Lower Respiratory Tract Disorders

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Lower Respiratory Tract Disorders
Assessment Management of Patients With
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Lower Respiratory Tract

• Trachea
• Bronchi
• Bronchioles
• Alveoli
• Cilia

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Clinical Manifestations

• 1. Local Manifestations
• Cough
• chronic, paroxysmal, dry , productive
• Excessive Nasal Secretion
• Expectoration of Sputum
• mucoid, purulent, mucopurulent, rusty, hemoptysis
• Pain
• pleuritic, intercostal, generalized chest pain
• Dyspnea- shortness of breath

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Clinical Manifestations

• 2. Systemic Manifestations
• Hypoxemia
• insufficient oxygenation of the blood
• cyanosis- bluish, grayish discoloration of skin
  mucous membranes
• Hypoxia
• inadequate tissue oxygenation
• Hypercapnia
• CO2 in arterial blood above normal limits
• Hypocapnia
• CO2 in arterial blood below normal limits
• Respiratory Failure

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Assessment of Respiratory System

• Health History
• Risk Factors
• Major Clinical Manifestations
• Cough
• Sputum production
• Chest pain
• Wheezing
• Clubbing of the fingers
• Cyanosis

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Physical Examination
Assessment of Respiratory System

• Inspection
• posture, shape, movement, dimensions of chest,
  flared nostrils, use of accessory muscles, skin
  color, and rate, depth, rhythm of respiration
• Palpation
• respiratory excursion, masses, tenderness
• Percussion
• flat, dull, resonant, hyperresonant sounds
• Auscultation
• breath sounds, voice sounds, crackles, wheezes

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Crackles
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Diagnostic Procedures

• Sputum Studies
• Methods- standard, saline inhalation, gastric
  washing
• Arterial Blood Gases
• measurements of blood pH , arterial O2 CO2
  tensions, acid-base balance
• Pulse Oximetry
• Chest X-ray
• Bronchoscopy
• Thoracentesis
• Laryngoscopy

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• Lower
• Respiratory
• Disorders

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Pneumonia

• Inflammation infection of lung- infecting
  organisms typically inhaled- organisms
  transmitted to lower airways and alveoli causing
  inflammation- impairs gas exchange
• Etiology bacteria, virus, Mycoplasma, fungus,
  or from aspiration or inhalation of chemicals or
  other toxic substances
• Risk factors cigarette smoking, chronic
  underlying disorders, severe acute illness,
  suppressed immune system, immobility

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Pneumonia

• Assessment Questions to ask
• Have you been experiencing difficulty breathing?
• Are you having pain? Where?
• Do you have a cough?
• Have you been running a fever?
• Have you been feeling tired?
• Clinical Manifestations
• fever, pleuritic chest pain, tachypnea, SOB,
  tachycardia, cough, sputum production- rusty,
  blood-tingled or yellow-green, fatigue, poor
  appetite

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Pneumonia

• Diagnostic
• Sputum and blood cultures, CBC, ABGs, CXR,
  Bronchoscopy
• Nursing Diagnoses
• Ineffective airway clearance r/t thick, tenacious
  sputum
• Ineffective breathing pattern r/t tachypnea,
  chest pain, airway inflammation
• Impaired gas exchange r/t exudate in alveoli
• Activity intolerance r/t hypoxemia, fatigue

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Pneumonia

• Planning Client Outcomes
• Maintain open clear airway, normal RR, PO2
  level without supplemental O2, complete physical
  care without frequent rest periods
• Interventions
• Improve airway patency- auscultate lung sounds,
  monitor ABGs or pulse oximetry, elevate HOB, C
  DB q 2hrs, ambulate , I/S, O2 as needed
• Promote fluid intake promote activity
  tolerance
• Monitor prevent complications

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Pneumonia

• Pharmacology
• Antibiotic therapy based on sputum culture
  sensitivity
• Levaquin, Tequin, Rocephin, Primaxin, Zithromax,
  Ketek, Zinacef, Cipro, Tetracycline
• Instruct to finish all antibiotics at prescribed
  intervals
• Evaluation
• breathing easier without chest pain
• temperature normal,
• activity level increased without frequent rest
  periods

