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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Medical Surgical Nursing
Preparation for Practice
CHAPTER
Nursing Assessment of
Patients with
Respiratory Disorders
33
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Medical Surgical Nursing: Preparation for Practice
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Complete Assessment
History
Biographic and demographic data
Chief complaint
Past medical history
Family history
Risk factors
Social history
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Medical Surgical Nursing: Preparation for Practice
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Complete Assessment
Components of Physical Exam
Inspection
Auscultation
Percussion
Pain
Genetic and gerontological considerations
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Social History
Patients lifestyles and habits and
Risk for developing pulmonary disease
Current and previous work settings
Home environment
Social settings
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Gerontological Considerations
aging decreases respiratory function
lower arterial oxygen values,
increase risk of pneumonia
Risk of aspiration may increase with aging
Aging may affect patient comfort needs
during the examination
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Genetic Considerations
Cystic fibrosis (CF): genetic disorder,
typically diagnosed in childhood
CF has serious pulmonary complications
thick mucus builds up in lungs
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Inspection
Initial assessment activity
General appearance:
Posture, facial expression and movements
Changes in mental status
Respiratory rates shallow breathing, irregular
patterns of breathing
Size and shape of the thorax, asymmetry
Diminished movement of rib cage, use of
accessory muscles
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Inspection
Color and appearance of skin
Pallor may indicate decreased oxygen-
carrying capacity of the blood due to anemia
Central cyanosis, where the mouth, lips, and
mucous membranes are blue-tinged,
indicates hypoxia in adults
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Inspection
Inspection of the neck
Appearance of veins, trachea and
musculature may indicate chronic cardiac or
pulmonary disease, pneumothorax
Goiter or lesions may obstruct the upper
airway
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Inspection
Palpation of skin and extremities
Edema of lower extremities
Skin temperature and moisture
Clinical reference points
Chest excursion
Tactile fremitus
Tenderness
Crepitus
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Clinical Reference Points
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Occupational Impact on
Respiratory Disease
Exposure to airborne particles, vapors,
and irritants
Can result in acute or chronic respiratory
disease in susceptible individuals
Early recognition, diagnosis, and treatment
of occupational asthma can prevent
pulmonary complications
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Auscultating Breath Sounds
Patient should be upright
Use the diaphragm of the stethoscope
Begin at C7 posteriorly and anteriorly from
above the clavicles
Move steadily from right to left upper and
lower
Compare breath sounds bilaterally
Do not auscultate over clothing

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Diaphragm - best for higher
pitched sounds, like breath
sounds and normal heart
sounds.

Bell - is best for detecting
lower pitch sounds, like some
heart murmurs, and some
bowel sounds. It is used for
the detection of bruits, and for
heart sounds (for a cardiac
exam, listen with the
diaphragm, and repeat with
the bell).
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Figure 33.1 In a respiratory assessment, it is important to palpate and count ribs and interspaces to
accurately record the location of lesions or adventitious breath sounds.
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Auscultating Breath Sounds
Figure 33.2 Lobes of the lunganterior.
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Auscultating Breath Sounds
Figure 33.3 Lobes of the lungposterior
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Tracheal Breath Sounds
Auscultated over the trachea
Loud and high pitched
Cause: airflow through tubular trachea
Best heard over the neck and trachea
Occurs during upper airway obstruction
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Bronchial Breath Sounds
Anterior: heard on either side of sternum,
over main stems of the bronchus from 2nd
to 4th intercostal spaces
Posterior: best heard lateral to the spine
between 3rd and 6th intercostal spaces
Loud, harsh, less turbulent and lower than
tracheal sounds
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Bronchial Breath Sounds
Pause between inspiration and expiration;
expiration is heard for a longer time than
inspiration
Sounds over smaller airways are low
pitched and softer
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Bronchovesicular Breath Sounds
Heard during inspiration and expiration
Midway in Pitch and loudness between
vesicular and bronchial breath sounds
Best heard in 1st and 2nd intercostal
spaces of anterior chest, between
scapulae of the posterior chest
Represent air movement in the moderate
airways between the bronchi and the
smaller airways
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Vesicular Breath Sounds
Heard over most of the thorax
Soft and low pitched, rustling, from air
moving through small airways
Heard longer during expiration, which
generally lasts twice as long as inspiration
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Adventitious Breath Sounds
Decreased or no sounds where normal
sounds should occur
Breath sounds occurring in abnormal
locations
Diminished breath sounds demonstrate
decreased airflow and potentially
decreased oxygen exchange
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Adventitious Breath Sounds
Adventitious/extra sounds:
Represent pathologic conditions of heart or
lungs
Indicate disrupted airflow due to airway
spasm, fluid, or secretions
Crackles (rales-term not used as much),
Wheezes, Stridor, Friction rubs

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Crackles
Caused by fluid in the airways
Intermittent or discontinuous, nonmusical, or
popping sounds
Caused by fluid, inflammation, infection, or
secretions
Crackles are described as either fine or coarse
Occur when closed airways snap open during
inspiration
Softer, gentler sound may also be heard on
inspiration


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Wheezes
Heard equally during inspiration and expiration
High-pitched musical sounds
Caused by air flowing across strands of mucus,
swollen pulmonary tissue that narrows the airway,
bronchospasm
Rhonchi (term for secretions in airways-not used as
much)
Inspiratory/expiratory, continuous/ discontinuous,
mild/moderate/severe
Asthma, allergies, reactive airway disease

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Stridor
Heard only during inspiration as air attempts to flow
across an obstruction
Heard without stethoscope as high-pitched, crowing
sound
With stethoscope, best heard over large airways,
e.g., trachea or bronchus
Report to the health care provider immediately
Indicates airway obstruction requiring
intervention
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Pleural Friction Rubs
Low-pitched, creaking or squeaking sounds
Occur when inflamed pleural surfaces rub
together
Heard on inspiration
Pitch usually increases with chest expansion
Have the patient hold breath to distinguish
between pleural and pericardial friction

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Adventitious Lung Sounds
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Travel and Area of Residence
An important aspect of the history in
diagnosing potential respiratory problems
Exposure to region-specific infectious
diseases
Exposure to environmental conditions, e.g.
high altitudes
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High-Altitude Pulmonary Edema
(HAPE)
HAPE can occur with travel to altitudes
greater than 5,000 feet
Increasing altitude decreasing
atmospheric pressure decreasing
available O
2

Rapid onset of hypoxemia may result
Compensatory increased respiratory rate
may contribute to fatigue
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High-Altitude Pulmonary Edema
(HAPE)
This causes further respiratory
insufficiency
Initial compensatory mechanisms
pulmonary vascular vasoconstriction
Later, inflammatory mediators cause
vasodilation
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Percussion
Assess presence of air, fluid, solid mass in
underlying tissues
Normal lungs produce a resonant, low-pitched clear
sound
Hyperresonance indicates airways are hyperinflated
or air is present outside of lung tissue
Dullness indicates that air is absent
Pneumonia, pleural effusion, hemothorax, solid
tumors

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Pain
Pain during respiration may decrease tidal
volumes
Pain management enables participation in
rehabilitative activities
Also promotes deep breathing to prevent
pneumonia and atelectasis
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Standard of Care
For patients with cardiac and respiratory
illness, standard is:
Continuous or intermittent observation of the
patients oxygen saturation
End-tidal carbon dioxide levels
Peak flow is utilized to trend treatment
effectiveness in patients with asthma
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Assessment of Arterial Oxygen
Levels
ABGs
Pulse oximetry
Physical assessment
FiO
2
will increase the PaO
2
four times
(normal patient)
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Pulse Oximetry
Measures O
2
saturation of hemoglobin
Reflects light off the hemoglobin
molecules
Measures the absorption of light by
hemoglobin
Normal range is from 95% to 100%
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Factors Interfering with
Pulse Oximetry
Nail polish
Automated BP cuffs, hemodialysis fistulas,
or arterial lines interfere with blood flow
Shock and hypovolemia
Patient movement, ambient light, and
venous pulsations may also cause
inaccurate readings
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Peak Flow Meters
Track trends in a patients condition,
evaluate air movement to determine
severity of asthma exacerbation
Measure the peak expiratory flow rate
Normal values based on age and body
size
Severity scale: Utilizes red, yellow, and
green zones to determine the severity of
decrease in peak flow
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Arterial Blood Gas Studies (ABG)
Provide information on arterial oxygen and
carbon dioxide levels
Oxygen saturation, bicarbonate, and blood
pH are also calculated
CO
2
is major determinant of respiratory
alkalosis/acidosis
Bicarbonate level is determinant of
metabolic acidosis/alkalosis
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Capnography
Measurement of exhaled CO
2
Some utilize paper treated to detect the
presence of acid such as CO
2

