Presentation of pulmonary nursing for lungs disease

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PULMONARY NURSING
Farhana Nisar
Lecturer
Dow Institute of Nursing & Midwifery
ADULT HEALTH NURSING –II
GENERIC BSCN YEAR-II SEMSETER IV

OBJECTIVES:
 By the end of the session learners will be able to:
 Review the anatomy & physiology of upper respiratory tract
 Discuss the causes, Pathophysiology and manifestation of the following Respiratory tract disorders
 Discuss the diagnostic, medical and surgical management of the below mentioned disorders
 Apply nursing process including assessment, planning, implementation and evaluation of care
provided to the clients with respiratory disorders
 Develop a teaching plan for a client experiencing disorders of the Respiratory tract.

Upper respiratory tract infections:
 Sinusitis
 Pharyngitis
 Tonsillitis
Lower respiratory tract infections:
 Influenza
 Pneumonia
 Pulmonary T.B
 Lung Abscess
Obstructive lung diseases:
 Asthma
 COPD
 Lung cancer
 Acute Respiratory failure
 Acute Respiratory Distress Syndrome
 Chest trauma

MAIN FUNCTIONS OF RESPIRATORY SYSTEM
 Gas exchange: Oxygen (O₂) into blood, Carbon dioxide (CO₂) out.
 Acid-base balance: Regulates blood pH by controlling CO₂ levels.
 Voice production: Larynx (voice box).
 Olfaction (smell): Nasal cavity receptors.
 Protection: Filters, warms, and moistens incoming air.

MAJOR STRUCTURES
Part Function
Nose/Nasal cavity Filters, warms, humidifies air.
Pharynx Passage for air and food.
Larynx Voice production; protects airway during swallowing.
Trachea Windpipe; carries air to lungs.
Bronchi Main airways branching into each lung.
Bronchioles Smaller branches inside lungs.
Alveoli Tiny sacs for gas exchange (O and CO ).
₂ ₂

MECHANICS OF BREATHING
Inhalation:
 Diaphragm contracts (moves down) lungs expand air in.
➔ ➔
Exhalation:
 Diaphragm relaxes lungs recoil air out.
➔ ➔
Accessory muscles:
Used when breathing is labored (e.g., during respiratory distress).

 Nose
 Pharynx (throut)
 Naso pharynx
 Oropharynx
 Hypopharynx (laryngopharynx)
 Larynx (voice box)
UPPER RESPIRATORY TRACT

 Trachea
 Bronchi (Primary, Secondary, Tertiary)
 Lung (Bronchioles, alveoli)
LOWER RESPIRATORY TRACT

 External (pulmonary) respiration
 exchange of O2 and CO2 between respiratory surfaces
and the blood (breathing)
 Internal respiration
 exchange of O2 and CO2 between the blood and cells
 Cellular respiration
 process by which cells use O2 to produce ATP
RESPIRATION

GAS PARTIAL PRESSURES
Gas
Atmospheric
air
Alveolar air Exhaled air
O2
21%
159 mmHg
14%
104 mmHg
16%
120 mmHg
N2
78%
597 mmHg
75%
569 mmHg
75%
566 mmHg
CO2
0.04%
0.3 mmHg
5%
40 mmHg
4%
27 mmHg
H2O
0.5%
4 mmHg
6%
47 mmHg
6%
47 mmHg

 Pulmonary respiration
 Internal respiration

GENRAL SYMPTOMS OF RESPIRATORY DISEASE
Hypoxia : Decreased levels of oxygen in the tissues
Hypoxemia : Decreased levels of oxygen in arterial blood
Hypercapnia : Increased levels of CO2 in the blood
Hypocapnia : Decreased levels of CO2 in the blood
Dyspnea : Difficulty breathing
Tachypnea : Rapid rate of breathing
Cyanosis : Bluish discoloration of skin and mucous membranes due to poor oxygenation of the blood
Hemoptysis : Blood in the sputum

UPPER RESPIRATORY DISEASES
 Common cold
 Sinusitis
 Nasal polyps
 Snoring and obstructive sleep apnea
 Hay Fever (seasonal allergic rhinitis)
 Tonsillitis, pharyngitis, laryngitis
 Influenza

LOWER RESPIRATORY DISEASES
 Chronic obstructive pulmonary disease
 Bronchitis
 Asthma
 Emphysema
 Pneumonia
 Pleurisy
 Pulmonary tuberculosis
 Cancer
 Cystic fibrosis

