chapter 20

Yes — and Chapter 20 is a good one to summarize carefully because it mixes infectious disease, pleural disease, occupational lung disease, pulmonary vascular disorders, lung cancer, and thoracic surgery.

This chapter is not COPD-focused; COPD is mainly Chapter 21. Chapter 20 is titled Management of Patients With Nonacute Disorders of the Chest and Lower Respiratory Tract and Disorders of the Pulmonary Vasculature. Its learning goals emphasize comparing nonacute pulmonary/pleural/vascular disorders, preventing occupational lung disease, managing lung cancer, and caring for patients after thoracotomy.

Chapter 20 — Detailed Nursing Summary

1. Big-picture organization

The easiest way to organize Chapter 20 is into five groups:

  • Nonacute infectious/inflammatory disorders

    • tuberculosis

    • lung abscess

    • sarcoidosis

  • Pleural disorders

    • pleurisy

    • pleural effusion

    • empyema

  • Pulmonary vascular disorders

    • pulmonary hypertension

    • cor pulmonale

    • pulmonary embolism

  • Occupational lung disease

    • silicosis

    • asbestosis

    • coal worker’s pneumoconiosis

  • Lung cancer and thoracic surgery

    • NSCLC vs SCLC

    • lobectomy

    • pneumonectomy

    • segmentectomy/wedge resection

    • thoracotomy nursing care.

2. Tuberculosis — TB

TB is caused by Mycobacterium tuberculosis and primarily affects the lungs, though it can spread elsewhere.

For nursing, the big concepts are:

  • recognizing active disease

  • preventing transmission

  • medication adherence

  • distinguishing infection from active disease

  • monitoring for treatment complications.

Latent vs active TB

Latent TB infection

The organism is present, but the patient:

  • has no active symptoms

  • is not contagious.

Active TB

The organism is multiplying and causing disease.

Possible findings:

  • persistent cough

  • sputum

  • hemoptysis

  • fatigue

  • weight loss

  • anorexia

  • fever

  • night sweats.

For exam purposes, think:

latent = infected but not sick/contagious
active = symptomatic and potentially contagious

3. TB transmission and precautions

Active pulmonary TB is spread through airborne transmission.

Nursing implications include:

  • airborne isolation

  • appropriate respiratory protection for staff

  • limiting exposure to others

  • teaching cough etiquette

  • strict adherence to therapy.

This is a major safety concept because untreated or inadequately treated active TB can continue to spread.

4. TB treatment: why adherence matters

TB treatment requires multiple drugs for a prolonged period.

The reason:
using several medications reduces the chance that resistant organisms survive.

Common multidrug therapy includes:

  • isoniazid

  • rifampin

  • pyrazinamide

  • ethambutol

A high-yield nursing principle:

Do not stop TB medications early just because symptoms improve.

Incomplete therapy increases risk for:

  • relapse

  • drug resistance

  • ongoing transmission.

Directly observed therapy may be used to improve adherence.

5. TB nursing management

Focus on:

  • medication adherence

  • monitoring adverse effects

  • nutrition

  • infection control

  • symptom monitoring

  • psychosocial support.

Patients may need repeated teaching because the treatment course is long.

Think:

TB nursing = isolate when infectious + complete therapy + monitor toxicity

6. Lung abscess

A lung abscess is a localized collection of pus in the lung caused by infection. The textbook notes that it commonly develops after bacterial pneumonia or aspiration of oral anaerobes.

Other causes include:

  • bronchial obstruction

  • tumor

  • foreign body

  • TB

  • PE

  • chest trauma.

Typical manifestations

A classic finding is:

copious, foul-smelling sputum

Other findings:

  • fever

  • productive cough

  • blood-tinged sputum

  • dyspnea

  • weakness

  • anorexia

  • weight loss

  • pleuritic or dull chest pain.

Diagnostic clues:

  • chest x-ray showing a cavity with an air-fluid level

  • sputum cultures

  • sometimes bronchoscopy.

7. Lung abscess nursing management

Main goals:

  • treat infection

  • promote drainage

  • clear secretions

  • maintain nutrition/hydration.

