PLT COLLEGE INC.

College of Nursing
Bayombong, Nueva Vizcaya

Nursing Care Management 103 (Care of the Clients with Problems in

Oxygenation)

LOWER RESPIRATORY TRACT DISEASES

1. ALLERGIC RHINITIS

Philip kept on rubbing at his nose for 2 days now. This was noticed by his mother, who
then asked if Philip is feeling okay. Philip complained that his nose feels stuffy, and he
keeps on sneezing. Philip’s mother brought him to his pediatrician and after several
tests, Philip was found out to have allergic rhinitis.

Description

 Although allergic rhinitis (AR) is a common disease, the impact on daily life cannot
be underestimated.
 Allergic rhinitis in children is most often caused by sensitization to animal dander,
house dust, pollens, and molds.
 Pollen allergy seldom appears before 4 or 5 years of age.
 Sensitization to outdoor allergens can occur in allergic rhinitis in children older than
2 years; however, sensitization to outdoor allergens is more common in children
older than 4-6 years.

Pathophysiology

Study Now & Be Successful Later…princerenerpera

 The purpose of the nose is to filter, humidify, and regulate the temperature of
inspired air; this is accomplished on a large surface area spread over 3 turbinates in
each nostril.
 A triad of physical elements (ie, a thin layer of mucus, cilia, and vibrissae [hairs] that
trap particles in the air) accomplishes temperature regulation.
 The amount of blood flow to each nostril regulates the size of the turbinates and
affects airflow resistance.
 The nature of the filtered particles can affect the nose.
 Irritants (eg, cigarette smoke, cold air) cause short-term rhinitis; however, allergens
cause a cascade of events that can lead to more significant, prolonged
inflammatory reactions.
 In short, rhinitis results from a local defense mechanism in the nasal airways that
attempts to prevent irritants and allergens from entering the lungs.

Statistics and Incidences

1
 Allergic rhinitis (AR) has no race predilection; however, individuals from nonwhite
backgrounds seek out medical attention less often than whites.
 AR has no sex predilection.
 Clinically significant sensitization to indoor allergens may occur in children younger
than 2 years.
 AR-like symptoms (runny nose, blocked nose, or sneezing apart from a cold) may
begin as early as age 18 months.
 In a report from the Pollution and Asthma Risk: an Infant Study (PARIS), 9.1% of the
1859 toddlers in the study cohort reported allergic rhinitis-like symptoms at age 18
months.

Causes

AR is caused by an immunoglobulin E (IgE)–mediated reaction to various allergens in

the nasal mucosa.
Allergens. The most common allergens include dust mites, pet danders, cockroaches,
molds, and pollens.

Clinical Manifestations

Symptoms of rhinitis consist of:

 Rhinorrhea. This condition is commonly called “runny nose”.
 Nasal congestion. The child may complain of stuffiness in the nose.
 Postnasal drainage. This occurs when excessive mucus is produced by the nasal
mucosa.
 Repetitive sneezing. Sneezing repeatedly is a sign that there is irritation.
 Itchiness. There is itching of the palate, ears, nose, or eyes.
 Allergic salute. The allergic salute is when the child pushes his or her nose upward
and backward to relieve itching and open the air passages in the nose.

Assessment and Diagnostic Findings

Study Now & Be Successful Later…princerenerpera

No studies are needed in allergic rhinitis (AR) if the patient has a straightforward history.

When the history is confusing, various studies are helpful, including the following:
 Skin-prick testing. This test is highly sensitive and specific for aeroallergens; however,
a false positive reaction can occur without corresponding clinical features,
especially when skin mast cells are easily activated by pressure or other physical
stimuli.
 Serum allergen-specific IgE testing. The main limitations are that patients may be
sensitive on a molecular level before IgE response is clinically seen on standard skin
testing; this may lead to positive results on laboratory tests that are not triggering
clinical symptoms.
 Nasal smear. Eosinophils usually indicate allergy.
 CBC count with differential. A CBC count may reveal an increased number of
eosinophils; an eosinophil count within the reference range does not exclude AR;
however, an elevated eosinophil count is suggestive of the diagnosis.

Medical Management

2
Treatment of allergic rhinitis (AR) can be divided into 3 categories: avoidance of
allergens or environmental controls, medications, and allergen-specific immunotherapy
(sublingual or allergy shots).

Environment control. Use of environmental controls is not adequately explored in most

patients; for many patients, the removal of the trigger can have a dramatic effect;
difficulty arises when the trigger needs to be identified and eliminated; eliminating the
trigger may be simple if removal of a feather pillow or blanket is involved; however, it
can be very difficult if a family pet needs to be removed.

Pharmacologic Management
Many groups of medications are used for allergic rhinitis (AR), including antihistamines,
corticosteroids, decongestants, saline, sodium cromolyn, and leukotriene receptor
antagonists.

 2nd generation antihistamines. Antihistamines are classified in several ways,

including sedating and nonsedating, newer and older, and first- and second-
generation antihistamines (most widely accepted classification); first-generation
antihistamines are primarily over-the-counter OTC) and are included in many
combination products for cough, colds, and allergies.
 Intranasal antihistamines. These agents are an alternative to oral antihistamines to
treat allergic rhinitis; currently, azelastine and olopatadine are the only agents
available in the United States.
 Intranasal corticosteroids. This class of medications is most effective; intranasal
corticosteroids are potent anti-inflammatory agents shown to decrease allergic
rhinitis symptoms in more than 90% of patients.
 Intranasal antihistamine and corticosteroids. Combination products are emerging
on the market for patients who require an intranasal antihistamine and
corticosteroids.
 Intranasal decongestants. Decongestants are effective for short-term symptom

Study Now & Be Successful Later…princerenerpera

control; they decrease nasal discharge and congestion and are available without
a prescription.
 Leukotriene receptor agonists. Montelukast has been approved as monotherapy
for allergic rhinitis; it has been shown to be most effective in patients in whom
significant congestion is a primary complaint.
 Allergen immunotherapy. Immunotherapy with daily sublingual (SL) tablets may be
able to replace weekly injections in some individuals, depending on the offending
allergens; depending on the particular SL tablet, therapy must be initiated at least
3-4 months before the allergen season that is being treated.
 Intranasal mast cell stabilizers. These are effective therapy for AR in approximately
70-80% of patients; they produce mast cell stabilization and antiallergic effects by
inhibiting mast cell degranulation.

Nursing Management

Nursing Assessment

3
History. Nurses should try to identify seasonal variations, provocative elements in the
environment, and the timing of events that lead to symptoms; for example, if the
patient only has issues during the week, this may lead to investigating the environment
of the child’s classroom or daycare for allergens like pets or molds.

Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses are:

Ineffective airway clearance related to obstruction or presence of thickened

secretions.
Disturbed sleep pattern related to obstruction of the nose.
Self-concept disturbance related to the condition.
Anxiety related to lack of knowledge about the disease and medical action
procedure.

Nursing Care Planning and Goals

 Child will no longer breathe through the mouth.
 Airway will be back to normal, especially the nose.
 Child will sleep 6-8 hours a day.
 Child and parents will describe the level of anxiety and coping patterns.
 Child and parents will know and understand about the disease and treatment.

Nursing Interventions
 Identification of the allergen. Identification and elimination is easiest for dust mite
allergens; pollen is more difficult to avoid because daily activities must be altered to
do so; an easy intervention is to keep the windows closed, which is easily
accomplished in air-conditioned homes and must be done throughout the year.
 Use of nasal sprays. Teach the patient and parents on how to use nasal sprays by
blowing the nose first then administering the medication.
 Encourage thorough cleaning of the house. Encourage a routine cleaning of the
house, furniture, and equipment which may house dust and other pollens.

Study Now & Be Successful Later…princerenerpera

 Encourage medication compliance. Administer pharmacologic treatment as
ordered by the physician.

