III.

RESPONSES TO
ALTERATIONS/PROBLEMS AND ITS
PATHOPHYSIOLOGIC BASIS IN LIFE-
THREATENING CONDITIONS, ACUTELY ILL
/MULTI-ORGAN PROBLEMS, HIGH
ACUITY, AND EMERGENCY SITUATION
 1
Physical Assessment
 SUBJECTIVE DATA
CURRENT HEALTH
STATUS
• FOCUS ON THE CLIENTS
PRESENTING PROBLEM
EXPLORE THE ONSET
LOCATION, DURATION,
CHARACTER AGGRAVATING
ALLEVIATING FACTORS
RADIATION (IF RELEVANT)
WHAT WILL YOU
ASK?
COUGH

ORTHOPNEA
CHEST PAIN
PAST
HEALTH
HISTORY
-IDENTIFICATION OF
PREVIOUS HEALTH
PROBLEMS
-CHILDHOOD
ILNESS
-IMMUNIZATION
-SMOKING HISTORY
-ALCOHOL HISTORY
Family history
Ask the patient if anyone in his family
has had cancer, diabetes, sickle cell
anemia, heart disease, or a chronic
illness, such as asthma or
emphysema. Be sure to determine
whether the patient lives with
anyone who has an infectious
disease, such as influenza or
tuberculosis (TB).
Lifestyle patterns
The patient’s history should also include
information about lifestyle, community,
and other environmental factors that
might affect his respiratory status or how
he deals with respiratory problems. Most
importantly, ask the patient if he smokes;
if he does, ask when he started and how
many cigarettes he smokes per day. Also
ask about interpersonal relationships,
mental status, stress management, and
coping style
OBJECTIVE DATA
Inspection Palpation
Percussion Auscultation
INSPECTION

CHEST SYMMETRY
COSTAL ANGLE
BREATHING RATE AND
PATTERN
CYANOSIS
CLUBBING
PALPATION
CREPITUS
PAIN
FREMITUS
CHEST WALL
EXPANSION
PERCUSSION
PERCUSSING THE
CHEST

PERCUSSING THE
DIAPHRAGM
AUSCULTATION NORMAL BREATH SOUNDS
VOCAL FREMITUS (Bronchophony, Egophony, Whispered pectoriloguy)
 2
Common Diagnostic
Assessments
 A. Non Invasive
1. Pulse Oximetry or SPO2
 continuously monitoring the
oxygen saturation of hemoglobin
(SaO2).
 A probe or sensor is attached to the
fingertip, forehead, earlobe, or
bridge of the nose.
 Normal Value: 95-100%
Special Considerations
 Place the probe or clip over the finger or other intended sensor site so
that the light beams and sensors are opposite each other
 Protect the transducer from exposure to strong light.
 Check the transducer site frequently to make sure the device is in
place and examine the skin for abrasion and circulatory impairment.
 Rotate the transducer at least every 4 hours to avoid skin irritation.
 If oximetry has been performed properly, the saturation readings are
usually within 2% of ABG values
B. iNVASIVE
1. Arterial Blood Gas
assessing the ability of the lungs to provide adequate oxygen and remove
carbon dioxide, which reflects ventilation, and the ability of the kidneys to
reabsorb or excrete bicarbonate ions to maintain normal body pH, which
reflects metabolic states.
Nursing considerations
• Blood for an ABG analysis should be drawn from an arterial line if the patient has one.
• The brachial, radial, or femoral arteries can be used.
• After the sample is obtained, apply pressure to the puncture site for 5 minutes and tape a gauze pad firmly in
place.
• Regularly monitor the site for bleeding, and check the arm for signs of complications, such as swelling,
discoloration, pain, numbness, and tingling.
• Make sure you note on the slip whether the patient is breathing room air or oxygen. If oxygen, document the
number of liters.
• If the patient is receiving mechanical ventilation, document the fraction of inspired oxygen. Also include the
patient’s temperature on the slip; results may be corrected if the patient has a fever or hypothermia.
 ACID BASE IMBALANCE
RESPIRATORY- ALKALOSIS
-INCRASE RR-HYPERVENTILATION-
ACID OUT
RESPIRATORY- ACIDOSIS
-LESS CO2 OUT THE MORE ACIDIC
-DECREASE RR
METABOLIC-ALKALOSIS
-VOMITING
-NGT SUCTIONING
METABOLIC-ACIDOSIS
-DIARRHEA (BASE OUT OF THE BUTT)
-RENAL FAILURE( KIDNEYS FAIL ACID
PREVAILS)
-DKA-KETONES-ACID
 ABG
INTERPRETATION
STEP BY STEP
1. Look at the PH
5. ANALYZE!
Normal Range: 7.35 – 7.45
HCO3 is dealt with by the KIDNEYS
if the PH is HIGH this is ALKALOSIS
So remember!!
if the PH is LOW this is ACIDOSIS
If HCO3 is BASE = METABOLIC
2. Check PaCO2 /PCO2
6. INTERPRET which is affected?
Normal Range 35 – 45 mm
Respiratory or metabolic?
CO2 is ACIDIC
If PaCO2 is mostly affected its RESPIRATORY
So if PaCO2 is HIGH this is ACIDOSIS
If HCO3 is mostly affected its METABOLIC
If PaCO2 is LOW this is ALKALOSIS
THEN, PH result
if it is ACIDOSIS or ALKALOSIS
3. ANALYZE!
CO2 is eliminated or held in by the LUNGS
7.Partial Compensated = EITHER IS TRYING TO
so remember!!
BALANCE OR COMPENSATE
If CO2 is ACIDIC = RESPIRATORY
fully compensated= BOTH TRYING TO BALANCE OR
COMPENSATE WITH EACH OTHER
4. Check the HCO3
Normal Range: 22-26

ABG INTERPRETATION
HCO3 (bicarb) is a BASE
So if HCO3 is HIGH, This is ALKALOSIS
if HCO3 LOW this is ACIDOSIS
NORMAL VALUES
PH 7.35-7.45
PACO2 (48,47,46)45-35 (34,33,32,31,30..)
HCO3 22-26
 TRY IT!!
WHY NOT??

PH= 7.50
PaCO2 = 47
HCO3 = 32
 OTHER
TECHNIQUE
TIKTOK
 EXAMPLE
PH = 7.23
Paco2 = 48
HCO3 = 25
ACID NORMAL ALKALOTIC
NORMAL VALUES
PH 7.35-7.45
PACO2 45-35
(48,47,46) (34,33,32,31,30..)

