CARE OF CLIENTS WITH

PROBLEMS IN
OXYGENATION
(Part 1)

CHEST X-RAY
Remove all jewelry and other metal objects

from the chest area

Assess the client's ability to inhale and hold

his or her breath

Question women regarding pregnancy
Help

the
procedure

client

get

dressed

after

the

SPUTUM SPECIMEN
Specimen

obtained by expectoration or
tracheal
suctioning
to
assist
in
the
identification of organisms or abnormal cells

Obtain an early morning sterile specimen

from suctioning or expectoration

Instruct the client to rinse the mouth with

water before collection

Obtain at least 15 mL of sputum

Instruct client to take several deep breaths and

then cough deeply to obtain sputum

Always collect the specimen before the client

begins antibiotic therapy

If a culture of sputum is prescribed, transport the

specimen to the laboratory immediately

Assist the client with mouth care

PULMONARY
ANGIOGRAPHY
An invasive fluoroscopic procedure in which a

catheter is inserted through the antecubital or

femoral vein into the pulmonary artery or one
of its branches
Involves an injection of iodine or radiopaque

contrast material
Obtain informed consent

Assess for allergies to iodine, seafood, or

other radiopaque dyes

Maintain NPO status of the client for 8 hours

before the procedure

Monitor vital signs
Assess results of coagulation studies
Instruct the client to lie still during the

procedure

Instruct the client that he or she may feel an urge

to cough, flushing, nausea, or a salty taste

following injection of the dye
Have emergency resuscitation equipment available
Avoid taking BP for 24 hours in the extremity used

for the injection

Assess insertion site for bleeding
Monitor for delayed reaction to the dye

BRONCHOSCOPY
Direct

visual examination of the larynx,

trachea, and bronchi with a fiberoptic
bronchoscope

Obtain informed consent

Maintain

NPO status for the client form

midnight before the procedure

Obtain vital signs

Remove dentures or eyeglasses

Prepare suction equipment
Establish an IV access as necessary and

administer
prescribed

medication

Have

emergency
available

for

sedation

resuscitation

as

equipment

Maintain the client in semi-Fowlers position

after the procedure

Assess for the return of gag reflex

Have an emesis basin readily available for the

client to expectorate sputum

Monitor for bloody sputum
Notify the physician if fever, difficulty in

breathing, or other signs of complications

occur following the procedure

THORACENTESIS
Removal of fluid or air from the pleural space

via a transthoracic aspiration

Obtain informed consent
Obtain vital signs
Prepare the client for ultrasound or chest

radiograph,
procedure

if

prescribed,

before

the

Note that the client is positioned sitting upright,

with the arms and shoulders supported by a table

at the bedside during the procedure
If the client cannot sit up, the client is placed

lying in bed toward the unaffected side, with the

head of the bed elevated
Instruct the client not to cough, breath deeply, or

move during the procedure

Apply

a pressure dressing,
puncture site for bleeding

and

assess

the

PULMONARY FUNCTION
TESTS
Tests used to evaluate lung mechanics, gas

exchange, and acid-base disturbance through

spirometric measurements, lung
volumes,
and arterial blood gas levels
Consult with the physician regarding holding

bronchodilators before testing

Instruct

the client to void before

procedure and to wear loose clothing

the

Remove dentures
Instruct the client to refrain from smoking or

eating a heavy meal for 4 to 6 hours before

the test
After

the procedure, client may resume

normal diet and any bronchodilators and
respiratory treatments that were held before
the procedure

VENTILATION-PERFUSION LUNG
SCAN
The perfusion scan evaluates blood flow to

the lungs
The ventilation scan determines the patency

of the pulmonary airways

abnormalities in ventilation
A

radionuclide
procedure

may

be

and

injected

detects

for

the

Obtain informed consent

Assess the client for allergies to dye, iodine or

seafood
Remove jewelry around the chest area
Review breathing methods that may be required

during testing
Monitor client for reaction to the radionuclide
Instruct client that the radionuclide clears from the

body in about 8 hours

ARTERIAL BLOOD GASES

Measurement of the dissolved oxygen and carbon

dioxide in the arterial blood that helps indicate

the acid-base state and how well oxygen is being
carried to the body
Perform Allen's test before drawing radial artery