Evaluation
Goals are met as evidenced by:
 Child no longer breathes through the mouth.
 Airway is back to normal, especially the nose.
 Child sleeps 6-8 hours a day.
 Child and parents describe the level of anxiety and coping patterns.
 Child and parents know and understand about the disease and treatment.

2. TONSILLITIS & ADENOIDITIS

Marisol, a 5-year old girl, complains of pain upon swallowing. She is also running a fever for
two days already. Her intake has been greatly reduced due to her difficulty in swallowing.

4
Her mother brought her to a pediatric clinic for assessment, and it was found out that Marisol
has tonsillitis.

Description
Tonsillitis is a common illness in childhood resulting from pharyngitis.
Tonsillitis is the inflammation of the pharyngeal tonsils; the inflammation usually
extends to the adenoid and the lingual tonsils.

Pathophysiology

 A ring of lymphoid tissue encircles the pharynx, forming a protective barrier

against upper respiratory infection.
 This ring consists of groups of lymphoid tonsils, including the faucial, the
commonly known tonsils; pharyngeal, known as adenoids; and lingual tonsils.
 Lymphoid tissue normally enlarges progressively in childhood between the
ages of 2 and 10 years and shrinks during preadolescence.
 If the tissue itself becomes a site of acute or chronic infection, it may
become hypertrophied and can interfere with breathing, may cause partial
deafness, or may become a source of infection in itself.

Statistics and Incidences

- Tonsillitis most often occur in children; however, the condition rarely occurs
in children younger than 2 years.
- Recurrent tonsillitis was reported in 11.7% of Norwegian children in one
study and estimated in another study to affect 12.1% of Turkish children.

- In one study, the mean prevalence of carrier status of schoolchildren for

group A Streptococcus, a cause of tonsillitis, was 15.9%.

Study Now & Be Successful Later…princerenerpera

Causes

- Epstein-Barr virus (EBV). In one study showing that EBV may cause tonsillitis
in the absence of systemic mononucleosis, EBV was found to be
responsible for 19% of exudative tonsillitis in children.
- Bacteria. Anaerobic bacteria play an important role in tonsillar disease;
most cases of bacterial tonsillitis are caused by group A beta-hemolytic
Streptococcus pyogenes (GABHS); S. pyogenes adheres to adhesin
receptors that are located on the tonsillar epithelium; immunoglobulin
coating of pathogens may be important in the initial induction of
bacterial tonsillitis.
- Immunologic. Local immunologic mechanisms are important in chronic
tonsillitis; the distribution of dendritic cells and antigen-presenting cells is

5
 altered during disease, with fewer dendritic cells on the surface epithelium
and more in the crypts and extrafollicular areas.

Clinical Manifestations

 Fever. The child may present with a fever of 101°F (38.4°C) or more.
 Sore throat. The child may also manifest a sore throat, often
with dysphagia or difficulty swallowing.
 Hypertrophied tonsils. Individuals with acute tonsillitis present with tender
and inflamed tonsils; exudate may also be visible on the tonsils.
 Airway obstruction. Airway obstruction may manifest as mouth breathing,
snoring, sleep-disordered breathing, nocturnal breathing pauses,
or sleep apnea.

Assessment and Diagnostic Findings

Testing is indicated when group A beta-hemolytic Streptococcus pyogenes

(GABHS) infection is suspected.
Throat cultures. Throat cultures are performed to diagnose tonsillitis and the
causative organism.
Imaging studies. For patients in whom acute tonsillitis is suspected to have
spread to deep neck structures (ie, beyond the fascial planes of the
oropharynx), radiologic imaging using plain films of the lateral neck or CT scans
with contrast is warranted.

Medical Management

Hydration. Inability to maintain adequate oral caloric and fluid intake may

Study Now & Be Successful Later…princerenerpera

require IV hydration, antibiotics, and pain control; home intravenous
therapy under the supervision of qualified home health providers or the
independent oral intake ability of patients ensures hydration;

Intravenous corticosteroids may be administered to reduce pharyngeal edema.

Management of airway obstruction. Airway obstruction may require

management by placing a nasal airway device, using intravenous
corticosteroids, and administering humidified oxygen; observe the patient in a
monitored setting until the airway obstruction is clearly resolving.

Tonsillectomy. Tonsillectomy is indicated for individuals who have

experienced more than six (6) episodes of streptococcal pharyngitis (confirmed
by positive culture) in 1 year, 5 episodes in 2 consecutive years, or 3 or more
infections of tonsils and/or adenoids per year for 3 years in a row despite
adequate medical therapy, or chronic or recurrent tonsillitis associated with the
6
streptococcal carrier state that has not responded to beta-lactamase–resistant
antibiotics.
Adenoidectomy. Because adenoid tissue has similar bacteriology to the
pharyngeal tonsils and because minimal additional morbidity occurs with
adenoidectomy if tonsillectomy is already being performed, most surgeons
perform an adenoidectomy if adenoids are present and inflamed at the time of
tonsillectomy.
Diet. Hydration is important, and the oral route is usually adequate.
Activity. Adequate rest for children with tonsillitis accelerates recovery.

Pharmacologic Management
Corticosteroids. Corticosteroids have anti-inflammatory properties and cause
profound and varied metabolic effects; these agents modify the body’s
immune response to diverse stimuli; corticosteroids reduce inflammation, which
may impair swallowing and breathing.
Antibiotics. Antibiotic therapy must be comprehensive and cover all likely
pathogens in the context of this clinical setting.
Immune globulins. These agents are used to improve clinical aspects of the
disease; it stimulates immune cells, reducing the severity of infection.
Analgesics. Pain and fever control are essential to quality patient care;
analgesics with antipyretic properties ensure patient comfort, promote
pulmonary toilet, and have sedating properties, which are beneficial for patients
who experience pain.

Nursing Management

Preadmission assessment. Much of the preoperative operations, including

laboratory studies, is done on a preadmission outpatient basis.

Study Now & Be Successful Later…princerenerpera

History. Ask about any bleeding tendencies because postoperative bleeding is
a concern.
Vital signs. Take and record vital signs to establish a baseline for postoperative
monitoring; the temperature is an important part of the data collection to
determine that the child has no upper respiratory infection.

Nursing Diagnoses

Risk for aspiration related to impaired swallowing and bleeding at the operative
site.
Acute pain related to inflammation of tonsils and the surgical procedure.
Deficient fluid volume related to inadequate oral intake secondary to painful
swallowing.
Deficient knowledge related to caregivers understanding of postdischarge
home care and signs and symptoms of complications.
The major nursing care planning goals for a child with tonsillitis include:
7
Preventing aspiration.
Relieving pain, especially while swallowing.
Improving fluid intake.
Increase knowledge and understanding of post-discharge care and possible
complications.

Nursing Interventions
 Prevent aspiration. Place the child in a partially prone position with head
turned to one side until the child is completely awake; encourage the
child to expectorate all secretions; discourage the child from coughing;
and keep the head slightly lower than the chest to help facilitate
drainage of secretions.
 Relieve pain. Apply an ice collar postoperatively; administer
pain medication as ordered; encourage the caregiver to remain at the
bedside to provide soothing reassurance; crying irritates the raw throat
and increases the child’s discomfort; thus, it should be avoided if possible.
 Encourage fluid intake. When the child is fully awake from surgery, give
small amounts of clear fluids or ice chips; avoid irritating liquids such as
orange juice and lemonade; milk and ice cream products tend to cling to
the surgical site and make swallowing more difficult; thus they are poor
choices; and record intake and output until adequate oral intake is
established.
 Provide family teaching. Instruct the caregiver to keep the child relatively
quiet for a few days after discharge; recommend giving soft foods and
nonirritating liquids for the first few days; teach family members to note
any signs of hemorrhage and notify the healthcare provider; and provide
written instructions and telephone numbers before discharge.

