MANAGEMENT OF PATIENTS WITH CHEST AND LOWER

RESPIRATORY TRACT DISORDERS

ATELECTASIS
- Closure or collapse of alveoli
- Acute or chronic
- Most common is acute atelectasis, which occurs in the postoperative setting
- Symptoms: insidious, increasing dyspnea, cough, and sputum production
- Acute: tachycardia, tachypnea, pleural pain, and central cyanosis if large areas of the lung
are affected
- Chronic: similar to acute, pulmonary infection may be present

- A collapsed or airless state of the lung

that may be the result of airway
obstruction caused by accumulated
secretions or failure of the client to
deep-breathe or ambulate after
surgery.
- a postoperative complication that
usually occurs 1 to 2 days after
surgery

❖ ASSESSMENT AND DIAGNOSIS #1

● Characterized by increased work of breathing and hypoxemia
● Decreased breath sounds and crackles over the affected area
● Chest x-ray may suggest a diagnosis of atelectasis before clinical symptoms appear
● Pulse oximetry (SpO2) may demonstrate a low saturation of hemoglobin with oxygen
(less than 90%)

❖ NURSING INTERVENTIONS
• Prevention
- Frequent turning
- Early mobilization
- Strategies to expand lungs and manage secretions
- Incentive spirometer

1
 - Voluntary deep breathing
- Secretion management
- Pressurized metered-dose inhaler

❖ MANAGEMENT
• Improve ventilation and remove secretions
• First line measures:
o Frequent turning, early ambulation, lung volume expansion maneuvers and
coughing
• PEEP, CPAB, bronchoscopy
• CPT
• Endotracheal intubation and mechanical ventilation
• Thoracentesis to relieve compression

❖ PULMONARY INFECTIONS
• Severe acute respiratory syndrome (SARS)—viral, no cases reported since 2004,
CDC
• Lung abscess
• Tuberculosis
• Tracheobronchitis
• Pneumonia

LUNG ABSCESS
- Most are a complication of bacterial pneumonia
- Symptoms vary from a mild productive cough to acute illness; plueral friction rub
- Drainage achieved through postural drainage and chest physiotherapy
- IV antibiotic therapy for 3 weeks or longer, followed by oral antibiotics for 4 to 12
weeks

❖ NURSING MANAGEMENT: LUNG ABSCESS

▪ Administer IV antibiotics
▪ CPT
▪ Educate patient to perform deep breathing and coughing exercises
▪ Encourage diet high in protein and calories
▪ Emotional support

PULMONARY TUBERCULOSIS
- Highly communicable disease caused by Mycobacterium tuberculosis

- M. tuberculosis is a nonmotile, nonsporulating, acid-fast rod that secretes niacin;

when the bacillus reaches a susceptible site, it multiplies freely.

- Because M. tuberculosisis an aerobic bacterium, it primarily affects the pulmonary

system, especially the upper lobes, where the oxygen content is highest, but also can
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 affect other areas of the body, such as the brain, intestines, peritoneum, kidney, joints,
and liver

- S&S are insidious

o Low grade fever
o Cough; nonproductive or mucopurulent; hemoptysis
o Night sweats, fatigue, weight loss

❖ RISK FACTORS FOR TUBERCULOSIS

• Close contact with someone who has active TB.

• Inhalation of airborne nuclei from an infected person is proportional to the amount
of time spent in the same air space, the proximity of the person, and the degree of
ventilation.
• Immunocompromised status (e.g., those with HIV infection, cancer, transplanted
organs, and prolonged high-dose corticosteroid therapy).
• Substance abuse (IV/injection drug users and alcoholics).
• Any person without adequate health care (the homeless; impoverished; minorities,
particularly children)
• Preexisting medical conditions or special treatment (e.g., diabetes, chronic kidney
injury, malnourishment, selected malignancies, hemodialysis, transplanted organ,
gastrectomy, and jejunoileal bypass).
• Immigration from or recent travel to countries with a high prevalence of TB
(southeastern Asia, Africa, Latin America, Caribbean).
• Institutionalization (e.g., long-term care facilities, psychiatric institutions, prisons).
• Living in overcrowded, substandard housing.
• Being a health care worker performing high-risk activities: administration of
aerosolized pentamidine and other medications, sputum induction procedures,

3
 bronchoscopy, suctioning, coughing procedures, caring for the immunosuppressed
patient, home care with the high-risk population, and administering anesthesia and
related procedures (e.g., intubation, suctioning).

