Assessment & Management
of Patients
With
Respiratory Tract
Disorders
Lower Respiratory Tract
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Trachea
Bronchi
Bronchioles
Alveoli
Cilia
Clinical Manifestations
1. Local Manifestations
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Cough
 chronic, paroxysmal, dry , productive
Excessive Nasal Secretion
Expectoration of Sputum
 mucoid, purulent, mucopurulent, rusty,
hemoptysis
Pain
 pleuritic, intercostal, generalized chest
pain
Dyspnea- shortness of breath
Clinical Manifestations
2. Systemic Manifestations
 Hypoxemia
 insufficient oxygenation of the blood
 cyanosis- bluish, grayish discoloration of skin &
mucous membranes
 Hypoxia
 inadequate tissue oxygenation
 Hypercapnia
 CO2 in arterial blood above normal limits
 Hypocapnia
 CO2 in arterial blood below normal limits
 Respiratory Failure
Assessment of Respiratory
System
Health History
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Risk Factors
Major Clinical Manifestations
 Cough
 Sputum production
 Chest pain
 Wheezing
 Clubbing of the fingers
 Cyanosis
Assessment of Respiratory System
Physical Examination
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Inspection
 posture, shape, movement, dimensions of
chest, flared nostrils, use of accessory
muscles, skin color, and rate, depth, & rhythm
of respiration
Palpation
 respiratory excursion, masses, tenderness
Percussion
 flat, dull, resonant, hyperresonant sounds
Auscultation
 breath sounds, voice sounds, crackles,
wheezes
Crackles
Diagnostic Procedures
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Sputum Studies
 Methods- standard, saline inhalation,
gastric washing
Arterial Blood Gases
 measurements of blood pH , arterial O2
& CO2 tensions, acid-base balance
Pulse Oximetry
Chest X-ray
Bronchoscopy
Thoracentesis
Laryngoscopy
Lower
Respiratory
Disorders
Pneumonia
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Inflammation & infection of lunginfecting organisms typically inhaledorganisms transmitted to lower airways
and alveoli causing inflammation- impairs
gas exchange
Etiology: bacteria, virus, Mycoplasma,
fungus, or from aspiration or inhalation
of chemicals or other toxic substances
Risk factors: cigarette smoking, chronic
underlying disorders, severe acute
illness, suppressed immune system, &
immobility
Pneumonia
Assessment: Questions to ask
 Have you been experiencing difficulty
breathing?
 Are you having pain? Where?
 Do you have a cough?
 Have you been running a fever?
 Have you been feeling tired?
Clinical Manifestations:
 fever, pleuritic chest pain, tachypnea, SOB,
tachycardia, cough, sputum production- rusty,
blood-tingled or yellow-green, fatigue, poor
appetite
Pneumonia
Diagnostic:
 Sputum and blood cultures, CBC, ABGs, CXR,
& Bronchoscopy
Nursing Diagnoses:
 Ineffective airway clearance r/t thick,
tenacious sputum
 Ineffective breathing pattern r/t tachypnea,
chest pain, & airway inflammation
 Impaired gas exchange r/t exudate in alveoli
 Activity intolerance r/t hypoxemia, fatigue
Pneumonia
Planning: Client Outcomes
 Maintain open & clear airway, normal RR, PO2 level
without supplemental O2, complete physical care
without frequent rest periods
Interventions
 Improve airway patency- auscultate lung sounds,
monitor ABGs or pulse oximetry, elevate HOB, C & DB q
2hrs, ambulate , I/S, O2 as needed
 Promote fluid intake & promote activity tolerance
 Monitor & prevent complications
Pneumonia
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Pharmacology:
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Antibiotic therapy based on sputum culture &
sensitivity
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Levaquin, Tequin, Rocephin, Primaxin, Zithromax,
Ketek, Zinacef, Cipro, Tetracycline
Instruct to finish all antibiotics at prescribed
intervals
Evaluation:
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breathing easier without chest pain
temperature normal,
activity level increased without frequent rest
periods
Tuberculosis
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Infectious disease that primarily affects
the lungs; may be transmitted to other
parts of the body
Pulmonary infiltrates accumulate, cavities
develop, & masses of granulated tissue
form within the lungs
Primary infectious agent- Mycobacterium
Bacilli Transmitted by inhalation of
droplets (talking, coughing, sneezing, &
singing)
Risk factors: immune system disorder,
preexisting medical conditions,
institutionalized, health care workers
Pulmonary Tuberculosis
Mycobacterium tuberculosis
 Airborne transmission
 Tuberculin skin testing
 Pharmacologic therapy- multidrug regimens and prophylaxis
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Tuberculosis
Assessment:
 Questions to ask - Are you suffering from night
sweats? Have you lost weight? Have you been
having low-grade fever? Have you been having
SOB and coughing up anything from your lungs?