Study Now & Be Successful Later…princerenerpera

Evaluation
 Goals are met as evidenced by:
 Prevention of aspiration.
 Relief from pain, especially while swallowing.
 Improvement of fluid intake.
 Increase of knowledge and understanding of post-discharge care and
possible complications.

3. ACUTE PHARYNGITIS
Eloisa discovered that her 3-year old has been having a difficulty of breathing
lately. She could see suprasternal retractions and shallow respirations whenever
her toddler breathes. The child also started having coughs and fever. Eloisa
brought her toddler to a pediatrician who diagnosed her with acute pharyngitis.

Acute Pharyngitis is caused by any number of different viruses,

8
  usually rhinoviruses, respiratory syncytial virus, adenovirus, influenza virus, or
parainfluenza virus.
 The common cold is one of the most common infectious conditions of childhood.
 The primary concern for pharyngitis in children aged 2 years or older is that
untreated GABHS pharyngitis may subsequently cause rheumatic fever.

Pathophysiology

 Primary bacterial pathogens account for approximately 30% of cases of

pharyngitis in children.
 GABHS pharyngitis is spread via respiratory droplets through close contact.
 It has an incubation period of 2-5 days.
 The bronchi and bronchioles become plugged with thick, viscid mucus, causing
air to be trapped in the lungs.
 The child can breathe air in but has difficulty expelling it.
 This hinders the exchange of gases, and cyanosis appears.

Statistics and Incidences

 Pharyngitis is a leading cause of pediatric ambulatory care visits.

 Approximately 10% of children seen by medical care providers each year have
pharyngitis, and 25-50% of these children have GABHS pharyngitis.
 Approximately 20% of asymptomatic children are chronic carriers of GABHS.
 According to the Red Book, from 1990-1995, approximately 48,000 cases of
epidemic diphtheria were reported in the former Soviet Union and central Asia.
 The peak prevalence of GABHS pharyngitis is in children aged 5-10 years.

Causes

 Multiple entities can cause irritation and inflammation of the pharynx.

 Group A Beta-Hemolytic Streptococci (GABHS). GABHS is the primary organism of

Study Now & Be Successful Later…princerenerpera

concern in most pediatric cases of pharyngitis because appropriate antibiotic
therapy is effective and can eliminate the cardiac complications of rheumatic
fever.
 Viruses. Viruses that may cause acute viral pharyngitis include the following: EBV
(mononucleosis), rhinovirus, adenovirus, parainfluenza virus, coxsackievirus,
coronavirus, echovirus, cytomegalovirus (CMV).

Clinical Manifestations

 Fever. Fever is common, especially in young children; older children have low-
grade fevers, which appear early and suddenly.
 Dyspnea. The onset of dyspnea is abrupt, sometimes preceded by a cough or
nasal discharge.
 Cough. Symptoms include a dry and persistent cough.
 Nasal inflammation. Nasal inflammation may lead to obstruction of passages,
and continual wiping away of secretions causes skin irritation to nares.
 Retractions. Suprasternal and substernal retractions are present.

9
  Barrel-shaped chest. The chest becomes barrel-shaped from the trapped air.
 Shallow respirations. Respirations are 60 to 80 breaths per minute.

Assessment and Diagnostic Findings

Throat culture. A throat culture remains the standard for diagnosis, though results can
take as long as 48 hours; throat culture results are highly sensitive and specific for group
A beta-hemolytic streptococci (GABHS), but results can vary according to technique,
sampling, and culture media.
Rapid testing. Most institutions and clinics have rapid testing, which is useful when
immediate therapy is desired; rapid testing can be highly reliable when used in
conjunction with throat cultures; several rapid diagnostic tests are available; compared
with throat culture, such tests are 70-90% sensitive and 95-100% specific.
Testing for viral causes. If Epstein-Barr virus (EBV) is considered, obtain a
complete blood count (CBC) to detect atypical cells in the white blood cell (WBC)
differential, along with a Monospot test (or another rapid heterophile antibody test).
Radiography. Imaging studies are usually not necessary unless a retropharyngeal,
parapharyngeal, or peritonsillar abscess is suspected; in such cases, a plain lateral neck
film can be used as an initial screening tool.
Medical Management

Approach considerations for a child with acute nasopharyngitis include:

Oxygen administration. Oxygen may be administered in addition to the mist tent.

Oral and IV fluids. For patients with signs of dehydration, administer adequate oral or
intravenous (IV) fluids; remember that pain may limit oral intake, complicating hydration
maintenance in the patient.

Pharmacologic Management

Antibiotics. Penicillin is the typical therapy for GABHS pharyngitis, in conjunction with

Study Now & Be Successful Later…princerenerpera

prevention of dehydration and supportive care for pain.
Antipyretics. Antipyretics are usually prescribed for mild fever and discomfort.
Corticosteroids. Corticosteroids (e.g., dexamethasone) have been suggested as
an adjunctive therapy to decrease pain and shorten symptom duration in adults with
pharyngitis.

Nursing Management
A cold is often the parents’ first introduction to an illness in their infants.

Nursing Assessment

History of exposure. A history of exposure to known carriers, fever, headache, and

abdominal pain in conjunction with a sore throat suggests group A beta-hemolytic
streptococcal (GABHS) pharyngitis.
History of intake. Because supportive care is a primary goal in all cases, historical
information regarding oral intake and hydration status is important.
Nursing Diagnoses

10
Based on the assessment data, the major nursing diagnoses are:

Ineffective breathing pattern related to the inflammatory process in the respiratory

tract.
Ineffective airway clearance related to mechanical obstruction of the airway
secretions and increased production of secretions.
Anxiety related to the disease experienced by the child.

Nursing Care Planning and Goals

The major nursing care planning goals for a child with acute nasopharyngitis are:
The patient will report increased energy.
The patient will remain afebrile.
The patient will expectorate sputum effectively.
The patient will express feelings of comfort in maintaining air exchange.
The patient will experience no further signs or symptoms of infection.

Nursing Interventions
Nursing interventions for a child with acute nasopharyngitis are:
Positioning. Place the child in a semi-Fowlers position using pillows to facilitate lung
expansion.
Increase fluid intake. Encourage increased fluid intake to decrease the viscosity of
secretions.
Increase room humidity. Increase the humidity by using cool mist vaporizers to relieve
stuffiness of the nose.
Administer medications. Administer antibiotics as prescribed after a positive culture result.

“Our greatest weakness lies in giving up. The

most certain way to succeed is always to try just

Study Now & Be Successful Later…princerenerpera

one more time. ”

– Thomas A. Edison

11
 PLT COLLEGE INC.
College of Nursing
Bayombong, Nueva Vizcaya

Nursing Care Management 103 (Care of the Clients with Problems in

Oxygenation)

UPPER RESPIRATORY TRACT DISEASES ( Part 1)

1. CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Mr. Martin, a nurse, smokes three packs of cigarette every day for the past 20 years. Now
on his late fifties, he started to notice that his cough has been going on for more than
three months. This has also occurred last year wherein his cough lasted for almost
three months. There is sputum production and he experiences difficulty of breathing
whenever he performs his daily activities.

Chronic Obstructive Pulmonary Disease (COPD) is a condition of chronic dyspnea with

expiratory airflow limitation that does not significantly fluctuate.

Chronic Obstructive Pulmonary Disease has been defined by The Global Initiative for
Chronic Obstructive Lung Disease as “a preventable and treatable disease with some
significant extrapulmonary effects that may contribute to the severity in individual
patients.”

There are two classifications of COPD: chronic bronchitis and emphysema. These two
types of COPD can be sometimes confusing because there are patients who have
overlapping signs and symptoms of these two distinct disease processes.

Study Now & Be Successful Later…princerenerpera

12
Chronic Bronchitis
- Chronic bronchitis is a disease of the airways and is defined as the presence
of cough and sputum production for at least 3 months in each of 2 consecutive
years.
 Chronic bronchitis is also termed as “blue bloaters”.
 Pollutants or allergens irritate the airways and leads to the production of sputum
by the mucus-secreting glands and goblet cells.

