Claire Maurice G.

Juanero

Upper Respiratory Disorders

Asthma
Asthma is a condition in which your airways narrow and swell and may produce extra mucus.
This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when you
breathe out and shortness of breath.
For some people, asthma is a minor nuisance. For others, it can be a major problem that
interferes with daily activities and may lead to a life-threatening asthma attack.
Asthma can't be cured, but its symptoms can be controlled. Because asthma often changes
over time, it's important that you work with your doctor to track your signs and symptoms and
adjust your treatment as needed.

Signs & Symptoms of Asthma

 Most common symptoms of asthma are cough (with or without mucus production),
dyspnea, and wheezing (first on expiration, then possibly during inspiration as well).
 Cough. There are instances that cough is the only symptom.
 Dyspnea. General tightness may occur which leads to dyspnea.
 Wheezing. There may be wheezing, first on expiration, and then possibly during
inspiration as well.
 Asthma attacks frequently occur at night or in the early morning.
 An asthma exacerbation is frequently preceded by increasing symptoms over days, but it
may begin abruptly.
 Expiration requires effort and becomes prolonged.
 As exacerbation progresses, central cyanosis secondary to severe hypoxia may occur.
 Additional symptoms, such as diaphoresis, tachycardia, and a widened pulse pressure,
may occur.
 Exercise-induced asthma: maximal symptoms during exercise, absence of nocturnal
symptoms, and sometimes only a description of a “choking” sensation during exercise.
 A severe, continuous reaction, status asthmaticus, may occur. It is life-threatening.
 Eczema, rashes, and temporary edema are allergic reactions that may be noted with
asthma.
 Prevention
 Patients with recurrent asthma should undergo tests to identify the substances that
precipitate the symptoms.

 Allergens. Allergens, either seasonal or perennial, can be prevented through avoiding

contact with them whenever possible.
 Knowledge. Knowledge is the key to quality asthma care.
 Evaluation. Evaluation of impairment and risk are key in the control.
 Causes of asthma

The fundamental causes of asthma are not completely understood. The strongest risk
factors for developing asthma are a combination of genetic predisposition with
environmental exposure to inhaled substances and particles that may provoke allergic
reactions or irritate the airways, such as:

 indoor allergens (for example house dust mites in bedding, carpets and stuffed furniture,
pollution and pet dander)
 outdoor allergens (such as pollens and moulds)
 tobacco smoke
 chemical irritants in the workplace
 air pollution
 Other triggers can include cold air, extreme emotional arousal such as anger or fear, and
physical exercise. Even certain medications can trigger asthma: aspirin and other non-
steroid anti-inflammatory drugs, and beta-blockers (which are used to treat high blood
pressure, heart conditions and migraine).

Urbanization has been associated with an increase in asthma. But the exact nature of
this relationship is unclear.

Medical Management
Immediate intervention may be necessary, because continuing and progressive dyspnea leads
to increased anxiety, aggravating the situation.

Pharmacologic Therapy
 Short-acting beta2 –adrenergic agonists. These are the medications of choice
for relief of acute symptoms and prevention of exercise-induced asthma.
 Anticholinergics. Anticholinergics inhibit muscarinic cholinergic receptors and
reduce intrinsic vagal tone of the airway.
 Corticosteroids. Corticosteroids are most effective in alleviating symptoms,
improving airway function, and decreasing peak flow variability.
 Leukotriene modifiers. Anti Leukotrienes are potent bronchoconstrictors that
also dilate blood vessels and alter permeability.
 Immunomodulators. Prevent binding of IgE to the high affinity receptors of
basophils and mast cells.

Peak Flow Monitoring

Peak Flow Meter
 Peak flow meters. Peak flow meters measure the highest airflow during a forced
expiration.
 Daily peak flow monitoring. This is recommended for patients who meet one or
more of the following criteria: have moderate or severe persistent asthma, have
poor perception of changes in airflow or worsening symptoms, have unexplained
 response to environmental or occupational exposures, or at the discretion of the
clinician or patient.
 Function. If peak flow monitoring is used, it helps measure asthma severity and,
when added to symptom monitoring, indicates the current degree of asthma
control.

Nursing Management
The immediate care of patients with asthma depend on the severity of the symptoms.

Nursing Assessment
Assessment of a patient with asthma includes the following:
 Assess the patient’s respiratory status by monitoring the severity of the symptoms.
 Assess for breath sounds.
 Assess the patient’s peak flow.
 Assess the level of oxygen saturation through the pulse oximeter.
 Monitor the patient’s vital signs.

Nursing Diagnosis
Based on the data gathered, the nursing diagnoses appropriate for the patient with asthma
include:
 Ineffective airway clearance related to increased production of mucus and
bronchospasm.
 Impaired gas exchange related to altered delivery of inspired O2.
 Anxiety related to perceived threat of death.

Nursing Care Planning & Goals

To achieve success in the treatment of a patient with asthma, the following goals should be
applied:
 Maintenance of airway patency.
 Expectoration of secretions.
 Demonstration of absence/reduction of congestion with breath sounds clear, respirations
noiseless, improved oxygen exchange.
 Verbalization of understanding of causes and therapeutic management regimen.
 Demonstration of behaviors to improve or maintain clear airway.
 Identification of potential complications and how to initiate appropriate preventive or
corrective actions.

Nursing Interventions
The nurse generally performs the following interventions:
  Assess history. Obtain a history of allergic reactions to medications before administering
medications.
 Assess respiratory status. Assess the patient’s respiratory status by monitoring the
severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs.
 Assess medications. Identify medications that the patient is currently taking. Administer
medications as prescribed and monitor the patient’s responses to those medications;
medications may include an antibiotic if the patient has an underlying respiratory
infection.
 Pharmacologic therapy. Administer medications as prescribed and monitor patient’s
responses to medications.
 Fluid therapy. Administer fluids if the patient is dehydrated.

Evaluation
To determine the effectiveness of the plan of care, evaluation must be performed. The following
must be evaluated:

 Maintenance of airway patency.

 Expectoration or clearance of secretions.
 Absence /reduction of congestion with breath sound clear, noiseless respirations, and
improved oxygen exchange.
 Verbalized understanding of causes and therapeutic management regimen.
 Demonstrated behaviors to improve or maintain clear airway.
 Identified potential complications and how to initiate appropriate preventive or corrective
actions.

Chronic Bronchitis
Chronic bronchitis is a type of COPD (chronic obstructive pulmonary disease). COPD is a group
of lung diseases that make it hard to breathe and get worse over time. The other main type of
COPD is emphysema. Most people with COPD have both emphysema and chronic bronchitis,
but how severe each type is can be different from person to person.

Chronic bronchitis is inflammation (swelling) and irritation of the bronchial tubes. These tubes
are the airways that carry air to and from the air sacs in your lungs. The irritation of the tubes
causes mucus to build up. This mucus and the swelling of the tubes make it harder for your
lungs to move oxygen in and carbon dioxide out of your body.

Signs & Symptoms

At first, you may have no symptoms or only mild symptoms. As the disease gets worse, your
symptoms usually become more severe. They can include
 Frequent coughing or a cough that produces a lot mucus
 Wheezing
  A whistling or squeaky sound when you breathe
 Shortness of breath, especially with physical activity
 Tightness in your chest
Some people with chronic bronchitis get frequent respiratory infections such as colds and
the flu. In severe cases, chronic bronchitis can cause weight loss, weakness in your lower
muscles, and swelling in your ankles, feet, or legs.

Causes
The cause of chronic bronchitis is usually long-term exposure to irritants that damage your lungs
and airways. In the United States, cigarette smoke is the main cause. Pipe, cigar, and other
types of tobacco smoke can also cause chronic bronchitis, especially if you inhale them.

Exposure to other inhaled irritants can contribute to chronic bronchitis. These include
secondhand smoke, air pollution, and chemical fumes or dusts from the environment or
workplace.

