management of patient with cheast and lower respiratory tract desorder

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 23
Management of Patients With
Chest and Lower Respiratory
Tract Disorders

Atelectasis
• Collapse or airless condition of alveoli caused by
hypoventilation, obstruction to airways, or compression
• Causes: bronchial obstruction by secretions due to
impaired cough mechanism or conditions that restrict
normal lung expansion on inspiration
• Postoperative patients at high risk
• Symptoms: insidious, include cough, sputum production,
low-grade fever
• Respiratory distress, anxiety, symptoms of hypoxia occur
if large areas of lung are affected

Atelectasis (cont’d)
• Refer to fig. 23-1

Nursing Management
• Prevention
– Frequent turning, early mobilization
– Strategies to improve ventilation: deep breathing
exercises at least every 2 hours, incentive spirometer
– Strategies to remove secretions: coughing exercises,
suctioning, aerosol therapy, chest physiotherapy

Nursing Management (cont’d)
• Treatment
– Strategies to improve ventilation, remove secretions
– Treatments: may include PEEP (positive end-
expiratory pressure), IPPB (intermittent positive-
pressure breathing)
– Bronchoscopy may be used to remove obstruction

Respiratory Infections
• Acute tracheobronchitis
• Pneumonia
– Community-acquired pneumonia
– Hospital-acquired pneumonia
– Pneumonia in immunocompromised host
– Aspiration pneumonia

Diagnostic Tests
• Chest x-ray
• Sputum examination

Medical Treatment of Pneumonia
• Supportive treatment includes fluids, oxygen for hypoxia,
antipyretics, antitussives, decongestants, antihistamines
• Administration of antibiotic therapy determined by gram-
stain results
• If etiologic agent is not identified, utilize empiric
antibiotic therapy
• Antibiotics not indicated for viral infections but are used
for secondary bacterial infection

Nursing Process: Care of the Patient with
Pneumonia - Assessment
• Changes in temperature, pulse
• Secretions
• Cough
• Tachypnea, shortness of breath
• Changes in physical assessment, especially inspection,
auscultation of chest
• Changes in CXR
• Changes in mental status, fatigue, dehydration,
concomitant heart failure, especially in elderly patients

Pneumonia - Diagnoses
• Ineffective airway clearance
• Activity intolerance
• Risk for fluid volume deficient
• Imbalanced nutrition
• Deficient knowledge

Collaborative Problems
• Continuing symptoms after initiation of therapy
• Shock
• Respiratory failure
• Atelectasis
• Pleural effusion
• Confusion
• Superinfection

Pneumonia - Planning
• Improved airway clearance
• Maintenance of proper fluid volume
• Maintenance of adequate nutrition
• Patient understanding of treatment, prevention
• Absence of complications

Improving Airway Clearance
• Encourage hydration; 2 to 3 L a day, unless
contraindicated
• Humidification may be used to loosen secretions
– By face mask or with oxygen
• Coughing techniques
• Chest physiotherapy
• Position changes
• Oxygen therapy administered to meet patient needs

Other Interventions
• Promoting rest
– Encourage rest, avoidance of overexertion
– Positioning to promote rest, breathing (Semi-
Fowler’s)
• Promoting fluid intake
– Encourage fluid intake to at least 2 L a day
• Maintaining nutrition
– Provide nutritionally enriched foods, fluids
• Patient teaching

Aspiration
• Risk factors
• Pathophysiology
• Prevention:
– Elevate HOB
– Turn patient to side when vomiting
– Prevention of stimulation of gag reflex with
suctioning or other procedures
– Assessment, proper administration of tube feeding
– Rehabilitation therapy for swallowing

Pleural Conditions
• Pleurisy: inflammation of both layers of pleurae
– Inflamed surfaces rub together with respirations,
cause sharp pain intensified with inspiration
• Pleural effusion: collection fluid in pleural space usually
secondary to another disease process
– Large effusions impair lung expansion, cause
dyspnea

