Angelite Nurses

RESPIRATORY SYSTEM

• Respiratory Care
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• Chest Physiotherapy
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• Mechanical Ventilation
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• Oxygen Therapy
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• Tracheobronchial Suctioning
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• Tracheostomy Care

• Tonsillitis
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• Acute Spasmodic Laryngitis (Croup)
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• Laryngotracheobronchitis
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• Epiglottitis
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• Bronchiolitis
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• Asthma
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• Aspiration of a Foreign Object
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• Cystic Fibrosis (CF)
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• Chronic Obstructive Pulmonary Disease (COPD)
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• Pulmonary Tuberculosis
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• Histoplasmosis
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• Fractured Ribs
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• Flail Chest
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• Pneumothorax/Hemothorax
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• Atelectasis
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• Pleural Effusion
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• Pneumonia
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• Bronchogenic Carcinoma
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• Thoracic Surgery
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• Acute Respiratory Distress Syndrome (ARDS)
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• Cancer of the Larynx
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• Total Laryngectomy

1. General information: consists of removal of the entire larynx, hyoid bone, pre-epiglottic space, cricoid cartilage, and 3-4 rings of trachea. The pharyngeal opening to the trachea is closed and remaining trachea brought out to the neck to form a permanent tracheostomy. The result is loss of normal speech and breathing and loss of olfaction.
2. Nursing care: preoperative
1. Provide routine pre-op care.
2. Explain expected procedures after surgery including suctioning, humidification, coughing and deep breathing, IV fluids, nasogastric tube feedings, tracheostomy or laryngectomy tube.
3. Reinforce physician's teaching regarding loss of normal speech, breathing patterns, and sense of smell.
4. Encourage client/significant others to talk about fears and hopes following surgery.
5. Introduce client to changes in modes of communication (esophageal speech, artificial larynx).
6. Establish method of communication to be used immediately post-op (Magic Slate, gestures).
3. Nursing interventions: postoperative
1. Promote optimum ventilatory status.
2. Suction nose frequently because of rhinitis.
3. Assess function of tracheostomy/laryngectomy tube and suction as needed.
4. Promote pain relief.
1. Elevate head of bed to decrease pressure on suture line.
2. Administer analgesics as needed and monitor effects.
3. Assist with moving head and turning by supporting back of neck with hands.
5. Promote wound drainage.
1. Elevate head of bed to promote lymphatic drainage from head.
2. Monitor amount, characteristics of drainage.
6. Promote nutrition.
1. Institute and monitor tube feedings as ordered.
2. Increase fluid intake as tolerated to improve hydration.
3. Encourage self-feeding.
4. Advance to normal diet as soon as client able to tolerate.
7. Prevent infection.
1. Assess WBC and report significant increases.
2. Take temperature every 4 hours.
3. Maintain sterile technique when suctioning and performing tracheostomy care.
4. Observe stoma/suture lines for signs of infection.
5. Provide frequent oral hygiene.
6. Monitor sputum and drainage for changes in color, odor, characteristics.
8. Enhance communication.
1. Carry out modes of communication determined pre-op.
2. Assess nonverbal behavior.
3. Allow client time to ask questions and do not anticipate answers.
4. Arrange for volunteer laryngectomee to visit client and assist with esophageal speech/artificial larynx.
5. Consult with speech therapist if needed.
6. Progress to normal diet as soon as possible to regain muscle tone of throat and abdomen.
9. Support client during adaptation to altered physical status.
1. Encourage client to discuss feelings about changes in appearance, body functioning, and life-style; be aware of nonverbal responses to the changes.
2. Assist to identify and use coping techniques that have been helpful in past.
3. Suggest flattering clothing styles that don't emphasize chest or neck configuration.
4. Monitor for and support behaviors indicative of positive adaptation to changes (e.g., interest in appearance).
10. Assess for respiratory complications (dyspnea, cyanosis, tachycardia, tachypnea, restlessness).
11. Provide client teaching and discharge planning concerning
1. Tracheostomy/laryngectomy and stomal care
2. Proper administration of nasogastric tube feedings and maintenance of nasogastric tube (see Nasogastric (NG) Tubes)
3. Control of dryness/crusting of tongue by brushing tongue regularly with soft toothbrush and toothpaste and using mouthwashes
4. Need for humidified air at home
5. Importance of protecting the stoma with a shield or towel while showering, directing shower nozzle away from stoma
6. Need to use electric razors only for 6 months after surgery as facial area will be numb
7. Need to lean forward when expectorating secretions and to cover stoma when coughing or sneezing
8. Snorkle devices to enable swimming (caution is advised since drowning can occur rapidly in these clients)
9. Need to wear an identification bracelet indicating that client is a neck breather
10. Types of stoma guards available
11. Necessity of installing smoke detectors since sense of smell is lost
12. Information about prosthetic devices, speech therapy, and reconstructive surgery