Rarely, a genetic condition called alpha-1 antitrypsin deficiency can play a role in causing
chronic bronchitis.

Medical Management
There is no cure for chronic bronchitis. However, treatments can help with symptoms, slow the
progress of the disease, and improve your ability to stay active. There are also treatments to
prevent or treat complications of the disease. Treatments include
 Lifestyle changes, such as
 Quitting smoking if you are a smoker. This is the most important step you can take
to treat chronic bronchitis.
 Avoiding secondhand smoke and places where you might breathe in other lung
irritants
 Ask your health care provider for an eating plan that will meet your nutritional
needs. Also ask about how much physical activity you can do. Physical activity
can strengthen the muscles that help you breathe and improve your overall
wellness.
 Medicines, such as
 Bronchodilators, which relax the muscles around your airways. This helps open
your airways and makes breathing easier. Most bronchodilators are taken
through an inhaler. In more severe cases, the inhaler may also contain steroids to
reduce inflammation.
  Vaccines for the flu and pneumococcal pneumonia, since people with chronic
bronchitis are at higher risk for serious problems from these diseases.
 Antibiotics if you get a bacterial or viral lung infection
 Oxygen therapy, if you have severe chronic bronchitis and low levels of oxygen in your
blood. Oxygen therapy can help you breathe better. You may need extra oxygen all the
time or only at certain times.
 Pulmonary rehabilitation, which is a program that helps improve the well-being of
people who have chronic breathing problems. It may include
 An exercise program
 Disease management training
 Nutritional counseling
 Psychological counseling
 A lung transplant, as a last resort for people who have severe symptoms that have not
gotten better with medicines
If you have chronic bronchitis, it's important to know when and where to get help for your
symptoms. You should get emergency care if you have severe symptoms, such as trouble
catching your breath or talking. Call your health care provider if your symptoms are getting
worse or if you have signs of an infection, such as a fever.

Medical Management

Healthcare providers perform medical management by considering the assessment data first
and matching the appropriate intervention to the existing manifestation.
Pharmacologic Therapy
 Bronchodilators. Bronchodilators relieve bronchospasm by altering the smooth
muscle tone and reduce airway obstruction by allowing increased oxygen distribution
throughout the lungs and improving alveolar ventilation.
 Corticosteroids. A short trial course of oral corticosteroids may be prescribed for
patients to determine whether pulmonary function improves and symptoms decrease.
 Other medications. Other pharmacologic treatments that may be used in COPD include
alpha1-antitrypsin augmentation therapy, antibiotic agents, mucolytic agents, antitussive
agents, vasodilators, and narcotics.
Management of Exacerbations
 Optimization of bronchodilator medications is first-line therapy and involves identifying
the best medications or combinations of medications taken on a regular schedule for a
specific patient.
  Hospitalization. Indications for hospitalization for acute exacerbation of COPD include
severe dyspnea that does not respond to initial therapy, confusion or lethargy,
respiratory muscle fatigue, paradoxical chest wall movement, and peripheral edema.
 Oxygen therapy. Upon arrival of the patient in the emergency room, supplemental
oxygen therapy is administered and rapid assessment is performed to determine if the
exacerbation is life-threatening.
 Antibiotics. Antibiotics have been shown to be of some benefit to patients with
increased dyspnea, increased sputum production, and increased sputum purulence.
Surgical Management

Patients with COPD also have options for surgery to improve their condition.
 Bullectomy. Bullectomy is a surgical option for select patients with bullous
emphysema and can help reduce dyspnea and improve lung function.
 Lung Volume Reduction Surgery. Lung volume reduction surgery is a palliative
surgery in patients with homogenous disease or disease that is focused in one area and
not widespread throughout the lungs.
 Lung Transplantation. Lung transplantation is a viable option for definitive surgical
treatment of end-stage emphysema.

Nursing Management

Management of patients with COPD should be incorporated with teaching and improving the
respiratory status of the patient.
Nursing Assessment
Assessment of the respiratory system should be done rapidly yet accurately.
 Assess patient’s exposure to risk factors.
 Assess the patient’s past and present medical history.
 Assess the signs and symptoms of COPD and their severity.
 Assess the patient’s knowledge of the disease.
 Assess the patient’s vital signs.
 Assess breath sounds and pattern.

Nursing Interventions
Patient and family teaching is an important nursing intervention to enhance self-management in
patients with any chronic pulmonary disorder.
To achieve airway clearance:
 The nurse must appropriately administer bronchodilators and corticosteroids and
become alert for potential side effects.
 Direct or controlled coughing. The nurse instructs the patient in direct or controlled
coughing, which is more effective and reduces fatigue associated with undirected
forceful coughing.
To improve breathing pattern:
 Inspiratory muscle training. This may help improve the breathing pattern.
 Diaphragmatic breathing. Diaphragmatic breathing reduces respiratory rate, increases
alveolar ventilation, and sometimes helps expel as much air as possible during
expiration.
 Pursed lip breathing. Pursed lip breathing helps slow expiration, prevents collapse of
small airways, and control the rate and depth of respiration.
To improve activity intolerance:
 Manage daily activities. Daily activities must be paced throughout the day and support
devices can be also used to decrease energy expenditure.
 Exercise training. Exercise training can help strengthen muscles of the upper and lower
extremities and improve exercise tolerance and endurance.
 Walking aids. Use of walking aids may be recommended to improve activity levels and
ambulation.
To monitor and manage potential complications:
 Monitor cognitive changes. The nurse should monitor for cognitive changes such as
personality and behavior changes and memory impairment.
 Monitor pulse oximetry values. Pulse oximetry values are used to assess the patient’s
need for oxygen and administer supplemental oxygen as prescribed.
 Prevent infection. The nurse should encourage the patient to be iunized
against influenza and S. pneumonia because the patient is prone to respiratory infection.

Lung Cancer

Lung cancer is a type of cancer that begins in the lungs. Your lungs are two spongy organs in
your chest that take in oxygen when you inhale and release carbon dioxide when you exhale.

Lung cancer is the leading cause of cancer deaths worldwide.

People who smoke have the greatest risk of lung cancer, though lung cancer can also occur in
people who have never smoked. The risk of lung cancer increases with the length of time and
number of cigarettes you've smoked. If you quit smoking, even after smoking for many years,
you can significantly reduce your chances of developing lung cancer.
Signs & Symptoms
Lung cancer typically doesn't cause signs and symptoms in its earliest stages. Signs and
symptoms of lung cancer typically occur when the disease is advanced.
Signs and symptoms of lung cancer may include:

 A new cough that doesn't go away

 Coughing up blood, even a small amount
 Shortness of breath
 Chest pain
 Hoarseness
 Losing weight without trying
 Bone pain
 Headache

Causes

Smoking causes the majority of lung cancers — both in smokers and in people exposed to
secondhand smoke. But lung cancer also occurs in people who never smoked and in those who
never had prolonged exposure to secondhand smoke. In these cases, there may be no clear
cause of lung cancer.

How smoking causes lung cancer

Doctors believe smoking causes lung cancer by damaging the cells that line the lungs. When
you inhale cigarette smoke, which is full of cancer-causing substances (carcinogens), changes
in the lung tissue begin almost immediately.
At first your body may be able to repair this damage. But with each repeated exposure, normal
cells that line your lungs are increasingly damaged. Over time, the damage causes cells to act
abnormally and eventually cancer may develop.

Types of lung cancer

Doctors divide lung cancer into two major types based on the appearance of lung cancer cells
under the microscope. Your doctor makes treatment decisions based on which major type of
lung cancer you have.
The two general types of lung cancer include:
 Small cell lung cancer. Small cell lung cancer occurs almost exclusively in heavy
smokers and is less common than non-small cell lung cancer.
 Non-small cell lung cancer. Non-small cell lung cancer is an umbrella term for several
types of lung cancers. Non-small cell lung cancers include squamous cell carcinoma,
adenocarcinoma and large cell carcinoma.

Medical Management

 Oxygen through nasal cannula based on level of dyspnea.

