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Disorders and management of patients with diseases of the Upper Respiratory System
A. ALLERGIC RHINITIS ( ) - sensitivity to allergens with whitish or clear nasal discharge;
inflammation and irritation of the mucus membranes of the nose
Non allergic: changes in temperature, odors, food
Allergic: exposure to an irritant or an allergen

B. VIRAL RHINITIS ( )- The term often is used when referring to an upper
respiratory tract infection that is self-limited and caused by a virus.
Nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise
Specifically, the term cold refers to an afebrile, infectious, acute inflammation of the mucous membranes of
the nasal cavity.
More broadly, the term refers to an acute upper respiratory tract infection, whereas terms such as rhinitis,
pharyngitis, and laryngitis distinguish the sites of the symptoms.

Clinical Manifestations:
nasal congestion
runnynose
sneezing
nasal discharge
nasal itchiness
tearing
watery eyes,
scratchy or sore throat
general malaise
low-grade fever

chills
headache and muscle aches.


As the illness progresses, cough usually appears. In some people, viral rhinitis exacerbates the herpes simplex,
commonly called ______________________________. The symptoms last from 1 to 2 weeks. If there is significant
fever or more severe systemic respiratory symptoms, it is no longer viral rhinitis but one of the other acute upper
respiratory tract infections.
PHARMA MANAGEMENT:
o Medication therapy for allergic and non-allergic rhinitis focuses on ____________________________.
________________________ are administered for sneezing, itching, and rhinorrhea.
________________________ are used for nasal obstruction.
________________________ may be used for severe congestion
________________________ are used to relieve irritation, itching, and redness of the eyes.

NURSING MANAGEMENT:
Reduce exposure to allergens and irritants, such as dusts, molds, animals, fumes, odors, powders, sprays, and tobacco
smoke.
The patient is instructed about the importance of controlling the environment at home and work.
Saline nasal or aerosol sprays may be helpful in soothing mucous membranes, softening crusted secretions, and removing
irritants.
The nurse instructs the patient in the proper use of and technique for administrating nasal medications.
To achieve maximal relief, the patient is instructed to blow the nose before applying any medication into the nasal
cavity.
In the case of infectious rhinitis, the nurse reviews with the patient hand hygiene technique as a measure to prevent
transmission of organisms.
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6 VIRUSES KNOWN TO CAUSE RHINITIS:
Rhinovirus
parainfluenza virus
coronavirus,
respiratory syncytial virus
(RSV)
influenza virus
adenovirus
C. SINUSITIS: inflammation of mucus membranes in the sinuses which may be followed by infection with a yellowish-
green discharge

Pathophysiology:





Focus of Management:
treatment with antibiotics, decongestants, antihistamines
surgery to drain and open sinuses
antral irrigation (sinus irrigation)
Caldwell-Luc procedure
Clinical Manifestations:
facial pain or pressure over the affected
sinus area
nasal obstruction
fatigue
purulent nasal discharge
fever
headache
ear pain and fullness
dental pain
cough
a decreased sense of smell
sore throat
eyelid edema
facial congestion or fullness
PHARMA MANAGEMENT:
o The goals of treatment of acute sinusitis are
____________________________________
____________________________________
____________________________________
First-line antibiotics
amoxicillin(Amoxil)
trimethoprim/sulfamethoxazole (Bactrim, Septra)
erythromycin.
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Second-line antibiotics
Cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), cefprozil (Cefzil) and amoxicillin
clavulanate (Augmentin).
Macrolides such as azithromycin (Zithromax), and clarithromycin (Biaxin).
Quinolones such as ciprofloxacin (Cipro), levofloxacin (Levaquin) (used with severe penicillin allergy), and
sparfloxacin (Zagam) have also been used.

o The course of treatment is usually 10 to 14 days.

OTHER MEDICATIONS:
Use of oral and topical decongestant agents may decrease mucosal swelling of nasal polyps,
__________________________________________________________
Heated mist and saline irrigation _______________________________________________
Decongestant agents such as pseudoephedrine (Sudafed, Dimetapp) _______________________________
Topical decongestant agents such as oxymetazoline (Afrin) may be used for up to 72 hours.
o It is important to administer them with the patients head tilted back to promote maximal dispersion of the medication.
Guaifenesin (Robitussin, Anti-Tuss), a mucolytic agent, may also be effective in reducing nasal congestion.
NURSING MANAGEMENT:
instruct the patient about methods to promote drainage
____________________________________________
____________________________________________
____________________________________________
Inform the patient about the side effects of nasal sprays and about rebound congestion.
In the case of rebound congestion, the bodys receptors, which have become dependent on the decongestant sprays
to keep the nasal passages open, close and congestion results after the spray is discontinued.

