Download Chapter 7 Body Systems

Chapter 14
Care of Patients with Disorders of the Lower
Respiratory System
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Theory Objectives


Compare and contrast commonalities and
differences in nursing care for patients with
bronchitis, influenza, pneumonia, empyema, and
pleurisy.
List nursing interventions appropriate for care of
patients with nursing diagnoses of Ineffective
airway clearance, Ineffective breathing pattern,
Impaired gas exchange, and Fatigue related to
hypoxia.
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2
Theory Objectives (Cont.)


Analyze ways a nurse can contribute to
prevention and prompt treatment of
tuberculosis (TB).
Summarize the pathophysiologic changes
that occur during an asthma attack.
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3
Theory Objectives (Cont.)


Evaluate problems that occur with aging that
may cause a restrictive pulmonary disorder.
Describe the specifics of nursing care for the
patient who has had thoracic surgery and has
chest tubes in place.
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4
Clinical Practice Objectives
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Complete a nursing care plan, including
home care, for the patient with chronic
obstructive pulmonary disease.
Review nursing interventions for the
tracheostomy patient on oxygen therapy.
Teach a patient how to use a peak flowmeter.
Observe a respiratory therapist (RT) who is
responsible for a patient on a mechanical
ventilator and identify how RTs and nurses
work together to deliver safe care.
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5
Acute Bronchitis
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An extension of an upper respiratory infection
involving the trachea
Usually viral in origin
Early symptoms are similar to those of the
common cold – cough producing some
sputum, sore throat, headache, muscle aches
Treatment includes humidification with warm
or cool moist air, cough mixtures, or
bronchodilators.
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Influenza
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
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An acute, highly infectious disease of the
upper and lower respiratory tracts.
Caused by three major types (A, B, and C)
and numerous subtypes of influenza viruses
Spread by direct and indirect contact –
coughing, sneezing, contaminated hands to
objects
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8
Signs and Symptoms



Appear 2 to 3 days after exposure
Headache, fever (101- 103), chills, and
muscle aches
Sore throat, hacking cough, runny nose, and
nasal congestion
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9
Treatment and Nursing Management
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Antiviral medications may be used in specific
patient populations.
Uncomplicated influenza usually is managed
more effectively by nursing intervention than
by drugs or other forms of medical treatment.
– see list on page 291
Antibiotics are given only if there is evidence
of bacterial infection secondary to the viral
infection
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10
Health Promotion: Immunization
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
The Advisory Committee on Immunization Practices
(2009) recommends annual influenza vaccination for
 People at high risk for influenza-related
complications and severe disease, including
children ages 6 to 59 months, pregnant women,
people older than 50 years, and people of any age
with certain chronic medical conditions
People who live with or care for persons at high risk,
including household contacts who have frequent
contact with people at high risk and who can transmit
influenza to those individuals, and health care
workers
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11
Complementary and Alternative
Therapy for the “Flu”
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Elderberry juice has been used for centuries
as a treatment to ease symptoms of the flu,
colds, and sinus infections.
Seems to prevent the virus from attaching to
cells
Antioxidants in the purple elderberry fruit
have an anti-inflammatory effect comparable
to aspirin.
May explain why the juice produces symptom
improvement
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13
Pneumonia
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An extensive inflammation of the lung with
either consolidation of the lung tissue as it fills
with exudate or interstitial inflammation and
edema.
Bacteria or viruses may cause pneumonia.



Viral pneumona does not produce exudate – it
causes interstitial inflammation
See concept map 14-1 page 292
Also can result from inhalation of irritating
gases
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14
Signs, Symptoms, and Diagnosis
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Usually a high fever accompanied by chills
A cough that produces rusty or blood-flecked
sputum
Sweating and chest pain that is made worse
by respiratory movement
A general feeling of malaise and aching
muscles
Diagnosis is confirmed by chest radiography,
which reveals densities in the affected lung.
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Complementary and Alternative
Therapy for Pneumonia pg 293
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
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Barberry root bark is used against bacteria,
fungi, and viruses as well as other organisms
and is an alternative treatment for
pneumonia.
It has antimicrobial action against both grampositive and gram-negative bacteria.
It should not be used during pregnancy
because it can cause spontaneous abortion.
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16
Cultural Considerations:
Pneumococcal Vaccine page 292