 Enteral or total parenteral nutrition for malnourished patient who is unable or unwilling to
eat.
 Removal of the pleural fluid (by thoracentesis or tube thoracostomy) and instillation of
sclerosing agent to obliterate pleural space and fluid recurrence.
 Radiation therapy in combination with other methods.
Surgical Intervention
 Resection of tumor, lobe, or lung.

Nursing Intervention

 Elevate the head of the bed to ease the work of breathing and to prevent fluid collection
in upper body (from superior vena cava syndrome).
 Teach breathing retraining exercises to increase diaphragmatic excursion and reduce
work of breathing.
 Augment the patient’s ability to cough effectively by splinting the patient’s chest
manually.
 Instruct the patient to inspire fully and cough two to three times in one breath.
 Provide humidifier or vaporizer to provide moisture to loosen secretions.
 Teach relaxation techniques to reduce anxiety associated with dyspnea. Allow the
severely dyspneic patient to sleep in reclining chair.
 Encourage the patient to conserve energy by decreasing activities.
 Ensure adequate protein intake such as milk, eggs, oral nutritional supplements; and
chicken, fowl, and fish if other treatments are not tolerated – to promote healing and
prevent edema.
 Advise the patient to eat small amounts of high-calorie and high-protein foods frequently,
rather than three daily meals.
 Suggest eating the major meal in the morning if rapid satiety is the problem.
 Change the diet consistency to soft or liquid if patient has esophagitis from radiation
therapy.
 Consider alternative pain control methods, such as biofeedback and relaxation methods,
to increase the patient’s sense of control.
 Teach the patient to use prescribed medications as needed for pain without being overly
concerned about addiction.

ATELECTASIS
Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung. It occurs
when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar
fluid.
Atelectasis is one of the most common breathing (respiratory) complications after surgery. It's
also a possible complication of other respiratory problems, including cystic fibrosis, lung tumors,
chest injuries, fluid in the lung and respiratory weakness. You may develop atelectasis if you
breathe in a foreign object.
Atelectasis can make breathing difficult, particularly if you already have lung disease. Treatment
depends on the cause and severity of the collapse.

Signs & Symptoms

There may be no obvious signs or symptoms of atelectasis. If you do have signs and symptoms,
they may include:
 Difficulty breathing
 Rapid, shallow breathing
 Wheezing
 Cough

Causes
Atelectasis occurs from a blocked airway (obstructive) or pressure from outside the lung
(nonobstructive).

General anesthesia is a common cause of atelectasis. It changes your regular pattern of

breathing and affects the exchange of lung gases, which can cause the air sacs (alveoli) to
deflate. Nearly everyone who has major surgery develops some amount of atelectasis. It often
occurs after heart bypass surgery.

Obstructive atelectasis may be caused by many things, including:

 Mucus plug. A mucus plug is a buildup of mucus in your airways. It commonly occurs
during and after surgery because you can't cough. Drugs given during surgery make you
breathe less deeply, so normal secretions collect in the airways. Suctioning the lungs during
surgery helps clear them, but sometimes they still build up. Mucus plugs are also common in
children, people with cystic fibrosis and during severe asthma attacks.
 Foreign body. Atelectasis is common in children who have inhaled an object, such as a
peanut or small toy part, into their lungs.
 Tumor inside the airway. An abnormal growth can narrow the airway.

Possible causes of nonobstructive atelectasis include:

 Injury. Chest trauma — from a fall or car accident, for example — can cause you to avoid
taking deep breaths (due to the pain), which can result in compression of your lungs.
 Pleural effusion. This condition involves the buildup of fluid between the tissues (pleura)
that line the lungs and the inside of the chest wall.
 Pneumonia. Various types of pneumonia, a lung infection, can cause atelectasis.
 Pneumothorax. Air leaks into the space between your lungs and chest wall, indirectly
causing some or all of a lung to collapse.
 Scarring of lung tissue. Scarring could be caused by injury, lung disease or surgery.
 Tumor. A large tumor can press against and deflate the lung, as opposed to blocking the air
passages.

Risk factors
Factors that make you more likely to develop atelectasis include:

 Older age
 Any condition that makes it difficult to swallow
 Confinement to bed with infrequent changes of position
 Lung disease, such as asthma, COPD, bronchiectasis or cystic fibrosis
 Recent abdominal or chest surgery
 Recent general anesthesia
 Weak breathing (respiratory) muscles due to muscular dystrophy, spinal cord injury or
another neuromuscular condition
 Medications that may cause shallow breathing
 Pain or injury that may make it painful to cough or cause shallow breathing, including
stomach pain or rib fracture
 Smoking

Medical/Surgical Management
Treatment of atelectasis depends on the cause. Mild atelectasis may go away without
treatment. Sometimes, medications are used to loosen and thin mucus. If the condition is due to
a blockage, surgery or other treatments may be needed.

Chest physiotherapy
Techniques that help you breathe deeply after surgery to re-expand collapsed lung tissue are
very important. These techniques are best learned before surgery. They include:
Performing deep-breathing exercises (incentive spirometry) and using a device to assist with
deep coughing may help remove secretions and increase lung volume.
Positioning your body so that your head is lower than your chest (postural drainage). This allows
mucus to drain better from the bottom of your lungs.
Tapping on your chest over the collapsed area to loosen mucus. This technique is called
percussion. You can also use mechanical mucus-clearance devices, such as an air-pulse
vibrator vest or a hand-held instrument.

Surgery
Removal of airway obstructions may be done by suctioning mucus or by bronchoscopy. During
bronchoscopy, the doctor gently guides a flexible tube down your throat to clear your airways.
If a tumor is causing the atelectasis, treatment may involve removal or shrinkage of the tumor
with surgery, with or without other cancer therapies (chemotherapy or radiation).

Breathing treatments
In some cases, a breathing tube may be needed.
Continuous positive airway pressure (CPAP) may be helpful in some people who are too weak
to cough and have low oxygen levels (hypoxemia) after surgery.

Nursing Management
 Encourage the patient to perform coughing and deep-breathing exercises every 1 to 2
hours.
 Help the patient use an incentive spirometer to encourage deep breathing.
 Gently reposition the patient often and help him walk as soon as possible.
 Administer adequate analgesics to control pain.
 Humidify inspired air and encourage adequate fluid intake to mobilize secretions.
 Use postural drainage and chest percussion to remove secretions.
 Provide suctioning as needed for patients who are intubated or unable to clear their own
secretions.
 Administer sedatives with care because these medications depress respirations and
cough reflex.
 Offer ample reassurance and emotional support because the patient’s limited breathing
capacity may frighten him.
 Assess breath sounds and respiratory status frequently. Report any changes
immediately.
 Evaluate the patient’s ability to perform bronchial hygiene.
 Monitor pulse oximetry readings and ABG values for evidence of hypoxia.
 Demonstrate comfort measures to promote relaxation and conserve energy.

ACUTE TRACHEOBRONCHITIS

Tracheobronchitis occurs when the windpipe or bronchi become inflamed. This is usually due to
a viral or bacterial infection, but it can also be the result of some kind of irritant, such as
cigarette smoke.
The windpipe and bronchi both carry air to the lungs, so when they become inflamed it usually
results in some difficulty breathing and a severe cough.
The condition is usually acute, which means it only lasts for a few weeks.
The term tracheobronchitis refers to the set of symptoms experienced, so it’s technically not
contagious. However, if the symptoms are the result of a viral or bacterial infection, it could be
contagious.

Signs & Symptoms

 severe cough
 sore throat
 fatigue
 nasal congestion
  shortness of breath
 wheezing
 nausea
 vomiting
 cyanosis (a blue tinge around the mouth)

Causes and Risk Factors

Tracheobronchitis is generally caused by a viral or bacterial infection. Viral infections will pass
on their own, whereas bacterial infections may require antibiotic treatment.
The condition can also be caused by an allergic reaction, so you should avoid known allergens.
If you develop tracheobronchitis as a reaction to an allergen that you weren’t aware of, then
take care to identify the cause so you can avoid it in the future.
People who smoke or work in environments where they’re exposed to excessive dust or fumes
are at increased risk of developing chronic bronchitis.