specimens
Have

the client rest for 30 minutes before

specimen
collection
to
ensure
accurate
measurement of body oxygenation

Avoid suctioning before drawing the ABG

sample
Do not turn off oxygen unless the ABG sample

is ordered to be drawn with the client

breathing room air
Place specimen on ice
Note the client temperature on the lab form
Note the oxygen and type of ventilation the

client is receiving on the lab form

Apply pressure to the puncture site for 5 to 10

minutes or longer if the client is taking

anticoagulant therapy or has a bleeding
disorder
Transport the specimen to the laboratory

within 15 minutes

BUT HOW IS
ALLENS TEST
PERFORMED?

Apply direct pressure over the clients ulnar and

radial arteries simultaneously

While applying pressure, ask the client to open and

close the hand repeatedly; the hand should blanch

release pressure from the ulnar artery while

compressing the radial artery and assess the color

of the extremity distal to the pressure point
If pinkness fails to return within 6 seconds, the ulnar

artery is insufficient, indicating that the radial artery

should not be used for obtaining a blood specimen

WHAT ARE THE

NORMAL VALUES
FOR ABG?

pH 7.35 7.45
PCO2 35 45 mmHg
HCO3 22 27 mEq/L

PULSE OXIMETRY
Is a noninvasive test that registers the oxygen

saturation of the clients hemoglobin

The capillary oxygen saturation is recorded as

a percentage
The normal value is 96% to 100%
A pulse oximeter reading can alert the nurse to

hypoxemia before clinical signs occur

A sensor is placed on the clients finger, toe, nose,

ear lobe or forehead to measure oxygen

saturation, which then is displayed on a monitor
Do not select an extremity with an impediment to

blood flow
Results lower than 91% necessitate immediate

treatment
If the oxygen saturation is lower than 85%,

oxygenation to body tissues is compromised; if

less than 70% it is life threatening

LUNG BIOPSY
A percutaneous lung biopsy is performed to

obtain tissue for analysis

cytological examination

by

culture

or

A needle biopsy is done to identify pulmonary

lesions, changes in lung tissue, and the cause

of pleural effusion

Obtain informed consent

Maintain NPO status of the client before the

procedure
Inform client that a local anesthetic will be

used but a sensation of pressure during

needle insertion and aspiration may be felt
Apply a dressing to the biopsy site and

monitor for drainage or bleeding

Monitor for signs of respiratory distress, and

notify the physician if they occur

Prepare

client
prescribed

for

chest

radiography

if

EPISTAXIS

Is more commonly known as nosebleed

Bleeding can either be in the anterior or

posterior region
Anterior

bleeds are more common and

originates from the group of vessels called
Kiesselbach Plexus

Etiology
Most common cause of epistaxis is dry,

cracked mucous membranes

Other causes include trauma, forceful nose

blowing, nose picking, and hypertension

Anything that reduces the blood clotting

ability can also trigger epistaxis (hemophilia,

anticoagulants, cocaine use)

Interventions
Let client sit in a chair and lean forward
Be

sure to
precautions

wear

gloves

and

standard

Place pressure on the nares for 5 to 10

minutes to stop bleeding (not done for clients

with nose fracture)
Apply ice packs or cold compress on the nose

area

Nasal pack with neosenephrine for 3 to 5 days

Liquid diet progressing to soft diet
Avoid oral temperature taking
Instruct client not to blow and pick nose for 2

days after removal of the nasal pack

Instruct client not to bend over
Notify physician if bleeding is recurrent

NASAL POLYPS

Are grapelike clusters of mucosa in the nasal

passages
Usually benign, but can obstruct the nasal

passages
Exact cause is unknown but are related to

chronic inflammation
Some people with allergies are prone to

develop polyps

Interventions
Control

allergy
symptoms
with
oral
antihistamines or nasal corticosteroid sprays

Removal

of polyps when it is

obstructs

breathing
Instruct client to avoid using aspirin after

surgery

DEVIATED SEPTUM

The septum dividing the nasal passages is

slightly deviated
May result form nasal trauma but often has no

cause
Clients may complain of chronically stuffy

nose
Other

client
nosebleeds

may

have

headaches

and

Interventions
Submucous

resection
(SMR)
nasoseptoplasty can be done

or

Nasal packing is placed postoperatively to

reduce bleeding

SINUSITIS

Inflammation of the mucosa of one or more

sinuses
Can either be acute or chronic
Chronic is present for more than 2 months

and are unresponsive to treatment

Maxillary and ethmoid sinuses are the most

commonly affected

Inflammation is often the result of a bacterial

infection
Because the mucous lining of the nose and sinuses

is continuous, nasal organisms easily travel to the

sinuses
Drainage is blocked when sinuses swell due to

infection
S. pneuomoniae and H. influenzae
Other causes are allergies, fungal infection and NGT

