Ignatavicius: Medical-Surgical Nursing, 6th Edition

Chapter 32: Care of Patients with Noninfectious Lower Respiratory Problems

Key Points – Print

Chapter 32 provides an overview of common noninfectious conditions of the lower respiratory

tract.
• Lower airway disorders affect gas exchange, oxygenation, and tissue perfusion.
• Many problems are chronic and progressive, requiring changes in lifestyle.

First, let’s review the diseases characterized by chronic airflow limitation such as asthma,
chronic bronchitis, and pulmonary emphysema.
• Asthma is an intermittent disease with reversible airflow obstruction and wheezing, affecting
only the airways.
• With poor control of asthma, chronic inflammation leads to damage and hyperplasia of the
bronchial epithelial cells and smooth muscle.
• Airway obstruction can occur as a result of inflammation, which obstructs the lumen of the
airways, or from airway hyperresponsiveness.
• Patients have episodes of dyspnea, chest tightness, coughing, wheezing (which is louder on
exhalation), increased mucus production, and accessory muscle use.
• Pulse oximetry demonstrates hypoxemia related to the degree of dyspnea.
• Laboratory tests include arterial blood gases, serum eosinophil count, immunoglobulin E
levels, and sputum cultures.
• The most accurate tests for asthma are pulmonary function tests.
• The goals of therapy are to improve airflow, relieve symptoms, and prevention.
• Pharmacologic management includes bronchodilators, anti-inflammatory agents, and
leukotriene inhibitors.
• Daily preventive therapy drugs change airway responsiveness to prevent asthma attacks.
• Rescue drugs are those used to stop an attack.
• Aerobic exercise assists in maintaining cardiac health, enhancing skeletal muscle strength,
and promoting ventilation and perfusion.
• Patients must be able to self-assess respiratory status, adjust the frequency and dosage of
prescribed drugs, and determine when to consult the health care provider.
• Teach patients with chronic airflow limitation how to use a peak flowmeter, since readings
determine if rescue treatment is working.
• Teach the patient who has a reading in the red zone to immediately use the rescue drugs and
seek emergency help.
• Remind patients with asthma to have their rescue inhalers with them at all times.
• Status asthmaticus is a severe, life-threatening, acute episode of airway obstruction that
intensifies once it begins and often does not respond to common therapy. It requires
immediate emergency treatment.

Now, let’s review key points about emphysema and chronic bronchitis.
• Emphysema and chronic bronchitis are termed chronic obstructive pulmonary disease and

Copyright © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

 result in irreversible and increasingly severe tissue damage.
• Pulmonary emphysema involves loss of lung elasticity and hyperinflation of the lung,
causing dyspnea, increased respiratory rate, and, eventually, cardiac failure.
• Bronchitis is an inflammation of the bronchi and bronchioles caused by chronic exposure to
irritants, especially tobacco smoke, triggering inflammation with vasodilation, congestion,
mucosal edema, and bronchospasm.
• Chronic obstructive pulmonary disease is classified from mild to severe.
• Arterial blood gases identify oxygenation, ventilation, and acid-base status.
• Good management strategies help maintain adequate oxygenation and tissue perfusion, as
well as overall health, even with irreversible damage.
• Careful use of drugs combined with controlled coughing, hydration, postural drainage, and
flutter valves may help in airway clearance.
• Nursing management includes airway maintenance, monitoring, drug therapy, cough
enhancement, oxygen therapy, and pulmonary rehabilitation.
• Remember to assess the airway and breathing for patients who experience shortness of breath or
changes in mental status, and apply oxygen to anyone who is hypoxemic.
• Ensure proper oxygen flow rate for patients with long-term carbon dioxide retention.
• Teach patients to monitor the peak expiratory flow rates at home and adjust drugs.
• Teach the patient techniques of pursed-lip breathing, diaphragmatic breathing, coughing and deep
breathing, positioning, relaxation therapy, and energy conservation,
• Lung transplantation and lung reduction surgery are surgical treatments.
• The goal of lung reduction surgery is improvement of gas exchange through removal of
hyperinflated lung tissue.

Another respiratory condition, primary pulmonary hypertension, occurs in the absence of lung
disorders from unknown causes, mostly in women between the ages of 20 and 40 years.
• About 50% of patients with the disorder have a genetic mutation.
• Dyspnea and fatigue are early symptoms in an otherwise healthy adult, with angina-like chest pain
occurring in some.
• Nonsurgical interventions that reduce pulmonary pressures and slow the development of cor
pulmonale involve drugs that dilate pulmonary vessels and prevent clot formation.
• Surgical management involves single-lung or whole-lung transplantation.

