Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

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Timby/Smith Introductory Medical-Surgical
Nursing, 10/e

• Chapter 21 Caring for Clients with Lower
  Respiratory Disorders

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Acute Bronchitis

• Inflammation of Bronchial Mucous Membranes
  Tracheobronchitis
• Cause Bacterial and fungal infection Chemical
  irritation
• Diagnostics Sputum cultures Chest film
• Signs/Symptoms (Initial) Non-productive cough,
  Fever, Malaise (Later) Blood-streaked sputum,
  Coughing attacks Inspiratory crackles
• Treatment Antipyretics Expectorants
  Antitussives Humidifiers Broad-spectrum
  antibiotics
• Nursing Management

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Pneumonia

• Pathophysiology
• Inflammatory Process Affecting Bronchioles and
  Alveoli Alveoli Filled with Exudate
• Reduced Surface Area for Gas Exchange Classified
  by Cause
• Etiology
• Acute infection
• Radiation therapy
• Chemical ingestion, inhalation
• Bacteria
• Steptococcus pneumoniae
• pneumocystis carinii(bacteria developed in AIDS
  pt)
• Virus
• Fungus
• Aspiration (stroke victims)
• Artificial Ventilation (VAP)
• Hypostasis

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Pneumonia

• At risk
• Very Young
• Elderly
• Hospitalized
• Intubated
• Immunocompromised
• Prevention (see box 21-2)
• Pneumococcal Vaccine
• Flu Vaccine
• Coughing and Deep Breathing
• Hand Washing
• Frequent Mouth Care, Continuous Suction for VAP

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Pneumonia

• Diagnostics
• Chest film
• Blood count
• Sputum C S
• Signs/Symptoms
• Chest Pain
• Fever, Chills
• Cough, Dyspnea
• Yellow, Rusty, or Blood-Tinged Sputum
• Crackles, Wheezes
• Malaise

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Pneumonia

• Complications
• Pleurisy
• CHF
• empyema
• Pleural Effusion
• Atelectasis
• septicemia
• Signs and Symptoms in Elderly
• New-Onset
• Confusion
• Lethargy
• Fever
• Dyspnea

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Pneumonia

• Treatment
• Antibiotic (bacterial) PO or IV
• Hydration
• Chest physical therapy
• Analgesics/Antipyretics
• Antiviral Medication (Zovirax)
• Bronchodilators
• Expectorants or cough suppressants
• Oxygen
• Nursing Management

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Pleurisy

• Acute Inflammation of Parietal, Visceral Pleurae
• Cause Usually secondary to pneumonia, pulmonary
  infections, tuberculosis, lung cancer, pulmonary
  embolism
• Diagnostics Chest radiography Sputum culture
  Thoracentesis Fluid specimen, pleural biopsy
• Signs/Symptoms Inspirational severe, sharp pain
  Shallow respirations Pleural fluid accumulation
  Dry cough Dyspnea Friction rub, fever, elevated
  WBC
• Treatment Treat underlying condition NSAIDs
  Analgesics/antipyretic drugs
• Nursing Management

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Pleural Effusion

• Pathophysiology
• Abnormal Fluid Collection Between Visceral,
  Parietal PleuraePleural Fluid Not Reabsorbed,May
  Collapse Lung
• Etiology
• Transudative
• Heart Failure
• Liver or Kidney Disease
• PE
• Exudative
• Pneumonia
• TB
• CA

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Pleural Effusion cont.

• Diagnostics
• Chest radiograph CT scan
• Signs/Symptoms Fever Pain Dyspnea Dullness
  upon chest percussion Dim breath sounds
  Friction rub Tachypnea Cough
• Treatment Antibiotics Analgesics
  Thoracentesis Chest tube
• Nursing Management

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Pleural Effusion
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Influenza

• Acute Respiratory Disease of Short Duration
• Cause Viral contamination via respiratory
  transmission Mutations
• Fatalities related to secondary bacterial
  complications, esp. those immunocompromised
• Diagnostics Chest radiography Sputum analysis
• Signs/Symptoms See Table 21-2
• Treatment Symptomatic
• Nursing Management
• Prevention
• Yearly Vaccination(85 effective)
• should not be give to clients with allergy to
  eggs
• At-Risk Individuals
• Health Care Workers
• Handwashing
• Avoidance of infected people

