CARDIOVASCULAR SYSTEMOVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEARTHEART- Muscular pumping organ of the body- Located on the left mediastinum- Resemble like a close fistWeighs approximately 300 400 grams- Covered by a serous membrane called the pericardium 2 layers of pericardium a. Parietal outer layer b. Visceral inner layer - In between is the pericardial fluid which is 10 20 cc - Prevent pericardial friction rub- Common among MI, pericarditis, Cardiac tamponade

A. Layers of Heart1. Epicardium outer layer 2. Myocardium middle layer 3. Endocardium inner layer- Myocarditis can lead to cardiogenic shock and rheumatic heart diseaseB. Chambers of the Heart1. Upper Chamber (connecting or receiving) a.Atria2. Lower Chamber (contracting or pumping) a.ventricles - Left ventricle has increased pressure which is 120 180 mmHg - In order to propel blood to the systemic circulation - Right atrium has decreased pressure which is 60 80 mmHgC. Valves- To promote unidimensional flow or prevent backflow

1. Atrioventricular Valves - guards opening betweena. tricuspid valveb. mitral valve - Closure of AV valves give rise to first heart sound (Slub)2. Semi lunar Valves a. pulmonic b. aortic- Closure of SV valve give rise to second heart sound (S2 dub)Extra Heart Sounds1. S3 ventricular gallop usually seen in Left Congestive Heart Failure2. S4 atrial gallop usually seen in Myocardial Infarctionand Hypertension

D. Coronary Arteries - Arises from base of the aortaTypes of Coronary Arteries 1. Right Main Coronary Artery 2. Left Main Coronary Artery- Supplies the myocardium

E. Cardiac Conduction System

1. Sino Atrial Node (SA or Keith Flack Node) - Located at the junction of superior vena cava and right atrium - Acts as primary pacemaker of the heart - Initiates electrical impulse of 60 100 bpm2. Atrio Ventricular Node (AV or Tawara Node) - Located at the inter atrial septum - Delay of electrical impulse for about .08 milliseconds to allow ventricular filling3. Bundle of His - Right Main Bundle of His - Left Main Bundle of His - Located at the interventricular septum4. Purkinje Fibers - Located at the walls of the ventricles for ventricular contraction

P WAVE (atrial depolarization) contraction-QRS WAVE (ventricular depolarization)-T WAVE (ventricular repolarization)Insert pacemaker if there is complete heart blockMost common pacemaker is the metal pacemaker and lasts up to 2 5 years

ABNORMAL ECG TRACING1. Positive U wave Hypokalemia2. Peak T wave . ST segment depression Angina Pectoris4. ST segment elevation Myocardial Infarction5. T wave inversion Myocardial Infarction6. Widening of QRS complexes Arrythmia

CARDIAC DISORDERS

Coronary Arterial Disease/ Ischemic Heart Disease

Stages of Development of Coronary Artery Disease1. Myocardial Injury Atherosclerosis2. Myocardial Ischemia Angina Pectoris3. Myocardial Necrosis Myocardial Infarction

ARTERIOSCLEROSIS - narrowing of artery - lipid or fat deposits -tunica intima ARTERIOSCLEROSIS - hardening of artery calcium and protein deposits -tunica mediaA. Predisposing Factors1. Sex male2. Race black3. Smoking4. Obesity5. Hyperlipidemia6. sedentary lifestyle7. Diabetes Mellitus8. Hypothyroidism9. Diet increased saturated fats10. Type A personality

B. Signs and Symptoms1. Chest pain2. Dyspnea3. Tachycardia4. Palpitations5. Diaphoresis

C. Treatment Percutaneous Translumina lCoronary Angioplasty Objectives of PTCA 1. Revascularize myocardium 2. To prevent angina 3. Increase survival rate- Done to single occluded vessels - If there is 2 or more occluded blood vessels CABG is done

Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG1. Pneumonia encourage to perform deep breathing, coughing exercise and use of incentive 2. Shock3. Thrombophlebitis