1. General information
1. Most common upper respiratory malignancy.
2. The majority of laryngeal malignancies are squamous cell carcinomas.
3. Types
1. Supraglottic (also called extrinsic laryngeal cancer): involves the epiglottis and false cords and is likely to produce no symptoms until advanced stages.
2. Glottic (also referred to as intrinsic laryngeal cancer): affects the true vocal cords; the most frequently occurring laryngeal cancer; produces early symptoms
4. Occurs most often in white men in middle or later life
5. Caused by cigarette smoking, excessive alcohol consumption, chronic laryngitis, vocal abuse, family predisposition to cancer of larynx
2. Medical management
1. Radiation therapy: may be effective in cases of localized disease, affecting only one vocal cord
2. Chemotherapy: used as adjuvant therapy to help shrink tumor and eradicate metastases (experimental)
3. Surgery
1. Partial laryngectomy: a lesion on the true cord on one side is removed along with adjoining tissue. Useful in early, intrinsic lesions. Client is able to talk and has a normal airway post-op.
2. Total laryngectomy (see below)
3. Radical neck dissection
1. performed when metastasis from cancer of the larynx is suspected
2. includes removal of entire larynx, lymph nodes, sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve
3. may also involve removal of the mandible, submaxillary gland, part of the thyroid and parathyroid gland
4. nursing care: same as for total laryngectomy, below
3. Assessment findings
1. Supraglottic: localized throat pain; burning when drinking hot liquids or orange juice; lump in the neck; eventual dysphagia; dyspnea; weight loss; debility; cough; hemoptysis; muffled voice
2. Glottic: progressive hoarseness (more than 2-week duration), eventual dyspnea
3. Enlarged cervical lymph nodes
4. Nursing interventions: provide care for the client with a laryngectomy.

1. General information
1. A form of pulmonary insufficiency more commonly encountered in adults with no previous lung disorders than in those with existing lung disease.
2. Initial damage to the alveolar-capillary membrane with subsequent leakage of fluid into the interstitial spaces and alveoli, resulting in pulmonary edema and impaired gas exchange.
3. There is cell damage, decreased surfactant production, and atelectasis, which in turn produce hypoxemia, decreased compliance, and increased work of breathing.
4. Predisposing conditions include shock, trauma, infection, fluid overload, aspiration, oxygen toxicity, smoke inhalation, pneumonia, DIC, drug allergies, drug overdoses, neurologic injuries, fat emboli.
5. Has also been called shock lung.
2. Assessment findings
1. Dyspnea, cough, tachypnea with intercostal/suprasternal retraction, scattered to diffuse rales/rhonchi
2. Changes in orientation, tachycardia, cyanosis (rare)
3. Diagnostic tests
1. pCO₂ and pO₂ decreased
2. Hypoxemia
3. Hgb and hct possibly decreased
4. pCO₂ increased in terminal stages
3. Nursing interventions
1. Promote optimal ventilatory status.
1. Perform ongoing assessment of lungs with auscultation every 1-2 hours.
2. Elevate head and chest.
3. Administer/monitor mechanical ventilation with PEEP.
4. Assist with chest physical therapy as ordered.
5. Encourage coughing and deep breathing every hour.
6. Monitor ABGs and report significant changes.
2. Promote rest by spacing activities and treatments.
3. Maintain fluid and electrolyte balance.

1. General information
1. Types
1. Exploratory thoracotomy: anterior or posterolateral incision through the fourth, fifth, sixth, or seventh intercostal spaces to expose and examine the pleura and lung
2. Lobectomy: removal of one lobe of a lung; treatment for bronchiectasis, bronchogenic carcinoma, emphysematous blebs, lung abscesses
3. Pneumonectomy: removal of an entire lung; most commonly done as treatment for bronchogenic carcinoma
4. Segmental resection: removal of one or more segments of lung; most often done as treatment for bronchiectasis
5. Wedge resection: removal of lesions that occupy only part of a segment of lung tissue; for excision of small nodules or to obtain a biopsy
2. Nature and extent of disease and condition of client determine type of pulmonary resection.
2. Nursing interventions: preoperative
1. Provide routine pre-op care.
2. Perform a complete physical assessment of the lungs to obtain baseline data.
3. Explain expected post-op measures: care of incision site, oxygen, suctioning, chest tubes (except if pneumonectomy performed)
4. Teach client adequate splinting of incision with hands or pillow for turning, coughing, and deep breathing.
5. Demonstrate ROM exercises for affected side.
6. Provide chest physical therapy to help remove secretions.
3. Nursing interventions: postoperative
1. Provide routine post-op care.
2. Promote adequate ventilation.
1. Perform complete physical assessment of lungs and compare with pre-op findings.
2. Auscultate lung fields every 1-2 hours.
3. Encourage turning, coughing, and deep breathing every 1-2 hours after pain relief obtained.
4. Perform tracheobronchial suctioning if needed.
5. Assess for proper maintenance of chest drainage system (except after pneumonectomy).
6. Monitor ABGs and report significant changes.
7. Place client in semi-Fowler's position (if pneumonectomy performed, follow surgeon's orders about positioning, often on back or operative side, but not turned to unoperative side).
3. Provide pain relief.
1. Administer narcotics/analgesics prior to turning, coughing, and deep breathing.
2. Assist with splinting while turning, coughing, deep breathing.
4. Prevent impaired mobility of the upper extremities by doing ROM exercises; passive day of surgery, then active.
5. Provide client teaching and discharge planning concerning
1. Need to continue with coughing/deep breathing for 6-8 weeks post-op and to continue ROM exercises
2. Importance of adequate rest with gradual increases in activity levels
3. High-protein diet with inclusion of adequate fluids (at least 2 liters/day)
4. Chest physical therapy
5. Good oral hygiene
6. Need to avoid persons with known upper respiratory infections
7. Adverse signs and symptoms (recurrent fever; anorexia; weight loss; dyspnea; increased pain; difficulty swallowing; shortness of breath; changes in color, characteristics of sputum) and importance of reporting to physician
8. Avoidance of crowds and poorly ventilated areas.

