Lower Respiratory System Disorders: Nursing Care

• Chapter 14 focuses on the care of patients with disorders of the lower respiratory system.

Lesson 14.1 Objectives

• Appropriate nursing care is required for patients with bronchitis, influenza, pneumonia, empyema, and pleurisy.
• Nursing interventions are needed for patients with altered airway clearance, altered breathing patterns, altered gas exchange, and fatigue due to hypoxia.
• Nurses play a role in preventing and promptly treating tuberculosis (TB).
• Understanding the pathophysiologic changes of asthma is important in nursing care.
• Assess problems that occur with aging that lead to restrictive pulmonary disorders.
• Nursing care should address the specific needs of patients after thoracic surgery and with chest tubes.
• Complete a nursing care plan for patients with chronic obstructive pulmonary disease, incorporating home care.
• Show patients how to use a peak flowmeter.
• Review interventions for tracheostomy patients on oxygen therapy.
• Understand how respiratory therapists and nurses collaborate to ensure patient safety on mechanical ventilators.

Acute Bronchitis

• A respiratory infection spreads from the upper to lower respiratory system, involving the trachea.
• Acute bronchitis is usually viral.
• Symptoms are similar to those of the common cold.
• Treatment includes humidification with warm or cool moist air, cough mixtures, or bronchodilators.

Influenza: Etiology

• An acute and highly infectious disease affects the upper and lower respiratory tracts.
• It is caused by types A, B, and C viruses, along with numerous subtypes.
• Influenza spreads through direct and indirect contact.

Influenza: Signs and Symptoms

• Symptoms appear 2 to 3 days post-exposure.
• Symptoms include headache, fever, chills, and muscle aches.
• Symptoms include sore throat, hacking cough, runny nose, and nasal congestion.

Influenza: Treatment and Nursing Management

• Antiviral medications may be used in specific patient populations.
• Nursing interventions are more effective than drugs or medical treatments for uncomplicated influenza.

Pneumonia: Etiology and Pathophysiology

• Lung inflammation occurs with consolidation, exudate, or interstitial inflammation and edema.
• Pneumonia can result from bacteria or viruses.
• Pneumonia can result from the inhalation of irritating gases.

Pneumonia: Signs, Symptoms, and Diagnosis

• High fever accompanied by chills is common.
• Rust or blood-flecked sputum is produced by a cough.
• Sweating and chest pain, which worsens with respiratory movement, occur.
• Patients may experience malaise and aching muscles.
• Diagnosis is confirmed by chest radiography, revealing densities in the affected lung.

Pneumonia: Treatment

• Bacterial pneumonia is treated with IV or neuroral antibiotic agents.
• Viral pneumonia may be treated with antiviral medications.
• Pneumocystis jiroveci which is treated with Trimethoprim-sulfamethoxazole (Bactrim)

Complementary and Alternative Therapy for Pneumonia

• Barberry root bark is used against bacteria, fungi, and viruses.
• Barberry root bark has both gram-positive and gram-negative antimicrobial action.
• It should not be used during pregnancy due to the risk of spontaneous abortion.

Atelectasis

• It is caused by incomplete expansion or collapse of the alveoli.
• It may occur from compression of the lungs, a decrease in surfactant, or bronchial obstruction.
• Breath sounds are diminished, and oxygen saturation (Sao₂) will decrease when airways are collapsed.
• Treatment involves expelling secretions through coughing.

Fungal Infections

• Fungal infections occur through inhalation of fungus or spores.
• They are caused when the organisms found normally in the body experience overgrowth.
• The most common fungal lung infections are coccidioidomycosis, aspergillus, and histoplasmosis.

Tuberculosis (TB)

• Tuberculosis is an infectious lung disease characterized by lesions in lung tissue.
• Lesions may degenerate, become necrotic, or heal by fibrosis and calcification.
• Mycobacterium tuberculosis is the causative organism.

TB: Signs and Symptoms

• Cough, low-grade fever in the afternoon, anorexia, loss of weight, fatigue, night sweats, and sometimes hemoptysis are common.
• Tight or dull chest pain and mucopurulent sputum may occur as the disease progresses.

TB: Diagnosis

• Diagnosed using tuberculin skin testing.
• Diagnosed using blood testing.
• Diagnosed using radiographic examinations and sputum cultures.

TB: Treatment

• Active TB treatment consists of at least four drugs for a long period.
• Rifamate contains rifampin (RIF) and isoniazid (INH).
• Rifater contains RIF, INH, and pyrazinamide (PZA).

Directly Observed Therapy

• Because of increased multidrug-resistant TB, directly observed therapy (DOT) is recommended for patients known to be at risk of noncompliance.
• Visual confirmation is needed during ingestion of each required dose of medication throughout treatment.
• Public health nurses administer medication at clinic sites.
• Follow-up visits are necessary for 12 months post-therapy to monitor potential resistant strains.

