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Chapter 49 Care of the Patient with a Respiratory Disorder

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1 Chapter 49 Care of the Patient with a Respiratory Disorder
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.

2 Overview of Anatomy and Physiology
External respiration Exchange of oxygen and carbon dioxide between the lung and the environment Internal respiration Exchange of oxygen and carbon dioxide at the cellular level The respiratory system functions to transport oxygen to the body. This function is vital to the survival of the body’s cells and organs.

3 Overview of Anatomy and Physiology
Upper respiratory tract Nose Pharynx Larynx Trachea Lower respiratory tract Bronchial tree Bronchioles, alveolar ducts, alveoli The respiratory system is divided into two tracts. Review the functions of each of the structures of each of the upper and lower respiratory tract. How do the functions of the upper and lower respiratory tracts differ?

4 Overview of Anatomy and Physiology
Mechanics of breathing Thoracic cavity Lungs Visceral pleura and parietal pleura Respiratory movements and ranges Rhythmic movements of the chest walls, ribs, and muscles allow air to be inhaled and exhaled Regulation of respiration Nervous control—medulla oblongata and pons of the brain; chemoreceptors—in the carotid and aorta The best known organs of respiration are the lungs. The lungs lie in the chest on either side of the heart. The lungs get their blood from the pulmonary artery directly from the heart. Describe the concentration of oxygen in the blood.

5 Assessment of the Respiratory System
Subjective data Shortness of breath, dyspnea, cough Objective data Expression, chest movement, and respirations Respiratory distress, wheezes, or orthopnea Adventitious breath sounds Sibilant wheezes Sonorous wheezes Crackles Pleural friction rubs Impaired functioning of the respiratory system impacts the entire body. A reduction in oxygenation prevents the body’s cells from carrying out their prescribed functions. Every physical examination provides an opportunity to check the functioning of the respiratory system. When performing a health assessment, what questions should be asked by the nurse concerning respiratory status?

6 Laboratory and Diagnostic Examinations
Chest roentgenogram Computed tomography (CT) Pulmonary function testing Mediastinoscopy Laryngoscopy Bronchoscopy Sputum specimen Cytological studies Thoracentesis Arterial blood gases Pulse oximetry In the event that complications involving the respiratory system are suspected, diagnostic testing can be ordered. Certain types of tests are noninvasive. Others require specific preparation and the completion of consent forms. Which of the listed tests are considered invasive? What special preparation is needed prior to performing them?

7 Fiberoptic bronchoscope.
Figure 49-7 The bronchoscopy involves the use of an illuminated, flexible scope. The scope is passed through the trachea into the bronchi. The physician can perform important assessments when using the bronchoscope. What can be viewed/evaluated using this technology? After the test is completed, when can the patient resume eating and drinking? (A, Courtesy of Olympus America, Melville, New York. B, from Meduri, G.U., et al. [1991]. Protected bronchoalveolar lavage, American Review of Respiratory Disease, 143:855, official journal of the American Thoracic Society, © American Lung Association.) Fiberoptic bronchoscope.

8 Figure 49-8 Thoracentesis.
Thoracentesis involves the perforation of the chest wall and pleural space. Discuss indications for performing this test. When the test is performed and fluid is removed, a limitation of 1,300 mL is imposed. No more than that can be taken in a 30-minute time period. What dangers exist if more fluid is removed? (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Thoracentesis.

9 Figure 49-9 Pulse oximetry is a noninvasive test used to determine the oxygen saturation level of the blood. The test can be performed on the ears, bridge of the nose, fingers, toes, or ear lobes. When attempting to perform the test, what factors might impair the ability of the machine to accurately measure the degree of oxygenation? Describe the technology the test uses to evaluate the body’s oxygenation level. (From Potter, P.A., Perry, A.G. [2009]. Fundamentals of nursing. [7th ed.]. St. Louis: Mosby.) Portable pulse oximeter with spring-tension digit probe displays oxygen saturation and pulse rate.

10 Disorders of the Upper Airway
Epistaxis Etiology/pathophysiology Bleeding from the nose Congestion of the nasal membranes leading to capillary rupture Primary or secondary Clinical manifestations/assessment Bright red bleeding from one or both nostrils Can lose as much as 1 liter per hour Nosebleeds are a common occurrence. They can be caused by a variety of events. What are potential causes of both primary and secondary epistaxis? Corticosteroid use can cause epistaxis. Explain how this results. When epistaxis occurs, it can appear to be a large quantity of blood. Fortunately, the episode rarely lasts for a prolonged period.