Nursing priorities:

  • monitor sputum amount/odor/color

  • administer prescribed antimicrobials

  • encourage airway clearance

  • monitor for spread into pleural space.

If infection enters the pleural cavity, it can cause empyema.

8. Sarcoidosis

Sarcoidosis is a chronic inflammatory disorder that can involve multiple organs, commonly the lungs.

Nursing care centers on:

  • supporting prescribed therapy

  • monitoring progression

  • teaching about corticosteroids

  • psychosocial support.

The textbook notes corticosteroids may be used to reduce inflammation, with other immune-modulating drugs considered if response is inadequate.

Patients need ongoing follow-up because no single test alone tracks disease progression or recurrence.

9. Pleurisy

Pleurisy, or pleuritis, = inflammation of the pleural layers.

The hallmark symptom is sharp pleuritic pain that gets worse with:

  • inspiration

  • coughing

  • sneezing.

The pain may:

  • be localized

  • radiate to shoulder/abdomen

  • decrease when the patient holds their breath.

A pleural friction rub may be heard when the inflamed pleural surfaces rub together.

10. Pleural effusion

Pleural effusion = abnormal accumulation of fluid in the pleural space.

The textbook distinguishes:

Transudate

Usually from pressure imbalance, especially:

  • heart failure.

Exudate

Usually from:

  • inflammation

  • infection

  • tumor.

Assessment findings

Classic findings:

  • decreased/absent breath sounds

  • decreased fremitus

  • dull/flat percussion

  • dyspnea.

A very large effusion can cause:

  • respiratory distress

  • tracheal deviation away from the affected side.

11. Pleural effusion management

Treatment goals:

  • identify/treat the cause

  • prevent recurrence

  • improve breathing.

Thoracentesis may be used to:

  • remove fluid

  • obtain a specimen

  • relieve dyspnea.

After thoracentesis, monitor for:

  • respiratory distress

  • pneumothorax

  • reaccumulation of fluid.

12. Empyema

Empyema = pus in the pleural space.

Think of it as an infected pleural effusion.

It can develop from:

  • pneumonia

  • lung abscess

  • chest infection.

Management may require:

  • prolonged antibiotics

  • drainage.

For exams:

pleural effusion = fluid
empyema = infected/purulent fluid

13. Pulmonary hypertension

Pulmonary hypertension means increased pressure/resistance in pulmonary circulation.

This forces the right ventricle to pump against more resistance.

Over time:

↑ pulmonary vascular resistance → ↑ RV workload → right ventricular enlargement/failure

The nurse should watch for:

  • dyspnea

  • fatigue

  • exercise intolerance

  • hypoxemia

  • signs of right-sided heart strain.

The textbook emphasizes identifying high-risk patients early, giving oxygen appropriately, and teaching about home oxygen and prescribed pulmonary vasodilator therapy.

14. Cor pulmonale

Cor pulmonale is right-sided heart disease/failure caused by pulmonary hypertension.

Path:

lung/pulmonary vascular disease → pulmonary HTN → RV works harder → RV enlargement → right-sided HF.

So if you see:

  • pulmonary hypertension

  • JVD

  • peripheral edema

  • right-sided failure findings

think:
cor pulmonale.

15. Pulmonary embolism — PE

A PE is obstruction of a pulmonary artery or one of its branches by an embolus, usually a thrombus originating in the venous system.

This ties directly back to Chapter 17:

air reaches alveoli, but blood flow is blocked → high V/Q / dead space

16. PE manifestations

The textbook says the most frequent symptom is:
dyspnea

and the most frequent sign is:
tachypnea.

Other possible findings:

  • sudden pleuritic chest pain

  • anxiety/apprehension

  • tachycardia

  • cough

  • diaphoresis

  • hemoptysis

  • syncope.

17. PE diagnosis

Diagnostic tools may include:

  • D-dimer

  • pulse oximetry

  • ABG

  • ECG

  • chest x-ray

  • V/Q scan

  • multidetector CT angiography.

The textbook identifies MDCTA as the standard diagnostic imaging method for PE.

ABGs may show:

  • hypoxemia

  • hypocapnia from tachypnea

but can sometimes be normal.