COMMON COLD
Common viral pathogens for the “common cold” are rhinovirus, adenovirus and coronavirus.
 Readily spread from person to person via respiratory secretions.
 Manifestations of the common cold include:
 Rhinitis: Inflammation of the nasal mucosa
 Sinusitis :Inflammation of the sinus mucosa
 Pharyngitis : Inflammation of the pharynx and throat
 Headache
 Nasal discharge and congestion

INFLUENZA VS COMMON COLD
 Influenza (flu) and the common cold are both respiratory illnesses caused by different viruses. While
they share some similarities in symptoms, there are key differences between the two:

Aspect Influenza (Flu) Common Cold
Causative Agent Influenza viruses, mainly types A and B.
Caused by multiple viruses — mainly
rhinoviruses, but also coronaviruses and
adenoviruses.
Onset & Severity Sudden onset with more intense symptoms. Gradual onset with milder symptoms.
Common Symptoms
High fever, chills, severe body aches, fatigue, dry cough, sore
throat, headache; GI upset may occur (esp. in children).
Sneezing, runny or stuffy nose, mild sore
throat, mild cough, and general malaise.
Fever High-grade fever (often >101°F / 38.5°C) is typical. Low-grade or no fever.
Complications
May cause serious complications: pneumonia, secondary
bacterial infections, or worsening of chronic illnesses (e.g.,
asthma, COPD).
Rare complications; usually self-limiting.
Duration Lasts 1–2 weeks, but fatigue may persist longer.
Lasts 3–7 days, with mild lingering cough or
congestion.
Vaccination Annual vaccination No vaccine available.
Transmission
Highly contagious — spreads via droplets, direct contact, and
contaminated surfaces.
Spread similarly but less contagious overall.
Seasonality
Peaks in late fall through winter; follows a predictable seasonal
pattern.
Occurs year-round, more common in fall and
spring.

PHARYNGITIS
Pharyngitis is inflammation of the pharynx, which is in the back of the throat, between the tonsils and
the voicebox (larynx).
Causes: Viral (most common, e.g., common cold, flu) or bacterial (e.g., Streptococcus).
Symptoms: Sore throat, difficulty swallowing, fever, swollen lymph nodes.
Diagnosis: Throat culture (for bacterial), rapid strep test, clinical evaluation.
Treatment: Antibiotics (for bacterial), pain relievers, throat lozenges, plenty of fluids, rest.

SINUSITIS
 Definition: Inflammation of the sinus cavities, often caused by infection.
 Causes: Viral or bacterial infections, allergies, nasal polyps, deviated septum.
 Symptoms: Facial pain/pressure, nasal congestion, discolored nasal discharge, headache, cough.
 Diagnosis: Clinical evaluation, imaging (CT or MRI), nasal endoscopy.
 Treatment: Antibiotics (if bacterial), pain relievers, nasal decongestants, saline nasal irrigation.

LARYNGITIS
 Laryngitis is the inflammation of the larynx (voice box), often resulting in hoarseness or loss of voice.
 Causative agent: Viral infection, Irritants, GERD, Allergies.
 Symptoms: Hoarseness, Sore or Irritated Throat, Dry Cough, Throat Pain, Difficulty Swallowing
 Treatment: Voice Rest, Hydration, Humidification, Avoiding irritants, treat underlying cause (such as
treating GERD or managing allergies)

TONSILLITIS
 Inflammation of the tonsils, which are two masses of tissue located at the back of the throat. most
commonly caused by viral or bacterial infection.
 A significant episode of tonsillitis is defined by one or more of the following criteria:
(1) A temperature greater than 101°F;
(2) Enlarged or tender neck lymph nodes;
(3) Pus material coating the tonsils; or
(4) a positive strep test.

CAUSES
 Bacterial Infections: Most commonly caused by Streptococcus bacteria (Strep throat), but can also
result from other bacteria.
 Viral Infections: Viruses such as adenovirus or Epstein-Barr virus can cause viral tonsillitis.
 Fungal Infections: Rarely, fungal infections may lead to tonsillitis.
 Chronic Tonsillitis: Recurrent or persistent inflammation of the tonsils.

SYMPTOMS
 Sore Throat: Pain or discomfort in the throat.
 Difficulty Swallowing: Painful or uncomfortable swallowing.
 Fever: Elevated body temperature, especially in bacterial tonsillitis.
 Enlarged Tonsils: Tonsils may appear red and swollen.
 White or Yellow Patches: Presence of pus on the tonsils in bacterial infections.
 Headache and Earache (otalgia): Associated with the inflammation

DIAGNOSIS
 Throat Examination: Visual inspection of the throat to assess the appearance of the tonsils.
 Throat Culture: To identify the causative organism, especially in cases of suspected bacterial tonsillitis.
 Tonsillitis usually spreads from person to person by contact with the throat or nasal fluids of someone
who is already infected.

