Nursing Management of Lower Respiratory Problems

JSB

Acute Bronchitis

• Inflammation of the bronchi• Supportive treatments– Fluids– Rest– Anti-inflammatory agents– Cough suppressants– Antiviral drugs– Mucolytic medications

Pertussis

• Highly contagious infection• Whooping cough• Gram-negative bacillus• Symptoms same as bronchitis• Treatment is antibiotics

Pneumonia

• Acute inflammation of lung caused by microbial organism – Previously, leading cause of death in the United

States from infectious disease• Discovery of sulfa drugs and penicillin decreased

morbidity and mortality rates.

4

Etiology

• Likely to result when defense mechanisms become incompetent or overwhelmed

• ↓ Cough and epiglottal reflexes may allow aspiration

5

Etiology

• Mucociliary mechanism impaired – Pollution– Cigarette smoking– Upper respiratory infections– Tracheal intubation – Aging

6

Etiology

• Three ways organisms reach lungs:– Aspiration from nasopharynx or oropharynx– Inhalation of microbes such as Mycoplasma

pneumoniae – Hematogenous spread from primary infection

elsewhere in body

7

Types of Pneumonia

• Community-acquired pneumonia – Lower respiratory infection of lung – Onset in community or during first

2 days of hospitalization

8

Types of Pneumonia

• Community-acquired pneumonia – Highest incidence in midwinter– Smoking important risk factor

9

Types of Pneumonia

• Organisms implicated– Streptococcus pneumoniae– Haemophilus influenzae– Legionella– Mycoplasma– Chlamydia

10

Types of Pneumonia

• Three-step approach to treatment– Assess ability to treat at home.– Calculate PORT (Pneumonia Patient Outcomes

Research Team).– Make clinician decision for inpatient or outpatient.

11

Types of Pneumonia

• HAP, VAP, HCAP– HAP: Occurring 48 hours or longer after admission

and not incubating at time of hospitalization– VAP: Occurring more than 48 hours after

endotracheal intubation

12

Types of Pneumonia

• Risk factors for HAP– Immunosuppressive therapy– General debility – Endotracheal intubation

13

Types of Pneumonia

• Treatment is based on– Known risk factors– Severity of illness– Early (5 days post admission) or late (more than 5

days post admission) onset• MDR organisms are major problem in treating

HCAP.

14

Types of Pneumonia

• Aspiration pneumonia– Sequelae occurring from abnormal entry of

secretions into lower airway

15

Types of Pneumonia

• Aspiration pneumonia– Usually with history of loss of consciousness• Gag and cough reflexes suppressed

– Forms of aspiration pneumonia • Mechanical obstruction • Chemical injury• Bacterial infection

16

Types of Pneumonia

• Opportunistic pneumonia– Patients at risk • Severe protein-calorie malnutrition• Immune deficiencies• Chemotherapy/radiation recipients• Long-term corticosteroid therapy

17

Types of Pneumonia

• Causes of opportunistic pneumonia – Bacterial and viral causative agents– Pneumocystis jiroveci (PCP)– Cytomegalovirus– Fungi

18

Types of Pneumonia

• Clinical manifestations of PCP– Fever– Tachypnea– Tachycardia– Dyspnea– Nonproductive cough– Hypoxemia

19

Pathophysiology

• Stage 1: Congestion from outpouring of fluid to alveoli– Organisms multiply. – Infection spreads.– Interferes with lung function

20

Pathophysiology

• Stage 2: Red hepatization– Massive dilation of capillaries – Alveoli fill with organisms, neutrophils, RBCs, and

fibrin.• Causes lungs to appear red and granular, similar to liver

21

Pathophysiology

• Gray hepatization– ↓ Blood flow – Leukocyte and fibrin consolidate in affected part

of lung.

22

Pathophysiology

• Resolution– Resolution and healing if no complications– Exudate lysed and processed by macrophages– Tissue restored

23

Pathophysiologic Course of Pneumococcal Pneumonia

24

Fig. 28-1. Pathophysiologic course of pneumococcal pneumonia.

Clinical Manifestations

• CAP symptoms– Sudden onset of fever– Shaking chills– Shortness of breath– Cough productive of purulent sputum – Pleuritic chest pain

25

Clinical Manifestations

• Physical examination findings– Dullness to percussion– ↑ Fremitus– Bronchial breath sounds– Crackles

26

Clinical Manifestations

• Atypical manifestations– Gradual onset– Dry cough– Extrapulmonary manifestations– Crackles

27

Clinical Manifestations

• Initial manifestations are highly variable in viral pneumonia.– Primary pneumonia can be caused by influenza

viral infection.– Can be a complication of systemic viral disease

28

Complications

• Pleurisy• Pleural effusion – Usually is sterile and reabsorbed in 1 to 2 weeks or

requires thoracentesis

29

Complications

• Atelectasis – Usually clears with cough and deep breathing

• Bacteremia– Bacterial infection in the blood

30

Complications

• Lung abscess– Seen when caused by S. aureus and

gram-negative pneumonias• Empyema– Requires antibiotics and drainage of exudate

31

Complications

• Pericarditis– Spread of microorganism to heart

• Meningitis– Patient who is disoriented, confused, or

somnolent should have lumbar puncture.

