copyright ©2010 by pearson education, inc. upper saddle river, new jersey 07458 all rights...

Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

Medical Surgical Nursing: Preparation for Practice

Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa

Medical Surgical NursingPreparation for Practice

CHAPTERCHAPTER CHAPTERCHAPTER

Nursing Assessment of Nursing Assessment of Patients with Patients with Respiratory DisordersRespiratory Disorders

Nursing Assessment of Nursing Assessment of Patients with Patients with Respiratory DisordersRespiratory Disorders

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Complete Assessment

• History– Biographic and demographic data– Chief complaint– Past medical history– Family history– Risk factors– Social history





Complete Assessment

• Components of Physical Exam – Inspection– Auscultation– Percussion– Pain– Genetic and gerontological considerations





Social History

• Patients’ lifestyles and habits and • Risk for developing pulmonary disease• Current and previous work settings• Home environment• Social settings





Gerontological Considerations

• aging decreases respiratory function• lower arterial oxygen values, • increase risk of pneumonia• Risk of aspiration may increase with aging• Aging may affect patient comfort needs

during the examination





Genetic Considerations

• Cystic fibrosis (CF): genetic disorder, typically diagnosed in childhood

• CF has serious pulmonary complications – thick mucus builds up in lungs





Inspection

• Initial assessment activity• General appearance:

– Posture, facial expression and movements – Changes in mental status – Respiratory rates shallow breathing, irregular

patterns of breathing – Size and shape of the thorax, asymmetry– Diminished movement of rib cage, use of

accessory muscles





Inspection

• Color and appearance of skin– Pallor may indicate decreased oxygen-

carrying capacity of the blood due to anemia– Central cyanosis, where the mouth, lips, and

mucous membranes are blue-tinged, indicates hypoxia in adults





Inspection

• Inspection of the neck– Appearance of veins, trachea and

musculature may indicate chronic cardiac or pulmonary disease, pneumothorax

– Goiter or lesions may obstruct the upper airway





Inspection

• Palpation of skin and extremities– Edema of lower extremities– Skin temperature and moisture – Clinical reference points – Chest excursion – Tactile fremitus – Tenderness – Crepitus





Clinical Reference Points





Occupational Impact on Respiratory Disease

• Exposure to airborne particles, vapors, and irritants

• Can result in acute or chronic respiratory disease in susceptible individuals

• Early recognition, diagnosis, and treatment of occupational asthma can prevent pulmonary complications





Auscultating Breath Sounds

• Patient should be upright • Use the diaphragm of the stethoscope• Begin at C7 posteriorly and anteriorly from

above the clavicles• Move steadily from right to left upper and

lower• Compare breath sounds bilaterally• Do not auscultate over clothing





Diaphragm - best for higher pitched sounds, like breath sounds and normal heart sounds.

Bell - is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. It is used for the detection of bruits, and for heart sounds (for a cardiac exam, listen with the diaphragm, and repeat with the bell).





Figure 33.1 In a respiratory assessment, it is important to palpate and count ribs and interspaces to accurately record the location of lesions or adventitious breath sounds.






Figure 33.2 Lobes of the lung—anterior.






Figure 33.3 Lobes of the lung—posterior





Tracheal Breath Sounds

• Auscultated over the trachea• Loud and high pitched• Cause: airflow through tubular trachea• Best heard over the neck and trachea• Occurs during upper airway obstruction





Bronchial Breath Sounds

• Anterior: heard on either side of sternum, over main stems of the bronchus from 2nd to 4th intercostal spaces

• Posterior: best heard lateral to the spine between 3rd and 6th intercostal spaces

• Loud, harsh, less turbulent and lower than tracheal sounds





Bronchial Breath Sounds

• Pause between inspiration and expiration; expiration is heard for a longer time than inspiration

• Sounds over smaller airways are low pitched and softer





Bronchovesicular Breath Sounds

• Heard during inspiration and expiration• Midway in Pitch and loudness between

vesicular and bronchial breath sounds• Best heard in 1st and 2nd intercostal

spaces of anterior chest, between scapulae of the posterior chest

• Represent air movement in the moderate airways between the bronchi and the smaller airways





Vesicular Breath Sounds

• Heard over most of the thorax• Soft and low pitched, rustling, from air

moving through small airways• Heard longer during expiration, which

generally lasts twice as long as inspiration





Adventitious Breath Sounds

• Decreased or no sounds where normal sounds should occur

• Breath sounds occurring in abnormal locations

• Diminished breath sounds demonstrate decreased airflow and potentially decreased oxygen exchange





Adventitious Breath Sounds

• Adventitious/extra sounds: – Represent pathologic conditions of heart or

lungs– Indicate disrupted airflow due to airway

spasm, fluid, or secretions – Crackles (rales-term not used as much),

Wheezes, Stridor, Friction rubs





Crackles

• Caused by fluid in the airways• Intermittent or discontinuous, nonmusical, or

popping sounds • Caused by fluid, inflammation, infection, or

secretions• Crackles are described as either fine or coarse• Occur when closed airways snap open during

inspiration• Softer, gentler sound may also be heard on

inspiration





Wheezes

• Heard equally during inspiration and expiration• High-pitched musical sounds • Caused by air flowing across strands of mucus,

swollen pulmonary tissue that narrows the airway, bronchospasm

• Rhonchi (term for secretions in airways-not used as much)

• Inspiratory/expiratory, continuous/ discontinuous, mild/moderate/severe

• Asthma, allergies, reactive airway disease





Stridor

• Heard only during inspiration as air attempts to flow across an obstruction

• Heard without stethoscope as high-pitched, crowing sound

• With stethoscope, best heard over large airways, e.g., trachea or bronchus

• Report to the health care provider immediately • Indicates airway obstruction requiring

intervention





Pleural Friction Rubs

• Low-pitched, creaking or squeaking sounds • Occur when inflamed pleural surfaces rub

together • Heard on inspiration• Pitch usually increases with chest expansion• Have the patient hold breath to distinguish

between pleural and pericardial friction





Adventitious Lung Sounds





Travel and Area of Residence

• An important aspect of the history in diagnosing potential respiratory problems

• Exposure to region-specific infectious diseases

• Exposure to environmental conditions, e.g. high altitudes





High-Altitude Pulmonary Edema (HAPE)

• HAPE – can occur with travel to altitudes greater than 5,000 feet

• Increasing altitude → decreasing atmospheric pressure → decreasing available O2

• Rapid onset of hypoxemia may result• Compensatory increased respiratory rate

may contribute to fatigue





High-Altitude Pulmonary Edema (HAPE)

• This causes further respiratory insufficiency

• Initial compensatory mechanisms – pulmonary vascular vasoconstriction

• Later, inflammatory mediators cause vasodilation





Percussion

• Assess presence of air, fluid, solid mass in underlying tissues

• Normal lungs produce a resonant, low-pitched clear sound

• Hyperresonance indicates airways are hyperinflated or air is present outside of lung tissue

• Dullness indicates that air is absent– Pneumonia, pleural effusion, hemothorax, solid

tumors





Pain

• Pain during respiration may decrease tidal volumes

• Pain management enables participation in rehabilitative activities

• Also promotes deep breathing to prevent pneumonia and atelectasis





Standard of Care

• For patients with cardiac and respiratory illness, standard is:– Continuous or intermittent observation of the

patient’s oxygen saturation – End-tidal carbon dioxide levels– Peak flow is utilized to trend treatment

effectiveness in patients with asthma





Assessment of Arterial Oxygen Levels

• ABG’s• Pulse oximetry• Physical assessment

• FiO2 will increase the PaO2 four times (normal patient)





Pulse Oximetry

• Measures O2 saturation of hemoglobin

• Reflects light off the hemoglobin molecules

• Measures the absorption of light by hemoglobin

• Normal range is from 95% to 100%





Factors Interfering with Pulse Oximetry

• Nail polish • Automated BP cuffs, hemodialysis fistulas,

or arterial lines interfere with blood flow • Shock and hypovolemia • Patient movement, ambient light, and

venous pulsations may also cause inaccurate readings





Peak Flow Meters

• Track trends in a patient’s condition, evaluate air movement to determine severity of asthma exacerbation

• Measure the peak expiratory flow rate• Normal values based on age and body

size• Severity scale: Utilizes red, yellow, and

green zones to determine the severity of decrease in peak flow





Arterial Blood Gas Studies (ABG)