Have you had chest pain? Where? Have you
had weight loss?
Clinical Manifestations- low-grade fever (late
afternoon), night sweats, weight loss, anorexia,
fatigue, chronic productive cough,pleuritic chest
pain, hemoptysis
Tuberculosis
Diagnostic:
 Sputum culture- + acid-fast bacilli (AFB)
 Skin testing- PPD
 CBC- WBC elevated
 CXR
 Bronchoscopy
Nursing Diagnosis:
 Ineffective airway clearance r/t thick, tenacious
secretions
 Ineffective breathing pattern r/t airway
inflammation
Tuberculosis
Altered nutrition less than body
requirements r/t anorexia and fatigue
 Anxiety r/t social isolation secondary to
isolation protocols
Planning: Clients Outcomes
 Maintain clear airway,normal RR, achieve
weight gain, anxiety decreased
Interventions:
 Maintain respiratory isolation- infectious
period - diversional activities
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Tuberculosis
Promote airway clearance- bedrest, increase
fluid intake, high humidity
 Pharmacology
 First-line meds- INH, Rifampin, Streptomycin,
Ehtambutol, & Pyrazinamide for 4 months
 INH and Rifampin continued for an additional
2 months or up to 12 months.
 Advocate adherence & prevention
 Monitor and manage potential complications
Evaluation:
 Client adheres to isolation precautions, takes
medication as prescribed
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Tuberculosis
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Questions to ask
 Do you have difficulty breathing- all the time
or is it caused by exertion?
 Do you cough frequently and is it productive?
 Have you had a weight loss?
 Do you feel tired quite often and are your
activities impaired by SOB or fatigue?
 Do you have many respiratory infections?
Over what period of time?
Tuberculosis
Nursing Diagnosis
 Ineffective airway clearance r/t thick, tenacious
secretion and fatigue
 Ineffective breathing pattern r/t fatigue and obstruction
of the bronchial tree
 Impaired gas exchange r/t increased sputum production
 Activity intolerance r/t hypoxemia & fatigue
 Altered nutrition r/t increased metabolic demands,
fatigue, & anorexia
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Anxiety r/t inability to breathe effectively
Tuberculosis
Diagnostics:
 ABGs, CBC, sputum culture, CXR,
Pulmonary function tests
Planning: Client Outcomes
 Effectively clear airway and breathing
pattern, maintain normal ABGs, increase
activity with decrease SOB or fatigue,
maintain weight, and less anxious with
episodes of SOB
Chronic Obstructive Pulmonary
Disease (COPD)
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A group of chronic, obstructive airflow
diseases of the lungs. Also known as
chronic airflow limitation (CAL)
Usually progressive & irreversible; Ciliary
cleansing mechanism of the respiratory
tract is affected
Involves 3 diseases- Chronic Bronchitis,
Asthma, & Emphysema
Risk factors- cigarette smoking, air
pollution, occupational exposure,
infections, allergens, stress
Chronic Bronchitis
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Inflammation of the bronchi caused by irritants
or infection
hypertrophy & hypersecretion of mucous- cause
increase in sputum production
increase mucous- decrease airway lumen sizelumen becomes colonized with bacteria.
