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BLOCK 18 STUDY GUIDE

RESPIRATORY NURSING

1. Respiratory System:
A. External respiration—breathing:
(1) Allows the exchange of oxygen and carbon dioxide between the lungs and the environment.
(2) Air is warmed, moistened and filtered to prepare it for use by the body.
(3) Respiratory system works with the cardiovascular system to deliver oxygen to the cells.

B. Internal respiration:
(1) Exchange of oxygen and carbon dioxide occurs by diffusion at the cellular level.
(2) Oxygen enters the cells and carbon dioxide leaves the cells (these processes occur along a
concentration gradient—from an area of higher concentration to an area of lower concentration).
(3) Respiratory system works with the cardiovascular system to deliver oxygen to the cells (if either the
respiratory system or the cardiovascular system fails, the result is the same—rapid cell death).

C. Upper respiratory tract:


(1) Nose:
(a) Air is filtered, moistened and warmed as it enters the two nares.
(b) Nasal septum separates the nares.
(c) Entire area is lined with mucous membranes, which are highly vascular (provides warmth and
moisture)—secretes approximately 1 liter moisture per day.
(d) Contains hairs which trap dust and other foreign particles and prevents them from entering the lower
respiratory tract.
(e) Turbinates:
1) Three scroll-like bones located laterally to the nasal cavities.
2) Cause the air to move over a larger surface area—allows more time for warming and moisturizing.
(f) Sinuses: frontal, maxillary, sphenoid and ethmoid.
1) Hollow areas which make the skull lighter.
2) Believed to give resonance to the voice.
3) Lined with mucous membranes continuous with the nasal cavity.
(g) Smell receptors—Located in the mucosa of the nasal cavity—nerve endings of the olfactory nerve
(CN I).
(h) Nasolacrimal ducts—communicate with the upper nasal chamber (when a person cries, his/her
nose runs).

(2) Pharynx—throat:
(a) Passageway for air and food.
(b) Three subdivisions:
1) Nasopharynx- most superior portion and contains the adenoids.
2) Oropharynx—posterior to mouth and contains the tonsils.
3) Laryngopharynx—directly superior to larynx.
(c) Eustachian tubes:
1) Enter either side of the nasopharynx, connecting it to the middle ear.
2) Inner lining of the pharynx continuous with the eustachian tube.

(3) Larynx—voicebox:
(a) Connects the pharynx with the trachea and contains the vocal cords—opening between the vocal cords
is the glottis.
(b) Supported by nine rings of cartilage.
1) Largest area composed of two fused plates called the thyroid cartilage (Adam's apple)—same size
in men and women until puberty when it enlarges in men.
(c) Epiglottis:
1) Large leaf shaped area that protects the larynx when swallowing.
2) Covers the larynx tightly to prevent food from entering the trachea and directs food to the
esophagus.

(4) Trachea—windpipe:
(a) Tubelike structure, containing C-shaped cartilaginous rings, that extends to the midchest where it
divides into the right and left bronchi.
(b) Lies anterior to the esophagus and connects the larynx with the bronchi.
(c) Anterior portion of the trachea is covered by the isthmus of the thyroid gland.
(d) Open portion of C-shaped cartilage faces the posterior, allowing the esophagus to expand while
swallowing, but maintaining patency of the trachea (necessary for uninterrupted breathing).
(e) Lined with mucous membranes and cilia that direct dust and debris up towards the nasal cavity.
(f) Large particles will stimulate the cough reflex, a protective mechanism that aids in the evacuation of
foreign material.

d. Lower respiratory tract:


(1) Bronchial tree:
(a) Right bronchus:
1) Enters the right lung;
2) Larger in diameter and more vertical in descent than the left; 3) Aspirated objects often enter
right bronchus.
(b) Left bronchus:
1) Enters the left lung;
2) Smaller in diameter and slightly horizontal in position, compared to the left.
(c) Bronchioles—smaller branches of the bronchi.
(d) Terminal bronchioles or alveolar ducts—smaller tubelike structures lined with ciliated mucous
membranes.
(e) Alveoli:
1) Terminal structure of the bronchial tree where gas exchange occurs.
2) Effective in gas exchange because they are thin-walled.
3) Surrounded by a capillary to facilitate diffusion of gases.
4) Lined with surfactant to reduce surface tension of alveolus and prevent it from collapsing.

e. Mechanics of breathing:
(1) Thoracic cavity:
(a) Lungs occupy almost the entire thoracic cavity, except the mediastinum.
(b) Cavity is called the intrapleural space and is enclosed by the sternum, ribs and thoracic vertebrae.
(c) Lungs:
1) Large, paired, spongy cone-shaped organs;
2) Right lung has 3 lobes and left lung has 2;
3) Blood supply: a) Receive their blood supply from the pulmonary arteries;
b) Gas exchange occurs via diffusion;
c) Oxygenated blood returns to the heart via pulmonary veins for distribution to the body.
4) Visceral pleura—Thin, moist serous membrane that covers the surface of each lung.
5) Parietal pleura—Thin, moist serous membrane that covers the thoracic cavity.
(d) Pleural cavity:
1) Airtight vacuum that contains negative pressure that helps keep the lungs inflated.
2) Air in the lungs is atmospheric pressure and higher than that in the pleural cavity.
3) Visceral and parietal pleura produce a serous secretion that allows the lungs to slide over the
walls of the thorax while breathing (accumulation of this fluid can result in a pleural effusion
that may need to be drained by a thoracentesis).

f. Respiratory regulation:
(1) Medulla oblongata and pons are responsible for the basic rhythm and depth of respiration
(rhythm can be modified to meet the demands of the body).
(2) Chemoreceptors:
(a) Located in the carotid and aortic bodies.
(b) Sensitive to blood carbon dioxide, oxygen and PH levels.
(c) Stimulate or suppress respirations to normalize blood values of the above.

2. Define the key terms in your own words


A. TED HOSE: TED stands for thromboembolic disease, which means "blood clots". TED Hose
stockings are long, tight fitting "socks" that keep mild pressure on the legs to prevent blood from clotting.
TED stockings are designed to reduce venous stasis in the entire leg. Correct graduated compression from
ankle to upper thigh helps insure optimum blood flow velocity. TED hose/antiembolism stockings help to
improve this condition by assisting blood flow and decreasing swelling. TED hose stockings should be
worn during inactive times after surgery, on airplanes, or often if the patient has a history of poor
circulation. TED hose may also be used for treating the patient with PE (Pulmonary Edema or
Pulmonary Embolism) to prevent peripheral edema.

B. CIPRO (ciprofloxacin): A broad-spectrum antiinfective.


Action: Interferes with conversion of intermediate DNA fragments into high-molecular-weight DNA in
bacteria; DNA gyrase inhibitor.
Uses: Infection caused by susceptible E. Coli, Enterobacter cloacae, Klebsiella pneumoniae,
Staphylococcus aureus, and Salmonella. Cipro is used in treating Acute sinusitis, Postexposure
inhalation anthrax, etc.
Dosage: PO 250 mg q12h.
Side Effects: Dizziness, fatigue, insomnia, depression, restlessness, confusion, Nausea, vomiting,
diarrhea, increased ALT, AST, flatulence, dysphagia, Rash, pruritus, urticaria, photosensitivity, flushing,
fever,, chills, tremor, arthralgia, tendon rupture.
Contraindications: Hypersensitivity to quinolones.
Nursing Considerations: Administer 2 hours before and 2 hours after antacids, zinc, iron,
magnesium, aluminum, and calcium intake. Perform limited intake of alkaline foods, drugs, milk, dairy
products, alkaline antacids, sodium bicarbonate. Evaluate therapeutic response. Increase fluid intake up to
3 L/day to avoid crystallization in kidneys.
Do not use Theophylline with this product (Cipro), will cause toxicity, contact prescriber if taking
theophylline.

C. Bronchodilator: Are divided into anticholinergics (Theophylline/Aminophylline), α/β-adrenergic


agonists (epinephrine), β-adrenergic agonists (e.g., albuterol—Proventil, Ventolin), and
phosphodiesterase inhibitors. Anticholinergics act by inhibiting interaction of acetylcholine at receptor
sites on bronchial smooth muscle; α/β-adrenergic agonists by relaxing bronchial smooth muscle and
increasing diameter of nasal passages; β-adrenergic agonists by action on β2 receptors, which relaxes
bronchial smooth muscles; phosphodiesterase inhibitors by blocking phosphodiesterase and increasing
cAMP, which mediates smooth muscle relaxation in the respiratory system.
Uses: Bronchodilators are used for bronchial asthma, bronchospasm associated with bronchitis,
emphysema, or other obstructive pulmonary diseases, Cheyne-Stokes respirations, prevention of exercise-
induced asthma.
Side Effects: Most common: tremors, anxiety, nausea, vomiting, and irritation in throat; Most serious:
bronchospasm, and dyspnea.
Contraindications: Narrow-angle glaucoma, tachydysrhythmias, and severe cardiac disease should not
use some of these products. Avoid using bronchodilators with pregnancy, lactation, hyperthyroidism,
hypertension, prostatic hypertrophy, and seizure disorders.

D. Thoracostomy: Resection of the chest wall to allow drainage of the chest cavity. Thoracotomy:
Surgical incision of the chest wall in order to insert a chest tube, e.g., in case of pneumothorax. The chest
tube is inserted in the fifth and sixth intercostal spaces at the midaxillary line. The chest-tube is attached
to a water-seal drainage system. Intermittent positive pressure may be administered.

E. Administration of oral inhaler: In asthma patients, bronchodilator like Albuterol (Ventolin,


Proventil) may be used as a metered dose inhaler (MDI) to quickly relax the muscles around the airway.
A MDI device is used for self-administration of exact doses of aerosolized drugs; may be attached with a
spacer or used in a nebulizer. The correct procedure for using a MDI is to first fully exhale, place the
mouth-piece end of the pump into the mouth, and having just started to inhale, depress the canister to
release the medicine. The aerosolized medicine is drawn into the lungs by continuing to inhale deeply
before holding the breath for 10 seconds to allow absorption into the bronchial walls. The co-ordination
between activating the inhaler and breathing in is critical for effective delivery of the drug into the lungs.
This can be difficult in younger asthma sufferers or elderly people with arthritis of their hands, or those
with a poor ability to hold their breath for 10 seconds after using an inhaler. Some breath-activated
inhalers do not require manual activation, but will automatically sense the patient breathing in and deliver
the dose. Alternatively a device called an Asthma spacer may be used which is an enclosed plastic
cylinder that mixes the medication with air in a simple tube, making it easier for patients to receive a full
dose of the drug.

F. Cyanosis: Lightly bluish, gray, slatelike, or dark purple discoloration of the skin resulting from the
presence of abnormally reduced amounts of oxygenated hemoglobin in the blood.

