1. Timby/Smith: Introductory Medical-Surgical Nursing, 10/e
Chapter 21: Caring for Clients with Lower Respiratory Disorders

2. 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

3. Pneumonia Pathophysiology Etiology
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

4. Pneumonia At risk: Prevention (see box 21-2) 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

5. Pneumonia Diagnostics: Signs/Symptoms Chest film Blood count
Sputum C & S
Signs/Symptoms
Chest Pain
Fever, Chills
Cough, Dyspnea
Yellow, Rusty, or Blood-Tinged Sputum
Crackles, Wheezes
Malaise

6. Pneumonia Complications Signs and Symptoms in Elderly New-Onset
Pleurisy
CHF
empyema
Pleural Effusion
Atelectasis
septicemia
Signs and Symptoms in Elderly
New-Onset
Confusion
Lethargy
Fever
Dyspnea

7. Pneumonia Treatment: Antibiotic (bacterial) PO or IV Hydration
Chest physical therapy
Analgesics/Antipyretics
Antiviral Medication (Zovirax)
Bronchodilators
Expectorants or cough suppressants
Oxygen
Nursing Management

8. Pleurisy 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

9. Pleural Effusion Pathophysiology Etiology
Abnormal Fluid Collection Between Visceral, Parietal PleuraePleural Fluid Not Reabsorbed,May Collapse Lung
Etiology
Transudative
Heart Failure
Liver or Kidney Disease PE
Exudative
Pneumonia TB CA

10. 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

11. Pleural Effusion

12. Influenza 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
Yearly Vaccination(85% effective)
should not be give to clients with allergy to eggs
At-Risk Individuals
Health Care Workers
Handwashing
Avoidance of infected people

13. 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

14. 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

15. Therapeutic Interventions
Technique to destroy; Transmission
Combination of Drugs for Months (toxicity, resistance);
INH
Rifampin
PZA
Ethambutol
Streptomycin
Occasional Surgical Removal: Segmental resection; Wedge resection; Lobectomy; Pneumonectomy
Isolation
Nursing Management (see ATI pg

16. 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

17. COPD Combination of Chronic Airflow Limitation Chronic Bronchitis
Emphysema
(Asthma)
Chronic Airflow Limitation
(in & out)

18. COPD (cont’d)

19. 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

20. COPD Etiology Smoking Passive Smoke Exposure Pollutants
Familial Predisposition
α1AT Deficiency (Emphysema)

21. Effects of Smoking

22. COPD Prevention
Smoking!!

23. 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

24. 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)

25. 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

26. 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

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

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

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

30. 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

31. 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

32. 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

33. MDI

34. Spacer

35. NMT

36. Incentive Spirometer

37. Chest Physiotherapy

38. Pulmonary Rehabilitation

39. Asthma
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

40. Asthma Triggers Complication Smoking Status Asthmaticus Allergens
Infection
Sinusitis
Stress
GERD
Complication
Status Asthmaticus
Severe, Sustained Asthma
Worsening Hypoxemia
Respiratory Alkalosis Progresses to Respiratory Acidosis
May Be Life Threatening

41. Asthma

42. Asthma Therapeutic Interventions
Monitor with Peak Flow Meter
Avoid Triggers
Avoid Smoking

43. 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

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

45. Impaired Gas Exchange Monitor Position Administer Oxygen
Lung Sounds, Respiratory Rate and Effort
Dsypnea
Mental Status
SaO2, ABGs
Position
Fowler’s
Good Lung Down
Administer Oxygen
Teach Breathing Exercises
Discourage Smoking

46. 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

47. Ineffective Breathing Pattern
Monitor
Respiratory Rate, Depth, Effort
ABGs, SaO2
Determine/Treat Cause
Position
Teach Diaphragmatic Breathing

48. 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

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

50. Postural Drainage

51. 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

52. 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

53. Pulmonary Hypertension

54. Pulmonary Embolism Pathophysiology Etiology
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

55. Pulmonary Embolism

56. 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

57. 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

58. 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

59. Respiratory Failure

60. 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

61. 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

62. 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

63. 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

64. Lung Cancer Etiology Smoking Environmental Tobacco Smoke
Smokers 13× as Likely to Develop Cancer as Nonsmokers
Environmental Tobacco Smoke
Other Carcinogens
Asbestos
Arsenic
Pollution

65. Lung Cancer Diagnostic Tests
Chest X-Ray
CT, PET Scan
MRI
Sputum Analysis
Biopsy
Additional Tests to Find Metastasis

66. 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

67. Therapeutic Interventions
Factor dependent, esp. on tumor classification, Stage (TNM System)
Chemotherapy (Usually Palliative)
Radiation (Usually Palliative)

68. Lung Cancer Complications
Pleural Effusion
Superior Vena Cava Syndrome
Ectopic Hormone Secretion
ADH (SIADH)
ACTH (Cushing’s Syndrome)
Actelectasis
Metastasis

69. Thoracic Surgery
Remove, repair chest wall traumas, tumors; Obtain biopsy sample
Thoracotomy
Thoracentesis
Pneumonectomy
Lobectomy
Resection
Transplant

70. Thoracic Surgery Preoperative Care
Monitor Respiratory Status
Teach
Routine Preop Teaching
What to Expect
Visit SICU
Include Family

71. 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

72. Thoracic Surgery

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

74. 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

75. Pneumothorax Diagnostic Tests Therapeutic Interventions
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

76. 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

77. Chest Drainage System

78. Thoracic Surgery

79. 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

80. End of Presentation