Chapter 30
Acute Respiratory
Disorders
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Learning Objectives
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Identify data to be collected in the nursing assessment
of the patient with a respiratory disorder.
Identify the nursing implications of age-related changes
in the respiratory system.
Describe diagnostic tests or procedures for respiratory
disorders and nursing interventions.
Explain nursing care of patients receiving therapeutic
treatments for respiratory disorders.
For selected respiratory disorders, describe the pathophysiology,
signs and symptoms, complications, diagnostic
measures, and medical treatment.
Assist in developing a nursing care plan for the patient
who has an acute respiratory disorder.
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Anatomy of the Respiratory System
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Nose
• External nose
• The part that is seen on the face
• Made of bones and cartilage covered with skin
• Lining: thick mucous membranes and small hairs
• Nasal cavity
• Lies over the roof of the mouth
• Lined with mucous membranes along with the cilia
(small hairlike projections)
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Pharynx
• A 5-inch tube extending from the back of the
mouth to the esophagus
• Nasopharynx lies behind the nose
• Oropharynx lies behind the mouth
• Laryngopharynx lies behind the larynx
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Pharynx
• A passage for respiratory and the digestive
systems
• Functions in the formation of sounds,
especially vowel sounds
• Tonsils located in the pharynx; may interfere
with breathing, particularly nasal breathing, if
they become enlarged
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Larynx
• The air passage between the pharynx and the trachea
• Contains vocal cords and several types of cartilage,
including the thyroid cartilage and the epiglottis
• During swallowing the epiglottis acts like a lid to help
prevent aspiration of food into the trachea
• Vocal cords: folds of mucous membranes attached to
cartilage; extend from the front to the back of the larynx
• Sounds produced when air from the lungs causes a rapid,
repeated opening and closing of the glottis
• Sounds transformed into speech by lips, jaws, and tongue
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Trachea
• A 4- to 5-inch tube descending from the larynx
into the bronchi
• Made of cartilage, smooth muscle, and
connective tissue lined by a layer of mucous
membrane
• A passageway for air to reach the lungs
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Bronchi
• Passageway for air to and from the lungs
• Two primary bronchi split to the right and left
from the trachea
• Right bronchus is shorter and wider and runs
straighter up and down than the left bronchus
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Bronchi
• Larger bronchi divide into smaller, or secondary,
bronchi; divide again into smaller tertiary
bronchi
• Tertiary bronchi divide into smaller bronchioles,
which lead into tiny air sacs called alveoli in the
lungs
• Through the walls of the alveoli, exchange of
oxygen and carbon dioxide takes place
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Figure 30-2
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Lungs
• Located in right and left sides of the thoracic
cavity within the chest wall
• Thoracic cavity is separated from the
abdominal cavity by the diaphragm, a large
sheet of muscle
• Three lobes on the right and two on the left
• Each lung covered by membrane: the pleura
• A sac containing a small amount of fluid that acts as
a lubricant for the lungs when they expand and
contract
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Physiology of the Respiratory System
• Mechanism of breathing
• Inspiration: air entering the lungs
• Active contraction of the muscles and diaphragm and can
be noted by an enlargement of the chest cavity
• Expiration: air leaving the lungs
• Muscles relax and the chest returns to normal size
• Normal breathing: 500 mL of air inhaled and
exhaled
• Apnea: temporary interruption in the normal
breathing pattern in which no air movement occurs
• Dyspnea: difficulty breathing, or shortness of breath
• Orthopnea: difficulty with breathing in a lying
position
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Physiology of the Respiratory System
• Respiratory center
• Located in medulla; controls breathing
• Stimulated by changing levels of carbon dioxide and
oxygen in arterial blood
• Chemoreceptors in the aorta and carotid artery
monitor the pH and amount of carbon dioxide and
oxygen in the bloodstream
• Changes in the pH, increased levels of carbon dioxide, or
decreased levels of oxygen cause signals to be sent to the
phrenic nerves, which in turn send signals to the
