chapter 9 care of the patient with a respiratory disorder jeanelle f. jimenez rn, bsn, ccrn mosby...

Chapter 9Chapter 9

Care of the Patient with a

Respiratory DisorderJeanelle F. Jimenez RN, BSN, CCRN

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.


When in doubt, just remember…

It’s all about the C, A, B’s and prioritization!


Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• External respiration Exchange of oxygen and carbon dioxide between the

lung and the environment

• Internal respiration Exchange of oxygen and carbon dioxide at the cellular

level



• Upper respiratory tract Nose Pharynx Larynx Trachea

• Lower respiratory tract Bronchial tree

• Bronchioles, alveolar ducts, alveoli


• Mechanics of breathing Thoracic cavity

• Lungs Visceral pleura and parietal pleura

• Respiratory movements and ranges Rhythmic movements of the chest walls, ribs, and

muscles allow air to be inhaled and exhaled

• Regulation of respiration Nervous control—medulla oblongata and pons of the

brain; chemoreceptors—in the carotid and aorta



Assessment of the Respiratory SystemAssessment of the Respiratory System

• Subjective data Shortness of breath, dyspnea, cough

• Objective data Expression, chest movement, and respirations Respiratory distress, wheezes, or orthopnea Adventitious breath sounds

• Sibilant wheezes (aka wheezes)

• Sonorous wheezes (aka rhonchi)

• Crackles

• Pleural friction rubs


Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations

• Chest roentgenogram/radiograph (CXR)• Computed tomography (CT)• Pulmonary angiography• Ventilation-Perfusion Scan (V/Q Scan)• Pulmonary function testing• Endoscopic Tests

(Mediastinoscopy/Laryngoscopy/Bronchoscopy)• Sputum specimen• Cytological studies• TB Testing• Lung biopsy• Thoracentesis• Pulse Oximetry • Arterial blood gases


CXRCXR

• Chest x-ray (CXR) Determines lung or heart abnormalities Abnormalities observed

• Lung tumors, other growths• Lung abscesses• Pulmonary tuberculosis (TB)• Foreign objects• Pneumonia • Enlarged heart


Pulmonary AngiographyPulmonary Angiography

• Pulmonary angiography Injection of radiopaque dye into the pulmonary blood

vessels to determine pathology


Pulmonary AngiogramPulmonary Angiogram


VQ ScanVQ Scan

• Lung perfusion scan Injection of radioactive material intravenously

eventually reaching lung capillaries Illustrates different views to locate lesions,

pneumonia, and other disorders


VQ ScanVQ Scan


PFT’sPFT’s

• Assesses the client’s general respiratory status

• Measures total lung capacity, vital capacity, residual volume, tidal volume, inspiratory volume, and expiratory volume

• Spirometer: machine used for pulmonary function tests Not to be confused with incentive spirometer

used by client postoperatively to perform respiratory exercises to maintain lung function


BronchoscopyBronchoscopy

• Invasive procedure

• Bronchoscope passed through the mouth and pharynx into the trachea and bronchi

• Purpose Observe lung tissue Obtain a biopsy or bronchial washings Remove mucous plugs or foreign objects Determine the location and extent of a mass


Figure 9-7Figure 9-7

Fiberoptic bronchoscope.

(A, Courtesy of Olympus America, Melville, New York. B, from Meduri, G.U., et al. [1991]. Protected bronchoalveolar lavage, American Review of Respiratory Disease, 143:855, official journal of the

American Thoracic Society, © American Lung Association.)


Bronchoscopy cont.Bronchoscopy cont.

• Note any loose natural teeth Bronchoscope may loosen or dislodge a tooth; could

lead to aspiration

• After bronchoscopy Anesthetic numbs throat; does not allow the person to

cough out secretions Position client on his or her side—keeps airways

open, preventing choking and aspiration


Sputum SpecimensSputum Specimens

• Best if retrieved early in the morning

• Use a sterile container to retrieve the sample

• May be retrieved from patients on a ventilator



Thoracentesis.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)


Skin TestsSkin Tests

• Commonly used to determine Exposure to tuberculosis or histoplasmosis

• Purified protein derivative (PPD) tuberculin test Mantoux tuberculin test Indicates whether a person has ever been

exposed to the tubercle bacillus Approximately 0.1 mL tuberculin serum (PPD)

injected intradermally, with a syringe and needle Injection site examined for edema and redness 2

to 3 days after the injection


Skin Tests cont.Skin Tests cont.

