Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders PDF

Chapter 19 Management of Patients with Chest and Lower Respiratory Tract Disorders Atelectasis Closure or collapse of alveoli Acute or chronic Most common is acute atelectasis, which occurs in the postoperative setting Symptoms: insidious, increasing dyspnea, cough, and sputum production...

Chapter 19 Management of Patients with Chest and Lower Respiratory Tract Disorders Atelectasis Closure or collapse of alveoli Acute or chronic Most common is acute atelectasis, which occurs in the postoperative setting Symptoms: insidious, increasing dyspnea, cough, and sputum production Acute: tachycardia, tachypnea, pleural pain, and central cyanosis if large areas of the lung are affected Chronic: similar to acute, pulmonary infection may be present Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnosis for Atelectasis Characterized by increased work of breathing and hypoxemia Decreased breath sounds and crackles over the affected area Chest x-ray may suggest a diagnosis of atelectasis before clinical symptoms appear Pulse oximetry (SpO2) may demonstrate a low saturation of hemoglobin with oxygen (less than 90%) Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for Atelectasis Prevention o Frequent turning o Early mobilization o Strategies to expand lungs and manage secretions o Incentive spirometer o Voluntary deep breathing o Secretion management o Pressurized metered-dose inhaler Copyright © 2022 Wolters Kluwer · All Rights Reserved Management of Atelectasis Improve ventilation and remove secretions First‐line measures: o Frequent turning, early ambulation, lung volume expansion maneuvers and coughing Multidisciplinary: ICOUGH (see Chart 19‐3) PEEP, CPAB, bronchoscopy CPT Endotracheal intubation and mechanical ventilation Thoracentesis to relieve compression Copyright © 2022 Wolters Kluwer · All Rights Reserved Acute Tracheobronchitis Inflammation of the mucous membranes of the trachea usually after a viral infection Pathophysiology o Mucopurulent sputum Clinical manifestations o Initially dry cough with mucoid sputum o As progresses, dyspnea, stridor, wheezes, purulent sputum Copyright © 2022 Wolters Kluwer · All Rights Reserved Management of Acute Tracheobronchitis  Medical management o Antibiotics o Analgesics o Increased fluid intake o Cool vapor therapy or steam inhalations o Suctioning  Nursing Management o Bronchial hygiene o Rest o Complete full course of medications Copyright © 2022 Wolters Kluwer · All Rights Reserved Pneumonia Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses Classification o Community-acquired (CAP) o Health care–associated (HCAP) o Hospital-acquired (HAP) o Ventilator-associated (VAP) o Refer to Chart 19-4 Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Pneumonia #1 Community-acquired o Community setting or within first 48 hours post hospitalization o Rate of infection increases with age o S. Pneumoniae is the most common cause among adults o Viral origin in infants and children Health care–associated o Often caused by multidrug‐resistant organisms o Early diagnosis and treatment are critical Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Pneumonia #2 Hospital-acquired o Develops 48 hours or more after hospitalization o Subtype of health care–associated pneumonia o Potential for infection from many sources o High mortality rate o Colonization by multiple organisms due to overuse of antimicrobial agents o Pleural effusion, high fever, and tachycardia o Common with debilitated, dehydrated patients with minimal sputum production Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Pneumonia #3  Ventilator-associated o Received mechanical ventilation for at least 48 hours o Prevention is key o VAP bundles (Chart 19-6)  Pneumonia in the immunocompromised host o Common agents include pneumocystis, fungi, and tuberculosis o Receiving immunosuppressive agents, history of immunosuppressive condition o Subtle onset with progressive dyspnea, fever, and nonproductive cough Copyright © 2022 Wolters Kluwer · All Rights Reserved Pneumonia Risk Factors Refer to Table 19-2 Occurs in patients with certain underlying disorders and diseases o Heart failure, diabetes, alcoholism, COPD, and AIDS o Influenza Cystic fibrosis Copyright © 2022 Wolters Kluwer · All Rights Reserved Clinical Manifestations of Pneumonia 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnosis of Pneumonia History Physical exam Chest x-ray Blood culture Sputum examination Bronchoscopy may be used for acute