Pleural Conditions (cont’d)
• Empyema: accumulation of thick, purulent fluid in pleural
space.
– Patient usually acutely ill; fluid, fibrin development,
loculation impair lung expansion
– Resolution is a prolonged process

Pleural Effusion

Causative Factors for Pulmonary Disease
• Cigarette smoking
• Air pollution

Acute Respiratory Distress Syndrome
• Severe form of acute lung injury
• Syndrome characterized by sudden, progressive
pulmonary edema, increasing bilateral lung infiltrates on
CXR, hypoxemia refractory to oxygen therapy, decreased
lung compliance
• Symptoms
– Rapid onset of severe dyspnea
– Hypoxemia that does not respond to supplemental
oxygen

Pathophysiology of ARDS

Management of ARDS
• Intubation, mechanical ventilation with PEEP to treat
progressive hypoxemia
• Positioning: frequent position changes, proning
• Nutritional support
• General supportive care

Pulmonary Emboli
• Obstruction of pulmonary artery or branch by blood clot,
air, fat, amniotic fluid, or septic thrombus
– Most thrombus are blood clots from leg veins
• Obstructed area has diminished or absent blood flow
– Although area is ventilated, no gas exchange occurs
• Inflammatory process causes regional blood vessels,
bronchioles to constrict, further increasing pulmonary
vascular resistance, pulmonary arterial pressure, right
ventricular workload
• Ventilation-perfusion imbalance, right ventricular failure,
shock occur

Risk Factors for Pulmonary Emboli
• Venous stasis
• Hypercoagulabilty
• Venous endothelial disease
• Certain disease states: heart disease, trauma,
postoperative/postpartum, diabetes mellitus, COPD
• Other conditions: pregnancy, obesity, oral contraceptive
use, constrictive clothing
• Previous history of thrombophlebitis

Prevention and Treatment of Pulmonary
Emboli
• Prevention
– Exercises to avoid venous stasis
– Early ambulation
– Anticoagulant therapy
– Sequential compression devices (SCDs)
• Treatment
– Measures to improve respiratory, CV status
– Anticoagulation, thrombolytic therapy

Umbrella Filter

Question
• Tell whether the following statement is true or false:
• Bradypnea is the most common sign for a possible
pulmonary embolism.

Answer
• False.
• Rationale: Tachypnea, not bradypnea, is the most
common sign for a possible pulmonary embolism.

Pneumoconioses
• Occupational lung diseases
• Cause of death of 124,846 people in United States (1968
to 2000)
• Causative agents
• Role of nurse as employee advocate
• Role of nurse in health education, teaching preventive
measures
• Role of OSHA

Care of the Patient with Lung Cancer
• Prevention, causes
• Classification of lung cancer
• Treatment
– Surgery
– Radiation
– Chemotherapy
• Palliative care

Nursing Care of the Patient with Cancer
• Psychological support
• Pain
• Airway clearance
• Fatigue
• Dyspnea

Question
• Which of the following is the most common surgery for a
small apparently curable tumor of the lung?
A.Lobectomy
B.Pneumonectomy
C.Segmentectomy
D.Sleeve resection

Answer
• A. Lobectomy
• Rationale: The most common surgical procedure for a
small, apparently curable tumor of the lung is a
lobectomy. A pneumonectomy is the removal an entire
lung. Segmentectomy is not recommended as curative
resection of lung cancer and is a removal of a segment of
the lung. A sleeve resection is removal of the cancerous
lobes with a segment of the main bronchus resected.

Chest Trauma
• Blunt trauma
• Sternal, rib fractures
• Flail chest
• Pulmonary contusion
• Penetrating trauma
• Pneumothorax
– Spontaneous or simple
– Traumatic
– Tension pneumothorax

Flail Chest

Open Pneumothorax and Tension
Pneumothorax

Question
• Tell whether the following statement is true or false:
• An initial characteristic symptom of a simple
pneumothorax is a sudden onset of chest pain.

Answer
• True.
• Rationale: An initial characteristic symptom of a simple
pneumonthorax is a sudden onset of chest pain.

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