Medical Management

If tracheobronchitis is caused by a viral infection, then treatment focuses on relieving symptoms,

since the condition will soon pass unaided. It’s recommended that you drink plenty of fluids. You
may also take over-the-counter pain medications and cough suppressants. Some find that a
humidifier is useful in helping them to breathe more easily and loosening the mucus in their
lungs.
If tracheobronchitis is caused by a bacterial infection, then antibiotics may be needed to clear it.
But all of the above methods can still be used to help relieve symptoms.
If you have chronic bronchitis, then the first step to limit damage is to remove the substance that
is irritating your lungs. So, for example, smokers should seek help to quit smoking immediately.
Anti-inflammatory medications, inhalers, and oxygen can also be prescribed.

Medical Management:
 Chest physiotherapy to mobilize secretions, if indicated.
 Hydration to liquefy secretions.

Pharmacologic Interventions:
 Inhaled bronchodilators to reduce bronchospasm and promote sputum expectoration.
 A course of oral antibiotics such as a macrolide may be instituted, but is controversial.
 Symptom management for fever and cough.
Nursing Management
 Encourage mobilization of secretion through ambulation, coughing, and deep breathing.
 Ensure adequate fluid intake to liquefy secretions and prevent dehydration caused by
fever and tachypnea.
 Encourage rest, avoidance of bronchial irritant, and a good diet to facilitate recovery.
 Instruct the patient to complete the full course of prescribed antibiotics and explain the
effect of meals on drug absorption.
 Caution the patient on using over-the-counter cough suppressants, antihistamines, and
decongestants, which may cause drying and retention of secretions. However, cough
preparations containing the mucolytic guaifenesin may be appropriate.
 Advise the patient that a dry cough may persist after bronchitis because of irritation of
airways. Suggest avoiding dry environments and using a humidifier at bedside.
Encourage smoking cessation.
 Teach the patient to recognize and immediately report early signs and symptoms of
acute bronchitis.

PNEUMONIA

Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill
with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and
difficulty breathing. A variety of organisms, including bacteria, viruses and fungi, can cause
pneumonia.
Pneumonia can range in seriousness from mild to life-threatening. It is most serious for infants
and young children, people older than age 65, and people with health problems or weakened
immune systems.

Pneumonia is classified into four: community-acquired pneumonia (CAP) and hospital-acquired

pneumonia (HAP), pneumonia in the immunocompromised host, and aspiration pneumonia.

Community-Acquired Pneumonia
 CAP occurs either in the community setting or within the first 48 hours after
hospitalization.
 The causative agents for CAP that needs hospitalization include streptococcus
pneumoniae, H. influenza, Legionella, and Pseudomonas aeruginosa.
 Only in 50% of the cases does the specific etiologic agent become identified.
 Pneumonia is the most common cause of CAP in people younger than 60 years of age.
 Viruses are the most common cause of pneumonia in infants and children.
Hospital-Acquired Pneumonia
 HAP is also called nosocomial pneumonia and is defined as the onset of pneumonia
symptoms more than 48 hours after admission in patients with no evidence of infection
at the time of admission.
  HAP is the most lethal nosocomial infection and the leading cause of death in patients
with such infections.
 Common microorganisms that are responsible for HAP include Enterobacter species,
Escherichia coli, influenza, Klebsiella species, Proteus, Serratia marcescens, S. aureus,
and S. pneumonia.
 The usual presentation of HAP is a new pulmonary infiltrate on chest x-ray combined
with evidence of infection.
Pneumonia in the Immunocompromised Host
 Pneumonia in immunocompromised hosts includes Pneumocystis pneumonia, fungal
pneumonias and Mycobacterium tuberculosis.
 Patients who are immunocompromised commonly develop pneumonia from organisms
of low virulence.
 Pneumonia in immunocompromised hosts may be caused by the organisms also
observe in HAP and CAP.
Aspiration Pneumonia
 Aspiration pneumonia refers to the pulmonary consequences resulting from entry of
endogenous or exogenous substances into the lower airway.
 The most common form of aspiration pneumonia is a bacterial infection from aspiration
of bacteria that normally reside in the upper airways.
 Aspiration pneumonia may occur in the community or hospital setting.
 Common pathogens are S. pneumonia, H.influenza, and S. aureus.

Signs & Symptoms

The signs and symptoms of pneumonia vary from mild to severe, depending on factors such as
the type of germ causing the infection, and your age and overall health. Mild signs and
symptoms often are similar to those of a cold or flu, but they last longer.

Signs and symptoms of pneumonia may include:

 Chest pain when you breathe or cough
 Confusion or changes in mental awareness (in adults age 65 and older)
 Cough, which may produce phlegm
 Fatigue
 Fever, sweating and shaking chills
 Lower than normal body temperature (in adults older than age 65 and people with weak
immune systems)
 Nausea, vomiting or diarrhea
 Shortness of breath
Newborns and infants may not show any sign of the infection. Or they may vomit, have a fever
and cough, appear restless or tired and without energy, or have difficulty breathing and eating.

Causes
Many germs can cause pneumonia. The most common are bacteria and viruses in the air we
breathe. Your body usually prevents these germs from infecting your lungs. But sometimes
these germs can overpower your immune system, even if your health is generally good.
Pneumonia is classified according to the types of germs that cause it and where you got the
infection.

Community-acquired pneumonia
Community-acquired pneumonia is the most common type of pneumonia. It occurs outside of
hospitals or other health care facilities. It may be caused by:

Bacteria. The most common cause of bacterial pneumonia in the U.S. is Streptococcus
pneumoniae. This type of pneumonia can occur on its own or after you've had a cold or the flu.
It may affect one part (lobe) of the lung, a condition called lobar pneumonia.
Bacteria-like organisms. Mycoplasma pneumoniae also can cause pneumonia. It typically
produces milder symptoms than do other types of pneumonia. Walking pneumonia is an
informal name given to this type of pneumonia, which typically isn't severe enough to require
bed rest.
Fungi. This type of pneumonia is most common in people with chronic health problems or
weakened immune systems, and in people who have inhaled large doses of the organisms. The
fungi that cause it can be found in soil or bird droppings and vary depending upon geographic
location.
Viruses, including COVID-19. Some of the viruses that cause colds and the flu can cause
pneumonia. Viruses are the most common cause of pneumonia in children younger than 5
years. Viral pneumonia is usually mild. But in some cases it can become very serious.
Coronavirus 2019 (COVID-19) may cause pneumonia, which can become severe.

Hospital-acquired pneumonia
Some people catch pneumonia during a hospital stay for another illness. Hospital-acquired
pneumonia can be serious because the bacteria causing it may be more resistant to antibiotics
and because the people who get it are already sick. People who are on breathing machines
(ventilators), often used in intensive care units, are at higher risk of this type of pneumonia.

Health care-acquired pneumonia

Health care-acquired pneumonia is a bacterial infection that occurs in people who live in long-
term care facilities or who receive care in outpatient clinics, including kidney dialysis centers.
Like hospital-acquired pneumonia, health care-acquired pneumonia can be caused by bacteria
that are more resistant to antibiotics.

Aspiration pneumonia
Aspiration pneumonia occurs when you inhale food, drink, vomit or saliva into your lungs.
Aspiration is more likely if something disturbs your normal gag reflex, such as a brain injury or
swallowing problem, or excessive use of alcohol or drugs.
Each type of pneumonia is caused by different and several factors.

Medical Management
The management of pneumonia centers is a step-by-step process that zeroes on the treatment
of the infection through identification of the causative agent.