severe infection Copyright © 2022 Wolters Kluwer · All Rights Reserved Pneumonia Prevention Pneumococcal vaccination o Reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the older adult population o Two types of pneumococcal vaccine o Recommended for all adults 65 years of age or older and 19 years or older with conditions that weaken the immune system Other preventive measures, see Table 19-2 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of Pneumonia Administration of the appropriate antibiotic as determined by the results of a culture and sensitivity Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, and antihistamines Antibiotics not indicated for viral infections but are used for secondary bacterial infection Refer to Table 19-3 Gerontologic considerations Copyright © 2022 Wolters Kluwer · All Rights Reserved COVID-19 Considerations SARS-CoV-2 Asymptomatic to severe viral pneumonia Fatigue, myalgia, congestion, sore throat, diarrhea, anosmia, and ageusia Mostly conservative outpatient management (rest, hydrate, antipyretic agents) Hospitalization for severe illness with pneumonia, increased risk of venous thromboembolism Can lead to shock and respiratory failure Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient with Bacterial Pneumonia Vital signs Secretions: amount, odor, color Cough: frequency and severity Tachypnea, shortness of breath Inspect and auscultate chest Changes in mental status, fatigue, edema, dehydration, concomitant heart failure, especially in older adult patients Copyright © 2022 Wolters Kluwer · All Rights Reserved Problems/Complications of the Patient with Bacterial Pneumonia Continuing symptoms after initiation of therapy Sepsis and septic shock Respiratory failure Atelectasis Pleural effusion Delirium Copyright © 2022 Wolters Kluwer · All Rights Reserved Planning and Goals for the Patient with Bacterial Pneumonia 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 Based on patient outcomes plan for home, community, and transitional care Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Bacterial Pneumonia Oxygen with Incentive spirometry humidification to loosen Nutrition secretions Hydration o Face mask or nasal cannula Rest Coughing techniques Activity as tolerated Chest physiotherapy Patient education Position changes Self-care Copyright © 2022 Wolters Kluwer · All Rights Reserved Expected Outcomes for the Patient with Bacterial Pneumonia Demonstrates improved airway patency Rests and conserves energy and then slowly increasing activities Maintains adequate hydration; adequate dietary intake Verbalizes increased knowledge about management strategies Complies with management strategies Exhibits no complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Aspiration Inhalation of foreign material into the lungs leads to inflammatory reaction, hypoventilation, and ventilation–perfusion mismatch Serious complication is broncho or lobar pneumonia Risk factor is LOC; refer to Chart 19-8 Key pathophysiology is the volume and character of aspirated contents (most often GI contents) Copyright © 2022 Wolters Kluwer · All Rights Reserved Aspiration Prevention Swallowing screening Nursing interventions o Keep HOB elevated and endotracheal cuff elevated (if intubated) o Avoid stimulation of gag reflex with suctioning or other procedures o Check for placement before tube feedings o Soft diet, small bites, no straws Refer to Chart 19-9 Copyright © 2022 Wolters Kluwer · All Rights Reserved Pulmonary Tuberculosis  Mycobacterium tuberculosis bacillus (TB)  10 million people with TB worldwide and 9,105 cases in the United States (2017)  Spreads by airborne transmission through droplets then moves to other parts of the body such as the kidneys, bones, and cerebral cortex.  Granulomas and Ghon tubercule  Risk factors for TB, refer to Chart 19-10  Low‐grade fever  Cough; nonproductive or mucopurulent; hemoptysis  Night sweats, fatigue, weight loss Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnostic Findings for TB History and physical TB skin test; Mantoux method: See Figure 19-3 o Significant versus nonsignificant reactions TB blood tests Sputum culture Sputum testing Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of TB Treated for 6 to 12 months Drug resistance is primary concern Initiate treatment with four or more medications Complete all therapy o Initial treatment phase (8 weeks) o Continuation phase (4 to 7 months) Table 19-4 Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of TB Promoting airway clearance Advocating adherence to the treatment regimen Promoting activity and nutrition Preventing transmission Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? Once a patient recovers from tuberculosis they cannot develop an active case in the future. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Rationale: When a patient recovers from TB, the bacteria and macrophages become necrotic and form a calcified fibrous masse, a Ghon tubercle. At this point, the bacteria become dormant. However, future reinfection and activation of the dormant bacteria are possible with bacteria becoming airborne and further spreading the disease. Copyright © 2022 Wolters Kluwer · All Rights Reserved Lung Abscess Most are a complication of bacterial pneumonia Symptoms vary from a mild productive cough to acute illness; plueral friction rub Site of lung abscess related to gravity and determined by position Can lead to empyema, bronchopleural fistula Symptoms vary from a mild productive cough to acute illness, productive cough with foul sputum, leukocytosis, pleurisy, dyspnea, weakness, anorexia, and weight loss Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnostic Findings for Lung Abscess Pleural friction rub Crackles Chest x-ray Sputum culture Bronchoscopy CT of the chest Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of Lung Abscess Prevention Adequate drainage of the lung Chest physiotherapy Diet high in protein and calories Antimicrobial therapy Pulmonary resection (rare) Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of Lung Abscess Administer IV antibiotics CPT Educate patient to perform deep breathing and coughing exercises Encourage diet high in protein and calories Emotional support Promote home, community-based, and transitional care Copyright © 2022 Wolters Kluwer · All Rights Reserved Sarcoidosis Occurs between 20 and 40 years of age More common in African American women Interstitial lung disease that is inflammatory, multisystem, granulomatous with unknown origin (any organ may be affected) Clinical picture depends on systems affected including dyspnea, cough, hemoptysis, congestion, anorexia, fatigue, and weight loss Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnostic Findings for Sarcoidosis Chest x-ray and CT scans Mediastinoscopy or transbronchial biopsy Pulmonary function test Arterial blood gases Need biopsy for definitive diagnosis Copyright © 2022 Wolters Kluwer · All Rights Reserved Management of Sarcoidosis  Medical management o Corticosteroids o May have spontaneous remission without treatment o Immune modulator  Nursing management o Support all medical treatments o Patient education for medication and when to notify the primary provider o Chronic illness management o Contact Foundation for Sarcoidosis Research for community resources Copyright © 2022 Wolters Kluwer · All Rights Reserved Pleural Conditions Disorders that involve o The membranes covering the lungs (visceral pleura) and the surface of the chest wall (parietal pleura) o Disorders affecting the pleural space Pluerisy Plueral effusion Empyema Pulmonary edema Copyright © 2022 Wolters Kluwer · All Rights Reserved Pleurisy Inflammation of both layers of pleurae Key characteristic of pleuritic pain 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, provide analgesia, teaching to splint the rib cage when coughing Copyright © 2022 Wolters Kluwer · All Rights Reserved Pleural Effusion  Fluid collection in pleural space usually secondary to heart failure, TB, pneumonia, pulmonary infections  Fever, chills, pleuritic pain, dyspnea (large effusion)  Decreased or absent breath sounds; decreased fremitus; and a dull, flat sound on percussion  May have tracheal deviation away from affected side  Chest x-ray, chest CT, and thoracentesis (fluid analysis)  Treat underlying cause  Pleurodesis  Nurse must support the medial regimen and provide patient and family education Copyright © 2022 Wolters Kluwer · All Rights Reserved Empyema Accumulation of thick, purulent fluid in pleural space Complication of bacterial pneumonia or lung abscess 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 and administer antibiotics for 4 to 6 weeks Nursing management focused on psychosocial support and lung-expanding breathing exercises Copyright © 2022 Wolters Kluwer · All Rights Reserved Acute Respiratory Failure Rapid deterioration to hypoxemia, hypercapnia, and respiratory acidosis Impaired ventilation of perfusion mechanisms Early signs: restlessness, tachycardia, hypertension, fatigue, headache Later signs: confusion, lethargy, central cyanosis, diaphoresis, respiratory arrest Clinical manifestations: use of accessory muscles, decreased breath sounds Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of ARF Identification and treatment of underlying cause Intubation, mechanical ventilation Nutritional support, enteral feedings preferred Reduce anxiety Provide patient a form of communication Prevent complications (turning, ROM, mouth care, skin care) Copyright © 2022 Wolters Kluwer · All Rights Reserved Endotracheal Intubation Passing an endotracheal tube through the nose or mouth into the trachea (Figure 19-5) Provides patent airway, access for mechanical ventilation, facilitates removal of secretions Nursing care, refer to Chart 19-12 Maintain cuff pressure between 20 and 25 mm Hg Intubation for no longer than 14 to 21 days (after will require a tracheostomy) Copyright © 2022 Wolters Kluwer · All Rights Reserved Tracheotomy Surgical procedure in which an opening is made into the trachea The indwelling tube inserted into the trachea is called a tracheostomy tube (stoma may be temporary or permanent) (Fig. 19-6) Preventing complications associated with endotracheal and tracheostomy tubes, refer to Chart 19-13 Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of Tracheostomy Continuous monitoring and assessment Maintain patency by proper suctioning Semi-Fowler Administer analgesia and sedatives Provide an effective means of communication Suctioning guidelines Educate patient and family about daily care and how to prevent an emergency Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 Is the following statement true or false? Suctioning is performed every four hours for a patient with a tracheostomy or endotracheal tube. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 False Rationale: Tracheal suctioning should be performed only when adventitious breath sounds, or copious sections are present. Unnecessary, frequent suctioning can lead to bronchospasms and trauma to the tracheal mucosa. Copyright © 2022 Wolters Kluwer · All Rights Reserved Mechanical Ventilation Positive or negative pressure device to maintain ventilation and oxygenation for a prolonged period General indications, refer to Chart 19-14 Classification of ventilators Ventilator modes, see Figure 19-8 Ventilator settings, refer to Chart 19-15 Weaning the patient from the ventilator, refer to Chart 19-19 Copyright © 2022 Wolters Kluwer · All Rights Reserved Noninvasive Positive-Pressure Ventilation Method of positive-pressure ventilation that can be given via facemasks that cover the nose and mouth, nasal masks, or other oral or nasal devices such as the nasal pillow Eliminates need for endotracheal intubation or tracheostomy Continuous positive airway pressure (CPAP) Bilevel positive airway pressure (BiPAP) Indications: respiratory arrest, serious dysrhythmias, cognitive impairment, head/facial trauma Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient Receiving Mechanical Ventilation Systematic assessment of all body systems: o In-depth respiratory assessment including all indicators of oxygenation status o Neurologic status o Effective coping and emotional needs o Comfort level and ability to communicate needs Assessment of the equipment and settings Alarm fatigue Copyright © 2022 Wolters Kluwer · All Rights Reserved Problems/Complications of the Patient Receiving Mechanical Ventilation Ventilator problems Alterations in cardiac function Barotrauma and pneumothorax Pulmonary infection and sepsis Delirium and postintensive care syndrome Copyright © 2022 Wolters Kluwer · All Rights Reserved Planning and Goals for the Patient Receiving Mechanical Ventilation Goals include: o Maintenance of patent airway o Optimal gas exchange o Absence of trauma or infection o Attainment of optimal mobility o Adjustment to nonverbal methods of communication o Successful coping measures Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient Receiving Mechanical Ventilation Enhancing gas exchange Promoting effective airway clearance Preventing injury and infection Promoting optimal level of mobility Promoting optimal communication Promoting coping ability Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Intervention: Enhancing Gas Exchange Judicious use of analgesics to relieve pain without suppressing respiratory drive Frequent repositioning to diminish the pulmonary effects of immobility Monitor for adequate fluid balance: o Assess peripheral edema o I&O and daily weights Administer medications to control primary