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Unit 5: Chapter 23��Management of Patients With Chest and Lower Respiratory Tract Disorders

Aspiration
Atelectasis
Pulmonary Infections
Pleural condations
Pulmonary Emboli

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Aspiration

Inhalation of foreign material into the lungs
Serious complication of pneumonia
Clinical picture: tachycardia, dyspnea, central cyanosis, hypertension, hypotension, and potential death.
Nursing interventions:

Keep HOB elevated >30 degrees
Avoid stimulation of gag reflex with suctioning or other procedures
Check for placement before tube feedings
Thickened fluids for swallowing problems

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Atelectasis

Collapse or airless condition of alveoli caused by hypoventilation, obstruction to airways, or compression
Atelectasis may be Acute or Chronic
Range from microatelectasis (not detectable on chest X-ray) to macroatelectasis with loss of segmental, lobar, or overall lung volume.
Postoperative & immobilized patients at high risk.
May result from bronchial obstruction from secretions
Occur from any condition leading to reduced alveolar ventilation.
Obstructive Atelectasis is the most common type.

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Atelectasis

Causes
Foreign body & tumor on an airway
Altered breathing patterns & retained secretions
Impaired cough mechanisms
Reduced lung volumes because of musculoskeletal or neurological problems
Prolonged supine position
Pleural effusion
Pneumothorax, or Hemothorax
Specific surgical procedures (open heart surgery)

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Atelectasis

Clinical Manifestations (Symptoms):
Closure or collapse of alveoli
Acute or chronic
Most common is acute atelectasis, which occurs in the postoperative setting
Symptoms: insidious(gradual with harmful effects) , increasing dyspnea, cough, and sputum production, Low-grade fever
Acute: tachycardia, tachypnea, pleural pain, and central cyanosis (A bluish skin hue that is a late sign of hypoxemia) if large areas of the lung are affected
Chronic: similar to acute, pulmonary infection may be present

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Atelectasis

Diagnostic Findings
Chest X-Ray: (patchy infiltrates or consolidations area). Chest x-ray may suggest a diagnosis of atelectasis before clinical symptoms appear
Characterized by increased work of breathing and hypoxemia
Decreased breath sounds and crackles over the affected area

Pulse Oximeter: low saturation of Hemoglobin with O₂ (i.e., < 90%)

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Nursing Management

Prevention
Change position frequently (from supine to upright)

Strategies to expand lungs and manage secretions
Cough, deep breathing exercise
Early mobilization from bed to chair
Incentive spirometer
Administer prescribed Opioids and sedatives
Chest physiotherapy
Frequent suctioning to remove tracheobronchial secretions

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Medical & Nursing Management

Remove Secretions: coughing exercises, suctioning, aerosol therapy, chest physiotherapy
Oxygen Therapy

Endotracheal tube intubation
Mechanical ventilation

Positive End Expiratory Pressure (PEEP) for those not responding to first-line treatment
Bronchoscopy to remove obstruction
Chest Physiotherapy (CPT)
Thoracentesis to relieve compression

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Pulmonary Infections

Severe acute respiratory syndrome (SARS)—viral, no cases reported since 2004, CDC
Lung abscess
Tracheobronchitis
Pneumonia
Tuberculosis

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Lung Abscess

Most are a complication of bacterial pneumonia
Symptoms vary from a mild productive cough to acute illness; plueral friction rub
Drainage achieved through postural drainage and chest physiotherapy
IV antibiotic therapy for 3 weeks or longer, followed by oral antibiotics for 4 to 12 weeks

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Nursing Management: Lung Abscess

Administer IV antibiotics
CPT
Educate patient to perform deep breathing and coughing exercises
Encourage diet high in protein and calories
Emotional support

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Acute Tracheobronchitis�

Acute inflammation of the mucous membranes of the trachea and the bronchial tree.
The inflamed mucosa of the bronchi produce mucopurulent sputum.
Causes:
Often follows infection of URT
Infection by Streptococcus pneumonia, Haemophilus influenza or mycoplasma pneumonia & Fungal infection
Aspiration of oropharyngeal secretions.
Inhalation of contaminated air or water or toxic gases/chemicals.

