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