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Tuberculosis

• Infectious disease that primarily affects the
  lungs may be transmitted to other parts of the
  body
• Pulmonary infiltrates accumulate, cavities
  develop, masses of granulated tissue form
  within the lungs
• Primary infectious agent- Mycobacterium Bacilli
• Transmitted by inhalation of droplets (talking,
  coughing, sneezing, singing)
• Risk factors immune system disorder,
  preexisting medical conditions,
  institutionalized, health care workers

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Pulmonary Tuberculosis

• Mycobacterium tuberculosis
• Airborne transmission
• Tuberculin skin testing
• Pharmacologic therapy- multi-drug regimens and
  prophylaxis

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Tuberculosis

• Assessment
• Questions to ask - Are you suffering from night
  sweats? Have you lost weight? Have you been
  having low-grade fever? Have you been having SOB
  and coughing up anything from your lungs? Have
  you had chest pain? Where? Have you had weight
  loss?
• Clinical Manifestations- low-grade fever (late
  afternoon), night sweats, weight loss, anorexia,
  fatigue, chronic productive cough,pleuritic chest
  pain, hemoptysis

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Tuberculosis

• Diagnostic
• Sputum culture- acid-fast bacilli (AFB)
• Skin testing- PPD
• CBC- WBC elevated
• CXR
• Bronchoscopy
• Nursing Diagnosis
• Ineffective airway clearance r/t thick, tenacious
  secretions
• Ineffective breathing pattern r/t airway
  inflammation

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Tuberculosis

• Altered nutrition less than body requirements r/t
  anorexia and fatigue
• Anxiety r/t social isolation secondary to
  isolation protocols
• Planning Clients Outcomes
• Maintain clear airway,normal RR, achieve weight
  gain, anxiety decreased
• Interventions
• Maintain respiratory isolation- infectious period
  - diversional activities

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Tuberculosis

• Promote airway clearance- bedrest, increase fluid
  intake, high humidity
• Pharmacology
• First-line meds- INH, Rifampin, Streptomycin,
  Ehtambutol, Pyrazinamide for 4 months
• INH and Rifampin continued for an additional 2
  months or up to 12 months.
• Advocate adherence prevention
• Monitor and manage potential complications
• Evaluation
• Client adheres to isolation precautions, takes
  medication as prescribed

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Tuberculosis

• Questions to ask
• Do you have difficulty breathing- all the time or
  is it caused by exertion?
• Do you cough frequently and is it productive?
• Have you had a weight loss?
• Do you feel tired quite often and are your
  activities impaired by SOB or fatigue?
• Do you have many respiratory infections? Over
  what period of time?

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Tuberculosis

• Nursing Diagnosis
• Ineffective airway clearance r/t thick, tenacious
  secretion and fatigue
• Ineffective breathing pattern r/t fatigue and
  obstruction of the bronchial tree
• Impaired gas exchange r/t increased sputum
  production
• Activity intolerance r/t hypoxemia fatigue
• Altered nutrition r/t increased metabolic
  demands, fatigue, anorexia
• Anxiety r/t inability to breathe effectively

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Tuberculosis

• Diagnostics
• ABGs, CBC, sputum culture, CXR, Pulmonary
  function tests
• Planning Client Outcomes
• Effectively clear airway and breathing pattern,
  maintain normal ABGs, increase activity with
  decrease SOB or fatigue, maintain weight, and
  less anxious with episodes of SOB

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Chronic Obstructive Pulmonary Disease (COPD)

• A group of chronic, obstructive airflow diseases
  of the lungs. Also known as chronic airflow
  limitation (CAL)
• Usually progressive irreversible Ciliary
  cleansing mechanism of the respiratory tract is
  affected
• Involves 3 diseases- Chronic Bronchitis, Asthma,
  Emphysema
• Risk factors- cigarette smoking, air pollution,
  occupational exposure, infections, allergens,
  stress

