1. Management of Patients With Chest
and Lower Respiratory Tract
Disorders
UNIVERSITY OF DETROIT MERCY
McAuley School of Nursing
NUR 3200
MedSurg I
Chapter 19
Course Faculty: Dr. Wilfred M. Allen

2. Atelectasis
 Closure or collapse of alveoli
 Acute or chronic
 Most common is acute atelectasis, which occurs in
the postoperative setting
 Symptoms: insidious, increasing dyspnea, cough, and
sputum production
 Acute: tachycardia, tachypnea, pleural pain, and
central cyanosis if large areas of the lung are affected
 Chronic: similar to acute, pulmonary infection may
be present

3. Assessment and Diagnosis for
Atelectasis
 Characterized by increased work of breathing and
hypoxemia
 Decreased breath sounds and crackles over the
affected area
 Chest x-ray may suggest a diagnosis of atelectasis
before clinical symptoms appear
 Pulse oximetry (SpO2) may demonstrate a low
saturation of hemoglobin with oxygen (less than
90%)

4. Nursing Interventions for
Atelectasis
 Prevention
 Frequent turning
 Early mobilization
 Strategies to expand lungs and manage secretions
 Incentive spirometer
 Voluntary deep breathing
 Secretion management
 Pressurized metered-dose inhaler

5. Management of Atelectasis
 Improve ventilation and remove secretions
 First line measures:
‐
 Frequent turning, early ambulation, lung volume
expansion maneuvers and coughing
 Multidisciplinary: ICOUGH (see Chart 19 3)
‐
 PEEP, CPAB, bronchoscopy
 CPT
 Endotracheal intubation and mechanical ventilation
 Thoracentesis to relieve compression

6. Pulmonary Infections
 Tracheobronchitis
 Pneumonia
 Tuberculosis
 Lung abscess

7. Acute Tracheobronchitis
 Inflammation of the mucous membranes of the
trachea usually after a viral infection
 Pathophysiology
 Mucopurulent sputum
 Clinical manifestations
 Initially dry cough with mucoid sputum
 As progresses, dyspnea, stridor, wheezes, purulent
sputum

8. Management of Acute
Tracheobronchitis
 Medical management
 Antibiotics
 Analgesics
 Increased fluid intake
 Cool vapor therapy or steam inhalations
 Suctioning
 Nursing Management
 Bronchial hygiene
 Rest
 Complete full course of medications

9. Pneumonia
 Inflammation of the lung parenchyma caused by
various microorganisms, including bacteria,
mycobacteria, fungi, and viruses
 Classification
 Community-acquired (CAP)
 Health care–associated (HCAP)
 Hospital-acquired (HAP)
 Ventilator-associated (VAP)
 Refer to Chart 19-4

10. Types of Pneumonia
 Community-acquired
 Community setting or within first 48 hours post
hospitalization
 Rate of infection increases with age
 S. Pneumoniae is the most common cause among adults
 Viral origin in infants and children
 Health care–associated
 Often caused by multidrug resistant organisms
‐
 Early diagnosis and treatment are critical

11. Types of Pneumonia
 Hospital-acquired
 Develops 48 hours or more after hospitalization
 Subtype of health care–associated pneumonia
 Potential for infection from many sources
 High mortality rate
 Colonization by multiple organisms due to overuse of
antimicrobial agents
 Pleural effusion, high fever, and tachycardia
 Common with debilitated, dehydrated patients with
minimal sputum production

12. Types of Pneumonia
 Ventilator-associated
 Received mechanical ventilation for at least 48 hours
 Prevention is key
 VAP bundles (Chart 19-6)
 Pneumonia in the immunocompromised host
 Common agents include pneumocystis, fungi, and
tuberculosis
 Receiving immunosuppressive agents, history of
immunosuppressive condition
 Subtle onset with progressive dyspnea, fever, and
nonproductive cough

13. Pneumonia Risk Factors
 Refer to Table 19-2
 Occurs in patients with certain underlying disorders
and diseases
 Heart failure, diabetes, alcoholism, COPD, and
AIDS
 Influenza
 Cystic fibrosis

14. Clinical Manifestations of
Pneumonia
 Varies depending on type, causal organism, and
presence of underlying disease
 Streptococcal: Sudden onset of chills, fever, pleuritic
chest pain, tachypnea, and respiratory distress
 Viral, mycoplasma, or Legionella: relative bradycardia
 Other: Respiratory tract infection, headache, low-grade
fever, pleuritic pain, myalgia, rash, and pharyngitis
 Orthopnea, crackles, increased tactile fremitus, purulent
sputum