D. CHRONIC SINUSITIS- is an inflammation of the sinuses that persists for more than 3 weeks in an adult and 2
weeks in a child

Pathophysiology











Clinical Manifestations:
impaired mucociliary clearance and ventilation
cough (because the thick discharge constantly drips backward into the nasopharynx)
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chronic hoarseness
chronic headaches in the periorbital area
facial pain.
o These symptoms are generally most pronounced on awakening in the morning.
Fatigue and nasal stuffiness are also common.
some patients experience a decrease in smell and taste
fullness in the ears

PHARMA MANAGEMENT:
antimicrobial agents of choice include the following
amoxicillin clavulanate (Augmentin)
ampicillin (Ampicin)
Clarithromycin (Biaxin)
third-generation cephalosporins such as
cefuroxime axetil (Ceftin)
cefpodoxime (Vantin)
cefprozil (Cefzil)
Quiolones such as:
Levofloxacin (Levaquin)
o The course of treatment may be 3 to 4 weeks.
o Decongestant agents, antihistamines, saline sprays, and heated mist are also recommended

SURGICAL MANAGEMENT:
Endoscopic surgery may be indicated to correct structural deformities that obstruct the ostia (openings) of the sinus.
Excising and cauterizing nasal polyps
correcting a deviated septum
incising and draining the sinuses
aerating the sinuses
removing tumors
When sinusitis is caused by a fungal infection, surgery is required to excise the fungus ball and necrotic tissue and
drain the sinuses.
Oral and topical corticosteroids are usually prescribed.
Antimicrobial agents are administered before and after surgery
Some patients with severe chronic sinusitis obtain relief only by moving to a dry climate.

Nursing Management:
Because the patient usually performs care measures for sinusitis at home, nursing management consists mainly of patient
teaching.
TEACHING PATIENTS SELF-CARE:
teach the patient how to promote sinus drainage by increasing the environmental humidity (steam bath, hot shower,
and facial sauna)
increasing fluid intake
applying local heat (hot wet packs)
instructs the patient about the importance of following the medication regimen.


