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  1. PNEUMONIA: acute inflammation of lungs with exudate accumulation in alveoli and other respiratory passages that interferes with ventilation process.
    1. Types:
      1. Typical/classic pneumonia: pneumococcal; related to diminished defense mechanisms, immunocompromised, critically ill, history of smoking, general anesthesia/abdominal surgery, exposure to airborne pathogens, hospitalization, recent respiratory tract infection, viral influenza, increased age, and chronic obstructive pulmonary disease (COPD).
        1. Lobar pneumonia—occurs abruptly when an acute bacterial infection affects a large portion of a lobe; causes pleuritic pain, heavy sputum production.
        2. Bronchopneumonia—involves patchy infiltration over a general area.
        3. Alveolar pneumonia—caused by virus; diffuse bilateral infection without patchy infiltrates.
      2. Atypical pneumonia: related to contact with specific organisms.
        1. Mycoplasma pneumoniae or Legionella pneumophila, if untreated, can lead to serious complications such as acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), thrombocytopenic purpura, renal failure, inflammation of the heart, neurological disorders, or possible death.
        2. Pneumocystis pneumonia in conjunction with AIDS.
      3. Aspiration pneumonia:
        1. Noninfectious: aspiration of fluids (gastric secretions, foods, liquids, tube feedings) into the airways.
        2. Bacterial aspiration pneumonia: related to poor cough mechanisms due to anesthesia, coma (mixed flora of upper respiratory tract cause pneumonia).
      4. Hematogenous pneumonia bacterial infections: related to spread of bacteria from the bloodstream.
    2. Pathophysiology: caused by infectious or noninfectious agents, clotting of an exudate rich in fibrinogen, consolidated lung tissue.
    3. Assessment:
      1. Subjective data:
        1. Pain location: chest (affected side), referred to abdomen, shoulder, flank.
        2. Irritability, restlessness.
        3. Apprehensiveness.
        4. Nausea, anorexia.
        5. History of exposure.
      2. Objective data:
        1. Cough:
          1. Productive, rust-colored (blood) or yellowish sputum (greenish with atypical pneumonia).
          2. Splinting of affected side when coughing.
        2. Sudden increased fever, chills.
        3. Nasal flaring, circumoral cyanosis.
        4. Respiratory distress: tachypnea.
        5. Auscultation:
          1. Decreased breath sounds on affected side.
          2. Exaggerated breath sounds on unaffected side.
          3. Crackles, bronchial breath sounds.
          4. Dullness on percussion over consolidated area.
          5. Possible pleural friction rub.
        6. Chest retraction (air hunger in infants).
        7. Vomiting.
        8. Facial herpes simplex.
        9. Diagnostic studies:
          1. Chest x-ray: haziness to consolidation.
          2. Sputum culture: Gram stain and culture; specific organisms, usually pneumococcus.
          3. Bronchoscopy if sputum results are inconclusive.
        10. Laboratory data:
          1. Blood culture: organism specific except when viral.
          2. WBC count: leukocytosis.
          3. Sedimentation rate: elevated.
      3. Factors contributing to the severity of pneumonia:
        1. Demographics:
          1. Age—severity increased with age.
          2. Gender.
          3. Nursing home resident.
        2. Comorbidities:
          1. Congestive heart failure (CHF).
          2. Active cancer.
          3. Liver disease.
          4. Renal insufficiency.
          5. Stroke with residual symptoms.
        3. Physical examination:
          1. Systolic BP less than 90; mean arterial pressure (MAP) less than 60.
          2. Heart rate (HR) ≥125.
          3. Respiratory rate ≥30.
          4. Temperature (PO) ≥104°F or less than 95°F.
          5. Altered level of consciousness (LOC).
        4. Laboratory results:
          1. Hematocrit (Hct) less than 30.
          2. Na+ less than 130.
          3. BUN ≥30.
          4. Arterial pH less than 7.35.
          5. Pleural effusion on chest x-ray.
          6. Glucose greater than 250 mg/dL.
    4. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to retained secretions.
      2. Activity intolerance related to inflammatory process.
      3. Pain related to continued coughing.
      4. Knowledge deficit (learning need) related to proper management of symptoms.
      5. Risk for fluid volume deficit related to tachypnea.
    5. Nursing care plan/implementation:
      1. Goal: promote adequate ventilation.
        1. Deep breathe, cough. Small-volume nebulizer treatment.
        2. Remove respiratory secretions, suction prn.
        3. High humidity with or without oxygen therapy.
        4. Intermittent positive-pressure breathing (IPPB); incentive spirometry, chest physiotherapy, as ordered and needed to loosen secretions.
        5. pillImageUse of expectorantsas ordered.
        6. Change position frequently.
        7. Percussion with postural drainage.
      2. Goal: control infection.
        1. Monitor vital signs; hypothermia for elevated temperature.
        2. pillImageAdminister antibioticsas ordered to control infection—broad spectrum (e.g. penicillin, quinolones, aminoglycosides). Note: need cultures before starting on antibiotics.
      3. Goal: provide rest and comfort.
        1. Planned rest periods.
        2. Adequate hydration by mouth, I&O; IVs as needed.
        3. foodImageDiet: high carbohydrate, high protein to meet energy demands and assist in the healing process.
        4. pillImageMild analgesics for pain—no opioids.
      4. Goal: prevent potential complications.
        1. Cross infection: use good hand-washing technique.
        2. Sterile technique when tracheobronchial suctioning to reduce risk of possible infection.
        3. Hyperthermia: tepid baths, hypothermia blanket.
        4. Respiratory insufficiency and acidosis: clear airway, promote expectoration of secretions.
        5. Assess cardiac and respiratory function.
        6. Keep ambulatory whenever possible.
      5. Goal: health teaching.
        1. Proper disposal of tissues, cover mouth when coughing.
        2. Expected side effects of prescribed medications.
        3. Need for rest, limited interactions, increased caloric intake.
        4. pillImageNeed to avoid future respiratory infections. Immunization: influenza each year for those at risk. Vaccine for pneumococcal pneumonia every 5 years.
        5. pillImageCorrect dosage of antibiotics and the importance of taking entire prescription at prescribed times (times evenly distributed throughout the 24-hour period to maintain blood level of antibiotic) for increased effectiveness.
    6. Evaluation/outcome criteria:
      1. Adheres to medication regimen.
      2. Has improved gas exchange as shown by improved pulmonary function tests.
      3. No acid-base or fluid imbalance: normal pH.
      4. Energy level: increased.
      5. Sputum production: decreased, normal color.
      6. Vital signs: stable.
      7. Breath sounds: clear.
      8. Cultures: negative.
      9. Reports comfort level increased.
  2. SEVERE ACUTE RESPIRATORY SYNDROME (SARS): viral respiratory illness caused by a coronavirus. Incubation period: 2 to 7 days, maybe as long as 10 to 14 days. Recommend limiting contact after infection until 10 days after fever has gone.
    1. Pathophysiology: little information is known about the SARS-associated coronavirus. May survive in the environment for several days—depends on temperature or humidity, and type of material or body fluid. Spread generally by respiratory droplets—up to 3 feet. May spread through air; other ways not known. Progresses to hypoxia→ pneumonia → respiratory distress syndrome.
    2. Risk factors:
      1. Weakened immune system.
      2. Close contact (within 3 feet)—kissing, hugging, sharing utensils.
    3. Assessment:
      1. Subjective data:
        1. Headache.
        2. Feeling of discomfort; body aches; chills.
        3. Dyspnea.
      2. Objective data:
        1. Temperature greater than 100.4°F (38.0°C), unless on antipyretics.
        2. Mild respiratory symptoms; dry cough.
        3. Diarrhea in 20%.
        4. Laboratory: reverse transcriptase–polymerase chain reaction (RT-PCR) of blood, stool, nasal secretions; serologic test for antibodies; viral culture (showing antibodies to virus more than 21 days after onset of illness).
        5. Additional laboratory findings:
          1. Leukopenia.
          2. Lymphopenia
          3. Thrombocytopenia.
          4. ↑ lactose dehydrogenase.
          5. ↑ aspartate aminotransferase.
          6. ↑ creatine kinase.