Emphysema
- Pulmonary Emphysema is a pathologic term that describes an abnormal distention
of airspaces beyond the terminal bronchioles and destruction of the walls of the
alveoli.
 People with emphysema are also called “pink puffers”.
 There is impaired carbon dioxide and oxygen exchange, and the exchange
results from the destruction of the walls of overdistended alveoli.
 There are two main types of emphysema: panlobular and centrilobular.

Pathophysiology

In COPD, the airflow limitation is both progressive and associated with an abnormal
inflammatory response of the lungs to noxious gases or particles.

Study Now & Be Successful Later…princerenerpera

13
Due to the chronic inflammation, changes and narrowing occur in the airways.
There is an increase in the number of goblet cells and enlarged submucosal glands
leading to hypersecretion of mucus.

Scar formation. This can cause scar formation in the long term and narrowing of the
airway lumen.
Wall destruction. Alveolar wall destruction leads to loss of alveolar attachments and a
decrease in elastic recoil.

Epidemiology

 Mortality for COPD has been increasing ever since while other diseases have
decreasing mortalities.
 COPD is the fourth leading cause of death in the United States.
 COPD also account for the death of 125, 000 Americans every year.
 Mortality from COPD among women has increased, and in 2005, more women than
men died of COPD.
 Approximately 12 million Americans live with a diagnosis of COPD.
 An additional 2 million may have COPD but remain undiagnosed.
 The annual cost of COPD is approximately $42.6 billion with overall healthcare
expenditures of $26.7 billion.

Causes

 Smoking depresses the activity of scavenger cells and affects the respiratory
tract’s ciliary cleansing mechanism.
 Occupational exposure. Prolonged and intense exposure to occupational dust
and chemicals, indoor air pollution, and outdoor air pollution all contribute to the
development of COPD.
 Genetic abnormalities. The well-documented genetic risk factor is a deficiency
of alpha1- antitrypsin, an enzyme inhibitor that protects the lung parenchyma

Study Now & Be Successful Later…princerenerpera

from injury.

Clinical Manifestations

 Chronic cough. Chronic cough is one of the primary symptoms of COPD.

 Sputum production. There is a hyperstimulation of the goblet cells and the
mucus-secreting gland leading to overproduction of sputum.
 Dyspnea on exertion. Dyspnea is usually progressive, persistent, and worsens
with exercise.
 Dyspnea at rest. As COPD progress, dyspnea at rest may occur.
 Weight loss. Dyspnea interferes with eating and the work of breathing is energy
depleting.
 Barrel chest. In patients with emphysema, barrel chest thorax configurationresults
from a more fixed position of the ribs in the inspiratory position and from loss of
elasticity.

14
Prevention

Smoking cessation. This is the single most cost-effective intervention to reduce the risk of
developing COPD and to stop its progression.

Complications

1. Respiratory failure. The acuity and the onset of respiratory failure depend on
baseline pulmonary function, pulse oximetry or arterial blood gas values, comorbid
conditions, and the severity of other complications of COPD.
2. Respiratory insufficiency. This can be acute or chronic, and may necessitate
ventilator support until other acute complications can be treated.

Assessment and Diagnostic Findings

 Health history. The nurse should obtain a thorough health history from patients with
known or potential COPD.
 Pulmonary function studies. Pulmonary function studies are used to help confirm the
diagnosis of COPD, determine disease severity, and monitor disease progression.
 Spirometry. Spirometry is used to evaluate airway obstruction, which is determined
by the ratio of FEV1 to forced vital capacity.
 ABG. Arterial blood gas measurement is used to assess baseline oxygenation and
gas exchange and is especially important in advanced COPD.
 Chest x-ray. A chest x-ray may be obtained to exclude alternative diagnoses.
 CT scan. Computed tomography chest scan may help in the differential diagnosis.
 Screening for alpha1-antitrypsin deficiency. Screening can be performed for
patients younger than 45 years old and for those with a strong family history of
COPD.
 Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, increased
retrosternal air space, decreased vascular markings/bullae (emphysema),
increased bronchovascular markings (bronchitis), normal findings during periods of

Study Now & Be Successful Later…princerenerpera

remission
 Pulmonary function tests: Done to determine cause of dyspnea, whether functional
abnormality is obstructive or restrictive, to estimate degree of dysfunction and to
evaluate effects of therapy, e.g., bronchodilators.
 Complete blood count (CBC) and differential: Increased hemoglobin
(advanced emphysema), increased eosinophils (asthma).
 Blood chemistry: alpha1-antitrypsin is measured to verify deficiency and diagnosis of
primary emphysema.
 Sputum culture: Determines presence of infection, identifies pathogen.
 Cytologic examination: Rules out underlying malignancy or allergic disorder.
 Electrocardiogram (ECG): Right axis deviation, peaked P waves (severe asthma);
atrial dysrhythmias (bronchitis), tall, peaked P waves in leads II, III, AVF
(bronchitis, emphysema); vertical QRS axis (emphysema).
 Exercise ECG, stress test: Helps in assessing degree of pulmonary dysfunction,
evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise
program.

15
Medical Management

Pharmacologic Therapy
 Bronchodilators. Bronchodilators relieve bronchospasm by altering the smooth
muscle tone and reduce airway obstruction by allowing increased oxygen
distribution throughout the lungs and improving alveolar ventilation.
 Corticosteroids. A short trial course of oral corticosteroids may be prescribed for
patients to determine whether pulmonary function improves and symptoms
decrease.
 Other medications. Other pharmacologic treatments that may be used in COPD
include alpha1-antitrypsin augmentation therapy, antibiotic
agents, mucolytic agents, antitussive agents, vasodilators, and narcotics.

Management of Exacerbations
 Hospitalization. Indications for hospitalization for acute exacerbation of COPD
include severe dyspnea that does not respond to initial therapy, confusion or
lethargy, respiratory muscle fatigue, paradoxical chest wall movement, and
peripheral edema.
 Oxygen therapy. Upon arrival of the patient in the emergency room, supplemental
oxygen therapy is administered and rapid assessment is performed to determine if
the exacerbation is life-threatening.
 Antibiotics. Antibiotics have been shown to be of some benefit to patients with
increased dyspnea, increased sputum production, and increased sputum
purulence.

Surgical Management

 Bullectomy. Bullectomy is a surgical option for select patients with bullous

emphysema and can help reduce dyspnea and improve lung function.
 Lung Volume Reduction Surgery. Lung volume reduction surgery is a palliative
surgery in patients with homogenous disease or disease that is focused in one area

Study Now & Be Successful Later…princerenerpera

and not widespread throughout the lungs.
 Lung Transplantation. Lung transplantation is a viable option for definitive surgical
treatment of end-stage emphysema.

Nursing Management

Management of patients with COPD should be incorporated with teaching and

improving the respiratory status of the patient.

Nursing Assessment
Assessment of the respiratory system should be done rapidly yet accurately.
Assess patient’s exposure to risk factors.
Assess the patient’s past and present medical history.
Assess the signs and symptoms of COPD and their severity.
Assess the patient’s knowledge of the disease.
Assess the patient’s vital signs.
Assess breath sounds and pattern.

16
Diagnosis
 Impaired gas exchange due to chronic inhalation of toxins.
 Ineffective airway clearance related to bronchoconstriction, increased mucus
production, ineffective cough, and other complications.
 Ineffective breathing pattern related to shortness of breath, mucus,
bronchoconstriction, and airway irritants.
 Self-care deficit related to fatigue.
 Activity intolerance related to hypoxemia and ineffective breathing patterns
.
Nursing Priorities
 Maintain airway patency.
 Assist with measures to facilitate gas exchange.
 Enhance nutritional intake.
 Prevent complications, slow progression of condition.
 Provide information about disease process/prognosis and treatment regimen.

