Disorders of the Lower Respi

7/31/2019 Disorders of the Lower Respi

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M E D I C A L S U R G I C A L

Chpt 27: Disorders of Lower

Respiratory Tract



Acute bronchitis PG 374

Characterized by inflammation of the mucousmembranes that line the major bronchi and their

branches.

Most common cause is a viral infection

Signs & symptoms: fever, malaise, and a dry, non-productive cough that later becomes productive of mucopurulent sputum



Acute Bronchitis

Acute bronchitis differs from pneumonia inthat with acute bronchitis there is initially anonproductive 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, expectorantsand antitussives and lots of fluids

If secondary bacterial infection occurs then it becomes a serious condition. Has persistent coughand thick purulent sputum if secondary infectionoccurs



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 handlingsoiled tissues

cover mouth when sneezing and coughing

Discard soiled tissues in a plastic bag Avoid sharing articles



Pneumonia PG 374

Infalmmatory process affecting bronchioles andalveoli

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 infectionscattered thruout both lungs

hypostatic--hypoventilation in immobile



Pneumonia

Organisms that cause pneumonia reach the alveoli by inhalation of droplets, aspiration of organismsfrom upper airway, or from bloodstream.

When organisms reach alveoli, an intenseinflammatory reaction occurs. This produces exudate which impairs gas exchange .



Pneumonia

Capillaries surrounding the alveoli become engorgedand 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 purulentarthritis

atelectasis hypotension and shock



Bacterial Pneumonia

Onset of bacterial is sudden. he has fever, chills, aproductive cough, and discomfort in chest wallmuscle from coughing. Malaise, breathing may causepain and he breathes shallowly

Classic symptom is rusty colored sputum



Viral Pneumonia

Differs from bacterial in that blood cultures aresterile, sputum may be more copious, chills are lesscommon, and pulse and resp rates are

characteristicly slow. Mortality rate low as less serious than bacterial.

Mortality rate increases if secondary bacterialinfection occurs. Wheezing, crackles, & decreased

breath sounds. Nail beds, lips & oral mucosa may be cyanotic



Nursing

When he has pneumonia, adequate oxygenationcan be accomplished by placing him in a semi-fowlers 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 visceralpleura

Respirations become shallow secondary to

excruciating pain caused by inflamed pleurarubbing together. This causes severe, sharp pain.Pleura fluid increases because it separates thepleura 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 affectedside. May also splint by using hands or a pillow whencoughing



Pleural effusion PG 377

collection of fluid between the visceral and parietalpleura

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 theheart and other organs



Pleural effusion

Fever, pain, and dyspnea are the most commonsymptoms. Chest percussion reveals dullness overthe 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 lungparenchyma. As pus increases, necrosis of thetissue occurs. Later the area collapses and creates a

cavity Signs and symptoms --chills, fever, weight loss,

chest pain and a productive cough. Sputum may bepurulent or blood streaked

There will be dull or absent breath sounds in thearea of abscess



Surgical Management

A lobectomy may be done to remove the abscess andsurrounding 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 topus or infected fluid in the pleural cavity

Fever chest pain, dyspnea, anorexia and malaise.

there will be diminished or absent breath soundsover area. Appears acutely ill

Thoracentesis and chest tube drainage used todrain purulent drainage. Following a thoracentesis

must observe for resp distress



Chest Tubes

The use of chest tubes is usually necessary to drainsecretions, air, and blood from the thoracic cavity inorder to re-expand the lung.

Chest tubes are inspected frequently since any break in the system could allow air to be drawn into thepleural space and collapse the lung



Chest Tubes

When inspecting chest tubes connected to anunderwater seal system, the nurse makes sure thesystem is kept below the level of the bed

If any break or major leak occurs the nurseimmediately clamps the chest tube

Clamps must be taped to the bed frame when chesttubes 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 chronicconditions (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 affectslungs but can affect kidney and other organs

Tubercle bacilli are gram-positive, rod-shaped,

acid fast bacteria. It can live in the dark for monthsin particles of dried sputum, exposure to directsunlight, heat and ultraviolet light destroys them ina 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 witha person who has the active disease thru inhalationof 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 isadvanced. as they develop they are often vague andcan be overlooked

Fatigue, anorexia, weight loss, and a slightnonproductive cough are early symptoms

Low grade fever, particularly in late afternoon, andnight sweats are common as it progresses. Cough

becomes productive of mucopurulent and blood-streaked sputum.



Marked weakness, wasting, hemoptysis and dyspneaare common late stage. Chest pain may result fromspread to pleura

Must identify bacteria to diagnose. Cultures of sputum ordered. Can do gastric washings to retrieveswallowed bacteria.Gastric gavage, gastric aspirationand bronchoscopy used.



