Answers to Case Study, Chapter 24, Management of Patients With Chronic
Pulmonary Disease
Objective : 5, 6
How should the nurse explain to the patient and family the pathophysiology of bronchiectasis as it related to the symptoms the patient is experiencing?
Over time as a person has repeated pulmonary infections or substances that irritate the bronchi (the large airways used to breathe), the inflammation damages the bronchial wall.
The bronchial wall as it is damaged loses its supporting structure and the result is thick sputum that can easily obstruct the bronchi. The walls become permanently distended and change shape, which makes it difficult to clear mucus from the lungs. The body’s cough reflex is used when there is irritation in the airway, such as secretions. There is a large amount of thick mucus produced each day, which explains the chronic cough trying to expel the irritation from the airways. Retention of some of the secretions and the resulting obstruction cause the alveoli (the small airways where oxygen and carbon dioxide are exchanged) to collapse so that there is less surface area in the lung to get the oxygen needed and get rid of the waste product of carbon dioxide. Scar tissue replaces the once functioning lung tissue. The decrease in functioning lung tissue leads to the respiratory system being insufficient to meet the body’s needs, which leads to shortness of breath even while at rest. The secretions tend to pool into a segment or lower lobes of the lungs and bacteria can grow in the secretions leading to frequent infections and the sputum becomes purulent (changes color and picks up an odor). There is no known specific cause of clubbing of the fingers, but it is seen with various lung diseases, including bronchiectasis.
How should the nurse explain to the patient and family the goals of medical management that may be used to treat the bronchiectasis?
The goals of the medical management for bronchiectasis include:
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Promote bronchial drainage and clear secretions from areas of the lung that are affected: o Chest physiotherapy and postural drainage. o Bronchoscopy to remove purulent sputum, if needed.
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Prevent or control infections as early as possible: o Annual influenza vaccination. o Pneumococcal vaccine, and repeat the vaccine once in 5 years. o Report signs of an infection including fever, chills, or purulent mucus as soon as it develops so the physician may order antibiotics to treat bacterial infections. Some physicians will order antibiotics for the winter to decrease recurrent infections, and some physicians keep the patient on different antibiotics at different intervals all year long to control the infection, if necessary.
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Smoking cessation is advised because smoking prevents proper drainage of the bronchi by paralyzing the cilia tiny hairs that line the respiratory tract and are

used to help propel mucus and secretions from the lung into the mouth. Smoking also increases secretion production and irritates the mucus membranes that line the entire airway system, Smoking causes the giblet cells (that make the mucus) to enlarge and make more mucus.
What does the nursing management for bronchiectasis entail?
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Provide symptom relief and comfort measures.
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Promote pulmonary toilet.
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Assess nutritional status and develop patient-focused strategies to promote adequate nutrition: o Six small meals each day. o Liquid high protein shakes fortified with vitamins and minerals when energy level is decreased. o Weigh patient at same time of day and report a decrease of weight of more than 2 pounds within a 24-hour period. o Collaborate with the physician for a dietician consult to help patient and family with meal planning.
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Instruct patient on smoking cessation and provide follow-up on attempts to quit: o For information on ways to quit smoking, visit the Centers for Disease
Control. Available at: www.cdc.gov/tobacco/sgr
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Instruct patient and family on how to do postural drainage and percussion.
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Instruct patient and family on strategies to conserve energy while promoting as active of a life as possible: o Make a list of activities that need to be done and prioritize the activities and determine which activities can be delegated to family members. o Take rest breaks in between activities throughout the day. Determine when the highest energy level is and do the activities that are most important during that time period. o Sit whenever possible to perform activities to conserve energy. o Collaborate with the physician for a pulmonary rehab consult.
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Instruct patient and family on ways to decrease risk for an infection: o Demonstrate proper method of hand washing and have patient and family return the demonstration. o Avoid persons with an upper respiratory infection or other infections. o Instruct on proper way to dispose of secretions. o Instruct on the signs and symptoms of an infection to report to the physician right away so that early treatment may be obtained. (Fever, change in color or odor of sputum should be reported).
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Instruct patient and family to avoid air pollutants that can irritate the airway and lead to worsening of the symptoms: o Avoid secondhand smoke. o Avoid aerosols. o Avoid going outside when the air quality index is poor or the pollen count or mold count is high.
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Provide emotional support to the patient and family through:

o Active listening. o Providing contact information for the American Lung Association support group. o Collaboration with physician to get additional support through psychosocial counseling.