Mononucleosis Symptoms Viral infection EpsteinBarr virus mimics Strep

Mononucleosis ¨ Symptoms • Viral infection (Epstein-Barr virus) -mimics Strep in presentation and physical findings • Referred to as the "kissing disease" for it's ability to be spread from one person to another via oral secretions • Sore throat, swollen lymph nodes, weakness, and fatigue that persists anywhere from days to weeks. • Mild hepatitis can also occur with mononucleosis Pain right upper quadrant and enlargement of the liver

Evaluation • Phsyical will usually reveal Swollen glands (string of pearls-cervical lymph nodes) and tonsillitis. • There may be some mild tenderness over the spleen and liver. • Lab studies will include the monospot, CBC, and throat culture to rule out strep throat. • A liver profile may show mild elevations in liver enzymes

Treatment • Antibiotics are ineffective - Bed rest, liberal fluid intake, and low doses of acetaminophen • Most cases end in 2 -3 weeks but medical follow-up is suggested. • Complications of Mono include splenic rupture and Guillain-Barre' syndrome

¨ Mononucleosis Test or Monospot • Venipuncture specimen • The test involves mixing reagents with a drop of blood on a microscope slide. • Results of the test are read, usually in less than one hour, as positive (mono) or negative. • Because the test may be negative in the early part of the illness, it must be repeated later if symptoms persist.

Peritonsillar Abscess ¨ Symptoms • Abscess located next to one of the Palatine tonsils • Complication of bacterial tonsillitis. • Starts with a sore throat and progresses to difficulty, or complete inability, in swallowing liquids or saliva. • Typically, this patient is UNABLE to open their mouth widely, or swallow water, secondary to swelling. • Other symptoms, common both to tonsillitis and peritonsillar abscess, include: fever, chills, and pain upon swallowing

Evaluation • Hstory and physical examination. o Patients UNABLE to open their mouths OR swallow water are highly suspect for this problem. o Oral examination will often show tremendous swelling about the tonsil, deviating the uvula to one side.

¨ Treatment • Treatment requires an incision of the abscess, allowing it to drain, so healing can occur. Antibiotics will likely be prescribed in follow-up. An ENT specialist is the expert in the management of this special situation

Cancers of the Head and Neck • Fairly common • Includes cancer of the lips, tongue, mouth, throat, and larynx. • Invariably, squamous cell carcinomas occur with the highest frequency in smokers o It is rare for nonsmokers to get cancers of the head and neck

Symptoms • Persistent hoarse voice, weight loss, difficulty swallowing, white or dark patches inside of the mouth, and an unexplained sore to the tongue, cheek, or lip that does not heal. • Spreading of this type of cancer is frequently to regional lymph nodes, before any kind of distant spread occurs. • It is extremely uncommon for cancer to spread beyond the head and neck area, when the disease is controlled (therapeutically) in that area

Treatment • Surgery • Radiation therapy as the initial management if cancer has spread to lymph nodes • Chemotherapy has recently been purported as a method of improving initial cure rates, when it is given in combination with radiation therapy prior to surgery

PROBLEMS ASSOCIATED WITH THE LOWER RESPIRATORY TRACT • Laryngitis and Voice Strain -Inflammation of the larynx o Viral infection in the larynx or secondary to postnasal drip o Voice strain cause mechanical laryngitis

Symptoms o Hoarse or raspy voice o May be associated with a sore throat, fever, posterior nasal drip, or congestion of the sinuses. o It should not be accompanied by difficulty swallowing food or fluids. This symptom could indicate epiglottitis or peritonsillar abscess

Evaluation • History and physical examination • Direct visual inspection of the throat done to check for signs of bacterial infection • In questionable cases, x-rays of the neck may be useful to diagnose more serious bacterial upper airway infections. A throat culture may be needed to exclude the possibility of strep throat.