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Tuberculosis

• Pathophysiology
• AFB Implant on Bronchioles or Alveoli
• Tubercle Formed
• Immune System Keeps in Check
• 5-10 Infected Become Ill
• May Activate with Impaired Immunity

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Pulmonary Tuberculosis

• Primarily a bacterial infectious disease affects
  lungs may infect kidneys, other organs Affects
  one-third of worlds population Leading cause of
  death from infectious disease, among those with
  HIV
• Cause Tubercle bacilli Gram-positive
  Transmitted via droplet inhalation
  Classifications
• Diagnostics Chest radiographs Tuberculin skin
  tests CT scan MRI Gastric lavage Gastric
  aspiration Bronchoscopy
• C S tests
• Signs/Symptoms Fatigue, weight loss clients at
  risk Low fever Night sweats Persistent Cough
  Blood-streaked sputum Weakness Hemoptysis
  Dyspnea
• At Risk elderly alcoholics crowded living
  conditions new immigrants immunocompromised
  lower socioeconomic status homeless

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Therapeutic Interventions

• Technique to destroy Transmission
• Combination of Drugs for 6 - 24 Months (toxicity,
  resistance)
• INH
• Rifampin
• PZA
• Ethambutol
• Streptomycin
• Occasional Surgical Removal Segmental resection
  Wedge resection Lobectomy Pneumonectomy
• Isolation
• Nursing Management (see ATI pg 125-126

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Prevention of TB Spread

• Clean, Well-Ventilated Living Areas
• Isolation of Patients who have Active TB
• High-Efficiency Filtration Masks
• Gowns, Gloves, Goggles If Contact with Sputum
  Likely

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COPD

• Combination of
• Chronic Bronchitis
• Emphysema
• (Asthma)
• Chronic Airflow Limitation
• (in out)

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COPD (contd)
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Obstructive Pulmonary Disease

• Airflow in lungs is obstructed caused by
  bronchial obstruction, congenital abnormalities
• Increased resistance to expiration, creating
  prolonged expiratory phase of respiration
• COPD
• Emphysema
• Chronic bronchitis
• Asthma
• Atelectasis
• Sleep apnea
• Cystic fibrosis
• bronchiectasis

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COPD Etiology

• Smoking
• Passive Smoke Exposure
• Pollutants
• Familial Predisposition
• a1AT Deficiency (Emphysema)

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Effects of Smoking
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COPD Prevention

• Smoking!!

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COPD diagnositics

• Chest X-Ray
• CT Scan
• ABGs
• CBC
• Spirometry
• Sputum Analysis

• PFT
• PULSE OX
• H/H
• Chest physiotherapy
• AAT levels
• Peak expiratory flow meters

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COPD signs and symptoms

• Wheezing, Crackles
• Thick, Tenacious Sputum
• Increased Susceptibility to Infection
• Mucous Plugs
• Accessory muscles
• Rapid, Shallow respirations
• Pallor cyanosis (late)
• Hyperresonance
• (emphysema)

• Chronic Cough
• Chronic Dyspnea
• Prolonged Expiration
• Barrel Chest
• Activity Intolerance
• Diminished breath sounds
• Hypoxemia
• Hypercarbia
• Thin extremities

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Complications of COPD

• Cor Pulmonale
• Weight Loss
• Resting before eating
• Avoid gas-producing food
• Eat four to six small meals rather than three
  large ones
• Take small bites and chew slow
• Pneumothorax
• Respiratory Failure

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COPD Therapeutic Interventions

• Stop Smoking!!
• Oxygen 1-2 L/m
• Supportive Care
• Pulmonary Rehab
• Surgery
• Mechanical Ventilation
• End-of-Life Planning

• Medications
• Bronchodilators
• Corticosteroids
• Expectorants
• NMT/MDI

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Bronchiectasis

• Pathyphysiology
• Chronic Infection
• Dilation of One or More Large Bronchi
• Airway Obstruction
• Etiology
• Secondary to CF, Asthma, TB

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Bronchiectasis Signs and Symptoms

• Dyspnea
• Cough
• Large Amounts of Sputum
• Anorexia
• Recurrent Infection
• Clubbing
• Crackles and Wheezes

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Bronchiectasis Therapeutic Interventions