11 Disorders of the Upper Airway
Epistaxis (continued) Medical management/nursing interventions Sitting position, leaning forward Direct pressure by pinching nose Ice compresses to nose Nasal packing Cautery Balloon tamponade Identify nursing diagnoses that can be applied to the patient experiencing epistaxis.

12 Disorders of the Upper Airway
Deviated septum and nasal polyps Etiology/pathophysiology Congenital abnormality Injury Nasal septum deviates from the midline and can cause a partial obstruction Nasal polyps are tissue growths usually due to prolonged inflammation Obstruction of the nares could occur due to a deviated septum or nasal polyps. When performing data collection on the patient suspected of having a nasal obstruction, what subjective data might be reported?

13 Disorders of the Upper Airway
Deviated septum and nasal polyps (continued) Clinical manifestations/assessment Stertorous respirations (snoring) Dyspnea Postnasal drip Medical management/nursing interventions Pharmacological management Corticosteroids, antihistamines, antibiotics, analgesics Nasoseptoplasty Nasal polypectomy If the presence of nasal polyps or a deviated septum is suspected, diagnostic testing is indicated. What tests can be ordered? Treatment might be conservative, using pharmacological therapies. What actions will corticosteroids and antihistamines take to manage polyps?

14 Disorders of the Upper Airway
Allergic rhinitis and allergic conjunctivitis (hay fever) Etiology/pathophysiology Antigen/antibody reactions in the nasal membranes, nasopharynx, and conjunctiva due to allergens Diagnostic testing Allergic rhinitis and allergic conjunctivitis are irritating conditions that plague people of all ages. These allergies are often seasonal. The reaction involves an antigen-antibody reaction. The ciliary action slows and is accompanied by an increase in mucus secretion. The body mounts a response involving the white blood cells. The increase in capillary permeability and vasodilation act as a catalyst for the characteristic nasal congestion. What are potential environmental causes?

15 Disorders of the Upper Airway
Allergic rhinitis and allergic conjunctivitis (continued) Clinical manifestations/assessment Edema Photophobia Excessive tearing Blurring of vision Pruritus Excessive nasal secretions and/or congestion Sneezing Cough Headache The clinical manifestations cause distress to the sufferer. If not treated, chronic sufferers can develop infections. Provide examples of the infections that could result.

16 Disorders of the Upper Airway
Allergic rhinitis and allergic conjunctivitis (continued) Diagnostic testing Medical management/nursing interventions Pharmacological management Antihistamines Decongestants Corticosteroids Analgesics Avoid allergen Hot packs over facial sinuses The clinical picture often presents adequate information to make a diagnosis. What diagnostic tests can be used to pinpoint causative agents? Discuss the use of patch and scratch testing. Compare and contrast the functions of antihistamines, decongestants, and corticosteroids in the medical management of allergic rhinitis and allergic conjunctivitis.

17 Figure 49-3 (From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.) Projections of paranasal sinuses and oral nasal cavities on the skull and face.

18 Disorders of the Upper Airway
Obstructive sleep apnea (OSA) Etiology and pathophysiology Characterized by partial or complete upper airway obstruction during sleep Apnea refers to the cessation of spontaneous respirations Hypopnea is the presence of unusually shallow or slow respirations Sleep apnea is considered a greatly underreported disorder. It is estimated to affect up to 18 million adults in the United States. Many are undiagnosed. Discuss the changes that take place during the cycle of apnea.

19 Disorders of the Upper Airway
Obstructive sleep apnea (OSA) Clinical manifestations Frequent awakening at night Insomnia Excessive daytime fatigue Witnessed apneic episodes Loud snoring Hypercapnia Personality changes Irritability

20 Disorders of the Upper Airway
Obstructive sleep apnea (continued) Complications Diagnostic tests Medical management/nursing interventions Avoid sedatives Avoid alcoholic beverages Support groups Oral appliances nCPAP Surgery Describe populations at risk for the development of obstructive sleep apnea. What factors do these individuals have in common? Describe polysomnography. What impact do sedatives and alcohol use have on sleep apnea?

