RESTRICTIV

E DISORDERS
Prepared by: Earl John S. Amado, RN, MSN
Restrictive lung diseases are
characterized by reduced lung volumes, either
because of an alteration in lung parenchyma or
because of a disease of the pleura, chest wall, or
neuromuscular apparatus.
Obstructive lung diseases – Normal or TLC

Restrictive disease - TLC

Expiratory airflow are preserved
Airway resistance is normal
Forced expiratory volume in 1 second
(FEV1)/Forced vital capacity (FVC) ratio is
increased.
Obstructive lung diseases – Normal or TLC

Restrictive disease - TLC

Expiratory airflow are preserved
Airway resistance is normal
Forced expiratory volume in 1 second
(FEV1)/Forced vital capacity (FVC) ratio is
increased.
This course unit module discusses the following
topics:

1. Pneumonia
2. Pleurisy
3. Pleural Effusion
4. Chest Injuries
5. Pneumothorax
6. Pulmonary Edema
7. Pulmonary Embolism
8. Pulmonary Tuberculosis
PNEUMONIA
PNEUMONIA
Inflammation of lung tissues.
leading cause of death among the elderly and
people who are suffering from long time illness.
PNEUMONIA
TYPES OF PNEUMONIA
TYPES OF PNEUMONIA

Acute pneumonia - It is a type which

usually develops rapidly and lasts for 2 to 3
weeks. It is spread easily and can cause
symptoms very soon.
Chronic pneumonia - These develop
gradually over a period of weeks to months.
This type pneumonia does not spread easily.
TYPES OF PNEUMONIA

Community acquired pneumonia(CAP) - is

a LRTI of lung tissues with the onset in
community or during firs 48 hours of
hospitalization. Streptococcus is the most
common bacterial cause of CAP. This occurs
most commonly in very young and very old
people.
TYPES OF PNEUMONIA

Hospital-acquired pneumonia(HAP) - is an
infection that patients get while they’re in the
hospital, occurring 48 hours or longer after
hospital admission.
 Ventilator-Associated Pneumonia(VAP) 48-
72 hours after Endotracheal Intubation.
 Health Care-Associated Pneumonia(HCAP)
includes any pt. with a new onset pneumonia
who:
a. Was hospitalized in acute care hospital for 2 or
more days within 90 days of the infection.
b. Reside in a long-term care facility.
c. Received recent IV antibiotic therapy,
chemotherapy or wound care within 30 days of
current infection.
d. Attend a hospital or hemodialysis unit.
(Usually bacterial and rarely viral or fungal)
TYPES OF PNEUMONIA

Aspiration pneumonia - is an inflammation

of the lungs and bronchial tubes caused by
inhaling foreign material, usually food, drink,
vomit, or secretions from the mouth into the
lungs.
TYPES OF PNEUMONIA

Severe Acute Respiratory Syndrome

(SARS) - SARS is a highly contagious and
deadly type of pneumonia which first
occurred in 2002 after initial outbreaks in
China. SARS is caused by a virus called as
coronavirus.
TYPES OF PNEUMONIA

Chemical pneumonia - Chemical pneumonia

is caused by chemical toxins such as
pesticides, which may enter the body by
inhalation or by skin contact.
TYPES OF PNEUMONIA

Fungal Pneumonia - Caused by fungi (e.g.,

Histoplasma capsulatum, Coccidioides
immitis, candida albicans).
TYPES OF PNEUMONIA

Opportunistic Pneumonia - Patients with

altered immune response at risk to respiratory
infection.
Pneumococcal Pneumonia – Is the most
common cause of bacterial pneumonia, It is
caused by streptococcus pneumoniae, also
called pneumococcus (usually found in nose
and throat).
CAUSATIVE ORGANISMS
CAUSATIVE ORGANISMS

Viruses: Some viruses that cause pneumonia

are adenoviruses, rhinovirus, influenza virus
(flu), respiratory syncytial virus (RSV), and
parainfluenza virus.
CAUSATIVE ORGANISMS

Bacteria : The bacterium Streptococcus

pneumoniae, a common cause of pneumonia.
Bacteria typically enter the lung when airborne
droplets are inhaled, but they can also reach the
lung through the bloodstream when there is an
infection in another part of the body. Many bacteria
live in parts of the upper respiratory tract, such as
the nose, mouth and sinuses, and can easily be
inhaled into the alveoli.
CAUSATIVE ORGANISMS

Fungi: Fungal pneumonia is uncommon, but

it may occur in individuals with reduced
immune system due to AIDS or other medical
problems.
CAUSATIVE ORGANISMS

Parasites: A variety of parasites can affect the

lungs. These parasites typically enter the body
through the skin or by being swallowed. Once
inside the body, they travel to the lungs,
usually through the blood and cause disease.
ACQUISITION OF ORGANISMS
ACQUISITION OF ORGANISMS THAT
CAUSE PNEUMONIA ARE AS FOLLOWS:

Aspiration from nasopharynx or oropharynx.