Treatment • Viral laryngitis is self-limiting and disappears by itself in • • • approximately 7 -10 days. Avoid talking, smoking, alcohol, hot liquids, frequent coughing and clearing the throat. Drink plenty of fluids and use analgesics or lozenges containing topical anesthetics as ordered. Acetaminophen can be used for pain or fever, A cool mist vaporizer can be therapeutic. Any suspicion of bacterial infection in the throat or sinuses will require antibiotic treatment. Any hoarseness of greater than 3 weeks duration should be evaluated by a physician or ENT specialist

Laryngeal Cancer • Laryngeal Tumors can initially result in a hoarse voice, or, in more serious cases, the total blockage of the airway. • Slow onset of a hoarse voice occurring over a period of weeks • Laryngeal cancer is most commonly seen in those over 40 years of age who smoke or "chew" tobacco

Evaluation/Treatment • Laryngoscopy to visually inspect the vocal cords • Questionable lesions mandate biopsy • Treatment for documented laryngeal cancer is based upon the extent the disease has progressed. • Surgical removal of part, or all of the larynx, is often necessary (laryngectomy). • Radiation therapy has also been used to control disease that has spread to surrounding tissue.

Laryngectomy Care • Total neck breather following surgery. CPR -ventilations • • • must be made mouth to neck not mouth to mouth. Immediate post-op. Watch for respiratory obstruction from swelling of the airway or increased secretions Post-op patients will be unable to form sounds. Air for speach no longer comes from the lungs. About 75% of postlaryngectomy patients learn to use "plosive" speech. Various mechanical aids are also available The laryngectomy tube is shorter and thicker than a tracheostomy tube. Laryngectomy tube used until the stoma heals. Observe for crusting: crust can be softened and removed with petrolatum jelly Proper room humidification is helpful

INFLUENZA ¨ Etiology • Viral upper respiratory infection that commonly affects a • • large percentage of children and adults Occurs more often in the winter months Transmitted through inhalation of particle droplets Wide variety of viruses responsible for flu-like illness Incubation period 1 to 6 days before onset of symptoms Viral upper respiratory infections can lead to pneumonia and sinusitis Children are commonly infected because they transmit these infections so easily. Flu in the elderly patient, more serious, can lead to a secondary bacterial infection with dehydration

Symptoms • Fever, chills, runny nose, sore throat, swollen lymph nodes, frontal headache, muscle and body aches, joint pains, dry cough, pleurisy with coughing, and weakness • Children and infants can have wheezing, particularly in a related infection, known as bronchiolitis

Evaluation o H&P rule out bacterial infection o CBC, blood cultures, and Chemogram as indicated o Chest x-ray to rule out pneumonia as indicated o Urinalysis to rule out UTI may be indicated

Treatment • Flu is usually nonserious and self-limited • Observe for signs of dehydration in infants and elderly • Rest, nutrition, fever control, fluids , avoid alcohol and caffeine • Wheezing may require bronchodilators, Cool mist vaporizer can reduce congestion in children • Saltwater nose drops followed by suctioning with a bulb syringe are helpful in infants • Vaccines against certain viruses (flu shot) have been quite successful and may be indicated in the elderly, diabetics, health-care workers, and other high risk groups.

BRONCHITIS ¨ Etiology and Symptoms • Inflammation of the bronchi in the lungs, most often occurs • • • secondary to a bacterial infection in the airways Bronchitis common in the smoking population Smokers have difficulty clearing their secretions (mucus) due to impaired ciliary action and have diminished immunity against infection. Productive cough (in smokers, may be bloody) fever, and chills, Shortness of breath is seen in more severe cases Similar symptoms to pneumonia Smokers may develop expiratory wheezes, breathing OUT more difficult than breathing IN.

Evaluation o H&P and chest x-ray to rule out pneumonia, CBC, chemistry and sputum cultures o Patients with shortness of breath may have an ABG's to determine if their oxygenation is acceptable

Treatment • Oral antibiotics- Some cases (long standing smokers with COPD) require hospitalization. • Patients with "wheezing" will require bronchodilators • Follow-up chest x-ray for patients not responding to treatment. The x-ray may reveal a developing pneumonia. • Acetaminophen or aspirin should be used for fever control