❖ PULMONARY TUBERCULOSIS ASSESSMENT/FINDINGS

▪ History and physical
▪ TB skin test; Mantoux method
▪ Chest x-ray
▪ Sputum testing
▪ Drug susceptibility testing

❖ CLINICAL MANIFESTATIONS
▪ May be asymptomatic in primary infection
▪ Fatigue
▪ Lethargy
▪ Anorexia
▪ Weight loss
▪ Low-grade fever
▪ Chills
▪ Night sweats
▪ Persistent cough and the production of mucoid and mucopurulent sputum,
which is occasionally streaked with blood
▪ Chest tightness and a dull, aching chest pain may accompany the cough.

❖ NURSING MANAGEMENT OF TUBERCULOSIS

▪ Promoting airway clearance
▪ Advocating adherence to the treatment regimen DOTS
▪ Promoting activity and nutrition
▪ Preventing transmission

PNEUMONIA

- Inflammation of the lung parenchyma caused by various microorganisms, including

bacteria, mycobacteria, fungi, and viruses

- Classification
o Community acquired (CAP)
o Healthcare associated (HCAP)
o Hospital acquired (HAP)
o Ventilator associated (VAP)

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❖ PNEUMONIA

The edema associated with inflammation stiffens

the lung, decreases lung compliance and vital
capacity, and causes hypoxemia.

The chest x-ray film shows lobar or segmental

consolidation, pulmonary infiltrates, or pleural
effusions.

A sputum culture identifies the organism.

The white blood cell count and the erythrocyte

sedimentation rate are elevated.

❖ PNEUMONIA RISK FACTORS

- age groups at highest risk are:
▪ Children who are 2 years old or younger
▪ People who are age 65 or older
- Other risk factors include:
▪ Being hospitalized

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 ▪ Chronic disease
▪ Smoking
▪ Weakened or suppressed immune system
▪ Cystic fibrosis

❖ CLINICAL MANIFESTATIONS
➢ Varies depending on type, causal organism, and presence of underlying disease
➢ Streptococcal: Sudden onset of chills, fever, pleuritic chest pain, tachypnea, and
respiratory distress
➢ Viral, mycoplasma, or Legionella: relative bradycardia
➢ Other: Respiratory tract infection, headache, low-grade fever, pleuritic pain, myalgia, rash,
and pharyngitis
➢ Orthopnea, crackles, increased tactile fremitus, purulent sputum

❖ ASSESSMENT AND DIAGNOSIS #2

• History
• Physical exam
• Chest x-ray
• Blood culture
• Sputum examination
• Bronchoscopy may be used for acute severe infection

❖ MEDICAL MANAGEMENT
▪ Administration of the appropriate antibiotic as determined by the results of a culture
and sensitivity
▪ Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives,
decongestants, and antihistamines
▪ Antibiotics not indicated for viral infections but are used for secondary bacterial
infection

❖ NURSING PROCESS: ASSESSMENT

➢ Vital signs
➢ Secretions: amount, odor, color
➢ Cough: frequency and severity
➢ Tachypnea, shortness of breath
➢ Inspect and auscultate chest (Rales lower lobe)
➢ Changes in mental status, fatigue, edema, dehydration, concomitant heart failure,
especially in older adult patients

❖ NURSING PROCESS: DIAGNOSES

▪ Ineffective Airway Clearance
▪ Fatigue and Activity Intolerance
▪ Risk for Fluid Volume Deficit
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 ▪ Imbalanced Nutrition
▪ Knowledge Deficit

❖ COLLABORATIVE PROBLEMS
• Continuing symptoms after initiation of therapy
• Sepsis and septic shock
• Respiratory failure
• Atelectasis
• Pleural effusion
• Delirium