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ACUTE PHARYNGITIS
Acute pharyngitis is an inflammation or infection in the throat,
usually causing symptoms of a sore throat.
Pathophysiology
Most cases of acute pharyngitis are caused by viral infection. When
group A beta-hemolytic streptococcus, the most common bacterial
organism, causes acute pharyngitis, the condition is known as
strep throat (Bisno, 2001). The body responds by triggering an inflammatory
response in the pharynx. This results in pain, fever,
vasodilation, edema, and tissue damage, manifested by redness and
swelling in the tonsillar pillars, uvula, and soft palate. A creamy exudate
may be present in the tonsillar pillars (Fig. 22-3).
Uncomplicated viral infections usually subside promptly,
within 3 to 10 days after the onset. However, pharyngitis caused
by more virulent bacteria such as group A beta-hemolytic streptococci
is a more severe illness. If left untreated, the complications
can be severe and life-threatening. Complications include sinusitis,
otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis.
In rare cases the infection may lead to bacteremia, pneumonia,
meningitis, rheumatic fever, or nephritis.
Clinical Manifestations
The signs and symptoms of acute pharyngitis include a fiery-red
pharyngeal membrane and tonsils, lymphoid follicles that are
swollen and flecked with white-purple exudate, and enlarged and
tender cervical lymph nodes and no cough. Fever, malaise, and
sore throat also may be present.
PHARMACOLOGIC THERAPY
If a bacterial cause is suggested or demonstrated, penicillin is usually
the treatment of choice. For patients who are allergic to penicillin
or have organisms that are resistant to erythromycin (one
fifth of group A beta-hemolytic streptococci and most S. aureus
organisms are resistant to penicillin and erythromycin), cephalosporins
and macrolides (clarithromycin and azithromycin) may
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be used. Antibiotics are administered for at least 10 days to
eradicate the infection from the oropharynx.
Severe sore throats can also be relieved by analgesic medications,
as prescribed. For example, aspirin or acetaminophen
(Tylenol) can be taken at 3- to 6-hour intervals; if required, acetaminophen
with codeine can be taken three or four times daily.
Antitussive medication, in the form of codeine, dextromethorphan
(Robitussin DM), or hydrocodone bitartrate (Hycodan),
may be required to control the persistent and painful cough that
often accompanies acute pharyngitis.
NUTRITIONAL THERAPY
A liquid or soft diet is provided during the acute stage of the disease,
depending on the patients appetite and the degree of discomfort
that occurs with swallowing. Occasionally, the throat is
so sore that liquids cannot be taken in adequate amounts by
mouth. In severe situations, fluids are administered intravenously.
Otherwise, the patient is encouraged to drink as much fluid as possible
(at least 2 to 3 L per day).
Nursing Management
The nurse instructs the patient to stay in bed during the febrile
stage of illness and to rest frequently once up and about. Used tissues
should be disposed of properly to prevent the spread of infection.
It is important to examine the skin once or twice daily for
possible rash, because acute pharyngitis may precede some other
communicable diseases (ie, rubella).
Warm saline gargles or irrigations are used depending on the
severity of the lesion and the degree of pain. The benefits of this
treatment depend on the degree of heat that is applied. The nurse
teaches the patient about the recommended temperature of the
solution: high enough to be effective and as warm as the patient
can tolerate, usually 105F to 110F (40.6C to 43.3C). Irrigating
the throat properly is an effective means of reducing spasm
in the pharyngeal muscles and relieving soreness of the throat.
Unless the purpose of the procedure and its technique are understood
clearly by the patient and family, the results may be less
than satisfactory.
An ice collar also can relieve severe sore throats. Mouth care may
add greatly to the patients comfort and prevent the development
of fissures (cracking) of the lips and oral inflammation when bacterial
infection is present. The nurse instructs the patient to resume
activity gradually. A full course of antibiotic therapy is indicated in
patients with group A beta-hemolytic streptococcal infection in
view of the possible development of complications such as nephritis
and rheumatic fever, which may have their onset 2 or 3 weeks
after the pharyngitis has subsided. The nurse instructs the patient
and family about the importance of taking the full course of therapy
and informs them about the symptoms to watch for that may
indicate complications.
CHRONIC PHARYNGITIS
Chronic pharyngitis is a persistent inflammation of the pharynx.
It is common in adults who work or live in dusty surroundings,
use their voice to excess, suffer from chronic cough, and habitually
use alcohol and tobacco.
Three types of chronic pharyngitis are recognized:
Hypertrophic: characterized by general thickening and congestion
of the pharyngeal mucous membrane