• Antibiotics
• Mucolytics, Expectorants
• Bronchodilators
• Chest Physiotherapy
• Oxygen
• Surgical Resection

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Atelectasis

• Collapse of Alveoli Prevents Gas Exchange
• Causes Mucus plug Aspiration Prolonged bed
  rest Fluid or air in thoracic cavity Enlarged
  heart Aneurysm hypoventilation
• Signs/Symptoms (Small area) Few (Large area)
  Cyanosis Dyspnea Fever Pain Tachycardia
  Tachypnea Increased secretions
• Treatment Removal of cause Raise secretions
  Bronchodilators Humidification O2
  administration
• Nursing Management TCDB incentive spirometer
  ambulate

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Chronic Bronchitis

• Prolonged inflammation of bronchi low grade
  fever hypertrophied mucous glands in bronchi
  impaired ciliary function Gradual development
• Ineffective airway clearance
• Signs/Symptoms
• Chronic, productive cough Thick mucus Frequent
  respiratory infections, lasting several weeks
  (winter)
• Treatment
• Prevent pulmonary irritation Medications
• Nursing Management

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Pulmonary Emphysema

• Abnormal Alveoli Distention, Destruction loss of
  elastic recoil damage to pulmonary capillaries
  air trapping disabling disease
• Impaired Gas Exchange
• Signs/Symptoms (Initial) Exertional dyspnea
  (Progressive) Chronic cough Mucopurulent sputum
  Barrel chest Pursed-lip breathing Prolonged,
  difficult expiration Wheezing (Advanced) Memory
  loss CO2 narcosis
• Treatment Slow progression Treat obstructed
  airways (Bronchodilators, O2, ATB, physical
  therapy, corticosteroids (limited)
• Nursing Management

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MDI
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Spacer
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NMT
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Incentive Spirometer
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Chest Physiotherapy
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Pulmonary Rehabilitation
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Asthma

• Reversible Obstructive Disease of Lower Airway
  spasm of bronchial smooth muscles air trapping
• Cause Inflammation Airway hyperreactivity to
  stimuli (Allergic Non-allergic Mixed)
• Diagnostic allergy skin testing
• Signs/Symptoms Paroxysms of SOB, wheezing,
  coughing Thick, tenacious sputum use of
  accessory muscles may be worse at night

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Asthma

• Complication
• Status Asthmaticus
• Severe, Sustained Asthma
• Worsening Hypoxemia
• Respiratory Alkalosis Progresses to Respiratory
  Acidosis
• May Be Life Threatening

• Triggers
• Smoking
• Allergens
• Infection
• Sinusitis
• Stress
• GERD

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Asthma
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Asthma Therapeutic Interventions

• Monitor with Peak Flow Meter
• Avoid Triggers
• Avoid Smoking

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Asthma Therapeutic Interventions (contd)

• Bronchodilators
• Adrenergic (Ventolin, Serevent)
• Leukotriene Inhibitors (Accolate, Singulair)
• Theophylline (Rare)
• Corticosteroids
• Inhaled, IV, PO
• Mast Cell Inhibitors (Exercise Induced)
• Antihistamines
• Oxygen PRN

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Nursing Diagnoses COPD

• Impaired Gas Exchange
• Ineffective Airway Clearance
• Ineffective Breathing Pattern
• Activity Intolerance
• Imbalanced Nutrition
• Anxiety
• Fatigue

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Impaired Gas Exchange

• Monitor
• Lung Sounds, Respiratory Rateand Effort
• Dsypnea
• Mental Status
• SaO2, ABGs

• Position
• Fowlers
• Good Lung Down
• Administer Oxygen
• Teach Breathing Exercises
• Discourage Smoking

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Ineffective Airway Clearance

• Monitor
• Lung Sounds
• Sputum
• Encourage
• Fluids
• Deep Breathing
• Coughing

• Administer Expectorants
• Turn q2h or Ambulate
• Suction prn
• Consider CPT or Mucus Clearance Device

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Ineffective Breathing Pattern

• Monitor
• Respiratory Rate, Depth, Effort
• ABGs, SaO2
• Determine/Treat Cause

• Position
• Teach Diaphragmatic Breathing

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Activity Intolerance

• Monitor Response to Activity
• Vital Signs
• SaO2
• Use Portable O2 for Ambulation

