NCM1128

Care of Clients with Problems in Oxygenation, Fluid and

Electrolytes, Infectious, inflammatory and Immunologic
Response, Cellular Aberrations, Acute and Chronic
Management
of Patients
With Chest and
Lower
Respiratory
Tract Disorders
 The collapse or airless condition of the alveoli
caused by hypoventilation, obstruction to the
airways, or compression.
Postoperative patients are at high risk for
Atelectasis atelectasis.
Symptoms are insidious and include cough,
sputum production, and a low-grade fever.
Respiratory distress, anxiety, and symptoms
of hypoxia occur if large areas of the lung are
affected.
Assessment and
Diagnosis
Characterized by increased work of breathing
and hypoxemia

Decreased breath sounds and crackles over the

affected area

Chest x-ray may suggest a diagnosis of

atelectasis before clinical symptoms appear

Pulse oximetry (SpO2) may demonstrate a low

saturation of hemoglobin with oxygen (less than
90%)
 Prevention
◦ Frequent turning and early
mobilization
Nursing ◦ Strategies to improve ventilation:
Intervention deep breathing exercises at least
every 2 hours, incentive
s spirometry
◦ Strategies to remove secretions:
coughing exercises, suctioning,
aerosol therapy and chest
physiotherapy.
 o Strategies to improve ventilation and
remove secretions: ICOUGH
o CPT (Chest Physiotherapy)
Management
o Endotracheal intubation and mechanical
ventilation
o Thoracentesis to relieve compression
 Severe acute respiratory
syndrome (SARS)—viral, no
cases reported since 2004,
CDC
Pulmonary
Lung abscess
Infections
Tuberculosis
Tracheobronchitis
Pneumonia
Covid-19
 Most are a complication of bacterial
pneumonia

Symptoms vary from a mild productive

cough to acute illness; pleural friction
rub
Lung Abscess
Drainage achieved through postural
drainage and chest physiotherapy

IV antibiotic therapy for 3 weeks or

longer, followed by oral antibiotics for 4
to 12 weeks
Nursing Management: Lung Abscess

 Administer IV antibiotics
 CPT
 Educate patient to perform deep breathing and coughing
exercises
 Encourage diet high in protein and calories
 Emotional support
 Chronic, recurrent,
infection caused by
Pulmonary Mycobacterium
Tuberculosis
Tuberculosis, M. Bovis or
M. Africanum.
 • asymptomatic
• bloody sputum
• chest X-ray finding of TB
Pulmonary
TB • "positive" Tuberculin Skin Test
Assessment/ • recurrent cough
Findings • Low grade fever
• Night sweats
• loss of weight
Mycobacterium
Tuberculosis
Mycobacterium tuberculosis
(stained red) in sputum
Opacification of
airspaces within
the lungs.
 Vaccines

Bacillus Calmette-
Guérin (BCG)
 Regular and complete intake
of the prescribed anti TB
medications

Directly Observed
Treatment Treatment, Short-course
(DOTS)

R, I, P, E, S
 Promoting airway clearance

Advocating adherence to the

Nursing treatment regimen
Management
of TB Promoting activity and
nutrition

Preventing transmission
 Inflammation of the lung
parenchyma caused by various
Pneumonia microorganisms, including
bacteria, mycobacteria, fungi,
and viruses
 Supportive treatment
Inflammatory process of
includes fluids, oxygen
lung parenchyma
for hypoxia, antipyretics,
associated with marked Rusty sputum
antitussives,
increase in interstitial
decongestants, and
and alveolar fluid
antihistamines.
Administration of antibiotic therapy is determined
by Gram stain results. - Antibiogram
If the etiologic agent is not identified, use empiric
antibiotic therapy.
Classification of Pneumonia
◦ Community acquired (CAP)
◦ Healthcare associated (HCAP)/ Hospital acquired
(HAP)
◦ Ventilator associated (VAP)
Pneumonia Risk Factors

