 NCM 112 LECTURE: NCM 112 Care of Clients with Problems in

Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory &

Immunologic Reaction
 Classroom Instructor: ROBERTO B. AGRAVANTE JR. RN
 LEARNING OUTCOMES
 1. Describe the clinical manifestations and nursing and
interprofessional management of problems of the nose.
2. Discuss the clinical manifestations and nursing and
interprofessional management of problems of the paranasal
sinuses.
3. Describe the clinical manifestations and nursing and
interprofessional management of problems of the pharynx
and larynx.
4. Relate the nursing and interprofessional management of the
patient who has a tracheostomy.
5. Identify the steps involved in performing tracheostomy care
and suctioning a patient with a tracheostomy.
Upper and Lower Respiratory
Problems
Influenza

We classify influenza viruses into 4

serotypes (A, B, C, D). Only A and B cause
significant illness in humans. Influenza A is
subtyped based on the presence of 2
surface proteins: hemagglutinin (H)
and neuraminidase (N). The H antigens
enable the virus to enter the cell, and the N
antigens facilitate cell-to-cell transmission.
As a result, we name influenza A viruses
according to their H and N type (e.g., H3N2)
Influenza
Etiology and Pathophysiology

As a result, we name influenza A viruses according

to their H and N type (e.g., H3N2). Influenza is
communicable between humans primarily through
infected droplets, inhalation of aerosolized
particles, and, to a lesser extent, through direct
contact with contaminated surfaces. The virus has
an incubation period of 1 to 4 days, with peak
transmission risk starting 1 day before onset of
symptoms and continuing for 5 to 7 days after
a person first becomes sick.

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INFLUENZA VS COMMON COLDS
CAN YOU IMAGINE??
 INTERPROFESSIONAL
CARE
 The most effective strategy for managing influenza is
prevention. Two types of flu vaccines are available:
inactivated and live attenuated. Receiving a flu vaccine
results in the production of antibodies against the
viruses in the vaccine. The influenza vaccine is changed
on a yearly basis, depending on
the virus strains the Centers for Disease Control and
Prevention (CDC) determines as being most likely to
cause illness in the upcoming flu season. The best time
to receive the vaccine is in September or October
(before flu exposure) because it takes 2 weeks for full
protection to occur. However, the vaccine can be given
at any time during the flu season.
SINUSITIS
SINUSITIS

