Chapter 21: Acute Respiratory Disorders

Chapter 21: Acute Respiratory Disorders

Airway structures allow air entry for oxygenation and tissue perfusion

Nursing priority in acute respiratory disorders: maintain a patent airway (promotes oxygenation)

Older adults are at higher risk due to:

• Decreased pulmonary reserves

• Decreased lung elasticity

• Thickened alveoli

• Increased susceptibility to infection

Common acute respiratory disorders:

• Rhinitis

• Sinusitis

• Influenza

• COVID-19

• Pneumonia

Health Promotion and Disease Prevention

• Perform hand hygiene (prevents transmission of bacteria and viruses)

• Encourage immunizations:

  • Influenza and pneumonia vaccines

  • Especially for young children, older adults, chronically ill, and immunocompromised clients

• Limit exposure to airborne allergens (prevents hypersensitivity reactions)

• Promote smoking cessation (reduces airway inflammation and infection risk)

Acute Respiratory Disorders Risk Factors

Extreme age (very young or advanced age)

Recent exposure to viral, bacterial, or influenza infections

Lack of current immunizations (influenza, pneumonia)

Exposure to:

• Plant pollen

• Molds

• Animal dander

• Foods

• Medications

• Environmental contaminants

Tobacco smoke

Substance use:

• Alcohol

• Cocaine

Chronic lung disease:

• Asthma

• Emphysema

Immunocompromised status

Presence of a foreign body

Conditions increasing aspiration risk:

• Dysphagia

Impaired ability to mobilize secretions:

• Decreased level of consciousness

• Immobility

• Recent abdominal or thoracic surgery

Inactivity and immobility

Rhinitis

Inflammation of the nasal mucosa and often the sinus mucosa

Causes:

• Infection (viral or bacterial)

• Allergens

Prevalence: affects ~10–30% of the global population annually

Commonly coexists with asthma and allergies

Classification:

• Acute

• Chronic

• Nonallergic

• Allergic (seasonal or perennial)

Types

• Viral (common cold)

  • Caused by viruses

  • Spread via respiratory droplets (sneezing, coughing) or direct contact

• Allergic

  • Allergen exposure triggers histamine and mediator release from WBCs

  • Mediators bind to blood vessel receptors → capillary leakage

  • Results in local edema and swelling

Rhinitis Expected Findings

Excessive nasal drainage and congestion

Rhinorrhea (runny nose)

Purulent nasal discharge

Sneezing and pruritus of nose, throat, and ears

Itchy, watery eyes

Sore, dry throat

Red, inflamed, swollen nasal mucosa

Low-grade fever, fatigue, cough (viral)

Diagnostic testing:

• Allergy testing to identify triggers

Rhinitis Care

Encourage rest (8–10 hr/day)

Encourage increased fluids (≥2,000 mL/day) (thins secretions)

Use home humidifier or inhale steam from hot shower (moistens airways)

Teach proper tissue disposal and cough etiquette (limits transmission)

Recommend saline nasal sprays (soothe mucosa, loosen secretions)

Warm saltwater gargles (relieve sore throat)

Reinforce hand hygiene (prevents spread)

Therapeutic Management

• Depends on underlying cause (viral vs allergic vs bacterial)

Rhinitis Meds

Antihistamines (block histamine effects)

• Example: brompheniramine/pseudoephedrine

Leukotriene inhibitors

• Example: montelukast

Mast cell stabilizers

• Example: cromolyn

• Older adults: monitor for vertigo, hypertension, urinary retention

Decongestants

• Example: phenylephrine

• Vasoconstriction reduces edema

• Use only 3–4 days (prevents rebound congestion)

Expectorants

• Example: guaifenesin (promotes mucus clearance)

Intranasal glucocorticoid sprays

• Most effective for prevention and treatment of seasonal and perennial rhinitis

Antipyretics

• For fever

Antibiotics/antimicrobials

• Only if bacterial infection is identified

Client Education

• Perform frequent hand hygiene (reduces transmission)

• Limit exposure to others during acute symptoms (protects vulnerable populations)

• Avoid known allergens (foods, medications, environmental triggers)

• Complementary therapies:

  • Echinacea, vitamin C, zinc may reduce severity and duration (limited evidence)

