Week 2 Notes
University of Memphis
Popular in Nurs Adult I/Common Hlth Alt
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This 12 page Class Notes was uploaded by Ashlan Notetaker on Friday September 9, 2016. The Class Notes belongs to NURS 3205 at University of Memphis taught by Harrell in Summer 2016. Since its upload, it has received 58 views. For similar materials see Nurs Adult I/Common Hlth Alt in NURSING at University of Memphis.
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Date Created: 09/09/16
Week 2 Notes Tuberculosis What is TB and what microorganism causes it? - mycobacterium tuberculosis What is the rout of transmission for TB? - airborne – travels through the air o airborne precautions - N95 (fit tested) fit testing- N95 shield overhead and mask over face and make sure it is comfortable. They then spray something in the air by the shield overhead – saccharin. They are going to ask can you taste saccharine, and if you can then the mask is not fit correctly. Then you have to refit and adjust until you cannot taste the saccharin. If you have facial hair you can keep it but cannot wear an N95 mask o Should be a sign on the door – Negative airflow room – air comes in, but does not go out. (whoosh is behind you) (TB) If room does not have negative airflow then it is being emitted to the whole hospital, our duty to make sure that the room is working properly If you suspect that a patient has TB, then treat them like they have TB Remember that positive airflow is for those that are immunocompromised and used in the operating room (whoosh is in front of you) The Centers for Disease Control and Prevention recommends screening people at high risk for TB. List 5 populations at high risk for developing active diseases. - Mission trip (medically underserved areas); overcrowded areas (prisons, dorms, nursing home, nurses, shelters); Increased immigrant’s areas; immunosuppressed population; IV drug users Takes 48 to 72 hours, if after 72 hours then the test must be redone Look at induration (feel) and not erythema (redness) Measured in millimeters Immunosuppressed – 5mm At risk population – 10mm Not at risk population – 15mm o Describe the two methods of TB screening - Mantoux Test - PPD injection – intradermal injection - ~ 25 degrees Takes 48 to 72 hours, if after 72 hours then the test must be redone Look at induration (feel- the whelp, like when we get a mosquito bite) and not erythema (redness) Measured in millimeters Immunosuppressed – 5mm; the first finger is roughly 2 centimeters wide At risk population – 10mm Not at risk population – 15mm or 1.5 centimeters TB antigen test – serum blood test (quick rapid test) Interferon-y test- another test for TB How do you determine whether a Mantoux test result is positive or negative? - Immunosuppressed – 5mm; the first finger is roughly 2 centimeters wide - At risk population – 10mm - Not at risk population – 15mm or 1.5 centimeters The case study - it’s about 18mm when we interpret the skin test Symptoms: active TB: cough(productive), SOB(dyspnea), night sweats, weight loss, hemoptysis (late sign) Patho of TB - Mycobacterium tubercula jumps into airway – to lung- sets up shop usually in the upper lobe – can live there and be latent for an entire life span; only 5%- 10% with latent infection actually develop active disease o If it does become active it invades surrounding tissues and creates scar tissue, inflammatory response in the lung occurs, which breaks down lung tissue and forms scare tissue among the broken down tissue; develops into a tubercle which is Tuberculosis (walled up tumor on an upper lobe) o If you have scar tissue and has built up a tumor around the infecting organism, it is hard to get antibiotics to kill it in that area Then you have to up the does and find a big bad drug You inform B.A. of the test result. She asks you what the result means. How will you respond? - Ms. B.A. I’m sorry to tell you, but you may have TB. We need to dig a little deeper. What steps need to be done to determine whether B.A. has an active TB infection? - Next step after a positive PPD test is to get a Chest Xray - If positive CXray then collect sputum to test culture (AFB - acid fast bacilli - smear/culture) o If it comes back positive, then it is ACTIVE - False positive can come up if a person has the BCG vaccine (administered to prevent TB) given to those who do mission work and military (make sure to ask about this) What is LTBI? - TB infection without disease (significant reaction to tuberculin skin test, negative bacteriologic studies, no x-ray