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