ANGINA PECTORIS (SYNDROME)Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine dueto temporary myocardial ischemiaA. Predisposing Factors1. Sex male2. Race black3. Smoking4. Obesity5. Hyperlipidemia6. sedentary lifestyle7. Diabetes Mellitus8. Hypothyroidism9. Diet increased saturated fats10. Type A personalityB. Precipitating Factors4 Es of Angina Pectoris1. Excessive physical exertion heavy exercises2. Exposure to cold environment3. Extreme emotional response fear, anxiety, excitement4. Excessive intake of foods rich in saturated fats skimmed milkC. Signs and Symptoms1.Levines Sign initial sign that shows the hand clutching the chest2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back, shoulder,arms, axilla and jaw muscles, usually relieved by rest or taking nitroglycerine3. Dyspnea4. Tachycardia5. Palpitations6. DiaphoresisD. Diagnostic Procedure1. History taking and physical exam2. ECG tracing reveals ST segment depression3. Stress test treadmill test, reveal abnormal ECG4. Serum cholesterol and uric acid is increasedE. Nursing Management1. Enforce complete bed rest2. Administer medications as ordered.

a. Nitroglycerine (NTG) when given in small doses will act as venodilator , but in large dosesb willact as vasodilator - Give first dose of NTG (sublingual) 3 5 minutes - Give second dose of NTG if pain persist after giving first dose with interval of 3 - 5 minutes - Give third and last dose of NTG if pain still persist at 3 5 minutes interval

Nursing Management when giving NTG -Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug -Monitor side effects Orthostatic hypotension Transient headache and dizziness -Instruct the client to rise slowly from sitting position -Assist or supervise in ambulation -When givingnitrolor transdermal patch Avoid placing near hairy areas as it may decrease drug absorption Avoid rotating transdermal patches as it may decrease drug absorption Avoid placing near microwave ovens or duting defibrillation as it may lead to burns ( mostimportant thing to remember )b. Beta-blockers - Propanolol - side effects PNS- Not given to COPD cases because it causes bronchospasm c. ACE Inhibitors Enalapril d. Calcium Antagonist- NIfedipine3. Administer oxygen inhalation4. Place client on semi fowlers position5. Monitor strictly vital signs, intake and output and ECG tracing6. Provide decrease saturated fats sodium and caffeine7. Provide client health teachings and discharge planning a. Avoidance of 4 Es b. Prevent complication (myocardial infarction) c. Instruct client to take medication before indulging into physical exertion to achieve the effect of drugc. The importance of follow up care

MYOCARDIAL INFARCTION Heart attackTerminal stage of coronary artery disease characterized by malocclusion, necrosis and scarring.A. Types 1. Transmural Myocardial Infarction -most dangerous type characterized by occlusion of both right and leftcoronary artery 2. Subendocardial Myocardial Infarction characterized by occlusion of either right or left coronary Artery

B. The Most Critical Period Following Diagnosis of Myocardial Infarction ** 6 8 hours because majority of death occurs due to arrhythmia leading to PVCs C. Prediosposing Factors 1. Sex male 2. Race black 3. Smoking 4. Obesity 5. Hyperlipidemia 6. sedentary lifestyle 7. Diabetes Mellitus 8. Hypothyroidism 9. Diet increased saturated fats 10. Type A personality

