Nursing Care of Patients with Lower Respiratory Tract Disorders

Nursing Care of Patients with Lower Respiratory Tract Disorders
Chapter 31 Nursing Care of Patients with Lower Respiratory Tract Disorders

Bronchiectasis Pathyphysiology Etiology Secondary to CF, Asthma, TB
Chronic Infection Dilation of One or More Large Bronchi Airway Obstruction Etiology Secondary to CF, Asthma, TB

Signs and Symptoms Dyspnea Cough Large Amounts of Sputum Anorexia
Recurrent Infection Clubbing Crackles and Wheezes

Diagnosis X-Ray CT Scan Sputum Culture Tests to Find Underlying Cause

Therapeutic Interventions
Antibiotics Mucolytics, Expectorants Bronchodilators Chest Physiotherapy Oxygen Surgical Resection

Pneumonia Pathophysiology Acute Lung Infection
Inflammation and Alveolar Damage Alveoli Filled with Exudate Reduced Surface Area for Gas Exchange

Etiology Bacteria, Usually Streptococcus pneumoniae Virus Fungus- PCP
Aspiration Artificial Ventilation (VAP)- patients that are intubated and mechanically ventillated Hypostasis- hypo-ventilate due to bed rest, immobility Chemical- due to toxic chemical

At Risk Very Young Elderly Hospitalized Intubated Immunocompromised

Prevention Pneumococcal Vaccine Flu Vaccine
Coughing and Deep Breathing Hand Washing Frequent Mouth Care, Continuous Suction for VAP

Signs and Symptoms Chest Pain Fever, Chills Cough, Dyspnea
Yellow, Rusty, or Blood-tinged Sputum Crackles, Wheezes Malaise

Signs and Symptoms in Elderly
New Onset Confusion Lethargy Fever Dyspnea

Complications Pleurisy (Inflammation of the pleura)
Pleural Effusion (excess fluid in the pleural space Atelectasis (collapsed aveoli) Spread of Infection

Diagnosis Chest X-Ray Sputum Culture Blood Cultures

Antibiotics – PO or IV Antiviral Medication (Zovirax) Bronchodilators Expectorants Oxygen Fluids

Tuberculosis Pathophysiology AFB Implant on Bronchioles or Alveoli
Tubercle Formed Immune System Keeps in Check 5% to 10% Infected Become Ill May Activate with Impaired Immunity

At Risk Elderly Alcoholics Those Living in Crowded Conditions
New Immigrants Those with HIV

Signs and Symptoms Cough Blood-tinged Sputum Night Sweats
Anorexia and Weight Loss Low-grade Fever Dyspnea, Chest Pain (Late)

Diagnostic Tests PPD Skin Test Chest X-Ray Sputum Cultures
QuatifFERON-TB Gold

Combination of Drugs for 6 to 24 Months INH Rifampin Streptomycin Ethambutol Occasional Surgical Removal Isolation

Nursing Diagnoses: Lower Respiratory Disorders
Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Activity Intolerance

Impaired Gas Exchange Monitor Position Administer Oxygen
Lung Sounds, Respiratory Rate And Effort Dsypnea Mental Status SpO2, 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 Every 2 Hours Daily or Ambulate Suction PRN Consider CPT or Mucus Clearance Device

Ineffective Breathing Pattern
Monitor Respiratory Rate, Depth, Effort ABGs, SpO2 Determine/Treat Cause Position Teach Diaphragmatic Breathing

Activity Intolerance Monitor Response to Activity
Vital Signs SpO2 Use Portable O2 for Ambulation Allow Rest Between Activities Obtain Bedside Commode Increase Activity Slowly Refer to Pulmonary Rehabilitation

Additional Diagnoses for TB
Risk for Ineffective Self Health Management Teach Patient and Family Consider Visiting Nurse/DOT Risk For Infection Transmission Maintain Isolation Precautions

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

Restrictive Disorders
Reduced Compliance Limited Chest Wall Expansion

Pleurisy Pathophysiology Etiology
Inflammation of Visceral and Parietal Pleurae Friction Between Pleurae on Inspiration Etiology Secondary to Pneumonia, TB, CA, PE