Signs and Symptoms

Pain over the affected sinuses
Purulent nasal drainage
Fever in acute infection
Fatigue
Foul breath

Maxillary sinus pain over the cheek and

upper teeth
Ethmoid sinus pain between and behind

the eyes
Frnotal sinus pain in the forehead

Diagnostic Tests
Uncomplicated sinusitis may be diagnosed

based on symptoms alone

X-ray, CT scan, or MRI may be done to confirm

the diagnosis and determine the cause

Culture and sensitivity of the nasal discharge

Interventions
Aimed

at relieving pain and promoting sinus

drainage

Place client in semi-Fowlers position

Hot moist packs for 1 to 2 hours twice a day
Acetaminophen or ibuprofen may be prescribed by

the physician for pain and fever

Encourage client to increase oral fluid intake unless

contraindicated

Antihistamines are generally avoided because

it dries and thickens secretions

Adrenergic

nasal
sprays
oxymetazoline for up to 3 days

Caldwell-Luc

conservative
symptoms

such

as

procedure to drain sinus if

treatments
cannot
relieve

RHINITIS

Also called as CORYZA

Inflammation

of

the

nasal

mucous

membranes
Occurs as a reaction to allergens or may be

caused by viral or bacterial infection

Signs and Symptoms

Nasal congestion
Localized itching
Sneezing
Nasal discharge
Fever and malaise may accompany viral or

bacterial rhinitis

Interventions
Rest

and
treatment

fluids

are

the

most

effective

Never give antibiotics for a viral infection

Acetaminophen

may
generalized discomfort

be

prescribed

for

Antihistamines may also be prescribed to

control symptoms

PHARYNGITIS

Inflammation of the pharynx

Usually related to bacterial or viral infection

as well as trauma
Beta-hemolytic streptococci
If strep throat is untreated it can lead to

rheumatic fever or glomerulonephritis

Signs and symptoms

Most common is sore throat
Dysphagia
Throat appears red and swollen, and exudate

may be present
Fever, chills, headache, and general malaise

Diagnostic test
Culture and sensitivity to identify the

causative organism and

antibiotic will be effective

determine

which

Interventions
Encourage rest
Increase fluid intake if not contraindicated
Saltwater gargles help reduce swelling
If bacterial, antibiotics may be prescribed
Acetaminophen may be prescribed to relieve

discomforts

LARYNGITIS

Inflammation of the mucous membrane lining

the larynx (voice box)

Caused by irritation from smoking, alcohol,

chemical exposure or infection

Often follows an upper respiratory infection

Signs and symptoms

Common symptom is hoarseness
Cough
Dysphagia
Fever

Diagnostic test
Laryngoscopy may be done if hoarseness

persists for more than 2 weeks to rule out

cancer of the larynx

Interventions
Provide rest
Encourage fluids unless contraindicated
Provide humidified oxygen
Encourage client to avoid talking
Obtain

paper
communicate

and

pen

to

help

client

Antibiotics may be prescribed for bacterial

infection
Throat lozenges may help increase comfort
Help client to identify causative factors that

need to be avoided

TONSILLITIS/ADEN
OIDITIS

Tonsils are masses of lymphoid tissue that lie

on each side of the oropharynx

Tonsils filter microorganisms to protect the

lungs from infection

Tonsillitis

occurs when the filtering function

becomes overwhelmed with virus or bacteria
and infection results

Adenoids is a mass of lymphoid tissue at the

back of the nasopharynx

Tonsillitis is more common in children
Streptococcus

species,
S.
aureus,
influenzae, and pneumococcus species

H.