findings compatible with TB, no clinical evidence of TB) - If we know that the person has active TB we will start medications - Or someone who has a high risk and may have TB will start medications Medications - Table 28-11 know these drugs - Administering some drugs what is the most important lab to monitor? o Monitor liver functions (LFT – liver function tests) AST ALT Alkaline phosphatase Bilirubin - CMP – lab with sodium and potassium and all that good stuff, BUN, creatinine, chloride and CO2 and sometimes these LFT o If elevated let provider know Streptomycin – ototoxicity(ear), neurotoxicity(nerves), nephrotoxicity(kidney) side effects Don’t need to know table 28-12, but nice to know Isoniazid (INH) one of the most important points in teaching for a patient is….. - No alcohol! Because the liver can be torn up with it DOT (direct observed therapy) – watch patient take their medication, go to a clinic or county place - Expensive drugs - Adherence and compliance - Used for patients with TB, mental, or those who are like homeless, substance abuse clinics Therapy is effective: - Patient reports decrease in night sweats Best measure to determine if a patient no longer has active TB is - Negative AFB cultures - To be cured from TB there must be 3 AFB cultures in a row to be negative How to take care of family when you have TB - Tell them they expose others and others can be affected - Ask them to wear a mask, good hand hygiene - Don’t go out and about (no church, grocery stores, shopping) if they go out make sure to wear a mask - Decrease contact with youngsters and older adults so that it is not transmitted as easily - Take a shower when everyone is out - Sleep in a different bedroom How to travel a TB patient somewhere outside of the unit/room - Don’t go! Bring others to the room and call the doctor to make sure that they know about the patients active TB - Ask for an alternate test - IF they need to leave hopefully they will have an N95 which they will wear o Don’t let them be in a room with other people, ESPECIALLY those who are older and immunocompromised If a patient goes bad in route to somewhere and the patient has TB. What do you do? - Start CPR! - Priority: save patient and stay safe individually - NEVER leave the patient Always prepare for the worst case scenario WWKYP - Goes unnoticed – sepsis – die - Goes unnoticed – hemoptysis – die - LTBI or active TBI – start drugs – liver failure – die - Drug reaction – die - Capreomycin/Streptomycin – kidney failure – die Streptomycin and urine input has gone out the drain. What lab value would be of concern? - Creatinine o Best way to check kidney function is creatinine and not BUN o Normal value is around .5-1.1 TB + Streptomycin =watch the kidneys TB + triple therapy (isoniazid, rifampin, ethambutol) = sick liver Asthma and COPD We talk about these together because they are very similar. As a nurse and we have a patient who is having trouble breathing we need to help them breathe. Nursing diagnosis: clearance issues and breathing pattern issues and gas exchange issues Asthma’s two components - Airway inflammation of the soft tissues of the airway (columnar epithelia cells that are ciliated) - Bronchoconstriction (muscular component) We expect these students - Step one know your triggers - Step two keep something with you at all times (albuterol – beta adrenergic agonist – inhaler which activates beta and relaxes smooth muscle) that allows airway to open up o Can get steroid to decrease inflammation also CMs: dyspnea, tachypnea, hypoxic (decreased O2 stat, irritability, cyanotic- late sign), cough, air gasping Know your triggers - Something causes the airways to become inflamed. - What type of triggers o Anything from plants (pollen) o Exercise o Common cold o Mold o Fumes (like Clorox and disinfectant cleaners, paint) o Smoke o Medications – nsaids (ibuprofen) Pt in ER says they have a long history of asthma and they can’t breathe right. There is no wheezing. - WWKYP – airway is so constricted that they cannot move enough air to get a wheeze through. Absent of a wheeze does not mean they do not have asthma. - What do we do? We have to restore breathing so the nurse puts the patient on O2 and quickly find something to get the airway working. In ER you may give steroids IV or a nebulizer treatment. - Sometimes administer epinephrine o which works on both alpha and beta adrenergic receptors as a blocker to suppress alpha and beta activity to either open airways prevent circulatory collapse o Epipen is used to open airway and prevent circulatory collapse when