G. Thoracentesis: The surgical perforation of the chest wall and pleural space with a needle for the
aspiration of fluid for diagnostic or therapeutic purposes.

H. Normal ABGs:
(1) Normal PH Range: 7.35—745.
(2) Normal bicarbonate (HCO3-) values in the blood: 21—28 mEq/L.
(3) Normal PaCO2: 35-45 mm Hg.
(4) Normal PaO2: 80—100 mm Hg.
(5) Normal SaO2: (95—100)%.
NOTE:
• PaCO2 reflects respiratory factors;
• HCO3- reflects metabolic (renal) factors.
• CO2 is a potential acid,
• PaCO2 of greater than 45 indicates respiratory acidosis.
• PaCO2 less than 35 mm Hg indicates respiratory alkalosis.
• HCO3- is a basic (alkaline) substance,
• HCO3- greater than 28 mEq/L indicates metabolic alkalosis;
• HCO3- less than 22 mEq/L indicates metabolic acidosis.

I. Acid-Base Imbalance:
(1) PH: The concentration of hydrogen ions (H+) in the blood is referred to as the PH. The PH is the
negative logarithm of the H+ concentration.
(2) In respiratory acidosis: Kidneys will retain increased amounts of bicarbonate (HCO3-) in an attempt
to increase PH through compensation.
(3) In respiratory alkalosis: Kidneys will excrete increased amounts of HCO3- in an attempt to lower PH
through compensation.
(4) In metabolic acidosis: The lungs attempt to compensate by “blowing off” CO2 to raise PH.
(5) In metabolic alkalosis: The lungs attempt to compensate by retaining CO2 to lower PH.

J. Adventitious: Abnormal sounds superimposed on breath sounds.

K. Crackles: Short, discrete, interrupted crackling or bubbling sounds; most commonly heard upon
inspiration.

L. Barrel Chest: Increased anteroposterior diameter caused by overinflation from emphysema, then
use accessory muscles for breathing (labored).

M. Pneumothorax: Collection of air or gas in the pleural cavity; causes the lung to collapse.

N. Sonorous wheeze: Low-pitched, loud, coarse, snoring sound.

O. Orthopnea: Abnormal condition in which a person must sit or stand in order to breathe deeply or
comfortably.

P. Stertorous breathing: Pertaining to a respiratory effort that is strenuous and struggling, which
provokes a snoring sound.

Q. Pleural friction rub: Low-pitched, grating, or creaking lung sounds that occur when inflamed
pleural surfaces rub together during respiration.

R. Pleural effusion: An abnormal accumulation of fluid in the thoracic cavity between the visceral
and parietal pleurae.

S. Anesthetic Block: A regional anesthetic injected into a nerve (intraneural) or immediately around
it (paraneural) causing insensibility over a particular area. Anesthetic block is used in different diagnostic
and surgical procedures (e.g., Bronchoscopy).

T. Sibilant wheeze: Musical, high-pitched, squeaking, or whistlelike sound caused by the rapid
movement of air through narrowed bronchioles.

U. Virulent: Power of a microorganism to produce disease; of or pertaining to a very pathogenic or


rapidly progressive condition.

V. Hypercapnia: Greater than normal amounts of carbon dioxide (CO2) in the blood. \
W. (1) Subjective data: What the patient says or complaints of, because only they feel them;
(2) Objective data: What you as a nurse see, assess or observe in the patient.

X. Allen’s Test: A test to find occlusion of radial or ulnar arteries. The patient’s hand is held above the
head with the fist clenched, both the redial and ulnar arteries are compressed. The hand is lowered and
opened. Pressure is then released over the ulnar artery. Color should return to the hand within 6 seconds,
indicating a patent ulnar artery and an intact superficial palmar arch. Failure of blood to return to the hand
indicates an obstruction of the artery that was not compressed.

Y. Status post (S/P) Tonsillectomy and Adenoidectomy (T&A): The tonsils and adenoids
are surgically excised. This procedure occurs in persons who have recurrent attacks of tonsillitis. The
procedure is usually performed from 4 to 6 weeks after an acute attack has subsided. Either local or
general anesthesia is used. When a T&A is performed, hemostasis is of utmost importance, because the
patient can lose a large amount of blood through hemorrhage without demonstrating any outward signs of
bleeding. The physician may be able to control minor postoperative bleeding by applying a sponge soaked
in a solution of epinephrine to the site. The patient who is bleeding excessively often is returned to the
operating room for surgical treatment to stop the hemorrhage. Medications include analgesics,
antipyretics, antibiotics (i.e., penicillin); IV fluids in case of nausea, otherwise give patient ice cold
liquids; Warm saline gargles and ice collar to the neck are also beneficial. Provide meticulous oral care to
promote comfort and assist in combating infection. Observe and report if the patient exhibits frequent
swallowing, because this is often a subtle but reliable indication of excessive bleeding.

Z. Theophylline: (Aminophylline)—Theophylline is a bronchodilator and spasmolytic. It relaxes


smooth muscle of respiratory system by blocking phosphodiesterase, which increases cAMP.
Theophylline is used for bronchial asthma, bronchospasm of COPD, and chronic bronchitis.
Nursing Implications: Do not crush sustained-release preparations; Contents of pellet-containing
capsules may be sprinkled over food; Avoid caffeine; Use with caution in peptic ulcer disease or cardiac
dysrhythmias; Metabolism affected by other medications are erythromycin, ciprofloxacin, cimetidine, and
Rifampin; This drug may cause toxicity; Monitor serum concentrations for toxic levels.

3. Assessment of the respiratory system


A. Function of the respiratory system is basically the exchange of oxygen and carbon dioxide
gas. The exchange process depends on the lungs capacity for contraction and expansion to produce
respiration. For this, respiratory system should always be included in any patient assessment.
B. Patients requiring a more extensive respiratory assessment:
(1) Chronic respiratory or cardiac disease;
(2) History of respiratory impairment related to trauma or allergic reactions.
(3) Recent surgery or anesthesia. Physical and emotional responses are often correlated, therefore the
nurse should inquire the patient about stress and anxiety.
a. Subjective data:
(1) Shortness of breath (SOB).
(2) Dyspnea on exertion (DOE);
(3) Any subjective experience that only the patient can describe. Such as:
1) Onset,
2) Duration,
3) Precipitating factors, and
4) Relief measures of the specific problem.
(4) Cough:
(a) Productive or non-productive;
(b) Harsh, dry or hacking;
(c) Color and amount of mucous.
b. Objective data—Assessment begins with observation, to include:
(1) Chest movement and expansion.
(2) Clues of distress such as wide-eyed, anxious look may indicate fear of suffocating.
(3) Flaring nostrils—late sign of respiratory distress.
(4) Retractions of chest wall between the ribs and under the clavicle during inspiration.
(5) Orthopnea.
(6) Auscultation of anterior and posterior body: Note presence of adventitious breath sounds:
• Sibilant wheeze (simple wheeze sound).
• Sonorous wheeze (rhonchi).
• Crackles (rales).
• Pleural friction rub.
(7) Sings/symptoms of hypoxia:
(a) Apprehension, anxiety, restlessness, decreased LOC;
(b) Decreased ability to concentrate;
(c) Disorientation;
(d) Dyspnea;
(e) Increased fatigue;
(f) Vertigo;
(g) Increased pulse;
(h) Increased rate and depth of respiration;
(i) Elevated blood pressure;
(j) Cardiac dysrhythmias;
(k) Pallor, cyanosis;
(l) Clubbing of the fingers.

3. LAB TESTS
A. Chest radiographs:
(1) Used to visualize the lungs, clavicles, humerus, scapulae, vertebrae, heart, and major thoracic vessels.
(2) Provides information on alterations in size and location of the pulmonary structures.
(3) Identifies the presence of lesions, infiltrates, foreign bodies or fluid.
(4) It can distinguish if a disorder involves the parenchyma or interstitial spaces.
(5) Chest X-ray can confirm pneumothorax, pneumonia, pleural effusion and pulmonary edema.
(6) Patients should be instructed to remove jewelry and wear a hospital gown.

B. Computed Tomography (CT):


(1) Scans the lungs in thin slices, usually to identify pulmonary lesions- views can be diagonal or cross-
sectional.
(2) Painless and non-invasive.
(3) Requires patient teaching to decrease anxiety (esp. with claustrophobic patients).

C. Arterial Blood Gases (ABGs): Essential tool for diagnosing and monitoring patients with
respiratory disorders; Measures the lungs’ ability to exchange oxygen and carbon dioxide and the body’s
acid-base balance.
(1) Normal values:
PH: 7.35-7.45; PaCO2: 35-45 mmHg; PaO2: 80-100 mmHg; HCO-3: 22-26 mEq/l;
SaO2>92%.
(2) Oxygenation: Carried in the bloodstream in two forms; Oxygen dissolved in plasma-expressed as
PaO2; Oxygen combined with hemoglobin-expressed as SaO2 represents the amount of oxygen bound to
hemoglobin.
(3) Ventilation: Respiratory component of the acid-base balance; Responsible for the relationship
between PH and PaCO2. (4) The HCO3- is a measure of the metabolic component of the acid-base balance;
The kidneys will respond to alterations in the PH due to a respiratory condition by wasting or retaining
HCO3-. ABG is performed at the bedside using a heparinized syringe and needle to withdraw 3 to 5
ml from an artery. Allen’s test is performed to check ulnar circulation before a radial artery stick.
After specimen obtained, pressure is held at the puncture site for five minutes. Syringe is capped, labeled,
placed in ice water and sent to the lab for analysis.

D. Pulsoximetry Monitoring: Noninvasive method for continuous monitoring of the SaO2; Allows
the nurse to continually assess for small changes in the respiratory status. Probe emits a beam of infrared
light and measures the amount of light being absorbed by oxygenated and deoxygenated blood and
displays a percentage value. An SaO2 of 90-100% is needed to adequately replenish the oxygen in the
plasma. An SaO2 85% and below shows ability of hemoglobin to feed O2 to plasma weakens. An
SaO2 below 70% is life threatening (low hemoglobin levels). For optimal results—Do not attach
probe to an extremity with diminished circulation; Place probe over pulsating vascular bed; Avoid
excess patient movement to ensure accuracy. Hypothermia, hypotension, vasoconstriction, BP cuff
placement, arterial catheter, sunlight, and movement can affect readings.

