NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Respiratory System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Infectious Diseases

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Pulmonary Tuberculosis

Focus topic: Medical–Surgical Nursing

Definition: Airborne, infectious, communicable disease thought to be caused by Mycobacterium tuberculosis. May affect any part of the body, but is most common in the lungs. Disease may be acute or chronic.

A. Tubercle bacilli is rod-shaped and gram-positive, acid fast.
B. Diagnostic findings.

  • Early am sputum for smear and culture: positive acid-fast bacillus.
  • Fiber-optic bronchoscopy and chest x-ray (to determine presence and extent of tuberculosis [TB]).
  • Increased WBC and ESR.
  • Positive Mantoux skin test.

C. Most people infected do not develop clinical illness because the immune system brings infection under control.
D. Persons at risk: persons with HIV, immunosuppressed, the elderly, certain minority groups, persons in close contact with infectious TB, persons who have live dormant bacilli from an initial infection acquired years before. Also, those with lowered resistance from alcoholism, those who take steroids, or those who are poorly nourished.

E. Pathophysiology.

  • Inhaled airborne droplets containing the bacteria infect the alveoli, which become the focus of infection—transmission requires close frequent or prolonged exposure.
  • After entrance of tubercle bacilli, the body attempts to wall off the organism by phagocytosis and lymphocytosis.
  • Macrophages surround the bacilli and form tubercles.
  • Tubercles go through the process of caseation—a necrotic process. (Cells become an amorphous cheese-like mass and may be encapsulated to form a nodule.)
  • Caseous nodule erodes, and sputum is released, leaving an air-filled cavity.
  • Initial lesion may disseminate by extension, via bloodstream or lymph system, and through bronchi.

Medical–Surgical Nursing

Assessment
A. Evaluate pulmonary symptoms.

  • Cough (at cavitation stage).
  • Sputum production—initially dry, then purulent.
  • Dyspnea.
  • Hemoptysis.
  • Pleuritic pain (with pleural involvement).
  • Rales.

B. Evaluate systemic symptoms.

  • Fatigue, malaise.
  • Night sweats, low-grade fever in afternoon.
  • Weight loss.
  • Anorexia.
  • Irritability, lassitude.
  • Tachycardia.

C. Complete physical examination.
D. Complete social and medical history.
E. Examine sputum—takes 3–8 weeks for results.
F. Check tuberculin test.

Implementation
A. Maintain respiratory precautions.

  • Client is not considered infectious 2–3 weeks after initiation of chemotherapy.
  • Teach client methods to prevent spread of droplets when coughing.

B. Monitor administration of medications—a combination of drugs are used to destroy variable microbial organisms.
C. Sputum smears obtained every 2–4 weeks until negative (sputum cultures become negative in 3–5 months).
D . Chemoprophylaxis.

  • Laniazid, Nydrazid (isoniazid—INH) and vitamin B6 therapy for 6 months given to those infected with tubercle bacillus without the disease, or to those at high risk for development of the disease.
  • Evaluate for potential complications of INH therapy: Check for hepatitis (rare), excessive tiredness, weakness, loss of appetite, nausea, vomiting, dark yellow or brown urine, jaundice, diarrhea, vision problems, eye pain, numbness or tingling in hands and feet, rash, fever, swollen glands, joint pain, sore throat, stomach pains or right upper quadrant (RUQ) tenderness.
  • Evaluate for potential complications of Rifadin
    (rifampin; RIF) therapy: hepatitis (rare), headache, muscle pain, bone pain, heartburn, nausea, vomiting, stomach cramps, chills, diarrhea, rash, sores on skin or in mouth, fever, jaundice. Urine, stools, saliva, sputum, sweat, and tears may turn red–orange.
  • Evaluate for potential complications of pyrazinamide (PZA) therapy: hepatitis (rare), upset stomach, fatigue, rash, fever, vomiting, loss of appetite, jaundice, darkened urine, pain and swelling in joints, unusual bleeding or bruising, difficulty urinating.
  • Evaluate for potential complications of Myambutol (ethambutol; EMB) therapy: blurred vision, sudden changes in vision, inability to see colors red and green, loss of appetite, upset stomach, vomiting, numbness and tingling in hands or feet, rash, itching.
  • Encourage client to report for frequent prescribed liver function studies.