Medications

Combined therapy with two or more drugs decreasethe likelihood of drug resistance, increases the actionof drugs

antibubercular drugs are given for long periods and without interruption because healing is slow andresistance to drugs is increased by interruptedtreatment.



Drug Regimen for TB table 27-1 pg 382

The primary focus of a teaching plan for TB is toencourage 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 takenfor...may take meds up to 18 to 24 months



Surgical Management

surgery may be done if disease is located primarily inone section of lung.

Segmental resection--one section removed

Wedge resection lobectomy

pneumonectomy--entire lung



Assessment

Breath sounds, breathing patterns, and overallrespiratory status

Any pain breathing?

Inspect sputum for color, viscosity, amount and forsigns of blood

Review page 382 and 383 for nursing care



Teaching

Take meds exactly as prescribed and observe timeintervals between each dose

Drugs must be taken for a long time, complete theentire series

Stress importance of continuous therapy becauselapses in taking the drugs result in reactivation of infection

Notify Dr if symptoms worsen or sudden chestpain or dyspnea



Teaching for TB

Drink extra fluids. Take med for fever but if itcontinues call Dr

Stop smoking and avoid second hand smoke

Eat a balanced but light diet. Call Dr if more than afew pounds lost

Avoid people with infections

follow up care is important!!



Obstructive Pulmonary Disease pg. 383

COPD is a broad, nonspecific term that describes agroup of pulmonary disorders with symptoms of chronic cough and expectoration, dyspnea, and animpaired expiratory air flow.

Bronchiecstasis, atelectasis, chronic bronchitis andemphysema are COPD disorders.



Obstructive Disease

Asthma is also an obstructive disorder that is moreepisodic--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 irreversibledilation of the bronchi and bronchioles andchronic infection

When clearance of airway is impeded an infectioncan develop in the walls of the bronchus or bronchiole. This leads to changes in the structureof the wall tissue and results in the formation of

saccular dilatations which collect purulent material



S/S

Chronic cough with expectoration of copiousamounts of purulent sputum and possiblehemoptysis.

Cough becomes worse when changing positions. Canspit up several ounces of sputum



Bronchiectasis

When sputum is collected it settles in three distinctlayers

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 ithelps mobilize and expectorate secretions

Performed three times a day in each position while

he inhales slowly and blows the breath out thru themouth. Usually takes 5 to 15 min.see picture pg385 (used to drain lower lobes) chest percussionand vibration also used



Atelectasis pg 384

Collapse of lung tissue. May involve a small portionof lung or entire lung.

Symptoms related to size of collapsed area

Small areas may have few symptoms. Large areascause cyanosis, fever, pain, dyspnea, increasedpulse and resp rates and increased pulmonary secretions

Crackling may be heard but usually absent breathsounds in the area



Nursing Management

Care focus is on prevention. Deep breathing andcoughing post-op can prevent

If it occurs encourage him to cough and deep breathefrequently and to use incentive spirometer (review guidelines pg. 386)



Chronic Bronchitis pg 384

Persistence of a chronic cough with excessiveproduction of mucus for at least 3 months a yearfor 2 consecutive years

Characterized by hypersecretions of mucus by the bronchial glands and recurrent or chronicrespiratory 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 morningand 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 exertionis a common symptom of pulmonary hypertension)

but leads to dyspnea with minimal activity and laterat 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, teachpostural 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 handsmoke, 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 onelarge 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 distendduring inspiration



Emphysema

In advanced cases memory loss, drowsiness,confusion, and loss of judgment may occur

CO2 levels may reach toxic levels resulting inlethargy, stupor, and eventually coma

Will have decreased breath sounds, wheezes andcrackles. Heart sounds will be diminished



Nursing Management

Respiratory center is sensitive to the level of CO2in the blood. If level increases slightly, therespiratory rate and depth increases to eliminateexcess. If it is chronically increased the resp center becomes insensitive to CO2

As long as oxygen is low he breathes, if it becomeshigh he stops…do not give oxygen over 2-3 liters



Emphysema

Safest to give O2 using a nasal cannula

If color improves but level of consciousnessdecreases 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 andpatient teaching page 389 & 390



Asthma pg. 390

Reversible obstructive disease. Three types: allergic asthma--pollen, dust, spores, animal dander

idiopathic asthma--upper resp infections, emotionalupsets 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, poorperfusion, possible atelectasis and respiratory failureif 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

h



Asthma

Coughing starts early and is non-productive early, but when gets better will expectorate large quantitiesof thick, stringy mucus

Skin is pale but if severe will have cyanosis

Perspiration is profuse Status asmaticus can be life threatening

di l



Medical Management

Should use humidified air when he begins to havean attack as dehydration of respiratory mucusmembranes may lead to asthma attacks. The use of steam or cool vapor humidifiers help. Push fluidsto liquify secretions

When assessing for bronchial asthma usualsymptoms found are dyspnea, wheezing and cough

i



Nursing Management

Adverse drug effects (epinephrine, aminophyllin may cause palpitations, nervousness, trembling, pallorand insomnia.

