RESPIRATORY SYSTEM &

RELATED DISORDERS

By
Grace Ann P. Mosqueda, RN
Objectives

Describe the basic physiological mechanisms and •

assessment of ventilation, circulation, oxygenation

Describe the impact of a client’s level of health age, •

lifestyle, and environment on tissue oxygenation

Identify and describe outcomes as a result of Ventricular •

tachycardia, Heart failure, Myocardial ischemia-
infarction,, and impaired tissue perfusion

Describe nursing interventions that promote oxygenation •

Describe various routes of oxygen administration, •

suctioning, chest tube, and artificial airway care
 Respiratory Physiology

Structure and function • •

Breathing: inspiration, expiration – •
Lung volumes and capacities – •
Pulmonary circulation – •
Respiratory gas exchange: oxygen, – •
carbon dioxide
Regulation of respiration – •
 Factors Affecting Oxygenation

Additional physiological factors • •

Decreased oxygen-carrying capacity – •
Decreased inspired oxygen concentration – •
Hypovolemia – •
Increased metabolic rate – •
Conditions affecting chest wall movement – •
Additional physiological factors • •
Musculoskeletal abnormalities – •
Trauma – •
Neuromuscular diseases – •
Central nervous system alterations – •
Chronic disease – •
Function of the Respiratory System •
Ventilation – mechanical process of moving oxygen •
and carbon dioxide into and out of lungs
Pressure changes w/in chest (negative pressure) – •
Inspiration: diaphragm, intercostals contract – •
Expiration: they relax – •
Gas diffusion – molecules move from an area of •
greater
concentration or PRESSURE to an area of lesser •
pressure
Insp.- O2 moves into blood as “partial pressure” is – •
lower, CO2
moves from blood to alveoli •
Exp. - Mechanical: CO2 is expelled from lung – •
Control of Ventilation •
Respiratory Centers: generate impulses to •
resp muscles – diaphragm & intercostals
Chemoreceptors: evaluate levels CO2,* •
O2, H+ (acid/base balance)
Central receptors: medula of brain * •
Peripheral receptors: aortic arch, carotid * •
arteries
PaCO2 – primary role in stimulation of * •
change in respiration
Normal Respiration •
Rate: 12 – 20bpm •
Usually the same volume of air w/ each •
Tidal volume – 500 ml per breath •
More volume when awake, less sleeping,- •
rate also decreases at night
The Respiratory Process •
the diaphragm descends into the abdominal •
cavity during inspiration, causing negative
pressure in the lungs
the negative pressure draws air from the area of •
greater pressure, the atmosphere, into the area
.of lesser pressure, the lungs
In the lungs, air passes through the terminal •
bronchioles into the alveoli to oxygenate the
body tissues
At the end of inspiration, the diaphragm and •
intercostal muscles relax and lungs recoil
As the lungs recoil, pressure within the •
lungs becomes greater than atmospheric
pressure, causing the air, which now
contains cellular waste products of carbon
dioxide and water, to move from the
alveoli of the lungs to the atmosphere
Expiration is a passive process •
 FACTORS AFFECTING OXYGENATION

Additional physiological factors • •

Decreased oxygen-carrying capacity – •
Decreased inspired oxygen concentration – •
Hypovolemia – •
Increased metabolic rate – •
Conditions affecting chest wall movement – •
Musculoskeletal abnormalities – •
Trauma – •
Neuromuscular diseases – •
Central nervous system alterations – •
Chronic disease – •
 Alterations in Cardiac Functioning that influence
:oxygenation

Conduction disturbances • •
Atrial and ventricular dysrhythmias – •
Altered cardiac output • •
Heart failure – •
Impaired valvular function • •
,Myocardial ischemia, Angina, MI • •
 :Lifestyle Factors influencing oxygenation

Nutrition -poor • •
Exercise • •
Smoking • •
Substance abuse- drugs, alcohol • •
Stress • •
Lifespan considerations: older adult

Decreased ciliary action* •

Decreased strength of cough * •
Decreased rib cage mobility * •
 ASSESSMENT

Subjective Data: explore the client's symptoms •

through characterization and history taking to
.help anticipate needs and plan care
Dyspnea- characteristics, associated factors, •
history, significance
Chest pain-characteristics,associated factors, •
history, significance
Cough- characteristics, associated factors, •
history, significance
 Manifestations of Impaired
Respiratory Function

:Objective •
Abnormal breath sounds – •
Accessory muscle use, tripod positioning – •
Cough and sputum production – •
Chest pain – related to infection, – •
inflammation
Cyanosis, clubbing – •
:Subjective •
Patient’s report of dyspnea – •
Signs/Symptoms of Hypoxia •
Changes in mental status: restlessness, confusion, irritability •
progressing to somnolence, coma •
Changes in vital signs: initial compensation for hypoxia* •
Late changes - Changes in skin* •
Secondary symptoms: change in GI function, change in renal •
Function •
Pulse Oximetry •
…Values are approximate* •
O2 sat. 90% = PaO2 55mmHg = moderate hypoxemia* •
O2 sat. 75% = PaO2 40mmHg = severe hypoxemia * •
O2 sat. 50% = PaO2 25mmHg = life threatening* •
O2 saturation of 90% is a critical value. Do assess baseline * •
.relative to patient’s history of pulmonary disease
 Physical Examination

I. Inspect shape of chest; note •

barrel chest: occurs with chronic respiratory disease
pectus carinatum (pigeon breast): sternum protrudes
outward, producing increased A-P diameter; usually not
significant
pectus excavatum (funnel chest): lower part of the sternum
is depressed; usually does not produce symptoms; may
impair cardiac function
II. note pattern of respirations •
rate •
regularity •
periodic respirations – normal in infants –
apnea episodes (cessation of respiration for 20 sec or more with –
color Changes); an abnormal finding
respiratory effort •
nasal flaring –attempt to widen airways and decrease –
resistance
open-mouth breathing – chin drops with each inhalation –
retractions – from use of accessory muscles –
III. Observe skin color and temperature; particularly mucus •
membranes and peripheral extremities
IV. note behavior: position of comfort, signs of irritability or •
lethargy, facial expression (anxiety)
V. Note speech abnormalities: hoarseness or muffled speech •
VI. Observe presence and quality of cough: productive, •
"paroxysmal, with inspiratory "whoop
VII. Auscultate for abnormal breath sounds •
grunting on expiration •
stridor – harsh inspiratory sound associated with obstruction or •
edema
wheezing – whistling noise during inspiration or expiration due to •
narrowed airways; common in asthma
snoring – noisy breathing associated with nasal abstruction •
 ANALYSIS

