1.
2.
3.
4.
5.
6.
7.
8.
9.
Pneumonia
Emphysema
Chronic bronchitis
Asthma
Acute Respiratory Failure
Epistaxis
Sinusitis
Acute Pharyngitis
Tonsillitis
Health problems affecting breathing and the respiratory system strike at the very root of human well-being
and are common in a wide range of patient’s illnesses affecting the respiratory system ranges from acute lifethreatening episodes such as an acute asthmatic attack to long-term debilitating conditions such as chronic
bronchitis. The consequences of such health problems are not only physical, but severe psychological distress can
also occur and be accompanied by major social disruptions. This study guide examines the specific issues relating
to the critical nursing care and treatment of patients with respiratory disorders.
1.
2.
3.
4.
5.
6.
7.
PreTrue/False
Immediate management of a nosebleed involves the insertion of cotton pledgets into the nose to reduce
blood flow.
Antibiotics are the initial medical treatment of choice in viral upper respiratory tract infections and
pneumonia.
The pathophysiology of emphysema involves the destruction of the walls of the alveoli leading to impaired
oxygen diffusion.
Smoking cessation is the single most cost-effective intervention to reduce the risk of developing COPD and
to stop its progression.
Administering oxygen to patients with COPD will result in cardiopulmonary arrest by suppressing the drive
to breathe.
Asthma is considered a distinct, separate disorder from COPD and is classified as an abnormal airway
condition characterized primarily by reversible inflammation.
Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may
cause dyspnea, static secretions, and infection.
An inflammatory process, involving the terminal airways (bronchioles) and alveoli of the lungs, caused by
an infectious agent.
Causative Agents
1. Bacterial Pneumonia:
a. Streptococcal pneumoniae
b. Staphylococcus aureus
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
After going through this topic, you will be able to:
•
Compare and contrast the upper respiratory tract infections concerning cause, incidence, clinical
manifestations, management, and the significance of preventive health care.
•
Use the nursing process as a framework for the care of the patient with pneumonia.
•
Describe the pathophysiology, major risk factors for developing COPD, and nursing interventions to
minimize or prevent these risk factors.
•
Describe nursing management and teaching plan for patients with COPD.
•
Describe the pathophysiology, medications used, and self-management strategies in the management
of asthma.
•
Identify the types, pathophysiology, manifestations, and management options for a person with
respiratory failure.
c.
d.
Haemophilus influenzae
Kleibsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, Enterobacter, and other gramnegative enteric bacilli
2. Nonbacterial pneumonia
a. Mycoplasma pneumoniae
b. Influenza viruses, parainfluenza viruses, and other viral infections
c. Pneumocystis carinii
d. Aspergillus fumigatus
Predisposing Factors
1. Conditions that produce mucus or bronchial obstruction and interfere with normal lung drainage (e.g.,
cancer, cigarette smoking, COPD)
2. Immunosuppressed patients and those with a low neutrophil count (neutropenic).
3. Smoking (cigarette smoke disrupts both mucociliary and alveolar macrophage activity)
4. Prolonged immobility and shallow respiration
5. Depressed cough reflex; aspiration of foreign material into the lungs during the period of unconsciousness
6. Nothing by mouth status; placement of orogastric, or endotracheal tube.
7. Supine positioning in patients unable to protect their airway
8. Antibiotic therapy
9. Alcohol intoxication (alcohol suppresses the body’s reflexes. Maybe associated with aspiration, and decrease
WBC mobilization and tracheobronchial ciliary motion)
10. General anesthetic, sedative, or opioid preparations that promotes respiratory depression.
11. Advanced age, because of possible depressed cough and glottic reflexes and nutritional depletion
12. Respiratory therapy with improperly cleaned equipment
13. Transmission of the organism from health care providers
Classifications
1. Community-Acquired Pneumonia (CAP): occurs either in the community setting or within the first 48 hours
after hospitalization. The development of CAP may be due to a defect in host defenses, exposure to a virulent
microorganism, or an overwhelming exposure.
2. Hospital-Acquired Pneumonia (HAP; nosocomial): onset of pneumonia symptoms more than 48 hours after
admission in patients with no evidence of infection at the time of admission.
3. Pneumonia in the Immunocompromised Host: occurs with the use of steroids or other immunosuppressive
agents, chemotherapy, nutritional depletion, use of broad-spectrum antimicrobial agents, AIDS, genetic
immune disorders, and long-term advanced life-support technology.
4. Aspiration pneumonia: refers to the pulmonary consequences resulting from the entry of endogenous or
exogenous substances into the lower airway. The most common form of aspiration pneumonia is a bacterial
infection from aspiration of bacteria that normally reside in the upper airways.
Clinical
1.
2.
3.
4.
5.
Manifestations
Sudden onset of chills; rapidly rising fever (38.5 -40.5 ⚫C)
Productive cough of purulent sputum
Pleuritic chest pain aggravated by respiration or coughing
Dyspnea (orthopnea)
Tachypnea (25 to 45 breaths/min) accompanied by respiratory grunting, nasal flaring, use of accessory
muscles of respiration.
