NUR 342

UNIT III
Management of Patients with
Chest and Lower Respiratory
Tract Disorders

Primary Lung Functions: Ventilation

& Diffusion

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Atelectasis

The collapse or airless condition of the alveoli caused by

hypoventilation, obstruction to the airways, or compression.
Causes include bronchial obstruction by secretions due to impaired
cough mechanism or conditions that restrict normal lung expansion
on inspiration.
Postoperative patients are at high risk for atelectasis.
Symptoms are insidious and include cough, sputum production, and
a low-grade fever.
Respiratory distress, anxiety, and symptoms of hypoxia occur if
large areas of the lung are affected.
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Relationship of Risk Factors, Pathogenic Mechanisms, and

Consequences of Acute Atelectasis in Post-op Patient

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Nursing Management

Prevention
See Chart 23-1

Frequent turning and early mobilization

Strategies to improve ventilation: deep-breathing exercises at least every 2
hours, incentive spirometer
Strategies to remove secretions: coughing exercises, suctioning, aerosol
therapy, and chest physiotherapy

Treatment

Strategies to improve ventilation and remove secretions

Treatments may include PEEP (positive end-expiratory pressure) and
IPPB (intermittent positive-pressure breathing). Bronchoscopy may also
be used to remove obstruction.
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Respiratory Infections
Acute

tracheobronchitis
Pneumonia
Community-acquired pneumonia
Health Care Associated Pneumonia
Hospital-Acquired pneumonia
Ventilator Associated Pneumonia
Pneumonia in the Immunocompromised Host
Aspiration pneumonia
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Pneumonia
Pathophysiology
Risk

Factors
Clinical Manifestations

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Pathophysiology of Pneumonia

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Distribution of Lung Involvement in

Bronchopneumonia & Lobar Pneumonia

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Diagnostic Tests
Chest

x-ray
Sputum examination

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Etiology

CAP

HAP

HCAP

Acquired in community
Typical vs. atypical

Occurs >48
hours after
admission to
hospital

Occurs after
interaction with
health care

Mechanism Inhalation

Colonization of Colonization of
oropharynx
oropharynx
Aspiration
Aspiration
Inhalation
Inhalation

S/S

Same as CAP

Hypoxemia, dyspnea,
sputum, cough, pleuritic
pain
(fever, chills)
Confusion may be only
sign in older adult

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Same as CAP

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CAP
Pneumonia

HAP

HCAP

Dx Tests

Chest x-ray

Chest x-ray
Gram stain and
culture

Chest x-ray
Gram stain and
culture

Mgt

Empirical (treat within

8 hours of admission to
hospital)
2 antibiotics for severe
CAP
O2, or mechanical
ventilation
Aggressive pulmonary
toilet
Nutritional support

Identify
pathogens
Consider multidrug resistance
O2/mechanical
ventilation
Aggressive
pulmonary toilet
Nutritional
support

Same as for
HAP

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CAP
Pneumonia
Prevention Smoking cessation
Influenza and
pneumococcal vaccine
Promote immune
system health

HAP

HCAP

Smoking
cessation
Health care
professionals
follow infection
control principles
and hand
washing
Surveillance of
pathogens
Identify clients
at risk for
aspiration
Discontinue
invasive lines
early

Same as for HAP

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Patient Outcomes Research Team

(PORT): Pneumonia

PORTS are a series of studies on the quality, effectiveness, and costeffectiveness of current therapies for treating some of the most
common and costly medical conditions in the US
Model to determine appropriate care for CAP (AHCPR, 1997)
Helps to guide initial decision on site of care
May not be appropriate for all patients; use in conjunction with PCP
judgment

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CURB 65 Severity Index for CAP

Confusion
Uremia

(BUN >/= 20mg/dL)

Respirations >/= 30 breaths/min
BP low - requiring fluids
>65 years of age
Source:

Kent (2011)
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Preventing Ventilator-associated
Pneumonia (VAP)
Ventilator