Occurs in patients with certain underlying

disorders and diseases
◦ Heart failure, diabetes, alcoholism, COPD, and AIDS
◦ Influenza
◦ Cystic fibrosis
 Varies depending on type, causal organism,
and presence of underlying disease
Streptococcal: Sudden onset of chills, fever,
pleuritic chest pain, tachypnea, and
respiratory distress
Clinical Viral, mycoplasma, or Legionella: relative
Manifestations bradycardia
Other: Respiratory tract infection, headache,
low-grade fever, pleuritic pain, myalgia, rash,
and pharyngitis
Orthopnea, crackles, increased tactile
fremitus, purulent sputum
 History

Physical exam

Assessment Chest x-ray

and
Diagnosis Blood culture

Sputum examination

Bronchoscopy may be used for acute severe infection

  Administration of the appropriate
antibiotic as determined by the
results of a culture and sensitivity
 Supportive treatment includes
Medical fluids, oxygen for hypoxia,
Management antipyretics, antitussives,
decongestants, and antihistamines
 Antibiotics not indicated for viral
infections but are used for
secondary bacterial infection
 Vital signs
Secretions: amount, odor, color
Cough: frequency and severity
Nursing
Process: Tachypnea, shortness of breath

Assessment Inspect and auscultate chest

Changes in mental status, fatigue,
edema, dehydration, concomitant
heart failure, especially in older
adult patients
Nursing Process: Diagnoses

INEFFECTIVE FATIGUE AND RISK FOR FLUID IMBALANCED KNOWLEDGE

AIRWAY ACTIVITY VOLUME DEFICIT NUTRITION DEFICIT
CLEARANCE INTOLERANCE
 Continuing symptoms after
initiation of therapy
Sepsis and septic shock
Collaborative
Problems / Respiratory failure
Complications Atelectasis
Pleural effusion
Delirium
 Improved airway patency

Increased activity

Nursing Maintenance of proper fluid volume

Process:
Planning Maintenance of adequate nutrition

Understanding of the treatment protocol and

preventive measures

Absence of complications
 Pneumococcal vaccination
◦ Reduces the incidence of
pneumonia, hospitalizations for
cardiac conditions, and deaths in
the older adult population
◦ Two types of pneumococcal
Prevention vaccine
◦ Recommended for all adults 65
years of age or older and 19
years or older with conditions
that weaken the immune system
Nursing Process: Interventions
Oxygen with
humidification to
loosen secretions Coughing Chest Position
• Face mask or nasal techniques physiotherapy changes
cannula

Incentive
Nutrition Hydration Rest
spirometry

Activity as
Patient teaching Self-care
tolerated
 Demonstrates improved airway patency

Rests and conserves energy and then slowly

increasing activities

Expected
Maintains adequate hydration; adequate dietary
intake

Outcomes Verbalizes increased knowledge about

management strategies

Complies with management strategies

Exhibits no complications
 Inhalation of foreign material
into the lungs
Serious complication of
pneumonia
Aspiration Clinical picture: tachycardia,
dyspnea, central cyanosis,
hypertension, hypotension,
and potential death
 Nursing interventions:
◦ Keep HOB elevated >30
degrees
◦ Avoid stimulation of gag
Aspiration reflex with suctioning or
other procedures
◦ Check for placement before
tube feedings
◦ Thickened fluids for
swallowing problems
 Disorders that involve

• The membranes covering the lungs (visceral

pleura) and the surface of the chest wall (parietal
pleura)
• Disorders affecting the pleural space

Pleural Pluerisy

Conditions
Plueral effusion

Emphysema

Pulmonary edema
 Key characteristic of
Inflammation of pleuritic pain is its
both layers of relationship to
pleurae respiratory
movement

Diagnostic tests may

Pleural friction rub
Pleurisy can be heard with
the stethoscope
include chest x-rays,
sputum analysis,
thoracentesis