Others use spectrography, generate
waveform readings
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Capnography
Useful in determining ventilatory status,
readiness for extubation
Also used to determine pulmonary vessel
perfusion in patients with pulmonary
embolus
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Capnography Monitor
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Medical Surgical Nursing
Preparation for Practice
CHAPTER
Caring for the Patient
with Upper Airway Disorders
34
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Facial Bones
Mandible
Maxilla
Zygoma
Temporal bones
Frontal bone
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Mandible
U-shaped bone
Together with the maxilla, largest and
strongest bone of the face
Forms lower jaw, holds the lower teeth in
place
Articulates with temporal bones at the
temporomandibular joint
Only mobile bone of the facial skeleton;
motion is essential for mastication
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Nursing Management for
Mandibular Fractures
Determine patients nutritional requirements and
knowledge deficits
Oral nutrition with high-protein liquid diet and calories
is essential
Avoid weight loss if possible to ensure nutritional
adequacy for healing
Nasogastric or oral gastric tube supports nutrition if
patient has extensive facial swelling
Observe for nausea and vomiting, intervene to
prevent aspiration

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Maxilla
Largest component of the middle third of
the facial skeleton
Attaches laterally to the zygomatic bones
Key bone in the midface, provides
structural support
Fractures less frequently than mandible or
nose due to strong structural support
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Classification System of
Maxillary Fractures
Le Fort I Fracture (horizontal)
Le Fort II Fracture (pyramidal)
Le Fort III Fracture (transverse)
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Zygoma
A paired bone, commonly called the
cheekbone
Articulates with maxilla, temporal,
sphenoid, and frontal bones
Forms prominence of the cheek
The masseter muscle is suspended from
the zygomatic arch
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Temporal Bone
Situated at the sides and base of the skull
Houses cochlear and vestibular end
organs, facial nerve, carotid artery, jugular
vein
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Nursing Management for
Temporal Bone Fractures
Care is conservative
Assess for nerve damage and hearing loss
Test for otorrhea; may indicate a CSF leak
Monitor lumbar drain if inserted
If facial nerve injury is present, provide eye
care
Institute CSF leak precautions HOB 30
o
, no
straining, bending or lifting
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Frontal Bone
Makes up the forehead, upper edge and
roof of the orbit
Forms the anterior portion of the cranium
Frontal sinus air-filled cavity between
lamina of the frontal bone
Serves as a mechanical barrier to protect
the brain
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Infectious Rhinitis
Usually caused by upper respiratory tract
infection of viral origin
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Allergy
Inappropriate immune response to usually
harmless substance in the environment
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Sinusitis
Inflammation of one or more paranasal
and frontal sinuses
Occurs with obstruction of the normal
drainage mechanism
Three classifications of sinusitis
Acute (symptoms lasting <3 weeks),
Subacute (symptoms lasting 3 weeks to 3
months)
Chronic (symptoms lasting >3 months)
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Sinusitis
Can be caused by bacterial, viral, and fungal
infections
May occur during a Upper RespiratoryInfection when
infection in the nose spreads to the sinuses
Contributing factors:
Air pollution
Diving and underwater swimming
Sudden temperature extremes
Structural defects

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Sinusitis
Pathophysiology
Paranasal sinuses in direct communication
with nasopharynx
Proximity can cause bacterial infection
When a bacterial or viral infection present,
person develops sinus infection
Tumors, polyps, trauma or benign growths
can cause obstruction
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Sinusitis
Pathophysiology
Ostia (sinus openings) obstruction can
impede normal flow of air
Reduced flow of air and mucus allows mucus
to become stagnant, contributing to growth of
bacteria causes inflammation and swelling
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Figure 34.4 Sites of sinusitis.
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Sinusitis
Clinical manifestations:
Fever
Weakness
Fatigue
Cough
Congestion
Discharge
Pain in face or forehead
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Sinusitis
Nursing management
Assessment
Thorough history
Education on causes and how to avoid
triggers (air pollutants, diving, underwater
swimming, allergies, irritants)
Education on complications with nasal
surgery
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Sinusitis
Postoperative nursing management
Patient education
Monitor for bleeding
Dressing care
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Figure 34.5 CT registered with
probe for sinus surgery.
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Loss of Smell
2 million Americans have smell and taste
disorders
About 200,000 visit a doctor each year
Causes include: nasal congestion, a cold,
obstruction, neurological disorder
May be idiopathic without any
identifiable cause
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Causes for Loss of Smell
Temporary anosmia is common with colds
and nasal allergies
Following a viral illness
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Causes for Loss of Smell
Disorders preventing air from reaching
smell receptors:
Nasal polyps
Nasal septal deformities
Nasal tumors
Tumors of the head or brain
Head trauma
Endocrine and nutritional disorders
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Categories of Smell Dysfunction
Anosmia: a complete loss of smell
Hyposmia: a partial loss of smell
Hyperosmia: enhanced smell sensitivity
Dysosmia: distortion in odor perception
Includes parosmia (distorted sense of smell)
and phantosmia
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Categories of Smell Dysfunction
Parosmia: distortion of perception of
external stimulus
Phantosmia: smell perception with no
external stimulus.
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Determine the Cause of Anosmia
Complete head and neck examination
Focus on the nose to determine whether it is a
conductive or sensorineural loss
Endoscope is used to provide reliable
observations
Chemosensory testing (sniffing sticks) and a
neuroradiologic (CT, MRI-to detect problems
with olfactory nerve) evaluation also are used
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Treatment of Anosmia
Antihistamines (if the condition is related
to allergy)
Surgical correction of physical blockages
Changes in medication
If permanent, dietary counseling may
include use of highly seasoned foods and
stimulation of taste sensations that remain
Caution should be taken to ensure safety
around the home
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MUCORMYSIS
Rare often fatal disease caused by fungi
Opportunistic infection
immunocompromised
Develops in patients receiving iron
chelating drug called Desferal as
treatment for actue iron poisioning
Can develop in nasal areas, the lungs and
brain
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Disorders Affecting Taste
Hairy tongue is a condition in which the
tongue is covered with hairlike papilla due
to the overgrowth of the fungus Candida
albicans or Aspergillus niger
Result of antibiotic therapy that inhibits the
growth of normal flora in the mouth
Dental caries are the result of the
destruction of tooth enamel caused by
dental plaque
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Treatment
Good dental hygiene
Antibiotics for bacteria
Mouth rinse
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Causes of Airway Obstruction
Foreign object
Allergy
Lesions
Stenosis
Swelling
Viral and bacterial infections
Fire or inhalation burns
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Causes of Airway Obstruction
Allergic responses to foods, medications,
or bee stings
Infections after dental extraction that have
a large amount of swelling
Laryngeal trauma
Aspiration of food material
Large boluses as well as small pieces of
food, such as peanuts
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Epiglottitis
Life-threatening bacterial illness that may
lead to airway obstruction
Epiglottis is a flap of tissue and cartilage
that covers the opening of the trachea
during swallowing
Seen more frequently in children, but
occurs in adults
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Epiglottitis
Cause of the infection usually is
Haemophilus influenzae group B
Symptoms: cherry red epiglottis, drooling,
inspiratory stridor, dyspnea, and high fever
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Nursing Management of Epiglottittis
Initial treatment focuses on maintaining a
patent airway
Conservative measures of oxygen,
humidification, and inhaled respiratory
therapy
Administer Corticosteroids to reduce
edema
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Nursing Management of Epiglottittis
Administer antibiotics as prescribed to
thwart the infection
IV fluids are given for hydration
Prepare for tracheotomy or endotracheal
tube if the airway is in immediate jeopardy
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Endotracheal (ET) Tube Intubation
May cause laryngeal trauma
Placement of an ET tube may induce
laryngeal swelling, which is a cause of
upper airway obstruction after extubation
Acute complications: perforation or
laceration of the trachea or esophagus,
bleeding, and arytenoid (cartilage that
form larynx) dislocation
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Nursing Management
Ensure the endotracheal tube remains
properly positioned and secured in place
Unnecessary movement of the tube can
irritate and inflame the laryngeal tissue
Maintain sedation of the patient as ordered
if the patient is restless
Prepare to set up for a tracheostomy tube
if intubation is anticipated to be necessary
for longer than 7 to 14 days
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Clinical Manifestations of
Airway Obstruction
Stridor (partial obstruction)
Unable to speak (complete obstruction)
Labored respirations and use of accessory
muscles
Air hunger (mild obstruction) vs. cyanosis
(complete obstruction)
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Clinical Manifestations of
Airway Obstruction
Confusion and unconsciousness indicate a
progression in the severity of the
obstruction
If not treated, a partial obstruction can lead
to a complete obstruction, rapid
suffocation, and death
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Nursing Management of
Airway Obstruction
The initial assessment of objective and
subjective data includes:
Presence of spontaneous breathing
Rate, depth, and effort of respirations
Presence of grunting or wheezing
Use of accessory muscles of respiration