• Provide information on arterial oxygen and carbon dioxide levels

• Oxygen saturation, bicarbonate, and blood pH are also calculated

• CO2 is major determinant of respiratory alkalosis/acidosis

• Bicarbonate level is determinant of metabolic acidosis/alkalosis





Capnography

• Measurement of exhaled CO2

• Some utilize paper treated to detect the presence of acid such as CO2

• Others use spectrography, generate waveform readings





Capnography

• Useful in determining ventilatory status, readiness for extubation

• Also used to determine pulmonary vessel perfusion in patients with pulmonary embolus





Capnography Monitor







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Facial Bones

• Mandible • Maxilla• Zygoma• Temporal bones • Frontal bone





Mandible

• U-shaped bone • Together with the maxilla, largest and

strongest bone of the face• Forms lower jaw, holds the lower teeth in

place• Articulates with temporal bones at the

temporomandibular joint• Only mobile bone of the facial skeleton;

motion is essential for mastication





Nursing Management for Mandibular Fractures

• Determine patient’s nutritional requirements and knowledge deficits

• Oral nutrition with high-protein liquid diet and calories is essential

• Avoid weight loss if possible to ensure nutritional adequacy for healing

• Nasogastric or oral gastric tube supports nutrition if patient has extensive facial swelling

• Observe for nausea and vomiting, intervene to prevent aspiration





Maxilla

• Largest component of the middle third of the facial skeleton

• Attaches laterally to the zygomatic bones • Key bone in the midface, provides

structural support • Fractures less frequently than mandible or

nose due to strong structural support





Classification System of Maxillary Fractures

• Le Fort I Fracture (horizontal)• Le Fort II Fracture (pyramidal)• Le Fort III Fracture (transverse)





Zygoma

• A paired bone, commonly called the cheekbone

• Articulates with maxilla, temporal, sphenoid, and frontal bones

• Forms prominence of the cheek• The masseter muscle is suspended from

the zygomatic arch





Temporal Bone

• Situated at the sides and base of the skull• Houses cochlear and vestibular end

organs, facial nerve, carotid artery, jugular vein





Nursing Management for Temporal Bone Fractures

• Care is conservative• Assess for nerve damage and hearing loss• Test for otorrhea; may indicate a CSF leak• Monitor lumbar drain if inserted • If facial nerve injury is present, provide eye

care • Institute CSF leak precautions – HOB 30o , no

straining, bending or lifting





Frontal Bone

• Makes up the forehead, upper edge and roof of the orbit

• Forms the anterior portion of the cranium• Frontal sinus – air-filled cavity between

lamina of the frontal bone• Serves as a mechanical barrier to protect

the brain





Infectious Rhinitis

• Usually caused by upper respiratory tract infection of viral origin





Allergy

• Inappropriate immune response to usually harmless substance in the environment





Sinusitis

• Inflammation of one or more paranasal and frontal sinuses

• Occurs with obstruction of the normal drainage mechanism

• Three classifications of sinusitis– Acute (symptoms lasting <3 weeks),– Subacute (symptoms lasting 3 weeks to 3

months)– Chronic (symptoms lasting >3 months)





Sinusitis

• Can be caused by bacterial, viral, and fungal infections

• May occur during a Upper RespiratoryInfection when infection in the nose spreads to the sinuses

• Contributing factors:– Air pollution– Diving and underwater swimming– Sudden temperature extremes– Structural defects





Sinusitis

• Pathophysiology– Paranasal sinuses in direct communication

with nasopharynx– Proximity can cause bacterial infection– When a bacterial or viral infection present,

person develops sinus infection– Tumors, polyps, trauma or benign growths

can cause obstruction





Sinusitis

• Pathophysiology– Ostia (sinus openings) obstruction can

impede normal flow of air– Reduced flow of air and mucus allows mucus

to become stagnant, contributing to growth of bacteria causes inflammation and swelling





Figure 34.4 Sites of sinusitis.





Sinusitis

• Clinical manifestations:– Fever– Weakness– Fatigue– Cough– Congestion– Discharge– Pain in face or forehead





Sinusitis

• Nursing management– Assessment– Thorough history– Education on causes and how to avoid

triggers (air pollutants, diving, underwater swimming, allergies, irritants)

– Education on complications with nasal surgery





Sinusitis

• Postoperative nursing management– Patient education– Monitor for bleeding– Dressing care





Figure 34.5 CT registered with probe for sinus surgery.





Loss of Smell

• 2 million Americans have smell and taste disorders

• About 200,000 visit a doctor each year• Causes include: nasal congestion, a cold,

obstruction, neurological disorder• May be idiopathic – without any

identifiable cause





Causes for Loss of Smell

• Temporary anosmia is common with colds and nasal allergies

• Following a viral illness





Causes for Loss of Smell

• Disorders preventing air from reaching smell receptors:– Nasal polyps– Nasal septal deformities– Nasal tumors– Tumors of the head or brain– Head trauma– Endocrine and nutritional disorders





Categories of Smell Dysfunction

• Anosmia: a complete loss of smell• Hyposmia: a partial loss of smell• Hyperosmia: enhanced smell sensitivity• Dysosmia: distortion in odor perception

– Includes parosmia (distorted sense of smell) and phantosmia





Categories of Smell Dysfunction

• Parosmia: distortion of perception of external stimulus

• Phantosmia: smell perception with no external stimulus.





Determine the Cause of Anosmia

• Complete head and neck examination • Focus on the nose to determine whether it is a

conductive or sensorineural loss • Endoscope is used to provide reliable

observations• Chemosensory testing (“sniffing sticks) and a

neuroradiologic (CT, MRI-to detect problems with olfactory nerve) evaluation also are used





Treatment of Anosmia

• Antihistamines (if the condition is related to allergy)

• Surgical correction of physical blockages• Changes in medication • If permanent, dietary counseling may

include use of highly seasoned foods and stimulation of taste sensations that remain

• Caution should be taken to ensure safety around the home





MUCORMYSIS

• Rare often fatal disease caused by fungi• Opportunistic infection –

immunocompromised• Develops in patients receiving iron

chelating drug called Desferal as treatment for actue iron poisioning

• Can develop in nasal areas, the lungs and brain





Disorders Affecting Taste

• Hairy tongue is a condition in which the tongue is covered with hairlike papilla due to the overgrowth of the fungus Candida albicans or Aspergillus niger

• Result of antibiotic therapy that inhibits the growth of normal flora in the mouth

• Dental caries are the result of the destruction of tooth enamel caused by dental plaque





Treatment

• Good dental hygiene• Antibiotics for bacteria• Mouth rinse





Causes of Airway Obstruction

• Foreign object• Allergy • Lesions• Stenosis• Swelling• Viral and bacterial infections• Fire or inhalation burns





Causes of Airway Obstruction

• Allergic responses to foods, medications, or bee stings

• Infections after dental extraction that have a large amount of swelling

• Laryngeal trauma • Aspiration of food material • Large boluses as well as small pieces of

food, such as peanuts





Epiglottitis

• Life-threatening bacterial illness that may lead to airway obstruction

• Epiglottis is a flap of tissue and cartilage that covers the opening of the trachea during swallowing

• Seen more frequently in children, but occurs in adults





Epiglottitis

• Cause of the infection usually is Haemophilus influenzae group B

• Symptoms: cherry red epiglottis, drooling, inspiratory stridor, dyspnea, and high fever





Nursing Management of Epiglottittis

• Initial treatment focuses on maintaining a patent airway

• Conservative measures of oxygen, humidification, and inhaled respiratory therapy

• Administer Corticosteroids to reduce edema





Nursing Management of Epiglottittis

• Administer antibiotics as prescribed to thwart the infection

• IV fluids are given for hydration• Prepare for tracheotomy or endotracheal

tube if the airway is in immediate jeopardy





Endotracheal (ET) Tube Intubation

• May cause laryngeal trauma • Placement of an ET tube may induce

laryngeal swelling, which is a cause of upper airway obstruction after extubation

• Acute complications: perforation or laceration of the trachea or esophagus, bleeding, and arytenoid (cartilage that form larynx) dislocation





Nursing Management

• Ensure the endotracheal tube remains properly positioned and secured in place

• Unnecessary movement of the tube can irritate and inflame the laryngeal tissue

• Maintain sedation of the patient as ordered if the patient is restless

• Prepare to set up for a tracheostomy tube if intubation is anticipated to be necessary for longer than 7 to 14 days





Clinical Manifestations of Airway Obstruction

• Stridor (partial obstruction)• Unable to speak (complete obstruction)• Labored respirations and use of accessory

muscles • Air hunger (mild obstruction) vs. cyanosis

(complete obstruction)





