Pneumonia

It is lower respiratory tract infection that cause inflammation of alveoli sacs.

- Germs like bacteria , virus and fungi attack the system. Alveoli , Bronchioles helps to gas exchange. Normal respiratory system fight of the germs by taking air through nose but certain conditions. When Alveoli sac get inflamed  and it starts fill with full of fluid , there is aggregation of WBCs and RBCs and bacteria which impair gas exchange.

Risk factors- 

1. Influenza -   influenzai highly contagious viral infection which spread easily from person to person. Influenza is most common cause of Pneumonia commonly in young child , pregnant mother.

2. Weak immune system- this also leads to pneumonia due to low immunity bacteria get easily multiply.

3. HIV infection - This leads to opportunistic infection for pneumonia. In HIV infection there is low immunity which leads to pneumonia.

4. Medications which spress autoimmune system.

5. Decreased consciousness and Increased risk of aspirations.

6. Chronic obstructive pulmonary disease.(COPD).

7. Post- op abdominal and chest surgery. After surgery there is chances of getting bacterial infection which may cause pneumonia.

8. Respiratory acidosis - in this lungs retain carbon dioxide and can't get oxygen to blood which cause hypoxemia. And decrease in PH.

Causes-

Most common causes pneumonia are 

1. streptococcal pneumoniae.
2. Mycoplasma pneumonia.

Virus - 
1. Influenza

Types-

1. Community Acquired- 

This type of infection occur patient get germs outside the health care settings.

2. Hospital acquired-

This type of infection occurs when patient in hospital settings and mainly occur in mechanical ventilation. This infection occurs 48-72 hrs after admission.

Diagnose- 

1. Notice on auscultation a coarse crackles bronchi or bronchioles breath sound due to lung consolidation.

2. X-ray

3. Sputum culture.

Sign and symptoms-

1. Productive cough.
2. Pain in chest.
3. Unusual breath sound.
4. Altered lab values e.g. Increased partial pressure of carbon dioxide and incrIncre WBCs.
5. Unusual breath sound.
6. Mild to high fever.
7. Nausea vomiting.
8. Increased Heart rate and pulse rate.
9. Activity intolerance.

Treatment-

Medications- 

1. Vancomycin- used in severe cases and can treat resistance bacteria. Most common side effect may have oto- toxicity.

2. Macrolide- Narrow spectrum and kill gram +ve bacteria.

3. Tetracycline- Broad spectrum not used in pregnancy.

4. Fluroquinolone - Broad spectrum and have side effect of frequent diarrhea , tendon rupture.

5. Cephalosporin.

6. Pencillin.

Supportive care-

1. Oxygen therapy.
2. Oral rehydration therapy.
3. Iv fluids.

Patient care-

1. Monitor lung sound impairment.

2. Monitor vital sign. Especially saturation and pulse rate.
3. Assess color of skin for cyanosis.
4. Monitor ABG results.
5. Collect sputum for test as ordered.
6. Provide suctioning if needed.
7. provide breathing and respiratory exercises.

Education- 

1. Encourage for incentive spirometry.

2. Encourage to hydrated and take 2-3 L/day water to keep secretions thin. And patient with heart failure and renal failure don't give more fluids.

3. Make sure patient is up to date with pneumothorax vaccine every 5 years.

4. Encourage to stop smoking and maintain hygiene.

5. Administer medications as per ordered.

COPD symptoms and treatment

It is a pulmonary disease which cause chronic destruction of airflow from lungs.
There is limited airflow due to the inflamed bronchioles and get narrow with excessive mucous. It also lead to inability to fully exhale.
This disease is irreversible and cases vary from mild to severe . This disease is managed with life style changes and medications.

Causes-

Most common cause is environmental from 
harmful irritants that are Inhaled into lungs e.g smoking.

- this disease happen gradually and most patient strat to notice sign and symptoms in middle age.

Types-

This disease is used now catch all terms for disease that limit air flow.

1. Chronic bronchitis-

This is also called bloating due to cyanosis and edema due to right heart failure. This lead to respiratory acidosis.

