Adult I: 27 Lower Respiratory Problems

acute bronchitis

a self-limiting inflammation of the bronchi in the lower respiratory tract and a common reason for seeking medical care

consolidation

occurs when fluid accumulates in the lungs

pneumonia

Consolidation is suggestive of...

bronchitis

Consolidation is absent with...

pertussis

A highly contagious infection of the respiratory tract whose hallmark characteristic is an uncontrollable, violent "whooping" cough

pneumonia

an acute infection of the lung parenchyma

aspiration, inhalation, hematogenous spread

Organisms that cause pneumonia reach the lung by three ways:

1. ___________ of normal flora from the nasopharynx or oropharynx. Many organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults.

2. ___________ of microbes present in the air. Examples include Mycoplasma pneumonia and fungal pneumonias.

3. _________ from a primary infection elsewhere in the body. Examples are streptococci and Staphylococcus aureus from infective endocarditis.

community, hospital

The most widely recognized and clinically effective way to classify pneumonia is as either ___________-acquired or _________-acquired.

curb 65 scale

The _____________ may be used as a supplement to clinical judgement to determine the severity of pneumonia and if patients need to be hospitalized.

confusion

Curb 65 Scale:

C - ____________

U - bUn > 20 mg/dL

R - Respiratory rate > or = 30 breaths/min

B - systolic Blood pressure <90 or diastolic < 60

65 - > or = 65 years of age

bun

Curb 65 Scale:

C - Confusion

U - ______ > 20 mg/dL

R - Respiratory rate > or = 30 breaths/min

B - systolic Blood pressure <90 or diastolic < 60

65 - > or = 65 years of age

respiratory rate

Curb 65 Scale:

C - Confusion

U - bUn > 20 mg/dL

R - ______________ > or = 30 breaths/min

B - systolic Blood pressure <90 or diastolic < 60

65 - > or = 65 years of age

blood pressure

Curb 65 Scale:

C - Confusion

U - bUn > 20 mg/dL

R - Respiratory rate > or = 30 breaths/min

B - systolic ______________ <90 or diastolic < 60

65 - > or = 65 years of age

3

A score of ___ or more on the Curb-65 Scale suggests hospital admission

HIV

P. jiroveci pneumonia rarely occurs in the healthy individual bus is the most common form of pneumonia in people with ________ disease.

inflammatory response

Specific pathophysiologic changes related to pneumonia vary according to the offending organism, but the majority of organisms trigger an _____________ in the lungs.

edema, fluid

Specific pathophysiologic changes related to pneumonia vary according to the offending organism, but the majority of organisms trigger an inflammatory response in the lungs. Inflammation, characterized by an increase in blood flow and vascular permeability, activates neutrophils to engulf and kill the offending organisms. As a result, the inflammatory process attracts more neutrophils, _______ of the airways occurs, and _______ leaks from the capillaries and tissues into alveoli.

hypoxia

Specific pathophysiologic changes related to pneumonia vary according to the offending organism, but the majority of organisms trigger an inflammatory response in the lungs. Inflammation, characterized by an increase in blood flow and vascular permeability, activates neutrophils to engulf and kill the offending organisms. As a result, the inflammatory process attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and tissues into alveoli. Normal oxygen transport is affected, leading to clinical manifestations of ___________.

fluid, debris, mucus

Specific pathophysiologic changes related to pneumonia vary according to the offending organism, but the majority of organisms trigger an inflammatory response in the lungs. Inflammation, characterized by an increase in blood flow and vascular permeability, activates neutrophils to engulf and kill the offending organisms. As a result, the inflammatory process attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and tissues into alveoli. Normal oxygen transport is affected, leading to clinical manifestations of hypoxia. Consolidation, a feature typical of bacterial pneumonia, occurs when the normally air-filled alveoli become filled with _______ and ________. ________ production also increases, which can potentially obstruct airflow and impair gas exchange even further.

atelectasis

Complications of pneumonia:

collapsed, airless alveoli of one or part of one lobe

pleurisy

Complications of pneumonia:

inflammation of the pleura

pleural effusion

Complications of pneumonia:

fluid in the pleural space

bacteremia

Complications of pneumonia:

bacterial infection in the blood; more likely to occur in infections with Streptococcus pneumoniae and haemophilus influenzae

pneumothorax

Complications of pneumonia:

can occur when air collects in the pleural space, causing the lungs to collapse

meningitis

Complications of pneumonia:

can be caused by Streptococcus pneumoniae; patient will be disoriented, confused or drowsy

acute respiratory failure

Complications of pneumonia:

one of the leading causes of death in patients with severe pneumonia; occurs when pneumonia damages the lungs' ability to facilitate the exchange of oxygen and carbon dioxide across the alveolar-capillary membrane

sepsis/septic shock

occurs when bacteria with alveoli enter the bloodstream; severe sepsis can lead to shock and multi system organ dysfunctions

mobilization, incentive spirometer, chlorhexidine

Early _____________, the use of an _____________, and twice-daily oral hygiene with _______________ swabs have been shown to significantly reduce the incidence of pneumonia in postoperative patients.