❖ NURSING PROCESS: PLANNING

➢ Improved airway patency
➢ Increased activity
➢ Maintenance of proper fluid volume
➢ Maintenance of adequate nutrition
➢ Understanding of the treatment protocol and preventive measures
➢ Absence of complications

❖ PREVENTION
▪ Pneumococcal vaccination
- Reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and
deaths in the older adult population
- Two types of pneumococcal vaccine
- Recommended for all adults 65 years of age or older and 19 years or older with
conditions that weaken the immune system

❖ NURSING PROCESS: INTERVENTIONS

• Incentive spirometry
• Oxygen with humidification to loosen
• Nutrition
secretions
o Face mask or nasal cannula • Hydration
• Coughing techniques • Rest
• Chest physiotherapy • Activity as tolerated
• Position changes • Patient teaching
• Self-care

❖ EXPECTED OUTCOMES
• Demonstrates improved airway patency
• Rests and conserves energy and then slowly increasing activities
• Maintains adequate hydration; adequate dietary intake
• Verbalizes increased knowledge about management strategies
• Complies with management strategies
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 • Exhibits no complications

❖ ASPIRATION #1
▪ Inhalation of foreign material into the lungs
▪ Serious complication of pneumonia
▪ Clinical picture: tachycardia, dyspnea, central cyanosis, hypertension,
hypotension, and potential death

❖ RISK FACTORS
o Decreased ability to clear oropharyngeal secretions - Poor cough or gag reflex,
impaired swallowing mechanism (eg, dysphagia in stroke patients), impaired ciliary
transport (eg, from smoking)
o Increased volume of secretions
o Increased bacterial burden of secretions
o Presence of other comorbidities - Anatomic abnormalities, gastroesophageal
reflux disease (GERD), achalasia.

❖ ASPIRATION #2
Nursing interventions:
✓ Keep HOB elevated >30 degrees
✓ Avoid stimulation of gag reflex with suctioning or other procedures
✓ Check for placement before tube feedings
✓ Thickened fluids for swallowing problems

❖ PLEURAL CONDITIONS
• Disorders that involve
o The membranes covering the lungs (visceral pleura) and the surface
of the chest wall (parietal pleura)
o Disorders affecting the pleural space
• Pluerisy
• Plueral effusion
• Empyema
• Pulmonary edema

PLEURISY
- Inflammation of both layers of pleurae
- Key characteristic of pleuritic pain is its relationship to respiratory movement
- Pleural friction rub can be heard with the stethoscope
- Diagnostic tests may include chest x-rays, sputum analysis, thoracentesis
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- Treat underlying cause, provide analgesia, teaching to splint the rib cage when coughing

❖ASSESSMENT
• Knifelike pain aggravated on deep breathing and coughing
• Dyspnea
• Pleural friction rub heard on auscultation

❖INTERVENTIONS
✓ Identify and treat the cause.
✓ Monitor lung sounds.
✓ Administer analgesics as prescribed.
✓ Apply hot or cold applications as prescribed.
✓ Encourage coughing and deep breathing.
✓ Instruct the client to lie on the affected side to splint chest.

❖PLEURAL EFFUSION
- Fluid collection in pleural space usually secondary to heart failure, TB, pneumonia,
pulmonary infections
- Fever, chills, pleuritic pain, dyspnea
- Decreased or absent breath sounds; decreased fremitus; and a dull, flat sound on
percussion
- May have tracheal deviation away from affected side
- Chest x-ray, chest CT, and thoracentesis

❖ASSESSMENT
• Pleuritic pain that is sharp and increases with inspiration
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 • Progressive dyspnea with decreased movement of the chest wall on the affected
side
• Dry, nonproductive cough caused by bronchial irritation or mediastinal shift
• Tachycardia
• Elevated temperature
• Decreased breath sounds over affected area
• Chest x-ray film that shows pleural effusion and a mediastinal shift away from the
fluid if the effusion is more than 250 mL

❖INTERVENTIONS
✓ Identify and treat the underlying cause.
✓ Monitor breath sounds.
✓ Place the client in a Fowler’s position.
✓ Encourage coughing and deep breathing.
✓ Prepare the client for thoracentesis.
✓ If pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as
prescribed.
Pleurectomy
1. Consists of surgically stripping the parietal pleura away from the visceral
pleura
2. This produces an intense inflammatory reaction that promotes adhesion
formation between the 2 layers during healing.
Pleurodesis
1. Involves the instillation of a sclerosing substance into the pleural space via
a thoracotomy tube
2. The substance creates an inflammatory response that scleroses tissue
together.

