AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Instructor
Serial/Semester
Location
Start/Finish Time
Date
LESSON OBJECTIVE
Performance: To gain an understanding of lower airway disorders.
Conditions:
The student will be presented a powerpoint presentation by the instructor and will have
all necessary references made available to him/her.
Standard:
1.
Given the five elements of the nursing care process and a patient with a lower
airway disorder by correctly responding to written, oral, and experiential
assessment measures
TEACHING POINTS
1. Describe the etiology/pathophysiology,
clinical manifestations, assessment, diagnosis,
and medical and nursing management of acute
bronchitis, Legionnaires' disease and anthrax.
2. Identify the etiology/pathophysiology, clinical
manifestations, assessment, diagnosis,
medical management and nursing
interventions of a patient with tuberculosis.
3. Describe the etiology/pathophysiology,
clinical manifestations, assessment, diagnosis,
and medical and nursing management of a
patient with pneumonia.
4. Identify older adult considerations for the
patient with pneumonia.
5. Compare and contrast the
etiology/pathophysiology, clinical
manifestations, assessment, diagnosis and
medical and nursing management of the
patient with pleurisy, pleural effusion and/or
empyema.
6.
Describe the management of a patient with
chest tubes and closed chest drainage bottles.
7.
Identify the etiology/pathophysiology, clinical
manifestations, assessment, diagnosis,
medical management and nursing
interventions of a patient with atelectasis
8
9.
10.
INSTRUCTIONAL STRATEGY
Interactive Lecture
Method:
Instructor
Media:
Classroom
Environment:
OTHER LESSON SPECIFICATIONS
Knowledge Lesson
Type of Lesson:
1/50
Ratio:
Resources:
.
End of Lesson Test: None
Instructional Time: 279
Reference(s):
ISBN 0-323-01728-2
Adult Health Nursing, 4th Edition
Minutes
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
01 Jan 2003
LESSON PLAN APPROVAL
Signature of Standards Officer
1
Date
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
INTRODUCTION
Allocated Time:
Review:
5 Minutes
You have had previous anatomy and physiology lectures in your combat medic
training, this lecture will build upon prior instruction.
Objective:
To discuss/describe topics related to the nursing process.
Importance:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Fit:
Caring for patients with lower airway conditions requires knowledge of
pulmonary anatomy and physiology, expert assessment skills and knowledge
of the infectious process. Practical nurses must be able to assess respiratory
problems so that appropriate nursing and medical interventions can be
implemented in a timely manner.
Approach:
You will be presented the subject in lecture format and will be tested using a
written exam at a later date.
Control Statement:
If you have any questions during the lesson please feel free to ask.
BODY
1. Teaching Point: Describe the etiology/pathophysiology, clinical manifestations, assessment,
diagnosis, and medical and nursing management of acute bronchitis, Legionnaires' disease and
anthrax.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Bronchitis
(1) Etiology /pathophysiology
(a) Usually secondary to an Upper Respiratory Infection (URI)
(b) May also be related to exposure to inhaled irritants
(c) Defined as an inflammation of the mucous membranes of the major bronchi and their branches,
resulting in tenacious secretions (become a culture medium for bacterial growth)
(2) Clinical manifestations
(a) Productive cough
(b) Low grade fever
2
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
(c) Diffuse rhonchi/wheezes, dyspnea
(d) Chest pain
(e) Generalized malaise, and headache
(3) Assessment
(a) Subjective- question patient regarding health and presence of headache, and/or aching chest pain
(b) Objective
1) Frequent assessment with vital signs
2) Auscultating breath sounds noting wheezing and basilar crackles
(4) Diagnostic test
(a) Chest x-ray to view lung fields
(b) Sputum culture to determine presence of bacterial infection
(5) Medical Management- is aimed at a quick recovery to prevent secondary infection
(a) Bronchodilators (Terbutaline)
(b) Antibiotics- for active infection or prophylaxis
(c) Cough suppressants (codeine) and antitussives (dextromethorphan)
(d) Antipyretics (Tylenol)
(6) Nursing Interventions the goal of nursing interventions is to facilitate recovery and prevent
secondary infections
3
NURSING DIAGNOSIS
Infection, risk for, related to
retained pulmonary secretions
OUTCOME
Patient will be free from
signs/symptoms of infection
Airway clearance, ineffective,
related to tenacious
pulmonary secretions
Patient will maintain patent
airway
NURSING INTERVENTIONS
1) Assess for signs of infection
2) Administer antibiotics and
antipyretics, as ordered
3) Frequent vital signs
4) Encourage adequate PO
intake
1) Bed rest with HOB elevated
2) Humidifier
3) Encourage increased fluid
intake
4) Teach/assess understanding
of the signs that may indicate
worsening infection – purulent
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
sputum and increased dyspnea
5) Teach/assess understanding
of the importance of following
the prescribed medication
regimen
6) Teach/assess understanding
of importance of limiting
exposure to others
7) Teach patient to avoid
smoking or other irritating
fumes
(7) Prognosis is good
b. Legionnaires’ disease
(1) Etiology/pathophysiology
(a) Caused by the microorganism Legionella pneumophila- first identified in 1976 when it caused an
outbreak of pneumonia at an American Legion convention in Philadelphia
(b) L. pneumonia is a gram- negative bacillus that thrives in water reservoirs such as humidifiers and
air conditioners
(c) Transmitted by airborne route
(d) Legionella microbe progresses in two different routes, influenza or Legionnaire’s disease
1) Legionnaire's results in life-threatening pneumonia
2) The pneumonia causes lung consolidation and alveolar necrosis
3) Progresses in less than 1 week and may result in respiratory and renal failure, bacteremic shock,
and ultimately death
(2) Clinical manifestations
(a) Significantly elevated temperature
(b) Headache
(c) Nonproductive cough
(d) Diarrhea
(e) General malaise
(3) Assessment
4
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
(a) Subjective- note patient’s complaints of dyspnea, headache, and chest pain on inspiration.