D. Signs and Symptoms 1. Chest pain- Excruciating visceral, viselike pain located at substernal and rarely in precordial- Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles (abdominal ischemia)- Not usually relieved by rest or by nitroglycerine 2. Dyspnea 3. Increase in blood pressure (initial sign) 4. Hyperthermia 5. Ashen skin 6. Mild restlessness and apprehension 7. Occasional findings a. Pericardial friction rub b. Split S1 and S2 c. Rales/Crackles upon auscultation d. S4 or atrial gallopE. Diagnostic Procedure 1. Cardiac Enzymes a. CPK MB - Creatinine phosphokinase is increased - Heart only, 12 24 hours b. LDH Lactic acid dehydroginase is increased c. SGPT Serum glutamic pyruvate transaminase is increased d. SGOT Serum glutamic oxal-acetic transaminase is increased 2. Troponin Test is increased 3. ECG tracing reveals a. ST segment elevation b. T wave inversionc. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Serum Cholesterol and uric acid are both increased 5. CBC increased WBCF. Nursing Management Goal: Decrease myocardial oxygen demand 1. Decrease myocardial workload (rest heart) - Administer narcotic analgesic/morphine sulfate- Side Effects: respiratory depression- Antidote: Narcan/Naloxone- Side Effects of Naloxone Toxicityis tremors 2. Administer oxygen low inflow to prevent respiratory arrest at 2 3 L/min 3. Enforce CBR without bathroom privilegesa. Using bedside commode 4. Instruct client to avoid forms of valsalva maneuver 5. Place client on semi fowlers position 6. Monitor strictly vital signs, intake and output and ECG tracing 7. Provide a general liquid to soft dietthat is low in saturated fats, sodium and caffeine 8. Encourage client to take 20 30 cc/week of wine, whisky and brandy to induce vasodilation 9. Administer medication as ordered a.Vasodilators - Nitroglycerine- ISD (Isosorbide Dinitrate, Isodil) sublingual b. Anti Arrythmic Agents - Lidocaine (Xylocane- Side Effects: confusion and dizziness- Brutylium c. Beta-blockers d.ACE Inhibitors e.Calcium Antagonist f.Thrombolytics/ Fibrinolytic Agents - Streptokinase- Side Effects: allergic reaction, pruritus - Urokinase- TIPAF (tissue plasminogen activating factor) -Side Effects:chest pain- Monitor for bleeding time g.Anti Coagulant - Heparin (check for partial thrombin time) -Antidote:protamine sulfate - Coumadin/ Warfarin Sodium (check for prothrombin time) -Antidote:Vitamin K h.Anti Platelet- PASA (Aspirin)- Anti thrombotic effect- Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia- Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10. Provide client health teaching and discharge planning concerning a. Avoidance of modifiable risk factors- arrhythmia (caused by premature ventricular contraction) b. Cardiogenic shock- late sign is oliguria c. Left Congestive Heart Failure d. Thrombophlebitis- homans sign e. Stroke/CVA f. Post MI Syndrome/ Dresslers Syndrome - client is resistant to pharmacological agents, administer 150,000 450,000 units of streptokinase as Ordered g. Resumption of ADL particularly sexual intercourse is 4 6 weeks post cardiac rehab, post CABG and instruct to -make sex as an appetizer rather than dessert - instruct client to assume a non weight bearing position - client can resume sexual intercourse if can climb staircase - dietary modification h. Strict compliance to mediation and importance of follow up care

CONGESTIVE HEART FAILURE Inability of the heart to pump blood towards systemic circulationTypes of Heart Failure1. LEFT SIDED HEART FAILURE A. Predisposing Factors 1. 90% is mitral valve stenosis due to a. RHD inflammation of mitral valve due to invasion of Grp. A beta-hemolytic streptococcus - Formation of aschoff bodies in the mitral valve - Common among children - ASO Titer (Anti streptolysin O titer) - Penicillin- Aspirin b. Aging 2. Myocardial Infarction 3. Ischemic heart disease 4. Hypertension 5. Aortic valve stenosis B. Signs and Symptoms 1. Dyspnea 2. Paroxysmal nocturnal dyspnea client is awakened at night due to difficulty of breathing 3. Orthopnea use 2 3 pillows when sleeping or place in high fowlers 4. Productive cough with blood tinged sputum 5. Frothy salivation 6. Cyanosis 7. Rales/Crackles 8. Bronchial wheezing 9. Pulsus Alternans weak pulse followed by strong bounding pulse 10. PMI is displaced laterally due to cardiomegaly 11. There is anorexia and generalized body malaise 12. S3 ventricular gallop C. Diagnostic Procedure 1. Chest x-ray reveals cardiomegaly 2. PAP (pulmonary arterial pressure) measures pressure in right ventricle or cardiac status PCWP (pulmonary capillary wedge pressure) measures end systolic and dyastolic pressure -both are increased -done by cardiac catheterization (insertion of swan ganz catheter ) 3. Ecocardiography enlarged heart chamber (cardiomyopathy), dependent on extent of heart Failure 4. ABG reveals PO2 is decreased (hypoxemia), PCO2 is increased (respiratory acidosis)