21 Disorders of the Upper Airway
Upper airway obstruction Etiology and pathophysiology Precipitated by a recent respiratory event Common airway obstructions Choking on food Dentures Aspiration of vomitus or secretions The tongue Upper airway obstruction involves any condition that can produce a reduction in airway expanse.

22 Disorders of the Upper Airway
Upper airway obstruction (continued) Clinical manifestations/assessment Stertorous respirations Altered respiratory rate and character; apneic periods Hypoxia; cyanosis Wheezing; stridor Medical management/nursing interventions Open the airway Remove obstruction Artificial airway; tracheostomy The presence of an upper airway obstruction is a clinical emergency. There is no need or time for the use of diagnostic testing. What will determine the type of management option selected? What are the priorities of nursing care for the patient diagnosed with an upper airway obstruction?

23 Disorders of the Upper Airway
Cancer of the larynx Etiology/pathophysiology Squamous cell carcinoma Heavy smoking and alcohol use Chronic laryngitis Vocal abuse Family history The number of cases of cancer of the larynx is growing. To what can this increase be attributed? What populations are most likely to develop cancer of the larynx?

24 Disorders of the Upper Airway
Cancer of the larynx (continued) Clinical manifestations/assessment Progressive or persistent hoarseness Pain radiating to the ear Difficulty swallowing Hemoptysis Medical management/nursing interventions Radiation Surgery Partial or total laryngectomy Radical neck dissection When a patient presents for medical attention with clinical manifestations consistent with cancer of the larynx, what diagnostic tests might be ordered? What findings will support a diagnosis of cancer? When diagnosed, cancer of the larynx is associated with a high rate of metastasis. Why is this cancer associated with rapid spreading? What type of prognosis accompanies the diagnosis of cancer of the larynx?

25 Respiratory Infections
Acute rhinitis (common cold) Etiology/pathophysiology Inflammation of the mucous membranes of the nose and accessory sinuses Virus(es) Clinical manifestations/assessment Thin, serous nasal exudate Productive cough Sore throat Fever Most people will become ill with the common cold each year. Although many associate their development only with the winter months, they can occur during any season. How is the common cold spread?

26 Respiratory Infections
Acute rhinitis (common cold) (continued) Medical management/nursing interventions Pharmacological management Analgesic Antipyretic Cough suppressant Expectorant Antibiotic (if infection present) No specific treatment Encourage fluids There is no specific treatment for the common cold. The best action is prevention. What can be done to reduce the transmission of the cold? One common misconception involves the need for antibiotics to treat colds. When is the use of an antibiotic indicated? When should it be avoided?

27 Respiratory Infections
Acute follicular tonsillitis Etiology/pathophysiology Inflammation of the tonsils Bacterial or viral infection Clinical manifestations/assessment Enlarged, tender, cervical lymph nodes Sore throat Fever; chills Enlarged, purulent tonsils Elevated WBC School-aged children represent the population most commonly affected with tonsillitis. What are the usual pathogens involved?

28 Respiratory Infections
Acute follicular tonsillitis (continued) Medical management/nursing interventions Pharmacological management Antibiotics; analgesics; antipyretics Warm saline gargles Tonsillectomy and adenoidectomy Postoperative Assess for excessive bleeding Ice-cold liquids—ice cream Ice collar Avoid coughing, sneezing, or vigorous nose blowing When a patient presents with the signs and symptoms consistent with tonsillitis, what diagnostic testing may be indicated? Identify the special relationship between tonsillitis and group A β-hemolytic streptococci.

29 Respiratory Infections
Laryngitis Etiology/pathophysiology Inflammation of the larynx due to virus or bacteria May cause severe respiratory distress in children under 5 years old Clinical manifestations/assessment Hoarseness Voice loss Scratchy and irritated throat Persistent cough Laryngitis frequently accompanies or occurs after other respiratory infections. It can be acute or chronic. The age of the patient impacts the severity. Explain the unique complications associated with laryngitis in children under the age of 5 years.

30 Respiratory Infections
Laryngitis (continued) Medical management/nursing interventions Pharmacological management Analgesics Antipyretics Antitussives Antibiotics—bacterial Viral—no specific treatment, supportive care Warm or cool mist vaporizer Limit use of voice The care and treatment employed to manage laryngitis are not specific. Individualized comfort measures are utilized. Identify two nursing diagnoses relating to the adult patient diagnosed with laryngitis.

