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Respiratory Disorders

Pharyngitis inflammation or infection causing symptoms of sore throat - mostly caused by viral infection: strep throat if caused by Group A beta hemolytic streptococcus Body responds through: inflammation in the pharynx pain fever Edema Vasodilation tissue damage creamy exudates

Nursing Mgt: 1. Bed rest during febrile stage 2. Dispose used tissues properly to avoid infection 3. Inspect skin for rashes 1x-2x weekly which can precede some communicable disease (ex: rubella) 4. Warm saline gargle or irrigation (40.6 C 43.3. C) to reduce spasm in the pharyngeal muscles and relieving soreness 5. Ice collar 6. Mouth care to prevent fissures (cacking) in the lips and oral inflammation. 7. Take full course of antibiotic. TONSILITIS faucial and palatine tonsils and lingual tonsils -adenoid or pharyngeal tonsil (near the center f the posterior wall of the esophagus) - caused by Group A beta streptococcus (most common causative organism) S/Sx: Sore throat earache snoring fever difficulty swallowing foul-smelling breath draining ears voice impairment mouth breathing noisy respiration

Complications: S/Sx: fiery red pharyngeal membrane and tonsils swollen lymph nodes follicles and white purple exudates tender cervical lymph nodes fever malaise sore throat Sinusitis otitis media peritonsillar abscess mastoiditis cervical adenitis pneumonia meningitis rheumatic heart fever

Complications: otitis media acute mastoiditis

Medical Mgt.: A. Pharmacological Therapy TOC: Penicillin Cephalosporins and macrolides (Clarithromycin and azithromycin) For patients allergic to penicillin or organism resistant to erythromycin (S. aureus) administer antibiotic within at least 10 days Analgesic medications: Aspirin and acetaminophen Antitussive: Codeine and dextromethorphan (for persistent and painful cough)

Medical Management: 1. Tonsillectomy for recurrent, hypertrophic, obstruction during sleep, peristonsillar abcess which obstructs the pharynx. 2. Antibiotic therapy is initiated - Penicillin, amoxicillin, eryhromycin Nursing Management 1. 2. 3. 4. Prone position; head turned to side Oral airway must be in place first Ice collar is placed. Provide basin and tissues

Provide post-op care. B. Nutritional Therapy - Liquid or soft diet on the acute stage. IV fluids if cannot tolerate PO due to pain. - Increase OFI up to 2-3 L/day 1. Bright red (bleeding) If no bleeding, give water and ice chips. Check on the 1st day and 10th day postop for sloughing of tissues.
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2. 3. 4. 5. 6. 7.

12-25 hours bleeding may occur. Liquids and semi-liquid for several days. Shorbet and gelatin. Avoid spicy, hot, acidic, rough foods. Milk and milk products may be restricted Hallitosis and minor ear pain may occur for the first few days. 8. Avoid vigorous brushing and gargling. PERITONSILLAR ABCESS a collection of purulent exudate between the tonsillar capsule and the surrounding tissue, including the soft palate. It is believed to develop after acute tonsillar infection which progresses into a local cellulitis and abcess.

S/Sx:

structured deformities neoplasm and masses chronic use of nasal decongestants use of oral contraception, cocaine and antihypertensive

rhinorrhea nasal congestion nasal discharge nasal itchiness sneezing headache

Medical Management: (viral) meds are given to relieve the symptoms (allergic) tests may be performed to determine the allergens Desensitizing immunization and corticosteroids may be required

S/Sx: symptoms of infection raspy voice odynophagia (a severe sensation of burning, squeezing pain while swallowing) unilateral tonsillar hypertrophy dehydration dysphagia (difficulty of swallowing) otalgia (pain in the ear) drooling marked swallowing of the soft palate, often occluding

Pharmacologic Management: Meds for allergic and non-allergic rhinitis focuses on symptomatic relief Antihistaminic: sneezing, itching and rhinorrhea Oral decongestants: nasal obstruction Intranasal corticosteroids- for severe congestion Opthalmic agents

Medical Management: Antibiotics (usually penicillin)- primarily bactericidal If treatment is delayed the abscess is evacuated through surgery (in a sitting position for easier expectoration of pus and blood) single or repeated aspiration to decompress the abscess Incision and draining

Nursing Management: 1. Teach patients self-care. 2. Avoid allergens 3. Saline nasal or aerosol spray Common Colds/ Viral Rhinitis The cold refers to an afebrile, infectious, acute inflammation of the mucous membrane of the nasal cavity. Highly contagious, virus shed for about 2 days before the symptoms appear and during the 1st part of the symptomatic phase Causative Agent: Rhinovirus (50% of all cases) Parainfluenza virus Coronavirus Respiratory Synctial Virus Influenza Virus Adenovirus

