Acute Bronchitis

Description:
Is an infection of the lower respiratory tract that
generally follows an upper respiratory tract
infection. As a result of this viral (most
common) or bacterial infection, the airways
become inflamed and irritated, and mucus
production increases.
Causes:
Acute bronchitis is usually caused by viruses. Established risk factors include a
history of smoking, occupational exposures, air pollution, reduced lung function,
and heredity. Children of parents who smoke are at higher risk for pulmonary
infections that may lead to bronchitis.

Assessment:

Fever, tachypnea, mild dyspnea, pleuritic

chest pain (possible).
Cough with clear to purulent sputum
production.
Diffuse rhonchi and crackles(contrast with
localized crackles usually heard with
pneumonia).
Diagnostic Evaluation:
 Chest X-ray may rule out pneumonia. In bronchitis, films show no
evidence of lung infiltrates or consolidation.

Primary Nursing Diagnosis

o Impaired gas exchange related to obstructed airways

Medical Management:
o Chest physiotherapy to mobilize secretions, if indicated.
 o Hydration to liquefy secretions.
Pharmacologic Interventions:
o Inhaled bronchodilators to reduce bronchospasm and promote sputum
expectoration.
o A course of oral antibiotics such as a macrolide may be instituted, but is
controversial.
o Symptom management for fever and cough.
o Nursing Interventions:
Encourage mobilization of secretion through ambulation, coughing, and
deep breathing.
o Ensure adequate fluid intake to liquefy secretions and prevent
dehydration caused by fever and tachypnea.
o Encourage rest, avoidance of bronchial irritant, and a good diet to
facilitate recovery.
o Instruct the patient to complete the full course of prescribed antibiotics
and explain the effect of meals on drug absorption.
o Caution the patient on using over-the-counter cough suppressants,
antihistamines, and decongestants, which may cause drying and retention
of secretions. However, cough preparations containing the mucolytic
guaifenesin may be appropriate.
o Advise the patient that a dry cough may persist after bronchitis because of
irritation of airways. Suggest avoiding dry environments and using a
humidifier at bedside. Encourage smoking cessation.
o Teach the patient to recognize and immediately report early signs and
symptoms of acute bronchitis.

Documentation Guidelines
o Respiratory status of the patient: Respiratory rate, breath sounds, use of
oxygen, color of nail beds and lips; note any respiratory distress
 o Response to activity: Degree of shortness of breath with any exertion,
degree of fatigue
o Comfort, body temperature
o Response to medications, oxygen, and breathing treatments
o Need for assistance with activities of daily living
o Response to diet and increased caloric intake, daily weights

Discharge and Home Healthcare Guidelines

1. Medications. Be sure that the patient understands all medications,
including the dosage, route, action, and adverse effects. Patients on
aminophylline should have blood levels drawn as ordered by the
physician. Before being discharged from the hospital, the patient should
demonstrate the proper use of metered-dose inhalers.

2. Complications. Instruct patients to notify their primary healthcare

provider of any change in the color or consistency of their secretions.
Green-colored secretions may indicate the presence of a respiratory
infection. Patients should also report consistent, prolonged periods of
dyspnea that are unrelieved by medications.

3. Follow-up. Consider that patients with severe disease may need

assistance with activities of daily living after discharge. Note any referrals
to social services. Send patients home with a diet, provided by the
dietitian and reinforced by the nurse, which provides a high-caloric
intake. Encourage the patient to cover the face with a scarf if he or she
goes out-of-doors in the winter. If the patient continues to smoke, provide
the name of a smoking cessation program or a support group. Encourage
the patient to avoid irritants in the air.
 Asthma

Definition:
o Asthma is a chronic inflammatory
disease of the airways
characterized by hyper-
responsiveness, mucosal edema,
and mucus production.
o This inflammation ultimately
leads to recurrent episodes of
asthma symptoms: cough, chest
tightness, wheezing, and dyspnea.

o Patients with asthma may experience symptom-free periods alternating

with acute exacerbations that last from minutes to hours or days.
o Asthma, the most common chronic disease of childhood, can begin at any
age.

Causes:
The main triggers for asthma are allergies, viral infections, autonomic
nervous system imbalances that can cause an increase in parasympathetic
stimulation, medications, psychological factors, and exercise. Of asthmatic
conditions in patients under 30 years old, 70% are caused by allergies. Three
major indoor allergens are dust mites, cockroaches, and cats. In older patients, the
cause is almost always nonallergic types of irritants such as smog. Heredity plays
a part in about one-third of the cases.