31 Respiratory Infections
Pharyngitis Etiology/pathophysiology Inflammation of the pharynx Chronic or acute Frequently accompanies the common cold Viral, most common Bacterial Pharyngitis is the most common inflammation of the throat. It is normally most contagious 2 to 3 days after the onset of symptoms.

32 Respiratory Infections
Pharyngitis (continued) Clinical manifestations/assessment Dry cough Tender tonsils Enlarged cervical lymph glands Red, sore throat Fever Medical management/nursing interventions Pharmacological management Antibiotics; analgesics; antipyretics Warm or cool mist vaporizer When performing the data collection on the patient who has presented with the clinical manifestations associated with pharyngitis, describe the health assessment.

33 Respiratory Infections
Sinusitis Etiology/pathophysiology Inflammation of the sinuses Usually begins with an upper respiratory infection; viral or bacterial Clinical manifestations/assessment Constant, severe headache Pain and tenderness in involved sinus region Purulent exudate Malaise Fever Sinusitis can be chronic or acute. Which sinuses are most commonly affected? Discuss the chain of events seen most frequently with sinusitis.

34 Respiratory Infections
Sinusitis (continued) Medical management/nursing interventions Pharmacological management Antibiotics Analgesics Antihistamines Vasoconstrictor nasal spray (Afrin) Warm mist vaporizer Warm, moist packs Nasal windows When the patient presents to the physician with complaints of headaches and congestion, x-rays might be indicated to provide support for the diagnosis. What are typical findings on an x-ray associated with the presence of sinusitis? When conservative management of sinusitis is not successful, surgical interventions would be undertaken. Describe potential surgical interventions.

35 Disorders of the Lower Airway
Acute bronchitis Etiology/pathophysiology Inflammation of the trachea and bronchial tree Usually secondary to upper respiratory infection Exposure to inhaled irritants Clinical manifestations/assessment Productive cough; wheezes Dyspnea; chest pain Low-grade fever Malaise; headache

36 Disorders of the Lower Airway
Acute bronchitis (continued) Medical management/nursing interventions Pharmacological management Cough suppressants Antitussives Antipyretics Bronchodilators Antibiotics Vaporizer Encourage fluids When providing care to the patient diagnosed with bronchitis, it is important to prevent secondary infections. When planning the care of the patient with bronchitis, what are two priority nursing diagnoses for the patient with bronchitis?

37 Disorders of the Lower Airway
Legionnaires’ disease Etiology/pathophysiology Legionella pneumophila Thrives in water reservoirs Causes life-threatening pneumonia Leads to respiratory failure, renal failure, bacteremic shock, and ultimately death Legionnaires’ disease first became famous in 1976 after participants in a Philadelphia convention became ill. Describe the mode of transmission for this disorder. Legionnaires’ causes a type of pneumonia resulting in lung consolidation and alveolar necrosis. Discuss the concepts of lung consolidation and alveolar necrosis.

38 Disorders of the Lower Airway
Legionnaires’ disease (continued) Clinical manifestations/assessment Elevated temperature Headache Nonproductive cough Difficult and rapid respirations Crackles or wheezes Tachycardia Signs of shock Hematuria Prompt diagnosis of Legionnaires’ disease is needed to reduce complications. What diagnostic tests are performed to confirm the condition? What findings support the diagnosis?

39 Disorders of the Lower Airway
Legionnaires’ disease (continued) Medical management/nursing interventions Pharmacological management Antibiotics Antipyretics Vasopressors Oxygen Mechanical ventilation, if necessary IV therapy Management of the patient with Legionnaires’ disease might require dialysis in addition to the anticipated respiratory support. Why might dialysis be indicated? What is the prognosis for Legionnaires’ disease?

40 Disorders of the Lower Airway
Severe Acute Respiratory Syndrome (SARS) Etiology/pathophysiology Infection caused by coronavirus Spread by close contact between people Airborne May be spread by touching contaminated objects Clinical manifestations/assessment Temperature Headache Muscle aches Mild respiratory symptoms Dry cough and SOB Discuss which manifestations are early and which will be later developments.