Inhalation of microbes present in the air.
(mycoplasma pneumoniae & fungal
pneumonias).
Hematogenous spread from a primary
infection elsewhere in the body.
(staphylococcus aureus).
PHATOPHYSIOLOGY
 CAUSES:
BACTERIAL, BACTERIAL, FUNGAL, PARASITE

Inflammation of Lung Tissues

HYPERTROPHY OF MUCOUS MEMBRANE
Increased sputum production
Wheezing, Rhonchi, Rales, Dyspnea, Cough,

HYPER CAPILLARY PERMEABILITY

Increased fluid in ICS(Interstitial compartment)
Consolidation, Hypoxia
 INFLAMMATION OF THE PLAURAE
Chest pain, Pleural effusion, Dullness,
Diminished breath sound, Decreased vocal fremitus

HYPOVENTELATION
Decreased chest expansion
Respiratory Acidosis
PROTECTIVE MECHANISM
Increased WBC(Leukocytosis)
Increased RR, Fever
CLINICAL
MANIFESTATION
CLINICAL MANIFESTATION

Fever, shaking chills

Shortness of breath
Productive cough(rust- colored sputum)
Pleuritic chest pain
Confusion, stupor(elderly or debilitated pt.,
related to hypoxia)
Pulmonary consolidation(dullness on
percussion, increased fremitus, crackles)
INTERPROFESSIONAL
COLLABORATIVE
MANAGEMENT
INTERPROFESSIONAL COLLABORATIVE
MANAGEMENT

Promote Resto
Provide adequate fluids
Incentive spirometry
O2 therapy
Semi fowler’s position
Oral hygiene
Humidifier
INTERPROFESSIONAL COLLABORATIVE
MANAGEMENT

Splint chest when coughing

Monitor: sputum, chest x-ray, Temperature
Pharmacotherapy: Antibiotics(Blood culture
should be done before starting antibiotics)
Influenza and pneumococcal vaccine prior to
discharge(As ordered)
INTERPROFESSIONAL COLLABORATIVE
MANAGEMENT

Splint chest when coughing

Monitor: sputum, chest x-ray, Temperature
Pharmacotherapy: Antibiotics(Blood culture
should be done before starting antibiotics)
Influenza and pneumococcal vaccine prior to
discharge(As ordered)
COMPLICATIONS
COMPLICATIONS

