1. Nursing Management of Lower Respiratory Problems JSB

2. Acute Bronchitis Inflammation of the bronchi Supportive treatments – Fluids – Rest – Anti-inflammatory agents – Cough suppressants – Antiviral drugs – Mucolytic medications

3. Pertussis Highly contagious infection Whooping cough Gram-negative bacillus Symptoms same as bronchitis Treatment is antibiotics

4. Pneumonia Acute inflammation of lung caused by microbial organism – Previously, leading cause of death in the United States from infectious disease Discovery of sulfa drugs and penicillin decreased morbidity and mortality rates. 4

5. Etiology Likely to result when defense mechanisms become incompetent or overwhelmed ↓ Cough and epiglottal reflexes may allow aspiration 5

6. Etiology Mucociliary mechanism impaired – Pollution – Cigarette smoking – Upper respiratory infections – Tracheal intubation – Aging 6

7. Etiology Three ways organisms reach lungs: – Aspiration from nasopharynx or oropharynx – Inhalation of microbes such as Mycoplasma pneumoniae – Hematogenous spread from primary infection elsewhere in body 7

8. Types of Pneumonia Community-acquired pneumonia – Lower respiratory infection of lung – Onset in community or during first 2 days of hospitalization 8

9. Types of Pneumonia Community-acquired pneumonia – Highest incidence in midwinter – Smoking important risk factor 9

10. Types of Pneumonia Organisms implicated – Streptococcus pneumoniae – Haemophilus influenzae – Legionella – Mycoplasma – Chlamydia 10

11. Types of Pneumonia Three-step approach to treatment – Assess ability to treat at home. – Calculate PORT (Pneumonia Patient Outcomes Research Team). – Make clinician decision for inpatient or outpatient. 11

12. Types of Pneumonia HAP, VAP, HCAP – HAP: Occurring 48 hours or longer after admission and not incubating at time of hospitalization – VAP: Occurring more than 48 hours after endotracheal intubation 12

13. Types of Pneumonia Risk factors for HAP – Immunosuppressive therapy – General debility – Endotracheal intubation 13

14. Types of Pneumonia Treatment is based on – Known risk factors – Severity of illness – Early (5 days post admission) or late (more than 5 days post admission) onset MDR organisms are major problem in treating HCAP. 14

15. Types of Pneumonia Aspiration pneumonia – Sequelae occurring from abnormal entry of secretions into lower airway 15

16. Types of Pneumonia Aspiration pneumonia – Usually with history of loss of consciousness Gag and cough reflexes suppressed – Forms of aspiration pneumonia Mechanical obstruction Chemical injury Bacterial infection 16

17. Types of Pneumonia Opportunistic pneumonia – Patients at risk Severe protein-calorie malnutrition Immune deficiencies Chemotherapy/radiation recipients Long-term corticosteroid therapy 17

18. Types of Pneumonia Causes of opportunistic pneumonia – Bacterial and viral causative agents – Pneumocystis jiroveci (PCP) – Cytomegalovirus – Fungi 18

19. Types of Pneumonia Clinical manifestations of PCP – Fever – Tachypnea – Tachycardia – Dyspnea – Nonproductive cough – Hypoxemia 19

20. Pathophysiology Stage 1: Congestion from outpouring of fluid to alveoli – Organisms multiply. – Infection spreads. – Interferes with lung function 20

21. Pathophysiology Stage 2: Red hepatization – Massive dilation of capillaries – Alveoli fill with organisms, neutrophils, RBCs, and fibrin. Causes lungs to appear red and granular, similar to liver 21

22. Pathophysiology Gray hepatization – ↓ Blood flow – Leukocyte and fibrin consolidate in affected part of lung. 22

23. Pathophysiology Resolution – Resolution and healing if no complications – Exudate lysed and processed by macrophages – Tissue restored 23

24. Pathophysiologic Course of Pneumococcal Pneumonia 24 Fig. 28-1. Pathophysiologic course of pneumococcal pneumonia.

25. Clinical Manifestations CAP symptoms – Sudden onset of fever – Shaking chills – Shortness of breath – Cough productive of purulent sputum – Pleuritic chest pain 25

26. Clinical Manifestations Physical examination findings – Dullness to percussion – ↑ Fremitus – Bronchial breath sounds – Crackles 26

27. Clinical Manifestations Atypical manifestations – Gradual onset – Dry cough – Extrapulmonary manifestations – Crackles 27

28. Clinical Manifestations Initial manifestations are highly variable in viral pneumonia. – Primary pneumonia can be caused by influenza viral infection. – Can be a complication of systemic viral disease 28

