Management of Patients with Respiratory Dysfunction PDF

MANAGEMENT OF PATIENTS WITH RESPIRATORY DYSFUNCTION Nisha Sivapalan RN MSN 1 Objectives Describe ventilation, perfusion, diffusion, shunting, and the relationship of pulmonary circulation to these processes. Discriminate between normal and abnormal breath sound...

MANAGEMENT OF PATIENTS WITH RESPIRATORY DYSFUNCTION Nisha Sivapalan RN MSN 1 Objectives Describe ventilation, perfusion, diffusion, shunting, and the relationship of pulmonary circulation to these processes. Discriminate between normal and abnormal breath sounds. Use assessment parameters appropriate for determining the characteristics and severity of the major symptoms of respiratory dysfunction. Identify the nursing implications of the various procedures used for diagnostic evaluation of respiratory function Identify the nursing management of the various disorders of respiratory system 2 3 Respiratory System 4 Functions of the Respiratory System 1.Oxygen Transport Oxygen is supplied to, and carbon dioxide is removed from, cells by way of the circulating blood. 2.Respiration This process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body is called respiration. 3.Ventilation –Act of breathing 4.Pulmonary diffusion and perfusion Diffusion is the process by which oxygen and carbon dioxide are exchanged at the air–blood interface. Pulmonary perfusion is the actual blood flow through the pulmonary circulation. 5 5.Ventilation and Perfusion Balance and Imbalance 7 640 sit as 6.Gas Exchange 7.Neurologic Control of Ventilation The inspiratory and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation to meet the body’s metabolic demands. The apneustic center - promote deep, prolonged inspirations. The pneumotaxic center – control the pattern of respirations. 6  Assessment To assess dyspnea effectively, nurses should ask: Health History 1.Is shortness of breath associated with any other symptoms, like a Focuses on the patient's presenting problem and cough? associated symptoms. 2.Was the onset sudden or gradual? Explores onset, location, duration, character, 3.At what times does shortness of aggravating and alleviating factors, radiation, and breath occur? timing of the problem. 4.Is it exacerbated by lying flat? Evaluates how these factors impact daily living, 5.What level of exertion triggers work, family activities, and quality of life. it? Does it occur at rest? 6.On a scale from 1 to 10, how Major signs and symptoms of respiratory disease would you rate your include dyspnea, cough, sputum production, chest breathlessness? pain, wheezing, and hemoptysis. Consider non pulmonary diseases during the assessment. 7  Dyspnea Visual Analogue Scale Subjective feeling of difficult or labored breathing, breathlessness, shortness of breath Associated with allergic reactions, anemia, neurologic or neuromuscular disorders, trauma, and advanced disease, and is common at the end of life. Acute diseases of the lungs produce a severe grade of dyspnea Sudden dyspnea in a healthy person may indicate pneumothorax, acute respiratory obstruction, allergic reaction, or myocardial infarction In immobilized patients, sudden dyspnea may denote pulmonary embolism (PE) Orthopnea (shortness of breath when lying flat, relieved by sitting or standing) may be found in patients with heart disease and occasionally in patients with chronic obstructive pulmonary disease (COPD) Dyspnea with an expiratory wheeze occurs with COPD The high-pitched sound heard (usually on inspiration) when someone is breathing through a partially blocked upper airway is called stridor croup disease 8  Cough Cough is a reflex that protects the lungs from the accumulation of secretions or the inhalation of foreign bodies Mucus, pus, blood, or an airborne irritant, such as smoke or a gas, may stimulate the cough reflex Coughing at night - onset of left-sided heart failure or bronchial asthma A cough in the morning with sputum production -bronchitis. A cough that worsens when the patient is supine - postnasal drip (rhinosinusitis). Coughing after food intake -aspiration of material into the tracheobronchial tree. A cough of recent onset -an acute infection A dry, irritative cough is -upper respiratory tract infection of viral origin, or side effect of ACE inhibitor therapy compine of Irritative, high-pitched cough -laryngotracheitis. dry Irritative cough Brassy cough -tracheal lesion. ask IF he take ACE Inhibitor drag Severe or changing cough -bronchogenic carcinoma. A nurse interviewing a patient who says he has a dry, irritating cough that is not “bringing anything up” should ask whether he is taking ACE inhibitors. 9  Sputum Production Profuse, purulent sputum or color change - bacterial infection. Thin, mucoid sputum -viral bronchitis. Gradual increase of sputum over time -chronic bronchitis or bronchiectasis. Pink-tinged mucoid sputum - lung tumor. Profuse, frothy, pink material -pulmonary edema. Foul-smelling sputum and bad breath - lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms. 10  Wheezing narrowing in airway Keyword Wheezing is a high-pitched, musical sound heard on either expiration (asthma) or inspiration (bronchitis). It is often the major finding in a patient with bronchoconstriction or airway narrowing. Rhonchi are low pitched continuous sounds heard over the lungs in partial airway obstruction.Keyword Depending on their location and severity, these sounds may be heard with or without a stethoscope Hemoptysis -is the expectoration of blood from the respiratory tract. 91blood Common causes include pulmonary infection, lung cancer, heart or blood vessel abnormalities, pulmonary artery or vein abnormalities, and PE or infarction. Chest Pain - pneumonia, pulmonary infarction, pleurisy, or as a late symptom of bronchogenic carcinoma. Pleuritic pain from irritation of the parietal pleura is sharp and "catch" on inspiration 11 Risk factors for Respiratory Disease I Smoking -the single most important contributor to lung disease Exposure to secondhand smoke Personal or family history of lung disease Genetic makeup Exposure to allergens and environmental pollutants Exposure to certain recreational and occupational hazards Dietary factors, including poor nutrition HIV infection, overcrowding Atypical immune responses Eg: asthma 12  Physical Assessment of the Respiratory System Clubbing of the fingers -sponginess of the nail bed and loss of the nail bed angle. Seen in chronic hypoxic conditions, chronic lung infections, or malignancies of the lung Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. A patient with a hemoglobin level of 15 g/dl does not demonstrate cyanosis until 5 g/dl of that hemoglobin becomes unoxygenated, a patient with anemia rarely manifests cyanosis Patient with polycythemia may appear cyanotic even if adequately oxygenated. Assessment of cyanosis is affected by room lighting, the patient’s skin color, and the distance of the blood vessels from the surface of the skin. Central cyanosis is assessed by observing the color of the tongue and lips. This indicates a decrease in oxygen tension in the blood. Peripheral cyanosis results from decreased blood flow to the body’s periphery (fingers, toes, or earlobes), as in vasoconstriction from exposure to cold, and does not necessarily indicate a central systemic problem. 