PNEUMONIA Etiology -Bacterial or viral infection of the lung tissue

• The most common forms of pneumonia are viral • • • Antibiotics have NO effect on viral infections Bacterial pneumonia - more severe and require antibiotics Pneumococcal pneumonia and streptococcal pneumonia - rust-colored sputum Foul smelling green or yellow sputum Pseudomonas pneumonia and lung abscesses Klebsiella pneumonia - blood tinged sputum Mycoplasmal pneumonia -neither bacterial nor viral. Tends to have milder symptoms Produces whiter colored sputum. Associated with H/A Smokers, elderly and immunocompromised (diabetics, cancer patients) are at risk for SERIOUS pneumonia

Symptoms • Productive cough, fever, shaking chills and • • • extreme fatigue Examination will usually reveal rales on asculatation, WBC over 11, 000 cu/ml Consolidation on the chest x-ray Crackling rales are likely to be heard anytime there is fluid in interstitial and alveolar areas. More severe pneumonia - associated SOB and/or pleuritic chest pain (pain worse with coughing and movement

Evaluation • History and physical examination for evidence of fever or upper respiratory infection • A chest x-ray can diagnose pneumonia, and, in most cases, is necessary for definitive diagnosis. • CBC, Blood Cultures, Chemogram and sputum cultures may be indicated • ABG's for evaluation of oxygenation in those who are short of breath

Treatment • Eliminate the organism, support oxygenation, and limit • • o activity Older patients, diabetics, and COPD patients should be admitted for IV antibiotics. Any patient SHORT OF BREATH while at rest, or with evidence for inadequate oxygenation by arterial blood gas analysis, will require admission to the hospital. Fatigue /activity intolerance is a common complication of pneumonia. May continue for weeks. Pneumovax vaccine - protects against bacterial pneumonia in those at high risk for infection. High Risk -over age 65, COPD, HIV, the chronically debilitated, or those who have had their spleen removed

ASPIRATION PNEUMONIA ¨ Etiology and Symptoms • Results in serious pneumonia, related to the type of • • material aspirated. Severe pneumonia can result from the aspiration of stomach acid or petroleum distillates Aspiration - passage of foreign materials into the lungs. Aspiration pneumonia can become infected secondarily with bacteria, requiring treatment with an antibiotic. Because of the anatomy of the respiratory tree, aspiration is more likely to affect the Right lung, as the right mainstem bronchus extends more vertically downward into the lungs, while the left bronchus is more horizontal.

Situations associated with a high risk for aspiration • Stroke patients (those who cannot swallow well • • • and protect their airway) Unconscious patients Children playing with toys or food (the "peanut" or toy aspiration is well known) Alcohol intoxicated patients Drowning Petroleum distillate ingestions (kerosene, gas, furniture polish, etc. ) Powder aspiration - talcum powder with babies

¨ Symptoms • Coughing, shortness of breath, and wheezing • Fever is a delayed symptom

¨ Evaluation • History to evaluate risk of aspiration, and physical examination. • Chest x-ray may show the foreign object or changes in the lung, indicating a pneumonia. • Arterial blood gas analysis will indicate the patient's overall lung function, including any need for oxygen therapy

Treatment • Suction patients who are unable to protect their • • • airway Bronchoscopy may be indicated in cases where a foreign object must be retrieved (generally children). Bronchodilators for wheezing Antibiotics for bacterial contamination Respirator for patients who cannot breath on their own. Fever control as indicated.

PLEURISY AND PLEURITIS ¨ • • Etiology/ Symptoms Pleura of the lung become inflamed Resulting chest pain is known as pleurisy Pain is sharp or "knife-like", and increases in severity as the patient breathes in Pleurisy is often one-sided and can radiate pain to the neck or shoulder. Movement of the thorax, including bending, stooping, or even turning in bed can increase pleural pain Shortness of breath with pleurisy may indicate a more serious problem such as pulmonary embolism Pleurisy can easily confused with chest wall pain which is much less serious. Chest wall pain can sometimes be distinguished from pleurisy by pressing down (palpation) on a region of the chest wall which will reproduce pain in the patient

Causes of pleurisy • Pneumonia (viral or bacterial) • Pulmonary Embolism • Pneumothorax • Lung cancer