E. Work with client to maintain compliance—the major problem in eliminating TB.

  • Strict compliance to drug regimen.
  • Monthly follow-up visits for sputum smear until conversion.

F. Directly observed therapy (DOT).

  • This therapy involves observing the ingestion of every dose of medicine the TB client is supposed to take.
    a. This observation continues for the entire course of treatment.
    b. Completing the course of therapy is essential; incomplete treatment can lead to reactivation of TB.
  • The decision to implement DOT is based on risk factors evaluated by the nurse.

G. Instruct client in ways to prevent spread of disease.

  • Cover nose and mouth with a few layers of disposable tissue when sneezing or coughing.
  • Expectorate into a disposable sputum container.
  • Maintain adequate air ventilation.

H. Decontaminate infected air by nonrecirculated air or ultraviolet rays.
I. Provide well-balanced diet: high carbohydrate, high protein, high vitamin B6.
J. Provide frequent oral hygiene.
K. Drug-resistant TB is beginning to appear in the United States.

Medical–Surgical Nursing

Medical–Surgical Nursing: Pneumonia

Focus topic: Medical–Surgical Nursing

Definition: An acute inflammatory process of the lung parenchyma, resulting in lung consolidation as the alveoli and bronchioles fill with exudate. Can be caused by bacteria, viruses, fungi, chemicals.

Assessment
A. Assess for type of pneumonia (classification).

  • Community-acquired pneumonia (CAP)—acquired outside the hospital; lower respiratory tract infection.
    a. Typical.
    (1) Streptococcus pneumoniae is the most common bacterial organism, followed by Haemophilus influenzae.
    (2) Communicable disease.
    (3) Young males most affected.
    (4) Clinical manifestations.
    (a) Rapid onset, severe chills, high temperature (103–106°F/39.4–41.1°C).
    (b) Tachypnea, rapid pulse.
    (c) Productive cough with purulent sputum.
    (d) Pleuritic pain.
    (e) Anxiety.
    (f) Dyspnea.
    (g) Bronchial breath sounds, crackles.
    b. Atypical.
    (1) Legionella, Mycoplasma, and Chlamydia are the common organisms causing infections.
    (2) More gradual onset.
    (3) Dry cough.
    (4) Headache, fatigue, sore throat.
    (5) Nausea, vomiting.
    (6) Crackles.
  • Hospital-acquired pneumonia (HAP)—leading cause of mortality stemming from healthcare-associated infections (HAI). Occurs 48 hours after hospitalization.
    a. Common organisms include Pseudomonas, Enterobacter, Staphylococcus aureus, and Streptococcus pneumoniae, which enter lungs after aspiration of particles from client’s own pharynx.
    b. Risk factors.
    (1) Aspiration.
    (2) Abdominal surgery.
    (3) Immunosuppressant therapy.
    (4) Prolonged mechanical ventilation.
    (5) Structural lung disease.
    c. Clinical manifestations—may represent other disease processes like tuberculosis, heart failure.
    (1) Fever, chills, diaphoresis.
  • (2) Wheezing, inspiratory rales.
    (3) Productive cough, increased pulmonary
    secretions.
    (4) Fatigue, pallor, malaise.
    (5) Tachypnea, tachycardia.
  • Aspiration pneumonia—aspiration of material in mouth into trachea and lungs. Dependent areas of lung most often affected. Aspirate can be food, water, vomitus, chemicals.
    a. Secondary to other conditions such as age, debilitation, stasis, loss of consciousness.
    b. Onset insidious—initial manifestation may be airway obstruction.
  • Opportunistic pneumonia—clients with altered immune response very susceptible to respiratory infections.
    a. At-risk individuals include those with malnutrition, HIV/AIDS, transplants, cancer, immune deficiencies.
    b. Most common organisms involved are Pneumocystis jiroveci pneumonia (PJP), cytomegalovirus, and fungi.
    c. Clinical manifestations: fever, chills, dry nonproductive cough, malaise, fatigue.

B. Assess for exacerbation of chronic obstructive pulmonary disease as respiratory infections precipitate this condition.
C. Observe for an increase in the amount of sputum.

  • Change in the character of sputum (particularly color—yellow to green).
  • Onset of malaise or fever may indicate infection.