Pleurisy
Pleural effusion
Atelectasis
Bacteremia(infection in the blood)
Lung abscess(s. aures & gram – pneumonia)
Empyema
Pericarditis
Meningitis
PLEURISY
PLEURISY
PLEURISY(pleuritis)
Refers to inflammation of both the visceral and
parietal pleurae.
When inflamed, pleural membranes rub together,
the result is severe, sharp, knifelike pain with
breathing that is intensified on inspiration.
Pleurisy may develop in
conjunction with:
Pneumonia or an upper respiratory tract infection
TB
Collagen disease
After trauma to the chest
Pulmonary infarction, or pulmonary embolism
(PE)
In patients with primary or metastatic cancer
After thoracotomy.
CLINICAL
MANIFESTATION
CLINICAL MANIFESTATION
Pain usually occurs on one side and worsens with
deep breaths, coughing, or sneezing.
Pain is decreased when the breath is held. Pain is
localized or radiates to the shoulder or abdomen.
As pleural fluid develops, pain lessens. A
friction rub can be auscultated but disappears as
fluid accumulates.
ASSESSMENT AND
DIAGNOSTIC METHODS
ASSESSMENT AND
DIAGNOSTIC METHODS
Auscultation for pleural friction rub
Chest x-rays
Sputum culture
Thoracentesis for pleural fluid examination,
pleural biopsy (less common)
NURSING
MANAGEMENT
NURSING MANAGEMENT
Enhance comfort by turning patient frequently on
affected side to splint chest wall.
Teach patient to use hands or pillow to splint rib
cage while coughing.
MEDICAL
MANAGEMENT
MEDICAL MANAGEMENT
Objectives of management are to discover the
underlying condition causing the pleurisy and to
relieve the pain.
Patient is monitored for signs and symptoms of
pleural effusion: shortness of breath, pain,
assumption of a position that decreases pain, and
decreased chest wall excursion.
MEDICAL MANAGEMENT
Prescribed analgesics, such as NSAIDs, are given
to relieve pain and allow effective coughing.
Applications of heat or cold are provided for
symptomatic relief.
An intercostal nerve block is done for severe pain.
PLEURAL EFFUSION
PLEURAL EFFUSION
A collection/accumulation of fluid in the pleural
space.
PLEURAL EFFUSION
Usually secondary to other diseases
Pneumonia
Pulmonary infections
Nephrotic syndrome
Connective tissue disease
Neoplastic tumors, congestive HF).
PLEURAL
EFFUSION
PLEURAL EFFUSION
The effusion can be relatively clear fluid (a
transudate or an exudates)
Water(Hydrothorax)
blood(Hemothorax)
Pus(Empyema/Pyothorax)
Lymphatic fluid(Chylothorax)
PLEURAL EFFUSION
Pleural fluid accumulates due to an imbalance in
hydrostatic or oncotic pressures (transudate) or
as a result of inflammation by bacterial products
or tumors (exudate).
PLEURAL EFFUSION
Pleural fluid accumulates due to an imbalance in
hydrostatic or oncotic pressures (transudate) or
as a result of inflammation by bacterial products
or tumors (exudate).
CLINICAL
MANIFESTATIONS
CLINICAL MANIFESTATIONS
Some symptoms are caused by the underlying
disease;
Pneumonia causes fever, chills, and pleuritic chest
pain.
Malignant effusion may result in dyspnea and
coughing.
CLINICAL MANIFESTATIONS
The size of the effusion, the speed of its formation,
and the underlying lung disease determine the
severity of symptoms.
Large effusion: shortness of breath to acute
respiratory distress.
Small to moderate effusion: Dyspnea may not be
present.
CLINICAL MANIFESTATIONS
Dullness or flatness to percussion over areas of
fluid, minimal or absence of breath sounds,
decreased fremitus, and tracheal deviation away
from the affected side.
ASSESSMENT AND
DIAGNOSTIC METHODS
ASSESSMENT AND
DIAGNOSTIC METHODS
Physical examination
Chest x-rays (lateral decubitus)
Chest CT scan
Thoracentesis
Pleural fluid analysis (culture, chemistry,
cytology)
Pleural biopsy
MEDICAL
MANAGEMENT
MEDICAL MANAGEMENT
Objectives of treatment are to discover the underlying
cause; to prevent reaccumulation of fluid; and to
relieve discomfort, dyspnea, and respiratory
compromise. Specific treatment is directed at the
underlying cause. Chest x-rays (lateral decubitus)
MEDICAL MANAGEMENT
Thoracentesis is performed to remove fluid, collect
specimen for analysis, and relieve dyspnea.
Chest tube and water-seal drainage may be
necessary for drainage and lung reexpansion.
MEDICAL MANAGEMENT
Chemical pleurodesis: Adhesion formation is
promoted when drugs are instilled into the pleural
space to obliterate the space and prevent further
accumulation of fluid.
Other treatment modalities include surgical
pleurectomy (insertion of a small catheter attached
to a drainage bottle) or implantation of a
pleuroperitoneal shunt.
NURSING
MANAGEMENT
NURSING MANAGEMENT