EMPYEMA
- Accumulation of thick, purulent fluid in pleural space
- Complication of bacterial pneumonia or lung abscess
- Acutely ill and has signs and symptoms similar to those of an acute respiratory infection
or pneumonia
- Chest auscultation demonstrates decreased or absent breath sounds over the affected
area
- Chest CT and a diagnostic thoracentesis

❖ ASSESSMENT

• Recent febrile illness or trauma

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 • Chest pain
• Cough
• Dyspnea
• Anorexia and weight loss
• Malaise
• Elevated temperature and chills
• Night sweats
• Pleural exudate on chest x-ray

❖ INTERVENTION

✓ Monitor breath sounds.

✓ Place the client in a semi-Fowler’s or high Fowler’s position.
✓ Encourage coughing and deep breathing.
✓ Administer antibiotics as prescribed.
✓ Instruct the client to splint the chest as necessary.
✓ Assist with thoracentesis or chest tube insertion to promote drainage and lung
expansion.
✓ If marked pleural thickening occurs, prepare the client for decortication, if prescribed;
this surgical procedure involves removal of the restrictive mass of fibrin and
inflammatory cells.Recent febrile illness or trauma

❖ ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

- Characterized by sudden, progressive pulmonary edema, increasing bilateral lung
infiltrates visible on chest x-ray, and absence of an elevated left atrial pressure
- Rapid onset of severe dyspnea
- Hypoxemia that does not respond to supplemental oxygen therapy
- The interstitial edema causes compression and obliteration of the terminal airways
and leads to reduced lung volume and compliance.
- The ABG levels identify respiratory acidosis and hypoxemia that do not respond to an
increased percentage of oxygen.
- The chest x-ray shows bilateral interstitial and alveolar infiltrates; interstitial edema
may not be noted until there is a 30% increase in fluid content.

❖ ASSESSMENT
• Tachypnea
• Dyspnea
• Decreased breath sounds
• Deteriorating ABG levels
• Hypoxemia despite high concentrations of delivered oxygen
• Decreased pulmonary compliance
• Pulmonary infiltrates
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 ❖ INTERVENTION
✓ Identify and treat the cause of the acute respiratory distress syndrome.
✓ Administer oxygen as prescribed.
✓ Place the client in a Fowler’s position.
✓ Prone positioning is best for oxygenation, frequent repositioning to safeguard
integumentary system
✓ Restrict fluid intake as prescribed.
✓ Nutritional support, enteral feedings preferred
✓ Provide respiratory treatments as prescribed.
✓ Administer diuretics, anticoagulants, or corticosteroids as prescribed.
✓ Prepare the client for intubation and mechanical ventilation using PEEP.

SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

- Respiratory illness caused by a coronavirus, called SARS-associated coronavirus
- The syndrome begins with a fever, an overall feeling of discomfort, body aches, and mild
respiratory symptoms.
- After 2 to 7 days, the client may develop a dry cough and dyspnea.
- Infection is spread by close person-to-person contact by direct contact with infectious
material (respiratory secretions from infected persons or contact with objects
contaminated with infectious droplets).
- Prevention includes avoiding contact with those suspected of having SARS, avoiding
travel to countries where an outbreak of SARS exists, avoiding close contact with crowds
in areas where SARS exists, and frequent hand washing if in an area where SARS exists.