• Positive tuberculin test Person has been exposed to the bacillus http://www.cdc.gov/tb/education/Mantoux/

appendix_D.htm

• Use of controls Candida and mumps antigen sera may be injected at

the same time as the PPD to determine a person’s ability to respond to any foreign agent


ThoracentesisThoracentesis

Involves puncturing the chest wall to remove excess fluid or air from the pleural cavity

Using sterile technique• Physician inserts a trocar into the pleural cavity

• Specimen collected in a sterile container; measured and sent for analysis



Portable pulse oximeter with spring-tension digit probe displays

oxygen saturation and pulse rate.

(From Potter, P.A., Perry, A.G. [2009]. Fundamentals of nursing. [7th ed.]. St. Louis: Mosby.)


ABG’sABG’s

• Blood gas determinations Best indicator of oxygen deficiency: level of arterial

blood gases

pH: 7.35-7.45

pCO2: 35-45 mmHg

HCO3: 22-26 mEq/L

pO2: 80-100 mmHg


ABG’s Nursing ConsiderationsABG’s Nursing Considerations

• Perform Allen’s Test

• Watch for hemorrhage

• Put pressure on the puncture site for at least 5 minutes or 10 minutes if on anticoagulants or coagulopathic


Respiratory AcidosisRespiratory Acidosis

• The total [ ] of buffer base is lower than normal with an increase in H ion [ ]system

• A greater number of H ions are circulating in blood that can be absorbed by the buffer system

• Any condition that causes an obstruction of the airway or depresses respiratory status can cause resp. acidosis


Causes of Respiratory AcidosisCauses of Respiratory Acidosis

• Asthma

• Atelectasis

• Brain trauma

• Bronchiectasis

• Bronchitis

• Emphysema

• Hypoventilation

• Medications

• Pulmonary Edema

• Basically disorders that depress the respiratory system


Respiratory AlkalosisRespiratory Alkalosis

• A deficit of carbonic acid or a decrease in H ion [ ]

• Results from an accumulation of base or a loss of acid without a comparable loss of base in the body fluids

• It is caused by conditions that cause overstimulation of the respiratory status


Causes of Respiratory AlkalosisCauses of Respiratory Alkalosis

• Fever

• Hyperventilation

• Hypoxia

• Hysteria

• Overventilation secondary to mechanical ventilation

• Pain


Metabolic AcidosisMetabolic Acidosis

• The total concentration of buffer base is lower than normal, with a relative increase in the H ion [ ]

• It results from losing buffer bases or retaining too much acid without sufficient base

• Often occurs as a result of renal failure, DKA, production of lactic acid, and ingestion of toxins such as aspirin


Causes of Metabolic AcidosisCauses of Metabolic Acidosis

Disorders that cause an increase in hydrogen ion concentrations (increased acid states)

with the loss of buffering capabilities or insufficient base

• DM or DKA

• Acetylsalicylic acid (aspirin) overdose

• High-fat diet

• Malnutrition

• Renal insufficiency or failure

• Severe diarrhea


Metabolic AlkalosisMetabolic Alkalosis

• A deficit or loss of H ions or acids or an excess of base (bicarbonate)

• It results from an accumulation of base or a loss of acid without a comparable loss of base in the body fluids

• Caused by conditions that result in hypovolemia, loss of gastric fluid, excessive bicarbonate intake, and massive transfusion of whole bood


Causes of Metabolic AlkalosisCauses of Metabolic Alkalosis

A loss of acids and an excess of base (bicarbonate)

• Diuretics

• Excessive vomiting or GI suctioning

• Hyperaldosteronism

• Ingestion of excess sodium bicarb

• Massive transfusion of whole blood


Interpreting ABG’sInterpreting ABG’s

• ROME

R = Respiratory

O = Opposite

M = Metabolic

E = Equal

1.Determine all normal/abnormal indicators

2.Determine the primary problem: Respiratory or Metabolic

3.Look at the other indicator if Compensation is taking place


ABG PracticeABG Practice

• pH = 7.24

• PCO2 = 51

• HCO3 = 22

• pO2 = 89

• O2 Sat = 95%



• pH = 7.60

• pCO2 = 35

• HCO3 = 35

• pO2 = 99

• O2 Sat = 99%



• pH = 7.19

• PCO2 = 69

• HCO3 = 35

• pO2 = 68

• O2 Sat = 83%


ABG Case Study #1ABG Case Study #1

Mr. Johnson is a 63 yr-old with pneumonia. He is admitted with dyspnea, fever, and chills.