13  Chest configuration Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1:2. Barrel Chest. - over inflation of the lungs. There is an increase in the diameter of the thorax. Funnel Chest (Pectus Excavatum). - a depression in the lower portion of the sternum. occurs with rickets or Marfan’s syndrome. Pigeon Chest (Pectus Carinatum).- displacement of the sternum. There is an increase in the diameter. occurs with rickets, or severe kyphoscoliosis. Kyphoscoliosis. -elevation of the scapula and a corresponding S-shaped spine. occurs with osteoporosis and skeletal disorders 14 Haakon 15 16 Breathing patterns and respiratory rates  Observe for the use of accessory muscles-sternocleidomastoid, Use of Accessory Muscles scalene, and trapezius muscles during inspiration, and the abdominal and internal intercostal muscles during expiration. Breath Sounds Bronchial sounds - loud, harsh, and high pitched, typically heard over the trachea or at the right apex. Vesicular breath sounds - soft, low pitched, predominantly inspiratory, appreciated especially at the posterior lung bases. Bronchovesicular sounds -heard during inspiration and expiration, with a mid-range pitch and intensity Bronchophony describes vocal resonance that is more intense and clearer than normal. Egophony describes voice sounds that are distorted. It is best i iii appreciated by having the patient repeat the letter E. Whispered pectoriloquy describes the ability to clearly and distinctly hear whispered sounds that should not normally be heard 17 18  Diagnostic Evaluation 3H Pulmonary Function Tests -Measures lung volumes, ventilatory function and mechanics of breathing, diffusion, and gas exchange Arterial Blood Gas (ABG) and Venous Blood Gas (VBG) Studies I ABG studies assess the lungs' ability to provide oxygen and remove carbon dioxide, reflecting ventilation. VBG studies provide data on oxygen delivery and consumption. Pulse Oximetry SpO2, is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). Normal SpO2 values are more than 95%, with values less than 90% indicating tissues are not receiving enough oxygen. SpO2 values are unreliable in cardiac arrest, shock, and other states of low perfusion. Other causes of inaccurate SpO2 results include anemia, abnormal hemoglobin, high carbon monoxide level, use of dyes, dark skin, bright light, and patient movement. 19 Diagnostic Evaluation Cultures ✓Throat, nasal, and nasopharyngeal cultures can identify pathogens responsible for respiratory infections. ✓Sputum Studies- Sputum is obtained for analysis to identify pathogenic bacteria. Sputum Studies ✓Obtain samples early in the morning before eating or drinking. ✓Clear nose and throat, rinse mouth to reduce sputum contamination. ✓ Cough deeply after deep breaths and expectorate sputum into a sterile container. ✓ If insufficient expulsion, administer aerosolized hypertonic solution via a nebulizer. 20  - Diagnostic Evaluation Imaging studies Chest X-Ray Fluid, tumors, foreign bodies, and other pathologic conditions can be detected by x-ray examination. ✓ Deep breath and comfortable holding necessary for visualization. ✓ Patient positioned in standing, sitting, or recumbent position for chest view. ✓ Patient required to wear gown, remove metal objects, and possibly given lead shield to minimize radiation exposure Computed Tomography-CT ✓ Patients must remain supine for less than 30 minutes while a body scanner takes multiple images. ✓ Antianxiety medications can be given if claustrophobia is a concern. ✓ NPO for 4 hours before contrast dye examination. ✓ Nurse should assess for iodine or shellfish allergies. 21 Magnetic Resonance Imaging MRI Remove all metal items, including hearing aids, hair clips, and medication patches with metallic foil components. Nurses should assess for implanted metal devices before MRI. Lie flat and remain still for 30 to 90 minutes while the table moves. Loud humming or thumping noise heard, with earplugs offered to minimize it. Communicate with MRI staff via a microphone and earphones. Patients with claustrophobia should be offered antianxiety medications Fluoroscopic Studies -is used to assist with invasive procedures, such as a chest needle biopsy or transbronchial biopsy, performed to identify lesions Pulmonary Angiography -Involves the rapid injection of a radiopaque agent into the vasculature of the lungs for radiographic study of the pulmonary vessels. Obtain informed consent before angiography. Assess for known allergies to radiopaque dye. Check anticoagulation status and renal function. NPO for 6 to 8 hours. Inform patient about warm flushing sensation or chest pain during dye injection. Radioisotope Diagnostic Procedures (Lung Scans) Eg: Ventilation-perfusion scan 22 Bronchoscopy direct inspection and examination of the larynx, trachea, and 23 bronchi through bronchoscope. ✓ Informed consent , NPO for 4-8 hours. ✓ Preoperative medications to suppress cough reflex, sedate the patient, and relieve anxiety. ✓ Remove dentures and other oral prostheses. ✓ Usually performed under local or moderate sedation. ✓ After the procedure, the patient must not eat until cough reflex returns. ✓ Respiratory status is monitored for hypoxia, hypotension, tachycardia, dysrhythmias, hemoptysis, and dyspnea. ✓ Sedation given to patients with respiratory insufficiency may precipitate respiratory arrest. Thoracoscopy Diagnostic procedure in which the pleural cavity is examined with an endoscope. Informed consent and NPO. Monitor vital signs, pain level, and respiratory status postoperatively. Look for signs of bleeding and infection at incisional site. Thoracentesis ⚫ Aspiration of pleural fluid for diagnostic or therapeutic purposes. Biopsy ⚫ The excision of a small amount of tissue, may be performed to permit examination of cells from the pharynx, larynx, and nasal passages. ✔ Pleural Biopsy ✔ Lung Biopsy -Monitor for complications like shortness of breath, bleeding, or infection. ✔ Lymph Node Biopsy 24  Oxygen therapy Oxygen is a colorless, odorless, tasteless gas that is essential for the body to function properly and to survive. Oxygen therapy is the administration of oxygen at a concentration of pressure greater than that found in the environmental atmosphere The air that we breathe contain approximately 21% oxygen. When oxygen is used at high flow rates, it should be moistened by passing it through a humidification system to prevent it from drying the mucous membranes of the respiratory tract. Methods of oxygen administration Oxygen Delivery Systems: 6. Oxygen Hood 1.Nasal Cannula 7. Oxygen Tent 2. Simple Mask 8. AMBU Bag 3. Partial Re-Breather Mask 9. Tracheostomy Collar 4. Non-Re Breather Mask (NRBM) 10. T-piece 5. Venturi Mask 25 Nasal cannula (prongs): The simple Oxygen mask. 1 L/min=24% 2 L/min =28% 3 L/min =32% 4 L/min =36% 5 It delivers 35% to 60% oxygen. L/min =40% 6 L/min=44% A flow rate of 6 to 10 liters per minute. Advantages Client able to talk and eat