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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