His blood gas is:

pH 7.28

pCO2 56

pO2 70

HCO3 25

O2 Sat: 89%



Ms. Rubio is a 21 yr-old college student. She has a history of Crohn’s disease

and is complaining of a four day history of bloody-watery diarrhea. A blood gas

is obtained to assess her acid/base balance:

pH 7.28

CO2 44

pO2 87

HCO3 19

O2 Sat 96%



Mr. Sams is an 82 yr-old nursing home resident admitted with urosepsis. Over

the last 2 hours he has developed shortness of breath and is becoming

confused. His ABG is as followed:

pH 7.10

pCO2 55

pO2 76

HCO3 15

O2 Sat 87%



Mrs. Gomez is a thin, elderly –looking 64 yr-old COPD patient. She has an ABG done as part of her routine care in the pulmonary clinic. The results are as

follows:

pH 7.37

pCO2 62

pO2 59

HCO3 34

O2 Sat 89%



Mrs. Ramos is found pulseless and not breathing this morning. After a couple minutes of CPR she responds with a

pulse and starts breathing on her own. An ABG reveals:

pH 6.99

pCO2 72

pO2 42

HCO3 13

O2 Sat 53%


OXYGEN THERAPY & MECHANICAL VENTILATIONOXYGEN THERAPY & MECHANICAL VENTILATION


Oxygen Therapy and Respiratory CareOxygen Therapy and Respiratory Care

• Oxygen Gaseous element essential to life Prescribed as a medication Administered under controlled conditions

• Therapeutic (supplemental) oxygen Used when client is unable to obtain sufficient oxygen

for the body’s needs

• Excess oxygen: can be harmful


Oxygen Provision, cont.Oxygen Provision, cont.

• Goals of oxygen therapy Reverses hypoxemia Decreases the work of the respiratory system Decreases the heart’s work in pumping blood

• Hazards of oxygen therapy Oxygen toxicity Vision difficulties in newborns Weakens the stimulus to breathe


The Client Who Is Having Difficulty BreathingThe Client Who Is Having Difficulty Breathing

• Primary concern is delivery of the desired percentage of oxygen

• Low-flow devices Do not provide exact oxygen concentrations; client’s

breathing pattern influences the concentration of oxygen obtained

• High-flow oxygen devices Oxygen percentage is constant


Low-Flow Delivery SystemsLow-Flow Delivery Systems

• Nasal cannula

• Simple face mask

• Partial-rebreathing mask

• Non-rebreathing mask


Low-Flow Delivery Systems Low-Flow Delivery Systems

• Nasal cannula (nasal prongs) Device used to deliver small to moderate

increases in oxygen concentration Two short tubes that fit into the nostrils Less confining Does not interfere with eating or talking Use with caution for clients with irregular

breathing patterns 24-44% oxygen delivered and 1-6 LPM


Simple Face MaskSimple Face Mask

• The simple mask requires a minimum oxygen flow rate of 6 LPM to prevent carbon dioxide buildup.

• Low-flow delivering 40-60% oxygen with a flow rate of 6-10 LPM


Partial Rebreathing MaskPartial Rebreathing Mask

• Low-flow

• Has a bag with the absence of valves on the mask

• 60-90% oxygen concentration achieved

• Flow rate 8-10 LPM (min. flow rate of 6 lpm required)

• Bag should remain inflated during inspiration & expiration (bag should be at least 1/3 inflated

• Page 1327 fig 86-1


Non-Rebreathing MaskNon-Rebreathing Mask

• Different from the PRM since it has valves on the mask

• 90-100% oxygen delivered

• Suggested flow rate is 12 LPM as long as 1/3 of the bag is inflated

• Must be continuously monitored since toxicity can occur within 72 hrs


Key ConceptKey Concept

• Both the partial-rebreathing mask and the non-rebreathing mask can deliver high concentrations of oxygen; however, they are both classified as low-flow system oxygen administration devices because it is difficult to get the mask to fit tightly enough to ensure 100% oxygen delivery.

Nursing Alert• The NRM is used only in intensive care units or in

one-to-one client care situations. • Rationale: Insufficient or interrupted oxygen flow will

seal the mask against the person’s face, potentially suffocating him or her. The client needs constant monitoring.


High-Flow Delivery SystemHigh-Flow Delivery System

• Venturi Mask

• IPPB

• Aerosal Mist Treatments


Venturi MaskVenturi Mask

• Delivers a specific amount of oxygen

• 24-50% oxygen delivered with flow rates of 4-8 LPM

• Draws room, air through its window


Nursing AlertNursing Alert

• Do NOT use a humidifier with a Venturi mask.

• Rationale: Significant back-pressure may activate the safety pressure valve on the humidifier, causing it to burst. The large amount of room air that a Venturi mask uses will humidify the gas adequately.