Nursing Diagnosis for people with respiratory system •

:"disorder may include
activity intolerance •
altered respiratory functions: ineffective airway •
clearance, ineffective breathing pattern, impaired gas
exchange
anxiety •
fatigue •
impaired oral mucus membrane •
altered nutrition •
disturbed sleep pattern •
 DIAGNOSTIC TESTS

I. Blood studies •
Complete blood count – •
II. Diagnostic tests: ventilation studies •
– Arterial blood gasesPulmonary function – •
– Chest x-ray Oximetry – •
– Lung scan Bronchoscopy – •
– Throat cultures Thoracentesis – •
Sputum specimens – •
Arterial Blood Gas (ABG) Analysis •
A measurement of oxygen, carbon dioxide, as •
well as the pH of the blood that provides a
means of assessing the adequacy of ventilation
.(PaCO2), oxygenation (PaO2)
Allows assessment of the acid-base (pH) status •
of the body –where alkalosis or acidosis is
present, whether acidosis or alkalosis is
respiratory or metabolic in origin and to what
.degree (compensated or uncompensated)
Allows evaluation (oxygen therapy, exercise •
.testing)
 Nursing and Patient Care Considerations

Blood can be obtained from any artery but is most .1 •

often drawn from the radial, brachial, or femoral site. It
can be drawn directly by arterial puncture or accessed
by way of indwelling arterial catheter. Determined
hospital policy for qualifications for ABG sampling and
.site of arterial puncture
If the radial artery is used, an Allen test must be .2 •
performed before the puncture to determine if collateral
.circulation is present
Arterial puncture should not be performed through a .3 •
lesion, through or distal to a surgical shunt, or in area
.where peripheral vascular disease or infection is present
Coagulopathy or medium- to high-dose antiagulation .4 •
therapy may be a relative contraindication for arterial
.puncture
Interpret ABGs by looking at the following (normal .5 •
:values are listed)
PaO2- partial pressure of oxygen in arterial blood (80 to •
100 mmHg)
PaCO2- partial pressure of carbon dioxide in arterial •
blood (35 to 45 mmHg)
SaO2- saturation of oxygen in arterial blood (greater •
than 95%)
pH- hydrogen ion concentration, or degree of acid-base •
balance (7.35 to 7.45)
 Sputum Examination

Sputum is obtained for evaluation of gross .1 •

appearance, microscopic examination, Gram's stain,
.culture, acid-fast bacillus, and cytology
The direct smear shows presence white blood cells and •
intracellular (pathogenic) bacteria and extra-cellular
.(mostly nonpathogenic) bacteria
The sputum culture is used to make a diagnosis, •
determine drug sensitivity, and serve as a guide for drug
.treatment (ie, choice of antibiotic)
Cytology (exfoliative cytology) used to identify tumor •
.cells
 Nursing and Patient Care Considerations

Patient receiving antibiotics, steroids, and .1 •

immuno-suppressive agents for prolonged time
may have periodic sputum examinations,
because these agents may give rise to
.opportunistic pulmonary infections
It is important that the sputum be collected .2 •
correctly and that the specimen be sent to the
lab immediately. Allowing it to stand in a warm
room will result in over-growth of organisms,
making identification of pathogens difficult; this
.also alters cell morphology
:Sputum can be obtained by various methods .3 •
Deep breathing and coughing •
Obtain early morning specimen—yields best sample of deep –
.pulmonary secretions from all lung fields
Have a patient clear nose and throat and rinse mouth—to –
.decrease sputum contamination
Instruct patient to take several deep breaths, exhale, and –
.perform a series of short coughs
Have patient cough deeply and expectorate the sputum into a –
.sterile container
ultrasonic and/or hypertonic saline nebulization •
Patient inhales through mouth slowly and deeply for 10 to 20 –
.minutes
Nebulization increases the moisture content of air going lower –
tract; particles will condense on tracheobronchial tree and aid
.in expectoration
Tracheal suction—aspiration of secretions through –
.endotracheal or tracheostomy tube
Bronchoscopic removal—provides sputum sampling •
by aspiration of secretions; brushing through sterile
catheter; bronchoaveolar lavage; and transbonchial
biopsy
Gastric aspiration (rarely necessary since advent of •
ultrasonic nebulizer)
nasogastric tube is inserted into the stomach to siphon out –
.swallowed pulmonary secretions
Useful only for culture of tubercle bacilli,but not for direct –
examination
Transtracheal aspiration (procedure guidelines 10-2) •
involves passing a needle and then a catheter through
a percutaneous puncture of the cricothyroid
membrane. Transtracheal aspiration bypasses the
oropharyx and avoids specimen contamination by
.mouth flora
Pleural fluid analysis •
Pleural fluid is continuously produced and reabsorbed, .1 •
with a thin layer of fluid normally in the pleural space.
Abnormal accumulation of pleural fluid (effusion) occurs
in diseases of the pleura, heart, or lymphatics. The
pleural fluid is studied, along with other tests, to
.determine the underlying cause
Obtained by aspiration (thoracentesis) or by tube .2 •
thoracotomy (chest tube insertion; procedure guidelines
.10-3)
The fluid is examined for cell count, differential, .3 •
specific gravity, cytology, protein, glucose, pH, lactate
dehydrogenase (LDH), and amylase. Pleural fluid is
.usually light straw colored
 Nursing and patient care considerations

Observe and record total amount of fluid withdrawn, .1 •

.nature of fluid, and its color and viscosity
Prepare sample of fluid and ensure transport to .2 •
.laboratory
 Radiology and Imagining

Chest X-Ray (Roentgenogram) •

Normal pulmonary tissue is radiolucent and appears .1 •
black film. Thus, densities produced by tumors, foreign
bodies, infiltrates, and so forth can be detected as lighter
.or white images
This test shows the position of normal structures, .2 •
displacement, and presence of abnormal shadows. It
may reveal pathology in the lungs in the absence of
.symptoms
 .Nursing and patient care considerations

Should be taken upright if patient's condition .1 •

permits. Assist technician at beside in preparing
.patient for portable chest x-ray
Encourage patient to take deep breath, hold .2 •
.breath, and remain still as x-ray is taken
Ensure that all jewelry or metal objects in x- .3 •
ray field are removed so as not to interfere with
.film
Consider the contraindication of x-rays for .4 •
.pregnant patients
 Computerized axial tomography (CAT,CT)

an imaging method in which lungs are .1 •

scanned in successive layers by a narrow x-ray
beam. A computer printout is obtained of the
absorption values of the tissues in the plane that
.is being scanned
it may be used to define pulmonary nodules, .2 •
pulmonary abnormalities, or to demonstrate
.mediastinal abnormalities and hilar adenopathy
 .Nursing and patient care considerations

