Nursing Considerations
Tuberculosis is a long-term illness. Nursing care consists of several elements:
• Careful administration of medications. Following a time schedule is important to maintain a constant blood level of the medications. Give medications at the same time each day, if a daily dose, or spread doses throughout the day. (If twice daily [bid], instruct the person to take every 12 hours; if three times daily [tid], take every 8 hours; if four times daily [qid], take every 6 hours, rather than four times during waking hours.)
• Teaching the client about the importance of continuing medications, even if symptoms seem to have subsided; home care nursing intervention may be indicated
• Encouraging the client to follow a well-balanced diet, high in protein and vitamins A and C
• Prevention of spread of the disease, with careful handwashing, and use of personal protective equipment
• Use of Transmission-Based Precautions (airborne precautions) if disease is active
• Encouraging client to get plenty of rest
• Ensuring a smoke-free environment
• Providing client with diversionary activities
Prevention
Nurses can take an active part in community health by seeking ways to prevent TB. The following are some suggestions:
• Educate the public in good, general health practices.
• In home care, burn all used tissues (the TB bacillus can survive for months in dried sputum). If unable to burn tissues, follow community guidelines for the disposal of biohazardous waste.
• Trace active cases and start early treatment of contacts to stop spread of the disease.
• Follow up with all persons who have had active TB. Regular examination is necessary for life to determine if there is a recurrence and to treat it immediately.
• Screen members of high-risk groups, such as individuals with immunocompromised systems (e.g., HIV/AIDS), immigrants from Southeast Asia, Africa, or Latin America and medically underserved persons of low-income populations.
• Give long-term residents of nursing homes, mental institutions, and correctional facilities the PPD tuberculin test on admission and at intervals thereafter.
• Screen healthcare workers yearly.
Vaccine. A live TB vaccine, known as bacille Calmette-Guérin (BCG), is available. It is a weakened strain of the bacterium. This should be used prophylactically on TB-negative persons who are repeatedly exposed to people with untreated or ineffectively treated TB. BCG is not generally used in the United States, but it is used in many countries that have a high incidence of TB. It does not prevent all cases of TB and may cause a false-positive PPD skin test. Individuals who have had BCG vaccinations are generally guided to get CXRs, rather than skin testing, because false-positive results are common.
Empyema
Empyema, sometimes called pyothorax, is a collection of purulent (pus-containing) exudate in the pleural cavity. It can be acute or chronic.
Acute Empyema
Acute empyema is a secondary infection that may follow TB, lung abscess, or pneumonia. It may also result from an infection of the chest wall or other surrounding tissue or may be introduced directly by a chest wound or surgery. Because it is almost always a secondary infection, empyema is difficult to diagnose. The primary problem usually masks symptoms.
Symptoms of empyema include chest pain (usually on one side), cough, fever, dyspnea, and general malaise. If empyema is suspected, more decisive information can be obtained by CXR and thoracentesis. The offending organism can also be determined by a C&S test on fluid aspirated by thoracentesis.
Antibiotics to combat the infection and measures to drain the empyema cavity are started. The latter may be done by closed drainage or by thoracentesis, in which case an antibiotic may be injected directly into the pleural cavity. Bed rest and sedative cough preparations are also given. If this is not successful, open drainage is done.
Chronic Empyema
Chronic empyema may be a complication of acute empyema or may be caused by bronchopleural fistula, osteomyelitis of the rib cage, or an aspirated foreign body. It may also be a complication of TB or a fungal infection of the lungs.
Soft rubber drainage tubes are inserted in the wound, and large, absorbent dressings and pads are applied. Usually, the drainage is profuse at first, so the dressings must be changed frequently. In open drainage, usually a rib is removed, causing some pain.
CHRONIC RESPIRATORY DISORDERS
Snoring
Snoring (or stertorous breathing) is a respiratory disorder that is common in some people when they sleep. Not usually a serious problem, snoring is considered a pathologic condition if the person cannot stop snoring, no matter what sleeping position he or she uses; if others can hear the snoring two or three rooms away; or if another person has to leave the room to be able to sleep. In extreme cases, surgery may be done. A procedure called palatopharyngoplasty, which removes extra material from the upper throat, has been successful in some cases. A relatively new, inexpensive external device (a tape strip) can be applied to the nasal bridge to help open the nasal passages. Other remedies include elevating the head of the bed; using a special pillow; sewing an object such as a ball on the back of the pajamas (so the person does not sleep on the back); avoiding heavy evening meals, smoking, sleeping pills, or alcohol; losing weight; and using decongestants.