respiratory muscles to carry out the major work of
breathing
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Age-Related Changes
• Muscle atrophy of pharynx and larynx, slackening
vocal cords, less elasticity of laryngeal muscles and
cartilages
• May result in a gravelly, softer voice with a rise in pitch
• Deviation of trachea if scoliosis of upper spinal column
• Loss of lung elasticity, enlargement of the bronchioles,
and a decreased number of functioning alveoli
• More susceptible to lung infections because of less
effective respiratory defense mechanisms
• Reduced chest movement and ability to inhale and
exhale, less effective cough, increased work of
breathing, and less tolerance for exercise and stress
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Nursing Assessment of the
Respiratory System
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Chief Complaint and History of
Present Illness
• Cough
• Onset, duration, frequency, type (wet or dry),
severity, and related symptoms (sputum production
and pain)
• Dyspnea
• Onset, duration, severity, and precipitating events
• Pain
• Location, severity, onset, duration, and precipitating
events (trauma, coughing, inspiration)
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Past Medical History and
Family History
• Allergies, colds, pneumonia, tuberculosis, chronic
bronchitis, emphysema, asthma, cancer of the
respiratory tract, cystic fibrosis, sinus infections, ear
infections, diabetes mellitus, and heart disease
• Conditions that suppress the immune response
• All recent and current medications, including over-thecounter drugs, and dates of the most recent chest
radiograph and tuberculosis test
• Inquire about pneumonia and influenza immunizations
• Family history; describe any major respiratory
conditions and the smoking history of members of the
household
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Review of Systems
• Assess for fatigue, weakness, fever, chills,
night sweats, earaches, nasal obstructions,
sinus pain, sore throat, hoarseness, edema,
dyspnea, and orthopnea
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Functional Assessment
• Patient’s occupational history, including
exposure to pathogens or substances that
might irritate or harm the respiratory tract
• Ask about the usual diet and fluid intake
• Smoking history reported in packs per day
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Physical Examination
• Head and neck
• Inspect the nose for symmetry and for deformity and
gently palpate for tenderness
• Palpate sinus tenderness with thumbs: apply
pressure over frontal and maxillary sinuses
• Inspect lips, tip of nose, top of auricles, the gums,
and area under the tongue for cyanosis
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Physical Examination
• Thorax
• Inspect chest for deformities and lesions and
observe the breathing pattern and effort
• Palpate thorax for tenderness and lumps
• Systematically auscultate the lungs bilaterally
• Inspect the abdomen for distention
• Inspect extremities for color; palpate for edema
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Figure 30-4
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Figure 30-5
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Diagnostic Tests and Procedures
• Radiologic studies
• Chest radiography, fluoroscopy, ventilation-perfusion scan
• Imaging procedures
• Computed tomography, magnetic resonance imaging, positron
emission tomography
• Pulmonary function tests
• Spirometry, arterial blood gas analysis
• Pulse oximetry
• Sputum analysis
• Culture and sensitivity, acid-fast test, cytologic specimens
• Fiberoptic bronchoscopy
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Common Therapeutic Measures
• Thoracentesis
• Breathing exercises
• Deep breathing and coughing exercises
• Pursed-lip breathing
• Sustained maximal inspiration
• Chest physiotherapy
• Chest percussion and vibration
• Postural drainage
• Suctioning
• Humidification and aerosol therapy
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Figure 30-8
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Figure 30-9
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Figure 30-10A
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Figure 30-10B
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Common Therapeutic Measures
• Oxygen therapy
• Intermittent positive-pressure breathing treatments
• Artificial airways
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Oral airway
Nasal airway
Endotracheal tube
Tracheostomy
• Mechanical ventilation
• Chest tubes
• Thoracic surgery
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Figure 30-11
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Figure 30-12
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Figure 30-13