Nursing Interventions
 Patient and family teaching is an important nursing intervention to enhance self-
management in patients with any chronic pulmonary disorder.
 To achieve airway clearance:
 The nurse must appropriately administer bronchodilators and corticosteroids and
become alert for potential side effects.
 Direct or controlled coughing. The nurse instructs the patient in direct or
controlled coughing, which is more effective and reduces fatigue associated
with undirected forceful coughing.
To improve breathing pattern:
1 Inspiratory muscle training. This may help improve the breathing pattern.
2 Diaphragmatic breathing. Diaphragmatic breathing reduces respiratory rate,
increases alveolar ventilation, and sometimes helps expel as much air as possible
during expiration.
3 Pursed lip breathing. Pursed lip breathing helps slow expiration, prevents collapse

Study Now & Be Successful Later…princerenerpera

of small airways, and control the rate and depth of respiration.
4 To improve activity intolerance:
5 Manage daily activities. Daily activities must be paced throughout the day and
support devices can be also used to decrease energy expenditure.
6 Exercise training. Exercise training can help strengthen muscles of the upper and
lower extremities and improve exercise tolerance and endurance.
7 Walking aids. Use of walking aids may be recommended to improve activity
levels and ambulation.
8 To monitor and manage potential complications:
9 Monitor cognitive changes. The nurse should monitor for cognitive changes such
as personality and behavior changes and memory impairment.
10 Monitor pulse oximetry values. Pulse oximetry values are used to assess the
patient’s need for oxygen and administer supplemental oxygen as prescribed.
11 Prevent infection. The nurse should encourage the patient to be immunized
against influenza and S. pneumonia because the patient is prone to respiratory
infection.

17
Evaluation
 Identifies the hazards of cigarette smoking.
 Identifies resources for smoking cessation.
 Enrolls in smoking cessation program.
 Minimizes or eliminates exposures.
 Verbalizes the need for fluids.
 Is free of infection.
 Practices breathing techniques.
 Performs activities with less shortness of breath.

Discharge and Home Care Guidelines

Setting goals. If the COPD is mild, the objectives of the treatment are to increase
exercise tolerance and prevent further loss of pulmonary function, while if COPD is
severe, these objectives are to preserve current pulmonary function and relieve
symptoms as much as possible.
Temperature control. The nurse should instruct the patient to avoid extremes of heat
and cold because heat increases the temperature and thereby raising oxygen
requirements and high altitudes increase hypoxemia.
Activity moderation. The patient should adapt a lifestyle of moderate activity and
should avoid emotional disturbances and stressful situations that might trigger a
coughing episode.
Breathing retraining. The home care nurse must provide the education and breathing
retraining necessary to optimize the patient’s functional status.

2.PNEUMONIA

Ofelia was admitted at the community hospital for a week because of

acute gastroenteritis and was discharged last Monday. On Thursday, her mother noticed
that her 9-year old is breathing faster than she normally does. She is also very warm

Study Now & Be Successful Later…princerenerpera

to touch and is complaining of chest pain. On Saturday, she began spitting out greenish
sputum.

Pneumonia is one of the most common respiratory problems and it affects all stages of
life.
- is an inflammation of the lung parenchyma caused by various microorganisms,
including bacteria, mycobacteria, fungi, and viruses.
- Pneumonitis is a more general term that describes the inflammatory process in the
lung tissue that may predispose and place the patient at risk for microbial invasion.

Classification

Pneumonia is classified into four: community-acquired pneumonia (CAP) and hospital-

acquired pneumonia (HAP), pneumonia in the immunocompromised host,
and aspiration pneumonia.

18
Community-Acquired Pneumonia
 CAP occurs either in the community setting or within the first 48 hours after
hospitalization.
 The causative agents for CAP that needs hospitalization
include streptococcus pneumoniae, H. influenza, Legionella, and Pseudomonas
aeruginosa.
 Only in 50% of the cases does the specific etiologic agent become identified.
 Pneumonia is the most common cause of CAP in people younger than 60 years of
age.
 Viruses are the most common cause of pneumonia in infants and children.

Hospital-Acquired Pneumonia
 HAP is also called nosocomial pneumonia and is defined as the onset of
pneumonia symptoms more than 48 hours after admission in patients with no
evidence of infection at the time of admission.
 HAP is the most lethal nosocomial infection and the leading cause of death in
patients with such infections.
 Common microorganisms that are responsible for HAP include Enterobacter
species, Escherichia coli, influenza, Klebsiella species, Proteus, Serratia
marcescens, S. aureus, and S. pneumonia.
 The usual presentation of HAP is a new pulmonary infiltrate on chest x-ray combined
with evidence of infection.

Aspiration Pneumonia
 refers to the pulmonary consequences resulting from entry of endogenous or
exogenous substances into the lower airway.
 The most common form of aspiration pneumonia is a bacterial infection from
aspiration of bacteria that normally reside in the upper airways.
 Aspiration pneumonia may occur in the community or hospital setting.
 Common pathogens are S. pneumonia, H.influenza, and S. aureus.

Study Now & Be Successful Later…princerenerpera

Pathophysiology

 Pneumonia arises from normal flora present in patients whose resistance has been
altered or from aspiration of flora present in the oropharynx.
 An inflammatory reaction may occur in the alveoli, producing exudates that
interfere with the diffusion of oxygen and carbon dioxide.
 White blood cells also migrate into the alveoli and fill the normally air-filled spaces.
 Due to secretions and mucosal edema, there are areas of the lung that are not
adequately ventilated and cause partial occlusion of the alveoli or bronchi.
 Hypoventilation may follow, causing ventilation-perfusion mismatch.
 Venous blood entering the pulmonary circulation passes through the under
ventilated areas and travels to the left side of the heart deoxygenated.
 The mixing of oxygenated and poorly oxygenated blood can result to arterial
hypoxemia.

19
Epidemiology

Pneumonia and influenza account for nearly 60,000 deaths annually.

Pneumonia also ranks as the eighth leading cause of death in the United States.
It is estimated that more than 915, 000 episodes of CAP occur in adults 65 years
old and above in the United States.
HAP accounts for 15% of hospital-acquired infections and is the leading cause of
death in patients with such infections.
The estimated incidence of HAP 4 to 7 episodes per 1000 hospitalizations.

Causes

1. Community-Acquired Pneumonia
Streptococcus pneumoniae. This is the leading cause of CAP in people younger
than 60 years of age without comorbidity and in those 60 years and older with
comorbidity.
Haemophilus influenzae. This causes a type of CAP that frequently
affects elderlypeople and those with comorbid illnesses.
Mycoplasma pneumoniae.
2. Hospital-Acquired Pneumonia
Staphylococcus aureus. Staphylococcus pneumonia occurs through inhalation
of the organism.
Impaired host defenses. When the defenses of the body are down, several
pathogens may invade the body.
Comorbid conditions. There are several conditions that lower the immune
system, causing bacteria to pool in the lungs and eventually result in pneumonia.
Supine positioning. When the patient stays in a prolonged supine position, fluid in
the lungs pools down and stays stagnant, making it a breeding place for
bacteria.
Prolonged hospitalization. The risk for hospital infections or nosocomial infections
increases the longer the patient stays in the hospital.

Study Now & Be Successful Later…princerenerpera

Clinical Manifestations

Rapidly rising fever. Since there is inflammation of the lung parenchyma, fever
develops as part of the signs of an infection.
Pleuritic chest pain. Deep breathing and coughing aggravate the pain in the
chest.
Rapid and bounding pulse. A rapid heartbeat occurs because the body
compensates for the low concentration of oxygen in the body.
Tachypnea. There is fast breathing because the body tries to compensate for the
low oxygen concentration in the body.
Purulent sputum. The sputum becomes purulent because of the infection in the
lung parenchyma which produced sputum-filled with pus.

