Diagnostic Studies and Therapies

PPD(Purified Protein Derivative Intradermal read 48-72 hours after injection (+) Mantoux test is in duration of 10 mm or more for HIV positive clients, induration of 5 mm is considered positive (+) Mantoux test signifies exposure to Mycobacterium tubercle bacilli

the client on how to hold his breath and to do deep breathing Instruct the client to remove metals from chest
Practice

Studies the lung and chest in motion

A radiopaque medium is instilled directly into the trachea and bronchi and the entire bronchial tree or selected areas may be visualized Nursing interventions before bronchogram Secure written consent Check for allergies to sea foods or iodine or anesthesia NPO for 6-8 hrs Pre-op meds: atropine sulfate and valium, topical anesthesia sprayed; followed by local anesthetic injected into the larynx Have oxygen and antispasmodic agents ready Nursing interventions after bronchogram Side-lying position NPO until cough and gag reflexes return Cough and deep breath client Low grade fever commom

The direct inspection and observation of the larynx, trachea and bronchi through flexible or rigid bronchoscope Diagnostic uses: To collect secretions To determine location of pathologic process and collect specimen for biopsy Therapeutic uses: Remove foreign objects Excise lesions

Nursing interventions before bronchoscopy Informed consent/permit needed Atropine and valium pre-procedure; topical anesthesia sprayed followed by local anesthesia injected into the larynx NPO for 6-8 hrs Remove dentures, prostheses, contact lenses Nursing interventions after bronchoscopy Side-lying position Check for the return of cough and gag reflexes before giving fluid per orem Watch for cyanosis, hypotension, tachycardia, arrhythmias, hemoptysis, dyspnea. These signs and symptoms indicate perforation of bronchial tree.

Following injection of a radioisotope, scans are taken with a scintillation camera. Measure blood perfusion through the lungs. Confirm pulmonary embolism or other blood-flow abnormalities Remain still during the procedure

   

Gross appearance Sputum C&S AFB staining Cytologic examination/Papanicolaou examination Early morning sputum specimen is to be collected Rinse mouth with plain water Use sterile container Sputum specimen for C&S is collected before the first dose of antimicrobial For AFB staining, collect sputum specimen for three consecutive mornings

Transbronchoscopic biopsydone during bronchoscopy  Percutaneous needle biopsy  Open lung biopsy


Lymphnode biopsy


Scalene or cervocomediastinal To assess metastasis of lung cancer Vital capacity The maximum volume of air that can be exhaled after a maximum inhalation Reduced in COPD The volume of air inhaled and exhaled with normal quiet breathing

Pulmonary Function Studies



Tidal volume


Inspiratory reserve volume



The maximum volume that can be inhaled following a normal quiet inhalation The volume of air that remains in the lungs after normal, quiet exhalation The volume of air that remains in the lungs after normal, quiet exhalation The volume of air that remains in the lungs after forceful exhalation

Expiratory reserve volume



Functional residual capacity



Residual volume


Purpose: to assess ventilation and acidbase balance Radial artery is the common site for withdrawal of blood specimen Allens test is done to assess for adequacy of collateral circulation of the hand 10 ml pre-heparinized syringe to prevent clotting of specimen Container with ice to prevent hemolysis of the specimen

Aspiration of the fluid or air from the pleural space Nursing intervention before thoracentesis Secure consent Take initial vital signs Position: upright leaning on over bed table Instruct to remain still, avoid coughing during insertion of needle Pressure sensation is felt on insertion of needle

Nursing interventions after thoracentesis: Turn on the unaffected side to prevent leakage of fluid in the thoracic cavity Bed rest until VS is stable Check for the expectoration of blood. Notify physician Monitor VS

 

Oxygen therapy Tracheobronchial suctioning a. Client should be in semi-fowlers position b. Use sterile gloves, sterile suction catheter c. Hyperventilate client with 100% oxygen before and after suction d. Insert catheter with gloved hand(3-5 length of catheter insertion) e. Apply suction during withdrawal of catheter f. When withdrawing catheter rotate while applying intermittent suction g. Suctioning should take only 10 seconds (maximum of 15 seconds) h. Evaluate: clear breath sounds on auscultation of the chest

Bronchial Hygiene Measures Suctioning: oropharyngeal;nasopharyngeal Steam inhalation Aerosol inhalation Madimist inhalation Chest Physiotherapy (CPT) Postural drainage Percussion Vibration

Nursing intervention in CPT

a. b. c. d. e. f. g.

h.