41 Disorders of the Lower Airway
Adult respiratory distress syndrome (continued) Diagnostic tests Chest radiograph Serum antibody testing Nasopharyngeal and oropharyngeal swabs Medical management/nursing interventions Pharmacological management Antibiotics Antiviral medications Respiratory isolation Oxygen The focus of SARS is on supportive care and treatment while managing the root cause of the problems. Discuss personal protective equipment that may be employed to protect the health care worker. Develop two nursing diagnoses for the care and support of the patient or family experiencing a diagnosis of SARS.

42 Disorders of the Lower Airway
Anthrax Etiology/pathophysiology Bacillus anthracis Spread by direct contact with bacteria or spores Three types: Cutaneous, GI, inhalational Clinical manifestations/assessment Cold or flu-like symptoms Hemorrhage, tissue necrosis, and lymphedema Medical management Antibiotics Anthrax is found in nature. It commonly infects hoofed animals. It is transmitted via spores. Describe the action that takes place when the spores are in an acceptable host. The disease is not transmitted by contact with an infected person. Review the diagnostic tests used to identify an anthrax infection. Discuss the use of anthrax as a chemical weapon.

43 Disorders of the Lower Airway
Tuberculosis Etiology/pathophysiology Inhalation of tubercle bacillus (Mycobacterium tuberculosis) Infection versus active disease Presumptive diagnosis Mantoux tuberculin skin test Chest x-ray film Acid-fast bacilli smear  3 Confirmed diagnosis Sputum culture; positive for TB bacilli Tuberculosis (TB) is a chronic pulmonary and extrapulmonary contagious disease. Discuss the demographics associated with TB. A TB infection differs from the active disease TB. Compare and contrast their differences. The number of cases of TB has had several historical fluctuations. Before the 1950s, TB was considered a near epidemic in the Western world. What factors in the 1950s resulted in a reduction in the number of cases? The number of TB cases has begun a gradual increase. What factors can help explain the recent increase in the number of cases?

44 Disorders of the Lower Airway
Tuberculosis (continued) Clinical manifestations/assessment Fever Weight loss; weakness Productive cough; hemoptysis Chills; night sweats Medical management/nursing interventions Tuberculosis isolation (acid-fast bacilli [AFB]) Multiple medications to which the organisms are susceptible The treatment/management of TB rely on drug therapies. What drugs are indicated for the treatment of TB? What precautions are needed to reduce the spread of disease when the patient with TB is in the hospital environment? What education will be needed by the patient and family experiencing a diagnosis of TB?

45 Disorders of the Lower Airway
Pneumonia Etiology/pathophysiology Inflammatory process of the bronchioles and the alveolar spaces due to infection Bacteria, viruses, mycoplasma, fungi, and parasites Clinical manifestations/assessment Productive cough Severe chills; elevated temperature Increased heart rate and respiratory rate Dyspnea Pneumonia is most commonly contracted in the winter and early spring months. The underlying causes of pneumonia might not only be related to an infection but also to oversedation, inadequate ventilation, or aspiration. What populations are at the greatest risk for contracting pneumonia?

46 Disorders of the Lower Airway
Pneumonia (continued) Medical management/nursing interventions Pharmacological management Antibiotics Analgesics Expectorants Bronchodilators Oxygen Chest percussion and postural drainage Encourage to cough and deep-breathe Humidifier or nebulizer The clinical manifestations associated with pneumonia will vary between individuals. Most will experience a productive cough. The other signs and symptoms will differ depending upon the causative agent. When attempting to pinpoint a diagnosis, what testing will be indicated?

47 Disorders of the Lower Airway
Pleurisy Etiology/pathophysiology Inflammation of the visceral and parietal pleura Bacterial or viral Clinical manifestations/assessment Sharp inspiratory pain Dyspnea Cough Elevated temperature Pleural friction rub Pleurisy can occur spontaneously but more often occurs as a complication of other respiratory disorders such as pneumonia, pulmonary infarctions, viral infections, pleural trauma, or early stages of TB or lung tumors.

48 Disorders of the Lower Airway
Pleurisy (continued) Medical management/nursing interventions Pharmacological management Antibiotics Analgesics Antipyretics Oxygen Anesthetic block for intercostal nerves When providing care for the patient diagnosed with pleurisy, the nurse’s responsibilities include both monitoring the patient and providing comfort measures. With what frequency should the nursing assessments be performed? What is the prognosis for the patient diagnosed with pleurisy?