Nursing Management 1. Considerable relief maybe obtained by the use of topical anesthetic agents and throat irrigation on the frequent use of mouthwashes or gargle, using saline or alkaline solutions (40.6 to 43.3 degC) 2. Instruct the patient to gargle at intervals of 1 to 2 hours for 24 to 36 hours. 3. Liquids that are cool or at room temperature may be well tolerated. RHINITIS- an inflammation of the mucous membranes of the nose; classified as infections (most commonly caused by URI), allergic Causes: Fernandez BSN

Clinical Manifestaion of Viral Rhinitis: Foreign bodies entering the nose nasal congestion runny nose
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nasal discharge nasal itchiness teary watery eyes scratchy sore throat general malaise low-grade fever chills headaches muscle ache

Expectorant may be used 3 L of daily fluid intake

COMMON PEDIATRIC RESPIRATORY DISORDERS A.) Epiglottitis bacterial infection of the epiglottis - Caused by Haemophilius Influenza type B or strep pneumonia - Age group : 2-5 y.o. - Onset is abrupt - Often occurs in winter - EMERGENCY situation - Tripod position S/Sx: fever sore throat (red & inflamed) spontaneous coughing drooling muffled voice respiratory stridor agitation TRIPOD position

May last 1 to 2 weeks If severe persists with S/Sx, URTI. Medical Management: No specific treatment Adequate fluid intake, rest, increase Vitamin C, expectorants Warm salt water gargles Pharmacologic Therapy: 1. NSAIDS 2. Antihistamines 3. Topical decongestants (rebound) 4. Zinc lozenges 5. Amantadine (symmetrel) 6. Rimantadine (flumadine) 7. Antibiotics should not be used Nursing Management: 1. Teach patient self-care 2. Direct contact must be avoided 3. Handwashing 4. Rest 5. Balanced diet LARYNGITIS- inflammation of the larynx, due to voice abuse, exposure to dust, chemicals, smoke, other pollutants and may be infection - Viral infection - Bacterial may be secondary - Associated woth other conditions Clinical manifestation: ACUTE o Hoarseness o Aphonia o Severe cough Chronic o Persistent hoarseness o complications of URTI Medical Management: Resting the voice Avoid smoking Resting Inhaling cool steam or alcohol Antibiotic is started Topical corticosteroids: Beclomethasone dipropionate (Vanceril) inhalation Rest the voice

Nursing Care 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Send immediately to hospital. Nasotracheal tube intubation Monitr signs of distress Maintain patent airway NPO Dont have child unattended Dont restrain IV Fluids Antibiotics Analgesic and antipyretic Cool mist oxygen Increase humidification Resuscitation Immunization (Haemophilus type B)

B.) Broncholitis (Respiratory Synctial Virus) - An inflammation of the bronchioles - Increase mucus production Assessment: Rhinorrhea and decrease fever Lethargy Poor feeding Irritability Tachypnea Dyspnea Nasal Flaring Wheezing Diminished Breath Sound Nursing Care Maintain airway High Fowlers
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Cool humidified oxygen Oral and IV fluids Assess for dehydration (for RSV) Place patient in private Room Observe proper handwashing Avoid contamination for others RIBAVIRIN (Virazol) DOC Pregnant health care providers must avoid contact with patients, considered as TERATOGENS

Medical Management: SC epinephrine or a corticosteroid if caused from an allergic reaction Ice pack to the neck Foreign body airway obstruction (FBAO) from APHYXIA Subdiaphragmatic abdominal thrust maneuver Immediate tracheotomy b.) Sleep Apnea Syndrome- cessation of breaqthing during sleep, frequent snoring and breathing cessation for 10 seconds or more Risk Factors: Men Overweight Smoking Reduced pharyngeal muscle tone Neuromuscular disease, sedative hypertropics Types: 1. Obstructive- lack of air flow due to pharyngeal obstruction 2. Central- simultaneously cessation of airflow and respiratory movements 3. Mixed- a combination of central and obstructive apnea with one apneic episode S/Sx:

c.) Laryngeotracheobronchitis (LTB)/ Croup S/Sx: inflammation of mucosal lining with the larynx and trachea and sometimes reaches the bronchi usually viral causative agent (Parainfluenza virus, RSV) commonly found in children less than 5 y.o.

