LOWER RESPIRATORY TRACK GIBONCE KIBONA JOSEPH

DISORDERS RESTRICTIVE BSCN,TA

DISORDERS SONPH UDOM

RESTRICTIVE DISORDERS
Restrictive disorders are those problems that limit the ability of the
patient to expand his or her lungs and, therefore, inhale air.
Restrictive disorders can be intrinsic, involving lung tissue (such as
pulmonary fibrosis), or extrinsic, involving structures outside the
lungs (such as pleural effusion).
Restrictive disorders covered below include
pleurisy,
pleural effusion,
empyema,
pulmonary fibrosis,
atelectasis.
PLEURISY (PLEURITIS)
 PLEURISY (PLEURITIS)
Pathophysiology
Recall that the visceral and parietal pleurae are the membranes that surround the
lungs
Between these membranes is a small amount of serous fluid that prevents friction
as the pleurae slide over each other during inhalation and exhalation.
If the membranes become inflamed for any reason, they do not slide as easily.
Instead of sliding, one membrane may “catch” on the other, causing it to stretch as
the patient attempts to take a breath. This causes the characteristic sharp pain on
inspiration. The irritation causes an increase in the formation of pleural fluid,
which in turn reduces friction and decreases pain.
Pleurisy or pleuritis refers to acute inflammation of the parietal and visceral
pleurae. During the acute phase, the pleurae are inflamed, thick, and swollen, and
an exudate forms from fibrin and lymph. Eventually the pleurae become rigid.
During inspiration, the inflamed pleurae rub together, causing severe, sharp pain.
PATHOPHYSIOLOGY AND ETIOLOGY

Pleurisy usually is a consequence of a primary

condition, such as
pneumonia
tuberculosis (TB),
lung cancer, cardiac or
other pulmonary infections.
The inflammatory process spreads from the lungs
to the parietal pleura.
SIGNS AND SYMPTOMS
SIGNS AND SYMPTOMS
Pleurisy causes a sharp pain in the chest on inspiration. Pain also occurs
during coughing or sneezing.
Breathing may be shallow and rapid because deep breathing increases pain.
The patient may also exhibit fever, chills,
an elevated white blood cell (WBC) count if the cause is infectious.
A pleural friction rub(coarse sounds heard during inspiration and early
expiration) is heard on auscultation. As fluid accumulates, the pleural friction
rub disappears.
The pain decreases as the fluid increases because the fluid separates the
pleurae. The client develops a dry cough, fatigues easily, and experiences
dyspnea.
Decreased ventilation may result in atelectasis, hypoxemia, and hypercapnia.
COMPLICATIONS
As pleural membranes become more
inflamed, serous fluid production increases,
which may result in pleural effusion.
If pleuritic pain is not controlled, patients
have difficulty breathing deeply and coughing,
which may lead to atelectasis. If infection goes
untreated, empyema can result.
 MEDICAL MANAGEMENT
The underlying condition dictates the treatment. Analgesic and antipyretic
drugs provide relief for pain and fever. A nonsteroidal anti-inflammatory
drug (NSAID)
Nursing Management
Provide comfort to the patient by
analgesic medications as prescribed.
Heat or cold applications may provide some topical comfort.
The nurse teaches the client to splint the chest wall by turning onto the
affected side in order to prevent pain during inspiration
The client also can splint the chest wall with his or her hands or a pillow
when coughing. Providing emotional support is essential—the client is
very anxious and needs reassurance.
PLEURAL EFFUSION
 PLEURAL EFFUSION
Pathophysiology
Pleural effusion as an abnormal collection of fluid in the pleural
space resulting from excess fluid production or decreased absorption
Fluid normally enters the pleural space from surrounding
capillaries and is reabsorbed by the lymphatic system.
When a pathological condition causes an increase in fluid
production or inadequate reabsorption of fluid, excess fluid collects.
A normal amount of pleural fluid around each lung is 1 to 15 mL.
More than 25 mL of fluid is considered abnormal; in pleural
effusion, as much as several liters of fluid can collect at one time.
ETIOLOGY

Altered permeability of the pleural membranes (e.g.

inflammation, malignancy, pulmonary embolus)
Reduction in intravascular oncotic pressure ( hypoalbuminemia,
cirrhosis)
Vascular disruption (e.g. trauma, malignancy, infections,
pulmonary infarction, drug hypersensitivity, uremia, pancreatitis)
Increased capillary hydrostatic pressure in the systemic and/or
pulmonary circulation( e.g. congestive heart failure)
Decreased lymphatic drainage or complete blockage, including
thoracic duct obstruction or rapture e.g. malignancy or trauma
 PLEURAL EFFUSION
The effusion can be either transudative, forming a watery fluid from the
capillaries, or exudative, with fluid containing WBCs and protein from an
inflammatory or infectious process.
Transudate is a thin fluid containing no protein that passes from cells into
interstitial spaces or through a membrane.
A transudate occurs in noninflammatory conditions and is often a
result of congestive heart failure, chronic liver failure, or renal disease.
Exudate is thicker; contains cells, proteins, and other substances; and is
slowly discharged from cells into a body space or to the outside of the body.
Exudative pleural effusion is caused by increased capillary
permeability characteristic of the inflammatory reaction. This type of
effusion occurs with lung cancer, pulmonary embolism, pancreatic
disease, and pulmonary infections.
MEDIASTINAL SHIFT
ASSESSMENT AND DIAGNOSTIC FINDINGS
THORACENTESIS
ASSESSMENT AND DIAGNOSTIC FINDINGS
Physical examination, chest x-ray, chest CT, and thoracentesis confirm the presence
of fluid.
In some instances, a lateral decubitus x-ray is obtained. For this x-ray, the patient
lies on the affected side in a side-lying position. A pleural effusion can be diagnosed
because this position allows for the “layering out” of the fluid, and an air–fluid line
is visible.
Pleural fluid is analyzed by
bacterial culture,
Gram stain,
acid-fast bacillus stain (for TB),
red and white blood cell counts,
chemistry studies (glucose, amylase, lactate dehydrogenase, protein),
cytologic analysis for malignant cells,
 pH.
A pleural biopsy also may be performed as a diagnostic tool.
MEDICAL MANAGEMENT
The objectives of treatment are
To discover the underlying cause of the pleural effusion
To prevent reaccumulation of fluid;
To relieve discomfort, dyspnea, and respiratory compromise.
Specific treatment is directed at the underlying cause (eg, heart
failure, pneumonia, cirrhosis).
If the pleural fluid is an exudate, more extensive diagnostic
procedures are performed to determine the cause.
Treatment for the primary cause is then instituted.
Thoracentesis is performed to remove fluid, to obtain a specimen for
analysis, and to relieve dyspnea and respiratory compromise
MEDICAL MANAGEMENT
Depending on the size of the pleural effusion, the patient may be treated
by removing the fluid during the thoracentesis procedure or by inserting
a chest tube connected to a water-seal drainage system or suction to
evacuate the pleural space and re-expand the lung
EMPYEMA
Empyema is the collection of pus in the pleural space. It is a pleural effusion that is infected.
Empyema is usually a complication of pneumonia, tuberculosis, or lung abscess. Symptoms,
diagnosis, therapeutic measures, and nursing care are the same as the care of the patient with a
pleural effusion, with an added emphasis on identifying and resolving the infection. A chest
tube or surgery may be necessary to drain the area.
THE END