a person is having an asthma attack - Patient with asthma usually wheezes, when you are in a situation when the patient is having an asthma attack and they are not wheezing, then it is a dangerous situation and notify the physician. The patient’s airway is closing. Pg 565* Risks for Asthma - Exercise (take inhaler before working out) o REALLY important for children when they go play - GERD (gastroesophageal reflux disease) – reflux in the airway (aspiration) which irritates the airways Top 3 causes for cough - Asthma - Postnasal drip - GERD You do have some production of mucus, but not primary pathology of the disease which is inflammatory process. Ask have you ever had to be intubated for your asthma when they are in the hospital. This is important because when judging how bad it has become you know that an asthma attack can kill them more easily if they had been intubated in the past. Know your H1 and H2 histamine drugs - If allergies are a trigger you would give an antihistamine to reduce allergies – H1 blocker to stop inflammatory activity in the long run Subjective vs objective - Subjective is what the patient is telling you (Subjective – says) - Objective what you say o Best form of data We want an objective number to know how bad a constrictive airway is measured by the amount of air that is being moved - PEFR – peak expiratory flow rate – quick breath out (best objective data) o Teach how to use a peak expiratory flow meter Take a deep breath Place lips around meter Blow out as hard as you can Marker should move along the scale o For asthma the peak expiratory flow rate decreases Usually it is hard to get the air out o Used to determine the extent of the disease o Green, yellow, and red zone Green is good Yellow is not to exercise today or make an appointment with your doctor Red is BAD! Go to ED because you could die Nursing diagnosis - Impaired gas exchange - Ineffective airway clearance - Impaired breathing pattern Other diagnostic tests for asthma - Cxray (pg 567) a chest xray in an asymptomatic patient with asthma is usually normal. A chest x-ray in a symptomatic patient is also usually normal. o COPD – you might see some inflammation - Blood count – o WBC – eosinophils is important in inflammatory actions Pg 568 – treatment of asthma steps 1. Avoid triggers a. Working in the coalmine and it aggervates asthma i. quit coalmine if you can, if not must continue to step 1 2. Saba – short acting beta agonist a. Best for an asthma attack b. Albuterol (Inhaler pro-air) (vintilin) i. Q 4 to 6 hours prn ii. for dyspnea c. Nebulizer i. q 4 to 6 hours prn ii. for dyspnea d. side effects are opposite of alpha adrenergic agonist i. Speed up heart rate ii. jittery 1. shaky after albuterol (usually in IV form), it is not a seizure iii. Nervous 3. ICS – inhaled corticoid steroid a. MDI - Meter dose inhaler i. Pressurized bottle that gives a puff of medicine ii. Proper care 1. Should always have their albuterol with them at all times a. Specifically if they know they will be around triggers 2. How do you know about medicine is left? a. Counters on the bottle and tells how many puffs are left b. See if it floats (if it floats it is empty) b. DPI – Dry Powder inhaler i. Puff in a powder form 4. – 6. Laba – long acting beta agonist - and more corticoid steroids a. Not used in asthma attacks, used for long term, which is why then should take it every day to prevent these asthma attacks b. Theopyline (old drug) i. Heart problem or coffee can lead to death with this drug c. Leukotriene Modifiers i. Commercial – singulair 1. Slow down and reduce production of mast cells ii. Every day for 2wks until it starts to be in effect because it is a maintenance drug iii. Usually take at night d. Wash mouth about 10 minutes after every use i. Can cause a fungus infection Acute asthma attack needs IV drugs - It is immediately there and you cannot get it back, so know what you are doing - IM absorbs slowly and takes a while unlike IV - When a patient is having an asthma attack the best drugs to give is o Methylprednisolone o Solumedrol o Decadron Steroid helps improve the inflammatory process o IV Theophylline o IV magnesium Smooth muscle relaxant CNS Sedative o IV sulfate Relaxes smooth muscle Nurse knows that treatment has been effective when - O2 stat has returned to normal - Wheezing and movement of air improves - Pt decreases cough When a patient is having an asthma attack administer Albuterol first and then the steroid. The albuterol opens the airways so that the steroid can work. Steroids work on the surface area and anything