• Ensure that the windows of the Venturi mask remain exposed to room air. Sheets or blankets must not cover the windows or the end of the adapter.

• Rationale: Prevent occlusion of the oxygen flow, which would alter the desired oxygen concentration.


Intermittent Positive Pressure Breathing (IPPB) Intermittent Positive Pressure Breathing (IPPB)

• IPPB treatment is ordered for children or adults with chronic lung conditions.

• Most often used for clients with cystic fibrosis

• Assists the client to breathe more easily by liquefying mucus


The Client Who Is Unable to BreatheThe Client Who Is Unable to Breathe

• Manual breathing bag The manual resuscitator or the AMBU bag affords

high oxygen concentrations and more effective and sanitary resuscitation than the mouth-to-mouth method.


Mechanical VentilationMechanical Ventilation

61


Ventilatory Support, cont.Ventilatory Support, cont.

• Negative pressure ventilator Seldom used today

• Positive pressure ventilator Volume or pressure ventilator Assisted-breath ventilator Controlled-breath ventilator


Ventilatory Support, cont.Ventilatory Support, cont.

• Care for the client receiving mechanical ventilation Assist the client to turn from side to side at least every

2 hours. Many of these clients are on special airflow beds. Suction lung secretions. Observe carefully any secretions that the client

expectorates or that are suctioned. Sedation or Paralytics?

64


Common Ventilator ModesCommon Ventilator Modes

• Assist Control (AC)

• Synchronized Intermittent Mandatory Ventilation (SIMV)

• Pressure Support (PS or PSV)

• Continuous Positive Airway Pressure (CPAP)


Common Medical Treatments for Pulmonary DisordersCommon Medical Treatments for Pulmonary Disorders


Postural DrainagePostural Drainage

Uses position and gravity to drain secretions and mucus from the individual’s lungs

Often done by respiratory therapist Client adopts a head-downward position;

secretions run into the trachea from the bronchi and are coughed out

Procedure called chest physiotherapy (CPT); often combined with other respiratory treatments


Chest Drainage SystemsChest Drainage Systems


Post-Chest Surgery CarePost-Chest Surgery Care

• Chest suction Follows most types of lung surgery Chest tubes inserted into the chest cavity and

attached to suction Purpose

• Restore negative pressure within the chest cavity and reinflate the lungs

or• Prevent loss of negative pressure and keep lungs

inflated


Post-Chest Surgery Care cont.Post-Chest Surgery Care cont.

• Closed water-seal drainage One or more catheters inserted into chest cavity If more than one catheter is inserted

• Each may be connected to a separate suction setup

or

• All may be joined and attached to one suction setup


Chest Tubes cont.Chest Tubes cont.

• Maintain the integrity of the suction apparatus and water seal at all times. Refill the water chamber if the fluid level gets low.

• Report at once any client who complains of severe pain or dyspnea.

• If a bottle or connection breaks, the closed system will be disrupted, and this is an emergency!

• Clamp the chest tubes immediately and summon help.


Chest Tubes cont.Chest Tubes cont.

• Closed water-seal drainage Water-seal drainage system must remain closed

• Air not allowed to enter chest cavity

• Pleur-Evac: disposable chest drainage system


Chest Tubes, cont.Chest Tubes, cont.

• Observe for Signs of shock, dyspnea, pain in the chest A rapid increase in chest tube drainage

• Report symptoms immediately


Caring for the Client with Chest SuctionCaring for the Client with Chest Suction

• Leakage of air into the drainage system, whether in a simple water-seal type or a mechanical suction type, is indicated by constant bubbling in the water-seal system, after the client’s lungs have been initially expanded. There will be bubbling in the control chamber-the one connected to suction. If bubbling in the control chamber stops, the suction pressure is to low


Caring for the Client with Chest Suction..contCaring for the Client with Chest Suction..cont

• Air leaks can occur at the insertion site of the chest tube, in connections, in the drainage system itself

• Checking the Air Leak….

• Keep all tubes, bags, and other devices below the level of tube insertion

• Never disconnect chest tubes! (These tubes provide the suction that keeps the lungs inflated. If disconnected, lungs will collapse



• If the tubes become disconnected, double-clamp all tubes close to the chest wall and summon assistance immediately (This is an emergency. If air enters the chest cavity lungs will collapse).

• Be aware that clamping chest tubes may cause a tension pneumothorax

• Never use pins to fasten tubes to the bed



• Avoid changing the dressing. The dressing may help maintain integrity of the chest wall.

