Upper resp. tract

Lower Resp. Tract

Lungs

Assessory muscles of the respiratory tract

Resp. Changes assoc. with age

Monitor for hemoptysis

Anterior

Posterior

Most common. Bleeding erupts when the relatively thin nasal mucosa overlying a dilated septal vessel dries, scabs, and fall (or is picked) off. More in younger children 

bleeds are located over the posterior middle turbinate, and are less common. This site of bleeding is higher and deeper within the nose and the blood flows primarily down the back of the throat. Seen more in older people and is more serious. 

 5-14 days    

Prevention   

Management

When to contact health care provider

When to obtain immediate health care    

3. If symptoms worsen after 3-5 days, new symptoms develop or symptoms do not improve after days. 

 Older adults,pregnant women, immunocompromised, chronic diseases: Increaed risk for developing complications 

Class 0: No TB exposure: No infection
Class 1: TB exposure, no evidence of infection

Class 2: Latent TB: infection without disease

Class 3: TB infection with clinically active disease

Class 4: No current disease
Class 5: TB suspect 

Close contact with TB active person
Injection drug use and alcoholism
Residence in overcrowded, substandard housing, or institutions. Immunocompromise
Preexisting medical conditions, no health care, immigrants

Occupation 

Low-grade fever, fatigue, anorexia, weight loss, night sweats, chest pain, and cough

Nonproductive cough, which may progress to mucopurulent sputum with hemoptysis 

Comply with therapeutic regimen

Have no recurrence of disease

Pulmonary function within set limits

Prevent spread of infection 

Instruct about best position to facilitate drainage
Encourage increased fluid intake
Provide high-humidity
Airborne isolation: High-efficiency particulate air (HEPA) mask use

Negative-pressure isolation room 

—  State of equilibrium in body

—  Naturally maintained by adaptive responses

—  Body fluids and electrolytes are maintained within narrow limits.

ž  Water Composition of the Body

—  50% to 60% of body weight in adult

—  45% to 55% in older adults

—  70% to 80% in infants

—  Varies with gender, body mass, and age

ž  Composition of body fluid compartments

ž  Intracellular fluid (ICF)

ž  Extracellular fluid (ECF)

ž  Substances whose molecules dissociate into ions (charged particles) when placed into water

—  Cations: positively charged

—  Anions: negatively charged

International standard 

millimoles per liter (mmol/L).ž 

U.S. uses milliequivalent (mEq).  Ions combine mEq for mEq.

ž  Electrolyte Composition of the ICF

ž  ICF

—  Prevalent cation is K⁺.

—  Prevalent anion is PO₄^3-.

—  Prevalent cation is Na⁺.

—  Prevalent anion is Cl^-.

—  Diffusion

ž  Movement of molecules from high to  low concentration

—  Occurs in liquids, solids, and gases

—  Membrane separating two areas must be permeable to diffusing substance.

—  Requires no energy

—  Movement of water between two compartments by a membrane permeable to water but not to solute

—  Moves from low solute to high solute concentration

—  Requires no energy

ž  Amount of pressure required to stop  osmotic flow of water

Determined by concentration of solutes in solution

—  Force within a fluid compartment

—  Major force that pushes water out of  vascular system at capillary level

—  The process by which water and dissolved substances (solutes) move from an area of high hydrostatic pressure to an area of low hydrostatic pressure

—  Occurs across capillary membranes

—  Glomerulus<-- where filtration occurs

  Oncotic Pressure?

ž  Osmotic pressure exerted by colloids in solution

—  Protein is a major colloid.

ž  Fluid and Electrolyte Imbalances

—  Common in most patients with major illness or injury

○      Directly caused by illness or disease (burns or heart failure)

○      Result of therapeutic measures
(IV fluid replacement or diuretics)

ž  Gerontologic Considerations for imbalances in fluids and electrolytes

—  Reduced thirst mechanism results in decreased fluid intake.

—  Nurse must assess for these changes and implement treatment accordingly

—  Structural changes in kidneys decrease ability to conserve water.

