OBSTRUCTION DURING SLEEP (OSA)

OVERVIEW PATHOPHYSIOLOGY SIGNS & SYMPTOMS LAB TEST PREVENTION TREATMENT NURSING CARE RATIONALE
▪ Obstructive NORMAL BREATHING ▪ Excessive daytime Polysomnography. Duri • Smoking Positive airway pressure ▪ Assess the • Patients with
sleep apnea is DURING SLEEP sleepiness ng this sleep study, contributes to sleep reduces the number of frequency and apnea have
a potentially ▪ Loud snoring you're hooked up to apnea by increasing respiratory events that pattern of periods of
serious sleep ▪ Observed episodes of equipment that inflammation and occur as you sleep, breathing; cessation of
disorder. It stopped breathing monitors your heart, fluid retention in reduces daytime Observe presence breathing over 15-
causes during sleep lung and brain activity, your throat and sleepiness and improves of apnea and 20
breathing to ▪ Abrupt awakenings breathing patterns, arm upper airway. your quality of life. changes in the seconds
repeatedly accompanied by and leg movements, • Avoid alcohol, heart rate. accompanied by
stop and start gasping or choking and blood oxygen levels sleeping pills, and CONTINUOUS POSITIVE ▪ Assess bradycardia
during sleep. ▪ Awakening with a dry while you sleep. sedatives, especially AIRWAY PRESSURE, or skin, nail beds, • Reveals presence
▪ There are OBSTRUCTIVE SLEEP mouth or sore throat before bedtime, CPAP (SEE-pap). The skin, mucous of hypoxemia
several types APNEA ▪ Morning headache Home sleep apnea because they relax most common type is membranes for causing cyanosis
of sleep apnea, ▪ Difficulty testing. Under certain the muscles in the called continuous pallor or cyanosis from an uneven
but the most concentrating during circumstances, The throat and interfere positive airway ▪ Position the distribution of
common is the day doctor may provide you with breathing. pressure, or CPAP (SEE- patient in side gases and blood in
obstructive ▪ Experiencing mood with an at-home version pap). With this lying. the lungs,
sleep apnea. changes, such as of polysomnography to treatment, the pressure ▪ Provide tactile and alveolar
This type of depression or diagnose obstructive of the air breathed is stimulation by hypoventilation
apnea occurs irritability sleep apnea. This test continuous, constant applying gentle caused by airway
when your ▪ High blood pressure usually involves and somewhat greater rub in the soles of obstruction and
throat muscles ▪ Nighttime sweating measurement of than that of the feet or chest wall absence of chest
intermittently ▪ Decreased libido airflow, breathing surrounding air, which ▪ Administer methyl wall movement.
relax and block patterns and blood is just enough to keep xanthines (e.g., • When your body is
your airway oxygen levels, and your upper airway (theophylline, caff positioned on it's
during sleep. A possibly limb passages open. This air eine) as side during rest
noticeable sign movements and snoring pressure prevents prescribed. the airways are
of obstructive intensity obstructive sleep apnea ▪ Use of Nasal more stable and
sleep apnea is and snoring. Continuous less likely to
snoring. The available screening positive airway collapse or restrict
▪ questionnaires and CPAP may be given at a pressure (CPAP). air.
clinical prediction tools continuous (fixed) • Indicated for mild
attempt to identify pressure or varied and intermittent
persons at higher risk of (autotitrating) pressure. episodes of apnea
sleep apnea. Many of In fixed CPAP, the to stimulate
them combine pressure stays constant. spontaneous
questions about In autotitrating CPAP, breathing.
symptoms with the levels of pressure • Used as a

EPIXTASIS
OVERVIEW
Nosebleeds (also called
epistaxis) are common. Some
60% of people will have at
least one nosebleed in their
lifetime. The location of the
nose in the middle of the face
and the large number of blood
vessels close to the surface in
the lining of your nose make it
an easy target for injury and
nosebleeds.
There are two main types and
objective findings (e.g., are adjusted if the smooth muscle rel
BMI). Screening device senses increased axant and a
questionnaires that airway resistance. cardiac muscle
could be considered for and
use in primary care Bilevel positive airway central nervous
include the Epworth pressure (BPAP), system stimulant.
Sleepiness Scale another type of positive • Indicated when
(ESS), the STOP airway pressure, the Patient
Questionnaire (Snoring, delivers a preset remains to have
Tiredness, Observed amount of pressure episodes of apnea
Apnea, High Blood when you breathe in despite producing
Pressure), STOP-Bang and a different amount a therapeutic level
Questionnaire (STOP of pressure when you of methylxanthine.
Questionnaire plus BMI, breathe out.
Age, Neck CPAP is more commonly
Circumference, and used because it's been
Gender. well studied for
obstructive sleep apnea
and has been shown to
effectively treat
obstructive sleep apnea.
PATHOPHYSIOLOGY SIGNS & SYMPTOMS LAB TEST PREVENTION TREATMENT NURSING CARE
Nosebleeds are caused by ▪ Bleeding from To diagnose epistaxis, Use a saline nasal spray Nasal packing. Gauze, Put on protective gear,
the rupture of a blood either or routine or saline nose drops two special nasal sponges or including gown, gloves, and
vessel within the nasal both nostrils. laboratory testing is not to three times a day in foam or an inflatable latex face shields. Quickly assess the
mucosa. Rupture can be ▪ A sensation of required. each nostril to keep balloon is inserted into your ABCs (airway, breathing, and
spontaneous, initiated by flowing liquid at your nasal passages nose to create pressure at circulation) and support them
trauma, use of certain the back of Patients with symptoms moist. These products the site of the bleed. The as indicated. Reassure the
medications, and/or the throat. or signs of a bleeding can be purchased over- material is often left in place patient.
secondary to other ▪ The urge to disorder and those with the-counter or made at for 24 to 48 hours before Have the patient sit upright
comorbidities or swallow severe or home. (To make the being removed by a with her head tilted forward,
malignancies. An increase frequently recurrent epistaxis should saline solution at home: healthcare professional. and instruct her to apply
in the patient's blood have CBC, PT, and PTT. CT mix 1 teaspoon of salt direct external digital pressure
pressure can increase the may be done if a foreign into 1 quart of tap Cauterization. This to the nares with her index
one is more serious than the
other.
An anterior nosebleed starts
in the front of the nose on the
lower part of the wall that
separates the two sides of the
nose (called the septum).
Capillaries and small blood
vessels in this front area of the
nose are fragile and can easily
break and bleed. This is the
most common type of
nosebleed and is usually not
serious. These nosebleeds are
more common in children and
are usually able to be treated
at home.
A posterior nosebleed occurs
deep inside the nose. This
nosebleed is caused by a
bleed in larger blood vessels in
the back part of the nose near
the throat. This can be a more
serious nosebleed than an
anterior nosebleed. It can
result in heavy bleeding,
which may flow down the
back of the throat. You may
need medical attention right
away for this type of
nosebleed. This type of
nosebleed is more common in
adults.
length of the episode. body, a tumor, or sinusitis
is suspected.
water) procedure involves applying
a chemical substance (silver
nitrate) or heat energy
(electrocautery) to seal the
bleeding blood vessel. A
local anesthetic is sprayed in
the nostril first to numb the
inside of your nose.
Medication
adjustments/new
prescriptions. Reducing or
stopping the amount of
blood thinning medications
can be helpful. In addition,
medications for controlling
blood pressure may be
necessary. Tranexamic (Lyste
daâ), a medication to help
blood clot, may be
prescribed.
Foreign body removal if this
is the cause of the nose
bleed.
Surgical repair of a broken
nose or correction of a
deviated septum if this is
the cause of the nosebleed.
Ligation. In this procedure,
the culprit blood vessel is
tied off to stop the bleeding.
finger and thumb. Tell her to
breathe through her mouth
while she holds firm pressure
on the soft flesh of her nose
for at least 10 minutes. If
bleeding persists, cotton
pledgets soaked in a
vasoconstrictor and anesthetic
will be placed in the anterior
nasal cavity, and direct
pressure should be applied at
both sides of the nose.
Ensure bedside suction is
functioning properly. Provide
an emesis basin and tissues.
Tell her to spit blood into the
basin if necessary. This helps
prevent nausea and vomiting
and lets you estimate the
amount of bleeding.
Obtain vital signs and
SpO2 level, and assess her
breath sounds. Administer
supplemental oxygen via
facemask if needed. Continue
to monitor vital signs closely.
Assess for signs and symptoms
of hemodynamic instability,
including change in mental
status, pallor, diaphoresis,
hypotension, tachycardia, and
tachypnea.
If bleeding is significant,
establish vascular access,
place the patient on a cardiac
monitor, and begin fluid
resuscitation with a crystalloid
 solution, as prescribed. Obtain
specimens for blood work,
including complete blood cell
count and coagulation profile,
as prescribed.