Sleep Apnea Syndrome
Sleep apnea syndrome causes the person to wake up many times during the night, resulting in inadequate amounts of deep sleep. It is most common in middle-aged, overweight men but is also seen in women. The formal definition of sleep apnea is more than five cessations of airflow for at least 10 seconds each per hour of sleep. It is believed to occur because soft tissues at the back of the throat fall back and occlude the airway. This airway occlusion can last as long as 90 seconds. The person suddenly awakens owing to lack of oxygen. Hundreds of episodes can occur during a single night. Diagnosis is based on symptoms and history, including
BOX 86-2. Continuous Positive Airway Pressure (CPAP) Oxygenation
The continuous positive airway pressure (CPAP) apparatus is commonly used to assist persons with sleep apnea. This machine looks like an oxygen-delivery system and is used at night, so the person can sleep. It delivers air, and sometimes oxygen, to the person at a continuous positive pressure that holds the alveoli open. (They usually close at the end of expiration.) This positive pressure prevents respiratory obstruction, increases oxygenation, and reduces breathing effort.
• Extreme tiredness all day
• Difficulty in concentration
• Memory loss
• Inability to perform one’s job
• Falling asleep during the day
• Episodes witnessed by sleeping partner
Almost all people with sleep apnea snore, although the reverse is not necessarily true. The person is at risk for auto or industrial accidents, high blood pressure with related disorders, or social and employment problems.
Treatment
Recommended treatment includes
• Weight reduction
• Smoking cessation
• Avoidance of alcohol, especially before bedtime
• Elevation of the head of the bed
• Use of continuous positive airway pressure (CPAP) oxygenation (Box 86-2)
Possible surgery (uvulopalatopharyngoplasty) can now be done with lasers. Only about half of the people who have this procedure done find significant improvement, however. Respiratory stimulant medications have not proved helpful. In severe cases, tracheostomy (which is plugged during the day) may be required to bypass upper airway obstruction.
Allergic Rhinitis
Rhinitis is an inflammation of the nasal mucous passages. Allergic rhinitis (“hay fever”) is a condition that occurs when inflammation results from an allergic reaction to a protein substance. It may be caused by pollen from weeds, flowers, or grasses at certain seasons, or it may be a reaction to dust, feathers, or animal dander. People with a family history of allergy are more susceptible to hay fever, as are those who have asthma or eczema. In the United States, at least 10% of the population has a hereditary tendency. Persons of all ages are affected; hay fever may appear suddenly at any age and may just as suddenly disappear.
Signs and Symptoms
Allergic rhinitis is disagreeable and inconvenient. Symptoms include edema, an itchy nose, excessive sneezing, and profuse, watery discharge from the nose and eyes. The condition worsens on windy days and in the mornings and evenings. Determining the cause is difficult, and detailed questioning and many skin tests may be needed to identify the offending substance. Sometimes, several substances are the offenders.
Treatment
The first step in treatment is to avoid the offending substance. It may mean eliminating a food from the diet, avoiding contact with animals, or avoiding dusty places. Air conditioning or filtering or purifying air can also help. Antihistamines relieve symptoms, and desensitization injections may eliminate them entirely. Corticosteroids may be given for severe attacks. An untreated allergy of this kind may lead to asthma, sinusitis, or nasal polyps.
Pneumoconioses
Pneumoconioses are “dust diseases” caused by habitual inhalation and retention in the lungs of certain heavy, harmful dusts. The most common disease is silicosis, common in miners, which is caused by breathing silica, or quartz dust. Asbestosis is another common form. As the person inhales dangerous dusts, the dusts eventually slow down or stop the ciliary action in the nose and lungs, and the dusts accumulate there. The dusts can cause irritation or allergic and chemical reactions.
Usually the first symptom of dust diseases is dyspnea. Later, the person develops a chronic cough and expectorates the offending particles in thick mucus. Chest pains are often a later result. Serious complications include TB, pneumonia, chronic bronchitis, and emphysema. Vast evidence now indicates that the presence of asbestos directly relates to a specific lung cancer (mesothelioma).
Treatment focuses on prevention because these diseases are difficult to treat after extensive areas of the lungs are involved. The only treatment at present is to reduce exposure to the dust. Damage previously done cannot be reversed.
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD), also called chronic obstructive lung disease (COLD), is a broad classification of disorders, including bronchial asthma, bronchiectasis, chronic bronchitis, and pulmonary emphysema. COPD is irreversible, but it is associated with persistent dyspnea on exertion and reduced airflow of less than one-half of normal.
Care of the client with COPD involves physical, psychological, and environmental measures. The goals of treatment are to improve ventilation and to overcome hypoxic states through the following measures:
• Avoidance of irritants: smoking, allergens, industrial chemicals
• Use of medications: bronchodilators, expectorants, liquefying agents
• Postural drainage
• Increased fluid intake (1,000-2,000 mL/d)
• Cautious use of oxygen
• Breathing exercises
• Activity, as tolerated
• Avoidance of extremes of heat and cold
• Positioning to facilitate breathing (Fowler’s or orthop-neic)
• Small, frequent meals
Fluid intake is important. Encourage the client to drink at least 2 to 3 quarts (2-3 liters) of water daily to thin mucus and make it easier to expectorate.