        6. Chest x-ray: focal interstitial infiltrates → generalized patchy infiltrates → areas of consolidation.
    4. Analysis/nursing diagnosis:
      1. Ineffective breathing pattern related to hypoxia and pneumonia.
      2. Risk for spread of infection related to droplet or airborne transmission.
      3. Impaired gas exchange related to pneumonia.
    5. Nursing care plan/implementation, evaluation/outcome criteria (also see I. PNEUMONIA, Respiratory System - Physiological Integrity):
      1. Goal: infection control.
        1. Standard precautions (e.g., strict hand hygiene).
        2. Contact precautions (e.g., gown and gloves) with eye protection.
        3. Airborne precautions (e.g., isolation room with negative pressure; use of an N95 filtering disposable respirator for those entering room, or surgical mask).
        4. Identify/isolate suspected SARS cases ( quarantine ).
      2. Goal: supportive care.
        1. pillImageEmpirical antibiotic therapy with broad coverage.
        2. Isolation (i.e., those without symptoms) for 10 days after becoming afebrile.
  3. H1N1 INFLUENZA VIRUS("swine flu"): respiratory disease caused by a new strain of the type A influenza virus (novel H1N1 or 2009 H1N1 flu). Described initially as a possible pandemic, a technical term that refers to the geographical (global) spread of the disease, not severity. Called swine flu because it resembled a strain that circulates in pigs.
    1. Pathophysiology:
      1. Influenza A virus with two proteins, hemagglutinin (H1) and neuraminidase (N1); humanto-human transmission through respiratory secretions (droplets) from coughing or sneezing; touching something with the virus on the surface and then touching mouth, eyes, or nose. Not spread by food.
      2. Incubation period: 1 day before symptoms occur and up to 7 days following illness onset.
      3. Infectious (viral shedding): as long as symptomatic; a minimum of 7 days after onset up to 13 days. Young children may be contagious for longer periods.
      4. Respiratory symptoms may progress to pneumonia → respiratory failure → death.
    2. Risk factors:
      1. Ages 6 months to 24 years; children younger than 5 years and especially younger than 2 years.
      2. Pregnant women and women who are 2 weeks postpartum.
      3. Persons 25 to 64 years with chronic conditions (e.g., asthma, diabetes, heart disease, kidney disease, and weakened immune system).
      4. Residents of nursing homes and chronic-care facilities.
    3. Assessment:
      1. Subjective data: Classic flu:
        1. Fatigue
        2. Body aches; chills
        3. Sore throat
        4. Headache
        5. Emergency signs with swine flu:
          1. Shortness of breath
          2. Chest pain or abdominal pain
          3. Sudden dizziness; confusion
      2. Objective data: Classic flu:
        1. Fever above 100.4°F
        2. Cough
        3. Diarrhea; vomiting
        4. Runny nose
        5. Emergency signs with swine flu:
          1. Severe or persistent vomiting
          2. Difficulty breathing; rapid respiratory rate
          3. Bluish or gray skin color (particularly in children)

            Emergency Warning Signs in Children with Swine Flu:

            • Fast breathing or trouble breathing
            • Bluish or gray skin color
            • Not drinking enough fluids
            • Being so irritable that the child does not want to be held
            • Not waking up or not interacting
            • Severe or persistent vomiting
            • Flu-like symptoms improve but then return with fever and worse cough

            Emergency Warning Signs in Adults with Swine Flu:

            • Difficulty breathing or shortness of breath
            • Pain or pressure in the chest or abdomen
            • Sudden dizziness
            • Confusion
            • Severe or persistent vomiting
            • Flu-like symptoms improve but then return with fever and worse cough

            Source: www.flu.gov.

        6. Diagnostic tests: viral culture, polymerase chain reaction (PCR), rapid antigen testing, and immunofluorescence. "Rapid influenza diagnostic test"—detects in 30 minutes, may not be conclusive.
    4. Analysis/nursing diagnosis:
      1. Ineffective breathing pattern related to hypoxia and pneumonia.
      2. Risk for spread of infection related to droplet or airborne transmission.
      3. Risk for fluid volume deficit related to persistent vomiting.
    5. Nursing care plan/implementation:
      1. Goal: prevent spread of infection.
        1. Stay home from work or school at least 24 hours after fever is gone without the use of a fever-reducing medicine; limit contact with others.
        2. Cover nose and mouth with tissue when coughing or sneezing.
        3. Wash hands after every sneeze or cough.
        4. Disinfect home surfaces to kill germs—virus can survive 2 to 8 hours; use hydrogen peroxide, iodophors, detergents, alcohol; heat.
      2. Goal: reduce risk of complications, alleviate symptoms.
        1. pillImageMedications
          1. Antipyretic: for fever 100°F or higher; acetaminophen or ibuprofen; aspirin if over 18 years of age.
          2. Antiviral: treatment or prevention; stop spread of virus: oseltamivir (oral, Tamiflu)—take with food, nausea and vomiting may occur; zanamivir (inhaled)—do not take with history of asthma or lung disease; may cause dizziness, stuffy nose, sinusitis; peramivir (IV, reserved for critically ill); neuraminidase inhibitors; suspected or confirmed cases; most effective within 48 hours; 5 days of treatment.
          3. Fluids, lozenges; cough suppressant for dry cough.
        2. foodImageFluids: clear liquids (water, broth, sports drinks, ice chips, frozen popsicles); avoid alcohol and caffeine.
        3. Monitor for dehydration: urine color (dark yellow with dehydration); frequency of trips to bathroom. Look for tears with infants/toddlers; wet diapers.
      3. Goal: prevent occupational exposure.
        1. Eliminate potential exposures: keep distance of 6 feet or more in community setting; restrict visitors who are ill; keep sick workers at home.
        2. Respiratory hygiene and cough etiquette. Encourage ill person to use tissues or wear a disposable face mask (use only once) or health-care provider should wear mask.
        3. Respiratory protection (personal protective equipment) in occupational health-care setting—N95 or higher filtering facepiece respirator; fit-tested ( not recommended for children or people with facial hair); disposable, single use, do not share. Remove gloves and wash hands before and after touching respirator. Extended use of N95 increases risk of contact transmission. Usually reserved if assisting with an aerosolgenerating procedure—intubation, extubation, bronchoscopy, nebulization.
        4. Isolation; standard (droplet) precautions—private room preferred; if not available at least 3-foot separation between patient beds with curtain between; share room with like diagnosis (cohorting). Caregiver wears mask—respirator not routinely necessary. Eye protection if within 6 feet of patient as treatments may cause splashing of respiratory secretions.
        5. Limit transport of patient; client wears mask outside of room.
        6. Vaccination of staff—may be required; exempt: with severe egg allergy; history of Guillain-Barré syndrome; religion prohibits vaccinations. May be required to wear mask if not vaccinated.
      4. Goal: health teaching—methods to prevent reinfection.
        1. Hand-washing technique—soap, water, and friction for at least 20 seconds; alcohol-based (antibacterial) hand rub may be used.
        2. pillImageAvoid touching eyes, nose, or mouth.
        3. Vaccination: one dose of swine flu and seasonal flu vaccine for those 10 years of age and older—may be given on same day; two doses of swine flu vaccine (separated 4 weeks, 21 days minimum) for children younger than 10 years.
        4. Pneumococcal vaccination if over 65 years, smoker, or history of chronic health problem.
    6. Evaluation/outcome criteria:
      1. No complications.
      2. Temperature normal for 24 hours without medication.
      3. Breath sounds clear; respirations unlabored.
      4. Covers nose/mouth when coughing or sneezing.
      5. Performs hand hygiene frequently.
  4. ATELECTASIS: collapsed alveoli in part or all of the lung.
    1. Pathophysiology: due to compression (tumor), airway obstruction, decreased surfactant production, or progressive regional hypoventilation.
    2. Risk factors:
      1. Shallow breathing due to pain, abdominal distention, narcotics, or sedatives.
      2. Decreased ciliary action due to anesthesia, smoking.
      3. Thickened secretions due to immobility, dehydration.
      4. Aspiration of foreign substances.
      5. Bronchospasms.
      6. Barotrauma; ↑ positive end-expiratory pressure (PEEP).
    3. Assessment:
      1. Subjective data:
        1. Restlessness.
        2. Pain.
      2. Objective data:
        1. Tachypnea.
        2. Tachycardia.
        3. Dullness on percussion.
        4. Absent bronchial breathing.
        5. Crackles at bases as alveoli "pop" open on inspiration.
        6. Tactile fremitus in affected area.
        7. ↓ O2 saturation.
