Chpt 27: Disorders of Lower Respiratory Tract

MEDICAL SURGICAL

Acute bronchitis PG 374

Characterized by inflammation of the mucous

membranes that line the major bronchi and their branches. Most common cause is a viral infection Signs & symptoms: fever, malaise, and a dry, nonproductive cough that later becomes productive of mucopurulent sputum

Acute Bronchitis
Acute bronchitis differs from pneumonia in

that with acute bronchitis there is initially a nonproductive cough. They have paroxysmal(sudden violent) attacks of coughing and may have wheezing May also have laryngitis and sinusitis. Moist inspiratory crackles may be heard

Acute Bronchitis
Usually self limiting, lasting for several days
Treated with bedrest, antipyretics, expectorants

and antitussives and lots of fluids If secondary bacterial infection occurs then it becomes a serious condition. Has persistent cough and thick purulent sputum if secondary infection occurs

Nursing Care
Auscultate breath sounds
Monitor vitals Encourage to cough and deep breathe q 2 hrs. while

awake and to expectorate rather than swallow sputum Change damp clothing and linen Offer fluids frequently

Prevent Spread
Wash hands frequently especially when handling

soiled tissues cover mouth when sneezing and coughing Discard soiled tissues in a plastic bag Avoid sharing articles

Pneumonia PG 374
Infalmmatory process affecting bronchioles and

alveoli Viral pneumonias are most common cause

Types of Pneumonia
Viral,Bacterial,Radiation,Chemical
Aspiration Lobar--confined to one or more lobes

bronchopneumonia--patchy and diffuse infection

scattered thruout both lungs hypostatic--hypoventilation in immobile

Pneumonia
Organisms that cause pneumonia reach the alveoli

by inhalation of droplets, aspiration of organisms from upper airway, or from bloodstream. When organisms reach alveoli, an intense inflammatory reaction occurs. This produces exudate which impairs gas exchange .

Pneumonia
Capillaries surrounding the alveoli become engorged

and cause the alveoli to collapse (atelectasis) If untreated consolidation occurs and the infection gets worse causing hypoxemia. Lung tissue gets necrotic and death can occur from failure.

Complications of Pneumonia
CHF
empyema-collection of pus in pleural cavity pleurisy-infalmmation of the pleura...major

complication of pneumonia septicemia-infective microorganisms in the blood-can cause endocarditis, pericarditis and purulent arthritis atelectasis hypotension and shock

Bacterial Pneumonia
Onset of bacterial is sudden. he has fever, chills, a

productive cough, and discomfort in chest wall muscle from coughing. Malaise, breathing may cause pain and he breathes shallowly Classic symptom is rusty colored sputum

Viral Pneumonia
Differs from bacterial in that blood cultures are

sterile, sputum may be more copious, chills are less common, and pulse and resp rates are characteristicly slow. Mortality rate low as less serious than bacterial. Mortality rate increases if secondary bacterial infection occurs. Wheezing, crackles, & decreased breath sounds. Nail beds, lips & oral mucosa may be cyanotic

Nursing
When he has pneumonia, adequate oxygenation

can be accomplished by placing him in a semifowlers position Semi-fowlers increases the amount of air taken in with each breath Assess for classic symptoms of chest pain, fever, shallow respirations. Assess for signs of Acute respiratory failure. Use of accessory muscles of respiraton is Ist sign

Nursing
Auscultate lung sounds and monitor for signs of

respiratory difficulty assess cough and nature of sputum production Increase fluids Monitor I & O, skin turgor and serum electrolytes Monitor pulse oximetry, ABGs and quality of breathing

Important Information
Review nursing guidelines 27-1 page 377 and care of

the client with TB page 382 as nursing care is same

Pleurisy PG 377
Acute inflammation of the parietal and visceral

pleura Respirations become shallow secondary to excruciating pain caused by inflamed pleura rubbing together. This causes severe, sharp pain. Pleura fluid increases because it separates the pleura and he develops a dry cough, fatigues easily and has shortness of breath. Friction rub heard

Nursing Care
Teach to splint the chest by turning onto the affected

side. May also splint by using hands or a pillow when coughing

Pleural effusion PG 377

collection of fluid between the visceral and parietal

pleura Complication of pneumonia, lung cancer, TB, pulmonary embolism and CHF Accumulated fluid may be so great that it collapses the lung on that side and pressure is placed on the heart and other organs

Pleural effusion
Fever, pain, and dyspnea are the most common

symptoms. Chest percussion reveals dullness over the involved area. May have diminished or absent breath sounds. Friction rub may be heard. Thoracentesis sometimes done.