32

Complications

• Endocarditis– Microorganisms attack endocardium and heart

valves.

33

Diagnostic Tests

• History • Physical examination• Chest x-ray• Gram stain of sputum• Sputum culture and sensitivity • Pulse oximetry or ABGs

34

Diagnostic Tests

• CBC, differential, chemistries• Blood cultures

35

Collaborative Care

• Antibiotic therapy• Oxygen for hypoxemia• Analgesics for chest pain• Antipyretics

36

Question

• A patient diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?– A. Administer the ordered oral antibiotic STAT.– B. Order the meal tray to be delivered as soon as

possible.– C. Obtain a sputum specimen for culture and sensitivity.– D. Have the unlicensed assistive personal weigh the

client.

Collaborative Care

• Fluid intake at least 3 L per day• Caloric intake at least 1500 per day

38

Collaborative Care

• Pneumococcal vaccine– Indicated for those at risk• Chronic illness such as heart and lung disease, diabetes

mellitus • Recovering from severe illness• 65 or older• In long-term care facility

39

Nursing Assessment

• History– Lung cancer– COPD– Diabetes mellitus– Debilitating disease– Malnutrition– AIDS

40

Nursing Assessment

• History– Use of antibiotics, corticosteroids, chemotherapy,

or immunosuppressants – Recent abdominal or thoracic surgery– Smoking– Alcoholism– Respiratory infections

41

Nursing Assessment

• Prolonged bed rest• Dyspnea• Nasal congestion• Pain with breathing

42

Nursing Assessment

• Sore throat • Muscle ache• Fever• Restlessness

43

Nursing Assessment

• Splinting affected area• Tachypnea• Asymmetric chest movements• Use of accessory muscles

44

Nursing Assessment

• Crackles• Green or yellow sputum• Tachycardia• Changes in mental status

45

Nursing Assessment

• Leukocytosis• Abnormal ABGs • Pleural effusion • Pneumothorax on x-ray

46

Nursing Diagnoses

• Ineffective breathing pattern• Ineffective airway clearance• Acute pain

47

Nursing Diagnoses

• Imbalanced nutrition: Less than body requirements

• Activity intolerance

48

Planning

• Clear breath sounds• Normal breathing patterns• No signs of hypoxia• Normal chest x-ray• No complications related to pneumonia

49

Nursing Implementation

• Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance.

• Prompt treatment of URIs• Strict asepsis

50

Nursing Implementation

• Encourage those at risk to obtain influenza and pneumococcal vaccinations.

• Reposition patient every 2 hours.• Elevate head of bed 30 to 45 degrees for

patients with feeding tube.

51

Nursing Implementation

• Assist patients at risk for aspiration with eating, drinking, and taking medications.

• Assist immobile patients with turning and deep breathing.

52

Nursing Implementation

• Emphasize need to take course of medication(s).

• Teach drug–drug interactions.

53

Evaluation

• Dyspnea not present• SpO2 ≥ 95• Free of adventitious breath sounds• Clear sputum from airway

54

Evaluation

• Reports pain control• Verbalizes causal factors• Adequate fluid and caloric intake• Performs activities of daily living

55

Question

During the assessment of a patient with pneumonia, the nurse suspects the development of a pleural effusion upon finding:

1. A barrel chest.2. Paradoxical respirations. 3. Hyperresonance on percussion.4. Localized absence of breath sounds.

56

Case Study

• 88-year-old woman who lives alone

• Feeling weaker over past 2 days, and last night became confused and disoriented

57

Case Study

• Housekeeper notified her daughter, who brought her to the clinic.

• She complains of coughing over the past 3 days but has no other history.

58

Case Study

• Examination findings– Bronchial breath sounds and dullness of left

posterior lung base with egophony

– O2 Sat 87%

59

Case Study

• Examination findings– WBC 18,000/µL– Segs 85%– Bands 15%– PA/lat chest x-ray: Lobar infiltrate– Sputum gram stain: Gram-positive diplococci,

many WBCs

60

Discussion Questions

1. What are the risk factors for her developing pneumonia?

2. What is her priority of care?

61

Discussion Questions

3. What important teaching should you provide to the patient and family?

62

Tuberculosis

• Infectious diseases caused by mycobacterium tuberculosis

• Gram positive • Acid – fast bacillus• Spread via airborne droplets– Contact with in 6 inches of persons mouth