E. Sputum Collection: Obtained for microscopic evaluation, i.e. Gram stain culture and sensitivity.
Nursing Interventions: Explain to patient that the sputum must be brought up from the lungs. Collection
should occur before prescribed antibiotics are started, and the best time for collection is the very
first thing in the morning. Collect specimens before meals to avoid possible emesis. Instruct patient
to inhale and exhale deeply three times, inhale swiftly, cough forcefully, and expectorate into the
sterile sputum container. Provide patient with hypertonic saline aerosol mist if unable to raise
sputum spontaneously. Instruct patient to rinse mouth with water before expectorating into sterile
specimen bottle. Instruct patient to notify staff as soon as a specimen is collected. If necessary, obtain
sample through endotracheal suctioning. Sputum Color: clear, white, yellow, green, brown, red, pink-
tinged, streaked with blood; Consistency: frothy, watery, tenacious (adhesive, sticky); Odor: none or
malodorous; Blood: all the time, occasionally, early in the morning.

F. Pulmonary Function Test (PFT):


(1) Performed to assess the presence and severity of disease in the large and small airways; One of
the most important tools for diagnosing respiratory diseases is the capacity for carbon dioxide to be
diffused.
(2) Composed of various procedures to obtain information on lung volume, ventilation, pulmonary
spirometry and gas exchange.
(a) Lung volume or vital capacity (VC) is a measurement of the volume of air that can be completely and
slowly exhaled after maximum inhalation.
(b) Inspiratory capacity (IC) is the largest amount of air that can be inhaled in one breath.
(c) Total lung capacity (TLC) is calculated to determine the volume of air in the lung after maximal
inhalation.
(d) Ventilation tests evaluate the volume of air inhaled or exhaled in each respiratory cycle.
(e) Pulmonary spirometry evaluates the amount of air that can be forcefully exhaled after maximum
inhalation.

G. Mediastinoscopy: (1) Surgical endoscopic procedure to obtain lymph nodes for biopsy for tumor
diagnosis. (2) Performed in the operating room under general anesthesia.
H. Laryngoscopy:
(1) Allows for direct or indirect visualization of larynx.
(a) Indirect most common used for assessment of respiratory difficulties- can be used for biopsy or
polyp removal.
(b) Direct exposes the vocal cords—requires local or general anesthesia.

I. Bronchoscopy:
(1) Bronchoscope is passed into the trachea and bronchi with either a flexible fiber optic bronchoscope
(most commonly used) or a rigid bronchoscope to visualize the larynx, trachea, and bronchi.
(2) Diagnostic examination includes observations of the tracheobronchial tree for:
(a) Abnormalities;
(b) Tissue biopsy;
(c) Secretions for cytological or bacteriological studies.
(3) General anesthetic agents are often used, however the patient may instead receive a local anesthetic in
conjunction with conscious sedation.
(4) Therefore, patient is treated as a surgical patient.
(5) Nursing interventions:
(a) Informed consent must be signed before procedure;
(b) Patient is NPO until gag reflex returns; approximately 2 hours post procedure.
(c) Patient placed in semi-fowlers position and turned to one side to facilitate removal of
secretions.
(d) Patient is monitored for signs of laryngeal edema or spasms (dyspnea or stridor).
(e) If biopsy is taken, sputum is monitored for signs of hemorrhage (blood-tinged sputum can be
expected for several days after biopsy).

J. Cytology studies—Performed on sputum or pleural fluid to detect the presence of abnormal or


malignant cells.

K. Thoracentesis:
(1) Surgical perforation of the chest wall and pleural space with a needle for the aspiration of fluid.
(a) Diagnostic purposes:
1) Examined for specific gravity, WBCs, RBCs, protein and glucose;
2) Cultured for pathogens and checked for abnormal or malignant cells;
3) Gross appearance, quantity drained and location of puncture site should be recorded.
(b) Biopsy of the pleura.
(c) Removal of fluid for patient comfort or well-being (can significantly decrease lung expansion).
(d) Instillation of medication (may be done for an empyema or for a lung that will not stay inflated
after a pneumothorax).
(2) Nursing interventions:
(a) Explain the procedure and obtain informed consent.
(b) Procedure performed at patient's bedside with patient sitting upright leaning over a bedside table or
with patient on side with affected side up and HOB at 30 degrees.
(c) Monitor vital signs, general appearance and respiratory status throughout procedure.
(d) Risk for subsequent pulmonary edema due to fluid shifts if > 1500 ml removed at one time.
(e) Place patient on unaffected side after procedure.
(f) CXR often obtained to rule out pneumothorax after procedure.
4. Oxygen Administration
A. Hypoxia: An inadequate (or a decrease in) oxygen at the tissue (cellular) level.
Signs and symptoms: Anxiety; Decreased O2 concentration; Disorientation; Fatigue; Vertigo; Behavioral
changes; Tachycardia then advances to Bradycardia; Respirations increase, then advance to shallow and
slow breathing; B/P elevates at first, then decreases if not corrected (O2 therapy); Cardiac dysrhythmias;
Pallor, cyanosis; Clubbing of the fingers; and dyspnea.

B. Hypoxemia: An abnormal deficiency of oxygen in the arterial blood (PaO2 <80 mm Hg).
Signs and symptoms: Pallor, cyanosis; dyspnea; anxiety; decreased level of consciousness; restlessness.

C. Cyanosis: A blue discoloration caused by O2 deficiency.


Signs and symptoms: Pallor; Dark skinned individuals may have a grayish skin color.

D. Oxygen Therapy Precautions: No smoking while receiving therapy; Avoid open flames and
smoking areas; Turn off O2 when not in use; Post O2 in use sign; No lighters, matches, candles, wool
blankets or nylon around; Electrical equipment—must be in good working order, use proper grounding
method; Drying of tissue—Without moisture tissue can become cracked and infected; Humidifier;
Bubbles; Oral hygiene; Inspect, Change equipment for deficiencies; Oxygen toxicity in COPD patients:
O2 concentrations above 60%; Monitor patient’s activities.

E. Equipment used for O2 therapy:


Nasal cannula; Simple Mask; Face tent; Ventury Mask; Partial Re-breather Mask; Non Re-breather Mask.

F. Oxygen Administration:
(1) Cannula: Check Orders; Patient condition; Supply @ 4-6 liters; COPD patients @ 2-3 liters (Oxygen
toxicity may occur if administering above 60% of O2 concentrations to COPD patients.); Monitor
patient activity; Risk of necrosis.

(2) Mask: Provide 24%-55% @ 3-7 liters.

(3) Simple mask: Low to medium concentrations >5 L per min.

(4) Partial rebreather: 60-80% concentration, reservoir bag.

(5) Venturi Mask: A special mask for administering a controlled concentration of oxygen to a
patient. Consistent FiO2 is delivered; concentration is listed on mask; accurate supply.

(6) Non-Rebreather Mask: Used in the critically ill patient with severe hypoxemia in an effort to
prevent the need for endotracheal intubation and mechanical ventilation; Delivers an FiO2 of 0.80 to 1.00
at flow rates between 9 and 15 L/min; Provide O 2 concentrations from 60—100%; The
nonrebreather has a valve that prevents exhaled gases and room air from entering the reservoir bag;
Oxygen flow must be high enough to prevent reservoir bag from collapsing; As long as reservoir bag is
partly inflated, CO2 will not accumulate; The purpose of the reservoir is to increase the amount of
oxygen delivered to the patient.

(7) Room air (RA) contains about 21% O2, Exhaled air contains 16% O2 and 3.5% CO2; Normal
respiratory rate: 12—20 bpm.
G. The goals of oxygen administration are to improve and maintain systemic oxygenation:
Increases oxygen saturation levels; Lessens fatigue; Improves cognition and Blood gas; Decreases
irritation. O2 is used to provide cells with energy to carry out metabolism; otherwise rapid cell death will
occur from oxygen starvation.

H. Nursing goals for O2 therapy:


(1) Prevent complications: (a) Dry mucus membranes; (b) Infection; (c) Obstruction. (2) Patient education
increased understanding of and compliance with treatment: (a) Reason for treatment; (b) Safety issues; (c)
Activity restrictions; (d) Stop smoking; (e) Home care.

5. UPPER AIRWAY DISORDERS


A. Nursing Management of Upper Airway Obstruction:
Pathophysiology: Precipitated by recent respiratory event, due to traumatic injury of the surrounding
tissues, dentures, aspirations of vomitus or secretions, and often caused by tongue in an unconscious
patient.
Clinical Manifestations: Stertorous respirations.
Assessment: Subjective: Patient is unable to talk; nurse makes prompt, accurate assessment.
Objective: Signs of hypoxia, cyanosis, stertorous respirations, wheezing, stridor, bradycardia, shallow,
and slow respirations.
Medical Management: Emergency tracheostomy with artificial airways.
Nursing Interventions: Open airway and restore patency;

Heimlich maneuver: A technique for removing a foreign body (obstruction) from the airway
(trachea or pharynx) of a choking victim. The obstruction is usually caused by a bolus of food.
Heimlich maneuver can be used safely on both adults and children, but most experts do not recommend
it for infants less than 1 year old. It can also be self-administered.
Procedure: For a conscious victim who is sitting or standing, position yourself behind the victim and
reach your arms around his or her waist. Place your fist, thumb side in, just above the victim’s navel
and grab the fist tightly with your other hand. Pull your fist abruptly upward and inward to increase
airway pressure behind the obstructing object and force it from the windpipe. The procedure may need
to be repeated several times before the object is dislodged. Briefly, a person performing the Heimlich
maneuver uses their hands to exert pressure on the bottom of the diaphragm. This compresses the lungs
and exerts pressure on any object lodged in the trachea, hopefully expelling it. This amounts to an
artificial cough. (The victim of an obstructed airway, having lost the ability to draw air into the lungs,
has lost the ability to cough on their own.)
Nursing Diagnosis: Airway clearance, ineffective, related to obstruction in airway: Reestablish and
maintain secure airway; Administer oxygen as ordered; Monitor vital signs; Aspiration, risk for partial
airway obstruction; Monitor respiratory rate, rhythm and effort; Prevent patient’s risk for swallowing
secretions by elevating the HOB; Assess and document breath sounds.

B. Epistaxis: Pathophysiology: Bleeding from the nose caused by congestion of the nasal
membranes, leading to capillary rupture; Frequently caused by injury; Occurs more frequently
in men; Either primary or secondary disorder to other conditions; May be related to menstrual
flow in women; or Hypertension. Clinical Manifestations: Presence of bright red blood draining
from one or both nostrils; Can lose up to one liter of blood per hour; May occur from irritation of nasal
mucosa, dryness, chronic infection, and vigorous nose blowing.