Verify doctors order Assess areas of accumulation of mucus secretions Position to allow expectoration of mucus secretions by gravity Place client in each position for 10 to 15 minutes Percussion and vibration done to loosen mucus secretions Change position gradually to prevent postural hypotension Procedure is best done 60 to 90 minutes before meals or in the morning upon awakening and at bedtime Provide oral care after the procedure

Incentive Spirometry To enhance deep inhalation Closed chest drainage (Thoracostomy Tube) Purpose: to remove air and/or fluids from the pleural space; to reestablished negative pressure and reexpand the lungs.

Types: a. one-bottle system

The bottle serves as a drainage bottle and water-seal bottle Immerse tip of the tube in 2-3 cm of sterile NSS to create water-seal bottle Keep bottle at least 2-3 ft below the level of the chest to allow drainage from the pleura by gravity Never raise the bottle above the level of the chest to prevent reflux of air or fluid

Assess for patency of the device: -observe for fluctuation of fluid along the tube -observe for intermittent bubbling of fluid; continuous bubbling means presence of air-leak In the absence of fluctuation: -suspect obstruction of the device-check for kinks along tubing; milk tubing towards the bottle -if there is no obstruction, consider lung reexpansion; validated by chest x-ray Air vent should be open to air

b. Two-bottle system

Not connected to the suction apparatus -the first bottle is drainage bottle; the second bottle is water-seal bottle -observe for fluctuation of fluid along the tube (water-seal bottle) and intermittent bubbling with each respiration

Connected to suction apparatus -the first bottle is drainage and water-seal bottle; the second bottle is suction control bottle -expect continuous bubbling in the suction control bottle; intermittent bubbling and fluctuation in the water-seal -immerse tip of the tube in the first bottle in 2-3 cm of sterile NSS; immerse the tube of the suction control bottle in 10-20 cm of sterile NSS to stabilize the normal negative pressure in the lungs. This protects the pleura from trauma if the suction pressure is inadvertently increased

c. Three-bottle system

The first bottle is drainage bottle; the second bottle is water-seal bottle, the third bottle is suction control bottle Observe for intermittent bubbling and fluctuation with respiration in water-seal bottle; continuous bubbling in the suction bottle

 

The term common cold is a popular phrase for a group of symptoms including sneezing, congestion, and mild malaise Symptoms can continue for two weeks Clinical presentation: Sneezing Sore throat Rhinorrhea Mild malaise and achiness Non-productive cough Sinus congestion Headache May include nasal mucosa edema and erythema, nasal secretions, low-grade fever or mild erythema in the larynx

Treatment: Decongestants are helpful to relieve rhinorrhea, sinus congestion, and headache Gargling with warm salt water often soothes a sore throat and can help clear oropharyngeal secretions Analgesic  Nursing interventions Good nutrition and adequate sleep strengthen the immune system Frequent and thorough hand washing


 

A seasonal viral respiratory illness It is similar to common cold in mode of infection and transmission, being spread by the aerosol method or close contact Older adults and those with chronic illnesses are most at risk for complications like pneumonia, exacerbation of commorbidities, and death

Clinical presentation: Exhaustion Chills Sinus congestion Nonproduvtive cough Headache Myalgias Fever Pharyngitis Cervical adenopathy

Treatment Acetamonophen Analgesia Nursing interventions Rest Increase fluid Those too ill to maintain hydration may need to be hospitalized. If symptoms do not resolve within 7 days, further medical attention is needed.

URTI Cigarette smoking Allergic rhinitis Inflammation Edema of the mucous membrane Hypersecretion of mucus Infection

Assessment Pain: Maxillary: cheek, upper teeth Frontal: above eyebrows Ethmoid: in and around the eyes Sphenoid: behind eye, occiput, top of the head General malaise Stuffy nose Headache Post-nasal drip Persistent cough Fever

Nursing interventions Rest Increase fluid intake Hot wet packs Codeine, avoid ASA. It increases the risk of developing nasal polyps Amoxicillin or other anti-infectives (acute-7 to 10 days; chronic-21 days) Nasal decongestants e.g. Sudafed, Dimetapp (used for 72 hrs) Irrigation of maxillary sinuses with warm NSS

Surgery:

Functional Endoscopic Sinus Surgery (FESS) Caldwell-Luc surgery (Radical Antrum Surgery) Ethmoidectomy Sphenoidectomy/ethmoidotomy Osteoplastic flap surgery for frontal sinusitis

Cigarette smoking Respiratory tract infection (RTI) Environmental pollutants

Inflammation

Bradykinin Histamine Prostaglandin

Increase capillary permeability

Fluid/cellular exudation

Edema of mucous membrane

Hypersecretion of mucus

Persistent cough

Allergy(extrinsic) Inflammation(Intrinsic)

Histamine,bradykinin,prostaglandin, Serotonin, Leukotrienes, ECF-A, SRS-A (a)Bronchospasm