Signs and Symptoms Sharp Pain on Inspiration Shallow Breathing
Fever, Elevated WBC Friction Rub

Pain Management Treat Underlying Cause

Pleural Effusion Pathophysiology
Excess Fluid Between Visceral and Parietal Pleurae Pleural Fluid Not Reabsorbed May Collapse Lung

Etiology Transudative Pleural effusions can result from:
Heart Failure Liver or Kidney Disease Exudative can result from: Pneumonia TB CA

Signs and Symptoms Dyspnea Pain Cough Tachypnea Diminished Lung Sounds

Diagnostic Tests Chest X-Ray Thoracentesis Tests to Determine Cause

Treat Underlyng Cause Analgesics Thoracentesis/Chest Tube

Pulmonary Fibrosis Pathophysiology Etiology Injury to Alveoli
Scarring, Fibrosis Impaired Gas Exchange Etiology Heredity Virus Environmental/ Occupational Exposure Immune Dysfunction Idiopathic

Pulmonary Fibrosis Pathophysiology Complications
Formation of scar tissue in lung tissue after inflammation or irritation Cigarette smoking, frequent aspiration, or exposure to environmental or occupational substances Complications Pulmonary hypertension, cor pulmonale, and ventilatory failure-which is end-stage disease

Signs and Symptoms Progressive Dyspnea Crackles Chronic Cough Fatigue
Clubbing

Diagnosis Chest X-Ray CT Scan Bronchoscopy Lung Biopsy
ANA Titer- autoimmune disorder

Glucocorticoids Immune Suppressants Smoking Cessation Oxygen Flu/Pneumonia Vaccines Pulmonary Rehabilitation Lung Transplant

Atelectasis Pathophysiology Etiology
Collapse of Alveoli Etiology Hypoventilation Most commonly occurs in post surgical patients who do not cough and deep breath effectively

Signs and Symptoms Fine Crackles Diminished Breath Sounds Dyspnea

Prevention Cough and Deep Breathe Incentive Spirometer Turn Ambulate

Nursing Diagnoses: Restrictive Disorders
Impaired Gas Exchange Ineffective Breathing Pattern Acute Pain

Obstructive Disorders
Airway Obstruction Difficult Exhalation

COPD Combination of Chronic Airflow Limitation Chronic Bronchitis
Emphysema (Asthma) Chronic Airflow Limitation

COPD (cont’d)

Pathophysiology Chronic Bronchitis
Chronic Inflammation Low-grade Infection Hypertrophied Mucous Glands in Bronchi Impaired Ciliary Function Ineffective Airway Clearance Diagnosed After Ill 3 Months of Year for 2 Consecutive Years

Pathophysiology (cont’d)
Emphysema Destruction of Alveolar Walls Loss of Elastic Recoil Damage to Pulmonary Capillaries Air Trapping Impaired Gas Exchange

Types of Emphysema

COPD Etiology Smoking Passive Smoke Exposure Pollutants
Familial Predisposition Α1AT Deficiency (Emphysema)

Effects of Smoking

Prevention Smoking!!

Signs and Symptoms Cough Sputum Production Dyspnea
Prolonged Expiration Barrel Chest Activity Intolerance

Chronic Bronchitis Signs and Symptoms
Wheezing, Crackles Chronic Cough Dyspnea Thick, Tenacious Sputum Increased Susceptibility to Infection Mucous Plugs

Pathophysiology Chronic bronchitis
Bronchial inflammation; increased production of mucus and chronic cough that persist for at least 3 months of the year for 2 consecutive years and by impaired ciliary action Cause: inhaled irritants, e.g., cigarette smoke Initially only large airways are affected but smaller ones eventually become affected as well Mucus obstructs the airway causing air to be trapped in the distal portion of the lungs, hypoxia can develop Cor pulmonale: right-sided heart failure secondary to pulmonary disease