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Nursing Management of
Airway Obstruction
The initial assessment of objective and
subjective data includes:
Symmetry of chest expansion (determined
through palpation) vital signs
Oxygen saturation level
Quality of the voice
Stridor or any type of noisy breathing
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Other Nurse Assessment
Monitor the patients orientation,
mentation, and general demeanor
Assess the patients ability to handle oral
secretions
Pain with speaking or swallowing
Assess for frequent drooling or productive
coughing to clear the airway
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Planning Care for the Patient with
Upper Airway Obstruction
A patient with complete airway obstruction
appears very anxious, agitated, and
apprehensive, and progresses quickly to
cyanosis and respiratory arrest
There is no cough and the patient will be
cyanotic and unable to speak
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Planning Care for the Patient with
Upper Airway Obstruction
If the patient is unable to speak, a
Heimlich maneuver should be performed
in case the obstruction is from a foreign
object or food
Anticipation is the key to saving patients
with a complete airway obstruction
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Planning Care for the Patient with
Upper Airway Obstruction
Supplies should be kept at the bedside for
creating an immediate artificial airway
Resuscitation equipment should be
brought to the bedside in case there is a
subsequent cardiac arrest
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Head and Neck Cancer
More uncommon cancers; may not
present until patient has a large tumor
burden
If detected early; head and neck cancer is
treatable and curable
If not treated; very disfiguring, alters
normal functions
Challenges for patient and family
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Head and Neck Cancer
Ablative surgery may leave patient with
facial disfigurement, functional impairment
Decisions regarding treatment must be
informed decisions that include:
Outcome without treatment
Implications, risks, and benefits of surgery
and radiation therapy
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Etiology
A variety of risk factors are associated with
head and neck cancer
Some patients do not have any of the
known risk factors
Not possible to know for sure how much
they contributed to causing the cancer
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Risk Factors for Oral and
Oropharyngeal Cancer
Alcohol: six times more likely to develop
these cancers
Alcohol and smoking combined significantly
increase risk over nonsmoking drinkers
Ultraviolet light: >30% of lip cancers
associated with prolonged exposure to
sunlight
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Risk Factors for Oral and
Oropharyngeal Cancer
Tobacco: Approx. 90% of people with oral
cavity and oropharyngeal cancer use
tobacco
Risk increases with amount smoked / chewed
and duration
Smokers six times more likely than
nonsmokers to develop these cancers
Tobacco smoke from cigarettes, cigars, pipes
all implicated
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Risk Factors for Oral and
Oropharyngeal Cancer
Tobacco: Approx. 90% of people with oral
cavity and oropharyngeal cancer use
tobacco
Can cause cancers anywhere in the oral
cavity or oropharynx, and larynx
Pipe smoking: significant risk for cancers
where lips contact the pipe stem
Smokeless tobacco increases risk by about
50 times
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Risk Factors for Oral and
Oropharyngeal Cancer
Tobacco: Approx. 90% of people with oral
cavity and oropharyngeal cancer use
tobacco
Associated with cancers of the cheek, gums,
and inner surface of the lips
Exposure to secondhand smoke (called
passive smoking) also a risk factor
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Risk Factors for Oral and
Oropharyngeal Cancer
Irritation: Long-term irritation to the lining
of the mouth from poorly fitting dentures
Poor nutrition: A diet low in fruits and
vegetables increases risk
Human papillomavirus infection: HPV
infection may contribute to around 20% of
cases
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Risk Factors for Oral and
Oropharyngeal Cancer
Immune system suppression:
Immunosuppressive drugs may increase
the risk
Gender: Twice as common in men as in
women
Ethnicity: Asian heritage, first generation
immigrant, are associated with
nasopharyngeal cancer from the Epstein-
Barr virus
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Medical Surgical Nursing: Preparation for Practice
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Nursing Management for Patients
with Head and Neck Cancer
Priorities are airway maintenance, pain
management, and nutrition
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Nursing Management for Patients
with Head and Neck Cancer
If surgery, special needs and
consideration:
Wound management
Drain assessment and care
Oral care
Wound complications
Carotid artery exposure assessment and
management

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Medical Surgical Nursing: Preparation for Practice
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Airway Management Assessment
Airway is the first priority
Outcome is to maintain a patent airway and normal
gas exchange
Ongoing assessment: SOB, stridor, blood-tinged
sputum, and infection
Monitor increased WOB, use of accessory muscles
Assess for increased heart rate and decreased O
2

saturation levels
Assess the type of airway that is being used

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Medical Surgical Nursing: Preparation for Practice
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Nurse Interventions
Secure airway with the appropriate ties
Prevents the possibility of the tube being
dislodged or accidentally removed
Change ties daily or when soiled to
decrease the possibility of infection
Clean the tracheostomy site regularly, e.g.
every 8 hours
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Nurse Interventions
Clean more frequently p.r.n. to remove
secretions that could obstruct the airway
For tracheostomy tube with inner cannula,
change if disposable or clean at every tie
tracheostomy care
Frequent assessment of secretions is
essential to patient safety
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Nurse Intervention for
Artificial Airway
Humidification to the airway is necessary
Bag/suction in early postop period if
patient is unable to clear own secretions
Patients may require mechanical
ventilation in early postop period
Monitor pulse oximetry, ABGs, respiratory
rate and effort
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Nurse Intervention for
Artificial Airway
Deflate cuff when the patient is off positive
pressure ventilation
Turn, cough, and deep breathe
Perform respiratory treatments with
bronchodilators, and chest physiotherapy

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Nurse Intervention for
Artificial Airway
Early mobilization and ambulation greatly
improve respiratory status
Stimulate coughing
Encouraging greater lung expansion
Recruiting lung fields
Mobilizing secretions
Early ambulation also benefits circulation
and increasing muscle strength
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Laryngectomy Stoma Care
Permanent change in their airway
Breathe only from their stoma
Clean stoma at least every 8 hours, p.r.n.
to prevent buildup of secretions, scarring
Position patients head so as not to
occlude the airway
Humidification after discharge until the
airway becomes used to room air
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Nurse Management of Pain
Greatest fears for any patient undergoing
cancer surgery is the fear of pain
High nursing priority to alleviate pain and
anxiety related to pain
Careful and exact assessment of the type
and location of the pain
Have the patient set a goal pain level,
using a pain rating scale
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Nurse Management of Pain
Use the pain scale to evaluate
effectiveness
Note clues for patients who are unable to
communicate
Teach the patient not to wait until the pain
is unbearable to request pain medication
Early, immediate, frequent intervention for
pain relief in immediate postop period
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Nurse Management of Pain
Increase the dosage as the patients
respiratory status tolerates it
Consider patient-controlled analgesia
(PCA) for alert cooperative patients
Transition to oral meds as patient is able
to swallow safely and in sufficient quantity
to sustain nutrition and medication
Treat joint pain with mobility, ambulation,
turning, as early as postop day 1
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Nutrition Management
Present with inadequate nutrition caused
by the tumor burden, cancer cachexia, or
the mechanical difficulty of eating because
of tumor impingement into the
aerodigestive tract
Early recognition of nutritional inadequacy
and early intervention is critical
Positive nitrogen balance, adequate
calories and protein needed for healing
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Nutrition Management
The best test is serum prealbumin,
transthyretin, or thyroxin-binding
prealbumin (TBPA)
Nutritionist in the multidisciplinary team is
mandatory
Nutritional goal for caloric intake in the
postop period roughly 35 kcal/kg
With artificial airway, extra water loss
through expiration, suctioning
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Nutrition Management
Carefully calculate replacement
requirements to ensure proper hydration
Feeding method depends on patients
level of consciousness and ability to
swallow
Route may be oral, nasogastric,
gastrostomy, jejunostomy
Nutrition replacement must begin early
and continue throughout the therapy
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Nutrition Management
Most feeding can begin on postop day 1
Advance to goals as quickly as tolerated
Dysphagia is a common issue; tumor
burden, invasion of the aerodigestive tract,
pain
Aspiration is a significant concern with
patients who are unable to maintain their
airway protection
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Medical Surgical Nursing
Preparation for Practice
CHAPTER
Caring for the Patient
with Lower Airway Disorders
35
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Restrictive vs. Obstructive
Lung Diseases
Restrictive lung diseases (interstitial lung
diseases)
Result in reduced lung volumes
Alteration in lung parenchyma (alveolar tissue w/
terminal bronchioles, respiratory bronchioles,
alveolar ducts)
Disease of pleura, chest wall or neuromuscular
apparatus
Characterized by reduced total lung capacity, vital
capacity, or resting lung volume
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Restrictive vs. Obstructive
Lung Diseases
Obstructive lung diseases A group of
disorders
Common characteristic chronic and
recurring blockage of airways
Limit airflow through the airways and out of
the lungs
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Restrictive (Interstitial)
Lung Diseases
Divided into two groups based on
anatomic structures:
Intrinsic lung diseases
Extrinsic lung diseases
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Intrinsic Lung Diseases
Diseases of the lung parenchyma
Cause inflammation or scarring of lung
tissue or result in filling of the air spaces
with exudate and debris
Characterized according to etiologic
factors
Exposure to dust, metals, or organic solvents
and agricultural employment increase risk
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Extrinsic Lung Diseases
Extraparenchymal diseases diseases of:
Chest wall
Pleura
Respiratory muscles
Result in:
Lung restriction
Impaired ventilatory function
Respiratory failure
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Extrinsic Lung Diseases
Extrinsic disorders of pleura and thoracic
cage
Total compliance by the respiratory system is
reduced
Lung volumes are reduced
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Restrictive (Interstital)
Lung Diseases
Clinical Manifestations of Intrinsic Lung
Disease
Onset can be acute or insidious (subtle
gradual)
Progressive exertional dyspnea
Hemoptysis
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Restrictive (Interstital)
Lung Diseases
Clinical Manifestations of
Extrinsic Lung Disease
Onset dyspnea, decreased exercise
tolerance, and respiratory infections
Dyspnea upon exertion, followed by dyspnea
at rest, ultimately advancing to respiratory
failure
Recurrent lower respiratory tract infections
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Restrictive (Interstital)
Lung Diseases
Diagnostic Tests
Generally no positive findings revealed in
intrinsic lung diseases
Chest radiography and CT to diagnose intrinsic
disorders
Anemia vasculitis
Poycythemia (high RBC count) - hypoxia