(b) Objective
1) Significantly elevated temperature 102-105 (38.8-40.5)
2) Non-productive cough with tachypnea
3) Auscultation will reveal crackles and wheezing
4) Signs of shock (tachycardia and hypotension)
5) Presence of hematuria indicting renal failure
(4) Diagnostic tests
(a) Cultures of blood, sputum, and pulmonary tissue/fluid to confirm presence of L. Pneumophila
(b) Chest x-ray reveals patchy infiltrates and small pleural effusions
(5) Medical Management
(a) Close observation for disease progression is required
(b) Patient may need to be placed on mechanical ventilation for respiratory support
(c) Adequate IV therapy for fluid and electrolyte replacement
(d) Medications
1) Antibiotics (erythromycin) will be given intravenously in the early course of the disease and
than orally for a prolonged period
2) Rifampin is also beneficial
3) Antipyretics to control severe hyperthermia
4) Patient may require vasopressors and/or inotropes (to promote an adequate cardiac output) and
to treat shock and analgesic to promote comfort
(6) Nursing interventions
NURSING DIAGNOSIS
Tissue perfusion, ineffective
cardiopulmonary or renal,
related to lack of oxygen
5
OUTCOME
Patient will maintain
adequate tissue perfusion to
all organs
NURSING INTERVENTIONS
1) Closely monitor and report
any S/S of impending shock
2) Administer vasopressors as
ordered and closely monitor
vital signs
3) Maintain hydration status
and urinary output (> 30 ml/hr)
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Breathing pattern, ineffective,
related to respiratory failure
Patient will maintain effective
breathing pattern
4) Assess for changes in level
of consciousness
1) Asses for S/S of respiratory
failure
2) Be alert for cyanosis and
dyspnea
3) Assist with oxygen therapy
or mechanical ventilation
4) Facilitate optimal
ventilation-place patient in
semi-fowlers, suction as needed
5) Have patient CDB every 2
hours
(7) Prognosis- severe, often fatal disease with mortality reaching 15-20%
c. Anthrax
(1) Etiology/pathophysiology
(a) Caused by the spore-forming bacterium Bacillus anthracis- anthrax most commonly infects wild
and domestic hoofed animals
(b) It is spread through direct contact with bacteria and its spores; dormant, encapsulated spores
become active when they enter a living host
(c) It is not contagious by person-to-person
(d) Three types of anthrax:
1) Cutaneous
a) Most common type
b) Occurs after a spore enters the skin through a break in the skin
c) A papule will occur that at first appears as an insect bite until a black eschar forms and
becomes edematous
d) Typically not fatal
2) Gastrointestinal
a) Least common
b) Occurs after ingestion of contaminated undercooked food
3) Inhalation
a) Most deadly type
6
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
b) Develops when spores inhaled deeply in to lungs
c) Immune cells sent to fight infection will seed lymph tissue and lead to systemic spread
(2) Clinical manifestations
(a) Initial symptoms of inhalational anthrax resemble those of the common cold or influenza, except
those infected will not develop nasal secretions
1) Subsequent breathing problems may be mistaken for pneumonia
2) Other symptoms include hemorrhage, tissue necrosis, and lymph edema due to bacterial toxins
3) Death usually results from blood loss and shock
(3) Diagnostic test
(a) Chest x-ray helps differentiate from pneumonia
1) Inhalational anthrax reveals a widened mediastinum due to lymphadenopathy
2) Pneumonia reveals infiltrates
(a) No single reliable screening test is available
1) Currently a rapid DNA test to identify anthrax in people and the environment
2) Culture is most reliable method for cutaneous and intestinal anthrax
(4) Medical Management
(a) Antibiotic therapy is indicated for anyone diagnosed with anthrax or exposed to anthrax spores
1) Ciprofloxacin (Cipro) is considered the treatment of choice for all three forms of anthrax due to
concerns the genetically altered forms may resist older antibiotics (although most strains are susceptible
to other antibiotics)
(b) Anthrax vaccine is available for soldiers
1) Used for over 50 years in the veterinary sciences
2) Safe and effective
3) Best chance of surviving inhalational anthrax attack
7
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
What is the primary goal in the treatment of acute bronchitis?