Complementary and Alternative Therapy for Tuberculosis

• Vitamin D is successful for the prevention and treatment of TB.
• White blood cells convert vitamin D into an active form that assists with the protein that kills TB bacteria.
• Moving to a sunny climate and solarium environments helped people with TB years ago.

TB: Nursing Management

• Control of infection is important to TB: Nursing Management.
• Promotion of immunity is important to TB: Nursing Management.
• Support is important to TB: Nursing Management.

Extrapulmonary Tuberculosis

• Extrapulmonary Tuberculosis frequently affects the lymph nodes, bones, meninges, digestive system, urinary system, and reproductive system.
• TB of the spine, known as Pott disease, is rare in the United States.
• A hunchback or Kyphosis, is a common deformity seen in Pott disease.

Occupational Lung Disorders

• Coal dust, hemp dust, flax dust, cotton processing, and silica exposure can lead to work-related lung disorders.
• Asbestos exposure may lead to mesothelioma, a rare cancer of the chest lining.

Sarcoidosis

• The lung disease, characterized by granulomas.
• Causes fibrotic changes in lung tissue, but its cause is unknown.
• Sarcoidosis affects other tissues in the body as well.
• A cellular immune response is responsible for tissue changes.

Pulmonary Fibrosis

• Results from severe, repeated infection or inflammation caused by scarring of the lung tissue.
• Scarring decreases functional lung tissue.

Pleuritis

• Pleuritis is an inflammation of the pleura.
• TB, pneumonia, neoplasm, and pulmonary infarction can cause pleurisy.
• Pleurisy pain is sharp, abrupt, and most evident on inspiration.
• Pain may lead to shallow breathing.
• Pleural friction rub may sometimes be heard.

Pleural Effusion

• Pleural Effusion is the collection of fluid in the pleural space.
• Occurs in noninflammatory conditions for Transudative.
• Often caused by congestive heart failure, chronic liver failure, or renal disease for Transudative.
• Transudate is a thin, protein-free fluid that passes from cells into interstitial spaces or through a membrane.

Empyema

• Empyema occurs when fluid within the pleural cavity becomes infected.
• Exudate becomes thick and purulent.
• The infection is often caused by staphylococci or streptococci.

Bronchiectasis

• Bronchiectasis is a chronic respiratory disorder with permanently dilated bronchi.
• Occurs as a result of frequent respiratory infections in childhood.

Cystic Fibrosis

• Cystic Fibrosis is a genetic disease involving excessive mucus production due to exocrine gland dysfunction.
• Occurs most often in whites.
• The lungs, intestines, sinuses, reproductive tract, sweat glands, and pancreas are affected by the disease.
• Cystic Fibrosis is diagnosed by medical history, physical examination, and positive sweat test result.

Restrictive Pulmonary Disorders

• The decreased elasticity or compliance of the lungs causes Restrictive Pulmonary Disorders
• The decreased ability of the chest wall to expand causes Restrictive Pulmonary Disorders.
• Disorders of the central or neuromuscular systems can cause restrictive lung disorders.
• Myasthenia gravis and arthritis are extrapulmonary restrictive disorder causes.
• Kyphosis of the spine or severe scoliosis may hamper lung expansion.
• Lung tissue generally remains normal in muscular and skeletal disorders.

Obstructive Pulmonary Disorders

• Obstructive Pulmonary Disorders is characterized by problems moving air in and out of the lungs.
• Narrowing of the openings in the tracheobronchial tree increases resistance to airflow.
• Reduced oxygen enters due to Narrowing, and air trapping makes exhalation challenging.
• Chronic bronchitis is classified as an obstructive pulmonary disorder.
• Asthma is classified as an obstructive pulmonary disorder.
• Emphysema is classified as an obstructive pulmonary disorder.
• Atelectasis is classified as an obstructive pulmonary disorder.

Chronic Obstructive Pulmonary Disease

• Emphysema and chronic bronchitis are the causes of Etiology and diagnosis : Chronic Obstructive Pulmonary Disease (COPD).
• Bronchodilators, antiinflammatory agents, smoking cessation, respiratory rehabilitation programs, nutrition, and complementary/alternative therapies are the treatments for Etiology and diagnosis : Chronic Obstructive Pulmonary Disease (COPD).

Complementary and Alternative Therapy for Emphysema

• Ginger and cinnamon are aromatic digestives that provide benefits.
• Very small doses of Capsicum annum (chili) or garlic can be effective mucolytic agents.

Complications of Chronic Obstructive Pulmonary Disease

• Cor pulmonale
• Acute respiratory failure
• Peptic ulcer and gastroesophageal reflux
• Spontaneous pneumothorax

Audience Response Question 1

• On initial assessment of a patient with acute exacerbation of COPD, expect tensing of shoulder muscles, flaring of nostrils, and sternal retraction.