Implement medical regimen: Prepare and position
patient for thoracentesis and offer support
throughout the procedure.
Monitor chest tube drainage and water-seal
system; record amount of drainage at prescribed
intervals
NURSING MANAGEMENT
Administer nursing care related to the underlying
cause of the pleural effusion.
Assist patient in pain relief. Assist patient to
assume positions that are least painful. Administer
pain medication as prescribed and needed to
continue frequent turning and ambulation.
NURSING MANAGEMENT
If the patient is to be managed as an outpatient
with a pleural catheter for drainage, educate the
patient and family about management and care of
the catheter and drainage system.
THORACENTESIS
THORACENTESIS
Removal of excess air and fluid from the pleural
cavity.
THORACENTESIS
PREVENT INFECTION:
Sterile technique o Site of insertion:
Depending on the MD’s assessment
Chest X-ray: best method to pinpoint the
THORACENTESIS
POSITION:
Sitting on the edge of the bed with feet supported
and arms on a padded over- bed table
Straddling a chair with arms and head resting on
the back of the chair
THORACENTESIS
If the patient cannot sit:
Lying on the unaffected side with the head of the
bed elevated 30-450
Kozier: sitting with arms above the head
THORACENTESIS
SECURE THE CONSENT:
Obtained by: MD
Secured by: RN
Given by: patient
THORACENTESIS
Instruction upon insertion:
Exhale and hold
Watch out for:
Respiratory distress
Hypotension
Prevent hypotension:
✓Do not remove >1000 mL for the first 30
mins.
THORACENTESIS
Post-procedure:
Apply vaselinized or petrolatum gauze
Position post-procedure:
Side-lying on the unaffected side
Emergency!
If the client expectorate blood (may mean
accidental puncture of the lungs) NOTIFY the
MD!
THORACENTESIS
Rule-out pneumothorax:
Chest X-Ray
Health teaching post procedure:
Avoid coughing
Deep breathing
Straining
CHEST INJURIES
CHEST INJURIES
Major chest trauma may occur alone or in
combination with multiple other injuries.
CHEST INJURIES
Classified as either blunt or penetrating.
Blunt chest trauma results from sudden compression or
positive pressure inflicted to the chest wall.
Penetrating trauma occurs when a foreign object
penetrates the chest wall.
RIB FRACTURE
Fracture resulting from direct blunt chest trauma
S/Sx:
Pain at the site (increases with respiration)
Mngt:
Unite spontaneously
High fowler’s position
RIB FRACTURE
Fracture resulting from direct blunt chest trauma
S/Sx:
Pain at the site (increases with respiration)
Mngt:
Unite spontaneously
High fowler’s position
FLAIL CHEST
Fracture or 3 or more ribs resulting from direct blunt chest
trauma.
S/Sx:
PARADOXICAL BREATHING
Mngt:
Oxygen
WOF respiratory distress
High fowler’s position
FLAIL CHEST
Fracture or 3 or more ribs resulting from direct blunt chest
trauma.
S/Sx:
PARADOXICAL BREATHING
Mngt:
Oxygen
WOF respiratory distress
High fowler’s position
PNEUMOTHORAX
PNEUMOTHORAX
Accumulation of atmospheric air in pleural space
which results in rise in intra- thoracic pressure.
PNEUMOTHORAX
TYPES OF
PNEUMOTHORAX
TYPES OF PNEUMOTHORAX
CLOSED Pneumothorax
It has no associated external wound(Spontaneous
pneumothorax caused by raptured bleb or bullae
on the visceral pleral space)
OPEN Pneumothorax
It occurs when air enters the plaural space
through ab opening in the chest wall.
TYPES OF PNEUMOTHORAX
OPEN Pneumothorax
Cover with a nonporous vented dressing.
If the object that cause the open wound is still in
place, it should not be removed until a physician
is present. Impaled object should be stabilized
with bulk dressing.
TYPES OF PNEUMOTHORAX
TENSION Pneumothorax
Rapid accumulation of air in the pleural space,
causing severely high intrapleral pressures with
resultant tension on the heart and greater vessels.
Intrathoracic pressure increase, the lungs
collapse, the mediastinum shift toward the
unaffected side, which is subsequently
compressed.
TYPES OF PNEUMOTHORAX
S/Sx:
Dyspnea
Decreased or Absent breath sound on the
affected side
Decreased chest expansion
Tracheal deviation to the unaffected side (CXR)
- Exclusive for TENSION pneumothorax
Mngt: Thoracentesis
TYPES OF PNEUMOTHORAX
S/Sx:
Dyspnea
Decreased or Absent breath sound on the
affected side
Decreased chest expansion
Tracheal deviation to the unaffected side (CXR)
- Exclusive for TENSION pneumothorax
Mngt: Thoracentesis
CHEST TUBES AND
DRAINAGE SYSTEM
CHEST TUBES AND
DRAINAGE SYSTEM
Aims to restore negative pressure of the pleural
cavity and drain collected fluid/blood.
CHEST TUBES AND
DRAINAGE SYSTEM