HCO3 22-26
 B. iNVASIVE
2. Pulmonary Capillary Wedge
pressure
 PCWP is the left atrial pressure
measurement obtained by the
passing of a catheter from the
right side of the heart into the
pulmonary artery, wedging it
into a small pulmonary branch

 Measures PCWP by using

“ Swan-Ganz Catheter”
 B. iNVASIVE
3. Pleural Fluid analysis
 Pleural Fluid is a liquid present in the
space between the chest wall and the
outer lining of lungs (PLEURA).
 Pleural fluid analysis is done to identify
the reason of pleural effusion
 Normal Result : a volume less than 20
millilitres of yellowish, clear serous
fluid
 Abnormal Result: Pleural fluid with
redish color, Pleural fluid with a thick
and cloudy apperance
 B. iNVASIVE
4. Pulmonary Angiography
 Pulmonary angiography involves an
x-ray examination of the
pulmonary vessels after
intravenous (IV) administration of
a radiopaque dye.
 A catheter is inserted into the
femoral, brachial, or jugular vein
and threaded through the heart to
the pulmonary artery, where the
dye is injected
 B. iNVASIVE
5. Ventilation-Perfusion scan (V/Q scan)
 This procedure is used clinically to measure the integrity of the pulmonary
vessels relative to blood flow and to evaluate blood flow abnormalities.
 A V/Q lung scan use a low-risk radioactive substance that can be traced by a
special type of scanner obtaining a scan of the chest to detect radiation.
 The isotope particles pass through the right side of the heart and are
distributed into the lungs in proportion to the regional blood flow, making it
possible to trace and measure blood perfusion through the lung.
 The patient takes a deep breath of a mixture of oxygen and radioactive gas,
which diffuses throughout the lungs.
 A scan is performed to detect ventilation abnormalities in patients who have
regional differences in ventilation.
 It may be helpful in the diagnosis of bronchitis, asthma, inflammatory
fibrosis, pneumonia, emphysema, and lung cancer.
 4
Conditions with altered
ventilator Functions
COPD
 Chronic Obstructive Pulmonary Disease
● Chronic obstructive pulmonary disease (COPD)
refers to long term pulmonary disorders
characterized by air flow resistance
● Having COPD makes it hard to breathe.
● progressive respiratory disease characterized by
the combination of signs and symptoms
of emphysema and bronchitis. It is a common
disease, affecting tens of millions of people and
causing significant numbers of deaths globally.
● There are two main forms of COPD:

○ Chronic bronchitis, which involves a long-term

cough with mucus

○ Emphysema, which involves damage to the lungs

over time
Risk Factors
 Smoking (ranks first)
 Air pollution
 Exposure to industrial
chemical
 Hereditary deficiency
of enzyme alpha-
antitrypsin

EMPHYSEMA
• Destruction of alveolar walls resulting in
decreased elastic recoil of lungs
• Types
1. Panacinar-involves alveoli and extends
to the central bronchioles
2. Centriacinar- Affects the bronchioles in
the central part of the repiratory lobules
CHRONIC BRONCHITIS
• Excessive mucus production with
productive cough and impaired
ciliary function which decreased
mucus clearance
“Smoker cough”
Repeated lung inflammation
damages the lungs causing a
scarring of the airway
EMPHYSEMA-PINK PUFFER CHRONIC BRONCHITIS-BLUE BLOATER

DIAGNOSTIC
following signs and symptoms may • Pulse Oximeter
occur: • Chest Xray
• reduced ability to exercise or do • ABG
strenuous work • Spirometry
• productive cough • Pulmonary Function test
• CT scan
• dyspnea with minimal exertion.
• Alpha 1-antitypsin screening levels
GRADES OF COPD
Common Types of Bronchodilator Medications
for Chronic Obstructive Pulmonary Disease
pathophysiology
 Nursing Responsibilities
• Urge the patient to stop smoking and to avoid other respiratory
irritants.
Management • Explain that bronchodilators alleviate bronchospasm and
enhance mucociliary clearance of secretions.
 SMOKING CESSATION • Familiarize the patient with prescribed bronchodilators.
 BRONCHODILATORS Teach or reinforce the correct method of using an inhaler.
 OXYGEN • To strengthen the muscles of respiration, teach the patient to
 ADEQUATE HYDRATION take slow, deep
 CHEST PHYSIOTHERAPHY
breaths and exhale through pursed lips.
 NEBULIZER TREATMENTS
 MUCOLYTICS
• Teach the patient how to cough effectively to help mobilize
 CORTICOSTEROIDS secretions. If secretions
 DIURETIC are thick, urge the patient to maintain adequate hydration.
• If the patient will continue oxygen therapy at home, teach him
how to use the
equipment correctly.
• administer 1 to 2 liters of low-flow oxygen because of carbon
dioxide retention.
PULMONARY
EMBOLISM
 PULMONARY EMBOLISM
● CLINICAL MANIFESTATION
● is a life-threatening
disorder typically caused
by blood clots in the
lungs.
● where emboli
mechanically obstruct
the pulmonary vessels,
cutting off the blood
supply to sections of the
lung
dyspnea for no apparent
reason.
Pleuritic chest pain
Tachypnea, gasping for
breath and appear anxious.
Tachycardia.
Auscultation may reveal
crackles or a friction rub.
If lung infarction has
occurred, hemoptysis
Some patients have no
symptoms at all.
Types of pulmonary emboli

The most common is pulmonary thromboembolism, which occurs when venous

thrombi, chiefly from the lower extremities, migrate to the pulmonary
circulation
Risk factors