Pathophysiology:
1. An asthma attack may occur
spontaneously or in response to a
trigger. Either way, the attack
progresses in the following
manner:
o There is an initial release of inflammatory
mediators from bronchial mast cells,
epithelial cells, and macrophages,
followed by activation of other
inflammatory cells
o Alteration of autonomic neural control of airway tone and epithelial
integrity occur and the increased responsiveness in airways smooth
muscle results in clinical manifestations (e.g. wheezing and dyspnea)

2. Three events contribute to clinical manifestations

o Bronchial spasm
o Inflammation and edema of the mucosa
 o Production of thick mucus, which results in increased airway
resistance, premature closure of airways, hyperinflation,
increased work of breathing, and impaired gas exchange

3. If not treated promptly, status asthmaticus – an acute, severe,

prolonged asthma attack that is unresponsive to the usual
treatment – may occur, requiring hospitalization.

Classification:

1. Extrinsic Asthma –
called Atopic/allergic
asthma. An “allergen”
or an “antigen” is a
foreign particle which
enters the body. Our
immune system over-
reacts to these often-
harmless items,
forming “antibodies”
which are normally
used to attack viruses
or bacteria. Mast cells
release these
antibodies as well as
other chemicals to
defend the body.

Common irritants:

o Cockroach particles
o Cat hair and saliva
o Dog hair and saliva
o House dust mites
o Mold or yeast spores
o Metabisulfite, used as a preservative in many beverages and some foods
o Pollen

2. Intrinsic asthma – called non-allergic asthma, is not allergy-related, in

fact it is caused by anything except an allergy. It may be caused by
inhalation of chemicals such as cigarette smoke or cleaning agents, taking
aspirin, a chest infection, stress, laughter, exercise, cold air, food
preservatives or a myriad of other factors.
 o Smoke
o Exercise
o Gas, wood, coal, and kerosene heating units
o Natural gas, propane, or kerosene used as cooking fuel
o Fumes
o Smog
o Viral respiratory infections
o Wood smoke
o Weather changes

Clinical Manifestation

o Most common symptoms of asthma are cough (with or without mucus

production), dyspnea, and wheezing (first on expiration, then possibly
during inspiration as well).
o Asthma attacks frequently occur at night or in the early morning.
o An asthma exacerbation is frequently preceded by increasing symptoms
over days, but it may begin abruptly.
o Chest tightness and dyspnea occur.
o Expiration requires effort and becomes prolonged.
o As exacerbation progresses, central cyanosis secondary to severe hypoxia
may occur.
o Additional symptoms, such as diaphoresis, tachycardia, and a widened
pulse pressure, may occur.
o Exercise-induced asthma: maximal symptoms during exercise, absence of
nocturnal symptoms, and sometimes only a description of a “choking”
sensation during exercise.
o A severe, continuous reaction, status asthmaticus, may occur. It is life-
threatening.
o Eczema, rashes, and temporary edema are allergic reactions that may be
noted with asthma.

Primary Nursing Diagnosis

Ineffective airway clearance related to obstruction from narrowed lumen

and thick mucus

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation;

Symptom control behavior; Treatment behavior: Illness or injury; Comfort level

INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy;

Airway suctioning; Airway insertion and stabilization; Cough enhancement;
Mechanical ventilation; Positioning; Respiratory monitoring
Assessment and Diagnostic Methods

o Family, environment, and occupational history is essential.

o During acute episodes, sputum and blood test, pulse oximetry, ABGs,
hypocapnia and respiratory alkalosis, and pulmonary function (forced
expiratory volume [FEV] and forced vital capacity [FVC] decreased) tests
are performed.
o Spirometry will detect:
a. Decreased for expiratory volume (FEV)
b. Decreased peak expiratory flow rate (PEFR)
c. Diminished forced vital capacity (FVC)
d. Diminished inspiratory capacity (IC)

Steps of Clinical and Diagnostic as per National Asthma Education and

Prevention Program

Mild Intermittent Asthma

o Symptoms ? 2 times per week

o Brief exacerbations
o Nighttime symptoms ? 2 times a month
o Asymptomatic and normal PEF (peak expiratory flow) between
exacerbations
o PEF or FEV, (forced expiratory volume in 1 second) ? 80% of predicted
value
o PEF variability < 20%

Mild Persistent Asthma

o Symptoms > 2 times/week, but less than once a day

o Exacerbations may affect activity
o Night times symptoms > 2 times a month
o PEF/FEV ? 80% of predicted value
o PEF variability 20%-30%

