Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 2 Respiratory System
Bronchiectasis
WHAT WENT WRONG?
Bronchi and bronchioles become abnormally and permanently dilated, caused by
infection and inflammation. This results in excessive production of mucous that
obstructs the bronchi. There is some obstruction of the airways and a chronic
infection. The changes within the lung can be localized or generalized. The lung
may develop areas of atelectasis where thick mucous obstructs the smaller air-
ways, making the mucous difficult to expel. This results in inflammation and
infection of the airways and leads to bronchiectasis.
PROGNOSIS
Early diagnosis and appropriate treatment of infections are essential for manage-
ment. Postural drainage and chest physical therapy aid in movement of mucous
from the airways. The difficulty in breathing is caused by excess mucus similar to
patients with Chronic Obstructive Pulmonary Disease (COPD) (emphysema or
chronic bronchitis).
HALLMARK SIGNS AND SYMPTOMS
•
Difficult breathing (dyspnea) due to the mucous production and irritation
within the airways.
•
Productive, foul-smelling odorous cough, due to thick, difficult-to-expel,
tenacious mucous, often with bacterial colonization.
•
Cough may be worse when lying down.
•
Recurrent bronchial infections.
•
Hemoptysis (blood-tinged or bloody mucous).
•
Loss of weight because patients are not eating well, due to respiratory
changes and foul-smelling mucous with cough. Increased respiratory effort
requires more calories to meet normal requirements.
•
Crackles or rhonchi on inspiration due to mucous build-up.
•
Anemia of chronic disease.
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•
Cyanosis.
•
Clubbing of the fingers.
INTERPRETING TEST RESULTS
•
Culture and sensitivity of sputum to identify bacteria and appropriate anti-
biotics.
•
Shadows in affected area of the lungs on the chest x-ray.
•
CT scan or high-resolution CT will show areas of bronchiectasis.
•
Decreased lung vital capacity on pulmonary function test.
TREATMENT
Treatment is focused on getting enough oxygen to meet current needs of the patient,
expel mucous, and treat infections.
•
Supplemental oxygen to help meet body’s needs.
•
Postural drainage to assist with drainage of secretions.
•
Chest PT to loosen secretions.
•
Remove excessive secretions during a bronchoscopy.
•
Administer bronchodilators to help keep airways open:
•
albuterol, levalbuterol
•
Administer antibiotics to treat infection:
•
selected based on the results of a culture and sensitivity study
NURSING DIAGNOSES
•
Ineffective airway clearance
•
Imbalanced nutrition: less than what the body requires
•
Impaired gas exchange
NURSING INTERVENTION
•
Monitor respiratory rate, effort, breath sounds, skin color, and use of acces-
sory muscles.
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CHAPTER 2 Respiratory System
•
Perform chest percussion to help loosen secretions.
•
Explain to the patient:
•
That family member can perform chest PT.
•
How to do postural drainage.
•
How to administer oxygen.
•
How to properly administer medications.
Bronchitis
WHAT WENT WRONG?
Increased mucus production, caused by infection and airborne irritants that block
airways in the lungs, results in the decreased ability to exchange gases. There are
two forms of bronchitis: acute bronchitis, where blockage of the airways is re-
versible, and chronic bronchitis, where blockage is not reversible. Patients with
acute bronchitis are symptomatic typically for 7 to 10 days often due to viral (but
sometimes bacterial) infection. Patients with chronic bronchitis will have symp-
toms of a chronic productive cough for at least 3 consecutive months in 2 consec-
utive years. There is increased mucous production, inflammatory changes, and,
ultimately, fibrosis in the airway walls. The patient with chronic bronchitis has an
increased incidence of respiratory infection.
PROGNOSIS
Patients with acute bronchitis who have a resolution of symptoms and respiratory
status will return to normal condition. Chronic bronchitis is classified as a chronic
obstructive pulmonary disease (COPD), which is often linked to smoking and has
a progressive pattern. Shortness of breath is initially present only with exertion,
and eventually is present even at rest. Patients with chronic bronchitis often develop
right-sided heart failure and peripheral or dependent edema. Patients will have
acute exacerbations of chronic bronchitis.
HALLMARK SIGNS AND SYMPTOMS
•
Cough due to mucous production and irritation of airways.
•
Shortness of breath.
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Fever in acute episodes due to infection.
•
Accessory muscles are used for breathing—as respiratory effort increases,
additional muscles are necessary to assist.
•
Productive cough due to irritation of airways. Mucous is a protective reac-
tion of the respiratory system.
•
Weight gain secondary to edema in chronic bronchitis is due to right-sided
heart failure.
•
Wheezing due to inflammation within the airways.
INTERPRETING TEST RESULTS
•
Shadows in affected area of the lungs on the chest x-ray during infection.
•
Pulmonary function testing shows:
•
Forced vital capacity (FVC) changes because more time is needed to
forcibly exhale an amount of air after a maximal inhalation.
•
FEV
1
is decreased because more time is needed for exhalation.
•
Residual volume (RV) is increased due to air trapping.
•
Decreased oxygen and increased carbon dioxide in arterial blood gas.