symptomps
Classic triad of PE
● Dyspnea
● Pleuritic chest pain
● Hemoptysis

The most predictive physical finding

for pulmonary embolism is not in the
chest but the leg: a swollen, tender,
warm, and reddened calf that provides
evidence for deep venous thrombosis
DIAGNOSTIC TEST
-chest Xray
-CT Pulmonary angiography ( standard)
-ECG (RULE OUT MI)
-ABG
-ELEVATED D-DIMER
-V/Q scan
 Medical-Surgical Management
 Warfarin therapy can be initiated 2 to 3 days after
 The body naturally dissolves clots in 7 to 10 days. However, if the
embolism is large, a thrombolytic agent might be used. These
agents, such as streptokinase, urokinase, reteplase and tissue
plasminogen activator (t-PA), dissolve clots and are very
effective. However, they must be used within 4 to 6 hours of the
clot’s occurrence and are associated with a risk for hemorrhage. 
 treatment is aimed at preventing extension of the clot and the 
formation of additional clots.
 Heparin, a potent anticoagulant medication, is administered via
continuous intravenous infusion.
 Heparin is never given intramuscularly because of the risk of
hematoma development.
 Sometimes heparin therapy is initiated even before a diagnosis of
PE is made.
 Oxygen is administered as ordered.
 Intubation and mechanical ventilation may be required in some
cases.
 Warfarin sodium (Coumadin), an oral anticoagulant, is used for at 
least 3 to 6 months following PE to prevent recurrence.
the initiation of heparin therapy.
 Because it has a slow onset of action, it may require
several days for the full anticoagulant effect to
occur.
The patient will be on both anticoagulants for a time.
Warfarin therapy is monitored regularly with
prothrombin time (PT) and international normalized
ratio (INR).
 In patients with life-threatening symptoms, a
surgical embolectomy can be performed. This is a
rare procedure that is reserved for emergency
situations.
 Transvenous catheter embolectomy. This is a technique in
which a vacuum-cupped catheter is introduced transvenously
into the affected pulmonary artery.
Interrupting the vena cava. This approach prevents
dislodged thrombi from being swept into the lungs while
allowing adequate blood flow
 Nursing Responsibilities
● Monitor coagulation studies and report results to the physician. Anticoagulant therapy
may be adjusted as often as every 6 hours based on laboratory results.
● Protect the patient from injury so that excessive bleeding does not occur.
● Encourage the patient to wear shoes or slippers when ambulating to protect from
injury.
● Teach patient to use a soft toothbrush and an electric razor to prevent injury.
● Avoid use of IM injections. IM injection can result in hematoma in an anticoagulated
patient.
● Instruct the patient to report any signs of bleeding, such as hematuria or easy bruising.
● Bleeding may be associated with excessively prolonged clotting and may require a
change in anticoagulant dosing or administration of an antidote.
ACUTE RESPIRATORY
DISTRESS SYNDROME
 ACUTE RESPIRATORY DISTRESS SYNDROME
● ARDS closely resembles severe pulmonary edema. results from
increased permeability of the alveolocapillary membrane.The
ETIOLOGY
acute phase of ARDS is marked by a rapid onset of severe dyspnea ● sepsis.
that usually occurs less than 72 hours after the precipitating ● Pneumonia
event ● Trauma
● Shock
● narcotic overdose
● inhalation of irritants, burns
● pancreatitis (rare)
● Each of these causes begins a chain of
events leading to alveolocapillary
damage and noncardiac pulmonary edema
(pulmonary edema that is not caused by
heart failure).
● ARDS usually affects patients without a
previous history of lung disease.

Clinical Manifestation
 Initially the patient may experience dyspnea and an
increase in respiratory rate. Respiratory alkalosis
results from hyperventilation.
 Fine inspiratory crackles may be auscultated.
 As the condition worsens, breathing becomes more
rapid and labored and the patient becomes cyanotic.
 The patient is no longer able to oxygenate the blood
and get rid of carbon dioxide, and respiratory acidosis
occurs.
 Oxygen therapy does not reverse the hypoxemia. I
 ARDS is not reversed, eventually hypoxemia leads to
decreased cardiac output, shock, and death.
 Complications that can result from ARDS include
heart failure, pneumothorax related to mechanical
ventilation, infection, and disseminated intravascular
coagulation (DIC).
Medical-surgical management
 An ECG is done to rule out a cardiac-related cause.
 The patient with ARDS is cared for in an intensive care unit.
 Treatment begins with oxygen therapy that is adjusted based
on repeated ABG results.
 Intubation and mechanical ventilation are necessary in most
cases, with the use of positive end-expiratory pressure (PEEP)
to keep the airways open.
 Diuretics may be used to reduce pulmonary edema, but care
must be taken to prevent fluid depletion.
 IV fluids are administered if blood pressure or urine output is
low.
 A pulmonary artery catheter may be used to monitor
hemodynamic status. If infection is the underlying cause,
antibiotics are administered.
 Parenteral nutrition may be given to maintain nutritional
status while the patient is acutely ill.
 Positioning the patient with the less involved lung in the
dependent position (“good lung down”) allows the better lung to
be well perfused with blood and may increase PaO2
 Prone positioning has also been shown to increase oxygenation
in patients with ARDS.
1. Injury reduces normal blood
flow to the lungs, allowing
platelets to aggregate. These
platelets release substances,
such as serotonin (S), bradykinin
(B), and histamine (H), that
inflame and damage the alveolar
membrane and later increase
capillary permeability.
 2. Histamines (H) and other
inflammatory substances
increase capillary
permeability. Fluids shift
into the interstitial space.

3. As capillary permeability
increases, proteins and
more fluid leak out, causing
pulmonary edema
4. Fluid in the alveoli and decreased
blood flow damage surfactant in the
alveoli. This reduces the alveolar
cells’ ability to produce more
surfactant. Without surfactant,
alveoli collapse, impairing gas
exchange.
5. The patient breathes faster, but
sufficient oxygen (O2 ) can’t cross
the alveolar capillary membrane.
Carbon dioxide (CO2 ), however,
crosses more easily and is lost with
every exhalation. Both O2 and CO2
levels in the blood decrease.
6. Pulmonary edema worsens.
Meanwhile, inflammation leads to
fibrosis, which further impedes gas
exchange. The resulting hypoxemia
leads to respiratory acidosis
DIAGNOSTIC TEST MANAGEMENT
● ABG ● VENTILATION
● PULSE OXIMETER ● MEDICATIONS(SEDATIVES, OPIOD
● PULMONARY ARTERY OR NEUROMUSCULAR )
CATHETERIZATION ● POSITIONING
● CHEST XRAYS ● FLUID RESTRICTIONS
● NUTRITIONAL SUPPORT
● ACID-BASE BALANCE CORRECTION
● ELECTROLYTE CORRECTION
 Nursing Responsibilities
a. Record intake and output of fluid: Monitor for signs of renal insufficiency or failure (decrease in urinary output less than
30 ml/h) and monitor BUN and Creatinine.
b. Monitor for possible fluid overload—more fluid going in than coming out. Patient may end up in heart failure,
compounding the fluid building up in the lungs.
c. Weigh the patient daily—inability to handle excess fluids, causing third spacing of fluids into interstitial spaces,
increasing weight and causing edema.
d. Change position at least every 2 hours to prevent pressure build-up, causing skin breakdown.
e. Avoid overexerting the patient during treatment—patient will tire easily and will have problems with increased oxygen
demands. Also provide rest periods during activities.
f. Explain to the patient:

i. The importance of doing coughing and deep-breathing exercises—after coming off the ventilator the patient
needs to move adequate air in and out of the lungs. Coughing helps to rid the lungs of any remaining fluid.