• Tape all connections to make sure they are airtight

• Do not milk/strip tubes

• Observe for excessive bleeding or for abrupt absence of drainage.


ThoracotomyThoracotomy

Incision into the thorax or chest cavity for lung surgery

• Caring for the client with chest surgery Preoperative teaching

• Deep-breathing techniques

• Range-of-motion (ROM) exercises


Chest SurgeryChest Surgery

• Caring for the client with chest surgery, cont. Postoperative care

• Maintain airway

• Prevent respiratory complications.

• Record vital signs frequently.

• Turn the client often to prevent complications of immobility.

• Encourage exercise soon after surgery.


Disorders of the Upper AirwayDisorders of the Upper Airway

• Epistaxis Etiology/pathophysiology

• Bleeding from the nose

• Congestion of the nasal membranes leading to capillary rupture

• Primary or secondary Clinical manifestations/assessment

• Bright red bleeding from one or both nostrils

• Can lose as much as 1 liter per hour



• Epistaxis (continued) Medical management/nursing interventions

• Sitting position, leaning forward

• Direct pressure by pinching nose

• Ice compresses to nose

• Nasal packing

• Cautery

• Balloon tamponade



• Deviated septum and nasal polyps Etiology/pathophysiology

• Congenital abnormality

• Injury

• Nasal septum deviates from the midline and can cause a partial obstruction

• Nasal polyps are tissue growths usually due to prolonged inflammation



• Deviated septum and nasal polyps (continued) Clinical manifestations/assessment

• Stertorous respirations (snoring)

• Dyspnea

• Postnasal drip Medical management/nursing interventions

• Pharmacological management Corticosteroids, antihistamines, antibiotics, analgesics

• Nasoseptoplasty

• Nasal polypectomy



• Allergic rhinitis and allergic conjunctivitis (hay fever) Etiology/pathophysiology

• Antigen/antibody reactions in the nasal membranes, nasopharynx, and conjunctiva due to allergens

Diagnostic testing



• Allergic rhinitis and allergic conjunctivitis (continued) Clinical manifestations/assessment

• Edema

• Photophobia

• Excessive tearing

• Blurring of vision

• Pruritus

• Excessive nasal secretions and/or congestion

• Sneezing

• Cough

• Headache



• Allergic rhinitis and allergic conjunctivitis (continued) Diagnostic testing Medical management/nursing interventions

• Pharmacological management Antihistamines Decongestants Corticosteroids Analgesics

• Avoid allergen

• Hot packs over facial sinuses



Projections of paranasal sinuses and oral nasal cavities on the skull and

face.

(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)



• Obstructive sleep apnea (OSA) Etiology and pathophysiology

• Characterized by partial or complete upper airway obstruction during sleep

• Apnea refers to the cessation of spontaneous respirations

• Hypopnea is the presence of unusually shallow or slow respirations



• Obstructive sleep apnea (OSA) Clinical manifestations

• Frequent awakening at night

• Insomnia

• Excessive daytime fatigue

• Witnessed apneic episodes

• Loud snoring

• Hypercapnia

• Personality changes

• Irritability



• Obstructive sleep apnea (continued) Complications Diagnostic tests Medical management/nursing interventions

• Avoid sedatives

• Avoid alcoholic beverages

• Support groups

• Oral appliances

• nCPAP

• Surgery



• Upper airway obstruction Etiology and pathophysiology

• Precipitated by a recent respiratory event

• Common airway obstructions Choking on food Dentures Aspiration of vomitus or secretions The tongue



• Upper airway obstruction (continued) Clinical manifestations/assessment

• Stertorous respirations

• Altered respiratory rate and character; apneic periods

• Hypoxia; cyanosis

• Wheezing; stridor Medical management/nursing interventions

• Open the airway

• Remove obstruction

• Artificial airway; tracheostomy



• Cancer of the larynx Etiology/pathophysiology

• Squamous cell carcinoma

• Heavy smoking and alcohol use

• Chronic laryngitis

• Vocal abuse

• Family history



• Cancer of the larynx (continued) Clinical manifestations/assessment

• Progressive or persistent hoarseness

• Pain radiating to the ear

• Difficulty swallowing

• Hemoptysis Medical management/nursing interventions

• Radiation

• Surgery Partial or total laryngectomy Radical neck dissection


Respiratory InfectionsRespiratory Infections

• Acute rhinitis (common cold) Etiology/pathophysiology

• Inflammation of the mucous membranes of the nose and accessory sinuses

• Virus(es) Clinical manifestations/assessment

• Thin, serous nasal exudate

• Productive cough

• Sore throat

• Fever



• Acute rhinitis (common cold) (continued) Medical management/nursing interventions