Bundle Compliance (IHI.org)

Bundle:

DVT prophylaxis, meds to reduce gastric

ulceration, HOB elevated 30-450, daily sedation
vacation or holding a sedative to assess whether the
patient can breathe off ventilator, daily Oral Care with
Chlorhexidine
Goal: 95% of all patients on mechanical ventilation
receive all 5 elements of the V. Bundle
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Autonomous Nursing Intervention

Bundle to Prevent VAP

Risk of developing VAP dropped by 97.6% when patients received a

bundle consisting of :
Keeping the endotracheal tube cuff pressure between 20 and 25
cm H2O
Maintaining the HOB 30-45o elevation
Providing mouth care every 2 or every 4 hours (Curtin, 2011)
Replication study with ET tube cuff pressure to 25-30 cm H2O.
Current literature increased the accepted range for ET tube cuff
pressure to this level (Curtin, 2011)

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Medical Treatment of Pneumonia

Supportive treatment includes fluids, oxygen for hypoxia,
antipyretics, antitussives, decongestants, and
antihistamines.
Administration of antibiotic therapy is determined by
Gram stain results.
If the etiologic agent is not identified, use empiric
antibiotic therapy.
Antibiotics are not indicated for viral infections but are
used for secondary bacterial infection.

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Pneumonia: Other Medical

Management
Hydration
Antitussives
Antipyretics
Warm,

moist inhalations
Oxygen as required

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Nursing Process: The Care of the

Patient with Pneumonia: Assessment
Changes in temperature and pulse
Secretions
Cough
Tachypnea and shortness of breath
Changes in physical assessment, especially inspection and
auscultation of the chest
Changes in CXR
Changes in mental status, fatigue, dehydration, and
concomitant heart failure, especially in elderly patients

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Nursing Process: The Care of the

Patient with Pneumonia: Diagnosis
Ineffective

airway clearance
Activity intolerance
Risk for deficient fluid volume
Imbalanced nutrition
Deficient knowledge

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Collaborative Problems
Continuing

symptoms after initiation of therapy

Shock
Respiratory

failure

Atelectasis
Pleural

effusion
Confusion
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Nursing Process: The Care of the

Patient with Pneumonia: Planning
Improved

airway clearance
Maintenance of proper fluid volume
Maintenance of adequate nutrition
Patient understanding of treatment and prevention
Absence of complications

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Improving Airway Clearance

Encourage

hydration; 2-3 L a day, unless

contraindicated
Humidification may be used to loosen secretions;
by face mask or with oxygen
Coughing techniques
Chest physiotherapy
Position changes
Oxygen therapy administered to patient needs
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Aspiration

Risk factors, Chart 23-5, p. 585

Pathophysiology
Prevention:
Elevate HOB
Turn patient to side when vomiting
Prevention of stimulation of gag reflex with suctioning or other
procedures
Assessment, proper administration of tube feeding
Rehabilitation therapy for swallowing
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Postural Drainage: Anterior Basal

Segments

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Postural Drainage:
Lower Lobes, Superior Segments

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Postural Drainage: Lower Lobes,

Lateral Basal Segments

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Postural Drainage: Upper Lobes,

Anterior Segment

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Postural Drainage: Upper Lobes,

Posterior Segment

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Postural Drainage: Upper Lobes,

Apical Segments

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CPT: Postural Drainage, Percussion,

Vibration, and HFCWO

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Other Interventions

Promoting rest
Encourage rest and avoidance of overexertion.
Positioning to promote rest and breathing (semi-Fowlers)

Promoting fluid intake

Maintaining nutrition

Encourage fluid intake to at least 2 L a day.

Provide nutritionally enriched foods and fluids.