Obtain a focused health

history, including previous
nosebleeds, other bleeding
episodes, easy bruising, and
medication use, especially use
of aspirin and other
nonsteroidal anti-
inflammatory drugs (NSAIDs),
antiplatelet agents, warfarin,
and herbal products.

If bleeding persists, assist in

preparing the epistaxis tray
and a headlamp. Make sure
lighting is adequate. Once the
bleeding site is identified, the
definitive treatment is cautery
(silver nitrate or electrical). If
cautery is unsuccessful, nasal
packing will be used to apply
direct pressure to the bleeding
site. During the procedure,
reassure the patient, monitor
vital signs, and assess for
hypoxia.

NASAL OBSTRUCTION

OVERVIEW PATHOPHYSIOLOGY SIGNS & SYMPTOMS LAB TEST/ SCREENING PREVENTION TREATMENT NURSING CARE
Nasal obstruction is Congestion can also be caused by ▪ “Nasally” voice Nasal exam- including the Humidify your home. Using Decongestants.  ▪ Identification of the
not a disease but physical obstruction of nasal ▪ Nasal drainage use of endoscopes, X- a humidifier may help These medicines help reduce allergen. Identification
rather a symptom passages and/or modulation of ▪ Breathing rays, CT scans and/or moisten your breathing the swelling in your nasal and elimination is easiest
of an underlying sensory perception. Mucosal
disorder that inflammation underlies many of
causes the nasal the specific and interrelated
passages to be factors that contribute to nasal
blocked or congestion, as well as other
obstructed. In symptoms of both allergic rhinitis
children, some of and rhinosinusitis. A wide range
the most common of biologically active agents (eg,
causes include histamine, tumor necrosis factor-
enlarged adenoids α, interleukins, cell adhesion
and nasal allergies. molecules) and cell types
Less common contribute to inflammation,
causes of nasal which can manifest as venous
blockages are nasal engorgement, increased nasal
polyps, tumors and secretions and tissue
congenital swelling/edema, ultimately
malformations of leading to impaired airflow and
the nose. the sensation of nasal congestion.
Inflammation-induced changes in
the properties of sensory
afferents (eg, expression of
peptides and receptors) that
innervate the nose can also
contribute to altered sensory
perception, which may result in a
subjective feeling of congestion.
Increased understanding of the
mechanisms underlying
inflammation can facilitate
improved treatment selection
and the development of new
therapies for congestion.
through the other imaging tests passages, improve the flow passages and ease the for dust mite allergens;
mouth most of of mucus from your sinuses, stuffiness and sinus pressure. pollen is more difficult to
the time Anterior rhinoscopy and help prevent blockages They come as nasal sprays, avoid because daily
▪ Recurrent sinus and/or nasal endoscopy and inflammation. Clean the like naphazoline (Privine),  activities must be altered
infections should be used for better humidifier daily to prevent Oxymetazoline (Afrin, Dristan,  to do so; an easy
visualization of internal bacteria from growing. Nostrilla, Vicks Sinus Nasal intervention is to keep the
nasal structures Spray), or phenylephrine (Neo windows closed, which is
Use a nasal rinse. Use a Synephrine, Sinex, Rhinall). easily accomplished in air-
Allergy testing, If saltwater (saline) spray or They also come as pills, such conditioned homes and
indicated nasal wash to rinse your as phenylephrine  must be done throughout
nasal passages. This may (Sudafed PE, and others) the year.
improve mucus flow and and pseudoephedrine ▪ Use of nasal sprays. Teach
remove allergens and other (Sudafed). the patient and parents on
irritants. how to use nasal sprays by
Antihistamines.   blowing the nose first then
If allergies are behind your administering
nasal congestion and sinus the medication.
pressure, controlling them will ▪ Encourage thorough
ease your symptoms. Look cleaning of the
for allergy medications that house. Encourage a
have an antihistamine to routine cleaning of the
relieve sniffling house, furniture, and
and sneezing along with a equipment which may
decongestant for congestion house dust and other
and sinus pressure. pollens.
▪ Encourage medication
You may also compliance. Administer
find antihistamines in some pharmacologic treatment
multi-symptom cold as ordered by the
medicines which can help physician.
a runny nose and sneezing.
You'll usually find them in
nighttime cold medicine,
because they can make you
sleepy. Read and follow the
label, and talk to your doctor
or pharmacist if you have
questions.
LARYNGEAL OBSTRUCTION

OVERVIEW PATHOPHYSIOLOGY
Obstruction of the ▪ Acute laryngitis is an
larynx because of inflammation of the
edema is a serious, vocal fold mucosa
often fatal, condition. and larynx that lasts
Swelling of the less than 3 weeks.
laryngeal mucous When the etiology of
membranes may close acute laryngitis is
off the opening tightly, infectious, white
leading to life- blood cells remove
threatening hypoxia or microorganisms
suffocation. during the healing
process.
Acute Laryngeal
Edema: edema ▪ The vocal folds then
formation on larynx become more
with inflammation, edematous, and
injury characterized by vibration is adversely
Hoarseness, dyspnea. affected. The
Its managed by phonation threshold
tracheostomy, pressure may
epinephrine 1: 1000 increase to a degree
that generating
Laryngospasm: spasm adequate phonation
of laryngeal muscle pressures in a
occurs after normal fashion
administration general becomes difficult,
anesthesia, traumatic thus eliciting
attempt at hoarseness. Frank
endotracheal aphonia results
intubation. Managed by when a patient
establish airway, cannot overcome
oxygen, the phonation
nerotransmitters threshold pressure
blocking agent – required to set the
succinyl choline vocal folds in
motion.
Laryngeal paralysis :loss
SIGNS & SYMPTOMS LAB TEST/ SCREENING PREVENTION TREATMENT NURSING CARE RATIONALE
• Hoarsenesss Direct laryngoscopy ▪ Avoid drinking a lot Speech Therapy Assess respiratory Nasal flaring, rapid
• Dypnea The “gold standard” of alcohol before A multicomponent rate, effort, pattern, breathing,
• Aspiration of food/ investigation for eating. speech therapy and depth. dyspnea, chest
saliva confirmation of ILO is ▪ Eat small bites of approach has been retractions,
• Neck swelling flexible laryngoscopy, if food. shown to be of benefit and apnea signifies
• Inability to speak necessary performed in ▪ Eat slowly. in chronic cough and is severe respiratory
• Cough the presence of a typical ▪ Supervise small recommended by distress that
trigger (e.g., exercise). children when current guidelines (63). requires
Laryngoscopy is typically eating. The therapeutic immediate airway
well tolerated and can ▪ Chew thoroughly approach successfully support.
be successfully before swallowing. employed by Vertigan
employed by trained ▪ Make sure your and colleagues (69) Auscultate lungs for Absent or
pulmonologists in a dentures fit comprised education, the presence of decreased lung
clinic-based properly. strategies to reduce normal or sounds may reveal
environment. It allows ▪ Keep small objects cough and laryngeal adventitious lung the presence of a
structural or neurological away from children. irritation, and sounds. mucous plug or
abnormalities to be ▪ Don’t smoke. psychoeducational airway obstruction.
detected and may counseling. This Stridor is a late
provide some insight approach resulted in a ominous sign of
regarding significant reduction in epiglottitis that
laryngopharyngeal reflux symptoms compared indicates
and general appearance with control (i.e., emergency airway
of vocal cords and lifestyle advice) management.
laryngeal responses to intervention.
phonatory tasks. Use pulse oximetry to Pulse oximetry is
Pharmacotherapy monitor oxygen used to detect
Challenge laryngoscopy Several drugs have saturation; assess changes in
Given the caveats shown promise for the arterial blood gases oxygenation.
described previously, treatment of refractory (ABGs) Oxygen saturation
laryngoscopy has been chronic cough, although should be
performed in the context only gabapentin has maintained at 90%
of exposure to a relevant been recommended as or greater.
occupational and an option for a trial of Alteration in ABGS
environmental trigger. treatment in more may result in
There is unfortunately recent guidelines (63), in increased
no currently accepted particular in light of its pulmonary
guidance on how best to beneficial effect on secretions and
 of sensation results of perform such challenge cough-related quality of respiratory fatigue.
neck surgery, tumour testing; however, the life (74). Oral morphine
use of a is also commonly used, After obtaining
Laryngeal injury: it “control”/placebo and has been associated Administer blood and
often result from exposure (i.e., visualizing with an improvement in IV antibiotics as epiglottic cultures,
trauma during motor stimulus) without cough symptoms, ordered. second-or-third
vehicle accident inhalation/exposure is although not cough generation
important. sensitivity (75).  cephalosporins
and beta-
lactamase resistant
antibiotic should
be started as soon
as possible.

An artificial
Prepare for airway is required
intubation to promote
or tracheostomy; oxygenation and
Anticipate the need ventilation and
of an artificial airway prevent aspiration.

MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY TRACT DISORDERS

ATELECTASIS

OVERVIEW
Atelectasis refers to
closure or collapse of the
alveoli and often is
described in relation to
chest x-ray findings and/or
clinical signs and
symptoms. It is one of the
most commonly
encountered abnormalities
seen on a chest x-ray. It
can be from
microatelectasis to
macroatelectasis. The most
PATHOPHYSIOLOGY SIGNS & SYMPTOMS
REDUCED VENTILATION OR • Cough & sputum
BLOCKAGE production
• Low-grade fever - due
OBSTRUCTION OF to infection or
PASSAGE OF AIR FROM & inflammation distal to
TO ALVEOLI the obstructed airway
• Marked respiratory
TRAPPED ALVEOLAR AIR distress
ABSORBED INTO • Dyspnea, tachycardia,
BLOODSTREAM pleural pain and
central cyanosis (a
AFFECTED PORTION FO bluish skin hue that is a
ALVEOLI BECOMES AIRLESS late sign of hypoxemia.
LAB TEST/ SCREENING
When clinically significant
atelectasis develops, it is
generally characterized by
increased work of
breathing or hypoxemia.
Decreased breath sounds
and crackles are heard
over the affected area.
A chest x-ray may suggest,
a diagnosis of atelectasis
before clinical symptoms
appear. The x-ray may
PREVENTION TREATMENT PROGNOSIS
• Change patient’s • The goal of the • In an adult, atelectasis
position frequently, treatment is to in a small area of the
especially from supine improve ventilation lung is usually not life
to upright position, to and remove secretions. threatening. The rest
promote ventilation • Strategies to prevent of the lung can make
and prevent secretions atelectasis which up for the collapsed
from accumulating. include frequent area, bringing in
• Encourage early turning, early enough oxygen for the
mobilization from bed ambulation, lung body to function.
to chair followed by volume, expansion • Large areas of
early ambulation. maneuvers and atelectasis may be life
• Encourage appropriate coughing. threatening, often in a
deep breathing and • Other treatment is also baby or small child, or
 commonly described is the
acute atelectasis.
Atelectasis is also observed
in patients with chronic
airway obstruction that
impedes or blocks the flow
of air to an area of the lung
(e.g obstructive atelectasis
in the patient with lung
cancer that is invading or
compressing the airways).
This type of atelectasis is
more insidious and have a
slower onset.
ACUTE BRONCHITIS
OVERVIEW
In acute tracheobronchitis,
the inflamed mucosa of
the bronchi produces
mucopurulent sputum,
often in response to
• Difficulty in breathing
ALVEOLI COLLAPSE while in supine
(ATELECTASIS) position
• Anxious
ICOUGH PROGRAM
• Incentive spirometry
• Coughing and deep
breathing
• Oral care (brushing
teeth and using
mouthwash twice a
day)
• Understanding (patient
and staff education)
• Getting out of bed at
least three times a
daily
• Head-of-bed elevation
PATHOPHYSIOLOGY SIGNS & SYMPTOMS
DUE TO E/F • Dry, irritating cough
and expectorates a
MICROORGANISM ENTER scanty amount of
INTO THE RESPIRATORY mucoid sputum
TRACT BY INHALATION • Complains of sternal
reveal patchy infiltrates or
consolidated areas.
Depending on the degree
of hypoxemia, pulse
oximetry (SpO2) may
demonstrate a low
saturation of hemoglobin
with oxygen (less than
90%) or a lower-than-
normal partial pressure of
arterial oxygen (PaO2).
LAB TEST / SCREENING
A sputum culture is
essential to identify the
specific causative
microorganism.
coughing to mobilize done to patients who
secretions and prevent do not respond to first-
them from line measures or those
accumulating. who cannot perform
• Educate/reinforce deep-breathing
appropriate technique exercises. Other
for incentive treatments like
spirometry. positive end-expiratory
• Administer prescribed pressure (PEEP). A
opioids and sedatives simple mask and one
judiciously to prevent way valve system with
respiratory depression. various amounts of
• Perform postural expiratory resistance =
drainage and chest 10 to 15 cm H2O.
percussion, if • Chest physiotherapy
indicated. may also be used to
• Institute suctioning to mobilize secretions.
remove • Nebulizer treatments
tracheobronchial with a bronchodilator
secretions, if indicated. or sodium bicarbonate
may be used to assist
patients in the
expectorations of the
secretions.
• Bronchoscopy is an
excellent measure to
acutely remove
secretions and
increase ventilation.
TREATMENT NURSING MANAGEMENT
• Antibiotic treatment • Encourage bronchial
may be indicated hygiene. Increase fluid
depending on the intake and directed
symptoms, sputum coughing to remove
purulence and results secretions.
in someone who has
another lung disease
or illness.
• The collapsed lung
usually reinflates
slowly if the airway
blockage has been
removed. Scarring or
damage may remain.
• The outlook depends
on the underlying
disease. For example,
people with extensive
cancer often don't do
well, while those with
simple atelectasis after
surgery have a very
good outcome.
PROGNOSIS
Patients with acute
bronchitis have a good
prognosis. Bronchitis is
almost always self-limited
in individuals who are
Streptococcus
pneumoniae, Haemophilus
influenza or Mycoplasma
pneumoniae. In addition, a
fungal infection,
Aspergillus may also cause
tracheobronchitis. A
sputum culture is essential
to identify the specific
causative microorganism.
Inhalation of chemical
irritants , gases or other air
contaminants can also
cause acute bronchial
irritation.
soreness from of sputum culture and • Encourage and sit up otherwise healthy,
WIDESPREAD coughing sensitivity frequently to cough although it may result in
INFLAMMATION OCCURS • Fever or chills and • Antihistamines are not effectively and to absenteeism from work
night sweats usually prescribed prevent retention of and school. Severe cases
THIN MUCUS LINING OF • Headache because they can mucopurulent sputum. occasionally produce
THE BRONCHI CAN • General malaise cause excessive drying • Complete full course of deterioration in patients
BECOME IRRITATED & • Shortness of breath and make secretions antibiotics is needed. with significant underlying
SWOLLEN • Noisy more difficult to • Fatigue is present. The cardiopulmonary disease
inspiration(inspiratory expectorate. patient must be or other comorbidities.
CELL THAT MAKE UP THIS stridor) and expiration • Expectorants may be avoided from
LINING MAY LEAK FLUID IN (expiratory wheeze) prescribed although overexertion, which
RESPONSE TO THE • With purulent (pus- their efficacy is can induce relapse or
INFLAMMATION filled) sputum questionable exacerbation or
• Blood-streaked • Fluid intake is infection.
COUGHING AS A REFLEX secretions may be increased to thin
THAT WORKS TO CLEAR expectorated as a viscous and tenacious
SECRETION FROM THE result of the irritation secretion
LUNGS of the mucosa of the • Suctioning and
airways bronchoscopy may be
ALVEOLAR FLUID needed to remove
RESPONSE secretions.
• Endotracheal
NARROWING OF THE intubation may be
AIRWAYS necessary in cases of
acute
VENTILATION DECREASE tracheobronchitis
AS A SECRETION THICKENS leading to acute
respiratory failure,
MUCUS WITHIN THE such as patients who
AIRWAYS PRODUCES are severely
RESISTANCE IN SMALL debilitated or who
AIRAYS AND CAN CAUSE have coexisting
SEVERE VENTILATION diseases that also
PERFUSION IMBALANCE impair the respiratory
system
BRONCHITIS • The patient is advised
to rest. Increase the
vapor pressure in the
air reduces airway
irritation. Cool vapor
 therapy or steam
inhalations may help
relieve laryngeal and
tracheal irritation.
• Moist heat to the chest
may relieve the
soreness and pain.
• Mild analgesics may be
prescribed.

PNEUMONIA

Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria and viruses. Pneumonitis is more general term that describes an inflammatory
process in the lung tissue that may predispose or place the patient at risk for microbial invasion.

CLASSIFICATIONS:

COMMUNITY ACQUIRED PNEUMONIA

• It is a common infectious disease, occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization. The need for hospitalization for CAP depends on the severity
of the pneumonia. Fever, purulent sputum or rusty, blood tinged sputum, orthopnea and dyspnea are some of the clinical manifestations of CAP.
• S. Pneumoniae (pneumococcus) is the common cause of CAP in people younger than 60 years without comorbidity and in those 60 years and older. S.Pneumoniae, a gram-positive organism that naturally
resides in the upper respiratory tract, colonizes the upper respiratory tract infections.
• H. Influenzae causes a type of CAP that frequently affects older adults and those with comorbid illnesses (COPD, alcoholism and diabetes). The presentation is indistinguishable from that of other forms of
bacterial CAP and may be subacute, with cough or low-grade fever for weeks before diagnosis.

HOSPITAL-ACQUIRED PNEUMONIA
(AKA Nosocomial Pneumonia)
• HAP develops 48 hours or more after admission and does not appear to be incubating at the time of admission.
• Common organisms responsible for HAP include the pathogens: Enterobacter species, E.coli, Klebsiella species, Proteus, Serratia marcescens, P. aeruginosa and Staphylococcus aureus.
Certain factors may predispose patients to HAP because of impaired host defenses, a variety of comorbid conditions, supine positioning and aspiration, coma, malnutrition, prolonged hospitalization,
hypotension and metabolic disorders.