Implementation
A. If possible, keep client ambulatory or change position frequently.
B. Elevate head of bed 30 degrees.
C. Encourage fluids to 3000 mL or more to provide hydration.
D. Observe and record type and amount of sputum.
E. Administer antibiotics as ordered.

  • Given for a period of 10–14 days.
  • Antibiotics most commonly used are penicillin G IV, ampicillin, Bactrim (sulfamethoxazole and trimethoprim), Vancocin (vancomycin) (staph pneumonia), and cephalosporins.

F. Provide physiotherapy as ordered (cough, deepbreathe, incentive spirometry).
G. Obtain throat sputum and blood cultures for specific organisms.
H. Determine O2 need according to O2 saturation and ABGs. Administer O2 as indicated.
I. Administer antipyretic drugs and analgesics as needed.

Medical–Surgical Nursing: Legionnaires’ Disease

Focus topic: Medical–Surgical Nursing

Definition: An acute respiratory infection caused by gram-negative bacteria. The name was derived from an outbreak of the disease in Philadelphia in 1973 when members of the American Legion were attending a convention.

Assessment
A. Assess the lungs, the organs most targeted by the bacteria.

  • Primary entry into the body is through the lungs.
  • The organisms are in infected water, usually transmitted via air conditioners and cooling towers.
  • Disease is not transmitted person to person.

B. Early symptoms.

  • Malaise.
  • Mild headache.
  • Dry cough.

C. Later symptoms.

  • Fever and chills—unremitting until therapy.
  • Other symptoms may be pleuritic pain, confusion, and impaired renal function.

Implementation
A. Diagnosis made from specific serum antibodies or by culture.
B. Monitor antibiotic therapy—erythromycin is drug of choice.
C. Nursing care is the same as for pneumonia.

Medical–Surgical Nursing: Chronic Obstructive Pulmonary Disease

Focus topic: Medical–Surgical Nursing

Definition: A functional category applied to respiratory disorders that obstruct the pathway of normal alveolar ventilation either by spasm of the airways, mucus secretions, or changes in the airway and/or alveoli.

Medical–Surgical Nursing

Medical–Surgical Nursing: Chronic Bronchitis

Focus topic: Medical–Surgical Nursing

Definition: A long-term inflammation of the mucous membranes of the bronchial tubes with recurrent cough and sputum production for 3 months or more in 2 consecutive years.

Characteristics
A. Cigarette smoking is probably the biggest culprit, inhibiting the ciliary activity of the bronchi, and resulting in increased stimulation of the mucous glands to secrete mucus.
B. Immunological factors and familial predisposition may also be implicated for those individuals who do not smoke.

Assessment
A. Assess for bronchoconstriction.
B. Evaluate malaise.
C. Check for exertional dyspnea.
D. Assess for hemoptysis.
E. Evaluate cough—may not be productive but may be purulent.
F. Assess for hypoxia.
G. Evaluate lung fields for the following: atelectasis, percussion—hyperresonant, tactile fremitus decreased, prolonged expiratory phase, expansion decreased, trachea midline, wheezes, rales.

Implementation
A. Administer antibiotics when infection occurs.
B. Administer bronchodilators (drug of choice) to relieve bronchospasm and facilitate mucus expectoration.
C. Steroid therapy may be used, but it is still controversial.
D. Encourage fluids to 3000 mL daily to dilute secretions.
E. Provide chest physiotherapy.
F. Monitor oxygen therapy.
G . Teaching principles.

  • Stop smoking—this is the major irritant to the lungs and the major cause of death from cancer.
  • Avoid irritants or allergens and pollutants when possible.
  • Avoid high altitudes (where there is less oxygen).
  • Teach pursed-lip breathing (helps to open airway and stretching exercises).
  • Monitor edema in legs and ankles, which may signify right-sided heart failure.
  • Yearly flu and pneumococcal vaccines.

Medical–Surgical Nursing: Bronchiectasis

Focus topic: Medical–Surgical Nursing

Definition: Thought to develop following airway obstruction or atelectasis. Characterized by permanent, abnormal dilation of one or more large bronchi, leading to destruction of elastic and muscular structures of bronchial wall. Most often associated with bacterial infections such as pneumonia or TB.

