1. Explain the procedure to the client.

2. Assist the client to an upright position.

3. Perform hand hygiene and don protective garb.

4. Prepare suctioning equipment and turn on the suction.

5. Hyperoxygenate the client.

6. Insert the catheter without suction applied.

7. Once inserted, apply suction intermittently while rotating and withdrawing the catheter.

8. Hyperoxygenate the client.

9. Listen to breath sounds.

10. Document the procedure, client response, and effectiveness.

Once the nurse has assessed the client, the nurse would explain the procedure. The client is assisted to a sitting upright position such as semi-Fowler’s with the head hyperextended (unless contraindicated). The nurse next performs hand hygiene (hand hygiene is also performed before positioning the client) and applies appropriate protective garb, using aseptic technique. The nurse prepares the needed suctioning equipment, turns on the suction device, and sets it to the appropriate pressure. The nurse hyperoxygenates the client with a resuscitation bag, increasing the oxygen flow rate, or asking the client to take deep breaths. The nurse next lubricates the catheter with sterile water or water-soluble lubricant (per agency procedure), inserts the catheter without the application of suction, and then applies intermittent suction for up to 10 seconds while rotating and withdrawing the catheter. After suctioning, the nurse hyperoxygenates the client and encourages the client to take deep breaths if possible. During the procedure the nurse monitors the client for toleration of the procedure and the presence of complications. Finally, the nurse listens to breath sounds to assist in determining effectiveness and documents the procedure, the client’s response, and effectiveness.

1. Description: Specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells

2. Preprocedure

a. Determine specific purpose of collection and check with institutional policy for appropriate method for collection of a specimen.

b. Obtain an early morning sterile specimen by suctioning or expectoration after a respiratory treatment if a treatment is prescribed.

c. Instruct the client to rinse the mouth with water before collection.

d. Obtain 15 mL of sputum.

e. Instruct the client to take several deep breaths and then cough deeply to obtain sputum.

f. Always collect the specimen before the client begins antibiotic therapy.

3. Postprocedure

a. If a culture of sputum is prescribed, transport the specimen to the laboratory immediately.

b. Assist the client with mouth care.

1. Description: Direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope

2. Preprocedure

a. Obtain informed consent.

b. Maintain NPO status for the client from midnight before the procedure.

c. Obtain vital signs.

d. Assess the results of coagulation studies.

e. Remove dentures and eyeglasses.

f. Prepare suction equipment.

g. Establish an intravenous (IV) access as necessary and administer medication for sedation as

prescribed.

h. Have emergency resuscitation equipment readily available.

3. Postprocedure

a. Monitor vital signs.

b. Maintain the client in a semi-Fowler’s position.

c. Assess for the return of the gag reflex.

d. Maintain NPO status until the gag reflex returns.

e. Have an emesis basin readily available for the client to expectorate sputum.

f. Monitor for bloody sputum.

g. Monitor respiratory status, particularly if sedation has been administered.

h. Monitor for complications, such as bronchospasm or bronchial perforation, indicated by facial or neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and pneumothorax.

i. Notify the health care provider (HCP) if fever, difficulty in breathing, or other signs of complications occur following the procedure.

1. Tissue samples are obtained from central lung masses and lymph nodes, using a bronchoscope with the help of ultrasound guidance.

2. Minimally invasive procedure performed on an outpatient basis.

3. Tissue samples are used for diagnosing and staging lung cancer, detecting infections, and identifying inflammatory diseases that affect the lungs, such as sarcoidosis.

4. Postprocedure, the client is monitored for signs of bleeding and respiratory distress.

1. Description

a. An invasive fluoroscopic procedure in which a catheter is inserted through the antecubital or femoral vein into the pulmonary artery or one of its branches

b. Involves an injection of iodine or radiopaque contrast material

2. Preprocedure

a. Obtain informed consent.

b. Assess for allergies to iodine, seafood, or other radiopaque dyes.

c. Maintain NPO status of the client for 8 hours before the procedure.

d. Monitor vital signs.

e. Assess results of coagulation studies.

f. Establish an intravenous access.

g. Administer sedation as prescribed.

h. Instruct the client to lie still during the procedure.

i. Instruct the client that he or she may feel an urge to cough, flushing, nausea, or a salty taste following injection of the dye.

j. Have emergency resuscitation equipment available.

3. Postprocedure

a. Monitor vital signs.

b. Avoid taking blood pressures for 24 hours in the extremity used for the injection.

c. Monitor peripheral neurovascular status of the affected extremity.

d. Assess insertion site for bleeding.

e. Monitor for delayed reaction to the dye.

1. Description: Removal of fluid or air from the pleural space via transthoracic aspiration

2. Preprocedure

a. Obtain informed consent.

b. Obtain vital signs.

c. Prepare the client for ultrasound or chest radiograph, if prescribed, before procedure.

d. Assess results of coagulation studies.

e. Note that the client is positioned sitting upright, with the arms and shoulders supported by a table at the bedside during the procedure

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f. If the client cannot sit up, the client is placed lying in bed toward the unaffected side, with the head of the bed elevated.

g. Instruct the client not to cough, breathe deeply, or move during the procedure.