ii. How to identify the signs of respiratory distress, any sign that symptoms may be returning: shortness of breath,
coughing, wheezing, rapid breathing, cyanosis, restlessness, or anxiety.
RESPIRATORY
FAILURE
 RESPIRATORY FAILURE
● Respiratory failure is a sudden and life-threatening deterioration of the
gas exchange function of the lung and indicates failure of the lungs to
provide adequate oxygenation or ventilation for the blood.
CLINICAL MANIFESTATION
 The patient with impending respiratory failure
may become restless, confused, agitated, or
sleepy.  use of accessory muscles, decreased breath
 Early signs are those associated with impaired sounds if the patient cannot adequately ventilate
oxygenation and may include restlessness,  Arterial blood gases show decreasing PaO2 and
fatigue, headache, dyspnea, air hunger, pH and increasing PaCO2, which lead to
tachycardia, and increased blood pressure. respiratory acidosis.
 hypoxemia progresses, more obvious signs may  The patient is cyanotic and dyspneic, and
be present, including confusion, lethargy, respiratory rate becomes rapid and deep in an
tachycardia, tachypnea, central cyanosis, effort to blow off excess CO2.
diaphoresis, and finally respiratory arrest.
 the ventilation or perfusion mechanisms in the
lung are impaired
Ventilatory failure mechanisms Oxygenation failure mechanisms
● impaired function of the central nervous system ● pneumonia, acute respiratory distress syndrome
(i.e., drug overdose, head trauma, infection, (ARDS), heart failure, COPD, PE, and restrictive
hemorrhage, and sleep apnea) lung diseases (diseases that cause decrease in lung
● neuromuscular dysfunction (i.e., myasthenia gravis, volumes).
Guillain–Barré syndrome, amyotrophic lateral
sclerosis, and spinal cord trauma)
● musculoskeletal dysfunction (i.e., chest trauma,
kyphoscoliosis, and malnutrition)
● pulmonary dysfunction (i.e., COPD, asthma, and
cystic fibrosis).
 MEDICAL SURGICAL MANAGEMENT
 Carefully assess the patient and report significant findings to the physician immediately.
 It is easy to mistakenly treat symptoms of agitation or confusion with sedatives, which will speed
the onset of respiratory failure.
 Oxygen therapy via nasal cannula or mask is provided.
 If the patient has a chronically high PaCO2, oxygen is administered at a flow rate of 1 to 2 L to
prevent interference with the hypoxic drive.
 Antibiotics or other treatments are ordered to correct the underlying cause of the failure.
 Bronchodilators promote ventilation and secretion removal.
 The patient is instructed to cough and deep breathe if able.
 Suctioning is indicated if the patient is unable to cough effectively.
 Mechanical ventilation via endoctracheal tube or noninvasive positive pressure ventilation (NIPPV)
may be required.
 Before invasive ventilation is initiated, it is important to check the patient ’s advance directives.
 Nursing responsibilities
1. Assess the patient’s degree of dyspnea on a scale of 0 to 10 if the patient is able to participate.
2. Respiratory rate, effort, and use of accessory muscles are noted.
3. Monitor:
a. Arterial blood gases and oxygen saturation values
b. The presence of cyanosis
c. Mental status, including restlessness, confusion, and level of consciousness, is also assessed,
because reduced oxygenation can produce central nervous system (CNS) symptoms.
d. Symptoms of the underlying cause of respiratory
i. If the cause is infectious, sputum amount and color, temperature, and white blood cell
counts are monitored.
e. All assessment findings should be compared with earlier data.
f. Even subtle changes in the assessment findings can be significant and should be reported
PNEUMONIA
e.Pneumonia
●
PNEUMONIAis an acute infection of the
lung parenchyma that commonly
impairs gas exchange
● Pneumonitis
● Pneumonia is caused by an infecting
pathogen (bacterial or viral) or by a
chemical or other irritant (such as
aspirated material).
● Classifications:

○ CAP

○ HAP (Nosocomial)

○ HCAP

○ VAP

○ Aspiration
CLASSIFICATION
Community Acquired
Pneumonia
• Occurs in the community setting or
<48 hours of admission
• Hospitalization depends on the
severity (CAP-LR, MR, HR)
• S. pneumoniae - 60 yo marker
• H. influenzae - older adults
• M. pneumoniae - MOT: contact with
respiratory droplets
• Primarily interstitial but may
eventually result to
bronchopneumonia
• Viruses is common for infants and
children
• Opportunistic viruses
Hospital-Acquired Pneumonia
Occurs 48 hours or more after admission
Exposure to potential bacteria from other sources
Intervention-related factors
Overuse and misuse of antimicrobial agents
Health Care-Associated Pneumonia
Pneumonia occurring in a non-
hospitalized patient with extensive
health care contact with one or more
of the following:
• Hospitalization for ≥2 days in an acute
care facility within 90 days of infection
• Residence in a nursing home or long-
term care facility
• Antibiotic therapy, chemotherapy, or
wound care within 30 days of current
infection
• Hemodialysis treatment at a hospital or
clinic
• Home infusion therapy or home wound
care
• Family member with infection due to
multidrug-resistant bacteria
Ventilator Associated Pneumonia Opportunistic Pneumonia
Seen in clients with very poor immune
A type of HAP that develops ≥48 hours after
systems: malnutrition, HIV/AIDS,
endotracheal tube intubation
transplant clients receiving steroids,
ventilator-associated pneumonia (VAP) it
cancer clients.
develops in patients who are intubated and
mechanically ventilated.
The endotracheal tube keeps the glottis
open, so secretions can be aspirated into Aspiration Pneumonia
the lungs
Entry of foreign substances into the lower
airway
Most common - aspiration of bacteria that
normally reside in the upper airways
Can occur both in the community and
hospital
Other sources: gastric contents, chemical
contents, irritating gases
CLINICAL MANIFESTATION
Fever
Pleuritic pain
DIAGNOSTIC TEST
Myalgia MEDICAL MANAGEMENT
Rash Chest Xray Pharmacologic Therapy
Sputum production Sputum GS/CS Antibiotic (C/S)
Increased tactile fremitus Bronchoscopy IV then Oral
Marked tachypnea Pulse oximeter Increase OFI
Respiratory distress ABG Nebulizer
Blood-tinged sputum Bronchodilator
Loss of appetite Antipyretic
Orthopnea Supportive Treatment
Pulse Oximetry & ABG
DETERMINATION THRU SPUTUM Oxygen Supplement
Strepto - rust-colored sputum Endotracheal Intubation and
Pseudomonas, haemophilus, pneumococcal - green sputum Mechanical Ventilator
Klebsiella - red currant jelly sputum
Anaerobic - foul-smelling or bad tasting sputum
Nursing Responsibilities
• Administer oxygen as prescribed.
• Monitor for labored respirations, cyanosis, and cold and clammy skin.
• Encourage coughing and deep breathing and use of the incentive spirometer.
• Place the client in a semi-Fowler’s position to facilitate breathing and lung expansion.
• Change the client’s position frequently and ambulate as tolerated to mobilize secretions and Provide CPT.
• Perform nasotracheal suctioning if the client is unable to clear secretions.
• Monitor pulse oximetry
• Monitor and record color, consistency, and amount of sputum.
• Provide a high-calorie, high-protein diet with small frequent meals.
• Encourage fluids, up to 3 L/day, to thin secretions unless contraindicated.
• Provide a balance of rest and activity, increasing activity gradually
• Administer antibiotics as prescribed.
• Administer antipyretics, bronchodilators, cough suppressants, mucolytic agents, and expectorants as
prescribed.
• Prevent the spread of infection by hand washing and the proper disposal of secretions.
• notify the HCP if chills, fever, dyspnea, hemoptysis, or increased fatigue occurs
• To receive a pneumococcal vaccine as recommended by the Health Care Provider
COVID 19
 Coronavirus disease (COVID-19)
● Coronavirus disease (COVID-19) is an infectious
disease caused by a newly discovered coronavirus
called SARS-CoV-2.
● First learned this virus on December 31, 2019 following
a report of a cluster of viral pneumonia in Wuhan,
People’ Republic of China.
● VARIANTS