❖ ASSESSMENT
• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• Loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

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 ❖NURSING CARE PLANNING AND GOALS
➢ Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange,
nutritional needs, and nausea
➢ Preventing the spread of coronavirus infection to the patient’s family members,
community, and healthcare providers
➢ Providing more information about COVID-19 and its management to the patient
Reducing fever
➢ Restoring normal respiratory patterns
➢ Easing anxiety, which is relatively common in COVID-19 patients, with a combination
of anxiolytic medications and psychotherapy that includes relaxation techniques,
breathing exercises and encouragement

❖ INTERVENTIONS
✓ Monitor vital signs
✓ Monitor O2 saturation
✓ Administer oxygen as prescribed.
✓ Place the client in a Fowler’s position.
✓ Prone positioning is best for oxygenation, frequent repositioning to safeguard
integumentary system
✓ Manage fever
✓ Maintain respiratory isolation
✓ Enforce strict hand hygiene
✓ Provide information
✓ Reduce anxiety

PULMONARY EMBOLI
- Obstruction of the pulmonary artery or one of
its branches by a thrombus (or thrombi) that
originates somewhere in the venous system
or in the right side of the heart

- Inflammatory process obstructs area, results

in diminished or absent blood flow

- Bronchioles constrict, further increasing

pulmonary vascular resistance, pulmonary
arterial pressure, and right ventricular
workload

- Ventilation–perfusion imbalance, right

ventricular failure, shock occurs 13
❖ RISK FACTORS FOR PULMONARY EMBOLI
• Trauma
• Surgery
• Pregnancy
• Heart failure
• Hypercoagulability
• Immobility, venous stasis
• Dyspnea is the most common symptom

❖ PREVENTION AND TREATMENT OF PULMONARY EMBOLI

▪ Exercises to avoid venous stasis
o Early ambulation
o Anti-embolism stockings
▪ Treatment
o Measures to improve respiratory and vascular status
o Anticoagulation and thrombolytic therapy
o Surgical interventions

QUESTION #1
Is the following statement true or false?
Bradypnea is the most common sign for a possible pulmonary embolism

ANSWER TO QUESTION #1
False
Rationale: Tachypnea is the most common sign for a possible pulmonary embolism

PNEUMOCONIOSES
- Occupational lung diseases and includes asbestosis, silicosis, and coal workers'
pneumoconiosis
- Refers to a nonneoplastic alteration of the lung resulting from inhalation of mineral
or inorganic dust
- Preventable, not treatable
- Reduce exposure, protective gear/devices
- Role of nurse is to be the employee advocate and provide health education on
preventive measures to reduce lung injury

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 MANAGEMENT OF PATIENTS WITH CHRONIC PULMONARY DISEASE

CHRONIC OBSTRUCTIVE PULMONARY DISEASEAND ASSOCIATED RESPIRATORY

DISEASES
- COPD is a slowly progressive respiratory disease of airflow obstruction
o Emphysema, chronic bronchitis
o Preventable and treatable but not fully reversible
o Involving the airways, pulmonary parenchyma, or both
- Other
o Cystic fibrosis, bronchiectasis, asthma

❖ PATHOPHYSIOLOGY OF COPD
• Airflow limitation is progressive, associated with abnormal inflammatory
response to noxious particles or gases
• Chronic inflammation damages tissue
• Scar tissue in airways results in narrowing
• Scar tissue in the parenchyma decreases elastic recoil (compliance)
• Scar tissue in pulmonary vasculature causes thickened vessel lining and
hypertrophy of smooth muscle (pulmonary hypertension)

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 CHRONIC BRONCHITIS
- Cough and sputum production for at least 3 months in each of 2 consecutive
years
- Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow,
and mucous may plug airways
- Alveoli become damaged, fibrosed, and alveolar macrophage function
diminishes
- The patient is more susceptible to respiratory infections

PATHOPHYSIOLOGY OF CHRONIC BRONCHITIS

QUESTION #1

Is the following statement true or false?

