NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: RESPIRATORY SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. PNEUMONIA: acute inflammation of lungs with exudate accumulation in alveoli and other respiratory passages that interferes with ventilation process.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Types:

  • Typical/classic pneumonia: pneumococcal; related to diminished defense mechanisms, immunocompromised, critically ill, history of smoking, general anesthesia/abdominal surgery, exposure to airborne pathogens, hospitalization, recent respiratory tract infection, viral influenza, increased age, and chronic obstructive pulmonary disease (COPD).
    a. Lobar pneumonia—occurs abruptly when an acute bacterial infection affects a large portion of a lobe; causes pleuritic pain, heavy sputum production.
    b. Bronchopneumonia—involves patchy infiltration over a general area.
    c. Alveolar pneumonia—caused by virus; diffuse bilateral infection without patchy infiltrates.
  • Atypical pneumonia: related to contact with specific organisms.
    a. Mycoplasma pneumoniae or Legionella pneumophila, if untreated, can lead to serious complications such as acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), thrombocytopenic purpura, renal failure, inflammation of the heart, neurological disorders, or possible death.
    b. Pneumocystis pneumonia in conjunction with AIDS.
  • Aspiration pneumonia:
    a. Noninfectious: aspiration of fluids (gastric secretions, foods, liquids, tube feedings) into the airways.                                                                                              b. Bacterial aspiration pneumonia: related to poor cough mechanisms due to anesthesia, coma (mixed flora of upper respiratory tract cause pneumonia).
  • Hematogenous pneumonia bacterial infections: related to spread of bacteria from the bloodstream.

B. Pathophysiology: caused by infectious or noninfectious agents, clotting of an exudate rich in fibrinogen, consolidated lung tissue.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:
    a. Pain location: chest (affected side), referred to abdomen, shoulder, flank.
    b. Irritability, restlessness.
    c. Apprehensiveness.
    d. Nausea, anorexia.
    e. History of exposure.
  • Objective data:
    a. Cough:
    (1) Productive, rust-colored (blood) or yellowish sputum (greenish with atypical pneumonia).
    (2) Splinting of affected side when coughing.
    b. Sudden increased fever, chills.
    c. Nasal flaring, circumoral cyanosis.
    d. Respiratory distress: tachypnea.
    e. Auscultation:
    (1) Decreased breath sounds on affected side.
    (2) Exaggerated breath sounds on unaffected side.
    (3) Crackles, bronchial breath sounds.
    (4) Dullness on percussion over consolidated area.
    (5) Possible pleural friction rub.
    f. Chest retraction (air hunger in infants).
    g. Vomiting.
    h. Facial herpes simplex.
    i. Diagnostic studies:
    (1) Chest x-ray: haziness to consolidation.
    (2) Sputum culture: Gram stain and culture; specific organisms, usually pneumococcus.
    (3) Bronchoscopy if sputum results are inconclusive.
    j. Laboratory data:
    (1) Blood culture: organism specific except when viral.
    (2) WBC count: leukocytosis.
    (3) Sedimentation rate: elevated.
  • Factors contributing to the severity of pneumonia:
    a. Demographics:
    (1) Age—severity increased with age.
    (2) Gender.
    (3) Nursing home resident.                                                                                                                                                                                                                     b. Comorbidities:
    (1) Congestive heart failure (CHF).
    (2) Active cancer.
    (3) Liver disease.
    (4) Renal insufficiency.
    (5) Stroke with residual symptoms.
    c. Physical examination:
    (1) Systolic BP less than 90; mean arterial pressure (MAP) less than 60.
    (2) Heart rate (HR) ≥125.
    (3) Respiratory rate ≥30.
    (4)Temperature (PO) ≥104°F or less than 95°F.
    (5) Altered level of consciousness (LOC).
    d. Laboratory results:
    (1) Hematocrit (Hct) less than 30.
    (2) Na+ less than 130.
    (3) BUN ≥30.
    (4) Arterial pH less than 7.35.
    (5) Pleural effusion on chest x-ray.
    (6) Glucose greater than 250 mg/dL.

D. Analysis/nursing diagnosis:

  • Ineffective airway clearance related to retained secretions.
  • Activity intolerance related to inflammatory process.
  • Pain related to continued coughing.
  • Knowledge deficit (learning need) related to proper management of symptoms.
  • Risk for fluid volume deficit related to tachypnea.

