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  3. 3. RHINITIS <ul><li>characterized by inflammation and irritation of the mucous membranes of the nose. </li></ul><ul><li>can be: </li></ul><ul><ul><li>acute or chronic </li></ul></ul><ul><ul><li>nonallergic or allergic </li></ul></ul><ul><li>Allergic rhinitis classified as: </li></ul><ul><ul><li>seasonal </li></ul></ul><ul><ul><ul><li>occurs during pollen seasons </li></ul></ul></ul><ul><ul><li>perennial rhinitis. </li></ul></ul><ul><ul><ul><li>occurs throughout the year </li></ul></ul></ul>
  4. 4. Pathophysiology <ul><li>Nonallergic rhinitis may be caused by: </li></ul><ul><ul><li>environmental factors such as changes in temperature or humidity </li></ul></ul><ul><ul><li>odors, or foods; </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>systemic disease; </li></ul></ul><ul><ul><li>drugs (eg, cocaine), over-the-counter (OTC) and prescribed nasal decongestants, and other medications; </li></ul></ul><ul><ul><li>presence of a foreign body </li></ul></ul><ul><ul><li>Most common cause of nonallergic rhinitis is the common cold. </li></ul></ul><ul><ul><li>Drug-induced rhinitis is associated with use of: </li></ul></ul><ul><ul><ul><li>antihypertensive agents </li></ul></ul></ul><ul><ul><ul><li>oral contraceptives </li></ul></ul></ul><ul><ul><ul><li>chronic use of nasal decongestants. </li></ul></ul></ul><ul><li>Allergic Rhinitis </li></ul><ul><li>IgE-mediated response which causes the release of vasoactive substances </li></ul>
  5. 5. Causes of Rhinitis Idiopathic Abuse of nasal decongestants (rhinitis medicamentosa) Psychological stimulation (anger, sexual arousal) Irritants (smoke, air pollution, exhaust fumes, cocaine) Vasomotor Causes Category Tumor Deviated septum Crusting Hypertrophied turbinates Foreign body Cerebrospinal fluid leak Mechanical
  6. 6. CAUSES CATEGORY Pregnancy Use of oral contraceptives Hypothyroidism Hormonal Acute viral infection Acute or chronic sinusitis Rare nasal infections (syphilis, tuberculosis) Infectious Polyps (in cystic fibrosis) Sarcoidosis Wegener's granulomatosis Midline granuloma Chronic inflammatory
  7. 7. Pathophysiology <ul><li>Allergic Rhinitis </li></ul><ul><li>Allergens bind with the cells in the nasal mucosa -> production of allergen-specific IgE which has a high affinity to IgE receptors present on the surface of mast cells located in the nasal mucosa </li></ul><ul><li>Sensitization of mast cells result to degranulation and initiation of inflammatory events (synthesis of interleukin and infiltration of inflammatory cells) </li></ul><ul><li>Early phase of inflammation </li></ul><ul><ul><li>Release of preformed mediators such as histamine, tryptase, kinin and heparin </li></ul></ul><ul><li>Late phase </li></ul><ul><ul><li>Migration of other inflammatory cells ( eosinophils, lymphocytes, macrophages to the nasal mucosa </li></ul></ul>
  8. 8. Pathophysiology <ul><li>Infectious Rhinitis </li></ul><ul><li>Infectious agent comes in contact with ciliated epithelial cells in the nasal mucosa </li></ul><ul><li>Increased production of mucus and immunoglobulin accompanied by shedding of epithelial cells </li></ul>
  9. 9. Rhinitis and Sinusitis <ul><li>The mucous membranes lining the nasal passages become inflamed, congested, and edematous. </li></ul><ul><li>The swollen nasal conchae block the sinus openings, and mucus is discharged from the nostrils. </li></ul>
  10. 10. Upper Respiratory Tract Disorders in the Elderly <ul><li>URI in the elderly may have more serious consequences if with concurrent medical problems that compromise their respiratory or immune status. </li></ul><ul><li>Antihistamines to treat upper respiratory disorders must be used cautiously in the elderly </li></ul><ul><ul><li>Due to side effects and potential interactions with other medications. </li></ul></ul><ul><li>Sinusitis in the elderly is often preceded by nasal packing for treatment of epistaxis. </li></ul><ul><li>Laryngitis & gastroesophageal reflux disease (GERD). </li></ul><ul><ul><li>elderly are likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. </li></ul></ul><ul><ul><li>Tx: </li></ul></ul><ul><ul><ul><li>sleeping with the head of the bed elevated </li></ul></ul></ul><ul><ul><ul><li>Meds: H2-receptor blockers (eg, famotidine [Pepcid], ranitidine [Zantac]) </li></ul></ul></ul><ul><ul><ul><ul><li>Proton pump inhibitors (omeprazole [Prilosec]). </li></ul></ul></ul></ul>
  11. 11. Clinical Manifestations <ul><li>nonallergic rhinitis include: </li></ul><ul><ul><li>rhinorrhea (excessive nasal drainage, runny nose); </li></ul></ul><ul><ul><li>nasal congestion; </li></ul></ul><ul><ul><li>nasal discharge (purulent with bacterial rhinitis); </li></ul></ul><ul><ul><li>sneezing; </li></ul></ul><ul><ul><li>pruritus of the nose, roof of the mouth, throat, eyes, and ears. </li></ul></ul><ul><ul><li>Headache may occur, particularly if sinusitis is also present. </li></ul></ul><ul><ul><li>can occur throughout the year. </li></ul></ul>
  12. 12. Medical Management <ul><li>depends on the cause, which may be identified through the history and physical examination. </li></ul><ul><li>Assess recent symptoms as well as possible exposure to allergens in the home, environment, or workplace. </li></ul><ul><li>If viral rhinitis is the cause, medications are given to relieve the symptoms. </li></ul><ul><li>In allergic rhinitis, tests may be performed to identify possible allergens. </li></ul><ul><ul><li>desensitizing immunizations and corticosteroids may be required (severity) </li></ul></ul><ul><li>If bacterial infection, an antimicrobial agent will be used </li></ul><ul><li>Patients with nasal septal deformities or nasal polyps may be referred to an ear, nose, and throat specialist. </li></ul>
  13. 13. Pharmacologic Therapy <ul><li>Medication therapy for allergic and nonallergic rhinitis focuses on symptom relief. </li></ul><ul><li>Antihistamines for sneezing, pruritus, and rhinorrhea. </li></ul><ul><li>1 st generation: </li></ul><ul><ul><li>diphenhydramine (Benadryl) </li></ul></ul><ul><ul><li>chlorpheniramine (Chlor-Trimeton) </li></ul></ul><ul><ul><li>brompheniramine. </li></ul></ul><ul><li>2 nd generation: </li></ul><ul><ul><li>loratadine (Alavert, Claritin) </li></ul></ul><ul><ul><li>fexofenadine (Allegra) </li></ul></ul><ul><ul><li>cetirizine (Zyrtec). </li></ul></ul><ul><ul><li>Dimetapp (brompheniramine/pseudoephedrine) is an example of a combination antihistamine. </li></ul></ul><ul><li>Oral decongestant agents for nasal obstruction. </li></ul><ul><li>cromolyn (Nasalcrom), which inhibits the release of histamine and other chemicals. </li></ul>
  14. 14. Pharmacologic Therapy <ul><li>Use of saline nasal spray </li></ul><ul><ul><li>act as a mild decongestant and can liquefy mucus to prevent crusting. </li></ul></ul><ul><li>2 inhalations of intranasal ipratropium (Atrovent) </li></ul><ul><ul><li>each nostril 2 to 3 times per day for symptomatic relief of rhinorrhea. </li></ul></ul><ul><li>Intranasal corticosteroids for severe congestion </li></ul><ul><li>Ophthalmic agents to relieve irritation, itching, and redness of the eyes. </li></ul><ul><li>The choice of medications depends on the symptoms, adverse reactions, adherence factors, risk of drug interactions, and cost to the patient. </li></ul>
  15. 15. Nursing Management <ul><li>Teaching Patients Self-Care </li></ul><ul><li>Avoid or reduce exposure to allergens and irritants, such as dusts, molds, animals, fumes, odors, powders, sprays, and tobacco smoke. </li></ul><ul><li>Patient education in the use of OTC medications. </li></ul><ul><ul><li>To prevent possible drug interactions, read drug labels before taking any OTC medication. </li></ul></ul><ul><li>Instructs the patient about the importance of controlling the environment at home and at work. </li></ul><ul><li>Saline nasal or aerosol sprays may be helpful in soothing mucous membranes, softening crusted secretions, and removing irritants. </li></ul><ul><li>Instructs the patient in the proper technique for administrating nasal medications. </li></ul><ul><ul><li>achieve maximal relief, instructed to blow the nose before applying any medication into the nasal cavity. </li></ul></ul><ul><ul><li>patient is taught to keep the head upright; spray quickly and firmly into each nostril away from the nasal septum, and wait at least 1 minute before administering the second spray. The container should be cleaned after each use. </li></ul></ul>
  16. 16. Nursing Management <ul><li>Infectious rhinitis </li></ul><ul><ul><li>Reviews hand hygiene technique with the patient as a measure to prevent transmission of organisms. </li></ul></ul><ul><ul><li>Teaches methods to treat symptoms of viral rhinitis. </li></ul></ul><ul><ul><li>In the elderly and other high-risk populations, review the value of receiving an influenza vaccination each year to achieve immunity before the beginning of the ‘flu season.’ </li></ul></ul>
  17. 17. Nursing Alert <ul><li>Be aware that some people use a variety of herbal products to prevent and treat nasal infection. </li></ul><ul><li>Vitamin C, zinc and Echinacea are safe to use but should not be taken in greater amounts. </li></ul><ul><li>Be aware that some people use a variety of herbal products to prevent and treat nasal infection. </li></ul><ul><li>Vitamin C, zinc and Echinacea are safe to use but should not be taken in greater amounts. </li></ul>
  18. 18. Viral Rhinitis (Common Cold) <ul><li>most frequent viral infection in the general population. </li></ul><ul><li>common cold often is used when referring to a URI that is self-limited and caused by a virus. </li></ul><ul><li>‘ cold’ refers to an afebrile, infectious, acute inflammation of the mucous membranes of the nasal cavity. </li></ul><ul><li>characterized by: </li></ul><ul><ul><li>nasal congestion, </li></ul></ul><ul><ul><li>rhinorrhea, </li></ul></ul><ul><ul><li>sneezing, </li></ul></ul><ul><ul><li>sore throat, </li></ul></ul><ul><ul><li>general malaise. </li></ul></ul><ul><li>Colds are highly contagious, because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. </li></ul>
  19. 19. Viral Rhinitis (Common Cold) <ul><li>Etiology: </li></ul><ul><ul><li>Rhinoviruses </li></ul></ul><ul><ul><li>Coronaviruses </li></ul></ul><ul><ul><li>Adenovirus </li></ul></ul><ul><ul><li>Respiratory syncytial virus (RSV) </li></ul></ul><ul><ul><li>Influenza virus </li></ul></ul><ul><ul><li>Parainfluenza virus. </li></ul></ul><ul><li>Each virus may have multiple strains. </li></ul><ul><li>Because of this diversity, development of a vaccine is almost impossible. </li></ul><ul><li>Immunity after recovery is variable and depends on many factors, including a person's natural host resistance and the specific virus that caused the cold. </li></ul><ul><li>Despite popular belief, cold temperatures and exposure to cold rainy weather do not increase the incidence or severity of the common cold. </li></ul>
  20. 20. Clinical Manifestations <ul><ul><li>nasal congestion </li></ul></ul><ul><ul><li>rhinorrhea and nasal discharge </li></ul></ul><ul><ul><li>Sneezing </li></ul></ul><ul><ul><li>tearing watery eyes </li></ul></ul><ul><ul><li>‘ scratchy’ or sore throat </li></ul></ul><ul><ul><li>general malaise </li></ul></ul><ul><ul><li>low-grade fever, chill </li></ul></ul><ul><ul><li>often headache and muscle aches </li></ul></ul><ul><li>As the illness progresses, cough usually appears. In some people, the virus exacerbates herpes simplex, commonly called a ‘cold sore’ (Chart 22-2). </li></ul><ul><li>may last from 1 to 2 weeks. </li></ul><ul><li>If there is significant fever or more severe systemic respiratory symptoms, it is no longer considered viral rhinitis but one of the other acute URIs. </li></ul><ul><li>Allergic conditions can also affect the nose, mimicking the symptoms of a cold. </li></ul><ul><ul><li>nasal congestion </li></ul></ul><ul><ul><li>rhinorrhea and nasal discharge </li></ul></ul><ul><ul><li>Sneezing </li></ul></ul><ul><ul><li>tearing watery eyes </li></ul></ul><ul><ul><li>‘ scratchy’ or sore throat </li></ul></ul><ul><ul><li>general malaise </li></ul></ul><ul><ul><li>low-grade fever, chill </li></ul></ul><ul><ul><li>often headache and muscle aches </li></ul></ul><ul><li>As the illness progresses, cough usually appears. In some people, the virus exacerbates herpes simplex, commonly called a ‘cold sore’ (Chart 22-2). </li></ul><ul><li>may last from 1 to 2 weeks. </li></ul><ul><li>If there is significant fever or more severe systemic respiratory symptoms, it is no longer considered viral rhinitis but one of the other acute URIs. </li></ul><ul><li>Allergic conditions can also affect the nose, mimicking the symptoms of a cold. </li></ul>