1. General information
1. The majority of primary pulmonary tumors arise from the bronchial epithelium and are therefore referred to as bronchogenic carcinomas.
2. Characteristic pathologic changes include nonspecific inflammation with hypersecretion of mucus, desquamation of cells, hyperplasia, and obstruction.
3. Metastasis occurs primarily by direct extension and via the circulatory or lymphatic system.
4. Men over age 40 affected most often; 1 out of every 10 heavy smokers; affects right lung more often than left.
5. Caused by inhaled carcinogens (primarily cigarette smoke but also asbestos, nickel, iron oxides, air silicone pollution; preexisting pulmonary disorders [TB, COPD])
2. Medical management: depends on cell type, stage of disease, and condition of client; may include
1. Radiation therapy
2. Chemotherapy: usually includes cyclophosphamide, methotrexate, vincristine, doxorubicin, and procarbazine; concurrently in some combination
3. Surgery: when entire tumor can be removed
3. Assessment findings
1. Persistent cough (may be productive or blood tinged), chest pain, dyspnea, unilateral wheezing, friction rub, possible unilateral paralysis of the diaphragm
2. Fatigue, anorexia, nausea, vomiting, pallor
3. Diagnostic tests
1. Chest x-ray may show presence of tumor or evidence of metastasis to surrounding structures
2. Sputum for cytology reveals malignant cells
3. Bronchoscopy: biopsy reveals malignancy
4. Thoracentesis: pleural fluid contains malignant cells
5. Biopsy of scalene lymph nodes may reveal metastasis
4. Nursing interventions
1. Provide support and guidance to client as needed.
2. Provide relief/control of pain.
3. Administer medications as ordered and monitor effects/side effects.
4. Control nausea: administer medications as ordered, provide good oral hygiene, provide small and more frequent feedings.
5. Provide nursing care for a client with a thoracotomy.
6. Provide client teaching and discharge planning concerning
1. Disease process, diagnostic and therapeutic interventions
2. Side effects of radiation and chemotherapy
3. Realistic information about prognosis

1. General information
1. An inflammation of the alveolar spaces of the lung, resulting in consolidation of lung tissue as the alveoli fill with exudate
2. The various types of pneumonias are classified according to the offending organism.
3. Bacterial pneumonia accounts for 10% of all hospital admissions; affects infants and elderly most often, and most often occurs in winter and early spring
4. Caused by various organisms: D. pneumoniae, S. aureus, E. coli, H. influenzae
2. Assessment findings
1. Cough with greenish to rust-colored sputum production; rapid, shallow respirations with an expiratory grunt; nasal flaring; intercostal rib retraction; use of accessory muscles of respiration; dullness to flatness upon percussion; possible pleural friction rub; high-pitched bronchial breath sounds; rales or crackles (early) progressing to coarse (later)
2. Fever, chills, chest pain, weakness, generalized malaise
3. Tachycardia, cyanosis, profuse perspiration, abdominal distension
4. Diagnostic tests
1. Chest x-ray shows consolidation over affected areas
2. WBC increased
3. pO₂ decreased
4. Sputum specimens reveal particular causative organism
3. Nursing interventions
1. Facilitate adequate ventilation.
1. Administer oxygen as needed and assess its effectiveness.
2. Place client in semi-Fowler's position.
3. Turn and reposition frequently clients who are immobilized/obtunded.
4. Administer analgesics as ordered to relieve pain associated with breathing (codeine is drug of choice).
5. Auscultate breath sounds every 2-4 hours.
6. Monitor ABGs.
2. Facilitate removal of secretions (general hydration, deep breathing and coughing, tracheobronchial suctioning as needed, expectorants as ordered, aerosol treatments via nebulizer, humidification of inhaled air, chest physical therapy).
3. Observe color, characteristics of sputum and report any changes; encourage client to perform good oral hygiene after expectoration.
4. Provide adequate rest and relief/control of pain.
1. Provide bed rest with limited physical activity.
2. Limit visits and minimize conversations.
3. Plan for uninterrupted rest periods.
4. Institute nursing care in blocks to ensure periods of rest.
5. Maintain pleasant and restful environment.
5. Administer antibiotics as ordered, monitor effects and possible toxicity.
6. Prevent transmission (respiratory isolation may be required for clients with staphylococcal pneumonia).
7. Control fever and chills: monitor temperature and administer antipyretics as ordered, maintain increased fluid intake, provide frequent clothing and linen changes.
8. Provide client teaching and discharge planning concerning prevention of recurrence.
1. Medication regimen/antibiotic therapy
2. Need for adequate rest, limited activity, good nutrition with adequate fluid intake, and good ventilation
3. Need to continue deep breathing and coughing for at least 6-8 weeks after discharge
4. Availability of vaccines (pneumonococcal pneumonia, influenza)
5. Techniques that prevent transmission (use of tissues when coughing, adequate disposal of secretions)
6. Avoidance of persons with known respiratory infections
7. Need to report signs and symptoms of respiratory infection (persistent or recurrent fever; changes in characteristics, color of sputum; chills; increased pain; difficulty breathing; weight loss; persistent fatigue)
8. Need for follow-up medical care and evaluation.