Bronchial wall becomes scarred - leads to
stenosis & airway obstruction
Defined as a productive cough that lasts 3
months a year for 2 consecutive years with other
causes excluded.
Cough in the morning with sputum production is
indicative of Chronic Bronchitis
Chronic Bronchitis
Risk Factors: cigarette smoking, exposure to
pollution, hazardous airborne substances
Clinical Manifestations: productive cough,
dyspnea esp. on exertion, wheezing, use of
accessory muscles to breathe, cyanosis- “blue
bloater”, clubbed fingers
Interventions:
 Assess patency of airway- suction if cough
ineffective, RR, accessory muscle use, lung
sounds, skin color changes, ABGs
 Encourage high fluid intake & instruct in effective
breathing & coughing
 Monitor oxygen administration & aerosol therapy
Chronic Bronchitis
Encourage to report sputum changes or
worsening of symptoms
 Encourage exercise to improve resp. fitness
 Counsel to avoid respiratory irritants and stop
smoking
 Immunize against common flu and pneumonia
Pharmacology:
 Antibiotic therapy- Tequin, Levaquin
 Bronchodilators- Albuterol, Combivent,
Theophylline
 Corticosteroids- Prednisone, SoluMedrol
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Asthma
Chronic inflammatory disease of the airways
- bronchial linings overreact to various
stimuli- causes episodic smooth muscle
spasms that severely constrict the airway thickened secretions & mucosal edema
further block the airways.
 Acute symptoms last from minutes to hours,
to days and then periods without symptoms
 Most common chronic disease of childhood
Risk Factors: allergy, chronic exposure to
airway irritants of allergens, stress, exertion,
sinusitis
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Asthma
Clinical Manifestations: cough with or without
sputum production, SOB & wheezing, generalized
chest tightness, expiration requires effort &
becomes prolonged, tachycardia, tachypnea,
increased restlessness
Interventions:
 Immediate care depends on severity of asthma
symptoms- assess resp. status, ABGs monitoring,
oxygen therapy
 Administered prescribed therapy & monitor
response
 Fluids & antibiotics
 Minimize anxiety
 Teach preventive measures- exercise
Asthma
Pharmacology:
 Bronchodilators
 Beta-agonists- Albuterol, Serevent
 Xanthines- Theophylline
 Corticosteroids
 Prednisone, SoluMedrol
 Inhalers- Flovent, Vanceril, Beclovent, Advair, Azmacort
 Anticholinergics- Atrovent, Combivent
 Leukotriene modifiers- Singulair
May be treated as outpatient or require hospitalization &
intensive care
Emphysema
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Enlargement of air spaces distal to airways that
conduct air to the alveoli
Enlarged spaces causes breakdown in alveoli
walls- increases in airway size on inspirationdecreases alveolar membrane for gas exchange
Small airways collapse on exhalation- air
trapped in alveolar spaces
Theses changes- products destruction of elastin
in distal airways and alveoli
Distinguishing characteristic- airflow limitation
caused by lack of elastic recoil in the lungs
COPDEmphysema
Emphysema
No trouble inhaling, but with hyperinflated
lungs & small airways- exhaling becomes
more difficult
Risk Factors: smoking, occupational
exposure, heredity
 Most common in fifth decade of life
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Emphysema
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Clinical Manifestations: SOB on exertion, use of accessory
muscles to breath, late cough after onset of SOB (if productive
sputum- scanty & mucoid), “pink puffer”, barrel chest (increase in
anterior-posterior diameter of chest), thin in appearance,
diminished breath sounds & prolonged expiration, speaks in short
jerky sentences, anxious
Interventions:
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Improve gas exchange- oxygen therapy
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Achieve airway clearance- aerosol therapy
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Encourage adequate hydration
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Prevent infections- immunizations
Emphysema
Minimize anxiety
 Physical therapy
 Patient teaching
Pharmacology:
 Beta-agonists- Albuterol, Theophylline
 Anticholinergics- Atrovent
 Antibiotic therapy- Levaquin, Tequin
 Corticosteroids
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Emphysema
Evaluation:
 Improved gas exchange, achieves
airway clearance, breathing pattern
improved, achieves activity tolerance,
acquires effective coping mechanisms,
and adheres to therapeutic program.