2. RIGHT SIDED HEART FAILURE A. Predisposing Factors 1. Tricuspid valve stenosis 2. Pulmonary embolism 3. Related to COPD 4. Pulmonic valve stenosis B. Signs and Symptoms (venous congestion) 1. Neck/jugular vein distension 2. Pitting edema 3. Ascites 4. Weight gain 5. Hepatosplenomegaly 6. Jaundice 7. Pruritus 8. Anorexia 9. Esophageal varices C. Diagnostic Procedures 1. Chest x-ray reveals cardiomegaly 2. Central venous pressure (CVP) - Measure pressure in right atrium (4 10 cm of water) - CVP fluid status measure - If CVP is less than 4 cm of water hypovolemic shock - Do the fluid challenge (increase IV flow rate -If CVP is more than 10 cm of water hypervolemic shock Administer loop diuretics as ordered - When reading CVP patient should be flat on bed - Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Ecocardiography reveals enlarged heart chambers (cardiomyopathy 4. Liver enzymes SGPT and SGOT is increased D. Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 6 L/min) 1. Enforce CBR 2. Administer medications as ordered a.Cardiac glycosides - Digoxin (Lanoxin)- Increase force of cardiac contraction - If heart rate is decreased do not give b. Loop Diuretics - Lasix (Furosemide) c. Bronchodilators d.Narcotic analgesics - Morphine Sulfate e.Vasodilators Nitroglycerine f.Anti Arrhythmic - Lidocaine (Xylocane) 3. Administer oxygen inhalation with high inflow, 3 4 L/min, delivered via nasal cannula 4. High fowlers position 5. Monitor strictly vital signs, intake and output and ECG tracing 6. Measure abdominal girth daily and notify physician 7. Provide a dietary intake of low sodium, cholesterol and caffeine 8. Provide meticulous skin care 9. Assist in bloodless phlebotomy rotating tourniquet, rotated clockwise every 15 minutes to promote decrease venous return 10. Provide client health teaching and discharge planning a. Prevent complications- Arrythmia- Shock- Right ventricular hypertrophy- MI- Thrombophlebitis b. Dietary modification c. Strict compliance to medications

PERIPHERAL VASCULAR DISORDER

Arterial Ulcer I. Thrombo Angitis Obliterans Burgers Disease Reynauds Disease Venous Ulcer 1. Varicose Veins 2. Thrombophlebitis (deep vein thrombosis)

THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremitiesA. Predisposing Factors 1. High risk groups men 30 years old and above2. SmokingB. Signs and Symptoms 1. Intermittent claudication leg pain upon walking 2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor) 3. Decreased peripheral pulses 4. Trophic changes 5. Ulceration 6. Gangrene formationC. Diagnostic Procedures 1.Oscillometry decrease in peripheral pulses 2.Doppler UTZ decrease blood flow to the affected extremity 3.Angiography reveals site and extent of malocclusionD. Nursing Management 1. Encourage a slow progressive physical activity a. walking 3 4 times a day b. out of bed 3 4 times a Day 2. Administer medications as ordered a. Analgesics b. Vasodilators c. Anti coagulants 3. Institute foot care management 4. Instruct client to avoid smoking and exposure to cold environment 5. Assist in surgical procedure bellow knee amputation

REYNAUDS DISEASE Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the handsA. Predisposing Factors 1. High risk group female 40 years old and above 2. Smoking 3. Collagen diseases a. SLE (butterfly rash) b. Rheumatoid Arthritis 4. Direct hand trauma a. Piano playing b. Excessive typing c. Operating chainsawB. Signs and Symptoms 1. Intermittent claudication leg pain upon walking 2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor) 3. Trophic changes 4. Ulceration 5. Gangrene formationC. Diagnostic Procedures 1.Doppler UTZ decrease blood flow to the affected extremity 2.Angiography reveals site and extent of malocclusionD. Nursing Management 1. Administer medications as ordered a. Analgesics b. Vasodilators 2. Encourage to wear gloves 3. Instruct client on importance of cessation of smoking and exposure to cold environment