ASPIRATION PNEUMONIA

• It refers to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway. The most common form of aspiration pneumonia is bacterial infection from
aspiration of bacteria that normally reside in the upper airways.
• Aspiration pneumonia may occur in the community and hospital setting.
• Common pathogens are S. aureus, Streptococcus species and gram-negative bacilli.

PNEUMONIA IN AN IMMUNOCOMPROMISED HOST

• Pneumonia in immunocompromised hosts includes Pneumocystis pneumonia (PCP), fungal pneumonias and Mycobacterium tuberculosis.
• Pneumonia in the immunocompromised hosts occurs with the use of corticosteroid or other immunosuppressive agents, chemotherapy, nutritional depletion, the use of broad spectrum antimicrobial
agents, acquired immunodeficiency syndrome (AIDS), advanced life support (mechanical ventilation).

RISK FACTOR ASSESSMENT SIGNA & LAB TEST/ SCREENING PREVENTION TREATMENT NURSING INTERVENTION DIAGNOSIS
SYMPTOMS
• Travel or • The nurse • Loss of • The diagnosis of • Pneumococcal MANAGEMENT FOR IMPROVING AIRWAY PATENCY • Ineffective airway
exposure to should be appetite, low pneumonia is made vaccination HAP: clearance related
certain alert if there is energy, and by history (recent reduces the • The nurse encourages to
environments fever, chills or fatigue respiratory tract incidence of Administration of hydration, 2-3 L/day because tracheobronchial
and residence in night sweats. • Nausea, infection), physical pneumonia , antibiotics depending on adequate hydration thins and secretions
a long term It is possible vomiting or examination, chest hospitalizations the type of organism. loosens secretions and improve • Fatigue and
facility. that the diarrhea x-ray, blood culture for cardiac ventilation. A high humidity activity
• Increasing patient has • Coughing that (bloodstream conditions and Viral Pneumonia – facemask delivers warm, intolerance
number of bacterial may produce invasion, occurs deaths in the treatment is supportive humidified air to the related to
patients who pneumonia. phlegm frequently and older adult tracheobronchial tree, helps impaired
have • Respiratory • Chest pain sputum population. Oxygen administration if liquefy secretions and relieves respiratory
compromised assessment when you examination (Pneumococcal there is hypoxemia the tracheobronchial irritation. function
defenses against for the clinical breathe or • The sputum sample conjugate • To improve airway patency, the • Risk for deficient
infections are manifestations cough is obtained by vaccine (PCV13) • Treatment of nurse encourages the patient to fluid volume
susceptible to such as • Shortness of having patients do and pneumonia includes perform a directed, effective related to fever
pneumonia. pleuritic-type breath the following: pneumococcal administration of the cough, which includes correct and a rapid
• Some are caused pain, fatigue, • Fever, (1) Rinse the polysaccharide appropriate positioning and a deep respiratory rate
by viral tachypnea, sweating and month with vaccine antibiotic as inspiratory maneuver. • Imbalanced
infections, occur the use of shaking chills water to (PPSV23). determined by the nutrition : less
in previously accessory • Confusion, minimize • PCV13 protects results of a C&S test. PROMOTING REST AND than body
healthy people, muscles for especially in contamination against 13 types • Inpatients should be CONSERVING ENERGY requirements
often after a viral breathing , older people by oral normal of pneumococcal switched from • The nurse encourages the • Deficient
illness. bradycardia or • headache flora. bacteria. It is intravenous (IV) to debilitated patient to rest and knowledge about
• Pneumonia relative (2) Breathe deeply recommended oral therapy when overexertion and possible the treatment
occurs in patients bradycardia, several times for all adults 65 they are exacerbation of symptoms. The regimen and
with certain coughing and (3) Cough deeply years of age as hemodynamically patient should assume a knowledge
underlying purulent (4) Expectorate the well as adults 19 stable, they are comfortable position to measures
disorders such as sputum. raised sputum years older with improving clinically. promote rest and breathing
heart failure, • The nurse into a sterile conditions that They are able to take (semi-Fowler’s) and should
diabetes, monitors the container. weaken the medications/fluids change positions frequently to
alcoholism, COPD patient for the • Sputum may be immune system. by mouth and have a enhance secretion clearance
and AIDS. These following obtained by • PPSV23 is a normally functioning and pulmonary ventilation and
 are caused by changes in nasotracheal or newer vaccine GI tract. perfusion.
pneumococci or temperature orotracheal and protects • In suspected HAP,
H.influenzae. and pulse; suctioning with against 23 types treatment is usually PROMOTING FLUID INTAKE
• amount, odor a sputum trap of pneumococcal initiated with a • Increased fluid intake (at least
and color of or fiberoptic bacteria. It is broad spectrum IV 2L/day) is encouraged.
the secretions, bronchoscopy . recommended antibiotic and may Hydration is achieved more
degree of Bronchoscopy is for all adults 65 be monotherapy or slowly and with careful
tachypnea or often used in years of age who combination monitoring in patients with
shortness of patients with smoke cigarettes therapy. For patients preexisting conditions such as
breath, acute viral who have with no known heart failure.
changes in infection. asthma. multidrug resistance,
physical • Bronchoscopic monotherapy with MAINTAINING NUTRITION
findings techniques may ceftriaxone • Many patients with shortness of
(inspection include a (Rocephin), breath and fatigue have a
and protected ampicillin/sulbactam decreased appetite and
auscultation) brush specimen (Unasyn), consume only fluids. Fluids with
and chest x- or levofloxacin electrolytes such as Gatorade. It
ray findings. bronchoalveolar (Levaquin), or helps provide fluid, calories and
• For older lavage. ertapenem (Invanz) electrolytes. Other nutritionally
people it is is used. enriched drinks such as oral
important to nutritional supplements may be
assess unusual used to supplement calories.
behavior, Small, frequent meals may be
altered mental advisable. IV fluids and
status, fatigue, nutrients may be given if
excessive necessary.
dehydration • The patient and family are
and instructed about the cause of
concomitant pneumonia, management, signs
heart failure. and symptoms, etc. should be
• reported by the nurse. They
should know the factors that
may have caused the
development of the disease.
• Strategies to promote recovery
during and discharge should be
taught also.

PROMOTING THE PATIENT’S

KNOWLEDGE
 • The patient and family are
instructed about the cause of
pneumonia, management of
symptoms of pneumonia and
the need for follow-up.
• The patient also needs
information about the factors
(both patient risk factors and
external factors) that may have
contributed to developing
pneumonia and strategies to
promote recovery and to
prevent recurrence.
• The patient is instructed about
the purpose and importance of
management strategies that
have been implemented and
about the importance of
adhering to them during and
after the hospital stay.

PULMONARY TUBERCULOSIS

CLASSIFICATION OF TB:

• Class 0 – no infection

• Class 1 – exposure ; no evidence of infection

• Class 2 – latent infection ; no diseases (eg, positive PPD reaction but no clinical evidence of active TB)