E. Nursing care plan/implementation:

  • Goal: promote adequate ventilation.
    a. Deep breathe, cough. Small-volume nebulizer treatment.
    b. Remove respiratory secretions, suction prn.
    c. High humidity with or without oxygen therapy.
    d. Intermittent positive-pressure breathing (IPPB); incentive spirometry, chest physiotherapy, as ordered and needed to loosen secretions.
    e. Use of expectorants as ordered.
    f. Change position frequently.
    g. Percussion with postural drainage.
  • Goal: control infection.
    a. Monitor vital signs; hypothermia for elevated temperature.
    b. Administer antibiotics as ordered to control infection—broad spectrum (e.g. penicillin, quinolones, aminoglycosides). Note: need cultures before starting on antibiotics.
  • Goal: provide rest and comfort.
    a. Planned rest periods.
    b. Adequate hydration by mouth, I&O; IV sas needed.                                                                                                                                                                           c. Diet: high carbohydrate, high protein to meet energy demands and assist in the healing process.
    d. Mild analgesics for pain—no opioids.
  • Goal: prevent potential complications.
    a. Cross infection: use good hand-washing technique.
    b. Sterile technique when tracheobronchial suctioning to reduce risk of possible infection.
    c. Hyperthermia: tepid baths, hypothermia blanket.
    d. Respiratory insufficiency and acidosis: clear airway, promote expectoration of secretions.
    e. Assess cardiac and respiratory function.
    f. Keep ambulatory whenever possible.
  • Goal: health teaching.
    a. Proper disposal of tissues, cover mouth when coughing.
    b. Expected side effects of prescribed medications.
    c. Need for rest, limited interactions, increased caloric intake.
    d. Need to avoid future respiratory infections. Immunization: influenza each year for those at risk. Vaccine for pneumococcal pneumonia every 5 years.
    e. Correct dosage of antibiotics and the importance of taking entire prescription at prescribed times (times evenly distributed throughout the 24-hour period to maintain blood level of antibiotic) for increased effectiveness.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Adheres to medication regimen.
  • Has improved gas exchange as shown by improved pulmonary function tests.
  • No acid-base or fluid imbalance: normal pH.
  • Energy level: increased.
  • Sputum production: decreased, normal color.
  • Vital signs: stable.
  • Breath sounds: clear.
  • Cultures: negative.
  • Reports comfort level increased.

II. SEVERE ACUTE RESPIRATORY SYNDROME (SARS): viral respiratory illness caused by a coronavirus. Incubation period: 2 to 7 days, maybe as long as 10 to 14 days. Recommend limiting contact after infection until 10 days after fever has gone.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: little information is known about the SARS-associated coronavirus. May survive in the environment for several days—depends on temperature or humidity, and type of material or body fluid. Spread generally by respiratory droplets—up to 3 feet. May spread through air; other ways not known. Progresses to hypoxia →pneumonia → respiratory distress syndrome.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Weakened immune system.
  • Close contact (within 3 feet)—kissing, hugging, sharing utensils.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:
    a. Headache.
    b. Feeling of discomfort; body aches; chills.
    c. Dyspnea.
  • Objective data:
    a. Temperature greater than 100.4°F (38.0°C), unless on antipyretics.
    b. Mild respiratory symptoms; dry cough.
    c. Diarrhea in 20%.
    d. Laboratory: reverse transcriptase–polymerase chain reaction (RT-PCR) of blood, stool, nasal secretions; serologic test for antibodies; viral culture (showing antibodies to virus more than 21 days after onset of illness).
    e. Additional laboratory findings:
    (1) Leukopenia.
    (2) Lymphopenia
    (3) Thrombocytopenia.
    (4) ↑ lactose dehydrogenase.
    (5) ↑ aspartate aminotransferase.
    (6) ↑ creatine kinase.
    f. Chest x-ray: focal interstitial infiltrates →generalized patchy infiltrates → areas of consolidation.

D. Analysis/nursing diagnosis:

  • Ineffective breathing pattern related to hypoxia and pneumonia.
  • Risk for spread of infection related to droplet or airborne transmission.
  • Impaired gas exchange related to pneumonia.

E. Nursing care plan/implementation, evaluation/outcome criteria

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: infection control.
    a. Standard precautions (e.g., strict hand hygiene).
    b. Contact precautions (e.g., gown and gloves) with eye protection.
    c. Airborne precautions (e.g., isolation room with negative pressure; use of an N95 filtering disposable respirator for those entering room, or surgical mask).
    d. Identify/isolate suspected SARS cases (quarantine).
  • Goal: supportive care.
    a. Empirical antibiotic therapy with broad coverage.
    b. Isolation (i.e., those without symptoms) for 10 days after becoming afebrile.