—  Hormonal changes lead to decrease in ADH and ANP.

—  Loss of subcutaneous tissue leads to increased loss of moisture.

what is ž  Hypovolemia

ž  ECF volume depletion

—  Occurs with abnormal loss of body fluids

—  Inadequate intake

—  Plasma-to-interstitial fluid shifts

—  Dehydration

—  Refers to loss of pure water alone without corresponding loss of Na+

ž  The tank is empty

Causes of Hypovolemia

(Gi issues)

—  Vomiting

—  Nasogastric suctioning

—  Diarrhea

—  Intestinal drainage

Hypovolemia causes

(hemorrhage)

—  Major trauma

—  GI bleeding

Hypovolemia causes

(altered intake)

—  Coma

—  Fluid deprivation

Hypovolemia causes

(abnormal skin losses)

—  Excessive diaphoresis

○      Fever

○      Exercise

—  Burns

Hypovolemia causes

(renal losses)

Diuretic therapy

ž  Hypovolemia

ž  Furrowed tongue/dry mucous membranes

ž  Sunken eyeballs

ž  Flat neck veins

ž  Clinical pallor

ž  Dizziness/syncope/weakness/fatigue

ž  Hypovolemia

ž  Anorexia

ž  Nausea/vomiting/constipation

ž  Thirst

ž  Confusion

ž  Hematocrit

—  Elevated with dehydration

—  Decreased with bleeding

ž  BUN

—  Elevated; BUN/Creatinine ration greater than 20:1 suggests hypovolemia

ž  Electrolytes

—  Levels will vary depending on the type of fluid lost

ž  I & O

ž  Monitor cardiovascular changes.

ž  Assess respiratory changes.

ž  Daily weights

ž  Skin assessment

ž  Restore normal fluid volume

—  Mixed isotonic saline/electrolyte solution- LR

—  Isotonic (0.9%) NaCl is used when rapid replacement is indicated

—  Blood- when volume loss is due to blood loss

ž  Correct acid-base

ž  Correct electrolyte disturbances

ž  A state of higher-than-normal intravascular volume

—  Excessive retention of Na+ and water

○      Chronic renal stimulus to conserve Na+ and water

—  Abnormal renal functioning

○      Reduced excretion of Na+ and water

—  Excessive administration of IV fluids

—  Interstitial-to-plasma fluid shifts

ž  Hematocrit

—  Decreased due to hemodilation by excess fluids in the vasculature

ž  BUN

—  Decreased in pure hypervolemia

—  Increased with renal failure

—  Periorbital edema

—  Warm, moist skin

—  Moist tongue

Pitting edema

—  Excessive, frothy saliva

—  Pulse- rapid

—  Respirations-dyspnea, rales, cough

—  BP- normal to high

—  Weight gain

ž  Serum Na+ greater than 145 mEq/L

—  Elevated serum sodium occurring with water loss or sodium gain

ž  Causes hyperosmolality leading to cellular dehydration

ž  Primary protection is thirst from  hypothalamus. 

ž  Excessive Na+ intake

—  IV fluids

○      Hypertonic NaCl, excessive isotonic NaCl,

○      Near-drowning in salt water

ž  Inadequate water intake

—  Unconscious

—  Cognitively impaired

ž  

—  Intense Thirst, lethargy, agitation, seizures, and coma

—  Impaired LOC

—  Restlessness, agitation, twitching, seizures, coma

—  Dry swollen tongue, sticky mucous membranes

—  Postural hypotension

—  Weight loss

—  Weakness, lethargy

—  Hypernatremia 

—  Water deficit

○      Prevent further water loss with oral fluids

○      IV D5W or hypotonic saline

—

  Sodium excess

○      Dilute the Na+ concentration

—  IV D5W

—  Diuretics

—  Dietary Na+ restriction

ž  Serum Na+ less than 135mEq/L

ž  Net gain of water

ž  Loss of Na+ rich fluids that have been replaced by water

GI loses- diarrhea, vomiting, NG suction,

ž  Renal losses- diuretics, adrenal insufficiency

ž  Skin losses- burns, wound drainage, excessive diaphoresis

ž  Irritability

ž  Apprehension

ž  Confusion

ž  Dizziness

ž  Personality changes

ž  Tremors

ž   Seizures

ž  Dry mucous membranes

ž  COMA

  Hyponatremia caused by water excess

—  Fluid restriction

  Severe symptoms

—  Small amounts of IV hypertonic saline (3% NaCl)