REVIEW
Choose the correct statement concerning chronic obstructive pulmonary disease.
A. Emphysema increases lung elasticity and hyperinflates the lung.
B. Apply 100% oxygen to patients with long-term chronic obstructive disease to ensure adequate
ventilation.
C. Use of certain drugs combined with pulmonary hygiene and flutter valves may help in
airway clearance.
D. Inflammation of the bronchioles results in vasoconstriction, congestion, wheezing, and
bronchospasm.

How to Use an Inhaler Correctly*

Key Points – Print 32-
3
With a Spacer
1. Before each use, remove the caps from the inhaler and the spacer.
2. Insert the mouthpiece of the inhaler into the non-mouthpiece end of the spacer.
3. Shake the whole unit vigorously three or four times.
4. Place the mouthpiece into your mouth and over your tongue, and seal your lips tightly
around it.
5. Press down firmly on the canister of the inhaler to release one dose of medication into
the spacer.
6. Breathe in slowly and deeply. If the spacer makes a whistling sound, you are breathing
in too rapidly.
7. Remove the mouthpiece from your mouth, and, keeping your lips closed, hold your
breath for at least 10 seconds. Then breathe out slowly.
8. Wait at least 1 minute between puffs.
9. Replace the caps on the inhaler and the spacer.
10. Rinse mouth without swallowing the water.
11. At least once a day, remove the canister from the inhaler and clean the plastic case
and cap of the inhaler by thoroughly rinsing in warm, running tap water. At least once a
week, clean the spacer in the same manner.

Without a Spacer (Preferred Technique)

1. Before each use, remove the cap and shake the inhaler according to the instructions in
the package insert.
2. Tilt your head back slightly, and breathe out fully.
3. Open your mouth, and place the mouthpiece 1 to 2 inches away.
4. As you begin to breathe in deeply through your mouth, press down firmly on the
canister of the inhaler to release one dose of medication.
5. Continue to breathe in slowly and deeply (usually over 3 to 5 seconds).
6. Hold your breath for at least 10 seconds to allow the medication to reach deep into the
lungs. Then breathe out slowly.
7. Wait at least 1 minute between puffs.
8. Replace the cap on the inhaler.
9. Rinse mouth without swallowing the water.
10. At least once a day, remove the canister and clean the plastic case and cap of the
inhaler by thoroughly rinsing in warm, running tap water.

Ignatavicius: Medical-Surgical Nursing, 6th Edition

Chapter 33: Care of Patients with Infectious Respiratory Problems

Key Points – Print

Chapter 33 provides an overview of respiratory diseases caused by infectious organisms.

We will review key points concerning the most common infectious respiratory disorders.
.
• Influenza is a highly contagious acute viral respiratory infection that
can occur in adults of all ages sometimes leading to complications of
pneumonia or death.
• People recommended to receive the flu vaccine each year include those
older than 50 years of age, people with chronic illness or immune
compromise, those living in institutions, people living with or
caring for adults with health problems, and health care personnel

Copyright © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

 providing direct care to patients.
• Pneumonia is an excess of fluid in the lungs resulting from an
inflammatory process triggered by many infectious organisms or by
inhalation of irritating agents.
• Ventilator-associated pneumonia is on the rise, especially among
patients with endotracheal tubes in place for mechanical ventilation.
Risk can be reduced with conscientious assessment and meticulous
nursing care.
• Chest x-ray continues to be the most common diagnostic test for
pneumonia, but may not show changes until 2 or more days after
manifestations are present.
• Assess any older patient who has acute confusion for pneumonia, since
they may not have a cough or fever.
• Incentive spirometry, also referred to as sustained maximal inspiration,
is used to improve inspiratory muscle performance and to prevent or
reverse atelectasis.
• Severe acute respiratory syndrome or SARS is a new virus from a
family of virus types known as coronaviruses.
• This family of viruses causes many forms of the common cold, but SARS
is a mutated form of the coronavirus and is more virulent than most
members of this virus family.
• The virus is easily spread by airborne droplets from infected individuals.
• Ask any patient with a respiratory infection if he or she is from a foreign
country or has recently visited a foreign country.

REVIEW
Which of the following is NOT an effective means of preventing the spread of infectious respiratory
diseases?
A. Washing hands after blowing the nose or using a tissue
B. Using airborne precautions for any patient who has TB or SARS manifestations until proven
otherwise
C. Covering your mouth with your hand when coughing
D. Encouraging the families of TB patients to ventilate their homes with outside air