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Timby/Smith: Introductory
Medical-Surgical Nursing,
10/e
Chapter 21: Caring for Clients
with Lower Respiratory Disorders
Acute Bronchitis

Inflammation of Bronchial Mucous
Membranes; Tracheobronchitis





Cause: Bacterial and fungal infection;
Chemical irritation
Diagnostics: Sputum cultures; Chest film
Signs/Symptoms: (Initial) Non-productive
cough, Fever, Malaise; (Later) Bloodstreaked sputum, Coughing attacks;
Inspiratory crackles
Treatment: Antipyretics; Expectorants;
Antitussives; Humidifiers; Broad-spectrum
antibiotics
Nursing Management
Pneumonia

Pathophysiology



Inflammatory Process Affecting Bronchioles and Alveoli;
Alveoli Filled with Exudate
Reduced Surface Area for Gas Exchange Classified by Cause
Etiology




Acute infection
Radiation therapy
Chemical ingestion, inhalation;
Bacteria







Steptococcus pneumoniae
pneumocystis carinii(bacteria developed in AIDS pt)
Virus
Fungus
Aspiration (stroke victims)
Artificial Ventilation (VAP)
Hypostasis
Pneumonia

At risk:






Very Young
Elderly
Hospitalized
Intubated
Immunocompromised
Prevention





(see box 21-2)
Pneumococcal Vaccine
Flu Vaccine
Coughing and Deep Breathing
Hand Washing
Frequent Mouth Care, Continuous Suction for VAP
Pneumonia

Diagnostics:




Chest film
Blood count
Sputum C & S
Signs/Symptoms






Chest Pain
Fever, Chills
Cough, Dyspnea
Yellow, Rusty, or Blood-Tinged Sputum
Crackles, Wheezes
Malaise
Pneumonia

Complications







Pleurisy
CHF
empyema
Pleural Effusion
Atelectasis
septicemia
Signs and Symptoms in Elderly
 New-Onset




Confusion
Lethargy
Fever
Dyspnea
Pneumonia

Treatment:

Antibiotic (bacterial) PO or IV
 Hydration
 Chest physical therapy
 Analgesics/Antipyretics
 Antiviral Medication (Zovirax)
 Bronchodilators
 Expectorants or cough suppressants
 Oxygen
Nursing Management

Pleurisy

Acute Inflammation of Parietal, Visceral
Pleurae





Cause: Usually secondary to pneumonia,
pulmonary infections, tuberculosis, lung
cancer, pulmonary embolism
Diagnostics: Chest radiography; Sputum
culture; Thoracentesis: Fluid specimen,
pleural biopsy
Signs/Symptoms: Inspirational severe,
sharp pain; Shallow respirations; Pleural
fluid accumulation; Dry cough; Dyspnea;
Friction rub, fever, elevated WBC
Treatment: Treat underlying condition;
NSAIDs Analgesics/antipyretic drugs
Nursing Management
Pleural Effusion

Pathophysiology


Abnormal Fluid Collection Between Visceral,
Parietal PleuraePleural Fluid Not Reabsorbed,May
Collapse Lung
Etiology

Transudative




Heart Failure
Liver or Kidney Disease
PE
Exudative



Pneumonia
TB
CA
Pleural Effusion cont.

Diagnostics


Chest radiograph; CT scan
Signs/Symptoms: Fever; Pain; Dyspnea;
Dullness upon chest percussion; Dim breath
sounds; Friction rub; Tachypnea; Cough

Treatment: Antibiotics; Analgesics;
Thoracentesis; Chest tube

Nursing Management
Pleural Effusion
Influenza

Acute Respiratory Disease of Short Duration

Cause: Viral contamination via respiratory transmission; Mutations

Fatalities related to secondary bacterial complications, esp. those
immunocompromised

Diagnostics: Chest radiography; Sputum analysis

Signs/Symptoms: See Table 21-2

Treatment: Symptomatic

Nursing Management

Prevention







Yearly Vaccination(85% effective)
should not be give to clients with allergy to eggs
At-Risk Individuals
Health Care Workers
Handwashing
Avoidance of infected people
Tuberculosis