3. Postprocedure

a. Monitor vital signs.

b. Monitor respiratory status.

c. Apply a pressure dressing, and assess the puncture site for bleeding and crepitus.

d. Monitor for signs of pneumothorax, air embolism, and pulmonary edema.

1. Description: Tests used to evaluate lung mechanics, gas exchange, and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gas levels.

2. Preprocedure

a. Determine whether an analgesic that may depress the respiratory function is being administered.

b. Consult with the HCP regarding withholding bronchodilators before testing.

c. Instruct the client to void before the procedure and to wear loose clothing.

d. Remove dentures.

e. Instruct the client to refrain from smoking or eating a heavy meal for 4 to 6 hours before the test.

3. Postprocedure: Client may resume a normal diet and any bronchodilators and respiratory treatments that were withheld before the procedure.

1. Description

a. A transbronchial biopsy and a transbronchial needle aspiration may be performed to obtain tissue for analysis by culture or cytological examination.

b. An open lung biopsy is performed in the operating room.

2. Preprocedure

a. Obtain informed consent.

b. Maintain NPO status of the client before the procedure.

c. Inform the client that a local anesthetic will be used for a needle biopsy but a sensation of pressure during needle insertion and aspiration may be felt.

d. Administer analgesics and sedatives as prescribed.

3. Postprocedure

a. Monitor vital signs.

b. Apply a dressing to the biopsy site and monitor for drainage or bleeding.

c. Monitor for signs of respiratory distress, and notify the HCP if they occur.

d. Monitor for signs of pneumothorax and air emboli, and notify the HCP if they occur.

e. Prepare the client for chest radiography if prescribed.

1. Description

a. The perfusion scan evaluates blood flow to the lungs.

b. The ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation.

c. A radionuclide may be injected for the procedure.

2. Preprocedure

a. Obtain informed consent.

b. Assess the client for allergies to dye, iodine, or seafood.

c. Remove jewelry around the chest area.

d. Review breathing methods that may be required during testing.

e. Establish an intravenous access.

f. Administer sedation if prescribed.

g. Have emergency resuscitation equipment available.

3. Postprocedure

a. Monitor the client for reaction to the radionuclide.

b. Instruct the client that the radionuclide clears from the body in about 8 hours

1. Determine hypersensitivity or previous reactions to skin tests.

2. Use a skin site that is free of excessive body hair, dermatitis, and blemishes.

3. Apply the injection at the upper third of the inner surface of the left arm.

4. Circle and mark the injection test site.

5. Document the date, time, and test site.

6. Advise the client not to scratch the test site to prevent infection and possible abscess formation.

7. Instruct the client to avoid washing the test site.

8. Interpret the reaction at the injection site 24 to 72 hours after administration of the test antigen.

9. Assess the test site for the amount of induration (hard swelling) in millimeters and for the presence of erythema and vesiculation (small blister-like elevations).

Breathing Retraining

This includes exercises to decrease use of the accessory muscles of breathing, to decrease fatigue, and to promote CO2 elimination.

The main types of exercises include pursed-lip breathing and diaphragmatic breathing.

The client should inhale slowly through the nose.

The client should place a hand over the abdomen while inhaling; the abdomen should expand with inhalation and contract during exhalation.

The client should exhale three times longer than inhalation by blowing through pursed lips.

Huff Coughing

This is an effective coughing technique that conserves energy, reduces fatigue, and facilitates mobilization of secretions.

The client should take three or four deep breaths using pursed-lip and diaphragmatic breathing.

Leaning slightly forward, the client should cough three or four times during exhalation.

The client may need to splint the thorax or abdomen to achieve a maximum cough.

1. Description: Percussion, vibration, and postural drainage techniques are performed over the thorax to loosen secretions in the affected area of the lungs and move them into more central

airways.

2. Interventions

Perform chest physiotherapy (CPT) in the morning on arising, 1 hour before meals, or 2 to 3 hours after meals.

Stop CPT if pain occurs.

If the client is receiving a tube feeding, stop the feeding and aspirate the residual before beginning CPT.

Administer the bronchodilator (if prescribed) 15 minutes before the procedure.

Place a layer of material (gown or pajamas) between the hands or percussion device and the client’s skin.

Position the client for postural drainage based on assessment.

Percuss the area for 1 to 2 minutes.

Vibrate the same area while the client exhales four or five deep breaths.

Monitor for respiratory tolerance to the procedure.

Stop the procedure if cyanosis or exhaustion occurs.

Maintain the position for 5 to 20 minutes after the procedure.

Repeat in all necessary positions until the client no longer expectorates mucus.

Dispose of sputum properly.

Provide mouth care after the procedure.

3. Contraindications

a. Unstable vital signs

b. Increased intracranial pressure

c. Bronchospasm

d. History of pathological fractures

e. Rib fractures

f. Chest incisions

1. Instruct the client to assume a sitting or upright position.

2. Instruct the client to place the mouth tightly around the mouthpiece of the device.

3. Instruct the client to inhale slowly to raise and maintain the flow rate indicator between the 600 and 900 marks.

4. Instruct the client to hold the breath for 5 seconds and then to exhale through pursed lips.

5. Instruct the client to repeat this process 10 times every hour.

High-Pressure Alarm

■ Increased secretions are in the airway.