For patients with chronic bronchitis, the nurse expects to see the major clinical symptoms of
tachypnea and tachycardia

ANSWER TO QUESTION #1

False
For patients with chronic bronchitis, the nurse expects to see the major clinical symptoms of
sputum and productive cough

EMPHYSEMA
- Abnormal distention of air spaces beyond the terminal bronchioles with destruction
of the walls of the alveoli
- Decreased alveolar surface area increases in “dead space,” impaired oxygen
diffusion
- Hypoxemia results
- Increased pulmonary artery pressure may cause right-sided heart failure (cor
pulmonale)

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 CHANGES IN ALVEOLAR STRUCTURE

❖ CLINICAL MANIFESTATIONS OF COPD

• Three primary symptoms
o Chronic cough
o Sputum production
o Dyspnea
• Weight loss due to dyspnea
• “Barrel chest”

NORMAL CHEST VERSUS BARREL-SHAPED CHEST

17
TYPICAL POSTURE OF A PERSON WITH COPD

Emphysema Vs. Chronic Bronchitis

18
 QUESTION #2

What is the primary clinical symptom of emphysema?

A. Chest pain
B. Productive cough
C. Sputum
D. Wheezing

ANSWER TO QUESTION #2
D. Wheezing
The primary symptom of emphysema is wheezing.
Sputum and productive cough are the primary symptoms of chronic bronchitis

❖ ASSESSMENT AND DIAGNOSIS OF COPD

o Pulmonary function tests
o Spirometry
o Arterial blood gas
o Chest x-ray

❖ Assessing Patients With Chronic Obstructive Pulmonary Disease

• Has the patient been exposed to risk factors (types, intensity, duration)?
• Does the patient have a past medical history of respiratory diseases/problems,
including asthma, allergy, sinusitis, nasal polyps, or respiratory infections?
• Does the patient have a family history of chronic obstructive pulmonary
disease or other chronic respiratory diseases?
• How long has the patient had respiratory difficulty?
• What is the pattern of symptom development?
• Does exertion increase the dyspnea? What type of exertion?
• What are the limits of the patient’s tolerance for exercise?
• At what times during the day does the patient complain most of fatigue and
shortness of breath?
• Does the patient describe any discomfort or pain in any part of the body?
• Which eating and sleeping habits have been affected?
• What is the impact of respiratory disease on quality of life?
• What does the patient know about the disease and their condition?
• What is the patient’s smoking history (primary and secondary)?

❖ Assessing Patients With Chronic Obstructive Pulmonary Disease

• What are the pulse and the respiratory rates?
• What is the character of respirations? Even and without effort? Other?
• Can the patient complete a sentence without having to take a breath?
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 • Does the patient contract the abdominal muscles during inspiration?
• Does the patient use accessory muscles of the shoulders and neck when
breathing?
• Does the patient take a long time to exhale (prolonged expiration)?
• Is central cyanosis evident? Are the patient’s neck veins engorged?
• Does the patient have peripheral edema?
• Is the patient coughing?
• What are the color, amount, and consistency of the sputum?
• Is clubbing of the fingers present?
• What types of breath sounds (i.e., clear, diminished or distant, crackles, and
wheezes) are heard?
• Describe and document findings and locations. Are there any sensory deficits?
• Is there short- or long-term memory impairment?
• Is there increasing stupor?
• Is the patient apprehensive?

❖ COMPLICATIONS OF COPD
o Respiratory insufficiency and failure
o Pneumonia
o Chronic atelectasis
o Pneumothorax
o Cor pulmonale

❖ MEDICAL MANAGEMENT
▪ Promote smoking cessation
▪ Reducing risk factors
▪ Managing exacerbations
▪ Providing supplemental oxygen therapy
▪ Pneumococcal vaccine
▪ Influenza vaccine
▪ Pulmonary rehabilitation
▪ Managing exacerbations

❖ SURGICAL MANAGEMENT
• Bullectomy
• Lung volume reduction
• Lung transplant

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❖ MEDICATIONS TO TREAT COPD
• Bronchodilators, MDIs
o Beta-adrenergic agonists
o Muscarinic antagonists (anticholinergics)
o Combination agents
• Corticosteroids
• Antibiotics
• Mucolytics
• Antitussives