Clinical Manifestations of Airway Obstruction

• Confusion and unconsciousness indicate a progression in the severity of the obstruction

• If not treated, a partial obstruction can lead to a complete obstruction, rapid suffocation, and death





Nursing Management of Airway Obstruction

• The initial assessment of objective and subjective data includes:– Presence of spontaneous breathing– Rate, depth, and effort of respirations– Presence of grunting or wheezing– Use of accessory muscles of respiration





Nursing Management of Airway Obstruction

• The initial assessment of objective and subjective data includes: – Symmetry of chest expansion (determined

through palpation) vital signs– Oxygen saturation level– Quality of the voice– Stridor or any type of noisy breathing





Other Nurse Assessment

• Monitor the patient’s orientation, mentation, and general demeanor

• Assess the patient’s ability to handle oral secretions

• Pain with speaking or swallowing• Assess for frequent drooling or productive

coughing to clear the airway





Planning Care for the Patient with Upper Airway Obstruction

• A patient with complete airway obstruction appears very anxious, agitated, and apprehensive, and progresses quickly to cyanosis and respiratory arrest

• There is no cough and the patient will be cyanotic and unable to speak






• If the patient is unable to speak, a Heimlich maneuver should be performed in case the obstruction is from a foreign object or food

• Anticipation is the key to saving patients with a complete airway obstruction






• Supplies should be kept at the bedside for creating an immediate artificial airway

• Resuscitation equipment should be brought to the bedside in case there is a subsequent cardiac arrest





Head and Neck Cancer

• More uncommon cancers; may not present until patient has a large tumor burden

• If detected early; head and neck cancer is treatable and curable

• If not treated; very disfiguring, alters normal functions

• Challenges for patient and family





Head and Neck Cancer

• Ablative surgery may leave patient with facial disfigurement, functional impairment

• Decisions regarding treatment must be informed decisions that include:– Outcome without treatment – Implications, risks, and benefits of surgery

and radiation therapy





Etiology

• A variety of risk factors are associated with head and neck cancer

• Some patients do not have any of the known risk factors

• Not possible to know for sure how much they contributed to causing the cancer





Risk Factors for Oral and Oropharyngeal Cancer

• Alcohol: six times more likely to develop these cancers– Alcohol and smoking combined significantly

increase risk over nonsmoking drinkers

• Ultraviolet light: >30% of lip cancers associated with prolonged exposure to sunlight






• Tobacco: Approx. 90% of people with oral cavity and oropharyngeal cancer use tobacco– Risk increases with amount smoked / chewed

and duration – Smokers six times more likely than

nonsmokers to develop these cancers– Tobacco smoke from cigarettes, cigars, pipes

all implicated






• Tobacco: Approx. 90% of people with oral cavity and oropharyngeal cancer use tobacco – Can cause cancers anywhere in the oral

cavity or oropharynx, and larynx– Pipe smoking: significant risk for cancers

where lips contact the pipe stem– Smokeless tobacco increases risk by about

50 times






• Tobacco: Approx. 90% of people with oral cavity and oropharyngeal cancer use tobacco – Associated with cancers of the cheek, gums,

and inner surface of the lips– Exposure to secondhand smoke (called

passive smoking) also a risk factor






• Irritation: Long-term irritation to the lining of the mouth from poorly fitting dentures

• Poor nutrition: A diet low in fruits and vegetables increases risk

• Human papillomavirus infection: HPV infection may contribute to around 20% of cases






• Immune system suppression: Immunosuppressive drugs may increase the risk

• Gender: Twice as common in men as in women

• Ethnicity: Asian heritage, first generation immigrant, are associated with nasopharyngeal cancer from the Epstein-Barr virus





Nursing Management for Patients with Head and Neck Cancer

• Priorities are airway maintenance, pain management, and nutrition





Nursing Management for Patients with Head and Neck Cancer

• If surgery, special needs and consideration:– Wound management– Drain assessment and care– Oral care– Wound complications– Carotid artery exposure assessment and

management





Airway Management – Assessment

• Airway is the first priority• Outcome is to maintain a patent airway and normal

gas exchange• Ongoing assessment: SOB, stridor, blood-tinged

sputum, and infection• Monitor increased WOB, use of accessory muscles

• Assess for increased heart rate and decreased O2 saturation levels

• Assess the type of airway that is being used





Nurse Interventions

• Secure airway with the appropriate ties • Prevents the possibility of the tube being

dislodged or accidentally removed• Change ties daily or when soiled to

decrease the possibility of infection• Clean the tracheostomy site regularly, e.g.

every 8 hours





Nurse Interventions

• Clean more frequently p.r.n. to remove secretions that could obstruct the airway

• For tracheostomy tube with inner cannula, change if disposable or clean at every tie tracheostomy care

• Frequent assessment of secretions is essential to patient safety





Nurse Intervention for Artificial Airway

• Humidification to the airway is necessary• Bag/suction in early postop period if

patient is unable to clear own secretions • Patients may require mechanical

ventilation in early postop period• Monitor pulse oximetry, ABGs, respiratory

rate and effort






• Deflate cuff when the patient is off positive pressure ventilation

• Turn, cough, and deep breathe• Perform respiratory treatments with

bronchodilators, and chest physiotherapy






• Early mobilization and ambulation greatly improve respiratory status – Stimulate coughing – Encouraging greater lung expansion– Recruiting lung fields– Mobilizing secretions

• Early ambulation also benefits circulation and increasing muscle strength





Laryngectomy Stoma Care

• Permanent change in their airway • Breathe only from their stoma • Clean stoma at least every 8 hours, p.r.n.

to prevent buildup of secretions, scarring • Position patient’s head so as not to

occlude the airway • Humidification after discharge until the

airway becomes used to room air





Nurse Management of Pain

• Greatest fears for any patient undergoing cancer surgery is the fear of pain

• High nursing priority to alleviate pain and anxiety related to pain

• Careful and exact assessment of the type and location of the pain

• Have the patient set a goal pain level, using a pain rating scale






• Use the pain scale to evaluate effectiveness

• Note clues for patients who are unable to communicate

• Teach the patient not to wait until the pain is unbearable to request pain medication

• Early, immediate, frequent intervention for pain relief in immediate postop period






• Increase the dosage as the patient’s respiratory status tolerates it

• Consider patient-controlled analgesia (PCA) for alert cooperative patients

• Transition to oral meds as patient is able to swallow safely and in sufficient quantity to sustain nutrition and medication

• Treat joint pain with mobility, ambulation, turning, as early as postop day 1





Nutrition Management

• Present with inadequate nutrition caused by the tumor burden, cancer cachexia, or the mechanical difficulty of eating because of tumor impingement into the aerodigestive tract

• Early recognition of nutritional inadequacy and early intervention is critical

• Positive nitrogen balance, adequate calories and protein needed for healing






• The best test is serum prealbumin, transthyretin, or thyroxin-binding prealbumin (TBPA)

• Nutritionist in the multidisciplinary team is mandatory

• Nutritional goal for caloric intake in the postop period – roughly 35 kcal/kg

• With artificial airway, extra water loss through expiration, suctioning






• Carefully calculate replacement requirements to ensure proper hydration

• Feeding method depends on patient’s level of consciousness and ability to swallow

• Route may be oral, nasogastric, gastrostomy, jejunostomy

• Nutrition replacement must begin early and continue throughout the therapy






• Most feeding can begin on postop day 1 • Advance to goals as quickly as tolerated• Dysphagia is a common issue; tumor

burden, invasion of the aerodigestive tract, pain

• Aspiration is a significant concern with patients who are unable to maintain their airway protection







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Restrictive vs. Obstructive Lung Diseases

• Restrictive lung diseases (interstitial lung diseases)– Result in reduced lung volumes – Alteration in lung parenchyma (alveolar tissue w/

terminal bronchioles, respiratory bronchioles, alveolar ducts)

– Disease of pleura, chest wall or neuromuscular apparatus

– Characterized by reduced total lung capacity, vital capacity, or resting lung volume





Restrictive vs. Obstructive Lung Diseases

• Obstructive lung diseases – A group of disorders – Common characteristic – chronic and

recurring blockage of airways– Limit airflow through the airways and out of

the lungs





Restrictive (Interstitial) Lung Diseases

• Divided into two groups based on anatomic structures: – Intrinsic lung diseases – Extrinsic lung diseases