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Preoperative Nursing Care of the
Patient with a Thoracotomy
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Routine Preoperative Nursing Care
• Emphasize postoperative breathing exercises
• If insertion of a chest tube is anticipated,
explain the procedure to the patient
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Assessment
• Monitor vital signs, lung sounds, mental status,
dressings, and chest tube function and
drainage
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Interventions
• Impaired Gas Exchange
• Ineffective Breathing Pattern
• Ineffective Airway Clearance
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Video Thoracoscopy
• Inserting an endoscope through small thoracic
incision
• Procedures that can be done with this
instrument include resection of pulmonary and
mediastinal lesions, biopsy, drainage of
effusions, sympathectomy, vagotomy, and
thymectomy
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Drug Therapy
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Decongestants
Antitussives
Antihistamines
Expectorants
Antimicrobials
Bronchodilators
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Corticosteroids
Mast cell stabilizers
Leukotriene inhibitors
Mucolytics
Thrombolytics
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Disorders of the
Respiratory System
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Acute Viral Rhinitis (Common Cold)
• Etiology and risk factors
• Caused by viruses that invade the upper respiratory
tract through airborne droplets
• Signs and symptoms
• Nasal dryness and stuffiness, sneezing, runny nose,
headache, sore throat, lethargy, and fatigue
• Complications
• Viral or bacterial pneumonitis
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Acute Viral Rhinitis (Common Cold)
• Medical diagnosis
• Patient history and physical examination
• Medical treatment
• Rest, fluids, proper diet, antipyretics, and analgesics
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Acute Viral Rhinitis (Common Cold)
• Assessment
• Symptoms, past medical history, and drug history
• Physical examination of the nose, throat, ears, neck,
and chest
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Acute Viral Rhinitis (Common Cold)
• Nursing diagnosis, goal, and outcome criteria
• Ineffective Therapeutic Regimen Management
• Goal: full recovery with no complications
• Assessing effective patient management: patient’s
verbalization of content presented and statement of
intent to follow plan of care
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Acute Viral Rhinitis (Common Cold)
• Interventions
• Rest and daily fluid intake of 2 to 3 L, if not
contraindicated
• Humidifier may provide comfort by keeping mucous
membranes moist
• Fever can be treated with antipyretics
• Avoid contact with others, especially those who are
at increased risk for infection
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Acute Bronchitis
• Etiology and risk factors
• Usually viral; bacterial causes also common
• Irritation and inflammation may occur throughout
upper respiratory tract, resulting in increased
production of mucus
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Signs and symptoms
• Fever, cough, yellow or green sputum, rapid
breathing, and occasionally chest pain
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Acute Bronchitis
• Medical diagnosis
• Health history and the physical findings
• Nursing care
• Similar to that for the common cold
• Encourage patients who are taking antibiotics to
take the full course of the medication
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Influenza
• Etiology
• Acute viral respiratory infection accompanied by
fever
• Complications
• Bronchitis and viral or bacterial pneumonia; less
common complications are myocarditis, pericarditis,
Reye’s syndrome, confusion, seizures, GuillainBarré syndrome, toxic shock syndrome, myositis,
and renal failure
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Influenza
• Signs and symptoms
• Chills, fever, sore throat, muscular pain, headache,
and dry, hacking cough
• Medical diagnosis
• History and physical findings
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Influenza
• Medical treatment
• Rest, fluids, proper diet, antipyretics, analgesics,
and antiviral agents
• Best treatment: prevention through immunization
• Nursing care
• Similar to that of the common cold
• Immunization for people at high risk
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Pneumonia
• Etiology and risk factors
• Inflammation of certain parts of the lung, such as
alveoli and bronchioles
• Caused by either infectious or noninfectious agents
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Pneumonia
• Pathophysiology
• Classified according to the causative organism,
usually bacteria or viruses