Exsanguination (loss of blood to the point at which life can no longer be sustained) from the usual
epistaxis is rare.
Assessment: Subjective data: Interview patient; Identification of precipitating factors.
Objective data: Assess bleeding from one or both nostrils, and bleeding occurring from anterior or
posterior nasal passageway; Assess vital signs and Assess for hypovolemic shock.
Diagnostic Tests: HGB and HCT; Coagulation studies; Rhinoscopy.
Medical Management: Nasal packing with cotton saturated with Epinephrine 1:1000 to promote local
vasoconstriction; Cautery—can be either electrical or chemical; Posterior packing; Or use of a
balloon tamponade may be required. Nursing Interventions: Keep patient quiet; Place in sitting
position, leaning forward; Apply direct pressure to soft portion of nose (that is, pince nose for 10
mins.); Apply ice compresses; Monitor for signs and symptoms. Nursing Diagnosis and Nursing
Interventions: Tissue perfusion, ineffective cerebral and/or cardiopulmonary, related to blood
loss: Assess vital signs and level of consciousness every 15 min and report any changes; Document
estimated blood loss; Aspiration, risk for, related to bleeding; Elevate head of bed; Encourage patient to
let blood drain from the nose; Pinch nostrils, apply ice.

C. Deviated Septum & Nasal Polyps:


Etiology: Caused by congenital abnormality or injury; The septum deviates from midline and causes a
partial obstruction of nasal passageway, which is stertorous; Tissue growths on the nasal tissues, caused
by inflammation; Allergies.
Clinical Manifestations: Stertorous breathing.
Assessment:
Subjective Data: History of previous injuries, infections, allergies; Dyspnea; Objective Data;
Identification and location; Rate and character of respirations.
Diagnostic Tests: Sinus x-rays.
Medical Management: Surgical correction;
Nasoseptoplasty—surgically reconstruct, align, and straighten the nasal septum.
Nursing Interventions/Patient Teaching: Contact physician if bleeding or infections develops;
Caution about use of nasal sprays and drops; Avoid nose blowing, vigorous coughing or Valsalva
maneuver; Ecchymosis and edema will be present for several days; Prevent and monitor closely
for hemorrhage/infection. Nursing Diagnosis and Nursing Interventions: Airway clearance,
ineffective related to nasal exudate: Keep airway patent; Document patient’s ability to clear
secretions; Elevate HOB and apply ice; Injury, risk for, related to trauma to bleeding site associated
with vigorous nose blowing; Instruct patient against blowing nose in immediate postoperative period.

D. Laryngeal Cancer: Cancer of the Larynx.


Pathophysiology: Squamous cell carcinoma; Occur in people over age 60; 90% occur in men, due to
alcohol and tobacco use; Chronic laryngitis; Vocal abuse; Familial history.
Clinical Manifestations: Progressive or persistent hoarseness; Metastasis includes pain in larynx
radiating to ear; Difficulty swallowing; Lump in throat; Enlarged cervical lymph nodes.
Assessment: Subjective data: Assess onset of symptoms; Difficulty breathing or swallowing.
Objective data: Examine sputum for presence of blood.
Diagnostic Tests: Visual examination with direct laryngoscopy with biopsy.
Medical Management: Radiation Therapy; Surgery.
Nursing Interventions and Patient Teaching: Airway patency; Skin integrity; Monitor I&O; Tube
feedings; Daily weight; Psychological concerns with disfigurement.
Nursing Diagnosis and Interventions: Airway clearance, ineffective, related to secretions or
obstruction: Suction secretions; Provide tracheostomy care; Offer small frequent meals; Turn, cough
and deep breathe; Auscultate lung sounds; Communication, impaired verbal, related to removal of
larynx; Provide patient with implements for communication.

E. Rhinitis: Acute coryza or Common Cold.


Pathophysiology: Inflammatory condition of mucous membranes of nose and accessory sinuses;
Usually caused by one or more viruses; May also be complicated by bacterial infection;
Characterized most typically by edema of the nasal mucous membrane.
Clinical Manifestations: Productive cough; Thin serous nasal exudate; Nasal drip (cause throat
irritation); Sore throat; Symptoms may be evident within 24—48 hrs after exposure.
Diagnostic Test: Throat and sputum cultures to determine presence of bacterial infection.
Medical Management: Analgesia; Antipyretics; Cough suppressant and expectorant; Antibiotics.
Nursing Interventions: Goal is to facilitate recovery and prevention of secondary infections. Tell
the patient that viral infection can not be treated with antibiotics.
Nursing Diagnosis: Airway clearance, ineffective, related to nasal exudate: Encourage fluids to
liquefy secretions and aid in their expectoration. Health-seeking behaviors: Illness prevention, related
to preventing exacerbation or spread of infection; Remind patient and family of health maintenance
behaviors to decrease risk of illness; Teach importance of hygiene measures to decrease spread of
infection. Prognosis: Good.

F. Tonsillitis: Pathophysiology: Can be a cause by microorganism group A beta-hemolytic


Streptococcus; Caused by air or foodborne bacterial infection; Most common in school-age children.
Clinical Manifestations: Sore throat; Fever; Chills; Malaise; Enlarged tonsils with purulent exudate.
Nursing Intervention: Goal is to facilitate recovery and prevent secondary infections. Nursing
Diagnosis and Interventions: Pain, related to inflammation or irritation of throat: Assess degree
of pain and need for analgesics; Maintain bedrest; Offer warm saline gargles, ice chips and ice
collar. Fluid volume, deficit, risk for, related to inability to maintain usual oral intake because of
painful swallowing: Assess hydration status by noting mucous membranes, skin turgor, and urine
output; Aspiration, risk for related to postoperative bleeding; Maintain patent airway; Observe for
vomiting of dark brown fluid; Watch for frequent swallowing because it may be due to bleeding
that is not seen.
Prognosis: Self limiting; Complications can occur.

G. Pharyngitis:
Pathophysiology: Either Acute or Chronic; Most common throat inflammation; Viral in origin; Severe
form known as strep throat.
Clinical Manifestations: Dry cough; Tender tonsils; Erythematous.
Diagnostic tests: Throat cultures.
Medical Management: Antibiotic therapy; Analgesics/Antipyretics.
Nursing Interventions and Patient Teaching: Nursing Diagnosis: Oral Mucous membrane, impaired,
related to edema: Provide warm saline gargles; Assess level of pain and offer medications; Offer
frequent oral care. Fluid volume, deficient, risk for, related to decreased oral intake: Observe and record
patient’s hydration status; Monitor I&O.
Prognosis: Symptoms resolve in 4-6 days.

H. Sinusitis:
Pathophysiology: Chronic or acute; Maxillary or frontal; Viral or bacterial; Often a complication
from pneumonia or nasal polyps; Usually begins with URI that leads to a sinus infection.
Clinical Manifestations: Constant severe headache; Pain and tenderness in affected area; Purulent
exudate. Diagnostic tests: Sinus x-rays; Transillumination.
Medical Management: Nasal windows or opening in sinus to facilitate drainage; Caldwell-Luc
operation to remove diseased tissue.
Medications: There is no treatment for viral infection; treat only for symptoms. Use
antibiotics for the treatment of bacterial infection; Analgesics—relieve fever and
pain/discomfort; Antihistamines—reduce congestion; Vasoconstrictors—reduce vascular congestion;
Warm moist heat—to promote drainage and provide comfort.
Nursing Diagnosis:
(1) Breathing pattern, ineffective, related to nasal congestion: Assess respiratory status
frequently; Mouth breathing may be necessary.
(2) Pain, related to sinus congestion: Document comfort level; Assess need for pain medication;
Elevate HOB to promote drainage; Apply warm moist packs 4 times/day.
Prognosis: Uncomplicated sinusitis has good prognosis; Spread of infection is possible.

I. Laryngitis:
Pathophysiology: Secondary to other respiratory disorders; Accompanies viral or bacterial infections;
Excessive use of voice; Inhalation of irritating fumes; Cause severe respiratory distress in children.
Clinical Manifestations: Hoarseness of varying degrees; Scratchy and irritated throat; Persistent
cough.
Diagnostic test: Laryngoscopy. Medical Management: If viral, no antibiotics; Comfort measures to
reduce coughing and decrease irritation; If cause is bacterial, antibiotic therapy.
Nursing Interventions and Patient Teaching:Nursing Diagnosis: Pain, related to throat irritation:
Assess level of pain, and offer medications to promote comfort.
Communication, impaired verbal, related to edematous vocal cord: Instruct patient on the
importance of resting the voice; Provide other means for communication; Anticipate needs.
Prognosis: Good for adults; Respiratory distress for children.

J. Adenoiditis: Pathophysiology: Inflammation of lymphatic tissue; Secondary to other airway


infections; Results in acute or chronic ear infections.
Signs/Symptoms: Sore throat; Pain with swallowing; Fever; Malaise; Noisy breathing.
Diagnostic findings: Enlarged reddened tonsils with patchy exudate; Throat culture and sensitivity for
causative microorganism.
Medical Management: Antibiotics; Analgesics; Surgery.
Nursing Diagnosis and Patient Teaching: Risk for aspiration, related to loss of gag reflex secondary
to anesthesia: Position on side; Elevate HOB 45 degrees; Monitor RR every hour; Auscultate breath
sounds every hour. Risk for trauma to tissues related to injury to the suture line: Monitor bloody
drainage from patient’s mouth or frequent swallowing; Instruct patient not to cough, clear
throat, blow nose, or use a straw in the first few postoperation days; Encourage carbonated fluids
and fluids high in citrus content; Add soft food after 24 hours postoperation. Pain related to
surgical incision in the throat: Administer analgesics liberally; Apply ice collar; Encourage to
gently gargle with warm saline.
Patient teaching: Report any signs of bleeding to physician immediately; Avoid spicy and rough
textured foods and milk products. Prognosis: Good.

K. Peritonsillar Abscess: Pathophysiology: Abscess develops in connective tissue. Result of


severe tonsillar infection either staphylococcal or streptococcal.
Signs/Symptoms: Difficulty and pain with swallowing; Fever, malaise; Ear pain and difficulty talking.
Medical Treatment: Penicillin injection; Surgical drainage.
Nursing Management: Patient should be placed in semi-fowler’s position; Ice collar; Observe for
respiratory distress and excessive bleeding; Encourage fluids.

6. Lower Airway Disorders


A. Bronchitis:
Pathophysiology: Secondary to an upper respiratory infection; Exposure to inhaled irritants;
Inflammation of the mucous membranes of the major bronchi and their branches.
Clinical Manifestations: Productive cough; Low grade fever; Diffuse rhonchi/wheezes, dyspnea;
Chest pain; Generalized malaise, and headache.
Assessment: Question patient regarding health and presence of headache, and/or aching chest pain;
Vital signs.
Diagnostic Test: Chest x-ray; Sputum culture.
Medical Management: Bronchodilators; Antibiotics; Cough suppressants; Antipyretics.
Nursing Interventions: The goal of nursing interventions is to facilitate recovery and prevent
secondary infections.
Nursing Diagnosis:
(1) Infection, risk for, related to retained pulmonary secretions.
Nursing Interventions: Assess for signs of infection; Administer antibiotics; Frequent vital signs;
Encourage adequate PO intake.
Nursing Diagnosis:
(2) Airway clearance, ineffective, related to tenacious pulmonary secretions.
Nursing Interventions: Bed rest; Humidifier; Encourage increased fluid intake; Teach/assess
understanding signs that may indicate worsening infection; Teach/assess understanding
importance of prescribed medication regimen; Teach/asses understanding of importance of
limiting exposure to others; Teach patient to avoid smoking or other irritating fumes.