TREATMENT
Acute bronchitis is treated in the short term with symptomatic treatment and
antibiotics when a bacterial infection is present. Chronic bronchitis is treated with
a combination of medications to keep the airways open, reduce inflammation
within airways, and prevent complications or exacerbations.
•
Administer beta
2
-agonists by inhaler or nebulizer to dilate the bronchi:
•
terbutaline, albuterol, levalbuterol
•
formoterol, salmeterol
•
Administer anticholinergics which allow for relaxation of bronchial smooth
muscle:
•
ipratropium, tiotropium inhaler
•
Administer steroids to decrease inflammation within the airways
•
hydrocortisone, methylprednisolone systemically
•
beclomethasone, triamcinolone, fluticasone, budesonide, flunisolide inhalers
•
prednisolone, prednisone orally
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CHAPTER 2 Respiratory System
•
Administer methylxanthines to enhance bronchodilation:
•
aminophylline
•
theophylline (Theo-Dur)
•
Administer diuretics to reduce fluid retention in patients who develop right-
sided heart failure:
•
furosemide, bumetanide
•
Administer expectorant to help liquefy secretions:
•
guaifenesin
•
Administer antibiotics in acute exacerbation of chronic bronchitis:
•
selected by culture and sensitivity study or given empirically
•
Administer antacid, H2 blocker, or proton pump inhibitor to decrease the
amount of acid in stomach, reducing possible ulcer formation due to stress
of disease or medication effects.
•
antacids: aluminum hydroxide/magnesium hydroxide, calcium carbonate
•
H2 blockers: ranitidine, famotidine, nizatidine, cimetidine
•
proton pump inhibitors: omeprazole, lansoprazole, esomeprazole, rabepra-
zole, pantoprazole
•
Administer vaccines—to decrease chances of infection:
•
influenza
•
pneumonia
•
Give 3 liters of fluid per day to help liquefy secretions
•
Oxygen: 2 liters per minute via nasal canula to help meet body’s needs; low
flow rates help reduce dyspnea while avoiding CO
2
retention.
•
Increase protein, calories, and vitamin C in diet to meet body’s needs.
•
Administer the incentive spirometer or flutter valve to encourage coughing
and expelling of mucous.
•
Nocturnal negative pressure ventilation used for hypercapnic (elevated CO
2
levels) patients.
NURSING DIAGNOSES
•
Ineffective airway clearance
•
Activity intolerance
•
Ineffective breathing pattern
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NURSING INTERVENTION
•
Monitor respirations looking at rate, effort, use of accessory muscles, skin
color; listen to breath sounds.
•
Place patient in high Fowler’s position to ease respiration.
•
Weigh the patient daily. Excess fluid due to heart failure will increase weight.
Notify physician, NP, or PA of weight gain of 2 pounds in 24 hours.
•
Have the patient perform the turning, coughing, and deep-breathing exer-
cises to enhance lung expansion and expel mucous.
•
Monitor sputum for changes in color or amount, which may signal infection
in patients with chronic bronchitis.
•
Monitor intake and output.
•
Increase fluids to keep mucous thinner and easier to expel.
•
Explain to the patient:
•
How to administer oxygen.
Cor Pulmonale
WHAT WENT WRONG?
In Cor Pulmonale, the structure and function of the right ventricle are compromised
by chronic obstructive pulmonary disease (COPD), obstruction of the airflow into and
out of the lungs. The heart tries to compensate, resulting in right-sided heart failure.
The patient has heart failure due to a primary lung disorder, which causes pul-
monary hypertension and enlargement of the right ventricle. Patients will have
symptoms of both the underlying pulmonary disorder and the right-sided heart
failure. COPD includes chronic bronchitis and emphysema.
PROGNOSIS
Management of both the underlying lung disease and the heart failure is necessary
to alleviate the symptoms for the patient. Medical management may provide sig-
nificant relief of symptoms for the patient. Exacerbations of the underlying disease
process are still likely. Progression of the disease state is possible, requiring adjust-
ment in medications or further lifestyle modifications.
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CHAPTER 2 Respiratory System
HALLMARK SIGNS AND SYMPTOMS
•
Cyanosis
•
Fatigue due to hypoxia and heart failure
•
Wheezing due to underlying lung condition such as COPD or emphysema
•
Difficulty breathing (dyspnea) on exertion and when lying down (orthopnea)
due to increased oxygen needs with movement and increased respiratory
effort of the diaphragm when lying down
•
Productive cough due to underlying respiratory condition
•
Edema due to right-sided failure; fluid build-up will be in dependent areas
•
Weight gain due to fluid retention
•
Respiration greater than 20 breaths per minute (tachypnea); rate increases to
meet body’s oxygen needs
•
Increased heart rate above 100 beats per minute (tachycardia) as the body
attempts to compensate for hypoxia and carry more oxygen
INTERPRETING TEST RESULTS
•
Enlarged pulmonary arteries and right ventricle shown on a chest x-ray.
•
Enlarged right ventricle shown on echocardiography as a result of pulmonary
hypertension.
•
Increased right ventricular and pulmonary artery pressures in a pulmonary
artery catheterization. The right ventricle is pumping against greater-than-
normal resistance within the pulmonary artery when sending blood to the lungs.
