ATELECTASIS 

CLINICAL MANIFESTATIONS
Respiratory distress, tachycardia,
 Is a complete or partial collapse of the entire tachypnea and DOB
 Decrease SaO2 and Decreased breath
lung or Lobe of the lung.
sounds, Central cyanosis (Acute
 The alveoli are deflated down to little or no
Atelectasis)
volume in Which they are filled with liquid
 Pain and Fever
 Acute or chronic  Crackles
 Cough (productive or nonproductive)
TYPES OF ATELECTASIS
ADHESIVE ATELECTASIS DIAGNOSTICS
 Occurs due to the decrease or absence  Chest X Ray- suggest atelectasis
of pulmonary surfactant produced by  Low oxygen saturation less than 90%
type II pneumocytes.
 It is most commonly seen in the NURSING DIAGNOSIS
neonate with RDS.
 Ineffective Airway Clearance related to
COMPRESSIVE ATELECTASIS foreign body, tumor in an airway,
 Due to compression by a space- retained secretions, compression of the
occupying process. lungs, as evidence by cyanosis, saO2
 Result from tumor, enlarged heart, 88%, DOB.
diaphragm elevation or fluids in the  Ineffective breathing pattern related to
pleural space disease process
OBSTRUCTIVE ATELECTASIS  Activity Intolerance
 due to obstruction of the airways
supplying a lung segment or lobe. MEDICAL MANAGEMENT
ACUTE ATELECTASIS  Frequent turning – Upright
 the lung has collapsed and airlessness.  Early ambulation
 most common type of atelectasis.  DBE, Coughing
 HOURS TO days related post-surgery.  Incentive spirometer.
CHRONIC ATELECTASIS  CPT (Postural drainage and chest
 characterized by a complex mixture of percussion)
airlessness, infection, widening of the  Bronchodilators
bronchi, destruction, and scarring.  Bronchoscopy
 Related to secondary diseases  Endotracheal intubation or mechanical
ventilation
 Thoracentesis/Chest tube insertion
PATHOPHYSIOLOGY
Reduce ventilation/Blockage of airways, NURSING INTERVENTIONS
Obstruction of passage of air from and to
 Position frequently from supine to upright
alveoli, Alveolar air trapping, affected portion of
 Early mobilization
the lung
becomes airless, Alveoli or lung collapse.  Do DBE and coughing
 Reinforce appropriate technique for
CAUSES OF ATELECTASIS Incentive spirometer
 foreign body, tumor, retained  Perform CPT
secretions, pain, alteration in small  Suctioning PRN
airway function, prolong supine
positioning, increase abdominal
pressure, reduce lung volumes due to EVIDENCE BASED STANDARDIZED
neurologic disorders INTERVENTION PROGRAM (CASSIDY
 Postoperative patients such as upper ET AL, 2013, SMETANA, 2015)
abdominal, thoracic and open-heart  Incentive Spirometry
surgery.  Coughing and DBE
 Impaired cough reflex in post operative  Oral Care (Brushing and mouth wash)
patients.  Getting out of the bed at least 3 times a
 Muscular and neurologic disorders and day
bed ridden  Head of the bed elevation
 Effects of anesthesia or analgesic
agents
 Liver diseases

1
 CLINICAL MANIFESTATIONS
PLEURAL EFFUSION  Coughing - non productive
 Accumulation or collection of fluids in the  Fever, Chills, Pleuritic chest pain, DOB
pleural space associated to secondary  Dullness (hemothorax) to percussion,
diseases  Decreased or absent breath sounds;
 A complication of heart failure, TB,  Increased Tactile Fremitus
Pneumonia, nephrotic syndrome and  Cyanosis
neoplastic tumors  Tracheal deviation away from the
 Associated in bronchogenic carcinoma affected side
 Disrupt the negative pressure in the lungs  Chest asymmetry
leading to Atelectasis.  Hyperresonance on chest percussion