B. Legionnaires’ Disease:
Pathophysiology: Caused by the microorganism Legionella pneumophila (A gram-negative
bacillus not previously recognized as an agent of human disease; This organism thrives in water
reservoirs, such as in air conditioners and humidifiers), and Gram-negative bacillus;
Transmitted by airborne routes. First identified in 1976 when it caused a pneumonia outbreak at a
convention of American Legion in Philadelphia, Pennsylvania. The Legionella microbe can progress
in two different forms: influenza or Legionnaires’ disease. The later characteristically results in life-
threatening pneumonia. This pneumonia causes lung consolidation and alveolar necrosis. The
disease progress rapidly (less than a week) and can result in respiratory failure, renal failure,
bacteremic shock, and ultimately death.
Clinical Manifestations: Elevated temperature; Headache; Nonproductive cough; Diarrhea; General
malaise. Assessment: Note patient’s complaints of dyspnea, headache, and chest pain on
inspiration; Elevated Temperature (102—105)0F; Nonproductive cough with tachypnea;
Auscultation will reveal crackles and wheezing; Signs of shock; Presence of hematuria indicating
renal failure. Diagnostic Tests: Cultures of blood, sputum, and pulmonary tissue; Chest x-ray.
Medical Management: Observation for disease progression; Mechanical ventilation; IV therapy.
Medications: Antibiotics (erythromycin); Rifampin; Antipyretics; Vasopressors (dopamine) and
analgesics to treat shock signs and promote comfort.
Nursing Diagnosis:
(1) Tissue perfusion, ineffective cardiopulmonary or renal, related to lack of oxygen.
Nursing Interventions: Monitor and report any S/S of impending shock; Administer vasopressors and
closely monitor vital signs; Maintain hydration and urinary output (30ml/hr); Assess for changes in
level of consciousness.
Nursing Diagnosis:
(2) Breathing pattern, ineffective, related to respiratory failure.
Nursing Interventions: Asses for S/S of respiratory failure; Be alert for cyanosis and dyspnea; Assist
with oxygen therapy or mechanical ventilation; Facilitate optimal ventilation-place patient in semi-
fowlers, suction as needed; Have patient Cough and Deep Breathe every 2 hours.
Prognosis: Poor prognosis, highly communicable disease, patient ultimately die.
C. Anthrax: Pathophysiology: Caused by the spore-forming bacterium Bacillus anthracis;
Anthrax most commonly infects wild and domestic hoofed animals; Spread through direct contact with
bacteria and its spores; It is not contagious by person-to-person.
Three types of anthrax: Cutaneous; Gastrointestinal; and Inhalation.

Clinical Manifestations: Symptoms of inhalational anthrax resemble those of the common cold
or influenza; Hemorrhage, tissue necrosis, and lymph edema; Death usually results from blood
loss and shock.
Diagnostic Test: Chest x-ray; Pneumonia reveals infiltrates.
Medical Management: Antibiotic therapy; Ciprofloxacin (For both children and adults, Cipro has
been considered the treatment of choice for all three form of anthrax because of concerns that
genetically engineered anthrax strains might resist older antibiotics. However, most anthrax
strains are susceptible to many other antibiotics, including penicillin and
doxycycline/Vibramycin.); Anthrax vaccine.

D. Tuberculosis (TB): Pathophysiology: Chronic infectious disease; Acquired by inhalation;


Most commonly, affects the lungs; Results in inflammatory infiltrations; Characterized by stages of
early infection (frequently asymptomatic), latency, and a potential for recurrent postprimary disease.
Tuberculosis infection is different from tuberculosis disease. TB infection vs. TB disease:
Infection always precedes the development of active disease. Only about 10% of infections
progress to active disease. Tuberculosis infection is characterized by the presence of
mycobacteria in the tissue of a host who is free of clinical signs and symptoms and who
demonstrates the presence of antibodies against the mycobacteria. Most people exposed to TB do
not become infected. Those who are infected but do not progresses to the active disease stage will
have a positive skin test and a negative chest x-ray, and remain asymptomatic and noninfectious.
These people still remain a life-long risk of developing reactivation TB if the immune system is
compromised.
TB disease (Active TB) is manifested by destructive activity of mycobacteria in host tissue;
Progression is rapid; 4 to 16 weeks from diagnosis to death; Mortality rates: 72%--89%.
Transmission of tuberculosis is primarily by inhalation of minute dried-droplet nuclei (each
containing a single tubercle bacillus) coughed or sneezed by a person whose sputum contains
virulent tubercle bacilli. Tubercle bacilli can survive more than 50 yrs; They are reactive when
immune system is compromised. Predisposing Factors/High-risk groups: Family history of TB;
Low income populations; Immunosuppression (especially HIV positive); Increased risk of developing
active TB after an infectious disease; Diabetes; Chronic renal failure; Underweight; Prolonged use of
corticosteroids; Residents of long-term care facilities, nursing homes, prisons, mental institutions,
homeless shelters, and other congregate housing settings; Alcoholics, IV drug users, cocaine and crack
users; Health care workers; Previous epidemic in the western world; Today 10 to 15 million
Americans are infected; 7.4 cases per 100,00 in 1997; Incidence of US-born active TB is decreasing,
but foreign-born US residents has increased 65% since 1985. Clinical Manifestations: The clinical
manifestations are insidious (subtle). Generally there is fever, weight loss, weakness, and a
productive cough. Later in the disease, daily recurring fever with chills, night sweats, and
hemoptysis is seen. Assessment: Note reports of loss of muscle strength and weight loss; Report
characteristics of sputum (amount, color).
Diagnostic Test: Mantoux tuberculin skin test; Performed within 2 to 10 weeks of exposure; Read 48-
72 hours later; A negative reaction is < 5 mm; Sputum culture-acid fast bacillus (AFB) will be done
to confirm the diagnosis of active TB; Sputum test will be done for three consecutive days. Chest
x-ray; All patients with TB must be reported to the appropriate public health authority. Medical
Management: Adult patients need respiratory isolation; Requires negative pressure room; Must wear
particulate matter mask when in patient’s room; Infants and children do not generally require
isolation. Medications: Isoniazid (INH); Rifampin; Requires 6-9 months’ minimum drug
treatment, often longer to arrest disease; 50% of patients do not complete treatment; Organisms
are resistant to many drugs; worse in the patient with HIV positive.
Nursing Interventions: Air droplet caution; Isolation measures; Negative pressure room; room air is
vented directly to the outside; Use of particulate matter mask (M-95/HEPA respirator); Focus on
preventing complications and illness transmission.
Nursing Diagnosis: (1) Breathing pattern, ineffective, related to pulmonary infection process.
Nursing Interventions: Monitor breathing; Evaluate respiratory effort; Assess sputum for
hemoptysis; Assist patient in Turning Coughing and Deep Breathing.
Nursing Diagnosis: (2) Infection, risk for (patient contacts), related to viable M tuberculosis in
respiratory secretions.
Nursing Interventions: Collection of sputum; Cover nose and mouth when coughing or sneezing;
Use AFB isolation; Administer anti-tuberculosis; Instruct on proper hand washing; Teach/assess
understanding of the importance to report hemoptysis, dyspnea, vertigo or chest pain.
Prognosis: As many as 50% of patients fail to complete treatment; Drug-resistant strains.

E. Pneumonia: Pathophysiology: An inflammation of the alveoli, interstitial tissue, and


bronchioles of the lungs due to infection by bacteria, viruses, or other pathogenic organisms, or
to irritation by chemicals or other agents (e.g., oil, radiation, drugs). Most common in winter
and spring; Most common in infants and the elderly; Susceptible patients: Persons with damaged
or altered respiratory defense mechanisms; Disease affecting antibody response; Alcoholics; Delayed
WBC reaction to infection; Mode of transmission dependant on infecting organisms; Classified based
on organisms. Causes: Bacterial pneumonia; Aspiration pneumonia; Viral pneumonia; Fungal; or
Chemical.

(a) Aspiration Pneumonia: Frequently called necrotizing pneumonia because of the


pathological changes in the lungs. Aspiration pneumonia occurs most commonly as a result of
aspiration of vomitus when the patient is in an altered state of consciousness due to a seizure,
drugs, alcohol, anesthesia, acute infection or shock. Aspiration pneumonia may be acquired
through foreign body aspiration or may follow aspiration of toxic materials such as gasoline or
kerosene. The causative agents of bacterial aspiration pneumonia include S. aureus, E. Coli,
Klebsiella pneumoniae, pseudomonas aeruginosa, and Proteus species. Aspiration pneumonia
presents with various physiological responses depending upon the PH of the aspirated substance.
Overview of pathophysiology: Pulmonary cillia cannot remove secretions; Retained secretions
become infected; Inflammation; Edema leads to decreased oxygen-carbon dioxide exchange.
Clinical manifestations: Sudden onset of pleurisy; Severe chills; Elevated temperature and night
sweats; Painful productive cough; Increased heart rate; Tachypnea with difficult expiration. A
productive cough is very common; color and consistency of sputum will vary depending on the type of
pneumonia present. Assessment:
Subjective: Description of onset, duration, and history of cough; Complaints of fever and night
sweats.
Objective: Level of consciousness; Vital signs; Monitor sputum; Observe respiratory effort; Crackles.
Diagnostic tests: Patient history and physical exam; Blood and sputum cultures; Chest X-ray; CBC;
PFT; ABG; Oximetry.
Medical management: Antibiotic therapy; O2 therapy; Analgesics and antipyretics; Expectorants;
Bronchodilators; Humidification; Physiotherapy; Vaccine.
Nursing diagnoses: Breathing pattern ineffective, related to the inflammatory process.
Nursing interventions: Assess ventilation to include respiratory effort and signs of respiratory
distress; Elevate HOB; Auscultate breath sounds; Instruct patient on the importance of consuming
large quantities of fluid; Encourage patient to conserve energy; Administer antibiotics; Encourage
deep breathing and coughing; Gas exchange impaired, related to alveolar-capillary membrane changes
secondary to inflammation; Assess patient to identify signs of hypoxia; Analgesics for pain; Monitor
color, pulse, temperature, respiratory rate, and pulse oximetry; Administer oxygen if ordered to
maintain oxygen saturation above 91%.
Patient teaching: Instruct/assess patient understanding of importance of hand washing and proper
sputum disposal; Instruct/assess understanding of the availability of a vaccine; Instruct/assess
understanding of when patient should return to see physician.
Prognosis: Usually resolves within 2-3 weeks with proper treatment; Major cause of disease and death
in critically ill patients; Most common cause of death in North America; Bacterial aspiration
pneumonia carries a poor prognosis.