-   Cyanosis due to not proper gas exchange. This status starts to compensate by the body by producing more RBCs in the body which leads to  more problems that the blood get thick and pressure on pulmonary artery get Increased and this lead to backflow of the blood from the artery to left atrium which lead to left side heart failure and lead to the edema of extremities.

2. Emphysema (pink puffer)-

It is called pink puffer because body don't have cyanosis. puffer is called because there is hyperventilation for compensation when decreased oxygen and breath rapidly.

In this alevoali loss the elasticity and which leads to not entering of  oxygen and exhale carbon dioxide which leads to lungs hyperinflation and which cause the depression of diaphragm from dome shape to flat. And this lead to compensation by the use of accessory muscles to breath and lead to barrel chest due to which anteroposterior diameter get Increased.

- hyperventilation occur and which does not lead cyanosis and have pink complexion.

Sign and symptoms-

1. Lack of energy due to improper blood supply.
2. Unable to tolerate activities due to lack of energy.
3. Loss of weight due to inadequate nutrition.
4. Dry and productive cough.
5. Accessory muscles usage for breathing most commonly in  emphysem , abnormal lung sound , coarse crackles or wheezing.
6.  Barrel chest due to increase in anterior diameter.
7. Extreme dyspnea.
8. Patient used one fixed position to breath. E.g. use of stick to breath..

Complications-

1. Heart failure.
2. Pneumothorax.
3. Lung infection.
4. Increased risk for lung cancer.

Diagnose- 

1. Spirometry-   to check to which extent  patient can breath and how much volume the lung can hold during inhalation and how much and how fast volume get exhaled.

2. Measuring forced vital capacity.

Patient care-

1. Monitor respiratory system.

2. Monitor lung sound if secretion present than suctioning may required.

3. There may be sputum production( Collect production if ordered for testing). There may be risk for pneumonia.

4. Keep saturation 89-93 % because patient with COPD are stimulated to breath due to low oxygen level rather than high carbon dioxide level. If we give them too much oxygen they start hypoventilating and which leads to carbon dioxide toxicity.

5. Monitor for efforts of breathing and encourage to pursed lip breathing.

6. Administer breathing treatment eg. Nebulization and corticosteroid as prescribed.

Education- 

1. Nutrition need - eat high calories and protiens meals. Maintain fluid intake 2-3 L/ day.

2. Instruct to avoid sick people , irritants hot humid or extreme cold also can affect them.

3. Instruct to stop smoking.

4. Vaccinations should be up to date.

Medications-

1. Corticosteroid- decrease inflammation and decrease mucous production. These are given oral , IV , Inhaled, they are used many times.

These drugs included - 

A. Prednisone.

B. Solumedrol.

2. Bronchodilator-  should used first than corticosteroid if both prescribed to the patient.

- After the use of corticosteroid inhaler patient should rinse mouth because it may cause Thrush.

3. Phosphodiesterase -4 Inhibitors ( Roflumilas)- used for patient with chronic bronchitis and help to decrease COPD exacerbation not bronchodilators. These drugs have side effect that it cause suicide ideation and weight loss.

4. Theophylline - Given orally many times. This is type of bronchodilators and used long term with sever COPD.

5. Short acting bronchodilators- Relax smooth muscles bronchial tubes and are used in emergency conditions for quick relief.

A. Albuterol - Beta 2 blockers.

B. Atrovent - Anticholinergics.

6. Long Acting Bronchodilators- same action as short acting bronchodilators but used for long time .

A. Salmetrol.

B. Spriva.

Asthma and it's treatment

Asthma is chronic lung disease that cause narrowing and inflammation of the airway.
It effect bronchi and bronchioles and these are chronically inflamed.

There are smooth muscles at outer part of bronchioles which constrict and dilated . When Asthma attack occur this leads to constriction of muscle and cause chest tightness and dyspnea.

Inside the bronchioles there are goblet cells  which are help to produce mucous. When Asthma occur they strat over stimulate  and start to produce extra mucous wnich lead to decreased air flow.