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Restrictive (Interstital)
Lung Diseases
Extrinsic disorders elevated creatinine
kinase (CK) may indicate myositis
(enflammation of muscle)
Fluoroscopy to diagnose extrinsic disorders
PFT and tests for extrinsic lung disorders:
Bronchoalveolar lavage, lung biopsy, surgical lung
biopsy
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Acute Bronchitis
Etiology
Most prevalent in children and older adults
Incidence is highest in the winter
High Risk
People with allergies, other respiratory illnesses
Chronic obstructive pulmonary disease (COPD),
chronic sinusitis, chronic tonsillitis, infected
adenoids
Smokers are at a higher risk
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Acute Bronchitis
Pathophysiology
Inflammation of the lower bronchial mucous membranes
Commonly follows a respiratory viral illness
Causative agents: viruses, bacteria, yeast, fungi,
noninfectious triggers
Most often the cause is viral; adenovirus, influenza virus,
and RSV
Common bacterial causes
Streptococcus pneumoniae, Haemophilus influenzae, and
Bordetella pertussis
Other causes: pollutants, such as ammonia and tobacco

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Acute Bronchitis
Clinical Manifestations
Fever, cough, chills, and malaise
Mimic pneumonia, but exam and chest
x-ray often are normal
Cough:
Typically gets steadily worse for 10 to 12 days
More profound at night
Becomes increasing loose over time
Most patients have a cough for less than 2 weeks
Shortness of breath and wheezing
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Acute Bronchitis
Assessment
Assessment findings reveal a cough
Viral bronchitis nonproductive cough
Bacterial bronchitis productive cough, fever,
pain behind the sternum aggravated by
coughing
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Acute Bronchitis
Nursing Diagnoses
Priority nursing diagnoses for the patient with
bacterial bronchitis include:
Ineffective airway clearance
Impaired gas exchange
Activity Intolerance
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Acute Bronchitis
Outcomes
Relief of the clinical manifestations
Return to the previous level of functioning
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Acute Bronchitis
Interventions and Rationales
Assist patients with prescribed therapies
Use of antitussives, analgesics, and
bronchodilator medications
Encourage fluids
Teach patients to cough effectively and avoid
infections
Offer mild analgesics for discomfort
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Medical Surgical Nursing: Preparation for Practice
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Acute Bronchitis
Interventions and Rationales
Offer patients deep breathing exercises,
incentive spirometer
Anticholinergics, antibiotic therapy (when
indicated), IV corticosteroids or
methylxanthines
Antibiotics not shown to be effective except in
patients with COPD
Beta-2 agonists (brochodilators)
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Acute Bronchitis
Prevention/Evaluation
Relief of the respiratory symptoms including
cough, wheezing, and shortness of breath
Teach prevention and avoidance of risk
factors
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Influenza
A contagious disease caused by the
influenza virus
10% to 20% of people in US get influenza
yearly
An average of 36,000 deaths per year
from influenza in US
People ages 65+, people with chronic
medical conditions more likely to have
complications from the flu
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Influenza
Etiology
Epidemics occur from December April in the
Northern Hemisphere
Yearly epidemics of influenza begin abruptly
and last 5 to 6 weeks
Influenza A and B are the viruses that cause
epidemic human disease
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Influenza
Etiology
Pandemics occur when a new virus emerges
for which there is no immunity
Influenza virus type C has not been classified
and usually does not induce illness
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Influenza
Pathophysiology
Transmission by small-particle aerosols
droplets from coughs, sneezes
Viruses deposited in the lower respiratory
tract
Attach to and infect epithelial cells
Contact with respiratory droplets, then
touches own mouth or nose
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Influenza
Clinical Manifestations
Fever, chills, headache, fatigue, dry,
nonproductive cough, sore throat, nasal
congestion, and myalgia
Cough may be associated with chest pain
Fever usually persists for 3-4 days, up to 1
week
Common complication is pneumonia, which
may be primary influenza
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Influenza
Nursing Management
Primary care goals: relieving symptoms,
preventing secondary infection
Rest, plenty of fluids, avoid alcohol and
tobacco, take mild pain relievers
Work with health care provider to ensure
medications taken appropriately
Antiviral drugs approved for prevention,
treatment
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Influenza
Prevention
Flu Vaccine
Avoid contact with others who have the flu
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Inflammatory process resulting in edema
of the parenchymal lung tissue
Extravasation of fluid into the alveoli
causing hypoxemia
Primarily affects terminal gas-exchanging
portions of the lung
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Etiology
Acute inflammation of lung tissue
Caused by bacteria, viruses, fungi, protozoa, parasites
Inhaled into lungs or transported via the bloodstream
Classified by causal agent, distribution, setting (hospital -
HAP or community - CAP)
Causative microorganism influences S&S, treatment,
prognosis
CAP typically caused by different microorganisms than HAP

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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Pathophysiology
Damage to bronchial membranes causes
buildup of infectious debris, exudates
Results in dyspnea, ventilation/perfusion
(V/Q) mismatching, and hypoxemia
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Pathophysiology
CAP: begins outside hospital or is diagnosed
w/in 48 hours after admission
Patient did not reside in a long-term facility prior to
admission
Incidence of CAP is highest in winter months
Smoking an important risk factor
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Pathophysiology
HAP: occurs > 48 hours after hospital
admission
HAP has a mortality rate of 20% to 50%
90% of HAP infections are bacterial
Compromised immune systems, chronic lung
disease, intubation and mechanical ventilation
increase risk
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Clinical Manifestations
Fever, chills
Increased respiratory rates
Rusty bloody sputum
Crackles
X-ray abnormalities
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Clinical Manifestations
Nonrespiratory symptoms
Headache
Abdominal pain
Nausea and vomiting
Diarrhea
Muscle aches
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Nursing Management
Administer antibiotics (prime treatment)
Primary nursing intervention: Maintain airway
and O
2
saturation above 93%
Common Nursing Diagnosis Readiness for
Enhanced Comfort
Promote nutrition and hydration
Provide small, frequent, high-carb, high-
protein meals
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Nursing Management
Monitor fluid intake closely
Provide oral hygiene before and after meals
Promote comfort
Monitor for chest pain, note character and
location
Elevate head of bed 45 to 90 degrees
Offer mild analgesics
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Discharge Priorities/Prevention
Teach patient about
Importance of rest, gradual increase in activity to
avoid fatigue
Maintain resistance with proper nutrition, adequate
fluid intake
Avoid chilling and exposure to others with URI,
viral infections
Medications that will be continued at home
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
Discharge Priorities/Prevention
Teach patient about
Continue deep breathing and coughing exercises
4x/day, 6-8 weeks
Signs and symptoms to report to health care
provider
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Etiology
Mycobacterium tuberculosis is nonmotile,
nonsporulating
Transmitted via aerosolization (i.e., an
airborne route)
Affects people with repeated close contact
with an infected but undiagnosed person
TB an opportunistic infections common with
HIV/AIDS
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Etiology
Continuous assessment and intervention to
prevent the spread of TB
The newest form of TB is multidrug-resistant
tuberculosis (MDRTB)
Resistant TB is difficult and costly to treat and
can be fatal
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Pathophysiology
Highly communicable disease transmitted via
aerosolization
Droplets spread when infected person laughs,
sneezes, or sings
Droplets may be inhaled by others
Tubercle finds a suitable site (bronchi or
alveoli), multiplies freely
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Pathophysiology
An exudative response occurs, causing a
nonspecific pneumonitis
Mediated or type IV immunity develops 2-10
weeks after infection
Manifested by a significant reaction to a
tuberculin test
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Clinical Manifestations
Dyspnea
Weight loss
Cough
Sputum production
Sleep disturbances
Symptoms present when the disease is well
advanced
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Clinical Manifestations
Lethargy, exhaustive fatigue, activity
intolerance, nausea, irregular menses
Low-grade fever may have occurred for
weeks or months
Fever also may be accompanied by night
sweats
Patient finally notes cough, production of
sputum, occasionally streaked with blood
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Clinical Manifestations
A dull aching chest pain may accompany the
cough
Dullness with percussion over involved
parenchymal areas
Bronchial breath sounds, increased
transmission of spoken or whispered sounds
Wheezing related to obstruction may also be
heard
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Laboratory and Diagnostic Procedures
Tuberculin skin test
Chest x-ray
Acid-fast bacillus smear
Sputum culture
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Nursing Management
Administer drug therapy as ordered by health care provider
Report the diagnosis to the local health department
Keep patient in negative pressure room with respiratory
airborne isolation
Maintain isolation until three consecutive sputum cultures
have tested negative
Focus on preventing the spread of the infection
Discuss pain management, handling fatigue, importance of
good nutrition