18. Unstable PE

An unstable PE can cause:

  • hypotension

  • tachycardia

  • confusion

  • cardiovascular collapse.

Why?

Large obstruction:
→ ↑ pulmonary resistance
→ right ventricle struggles
→ right-sided failure
→ cardiac output falls.

This is life-threatening.

19. PE nursing priorities

Main goals:

  • oxygenation

  • hemodynamic stability

  • prevent more clot formation

  • monitor anticoagulant/thrombolytic therapy.

Nursing care includes:

  • monitor oxygenation

  • monitor bleeding

  • limit unnecessary invasive procedures during thrombolysis

  • assess chest pain/dyspnea

  • position for comfort

  • reduce anxiety.

20. Occupational lung disease

Pneumoconiosis is lung disease caused by inhaled dust depositing deep in the lungs and causing damage/fibrosis.

Major examples:

Silicosis

Associated with:

  • stone cutting

  • foundry work

  • glass manufacturing.

Can cause:

  • fibrosis

  • restrictive disease

  • hypoxemia

  • pulmonary hypertension

  • cor pulmonale.

Asbestosis

Associated with:

  • shipbuilding

  • demolition/construction.

Can cause:

  • pleural thickening/plaques

  • restrictive disease

  • hypoxemia

  • respiratory failure

  • increased risk of lung cancer and mesothelioma.

Coal worker's pneumoconiosis

Also called:
black lung disease

Associated with coal dust exposure.

21. Prevention of occupational lung disease

This is specifically one of the chapter learning outcomes.

Prevention includes:

  • reducing exposure

  • engineering controls/ventilation

  • appropriate protective equipment

  • workplace monitoring

  • screening workers

  • following exposure regulations.

The important idea:

These diseases are often preventable but not easily reversible once fibrosis develops.

22. Lung cancer

The textbook divides most lung cancers into:

NSCLC — non-small cell lung cancer

About 80–85%.

Includes:

  • adenocarcinoma

  • squamous cell carcinoma

  • large cell carcinoma.

SCLC — small cell lung cancer

About 10–15%.

More aggressive:

  • grows rapidly

  • metastasizes early.

23. NSCLC vs SCLC

NSCLC

More likely to be surgically treated if:

  • localized

  • no metastasis

  • patient can tolerate surgery.

SCLC

Usually:

  • grows quickly

  • spreads early

  • more often treated with systemic therapy/radiation.

Surgery is used much less often because metastasis commonly exists by diagnosis.

Easy memory:

NSCLC = surgery may be possible
SCLC = spreads sooner

24. Lung cancer risk factors

Biggest risk emphasized in the textbook:
cigarette smoke

Other risk factors include:

  • secondhand smoke

  • occupational exposures

  • asbestos

  • radon

  • environmental pollutants

  • genetic predisposition

  • underlying lung disease.

The text also notes asbestos exposure raises risk for:

  • lung cancer

  • mesothelioma.

25. Lung cancer manifestations

Possible findings can include:

  • persistent/change in cough

  • hemoptysis

  • dyspnea

  • chest pain

  • recurrent respiratory infection

  • unexplained weight loss

  • fatigue.

Symptoms vary depending on:

  • tumor location

  • size

  • metastasis.

26. Lung cancer diagnosis

Common tools include:

  • chest imaging

  • bronchoscopy

  • biopsy

  • CT-guided needle aspiration

  • PET scans

  • brain imaging

  • lymph-node sampling.

Bronchoscopy is particularly useful because it can:

  • directly inspect airways

  • obtain washings

  • obtain brushings

  • biopsy lesions.

27. Lung cancer treatments

Depends on:

  • cell type

  • stage

  • cardiopulmonary status.

Possible therapies:

  • surgery

  • chemotherapy

  • radiation

  • immunotherapy

  • targeted therapy.

28. Thoracotomy

Thoracotomy = surgical opening of the chest.

Used for procedures such as lung resection.

Types of resection include:

Pneumonectomy

Entire lung removed.

Lobectomy

One lobe removed.

Segmentectomy

One bronchopulmonary segment removed.

Wedge resection

Small wedge-shaped area removed.