1. General information
1. Collection of fluid in the pleural space
2. A symptom, not a disease; may be produced by numerous conditions
3. Classification
1. Transudative: accumulation of protein-poor, cell-poor fluid
2. Suppurative (empyema): accumulation of pus
4. May be found in clients with liver/kidney disease, pneumonia, tuberculosis, lung abscess, bronchial carcinoma, leukemia, trauma, pulmonary edema, systemic infection, disseminated lupus erythematosus, polyarteritis nodosa
2. Medical management
1. Identification and treatment of the underlying cause
2. Thoracentesis
3. Drug therapy
1. Antibiotics: either systemic or inserted directly into pleural space
2. Fibrinolytic enzymes: trypsin, streptokinase-streptodornase to decrease thickness of pus and dissolve fibrin clots
4. Closed chest drainage
5. Surgery: open drainage
3. Assessment findings
1. Dyspnea, dullness over affected area upon percussion, absent or decreased breath sounds over affected area, pleural pain, dry cough, pleural friction rub
2. Pallor, fatigue, fever, and night sweats (with empyema)
3. Diagnostic tests
1. Chest x-ray positive if greater than 250 ml pleural fluid
2. Pleural biopsy may reveal bronchogenic carcinoma
3. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or tuberculosis; positive for specific organism in empyema
4. Nursing interventions: vary depending on etiology
1. Assist with repeated thoracentesis.
2. Administer narcotics/sedatives as ordered to decrease pain.
3. Assist with instillation of medication into pleural space (reposition client every 15 minutes to distribute the drug within the pleurae).
4. Place client in high-Fowler's position to promote ventilation.

1. General information
1. Collapse of part or all of a lung due to bronchial obstruction
2. May be caused by intrabronchial obstruction (secretions, tumors, bronchospasm, foreign bodies); extrabronchial compression (tumors, enlarged lymph nodes); or endobronchial disease (bronchogenic carcinoma, inflammatory structures)
2. Assessment findings
1. Signs and symptoms may be absent depending upon degree of collapse and rapidity with which bronchial obstruction occurs
2. Dyspnea, decreased breath sounds on affected side, decreased respiratory excursion, dullness to flatness upon percussion over affected area
3. Cyanosis, tachycardia, tachypnea, elevated temperature, weakness, pain over affected area
4. Diagnostic tests
1. Bronchoscopy: may or may not reveal an obstruction
2. Chest x-ray shows diminished size of affected lung and lack of radiance over atelectic area
3. pO₂ decreased
3. Nursing interventions (prevention of atelectasis in hospitalized clients is an important nursing responsibility)
1. Turn and reposition every 1-2 hours while client is bedridden or obtunded.
2. Encourage mobility (if permitted).
3. Promote liquification and removal of secretions.
4. Avoid administration of large doses of sedatives and opiates that depress respiration and cough reflex.
5. Prevent abdominal distension.
6. Administer prophylactic antibiotics as ordered to prevent respiratory infection.

1. General information
1. Partial or complete collapse of the lung due to an accumulation of air or fluid in the pleural space
2. Types
1. Spontaneous pneumothorax: the most common type of closed pneumothorax; air accumulates within the pleural space without an obvious cause. Rupture of a small bleb on the visceral pleura most frequently produces this type of pneumothorax.
2. Open pneumothorax: air enters the pleural space through an opening in the chest wall; usually caused by stabbing or gunshot wound.
3. Tension pneumothorax: air enters the pleural space with each inspiration but cannot escape; causes increased intrathoracic pressure and shifting of the mediastinal contents to the unaffected side (mediastinal shift).
4. Hemothorax: accumulation of blood in the pleural space; frequently found with an open pneumothorax resulting in a hemopneumothorax.
2. Assessment findings
1. Sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side, decreased respiratory excursion on affected side, hyperresonance on percussion, decreased vocal fremitus, tracheal shift to the opposite side (tension pneumothorax accompanied by mediastinal shift)
2. Weak, rapid pulse; anxiety; diaphoresis
3. Diagnostic tests
1. Chest x-ray reveals area and degree of pneumothorax
2. pCO₂ elevated
3. pO₂, pH decreased
3. Nursing interventions
1. Provide nursing care for the client with an endotracheal tube: suction secretions, vomitus, blood from nose, mouth, throat, or via endotracheal tube; monitor mechanical ventilation.
2. Restore/promote adequate respiratory function.
1. Assist with thoracentesis and provide appropriate nursing care.
2. Assist with insertion of a chest tube to water-seal drainage and provide appropriate nursing care.
3. Continuously evaluate respiratory patterns and report any changes.
3. Provide relief/control of pain.
1. Administer narcotics/analgesics/sedatives as ordered and monitor effects.
2. Position client in high-Fowler's position.

1. General information
1. Fracture of several ribs and resultant instability of the affected chest wall.
2. Chest wall is no longer able to provide the bony structure necessary to maintain adequate ventilation; consequently, the flail portion and underlying tissue move paradoxically (in opposition) to the rest of the chest cage and lungs.
3. The flail portion is sucked in on inspiration and bulges out on expiration.
4. Result is hypoxia, hypercarbia, and increased retained secretions.
5. Caused by trauma (sternal rib fracture with possible costochondral separations).
2. Medical management
1. Internal stabilization with a volume-cycled ventilator
2. Drug therapy (narcotics, sedatives)
3. Assessment findings
1. Severe dyspnea; rapid, shallow, grunty breathing; paradoxical chest motion
2. Cyanosis, possible neck vein distension, tachycardia, hypotension
3. Diagnostic tests
1. pO₂ decreased
2. pCO₂ elevated
3. pH decreased
4. Nursing interventions
1. Maintain an open airway: suction secretions/blood from nose, throat, mouth, and via endotracheal tube; note changes in amount, color, characteristics.
2. Monitor mechanical ventilation.
3. Encourage turning, coughing, and deep breathing.
4. Monitor for signs of shock.