Evaluation • Chest x-ray to rule out pneumothorax or pneumonia. • Those short of breath may require ABG's. • May need an EKG to exclude the possibility of angina (angina pain in rare cases can be pleuritic in nature)

Treatment • Ventilation/perfusion scanning of the lung is performed in cases of suspected pulmonary embolism. • Treatment is directed at the underlying cause. • Narcotic analgesics may be necessary when pain is severe. • Anti-inflammatory agents (ibuprofen) can be helpful in mild to moderate pleurisy

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) ¨ Etiology • Progressive disease with occasional exacerbations • • requiring hospitalization Most common chronic respiratory disorder Spectrum of diseases characterized by limited airflow and poor oxygenation of the blood. The two main disease processes are emphysema and chronic bronchitis. Chronic asthma, cystic fibrosis, and chronic bronchiectasis are also COPD smoking is the leading cause of COPD

• Other causes, cystic fibrosis, alpha-antitrypsinase • o o enzyme deficiency (inherited condition), and chronic exposure to some chemicals/irritants (asbestos, silica, and coal dust) Smoking 10 years or more Inflammation and destruction of the bronchioles and destruction of the alveolar walls Increased obstruction to air flow Hyperinflation of the alveoli poor oxygenation of the bloodstream

Continued smoking Breathing becomes more difficult Wheezing will develop. COPD patients also have increased risk of pulmonary infection (pneumonia and bronchitis) due to compromised immune system function in the upper respiratory tree. o Smokers have a 25 fold increased risk of lung cancer, and they are also at high risk for heart disease and stroke through the acceleration of atherosclerosis in the blood vessels • o o o

Symptoms -begin insidiously • Chronic productive cough • Barrel chest • Increasing tolerance of high CO 2 levels and • • low O 2 levels Shortness of breath upon exertion Club fingers Wheezing Fever if an infection (bronchitis) is present

Evaluation • History and physical • Pulmonary function tests • Chest x-ray may show changes consistent with emphysema (lung "disappearing" on the x-ray), scarring, or tumor • Normally, excessive levels of CO 2 stimulate respirations. However, in the COPD patient, the Chemoreceptors become insensitive to CO 2 and respond only to hypoxia. • If too much Oxygen is given to a COPD patient, the stimulus to breathe is removed and the client may stop breathing completely. • Most clients with COPD can tolerate Oxygen at 2 per N/C at 2 -3 l/min, but ABG's need to be monitored

CHRONIC BRONCHITIS ¨ Etiology • Prolonged exposure to bronchial irritants such as smoking • It is more common in females, whites, and city dwellers. • Chronic bronchitis causes inflammation of the bronchi with enlargement and hypersecretion of the mucous glands which causes diffuse airway obstruction

Symptoms of the "Blue Bloater • Heavy productive cough, particularly at night, • o o generally worse in cold, damp weather Progression Cough becomes continuous Dyspnea and wheezing become more severe. Cyanosis is common secondary to the chronic hypoxemia, and hypercapnia caused by the airway obstruction Generalized edema is also often present, and this swollen appearance, together with the cyanosis, gives rise to the phrase "blue bloater" used to describe these patients.

EMPHYSEMA

Etiology • Chronic progressive disease • Enlargement of air spaces - destruction of the alveolar • • • walls by enzymes. Smoking is primary cause but any continuous irritant (coal dust) can destroy alveoli. Deficiency of alpha-antitrypisn (an enzyme inhibitor) also indicated in the development/ progression of emphysema. Enzymes in the lung destroy elastic structure around the alveoli; resulting in loss of elasticity, stiffening of the lungs, and decreased compliance. The loss of alveolar function diminishes lung recoil (like an overstretched elastic band) and weakens expiration. The lung therefore remains partially expanded following expiration, producing air trapping and a visible barrel chest over time

Symptoms • Chronic cough • Dyspnea - hallmark of emphysema, worsens over time, may be present even at rest and is severe on exertion. • Pursed-lip breathing with prolonged expiration. • Barrel chest • Use of accessory muscles

• Hyperresonance on percussion • Decreased vocal fremitus on palpation. • Distant Breath and heart sounds • Anorexia, Weakness, Decreased muscle, Weight loss • The patient remains acyanotic until very late in the disease because of compensatory mechanisms. Thus, emphysema patients are referred to as "pink puffers" as opposed to the oxygen-starved "blue bloaters" with chronic bronchitis.