COMPONENTS:
Suction control chamber
Water seal chamber
Closed collection chamber
CHEST TUBES AND
DRAINAGE SYSTEM
COMPONENTS:
Suction control chamber
Water seal chamber
Closed collection chamber
CHEST TUBES AND DRAINAGE
SYSTEM
ASSESSMENT OF THE SITE:
At least every 4 hours for:
Excessive or abnormal drainage
Cracking sound upon palpation for subcutaneous
emphysema
REPOSITIONING:
Every 2 hours
If lying on the affected side
(put a rolled towel beside the tubing)
CHEST TUBES AND
DRAINAGE SYSTEM
REMEMBER:
Keep the collection device below the client’s
chest level
OSCILLATIONS OR FLUCTUATIONS ON
WATER SEAL:
NORMAL
CHEST TUBES AND
DRAINAGE SYSTEM
ABSENCE:
Re-expansion of the lungs
Obstruction
Mngt:
Notify the MD for CXR
Obstruction: NO milking and stripping
SQUEEZE (hand-over-hand)
CHEST TUBES AND
DRAINAGE SYSTEM
PRESENCE OF BUBBLING:
Drainage Bottle: NO BUBBLING
Water Seal Bottle: INTERMITTENT
BUBBLING
Suction Control Bottle: CONTINOUS GENTLE
BUBBLING
CHEST TUBES AND
DRAINAGE SYSTEM
ABNORMAL BUBBLING:
Water Seal Bottle: CONTINOUS BUBBLING
Suction Control Bottle: VIGOROUS
BUBBLING
ALERT: LEAKAGE!!!
CHEST TUBES AND
DRAINAGE SYSTEM
MANAGEMENT:
CLAMP the tube and TAPE the leak (allowed
for short periods)
PROLONGED CLAMPING: can cause tension
pneumothorax
CHEST TUBES AND DRAINAGE
SYSTEM
ABSENCE OF BUBBLING:
Water Seal Bottle
Suction Control Bottle
May mean:
Lung Re-expansion
Obstruction
Mngt:
Notify the MD for CXR
Obstruction: NO milking and stripping
SQUEEZE (hand-over-hand)
CHEST TUBES AND
DRAINAGE SYSTEM
POINTS TO REMEMBER:
TUBE PULLED FROM THE SITE
Cover the puncture site with thick layers of
sterile gauze or non-porous material,
✓ If not available in the choices:
Vaselinized gauze
Petrolatum gauze
CHEST TUBES AND
DRAINAGE SYSTEM
TUBE DISCONNECTED or WATER SEAL
BOTTLE BREAKS:
Submerge the end/tip of the rubber tubing in a
bottle of sterile saline or water
Reconnect
PULMONARY
EDEMA
PULMONARY EDEMA
is the abnormal accumulation of fluid in the
interstitial spaces of the lungs that diffuses into
the alveoli.
PULMONARY
EDEMA
CLINICAL
MANIFESTATIONS
CLINICAL
MANIFESTATIONS
restless and anxious.
Along with a sudden onset of breathlessness and
a sense of suffocation, the patient’s hands
become cold and moist, the nail beds become
cyanotic (bluish), and the skin turns ashen
(gray).
CLINICAL
MANIFESTATIONS
The pulse is weak and rapid, and the neck veins
are distended.
Incessant coughing may occur, producing
increasing quantities of foamy sputum.
As pulmonary edema progresses, the patient’s
anxiety and restlessness increase; the patient
becomes confused, then stuporous.
CLINICAL
MANIFESTATIONS
Breathing is rapid, noisy, and moist-sounding;
the patient’s oxygen saturation is significantly
decreased.
The patient, nearly suffocated by the blood-
tinged, frothy fluid filling the alveoli, is literally
drowning in secretions. The situation demands
emergent action.
ASSESSMENT AND
DIAGNOSTIC METHODS
ASSESSMENT AND
DIAGNOSTIC METHODS
Diagnosis is made by evaluating the clinical
manifestations resulting from pulmonary
congestion
Abrupt onset of LSHF(e.g., crackles on
auscultation of the lungs) may occur without
evidence of RSHF (e.g., no jugular venous
distention [JVD], no dependent edema).
ASSESSMENT AND
DIAGNOSTIC METHODS
Chest x-ray reveals increased interstitial
markings.
Pulse oximetry to assess ABG levels.
MEDICAL
MANAGEMENT
MEDICAL MANAGEMENT
Goals of medical management are to reduce volume
overload, improve ventricular function, and increase
respiratory exchange using a combination of
oxygen and medication therapies.
MEDICAL MANAGEMENT
OXYGENATION
Oxygen in concentrations adequate to relieve
hypoxia and dyspnea.
Endotracheal intubation and mechanical
ventilation, if respiratory failure occurs.
Positive end-expiratory pressure (PEEP)
Monitoring of pulse oximetry and ABGs
MEDICAL MANAGEMENT
PHARMACOLOGIC THERAPY
Morphine given intravenously in small doses to
reduce anxiety and dyspnea.
 have naloxone hydrochloride (Narcan) available for
excessive respiratory depression.
Diuretics (eg, furosemide) to produce a rapid
diuretic effect.
Vasodilators such as IV nitroglycerin or
nitroprusside (Nipride) may enhance symptom
relief.
NURSING
MANAGEMENT
NURSING MANAGEMENT
Assist with administration of oxygen and
intubation and mechanical ventilation.
Position patient upright (in bed if necessary) or
with legs and feet down to promote circulation.
Preferably position patient with legs dangling
over the side of bed.
NURSING MANAGEMENT
Provide psychological support by reassuring