confusion

___________ from hypoxia is the most common manifestation of pneumonia in older adult clients.

before

Sputum culture and sensitivity:

Obtain specimen _________ starting antibiotic therapy.

high-Fowler's, coughing, oxygen, incentive spirometer

Nursing care for patient's with pneumonia:

-position the client to maximize ventilation (__________ position) unless contraindicated

-encourage _________ or suction to remove secretions

-administer __________ therapy

-encourage deep breathing with an ____________ to prevent alveolar collapse

immunity, hyperglycemia, tarry, fluid, aphthous

Nursing considerations for Anti-inflammatories prescribed to decrease airway inflammation with pneumonia:

-monitor for decreased __________ function

-monitor for ____________

-advise client to report black, ________ stools

-observe for _______ retention and weight gain; this can be common

-monitor the throat and mouth for ________ lesions (canker sores)

atelectasis, bacteremia, ARDS (acute respiratory distress syndrome)

Three serious complications of pneumonia

A, B, E, F

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 ventilation

F. client who has myasthenia graves

A

A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. 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. provide a pneumococcal vaccine

B, C, A, D

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8° C (100° F), respirations 30/min, BP 130/76, HR 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions.

A. administer antibiotics

B. administer oxygen therapy

C. perform a sputum culture

D. administer an antipyretic medication to promote client comfort

Spontaneous pneumothorax

pneumothorax that occurs from a rupture of air filled blebs

Tension pneumothorax

pneumothorax when air enters pleural space but cannot escape, shift compromises oxygenation

medical emergency

A tension pneumothorax is a...

tension

Because a __________ pneumothorax is a medical emergency, treat this patient first.

Iatrogenic pneumothorax

pneumothorax caused by a puncture of the lung during a procedure

Hemothorax

blood in pleural space from injury

Chylothorax

lymphatic fluid in pleural space

occlusive dressing

Cover an open pneumothorax with ______________________ (3 sides), do not remove object, stabilize w/ bulky dressing

3

Cover an open pneumothorax with occlusive dressing (___ sides), do not remove object, stabilize w/ bulky dressing

D

The nurse is caring for a patient with pneumonia. If a pleural effusion is developing, the nurse would expect which finding?

A. Barrel-shaped chest

B. Paradoxical respirations

C. Hyperresonance on percussion

D. Localized decreased breath sounds

A, B, E

For which pt w/ pneumonia would the nurse suspect aspiration as the likely cause of pneumonia? (select all that apply)

A. Pt w/ seizures

B. Pt w/ head injury

C. Pt who had thoracic sx

D. Pt who had MI

E. Pt who is receiving NGT feeding

Age, limited mobility, chronic heart failure

D.T. is an 88-year-old woman who lives alone. She has been feeling weaker over past 2 days. Last night became confused and disoriented. Her housekeeper notified her daughter, who brought D.T. to the clinic. She complains of coughing over the past 3 days. She has a history of mild heart failure that is treated medically but has no other significant health disorders. She last saw her health care provider 4 months ago. What are D.T.'s risk factors for pneumonia?

CAP (no mention of hospitalization or LTC; saw HCP 4 months ago)

D.T. is an 88-year-old woman who lives alone. She has been feeling weaker over past 2 days. Last night became confused and disoriented. Her housekeeper notified her daughter, who brought D.T. to the clinic. She complains of coughing over the past 3 days. She has a history of mild heart failure that is treated medically but has no other significant health disorders. She last saw her health care provider 4 months ago. What type of pneumonia is D.T. likely exhibiting?

Cough, weakness, confusion

D.T. is an 88-year-old woman who lives alone. She has been feeling weaker over past 2 days. Last night became confused and disoriented. Her housekeeper notified her daughter, who brought D.T. to the clinic. She complains of coughing over the past 3 days. She has a history of mild heart failure that is treated medically but has no other significant health disorders. She last saw her health care provider 4 months ago. What clinical manifestations of pneumonia is D.T. displaying?