Emphysema Signs and Symptoms
Diminished Breath Sounds Dyspnea Progressive Activity Intolerance

Pathophysiology Emphysema
Degenerative, nonreversible disease: enlargement of the airways beyond the terminal bronchioles Two types of Emphysema Centrilobular emphysema Associated with cigarette smoking; affects mainly the respiratory bronchioles Panlobular emphysema-Affects the respiratory bronchioles and the alveoli- usually a hereditary deficiency of enzymes inhibitor alpha-titrypsin

Complications of COPD Cor Pulmonale Weight Loss Pneumothorax
Respiratory Failure

Diagnostic Tests Chest X-Ray CT Scan ABGs CBC Spirometry
Sputum Analysis

Stop Smoking!! Oxygen 1 to 2 L/m Supportive Care Pulmonary Rehab Surgery (LVRS) Mechanical Ventilation End-of-Life Planning Medications Bronchodilators Corticosteroids Expectorants NMT/MDI

Pulmonary Rehabilitation

Asthma Pathophysiology Inflammation of Bronchial Mucosa
Spasm of Bronchial Smooth Muscles Air Trapping Usually Reversible Airway Remodeling

Pathophysiology: Acute Episode
Patients have attacks of varying degrees, attacks have two distinct phases Early phase- Begins when “triggers” activate the inflammatory process Airways constrict and become edematous Mucous secretion increases, forming plugs in the airways, and tenacious sputum is produced Obstruction causes air to be trapped in the alveoli, creating a ventilation-perfusion mismatch (perfused with blood but not fresh air) Effect is hypoxemia with compensatory hyperventilation Acute episodes begin within 30 to 60 minutes after exposure to trigger and resolve 30 to 90 minutes later

Pathophysiology 2nd is the Late phase
Begins 5 to 6 hours after the early phase response when airway inflammation is pronounced Red and white blood cells infiltrate swollen tissues of the airways During this phase, which lasts several hours or days, the airways are hyperreactive (very sensitive) Risk for another episode until phase subsides When no specific trigger can be identified, the patient may be said to have “intrinsic” asthma Asthma with known triggers: “extrinsic” asthma

Etiology Heredity Airborne Allergies Pollution Smoking

Triggers Smoking Allergens Infection Sinusitis Emotional upset GERD

Signs and Symptoms Dyspnea, productive cough, use of accessory muscles of respiration, audible expiratory wheezing, tachycardia, and tachypnea

Complication Status Asthmaticus Severe, Sustained Asthma
Worsening Hypoxemia Respiratory Alkalosis Progresses to Respiratory Acidosis May Be Life-threateningStatus Asthmaticus- Severe persistent bronchospasm, if not corrected can lead to right sided heart failure, pneumothorax, worsening hypoxia, acidosis, and respiratory or cardiac arrest.

Diagnostic Tests History and Physical Examination Spirometry ABGs
Allergy Skin Testing

Monitor With Peak Flow Meter- patients personal best Avoid Triggers Avoid Smoking

Peak Flow Chart

Therapeutic Interventions (cont’d)
Bronchodilators Adrenergic (Albuterol) Leukotriene Inhibitors (Accolate, Singulair) Theophylline (Rare)

Corticosteroids Inhaled, IV, PO Mast Cell Inhibitors (Exercise Induced) Antihistamines Oxygen PRN

Cystic Fibrosis Pathophysiology Etiology Exocrine Gland Disorder
Thick Tenacious Secretions Blocked Pancreatic Enzymes Etiology Heredity

Cystic Fibrosis Hereditary disorder characterized by dysfunction of the exocrine glands and production of thick, tenacious mucus Cough is the first pulmonary symptom Becomes productive of thick, purulent sputum; obstructs airways Results in obstruction of the pancreatic ducts so that pancreatic enzymes cannot be delivered to the GI tract- patients can not absorb fats, proteins, and fat soluble vitamins

Signs and Symptoms Thick, Tenacious Sputum
Frequent Respiratory Infections Finger Clubbing Malabsorption Fatty, Foul-smelling Stools Death from Antibiotic-resistant Infection