15. Assessment and Diagnosis of
Pneumonia
 History
 Physical exam
 Chest x-ray
 Blood culture
 Sputum examination
 Bronchoscopy may be used for acute severe infection

16. Pneumonia Prevention
 Pneumococcal vaccination
 Reduces the incidence of pneumonia,
hospitalizations for cardiac conditions, and deaths
in the older adult population
 Two types of pneumococcal vaccine
 Recommended for all adults 65 years of age or
older and 19 years or older with conditions that
weaken the immune system
 Other preventive measures, see Table 19-2

17. Medical Management of
Pneumonia
 Administration of the appropriate antibiotic as
determined by the results of a culture and sensitivity
 Supportive treatment includes fluids, oxygen for
hypoxia, antipyretics, antitussives, decongestants,
and antihistamines
 Antibiotics not indicated for viral infections but are
used for secondary bacterial infection
 Refer to Table 19-3
 Gerontologic considerations

18. COVID-19 Considerations
 SARS-CoV-2
 Asymptomatic to severe viral pneumonia
 Fatigue, myalgia, congestion, sore throat, diarrhea,
anosmia, and ageusia
 Mostly conservative outpatient management (rest,
hydrate, antipyretic agents)
 Hospitalization for severe illness with pneumonia,
increased risk of venous thromboembolism
 Can lead to shock and respiratory failure

19. Assessment of the Patient with
Bacterial Pneumonia
 Vital signs
 Secretions: amount, odor, color
 Cough: frequency and severity
 Tachypnea, shortness of breath
 Inspect and auscultate chest
 Changes in mental status, fatigue, edema,
dehydration, concomitant heart failure, especially in
older adult patients

20. Problems/Complications of the Patient
with Bacterial Pneumonia
 Continuing symptoms after initiation of
therapy
 Sepsis and septic shock
 Respiratory failure
 Atelectasis
 Pleural effusion
 Delirium

21. Planning and Goals for the Patient with
Bacterial Pneumonia
 Improved airway patency
 Increased activity
 Maintenance of proper fluid volume
 Maintenance of adequate nutrition
 Understanding of the treatment protocol and
preventive measures
 Absence of complications
 Based on patient outcomes plan for home,
community, and transitional care

22. Nursing Interventions for the Patient with
Bacterial Pneumonia
 Oxygen with
humidification to
loosen secretions
 Face mask or nasal
cannula
 Coughing techniques
 Chest physiotherapy
 Position changes
 Incentive spirometry
 Nutrition
 Hydration
 Rest
 Activity as tolerated
 Patient education
 Self-care

23. Expected Outcomes for the Patient with
Bacterial Pneumonia
 Demonstrates improved airway patency
 Rests and conserves energy and then slowly
increasing activities
 Maintains adequate hydration; adequate dietary
intake
 Verbalizes increased knowledge about management
strategies
 Complies with management strategies
 Exhibits no complications

24. Aspiration
 Inhalation of foreign material into the lungs leads to
inflammatory reaction, hypoventilation, and
ventilation–perfusion mismatch
 Serious complication is broncho or lobar pneumonia
 Risk factor is LOC; refer to Chart 19-8
 Key pathophysiology is the volume and character of
aspirated contents (most often GI contents)

25. Aspiration Prevention
 Swallowing screening
 Nursing interventions
 Keep HOB elevated and endotracheal cuff elevated
(if intubated)
 Avoid stimulation of gag reflex with suctioning or
other procedures
 Check for placement before tube feedings
 Soft diet, small bites, no straws
 Refer to Chart 19-9

26. Pulmonary Tuberculosis
 Mycobacterium tuberculosis bacillus (TB)
 10 million people with TB worldwide and 9,105 cases in the
United States (2017)
 Spreads by airborne transmission through droplets then moves
to other parts of the body such as the kidneys, bones, and
cerebral cortex.
 Granulomas and Ghon tubercule
 Risk factors for TB, refer to Chart 19-10
 Low grade fever
‐
 Cough; nonproductive or mucopurulent; hemoptysis
 Night sweats, fatigue, weight loss

27. Assessment and Diagnostic
Findings for TB
 History and physical
 TB skin test; Mantoux method: See Figure 19-3
 Significant versus nonsignificant reactions
 TB blood tests
 Sputum culture
 Sputum testing