        8. X-ray:
          1. Patches of consolidation.
          2. Elevated diaphragm.
          3. Mediastinal shift.
    4. Analysis/nursing diagnosis:
      1. Impaired gas exchange related to shallow breathing.
      2. Pain, acute, related to collapse of lung.
      3. Fear related to altered respiratory status.
    5. Nursing care plan/implementation:
      1. Goal: relieve hypoxia.
        1. Frequent respiratory assessment.
        2. Respiratory hygiene measures, cough, deep breathe. Use bedside inspirometer q1h when awake.
        3. Oxygen as ordered.
        4. Monitor effects of respiratory therapy, ventilators, breathing assistance measures to ensure proper gas exchange.
        5. infoImagePosition: on unaffected side to allow for lung expansion.
        6. Prepare for possible needle decompression or chest tube insertion.
      2. Goal: prevent complications.
        1. pillImage  Antibiotics as ordered.
        2. Turn, cough, and deep breathe. Out of bed, ambulation.
        3. foodImageIncrease fluid intake to liquefy secretions.
      3. Goal: health teaching.
        1. Need to report signs and symptoms listed in assessment data for early recognition of problem.
        2. Importance of coughing and deep breathing to improve present condition and prevent further problems.
    6. Evaluation/outcome criteria:
      1. Lung expanded on x-ray.
      2. Acid-base balance obtained and maintained.
      3. No pain on respiration.
      4. Activity level increased.
  5. PULMONARY EMBOLISM: undissolved mass that travels in bloodstream and occludes a blood vessel; can be thromboembolus, fat, air, or catheter. Constitutes a critical medical emergency.
    1. Pathophysiology: obstructs blood flow to lung → increased pressure on pulmonary artery and reflex constriction of pulmonary blood vessels → poor pulmonary circulation → pulmonary infarction.
    2. Risk factors:
      1. Thrombophlebitis.
      2. Recent surgery.
      3. Invasive procedures.
      4. Immobility.
      5. Obesity
      6. Myocardial infarction, heart failure.
      7. Smoking.
      8. Varicose veins.
      9. Hormone replacement therapy.
    3. Assessment:
      1. Subjective data:
        1. Chest pain: substernal, localized; type—crushing, sharp, stabbing with respirations.
        2. Sudden onset of profound dyspnea.
        3. Restless, irritable, anxious.
        4. Sense of impending doom.
      2. Objective data:
        1. Respirations: either rapid, shallow or deep, gasping.
        2. Elevated temperature.
        3. Auscultation: friction rub, crackles; diminished breath sounds.
        4. Shock:
          1. Tachycardia.
          2. Hypotension.
          3. Skin: cold, clammy.
        5. Cough: hemoptysis.
        6. X-ray: area of density.
        7. ECG changes that reflect right-sided failure.
        8. Echocardiogram shows increased pulmonary dynamics.
        9. Lung scan; pulmonary angiography.
        10. Laboratory data:
          1. Decreased PaCO2.
          2. Elevated WBC count.
    4. Analysis/nursing diagnosis:
      1. Ineffective breathing pattern related to shallow respirations.
      2. Impaired gas exchange related to dyspnea.
      3. Pain related to decreased tissue perfusion.
      4. Altered peripheral tissue perfusion related to occlusion of blood vessel.
      5. Fear related to emergency condition.
      6. Anxiety related to sense of impending doom.
    5. Nursing care plan/implementation:
      1. Goal: monitor for signs of respiratory distress.
        1. Auscultate lungs for areas of decreased/absent breath sounds.
        2. infoImageElevate head of bed.
        3. Monitor arterial blood gases (ABGs).
        4. Monitor pulse oximetry; administer oxygen, supplemental humidification as indicated.
        5. Monitor blood coagulation studies (e.g., activated partial thromboplastin time [aPTT]).
        6. pillImageAdminister anticoagulation therapy, thrombolytic agents, morphine for pain, vasopressor medications.
        7. Fluids: IV/PO as indicated.
        8. Monitor signs: Homans', acidosis.
        9. Ambulate as tolerated/indicated; change position.
        10. Prepare for surgery if peripheral embolectomy is indicated.
      2. Goal: health teaching.
        1. Prevent further occurrence; importance of antiembolism stockings, intermittent pneumatic compression devices.
        2. Decrease stasis.
        3. If history of thrombophlebitis, avoid birth control pills.
        4. Need to continue medication.
        5. Follow-up care.
    6. Evaluation/outcome criteria:
      1. No complications; no further incidence of emboli.
      2. Respiratory rate returns to normal.
      3. Coagulation studies within normal limits (aPTT 25 to 41 seconds, ABGs within normal limits).
      4. Reports comfort achieved.
  6. HISTOPLASMOSIS: infection found mostly in central United States. Not transmitted from human to human but from dust and contaminated soil. Progressive histoplasmosis, seen most frequently in middle-aged white men who have COPD, is characterized by cavity formation, fibrosis, and emphysema.
    1. Pathophysiology: spores of Histoplasma capsulatum (from droppings of infected birds and bats) are inhaled, multiply, and cause fungal infections of respiratory tract. Leads to necrosis and healing by encapsulation.
    2. Assessment:
      1. Subjective data:
        1. Malaise.
        2. Chest pain, dyspnea.
      2. Objective data:
        1. Weight loss.
        2. Nonproductive cough.
        3. Fever.
        4. Positive skin test for histoplasmosis.
        5. Benign acute pneumonitis.
        6. Chest x-ray: nodular infiltrate.
        7. Sputum culture shows Histoplasma capsulatum.
        8. Hepatomegaly, splenomegaly.
    3. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to pneumonitis.
      2. Ineffective breathing pattern related to dyspnea.
      3. Pain, acute, related to infectious process.
      4. Risk for infection related to repeated exposure to fungal spores.
      5. Impaired gas exchange related to chronic pulmonary disease.
      6. Knowledge deficit (learning need) related to prevention of disease and potential side effects of medications.
    4. Nursing care plan/implementation:
      1. Goal: relieve symptoms of the disease.
        1. pillImageAdminister medications as ordered.
          1. Amphotericin B (IV) and ketoconazole.
            1. Monitor for drug side effects: local phlebitis, renal toxicity, hypokalemia, anemia, anaphylaxis, bone marrow depression.
            2. Azotemia (presence of nitrogen-containing compounds in blood) is monitored by biweekly BUN or creatinine levels.
              BUN greater than 40 mg/dL or creatinine greater than 3.0 mg/dL necessitates stopping amphotericin B until values return to within normal limits.
          2. Aspirin, diphenhydramine HCl (Benadryl), promethazine HCl (Phenergan), prochlorperazine (Compazine): used to decrease systemic toxicity of chills, fever, aching, nausea, and vomiting.
      2. Goal: health teaching.
        1. Desired effects and side effects of prescribed medications; importance of taking medications for entire course of therapy (usually from 2 weeks to 3 months).
        2. Importance of follow-up laboratory tests to monitor toxic effects of drug.
        3. Identify source of contamination if possible and avoid future contact if possible.
        4. Importance of deep breathing, pursed-lip breathing, coughing (see VIII. EMPHYSEMA, Respiratory System - Physiological Integrity, for specific care).
        5. Signs and symptoms of chronic histoplasmosis, COPD, drug toxicity, and drug side effects.
    5. Evaluation/outcome criteria:
      1. Complies with treatment plan.
      2. Respiratory complications avoided.
      3. Symptoms of illness decreased.
      4. No further spread of disease.
      5. Source of contamination identified and removed.
  7. TUBERCULOSIS: inflammatory, communicable disease that commonly attacks the lungs, although may occur in other body parts.
    1. Pathophysiology: exposure to causative organism (Mycobacterium tuberculosis) in the alveoli in susceptible individual leads to inflammation. Infection spreads by lymphatics to hilus; antibodies are released, leading to fibrosis, calcification, or inflammation. Exudate formation leads to caseous necrosis, then liquefication of caseous material leads to cavitation.
    2. Risk factors:
      1. Persons who have inhaled the tubercle bacillus infectious particles called droplet nuclei.
      2. Persons who have diseases or therapies known to suppress the immune system.
      3. Immigrants from Latin America, Africa, Asia, and Oceania living in the United States for less than 1 year.
      4. Americans living in those regions for a prolonged time.
      5. Residents of U.S. metropolitan cities such as New York, Miami; those who live in poverty and are in overcrowded, poorly ventilated living conditions.