Abnormal fluid loss

—  Fluid replacement with Na+ containing solutions

—  Transmission and conduction of nerve and muscle impulses

—  Cellular growth

—  Maintenance of cardiac rhythms

—  Acid-base balance

—  Fruits and vegetables (bananas and oranges)

—  Salt substitutes

—  Potassium medications (PO, IV)

—  Stored blood

ž  Serum K+ level greater than 5mEq/L

—  Increased intake of K+

○      Excessive or rapid parenteral administration

○      K+ containing drugs

○      K+ containing salt substitutes

—  Decreased urinary excretion of K+

○      Renal disease

○      K+ sparing diuretics

○      ACE inhibitors

—  Irritability

—  Anxiety

—  Abdominal cramping/diarrhea

—  Weakness of lower extremities

—  Paresthesias

—  Irregular pulse

—  Cardiac arrest

"ž  K+ loss

—  GI losses- diarrhea, vomiting,  NG suction

—  Renal losses- diuretics,  Mg+ depletion

ž  Shift of K+ into cells

"—  Increased insulin

—  Alkalosis

ž"  Lack of K+ intake

—  Starvation

—  Diet low in K+

—  Failure to include K+ in parenteral fluids if NPO

—  Fatigue

—  Muscle weakness, leg cramps

—  Nausea, vomiting

—  Soft, flabby muscles

—  Parasthesias, deceased reflexes

—  Weak, irregular pulse

—  Polyuria

—  Hyperglycemia

ž  Bones are readily available store.

ž  Blocks sodium transport and stabilizes cell membrane

ž  Ionized form is biologically active.

ž  Functions

—  Transmission of nerve impulses

—  Myocardial contractions

—  Blood clotting

—  Formation of teeth and bone

—  Muscle contractions

ž  High serum calcium levels caused by

—  Hyperparathyroidism (two thirds of cases)

—  Malignancy

—  Vitamin D overdose

—  Prolonged immobilization

—  Decreased memory

—  Confusion

—  Disorientation

—  Fatigue

—  Constipation 

ž  Excretion of Ca with loop diuretic

ž  Hydration with isotonic saline infusion

ž  Synthetic calcitonin

ž  Mobilization

ž  Hypocalcemia

ž  Serum Ca++ less than 8.5 mg/dl

ž  Increased calcium loss

ž  Reduced intake secondary to altered intestinal absorption

ž  Altered regulation

—  Positive Trousseau’s or Chvostek’s sign

—  Laryngeal stridor

—  Dysphagia

—  Tingling around the mouth or in the extremities

—  Tetany

—  Seizures

 Primary anion in ICF

  Essential to function of muscle, red blood cells, and nervous system

  Deposited with calcium for bone and tooth structure

  Involved in acid-base buffering system, ATP production, and cellular uptake of glucose

  Maintenance requires adequate renal functioning.

ž  Serum phosphate greater than 4.5mg/dl or 2.6mEq/L

ž  Common in patients with renal failure

—  Kidneys cannot excrete excess phosphorus

ž  Causes

—  Renal failure

—  Chemo agents

—  Enemas containing phosphorus (Fleet enema)

—  Excessive ingestion- milk, phosphate-containing laxatives

—  Large vitamin D intake

—  Calcified deposition in soft tissue such as joints, arteries, skin, kidneys, and corneas

—  Neuromuscular irritability and tetany

ž  Identify and treat the underlying cause

ž  Hyperphosphatemia causes Hypocalcemia

ž  Signs and symptoms of acute hyperphosphatemia are due to the effects of hypocalcemia. 