6. Rusty, blood-tinged sputum may be expectorated with streptococcal (pneumococcal), staphylococcal, and
Klebsiella pneumonia
7. Rapid bounding pulse (tachycardia)
8. Crackles
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
Pathophysiology
The organism gains access to the lungs through aspiration of oropharyngeal contents, by inhalation of
respiratory secretions from infected individuals, via the bloodstream, or from direct spread to the lungs
from surgery or trauma
↓
The infecting organisms trigger inflammation of the airways
↓
Vasodilation and increase capillary permeability
↓
Plasma leaks out and WBC migrate in the alveoli & fill the normally air-containing spaces
↓
Inflammatory exudates fill the alveolar air spaces that interfere with the diffusion of O2 & CO2, producing
lung consolidation
↓
Impaired gas exchange in the alveoli leads to varying degrees of hypoxia, depending on the amount of
lung tissue affected
9. Physical findings that indicated consolidations like increased tactile fremitus and percussion dullness
10. Fatigue
Diagnostic Evaluation
1. Chest X-ray shows a discernible infiltrate and presence/extent of pulmonary disease, typically consolidation.
2. Sputum examination may indicate the offending microorganism and to determine the appropriate antibiotic.
3. Blood culture to detect bacteremia occurring with bacterial pneumonia
Medical Management
1. Antimicrobial therapy: depends on laboratory identification of the causative organism and sensitivity to
specific antimicrobials.
➢ Penicillin, Erythromycin, Nafcillin, Gentamycin, Tobramycin, Tetracycline
2. Mucolytic: acts directly to break up mucus plug in the tracheobronchial passages
➢ Acetylcysteine (Mucomyst), Carbocysteine (mucosolvan)
3. Expectorant: facilitate sputum expectoration.
➢ Guaifenesin (Robitussin, Mucinex)
4. Oxygen therapy, if the patient has inadequate gas exchange.
Nursing Interventions
1. Improving gas exchange
a. Administer oxygen at a concentration to maintain PaO2 at an acceptable level.
b. Avoid high concentrations of oxygen in patients with chronic obstructive pulmonary disease. The
use of high oxygen concentrations may worsen alveolar ventilation in some patients by depressing
the patient’s only remaining ventilatory drive.
c. Place the patient in a fairly upright position as tolerated to obtain greater lung expansion and
improve aeration.
d. Frequent turning and increased activity (up in a chair, ambulate as tolerated) should be employed
if clinically stable.
2. Improving airway clearance
a. Auscultate the chest for crackles.
b. Encourage the patient to deep breaths and cough to reduce retained secretions that interfere with
gas exchange. Suction as necessary.
c. Encourage a high level of fluid intake to replace fluid losses caused by fever, diaphoresis,
dehydration, and tachypnea.
d. Humidify air to loosen secretions and improve ventilation
e. Employ chest wall percussion and postural drainage when appropriate
f. Control cough when coughing is nonproductive, debilitating, and when coughing paroxysms cause
serious hypoxemia.
3. Achieving relief of pleuritic pain and discomfort
a. Place in a comfortable position for resting and breathing and encourage frequent change in position
to prevent pooling of secretions in lungs and atelectasis.
b. Demonstrate how to splint the chest while coughing.
c. Avoid suppressing a productive cough.
d. Administer prescribe analgesic agents to relieve pain.
e. Apply heat to the chest
4. Promoting rest and conserve energy
a. Bed rest and avoid overexertion
b. Semi-fowler’s position
5. Promoting fluid intake
a. Increase fluid intake at least 2-3 liter/day
Patient
1.
2.
3.
4.
5.
6.
Education
Disease process, cause, treatment, expected response
Advise the patient to complete the entire course of antibiotics
Encourage deep breathing and coughing exercises to clear lungs and promote full expansion and function.
Emphasize the importance of thorough hand washing to help prevent infection transmission
Stress the importance of nutrition; adequate rest, avoidance of fatigue, and overexertion.
Advice alcohol and tobacco cessation, which lower resistance to pneumonia.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
Nursing Diagnoses
1. Impaired gas exchange related to decreased ventilation secondary to inflammation and infection involving
distal airspaces; abnormal ventilation-perfusion ratios.
2. Ineffective airway clearance related to excessive tracheobronchial secretions.
3. Pain related to the inflammatory process and dyspnea.
4. Activity intolerance related to impaired respiratory function
5. Risk for deficient fluid volume related to fever and a rapid respiratory rate
7. Emphasize the importance of follow-up medical visit for a chest x-ray and influenza immunizations at
prescribed times
A group of disorders associated with persistent or recurrent obstruction of airflow and/or alveolar
abnormalities usually caused by significant exposure to noxious particles or gases, which cause an abnormal
inflammatory response in the airways. The airflow limitation is not fully reversible
Risk Factors:
1. Cigarette smoking (primary risk factor) and passive smoking
2. Occupational exposure
3. Environmental air pollution
4. Genetic abnormalities, including a deficiency of alpha-antitrypsin (a protective agent for the lung)
Pathophysiology
➢ Irritation from cigarette smoke and pollutants deposited in the lower respiratory tract → inflammation →
release of bradykinin, histamine, and prostaglandin → fluid or cellular exudation → edema of the mucous
membrane → narrowing & obstruction to airflow.
➢ Hypertrophy and hypersecretion in goblet cells
and bronchial mucus glands → increased
sputum secretion, bronchial congestion of
mucus, narrowing of bronchioles, and small
bronchi & mucus may plug the airways.
➢ Impaired ciliary function → reduce mucus
clearance
➢ Chronic inflammation and the body’s attempt to
repair it, overtime this injury & repair process
causes scar tissue formation & narrowing of the
airway lumen
➢ Alveoli become damaged and fibrosed, and
alveolar macrophage function diminishes.
Clinical Manifestations: usually insidious, developing over a period of years
1. Presence of productive cough lasting at least 3 months a year for 2 successive years in a patient in whom
other causes of cough are excluded.
2. Production of thick, gelatinous sputum
3. Wheezing and dyspnea as the disease progresses
Diagnostic Evaluation
1. Pulmonary Function test; decreased forced expiratory volume (FEV) and forced vital capacity (FVC; and
increase residual volume.