Causes-

1. Smoke , pollen , pollution , perfumes.

2. Danders , dust mites , pests.

3. Cold and dry air .

4. Respiratory infection.

5. Exercise induced.

6. Drugs e.g. badrenergics  blockers e.g. NSAIDS  , Aspirin.

Early sign and symptoms-

1. Shortness of breath.

2. Easily fatigued with physical activity.

3. Frequent cough at night.

4. Symptoms related to cold , sneezing , scratchy throat.

5. Irritable.

Active sign and symptoms-

1. Chest tightness.

2. Wheezing.

3. Coughing.

4. Dyspnea.

5. Increased pulse rate.

And if these signs are not treated than it can lead to -

1. Inhaler can't work.

2. Patient can't speak.

3. Chest refraction.

4. Cyanosis mainly on lips skin.

5. Sweaty and need medical treatment very fast.

Treatment-

Medications-

1. Bronchodilators- 

A. Short acting- Albuterol. Fast relief during an attack. And not used for daily treatment. These medications should not use more than 2 time for week.

B. Long acting - a. Salmetrol 

                             b. Symbicort

These both drugs used with corticosteroids. And not used for acute attack.

C. Anticholinergics-  inhaled and are short acting ( Ipratropium).

Long acting-  Tiotropium . This medication cause dry mouth.

D. Theophylline - oral and not common used because cause toxicity.

2. Anti- inflammatory- 

a. Corticosteroid - Inhaled , Intravenous , oral , and used for long term   not used in acute attack. Fluticasone , Budesonide , Beclomethosone.  They cause thrush and to prevent this use spacer with it.

- These are used after 5 mintues of bronchodilators if bronchodilator are prescribed along with this.

- These corticosteroid may lead to osteoporosis and catract.

b. Leukotriene modifiers- these are oral medications .

 Montelukast- these blocks the functions of of leukotriene (smooth muscles to constrict and Increased mucous production). These relaxed smooth muscles and decreased mucous. These are not used in acute attack.

c. Omalizumab - These blocks role of immunoglobulin IGE and decrease allergic response. These drugs are used when Asthma is poorly controlled and when another treatment are not working. Its not for quick relief and no live vaccine should used with it.

d. Cromolyn ( Inhaled) - non steroidal anti- allergy . Decreased functions of cells secreting histamine and also used for long term not for quick relief.

 Patient may have sneezing , burning in nose , watery eyes , bad taste in mouth.

Self care- quit smoking and avoid substance that cause allergy.

Supportive care - oxygen therapy ( provide extra oxygen to patient have difficulty in breathing  as per ordered ).

What is diverticulitis

Diverticulitis is formation of hollow sac cavities through intestinal wall. Found throughput the large intestine and most common in sigmoid.

Person can have many out pouching area is diverticula and or single called diverticulum.
When diverticulitis occur there is formation of hollow sac from diverticulum.

Patient with disease is usually asymptomatic and sometimes get experience disturbed bowel pattern and bloating.

Causes-

Causes are not 100% known .

- low fiber diet.

- constipation and cause Increased pressure on wall cause herniation.

Diagnosis-

1. Colonoscopy-  tube inserted inside the colon through rectum with camera and visualised on screen.

2. Barium anema- It is X- Ray examination in which a contrast with barium metal element delivered into the colon. And X- Ray taken of area where this barium moved and give pictures if obstructions occur.

3. CT scan of abdomen.

Complications- 

1. Painless bleeding , blood with stool. Rupture of diverticula leads to leak of the content in abdomen which may cause peritonitis.

2. Strictures and obstructions.

3. Formation of fistula ( abnormal connection between organ and other organ ). Most common fistula occur from intestine to the bladder are most common which leads to the leakage of all content and bacteria into the bladder.

4. Mainly this disease is supposed to cause by entering of stool ito the pouch of intestine which may cause inflammation and other cause will be the eating of seed food. So these food have to avoid.

5. Other cause are Increased pressure to the colon that lead to the ruptures of diverticula and invade by bacteria cause abscess formation.