○ BA.2.12.1

○ BA.2
 Clinical MAnifestations
The MOST COMMON SYMPTOMS OF COVID-19
-Fever Symptoms of severe COVID‐19 disease include:
-Dry cough Shortness of breath,
-Fatigue Loss of appetite,
Confusion,
OTHER SYMPTOMPSARE LESS COMMON Persistent pain or pressure in the chest,
Loss of taste or smell, High temperature (above 38 °C).
Nasal congestion, Other less common symptoms are:
Conjunctivitis (also known as red eyes) Irritability,
Sore throat, Confusion,
Headache, Reduced consciousness (sometimes associated with seizures),
Muscle or joint pain, Anxiety,
Different types of skin rash, Depression,
Nausea or vomiting, Sleep disorders,
Diarrhea, More severe and rare neurological complications such as
Chills or dizziness. strokes, brain inflammation, delirium and nerve
damage.
Which Symptoms Should You Watch For?
 Fever or chills
 Cough
 Shortness of breath or difficulty
breathing How Long After COVID Exposure
 Fatigue Could Symptoms Start?
 Muscle or body aches
 Headache symptoms can appear anywhere from two to 14 days
 New loss of taste or smell after someone is exposed to the virus.
 Sore throat
 Congestion or runny nose
But guidelines state those who were exposed should
 Nausea or vomiting watch for symptoms until at least 10 days after
 Diarrhea the last close contact with someone who had
COVID.
Anyone with symptoms should get tested.
 What is the Incubation Period for COVID and
How Long Are You Contagious?

"A person with COVID-19 is considered Regardless of symptoms, those who

infectious starting two days before they test positive are advised to take
develop symptoms, or two days before specific precautions for at least 10
the date of their positive test if they do
days.
not have symptoms," according to the
CDC.
 When Should You Get a COVID Test?
Regardless of symptoms or vaccinations, those Those who develop symptoms should get tested as
who are exposed to someone with coronavirus symptoms develop, but if a test is negative
should get tested at least five days after and symptoms persist another test might be
their exposure. needed a few days later, particularly for
those who use at-home test kits.
2022 recommendations for people with covid
ISOLATE. STAY AT HOME FOR 5 DAYS
-stay at home to keep others safe
-wear a mask ( IF YOU CANT WEAR A MASK STAY AT
HOME AND AWAT FROM PEROPLE FOR 10 DAYS)
-stay in a separate room
-Use separate bathroom if you can
DO NOT TRAVEL FOR 10 DAYS
TO CALCULATE THE RECOMMENDED TIME FRAMES, DAY 0 IS
THE DAY YOU WERE TESTED IF YOU DON’T HAVE
SYMPTOMPS, OR THE DATE YOUR SYMPTOMS
STARTED.
Contact your healthcare provider to discuss your test
results and available treatment options.
Watch for symptoms, especially fever. If you have
emergency warnig signs, such as trouble breathing or
persistent chest pain or pressure, seek emergency
medical care immediately.
DAY 6: DO A SELF CHECK.
How are you feeling?
(you could have lost your taste or smell for week or months
after you feel better. These symptoms should not delay
the end of isolation
-IF NO SYMPTOMS OR SYMPTOMS IMPROVING
no fever without fever reducing medication for 24 hours.
You can leave isolation. Keep wearing mask around other
people at home and in public for 5 more days( 6-10 days)
-IF SYMPTOMS NOT IMPROVING AND/OR STILL HAVE FEVER.
continue to stay home until 24 hours after your fever
stops without using fever reducing medication and your
symptoms have improved.
after you feel completely better, keep wearing mask
around other people at home and in public through day 10
 QUARANTINE
If you come into close contact with someone with COVID-19, you should quarantine if you
are not up-to-date on COVID-19 vaccines or are unvaccinated.
For these individuals, the CDC and IDPH recommend you:
Stay home and away from other people for at least 5 days (day 0 through day 5) after your last contact
with a person who has COVID-19. The date of your exposure is considered day 0. Wear a well-fitting
mask when around others at home, if possible.

For 10 days after your last close contact with someone with COVID-19, watch for fever (100.4◦F or
greater), cough, shortness of breath, or other COVID-19 symptoms.

If you develop symptoms, get tested immediately and isolate until you receive your test results. If you
test positive, follow isolation recommendations.
 QUARANTINE
If you do not develop symptoms, get tested at least 5 days after you last had close contact with someone with
COVID-19.
If you test negative, you can leave your home, but continue to wear a well-fitting mask when around others at
home and in public until 10 days after your last close contact with someone with COVID-19.
If you test positive, you should isolate for at least 5 days from the date of your positive test (if you do not
have symptoms). If you do develop COVID-19 symptoms, isolate for at least 5 days from the date your
symptoms began (the date the symptoms started is day 0). Follow recommendations in
the isolation section below.
If you are unable to get a test 5 days after last close contact with someone with COVID-19, you can leave
your home after day 5 if you have been without COVID-19 symptoms throughout the 5-day period. Wear
a well-fitting mask for 10 days after your date of last close contact when around others at home and in
public.
Avoid people who are have weakened immune systems or are more likely to get very sick from COVID-19, and
nursing homes and other high-risk settings, until after at least 10 days.
 QUARANTINE
If possible, stay away from people you live with, especially people who are at higher risk for getting very sick from COVID-19, as
well as others outside your home throughout the full 10 days after your last close contact with someone with COVID-19.

If you are unable to quarantine, you should wear a well-fitting mask for 10 days when around others at home and in public.

If you are unable to wear a mask when around others, you should continue to quarantine for 10 days. Avoid people who
have weakened immune systems or are more likely to get very sick from COVID-19, and nursing homes and other high-risk
settings, until after at least 10 days.

Do not travel during your 5-day quarantine period. Get tested at least 5 days after your last close contact and make sure your test
result is negative and you remain without symptoms before traveling. If you don’t get tested, delay travel until 10 days after
your last close contact with a person with COVID-19. If you must travel before the 10 days are completed, wear a well-fitting
mask when you are around others for the entire duration of travel during the 10 days. If you are unable to wear a mask, you
should not travel during the 10 days.

Do not go to places where you are unable to wear a mask, such as restaurants and some gyms, and avoid eating around others at
home and at work until after 10 days after your last close contact with someone with COVID-19.
 QUARANTINE

Those who are close contacts of someone with COVID but are up-to-date
on their vaccinations or have had a confirmed case of COVID-19 within the
last 90 days do not need to quarantine, but the CDC does recommend they
wear a well-fitting mask around others for 10 days after their most
recent exposure and get tested after at least five days.
 ISOLATION
people who are positive for COVID should stay home until it's safe for them
to be around others, including even other members of their home.
-Health officials recommend a "sick room" or area for those who are infected and a separate
bathroom, if possible.