Sinusitis

Inflammation of the mucous membranes of one or more sinuses

Most commonly affects maxillary and frontal sinuses

Mucosal swelling blocks drainage of secretions → infection risk

Often follows rhinitis

Associated factors:

• Deviated nasal septum

• Nasal polyps

• Inhaled air pollutants or cocaine

• Facial trauma

• Dental infections

• Loss of immune function

Common causative organisms:

• Viral

• Streptococcus pneumoniae

• Haemophilus influenzae

• Diplococcus

• Bacteroides

Sinusitis Expected Findings

Nasal congestion

Headache

Facial pressure or pain (worse when bending forward)

Cough

Bloody or purulent nasal drainage

Tenderness on palpation of:

• Forehead

• Orbital areas

• Facial areas

Fever patterns:

• Low-grade fever (viral)

• High-grade fever (bacterial)

Sinusitis Exams

Diagnostic Procedures

• CT scan or sinus x-rays to confirm diagnosis (supports clinical findings)

• Endoscopic sinus lavage or surgery may be used to relieve obstruction and promote drainage

Sinusitis Care

Encourage steam humidification (reduces congestion)

Promote sinus irrigation and saline nasal sprays (improves drainage)

Apply hot and wet packs to sinuses (relieves pain and pressure)

Teach increased fluid intake and adequate rest (thins secretions)

Discourage air travel, swimming, and diving (prevents pressure changes)

Encourage tobacco cessation in all forms (reduces mucosal irritation)

Instruct on proper technique for sinus irrigation and nasal spray use

Therapeutic Procedures

• Repair of deviated nasal septum

• Surgical excision of nasal polyps

Client Education

• Sinus irrigation and saline sprays can relieve congestion and reduce antibiotic use

• Report severe symptoms immediately:

  • Severe headache

  • Neck stiffness (nuchal rigidity)

  • High fever
    (may indicate complications)

Sinusitis Meds

Nasal decongestants (reduce mucosal swelling)

• Example: phenylephrine

Broad-spectrum antibiotics

• Example: amoxicillin

• Use limited to confirmed bacterial infection

Pain relief

• NSAIDs

• Acetaminophen

• Aspirin

Client Education

• Start OTC decongestants at first signs of sinusitis

• Avoid use longer than 3 to 4 days (prevents rebound congestion)

Sinusitis Complications

Meningitis or encephalitis (pathogens enter bloodstream from sinuses)

Mucocele formation (cyst in paranasal sinus)

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder?

a

Percussion of posterior lobes of lungs

b

Auscultation of the trachea

c

Inspection of the conjunctiva

d

Palpation of the orbital areas

d Palpation of the orbital areas

A client who has sinusitis may report tenderness when the orbital, frontal, and facial areas are palpated.

Influenza

Acute, highly contagious viral respiratory infection

Occurs seasonally as epidemics, most often in fall and winter

Affects children and adults of all ages

Caused by several virus families that vary yearly

Adults are contagious:

• 24 hr before symptoms appear

• Up to 5 days after symptom onset

Pandemic Influenza

• Originates in animals or birds with mutation allowing human transmission

• High potential for global spread

• Examples:

  • H1N1 (swine flu)

  • H5N1 (avian flu)

Influenza Expected Findings

Severe headache and myalgias

Chills

Fatigue and weakness

Fever

Cough

Severe diarrhea and cough (avian flu)

Hypoxia (avian flu) (impaired gas exchange)

Influenza Exams

Diagnostic Procedures

• Viral cultures and lab tests available

• CDC recommends testing only if results will guide treatment decisions

Influenza Care

Maintain droplet and contact precautions for hospitalized clients with pandemic influenza (prevents transmission)

Provide saline gargles (relieves throat irritation)

Monitor hydration status, intake, and output (prevents dehydration)

Administer IV fluids as prescribed

Monitor respiratory status closely (early detection of hypoxia)

Interprofessional Care

• Consult respiratory therapy for respiratory support

• Notify community health officials of outbreaks

• Coordinate with state and federal public health agencies during pandemics for containment and prevention measures

Client Education

• Obtain yearly influenza vaccination when available

• Perform frequent hand hygiene and follow cough etiquette (limits spread)

• Avoid crowds and close personal contact during outbreaks

• If symptomatic:

  • Increase fluid intake

  • Rest

  • Stay home from work or school

• Avoid travel to areas with identified pandemic influenza

• Follow public health announcements and early warning systems during pandemics

Influenza Meds

Antivirals

• Examples:

  • Amantadine

  • Rimantadine

  • Ribavirin

  • Oseltamivir

  • Zanamivir

  • Peramivir

• Antivirals shorten illness duration when started early

• Oral zanamivir and oral oseltamivir commonly used

• During pandemics, antivirals may be distributed broadly

Client Education

• Start antiviral therapy within 24 to 48 hr of symptom onset (maximizes effectiveness)

Influenza Vaccines

• Quadrivalent or trivalent vaccines prepared annually based on predicted strains

• Annual vaccination recommended for everyone ≥6 months of age

• High-risk groups requiring vaccination:

  • History of pneumonia

  • Chronic medical conditions

  • Adults >65 years

  • Pregnant women

  • Health care workers

• H1N1 vaccine available for general population

• H5N1 vaccine stockpiled for pandemic use

Influenza Complications

Pneumonia

• Higher risk in older adults

• Higher risk in debilitated or immunocompromised clients

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching?

a

“I should wash my hands after blowing my nose to prevent spreading the virus.”

b

“I need to avoid drinking fluids if I develop symptoms.”

c

“I need a flu shot every 2 years because of the different flu strains.”

d

 “I should cover my mouth with my hand when I sneeze.”

a

“I should wash my hands after blowing my nose to prevent spreading the virus.”

Pneumonia

Inflammatory lung process with excess fluid in alveoli

Caused by:

• Infectious organisms

• Aspiration of irritants (fluid or foreign body)

Inflammation of lung parenchyma → edema and exudate filling alveoli (impaired gas exchange)

Can be:

• Primary disease

• Complication of another illness (common after influenza)

High-risk populations:

• Infants and young children

• Older adults

• Immunocompromised clients

Immobility is a major contributing factor

Types of Pneumonia

• Community-Acquired Pneumonia (CAP)

  • Most common

  • Often a complication of influenza

• Health Care–Associated Pneumonia (HCAP)

  • Higher mortality

  • More antibiotic resistance

  • Acquired 24–48 hr after exposure

  • Associated with non-hospital admission and health care contact

• Hospital-Acquired Pneumonia (HAP)

  • Occurs >48 hr after hospital admission

• Ventilator-Associated Pneumonia (VAP)

  • Occurs >48 hr after intubation

Types of Pneumonia

Community-Acquired Pneumonia (CAP)

• Most common

• Often a complication of influenza

Health Care–Associated Pneumonia (HCAP)

• Higher mortality

• More antibiotic resistance

• Acquired 24–48 hr after exposure

• Associated with non-hospital admission and health care contact

Hospital-Acquired Pneumonia (HAP)

• Occurs >48 hr after hospital admission

Ventilator-Associated Pneumonia (VAP)

• Occurs >48 hr after intubation

Pneumonia Expected Findings

Anxiety

Fatigue

Weakness

Chest discomfort from coughing

Confusion from hypoxia (most common sign in older adults)

Physical Assessment

• Fever and chills

• Flushed face

• Diaphoresis

• Shortness of breath or dyspnea

• Tachypnea

• Sharp pleuritic chest pain

• Productive cough

• Yellow-tinged sputum

• Purulent, blood-tinged, or rust-colored sputum (may be absent)

• Crackles and wheezes

• Dullness to percussion over consolidated areas

• Decreased oxygen saturation (normal 95%–100%)

Pneumonia Exams

Sputum Culture and Sensitivity

• Obtain specimen before antibiotics

• Suction specimen if client cannot cough

• Older adults may have weak cough and difficulty expectorating

CBC

• Elevated WBC count (may be absent in older adults)

ABGs

• Hypoxemia

• PaO₂ <80 mm Hg

Blood Cultures

• Rule out bacteremia

Electrolytes

• Signs of dehydration:

  • Elevated BUN

  • Hypernatremia

Diagnostic Procedures

Chest X-Ray

• Shows lung consolidation

• May be negative early in disease

• Important in older adults due to vague early symptoms

Pulse Oximetry

• Usually <95% in pneumonia

Pneumonia (Image)