• When pathogens invade lungs, inflammation causes
fluid accumulation in affected alveoli; capillaries
dilate and neutrophils, red blood cells, and fibrin fill
alveoli; lung appears red and granular; blood flow
decreases and leukocytes and fibrin infiltrate and
consolidate; as infection resolves, consolidated
material dissolves and is ingested and removed by
macrophages
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Pneumonia
• Complications
• Pleurisy, pleural effusion, and atelectasis
• Less common: lung abscesses, delayed resolution,
and empyema
• Systemic complications: pericarditis, arthritis,
meningitis, and endocarditis
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Pneumonia
• Signs and symptoms
• Fever, chills, sweats, chest pain, cough, sputum
production, hemoptysis, dyspnea, headache, and
fatigue
• Medical diagnosis
• History and physical examination, sputum culture
and Gram stain, chest radiograph, complete blood
count, and blood culture
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Pneumonia
• Medical treatment
• Increased fluid intake (at least 3 L every 24 hours),
limited activity or bed rest, antipyretics, analgesics,
oxygen and aerosol intermittent positive-pressure
breathing therapy
• Bacterial pneumonias are treated with appropriate
antibacterials
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Pneumonia
• Interventions
• Ineffective Airway Clearance; Impaired Gas
Exchange
• Activity Intolerance
• Imbalanced Nutrition: Less Than Body
Requirements
• Risk for Deficient Fluid Volume
• Pain
• Prevention of Aspiration Pneumonia
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Pleurisy (Pleuritis)
• Inflammation of the pleura
• Causes: pneumonia, tuberculosis, injury to the
chest wall, pulmonary infarction, and tumors
• Symptom of pleurisy is abrupt and severe pain
• Almost always on one side of the chest; breathing
and coughing aggravate the pain
• Treatment: underlying disease and pain relief
• Analgesics, anti-inflammatories, antitussives,
antimicrobials, local heat therapy
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Pleurisy (Pleuritis)
• Interventions
• Acute Pain
• Ineffective Breathing Pattern
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Chest Trauma
• Etiology
• Nonpenetrating or blunt injuries
• From automobile accidents, falls, or blast injuries
• Rib fractures, pneumothorax, pulmonary contusion, and
cardiac contusion
• Penetrating injuries
• From gunshot or stab wounds to the chest
• Pneumothorax and life-threatening tears of the aorta, vena
cava, or other major vessels
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Chest Trauma
• Signs and symptoms
• Obvious trauma to the chest wall; chest pain;
dyspnea; cough; asymmetric movement of the chest
wall; marked cyanosis of the mouth, face, nail beds,
and mucous membranes; rapid, weak pulse;
decreased blood pressure; deviation of the trachea;
distended neck veins; and bloodshot or bulging
eyes
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Chest Trauma
• Medical treatment
• Treat bleeding
• Cover open chest wound with an airtight dressing
taped on three sides
• Vital signs and level of consciousness
• Oxygen by nasal cannula
• Place in semi-Fowler’s or on injured side
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Pneumothorax
• Etiology
• Accumulation of air in pleural cavity: results in
complete or partial collapse of a lung
• Tension pneumothorax
• Air repeatedly enters the pleural space with inspiration,
causing the pressure to rise
• Open pneumothorax
• From a chest wound: allows air to move in and out freely
with inspiration and expiration
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Pneumothorax
• Signs and symptoms
• Dyspnea, tachypnea, tachycardia, restlessness,
pain, anxiety, decreased movement of the involved
chest wall, asymmetric chest wall movement,
diminished breath sounds on the injured side, and
progressive cyanosis
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Pneumothorax
• Medical treatment
• Physician may insert an 18-gauge needle through
chest wall into pleural space and aspirate
accumulated air or fluid, then insert a chest tube
• If air is entering the pleural space from a tear in the
lung or bronchus, surgery may be needed to repair
the tear
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Pneumothorax
• Interventions
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Ineffective Breathing Pattern
Fear
Decreased Cardiac Output
Acute Pain
Risk for Infection
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Hemothorax
• Blood accumulation between chest wall and lung that
is often associated with pneumothorax
• From lacerated or torn blood vessels or lung tissues,
lung malignancy, or pulmonary embolus
• When air or blood collects in pleural space, pressure
around lung increases; causes partial/complete