Signs and symptoms

Begins suddenly with a sore throat
May be accompanied by fever, chills, and pain

on swallowing
Headache, malaise and myalgia
Tonsils appear red and swollen and may have

yellow or white exudates

If adenoids are involved client may have

complaints of snoring, nasal obstruction, and

a nasal tone to the voice

Diagnostic tests
Throat culture and sensitivity
WBC count
Chest x-ray

Interventions
Promote rest
Increase fluid intake if not contraindicated
Warm saline gargle
Analgesics as ordered
Antibiotics as ordered (penicillin)
Surgery: TONSILLECTOMY/ADENOIDECTOMY

TONSILLECTOMY/
ADENOIDECTOMY
Indicated if tonsillitis recurs 5 to 6 times a year or

unresponsive to antibiotic therapy

If breathing or swallowing is affected
If it causes obstruction and obstructive sleep apnea
If client will have repeated attacks of purulent otitis

media

Preoperative care
Assess for URTI. Coughing and sneezing may

cause bleeding in the postoperative period

Check prothrombin time

Postoperative care
Position client prone with head turned to side

or lateral position
Semi-Fowlers if client is already awake
Provide oral airway until swallowing reflex

returns
Monitor

for
hemorrhage
swallowing/bright red vomitus)

(frequent

Apply ice collar

Avoid administration of ASA
Offer ice cold fluids if client is able to eat
Bland diet
Instruct client to avoid clearing of throat

Inform client to avoid coughing, sneezing,

blowing nose for 1 to 2 weeks

Encourage client to take 2 to 3 liters of fluid a

day until mouth odor disappears

Educate client to avoid hard/scratchy foods

until throat is healed

Inform client that throat discomfort between

the 4th and 8th postoperative day is expected

Inform

client that his/her

black/dark for few days

stools

will

be

Encourage client to take rest for 2 weeks

Instruct client to avoid colds and overcrowded

places

INFLUENZA

Commonly refereed to as the flu

A viral infection of the respiratory tract
New strains appear each year
Easily transmitted via droplets from coughs and

sneezes of infected individuals

May also be transmitted by physical contact with an

infected person or object

Incubation period is 1 to 3 days

Signs and symptoms

Abrupt onset of fever
Chills
Myalgia
Sore throat and cough
General malaise with headache

Diagnostic test
Viral culture

Interventions
Treatment is primarily symptomatic
Encourage rest and fluids
Acetaminophen may be prescribed for fever,

headache, and myalgia

Oseltamivir (Tamiflu) may be prescribed to

reduce severity and duration of symptoms

PLEURISY

Visceral

and parietal pleurae

inflamed and does not slide easily

Usually

related to
respiratory disorder

The

another

becomes

underlying

irritation causes an increase in the

formation of pleural fluid, which in turn
reduces friction and decreases pain

Signs and symptoms

Sharp pain in the chest on inspiration
Pain during coughing or sneezing
Shallow and rapid breathing
Fever, chills and elevated WBC
Pleural friction rub upon auscultation

Diagnostic tests
Auscultation
Chest x-ray examination

PLEURAL
EFFUSION

Excess fluid collects in the pleural space

With

increase in fluid
inadequate reabsorption

production

and

Normal amount of pleural fluid for each lung

is 1 to 15mL
Effusion can be transudative or exudative
Generally caused by another lung disorder

Signs and symptoms

May or may not experience pleuritic pain
Shortness of breath
Cough and tachypnea
Dull sound upon percussion of the affected area
Lung sounds can be decreased or absent over

the effusion

Diagnostic tests
Chest x-ray
Thoracentesis

Interventions
Encourage bedrest
Therapeutic thoracentesis
Treatment of underlying cause