COMMON COMPLICATIONS OF COPD ¨ HYPOXEMIA (Pa. O 2 of 55 mm. Hg or less, with an oxygen saturation of 85% or less ¨ HYPERCAPNIA (elevated CO 2) and Respiratory acidosis. ¨ Respiratory infections ¨ COR PULMONALE (RIGHT VENTRICULAR HEART FAILURE

Symptoms of Hypoxemia o Mood changes o Forgetfulness o Inability to concentrate o Later signs are increasing restlessness. o Cyanosis is a late sign of hypoxemia

HYPERCAPNIA (elevated CO 2) and Respiratory acidosis o Decreased in oxygen/carbon dioxide exchange o Rising carbon dioxide levels result in respiratory o o o o acidosis. Symptoms of hypercapnia Increased respiratory rate SOB Headache Confusion Lethargy Nausea and Vomiting

Respiratory infections • Frequent respiratory infections related to: o Increased production of mucus o Increased irritability of the bronchial smooth muscle o Edema of the respiratory mucosa. • Many COPD patients are prescribed antibiotics on a PRN basis and the client self-administer the antibiotic according to changes in sputum appearance, which may indicate infection.

COR PULMONALE (RIGHT VENTRICULAR HEART FAILURE) • Most frequently associated with chronic bronchitis • Detection of cor pulmonale (pulmonary heart disease) is • • difficult because its clinical signs are generally masked by those of COPD. As COPD progresses, the amount of oxygen in the blood decreases, which causes major blood vessels in the lung to constrict. The body produces more RBC's to attempt to carry more oxygen. Leads to polycythemia and increased blood viscosity. Right side of the heart must pump harder, enlarges and leads to right-sided heart failure

Symptoms of cor pulmonale • • • Increasing dyspnea Fatigue Enlarged and tender liver Warm cyanotic extremities with bounding pulses Cyanotic lips Distended neck veins Right ventricular hypertrophy Nausea Dependent edema Metabolic and respiratory acidosis

TREATMENT FOR COPD • STOP SMOKING • BRONCHODILATORs for Wheezing (Proventil • • and Theophylline) ANTIBIOTICS (in infection) HOME OXYGEN THERAPY Most clients with COPD can tolerate Oxygen at 2 per N/C at 2 -3 l/min, but ABG's need to be monitored Steroid medications (Prednisone) for severe cases to reduce inflammation in bronchial tissue. Pulmonary disease diet is recommended

RESPIRATORY EMERGENCIES ¨ PNEUMOTHORAX¨ Common symptoms of a pneumothorax include the sudden onset of breathing difficulty, accompanied by chest pain (pleurisy) that INCREASES while breathing in. Will also have diminished lung sounds on the affected side. CXR will show collapsed lung. ¨ Treatment Surgical placement of a plastic tube into the chest cavity to remove the excess air and restore the negative air pressure within the pleural space

HEMOTHORAX ¨ Common symptoms include: chest pain, difficulty in breathing, and hemorrhagic shock, if the accumulation of blood in the chest is massive. ¨ Evaluation includes a chest x-ray which allows diagnosis and estimation of the hemothorax size. Blood tests (CBC) to check blood counts will help gauge the overall extent of blood loss ¨ Treatment involves placement of a chest tube to remove the accumulated blood. The chest tube will remain in place until the bleeding has stopped and the lung (indicated by x-ray) has adequately re-expanded.

PULMONARY EMBOLISM • Clot which obstructs perfusion in the lung o Can result in infarction of a portion of the lung o Symptoms include a SUDDEN onset of shortness of breath, pleurisy, elevated pulse and respirations and Pink frothy sputum o A nuclear scan of the lung, known as a ventilation-perfusion scan diagnose most pulmonary emboli o A more specific test is the pulmonary angiogram

Treatment • Streptokinase- dissolves clots and heparin - keeps further clots from forming