• Class 3 – clinically active

• Class 4 – disease ; not clinically active

• Class 5 – suspected disease ; diagnosis pending

OVERVIEW TRANSMISSION / RISK SIGNS & SYMPTOMS ASSESSMENT MEDICAL TREATMENT DIAGNOSTIC FINDINGS NURSING MANAGEMENT
 FACTORS
Tuberculosis (TB) is an TB spreads from person to
infectious disease that person by airborne
primarily affects the transmission. An infected
lung parenchyma. It person releases droplet
may also be transmitted nuclei (usually particles 1 to
to other parts of the 5 mcm in diameter) through
body, including the talking, coughing, sneezing,
meninges, kidneys, laughing or singing. Larger
bones and lymph nodes. droplets settle, smaller
droplets remain suspended
The primary infectious in the air and inhaled by a
agent is M.tuberculosis susceptible person.
– an acid fast aerobic
rod that grows slowly • Close contact with
and is sensitive to heat someone who has active
and ultraviolet light. TB
• Immunocompromised
patients
• Substance abuse (drug
users and alcoholics)
• Any person with
inadequate health care
(homeless, children
under age 15 years and
young adults between
ages 15 and 44 years.
• Low grade fever • Once a patient presents Pulmonary TB is treated TUBERCULIN SKIN TEST • Increase the fluid intake
• Cough (may be with a positive skin test, primarily with anti-TB agents promotes systemic
nonproductive blood test or sputum for 6 to 12 months. A • The Mantoux method hydration and serves as an
or mucopurulent culture for acid fast prolonged treatment is used to determine effective expectorant. The
sputum may be bacilli (AFB), additional duration is necessary to whether a person has nurse instructs the patient
expectorated) assessments must be ensure eradication of the been infected with the about correct positioning
• Night sweats done. organisms and to prevent TB bacillus and is used to facilitate airway
• Fatigue • Tests include a complete relapse. widely in screening for drainage (postural
• Weight loss history, physical latent M.tuberculosis drainage).
• Hemoptysis examination, tuberculin Several types of drug infection. • The patient must
skin test, chest x-ray and resistance must be • The Mantoux method understand the
drug susceptibility considered: is a standardized, medications, schedule and
testing intracutaneous side effects. It is the most
• Clinical manifestations Primary drug resistance: injection procedure effective means of
such as fever, anorexia, resistance to one of the first- and should be preventing transmission.
weight loss, night line antituberculosis agents performed only by • The nurse must plan a
sweats, fatigue, cough in a person who has not had those trained in progressive activity
and sputum production previous treatment administration and schedule that focuses on
prompt a more thorough reading. increasing activity
assessment of Secondary or acquired drug • Tubercle bacillus tolerance and muscle
respiratory function. resistance : resistance to extract (tuberculin), strength. A nutritional
• Assess the lungs for one or more antituberculosis purified protein plan that allows for small,
consolidation by agents in a patient derivative (PPD), is frequent meals and liquid
evaluating breath undergoing therapy injected into the supplements.
sounds (diminished, intradermal layer of • It is important to assess
bronchial sounds, Multidrug resistance: the inner aspect of the medication side effects
crackles), fremitus and resistance to two agents, forearm, because they are often a
egophony. If the patient isoniazid (INH) and rifampin. approximately 4 inches reason the patient fails to
is infected with TB, the The populations at higher below the elbow. adhere to the prescribed
chest x-ray reveals risk for multidrug resistance medication regimen.
lesions in the upper are those who are HIV- INTERPRETATION OF • The nurse instructs the
lobes. positive, institutionalized or RESULTS patient to take the
• Drug susceptibility homeless. medication either on an
patterns should be • The size of the empty stomach or at least
repeated at 3 months for RIPES induration determines 1 hour before meals
patients who do not RIFAMPICIN the significance of the because food interferes
respond to the therapy. 1. Red- orange reaction of 0 to 4 mm with medication
secretions and urine is considered not absorption.
ISONIAZID significant. A reaction • Patients taking INH should
 2. Peripheral neuritis of 5mm or greater may avoid foods containing
PYRAZINAMIDE be significant in tyramine and histamine
3. Increase uric acid individuals who are (tuna,aged cheese,red
ETHAMBUTOL considered at risk. wine,soy sauce yeast
4. Visual problems • An induration of 10mm extract). It may result in
STREPTOMYCIN or greater is usually headache, flushing,
5. ototoxic considered significant hypotension, light-
in individuals who have headedness, palpitations
normal or mildly and diaphoresis.
impaired immunity. • The nurse informs the
• A significant reaction patient that Rifampin may
indicates that a patient discolor contact lenses, so
has been exposed to the patient may want to
M.tuberculosis recently wear eyeglasses during
or in the past has been treatment.
vaccinated with bacilli • The nurse monitors for
Calmette-Guerin (BCG) other side effects of anti-
vaccine. The BCG TB medications such as
vaccine is given to hepatitis, hearing loss,
produce a greater neuritis and rash.
resistance to • The nurse carefully
developing TB. monitors vital signs and
observes for spikes in
temperature or changes in
the clinical status. The
nurse reports any change
in the patient’s respiratory
status to the primary
health care provider.
• The nurse instructs the
patient about the risk of
drug resistance.

LUNG ABSCESS

OVERVIEW PATHOPHYSIOLOGY SIGNS & SYMPTOMS ASSESSMENT / MEDICAL MANAGEMENT DISCHARGE NURSING PROGNOSIS
DIAGNOSTIC FINDINGS PLANNING MANAGEMENT
A lung abscess is a ASPIRATION OF • Mild productive • Physical • Adequate drainage of the lung • A patient who • The nurse The prognosis for
localized necrotic INFECTED MATERIAL cough with examination of the abscess may be achieved has had surgery administers lung abscess
lesion of the lung OR FOREIGN BODY moderate to chest may reveal through the postural drainage may return antibiotics and IV following
parenchyma copious amounts dullness on and chest physiotherapy. home before the treatments as antibiotic
containing purulent PNEUMONITIS of foul-smelling, percussion and Patients should be assessed for wound closes prescribed and treatment is
material that collapses IMPAIRS DRAINAGE often bloody, decreased or absent adequate cough. entirely with a monitors for side generally
and forms a cavity. It OF FLUID OR sputum. breath sounds with • Some patients may require drain or tube in effects. favorable. Over
is generally caused by ASPIRATED MATERIAL • Fever an intermittent insertion of a percutaneous place. • Chest 90% of lung
aspiration of • Leukocytosis pleural friction rub chest catheter for long term • The nurse physiotherapy is abscesses are
anaerobic bacteria. By INFLAMMATORY • Pleurisy or dull (grating or creaking drainage of the abscess. Use of a educates the initiated as cured with
definition, the chest x- VASCULAR chest pain sound) during bronchoscopy is uncommon. patient or prescribed to medical
ray will demonstrate a OBSTRUCTION • Dyspnea auscultation. • Diet in high protein and calories caregivers about facilitate drainage management
cavity of 2cm. Patients • Weakness Crackles may be is necessary to facilitate healing. how to change of the abscess. alone, unless
who have impaired TISSUE NECROSIS, • Anorexia and present. • Surgical intervention is the dressings to • The nurse caused by
cough reflexes and LIQUEFACTION weight loss • Confirmation of the performed if massive prevent skin educates the bronchial
cannot close the diagnosis is made hemoptysis occur if there is no excoriation and patient to obstruction.
glottis or those with ABSCESS FORMATION PREVENTION: by chest x-ray, response to any medical odor. perform deep-
swallowing difficulties • Appropriate sputum culture and management. • Monitor signs breathing and
are at risk for antibiotic in some cases, • IV antimicrobial therapy and symptoms of coughing
aspirating foreign therapy before fiberoptic depends on the results of the infection and exercises to help
material and any dental bronchoscopy. The sputum and sensitivity and is how to care and expand the lungs.
developing a lung procedures in chest x-ray reveals given for an extended period. maintain the • The nurse
abscess. patients who an infiltrate with an • Treatment for the anaerobic drain or tube. encourages a diet
must have teeth air-fluid level. lung infection includes the • The nurse also that is high in
Other patients who extracted while • Computed following medications: reminds the protein and
are at risk are those their gums and tomography (CT) • Clindamycin (Cleocin) patients to calories.
with CNS disorders teeth are scan of the chest • Ampicillin – Sulbactam (Unasyn) perform deep • The nurse offers
(seizure & stroke), infected. may be required to • Carbapanem breathing and emotional
drug addiction, • Adequate dental provide more • Large IV doses are usually coughing support, because
alcoholism, and oral hygiene, detailed images of required because the antibiotic exercises every 2 the abscess takes
esophageal disease or because different cross- must penetrate the necrotic hours during the a long time to
immunocompromised. anaerobic sectional areas of tissue and fluid in the abscess. It day to facilitate recover.
As well as patients bacteria play a the lung. must be continued for 3 weeks expectoration of
receiving nasogastric role in the or longer depending on the the lung
tube feedings and pathogenesis of clinical severity. secretions.
those with an altered lung abscess. • Improvement is demonstrated
state of consciousness • Appropriate by ↓WBC and improvement of
from anesthesia. antimicrobial chest x-ray – resolution of
therapy for surrounding infiltrate, reduction
patients with in the cavity size and absence of
pneumonia. fluid.
 • IV antibiotics are discontinued
once improvement is seen. Oral
administration of antibiotic
therapy is continued for 4 to 12
weeks.