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Chronic Bronchitis

• Inflammation of the bronchi caused by irritants
  or infection
• hypertrophy hypersecretion of mucous- cause
  increase in sputum production
• increase mucous- decrease airway lumen size-
  lumen becomes colonized with bacteria.
• Bronchial wall becomes scarred - leads to
  stenosis airway obstruction
• Defined as a productive cough that lasts 3 months
  a year for 2 consecutive years with other causes
  excluded.
• Cough in the morning with sputum production is
  indicative of Chronic Bronchitis

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Chronic Bronchitis

• Risk Factors cigarette smoking, exposure to
  pollution, hazardous airborne substances
• Clinical Manifestations productive cough,
  dyspnea esp. on exertion, wheezing, use of
  accessory muscles to breathe, cyanosis- blue
  bloater, clubbed fingers
• Interventions
• Assess patency of airway- suction if cough
  ineffective, RR, accessory muscle use, lung
  sounds, skin color changes, ABGs
• Encourage high fluid intake instruct in
  effective breathing coughing
• Monitor oxygen administration aerosol therapy

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Chronic Bronchitis

• Encourage to report sputum changes or worsening
  of symptoms
• Encourage exercise to improve resp. fitness
• Counsel to avoid respiratory irritants and stop
  smoking
• Immunize against common flu and pneumonia
• Pharmacology
• Antibiotic therapy- Tequin, Levaquin
• Bronchodilators- Albuterol, Combivent,
  Theophylline
• Corticosteroids- Prednisone, SoluMedrol

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Asthma

• Chronic inflammatory disease of the airways -
  bronchial linings overreact to various stimuli-
  causes episodic smooth muscle spasms that
  severely constrict the airway - thickened
  secretions mucosal edema further block the
  airways.
• Acute symptoms last from minutes to hours, to
  days and then periods without symptoms
• Most common chronic disease of childhood
• Risk Factors allergy, chronic exposure to
  airway irritants of allergens, stress, exertion,
  sinusitis

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Asthma

• Clinical Manifestations cough with or without
  sputum production, SOB wheezing, generalized
  chest tightness, expiration requires effort
  becomes prolonged, tachycardia, tachypnea,
  increased restlessness
• Interventions
• Immediate care depends on severity of asthma
  symptoms- assess resp. status, ABGs monitoring,
  oxygen therapy
• Administered prescribed therapy monitor
  response
• Fluids antibiotics
• Minimize anxiety
• Teach preventive measures- exercise

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Asthma

• Pharmacology
• Bronchodilators
• Beta-agonists- Albuterol, Serevent
• Xanthines- Theophylline
• Corticosteroids
• Prednisone, SoluMedrol
• Inhalers- Flovent, Vanceril, Beclovent, Advair,
  Azmacort
• Anticholinergics- Atrovent, Combivent
• Leukotriene modifiers- Singulair
• May be treated as outpatient or require
  hospitalization intensive care

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Emphysema

• Enlargement of air spaces distal to airways that
  conduct air to the alveoli
• Enlarged spaces causes breakdown in alveoli
  walls- increases in airway size on inspiration-
  decreases alveolar membrane for gas exchange
• Small airways collapse on exhalation- air trapped
  in alveolar spaces
• Theses changes- products destruction of elastin
  in distal airways and alveoli
• Distinguishing characteristic- airflow limitation
  caused by lack of elastic recoil in the lungs

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COPD-Emphysema
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Emphysema

• No trouble inhaling, but with hyperinflated lungs
  small airways- exhaling becomes more difficult
• Risk Factors smoking, occupational exposure,
  heredity
• Most common in fifth decade of life

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Emphysema

• Clinical Manifestations SOB on exertion, use of
  accessory muscles to breath, late cough after
  onset of SOB (if productive sputum- scanty
  mucoid), pink puffer, barrel chest (increase in
  anterior-posterior diameter of chest), thin in
  appearance, diminished breath sounds prolonged
  expiration, speaks in short jerky sentences,
  anxious
• Interventions
• Improve gas exchange- oxygen therapy
• Achieve airway clearance- aerosol therapy
• Encourage adequate hydration
• Prevent infections- immunizations

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Emphysema

• Minimize anxiety
• Physical therapy
• Patient teaching
• Pharmacology
• Beta-agonists- Albuterol, Theophylline
• Anticholinergics- Atrovent
• Antibiotic therapy- Levaquin, Tequin
• Corticosteroids

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Emphysema

• Evaluation
• Improved gas exchange, achieves airway clearance,
  breathing pattern improved, achieves activity
  tolerance, acquires effective coping mechanisms,
  and adheres to therapeutic program.