28. Medical Management of TB
 Treated for 6 to 12 months
 Drug resistance is primary concern
 Initiate treatment with four or more medications
 Complete all therapy
 Initial treatment phase (8 weeks)
 Continuation phase (4 to 7 months)
 Table 19-4

29. Nursing Management of TB
 Promoting airway clearance
 Advocating adherence to the treatment
regimen
 Promoting activity and nutrition
 Preventing transmission

30. Lung Abscess
 Most are a complication of bacterial pneumonia
 Symptoms vary from a mild productive cough to acute
illness; plueral friction rub
 Site of lung abscess related to gravity and determined by
position
 Can lead to empyema, bronchopleural fistula
 Symptoms vary from a mild productive cough to acute
illness, productive cough with foul sputum, leukocytosis,
pleurisy, dyspnea, weakness, anorexia, and weight loss

31. Assessment and Diagnostic
Findings for Lung Abscess
 Pleural friction rub
 Crackles
 Chest x-ray
 Sputum culture
 Bronchoscopy
 CT of the chest

32. Medical Management of Lung
Abscess
 Prevention
 Adequate drainage of the lung
 Chest physiotherapy
 Diet high in protein and calories
 Antimicrobial therapy
 Pulmonary resection (rare)

33. Nursing Management of Lung
Abscess
 Administer IV antibiotics for 3 to 5 days, followed
by oral antibiotics for 4 to 12 weeks
 CPT
 Educate patient to perform deep breathing and
coughing exercises
 Encourage diet high in protein and calories
 Emotional support
 Promote home, community-based, and transitional
care

34. Sarcoidosis
 Occurs between 20 and 40 years of age
 More common in African American women
 Interstitial lung disease that is inflammatory,
multisystem, granulomatous with unknown origin
(any organ may be affected)
 Clinical picture depends on systems affected
including dyspnea, cough, hemoptysis, congestion,
anorexia, fatigue, and weight loss

35. Assessment and Diagnostic
Findings for Sarcoidosis
 Chest x-ray and CT scans
 Mediastinoscopy or transbronchial biopsy
 Pulmonary function test
 Arterial blood gases
 Need biopsy for definitive diagnosis

36. Management of Sarcoidosis
 Medical management
 Corticosteroids
 May have spontaneous remission without treatment
 Immune modulator
 Nursing management
 Support all medical treatments
 Patient education for medication and when to notify the primary
provider
 Chronic illness management
 Contact Foundation for Sarcoidosis Research for community
resources

37. Pleural Conditions
 Disorders that involve
 The membranes covering the lungs (visceral
pleura) and the surface of the chest wall (parietal
pleura)
 Disorders affecting the pleural space
 Pleurisy
 Pleural effusion
 Empyema
 Pulmonary edema

38. Pleurisy
 Inflammation of both layers of pleurae
 Key characteristic of pleuritic pain is its relationship to
respiratory movement
 Pleural friction rub can be heard with the stethoscope
 Diagnostic tests may include chest x-rays, sputum
analysis, thoracentesis
 Treat underlying cause, provide analgesia, teaching to
splint the rib cage when coughing

39. Pleural Effusion
 Fluid collection in pleural space usually secondary to heart failure, TB,
pneumonia, pulmonary infections
 Fever, chills, pleuritic pain, dyspnea (large effusion)
 Decreased or absent breath sounds; decreased fremitus; and a dull, flat
sound on percussion
 May have tracheal deviation away from affected side
 Chest x-ray, chest CT, and thoracentesis (fluid analysis)
 Treat underlying cause
 Pleurodesis
 Nurse must support the medial regimen and provide patient and family
education

40. Pleural Effusion

41. Empyema
 Accumulation of thick, purulent fluid in pleural space
 Complication of bacterial pneumonia or lung abscess
 Acutely ill and has signs and symptoms similar to those of an
acute respiratory infection or pneumonia
 Chest auscultation demonstrates decreased or absent breath
sounds over the affected area
 Chest CT and a diagnostic thoracentesis
 Drain fluid and administer antibiotics for 4 to 6 weeks
 Nursing management focused on psychosocial support and
lung-expanding breathing exercises

42. Acute Respiratory Failure
 Rapid deterioration to hypoxemia, hypercapnia, and
respiratory acidosis
 Impaired ventilation of perfusion mechanisms
 Early signs: restlessness, tachycardia, hypertension,
fatigue, headache
 Later signs: confusion, lethargy, central cyanosis,
diaphoresis, respiratory arrest
 Clinical manifestations: use of accessory muscles,
decreased breath sounds