-But isolation may not just be for those who test positive. The CDC also recommends those
who have symptoms of COVID-19 and are awaiting test results or have not yet been tested
isolate, "even if they do not know if they have been in close contact with someone with
COVID-19."
Under the CDC guidance, those in isolation
should:
1. Monitor your symptoms. If you have an emergency warning
sign (including trouble breathing), seek emergency medical care
immediately.
2. Stay in a separate room from other household members, if possible.
3. Use a separate bathroom, if possible.
4. Take steps to improve ventilation at home, if possible.
5. Avoid contact with other members of the household and pets.
6. Don’t share personal household items, like cups, towels, and utensils.
7. Wear a well-fitting mask when you need to be around other people.
 How do you end isolation?
1. You can end isolation after five full days if you are fever-free for 24 hours without
the use of fever-reducing medication and your other symptoms have improved (Loss
of taste and smell may persist for weeks or months after recovery and need not
delay the end of isolation).
2. If you continue to have fever or your other symptoms have not improved after 5 days
of isolation, you should wait to end your isolation until you are fever-free for 24
hours without the use of fever-reducing medication and your other symptoms have
improved. Continue to wear a well-fitting mask through day 10. Contact your
healthcare provider if you have questions.
3. Do not go to places where you are unable to wear a mask, such as restaurants and
some gyms, and avoid eating around others at home and at work until a full 10 days
after your first day of symptoms.
So how do you calculate your isolation
period?
"day 0 is your first day of symptoms." That means that Day 1 is the first full
day after your symptoms developed.

For those who test positive for COVID but have no symptoms, day 0 is the day of
the positive test. Those who develop symptoms after testing positive must start
their calculations over, however, with day 0 then becoming the first day of
symptoms.
PPE
MERS-COV
 Middle East respiratory syndrome
coronavirus, or MERS‐CoV
● Middle East Respiratory Syndrome (MERS) is an illness
caused by a virus (more specifically, a coronavirus)
called Middle East Respiratory Syndrome Coronavirus
(MERS-CoV). Most MERS patients developed severe
respiratory illness with symptoms of fever, cough and
shortness of breath. About 3 or 4 out of every 10
patients reported with MERS have died.
● Through first reported in Saudi Arabia, it was later
identified that the first known cases of MERS occurred
in Jordan in April 2012.
● A large MERS outbreak occurred in the Republic of
South Korea linked to a traveler from the Arabian
Peninsula in 2015.
● MERS-CoV likely came from an animal
source in the Arabian Peninsula and
humans
● In addition to humans, MERS-CoV has
been found in camels in several
countries. It is possible that some people
became infected after having contact
with camels.
● MERS-CoV, like other coronaviruses, is
thought to spread from an infected
person’s respiratory secretions, such as
through coughing. However, the precise
ways the virus spreads are not currently
well understood. MERS-CoV has spread
from ill people to others through close
contact, such as caring for or living with
an infected person.
Clinical manifestation Diagnostic test
The symptoms of MERS start to appear about 5 or 6 days after a person is ● rRT-PCR assay
exposed, but can range from 2 to 14 days. ● Serology
● Chest Xray
Most people confirmed to have MERS-CoV infection have had severe respiratory
illness with symptoms of:
● fever
● cough
● shortness of breath
● Some people also had diarrhea and nausea/vomiting.

Some laboratory-confirmed cases of MERS-CoV infection are reported as

asymptomatic, meaning that they do not have any clinical symptoms, yet they
are positive for MERS-CoV infection following a laboratory test. Most of these
asymptomatic cases have been detected following aggressive contact tracing of a
laboratory-confirmed case.
Am I at risk for MERS-CoV ?
risk for MERS-CoV infection, including
• recent travelers from the Arabian Peninsula1
Is there a vaccine?
• people who have had close contact, such as caring
for or living with, an ill traveler from the
Arabian Peninsula1
• people who have had close contact, such as caring
There is currently no vaccine to protect
for or living with, a confirmed case of MERS
against MERS
• healthcare personnel who do not use
recommended infection-control precautions
• people who have had contact with camels
 Medical surgical management
1. No vaccine or specific treatment is currently available, although several MERS-CoV specific vaccines and
treatments are in development. Treatment is supportive and based on the patient’s clinical condition.
2. As a general precaution, anyone visiting farms, markets, barns, or other places where dromedary camels and
other animals are present should practice general hygiene measures, including regular hand washing before
and after touching animals and avoiding contact with sick animals.
3. The consumption of raw or undercooked animal products, including milk and meat, carries a high risk of
infection that can cause disease in humans. Animal products that are processed appropriately through cooking
or pasteurization are safe for consumption but should also be handled with care to avoid cross contamination
with uncooked foods. Camel meat and camel milk are nutritious products that can continue to be consumed
after pasteurization, cooking or other heat treatments.
4. Transmission of the virus has occurred in health care facilities in several countries, including transmission
from patients to health care providers and transmission between patients before MERS-CoV was diagnosed. It
is not always possible to identify patients with MERS‐CoV early or without testing because symptoms and
other clinical features may be non‐specific
 NURSING RESPONSIBILITIES
1. Wash hands often with soap and water for 20
seconds; if water and soap are not available, use an
alcohol-based hand sanitizer.
2. Practice respiratory etiquette. Cover nose and
mouth with a tissue or the inner elbow when
coughing or sneezing.
3. Avoid touching eyes, nose, and mouth with
unwashed hands.
4. Avoid close contact with sick individuals, such as
kissing, sharing cups, or sharing eating utensils.
5. Clean and disinfect frequently touched surfaces,
such as toys and doorknobs.
Prevention Steps for People Confirmed to Have,
or Being Evaluated for, MERS-CoV Infection
1. If you are confirmed to have, or being evaluated for, MERS-CoV infection you should follow the prevention steps below
until a healthcare provider or local or state health department says you can return to your normal activities.
2. Stay home
You should restrict activities outside your home, except for getting medical care. Do not go to work, school, or public
areas, and do not use public transportation or taxis.
3. Separate yourself from other people in your home
As much as possible, you should stay in a different room from other people in your home. Also, you should use a separate
bathroom, if available.
4. Call ahead before visiting your doctor
Before your medical appointment, call the healthcare provider and tell him or her that you have, or are being evaluated
for, MERS-CoV infection. This will help the healthcare provider’s office take steps to keep other people from getting
infected.
5. Wear a facemask
You should wear a facemask when you are in the same room with other people and when you visit a healthcare provider. If
you cannot wear a facemask, the people who live with you should wear one while they are in the same room with you.
 Prevention Steps for People Confirmed to Have,
or Being Evaluated for, MERS-CoV Infection
6. Cover your coughs and sneezes
Cover your mouth and nose with a tissue when you cough or sneeze, or you can cough or sneeze into your sleeve. Throw used
tissues in a lined trash can, and immediately wash your hands with soap and water for at least 20 seconds.
7. Wash your hands
Wash your hands often and thoroughly with soap and water for at least 20 seconds. You can use an alcohol-based hand sanitizer
if soap and water are not available and if your hands are not visibly dirty. Avoid touching your eyes, nose, and mouth with
unwashed hands.
8. Avoid sharing household items
You should not share dishes, drinking glasses, cups, eating utensils, towels, bedding, or other items with other people in your
home. After using these items, you should wash them thoroughly with soap and water.
9. Monitor your symptoms
Seek prompt medical attention if your illness is worsening (e.g., difficulty breathing). Before going to your medical
appointment, call the healthcare provider and tell him or her that you have, or are being evaluated for, MERS-CoV infection.
This will help the healthcare provider’s office take steps to keep other people from getting infected. Ask your healthcare
provider to call the local or state health department.
Prevention Steps for Caregivers and Household Members
1. If you live with, or provide care at home for, a person confirmed to have, or being evaluated for, MERS-CoV
infection, you should:
2. Make sure that you understand and can help the person follow the healthcare provider’s instructions for
medication and care. You should help the person with basic needs in the home and provide support for getting
groceries, prescriptions, and other personal needs.
3. Have only people in the home who are essential for providing care for the person.