Preventing further complications of secondary infections
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
2. Teaching Point: Identify the etiology/pathophysiology, clinical manifestations, assessment, diagnosis,
medical management and nursing interventions of a patient with tuberculosis.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Etiology/pathophysiology
(1) Chronic pulmonary and and extrapulmonary infectious disease
(2) Acquired by inhalation of a dried droplet nucleus containing a tubercule bacillus, Mycobacterium
tuberculosis, into the alveoli (not easily transmitted, as the upper respiratory system is effective at
preventing transmission to alveoli)
(3) Most commonly, affects the lungs but can affect other parts such as skin, gastrointestinal system,
genitourinary system, musculoskeletal system, nervous system and lymph nodes
(4) Results in inflammatory infiltrations, formation of tubercles, cavities, necrosis, abscesses, fibrosis,
and calcification
(a) In the lung, the pulmonary macrophages ingest TB bacteria, they engulf the organisms, but do not
kill them and eventually form tubercles
(b) Lymphocytes are activated and control the infection in the lungs and non-pulmonary sites within
2 to 10 weeks
(c) The tubercle bacillus can remain dormant for more than 50 years; therefore patients who are
positive for the infection may develop the disease in later years, if immunocompromised
(5) Characterized by stages of early infection (frequently asymptomatic), latency and potential for
recurrence
(6) Infection vs. disease
(a) Infection always precipitates active disease
1) Characterized by the presence of mycobacteria in the tissue of a patient who is free from clinical
signs and symptoms and demonstrates antibodies against the mycobacteria
2) Only about 10% of infections progress to active disease
8
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
3) Those infected but not converted will have a positive skin test and a negative chest x-ray
(b) Disease
1) Pathologic and functional signs and symptoms indicating destructive activity of mycobacteria in
host tissue
(7) Predisposing factors
1) Family history of TB
2) Low income populations
3) Immunosuppression (especially HIV positive)
4) Persons with increased risk of developing active TB after infection:
a) Diabetes
b) Chronic renal failure
c) Underweight (more than 10% below ideal body weight)
d) Prolonged use of corticosteroids
5) Alcoholics, IV drug users, cocaine and crack users
6) Health care workers
(8) Previous epidemic in the western world
(a) Today 10 to 15 million Americans are infected
(b) 7.4 cases per 100,000 in 1997
(c) Incidence of US-born active TB is decreasing, but in foreign-born US residents it has increased
65% since 1985
1) More than two-thirds occur in racial and ethnic minorities
2) Many of these cases are drug resistant
b. Clinical manifestations- May be no clinical manifestations or symptoms may develop insidiously
(1) Early symptoms include:
(a) Fatigue
(b) Anorexia/weight loss
9
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
(c) Productive cough
(d) Fever
(e) Weakness
(2) Later symptoms:
(a) Daily reoccurring fever with chills
(b) Night sweats
(c) Hemoptysis
c. Assessment
(1) Subjective- note reports of loss of muscle strength and weight loss
(2) Objective- evaluating and reporting characteristics of sputum (amount, color)
d. Diagnostic test:
(1) Mantoux tuberculin skin test (TB skin tests or PPD)
(a) Can be performed within 2 to 10 weeks of exposure to identify infection with the bacillus
(b) The PPD needs to be read 48-72 hours later
1) Measure and record the subsequent induration (an area of hardened tissue); do not measure the
erythema (redness)
2) A negative reaction is less than 5mm
3) Generally, the larger the reaction, the greater the likelihood the person is infected with the TB
organism
4) A positive TB test indicates tubercle bacillus is present in body, but not necessarily that the
patient has active tuberculosis
(2) Sputum culture-acid fast bacillus (AFB) will be done to confirm the diagnosis of active TB- three
positive acid-fast smears indicate a presumptive diagnosis
(3) Chest x-ray may show hilar enlargement, cavitation, pleural effusions, or calcification
(4) All patients with TB must be reported to the appropriate public health authority for case follow-up
and investigation of contacts
QUESTION: What does a positive TB skin test indicate?
10
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
ANSWER:
A positive TB skin test indicates that tubercle bacillus is present in the body, but not
necessarily that the patient has active TB
e. Medical management
(1) Isolation
(a) Adult patients remain in respiratory isolation during hospital stay
(b) Requires negative pressure room. Patients must wear particulate matter mask when leaving room
(c) Infants and children do not generally require isolation because they rarely cough and have low
concentrations of AFB in their sputum
(2) Medications- drug therapy is the specific treatment for active TB, regardless of the organ involved.