1. General information: a systemic fungal disease caused by inhalation of dust contaminated by Histoplasma capsulatum which is transmitted through bird manure.
2. Medical management: antifungal agent Amphotericin B
1. Very toxic: toxicity includes anorexia, chills, fever, headache, and renal failure
2. Acetaminophen, Benadryl, and steroids given with Amphotericin B to prevent reactions
3. Assessment findings
1. Symptoms similar to tuberculosis or pneumonia
1. Cough
2. Fever
3. Joint pain
4. Malaise
2. Sometimes asymptomatic
3. Diagnostic tests
1. Chest x-ray (often appears similar to tuberculosis)
2. Histoplasmin skin test (read the same as PPD)
4. Nursing interventions
1. Monitor respiratory status
2. Administer medications as ordered; observe for severe side effects of Amphotericin B: fever (acetaminophen given prophylactically), anaphylactic reaction (Benadryl and steroids given prophylactically), abnormal renal function with hypokalemia and azotemia.

1. General information
1. Bacterial infectious disease caused by M. tuberculosis and spread via airborne droplets when infected persons cough, sneeze, or laugh
2. Once inhaled, the organisms implant themselves in the lung and begin dividing slowly, causing inflammation, development of the primary tubercle, and eventual caseation and fibrosis.
3. Infection spreads via the lymph and circulatory systems.
4. Half of the cases occur in inner-city neighborhoods, and incidence is highest in areas with a large population of native Americans. Nonwhites affected four times more often than whites. Men affected more often than women. The greatest number of cases occur in persons age 65 and over. Socially and economically disadvantaged, alcoholic, and malnourished individuals affected more often.
5. The causative agent, M. tuberculosis, is an acid-fast bacillus spread via droplet nuclei from infected persons.
2. Assessment findings
1. Cough (yellow mucoid sputum), dyspnea, hemoptysis, rales or crackles
2. Anorexia, malaise, weight loss, afternoon low-grade fever, pallor, pain, fatigue, night sweats
3. Diagnostic tests
1. Chest x-ray indicates presence and extent of disease process but cannot differentiate active from inactive form
2. Skin test (PPD) positive; area of induration 10 mm or more in diameter after 48 hours
3. Sputum positive for acid-fast bacillus (three samples is diagnostic for disease)
4. Culture positive
5. WBC and ESR increased
3. Nursing interventions
1. Administer medications as ordered (see Table 2.23).
2. Prevent transmission.
1. Strict isolation not required if client/significant others adhere to special respiratory precautions for tuberculosis.
2. Client should be in a well-ventilated private room, with the door kept closed at all times.
3. All visitors and staff should wear masks when in contact with the client and should discard the used masks before leaving the room; client should wear a mask when leaving the room for tests.
4. All specimens should be labelled "AFB precautions."
5. Handwashing is required after direct contact with the client or contaminated articles.
3. Promote adequate nutrition.
1. Make ongoing assessments of client's appetite and do kcal counts for 3 days; consult dietitian for diet guidelines.
2. Offer small, frequent feedings and nutritional supplements; assist client with menu selection stressing balanced nutrition.
3. Weigh client at least twice a week.
4. Encourage activity as tolerated to increase appetite.
4. Prevent social isolation.
1. Impart a comfortable, confident attitude when caring for the client.
2. Explain the nature of the disease to the client, significant others, and visitors in simple terms.
3. Stress that visits are important, but isolation precautions must be followed.
5. Vary the client's routine to prevent boredom.
6. Discuss the client's feelings and assess for boredom, depression, anxiety, fatigue, or apathy; provide support and encourage expression of concerns.
7. Provide client teaching and discharge planning concerning
1. Medication regimen: prepare a sheet with each drug name, dosage, time due, and major side effects; stress importance of following medication schedule for prescribed period of time (usually 9 months); include significant others
2. Transmission prevention: client should cover mouth when coughing, expectorate into a tissue and place it in a paper bag; client should also wash hands after coughing or sneezing; stress importance of plenty of fresh air; include significant others
3. Importance of notifying physician at the first sign of persistent cough, fever, or hemoptysis (may indicate recurrence)
4. Need for follow-up care including physical exam, sputum cultures, and chest x-rays
5. Availability of community health services
6. Importance of high-protein, high-carbohydrate diet with inclusion of supplemental vitamins

Refers to respiratory conditions that produce obstruction of air flow; includes emphysema, bronchitis, bronchiectasis, and asthma.