III. H1N1 INFLUENZA VIRUS (“swine flu”): respiratory disease caused by a new strain of the type A influenza virus (novel H1N1 or 2009 H1N1 flu). Described initially as a possible pandemic, a technical term that refers to the geographical (global) spread of the disease, not severity. Called swine flu because it resembled a strain that circulates in pigs.
A. Pathophysiology:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Influenza A virus with two proteins, hemagglutinin (H1) and neuraminidase (N1); human to-human transmission through respiratory secretions (droplets) from coughing or sneezing; touching something with the virus on the surface and then touching mouth, eyes, or nose. Not spread by food.
  • Incubation period: 1 day before symptoms occur and up to 7 days following illness onset.
  • Infectious (viral shedding): as long as symptomatic; a minimum of 7 days after onset up to 13 days. Young children may be contagious for longer periods.
  • Respiratory symptoms may progress to pneumonia → respiratory failure → death.

B. Risk factors:

  • Ages 6 months to 24 years; children younger than 5 years and especially younger than 2 years.
  • Pregnant women and women who are 2 weeks postpartum.
  • Persons 25 to 64 years with chronic conditions (e.g., asthma, diabetes, heart disease, kidney disease, and weakened immune system).
  • Residents of nursing homes and chronic-care facilities.

C. Assessment:

  • Subjective data: Classic flu:
    a. Fatigue
    b. Body aches; chills
    c. Sore throat
    d. Headache
    e. Emergency signs with swine flu:
    (1) Shortness of breath
    (2) Chest pain or abdominal pain
    (3) Sudden dizziness; confusion
  • Objective data: Classic flu:
    a. Fever above 100.4°F
    b. Cough
    c. Diarrhea; vomiting
    d. Runny nose
    e. Emergency signs with swine flu:
    (1) Severe or persistent vomiting
    (2) Difficulty breathing; rapid respiratory rate
    (3) Bluish or gray skin color (particularly in children)                                                                                                                                                                              f. Diagnostic tests: viral culture, polymerase chain reaction (PCR), rapid antigen testing, and immunofluorescence. “Rapid influenza diagnostic test”—detects in 30 minutes, may not be conclusive.

D. Analysis/nursing diagnosis:

  • Ineffective breathing pattern related to hypoxia and pneumonia.
  • Risk for spread of infection related to droplet or airborne transmission.
  • Risk for fluid volume deficit related to persistent vomiting.

Physiological Integrity: Nursing Care of the Adult Client

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prevent spread of infection.
    a. Stay home from work or school at least 24 hours after fever is gone without the use of a fever-reducing medicine; limit contact with others.
    b. Cover nose and mouth with tissue when coughing or sneezing.
    c. Wash hands after every sneeze or cough.
    d. Disinfect home surfaces to kill germs—virus can survive 2 to 8 hours; use hydrogen peroxide, iodophors, detergents, alcohol; heat.
  • Goal: reduce risk of complications, alleviate symptoms.
    a. Medications
    (1) Antipyretic: for fever 100°F or higher; acetaminophen or ibuprofen; aspirin if over 18 years of age.
    (2) Antiviral: treatment or prevention; stop spread of virus: oseltamivir (oral, Tamiflu)—take with food, nausea and vomiting may occur; zanamivir (inhaled)—do not take with history of asthma or lung disease; may cause dizziness, stuffy nose, sinusitis; peramivir (IV, reserved for critically ill); neuraminidase inhibitors; suspected or confirmed cases; most effective within 48 hours; 5 days of treatment.
    (3) Fluids, lozenges; cough suppressant for dry cough.
    b. Fluids: clear liquids (water, broth, sports drinks, ice chips, frozen popsicles); avoid alcohol and caffeine.
    c. Monitor for dehydration: urine color (dark yellow with dehydration); frequency of trips to bathroom. Look for tears with infants/ toddlers; wet diapers.
  • Goal: prevent occupational exposure.
    a. Eliminate potential exposures: keep distance of 6 feet or more in community setting; restrict visitors who are ill; keep sick workers at home.
    b. Respiratory hygiene and cough etiquette. Encourage ill person to use tissues or wear a disposable face mask (use only once) or health-care provider should wear mask.
    c. Respiratory protection (personal protective equipment) in occupational health-care setting—N95 or higher filtering facepiece respirator; fit-tested (not recommended for children or people with facial hair); disposable, single use, do not share. Remove gloves and wash hands before and after touching respirator. Extended use of N95 increases risk of contact transmission. Usually reserved if assisting with an aerosolgenerating procedure—intubation, extubation, bronchoscopy, nebulization.
    d. Isolation; standard (droplet) precautions—private room preferred; if not available at least 3-foot separation between patient beds with curtain between; share room with like diagnosis (cohorting). Caregiver wears mask—respirator not routinely necessary. Eye protection if within 6 feet of patient as treatments may cause splashing of respiratory secretions.
    e. Limit transport of patient; client wears mask outside of room.
    f. Vaccination of staff—may be required; exempt: with severe egg allergy; history of Guillain-Barré syndrome; religion prohibits vaccinations. May be required to wear mask if not vaccinated.
  • Goal: health teaching—methods to prevent reinfection.
    a. Hand-washing technique—soap, water, and friction for at least 20 seconds; alcohol-based (antibacterial) hand rub may be used.
    b. Avoid touching eyes, nose, or mouth.
    c. Vaccination: one dose of swine flu and seasonal flu vaccine for those 10 years of age and older—may be given on same day; two doses of swine flu vaccine (separated 4 weeks, 21 days minimum) for children younger than 10 years.
    d. Pneumococcal vaccination if over 65 years, smoker, or history of chronic health problem.