49 Disorders of the Lower Airway
Pleural effusion/empyema Etiology/pathophysiology Pleural effusion Accumulation of fluid in the pleural space Empyema—infection Clinical manifestations/assessment Dyspnea Air hunger Respiratory distress Fever Pleural effusion rarely results independently. It usually accompanies another disease process. With what diseases is pleural effusion often associated?

50 Disorders of the Lower Airway
Pleural effusion/empyema (continued) Medical management/nursing interventions Thoracentesis Chest tube with closed water-seal drainage system Antibiotics Cough and deep-breathe The focus of nursing care for the patient experiencing pleural effusion involves monitoring, education concerning the disease process, and respiratory care treatments.

51 Disorders of the Lower Airway
Atelectasis Etiology/pathophysiology Collapse of lung tissue due to occlusion of air to a portion of the lung Clinical manifestations/assessment Dyspnea; tachypnea Pleural friction rub; crackles Restlessness Elevated temperature Decreased breath sounds Atelectasis causes an imbalance in the body between carbon dioxide and oxygen. In this condition, a blockage prevents the normal exchange of gases. What are potential causes of atelectasis? The location of the occlusion will determine the severity and the clinical manifestations.

52 Disorders of the Lower Airway
Atelectasis (continued) Medical management/nursing interventions Pharmacological management Bronchodilators Antibiotics Mucolytic agents Analgesics Cough and deep-breathe Early ambulation Respiratory treatments Incentive spirometry; intermittent positive-pressure breathing (IPPB) Oxygen Chest percussion and postural drainage Chest tube When caring for the patient diagnosed with atelectasis, what items will need to be included in the nursing assessment? What diagnostic tests will be used to confirm the presence of atelectasis? What is the prognosis for the patient diagnosed with atelectasis? What factors will aid in determining this?

53 Disorders of the Lower Airway
Pneumothorax Etiology/pathophysiology A collection of air or gas in the pleural space, causing the lung to collapse Clinical manifestations/assessment Decreased breath sounds Sudden, sharp chest pain with dyspnea Diaphoresis; tachycardia; tachypnea No chest movement on affected side Sucking chest wound The disruption in the negative pressure of the pleural space is what impairs the ability of the lung to remain inflated. What events might cause a pneumothorax?

54 (complete collapse of the right lung).
Figure 49-13 Ask the students to study the illustration. As they view it, ask them what they anticipate will occur to the initially unaffected side as the pressure forces the lung to remain collapsed and then presses to that side. Ask the students to consider the cardiac implications. (From Wilson, S., Thompson, J. [1991]. Respiratory disorders, Mosby’s clinical nursing series. St. Louis: Mosby.) Pneumothorax (complete collapse of the right lung).

55 Disorders of the Lower Airway
Pneumothorax (continued) Medical management/nursing interventions Chest tube to water-seal drainage system Oxygen Analgesics Encourage fluids When providing care to the patient diagnosed with a pneumothorax, what are the priorities for care? Identify three nursing diagnoses appropriate for the care of this patient.

56 Disorders of the Lower Airway
Lung cancer Etiology/pathophysiology Primary tumor or metastasis Small-cell, non–small-cell, squamous cell, and large-cell carcinoma Clinical manifestations/assessment Hemoptysis Dyspnea; wheezing Fever; chills Pleural effusion The number of people in the United States diagnosed with lung cancer has continued to grow over the past several decades. To what factors can this increase be attributed? List risk factors associated with the development of lung cancer. Discuss the concept of “passive smoke.”

57 Disorders of the Lower Airway
Lung cancer (continued) Medical management/nursing interventions Surgery Most are not diagnosed early enough for curative surgical intervention Segmental resection Lobectomy Pneumonectomy Radiation Chemotherapy The plan of treatment is largely determined by the stage of the malignancy when diagnosed. Unfortunately, diagnosis is often made late in the disease. This is related to the subtlety and gradual occurrence of clinical manifestations. Discuss the areas of the body to which lung cancer is known to metastasize. What types of cancer are associated with spreading to the lungs? What is the prognosis for patients with lung cancer?