Infectiousness declines rapidly once treatment has begun
(a) Isoniazid (INH)
(b) Rifampin
(c) These two drugs are considered first-line drugs and are used in combination
(d) Multiple antibiotics with multiple combinations are used to treat TB
(e) If only one medication is used the patient may become resistant
(f) Treatment is 6-9 months, if treatment is not continued for a sustained period of time the patient
will be at risk for reinfection with a more resistant bacilli
(g) Directly Observed Therapy (DOT) may be instituted for certain patients who are at risk for noncompliance and requires a health care worker to observe the patient ingesting the medications
f. Nursing interventions
(1) Isolation measures (respiratory isolation/ negative pressure) must be implemented immediately for
suspected untreated TB.
(a) Negative pressure room with doors and windows kept closed- room air is vented directly to the
outside to prevent contamination
(b) Use of particulate matter mask
(2) Focus on preventing complications and illness transmission
NURSING DIAGNOSIS
Breathing pattern, ineffective,
related to pulmonary
infection process
11
OUTCOME
Patient will maintain effective
breathing pattern
NURSING INTERVENTIONS
1) Monitor breathing for signs
of pneumothorax (decreased
breath sounds on affected side,
SOB, deviated trachea)
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Infection, risk for (patient
contacts), related to viable M
tuberculosis in respiratory
secretions
Patient contacts will be free
from contamination by
bacteria
2) Evaluate degree of
respiratory effort and assist as
needed
3) Assess sputum for
hemoptysis
4) Assist patient to turn, cough,
and deep breathe
1) Proper collection of sputum
specimens
2) Instruct patient to cover nose
and mouth when coughing or
sneezing and proper disposal of
expectorated sputum
3) Use AFB isolation until
antimicrobial therapy is
effective
4) Administer antituberculosis
medications as ordered
5) Instruct the patient on proper
hand washing
6) Teach/assess understanding
of the importance to report
hemoptysis, dyspnea, vertigo or
chest pain
7) Teach/assess understanding
of maintaining adequate volume
intake and nutritional balance
g. Prognosis
(1) As many as 50% of patients fail to complete treatment
(2) Numerous drug resistant strains have been reported (esp. in HIV patients)- these strains are often
highly virulent and have a mortality rate of 72 to 89%
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
What treatment related problem leads to drug resistance?
Non-compliance with medication therapy
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
3. Teaching Point: Describe the etiology/pathophysiology, clinical manifestations, assessment,
diagnosis, and medical and nursing management of a patient with pneumonia.
Minutes
Allocated Time:
Introduction:
12
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Etiology/pathophysiology of pneumonia
(1) Inflammatory process of the respiratory bronchioles and the alveolar spaces caused by an infectionmay also be caused by aspiration, over-sedation and inadequate ventilation
(2) Can occur in any season, but is most common during the winter and spring
(3) Persons of all ages are susceptible, but more common in infants and older adults
(4) Susceptible patients
(a) Persons with damaged or altered respiratory defense mechanisms
1) COPD
2) Influenza
3) Tracheostomy
4) Recent anesthesia
(b) Persons with a disease affecting antibody response
(c) Alcoholics (increased danger of aspiration)
(d) Persons with delayed WBC reaction to infection
(5) Communicable disease and mode of transmission is dependent on infecting organism
(6) Classified according to organism and not location of infection (as was done in the past)
(7) Causes
(a) Bacterial pneumonia is marked by alveolar pus formation with consolidation (half of the cases of
pneumonia are bacterial and half are viral)
1) Streptococcus pneumoniae (pneumococcal)
2) Hemolytic strep type A
3) Staphylococcus aureus
3) Haemophilus influenza (type B)
4) Nonbacterial or atypical pneumonia
13
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
a) Mycoplasma
b) Legioannaire's disease
c) Pneumocystis carinii
5) Aspiration pneumonia (usually caused by aspiration of vomitus when the patient's consciousness
is altered)
a) Staphylococcus aureus
b) Escherichia coli
c) Klebsiella
d) Pseudomonas
e) Proteus
(b) Viral produces interstitial inflammation with no consolidation or exudates (mycoplasma included
here)
(c) Fungal/mycobacterial marked by patchy distribution with necrosis and development of cavities
(d) Chemical- presentation depends on the causative agent
(8) Pathophysiology:
(a) Pulmonary cilia cannot remove secretions
(b) Retained secretions become infected
(c) Inflammation of the respiratory tract leads to localized edema
(d) The edema leads to decreased oxygen-carbon dioxide exchange, resulting in retained CO2 and
hypoxia
b. Clinical manifestations- dependent on the type of pneumonia. See page 380 for a detailed list of
