Lower Respiratory Problems

Ch 28

Megan McClintock, MS, RN

 Lower Respiratory Problems
 Acute bronchitis
 Occurs after an URI
 Persistent night-time cough with clear sputum
 Self-limiting, supportive tx, no abx
 Pertussis
 Highly contagious
 Paroxysms of coughing followed by inspiratory gasps,
vomiting; cough lasts 6-8 weeks
 Treat with Zithromax
 Adolescents and adults need booster immunizations
 Pneumonia
 Acute inflammation of the lung
parenchyma
 Results when the normal defense
mechanisms become incompetent
or are overwhelmed
 Organisms get to the lungs by:
 Aspiration
 Inhalation
 Spread from a primary
infection elsewhere
 Types of Pneumonia
 Community-Acquired (CAP)

 Hospital-Acquired (HAP), Ventilator-Associated

(VAP), Health Care-Associated (HCAP)

 Aspiration

 Opportunistic
 Assessment
 Sudden onset of fever, chills
 Cough with purulent sputum
 May have pleuritic chest pain
 Confusion or stupor (in the elderly)
 Breath sounds – increased fremitus, crackles,
wheezing, dull to percussion
 Viral pneumonia symptoms are highly variable
 Complications
 Pleurisy
 Pleural effusion
 Atelectasis
 Bacteremia
 Lung abscess
 Empyema
 Pericarditis
 Meningitis
 Endocarditis
 Dx Studies
 History and physical exam
 Chest Xray
 Shows a typical pattern consistent with the
organism
 Sputum culture before beginning abx
(ideally)
 ABGs
 WBCs
 Treatment
 Flu vaccine annually
 Pneumococcal vaccine every 5 years for those at
risk (see Table 28-5, pg 550)
 Prompt abx tx (expect response w/in 48-72 hrs)
 Supportive tx (oxygen, analgesics, antipyretics)
 No treatment is necessary for viral pneumonia
 Nutrition and hydration
 Nursing Care
 Influenza and pneumococcal vaccines if at risk
 If decreased level of consciousness:
 Position side-lying, upright to prevent
aspiration
 Turn q 2 hrs
 If difficulty swallowing:
 Assist with eating and drinking
 Take meds to prevent aspiration
 Strict medical asepsis and handwashing
 Strict sterile technique with tracheal suctioning
Acute Care
Interventions
Ambulatory/Home Care
Interventions
 Question
 Following assessment of a pt with pneumonia,
the nurse identifies a nursing diagnosis of
ineffective airway clearance. Which
information best supports this diagnosis?
A. Resting pulse oximetry of 85%
B. Respiratory rate of 28
C. Breathing is shallow and rapid
D. Weak, nonproductive cough
 Question
 To promote airway clearance in a patient
with pneumonia, the nurse instructs the
patient to:
A. Splint the chest when coughing
B. Maintain fluid restrictions
C. Wear the nasal oxygen cannula
D. Try the pursed-lip breathing technique
 Question
 The nurse notes new onset confusion in an
89-year-old patient in a long-term care facility;
the patient is normally alert and oriented.
Which action should the nurse take next?
A. Check the patient’s pulse rate
B. Obtain an oxygen saturation
C. Notify the health care provider
D. Document the change
 TB
 Not just the lungs
 Resurgence
 HIV patients
 MDR strains
 Poor compliance
 No follow-up

 Ineffective drug therapy

At Risk for TB
 TB
 Spread person to person via airborne droplets in
repeated contact, particles can remain airborne
indoors for hours
 Classification
 Latent TB infection (LTBI) – positive skin test, normal
CXR, not sick, can’t spread it to others, but needs to be
treated
 TB disease – clinically active disease, positive skin test,
abnormal CXR or positive sputum culture, can spread it
to others, needs tx
 Signs/Symptoms
 Cough lasting 3 weeks or longer
 Fatigue, malaise, anorexia, weight loss
 Night sweats, low-grade fevers
 No dyspnea or hemoptysis
 Will look different with HIV infection
 Complications:
 Miliary TB
 Pleural effusion, empyema
 TB pneumonia
 Other organ involvement
 Dx Studies
 TB skin test (Mantoux test)
 Induration >10 mm (not redness) means

exposure to TB and presence of antibodies

 If positive once, will be positive for life

 In the immunocompromised pt, > 5mm is still

positive
 Exposure to BCG vaccine will cause a positive test

 CXR (can not dx with this alone)

 Sputum smear for AFB (do 3 on separate days)
Treatment
 Drugs for TB
 INH (isoniazid)
 Alcohol increases hepatotoxicity
 Must monitor for liver damage
 Rifampin
 Causes orange discoloration of urine, sweat, tears, sputum)
 Hepatotoxicity
 Ethambutol
 Can cause vision changes
 DOT (directly observed therapy) is best
 Question
 The nurse recognizes that the goals of
teaching regarding the transmission of TB
have been met when the patient with TB:
A. Demonstrates correct use of a nebulizer
B. Reports daily to the public health
department
C. Washes dishes and personal items after use.
D. Covers the mouth and nose when coughing
 Environmental Lung Diseases
 Pneumoconiosis

 Chemical pneumonitis

 Hypersensitivy pneumonitis

 Lung cancer
 Question
 The nurse has received change-of-shift
report about these respiratory patients.
Which patient should the nurse assess first?
A. A patient with loud expiratory wheezes.
B. A patient who has a cough productive of
thick, green mucus
C. A patient with oxygen sats of 91%
D. A patient with a respiratory rate of 38
 Lung Cancer
 Cigarette smoking most important risk factor
 Mortality risk reduced 30-50% after 10
years of smoking cessation
 Slow growing
 NSCLC (80%), SCLC (20%)
 Commonly metastasize
 Leading cause of cancer-
related deaths
 Lung Cancer
 Signs/symptoms
 Asymptomatic until late in the disease process
 Persistent cough with sputum (hemoptysis is not

common) is first sign

 Anorexia, fatigue, wt loss, n/v, hoarseness

 Diagnostic Studies
 Chest X-Ray
 Computerized Tomography (CT)

 Biopsy

 Staging is not done with small cell lung cancer b/c

it is always aggressive and systemic

 Treatment & Nursing Care
 Surgery – lobectomy,
pneumonectomy
 Radiation therapy
 Chemotherapy
 Stop smoking
 Teach pt to report
hemoptysis, dysphagia,
chest pain, hoarseness
 Hospice