58 Disorders of the Lower Airway
Pulmonary edema Etiology/pathophysiology Accumulation of serous fluid in interstitial tissue and alveoli Clinical manifestations/assessment Dyspnea; cyanosis Tachypnea; tachycardia Pink or blood-tinged, frothy sputum Restlessness; agitation Wheezing; crackles Decreased urinary output; sudden weight gain Pulmonary edema is a serious condition that could result in death unless treated promptly. What factors can lead to the occurrence of pulmonary edema? Outline the sequence of events that take place during the onset and progression of pulmonary edema.

59 Disorders of the Lower Airway
Pulmonary edema (continued) Medical management/nursing interventions Pharmacological management Diuretics Narcotic analgesics Nipride Oxygen Mechanical ventilation, if necessary Strict I&O; daily weight Low-sodium diet Prompt diagnosis and treatment of the patient suspected of pulmonary edema is vital for survival. What diagnostic tests are indicated for the disorder? What findings will support the presence of pulmonary edema? What information will need to be collected and documented by the nurse?

60 Disorders of the Lower Airway
Pulmonary embolism Etiology/pathophysiology Foreign substance in the pulmonary artery Blood clot, fat, air, or amniotic fluid Clinical manifestations/assessment Sudden, unexplained dyspnea, tachypnea Hemoptysis Chest pain Elevated temperature Increased WBCs The most common abnormal occurrence relating to pulmonary perfusion is pulmonary embolus. What populations are at highest risk for the development of an embolus? What characteristics place them at this elevated risk?

61 Disorders of the Lower Airway
Pulmonary embolism (continued) Medical management/nursing interventions Pharmacological management Anticoagulants Fibrinolytic agents Oxygen HOB up 30 degrees When events occur that indicate the presence of a pulmonary embolus, what diagnostic tests will be used to support the diagnosis? What findings will confirm the presence of the pulmonary embolus? The treatment of a pulmonary embolus is long-term and will continue long after the initial hospitalization. What will be included in the long-term care plan of this patient?

62 Disorders of the Lower Airway
Acute respiratory distress syndrome (ARDS) Etiology and pathophysiology Results from direct or indirect pulmonary injury Alveolar capillary membranes are altered resulting increased permeability creating pulmonary edema and hypoxia Causes of ARDS may be viral or bacterial. Identify sources of pulmonary trauma or injury that may also cause the disorder.

63 Disorders of the Lower Airway
Acute respiratory distress syndrome (continued) Clinical manifestations Respiratory distress Changes in level of consciousness Tachycardia Hypotension Decreased urinary output ARDS manifests 12 to 24 hours after injury. Diagnostic testing focuses on pulmonary function testing

64 Disorders of the Lower Airway
Acute respiratory distress syndrome (continued) Medical management/nursing interventions Pharmacological management Corticosteroids Antibiotics Vasodilators Bronchodilators Mucolytics Diuretics Morphine sulfate Neurologic blocking agents Cardiotonic glycosides (digoxin)

65 Disorders of the Lower Airway
Acute respiratory distress syndrome (continued) Medical management/nursing interventions (continued) Oxygen Position changes Close assessment of vital signs What is the prognosis for the patient with acute respiratory distress syndrome? Identify two nursing diagnoses for the patient with acute respiratory distress syndrome.

66 Chronic Obstructive Pulmonary Disease (COPD)
Emphysema Etiology/pathophysiology The bronchi, bronchioles, and alveoli become inflamed as a result of chronic irritation Air becomes trapped in the alveoli during expiration, causing alveolar distention, rupture, and scar tissue Complication Cor pulmonale Right-sided congestive heart failure due to pulmonary hypertension Emphysema is a chronic obstructive pulmonary disease. The initial clinical manifestations often begin between the ages of 50 to 60 years. What risk factors are associated with the development of emphysema?

67 Figure 49-14 Compare and contrast the disorders on the chart. Which students have cared for patients with any of the diagnoses highlighted during their clinical rotations? (From Lewis, S.M., Collier, I., & Heitkemper, M.M. [1996]. Medical-surgical nursing: assessment and management of clinical problems. [4th ed.]. St. Louis: Mosby.) Disorders of the airways in patients with chronic bronchitis, asthma, and emphysema.