• Pharmacological management Analgesic Antipyretic Cough suppressant Expectorant Antibiotic (if infection present)

• No specific treatment

• Encourage fluids



• Acute follicular tonsillitis Etiology/pathophysiology

• Inflammation of the tonsils

• Bacterial or viral infection Clinical manifestations/assessment

• Enlarged, tender, cervical lymph nodes

• Sore throat

• Fever; chills

• Enlarged, purulent tonsils

• Elevated WBC



• Acute follicular tonsillitis (continued) Medical management/nursing interventions

• Pharmacological management Antibiotics; analgesics; antipyretics

• Warm saline gargles

• Tonsillectomy and adenoidectomy Postoperative

o Assess for excessive bleedingo Ice-cold liquids—ice creamo Ice collaro Avoid coughing, sneezing, or vigorous nose blowing



• Laryngitis Etiology/pathophysiology

• Inflammation of the larynx due to virus or bacteria

• May cause severe respiratory distress in children under 5 years old

Clinical manifestations/assessment• Hoarseness

• Voice loss

• Scratchy and irritated throat

• Persistent cough



• Laryngitis (continued) Medical management/nursing interventions

• Pharmacological management Analgesics Antipyretics Antitussives Antibiotics—bacterial

• Viral—no specific treatment, supportive care

• Warm or cool mist vaporizer

• Limit use of voice



• Pharyngitis Etiology/pathophysiology

• Inflammation of the pharynx

• Chronic or acute

• Frequently accompanies the common cold

• Viral, most common

• Bacterial



• Pharyngitis (continued) Clinical manifestations/assessment

• Dry cough

• Tender tonsils

• Enlarged cervical lymph glands

• Red, sore throat

• Fever Medical management/nursing interventions

• Pharmacological management Antibiotics; analgesics; antipyretics

• Warm or cool mist vaporizer



• Sinusitis Etiology/pathophysiology

• Inflammation of the sinuses

• Usually begins with an upper respiratory infection; viral or bacterial

Clinical manifestations/assessment• Constant, severe headache

• Pain and tenderness in involved sinus region

• Purulent exudate

• Malaise

• Fever



• Sinusitis (continued) Medical management/nursing interventions

• Pharmacological management Antibiotics Analgesics Antihistamines

• Vasoconstrictor nasal spray (Afrin)

• Warm mist vaporizer

• Warm, moist packs

• Nasal windows


Disorders of the Lower AirwayDisorders of the Lower Airway

• Acute bronchitis Etiology/pathophysiology

• Inflammation of the trachea and bronchial tree

• Usually secondary to upper respiratory infection

• Exposure to inhaled irritants Clinical manifestations/assessment

• Productive cough; wheezes

• Dyspnea; chest pain

• Low-grade fever

• Malaise; headache



• Acute bronchitis (continued) Medical management/nursing interventions

• Pharmacological management Cough suppressants Antitussives Antipyretics Bronchodilators Antibiotics

• Vaporizer




• Legionnaires’ disease Etiology/pathophysiology

• Legionella pneumophila

• Thrives in water reservoirs

• Causes life-threatening pneumonia

• Leads to respiratory failure, renal failure, bacteremic shock, and ultimately death



• Legionnaires’ disease (continued) Clinical manifestations/assessment

• Elevated temperature

• Headache

• Nonproductive cough

• Difficult and rapid respirations

• Crackles or wheezes

• Tachycardia

• Signs of shock

• Hematuria



• Legionnaires’ disease (continued) Medical management/nursing interventions

• Pharmacological management Antibiotics Antipyretics Vasopressors

• Oxygen

• Mechanical ventilation, if necessary

• IV therapy



• Severe Acute Respiratory Syndrome (SARS) Etiology/pathophysiology

• Infection caused by coronavirus

• Spread by close contact between people

• Airborne

• May be spread by touching contaminated objects Clinical manifestations/assessment

• Temperature

• Headache

• Muscle aches

• Mild respiratory symptoms Dry cough and SOB



• Adult respiratory distress syndrome (continued) Diagnostic tests

• Chest radiograph

• Serum antibody testing

• Nasopharyngeal and oropharyngeal swabs Medical management/nursing interventions

• Pharmacological management Antibiotics Antiviral medications

• Respiratory isolation

• Oxygen



• Anthrax Etiology/pathophysiology

• Bacillus anthracis

• Spread by direct contact with bacteria or spores

• Three types: Cutaneous, GI, inhalational Clinical manifestations/assessment

• Cold or flu-like symptoms

• Hemorrhage, tissue necrosis, and lymphedema Medical management

• Antibiotics



• Tuberculosis Etiology/pathophysiology

• Inhalation of tubercle bacillus (Mycobacterium tuberculosis)