2. ABG: increased PaCO2 and decreased PaO2 (PaO2 less than 60 mm Hg with or without PCO2 greater than
50 mm Hg on room air); Pulse oximetry: SaO2 less than 92%
3. Chest x-ray for the diagnosis of pneumonia and pneumothorax.
: a disease of the airways characterized by destruction of the walls of overdistended alveoli.
Pathophysiology
➢ Alveolar wall destruction and loss of elastic recoil→ distention of the air spaces
➢ As the wall of the alveoli are destroyed, the alveolar surface area in direct contact with the pulmonary
capillaries continually decreases, causing an increase in dead space and impaired oxygen diffusion →
Hypoxemia. In the later stages, CO2 elimination is impaired → Hypercapnia → Respiratory acidosis.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
: is a chronic infection of the lower respiratory tract characterized by excessive
mucus secretion, cough, and dyspnea associated with recurring infections of the lower respiratory tract.
➢
Continued alveolar wall breakdown, the pulmonary capillary bed is reduced in size → resistant to pulmonary
blood flow is increased, forcing the right ventricle to maintain a higher BP in the pulmonary artery → rightsided heart failure (cor pulmonale)
Diagnostic Evaluation
1. Pulmonary Function Test
2. Chest radiograph
3. ABG
4. Alpha1-antitrypsin assay is useful in identifying genetically
determined deficiency in emphysema (helpful when COPD occurs at
young age or nonsmoker).
Manifestations
Progressive dyspnea
Progressive cough & increase sputum production.
Profound weakness
Clubbing of fingers
Hyper inflated Chest (Barrel Chest)
Anorexia and Weight Loss
Medical Management
1. Smoking cessation to reduce disease progression
2. Pharmacologic Therapy: Inhaled bronchodilators reduce dyspnea and bronchospasm and improve secretion
clearance. These are delivered by metered-dose inhalers (MDIs), dry powder inhalers, or nebulizer devices.
a. Beta2-Adrenergic Agonist Agents (Adrenergic or sympathomimetic): dilate bronchial smooth muscles
to relieve bronchospasm.
➢ salbutamol, albuterol (Proventil, Ventolin); metoproterenol (Alupent); terbutaline (Brethine);
salmeterol (Severent Diskus)
b. Anticholinergic agents
➢ Ipratropium bromide (Atrovent); tiotropium bromide (Spiriva HandiHaler)
c. Methylxanthines: relax bronchial smooth muscle. Oral bronchodilators, but are not considered firstline treatment because of suboptimal effectiveness and side effects.
➢ aminophylline (Phyllocontin), theophylline (Theo-Dur), ephedrine (adrenalin, Primatene)
d. Corticosteroids: used in acute exacerbations for anti-inflammatory effect.
➢ dexamethasone; methylprednisolone (Medrol, Solu-Medrol); hydrocortisone (Solu-Cortef)
e. Regular infusion of human alpha-antitrypsin (Prolastin) replacement therapy (normally every week)
replacement therapy to correct the antiprotease imbalance in the lungs.
3. Antimicrobial agents for periods of respiratory infection.
4. Low flow oxygen therapy for patients with hypoxemia (1-3 L/min)
5. Influenza (annual) and pneumococcal vaccination.
6. Lung transplantation may be considered for people with advanced COPD.
Nursing Diagnoses
1. Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough,
and possible bronchopulmonary infection.
2. Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, and airway
irritants.
3. Impaired gas exchanged related to chronic pulmonary obstruction; ventilation/perfusion abnormalities.
4. Activity intolerance related to compromised pulmonary function, resulting in shortness of breath, fatigue,
and hypoxemia.
5. Impaired individual coping related to the stress of living with chronic disease.
Nursing Interventions
1. Improving airway clearance
a. Eliminate pulmonary irritants, particularly cigarette smoking.
b. Control bronchospasm to decrease the workload of breathing
c. Chest physiotherapy to aid in the clearance of secretion
d. Used controlled coughing
i. Inhale slowly and deeply; exhale through pursed lips: empties lung of residual volume
ii. Cough in short bursts of “huffing” rather than vigorously forcing cough, which causes
the airway to collapse
e. Keep secretions thin by encouraging a high level of fluid intake within the level of cardiac reserves
or give aerosolized sterile water or nebulized normal saline to humidify bronchial tree and liquefy
sputum.
2. Improving respiratory pattern
a. Teach and supervise breathing retraining exercises to strengthen the diaphragm and muscles of
expiration to decrease work of breathing and reduce air trapping.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
Clinical
1.
2.
3.
4.
5.
6.
a
i.Use diaphragmatic breathing: reduces respiratory rate, increase alveolar ventilation
ii.Use pursed-lip breathing to control rate and depth of respiration and improve respiratory
muscle coordination
b. Discuss and demonstrate relaxation exercises to reduce stress, tension, and anxiety.
c. Encourage the patient to assume a position of comfort to decrease dyspnea. The position might
include leaning trunk with arms supported on a fixed object, sleeping 2 or 3 pillows, or sitting upright
3. Improving the gas exchange
a. Give low flow oxygen to selected patients to correct hypoxemia
b. Proper administration of bronchodilators and corticosteroids as ordered
c. Reduction of pulmonary irritants
d. Be prepared to assist with noninvasive ventilation or intubation and mechanical ventilation if acute
respiratory failure and significant CO2 retention occur.
Patient
1.
2.
3.
4.
Education
Give the patient a clear explanation of the disease process
Medications
When and how to seek help
Prevention of infections like avoiding exposure to persons with respiratory infection; avoiding crowds and
areas of poor ventilation; obtaining influenza and pneumococcal vaccines.