43. Medical and Nursing Management
of ARF
 Identification and treatment of underlying cause
 Intubation, mechanical ventilation
 Nutritional support, enteral feedings preferred
 Reduce anxiety
 Provide patient a form of communication
 Prevent complications (turning, ROM, mouth care,
skin care)

44. Endotracheal Intubation
 Passing an endotracheal tube through the nose or mouth
into the trachea (Figure 19-5)
 Provides patent airway, access for mechanical
ventilation, facilitates removal of secretions
 Nursing care, refer to Chart 19-12
 Maintain cuff pressure between 20 and 25 mm Hg
 Intubation for no longer than 14 to 21 days (after will
require a tracheostomy)

45. Tracheotomy
 Surgical procedure in which an opening is made into
the trachea
 The indwelling tube inserted into the trachea is called
a tracheostomy tube (stoma may be temporary or
permanent) (Fig. 19-6)
 Preventing complications associated with
endotracheal and tracheostomy tubes, refer to Chart
19-13

46. Nursing Management of
Tracheostomy
 Continuous monitoring and assessment
 Maintain patency by proper suctioning
 Semi-Fowler
 Administer analgesia and sedatives
 Provide an effective means of communication
 Suctioning guidelines
 Educate patient and family about daily care and how
to prevent an emergency

47. Mechanical Ventilation
 Positive or negative pressure device to maintain
ventilation and oxygenation for a prolonged period
 General indications, refer to Chart 19-14
 Classification of ventilators
 Ventilator modes, see Figure 19-8
 Ventilator settings, refer to Chart 19-15
 Weaning the patient from the ventilator, refer to
Chart 19-19

48. Noninvasive Positive-Pressure
Ventilation
 Method of positive-pressure ventilation that can be
given via facemasks that cover the nose and mouth,
nasal masks, or other oral or nasal devices such as the
nasal pillow
 Eliminates need for endotracheal intubation or
tracheostomy
 Continuous positive airway pressure (CPAP)
 Bilevel positive airway pressure (BiPAP)
 Indications: respiratory arrest, serious dysrhythmias,
cognitive impairment, head/facial trauma

49. Assessment of the Patient Receiving
Mechanical Ventilation
 Systematic assessment of all body systems:
 In-depth respiratory assessment including all
indicators of oxygenation status
 Neurologic status
 Effective coping and emotional needs
 Comfort level and ability to communicate needs
 Assessment of the equipment and settings
 Alarm fatigue

50. Problems/Complications of the Patient
Receiving Mechanical Ventilation
 Ventilator problems
 Alterations in cardiac function
 Barotrauma and pneumothorax
 Pulmonary infection and sepsis
 Delirium and post-intensive care syndrome

51. Planning and Goals for the Patient
Receiving Mechanical Ventilation
 Goals include:
 Maintenance of patent airway
 Optimal gas exchange
 Absence of trauma or infection
 Attainment of optimal mobility
 Adjustment to nonverbal methods of
communication
 Successful coping measures

52. Nursing Interventions for the Patient
Receiving Mechanical Ventilation
 Enhancing gas exchange
 Promoting effective airway clearance
 Preventing injury and infection
 Promoting optimal level of mobility
 Promoting optimal communication
 Promoting coping ability

53. Nursing Intervention: Enhancing
Gas Exchange
 Judicious use of analgesics to relieve pain without
suppressing respiratory drive
 Frequent repositioning to diminish the pulmonary
effects of immobility
 Monitor for adequate fluid balance:
 Assess peripheral edema
 I&O and daily weights
 Administer medications to control primary disease

54. Nursing Intervention: Promoting
Effective Airway Clearance
 Assess lung sounds at least every 2 to 4 hours
 Measures to clear airway: suctioning, CPT, position
changes, promote increased mobility
 Humidification of airway
 Administer medications
 Bronchodilators
 Mucolytics
 Suctioning only if excessive secretions

55. Nursing Intervention: Preventing
Injury and Infection
 Infection control measures
 Tube care
 Cuff management
 Oral care
 Elevation of HOB

56. Other Interventions for the Patient
Receiving Mechanical Ventilation
 ROM and immobility
 Communication methods
 Stress reduction techniques
 Interventions to promote coping
 Include in care: family teaching, and the emotional
and coping support of the family
 Nutrition
 Home and transitional care, refer to Charts 19-17 and
19-18