Describe test to patient/family and ensure .1 •

consent is obtained (if required test takes about
.30 minutes
Be alert to any allergies to iodine or other .2 •
radiographic contrast media that might be used
.during testing
consider the contraindication of x-rays for the .3 •
pregnant patient, especially for Ct scans with
.contrast media
 MAGNETIC RESONANCE IMAGING (MRI)

a type of emission tomography based on magnetizing .1 •

patient tissue, generating a weak electromagnetic signal.
.And mapping that signal for visualization
.provides contrast between various soft tissues .2 •
traditional radiographic contrast media are not used .3 •
it is helpful to synchronize the MRI image to the .4 •
electrocardiogram in thoracic studies
consider the contraindications of x-rays for pregnant .5 •
women
 :Nursing considerations

Explain the procedure to patient and assess the ability to •

remain still in an enclosed space; sedation may be
necessary if the patient is claustrophobic
Evaluate the patient for magnetic implants such as •
pacemakers, prosthetic valves or joints, or metallic
surgical clips which contraindicates the use of MRI
Evaluate the patient for claustrophobia and teach •
relaxation techniques to use during test. Sedation may
.be necessary
Instruct the patient after the procedure to drink plenty of •
.water to facilitate excretion of dye
 PULMONARY ANGIOGRAPHY

an imaging method used to study the - •

pulmonary vessels and the pulmonary circulation
for visualization, radiopaque medium is injected - •
by way of a catheter in the main pulmonary
artery rapidly into the vasculature of the lungs.
Films are then taken in rapid succession after
injection
It is considered a "gold standard" for the - •
diagnosis of pulmonary embolus, but spiral CT
.can also be effectively used
 :Nursing Responsibilities

Determine if patient is allergic to radiographic •

contrast media
Instruct patient that injection of dye can cause •
flushing, cough and a warm sensation
After the procedure, make sure the pressure is •
maintained over access site and monitor pulse
rate, blood pressure, and circulation distal to the
.injection site
 VENTILATION – PERFUSION (V/Q) SCAN

radioisotope imaging of ventilation and blood flow to the •

lungs. The scintillation camera may be interfaced to a
.computer to record, collate and refine data
Perfusion scan is done after injection of a radioactive •
isotope
measures blood perfusion through the lungs; evaluates •
lung function on a regional basis
useful in perfusion (vascular) abnormalities such as •
pulmonary embolism
ventilation scan is done after inhalation of radioactive gas •
(xenon, krypton), which diffuses throughout the lungs;
useful in detecting ventilation abnormalities such as
emphysema
:Nursing consideration •
explain the procedure to the patient and encourage cooperation with •
.inhalation and brief episodes of breath holding
 BRONCHOSCOPY

the direct inspection and observation of the larynx, •

trachea and bronchi through a flexible or rigid
.bronchoscope
flexible fiberoptic bronchoscope allows for more patient •
comfort and better visualization of smaller airways
rigid bronchoscopy is preferred for small children and •
endobronchial tumor resection has both diagnostic and
.therapeutic uses in pulmonary conditions
 LUNG BIOPSY

procedures used to obtain histologic material from the •

:lungs to aid in diagnosis. These include
transbronchoscopic biopsy – biopsy forceps inserted •
through the bronchoscope and specimen of lung tissue
obtained
transthoracic needle aspiration biopsy- specimen •
obtained through needle aspiration under fluoroscopic
guidance
open lung biopsy – specimen obtained through a small •
anterior thoracotomy; used in making a diagnosis when
other biopsy methods have not been effective or are not
possible
 :Nursing Responsibilities

.obtain permit for consent, if required •

Observe for possible complications including •
pneumothorax, hemorrhage (hemoptysis), and
.bacterial contamination of pleural space
Monitor respiratory rate, rhythm and breath •
sounds
Be alert for signs of pneumothorax, •
.dysrhythmias and bronchospasm
 PULMONARY FUNCTION TEST (PFTS)
used to detect and measure abnormalities in respiratory function, •
and quantify severity of various lung diseases. Such tests include
measurements of lung volumes , ventilatory function, diffusing
capacity, gas exchange, lung compliance, airway resistance and
.distribution of gases in the lung

Ventilatory studies (spirometry) are the most common group of •

.tests
requires spirometer that plots volume against time (timed vital •
capacity)

patient is asked to take a deep breath as possible and then to •

.exhale into a spirometer as completely and forcefully as possible
A reduction in the vital capacity, inspiratory capacity, and total lung •
capacity may indicate a restrictive form of lung disease (disease due
to increased lung stiffness)
An increase in functional reserve capacity, total lung •
capacity and reduction in flow rates usually indicate an
obstructive flow due to bronchial obstruction or loss of
.lung elastic recoil

Lung volumes are determined by asking the patient to •

inhale a known concentration of inert gases such as
helium or 100% oxygen and measuring concentration
.of inert gas or nitrogen in exhaled air (dilution method)

yields thoracic volume (total lung capacity plus any •

unventilated bleb or bullae)
an increased residual volume is found in air trapping •
.due to obstructive lung disease
A reduction in several parameters usually indicates a •
.restrictive form of lung disease or chest wall abnormality
diffusing capacity measures lung surface effective for the •
transfer of gas in the lung by having patient inhale gas
containing known low concentration of carbon monoxide
and measuring carbon monoxide concentration in
.exhaled air

Difference between inhaled and exhaled concentrations •

is related directly to uptake of carbon monoxide across
.alveolar –capillary membrane
Is reduced in parenchymal lung disease, possibly in •
.severe anemia, and in some forms of heart disease
 :Nursing Responsibilities

instruct patient in correct technique for •

completing PFTs; coach patient through
.test, if needed

Instruct patient not to use oral or inhaled •

bronchodilators (such as albuterol),
caffeine or tobacco 4 hours before the
.test
 PULSE OXIMETRY

provides an estimate of arterial oxyhemoglobin •

saturation by using selected wavelengths to light to
noninvasively determine the saturation of
.oxyhemoglobin

Oximeters function by passing a light beam through a •

vascular bed , such as a finger or earlobe, to determine
the amount of light absorbed by oxygenated (red) and
.deoxygenated (blue) blood