PATHOPHYSIOLOGY DIAGNOSTIC TEST

 Increase Hydrostatic Pressure/Pressure  Chest X Ray
in subpleural capillaries/increase  Physical findings
capillary permeability/ Decrease  Thoracentesis- aspiration of fluids or air
oncotic, Pressure/Secondary Diseases in the pleural space.
 Unable to remain fluid into the  Pleural fluid analysis
intravascular space
 Shifting of fluids into the interstitial space NURSING INTERVENTIONS
 Fluids accumulates in the Pleural Space  Assess the signs and symptoms
 Prepare and position the patient for
TYPES OF PLEURAL EFFUSION thoracentesis
TRANSUDATE  Record the amount of fluid and sent for
 occurs when factors influencing the appropriate laboratory testing
formation and reabsorption of pleural  Monitor the chest tube drainage and
fluid are altered usually by imbalances water seal system and record the
in hydrostatic or oncotic pressure. amount of drainage.
 Causes: CHF, Atelectasis  Assess the level of pain and administer
EXUDATIVE analgesics, antibiotics as prescribed
 Results from leakage of fluid across an
injured capillary bed into the pleural MEDICAL MANAGEMENT
cavity.  Thoracentesis
 Types: Hemothorax, Pyothorax,  Chest tube thoracostomy connected to
Hydrothorax water seal drainage system
 Pleurodesis - cause by malignancy
TYPES OF EXUDATIVE PLEURAL
EFFUSION PLEURODESIS
HEMOTHORAX  Accomplished by CCD, and intrapleural
 blood in the pleural space due to instillation of sclerosing agent
cancer, trauma, CVP, thoracentesis. (tetracycline)
PYOTHORAX/EMPYEMA  The agent is instilled, the tube is
 Pus in the pleural space and requires clamped for 60-90 minutes and the
drainage from a chest tube. patient is assisted to assume various
HYDROTHORAX positions
 Water in the pleural space.  Tube is unclamped as ordered and
chest drainage continued
 Apply petroleum gauze
CAUSES OF EXUDATIVE PLEURAL  Maintain the patency of the tubes
EFFUSION
 Pneumonia is the most common cause
 Cancer (lung, breast, gastric and EVALUATION
ovarian) – second common cause  No signs of DOB, Dullness, tactile
fremitus, Cyanosis, fever, cough, chills,
pleuritic pain
 Normal breath sounds, oxygen
saturation greater than 95%

2
PNEUMONIA
HOSPITAL-ACQUIRED PNEUMONIA (HAP)
 patients who are on mechanical
ventilation at major risk
 The inflammation of the alveoli sacs that  Cause by bacteria and difficult to treat
leads to impaired gas exchange.  Criteria: patient must have developed
48-72 hours after admission
KEY PLAYERS PNUEMONIA IN IMMUNOCOMPROMISED
 Germs: Bacteria, Virus, Fungi PERSON (PIP)
 Lung Parenchyma: Alveoli, Alveolar  Low immunity due to secondary disease.
Ducts, and Bronchioles (the trio in gas
exchange) DIAGNOSTIC TEST
 Chest X Ray – lung consolidation
RISK FACTORS  Sputum culture - Confirmatory test
 Prior infection: flu or cold  ABG - PO2: <90 mmHg, pH - lower 7.35
 Weak immune system: Elderly, infants, mmHg, PCO2: higher than 45 mmHg-
HIV, autoimmune medications Respiratory acidosis
 Immobile: strokes, SCI  Abnormal breath sounds - coarse
 Lung problems: COPD, asthma, crackles, and rhonchi.
smokers
 Post-opt patient: not coughing and deep SIGNS AND SYMPTOMPS
breathing
 Productive cough, Pleuritic pain
 Neuro changes
PATHOPHYSIOLOGY  Elevated labs: PCO2 >45, WBC
 CA get into the lungs by inhalation,  Unusual breath sounds: coarse
aspiration, or from the blood crackles, rhonchi, or bronchial in the
 Attack the alveoli sacs peripheral lung fields
 Alveoli sacs become very inflamed and  Mild to high Fever
fill with fluid lose the ability to inflate and  Oxygen saturation decreased
deflate  Nausea and vomiting (won’t feel like
 Hypoxemia & respiratory acidosis eating)
 Increase heart rate and respirations
GERMS THAT CAUSE PNEUMONIA  Aching all over with joint pain, Activity
BACTERIA intolerance with shortness of breath
 most common cause of pneumonia
especially in community-acquired is NURSING INTERVENTIONS
caused by Streptococcus pneumoniae.  Monitor lung Sounds, vital signs,
ATYPICAL BACTERIA Oxygen saturation, ABGS
 Mycoplasma pneumoniae that causes  Encourage usage of incentive
“walking pneumonia”. spirometer
VIRUS  Fluids 2-3 L
 influenza, respiratory syncytial virus  Elevate HOB greater than 30 degrees
(RSV) - most common causes of PNA in  Prevention: Up-to-date Vaccinations
children (Pneumovax every 5 years for patients
FUNGI 65+ and 19-64 years)
 least common  Stop smoking, avoid people who are
 most likely to affect people with severe sick, hand-washing
suppressed immune system and  Bronchodilators, antibiotics, chest
typically is contracted from outside in percussion.
nature from plants, animals etc.
ANTIBIOTICS GROUPS FOR
TYPES OF PNEUMONIA BACTERIAL PNUEMONIA
COMMUNITY-ACQUIRED PNEUMONIA (CAP) VANCOMYCIN
 most occurring, obtains the germs  Used to treat severe cases and is one
outside of the healthcare system. of the few that can treat bacteria that
may be resistant to other antibiotics
 Watch for hearing loss - sign of
ototoxicity