symptoms caused by organisms. The general clinical manifestations are as follows:
(1) Sudden onset of severe, sharp pain in chest (pleurisy)
(2) Severe chills
(3) Elevated temperature and night sweats
(4) Painful, productive cough
14
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
(5) Purulent sputum- color and consistency of sputum will vary depending on the type of pneumonia
present
(6) Increased heart rate
(7) Tachypnea with difficult expiration
c. Assessment
(1) Subjective
(a) Description of onset, duration, and history of cough
(b) Complaints of fever and night sweats
(2) Objective
(a) Level of consciousness
(b) Vitals signs every two hours with emphasis on temperature
(c) Monitor color, consistency, and amount of sputum
(d) Observe respiratory effort (use of accessory muscles, etc.) and difficulty with breathing
(e) Crackles
d. Diagnostic tests
(1) Patient history and physical exam
(2) Blood and sputum cultures to identify organism - sputum culture and sensitivity should be collected
before initiation of antibiotic therapy to identify causative agent
(3) Chest x-ray reveals changes in density, particularly in the lower lobes
(4) CBC- WBC may be elevated in bacterial pneumonia and decreased in viral pneumonia
(5) Pulmonary function test- to determine if lung volume is decreased
(6) ABG- to identify altered gas exchange
(7) Oximetry- for rapid and continuous assessment of oxygen requirements
e. Medical management
(1) Medications
(a) Antibiotic therapy as appropriate, depending on the causative organism and sensitivity- common
agents: penicillin, erythromycin, cephalosporins and tetracycline
15
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
NOTE: Antibiotics should not be used for viral pneumonias, as they are not effective and this practice
leads to the development of drug resistance
(b) O2 therapy if inadequate gas exchange (If oxygen saturation of less than 91%)
(c) Analgesics/antipyretics
(d) Expectorants
(e) Bronchodilators
(f) Vaccine is now available for the most common and important bacterial pneumonia, streptococcal
pneumonia
1) Indicated for
a) Patients with chronic illness, i.e. respiratory or cardiac
b) Patients recovering from serious illness
c) Patients older than 65
d) Patients in a nursing home or long-term health care facility
(2) Physiotherapy – chest percussion and postural drainage- encourage patient to cough, deep breathe,
use incentive spirometer and ambulate, as able to mobilize secretions
(3) Humidification with humidifier or nebulizer if secretions are tenacious and copious
f. Nursing implications are aimed at assisting the patient to conserve energy
NURSING DIAGNOSIS
Breathing pattern, ineffective,
related to the inflammatory
process and pleuritic pain
16
OUTCOME
Patient will maintain effective
breathing pattern
NURSING INTERVENTIONS
1) Assess ventilation to include
respiratory effort and signs of
respiratory distress
2) Elevate HOB to facilitate
breathing (High Fowler’s
position). Place “good lung
down” to improve oxygenation.
3) Auscultate breath sounds
crackles, wheeze, and pleural
friction rub frequently.
4) Instruct patient on the
importance of consuming large
quantities of fluid up to 3L/day
and measure I&O.
5) Encourage patient to
conserve energy to prevent
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Gas exchange, impaired,
related to alveolar-capillary
membrane changes secondary
to inflammation.
Patient will maintain gas
exchange within normal
limits
fatigue.
6) Administer antibiotics;
instruct patient on action,
dosage, and frequency of
administration and side effects.
7) Encourage deep breathing
and coughing.
1) Assess patient to identify
signs of hypoxia.
2) Analgesics for pain with
careful monitoring of
respiratory status.
3) Monitor color, pulse,
temperature, respiratory rate,
and pulse oximetry readings.
4) Administer oxygen if
ordered to maintain oxygen
saturation above 91%.
(a) Patient teaching should focus on disease process and management
(1) Instruct/assess patient understanding of importance of handwashing and on the proper disposal of
sputum
(2) Instruct/assess understanding of the availability of streptococcal pneumonia vaccine and its
impact on the patient's overall health
(3) Teach/assess understanding of when the patient should return to see the physician (change in
sputum color or characteristic, decreased activity tolerance, fever despite antibiotics, increasing chest
pain)
g. Prognosis
(1) Pneumonia usually resolves within 2-3 weeks with proper treatment
(2) Major cause of disease and death in critically ill patients
(3) Despite the use of antibiotics, it is still the most common cause of death in North America with 27.7
of every 100,000 deaths
(4) Bacterial aspiration pneumonia carries a poor prognosis even with antibiotic therapy. It may cause
extensive lung damage, resulting in lung abcess or empyema. Mortality ranges between 15 and 70%
depending on the causative agent
17
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Is bacterial pneumonia exudative or non-exudative?