■ Wheezing or bronchospasm is causing decreased airway size.

■ The endotracheal tube is displaced.

■ The ventilator tube is obstructed because of water or a kink in the tubing.

■ Client coughs, gags, or bites on the oral endotracheal tube.

■ Client is anxious or fights the ventilator.

Low-Pressure Alarm

■ Disconnection or leak in the ventilator or in the client’s airway cuff occurs.

■ The client stops spontaneous breathing.

1. SIMV

a. The client breathes between the preset breaths per minute rate of the ventilator.

b. The SIMV rate is decreased gradually until the client is breathing on his or her own without the use of the ventilator.

2. T-piece

a. The client is taken off the ventilator and the ventilator is replaced with a T-piece or continuous positive airway pressure, which delivers humidified oxygen.

b. The client is taken off the ventilator for short periods initially and allowed to breathe spontaneously.

c. Weaning progresses as the client is able to tolerate progressively longer periods off the ventilator.

3. Pressure support

a. Pressure support is a predetermined pressure set on the ventilator to assist the client in respiratory effort.

b. As weaning continues, the amount of pressure is decreased gradually.

c. With pressure support, pressure may be maintained while the preset breaths per minute of the ventilator gradually are decreased.

1. Description

a. Results from direct blunt chest trauma and causes a potential for intrathoracic injury, such as pneumothorax or pulmonary contusion

b. Pain with movement and chest splinting result in impaired ventilation and inadequate clearance of secretions.

2. Assessment

a. Pain at the injury site that increases with inspiration

b. Tenderness at the site

c. Shallow respirations

d. Client splints chest

e. Fractures noted on chest x-ray

3. Interventions

a. Note that the ribs usually reunite spontaneously.

b. Place the client in a Fowler’s position.

c. Administer pain medication as prescribed to maintain adequate ventilatory status.

d. Monitor for increased respiratory distress.

e. Instruct the client to self-splint with the hands and arms.

f. Prepare the client for an intercostal nerve block as prescribed if the pain is severe.

1. Description

a. Occurs from blunt chest trauma associated with accidents, which may result in hemothorax and rib fractures.

b. The loose segment of the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall.

2. Assessment

a. Paradoxical respirations (inward movement of a segment of the thorax during inspiration with outward movement during expiration)

b. Severe pain in the chest

c. Dyspnea

d. Cyanosis

e. Tachycardia

f. Hypotension

g. Tachypnea, shallow respirations

h. Diminished breath sounds

3. Interventions

a. Maintain the client in a Fowler’s position.

b. Administer humidified oxygen as prescribed.

c. Monitor for increased respiratory distress.

d. Encourage coughing and deep breathing.

e. Administer pain medication as prescribed.

f. Maintain bed rest and limit activity to reduce oxygen demands.

g. Prepare for intubation with mechanical ventilation, with positive end-expiratory pressure (PEEP) for severe flail chest associated with respiratory failure and shock.

1. Description

a. Characterized by interstitial hemorrhage associated with intraalveolar hemorrhage, resulting in decreased pulmonary compliance

b. The major complication is acute respiratory distress syndrome.

2. Assessment

a. Dyspnea

b. Hypoxemia

c. Increased bronchial secretions

d. Hemoptysis

e. Restlessness

f. Decreased breath sounds

g. Crackles and wheezes

3. Interventions

a. Maintain a patent airway and adequate ventilation.

b. Place the client in a Fowler’s position.

c. Administer oxygen as prescribed.

d. Monitor for increased respiratory distress.

e. Maintain bed rest and limit activity to reduce oxygen demands.

f. Prepare for mechanical ventilation with PEEP if required.

1. Description

a. Accumulation of atmospheric air in the pleural space, which results in a rise in intrathoracic pressure and reduced vital capacity

b. The loss of negative intrapleural pressure results in collapse of the lung.

c. A spontaneous pneumothorax occurs with the rupture of a pulmonary bleb.

d. An open pneumothorax occurs when an opening through the chest wall allows the entrance of positive atmospheric air pressure into the pleural space.

e. A tension pneumothorax occurs from a blunt chest injury or from mechanical ventilation with PEEP when a buildup of positive pressure occurs in the pleural space.

f. Diagnosis of pneumothorax is made by chest x-ray.

2. Assessment

■ Absent breath sounds on affected side

■ Cyanosis

■ Decreased chest expansion unilaterally

■ Dyspnea

■ Hypotension

■ Sharp chest pain

■ Subcutaneous emphysema as evidenced by crepitus on palpation

■ Sucking sound with open chest wound

■ Tachycardia

■ Tachypnea

■ Tracheal deviation to the unaffected side with tension pneumothorax

3. Interventions

a. Apply a nonporous dressing over an open chest wound.

b. Administer oxygen as prescribed.

c. Place the client in a Fowler’s position.

d. Prepare for chest tube placement, which will remain in place until the lung has expanded

fully.

e. Monitor the chest tube drainage system.

f. Monitor for subcutaneous emphysema.