Atelectasis
Inadequate ventilation
 Mucus plugs
 Pleural effusion
 Pneumothorax
 Hemothorax
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Pleural
Effusion
Pneumothorax
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Condition in which air or gas exists in the
pleural space
Normally negative pressure (suction)
between the visceral and parietal pleuraany injury that allows air or positive
pressure to enter pleural space- prevents
the lung from remaining inflated
Air in pleural space- increased intrapleural
pressure- partial or total collapse of the
lung
Types: Simple, Traumatic, or Tension
Pneumothorax
Pneumothorax
Simple (Closed or spontaneous)
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Air enters the pleural space from the lung
in the absence of disease
Occurs in men ages 20 to 40 & result of
rupture of small blister on the apex of the
lung
If occurs from trauma or pulmonary
disease- referred to as secondary or
complicated
Basic symptoms: SOB & chest pain
Treatment of Simple
Pneumothorax
Pneumothorax
Pneumothorax
Traumatic (Open)
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A hole in the chest wall allows atmospheric air
to flow into the pleural space
Air in the pleural space - increased intrapleural
pressure- resulting in partial or total collapse of
the lung
Results from a penetrating injury, a therapeutic
procedure, or insertion of a CVP or pulmonary
artery catheter
A sucking sound audible on inspiration as the
chest wall rises & varying degrees of resp.
distress
Pneumothorax
Tension
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Injury allows air to leak into pleural space
during inspiration- prevents air from leaking
out during expiration
Each inspiration-amount of air increasesbecomes trapped to point causing increased
thoracic pressure- pushes the heart, vena cava,
and aorta out of position (mediastinum shift)results in poor venous return to heart - leads
to poor cardiac output
Medical emergency- disruption of cardiac
output & respiratory distress
Pneumothorax
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Etiology:
 Blunt chest trauma (MVAs and falls),
 penetrating trauma (gunshot and knife injuries), rib
fractures, & flail chest
Assessment: Questions to ask
 Are you having difficulty breathing?
 Do you have pain in your chest? Point to your pain
with one finger.
Clinical Manifestations:
 SOB, CP, tachypnea, tachycardia, cyanosis, diminished
breath sounds, hyper-resonance on affected side, neck
vein engorgement, paradoxical movement of the chest,
deviated trachea, cardiogenic shock & anxiety
Pneumothorax
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Diagnostic:
 ABGs, CXR
Nursing Diagnosis:
 Ineffective breathing pattern r/t decreased lung
expansion
 Impair gas exchange r/t collapse of an area of the
lung
 Anxiety r/t inability to ventilate effectively
Planning: Client Outcomes
 RR & ABGs within normal limits, client states
rationale for treatment & procedures, & client rests
without behavioral signs of excessive anxiety
Pneumothorax
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Nursing Interventions:
 Comprehensive respiratory assessment- airway
patency, RR, lung sounds, chest rise & fall
symmetrically, ABGs, blood counts, electrolytes,
cardiac status, urinary output, chest wall
 Maintain semi-Fowler’s position
 Encourage deep breathing & coughing
 Administer oxygen therapy
 Medicate for pain as needed
 Explain all procedures- calm & reassure about overall
treatment & condition as needed
 Encourage use of relaxation techniques
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Medical- Mechanical Ventilation & Chest tubes
Chest Tubes
Chest Drainage System
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Inserted after most thoracic &
cardiac surgeries
Consists of chest tube attached to
valve mechanism- allow air or fluid
to drain out of the chest cavity
Include one, two, and three-bottle
systems and the one-piece, three
chamber, disposable plastic systems
Purpose of Chest Drainage System
 Removes air, blood,
& other fluids from
pleural space or
mediastinal space
 Facilitates re-
expansion of the
lungs and restore
negative pressure in
thoracic cavity
Indications for
Chest Drainage System
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After thoracic & cardiac surgery
Traumatic injury- Fractured Rib
Intrapleural- pneumothorax,