29. Complications Pleurisy Pleural effusion – Usually is sterile and reabsorbed in 1 to 2 weeks or requires thoracentesis 29

30. Complications Atelectasis – Usually clears with cough and deep breathing Bacteremia – Bacterial infection in the blood 30

31. Complications Lung abscess – Seen when caused by S. aureus and gram-negative pneumonias Empyema – Requires antibiotics and drainage of exudate 31

32. Complications Pericarditis – Spread of microorganism to heart Meningitis – Patient who is disoriented, confused, or somnolent should have lumbar puncture. 32

33. Complications Endocarditis – Microorganisms attack endocardium and heart valves. 33

34. Diagnostic Tests History Physical examination Chest x-ray Gram stain of sputum Sputum culture and sensitivity Pulse oximetry or ABGs 34

35. Diagnostic Tests CBC, differential, chemistries Blood cultures 35

36. Collaborative Care Antibiotic therapy Oxygen for hypoxemia Analgesics for chest pain Antipyretics 36

37. Question A patient diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? – A. Administer the ordered oral antibiotic STAT. – B. Order the meal tray to be delivered as soon as possible. – C. Obtain a sputum specimen for culture and sensitivity. – D. Have the unlicensed assistive personal weigh the client.

38. Collaborative Care Fluid intake at least 3 L per day Caloric intake at least 1500 per day 38

39. Collaborative Care Pneumococcal vaccine – Indicated for those at risk Chronic illness such as heart and lung disease, diabetes mellitus Recovering from severe illness 65 or older In long-term care facility 39

40. Nursing Assessment History – Lung cancer – COPD – Diabetes mellitus – Debilitating disease – Malnutrition – AIDS 40

41. Nursing Assessment History – Use of antibiotics, corticosteroids, chemotherapy, or immunosuppressants – Recent abdominal or thoracic surgery – Smoking – Alcoholism – Respiratory infections 41

42. Nursing Assessment Prolonged bed rest Dyspnea Nasal congestion Pain with breathing 42

43. Nursing Assessment Sore throat Muscle ache Fever Restlessness 43

44. Nursing Assessment Splinting affected area Tachypnea Asymmetric chest movements Use of accessory muscles 44

45. Nursing Assessment Crackles Green or yellow sputum Tachycardia Changes in mental status 45

46. Nursing Assessment Leukocytosis Abnormal ABGs Pleural effusion Pneumothorax on x-ray 46

47. Nursing Diagnoses Ineffective breathing pattern Ineffective airway clearance Acute pain 47

48. Nursing Diagnoses Imbalanced nutrition: Less than body requirements Activity intolerance 48

49. Planning Clear breath sounds Normal breathing patterns No signs of hypoxia Normal chest x-ray No complications related to pneumonia 49

50. Nursing Implementation Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance. Prompt treatment of URIs Strict asepsis 50

51. Nursing Implementation Encourage those at risk to obtain influenza and pneumococcal vaccinations. Reposition patient every 2 hours. Elevate head of bed 30 to 45 degrees for patients with feeding tube. 51

52. Nursing Implementation Assist patients at risk for aspiration with eating, drinking, and taking medications. Assist immobile patients with turning and deep breathing. 52

53. Nursing Implementation Emphasize need to take course of medication(s). Teach drug–drug interactions. 53

54. Evaluation Dyspnea not present SpO 2 ≥ 95 Free of adventitious breath sounds Clear sputum from airway 54

55. Evaluation Reports pain control Verbalizes causal factors Adequate fluid and caloric intake Performs activities of daily living 55

56. Question During the assessment of a patient with pneumonia, the nurse suspects the development of a pleural effusion upon finding: 1. A barrel chest. 2. Paradoxical respirations. 3. Hyperresonance on percussion. 4. Localized absence of breath sounds. 56

57. Case Study 88-year-old woman who lives alone Feeling weaker over past 2 days, and last night became confused and disoriented 57

58. Case Study Housekeeper notified her daughter, who brought her to the clinic. She complains of coughing over the past 3 days but has no other history. 58

59. Case Study Examination findings – Bronchial breath sounds and dullness of left posterior lung base with egophony – O 2 Sat 87% 59

60. Case Study Examination findings – WBC 18,000/µL – Segs 85% – Bands 15% – PA/lat chest x-ray: Lobar infiltrate – Sputum gram stain: Gram-positive diplococci, many WBCs 60

61. Discussion Questions 1.What are the risk factors for her developing pneumonia? 2.What is her priority of care? 61

62. Discussion Questions 3.What important teaching should you provide to the patient and family? 62

63. Tuberculosis Infectious diseases caused by mycobacterium tuberculosis Gram positive Acid – fast bacillus Spread via airborne droplets – Contact with in 6 inches of persons mouth