Clients with a respiratory disorder should be positioned with the head of the bed elevated.

A. Description

1. Occurs when insufficient oxygen is transported to the blood or inadequate carbon dioxide is removed from the lungs and the client’s compensatory mechanisms fail

2. Causes include a mechanical abnormality of the lungs or chest wall, a defect in the respiratory control center in the brain, or an impairment in the function of the respiratory muscles.

3. In oxygenation failure, or hypoxemic respiratory failure, oxygen may reach the alveoli but cannot be absorbed or used properly, resulting in a Pao2 lower than 60 mm Hg, arterial oxygen saturation (SaO2) lower than 90%, or partial pressure of arterial carbon dioxide (PaCO2)

greater than 50 mm Hg occurring with acidemia.

4. Many clients experience both hypoxemic and hypercapnic respiratory failure and retained carbon dioxide in the alveoli displaces oxygen, contributing to the hypoxemia.

5. Manifestations of respiratory failure are related to the extent and rapidity of change in Pao2 and Paco2.

B. Assessment

1. Dyspnea

2. Headache

3. Restlessness

4. Confusion

5. Tachycardia

6. Hypertension

7. Dysrhythmias

8. Decreased level of consciousness

9. Alterations in respirations and breath sounds

C. Interventions

1. Identify and treat the cause of the respiratory failure

2. Administer oxygen to maintain the Pao2 level higher than 60 to 70 mm Hg.

3. Place the client in a Fowler’s position.

4. Encourage deep breathing.

5. Administer bronchodilators as prescribed.

6. Prepare the client for mechanical ventilation if supplemental oxygen cannot maintain acceptable Pao2 and Paco2 levels.

A. Description

1. A form of acute respiratory failure that occurs as a complication of some other condition; it is caused by a diffuse lung injury and leads to extravascular lung fluid.

2. The major site of injury is the alveolar capillary membrane.

3. The interstitial edema causes compression and obliteration of the terminal airways and leads to reduced lung volume and compliance.

4. The ABG levels identify respiratory acidosis and hypoxemia that do not respond to an increased percentage of oxygen.

5. 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.

6. Causes include sepsis, fluid overload, shock, trauma, neurological injuries, burns, disseminated intravascular coagulation, drug ingestion, aspiration, and inhalation of toxic substances.

B. Assessment

1. Tachypnea

2. Dyspnea

3. Decreased breath sounds

4. Deteriorating ABG levels

5. Hypoxemia despite high concentrations of delivered oxygen

6. Decreased pulmonary compliance

7. Pulmonary infiltrates

C. Interventions

1. Identify and treat the cause of the acute respiratory distress syndrome.

2. Administer oxygen as prescribed.

3. Place the client in a Fowler’s position.

4. Restrict fluid intake as prescribed.

5. Provide respiratory treatments as prescribed.

6. Administer diuretics, anticoagulants, or corticosteroids as prescribed.

7. Prepare the client for intubation and mechanical ventilation using PEEP.

A. Description

1. Chronic inflammatory disorder of the airways that causes varying degrees of obstruction in the airways

2. Marked by airway inflammation and hyperresponsiveness to a variety of stimuli or triggers

3. Causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing associated

with airflow obstruction that may resolve spontaneously; it is often reversible with treatment.

5. Status asthmaticus is a severe life-threatening asthma episode that is refractory to treatment and

may result in pneumothorax, acute cor pulmonale, or respiratory arrest.

B. Assessment

1. Restlessness

2. Wheezing or crackles

3. Absent or diminished lung sounds

4. Hyperresonance

5. Use of accessory muscles for breathing

6. Tachypnea with hyperventilation

7. Prolonged exhalation

8. Tachycardia

9. Pulsus paradoxus

10. Diaphoresis

11. Cyanosis

12. Decreased oxygen saturation

13. Pulmonary function test results that demonstrate decreased air flow rates

C. Interventions

1. Monitor vital signs.

2. Monitor pulse oximetry.

3. Monitor peak flow.

4. During an acute asthma episode, provide interventions to assist with breathing

D. Client education

1. On the intermittent nature of symptoms and need for long-term management

2. To identify possible triggers and measures to prevent episodes

3. About the management of medication and proper administration

4. About the correct use of a peak flowmeter

5. About developing an asthma action plan with the primary HCP and what to do if an asthma episode occurs

Severe Persistent

■ Symptoms are continuous.

■ Physical activity requires limitations.

■ Frequent exacerbations occur.

■ Nocturnal symptoms occur frequently.

Moderate Persistent

■ Daily symptoms occur.

■ Daily use of inhaled short-acting β-agonist is needed.

■ Exacerbations affect activity.

■ Exacerbations occur at least twice weekly and may last for days.

■ Nocturnal symptoms occur more frequently than once weekly.

Mild Persistent

■ Symptoms occur more frequently than twice weekly but less often than once daily.

■ Exacerbations may affect activity.

■ Nocturnal symptoms occur more frequently than twice a month.