Treat underlying
cause, provide
analgesia, teaching
to splint the rib cage
when coughing
 Fluid collection in pleural space usually
secondary to heart failure, TB,
pneumonia, pulmonary infections
Fever, chills, pleuritic pain, dyspnea
Decreased or absent breath sounds;
Pleural decreased fremitus; and a dull, flat
effusion sound on percussion
May have tracheal deviation away from
affected side
Chest x-ray, chest CT, and thoracentesis
Treat underlying cause
 Accumulation of thick, purulent fluid in
pleural space
Complication of bacterial pneumonia or
lung abscess
Acutely ill and has signs and symptoms
similar to those of an acute respiratory
Emphysema infection or pneumonia
Chest auscultation demonstrates decreased
or absent breath sounds over the affected
area
Chest CT and a diagnostic thoracentesis
Drain fluid and administer antibiotics for 4
to 6 weeks
 Characterized by sudden,
Acute progressive pulmonary edema,
Respiratory increasing bilateral lung infiltrates
Distress visible on chest x-ray, and absence
Syndrome of an elevated left atrial pressure
(ARDS) Rapid onset of severe dyspnea
◦ Hypoxemia that does not respond to
supplemental oxygen therapy
 Identification and treatment of
underlying cause
Intubation, mechanical ventilation with
PEEP to keep alveoli open

ARDS Hypovolemia treated

Medical Prone positioning is best for

oxygenation, frequent repositioning to
Management safeguard integumentary system
Nutritional support, enteral feedings
preferred
Reduce anxiety
 Obstruction of the pulmonary artery or one of its
branches by a thrombus (or thrombi) that originates
somewhere in the venous system or in the right side
of the heart

Inflammatory process obstructs area,

Pulmonary
results in diminished or absent blood flow

Emboli Bronchioles constrict, further increasing

pulmonary vascular resistance, pulmonary
arterial pressure, and right ventricular workload

Ventilation–perfusion imbalance, right

ventricular failure, shock occurs
 Trauma
Surgery
Risk Factors Pregnancy
for
Heart failure
Pulmonary
Emboli Hypercoagulability
Immobility, venous stasis
Dyspnea is the most common
symptom
Prevention Exercises to avoid venous stasis
and ◦ Early ambulation
◦ Anti-embolism stockings
Treatment
of Treatment
Pulmonary ◦ Measures to improve respiratory
and vascular status
◦ Anticoagulation and thrombolytic
Emboli therapy
◦ Surgical interventions
 Occupational lung diseases and includes
asbestosis, silicosis, and coal workers'
pneumoconiosis
Refers to a nonneoplastic alteration of
the lung resulting from inhalation of
mineral or inorganic dust

Pneumoconiosis Preventable, not treatable

Reduce exposure, protective
gear/devices
Role of nurse is to be the employee
advocate and provide health education
on preventive measures to reduce lung
injury
SARCOIDOSIS
Multi-system, granulomatous disease of
unknown etiology but may be due to
hypersensitivity to agents, which release
cytokines and cause fibroblasts formation

CXR reveals hilar adenopathy and nodular

lesions in lungs

Corticosteroid therapy
 Leading cause of death in the United
States

>85% caused by cigarette smoke

Classification: 15% SCLC and 85% NSCLC

Lung Cancer tumors

Treatment:
◦ Surgery
◦ Radiation
◦ Chemotherapy
 Airway clearance
Dyspnea
Nursing Care
of the Patient Fatigue
With Cancer Pain
Psychological support
 Blunt trauma
Sternal, rib Pneumothorax
fractures ◦ Spontaneous or
Chest Flail chest simple
◦ Traumatic
Trauma Pulmonary ◦ Tension
contusion pneumothorax
Penetrating
trauma
 Sudden compression or
positive pressure in chest
Blunt/ non- wall
penetrating
trauma Secondary to falls, blow to
chest, rib fractures
Flail Chest
life-threatening medical
condition that occurs when
a segment of the rib cage
breaks under extreme stress
and becomes detached
from the rest of the chest
wall
PNEUMOTHORAX

Occurs when positive

atmospheric pressure enters the
parietal or visceral pleura or
pleural space
Aspiration
o Aspiration of stomach contents into the lungs is a serious
complication that may cause pneumonia and result in the
following clinical picture: tachycardia, dyspnea, central
cyanosis, hypertension, hypotension, and finally death.
o It can occur when the protective airway reflexes are
decreased or absent
Prevention

• Prevention is the primary goal when caring

for patients at risk for aspiration.
Thank you. 