• Bacteria, usually Streptococcus

Chapter 31 pneumoniae
• Virus
Nursing care of patients with • Fungus
lower respiratory tract disorders • Aspiration
• Artificial ventilation (ventilator-
associated pneumonia [V A P])
INFECTIOUS DISORDERS • Chemical
§ Persons at risk
BRONCHIECTASIS • Very young
§ Pathophysiology • Elderly
• Chronic infection • Hospitalized
• Dilation of one or more large bronchi • Intubated
• Airway obstruction • Immunocompromised
§ Etiology § Prevention
• Secondary to cystic fibrosis, asthma, • Pneumococcal vaccine
tuberculosis (T B) • Flu vaccine
• Infection & inflammation of the • Coughing and deep breathing
airways in these disorders weaken • Handwashing
bronchial walls & reduce ciliary • Frequent mouth care, continuous
action suction for V A P
§ Signs and symptoms § Signs and symptoms
• Dyspnea • Chest pain
• Cough: can produce 200 mL of • Fever, chills
thick, foul smelling sputum in • Cough, dyspnea
single episode of cough • Yellow, rusty, or blood-tinged
• Anorexia sputum
• Recurrent infection • Crackles, wheezes
• Clubbing • Malaise
• Crackles and wheezes § Signs and symptoms in elderly
§ Diagnostic tests • New onset
• X-ray ‒ Confusion
• CT scan ‒ Lethargy
• Sputum culture ‒ Fever
§ Therapeutic interventions ‒ Dyspnea
• Antibiotics: (Azithromycin) § Complications
• Mucolytics, expectorants: relax • Pleurisy
smooth muscles in airways • Pleural effusion
• Bronchodilators: loosen • Atelectasis: collapsed alveoli
secretions • Spread of infection
• Chest physiotherapy (C P T) § Diagnostic tests
• Oxygen • Chest x-ray
• Surgical resection • Sputum culture
• Blood cultures
PNEUMONIA § Therapeutic interventions
§ Pathophysiology • Antibiotics: By mouth (P O) or I
• Acute lung infection V
• Inflammation and alveolar • Antiviral medication
damage • Bronchodilators
• Alveoli filled with exudate • Expectorants
• Reduced surface area for gas • Oxygen
exchange • Fluids
§ Etiology

TUBERCULOSIS
§ Pathophysiology
• Acid-fast bacillus implant on
bronchioles or alveoli
• Tubercle formed: seals off the
bacteria and prevents spread
• Immune system keeps in check
• 5% to 10% infected become ill
• May activate with impaired
immunity
§ Persons at risk
• Elderly
• Alcoholics
• Those living in crowded
conditions
• New immigrants
• Those with H I V
§ Signs and symptoms
• Cough
• Blood-tinged sputum
• Night sweats
• Anorexia and weight loss
• Low-grade fever
• Dyspnea, chest pain (late)
§ Diagnostic tests
• Purified protein derivative skin
test
• Chest x-ray
• Sputum cultures
• QuantiFERON-T B and T-SPOT
tests
§ Therapeutic interventions
• Combination of drugs for 6 to 24
months
‒ Isoniazid
‒ Rifampin
‒ Ethambutol
‒ Pyrazinamide
• Occasional surgical removal
• Isolation of patients who have
active TB
• High efficiency filtration mask
NURSING DIAGNOSES FOR LOWER
RESPIRATORY DISORDERS
IMPAIRED GAS EXCHANGE
§ Monitor
• Lung sounds, respiratory rate and
effort
• Dyspnea
• Mental status
• Peripheral capillary oxygen
saturation (S p O subscript 2),
arterial blood gases (A B G’s)
§ Position
• Fowler
• “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 as needed (P R N).
§ Consider C P T or mucus clearance
device.
INEFFECTIVE BREATHING PATTERN
§ Monitor
• Respiratory rate, depth, effort
• A B G’s, S p O subscript 2
§ Determine/treat cause
§ Position
§ Teach diaphragmatic breathing.
ACTIVITY INTOLERANCE
§ Monitor response to activity.
• Vital signs
• S p O subscript 2
§ Use portable O subscript 2 for ambulation.