ATELECTASIS

Collapse of the alveoli

Commonly occurs in postsurgical clients who

do not cough and deep breathe effectively

Areas of the lungs that are not well aerated

become plugged with mucus, which prevents

inflation of alveoli

Instruct client to perform coughing and deep

breathing exercises
Encourage frequent position changes and

ambulation

PULMONARY
EMBOLISM

Occurs when a thrombus forms (deep vein)

detaches, travels to the right side of the

heart, and then lodges in a branch of the
pulmonary artery
At risk are those with deep vein thrombosis

including those with prolonged immobilization,

surgery, obesity, pregnancy, congestive heart
failure, advanced age, or a history of
thromboembolism
Fate emboli can occur as a complication

following fracture of a long bone

Signs and symptoms

Blood-tinged sputum
Chest pain
Cough
Cyanosis
Distended neck veins

Dyspnea

accompanied by anginal
pleuritic pain, exacerbated by inspiration

Hypotension
Shallow respirations
Tachypnea and tachycardia
Wheezes on auscultation

and

Diagnostic tests
CT scan can diagnose PE quickly
Ventilation-perfusion scan
Pulmonary angiogram
Chest x-ray, ECG, ABG analysis, MRI
D-dimer a blood test to help rule out PE

Interventions
Administer oxygen as prescribed
Place client in high fowlers position
Monitor lung sounds
Maintain bed rest and active and passive ROM

exercises
Encourage use of incentive spirometry

Monitor pulse oximetry

Prepare

for intubation and

ventilation for severe hypoxemia

Administer

mechanical

anticoagulation
intravenously or orally as prescribed

therapy

Monitor coagulation studies closely

Prepare the client for embolectomy or vein

ligation

CYSTIC FIBROSIS

Is

a
chronic
multisystem
disorder
characterized by exocrine gland dysfunction

Autosomal recessive trait disorder

The mucus produced by the exocrine glands is

abnormally thick, tenacious, and copious,

causing obstruction of the small passageways
of the affected organs, particularly in the
respiratory, GI, and reproductive systems

The most common symptoms are pancreatic

enzyme deficiency caused by duct blockage,

progressive chronic lung disease associated
with infection, and sweat gland dysfunction
resulting in increased sodium and chloride
sweat concentrations
Is a fatal genetic disorder and respiratory

failure is the most common cause of death

Signs and symptoms

Thick tenacious or purulent sputum
Cough
Chronic sinusitis
Finger clubbing
Hemoptysis

Frequent bouts of infection

Foul-smelling stools
Poor appetite
Malnutrition
Bowel obstruction
Delayed sexual maturation and infertility

Diagnostic test
Sweat chloride test most reliable
Production
of sweat is stimulated
pilocarpine iontophoresis

with

Sweat is collected and the sweat electrolytes

are measured (minimum of 50mg of sweat)

Normal

sweat

chloride

concentration

is

40mEq/L
Between 40-60 requires repeat testing; above

60 is positive

Interventions
Chest physiotherapy (percussion and postural

drainage) on awakening and the evening

Administer bronchodilators as prescribed
Instruct significant others not to give cough

suppressants such as guaifenesin (Robitussin)

Teach client on forced expiratory technique to

mobilize secretions

Administer antibiotics as prescribed

Administer oxygen as prescribed
Monitor for hemoptysis; more than 300mL in

24 hours for older children needs to be

treated immediately
Promote bed rest in case of hemoptysis
Pancreatic insufficiency should be replaced

with pancreatic enzymes

Administer pancreatic enzymes (Pancrease,

Viokase) with all meals and snacks

Enteric-coated pancreatic enzymes should not

be crushed or chewed
Pancreatic enzymes should not be given if the

child is NPO
Encourage

a well-balanced,
high-calorie diet

high-protein,

Assess for weight and monitor for failure to thrive

Monitor for constipation and intestinal obstruction
Ensure adequate fluid and salt intake
Promote adequate hydration
Encourage regular exercise
Recommend use of hot shower occasionally
Inform

client
exercises

to

use

breathing

and

coughing

SUDDEN INFANT
DEATH SYNDROME
(SIDS)

Unexpected death of an apparently healthy infant

younger than 1 year for whom a thorough autopsy

fails to demonstrate and adequate cause of death
Unknown cause that may be related to a brain

stem abnormality in the neurological regulation of

cardiorespiratory control
Most frequently occurs during winter months
Death usually occurs during sleep periods, but not

necessarily at night

Most frequently affects infants from 2 months

to 4 months of age
Incidence is higher in males
Incidence

is higher in Native Americans,

African Americans, Hispanics

Signs and symptoms

Child is apneic, blue, and lifeless
Frothy blood-tinged fluid in the nose and mouth
Typically found in disheveled bed, with blankets

over the head, and huddled in a corner

Child may appear to have been clutching bedding
Diaper may be wet and full of stool