patient. Use touch to convey a sense of concrete
reality. Maximize time at the bedside.
Give frequent, simple, concise information about
what is being done to treat the condition and
what the responses to treatment mean.
NURSING MANAGEMENT
Monitor effects of medications. Observe patient
for excessive respiratory depression,
hypotension, and vomiting. Keep a morphine
antagonist available (e.g., naloxone
hydrochloride).
Insert and maintain an indwelling catheter if
ordered or provide bedside commode.
NURSING MANAGEMENT
The patient receiving continuous IV infusions of
vasoactive medications requires ECG monitoring
and frequent measurement of vital signs.
PULMONARY
EMBOLISM(PE)
PULMONARY EMBOLISM
is the abnormal accumulation of fluid in the
interstitial spaces of the lungs that diffuses into
the alveoli.
PULMONARY EMBOLISM
Gas exchange is impaired in the lung mass
supplied by the obstructed vessel. Massive PE is
a life- threatening emergency; death commonly
occurs within 1 hour after the onset of
symptoms.
PULMONARY EMBOLISM
It is a common disorder associated with;
Trauma
Surgery (orthopedic, major abdominal, pelvic,
gynecologic)
Pregnancy
HF
Age more than 50 years
Hypercoagulable states, and prolonged immobility.
It also may occur in apparently healthy people. Most
thrombi originate in the deep veins of the legs.
CLINICAL
MANIFESTATIONS
CLINICAL
MANIFESTATIONS
Restlessness(Cardinal initial sign)
Dyspnea is the most common symptom.
Tachypnea is the most frequent sign.
Chest pain is common, usually sudden in onset
and pleuritic in nature; it can be substernal and
may mimic angina pectoris or a myocardial
infarction.
CLINICAL
MANIFESTATIONS
Anxiety, fever, tachycardia, apprehension,
cough, diaphoresis, hemoptysis, syncope, shock,
and sudden death may occur.
Clinical picture may mimic that of
bronchopneumonia or HF.
CLINICAL
MANIFESTATIONS
In atypical instances, PE causes few signs and
symptoms, whereas in other instances it mimics
various other cardiopulmonary disorders.
ASSESSMENT AND
DIAGNOSTIC METHODS
ASSESSMENT AND
DIAGNOSTIC METHODS
Because the symptoms of PE can vary from few
to severe, a diagnostic workup is performed to
rule out other diseases.
The initial diagnostic workup may include chest
x-ray, ECG, ABG analysis, and ventilation–
perfusion scan.
ASSESSMENT AND
DIAGNOSTIC METHODS
Pulmonary angiography is considered the best
method to diagnose PE; however, it may not be
feasible, cost-effective, or easily performed,
especially with critically ill patients.
Spiral CT scan of the lung, D-dimer assay (blood
test for evidence of blood clots), and pulmonary
arteriogram may be warranted.
PREVENTION
PREVENTION
Ambulation or leg exercises in patients on bed
rest.
Application of sequential compression devices.
Anticoagulant therapy for patients whose
hemostasis is adequate and who are undergoing
major elective abdominal or thoracic surgery.
MEDICAL
MANAGEMENT
MEDICAL MANAGEMENT
Immediate objective is to stabilize the
cardiopulmonary system.
Nasal oxygen is administered immediately to
relieve hypoxemia, respiratory distress, and
central cyanosis.
IV infusion lines are inserted to establish routes
for medications or fluids that will be needed.
MEDICAL MANAGEMENT
A perfusion scan, hemodynamic measurements,
and ABG determinations are performed. Spiral
(helical) CT or pulmonary angiography may be
performed.
Hypotension is treated by a slow infusion of
dobutamine (Dobutrex), which has a dilating
effect on the pulmonary vessels and bronchi, or
dopamine (Intropin).
MEDICAL MANAGEMENT
The ECG is monitored continuously for
dysrhythmias and right ventricular failure, which
may occur suddenly.
Digitalis glycosides, IV diuretics, and
antiarrhythmic agents are administered when
appropriate.
MEDICAL MANAGEMENT
Blood is drawn for serum electrolytes, complete
blood cell count, and hematocrit.
If clinical assessment and ABG analysis indicate
the need, the patient is intubated and placed on a
mechanical ventilator.
MEDICAL MANAGEMENT
If the patient has suffered massive embolism and
is hypotensive, an indwelling urinary catheter is
inserted to monitor urinary output.
Small doses of IV morphine or sedatives are
administered to relieve patient anxiety, to
alleviate chest discomfort, to improve tolerance
of the endotracheal tube, and to ease adaptation
to the mechanical ventilator.
ANTICOAGULATION
THERAPY
ANTICOAGULATION THERAPY
Anticoagulant therapy (heparin, warfarin sodium
[Coumadin]) has traditionally been the primary
method for managing acute DVT and PE (numerous