Moderate Persistent Asthma

o Daily Symptoms
o Daily use of inhaled short-acting ?2 – agonists
o Exacerbations affect activity
o Exacerbations ? 2 times a week
o Exacerbations may last days
o Nighttime symptoms > once a week
o PEF/FEV > 60%-<80% of predicted value
 o PEF variability > 30%
Severe Persistent Asthma

o Continual symptoms
o Frequent exacerbations
o Frequent nighttime symptoms
o Limited physical activity
o PEF or FEV ? 60% of predicted value
o PEF variability > 30 %

Medical Management

Pharmacologic Therapy

There are two classes of medications—long-acting control and quick-

relief medications—as well as combination products.

o Short-acting beta2-adrenergic agonists

o Anticholinergics
o Corticosteroids: metered-dose inhaler (MDI)
o Leukotriene modifiers inhibitors/antileukotrienes
o Methylxanthines

Nursing Management

The immediate nursing care of patients with asthma depends on the

severity of symptoms. The patient and family are often frightened and anxious
because of the patient’s dyspnea. Therefore, a calm approach is an important
aspect of care.

o Assess the patient’s respiratory status by monitoring the severity of

symptoms, breath sounds, peak flow, pulse oximetry, and vital signs.
o Obtain a history of allergic reactions to medications before administering
medications.
o Identify medications the patient is currently taking.
o Administer medications as prescribed and monitor the patient’s responses
to those medications; medications may include an antibiotic if the patient
has an underlying respiratory infection.
o Administer fluids if the patient is dehydrated.
o Assist with intubation procedure, if required.

Teaching Points
 o Teach patient and family about asthma (chronic inflammatory), purpose
and action of medications, triggers to avoid and how to do so, and proper
inhalation technique.
o Instruct patient and family about peak-flow monitoring.
o Teach patient how to implement an action plan and how and when to seek
assistance.
o Obtain current educational materials for the patient based on the patient’s
diagnosis, causative factors, educational level, and cultural background.
Continuing Care

o Emphasize adherence to prescribed therapy, preventive measures, and

need for follow up appointments.
o Refer for home health nurse as indicated.
o Home visit to assess for allergens may be indicated (with recurrent
exacerbations).
o Refer patient to community support groups.
o Remind patients and families about the importance of health promotion
strategies and recommended health screening.

Documentation Guidelines

o Respiratory status: Patency of airway, auscultation of the lungs, presence

or absence of adventitious breath sounds, respiratory rate and depth
o Response to medications, oxygen therapy, hydration, bedrest
o Presence of complications: Respiratory failure, ruptured bleb that may
result in a pneumothorax
 Chronic Bronchitis
Description
Is an inflammation of the lower airways characterized by excessive
secretion of mucus, hypertrophy of mucous glands, and recurring infection,
progressing to narrowing and obstruction of airflow.

Causes/ Risk Factors

The primary cause of chronic bronchitis is
smoking or exposure to some type of
respiratory irritant. Established risk factors
include a history of smoking, occupational
exposures, air pollution, reduced lung
function, and heredity. Children of parents
who smoke are at higher risk for pulmonary
infections that may lead to bronchitis.
Pathophysiology

Assessment

1) Signs and symptoms of chronic bronchitis (insidious onset):

o Productive cough lasting at least 3 months during a year for 2
successive years.
o Thick, gelatinous sputum (greater amounts produced during
superimposed infections).
o Dyspnea and wheezing as disease progresses.

Diagnostic Evaluation

o Pulmonary function tests, to demonstrate airflow obstruction-reduced

forced expiratory volume in 1 second (FEV1), FEV1 to forced vital
capacity ratio; increased residual volume to total lung capacity (TLC)
ration, possibly increased TLC.
 o Chest X-rays to detect hyperinflation, flattened diaphragm, increased
retrosternal space, decreased vascular markings, possible bullae (all in
late stages).
o Arterial blood gases, to detect decreased arterial oxygen pressure (PaO2),
pH, and increased arterial carbon dioxide pressure (Paco2).
o Sputum smears and cultures to identify pathogens.

Primary Nursing Diagnosis

o Impaired gas exchange related to obstructed airways

Therapeutic Intervention / Medical Management

1. Smoking cessation to stop the progression and preserve lung capacity.

2. Low-flow oxygen to correct severe hypoxemia in a controlled manner
and minimize carbon dioxide retention.
3. Home oxygen therapy, especially at night to prevent turnal oxygen
desaturation.
4. Pulmonary rehabilitation to reduce symptoms that limit activity.
5. Chest physical therapy, including postural drainage and breathing
retraining.
6. Lung transplant in severe cases of alpha1-antitrypsin deficiency.