with oxygen in place It has vents on its sides which allow room air to leak in at Easily used in home setting Safe and simple Easily tolerated many places, thereby diluting the source oxygen. Advantages: Delivers low concentrations Can provide increased delivery of oxygen for short period of Nursing interventions: time Be alert for skin breakdown over the ears and in the nostrils Disadvantages: from too tight an application Potential for skin breakdown (pressure, moisture) Observe for mucosal dryness Uncomfortable for pt while eating or talking Check frequently that both prongs are in clients nares Nursing interventions: Monitor client frequently to check placement of the mask. Secure physician's order to replace mask with nasal cannula during meal time The Non Re Breather Mask provides the highest concentration of oxygen (95-100%) at a flow rate 6-15 L/min. It is similar to the partial re-breather mask except two one-way valves prevent conservation of exhaled air. Advantages Delivers the highest possible oxygen concentration Disadvantages Impractical for long term Therapy Malfunction can cause CO2 buildup Nursing Interventions Maintain flow rate so reservoir bag collapses only slightly during inspiration Check that valves and rubber flaps are functioning properly (open during expiration)  Venturi Mask high flow oxygen delivery device. Oxygen from 40 - 50% with flow of 4 to 15 L/min. The mask is constructed so that there is a constant flow of room air blended with a fixed concentration of oxygen. Used primarily for patients with chronic obstructive pulmonary disease Advantages : Delivers most precise oxygen Concentration Disadvantages: Produce respiratory depression in Oxygen tent COPD patient with high oxygen concentration 50% Nursing Interventions Requires careful Ambu bag monitoring to verify FiO2 at flow rate ordered Check that air intake valves are not blocked Tracheal collar/mask Nursing Management Indicate when a humidifier should be used. Identify signs and symptoms indicating the need for change in oxygen therapy safety measures NOT to smoke or be around people who are smoking while using oxygen. Post “No Smoking—Oxygen In Use” signs on doors. Notify local fire department and electric company of oxygen use in home. Never use paint thinners, cleaning fluids, gasoline, aerosol sprays, and other flammable materials while using oxygen. Keep all methods of oxygen delivery at least 15 ft away from matches, candles, gas stove, or other source of flame, and 5 ft away from television, radio, and other appliances. Keep oxygen tank out of direct sunlight. When traveling in automobile, place oxygen tank on floor behind front seat 29 Postural Drainage (Segmented Bronchial Drainage) Uses gravity to remove bronchial secretions. Secretions drain from affected bronchioles into the bronchi and trachea, removed by coughing or suctioning Instruct patient to inhale bronchodilators and mucolytic agents before postural drainage 30  Nursing Management Postural drainage is performed two to four times daily, before meals and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before drainage. Patient is made comfortable in each position and provided with emesis basin, sputum cup, and paper tissues. Patient remains in each position for 10 to 15 minutes, breathing in and out slowly to keep airways open. If coughing is not possible, mechanical suctioning may be necessary. After procedure, the amount, color, viscosity, and character of expelled sputum are noted. Skin color and pulse are evaluated first few times. 31 Upper Respiratory Tract Disorders Rhinitis Group of disorders characterized by inflammation and irritation of the mucous membranes of the nose Often coexists with other respiratory disorders, such as asthma may be acute or chronic, and allergic or nonallergic Causes: temperature changes, odors, infection, age, systemic disease, use of OTC and prescribed nasal decongestants, and foreign body presence. Allergic rhinitis - exposure to allergens(Dust mite, pet dander, trees), medications Nonallergic rhinitis - due to the common cold. Drug-induced rhinitis - antihypertensive agents, "statins," antidepressants, antipsychotics, aspirinetc 32  Clinical manifestations Rhinorrhea: Excessive nasal drainage and runny nose, Nasal congestion, Sneezing, Headache Management: Viral rhinitis – medications,Bacterial infection-antimicrobial agent Allergic rhinitis-allergy tests,desensitizing immunizations and corticosteroids Septal deformities or nasal polyps - refer to an ENT specialist. Pharmacologic Therapy ✓ Antihistamines and corticosteroid nasal sprays ✓ Oral decongestant agents -for nasal obstruction. ✓ Saline nasal spray -prevents crusting. ✓ Intranasal ipratropium (Atrovent) is given for symptomatic relief - ✓ Intranasal corticosteroids -for severe congestion. ✓ Ophthalmic agents -relieve irritation, itching, and redness of the eyes. ✓ Leukotriene modifiers and immunoglobulin E modifiers. Nursing management-avoiding allergens and irritants ❖Correct administration of nasal medications, including blowing the nose before application, keeping head upright, and waiting for at least 1 minute before administering the second spray. ❖Hand hygiene 33  Obstructive Sleep Apnea Disorder characterized by recurrent episodes of upper airway obstruction and reduced ventilation. Prevalence is around 26% in adults aged 30-70. OSA interferes with adequate rest, affecting memory, learning, and decision making. Risk factors include obesity, male gender, postmenopausal status, and advanced age. Major risk factor is obesity, with larger neck circumference and increased peripharyngeal fat. Other factors include structural changes in the upper airway. 34  Clinical Manifestations Frequent, loud snoring, at least five episodes per hour, and abrupt awakenings due to blood oxygen level drops. Symptoms include the "3S's": snoring, sleepiness, and significant other sleep apnea episodes. Symptoms progress with weight and aging. Patients often complain of insomnia, chronic fatigue, and hypersomnolence(daytime sleepiness). Pathologic hypersomnolence is considered when sleep during normal activities is observed. Diagnostic test: A polysomnographic test- is an overnight study in a specialized sleep disorders center. Medical Management : weight loss, alcohol avoidance, positional therapy, and oral applications like mandibular advancement devices (MADs). In severe cases, CPAP or bilevel positive airway pressure (BiPAP) therapy with supplemental oxygen is used Surgical Management -Simple tonsillectomy, Uvulopalatopharyngoplasty, Nasal septoplasty, Maxillomandibular surgery, Tracheostomy - for patients with concomitant cardiovascular disease, life-threatening dysrhythmias 35 Pharmacologic Therapy for OSA Modafinil (Provigil) reduces daytime sleepiness. Protriptyline (Triptil) increases respiratory drive and improves upper airway muscle tone. Medroxyprogesterone acetate (Provera) and acetazolamide (Diamox) treat sleep apnea. Low-flow nasal oxygen at night can relieve hypoxemia but doesn't affect apnea frequency or severity. Nursing Management Explain OSA in understandable terms. Educate patient and family about treatments, including correct use of CPAP, BiPAP, MAD, and oxygen therapy. Educate patient about untreated OSA risk and treatment benefits. 