5. Avoidance of respiratory irritants; indoor and outdoor pollution and occupational exposure
6. Lifestyle changes, including cessation of smoking
7. Diet: high calorie, high protein to help maintain the integrity of alveolar walls and provide an adequate
source of energy; eat 5-6- small meals daily to ease shortness of breath during and after a meal.
A disease characterized by variable, recurrent, reversible airway obstruction clinically manifested by
intermittent episodes of wheezing and dyspnea. It differs from other obstructive lung diseases because it is largely
reversible, either spontaneous or with treatment.
Pathophysiology
➢ Exposure to allergen & irritants, stress, cold air, exercise, and other factors
➢ Immunoglobulin E (IgE) is produced by B-lymphocytes. IgE antibodies attach to mast cells & basophils in
the bronchial walls.
➢ Mast cell empties, releasing chemical mediators of inflammation (histamine, bradykinin, prostaglandins,
leukotrienes & slow-reacting substance of anaphylaxis). These substances induce capillary dilation →
Increase blood flow and fluid leaks from the vasculature → Mucosal edema of the airways; it also induces
bronchospasm & hypersecretion of mucus → Narrowing of airways → Increase work of breathing →
Exhaustion → Hypoventilation → Retention of CO2 (air trapping) → Hypoxia & respiratory acidosis.
Triggers of Asthma
1. Environmental allergens (often small glycoproteins, e.g. dust mites, animal dander, pollen, fungi)
2. Respiratory infections often viral
3. Inhalation of irritating substances (fumes from volatile compounds, e.g. cleaning agents, glues, paints)
4. Environmental factors (pollution, cigarette smoke)
5. Physical factors (exercise, changes in temperature particularly in cold weather)
6. Medications (aspirin, non-steroidal anti-inflammatory drugs, beta-blockers)
7. Occupational exposure to organic compounds
8. Food additives and preservatives (sulfites, beer, wine, shrimp, monosodium glutamate, tartrazine, etc.)
9. Emotional factors (crying, laughing, anger, and fear)
Clinical Manifestations
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
4. Increasing Activity tolerance
a. Focus on rehabilitation activities to improve ADLs and promote independence.
b. Encourage patients to carry out regular exercise and physical conditioning programs like brisk
walking, stationary bicycling, swimming, etc.
c. Train patient in energy conservation techniques and pacing of activities to avoid overexertion. Help
employ work simplification techniques, such as sitting for tasks, pacing activities, and using a shower
bench, and a handheld showerhead.
d. Walking aids
5. Enhancing Self-care Strategies
a. Set realistic goals.
b. Avoid extreme temperatures.
c. Enhance coping strategies by demonstrating a sincere, supportive, and open approach to the patient.
d. Monitor for and manage potential complications.
1.
2.
3.
4.
5.
6.
Cough with or without mucus production
Dyspnea
Wheezing
Chest Tightness
Tachypnea and tachycardia
Anxiety
Medical Management
1. Bronchodilators
a. Beta2-adrenergic agonists
➢ Salmeterol (Serevent Diskus); formoterol (Foradil, Aerolizer); albuterol (Proventil,
Ventolin); salbutamol
b. Anticholinergics: blocks the effect of the parasympathetic system. When the vagus nerve is
stimulated, bronchial smooth muscle tone increases.
➢ ipratropium bromide (Atrovent)
c. Methylxanthine
➢ Theophylline (Slo-Bid, Theo-Dur); aminophylline
2. Corticosteroids: potent and effective anti-inflammatory agent
➢ Systemic corticosteroids: hydrocortisone; prednisolone (Prelone); prednisone (Deltasone,
Orasone); methylprednisone (Solu-Medrol)
➢ Inhaled corticosteroids: beclomethasone (Beclovent); fluticasone (Flovent)
3. Combined medication
➢ fluticasone/salmeterol (Advair)
4. Cromolyn sodium: anti-inflammatory agents and has a bronchodilating effect.
➢ Cromolyn sodium (Crolom, Intal)
5. Antihistamine: blocks the effect of histamine
➢ diphenhydramine (Benadryl)
6. Leukotriene modifiers (inhibitors): prevent bronchoconstriction, decrease mucosal edema, and mucus
production.
➢ montelukast (Singulair); zafirlukast (Accolate); zileuton (Zyflo)
Nursing Diagnoses
1. Ineffective airway clearance related to bronchospasm and bronchoconstriction, increased mucus secretion
and airway edema narrow the airways and impair airflow during an acute attack of asthma.
2. Ineffective breathing pattern related to impaired lung expansion and emptying.
3. Anxiety related to fear of suffocating, difficulty in breathing, death
Nursing Interventions
1. Attaining relief of dyspneic breathing
a. Monitor skin color and temperature and level of consciousness (LOC). Cyanosis, cool clammy skin,
and changes in LOC (agitation, lethargy, or confusion) indicate worsening hypoxia.
b. Monitor airway functioning through peak flow meter or pulmonary function testing to assess the
effectiveness of treatment; ABG and pulse oximetry to provide information about gas exchange and
the adequacy of alveolar ventilation.
c. Place the patient in orthopneic (with head and arms supported on the over-bed table) or Fowler’s,
high-Fowler’s, or position to facilitate breathing and lung expansion. These positions reduce the
work of breathing and increase lung expansion, especially of basilar areas.
d. Administer oxygen as ordered by the physician to reduce hypoxemia.
e. Provide nebulization therapy as prescribed by the physician since this treatment is used to
administer bronchodilators and other medications; humidity helps loosen secretions.
f. Employ chest physical therapy/postural drainage. Percussion and postural drainage facilitate the
movement of secretions and airway clearance.
g. Increase fluid intake helps reduce the viscosity of the secretions.