Clinical Manifestation

• Classification -Table 28-8• Positive skin test• Fatigue • Malaise• Anorexia• Unexplained weight loss• Low grade fever• Night sweats• Mucopurulent sputum• HIV high risk

Complications

• Miliary TB– Spread via blood stream to all body organs

• Pleural effusion and empyema• Tuberculosis pneumonia• Other organ involvement

Diagnostic Studies

• Tuberculin Skin Test• Chest x-ray• AFB test (acid fast bacilli)

Collaborative Care

• Drug therapy– Isoniazid– Rifampin– Pyrazinamide– Ethambutol– Rifabutin– Rifapentine– Fluoroquinolones– Table 28-11

Nursing Management

• Ethical dilemmas• Health promotion• Acute intervention• Ambulatory and home care

Fungal infections of the lung

• Table 28-14• Candidiasis• Pheumosystis Pneumonia (PCP)• Amphotericin B standard of care

Chest Trauma and Thoracic Injuries

JSBrinley, RN, MSN/Ed, CNE

Types

• Blunt– Steering-wheel– Shoulder-harness seat belt– crush

• Penetrating– Stab wound– Gunshot wound

Types of Pneumothorax

• Closed pneumothorax• Open pneumothorax• Tension pneumothorax• Hemothorax• Chylothorax

Manifestations

• Tachycardia• Dyspnea• Hypoxemia• Chest pain• Cough• Absent breath sounds• CXR shows the presence of air or fluid in the

plural space and reduction in lung volume

Question

• The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax

• A. Bronchovesicular lung sound and bradypnea.• B. Unequal lung expansion and dyspnea.• C. Frothy, bloody sputum and consolidation.• D. Barrel chest and polycythemia

Collaborative Care

• Medical emergency!• Thoracentesis• Chest tube insertion and water seal drainage

system

Fractured Ribs

• Most common type of chest injury resulting from blunt trauma– Complication is pneumonia from atelectasis

• Flail chest– Fracture of two or more ribs– Apparent on visual examination– Asymmetric and uncoordinated chest movement– Treatment is mechanical ventilation

Chest tubes and Pleural Drainage

• Chest tube insertion• Flutter or heimlich valve• Plural drainage• Three compartments– Collection chamber– Water-seal chamber– Suction control chamber

Nursing Management of Chest Drainage

• Table 28-23• Know this table!

Question

• The client had a right-sided chest tube inserted two (2) hours ago for a pheumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment?– A. Obtain an order for a STAT chest x-ray.– B. Increase the amount of wall suction.– C. Check the tubing for kinks or clots.– D. Monitor the client’s pulse oximeter reading.

Question

• Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax?– A. Gentle bubbling in the suction compartment.– B. No fluctuation (tidaling) in the water-seal

compartment.– C. The drainage compartment has 250 mL of blood– D. The client is able to deep breathe without any pain.

Question

• The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply– A. Place the client in the low fowler’s position.– B. Assess chest tube drainage system frequently.– C. Maintain strict bedrest for the client.– D. Secure a loop of drainage tubing to the sheet.– E. Observe the site for subcutaneous emphysema.

Chest Surgery

• Baseline assessment• Encourage patient to stop smoking• Teach deep breathing and cough exercises• Explain purpose of chest tube and oxygen

supplement

Types

• Thoracotomy• Video-Assisted Thoracic Surgery (VAT)

Post-Op Care

• 28-2 pg 574

Plural Effusion

• Abnormal collection of fluid in the plural space• Empyema• Manifestations– Dyspnea – Decreased movement of the chest wall– Pain– Absent breath sounds– Fever night sweats, cough and weight loss– CXR reveal volume and location of the effusion

Pulmonary Edema

• Abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs

• Causes– Heart failure– Overhydration with intravenous fluids– Hypoalbuminemia

• Nephrotic syndrome, hepatic disease, nutritional disorders

– Altered capillary permeability of lungs• Toxins, inflammation, severe hypoxia, near drowning

– Malignancies of the lymph system– Respiratory distress syndrome– Unknown causes

Pulmonary Embolism

• Is a blockage of pulmonary arteries by a thrombus, fat, air, or tumor tissue

• Causes– DVT– Atrial fibrillation– Fat emboli– Bacterial vegetations– Amniotic fluid– Tumors

Pulmonary Embolism

– Most common risk factors• Immobility• Surgery• Stroke • Paresis• Paralysis• Obesity• Smoking• hypertension

Manifestation of PE

• Dyspnea• Chest pain• Hemoptysis• Hypoxemia• Abrupt hypotension• Vague symptoms• Can be difficult to diagnose

Complications Of PE

• Pulmonary infarction• pulmonary hypertension– Diagnostic studies• CT• V/Q• D-dimer

– Measures the amount of cross-linked fibrin fragments

Treatment of PE

• See pg 579