  21. 21. Medical Management <ul><li>symptomatic therapy. </li></ul><ul><li>providing adequate fluid intake </li></ul><ul><li>encouraging rest </li></ul><ul><li>preventing chilling </li></ul><ul><li>use expectorants as needed. </li></ul><ul><li>Warm salt-water gargles soothe the sore throat </li></ul><ul><li>non-steroidal anti-inflammatory agents (NSAIDs), such as aspirin or ibuprofen </li></ul><ul><ul><li>relieve the aches, pains, and fever in adults. </li></ul></ul><ul><li>Antihistamines </li></ul><ul><ul><li>relieve sneezing, rhinorrhea, and nasal congestion. </li></ul></ul><ul><li>Topical (nasal) decongestant agents may relieve nasal congestion; however, overused result to rebound congestion </li></ul>
  22. 22. Medical Management <ul><li>zinc lozenges </li></ul><ul><ul><li>may reduce the duration of cold symptoms if taken within the first 24 hours of onset (Marshall, 2006). </li></ul></ul><ul><li>Amantadine (Symmetrel) or rimantadine (Flumadine) may be prescribed prophylactically </li></ul><ul><ul><li>to decrease the signs and symptoms as well. </li></ul></ul><ul><li>Antibiotics should not be used </li></ul><ul><ul><li>do not affect the virus or reduce the incidence of bacterial complications. </li></ul></ul>
  23. 23. Nursing Management <ul><li>Teaching Patients Self-Care </li></ul><ul><li>TRANSMISSION: </li></ul><ul><ul><li>direct contact with infected secretions; </li></ul></ul><ul><ul><li>inhalation of large particles from others' coughing or sneezing; </li></ul></ul><ul><ul><li>inhalation of small particles (aerosol) that may be suspended in the air for up to an hour. </li></ul></ul><ul><li>Teaches the patient how to break the chain of infection. </li></ul><ul><li>Handwashing remains the most effective measure </li></ul><ul><ul><li>to prevent transmission of organisms. </li></ul></ul><ul><li>Provides both verbal and written information to assist the patient in the prevention and management of URIs. </li></ul>
  24. 24. Preventing and Managing URI <ul><li>Preventive measures </li></ul><ul><ul><li>Hand hygiene </li></ul></ul><ul><ul><li>Use of disposable tissues </li></ul></ul><ul><ul><li>Cover mouth when coughing or sneezing </li></ul></ul><ul><ul><li>Avoid crowds during the flu season </li></ul></ul><ul><ul><li>Avoid people with infections </li></ul></ul><ul><ul><li>Obtain annual flu vaccines (esp elderly/with chronic illness) </li></ul></ul><ul><li>Practice good health habits </li></ul><ul><ul><li>Eat nutritious diet </li></ul></ul><ul><ul><li>Adequate sleep, rest and exercise </li></ul></ul><ul><ul><li>Avoid tobacco in all forms </li></ul></ul><ul><ul><li>Avoid second hand smoke </li></ul></ul><ul><ul><li>Increase humidity in the home </li></ul></ul><ul><ul><li>Avoid irritants (dust/chemicals) to include exposure to animals </li></ul></ul><ul><ul><li>Use central air conditioning with microstatic air filters </li></ul></ul>
  25. 25. Preventing and Managing URI <ul><li>Strategies to relieve symptoms of URI </li></ul><ul><ul><li>Increase fluid intake </li></ul></ul><ul><ul><ul><li>Warm fluids (chicken soup) soothing for irritated throat </li></ul></ul></ul><ul><ul><li>Elevate HOB </li></ul></ul><ul><ul><li>Gargle with salt water frequently for sore throat (1/4 tsp of salt in 8 oz warm water) </li></ul></ul><ul><ul><li>Use throat lozenges for cough/sore throat </li></ul></ul><ul><ul><li>Use saline nose drops/spray </li></ul></ul>
  26. 26. Nursing Alert <ul><li>Due to the risk of gastrointestinal bleeding, the following medication should be avoided: </li></ul><ul><ul><li>Aspirin </li></ul></ul><ul><ul><li>Ibuprofen </li></ul></ul><ul><ul><li>Naproxen </li></ul></ul><ul><li>Especially persons who are: </li></ul><ul><ul><li>Not eating well </li></ul></ul><ul><ul><li>Hx of peptic ulcer or related disorder </li></ul></ul><ul><ul><li>With aspirin-sensitive asthma </li></ul></ul><ul><ul><li>Renal dysfunction. </li></ul></ul><ul><li>Patients who have high blood pressure, diabetes, or thyroid disease, and those who are pregnant should check with their physician before using a decongestant. </li></ul><ul><li>Pregnant women should avoid use of zinc and dextromethorphan (Benylin) </li></ul><ul><li>Patients taking monoamine oxidase (MAO) inhibitors (eg, phenelzine sulfate [Nardil], tranylcypromine [Parnate]) should not use dextromethorphan [Robitussin]. </li></ul>
  27. 27. Acute Sinusitis
  28. 28. Acute Sinusitis <ul><li>Sinusitis (inflammation of the sinuses) </li></ul><ul><li>The sinuses, mucus-lined cavities filled with air, normally drain into the nose and are involved in many URIs. </li></ul><ul><li>If their openings into the nasal passages are clear, the infections resolve promptly. </li></ul><ul><li>Continuous exposure to environmental hazards such as paint, sawdust, and chemicals may result in chronic inflammation of the nasal passages. </li></ul>
  29. 29. Pathophysiology <ul><li>Acute sinusitis is an infection of the mucous membranes that line the paranasal sinuses. </li></ul><ul><li>Five subtypes of sinusitis have been identified: </li></ul><ul><ul><li>Acute </li></ul></ul><ul><ul><ul><li>rapid-onset infection in one or more of the paranasal sinuses that resolves with treatment </li></ul></ul></ul><ul><ul><li>Subacute </li></ul></ul><ul><ul><ul><li>persistent purulent nasal discharge despite therapy with symptoms lasting less than 3 months. </li></ul></ul></ul><ul><ul><li>Chronic </li></ul></ul><ul><ul><ul><li>occurs with episodes of prolonged inflammation and with repeated or inadequate treatment of acute infections. Irreversible damage to the mucosa may occur. Symptoms last for longer than 3 months. </li></ul></ul></ul><ul><ul><li>Allergic </li></ul></ul><ul><ul><li>Hyperplastic sinusitis. </li></ul></ul>
  30. 30. Sinusitis <ul><li>marked by inflammation and congestion, with thickened mucous secretions filling the sinus cavities and occluding the openings. </li></ul>
  31. 31. <ul><li>Sinusitis often follows a URI or cold, such as an unresolved viral or bacterial infection, or an exacerbation of allergic rhinitis. </li></ul><ul><li>Nasal congestion, caused by: </li></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Edema </li></ul></ul><ul><ul><li>transudation of fluid secondary to URI </li></ul></ul><ul><ul><li>leads to obstruction of the sinus cavities as this provides an excellent medium for bacterial growth. </li></ul></ul><ul><li>Other conditions that can block the normal flow of sinus secretions include: </li></ul><ul><ul><li>abnormal structures of the nose, </li></ul></ul><ul><ul><li>enlarged adenoids, </li></ul></ul><ul><ul><li>diving and swimming, </li></ul></ul><ul><ul><li>tooth infection, </li></ul></ul><ul><ul><li>trauma to the nose, </li></ul></ul><ul><ul><li>Tumors </li></ul></ul><ul><ul><li>pressure of foreign objects. </li></ul></ul><ul><li>BACTERIAL CAUSES: </li></ul><ul><ul><li>Streptococcus pneumonia, </li></ul></ul><ul><ul><li>Haemophilus influenzae </li></ul></ul><ul><ul><li>Moraxella catarrhalis </li></ul></ul>
  32. 32. Pathophysiology <ul><li>Ciliated mucus membranes aid the movement of fluids and microorganisms from the sinuses into the nasal cavity. </li></ul><ul><li>Swelling can obstruct the sinus opening and impair mucociliary function. </li></ul><ul><li>Due to the lower oxygen content in the sinuses, growth of microorganisms can easily occur and alter immune cell function. </li></ul><ul><li>Changes in barometric pressure can lead to altered sinus ventilation and can delay clearance of secretions. </li></ul>
  33. 33. Clinical Manifestations <ul><li>Symptoms vary among people and dependent on the age of the person. </li></ul><ul><li>In adults involve: </li></ul><ul><ul><li>maxillary and anterior ethmoidal sinuses. </li></ul></ul><ul><li>Symptoms may include: </li></ul><ul><ul><li>facial pain or pressure over the affected sinus area, </li></ul></ul><ul><ul><li>nasal obstruction, </li></ul></ul><ul><ul><li>fatigue, </li></ul></ul><ul><ul><li>purulent nasal discharge, </li></ul></ul><ul><ul><li>fever, </li></ul></ul><ul><ul><li>headache, </li></ul></ul><ul><ul><li>ear pain and a sense of fullness, </li></ul></ul><ul><ul><li>dental pain, </li></ul></ul><ul><ul><li>decreased sense of smell, </li></ul></ul><ul><ul><li>sore throat, </li></ul></ul><ul><ul><li>early morning periorbital edema, and </li></ul></ul><ul><ul><li>cough that worsens when the patient is supine. </li></ul></ul><ul><li>< 2 symptoms rules out acute bacterial sinusitis </li></ul><ul><li>4 or more symptoms suggest acute bacterial sinusitis </li></ul><ul><ul><li>(DeAlleaume, Parker & Reider, 2003). </li></ul></ul>
  34. 34. Assessment and Diagnostic Findings <ul><li>A careful history and physical examination are performed. </li></ul><ul><li>There may be tenderness to palpation over the infected sinus area. </li></ul><ul><li>The affected area is also transilluminated; with sinusitis, there is a decrease in the transmission of light. </li></ul><ul><li>Sinus x-rays and computed tomography (CT) scans may be obtained for patients with frontal headaches, </li></ul><ul><li>Sinus aspirate </li></ul><ul><ul><li>To confirm the diagnosis of maxillary and frontal sinusitis and identify the pathogen. </li></ul></ul><ul><ul><li>Flexible endoscopic culture techniques have been used for this purpose as well as swabbing of the sinuses. </li></ul></ul>
  35. 35. Complications <ul><li>If untreated, may lead to severe and occasionally life-threatening complications: </li></ul><ul><ul><li>meningitis, </li></ul></ul><ul><ul><li>brain abscess = occur by direct spread (Frontal epidural abscesses ) </li></ul></ul><ul><ul><li>ischemic brain infarction, and </li></ul></ul><ul><ul><li>osteomyelitis. </li></ul></ul><ul><ul><li>severe orbital cellulitis, </li></ul></ul><ul><ul><li>subperiosteal abscess, </li></ul></ul><ul><ul><li>cavernous sinus thrombosis </li></ul></ul>
  36. 36. Medical Management <ul><li>GOAL: </li></ul><ul><ul><li>to treat the infection, shrink the nasal mucosa, and relieve pain. </li></ul></ul><ul><ul><li>Antibiotic therapy is used to eradicate the infecting organism. </li></ul></ul><ul><ul><li>First-line antibiotics </li></ul></ul><ul><ul><ul><li>amoxicillin, </li></ul></ul></ul><ul><ul><ul><li>ampicillin, </li></ul></ul></ul><ul><ul><ul><li>trimethoprim/sulfamethoxazole (Bactrin, Septra), and </li></ul></ul></ul><ul><ul><ul><li>erythromycin. </li></ul></ul></ul><ul><ul><li>Second-line antibiotic </li></ul></ul><ul><ul><ul><li>cephalosporins such as cefuroxime axetil (Ceftin) and cefprozil (Cefzil) and </li></ul></ul></ul><ul><ul><ul><li>amoxicillin clavulanate (Augmentin). </li></ul></ul></ul><ul><ul><li>Newer and more expensive antibiotics: </li></ul></ul><ul><ul><ul><li>Macrolides (clarithromycin [Biaxin], azithromycin [Zithromax]) and </li></ul></ul></ul><ul><ul><ul><li>quinolones such as levofloxacin (Levaquin) can be used if the patient has a severe allergy to penicillin. </li></ul></ul></ul><ul><ul><li>Deep-seated bacterial sinusitis treatment for 2 to 3 weeks. </li></ul></ul>
  37. 37. Medical Management <ul><li>nasal decongestants (pseudoephedrine hydrochloride [Sudafed]). </li></ul><ul><li>Decongestants or nasal saline spray (improve patency of the ostiomeatal unit and improve drainage of the sinuses.) </li></ul><ul><li>Topical decongestants are used only in adults and should not be used for longer than 3 or 4 days. </li></ul><ul><li>Oral decongestants must be used cautiously in patients with hypertension. </li></ul><ul><li>OTC antihistamines: </li></ul><ul><ul><li>diphenhydramine (Benadryl) </li></ul></ul><ul><ul><li>cetirizine, fexofenadine are used if an allergic component is suspected. </li></ul></ul><ul><li>opening blocked passages : Heated mist and saline irrigation </li></ul><ul><li>If the patient continues to have symptoms after 7 to 10 days, the sinuses may need to be irrigated and hospitalization may be required. </li></ul><ul><li>nasal decongestants (pseudoephedrine hydrochloride [Sudafed]). </li></ul><ul><li>Decongestants or nasal saline spray (improve patency of the ostiomeatal unit and improve drainage of the sinuses.) </li></ul><ul><li>Topical decongestants are used only in adults and should not be used for longer than 3 or 4 days. </li></ul><ul><li>Oral decongestants must be used cautiously in patients with hypertension. </li></ul><ul><li>OTC antihistamines: </li></ul><ul><ul><li>diphenhydramine (Benadryl) </li></ul></ul><ul><ul><li>cetirizine, fexofenadine are used if an allergic component is suspected. </li></ul></ul><ul><li>opening blocked passages : Heated mist and saline irrigation </li></ul><ul><li>If the patient continues to have symptoms after 7 to 10 days, the sinuses may need to be irrigated and hospitalization may be required. </li></ul>