Exudative
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
4. Teaching Point: Identify older adult considerations for the patient with pneumonia.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Changes of aging affect respiratory function and ability to fight infection
b. Drier mucous membranes decrease cilia function and increase the risk for inflammation and infectionadequate hydration is important, as it helps liquify secretions and aids expectoration
c. Kyphosis and calcification of costal cartilage are common changes that cause restriction of the
expansion of the thoracic cavity
d. Intercostal muscles and diaphragm lose elasticity results in decrease ability to breathe deeply and
cough
e. The elasticity of airways and alveoli , and pulmonary blood decreases, resulting in an increased risk for
impaired gas exchange
f. Inactivity and immobility increase the risk of pooling of secretions, increasing the risk for pneumonia
g. Older patients often have trouble expectorating, increasing breathing difficulty and making specimen
retrieval more difficult
h. Neurologic changes associated with stroke and other conditions increase risk for aspiration pneumonia
i. Signs and symptoms of pneumonia are often atypical
(1) Fever, cough, and purulent sputum are often absent
(2) Generalized symptoms such as lethargy, chills, chest pain, tachypnea, vomiting and exacerbation of
pre-existing conditions should be viewed with suspicion as they could indicate pneumonia
j. Older patients living in institutions should have yearly TB screening- many patients are positive for TB
infection from childhood, and therefore should receive a yearly CXR
k. Watch older immigrants and immunosuppressed patients for drug-resistant strains of TB
18
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
5. Teaching Point: Compare and contrast the etiology/pathophysiology, clinical manifestations,
assessment, diagnosis and medical and nursing management of the patient with pleurisy, pleural
effusion and/or empyema.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Pleurisy
(1) Etiology/pathophysiology
(a) Inflammation of the visceral and parietal pleura (the double membrane covering the lungs)
(b) Causes
1) Bacterial
2) Tuberculosis
3) Pleural trauma
4) Pulmonary infarction
5) Lung cancer
6) Viral infections of intercostal muscles
(2) Clinical manifestation
(a) Sharp inspiratory pain often radiating to the shoulder or the abdomen of the affected side (caused
by stretching of the inflamed pleura)
(b) Fever and dry cough will result if the patient develops a pleural effusion (and severe pain will
diminish)
(c) Dyspnea
19
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
(d) Elevated temperature
(3) Assessment
(a) Subjective: Patient’s complaint of chest pain on inspiration and possibly elevated temperature
(b) Objective
1) Assess the nature of inspiratory points, to include radiation
2) Frequent vital sings, including temperature (Q 2-4 hours)
3) Respiratory rate and rhythm, noting dyspnea
4) Pleural friction rub
(4) Diagnostic tests
(a) Pleural friction rub may be considered diagnostic
(b) Chest x-ray is of limited value unless there is presence of a pleural effusion
(5) Medical management
(a) Medications
1) Analgesics (demerol or morphine) and antipyretics (Tylenol)
2) Antibiotics to treat underlying cause (penicillin)
3) Oxygen therapy with inadequate gas exchange
4) Anesthetic block of intercostal nerves
(6) Nursing diagnosis and interventions
20
NURSING DIAGNOSIS
Pain, related to stretching of
pulmonary pleura as a result
of fluid accumulation
OUTCOME
Patient will verbalize
adequate pain relief
Gas exchange, impaired,
related to pain on inspiration
and expiration.
Patient will maintain
effective gas exchange
NURSING INTERVENTIONS
1) Assess for pain.
2) Administer medications as
ordered and assess effectiveness
3) Provide non-pharmacologic
comfort measures
4) Encourage lying on the
affected side occasionally to
splint chest wall.
1) Teach patient to cough and
deep breathe every 2 hours and
to splint rib cage when
coughing
2) Heat may be applied to the
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
affected side.
3) Elevate head of bed
4) Reposition patient every two
hours
b. Pleural effusion/Empyema
(1) Etiology/pathophysiology
(a) Fluid accumulation in the pleural space; may or may not be infected
(b) Rarely a primary process, but occurs when the physiologic pressure in the lungs and pleurae is
disturbed. Pancreatitis, cirrhosis of the liver and heart failure are common causes that can alter the
permeability in the lungs and pleura
(c) When the fluid is infected, it is called empyema. (usually bacterial associated with pneumonia,
TB and blunt chest trauma)
1) May be acute or chronic
2) If untreated, the pleura may become scarred and fibrosed, losing its elasticity
(2) Clinical manifestations- persistent fever despite antibiotics
(3) Assessment
(a) Subjective:
1) Assess patient’s dyspnea and complaints of air hunger
2) Assess fear and anxiety related to decreased level of oxygen
(b) Objective:
1) Assess for signs and symptoms of respiratory distress
a) Nasal flaring
b) Tachypnea
c) Dyspnea
d) Decreased breath sounds
e) Frequent vital signs, especially temperature
(4) Diagnostic tests
(a) CXR to visualize effusions or fluid accumulation
(b) Thoracentesis to obtain specimen for culture, as well as symptomatic treatment of dyspnea
21
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
(5) Medical management
(a) Thoracentesis
1) Performed to remove fluid from the pleural space and obtain specimen for culture
2) Fluid should not be removed too rapidly to avoid hypotension (less than 1300-1500 ml at a time
is recommended)
(b) Chest tube placement
1) Instituted for continuous drainage (see objective G for chest tube management)
2) Re-establishes a negative pressure in the pleural cavity that will facilitate expansion of the lung,
restoring normal pleural pressure
(6) Nursing diagnosis and patient interventions
NURSING DIAGNOSIS
Gas exchange, impaired,
related to ineffective
breathing pattern.