36  Epistaxis (Nosebleed) Hemorrhage from the nose, is caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose Risk factors Local infections (vestibulitis, rhinitis, rhinosinusitis), Systemic infections (scarlet fever, malaria) Drying of nasal mucous membranes Nasal inhalation of corticosteroids (e.g., beclomethasone) or illicit drugs (e.g., cocaine) Trauma (digital trauma, blunt trauma, fracture, forceful nose blowing) Hypertension Tumor (sinus or nasopharynx) Thrombocytopenia Use of aspirin Liver disease 37  Medical Management Cause and location of bleeding determine management. Nasal speculum, penlight, or headlight can identify bleeding site. Initial treatment includes direct pressure and application of nasal decongestants. If unsuccessful, nose examination and cauterization with silver nitrate or electrocautery are necessary. Supplemental patch of Surgicel or Gelfoam may be used. Use of cotton tampon to stop bleeding. Suction to remove excess blood and clots. If bleeding origin is unknown, pack nose with gauze impregnated with petrolatum jelly or antibiotic ointment. Use topical anesthetic spray and decongestant agent before gauze packing. Packing may remain in place for 3-4 days. Antibiotics may be prescribed due to risk of iatrogenic rhinosinusitis and sepsis. 38  Nursing Management Assists in bleeding control. Provides tissues and an emesis basin for patient's blood collection. Assists in reducing patient anxiety by reassured about bleeding control. Continuously assesses patient's airway, breathing, and vital signs. In rare cases, IV infusions of crystalloid solutions and cardiac and pulse oximetry monitoring are required. Patient Education Patient advised to avoid vigorous exercise, hot/spicy foods, and tobacco for several days. Avoid forceful blowing, straining, high altitudes, and nasal trauma. Adequate humidification with oxygen therapy. Direct pressure applied to nose for 15 minutes in case of recurrent bleeding. If bleeding persists, patient advised to seek additional medical attention. 39 Cancer of the Larynx Accounts for half of all head and neck cancers. Most common in people over 65 years and four times more common in men. 55% of patients present with involved lymph nodes at diagnosis. Recurrence usually occurs within the first 2 to 3 years. Risk factors ✓Carcinogens from tobacco. ✓Asbestos, secondhand smoke, paint fumes, wood dust, cement dust. ✓Chemicals, tar products, mustard gas, leather, metals. ✓Other factors: nutritional deficiencies, history of alcohol abuse, genetic predisposition ✓Age (higher incidence after 65 years of age) ✓Gender (more common in men) ✓Race (more prevalent in African Americans and Caucasians) 40 Clinical Manifestations Over 2 weeks of hoarseness due to tumor obstructing vocal cords. Voice sounds harsh, raspy, and lower in pitch. Persistent cough, sore throat, pain, and burning in throat. Symptoms may include dysphagia, dyspnea, nasal obstruction, persistent hoarseness, ulceration, and foul breath. Metastasis may lead to cervical lymph adenopathy, unintentional weight loss, debilitation, and ear pain. Assessment and Diagnostic Findings Complete history and physical examination of the head and neck. Indirect laryngoscopy -to visually evaluate the pharynx, larynx, and potential tumor. Lymph nodes of the neck and thyroid gland are palpated for enlargement. Fine-needle aspiration (FNA) biopsy, barium swallow, endoscopy, CT or MRI scan, and positron emission tomography (PET) scan, Direct laryngoscopic examination 41  Medical Management Treatment options include surgery, radiation therapy, and adjuvant chemoradiation therapy. Early-stage tumors and lesions without lymph node involvement may benefit from external-beam radiation therapy or conservation surgery. Stage III and IV tumors may require total laryngectomies with or without postoperative radiation therapy or chemotherapy. Surgical treatment Vocal Cord Stripping, Cordectomy, Laser Surgery, Partial Laryngectomy, Total Laryngectomy Speech Therapy - communication including writing, lip speaking, reading, and word boards. 42 NURSING DIAGNOSES The Patient Undergoing Laryngectomy Deficient knowledge about the surgical procedure and postoperative course Anxiety related to the diagnosis of cancer and impending surgery Ineffective airway clearance related to excess mucus production secondary to surgical alterations in the airway Impaired verbal communication related to anatomic deficit secondary to removal of the larynx and to edema Imbalanced nutrition: less than body requirements, related to inability to ingest food secondary to swallowing difficulties Disturbed body image and low self-esteem secondary to major neck surgery, change in appearance, and altered structure and function Self-care deficit related to pain, weakness, fatigue, musculoskeletal impairment related to surgical procedure and postoperative course 43  Nursing Interventions Providing preoperative patient education If a complete laryngectomy is planned, the patient must understand that their natural voice will be lost. Teach coughing and deep breathing exercises, and assists with return demonstrations. Reducing anxiety Address patient and family's fears and misconceptions, providing opportunities for open communication and discussion. Visits from previous laryngectomy patients can reassure patients about the possibility of rehabilitation. 44 Nursing Interventions Maintaining a patent airway Position the patient in the semi-Fowler or Fowler position post-anesthesia to promote lung expansion and decrease surgical edema. Observations for restlessness, labored breathing, apprehension, and increased pulse rate help identify potential respiratory or circulatory problems Encourages the patient to turn, cough, and take deep breaths Change the inner cannula (if tracheostomy tube present) every 8 hours if it is disposable. If a tracheostomy tube without an inner cannula is used, humidification and suctioning of this tube are essential to prevent formation of mucus plugs. Clean the stoma daily with soap and water or another prescribed solution and a soft cloth or gauze. After the patient coughs, the tracheostomy opening must be wiped clean and clear of mucus. 