Calculates the amount of arterial blood that is saturated •

.with oxygen (SaO2) and displays this as a digital value
:Indications include •
monitor adequacy of oxygen saturation; quantify response to •
therapy

monitor unstable patient who may experience sudden changes •

in blood oxygen level
evaluation of need for home oxygen therapy •
determine supplemental oxygen needs at rest and with exercise •
need to follow the trend and need to decrease number of ABGs •
drawn

Note: if the SaO2 drops below 80%, the reading displayed by the •
oximeter may vary by+-2% from the actual SaO2. Oximeters rely
on differences in light absorption to determine SaO2. At lower
saturations, oxygenated hemoglobin appears more blue in color
and is less easily distinguished from deoxygenated hemoglobin.
.ABG should be used in this situation
 :Nursing Considerations

Assess patient's hemoglobin. SaO2 may not correlate well •

.PaO2 if hemoglobin is not within normal limits
Remove patient's nail polish because it can affect the ability of •
.the sensor to correctly determine oxygen saturation
Correlate oximetry with ABG and then use for single reading •
or trending of oxygenation

Display heart rate should correlate with patient's heart rate •

To improve quality of signal, hold finger dependent and •
motionless (motion may alter results) and cover finger sensor
.to occlude ambient light
Assess site of oximetry monitoring for perfusion on a regular •
basis, because pressure ulcer may occur from prolonged
.application of probe
Device limitations: motion, abnormal hemoglobins, IV •
dye, exposure of probe to ambient light, low perfusion
states, skin pigmentation, nail polish or nail coverings,
.and nail deformities such as severe clubbing
Document inspired oxygen or supplemental oxygen, •
.type of oxgen delivery device

Normal Values •
TERM VALUES •
Ph 7.35-7.45 •
P CO2 35-45mmHg •
HCO3 22-27mEq/L •
PO2 80-100mmHg •
O2 Saturation 96%-100% •
 PLANNING and IMPLEMENTATION

:Goals •
:Patient will have •
patent airway and satisfactory oxygenation •
freedom from symptoms of respiratory distress •
improved ability to tolerate exercise •
improved ability to conserve energy •
coordination with significant others for care •
more effective communication pattern •
increased tolerance of activities •
 INTERVENTIONS

Respiratory Medications •
SYMPATHOMIMETIC BRONCHODILATORS •
dilates the airways of the respiratory tree, thereby making air - •
exchange and respiration easier for the client
relaxes the smooth muscle of the bronchi - •
used to treat allergic rhinitis and sinusitis, asthma, bronchitis, - •
chronic obstructive pulmonary disease (COPD) and
emphysema

Contraindication: Individuals with •

peptic ulcer disease Hypersensitivity •
cardiac dysrhythmias severe cardiac disease •
uncontrolled seizure disorders Hyperthyroidism •
use cautiously in patients with hypertension and diabetes •
mellitus
medications
 Chronic Obstructive Pulmonary Disease (COPD)

people with chronic bronchitis or emphysema •

aka Chronic airway limitation (CAL) •

incidence: in 2000, 11.4 million Americans were •

affected by COPD
more frequent in men than in women •
common in blacks more than in whites •
4th leading cause of death in the US in 2000 •
Accounted for 123, 500 deaths •
Affects middle-aged and older adults •
 :Risk Factors

cigarette smoking- contain irritants .1 •

Effects: impair ciliary movement •
inhibit the function of alveolar macrophages •
cause mucus-secreting glands to hypertrophy •
air pollution .2 •
occupational exposure to noxious dust and .3 •
gases
airway infection .4 •
familial or genetic factors .5 •
 :Pathophysiology

characterized by slowly progressive obstruction of the •

airways
with periods of exacerbations related to respiratory infections •
.causing symptoms of dyspnea and sputum production
Unlike acute processes in which lung tissue recovers, airway •
and lung parenchyma do not return to normal after
exacerbation, instead, they progressively exhibit destructive
changes
Emphysema or chronic bronchitis may manifest but one •
condition predominates
Symptoms are airway obstruction, airflow resistance is •
increased and expiration becomes slow or difficult
Resulting to mismatch between alveolar ventilation and •
blood flow or perfusion, thereby leading to impaired gas
exchange
 Chronic Bronchitis

a disorder of excessive bronchial mucus secretion •

characterized by productive cough (3+ months in 2 consecutive •
years)
major factor: cigarette smoking •
:Pathophysiology •
Inhaled irritants lead to chronic inflammatory process - •
cause vasodilation, congestion and edema of the bronchial mucosa - •
thick mucus is produced in increased amounts - •
cause narrowed airway and then airway obstruction - •
problems with expiration then inspiration result - •
impaired ciliary function(normal defense is altered) causes inability to - •
clear mucus and pathogens
imbalance in ventilation and perfusion leads to hypoxemia,- •
hypercapnia(increased level of CO2 in the blood) and pulmonary
hypertension
right-sided heart failure would result from pulmonary hypertension- •
 :Manifestations •
productive cough with thick, tenacious sputum .1 •
cyanosis .2 •
right-sided heart failure – sx: distended neck .3 •
veins, edema, liver engorgement, enlarged heart
loud rhonchi upon auscultation .4 •
 Emphysema

characterized by destruction of the walls of the alveoli, with •

resulting enlargement of abnormal air spaces
usual onset 40 years old and above •
insidious onset •
stimulus to breathe is low PO2 instead of increased PCO2 •
major implication: cigarette smoking •
:Pathophysiology •
deficient alpha-antitrypsin (enzyme that inhibits activity of- •
proteolytic enzymes) cause tissue destruction in lungs
alveolar wall destruction causes alveoli and air spaces to - •
enlarge with loss of portions of pulmonary capillary bed
causing reduction in surface area for alveolar-capillary - •
diffusion, thus, affecting gas exchange
elastic recoil is lost, reducing volume of air that is passively - •
expired
usually affects respiratory bronchioles or alveoli - •
 :Manifestations •
dyspnea – starts with exertion then progress to even at rest .1 •
cough – minimal or absent .2 •
increased antero-posterior diameter (barrel chest)- due to.3 •
air trapping and hyperinflation
thin client .4 •
tachypnea .5 •
use accessory muscle .6 •
assumes sitting and leaning forward position .7 •
prolonged expiratory phase .8 •
diminished breath sounds .9 •
hyperresonance upon percussion .10 •
cyanosis .11 •
clubbing .12 •
ABGs indicate respiratory acidosis and hypoxemia .13 •
congestion and hyperinflation of lungs seen on X-ray .14 •
 :Diagnostic Test