Routine use of pneumococcal polysaccharide
vaccine is not recommended for persons of
Alaskan Native or American Indian heritage
unless they have underlying medical
conditions such as chronic lung, liver, or renal
disease.
Local public health authorities may consider
recommending the vaccine for occurrences of
increased risk.
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17
Nursing Management of Pneumonia pg
293
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Promote oxygenation.
Control elevated temperature.
Maintain nutritional and fluid intake.
Provide adequate rest.
Monitor vital signs and respiratory status.
Relieve pain and discomfort.
Provide good oral hygiene.
Prevent irritation of the lungs by smoke and other
irritants.
Avoid secondary bacterial infections.
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Clinical Cues
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The first signs of decreasing oxygenation may be
restlessness or confusion.
The patient may want to sit upright to allow for
better chest excursion.
The respiratory rate will increase, and later there
will be flaring of the nares and then retraction of
respiratory muscles if the condition worsens.
Cyanosis is a very late sign.
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Older Adult Care Points pg 294
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Older adults are more at risk for influenza and
pneumonia because of a less efficient immune
system, decreased action of cilia, and decreased
elasticity and muscle tone.
Confusion often is the most obvious sign of
atypical pneumonia in older adults.
It may take 6 to 12 weeks after a bout of
pneumonia for the older person to be able to
resume normal activities without undue fatigue.
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20
Older Adult Care Points (Cont.)


Very old patients may never quite regain the
former level of wellness after a serious episode
of pneumonia.
Teach older adults to seek medical attention
quickly if symptoms of pneumonia occur.
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22
Empyema – potential problem with
pneumonia
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
Empyema occurs when the fluid within the
pleural cavity becomes infected and the
exudate becomes thick and purulent.
The organisms causing the infection may be
staphylococci or streptococci.
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Atelectasis
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An incomplete expansion, or collapse, of
alveoli
May occur from compression of the lungs
from outside, a decrease in surfactant, or
bronchial obstruction
Breath sounds are diminished when the
airways are collapsed, and oxygen saturation
(SaO2) will decrease.
Treatment consists of expelling secretions by
coughing.
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25
Fungal Infections
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Fungal infections are caused by the
inhalation of the fungus or spores or by
overgrowth of organisms found normally in
the body.
The most common fungal lung infections are
coccidioidomycosis and histoplasmosis.
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26
Tuberculosis page 294
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TB is an infectious disease of the lung
characterized by lesions within the lung
tissue.
The lesions may continue to degenerate and
become necrotic, or they may heal by fibrosis
and calcification.
The causative organism is the true tubercle
bacillus Mycobacterium tuberculosis.
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27
Extrapulmonary Tuberculosis
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It is possible for the tubercle bacillus to attack
and damage parts of the body other than the
lungs.
Areas most frequently affected are the bones,
meninges, urinary system, and reproductive
system.
TB of the spine, called Pott’s disease, is now
quite rare in the United States.
The deformity most commonly seen in Pott’s
disease is kyphosis, or “hunchback.”
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Tuberculosis

Diagnosis


Tuberculin skin testing
Radiographs and sputum cultures
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29
Signs and Symptoms


Cough, low-grade fever in the afternoon,
anorexia, loss of weight, fatigue, night
sweats, and sometimes hemoptysis
Tight or dull chest pain and mucopurulent
sputum may occur as the disease
progresses.
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Diagnosis
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Essential for early detection of the disease
because the anti-TB drugs are more effective
in the early stages, prevent spread, prevent
complications and period of disability is
shorter
Tuberculin skin testing
Blood testing
Radiographic examinations and sputum
cultures
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31
Treatment