Atrophic: probably a late stage of the first type (the membrane
is thin, whitish, glistening, and at times wrinkled)
Chronic granular (clergymans sore throat): characterized
by numerous swollen lymph follicles on the pharyngeal
wall
Clinical Manifestations
Patients with chronic pharyngitis complain of a constant sense of
irritation or fullness in the throat, mucus that collects in the throat
and can be expelled by coughing, and difficulty swallowing.
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Medical Management
Treatment of chronic pharyngitis is based on relieving symptoms,
avoiding exposure to irritants, and correcting any upper respiratory,
pulmonary, or cardiac condition that might be responsible
for a chronic cough.
Nasal congestion may be relieved by short-term use of nasal
sprays or medications containing ephedrine sulfate (Kondons
Nasal) or phenylephrine hydrochloride (Neo-Synephrine). If there
is a history of allergy, one of the antihistamine decongestant medications,
such as Drixoral or Dimetapp, is taken orally every 4 to
6 hours. Aspirin or acetaminophen is recommended for its anti-inflammatory
Nursing Management
TEACHING PATIENTS SELF-CARE
To prevent the infection from spreading, the nurse instructs the
patient to avoid contact with others until the fever subsides.
Alcohol, tobacco, second-hand smoke, and exposure to cold are
avoided, as are environmental or occupational pollutants if possible.
The patient may minimize exposure to pollutants by wearing
a disposable facemask. The nurse encourages the patient
to drink plenty of fluids. Gargling with warm saline solutions
may relieve throat discomfort. Lozenges will keep the throat
moistened.
and analgesic properties
E. Upper airway obstruction (choking)
1. Findings
a. stridor (harsh, vibrating breath)
b. no sound of air
c. both hands of client around the throat
d. management: emergency treatment
i. Heimlich maneuver
ii. cricothyrotomy (cut cricoid cartilage)
iii. tracheotomy/tracheostomy
D. Pharyngitis
1. Inflammation of mucous membranes of pharynx
2. Bacterial, viral, environmental causes
3. Treat findings; if culture shows bacteria, use antibiotics
E. Tonsillitis
1. Inflammation and/or infection of tonsils
2. Acute form is usually bacterial
3. Treat findings; if culture shows bacteria, use antibiotics
F. Peritonsillar abscess
1. Complication of acute tonsillitis
2. Infection spreads to surrounding tissue
3. If swelling is massive, can endanger airway
4. Treat findings; if culture shows bacteria, use antibiotics
G. Vocal cord disorders
1. Laryngitis
a. inflammation of vocal cords and surrounding mucous membranes
b. cause: something irritates the larynx
c. occurs in viral and bacterial infections
d. in children, called croup (larynx blocked by edema, spasm or both)
e. treat findings, rest voice, remove irritants, gargle with warm salt water
2. Vocal cord paralysis
a. injury, trauma or disease of larynx, laryngeal nerves or vagus nerve
b. may result as a complication after thyroidectomy surgery
c. assess how well client can protect airway
d. can sometimes be surgically treated with Teflon injection
H. Cancer of the larynx
1. Etiology
a. most tumors of the larynx are squamous cell carcinoma
b. more common among men, age 50 to 65
c. cigarette smoking and alcohol consumption are related
2. Findings
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a. persistent sore throat
b. dyspnea
c. dysphagia
d. increasing persistent hoarseness
e. weight loss
f. enlarged cervical lymph nodes
3. Management
a. radiation therapy
b. chemotherapy
c. surgery: removal of all or part of larynx to treat cancer
i. total laryngectomy: no voice, permanent stoma in neck with no risk of aspiration from oral
cavity
ii. radical neck dissection: when cancer has metastasized to surrounding tissues
4. Nursing interventions
a. arrange for clients with larnygectomies to meet with members of support groups
b. establish a method for communication before surgery
c. maintain airway; have suction equipment at bedside
d. observe for signs of hemorrhage or infection
e. teach about trach and stoma care
f. assist with period of grieving
VI. Disorders of Lower Respiratory System (LRS): Obstructive
A. General facts: process in chronic obstructive pulmonary diseases
1. Block airflow out of lungs
2. Trap air, with impairment of gas exchange
3. Increase the work of breathing
B. Emphysema
1. Destroys alveoli
2. Narrows and collapses small airways
3. Overall lung loses elasticity
4. Traps air
5. As alveolar walls die, there is less surface for vital gas exchange
C. Chronic bronchitis
1. Definition
a. inflammatory response in the lung
b. affects few alveoli, mostly airways
2. Findings
a. lungs chronically produce fluids
b. inflammation and mucus narrow the airways
D. Asthma
1. Definition/etiology
a. reversible obstruction of airways
b. inflammation of airways
c. airways hypersensitive to variety of stimuli
d. bronchospasm is a minor component
e. disease waxes and wanes, remissions and exacerbations
2. Findings
a. orthopnea, expiratory wheezing
b. barrel chest, cyanosis, clubbing of fingers
c. distention of neck veins
d. edema of extremities
e. increased PCO
2
and decreased PO
2