Prevention
Place infant in supine position when sleeping
Soft moldable mattresses and bedding, such

as pillows, should not be used for bedding

Stuffed animals should be removed from the

crib while the infant is sleeping

Discourage bed sharing
Avoid overheating during sleep

ASTHMA

Chronic inflammatory disorder of the airways

that causes varying degrees of obstruction in

the airways
Marked

by
airway
inflammation
and
hyperresponsiveness to a variety of stimuli or
triggers

Causes

recurrent episodes of wheezing,

breathlessness, chest tightness, and coughing
associated with airflow obstruction that may
resolve spontaneously; it is often reversible
with treatment

Classification
Severe Persistent
Symptoms are continuous
Physical activity requires limitation
Frequent exacerbations occur
Nocturnal symptoms occur frequently

Moderate Persistent
Daily symptoms occur
Daily use of inhaled short acting beta agonist is

needed
Exacerbations affect activity
Exacerbations occur at least twice a week and may

last for days

Nocturnal symptoms occur more frequently than once

weekly

Mild Persistent
Symptoms occur more frequently than twice
weekly but less often than once daily
Exacerbations may affect activity
Nocturnal

symptoms occur more frequently

than twice a month

Mild Intermittent
Symptoms occur twice weekly or less
Client is asymptomatic between exacerbations
Exacerbations are brief (hours to days)
Intensity of exacerbations vary
Nocturnal symptoms occur twice a month or

less

Signs and symptoms

Restlessness
Wheezing or crackles upon auscultation
Absent or diminished lung sounds
Hyperresonance
Use of accessory muscles for brething

Tachypnea
Prolonged exhalation
Tachycardia
Pulsus paradoxus
Diaphoresis
Cyanosis
Decreased oxygen saturation

Interventions
Position client in a high Fowlers position or

sitting to aid in breathing

Administer oxygen as prescribed
Stay with the client to decrease anxiety
Administer bronchodilators as prescribed

Record the color, amount and consistency of

sputum, if any
Administer corticosteroids as prescribed
Auscultate lung sounds before, during, and after

treatments
Monitor vital signs
Monitor pulse oximetry
Instruct client to avoid triggers

CHRONIC
OBSTRUCTIVE
PULMONARY
DISEASE

Also known as chronic obstructive lunge disease

and chronic airflow limitation

Is

a disease state characterized by airflow

obstruction caused by emphysema or chronic
bronchitis

Progressive airflow limitation occurs, associated

with an abnormal inflammatory response of the

lungs that is not completely reversible
Can lead to pulmonary insufficiency or pulmonary

hypertension

Diagnostic tests
Chest x-ray
Ultrasound
ABG
CBC
Sputum analysis

Signs and Symptoms

Cough
Exertional dyspnea
Wheezing and crackles
Sputum production
Weight loss

Barrel chest (emphysema)

Use of accessory muscles for breathing
Prolonged expiration
Orthopnea
Congestion and hyperinflation seen on chest x-

ray
Respiratory acidosis

Interventions
Monitor vital signs
Administer low concentration of oxygen as

prescribed
Monitor pulse oximetry
Provide chest physiotherapy
Instruct client to do breathing techniques

Record the color, amount, and consistency of

sputum
Monitor weight
Encourage small frequent meals to maintain

nutrition and prevent dyspnea

Provide a high caloric, high protein diet with

supplements
Encourage fluid intake up to 3L per day

Place client in high Fowlers position

Allow activity as tolerated
Administer bronchodilators as prescribed
Administer corticosteroids as prescribed
Administer mucolytics as prescribed
Administer

prescribed

antibiotics

for

infection

if

Client education
Adhere to activity limitations, alternating rest

periods with activity

Avoid eating gas producing foods, spicy foods,

and extremely hot or cold beverages

Avoid crowds
Avoid extremes in temperature

Avoid fireplaces, pets, feather pillows and

other environmental allergens

Avoid powerful odors
Receive immunization as recommended
Stop smoking
Recognize signs of infection

Use medications and inhalers as prescribed

Use oxygen therapy as prescribed
Use breathing techniques
When dusting, use a wet cloth