Oxygen must be administered with caution. The amount should not exceed 3 L/minute because many people with COPD retain carbon dioxide. Too high a level of oxygen could suppress the person’s respiratory drive (i.e., the person loses the natural stimulus to breathe). Some clients may need to be reminded of the dangers of smoking in the presence of supplemental oxygen.
Breathing exercises, combined with other respiratory treatments, increase the volume of air the person is able to exhale. Inhaling and holding the breath also improves breathing. Practicing pursed-lip breathing, especially during periods of dyspnea, is effective. Rationale: This technique forces air into the lungs. Avoid rapid or forceful exhalation because it may cause the terminal bronchioles to collapse. The person must be faithful in consistently carrying out breathing exercises.
Advise the person to keep active, but to pace activity with rest before and after activities. Rationale: Give the client support and direction to enable him or her to accept that therapy is a lifelong commitment. Teach the client to limit activities to whatever the heart and breathing capacities can tolerate. The individual has the potential to lead a fairly active life if he or she chooses.
Persons with COPD have special needs because of the chronic nature of the disease. Help these individuals to live optimally through the following measures:
• Assist with developing energy-conserving measures in daily living.
• Teach relaxation techniques to use in situations of respiratory distress.
• Teach management of acute exacerbations of the disease and when to call for help.
• Help to identify situations or other factors that “trigger” symptoms and assist to find ways to modify or remove these triggers.
If the client is having difficulty with one or more aspects of managing COPD, a pulmonary rehabilitation program may be helpful. This is a program that includes medical management, breathing retraining, emotional support, exercise, nutritional information, and education about living with this disease. A multidisciplinary team of pulmonary experts works with the client to optimize quality of life.
Bronchial Asthma
Asthma is a chronic condition characterized by inflammation of the lining of the bronchial airways. Cells that line the bronchi release chemicals that cause inflammation when they are stimulated by irritants and allergens. When the airway is inflamed, swollen, and narrowed, it becomes more sensitive to things that may trigger an asthma attack. Obstruction of the airway is further complicated by tightening and narrowing of the surrounding muscles (bronchospasms). In some cases, mucous glands in the airways secrete thick mucus, which further obstructs the airways.
FIGURE 86-4 · Clubbing of the finger: Normally, there is an obtuse angle of about 160 degrees between the base of the nail and the adjacent dorsal surface of the finger; with clubbing, this angle exceeds 180 degrees.
An asthma attack is a frightening experience for the person struggling to get air into the lungs. It is the most common chronic disease in childhood.
Signs and Symptoms. Onset of an asthma attack is sudden. The person experiences coughing, wheezing, SOB, and chest tightness. The individual may be very pale and dysp-neic, especially on expiration. As the attack subsides, the person may cough up thick, white mucus.
Asthma attacks may be occasional or frequent, but the individual is often symptom free between episodes. Poorly managed asthma with frequent attacks may lead to emphysema. Those who have hay fever or chronic bronchitis are especially susceptible. Asthma can occur at any age and at any time. Chronic, severe respiratory conditions may lead to the clubbing of fingers (Fig. 86-4).
Children with asthma usually have fewer symptoms as they grow older, but symptoms for asthmatic adults grow worse with age. Sudden change in temperature, extreme physical exertion, contact with animal dander, overeating, emotional stress, and exposure to antigens may trigger attacks.
An attack that persists for more than 24 hours and that does not respond to treatment is called status asthmaticus, a medical emergency that can lead to death. Worldwide, there are about 100,000 deaths from asthma each year.
Treatment. The main treatment objective in an acute attack is to relieve breathing difficulties. In the long term, it is important to assist the client in proper medical management of asthma to improve overall quality of life. This strategy will include the use of several classifications of medications. All people with moderate to severe asthma should be taking anti-inflammatory inhalers as front-line therapy. The inhaled steroids improve lung function, decrease inflammation, and decrease asthma symptoms and flare-ups (attacks) (see Fig. 86-5 and In Practice: Important Medications 86-2).
FIGURE 86-5 · A metered-dose inhaler and spacer in use.
Special Considerations: LIFESPAN
Asthma
The pregnant woman must take her medications faithfully and follow her asthma action plan. If her asthma is not under control, she is not getting enough oxygen to her lungs or to the baby’s lungs.
Goals include decreasing symptoms and complications, improving physical conditioning and emotional well-being, and encouraging self-management (which will reduce hospitalizations). These goals can be accomplished by the introduction of an action plan (or crisis intervention plan) that assists the client in the determination of how best to manage his or her asthma. Education, with full understanding noted by the client and family, is essential. Teaching must include:
• Use of routine (maintenance) medications and emergency (rescue) medications
• Use of a peak flow meter, a small piece of equipment used to determine lung function by showing how fast a person can exhale after deep inhalation
• When to call the physician
• When to go to the hospital for emergency care
Many people with asthma have the condition well controlled.