VARICOSITIES Abnormal dilation of veins of lower extremities and trunks due to Incompetent valve resulting to Increased venous pooling resulting to Venous stasis causing Decrease venous return

A. Predisposing Factors 1. Hereditary 2. Congenital weakness of veins 3. Thrombophlebitis 4. Cardiac disorder 5. Pregnancy 6. Obesity 7. Prolonged standing or sittingB. Signs and Symptoms 1.Pain after prolonged standing 2. Dilated tortuous skin veins 3. Warm to touch 4. Heaviness in legsC. Diagnostic Procedure 1. Venography 2. Trendelenburgs Test - veins distends quickly in less than 35 secondsD. Nursing Management 1. Elevate legs above heart level to promote increased venous return by placing 2 3 pillows under the Legs 2. Measure the circumference of leg muscle to determine if swollen 3. Wear anti embolic stockings 4. Administer medications as ordered a. Analgesics 5. Assist in surgical procedure a. Vein stripping and ligation (most effective) b. Sclerotherapy can recur and only done in spider web varicosities and danger of thrombosis (2 3years for embolism)THROMBOPHLEBITIS Deep vein thrombosisInflammation of the veins with thrombus formationA. Predisposing Factors 1. Obesity 2. Smoking 3. Related to pregnancy 4. Chronic anemia 5. Prolong use of oral contraceptives promotes lipolysis 6. Diabetes mellitus 7. Congestive heart failure 8. Myocardial infarction 9. Post op complication 10. Post cannulation insertion of various cardiac catheter 11. Increase in saturated fats in the diet.B. Signs and Symptoms 1. Pain at affected extremity 2. Warm to touch 3. Dilated tortuous skin veins 4. Positive Hpmans Signs pain at the calf or leg muscle upon dorsi flexion of the footC. Diagnostic Procedure 1. Venography 2. AngiographyD. Nursing Management 1. Elevate legs above heart level to promote increase venous return 2. Apply warm moist pack to reduce lymphatic congestion 3. Measure circumference of leg muscle to determine if swollen 4. Encourage to wear anti embolic stockings or knee elastic stockings 5. Administer medications as ordered a. Analgesics b. Anti Coagulant- Heparin 6. Monitor for signs of complications Embolism a.Pulmonary- Sudden sharp chest pain - Unexplained dyspnea - Tachycardia - Palpitations - Diaphoresis - Restlessness b.Cerebral Headache - Dizziness - Decrease LOCMURPHYS SIGN is seen in clients with cholelithiasis, cholecystitis characterized by pain at theright upper quadrant with tenderness

RESPIRATORY SYSTEMOVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM

I. Upper Respiratory System 1. Filtering of air 2. Warming and moistening of air 3. HumidificationA. Nose - Cartillage - Right nostril - Left nostril - Separated by septum Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding)B. Pharynx/Throat - Serves as a muscular passageway for both food and air C. Larynx - For phonation (voice production) - For cough reflexGlottis - Opening of larynx - Opens to allow passage of air - Closes to allow passage of food going to the esophagus - The initial sign of complete airway obstruction is the inability to coughII. Lower Respiratory System - For gas exchangeA. Trachea/Windpipe - Consist of cartilaginous rings - Serves as passageway of air going to the lungs - Site of tracheostomyB. Bronchus - Right main bronchus - Left main bronchus

C. Lungs - Right lung (consist of 3 lobes, 10 segments) - Left lung (consist of 2 lobes, 8 segments) - Serous membranes Pleural Cavity a.Pareital b.Pleural fluid c.Visceral With Pleuritic Friction Rub a. Pneumonia b. Pleural effusion c. Hydrothorax (air and blood in pleural space Alveoli - Site of gas exchange (CO2 and O2) - Diffusion (Daltons law of partial pressure of gases)