F. Evaluation/outcome criteria:

  • No complications.
  • Temperature normal for 24 hours without medication.
  • Breath sounds clear; respirations unlabored.
  • Covers nose/mouth when coughing or sneezing.
  • Performs hand hygiene frequently.

IV. ATELECTASIS: collapsed alveoli in part or all of the lung.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: due to compression (tumor), airway obstruction, decreased surfactant production, or progressive regional hypoventilation.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Shallow breathing due to pain, abdominal distention, narcotics, or sedatives.
  • Decreased ciliary action due to anesthesia, smoking.
  • Thickened secretions due to immobility, dehydration.
  • Aspiration of foreign substances.
  • Bronchospasms.
  • Barotrauma; ↑ positive end-expiratory pressure (PEEP).

C. Assessment:

  • Subjective data:
    a. Restlessness.
    b. Pain.
  • Objective data:
    a. Tachypnea.
    b. Tachycardia.
    c. Dullness on percussion.
    d. Absent bronchial breathing.
    e. Crackles at bases as alveoli “pop” open on inspiration.
    f. Tactile fremitus in affected area.
    g. ↓ O2 saturation.
    h. X-ray:
    (1) Patches of consolidation.
    (2) Elevated diaphragm.
    (3) Mediastinal shift.

D. Analysis/nursing diagnosis:

  • Impaired gas exchange related to shallow breathing.
  • Pain, acute, related to collapse of lung.
  • Fear related to altered respiratory status.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: relieve hypoxia.
    a. Frequent respiratory assessment.
    b. Respiratory hygiene measures, cough, deep breathe. Use bedside inspirometer q1h when awake.                                                                                                c. Oxygen as ordered.
    d. Monitor effects of respiratory therapy, ventilators, breathing assistance measures to ensure proper gas exchange.
    e. Position: on unaffected side to allow for lung expansion.
    f. Prepare for possible needle decompression or chest tube insertion.
  • Goal: prevent complications.
    a. Antibiotics as ordered.
    b. Turn, cough, and deep breathe. Out of bed, ambulation.
    c. Increase fluid intake to liquefy secretions.
  • Goal: health teaching.
    a. Need to report signs and symptoms listed in assessment data for early recognition of problem.
    b. Importance of coughing and deep breathing to improve present condition and prevent further problems.

F. Evaluation/outcome criteria:

  • Lung expanded on x-ray.
  • Acid-base balance obtained and maintained.
  • No pain on respiration.
  • Activity level increased.

V. PULMONARY EMBOLISM: undissolved mass that travels in bloodstream and occludes a blood vessel; can be thromboembolus, fat, air, or catheter. Constitutes a
critical medical emergency.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: obstructs blood flow to lung→ increased pressure on pulmonary artery and reflex constriction of pulmonary blood vessels→ poor pulmonary circulation → pulmonary infarction.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Thrombophlebitis.
  • Recent surgery.
  • Invasive procedures.
  • Immobility.
  • Obesity
  • Myocardial infarction, heart failure.
  • Smoking.
  • Varicose veins.
  • Hormone replacement therapy.