Diagnostic Tests “Kiss Your Baby” Campaign Sweat Chloride Test

Hydration Inhaled Mucolytic Medication Bronchodilators, Corticosteroids Expectorants Chest Physiotherapy Antibiotics

Prevent Infection Pancreatic Enzyme Replacement (Pancrease, Viokase) Ibuprofen May Slow Lung Deterioration Lung Transplant

Nursing Diagnoses: COPD
Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Activity Intolerance Imbalanced Nutrition Anxiety

Patient Education Assist Patient to Stop Smoking!
Pulmonary Rehabilitation Breathing Exercises Energy Conservation

Pulmonary Embolism (PE)
Pathophysiology Blood Clot in Pulmonary Artery Ventilation-perfusion Mismatch Impaired Gas Exchange Lung Infarction

Pulmonary Embolism (PE) (cont’d)

Etiology DVT Most Common Fat Emboli From Compound Fracture
Amniotic Fluid Emboli During L&D

Prevention of Pulmonary Embolism
Regular Ambulation Prompt Treatment of DVT In High-risk Patients Warfarin (Coumadin) Enoxaparin Heparin

Signs and Symptoms Sudden Onset Dyspnea Tachycardia Tachypnea Cough
Crackles Hemoptysis

Diagnosis Spiral CT Scan Lung Scan Angiogram D-Dimer

Thrombolytics Heparin Warfarin (Coumadin) Oxygen Embolectomy (Rare) Jugular or Femoral Filter for Recurrent PE

Nursing Diagnoses Impaired Gas Exchange
Risk for Injury Related to Anticoagulant Use

Pulmonary Arterial Hypertension
Pathophysiology Elevated Pressure in Pulmonary Arteries Right Ventricular Failure Etiology Unknown- tends to have a hereditary tendency Most common in women ages 20-40 Secondary: CAD, Valve Disease

Signs and Symptoms Dyspnea Fatigue Crackles Cyanosis Tachypnea

Diagnostic Tests ABGs Cardiac Catheterization ECG
Additional Tests to Find Cause

No cure except for lung or heart lung transplant Low-sodium Diet Diuretics Vasodilators Oxygen Warfarin

Nursing Care Monitor Respiratory Status Bedrest Positioning
Comfort Measures

Pneumothorax Pathophysiology Air in the Intrapleural Space
Complete or Partial Collapse of Lung

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

Diagnostic Tests History and Physical Examination Bedside Ultrasound
Chest X-Ray ABGs, SpO2

Monitor ABGs and Respiratory Status Chest Tube to Water Seal Drainage Pleurodesis (Sclerosis) for Recurrent Collapse- Inject TCN or sterile talc into the pleural space irritating the pleural membrane and making them stick together

Nursing Care Monitor Respiratory Status Monitor Chest Drainage System
Report Changes Promptly

Rib Fractures Etiology Care Trauma Cough CPR Control Pain
Encourage Coughing and Deep Breathing Promote Adequate Ventilation

Flail Chest Cause Care Multiple Rib Fractures
Ribcage Not Able to Maintain Bellows Action Care Monitor ABGs Mechanical Ventilation

Flail Chest An injury in which two adjacent ribs on the same side of the chest are broken into two or more segments Affected section of the rib cage is, in a sense, detached from the rest of the rib cage Permits it to move independently: moves in with inspiration and out with expiration known as Paradoxial movement, ventilation is impaired and the patient becomes hypoxemic, contusion of underlying lung tissue may cause fluid to accumulate in the alveoli

Flail Chest Medical treatment
If patient can maintain adequate oxygenation, treatment may consist of deep breathing and coughing, IPPB treatment, and pain management The patient in respiratory distress usually requires intubation and mechanical ventilation

Nursing Diagnoses: Chest Trauma
Impaired Gas Exchange Ineffective Breathing Pattern Acute Pain

Acute Respiratory Failure
Pathophysiology Hypoventilation Unable to Maintain ABGs