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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
Health Promotion and Prevention
The main focus of TB management is
preventing spread of the infection
Patient typically must take drugs for 9 months
Test and treat all persons in close contact
with the infected individual
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
Etiology:
The incidence of lung abscess is not well
known, as it rarely occurs in isolation. Most
often such an abscess is secondary to
anaerobic and aerobic organisms that
colonize the upper respiratory tract.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
Etiology:
Patients presenting with this problem often
have a history of pneumonia, possibly
complicated by aspiration of oropharyngeal
contents. Formation of multiple abscesses
and cavities occurs commonly in patients with
TB or fungal infections of the lung.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
Clinical Manifestations
Clinical manifestations are often insidious,
although often more acute after pneumonia.
Typically they include spiking temperature
with rigors and night sweats; cough with foul
sputum; pleuritic chest pain; tachycardia;
dullness on percussion over the abcessed
area. Oxygen saturation may decrease with
larger abcesses
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
Laboratory and Diagnostic Procedures
CT scan
Pleural fluid and blood cultures may be
obtained (thoracentesis)
Bronchoscopy
Transtracheal aspiration via suction
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
Nursing Interventions
Assess the patient for adequate cough
Administer IV antibiotic therapy if ordered
Penicillin G or clindamycin is the
pharmacologic therapy of choice
Assess for recent history of influenza,
pneumonia, febrile illness, cough, and sputum
production
Auscultate breath sounds
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
Nursing Interventions
Manage patients clinical manifestations
Monitor oxygen levels ongoing
Assess the work of breathing, respiratory and
heart rate
Administer antipyretic, antibiotic, and pain
medications
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
Nursing Interventions
Follow-up assessment of effectiveness
Space physical care to allow for periods of
rest between activities
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
Outcomes/Prevention
Relief of clinical manifestations
Return to the previous level of function
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive
Pulmonary Disease
Refers to a group of respiratory disorders
Characterized by chronic, recurrent
obstruction in pulmonary airways
Encompasses chronic bronchitis and
emphysema
Obstruction is generally permanent and
progressive
Chronic bronchitis defined in clinical terms
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive
Pulmonary Disease
Emphysema defined in terms of anatomic
pathology
Chronic bronchitis and emphysema
typically coexist
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive
Pulmonary Disease
Unifying symptoms
Dyspnea
Wheezing
Use of accessory muscles
Ventilation/perfusion (V/Q) mismatching
Decreased forced expiratory volume
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive
Pulmonary Disease
Emphysema: abnormal, permanent
enlargement of the air spaces distal to the
terminal bronchioles, accompanied by
destruction of their walls and without
obvious fibrosis
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive
Pulmonary Disease
Chronic bronchitis: characterized by
hypersecretion of mucus and chronic
productive cough that continues at least 3
months of the year for at least two
consecutive years
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Etiology
The primary cause of COPD is exposure
to tobacco smoke. Clinically significant
COPD develops in 15% of cigarette
smokers. Age of initiation, total pack-
years, and current smoking status predict
COPD mortality
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology of
Chronic Bronchitis
Inflammatory changes in the bronchial
walls
Causes them to thicken and impinge on
the airway lumen
Diffuse airway obstruction occurs
Initially affects only larger bronchi;
eventually involves all airways
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology of
Chronic Bronchitis
Obstructed airways are likely to close on
expiration
Traps air in the distal portions of the lung,
causing:
Hypoventilation (increased PaCO
2
)
Ventilation/perfusion mismatching
Hypoxemia
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology of
Chronic Bronchitis
Characterized by an increase in mucus
production
Mucus is thicker and more tenacious than
normal
Bacteria become embedded in the airway
secretions and reproduce
Ciliary function is impaired
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology of
Chronic Bronchitis
Edema and accumulation of inflammatory
cells lead to bronchial wall inflammation
and thickening
Airway enlargement, loss of elastic recoil
in the alveoli trap air, limit outflow
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathyphysiology of Emphysema
Enzymes called proteases break down
elastin, cause alveolar destruction
Result is collapse or narrowing of the
small airways
Eliminates portions of the capillary bed
necessary for gas exchange
Airway enlargement, loss of elastic recoil
combine to trap stagnant air
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathyphysiology of Emphysema
Airway resistance is increased due to
compromised alveolar walls
Bullae and blebs (thin walled balloon-like
extensions or air sacs) develop due to
hyperinflation of alveoli
inflammatory hyperactivity can lead to
additional airway narrowing
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of
COPD Patient
Assess for dyspnea, muscle fatigue, work
of breathing, worsening symptoms
Monitor ABG results
Assist patient to manage the anxiety that
often occurs

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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of
COPD Patient
A major role of the nurse is patient and
family education
Breathing retraining
Use of postural drainage techniques
Energy conservation
Physical reconditioning
Single most important factor in preventing
COPD smoking cessation
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Asthma
A chronic hyperreactive disorder of the
airways (bronchioles)
Episodic reversible airflow obstruction and
airway inflammation
Inflammatory process causes recurrent
episodes of wheezing, breathlessness,
chest tightness, and coughing, particularly
at night or in the early morning
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Asthma
Caused by a complex interaction of
genetic and environmental factors
Airflow obstruction can be caused by a
variety of changes, including:
Acute bronchoconstriction
Airway edema
Chronic mucous plug formation
Airway remodeling
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Manifestations
Persons with asthma exhibit a wide range
of signs and symptoms
Episodic wheezing, feelings of chest
tightness to acute immobilizing attacks
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of the
Patient with Asthma
A holistic approach to care through the
nursing process
Educate patient and family about
prevention of attacks
Thoroughly assess symptoms and history
of attacks
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of the
Patient with Asthma
Assesses patients respiratory status by
monitoring:
Severity of symptoms
Breath sounds
Peak flow meter
Pulse oximetry
Vital signs
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of the
Patient with Asthma
Administer medication
Educate public on symptoms and dangers
of asthma
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Etiology and Pathophysiology -
Cystic Fibrosis
A person is born with CF, and it affects boys more than girls
Affects Caucasians 5 times more often than African American
people
Typical features: mucous plugging, chronic inflammation,
infection
Peripheral bullae or blebs may develop due to obstruction,
airway wall weakening
Affects mucous glands of the lungs, liver, pancreas, and
intestines
Causes progressive disability due to multiple-system failure