Sinusitis affects 1 in every 7 adults. It develops when

inflammation or swelling of the mucosa blocks the
openings (ostia) in the sinuses, through which mucus
drains into the nose. Rhinosinusitis, which may
accompany sinusitis, is concurrent inflammation or
infection of the nasal mucosa. Nasal polyps, foreign
bodies, deviated septa, or tumors can cause
obstruction of mucus drainage. Secretions that
accumulate behind the blocked ostia provide a rich
medium for growth of bacteria, viruses, and fungi, all of
which may cause infection.
CLINICAL MANIFESTATIONS
Acute sinusitis causes significant pain over the affected
sinus, purulent nasal drainage, nasal obstruction,
congestion, fever, and malaise. The patient may appear
acutely ill. Inspect the nasal mucosa and palpate the
paranasal sinuses for pain. Findings that indicate acute
sinusitis include edematous mucosa, discolored
purulent nasal drainage, enlarged turbinates,
tenderness over the involved frontal and/or maxillary
sinuses, and halitosis (bad breath).
Recurrent headaches are common and may change in
intensity with position changes or when secretions
drain.
 INTERPROFESSIONAL
CARE
If allergies are the precipitating cause of sinusitis, teach the
patient ways to reduce sinus inflammation and infection,
including environmental control of allergens and appropriate drug
therapy. Initial treatment for acute sinusitis focuses on symptom
relief.
Medications include oral or topical decongestants to promote
drainage, intranasal corticosteroids to decrease
inflammation, analgesics to relieve pain, and saline nasal spray to
relieve congestion.
Teach patients using topical decongestants to use the medication for
no longer than 4 to 5 days to prevent rebound congestion caused
by vasodilation. Saline irrigation of the nasal cavity can rinse nasal
passages, promote drainage, and decrease inflammation. Saline
nasal spray is available over the counter.
Airway Obstruction
Acute airway obstruction is a medical
emergency. Airway obstruction can be caused by
aspiration of food or a foreign body,
allergic reactions, edema and inflammation
caused by infections or burns, peritonsillar or
retropharyngeal abscesses, cancer, laryngeal or
tracheal stenosis, and trauma.
Airway obstruction may be partial or complete.
The presentation of an airway obstruction often
depends on the cause of the obstruction and/or
location of the blockage.
Manifestations include choking, stridor,
use of accessory muscles, suprasternal and
intercostal retractions, flaring nostrils,
wheezing, restlessness, tachycardia,
cyanosis, and change in level
of consciousness. Prompt assessment and
treatment are essential because partial
obstruction may quickly progress to
complete obstruction. Complete airway
obstruction can result in permanent brain
damage or death if not corrected within 3
to 5 minutes.
 Tracheostomy
A tracheostomy is a surgically created stoma (opening) in the anterior part of the trachea (Fig. 26.3, A). A tracheostomy may be done to
(1) establish a patent airway, (2) bypass an upper airway obstruction, (3) facilitate removal of secretions, (4) permit long-term
mechanical ventilation, and (5) assist with weaning from mechanical ventilation. The tracheostomy tube is shorter in length and slightly
wider in diameter than an ET tube. This makes it easier to keep the tube clean and facilitates better oral and bronchial hygiene.
A tracheostomy (compared to an ET tube) may increase patient comfort because no tube is present in the mouth. There is also less risk for
long-term damage to vocal cords.
LOWER TRACT RESPIRATORY INFECTION
ACUTE BRONCHITIS
Acute bronchitis is a self-limiting inflammation of the bronchi
in the lower respiratory tract. It is the reason for 10% of all
clinic visits and 100 million ED visits per year.2 Most acute
bronchial infections are caused by viruses. Air pollution, dust,
inhalation of chemicals, smoking, chronic sinusitis, and asthma
are other triggers.
Cough, which is the most common symptom, may last for up to
3 weeks. It is the main reason for seeking medical care. Clear
sputum is often present, although some patients have purulent
sputum.
Thepresence of colored (e.g., green) sputum is not a reliable
indicator of bacterial infection. Other symptoms may include
headache, fever, malaise, hoarseness, myalgias, dyspnea, and
chest pain
PNEUMONIA
Inflammation of the lung parenchyma (bacteria, mycobacteria, fungi and viruses)
Inflammation stiffens the lung, decreases lung compliance and vital capacity and causes
hypoxemia
 Community-Acquired Pneumonia
Classificatio Hospital-Acquired Pneumonia
n: Aspiration pneumonia
 Risk Factors
Condition that produce mucus or bronchial obstruction
and interfere with normal lung drainage

Immunosuppressed patients

Smoking

Prolonged immobility

Depressed cough reflex

NPO status, placement of tube

Supine position

Alcohol intoxication

Advanced age
MANIFESTATIONS
 ASSESSMENT, PREVENTION
AND MEDICAL MANAGEMENT

Assessment
History taking
APhysical examination
Chest X-ray
Blood culture
Sputum examination
Bronchoscopy: acute severe infection
ASSESSMENT, PREVENTION AND MEDICAL
MANAGEMENT
Prevention

PNEUMONIA VACCINE

People over 65 years of age

Immunocompromised patients

People living in environment in high risk

Medical Management

Antibiotic therapy

Supplemental oxygen
 Nursing Intervention
Improve airway patency

Promoting rest and conserving energy

Promoting fluid intake

Maintaining nutrition

Promoting patient’s knowledge

Monitoring and managing potential

complications

Administer antibiotic, as prescribed

Client education: immunization

 TUBERCULOSIS

Infectious disease that affect the

lung parenchyma.
Transmitted: meninges, kidney,
bones and lymph nodes.
Causative agent: M. tuberculosis
Associated with poverty,
malnutrition, overcrowding,
substandard housing, inadequate
health care.
Transmission: airborne (talking,
coughing, sneezing, laughing, or
singing)
 Close contact with infected client

Immunocompromised status

Substance abuse

Risk Factors Pre-existing medical condition or special treatment

Immigration to countries with high incidence of TB

Living in crowded places

Healthcare worker
MANIFESTATIONS

Assessment
Complete history
Physical
examination
Tuberculin skin test
Medical Management
S/E: peripheral neuritis
(Pyridoxine), hepatic
Antituberculosis agent: Daily dose: 5mg/kg Monitor SGPT and
Isoniazid (INH) enzyme elevation,
6 to 12 months (300mg max dose daily) SGOT
hepatitis,
hypersensitivity

Orange urine and other

S/E: hepatitis, febrile body secretions
Daily dose: 10mg/kg
Rifampin (Rifadin) reaction, nausea, Streptomycin
(600mg max daily)
vomiting, purpura Monitor SGPT and
SGOT

S/E: 8th cranial nerve Monitor vestibular

Daily dose: 15mg/kg caution: elderly, renal
damage (deafness), function, audiograms,
(1gm max daily) disease
nephrotoxicity BUN and creatinine
Medical Management
Daily dose: 15 to S/E: Hyperuricemia,
Monitor SUA, SGPT,
Pyrazinamide 30mg/kg (2.0gm hepatotoxicity, skin
SGOT
max daily) rashes, GI distress

S/E: optic neuritis caution: renal

Daily dose: 15 to
Ethambutol (blindness), skin disease, eye testing
25mg/kg
rashes is not feasible

Monitor VA, color

discrimination
 Nursing Management
Promoting airway clearance

Encourage to increase oral fluid intake.