 Blood culture. Blood culture is performed for identification of the causal pathogen and
prompt administration of antibiotics in patients in whom CAP is strongly suspected.
 Administration of macrolides. Macrolides are recommended for people with drug-
resistant S. pneumoniae.
 Hydration is an important part of the regimen because fever and tachypnea may result
in insensible fluid losses.
 Administration of antipyretics. Antipyretics are used to treat fever and headache.
 Administration of antitussives. Antitussives are used for treatment of the associated
cough.
 Bed rest. Complete rest is prescribed until signs of infection are diminished.
 Oxygen administration. Oxygen can be given if hypoxemia develops.
 Pulse oximetry. Pulse oximetry is used to determine the need for oxygen and to
evaluate the effectiveness of the therapy.
 Aggressive respiratory measures. Other measures include administration of high
concentrations of oxygen, endotracheal intubation, and mechanical ventilation.

Nursing Management

Nursing Assessment
Nursing assessment is critical in detecting pneumonia. Here are some tips for your nursing
assessment for pneumonia.

 Assess respiratory symptoms. Symptoms of fever, chills, or night sweats in a patient

should be reported immediately to the nurse as these can be signs of bacterial
pneumonia.
 Assess clinical manifestations. Respiratory assessment should further identify clinical
manifestations such as pleuritic pain, bradycardia, tachypnea, and fatigue, use of
accessory muscles for breathing, coughing, and purulent sputum.
 Physical assessment. Assess the changes in temperature and pulse; amount, odor,
and color of secretions; frequency and severity of cough; degree of tachypnea or
shortness of breath; and changes in the chest x-ray findings.
 Assessment in elderly patients. Assess elderly patients for altered mental status,
dehydration, unusual behavior, excessive fatigue, and concomitant heart failure.
Nursing Interventions
To improve airway patency:

 Removal of secretions. Secretions should be removed because retained secretions

interfere with gas exchange and may slow recovery.
 Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.
 Humidification may loosen secretions and improve ventilation.
 Coughing exercises. An effective, directed cough can also improve airway patency.
 Chest physiotherapy. Chest physiotherapy is important because it loosens and
mobilizes secretions.

To promote rest and conserve energy:

 Encourage avoidance of overexertion and possible exacerbation of symptoms.
 Semi-Fowler’s position. The patient should assume a comfortable position to promote
rest and breathing and should change positions frequently to enhance secretion
clearance and pulmonary ventilation and perfusion.

To promote fluid intake:

 Fluid intake. Increase in fluid intake to at least 2L per day to replace insensible fluid
losses.

To maintain nutrition:
 Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
 Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help
restore proper nutrition.

To promote patient’s knowledge:

 Instruct patient and family about the cause of pneumonia, management of symptoms,
signs, and symptoms, and the need for follow-up.
 Instruct patient about the factors that may have contributed to the development of the
disease.

ASPIRATIONS

Aspiration is when something you swallow "goes down the wrong way" and enters your airway
or lungs. It can also happen when something goes back into your throat from your stomach. But
your airway isn’t completely blocked, unlike with choking.
People who might aspirate often or have problems swallowing include those who are older
adults, who have had a stroke, and who have developmental disabilities.

Signs & Symptoms

Sometimes, there’s no clear sign that food or liquid is going down the wrong way. Because you
don't notice it, you don't cough. But in most cases, you:

 Feel something stuck in your throat

 Hurt when you swallow, or it's hard to do
 Cough while or after you eat or drink
 Feel congested after you eat or drink
 Have a gurgling or "wet-sounding" voice when you eat

Other signs are:

 Too much saliva in your mouth
 Chest discomfort or heartburn
 Shortness of breath or fatigue while eating
 Fever within a half-hour of eating
 Frequent pneumonia
 Trouble chewing

Causes and Risk Factors

Usually when a person eats or drinks, the food or liquid moves from the mouth into the
throat and down through the esophagus, or food pipe, into the stomach.

Pulmonary aspiration occurs when the substance accidentally passes into the windpipe
and lungs instead of the esophagus. This typically results from a problem with the
swallowing reflex or a lack of tongue control.

Aspiration can also occur while a person is having surgery under anesthesia. The
stomach contents can travel up to the mouth, then down through the windpipe and into
the lungs.

Anesthesia reduces a person’s level of consciousness and ability to protect their

airways, which increases the risk of aspiration. This is why doctors often ask people to
fast before having a surgical procedure.

Anesthetists also take precautions to prevent aspiration, such as by protecting the

airways with intubation after administering anesthesia.

Some health conditions can also increase a person’s risk of pulmonary aspiration.
 Risk factors

Most people occasionally aspirate something into their lungs, and certain issues can
increase this risk.

A 2015 cross-sectional study investigated risk factors for aspiration in 105 people who
had experienced at least one stroke.

The research indicated that participants with any of the following conditions were seven
times more likely to develop aspiration:
 dysphagia, which is the medical term for difficulty swallowing
 an impaired or absent gag reflex
 reduced physical mobility
 neurological disorders, such as Parkinson’s disease
 Additional factors that may increase a person’s risk of aspiration include:

 intoxication from drugs or alcohol, which can lead to impaired consciousness and
reflexes
 dementia
 gastroesophageal reflux disease (GERD)

Medical Management

Treatment for aspiration depends on the severity of a person’s symptoms and the material they
inhaled. In some instances, treatment is unnecessary.
If an object, such as a piece of food, is still in the lungs, the doctor may recommend a
bronchoscopy.
During this procedure, a healthcare professional will insert a tube with a camera down a
person’s throat and into the lungs to remove the foreign material.
For people aspiration pneumonia, a doctor may prescribe antibiotics to help clear the infection.
When aspiration results from a medical condition, such as a stroke, speech therapy may help to
improve a person’s swallowing reflex and lower their risk of aspiration.
Dietary and lifestyle changes can also help treat chronic aspiration. If it fails to respond to these
methods, a person may require tube-feeding to meet their nutritional needs.

Nursing Management

AIRWAY PROTECTION. Maintain a patent airway

 Prevention is key, but since this patient has already slipped substances past the
epiglottis (AKA royal lung guard) everything that applies to prevention (NPO, head of
 bed greater than 30 degrees, oral hygiene, etc.) is even more important to prevent
further complications.

 Intubation: Be prepared to intubate, not because the patient will for sure be intubated,
but because not being prepared is costly (like someones life kind of cost).

 Suction: Lastly have suction ready. You should always have suction ready no matter
the patient’s chief complaint, but especially for a patient with aspiration.

 Oxygen: Have all the stuff for oxygen ready. Monitor their oxygen levels. If they dip low
(<94%) help them out with oxygen. Key note here: have a full tank of oxygen ready to go
on their bed incase you need to rush them off somewhere due to emergent situations.
These patients are high risk for low oxygenation.

Suction when necessary

 Have the suction ready to go to help keep the airway clear and increase the surface area
for oxygen absorption.

Perform a Swallow Screen

This is a simple, nurse initiated test that should really be performed on any patient that is
not NPO.
Checking the patient’s ability to swallow gives the nurse so much information about how
to proceed with the plan of care.

For example: That fever they have, is not going to be treated via oral Tylenol if they
cannot swallow. Doctors WILL order this- you will not give it because you are awesome
and have checked the patient’s ability to swallow. Then you will beg for IV Tylenol and
get an order for rectal Tylenol because it is cheaper and the standard of care. After you
and the patient cry it out for a minute, you will administer the Tylenol in the no go zone
with the promise of blankets as a reward for breaking the fever.

If they do not pass the swallow screen the patient will be NPO, or they should be
anyway.

Acquire a chest X-ray

A chest x-ray helps to differentiate the patient with aspiration as to whether they have
acquired pneumonia or not.
 The results of the x-ray determine the patient’s plan of care (meaning pneumonia
treatment or not).
As a nurse, it is important to monitor for s/s of aspiration and to inform the doctor if you
suspect aspiration has occurred so the team can assess the need for an x-ray.