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Atelectasis

• Inadequate ventilation
• Mucus plugs
• Pleural effusion
• Pneumothorax
• Hemothorax

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Pleural Effusion
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Pneumothorax

• Condition in which air or gas exists in the
  pleural space
• Normally negative pressure (suction) between the
  visceral and parietal pleura- any injury that
  allows air or positive pressure to enter pleural
  space- prevents the lung from remaining inflated
• Air in pleural space- increased intrapleural
  pressure- partial or total collapse of the lung
• Types Simple, Traumatic, or Tension

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Pneumothorax
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Pneumothorax Simple (Closed or spontaneous)

• Air enters the pleural space from the lung in the
  absence of disease
• Occurs in men ages 20 to 40 result of rupture
  of small blister on the apex of the lung
• If occurs from trauma or pulmonary disease-
  referred to as secondary or complicated
• Basic symptoms SOB chest pain

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Treatment of Simple Pneumothorax
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Pneumothorax
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Pneumothorax Traumatic (Open)

• A hole in the chest wall allows atmospheric air
  to flow into the pleural space
• Air in the pleural space - increased intrapleural
  pressure- resulting in partial or total collapse
  of the lung
• Results from a penetrating injury, a therapeutic
  procedure, or insertion of a CVC or pulmonary
  artery catheter
• A sucking sound audible on inspiration as the
  chest wall rises varying degrees of resp.
  distress

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Pneumothorax Tension

• Injury allows air to leak into pleural space
  during inspiration- prevents air from leaking out
  during expiration
• Each inspiration-amount of air increases- becomes
  trapped to point causing increased thoracic
  pressure- pushes the heart, vena cava, and aorta
  out of position (mediastinum shift)- results in
  poor venous return to heart - leads to poor
  cardiac output
• Medical emergency- disruption of cardiac output
  respiratory distress

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Pneumothorax

• Etiology
• Blunt chest trauma (MVAs and falls), penetrating
  traumas (gunshot and knife injuries), rib
  fractures, flail chest
• Assessment Questions to ask
• Are you having difficulty breathing?
• Do you have pain in your chest? Point to your
  pain with one finger.
• Clinical Manifestations
• SOB, CP, tachypnea, tachycardia, cyanosis,
  diminished breath sounds, hyper-resonance on
  affected side, neck vein engorgement, paradoxical
  movement of the chest, deviated trachea,
  cardiogenic shock anxiety

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Pneumothorax

• Diagnostic
• ABGs, CXR
• Nursing Diagnosis
• Ineffective breathing pattern r/t decreased lung
  expansion
• Impair gas exchange r/t collapse of an area of
  the lung
• Anxiety r/t inability to ventilate effectively
• Planning Client Outcomes
• RR ABGs within normal limits, client states
  rationale for treatment procedures, client
  rests without behavioral signs of excessive
  anxiety

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Pneumothorax

• Nursing Interventions
• Comprehensive respiratory assessment- airway
  patency, RR, lung sounds, chest rise fall
  symmetrically, ABGs, blood counts, electrolytes,
  cardiac status, urinary output, chest wall
• Maintain semi-Fowlers position
• Encourage deep breathing coughing
• Administer oxygen therapy
• Medicate for pain as needed
• Explain all procedures- calm reassure about
  overall treatment condition as needed
• Encourage use of relaxation techniques
• Medical- Mechanical Ventilation Chest tubes

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Chest Tubes
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Chest Drainage System

• Inserted after most thoracic cardiac surgeries
• Consists of chest tube attached to valve
  mechanism- allow air or fluid to drain out of the
  chest cavity
• Include one, two, and three-bottle systems and
  the one-piece, three chamber, disposable plastic
  systems

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Purpose of Chest Drainage System