2. Improving breathing pattern
a. Monitor vital signs and laboratory results. Tachypnoea, tachycardia, elevated blood pressure, and
increasing hypoxemia and hypercapnia are signs of compromised respiratory status.
b. Provide rest periods between scheduled activities and treatments since scheduled rest is important
to prevent fatigue and reduce oxygen demands.
c. Teach and assist to use techniques to control breathing pattern:
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
Diagnostic Evaluation
1. History
2. Pulmonary Function Test
3. Skin Testing to identify causative allergens
4. Sputum and blood test discloses eosinophilia
5. Serum IgE may be elevated if an allergy is present
6. ABG and Pulse oximetry
i. Pursed-lip breathing helps keep airways open by maintaining positive pressure
ii. abdominal breathing improves lung expansion abdominal
iii. relaxation techniques to reduce anxiety and its effect on the respiratory rate.
d. Administer medications, including bronchodilators and anti-inflammatory drugs, as ordered. Monitor
for desired and possible adverse effects. Medications are used to improve airway status and facilitate
breathing.
3. Relieving Anxiety
a. Explain the rationale for interventions to gain patient’s cooperation
b. Assist to identify coping skills that have been successful in the past to helps the person to regain
control of the situation, reducing anxiety.
c. Listen actively to concerns; do not deny or negate the fear of dying or of being unable to breathe.
Active listening promotes trust and helps the person express concerns.
d. Allow supportive family members to remain with the person to provide additional support and can
help reduce anxiety.
e. Assist to use relaxation techniques, such as guided imagery, muscle relaxation, and meditation.
These techniques help restore psychological balance and reduce sympathetic stimulation and
responses.
Education
Provide information on the nature of asthma and methods of treatment.
Provide information regarding medications, including the proper use of inhaler devices.
Demonstrate the use of peak flow meters and recording of peak flow measurements.
Help the patient to identify what triggers his asthma, early warning signs of an impending attack, and
intervention strategies for preventing an attack.
5. Teach adaptive breathing techniques and breathing exercises, such as pursed-lip breathing, positioning for
comfort.
6. Discuss environmental control
a. Avoid persons with respiratory infections
b. Avoid substances and situation known to precipitate bronchospasms, such as irritants, gases, fumes,
and smoke
c. Wear a mask if cold weather precipitates bronchospasm
d. Stay inside when pollution is high
7. Promote optimal health practices, including nutrition, rest, and exercise.
a. Encourage regular exercise to improve cardiorespiratory and musculoskeletal conditioning.
b. Drink liberal amounts of fluids to keep secretion thin.
c. Try to avoid upsetting situations.
d. Use relaxation techniques, biofeedback, stress management.
(
)
A condition resulting when the exchange of O 2 and CO2 in the normal lung cannot match the rate of O 2
consumption and CO2 production in body cells. Characterized by hypoxemia or hypercapnia and acidemia. Occurs
rapidly, usually in minutes to hours or days
Etiology
1. Decrease Respiratory Drive
a. Severe brain damage (head trauma)
b. Large lesions of the brainstem (multiple sclerosis)
c. Metabolic disorders (hypothyroidism)
d. Sedative medications (midazolam, secobarbital)
2. Dysfunction of the Chest Wall
a. Musculoskeletal disorders (Muscular dystrophy)
b. Neuromuscular junction disorders (Myasthenia Gravis)
c. Some peripheral nerve disorders and spinal cord disorders (amyotrophic lateral sclerosis, GuillainBarre Syndrome, and cervical spinal cord injuries)
3. Dysfunction of Lung Parenchyma
a. Pleural effusion
b. Hemothorax
c. Pneumothorax
d. Upper airway obstruction
4. Other causes
a. Effects of anesthetic agents, analgesics, and sedatives after the operation
b. Pain after thoracic or abdominal surgery
Pathophysiology: ARF occurs whenever O2 and CO2 exchange in normal lungs fail to fulfill O2 need of the body
causing alveolar hypoventilation.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
Patient
1.
2.
3.
4.
Clinical Manifestations
1. Restlessness, agitation, dyspnea, disorientation, confusion, delirium, and loss of consciousness due to
hypoxemia
2. Headache, somnolence, dizziness, and confusion due to hypercapnia
3. Tachypnea (initially)
4. Tachycardia
5. Central cyanosis
6. Decrease or absent breath sounds if the patient cannot adequately ventilate
7. Use of accessory muscles
Diagnostic Evaluation
1. ABG analysis: PaO2 < 60 mmHg; PaCO2 >50 mmHg; pH < 7.35
2. Pulse oximetry: decreasing SpO2 (less than 90%).
3. Complete blood count, serum electrolytes, chest x-ray, urinalysis, electrocardiogram (ECG), and blood and
sputum cultures to aid in the determination of underlying cause and patient’s condition.
Nursing Management
1. Restore and maintain a patent airway by suctioning or performing endotracheal intubation as ordered
2. Administer oxygen therapy to maintain adequate alveolar ventilation
3. Provide measures to prevent hypoventilation and atelectasis, and promote chest expansion and secretion
clearance, such as incentive spirometer, nebulization, head of the bed elevated 30 degrees, turn frequently,
out of bed when clinically stable.
4. Assesses the patient respiratory status by monitoring the level of responsiveness, ABG, pulse oximetry, and
vital signs
5. Assesses the entire respiratory system and implement strategies like turning schedule, mouth care,
skincare, ROM of extremities to prevent complications
: nose bleeding
Etiology
1. Infection
2. Trauma
3. HPN
4. Tumor
5. Thrombocytopenia
6. Use of aspirin
7. Liver disease
Medical Management
1. Application of nasal decongestant (phenylephrine). Decongestants promote vasoconstriction, reducing the
inflammation and edema of the nasal mucosa, and relieving nasal congestion. They are very effective when
applied topically (by nasal spray) because of their rapid onset of action.