Pharmacologic Intervention

1. Bronchodilators to reduce dyspnea and control bronchospasm delivered

by metered-dose inhaler, other handheld devices, or nebulization.
2. Inhaled corticosteroids may be useful for some with severe airflow
limitation and frequent exacerbations.
3. Corticosteroids by mouth or I.V. in acute exacerbations.
4. Antimicrobials to control secondary bacterial infections in the bronchial
tree, thus clearing the airways.
5. Alpha1-antitrypsin replacement delivered by I.V. infusion.

Nursing Intervention

1. Monitor for adverse effects of bronchodilators-tremulousness,

tachycardia, cardiac arrhythmias, central nervous system stimulation,
hypertension.
 2. Monitor oxygen saturation at rest and with activity.
3. Eliminate all pulmonary irritants, particularly cigarette smoke. Smoking
cessation usually reduces pulmonary irritation, sputum production, and
cough. Keep the patient’s room as dust-free as possible.
4. Use postural drainage positions to help clear secretions responsible for
airway obstruction.
5. Teach controlled coughing.
6. Encourage high level of fluid intake (8 to 10 glasses; 2 to 2.5 L daily)
within level of cardiac reserve.
7. Give inhalations of nebulized saline to humidify bronchial tree and
liquefy sputum. Add moisture (humidifier, vaporizer) to indoor air.
8. Avoid dairy products if these increase sputum production.
9. Encourage the patient to assume comfortable position to decrease
dyspnea.
10. Use pursed lip breathing at intervals and during periods of dyspnea to
control rate and depth of respiration and improve respiratory muscle
coordination.
11. Discuss and demonstrates relaxation exercises to reduce stress, tension,
and anxiety.
12. Encourage frequent small meals if the patient is dyspneic; en a small
increase in abdominal contents may press on diaphragm and impede
breathing.
13. Offer liquid nutritional supplements to improve caloric intake and
counteract weight loss.
14. Avoid foods producing abdominal discomfort.
15. Encourage use of portable oxygen system for ambulation for patients with
hypoxemia and marked disability.
16. Encourage the patient in energy conservation techniques.

Documentation Guidelines

o Respiratory status of the patient: Respiratory rate, breath sounds, use of

oxygen, color of nail beds and lips; note any respiratory distress
o Response to activity: Degree of shortness of breath with any exertion,
degree of fatigue
o Comfort, body temperature
o Response to medications, oxygen, and breathing treatments
o Need for assistance with activities of daily living
o Response to diet and increased caloric intake, daily weights
Discharge and Home Healthcare Guidelines

1. Medications. Be sure that the patient understands all medications,

including the dosage, route, action, and adverse effects. Patients on
aminophylline should have blood levels drawn as ordered by the
physician. Before being discharged from the hospital, the patient should
demonstrate the proper use of metered-dose inhalers.
2. Complications. Instruct patients to notify their primary healthcare
provider of any change in the color or consistency of their secretions.
Green-colored secretions may indicate the presence of a respiratory
infection. Patients should also report consistent, prolonged periods of
dyspnea that are unrelieved by medications.
3. Follow-up. Consider that patients with severe disease may need
assistance with activities of daily living after discharge. Note any referrals
to social services. Send patients home with a diet, provided by the
dietitian and reinforced by the nurse, which provides a high-caloric
intake. Encourage the patient to cover the face with a scarf if he or she
goes out-of-doors in the winter. If the patient continues to smoke, provide
the name of a smoking cessation program or a support group. Encourage
the patient to avoid irritants in the air.

Emphysema
Causes
The actual cause of emphysema is unknown. Risk factors for the development of
emphysema include cigarette smoking, living or working in a highly polluted
area, and a family history of pulmonary disease. Frequent childhood pulmonary
infections have been identified as a cause of bronchiectasis.

Assessment:

1. Anorexia, fatigue, weight loss

2. Feeling of breathlessness, cough,
sputum production, flaring of the
nostrils, use of accessory muscles of
respiration, increased rate and depth
of breathing, dyspnea.
 3. Decreased respiratory excursion, resonance to hyperresonance, decreased
breath sounds with prolonged expiration, normal or decreased fremitus

Primary Nursing Diagnosis

o Impaired gas exchange related to destruction of alveolar walls

Diagnostic Evaluation

o Evaluation entails primarily chest x-rays, chest computed tomography

(CT) scans, pulmonary function tests, pulse oximetry, blood gases, and
complete blood count.