Assessment
A. Evaluate for frequent, severe paroxysms of coughing.
B. Assess for hemoptysis.
C. Check for fetid breath.
D. Assess for thick, profuse sputum.
E. Observe for breathlessness, fatigue.
F. Assess for profuse night sweats.
G. Assess for weight loss, anorexia.
H. Evaluate lung fields and chest for the following:

  • Trachea deviates to the affected side.
  • Decreased expansion.
  • Percussion—dull.
  • Vocal fremitus and breath sounds absent if bronchus occluded.
  • Vocal fremitus increased; bronchovesicular/ bronchial breath sounds if bronchus open.
  • Rales, rhonchi.

Implementation
A. Administer antibiotics as ordered. Usually given for 7–10 days—may be long term.
B. Provide chest physiotherapy—postural drainage.
C. Administer bronchodilators and aerosolized nebulizer treatments to assist in removal of secretions.
D. Monitor oxygen therapy if hypoxia occurs.
E. Prepare client for surgery if severe hemoptysis occurs.
F. Encourage client to rest by providing quiet environment.
G. Provide high-protein diet with increased fluid intake.
H. Provide frequent mouth care.

Medical–Surgical Nursing: Emphysema

Focus topic: Medical–Surgical Nursing

Definition: The permanent overdistention of the alveoli with resulting destruction of the alveolar walls. (Emphysema is a Greek word meaning “overinflated.”)

Assessment
A. Alpha-antitrypsin deficiency causes condition to develop at a young age.
B. Individual usually has a history of smoking, chronic cough, wheezing, and shortness of breath.
C. Observe for dyspnea—chief complaint.
D. Assess sputum production.
E. Observe for weight loss.
F. Assess for hypoxia, hypercapnia.
G. Observe physical characteristics of chest.

  • Barrel chest.
  • Expansion decreased.
  • Flat diaphragm.
  • Accessory muscles of respiration used.

H. Assess for decreased tactile fremitus.
I. Percuss for hyperresonance.
J. Auscultate for distant breath sounds.
K. Assess for prolonged expiratory phase.
L. Assess for wheezes, forced expiratory rhonchi.
M. Assess for complications.

  • Pulmonary hypertension.
  • Right-sided heart failure.
  • Spontaneous pneumothorax.
  • Acute respiratory failure.
  • Peptic ulcer disease, gastroesophageal reflux disease (GERD).

Implementation
A. Monitor for signs of impending hypoxia.
B. Monitor for alterations in lung sounds.
C. Instruct on pursed lip breathing exercises.
D. Administer low-concentration oxygen.

  • Usually 2 L/min.
  • Raise PaO2 to 65–80 mm Hg.

E. Monitor for signs of carbon dioxide narcosis.
F. Monitor medications.

  • Inhaled bronchodilators: beta agonists: Proventil, Ventolin (albuterol); Alupent (metaproterenol)—to improve gas exchange by stimulating beta receptors in the lungs.
  • Systemic corticosteroids: controversial—used when bronchodilators are unsuccessful or during an acute attack.
  • Inhaled corticosteroids: Azmacort (triamcinolone), Beclovent (beclomethasone), AeroBid (flunisolide)—affect lungs with no systemic effects.
  • Antibiotics—to combat infection.

G. Provide hydration.

  • Necessary to liquefy secretions present, or to prevent formation of thick, tenacious secretions in clients with pulmonary disease.
  • Modalities.
    a. Oral intake of fluids.
    b. IV administration of fluids.
    c. Humidification to tracheobronchial tree.

H. Monitor humidification and aerosol therapy—important part of treatment plan.

  • Humidification can be delivered through humidifier or nebulizer.
  • Metered-dose inhaler (MDI) therapy, nebulizer.
    a. Corticosteroids, beta2-adrenergic agonists (isoproterenol), and anticholinergic agents may be administered alone or in combination.
    b. Nebulizers deliver aerosols.
  • Clinical implications.
    a. Relief of bronchospasm and mucosal edema.
    b. Mobilization of secretions.
    c. Humidification of the tracheobronchial tree.