20
Prevention

Pneumococcal vaccine. This vaccine can prevent pneumonia in healthy

patients with an efficiency of 65% to 85%.
Staff education. To help prevent HAP, the CDC (2004) encouraged staff
education and involvement in infection prevention.
Infection and microbiologic surveillance. It is important to carefully observe the
infection so that there could be an appropriate application of prevention
techniques.
Modifying host risk for infection. The infection should never be allowed to
descend on any host, so the risk must be decreased before it can affect one.

Complications

Shock and respiratory failure. These complications are encountered chiefly in patients
who have received no specific treatment and inadequate or delayed treatment.
Pleural effusion. In pleural effusion, the fluid is sent to the laboratory for analysis, and
there are three stages: uncomplicated, complicated, and thoracic empyema.

Assessment and Diagnostic Findings

History taking. The diagnosis of pneumonia is made through history taking,

particularly a recent respiratory tract infection.
Physical examination. Mainly, the number of breaths per minute and breath
sounds is assessed during physical examination.
Chest x-ray. Identifies structural distribution (e.g., lobar, bronchial); may also
reveal multiple abscesses/infiltrates, empyema (staphylococcus); scattered or
localized infiltration (bacterial); or diffuse/extensive nodular infiltrates (more often
viral). In mycoplasmal pneumonia, chest x-ray may be clear.
Fiberoptic bronchoscopy. May be both diagnostic (qualitative cultures) and
therapeutic (re-expansion of lung segment).

Study Now & Be Successful Later…princerenerpera

ABGs/pulse oximetry. Abnormalities may be present, depending on extent of
lung involvement and underlying lung disease.
Gram stain/cultures. Sputum collection; needle aspiration of empyema, pleural,
and transtracheal or transthoracic fluids; lung biopsies and blood cultures may
be done to recover causative organism.
CBC. Leukocytosis usually present, although a low white blood cell (WBC) count
may be present in viral infection, immunosuppressed conditions such as AIDS,
and overwhelming bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is
elevated.
Pulmonary function studies. Volumes may be decreased (congestion and
alveolar collapse); airway pressure may be increased and compliance
decreased. Shunting is present (hypoxemia).
Electrolytes. Sodium and chloride levels may be low.
Bilirubin. May be increased.
Percutaneous aspiration/open biopsy of lung tissues. May reveal typical
intranuclear and cytoplasmic inclusions (CMV), characteristic giant cells
(rubeola).

21
Medical Management

Blood culture. Blood culture is performed for identification of the causal pathogen
and prompt administration of antibiotics in patients in whom CAP is strongly
suspected.
Administration of macrolides. Macrolides are recommended for people with drug-
resistant S. pneumoniae.
Administration of antipyretics. Antipyretics are used to treat fever and headache.
Administration of antitussives. Antitussives are used for treatment of the
associated cough.
Bed rest. Complete rest is prescribed until signs of infection are diminished.
Oxygen administration. Oxygen can be given if hypoxemia develops.
Pulse oximetry. Pulse oximetry is used to determine the need for oxygen and to
evaluate the effectiveness of the therapy.
Aggressive respiratory measures. Other measures include administration of high
concentrations of oxygen, endotracheal intubation, and mechanical ventilation.

Nursing Management

Assess respiratory symptoms. Symptoms of fever, chills, or night sweats in a patient

should be reported immediately to the nurse as these can be signs of bacterial
pneumonia.
Assess clinical manifestations. Respiratory assessment should further identify clinical
manifestations such as pleuritic pain, bradycardia, tachypnea, and fatigue, use of
accessory muscles for breathing, coughing, and purulent sputum.
Physical assessment. Assess the changes in temperature and pulse; amount, odor, and
color of secretions; frequency and severity of cough; degree of tachypnea or shortness
of breath; and changes in the chest x-ray findings.
Assessment in elderly patients. Assess elderly patients for altered mental
status, dehydration, unusual behavior, excessive fatigue, and concomitant heart failure.

Study Now & Be Successful Later…princerenerpera

Diagnosis
Ineffective airway clearance related to copious tracheobronchial secretions.
Activity intolerance related to impaired respiratory function.
Risk for deficient fluid volume related to fever and a rapid respiratory rate.

Nursing Priorities
Maintain/improve respiratory function.
Prevent complications.
Support recuperative process.
Provide information about disease process, prognosis, and treatment.

Nursing Interventions
1 To improve airway patency:
2 Removal of secretions. Secretions should be removed because retained secretions
interfere with gas exchange and may slow recovery.
3 Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.
4 Humidification may loosen secretions and improve ventilation.
22
5 Coughing exercises. An effective, directed cough can also improve airway
patency.
6 Chest physiotherapy. Chest physiotherapy is important because it loosens and
mobilizes secretions.
7 To promote rest and conserve energy:
8 Encourage avoidance of overexertion and possible exacerbation of symptoms.
9 Semi-Fowler’s position. The patient should assume a comfortable position to
promote rest and breathing and should change positions frequently to enhance
secretion clearance and pulmonary ventilation and perfusion.
10 To promote fluid intake:
11 Fluid intake. Increase in fluid intake to at least 2L per day to replace insensible fluid
losses.
12 To maintain nutrition:
13 Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
14 Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also
help restore proper nutrition.
15 To promote patient’s knowledge:
16 Instruct patient and family about the cause of pneumonia, management of
symptoms, signs, and symptoms, and the need for follow-up.
17 Instruct patient about the factors that may have contributed to the development
of the disease.

Evaluation
Expected patient outcomes include the following:
Demonstrates improved airway patency.
Rests and conserves energy by limiting activities and remaining in bed while
symptomatic and then slowly increasing activities.
Maintains adequate hydration.
Consumes adequate dietary intake.
States explanation for management strategies.
Complies with management strategies.

Study Now & Be Successful Later…princerenerpera

Exhibits no complications.
Complies with treatment protocol and prevention strategies.
Discharge and Home Care Guidelines
Patient education is crucial regardless of the setting because self-care is essential
in achieving a patient’s well-being.

Oral antibiotics. Teach the patient about the proper administration, potential side
effects, and symptoms to report.
Breathing exercises. Teach the patient breathing exercises to promote secretion
clearance and volume expansion.
Follow-up check up. Strict compliance to follow-up checkups is important to check the
latest chest x-ray result or physical examination findings.
Smoking cessation. Smoking should be stopped because it inhibits tracheobronchial
ciliary action and irritates the mucous cells of the bronchi.

23
3. PULMONARY TUBERCULOSIS
Mr. Mabita, 67-year-old retired architect and nurse anesthetist, is admitted to the
clinical area because of productive cough of more than 2 weeks, hemoptysis, anorexia,
and weight loss. His temperature is slightly elevated every afternoon. After performing
a Mantoux skin test, he is considered as a patient suspected with pulmonary
tuberculosis.

- is a chronic respiratory disease common among crowded and poorly ventilated

areas.
- An acute or chronic infection caused by Mycobacterium tuberculosis,
tuberculosis is characterized by pulmonary infiltrates, formation of granulomas
with caseation, fibrosis, and cavitation.
- Tuberculosis is an infectious disease that primarily affects the lung parenchyma.
- It also may be transmitted to other parts of the body, including the meninges,
kidneys, bones, and lymph nodes.
- The primary infectious agent, M. tuberculosis, is an acid-fast aerobic rod that
grows slowly and is sensitive to heat and ultraviolet light.

Pathophysiology

Inhalation. Tuberculosis begins when a susceptible person inhales mycobacteria

and becomes infected.
Transmission. The bacteria are transmitted through the airways to the alveoli, and
are also transported via lymph system and bloodstream to other parts of the body.
Defense. The body’s immune system responds by initiating an inflammatory
reaction and phagocytes engulf many of the bacteria, and TB-
specific lymphocytes lyse the bacilli and normal tissue.
Protection. Granulomas new tissue masses of live and dead bacilli, ate surrounded
by macrophages, which form a protective wall.
Ghon’s tubercle. They are then transformed to a fibrous tissue mass, the central

Study Now & Be Successful Later…princerenerpera

portion of which is called a Ghon tubercle.
Scarring. The bacteria and macrophages turns into a cheesy mass that may
become calcified and form a collagenous scar.
Dormancy. At this point, the bacteria become dormant, and there is no further
progression of active disease.
Activation. After initial exposure and infection, active disease may develop
because of a compromised or inadequate immune system response.