(b) Older adult considerations: Changes of aging; Drier mucous membranes; Kyphosis; Weak
intercostal muscles and diaphragm; Less elasticity of airways; Inactivity and immobility; Trouble
expectorating; Neurologic changes; Signs and symptoms are atypical (absent); Yearly TB screening;
Watch older immigrants and immunosuppressed patients; Years of exposure to pollution and smoke;
Hydration to liquefy secretions and promote expectoration; Deep breathing and coughing may be
difficult, therefore suctioning may be needed.
S&S: Fever, cough, and chills; Sputum may be absent; Lethargy; Disorientation; Dyspnea;
Tachypnea; Chest pain; Vomiting; Strokes; Parkinson’s disease; Left/right side heart failure; Increased
risk for pneumonia.

F. Pleurisy: Pathophysiology: Inflammation of visceral and parietal pleura; May be caused by


bacteria; Tuberculosis; Pleural trauma; Pulmonary infarction; Lung cancer; Viral infections of
intercostal muscles. Clinical manifestation: Sharp inspiratory pain radiates to shoulder,
abdomen or the affected side (first sign); Fever and dry cough; Dyspnea; Elevated temperature.
Assessment: Complaint of chest pain on inspiration and possibly elevated temperature; Assess
inspiratory points; On auscultation, the nurse will hear pleural friction rub; Vital signs;
Respiratory rate and rhythm. Diagnostic Tests: Pleural friction rub may be considered diagnostic;
Chest x-ray.
Medical Management: Medications: Analgesics; Antibiotics; Oxygen.
Nursing Diagnosis: (1) Pain, related to stretching of pulmonary pleura as a result of fluid
accumulation.
Nursing Interventions: Assess for pain; Medications; Comfort measures; Lying on the affected side.
Nursing Diagnosis: (2) Gas exchange, impaired, related to pain on inspiration and expiration.
Nursing Interventions: Cough and deep breathing; Heat; Elevate head of bed and reposition.

G. Pleural Effusion/Empyema: Etiology: Accumulation of pus/fluid in a body cavity,


especially the pleural space, as a result of infection. It occurs when the physiologic pressure in the lung
and pleurae is disturbed. When the fluid is infected, it is called empyema.
Clinical Manifestations: Persistent fever despite antibiotics. Assessment: Assess patient’s dyspnea;
Assess fear and anxiety related to decreased level of oxygen; Assess for signs and symptoms; Nasal
flaring; Tachypnea; Dyspnea; Decreased breath sounds; Vital signs.
Diagnostic Tests: CXR; Thoracentesis.
Medical Management: Thoracentesis; Chest tube placement.
Nursing Diagnosis: (1) Gas exchange, impaired, related to ineffective breathing pattern.
Nursing Interventions: Asses for change in LOC; Monitor ABG and pulse oximetry; Encourage
cough; and reposition.
Nursing Diagnosis: (2) Self-care, deficit, related to mobility restriction.
Nursing Interventions: Patient’s ability to care for self; Encourage increased level of activity.
Prognosis: Depending on the patient’s overall health status; Indications; Inserted for continuous
drainage and medication instillatioon; Closed system; Normal interpleural pressure is below
atmospheric pressure; Closed drainage system are placed in the pleural cavity; The anterior chest tube;
Posterior chest tube; Two or three glass bottle.
H. Chest Tube Drainage Management: Chest tube is inserted for continuous drainage and
medication instillation; saturated into place and covered with a sterile dressing. To prevent lung from
collapsing, a closed system is used, which maintains the negative pressure in the lung.
Nursing interventions and patient teaching: Bed rest; Patency of chest tubes; Proper system
function; Potential atelectasis; Increased air in the pleural space; Infection; Position patient on
unaffected side; Ambulation; Teach patient how to use incentive spirometry; Facilitate cough, and
deep breathing exercise q2hr; Auscultate breath sounds frequently; Document amount and
characteristics of fluid every shift; Keep tubing straight and coiled loosely and never place
tubing over side rails; Carefully position drainage system; Keep water sealed bottle below chest
level so it does not drain back into chest.

i. Atelectasis: An abnormal condition characterized by the collapse of lung tissues, preventing


the respiratory exchange of carbon dioxide and oxygen.
Pathophysiology: Small area or larger areas of the lung is collapsed preventing the exchange CO2 and
O2 (internal respiration); Occurs from air blockage to a portion of the lung. Atelectasis is a common
postoperative complication resulting from shallow breathing. Causes: All or part of the lung
collapses, usually as a result of hypoventilation (an abnormal condition of the respiratory system
that occurs when the volume of air that enters the alveoli and takes part in gas exchange is not
adequate for the metabolic needs of the body), which then leads to bronchial obstruction caused by
mucous accumulation. Other causes: shallow breathing; prolonged bed rest and hypoventilation;
Aspiration of food or vomitus; Compression in lung tissue by tumors; Stasis of pneumonia.
Clinical Manifestations: Dyspnea, tachypnea (an abnormally rapid rate of breathing); Pleural
friction; Restlessness; Hypertension and Elevated temperature (Fever).
Assessment: Patient complaints of shortness of breath, air hunger, anxiety, and fatigue. Assess
for altered lever of consciousness (caused by hypoxia); Decreased breath sounds and crackles;
Hypertension followed by hypotension; Monitor respiratory rate and effort.
Diagnostic Tests: Bronchoscopy; Chest x-ray; ABGs.
Medical Management: Chest tube insertion; Deep breathing and coughing; Intubation;
Bronchodilators (Proventil); Mucolytic agents (acetylcysteine).
Nursing Diagnosis:
(1) Airway clearance, ineffective, related to inability to clear secretions.
Nursing Interventions: Humidifying air and bronchodilators; Incentive spirometry, deep breathing
and coughing; Intermittent positive pressure breathing (IPPB) may be ordered; Change positions every
2 hours; Hydration; Early ambulation; Assess sputum; Chest physiotherapy with postural drainage will
be administered; May require sectioning; Saline lavage often helps loosen secretions for easier
removal.
(2) Coping, ineffective, related to invasive medical regimen: Patient’s emotional support system;
and patient’s ability to comply.

7. Acute Respiratory Disorder


A. Pneumothorax: Pathophysiology: Accumulation of air or gas in the pleural space, causing
the lung to collapse and interrupting normal negative pressure in the lung.
Causes: Chest trauma; Ruptured bleb; Pleural lining injury; Spontaneous; Interrupts the
normal negative pressure, keeping the lung from remaining inflated.
Tension pneumothorax: Build up of air in the pleural space (Air escapes into pleural cavity
from bronchus and collapses lung tissue), causing interference with the ability of the heart and
lungs to fill; A life threatening condition.
Clinical Manifestations: Patient may present with a recent chest injury; Decreased breath sounds on
affected side; Sharp pleuritic pain, dyspnea; Diaphoresis, tachycardia; Tachypnea; Abnormal chest
movement; Possible sucking chest wound on inspiration; Shifting of mediastinum; Hypotension;
Hypoxia. Assessment: Inquire to a recent injury or coughing episode; May c/o shortness of breath,
anxiety, hypoxia; Breath sounds unequal, or diminished; Penetrating or blunt wounds to the
chest, unequal movement with flail segments (paradoxical movement of the chest); Assess
respiratory and cardiac, rate and rhythm; Monitor vital signs frequently; Note color characteristics, and
amount of sputum.
Diagnostic tests: Patient’s history of recent chest injury or a precipitating respiratory condition,
such as COPD; Chest x-ray; Changes in ABGs (decreased PH and PaO2; increased PaCO2.)
Medical management: Heimlich Valve (A stopgap measure until chest tube therapy can be
started. The valve attaches to chest tube and is inserted into the chest. As the patient exhales, air
and fluid drain through the valve into a plastic bag. When the patient inhales, the flexible tubing
in the valve collapses, preventing secretions and air from entering the pleura.); Needle
thoracotomy (Insertion of chest tube in the 5th/6th intercostal spaces at the midaxillary line;
The chest tube is attached to a water-seal drainage system. Intermittent positive pressure may be
administered.). Emergency aspiration of air from the pleural cavity is necessary, if untreated
lung will collapse and make a mediastinal shift interfering with heart and lungs normal
functions.
Nursing diagnoses: Breathing pattern ineffective r/t nonfunctioning lung; Fear related to feeling of
air hunger.
Nursing interventions: Maintain airway patency and oxygenation; Assess and document patency of
chest tube; Provide analgesics; Assist with coughing and deep breathing; Splint or support; Observe
for color amount of drainage; Assess integrity of drainage system; Put patient on high fowlers;
Increase fluid intake; Avoid fatigue; Report signs and symptoms of recurrence.