§ Allow rest between activities.
§ Obtain bedside commode.
§ Increase activity slowly.
§ Refer to pulmonary rehabilitation.
RESTRICTIVE DISORDERS
PLEURISY (PLEURITIS)
§ Pathophysiology
• Inflammation of visceral and
parietal pleurae
• Friction between pleurae on
inspiration
 § Etiology • Scarring, fibrosis
• Secondary to pneumonia, T B, • Impaired gas exchange
cancer § Etiology
§ Signs and symptoms • Heredity
• Sharp pain on inspiration • Virus
• Shallow breathing • Environmental/
• Fever, elevated white blood cells occupational exposure
• Friction rub • Immune dysfunction
§ Diagnostic tests • Idiopathic
• Chest x-ray § Signs and symptoms
• CBC • Progressive dyspnea
• Forced vital capacity (F V C), • Crackles
forced expiratory volume in 1 • Chronic cough
second (F E V1) • Fatigue
• Tests to determine cause • Clubbing
§ Therapeutic interventions § Diagnostic tests
• Pain management • Chest x-ray
• Treat underlying cause • C T scan
• A B G’s
PLEURAL EFFUSION • Bronchoscopy
§ Pathophysiology • Lung biopsy
• Excess fluid between visceral and • Antinuclear antibodies titer
parietal pleurae § Therapeutic interventions
• Pleural fluid not reabsorbed • Pirfenidone (Esbriet)
• May collapse lung • Nintedanib (Ofev)
§ Etiology • Smoking cessation
• Transudative • Oxygen
‒ Heart failure • Flu/pneumonia vaccines
‒ Liver or kidney disease • Pulmonary rehabilitation
• Exudative • Lung transplant
‒ Pneumonia
‒ TB ATELECTASIS
‒ Cancer § Pathophysiology
§ Signs and symptoms • Collapse of alveoli
• Dyspnea § Etiology
• Pain • Hypoventilation
• Cough § Signs and symptoms
• Tachypnea • Fine crackles
• Diminished lung sounds • Diminished breath sounds
§ Diagnostic tests • Dyspnea
• Chest x-ray  Therapeutic interventions
• Thoracentesis • Prevention
• Tests to determine cause ‒ Cough and deep breathe
§ Therapeutic interventions ‒ Incentive spirometer
• Treat underlying cause ‒ Turn
• Analgesics ‒ Ambulate
• Thoracentesis/chest tube
OBSTRUCTIVE DISORDERS:
PULMONARY FIBROSIS
airway obstruction & difficult
§ Pathophysiology exhalation
• Injury to alveoli
CHRONIC OBSTRUCTION • Barrel chest
PULMONARY DISEASE (COPD) • Activity intolerance
§ Combination of § Complications
• Chronic bronchitis • Cor pulmonale
• Emphysema (asthma) • Weight loss
§ Chronic airflow limitation • Pneumothorax
§ Pathophysiology ‒ Bullae
• Chronic bronchitis ‒ Blebs
‒ Chronic inflammation • Respiratory failure
‒ Low-grade infection § Diagnostic tests
‒ Hypertrophied mucous • Chest x-ray
glands in bronchi • C T scan
‒ Impaired ciliary function • A B G’s
‒ Ineffective airway • CBC
clearance • alpha1 A T level
• Spirometry
‒ Diagnosed after ill for 3
• Sputum analysis
months of year for 2
§ Therapeutic interventions
consecutive years
• Stop smoking!