Etiology COPD Aspiration Neurological Disease

Signs and Symptoms Worsening ABGs Increasing Dyspnea
Restlessness, Confusion Lethargy Coma and Death

Diagnostic Tests ABGs Tests to Determine Cause PaO2 <60 mm Hg
PaCO2 >50 mm Hg Tests to Determine Cause

Oxygen Bronchodilators Correct Underlying Cause Intubation and Ventilation Check Advance Directives

Acute Respiratory Distress Syndrome (ARDs)
Pathophysiology Alveolocapillary Membrane Damage Pulmonary Edema Alveolar Collapse Lungs Stiff and Noncompliant Lungs May Hemorrhage

Etiology Acute Lung Injury
Sepsis Shock Aspiration Not Usually in Patients with Chronic Respiratory Disease

Signs and Symptoms Dyspnea Elevated RR Fine Crackles
Respiratory Acidosis Restlessness, Confusion Death Rate 45% to 50%

Signs and Symptoms Etiology and risk factors
Progressive pulmonary disorder that follows trauma to the lung Pulmonary infiltrates develop and lung compliance decreases Signs and symptoms Increased respiratory rate; fine crackles; restlessness, agitation, and confusion; pulse rate increases, and cough may be present

Diagnostic Tests ABGs Chest X-Ray ECG Tests to Determine Cause

Oxygen Intubation Mechanical Ventilation Treat Underlying Cause Supportive Care

Nursing Diagnoses: Respiratory Failure
Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Activity Intolerance Anxiety Disturbed Thought Processes Self-care Deficit

Lung Cancer Small Cell Lung Cancer Large Cell Carcinoma Adenocarcinoma
Squamous Cell Carcinoma

Lung Cancer Pathophysiology- 2 major categories
Small cell (“oat cell”) lung carcinoma (SCLC) Non–small cell lung carcinoma (NSCLC) Squamous cell carcinomas, adenocarcinomas, large cell carcinomas, and bronchial carcinoids Small cell and large cell undifferentiated carcinomas grow rapidly: other lung cancers grow slowly All can metastasize to other body organs SCLCs, which grow rapidly, tend to metastasize early Can invade the pericardium, causing pericardial effusion and possibly triggering dysrhythmias

Etiology Smoking Environmental Tobacco Smoke Other Carcinogens
Smokers 13 Times More Likely to Develop Cancer as Nonsmokers Environmental Tobacco Smoke Other Carcinogens Asbestos Arsenic Pollution

Signs and Symptoms None Until Late Productive Cough
Recurrent Infection Dyspnea Hemoptysis Anorexia and Weight Loss Pain Wheezing/Stridor

Complications Pleural Effusion Superior Vena Cava Syndrome
Ectopic Hormone Secretion ADH (SIADH) ACTH (Cushing’s Syndrome) PTH (Hypercalcemia) Actelectasis Metastasis

Diagnostic Tests Chest X-Ray CT Scan Sputum Analysis Biopsy
Additional Tests to Find Metastasis

Lung Cancer

Stage (TNM System) Chemotherapy (Usually Palliative) Radiation (Usually Palliative)

Nursing Diagnoses: Lung Cancer
Impaired Gas Exchange Ineffective Airway Clearance Imbalanced Nutrition Pain Constipation Anticipatory Grieving Activity Intolerance

Thoracic Surgery Pneumonectomy Lobectomy Resection
VATS- Video assisted thorascopic surgery Transplant

Preoperative Care Monitor Respiratory Status Teach
Routine Pre-op Teaching What to Expect Visit SICU Include Family

Postoperative Care Intensive Care Setting Monitor Ventilator
Vital Signs SpO2, ABGs Hemodynamic Parameters Lung Sounds Ventilator Chest Tubes

Nursing Diagnoses Ineffective Airway Clearance Impaired Gas Exchange
Acute Pain Impaired Physical Mobility Risk for Infection

Nursing Care of Patients with Lower Respiratory Tract Disorders

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Nursing Care of Patients with Lower Respiratory Tract Disorders

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