Respiratory Distress Syndrome - Decrease oxygen stimulates breathing - Increase carbon dioxide is a powerful stimulant for breathingType II Cells of Alveoli - Secretes surfactant - Decrease surface tension - Prevent collapse of alveoli - Composed of lecithin and spingomyelin - L/S ratio to determine lung maturity - Normal L/S ratio is 2:1 - In premature infants 1:2 - Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias - retinopathy/blindness in prematurity

Disorders of Respiratory System

1. PTB/Pulmonary Tuberculosis (Kochs Disease) - Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli- An acid fast, gram negative, aerobic and easily destroyed by heat or sunlightA. Precipitating Factors 1. Malnutrition 2. Overcrowded places 3. Alcoholism 4. Over fatigue 5. Ingestion of an infected cattle with mycobacterium bovis 6. Virulence (degree of pathogenecity) of microorganismB. Mode of Transmission 1. Airborne transmission via droplet nucleiC. Signs and Symptoms 1. Low grade afternoon fever, night sweats 2. Productive cough (yellowish sputum) 3. Anorexia, generalized body malaise 4. Weight loss 5. Dyspnea 6. Chest pain 7. Hemoptysis (chronic)D. Diagnostic Procedure 1. Mantoux Test (skin test) - Purified protein derivative - DOH 8 10 mm induration, 48 72 hours - WHO 10 14 mm induration, 48 72 hours - Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2.Sputum Acid Fast Bacillus - Positive to cultured microorganism 3. Chest X-ray - Reveals pulmonary infiltrates 4. CBC - Reveals increase WBCE. Nursing Management 1. Enforce CBR 2. Institute strict respiratory isolation 3. Administer oxygen inhalation 4. Force fluids to liquefy secretions 5. Place client on semi fowlers position to promote expansion of lungs 6. Encourage deep breathing and coughing exercise 7. Nebulize and suction when needed 8. Comfortable and humid environment 9. Institute short course chemotherapy a.Intensive phase - INH (Isonicotinic Acid Hydrazide) - Rifampicin (Rifampin) - PZA (Pyrazinamide) - Given everyday simultaneously to prevent resistance - INH and Rifampicin is given for 4 months, taken before meals to facilitate absorption - PZA is given for 2 months, taken after meals to facilitate absorption- Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6 /Pyridoxine)- Side Effect Rifampicin: all bodily secretions turn to red orange color Side Effect PZA: allergic reaction, hepatotoxicity, nephrotoxicity - PZA can be replaced by Ethambutol- Side Effect Ethambutol: optic neuritis b. Standard phase - Injection of streptomycin (aminoglycoside) - Kanamycin - Amikacin - Neomycin - Gentamycin- Side Effect: -Ototoxicity damage to the 8thcranial nerve resulting to tinnitus leading to hearing loss- Nephrotoxicity check for BUN and Creatinine - Give aspirin if there is fever Side Effect:tinnitus, dyspepsia, heartburn 10. Provide increase carbohydrates, protein, vitamin C and calories 11. Provide client health teaching and discharge planning a. Avoidance of precipitating factors b. Prevent complications (atelectasis, military tuberculosis) PTB - Bones (potts) - Meninges - Eyes - Skin - Adrenal gland c. Strict compliance to medications d. Importance of follow up carePNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudatesA. Etiologic Agents 1. Streptococcus Pneumonae causing pneumococal pneumonia 2. Hemophylus Influenzae causing broncho pneumonia 3. Diplococcus Pneumoniae 4.Klebsella Pneumoniae 5.Escherichia Pneumoniae 6.PseudomonasB. High Risk Groups 1. Children below 5 years old 2. ElderlyC. Predisposing Factors 1. Smoking 2. Air pollution 3. Immuno compromised a.AIDS - Pneumocystic carini pneumonia- Drug of choice is Retrovir b.Bronchogenic Cancer - Initial sign is non productive cough - Chest x-ray confirms lung cancer 4. Related to prolonged immobility (CVA clients), causing hypostatic pneumonia 5. Aspiration of food causing aspiration pneumoniaD. Signs and Symptoms 1. Productive cough with greenish to rusty sputum 2. Dyspnea with prolong expiratory grunt 3. Fever, chills, anorexia and general body malaise 4. Weight loss 5. Rales/crackles 6. Bronchial wheezing 7. Cyanosis 8. Pleuritic friction rub 9. Chest pain 10. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Diagnostic Procedure 1. Sputum Gram Staining and Culture Sensitivity positive to cultured microorganisms 2. Chest x-ray reveals pulmonary consolidation 3. ABG analysis reveals decrease PO2 4. CBC reveals increase WBC, erythrocyte sedimentation rate is increasedF. Nursing Management 1. Enforce CBR 2. Administer oxygen inhalation low inflow 3. Administer medications as ordered Broad Spectrum Antibiotic a.Penicillin b.Tetracycline c.Microlides (Zethromax) - Azethromycin (Side Effect:Ototoxicity) -Antipyretics-Mucolytics/Expectorants -Analgesics 4. Force fluid 5. Place on semi fowlers position 6. Institute pulmonary toilet (tends to promote expectoration) - Deep breathing exercises- Coughing exercises Chest physiotherapy - Turning and reposition 7. Nebulize and suction as needed 8. Assist in postural drainage - Drain uppermost area of lungs - Placed on various position Nursing Management for Postural Drainage a. Best done before meals or 2 3 hours to prevent gastro esophageal reflux b. Monitor vital signs c. Encourage client deep breathing exercises d. Administer bronchodilators 15 30 minutes before procedure e. Stop if client cannot tolerate procedure f. Provide oral care after procedure g. Contraindicated with- Unstable vital signs - Hemoptysis - Clients with increase intra ocular pressure (Normal IOP 12 21 mmHg) - Increase ICP 9. Provide increase carbohydrates, calories, protein and vitamin C 10. Health teaching and discharge planning a. Avoid smoking b. Prevent complications- Atelectasis- Meningitis (nerve deafness, hydrocephalus) c. Regular adherence to medications d. Importance of follow up care