Intrinsic Lung Diseases

• Diseases of the lung parenchyma • Cause inflammation or scarring of lung

tissue or result in filling of the air spaces with exudate and debris

• Characterized according to etiologic factors– Exposure to dust, metals, or organic solvents

and agricultural employment increase risk





Extrinsic Lung Diseases

• Extraparenchymal diseases – diseases of:– Chest wall– Pleura – Respiratory muscles

• Result in:– Lung restriction– Impaired ventilatory function– Respiratory failure





Extrinsic Lung Diseases

• Extrinsic disorders of pleura and thoracic cage– Total compliance by the respiratory system is

reduced Lung volumes are reduced





Restrictive (Interstital) Lung Diseases

• Clinical Manifestations of Intrinsic Lung Disease– Onset can be acute or insidious (subtle

gradual)– Progressive exertional dyspnea– Hemoptysis






• Clinical Manifestations of Extrinsic Lung Disease– Onset dyspnea, decreased exercise

tolerance, and respiratory infections– Dyspnea upon exertion, followed by dyspnea

at rest, ultimately advancing to respiratory failure

– Recurrent lower respiratory tract infections






• Diagnostic Tests– Generally no positive findings revealed in

intrinsic lung diseases Chest radiography and CT to diagnose intrinsic

disorders Anemia – vasculitis Poycythemia (high RBC count) - hypoxia






• Extrinsic disorders – elevated creatinine kinase (CK) may indicate myositis (enflammation of muscle)– Fluoroscopy to diagnose extrinsic disorders– PFT and tests for extrinsic lung disorders:

Bronchoalveolar lavage, lung biopsy, surgical lung biopsy





Acute Bronchitis

• Etiology– Most prevalent in children and older adults– Incidence is highest in the winter– High Risk

People with allergies, other respiratory illnesses Chronic obstructive pulmonary disease (COPD),

chronic sinusitis, chronic tonsillitis, infected adenoids

Smokers are at a higher risk





Acute Bronchitis

• Pathophysiology– Inflammation of the lower bronchial mucous membranes– Commonly follows a respiratory viral illness – Causative agents: viruses, bacteria, yeast, fungi,

noninfectious triggers– Most often the cause is viral; adenovirus, influenza virus,

and RSV– Common bacterial causes

Streptococcus pneumoniae, Haemophilus influenzae, and Bordetella pertussis

– Other causes: pollutants, such as ammonia and tobacco





Acute Bronchitis

• Clinical Manifestations– Fever, cough, chills, and malaise– Mimic pneumonia, but exam and chest

x-ray often are normal– Cough:

Typically gets steadily worse for 10 to 12 days More profound at night Becomes increasing loose over time Most patients have a cough for less than 2 weeks

– Shortness of breath and wheezing





Acute Bronchitis

• Assessment– Assessment findings reveal a cough – Viral bronchitis – nonproductive cough– Bacterial bronchitis – productive cough, fever,

pain behind the sternum aggravated by coughing





Acute Bronchitis

• Nursing Diagnoses– Priority nursing diagnoses for the patient with

bacterial bronchitis include:– Ineffective airway clearance– Impaired gas exchange– Activity Intolerance





Acute Bronchitis

• Outcomes– Relief of the clinical manifestations – Return to the previous level of functioning





Acute Bronchitis

• Interventions and Rationales– Assist patients with prescribed therapies – Use of antitussives, analgesics, and

bronchodilator medications – Encourage fluids– Teach patients to cough effectively and avoid

infections– Offer mild analgesics for discomfort





Acute Bronchitis

• Interventions and Rationales– Offer patients deep breathing exercises,

incentive spirometer – Anticholinergics, antibiotic therapy (when

indicated), IV corticosteroids or methylxanthines

– Antibiotics not shown to be effective except in patients with COPD

– Beta-2 agonists (brochodilators)





Acute Bronchitis

• Prevention/Evaluation– Relief of the respiratory symptoms including

cough, wheezing, and shortness of breath – Teach prevention and avoidance of risk

factors





Influenza

• A contagious disease caused by the influenza virus

• 10% to 20% of people in US get influenza yearly

• An average of 36,000 deaths per year from influenza in US

• People ages 65+, people with chronic medical conditions more likely to have complications from the flu





Influenza

• Etiology– Epidemics occur from December – April in the

Northern Hemisphere– Yearly epidemics of influenza begin abruptly

and last 5 to 6 weeks– Influenza A and B are the viruses that cause

epidemic human disease





Influenza

• Etiology– Pandemics occur when a new virus emerges

for which there is no immunity– Influenza virus type C has not been classified

and usually does not induce illness





Influenza

• Pathophysiology– Transmission by small-particle aerosols –

droplets from coughs, sneezes– Viruses deposited in the lower respiratory

tract – Attach to and infect epithelial cells – Contact with respiratory droplets, then

touches own mouth or nose





Influenza

• Clinical Manifestations– Fever, chills, headache, fatigue, dry,

nonproductive cough, sore throat, nasal congestion, and myalgia

– Cough may be associated with chest pain– Fever usually persists for 3-4 days, up to 1

week– Common complication is pneumonia, which

may be primary influenza





Influenza

• Nursing Management– Primary care goals: relieving symptoms,

preventing secondary infection– Rest, plenty of fluids, avoid alcohol and

tobacco, take mild pain relievers– Work with health care provider to ensure

medications taken appropriately– Antiviral drugs approved for prevention,

treatment





Influenza

• Prevention– Flu Vaccine– Avoid contact with others who have the flu





Pneumonia

• Inflammatory process resulting in edema of the parenchymal lung tissue

• Extravasation of fluid into the alveoli causing hypoxemia

• Primarily affects terminal gas-exchanging portions of the lung





Pneumonia

• Etiology– Acute inflammation of lung tissue – Caused by bacteria, viruses, fungi, protozoa, parasites– Inhaled into lungs or transported via the bloodstream– Classified by causal agent, distribution, setting (hospital -

HAP or community - CAP)– Causative microorganism influences S&S, treatment,

prognosis– CAP typically caused by different microorganisms than HAP





Pneumonia

• Pathophysiology – Damage to bronchial membranes causes

buildup of infectious debris, exudates– Results in dyspnea, ventilation/perfusion

(V/Q) mismatching, and hypoxemia





Pneumonia

• Pathophysiology– CAP: begins outside hospital or is diagnosed

w/in 48 hours after admission Patient did not reside in a long-term facility prior to

admission Incidence of CAP is highest in winter months Smoking an important risk factor





Pneumonia

• Pathophysiology– HAP: occurs > 48 hours after hospital

admission HAP has a mortality rate of 20% to 50% 90% of HAP infections are bacterial Compromised immune systems, chronic lung

disease, intubation and mechanical ventilation increase risk





Pneumonia

• Clinical Manifestations – Fever, chills – Increased respiratory rates– Rusty bloody sputum– Crackles– X-ray abnormalities





Pneumonia

• Clinical Manifestations– Nonrespiratory symptoms

Headache Abdominal pain Nausea and vomiting Diarrhea Muscle aches





Pneumonia

• Nursing Management– Administer antibiotics (prime treatment)– Primary nursing intervention: Maintain airway

and O2 saturation above 93%

– Common Nursing Diagnosis – Readiness for Enhanced Comfort

– Promote nutrition and hydration – Provide small, frequent, high-carb, high-

protein meals





Pneumonia

• Nursing Management– Monitor fluid intake closely– Provide oral hygiene before and after meals– Promote comfort – Monitor for chest pain, note character and

location – Elevate head of bed 45 to 90 degrees– Offer mild analgesics





Pneumonia

• Discharge Priorities/Prevention– Teach patient about

Importance of rest, gradual increase in activity to avoid fatigue

Maintain resistance with proper nutrition, adequate fluid intake

Avoid chilling and exposure to others with URI, viral infections

Medications that will be continued at home





Pneumonia

• Discharge Priorities/Prevention– Teach patient about

Continue deep breathing and coughing exercises 4x/day, 6-8 weeks

Signs and symptoms to report to health care provider





Tuberculosis

• Etiology– Mycobacterium tuberculosis is nonmotile,

nonsporulating– Transmitted via aerosolization (i.e., an

airborne route)– Affects people with repeated close contact

with an infected but undiagnosed person – TB an opportunistic infections common with