Mild Intermittent

■ Symptoms occur twice weekly or less.

■ Client is asymptomatic between exacerbations.

■ Exacerbations are brief (hours to days).

■ Intensity of exacerbations varies.

■ Nocturnal symptoms occur twice a month or less.

A. Description

1. Also known as chronic obstructive lung disease and chronic airflow limitation

2. Chronic obstructive pulmonary disease is a disease state characterized by airflow obstruction caused by emphysema or chronic bronchitis.

3. Progressive airflow limitation occurs, associated with an abnormal inflammatory response of the lungs that is not completely reversible.

4. Chronic obstructive pulmonary disease leads to pulmonary insufficiency, pulmonary hypertension, and cor pulmonale.

B. Assessment

1. Cough

2. Exertional dyspnea

3. Wheezing and crackles

4. Sputum production

5. Weight loss

6. Barrel chest (emphysema)

7. Use of accessory muscles for breathing

8. Prolonged expiration

9. Orthopnea

10. Cardiac dysrhythmias

11. Congestion and hyperinflation seen on chest x-ray

12. ABG levels that indicate respiratory acidosis and hypoxemia

13. Pulmonary function tests that demonstrate decreased vital capacity

C. Interventions

1. Monitor vital signs.

2. Administer a low concentration of oxygen (1 to 2 L/minute) as prescribed; the stimulus to

breathe is a low arterial Po2 instead of an increased Pco2.

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 a Fowler’s position and leaning 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.

Adhere to activity limitations, alternating rest periods with activity.

Avoid eating gas-producing foods, spicy foods, and extremely hot or cold foods.

Avoid exposure to individuals with infections and avoid crowds.

Avoid extremes in temperature.

Avoid fireplaces, pets, feather pillows, and other environmental allergens.

Avoid powerful odors.

Meet nutritional requirements.

Receive immunizations as recommended.

Recognize the signs and symptoms of respiratory infection and hypoxia.

Stop smoking.

Use medications and inhalers as prescribed.

Use oxygen therapy as prescribed.

Use pursed-lip and diaphragmatic or abdominal breathing.

When dusting, use a wet cloth. 

A. Respiratory illness caused by a coronavirus, called SARS-associated coronavirus

B. The syndrome begins with a fever, an overall feeling of discomfort, body aches, and mild

respiratory symptoms.

C. After 2 to 7 days, the client may develop a dry cough and dyspnea.

D. 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).

E. 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. 

A. Description

1. Infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles.

2. The edema associated with inflammation stiffens the lung, decreases lung compliance and vital capacity, and causes hypoxemia.

3. Pneumonia can be community-acquired or hospital-acquired.

4. The chest x-ray film shows lobar or segmental consolidation, pulmonary infiltrates, or pleural effusions.

5. A sputum culture identifies the organism.

6. The white blood cell count and the erythrocyte sedimentation rate are elevated.

B. Assessment

1. Chills

2. Elevated temperature

3. Pleuritic pain

4. Tachypnea

5. Rhonchi and wheezes

6. Use of accessory muscles for breathing

7. Mental status changes

8. Sputum production

C. Interventions

1. Administer oxygen as prescribed.

2. Monitor respiratory status.

3. Monitor for labored respirations, cyanosis, and cold and clammy skin.

4. Encourage coughing and deep breathing and use of the incentive spirometer.

5. Place the client in a semi-Fowler’s position to facilitate breathing and lung expansion.

6. Change the client’s position frequently and ambulate as tolerated to mobilize secretions.

7. Provide CPT.

8. Perform nasotracheal suctioning if the client is unable to clear secretions.

9. Monitor pulse oximetry.

10. Monitor and record color, consistency, and amount of sputum.

11. Provide a high-calorie, high-protein diet with small frequent meals.

12. Encourage fluids, up to 3 L/day, to thin secretions unless contraindicated.

13. Provide a balance of rest and activity, increasing activity gradually.

14. Administer antibiotics as prescribed.

15. Administer antipyretics, bronchodilators, cough suppressants, mucolytic agents, and expectorants as prescribed.

16. Prevent the spread of infection by hand washing and the proper disposal of secretions.

D. Client education

1. About the importance of rest, proper nutrition, and adequate fluid intake

2. To avoid chilling and exposure to individuals with respiratory infections or viruses

3. Regarding medications and the use of inhalants as prescribed

4. To notify the HCP if chills, fever, dyspnea, hemoptysis, or increased fatigue occurs

5. To receive a pneumococcal vaccine as recommended by the health care provider

Teach clients that using proper hand washing techniques, disposing of respiratory secretions properly, and receiving vaccines will assist in preventing the spread of infection.

A. Description

1. Also known as the flu; highly contagious acute viral respiratory infection

2. May be caused by several viruses, usually known as types A, B, and C

3. Yearly vaccination is recommended to prevent the disease, especially for those older than 50 years of age, individuals with chronic illness or who are immunocompromised, those living in institutions, and health care personnel providing direct care to clients (the vaccination is

contraindicated in the individual with egg allergies).

4. Additional prevention measures include avoiding those who have developed influenza, frequent and proper hand washing, and cleaning and disinfecting surfaces that have become contaminated with secretions.