PLEURAL CONDITION

OVERVIEW PATHOPHYSIOLOGY SIGNS & SYMPTOMS CAUSES/ RISK LAB TEST / SCREENING MEDICAL COMPLICATIONS NURSING
FACTORS MANAGEMENT MANAGEMENT
The pleura is the thin • Infection/ • Severe, fleeting, CAUSES: • Biopsy: In some cases, Treatment for pleurisy • Lungs that are Ineffective Breathing
membrane that lines inflammation/trauma sharp pain in chest • Pneumonia a doctor will take a focuses primarily on blocked or can’t Pattern related to
the outside of the ( causative factors) that radiates to (bacterial, small sample of lung the underlying cause. expand the way stabbing chest pain
lungs and the inside • Inflammation of the neck, shoulder, viral) tissue to determine For example, if they should • Assist patient to find
of the chest cavity. pleura back or abdomen • TB whether cancer or bacterial pneumonia is (atelectasis) comfortable position
• Irritate the sensory • Cough • Pulmonary tuberculosis is present. the cause, an antibiotic • Pus in your that will promote
There’s a bit of fluid fibers of the parietal • Fatigue (extreme infarction, • Blood test: Doctors use will be prescribed to pleural cavity respiration; lying on
that lubricates within pleura tiredness) embolism blood tests to look for manage the infection. (empyema) affected side
the narrow space • During respiration • Fever • Pulmonary signs of infection or If the cause is viral, • A sudden drop in decreases stretching
between the two ( intensified on • Shortness of abscess autoimmune disorders pleurisy may resolve blood flow of the pleura and,
layers of pleura to inspiration), the breath • Upper such as lupus or on its own. (shock) therefore, the pain
keep everything pleural membrane rub • Unexplained respiratory rheumatoid arthritis. The pain and • A dangerous decreases.
moving smoothly. together the result is weight loss tract • Electrocardiogram (EK inflammation reaction to • Instruct patient in
When the membranes severe, sharp, infection G or ECG): This test associated with infection (sepsis) splinting chest while
become inflamed, knifelike pain. • Pulmonary uses small electrodes pleurisy is usually taking a deep breath
they rub painfully neoplasm placed on the chest to treated with or coughing.
against each other • Chest trauma measure the heart’s nonsteroidal anti- • Administer or teach
instead. Pleurisy is an electrical activity. It inflammatory drugs self-administration of
inflammation RISK FACTORS: helps doctors rule out (NSAIDs), such as pain medications as
(swelling or irritation) • Advanced problems or defects of ibuprofen (Advil, ordered.
of these two layers of age the heart. Motrin IB, others). • Employ
tissue. • Smoking • Imaging tests: Imaging nonpharmacologic
• Chronic lung tests such as X-rays, CT Occasionally, the interventions for pain
diseases scans and ultrasounds doctor may prescribe relief, such as
• Asthma allow your doctor to steroid medication. application of heat,
• Bronchitis see abnormalities in the muscle relaxation,
• Cystic fibrosis pleural space, including and imagery.
• Heart failure air, gas or a blood clot. • Assist with
• Diabetes • Physical intercostal nerve
 • Cancer exam: Listening to your block if indicated.
• Immobility lungs with a • Evaluate patient for
stethoscope allows signs of hypoxia
your doctor to hear a thoroughly when
rubbing sound in your anxiety, restlessness,
lungs that may be a sign and agitation of new
of pleurisy. onset are noted,
• Fluid extraction before administering
(thoracentesis): A as needed sedatives.
doctor inserts a small Consider evaluation
needle into the pleural by a health care
space and removes provider when these
fluid to look for signs of signs are present,
infection or other especially if
causes of pleurisy. accompanied by
cyanotic nail beds,
circumoral pallor,
and increased
respiratory rate.

PLEURAL EFFUSION

OVERVIEW PATHOPHYSIOLOGY SIGNS & SYMPTOMS CAUSES/ RISK LAB TEST / SCREENING MEDICAL MANAGEMENT COMPLICATIONS NURSING
FACTORS MANAGEMENT
A pleural effusion is HYDROSTATIC • chest pain CAUSES: Chest X-ray. • Thoracentesis. If the • pulmonary • Maintaining
an unusual amount PRESSURE • dry cough • congestive heart Pleural effusions appear effusion is large, the edema or fluid in Normal
of fluid around • fever failure (the most white on X-rays, while air doctor may take more the lungs, which Breathing
the lung. The pleural ONCOTIC PRESSURE • difficulty common cause space looks black. If a pleural fluid than needs for can result from Pattern
space normally breathing when overall) effusion is likely, you may testing, just to ease the draining fluid too • Institute
contains only about UNABLE TO REMAIN lying down • cirrhosis or poor get more X-ray films while symptoms. quickly during treatments to
5-15 ml of fluid THE FLUID WITH IN A • shortness of liver function you lie on your side. These • Tube thoracostomy thoracentesis resolve the
which acts as a INTRAVASCULAR breath • pulmonary can show if the fluid flows (chest tube). Your doctor • partial collapsed underlying
lubricant that allows SPACE • difficulty taking embolism, which freely within the pleural makes a small cut in your lung cause as
the pleural surfaces deep breaths is caused by space. chest wall and puts a • infection or ordered.
to move without FLUID SHIFT • persistent a blood clot and is plastic tube into your bleeding • Assist with
friction. INTERSTITIAL SPACE hiccups a blockage in the X-ray- the patient lies on the pleural space for several • Lung damage thoracentesis if
• difficulty with lung arteries affected side in a side-lying days. • Infection that turns indicated
Pleural effusions are EFFUSION physical activity • complications position. • Pleural drain. If your into an abscess, • Maintain chest
common, with • weight loss from open-heart A pleural effusion can be pleural effusions keep called an empyema drainage as
approximately 1 surgery diagnosed because this coming back, your • Air in the chest needed
million Imbalances in • pneumonia position allows for the doctor may put a long- cavity • Provide care
cases diagnosed in hydrostatic or • severe kidney “layering of the fluid, and an term catheter through (pneumothorax) after
the United States oncotic pressure disease air-fluid” line is visible your skin into the pleural after drainage of pleurodesis.
every year, Filtrate of plasma • autoimmune space. You can then the effusion • Monitor for
according to the that moves across diseases, such Computed tomography (CT drain the pleural effusion • Pleural thickening excessive pain
American Thoracic intact capillary walls as lupus and rheu scan).  at home. Your doctor (scarring of the from the
Society. It’s a serious It occurs when matoid arthritis A CT scanner takes many X- will tell you how and lining of the lung) sclerosing
condition associated factors influencing rays quickly, and a computer when to do that. agent, which
with an increased the formation and RISK FACTORS: constructs images of the • Pleurodesis. the doctor may cause
risk of death. In one reabsorption of • Smoking and entire chest -- inside and injects an irritating hypoventilation.
study, 15 percent of pleural fluid are drinking alcohol out. CT scans show more substance (such as talc • Administer
hospitalized people altered • Any previous detail than chest X-rays do. or doxycycline) through prescribed
diagnosed with complaint of high a chest tube into the analgesic.
pleural effusions blood pressure Ultrasound.  pleural space. The • Assist patient
died within 30 days. • History of any A probe on your chest will substance inflames the undergoing
• Pleural effusion contact with create images of the inside pleura and chest wall, instillation of
is a collection of asbestos of your body, which show up which then bind tightly intrapleural
abnormal on a video screen. Your to each other as they lidocaine if pain
amount of fluid doctor may use the heal. Pleurodesis can relief is not
in the pleural ultrasound to locate the fluid prevent pleural effusions forthcoming.
space so they can get a sample for from coming back in • Administer
analysis. many cases. oxygen as
• Pleural indicated by
decortication. Surgeons dyspnea and
can operate inside the hypoxemia.
pleural space, removing • Observe
potentially dangerous patient's
inflammation and breathing
unhealthy tissue. To do pattern, oxygen
this, your surgeon may saturation
make small cuts
(thoracoscopy) or a large
one (thoracotomy).

EMPHYEMA
 OVERVIEW SIGNS & RISK FACTORS COMPLICATIONS LAB TEST / SCREENING MEDICAL MANAGEMENT NURSING MANAGEMENT
SYMPTOMS
Emphyema is also • Shortness of • Sepsis • Chest X-rays. Uses invisible SURGERY • Assess for any previous history of
called pyothorax or breath • Pneumonia • Pneumothorax radiation energy beams to respiratory infections like untreated
purulent pleuritis. It’s a • Dry cough • Bronchiectasi • Broncho- produce images of internal Percutaneous thoracentesis. pneumonia in the past
condition in which pus • Fever s pleural fistula tissues, bones, and organs on A needle is inserted into the • Assess the level of vital signs like
gathers in the area • Night sweating • COPD film or digital media. pleural space to drain fluid. temperature, pulse, respiration and
between the lungs and • Chest pain • Rheumatoid • CT scans. Uses a combination of blood pressure, any abnormal
the inner surface of the • Headache arthritis x-rays and computer technology Thoracostomy. Inserting of readings should be indicated
chest wall. • Confusion • Alcoholism to produce horizontal, or axial, plastic tube into the chest • Assess the degree of pain (chest)
• Loss of appetite • Elderly images of any part of the body, between two ribs. Then connect any difficulty in breathing & or
Pus is a fluid that’s • Difficulty • Diabetes including the bones, muscles, fat the tube to a suction device and shortness of breath
filled with immune breathing • A weakened and organs. remove the fluid. it may also • Assess the degree of headache,
cells, dead cells, and • Weight loss immune • Ultrasound. Uses sound waves inject medication to help drain lethargy or malaise
bacteria. Pus in the system to tell where the fluid is located. the fluid. • Any abdominal distension
pleural space can’t be • Surgery or • Blood test. Help to check the • if patient is on thoracotomy, assess
coughed out. Instead, it recent trauma white blood cell count, look for Video-assisted thoracic surgery. the level of pus drainage, quantity,
needs to be drained by • Lung abscess the C-reactive protein, and Removing of the affected tissue color and amount should be noted
a needle or surgery. identify the bacteria causing the around the lungs and then • Monitor the patient’s vital signs
infection. insert a drainage tube or use especially respiration at interval.
Empyema usually • Thoracentesis. A needle is medication to remove the fluid. • Encourage the client to reduce
develops after inserted through the back of the It will create three small exposure to excessive air pollutants
pneumonia, which is an ribcage into the pleural space to insicions and use a tiny camera and avoid smoking.
infection of the lung remove fluid or air. called a thoracoscope. • Instruct the patient on proper deep
tissue. • Pleural fluid analysis. Examines breathing exercise to restore the
the fluid under a microscope to Open decortication. normal respiratory functions.
look for bacteria, protein and • Position the patient correctly to
cancer cells. Peeling away the scar peel that promote postural drainage.
• formed on the lung so it can re- • Encourage the client to take
expand. This can prevent adequate fluid to liquify the
permanent disability. solution.
• Suction the patient at interval to
clear the air ways.
• Encourage adequate rest, diet,
exercise and provide diversional
activities.
• Assist the doctor during
bronchoscopy to remove thicker
secretion by providing the
necessary instrument.
 • Monitor the patient’s vital signs
especially respiration at interval.
• Encourage the client to reduce
exposure to excessive air pollutants
and avoid smoking.
• Instruct the patient on proper deep
breathing exercise to restore the
normal respiratory functions.
• Position the patient correctly to
promote postural drainage.
• Encourage the client to take
adequate fluid to liquify the
solution.
• Suction the patient at interval to
clear the air ways.
• Encourage adequate rest, diet,
exercise and provide diversional
activities.
• Assist the doctor during
bronchoscopy to remove thicker
secretion by providing the
necessary instrument.