Lung abscess PG 378

Localized area of pus formation within the lung

parenchyma. As pus increases, necrosis of the tissue occurs. Later the area collapses and creates a cavity Signs and symptoms --chills, fever, weight loss, chest pain and a productive cough. Sputum may be purulent or blood streaked There will be dull or absent breath sounds in the area of abscess

Surgical Management
A lobectomy may be done to remove the abscess and

surrounding lung tissue Teach to cough and deep breathe and to eat a diet high in protein and calories

Empyema PG 378
Presence of pus in a body cavity..usually refers to

pus or infected fluid in the pleural cavity Fever chest pain, dyspnea, anorexia and malaise. there will be diminished or absent breath sounds over area. Appears acutely ill Thoracentesis and chest tube drainage used to drain purulent drainage. Following a thoracentesis must observe for resp distress

Chest Tubes
The use of chest tubes is usually necessary to drain

secretions, air, and blood from the thoracic cavity in order to re-expand the lung. Chest tubes are inspected frequently since any break in the system could allow air to be drawn into the pleural space and collapse the lung

Chest Tubes
When inspecting chest tubes connected to an

underwater seal system, the nurse makes sure the system is kept below the level of the bed If any break or major leak occurs the nurse immediately clamps the chest tube Clamps must be taped to the bed frame when chest tubes are inserted to use in an emergency

Influenza pg 379
Acute respiratory disease caused by virus.

Transmitted thru respiratory tract Fatalities usually due to secondary bacterial infection and complications, especially in pregnant women, elderly and debilitated or ones with chronic conditions (cardiac, emphysema, COPD, diabetes)

Nursing Management
Prevention and influenza vaccinations recommended
Respiratory isolation required Review table 27-2 page 379 for symptoms

Pulmonary Tuberculosis Pg 380

Bacterial infection disease that primarily affects

lungs but can affect kidney and other organs Tubercle bacilli are gram-positive, rod-shaped, acid fast bacteria. It can live in the dark for months in particles of dried sputum, exposure to direct sunlight, heat and ultraviolet light destroys them in a few hours.

TB Pathophysiology
The microorganism is difficult to kill with ordinary

disinfectants. Tubercle bacilli are killed by pasteurization, a process widely used in preventing the spread of TB by milk and milk products.

TB
Most commonly transmitted by direct contact with

a person who has the active disease thru inhalation of droplets produced by coughing, sneezing, and spitting. Brief contact usually does not result in disease. Bacilli may stay dormant for years and reactivate

S/S
Symptoms may not appear until the disease is

advanced. as they develop they are often vague and can be overlooked Fatigue, anorexia, weight loss, and a slight nonproductive cough are early symptoms Low grade fever, particularly in late afternoon, and night sweats are common as it progresses. Cough becomes productive of mucopurulent and bloodstreaked sputum.

 Marked weakness, wasting, hemoptysis and dyspnea

are common late stage. Chest pain may result from spread to pleura Must identify bacteria to diagnose. Cultures of sputum ordered. Can do gastric washings to retrieve swallowed bacteria.Gastric gavage, gastric aspiration and bronchoscopy used.

Medications
Combined therapy with two or more drugs decrease

the likelihood of drug resistance, increases the action of drugs antibubercular drugs are given for long periods and without interruption because healing is slow and resistance to drugs is increased by interrupted treatment.