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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Manifestations of CF
Acute exacerbation characterized by:
Increasing breathlessness
Change in sputum volume, color, and
viscosity
Tiredness
Loss of appetite
Weight loss
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Manifestations of CF
Include barrel chest and digital clubbing
GI: malabsorptive symptoms e.g. frequent
loose and oily stools, cramping
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Manifestations of CF
Signs and symptoms of diabetes including
abnormal glucose tolerance, polydipsia,
polyuria, and polyphagia
Subtle manifestations: chronic sinusitis,
nasal polyps, rectal prolapse
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of CF
Assist patient to maintain adequate airway
clearance, reduce risk factors, perform
ADLs
Prevent complications
Involve patient/family in planning and
implementing the therapeutic regimen
Obtain objective and subjective data from
the patient and family
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of CF
Encourage use of corticosteroids,
bronchodilators, and antibiotics
Functional health patterns
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of CF
Assessment of general impressions
Mood, anxiety, depression, restlessness,
failure to thrive
Cyanosis of skin and nail beds
Persistent runny nose, diminished breath
sounds, sputum characteristics
Tachycardia
Protuberant abdomen, abdominal distention,
foul and fatty stools
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of CF
Possibly abnormal ABGs and PFTs;
abnormal sweat chloride test, chest x-ray,
and fecal fat analysis
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Diagnoses
Ineffective airway clearance related to thick and
abundant mucus, weakness, fatigue
Ineffective breathing pattern related to
bronchoconstriction, anxiety, and airway obstruction
Impaired gas exchange related to lung infections
Imbalanced nutrition related to dietary intolerances,
intestinal gas, and altered pancreatic enzyme
production

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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Goals
Focus on the patient having adequate airway clearance
Reduced risk factors associated with respiratory infections
Assist clients to perform ADLs, stay free of complications,
actively participate in planning and implementing a restorative
regimeAssist patients in gaining and maintaining
independence by assuming responsibility for their own care.
Active interventions include relief of bronchoconstriction,
airway obstruction, and airflow limitation
Encourage frequent hand washing, especially after coughing


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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Goals
Frequent mouth care, especially after
chest physical therapy regime
Avoid exposure to persons who are ill
especially with Upper Respiratory
Infections
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pulmonary Embolism
Thrombus breaks loose and blocks a
branch of the pulmonary artery
Produces widespread pulmonary
vasoconstriction
Predominantly a disease of older
individuals
Highest incidence of recognized PE
occurs in hospitalized patients
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Pulmonary Embolism
Pulmonary embolism is a complication of a
DVT
Most common risk factors for PE are:
Prior history of DVT or PE
Recent surgery or pregnancy
Prolonged immobilization
Underlying malignancy
Risks also include situations of venous
stasis or increased hypercoagulability
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Pathophysiology and
Clinical Manifestations of PE
A pulmonary occlusion occurs when a
bloodborne substance occludes a branch
of the pulmonary artery and obstructs
blood flow
Hemoptysis, dyspnea, and chest pain
Pleuritic chest pain, chest wall tenderness,
a pulmonary friction rub, or hypotension
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Pathophysiology and
Clinical Manifestations of PE
Tachypnea, crackles, an accentuated
second heart sound, tachycardia, fever,
diaphoresis, S
3
or S
4
gallop,
thrombophlebitis, lower extremity edema,
cardiac murmur, and cyanosis
Massive PEs typically present with sudden
crushing substernal chest pain, shock, and
loss of consciousness
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Medical Surgical Nursing: Preparation for Practice
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Nursing Management of PE
The nursing process guides the nursing
care for patients with a PE
Evaluation of risk factors on admission
and throughout the patients hospital stay
Initially clients may be on bed rest
Nurses should encourage maximal
mobility, including range of motion and
walking where appropriate while also
staying alert to symptoms of DVT
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Nursing Management of PE
Nursing diagnoses: ineffective tissue
perfusion and impaired gas exchange
Assist the patient to maintain the
therapeutic regime during the acute period
Anticoagulant medication should be given
at the same time each day
Monitor liver function when patients receive
anticoagulants
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of PE
Monitor hemoglobin, hematocrit, platelet,
and the international normalized ratio
(INR) levels, and other clotting studies as
needed to assess the effectiveness of
anticoagulants
Assess for symptoms of bleeding and
heparin-induced thrombocytopenia (HIT)

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Nursing Management of PE
Discharge priorities include educating the
patient and family about risk factors and
treatment regimes
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Cor Pulmonale
Alteration in the structure and function of
the right ventricle
Caused by a primary disorder of the
respiratory system
Chronic lung disease
Pulmonary embolism
Interstitial lung disease
Primary pulmonary hypertension
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Cor Pulmonale
Pathophysiological mechanisms lead to Primary
Pulmonary Hypertension and consequently, cor
pulmonale
Pulmonary vasoconstriction due to alveolar hypoxia
Anatomic compromise of the pulmonary vascular
bed
Increased blood viscosity secondary to blood
disorders
Idiopathic primary pulmonary hypertension
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Two Forms of Cor Pulmonale
Acute: usually results from massive PE or
injury d/t mechanical ventilation for ARDS
Chronic cor pulmonale usually caused by
COPD
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Laboratory and
Diagnostic Procedures
Echocardiography gives information about
the size of the heart
Chest x-rays and CAT scan
PFT evaluate ventilation/perfusion
mismatch
ABG tests identify gas exchange,
presence of acidosis and alkalosis
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Medical Surgical Nursing: Preparation for Practice
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Clinical Manifestations
Asymptomatic initially
Later, as right ventricular (RV) pressures
increase, physical signs commonly
include:
Left parasternal systolic lift (visible pulsations
to left midsternal)
Loud pulmonic component of the second
heart sound (S
2
)
Murmurs of functional tricuspid and pulmonic
insufficiency

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Clinical Manifestations
Later, as right ventricular (RV) pressures
increase, physical signs commonly
include:
Later, an RV gallop rhythm (third [S
3
] and
fourth [S
4
] heart sounds)
Distended jugular veins, hepatomegaly
Lower extremity edema
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Clinical Manifestations
Later, as right ventricular (RV) pressures
increase, physical signs commonly
include:
Patient may complain of fatigue, dyspnea or
chest pain on exertion, cough
In advanced stages, hepatic congestion leads
to anorexia, RUQ abdominal discomfort
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Nursing Management
Physical assessment findings:
Increased chest diameter
Labored respirations with retractions of the
chest wall and use of accessory muscles
Hyperresonance to percussion
Diminished breath sounds
Wheezing, rarely
Cyanosis
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Nursing Management
Physical assessment findings:
Auscultation of the heart may reveal a split
second heart sound, a systolic ejection
murmur with a sharp ejection click over the
pulmonary artery, along with a diastolic
regurgitation
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Medical Surgical Nursing: Preparation for Practice
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The Primary Role of the Nurse
Manage dyspnea by administration of
oxygen
Administer medications to treat right
ventricular hypertrophy and pulmonary
hypertension
Provide patient education re: managing
equipment and medications
Refer to home health and pulmonary
rehabilitation
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The Primary Role of the Nurse
Regularly assess oxygen needs and
medications
Single most preventive measure
encourage smoking cessation
Avoid exposure to secondhand smoke and
respiratory pollutants
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LEARNING OBJECTIVE 4
Compare and contrast the etiology and
nursing management for patients with a
variety of chest trauma and thoracic
injuries.
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Medical Surgical Nursing: Preparation for Practice
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Chest Trauma and
Thoracic Injuries
16,000 deaths in the United States each
year
Cause of death in 25% of all trauma
patients
hand gun use has contributed to rise in
penetrating injuries
These injuries impair airway patency,
breathing, and circulation
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Rib Fractures
Most common blunt thoracic injury in
adults
Associated with other injuries such as flail
chest, pulmonary contusion, and
pneumothorax
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Etiology
Usually are caused by a direct blow to the
ribs
Sternal fractures are most common in
motor vehicle accidents
Forceful compression of the rib cage
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Nursing Management
Astute assessment for respiratory
complications
Diligent patient monitoring for dyspnea,
hypoxemia, and pain
Administer pain medication and assess for
pain relief
Auscultate lung fields regularly for
adventitious sounds
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Nursing Management
Provide written instructions regarding the
plan of care
Teach patient and family when to call
members of the health team
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Pneumothorax
Partial or complete collapse of the lung on
the affected side
Under normal circumstances the pleural
cavity is free of air
When air or gas enters the pleural space
pneumothorax results