Patient teaching
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Pulmonary Tuberculosis

Infectious agent: Mycobacterium tuberculosis

Acid-fast bacillus aerobic rod

Airborne transmission:Droplet nuclei

Risk factors, Chart 23-6, p. 587

Pathophysiology
Clinical manifestations

Cough, low-grade fever, night sweats, fatigue, weight loss.

Cough: non-productive or productive

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Pulmonary Tuberculosis
Assessment and Diagnostic Findings

Tuberculin skin testing: Mantoux

Correct

New

technique & interpretation are important

test: QuantiFERON-TB Gold

Classification

of TB

Pharmacologic therapy multi-drug

regimens

prophylaxis

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Mantoux Testing for TB

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Nursing Process: The Patient with TB

Assessment
Nursing

Diagnoses

Ineffective

airway clearance
Deficient knowledge
Activity intolerance
Collaborative

Problems

Malnutrition,

Med side effects, Drug resistance, Spread

of TB infection (miliary TB)
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TB: Nursing Interventions

Promoting

airway clearance
Advocating adherence to treatment regimen
Promoting activity & adequate nutrition
Monitoring and managing potential complications
Patient/family teaching and follow-up

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Lung Abscess
Complication

of bacterial pneumonia or
caused by aspiration or oral anaerobes
Mild productive cough may lead to acute
illness
Pleural friction rub
IV antibiotics
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Pleural Conditions
Pleurisy
Pleural

effusion
Empyema

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Pleural Conditions

Pleurisy: an inflammation of both layers of the pleurae

Pleural effusion: a collection of fluid in the pleural space, usually

secondary to another disease process

Inflamed surfaces rub together with respirations and cause sharp pain
that is intensified with inspiration.

Large effusions impair lung expansion and cause dyspnea.

Empyema: accumulation of thick, purulent fluid in the pleural

space

Patient is usually acutely ill. Fluid, fibrin development, and loculation

will impair lung expansion. Resolution is a prolonged process.
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Pleural Effusion

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Pulmonary Edema Noncardiogenic

Accumulation

of fluid in lung tissue or alveolar space

Noncardiogenic versus cardiogenic
Noncardiogenic due to damage of the pulmonary
capillary lining; caused by direct injury to lung or
other causes.
Treatment similar to cardiogenic pulmonary edema
Hypoxemia is persistent; refractory to high FIO2 due
to intrapulmonary shunting of blood

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Acute Respiratory Failure

Decreased

respiratory drive
Dysfunction of the chest wall
Dysfunction of lung parenchyma
Inadequate ventilation
Treat underlying cause
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Acute Respiratory Distress Syndrome

A severe form of acute lung injury
A syndrome characterized by sudden and progressive
pulmonary edema, increasing bilateral lung infiltrates on
CXR, hypoxemia refractory to oxygen therapy, and
decreased lung compliance
Symptoms:

Rapid onset of severe dyspnea

Hypoxemia that does not respond to supplemental oxygen

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Acute Respiratory Distress Syndrome

(ARDS)

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Phase I ARDS: Injury reduces normal

blood flow to lungs

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Phase II ARDS: Increased capillary

permeability: fluids shift into interstitial space

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Phase 3: Continued capillary permeability

increase: Pulmonary edema

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Phase 4: Alveoli collapse with impaired gas

exchange & decreased lung compliance

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Phase 5: Sufficient O2 cannot cross the

alveolar-capillary membrane; CO2 can cross;
Oxygen &
Carbon
Dioxide levels
decrease in
the blood

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Pulmonary Edema in ARDS

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Management of ARDS
Intubation

and mechanical ventilation with PEEP

(positive end-expiratory pressure) to treat
progressive hypoxemia
Positioning: frequent position changes
Nutritional support
General supportive care
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ARDS: Medical/
Nursing Management
Treat

underlying condition

Ventilator

considerations

PEEP
Goal:

Pa02>60mmHg or Sa02>90 % at
Lowest possible Fi02
Positioning: Prone considered
Reduce anxiety
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Pulmonary Arterial Hypertension