5. Avian influenza A (H5N1)

a. Affects birds; does not usually affect humans; however, human cases have been reported in some countries.

b. An H5N1 vaccine has been developed for use if a pandemic virus were to emerge.

c. Reported symptoms are similar to those associated with influenza types A, B, and C.

d. Prevention measures include thorough cooking of poultry products, avoiding contact with wild animals, frequent and proper hand washing, and cleaning and disinfecting surfaces that have become contaminated with secretions.

6. Swine (H1N1) influenza

a. A strain of flu that consists of genetic materials from swine, avian, and human influenza viruses

b. Signs and symptoms are similar to those that present with seasonal flu; in addition, vomiting and diarrhea commonly occur.

c. Prevention measures and treatment are the same as for the seasonal flu.

d. Refer to Chapter 48 for additional information on swine flu and Chapter 59 for information on H1N1 vaccines.

B. Assessment

1. Acute onset of fever and muscle aches

2. Headache

3. Fatigue, weakness, anorexia

4. Sore throat, cough, and rhinorrhea

C. Interventions

1. Encourage rest.

2. Encourage fluids to prevent pulmonary complications (unless contraindicated).

3. Monitor lung sounds.

4. Provide supportive therapy such as antipyretics or antitussives as indicated.

5. Administer antiviral medications as prescribed for the current strain of influenza

A. Description

1. Acute bacterial infection caused by Legionella pneumophila

2. Sources of the organism include contaminated cooling tower water and warm stagnant water supplies, including water vaporizers, water sonicators, whirlpool spas, and showers.

3. Person-to-person contact does not occur; the risk for infection is increased by the presence of other conditions.

B. Assessment: Influenza-like symptoms with a high fever, chills, muscle aches, and headache that may progress to dry cough, pleurisy, and sometimes diarrhea.

C. Interventions: Treatment is supportive and antibiotics may be prescribed.

A. Description

1. Pleural effusion is the collection of fluid in the pleural space.

2. Any condition that interferes with secretion or drainage of this fluid will lead to pleural effusion.

B. Assessment

1. Pleuritic pain that is sharp and increases with inspiration

2. Progressive dyspnea with decreased movement of the chest wall on the affected side

3. Dry, nonproductive cough caused by bronchial irritation or mediastinal shift

4. Tachycardia

5. Elevated temperature

6. Decreased breath sounds over affected area

7. Chest x-ray film that shows pleural effusion and a mediastinal shift away from the fluid if the effusion is more than 250 mL

C. Interventions

1. Identify and treat the underlying cause.

2. Monitor breath sounds.

3. Place the client in a Fowler’s position.

4. Encourage coughing and deep breathing.

5. Prepare the client for thoracentesis.

6. If pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as prescribed.

D. 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 two layers during healing.

E. 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.

A. Description

1. Collection of pus within the pleural cavity

2. The fluid is thick, opaque, and foul-smelling.

3. The most common cause is pulmonary infection and lung abscess caused by thoracic surgery or chest trauma, in which bacteria are introduced directly into the pleural space.

4. Treatment focuses on treating the infection, emptying the empyema cavity, reexpanding the lung, and controlling the infection.

B. Assessment

1. Recent febrile illness or trauma

2. Chest pain

3. Cough

4. Dyspnea

5. Anorexia and weight loss

6. Malaise

7. Elevated temperature and chills

8. Night sweats

9. Pleural exudate on chest x-ray

C. Interventions

1. Monitor breath sounds.

2. Place the client in a semi-Fowler’s or high Fowler’s position.

3. Encourage coughing and deep breathing.

4. Administer antibiotics as prescribed.

5. Instruct the client to splint the chest as necessary.

6. Assist with thoracentesis or chest tube insertion to promote drainage and lung expansion.

7. 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.

A. Description

1. Inflammation of the visceral and parietal membranes; may be caused by pulmonary infarction or pneumonia.

2. The visceral and parietal membranes rub together during respiration and cause pain.

3. Pleurisy usually occurs on one side of the chest, usually in the lower lateral portions in the chest wall.

B. Assessment

1. Knifelike pain aggravated on deep breathing and coughing

2. Dyspnea

3. Pleural friction rub heard on auscultation

4. Apprehension

C. Interventions

1. Identify and treat the cause.

2. Monitor lung sounds.

3. Administer analgesics as prescribed.

4. Apply hot or cold applications as prescribed.

5. Encourage coughing and deep breathing.

6. Instruct the client to lie on the affected side to splint chest. 

A. Description

1. Occurs when a thrombus forms (most commonly in a deep vein), detaches, travels to the right side of the heart, and then lodges in a branch of the pulmonary artery

2. Clients prone to pulmonary embolism are those at risk for deep vein thrombosis, including those with prolonged immobilization, surgery, obesity, pregnancy, heart failure, advanced age, or a history of thromboembolism.