PFT .1 •
ventilation-perfusion scan .2 •
serum alpha1-antitrypsin levels (normal is 80-.3 •
160mg/dL)
ABG .4 •
pulse oximetry .5 •
CBC with WBC differential – increased RBC and .6 •
hematocrit to increase oxygen-carrying capacity
chest X-ray – show flattening of the diaphragm due to .7 •
hyperinflation
:Management of COPD •
Preventive: smoking abstinence •
Rehabilitative: relieving symptoms- giving meds, PVD or •
chest physiotherapy to minimize obstruction
smoking cessation .1 •
:medications .2 •
a. pneumococcal vaccinations •
b. bronchodilators – improve airflow and reduce air •
trapping
c. corticosteroid – when patient also has asthma – •
reduce the severity of exacerbations
d. alpha1-antitrypsin replacement therapy – expensive; •
IV weekly; reduce airflow decline and mortality
avoid exposure to allergens and irritants .3 •
pulmonary hygiene measures : hydration; effective .4 •
cough, percussion and postural drainage
to improve clearance of airway secretions – •
avoid cough suppressants; cause retention of- •
secretions
regular exercise program – i.e. walking 20 min/day 3x .5 •
per week
:benefits •
a. improving exercise tolerance •
b. enhancing ability to perform ADL •
c. preventing deterioration of physical condition •
breathing exercises- relieve accessory muscle fatigue .6 •
and slows the respiratory rate
oxygen – improves exercise tolerance, meantal .7 •
functioning and quality of life
surgery- ie lung transplant (2-yr survival rate of 75%) .8 •
Dietary changes – minimize dairy and salt to reduce .9 •
mucus production
 :Implementation •
monitor vital signs .1 •
administer oxygen as prescribed at 2-3L/min .2 •
monitor pulse oximetry .3 •
provide respiratory treatments and chest .4 •
physiotherapy
reposition client for breathing comfort and mobilization .5 •
of secretions
record the amount, consistency and color of secretion .6 •
increase fluid intake .7 •
position to high Fowler's .8 •
monitor weight .9 •
encourage small, frequent feeding .10 •
provide a high-calorie, high-protein diet with dietary .11 •
supplements
allow activity as tolerated .12 •
administer medications as prescribed .13 •
suction client as necessary .14 •
 :Client Education

stop smoking .1 •
recognize the signs and symptoms of infection .2 •
adhere to activity limitations .3 •
demonstrate pursed-lip breathing .4 •
avoid exposure to individuals with resp.infection .5 •
instruct on nutritional requirements .6 •
avoid eating gas-producing foods, spicy and extremely.7 •
hot or cold food
instruct the importance of vaccination .8 •
avoid powerful odors .9 •
avoid extreme temperatures .10 •
avoid fireplaces, pets and feather pillows .11 •
 Pleural Effusion

the collection of fluid in the pleural space – •

any condition that interferes with either secretion or •
drainage of this fluid
:Manifestations •
pleuritic pain that is sharp and increases with .1 •
respiration
dyspnea on exertion .2 •
dry,non-productive cough caused by bronchial .3 •
irritation or mediastinal shift
malaise .4 •
tachycardia .5 •
elevated temperature .6 •
decreased breath sounds .7 •
chest X-ray shows pleural effusion .8 •
:Implementation •
identify and treat underlying cause .1 •
monitor vital signs .2 •
monitor breath sounds .3 •
position in high-Fowler's .4 •
encourage coughing and deep breathing .5 •
prepare client for thoracentesis .6 •
if pleural effusion is recurrent, prepare client for .7 •
pleurectomy or pleurodesis
Pleurectomy – consist of surgically stripping the parietal •
pleura away from the visceral pleura
it produces an intense inflammatory reaction that •
promotes adhesion formation between the 2 layers
during healing
Pleurodesis- involves the instillationof sclerosing •
substance into the pleural space via a thoracotomy tube
this creates an inflammatory response that scleroses •
tssue together
 Empyema •
the collection of pus within the pleural cavity –
the fluid is thick, opaque and foul-smelling –
the most common cause is pulmonary infection and lung –
abscess caused by thoracic surgery or chest trauma, in which
bacteria are introduced into the pleural space
treatment focuses on emptying the empyema cavity,re- –
expanding the lung and controlling the infection

:Manifestations •
recent febrile illness or trauma .1 •
chest pain .2 •
cough .3 •
dyspnea .4 •
anorexia with weight loss .5 •
malaise .6 •
elevated temperature with chills .7 •
night sweats .8 •
diminished chest wall movement on the affected side .9 •
pleural exudates on chest x-ray .10 •
:Implementation •
monitor vital signs .1 •
monitor breath sounds .2 •
position client on semi-or high-Fowler's .3 •
encourage coughing and deep breathing .4 •
administer antibiotics as prescribed .5 •
instruct client to splint chest as necessary –(pillow) .6 •
assist with chest tube insertion to promote drainage .7 •
and lung expansion
if marked pleural thickening occurs, prepare client for .8 •
decortication as prescribed. This is a surgical procedure
that involves removal of the restrictive mass of fibrin and
inflammatory cells
 Pleurisy
inflammation of the visceral and parietal membranes •
these membranes rub together during respiration and •
cause pain

may be caused by pulmonary infarction or pneumonia •

it usually occurs on one part of the chest, usually in the •
lower, lateral portions in the chest wall

:Manifestations •
knife-like pain that is aggravated in deep breathing and .1 •
coughing
dyspnea .2 •
pleural friction rub heard on auscultation .3 •
Apprehension .4 •
 :Implementation

monitor vital signs .1 •

monitor lung sounds .2 •
identify and treat cause .3 •
administer analgesics as prescribed .4 •
apply hot or cold applications as prescribed .5 •
encourage coughing and deep breathing .6 •
instruct client to lie on affected side to splint the .7 •
chest
 Histoplasmosis

a pulmonary fungal infection caused by spores of Histoplasma •

capsulatum
transmission occurs by the inhalation of spores, which are normally •
found in contaminated soil
spores are usually found in bird droppings •

:Manifestations •
dyspnea .1 •
chills .2 •
chest pain .3 •
elevated temperature .4 •
pulmonary infiltrates on chest X- ray film .5 •
elevated WBCs .6 •
positive histoplasmin skin test .7 •
Positive agglutination test .8 •
splenomegaly .9 •
hepatomegaly .10 •
:Implementation •
administer oxygen as prescribed .1 •
administer antiemetics, antihistamines, antipyretics, .2 •
and steroids as prescribed (benadryl, acetaminophen-
tylenol)
encourage coughing and deep breathing .3 •
4. administer fungicidal medications as prescribed
position in semi-Fowler's .5 •
monitor vital signs .6 •
monitor breath sounds .7 •
instruct client to spray chicken coop and barns with .8 •
water before sweeping
 Silicosis

aka occupational lung disease; asbestosis; coal worker's •

pneumoconiosis

fibrotic disease of lungs caused by inhalation of inorganic •

dusts over long periods of time
common in miners and sandblasters •
tuberculosis is a frequent complication •