Treatment of active TB consists of at least
four drugs for an extended period of time.
See list page 296 –Bactericidal agents
Isoniazid, Ethambutol, Rifampin
Pyrazinamide
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Latent Tuberculosis Infection
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
Latent TB infection (LTBI) is the current
terminology for an infection with
Mycobacterium tuberculosis but no current
active disease.
LTBI may develop into active TB if the
immune system is weakened by a serious
illness such as HIV or when the system is
less efficient, as with advanced age.
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Cultural Considerations
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American Indian, Alaska Natives, Asian/Pacific
Islanders, black non-Hispanics, and Hispanics
have a high incidence of TB.
The disease is most prevalent in people older
than 65 years of age in these groups.
For the first few years of residence in the
United States, new immigrants from areas
where TB is prevalent have incidence rates
similar to those of their former countries.
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35
Directly Observed Therapy

Because of an increase in the incidence of multidrugresistant TB, directly observed therapy (DOT) is
recommended for patients who are known to be at
risk of noncompliance with therapy.

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Visual observation of the ingestion of each required
dose of medication for the entire course of treatment
Often a public health nurse administers the medication
at a clinic site.
Follow-up visits are necessary for 12 months after
completion of therapy to monitor for the presence of
resistant strains.
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36
Legal and Ethical Consideration
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
When someone is found to have TB and the
person is non-compliant with treatment, is it
legal or ethical to compel the person to come
for treatment?
What would happen if the person is allowed
to remain in the community without
treatment?
37
Complementary and Alternative
Therapy for Tuberculosis



Vitamin D has been found to be successful in the
prevention and treatment of TB.
White blood cells convert vitamin D into an active
form that helps make a protein that kills TB bacteria.
Perhaps this is why moving to a sunny climate and a
solarium environment helped people with TB years
ago.
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38
Nursing Management of Tuberculosis
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Nursing diagnoses
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Ineffective breathing pattern related to decreased
lung capacity
Noncompliance related to lack of knowledge of
disease process and long-term requirements for
treatment
Activity intolerance related to fatigue, febrile
status, and poor nutritional status
Imbalanced nutrition: less than body requirements
related to anorexia, fatigue, and productive cough
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39
Nursing Management of Tuberculosis
(Cont.)
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Control infection.
Promote immunity.
Support.
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40
Occupational Lung Disorders
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Coal dust; dust from hemp, flax, and cotton
processing; and exposure to silica in the air
all can cause work-related lung disorders.
Asbestos exposure may cause a rare cancer
of the chest lining called mesothelioma.
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41
Restrictive Pulmonary Disorders
Sarcoidosis
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
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A lung disease characterized by granulomas
It causes fibrotic changes in the lung tissue
over time, and the cause is unknown.
It affects other tissues in the body as well.
A cellular immune response seems to be
responsible for the tissue changes.
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44
Pulmonary Fibrosis


Occurs from severe infection, repeated
infection, or inflammation that causes
scarring of the lung tissue
The scarring decreases functional lung
tissue.
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Pleurisy
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An inflammation of the pleura
TB, pneumonia, neoplasm, and pulmonary
infarction all can cause pleurisy.
Pleurisy pain is sharp and abrupt in onset and
is most evident on inspiration.
Pain causes shallow breathing.
Pleural friction rub may sometimes be heard.
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47
Bronchiectasis
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
Chronic respiratory disorder in which one or
more bronchi are permanently dilated
Thought to occur as a result of frequent
respiratory infections in childhood
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Cystic Fibrosis
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A genetic disease in which there is excessive
mucus production because of exocrine gland
dysfunction
It occurs most often in whites.
The lungs, intestines, sinuses, reproductive
tract, sweat glands, and pancreas are all
affected.
It is diagnosed by history, physical
examination, and a positive sweat test result.
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50
Restrictive Pulmonary Disorders
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Caused by decreased elasticity or
compliance of the lungs or decreased ability
of the chest wall to expand
Disorders of the central nervous system or of
the neuromuscular system can cause a
restrictive lung disorder.
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51
Restrictive Pulmonary Disorders
(Cont.)
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
Myasthenia gravis and arthritis are examples
of extrapulmonary causes of a restrictive
disorder
Kyphosis of the spine or severe scoliosis may
also hamper lung expansion, although in
these muscular and skeletal disorders, the
lung tissue remains normal.
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Pleural Effusion
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A collection of fluid in the pleural space
Transudative
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Occurs in noninflammatory conditions
Often a result of congestive heart failure, chronic
liver failure, or renal disease
Transudate is a thin fluid containing no protein that
passes from cells into interstitial spaces or through
a membrane.
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54
Pleural Effusion (Cont.)