      6. Men older than 65 years.
      7. Women between ages 26 and 44 years and older than 65 years.
      8. Children younger than 5 years.
    3. Assessment:
      1. Subjective data:
        1. Loss of appetite, weight loss.
        2. Weakness, loss of energy.
        3. Pain: knifelike , chest.
        4. Though client may be symptom free, the disease is found on screening.
      2. Objective data:
        1. Night sweats, chills.
        2. Fever: low grade, late afternoon.
        3. Pulse: increased.
        4. Respiratory assessment:
          1. Productive persistent cough, hemoptysis.
          2. Respirations: normal, increased depth.
          3. Asymmetrical lung expansion.
          4. Increased tactile fremitus.
          5. Dullness to percussion.
          6. Crackles following short cough.
        5. Hoarseness.
        6. Unexplained weight loss.
        7. Diagnostic tests:
          1. Positive tuberculin test (Mantoux)—reaction to test begins approximately 12 hours after administration with area of redness and a central area of induration. The peak time is 48 hours. Determination of positive or negative is made. A reaction is positive when it measures 10 mm. Contacts reacting from 5 to 10 mm may need to be treated prophylactically. This test is referred to as purified protein derivative (PPD) or intradermal skin test.
          2. Sputum: three specimens tested positive for acid-fast bacilli (AFB) (smear and culture). Positive equals greater than 10 AFB per field.
          3. X-ray: infiltration cavitation.
        8. Laboratory data: blood—decreased red blood cell (RBC) count, increased sedimentation rate.
        9. Classification of tuberculosis:
          ClassDescription
          0No TB exposure, not infected
          1TB exposure, no evidence of infection
          2TB infection, no disease
          3TB: current disease (persons with completed diagnostic evidence of TB—both a significant reaction to tuberculin skin test and clinical or x-ray evidence of disease)
          4TB: no current disease (persons with previous history of TB or with abnormal x-ray films but no significant tuberculin skin test reaction or clinical evidence)
          5TB: suspected (diagnosis pending) (used during diagnostic testing period of suspected persons, for no longer than 3 months)
    4. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to productive cough.
      2. Impaired gas exchange related to asymmetrical lung expansion.
      3. Pain related to unresolved disease process.
      4. Body image disturbance related to feelings about tuberculosis.
      5. Social isolation related to fear of spreading infection.
      6. Knowledge deficit (learning need) related to medication regimen.
    5. Nursing care plan/implementation:
      1. Goal: reduce spread of disease.
        1. pillImageAdminister medications: isoniazid (INH), rifampin, pyrazinamide, ethambutol, or streptomycin; or drug combinations such as Rifadin or Rifamate. Client will be treated as an outpatient; may need to go to clinic for directly observed therapy (DOT) to ensure compliance with this long-term medication regimen.
        2. pillImageThe following may need to take 300 mg of INH daily for 1 year as prophylactic measure: positive skin test reactors, including contacts; persons who have diseases or are receiving therapies that affect the immune system; persons who have leukemia, lymphoma, or uncontrolled diabetes or who have had a gastrectomy.
        3. Avoid direct contact with sputum.
          1. Use good hand-washing technique after contact with client, personal articles.
          2. Have client cover mouth and nose when coughing and sneezing, and use disposable tissues to collect sputum.
        4. Provide good circulation of fresh air. (Changes of air dilute the number of organisms. This plus chemotherapy provide protection needed to prevent spread of disease.)
        5. Implement airborne or droplet precautions (see Chapter 3. Safe, Effective Care Environment, Safety and Infection Control: Guidelines for Isolation and Standard Precautions, Table 3.5. Airborne and Droplet Precautions—Summary, Standard Precautions—Summary, Table 3.7. Infection Control When Caring for Infants, Children, and Adolescents and Table 3.8. Summary: Types of Precautions and Illnesses Requiring the Precautions).
      2. foodImageGoal: promote nutrition.
        1. Increased protein, calories to aid in tissue repair and healing.
        2. Small, frequent feedings.
        3. Increased fluids, to liquefy secretions so they can be expectorated.
      3. Goal: promote increased self-esteem.
        1. Encourage client and family to express concerns regarding long-term illness and treatment protocol.
        2. Explain methods of disease prevention, and encourage contacts to be tested and treated if necessary.
        3. Encourage client to maintain role in family while home treatment is ongoing and to return to work and social contacts as soon as it is determined safe for progress of treatment plan.
      4. Goal: health teaching.
        1. pillImageDesired effects and side effects of medications:
          1. INH may affect memory and ability to concentrate. May result in peripheral neuritis, hepatitis, rash, or fever.
          2. Streptomycin may cause eighth cranial nerve damage and vestibular ototoxity, causing hearing loss; may cause labyrinth damage, manifested by vertigo and staggering; also may cause skin rashes, itching, and fever.
          3. Important for client to know that medication regimen must be adhered to for entire course of treatment.
          4. Discontinuation of therapy may allow organism to flourish and make the disease more difficult to treat.
        2. Need for follow-up, long-term care, and contact identification.
        3. Importance of nutritious diet, rest, avoidance of respiratory infections.
        4. Identify community agencies for support and follow-up.
        5. Inform that this communicable disease must be reported.
    6. Evaluation/outcome criteria:
      1. Complies with medication regimen.
      2. Lists desired effects and side effects of medications prescribed.
      3. Gains weight, eats food high in protein and carbohydrates.
      4. Sputum culture becomes negative.
      5. Retains role in family.
      6. No complications (i.e., no hemorrhage, bacillus not spread to others).
  8. EMPHYSEMA: chronic disease with excessive inflation of the air spaces distal to the terminal bronchioles, alveolar ducts, and alveoli; characterized by increased airway resistance and decreased diffusing capacity. Emphysema and chronic bronchitis together constitute chronic obstructive pulmonary disease (COPD).
    1. Pathophysiology: imbalance between proteases, which break down lung tissue, and α1-antitrypsin, which inhibits the breakdown. Increased airway resistance during expiration results in air trapping and hyperinflation → increased residual volumes. Increased dead space → unequal ventilation → perfusion of poorly ventilated alveoli → hypoxia and carbon dioxide retention (hypercapnia). Chronic hypercapnia reduces sensitivity of respiratory center; chemoreception in aortic arch and carotid sinus become principal regulators of respiratory drive (respond to hypoxia).
    2. Risk factors:
      1. Smoking.
      2. Air pollution: long-term exposure to environmental irritants, fumes, dust.
      3. Antienzymes and α1-antitrypsin deficiencies.
      4. Destruction of lung parenchyma.
      5. Family history and increased age.
    3. Assessment:
      1. Subjective data:
        1. Weakness, lethargy.
        2. History of repeated respiratory infections, shortness of breath.
        3. Long-term smoking.
        4. Irritability.
        5. Inability to accept medical diagnosis and treatment plan.
        6. Refusal to stop smoking.
        7. Dyspnea on exertion, dyspnea at rest (Table 6.14. Differentiating Between Causes of Dyspnea).
      2. Objective data:
        1. Increased BP.
        2. Increased pulse. Decreased O2 saturation.
        3. Nostrils: flaring.
        4. Cough: chronic, productive.
        5. Episodes of wheezing, crackles.
        6. Increased anterior-posterior diameter of chest (barrel chest).
        7. Use of accessory respiratory muscles, abdominal and neck.
        8. Asymmetrical thoracic movements, decreased diaphragmatic excursion.
        9. infoImage  Position: sits up, leans forward to compress abdomen and push up diaphragm, increasing intrathoracic pressure, producing more efficient expiration.
        10. Pursed lips for greater expiratory breathing phase ( "pink puffer" ).
        11. Weight loss due to hypoxia.
        12. Skin: ruddy color, nail clubbing; when combined with bronchitis: cyanosis ( "blue bloater" ).
        13. Respiratory: early disease—alkalosis; late disease—acidosis, respiratory failure.
        14. Spontaneous pneumothorax.
        15. Cor pulmonale (emergency cardiac condition involving right ventricular failure due to increased pressure within pulmonary artery).