  38. 38. Nursing Management <ul><li>Teaching Patients Self-Care </li></ul><ul><li>Referral to a physician is indicated if periorbital edema and severe pain on palpation occur. </li></ul><ul><li>promote drainage of the sinuses, including humidification of the air in the home and use of steam inhalation and warm compresses to relieve pressure. </li></ul><ul><li>Advised to avoid swimming, diving, and air travel during the acute infection. </li></ul><ul><li>Instructed to immediately stop smoking or using any form of tobacco. </li></ul><ul><li>Teaches the patient about the side effects of nasal sprays and about rebound congestion. </li></ul><ul><ul><li>body's receptors have become dependent on the decongestant sprays to keep the nasal passages open. </li></ul></ul>
  39. 39. Chronic Sinusitis
  40. 40. Chronic Sinusitis <ul><li>a result of prolonged inflammation or repeated or inadequately treated acute sinus infections. </li></ul><ul><li>symptoms lasting longer than 3 months. </li></ul>
  41. 41. Chronic Sinusitis <ul><li>Pathophysiology </li></ul><ul><li>Causes: Mechanical obstruction of sinuses </li></ul><ul><li>Obstruction prevents adequate drainage to the nasal passages. </li></ul><ul><li>Blockage that persists longer than 3 weeks in an adult may occur: </li></ul><ul><ul><li>infection, </li></ul></ul><ul><ul><li>allergy, </li></ul></ul><ul><ul><li>structural abnormalities </li></ul></ul><ul><li>Result in stagnant secretions, an ideal medium for growth of bacteria. T </li></ul><ul><li>Immunocompromised patients are at increased risk for development of fungal sinusitis. </li></ul>
  42. 42. Chronic Sinusitis <ul><li>Clinical Manifestations </li></ul><ul><li>Impaired mucociliary clearance and ventilation, </li></ul><ul><li>Cough -thick discharge constantly drips backward into the nasopharynx </li></ul><ul><li>Chronic hoarseness </li></ul><ul><li>Chronic headaches in the periorbital area </li></ul><ul><li>Facial pain. </li></ul><ul><li>Breathe through the mouth. </li></ul><ul><li>Snoring </li></ul><ul><li>Sore throat </li></ul><ul><li>Periorbital edema and facial pain are common </li></ul><ul><ul><li>pronounced on awakening in the morning. </li></ul></ul><ul><li>a decrease in smell and taste </li></ul><ul><li>a sense of fullness in the ears. </li></ul>
  43. 43. Chronic Sinusitis <ul><li>Complications </li></ul><ul><ul><li>subperiosteal abscess </li></ul></ul><ul><ul><li>cavernous sinus thrombosis </li></ul></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><li>encephalitis, and </li></ul></ul><ul><ul><li>ischemic infarction. </li></ul></ul>
  44. 44. Chronic Sinusitis <ul><li>Medical Management </li></ul><ul><ul><li>same as for acute sinusitis. </li></ul></ul><ul><li>Antimicrobial agents of choice include: </li></ul><ul><ul><li>amoxicillin clavulanate (Augmentin) </li></ul></ul><ul><ul><li>ampicillin (Ampicin). </li></ul></ul><ul><ul><li>Clarithromycin (Biaxin) </li></ul></ul><ul><ul><li>Cephalosporins </li></ul></ul><ul><ul><li>Macrolides (eg, clarithromycin [Biaxin]) </li></ul></ul><ul><ul><ul><li>increase mucociliary clearance </li></ul></ul></ul><ul><ul><ul><li>improve sinusitis symptoms </li></ul></ul></ul><ul><ul><ul><li>decrease nasal secretions and polyp size associated with chronic sinusitis. </li></ul></ul></ul><ul><ul><li>course of treatment may be 3 to 4 weeks. </li></ul></ul><ul><li>As with acute sinusitis, decongestant agents, antihistamines, saline sprays, and heated mist may also provide some symptom relief. </li></ul>
  45. 45. Chronic Sinusitis <ul><li>Teaching Patients Self-Care </li></ul><ul><li>Frequent blowing of nose with force to clear their nasal passages </li></ul><ul><ul><li>increases the symptoms. </li></ul></ul><ul><li>Patient is instructed to blow the nose gently and to use tissue to remove the nasal drainage </li></ul><ul><li>Increasing the environmental humidity (eg, steam bath, hot shower, vaporizer) </li></ul><ul><li>increasing fluid intake </li></ul><ul><li>applying local heat (hot wet packs) </li></ul><ul><li>elevating the head of the bed promote drainage of the sinuses. </li></ul><ul><li>Following the medication regimen </li></ul>
  46. 46. Acute and Chronic Pharyngitis
  47. 47. Pharyngitis <ul><li>Acute Pharyngitis </li></ul><ul><ul><li>sudden inflammation of the pharynx that is more common in patients younger than 25 years of age (particularly between 5 and 15 years). </li></ul></ul><ul><ul><li>most common in adolescents and young adults. </li></ul></ul><ul><ul><li>It occurs less frequently in the elderly. </li></ul></ul><ul><ul><li>primary symptom is a sore throat </li></ul></ul><ul><li>Chronic Pharyngitis </li></ul><ul><ul><li>persistent inflammation of the pharynx. </li></ul></ul><ul><ul><li>common in adults who work or live in dusty surroundings, use their voice to excess, suffer from chronic cough, or habitually use alcohol and tobacco. </li></ul></ul>
  48. 48. Pharyngitis <ul><li>3 types of chronic pharyngitis: </li></ul><ul><li>Hypertrophic: </li></ul><ul><ul><li>characterized by general thickening and congestion of the pharyngeal mucous membrane </li></ul></ul><ul><li>Atrophic: </li></ul><ul><ul><li>late stage of the first type (the membrane is thin, whitish, glistening, and at times wrinkled) </li></ul></ul><ul><li>Chronic granular (‘clergyman's sore throat’), </li></ul><ul><ul><li>characterized by numerous swollen lymph follicles on the pharyngeal wall. </li></ul></ul>
  49. 49. Pharyngitis <ul><li>Etiology </li></ul><ul><li>Bacterial: </li></ul><ul><ul><li>Group A-hemolytic streptococci, </li></ul></ul><ul><ul><li>Hemophilus influenza, </li></ul></ul><ul><ul><li>Moraxella catarrhalis, </li></ul></ul><ul><ul><li>Corynebacterium gonorrhoeae </li></ul></ul><ul><li>Viral: </li></ul><ul><ul><li>Rhinovirus, </li></ul></ul><ul><ul><li>adenovirus, </li></ul></ul><ul><ul><li>parainfluenza virus, </li></ul></ul><ul><ul><li>coronavirus, </li></ul></ul><ul><ul><li>coxsackie virus </li></ul></ul><ul><li>Chronic causes: </li></ul><ul><ul><li>postnas al drip from allergic rhinitis , </li></ul></ul><ul><ul><li>Sinusitis </li></ul></ul><ul><ul><li>chemical irritation. </li></ul></ul>
  50. 50. Pharyngitis <ul><li>Pathophysiology </li></ul><ul><li>Beta-hemolytic streptococcus causes acute pharyngitis or strep throat. </li></ul><ul><li>As a response, an inflammatory reaction occurs resulting to symptoms. </li></ul>
  51. 51. Pharyngitis <ul><li>Clinical manifestations of acute pharyngitis: </li></ul><ul><ul><li>swollen & red pharyngeal membrane, </li></ul></ul><ul><ul><li>edematous lymphoid follicles with exudates, </li></ul></ul><ul><ul><li>enlarged and tender cervical lymph nodes, </li></ul></ul><ul><ul><li>fever, </li></ul></ul><ul><ul><li>malaise </li></ul></ul><ul><ul><li>sore throat. </li></ul></ul><ul><li>Clinical manifestations of chronic pharyngitis: </li></ul><ul><ul><li>constant irritation or fullness of throat, </li></ul></ul><ul><ul><li>frequent coughing to expel mucus </li></ul></ul><ul><ul><li>difficulty swallowing. </li></ul></ul><ul><li>Culture and sensitivity of the throat may reveal the type of organism present to determine the most effective antibiotic </li></ul>
  52. 52. Pharyngitis <ul><li>Medical-Surgical Interventions </li></ul><ul><li>Acute Pharyngitis </li></ul><ul><li>Antibiotic Therapy </li></ul><ul><ul><li>Administer penicllin (drug of choice) </li></ul></ul><ul><ul><li>Administer erythromycin to those resistant to penicillin </li></ul></ul><ul><ul><li>Should be administered 10 days </li></ul></ul><ul><li>Pain medication: </li></ul><ul><ul><li>Aspirin </li></ul></ul><ul><ul><li>Acetaminophen (Tylenol) </li></ul></ul><ul><ul><li>Antitussive (Robitussin DM) </li></ul></ul><ul><ul><ul><li>may be given to control pain associated with coughing </li></ul></ul></ul><ul><li>Liquid or soft diet </li></ul><ul><ul><li>Cool beverages, warm liquids, and flavored frozen desserts such as popsicles are often soothing </li></ul></ul><ul><li>Fluid intake at least 2-3 L per day </li></ul><ul><li>IV therapy may be initiated when situation becomes severe </li></ul>
  53. 53. <ul><li>Medical-Surgical Interventions </li></ul><ul><li>Chronic Pharyngitis </li></ul><ul><li>Correction of respiratory or cardiac condition to relieve chronic cough </li></ul><ul><li>Administer ephedrine sulfate via nasal spray for nasal congestion </li></ul><ul><li>Acetaminophen and aspirin for pain and inflammation </li></ul>Pharyngitis
  54. 54. <ul><li>Nursing Diagnoses </li></ul><ul><li>Pain r/t pharyngeal swelling </li></ul><ul><li>Activity Intolerance r/t body malaise </li></ul><ul><li>Potential for altered nutrition r/t difficulty in swallowing </li></ul><ul><li>Impaired verbal communication r/t physiologic changes and irritation secondary to infection or swelling </li></ul>Pharyngitis
  55. 55. Nursing Management <ul><li>Administer prescribed antibiotics, analgesics, antitussives, and decongestants. </li></ul><ul><li>Instruct client to gargle with warm saline or take oral lozenges. </li></ul><ul><li>Emphasize the importance of proper oral care to relieve sore throat. </li></ul><ul><li>Encourage a soft or liquid diet. If the client is not able to tolerate oral intake, administer fluids intravenously as ordered. </li></ul><ul><li>Instruct client to increase fluid intake to two liters a day and to avoid eating spicy food and drinking citrus juice. </li></ul><ul><li>Tell the client that antibiotic therapy must be taken for 10 days even if symptoms have already disappeared. </li></ul><ul><li>Inform client to avoid exposure to irritant, secondhand smoke, and contact with individuals with upper respiratory infection. </li></ul>
  56. 56. <ul><li>stay in bed during the febrile stage of illness and to rest frequently once up and about. </li></ul><ul><li>Used tissues should be disposed of properly to prevent the spread of infection </li></ul>Pharyngitis
  57. 57. Acute and Chronic Tonsilitis Tonsillitis and Adenoiditis
  58. 58. Tonsillitis and Adenoiditis <ul><li>tonsils are composed of lymphatic tissue and are situated on each side of the oropharynx </li></ul><ul><li>frequently serve as the site of acute infection (tonsillitis </li></ul><ul><li>pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. </li></ul><ul><li>Infection of the adenoids frequently accompanies acute tonsillitis. </li></ul><ul><li>Caused by: </li></ul><ul><ul><li>Group A beta-hemolytic streptococcus </li></ul></ul>
  59. 59. Tonsillitis and Adenoiditis <ul><li>Etiology </li></ul><ul><ul><li>Group A Streptococcus </li></ul></ul><ul><li>Pathophysiology </li></ul><ul><ul><li>Inflammation occurs when bacteria attacks the lymphoid tissues on the tonsils </li></ul></ul>
  60. 60. Tonsillitis and Adenoiditis <ul><li>Clinical Manifestations </li></ul><ul><li>Tonsilitis </li></ul><ul><ul><li>sore throat, </li></ul></ul><ul><ul><li>fever, </li></ul></ul><ul><ul><li>snoring, </li></ul></ul><ul><ul><li>difficulty swallowing. </li></ul></ul><ul><li>may result in acute otitis media which can lead to spontaneous rupture of the tympanic membranes (eardrums) </li></ul><ul><li>further cause acute mastoiditis </li></ul><ul><li>Enlarged adenoids cause: </li></ul><ul><ul><li>mouth-breathing, </li></ul></ul><ul><ul><li>earache, </li></ul></ul><ul><ul><li>draining ears, </li></ul></ul><ul><ul><li>frequent head colds, </li></ul></ul><ul><ul><li>bronchitis, </li></ul></ul><ul><ul><li>foul-smelling breath, </li></ul></ul><ul><ul><li>voice impairment, </li></ul></ul><ul><ul><li>noisy respiration. </li></ul></ul>