2. The physician may insert nasal packing with cotton tampon
Nursing Management
1. Sit-upright with the head leaning forward to prevent aspiration of blood
2. Apply direct pressure over the soft outer portion of the nose for a least 5-10 minutes
3. Apply cold compress or ice pack over the nose to promote vasoconstriction
4. Patient Education
a. Instruct the patient to avoid vigorous exercise for several days once bleeding is controlled
b. Avoid hot and spicy foods and tobacco
c. Teach ways to prevent epistaxis like avoiding forceful nose blowing, straining, and nasal trauma
: is an inflammation of the sinuses. The sinuses (or paranasal sinuses) are air-filled cavities in the
facial bones that open into the turbinates of the nasal cavity. They are lined with ciliated mucous membranes that
help move fluid and microorganisms out of the sinuses into the nasal cavity. The maxillary is affected most often.
It can lead to serious complications, such as infection of the middle ear or brain
Causes: Upper Respiratory Tract Infection (URTI) caused by streptococci, S. pneumoniae, Haemophilus influenzae
and staphylococci; Cigarette smoking and Allergic Rhinitis → Inflammation → Edema of the mucous membrane →
Hypersecretion of mucus → Mucus secretions collect in the sinus cavity, serving as a medium for bacterial growth →
Infection
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
Medical Management
1. Correct the underlying cause
2. Oxygen therapy to correct hypoxemia
3. Intubation and mechanical ventilation to support ventilation
4. Administer medication to increase alveolar ventilation: bronchodilators, corticosteroids, mucolytics
Clinical Manifestations
1. Pain and tenderness over the infected sinuses
a. Maxillary: cheek, upper teeth
b. Frontal: above the eyebrow
c. Ethmoid: around the eyes
d. Sphenoid: behind the eye, occiput, and top of the head
2. Headache
3. Fever
4. Body malaise
5. Nasal congestion “stuffy nose” and purulent nasal discharge
6. Persistent cough
7. Halitosis (bad breath)
Medical Management
1. Administer Codeine as prescribed. It may cause drowsiness and constipation so advise the patient to avoid
driving and operating electrical machines to prevent accidents. Increase fluid intake to prevent constipation.
Avoid ASA since it increases the risk of developing nasal polyps among clients with sinusitis.
2. Administer Amoxicillin or other anti-infective drugs as ordered by the doctor at the usual organisms causing
sinusitis.
3. Oral or topical (in the form of nasal sprays) decongestants such as pseudoephedrine or phenylephrine
(vasoconstrictors) are also prescribed to reduce mucosal edema and promote sinus drainage
4. Surgery is often indicated in the treatment of chronic sinusitis to prevent possible complications
Nursing Management
1. Promote plenty of rest
2. Increase fluid intake to liquefy secretions
3. Apply hot wet packs over the area to liquefy mucus secretions and relieve pain
4. Normal Saline Solution (NSS) nose drops or sprays to liquefy mucus secretion and promote sinus drainage
5. Inhalation of warm steam to loosen secretion and increase comfort.
6. Eat a well-balanced diet
7. Avoid allergens
: an acute inflammation of the pharyngeal walls. It may include the tonsils, palate, and uvula.
Inadequate treatment of acute streptococcal pharyngitis can result in Rheumatic heart disease or glomerulonephritis
as a sequela to the infection.
Etiology: viral, bacterial (group A beta-hemolytic streptococcus (strep throat), or fungal. Viral pharyngitis accounts
for 70% of cases. Fungal pharyngitis, especially candidiasis, can develop with prolonged use of antibiotics or
corticosteroids or among immunosuppressed patients, especially those with HIV. Group A beta-hemolytic
streptococcus is the most serious agent that can lead to heart and renal complications. Pharyngitis is highly
contagious and spread via inhalation or direct contamination with droplets.
Clinical
1.
2.
3.
4.
5.
Manifestations
Scratchy or sore throat (pain)
Possible dysphagia (difficulty swallowing)
Fever, chills, and headache
Red edematous pharynx with or without yellow exudates
White irregular patches suggest fungal infection with Candida Albicans
Diagnostic Evaluation: throat culture and sensitivity test to identify the infective organism
Medical Management
1. Administer antibiotics for “strep throat”. Penicillin or penicillin derivatives are generally the choice and are
given for 7 to 14 days. Erythromycin is given to patients who are sensitive to penicillin.
2. Nystatin (Mycostatin) for candida infection as ordered by the physician.
Nursing Management: goals are infection control, symptomatic relief, prevention of secondary complications.
1. Increase fluid intake
2. Cool, bland liquids, and gelatin.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
Diagnostic Evaluation:
1. A thorough history, including an allergy history (usually confirm the diagnosis)
2. A nasal smear is obtained and used for culture and sensitivity test to identify the infectious microorganism
and appropriate antibiotic therapy
3. Avoid citrus juices since it can be irritating
4. Application of an ice collar to soothe the throat
: inflammation of the tonsils. More commonly seen in children but may also occur in adults. Tonsils
are composed of lymphatic tissues and are located on the pharynx. Chronic infection of the tonsils leads to
enlargement and partial upper airway obstruction.
Etiology: Bacterial pathogen (Group A beta-hemolytic streptococcus); viral pathogen (Epstein-Barr)
Clinical
1.
2.
3.
4.