Drug Regimen for TB table 27-1 pg 382

The primary focus of a teaching plan for TB is to

encourage them to complete the prescribed meds Drug typically used for treatment initially is isoniazid. Rifampin, PZA is also given Isoniazid may be given alone initially or a combination drug of the three above may be taken for...may take meds up to 18 to 24 months

Surgical Management
surgery may be done if disease is located primarily in

one section of lung. Segmental resection--one section removed Wedge resection lobectomy pneumonectomy--entire lung

Assessment
Breath sounds, breathing patterns, and overall

respiratory status Any pain breathing? Inspect sputum for color, viscosity, amount and for signs of blood Review page 382 and 383 for nursing care

Teaching
Take meds exactly as prescribed and observe time

intervals between each dose Drugs must be taken for a long time, complete the entire series Stress importance of continuous therapy because lapses in taking the drugs result in reactivation of infection Notify Dr if symptoms worsen or sudden chest pain or dyspnea

Teaching for TB
Drink extra fluids. Take med for fever but if it

continues call Dr Stop smoking and avoid second hand smoke Eat a balanced but light diet. Call Dr if more than a few pounds lost Avoid people with infections follow up care is important!!

Obstructive Pulmonary Disease pg. 383

COPD is a broad, nonspecific term that describes a

group of pulmonary disorders with symptoms of chronic cough and expectoration, dyspnea, and an impaired expiratory air flow. Bronchiecstasis, atelectasis, chronic bronchitis and emphysema are COPD disorders.

Obstructive Disease
Asthma is also an obstructive disorder that is more

episodic--generally more acute than chronic Sleep apnea syndrome is the cessation of airflow in and out of the lungs during sleep. Can be caused by obstructive causes

Bronchiecstasis pg. 383

Chronic disease characterized by irreversible

dilation of the bronchi and bronchioles and chronic infection When clearance of airway is impeded an infection can develop in the walls of the bronchus or bronchiole. This leads to changes in the structure of the wall tissue and results in the formation of saccular dilatations which collect purulent material

S/S
Chronic cough with expectoration of copious

amounts of purulent sputum and possible hemoptysis. Cough becomes worse when changing positions. Can spit up several ounces of sputum

Bronchiectasis
When sputum is collected it settles in three distinct

layers Top layer--frothy and cloudy Middle layer--clear saliva bottom layer--heavy, thick and purulent Also have fatigue, weight loss, anorexia and dyspnea

Bronchiectasis Nursing Care

A major treatment used is postural drainage as it

helps mobilize and expectorate secretions Performed three times a day in each position while he inhales slowly and blows the breath out thru the mouth. Usually takes 5 to 15 min.see picture pg 385 (used to drain lower lobes) chest percussion and vibration also used

Atelectasis pg 384
Collapse of lung tissue. May involve a small portion

of lung or entire lung. Symptoms related to size of collapsed area Small areas may have few symptoms. Large areas cause cyanosis, fever, pain, dyspnea, increased pulse and resp rates and increased pulmonary secretions Crackling may be heard but usually absent breath sounds in the area

Nursing Management
Care focus is on prevention. Deep breathing and

coughing post-op can prevent If it occurs encourage him to cough and deep breathe frequently and to use incentive spirometer (review guidelines pg. 386)

Chronic Bronchitis pg 384

Persistence of a chronic cough with excessive

production of mucus for at least 3 months a year for 2 consecutive years Characterized by hypersecretions of mucus by the bronchial glands and recurrent or chronic respiratory tract infections Secretions remain in lungs and form plugs within smaller bronchi can cause necrosis and fibrosis

Chronic Bronchitis
Earliest symptom is a productive cough of thick

white mucus, especially when rising in the morning and in the evening. Bronchospasm may occur during severe bouts of coughing As condition worsens the sputum becomes yellow, purulent, copious and after paroxysms of coughing, blood streaked

Chronic Bronchitis
Cyanosis secondary to hypoxemia may be noted,

especially after coughing. Dyspnea begins with exertion (dyspnea on exertion is a common symptom of pulmonary hypertension) but leads to dyspnea with minimal activity and later at rest

Chronic Bronchitis
Called the blue bloater as color is dusky and cyanotic

Medical Management
Stop smoking Bronchodilators Increased fluid Well balanced diet; Postural drainage steroids change in occupation if exposure to dust and

chemicals Air filters and antibiotics

Nursing
Identify ways to eliminate environmental irritants Avoid cold air and wind exposure that causes

bronchospasms Avoid others with resp. infections Get flu and pneumonia immunizations Monitor sputum for signs of infection, teach postural drainage Teach how to use inhalers (27-3 pg.387)