• Signs and symptoms
• Oxygen
‒ Wheezing, crackles
• Supportive care
‒ Chronic cough
• Pulmonary rehabilitation
‒ Dyspnea • Surgery
‒ Thick, tenacious sputum • Endobronchial valve
‒ Increased susceptibility • Mechanical ventilation
to infection • End-of-life planning
‒ Mucous plugs • Medications
• Emphysema ‒ Bronchodilators
‒ Destruction of alveolar ‒ Corticosteroids
walls ‒ Expectorants
‒ Loss of elastic recoil • Nebulized mist
‒ Damage to pulmonary treatments/metered-dose inhalers
capillaries
‒ Air trapping
‒ Impaired gas exchange ASTHMA
• Signs and symptoms § Pathophysiology
‒ Diminished breath • Inflammation of bronchial
sounds mucosa
‒ Dyspnea • Spasm of bronchial smooth
‒ Progressive activity muscles
intolerance • Air trapping
§ Etiology • Usually reversible
• Smoking • Airway remodeling
• Passive smoke exposure § Etiology
• Pollutants • Heredity
• Familial predisposition • Airborne allergies
• Alpha-1 antitrypsin (alpha1 A T) • Pollution
deficiency (emphysema) • Smoking
§ Signs and symptoms § Triggers
• Cough • Smoking
• Sputum production • Allergens
• Dyspnea • Infection
• Prolonged expiration
 • Sinusitis • Finger clubbing
• Exercise • Malabsorption
• Stress • Fatty, foul-smelling stools
• Some medications • Death from antibiotic-resistant
§ Signs and symptoms infection
• Dyspnea § Diagnostic tests
• Wheezing • Genetic testing
• Cough • Blood immunoreactive
• Sputum trypsinogen
• Use of accessory muscles • “Kiss your baby” campaign
• May be worse at night • Sweat chloride test
§ Complication • Chest x-ray
• Status asthmaticus • Spirometry
‒ Severe, sustained asthma • Gastrointestinal testing
‒ Worsening hypoxemia § Therapeutic interventions
‒ Respiratory alkalosis • Hydration
progresses to respiratory • Inhaled mucolytic medication
acidosis • Inhaled hypertonic saline
‒ May be life-threatening • Bronchodilators, corticosteroids
§ Diagnostic tests • Expectorants
• History and physical examination • CPT
• Spirometry • Prevent infection
• A B G’s • Antibiotics
• Allergy skin and blood testing • Dornase alfa (Pulmozyme)
§ Therapeutic interventions • Ivacaftor (Kalydeco)
• Monitor with peak flow meter. • Pancreatic enzyme replacement
• Avoid triggers. (Pancrease, Viokase)
• Avoid smoking. • Ibuprofen may slow lung
• Bronchodilators deterioration.
‒ Short-acting beta • Lung transplant
agonists (S A B A’s),
long-acting beta agonists PULMONARY EMBOLISM
(L A B A’s) § Pathophysiology
‒ Leukotriene inhibitors: • Blood clot in pulmonary artery
Zafirlukast (Accolate), • Ventilation-perfusion mismatch
montelukast (Singulair) • Impaired gas exchange
• Corticosteroids • Lung infarction
‒ Inhaled, I V, P O § Etiology
• Combined inhaled L A B A with • Deep vein thrombosis (D V T)
corticosteroid most common
• Oxygen as needed • Fat emboli from compound
fracture
CYSTIC FIBROSIS • Amniotic fluid emboli during
§ Pathophysiology labor and delivery
• Exocrine gland disorder § Prevention
• Thick tenacious secretions • Regular ambulation
• Blocked pancreatic enzymes • Prompt treatment of D V T
§ Etiology • Anticoagulant medication in
• Heredity high-risk patients
§ Signs and symptoms § Signs and symptoms
• Thick, tenacious sputum • Sudden onset dyspnea
• Frequent respiratory infections • Tachycardia
• Tachypnea
 • Cough
• Crackles RIB FRACTURES
• Hemoptysis § Etiology
§ Diagnostic tests • Trauma
• D-dimer • Cough
• Spiral C T scan • CPR
• Lung scan § Care
• Angiogram • Control pain.
§ Therapeutic interventions • Encourage coughing and deep
• Thrombolytics breathing.
• Anticoagulants • Promote adequate ventilation.
