This document discusses respiratory disorders such as pneumonia and tuberculosis. Pneumonia is an inflammation of the lungs caused by microbial infection. Factors like smoking, age, and medical conditions can predispose individuals to pneumonia. Clinical manifestations include fever, cough, and signs of lung consolidation. Diagnosis involves physical exam, chest x-ray, and sputum tests. Treatment involves antibiotics and rest. Tuberculosis is caused by the bacterium Mycobacterium tuberculosis and can affect the lungs or other organs. Symptoms vary depending on whether it is a primary infection or reactivation. Diagnosis involves skin tests, imaging, and sputum/tissue cultures. Treatment involves antibiotic therapy.

1. RESPIRATORY DISORDER

2. q Pneumonia is an acute inflammation of the lung parenchyma
caused by a microbial organism.
q Until 1936, pneumonia was the leading cause of death in the
United States.
q The discovery of sulfa drugs and penicillin was pivotal in the
treatment of pneumonia.
q Since that time, there has been remarkable progress in the
development of antibiotics to treat pneumonia.
q However, despite the new antimicrobial agents, pneumonia is
still common and is associated with significant morbidity and
mortality.
q Pneumonia and influenza are the seventh leading cause of
death in the United States.
q Data indicate that the mortality from pneumonia and
influenza is increasing (3.2%).
q Pneumonia is currently the leading cause of death from an
infectious disease in the United States.

3. Etiology
– Normal Defense Mechanisms.
– Normally, the airway distal to the
larynx is sterile because of
protective defense mechanisms.
– These mechanisms include the
following: filtration of air, warming
and humidification of inspired air,
epiglottis closure over the trachea,
cough reflex, mucociliary escalator
mechanism, secretion of
immunoglobulin A, and alveolar
macrophages

4. Factors Predisposing to Pneumonia.
– Pneumonia is more likely to result when defense
mechanisms become incompetent or are overwhelmed
by the virulence or quantity of infectious agents.
– Decreased consciousness depresses the cough and
epiglottal reflexes, which may allow aspiration of
oropharyngeal contents into the lungs.
– Tracheal intubation interferes with the normal cough
reflex and the mucociliary escalator mechanism.
– It also bypasses the upper airways, in which filtration
and humidification of air normally take place.
– The mucociliary mechanism is impaired by air
pollution,

5. – cigarette smoking, viral upper respiratory
infections (URIs), and normal changes of aging.
– In cases of malnutrition, the functions of
lymphocytes and polymorphonuclear (PMN)
leukocytes are altered.
– Diseases such as leukemia, alcoholism, and
diabetes mellitus are associated with an
increased frequency of gram-negative bacilli in
the oropharynx. (Gram-negative bacilli are not
normal flora in the respiratory tract.)
– Altered oropharyngeal flora can also occur
secondary to antibiotic therapy given for an
infection elsewhere in the body.

6. Pneumonia
l Bacterial agents
l Streptococcus pneumoniae  mcc of
community-acquired pneumonia's
l S&S: fever, chills, rigors, cough,
respiratory distress, signs of pulmonary
consolidation,
l CXR  lobar consolidations,; patchy
bronchopneumonic pattern

7. Clinical Manifestations
• Patients with pneumonia usually have a sudden
onset of symptoms, including fever, shaking
chills, shortness of breath, cough productive of
purulent sputum (rust-colored sputum can be seen
in pneumococcal pneumonia), and pleuritic chest
pain (in some cases).
• In the elderly or debilitated patient, confusion or
stupor (possibly related to hypoxia) may be the
only finding.
• On physical examination, signs of pulmonary
consolidation, such as dullness to percussion,
increased fremitus, bronchial breath sounds, and
crackles, may be found

8. » Diagnostic
» History and physical examination
» Chest x-ray
» Gram stain of sputum
» Sputum culture and sensitivity test (if drug-resistant pathogen or organism
not covered by empiric therapy)
» Pulse oximetry or ABGs (if indicated)
» Complete blood count, differential, and routine blood chemistries (if
indicated)
» Blood cultures (if indicated)
» Collaborative Therapy
» Appropriate antibiotic therapy
» Increased fluid intake (at least 3 L/day)
» Limited activity and rest
» Antipyretics
» Analgesics
» Oxygen therapy (if indicated)
» ABGs, Arterial blood gases.
l )>

9. Pneumococcal Vaccine.
– Pneumococcal vaccine is indicated primarily for the
individual considered at risk who
– has chronic illnesses such as lung and heart disease and
diabetes mellitus,
– is recovering from a severe illness,
– is 65 years of age or older,
– is in a long-term care facility.
– In the immunosuppressed individual at risk for
development of fatal pneumococcal infection (e.g.,
asplenic patient; patient with nephrotic syndrome, renal
failure, or AIDS; transplant recipient),
– All persons ≥65 years of age who have not received
vaccine within 5 years (and were <65 years of age at the
time of vaccination) should receive another dose of
vaccine.