Bronchoconstriction (b) edema of mucous membrane (c) hypersecretion of mucus

Narrowing of air ways Increase work of breathing

Tends to sit up, Restlessness, tachypnea/dyspnea, tachycardia, Flaring of the alae nasi, diaphoresis, Cold clammy skin, wheezing, retractions, Pallor-cyanosis

Exhaustion Slow, shallow respiration (hypoventilation)

Retention of carbon dioxide (air trapping)

Hypoxia

Respiratory acidosis

Assessment in COPD Cough Dyspnea Chest pain Sputum production Adventitious breath sounds Pursed-lip breathing Tends to assume upright, leaning forward position Alteration in LOC


Alteration in skin color (pallor to cyanosis) Alteration in skin temoerature (cold to touch) Voice changes Decreased metabolism: weakness, fatigue, anorexia, weight loss Alteration in thoracic anatomy (barrel chest) Clubbing of fingers Polycythemia

Collaborative Management Rest to reduce oxygen demands of tissues Increase fluid intake to liquefy mucus secretions Good oral care to remove sputum and prevent infection Diet: high caloric diet provides source of energy; high protein diet helps maintain integrity of alveolar wall; low carbohydrate diet limits carbon dioxide production (natural end product),the client has difficulty in exhaling carbon dioxide.

Oxygen therapy of 1 to 2 Lpm. Do not give high concentration of oxygen. The drive for breathing may be depressed. Avoid cigarette smoking, alcohol, environmental pollutants. These inhibits mucociliary function CPT- percussion, vibration, postural drainage Bronchial hygiene measures: steam inhalation, aerosol inhalation, medimist inhalation

Pharmacotherapy: >Expectorants (guaiafenessin)/ mucolytic(mucomyst/mucosolval) >Antitussive: -Dextrometorphan, Codeine Observe for drowsiness Avoid activities that involve mental alertness Causes decrease of peristalsis thereby constipation

>Bronchodilators: -Aminophylline(Theophyline), Ventolin(Slbutamol) Observe for tachycardia >Anti-histamine -Benadryl(Diphenhydramine) Observe for drowsiness >Steroids -Anti-inflammatory effect >Antimicrobials

Causes: Bacterial Viral Fungal Aspiration Chemical irritants

Inflammation of lung tissue

Hypertrophy of mucous membrane Increased sputum production Wheezing Dyspnea Cough Rales Rhonchi Increase capillary permeability Increased fluid ISC Consolidation Hypoxemia

Inflammation of the pleura Chest pain Pleural effusion Dullness Decreased breath sounds Decreased vocal fremitus Hypoventilation Decreased chest expansion Respiratory acidosis

Protective mechanism Increased WBC Increased RR Fever Nursing interventions Rest Fluids Incentive spirometry Oxygen therapy Semi-fowlers position Bronchial hygiene

Oral hygiene Humidifier Splint chest when coughing Monitor: sputum, chest x-ray, temperature Pharmacotherapy: antibiotics

Reportable, communicable, inflammatory disease that can occur in any part of the body; most frequent site- pulmonary


a. b. c.

d. e. f.

Classification of TB Class 0: no exposure, no infection Class 1: exposure, no infectio Class 2: infection, no disease (+PPD reaction but no clinical evidence of active TB) Class 3: disease , clinically active Class 4: disease, not clinically active Class 5: suspected disease, diagnosis pending

Pathophysiology Mycobacterium tubercle bacilli

Dried droplet nuclei

Inflammation in alveoli

1. lymph nodes filter drainage 2. primary tubercle 3. necrosis 4.caseation

Calcified

Liquefaction

GHON TUBERCLE (primary)

coughed up

Cavity


a.

Client education guide: PTB

TB is infectious; it may be cured or arrested by medications TB is transmitted by droplet infection 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

b. c.

d.

e. f.

Primary anti-TB drugs: >Isoniazid (INH) -may be used at any age and among pregnant women -side effects: peripheral neuritis, hepatotoxicity -administer vitamin B6 (pyridoxine) to prevent peripheral neuritis -monitor ALT (SGPT), AST(SGOT) -used as prophylaxis for 6 months to 1 yr >Streptomycin -Side effects: ototxicity,nephrotoxicity

>Rifampicin -side effects: red orange to body secretions, hepatoxicity, -Nausea and vomiting, thrombocytopenia >Ethambutol -side effects: optic neuritis, skin rash -opthalmologic examination at regular basis

NOTES: Evaluate effectiveness of anti-TB drugs by sputum culture for acid fast bacilli

>Anti-TB drugs must be taken in combination to avoid bacterial resistance >drugs to be taken on empty stomach for maximum absorption