C. Assessment:

  • Subjective data:
    a. Chest pain: substernal, localized; type—crushing, sharp, stabbing with respirations.
    b. Sudden onset of profound dyspnea.
    c. Restless, irritable, anxious.
    d. Sense of impending doom.
  • Objective data:
    a. Respirations: either rapid, shallow or deep, gasping.
    b. Elevated temperature.                                                                                                                                                                                                                         c. Auscultation: friction rub, crackles; diminished breath sounds.
    d. Shock:
    (1) Tachycardia.
    (2) Hypotension.
    (3) Skin: cold, clammy.
    e. Cough: hemoptysis.
    f. X-ray: area of density.
    g. ECG changes that reflect right-sided failure.
    h. Echocardiogram shows increased pulmonary dynamics.
    i. Lung scan; pulmonary angiography.
    j. Laboratory data:
    (1) Decreased PaCO2.
    (2) Elevated WBC count.

D. Analysis/nursing diagnosis:

  • Ineffective breathing pattern related to shallow respirations.
  • Impaired gas exchange related to dyspnea.
  • Pain related to decreased tissue perfusion.
  • Altered peripheral tissue perfusion related to occlusion of blood vessel.
  • Fear related to emergency condition.
  • Anxiety related to sense of impending doom.

E. Nursing care plan/implementation:

  • Goal: monitor for signs of respiratory distress.
    a. Auscultate lungs for areas of decreased/absent breath sounds.
    b. Elevate head of bed.
    c. Monitor arterial blood gases (ABGs).
    d. Monitor pulse oximetry; administer oxygen, supplemental humidification as indicated.
    e. Monitor blood coagulation studies (e.g., activated partial thromboplastin time [aPTT]).
    f. Administer anticoagulation therapy, thrombolytic agents, morphine for pain, vasopressor medications.
    g. Fluids: IV/PO as indicated.
    h. Monitor signs: Homans’, acidosis.
    i. Ambulate as tolerated/indicated; change position.
    j. Prepare for surgery if peripheral embolectomy is indicated.
  • Goal: health teaching.
    a. Prevent further occurrence; importance of antiembolism stockings, intermittent pneumatic compression devices.
    b. Decrease stasis.
    c. If history of thrombophlebitis, avoid birth control pills.
    d. Need to continue medication.
    e. Follow-up care.

F. Evaluation/outcome criteria:

  • No complications; no further incidence of emboli.
  • Respiratory rate returns to normal.
  • Coagulation studies within normal limits (aPTT 25 to 41 seconds, ABGs within normal limits).
  • Reports comfort achieved.

VI. HISTOPLASMOSIS: infection found mostly in central United States. Not transmitted from human to human but from dust and contaminated soil. Progressive histoplasmosis, seen most frequently in middle-aged white men who have COPD, is characterized by cavity formation, fibrosis, and emphysema.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: spores of Histoplasma capsulatum (from droppings of infected birds and bats) are inhaled, multiply, and cause fungal infections of respiratory tract. Leads to necrosis and healing by encapsulation.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Assessment:

  • Subjective data:
    a. Malaise.
    b. Chest pain, dyspnea.
  • Objective data:
    a. Weight loss.
    b. Nonproductive cough.
    c. Fever.
    d. Positive skin test for histoplasmosis.
    e. Benign acute pneumonitis.
    f. Chest x-ray: nodular infiltrate.
    g. Sputum culture shows Histoplasma capsulatum.
    h. Hepatomegaly, splenomegaly.

C. Analysis/nursing diagnosis:

  • Ineffective airway clearance related to pneumonitis.
  • Ineffective breathing pattern related to dyspnea.
  • Pain, acute, related to infectious process.
  • Risk for infection related to repeated exposure to fungal spores.
  • Impaired gas exchange related to chronic pulmonary disease.
  • Knowledge deficit (learning need) related to prevention of disease and potential side effects of medications.