10. Factors Predisposing to Pneumonia

11. Pneumonia
q Labs
• Leukocytosis 15,000-30,000 cells
• leukopenia may be observed in HIV
and alcoholics
• Gram-positive diplococci on Gram’s
stain

12. Pneumonia
l S&S:
q Dry cough, respiratory distress,, malaise,
HA, confusion, and GI disturbance
q CXR  alveolar shadowing, patchy or
lobar distribution w/ or w/o pleural effusions
q Dx suggested clinically by rapidly
progressive pneumonia, dry cough, and
mutli-organ involvement
q Gram’s stain  neutrophils, no organisms

13. » Nursing Diagnosis
» Ineffective breathing pattern related
to inflammation and pain as evidenced
by dyspnea, tachypnea, nasal flaring,
altered chest excursion
» Patient Goal
» Demonstrates an effective respiratory
rate, rhythm, and depth of respirations

14. » Ineffective airway clearance related
to retained secretions and excessive
mucus as evidenced by ineffective
cough, adventitious breath sounds,
dyspnea
» Patient GoalS
» 1. Demonstrates effective coughing
and increased air exchange
» 2. Experiences normal breath
sounds

15. Chronic Bronchitis
q Air pollution  incidence and mortality 
higher in highly industrialized areas
• exacerbation's related to heavy pollution
w/sulfur dioxide and particulate matter
q Occupation  exposure to inorganic or
organic dust or noxious gases

16. Chronic Bronchitis
q Infection  ’ed morbidity, mortality
and frequency in acute respiratory
infections

17. Chronic Bronchitis
l Predominant bronchitis
q hx of cough and sputum production for yrs
and immodest hx of smoking
q no apparent distress at rest, respiratory
rate nl or only slightly increased
q chest percussion resonant, coarse rhonchi
and wheezes which change location and
intensify after deep and productive cough

18. Chronic Bronchitis
q May have a heave lower LSB 
RVH
q often overweight, edematous and cyanotic
(Blue bloaters)
q TLC often nl, moderate elevation of RV
q PaCO2 high 40’s to low 50’s, PaO2 45-60

19. Tuberculosis
l Clinical presentation
q Primary infection:
• >90% are asymptomatic w/ positive skin testing
• majority have nl CXR
• may present w/ erythema nodosum

20. Tuberculosis
l Among the 10% who progress to
symptomatic ds, four syndromes can be
identified
q 1) Atypical pneumonia- most common
q 2) Tuberculous pleurisy
q 3) Direct progression
q 4) Early systemic dissemination

21. Tuberculosis
l Reactivation (Post-primary) TB
• most common clinical form
• symptoms begin insidiously  weeks to
months before dx is made
q Constitutional symptoms often prominent
• anorexia,, weight loss, and night sweats
– most have low-grade fever  high
temps can be seen w/rapid ds
progression

22. Tuberculosis
PE usually non-diagnostic
• dyspnea uncommon w/o chronic lung ds
• hemoptysis  frequent complaint
CXR’s highly suggestive of ds
q typical features  infiltration in posterior
apical pulmonary segment, may be
unilateral or B/L  progresses to cavitation
l TB skin test (+) in approx 80% of pts w/
reactivation TB

26. Tuberculosis
q Extra-pulmonary TB
• approx 20% of all newly dx’ed cases in
US
’ing due to HIV (+) pts
• clinical features vary
• past hx of TB not reliable
• typically long latent period between first
episode of infection
• approx 50% have nl CXR
• can involve all organs  mc: GU tract,
M/S system, and lymph nodes

27. Tuberculosis
l Extra-pulmonary TB in HIV pts  AIDS
q HIV + pt’s w/TB may have early extra-pulmonary
ds and dissemination
q High risk  IV drug abusers and non-whites
• may be severe, widespread and atypical
presentatio
q PPD skin  usually negative in HIV pt’s
w/disseminated ds
q CXRS nl in approx 10%
q Dx  visualization or culture from sputum or
extra-pulmonary sites

28. Tuberculosis
q Atypical Myco-bacterial infection
• not comm in primary care
• disseminated ds usually in immuno-suppressed
– Mycobacterium avium intracellulare major
problem causing disseminated infection in
AIDS pt’s
l Tubercullin skin test
q most sensitive for dx of M. tuberculosis
• (+) test does not prove active ds  indicates
infection has occurred
• negative results  20% w/TB

29. Tuberculosis
q Anergy testing  immunologic impairment
• Candida, mumps, Tetanus toxoid
antigens used simultaneously on pts
testing negative but w/high suspicion of
infection  assesses Active TB ds
• TB confirmed  sputum
– bronchoscopy or broncholabage may
be necessary

30. Tuberculosis
l TX
q Prophylaxis in uninfected individuals:
• close contacts should be considered for
isoniazid (INH) tx
q Bacille Callette-Guerin (BCG) vaccine 
countries outside of US
• Prophylaxis not given to pt’s w/positive skin test