TREATMENT
 Antibiotics: Prescribed for bacterial tonsillitis to eliminate the infection.
 Pain Relievers: Over-the-counter pain relievers like acetaminophen or ibuprofen for symptom relief.
 Throat Lozenges or Sprays: Soothing agents for throat discomfort.
 Hydration and Rest: Adequate fluid intake and rest to support recovery.
 Gargle with warm salt water

PNEUMONIA
 Inflammation of the lung affecting the alveoli
 Alveoli
 Tiny air sacs of the lungs which allow for gas exchange
 Alveoli become filled with pus and liquid

RISK FACTOR
 These risk factors include:
 Prior infection: flu or cold
 Weak immune system: Elderly, infants, HIV, autoimmune medications
 Lung problems: COPD, asthma, smokers
 Post-opt patient: not coughing deep breathing

LOBAR PNEUMONIA
 Lobar pneumonia is inflammation of a section, often an entire lobe, of the
lung.
 It is most often caused by the pneumococcus bacterium, Streptococcus
pneumoniae.

BRONCHOPNEUMONIA
 Obstruction of the small bronchi
 Due to infection or by aspirated gastric contents
 Diffuse pattern of inflammation on x-ray

INTERSTITIAL PNEUMONIA:
In which the inflammatory process is confined within the alveolar walls,
peribronchial & interlobular tissues.

 Bacteria (Typical): most common cause of pneumonia especially in community-acquired is caused by
Streptococcus pneumoniae
 Atypical Bacteria: Mycoplasma pneumoniae that causes “walking pneumonia” which is a milder form
of pneumonia that isn’t severe enough to require complete bed rest
 Virus: influenza, RSV most common causes of PNA in children
 Fungi: least common…most likely to affect people with severe suppressed immune system and
typically is contracted from outside in nature from plants, animals etc.

TYPES OF PNEUMONIA
 Community-acquired Pneumonia (most occurring): patient obtains the germs that causes the
pneumonia OUTSIDE of the healthcare system hence in the community.
Criteria: patient must have developed symptoms within 48 hours after admission
 Hospital-acquired Pneumonia: patients who are on mechanical ventilation at major risk…it is hard to
treat because the bacteria tend to be resistant to antibiotics and more likely a bacteria cause.
Criteria: patient must have developed 48-72 hours after admission

DIAGNOSED
 Chest x-ray “Patchy infiltrates”
 Sputum culture
 Elevated labs: PCO2 >45
 Increased WBC
 Coarse crackles, rhonchi, or bronchial in the peripheral lung fields this represents lung consolidation

SIGNS & SYMPTOMS OF PNEUMONIA
 Productive cough
 Pleuritic pain (chest pain that is caused by coughing, breathing etc.)
 Mild to high Fever (bacteria cause produces highest fever….. greater than 104’F)
 Oxygen saturation decreased (want >90%) will need supplementary oxygen
 Increase heart rate and respirations
 Crackles
 Work of breathing
• Retractions
• Tracheal tug
• Nasal Flaring
• Grunting
• Head bobbing

NURSING INTERVENTIONS FOR PNEUMONIA
 Maintain airway
• Suction
• Monitor SpO2
 Monitor breathing
• Assess for increased work of breathing
• Provide support as needed
• Humidified oxygen
 Maintain circulation
• Monitor for dehydration
• IVF if unable to tolerate PO
 Chest physiotherapy
 Antipyretics
 Analgesia
 Cough suppressant
 Expectorants
 Antibiotics if bacterial
 Isolation

 Education on prevention: Up-to-date Vaccinations (Pneumovax every 5 years for patients 65+ and 19-
64 years old with risk factors and annual flu shot)
 Education about stop smoking, avoid people who are sick, hand-washing
 Keeping head of bed elevated greater than 30 degree for immobile patients to prevent aspiration
especially while eating and after meals along with frequent turning.

COMPLICATIONS OF PNEUMONIA
 Fibrosis- scarring can occur when the walls of the alveoli thicken and become stiff
 Bronchitis – A lung infection that causes inflammation in the bronchi.
 Lung abscesses – A collection of pus in one or more lungs.
 Empyema – An accumulation of pus in the space between the lungs and chest wall.]
 Pleural Effusion – Fluid that fills the pleural space (space between the lung itself & the chest wall). This prevents full
lung expansion, resulting in decreased gas exchange.
Signs of pleural effusion memory trick:
 During inhalation = Chest pain
 Dyspnea
 Diminished breath sounds
 Dull resonance on percussion

PLEURISY
 Inflammation of the pleural membranes that occurs as a complication of various lung
diseases, like pneumonia or tuberculosis.
 May also develop from an injury or tumor formation.
 Pleurisy is extremely painful; a sharp, stabbing pain accompanies each inspiration.