        16. X-ray: hyperinflation of lung, flattened diaphragm; lung scan differentiates between ventilation and perfusion.
        17. Pulmonary function tests:
          1. Prolonged rapid, forced exhalation.
          2. Decreased: vital capacity (<4,000 mL); forced expiratory volume.
          3. Increased: residual volume (may be 200%); total lung capacity.
        18. Laboratory data:
          1. PaO2 less than 80 mm Hg, pH less than 7.35.
          2. PaCO2 greater than 45 mm Hg.
            Note: In clients whose compensatory mechanisms are functioning, laboratory values may be out of the normal range, but if a 20:1 ratio of bicarbonate to carbonic acid is maintained, then appropriate acid-base balance also will be maintained. (Carbonic acid value can be obtained by multiplying the PCO2 value by 0.003.)
    4. Analysis/nursing diagnosis:
      1. Impaired gas exchange related to thick pulmonary secretions.
      2. Ineffective breathing pattern related to hyperinflated alveoli.
      3. Ineffective airway clearance related to pulmonary secretions.
      4. Altered nutrition, less than body requirements, related to weight loss due to hypoxia.
      5. Infection related to chronic disease process and decreased ciliary action.
      6. Activity intolerance related to increased energy demands used for breathing.
      7. Sleep pattern disturbance related to changes in body positions necessary for breathing.
      8. Anxiety related to disease progression.
      9. Knowledge deficit (learning need) related to disease, treatment, and self-care needs.
    5. Nursing care plan/implementation:
      1. Goal: promote optimal ventilation.
        1. Institute measures designed to decrease airway resistance and enhance gas exchange.
        2. infoImagePosition: Fowler's or leaning forward to encourage expiratory phase.
        3. Oxygen with humidification, as ordered—no more than 2 L/min to prevent depression of hypoxic respiratory drive (see Oxygen Therapy in Chapter 11. Reduction of Risk Potential). May need long-term oxygen therapy as disease progresses, to improve quality of life and reduce risk of complications.
        4. Intermittent positive-pressure breathing (IPPB) with nebulization as ordered. Small-volume nebulizer treatment.
        5. Assisted ventilation.
        6. pillImagePostural drainage, chest physiotherapy.
        7. Medications, as ordered:
          1. Bronchodilatorsto increase airflow through bronchial tree: inhaled: beta2-adrenergic agonists (albuterol, metaproterenol); anticholinergic agent: ipratropium (Atrovent); aminophylline, theophylline, terbutaline, isoproterenol (Isuprel).
          2. Antimicrobials to treat infection (determined by sputum cultures and sensitivity): trimethoprim and sulfamethoxazole (Bactrim, Septra); doxycycline, erythromycin, amoxicillin, cephalosporins, and macrolides (condition deteriorates with respiratory infections).
          3. Corticosteroidsto decrease inflammation, mucosal edema, improve pulmonary function during exacerbation; systemic: prednisone, methylprednisolone sodium succinate (Solu-Medrol); inhaled: triamcinolone acetonide (Azmacort), beclomethasone (Beclovent, Vanceril), flunisolide (AeroBid).
          4. Expectorants (increase water intake to achieve desired effect): glyceryl guaiacolate (Robitussin).
          5. Bronchial detergents/liquefying agents (Mucomyst).
        8. pillImageImmunotherapy: helps ward off life-threatening influenza and pneumonia. Flu vaccination every October or November. Pneumococcal vaccination routinely one dose; revaccinate 5 years later if high risk.
      2. Goal: employ comfort measures and support other body systems.
        1. Oral hygiene prn; frequently client is mouth breather.
        2. Skin care: waterbed, air mattress, foam pads to prevent skin breakdown.
        3. Active and passive ROM exercises to prevent thrombus formation; antiembolic stocking or woven elastic (Ace) bandages may be applied.
        4. Increase activities to tolerance.
        5. Adequate rest and sleep periods to prevent mental disturbances due to sleep deprivation and to reduce metabolic rate.
      3. foodImageGoal: improve nutritional intake.
        1. High-protein, high-calorie diet to prevent negative nitrogen balance.
        2. Give small, frequent meals.
        3. Supplement diet with high-calorie drinks.
        4. Push fluids to 3,000 mL/day, unless contraindicated—helps moisten secretions.
      4. Goal: provide emotional support for client and family.
        1. Identify factors that increase anxiety:
          1. Fears related to mechanical equipment.
          2. Loss of body image.
          3. Fear of dying.
        2. Assist family coping:
          1. Do not reinforce denial or encourage overconcern.
          2. Give accurate, up-to-date information on client's condition.
          3. Be open to questioning.
          4. Encourage client–family communication.
          5. Provide appropriate diversional activities.
      5. Goal: health teaching.
        1. Breathing exercises, such as pursed-lip breathing and diaphragmatic breathing.
        2. Stress-management techniques.
        3. Methods to stop smoking.
        4. Importance of avoiding respiratory infections.
        5. Desired effects and side effects of prescribed medications, possible interactions with over-the-counter drugs.
        6. Purposes and techniques for effective bronchial hygiene therapy.
        7. Rest/activity schedule that increases with ability.
        8. Food selection for high-protein, high-calorie diet.
        9. Importance of taking 2,500 to 3,000 mL fluid per day (unless contraindicated by another medical problem).
        10. Importance of medical follow-up.
    6. Evaluation/outcome criteria:
      1. Takes prescribed medication.
      2. Participates in rest/activity schedule.
      3. Improves nutritional intake, gains appropriate weight for body size.
      4. No complications of respiratory failure, cor pulmonale.
      5. No respiratory infections.
      6. Acid-base balance maintained through compensatory mechanisms, acidosis prevented.
  9. ASTHMA: sometimes called reactive airway disease (RAD) or reversible obstructive airway disease (ROAD); a complex inflammatory process that causes increased airway resistance and, over time, airway tissue damage. Characterized by airway inflammation and hyperresponsiveness to a variety of stimuli such as allergens, cold air, dust, smoke, exercise, medications (e.g., aspirin), some food additives, and viral infections. Immunologic asthma occurs in childhood and follows other allergic disease. Nonimmunologic asthma occurs in adulthood and is associated with a history of recurrent respiratory tract infections.
    1. Pathophysiology: triggers initiate the release of inflammatory mediators such as histamine, which produce airway obstruction through smooth muscle constriction, microvascular leakage, mucus plugging, and swelling. This process involves six sequential steps: (1) triggering—the allergic or antigenic stimuli activate the inflammatory (mast) cells; (2) these mast cells signal the systemic immune system to release proinflammatory substances; (3) migration of circulating inflammatory cells to regions of inflammation in the respiratory tract; (4) migrating cells are activated by the proinflammatory mediators; (5) this results in tissue damage; and (6) resolution. The airways of many clients with asthma are chronically inflamed.
      1. Immunologic, or allergic asthma in persons who are atopic (hypersensitivity state that is subject to hereditary influences); immunoglobulin E (IgE) usually elevated.
      2. Nonimmunologic, or nonallergic asthma in persons who have a history of repeated respiratory tract infections; age usually more than 35 years.
      3. Mixed, combined immunologic and nonimmunologic; any age, allergen or nonspecific stimuli.
    2. Risk factors:
      1. History of allergies to identified or unidentified irritants; seasonal and environmental inhalants.
      2. Recurrent respiratory infection.
    3. Assessment:
      1. Subjective data:
        1. History: upper respiratory infection (URI), rhinitis, allergies, family history of asthma.
        2. Increasing tightness of the chest → dyspnea (see Table 6-14. Differentiating Between Causes of Dyspnea ).
        3. Anxiety, restlessness.
        4. Attack history:
          1. Immunologic: contact with allergen to which person is sensitive; seen most often in children and young adults.
          2. Nonimmunologic: develops in adults older than 35 years; aggravated by infections of the sinuses and respiratory tract.
      2. Objective data:
        1. Peak flowmeter level drops.
        2. Respiratory assessment: increased rate, audible expiratory wheeze (also inspiratory when severe) on auscultation, hyperresonance on percussion, rib retractions, use of accessory muscles on inspiration.
        3. Tachycardia, tachypnea.
        4. Cough: dry, hacking, persistent.
        5. General appearance: pallor, cyanosis, diaphoresis, chronic barrel chest, elevated shoulders, flattened malar bones, narrow nose, prominent upper teeth, dark circles under eyes, distended neck veins, orthopnea.