Educate patient with positioning to promote drainage.

Advocating adherence to treatment regimen

Promoting activity and adequate nutrition

Monitoring and managing potential complications

Promoting home and community –based care

Nursing Management
Promoting airway clearance

Encourage to increase oral fluid intake.

Educate patient with positioning to promote

drainage.

Advocating adherence to treatment regimen

Promoting activity and adequate nutrition

Monitoring and managing potential

complications

Promoting home and community –based care

Nursing Management

Expected patient outcome

Maintains patent airway
Demonstrates an adequate level of knowledge
Adheres to treatment regimen
Participates in preventive measures
Maintain activity schedule
Exhibits no complications
Take steps to minimize side effects of
medications
Accumulation of atmospheric air in the
pleural space, which results in a rise in
intrathoracic pressure and reduced vital
capacity.
Loss of negative intrapleural pressure
results in collapse of the lung.
Types of Pneumothorax
Spontaneous pneumothorax: occurs with
the rupture of a bleb.
Open pneumothorax: occurs when an
opening through the chest wall allows the
entrance of positive atmospheric
pressure into the pleural space.
Tension pneumothorax: occurs from a
blunt chest injury or from mech vent.
With PEEP when a buildup of positive
pressure occurs in the pleural space.
Assessment
Absent breath sounds on affected side
Cyanosis
Decreased chest expansion unilaterally
Dyspnea
Hypotension
Sharp chest pain
Subcutaneous emphysema as evidenced
by crepitus on palpation
Sucking sound with open chest wound
Tachycardia
Tachypnea
Tracheal deviation to the unaffected side
with tension pneumothorax
Nursing Management

Apply dressing over an open chest wound.

Administer oxygen as prescribed.
Position the client in high Fowler’s
position.
Prepare for chest tube placement until
the lung has expanded fully.
Monitor chest tube drainage system.
Monitor for subcutaneous emphysema.
ATELECTASIS

Closure or collapse of alveoli

ATELECTASIS Common in post-operative setting ang with people
who are immobilized
 ATELECTASIS
Reduced ventilation/blockage in the alveoli

Reducing alveolar ventilation

Lung becomes airless

alveoli collapse
 ATELECTASIS
Causes: altered breathing pattern, retained secretions, prolonged supine
position . At risk: post-operative patients due to monotonous, low tidal
breathing pattern

Manifestation

Acute and Chronic

Increasing dyspnea, cough, sputum production

Tachycardia
 Increase work in breathing
MANIFESTATIONS
Decreased breath sounds

Crackles

Low 02 saturation: < 90%

X-Ray: patchy infiltrates

 Change
• Change client’s position frequently

Encourage
• Encourage early ambulation

Encourage
• Encourage appropriate deep breathing and coughing exercises
Prevention
Teach/reinforce
• Teach/reinforce appropriate technique for incentive spirometry

Perform
• Perform postural drainage and chest percussion, if prescribed

Institute
• If indicated, institute suctioning
OXYGENATION
Intended Learning Outcome
At the end of this lesson, you are expected to:
Familiarize alterations in oxygenation particularly in alterations
in cardiac performance in terms of:
Pathophysiologic mechanisms.
Nursing diagnosis taxonomy.
Principles of various modalities of management.
Pharmacologic actions, therapeutic uses, side effects,
indications, contraindications, and nursing responsibilities in
administering medications.
Purposes, indications and nursing responsibilities for surgical
and special procedures
INTRODUCTION
Conditions like myocardial infarction, hypertension, valvular heart
disease, congenital heart disease, cardiomyopathy, heart failure,
pulmonary disease, arrhythmias, drug effects, fluid overload,
decrease fluid volume, and electrolyte imbalance are considered the
common causes of Decreased Cardiac Output. The aging process
causes reduced compliance of the ventricles, which makes the older
population at high risk of developing cardiac problems. In an aging
population with steadfast high prevalence of cardiovascular disease
(CVD), the health care system is handling a growing challenge to
efficiently care for these patients. Patients may be managed in an
acute care, ambulatory care, or home care setting.
 COR
PULMONALE