 Laboratory testing: Venous or Arterial Blood gas Complete Blood Count (CBC) Sputum
culture/Blood culture
The goal of the blood gas is to monitor the patient PaCO2/PCO2 and their PaO2/PO2
The goal of the CBC is to monitor White Blood Cells (WBC)

 Sputum culture/blood cultures will be not helpful right away but after they result can
change the antibiotics that the patient is receiving.

 Antibiotics- if indicated (Clindamycin or Metronidazole)

This may be used as prophylaxis, or because the patient developed
pneumonia.Clindamycin: most commonly used for aspiration pneumonia.Metronidazole:
used in conjunction with clindamycin to offer further coverage.

 Assess respiratory function: Auscultate lung sounds Monitor O2 saturation Assess

skin color (are they blue?) Assess depth, rate, regularity of breathing as well as
symmetry of chest rise and fall
This should be done on every patient. But just like for a patient who has stroke like
symptoms, you will be checking neuro function more frequently, a patient with aspiration
needs to have their respiratory functions assess more frequently. The frequency is
based on each patient and the situation-use clinical judgement here.

PULMONARY TUBERCULOSIS

Tuberculosis (TB) or known as the White Plague during the 19thcentury, has inflicted the human
race ever since. It is described as a chronic infectious disease caused by an organism called
Mycobacterium tuberculosis through droplet transmission, like coughing, sneezing, or if the
person inhales the infected droplet.

It can be considered as primary or secondary infection depending on recovery of the client from
the communicable infection. It is a reportable communicable disease and a repeated exposure
to it causes a person to acquire it.

According to a study conducted by Knechel, the progression of tuberculosis has several stages.
 1. Latent Tuberculosis – It is the stage of infection when the person who had been
exposed to the M. tuberculosis nuclei does not manifest signs and symptoms of the
disease and do not have the capacity to infect other people. The nuclei just persist in the
system in its necrotic form which could stay for a long time, not until that
immunosuppression or a certain factor triggers it to become its virulent form.

2. Primary Pulmonary Tuberculosis – Since the most immediate location of

pathogenesis of the organism is in the lungs, primary activation of disease in the
pulmonary cavity is considered. It is usually asymptomatic and only identified through
significant diagnostic examinations. Only the presence of lymphadenopathy is something
that is indicative for its infection.

3. Primary Progressive Tuberculosis – It is the stage of the disease process when it is

already considered as active. Clinical manifestations are evident and the client may
reveal positive in sputum examination for presence of the organism. Sometimes, he or
she may manifest cough with purulent sputum and some pleuritic chest pains because of
inflammation in the parenchymal walls.

4. Extrapulmonary Tuberculosis – It is when tuberculosis extends its infection to other

parts of the aside from the pulmonary cavity. The most fatal location is the central
nervous system and its infection to the bloodstream. Other locations may include the
lymphatic system, the bones and joints and at times the genitourinary system.

Tuberculosis is caused by infection by an organism called Mycobacterium tuberculosis. This

organism most often (85%) presents as a lung infection due to its airborne transmission. It
causes granulomas to form in the alveolar sacs, which will create cavitation as immune cells
surround it. If the host’s immune system cannot fight it off, the inflammation and infection will
continue to spread, damaging more and more alveoli. The more damage to alveoli, the worse
the patient’s oxygenation and gas exchange will be.

Signs & Symptoms

Symptoms of TB can develop slowly and may vary. The main symptoms of pulmonary TB
include:
 a bad cough that lasts for at least 3 weeks
 chest pain
 coughing up blood or phlegm from the lungs
 breathlessness

More general symptoms of TB can include:
 weight loss
 a loss of appetite
  nausea and vomiting
 low energy or fatigue
 fever and chills
 night sweats

People with latent TB do not have any symptoms or feel sick.

Etiology

Tuberculosis is spread via airborne aerosolization of particles. If the host’s immune system is
strong enough to resist initial infection, the infection may lay dormant in the form of “Latent TB
Infection” for years until the host’s immune system is compromised. Countries with
overcrowded populations or other crowded or closed environments (i.e. prisons, homeless
shelters) carry higher risks, as well as a history of HIV, diabetes mellitus, substance abuse,
cancer, end-stage renal disease, and smoking.

Causes
Causes of acquiring tuberculosis include the following:

Close contact. Having close contact with someone who has an active TB.
Low immunity. Immunocompromised status like those with HIV, cancer, or transplanted organs
increases the risk of acquiring tuberculosis.
Substance abuse. People who are IV/injection drug users and alcoholics have a greater
chance of acquiring tuberculosis.
Inadequate health care. Any person without adequate health care like the homeless,
impoverished, and the minorities often develop active TB.
Immigration. Immigration from countries with a high prevalence of TB could affect the patient.
Overcrowding. Living in an overcrowded, substandard housing increases the spreading of the
infection.

Medical Management
Pulmonary tuberculosis is treated primarily with antituberculosis agents for 6 to 12 months.

 First line treatment. First-line agents for the treatment of tuberculosis are isoniazid
(INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide.
 Active TB. For most adults with active TB, the recommended dosing includes the
administration of all four drugs daily for 2 months, followed by 4 months of INH and RIF.
 Latent TB. Latent TB is usually treated daily for 9 months.
  Treatment guidelines. Recommended treatment guidelines for newly diagnosed cases
of pulmonary TB have two parts: an initial treatment phase and a continuation phase.
 Initial phase. The initial phase consists of a multiple-medication regimen of INH,
rifampin, pyrazinamide, and ethambutol and lasts for 8 weeks.
 Continuation phase. The continuation phase of treatment include INH and rifampin or
INH and rifapentine, and lasts for an additional 4 or 7 months.
 Prophylactic isoniazid. Prophylactic INH treatment involves taking daily doses for 6 to
12 months.
 DOT. Directly observed therapy may be selected, wherein an assigned caregiver directly
observes the administration of the drug.

Pharmacologic Therapy
The first line antituberculosis medications include:•

Isoniazid (INH). INH is a bactericidal agent that is used as prophylaxis for neuritis, and has side
effects of peripheral neuritis, hepatic enzyme elevation, hepatitis, and hypersensitivity.
Rifampin (Rifadin). Rifampin is a bactericidal agent that turns the urine and other body
secretions into orange or red, and has common side effects of hepatitis, febrile reaction,
purpura, nausea, and vomiting.
Pyrazinamide. Pyrazinamide is a bactericidal agent which increases the uric acid in the blood
and has common side effects of hyperuricemia, hepatotoxicity, skin rash, arthralgias, and GI
distress.
Ethambutol (Myambutol). Ethambutol is a bacteriostatic agent that should be used with
caution with renal disease, and has common side effects of optic neuritis and skin rash.

Nursing Management
Nursing management includes the following:

Nursing Assessment
The nurse may assess the following:
 Complete history. Past and present medical history is assessed as well as both of the
parents’ histories.
 Physical examination. A TB patient loses weight dramatically and may show the loss in
physical appearance.

Nursing Interventions
 Promoting airway clearance. The nurse instructs the patient about correct positioning
to facilitate drainage and to increase fluid intake to promote systemic hydration.
  Adherence to the treatment regimen. The nurse should teach the patient that TB is a
communicable disease and taking medications is the most effective means of preventing
transmission.
 Promoting activity and adequate nutrition. The nurse plans a progressive activity
schedule that focuses on increasing activity tolerance and muscle strength and a
nutritional plan that allows for small, frequent meals.
 Preventing spreading of tuberculosis infection. The nurse carefully instructs the
patient about important hygienic measures including mouth care, covering the mouth
and nose when coughing and sneezing, proper disposal of tissues, and handwashing.
 Acid-fast bacillus isolation. Initiate AFB isolation immediately, including the use of a
private room with negative pressure in relation to surrounding areas and a minimum of
six air changes per hour.
 Disposal. Place a covered trash can nearby or tape a lined bag to the side of the bed to
dispose of used tissues.
 Monitor adverse effects. Be alert for adverse effects of medications.