45 Promoting alternative communication methods Communication methods are established preoperatively and must be consistently used postoperatively. Call bells or hand bells are placed within easy reach of the patient. Handheld communication devices like Magic Slate, electronic tablets, notebooks, and smartphones are used. Picture-word-phrase board or hand signals are used if writing is not possible. Notes used for communication are discarded to ensure privacy. Adequate time is given for patient to communicate their needs. Promoting adequate nutrition and hydration ✓Patients may not eat or drink for at least 7 days post-surgery, include IV fluids, enteral feedings, and parenteral nutrition. ✓A swallow study may be conducted to evaluate the patient's risk of aspiration. ✓Thin liquids are used first due to their ease of swallowing. ✓avoid sweet foods and introduce solid foods as tolerated ✓Taste sensations may be altered after surgery 46 Monitoring and managing potential complications Respiratory Distress and Hypoxia Reposition the patient and administering prescribed oxygen. Remain with the patient during respiratory distress and initiate calls to the rapid response team. Hemorrhage Notify the surgeon of any active bleeding. IV fluids and blood components Infection Monitor the patient for signs of postoperative infection, including increased temperature and pulse, changes in wound drainage, and increased areas of redness or tenderness. Wound Breakdown Aspiration -Patients receiving tube feedings are positioned with the head of the bed at 30° or higher during feedings and for 30 to 45 minutes after tube feedings. 47  Educating Patients About Self-Care. Tracheostomy and Stoma Care Instruct the patient and family on suctioning, emergency measures, and tracheostomy and stoma care. Emphasizes the importance of home humidification and instructs the family to set up a humidification system. Hygiene and Safety Measures Special precautions are needed in the shower to prevent water from entering the stoma. Barbers and beauticians should be alerted to prevent hair sprays, loose hair, and powder from getting near the stoma. Encourage frequent oral care to prevent halitosis and infection Recreation and Exercise Avoid strenuous exercise and fatigue. The patient should wear or carry medical identification to alert medical personnel to special requirements for resuscitation. 48 Lower Respiratory Tract Disorders Atelectasis Atelectasis refers to closure or collapse of alveoli and often is described in relation to chest x-ray findings and/or clinical signs and symptoms acute or chronic microatelectasis -not detectable on chest x-ray macroatelectasis - loss of segmental, lobar, or overall lung volume. Etiology Acute atelectasis is most common, often in postoperative settings or immobilized individuals with shallow, monotonous breathing. Postoperatively, patients are at high risk due to factors such as monotonous, low tidal breathing pattern, secretion retention, airway obstruction, and impaired cough reflex. Atelectasis may also occur in patients with impaired cough mechanisms, debilitated and bedridden individuals Excessive pressure on the lung tissue (compressive atelectasis) can be produced by fluid accumulating within the pleural space (pleural effusion), air in the pleural space (pneumothorax), or blood in the pleural space (hemothorax). 49  Clinical Manifestations Insidious development with signs like increased dyspnea, cough, and sputum production. Acute atelectasis with large lung tissue (lobar atelectasis) may cause respiratory distress, tachycardia, tachypnea, pleural pain, and central cyanosis. Patients often have difficulty breathing in the supine position(Orthopnea) and are anxious. Chronic atelectasis shares symptoms with acute atelectasis due to the chronic nature of alveolar collapse. 50  Assessment and Diagnostic Findings Decreased breath sounds and crackles over affected area. Chest x-ray may suggest diagnosis before symptoms appear. Pulse oximetry may show low saturation of hemoglobin with oxygen or lower-than- normal partial pressure of arterial oxygen. Tachypnea, dyspnea, and mild-to-moderate hypoxemia are hallmarks of the severity of atelectasis Prevention Frequent position changes, especially from supine to upright, for ventilation. Encourage early mobilization and ambulation. Encourage deep breathing and coughing for secretion mobilization. Educate on incentive spirometry technique. Judicious administration of prescribed opioids and sedatives. Perform postural drainage and chest percussion. Implement suctioning for tracheobronchial secretions removal. 51  Management Treatment aims to improve ventilation and remove secretions. First-line measures include frequent turning, early ambulation, and coughing. Chest physiotherapy and nebulizer treatments If first-line measures fail, other treatments like PEEP, CPAP may be used. Endotracheal intubation and mechanical ventilation Thoracentesis or chest tube insertion 52  Pneumonia Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses. Pneumonitis is a more general term that describes an inflammatory process in the lung tissue that may predispose or place the patient at risk for microbial invasion. Pneumonia and influenza are the most common causes of death from infectious diseases in the United States. 53  Classifications and Definitions of Pneumonias Community-acquired pneumonia (CAP): Pneumonia occurring in the community or ≤48 hours after hospital admission Health care–associated pneumonia (HCAP): Pneumonia occurring in a nonhospitalized patient with extensive health care contact with one or more of the following: ✓Hospitalization for ≥2 days in an acute care facility within 90 days of infection ✓Residence in a nursing home or long-term care facility ✓Antibiotic therapy, chemotherapy, or wound care within 30 days of current infection ✓Hemodialysis treatment at a hospital or clinic ✓Home infusion therapy or home wound care ✓Family member with infection due to multidrug-resistant bacteria Hospital-acquired pneumonia (HAP): Pneumonia occurring ≥48 hours after hospital admission that did not appear to be incubating at the time of admission Ventilator-associated pneumonia (VAP): A type of HAP that develops ≥48 hours after endotracheal tube intubation 54  Risk Factors Risk Factors for Infection With Enteric GramNegative Bacteria Risk Factors for Infection With Penicillin- Resistant and Drug-Resistant Pneumococci Residency in a long-term care facility Age >65 years Multiple medical comorbidities Alcoholism Recent antibiotic therapy Beta-lactam therapy (e.g., Structural lung disease (e.g., cephalosporins) in past 3 months bronchiectasis) Immunosuppressive disorders Corticosteroid therapy Multiple medical comorbidities Broad-spectrum antibiotic therapy (>7 days in the past month) Malnutrition 55  Community-acquired pneumonia -Causative pathogens vary. Streptococcus pneumoniae (Pneumococcus) - Most common cause of CAP in people younger than 60 years without comorbidity. H. Influenzae- CAP that frequently affects older adults and those with comorbid illnesses. Mycoplasma Pneumonia-spread by infected respiratory droplets through person-to-person contact. Cytomegalovirus -most common viral pathogen in immunocompromised adults. Health Care–Associated Pneumonia - Causative pathogens are often MDR, making early antibiotic treatment crucial. Ventilator-Associated Pneumonia-complication in up to 28% of patients requiring mechanical ventilation 56  Hospital-Acquired Pneumonia (HAP) Predisposing factors -impaired host defenses, comorbid conditions, supine positioning and aspiration, coma, malnutrition, prolonged hospitalization, and metabolic disorders. Hospitalized patients are exposed to potential bacteria from other sources, such as respiratory therapy devices and equipment, and transmission of pathogens by healthcare personnel. Intervention-related factors - prolonged or inappropriate use of antibiotics, and use of nasogastric tubes etc. HAP is associated with a high mortality rate due to the virulence of the organisms, resistance to antibiotics, and the patient’s underlying disorder. Common organisms -Enterobacter species, Escherichia coli, Pseudomonas aeruginosa, methicillin-sensitive or methicillin-resistant Staphylococcus aureus (MRSA). 