Pneumonia Care

Position to maximize ventilation:

• High-Fowler’s (≈90%) if not contraindicated

Encourage coughing or suctioning (clears secretions)

Administer prescribed breathing treatments and medications

Administer oxygen therapy

Monitor skin integrity around oxygen devices

Encourage incentive spirometry (prevents alveolar collapse)

Structure activity with rest periods

Promote nutrition and hydration:

• Increased work of breathing increases caloric needs

• Adequate nutrition reduces secondary infection risk

• Fluids 2–3 L/day unless contraindicated (thins secretions)

Provide rest for dyspneic clients

Reassure clients experiencing respiratory distress

Interprofessional Care

• Respiratory therapy:

  • Inhalers

  • Breathing treatments

  • Suctioning

• Nutrition services for weight changes

• Rehabilitation services for prolonged weakness and activity intolerance

Client Education

• Complete all prescribed medications

• Rest as needed

• Maintain hand hygiene

• Avoid crowded areas during recovery

• Recovery may take time

• Obtain influenza and pneumonia vaccines

• Stop tobacco use if applicable

Pneumonia Meds

Antibiotics

• Used to destroy infectious pathogens

• Common classes:

  • Penicillins

  • Cephalosporins

• Often started IV, then switched to oral

• Obtain cultures before first dose

• Begin antibiotics after specimen collection

Nursing Actions

• Monitor for frequent stools

• Monitor kidney function, especially in older adults

Client Education

• Take antibiotics as prescribed

• Some penicillins should be taken:

  • With food

  • Or 1 hr before or 2 hr after meals (specific agent dependent)

Bronchodilators

• Reduce bronchospasm and airway irritation

• Short-acting beta₂ agonists

  • Albuterol (rapid relief)

• Anticholinergics

  • Ipratropium (blocks parasympathetic response)

• Methylxanthines

  • Theophylline (narrow therapeutic range)

Nursing Actions

• Monitor theophylline levels (toxicity risk)

  • Tachycardia, nausea, diarrhea

• Monitor for tremors and tachycardia with albuterol

• Monitor for dry mouth, palpitations, headache, blurred vision with ipratropium

Client Education

• Suck on hard candy for dry mouth (ipratropium)

• Increase fluid intake unless contraindicated

Anti-Inflammatories

• Reduce airway inflammation

• Glucocorticoids

  • Fluticasone

  • Prednisone

• Monitor for:

  • Immunosuppression

  • Fluid retention

  • Hyperglycemia

  • Hypokalemia

  • Poor wound healing

Nursing Actions

• Monitor immunity status

• Monitor blood glucose

• Monitor weight and edema

• Assess mouth and throat for aphthous ulcers

Client Education

• Take steroids with food

• Do not stop steroids abruptly

• Report black, tarry stools

• Increase fluid intake

Pneumonia

Atelectasis

• Alveolar collapse from inflammation and edema

• Increased hypoxemia risk

• Findings:

  • Dyspnea

  • Hypoxemia

  • Diminished or absent breath sounds

  • Chest x-ray shows density

Bacteremia (Sepsis)

• Pathogens enter bloodstream from lungs

Acute Respiratory Distress Syndrome (ARDS)

• Persistent hypoxemia despite oxygen therapy

• Reduced lung volume and elasticity

• Worsening dyspnea with noncardiac pulmonary edema

• Chest x-ray: ground-glass appearance

• ABGs:

  • Hypercapnia

  • Decreased oxygen saturation despite oxygen therapy

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? 

Select all that apply.

a

Client who has dysphagia

b

Client who has AIDS

c

Client who was vaccinated for pneumococcus and influenza 6 months ago

d

Client who is postoperative and has received local anesthesia

e

Client who has a closed head injury and is receiving mechanical ventilation

f

Client who has myasthenia gravis

a

Client who has dysphagia

b

Client who has AIDS

e

Client who has a closed head injury and is receiving mechanical ventilation

f

Client who has myasthenia gravis

A nurse is assessing a client who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?

a

Obtain baseline vital signs and oxygen saturation.

b

Obtain a sputum culture.

c

Obtain a complete history from the client.

d

Informed client about recommended pneumococcal vaccine.

a

Obtain baseline vital signs and oxygen saturation.