HIV/AIDS





Tuberculosis

• Etiology– Continuous assessment and intervention to

prevent the spread of TB– The newest form of TB is multidrug-resistant

tuberculosis (MDRTB)– Resistant TB is difficult and costly to treat and

can be fatal





Tuberculosis

• Pathophysiology– Highly communicable disease transmitted via

aerosolization– Droplets spread when infected person laughs,

sneezes, or sings– Droplets may be inhaled by others– Tubercle finds a suitable site (bronchi or

alveoli), multiplies freely





Tuberculosis

• Pathophysiology– An exudative response occurs, causing a

nonspecific pneumonitis– Mediated or type IV immunity develops 2-10

weeks after infection – Manifested by a significant reaction to a

tuberculin test





Tuberculosis

• Clinical Manifestations– Dyspnea– Weight loss– Cough– Sputum production– Sleep disturbances– Symptoms present when the disease is well

advanced





Tuberculosis

• Clinical Manifestations– Lethargy, exhaustive fatigue, activity

intolerance, nausea, irregular menses– Low-grade fever may have occurred for

weeks or months– Fever also may be accompanied by night

sweats– Patient finally notes cough, production of

sputum, occasionally streaked with blood





Tuberculosis

• Clinical Manifestations– A dull aching chest pain may accompany the

cough– Dullness with percussion over involved

parenchymal areas– Bronchial breath sounds, increased

transmission of spoken or whispered sounds– Wheezing related to obstruction may also be

heard





Tuberculosis

• Laboratory and Diagnostic Procedures– Tuberculin skin test– Chest x-ray– Acid-fast bacillus smear– Sputum culture





Tuberculosis

• Nursing Management– Administer drug therapy as ordered by health care provider – Report the diagnosis to the local health department– Keep patient in negative pressure room with respiratory

airborne isolation – Maintain isolation until three consecutive sputum cultures

have tested negative– Focus on preventing the spread of the infection– Discuss pain management, handling fatigue, importance of

good nutrition





Tuberculosis

• Health Promotion and Prevention– The main focus of TB management is

preventing spread of the infection– Patient typically must take drugs for 9 months– Test and treat all persons in close contact

with the infected individual





Lung Abcess

• Etiology: – The incidence of lung abscess is not well

known, as it rarely occurs in isolation. Most often such an abscess is secondary to anaerobic and aerobic organisms that colonize the upper respiratory tract.





Lung Abcess

• Etiology:Patients presenting with this problem often have a history of pneumonia, possibly complicated by aspiration of oropharyngeal contents. Formation of multiple abscesses and cavities occurs commonly in patients with TB or fungal infections of the lung.





Lung Abcess

• Clinical Manifestations– Clinical manifestations are often insidious,

although often more acute after pneumonia. Typically they include spiking temperature with rigors and night sweats; cough with foul sputum; pleuritic chest pain; tachycardia; dullness on percussion over the abcessed area. Oxygen saturation may decrease with larger abcesses





Lung Abcess

• Laboratory and Diagnostic Procedures– CT scan– Pleural fluid and blood cultures may be

obtained (thoracentesis)– Bronchoscopy – Transtracheal aspiration via suction





Lung Abcess

• Nursing Interventions– Assess the patient for adequate cough– Administer IV antibiotic therapy if ordered– Penicillin G or clindamycin is the

pharmacologic therapy of choice – Assess for recent history of influenza,

pneumonia, febrile illness, cough, and sputum production

– Auscultate breath sounds





Lung Abcess

• Nursing Interventions– Manage patient’s clinical manifestations– Monitor oxygen levels ongoing– Assess the work of breathing, respiratory and

heart rate – Administer antipyretic, antibiotic, and pain

medications





Lung Abcess

• Nursing Interventions– Follow-up assessment of effectiveness– Space physical care to allow for periods of

rest between activities





Lung Abcess

• Outcomes/Prevention– Relief of clinical manifestations – Return to the previous level of function





Chronic Obstructive Pulmonary Disease

• Refers to a group of respiratory disorders • Characterized by chronic, recurrent

obstruction in pulmonary airways • Encompasses chronic bronchitis and

emphysema– Obstruction is generally permanent and

progressive

• Chronic bronchitis defined in clinical terms






• Emphysema defined in terms of anatomic pathology

• Chronic bronchitis and emphysema typically coexist






• Unifying symptoms – Dyspnea– Wheezing– Use of accessory muscles– Ventilation/perfusion (V/Q) mismatching– Decreased forced expiratory volume






• Emphysema: abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis






• Chronic bronchitis: characterized by hypersecretion of mucus and chronic productive cough that continues at least 3 months of the year for at least two consecutive years





Etiology

• The primary cause of COPD is exposure to tobacco smoke. Clinically significant COPD develops in 15% of cigarette smokers. Age of initiation, total pack-years, and current smoking status predict COPD mortality





Pathophysiology of Chronic Bronchitis

• Inflammatory changes in the bronchial walls

• Causes them to thicken and impinge on the airway lumen

• Diffuse airway obstruction occurs • Initially affects only larger bronchi;

eventually involves all airways






• Obstructed airways are likely to close on expiration

• Traps air in the distal portions of the lung, causing:– Hypoventilation (increased PaCO2)

– Ventilation/perfusion mismatching– Hypoxemia






• Characterized by an increase in mucus production

• Mucus is thicker and more tenacious than normal

• Bacteria become embedded in the airway secretions and reproduce

• Ciliary function is impaired






• Edema and accumulation of inflammatory cells lead to bronchial wall inflammation and thickening

• Airway enlargement, loss of elastic recoil in the alveoli trap air, limit outflow





Pathyphysiology of Emphysema

• Enzymes called proteases break down elastin, cause alveolar destruction

• Result is collapse or narrowing of the small airways

• Eliminates portions of the capillary bed necessary for gas exchange

• Airway enlargement, loss of elastic recoil combine to trap stagnant air





Pathyphysiology of Emphysema

• Airway resistance is increased due to compromised alveolar walls

• Bullae and blebs (thin walled balloon-like extensions or air sacs) develop due to hyperinflation of alveoli

• inflammatory hyperactivity can lead to additional airway narrowing





Nursing Management of COPD Patient

• Assess for dyspnea, muscle fatigue,↑ work of breathing, worsening symptoms

• Monitor ABG results• Assist patient to manage the anxiety that

often occurs





Nursing Management of COPD Patient

• A major role of the nurse is patient and family education– Breathing retraining– Use of postural drainage techniques– Energy conservation– Physical reconditioning

• Single most important factor in preventing COPD – smoking cessation





Asthma

• A chronic hyperreactive disorder of the airways (bronchioles)

• Episodic reversible airflow obstruction and airway inflammation

• Inflammatory process causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning





Asthma

• Caused by a complex interaction of genetic and environmental factors

• Airflow obstruction can be caused by a variety of changes, including:– Acute bronchoconstriction– Airway edema– Chronic mucous plug formation– Airway remodeling





Clinical Manifestations

• Persons with asthma exhibit a wide range of signs and symptoms

• Episodic wheezing, feelings of chest tightness to acute immobilizing attacks





Nursing Management of the Patient with Asthma

• A holistic approach to care through the nursing process

• Educate patient and family about prevention of attacks

• Thoroughly assess symptoms and history of attacks






• Assesses patient’s respiratory status by monitoring:– Severity of symptoms – Breath sounds– Peak flow meter– Pulse oximetry– Vital signs






• Administer medication• Educate public on symptoms and dangers

of asthma





Etiology and Pathophysiology - Cystic Fibrosis

• A person is born with CF, and it affects boys more than girls • Affects Caucasians 5 times more often than African American

people• Typical features: mucous plugging, chronic inflammation,

infection • Peripheral bullae or blebs may develop due to obstruction,

airway wall weakening• Affects mucous glands of the lungs, liver, pancreas, and

intestines• Causes progressive disability due to multiple-system failure





Clinical Manifestations of CF

• Acute exacerbation characterized by:– Increasing breathlessness– Change in sputum volume, color, and

viscosity– Tiredness– Loss of appetite– Weight loss






• Include barrel chest and digital clubbing• GI: malabsorptive symptoms e.g. frequent

loose and oily stools, cramping






• Signs and symptoms of diabetes including abnormal glucose tolerance, polydipsia, polyuria, and polyphagia

• Subtle manifestations: chronic sinusitis, nasal polyps, rectal prolapse





Nursing Management of CF

• Assist patient to maintain adequate airway clearance, reduce risk factors, perform ADLs