a. Other household members should stay in another home or place of residence. If this is not
possible, they should stay in another room, or be separated from the person as much as
possible. Use a separate bathroom, if available.

b. Restrict visitors who do not have an essential need to be in the home.

c. Keep elderly people and those who have compromised immune systems or certain health
conditions away from the person. This includes people with chronic heart, lung or kidney
conditions, and diabetes.
Prevention Steps for Caregivers and Household Members
4. Make sure that shared spaces in the home have good air flow, such as by an air conditioner or an opened
window, weather permitting.
5. Wash your hands often and thoroughly with soap and water for at least 20 seconds. You can use an alcohol-
based hand sanitizer if soap and water are not available and if your hands are not visibly dirty. Avoid touching
your eyes, nose, and mouth with unwashed hands.
6. Wear a disposable facemask, gown, and gloves when you touch or have contact with the person’s blood, body
fluids and/or secretions, such as sweat, saliva, sputum, nasal mucus, vomit, urine, or diarrhea.

a. Throw out disposable facemasks, gowns, and gloves after using them. Do not reuse.

b. Wash your hands immediately after removing your facemask, gown, and gloves.
7. Avoid sharing household items. You should not share dishes, drinking glasses, cups, eating utensils, towels,
bedding, or other items with a person who is confirmed to have, or being evaluated for, MERS-CoV infection.
After the person uses these items, you should wash them thoroughly (see below “Wash laundry thoroughly”).
Prevention Steps for Caregivers and Household Members
8. Clean all “high-touch” surfaces, such as counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and
bedside tables, every day. Also, clean any surfaces that may have blood, body fluids and/or secretions or excretions on them.

a. Read label of cleaning products and follow recommendations provided on product labels. Labels contain instructions
for safe and effective use of the cleaning product including precautions you should take when applying the product,
such as wearing gloves or aprons and making sure you have good ventilation during use of the product.

b. Use a diluted bleach solution or a household disinfectant with a label that says “EPA-approved.” To make a bleach
solution at home, add 1 tablespoon of bleach to 1 quart (4 cups) of water. For a larger supply, add ¼ cup of bleach to
1 gallon (16 cups) of water.
9. Wash laundry thoroughly.

a. Immediately remove and wash clothes or bedding that have blood, body fluids and/or secretions or excretions on
them.

b. Wear disposable gloves while handling soiled items. Wash your hands immediately after removing your gloves.

c. Read and follow directions on labels of laundry or clothing items and detergent. In general, wash and dry with the
warmest temperatures recommended on the clothing label.
Prevention Steps for Caregivers and Household Members

10. Place all used gloves, gowns, facemasks, and other contaminated items in a lined container before disposing
them with other household waste. Wash your hands immediately after handling these items.
11. Monitor the person’s symptoms. If they are getting sicker, call his or her medical provider and tell him or her
that the person has, or is being evaluated for, MERS-CoV infection. This will help the healthcare provider’s
office take steps to keep other people from getting infected. Ask the healthcare provider to call the local or
state health department.
12. Caregivers and household members who do not follow precautions when in close contact2 with a person who is
confirmed to have, or being evaluated for, MERS-CoV infection, are considered “close contacts” and should
monitor their health. Follow the prevention steps for close contacts below.
SARS
 Severe acute respiratory syndrome (SARS)
● Severe acute respiratory syndrome (SARS) is a viral
respiratory disease caused by a SARS-associated
coronavirus.
● It was first identified at the end of February 2003
during an outbreak that emerged in China and
spread to 4 other countries
● The incubation period of SARS is usually
2-7 days but may be as long as 10 days.
 How SARS spreads
● The main way that SARS seems to spread is by close person-to-person
contact. The virus that causes SARS is thought to be transmitted most
readily by respiratory droplets (droplet spread) produced when an
infected person coughs or sneezes. Droplet spread can happen when
droplets from the cough or sneeze of an infected person are propelled
a short distance (generally up to 3 feet) through the air and deposited
on the mucous membranes of the mouth, nose, or eyes of persons who
are nearby. The virus also can spread when a person touches a surface
or object contaminated with infectious droplets and then touches his or
her mouth, nose, or eye(s). In addition, it is possible that the SARS
virus might spread more broadly through the air (airborne spread) or
by other ways that are not now known.
 What does “close contact” mean?
-close contact means having cared for or lived with someone with SARS or having direct contact with respiratory secretions
or body fluids of a patient with SARS.