PULMONARY EDEMA

OVERVIEW PATHOPHYSIOLOGY SIGNS & SYMPTOMS LAB TEST / SCREENING MEDICAL MANAGEMENT NURSING MANAGEMENT
• Pulmonary Pulmonary edema is often caused • Shortness of breath • A chest x-ray, done • For acute myocardial Patient Monitoring
edema is an by congestive heart failure. When • Orthopnea immediately, is usually infarction or another • Continuously monitor oxygenation
abnormal the heart is not able to pump • Moist cough with pink diagnostic, showing marked acute coronary syndrome, status with pulse oximetry monitoring.
accumulation of efficiently, blood can back up into frothy sputum interstitial edema. Bedside thrombolysis or direct • Monitor ECG for dysrhythmia
extravascular fluid the veins that take blood through • Chest discomfort measurement of serum percutaneous coronary development that may be related to
as the lung the lungs. • Palpitations BNP/NT-proBNP levels angioplasty with or hypoxemia, acid-base imbalance, or
parenchyma that • Fatigue (elevated in pulmonary without stent placement ventriculpmar irritability.
interferes with • Syncope edema; normal in COPD • For severe hypertension, • Calculate arterial-alveolar oxygen
adequate gas As the pressure in these blood • Cyanosis exacerbation) is helpful if an IV vasodilator tension ratio as an index of gas exchange
exchange. vessels increases, fluid is pushed • Respiratory distress the diagnosis is in doubt. • For supraventricular or efficiency.
• This is a life into the air spaces (alveoli) in the • ECG, pulse oximetry, and ventricular tachycardia, • Document hourly the input and output
threatening lungs. This fluid reduces normal blood tests (cardiac direct-current to monitor fluid status. Obtain daily
situation that oxygen movement through the markers, electrolytes, BUN cardioversion weights.
 needs immediate lungs. These two factors combine [blood urea nitrogen], • For rapid atrial fibrillation,
treatment. to cause shortness of breath. creatinine and, for severely cardioversion is preferred. Patient Assessment
• The most common ill patients, arterial blood To slow the ventricular • Measure HR, RR, and BP every 15
cause of Congestive heart failure that leads gas [ABG] measurements) rate, an IV beta-blocker, minutes to evaluate the patient’s
cardiogenic to pulmonary edema may be are done. IV digoxin, or cautious use response to therapy and to detect
pulmonary edema caused by: of an IV calcium channel cardiopulmonary deterioration.
is left ventricular • Heart attack, or any disease of Echocardiography may be blocker • Assess the patient for changes that may
failure exhibited by the heart that weakens or helpful to determine the cause indicate respiratory compromise,
increased left atrial stiffens the heart muscle of the pulmonary edema necessitating intubation and mechanical
ventricular (cardiomyopathy) (eg, myocardial Treatment of cause ventilation.
pressures. • Leaking or narrowed heart infarction, valvular • Oxygen
• Risk factors include valves (mitral or aortic valves) dysfunction, hypertensive heart • IV diuretic Diagnostic Assessment
ischemic heart • Sudden, severe high blood disease, dilated • Nitrates • Review ABGs for hypoxemia (Pao2 < 60
disease, pressure (hypertension) cardiomyopathy) and may • IV inotropes mm Hg) and acidosis (pH < 7.35), which
cardiomyopathy, influence the choice of • Morphine may further compromise tissue
valvular disease, Pulmonary edema may also be therapies. • Ventilatory assistance perfusion and to indicate need for
myocardial caused by: mechanical ventilation.
infarction, and • Certain medicines Hypoxemia can be severe. • Review serial chest radiographs for
acute septal • High altitude exposure Carbon dioxide retention is a worsening or resolving pulmonary
defects. • Kidney failure late, ominous sign of secondary congestion.
• Narrowed arteries that bring hypoventilation. • Review lactate levels as an indicator of
blood to the kidneys Clinical evaluation showing anaerobic metabolism.
• Lung damage caused by severe dyspnea and pulmonary
poisonous gas or severe crackles Patient Management
infection Chest x-ray • Provide supplemental oxygen via mask
• Major injury Sometimes serum brain as indicated.
natriuretic peptide (BNP) or N- • Administer diuretic agents or nesiritide
terminal-pro BNP (NT-pro-BNP) to reduce circulating volume, which will
ECG, cardiac markers, and other improve gas exchange.
tests for etiology as needed • Monitor urine output and electrolytes.
• Administer vasodilating agents to
redistribute fluid volumes, which will
facilitate gas exchange.
• Morphine sulfate maybe ordered to
promote preload and afterload
reduction and to decrease anxiety.

ACUTE RESPIRATORY FAILURE

OVERVIEW PATHOPHYSIOLOGY SIGNS & SYMPTOMS PREVENTION/SCREENING TREATMENT/PROGNOSIS NURSING MANAGEMENT

Respiratory failure is a • Respiratory failure can
serious condition that arise from an
develops when the abnormality in any of the
lungs can’t get enough components of the
oxygen into the blood. respiratory system,
Buildup of carbon including the airways,
dioxide can also alveoli, central nervous
damage the tissues and system (CNS), peripheral
organs and further nervous system,
impair oxygenation of respiratory muscles, and
blood and, as a result, chest wall. Patients who
slow oxygen delivery to have hypoperfusion
the tissues. secondary to
cardiogenic,
Acute respiratory hypovolemic, or septic
failure happens quickly shock often present with
and without much respiratory failure.
warning. It is often • Ventilatory capacity is
caused by a disease or the maximal
injury that affects your spontaneous ventilation
breathing, such that can be maintained
as pneumonia, opioid without development of
overdose, stroke, or a respiratory muscle
lung or spinal cord fatigue. Ventilatory
injury. Acute demand is the
respiratory failure spontaneous minute
requires emergency ventilation that results in
treatment. a stable PaCO2.
• Normally, ventilatory
capacity greatly exceeds
ventilatory demand.
Respiratory failure may
result from either a
reduction in ventilatory
capacity or an increase in
ventilatory demand (or
both). Ventilatory
capacity can be
decreased by a disease
process involving any of
Symptoms may include Not all causes of acute
changes in a person’s respiratory failure, such as
appearance, ease of trauma, are preventable.
breathing, and how they
act. However, in the case of
pneumonia and some other
Examples of symptoms airway-related illnesses, a
include: person can take some steps to
• appearing very sleepy protect their lungs.
• a blue tinge to a These include:
person’s fingernails, • refraining from smoking
lips, or skin cigarettes, which can
• confusion damage the lungs
• irregular heart rhythms • seeing a doctor at early
• passing out signs of a bacterial
• rapid breathing infection, such as a fever,
• shortness of breath cough, and high mucus
production
Generally, the symptoms of • taking all medications a
acute respiratory failure doctor prescribes to keep
depend on the underlying the heart and lungs healthy
cause. • if necessary, using assistive
devices to maintain oxygen
levels, such as continuous
positive airway pressure
masks, which a person can
wear at home
• Engaging in appropriate
levels of physical activity to
enhance lung function
• If a person has a history of
lung problems and
hospitalization, they should
talk to their doctor about
strategies to enhance their
overall health.
• Perform a physical exam
• Ask you questions about
your family or personal
health history
• Treatment usually addresses any
underlying conditions you may
have. Your doctor will then treat
your respiratory failure with a
variety of options.
• Your doctor may prescribe pain
medications or other medicines to
help you breathe better.
• If you can breathe adequately on
your own and your hypoxemia is
mild, you may receive
oxygen from an oxygen tank to
help you breathe better. Portable
air tanks are available if your
condition requires one.
• If you can’t breathe adequately on
your own, your doctor may insert
a breathing tube into your mouth
or nose, and connect the tube to a
ventilator to help you breathe.
• If you require prolonged ventilator
support, an operation that creates
an artificial airway in the windpipe
called a tracheostomy may be
necessary.
• You may receive oxygen via an
oxygen tank or ventilator to help
you breathe better.
• Maintain patent airwaY
• Obtain and evaluate labs (ABG)
• Complete a full respiratory
assessment to detect changes or
further decompensation as early as
possible, and notify MD as indicated
• )Provide supplemental oxygen as
appropriate
• Ensure patient is in the optimal
position to decrease work of
breathing
• Prepare for rapid sequence
intubation, if necessaryR
• Remove any negative/distracting
stimuli: turn the TV off, encourage
family members to be calm
• Prevent ventilator acquired
pneumonia (VAP) if the patient is
intubated
• Provide oral care
•  Cluster care
• Promote appropriate nutrition
• Assist to treat underlying causes. If
the patient has pneumonia,
administering antibiotics is essential
to healing, if the patient has a PE,
administer appropriate blood
thinners, if the patient has asthma,
you’re auscultating lungs sounds
before and after to evaluate
effectiveness.
• Monitor for conditions that can
increase the oxygen demands (fever,
anemia)
• Prevent aspiration pneumonia in
patients who cannot maintain their
airway
• Manage secretions
• Assess ability to swallow safely post-
intubation