OUTCOME
Patient will maintain gas
exchange within normal
limits
Self-care, deficit, related to
mobility restriction.
Patient will preform ADLs
with minimal assistance
NURSING INTERVENTIONS
1) Asses for change in LOC.
2) Monitor ABG and pulse
oximetry.
3) Encourage cough and deep
breathe
4) Reposition at least every two
hours.
1) Assess patient’s ability to
care for self, assist as necessary.
2) Encourage increased level of
activity.
(7) Prognosis- variable, depending on the patient's overall health status
Knowledge Lesson:
Question:
Answer:
Skill Lesson:
Check on Learning
In a knowledge lesson, pose questions to the class.
What is the limit of pleural effusion that should be drained at one time and
why?
1500ml to avoid hypotension from fluid shifts
In a skill lesson, provide practice and watch students perform a skill.
6. Teaching Point: Describe the management of a patient with chest tubes and closed chest drainage
bottles.
Minutes
Allocated Time:
Introduction:
Learner Participation:
22
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Knowledge Lesson
Skill Lesson
Learning Support:
Please follow along with your hand outs and take notes.
Powerpoint presentation with associated handouts.
a. Indications
(1) Chest tubes are inserted for continuos drainage and medication instillation
(2) There may be a thoracic drainage system in place. A closed system is used to prevent lung from
collapsing by maintaining normal negative pressure in the pleural space
(a) Normal intrapleural pressure is below atmospheric pressure
1) During expirations 4-5 cm H2O below atmospheric pressure
2) During inspiration 8-10 cm H2O below atmospheric pressure
(b) If intrapleural pressure becomes equal to atmospheric, the lungs will collapse
(3) Chest tubes attached to closed drainage system are placed in the pleural cavity
(a) One or two chest tubes are placed. See figure 9-10, page 384 for an illustration of tube
placement
1) The anterior chest tube is placed in the anterior chest wall and is used to remove air from the
pleural space (chest tube will terminate near the apex of the lung)
2) The posterior chest tube is inserted in the posterior chest through an incision and is used
primarily to drain serosanguinous fluid or purulent drainage (sits along the diaphragm)
3) When the drainage system is initiated, it can be the two or three glass bottle configuration (see
figure 9-12, page 385) or a commercial prepared chest drainage system (see figure 9-11, page 384)
b. Nursing interventions and patient teaching.
(1) General nursing measures include placing patient on bedrest and ensuring patency of chest tubes.
Areas of concern for maintaining chest tubes and closed system drainage include the following:
(a) Proper system function:
1) Ensure that water in the water seal chamber fluctuates when suction is applied
2) Bubbling in the water seal indicates an air leak
(b) Potential atelectasis resulting from hypoventilation- assess for dyspnea and ensuring serial chest
x-ray are done
(c) Increased air in the pleural space noting air leaks and tube patency
23
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
1) Air leaks will be noted with bubbling in the water seal chamber (often indicates that one of the
ports of the CT is outside of the chest- can be controlled with petroleum gauze if small)
2) Check often for blocking of tube with clots, or kinking of tube
(d) Infection:
1) Monitor for increase in WBC
2) Monitor for purulent drainage
(2) Position patient on unaffected side to avoid tube kinking, but allow patient to assume a position of
comfort and recheck tube for kinks
(3) Ambulation is not contraindicated as long as water seal remain below level of chest (patients are
usually not allowed to ambulate around the ward until the chest tube drainage is controlled enough for
patient to go to water seal)
(4) Facilitate incentive spirometry, cough, and deep breathe
(5) Document amount and characteristic drainage by marking the drainage level at the end of each shift
(mark drainage device each shift and document on I&O)
(6) Carefully position drainage system (should not have dependent loops and should not go over side
rails) and secure connections (with tape) to avoid accidental removal of the chest tube
(7) See box 9-6 p. 385- Maintaining chest tubes and closed chest drainage bottles for more detail on
managing chest tubes
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
What is an indication of an air leak in a closed drainage system?