a. kissing

b. hugging

c. sharing eating

d. drinking utensils

e. talking to someone within 3 feet

f. touching someone directly

-Close contact does not include activities like walking by a person or briefly sitting across a waiting room or office.
CLINICAL MANIFESTATION
The first symptom of the illness is generally fever (>38°C), which
is often high, and sometimes associated with chills and rigors.
It may also be accompanied by other symptoms including headache,
malaise, and muscle pain.
At the onset of illness, some cases have mild respiratory
symptoms.
Typically, rash and neurologic or gastrointestinal findings are
absent, although a few patients have reported diarrhea during
the early febrile stage.
After 3-7 days, a lower respiratory phase begins with the onset of
a dry, non-productive cough or dyspnea (shortness of breath)
that may be accompanied by, or progress to, hypoxemia (low
blood oxygen levels).
In 10–20% of cases, the respiratory illness is severe enough to
require intubation and mechanical ventilation.
Chest radiographs may be normal throughout the course of illness,
though not for all patients.
The white blood cell count is often decreased early in the disease,
and many people have low platelet counts at the peak of the
disease.
Medical-Surgical Management
There is no cure or vaccine for SARS and treatment should be
supportive and based on the patient’s symptoms.
Controlling outbreaks relies on containment measures
including:
prompt detection of cases through good surveillance
networks and including an early warning system;
isolation of suspected of probably cases;
tracing to identify both the source of the infection
and contacts of those who are sick and may be at
risk of contracting the virus;
quarantine of suspected contacts for 10 days;
exit screening for outgoing passengers from areas
with recent local transmission by asking
questions and temperature measurement;
anddisinfection of aircraft and cruise vessels
having SARS cases on board using WHO
guidelines.
NURSING MANAGEMENT
1. Personal preventive measures to prevent
spread of the virus include frequent hand
washing using soap or alcohol-based
disinfectants.
2. For those with a high risk of contracting
the disease, such as health care workers,
use of personal protective equipment,
including a mask, goggles and an apron is
mandatory.
3. Whenever possible, household contacts
should also wear a mask.
PULMONARY ARTERIAL
HYPERTENSION
 Pulmonary Arterial Hypertension
● Primary pulmonary arterial hypertension (PAH) occurs
when the arteries that carry deoxygenated blood from
the heart to the lungs become narrowed as a result of
changes in the lining and smooth muscle of the vessels.
● The result is elevated pressure in the pulmonary
arteries, causing the right ventricle to work harder to
Clinical manifestations
push blood into them. Eventually the right ventricle ● Dyspnea
fails (cor pulmonale). ● Fatigue
● The reason for these vascular changes is not known. ● Crackles
Primary PAH is more common in women between ages ● Decreased breath sounds
20 and 40 and has a hereditary tendency. ● Peripheal edema
● Distended jugular veins
● Angina may result from right
ventricular ischemia
 Nursing Management
1. Nursing care is collaborative
and focuses primarily on
patient assessment.
2. Fowler’s or high-Fowler’s
position may help reduce
dyspnea, and rest and
comfort measures are helpful
in treating fatigue and
anxiety.
 Medical Surgical Management
1. No cure is available for pulmonary hypertension except for lung or heart-lung transplant.
2. In secondary pulmonary hypertension, the underlying disorder is treated.
3. Supportive care includes a low-sodium diet and diuretics to reduce blood volume (and therefore
pressure), oxygen, and cardiac monitoring.
4. Vasodilators such as calcium channel blockers or angiotensin-converting enzyme (ACE)
inhibitors may be used to reduce pulmonary artery pressure.
5. Warfarin may be used to prevent clotting.
6. Epoprostenol (Flolan) is a vasodilator that may reverse some of the vascular changes and
prolong survival, but has many serious side effects, and must be continuously administered IV
via an implanted pump.
7. Bosentan (Tracleer) is a new oral drug that blocks endothelin, a substance that causes blood
vessels to constrict.
PNEUMOTHORAX
i. PNEUMOTHORAX air or gas accumulates between the parietal and
visceral pleurae, causing the lungs to collapse.
Accumulation of atmospheric air in the pleural
space, which results in a rise in intra thoracic
pressure and reduced vital capacity.

CLINICAL MANIFESTATION DIAGNOSTIC

• SUDDEN PLEURITIC PAIN
CHEST XRAY
• TACHYPNEA
ABG
• ANXIOUXS
• DYSPNEA(AIR HUNGER) MANAGEMENT
• USE OF ACCESORY MUSCLE
• CYANOSIS THORACENTESIS
CHEST TUBE DRAINAGE
• TACHYCARDIA
THORACOTOMY
• PROFUSE DIAPHORESIS PAIN RELIEVER
• ASSYMETRICAL CHEST WALL EXPANSION
 SIMPLE PNEUMOTHORAX
A simple, or spontaneous, pneumothorax
occurs when air enters the pleural space
TRAUMATIC PNEUMOTHERAX
through a breach of either the parietal or
visceral pleura. Most commonly, this occurs A traumatic pneumothorax occurs when air
escapes from a laceration in the lung
as air enters the pleural space through the
itself and enters the pleural space or
rupture of a bleb or a bronchopleural from a wound in the chest wall. It may
fistula result from blunt trauma (e.g., rib
fractures), penetrating chest or
TENSION PNEUMOTHERAX
abdominal trauma (e.g., stab wounds or
A tension pneumothorax occurs when air is drawn gunshot wounds), or diaphragmatic tears.
into the pleural space from a lacerated lung or
through a small opening or wound in the chest
wall.
Open Pneumothorax
If air can enter and escape through the opening
in the pleural space, it is considered an open
pneumothorax.

Hemothorax
The term hemothorax refers to the presence of
blood in the pleural space.

This can occur with or without accompanying

pneumothorax (hemopneumothorax) and is
often the result of traumatic injury.
Close pneumothorax
If air collects in the space and is
unable to escape, a closed
pneumothorax exists.
Chest tube Drainage

Chest drainage systems

have a suction source, a
collection chamber for
pleural drainage, and a
mechanism to prevent
air from re-entering the
chest with inhalation.
Various types of chest
drainage systems
are available for use in
the removal of air and
fluid from the
pleural space and re-
expansion of the lungs
-DRAINAGE BOTTLE/ COLLECTION
CHAMBER-collect fluid from the lung serosanguinous
drainage

-WATERSEAL BOTTLE-filled with water

The purpose is to prevent air from entering to the
chest.
NOTE: fluctuation-TIDALING of water – rise and
fall = respiration
Bubbles= INTERMITTENT=NORMAL CONTINOUS
BUBBLING=LEAKING

-SUCTION BOTTLE= amount or level of suction

=gentle bubbling

Nsg resp
-ASSESSMENT-breathing, breathing sound, crepitus,
drainage
-level of drainage upon receiving and endorsing
-leakage or clog=NO FLUCTUATION
-NO MILKING OF THE CHEST TUBE
-always place BELOW CHEST LEVEL
BEDSIDE: VASELINE GAUZE, FORCEP, STERILE GAUZE
Nursing Responsibilities
• Apply a nonporous dressing over an open chest wound
• Monitor Vital signs for indications of shock or increasing respiratory distress
• Administer oxygen as prescribed
• Place the client in a fowler’s position
• Prepare for chest tube placement which will remain in place until the lung has expanded fully
• If chest tube is in place, encourage the patient to cough and breathe deeply at least once per
hour to promote lung expansion.
• In the patient undergoing chest tube drainage, watch for continuing air leakage (bubbling) in
the water-seal chamber. This indicates the lung defect has failed to close and may require
surgery.
• Observe for increasing subcutaneous emphysema by checking around the neck or at the tube
insertion site for crackling beneath the skin.
• If the patient is on a ventilator, be alert for any difficulty in breathing in time with the ventilator
as you monitor its gauges for pressure increases.
• Change dressings around the chest tube insertion site as needed and as per your facility’s
policy.
• Don’t reposition or dislodge the tube; if the tube does dislodge, immediately place a petroleum
gauze dressing over the opening to prevent rapid lung collapse.
• Observe the chest tube site for leakage, and note the amount and color of drainage.
 Thank
YOU!
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