Pathophysiology





AFB Implant on Bronchioles or Alveoli
Tubercle Formed
Immune System Keeps in Check
5%-10% Infected Become Ill
May Activate with Impaired Immunity
Pulmonary Tuberculosis

Primarily a bacterial infectious disease affects lungs;
may infect kidneys, other organs; Affects one-third of
world’s population; Leading cause of death from
infectious disease, among those with HIV
 Cause: Tubercle bacilli: Gram-positive; Transmitted via



droplet inhalation; Classifications
Diagnostics: Chest radiographs; Tuberculin skin tests; CT
scan; MRI; Gastric lavage; Gastric aspiration; Bronchoscopy;
C & S tests
Signs/Symptoms: Fatigue, weight loss; clients at risk;
Low fever; Night sweats; Persistent Cough; Blood-streaked
sputum; Weakness; Hemoptysis; Dyspnea
At Risk: elderly; alcoholics; crowded living conditions; new
immigrants; immunocompromised; lower socioeconomic status;
homeless
Therapeutic Interventions


Technique to destroy; Transmission
Combination of Drugs for 6 - 24 Months
(toxicity, resistance);








INH
Rifampin
PZA
Ethambutol
Streptomycin
Occasional Surgical Removal: Segmental
resection; Wedge resection; Lobectomy;
Pneumonectomy
Isolation
Nursing Management (see ATI pg 125-126
Prevention of TB Spread




Clean, Well-Ventilated Living Areas
Isolation of Patients who have Active TB
High-Efficiency Filtration Masks
Gowns, Gloves, Goggles If Contact with
Sputum Likely
COPD

Combination of




Chronic Bronchitis
Emphysema
(Asthma)
Chronic Airflow
Limitation

(in & out)
COPD (cont’d)
Airflow in lungs isPulmonary
obstructed caused
by
Obstructive
Disease
bronchial obstruction, congenital abnormalities


Increased resistance to expiration, creating
prolonged expiratory phase of respiration
 COPD







Emphysema
Chronic bronchitis
Asthma
Atelectasis
Sleep apnea
Cystic fibrosis
bronchiectasis
COPD Etiology





Smoking
Passive Smoke Exposure
Pollutants
Familial Predisposition
α1AT Deficiency (Emphysema)
Effects of Smoking
COPD Prevention
Smoking!!
COPD diagnositics






Chest X-Ray
CT Scan
ABGs
CBC
Spirometry
Sputum Analysis






PFT
PULSE OX
H/H
Chest physiotherapy
AAT levels
Peak expiratory flow
meters
COPD signs and symptoms









Chronic Cough
Chronic Dyspnea
Prolonged Expiration
Barrel Chest
Activity Intolerance
Diminished breath
sounds
Hypoxemia
Hypercarbia
Thin extremities








Wheezing, Crackles
Thick, Tenacious
Sputum
Increased Susceptibility
to Infection
Mucous Plugs
Accessory muscles
Rapid, Shallow
respirations
Pallor; cyanosis (late)
Hyperresonance

(emphysema)
Complications of COPD




Cor Pulmonale
Weight Loss
 Resting before eating
 Avoid gas-producing food
 Eat four to six small meals rather than
three large ones
 Take small bites and chew slow
Pneumothorax
Respiratory Failure
COPD
Therapeutic Interventions







Stop Smoking!!
Oxygen 1-2 L/m
Supportive Care
Pulmonary Rehab
Surgery
Mechanical
Ventilation
End-of-Life Planning

Medications




Bronchodilators
Corticosteroids
Expectorants
NMT/MDI
Bronchiectasis
Pathyphysiology




Chronic Infection
Dilation of One or
More Large Bronchi
Airway Obstruction
Etiology

Secondary to CF,
Asthma, TB
Bronchiectasis
Signs and Symptoms







Dyspnea
Cough
Large Amounts of Sputum
Anorexia
Recurrent Infection
Clubbing
Crackles and Wheezes
Bronchiectasis
Therapeutic Interventions