PNEUMONIA

Infection of the pulmonary tissue, including

the interstitial spaces, the alveoli, and the

bronchioles
The

edema associated with inflammation

stiffens the lung, decreases lung compliance
and vital capacity, and causes hypoxemia

Can

be
acquired

Chest

community-acquired

or

hospital

x-ray shows lobar or segmental

consolidation, pulmonary infiltrates, or pleural

A sputum culture identifies the organism

The

white blood cell count and the

erythrocyte sedimentation rate are elevated

Signs and symptoms

Chills
Elevated temperature
Pleuritic pain
Tachypnea
Rhonchi and wheezes

Use of accessory muscles for breathing

Mental status changes
Sputum production

Interventions
Administer oxygen as prescribed
Monitor respiratory status
Monitor for labored respirations, cyanosis, and

cold and clammy skin

Encourage coughing and deep breathing and

use of the incentive spirometer

Place the client in a semi-Fowlers position to

facilitate breathing and lung expansion

Change the clients position frequently and

ambulate as tolerated to mobilize secretions

Provide CPT
Perform nasotracheal suctioning if the client is

unable to clear secretions

Monitor pulse oximetry

Monitor and record color, consistency, and amount

of sputum
Provide a high-calorie, high-protein diet with small

frequent meals
Encourage fluids, up to 3 liters/day, to thin

secretions unless contraindicated

Provide a balance of rest and activity, increasing

activity gradually

Administer antibiotics as prescribed

Administer

antipyretics,
bronchodilators,
cough suppressants, mucolytic agents, and
expectorants as prescribed

Prevent the spread of infection by hand

washing and the proper disposal of secretions

TUBERCULOSIS

Highly

communicable
disease
Mycobacterium tuberculosis

caused

by

An aerobic bacterium that primarily affects the

pulmonary system, especially the higher lobes,

where the oxygen content is highest
TB has an insidious onset, and many client are not

aware of
advanced

symptoms

until

the

disease

is

well-

Improper or noncompliant use of treatment programs

may cause the development of multidrug-resistant

strain of TB

Transmission is via the airborne route by

droplet infection
Droplets enter the lungs, and the bacteria

form a tubercle lesion

Risk Factors
Child younger than 5 years of age
Drinking unpasteurized milk
Homeless

individuals
socioeconomic status

or

those

from

low

Individuals in constant, frequent contact with

an untreated or undiagnosed individual

Individuals living in crowded areas

Older client
Individuals

with
malnutrition,
infection,
immune dysfunction or HIV infection, or
immunosuppressed

Signs and Symptoms

Fatigue
Lethargy
Anorexia
Weight loss
Low-grade fever

Chills
Night sweats
Persistent

cough and the production of

mucoid and mucopurulent sputum, which is
occasionally streaked with blood

Chest tightness and a dull, aching chest pain

may accompany the cough

Chest x-ray reveals multinodular infiltrates

with calcification in the upper lobes

Sputum cultures reveal presence of causative

agent
Mantoux test

Interventions
Place

client
in
respiratory
isolation
precautions in a negative-pressure room

Provide the client and family with information

about TB
Instruct

client to follow the

regimen exactly as prescribed

medication

Inform client to resume activities gradualy

Instruct client to increase intake of foods rich in iron,

protein, and vitamin C

Instruct client to cover nose and mouth when

coughing or sneezing
Encourage handwashing
Inform client that when the results of three sputum

cultures are negative he/she is no longer considered

infectious

Advise client to avoid excessive exposure to

silicone or dust
Instruct client regarding the importance of

compliance with treatment, follow-up care,

and sputum cultures, as prescribed

DRUGS

Bronchodilators
Sympathomimetic bronchodilators dilate the

airways of the respiratory tree and relax the

smooth muscle of the bronchi (Albuterol)
Methylxanthine bronchodilators stimulate the

CNS and respiration, dilate coronary and

pulmonary vessels, cause diuresis, and relax
smooth muscle (theophylline)

Side effects
Palpitations and tachycardia
Dysrhythmias
Hyperglycemia
Restlessness, nervousness, tremors
Anorexia, nausea, and vomiting
Headaches and dizziness
Mouth dryness and throat irritation