Review teaching page 392

C i Fib i



Cystic Fibrosis pg. 392

Cystic Fibrosis (CF) is a multisystem disorder thataffects infants, children, and young adults.

CF results from a defective autosomal recessive gene.

Inherits from both parents.

C i Fib i



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.

C i Fib i S/S



Cystic Fibrosis S/S

3 major reasons to suspect CF in children arerespiratory symptoms, failure to thrive, and foul-smelling, 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.

M di l M t



Medical Management

Promoting the removal of the thick sputum throughpostural drainage, chest physical therapy with

vigorous percussion and vibration, breathingexercises, hydration to help thin secretions,

bronchodilator med’s, nebulized mist treatments with saline or mucolytic med’s and prompt treatmentof lung infections with antibiotics.

M di l M t



Medical Management

When the digestive system is involved, clients takepancreatic enzyme replacements (Pancrease) withmeals to aid with digestion and absorption of fats.

Fat-soluble vitamin supplements

High-calorie diet

Lung and/or liver transplant

N i M t



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 walloscillation through the use of an inflatable vest

P l H t i



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, orthopneaand peripheral edema.

Nursing focus is on identifying symptoms of respdistress, and reducing O2 requirements

P l E b li 39



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



PE S/S

Small area of the lung involved: pain, tachycardia,and dypnea. Fever, cough and blood-streakedsputum 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 M di l M t



PE Medical Management

IV heparin IV injection of a thrombolytic drug

Complete bed rest, oxygen, analgesics

May require surgery pulmonary embolectomy-----

Nursing Management PE



Nursing Management PE

Patent IV stat Administer vasopressor for TX hypotension

Oxygen

Continuous EKG monitoring Monitor anticoagulant blood studies

Pulmonary Edema pg 397



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 productivecough of blood tinged frothy fluid.

Pulmonary Edema



Pulmonary Edema

Hallmark symptoms is a cough producing copiousfrothy blood tinged sputum often appearing pinkish.

Adult respiratory distress syndrome



Adult respiratory distress syndrome

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

risk

Review factors that precipitate resp. failure table 27-4 page 397.

Malignant Disorders



Malignant Disorders

Review on own

Trauma pg 401



Trauma pg 401

A client with a chest injury must be observed fordyspnea, cyanosis, chest pain, weak and rapid pulse,and hypotension---all s/s of respiratory distress.

Fractured Ribs pg 401



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 afteremergency tx.

Fractured Ribs



Fractured Ribs

Flail chest occurs when two or more adjacent ribs arefractured in multiple places (more than two), and thefragments are free-floating.

The stability of the chest wall is affected and resultsin a paradoxical chest wall movement.

Flail Chest



Flail Chest

With inspiration the chest expands, but the free-floating segments move inward instead of outward.

With expiration the free-floating segments moveoutward, interfering with exhalation.

S/s –severe pain on inspiration and expiration andobvious trauma

Nursing Management



Nursing Management

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

2 hours

Assess for s/s respiratory distress, infection andincreased pain

Blast Injuries pg 402



Blast Injuries pg 402

Compression of the chest by an explosion canseriously damage the lungs by rupturing the alveoli.

Death often results from hemorrhage andasphyxiation

Subcutaneous emphysema (air in SQ tissue) is acommon finding because the lungs or air passageshave sustained injury

Penetrating Wounds



Penetrating Wounds

Serious because an opening into the thorax, whichon inspiration normally is at negative pressure,creates continuous and direct communication withthe outside, which is at positive pressure.

An open or penetrating wound permits air to enterthe thoracic cavity, causing a pneumothorax. If notrecognized and Tx—death may occur.

Penetrating Wounds



Penetrating Wounds

If the wound is large, a sucking noise may be heardas air enters & leaves.

Depending on the size of the wound, it takesseconds to hours before the lung collapses as thepressure in the thorax reaches atmosphericpressure.

Tx—application of a tight pressure dressing over

the injury site to prevent more air from enteringthe thorax. O2 given until further tx.

Thoracic Surgery pg 403



Review on own

Disorders of the Lower Respi

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