:Manifestations •
frequent respiratory infections .1 •
blood-streaked sputum .2 •
cough .3 •
nodular lesions on lungs upon chest x-ray .4 •
:Implementation •
give antitussive for cough .1 •
medication for TB .2 •
eliminate toxic substances .3 •
oxygen .4 •
encourage coughing and deep .5 •
breathing
 Bronchiectasis

permanent abnormal dilation of the bronchi with •

destruction of the muscular and elastic structure of the
bronchial wall
caused by bacterial infection; recurrent lower respiratory •
tract infection; lung tumors; thick, tenacious secretions

:Manifestations •
chronic cough with production of mucopurulent .1 •
sputum, hemoptysis, exertional dyspnea, wheezing
anorexia, fatigue, weight loss .2 •

:Diagnostic studies •
bronchoscopy reveals sources and sites of secretions •
possible elevation of WBC •
 :Implementation

monitor vital signs .1 •

administer oxygen as prescribed at 2-3L/min .2 •
monitor pulse oximetry .3 •
provide respiratory treatments and chest physiotherapy .4 •
reposition client for breathing comfort and mobilization of .5 •
secretions
record the amount, consistency and color of secretion .6 •
increase fluid intake .7 •
position to high Fowler's .8 •
monitor weight .9 •
encourage small, frequent feeding .10 •
provide a high-calorie, high-protein diet with dietary .11 •
supplements
allow activity as tolerated .12 •
administer medications as prescribed .13 •
suction client as necessary .14 •
 :Client Education

stop smoking .1 •
recognize the signs and symptoms of infection .2 •
adhere to activity limitations .3 •
demonstrate pursed-lip breathing .4 •
avoid exposure to individuals with resp.infection .5 •
instruct on nutritional requirements .6 •
avoid eating gas-producing foods, spicy and extremely.7 •
hot or cold food
instruct the importance of vaccination .8 •
:Diagnostic uses include –
collecting secretions for cytologic/bacteriologic •
studies determining location and extent for
pathologic process and obtaining tissue or brush
biopsy for cytologic examination or culture

determining whether a tumor can be resected •

surgically diagnosing bleeding sites (source of
hemoptysis) therapeutic uses include removal of
foreign bodies or thickened secretions from
tracheobronchial tree and the excision of lesion
:Nursing Responsibilities •
See that an informed consent form has been signed and that risks •
.and benefits have been explained to the patient
Determine if the patient is allergic to radiographic dye before V/Q •
scan
Administer prescribed medication to reduce secretions, block the •
vasovagal reflex, gag reflex and relieve anxiety. Give
.Encouragement and nursing support

Restrict fluid and food for 6-12 hours before procedure (to reduce •
.the risk of aspiration when reflexes are blocked)
.Remove dentures, contact lenses and other prosthesis •
After the procedure: a. monitor cardiac rhythm and rate, blood •
pressure and level of consciousness
withhold cracked ice/fluids until after the patient demonstrates gag •
reflex
monitor respiratory effort and rate •
monitor oximetry -promptly report cyanosis, hypoventilation, etc •
INTERVENTIONS
Critical Thinking Exercise •
What if you are caring for Miss Taylor, a 26 • •
year old patient with asthma? The patient
complains of chest tightness and wheezing.
What nursing interventions are appropriate
?for this patient
 Case Study •
Mr. Mathews is a 70 year old male with ten year history • •
of emphysema. He is in intensive care unit with
respiratory failure. He now has a tracheostomy and is on
40% percent oxygen via trach mask. The nurse is
suctioning him every one hour for thick, tenacious
secretions. On auscultation of the
.lungs the nurse notes rhonchi anteriorly over the bronchi •
Which of the following is the most appropriate nursing • •
?diagnosis for Mr. Mathews
.A. Sleep pattern disturbance related to orthopnea • •
.B. Alteration in comfort: pain related to tracheostomy • •
.C. Knowledge deficit related to effects of smoking • •
Ineffective airway clearance related to increased • •
.tracheobronchial secretions
 Test Question •
Mr. Mathews is a 70 year old male with ten year history of • •
emphysema. He is in intensive care unit with respiratory •
failure. He now has a tracheostomy and is on 40% percent oxygen •
via trach mask. The nurse is suctioning him every one hour for thick,
tenacious secretions. On auscultation of the lungs the nurse notes
rhonchi anteriorly
.over the bronchi •
Which of the following is an appropriate outcome criteria for • •
?Mr. Matthews nursing diagnosis •
.A. All pulses palpable and strong • •
.B. Normal arterial blood gases • •
.C. Has a patent airway • •
.D. Performs activities of daily living without shortness of breath • •
 Chest Injuries
Rib Fracture

results from direct blunt chest trauma and causes a - –

potential for intrathoracic injury such as
pneumothorax or pulmonary contusion

pain with movement and chest splinting result in - –

impaired ventilation and inadequate clearance of
secretions
 Signs/symptoms

pain at injury site that increases with inspiration .1 •

tenderness at site .2 •
shallow respirations .3 •
client splints chest .4 •
fractures noted on x-ray film .5 •
 :Implementation

note that ribs usually unite spontaneously -

place client on high-Fowler's position -
administer pain medication as prescribed to -
maintain adequate ventilatory status

monitor for increased respiratory distress -

-instruct client to self-splint with hands and arms -
prepare the client for an intercostals nerve block -
as prescribed if the pain is severe
 Flail Chest

a blunt chest trauma associated with accidents, -

which may result in hemothorax and rib fractures

the loose segment of the chest wall becomes - -

paradoxical to the expansion and contraction of the
rest of the chest wall
 Signs/symptoms

paradoxical respirations (the inward movement of the .1

thorax during inspiration with outward movement
during expiration)
Severe pain in chest .2
dyspnea .3
cyanosis .4
tachycardia .5
hypotension .6
shallow respirations .7
tachypnea .8
diminished breath sounds .9
 :Implementation