Antibiotics
Mucolytics, Expectorants
Bronchodilators
Chest Physiotherapy
Oxygen
Surgical Resection
Atelectasis

Collapse of Alveoli Prevents Gas Exchange

Causes: Mucus plug; Aspiration; Prolonged bed rest;
Fluid or air in thoracic cavity; Enlarged heart; Aneurysm;
hypoventilation

Signs/Symptoms: (Small area) Few; (Large area):
Cyanosis; Dyspnea; Fever; Pain; Tachycardia; Tachypnea;
Increased secretions

Treatment: Removal of cause; Raise secretions;
Bronchodilators; Humidification; O2 administration

Nursing Management: TCDB; incentive spirometer;
ambulate
Chronic Bronchitis

Prolonged inflammation of
bronchi; low grade fever;
hypertrophied mucous
glands in bronchi; impaired
ciliary function; Gradual
development


Signs/Symptoms:


Chronic, productive cough;
Thick mucus; Frequent
respiratory infections, lasting
several weeks (winter)
Treatment:


Ineffective airway clearance
Prevent pulmonary irritation;
Medications
Nursing Management
Pulmonary Emphysema

Abnormal Alveoli Distention, Destruction; loss
of elastic recoil; damage to pulmonary
capillaries; air trapping; disabling disease




Impaired Gas Exchange
Signs/Symptoms: (Initial) Exertional dyspnea;
(Progressive) Chronic cough; Mucopurulent sputum;
“Barrel chest”; Pursed-lip breathing; Prolonged,
difficult expiration; Wheezing; (Advanced) Memory
loss; CO2 narcosis
Treatment: Slow progression; Treat obstructed
airways (Bronchodilators, O2, ATB, physical therapy,
corticosteroids (limited)
Nursing Management
MDI
Spacer
NMT
Incentive Spirometer
Chest Physiotherapy
Pulmonary Rehabilitation
Asthma

Reversible Obstructive Disease of Lower
Airway; spasm of bronchial smooth
muscles; air trapping



Cause: Inflammation; Airway hyperreactivity
to stimuli (Allergic; Non-allergic; Mixed)
Diagnostic: allergy skin testing
Signs/Symptoms: Paroxysms of SOB,
wheezing, coughing; Thick, tenacious
sputum; use of accessory muscles; may be
worse at night
Asthma

Triggers






Smoking
Allergens
Infection
Sinusitis
Stress
GERD

Complication

Status Asthmaticus




Severe, Sustained Asthma
Worsening Hypoxemia
Respiratory Alkalosis
Progresses to Respiratory
Acidosis
May Be Life Threatening
Asthma
Asthma
Therapeutic Interventions



Monitor with Peak
Flow Meter
Avoid Triggers
Avoid Smoking
Asthma
Therapeutic Interventions (cont’d)

Bronchodilators




Corticosteroids




Adrenergic (Ventolin, Serevent)
Leukotriene Inhibitors (Accolate, Singulair)
Theophylline (Rare)
Inhaled, IV, PO
Mast Cell Inhibitors (Exercise Induced)
Antihistamines
Oxygen PRN
Nursing Diagnoses: COPD







Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Activity Intolerance
Imbalanced Nutrition
Anxiety
Fatigue
Impaired Gas Exchange

Monitor




Lung Sounds,
Respiratory Rate
and Effort
Dsypnea
Mental Status
SaO2, ABGs

Position





Fowler’s
Good Lung Down
Administer Oxygen
Teach Breathing
Exercises
Discourage Smoking
Ineffective Airway Clearance

Monitor



Lung Sounds
Sputum


Encourage



Fluids
Deep Breathing
Coughing


Administer
Expectorants
Turn q2h or
Ambulate
Suction prn
Consider CPT or
Mucus Clearance
Device
Ineffective Breathing Pattern

Monitor



Respiratory Rate,
Depth, Effort
ABGs, SaO2
Determine/Treat
Cause


Position
Teach Diaphragmatic
Breathing
Activity Intolerance

Monitor Response to
Activity



Vital Signs
SaO2
Use Portable O2 for
Ambulation




Allow Rest Between
Activities
Obtain Bedside
Commode
Increase Activity
Slowly
Refer to Pulmonary
Rehabilitation
Patient Education