Shaking chills; dyspnea; tachypnea; pleuritic chest pain; green, yellow, or rust-colored sputum; rhonchi and rales; bronchial breath sounds; egophony; ↑ fremitus; dullness to percussion if pleural effusion present; nonspecific manifestations including diaphoresis, anorexia, myalgias, headache, and abdominal pain

She has been feeling weaker over past 2 days. Last night became confused and disoriented. Her housekeeper notified her daughter, who brought D.T. to the clinic. She complains of coughing over the past 3 days. She has a history of mild heart failure that is treated medically but has no other significant health disorders. She last saw her health care provider 4 months ago. For what other clinical manifestations would you assess D.T. ?

Chest x-ray, sputum and culture and sensitivity, CBC, electrolytes, BNP (brain natriuretic peptide)

She has been feeling weaker over past 2 days. Last night became confused and disoriented. Her housekeeper notified her daughter, who brought D.T. to the clinic. She complains of coughing over the past 3 days. She has a history of mild heart failure that is treated medically but has no other significant health disorders. She last saw her health care provider 4 months ago. What diagnostic tests would you expect the nurse practitioner in the clinic to order?

pulse ox, antibiotics, fall precautions, analgesics, adequate hydration and nutrition

She has been feeling weaker over past 2 days. Last night became confused and disoriented. Her housekeeper notified her daughter, who brought D.T. to the clinic. She complains of coughing over the past 3 days. She has a history of mild heart failure that is treated medically but has no other significant health disorders. She last saw her health care provider 4 months ago. D.T.'s chest x-ray reveals consolidation in her left lower lobe, consistent with pneumonia. Her WBC is 17,000/μL (17 × 109/L) with an increased number of bands. Her electrolytes and BNP are within normal limits. Sputum Gram stain shows gram-positive diplococci and many WBCs. Because of her age and altered mentation, the health care provider admits her to the hospital for treatment. On admission, D.T. has bronchial breath sounds with dullness of the left lower lobe and egophony. Her O2 saturation is 87%. What is your priority of care for D.T.?

fluids, finish antibiotics, follow-up chest x-ray

She has been feeling weaker over past 2 days. Last night became confused and disoriented. Her housekeeper notified her daughter, who brought D.T. to the clinic. She complains of coughing over the past 3 days. She has a history of mild heart failure that is treated medically but has no other significant health disorders. She last saw her health care provider 4 months ago. D.T.'s chest x-ray reveals consolidation in her left lower lobe, consistent with pneumonia. Her WBC is 17,000/μL (17 × 109/L) with an increased number of bands. Her electrolytes and BNP are within normal limits. Sputum Gram stain shows gram-positive diplococci and many WBCs. Because of her age and altered mentation, the health care provider admits her to the hospital for treatment. On admission, D.T. has bronchial breath sounds with dullness of the left lower lobe and egophony. Her O2 saturation is 87%. It has been 4 days since D.T. was admitted for pneumonia. She is hemodynamically stable and neurologically intact. She has been switched from IV antibiotics to oral antibiotics and is ready for discharge. What important teaching should you provide to the patient and family?

tension pneumothorax

air in pleural space that does not escape; increased air in the pleural space shifts trans and increases intrathoracic pressure

flail chest

fracture of two or more adjacent ribs in two or more places with loss of chest wall stability

cardiac tamponade

blood rapidly collects in pericardial sac, compasses myocardium because pericardium does not stretch, and prevents ventricles from filling

pneumothorax

Manifestations of ____________:

dyspneal, decreased movement of involved chest wall, diminished or absent breath sounds on the affected side, hyperresonance to percussion

hemothorax

Manifestations of ____________:

dyspnea, diminished or absent breath sounds, dullness to percussion, decreased Hgb, shock depending on blood volume lost

tension pneumothorax

Manifestations of ____________:

cyanosis, air hunger, extreme agitation, tracheal deviation away from affected side subcutaneous emphysema, neck vein distention, hyper resonance to percussion

flail chest

Manifestations of ____________:

paradoxical movement of chest wall, respiratory distress; may be associated with hemothorax, pneumothorax, or pulmonary contusion

cardiac tamponade

Manifestations of ____________:

muffled, distant heart sounds, hypotension, neck vein distention, increased central venous pressure

pneumothorax

Intervention for _____________:

chest tube insertion with chest drainage system

hemothorax

Intervention for _____________:

chest tube insertion with chest drainage system; auto transfusion of collected blood, treatment of hypovolemia as necessary

tension pneumothorax

Intervention for ____________:

medical emergency; needle decompression followed by chest tube insertion with chest drainage system

flail chest

Intervention for _____________:

oxygen as needed to maintain oxygen saturation; analgesia; stabilize flail segment with positive pressure ventilation (intubation and mechanical ventilation); treat associated injuries; surgical fixation

cardiac tamponade

Intervention for _____________:

medical emergency; pericardiocentesis with surgical repair as appropriate

no breath sounds

On auscultation of a pneumothorax, _______________ are detected over the affected area.