ž  Serum PO₄^3-   less than 2.5mg/dl

ž  Low serum PO₄^3- caused by

—  Malnourishment/malabsorption

—  Alcohol withdrawal

—  Use of phosphate-binding antacids

—  During parenteral nutrition with inadequate replacement

—  CNS depression

—  Confusion

—  Muscle weakness and pain

—  Dysrhythmias

—  Cardiomyopathy 

—  Oral supplementation

—  Ingestion of foods high in phosphorus

—  IV administration of sodium or potassium phosphate 

ž  50% to 60% contained in bone.

ž  Coenzyme in metabolism of protein and carbohydrates

ž  Factors that regulate calcium balance appear to influence magnesium balance.

ž  Acts directly on myoneural junction

ž  Important for normal cardiac function

Hypermagnesium

(how high?)

ž  Serum Mg+ greater than 2.5 mEq/L

ž  Occurs almost exclusively in individuals with renal failure who have an increased intake of Mg+

—  Mild levels

○      Lethargy, drowsiness

○      Nausea, vomiting

—  Increased levels

○      DTR’s are lost

○      Somnolence

—  If continues

○      Respiratory and/or cardiac arrest

—  Prevention

—  Emergency treatment

○      IV CaCl or calcium gluconate

—  Fluids to promote urinary excretion

ž  Serum Mg less than 1.5

ž  Low serum Mg caused by

—  Prolonged fasting or starvation

—  Chronic alcoholism

—  Fluid loss from gastrointestinal tract

—  Prolonged parenteral nutrition without supplementation

—  Diuretics

—  Confusion

—  Hyperactive deep tendon reflexes

—  Tremors

—  Seizures

—  Cardiac dysrhythmias 

—  Oral supplements

—  Increase dietary intake.

—  Parenteral IV or IM magnesium when severe

• Normal plasma pH is 7.35 to 7.45: hydrogen ion concentration
• Major extracellular fluid buffer system; bicarbonate-carbonic acid buffer system
• Kidneys regulate bicarbonate in ECF
• Lungs under the control of the medulla regulate CO₂ and, therefore, carbonic acid in ECF
• Other buffer systems

ú  ECF: inorganic phosphates and plasma proteins

ú  ICF: proteins, organic and inorganic phosphates

ú  Hemoglobin

—  Renal failure

—  Diabetic acidosis

—  Lactic acidosis

—  Ingestion of paraldehyde, anti-freeze, ASA, methyl ETOH

—  Severe diarrhea

—  Headache, confusion, drowsiness

—  Increased respiratory rate and depth

—  Decreased blood pressure

—  Decreased cardiac output, dysrhythmias

—  Shock

—   If decrease is slow, patient may be asymptomatic until bicarbonate is 15 mEq/L or less

ž  With acidosis, hyperkalemia may occur as potassium shifts out of the cell

ž  As acidosis is corrected, potassium shifts back into the cell and potassium levels decrease

ž  Monitor potassium levels

ž  Serum calcium levels may be low with chronic metabolic acidosis and must be corrected before treating the acidosis

• High pH >7.45
• High bicarbonate >26 mEq/L
• Most commonly due to vomiting or gastric suction; may also be caused by medications, especially long-term diuretic use
• Hypokalemia will produce alkalosis 

—  Symptoms related to decreased calcium

—  Respiratory depression

—   Tachycardia

—  Symptoms of hypokalemia

ž  Correct underlying disorder,

—   Supply chloride to allow excretion of excess bicarbonate

—   Restore fluid volume with sodium chloride solutions

ž  IV solutions

ž  Purposes

—  Maintenance

○      When oral intake is not adequate

—  Replacement

○      When losses have occurred 

—  More water than electrolytes

○      Pure water lyses RBCs.

—  Water moves from ECF to ICF by osmosis.

—  Usually maintenance fluids

—  Expands only ECF

—  No net loss or gain from ICF

—  Initially expands and raises the osmolality of ECF

—  Require frequent monitoring of

○      Blood pressure

○      Lung sounds

○      Serum sodium levels