B. Lung Cancer: Pathophysiology: Leading cause of cancer related death in men and women;
Causes 34% of cancer deaths in men. Accounts for 28% of all cancer deaths; 80-90% r/t
cigarettes; Second hand smoking (“Passive smoking”—breathing in sidestream smoke);
Tumors; Asbestos and air pollution. A history of smoking, especially for 20 years o more, is
considered to be a prime risk factor.
Types of lung cancer:
Small cell; Non-small cell;
Squamous cell carcinoma;
Large cell.
Clinical manifestations: Peripheral lesions (pleural effusion, severe pain); Central lesions
(hemoptysis, dyspnea, wheezing, fever and chills); as the disease progresses, metastasis may
occur, along with weight loss. Primary lung tumors usually metastasize to the liver or to nearby
structures, such as the esophagus, heart pericardium, skeletal bone, and brain.
Assessment/symptoms: Chronic hoarseness; Chronic cough; History of smoking or environmental
exposure; Weight loss; Extreme fatigue; Hemoptysis; Shortness of breath, wheeze; Pleural effusion;
Invasion of the superior vena cava causes edema of the neck and face (which is called superior
vena cava syndrome); Friction rub; Clubbing of fingers; Pericardial effusion. Assess the cough,
noting color (especially blood streaked) and consistency of sputum, as well as frequency, duration and
precipitating factors.
Diagnostic tests: Chest X-Ray; CT; MRI; Bronchoscopy; Needle aspiration; Biopsy;
Mediastinoscopy; Scalene lymph node biopsy.
Medical management: Depends on type and stage of lung cancer; Unfortunately most patient are not
diagnosed early enough for curative surgical intervention. It is estimated that 1/3 of the patients are
inoperable when first diagnosed; Another 1/3 found to be inoperable during exploratory
thoracotomy; Of the third who are operable, the surgical mortality is 10% for
Pneumonectomy and 2% to 3% for Lobectomy. A Pneumonectomy is the most common surgical
treatment.
Surgical treatment: A Lobectomy (removal of a lobe) is performed when one lobe is involved rather
than the entire lung. If only a portion of a lobe of a lung is involved, a segmental resection (portion of
a lobe is resected) is done. Both Lobectomy and segmental resection require chest tube insertion
with water-seal drainage to facilitate lung reexpansion. Other treatments include pneumonectomy
(removal of the entire lung—most common); Video assisted thorascopic surgery; Radiation and
chemotherapy are often done in conjunction with surgery to enhance recovery. In the small cell
cancer of the lung (SCLC), chemotherapy alone or combined with radiation has largely replaced
surgery as a treatment of choice because regardless of staging, SCLC is considered to be
metastatic at diagnosis. Nursing interventions: Directed at improving quality of life.
General nursing measures: Monitor antineoplastic side effects; Reduce exertion; Maintain body
weight; Relieve pain, administer analgesics; Encourage patient to stop smoking; Refer to American
Cancer Society resources; For weight loss—maintain a high-protein, high-calorie diet.
Nursing diagnosis and interventions: Airway clearance ineffective r/t lung surgery; Facilitate
optimal breathing; Encourage ambulation; Position changes; Cough deep breathe; Assess breath
sounds; Fear r/t cancer treatment and prognosis; Explain treatments and procedures; Listen to the
patient, accept feelings of anger; Encourage verbalization of feelings; Supportive services; Monitor for
signs and symptoms of worthlessness, anxiety, powerlessness.
Prognosis: 13% live 5 years or longer. Survival rate: 40% for cancers identified in local stage.

C. Pulmonary Edema: Pathophysiology: Accumulation of serous fluid in interstitial lung


tissue and alveoli; Results from severe left ventricular failure that causes pooling and fluid back
up into left atrium and then into pulmonary veins and capillaries; Inhalation of irritating gases;
Rapid administration of I.V. fluids (fluid overload); Barbiturate and opiate overdose; Serous
fluid forced into alveoli; Gas diffusion severely affected; Can lead to death if untreated. Clinical
manifestations: Dyspnea; Tachypnea; Tachycardia; Hypoxia, cyanosis; Pink (blood tinged)
frothy sputum; Restlessness, agitation; Labored breathing; weight gain. Assessment: Note c/o
dyspnea; May express feelings of impending doom (death); Assess for signs and symptoms of
respiratory distress; Wheezing and crackles; Decreased urinary output; Productive cough with
frothy pink sputum.
Diagnostic tests: CXR; ABG; Oxygen therapy.
Medications: Lasix; Morphine sulfate; Nipride (nitroprusside): vasodilator—drug of choice for
pulmonary edema; and Digoxin.
Nursing interventions: Assess respiratory status frequently; O2 therapy; Volume status; Patient
teaching.

D. Pulmonary Embolus: A foreign substance (blood clot, fat, air, amniotic fluid), which
causes an obstruction of blood supply to lung tissue. Clinical manifestations: Chest pain;
Dyspnea; Tachypnea; Hemoptysis; Diminished lung sounds; Elevated temperature; Hypotension;
Regional bronchoconstriction, Atelectasis; Pulmonary edema, decreased surfactant.
Assessment: Note degree of dyspnea and chest pain; Identify risk factors.
Observe for: Pleuritic chest pain; Nature of cough; Tachypnea, tachycardia, hypotension; Crackles,
decreased breathe sounds; Pleural friction rub, anxiety, air hunger.
Diagnostic tests: ABG’s; CXR; CT angiogram; V/Q scan; Pulmonary arteriogram (the “gold
standard” for detecting PE because it provides direct anatomical view of the pulmonary vessels
to assess perfusion defects); D-dimer serum test ( D-dimer is a product of fibrin degradation.
When a thrombus or embolus is present, plasma D-dimer concentrations are usually greater
than 1591 ng/ml. The normal range for D-dimer is 68 to 494 ng/ml); Venous ultrasound.
Medications: Anticoagulants; Thrombolytics; Filter device—green filter (a umbrella filter may be
placed in the inferior vena cava to retain the emboli, preventing their migration to other parts of
the body.); Embolectomy.
Nursing interventions: Apply TED hose and elevate the lower extremities; Assess
sensorium and vital signs every 2 hours; Elevate head of bed 30 degrees to improve ventilation;
Check peripheral pulses and measure calf circumference to check for occlusion from a clot;
Administer O2; Promote cough and deep breathing; Monitor cardiorespiratory status; DVT
treatment; Assess for signs of bleeding from anticoagulant therapy (specially gums—use sponge
tip); For shaving use electric razors. Prognosis: 30% mortality rate if untreated; 5% mortality with
early diagnosis and treatment.

E. ARDS (Adult Respiratory Distress Syndrome): ARDS is not a disease but a


complication from another disease; There are many different causes of ARDS, which results from
either a direct or indirect pulmonary injury. Pathophysiology: Also called non-cardiogenic
pulmonary edema; Secondary to an acute disease process, a syndrome of pulmonary shunting,
hypoxemia, reduced lung compliance and parenchymal lung damage.
Causes: Viral or bacterial Pneumonia; Chest trauma; Aspiration; Inhalation injury; Near drowning;
Fat emboli; Sepsis (most common); Shock; Drug overdoses, Renal failure, Pancreatitis. Regardless of
the cause of ARDS, there is a certain sequela of events in the body’s response that remain the same.
The surface of the alveolar capillary membrane becomes altered, causing increased permeability,
which then allows fluid to leak into the interstitial spaces and alveoli; Results in pulmonary edema and
hypoxia; The alveoli lose elasticity and collapse, which causes the blood to be shunted trough the
impaired alveoli, hence interfering with oxygen transport. The damaged capillaries allow plasma and
red blood cells to leak out, resulting in hemorrhage. ARDS is characterized by pulmonary artery
hypertension, which results from vasoconstriction.
Clinical manifestations: Usually manifests in 12-24 hours after injury/post surgery; Resulting in
lung tissue damage or hypovolemic shock; Sepsis development after 5-10 days, the patient will
experience respiratory distress with altered breath sounds; There may be altered sensorium as a
result of an elevated PaCO2 and decreased PaO2; Tachycardia; hypotension, and decreased
urinary output. Assessment: Obtain background information; Observe changes in patient’s
condition; Assess respiratory rate rhythm and effort; Assess for nasal flaring, retractions, or cyanosis;
Assess for crackles and wheezing; Assess level of consciousness.
Diagnostic tests: Pulmonary functions tests will be done to determine the ease or difficulty of
oxygen in crossing the alveolar capillary membrane; ABGs will show definitive changes: the PaO2
will be decreased (less than 70 mm Hg), the PaCO2 will be increased (greater than 35 mm Hg), and the
bicarbonate ion (HCO3-) will be decreased (less than 22 mEq/L); CXR will depict thickened bronchial
margins and possibly diffuse infiltrates.
Medical management: Focuses on supportive treatment by maintaining adequate oxygenation and
treating the primary diagnosis (cause).
Medications: Diuretics; Morphine sulfate; Digoxin; Antibiotics; Ventilatory support; Nitric oxide.
Nursing interventions and patient teaching: Provide adequate oxygenation and ventilation and
treat multi-system response to ARDS; Monitor respiratory status; Assess vital signs; Position
patient to facilitate optimal ventilation; Turn, cough and deep breath; 10 breaths above baseline
indicates activity intolerance. Monitor use of accessory muscles, pursed lips, nasal flaring;
Organized care for rest period; ROM exercises; Daily weight at same time, same scale; Monitor I&O
and electrolytes; Suction as needed (note amount, color, and characteristics of secretions).
Nursing diagnoses:
(1) Gas exchange impaired r/t tachypnea. Nursing interventions: Administer oxygen; Monitor for
restlessness; Monitor ABG’s and ECG changes; Report changes in v/s, ABGs and L.O.C.
(2) Breathing pattern, ineffective r/t respiratory distress. Nursing interventions: Assess respiratory
rate rhythm and effort; Proper positioning; Maintain airway patency and promote Cough and Deep
Breathing.

8. Chronic Obstructive Pulmonary Disease (COPD)


A. COPD:
a. Etiology:
(1) Characterized by a recurrent chronic productive cough for a minimum of three months for at
least two years.
(2) Caused by physical or chemical irritants or bacterial or viral infection.
(3) Smoking is the most common cause of bronchitis.
(4) The cilia are impaired and can no longer move secretions- mucous gland hypertrophy causes
hypersecretion of mucous causing the ciliary dysfunction.
(5) Results in an increased susceptibility to infection.
(6) Chronic infection leads to scarring which causes obstruction.
(7) Chronic obstruction of air to/from bronchioles leads to increased airway resistance and bronchospasm.
(8) Results in hypoxia and hypercapnia.
(9) Examples of COPD: Emphysema, Chronic bronchitis, Asthma, and Bronchiectasis.

b. Clinical Manifestations:
(1) Primary sign is productive cough which is most pronounced in the morning.
(2) Dyspnea and use of accessory muscles.
(3) Later signs include cyanosis and right ventricle failure (cor pulmonale).
(4) Many patients exhibit characteristic reddish-blue skin resulting from polycythemia, cyanosis and
dependent edema (from right heart failure).

c. Assessment:
(1) Subjective:
(a) Focused on detailed smoking history exposure to irritants.
(b) Identify family history of respiratory disease.
(c) Determine patient's disease progression and current treatment regimen.
(2) Objective:
(a) Assess cough, including characteristics and amount of sputum.
(b) Assess severity of dyspnea.
(c) Auscultation for presence of wheezing.
(d) Asses patient’s anxiety/restlessness level.
(e) Vital signs observing for tachypnea, tachycardia, and hyperthermia.
d. Diagnostic tests:
(1) CBC reveals polycythemia and elevated WBCs.
(2) ABG may reveal respiratory acidosis (although may be normal due to compensation), hypoxia,
and hypercapnia.
(3) Pulse oximetry to continuously monitor saturation levels due to potential for hypoxia.
(4) PFT reveals decreased flow on expiration and increased airway resistance and residual volumes.
(5) Patients often experience electrolyte abnormalities.

e. Medical management:
(1) Aimed at minimizing disease progression and facilitating optimal air exchange.
(2) Medications:
(a) Bronchodilators (same agents as with emphysema);
(b) Mucolytics;
(c) Antibiotics.

f. Nursing interventions:
(1) Secretion management:
(a) Provide adequate hydration;
(b) Suction as needed.
(2) Oxygenation: Maintain on low-flow oxygen (1 to 2 L by nasal cannula) as ordered;
(3) Provide frequent oral hygiene;
(4) Provide frequent rest periods.
(5) Nutrition—A high-calorie, high-protein diet should be divided into five or six small meals a day
(similar to the requirements for the patient with emphysema).
(6) The patient with COPD should have a vaccination with influenza virus vaccine yearly;
pneumococcal revaccination is recommended every 5 years for the patients with COPD;
(7) Cessation of cigarette smoking in the early stages is probably the most significant factor in slowing the
progression of the disease and improving pulmonary function. The use of nicotine replacement therapy
and the newer non-nicotine medication Bupropion (Zyban) may be helpful in minimizing the effects of
nicotine withdrawal.
(8) Oral fluid intake should be maintained at 2 to 3 L/day unless contraindicated (because of congestive
heart failure, for example). Instruct patient to drink fluids between meals, rather than with meals, to
reduce gastric distention and pressure on the diaphragm.