EMPYEMA
 It is an accumulation of infected purulent exudates (pus) in the pleural
cavity.
 It is the most common complication of staphylococcal pneumonia that
requires thoracentesis.

TUBERCULOSIS
 It’s a contagious bacterial infection caused by
mycobacterium tuberculosis that affects
mainly the lungs BUT it can also affect the
kidneys, brain, spine, joints, and liver.

 It’s acid-fast (it stains bright red with the acid-fast staining smear)
 It’s an AEROBIC bacteria (so it LOVES oxygen and must have it to grow):
 Tuberculosis is spread through the air (airborne precautions). The bacteria is very small, so it can
suspend itself in the air….it’s different than droplet type of infections.

RISK FACTORS FOR DEVELOPING TUBERCULOSIS
 Tight living quarters: long-term health care facilities, homeless shelters, prisons etc.
 Below or at the poverty line (poor…homeless)
 Refugees (high incidence of TB in their home country)
 Immune system issues: HIV
 Substance abusers (IV drugs, ETOH)
 Kids less than the age of 4-5….weak immune systems

 Latent tuberculosis infection (LTBI): the mycobacterium tuberculosis bacteria is lying dormant
and being controlled by the immune system….it’s encapsulated
 Therefore, the person is: NOT contagious and does NOT have signs and symptoms, will have a
normal chest x-ray, and negative sputum test
 Only sign the person will have is a positive TB skin test or blood test. This means that the immune
system has responded to the bacteria.
 According to the CDC, 5-10% of patients who do NOT receive treatment for latent TB will develop
active TB at some point.

 Active TB: the immune system isn’t able to contain the bacteria so it takes over (ex: weaken
immune system due to HIV). Most cases of active TB are due to a latent case that turns into an active
case
 Therefore, the person is: CONTAGIOUS AND HAS SIGNS/SYMPTOMS, positive Purified Protein
Derivative or blood test, will have an ABNORMAL chest x-ray and positive sputum culture (AFB).
 The bacteria can now spread via the lymphatic system throughout the body and affect other areas of
the body like the brain, spine, joints etc.

SIGNS AND SYMPTOMS OF TUBERCULOSIS (ACTIVE)
 Most patients are asymptomatic until they reach the active stage
 Cough that lasts three weeks or more
 Coughing up blood
 Fever
 Night sweats
 Fatigue
 Unintentional weight loss
 Chills
 Loss of appetite
 Chest pain, or pain with breathing or coughing

TESTING FOR TUBERCULOSIS
1) Purified Protein Derivative (PPD) tuberculin skin test (also called
Mantoux Test, TST, TB skin test)
 purified protein derivative is injected with a tuberculin needle on
the inner part of the forearm…after the injection it will look like
this.
 It is read in 48-72 hours
 A positive result doesn’t necessarily mean the patient has an active
infection of TB. It just means they have been exposed to it.
 Induration is a hard or swollen area that is raised on the skin. This
will be measured in millimeters (mm).
 Redness is not measured…the induration is measured

Criteria for positive results
• 15 millimeters (mm) or more: Positive in all persons
(doesn’t matter if the person does not have any risk factors)
• 10 mm or more: positive if the person is an immigrant, IV drug
user, working or living in tight living quarters, child less than 4
• 5 mm or more: positive if person have HIV, in contact with
someone with TB, organ transplant patient, or
immunosuppressed

2) Interferon-Gamma Release Assays (IGRA Test)
3) Sputum: (AFB “acid-fast bacilli” Smear): three different sputum specimens on 3 different days
4) Chest x-ray

NURSING INTERVENTIONS AND TREATMENTS FOR TUBERCULOSIS
 Initiate airborne precautions:
 Negative pressure room (door closed at all times)
 Must wear a respirator when providing care
 Strict hand hygiene
 Patient Education at home: strict compliance for medication(6 months to a year), wear surgical mask

 DOT (directly observed therapy)
 Most common drug regime used includes four drugs:
1) Pyrazinamide: bactericidal effect (kills the bacteria)
 take with food
 Monitor uric acid level, liver and kidney function
2) Ethambutol: stop RNA synthesis and is bacteriostatic (stops the bacteria from reproducing)
 Can inflame optic nerve (monitor for blurred or color changes in vision)
 Peripheral neuropathy (damage to peripheral nerves): report numbness or burning in the hands or feet
3) Rifampin: kills the bacteria by stopping RNA-polymerase
 Educate about turning body fluids orange
 watch for jaundice, issues bleeding etc.)
4) Isoniazid (INH): kills the bacteria and stops it growth
 decrease Vitamin B6 levels monitor for tingling in extremities, tried, irritable, depressed (peripheral neuropathy

ASTHMA
 A respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing.
• Chronic inflammation of bronchi and bronchioles.
• Excess mucus.
• Result of an allergic reaction or hypersensitivity.