• Oxygen
• Embolectomy (rare) FLAIL CHEST
• Jugular or femoral filter for § Cause
recurrent pulmonary embolism • Multiple rib fractures
• Ribcage not able to maintain
PNEUMOTHORAX bellows action
§ Air in the intrapleural space § Care
• Complete or partial collapse of • Monitor A B G’s
lung • Mechanical ventilation
§ Types (shown in illustration)
A. Spontaneous pneumothorax ACUTE RESPIRATORY FAILURE
B. Traumatic pneumothorax § Pathophysiology
C. Tension pneumothorax with • Hypoventilation
mediastinal shift • Unable to maintain A B G’s
§ Signs and symptoms § Etiology
• Shallow, rapid respirations • COPD
• Asymmetrical chest expansion • Aspiration
• Dyspnea • Neurological disease
• Chest pain • Opioid overdose
• Absent breath sounds over § Signs and symptoms
affected area • Worsening A B G’s
§ TENSION PNEUMOTHORAX: Signs • Increasing dyspnea
and symptoms • Restlessness, confusion
• Tracheal deviation • Lethargy
• Bradycardia • Coma and death
• Cyanosis § Diagnostic tests
• Shock and death if untreated • A B G’s
§ Diagnostic tests ‒ Partial pressure of
• History and physical examination oxygen (P a O subscript
• Bedside ultrasound 2) <60 millimeters of
• Chest x-ray mercury
• A B G’s, S p O subscript 2 ‒ Partial pressure of carbon
§ Therapeutic interventions dioxide (P a C o
• Monitor A B G’s and respiratory subscript 2) >50
status millimeters of mercury
• Chest tube to water seal drainage • Tests to determine cause
• Pleurodesis (sclerosis) for § Therapeutic interventions
recurrent collapse • Oxygen to maintain S p O
§ Nursing care subscript 2 88% to 92%
• Monitor respiratory status. • Bronchodilators
• Monitor chest drainage system. • Correct underlying cause
• Report changes promptly.
 • Intubation and ventilation ‒ Pollution
‒ Check advance directives § Signs and symptoms
§ None until late
ACUTE RESPIRATORY DISRESS § Productive cough
SYNDROME (ARDS) § Recurrent infection
§ Pathophysiology § Dyspnea
• Alveolocapillary membrane § Hemoptysis
damage § Anorexia and weight loss
• Pulmonary edema § Pain
• Alveolar collapse § Wheezing/stridor
• Lungs stiff and noncompliant § Complications
• Lungs may hemorrhage § Pleural effusion
§ Etiology § Superior vena cava syndrome
• Acute lung injury § Ectopic hormone secretion
‒ Sepsis ‒ Antidiuretic hormone (A
‒ Shock D H; syndrome of
‒ Aspiration inappropriate A D H [S I
• Not usually in patients with A D H])
chronic respiratory disease ‒ Adrenocorticotropic
§ Signs and symptoms hormone (A C T H;
• Dyspnea Cushing syndrome)
• Elevated respiratory rate § Metastasis
• Fine crackles § Diagnostic tests
• Respiratory acidosis § Chest x-ray
• Restlessness, confusion § C T scan
• Death rate 40% § Sputum analysis
§ Diagnostic tests § Biopsy
• A B G’s § Additional tests to find metastasis
• Chest x-ray § Therapeutic interventions
• C T scan § Stage (tumor-node-metastasis
• Electrocardiogram system)
• Tests to determine cause § Chemotherapy (usually palliative)
§ Therapeutic interventions § Radiation (usually palliative)
• Oxygen
• Intubation THORACIC SURGERY
• Mechanical ventilation § Pneumonectomy
• Treat underlying cause § Lobectomy
• Supportive care § Resection
§ Video-assisted thoracoscopic surgery
LUNG CANCER § Transplant
§ Preoperative care
§ Small cell lung cancer
§ Monitor respiratory status
§ Large cell carcinoma
§ Teach
§ Adenocarcinoma
§ Squamous cell carcinoma ‒ Routine pre-op teaching
§ Etiology ‒ What to expect
§ Smoking ‒ Visit surgical intensive
‒ Smoking causes 80% to care unit
90% of lung cancers. ‒ Include family
§ Environmental tobacco smoke § Postoperative care
§ Other carcinogens § Intensive care setting
‒ Asbestos § Monitor
‒ Arsenic ‒ Vital signs
 ‒ S p O subscript 2, A B
G’s
‒ Hemodynamic
parameters
‒ Lung sounds
§ Ventilator
§ Chest tubes