        6. Expectoration of tenacious mucoid sputum.
        7. Diagnostic tests:
          1. Forced vital capacity (FVC): decreased.
          2. Forced expiratory volume in 1 second (FEV1): decreased.
          3. Peak expiratory flow rate: decreased.
          4. Residual volume: increased.
        8. Laboratory data: blood gases—elevated PCO2; decreased PO2, pH. Emergency note: Persons severely affected may develop status asthmaticus, a life-threatening asthmatic attack in which symptoms of asthma continue and do not respond to usual treatment. Could lead to respiratory failure and hypoxemia.
    4. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to tachypnea.
      2. Impaired gas exchange related to constricted bronchioles.
      3. Anxiety related to breathlessness.
      4. Activity intolerance related to persistent cough.
      5. Knowledge deficit (learning need) related to causal factors and self-care measures.
    5. Nursing care plan/implementation:
      1. Goal: promote pulmonary ventilation.
        1. infoImagePosition: high-Fowler's for comfort.
        2. pillImage Medications as ordered:
          1. Rescue medications: corticosteroids (e.g., prednisone, methylprednisolone [Medrol]; beta-adrenergic agonists, such as albuterol [Proventil, Ventolin], metaproterenol [Alupent, Metaprel]).
          2. Maintenance medications: nonsteroidal anti-inflammatory drugs: cromolyn (Intal), nedocromil (Tilade); corticosteroids: beclomethasone (Vanceril), triamcinolone (Azmacort); leukotriene inhibitors/receptor antagonists: zafirlukast (Accolate), zileuton (Zyflo); theophylline (Theo-Dur, Slo-Bid, Uni-Dur, theophylline ethylenediamino [Aminophylline]); anticholinergic: ipratropium (Atrovent); beta agonists: salmeterol (Serevent); mast cell stabilizers: nedocromil sodium (Tilade).
          3. Antibiotics to control infection.
        3. Oxygen therapy with increased humidity as ordered.
        4. Frequent monitoring for respiratory distress.
        5. Rest periods and gradual increase in activity.
      2. Goal: facilitate expectoration.
        1. High humidity.
        2. Increase fluid intake.
        3. Monitor for dehydration.
        4. Respiratory therapy: IPPB.
      3. Goal: health teaching to prevent further attacks.
        1. Identify and avoid all asthma triggers.
        2. Teach importance of peak flowmeter readings.
        3. Medications—when to use, how to use, side effects, withdrawals.
        4. Using a metered-dose inhaler:
          1. Shake vigorously.
          2. Position inhaler about 1 inch in front of mouth. Use 2 fingers to measure the 1-inch distance.
          3. A spacer is recommended: connect spacer device, shake, press down the canister; place lips on the mouthpiece and take a slow deep breath through mouth. Without spacer: breathe out all the way, open mouth wide, and take a slow deep breath through mouth. Press down the canister and continue to breathe in.
          4. Once lungs are full, hold breath for 10 seconds if possible.
          5. Exhale normally through pursed lips.
          6. Wait 1 to 2 minutes between puffs. Depending on the particular medication, may need to rinse mouth with water or mouthwash after each treatment.
        5. Methods to facilitate expectoration—increase humidity, postural drainage when appropriate, percussion techniques.
        6. Breathing techniques to increase expiratory phase.
        7. Stress-management techniques.
        8. Importance of recognizing early signs of asthma attack and beginning treatment immediately.
        9. Steps to take during an attack.
    6. Evaluation/outcome criteria:
      1. No complications.
      2. Has fewer attacks.
      3. Takes prescribed medications, avoids infections.
      4. Adjusts lifestyle.
      5. Pulmonary function tests return to normal.
  10. BRONCHITIS: acute or chronic inflammation of bronchus resulting as a complication from colds and flu. Acute bronchitisis caused by an extension of upper respiratory infection, such as a cold, and can be given to others. It can also result from an irritation from physical or chemical agents. Chronic bronchitis is characterized by hypersecretion of mucus and chronic cough for 3 months per year for 2 consecutive years.
    1. Pathophysiology: bronchial walls are infiltrated with lymphocytes and macrophages; lumen becomes obstructed due to decreased ciliary action and repeated bronchospasms. Hyperventilation of alveolar sacs occurs. Long-term condition results in respiratory acidosis, recurrent pneumonitis, emphysema, or cor pulmonale.
    2. Risk factors:
      1. Smoking.
      2. Repeated respiratory infections.
      3. History of living in area where there is much air pollution.
    3. Assessment:
      1. Subjective data:
        1. History: recurrent, chronic cough, especially when arising in the morning.
        2. Anorexia.
      2. Objective data:
        1. Respiratory:
          1. Shortness of breath.
          2. Use of accessory muscles.
          3. Cyanosis, dusky complexion: "blue bloater."
          4. Sputum: excessive, nonpurulent.
          5. Vesicular and bronchovesicular breath sounds; wheezing.
        2. Weight loss.
        3. Fever.
        4. Pulmonary function tests:
          1. Decreased forced expiratory volume.
          2. PaO2 less than 90 mm Hg; PaCO2 greater than 40 mm Hg.
        5. Laboratory data:
          1. RBC count: elevated to compensate for hypoxia (polycythemia).
          2. WBC count: elevated to fight infection.
    4. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to excessive sputum.
      2. Ineffective breathing pattern related to need to use accessory muscles for breathing.
      3. Impaired gas exchange related to shortness of breath.
      4. Activity intolerance related to increased energy used for breathing.
    5. Nursing care plan/implementation:
      1. Goal: assist in optimal respirations.
        1. Increase fluid intake.
        2. pillImage IPPB, chest physiotherapy.
        3. Administer medications as ordered:
          1. Bronchodilators.
          2. Antibiotics.
          3. Bronchial detergents, liquefying agents.
      2. Goal: minimize bronchial irritation.
        1. Avoid respiratory irritants (e.g., smoke, dust, cold air, allergens).
        2. Environment: air-conditioned, increased humidity.
        3. Encourage nostril breathing rather than mouth breathing.
      3. Goal: improve nutritional status.
        1. foodImageDiet: soft, high calorie.
        2. Small, frequent feedings.
      4. Goal: prevent secondary infections.
        1. pillImageAdminister antibiotics as ordered.
        2. Avoid exposure to infections, crowds.
      5. Goal: health teaching.
        1. Avoid respiratory infections.
        2. Medications: desired effects and side effects.
        3. Methods to stop smoking.
        4. Rest and activity balance.
        5. Stress management.
    6. Evaluation/outcome criteria:
      1. Stops smoking.
      2. Acid-base balance maintained.
      3. Respiratory infections less frequent.
  11. ACUTE ADULT RESPIRATORY DISTRESS SYNDROME (ARDS) (formerly called by other names, including shock lung): noncardiogenic pulmonary infiltrations resulting in stiff, wet lungs and refractory hypoxemia in an adult who was previously healthy. Acute hypoxemic respiratory failure without hypercapnea.
    1. Pathophysiology: damage to alveolar capillary membrane, increased vascular permeability creating noncardiac pulmonary edema, and impaired gas exchange; decreased surfactant production → atelectasis; severe hypoxia; refractory to ↑ FiO2 → possible death.
    2. Risk factors:
      1. Primary:
        1. Shock, multiple trauma.
        2. Infections.
        3. Aspiration, inhalation of chemical toxins.
        4. Drug overdose.
        5. Disseminated intravascular coagulation (DIC).
        6. Emboli, especially fat emboli.
      2. Secondary:
        1. Overaggressive fluid administration.
        2. Oxygen toxicity.
        3. Mechanical ventilation.
    3. Assessment:
      1. Subjective data:
        1. Restlessness, anxiety.
        2. History of risk factors.
        3. Severe dyspnea (see Table 6-14. Differentiating Between Causes of Dyspnea ).
      2. Objective data:
        1. Cyanosis.
        2. Tachycardia.
        3. Hypotension.
        4. Hypoxemia, acidosis.
        5. Crackles.
        6. X-ray—bilateral patchy infiltrates.
        7. Death if untreated.
    4. Analysis/nursing diagnosis:
      1. Anxiety related to serious physical condition.
      2. Ineffective breathing pattern related to severe dyspnea.
      3. Impaired gas exchange related to alveolar damage.
      4. Altered tissue perfusion related to hypoxia.
    5. Nursing care plan/implementation:
      1. Goal: assist in respirations.
        1. May require mechanical ventilatory support to maintain respirations.
        2. May need to be transferred to ICU.
        3. May need oxygen to combat hypoxia.
        4. Suction prn.
        5. Monitor blood gas results to detect early signs of acidosis/alkalosis.
        6. If not on ventilator, assess vital signs and respiratory status every 15 minutes.
        7. Cough, deep breathe every hour.
        8. May need:
          1. infoImageRotation therapy and/or prone position.