57. Acute Respiratory Distress
Syndrome (ARDS)
 Mortality rate of 27% to 50%
 Characterized by sudden, progressive pulmonary edema,
increasing bilateral lung infiltrates visible on chest x-ray,
and absence of an elevated left atrial pressure
 Refer to Figure 19-9
 Rapid onset of severe dyspnea and V/Q mismatch <72
hours after precipitating event
 Classified by severity of hypoxemia that does not respond
to supplemental oxygen therapy
 Crackles, intercostal retractions and BNP levels

58. Medical Management of ARDS
 Identification and treatment of underlying cause
 Intubation, mechanical ventilation with PEEP to
keep alveoli open
 Treat hypovolemia to keep hemodynamically stable
 Prone positioning is best for oxygenation, frequent
repositioning to safeguard integumentary system
 Nutritional support, enteral feedings preferred
 Reduce anxiety, sedation, paralysis
 Supportive care

59. Pulmonary Vascular Disorders
 Pulmonary embolism
 Pulmonary edema
 Pulmonary hypertension
 Pulmonary arterial pressure >30 mm Hg with heart
failure
 Cor pulmonale

60. Pulmonary Emboli
 Obstruction of pulmonary artery or branch by blood
clot, air, fat, amniotic fluid, or septic thrombus
 Inflammatory process obstructs area, results in
diminished or absent blood flow
 Bronchioles constrict, further increasing pulmonary
vascular resistance, pulmonary arterial pressure, and
right ventricular workload
 Ventilation–perfusion imbalance, right ventricular
failure, shock occur

61. Risk Factors for Pulmonary Emboli
 Immobility, venous stasis
 Hypercoagulability
 Venous endothelial disease
 Heart disease, trauma,
postoperative/postpartum, diabetes, COPD
 Obesity, oral contraceptive use
 Previous history of thrombophlebitis

62. Prevention and Treatment of Pulmonary
Emboli
 Prevention, refer to Chart 23-10
 Exercises to avoid venous stasis
 Early ambulation
 Sequential compression devices (SCDs)
 Treatment
 Refer to Figure 23-6
 Anticoagulation, thrombolytic therapy

63. Umbrella Filter

64. Occupational Lung Disease:
Pneumoconioses
 Includes asbestosis, silicosis, and coal workers’ pneumoconiosis
 Refers to a nonneoplastic alteration of the lung resulting from
inhalation of mineral or inorganic dust
 Preventable, not treatable
 Reduce exposure, protective gear/devices
 Role of nurse is to be the employee advocate and provide health
education on preventive measures to reduce lung injury
 Assessment: exposure to agent, length of time exposed to onset
of symptoms, congruence of symptoms
 Refer to Table 19-6

65. Lung Cancer
 Leading cause of cancer death in the United States
 >85% caused by cigarette smoke
 Classification (cell type): 13% SCLC and 84% NSCLC
tumors
 Staging: size, location, lymph node involvement,
metastasis (refer to Table 19-7)
 Often asymptomatic until late stage
 Treatment:
 Surgery, radiation, chemotherapy, immunotherapy
 Nurse navigators (palliative care)

66. Nursing Care of the Patient with
Lung Cancer
 Strategies to ensure relief of pain and discomfort and
prevent complications
 Managing symptoms
 Dyspnea, fatigue, nausea and vomiting, anorexia
 Relieving breathing problems
 Airway clearance techniques
 Reducing fatigue
 Psychological support

67. Preoperative Management of the
Patient Having a Thoracotomy
 Assessment and diagnosis
 Improving airway clearance
 Educating the patient
 Forced expiratory technique, diaphragmatic and
pursed-lip breathing
 Relieving anxiety

68. Postoperative Management of the Patient
Having a Thoracotomy
 Vital signs checked frequently, monitor for
complications
 Oxygen
 Elevate HOB 30 to 45 degrees
 Careful positioning
 Medication for pain
 Mechanical ventilation
 Chest drainage
 Refer to Charts 19-23 and 19-25

69. Chest Trauma
 Blunt trauma
 Sternal, rib fractures
 Flail chest
 Pulmonary contusion
 Penetrating trauma
 Pneumothorax
 Simple or
spontaneous
 Traumatic
 Tension

70. Flail Chest

71. Open Pneumothorax and Tension
Pneumothorax

72. Chest Tube Drainage System
 Chest drainage systems have: (Refer to Figures 19-14 and 19-
15)
 A suction source
 A collection chamber for pleural drainage
 And a mechanism to prevent air from reentering the chest
with inhalation
 Used in removal of air and fluid from the pleural space and
re-expansion of the lungs
 Wet (water seal) or dry suction control
 Refer to Table 19-8