PATHOPHYSIOLOGY
 Asthma attack is triggered by allergens or irritants.
 Bronchi and bronchioles become inflamed and constricted.
 Airflow decreases, causing chest tightness and shortness of breath.
 Gas exchange is impaired: low oxygen in, CO₂ builds up → respiratory acidosis.
 Mucosal lining becomes inflamed; goblet cells produce excess mucus.
 Mucus further blocks airways, leading to coughing and wheezing.

 Individuals with asthma produce large amounts of IgE antibodies.
 IgE attaches to mast cells found in various tissues.
 When exposed to triggers (e.g., pollen), allergens bind to IgE on mast cells.
 This causes the release of inflammatory mediators: histamine, leukotrienes,
and eosinophilic chemotactic factor.

 Asthmatic response occurs in two phases:
 Early phase – immediate bronchoconstriction and symptoms.
 Late phase – delayed inflammation and worsening of symptoms.

Early phase of asthma:
The early phase of asthma is characterized by:
a. marked constriction of bronchial
airways (bronchospasm)
b. edema of the airways
c. production of excess mucus.

Late phase of asthma:
 The late phase of asthma occurs hours after the initial symptoms.
 It involves an inflammatory response mainly driven by eosinophils.
 Eosinophils trigger mast cell degranulation and attract more white blood cells.
 Neutrophils and lymphocytes also enter the airway, increasing inflammation.

CAUSE
 Unknown, but may be genetically or environmental.
 Certain “triggers” can lead to an asthma attack:
Environment: smoke, pollen, pollution, perfumes, dander, dust mites, pests (cockroaches), cold and dry
air, mold
Body Issue: respiratory infection, GERD, hormonal shifts, exercise-induced
Intake of Certain Substances: drugs (beta adrenergic blockers that are nonselective), NSAIDS, aspirin,
preservatives (sulfites)

DIAGNOSTIC TESTS:
 Pulmonary Function Tests (PFTs): Spirometry measures airflow obstruction.
 Peak Expiratory Flow (PEF): Monitors the effectiveness of asthma management.
 Chest X-ray: May be done to rule out other respiratory conditions.

PULMONARY FUNCTION TEST (PFT):
 Diagnostic test to assess lung function and measure the volume and flow of air during breathing.
Purpose:
 Evaluate respiratory conditions like asthma, chronic obstructive pulmonary disease (COPD), and restrictive lung
diseases.
 Guides treatment planning and evaluates treatment effectiveness.
Components:
 Spirometry: Measures lung volume and airflow.
 Peak Expiratory Flow (PEF): Measures maximum airflow during forced expiration.
 Lung Volumes: Assesses total lung capacity, vital capacity, and residual volume.
Procedure:
 Involves breathing into a spirometer connected to a computerized system.

EARLY WARNING SIGNS
 Shortness of breath
• Unable to speak
 Evaluate how many words they can say before taking a breath
• Cough
 Increased work of breathing
• Retractions
• Tracheal tug
• Head bobbing
 Wheeze (High-pitched sound during expiration due to narrowed airways. (auscultate…expiratory wheezing and
can progress to inspiration in severe cases)
 Prolonged expiration
 Can’t hear any breath sounds? Complete obstruction.
 Reduced peak flow meter reading

NURSING INTERVENTIONS FOR ASTHMA
 Position in high Fowler’s to help with ease of breathing
 Administer bronchodilators as ordered by MD
 Administer oxygen (oxygen saturation 95-99%)
 Assess peak flow meter reading (watch for numbers less than 50% of the patient’s personal best
reading)
 Monitor skin color and for any retractions of the chest
 Current peak flow meter reading numbers (if the patient uses this device…ask patient (if they know)
their personal best reading and current readings, and medications they’ve taken

MEDICATIONS USED TO TREAT ASTHMA
 Bronchodilators: opens the airways to increase air flow
 Beta-agonists
 Anticholingerics
 Theophylline
Commonly given as inhaled routes for asthma…theophylline is oral

Short-acting beta agonist (Albuterol):
 inhaler or nebulizer: used as the fast acting relief during an asthma attack or prior to exercise for
asthma that is exercise-induced NOT for daily treatment
 ***(if patient is using their inhaler more than 2 times a week, then the patients asthma plan needs to
be readjusted because their asthma is not under good control).