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Acute Tracheobronchitis�

Clinical Manifestations

Dry irritating cough, aggravated by cold, dry, dust

Purulent sputum, Expectorates mucoid sputum
Sternal soreness from cough
Fever or chills
Night sweat, headache & general malaise
Short of breath
Noisy inspiration & expiration (expiratory wheeze)
Blood-streaked secretions in sever tracheobronchitis

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Acute Tracheobronchitis�

Nursing Management- Primarily educational

Encourage bronchial hygiene
Increase fluid intake
Direct cough to remove secretions
Encourage patient to sit up frequently to cough effectively
Complete the full course of Antibiotics
Rest
Steam inhalation
Avoid irritant and Smoking

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Pneumonia

Inflammation of the lung parenchyma
Causes:
Caused by various micro organisms: Bacteria, Mycobacteria, Chlamydia, Fungi, and Viruses.
Viruses are the most common cause of pneumonia in infants and children.
Classification:
Community acquired pneumonia (CAP)
Health care associated pneumonia (HCAP)
Hospital acquired pneumonia (HAP)
Ventilator associated pneumonia (VAP)

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Pneumonia

Risk Factors:
Conditions that produce mucus or bronchial obstruction (Cigarette smoking, Cancer, COPD, alcoholism, HF, Influenza)
Immuno suppressed patients (AIDS)
Prolonged immobility patients and shallow breathing pattern
Supine positioning
Cystic fibrosis
Aspiration of foreign material
General Anesthetic, Sedative or Opioid
Advanced age

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Pneumonia

Clinical Manifestation:
Varies depending on type, causal organism, and presence of underlying disease
Streptococcal: Sudden onset of chills, fever, pleuritic chest pain, tachypnea, and respiratory distress
Viral, mycoplasma, or Legionella: relative bradycardia
Other: Respiratory tract infection, headache, low-grade fever, pleuritic pain, myalgia, rash, and pharyngitis
Orthopnea, crackles, increased tactile fremitus, purulent sputum

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Pneumonia

Assessment and Diagnostic Finding:
History
Physical Examination
Chest x- ray
Sputum culture and sensitivity
Blood culture
Bronchoscopy may be used for acute severe infection

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Medical Management

Supportive treatment includes fluids, oxygen for hypoxia, Antipyretics, Antitussives, decongestants, and Antihistamines
Administration of Antibiotic therapy determined by Gram stain results
Antibiotics not indicated for Viral infections but are used for secondary Bacterial infection
Warm, moist inhalations
Bed rest
Prevention: pneumococcal polysaccharide vaccine (PPSV)

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Nursing Process: Assessment

Vital signs, pulse Oximetry, ABGs
Secretions: amount, odor, color and thickness
Cough : frequency and severity
Tachypnea, shortness of breath
Inspect chest and auscultate all lobes of lungs, note any changes in air exchange, or chest excursion
Changes in mental status, fatigue, edema, dehydration, concomitant heart failure, especially in older adult patients

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Nursing Process: Diagnosis

Ineffective airway clearance R/L tracheo bronchial secretions
Activity intolerance
Risk for fluid volume deficit R/L fever and dyspnea
Imbalanced nutrition: fatigue and shortness of breath decreased appetite
Knowledge deficit about the treatment regimen and preventive health measures.

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Collaborative Problems

Continuing symptoms after initiation of therapy
Sepsis and septic shock
Respiratory failure
Atelectasis
Pleural effusion
Delirium

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Nursing Process: Planning

Improved airway patency
Increased activity
Maintenance of proper fluid volume
Maintenance of adequate nutrition
Understanding of the treatment protocol and preventive measures
Absence of complications

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Nursing Process: Interventions

Oxygen with humidification to loosen secretions

Face mask or Nasal cannula

Coughing techniques
Chest physiotherapy
Position changes to enhance secretion clearance

Incentive spirometry
Nutrition
Hydration 2 to 3 L/day
Rest
Activity as tolerated
Patient teaching
Self-care
Placed patient in comfortable position eg: Semi- fowlers

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Tuberculosis (TB)

The primary infectious agent (Mycobacterium tuberculosis bacillus)
An infectious disease that primarly affects the lung parenchyma.
It also may be transmitted to other parts of the body including meninges, kidneys, bones, and lymph nodes.
TB is associated with poverty, malnutrition, over crowding, and inadequate health care.
Transmission by droplet nuclei (airborne transmission)

Suspended in air for hours

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Tuberculosis (TB)

RISK FACTORS:
Close contact with someone who has active T.B
Immune compromised status eg: HIV, cancer, trans planted organs.
Substance abuse (injection drug users)
Any person without adequate health care
Those in lower socioeconomic groups, Living in over crowded housing, the homeless, and people with Alcoholism or HIV infection.
TB it is the leading cause of death among HIV positive people.