3. Fat emboli can occur as a complication following fracture of a long bone and can cause pulmonary emboli.

4. Treatment is aimed at prevention through risk factor recognition and elimination.

B. Assessment

■ Apprehension and restlessness

■ Blood-tinged sputum

■ Chest pain

■ Cough

■ Crackles and wheezes on auscultation

■ Cyanosis

■ Distended neck veins

■ Dyspnea accompanied by anginal and pleuritic pain, exacerbated by inspiration

■ Feeling of impending doom

■ Hypotension

■ Petechiae over the chest and axilla

■ Shallow respirations

■ Tachypnea and tachycardia

C. Interventions

1. Notify the Rapid Response Team.

2. Reassure the client and elevate the head of the bed.

3. Prepare to administer oxygen.

4. Obtain vital signs and check lung sounds.

5. Prepare to obtain an arterial blood gas.

6. Prepare for the administration of heparin therapy or other therapies.

7. Document the event, interventions taken, and the client’s response to treatment.

Signs and symptoms of a pulmonary embolism include the sudden onset of dyspnea, apprehension and restlessness, a feeling of impending doom, cough, hemoptysis, tachypnea, crackles, petechiae over the chest and axillae, and a decreased arterial oxygen saturation. If suspected, the nurse immediately notifies the Rapid Response Team. The nurse stays with the client, reassures the client, and elevates the head of the bed. The nurse prepares to administer oxygen and obtains the vital signs and checks lung sounds. The nurse continues to monitor the client closely, prepares the client for tests prescribed to confirm the diagnosis, and prepares to obtain an arterial blood gas.

When prescribed, the client is prepared for the administration of heparin therapy or other therapies such as embolectomy or placement of a vena cava filter if necessary. Finally, the nurse documents the event, interventions taken, and the client’s response to treatment.

A. Description

1. Pulmonary fungal infection caused by spores of Histoplasma capsulatum

2. Transmission occurs by the inhalation of spores, which commonly are found in contaminated soil.

3. Spores also are usually found in bird droppings.

B. Assessment

1. Similar to pneumonia

2. Positive skin test for histoplasmosis

3. Positive agglutination test

4. Splenomegaly, hepatomegaly

C. Interventions

1. Administer oxygen as prescribed.

2. Monitor breath sounds.

3. Administer antiemetics, antihistamines, antipyretics, and corticosteroids as prescribed.

4. Administer fungicidal medications as prescribed.

5. Encourage coughing and deep breathing.

6. Place the client in a semi-Fowler’s position.

7. Monitor vital signs.

8. Monitor for nephrotoxicity from fungicidal medications.

9. Instruct the client to spray the floor with water before sweeping barn and chicken coops.

A. Description

1. Presence of epithelioid cell tubercles in the lung

2. The cause is unknown, but a high titer of Epstein-Barr virus may be noted.

3. Viral incidence is highest in African Americans and young adults.

B. Assessment

1. Night sweats

2. Fever

3. Weight loss

4. Cough and dyspnea

5. Skin nodules

6. Polyarthritis

7. Kveim test: Sarcoid node antigen is injected intradermally and causes a local nodular lesion in about 1 month.

C. Interventions

1. Administer corticosteroids to control symptoms.

2. Monitor temperature.

3. Increase fluid intake.

4. Provide frequent periods of rest.

5. Encourage small, frequent, nutritious meals.

A. Description

1. Caused by exposure to environmental or occupational fumes, dust, vapors, gases, bacterial or fungal antigens, and allergens; can result in acute reversible effects or chronic lung disease

2. Common disease classifications include occupational asthma pneumoconiosis (silicosis or coal miner’s [black lung] disease), diffuse interstitial fibrosis (asbestosis, talcosis, berylliosis), or extrinsic allergic alveolitis (farmer’s lung, bird fancier’s lung, or machine operator’s lung).

B. Assessment: Manifestations depend on the type of disease and respiratory symptoms.

C. Interventions

1. Prevention through the use of respiratory protective devices

2. Treatment is based on the symptoms experienced by the client.

A. Description

1. Highly communicable disease caused by Mycobacterium tuberculosis

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

bacillus reaches a susceptible site, it multiplies freely.

3. Because M. tuberculosis is an aerobic bacterium, it primarily affects the pulmonary system,

especially the upper lobes, where the oxygen content is highest, but also can affect other areas

of the body, such as the brain, intestines, peritoneum, kidney, joints, and liver.

4. An exudative response causes a nonspecific pneumonitis and the development of granulomas in

the lung tissue.

5. Tuberculosis has an insidious onset, and many clients are not aware of symptoms until the

disease is well advanced.

6. Improper or noncompliant use of treatment programs may cause the development of mutations in

the tubercle bacilli, resulting in a multidrug-resistant strain of tuberculosis (MDR-TB).

7. The goal of treatment is to prevent transmission, control symptoms, and prevent progression of

the disease.

C. Transmission

1. Via the airborne route by droplet infection.

2. When an infected individual coughs, laughs, sneezes, or sings, droplet nuclei containing

tuberculosis bacteria enter the air and may be inhaled by others.

3. Identification of those in close contact with the infected individual is important so that they can

be tested and treated as necessary.

4. When contacts have been identified, these persons are assessed with a tuberculin skin test and

chest x-rays to determine infection with tuberculosis.