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Spontaneous Pneumothorax
Occurs unexpectedly in healthy individuals
ages 20-40
More common in tall, thin men
Smoking also is a risk factor, due to
disease in the small airways
Caused by a ruptured, air-filled bleb or
blister on the lung surface
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Spontaneous Pneumothorax
Bleb rupture allows atmospheric air to
enter the pleural cavity
Results in a loss of negative pressure and
collapse of the lung
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Tension Pneumothorax
Rapidly developing complication of blunt
chest trauma
Occurs as a result of an air leak in the lung
or chest wall
Caused by blunt chest trauma
Parenchymal injury has failed to seal,
causes complete collapse of the lung
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Hemothorax
Common problem encountered following
blunt chest trauma
Blood loss of <2,000 mL into the thoracic
cavity
Absence of breath sounds over the lung
and dullness to percussion
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Clinical Manifestations
Pleuritic pain
Breathlessness
Respiratory distress
Breath sounds are unilaterally decreased
or absent
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Nursing Management
Assess pulmonary status quickly
The nurse focuses on relieving dyspnea
and supporting oxygenation
Mobilize health team to provide re-
expansion of the lung via a chest tube
Prepare for insertion of the chest tube
Monitor patency of chest tube
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Medical Surgical Nursing: Preparation for Practice
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Nursing Management
Provide the patient with written instructions
regarding the plan of care
Encourage patients/caregivers to call
health team for persistent problems
Explain risk of reoccurrence
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LUNG CANCER - Etiology
Prevention efforts target preventing
exposure to known risk factors, e.g.
smoking
Cellular genetic destruction results from
repeated exposure to carcinogens
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Etiology
Smoking accounts for 87% of all lung
cancer deaths
Other risk factors: occupational hazards,
air pollution, genetics, dietary factors,
advancing age, and race
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Pathophysiology
Four major histologic types of lung cancer
Small cell carcinoma (SCLC)
Squamous cell carcinoma
Adenocarcinoma
Large cell carcinoma
SCLC accounts for 15% of cases in US
SCLC disseminates widely by the time of
diagnosis, leads to a poor prognosis
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Pathophysiology
85% of all lung cancers are non-small cell
lung cancer (NSCLC)
NSCLCs all have unique patterns of
growth and clinical appearance
Squamous cell tumors malignancies tend to
be slow growing

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Pathophysiology
NSCLCs all have unique patterns of
growth and clinical appearance
Adenocarcinoma most common form of lung
cancer, most common type in nonsmokers
Progression is slow
Adenocarcinoma invades the lymphatic/blood
vessels early
Result is a worse prognosis compared to that for
SCLCs
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Pathophysiology
NSCLCs all have unique patterns of
growth and clinical appearance
Large cell lung cancer commonly located in
periphery of the lung
Often spreads to the subsegmental bronchi or
larger airways
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Clinical Manifestations
Cough
Dyspnea
Sputum production
Wheezing
Hemoptysis
Chest pain
Dysphagia
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Clinical Manifestations
Hoarseness
Fatigue
Weakness
Nausea
Disturbed sleep
Memory impairments
Anorexia
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Clinical Manifestations
Night sweats
Early diagnosis of lung cancer is difficult
Typically no symptoms until disease has
metastasized
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Nursing Management
Close postoperatice observation for
cardiac and pulmonary complications
Dyspnea is the most common
postoperative symptom
Effective pain management enables
participation in progressive mobilization
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Lung Transplant
Viable alternative for patients with
advanced pulmonary disease
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Lung Transplant
Indications:
AAT deficiency (Alpha-1 antitrypsin (AAT) deficiency is a condition in
which the body does not make enough of a protein that protects the lungs and liver
from damage.)
Bronchiectasis
Cystic fibrosis
Emphysema
Idiopathic pulmonary fibrosis
Interstitial lung disease
Pulmonary hypertension
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Lung Transplant
Persons >60 years of age not
recommended for single lung transplant
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Lung Transplant
The following do not qualify for lung
transplant:
Colonization with antibiotic-resistant
organisms
Noncompliance with medical regime
Inability to walk 600 feet
Diagnosis of a malignancy within 2 years
Renal or liver insufficiency
Positive for HIV
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Lung Transplant
Infection postoperatively is the leading
cause of morbidity and mortality
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Occupational Lung Disorders:
Pneumoconiosis
Long-term exposure to toxic dust and
particulates can lead to irreversible chronic
pulmonary disease
Most common causes: silica, asbestos,
and coal
Dust deposits are permanent
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Occupational Lung Disorders:
Pneumoconiosis
No definitive treatment for the pulmonary
fibrotic changes
Treatment is palliative
Focuses on preventing further exposure
and improving workplace safety
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Occupational Asthma
Exposure to particulate matter, workplace
chemicals, gases, cereal grains, or irritants
Causes inflammation and edema of any
portion of the respiratory tract
Results in bronchospasm, hypersecretion
of mucus, dyspnea, wheezing
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Occupational Asthma
Symptoms are dyspnea, wheezing, and
chest tightness
Difficult to recognize because symptoms
continue when away from the source of
exposure
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Coal Miner Pneumoconiosis
Known as black lung or coal miners lung
Caused by coal dust deposits in the lung
Disease affects about 4.5% of coal miners
Patients experience a restrictive disease in
which they cannot fully expand their lungs
as well as an obstructive disease from
secondary emphysema
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Asbestosis
Progressive lung disease
Caused by exposure to microscopic fibers
of asbestos
Results in diffuse interstitial fibrosis with
diaphragmatic calcification
Fibrous tissue eventually obliterates the
alveoli
Latency period 10-20 years between
exposure and symptoms
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Whose at Risk for Asbestosis?
Asbestos miners, millers
Those employed in building trades and
shipyards
Insulation workers, pipe fitters and
steamfitters
Sheet metal workers, welders
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Diagnosis and
Clinical Manifestations
PFT findings restrictive ventilatory
defect, restricted lung volume
Dyspnea and hypoxemia
Removal of the individual from exposure is
essential
Crackles of a dry quality can be
auscultated in 70% to 90% of patients
Clubbing also is present frequently
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Diagnosis and
Clinical Manifestations
Chronic cough and sputum production,
similar to acute bronchitis
Sputum is expectorated in large amounts
May contain black fluid, particularly with
smokers
Respiratory failure and cor pulmonale
result
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Nursing Management
Offer supportive care and education for
patient and caregiver
Address issues: dyspnea, fatigue, and
activity tolerance
Teach physical conditioning and breathing
exercises are helpful
Encourage liberal fluids intake
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Nursing Management
Administer bronchodilators,
glucocorticoids, and antibiotics
Address emotional issues such as
depression, anxiety, and anger
Educate patient prior to discharge about
all aspects of the treatment regime
Provide relevant contact numbers to the
patient and caregiver
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Medical Surgical Nursing
Preparation for Practice
CHAPTER
Caring for the Patient
with Complex
Respiratory Disorders
36
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Complex Respiratory Disorders
Lead to alteration of oxygen perfusion
Caused by problems elsewhere in the
body
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Goals of Treatment
Medical Management
Correct and treat hypoxemia
Discover and correct primary organ system
failure
Nursing Management
Manage the airway
Manage oxygen for perfusion

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The Alveolar-Capillary (A-C)
Membrane
Central component of gas exchange in
lungs
Oxygen diffuses from alveoli into
pulmonary capillaries
Attaches to the hemoglobin in the red blood
cells
Carbon dioxide moves in the opposite
direction, into the lungs
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The Alveolar-Capillary (A-C)
Membrane
Figure 36.2 Alveolar-capillary membrane
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Ventilation/Perfusion
Ventilation (V) movement of air
Perfusion (Q) the movement of blood
carrying oxygen
Near equal relationship of ventilation
(4L/min) and perfusion (5L/min)
Acute Respiratory Failure commonly
caused by mismatch of ventilation and
perfusion
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Figure 36.4 Ventilation/perfusion relationships: (A) normal
unit; (B) dead space unit; (C) shunt unit; (D) silent unit.
(a) V/Q is equal to 0.8
no miss match
(b) V/Q is >0.8 there
is ventilation but no
perfusion
(c) V/Q is <0.8 there
is perfusion but
little or no
ventilation
(d) V/Q no perfusion
and no ventilation
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Acute Respiratory Failure
Defined as a failure of gas exchange
Respiratory system unable to provide O
2