          2. pillImagePostural drainage, suction.
          3. Bronchodilator medications.
      2. Goal: prevent complications.
        1. Decrease anxiety and provide psychological care:
          1. Maintain a calm atmosphere.
          2. Encourage rest to conserve energy.
          3. Emotional support.
        2. Obtain fluid balance:
          1. pillImageSlow IV flow rate.
          2. Diuretics: rapid acting, low dose.
        3. Monitor:
          1. Pulmonary artery and capillary wedge pressure cardiac output.
          2. Central venous pressure (CVP), peripheral perfusion, arterial line BP.
          3. I&O.
          4. Assess for bleeding tendencies, potential for disseminated intravascular coagulation.
        4. Protect from infection:
          1. pillImageStrict aseptic technique.
          2. Antibiotic therapy.
          3. Deep vein thrombosis prophylaxis.
        5. Provide physiological support:
          1. Maintain nutrition.
          2. Skin care.
      3. Goal: health teaching.
        1. Briefly explain procedures as they are happening (emergency situation can frighten client).
        2. Give rationale for follow-up care.
        3. Identify risk factors as appropriate for prevention of recurrence.
    6. Evaluation/outcome criteria:
      1. Client survives and is alert.
      2. Skin warm to touch.
      3. Respiratory rate within normal limits.
      4. Laboratory values and pressures within normal limits.
      5. Urinary output greater than 30 mL/hr.
  12. PNEUMOTHORAX: presence of air within the pleural cavity; occurs spontaneously or as a result of trauma (Figure. 6.3. Pneumothorax).
    1. Types:
      1. Closed (spontaneous): rupture of a subpleural bulla, tuberculous focus, carcinoma, lung abscess, pulmonary infarction, severe coughing attack, or blunt trauma.
      2. Open (traumatic): communication between atmosphere and pleural space because of opening in chest wall.
      3. Tension: one-way leak; may occur during mechanical ventilation or cardiopulmonary resuscitation (CPR), or as a complication of any type of spontaneous or traumatic pneumothorax. Positive pressure within chest cavity resulting from accumulated air that cannot escape during expiration. Leads to collapse of lung, mediastinal shift, and compression of the heart and great vessels.
    2. Pathophysiology: pressure builds up in the pleural space, lung on the affected side collapses, and the heart and mediastinum shift toward the unaffected lung.
    3. Assessment:
      1. Subjective data:
        1. Pain:
          1. Sharp, aggravated by activity.
          2. Location—chest; may be referred to shoulder, arm on affected side.
        2. Restlessness, anxiety.
        3. Dyspnea (see Table 6-14. Differentiating Between Causes of Dyspnea ).
      2. Objective data:
        1. Cough.
        2. Cessation of normal movements on affected side.
        3. Absence of breath sounds on affected side.
        4. Pallor, cyanosis.
        5. Shock.
        6. Tracheal deviation to unaffected side.
        7. X-ray: air in pleural space.
    4. Analysis/nursing diagnosis:
      1. Ineffective breathing pattern related to collapse of lung.
      2. Impaired gas exchange related to abnormal thoracic movement.
      3. Pain related to trauma to chest area.
      4. Fear related to emergency situation.
    5. Nursing care plan/implementation:
      1. Goal: prevent damage until medical intervention available.
        1. Place sterile occlusive gauze dressing over wound.
        2. Tape dressing on three sides to allow air to escape during expiration.
        3. infoImagePlace client on affected side to diminish possibility of tension pneumothorax.
      2. Goal: protect against injury during thoracentesis.
        1. Provide sterile equipment.
        2. Explain procedure.
        3. Monitor vital signs for shock.
        4. Monitor for respiratory distress, mediastinal shift.
      3. Goal: promote respirations.
        1. infoImagePosition: Fowler's.
        2. Oxygen therapy as ordered.
        3. Encourage slow breathing to improve gas exchange.
        4. pillImageCareful administration of narcotics to prevent respiratory depression ( avoid morphine).
      4. Goal: prepare client for closed chest drainage, physically and psychologically.
        1. Explain purpose of the procedure—to provide means for evacuation of air and fluid from pleural cavity; to reestablish negative pressure in pleural space; to promote lung reexpansion.
        2. infoImageExplain procedure and apparatus (see Chest tubes section in Table 11-5. Review of the Use of Common Tubes ).
        3. Cleanse skin at tube insertion site; place client in sitting position, ensuring safety by having locked over-the-bed table for client to lean on, or have a nurse stay with client so appropriate position is maintained throughout the procedure.
      5. Goal: prevent complications with chest tubes.
        1. Observe for and immediately report: crepitations (air under skin, also called subcutaneous emphysema), labored or shallow breathing, tachypnea, cyanosis, tracheal deviation, or signs of hemorrhage.
        2. Monitor for signs of infection.
        3. Ensure that tubing stays intact.
        4. Monitor proper tube function. Attach chest tube to a water-seal drainage apparatus and use wall suction for negative pressure. Monitor amount and color of tube drainage every 2 hours. Notify physician if bloody drainage exceeds 100 mL/hr. Chest drainage system should be at least 1 foot (30 cm) below the chest tube insertion site. Change dressing at tube insertion site every 48 hours. Air bubbles will continue in the water-seal chamber for 24 to 48 hours after insertion. Persistent air bubbles indicate an air leak between alveoli and pleural space. Fluctuation of fluid level is expected (when suction is off) because respiration changes the pleural pressure. If a clot forms in the tube, gently squeeze the tube, without occluding it, to move the clot, or follow specific orders as written. Make sure tube is free of kinks. When moving client, do not clamp tube; disconnect it from the wall suction. See key points for nursing intervention with chest tubes in Table 11-5. Review of the Use of Common Tubes .
        5. Change position every 1 to 2 hours.
        6. Arm and shoulder ROM.
      6. Goal: health teaching.
        1. How to prevent recurrence by avoiding overexertion; avoid holding breath.
        2. Signs and symptoms of condition.
        3. Methods to stop smoking.
        4. Encourage follow-up care.
    6. Evaluation/outcome criteria:
      1. No complications noted.
      2. Closed system remains intact until chest tubes are removed.
      3. Lung reexpands, breath sounds heard, pain diminished, symmetrical thoracic movements.
  13. HEMOTHORAX: presence of blood in pleural cavity related to trauma or ruptured aortic aneurysm (see XII. PNEUMOTHORAX for assessment, analysis/nursing diagnosis, nursing care plan/implementation, and evaluation/outcome criteria). Table 6-15. Comparison of Pneumothorax and Hemothorax compares pneumothorax and hemothorax.
  14. CHEST TRAUMA
    Flail chest: multiple rib fractures resulting in instability of the chest wall, with subsequent paradoxical breathing (portion of lung under injured chest wall moves in on inspiration while remaining lung expands; on expiration, the injured portion of the chest wall expands while unaffected lung tissue contracts).
    Sucking chest wound: penetrating wound of chest wall with hemothorax and pneumothorax, resulting in lung collapse and mediastinal shift toward unaffected lung.
    1. Assessment:
      1. Subjective data:
        1. Severe, sudden, sharp pain.
        2. Dyspnea.
        3. Anxiety, restlessness, fear, weakness.
      2. Objective data:
        1. Vital signs:
          1. Pulse: tachycardia, weak.
          2. BP: hypotension.
          3. Respirations: shallow, decreased expiratory force, tachypnea, stridor, accessory muscle breathing.
        2. Skin color: cyanosis, pallor.
        3. Chest:
          1. Asymmetrical chest expansion (paradoxical movement).
          2. Chest wound, rush of air through trauma site.
          3. Crepitus over trauma site (from air escaping into surrounding tissues).
          4. Lateral deviation of trachea, mediastinal shift.
        4. Pneumothorax: documented by absence of breath sounds, x-ray examination.
        5. Hemothorax: documented by needle aspiration by physician, x-ray examination.
        6. Shock; blood and fluid loss.
        7. Hemoptysis.
        8. Distended neck veins.
    2. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to shallow respirations.