5. After the infected individual has received tuberculosis medication for 2 to 3 weeks, the risk of

transmission is reduced greatly.

D. Disease progression

1. Droplets enter the lungs, and the bacteria form a tubercle lesion.

2. The defense systems of the body encapsulate the tubercle, leaving a scar.

3. If encapsulation does not occur, bacteria may enter the lymph system, travel to the lymph nodes,

and cause an inflammatory response termed granulomatous inflammation.

4. Primary lesions form; the primary lesions may become dormant but can be reactivated and

become a secondary infection when reexposed to the bacterium.

5. In an active phase, tuberculosis can cause necrosis and cavitation in the lesions, leading to

rupture, the spread of necrotic tissue, and damage to various parts of the body.

E. Client history

1. Past exposure to tuberculosis

2. Client’s country of origin and travel to foreign countries in which the incidence of tuberculosis

is high

3. Recent history of influenza, pneumonia, febrile illness, cough, or foul-smelling sputum

production

4. Previous tests for tuberculosis; results of the testing

5. Recent bacille Calmette-Guérin vaccine (a vaccine containing attenuated tubercle bacilli that

may be given to persons in foreign countries or to persons traveling to foreign countries to

produce increased resistance to tuberculosis).

An individual who has received a bacille Calmette-Guérin vaccine will have a positive

tuberculin skin test result and should be evaluated for tuberculosis with a chest x-ray.

F. Clinical manifestations

1. May be asymptomatic in primary infection

2. Fatigue

3. Lethargy

4. Anorexia

5. Weight loss

6. Low-grade fever

7. Chills

8. Night sweats

9. A persistent cough and the production of mucoid and mucopurulent sputum, which is occasionally

streaked with blood

10. Chest tightness and a dull, aching chest pain may accompany the cough.

G. Chest assessment

1. A physical examination of the chest does not provide conclusive evidence of tuberculosis.

2. A chest x-ray is not definitive, but the presence of multinodular infiltrates with calcification in the upper lobes suggests tuberculosis.

3. If the disease is active, caseation and inflammation may be seen on the chest x-ray.

4. Advanced disease

a. Dullness with percussion over involved parenchymal areas, bronchial breath sounds, rhonchi, and crackles indicate advanced disease.

b. Partial obstruction of a bronchus caused by endobronchial disease or compression by lymph nodes may produce localized wheezing and dyspnea.

H. QuantiFERON-TB Gold test

1. A blood analysis test by an enzyme-linked immunosorbent assay.

2. A sensitive and rapid test (results can be available in 24 hours) that assists in diagnosing the client.

I. Sputum cultures

1. Sputum specimens are obtained for an acid-fast smear.

2. A sputum culture identifying M. tuberculosis confirms the diagnosis.

3. After medications are started, sputum samples are obtained again to determine the effectiveness of therapy.

4. Most clients have negative cultures after 3 months of treatment.

J. Tuberculin skin test (TST)

1. A positive reaction does not mean that active disease is present but indicates previous exposure to tuberculosis or the presence of inactive (dormant) disease.

2. Once the test result is positive, it will be positive in any future tests.

3. Skin test interpretation depends on two factors: Measurement in millimeters of the induration, and the person’s risk of being infected with TB and progression to disease if infected.

4. Once an individual’s skin test is positive, a chest x-ray is necessary to rule out active tuberculosis or to detect old healed lesions.

K. The hospitalized client

1. The client with active tuberculosis is placed under airborne isolation precautions in a negativepressure room; to maintain negative pressure, the door of the room must be tightly closed.

2. The room should have at least six exchanges of fresh air per hour and should be ventilated to the outside environment, if possible.

3. The nurse wears a particulate respirator (a special individually fitted mask) when caring for the client and a gown when the possibility of clothing contamination exists.

4. Thorough hand washing is required before and after caring for the client.

5. If the client needs to leave the room for a test or procedure, the client is required to wear a surgical mask.

6. Respiratory isolation is discontinued when the client is no longer considered infectious.

7. After the infected individual has received tuberculosis medication for 2 to 3 weeks, the risk of transmission is reduced greatly.

Provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection.

Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand.

Advise the client that the medication regimen is continued over 6 to 12 months depending on the situation.

Advise the client of the side/adverse effects of the medication and ways of minimizing them to ensure compliance.

Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone.

Inform the client to resume activities gradually.

Instruct the client about the need for adequate nutrition and a well-balanced diet to promote healing and to prevent recurrence of the infection.

Instruct the client to increase intake of foods rich in iron, protein, and vitamin C.

Inform the client and family that respiratory isolation is not necessary because family members already have been exposed.

Instruct the client to cover the mouth and nose when coughing or sneezing and to put used tissues into plastic bags.

Instruct the client and family about thorough hand washing.

Inform the client that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.

Inform the client that when the results of three sputum cultures are negative, the client is no longer considered infectious and usually can return to former employment.

Advise the client to avoid excessive exposure to silicone or dust because these substances can cause further lung damage.

Instruct the client regarding the importance of compliance with treatment, follow-up care, and sputum cultures, as prescribed.