6. Abscess formation may lead to peritonitis and obstruction and lead to pain , fever and Increased wbc count.

Sign and symptoms-

1. Pain in left lower quadrant.

2. Bloating of stomach.

3. Unrealting cramps - intense pain like the child birth pain of 6 child.

4. Constipation or diarrhea.

5. High temperature due to infection.

Treatment-

1. Drain abscess of infected pouch.

2. In mild cases oral antibiotics and bowel rest ordered by doctor.

3. In moderate case I.V antibiotics , hospital stay , IV fluid and bowel rest ordered.

4. In cronic cases bowel resection may need multiple surgeries where can't may be recommend.

Patient care-

1. Focus on GI assessment.

2. Administer IV antibiotics in the severe cases and oral if mild cases. 

3. Diet should maintain NPO ( mill per oral ) and administer IV fliud as per ordered.

4. Nurse have to monitor sign and symptoms of peritonitis for unrelating fever , Increased pain , incIncrea pulse rate , Increased Heart rate , Increased bloating and hydration.

5. When symptoms recover as per the the doctor order strat clear liquid , broaths , pulp free clear juice.

6. Low fiber diet should provide to patient to work intestine in good work. Diet included white rice , cooked / skimmed fruits , vegetables , egg and no high fibers.

7. When patient get improved than have to provide high fiber diet to avoid constipation. Diet included fresh veg , fruits , grains , beans , plenty of fluid 2-3 l per day.

8. As per doctor ordered administer psyllium which absorb water from intestine and help to pass stool easily.

9. Probiotic also help to maintain health flora.

Appendicitis and it's treatment

Appendicitis is the inflammation of the  appendix. Appendix is the finger like structure originated from the cecum part of ascending colon.

Appendix functions-

Appendicitis is the inflammation of the appendix . Appendix play an important role in storing good bacteria in the GI tract after a diarrhea and illness and help to maintain gut flora.

Causes-

1. Obstructions- Fecolith ( term used for calcified and obstruction and lead to rupture ) which cause perforation , Abscess formation peritonitis.

2. Parasites , foreign bodies , swollen lymph nodes in lining of appendix.

3. Trauma and injuries.

Pathophysiology-

1. Blockage in the lumen of appendix leads to increase pressure inside the appendix because of increase amount of mucous from mucosal lining and increase fluid along with Increased bacteria. These bacteria are already present in appendix which maintain flora. These bacteria can go anywhere and increase again pressure so within 48-72 hrs patient have risk of perforation.

2. When Increased pressure cause major venous obstruction ( occlusion of the blood flow) and blood remain stagnant which leads to clot formation and cause ischemia to appendix ( diminished blood supply to appendix) which cause slow breakdown of walls of appendix.

3. These all conditions lead to the peritonitis and which leads to septic shock and death.

Sign and symptoms-

1. Abdominal pain which is dull around the belly button and radiate right Lower quadrant also called mecburney's point.

2. Poor appetite.

3. Elevated temperature.

4. Nausea and vomiting.

5. Desire to be in lie in fetal position which give relief in pain.

6. Increased wBCs and infection.

7. Inability to pass gas , stool and may have constipation and diarrhea.

8. Experience rebound tenderness i.e. when press there will be no pain but when left pressure there is too much pain.

9. Abdominal rigidity.

Treatment-

Surgeries- 

1. Appendectomy - Removal of Appendix.

2. Laparotomy - surgical opening made in abdomen to treat and diagnose many diseases.

3. Laproscopic surgeries- A vedio camera with tube is inserted in small cut on body to repair and remove tissues.

Medications-

Generally antibiotics are given to patient to overcome the infection and reduce infection.

Patient care-

Pre- op ( before operation)-

1. Vital signs monitor.

2. Monitor sign of peritonitis and perforation.

Perforation-

 

In this case patient have relief of pain with Increased level of pain. If pain get relief after the sever pain it will indicate that appendix may have rupture and all content get release into the abdomen. Which leads to the peritonitis and cause.

• Increase heart rate.
• Increase pulse rate.
• Increase temperature.
• Pain relief with fetal position.