Data from the history, physical examination, TB test, chest xray, and microbiologic
studies are used to classify TB into one of five classes.
Class 0. There is no exposure or no infection.
Class 1. There is an exposure but no evidence of infection.
Class 2. There is latent infection but no disease.
Class 3. There is a disease and is clinically active.
Class 4. There is a disease but not clinically active.
Class 5. There is a suspected disease but the diagnosis is pending.

24
Statistics and Incidences

Tuberculosis is a worldwide public health problem that is closely associated with

poverty, malnutrition, overcrowding, substandard housing, and inadequate
health care.
M. tuberculosis infects an estimated one-third of the world’s population and
remains the leading cause of death from infectious disease in the world.
According to the WHO, an estimated 1.6 million deaths resulted from TB in 2005.
After exposure to M. tuberculosis, roughly 5% of infected people develop active
TB within a year.

Causes

1. Close contact. Having close contact with someone who has an active TB.
2. Low immunity. Immunocompromised status like those with HIV, cancer, or
transplanted organs increases the risk of acquiring tuberculosis.
3. Substance abuse. People who are IV/injection drug users and alcoholics have a
greater chance of acquiring tuberculosis.
4. Inadequate health care. Any person without adequate health care like the
homeless, impoverished, and the minorities often develop active TB.
5. Immigration. Immigration from countries with a high prevalence of TB could
affect the patient.
6. Overcrowding. Living in an overcrowded, substandard housing increases the
spreading of the infection.

Clinical Manifestations
Nonspecific symptoms. Nonspecific symptoms may be produced such as fatigue,
weakness, anorexia, weight loss, night sweats, and low-grade fever, with fever and
night sweats as the typical hallmarks of tuberculosis.
Cough. The patient may experience cough with mucopurulent sputum.
Hemoptysis. Occasional hemoptysis or blood on the saliva is common in TB patients.

Study Now & Be Successful Later…princerenerpera

Chest pains. The patient may also complain of chest pain as a part of discomfort.

Prevention
To prevent transmission of tuberculosis, the following should be implemented.
Identification and treatment. Early identification and treatment of persons with active
TB.
Prevention. Prevention of spread of infectious droplet nuclei by source control methods
and by reduction of microbial contamination of indoor air.
Surveillance. Maintain surveillance for TB infection among health care workers by
routine, periodic tuberculin skin testing.

Complications
If left untreated or mistreated, pulmonary tuberculosis may lead to:
Respiratory failure. Respiratory failure is one of the most common complication of
pulmonary tuberculosis.
Pneumothorax. Pneumothorax becomes a complication when tuberculosis is not
treated properly.

25
Pneumonia. One of the most fatal complications of tuberculosis is pneumonia as it
could cause infection all over the lungs.

Assessment and Diagnostic Findings

To diagnose tuberculosis, the following tests could be performed:
Sputum culture: Positive for Mycobacterium tuberculosis in the active stage of the
disease.
Ziehl-Neelsen (acid-fast stain applied to a smear of body fluid): Positive for acid-fast
bacilli (AFB).
Skin tests (purified protein derivative [PPD] or Old tuberculin [OT] administered by
intradermal injection [Mantoux]): A positive reaction (area of induration 10 mm or
greater, occurring 48–72 hr after interdermal injection of the antigen) indicates past
infection and the presence of antibodies but is not necessarily indicative of active
disease.
Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal presence
of HIV.
Chest x-ray: May show small, patchy infiltrations of early lesions in the upper-lung
field, calcium deposits of healed primary lesions, or fluid of an effusion. Changes
indicating more advanced TB may include cavitation, scar tissue/fibrotic areas.
CT or MRI scan: Determines degree of lung damage and may confirm a difficult
diagnosis.
Bronchoscopy: Shows inflammation and altered lung tissue. May also be performed
to obtain sputum if patient is unable to produce an adequate specimen.
Histologic or tissue cultures (including gastric washings; urine and cerebrospinal
fluid [CSF]; skin biopsy): Positive for Mycobacterium tuberculosis and may indicate
extrapulmonary involvement.
Needle biopsy of lung tissue: Positive for granulomas of TB; presence of giant cells
indicating necrosis.
Electrolytes: May be abnormal depending on the location and severity of infection;
e.g., hyponatremia caused by abnormal water retention may be found in extensive
chronic pulmonary TB.

Study Now & Be Successful Later…princerenerpera

ABGs: May be abnormal depending on location, severity, and residual damage to
the lungs.

Medical Management
Pulmonary tuberculosis is treated primarily with anti-tuberculosis agents for 6 to 12
months.
First line treatment. First-line agents for the treatment of tuberculosis are isoniazid (INH),
rifampin (RIF), ethambutol (EMB), and pyrazinamide.
Active TB. For most adults with active TB, the recommended dosing includes the
administration of all four drugs daily for 2 months, followed by 4 months of INH and RIF.
Latent TB. Latent TB is usually treated daily for 9 months.

Treatment guidelines. Recommended treatment guidelines for newly diagnosed cases

of pulmonary TB have two parts: an initial treatment phase and a continuation phase.
Initial phase. The initial phase consists of a multiple-medication regimen of INH, rifampin,
pyrazinamide, and ethambutol and lasts for 8 weeks.

26
Continuation phase. The continuation phase of treatment include INH and rifampin or
INH and rifapentine, and lasts for an additional 4 or 7 months.
Prophylactic isoniazid. Prophylactic INH treatment involves taking daily doses for 6 to 12
months.
DOT. Directly observed therapy may be selected, wherein an assigned caregiver
directly observes the administration of the drug.

Pharmacologic Therapy
The first line antituberculosis medications include:•
Isoniazid (INH). INH is a bactericidal agent that is used as prophylaxis for neuritis,
and has side effects of peripheral neuritis, hepatic enzyme elevation, hepatitis, and
hypersensitivity.
Rifampin (Rifadin). Rifampin is a bactericidal agent that turns the urine and other
body secretions into orange or red, and has common side effects of hepatitis,
febrile reaction, purpura, nausea, and vomiting.
Pyrazinamide. Pyrazinamide is a bactericidal agent which increases the uric acid in
the blood and has common side effects of hyperuricemia, hepatotoxicity, skin rash,
arthralgias, and GI distress.
Ethambutol (Myambutol). Ethambutol is a bacteriostatic agent that should be used
with caution with renal disease, and has common side effects of optic neuritis and
skin rash.

Nursing Management
Nursing Assessment
The nurse may assess the following:
Complete history. Past and present medical history is assessed as well as both of the
parents’ histories.
Physical examination. A TB patient loses weight dramatically and may show the loss in
physical appearance.

Nursing Diagnosis

Study Now & Be Successful Later…princerenerpera

Based on the assessment data, the major nursing diagnoses for the patient include:
Risk for infection related to inadequate primary defenses and lowered resistance.
Ineffective airway clearance related to thick, viscous, or bloody secretions.
Risk for impaired gas exchange related to decrease in effective lung surface.
Activity intolerance related to imbalance between oxygen supply and demand.
Imbalanced nutrition: less than body requirements related to inability to ingest
adequate nutrients.

Nursing Care Planning & Goals

Promote airway clearance.
Adhere to treatment regimen.
Promote activity and adequate nutrition.
Prevent spread of tuberculosis infection.