Pulmonary Emphysema pg. 387

Emphysema is a chronic disease characterized by

abnormal distention of the alveoli Major cause is smoking. Exposure to second hand smoke, air pollution, chronic infection and allergens also cause it. The alveoli lose elasticity, trapping air that normally should be expired

Emphysema
The walls of the alveoli break down and form one

large sac Shortness of breath occurs with minimal activity (exertional dyspnea) and is often the first symptom Breathlessness occurs even with rest Chronic productive cough and inspiration is difficult because of barrel chest

Emphysema
Uses accessory muscles to breathe expiration is prolonged, difficult and has wheezing Advanced emphysema pt. Appears drawn, anxious,

pale and speak in short jerky sentences. They lean forward and are short of breath. Neck veins distend during inspiration

Emphysema
In advanced cases memory loss, drowsiness,

confusion, and loss of judgment may occur CO2 levels may reach toxic levels resulting in lethargy, stupor, and eventually coma Will have decreased breath sounds, wheezes and crackles. Heart sounds will be diminished

Nursing Management
Respiratory center is sensitive to the level of CO2

in the blood. If level increases slightly, the respiratory rate and depth increases to eliminate excess. If it is chronically increased the resp center becomes insensitive to CO2 As long as oxygen is low he breathes, if it becomes high he stopsdo not give oxygen over 2-3 liters

Emphysema
Safest to give O2 using a nasal cannula If color improves but level of consciousness

decreases DC O2 as may go into resp arrest Teach to use diaphragm and abdomen to help breathe and to use pursed lip breathing Take a deep breath and bend forward at the waist while exhaling

Important Information
Review care for obstructive pulmonary disorder and

patient teaching page 389 & 390

Asthma pg. 390

Reversible obstructive disease. Three types: allergic asthma--pollen, dust, spores, animal dander idiopathic asthma--upper resp infections, emotional

upsets and exercise mixed asthma--both of above--most common type

asthma
Acute occurs as a result of increasing airway

obstruction caused by bronchospasm and bronchoconstriction, inflammation and edema of lining of bronchi and production of thick mucus that can plug airway

Asthma
Will have interference with gas exchange, poor

perfusion, possible atelectasis and respiratory failure if not treated

S/S of Asthma
Will have paroxysms of shortness of breath,

wheezing and coughing and production of thick, tenacious sputum Every breath becomes an effort and may have sensation of suffocation classic sitting position used--body leaning slightly forward and arms at shoulder height

Asthma
Coughing starts early and is non-productive early,

but when gets better will expectorate large quantities of thick, stringy mucus Skin is pale but if severe will have cyanosis Perspiration is profuse Status asmaticus can be life threatening

Medical Management
Should use humidified air when he begins to have

an attack as dehydration of respiratory mucus membranes may lead to asthma attacks. The use of steam or cool vapor humidifiers help. Push fluids to liquify secretions When assessing for bronchial asthma usual symptoms found are dyspnea, wheezing and cough

Nursing Management
Adverse drug effects (epinephrine, aminophyllin may

cause palpitations, nervousness, trembling, pallor and insomnia. Review teaching page 392

Cystic Fibrosis pg. 392

Cystic Fibrosis (CF) is a multisystem disorder that

affects infants, children, and young adults. CF results from a defective autosomal recessive gene. Inherits from both parents.

Cystic Fibrosis
Major abnormalities include: Faulty transport of sodium and chloride in cells lining organs, such as the lungs and pancreas, to their outer surfaces. Production of abnormally thick, sticky mucus in many organs, especially the lungs and pancreas. Altered electrolyte balance in the sweat glands.

Cystic Fibrosis S/S

3 major reasons to suspect CF in children are

respiratory symptoms, failure to thrive, and foulsmelling, bulky, greasy stools. Salty-tasting skin. Frequent resp. infections Finger clubbing is common. Hymoptysis Malabsorption of fats and fat soluble vitamins, difficulty gaining weight. Risk of bowel obstruction, cholecystitis, and cirrhosis is increased.

Medical Management
Promoting the removal of the thick sputum through

postural drainage, chest physical therapy with vigorous percussion and vibration, breathing exercises, hydration to help thin secretions, bronchodilator meds, nebulized mist treatments with saline or mucolytic meds and prompt treatment of lung infections with antibiotics.