• Prevent complications• Involve patient/family in planning and

implementing the therapeutic regimen• Obtain objective and subjective data from

the patient and family






• Encourage use of corticosteroids, bronchodilators, and antibiotics

• Functional health patterns






• Assessment of general impressions– Mood, anxiety, depression, restlessness,

failure to thrive– Cyanosis of skin and nail beds– Persistent runny nose, diminished breath

sounds, sputum characteristics – Tachycardia– Protuberant abdomen, abdominal distention,

foul and fatty stools






• Possibly abnormal ABGs and PFTs; abnormal sweat chloride test, chest x-ray, and fecal fat analysis





Nursing Diagnoses

• Ineffective airway clearance related to thick and abundant mucus, weakness, fatigue

• Ineffective breathing pattern related to bronchoconstriction, anxiety, and airway obstruction

• Impaired gas exchange related to lung infections• Imbalanced nutrition related to dietary intolerances,

intestinal gas, and altered pancreatic enzyme production





Goals

• Focus on the patient having adequate airway clearance• Reduced risk factors associated with respiratory infections • Assist clients to perform ADLs, stay free of complications,

actively participate in planning and implementing a restorative regimeAssist patients in gaining and maintaining independence by assuming responsibility for their own care. Active interventions include relief of bronchoconstriction, airway obstruction, and airflow limitation

• Encourage frequent hand washing, especially after coughing





Goals

• Frequent mouth care, especially after chest physical therapy regime

• Avoid exposure to persons who are ill especially with Upper Respiratory Infections





Pulmonary Embolism

• Thrombus breaks loose and blocks a branch of the pulmonary artery

• Produces widespread pulmonary vasoconstriction

• Predominantly a disease of older individuals

• Highest incidence of recognized PE occurs in hospitalized patients





Pulmonary Embolism

• Pulmonary embolism is a complication of a DVT

• Most common risk factors for PE are:– Prior history of DVT or PE– Recent surgery or pregnancy– Prolonged immobilization– Underlying malignancy

• Risks also include situations of venous stasis or increased hypercoagulability





Pathophysiology and Clinical Manifestations of PE

• A pulmonary occlusion occurs when a bloodborne substance occludes a branch of the pulmonary artery and obstructs blood flow

• Hemoptysis, dyspnea, and chest pain • Pleuritic chest pain, chest wall tenderness,

a pulmonary friction rub, or hypotension





Pathophysiology and Clinical Manifestations of PE

• Tachypnea, crackles, an accentuated second heart sound, tachycardia, fever, diaphoresis, S3 or S4 gallop, thrombophlebitis, lower extremity edema, cardiac murmur, and cyanosis

• Massive PEs typically present with sudden crushing substernal chest pain, shock, and loss of consciousness





Nursing Management of PE

• The nursing process guides the nursing care for patients with a PE

• Evaluation of risk factors on admission and throughout the patient’s hospital stay

• Initially clients may be on bed rest• Nurses should encourage maximal

mobility, including range of motion and walking where appropriate while also staying alert to symptoms of DVT






• Nursing diagnoses: ineffective tissue perfusion and impaired gas exchange

• Assist the patient to maintain the therapeutic regime during the acute period

• Anticoagulant medication should be given at the same time each day– Monitor liver function when patients receive

anticoagulants






• Monitor hemoglobin, hematocrit, platelet, and the international normalized ratio (INR) levels, and other clotting studies as needed to assess the effectiveness of anticoagulants

• Assess for symptoms of bleeding and heparin-induced thrombocytopenia (HIT)






• Discharge priorities include educating the patient and family about risk factors and treatment regimes





Cor Pulmonale

• Alteration in the structure and function of the right ventricle

• Caused by a primary disorder of the respiratory system– Chronic lung disease– Pulmonary embolism– Interstitial lung disease– Primary pulmonary hypertension





Cor Pulmonale

• Pathophysiological mechanisms lead to Primary Pulmonary Hypertension and consequently, cor pulmonale– Pulmonary vasoconstriction due to alveolar hypoxia– Anatomic compromise of the pulmonary vascular

bed– Increased blood viscosity secondary to blood

disorders – Idiopathic primary pulmonary hypertension





Two Forms of Cor Pulmonale

• Acute: usually results from massive PE or injury d/t mechanical ventilation for ARDS

• Chronic cor pulmonale usually caused by COPD





Laboratory and Diagnostic Procedures

• Echocardiography gives information about the size of the heart

• Chest x-rays and CAT scan • PFT evaluate ventilation/perfusion

mismatch• ABG tests identify gas exchange,

presence of acidosis and alkalosis






• Asymptomatic initially• Later, as right ventricular (RV) pressures

increase, physical signs commonly include:– Left parasternal systolic lift (visible pulsations

to left midsternal)– Loud pulmonic component of the second

heart sound (S2)– Murmurs of functional tricuspid and pulmonic

insufficiency






• Later, as right ventricular (RV) pressures increase, physical signs commonly include: – Later, an RV gallop rhythm (third [S3] and

fourth [S4] heart sounds)

– Distended jugular veins, hepatomegaly– Lower extremity edema






• Later, as right ventricular (RV) pressures increase, physical signs commonly include: – Patient may complain of fatigue, dyspnea or

chest pain on exertion, cough– In advanced stages, hepatic congestion leads

to anorexia, RUQ abdominal discomfort





Nursing Management

• Physical assessment findings: – Increased chest diameter– Labored respirations with retractions of the

chest wall and use of accessory muscles– Hyperresonance to percussion– Diminished breath sounds– Wheezing, rarely– Cyanosis





Nursing Management

• Physical assessment findings: – Auscultation of the heart may reveal a split

second heart sound, a systolic ejection murmur with a sharp ejection click over the pulmonary artery, along with a diastolic regurgitation





The Primary Role of the Nurse

• Manage dyspnea by administration of oxygen

• Administer medications to treat right ventricular hypertrophy and pulmonary hypertension

• Provide patient education re: managing equipment and medications

• Refer to home health and pulmonary rehabilitation





The Primary Role of the Nurse

• Regularly assess oxygen needs and medications

• Single most preventive measure – encourage smoking cessation

• Avoid exposure to secondhand smoke and respiratory pollutants





LEARNING OBJECTIVE 4

• Compare and contrast the etiology and nursing management for patients with a variety of chest trauma and thoracic injuries.





Chest Trauma and Thoracic Injuries

• 16,000 deaths in the United States each year

• Cause of death in 25% of all trauma patients

• ↑ hand gun use has contributed to rise in penetrating injuries

• These injuries impair airway patency, breathing, and circulation





Rib Fractures

• Most common blunt thoracic injury in adults

• Associated with other injuries such as flail chest, pulmonary contusion, and pneumothorax





Etiology

• Usually are caused by a direct blow to the ribs

• Sternal fractures are most common in motor vehicle accidents

• Forceful compression of the rib cage





Nursing Management

• Astute assessment for respiratory complications

• Diligent patient monitoring for dyspnea, hypoxemia, and pain

• Administer pain medication and assess for pain relief

• Auscultate lung fields regularly for adventitious sounds





Nursing Management

• Provide written instructions regarding the plan of care

• Teach patient and family when to call members of the health team





Pneumothorax

• Partial or complete collapse of the lung on the affected side

• Under normal circumstances the pleural cavity is free of air

• When air or gas enters the pleural space pneumothorax results





Spontaneous Pneumothorax

• Occurs unexpectedly in healthy individuals ages 20-40

• More common in tall, thin men • Smoking also is a risk factor, due to

disease in the small airways• Caused by a ruptured, air-filled bleb or

blister on the lung surface





Spontaneous Pneumothorax

• Bleb rupture allows atmospheric air to enter the pleural cavity

• Results in a loss of negative pressure and collapse of the lung





Tension Pneumothorax

• Rapidly developing complication of blunt chest trauma

• Occurs as a result of an air leak in the lung or chest wall

• Caused by blunt chest trauma • Parenchymal injury has failed to seal,

causes complete collapse of the lung





Hemothorax

• Common problem encountered following blunt chest trauma

• Blood loss of <2,000 mL into the thoracic cavity

• Absence of breath sounds over the lung and dullness to percussion






• Pleuritic pain • Breathlessness • Respiratory distress• Breath sounds are unilaterally decreased

or absent





Nursing Management

• Assess pulmonary status quickly • The nurse focuses on relieving dyspnea

and supporting oxygenation • Mobilize health team to provide re-

expansion of the lung via a chest tube• Prepare for insertion of the chest tube• Monitor patency of chest tube





Nursing Management

• Provide the patient with written instructions regarding the plan of care

• Encourage patients/caregivers to call health team for persistent problems

• Explain risk of reoccurrence





LUNG CANCER - Etiology

• Prevention efforts target preventing exposure to known risk factors, e.g. smoking