• Allow Rest Between Activities
• Obtain Bedside Commode
• Increase Activity Slowly
• Refer to Pulmonary Rehabilitation

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Patient Education

• Assist Patient to Stop Smoking!
• Pulmonary Rehabilitation
• Breathing Exercises
• Energy Conservation

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Postural Drainage
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Occupational Lung Diseases

• Cause Exposure to organic, inorganic dusts and
  noxious gases of long periods of time
• Diagnostics Chest radiograph Pulmonary function
  tests
• Symptoms Dyspnea cough (Coal dust)
  Black-streaked sputum
• Treatment Conservative Symptomatic O2 therapy
  for severe dyspnea
• Nursing Management

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Pulmonary Arterial Hypertension

• Continuous High Pressure in the Pulmonary
  Arteries
• Cause Rt Ventricular Failure CAD Valve
  Disease Lung disease
• Diagnostics EKG ABG analysis Cardiac
  catheterization Pulmonary function tests
  Echocardiography Ventilation-perfusion scan
  Pulmonary angiography
• Signs/Symptoms Dyspnea on exertion Weakness
  fatigue crackles cyanosis tachypnea
• Treatment Vasodilators, Anticoagulants
  (Right-sided failure) Digitalis, diuretics
  Heartlung transplantation low sodium diet
• Nursing Management

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Pulmonary Hypertension
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Pulmonary Embolism

• Pathophysiology
• Blood Clot in Pulmonary Artery or branches
• Ventilation-Perfusion Mismatch
• Impaired Gas Exchange
• Lung Infarction
• Etiology
• Thrombus formed in the venous system or right
  side of heart
• DVT Most Common
• Fat Emboli From Compound Fracture
• Amniotic Fluid Emboli During LD

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Pulmonary Embolism
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Pulmonary Embolism

• Obstruction of Pulmonary Arteries or Branches
• Cause Thrombus formed in the venous system or
  right side of heart
• Diagnostics Chest radiograph Serum enzymes
  Lung, CT scan Pulmonary angiography
  Ultrasonography Impedance plethysmography
  D-dimer
• Signs/Symptoms (Small area) Pain Tachycardia
  Dyspnea (Large area) Severe dyspnea Severe pain
  Cyanosis Tachycardia Restlessness Shock
  Sudden death
• Treatment Thrombolytics Anticoagulation
  Surgery Procedures
• Nursing Management

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Pulmonary Edema

• Fluid Accumulation in Interstitium, Alveoli of
  Lungs
• Cause Right side of heart delivers more blood to
  pulmonary circulation than left side can handle
• Signs/Symptoms Dyspnea Cyanotic extremities
  Skin color Continual blood-tinged (pink), frothy
  sputum Cough
• Treatment Emergency treatment for cardiogenic
  pulmonary edema
• Nursing Management

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Respiratory Failure

• Inability to Exchange Sufficient Amounts of O2,
  CO2
• Cause (Acute) Life-threatening, occurs suddenly
  (Chronic) Underlying disease COPD, aspiration,
  neuromuscular disorders
• Diagnostics Chest radiography Serum
  electrolytes History ABGs (PaO² lt60mm Hg PaCO²
  gt50mm Hg)
• Signs/Symptoms Restlessness Wheezing Cyanosis
  Accessory muscle use for breathing
• Treatment Endotracheal, tracheostomy tube
  Humidified O2 via nasal cannula, Venturi or
  rebreather masks Mechanical ventilation
• Nursing Management

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Respiratory Failure
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Acute Respiratory Distress Syndrome (ARDs)

• Noncardiogenic Pulmonary Edema, secondary to
  other clinical condition Can lead to respiratory
  failure, death
• Pathophysiology
• Alveolocapillary Membrane Damage
• Pulmonary Edema
• Alveolar Collapse
• Lungs Stiff and Noncompliant
• Lungs May Hemorrhage

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ARDs Etiology

• Acute Lung Injury
• Septicemia
• Shock
• Aspiration
• Drug ingestion/overdose
• Hematologic disorders
• Metabolic disorders
• Trauma
• Surgery
• Embolism
• Not Usually in Patients With Chronic Respiratory
  Disease

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Acute Respiratory Distress Syndrome