Nursing Considerations. Asthma can be frustrating and frightening. Be calm and supportive and promptly administer the prescribed medications during an attack.Client and family teaching are highlighted within In Practice: Educating the Client 86-1.
IN PRACTICE: IMPORTANT MEDICATIONS 86-2
MEDICATIONS USED FOR TREATING ASTHMA
Anticholinergics
These bronchodilators work on the nervous system to control airway size:
• atropine methylnitrate
• ipratropium bromide (Atrovent)
Beta-Agonists
These medications dilate bronchial airways by working on the nervous system that controls the muscle tissue around the airway:
• albuterol (Asmavent, Proventil, Ventolin, Volmax)
• epinephrine (Adrenalin, AsthmaNefrin, Epifrin, microNefrin, Sus-Phrine)
• metaproterenol sulfate (Alupent)
• pirbuterol acetate (Maxair Inhaler)
• terbutaline sulfate (Brethine, Bricanyl)
Corticosteroids
These act as anti-inflammatory agents:
• beclomethasone (Vanceril, Beclovent, Beconase)
• budesonide (Pulmicort, Rhinocort)
• flunisolide (AeroBid, Nasalide)
• fluticasone propionate (Flovent, Flonase)
• methylprednisone (Medrol)
• nedocromil (Tilade)
• prednisone (Meticorten, Orasone, Deltasone)
• triamcinolone (Azmacort)
Leukotriene Antagonists
These medications block the inflammatory biochemical pathway making the airway less sensitive to asthma triggers:
• montelukast sodium (Singulair)
• zafirlukast (Accolate)
• zileuton (Zyflo)
Methylxanthines
These bronchodilators relax the smooth muscle of the bronchials:
• aminophylline/theophylline ethylenediamine (Truphylline)
• theophylline (Theo-Dur Theovent, Slo-Phyllin, Uni-Dun Uniphyl)
Mast Cell Stabilizers
These agents inhibit the allergen-triggered release of histamine and slow-releasing substance of anaphylaxis (leukotriene) from the mast cells:
• cromolyn sodium (Intal, NasalCrom)
Bronchiectasis
Bronchiectasis is a chronic dilation of the bronchi in which the walls become permanently distended. The main cause is infection following TB, influenza, pneumonia, chronic sinusitis, upper respiratory infection, measles, or aspiration of a foreign body. Often, bronchiectasis begins in early adulthood and progresses slowly over a long period. Bronchial disorders in young adults are linked to exposure to passive cigarette smoke in childhood. In a child, it may be a complication of cystic fibrosis and immunodeficiency diseases. It is rarely fatal, but may have serious complications. It is usually chronic; the client must modify his or her lifestyle.
IN PRACTICE :EDUCATING THE CLIENT 86-1
ASTHMA
• Have an action plan for asthma management.
• Know what medications you are using.
• Use the peak flow meter to determine how your lungs are functioning.
• Know your values for your personal best lung function and when you are at 50% to 80% of your personal best.
• Check with your primary healthcare provider about situations in which you should start adding or changing medications, notify the provider, or seek emergency care.
• Know what triggers your asthma and take steps to identify and avoid things that may trigger an asthma attack.
• Rinse your mouth with water after using a steroid inhaler to help prevent fungal infections of the mouth.
• Rinse your inhaler mouthpiece daily
• Use your inhaler properly as shown. Inhalers are not helpful if used incorrectly
• Take your medications on time. Using medications regularly helps to prevent difficulties and complications.
Signs and Symptoms. The characteristic symptom is a chronic cough, most often occurring when the client arises in the morning. The cough produces greenish-yellow sputum with a foul odor. As the disease progresses, the amount of sputum increases. Sometimes the person coughs up blood. In fact, bronchiectasis is the most common cause of hemoptysis (bloody sputum). The person loses weight because of poor appetite and may experience chronic fatigue.
Treatment. Drainage of the purulent material is part of the treatment. Drainage is accomplished by postural drainage, in which the head is lower than the chest. Encourage the person to cough and breathe deeply. Humidification of air is recommended to help thin secretions and make expectoration easier. Expectorant cough medicines may be prescribed. Give ordered antibiotics to control the infection. Good nutrition, fresh air, and rest are also important. The person should not smoke. Give special mouth care to overcome the offensive taste and breath odor and to make food more palatable.
Prompt attention to such conditions as bronchial asthma and bronchitis helps to prevent bronchiectasis (see In Practice: Educating the Client 86-2).
Surgical intervention may be necessary for individuals who continue to have bouts of pneumonia after treatment. Because bronchiectasis can be prevented, it is seen less frequently than in the past.