• Cellular genetic destruction results from repeated exposure to carcinogens





Etiology

• Smoking accounts for 87% of all lung cancer deaths

• Other risk factors: occupational hazards, air pollution, genetics, dietary factors, advancing age, and race





Pathophysiology

• Four major histologic types of lung cancer– Small cell carcinoma (SCLC)– Squamous cell carcinoma– Adenocarcinoma – Large cell carcinoma

• SCLC accounts for 15% of cases in US– SCLC disseminates widely by the time of

diagnosis, leads to a poor prognosis





Pathophysiology

• 85% of all lung cancers are non-small cell lung cancer (NSCLC)

• NSCLCs all have unique patterns of growth and clinical appearance– Squamous cell tumors malignancies tend to

be slow growing





Pathophysiology

• NSCLCs all have unique patterns of growth and clinical appearance– Adenocarcinoma – most common form of lung

cancer, most common type in nonsmokers Progression is slow Adenocarcinoma invades the lymphatic/blood

vessels early Result is a worse prognosis compared to that for

SCLCs





Pathophysiology

• NSCLCs all have unique patterns of growth and clinical appearance– Large cell lung cancer commonly located in

periphery of the lung Often spreads to the subsegmental bronchi or

larger airways






• Cough• Dyspnea • Sputum production• Wheezing • Hemoptysis • Chest pain• Dysphagia






• Hoarseness • Fatigue • Weakness • Nausea • Disturbed sleep• Memory impairments• Anorexia






• Night sweats• Early diagnosis of lung cancer is difficult • Typically no symptoms until disease has

metastasized





Nursing Management

• Close postoperatice observation for cardiac and pulmonary complications

• Dyspnea is the most common postoperative symptom

• Effective pain management enables participation in progressive mobilization





Lung Transplant

• Viable alternative for patients with advanced pulmonary disease





Lung Transplant

• Indications:– AAT deficiency (Alpha-1 antitrypsin (AAT) deficiency is a condition in

which the body does not make enough of a protein that protects the lungs and liver from damage.)

– Bronchiectasis – Cystic fibrosis– Emphysema – Idiopathic pulmonary fibrosis – Interstitial lung disease– Pulmonary hypertension





Lung Transplant

• Persons >60 years of age not recommended for single lung transplant





Lung Transplant

• The following do not qualify for lung transplant:– Colonization with antibiotic-resistant

organisms– Noncompliance with medical regime– Inability to walk 600 feet – Diagnosis of a malignancy within 2 years– Renal or liver insufficiency– Positive for HIV





Lung Transplant

• Infection postoperatively is the leading cause of morbidity and mortality





Occupational Lung Disorders: Pneumoconiosis

• Long-term exposure to toxic dust and particulates can lead to irreversible chronic pulmonary disease

• Most common causes: silica, asbestos, and coal

• Dust deposits are permanent





Occupational Lung Disorders: Pneumoconiosis

• No definitive treatment for the pulmonary fibrotic changes

• Treatment is palliative • Focuses on preventing further exposure

and improving workplace safety





Occupational Asthma

• Exposure to particulate matter, workplace chemicals, gases, cereal grains, or irritants

• Causes inflammation and edema of any portion of the respiratory tract

• Results in bronchospasm, hypersecretion of mucus, dyspnea, wheezing





Occupational Asthma

• Symptoms are dyspnea, wheezing, and chest tightness

• Difficult to recognize because symptoms continue when away from the source of exposure





Coal Miner Pneumoconiosis

• Known as black lung or coal miner’s lung• Caused by coal dust deposits in the lung• Disease affects about 4.5% of coal miners• Patients experience a restrictive disease in

which they cannot fully expand their lungs as well as an obstructive disease from secondary emphysema





Asbestosis

• Progressive lung disease • Caused by exposure to microscopic fibers

of asbestos • Results in diffuse interstitial fibrosis with

diaphragmatic calcification• Fibrous tissue eventually obliterates the

alveoli• Latency period 10-20 years between

exposure and symptoms





Whose at Risk for Asbestosis?

• Asbestos miners, millers• Those employed in building trades and

shipyards• Insulation workers, pipe fitters and

steamfitters• Sheet metal workers, welders





Diagnosis and Clinical Manifestations

• PFT findings – restrictive ventilatory defect, restricted lung volume

• Dyspnea and hypoxemia• Removal of the individual from exposure is

essential • Crackles of a dry quality can be

auscultated in 70% to 90% of patients• Clubbing also is present frequently





Diagnosis and Clinical Manifestations

• Chronic cough and sputum production, similar to acute bronchitis

• Sputum is expectorated in large amounts– May contain black fluid, particularly with

smokers

• Respiratory failure and cor pulmonale result





Nursing Management

• Offer supportive care and education for patient and caregiver

• Address issues: dyspnea, fatigue, and activity tolerance

• Teach physical conditioning and breathing exercises are helpful

• Encourage liberal fluids intake





Nursing Management

• Administer bronchodilators, glucocorticoids, and antibiotics

• Address emotional issues such as depression, anxiety, and anger

• Educate patient prior to discharge about all aspects of the treatment regime

• Provide relevant contact numbers to the patient and caregiver







Caring for the Patient Caring for the Patient with Complex with Complex Respiratory DisordersRespiratory Disorders

Caring for the Patient Caring for the Patient with Complex with Complex Respiratory DisordersRespiratory Disorders

3636





Complex Respiratory Disorders

• Lead to alteration of oxygen perfusion• Caused by problems elsewhere in the

body





Goals of Treatment

• Medical Management– Correct and treat hypoxemia– Discover and correct primary organ system

failure

• Nursing Management– Manage the airway– Manage oxygen for perfusion





The Alveolar-Capillary (A-C) Membrane

• Central component of gas exchange in lungs

• Oxygen diffuses from alveoli into pulmonary capillaries – Attaches to the hemoglobin in the red blood

cells

• Carbon dioxide moves in the opposite direction, into the lungs





The Alveolar-Capillary (A-C) Membrane

Figure 36.2 Alveolar-capillary membrane





Ventilation/Perfusion

• Ventilation (V) – movement of air• Perfusion (Q) – the movement of blood

carrying oxygen• Near equal relationship of ventilation

(4L/min) and perfusion (5L/min)• Acute Respiratory Failure commonly

caused by mismatch of ventilation and perfusion





Figure 36.4 Ventilation/perfusion relationships: (A) normal unit; (B) dead space unit; (C) shunt unit; (D) silent unit.

(a) V/Q is equal to 0.8 – no miss match

(b) V/Q is >0.8 – there is ventilation but no perfusion

(c) V/Q is <0.8 – there is perfusion but little or no ventilation

(d) V/Q no perfusion and no ventilation





Acute Respiratory Failure

• Defined as a failure of gas exchange

• Respiratory system unable to provide O2 and remove CO2

• Results in failure of oxygenation, failure of ventilation, or both





Classification of Acute Respiratory Failure (ARF)

• Hypoxemia (deprived of oxygen)– Caused by failure of oxygenation

• Hypercapnea (high CO2 in blood)– Caused by failure of respiratory system to

ventilate

• Failure of respiratory centers in the brain





Classification of ARF

• Hypoxemia: – PaO2 below normal (<60 mmHg)

– SaO2 <90% on room air

• Hypercapnea: – PaCO2 above normal (>50 mmHg)

– pH <7.3





Pathophysiology

• Hypoventilation• Shunting• Ventilation/perfusion mismatch: most

common cause





Acute Pulmonary Edema

• Abnormal accumulation of fluid in the lungs

• Occurs rapidly – over minutes or hours• Etiologies – all relate to failure of heart

and/or lungs





Cardiogenic Pulmonary Edema

• Initial insult is caused by heart failure– ↑ Pulmonary venous pressure leads to– ↑ Hydrostatic pressure in pulmonary

capillaries Result: pulmonary edema

• Cardiac dysfunction is most common factor

• Fluid overload, and chronic hypoxemia may also be present





Noncardiogenic Pulmonary Edema

• Insult to the A-C membrane• Changes the permeability of the A-C

membrane• Major causes: sepsis, inflammation,

inhaled toxins, drugs





Neurogenic Pulmonary Edema

• Direct insult to central nervous system– Examples: seizures, cerebral hemorrhage,

head injury

• Dyspnea (shortness of breath) is primary presenting symptom– Other symptoms may be present– Crackles, pink frothy sputum