Medical Management

The major goals of medical management are to improve quality of life,

slow progression of the disease, and treat obstructed airways to relieve hypoxia.
Treatment is directed at improving ventilation, decreasing work of breathing and
preventing infection.
o Smoking cessation
o Physical therapy to conserve and increase pulmonary ventilation
o Maintenance of proper environmental conditions to facilitate breathing
o Psychological support
o Ongoing program of patient education and rehabilitation
o Bronchodilators and metered-dose inhalers (aerosol therapy, dispensing
particles in fine mist).
o Treatment of infection (antimicrobial therapy at the first sign of
respiratory infection)
o Oxygenation in low concentrations for severe hypoxemia.
Pharmacologic Intervention

o Bronchodilators: Anticholinergic agents such as atropine sulfate,

ipratropium bromide are used in reversal of bronchoconstriction.
o Bronchodilators: Beta2-adrenergic agents such as( inhaled beta2-
adrenergic agonists by metered-dose inhaler (MDI) such as albuterol,
metaproterenol, or terbutaline )are used in reversal of bronchoconstriction
 o Systemic corticosteroids such as methylprednisolone IV; prednisone PO
is used to decrease inflammatory response and improve airflow in some
patients for a few days during acute exacerbations
o Other Drug Therapy: Bronchodilators, which are used for prevention and
maintenance therapy, can be administered as aerosols or oral medications.
Generally, inhaled anticholinergic agents are the first-line therapy for
emphysema, with the addition of beta-adrenergic agonists added in a
stepwise fashion. Antibiotics are ordered if a secondary infection
develops. As a preventive measure, influenza and pneumonia vaccines are
administered.

Nursing Interventions

o Maintaining a patent airway is a priority. Use a humidifier at night to help

the patient mobilize secretions in the morning.
o Encourage the patient to use controlled coughing to clear secretions that
might have collected in the lungs during sleep.
o Instruct the patient to sit at the bedside or in a comfortable chair, hug a
pillow, bend the head downward a little, take several deep breaths, and
cough strongly.
o Place patients who are experiencing dyspnea in a high Fowler position to
improve lung expansion. Placing pillows on the overhead table and
having the patient lean over in the orthopneic position may also be
helpful. Teach the patient pursed-lip and diaphragmatic breathing.
o To avoid infection, screen visitors for contagious diseases and instruct the
patient to avoid crowds.
o Conserve the patient’s energy in every possible way. Plan activities to
allow for rest periods, eliminating nonessential procedures until the
patient is stronger. It may be necessary to assist with the activities of daily
living and to anticipate the patient’s needs by having supplies within easy
reach.
o Refer the patient to a pulmonary rehabilitation program if one is available
in the community.
o Patient education is vital to long-term management. Teach the patient
about the disease and its implications for lifestyle changes, such as
avoidance of cigarette smoke and other irritants, activity alterations, and
any necessary occupational changes. Provide information to the patient
and family about medications and equipment.
Documentation Guidelines

o Rate, quality, and depth of respirations; vital signs

o Physical findings: Dyspnea, cyanosis, decreased muscle mass, cough,
increased anteroposterior chest diameter, and use of accessory muscles
during respiration; characteristics of sputum
o Activity tolerance, ability to perform self-care
o Signs and symptoms of infection; response to pharmacologic therapy,
response to oxygen therapy

Discharge and Home Healthcare Guidelines

o Be sure the patient and family understand any medication prescribed,

including dosage, route, action, and side effects.
o Instruct the patient to report any signs and symptoms of infection to the
primary healthcare provider.
o Explain necessary dietary adjustments to the patient and family.
Recommend eating small, frequent meals, including high-protein, high-
density foods.
o Encourage the patient to plan rest periods around his or her activities,
conserving as much energy as possible.
o Arrange for return demonstrations of equipment used by the patient and
family. If the patient requires home oxygen therapy, refer the patient to
the appropriate rental service, and explain the hazards of combustion and
increasing the flow rate without consultation from the primary healthcare
provider.