57  Pneumonia in the Immunocompromised Host Pneumocystis pneumonia (PCP), fungal pneumonias, and Mycobacterium tuberculosis are common in immunocompromised hosts. Pneumonia can occur due to immunosuppressive agents, chemotherapy, nutritional depletion, broad-spectrum antimicrobial agents, AIDS, genetic immune disorders, and long-term advanced life support technology. Higher morbidity and mortality rates in immunocompromised patients Aspiration Pneumonia Pulmonary consequences from entry of endogenous or exogenous substances into the lower airway. May occur in community or hospital settings. Common pathogens include anaerobes, S. aureus, Streptococcus species, and gram-negative bacilli. 58  Clinical Manifestations of Pneumonia Sudden chills and rapidly rising fever (38.5C to 40.5C [101F to 105F]). Pleuritic chest pain aggravated by respiration and coughing. Severely ill patient has marked tachypnea (25 to 45 breaths/min) and dyspnea; orthopnea when not propped up. Pulse rapid and bounding; may increase 10 beats/min per degree of temperature elevation (Celsius). Other signs: upper respiratory tract infection, headache, myalgia, rash, and pharyngitis; after a few days, mucoid or mucopurulent sputum is expectorated. Severe pneumonia: flushed cheeks; lips and nail beds demonstrating central cyanosis. Sputum purulent, rusty, blood-tinged, Appetite is poor, and the patient is diaphoretic and tires easily. 59 Assessment and Diagnostic Findings History, physical examination, chest x-ray, blood culture, and sputum examination. The sputum sample is obtained by having patients do the following: 1. Rinse the mouth with water to minimize contamination by normal oral flora, 2. Breathe deeply several times, 3. Cough deeply 4. Expectorate the raised sputum into a sterile container Sputum can be obtained by nasotracheal or orotracheal suctioning with a sputum trap or by fiberoptic bronchoscopy also Prevention -Pneumococcal vaccination 60 Pharmacologic therapy Antibiotics. Combination therapy may also be used. Supportive treatment includes hydration, antipyretics, antitussive medications, antihistamines, or nasal decongestants. Bed rest is recommended until infection clears. Oxygen therapy is given for hypoxemia. Respiratory support includes high inspiratory oxygen concentrations, endotracheal intubation, and mechanical ventilation. For those at high risk, pneumococcal vaccination is advised. 61 Nursing diagnoses Ineffective airway clearance related to copious tracheobronchial secretions Fatigue and activity intolerance related to impaired respiratory function Risk for deficient fluid volume related to fever and a rapid respiratory rate Imbalanced nutrition: less than body requirements Deficient knowledge about the treatment regimen and preventive measures 62 Nursing Interventions Improving Airway Patency Encourage hydration: fluid intake (2 to 3 L/day) to loosen secretions. Provide humidified air using high-humidity face mask. Encourage patient to cough effectively, and provide correct positioning, chest physiotherapy, and incentive spirometry. Provide and monitor oxygen therapy. Promoting Rest and Conserving Energy Encourage the patient to rest and avoid overexertion. Patient should assume a comfortable position to promote rest and breathing (eg, semi-Fowler’s position) and should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion. Promoting Fluid Intake and Maintaining Nutrition Encourage fluids (2 L/day minimum with electrolytes and calories). Administer IV fluids and nutrients, if necessary 63  Nursing Interventions Promoting Patients’ Knowledge Explain treatments in simple manner and using appropriate language Monitoring and Preventing Potential Complications Assess for signs and symptoms of shock, multisystem organ failure, and respiratory failure, atelectasis and pleural effusion. Assess for confusion or cognitive changes Teaching patients self-care Instruct patient to : ✓Continue taking full course of antibiotics as prescribed ✓Increase activities gradually after fever subsides. ✓Do breathing exercises. ✓Stop smoking. ✓Avoid stress, fatigue, sudden changes in temperature, and excessive alcohol intake. ✓Take influenza vaccine (pneumovax). 64  Pulmonary Tuberculosis Infectious disease primarily affecting lung parenchyma, caused by Mycobacterium tuberculosis. Spreads to various body parts including meninges, kidney, bones, and lymph nodes. Infection usually occurs 2 to 10 weeks after exposure. Active disease may develop due to compromised immune system response. Global public health problem linked to poverty, malnutrition, overcrowding, substandard housing, and inadequate healthcare. TB Transmission Spread via airborne transmission. Infected person releases droplet nuclei through talking, coughing, sneezing, laughing, or singing. Larger droplets settle, smaller remain suspended, inhaled by susceptible person. 65 Risk Factors Close contact with someone who has active TB Immunocompromised status Alcoholism People lacking adequate health care (eg, homeless or impoverished, minorities, children, and young adults) Preexisting medical conditions, including diabetes, chronic renal failure, silicosis, and malnourishment Immigrants from countries with a high incidence of TB (eg, (southeastern Asia, Africa, Latin America) Institutionalization (eg, long-term care facilities, prisons) Living in overcrowded, substandard housing Health care workers -administration of aerosolized medications, sputum induction procedures, bronchoscopy, suctioning, coughing procedures, caring for the immunosuppressed patient, and administering anesthesia and related procedures (e.g., intubation, suctioning). 66  Clinical Manifestations Low-grade fever, cough, night sweats, fatigue, and weight loss Nonproductive cough, which may progress to mucopurulent sputum with hemoptysis Assessment and Diagnostic Methods TB skin test (Mantoux test); QuantiFERON-TB Gold (QFT-G) test Chest x-ray Acid-fast bacillus smear Sputum culture 67 Tuberculin Skin Test Tubercle bacillus extract (tuberculin) is injected into the forearm's inner layer. 0.1 mL of PPD is injected, creating an elevated wound 6-10 mm in diameter. Test results are recorded 48 to 72 hours after injection. The size of the induration determines the significance of the reaction. ✓0 to 4 mm is not significant. ✓5 mm or greater may be significant in people considered at risk. ✓10 mm or greater is usually significant in people with normal or mildly impaired immunity. A significant reaction indicates past exposure to M. tuberculosis or vaccination with the bacille Calmette-Guérin (BCG) vaccine. A significant reaction does not necessarily mean active disease is present in the body. A nonsignificant (negative) skin test means the person’s immune system did not react to the test and that latent TB infection or TB disease is not likely. 