Right ventricle of
the heart enlarges
Disease affecting
the lungs and
accompanied by
hypoxemia
Cause: COPD
Here are some factors that may be
related to Decreased Cardiac Output:
Alteration in heart rate, rhythm, and conduction
Cardiac muscle disease
Decreased oxygenation
Impaired contractility
Increased afterload
Increased or decreased ventricular filling (preload)
Medical Management
Medical Management
Goal: decrease workload of the right ventricle by lowering
pulmonary artery pressure
Importance of close monitoring (fluid retention, weight gain and
edema)
Teaching patient self-care
Continuing Care
 PULMONARY
EDEMA

Abnormal accumulation
of fluid in the lung
tissue, alveolar space,
or both
Severe and life
threatening
 Abnormal cardiac function increased
macrovascular pressure:

back up of blood into the pulmonary

vasculature
PATHOPHYSIOLOGY
fluid leak into the interstitial space
and alveoli

Hypovolemia or sudden increase in

the intravascular pressure in the lungs
 Increasing respiratory distress: dyspnea, air
hunger, central cyanosis
Anxious and agitated
Manifestation
Presence of foamy, frothy often blood
tinged secretions (fluid mixes with air and
form a foam or froth)
PLEURAL EFFUSION

a collection of fluid in
the pleural space may
be a complication of
heart failure, TB,
pneumonia,
pulmonary infections,
nephrotic syndrome,
connective tissues
diseases, neoplastic
tumors.
CORONARY ARTERY
DISEASE

The most prevalent

type of cardiovascular
disease in adults. The
nurse must recognize
various manifestations
of coronary artery
conditions and
evidenced-based
methods for assessing,
preventing and treating
these disorders.
CORONARY
ATHEROSCLEROSIS

abnormal accumulation of lipid, or

fatty substances and fibrous
tissues in the lining of arterial
blood vessels walls which reduces
blood flow to the myocardium.
 Management and Prevention
Controlling cholesterol abnormalities
Dietary Measures (see Table 27-1 for recommendations of the
Therapeutic Lifestyle Changes (TLC) diet)
Physical Activity – weight reduction and increased physical
activity
Medication
Promoting cessation of tobacco Use – cigarette smoking
contributes to the development and severity of CAD.
Managing hypertension
Controlling Diabetes
 \

Improving Peripheral Arterial Circulation

For lower extremities; elevate the head of the patient’s bed
Assist with walking or other moderate or graded isometric exercises
prescribed to promote blood flow and the development of collateral
circulation.

NURSING Promoting Vasodilation and Preventing Vascular Compression

Arterial dilation promotes increased blood flow to the extremities.
INTERVENTIONS Application of warmth to promote arterial flow and instructions to the
patient to avoid exposure to cold temperatures, which causes
vasoconstriction.
Encourage to STOP SMOKING
Avoid stressful situations when possible
Constructive clothing and accessories impede circulation and therefore
should be avoided.
 Relieving Pain
Analgesics may be helpful so that patient can
participate in therapies that can increase circulation
and relieve pain.
Maintaining Tissue Integrity
Trauma to the extremities must be avoided.
NURSING Encourage good nutrition to promote healing and
INTERVENTIONS prevents tissues breakdown.
Promoting Home and Community-Based Care
Self-care programs are planned with the patient so
that activities that promote arterial and venous
circulation, relieve pain, and promote tissue integrity
are acceptable.
MYOCARDIAL INFARCTION

also known as a heart attack, occurs

when blood flow decreases or stops to a
part of the heart, causing damage to the
heart muscle. The most common
symptom is chest pain or discomfort
which may travel into the shoulder, arm,
back, neck or jaw.
INFLAMMATORY AND STRUCTURAL
HEART DISORDERS
Valvular Disorders
Valves of the heart control the flow of the blood through
the heart into the pulmonary artery and aorta by opening
and closing in response to blood pressure changes during
each cardiac cycle (contraction and relaxation)
MITRAL VALVE
PROLAPSE

Deformity that usually

produces no symptoms
Cause: may inherited
connective tissue
disorders resulting in
enlargement of one or
both of the mitral valve
leaflets
Assessment
Extra heart sound “mitral click”
Murmur of mitral regurgitation may be heard – may experience symptoms of heart failure
Medical Management
Goal: controlling the symptoms
Dysrhythmias
Eliminate caffeine and alcohol
Stop smoking
Chest pain
Calcium channel blockers or beta blockers
Severe mitral regurgitation and heart failure symptoms
Mitral valve repair or replacement
Nursing Management
Educate the patient that the condition may be hereditary in origin.
Avoid caffeine and alcohol in the diet
Explores diet, activity, sleep, and other lifestyle factors that may
correlate with symptoms.