Emphysema

1. General information
1. Enlargement and destruction of the alveolar, bronchial, and bronchiolar tissue with resultant loss of recoil, air trapping, thoracic overdistension, sputum accumulation, and loss of diaphragmatic muscle tone
2. These changes cause a state of carbon dioxide retention, hypoxia, and respiratory acidosis.
3. Caused by cigarette smoking, infection, inhaled irritants, heredity, allergic factors, aging
2. Assessment findings
1. Anorexia, fatigue, weight loss
2. Feeling of breathlessness, cough, sputum production, flaring of the nostrils, use of accessory muscles of respiration, increased rate and depth of breathing, dyspnea
3. Decreased respiratory excursion, resonance to hyperresonance, decreased breath sounds with prolonged expiration, normal or decreased fremitus
4. Diagnostic tests: pCO₂ elevated or normal; pO₂ normal or slightly decreased
3. Nursing interventions
1. Administer medications as ordered.
1. Bronchiodilators: aminophylline, isoproterenol (Isuprel), terbutaline (Brethine), metaproterenol (Alupent), theophylline, isoetharine (Bronkosol); used in treatment of bronchospasm
2. Antimicrobials: tetracycline, ampicillin to treat bacterial infections
3. Corticosteroids: prednisone
2. Facilitate removal of secretions.
1. Ensure fluid intake of at least 3 liters/day.
2. Provide (and teach client) chest physical therapy, coughing and deep breathing, and use of hand nebulizers.
3. Suction as needed.
4. Provide oral hygiene after expectoration of sputum.
3. Improve ventilation.
1. Position client in semi- or high-Fowler's.
2. Instruct client to use diaphragmatic muscle to breathe.
3. Encourage productive coughing after all treatments (splint abdomen to help produce more expulsive cough).
4. Employ pursed-lip breathing techniques (prolonged, slow relaxed expiration against pursed lips).
4. Provide client teaching and discharge planning concerning
1. Prevention of recurrent infections
1. avoid crowds and individuals with known infection.
2. adhere to high-protein, high-carbohydrate, increased vitamin C diet.
3. receive immunizations for influenza and pneumonia.
4. report changes in characteristics and color of sputum immediately.
5. report worsening of symptoms (increased tightness of chest, fatigue, increased dyspnea).
2. Control of environment
1. use home humidifier at 30%-50% humidity.
2. wear scarf over nose and mouth in cold weather to prevent bronchospasm.
3. avoid smoking and others who smoke.
4. avoid abrupt changes in temperature.
3. Avoidance of inhaled irritants
1. stay indoors if pollution levels are high.
2. use air conditioner with high-efficiency particulate air filter to remove particles from air.
4. Increasing activity tolerance
1. start with mild exercises, such as walking, and gradually increase amount and duration.
2. use breathing techniques (pursed lip, diaphragmatic) during activities/exercises to control breathing.
3. have oxygen available as needed to assist with activities.
4. plan activities that require low amounts of energy.
5. plan rest periods before and after activities.

Bronchitis

1. General information
1. Excessive production of mucus in the bronchi with accompanying persistent cough.
2. Characteristic changes include hypertrophy/hyperplasia of the mucus-secreting glands in the bronchi, decreased ciliary activity, chronic inflammation, and narrowing of the small airways.
3. Caused by the same factors that cause emphysema.
2. Medical management: drug therapy includes bronchodilators, antimicrobials, expectorants (e.g., Robitussin)
3. Assessment findings
1. Productive (copious) cough, dyspnea on exertion, use of accessory muscles of respiration, scattered rales and rhonchi
2. Feeling of epigastric fullness, slight cyanosis, distended neck veins, ankle edema
3. Diagnostic tests: increased pCO₂, decreased pO₂
4. Nursing interventions: same as for emphysema

Bronchiectasis

1. General information
1. Permanent abnormal dilation of the bronchi with destruction of muscular and elastic structure of the bronchial wall
2. Caused by bacterial infection; recurrent lower respiratory tract infections; congenital defects (altered bronchial structures); lung tumors; thick, tenacious secretions
2. Medical management: same as for emphysema.
3. Assessment findings
1. Chronic cough with production of mucopurulent sputum, hemoptysis, exertional dyspnea, wheezing
2. Anorexia, fatigue, weight loss
3. Diagnostic tests
1. Bronchoscopy reveals sources and sites of secretions
2. Possible elevation of WBC
4. Nursing interventions: same as for emphysema