Negative Pressure Pulmonary Edema

• Caused by ventilation with airway obstruction

• High pressures required • When obstruction is relieved

– Hydrostatic pressure pushes fluid into lungs





PE and Specific Populations

• Mountain climbers• Heroin users• Scuba divers/hyperbaric chamber users• Excessive intravenous fluid administration





Clinical Manifestations of Cardiogenic PE/Non-Cardiogenic PE

• Respiratory clues are identical• Agitation, confusion common to both CPE

and NCPE• Distinguishing factors are subtle• Most evident in cardiac assessment, skin

appearance





Differentiating CPE/Non-CPE

• Mostly evident in cardiac assessment, skin appearance– Example 1: tachycardia with hypotension and

cool diaphoretic skin suggests CPE– Example 2: tachycardia with hypertension,

bounding pulses and dry skin suggests NCPE





Differentiating CPE/Non-CPE

• Other Distinguishing Factors– Jugular Vein Distension more common in

CPE– If coronary artery catheter is used, Pulmonary

Artery Occlusion Pressures (PAOP) or Pulmonary Capillary Wedge Pressure (PCWP) above 18mmHg confirms CPE





Acute Respiratory Distress Syndrome (ARDS)

• Most severe type of respiratory failure• Caused by injury to A-C membrane• Mortality rate = 40%• Acute lung injury (ALI) less severe than

ARDS





Acute Respiratory Distress Syndrome (ARDS)

• Lets fluids, proteins etc. flow into the lungs• Lung injury

→ Inflammation→ Pulmonary edema

→ Hypoxemia





Acute Injury to the Lungs

• Causes of direct injury– Aspiration of gastric contents – most common

cause of ALI – Trauma, Infection

• Indirect injury – intermediary process causes injury– Sepsis, acute pancreatitis, major inflammatory

process





Treatment of ARDS/ALI

• Specific therapy to treat underlying cause• Supportive treatment

– Oxygen– Mechanical ventilation– Fluid management





How the Ventilator Works

• Monitors respiratory rate, pressure, volume

• Delivers specified volume, pressure, or both

• Controls concentration of oxygen • Mixes compressed air with oxygen to

reach desired FiO2





Nursing Issues

• Complexity of equipment is increasing• Variety of equipment is increasing• No standard terminology among

manufacturers





Terminology

• Spontaneous breaths• Mandatory breaths• Assisted breaths• Types of ventilation• Modes





Types of Breath

• Spontaneous breaths– Patient initiates breath– Patient controls switch from inspiration to

expiration

• Assisted breaths– Patient initiates breath– Ventilator controls switch to expiration– Ventilator controls volume and pressure





Terminology

• Mandatory breaths – controlled entirely by ventilator– Inspiration– Expiration– Volume/pressure of gas delivery





Types of Ventilation

• Volume – clinician controls tidal volume; pressure can vary – can set rate, set volume

• Pressure – clinician controls pressure; tidal volume can vary - set rate, set pressure, need to monitor minute volumes

• No clinical consensus on preferred type





Common Ventilator Modes

• Mode: describes the pattern of breath delivery

• Common modes– Assist control mode (ACM) – Synchronized mandatory intermittent

ventilation (SIMV) – Pressure support (PS or PSV) – Pressure controlled ventilation (PCV)





Assist Control Mode

• ACM delivers a preset volume or a preset pressure for each breath

• Patient can trigger a breath or the breath can be time triggered (CMV, A/C)

• Commonly used in care of in the postoperative patient





Assist Control Mode

• Nursing Implications of ACM – As patient awakens, she or he may begin

initiating breaths– Machine may not have time to deliver set

volume– Patient can become hypoxic by attempt to

breathe faster, stacking breaths– Pressure builds; lungs may be injured





Assist Control Mode

• Nursing Implications of ACM– Nurse must monitor to assure that patient and

machine are working together





Synchronized Intermittent Mandatory Ventilation

• Very common mode in US• SIMV sets the mandatory respiratory rate

(VE )• Ventilator will deliver a set volume or

pressure• Patient can also initiate a breath

– Ventilator waits for the patient, to breathe– Synchronizes delivery of breath in concert

with the patient





Synchronized Intermittent Mandatory Ventilation

• Nursing Implications of SIMV – Desirable for patient to “overbreathe” the

machine; i.e. breathe faster than the VE

– In SIMV, patient may initiate breaths, some are assisted and some are not

– Team should evaluate VE, level of sedation or analgesia





Pressure Support

• PS is a form of assisted ventilation• Requires stable respiratory effort from

patient• IF ventilator senses negative pressure on

inspiration– THEN ventilator supports the patient-initiated

breath





Pressure Support

• Does not control the rate or tidal volume– Therefore, usually used with SIMV, CPAP

mode– PS not triggered unless patient breathes

above the VE (mandatory rate)





Pressure Support

• Nursing Implications of PS with SIMV– If patient does not “overbreathe” the machine,

no benefit from PS– The nurse should assess the patient and talk

to the team to determine a course of action





Pressure Control Ventilation

• Clinician sets rate and pressure• Tidal volume is allowed to vary• Usually reserved for patients with

noncompliant lungs, difficult to ventilate and oxygenate

• Gas delivery distinguishes PCV from PS– Breath triggers rapid delivery of gas to reach

set pressure, then the flow is decelerated





Pressure Control Ventilation

• Nursing Implications of PCV– The nurse should trend the VE and the

expiratory volume over time– Volume decrease may indicate lungs are

becoming less compliant– Adjust Pressure to Achieve the Same Volume





Positive End-Expiratory Pressure

• PEEP is a ventilator setting, not a mode• Provides resistance at end of exhalation• Prevents alveoli from collapsing• CPAP – continuous positive airway

pressure – related to PEEP





Three Types of PEEP

• Physiological PEEP – 5 cm of H2O

• Treatment PEEP – >5 cm of H2O

• Auto-PEEP • For most ventilated patients, PEEP of at

least 5 cm of H2O required to prevent alveolar collapse





Nursing Implications of PEEP

• PEEP of greater than 5 cm of H2O can cause decreased cardiac output

• Pneumothorax at higher levels of PEEP• The nurse should be aware of the level of

PEEP





Auto-PEEP

• Potential problems– Ventilator set rate is too high– Overaggressive use of an Ambu bag

• Result: pressure builds in the lungs– Disconnect the ventilator or Ambu briefly– Allows the excess pressure to dissipate





CPAP

• Commonly used prior to extubation• Patient is breathing spontaneously• Ventilator support at end of expiration only





Nursing Assessment in ARF

• Priorities are airway and oxygenation status

• Frequent, ongoing assessment is vital





Assessment Data

• Ask if the patient feels s/he is getting enough air

• Evaluate for anxiety

• Respiratory rate, work of breathing, SO2, vital signs

• Assess skin and nail beds for cyanosis and pallor





Nursing Diagnosis

• Impaired gas exchange • Ineffective tissue perfusion:

cardiopulmonary and peripheral• Deficient knowledge related to the disease

process• Self-care deficit• Ineffective airway clearance• Ineffective breathing pattern





Nursing Interventions in ARF

• Encourage deep breathing and coughing• Encourage incentive spirometer use, if

ordered• Frequent turning and repositioning





Indications for Endotracheal Intubation

• Inability to maintain oxygenation/ ventilation

• Airway protection• Elective surgery





Nurse’s Role

• Know the proper equipment and its use• Anticipate the health provider’s needs • Position the patient • Preoxygenate the patient• Provide suction as necessary• Monitor the patient• Provide information and reassurance





How Intubation Works

Figure 36.6 Endotracheal tube.





Documentation

• Size of ET tube• Location of ET tube in airway• Medications administered• Patient’s tolerance of procedure





Suctioning

• Performed based on assessment only• Never routinely ordered• DO: Hyperoxegenate before/after

suctioning• DON’T: Routinely instill normal saline

before suctioning





Complications

• Hypoxemia• Bronchospasm• Cardiac arrhythmias• Tissue injury• Increased risk of infection





Closed Suctioning System

• Patient with high PEEP, high FiO2

– Closed system keeps pressure up

• Patient cannot tolerate use of open system• Patient with airborne infectious disease

– Avoids exposing others to aerosolized infectious secretions





LEARNING OBJECTIVE 9

• State two indications for insertion of a chest tube in a patient in an acute care setting.





Chest Tube

• Another major intervention for respiratory compromise

• Tension pneumothorax – common reason for chest tube insertion

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