 Long-acting beta agonists (Salmeterol, Symbicort…this drug is a combination of a long-acting beta
agonist AND corticosteroid)
 NOT for an acute asthma attack
 ****Side effects of these medications: tachycardia, feeling nervous/jittery, monitor heart rhythm for
dysrhythmia

Anticholinergics:
 Ipratropium: a bronchodilator that also is short-acting and relaxes airway….used when a patient can’t
tolerate short-acting beta agonist.
 Tiotropium: a bronchodilator that is long-acting
 These drugs can cause dry mouth….. “sugarless candy helps with this”

 Theophylline: given PO
 not as common because of possible toxicity and maintaining blood levels of 10-20 mcg/mL
 AVOID consuming products with caffeine while taking this medication…WHY? Caffeine has the same
properties as Theophylline, which can increase the toxic effects of the medication.
 *****Always administer the bronchodilator FIRST and then 5 minutes later the corticosteroid.
 If not responding to treatment, may need intubation and mechanical ventilation.

COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)
 Pulmonary disease that causes chronic obstruction of airflow from the lungs
 Characterized by long-term inflammation and scarring in the airways, which lead to difficulty
breathing and shortness of breath.

TYPES OF COPD INCLUDE:
 Emphysema “pink puffers”: alveoli sacs lose their ability to inflate and deflate due to an
inflammatory response in the body.
 Chronic bronchitis “blue bloaters”: is a disease of the airways, is defined as the presence of cough and
sputum production for at least 3 months in each 2 consecutive years.

Chronic bronchitis “blue bloaters”:
 The name “blue bloaters” is due to cyanosis from “hypoxia”
 Bloating from edema AND increase in lung volume. The bloating is from the effects of the lung disease on
the heart which causes right-sided heart failure.
 In chronic bronchitis, the bronchioles become damage—leads to thick and swollen accompany by more
sputum production.
 Person is unable to exhale so, when a person take another breath in, it will increase the air volume----
leads to hyperinflation.
 Low oxygen and more carbon dioxide leads to cyanosis. To compensate, the body increase RBC
production.

 Emphysema “pink puffers”:
 The name comes from hyperventilation (puffing to breathe)
 Pink complexion (they maintain a relatively normal oxygen level due to rapid breathing) rather than
cyanosis as in chronic bronchitis.
 In emphysema, the alveoli sacs lose their ability to inflate and deflate so inhaled air starts to get
trapped in the sacs and this causes major hyperinflation of the lungs because the patient is retaining
so much volume.
 Hyperinflation causes the diaphragm to flatten.
 In order to fully exhale, the patient starts to hyperventilate and use accessory muscles this leads to
the barrel chest.

SIGN & SYMPTOMS
Chronic bronchitis “Blue bloater”
 Big & Blue skin “Cyanosis” (hypoxia)
 Long-term “chronic” COUGH & Sputum
 Unusual lung sounds: Crackles & Wheezes
 Edema peripherally (due to cor pulmonale)
Emphysema “Pink puffer”
 Pink skin & Pursed-Lip breathing
 Increased chest “Barrel Chest”
 No chronic cough (minimal)
 Keep Tripoding

Feature Chronic Bronchitis (Blue Bloaters) Emphysema (Pink Puffers)
Main Cause Inflammation & mucus in bronchi Alveolar wall destruction
Oxygen Level Low (hypoxia) → cyanosis (blue) Near normal (due to
hyperventilation)
Carbon Dioxide Level High (CO₂ retention) Initially normal or low, may rise later
Skin Color Cyanotic (blue-tinged) Pink complexion
Breathing Pattern Less effort initially, but shallow Hyperventilation with pursed lips
Body Appearance Overweight with edema (bloating) Thin with barrel chest
Chest Shape Normal to slightly enlarged Barrel-shaped chest
Heart Involvement Common right-sided heart failure Less common
Cough Frequent, productive (sputum) Mild, dry cough
Airway Obstruction Due to mucus and inflammation Due to alveolar damage and air
trapping

NURSING INTERVENTIONS FOR COPD
Administer
 oxygen as prescribed in low amounts 1-2 liters
 keep oxygen saturation (88%-93%)
 Fluid management
Perform
 A history and physical exam to assess the client’s respiratory status
 Respiratory management

Monitor
 Oxygen saturation levels
 Breathing patterns
 Pulse rate
 Chest sounds (may need suction)
 Respiratory rate (and depth)
 Lung function

COPD MEDICATIONS
 Bronchodilators are used to open up the lung airways for better breathing.
 Anticholinergics reduce inflammation in the airways and make it easier to breathe.
 Corticosteroids reduce inflammation in the airways and make it easier to breathe.