      2. Impaired gas exchange related to asymmetrical chest expansion.
      3. Pain related to chest trauma.
      4. Fear related to emergency situation.
      5. Risk for trauma related to fractured ribs.
      6. Risk for infection related to open chest wound.
    3. Nursing care plan/implementation:
      1. Goal: restore adequate ventilation and prevent further air from entering pleural cavity: MEDICAL EMERGENCY.
        1. In emergency situation: place air-occlusive dressing or hand over open wound as client exhales forcefully against glottis ( Valsalva maneuver helps expand collapsed lung by creating positive intrapulmonary pressures); or place client's weight onto affected side. Administer oxygen.
        2. Assist with endotracheal tube insertion; client will be placed on volume-controlled ventilator. (See discussion of ventilators under Oxygen Therapy in Chapter 11. Reduction of Risk Potential.)
        3. Assist with thoracentesis and insertion of chest tubes with connection to water-seal drainage as ordered (see Chest tubes section in Table 11-5. Review of the Use of Common Tubes ).
        4. Monitor vital signs to determine early shock.
        5. Monitor blood gases to determine early acid-base imbalances.
        6. pillImagePain medications given with caution, so as not to depress respiratory center.
    4. Evaluation/outcome criteria:
      1. Respiratory status stabilizes, lung reexpands.
      2. Shock and hemorrhage are prevented.
      3. No further damage done to surrounding tissues.
      4. Pain is controlled.
  15. THORACIC SURGERY: used for bronchogenic and lung carcinomas, lung abscesses, tuberculosis, bronchiectasis, emphysematous blebs, and benign tumors.
    1. Types:
      1. Thoracotomy—incision in the chest wall, pleura is entered, lung tissue examined, biopsy secured. Chest tube is needed postoperatively.
      2. Lobectomy—removal of a lobe of the lung. Chest tube is needed postoperatively.
      3. Pneumonectomy—removal of an entire lung. No chest tube is needed postoperatively.
    2. Analysis/nursing diagnosis:
      1. Risk for injury related to chest wound.
      2. Impaired gas exchange related to pain from surgical procedure.
      3. Ineffective airway clearance related to decreased willingness to cough due to pain.
      4. Pain related to surgical incision.
      5. Impaired physical mobility related to large surgical incision and chest tube drainage apparatus.
      6. Knowledge deficit (learning need) related to importance of coughing and deep breathing to prevent complications.
    3. Nursing care plan/implementation:
      1. Preoperative care:
        1. Goal: minimize pulmonary secretions.
          1. Humidify air to moisten secretions.
          2. Use IPPB, as ordered, to improve ventilation.
          3. pillImageAdminister bronchodilators, expectorants, and antibiotics as ordered.
          4. Use postural drainage, cupping, and vibration to mobilize secretions.
        2. Goal: preoperative teaching.
          1. Teach client to cough against a closed glottis to increase intrapulmonary pressure for improved expiratory phase.
          2. Instruct in diaphragmatic breathing and coughing.
          3. Encourage to stop smoking.
          4. Instruct and supervise practice of postoperative arm exercises—flexion, abduction, and rotation of shoulder—to prevent ankylosis.
          5. Explain postoperative use of chest tubes, IV, and oxygen therapy.
      2. Postoperative care:
        1. Goal: maintain patent airway.
          1. Auscultate chest for breath sounds; report diminished or absent breath sounds on unaffected side (indicates decreased ventilation → respiratory embarrassment).
          2. Turn, cough, and deep breathe, every 15 minutes to 1 hour for first 24 hours and prn according to pulmonary congestion heard on auscultation.
        2. Goal: promote gas exchange.
          1. Splint chest during coughing—support incision to help cough up sputum (most important activity postoperatively).
          2. infoImagePosition: high-Fowler's.
            1. Turn client who has had a pneumonectomy to operative side ( avoid extreme lateral positioning and mediastinal shift) to allow unaffected lung expansion and drainage of secretions; can also be turned onto back.
            2. Client who has had a lobectomy or thoracotomy can be turned on either side or back because chest tubes will be in place.
        3. Goal: reduce incisional stress and discomfort—pad area around chest tube when turning on operative side to maintain tube patency and promote comfort.
        4. Goal: prevent complications related to respiratory function.
          1. Maintain chest tubes to water-seal drainage system.
          2. See Chest tubes section in Table 11-5. Review of the Use of Common Tubes .
          3. Observe for mediastinal shift (trachea should always be midline; movement toward either side indicates shift).
            1. infoImageMove client onto back or toward opposite side.
            2. MEDICAL EMERGENCY: Notify physician immediately.
        5. Goal: maintain fluid and electrolyte balance.
          1. Administer parenteral infusion slowly (risk of pulmonary edema due to decrease in pulmonary vasculature with removal of lung lobe or whole lung).
        6. Goal: postoperative teaching.
          1. Prevent ankylosis of shoulder—teach passive and active ROM exercises of operative arm.
          2. Importance of early ambulation, as condition permits.
          3. Importance of stopping smoking.
          4. Dietary instructions—nutritious diet to aid in healing process.
          5. Importance of deep breathing, coughing exercises, to prevent stasis of respiratory secretions.
          6. Importance of increased fluids in diet to liquefy secretions.
          7. Desired and side effects of prescribed medications.
          8. Importance of rest, avoidance of heavy lifting and work during healing process.
          9. Importance of follow-up care; give names of referral agencies where client and family can obtain assistance.
          10. Signs and symptoms of complications.
    4. Evaluation/outcome criteria:
      1. Client or significant other or both will be able to:
        1. Give rationale for activity restriction and demonstrate prescribed exercises.
        2. Identify name, dosage, side effects, and schedule of prescribed medications.
        3. State plans for necessary modifications in lifestyle, home.
        4. Identify support systems.
      2. Wound heals without complications.
      3. Obtains ROM in affected shoulder.
      4. No complications of thoracotomy, such as:
        1. Respiratory—pulmonary insufficiency, respiratory acidosis, pneumonitis, atelectasis, pulmonary edema.
        2. Circulatory—hemorrhage, hypovolemia, shock, myocardial infarction.
        3. Mediastinal shift.
        4. Renal failure.
        5. Gastric distention.
  16. TRACHEOSTOMY: opening into trachea, temporary or permanent. Rationale: airway obstruction due to foreign body, edema, tumor, excessive tracheobronchial secretions, respiratory depression, decreased gaseous diffusion at alveolar membrane, increased dead space (e.g., severe emphysema), or failure to wean from mechanical ventilator.
    1. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to increased secretions and decreased ability to cough effectively.
      2. Ineffective breathing pattern related to physical condition that necessitated tracheostomy.
      3. Impaired verbal communication related to inability to speak when tracheostomy tube cuff inflated.
      4. Fear related to need for specialized equipment to breathe.
    2. Nursing care plan/implementation:
      1. Preoperative care:
        1. Goal: relieve anxiety and fear.
          1. Explain purpose of procedure and equipment.
          2. Demonstrate suctioning procedure.
          3. Establish means of postoperative communication (e.g., paper and pencil, "magic slate," picture cards, and call bell). Specialized tubes such as a fenestrated tracheostomy tube or a tracheostomy button allow the individual to talk when the external opening is plugged.
          4. Remain with client as much as possible.
      2. Postoperative care:
        1. Goal: maintain patent airway (Table 6.16. Tracheostomy Suctioning Procedure).
        2. Goal: alleviate apprehension.
          1. Remain with client as much as possible.
          2. Encourage client to communicate feelings using preestablished communication system.
        3. foodImageGoal: improve nutritional status.
          1. Provide nutritious foods/liquids the client can swallow.
          2. Give supplemental drinks to maintain necessary calories.
        4. Goal: health teaching.
          1. Explain all procedures.
          2. Teach alternative methods of communication (best if done before the tracheostomy if it is not an emergency situation).
          3. Teach self-care of tracheostomy as soon as possible.
    3. Evaluation/outcome criteria:
      1. Airway patent.
      2. Acid-base balance maintained.
      3. No respiratory infection/obstruction.