  61. 61. Tonsillitis and Adenoiditis <ul><li>Medical-Surgical Interventions </li></ul><ul><li>Supportive measures that include increased: </li></ul><ul><ul><li>Fluid intake </li></ul></ul><ul><ul><li>Analgesics </li></ul></ul><ul><ul><li>Salt-water gargles </li></ul></ul><ul><ul><li>Rest </li></ul></ul><ul><li>Administration of penicillin or other antibiotics 7-10 days </li></ul><ul><ul><li>Amoxicillin and erythromycin (alternative drugs) </li></ul></ul><ul><li>Tonsillectomy may be indicated if: </li></ul><ul><ul><li>Client experiences frequent episodes of tonsilitis despite antibiotic therapy </li></ul></ul><ul><ul><li>Hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea </li></ul></ul><ul><ul><li>Hearing loss is suspected due to otitis media associated with enlarged tonsils </li></ul></ul><ul><ul><li>Some conditions, such as an exacerbation of asthma or rheumatic fever. </li></ul></ul><ul><ul><li>Presence peritonsillar abscess </li></ul></ul><ul><ul><ul><li>occludes the pharynx, </li></ul></ul></ul><ul><ul><ul><li>making swallowing difficult </li></ul></ul></ul><ul><ul><ul><li>endangering the patency of the airway (particularly during sleep). </li></ul></ul></ul>
  62. 62. Tonsillitis and Adenoiditis <ul><li>Nursing Management (Providing Postoperative Care) </li></ul><ul><li>Continuous observation is required in the immediate postoperative and recovery periods </li></ul><ul><ul><li>significant risk of hemorrhage. </li></ul></ul><ul><li>Immediate postoperative period, position is prone with the head turned to the side to allow drainage from the mouth and pharynx. </li></ul><ul><li>The nurse must not remove the oral airway until the patient's gag and swallowing reflexes have returned. </li></ul><ul><li>Applies an ice collar to the neck, and a basin and tissues are provided for the expectoration of blood and mucus. </li></ul>
  63. 63. Tonsillitis and Adenoiditis <ul><li>Postop complications: </li></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Throat pain </li></ul></ul><ul><ul><li>Ear pain </li></ul></ul><ul><ul><li>Bleeding </li></ul></ul>
  64. 64. Tonsillitis and Adenoiditis <ul><li>Teaching Patients Self-Care </li></ul><ul><li>Post-tonsillectomy = hemorrhage occurs 1 st 12-24hrs </li></ul><ul><li>Alkaline mouthwashes and warm saline solutions </li></ul><ul><ul><li>coping with the thick mucus and halitosis that may be present after surgery. </li></ul></ul><ul><li>Explain to the patient that a sore throat, stiff neck, and vomiting may occur in the first 24 hours. </li></ul><ul><li>A liquid or semiliquid diet is given for several days. </li></ul><ul><li>Sherbet and gelatin are acceptable foods. </li></ul><ul><li>Food to avoid: </li></ul><ul><ul><li>spicy, hot, acidic, or rough foods. </li></ul></ul><ul><ul><li>Milk and milk products (ice cream and yogurt) </li></ul></ul><ul><ul><ul><li>make removal of mucus more difficult for some patients. </li></ul></ul></ul><ul><ul><li>Instructs to avoid vigorous tooth brushing or gargling </li></ul></ul><ul><ul><ul><li>cause bleeding. </li></ul></ul></ul>
  65. 65. LARYNGITIS
  66. 66. LARYNGITIS <ul><li>an inflammation of the larynx </li></ul><ul><li>often occurs as a result of: </li></ul><ul><ul><li>voice abuse </li></ul></ul><ul><ul><li>exposure to dust, chemicals, smoke, and other pollutants </li></ul></ul><ul><ul><li>Part of a complications of URI. </li></ul></ul><ul><li>It also may be caused by isolated infection involving only the vocal cords. </li></ul><ul><li>is common in the winter and is easily transmitted to others. </li></ul><ul><li>Often associated with allergic rhinitis or pharyngitis </li></ul><ul><li>tends to be more severe in elderly patients and may be complicated by pneumonia. </li></ul>
  67. 67. LARYNGITIS <ul><li>ETIOLOGY: </li></ul><ul><li>The same pathogens that cause allergic rhinitis and pharyngitis. </li></ul><ul><li>Onset of infection associated with: </li></ul><ul><ul><li>a change in temperature, </li></ul></ul><ul><ul><li>nutrient deficiency or malnutrition, </li></ul></ul><ul><ul><li>immunosuppression. </li></ul></ul>
  68. 68. LARYNGITIS <ul><li>Pathophysiology </li></ul><ul><li>Inflammation of the vocal cords caused by URI, vocal cord abuse, smoking or reflux esophagitis </li></ul><ul><li>Vocal cord become edematous due to inflammation that restricts the normal movement of the larynx. </li></ul><ul><li>Inflammatory response to cell damage by viruses results in hyperemia and fluid exudation </li></ul><ul><li>Kinins and other inflammatory mediators induce upper airway smooth muscle spasm. </li></ul>
  69. 69. LARYNGITIS <ul><li>CLINICAL MANIFESTATIONS </li></ul><ul><li>Acute Laryngitis </li></ul><ul><li>Aphonia </li></ul><ul><ul><li>Complete loss of voice </li></ul></ul><ul><li>Severe cough </li></ul><ul><li>Sudden onset made worse by cold dry wind </li></ul><ul><li>Throat feel worse in the morning and improves when indoors in a warmer climate </li></ul><ul><li>Dry cough and Dry, sore throat worsen in the evening </li></ul><ul><li>+ allergies, uvula - edematous </li></ul><ul><li>Chronic Laryngitis </li></ul><ul><li>Persistent hoarseness </li></ul>
  70. 70. LARYNGITIS <ul><li>Diagnostic Test </li></ul><ul><li>Direct and indirect laryngoscopy </li></ul><ul><ul><li>To visualize the vocal cords </li></ul></ul><ul><li>Videotroboscopy </li></ul><ul><ul><li>To observe vocal cord and movement through the use of fiberoptic laryngoscopy </li></ul></ul><ul><li>Electromyography </li></ul><ul><ul><li>To determine innervations of vocal cord </li></ul></ul>
  71. 71. LARYNGITIS <ul><li>Medical-Surgical Interventions Pharmacologic Interventions 1. Antacids to neutralize gastric acid in reflux. 2. Histamine inhibitors to reduce gastric acid. 3. Systemic steroids to relieve swelling. 4. Botulinum toxin injection </li></ul><ul><li>- to paralyze spastic movement. 5. Antibacterial therapy </li></ul><ul><li>- part of URI complications caused by bacteria </li></ul><ul><li>Tracheotomy if laryngitis becomes chronic . </li></ul>
  72. 72. LARYNGITIS <ul><li>Medical Management : Acute stage </li></ul><ul><li>Resting the voice </li></ul><ul><li>Avoiding irritants (including smoking), </li></ul><ul><li>Resting </li></ul><ul><li>Inhaling cool steam or an aerosol </li></ul>
  73. 73. LARYNGITIS <ul><li>Medical Management : Chronic stage </li></ul><ul><li>Resting the voice </li></ul><ul><li>Eliminating any primary respiratory tract infection </li></ul><ul><li>Eliminating smoking </li></ul><ul><li>Avoiding second hand smoke. </li></ul><ul><li>Topical / Inhalation corticosteroids </li></ul><ul><ul><li>beclomethasone dipropionate (Vanceril), </li></ul></ul><ul><ul><li>few systemic or long-lasting effects </li></ul></ul><ul><ul><li>may reduce local inflammatory reactions. </li></ul></ul>
  74. 74. LARYNGITIS <ul><li>Nursing Diagnoses 1. Acute pain related to vocal cord edema 2. Activity intolerance related to body malaise 3. Risk for aspiration related to difficulty swallowing 4. Risk for bleeding related to surgery 5. Impaired verbal communication related to throat pain </li></ul>
  75. 75. LARYNGITIS <ul><li>Nursing Management </li></ul><ul><li>Encourage to rest his/her voice as much as possible and avoid whispering. Provide alternative means of communication during this time. </li></ul><ul><li>Assess respiratory status, including breath sounds, ABG, pulse oximetry level, rate and depth of respiration </li></ul><ul><li>Provide instruction on the administration, dosage and side effects of medications, if indicated </li></ul><ul><li>Ensure availability of emergency equipment, such as endotracheal intubation set and emergency tracheostomy tray </li></ul><ul><li>Instruct client to avoid exposure to individuals with URI </li></ul><ul><li>Tell client not to perform strenuous activities because this can increase airway edema, resulting to distress </li></ul><ul><li>Encourage client to eat food with thick consistency rather than liquids </li></ul><ul><li>Elevate the HOB and provide supplemental humidification </li></ul><ul><li>Provide comfort measures such as ice collar and throat irrigation. </li></ul>
  76. 76. Possible Nursing Diagnosis for URI <ul><li>Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation </li></ul><ul><li>Acute pain related to upper airway irritation secondary to an infection </li></ul><ul><li>Impaired verbal communication related to physiologic changes and upper airway irritation secondary to infection or swelling </li></ul><ul><li>Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever </li></ul><ul><li>Deficient knowledge regarding prevention of URIs, treatment regimen, surgical procedure, or postoperative care </li></ul>
  78. 78. EPISTAXIS
  79. 79. EPISTAXIS <ul><li>a hemorrhage from the nose </li></ul><ul><li>caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose. </li></ul>
  80. 80. EPISTAXIS <ul><li>Anterior septum = most common site </li></ul><ul><li>3 major blood vessels enter the nasal cavity: </li></ul><ul><ul><li>the anterior ethmoidal artery on the forward part of the roof (Kiesselbach's plexus), </li></ul></ul><ul><ul><li>(2) the sphenopalatine artery in the posterosuperior region </li></ul></ul><ul><ul><li>(3) the internal maxillary branches (the plexus of veins located at the back of the lateral wall under the inferior turbinate). </li></ul></ul>
  81. 81. EPISTAXIS <ul><li>Risk Factors for Epistaxis </li></ul><ul><li>Local infections </li></ul><ul><ul><li>vestibulitis, rhinitis, sinusitis </li></ul></ul><ul><li>Systemic infections </li></ul><ul><ul><li>scarlet fever, malaria </li></ul></ul><ul><li>Drying of nasal mucous membranes </li></ul><ul><li>Nasal inhalation of illicit drugs (eg, cocaine) </li></ul><ul><li>Trauma </li></ul><ul><ul><li>digital trauma as in picking the nose; blunt trauma; fracture; forceful nose blowing </li></ul></ul><ul><li>Arteriosclerosis </li></ul><ul><li>Hypertension </li></ul><ul><li>Tumor (sinus or nasopharynx) </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>Use of aspirin </li></ul><ul><li>Liver disease </li></ul><ul><li>Redu-Osler-Weber syndrome (hereditary hemorrhagic telangiectasia) </li></ul>
  82. 82. EPISTAXIS <ul><li>Pathophysiology </li></ul><ul><li>MOSTLY ORIGINATE ON : Anterior nasal bleeding occurs on the anterior nasal septum </li></ul><ul><li>Posterior nasal bleeding occurs high in the nasal septum or in the Woodruff’s plexus under the posterior, inferior turbinate. </li></ul><ul><li>Nasal infection produces inflammation and bleeding of nasal mucosa. </li></ul><ul><li>Blood disorders that can cause epistaxis: </li></ul><ul><ul><li>hemophilia, </li></ul></ul><ul><ul><li>Immunodeficiency </li></ul></ul><ul><ul><li>Other contributing factors: </li></ul></ul><ul><ul><li>Atherosclerosis </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><ul><li>Due to altered contraction of blood vessels and increased BP </li></ul></ul></ul>
  83. 83. EPISTAXIS <ul><li>Clinical Manifestation </li></ul><ul><li>Nasal bleeding </li></ul><ul><li>Mouth breathing secondary to nasal obstruction </li></ul><ul><li>Hypotension secondary to blood loss </li></ul><ul><li>Increased pulse rate and respiration rate </li></ul>
  84. 84. EPISTAXIS <ul><li>Immediate Medical Mgt </li></ul><ul><li>Applying direct pressure </li></ul><ul><li>Sit upright with head tilted forward </li></ul><ul><ul><li>To prevent swallowing and aspiration of blood </li></ul></ul><ul><li>Directed to pinch the soft outer portion of the nose against the midline for 5-10 min </li></ul><ul><li>For anterior nosebleed </li></ul><ul><li>Treat with silver nitrate applicator and Gelfoam or by electrocautery. </li></ul>
  85. 85. EPISTAXIS <ul><li>Pharmacologic Interventions </li></ul><ul><li>Medications that promote vasoconstriction, relieve anxiety and decrease discomfort </li></ul><ul><ul><li>Topical: adrenaline, cocaine and phenylephrine </li></ul></ul><ul><li>Topical decongestants to promote vasoconstriction </li></ul>
  86. 86. EPISTAXIS <ul><li>Medical-Surgical Interventions </li></ul><ul><li>IV hydration and administration of blood products </li></ul><ul><li>Insertion of nasal packing (impregnated with petrolatum jelly/antibiotic) </li></ul><ul><ul><li>Packing remain in place for 2-6 days if necessary </li></ul></ul><ul><li>Administration of supplemental humidified oxygen through face mask. </li></ul><ul><li>Cotton pledgets soaked in a vasoconstricting solution (ie, epinephrine, ephedrine, cocaine) may be inserted into the nose to reduce the blood flow </li></ul><ul><li>Suction may be used to remove excess blood and clot </li></ul>
  87. 87. Control of Epistaxis Packing to control bleeding from the posterior nose Catheter is inserted and packing is attached Packing is drawn into position as the catheter is removed. Strip is tied over a bolster to hold the packing in place with an anterior pack installed ‘accordion pleat’ style. Alternative method, using a balloon catheter instead of gauze packing.