• Diagnostics
• Chest radiography
• Evidence of acute respiratory failure
• ABGs
• Signs/Symptoms
• Tachypnea
• Dyspnea, fine crackles
• Cyanosis
• Anxiety
• Restlessness Mental confusion
• Treatment
• Intubation
• Mechanical ventilation
• Colloids
• Nutritional support

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Lung Cancer

• Common Cancer, esp. smokers 1 cause of CA death
  in U.S.
• Types
• Small Cell Lung Cancer
• Large Cell Carcinoma
• Adenocarcinoma
• Squamous Cell Carcinoma

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Lung Cancer Etiology

• Smoking
• Smokers 13 as Likely to Develop Cancer as
  Nonsmokers
• Environmental Tobacco Smoke
• Other Carcinogens
• Asbestos
• Arsenic
• Pollution

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Lung Cancer Diagnostic Tests

• Chest X-Ray
• CT, PET Scan
• MRI
• Sputum Analysis
• Biopsy
• Additional Tests to Find Metastasis

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Lung Cancer Signs and Symptoms

• None Until Late
• Dyspnea Cell type, tumor size location, degree
  of metastasis determine
• Recurrent Infection
• Anorexia and Weight Loss

• Cardinal signs
• Cough
• Productive of mucopurulent or blood-streaked
  sputum
• Hemoptysis
• Pain
• Wheezing/Stridor

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Therapeutic Interventions

• Factor dependent, esp. on tumor classification,
  Stage (TNM System)
• Chemotherapy (Usually Palliative)
• Radiation (Usually Palliative)

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Lung Cancer Complications

• Pleural Effusion
• Superior Vena Cava Syndrome
• Ectopic Hormone Secretion
• ADH (SIADH)
• ACTH (Cushings Syndrome)
• Actelectasis
• Metastasis

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Thoracic Surgery

• Remove, repair chest wall traumas, tumors Obtain
  biopsy sample
• Thoracotomy
• Thoracentesis
• Pneumonectomy
• Lobectomy
• Resection
• Transplant

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Thoracic Surgery Preoperative Care

• Monitor Respiratory Status
• Teach
• Routine Preop Teaching
• What to Expect
• Visit SICU
• Include Family

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Thoracic Surgery Postoperative Care

• Intensive Care Setting
• Monitor
• Vital Signs
• SaO2, ABGs
• Hemodynamic Parameters
• Lung Sounds
• Ventilator
• Chest Tubes
• Surgery interferes with normal thoracic cavity
  pressures Lung expansion
• Lungs must be post-operatively reinflated
• Draining secretions, air, blood from thoracic
  cavity via surgically-placed catheter(s)
• Connected to closed, underwater-seal drainage
  system 1 2 catheters
• Anterior Removes air
• Posterior Removes fluid

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Thoracic Surgery
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Pneumothorax
Types

• Pathophysiology
• Air in the Intrapleural Space
• Complete or Partial Collapse of Lung

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Signs and Symptoms

• Tension Pneumothorax Signs and Symptoms
• Tracheal Deviation
• Bradycardia
• Cyanosis
• Shock and Death If Untreated

• Shallow, Rapid Respirations
• Asymmetrical Chest Expansion
• Dyspnea
• Chest Pain
• Absent Breath Sounds Over Affected Area

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Pneumothorax

• Diagnostic Tests
• History and Physical Examination
• Chest X-Ray
• ABGs, SaO2
• Therapeutic Interventions
• Monitor ABGs and Respiratory Status
• Chest Tube to Water Seal Drainage
• Pleurodesis (Sclerosis) for Recurrent Collapse

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Pneumothorax Nursing Care

• Monitor Respiratory Status
• Monitor Chest Drainage System
• Equipment at bedside
• hemostats or clamps
• vaseline gauze
• Monitor and assess drainage system for
• amount of suction
• presence of air leaks
• integrity of the water seal chamber
• absence of kinks in the tubing
• Report Changes Promptly

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Chest Drainage System
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Thoracic Surgery
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Rib Fractures/Flail Chest

• Etiology
• Trauma
• Cough
• CPR
• Care
• Control Pain
• Encourage Coughing and Deep Breathing
• Promote Adequate Ventilation

• Cause
• Multiple Rib Fractures
• Ribcage Not Able to Maintain Bellows Action
• Care
• Monitor ABGs
• Mechanical Ventilation

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End of Presentation