place client in high-Fowler's position .1

administer humidified oxygen as prescribed .2
monitor for increased respiratory distress .3
encourage coughing and deep breathing .4
administer pain medications as prescribed .5
maintain bed rest and limit activity to reduce O2 .6
demands
prepare for intubation with mechanical ventilation .7
for severe flail chest associated with respiratory
failure and shock
 Pulmonary Contusion

characterized by interstitial hemorrhage -

associated with intra-alveolar hemorrhage,
resulting in decreased pulmonary
compliance
the major complication is Adult Respiratory -
Distress Syndrome (ARDS)
 :Signs/Symptoms

dyspnea .1
hypoxemia .2
increased bronchial secretions .3
hemoptysis .4
restlessness .5
decreased breath sounds .6
rales and wheezes .7
 :Implementation

maintain airway and ventilation .1

position client in high-Fowler's .2
administer oxygen as prescribed .3
monitor for increased respiratory distress .4
maintain bed rest and limit activity to reduce O2 .5
demand
prepare for mechanical ventilation if required .6
 Pneumothorax/hemothorax

the accumulation of atmospheric air or fluid -

in the pleural space, which results in a rise
in intrathoracic pressure and reduced vital
capacity
the loss of negative intrapleural pressure -
results in collapse of the lung
a spontaneous pneumothorax occurs with -
the rupture of a bleb
an open pneumothorax occurs when an opening -
through the chest wall allows the entrance of
positive atmospheric pressure into the pleural
.space
a tension pneumothorax can occur from a blunt -
chest injury or from mechanical ventilation with
positive end-expiratory pressure when there is a
build up of positive pressure in the pleural
.space
diagnosis of pneumothorax is made by chest x- -
.ray film
 Types of Pneumothorax

spontaneous pneumothorax
the most common type of closed pneumothorax; –
air accumulates within the pleural space without
an obvious cause. Rupture of small bleb on the
visceral pleura most commonly produces this
type of pneumothorax

open pneumothorax
air enters the pleural space through an opening –
in the chest wall; usually caused by stabbing or
gun shot wound
 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)

hemothorax
accumulation of blood in the pleural space; –
frequently found with an open pneumothorax,
resulting in a hemopneumothorax
 :Signs/Symptoms

dyspnea .1
tachycardia .2
tacypnea .3
sharp chest pain .4
absent breath sounds on affected side .5
.decreased chest expansion unilaterally .6
cyanosis .7
hypotension .8
subcutaneous emphysema .9
sucking sound with open chest wound .10
tracheal deviation to the unaffected side with .11
.tension pneumothorax
 Implementation

apply pressure dressing over open chest .1

.wound
administer oxygen as prescribed .2
position client in high fowler's .3
prepare the chest tube placement with .4
underwater seal drainage until the lung has fully
expanded
monitor chest tube drainage system .5
monitor for subcutaneous emphysema .6
 Respiratory failure

occurs when the client cannot eliminate -

the carbon dioxide retention results in hypoxemia -
oxygen reaches the alveoli but cannot be -
absorbed or used properly
the lungs can move air sufficiently but cannot -
.oxygenate the pulmonary blood properly
respiratory failure occurs as a result of a -
mechanical abnormality of the lungs or chest wall,
a defect in the respiratory control center in the
brain, or an impairment in the function of the
.respiratory muscles
.the PaCO2 level is greater than 45 mmHg -
 :Signs/Symptoms

dyspnea .1
headache .2
confusion .3
restlessness .4
tachycardia .5
cyanosis .6
dysrhythmias .7
decreased level of consciousness .8
.alternation is respirations and breath sounds .9
 Implementation

.a. Identify and treat the cause of respiratory failure

b. Administer oxygen to maintain the PaO2 level
.above 60 mmHg
.c. Position the client in high fowler's
.d. Encourage deep breathing
e. Administer bronchodilators as prescribed
f. Prepare the client for mechanical ventilation if
supplemental oxygen cannot maintain
.acceptable PaO2 levels
 Empyema

the collection of pus within the pleural cavity -

the fluid is thick, opaque, and foul-smelling -
the most common cause is pulmonary infection -
and lung abscess caused by thoracic surgery or
chest trauma, in which bacteria are introduced
directly into the pleural space
treatment focuses on emptying the empyema-
cavity, re-expanding the lung and controlling the
infection
 :Signs/Symptoms

recent febrile illnesses or trauma .1

chest pain .2
cough .3
dyspnea .4
anorexia and weight loss .5
malaise .6
elevated temperature and chills .7
night sweats .8
diminished chest wall movement on the affected side .9
pleural exudates on chest X-ray .10
 :Implementation

monitor vital signs .1

monitor breath sounds .2
position client on semi- or high-Fowler's .3
encourage coughing and deep breathing .4
administer antibiotics as prescribed .5
instruct client to splint chest as necessary .6
assist with chest tube insertion to promote .7
drainage and lung expansion
 Lung Cancer

malignant tumor of the lung that may be primary or -

metastatic
the lungs are common target for metastasis from other -
organs

bronchogenic carcinoma spreads through direct extension-

and lymphatic dissemination
diagnosis is made by chest x-ray film that shows a lesion -
or mass and bronchoscopy and sputum studies that
demonstrate a positive cytology
biopsy is the confirmative test for atypical cells -
 :the 4 major types of lung cancer are

small cell (oat cell) .1

epidermal (squamous cell) – has the most .2
positive prognosis
adenocarcinoma – second most positive .3
prognosis
large cell anaplastic carcinoma .4
:Causes
cigarette smoking *
exposure to environmental pollutants*
exposure to occupational pollutants*
 :Signs/Symptoms

cough .1
dyspnea .2
hoarseness .3
hemoptysis .4
chest pain .5
weight loss .6
weakness .7
anorexia .8
 :Types of Thoracic Surgery
Exploratory thoracotomy
anterior or posterolateral incision through the 4th, 5th, 6th or 7th –
intercostals spaces to expose and examine the pleura and lung

Lobectomy
removal of one lobe of a lung; treatment for bronchiectasis, carcinoma, –
emphysematous blebs and lung abscesses

Pneumonectomy
removal of an entire lung; most commonly done as treatment of –
carcinoma

Segmental resection
removal of one or more segments of the lung; most often done as –
treatment of bronchiectasis