68 Medical Management Pulmonary TB is treated primarily with antituberculosis agents for 6 to 12 months. Pharmacologic Therapy First-line medications: isoniazid or INH (Nydrazid), rifampin (Rifadin), pyrazinamide, and ethambutol (Myambutol) daily for 8 weeks and continuing for up to 4 to 7 months Second-line medications: capreomycin (Capastat), ethionamide (Trecator), para-aminosalicylate sodium, and cycloserine (Seromycin) Vitamin B (pyridoxine) usually administered with INH 69  Nursing Management Promoting airway clearance Encourage increased fluid intake. Instruct about best position to facilitate drainage. Advocating adherence to treatment regimen Explain that TB is a communicable disease and that taking medications is the most effective way of preventing transmission. Instruct about the risk of drug resistance if the medication regimen is not strictly and continuously followed. Carefully monitor vital signs and observe for spikes in temperature or changes in the patient’s clinical status. Promoting activity and adequate nutrition Plan a progressive activity schedule. Small, frequent meals and nutritional supplements Identify facilities (eg, shelters, soup kitchens, meals on wheels) that provide meals in the patient’s neighborhood Preventing Spreading of TB Infection Instruct the patient about important hygiene measures, including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and handwashing. 70 Pleural Effusion Collection of fluid in the pleural space, usually secondary to other diseases (eg, pneumonia, pulmonary infections, nephrotic syndrome, connective tissue disease, neoplastic tumors, congestive HF) Normally, the pleural space contains a small amount of fluid (5 to 15 ml), which acts as a lubricant that allows the pleural surfaces to move without friction Pleural fluid accumulates due to an imbalance in hydrostatic or oncotic pressures (transudate) or as a result of inflammation by bacterial products or tumors (exudate). 71 Clinical Manifestations Large effusion: shortness of breath to acute respiratory distress. Small to moderate effusion: Dyspnea may not be present. Dullness or flatness to percussion over areas of fluid, minimal or absence of breath sounds, decreased fremitus, and tracheal deviation away from the affected side. Assessment and Diagnostic Methods Physical examination Chest X-ray Chest CT scan Thoracentesis and Pleural fluid analysis Pleural biopsy 72  Medical Management Thoracentesis is performed to remove fluid, collect specimen for analysis, and relieve dyspnea. Chest tube and water-seal drainage may be necessary for drainage and lung re expansion. Chemical pleurodesis: drugs are instilled into the pleural space to obliterate the space and prevent further accumulation of fluid. Surgical pleurectomy (insertion of a small catheter attached to a drainage bottle) or implantation of a pleuroperitoneal shunt 73 Nursing Management Prepare and position patient for thoracentesis and offer support throughout the procedure. Monitor chest tube drainage and water-seal system; record amount of drainage at prescribed intervals. Assist patient to assume positions that are least painful. Administer pain medication as prescribed and needed to continue frequent turning and ambulation. 74 Chronic Obstructive Pulmonary Disease(COPD) COPD is a disease characterized by airflow limitation that is not fully reversible Causes narrowing of airways, hypersecretion of mucus, and changes in pulmonary vasculature. Risk factors include tobacco smoking, air pollution, and occupational exposure. Development can occur over 20-30 years. Risk Factors -Exposure to tobacco smoke (80% to 90% of cases) Passive smoking (i.e., secondhand smoke) Increased age Occupational exposure—dust, chemicals Indoor and outdoor air pollution Genetic abnormalities, including a deficiency of alpha1-antitrypsin, an enzyme inhibitor that normally counteracts the destruction of lung tissue by certain other enzymes 75 76 TYPES OF COPD Emphysema Chronic Bronchitis  Chronic Bronchitis Disease of the airways, defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years. Environmental pollutants irritate airways, leading to inflammation and mucus hypersecretion. Constant irritation increases mucus-secreting glands and goblet cells, reducing ciliary function. Bronchial walls thicken, narrowing the bronchial lumen. 77 Emphysema A pathologic term describing abnormal air spaces and alveoli wall destruction. The destruction leads to impaired oxygen and carbon dioxide exchange, causing hypoxemia. Complications include right-sided heart failure, dependent edema, distended neck veins, and liver pain. Two types of emphysema : ✓Panlobular (panacinar): Distruction of respiratory bronchiole, alveolar duct, and alveolus. ✓Centrilobular (centroacinar): Pathologic changes mainly in the center of the secondary lobule, preserving peripheral portions of the acinus. 78 79 Clinical Manifestations Progressive Disease characterized by chronic cough, sputum production, and dyspnea. Cough can be intermittent or unproductive. Dyspnea can be severe and interfere with activities and quality of life. Dyspnea is progressive, worse with exercise, and persistent. Weight loss is common due to dyspnea's energy depletion. Patients with COPD are at risk for respiratory infections and respiratory failure. Chronic hyperinflation leads to "barrel chest" thorax configuration. 80  Assessment and Diagnostic Findings Comprehensive health history. Pulmonary function studies , Chest X-rays. Arterial blood gas measurements High-resolution CT chest scans. Screening for alpha1-antitrypsin deficiency may be performed for patients under 45 and those with a family history of COPD. Medical Management ✓ Smoking cessation. ✓ Bronchodilators -relieve bronchospasm ✓ Corticosteroids. ✓ Supplemental oxygen therapy as needed. ✓ Alpha1-antitrypsin augmentation therapy, antibiotics, mucolytic agents, antitussive agents, vasodilators, and narcotics. ✓ Pneumococcal vaccination 81  Management of Exacerbations in COPD Exacerbations of COPD are acute changes in respiratory symptoms beyond normal variations. Primary causes - tracheobronchial infection and air pollution. Roflumilast (Daliresp) is a treatment to reduce exacerbation risk in severe COPD patients with chronic bronchitis and a history of exacerbations. 82  oxygen therapy Long term oxygen therapy (more than 15 hours per day) has also been shown to improve quality of life Nighttime oxygen therapy is recommended for patients who are hypoxemic while awake and are likely to be so during sleep. Intermittent oxygen therapy is indicated for patients who desaturate only during daily living, exercise, or sleep. Excessive oxygen can lead to CO2 retention and worsen respiratory failure. Careful oxygen titration necessary to prevent complications. 