reduction in lung volume

A chest x-ray of a pneumothorax shows air or fluid in the pleural space and...

unclamping, tube, relieving, obstruction

A tension pneumothorax can occur if chest tubes are clamped or become blocked in a patient with a pneumothorax. _________ the __________ or __________ the ___________ may correct this situation.

tracheal deviation

____________ is a manifestation of a tension pneumothorax.

chest tube

The most definitive and common treatment of pneumothorax and hemothorax is to insert a ____________ and connect it to water-seal drainage.

needle decompression

Tension pneumothorax is a medical emergency, requiring urgent _____________ followed by chest tube insertion to water-seal drainage.

rib fractures

____________ are the most common type of chest injury resulting from blunt trauma.

pain

Clinical manifestations of fractured ribs include __________ at the site of injury, especially during inspiration and with coughing.

deep, coughing, spirometry, pain

Patient teaching for patients with fractured ribs should emphasize ________ breathing, ________, incentive __________, and appropriate use of ________ medications.

paradoxical movement

Flail chest results from the fracture of several consecutive ribs, in two or more separate places, causing an unstable segment. The resultant instability of the chest wall causes _____________ during breathing.

expansion, oxygenation

Initial therapy of flail chest consists of ensuring adequate ventilation and supplemental O2 therapy. The goal is to facilitate lung ___________ and ensure adequate ___________.

chest x-ray

Proper test tube placement is confirmed by...

chest wall, lungs

The pleural space normally contains 5 to 15 mL of fluid that acts as a lubricant between the __________ (parietal pleura) and _________ (visceral pleura).

pleural effusion

The pleural space normally contains 5 to 15 mL of fluid that acts as a lubricant between the chest wall (parietal pleura) and lungs (visceral pleura). ___________ is an abnormal collection of fluid in this space.

empyema

An ___________ is the collection of purulent fluid in the pleural space. It is caused by conditions such as pneumonia, TB, lung abscess, and infection of surgical wounds of the chest.

thoracentesis

aspiration of intrapleural fluid for diagnostic and therapeutic purposes

edge, lean forward

For a thoracentesis, the patient may sit on the _________ of a bed and ___________ over a bedside table.

pleurisy (pleurites)

an inflammation of the pleura that can be caused by infectious diseases, neoplasms, autoimmune disorders, chest trauma, GI disease, and certain medications.

pleural friction rub

With pleurisy, a _____________ may occur, which is the sound heard over areas where inflamed visceral pleural and parietal pleura rub over one another during inspiration.

pulmonary edema

____________ is an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs. It is a complication of various heart and lung diseases.

left-sided heart failure

The most common cause of pulmonary edema is...

PE (pulmonary embolism)

________ is the blockage of one or more pulmonary arteries by a thrombus, fat or air embolus, or tumor tissue.

DVT (deep vein thrombosis)

Most pulmonary emboli arise from _________ in the deep veins of the legs.

dyspnea

____________ is the most common presenting symptom of patients with PE, though signs and symptoms of PE are varied and nonspecific.

pulmonary hypertension

____________ is characterized by elevated pulmonary artery pressure resulting from an increase in resistance to blood flow through the pulmonary circulation.

pulmonary emboli

Recurrent _____________ gradually cause a reduction in the capillary bed and eventual pulmonary hypertension.

SOB, fatigue

Pulmonary hypertension commonly manifests with _______ and ________. it can occur as a primary disease (idiopathic pulmonary arterial hypertension) or a secondary complication of a respiratory, cardiac, autoimmune, hepatic, or connective tissue disorder.

right-sided heart failure

If left untreated, idiopathic pulmonary arterial hypertension can be rapidly progressive, causing ___________ and death within a few years.

cor pulmonale

Pulmonary hypertension increases the workload of the right ventricle and causes right ventricular hypertrophy (a condition called ___________) and eventually heart failure.

right ventricle

Cor pulmonale is enlargement of the ____________ caused by a primary disorder of the respiratory system.

COPD

The most common cause of cor pulmonale is _______.

A

When caring for a patient with acute bronchitis, the nurse will prioritize

A. auscultating lung sounds

B. encouraging fluid restriction

C. administering antibiotic therapy

D. teaching the patient to avoid cough suppressants

A, B, E

For which patients with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia? (select all that apply)

A. patient with seizures

B. patient with head injury

C. patient who had thoracic surgery

D. patient who had myocardial infarction

E. patient who is receiving nasogastric tube feeding