❖ NURSING MANAGEMENT

1. Monitor vital signs.

2. Administer a concentration of oxygen based on ABG values and oxygen
saturation by pulse oximetry as prescribed.
3. Monitor pulse oximetry.
4. Provide respiratory treatments and CPT.
5. Instruct the client in diaphragmatic or abdominal breathing techniques
and pursed-lip breathing techniques, which increase airway pressure and
keep air passages open, promoting maximal carbon dioxide expiration.
6. Record the color, amount, and consistency of sputum.
7. Suction the client’s lungs, if necessary, to clear the airway and prevent
infection.
8. Monitor weight.
9. Encourage small, frequent meals to maintain nutrition and prevent
dyspnea.
10. Provide a high-calorie, high-protein diet with supplements.
11. Encourage fluid intake up to 3000 mL/day to keep secretions thin, unless
contraindicated.
12. Place the client in Fowler’s position and lean forward to aid in breathing.
13. Allow activity as tolerated.
14. Administer bronchodilators as prescribed and instruct the client in the
use of oral and inhalant medications.
15. Administer corticosteroids as prescribed for exacerbations.
16. Administer mucolytics as prescribed to thin secretions.
17. Administer antibiotics for infection if prescribed.

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 BRONCHIECTASIS
- Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles
- Caused by:
o Airway obstruction, pulmonary infections
o Diffuse airway injury
o Genetic disorders
o Abnormal host defenses
o Idiopathic causes

❖ BRONCHIECTASIS: CLINICAL MANIFESTATIONS AND MEDICAL MANAGEMENT

• Chronic cough
• Purulent sputum in copious amounts
• Clubbing of the fingers
• Postural drainage
• Chest physiotherapy
• Smoking cessation
• Antimicrobial therapy
• Bronchodilators and mucolytics

❖ BRONCHIECTASIS: NURSING MANAGEMENT

• Focus is on alleviating symptoms and clearing pulmonary secretions
• Patient teaching
➢ Smoking cessation
➢ Postural drainage
➢ Early signs and symptoms of respiratory infections
➢ Conserving energy

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 ASTHMA

● Chronic inflammatory disease of the

airways that causes
hyperresponsiveness, mucosal edema,
and mucus production

● Inflammation leads to cough, chest

tightness, wheezing, and dyspnea

● Asthma is largely reversible;

spontaneously or with treatment

● Allergy is the strongest predisposing

factor

❖ CLINICAL MANIFESTATIONS
• Cough, dyspnea, wheezing
• Exacerbations
- Cough, productive or not
- Generalized wheezing
- Chest tightness and dyspnea
- Diaphoresis
- Tachycardia
- Hypoxemia and central cyanosis

❖ MEDICATIONS MANAGEMENT FOR ASTHMA

• Quick-relief medications
- Beta2-adrenergic agonists
- Anticholinergics
• Long-acting medications
- Corticosteroids
- Long-acting beta2-adrenergic agonists
- Leukotriene modifiers

❖ PATIENT TEACHING
• How to identify and avoid triggers
• Proper inhalation techniques
• How to perform peak flow monitoring
• How to implement an action plan
• When and how to seek assistance
23
 USING A PEAK FLOW METER

CYSTIC FIBROSIS
- Most common autosomal recessive disease among the Caucasian population
- Genetic screening to detect carriers
- Genetic counseling for couples at risk
- Genetic mutation changes chloride transport which leads to thick, viscous
secretions in the lungs, pancreas, liver, intestines, and reproductive tract
- Respiratory infections are the leading cause of morbidity and mortality

❖ MEDICAL MANAGEMENT OF CYSTIC FIBROSIS

• Chronic: control of infections; antibiotics

• Acute: aggressive therapy involves airway clearance and antibiotics
based on results of sputum cultures
• Anti-inflammatory agents
• Corticosteroids; inhaled, oral, IV during exacerbations
• Inhaled bronchodilators
• Oral pancreatic enzyme supplementation with meals
• Cystic fibrosis transmembrane conductance regulator (CFTR) modulators
are a new class of drugs and help to improve function of the defective
CFTR protein

❖ NURSING MANAGEMENT OF CYSTIC FIBROSIS

• Strategies that promote removal of pulmonary secretions
- CPT and breathing exercises
• Remind patient to reduce risk factors for resp infection
• Adequate fluid and electrolyte intake
• Palliative care
• Discuss end-of-life issues and concerns

24