HISTOPLASMOSIS Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma Capsulatum derived from birds manureA. Signs and Symptoms PTB or Pneumonia like 1. Productive cough 2. Dyspnea 3. Fever, chills, anorexia, general body malaise 4. Cyanosis 5. Hemoptysis 6. Chest and joint painsB. Diagnostic Procedures 1. Histoplasmin Skin Test positive 2. ABG analysis PO2 decreaseC. Nursing Management 1. Enforce CBR 2. Administer oxygen inhalation 3. Administer medications as ordered a. Antifungal- Amphotericin B - Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia) b. Steroids c. Mucolytics d. Antipyretics 4. Force fluids to liquefy secretions 5. Nebulize and suction as needed 6. Prevent complications bronchiectasis 7. Prevent the spread of infection by spraying of breeding places

COPD (Chronic Obstructive Pulmonary/Lung Disease)Chronic Bronchitis Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airwaysA. Predisposing Factors 1. Smoking 2. Air pollutionB. Signs and Symptoms 1. Productive cough (consistent to all COPD) 2. Dyspnea on exertion 3. Prolonged expiratory grunt 4. Anorexia and generalized body malaise 5. Scattered rales/ronchi 6. Cyanosis 7. Pulmonary hypertension a. Peripheral edema b.Cor Pulmonale(right ventricular hypertrophy)C. Diagnostic Procedure ABG analysis reveals PO2 decrease (hypoxemia), PCO2 increase, pH decrease

Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airwaysA. Predisposing Factors (Depending on Types) 1. Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Pollen b. Dust c. Fumes d. Smoke e. Gases f. Danders g. Fursh. Lints 2. Intrinsic Asthma (Non atopic/Non allergic) Causes a. Hereditary b. Drugs (aspirin, penicillin, beta blocker) c. Foods (seafoods, eggs, milk, chocolates, chicken d. Food additives (nitrates) e. Sudden change in temperature, air pressure and humidity f. Physical and emotional stress 3. Mixed Type 90 95%B. Signs and Symptoms 1. Cough that is non productive 2. Dyspnea 3. Wheezing on expiration 4. Cyanosis 5. Mild Stress/apprehension 6. Tachycardia, palpitations 7. DiaphoresisC. Diagnostic Procedure 1. Pulmonary Function Test- Incentive spirometer reveals decrease vital lung capacity 2. ABG analysis PO2 decrease- Before ABG test for positive Allens Test, apply direct pressure to ulnar and radial artery to determinepresence of collateral circulationD. Nursing Management 1. Enforce CBR 2. Oxygen inhalation, with low inflow of 2 3 L/min 3. Administer medications as ordered a. Bronchodilators given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Steroids decrease inflammation c. Mucomysts (acetylceisteine) d. Mucolytics/expectorantse. Anti histamine 4. Force fluids 5. Semi fowlers position 6. Nebulize and suction when needed 7. Provide client health teachings and discharge planning concerning a. Avoidance of precipitating factor b. Prevent complications - Emphysema - Status Asthmaticus (give drug of choice) - Epinephrine - Steroids - Bronchodilators c. Regular adherence to medications to prevent development of status asthmaticus d. Importance of follow up care

BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoliA. Predisposing Factors 1. Recurrent lower respiratory tract infections 2. Chest trauma 3. Congenital defects 4. Related to presence of tumor B. Signs and Symptoms 1. Productive cough 2. Dyspnea 3. Cyanosis 4. Anorexia and generalized body malaise 5. Hemoptysis (only COPD with sign)C. Diagnostic Procedure 1. ABG PO2decrease 2. Bronchoscopy direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Secure inform consent and explain procedure to client 2. Maintain NPO 6 8 hours prior to procedure 3. Monitor vital signs and breath sound POST Bronchoscopy 1. Feeding initiated upon return of gag reflex 2. Avoid talking, coughing and smoking, may cause irritation 3. Monitor for signs of gross 4. Monitor for signs of laryngeal spasm prepare tracheostomy setD. Treatment 1. Surgery (pneumonectomy , 1 lung is removed and position on affected side) 2. Segmental Wedge Lobectomy (promote re expansion of lungs)- Unaffected lobectomy facilitate drainage

EMPHYSEMA Irreversible terminal stage of COPD characterized by a. Inelasticity of alveoli b. Air trapping c. Maldistribution of gases d. Over distention of thoracic cavity (barrel chest)A. Predisposing Factors 1. Smoking 2. Air pollution 3. Allergy 4. High risk: elderly 5. Hereditary it involves deficiency of ALPHA-1 ANTI TRYPSIN(needed to form Elastase, for recoil of alveoli)B. Signs and Symptoms 1. Productive cough 2. Dyspnea at rest 3. Prolong expiratory grunt 4. Anorexia and generalized body malaise 5. Resonance to hyperresonance 6. Decrease tactile fremitus 7. Decrease or diminished breath sounds 8. Rales or ronchi 9. Bronchial wheezing 10. Barrel chest 11. Flaring of alai nares 12. Purse lip breathing to eliminates excess CO2(compensatory mechanism)C. Diagnostic Procedure 1. Pulmonary Function Test reveals decrease vital lung capacity 2. ABG analysis reveals a. Panlobular/ centrilobular - Decrease PO2(hypoxemia leading to chronic bronchitis, Blue Bloaters) - Decrease ph- Increase PCO2- Respiratory acidosis b. Panacinar/ entriacinar - Increase PO2(hyperaxemia, Pink Puffers)- Decrease PCO2 - Increase ph- Respiratory alkalosisD. Nursing Management 1. Enforce CBR 2. Administer oxygen inhalation via low inflow 3. Administer medications as ordered a. Bronchodilators b. Steroids c. Antibiotics d. Mucolytics/expectorants 4. High fowlers position 5. Force fluids 6. Institute pulmonary toilet 7. Nebulize and suction when needed 8. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9. Provide comfortable and humid environment 10. Provide high carbohydrates, protein, calories, vitamins and minerals 11. Health teachings and discharge planning concerning a. Avoid smoking b. Prevent complications - Atelectasis - Cor Pulmonale - CO2narcosis may lead to coma - Pneumothorax c. Strict compliance to medication d. Importance of follow up care