LUNG ABCESS

Lung abscess is defined as necrosis of the pulmonary tissue and formation of cavities
containing necrotic debris or fluid caused by microbial infection. The formation of multiple small
(<2 cm) abscesses is occasionally referred to as necrotizing pneumonia or lung gangrene. Both
lung abscess and necrotizing pneumonia are manifestations of a similar pathologic process.
Failure to recognize and treat lung abscess is associated with poor clinical outcome.

Etiology

 Aspiration of oral secretions (most common)

 Endobronchial obstruction
 Hematogenous seeding of the lungs (less common)

Most lung abscesses develop after aspiration of oral secretions by patients with gingivitis or
poor oral hygiene. Typically, patients have altered consciousness as a result of alcohol
intoxication, illicit drugs, anesthesia, sedatives, or opioids. Older patients and those unable to
handle their oral secretions, often because of neurologic disease, are also at risk. Lung
abscesses can also develop secondary to endobronchial obstruction (eg, due to bronchial
carcinoma) or to immunosuppression (eg, due to HIV/AIDS or after transplantation and use of
immunosuppressive drugs).

A less common cause of lung abscess is necrotizing pneumonia that may develop from
hematogenous seeding of the lungs due to suppurative thromboembolism (eg, septic embolism
due to IV drug use or Lemierre syndrome) or right-sided endocarditis. In contrast to aspiration
and obstruction, these conditions typically cause multiple rather than isolated lung abscesses.

Symptoms and Signs

Symptoms of abscess due to anaerobic bacteria or mixed anaerobic and aerobic bacteria are
usually chronic (eg, occurring over weeks or months) and include productive cough, fever, night
sweats, and weight loss. Patients may also present with hemoptysis and pleuritic chest pain.
Sputum may be purulent or blood-streaked and classically smells or tastes foul.

Symptoms of abscess due to aerobic bacteria develop more acutely and resemble bacterial
pneumonia. Abscesses due to organisms other than anaerobes (eg, Mycobacteria,Nocardia)
lack putrid respiratory secretions and may be more likely to occur in nondependent lung regions.

Signs of lung abscess, when present, are nonspecific and resemble those of pneumonia:
decreased breath sounds indicating consolidation or effusion, temperature ≥ 38° C, crackles
over the affected area, egophony, and dullness to percussion in the presence of effusion.
Patients typically have signs of periodontal disease and a history of a predisposing cause of
aspiration, such as dysphagia or a condition causing impaired consciousness.

Medical Management

 IV antibiotics or, for less seriously affected patients, oral antibiotics

 Percutaneous, endobronchial, or surgical drainage of any abscess that does not respond
to antibiotics or of any empyema

Treatment is with antibiotics. Clindamycin 600 mg IV every 6 to 8 hours is usually the drug of
choice because it has excellent activity against streptococci and anaerobic organisms. The
primary alternative is a combination beta-lactam/beta-lactamase inhibitor (eg,
ampicillin/sulbactam 1 to 2 g IV every 6 hours). Other alternatives include a carbapenem (eg,
imipenem/cilastatin 500 mg IV every 6 hours) or combination therapy with metronidazole 500
mg every 8 hours plus penicillin 2 million units IV every 6 hours. Less seriously ill patients may
be given oral antibiotics such as clindamycin 300 mg orally every 6 hours or
amoxicillin/clavulanate 875/125 mg orally every 12 hours. IV regimens can be converted to oral
ones when the patient defervesces. For very serious infections involving MSRA, the best
treatment is vancomycin or linezolid.

Optimal duration of treatment is unknown, but common practice is to treat until the chest x-ray
shows complete resolution or a small, stable, residual scar, which generally takes 3 to 6 weeks
or longer. In general, the larger the abscess, the longer it will take for x-rays to show resolution.
Most authorities do not recommend chest physical therapy and postural drainage because of
the potential for spillage of infection into other bronchi with extension of the infection or acute
obstruction.

An accompanying empyema must be drained. Surgical removal or drainage of lung abscesses

is necessary in the roughly 10% of patients in whom lesions do not respond to antibiotics, and in
those who develop pulmonary gangrene. Resistance to antibiotic treatment is most common
with large cavities and with post-obstructive abscesses. If patients fail to defervesce or to
improve clinically after 7 to 10 days, they should be evaluated for resistant or unusual
pathogens, airway obstruction, and noninfectious causes of cavitation.

When surgery is necessary, lobectomy is the most common procedure; segmental resection
may suffice for small lesions (< 6 cm diameter cavity). Pneumonectomy may be necessary for
multiple abscesses unresponsive to drug therapy or for pulmonary gangrene. In patients likely to
have difficulty tolerating surgery, percutaneous drainage or, rarely, bronchoscopic placement of
a pigtail catheter can help facilitate drainage. Endobronchial ultrasonography to guide
placement of a sheath has emerged as another drainage method.

Nursing Management

 Monitor patient’s temperature (degree and pattern) as there may be increased body
temperature; note shivering / diaphoresis
 Monitor the temperature of the environment. Give a warm compress and teach and
encourage family
 Review / monitor respiratory frequency, record the ratio of inspiration and expiration
 Auscultate breath sounds and note the existence of bronchial breath sounds
 Assist the patient to a comfortable position
 Perform adequate drainage thru postural drainage aided by percussion, effective
coughing and breathing exercises.
 Observe the characteristic of cough
 Provide fluid intake of 3000 ml / day according to tolerance and provide a warm heart
and fluid intake between meals instead of
 Give the drugs as ordered (antipyretics, bronchodilators, antibiotics)
 Teach and encourage chest physiotherapy, postural drainage
 Drainage bronchoscopy may be ordered to aid in drainage of abscess.
 Ensure proper nutritional intake. Provide high calorie, high protein diet since chronic
infection is associated with a catabolic state.

PLEURISY
Pleurisy (PLOOR-ih-see) is a condition in which the pleura — two large, thin layers of tissue that
separate your lungs from your chest wall — becomes inflamed. Also called pleuritis, pleurisy
causes sharp chest pain (pleuritic pain) that worsens during breathing.

One pleural layer of tissue wraps around the outside of the lungs. The other pleural layer lines
the inner chest wall. Between these two layers is a small space (pleural space) that's usually
filled with a very small amount of liquid. Normally, these layers act like two pieces of smooth
satin gliding past each other, allowing your lungs to expand and contract when you breathe.

If you have pleurisy, these tissues swell and become inflamed. As a result, the two layers of the
pleural membrane rub against each other like two pieces of sandpaper, producing pain when
you inhale and exhale. The pleuritic pain lessens or stops when you hold your breath.

Treatment of pleurisy involves pain control and treating the underlying condition.

Signs & Symptoms

 Chest pain that worsens when you breathe, cough or sneeze

 Shortness of breath — because you are trying to minimize breathing in and out
 A cough — only in some cases
 A fever — only in some cases

Pain caused by pleurisy might worsen with movement of your upper body and can radiate to
your shoulders or back.

Pleurisy can be accompanied by pleural effusion, atelectasis or empyema:

 Pleural effusion. In some cases of pleurisy, fluid builds up in the small space between
the two layers of tissue. This is called pleural effusion. When there is a fair amount of
fluid, pleuritic pain lessens or disappears because the two layers of pleura are no longer
in contact and don't rub together.
 Atelectasis. A large amount of fluid in the pleural space can create pressure,
compressing your lung to the point that it partially or completely collapses (atelectasis).
This makes breathing difficult and might cause coughing.
 Empyema. The extra fluid can also become infected, resulting in an accumulation of pus.
This is called an empyema. An empyema is often accompanied by fever.