• Removes air, blood, other fluids from pleural
  space or mediastinal space
• Facilitates re-expansion of the lungs and restore
  negative pressure in thoracic cavity

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Indications forChest Drainage System

• After thoracic cardiac surgery
• Traumatic injury- Fractured Rib
• Intrapleural- pneumothorax, hemothorax, pleural
  effusion
• Mediastinal- cardiac surgery, chest trauma
• Complication from procedures
• CVC insertion
• Lung biopsy

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Types of Chest Drainage Systems

• Water-seal
• Remove air or fluid from pleural space or
  mediastinum
• Mechanism for collection of drainage
• One-way mechanism to keep air from getting back
  into the pleural space
• Water-seal acts one-way valve
• Allows air to leave pleural space- but not to
  return-maintaining negative pressure

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Types of Chest Drainage Systems

• Waterless
• Valve to regulate suction
• Valve can be opened for air liquid drainage to
  move out
• Remain closed to prevent air from entering
  pleural space
• Autotransfusion
• Variation of water-seal system
• Attached container so that blood drained from
  chest can be salvaged for autotransfusion

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Assessment
Pt with Chest Drainage Systems

• Respiratory status
• SS of extended pneumothorax or hemothorax
• Function of drainage system every 1 hr
• System below level of patients chest
• Tube free of kinks, or external obstruction
• All connections secured
• Color and amount of drainage
• Fluctuation of fluid level in water-seal chamber
• Constant bubbling in water-seal chamber
• Anxiety level understanding

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Chest Drainage Systems

• Nursing Diagnosis
• Ineffective breathing pattern related to
  decreased lung expansion as evidence by
• Planning Patient Outcomes
• Breath sounds are normal
• Respiration unlabored occur at rate of 16 to 20
  breaths per minute
• ABG values approaching normal
• Lung re-expansion seen on chest x-ray film

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Chest Drainage Systems

• Nursing Interventions
• Maintain airtight, patent, functioning chest
  drainage system
• Re-tape all connections as needed
• Re-tape or reinforce chest-tube dressing
• Tubing free of kinks, loops external pressure
• Place roll towel under chest- protect tubing from
  body weight
• Encourage cough and deep breathe position
  change frequently
• Keep occlusive petrolatum jelly dressing at
  bedside

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Chest Drainage Systems

• Mark amount of drainage in collection container
  at 1 to 4 hour intervals
• Check water levels in suction control
  water-seal pressure chambers
• Notify MD of constant bubbling in water-seal or
  drainage becoming bright red or increases
  suddenly
• Reassure the patient that staff is nearby- call
  light in reach
• Documentation for chest drainage systems
• Assist with chest tube insertion or removal

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Chest Drainage Systems

• Evaluation
• RR ABGs within normal limits
• Decreased difficulty breathing
• Chest pain diminished
• Equal lung sounds
• Bilateral chest movement
• Decreased chest tube drainage
• Client able to verbalize rationale for treatment
  and procedures
• Client rests without behavioral signs of
  excessive anxiety

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Older Adult Alert

• Be concern about any changes in orientation.
  This may be a first indication of pneumonia in
  older adults.
• Be cautious in fluid administration.
  Overhydration may initiate CHF.
• Older clients may become confused with multiple
  drug therapies and may not follow the regimen
  correctly. Theses clients may need assistance to
  ensure proper administration. In older clients,
  the thoracic muscles are weaker which may make
  the older adult unable to tolerate the increased
  work of breathing required of COPD.
• Older adult clients have fewer alveoli than
  younger adults- oxygen exchange will be even more
  impaired in older adult clients with COPD.

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Older Adult Alert

• The weaker thoracic muscles in older adults will
  also make coughing more difficult, and thus,
  retained secretions will be a problem in many
  cases.
• Older adults high risk for infection due to
  decreased immune response. Chest injuries
  evaluated carefully for signs of infection.
  Temperature of 99 degrees F may indicate an
  initial infection.
• Cough will be impaired due to decreased muscle
  strength- older adults greater risk for
  atelectasis and pneumonia after a chest injury.

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• Thank you!