f. polycythemia
3. Diagnostics
a. physical examination with history of findings
b. arterial blood gases
c. chest x-ray
4. Complications
a. hypoxemia
b. hypercapnia
c. variety of respiratory infections
d. cor pulmonale
e. dysrhythmias
E. Management for obstructive disease
1. Antibiotics and corticosteroids for infection or chronic inflammation
2. Bronchodilators
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3. Mucolytics
4. Expectorants
5. Respiratory program: postural drainage, exercise, nebulizer, high protein diet
F. Nursing interventions common to obstructive diseases
1. Assess client's risk of respiratory failure
2. Assess for degree of respiratory effort for an increased work of breathing or dyspnea
3. Assess oxygenation with pulse oximeter if hemoglobin level is within normal limits
4. Measure arterial blood gases (ABG) to evaluate gas exchange
5. Administer oxygen as indicated
6. If risk of respiratory failure, anticipate ventilation
7. Assist with secretion removal as indicated
8. Pace client activities to reduce oxygen demand
9. Teach diaphragmatic breathing and pursed-lip breathing
10. Position in a high Fowler's to ease breathing effort
11. Provide for nutritional consults as indicated
12. Reinforce the plan for small, frequent high carbohydrate meals
13. Provide referrals for:
a. depression associated with disease
b. pulmonary rehabilitation
c. stop smoking support groups
14. For asthma, teach clients that aspirin or peanuts may stuimulate an asthma attack
VII. LRS Disorders: Restrictive
A. In general: these disorders prevent full lung expansion via three mechanisms
1. Lung stiffening
2. External compression
3. Muscle weakness
B. Pulmonary fibrosis- lung stiffening
1. Occupational lung diseases
a. coal worker's pneumoconiosis - risk increases with length of exposure to coal dust (>15 years),
intensity of exposure, and silica content of dust
b. silicosis: workers who will have inhaled silica dust
2. Asbestosis
a. inhalation of asbestos fibers
b. disease may develop 15 to 20 years after exposure
C. Pulmonary sarcoidosis - lung stiffening
1. Etiology
a. unknown origin
b. characterized by formation of tubercles, most often in the lungs
c. may progress to fibrosis
2. Findings
a. dyspnea
b. anxiety
3. Diagnostics
a. chest x-ray
b. biopsy of affected tissue
4. Management
a. antitussives
b. oxygen therapy
c. removal of toxic substances
D. Nursing interventions common to all types of pulmonary fibrosis
1. Prevent infection or exposure to infection
2. Pace clients' activities to reduce oxygen demands and dyspnea
3. Reinforce the need for small, frequent meals
4. Encourage daily activities within pulmonary tolerance
a. provide referrals for:
i. depression associated with disease
ii. stop smoking support groups
iii. occupational rehabilitation
E. Disorders of fluid in pleurae
1. Pleural fluid disorders - all treated with water seal chest drainage systems
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2. Pneumothorax: air between the pleurae
a. open pneumothorax: hole in the chest wall, communicates with the lung
b. closed pneumothorax: hole in lung, chest wall intact
c. tension pneumothorax - a nursing and medical emergency
i. closed pneumothorax
ii. air is forced into the pleural space with a continued pressure build up
iii. shifts mediastinum away from affected side with results of a compressed heart
iv. treated with chest tube insertion
v. cardiac and respiratory arrest if not treated
d. examples of the above
3. Pleural effusion
a. fluid (transudate or exudate) in the pleural space
b. if small, no treatment
c. if larger, treated with chest tube insertion
4. Hemothorax
a. blood in the pleural space
b. treated with thoracentesis or chest tube
5. Empyema
a. purulent drainage in the pleural space
b. often from a chronic condition such as lung cancer
c. treated with chest tube inserton
6. Chylothorax
a. lymphatic fluid in pleural space
b. treated with thoracentesis or chest tube
F. Musculoskeletal diseases associated with difficulty breathing
1. Guillain-Barre syndrome - follows a viral infection
a. ascending paralysis that may affect muscles of respiration as paralysis ascends
b. muscles so weak that client cannot breathe deeply, a nursing and medical emergency
c. may progress to respiratory failure
i. may require intubation
ii. mechanical ventilation
iii. course of illness varies from a few months to years
2. Myasthenia gravis
a. sporadic, progressive weakness of skeletal muscle
b. cause: lack of acetylcholine with results of a myoneural junction malfunction
c. may not be able to chew and swallow well
i. may aspirate
ii. may lose protective airway reflexes
d. repeated muscle movements, especially towards days end, can exacerbate acute respiratory failure
3. Poliomyelitis
a. viral infection
b. if disease strikes the respiratory muscles the result may be respiratory failure
c. may not swallow well
i. may aspirate
ii. may lose protective airway reflexes
4. Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease)