1. General information
1. Disorder characterized by dysfunction of the exocrine glands (mucus-producing glands of the respiratory tract, GI tract, pancreas, sweat glands, salivary glands)
2. Transmitted as an autosomal recessive trait
3. Incidence: 1 in 1500-2000 live births
4. Most common lethal genetic disease among Caucasians in U.S. and Europe
5. No test to detect carriers
6. Prenatal diagnosis of CF is not reliable
7. Secretions from mucous glands are thick, causing obstruction and fibrosis of tissue
8. Sweat and saliva have characteristic high levels of sodium chloride
9. Affected organs
1. Pancreas: 85% of CF clients have pancreatic involvement
1. obstruction of pancreatic ducts and eventual fibrosis and atrophy of the pancreas leads to little or no release of enzymes (lipase [fats], amylase [starch], and trypsin [protein])
2. absence of enzymes causes malabsorption of fats and proteins
3. unabsorbed food fractions excreted in the stool produce steatorrhea
4. loss of nutrients and inability to absorb fat-soluble vitamins causes failure to thrive
2. Respiratory tract: 99.9% of CF clients have respiratory involvement
1. increased production of secretions causes increased obstruction of airway, air trapping, and atelectasis
2. pulmonary congestion leads to cor pulmonale
3. eventually death occurs by drowning in own secretions
3. Reproductive system
1. males are sterile
2. females can conceive, but increased mucus in vaginal tract makes conception more difficult
3. pregnancy causes increased stress on respiratory system of mother
4. Liver: one-third of clients have cirrhosis/portal hypertension
10. The disease is ultimately fatal; average age at death is 20 years; 95% of deaths are from abnormal mucus secretion and fibrosis in the lungs
2. Medical management
1. Pancreatic involvement: aimed at promoting absorption of nutrients
1. Diet modification
1. infant: predigested formula
2. older children: may require high-calorie, high-protein, or low/limited-fat diet, but many CF clients tolerate normal diet
2. Pancreatic enzyme supplementation: enzyme capsules, tablets, or powders (Pancrease, Cotazym, Viokase) given with meals and snacks
2. Respiratory involvement: goals are to maintain airway patency and to prevent lung infection
1. Chest physiotherapy
2. Antibiotics for infection
3. Assessment findings: symptoms vary greatly in severity and extent
1. Pancreatic involvement
1. Growth failure; failure to thrive
2. Stools are foul smelling, large, frequent, foamy, fatty (steatorrhea), contain undigested food
3. Meconium ileus (meconium gets stuck in bowel due to lack of enzymes) in newborns
4. Rectal prolapse is possible due to greasy stools
5. Voracious appetite
6. Characteristic protruding abdomen with atrophy of extremities and buttocks
7. Symptoms associated with deficiencies in the fat-soluble vitamins
8. Anemia
9. Diagnostic tests
1. trypsin decreased to absent in aspiration of duodenal contents
2. fecal fat in stool specimen increased
2. Respiratory involvement
1. Signs of respiratory distress
2. Barrel chest due to air trapping
3. Clubbing of digits
4. Decreased exercise tolerance due to distress
5. Frequent productive cough
6. Frequent pseudomonas infections
7. Diagnostic tests
1. chest x-ray reveals atelectasis, infiltrations, emphysemic changes
2. pulmonary function studies abnormal
3. ABGs show respiratory acidosis
3. Electrolyte involvement
1. Hyponatremia/heat exhaustion in hot weather
2. Salty taste to sweat
3. Diagnostic tests
1. pilocarpine iontophoresis sweat test: indicates 2-5 times normal amount of sodium and chloride in the sweat
2. fecal fat elevated
3. fecal trypsin absent or decreased
4. Nursing interventions
1. Pancreatic involvement
1. Administer pancreatic enzymes with meals as ordered: do not mix enzymes until ready to use them; best to mix in applesauce.
2. Provide a high-calorie, high-carbohydrate (no empty-calorie foods), high-protein, normal-fat diet.
3. Provide a double dose of multivitamins per day, especially fat-soluble vitamins (A, D, E, K), in water-soluble form.
4. If low-fat diet required, MCT (medium-chain triglycerides) oil may be used.
2. Respiratory involvement
1. Administer antibiotics as ordered (all antibiotics for pseudomonas are given IV; doses may be above recommended levels (for virulent organisms)
2. Administer expectorants, mucolytics (rarely used) as ordered.
3. Avoid cough suppressants and antihistamines.
4. Encourage breathing exercises.
5. Provide percussion and postural drainage 4 times a day.
6. Provide aerosol treatments as needed; hand-held nebulizers, mask, intermittent positive pressure breathing (IPPB), mist tent.
3. Electrolyte involvement
1. Add salt to all meals, especially in summer.
2. Give salty snacks (pretzels).
4. Provide appropriate long-term support to child and family.
5. Provide client teaching and discharge planning concerning
1. Genetic counseling
2. Promotion of child's independence
3. Avoidance of cigarette smoking in the house
4. Availability of support groups/community agencies
5. Alternative school education during extended hospitalization/home recovery

1. General information
1. Relatively common airway problem.
2. Severity depends on object (e.g., pins, coins, nuts, buttons, parts of toys) aspirated and the degree of obstruction.
3. Depending on object aspirated, symptoms will increase over hours or weeks.
4. The curious toddler is most frequently affected.
5. If object does not pass trachea immediately, respiratory distress will be evident.
6. If object moves beyond tracheal region, it will pass into one of the main stem bronchi; symptoms will be vague, insidious.
7. Causes 400 deaths per year in children under age 4.
2. Medical management
1. Objects in upper airway require immediate removal.
2. Lower airway obstruction is less urgent (bronchoscopy or laryngoscopy).
3. Assessment findings
1. Sudden onset of coughing, dyspnea, wheezing, stridor, apnea (upper airway)
2. Persistent or recurrent pneumonia, persistent croupy cough or wheeze
3. Object not always visible on x-ray
4. Secondary infection
4. Nursing interventions
1. Perform Heimlich maneuver if indicated.
2. Reassure the scared toddler.
3. After removal, place child in high-humidity environment and treat secondary infection if applicable.
4. Counsel parents regarding age-appropriate behavior and safety precautions.