I. Provide for chest physiotherapy.

  • Postural drainage.
    a. Positions are utilized to promote gravitational drainage and mobilization of secretions of affected lung segments.
    b. Allows the client to expectorate secretions.
    c. Secretions may be aspirated through a sterile suctioning procedure.
  • Percussion and vibration.
    a. Valuable and necessary adjunct to postural drainage. Cupped-hand position used in percussion.
    b. Vibration of the chest is performed only during the expiratory phase of respiration.
  • Deep breathing and coughing.
    a. Should be encouraged often.
    b. Clients with COPD should be taught the mechanics of an effective cough.
    (1) Contract intercostal muscles.
    (2) Contract diaphragm.
    (3) Fill lungs with air.
  • Breathing exercises or exercise regimen—an integral part in the management of clients with coronary disease.
    a. Diaphragmatic breathing.
    (1) Breathe in via nose.
    (2) Exhale through slightly pursed lips.
    (3) Contract abdominal muscles while exhaling.
    (4) Chest should not move, but abdomen should do the moving. (Abdomen contracts at expiration.)
    (5) Exercises can be learned with client flat on back and then done in other positions.
    b. Accelerated diaphragmatic breathing.
    c. Chest expansion—apical, lateral (unilateral, bilateral), basal.
    d. Controlled breathing with daily activities and graded exercises to improve general physical fitness.
    e. Relaxation and stretching.
    f. General relaxation.
  • Pressure ventilation options.
    a. PEP (positive expiratory pressure).
    b. NIPPV (noninvasive positive-pressure ventilation).
  • c. IPV (intrapulmonary percussive ventilation).
    d. Intermittent positive pressure breathing (IPPB) use is very controversial and is not treatment of choice.

J. Monitor carefully for complications of right-sided (cor pulmonale) and left-sided heart failure.

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Medical–Surgical Nursing: Asthma

Focus topic: Medical–Surgical Nursing

Definition: An obstructive chronic inflammatory disorder of the airways manifested by narrowing of the airways and characterized by generalized bronchoconstriction, excess mucus secretion, and mucosal edema. More than 14.6 million people have asthma in the United States.

Assessment
A. Assess classification of asthma.

  • Mild intermittent.
  • Mild persistent.
  • Moderate persistent.
  • Severe persistent.

B. Evaluate for precipitating factors and triggers, which may include emotions, infection, seasonal changes, occupational exposure to dusts or chemical irritants, certain drugs, exercise.
C. Evaluate for respiratory problems.

  • Cough may be nonproductive or very purulent.
  • Air hunger, dyspnea.
  • Wheezing.
  • Tachypnea.
  • Prolonged expiratory phase.
  • Tachycardia.
  • Hypoxia, cyanosis, hypercapnia.
  • Assess physical signs.
    a. Retraction of intercostal and sternal muscles.
    b. Percussion—hyperresonant.
    c. Distant breath sounds.
    d. Rhonchi, wheezes, rales.
  • Ominous signs.
    a. Diminished breath sounds.
    b. No wheezing (quiet chest).
    c. Increased respiratory rate.

Implementation
A. Provide supportive respiratory care.
B. Identify and avoid known triggers for asthma.
C. Avoid aspirin, NSAIDS.
D. Teach peak-flow monitoring.
E. Administer drug therapy.

  • Beta agonists: Adrenaline (epinephrine), Proventil, Ventolin (albuterol), Bricanyl, Brethine (terbutaline), Bronkosol (isoetharine).
  • Methylxanthines: Truphylline (aminophylline and derivatives).
  • Corticosteroids.
  • Anticholinergics (atropine).
  • Mast cell inhibitors: Nasalcrom (cromolyn sodium).

F. Current treatment approach for asthma attack.

  • During attack, bronchial mucosa releases histamine and slow-reacting substances of anaphylaxis (SRS-A) bronchoconstrictors.
  • SRS-A are leukotrienes that cause airway inflammation, edema, and mucus secretion.
  • New drugs that antagonize leukotrienes and reduce symptoms are available.
  • Anti-inflammatory drugs taken orally are Accolate (zafirlukast), Zyflo (zileuton), and Singulair (montelukast).

G. Sedatives and narcotics should be used with caution.
H. Administer oxygen via nasal cannula.
I. Encourage fluids to 3000 mL daily.
J. Breathing exercises, postural drainage.
K. Metered-dose inhaler (MDI) therapy has advantages over nebulized medications.

  • Teach client to coordinate puff of drug with breath, hold for 10 seconds, one puff at a time.
  • Use of holding chambers attached to MDI mouthpiece (spacers) enhance effectiveness.
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