced into the pleural space with a continued pressure build up shifts mediastinum away from affected side with results of a compressed heart treated with chest tube insertion cardiac and respiratory arrest if not treated

Pleural effusion fluid (transudate or exudate) in the pleural space if small, no treatment if larger, treated with chest tube insertion Hemothorax blood in the pleural space treated with thoracentesis or chest tube Empyema purulent drainage in the pleural space often from a chronic condition such as lung cancer treated with chest tube inserton Chylothorax lymphatic fluid in pleural space treated with thoracentesis or chest tube Flail Chest result from direct blunt chest trauma and causes a potential for intrathoracic injury pain with movement and chest splinting result in impaired ventilation and inadequate clearance of secretions blunt chest trauma associated with accidents, which may result in hemothorax and rib fractures; loose segment of the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall Clinical Manifestations Pain at injury site that increases with inspiration Tenderness at site Shallow respirations Client splints chest Fractures noted on chest x-ray Paradoxical respirations (inward movement of a segment of the thorax during inspiration with outward movement during expiration) Management: Position the client in high Fowlers Administer humidified air as prescribed Monitor for increased respiratory distress Encourage coughing and deep breathing Administer pain medication as prescribed Maintain bed rest and limit activity to reduce oxygen demands Prepare for intubation with mechanical ventilator USJR NURSING MS TEAM 2010 Page 15

Tuberculosis Reportable, communicable, inflammatory disease that can occur in any part of the body, especially the lungs Infectious but may be cured or arrested by medications Transmitted by droplet infection Client Education: Cover nose and mouth when coughing, sneezing or laughing Wash hands after any contact with body substances, masks or soiled tissues Wear masks when advised Take medications regularly as prescribed Primary TB drugs with Side Effects Second-line TB drugs Isoniazid (INH) - peripheral Capreomycin sulfate neuritis, hepatotoxicity (Capastat sulfate) Administer Vitamin B6 Kanamycin (Kantrex) (Pyridoxine) Ethiomide (Trecator-SC) Streptomycin ototoxicity, Amikacin (Amikin) nephrotoxicity Quinolones Rifamficin jaundice, red-orange Cycloserine (Seromycin) secretions Para-aminsalicylic acid Ethambutol optic neuritis (Tubasal) Pyrazinamide gout, arthralgia Avian Flu Agent: Avian influenza viruses (H5N1 virus the most virulent) Infected birds shed influenza virus in their saliva, nasal secretions, and feces. Mode of Transmission: direct contact with infected waterfowl or other infected poultry, or through contact with surfaces (such as dirt or cages) or materials (such as water or feed) that have been contaminated with the virus Outbreak in countries: Cambodia, China(Tibet), Indonesia, Japan, Laos, South Korea, Thailand, and Vietnam, Kazakhstan, Malaysia, Mongolia, Russia [Siberia] High risk: people having direct or close contact with infected poultry or contaminated surfaces Immunity: none since the virus do not commonly infect humans Treatment: oseltamavir (Tamiflu) and zanamavir; resistant to amantadine and rimantadine Vaccination: none Clinical manifestations: initial symptoms of fever (38 C or higher) cough sore throat muscle aches eye infections pneumonia and other severe respiratory diseases (such as acute respiratory distress) rhinorrhea Watery diarrhea Personal protective equipment: Interventions: Protective clothing, Isolate suspected patients preferably coveralls plus an Give the patient a mask impermeable apron or Maintain a minimum distance surgical gowns with long of 1 meter from the patient cuffed sleeves plus an impermeable apron; Heavy-duty rubber work gloves that may be disinfected; Standard well-fitted surgical masks (N95 respiratory masks); Goggles; Rubber or polyurethane boots Histoplasmosis Systemic fungal disease caused by inhalation of dust contaminated by Histoplasma capsulatum Common in Western countries USJR NURSING MS TEAM 2010 Page 16

Not spread from human to human Fungus seen in pigeon and chicken manure Diagnosis Chest x-ray Histoplasmin skin test (read same as PPD) Management Amphotericin B Teach farmers to wet down chicken coops before shoveling manure so fungal spores will not become airborne Clinical Manifestations Symptoms similar to tuberculosis or pneumonia Cough Fever Joint pain malaise Sometimes asymptomatic Acute Respiratory Distress Syndrome Sudden progressive pulmonary edema Noncardiac origin Reduced lung compliance Severe dyspnea Diffuse pulmonary infiltrates Refractory hypoxemia Clinical Manifestations

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Tachypnea Dyspnea Retractions Central cyanosis Dry cough Fine crackles Fever Alteration in level of consciousness ABG: Pa O2 Pa CO2 Management Oxygen therapy (8-10 LPM) Semi- to high-Fowlers position Chest physiotherapy Increase fluid intake Meticulous eye care If on Positive End Expiratory Pressure (PEEP) ventilation, administer Ativan/Morphine to reduce resistance

When caring for a client on a ventilator, if an alarm sounds, first, assess the client. See if the alarm resets or if the cause is obvious. If the alarm continues to sound and the client develops distress, disconnect the client from the ventilator, use a manual resuscitation bag to ventilate with 100% oxygen and page or call the respiratory therapist immediately. If the ventilator tube disconnects, the low pressure alarm will sound. If the high pressure alarm sounds on the ventilator, the nurse should check for some type of obstruction or occlusion of the airway: mucous plugs, biting of the tube by the client, tube slips into right main stem bronchus, or increased secretions. To maximize therapeutic effect of inhalers, the key is technique. It is critical to teach clients the right technique and observe how well they use the inhaler.

MAY YOUR DREAMS COME TRUE AND GOD BLESS

PREPARED BY: ECHEVARRIA, SUSON, TAMAYO, FLORES, NEPANGUE, YLLANAN

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