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
OVERVIEW
Acute respiratory distress
syndrome (ARDS) is
sudden, progressive form
of respiratory failure
characterized by severe
dyspnea, refractory
hypoxemia, and diffuse
bilateral infiltrates.
Acute respiratory distress
syndrome (ARDS) occurs
when fluid builds up in the
tiny, elastic air sacs
(alveoli) in your lungs. The
fluid keeps your lungs from
filling with enough air,
which means less oxygen
reaches your bloodstream.
This deprives your organs
of the oxygen they need to
function.
ARDS typically occurs in
people who are already
critically ill or who have
the functional
components of the
respiratory system and
its controller. Ventilatory
demand is augmented by
an increase in minute
ventilation and/or an
increase in the work of
breathing.
PATHOPHYSIOLOGY
ARDS can be caused by any
major swelling
(inflammation) or injury to
the lung. Some common
causes include:
• Breathing vomit into
the lungs (aspiration)
• Inhaling chemicals
• Pneumonia
• Septic shock
• Trauma
ARDS leads to a buildup of
fluid in the air sacs. This
fluid prevents enough
oxygen from passing into
the bloodstream.
The fluid buildup also
makes the lungs heavy and
stiff, and decreases the
lungs’ ability to expand.
The level of oxygen in the
blood can stay dangerously
• Check your body’s oxygen
and carbon dioxide levels
level with a pulse oximetry
device and an arterial blood
gas test
• Order a chest x-ray to look
for abnormalities in your
lung.
•
SIGNS & SYMPTOMS RISK FACTORS
Early signs/symptoms Direct pulmonary trauma
• Restlessness • Viral, bacteria or fungal
• Dyspnea pneumonia
• Low blood pressure • Lung contusion
• Confusion • Fat embolus
• Extreme tiredness • Aspiration
• Change in patients • Massive smoke
behaviour inhalation
o Mood swing • Inhaled toxins
o Disorientation • Prolonged exposure to
o Change in LOC high concentration of
• If pneumonia Is oxygen
causing ARDS then
client may have: Indirect pulmonary
o Cough trauma
o Fever • Sepsis
• Shock
Late sign/symptoms • Multisystem trauma
• Severe difficulty in • Disseminated
breathing ie., labored, intravascular
rapid breathing coagulation (DIC) is a
• Shortness of breath rare but serious
• Tachycardia condition that causes
• Thick frothy sputum abnormal blood
• Metabolic acidosis clotting throughout the
LAB TEST / SCREENING
Complete history
On physical examination:
auscultation reveals
abnormal breath sounds –
wheezing, crackles
TEST:
• Arterial blood gas
analysis
• Blood tests
• Chest X-rays
• Bronchoscopy
• Sputum cultures and
analysis
• CT scan
• Echocardiogram
A person suffering from
severe infection or injury
develops breathing
problems
A chest x-ray shows fluid in
the air sacs of both lungs
MEDICAL MANAGEMENT NURSING MANAGEMENT
Treatment of the cause
• Oxygen therapy
• Often mechanical
ventilation
People with ARDS are
treated in an intensive care
unit (ICU).
No specific therapy for
ARDS exist.
Supportive measures:
• Supplemental oxygen
• Mechanical ventilation
Positioning strategies:
Prone Positioning
• Improve their
oxygenation after
being placed in a prone
position
• Mechanism that may
explain the
improvement include:
significant injuries. Severe
shortness of breath — the
main symptom of ARDS —
usually develops within a
few hours to a few days
after the precipitating
injury or infection.
Many people who develop
ARDS don't survive. The
risk of death increases with
age and severity of illness.
Of the people who do
survive ARDS, some
recover completely while
others experience lasting
damage to their lungs.
low, even if the person
receives oxygen from a
breathing machine • Abnormal breath
(mechanical ventilator)
through a breathing tube • Decreased PaCo2 with
(endotracheal tube).
• Decreased PaCo2
ARDS often occurs along
with the failure of other
organ systems, such as the
liver or the kidneys.
Cigarette smoking and
heavy alcohol use may be
risk factors.
• Cyanosis (blue skin, lips
and nails)
sounds, like crackles
respiratory alkalosis
• Pancreatitis is an
• Uremia is a buildup of
• Drug overdose
• Anaphylaxis is a
body's blood vessels. It Blood tests show a low o Increased
is caused by another level of oxygen in the functional
disease or condition, blood residual
such as an infection or capacity
injury that makes the Other conditions that o Change in
body's normal blood could cause breathing regional
clotting process problems have been ruled diaphragmatic
become overactive. out capacity
o Perfusion
inflammation Blood pressure check redistribution
(swelling) of the o Improve
pancreas. When the Blood tests for oxygen clearance of
pancreas is inflamed, levels and signs of infection secretions
the powerful digestive as well as levels of BNP Lateral rotation therapy
enzymes it makes can (brain natriuretic peptide) • To stimulate postural
damage its tissue. The a marker of heart failure drainage & help
inflamed pancreas can mobilized the
cause release of Chest x-ray secretion
inflammatory cells and • The lateral movement
toxins that may harm Analysis of coughed-up of bed is done for 18-
your lungs, kidneys and matter 24 hours slowly.
heart.
Occasionally, an Fluid
toxins in your blood. It echocardiogram (heart therapy/Management
occurs when the ultrasound), to rule 6. Distinction
kidneys stop filtering out congestive heart between primary
toxins out through failure ARDS due to
your urine. Uremia is aspiration,
often a sign of end- Bronchoscopy to analyze pneumonia, or
stage renal (kidney) airways. A laboratory inhalational injury,
disease. Treatments examination may indicate which is usually
include medication, presence of certain can be treated
dialysis and kidney viruses, cancer cells etc. with fluid
transplant surgery. restriction, from
Open lung biopsy is secondary ARDS
reserved for cases when due to remote
severe, potentially life- diagnosis is difficult to infection or
threatening allergic establish. inflammation that
reaction. It can occur requires initial fluid
within seconds or
 minutes of exposure to and potential
something you're vasoactive drug
allergic to, such as therapy is central
peanuts or bee stings. in directing initial
• Idiopathic treatments to
• Prolonged heart stabilize the
bypass surgery patient.
• Massive blood
transfusion Respiratory therapy
• Pregnancy induced
hypertension
• Increased intracranial Successful treatment
pressure usually depends on
treating the underlying
disorder (for example,
pneumonia). 

Oxygen therapy, which is

vital to correcting low
oxygen levels, also is given.
If oxygen delivered by a
face mask or nasal prongs
does not correct the low
blood oxygen levels, or if
very high doses of inhaled
oxygen are
required, mechanical
ventilation must be used.
Usually a ventilator
delivers oxygen-rich air
under pressure using a
tube inserted through the
mouth into the windpipe
(trachea).

Without prompt
treatment, many people
who have ARDS will not
survive. However, with
appropriate treatment,
about 60 to 75% of people
with ARDS survive.
People who respond
promptly to treatment
usually recover completely
with few or no long-term
lung abnormalities. Those
whose treatment involves
long periods on a
ventilator (a machine that
helps air get in and out of
the lungs) are more likely
to develop lung scarring.
Such scarring may
decrease over a few
months after the person is
taken off the ventilator.
Lung scarring, if extensive,
can impair lung function
permanently in ways that
are noticeable during
certain day-to-day
activities. Less extensive
scarring may impair lung
function only when the
lungs are stressed, such as
during exercise or an
illness.
Many people lose large
amounts of weight and
muscle during the
illness. Rehabilitation in
the hospital can help them
regain their strength and
independence.