Manifestations
Sore throat
Fever and malaise
Snoring due to airway obstruction
Dysphagia (difficulty or pain on swallowing)
Diagnostic Evaluation: visual examination reveals enlargement and reddening of the tonsils. White patches may be
present on the tonsils if group A beta-hemolytic streptococcus is the cause of the infection. A throat culture and
sensitivity test determine the causative microorganism and appropriate antibiotic therapy.
Nursing Management
1. Promote rest to facilitate recovery
2. Increase fluid intake to excrete microorganism
3. Warm saline gargle to soothe the throat and relieve discomfort
Preoperative care (tonsillectomy)
1. Assess for URTI since coughing and sneezing postoperatively may cause bleeding
2. Check for prothrombin time since bleeding is a common postoperative complication
Post-operative care
1. Place the client in a lateral position or prone with the head turned to the side to promote drainage from the
mouth to prevent aspiration. Once the client is awake, place the patient in semi-Fowler’s to promote
breathing.
2. Keep oral airway in place until swallowing reflex returns
3. Monitor for hemorrhage. Observe the following signs and symptoms
a. Frequent swallowing
b. Bright red vomitus
c. Tachycardia
4. Promote comfort
a. Place ice collar over the neck
b. Administer acetaminophen to relieve pain. Do not give aspirin (ASA) since it may cause bleeding.
5. Foods and fluids
a. Provide ice-cold fluids to prevent bleeding. Milk and ice cream are contraindicated since milk
increases the viscosity of the sputum that may trigger a clearing of the throat and coughing
b. A liquid or semi-liquid diet is recommended for several days.
c. Provide bland foods to prevent irritation of the throat.
d. Avoid red or dark-colored beverages like cola, chocolate milk, grape juice that may conceal bleeding.
e. Avoid citrus juices hot or spicy foods, and rough-textured foods for 1 week to prevent irritation of
the throat.
Client Education after tonsillectomy
1. Avoid clearing of the throat to prevent bleeding
2. Avoid coughing sneezing, blowing the nose for 1 to 2 weeks to prevent bleeding
3. Provide 2-3 liters of fluid/day until mouth odor disappear
4. Avoid hard/scratchy foods until throat healed
5. Report signs and symptoms of bleeding
6. Throat discomfort between 4th to 8th postoperative day is expected this is due to sloughing off of mucous
membrane at the operative site
7. The stool is black or dark for a few days due to swallowed blood
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
Medical Management
1. Analgesics such as acetaminophen as prescribed by the doctor
2. Antimicrobials as prescribed by the doctor such as penicillin or cephalosporins
3. Tonsillectomy is indicated if tonsillitis recurs 5 to 6 times a year. Recurrent tonsillitis caused by Group A
beta-hemolytic streptococcus may trigger autoimmune disorders like glomerulonephritis and rheumatic
heart disease
8. Plenty of rest for 2 weeks
9. Avoid colds, overcrowded or public places since coughing and sneezing may cause bleeding
Written Assignment: Design a diagrammatic representation of the pathophysiology of chronic obstructive
pulmonary disease (COPD).
Group Assignments: 1. Within a group, develop a teaching plan for a patient with COPD. Identify the
learning needs associated with this disease process; 2. As a group, present a case study emphasizing the nursing
process for a patient with COPD. Discuss elements of the nursing process with classmates
Web Assignments: 1. Use the Internet to research a current article describing how smoking and air
pollution are causative agents of the development of a pulmonary disease. 2. Research the Internet for information
on asthma self-management strategies.
Pneumonia, inflammation of the respiratory bronchioles, and alveoli, usually are bacterial in origin. Different
organisms are usually found in hospital-acquired pneumonia than in community-acquired pneumonia. Nursing care
focuses on promoting airway clearance, supporting effective gas exchange, and promoting rest. Infection control
measures, including standard, airborne, and contact precautions, are vital to prevent the spread of viral severe acute
respiratory syndrome.
Obstructive disorders of the lower respiratory system, including asthma and COPD, impair airflow into and
out of the lungs, often affecting the outflow of air to a greater extent than inflow. As a result, air trapped in the alveoli
increases the residual volume of the lungs and reduces functional residual capacity. Alveolar ventilation is reduced as
well. The net result is less available oxygen in the alveoli and impaired gas exchange.
In many instances, acute episodes of asthma can be avoided through the use of inhaled steroids to reduce
airway inflammation, inhaled long-acting bronchodilators, and frequent self-monitoring of expiratory flow rate.
Nursing care focuses on teaching for self-management and providing care during acute episodes of airway
constriction.
Chronic obstructive pulmonary disease (COPD) is a long-term process of progressive lung dysfunction. COPD
involves two different disease processes: chronic bronchitis, characterized by airway edema; and excessive mucus
production and emphysema, characterized by destruction of supporting tissue resulting in airway collapse with
enlargement of respiratory bronchioles and alveolar spaces and loss of alveolar surface area for gas exchange.
Smoking and exposure to tobacco smoke is the single greatest risk factor for COPD. A small percentage of
cases result from an inherited deficiency of α1-antitrypsin, an enzyme that inhibits lung tissue destruction. Although
smoking cessation does not reverse COPD, it does slow the progress of the disease.
Epistaxis (nosebleed) is relatively common and poses a risk only when airway clearance is impaired.
Emergency care for epistaxis includes pinching the nares or bridge of the nose, sitting upright and leaning forward,
and applying ice to the nose. When nasal packing is required to control bleeding, close monitoring of respiratory status
(respiratory rate and effort, oxygen saturation) is critical.