Systolic

pulmonary artery pressure > 30 mm

Hg. or mean pulmonary artery pressure >25
mm Hg.
Primary is idiopathic
Secondary results from existing cardiac or
pulmonary disease
Manage underlying disease
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Pulmonary Heart Disease

(Cor Pulmonale)

Right

ventricle enlarges with or without

right-sided heart failure
Caused by severe COPD
Improve ventilation with supplemental
oxygen, chest physical therapy, and bronchial
hygiene
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Pulmonary Embolism

Obstruction of pulmonary artery or branch by blood clot, air, fat,

amniotic fluid, or septic thrombus
Most thrombus are blood clots from leg veins
Obstructed area has diminished or absent blood flow
Although area is ventilated, no gas exchange occurs
Inflammatory process causes regional blood vessels, bronchioles to
constrict, further increasing pulmonary vascular resistance,
pulmonary arterial pressure, right ventricular workload
Ventilation-perfusion imbalance, right ventricular failure, shock
occur
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Pulmonary Embolism
Clinical

Manifestations

Dyspnea,

tachypnea, and chest pain occur suddenly

Assessment/Diagnostic

findings

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Sites of Pulmonary Emboli

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Risk Factors for Pulmonary Emboli

See Chart 30-7, p. 846, Chapter 30
Venous stasis
Hypercoagulability
Venous endothelial disease
Certain disease states: heart disease, trauma,
postoperative/postpartum, diabetes mellitus, COPD
Other conditions: pregnancy, obesity, oral contraceptive
use, constrictive clothing
Previous history of thrombophlebitis

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Prevention and Treatment of

Pulmonary Emboli

Prevention of recurrent/Home Care Checklist

See Chart 23-10, p. 604
Exercises to avoid venous stasis
Early ambulation
Anticoagulant therapy
Sequential compression devices (SCDs)

Treatment
Measures to improve respiratory and CV status
Anticoagulation and thrombolytic therapy

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Pulmonary Embolism: Management

Medical

Management

Emergency
Pharmacologic

management
therapy

Anticoagulants
Thrombolytic
Surgical

therapy

Management: IVC filter or clipping

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Umbrella Filter

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Pulmonary Embolism: Nursing

Management
Minimizing the risk
Preventing thrombus formation
Assessing potential for Pulmonary Embolism
Monitoring thrombolytic therapy
Managing pain
Managing oxygen therapy
Relieving anxiety
Monitoring for complications
Providing postoperative nursing care

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Question
Tell

whether the following statement is true or

false:
Bradypnea is the most common sign for a possible
pulmonary embolism.

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Answer
False.
Rationale:

Tachypnea, not bradypnea, is the most

common sign for a possible pulmonary embolism.

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Sarcoidosis
Multisystem

granulomatous disease of
unknown etiology
Involves lungs, lymph nodes, liver, spleen,
CNS, skin, eyes, fingers, and parotid glands
Hypersensitivity response
Corticosteroid therapy or other cytotoxic and
immunosuppressive agents may be used
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Pneumoconioses
Occupational

lung diseases
Cause of death of 124,846 people in the U.S.
between 1968 and 2000
Causative agents
Role of the nurse as employee advocate
Role of the nurse in health education and in
teaching of preventive measures
Role of OSHA
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Lung Cancer
Overview
Leading

cancer killer among men & women

Regional spread at diagnosis
Long term survival rate low
Five year survival rate: 16%
Pathophysiology
Common

cause: Inhaled carcinogen, cigarette smoke

(90%)Damage to cells DNAcellular
changesinvasive carcinoma
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Which Statement is true?

All

All

cancer is genetic.

cancer is inherited.