68 Chronic Obstructive Pulmonary Disease (COPD)
Emphysema (continued) Clinical manifestations/assessment Dyspnea on exertion Sputum Barrel chest Chronic weight loss Emaciation Clubbing of fingers The physical changes that characteristically accompany emphysema include clubbing of fingers, weight loss resulting in emaciation, and “barrel chesting.” What elements in the disease process can explain these changes in appearance?

69 Barrel chest. Note increase in AP diameter.
Figure 49-16 Barrel chest. Note increase in AP diameter.

70 Chronic Obstructive Pulmonary Disease (COPD)
Emphysema (continued) Medical management/nursing interventions Pharmacological management Bronchodilators; corticosteroids; antibiotics; diuretics Oxygen (low-flow) Chest physiotherapy Humidifier Pursed-lip breathing High-protein, high-calorie diet Emphysema is a disease that has no cure. The treatment plan will be lifelong. What are the psychosocial implications associated with the diagnosis of this disease?

71 Chronic Obstructive Pulmonary Disease (COPD)
Chronic bronchitis Etiology/pathophysiology Hypertrophy of mucous glands causes hypersecretion and alters cilia function Increased airway resistance causes bronchospasm Clinical manifestations/assessment Productive cough Dyspnea Use of accessory muscles to breathe Wheezing Criteria needed to achieve a diagnosis of chronic bronchitis involve the presence of a recurrent or chronic, productive cough for at least 3 months a year for a 2-year time period. What populations/behaviors are associated with the development of chronic bronchitis? Explain in detail the progression of the development of the disease.

72 Chronic Obstructive Pulmonary Disease (COPD)
Chronic bronchitis (continued) Medical management/nursing interventions Pharmacological management Bronchodilators Mucolytics Antibiotics Oxygen (low-flow) Pursed-lip breathing Initial chest x-rays might not demonstrate abnormalities. Changes might not be evident until the later stages of the disease. What laboratory tests could be employed? What findings will support a diagnosis of chronic bronchitis?

73 Chronic Obstructive Pulmonary Disease (COPD)
Asthma Etiology/pathophysiology Narrowing of the airways due to various stimuli Extrinsic or intrinsic factors Influenced by secondary factors Antigen-antibody reaction

74 Chronic Obstructive Pulmonary Disease (COPD)
Asthma (continued) Clinical manifestations/assessment Mild asthma Dyspnea on exertion Wheezing Acute asthma attack Tachypnea Expiratory wheezing; productive cough Use of accessory muscles; nasal flaring Cyanosis In addition to mild asthma and acute asthmatic attacks, sufferers can also experience an event known as status asthmaticus. This is a life-endangering episode that does not respond to normal interventions. Explain the process that takes place during status asthmaticus.

75 Chronic Obstructive Pulmonary Disease (COPD)
Asthma (continued) Medical management/nursing interventions Maintenance therapy Serevent inhalant, prophylactic Corticosteroid inhalant Avoid allergens Acute or rescue therapy Proventil inhalant; aminophylline IV Corticosteroid and epinephrine oral or subcutaneous Oxygen The medical management of asthma involves maintenance therapy and acute/rescue therapy. Maintenance therapy is geared toward providing medications to allow the patient to live as normally as possible by controlling the symptoms. Describe rescue therapy.

76 Chronic Obstructive Pulmonary Disease (COPD)
Bronchiectasis Etiology/pathophysiology Gradual, irreversible process that involves chronic dilation of bronchi resulting in loss of elasticity Clinical manifestations/assessment Dyspnea; coughing; wheezes and crackles Cyanosis; clubbing of fingers Fatigue; weakness Loss of appetite What conditions might promote the development of bronchiectasis? Discuss preventive measures.

77 Chronic Obstructive Pulmonary Disease (COPD)
Bronchiectasis (continued) Medical management/nursing interventions Pharmacological management Mucolytic agents Antibiotics Bronchodilators Oxygen (low-flow) Chest physiotherapy Hydration Cool mist vaporizer Surgery: Lobectomy When suspecting bronchiectasis, what diagnostic testing will be done? Outline the prognosis for the patient experiencing bronchiectasis.

78 Nursing Process Nursing diagnoses Airway clearance, ineffective
Breathing pattern, ineffective Gas exchange, impaired Anxiety Activity intolerance Nutrition, imbalanced: less than body requirements


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