specific options for treatment are available).
Patients must continue to take some form of
anticoagulation for at least 3 to 6 months after the
embolic event.
WOF: ANY SIGNS OF BLEEDING!!
THROMBOLYTIC
THERAPY
THROMBOLYTIC THERAPY
Thrombolytic therapy may include urokinase,
streptokinase, and alteplase. It is reserved for PE
affecting a significant area and causing
hemodynamic instability.
Bleeding is a significant side effect; nonessential
invasive procedures are avoided.
WOF: ANY SIGNS OF BLEEDING!!
SURGICAL
MANAGEMENT
SURGICAL MANAGEMENT
A surgical embolectomy is rarely performed but
may be indicated if the patient has a massive PE
or hemodynamic instability or if there are
contraindications to thrombolytic therapy.
Transvenous catheter embolectomy with or
without insertion of an inferior vena caval filter
(eg, Greenfield).
PREVENTING
THROMBUS FORMATION
PREVENTING THROMBUS
FORMATION
Encourage early ambulation and active and passive leg
exercises.
Instruct patient to move legs in a “pumping” exercise.
Advise patient to avoid prolonged sitting, immobility, and
constrictive clothing.
Do not permit dangling of legs and feet in a dependent
position.
Instruct patient to place feet on floor or chair and to avoid
crossing legs.
Do not leave IV catheters in veins for prolonged periods.
MINIMIZING CHEST
PAIN, PLEURITIC
MINIMIZING CHEST PAIN,
PLEURITIC
Place patient in semi-Fowler’s position; turn and
reposition frequently.
Administer analgesics as prescribed for severe
pain.
MANAGING OXYGEN
THERAPY
MANAGING OXYGEN
THERAPY
Assess the patient frequently for signs of
hypoxemia and monitors the pulse oximetry values.
Assist patient with deep breathing and incentive
spirometry.
Nebulizer therapy or percussion and postural
drainage may be necessary for management of
secretions.
ALLEVIATING ANXIETY
ALLEVIATING ANXIETY
Encourage patient to express feelings and
concerns.
Answer questions concisely and accurately.
Explain therapy, and describe how to recognize
untoward effects early.
MONITORING FOR
COMPLICATIONS
MONITORING FOR
COMPLICATIONS
Be alert for the potential complication of
cardiogenic shock or right ventricular failure
subsequent to the effect of PE on the
cardiovascular system.
PROVIDING
POSTOPERATIVE
NURSING CARE
PROVIDING
POSTOPERATIVE NURSING
CARE
Measure pulmonary arterial pressure and urinary
output.
Assess insertion site of arterial catheter for
hematoma formation and infection.
Maintain blood pressure to ensure perfusion of
vital organs.
PROVIDING
POSTOPERATIVE NURSING
CARE
Encourage isometric exercises, antiembolism
stockings, and walking when permitted out of
bed; elevate foot of bed when patient is resting.
Discourage sitting; hip flexion compresses large
veins in the legs.
PULMONARY
TUBERCULOSIS
PULMONARY
TUBERCULOSIS(PTB)
An infectious disease primarily affecting the
lung parenchyma, is most often caused by
Mycobacterium tuberculosis.
PULMONARY
TUBERCULOSIS(PTB)
It may spread to almost any part of the body,
including the meninges, kidney, bones, and
lymph nodes. The initial infection usually occurs
2 to 10 weeks after exposure.
PULMONARY
TUBERCULOSIS
(PTB)
RISK FACTORS
RISK FACTORS
Close contact with someone who has active TB
Immunocompromised status (eg, elderly, cancer,
corticosteroid therapy, and HIV)
Injection drug use and alcoholism
RISK FACTORS
People lacking adequate health care (eg,
homeless or impoverished, minorities, children,
and young adults)
Preexisting medical conditions, including
diabetes, chronic renal failure, silicosis, and
malnourishment
Immigrants from countries with a high incidence
of TB (eg, Haiti, southeast Asia)
RISK FACTORS
Institutionalization (eg, long-term care facilities,
prisons)
Living in overcrowded, substandard housing
Occupation (eg, health care workers, particularly
those performing high-risk activities)
MULTI-DRUG
RESISTANCE TB(MDR-TB)
MULTI-DRUG RESISTANCE
TB(MDR-TB)
Occurs when a person develops resistance to
isoniazid and rifampicin.
 Poor compliance to medications, leading to
treatment failure;
>Lost to follow up treatment.
>Placed on a regimen to which their
infections were no longer susceptible.
CLASSIFICATION OF TB
CLASSIFICATION OF TB
Class 0: No exposure, no infection.
Class 1: Exposure; no infection.
Class 2: Infection; no disease (+PPD reaction but
no clinical evidence of active PTB).
Class 3: Disease; clinically active.
Class 4: Disease; not clinically active.
Class 5: Suspected disease, diagnosis pending.
CLASSIFICATION OF TB
PHATOPHYSIOLOGY
MYCOBACTERIUM TUBERCULOSIS
(Gram – positive, acid fast bacillus)