3
MACROLIDES
 Zithromax - used in patients with
Penicillin allergy
 Narrow-spectrum targets mainly gram-
positive bacteria
TETRACYLINES
 Doxycycline” broad-spectrum” that
targets gram positive and negative
bacteria.
 Side effects: not for pregnant women or
8 years or younger due to growth
retardation and teeth discoloration,
photosensitivity of the skin and
decreases effectiveness of birth control,
no antacids or milk product while taking
this medication because it affects
absorption.
FLUROQUINOLONES
 Levaquin - broad-spectrum (targets
gram-negative and positive treatment
for severe infection that are found in the
hospital that are resistant
 Side effects: c. diff infection, tendon
rupture, cardiac arrhythmias such as QT
interval prolonged
CEPHALOSPORINS
 Keflex, Rocephin
 watch with patients who are allergic to
penicillin (can also be allergic to
cephalosporin)
 Great for community acquired
pneumonia
PENICILLIN
 “Penicillin G” …narrow-spectrum
 Target gram positive bacteria
 Monitor if patient is allergic to
cephalosporins, decrease effectiveness
of birth control.

4
ASTHMA
 Easily fatigued with physical activity
 Frequent coughing (mainly at night) and
trouble sleeping at night
 Is a chronic lung disease that causes  Sneezing, scratchy throat, tired,
narrowing and inflammation of the airways headache, irritable
(bronchi and bronchioles)  Reduced peak flow meter reading
 It is reversible. ACTIVE SIGNS
 Expiratory Wheezing, Chest Tightness
CAUSES  Coughing, Difficulty Breathing
 Unknown  Increased respiratory rate
 Genetic  Can progress to chest retractions,
 Environmental cyanosis and sweating, decrease
 Triggers factors oxygen level
 Body issues
 Intake of certain substances CLINICAL MANIFESTATIONS
 A - Accessory Muscle use
WHAT CAN TRIGGER ASTHMA?  S - SOB
 ALLERGY- Common Allergens  T -Tight Chest and tachypnea
 Environment  H - High pitch Wheezing
 Body Issue  M - minimal Diminish breath sounds
 Intake of Certain Substances drugs  A - 3 A’s (Absent breath sounds,
(beta adrenergic blockers, NSAIDS, Acidosis, Air trapping)
aspirin, preservatives (sulfites),
histamine rich foods like eggs, sea- STATUS ASTHMATICUS
foods, snacks  Severe and persistent Asthma
foods.
 Emergency and most deadly
KEY PLAYERS OF AN ASTHMA ATTACK  Not responsive to drugs
BRONCHI AND BRONCHIOLES  Last for longer than 24 hours
 Surrounding these structures are smooth  ET tube is required
muscles that wrap around the airway.  Key Sign: pulsus paradoxus - drop in
 helps with dilating and constricting the SBP more than 10 mmHg (decrease
airway. Stroke volume) during inhalation and
 In asthma attack, these smooth muscles increased during exhalation.
constrict causing chest tightness and
difficulty breathing.
NURSING INTERVENTIONS
 Assess the signs and vital signs-RR,
PATHOPHYSIOLOGY O2sat, HR
 Trigger factor  High Fowler’s or Orthopneic position
 Airway inflammation  Keep patient calm and comfort the
 Hypersecretion of mucus, airway patient
muscle constriction, swelling bronchial  Do Purse Lip Breathing
membranes  Assess precipitating factors and
 Narrow breathing passages eradicate this source
 Wheezing, cough, shortness of breath,  Instruct patient to avoid 3 E’s (Exercise
tightness in chest. in cold weather, environmental factors,
 Hypoventilation, hypoxia, respiratory Emotional factors)
acidosis  Auscultate lung sounds
 Monitor skin color and for any
DIAGNOSTIC TEST retractions of the chest
 Assess peak flow meter reading
 PFT’s
 Administer bronchodilators and
 Elevated immunoglobulin E
corticosteroids as ordered by MD
 ABG analysis
 Oxygen (oxygen saturation 95-99%)
 Current peak flow meter reading
CLINICAL MANIFESTATIONS numbers
EARLY WARNING SIGNS
 Short of breath or Dyspnea- Initial sign
 Wheezing