and remove CO
2
Results in failure of oxygenation, failure of
ventilation, or both
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Classification of Acute
Respiratory Failure (ARF)
Hypoxemia (deprived of oxygen)
Caused by failure of oxygenation
Hypercapnea (high CO2 in blood)
Caused by failure of respiratory system to
ventilate
Failure of respiratory centers in the brain
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Classification of ARF
Hypoxemia:
PaO
2
below normal (<60 mmHg)
SaO
2
<90% on room air
Hypercapnea:
PaCO
2
above normal (>50 mmHg)
pH <7.3
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Pathophysiology
Hypoventilation
Shunting
Ventilation/perfusion mismatch: most
common cause
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Acute Pulmonary Edema
Abnormal accumulation of fluid in the
lungs
Occurs rapidly over minutes or hours
Etiologies all relate to failure of heart
and/or lungs
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Cardiogenic Pulmonary Edema
Initial insult is caused by heart failure
Pulmonary venous pressure leads to
Hydrostatic pressure in pulmonary
capillaries
Result: pulmonary edema
Cardiac dysfunction is most common
factor
Fluid overload, and chronic hypoxemia
may also be present
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Noncardiogenic Pulmonary Edema
Insult to the A-C membrane
Changes the permeability of the A-C
membrane
Major causes: sepsis, inflammation,
inhaled toxins, drugs
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Neurogenic Pulmonary Edema
Direct insult to central nervous system
Examples: seizures, cerebral hemorrhage,
head injury
Dyspnea (shortness of breath) is primary
presenting symptom
Other symptoms may be present
Crackles, pink frothy sputum
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Negative Pressure
Pulmonary Edema
Caused by ventilation with airway
obstruction
High pressures required
When obstruction is relieved
Hydrostatic pressure pushes fluid into lungs
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
PE and Specific Populations
Mountain climbers
Heroin users
Scuba divers/hyperbaric chamber users
Excessive intravenous fluid administration
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Manifestations of
Cardiogenic PE/Non-Cardiogenic PE
Respiratory clues are identical
Agitation, confusion common to both CPE
and NCPE
Distinguishing factors are subtle
Most evident in cardiac assessment, skin
appearance
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Differentiating CPE/Non-CPE
Mostly evident in cardiac assessment, skin
appearance
Example 1: tachycardia with hypotension and
cool diaphoretic skin suggests CPE
Example 2: tachycardia with hypertension,
bounding pulses and dry skin suggests NCPE
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Differentiating CPE/Non-CPE
Other Distinguishing Factors
Jugular Vein Distension more common in
CPE
If coronary artery catheter is used, Pulmonary
Artery Occlusion Pressures (PAOP) or
Pulmonary Capillary Wedge Pressure
(PCWP) above 18mmHg confirms CPE

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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Acute Respiratory Distress
Syndrome (ARDS)
Most severe type of respiratory failure
Caused by injury to A-C membrane
Mortality rate = 40%
Acute lung injury (ALI) less severe than
ARDS
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Acute Respiratory Distress
Syndrome (ARDS)
Lets fluids, proteins etc. flow into the lungs
Lung injury
Inflammation
Pulmonary edema
Hypoxemia
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Acute Injury to the Lungs
Causes of direct injury
Aspiration of gastric contents most common
cause of ALI
Trauma, Infection
Indirect injury intermediary process
causes injury
Sepsis, acute pancreatitis, major inflammatory
process
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Treatment of ARDS/ALI
Specific therapy to treat underlying cause
Supportive treatment
Oxygen
Mechanical ventilation
Fluid management
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
How the Ventilator Works
Monitors respiratory rate, pressure,
volume
Delivers specified volume, pressure, or
both
Controls concentration of oxygen
Mixes compressed air with oxygen to
reach desired FiO
2

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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Issues
Complexity of equipment is increasing
Variety of equipment is increasing
No standard terminology among
manufacturers
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Terminology
Spontaneous breaths
Mandatory breaths
Assisted breaths
Types of ventilation
Modes

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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Types of Breath
Spontaneous breaths
Patient initiates breath
Patient controls switch from inspiration to
expiration
Assisted breaths
Patient initiates breath
Ventilator controls switch to expiration
Ventilator controls volume and pressure
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Terminology
Mandatory breaths controlled entirely by
ventilator
Inspiration
Expiration
Volume/pressure of gas delivery
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Types of Ventilation
Volume clinician controls tidal volume;
pressure can vary can set rate, set
volume
Pressure clinician controls pressure;
tidal volume can vary - set rate, set
pressure, need to monitor minute volumes
No clinical consensus on preferred type
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Common Ventilator Modes
Mode: describes the pattern of breath
delivery
Common modes
Assist control mode (ACM)
Synchronized mandatory intermittent
ventilation (SIMV)
Pressure support (PS or PSV)
Pressure controlled ventilation (PCV)
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assist Control Mode
ACM delivers a preset volume or a preset
pressure for each breath
Patient can trigger a breath or the breath
can be time triggered (CMV, A/C)
Commonly used in care of in the
postoperative patient
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assist Control Mode
Nursing Implications of ACM
As patient awakens, she or he may begin
initiating breaths
Machine may not have time to deliver set
volume
Patient can become hypoxic by attempt to
breathe faster, stacking breaths
Pressure builds; lungs may be injured
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assist Control Mode
Nursing Implications of ACM
Nurse must monitor to assure that patient and
machine are working together
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Synchronized Intermittent
Mandatory Ventilation
Very common mode in US
SIMV sets the mandatory respiratory rate
(V
E
)
Ventilator will deliver a set volume or
pressure
Patient can also initiate a breath
Ventilator waits for the patient, to breathe
Synchronizes delivery of breath in concert
with the patient
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Synchronized Intermittent
Mandatory Ventilation
Nursing Implications of SIMV
Desirable for patient to overbreathe the
machine; i.e. breathe faster than the V
E

In SIMV, patient may initiate breaths, some
are assisted and some are not
Team should evaluate V
E
, level of sedation or
analgesia
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Support
PS is a form of assisted ventilation
Requires stable respiratory effort from
patient
IF ventilator senses negative pressure on
inspiration
THEN ventilator supports the patient-initiated
breath
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Support
Does not control the rate or tidal volume
Therefore, usually used with SIMV, CPAP
mode
PS not triggered unless patient breathes
above the V
E (mandatory rate)
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Support
Nursing Implications of PS with SIMV
If patient does not overbreathe the machine,
no benefit from PS
The nurse should assess the patient and talk
to the team to determine a course of action
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Control Ventilation
Clinician sets rate and pressure
Tidal volume is allowed to vary
Usually reserved for patients with
noncompliant lungs, difficult to ventilate
and oxygenate
Gas delivery distinguishes PCV from PS
Breath triggers rapid delivery of gas to reach
set pressure, then the flow is decelerated
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Control Ventilation
Nursing Implications of PCV
The nurse should trend the V
E
and the
expiratory volume over time
Volume decrease may indicate lungs are
becoming less compliant
Adjust Pressure to Achieve the Same Volume
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Positive End-Expiratory Pressure
PEEP is a ventilator setting, not a mode
Provides resistance at end of exhalation
Prevents alveoli from collapsing
CPAP continuous positive airway
pressure related to PEEP
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Three Types of PEEP
Physiological PEEP 5 cm of H
2
O
Treatment PEEP >5 cm of H
2
O
Auto-PEEP
For most ventilated patients, PEEP of at
least 5 cm of H
2
O required to prevent
alveolar collapse
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Implications of PEEP
PEEP of greater than 5 cm of H
2
O can
cause decreased cardiac output
Pneumothorax at higher levels of PEEP
The nurse should be aware of the level of
PEEP
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Auto-PEEP
Potential problems
Ventilator set rate is too high
Overaggressive use of an Ambu bag
Result: pressure builds in the lungs
Disconnect the ventilator or Ambu briefly
Allows the excess pressure to dissipate
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
CPAP
Commonly used prior to extubation
Patient is breathing spontaneously
Ventilator support at end of expiration only
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Assessment in ARF
Priorities are airway and oxygenation
status
Frequent, ongoing assessment is vital
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assessment Data
Ask if the patient feels s/he is getting
enough air
Evaluate for anxiety
Respiratory rate, work of breathing, SO
2
,
vital signs
Assess skin and nail beds for cyanosis
and pallor
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Diagnosis
Impaired gas exchange
Ineffective tissue perfusion:
cardiopulmonary and peripheral
Deficient knowledge related to the disease
process
Self-care deficit
Ineffective airway clearance
Ineffective breathing pattern
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Interventions in ARF
Encourage deep breathing and coughing
Encourage incentive spirometer use, if
ordered
Frequent turning and repositioning
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Indications for
Endotracheal Intubation
Inability to maintain oxygenation/
ventilation
Airway protection
Elective surgery
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nurses Role
Know the proper equipment and its use
Anticipate the health providers needs
Position the patient
Preoxygenate the patient
Provide suction as necessary
Monitor the patient
Provide information and reassurance
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
How Intubation Works
Figure 36.6 Endotracheal tube.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Documentation
Size of ET tube
Location of ET tube in airway
Medications administered
Patients tolerance of procedure
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Suctioning
Performed based on assessment only
Never routinely ordered
DO: Hyperoxegenate before/after
suctioning
DONT: Routinely instill normal saline
before suctioning
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Complications
Hypoxemia
Bronchospasm
Cardiac arrhythmias
Tissue injury
Increased risk of infection
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Closed Suctioning System
Patient with high PEEP, high FiO
2
Closed system keeps pressure up
Patient cannot tolerate use of open system
Patient with airborne infectious disease
Avoids exposing others to aerosolized
infectious secretions
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
LEARNING OBJECTIVE 9
State two indications for insertion of a
chest tube in a patient in an acute care
setting.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chest Tube
Another major intervention for respiratory
compromise
Tension pneumothorax common reason
for chest tube insertion