Inhalation of dried droplet nuclei

(Airborne droplets)
INFLAMMATION OF ALVEOLI

1. Lymph nodes filter drainage

2. Primary Tubercle
3. Necrosis
4. Caseation
 Tubercle bacilli

Calcified

“GHON TUBERCLE”
(Primary complex)
Fibrotic tissue

Liquefaction

Coughed up
 Cavity

Hemoptysis
CLINICAL
MANIFESTATION
CLINICAL MANIFESTATION
Fatigue
Malaise
Anorexia
Unexpected weight loss
Low grade fever
Night sweats
Cough(frequent, with white frothy sputum)
Hemoptysis(in advance cases)
CLINICAL MANIFESTATION
NOTE: In early stage of TB, the person is usually
free from symptoms. People with latent TB
infection (LTBI) have positive skin test but are
asymptomatic.
ASSESSMENT AND
DIAGNOSTIC METHODS
ASSESSMENT AND
DIAGNOSTIC METHODS
TB skin test (Mantoux test);
PPD(Protein purified derivative)
Induration(not redness) 48-72 hrs. after test means
the person has been exposure to TB and has develop
antibodies.
QuantiFERON-TB Gold (QFT-G) test
Chest x-ray
Acid-fast bacillus smear
Sputum culture
MEDICAL
MANAGEMENT
MEDICAL MANAGEMENT
Pulmonary TB is treated primarily with
antituberculosis agents for 6 to 12 months. A
prolonged treatment duration is necessary to
ensure eradication of the organisms and to
prevent relapse.
PHARMACOLOGIC
THERAPY
PHARMACOLOGIC THERAPY
First-line medications: isoniazid or INH
(Nydrazid), rifampin (Rifadin), pyrazinamide, and
ethambutol (Myambutol) daily for 8 weeks and
continuing for up to 4 to 7 months
Second-line medications: capreomycin (Capastat),
ethionamide (Trecator), para aminosalicylate
sodium, and cycloserine (Seromycin)
Vitamin B (pyridoxine) usually administered with
INH
NURSING MANAGEMENT
PROMOTING AIRWAY
CLEARANCE
NURSING MANAGEMENT
PROMOTING AIRWAY
CLEARANCE
Encourage increased fluid intake.
Instruct about best position to facilitate drainage.
ADVOCATING
ADHERENCE TO
TREATMENT REGIMEN
ADVOCATING ADHERENCE
TO TREATMENT REGIMEN
Explain that TB is a communicable disease and
that taking medications is the most effective way
of preventing transmission.
Instruct about medications, schedule, and side
effects; monitor for side effects of anti-TB
medications.
ADVOCATING ADHERENCE
TO TREATMENT REGIMEN
Instruct about the risk of drug resistance if the
medication regimen is not strictly and
continuously followed.
Carefully monitor vital signs and observe for
spikes in temperature or changes in the patient’s
clinical status.
ADVOCATING ADHERENCE
TO TREATMENT REGIMEN
Teach caregivers of patients who are not
hospitalized to monitor the patient’s temperature
and respiratory status; report any changes in the
patient’s respiratory status to the primary health
care provider.
PROMOTING ACTIVITY
AND ADEQUATE
NUTRITION
PROMOTING ACTIVITY AND
ADEQUATE NUTRITION
Plan a progressive activity schedule with the
patient to increase activity tolerance and muscle
strength.
Devise a complementary plan to encourage
adequate nutrition. A nutritional regimen of
small, frequent meals and nutritional
supplements may be helpful in meeting daily
caloric requirements.
PROMOTING ACTIVITY AND
ADEQUATE NUTRITION
Identify facilities (eg, shelters, soup kitchens,
Meals on Wheels) that provide meals in the
patient’s neighborhood may increase the
likelihood that the patient with limited resources
and energy will have access to a more nutritious
intake.
PREVENTING SPREADING
OF TB INFECTION
PREVENTING SPREADING
OF TB INFECTION
Carefully instruct the patient about important
hygiene measures, including mouth care,
covering the mouth and nose when coughing and
sneezing, proper disposal of tissues, and
handwashing.
PREVENTING SPREADING
OF TB INFECTION
Report any cases of TB to the health department
so that people who have been in contact with the
affected patient during the infectious stage can
undergo screening and possible treatment, if
indicated.
PREVENTING SPREADING
OF TB INFECTION
Instruct patient about the risk of spreading TB to
other parts of the body (spread or dissemination
of TB infection to non pulmonary sites of the
body is known as miliary TB).
PREVENTING SPREADING
OF TB INFECTION
Carefully monitor patient for military TB:
Monitor vital signs and observe for spikes in
temperature as well as changes in renal and
cognitive function; few physical signs may be
elicited on physical examination of the chest, but
at this stage the patient has a severe cough and
dyspnea. Treatment of miliary TB is the same as
for pulmonary TB.
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