5
 PEAK FLOW METER LONG-ACTING BETA AGONISTS
 Device will then measure how much air Salmeterol, Symbicort
was exhaled out of the lungs.  is a combination of a long-acting beta
agonist and corticosteroid
 Not for an acute asthma attack
 Side effects: tachycardia, feeling
nervous/jittery, dysrhythmia.
ANTI-CHOLINERGICS
 Ipratropium: a bronchodilator, short-
ZONES OF PEAK FLOW METER acting and relaxes the airway
GREEN ZONE  Tiotropium: a bronchodilator, long-
 Asthma is under control acting can cause dry mouth
 No medications needed THEOPHYLLINE
YELLOW ZONE Bronchodilator
 Asthma is NOT under control  Effects: Ease of breathing Commonly
 Additional medication is needed given as inhaled routes/oral
RED ZONE  Not as common because of possible
 Really bad, emergency medication is toxicity and maintaining blood levels of
needed 10-20 mcg/ml
 Avoid caffeine
NOTES FOR PEAK FLOW METER  Avoid consuming products with caffeine
 The patient will exhale as hard as they  Stop Smoking
can onto the device.  Check the HR - tachycardia
 FIRST figure out the personal best peak  Theophylline toxicity: nausea,
flow meter reading. abdominal pain vomiting, tachycardia,
 Measure it once in the morning and and muscle tremors are usually seen
once at night for 3 weeks usually with levels
 Record the numbers BEFORE TAKING around 20 to 25 mg/L.
MEDICATION. ANTI-INFLAMMATORIES
 Compare it with the personal best  Decreases swelling and mucus
reading. production
 If the reading is 80% or less than their  Used as long-term treatment to control
personal best, follow the action plan asthma “corticosteroids, leukotriene
created by your doctor. modifiers, immunomodulators,
cromolyn”
INHALED CORTICOSTEROIDS
WHAT IF A TRIGGER IS EXERCISE- Fluticasone, budesonide, beclomethasone
INDUCED?  Watch for thrush (use spacer with
 Warm up before exercising for 10-15 inhaler and rinsing mouth after
minutes administration)
 Administer short acting beta agonists  Risk for osteoporosis and cataracts
before exercising  May be given iv or po for severe asthma
 Breathe through nose instead of mouth attack.
during cold windy days LEUKOTRIENE MODIFIERS
 Avoid exercising when sick with a Montelukast
respiratory illness  blocks the function of leukotriene that
relax the smooth muscle and decreased
PHARMACOLOGY mucous production Not use for acute
BRONCHODILATORS attacks of Asthma
 opens the airways to increase air flow IMMUNOMODULATORS
 Beta-agonists Omalizumab
 Anti-cholinergic  blocks the role of the immunoglobulin
 Theophylline IgE
SHORT-ACTING BETA AGONIST  Route: Subcutaneous
 Albuterol  NOT use as quick relief
 No Live vaccines while receiving
 Inhaler or nebulizer
 used as the fast-acting relief during an NONSTEROIDAL ANTI-ALLERGY
asthma attack or prior to exercise Cromolyn” (inhaled)
 Not for daily treatment  long term use

6
  stops mast cells from secreting
histamine
 the patient may temporarily experience
sneezing, burning in nose, itchy/watery
eyes, bad taste in mouth.
HISTAMINE ANTAGONIST
Benadryl (Diphenhydramine Hcl)
 used to relieve symptoms of allergy, hay
fever, and the common cold.
 Best taken with food if GI upset occurs
or at night
 Negative allergy
 SE: drowsiness, fatigue, tiredness,
sleepiness, dizziness, disturbed
coordination, constipation, dry
mouth/nose/throat

IN CAPSULE
B - bronchodilators
R - rest
O - Oxygen, Orthopneic position
N - Nutrition- avoid food triggers
C - P-T
I - Instruct to avoid 3 E’s, Immunomodulators
A - Aerosol using bronchodilators
L - Liberal fluid intake
A - Aminophylline
S - Steroids (Corticosteroids)
T - theophylline
H - Histamine antagonist
M - Mucolytics
A - anti-inflammatory drugs