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Cancer Facts
All

cancer is genetic in that it is always caused

by changes in the expression of genes involved
in cell division

Cancer

cells transmit gene changes from one

cell generation to another but cancer is not
inherited from one human generation to
another
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Classification and Staging

Classification
Non

small cell (80%):Squamous cell, large cell,

adenocarcinoma (40%)
Small cell (15-20%)
Staging
Non

small cell: Stage I (early) Stage IV (metastatic)

Small cell Limited or extensive
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Lung Cancer: Risk Factors

Risk

Factors

Tobacco
Pack

smoke

year history

Second-hand

smoke
Environmental & occupational exposure
Genetics

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Lung Cancer: Assessment

Clinical manifestations
Insidious; often asymptomatic until late
Most frequent is cough or change in cough: persistent
dry cough initially
Wheezing; dyspnea; hemoptysis
Pain is a late finding; may be r/t bone metastasis
Diagnostic findings
CXR, CT, bronchoscopy with biopsy, bone scan for
metastasis

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Lung Cancer: Assessment

Clinical manifestations
Insidious; often asymptomatic until late
Most frequent is cough or change in cough: persistent
dry cough initially
Wheezing; dyspnea; hemoptysis
Pain is a late finding; may be r/t bone metastasis
Diagnostic findings
CXR, CT, bronchoscopy with biopsy, bone scan for
metastasis

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Care of the Patient with Lung Cancer

Prevention

and causes
Classification of lung cancer
Treatment
Surgery

Types of lung resections See Chart 23-11, p. 608

Radiation
Chemotherapy
Palliative

care
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Nursing Care of the Patient with Lung

Cancer
Psychological

support

Pain
Airway

clearance

Fatigue
Dyspnea

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Care of the Patient Undergoing

Thoracic Surgery
Pre-operative

care

See

risk factors for Surgery-related Atelectasis &

Pneumonia, Chapter 21, Chart 21-19, p. 523
Pre-op care similar to other surgical procedures,
Chapter 21, p. 523
Chart 21-18, Thoracic surgeries and procedures
Specific teaching r/t chest tubes; discussed in
respiratory lab; important information
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Post-operative Management of the

Patient with a Thoracotomy
Chest

tube drainage

Water

seal
Dry suction water seal
Dry suction with a one-way valve system
Positioning

See Chart 21-21, Preventing Postoperative

Cardiopulmonary Complications after Thoracic Surgery,
p. 527
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Post-op Care of the Thoracotomy

Patient
Nursing

Diagnoses

Impaired

gas exchange
Ineffective airway clearance
Acute pain
Impaired physical mobility
Risk for imbalanced fluid volume
Imbalanced nutrition
Deficient knowledge
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Techniques for
Supporting
Incision after
Thoracic Surgery
to Facilitate
Coughing

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Question
Which

of the following is the most common

surgery for a small apparently curable tumor of the
lung?
A. Lobectomy
B. Pneumonectomy
C. Segmentectomy
D. Sleeve resection
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Answer
A.

Lobectomy
Rationale: The most common surgical procedure for a
small, apparently curable tumor of the lung is a
lobectomy. A pneumonectomy is the removal an entire
lung. Segmentectomy is not recommended as curative
resection of lung cancer and is a removal of a segment of
the lung. A sleeve resection is removal of the cancerous
lobes with a segment of the main bronchus resected.
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Chest Trauma
Blunt trauma
Sternal and rib fractures
Flail chest
Pulmonary contusion
Penetrating trauma
Pneumothorax

Spontaneous or simple
Traumatic
Tension pneumothorax

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Flail Chest

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Open
Pneumothorax
versus
Tension
Pneumothorax
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Question
Tell

whether the following statement is true or

false:
An initial characteristic symptom of a simple
pneumothorax is a sudden onset of chest pain.

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Answer
True.
Rationale: An

initial characteristic symptom of a

simple pneumonthorax is a sudden onset of chest
pain.

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Cardiac Tamponade and

Subcutaneous Emphysema

Cardiac

Tamponade -Compression of
heart as result of fluid within the
pericardial sac
Subcutaneous Emphysema- Air entering
the tissue planes and passing under skin
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