  88. 88. EPISTAXIS <ul><li>Special medical-surgical procedure </li></ul><ul><li>Ligation of ethmoid maxillary and carotid artery </li></ul><ul><li>Endoscopic cautery </li></ul><ul><li>Angiogram with embolization in clients unable to have surgery </li></ul>
  89. 89. EPISTAXIS <ul><li>Nursing Diagnoses </li></ul><ul><li>Risk for fluid volume deficit related to nasal bleeding </li></ul><ul><li>Risk for aspiration related to nasal bleeding </li></ul><ul><li>Risk for infection related to nasal packing </li></ul><ul><li>Ineffective breathing pattern related to nasal bleeding </li></ul>
  90. 90. Nursing Care of Patients with Epistaxis <ul><li>Assessment of bleeding </li></ul><ul><li>Monitor airway and breathing </li></ul><ul><li>Vital signs </li></ul><ul><li>Reduce anxiety </li></ul><ul><li>Patient teaching </li></ul><ul><ul><li>Avoid nasal trauma, nose picking, and nose blowing </li></ul></ul><ul><ul><li>Air humidification </li></ul></ul><ul><ul><li>Pressure on the nose to stop bleeding. If bleeding does not stop in 15 minutes, seek medical attention. </li></ul></ul>
  91. 91. EPISTAXIS <ul><li>Nursing Management </li></ul><ul><li>Assist the client in a sitting position with the head tilted forward and apply direct pressure on the soft outer portion of the nose against the midline septum for 5 to 10 minutes. </li></ul><ul><li>Administer topical vasoconstrictors such as adrenaline, cocaine, or phenylepinephrine. </li></ul><ul><li>Practice universal precautions by wearing goggles, gloves, mask, and gown when treating a client with epistaxis. </li></ul><ul><li>Assist with the insertion of nasal packing. Plain ribbon gauze coated with antibiotic ointment is inserted into the anterior nasal cavity and remains in place for 48 to 72 hours. </li></ul><ul><li>Monitor fluid, electrolyte, and hematologic values. </li></ul><ul><li>Apply ice compress on the nose and face. </li></ul><ul><li>Perform suctioning if client vomits a large amount of blood. </li></ul><ul><li>Monitor blood pres sure, pulse, respiration, and level of consciousness. </li></ul>
  92. 92. NASAL POLYPS overgrowths of the mucosa that frequently accompany allergic rhinitis. They are freely movable and nontender.
  93. 93. NASAL POLYPS <ul><li>Etiology </li></ul><ul><li>Unknown </li></ul><ul><li>Maybe a response to inflammatory response as a result of chronic viral/bacterial infection </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Nasal polyps can cause obstruction of the sinus opening and facilitate a sinus infection. </li></ul><ul><li>Infections caused by nasal polyps can be self-perpetuation because constant irritation can lead to growth of more polyps. </li></ul>
  94. 94. NASAL POLYPS
  95. 95. NASAL POLYPS <ul><li>Clinical Manifestation: </li></ul><ul><li>Difficulty breathing thru nose </li></ul><ul><li>Growth of visible tissue upon nasal examination </li></ul><ul><li>Mouth breathing </li></ul><ul><li>Feeling of foreign object in nose </li></ul><ul><li>Decrease olfaction </li></ul><ul><li>Rhinorrhea </li></ul><ul><li>Excessive sneezing </li></ul><ul><li>Excessive tearing </li></ul>
  96. 96. NASAL POLYPS <ul><li>Pharmacologic interventions </li></ul><ul><li>Antihistamines to treat allergy symptoms </li></ul><ul><li>Antibiotics </li></ul><ul><li>Corticosteroids to reduce size of polyps </li></ul><ul><li>(Fluticasone and Betamethasone) </li></ul>
  97. 97. NASAL POLYPS <ul><li>Special medical-surgical procedures </li></ul><ul><li>Nasal polypectomy </li></ul><ul><ul><li>surgical of removal polyps from the internal nose </li></ul></ul><ul><li>Caldwell-Luc surgery </li></ul><ul><ul><li>making an incision in the gingival buccal sulcus to have access into the maxillary sinus and facilitate polyp removal </li></ul></ul>
  98. 98. NASAL POLYPS <ul><li>3. Functional endoscopic sinus surgery to remove polyps </li></ul>
  99. 99. NASAL POLYPS <ul><li>Nursing Diagnoses </li></ul><ul><li>Ineffective breathing pattern related to nasal obstruction </li></ul><ul><li>Altered sensory perception (olfactory) related to nasal obstruction. </li></ul><ul><li>Risk for infection related to nasal obstruction </li></ul>
  100. 100. NASAL POLYPS <ul><li>NURSING MANAGEMENT </li></ul><ul><li>Increase humidification through the use of humidifier and nasal saline spray. </li></ul><ul><li>Encourage client to increase his/her fluid intake. </li></ul><ul><li>Elevate the head of bed. </li></ul><ul><li>Instruct client to avoid exposure to individuals with upper respiratory infections. </li></ul><ul><li>Administer nasal steroid spray as ordered. Explain that the nozzle of the spray must be aimed towards the cheek (sinuses). </li></ul>
  102. 102. DEVIATED NASAL SEPTUM & NASAL FRACTURE <ul><li>displacement of the nasal septum. </li></ul><ul><li>Etiology: </li></ul><ul><li>Congenital disproportion </li></ul><ul><li>Trauma during birth </li></ul><ul><li>Trauma during the life span </li></ul>
  103. 103. DEVIATED NASAL SEPTUM & NASAL FRACTURE <ul><li>Pathophysiology </li></ul><ul><li>Anatomical deformities: </li></ul><ul><ul><li>dislocation of the lower end of the septum into one of the nostrils </li></ul></ul><ul><ul><li>deviation of the posterior part of the septum further back in the nose. </li></ul></ul><ul><li>Displacement causes altered air flow through the nose and sinuses </li></ul><ul><ul><li>Lead to impaired ventilation and hypertrophy of middle turbinate bone </li></ul></ul><ul><li>Facial trauma during sports, assault or accidents </li></ul><ul><ul><li>Result in fracture of the nasal bone </li></ul></ul>
  104. 104. DEVIATED NASAL SEPTUM & NASAL FRACTURE <ul><li>Medical-Surgical Interventions </li></ul><ul><li>Drugs: </li></ul><ul><li>Systemic decongestant </li></ul><ul><li>Topical nasal steroid sprays </li></ul><ul><ul><li>to relieve nasal edema </li></ul></ul><ul><li>Analgesics for pain </li></ul><ul><li>Septoplasty – for client with septal dislocation </li></ul><ul><ul><li>Minimal removal of cartilage, repositioning of septum in midline </li></ul></ul><ul><li>Nasal packing – to hold fragments together (fractured) </li></ul><ul><ul><li>Plaster of paris or thermostat splint </li></ul></ul><ul><li>Fractures left longer than 10-14 days, a formal rhinoplasty may be performed. </li></ul>
  105. 105. DEVIATED NASAL SEPTUM & NASAL FRACTURE <ul><li>CLINICAL MANIFESTATION </li></ul><ul><li>Obstruction of nasal breathing </li></ul><ul><li>Mouth breathing </li></ul><ul><li>Twisting of nasal septum </li></ul><ul><li>Excoriation of nasal mucosa </li></ul><ul><li>Nosebleed </li></ul><ul><li>Facial edema </li></ul><ul><li>Echhymosis </li></ul><ul><li>Pain </li></ul><ul><li>Tenderness on palpation </li></ul>
  106. 106. DEVIATED NASAL SEPTUM & NASAL FRACTURE <ul><li>Nursing Diagnosis </li></ul><ul><li>Ineffective breathing pattern related to nasal obstruction </li></ul><ul><li>Risk for fluid volume deficit related to bleeding </li></ul>
  107. 107. DEVIATED NASAL SEPTUM & NASAL FRACTURE <ul><li>NURSING MANAGEMENT </li></ul><ul><li>1. Elevate the head of the client’s bed. </li></ul><ul><li>2. Administer systemic decongestants and nasal sprays as ordered. </li></ul><ul><li>3. Apply ice compress to the nose following acute injury. </li></ul><ul><li>4. Pinch the nostrils at the tip for a minimum of 10 minutes if bleeding occurs . </li></ul><ul><li>5. Increase supplemental humidification. </li></ul>
  109. 109. LARYNGEAL OBSTRUCTION <ul><li>ETIOLOGY: </li></ul><ul><li>Aspiration of foreign body into the pharynx </li></ul><ul><li>Hereditary angioedema (HAE) </li></ul>
  110. 110. LARYNGEAL OBSTRUCTION <ul><li>HEREDITARY ANGIOEDEMA (HAE) </li></ul><ul><li>Disorder characterized by episodes of laryngeal edema </li></ul><ul><ul><li>Risk factors: </li></ul></ul><ul><ul><ul><li>Hx fo allergy </li></ul></ul></ul><ul><ul><ul><li>Heavy alcohol consumption </li></ul></ul></ul><ul><ul><ul><li>Use of ACE inhibitors </li></ul></ul></ul><ul><ul><ul><li>Recent throat pain </li></ul></ul></ul><ul><ul><ul><li>Hx of previous tracheostomy </li></ul></ul></ul>
  111. 111. LARYNGEAL OBSTRUCTION <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>Foreign bodies obstruct the air passages in the larynx and cause difficulty breathing. </li></ul><ul><li>may be pushed down to the bronchi causing irritation, cough, expectoration of blood or mucus, and labored breathing. </li></ul>
  112. 112. LARYNGEAL OBSTRUCTION <ul><li>CLINICAL MANIFESTATION </li></ul><ul><li>Use of accessory muscles when breathing </li></ul><ul><li>Inability to speak </li></ul><ul><li>Coughing </li></ul><ul><li>Drooling </li></ul><ul><li>Inability to swallow </li></ul><ul><li>Pain/pressure in the throat </li></ul><ul><li>Edema of esophagus </li></ul>
  113. 113. LARYNGEAL OBSTRUCTION <ul><li>DIAGNOSTIC STUDIES: </li></ul><ul><li>Soft tissue radiograph </li></ul><ul><li>Barium swallow </li></ul><ul><li>CT scan </li></ul><ul><ul><li>Aid in visualization of foreign body </li></ul></ul>
  114. 114. LARYNGEAL OBSTRUCTION <ul><li>MEDICAL-SURGICAL INTERVENTIONS </li></ul><ul><li>If foreign object is visible </li></ul><ul><ul><li>dislodge it manually </li></ul></ul><ul><li>If in the larynx/trachea </li></ul><ul><ul><li>Subdiaphragmatic abdominal thrust maneuver (Heimlich maneuver) </li></ul></ul><ul><li>If all interventions failed </li></ul><ul><ul><li>Tracheostomy is required </li></ul></ul>
  115. 115. LARYNGEAL OBSTRUCTION <ul><li>HEIMLICH MANEUVER </li></ul><ul><li>Stand behind the client </li></ul><ul><li>Place both arms around his/her waist </li></ul><ul><li>Make a fist with one hand making use that the thumb is outside the fist. </li></ul><ul><li>Place the thumb against the client’s abdomen above the navel and below the xiphoid process. </li></ul><ul><li>Grasp the fist with other hand </li></ul><ul><li>Apply pressure against the client’s diaphragm using quick, upward thrusts until obstruction is cleared (6-10x) </li></ul>
  116. 116. LARYNGEAL OBSTRUCTION <ul><li>NURSING DIAGNOSIS </li></ul><ul><li>Ineffective breathing pattern related to foreign body in the airway </li></ul><ul><li>Impaired swallowing related to obstruction and edema from trauma </li></ul><ul><li>Anxiety related to breathing difficulty </li></ul><ul><li>NURSING DIAGNOSIS </li></ul><ul><li>Ineffective breathing pattern related to foreign body in the airway </li></ul><ul><li>Impaired swallowing related to obstruction and edema from trauma </li></ul><ul><li>Anxiety related to breathing difficulty </li></ul>
  117. 117. LARYNGEAL OBSTRUCTION <ul><li>NURSING INTERVENTIONS: </li></ul><ul><li>If client is unable to speak , instruct him/her to cough deeply. </li></ul><ul><li>If unable to dislodge the object, loosen clothing and instruct client to lean over a table and cough deeply. </li></ul><ul><li>Do not give anything by mouth if client has total laryngeal obstruction. </li></ul><ul><li>Place client in a high-Fowler’s position for partial obstruction. </li></ul><ul><li>If Heimlich maneuver is unsuccessful, prepare client for surgical removal of foreign object. </li></ul><ul><li>After surgery, assess arterial blood gases, respiratory rate and depth, and breath sounds . </li></ul>
  120. 120. TRACHEOBRONCHITIS <ul><li>acute inflammation of the mucous membranes of the trachea and the bronchial tree </li></ul><ul><li>often follows infection of the upper respiratory tract </li></ul><ul><li>Adequate treatment of upper respiratory tract infection is one of the major factors in the prevention of acute bronchitis. </li></ul>
  121. 121. TRACHEOBRONCHITIS <ul><li>Etiology: </li></ul><ul><ul><li>Haemophilus influenzae </li></ul></ul><ul><ul><li>Mycoplasma pneumoniae </li></ul></ul><ul><ul><li>Streptococcus pneumoniae </li></ul></ul><ul><ul><li>Aspergillus </li></ul></ul><ul><ul><li>Inhlation of physical and chemical irritants and gases </li></ul></ul><ul><li>sputum culture is essential to identify the specific causative organism </li></ul>
  122. 122. TRACHEOBRONCHITIS <ul><li>Pathophysiology </li></ul><ul><li>the inflamed mucosa of the bronchi produces mucopurulent sputum, often in response to infection </li></ul>