collapse
• Treated like pneumothorax; nursing care similar
• Surgical intervention: control source of bleeding
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Rib Fractures
• Etiology
• Most common cause: blunt injury
• Signs and symptoms
• Pain at the site of injury, occasional bruising or surface
markings, swelling, visible bone fragments at the site of the
injury, and shallow breathing or holding the chest protectively
• Medical treatment
• Intercostal nerve blocks; analgesics; mild sedatives
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Rib Fractures
• Assessment
• For signs of increasing respiratory distress
• Nursing diagnosis, goal, and outcome criteria
• Ineffective Breathing Pattern related to pain
• Goal: effective breathing pattern
• Outcome criteria: vital signs within normal range,
absence of dyspnea, and breath sounds clear to
auscultation
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Rib Fractures
• Interventions
• Breathing exercises
• Assess pain every 2 hours
• Administer prescribed analgesics
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Flail Chest
• Etiology
• An injury in which two adjacent ribs on the same
side of the chest are broken into two or more
segments
• Affected section of the rib cage is, in a sense,
detached from the rest of the rib cage
• Permits it to move independently: moves in with
inspiration and out with expiration
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Flail Chest
• Signs and symptoms
• Severe dyspnea, cyanosis, tachypnea, tachycardia,
and paradoxical movement of the chest
• Medical diagnosis
• History, physical examination, and chest
radiographs
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Flail Chest
• Medical treatment
• If patient can maintain adequate oxygenation,
treatment may consist of deep breathing and
coughing, IPPB treatment, and pain management
• The patient in respiratory distress usually requires
intubation and mechanical ventilation
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Flail Chest
• Assessment
• Respiratory status, vital signs, other medical
diagnoses, and a drug history
• Interventions
• Similar to those for fractured ribs
• Reduce anxiety
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Pulmonary Embolus
• Etiology and risk factors
• Risk factors for emboli: surgery of the pelvis or
lower legs, immobility, obesity, estrogen therapy,
and clotting abnormalities
• A portion of a pulmonary blood vessel is occluded
by an embolus
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Pulmonary Embolus
• Signs and symptoms
• Sudden chest pain that worsens with breathing,
tachypnea, and dyspnea
• Patient may be apprehensive and diaphoretic with a
cough and hemoptysis
• Crackles may be heard on auscultation of the lungs;
patient may have fever and tachycardia
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Pulmonary Embolus
• Medical diagnosis
• History and physical findings; confirmed by arterial
blood gas analysis, electrocardiogram, lung scan,
and pulmonary angiogram
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Pulmonary Embolus
• Medical and surgical treatment
• Anticoagulation therapy
• Oxygen therapy, endotracheal intubation, and/or
mechanical ventilation
• IV fluids and drugs: improve cardiac function
• IV morphine sulfate: relieve chest pain and
apprehension
• Surgical interventions: embolectomy, vena cava
interruption, and venous thrombectomy
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Pulmonary Embolus
• Assessment
• Monitor cardiopulmonary function
• Homans’ sign should be assessed in each leg
• Interventions
• Ineffective Tissue Perfusion
• Anxiety
• Risk for Injury
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Acute Respiratory Distress Syndrome
(ARDS)
• Etiology and risk factors
• Progressive pulmonary disorder that follows trauma
to the lung
• Pulmonary infiltrates develop and lung compliance
decreases
• Signs and symptoms
• Increased respiratory rate; fine crackles;
restlessness, agitation, and confusion; pulse rate
increases, and cough may be present
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ARDS
• Medical diagnosis
• History and physical; arterial blood gas analysis and
chest radiographs
• Medical treatment
• Mechanical ventilator with positive end-expiratory
pressure
• Sedation or pharmacologic paralysis
• Drug therapy depends on underlying cause
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ARDS
• Should be treated in intensive care setting
• Nurses must be aware of the risk of ARDS and
respond promptly when a patient exhibits
progressive respiratory distress
• Rapid progression of the condition is
frightening to patient and family
• Recognize their anxiety and fear and offer
emotional support and simple explanations
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