• Infection versus active disease

• Presumptive diagnosis Mantoux tuberculin skin test Chest x-ray film Acid-fast bacilli smear 3

• Confirmed diagnosis Sputum culture; positive for TB bacilli



• Tuberculosis (continued) Clinical manifestations/assessment

• Fever

• Weight loss; weakness

• Productive cough; hemoptysis

• Chills; night sweats Medical management/nursing interventions

• Tuberculosis isolation (acid-fast bacilli [AFB])

• Multiple medications to which the organisms are susceptible



• Pneumonia Etiology/pathophysiology

• Inflammatory process of the bronchioles and the alveolar spaces due to infection

• Bacteria, viruses, mycoplasma, fungi, and parasites Clinical manifestations/assessment


• Severe chills; elevated temperature

• Increased heart rate and respiratory rate

• Dyspnea



• Pneumonia (continued) Medical management/nursing interventions

• Pharmacological management Antibiotics Analgesics Expectorants Bronchodilators

• Oxygen

• Chest percussion and postural drainage

• Encourage to cough and deep-breathe

• Humidifier or nebulizer



• Pleurisy Etiology/pathophysiology

• Inflammation of the visceral and parietal pleura

• Bacterial or viral Clinical manifestations/assessment

• Sharp inspiratory pain

• Dyspnea

• Cough


• Pleural friction rub



• Pleurisy (continued) Medical management/nursing interventions

• Pharmacological management Antibiotics Analgesics Antipyretics

• Oxygen

• Anesthetic block for intercostal nerves



• Pleural effusion/empyema Etiology/pathophysiology

• Pleural effusion

• Accumulation of fluid in the pleural space

• Empyema—infection Clinical manifestations/assessment

• Dyspnea

• Air hunger

• Respiratory distress

• Fever



• Pleural effusion/empyema (continued) Medical management/nursing interventions

• Thoracentesis

• Chest tube with closed water-seal drainage system

• Antibiotics

• Cough and deep-breathe



• Atelectasis Etiology/pathophysiology

• Collapse of lung tissue due to occlusion of air to a portion of the lung

Clinical manifestations/assessment• Dyspnea; tachypnea

• Pleural friction rub; crackles

• Restlessness


• Decreased breath sounds



• Atelectasis (continued) Medical management/nursing interventions

• Pharmacological management Bronchodilators Antibiotics Mucolytic agents Analgesics

• Cough and deep-breathe• Early ambulation• Respiratory treatments

Incentive spirometry; intermittent positive-pressure breathing (IPPB)

Oxygen Chest percussion and postural drainage

• Chest tube



• Pneumothorax Etiology/pathophysiology

• A collection of air or gas in the pleural space, causing the lung to collapse

Clinical manifestations/assessment• Decreased breath sounds

• Sudden, sharp chest pain with dyspnea

• Diaphoresis; tachycardia; tachypnea

• No chest movement on affected side

• Sucking chest wound



Pneumothorax (complete collapse of the right lung).

(From Wilson, S., Thompson, J. [1991]. Respiratory disorders, Mosby’s clinical nursing series. St. Louis: Mosby.)



• Pneumothorax (continued) Medical management/nursing interventions

• Chest tube to water-seal drainage system

• Oxygen

• Analgesics




• Lung cancer Etiology/pathophysiology

• Primary tumor or metastasis

• Small-cell, non–small-cell, squamous cell, and large-cell carcinoma

Clinical manifestations/assessment• Hemoptysis

• Dyspnea; wheezing

• Fever; chills

• Pleural effusion



• Lung cancer (continued) Medical management/nursing interventions

• Surgery Most are not diagnosed early enough for curative

surgical intervention Segmental resection Lobectomy Pneumonectomy

• Radiation

• Chemotherapy



• Pulmonary edema Etiology/pathophysiology

• Accumulation of serous fluid in interstitial tissue and alveoli

Clinical manifestations/assessment• Dyspnea; cyanosis

• Tachypnea; tachycardia

• Pink or blood-tinged, frothy sputum

• Restlessness; agitation

• Wheezing; crackles

• Decreased urinary output; sudden weight gain



• Pulmonary edema (continued) Medical management/nursing interventions

• Pharmacological management Diuretics Narcotic analgesics Nipride

• Oxygen

• Mechanical ventilation, if necessary

• Strict I&O; daily weight

• Low-sodium diet



• Pulmonary embolism Etiology/pathophysiology

• Foreign substance in the pulmonary artery Blood clot, fat, air, or amniotic fluid