Pleural Effusion
Definition
It is a collection of fluid in the pleural space of the lungs. Fluid normally
resides in the pleural space and acts as a lubricant for the pleural membranes to
slide across one another when we breathe. Fluid is constantly being added and
reabsorbed by capillaries and lymph vessels in the pleura. When this recycling
process is interrupted, a pleural effusion can result.
 Causes
Physicians determine the cause
of the effusion based on the type of fluid
that is accumulating.

o Transudative (watery fluid)

effusions: Heart failure,
pulmonary embolism, cirrhosis, post open heart surgery, trauma
o Exudative (protein-rich fluid) effusions: Pneumonia , cancers, pulmonary
embolism, kidney disease, inflammatory diseases
Pleural fluid may be bloody (hemorrhagic), chylous (thick and white), rich in
cholesterol, or purulent.

Signs and symptoms

(Small effusions may not present with symptoms and may only be found via chest
X-ray. Larger effusions can cause symptoms such as:)
o Decreased lung expansion
o Dyspnea
o Dry, non-productive cough
o Tactile fremitus
o Orthopnea
o Tachycardia
Diagnostic Procedures
o Chest x-ray
o CT scan of the chest
o Ultrasound of the chest
o Thoracentesis
o Pleural fluid analysis via thoracentesis
Medical Management
o Thoracentesis
o Pleurectomy- consists of surgically stripping the parietal pleura from the
visceral pleura. This produces and inflammatory reaction that causes
adhesion formation between the two layers as they heal.
o Pleurodesis- involves the instillation of a sclerosing agent (talc,
doxycycline, or tetracycline) into the pleural space via a thoracotomy
tube. These agents cause the pleura to sclerose together.

Nursing interventions for pleural effusions

1. Identify and treat the underlying cause
2. Monitor breath sounds
3. Place the client in a high Fowler’s position
4. Encourage coughing and deep breathing
5. Prepare the client for thoracentesis
6. If pleural effusion is recurrent, prepare the client for pleurectomy or
pleurodesis as prescribed

Pneumonia

Description
1. Pneumonia is an infection of the
pulmonary tissue, including the
interstitial spaces, the alveoli, and
the bronchioles.
 2. The edema associated with inflammation stiffens the lung, decreases lung
compliance and vital capacity, and causes hypoxemia.
3. Pneumonia can be community acquired or hospital acquired.
4. The chest x-ray film shows diffuse patches throughout the lungs or
consolidation in a lobe.
5. A sputum culture identifies the organism.
6. The white blood cells and the erythrocyte sedimentation rate are elevated.

Causes
o Primary pneumonia is caused by the patient’s inhaling or aspirating a
pathogen such as bacteria or a virus. Bacterial pneumonia, often caused
by staphylococcus, streptococcus, or klebsiella, usually occurs when the
lungs’ defense mechanisms are impaired by such factors as suppressed
cough reflex, decreased cilia action, decreased activity of phagocytic
cells, and the accumulation of secretions. Viral pneumonia occurs when a
virus attacks bronchiolar epithelial cells and causes interstitial
inflammation and desquamation, which eventually spread to the alveoli.
o Secondary pneumonia ensues from lung damage that was caused by the
spread of bacteria from an infection elsewhere in the body or by a
noxious chemical. Aspiration pneumonia is caused by the patient’s
inhaling foreign matter such as food or vomitus into the bronchi. Factors
associated with aspiration pneumonia include old age, impaired gag
reflex, surgical procedures, debilitating disease, and decreased level of
consciousness.
o Community-acquired pneumonia is caused by bacteria that are divided
into two groups: typical and atypical. Organisms that cause typical
pneumonia include Streptococcus pneumonia (pneumococcus) and
Haemophilus and Staphylococcus species. Organisms that cause atypical
pneumonia include Legionella, Mycoplasma, and Chlamydia species.
Pathophysiology

Risk factors
o Cigarette smoking
o Recent viral respiratory infection (common cold, laryngitis, influenza)
o Difficulty swallowing (due to stroke, dementia, Parkinson’s disease, or
other neurological conditions)
o Chronic lung disease (COPD, bronchiectasis, cystic fibrosis)
o Cerebral palsy
o Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes
mellitus
o Living in a nursing facility
o Impaired consciousness (loss of brain function due to dementia, stroke, or
other neurologic conditions)
o Recent surgery or trauma
o Immune system problem

Assessment
 1. Chills
2. Elevated temperature
3. Pleuritic pain
4. Rhonchi and wheezes
5. Use of accessory muscles for breathing
6. Cyanosis
7. Mental status changes
8. Sputum production

Complications
o Respiratory failure, which requires a breathing machine or ventilator
o Empyema or lung abscesses. These are infrequent, but serious,
complications of pneumonia. They occur when pockets of pus form inside
or around the lung. These may sometimes need to be drained with
surgery.
o Sepsis, a condition in which there is uncontrolled swelling (inflammation)
in the body, which may lead to organ failure
o Acute respiratory distress syndrome (ARDS), a severe form of respiratory
failure