Medical Management
When the digestive system is involved, clients take

pancreatic enzyme replacements (Pancrease) with meals to aid with digestion and absorption of fats. Fat-soluble vitamin supplements High-calorie diet Lung and/or liver transplant

Nursing Management
Strict adherence to a vigorous pulmonary toilet Chest physical therapy (postural drainage,

percussion, and vibration) 2-4 x a day Deep breathing and coughing exercises Nebulized treatments Medications New methods, such as high-frequency chest wall oscillation through the use of an inflatable vest

Pulmonary Hypertension pg. 394

Results from heart or lung disease or both. Most common symptoms are dyspnea on exertion

and weakness and cardiac symptoms ( chest pain, fatigue, weakness, distended neck veins, orthopnea and peripheral edema. Nursing focus is on identifying symptoms of resp distress, and reducing O2 requirements

Pulmonary Embolism pg 395

Involves the obstruction of one or more pulmonary

vessels. The blockage is the result of a thrombus that forms in the venous system or right side of the heart. An embolus is any foreign substance, such as a blood clot, air, or particle of fat that travels in the venous blood flow to the lungs.

PE S/S
Small area of the lung involved: pain, tachycardia,

and dypnea. Fever, cough and blood-streaked sputum may also occur. Larger area: severe dyspnea, severe pain, cyanosis, tachycardia, restlessness, and shock. Sudden death may follow a massive pulmonary infarction when a large embolism occludes a main section of the pulmonary artery.

PE Medical Management
IV heparin IV injection of a thrombolytic drug Complete bed rest, oxygen, analgesics

May require surgery pulmonary embolectomy-----

Nursing Management PE
Patent IV stat Administer vasopressor for TX hypotension Oxygen

Continuous EKG monitoring

Monitor anticoagulant blood studies

Pulmonary Edema pg. 397

Accumulation of fluid in alveoli of lungs will have dyspnea, breathlessness, and a feeling of

suffocation. Cool moist, and cyanotic extremities Skin color is cyanotic and gray. Has a productive cough of blood tinged frothy fluid.

Pulmonary Edema
Hallmark symptoms is a cough producing copious

frothy blood tinged sputum often appearing pinkish.

Adult respiratory distress syndrome

Important to recognize stat Elderly, neuro patients and drug overdose increases

risk Review factors that precipitate resp. failure table 274 page 397.

Malignant Disorders
Review on own

Trauma pg 401
A client with a chest injury must be observed for

dyspnea, cyanosis, chest pain, weak and rapid pulse, and hypotension---all s/s of respiratory distress.

Fractured Ribs pg 401

Common injury and may be caused by: hard fall,

blow to the chest, MVA, household accidents. Not usually serious unless the sharp end of the broken bone tears the lung or thoracic blood vessels. If no complications, may return home after emergency tx.

Fractured Ribs
Flail chest occurs when two or more adjacent ribs are

fractured in multiple places (more than two), and the fragments are free-floating. The stability of the chest wall is affected and results in a paradoxical chest wall movement.

Flail Chest
With inspiration the chest expands, but the free-

floating segments move inward instead of outward. With expiration the free-floating segments move outward, interfering with exhalation. S/s severe pain on inspiration and expiration and obvious trauma

Nursing Management
Apply the immobilization device Stress the importance of taking deep breaths every 1-

2 hours Assess for s/s respiratory distress, infection and increased pain

Blast Injuries pg 402

Compression of the chest by an explosion can

seriously damage the lungs by rupturing the alveoli. Death often results from hemorrhage and asphyxiation Subcutaneous emphysema (air in SQ tissue) is a common finding because the lungs or air passages have sustained injury

Penetrating Wounds
Serious because an opening into the thorax, which

on inspiration normally is at negative pressure, creates continuous and direct communication with the outside, which is at positive pressure. An open or penetrating wound permits air to enter the thoracic cavity, causing a pneumothorax. If not recognized and Txdeath may occur.

Penetrating Wounds
If the wound is large, a sucking noise may be heard

as air enters & leaves. Depending on the size of the wound, it takes seconds to hours before the lung collapses as the pressure in the thorax reaches atmospheric pressure. Txapplication of a tight pressure dressing over the injury site to prevent more air from entering the thorax. O2 given until further tx.

Thoracic Surgery pg 403

Review on own