hemothorax, & pleural effusion
Mediastinal- cardiac surgery, chest
trauma
Complication from procedures:
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CVC insertion
Types of Chest Drainage Systems
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Water-seal
 Remove air or fluid from pleural space or
mediastinum
 Mechanism for collection of drainage
 One-way mechanism to keep air from
getting back into the pleural space
 Water-seal acts = one-way valve
 Allows air to leave pleural space- but
not to return-maintaining negative
pressure
Types of Chest Drainage Systems
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Waterless
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Valve to regulate suction
Valve can be opened for air & liquid drainage to
move out
Remain closed to prevent air from entering
pleural space
Autotransfusion
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Variation of water-seal system
Attached container so that blood drained from
chest can be salvaged for autotransfusion
Assessment Pt with Chest Drainage
Systems
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Respiratory status
S&S of extended pneumothorax or hemothorax
Function of drainage system every 1 hr:
 System below level of patient’s chest
 Tube free of kinks, or external obstruction
 All connections secured
 Color and amount of drainage
 Fluctuation of fluid level in water-seal chamber
 Constant bubbling in water-seal chamber
Anxiety level & understanding
Chest Drainage Systems
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Nursing Diagnosis
 Ineffective breathing pattern related to
decreased lung expansion as evidence by:
Planning: Patient Outcomes
 Breath sounds are normal
 Respiration unlabored & occur at rate of 16 to 20
breaths per minute
 ABG values approaching normal
 Lung re-expansion seen on chest x-ray film
Chest Drainage Systems
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Nursing Interventions:
 Maintain astraight, patent, functioning chest drainage
system
 Re-tape all connections as needed
 Re-tape or reinforce chest-tube dressing
 Tubing free of kinks, loops & external pressure
 Place roll towel under chest- protect tubing from body
weight
 Encourage cough and deep breathe & position change
frequently
 Keep occlusive petrolatum jelly dressing at bedside
Chest Drainage Systems
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Mark amount of drainage in collection container
at 1 to 4 hour intervals
Check water levels in suction control & waterseal pressure chambers
Notify MD of constant bubbling in water-seal or
drainage becoming bright red or increases
suddenly
Reassure the patient that staff is nearby- call
light in reach
Documentation for chest drainage systems
Assist with chest tube insertion or removal
Chest Drainage Systems
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Evaluation:
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RR & ABGs within normal limits
Decreased difficulty breathing
Chest pain diminished
Equal lung sounds
Bilateral chest movement
Decreased chest tube drainage
Client able to verbalize rationale for treatment
and procedures
Client rests without behavioral signs of
excessive anxiety
Older Adult Alert
1.
2.
3.
4.
Be concern about any changes in orientation. This may
be a first indication of pneumonia in older adults.
Be cautious in fluid administration. Overhydration may
initiate CHF.
Older clients may become confused with multiple drug
therapies and may not follow the regimen correctly.
Theses clients may need assistance to ensure proper
administration. In older clients, the thoracic muscles are
weaker which may make the older adult unable to
tolerate the increased work of breathing required of
COPD.
Older adult clients have fewer alveoli than younger
adults- oxygen exchange will be even more impaired in
older adult clients with COPD.
Older Adult Alert
5.
6.
7.
The weaker thoracic muscles in older adults
will also make coughing more difficult, and
thus, retained secretions will be a problem in
many cases.
Older adults high risk for infection due to
decreased immune response. Chest injuries
evaluated carefully for signs of infection.
Temperature of 99 degrees F may indicate an
initial infection.
Cough will be impaired due to decreased
muscle strength- older adults greater risk for
atelectasis and pneumonia after a chest injury.