Primary Nursing Diagnosis

o Ineffective airway clearance related to increased production of secretions
and increased viscosity

Diagnostic Evaluation
o Sputum cultures and sensitivities reveals presence of infecting organisms.
Cultures identify organism; sensitivity testing identifies how resistant or
sensitive the bacteria are to antibiotics.
o Chest x-ray reveals areas of increased density, (can be a lung segment,
lobe, one lung, or both lungs). Findings reflect areas of infection and
consolidation.

Medical Management
1. Antibiotics are prescribed based on Gram stain results and antibiotic
guidelines (resistance patterns, risk factors, etiology must be considered).
Combination therapy may be used.
2. Supportive treatment includes hydration, antipyretics, antihistamines, or
nasal decongestants.
3. Best rest is recommended until infection shows signs of clearing.
 4. Oxygen therapy is given for hypoxemia.
5. Respiratory support includes endotracheal intubation, high inspiratory
oxygen concentrations, and mechanical ventilation.
6. Treatment of atelectasis, pleural effusion, shock, respiratory failure,
superinfection is instituted, if needed.
7. For groups of high risk for community-acquired pneumonia,
pneumococcal vaccination is advised.

Pharmacologic Intervention
Antibiotics
o Initial antibiotic: macrolides including erythromycin, azithromycin,
roxithromycin and clarithromycin. Macrolides provide coverage for likely
organisms in community-acquired bacterial pneumonia.
o Other antibiotics: Penicillin G for streptococcal pneumonia; nafcillin or
oxacillin for staphylococcal pneumonia; aminoglycoside or a
cephalosporin for klebsiella pneumonia; penicillin G or clindamycin for
aspiration pneumonia .Alternatives: amoxicillin and clavulanate
(Augmentin); doxycycline; trimethoprim and sulfamethoxazole (Bactrim
DS, Septra); levofloxacin (Levaquin)

Nursing Interventions
1. Administer oxygen as prescribed.
2. Monitor respiratory status.
3. Monitor for labored respirations, cyanosis, and cold and clammy skin.
4. Encourage coughing and deep breathing and use of incentive spirometer.
5. Position client in semi-Fowler position to facilitate breathing and lung
expansion.
6. Change client’s position frequently and ambulate as tolerated to mobilize
secretions
7. Provide CPT
8. Perform nasotracheal suctioning if the client is unable to clear secretions.
9. Monitor pulse oximetry.
10. Monitor and record color, consistency, and amount of sputum.
11. Provide a high-calorie, high protein diet with small frequent meals.
12. Encourage fluids up to 3 L a day to thin secretions unless contraindicated.
13. Provide a balance of rest and activity, increasing activity gradually.
14. Administer antibiotics as prescribed.
 15. Administer antipyretics, bronchodilators, cough suppressants, mucolytic
agents, and expectorants as prescribed.
16. Prevent the spread of infection by hand washing and the proper disposal
of secretions.

Documentation Guidelines
o Physical findings of chest assessment: Respiratory rate and depth,
auscultation findings, chest tightness or pain, vital signs
o Assessment of degree of hypoxemia: Lips and mucous membrane color,
oxygen saturation by pulse oximetry
o Response to deep-breathing and coughing exercises, color and amount of
sputum
o Response to medications: Body temperature, clearing of secretions

Discharge and Home Healthcare Guidelines

o Be sure the patient understands all medications, including dosage, route,
action, and adverse effects.
o The patient and family or significant other need to understand the
importance of avoiding fatigue by limiting activity and taking frequent
rests.
o Advise small, frequent meals to maintain adequate nutrition.
o Fluid intake should be maintained at approximately 3000 mL/day so that
the secretions remain thin.
o Teach the patient to maintain pulmonary hygiene measures of coughing,
deep breathing, and incentive spirometry at home.
o Provide information about how to stop smoking.
 Pneumothorax

Description
1. Pneumothorax is the accumulation
of atmospheric air in the pleural
space, which results in a rise in
intrathoracic pressure and reduced
vital capacity.
2. The loss of negative intrapleural
pressure results in collapse of the
lung.
3. A spontaneous
pneumothorax occurs with the rupture of a bleb.
4. An open pneumothorax occurs when an opening through the chest wall
allows the entrance of positive atmospheric pressure into the pleural
space.
5. Diagnosis of pneumothorax is made by chest x-ray film.