1. General information
1. Obstructive disease of the lower respiratory tract
2. Most common chronic respiratory disease in children, in younger children affects twice as many boys as girls; incidence equal by adolescence
3. Often caused by an allergic reaction to an environmental allergen, may be seasonal or year round
4. Immunologic/allergic reaction results in histamine release, which produces three main airway responses
1. Edema of mucous membranes
2. Spasm of the smooth muscle of bronchi and bronchioles
3. Accumulation of tenacious secretions
5. Status asthmaticus occurs when there is little response to treatment and symptoms persist
2. Medical management
1. Drug therapy
1. Bronchodilators to relieve bronchospasm
1. Beta-adrenergic agents: rapid onset of action when administered by aerosol (see Figure 5.3 below)
2. theophylline: check pulse and blood pressure
2. Corticosteroids to relieve inflammation and edema
3. Antibiotics: if secondary infection
4. Cromolyn sodium: not used during acute attack; inhaled; inhibits histamine release in lungs and prevents attack
2. Physical therapy
3. Hyposensitization
4. Exercise
3. Assessment findings
1. Family history of allergies
2. Client history of eczema
3. Respiratory distress: shortness of breath, expiratory wheeze, prolonged expiratory phase, air trapping (barrel chest if chronic), use of accessory muscles, irritability (from hypoxia), diaphoresis, change in sensorium if severe attack
4. Diagnostic tests: ABGs indicate respiratory acidosis
4. Nursing interventions
1. Place client in high-Fowler's position.
2. Administer oxygen as ordered.
3. Administer medications as ordered.
4. Provide humidification/hydration to loosen secretions.
5. Provide chest percussion and postural drainage when bronchodilation improves.
6. Monitor for respiratory distress.
7. Provide client teaching and discharge planning concerning
1. Modification of environment
1. ensure room is well ventilated.
2. stay indoors during grass cutting or when pollen count is high.
3. use damp dusting.
4. avoid rugs, draperies or curtains, stuffed animals.
5. avoid natural fibers (wool and feathers).
2. Importance of moderate exercise (swimming is excellent)
3. Purpose of breathing exercises (to increase the end expiratory pressure of each respiration)

FIGURE 5.3 Instructions for use of an oral inhaler

1. General information
1. Pulmonary viral infection characterized by wheezing
2. Usually caused by respiratory syncytial virus
3. Virus invades epithelial cells of nasopharynx and spreads to lower respiratory tract, causing increased mucus production, decreased diameter of bronchi, hyperinflation, and possible atelectasis
4. Affects infants ages 2-8 months
5. Increased incidence of asthma as child grows older
2. Medical management: IV epinephrine (if provides relief, follow with epinephrine suspension [Sus-Phrine], which is longer acting, then theophylline); if no response to epinephrine, all treatment is supportive
3. Assessment findings
1. Difficulty feeding, fever
2. Cough, coryza
3. Wheezing, prolonged expiratory phase, tachypnea, nasal flaring, retractions (intercostal more pronounced than supraclavicular retractions)
4. Diagnostic tests
1. WBC normal
2. X-ray reveals hyperaeration
4. Nursing interventions
1. Provide high-humidity environment, with oxygen in some cases (instruct parents to take child into steamy bathroom if at home).
2. Offer small, frequent feedings; clear fluids if trouble with secretions.
3. Provide adequate rest.
4. Administer antipyretics as ordered to control fever.

1. General information
1. Life-threatening bacterial infection of epiglottis and surrounding structures
2. Primary organism: H. influenzae, type B
3. Often preceded by upper respiratory infection
4. Rapid progression of swelling causes reduction in airway diameter; may lead to sudden respiratory arrest
5. Affects children ages 3-7 years
2. Assessment findings
1. Fever, tachycardia, inspiratory stridor, labored respirations with retractions, sore throat, dysphagia, drooling
2. Irritability, restlessness, anxious-looking
3. Position: sitting upright, head forward and jaw thrust out
4. Diagnostic tests
1. WBC increased
2. Lateral neck x-ray reveals characteristic findings
3. Nursing interventions
1. Provide mist tent with oxygen.
2. Administer IV antibiotics as ordered.
3. Provide tracheostomy or endotracheal tube care (see The Respiratory System - Traceostomy Care, in Unit 4); note the following
1. Restlessness, fatigue, dyspnea, cyanosis, pallor, tachycardia, tachypnea, diminished breath sounds, adventitious lung sounds.
2. Need for suctioning to remove secretions; note amount, color, consistency.
4. Reassure child through touch, sound, and physically being present.
5. Involve parents in all aspects of care.
6. Avoid direct examination of the epiglottis as it may precipitate spasm and obstruction.
7. Remember this is extremely frightening experience for child and parents; explain procedures and findings; reinforce explanations of physician.

1. General information
1. Viral infection of the larynx that may extend into trachea and bronchi
2. Most common cause for stridor in febrile child
3. Parainfluenza viruses most common cause
4. Infection causes endothelial insult, increased mucous production, edema, low grade fever
5. Affects children less than five years of age
6. Onset more gradual than with croup, takes longer to resolve; usually develops over several days with upper respiratory infection
7. Usually treated on outpatient basis; indications for admission include dehydration and respiratory compromise
2. Medical management
1. Drug therapy
1. Aerosolized racemic epinephrine
2. Antibiotics only if secondary bacterial infection present
3. Steroids: still controversial
2. Oxygen therapy: low concentrations to relieve mild hypoxia (concentrations greater than 30% may mask signs of obstruction and should not be used)
3. Oral or nasotracheal intubation for moderate hypoxia
4. IV fluids to maintain hydration
3. Assessment findings
1. Fever, coryza, inspiratory stridor, barking cough, tachycardia, tachypnea, retractions
2. May have difficulty taking fluids
3. WBC normal
4. Nursing interventions
1. Instruct parents to take child into steamy bathroom for acute distress.
2. Keep child calm.
3. After distress subsides, use cool mist vaporizer in bedroom.
4. Child can vomit large amounts of mucus after the episode; reassure parents that this is normal.
5. For hospitalized child
1. Monitor vital signs, I&O, skin color, and respiratory effort.
2. Maintain hydration.
3. Provide care for the intubated child.
4. Plan care to disturb the child as little as possible.
5. Avoid direct examination of the epiglottis as it may precipitate spasm and obstruction.