  123. 123. TRACHEOBRONCHITIS <ul><li>Clinical Manifestations: </li></ul><ul><li>Dry cough (mucoid sputum) </li></ul><ul><li>Sternal soreness due to frequent coughing </li></ul><ul><li>Fever and chills </li></ul><ul><li>Night sweats </li></ul><ul><li>Headache </li></ul><ul><li>Malaise (initial) </li></ul><ul><li>SOB </li></ul><ul><li>Inspiratory Stridor & expiratory wheeze </li></ul><ul><li>Purulent sputum (pus-filled) </li></ul><ul><li>Blood-streaked secretions (severe case due to irritation on mucosa) </li></ul>
  124. 124. TRACHEOBRONCHITIS <ul><li>Medical-Surgical Interventions </li></ul><ul><li>Antibiotic therapy depending on specific agent </li></ul><ul><li>Endotracheal intubation </li></ul><ul><ul><li>if with acute respiratory failure (with co-existing respiratory disorders) </li></ul></ul><ul><li>Cool vapor therapy and steam inhalation </li></ul><ul><ul><li>To relieve laryngeal and tracheal irritation </li></ul></ul><ul><li>moist heat on chest </li></ul><ul><ul><li>Relieve soreness and pain </li></ul></ul><ul><li>Mild analgesic or antipyretic </li></ul>
  125. 125. TRACHEOBRONCHITIS <ul><li>Antihistamine are not prescribe </li></ul><ul><ul><li>Can cause excessive drying and make secretions more difficult to expectorate </li></ul></ul>
  126. 126. TRACHEOBRONCHITIS <ul><li>Nursing Diagnoses </li></ul><ul><li>Ineffective airway clearance related to copious secretions </li></ul><ul><li>Ineffective breathing pattern related bronchial irritation </li></ul><ul><li>Risk for infection related to stasis of secretions </li></ul>
  127. 127. TRACHEOBRONCHITIS <ul><li>Nursing Interventions: </li></ul><ul><li>Suction as needed to remove secretions </li></ul><ul><li>Encourage increased oral fluid intake to thin vicious secretion </li></ul><ul><li>Assist client to an upright position and teach how to cough and deep-breathe effectively. </li></ul><ul><li>Emphasize the need for completing the course of antibiotic therapy as prescribed </li></ul><ul><li>Allow the client to rest to prevent relapse or exacerbation of infection. </li></ul>
  128. 128. BRONCHIECTASIS Dilation of bronchial airway
  129. 129. BRONCHIECTASIS <ul><li>Permanent dilation of a bronchus or bronchi; </li></ul><ul><li>the dilated airways become saccular and are a medium for chronic infection. </li></ul><ul><li>No longer considered a category of COPD. </li></ul>
  130. 130. BRONCHIECTASIS <ul><li>Etiology: </li></ul><ul><li>occurs secondary to another chronic respiratory disorder, such as: </li></ul><ul><ul><li>cystic fibrosis, </li></ul></ul><ul><ul><li>asthma, </li></ul></ul><ul><ul><li>tuberculosis, </li></ul></ul><ul><ul><li>bronchitis, </li></ul></ul><ul><ul><li>exposure to a toxin. </li></ul></ul><ul><li>Predisposing factor: </li></ul><ul><ul><li>Airway obstruction from a tumor or foreign body </li></ul></ul><ul><ul><li>Airway obstruction from excessive secretions </li></ul></ul><ul><li>Infection and inflammation of the airways weakens the bronchial walls and reduces ciliary function. </li></ul>
  131. 131. <ul><li>Bronchiectasis </li></ul><ul><li>Destruction of bronchial </li></ul><ul><li>mucosa with fibrous scar </li></ul><ul><li>tissue formation </li></ul><ul><li> </li></ul><ul><li>Loss of resilience </li></ul><ul><li>& airway dilation causes </li></ul><ul><li>pooling of secretions </li></ul><ul><li> </li></ul><ul><li>Obstruction of airflow </li></ul>
  132. 132. BRONCHIECTASIS <ul><li>Pathophysiology </li></ul><ul><li>A form of obstructive lung disease characterized by chronic dilation of bronchus and bronchioles which often begins during childhood. </li></ul><ul><li>↓ </li></ul><ul><li>Chronic inflammation weakens the bronchial walls; as a purulent secretions collect in these areas. </li></ul><ul><li>↓ </li></ul><ul><li>Stasis of secretion leads to recurrent infections which cause increased irritation of the bronchial walls, creating a cycle of inflammation. </li></ul>
  133. 133. BRONCHIECTASIS <ul><li>Clinical Manifestations </li></ul><ul><li>Chronic, productive cough </li></ul><ul><li>Foul-smelling purulent sputum </li></ul><ul><li>Hemoptysis </li></ul><ul><li>Clubbing of nails </li></ul><ul><li>Night sweats </li></ul><ul><li>Fever </li></ul><ul><li>Cor pulmonale </li></ul><ul><li>Dyspnea during late stage </li></ul>
  134. 134. BRONCHIECTASIS <ul><li>Medical-Surgical Interventions </li></ul><ul><li>Oxygen therapy to maintain oxygen above 55mmHg </li></ul><ul><li>Administration of BRONCHODILATORS and ANTIBIOTICS </li></ul><ul><ul><li>To relieve bronchospasm caused by inflammation and infection </li></ul></ul><ul><li>Use of adrenal GLUCOCORTICOIDS </li></ul><ul><ul><li>To reduce bronchial inflammation </li></ul></ul><ul><li>MUCOLYTIC agent help thin secretions </li></ul><ul><li>Chest physiotherapy and postural drainage to mobilize secretions </li></ul><ul><li>Intubation and mechanical ventilation if client develops acute respiratory failure. </li></ul><ul><li>Prevent infection through vaccinations for flu and pneumonia </li></ul>
  135. 135. BRONCHIECTASIS <ul><li>Nursing Diagnosis </li></ul><ul><li>Impaired gas exchange related to decreased ventilation and presence of mucus plugs </li></ul><ul><li>Ineffective airway clearance related to thick, copious secretions, respiratory muscle weakness, and ineffective coughing </li></ul><ul><li>Altered nutrition, less than body requirements related to decreased appetite and dyspnea </li></ul><ul><li>Activity intolerance related to fatigue and dyspnea </li></ul><ul><li>Risk for infection related to thick sputum, ineffective coughing and fatigue </li></ul>
  136. 136. BRONCHIECTASIS <ul><li>Nursing Management </li></ul><ul><li>Monitor respiratory status such as rate, rhythm, depth and use of accessory muscles </li></ul><ul><li>Monitor ABGs for hypoxemia and hypercapnea </li></ul><ul><li>Auscultate breath sounds every 4 hours </li></ul><ul><li>Monitor oxygen saturation via pulse oximeter </li></ul><ul><li>Monitor sputum for changes in color, consistency, amount and odor </li></ul><ul><li>Assist client to a high-Fowler’s position to promote lung expansion and improve gas exchange </li></ul><ul><li>Encourage fluid intake of at least 8 glasses of water a day </li></ul><ul><li>Teach and encourage proper turning, coughing and deep breathing </li></ul><ul><li>Provide small, frequent meals. Adjust feeding schedule so as not to interrupt with rest periods </li></ul>
  137. 137. PNEUMONIA inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, chlamydiae, mycoplasma, fungi, parasites, and viruses.
  138. 138. PNEUMONIA <ul><li>“ Pneumonitis” describes as an inflammatory process in the lung tissue that may predispose or place the patient at risk for microbial invasion. </li></ul>
  139. 139. Pneumonia <ul><li>Acute inflammatory process of the alveolar spaces </li></ul><ul><li> lung consolidation  exudate [alveoli] </li></ul><ul><li>Classification </li></ul><ul><li>CAP: most common; occurs in the community or 48 H before hospitalization </li></ul><ul><li>S. pneumoniae, H. influenza, M. pneumoniae </li></ul><ul><li>Nosocomial: onset of S/S is 48-72 H post-hospitalization </li></ul><ul><li>P. aeruginosa, S. pneumoniae, K. pneumoniae </li></ul><ul><li>Aspiration pneumonia </li></ul><ul><li>S. pneumoniae, H. influenzae, S. pneumoniae, gastric contents </li></ul>
  140. 140. <ul><li>Classifications: </li></ul><ul><li>Community-Acquired Pneumonia (CAP) </li></ul><ul><ul><li>Community setting or within 1 st 48 hours after hospitalization </li></ul></ul><ul><li>Hospital-Acquired (Nosocomial) Pneumonia (HAP) </li></ul><ul><ul><li>Onset of pneumonia symptoms more than 48 hrs after admission </li></ul></ul><ul><li>Pneumonia in immunocompromised host </li></ul><ul><ul><li>Pneumocystis jiroveci </li></ul></ul><ul><ul><li>occurs with use of corticosteroids or other immunosuppressive agents, chemotherapy, nutritional depletion, use of broad-spectrum antimicrobial agents, acquired immunodeficiency syndrome (AIDS), genetic immune disorders, and long-term advanced life-support technology (mechanical ventilation). </li></ul></ul><ul><li>Aspiration Pneumonia </li></ul>
  141. 141. Pneumonia <ul><li>Types </li></ul><ul><li>Bacterial pneumonia </li></ul><ul><ul><li>Lobar [Strep] – constant dry, hacking cough, pleuritic pain, watery to rust-colored sputum </li></ul></ul><ul><ul><li>Bronchopneumonia [Strep/Staph] – due to aspiration, productive cough w/ yellow or green sputum </li></ul></ul><ul><li>Alveolar pneumonia [viral] – scanty sputum </li></ul><ul><li>Atypical pneumonia [rickettsial] – “walking”, non-productive cough </li></ul>
  144. 145. CAUSATIVE FACTORS INFECTIOUS ORGANISMS NONINFECTIOUS HOSPITAL ACQUIRED COMMUNITY ACQUIRED Bacteria,viruses,fungi, rickettsiae, protozoa, helminths Aspiration of fluids, foods & vomitus Inhalation of toxic gases,chemicals,smoke environment people Equipment & supplies Invasive devices SETTING CAUSATIVE
  145. 146. PNEUMONIA <ul><li>Etiology </li></ul><ul><li>Bacteria: </li></ul><ul><ul><li>Streptococcus pneumoniae </li></ul></ul><ul><ul><li>Staphylococcus aureus </li></ul></ul><ul><ul><li>Haemophilus influenzae </li></ul></ul><ul><ul><li>Pseudomonas aeruginosa </li></ul></ul><ul><ul><li>Klebsiella pneumoniae </li></ul></ul><ul><li>Virus: </li></ul><ul><ul><li>Influenza virus </li></ul></ul><ul><ul><li>Adenovirus </li></ul></ul><ul><li>Fungi: </li></ul><ul><ul><li>Candida sp </li></ul></ul><ul><ul><li>Histoplasma sp </li></ul></ul><ul><ul><li>Aspergillus sp </li></ul></ul><ul><ul><li>Coccidoides sp </li></ul></ul><ul><li>Others: </li></ul><ul><ul><li>Aspiration of gastric content </li></ul></ul>
  146. 148. Pathophysiology Fluid in lungs Inflammation in interstitial spaces, alveoli and bronchioles By surviving lung defenses (inflammation), organisms penetrate airway mucosa & multiply in alveolar spaces WBCs migrate to infection causing capillary leak,edema & exudate Fluids collect in & around alveoli & walls thicken reducing gas exchange Capillary leak spreads infection to other areas of lung & if + organisms in blood = SEPSIS Fibrin & edema stiffen lung ↓ vital capacity Alveolar collapse further reducing gas exchange to blood causing hypoxemia ↑ HR, ↑ RR, dyspnea Pain
  147. 149. PNEUMONIA <ul><li>Pathophysiology </li></ul><ul><li>The organism enters the lungs through: </li></ul><ul><ul><li>aspiration of oropharyngeal contents, </li></ul></ul><ul><ul><li>inhalation of respiratory secretions from infected individuals, </li></ul></ul><ul><ul><li>through the bloodstream, </li></ul></ul><ul><ul><li>direct spread to the lungs as a result of surgery or trauma. </li></ul></ul><ul><li>To fight infection, inflammatory cells and fibrin move into the alveolar spaces of the lungs. </li></ul><ul><li>The defense mechanisms of the susceptible individual become weak. </li></ul><ul><li>The infectious agent then advances to the lower airways and begins to proliferate. </li></ul>
  148. 150. PNEUMONIA <ul><li>Clinical Manifestations </li></ul><ul><li>Fever and chills </li></ul><ul><li>Nonproductive to productive cough </li></ul><ul><li>Dyspnea </li></ul><ul><li>Tachypnea </li></ul><ul><li>Tachycardia </li></ul><ul><li>Pleuritic pain </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Headache </li></ul><ul><li>fatigue </li></ul><ul><li>Bronchial breath sounds over affected area </li></ul><ul><li>Whispered pectoriloquy </li></ul><ul><li>Increased tactile fremitus over affected area </li></ul><ul><li>Dull upon percussion </li></ul><ul><li>Unequal lung expansion </li></ul>
  149. 151. Diagnostic test Culture & sensitivities CXR (early dx) Pulse oximetry CBC, electrolytes, BUN & creatinine
  150. 152. TREATMENTS Pain control Fluid & oxygen mgt Anti-infective drugs Health promotion Patent airway Bronchodilators = bronchospasm Cough & deep breathe q 2 hrs
  151. 153. PNEUMONIA <ul><li>Medical-Surgical Interventions </li></ul><ul><li>Administration of ANTIMICROBIAL agent </li></ul><ul><ul><li>depending on the identified causative organism and </li></ul></ul><ul><ul><li>client’s sensitivity to specific antimicrobials. </li></ul></ul><ul><li>Oxygen therapy to improve gas exchange. </li></ul><ul><li>Chest wall percussion and postural drainage </li></ul><ul><ul><li>to loosen secretions and improve ventilation. </li></ul></ul>