barky, brassy cough hoarseness restlessness low-grade fever inspiratory stridor non-toxic appearance

Management: mist tents rocemiec epinephrine corticosteroids HELIOX- svere cases (TOC) Monitor for respiratory status Rest Avoid use of cough syrup and cold medicine Walk the child outdoors Open the faucet (steam inhalation) Increase moisture in the air Cool vapor therapy/stram inhalation to relieve laryngeal and tracheal irritation Moist heat to chest to relieve soreness and pain Povide mild analgesics

Daytime sleepiness Morning headache Sore throat Intellectual deterioration Personality Disorders Behavioral changes Enuresis (urinary incontinence) Impotence Obesity Loud Snoring

Nursing Management: 1. CPAP- face mask c.) Nasal Obstruction- passageway of air through the nostrils obstructed by deviated nasal septum - Hypertrophy of the turbinate bones or pressure of the nasal polyp (grapelike swelling) - May lead to nasal infection Management: Removal of obstruction Treat chronic infection and allergy Endoscopic surgery Submucous resection/ Septoplasty -incision of mucous membrane and removing deviated bone and cartilage Nasal polyp removal by clipping them at the base with a WIRE SNARE
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OBSTRUCTION of the UPPER AIRWAY a.) Laryngeal Obstruction- larynx contains a narrow space between the vocal chords (glottis) through which the air pass -swelling of the laryngeal mucous membranes sloughs off the opening tightly leading to suffocation because larynx cannot stretch Causes: Laryngitis Client with uticaria Severe inflammation of the throat Death in severe anaphylaxis Foreign bodies

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d.) Fracture of the Nose- direct assault; deformity Assessment: X-ray- to reveal displacement of fractured bones and possible fracture of the skull Internal examination DIPSTICK or DEXTROSTIX- clear fluid draining from either nostril suggest CSF leakage; yellowish halo ring Management: Cold compress for bleeding Nose symmetry assessed before and after swelling Reffered to a specialist 7-10 days after injury Apply ice pack to nose for 20 min 4x a day to decrease swelling Mouth rinses to moisten mucous membrane MANAGEMENT of CLIENTS with LOWER AIRWAY VESSEL DISORDER 1. Asthma- disorder of the bronchial airways characterized by periods of reversible bronchospasm o Commonly caused by physical and chemical irritants o Bronchial obstruction Status Asthmaticus- child displays respiratory distress despite vigorous treatment Assessment: Wheezing Dyspnea Chest tightness Exacerbation- air is trapped behind, occluded Asthmatic Episode: Irritability Restlessness Headache Chest tightness Non-productive cough Later stage: productive, frothy Nursing Management: Airway Humidified oxygen Monitor respiratory status Oral and IV fluids Nutrition: Electrolyte replacement if needed Prepare the child for CXR Medications: 1. B2 Agonist- albuterol (Froventil), Salbutamol (Ventolin), Metaproterinol sulfate ( Alupent), Terbutaline sulfate (Brethaire, Brethine, Bricanyl)
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2. Anticholinergic- atropine sulfate, ipratoropium bromide, atrovent 3. Systemic corticosteroids 4. Methylxanthines- increase the cAMP which relaxes the smooth muscles promoting bronchodilation 5. Leukotrienes Modifiers- Zafirlukast (Accoloate) and Zileuton (Zyfic), given for ABOVE 12 years old only 6. Long-Acting Bronchodilators Home Care Measures: Allergens control Avoid extremes of temperature Avoid exposure to viral respiratory infection Recognize early symptoms Exercise as tolerated CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) - Disease state characterized by airflow limitation that is NOT REVERSIBLE - Include disease that cause airflow obstruction - Includes emphysema and chronic bronchitis Pathophysiology: Inflammation response to noxious particles and gases I Affecting airways, parenchyma, pulmonary vasculature I Chronic inflammation and bodys effort to repair it I Narrowing in small peripheral airways I Chronic injury and repair process I Scar tissue formation and narrowing of airway lumen I Airflow Obstruction Risk Factors: Exposure to tobacco smoking Passive smoking Occupational exposure Ambient air pollution Deficient alpha 1 antitrypsin- an enzyme inhibitor that protect the lung parenchyma Effects of Smoking Depresses activity of scavenger cells and affects the ciliary cleansing mechanism which keeps breathing passages free of irritants, bacteria, and other foreign matter I Airflow is obstructed and air becomes trapped, behind the obstruction I Alveoli distended, diminishing lung capacity I
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Goblet cells and mucus irritation I Increased accumulation of muscles (more mucus irritation) I CO binds with Hemoglobin and becomes carboxyhemoglobin I Insufficient transport of oxygen 1. Chronic Bronchitis - Presence of cough and sputum production for at least 3 months in each of two consecutive years - Smoke/ environmental pollutants irritate the airways - BLUE BLOATER - Thickened bronchial walls, narrowed bronchial lumen, mucus plug airways - Dysfunctional macrophages from damaged and fibrosed bronchioles Assessment Chronic cough blue bloater Edematous cyanotic 2. Emphysema - Impaired gas exchange (oxygen and carbon dioxide) results from destruction of the walls of overdistended alveoli - Abnormal distention of the air spaces begin the terminal bronchioles with alveoli wall destruction - Recurrent infection destroy alveoli walls - Impaired oxygen diffusion resulting to hypoxemia - Hypercapnea, causing respiratory acidosis - Weight loss Complication: 1. Cor pulmonale - R-sided heart failure - Increase pulmonary blood flow because of reduced capillary blood flow - RV must maintain a higher blood pressure in the PA 2. Respiratory Insufficiency and failure 3. Pneumonia 4. Pneumothorax S/Sx:

Types of Emphysema: 1. Panlobular (Panacinar) - Distribution of the bronchioles, alveolar ducts and alveoli - Enlarged air spaces but little inflammatory disease - BARREL CHEST appearance- hyperinflated, hyperexpanded Inhalation o Normal: (-) pressure o Emphysema: Resting Position Exhalation o Normal: (+) pressure, involuntary passive act o Emphysema: active and muscular effort (SOB, rigid chest) 2. Centrilobular (Centroacinar) - Pathologic changes in the center of the secondary lobule, preserving the peripheral portions of the alveoli - Hypoxemia, hypercapnea, episodes of RHF which may lead to cyanosis, peripheral edema and respiratory failure Risk Factors: Smoking cigarette and passive smoker Prolonged intense exposure to occupational dusts and chemicals Air pollution (indoor and outdoor) Deficient alpha 1-antitryspin (enzyme inhibitor test that protects lung parenchyma)

S/Sx:

Cough Sputum production Dyspnea or exertion and at rest, if severe Weight loss Barrel chest Shoulders heave forward and upward

Exertional dyspnea Congestion Dependent edema Distended neck veins Pain in the region of the liver (RUQ) Weight loss PINK PUFFER

Management: Risk reduction Smoking cessation Meds for long term smoking Abstinence Bupropion SR (zyban) Antidepressant Nicotine Gum Nicotine Inhaler Nicotine Nasal Spray Nicotine patch Pharmacologic Therapy o Bronchodilators - relieve bronchospasm, reduce airway obstruction by allowing increased oxygen distribution through out the lungs and improving alveolar ventilation
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-via metered dose inhaler (MDI), nebulization, oral B adrenergic agonists -anticholinergic -methylxanthine o Corticosteriods - Inhaled or systemic (oral IV) - Beclomethasone (beclovent) - Budesonide - Flusisonide - Fluticasone (fluvent) - Triamcinolone (azmacort) o Other meds - Yearly influenza vaccine - Every 3-5 years pneumonia vaccine - Alpha 1-antitrypsin augmentation therapy - antibiotics, antitussive, mucolytic Management of Exacerbation: Casues: Tracheobronchial infection Air pollution Pneumonia Pulmonary embolism Pneumothorax Rib fractures, chest trauma Inappropriate use of sedatives, opiods, B-blockers R or L sided heart failure. 1. Identify primary cause. 2. Optimize bronchodilator therapy. 3. Hospital if with uncontrolled dyspnea, lethargy, respiratory distress, muscle fatigue, peripheral edema, worsening of central cyanosis. 4. Oxygen 1-2 LPM Surgery BULLECTOMY removal of BULLOUS EMPHYSEMA Bullous are enlarged air spaces that do not contribute to ventilation but occupy space in the thorax compressing areas of lungs that have adequate space. LUNG VOLUME REDUCTION removal of a portion of a diseased lung parenchyma, allowing expansionof functional tissue improving elastic recoil. LUNG TRANSPLANTATION end-stage emphysema; organs are in short in supply.