Exudative
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
Thicker, contains cells and other substances, and
is slowly discharged from cells into a body space
or to the outside of the body.
Exudative pleural effusion occurs in an area of
inflammation caused by the increased capillary
permeability characteristic of the inflammatory
reaction.
Occurs with lung cancer, pulmonary embolism,
pancreatic disease, and pulmonary infections
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56
Chronic Obstructive Pulmonary
Disease
Obstructive Pulmonary Disorders

Characterized by problems with moving air
into and out of the lungs
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Narrowing of the openings in the tracheobronchial
tree increases resistance to the flow of air, making
it difficult for oxygen to enter, and contributes to air
trapping because exhalation also is difficult.
Chronic bronchitis
Asthma
Emphysema
Atelectasis
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Chronic Obstructive Pulmonary
Disease

Etiology and diagnosis
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Emphysema
Chronic bronchitis
Treatment

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Bronchodilators and anti-inflammatory agents
Smoking cessation
Respiratory rehabilitation programs
Nutrition
Complementary and alternative therapies
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59
Comparison of Pulmonary Emphysema
and Chronic Bronchitis
Table 14-2 Page 301
Complementary and Alternative
Therapy for Emphysema


Ginger and cinnamon are aromatic digestives
that provide benefit for emphysema patients.
Very small doses of Capsicum annum (chili)
or garlic can be useful as mucolytic agents.
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61
Complications of Chronic Obstructive
Pulmonary Disease page 300
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
Cor pulmonale- enlarged right side of heart
Acute respiratory failure
Peptic ulcer and gastroesophageal reflux
disease
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62
Asthma
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
Chronic lung disease characterized by
reversible airway obstruction, airway edema
or swelling from inflammation.
Respiratory distress without a wheeze is an
ominous sign for the asthma patient; this
suggests further constriction with very little air
movement.
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64
Goals of Medical Treatment
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Minimize irritation of the air passages and
relieve obstruction by secretions, edema, or
bronchospasm.
Prevent or control infection and allergy.
Increase the patient’s tolerance for activity.
Determine the best drug combination in the
least amount that will control symptoms.
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65
Peak Flowmeter used by asthma
patients
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
The peak flowmeter helps determine the drug
dosage needed to control the asthma, predict
the effectiveness of therapy, and detect
airflow obstruction buildup before it becomes
serious and requires hospitalization.
See “using a peak flowmeter” page 306
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Patient Teaching

Know your “green zone” (when airflow is
normal), your “yellow zone” (when usual
airflow has decreased and routine
medications should be increased), and your
“red zone” (when you need to use rescue
medications and call your health care
provider).
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68
The Step System of Asthma Treatment
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I. Mild intermittent
II. Mild persistent
III. Moderate persistent
IVa. Severe persistent
IVb. Severe persistent, not responsive to the
previous step
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69
Asthma

Nursing management
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Smoking cessation
Psychosocial care
Patient and family teaching
How to avoid bronchial irritation and infection
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70
Audience Response Question 1

On initial admission assessment of a patient
with acute exacerbation of chronic obstructive
pulmonary disease (COPD), the nurse is
likely to expect which sign(s) and
symptom(s)? (Select all that apply.)
1.
2.
3.
4.
5.
Tensing of the shoulder muscles
Inability to tolerate sitting up
Flaring of the nostrils
Completes sentences with no effort
Sternal retraction
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Respiratory Distress see page 306
Clinical Cues
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Apply high-flow oxygen and monitor the
saturation level with a pulse oximeter.
Observe and monitor continuously.
Immediately alert the RN and the physician.
If there is a history of COPD, the oxygen rate
should be changed, as ordered, to a lower
flow of 1 to 3 L per nasal cannula after the
respiratory crisis has been resolved.
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72
Lung Cancer page 307

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
Etiology and pathophysiology
Signs and symptoms
Diagnosis
Treatment