Assist Patient to Stop Smoking!
Pulmonary Rehabilitation
Breathing Exercises
Energy Conservation
Postural Drainage
Occupational Lung Diseases

•



Cause: Exposure to organic, inorganic
dusts and noxious gases of long
periods of time
Diagnostics: Chest radiograph; Pulmonary
function tests
Symptoms: Dyspnea; cough; (Coal
dust) Black-streaked sputum
Treatment: Conservative; Symptomatic;
O2 therapy for severe dyspnea
Nursing Management
Pulmonary Arterial Hypertension

Continuous High Pressure in the Pulmonary
Arteries





Cause: Rt Ventricular Failure; CAD; Valve Disease;
Lung disease
Diagnostics: EKG; ABG analysis; Cardiac
catheterization; Pulmonary function tests;
Echocardiography; Ventilation-perfusion scan;
Pulmonary angiography
Signs/Symptoms: Dyspnea on exertion; Weakness;
fatigue; crackles; cyanosis; tachypnea
Treatment: Vasodilators, Anticoagulants; (Rightsided failure) Digitalis, diuretics; Heart–lung
transplantation; low sodium diet
Nursing Management
Pulmonary Hypertension
Pulmonary Embolism

Pathophysiology





Blood Clot in Pulmonary Artery or branches
Ventilation-Perfusion Mismatch
Impaired Gas Exchange
Lung Infarction
Etiology




Thrombus formed in the venous system or right
side of heart
DVT Most Common
Fat Emboli From Compound Fracture
Amniotic Fluid Emboli During L&D
Pulmonary Embolism
Pulmonary Embolism

Obstruction of Pulmonary Arteries or
Branches





Cause: Thrombus formed in the venous system or
right side of heart
Diagnostics: Chest radiograph; Serum enzymes;
Lung, CT scan; Pulmonary angiography;
Ultrasonography; Impedance plethysmography;
D-dimer
Signs/Symptoms: (Small area) Pain; Tachycardia;
Dyspnea (Large area) Severe dyspnea; Severe pain;
Cyanosis; Tachycardia; Restlessness; Shock; Sudden
death
Treatment: Thrombolytics; Anticoagulation; Surgery;
Procedures
Nursing Management
Pulmonary Edema

Fluid Accumulation in Interstitium, Alveoli
of Lungs




Cause: Right side of heart delivers more
blood to pulmonary circulation than left side
can handle
Signs/Symptoms: Dyspnea; Cyanotic
extremities; Skin color; Continual bloodtinged (pink), frothy sputum; Cough
Treatment: Emergency treatment for
cardiogenic pulmonary edema
Nursing Management
Respiratory Failure

Inability to Exchange Sufficient Amounts
of O2, CO2





Cause: (Acute) Life-threatening, occurs suddenly;
(Chronic) Underlying disease – COPD, aspiration,
neuromuscular disorders
Diagnostics: Chest radiography; Serum electrolytes;
History; ABGs (PaO² <60mm Hg; PaCO² >50mm Hg)
Signs/Symptoms: Restlessness; Wheezing;
Cyanosis; Accessory muscle use for breathing
Treatment: Endotracheal, tracheostomy tube;
Humidified O2 via nasal cannula, Venturi or
rebreather masks; Mechanical ventilation
Nursing Management
Respiratory Failure
Acute Respiratory Distress
Syndrome (ARDs)


Noncardiogenic Pulmonary Edema, secondary
to other clinical condition; Can lead to
respiratory failure, death
Pathophysiology





Alveolocapillary Membrane Damage
Pulmonary Edema
Alveolar Collapse
Lungs Stiff and Noncompliant
Lungs May Hemorrhage
ARDs Etiology








Acute Lung Injury
 Septicemia
 Shock
 Aspiration
Drug ingestion/overdose
Hematologic disorders
Metabolic disorders
Trauma
Surgery
Embolism;
Not Usually in Patients With Chronic Respiratory
Disease
Acute Respiratory Distress Syndrome

Diagnostics:




Signs/Symptoms






Chest radiography
Evidence of acute respiratory failure
ABGs
Tachypnea
Dyspnea, fine crackles
Cyanosis
Anxiety
Restlessness; Mental confusion
Treatment:




Intubation
Mechanical ventilation
Colloids
Nutritional support
Lung Cancer


Common Cancer, esp. smokers; #1
cause of CA death in U.S.
Types




Small Cell Lung Cancer
Large Cell Carcinoma
Adenocarcinoma
Squamous Cell Carcinoma
Lung Cancer Etiology

Smoking



Smokers 13× as Likely to Develop Cancer
as Nonsmokers
Environmental Tobacco Smoke
Other Carcinogens



Asbestos
Arsenic
Pollution
Lung Cancer Diagnostic Tests






Chest X-Ray
CT, PET Scan
MRI
Sputum Analysis
Biopsy
Additional Tests to Find Metastasis
Lung Cancer
Signs and Symptoms




None Until Late
Dyspnea Cell type,
tumor size +
location, degree of
metastasis
determine
Recurrent Infection
Anorexia and Weight
Loss

Cardinal signs





Cough
Productive of
mucopurulent or
blood-streaked
sputum
Hemoptysis
Pain
Wheezing/Stridor
Therapeutic Interventions



Factor dependent,
esp. on tumor
classification, Stage
(TNM System)
Chemotherapy
(Usually Palliative)
Radiation (Usually
Palliative)
Lung Cancer Complications



Pleural Effusion
Superior Vena Cava Syndrome
Ectopic Hormone Secretion




ADH (SIADH)
ACTH (Cushing’s Syndrome)
Actelectasis
Metastasis
Thoracic Surgery







Remove, repair chest wall traumas, tumors;
Obtain biopsy sample
Thoracotomy
Thoracentesis
Pneumonectomy
Lobectomy
Resection
Transplant
Thoracic Surgery
Preoperative Care


Monitor Respiratory Status
Teach




Routine Preop Teaching
What to Expect
Visit SICU
Include Family
Thoracic Surgery
Postoperative Care


Intensive Care Setting
Monitor






Vital Signs
SaO2, ABGs
Hemodynamic Parameters
Lung Sounds
Ventilator
Chest Tubes


Surgery interferes with normal thoracic cavity pressures;
Lung expansion
Lungs must be post-operatively reinflated

Draining secretions, air, blood from thoracic cavity via
surgically-placed catheter(s)
 Connected to closed, underwater-seal drainage system: 1
– 2 catheters
 Anterior: Removes air
 Posterior: Removes fluid
Thoracic Surgery
Pneumothorax

Pathophysiology

Air in the Intrapleural
Space

Complete or Partial
Collapse of Lung
Types
Signs and Symptoms





Shallow, Rapid
Respirations
Asymmetrical Chest
Expansion
Dyspnea
Chest Pain
Absent Breath Sounds
Over Affected Area

Tension Pneumothorax
Signs and Symptoms




Tracheal Deviation
Bradycardia
Cyanosis
Shock and Death If
Untreated
Pneumothorax

Diagnostic Tests




History and Physical Examination
Chest X-Ray
ABGs, SaO2
Therapeutic Interventions



Monitor ABGs and Respiratory Status
Chest Tube to Water Seal Drainage
Pleurodesis (Sclerosis) for Recurrent
Collapse
Pneumothorax
Nursing Care


Monitor Respiratory Status
Monitor Chest Drainage System

Equipment at bedside



Monitor and assess drainage system for





hemostats or clamps
vaseline gauze
amount of suction
presence of air leaks
integrity of the water seal chamber
absence of kinks in the tubing
Report Changes Promptly
Chest Drainage System
Thoracic Surgery
Rib Fractures/Flail Chest

Etiology





Trauma
Cough
CPR
Cause


Care



Control Pain
Encourage Coughing
and Deep Breathing
Promote Adequate
Ventilation

Multiple Rib
Fractures
Ribcage Not Able to
Maintain Bellows
Action
Care


Monitor ABGs
Mechanical
Ventilation
End of Presentation