  152. 154. Medical Treatment of Pneumonia <ul><li>Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, and antihistamines. </li></ul><ul><li>Administration of antibiotic therapy is determined by Gram stain results. </li></ul><ul><li>If the etiologic agent is not identified, use empiric antibiotic therapy. </li></ul><ul><li>Antibiotics are not indicated for viral infections but are used for secondary bacterial infection. </li></ul><ul><li>Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, and antihistamines. </li></ul><ul><li>Administration of antibiotic therapy is determined by Gram stain results. </li></ul><ul><li>If the etiologic agent is not identified, use empiric antibiotic therapy. </li></ul><ul><li>Antibiotics are not indicated for viral infections but are used for secondary bacterial infection. </li></ul>
  153. 155. Collaborative Problems <ul><li>Continuing symptoms after initiation of therapy </li></ul><ul><li>Shock </li></ul><ul><li>Respiratory failure </li></ul><ul><li>Atelectasis </li></ul><ul><li>Pleural effusion </li></ul><ul><li>Confusion </li></ul><ul><li>Superinfection </li></ul>
  154. 156. PNEUMONIA <ul><li>ASSESSMENT: </li></ul><ul><li>Changes in temperature and pulse </li></ul><ul><li>Amount, odor and color of secretions </li></ul><ul><li>Frequency and severity of cough </li></ul><ul><li>Degree of tachypnea or SOB </li></ul><ul><li>Changes in physical assessment findings </li></ul><ul><li>Changes in CXR </li></ul><ul><li>ADULT: (in addition) </li></ul><ul><li>Unusual behavior </li></ul><ul><li>Altered mental status </li></ul><ul><li>Dehydration </li></ul><ul><li>Excessive fatigue </li></ul><ul><li>Concomitant heart failure </li></ul>
  155. 157. PNEUMONIA <ul><li>Nursing Diagnoses </li></ul><ul><li>Impaired gas exchange related to decreased ventilation secondary to inflammation and infection </li></ul><ul><li>Ineffective airway clearance related to excessive tracheobronchial secretions </li></ul><ul><li>Pain related to inflammatory process </li></ul><ul><li>Risk for injury related to resistant infection </li></ul><ul><li>Activity intolerance related to impaired respiratory function </li></ul><ul><li>Risk for deficient fluid volume related to fever and rapid respiratory rate </li></ul>
  156. 158. PNEUMONIA <ul><li>Nursing Management: </li></ul><ul><li>Observe for cyanosis, dyspnea, hypoxia and confusion, which indicate worsening of the client’s condition. </li></ul><ul><li>Monitor sputum production, noting the color, consistency, amount and odor. </li></ul><ul><li>Administer nasotracheal suction if indicated. </li></ul><ul><li>Assist client in an upright position to promote lung expansion and improve aeration. </li></ul><ul><li>Avoid giving high oxygen concentrations in clients with COPD, particularly with evidence of carbon dioxide retention. </li></ul><ul><li>Obtain freshly expectorated sputum for culture and sensitivity, most preferably an early morning specimen. </li></ul><ul><li>Encourage client to increase his/her fluid intake, unless contraindicated, to liquefy thick, viscous secretions and replace fluid losses due to fever, diaphoresis, dehydration and dyspnea. </li></ul><ul><li>Encourage ambulation or frequent position changes to mobilize secretions and reduce the risk of atelectasis. </li></ul>
  157. 159. Improving Airway Clearance <ul><li>Encourage hydration; 2-3 L a day, unless contraindicated </li></ul><ul><li>Humidification may be used to loosen secretions; by face mask or with oxygen </li></ul><ul><li>Coughing techniques </li></ul><ul><li>Chest physiotherapy </li></ul><ul><li>Position changes </li></ul><ul><li>Oxygen therapy administered to patient needs </li></ul>
  158. 160. Other Interventions <ul><li>Promoting rest </li></ul><ul><ul><li>Encourage rest and avoidance of overexertion. </li></ul></ul><ul><ul><li>Positioning to promote rest and breathing (semi-Fowler’s) </li></ul></ul><ul><li>Promoting fluid intake </li></ul><ul><ul><li>Encourage fluid intake to at least 2 L a day. </li></ul></ul><ul><li>Maintaining nutrition </li></ul><ul><ul><li>Provide nutritionally enriched foods and fluids. </li></ul></ul><ul><li>Patient teaching </li></ul><ul><li>Promoting rest </li></ul><ul><ul><li>Encourage rest and avoidance of overexertion. </li></ul></ul><ul><ul><li>Positioning to promote rest and breathing </li></ul></ul><ul><ul><ul><li>(Semi-Fowler’s) </li></ul></ul></ul><ul><li>Promoting fluid intake </li></ul><ul><ul><li>Encourage fluid intake to at least 2 L a day. </li></ul></ul><ul><li>Maintaining nutrition </li></ul><ul><ul><li>Provide nutritionally enriched foods and fluids. </li></ul></ul><ul><li>Patient teaching </li></ul>
  160. 162. SEVERE ACUTE RESPIRATORY SYNDROME (SARS) <ul><li>a viral respiratory illness caused by a coronavirus, called SARS-associated coronavirus (Denison, 2004) </li></ul><ul><li>first reported in Asia in February 2003. </li></ul><ul><li>Illness quickly spread to countries in: </li></ul><ul><ul><li>North America </li></ul></ul><ul><ul><li>South America </li></ul></ul><ul><ul><li>Europe </li></ul></ul><ul><ul><li>Asia </li></ul></ul><ul><li>The World Health Organization (WHO) reported that 8098 people worldwide became sick with SARS during the 2003 outbreak, and 774 died (CDC, 2004c). </li></ul>
  161. 163. SEVERE ACUTE RESPIRATORY SYNDROME (SARS) <ul><li>Transmission: </li></ul><ul><li>Respiratory droplets (cough/sneeze) </li></ul><ul><ul><li>Deposited on mucous membrane (mouth,nose,eyes) </li></ul></ul><ul><ul><li>Direct/close contact with contaminated object </li></ul></ul><ul><ul><li>Virus can live on human hands for 6hrs and stool of infected human up to 4 days. </li></ul></ul><ul><ul><li>Contagious when symptoms are present and during 2 nd week </li></ul></ul><ul><ul><li>Limit interaction outside until 10 days after fever </li></ul></ul>
  162. 164. SEVERE ACUTE RESPIRATORY SYNDROME (SARS) <ul><li>Clinical Manifestations: </li></ul><ul><li>High fever with headache </li></ul><ul><li>SOB </li></ul><ul><li>Headaches, chills </li></ul><ul><li>Body aches </li></ul><ul><li>Dry cough (2-7 days) </li></ul><ul><li>Hypoxemia and subsequent pneumonia </li></ul>
  163. 165. SEVERE ACUTE RESPIRATORY SYNDROME (SARS) <ul><li>Medical-Surgical Interventions </li></ul><ul><li>Provide supplemental oxygen, chest physiotherapy and mechanical ventilation (in severe cases). </li></ul><ul><li>Implement quarantine procedures to prevent transmission. </li></ul><ul><li>Administer antibiotics and high doses of corticosteroids. </li></ul>
  164. 166. SEVERE ACUTE RESPIRATORY SYNDROME (SARS) <ul><li>Diagnosis: </li></ul><ul><li>Fever greater than 38oC </li></ul><ul><li>Hx of casual or sexual contact with infected individual within last 10 days </li></ul><ul><li>Travel to any affected regions </li></ul><ul><ul><li>China </li></ul></ul><ul><ul><li>Hong Kong </li></ul></ul><ul><ul><li>Singapore </li></ul></ul><ul><ul><li>Canada </li></ul></ul><ul><li>Cell culture of SARS-CoV </li></ul><ul><li>Detection of SARS-CoV RNA by reverse transcription through PCR test </li></ul><ul><li>Identification of antibodies through ELISA test within 14 days </li></ul>
  165. 167. SEVERE ACUTE RESPIRATORY SYNDROME (SARS) <ul><li>Nursing Diagnoses: </li></ul><ul><li>Ineffective breathing pattern related to lethargy and cough </li></ul><ul><li>Risk for infection transmission </li></ul>
  166. 168. SEVERE ACUTE RESPIRATORY SYNDROME (SARS) <ul><li>Nursing Managements: </li></ul><ul><li>Observe standard precautions when providing nursing care </li></ul><ul><li>Place client in negative-pressure isolated room with an N95 respirator </li></ul><ul><li>Frequently monitor vital signs and respiratory status </li></ul><ul><li>Watch out for complications such as respiratory failure, liver failure and heart failure </li></ul><ul><li>Ensure patent airway </li></ul><ul><li>Encourage small, frequent meals to prevent adequate nutrition. </li></ul>
  167. 169. TUBERCULOSIS
  168. 170. TUBERCULOSIS <ul><li>an infectious disease that primarily affects the lung parenchyma. </li></ul><ul><li>may be transmitted to other parts of the body, including the meninges, kidneys, bones, and lymph nodes. </li></ul>
  169. 171. TUBERCULOSIS <ul><li>Considered as the world’s deadliest disease and remain as a major public health problem in the Philippines. </li></ul><ul><li>Highly infectious chronic disease caused by the tubercle bacilli. </li></ul><ul><li>Respiratory disease but can also affect other organs of the body and is common among malnourished individuals living in crowded areas. </li></ul><ul><li>Common in children of underdeveloped and developing countries in a form of PRIMARY COMPLEX especially after a bout of debilitating childhood disease such as measles. </li></ul><ul><li>1993, TB was declared as global emergency by WHO due to resurgence in many parts of the world. </li></ul>
  170. 172. INCIDENCE IN THE PHILIPPINES <ul><li>Philippines ranks 6 TH in the leading cause of morbidity (2002) and mortality (2002). </li></ul><ul><li>Incidence rate of all TB cases in is 243/100,000 population/yr (WHO Report 2006) </li></ul><ul><li>Philippines ranks 9 th among the 22 high burdened countries under the WHO watchlist. </li></ul>
  171. 173. Introduction <ul><li>Estimated to affect 1.7 billion people world wide – about a third of the world’s population </li></ul><ul><li>8-10 million cases each year </li></ul><ul><li>1.7 million deaths each year </li></ul><ul><li>2 nd leading infectious cause of death after HIV </li></ul><ul><li>Infection with HIV makes people susceptible to rapidly progressive tuberculosis </li></ul>
  172. 174. Introduction
  173. 175. <ul><li>Tuberculosis </li></ul><ul><li>Koch’s Disease, Phthisis, galloping consumption, TB </li></ul><ul><li>Mode of Transmission: Droplet infection, Cow’s Milk containing Mycobacterium bovis. </li></ul>
  174. 176. TB: Global Incidence <ul><li>TB infects both rich and poor people. </li></ul><ul><li>But 80% of the global TB burden is carried by just 22 countries, already severely impacted by malnutrition, poor sanitation and poverty. </li></ul><ul><li>Africa </li></ul><ul><ul><li>Nigeria </li></ul></ul><ul><ul><li>Ethiopia </li></ul></ul><ul><ul><li>South africa </li></ul></ul><ul><ul><li>Congo </li></ul></ul><ul><ul><li>Kenya </li></ul></ul><ul><ul><li>Uganda </li></ul></ul><ul><ul><li>Mozambique </li></ul></ul><ul><ul><li>Zimbabwe </li></ul></ul><ul><li>Europe/Americas </li></ul><ul><ul><li>Russian Federation </li></ul></ul><ul><ul><li>Brazil </li></ul></ul><ul><li>Asia </li></ul><ul><ul><li>India </li></ul></ul><ul><ul><li>China </li></ul></ul><ul><ul><li>Indonesia </li></ul></ul><ul><ul><li>Bangladesh </li></ul></ul><ul><ul><li>Philippines </li></ul></ul><ul><ul><li>Pakistan </li></ul></ul><ul><ul><li>Vietnam </li></ul></ul><ul><ul><li>Thailand </li></ul></ul><ul><ul><li>Myanmar </li></ul></ul><ul><ul><li>Afghanistan </li></ul></ul><ul><ul><li>Cambodia </li></ul></ul>
  175. 177. Etiologic agent <ul><li>A chronic infectious disease caused by mycobacterium of the “tuberculosis”. </li></ul><ul><li>Mycobacterium tuberculosis </li></ul><ul><li>Mycobacterium africanum from humans and </li></ul><ul><li>Mycobacterium bovis primarily from cattle. </li></ul><ul><li>Agent can be identified only by culture of the organisms. </li></ul>
  176. 178. <ul><li>At present, there are 23 new strains of TB bacilli found in the US. </li></ul><ul><li>Thus, TB is no longer considered to be a disease of the past but of the present. </li></ul><ul><li>It usually affects the lung , but it can affect any organs in the body. Such as digestive system 、 skin. </li></ul>
  177. 179. Mycobacterium tuberculosis <ul><li>Rod-shaped </li></ul><ul><li>Slow-growing bacterium, can be detected in 1-3 weeks in selective liquid medium using radiolabeled nutrients(BACTEC) </li></ul><ul><li>Non-spore forming </li></ul><ul><li>Thin obligate aerobic bacterium </li></ul><ul><li>Neutral in Gram’s staining </li></ul><ul><ul><li>because of it’s content in huge cell-wall lipids . </li></ul></ul>
  178. 180. <ul><li>Acid-Fast bacillus, AFB (Robert Koch, 1882) </li></ul><ul><li>M. tuberculosis , M. africanum & M. bovis are main species causing tuberculosis in human. </li></ul>
  179. 181. AFB
  180. 182. <ul><li>Source of infection </li></ul><ul><li>the open pulmonary tuberculosis patients with viable tubercle bacilli being discharged in the sputum. </li></ul>