3. Do not provide hot applications on stomach to pain relief because it can lead to rupture of appendix.

4. Do not use enema and laxatives because it can lead to rupture of appendix.

Post op care ( after operation )-

1. Monitor vital sign.

2. Monitor site for infection.

3. Care for drain as per doctor ordered.

4. Positioning should provide to the patient to remove drainage.

5. Ambulate patient which help to come out all waste fluid easily into drain.

6. Provide spirometry , coughing and deep breathing exercises.

7. Administer IV antibiotics as per ordered.

8. Administer pain medications as per ordered.

9. Monitor bowel sound and should present 2- 3 days after surgery.

10. Also flatus should pass within 2 days.

Crohan's disease and it's treatment.

It is a type of inflammaory bowel disease that cause inflammation ulcers formation in the GI tract . Another type of inflammaory bowel disease is ulcerative colitis.

Some common facts about the disease-

1. This disease can be found in both large and small intestine but ulcerative colitis occur in only large intestine.

2. It most likely found in the terminal of ileum and starts from the colon.

3. This disease affect all lining of the bowel and ulcerative colitis only effect the inner lining of the bowel it cause more complications.

4. Diseases found in scattered patches of infected lines after healthy lines this called cobble stone appearance.

5. Causes of diseases are unknown and most commonly caused by the faulty immune system and may be triggers by the genes.

6. This diseases have periods of flare up and remission.

7. There is no care and no colostomy and ileostomies because all parts of small and large intestine are affected. Only bowel resection , medication and diet can prevent this.

Types -

Ileocolitits - inflammation found in ileum colon.

Gastroduodenal- ulcers found in part of colon of stomach and duodenum.

Jejuno ileitis - found in jejunum.

Ileitis- ulcers found in the ileum.

Granulomatous colitis - this is only found in the colon.

Causes- 

Causes are unknown but it is mainly caused by immunodeficiency ,  genetic and environmental factors.

Complications- 

1. Abscessing fistulas - it forms sepsis. Abscessing packets of infection form within the intestine wall. Fistulas ulcers and abscess form deep in intestine wall creating an opening channel and passage of infection between intestine to intestine , intestine to organ and other skin surface.

Entro enteric- intestine to intestine abscess formations.

Perianal - due to anal abscess.

Entro vesical - abscess form Intestine to bladder.

Entrovaginal - abscess form intestine to vagina 

Entro-cutaneous -  abscess form intestine to skin surfaces.

2. Malnaurisment-

Small intestine get infalmed and all enzymes required for digestion of food not secret and cause malnaurisment.

3. Anal tear and fissures is complication.

4. strictures- 

obstructions is common complications major narrowing of intestinal wall due to chronic inflammation which leads to scarring and limit flow of GI contents , food get stuck and cause obstructions.

5. Other complications will the arthritis , stress in gall bladder , skin rashes and eyes issues.

Sign and symptoms- 

1. Abdominal pain and mainly in the right Lower side because it mainly effect ileum and that part is present in the right Lower side.

2. Ulcers in mouth and GI tract.

3. Diarrhea may be with pus , blood and mucous.

4. Loss of weight , malnaurisment  and electrolyte imbalance.

5. Fissure Anal that bleed .

6. Bloating.

Treatment-

Medications-

NSAIDS - decrease pain decrease inflammation and fever.

  Ant inflammatory - prevent swelling in tissues

Immuno suppressors- reduce immune response.

Steroids - modifies and stimulate hormonal effect.

Analgesic - relief pain.

Surgery-

Colostomy - surgical creation of abdominal opening In large intestine where stool can leave.

Ileostomy- surgical connecting of small intestine to opening in abdomen so stool can leave to it.

Proto colectomy- surgical removal of rectum and all part of colon.

Colectomy- surgical removal of all part of colon.

Iv fliud therapy-

Administration of Iv fluids done to recover electrolyte imbalance.

Enema may be administer to increase bowel movement and clear out stool .

Patient Care-

Goal -

Help patient to understand diet medications , surgeries .

1. Advice for smoke cessation.

2. In severe cases have to give rest for bowel and maintain NPO and administer TPN as per ordered. Patient may have risk for nutrition imbalance.