Causes
The cause of a closed or primary spontaneous pneumothorax is the
rupture of a bleb (vesicle) on the surface of the visceral pleura. Secondary
spontaneous pneumothorax can result from chronic obstructive pulmonary disease
(COPD), which is related to hyperinflation or air trapping, or from the effects of
cancer, which can result in the weakening of lung tissue or erosion into the pleural
space by the tumor. Blunt chest trauma and penetrating chest trauma are the
primary causes of traumatic and tension pneumothorax. Other possible causes
include therapeutic procedures such as thoracotomy, thoracentesis, and insertion
of a central line.

Assessment
1. Absent breath sounds on affected side
2. Cyanosis
3. Decreased chest expansion unilaterally
4. Dyspnea
5. Hypotension
6. Sharp chest pain
7. Subcutaneous emphysema as evidenced by crepitus on palpation
8. Sucking sound with open chest wound
9. Tachycardia
10. Tachypnea
11. Tracheal deviation to the unaffected side with tension pneumothorax
Complications
o Another collapsed lung in the future
o Shock

Primary Nursing Diagnosis

o Impaired gas exchange related to decreased oxygen diffusion capacity

Diagnostic Evaluation
o Chest x-ray reveals lung collapse with air between chest wall and visceral
pleura. Lungs are not filled with air but rather are collapsed.
o Other Tests: Complete blood count, plasma alcohol level, arterial blood
gases, rib x-rays, computed tomography (CT) scan.

Medical Management
o The priority is to maintain airway, breathing, and circulation. The most
important interventions focus on reinflating the lung by evacuating the
pleural air. Patients with a primary spontaneous pneumothorax that is
small with minimal symptoms may have spontaneous sealing and lung re-
expansion.
o For patients with jeopardized gas exchange, chest tube insertion may be
necessary to achieve lung re-expansion.
o Maintain a closed chest drainage system; be sure to tape all connections,
and secure the tube carefully at the insertion site with adhesive bandages.
Regulate suction according to the chest tube system directions; generally,
suction does not exceed 20 to 25 cm H2O negative pressure.
o Monitor a chest tube unit for any kinks or bubbling, which could indicate
an air leak, but do not clamp a chest tube without a physician’s order
because clamping may lead to tension pneumothorax.
o Stabilize the chest tube so that it does not drag or pull against the patient
or against the drainage system. Maintain aseptic technique, changing the
chest tube insertion site dressing and monitoring the site for signs and
symptoms of infection such as redness, swelling, warmth, and drainage.
o Oxygen therapy and mechanical ventilation are prescribed as needed.
Surgical interventions include removing the penetrating object,
exploratory thoracotomy, if necessary, thoracentesis, and thoracotomy for
 patients with two or more episodes of spontaneous pneumothorax or
patients with pneumothorax that does not resolve within 1 week.

Pharmacologic Highlights
No routine pharmacologic measures will treat pneumothorax, but the
patient may need antibiotics, local anesthesia agents for procedures, and
analgesics, depending on the extent and nature of the injury. Analgesia is
administered for pain once the patient’s pulmonary status has stabilized.

Nursing Interventions
1. Apply a dressing over an open chest wound.
2. Administer oxygen as prescribed.
3. Position the client in high fowler’s position.
4. Prepare for chest tube placement until the lung has expanded fully.
5. Monitor chest tube drainage system.
6. Monitor for subcutaneous emphysema.

Documentation Guidelines
o Physical findings: Breath sounds, vital signs, level of consciousness,
urinary output, skin temperature, amount and color of chest tube drainage,
dyspnea, cyanosis, nasal flaring, altered chest expansion, tracheal
deviation, absence of breath sounds
o Response to pain: Location, description, duration, response to
interventions
o Response to treatment: Chest tube insertion—type and amount of
drainage, presence of air leak, presence or absence of crepitus, amount of
suction, presence of clots, response to fluid resuscitation; response to
surgical management
o Complications: Infection (fever, wound drainage); inadequate gas
exchange (restlessness, dropping SaO2); tension pneumothorax

Discharge and Home Healthcare Guidelines

o Review all follow-up appointments, which often involve chest x-rays,
arterial blood gas analysis, and a physical exam. If the injury was alcohol-
related, explore the patient’s drinking pattern.
o Refer for counseling, if necessary. Teach the patient when to notify the
physician of complications (infection, an unhealed wound, and anxiety)
and to report any sudden chest pain or difficulty breathing.