disease Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Intervention: Promoting Effective Airway Clearance Assess lung sounds at least every 2 to 4 hours Measures to clear airway: suctioning, CPT, position changes, promote increased mobility Humidification of airway Administer medications o Bronchodilators o Mucolytics Suctioning only if excessive secretions Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Intervention: Preventing Injury and Infection Infection control measures Tube care Cuff management Oral care Elevation of HOB Copyright © 2022 Wolters Kluwer · All Rights Reserved Other Interventions for the Patient Receiving Mechanical Ventilation ROM and immobility Communication methods Stress reduction techniques Interventions to promote coping Include in care: family teaching, and the emotional and coping support of the family Nutrition Home and transitional care, refer to Charts 19-17 and 19-18 Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #3 Is the following statement true or false? Alarm fatigue occurs when nurses become desensitized to alarms and do not respond with sufficient speed. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 True Rationale: Alarm fatigue occurs in ICU settings and can be life threatening for those patients receiving mechanical ventilation. To prevent alarm fatigue, consider the layout of the critical care unit, devise protocols for setting of alarms based on best practices, and educate staff on how to set and respond to alarms. Copyright © 2022 Wolters Kluwer · All Rights Reserved Acute Respiratory Distress Syndrome (ARDS) Mortality rate of 27% to 50% Characterized by sudden, progressive pulmonary edema, increasing bilateral lung infiltrates visible on chest x-ray, and absence of an elevated left atrial pressure Refer to Figure 19-9 Rapid onset of severe dyspnea and V/Q mismatch 30 mm Hg with heart failure o Cor pulmonae Pulmonary embolism Copyright © 2022 Wolters Kluwer · All Rights Reserved Occupational Lung Disease: Pneumoconioses  Includes asbestosis, silicosis, and coal workers’ pneumoconiosis  Refers to a nonneoplastic alteration of the lung resulting from inhalation of mineral or inorganic dust  Preventable, not treatable  Reduce exposure, protective gear/devices  Role of nurse is to be the employee advocate and provide health education on preventive measures to reduce lung injury  Assessment: exposure to agent, length of time exposed to onset of symptoms, congruence of symptoms  Refer to Table 19-6 Copyright © 2022 Wolters Kluwer · All Rights Reserved Lung Cancer  Leading cause of cancer death in the United States  >85% caused by cigarette smoke  Classification (cell type): 13% SCLC and 84% NSCLC tumors  Staging: size, location, lymph node involvement, metastasis (refer to Table 19-7)  Often asymptomatic until late stage  Treatment: o Surgery, radiation, chemotherapy, immunotherapy o Nurse navigators (palliative care) Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Care of the Patient with Lung Cancer Strategies to ensure relief of pain and discomfort and prevent complications Managing symptoms o Dyspnea, fatigue, nausea and vomiting, anorexia Relieving breathing problems o Airway clearance techniques Reducing fatigue Psychological support Copyright © 2022 Wolters Kluwer · All Rights Reserved Preoperative Management of the Patient Having a Thoracotomy Assessment and diagnosis Improving airway clearance Educating the patient Forced expiratory technique, diaphragmatic and pursed-lip breathing Relieving anxiety Copyright © 2022 Wolters Kluwer · All Rights Reserved Postoperative Management of the Patient Having a Thoracotomy Vital signs checked frequently, monitor for complications Oxygen Elevate HOB 30 to 45 degrees Careful positioning Medication for pain Mechanical ventilation Chest drainage Refer to Charts 19-23 and 19-25 Copyright © 2022 Wolters Kluwer · All Rights Reserved Chest Trauma Blunt trauma Pneumothorax o Sternal, rib fractures o Simple or spontaneous o Flail chest o Traumatic o Pulmonary contusion o Tension Penetrating trauma Copyright © 2022 Wolters Kluwer · All Rights Reserved Chest Tube Drainage System Chest drainage systems have: (Refer to Figures 19- 14 and 19-15) o A suction source o A collection chamber for pleural drainage o And a mechanism to prevent air from reentering the chest with inhalation Used in removal of air and fluid from the pleural space and re-expansion of the lungs Wet (water seal) or dry suction control Refer to Table 19-8 Copyright © 2022 Wolters Kluwer · All Rights Reserved