a. affects motor neurons; autonomic, sensory and mental function unchanged
b. manifests as a chronic, progressive irreversible disorder
c. begins usually in distal ends of upper extremities
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d. often leads to respiratory failure within two to five years
e. results in ethical issue
i. whether clients want mechanical ventilation
ii. whether nutritional support is desired
iii. if they would rather die when disease becomes this severe
f. results in clients' inability to communicate or physically move from voluntarily and/or clients lack
involuntary reflexes, such as blinking or gag reflex
5. Muscular dystrophies
a. progressive symmetrical wasting of voluntary muscles with no nerve effect
b. as thoracic muscles weaken, breathing becomes more difficult
c. may not swallow well; risk for aspiration with loss of protective airway reflexes
6. Interventions common to musculoskeletal disorders
a. monitor carefully for changes in condition
b. assess regular swallowing and ability to protect the upper airway
c. discuss chances of mechanical ventilation or nutritional support: does client wish it?
d. assist with coughing and secretion clearance as indicated
e. prevent infection
f. assess for with appropriate referrals for depression that is often associated with these diseases
g. administer medications specific to the disease condition
h. assist/provide occupational or/and physical rehibilitation as indicated
i. maintain adequate nutrition
j. with terminal disorders, provide for referrals for family
VIII. LRS Disorders: Infectious
A. Pneumonia
1. Definition/etiology
a. acute infection of lung parenchyma
b. cause: bacterium, virus, protozoan, mycobacterium, mycoplasma, or rickettsia
c. pneumonia is the leading cause of death from infectious causes
d. may affect only a region of lung: lobar pneumonia, bronchopneumonia
e. may be the result of:
i. primary infection
ii. secondary to other lung damage
iii. aspiration
2. Risk factors for pneumonia
a. pre-existing pulmonary disease
b. abdominal and thoracic surgery
c. mechanical ventilation
d. advanced age
e. decreased ability to protect airway or cough effectively
f. artificial airway
g. chronic illness and debilitation
h. depressed immune function
i. cancer
3. Diagnostics
a. chest radiograph
b. sputum culture, sensitivity and microscopic analysis, Gram stain, cytology
c. ABG as indicated by clinical condition
4. Management
a. antimicrobials, depending on pathogen
b. antipyretic
c. expectorants
d. antitussives
e. supplemental oxygen, as indicated
f. IV fluids to treat dehydration
5. Nursing interventions
a. monitor finger oximeter if hemoglobin levels within normal limits
b. promote hydration to liquify secretions
c. teach effective coughing techniques to minimize energy expenditure
d. suction if necessary
e. teach the need to continue entire course of antimicrobial therapy which is usually seven to ten
days
f. teach that findings are expected to be less within 48 to 72 hours of initial therapy
B. Pulmonary tuberculosis (PTB)
1. Etiology
a. mycobacterium tuberculosis
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b. bacilli lodge in alveoli
c. pulmonary infiltrates
d. can spread throughout body via blood
e. multi-drug resistant PTB is becoming more prevalent
f. PTB incidence is rising with increasing homelessness and AIDS
2. Findings
a. weakness with fatigue
b. anorexia with weight loss
c. night sweats
d. chest pain
e. productive cough
3. Diagnostics
a. sputum and gastric contents, analysis for the presence of acid-fast bacilli
b. chest x-ray for presence of active or calcified lesions, "coin" lesions
c. tuberculin testing
i. tine, mantoux tests
checked 48 to 72 hours for induration
positive if >10 mm induration in healthy persons
d. establishes if there is an antibody response to the tubercle bacillus
e. if positive, indicates prior exposure to bacillus, not an active disease
4. Management
a. long-term, six to 24 months, antimicrobial therapy with isoniazid (INH) (Hyzyd) or
rifampin (Rifadin), with ethambutol HCL (Etibi) in some cases
b. bed rest or chair rest until findings abate
c. surgical resection of involved lung if medication is not effective
d. high carbohydrate, high protein diet with frequent small meals
5. Nursing interventions
a. with active infection, client must be isolated with airborne precautions when in the
hospital
b. teach client
i. proper techniques to prevent spread of infection: hand washing, etc.
ii. to report bloody sputum
iii. not to use over the counter (OTC) medications without health care provider's
approval
iv. importance of taking medications as prescribed
adherence to treatment regimen
return at scheduled times for lab testing of liver enzymes
an increase in B
6
to minimize peripheral neuropathies, a common side
effect of drug therapy
C. Lung abscess
1. Localized area of lung infection
2. Usually follows pneumonia, TB or aspiration
3. Treatment consists of draining and culturing abscess and antimicrobial therapy
IX. LRS Disorders: Miscellaneous