Clinical manifestations/assessment• Sudden, unexplained dyspnea, tachypnea

• Hemoptysis

• Chest pain


• Increased WBCs



• Pulmonary embolism (continued) Medical management/nursing interventions

• Pharmacological management Anticoagulants Fibrinolytic agents

• Oxygen

• HOB up 30 degrees



• Acute respiratory distress syndrome (ARDS) Etiology and pathophysiology

• Results from direct or indirect pulmonary injury

• Alveolar capillary membranes are altered resulting increased permeability creating pulmonary edema and hypoxia



• Acute respiratory distress syndrome (continued) Clinical manifestations

• Respiratory distress

• Changes in level of consciousness

• Tachycardia

• Hypotension

• Decreased urinary output



• Acute respiratory distress syndrome (continued) Medical management/nursing interventions

• Pharmacological management Corticosteroids Antibiotics Vasodilators Bronchodilators Mucolytics Diuretics Morphine sulfate Neurologic blocking agents Cardiotonic glycosides (digoxin)



• Acute respiratory distress syndrome (continued) Medical management/nursing interventions

(continued)• Oxygen

• Position changes

• Close assessment of vital signs


Chronic Obstructive Pulmonary Disease (COPD)Chronic Obstructive Pulmonary Disease (COPD)

• Emphysema Etiology/pathophysiology

• The bronchi, bronchioles, and alveoli become inflamed as a result of chronic irritation

• Air becomes trapped in the alveoli during expiration, causing alveolar distention, rupture, and scar tissue

Complication• Cor pulmonale

Right-sided congestive heart failure due to pulmonary hypertension


Emphysema PreventionEmphysema Prevention



Disorders of the airways in patients with chronic bronchitis, asthma, and emphysema.

(From Lewis, S.M., Collier, I., & Heitkemper, M.M. [1996]. Medical-surgical nursing: assessment and management of clinical problems. [4th ed.]. St. Louis: Mosby.)


• Emphysema (continued) Clinical manifestations/assessment

• Dyspnea on exertion

• Sputum

• Barrel chest

• Chronic weight loss

• Emaciation

• Clubbing of fingers




Barrel chest. Note increase in AP diameter.


Pink Puffer & Blue BloaterPink Puffer & Blue Bloater


• Emphysema (continued) Medical management/nursing interventions

• Pharmacological management Bronchodilators; corticosteroids; antibiotics; diuretics

• Oxygen (low-flow)

• Chest physiotherapy

• Humidifier

• Pursed-lip breathing

• High-protein, high-calorie diet



• Chronic bronchitis Etiology/pathophysiology

• Hypertrophy of mucous glands causes hypersecretion and alters cilia function

• Increased airway resistance causes bronchospasm Clinical manifestations/assessment


• Dyspnea

• Use of accessory muscles to breathe

• Wheezing



• Chronic bronchitis (continued) Medical management/nursing interventions

• Pharmacological management Bronchodilators Mucolytics Antibiotics


• Pursed-lip breathing



• Asthma Etiology/pathophysiology

• Narrowing of the airways due to various stimuli

• Extrinsic or intrinsic factors

• Influenced by secondary factors

• Antigen-antibody reaction



• Asthma (continued) Clinical manifestations/assessment

• Mild asthma Dyspnea on exertion Wheezing

• Acute asthma attack Tachypnea Expiratory wheezing; productive cough Use of accessory muscles; nasal flaring Cyanosis



• Asthma (continued) Medical management/nursing interventions

• Maintenance therapy Serevent inhalant, prophylactic Corticosteroid inhalant Avoid allergens

• Acute or rescue therapy Proventil inhalant; aminophylline IV Corticosteroid and epinephrine oral or subcutaneous Oxygen



• Bronchiectasis Etiology/pathophysiology

• Gradual, irreversible process that involves chronic dilation of bronchi resulting in loss of elasticity

Clinical manifestations/assessment• Dyspnea; coughing; wheezes and crackles

• Cyanosis; clubbing of fingers

• Fatigue; weakness

• Loss of appetite



• Bronchiectasis (continued) Medical management/nursing interventions

• Pharmacological management Mucolytic agents Antibiotics Bronchodilators


• Chest physiotherapy

• Hydration

• Cool mist vaporizer

• Surgery: Lobectomy


chapter 9 care of the patient with a respiratory disorder jeanelle f. jimenez rn, bsn, ccrn mosby...

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