Sleeve resection

Part of a bronchus removed and remaining ends reconnected.

29. Lobectomy vs pneumonectomy

Lobectomy

One lobe is removed.

Usually chest tubes are inserted:

  • upper tube removes air

  • lower tube drains fluid.

Pneumonectomy

Entire lung removed.

The textbook notes that a chest drain is usually not used, because fluid gradually fills the empty hemithorax and helps prevent mediastinal shift.

That distinction is very testable.

30. Pre-op thoracotomy nursing care

Teaching should begin before surgery.

Teach:

  • what to expect

  • oxygen therapy

  • possible ventilator use

  • chest tubes/drainage

  • frequent turning

  • coughing

  • deep breathing

  • incentive spirometry

  • diaphragmatic breathing

  • pursed-lip breathing

  • incision splinting.

This connects directly back to Chapter 16 and 19:
preventing atelectasis and retaining pulmonary function after surgery.

31. Post-thoracotomy nursing priorities

Think:

Airway + breathing + pain + drainage + mobility

Monitor:

  • respiratory status

  • oxygen saturation

  • breath sounds

  • chest-tube drainage if present

  • incision

  • pain

  • activity tolerance.

Pain control is essential because without it:
→ shallow breathing
→ poor cough
→ secretion retention
→ atelectasis/pneumonia.

32. Why thoracic pain control is so important

This is a recurring concept from Chapters 16, 19, and 20.

If the patient doesn't breathe deeply because of pain:

pain → splinting/shallow breathing → ↓ expansion → retained secretions → atelectasis → pneumonia

So analgesia is not just comfort.

It is part of respiratory-complication prevention.

33. Key connections to previous chapters

Chapter 17

You learned:
ventilation + diffusion + perfusion + V/Q

Chapter 20 applies that:

  • PE → perfusion problem / dead space

  • pleural effusion → compressed lung / reduced ventilation

  • occupational fibrosis → impaired diffusion/compliance

  • lung cancer → obstruction/compression/gas-exchange impairment.

Chapter 19

You learned:

  • acute respiratory failure

  • pneumonia

  • pneumothorax

  • chest tubes.

Chapter 20 takes you into longer-term/nonacute causes and surgery.

What I would memorize for your nursing exam

  1. TB active disease → airborne transmission precautions.

  2. TB treatment requires multiple drugs and strict adherence.

  3. Lung abscess = cavity of pus, often after aspiration/pneumonia.

  4. Foul-smelling copious sputum = think lung abscess.

  5. Sarcoidosis = chronic inflammatory disease; corticosteroids may be used.

  6. Pleuritic pain worsens with inspiration/coughing.

  7. Pleural effusion → ↓ breath sounds + ↓ fremitus + dull percussion.

  8. Thoracentesis removes pleural fluid and relieves dyspnea.

  9. Empyema = pus in pleural space.

  10. Pulmonary HTN increases RV workload.

  11. Cor pulmonale = right-sided heart failure from pulmonary hypertension.

  12. PE = pulmonary artery obstruction, usually from venous thrombus.

  13. PE: dyspnea most common symptom; tachypnea common sign.

  14. PE creates a high V/Q / dead-space problem.

  15. Pneumoconiosis = dust-related occupational lung disease.

  16. Silicosis/asbestosis → fibrosis/restrictive physiology.

  17. Asbestos exposure increases mesothelioma/lung cancer risk.

  18. NSCLC is more commonly surgical when localized.

  19. SCLC grows and metastasizes rapidly.

  20. Lobectomy = remove lobe; pneumonectomy = remove entire lung.

  21. After lobectomy, chest tubes are common.

  22. After pneumonectomy, chest drainage is usually not used.

  23. Thoracotomy teaching: cough, deep breathe, IS, turn, splint incision.

  24. Adequate pain control prevents postoperative pulmonary complications.

A good one-line map for Chapter 20 is:

INFECTION → PLEURA → VASCULATURE → EXPOSURE → CANCER → SURGERY

That gives you:
TB/lung abscess → pleurisy/effusion → PH/PE → pneumoconiosis → lung cancer → thoracotomy.