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
 :Implementation

monitor vital signs .1

assess breathing patterns and for signs of .2
respiratory impairment
assess breath sounds .3
assess tracheal deviation .4
administer analgesics as prescribed for pain .5
management
position client upright for ease in breathing .6
administer oxygen as prescribed and .7
humidification to moisten and loosen secretions
monitor pulse oximetry .8
provide respiratory treatments as prescribed .9
administer bronchodilators and steroids as .10
prescribed to decrease bronchospasm,
inflammation and edema
provide a high-protein, high-calorie diet .11
provide activity as tolerated and active/passive .12
ROM
provide rest periods .13
 :Nonsurgical Implementation

radiation therapy for localized intrathoracic lung *

cancers
chemotherapy to promote tumore regression*
immunotherapy with tumor extracts, irradiated*
whole tumor cells or cells killed by other
methods
immunotherapy directed at enhancing an effective *
immune response
 :Surgical Implementation

laser therapy – to relieve endobronchial .1

obstruction
thoracotomy with pneumonectomy – surgical.2
removal of a lung for bronchiogenic carcinoma
thoracotomy with segmental resection – surgical .3
removal of one lobe of a lung for tumors
confined to a single lobe
thoracotomy with segmental resection – surgical .4
removal of a lobe segment for clients unable to
tolerate lobectomy or pneumonectomy
:Preoperative

explain the potential postoperative need for chest tubes *

note that a chest tube is not inserted for a*

pneumonectomy and the serum fluid that accumulates in
the empty thoracic cavity eventually consolidates,
preventing shifts of the mediastinum, heart and the
remaining lung
:Postoperatively
monitor vital signs*
assess cardiac and respiratory status*
maintain chest tube drainage system, which will drain air*
or blood or both that accumulates in the pleural space
monitor for the absence and presence of lung sounds*
assess chest tube insertion site for subcutaneous air and*
drainage
administer oxygen as prescribed*
monitor pulse oximetry*
provide activity as tolerated*
encourage ROM exercise of the operated shoulder as*
prescribed
maintain client position based on position performed*
 :Pneumonectomy

avoid complete lateral positioning because the *

mediastinum is no longer held in place on both
sides by lung tissue
extreme turning may cause mediastinum shift and*
compression of the remaining lung
:Segmental or wedge resection*
Elevate the head of the bed 30-45 degrees -
Avoid positioning client on the operative side-
 Laryngeal Cancer

a malignant tumor of the larynx-

laryngeal cancer presents as malignant-
ulcerations with underlying filtration
metastasis to the lung is common-
diagnosis is made through laryngoscopy-
and biopsy showing a positive cytology for
cancer cells
:Causes
cigarette smoking
alcohol abuse
exposure to environmental pollutants
exposure to radiation
voice strain
 :signs/symptoms

persistent hoarseness*
persistent sore throat*
painless neck mass*
a feeling of a lump in the throat*
burning sensation in the throat*
dysphagia*
changes in voice quality*
dyspnea*
hemoptysis*
weakness*
weight loss*
foul breath*
 :Implementation

place in high-Fowler's position to promote optimal gas .1

exchange
administer oxygen as prescribed .2
provide respiratory treatments as prescribed .3
monitor respiratory status .4
monitor for signs of aspiration of food or fluids .5
provide activity as tolerated .6
provide a high-calorie, high-vitamin, high-protein diet .7
provide nutritional support viaTPN, NGT or gastrostomy .8
as prescribed
administer analgesics as prescribed .9
 :Non-surgical Implementation

radiation therapy if the cancer is limited to a small area in *

one vocal cord
chemotherapy, which may be done in combination with *
radiation and surgery

:Surgical Implementation
small tumor excision or total laryngectomy: performed for*
infiltrate tumors that involve vocal cord paralysis and for
tumors that do not respond to radiation therapy
radical neck dissection
involves a laryngectomy and tracheostomy*
performed when lymph node involvement is present
 :Preoperative
establish methods of communication for the
client
encourage the client to express feelings
about changes in body image and loss of
voice
describe the rehabilitation program (speech
therapist) and information about
tracheostomy and suctioning
 :Postoperatively

monitor vital signs

assess respiratory status
position client in high Fowler's
monitor airway patency and provide frequent suctioning
maintain surgical drains in the neck area if present
observe for hemorrhage and edema of the neck
administer oxygen via tent
assess the color, amount and consistency of sputum
monitor pulse oximetry
Monitor IV fluids or TPN
Assess gag and cough reflex and the ability to swallow
Provide oral hygiene
Provide stoma and laryngectomy care
Reinforce method of communication established preoperatively
 :Client Education

teach clean suctioning technique*

instruct client how to provide stoma care*
protect neck from injury*
avoid swimming, showering, and using aerosol sprays*
demonstrate ways to prevent debris from entering the stoma *
(dress)
instruct client to wear a stoma shield*
advise client o wear loose-fitting, high-collar clothes to hide the*
stoma
instruct to do ROM of arms, shoulders and neck daily*
avoid exposure to people with infections*
alternate rest and activity*
increase fluid intake*
wear Medic Alert bracelet*
Histoplasmosis
a pulmonary fungal infection caused by -
spores of Histoplasma capsulatum
transmission occurs by the inhalation of -
spores which are commonly located in
contaminated soil
spores are also usually found in bird -
droppings
 :Signs/Symptoms

dyspnea
chills
chest pain
elevated temperature
pulmonary infiltrates on CXR film
elevated WBCs
positive agglutination test for histoplasmosis
positive skin test for Histoplasmin (read the same as PPD)
splenomegaly
hepatomegaly
 :Implementation

administer oxygen as prescribed

administer antiemetics,antihistamines, antipyretics, and
steroids as prescribed (amphotericin B –cause fever;
benadryl)
administer fungicidal medications as prescribed
encourage coughing and deep breathing
position client in semi-Fowler's
monitor vital signs
monitor breath sounds
monitor for nephrotoxicity from fungicidal medications
instruct client to spray water before sweeping barn and
chicken coops
Lung Abscess

a lung infection accompanied by pus accumulation

and tissue destruction
abscess may be putrid (due to anaerobic bacteria)
or non-putrid (due to aerobes); has well-defined
borders

:Causes
aspiration of oropharyngeal contents
poor oral hygiene (esp. with teeth or gum disease)
septic pulmonary emboli
 :signs/symptoms

cough
sputum with blood; foul-smelling
pleuritic chest pain
dyspnea
excessive sweating
chills
fever
headache
malaise
diaphoresis
weight loss
:Diagnosis

auscultation of chest – may reveal crackles and

decreased breath sounds
chest x-ray – shows a localized infiltrates
bronchoscopy – for aspiration and culture of
samples
WBCs- more than 10,000/uL
:Implementation
Administer antibiotics as prescribed .1
administer oxygen as prescribed .2
provide chest physiotherapy (coughing .3
and deep breathing)
instruct to increase fluid intake .4