83 Surgical Management ✓Bullectomy ✓Lung Volume Reduction Surgery ✓Lung Transplantation Pulmonary Rehabilitation ✓Smoking Cessation Support ✓Physical Reconditioning ✓Nutritional Counseling ✓Psychological Support 84 Patient Education Common breathing pattern in COPD is shallow, rapid, and inefficient. ✓Diaphragmatic breathing can reduce respiratory rate and increase alveolar ventilation. ✓Pursed-lip breathing slows expiration, prevents small airway collapse, and helps control respiration rate and depth. Activity Pacing-People with COPD have decreased exercise tolerance in the morning on arising, because bronchial secretions have collected in the lungs during the night while the patient was lying down. Patients should coordinate diaphragmatic breathing with activities like walking, bathing, bending, or climbing stairs. Fluids should be readily available and patients should start drinking Home-supplied oxygen systems allow patients to exercise, work, and travel. Caution the patient that smoking with or near oxygen is extremely dangerous 85 86  Nutritional Therapy A thorough assessment of caloric needs and counseling about meal planning and supplementation ✓Rest at least 30 minutes prior to eating ✓Use bronchodilator before meals ✓Select foods that can be prepared in advance ✓5-6 small meals to avoid bloating ✓Avoid foods that require a great deal of chewing ✓Avoid exercises and treatments 1 hour before and after eating 87  Nursing Management Achieving Airway Clearance Chest physiotherapy with postural drainage, intermittent positive-pressure breathing, increased fluid intake Improving Breathing Patterns Inspiratory muscle training, diaphragmatic breathing, Pursed-lip breathing Improving Activity Tolerance Recommend use of walking aids, if appropriate, to improve activity levels and ambulation. Monitoring and Managing Complications Monitor for cognitive changes, increasing dyspnea, tachypnea, and tachycardia. Encourage patient to be immunized against influenza and Streptococcus pneumonia. Teaching Patients Self-Care Instruct patient to avoid extremes of heat and cold and air pollutants (eg, fumes, smoke, dust, talcum, lint, and aerosol sprays). High altitudes aggravate hypoxemia. 88  Asthma Chronic inflammatory disease of airways characterized by hyperresponsiveness, mucosal edema, and mucus production. Patients may experience symptom-free periods and acute exacerbations. Common chronic disease of childhood, can begin at any age. Risk factors include family history, allergy, and chronic exposure to airway irritants. Common triggers include airway irritants, exercise, stress, rhinosinusitis, medications, viral respiratory tract infections, and gastroesophageal reflux. 89 Clinical Manifestations Cough (with or with out mucus production), dyspnea, wheezing (first on expiration, then possibly during inspiration as well), and chest tightness. asthma attacks frequently occur at night or in the early morning. Expiration requires effort and becomes prolonged. As exacerbation progresses, central cyanosis secondary to severe hypoxia may occur. Additional symptoms, such as diaphoresis, tachycardia, and a widened pulse pressure, may occur. Exercise-induced asthma: maximal symptoms during exercise, absence of nocturnal symptoms, and sometimes only a description of a “choking” sensation during exercise. A severe, continuous reaction, status asthmaticus, may occur. It is life- threatening. Eczema, rashes, and temporary edema are allergic reactions that may be noted with asthma 90 Assessment and Diagnostic Methods Family, environment, and occupational history. During acute episodes, sputum and blood test, pulse oximetry, ABGs, and pulmonary function Medical Management Pharmacologic Therapy Two classes of medications—long-acting control and quick-relief medications—as well as combination products. ✓Short-acting beta2-adrenergic agonists ✓Anticholinergics ✓Corticosteroids: metered-dose inhaler (MDI) ✓Leukotriene modifiers inhibitors/antileukotrienes ✓Methylxanthines 91 Nursing Management Assess the patient’s respiratory status by monitoring the severity of symptoms, breath sounds, pulse oximetry, and vital signs. Obtain a history of allergic reactions to medications before administering medications. Identify medications the patient is currently taking. Administer medications as prescribed and monitor the patient’s responses to those medications Administer fluids if the patient is dehydrated. Home visit to assess for allergens may be indicated Refer patient to community support groups 92 Bronchiectasis Chronic, irreversible dilation of the bronchi and bronchioles and is considered a disease process separate from chronic obstructive pulmonary disease Causes: ✓Airway obstruction ✓Diffuse airway injury ✓Pulmonary infections and obstruction of the bronchus ✓Genetic disorders such as cystic fibrosis ✓Idiopathic causes 93 Clinical Manifestations Chronic cough and production of copious purulent sputum Hemoptysis, clubbing of the fingers, and repeated episodes of pulmonary infection Assessment and Diagnostic Findings Prolonged history of productive cough, with sputum consistently negative for tubercle bacilli. Diagnosis is established on the basis of CT scan Medical Management Chest physiotherapy with percussion; postural drainage, expectorants, or bronchoscopy to remove bronchial secretions. Antimicrobial therapy guided by sputum sensitivity studies. Vaccination against influenza and pneumococcal pneumonia. Bronchodilators. Smoking cessation. Surgical intervention (segmental resection of lobe or lung removal) 94  Nursing Management Provide a warm, quiet, comfortable environment, and urge the patient to rest as much as possible. Perform chest physiotherapy several times per day (early morning and bedtime are best) Postural drainage Encourage balanced, high-protein meals. Provide frequent mouth care to remove foul-smelling sputum. Patient teaching Show family members how to perform postural drainage and percussion. Teach coughing and deep breathing techniques Advise the patient to stop smoking Teach the patient to dispose of secretions properly. Tell the patient to avoid air pollutants and people with upper respiratory tract infections. 95  REFERENCES ▪ Smeltzer, S.C., & Bare B.G. (2018). Brunner & Suddarth’s textbook of medical surgical nursing. 15th ed. Philadelphia: Lippincott. ▪ Clinical Handbook for Brunner & Suddarth's Textbook of Medical-Surgical Nursing,14th Ed. 2018 Author(s): Lippincott Williams & Wilkins ISBN/ISSN978149635514 ▪ Medical-Surgical Nursing Assessment and Management of Clinical Problems, 12th Edition, 2020. Author(s): Sharon Lewis, Linda Bucher, Margaret Heitkemper, Mariann Harding, Jeffrey Kwong, and Dottie Roberts. eBook ISBN: 9780323371438 Imprint: Mosby Published Date: September 2016 Page Count: 1776 ▪ Doenges, M., Moorhouse, M., Murr, A. (2019). Nursing Care Plans: Guidelines for individualizing client care across the life span 10th edition. Philadelphia: F.A. Davis company. ▪ Vallerand, A. and Sanoski, C. (2019) Davis’s Drug Guide for nurses, 17th ed. D.A. Davis ▪ Adams, M, Holland, L, & Urban, C. (2017). Pharmacology for Nurses: A Pathophysiological Approach, Second Canadian Edition, 5th edition, Pearson ▪ Berman A. , Snyder, S. , & Frandsen, G. (2021). Kozier & Erb's Fundamentals of Nursing: concepts, process and practice. 11th ed. 96 97