Interventions
Assess vital signs
Monitor for cardiac dysrhythmias
Assess for cough, wheezing, decreased breath

sounds, and sputum production

Monitor for restlessness and confusion
Provide

adequate hydration
medications with or after meals

administer

oral

Instruct the client to stop smoking

Monitor for a therapeutic serum theophylline

level of 10 to 20mcg/mL

Antihistamines
Are

called histamine antagonists or H1

blockers; these medications compeet with
histamine for receptor sites

Decrease nasopharyngeal, GI, and bronchial

secretions by blocking the H1 receptor

Diphenhydramine

(Benadryl),
Loratadine
(Claritin), Cetirizine hydrochloride (Zyrtec)

Side effects
Drowsiness and fatigue
Dizziness
Urinary retention
Blurred vision
Wheezing

Constipation
Dry mouth
GI irritation
Hypotension
Confusion

Interventions
Monitor vital signs
Administer with food or milk
Instruct client to avoid hazardous activities,

alcohol, and other CNS depressants

Instruct the client to suck on hard candy or

ice chips for dry mouth

Expectorants and Mucolytic Agents

Expectorants loosen bronchial secretions so

that they can be eliminated with coughing;

they are used for dry, unproductive cough and
to stimulate bronchial secretions
Mucolytic agents thin mucous secretions to

help make the cough more productive

Acetylcysteine

(Pulmozyme)

(Mucomyst),

Dornase

alfa

Side effects
GI irritation
Skin rash
Oropharyngeal irritation

Interventions
Take medication with full glass of water to

loosen mucus
Maintain adequate fluid intake
Encourage client to cough and deep breathe
Monitor for side effects

Isoniazid
Inhibits the synthesis of mycolic acids and

acts to kill actively growing organisms in the

extracellular environment
Active only during cell division and is used in

combination with other anti TB drugs

Side effects
Hypersensitivity reactions
Peripheral neuritis
Hepatotoxicity
Pyridoxine (vitamin B6) deficiency
Nausea and vomiting
Dry mouth

Interventions
Assess for hypersensitivity
Assess for hepatic dysfunction
Monitor for tingling, numbness, or burning of the

extremities
Administer 1 hour before or 2 hours after meals
Administer pyridoxine as prescribed

Instruct client to avoid alcohol

Instruct the client not to skip doses

Rifampin (Rifadin)
Inhibits bacterial RNA synthesis
Binds to DNA-dependent RNA polymerase and

blocks RNA transcription

Side effects
Hypersensitivity reaction
Heartburn
Nausea and vomiting
Red-orange-colored body secretions
Hepatotoxicity

Interventions
Asses for hypersensitivity
Evaluate CBC, uric acid, and liver function test

results
Monitor mental status
Instruct client not to skip doses
Instruct client to avoid alcohol

Ethambutol
Interferes

with
cell
metabolism
multiplication by inhibiting one or
metabolites in susceptible organisms

Inhibits bacterial RNA synthesis

and
more

Side effects
Hypersensitivity reactions
Nausea and vomiting
Dizziness
Malaise
Mental confusion
Optic neuritis
Increased uric acid levels

Interventions
Assess the client for hypersensitivity
Evaluate the results of CBC, uric acid, and

renal and liver function tests

Obtain

baseline visual acuity and

discrimination, especially to green

Monitor for visual changes

color

Monitor intake and output

Asses mental status
Instruct client not to skip doses

Pyrazinamide
Exact mechanism of action is unknown

Side effects
Increases liver function tests and uric acid

levels
Myalgia
Photosensitivity
Hepatotoxicity
Thrombocytopenia

Interventions
Assess for hypersensitivity
Evaluate CBC, liver function test results, and uric acid

levels
Assess for painful or swollen joints
Take with food
Avoid sunlight or UV light
Instruct client not to skip doses

Streptomycin
An aminoglycoside antibiotic used with at

least one other antitubercular medication

Interferes with protein synthesis

Side effects
Hypersensitivity
Visual changes
Increased liver and renal function studies
Peripheral neuritis

Interventions
Assess for hypersensitivity
Monitor liver and renal function test results
Perform baseline audiometric testing and

repeat every 1 to 2 months because the

medication impairs the eighth cranial nerve
Monitor for visual changes

Monitor intake and output

Instruct the client not to skip doses