ARDS (ACUTE RESPIRATORY DISTRESS SYNDROME)
 ARDS is a severe type of respiratory failure caused by damage to the alveolar-capillary membrane,
leading to fluid leakage into the alveoli and poor oxygen exchange.

PATHOPHYSIOLOGY:
 Injury to alveolar-capillary membrane → ↑ permeability
 Fluid, protein, and cells leak into alveoli → pulmonary edema
 Surfactant dysfunction → alveolar collapse
 ↓ Lung compliance and gas exchange
 Severe hypoxemia resistant to oxygen therapy

PHASES OF ARDS
1. Exudative Phase (Day 1–7)
 Begins within 24 hours after lung injury
 Damage to alveolar-capillary membrane
 Fluid, protein, and inflammatory cells leak into alveoli
 Leads to pulmonary edema, inflammation and impaired gas exchange

2. Proliferative Phase (Day 7–14)
 Body attempts to repair the lung
 Fluid is reabsorbed, but lung tissue becomes thick and fibrotic
 Decreased lung compliance
 Worsening hypoxemia due to stiff lungs

3. Fibrotic Phase (After Day 14–21)
 Severe fibrosis (scarring) of lung tissue
 Alveoli are destroyed and replaced with fibrous tissue
 Markedly decreased lung compliance
 Dead space increases → persistent hypoxemia and poor prognosis, Long-term ventilator dependence

SIGNS AND SYMPTOMS OF ARDS
 Dyspnea, tachypnea.
 Hypoxemia: unresponsive to oxygen therapy (refractory hypoxemia)
 Accumulation of fluids in alveoli and around alveolar spaces.(Bilateral crackles on auscultation)
 Changes in blood pH due to altered blood levels of CO2.
 Respiratory failure.

DIAGNOSTIC TOOL
Pulmonary Artery Wedge Pressure (PAWP) in ARDS Diagnosis
 Purpose: Helps differentiate the cause of pulmonary edema — whether it's due to non-cardiogenic (like ARDS) or cardiogenic
(like heart failure) origin.
 Procedure: A pulmonary artery catheter (Swan-Ganz catheter) is inserted, and the balloon is inflated to measure pressure in the
left atrium via the pulmonary circulation.
 Normal PAWP: 6–12 mmHg
 In ARDS: PAWP is typically ≤ 18 mmHg, indicating that the pulmonary edema is not due to heart failure (non-cardiogenic).
 In Cardiogenic Pulmonary Edema: PAWP is > 18 mmHg, suggesting fluid overload due to left-sided heart failure.

NURSING INTERVENTIONS FOR ARDS :
Maintain Airway/Respiratory Function:
 Mechanical Ventilation with PEEP (Positive End-Expiratory Pressure).
 Adjust PEEP levels (typically 10-20 cm of water) to open collapsed sacs, improve gas exchange, and prevent
fluid accumulation.
 Monitor for intrathoracic pressure issues, decreased cardiac output, and potential lung complications.
Monitoring ABGs (Arterial Blood Gases):
 Regularly assess blood gas levels to evaluate oxygenation and acid-base balance.
Positioning for Respiratory Function:
 Prone Positioning: Turning the patient onto their belly.
 Improves oxygen levels by alleviating pressure on the back of the lungs.
 Facilitates drainage in areas inaccessible in the supine position.
 Aids in perfusion, ventilation, secretion movement, and atelectasis prevention.

Abnormal collection of air or gas in the pleural space separating
the lung from the chest wall which may interfere with normal
breathing.
Pneumothorax

PRIMARY PNEUMOTHORAX:
 Seen in previously healthy lung tissue which is free of any underlying disease.
 It is believed to occur due to rupture of sub pleural blebs at the apex of the lung.
 Some of the causes are a family history and cigarette smoking.

2. SECONDARY PNEUMOTHORAX:
 Is pneumothorax seen in previously diseased lung tissue.
 It happens as a complication of COPD, asthma, cystic fibrosis, tuberculosis,

1. Open or communicating pneumothorax
or Traumatic Pneumothorax:
• Usually involves a traumatic chest wound.
• Air enters the pleural cavity from the atmosphere.
2. Closed or spontaneous pneumothorax
• Occurs when air “leaks” from the lungs into the
pleural cavity.
• May be caused by lung cancer, rupture, pulmonary
disease.
• The increased plural pressure prevents lung
expansion during inspiration and the lung remains
collapsed.
Types of pneumothorax:

IATROGENIC PNEUMOTHORAX:
 May be seen after procedures like thoracocentesis, pleural biopsy, subclavian or internal jugular vein
catheter placement, percutaneous lung biopsy, bronchoscopy with transbronchial biopsy and positive
pressure ventilation.