3. Daily weight monitoring.

4. Monitor intake and output.

5. GI assessment eg. Frequency of bowel movement have to check and also bowel sound.

6. Patient have to advise to avoid food with high fiber  , dairy products, spicy food fatty food .

7. Consume high protiens.

Ulcerative colitis and its treatment

A type of inflammatory bowel disease that causes inflammation ulcers in the inner lining of the colon rectum.

Causes-

1. Autoimmune triggering the body to inflame the colon.
2. High fat diet.
3. Milk allergy
4. Stress and illness.
5. Viral and bacterial infection.
6. NSAIDS

Types of ulcerative colitis-

1. Ulcerative proctitis- affect the area of rectum.
2. Proctus sigmoiditis- affect the area of rectum and sigmoid.
3. Left sided colitis- it affect rectum sigmoid and descending.
4. Pancolitis- sever case affect all colon.

What happened to large intestine when ulcer forms- (pathophysiology)-

Inflammation in large intestine leads to the cell damage and kill cells of the lining. Which leads to the ulcer formation. These ulcer formation cause the bleeding , pus formation which leads to the fever , diarrhea and anemia due to blood loss. Patient have abdominal pain due to inflammation. Colon can't do it's function of absorption of water which may lead to the dehydration, fluid electrolytes imbalance and decreased appetite and leads to weight loss.

Patient have frequent bowel movements so feel urgent frequency.

Sign and symptoms-

1. Urgent bowel movements.

2. Low RBCs cause anemia .

3. Weight loss due to improper digestion of food.

4. Cramps in abdomen which are very painful. This is due to inflammation and after taking food this pain becomes more severe.

5. Electrolyte imbalance occur due to dehydration because large intestine fail to absorb water.

6. Fever due to pus formation and infections.

7. Rectal bleeding.

8. Severe diarrhea with blood pus mucosa.

Complications-

1. Scars in the lining get flare up again after healing that cause  pseudo polyps, scar tissue and narrowing.

2. With sever case large intestine starts to loose it's pouch like structure called hustra which help to chum food properly and leads to colon become smooth called lead pipe sign.

3. Rupture of intestine due to hole formation after ulcers leads to leakage of bacteria , pus into abdominal cavity which leads to peritonitis.

4. Toxic megacolon occur due to the overwhelming inflammation which dilate colon and that become paralyzed and can't work properly. Which is very life threatening condition.

5. Patient is also in risk of colon cancer.

Diagnosis- 

1. Colonoscopy

2. Barium enema.

Treatment- 

1. Surgery in severe cases including.

Proctocolectomy - surgical removal of rectum and all part of colon.

Ileostomy - surgical opening of ileum.

Ileoanal Anastomosis with J pouch - in this rectum removal and pouch create that attached to ilium which allows stool to pass from small intestine to Anus without Ostomy.

2. Medications- 

A . Anti inflammatory - 5 Amino salicylate (sulfate salazine) most important and these are first line treatment and can't given to patient have allergy with sulfa.

B. Corticosteroid (predinsone) these are not used long term and have trapped off because have side effect e.g Increased glucose level , thinning of skin , bruising and osteoporosis.

C. Immuno suppressors- these are strong drugs and are used in severe cases of ulcerative colitis. Common drug is Azathiarine. ( Imuron)

These drugs decreased immune system and have great risk to development of the cancer.

D. Immuno modulators ( Adalimumab, Humaria).- 

They blocks TNF which is protien play role in inflammation.

 

Diet- 

Patient care-

1. Monitor vital signs .

2. Monitor bowel movement , sounds and 

frequency.

3. Focus to complications e.g . Peritonitis , toxic megacolon , abdominal pain , bloating , fever, increased heart rate , Increased respiratory rate .

4. Keep NPO and administrator IV fluid.

5. Food not given included high fiber because they require lot of digestion , nuts , popcorn , raw fruit and vegetables. Dairy , spicy and high fat food.

6. Easy to digest food includes low fiber high protien diet.

7. Regular colon cancer screening should done.

8. Ostomy care should provide to patient.