A. Pulmonary embolism
1. Definition/etiology
a. clot blocks blood from the "bed" of arteries that feed the lung
b. client is breathing but gases are not exchanged - ventilation without perfusion
c. hypoxemia results
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d. can be mild or immediately fatal, based on the size and location of clot(s)
e. usually clot has traveled from deep veins in the leg or pelvis
2. Diagnostics
a. ventilation/perfusion (V/P) scan, also called V/Q scan
b. ABG
c. EKG
3. Management
a. oxygen via mask
b. anticoagulation - heparin in acute and coumadin for chronic risk
c. thrombolytics
d. filter surgically placed in vena cava for long term care
B. Acute respiratory distress syndrome (ARDS)
1. Definition/etiology
a. alveolar capillary membrane becomes more permeable to fluids
b. increased extravascular lung fluid
c. pulmonary compliance decreases
d. intrapulmonary shunt increases
e. refractory hypoxemia
f. usually seen after lung injury or massive multi-system organ disease
2. Findings
a. restlessness, anxiety
b. dyspnea
c. tachycardia
d. cyanosis
e. intercostal retractions
3. Diagnostics
a. clinical presentation and history of findings
b. hypoxemia on ABG despite increasing inspired oxygen level
c. chest x-ray shows diffuse infiltrates
4. Management
a. optimize oxygenation
i. mechanical ventilation
ii. sedation may be required
iii. paralytic agents may be necessary
b. antibiotics, as indicated
c. corticosteroids
5. Nursing interventions
a. plan for frequent rest periods
b. monitor trends in oxygenation status, ABGs, respiratory effort
c. observe for behavioral changes and vital signs; confusion and hypertension may indicate cerebral
hypoxia
C. Lung cancer
1. Definition/etiology
a. types of lung cancer
i. squamous cell carcinoma
ii. small-cell (oat cell) carcinoma
iii. adenocarcinoma
iv. large cell carcinoma
b. prognosis is generally poor
c. largely preventable if smokers stop and nonsmokers avoid second hand smoke
2. Findings
a. hoarse voice
b. changes in breathing
c. persistent cough or change in cough
d. blood-streaked or bloody sputum
e. chest pain or tightness in chest wall
f. recurring pneumonia, pleural effusion
g. weight loss
3. Diagnostics
a. medical imaging examinations
b. cytological sputum analysis
c. bronchoscopy
d. biopsy
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4. Management
a. nonsurgical
i. chemotherapy
ii. radiation therapy
iii. laser therapy to de-bulk tumor
iv. thoracentesis and pleurodesis
b. surgical
i. thoracotomy
wedge resection - part of a lobe
segmental resection- part of a lobe
lobectomy - one or more lobes
pneumonectomy - entire right or left lung
5. Nursing interventions
a. post-operative care
i. chest drainage
ii. routine post operative care
monitor respiratory status frequently
teach effective deep breathing and cough techniques
refer to physical therapy for exercises for shoulder on affected side
relieve pain
iii. optimize oxygenation
iv. provide opportunities for the client to talk about cancer; as needed, refer to support
groups
v. teach information as based on treatment plan and prognosis
vi. optimize nutritional status
D. Cor pulmonale
1. Definition/etiology
a. right ventricular hypertrophy and subsequent chronic heart failure
b. cause: heart must pump against great resistance from lung's blood vessels: called increased
pulmonary vascular resistance (PVR)
c. increased PVR results from chronic lung disease
d. may be due to primary pulmonary hypertension as well
2. Diagnostics
a. pulmonary artery pressure readings via a catheter
b. echocardiogram
c. chest radiograph
d. ABG
e. EKG
3. Management
a. administer oxygen as ordered
b. if hemoglobin within normal limits (WNL), monitor oxygenation with finger or pulse oximeter
c. bed rest, as needed
d. monitor effects of medications
i. cardiac glycosides
ii. pulmonary artery vasodilator
iii. diuretics
iv. restricted fluid intake as indicated
e. nursing interventions
i. monitor for changes in oxygenation status
ii. pace activities in clients who tire easily
E. Respiratory failure
1. Definition: lungs cannot maintain arterial oxygen levels or eliminate carbon dioxide
a. PaCO
2
> 50 mm Hg
b. PaO
2
< 50 mm Hg
c. clients with chronic lung disease precautions
i. look for drop from baseline function
ii. this is a nursing and medical emergency
iii. clients are always hypoxemic
2. Etiology
a. lung diseases that harden the alveolar-capillary membrane to trap O
2

b. neuro-muscular or musculoskeletal disorders
i. respiratory drive dulled or blunted
ii. muscles too weak to breathe
3. Diagnostics: ABG
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4. Management
a. oxygen per mask
b. mechanical ventilation
c. monitor for improvement in the underlying cause for the respiratory failure