Physical fitness and respiratory fitness Oxygen therapy Nutrition C. BRONCHIECTASIS a chronic irreversible dilation of the bronchi and bronchioles ASPIRATION PNEUMONIA Non-infectious Aspiration of fluids (gastric secretion), foods, liquids, tube (feedings) into the airways. BACTERIAL ASPIRATION PNEUMONIA -related to poor cough mechanisms due to anesthesia, coma (mixed flora of URT cause pneumonia) HEMATOGENOUS PNEUMONIA BACTERIAL INFECTIONS -related to spread of bacteria from the bloodstream S/Sx: Marked tachypnea Signs of resp. distress: SOB, use of accessory muscles RAPID bouncing pulse URTI: nasal congestion, sore throat PREDOMINANT SYMPTOMS Headeache Low grade fever Pleuretic pain Myalgia Rash Pharyngitis Pain location: chest (affected side), reffered to abdominal shoulder and flank Flushed cheeks and cyanotic lips and nailbeds Orthopnea Poor appetite Diaphoretic and tires easily N/V, anorexia Productive, rust (blood) or yellowish sputum (greenish with atypical pneumonia) Sudden fever, chills Nasal flaring, circumoral cyanosis Respiratory distress, tachypnea Decrease breath sounds in affected side Crackles, bronchial breath sound Dullness on percussion over consolidated area Possible friction rub Chest rertraction (air hunger in infants) Management: A. Pharmacological Therapy 1. Hospital patient with no CP disease - IV azithromycin (zithromax) - Fluoroqionolone 2. In patients with CP disease - IV beta-lactam - IV or oral macrolide or doxycyline
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Nursing Management Patient Education Breathing exercises teach diaphragmatic breathing, reduce RR, involve alveolar ventilation, expel as much air as possible during expiration. (Yoga Breathing) Pursed lip breathing Slow expiration prevents collapse of small airways. Active self-care and activity pacine
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3. Mycoplasma Pneumonia - Doxycyline or Macrolide VIRAL Treatment is supportive antibiotics are ineffective in viral URTI. Hydration, anitpyretucs for headache and fever Antitussive Warm moist inhalation Anitihistamines Bed rest Oxygen & ABG 4. 5. 6. 7.

Cough and deep breathing exercise Use bedside spirometer q 1 hour Oxygen as ordered Monitor effects of respiratory therapy, ventilators Position: On unaffected side to allow for lung expansion. Positive End Expiratory Pressure (PEEP) Therapy (simple mask and 1-way valve system that provides varying amounts of oxygen)

COMPLICATIONS: 1. Shock and Respiratory Failure TX: o Hemodynamic and ventilator support to combat peripheral collapse o Maintain BP and provide adequate oxygenation o Vasopressors (vasopressin, norepinephrine) o Corticosteroids (digoxin, dobutamine) 2. Atelectasis and Pleural Effusion Tx: o Thoracentesis *empymea (thick purulent fluid which in th pleural space) o Chest Tube for proper drainiage of empyema 3. Superinfection very large doses of penicillin, or a combination of antibiotics - Bacteria become RESISTANT to the antibiotic - If patient improves and fever DIMINISHES after the intial antibiotic therapy but SUBSEQUENTLY there is a rise in temperature with cough and evidence that pneumonia has spread - Revise antibiotics or D/C entirely - X-Ray : patches of consolidation; elevated diaphragm; mediastinial shift These are strategies to expand the lung: Frequent turning Early mobilization Deep breathing q 2 hours Incentive spirometry voluntary deep breathing coughing suctioning aerosol nebulizer treatment: postural drainage chest percussion bronchoscopy Management: 1. Relieve hypoxia 2. Frequent respiratory assessment 3. Respiratory hygiene measures

Prevent Complications - Antibiotics as ordered - Turn and early ambulation - Increase fluid intake to liquefy secretions Health Teachings - Need to repeat s/sx for early recognition of problem - Importance of coughing and deep breathing INFECTIOUS DISORDER A. Pneumonia acute inflammation of lungs with exudates accumulated in alveoli and other respiratory passages that interferes with ventilation Management: o Rest o Supplemental oxygen o Ca-Channel blockers for VASODILATION o Cardiac Glycosides to improve cardiac function Ex. Digoxin (+) inotropic o In presence of COR PULMONALE, tx include: fluid restriction o Diuretics to decrease fluid accumulation o Manage the underlying cardiac or pulmonary condition. o IV prostacylin (epoprostanol) - Helps to decrease pulmonary hypertension by reducing pulmonary vascular resistance and pressure and increase carbon dioxide o Anticoagulants: Warfarin Nursing Management: o Identify patient at high risk, such as those with COPD, pulmonary emboli, CHD, and Mitral Valve disease o Must be alert for s/sx o Administer oxygen therapy appropriately o Health teaching and monitor patients compliance to meds.

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