31. Tuberculosis
q Prophylaxis in Tubercullin converters
and pt’s w/latent ds:
• Tx  INH
– risk of reactivation must be
weighed w/risk if tx’ed
– S & S of reactivation  cough,
fever, pleuritic chest pain,
lymphadenopathy, effusion, CXR
changes

32. Recommendation of INH prophylaxis
l Risk TB Test Months
HIV >5mm 12
Close contacts >5mm 6 (9 peds)
CXR lesions >5mm 12
Recent infection >10mm 6
High w/PMH >10mm 6-12
High <35 y/o > 10mm 6
Low < 35 y/o > 15mm 6

33. Tuberculosis
q Active TB tx:
• Multi-drug regimen
• INH plus rifampin for 9 months or INH, rifampin
and pyrazinamide for 2 months
• HIV (+) and pt’s w/extra-pulmonary ds or
advance pulmonary ds  INH, rifampin,
pyrazinamide or ethambutol  if response
favorable  INH and rifampin after 2 mo x 1 yr
• if INH and rifampin not tolerated or drug
resistance  INH or rifampin given
w/pyrazinamide or ethambutol

34. Nursing Diagnoses
• Nursing diagnoses for the patient with TB may include, but are
not limited to, the following:
– • Ineffective breathing pattern related to decreased lung
capacity
– • Imbalanced nutrition: less than body requirements related
to chronic poor appetite, fatigue, and productive cough
– • Noncompliance related to lack of knowledge of disease
process, lack of motivation, and long-term nature of
treatment
– • Ineffective health maintenance related to lack of
knowledge about the disease process and therapeutic
regimen
– • Activity intolerance related to fatigue, decreased
nutritional status, and chronic febrile episodes

35. PULMONARY EMBOLISM
(PE)
lMC embolic material 
thromboemboli
q Most deep veins of thighs
l Deep Vein thrombosis (DVT)
q Virchow’s Triad 
• Stasis,
• Intimal injury and
• Hypercoagulable state

36. PE
S&S varies from persistent tachycardia, or
mild dyspnea to cardiopulmonary arrest
q Dyspnea (80%), pleuritic CP (70%), hemoptysis
(20-30%)
l PE  tachypnea (70%), acute right
ventricular strain (<40%), occasionally rubs,
crackles, or wheezing, low grade fever
common
l >97% present w/combo of dyspnea, pleuritc
CP, or tachypnea

37. PE
l CXR
q Usually abnormal
q Non-specific  atelectasis, infiltrates,
pleural effusions, and an elevated
diaphragm
• r/o pneuomothorax or abscess
l EKG
q Non-specific abnormalities  ST and T
wave changes, sinus tachycardia or right
ventricular strain

38. PE
lABG
q Hypoxemia and hypocapnia
common
• PO2 >80% in 23 % of patients
lConfirmation
q Ventilation perfusion scan or
pulmonary angiography

39. PE
l Nl ventilation scan w/ a perfusion scan
showing segmental or larger defects 
high-probability
q HIGHLY SPECIFIC OF PE
• 87% specificity
• 96% w/high degree of clinical suspicion
q Low-probability scan does not exclude PE
 14% found by angiography

40. PE
l Pulmonary angiography
q for indeterminate lung scans
l Tx
q Acute DVT and PE  anticoagulation w/heparin
continuous infusion to prolong partial thromboplastin
time (PTT) 1.5-2 times control
• Bolus given to achieve quicker therapeutic PTT
• Tx After 24 hrs  mcc progression to venous
thrombosis ds and tx failure

41. PE
q Monitore platelets  heparin induced
thrombocytopenia
q Oral anticoagulation  warfarin (coumadin)
• Started first day of tx
• Monitored w/ International Normalization Ratio
(INR)  2.0-3.0 times control for thromboembolic ds
q Long term anticoagulation for 3 months
• Risks resolved
q Indefinite if predisposing condition continues

42. PULMONARY EMBOLISM
lTx of PE with added risk
q Thrombolytics (streptokinase,
urokinase, tissue plasminogen
activator-tPA) augment
dissolution of fresh emboli
• Indications  massive emboli or
hemodynamic instability
• Does not alter mortality or morbidity
• High risk of bleeding

43. PE
q Vena caval interruption  when
thrombolytics contraindicated or tx failure
• Considered when thrombus is from lower
extremities
l Prevention is best tx for
thromboembolic ds
l Prophylaxis of high risk pts is safe and
efficacious

44. PE
l Prophylaxis
q 5000 units every 12 hrs w/ low dose
subcutaneous heparin

45. Reference
l Brunner, L. S., Suddarth, D. S., & Smeltzer,
S. C. O. (2008). Brunner & Suddarth's
textbook of medical-surgical nursing (11th
ed.). Philadelphia: Lippincott Williams &
Wilkins.