Pharyngitis (sore throat) may be either viral or bacterial in origin; manifestations are similar. People with
persistent or severe symptoms that include fever enlarged lymph nodes and myalgias should be evaluated to rule out
streptococcal pharyngitis, which can have significant complications such as rheumatic fever or post-streptococcal
glomerulonephritis.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
The constant exchange of oxygen and carbon dioxide between an individual and the environment is essential
to life. Improvement of respiratory function threatened the individual’s survival and either temporal or permanently
disrupts health and quality of life.
This unit has looked into pneumonia, emphysema, chronic bronchitis, asthma, and upper respiratory tract
infections. Your careful studying of this unit will essentially prepare you for the challenges of critical nursing care of
patients with a respiratory disorder.
Textbook of Medical-Surgical Nursing-13th Edition. Brunner & Suddarth, 2014
LeMone, Medical-Surgical Nursing, Critical Thinking for Person-centered Care. 3rd Edition. Pearson Australia,
2017
Medical-Surgical Nursing, Concepts and Clinical Applications. 3rd edition. Josie Quiambao-Udan, 2017.
Medical-Surgical Nursing 8th Edition. Joyce Black, 2014
Mosby’s Comprehensive Review of Nursing 20th Edition. Nugent et al., 2014
Assessment & Management of Clinical Problems 9th Edition. Lewis et al., 2014
Textbook of Medical-Surgical Nursing. Luckmann and Sorensen, 2008.
Pathophysiology Review. Marlene Hurst, 2008
Patient Profile
E.S. is a 35-year-old mother of two school-age boys who arrives via ambulance in the emergency
department (ED) with severe wheezing, dyspnea, and anxiety. She was in the ED 6 hours earlier with
an asthma attack.
Subjective Data
• Treated during previous ED visit with nebulized albuterol and responded quickly
• Allergic to cigarette smoke
• Began to experience increasing tightness in her chest and shortness of breath when she returned
home following her previous ED visit
• Used the albuterol several times after she returned home with no relief
• Diagnosed with asthma 2 years ago
• Does not have a health care provider and is not on any medications
Objective Data
Physical Examination
• Sitting upright and using accessory muscles to breathe
• Talks in one- to three-word sentences
• RR: 34 and shallow
• Audible wheezing
• Auscultation of lung fields reveals no air movement in lower lobes
• HR: 126 bpm
• Noted to be extremely anxious and restless
Diagnostic Studies
• ABGs: pH 7.46, PaCO2 36 mm Hg, PaO2 76 mm Hg, O2 saturation 88%
• Chest x-ray: bilateral lung hyperinflation with lower lobe atelectasis
• CBC with differential and electrolytes: within normal limits
An IV is started in her left forearm with normal saline infusing at 100 mL/hr.
Discussion Questions
Using a separate sheet of paper, answer the following questions:
1. What other assessment information should be obtained from E.S.?
2. Priority Decision: What is the priority of collaborative intervention for E.S.?
3. What data obtained from the brief history, physical examination, and diagnostic studies indicate that E.S. is
experiencing a severe or life-threatening asthma attack?
4. Identify two classifications of medications the nurse should expect to be administered to this patient. What
effect is expected with these medications?
5. In addition to medication administration and close monitoring of the patient, what other key roles can the
nurse take in helping the patient through this episode?
6. What value would peak expiratory flow rate (PEFR) measures have during the care of E.S.?
7. What health care teaching should be included for this patient-related to her asthma?
8. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? What
are the collaborative problems?
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
https://tinyurl.com/yyrzafmj (Pneumonia)
https://tinyurl.com/yyr2rs9z (COPD part 1)
https://tinyurl.com/y64y6wq5 (COPD part 2)
https://tinyurl.com/y22hwyce (Asthma)
❖
Fast Facts about Chronic Bronchitis (Blue Bloater)
▪
Main problem: excessive mucus secretion with the airways and recurrent cough usually related to smoking, pollution,
and infection.
▪
Initial Manifestation: Cough with copious sputum
▪
Laboratory data: ABG reveals respiratory acidosis
▪
Nursing Diagnosis: Impaired breathing pattern
▪
Interventions: Increase Humidity
Provide postural drainage before meals
Relieve bronchospasm
Teach the patient about breathing techniques like blowing bubbles, blowing a trumpet, blowing a feather
in the air
❖
Fast Facts about Asthma
▪
Main Problem: Abnormal Bronchial hyperactivity to certain substances and conditions
▪
Initial manifestation: dyspnea and wheezing (asymptomatic between attacks)
▪
Laboratory data: PFT’s during attacks show decreased forced expiratory volumes, elevated immunoglobulin E, ABG
reveals respiratory acidosis, peak flow levels below normal
▪
Nursing diagnosis: Ineffective Breathing Pattern related to bronchospasm
▪
Interventions: Assess precipitating factor and eradicate these sources
Instruct patient to avoid 3 E’s (exercise especially in cold weather, environmental factors like dust,
emotional factors)
Position patient in orthopneic position and encourage patient to do pursed-lip breathing
Administer medications – Bronchodilators and corticosteroids usually via nebulization
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
NCM 112
Fast Facts about Emphysema (Pink Puffer)
▪
Main problem: destruction of the alveoli, narrowing of small airways, and trapping of air resulting in loss of lung
elasticity
▪
Initial manifestation: shortness of breath; barrel chest (increase in the anteroposterior diameter of the chest) is a
late sign
▪
Laboratory data: ABG reveals Respiratory Acidosis
▪
Nursing Diagnosis: Ineffective breathing Pattern
▪
Interventions: Keep the patient in orthopneic position/sitting
Administer low flow oxygen
Encourage patient to do pursed-lip breathing
Instruct patient to avoid powerful odors, extremes of temperature, pets, fireplace and feather pillows