  181. 183. Period of Communicability <ul><li>Degree of communicability depends on: </li></ul><ul><ul><li>On the # of bacilli discharges </li></ul></ul><ul><ul><li>Virulence of the bacilli </li></ul></ul><ul><ul><li>Adequacy of ventilation </li></ul></ul><ul><ul><li>Exposure of the bacilli to sun or UV light </li></ul></ul><ul><li>Opportunities for their aerosolization by coughing, sneezing, talking or singing </li></ul><ul><li>Effective antimicrobial chemotherapy usually reduces communicability to insignificant levels within days to a few weeks. </li></ul><ul><li>Children with primary TB are generally not infectious. </li></ul>
  182. 184. Susceptibility and Resistance <ul><li>1 st 6-12 months after infection is the most hazardous period for developing clinical disease </li></ul><ul><li>Susceptible host: </li></ul><ul><ul><li>Children under 3 years old (low in later childhood) </li></ul></ul><ul><ul><li>Adolescents </li></ul></ul><ul><ul><li>Young adults </li></ul></ul><ul><ul><li>Elderly (reactivation of latent infection) </li></ul></ul><ul><ul><li>HIV infected individual </li></ul></ul><ul><ul><li>Immunosuppressed patients </li></ul></ul><ul><ul><li>Underweight </li></ul></ul><ul><ul><li>Undernourished persons with silicosis, diabetes, gastrectomies </li></ul></ul><ul><ul><li>Substance abusers. </li></ul></ul>
  183. 185. <ul><li>Susceptible population </li></ul><ul><ul><li>Poverty </li></ul></ul><ul><ul><li>Over-crowding </li></ul></ul><ul><ul><li>Poor nutrition </li></ul></ul><ul><ul><li>Socioeconomic fall behind (developments slowly ) </li></ul></ul>
  184. 186. Transmission <ul><li>person to person </li></ul><ul><li>by airborne mucus droplet nuclei through coughing, singing or sneezing </li></ul><ul><li>Direct invasion through mucous membranes or breaks in the skin may occur, but is extremely rare. </li></ul><ul><li>Bovine tuberculosis results from exposure to tuberculosis cattle, ususally by ingestion of unpasteurized milk or dairy products. </li></ul><ul><li>Extrapulmunary tuberculosis, other than laryngeak, is generally not communicable, even if there is a draining sinus. </li></ul>
  185. 187. Transmission
  186. 188. Transmission
  187. 191. Pathogenicity <ul><li>The risk for developing tuberculosis disease in children depend on: </li></ul><ul><ul><li>Immune status of the host , </li></ul></ul><ul><ul><li>the virulence and the quantity of the bacillus tuberculosis, </li></ul></ul><ul><ul><li>the status of the cell-mediated immunity (CMI). </li></ul></ul><ul><ul><li>After infection, the body produces the allergy and immunity at the same time . </li></ul></ul>
  188. 192. The allergic reaction and immunity of TB PATHOGEN Tubercle bacillus Through infective route (respiratory tract, alimentary canal, skin and placenta) Child The thymus-dependent LC be sensitized and proliferate Delayed allergic reaction Activating factors Inhibiting factors of Macrophage movement Activating macrophage Engulf and kill tubercle bacillus Eptheloid cells and tubercle Infection is focused TB is surrounded by sensitized TLC
  193. 197. Pathophysiology <ul><li>SOME PEOPLE DEVELOPS REACTIVATION TB (ALSO CALLED ADULT TYPE TB) </li></ul><ul><ul><li>RESULTS FROM A BREAK DOWN OF THE HOST DEPENSES </li></ul></ul><ul><ul><li>MOST COMMONLY OCCURS: </li></ul></ul><ul><ul><ul><li>WITHIN THE LUNG, USUALLY IN THE APICAL </li></ul></ul></ul><ul><ul><ul><li>POSTERIOR SEGMENTS OF THE UPPER LOBES </li></ul></ul></ul><ul><ul><ul><li>THE SUPERIOR SEGMENT OF THE LOWER LOBES. </li></ul></ul></ul>
  194. 199. Manifestations: <ul><li>Low grade fever with night sweats </li></ul><ul><li>Anorexia </li></ul><ul><li>Fatigability </li></ul><ul><li>Body malaise </li></ul><ul><li>Back pains </li></ul><ul><li>Productive cough </li></ul><ul><li>Hemoptysis </li></ul><ul><li>Weight loss </li></ul><ul><li>Dyspnea </li></ul><ul><li>Anemia </li></ul><ul><li>Amenorrhea </li></ul><ul><li>Chest pain </li></ul>
  195. 200. <ul><li>Image credit : http://sitemaker.umich.edu/medchem13/files/tb.htm </li></ul>
  196. 201. <ul><li>Classification (according to extent) </li></ul><ul><li>a. Minimal </li></ul><ul><li>- slight lesion without demonstrate excavation, confined to a small part of one or both lungs </li></ul><ul><li>b. Moderately advance </li></ul><ul><li>- total diameter of the cavities less than 4cm; lesions not more than the volume of the lungs </li></ul><ul><li>c. Far advance </li></ul><ul><li>– lesions more extensive than moderately advance </li></ul>
  197. 202. . <ul><li>PPD- Purified Protein Derivative </li></ul><ul><li> - given ID </li></ul><ul><li>- interpreted 48-72 o </li></ul><ul><li> + >10mm in duration </li></ul><ul><li>+HIV > 5 mm in duration </li></ul><ul><li>Techniques: </li></ul><ul><li>Mantoux-like skin testing </li></ul><ul><ul><li>Exposure to TB due to dev’t of cell-mediated immunity, typically takes between 2-10 weeks from time of exposure </li></ul></ul><ul><li>CXR – areas of granulomas/cavitation </li></ul><ul><li>Sputum Test </li></ul>
  198. 203. Methods of Control <ul><li>PREVENTIVE MEASURES: </li></ul><ul><ul><li>Prompt dx and tx of infectious cases </li></ul></ul><ul><ul><li>BCG vaccination of newborn, infants and grade I/school entrants </li></ul></ul><ul><ul><li>Educate the public in mode of spread and method of control and the imporatancde of early diagnosis </li></ul></ul><ul><ul><li>Improve social conditions, which increase the risk of becoming infected, such as overcrowding </li></ul></ul>
  199. 204. <ul><li>Maintain good personal and environmental hygiene. </li></ul><ul><li>Adopt a healthy lifestyle, i.e., have balanced diet, adequate exercise and rest. </li></ul><ul><li>Keep hands clean and wash hands properly. </li></ul><ul><li>Wash hands when they are dirtied by respiratory secretions e.g. after sneezing. </li></ul><ul><li>Cover nose and mouth while sneezing or coughing and dispose of nasal and mouth discharge properly. </li></ul><ul><li>Seek treatment promptly if symptoms similar to tuberculosis appear, particularly persistently cough for more than one month. </li></ul><ul><li>Receive BCG immunization according to immunization schedule. </li></ul>
  200. 205. <ul><li>Nursing Mgt: </li></ul><ul><li>3 Important Aspects of Care </li></ul><ul><li>Diet </li></ul><ul><ul><li>if with anorexia </li></ul></ul><ul><ul><ul><li>small, frequent feedings </li></ul></ul></ul><ul><li>Drug- strict compliance </li></ul><ul><li>Rest </li></ul><ul><li>Contraindicated nursing Care: </li></ul><ul><ul><li>Chest Chapping </li></ul></ul><ul><ul><ul><li>stimulates hemoptysis </li></ul></ul></ul>
  201. 206. DRUGS <ul><li>DRUGS: </li></ul><ul><ul><li>ISONIAZID (H) </li></ul></ul><ul><ul><li>RIFAMPICIN(R ) </li></ul></ul><ul><ul><li>PYRAZINAMIDE (Z) </li></ul></ul><ul><ul><li>ETHAMBUTOL (E ) </li></ul></ul><ul><ul><li>STREPTOMYCIN (S) </li></ul></ul><ul><li>EXTRAPULMUNARY TB (EPTB) </li></ul><ul><li>TB DOTS-CENTER (TBDC) </li></ul>
  202. 207. Recommended Category of Treatment Regimen Category Type of TB patient Treatment Regimen Intensive phase Continuation phase I New smear + PTB 2HRZE 4HR New smear - PTB with extensive parenchymal lesion on CXR as assessed by TBDC EPTB Severe concomitant HIV disease II Treatment Failure 2HRZES/ 1HRZE 5HRE Relapse Return After Default Other III New smear - PTB with minimal parenchymal lesions on CXR as assessed by the TBDC 2HRZE 4HR IV Chronic (still smear + after supervised re-treatment Refer to specialized facility or DOTS plus Center Refer to Provincial/City NTP Coordinator
  203. 208. For diagnosed of Paediatric TB <ul><li>Pulmonary TB Suspect </li></ul><ul><ul><li>Fever and/or cough >2 weeks </li></ul></ul><ul><ul><li>Loss of wt/No wt gain </li></ul></ul><ul><ul><li>History of contact with suspected or diagnosed case of active TB </li></ul></ul>Sputum Sputum +ve Sputum-ve Case Course of antibiotics for 7-10 Days Symptoms persists Do X-ray & Mx All other situation Mx + and X-ray abnormal Refer to Paediatrician Treatment for Pul. TB
  204. 209. Patient on R x <ul><li>Satisfactory response </li></ul><ul><ul><li>Improved symptoms </li></ul></ul><ul><li>No wt. loss </li></ul><ul><li>Non- satisfactory response </li></ul><ul><li>Review at 2 Months. </li></ul><ul><ul><li>Compliance poor </li></ul></ul><ul><ul><li>Wt. loss </li></ul></ul><ul><ul><li>Worsening of symptom </li></ul></ul>Follow up clinically Refer to Pediatrician. Consider sputum exam. X-ray at completion of treatment at 6 months
  205. 210. <ul><li>TB drug: </li></ul><ul><li>1. INH; Isoniazid </li></ul><ul><li>a. Action: bactericidal </li></ul><ul><li>b. Side effects: </li></ul><ul><li>Tingling and numbness (hands and feet) </li></ul><ul><li>Fatigue </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Blurred vision </li></ul><ul><li>Ataxia </li></ul><ul><li>Weakness </li></ul><ul><li>c. Nursing Implications: </li></ul><ul><li>1. Administer in an empty stomach </li></ul><ul><li>2. Pyridoxine – to counteract peripheral neuropathies </li></ul><ul><li>3. Avoid taking alcohol </li></ul>
  206. 211. <ul><li>2. Rifampicin </li></ul><ul><li>a. Action – decrease tubercle replication </li></ul><ul><li>b. Side effects: </li></ul><ul><li>heartburn anorexia </li></ul><ul><li>nausea & vomiting cramps </li></ul><ul><li>diarrhea headache </li></ul><ul><li>dizziness confusion </li></ul><ul><li>visual disturbances + reddish-orange secretion (urine, stool) </li></ul><ul><li>c. Nursing Implication </li></ul><ul><li>Administer food if GI upset occurs </li></ul><ul><li>Avoid taking alcohol </li></ul><ul><li>Inform client avoid the reddish secretion </li></ul>
  207. 212. <ul><li>3. Streptomycin </li></ul><ul><li>a. Action- protein synthesis in bacterial cell </li></ul><ul><li>b. Side effect- </li></ul><ul><li>Ototoxicity </li></ul><ul><li>Nephrotoxicity </li></ul><ul><li>Neurotoxicity </li></ul><ul><li>Agranulocytosis </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>c. Nursing Implication: </li></ul><ul><li>Weigh client before treatment </li></ul><ul><li>Monitor urinalysis and kidney function test </li></ul><ul><li>Do not mix other drugs in the same syringe </li></ul>
  208. 213. <ul><li>ROUTE, DOSAGE & COMMON SIDE EFFECTS OF ANTI-TB DRUGS </li></ul>Drug Dosage(kg/day) {Maximum dose} Route of administration Major side effects INH 10mg {≤300mg/day} Po/im/iv.drop Hepatotoxicity; Peripheral neuritis Hypersensitivity reaction RFP 10mg {≤450mg/day} po Hepatotoxicity; Gastrointestinal reactions SM 20-30mg {≤0.75/day} im Ototoxicity nepatotoxicity Hypersensitivity reaction PZA 20-30mg {≤0.75/day} po Hepatotoxicity; hyperuricemia Acute gouty arthritis EMB 15-25mg po Optic neuritis
  209. 214. LUNG ABSCESS
  210. 215. LUNG ABSCESS <ul><li>a localized necrotic lesion of the lung parenchyma containing purulent material that collapses and forms a cavity. </li></ul><ul><li>generally caused by aspiration of anaerobic bacteria. </li></ul><ul><li>CXR: </li></ul><ul><ul><li>demonstrates a cavity of at least 2 cm. </li></ul></ul><ul><li>Risk for aspiration of foreign material and development of a lung abscess: </li></ul><ul><ul><li>have impaired cough reflexes </li></ul></ul><ul><ul><li>cannot close the glottis, and </li></ul></ul><ul><ul><li>those with swallowing difficulties </li></ul></ul>
  211. 216. ETIOLOGY Aspiration Chest Trauma Pulmonary embolus Neoplasms Pneumonia Dental Infections <ul><li>Debilitating conditions: </li></ul><ul><ul><li>Congestive heart failure </li></ul></ul><ul><ul><li>Malnutrition </li></ul></ul><ul><ul><li>Alcoholism </li></ul></ul>
  212. 217. <ul><li>If left untreated, it can lead to obstruction and necrosis of surrounding tissues. </li></ul>LUNG ABSCESS A lung abscess is the accumulation of pus in the lungs resulting in disintegration of tissues. Location of the abscess depends on position at the time of inhalation. The substance travels to the lowest portion of the lungs as an effect of gravity. As the material settles in the lungs, fibrin surrounds it and forms a pocket-filled pus. As the pressure from the accumulation of pus increases, the pocket ruptures and spreads pus throughout other regions. Sometimes, rupture results in localized healing. O