Nursing Interventions
Nursing interventions for the patient include:

27
 Promoting airway clearance. The nurse instructs the patient
about correct positioning to facilitate drainage and to increase fluid intake to
promote systemic hydration.
Adherence to the treatment regimen. The nurse should teach the patient that TB is a
communicable disease and taking medications is the most effective means of
preventing transmission.
Promoting activity and adequate nutrition. The nurse plans a progressive activity
schedule that focuses on increasing activity tolerance and muscle strength and a
nutritional plan that allows for small, frequent meals.
Preventing spreading of tuberculosis infection. The nurse carefully instructs the
patient about important hygienic measures including mouth care, covering the
mouth and nose when coughing and sneezing, proper disposal of tissues,
and handwashing.
Acid-fast bacillus isolation. Initiate AFB isolation immediately, including the use of a
private room with negative pressure in relation to surrounding areas and a minimum
of six air changes per hour.
Disposal. Place a covered trash can nearby or tape a lined bag to the side of the
bed to dispose of used tissues.
Monitor adverse effects. Be alert for adverse effects of medications.
Evaluation
1. Expected patient outcomes include:
2. Promoted airway clearance.
3. Adhered to treatment regimen.
4. Promoted activity and adequate nutrition.
5. Prevented spread of tuberculosis infection.

4. ASTHMA
Zyrah just got home from her gardening class. She has noticed that every time she
finishes her class, she keeps on coughing and coughing. She also feels that her chest
tightens and she has trouble breathing. Today, she almost could not breathe that she

Study Now & Be Successful Later…princerenerpera

28
hurriedly drove to the nearest emergency room. The ER physician diagnosed her
with asthma.

- Asthma is a chronic inflammatory disease of the airways that causes airway

hyperresponsiveness, mucosal edema, and mucus production.
Inflammation ultimately leads to recurrent episodes of asthma symptoms.
Patients with asthma may experience symptom-free periods alternating with
acute exacerbations that last from minutes to hours or days.
Asthma, the most common chronic disease of childhood, can begin at any age.

Pathophysiology

 Activation. When the mast cells are activated, it releases several chemicals
called mediators.
 Perpetuation.These chemicals perpetuate the inflammatory response, causing
increased blood flow, vasoconstriction,, fluid leak from the vasculature, attraction
of white blood cells to the area, and bronchoconstriction.
 Bronchoconstriction. Acute bronchoconstriction due to allergens results from
a release of mediators from mast cells that directly contract the airway.
 Progression. As asthma becomes more persistent, the inflammation progresses and
other factors may be involved in the airflow limitation.

Statistics and Epidemiology

 Asthma is considered as the most common chronic disease of childhood, and is a

disruptive disease that affects school and work attendance.
 Asthma affects more than 22 million people in the United States.
 Asthma accounts for more than 497, 000 hospitalizations annually.
 The total economic cost of asthma exceeds $27.6 billion.

Causes

Study Now & Be Successful Later…princerenerpera

1. Allergy. Allergy is the strongest predisposing factor for asthma.
2. Chronic exposure to airway irritants. Irritants can be seasonal (grass, tree, and weed
pollens) or perennial (mold, dust, roaches, animal dander).
3. Exercise. Too much exercise can also cause asthma.
4. Stress/ Emotional upset. This can trigger constriction of the airway leading to asthma.
5. Medications. Certain medications can trigger asthma.

Clinical Manifestations

Cough. There are instances that cough is the only symptom.

Dyspnea. General tightness may occur which leads to dyspnea.
Wheezing. There may be wheezing, first on expiration, and then possibly during
inspiration as well.

Asthma attacks frequently occur at night or in the early morning.

29
Prevention

Allergens. Allergens, either seasonal or perennial, can be prevented through avoiding

contact with them whenever possible.
Knowledge. Knowledge is the key to quality asthma care.
Evaluation. Evaluation of impairment and risk are key in the control.

Complications

Status asthmaticus. Airway obstruction in status asthmaticus often results in hypoxemia.

Respiratory failure. Asthma, if left untreated, progresses to respiratory failure.
Pneumonia. Mucus that pools in the lungs and becomes infected can lead to the
development of pneumonia.

Assessment and Diagnostic Findings

Positive family history. Asthma is a hereditary disease, and can be possibly acquired by
any member of the family who has asthma within their clan.
Environmental factors. Seasonal changes, high pollen counts, mold, pet dander,
climate changes, and air pollution are primarily associated with asthma.
Comorbid conditions. Comorbid conditions that may accompany asthma may include
gastroeasophageal reflux, drug-induced asthma, and allergic broncopulmonary
aspergillosis.

Medical Management

Short-acting beta2 –adrenergic agonists. These are the medications of choice for
relief of acute symptoms and prevention of exercise-induced asthma.
Anticholinergics. Anticholinergics inhibit muscarinic cholinergic receptors and
reduce intrinsic vagal tone of the airway.
Corticosteroids. Corticosteroids are most effective in alleviating symptoms,

Study Now & Be Successful Later…princerenerpera

improving airway function, and decreasing peak flow variability.
Leukotriene modifiers. Anti Leukotrienes are potent bronchoconstrictors that also
dilate blood vessels and alter permeability.
Immunomodulators. Prevent binding of IgE to the high affinity receptors of basophils
and mast cells.

Nursing Management

Assess the patient’s respiratory status by monitoring the severity of the symptoms.
Assess for breath sounds.
Assess the patient’s peak flow.
Assess the level of oxygen saturation through the pulse oximeter.
Monitor the patient’s vital signs.

Nursing Diagnosis
Based on the data gathered, the nursing diagnoses appropriate for the patient with
asthma include:

30
Ineffective airway clearance related to increased production of mucus and
bronchospasm.
Impaired gas exchange related to altered delivery of inspired O2.
Anxiety related to perceived threat of death.

Nursing Interventions
Assess history. Obtain a history of allergic reactions to medications before
administering medications.
Assess respiratory status. Assess the patient’s respiratory status by monitoring
the severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs.
Assess medications. Identify medications that the patient is currently
taking. 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.
Pharmacologic therapy. Administer medications as prescribed and monitor
patient’s responses to medications.
Fluid therapy. Administer fluids if the patient is dehydrated.

Evaluation
Maintenance of airway patency.
Expectoration or clearance of secretions.
Absence /reduction of congestion with breath sound clear, noiseless respirations,
and improved oxygen exchange.
Verbalized understanding of causes and therapeutic management regimen.
Demonstrated behaviors to improve or maintain clear airway.
Identified potential complications and how to initiate appropriate preventive or
corrective actions.

Study Now & Be Successful Later…princerenerpera

“To be successful you must accept all
challenges that come your way. You
can’t just accept the ones you like. ”
– Mike Gafka

31
 PLT COLLEGE INC.
College of Nursing
Bayombong, Nueva Vizcaya

Nursing Care Management 103 (Care of the Clients with Problems in

Oxygenation)

WORKING PAPER
I. Read the following diseases and make a short explanation of each (in your own words, you
may use Tagalog & Ilocano if you want). Do not copy and paste from a source (copied
answers will not be given points) 60 points

1. Tracheitis
2. Atelectasis
3. Pulmonary Edema
4. Adult Respiratory Distress Syndrome
5. Respiratory Failure
6. Bronchiectasis
7. Cystic Fibrosis
8. Pleural Effusion
9. Cor Pulmonale
10. Pulmonary Embolism
11. Pneumothorax
12. Hemothorax

II. Answer the following questions. 8 points each.

1. Explain the pulmonary restrictive and obstructive issues in Cor Pulmonale?
2. Explain the net movement of fluids from the interstitial spaces to the alveolar space in

Study Now & Be Successful Later…princerenerpera

Pulmonary Edema?
3. Immobilization accounts to almost 5% of deaths related to Pulmonary embolism?
Explain why?
4. Compare & Contrast Hemothorax & Pneumothorax?
5. Explain the Virchow’s Triad?

Deadline: Submit your output on Tuesday (August 27, 2019)

SUCCESS often comes to those who DARE TO ACT. It seldom comes to the TIMID
Who are always afraid of the consequences.
--princerenerpera--

32