Bubbles in the water seal chamber
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
7. Teaching Point: Identify the etiology/pathophysiology, clinical manifestations, assessment, diagnosis,
medical management and nursing interventions of a patient with atelectasis
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Etiology/pathophysiology
(1) The collapse of lung tissue
24
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
(a) May be limited to a small area or larger areas of the lung
(b) Prevents the exchange of carbon dioxide and oxygen
(2) Occurs from air blockage to a portion of the lung
(3) Causes
(a) Shallow breathing postoperatively (hypoventilation)
(b) Mucous accumulation
(c) Prolonged bedrest and hypoventilation
(d) Aspiration of food or vomitus (blocking of a bronchiole)
(e) Compression in lung tissue by tumors
(4) Hypoventilation causes all or part of the lung to collapse
(5) Mucous accumulation leads to bronchial obstruction
(6) Can lead to stasis pneumonia because the retained secretions can lead to bacterial growth
b. Clinical manifestations
(1) May cause few, if any, symptoms, as the remainder of the lungs will attempt to compensate
(2) Fever, and dyspnea
(3) Pleural friction rub
(4) Restlessness
(5) Hypertension
c. Assessment
(1) Subjective- patient complaints of shortness of breath, air hunger, anxiety, and fatigue
(2) Objective
(a) Decreased breath sounds and crackles
(b) Hypertension initially, followed by hypotension
(c) Monitor respiratory rate and effort
(d) Assess for altered level of consciousness due to hypoxia.
25
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
d. Diagnostic tests
(1) Serial chest x-ray reveal atelectatic changes.
(2) ABG may reveal PaO2 less than 80mmHg, pulsoximetry may reveal oxygen saturation less than
90%
(3) Bronchoscopy may reveal a bronchial obstruction
e. Medical management.
(1) Atelectasis frequently requires chest tube insertion to re-expand lung
(a) Instruct patient to deep breathe and cough to raise secretions
(b) Patient may require intubation and mechanical intubation
f. Nursing Intervention includes improving ventilation with main focus should be prevention of
atelectasis
26
NURSING DIAGNOSIS
Airway clearance, ineffective,
related to inability to clear
secretions
OUTCOME
Patient will maintain patent
airway
Coping, ineffective, related to
invasive medical regimen
Patient will demonstrate
effective coping mechanisms
regarding diagnosis
NURSING INTERVENTIONS
1) Humidifying air and
bronchodilators to loosen and
remove secretions
2) Incentive spirometry, deep
breathing and coughing after
any type of surgery can prevent
atelectasis
3) Encourage adequate
hydration to liquify secretions
4) Assess color, amount, and
consistency of sputum
5) Chest physiotherapy with
postural drainage
1) Identify patient’s emotional
support system
2) Asses patient’s ability to
comply with prescribed
regimen
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Knowledge Lesson:
Question:
Answer:
Skill Lesson:
Check on Learning
In a knowledge lesson, pose questions to the class.
Identify a nursing intervention for a patient with an elevated temperature with
suspected atelectasis.
Incentive spirometer
In a skill lesson, provide practice and watch students perform a skill.
END OF LESSON TEST
Allocated Time:
Instructions:
Test Questions or
Performance
Expected:
Test Key:
0 Minutes
You will be tested on this subject at a later date.
You will be expected to review and study the material taught in this session in
order to pass the associated written test. If you have difficulty with the material
please see me so we can review together.
None.
CONCLUSION
Allocated Time:
Summary:
5 Minutes
Review and re-emphasize the difficult Teaching Points below.
1.
2.
3.
4.
5.
6.
7.
Describe the etiology/pathophysiology, clinical manifestations,
assessment, diagnosis, and medical and nursing management of acute
bronchitis, Legionnaires' disease and anthrax.
Identify the etiology/pathophysiology, clinical manifestations,
assessment, diagnosis, medical management and nursing interventions
of a patient with tuberculosis.
Describe the etiology/pathophysiology, clinical manifestations,
assessment, diagnosis, and medical and nursing management of a
patient with pneumonia.
Identify older adult considerations for the patient with pneumonia.
Compare and contrast the etiology/pathophysiology, clinical
manifestations, assessment, diagnosis and medical and nursing
management of the patient with pleurisy, pleural effusion and/or
empyema.
Describe the management of a patient with chest tubes and closed
chest drainage bottles.
Identify the etiology/pathophysiology, clinical manifestations,
assessment, diagnosis, medical management and nursing interventions
of a patient with atelectasis
8
9.
10.
Closing Statement:
27
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
AFAMS Master Lesson Plan (MLP)
Nursing Program
Lower Airway Disorders
Re-motivating
Statement:
28
Caring for patients with lower airway conditions requires knowledge of
pulmonary anatomy and physiology, expert assessment skills and knowledge
of the infectious process. Practical nurses must be able to assess respiratory
problems so that appropriate nursing and medical interventions can be
implemented in a timely manner.