that it touches to reduce inflammation. PFT – pulmonary function tests (we don’t need to know anything about this) all we need to know is that patients with an asthma attack cannot breathe well Spacer – 80% and more of the medication is delivered when given with a spacer only MDI (meter dose inhaler) - Without a spacer only 20-40% of the medication is delivered to the patient - Some spacers will have tones and if they breathe at the right rate the tones will go off, if you don’t breathe correctly there will only be one tone or no tone at all - Administer the medication into the spacer BEFORE the patient breathes in - Don’t use spacers with powder inhalers Pt with asthma attack and are about to die can give off what is called air hunger – Fear and anxiety of not breathing makes breathing worse When a patient is having an asthma attack. They are having anxiety and are scared and their breathing is getting worse what do you do? - Stay with the patient and talk with the patient and reassure them o Hyperventilation protocol -get in the patients face and help them out by talking Make them zone in Make them breathe slower o Stay with patient until they can breathe better - Family members can sometimes get in the way Manage COPD patient the exact same way as asthma patients -wheeze like asthma Two prong disease progression - Emphysema (pink puffers) o Types of patients Patients with chronic asthma Smokers – or occupation that deals with smoke o Destruction of alveoli Leads to no gas exchange o Air trapping breath in but cannot exhale Acid vasodilates o Don’t think about sputum production its more about the gas exchange o Bullae emphysema is where parts of the lung is not useable (not useable lung tissue) o Complication Cor pumonale Right sided heart failure o Pulmonary artery -right ventricle -right atrium – superior and inferior vena cava (contain all venous and lymphatic return of the entire body) o Vein in neck that pops out is not normal - Chronic bronchitis (blue bloaters) o People at risk: Smoking; occupational chemicals; dust; pollution o Cannot get air in o Chronic coughers o Mucus o Cyanotic (blue) o Get pneumonia – bronchitis- and then dead if not caught o Present: wheezes, crackles, cough (but doesn’t come out) o Thin mucus and get it out – what we want o Improve gas exchange o Thin out secretions Guaifenesin Hydrate Mucomyst – antidote for Tylenol Inhaled or PO Smells like sulfur alpha-1 antitrypsin (aat) deficiency - Works on how lung surfactant is used and produced and alveoli is coated with surfactant which helps the alveoli move smoothly - Kids we can give them lung surfactant - if they don’t they can get COPD COPD happens in what age person? - Usually 60s - With aat deficiency – 40s - Yong person with COPD nurse is to think AAT deficiency Chest diameter - Different from the 1:2 chest (a-p diameter) - Usually 1:1 with empha Important thing to teach the patient of COPD - Smoking Cessation How do you treat a patient with COPD - Same way as asthma Need oxygen – we can administer oxygen to patients if they need it - Under standard of care - Important as an order - We have to have an order at some point soon after we put on oxygen - BNC o 24-44% of oxygen - Simple face mask o Use this if the nasal cannula is annoying the patient - Partial and nonrebreathers o Bag on mask o Partial – with disk o Nonrebreather Best way to give the most oxygen with invasive techniques Deliver almost 100% (in the 90%) o Bag valve mask C method or E method and give breaths 100% o Ventilating patient o Trach – trach collar is like a face mask that just blows oxygen down their trach o Venturi mask – more fancy tubs and you can control the amount of oxygen that the patient can get o Basic way to measure the amount of air the patient is breathing - Which is best for the COPD patient o Depends on the situation o Usually nasal cannula - If you give too much oxygen it can change the imbalance o CO2 is to call respiration to happen so it can kill the respiratory drive pg 592 - We don’t want to usually get above 6L of oxygen BNC Best lab value to tell their breathing status - ABG O2 sat - Peripheral O2 sat Sometimes look at their ability to function their ADLs (function ability) Prevent exposure - If they get an active infection they need to start taking medications immediately!! - techniques – pursed lip breathing - Chest physiotherapy - Lung drain - Oxygen Nutrition - Patients need frequent smaller meals - High protein - Easier to chew Best prevention for COPD is to STOP smoking
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