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Tuberculosis (TB)

Manifestations and Complications

Fatigue
Weight loss
Anorexia
Low-grade afternoon fever
Dry cough & Hemoptysis
Night sweats
Tuberculosis empyema
Bronchopleural fistula

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Tuberculosis (TB)

ASSESSMENT AND DIAGNOSTIC FINDINGS:
History and physical
Chest x-ray
Drug susceptibility testing
Sputum culture
Tuberculin skin test

Methods of tuberculin testing:

Intradermal PPD (Mantoux) test
Multiple-puncture (tine) testing
A positive tuberculin test alone does not indicate active disease.

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Tuberculin Testing (Mantoux) Test

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Tuberculin Testing

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Tuberculosis (TB)

MEDICAL MANAGEMENT:
Pulmonary T.B is treated primarly with Chemotherapeutic agents (Anti Tuberculosis Agents) for 6 to 12 months.
Prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse.
Medications:

Single-drug therapy (e.g. Isoniazid (INH))
Bacillus Calmette-Guerin (BCG) Vaccination
Two-or-more-drugs therapy (e.g. Isoniazid, Rifampin, Ethambutol, Streptomycin)
If a drug-resistant strain of TB (Therapy tailored to that resistance

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Nursing Diagnosis:
Ineffective airway clearance related to bronchial secretions.
Knowledge deficient about treatment regimen and preventive measures.
Activity intolerance related to fatigue, fever and altered nutritional status.
Ineffective Therapeutic Regimen Management.
Risk for Infection.

Tuberculosis (TB)

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Nursing Interventions:
Promoting airway clearance
Advocating adherence to treatment regimen
Promoting activity and adequate nutrition
Preventing transmission of TB
Monitoring and managing potential complications.

Teaching: effect, dose, and timing for all medications, and potential side effects and their management
Importance of long-term therapy in eradicating the disease

Tuberculosis (TB)

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Pleural Conditions

Disorders that involve:
The membranes covering the lungs (visceral pleura) and the surface of the chest wall (parietal pleura)
Disorders affecting the pleural space such as:
Pluerisy
Plueral effusion
Empyema
Pulmonary edema

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Pleurisy

Pleurisy (Pleuritis): Inflammation of both layers of pleurae
Key characteristic of pleuritic pain (e.g. sharp, knife pain intensified with inspiration) is its relationship to respiratory movement
Pleural friction rub can be heard with the stethoscope
Diagnostic tests may include chest x-rays, sputum analysis, thoracentesis
Treat underlying cause (pneumonia, infection, provide analgesia, teaching to splint the rib cage when

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Pleural Effusion

Pleural Effusion: fluid collection in pleural space usually secondary to heart failure, TB, pneumonia, pulmonary infections
Normally pleural space contains 5 to 15 ml of fluid
Large effusions impair lung expansion, causing dyspnea
May have tracheal deviation away from affected side
The effusion can be clear fluid, bloody, or purulent.
DX: decreased or absent breath sounds, dull & flat percussion sound, tracheal deviation, chest X-ray & Thoracentesis
RX: treat underlying cause, Thoracentesis to remove fluid, & Chest tube

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Pleural Effusion

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Empyema

Empyema: accumulation of thick, purulent fluid in pleural spaces.
Complication of bacterial pneumonia or lung abscess penetrating chest trauma, after Thoracentesis
Acutely ill and has signs and symptoms similar to those of an acute respiratory infection or pneumonia
Chest auscultation demonstrates decreased or absent breath sounds over the affected area
Chest CT and a diagnostic thoracentesis
Drain fluid by using chest tube and administer antibiotics for 4 to 6 weeks

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Pulmonary Emboli

Obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart
Inflammatory process obstructs area, results in diminished or absent blood flow
Bronchioles constrict, further increasing pulmonary vascular resistance, pulmonary arterial pressure, and right ventricular workload
Tachypnea is the most common sign for a possible pulmonary embolism
Ventilation–perfusion imbalance, right ventricular failure, shock occurs

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Risk Factors for Pulmonary Emboli

Trauma
Surgery
Pregnancy
Heart failure
Hypercoagulability
Immobility, venous stasis
Dyspnea is the most common symptom

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Prevention and Treatment of Pulmonary �Emboli

Exercises to avoid venous stasis

Early ambulation
Anti-embolism stockings

Treatment

Measures to improve respiratory and vascular status
Anticoagulation and thrombolytic therapy
Surgical interventions