(9) Nursing Diagnoses:

NURSING DIAGNOSES OUTCOME NURSING


INTERVENTIONS
Breathing pattern, Patient will maintain 1) Assess degree of dyspnea
ineffective, related to effective breathing pattern 2) Teach/assess
retained pulmonary and patent airway understanding of effective
secretions breathing techniques
3) Suction as needed
Fatigue, related to Patient will deny fatigue 1) Assess degree of fatigue
increased respiratory effort and achieve adequate rest 2) Provide treatments in a
calm, unhurried manner
3) Encourage adequate
periods of rest
4) Identify support systems
and support if needed

g. Prognosis: Irreversible, and with emphysema is the fourth leading cause of death in the US.
B. Emphysema:
Etiology/Pathophysiology: Symptoms begin in 40’s progressing to disability in 50’s and 60’s; Changes
in alveolar walls and capillaries; Lung elastin; Decreased pulmonary surface area; Bronchi,
bronchioles and alveoli become inflamed; Alveolar distention; Alveoli losing their elasticity; Blebs;
Capillary beds replaced with scarring; Hypoxia and hypercarbia. Causes: Protolytic enzymes
destroy lung tissues, resulting in enlarged air sacs and impaired gas exchange; Primarily cigarette
smoking; Air pollution; Age; May lead to cor pulmonale (An abnormal cardiac condition
characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the
pulmonary circulation. Cor Pulmonale results in the presence of edema in the lower extremities as well
as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites. These
signs result from the development of right-sided heart failure, one of the late complications of
emphysema.).
Clinical Manifestation: Exertional dyspnea; Sputum; Use of accessory muscles; Development of barrel-
chest; Wheezing; Spontaneous pursed-lip breathing and chronic weight loss with emaciation ensue.
Assessment: History; Tachycardia; Tachypnea; Peripheral cyanosis; Clubbing of fingers; Lung
examination.
Diagnostic test: Pulmonary function test (PFT); Arterial blood gas; Chest x-ray; Labs; Alpha–antitrypsin
assay; Complete blood count.
Medical Management: Bronchodilators (e.g., Theophylline to enlarge bronchioles for ease of
breathing); Antibiotics; Corticosteroids; Diuretics; Oxygen therapy; Anti-anxiety agents.
Nursing interventions: Decrease patient’s anxiety; Promote optimal air exchange; Oxygenation.
Nursing Diagnosis: Airway clearance, ineffective, related to narrowed bronchioles.
Nursing Interventions: Assist with chest postural drainage; Encourage fluids 2-3 L/day; Assist with
respiratory treatments; Auscultate lungs frequently; Administer medications.
Nursing Diagnosis: Activity intolerance, related to imbalance between oxygen demand, secondary to
inefficient work of breathing. Organize care; Advise patient to rest 30 minutes before meals; Assist
patient with ADL’s and exercises to increase stamina; Asses patient’s respiratory response to activity.
Patient teaching: Focus on optimizing nutrition and smoking cessation.
Nutrition: Smoking cessation; Infection control; Relaxation techniques.
Note: COPD is usually irreversible and is the fourth leading cause of death in the US.

C. Chronic Bronchitis: Recurrent chronic productive cough for a minimum of three months for
at least two years; Physical/chemical irritants or bacterial or viral infections; Smoking is the most
common cause. The cilia are impaired (no longer move secretions); Mucous gland hypertrophy
causes hypersecretion of mucous; Susceptibility to infection. Chronic infection leads to scarring of
the lung tissue that causes obstruction, and also leads to increased airway resistance and
bronchospasm, hypoxia and hypercapnia (greater than normal amounts of CO2 in the blood).
Clinical Manifestations: Productive cough most pronounced in the morning; Dyspnea; Cyanosis
and right ventricle failure; Polycythemia; Cyanosis; Depending edema. Assessment: Assess cough;
Assess severity of dyspnea; Auscultation for presence of wheezing; Asses patient’s anxiety/restlessness
level; Vital signs.
Diagnostic tests: CBC; ABG; Pulse oximetry; PFT; Electrolyte abnormalities.
Medical Management: Aimed at minimizing disease progression and facilitating optimal air exchange.
Medications: Bronchodilators; Mucolytics; Antibiotics.
Nursing Interventions: Secretion management; Provide adequate hydration; Suction as needed;
Oxygenation; Nutrition.
Nursing Diagnosis:
(1) Breathing pattern, ineffective, related to retained pulmonary secretions: Assess degree of
dyspnea; Teach/assess understanding of effective breathing techniques; Suction as needed.
(2) Fatigue, related to increased respiratory effort: Assess degree of fatigue; Provide treatments;
Encourage adequate periods of rest; Identify support systems and support if needed.

Acute Bronchitis: Usually secondary to an upper respiratory infection, it can also be r/t exposure to
inhaled irritant. Inflammation of trachea and bronchial tree causes congestion of mucous membranes and
secretions. The secretions can become a culture medium for bacterial growth.
S&S: Productive cough; wheezes; dyspnea; chest pain; low grade temperature; Malaise; and Headache.
Nursing Interventions: Increase fluid intake; Use humidifier; and Bedrest.

D. Asthma: Causes of Asthma:


(a) Extrinsic asthma—Caused by external factors and occurs in response to allergens, such as pollens,
dust spores, feathers, or animal dander, or foods etc.

(b) Intrinsic asthma— Caused from internal factors. Not fully understood but often triggered by
upper respiratory infection and emotional upsets; Reoccurrence of attacks is influenced by mental or
physical fatigue.
Pathophysiology: Increased tracheal/bronchial responsiveness to various stimuli; Narrowing of the
airways; Classified as intrinsic or extrinsic; Asthma results from an altered immune response;
Acute attacks are caused by the release of histamine; Three primary mechanism involved in
producing allergy symptoms. Clinical Manifestations: Mild asthma; Acute asthma; Status
asthmaticus (Severe unrelenting asthma attack that fails to respond to usual treatment. Symptoms of an
acute attack are present, and the trapped air leads to exhaustion and respiratory failure).

(c) Bronchial asthma: Bronchial smooth muscle constricts in response to irritants; Resulting in
recurrent, reversible air flow obstruction by narrowing air passages.
Assessment: Gather information related to quality of life, medications, asthma triggers and anxiety;
Presence of cyanosis; Amount of respiratory effort; Frequent vital signs; Auscultate for wheezing and
decreased air movement; Check for patient position.
Diagnostic Tests: ABG; PFT’s; Chest x-ray; Sputum culture; CBC; Theophylline level.
Medical Management: Maintenance therapy (to prevent and minimize symptoms): The medications
are to be taken on a regular basis, such as Bronchodilators; Corticosteroids; Leukotriene inhibitors (a new
group of drugs, used as the prophylactic and chronic treatment of asthma). Acute or rescue therapy (to
immediately relieve symptoms of an asthma attack): Short acting inhaled bronchodilators; oral or IV
Corticosteroids; Epinephrine; IV Aminophylline; Oxygen therapy monitored by pulse oximetry. Using a
peak flow meter can help the patient manage asthma. This device measures peak expiratory flow
rate (PEFR)—the flow of air in a forced exhalation in liters per minute, which is a good indicator of
lung function. Normal peak flow is 80% to 100% of the value predicted for the patient based on
height, weight, age, and sex. Severe, persistent asthma is characterized by a peak flow less than
60% of the value predicted. A severe, life-threatening exacerbation of asthma is characterized by a
peak flow less than 50% of the patient’s predicted value.
Nursing Diagnosis:
(1) Breathing pattern, ineffective, related to narrow airway.
Nursing Interventions: Assess ventilation and respiratory effect; Monitor for signs/symptoms of
increasing dyspnea; Maintain position; Administer medications; Assist with respiratory treatments; Care
in calm manner; Minimize exposure to triggers; Maintain adequate hydration.
(2) Health maintenance, ineffective, related to possible allergens in the home: Assist with identity of
allergens and asthma triggers; Allergy testing; Teach/assess understanding of allergy avoidance;
Teach/assess proper use of medications; Teach/assess understanding use of peak flow meter; Teach/assess
understanding of reasons to call physician.
Prognosis: Death rate for asthma has increased by 50% over the past 10 years. Status asthmaticus is fatal
if not reversed.
E. Bronchiectasis: A gradual irreversible process of chronic dilation of the bronchi that
eventually destroys the elastic and muscular properties of the lung; Follows repeated lung
infections; Pulmonary muscle tone is lost after one or repeated pulmonary infections in adults and
children; Secondary to failure of normal lung tissue defenses; Complications of inflammation.
Assessment: Note the patient’s complaint of dyspnea, weight loss; Fever; Dyspnea; Cyanosis and
Clubbing of fingers; There are paroxysms (a sudden sharp attack) of Coughing episodes upon
arising in the morning and when lying down; Foul-smelling sputum; Fatigue, weakness and anorexia;
Crackles and wheezing; Prolonged expiratory phase; Hemoptysis. Medical Management: Low-flow
oxygen; Chest physiotherapy; Adequate hydration.
Medications: Mucolytic agents; Bronchodilators; Antibiotics.
Nursing Diagnosis: (1) Airway clearance, ineffective, related to retained pulmonary secretions.
Nursing Interventions: Assess patient’s ability to mobilize secretions; Encourage postural drainage,
cough, and suction as needed; Encourage frequent position changes; Maintain adequate hydration;
Administer medications as prescribed and monitor effects.
Nursing Diagnosis: (2) Physical mobility, impaired, related to decreased exercise tolerance.
Nursing Interventions: Asses patient’s activity tolerance and promote adequate rest periods; Promote
gradual increase of activity; Problem solve with patient and family on energy conserving techniques.

NOTE: Room Air contains about 21% O2; Exhaled air 16% O2 and 3.5% CO2; Normal respiratory
rate: 14-20 bpm.

BLOCK 18 STUDY GUIDE