64. Clinical Manifestation Classification -Table 28-8 Positive skin test Fatigue Malaise Anorexia Unexplained weight loss Low grade fever Night sweats Mucopurulent sputum HIV high risk

65. Complications Miliary TB – Spread via blood stream to all body organs Pleural effusion and empyema Tuberculosis pneumonia Other organ involvement

66. Diagnostic Studies Tuberculin Skin Test Chest x-ray AFB test (acid fast bacilli)

67. Collaborative Care Drug therapy – Isoniazid – Rifampin – Pyrazinamide – Ethambutol – Rifabutin – Rifapentine – Fluoroquinolones – Table 28-11

68. Nursing Management Ethical dilemmas Health promotion Acute intervention Ambulatory and home care

69. Fungal infections of the lung Table 28-14 Candidiasis Pheumosystis Pneumonia (PCP) Amphotericin B standard of care

70. Chest Trauma and Thoracic Injuries JSBrinley, RN, MSN/Ed, CNE

71. Types Blunt – Steering-wheel – Shoulder-harness seat belt – crush Penetrating – Stab wound – Gunshot wound

72. Types of Pneumothorax Closed pneumothorax Open pneumothorax Tension pneumothorax Hemothorax Chylothorax

73. Manifestations Tachycardia Dyspnea Hypoxemia Chest pain Cough Absent breath sounds CXR shows the presence of air or fluid in the plural space and reduction in lung volume

74. Question The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax A. Bronchovesicular lung sound and bradypnea. B. Unequal lung expansion and dyspnea. C. Frothy, bloody sputum and consolidation. D. Barrel chest and polycythemia

75. Collaborative Care Medical emergency! Thoracentesis Chest tube insertion and water seal drainage system

76. Fractured Ribs Most common type of chest injury resulting from blunt trauma – Complication is pneumonia from atelectasis Flail chest – Fracture of two or more ribs – Apparent on visual examination – Asymmetric and uncoordinated chest movement – Treatment is mechanical ventilation

77. Chest tubes and Pleural Drainage Chest tube insertion Flutter or heimlich valve Plural drainage Three compartments – Collection chamber – Water-seal chamber – Suction control chamber

78. Nursing Management of Chest Drainage Table 28-23 Know this table!

79. Question The client had a right-sided chest tube inserted two (2) hours ago for a pheumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? – A. Obtain an order for a STAT chest x-ray. – B. Increase the amount of wall suction. – C. Check the tubing for kinks or clots. – D. Monitor the client’s pulse oximeter reading.

80. Question Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? – A. Gentle bubbling in the suction compartment. – B. No fluctuation (tidaling) in the water-seal compartment. – C. The drainage compartment has 250 mL of blood – D. The client is able to deep breathe without any pain.

81. Question The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply – A. Place the client in the low fowler’s position. – B. Assess chest tube drainage system frequently. – C. Maintain strict bedrest for the client. – D. Secure a loop of drainage tubing to the sheet. – E. Observe the site for subcutaneous emphysema.

82. Chest Surgery Baseline assessment Encourage patient to stop smoking Teach deep breathing and cough exercises Explain purpose of chest tube and oxygen supplement

83. Types Thoracotomy Video-Assisted Thoracic Surgery (VAT)

84. Post-Op Care 28-2 pg 574

85. Plural Effusion Abnormal collection of fluid in the plural space Empyema Manifestations – Dyspnea – Decreased movement of the chest wall – Pain – Absent breath sounds – Fever night sweats, cough and weight loss – CXR reveal volume and location of the effusion

86. Pulmonary Edema Abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs Causes – Heart failure – Overhydration with intravenous fluids – Hypoalbuminemia Nephrotic syndrome, hepatic disease, nutritional disorders – Altered capillary permeability of lungs Toxins, inflammation, severe hypoxia, near drowning – Malignancies of the lymph system – Respiratory distress syndrome – Unknown causes

87. Pulmonary Embolism Is a blockage of pulmonary arteries by a thrombus, fat, air, or tumor tissue Causes – DVT – Atrial fibrillation – Fat emboli – Bacterial vegetations – Amniotic fluid – Tumors

88. Pulmonary Embolism – Most common risk factors Immobility Surgery Stroke Paresis Paralysis Obesity Smoking hypertension

89. Manifestation of PE Dyspnea Chest pain Hemoptysis Hypoxemia Abrupt hypotension Vague symptoms Can be difficult to diagnose

90. Complications Of PE Pulmonary infarction pulmonary hypertension – Diagnostic studies CT V/Q D-dimer – Measures the amount of cross-linked fibrin fragments

91. Treatment of PE See pg 579