3.Tension pneumothorax
A condition in which there is a one-way
movement of air into but not out of the pleural
cavity.
• May involve a hole or wound to the pleural
cavity that allows air to enter and the lung to
collapse. Upon expiration, the hole or opening
closes, which prevents the movement of air back
out of the pleural cavity.

Manifestations of pneumothorax:
 Tachypnea
 Dyspnea
 Restlessness
 Anxiety
 Tachycardia
 Cyanosis
 Use of accessory breathing muscles
 Decreased or absent breathing sounds
 Decreased movement on the affected side

TREATMENT OF PNEUMOTHORAX:
• Removal of air from the pleural cavity with a needle or chest tube
• Repair of trauma and closure of opening into pleural cavity

NURSING INTERVENTIONS FOR PNEUMOTHORAX
 Monitor breath sounds (equal sounds on both sides), equal rise and fall of the chest, vital signs (HR,
blood pressure, oxygen saturation), and patient effort of breathing.
 Maintain chest tube drainage system if placed by physician:
 Assessing for air leaks in the system, keep it secure
 Troubleshooting if drain comes out or system breaks
 Water seal chamber: may have intermittent bubbling as air is drained from the pleural space.
The water seal chamber fluctuates as the patient breathes in and out. If it stops fluctuating
there may be a kink somewhere or the lung has re-expanded. NOT normal to have excessive
bubbling in the water seal chamber (air leak somewhere).
 Keep HOB of the bed elevated…Fowler’s position

WHY WOULD OUR CLIENT NEED A CHEST TUBE?
● There is something in the pleural
space….and we need to get it out.
○ Air
○ Fluid
○ Blood
● This allows the lung to fully expand.

NURSING CONSIDERATIONS
● Always keep the drainage system below the level of the client's chest
● Ensure the tubing is free of kinks and draining freely
● There should be no dependent loops in the tubing
● Monitor the drainage
○ Color - serous - serosanguinous.
○ Odor - none
○ Consistency - thin-thick
○ Amount - no more than 100ml/hr. More? Call the doc!!
■ Mark hourly

WHAT TO DO IF THE CHEST TUBE COMES OUT
 Cover the site with a
 sterile dressing
 Tape on 3 sides
○ Air can escape this way. If you tape on 4 sides you might cause a tension pneumothorax
 Call the provider
 STAY WITH THE CLIENT

WHAT TO DO IF THE TUBE COMES OUT OF THE ATRIUM?
 Still in the client, but becomes disconnected from the collection chamber
• Place the end of the chest tube in a bottle of sterile water

ATELECTASIS (COLLAPSE)
 Incomplete expansion of the lungs or collapse of
previously inflated lung substance.
 Significant atelectasis reduce oxygenation and
predispose to infection.

TYPES OF ATELECTASIS
1. Resorption atelectasis.
2. Compression atelectasis.
3. Contraction atelectasis.

TYPES OF ATELECTASIS
1. Resorption atelectasis
- Result from complete obstruction of
an airway and absorption of entrapped air.
Obstruction can be caused by:
a. Mucous plug ( postoperatively or exudates
within small bronchi seen in bronchial
asthma and chronic bronchitis).
b. Aspiration of foreign body.
c. Neoplasm.
d. enlarged lymph node
- The involvement of lung depend on
the level of airway obstruction.
- Lung volume is diminished and the
mediastinum may shift toward the
atelectatic lung.

2. Compression atelectasis
Results whenever the pleural cavity is
partially or completely filled by fluid,
blood, tumor or air, e.g.
- patient with cardiac failure
- patient with neoplastic
effusion
- patient with abnormal
elevation of diaphragm in peritonitis
or subdiaphragmatic abscess.

3. Contraction atelectasis.
 Local or generalized fibrotic
changes in pleura or lung
preventing full expansion of
the lung.

Manifestations of atelectasis:
• Dyspnea, cough.
• Reduced gas exchange.
Treatment of atelectasis:
 Removal of airway blockage
 Removal of air, blood, fluids, tumors, etc. that are
compressing lung tissues

 References:
 Hinkle, J.L. & Cheever, K.H. (2018). Brunner &Suddarth's
Textbook of Medical-Surgical Nursing (10th ed.). Philadelphia:
Wolters Kluwer

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