Asthma: Etiology

• Asthma: Etiology may be caused by allergens, viruses and other infectious agents, occupational and environmental toxins, and exercise.
• Asthma: Etiology may be caused by perfumes, genetics, and/or obesity, emotional stress.

Asthma: Pathophysiology

• Asthma is a chronic lung disease with reversible airway obstruction, swelling from inflammation, and airway hypersensitivity to stimuli.
• A precipitating factor creates airway inflammation, leading to bronchospasm and edema.

Asthma: Signs, Symptoms, and Diagnosis

• Diagnosis is made through medical history, physical examination, pulmonary function testing, and chest radiograph.
• Symptoms can be continuous or episodic.
• Wheezing, cough, difficulty breathing, and chest tightness occurs

Asthma: Treatment

• Asthma is treated with bronchodilators.
• Asthma is treated with theophyllines or anticholinergic agents.
• Asthma is treated with Mucolytics and antibiotics.
• Asthma is treated with Oxygen.

Lung Cancer

• Leading cause of cancer deaths worldwide.
• Non-small cell lung cancer (NSCLC) includes adenocarcinoma, squamous cell, and large cell carcinoma.
• Symptoms begin with cough and wheezing and evolve to chest pain, exertional dyspnea, and blood-streaked sputum.
• Diagnosis is confirmed after chest radiograph, sputum cytology, low-dose computed tomography (CT), positron emission tomography (PET), cytology of specimens, bronchoscopy, electromagnetic navigation, thoracentesis, fine-needle biopsy of the tumor, and video-assisted thoracoscopic surgery.
• Treatment includes surgery, chemotherapy, and/or radiation therapy.

Pulmonary Embolism

• A pulmonary vessel is blocked by a mass or clot.
• Symptoms include respiratory distress with dyspnea, chest pain, cough, hemoptysis, and anxiety.
• Diagnosis is based on symptoms, risk factors, and a plasma D-dimer test.
• Treatment includes oxygen, IV heparin, thrombolytic therapy, embolectomy, and/or an IVC filter.

Chest Injuries

• Fractured ribs are classified as chest injuries.
• Flail chest are classified as chest injuries.
• Penetrating wounds are classified as chest injuries.
• Pneumothorax and hemothorax are classified as chest injuries.
• Spontaneous and Tension Pneumothorax are classified as subcategories of a pneumothorax and hemothorax.

Pulmonary Edema

• Involves an abnormal collection of fluid in the interstitial spaces of the lung and inside the alveoli.
• Nursing care involves placing the patient in high Fowler position.
• Oxygen is started immediately, and continuous positive airway pressure (CPAP) or intubation may be necessary.
• Furosemide and Morphine reduces anxiety and decreases the workload on the heart.

Acute Respiratory Distress Syndrome

• Pulmonary changes occur with sepsis, major trauma, major surgery, or any critical illness.
• Signs and symptoms include dyspnea, tachypnea, tachycardia, hypoxemia, fine, scattered crackles, and respiratory alkalosis.
• Treatment includes ventilator support and treating the underlying cause.

Respiratory Failure

• Results from insufficient oxygen or excessive carbon dioxide.
• Signs and symptoms include restlessness, agitation, or confusion.
• An increase in respiratory rate, pulse, and blood pressure is a physiologic attempt to compensate for inadequate oxygenation.
• The patient may sit upright, bend forward, and be unable to speak without pausing.

Common Therapeutic Measures

• Intrathoracic surgery measures include preoperative and postoperative care.
• Medication administration measures.
• Humidification measures.
• Pulmonary hygiene measures.
• Oxygen therapy measures.

Chest Tubes and Closed Drainage

• They provide drainage of air and blood from within the pleural cavity for purposes of chest tubes and closed drainage.
• They allow for gradual re-expansion of the lung for purposes of chest tubes and closed drainage.
• Assessments include the respiratory status, the insertion site of the tube, and the amount/character of the drainage.

Mechanical Ventilation

• Modes of ventilation.
• Pressure support ventilation.
• Continuous positive airway pressure.
• Noninvasive positive ventilation.

Preventing Ventilator-Acquired Pneumonia

• Centers for Disease Control and Prevention recommends raising the head of the bed between 30-45 degrees.
• Continuous removal of subglottic secretions.
• Change of ventilator circuit no more often than every 48 hours and frequent hand washing.
• Facility bundle policies may include checking the residual volume in the nasogastric tube for preventing ventilator-acquired pneumonia.
• Providing oral care with chlorhexidine and deep vein thrombosis prophylaxis.
• Prophylaxis for peptic ulcer.