Surgery
Chemotherapy
Radiation therapy
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Pulmonary Vascular Disorders
Pulmonary Vascular Disorders
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Pulmonary embolism – pulmonary vessel is
plugged with a mass or a clot. Page 308
s/s depends on size and location of the clot –
respiratory distress, dyspnea, chest pain,
cough.
D-dimer testing of plasma, CTA, ABGs, ECG
Tx- heparin IV, Xarelto, Thrombolytic therapy
Prevention is the best intervention
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76
Chest Injuries

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
Fractured ribs
Flail chest
Penetrating wounds
Pneumothorax and hemothorax


Spontaneous pneumothorax
Tension pneumothorax
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Pulmonary Vascular Disorders page
309



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Primary pulmonary hypertension – elevated
pressure in the pulmonary artery.
s/s – dyspnea, fatigue, chest pain with
exertion, dizziness, syncope.
Eventually leads to right-sided heart
enlargement (cor pulmonale)
Tx- drug therapies, calcium channel blockers,
anticoagulants
Lung transplantation
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Pulmonary Vascular Disorders




Lung transplantation - option for end-stage
lung disease
Normal wait for organ is one year
Most common cause of death is infection
Immunosuppressive therapy is lifelong to
prevent organ rejection
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Major Concerns for Patients with
Chest Injuries
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Maintenance of an airway
Assurance of adequate ventilation
Treatment of circulatory problems to ensure
circulation of oxygenated blood
Pneumothorax (air in the pleural cavity) and
hemothorax (blood in the pleural cavity) often
occur as a result of a blunt or penetrating
injury to the chest wall.
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Lung Disorders page 310



Pulmonary edema – abnormal collection of
fluid in the interstitial spaces of the lung and
inside the alveoli.
Adult (acute) respiratory distress syndrome –
result of sepsis, major trauma- alveoli fill with
fluid and the oxygen and carbon dioxide
cannot cross the membrane
Respiratory failure – insufficient oxygen or
excessive carbon dioxide.
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Common Therapeutic Measures

Intrathoracic surgery



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

Preoperative care
Postoperative care
Medication administration
Humidification
Pulmonary hygiene
Oxygen therapy
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Chest Tubes and Closed Drainage

Purposes



Major assessments



Provide for drainage of air and blood from within
the pleural cavity.
Allow for gradual re-expansion of the lung.
The respiratory status of the patient
The site at which the tube is inserted into the chest
and the length of the tube (for kinks)
The amount and character of the drainage in
the collection chamber
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83
Location of Sites for Insertion of Chest
Tubes
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84
Disposable Water-Seal Drainage System
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Various Oxygen Delivery Devices see p
320
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Mechanical Ventilation

Mechanical Ventilation is needed when the
patient cannot maintain adequate ventilation
due to respiratory, neurologic or
neuromuscular problems or trauma
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Mechanical Ventilation (cont) page 322

Modes of ventilation – pressure cycled and
volume cycled





Controlled mode – fixed number of breaths per
minute at a set volume
Assist-mode – when patient takes a breath, the
machine delivers a set tidal volume
Pressure support ventilation – adjunct to
standard ventilator modes pg 323
Continuous positive airway pressure -CPAP
Noninvasive positive ventilation
88
Dangers of Mechanical Ventilation page
324
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Barotrauma
Oxygen toxicity
Impaired cardiac output
Infection
Fluid retention
Gastric distention
Gastrointestinal bleeding
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Preventing Ventilator-Acquired
Pneumonia

The Centers for Disease Control and
Prevention recommends



Elevation of the head of the bed to 30 to 45
degrees
Continuous removal of subglottic secretions
Change of ventilator circuit no more often than
every 48 hours and washing hands before and
after contact with every patient
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90
Preventing Ventilator-Acquired
Pneumonia (Cont.)

In addition, facility bundle policy may include




Checking the residual volume in the nasogastric
tube
Providing oral care with chlorhexidine
Deep vein thrombosis prophylaxis
Peptic ulcer prophylaxis
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Mechanical Ventilation

When caring for a patient on mechanical
ventilation, the nurse should



Check the physician’s order each shift and then
check the ventilator for the proper settings.
Check alarms to see that they are turned on.
Keep tubing clear of pooled water; empty the
water into an appropriate receptacle as needed.
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