•
Decreased oxygen and increased carbon dioxide in arterial blood gas due to
underlying lung disease.
•
Pulse oximetry shows decreased oxygen saturation.
•
Increased hemoglobin to compensate for hypoxia.
TREATMENT
•
Bedrest or decreased activity.
•
Oxygen therapy at 2 liters/minute (low flow rate) to help meet body’s needs.
The COPD patient cannot tolerate a high flow of oxygen.
•
Administer calcium channel blockers to vasodilate:
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Medical-Surgical Nursing Demystified
•
diltiazem, nifedipine, nicardipine, amlodipine
•
Administer medications to vasodilate the pulmonary artery:
•
diazoxide, hydralazine, nitroprusside
•
Administer angiotensin-converting enzyme inhibitor:
•
captopril, enalapril
•
Administer anticoagulant to reduce risk of clot formation:
•
heparin
•
Administer diuretic to remove excess fluid:
•
furosemide, bumetanide
•
Administer cardiac glycoside for symptom relief of heart failure:
•
digoxin
•
Reduce sodium in the diet to reduce fluid retention.
•
Reduce fluid intake to reduce fluid retention.
NURSING DIAGNOSES
•
Excessive fluid volume
•
Impaired gas exchange
•
Activity intolerance
NURSING INTERVENTION
•
Limit fluid to 2 liters per day.
•
Monitor digoxin level to avoid toxic effect.
•
Check pulse before administering cardiac glycoside. A side effect of the drug
is slowing of the heart rate. Hold medication and contact the physician as
needed.
•
Monitor serum potassium levels; ACE inhibitors and some diuretics can
cause potassium retention.
•
Monitor respiratory status for rate, effort, use of accessory muscle, skin color,
and breath sounds.
•
Explain to the patient:
•
How to administer oxygen therapy.
•
Medication management.
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CHAPTER 2 Respiratory System
Emphysema
WHAT WENT WRONG?
Chronic inflammation reduces the flexibility of the walls of alveoli, resulting in
over-distention of the alveolar walls. This causes air to be trapped in the lungs,
impeding gas exchange. Smoking is often linked to development of emphysema.
A less frequent cause is an inherited alpha
1
-antitrypsan deficiency.
PROGNOSIS
Symptoms often begin insidiously and are progressive. Shortness of breath is ini-
tially associated with exertion, then presents at rest. These patients are more sus-
ceptible to lung infections. Supplemental oxygen becomes necessary at first for
exacerbations, then for daily use. Periodic exacerbations requiring hospitalization
are not unusual.
HALLMARK SIGNS AND SYMPTOMS
•
Difficulty breathing (dyspnea) due to air trapping, which retains carbon
dioxide and reduces alveolar gas exchange.
•
Barrel chest develops over time as more air is trapped within the distal air-
ways. The anteroposterior diameter (distance between front and back of the
chest) increases, giving the chest a more barrel-like appearance.
•
Use of accessory muscles to breathe as the respiratory effort increases. The
number of muscles used to inhale will increase in an effort to get enough
oxygen into the body.
•
Loss of weight as extra calories are needed to maintain respiration. Increased
effort of breathing also detracts from eating.
•
Patients prefer a seated position which allows for greater chest expansion.
INTERPRETING TEST RESULTS
•
Increased residual volume shown in pulmonary function test due to air
trapping.
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Medical-Surgical Nursing Demystified
•
Decreased oxygen and increased carbon dioxide in arterial blood gas as gas
exchange is impaired due to air trapping; more pronounced as disease pro-
gresses.
•
Chest x-ray shows overinflation of lungs and flattening of the diaphragm.
TREATMENT
Treatment will vary depending on the stage of the emphysema. As the disease pro-
gresses the treatment will change. Medications to control symptoms and keep air-
ways open, use of supplemental oxygen, and smoking cessation are the mainstays
of treatment.
•
Administer beta
2
-agonists to bronchodilate by inhaler or nebulizer:
•
terbutaline, albuterol, levalbuterol
•
Administer long-acting bronchodilating medications by metered dose inhaler
or dry powder inhaler:
•
formoterol, salmeterol
•
Administer anticholinergics which allow for relaxation of bronchial smooth
muscle:
•
ipratropium, tiotropium inhaler
•
Administer methylxanthines to dilate the bronchi. These are typically used
in conjunction with other medications, not for acute effect:
•
aminophylline
•
theophylline
•
Administer steroids to decrease inflammation within the airways:
•
hydrocortisone, methylprednisolone systemically
•
beclomethasone, triamcinolone, fluticasone, budesonide, flunisolide in-
halers
•
prednisolone, prednisone orally
•
Administer antacid, H2 blocker, or proton pump inhibitor to decrease the
amount of acid in stomach, reducing possible ulcer formation due to stress
of the disease or medication effects:
•
antacids: aluminum hydroxide/magnesium hydroxide, calcium carbonate
•
H2 blockers: ranitidine, famotidine, nizatidine, cimetidine
•
Proton pump inhibitors: omeprazole, lansoprazole, esomeprazole, rabepra-
zole, pantoprazole