Medical Management
  Antibiotics that are specific for bacteria-caused pleurisy
 Antifungals –for fungal-caused pleurisy
 If pleurisy is caused by a virus – antiviral may not be required as it can resolve on its
own. The doctor may
 ask the patient to rest for a few days, with close monitoring.
 Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen are effective to
relieve pleuritic pain
 In cases when NSAIDS are not helpful, paracetamol or codeine can be administered.
Codeine can also help
 suppress cough.
 Chest drain –If pleurisy is associated with pleural effusion, a tube is inserted into the
pleural space to drain
 excess fluid
 Smoking cessation – smoking causes irritation to the lungs

Nursing Management

o Assess respiratory function.

o Administer analgesic.
o Teach patient to support ribcage when coughing.
o Help reposition to alleviate pain, such as lying on the affected side.
o Assess level of anxiety and provide reassurances of safety.

PLEURAL EFFUSION

It is a collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural
space and acts as a lubricant for the pleural membranes to slide across one another when we
breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the
pleura. When this recycling process is interrupted, a pleural effusion can result.

Causes
The pleura creates too much fluid when it’s irritated, inflamed, or infected. This fluid
accumulates in the chest cavity outside the lung, causing what’s known as a pleural effusion.

Certain types of cancer can cause pleural effusions, lung cancer in men and breast cancer in
women being the most common.

Other causes of pleural effusions include:

 congestive heart failure (the most common cause overall)

 cirrhosis or poor liver function
 pulmonary embolism, which is caused by a blood clot and is a blockage in the lung
arteries
 complications from open-heart surgery
 pneumonia
 severe kidney disease
 autoimmune diseases, such as lupus and rheumatoid arthritis

Signs & Symptoms

Some people show no symptoms of pleural effusion. These people usually find out they have
the condition through chest X-rays or physical examinations done for another reason.

Common symptoms of pleural effusion include:

 chest pain
 dry cough
 fever
 difficulty breathing when lying down
 shortness of breath
 difficulty taking deep breaths
 persistent hiccups
 difficulty with physical activity

Medical/Surgical Nursing

Draining fluid
Generally, treatment involves draining the fluid from the chest cavity, either with a needle or a
small tube inserted into the chest.

You’ll receive a local anesthetic before this procedure, which will make the treatment more
comfortable. You may feel some pain or discomfort at the incision site after the anesthetic wears
off. Most doctors will prescribe medication to help relieve pain.

You may need this treatment more than once if fluid builds up again.

Other treatments may be necessary to manage fluid buildup if cancer is the cause of the pleural
effusion.

Pleurodesis

Pleurodesis is a treatment that creates mild inflammation between the lung and chest cavity
pleura. After drawing the excess fluid out of the chest cavity, a doctor injects a drug into the
area. The drug is often a talc mixture. This medication causes the two layers of the pleura to
stick together, which prevents the future buildup of fluid between them.

Surgery

In more serious cases, a doctor surgically inserts a shunt, or small tube, into the chest cavity.
This helps redirect the fluid from the chest into the abdomen, where it can be more easily
removed by the body. This may be an option for those who don’t respond to other treatments.
Pleurectomy, in which part of the pleural lining is surgically removed, may also be an option in
certain cases.

Nursing Intervention

 Identify and treat the underlying cause

 Monitor breath sounds
 Place the client in a high Fowler’s position
 Encourage coughing and deep breathing
 Prepare the client for thoracentesis
 If pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as
prescribed

EMPYEMA
Empyema is also called pyothorax or purulent pleuritis. It’s a condition in which pus gathers in
the area between the lungs and the inner surface of the chest wall. This area is known as the
pleural space. Pus is a fluid that’s filled with immune cells, dead cells, and bacteria. Pus in the
pleural space can’t be coughed out. Instead, it needs to be drained by a needle or surgery.

Empyema usually develops after pneumonia, which is an infection of the lung tissue.

Causes

Empyema can develop after you have pneumonia. Many different types of bacteria may cause
pneumonia, but the two most common are Streptococcus pneumoniae and Staphylococcus
aureus. Occasionally, empyema may happen after you’ve had surgery on your chest. Medical
instruments can transfer bacteria into your pleural cavity.

The pleural space naturally has some fluid, but infection can cause fluid to build up faster than it
can be absorbed. The fluid then becomes infected with the bacteria that caused the pneumonia
or infection. The infected fluid thickens. It can cause the lining of your lungs and chest cavity to
stick together and form pockets. This is called an empyema. Your lungs may not be able to
inflate completely, which can lead to breathing difficulties.

Signs & Symptoms

Empyema can be simple or complex.

Simple empyema

Simple empyema occurs in the early stages of the illness. A person has this type if the pus is
free-flowing. The symptoms of simple empyema include:

 shortness of breath
 dry cough
 fever
 sweating
 chest pain when breathing that may be described as stabbing
 headache
 confusion
 loss of appetite

Complex empyema
Complex empyema occurs in the later stage of the illness. In complex empyema, the
inflammation is more severe. Scar tissue may form and divide the chest cavity into smaller
cavities. This is called loculation, and it’s more difficult to treat.

If the infection continues to get worse, it can lead to the formation of a thick peel over the pleura,
called a pleural peel. This peel prevents the lung from expanding. Surgery is required to fix it.

Other symptoms in complex empyema include:

 difficulty breathing
 decreased breath sounds
 weight loss
 chest pain

Medical Management

Treatment is aimed at removing the pus and fluid from the pleura and treating the infection.
Antibiotics are used to treat the underlying infection. The specific type of antibiotic depends on
what type of bacteria is causing the infection.

The method used to drain the pus depends on the stage of the empyema.

In simple cases, a needle can be inserted into the pleural space to drain the fluid. This is called
percutaneous thoracentesis.

In the later stages, or complex empyema, a drainage tube must be used to drain the pus. This
procedure is usually performed under anesthesia in an operating room. There are different
types of surgery for this:

Thoracostomy: In this procedure, your doctor will insert a plastic tube into your chest between
two ribs. Then they’ll connect the tube to a suction device and remove the fluid. They may also
inject medication to help drain the fluid.

Video-assisted thoracic surgery: Your surgeon will remove the affected tissue around your
lung and then insert a drainage tube or use medication to remove the fluid. They will create
three small incisions and use a tiny camera called a thoracoscope for this process.

Open decortication: In this surgery, your surgeon will peel away the pleural peel.
Nursing Intervention

Auscultate lung sounds

If wheezy they may need a breathing treatment If you hear crackles they may have pneumonia
and potentially could use suctioning.

Monitor ABGs

Blood gases help to determine if the patient is in respiratory acidosis.

To interpret the ABG you must know normal ABG values.

pH: 7.35-7.45 PaCO2: 35-45 Bicarbonate: 22-26

Respiratory acidosis is when the pH is below 7.35 and the PaCO2 is above 45.

Encourage a healthy weight Early stages of emphysema: overweight Late stages of

emphysema: underweight

Having excess weight on the patient decreases the space for the lungs to expand. Plus,
generally, those who lose weight are also moving more to lose the weight, double win.

In later stages of emphysema, the patient can be very thin (barrel-chested) and it is important to
make sure they are getting the proper nutrition so their body is at the optimal performance (for
that patient).

Monitor Oxygen saturation

This is subjective as you need to make sure to understand the patient’s baseline. Plan oxygen
monitoring with the physician.

Give oxygen as ordered and needed. Be careful about turning their drive to breath off by giving
too much O2, as a general rule, emphysema patients should be kept around 88%-92%.

Prepare for the worst: If the patient has been working very hard to breathe for a long period of
time and is getting worse, be prepared with an airway cart. And for the love of the airway, have
your respiratory therapist aware of the patient!
Plus you do not want to wait until the impending airway closure happens to try to secure their
airway. Sometimes the patient will be sedated and intubated to try to correct any respiratory
acidosis or alkalosis

Breathing treatments and medications

Beta-Agonists: Such as albuterol work as bronchodilators

Anticholinergics: Such as Ipratropium work to relax bronchospasms

Corticosteroids: Such as Fluticasone work as an anti-inflammatory

Assess for/Administer influenza vaccine and pneumococcal vaccine

Preventing complications such as influenza or pneumonia is important because the lungs are
already working harder to keep the body balanced with oxygen and CO2, an increased risk of
infection only complicates the patient’s ability to breathe.