D. Nursing care plan/implementation:

  • Goal: relieve symptoms of the disease.
    a. Administer medications as ordered.
    (1) Amphotericin B (IV) and ketoconazole.
    (a) Monitor for drug side effects: local phlebitis, renal toxicity, hypokalemia, anemia, anaphylaxis, bone marrow depression.
    (b) Azotemia (presence of nitrogencontaining compounds in blood) is monitored by biweekly BUN or creatinine levels. BUN greater than 40 mg/dL or creatinine
    greater than 3.0 mg/dL necessitates stopping amphotericin B until values return to within normal limits.                                                                                             (2) Aspirin, diphenhydramine HCl (Benadryl), promethazine HCl (Phenergan), prochlorperazine (Compazine): used to decrease systemic toxicity of chills, fever, aching, nausea, and vomiting.
  • Goal: health teaching.
    a. Desired effects and side effects of prescribed medications; importance of taking medications for entire course of therapy (usually from 2 weeks to 3 months).
    b. Importance of follow-up laboratory tests to monitor toxic effects of drug.
    c. Identify source of contamination if possible and avoid future contact if possible.
    d. Importance of deep breathing, pursed-lip breathing, coughing, for specific care).
    e. Signs and symptoms of chronic histoplasmosis, COPD, drug toxicity, and drug side effects.

E. Evaluation/outcome criteria:

  • Complies with treatment plan.
  • Respiratory complications avoided.
  • Symptoms of illness decreased.
  • No further spread of disease.
  • Source of contamination identified and removed.

VII. TUBERCULOSIS: inflammatory, communicable disease that commonly attacks the lungs, although may occur in other body parts.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: exposure to causative organism (Mycobacterium tuberculosis) in the alveoli in susceptible individual leads to inflammation. Infection spreads by lymphatics to hilus; antibodies are released, leading to fibrosis, calcification, or inflammation. Exudate formation leads to caseous necrosis, then liquefication of caseous material leads to cavitation.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Persons who have inhaled the tubercle bacillus infectious particles called droplet nuclei.
  • Persons who have diseases or therapies known to suppress the immune system.
  • Immigrants from Latin America, Africa, Asia, and Oceania living in the United States for less than 1 year.
  • Americans living in those regions for a prolonged time.
  • Residents of U.S. metropolitan cities such as New York, Miami; those who live in poverty and are in overcrowded, poorly ventilated living conditions.
  • Men older than 65 years.
  • Women between ages 26 and 44 years and older than 65 years.
  • Children younger than 5 years.

C. Assessment:

  • Subjective data:
    a. Loss of appetite, weight loss.
    b. Weakness, loss of energy.
    c. Pain: knifelike, chest.
    d. Though client may be symptom free, the disease is found on screening.
  • Objective data:
    a. Night sweats, chills.
    b. Fever: low grade, late afternoon.
    c. Pulse: increased.
    d. Respiratory assessment:
    (1) Productive persistent cough, hemoptysis.
    (2) Respirations: normal, increased depth.
    (3) Asymmetrical lung expansion.
    (4) Increased tactile fremitus.
    (5) Dullness to percussion.
    (6) Crackles following short cough.                                                                                                                                                                                                         e. Hoarseness.
    f. Unexplained weight loss.
    g. Diagnostic tests:
    (1) Positive tuberculin test (Mantoux)—reaction to test begins approximately 12 hours after administration with area of redness and a central area of induration. The peak time is 48 hours. Determination of positive or negative is made. A reaction is positive when it measures 10 mm. Contacts reacting from 5 to 10 mm may need to be treated prophylactically. This test is referred to as purified protein derivative (PPD) or intradermal skin test.
    (2) Sputum: three specimens tested positive for acid-fast bacilli (AFB) (smear and culture). Positive equals greater than 10 AFB per field.                                       (3) X-ray: infiltration cavitation.
    h. Laboratory data: blood—decreased red blood cell (RBC) count, increased sedimentation rate.
    i. Classification of tuberculosis:

Physiological Integrity: Nursing Care of the Adult Client

D. Analysis/nursing diagnosis:

  • Ineffective airway clearance related to productive cough.
  • Impaired gas exchange related to asymmetrical lung expansion.
  • Pain related to unresolved disease process.
  • Body image disturbance related to feelings about tuberculosis.
  • Social isolation related to fear of spreading infection.
  • Knowledge deficit (learning need) related to medication regimen.

E. Nursing care plan/implementation:http://brilliantnurse.com/nclex-psychosocial-integrity-behavioralmental-health-care-throughout-life-span/

  • Goal: reduce spread of disease.
    a. Administer medications: isoniazid (INH), rifampin, pyrazinamide, ethambutol, or streptomycin; or drug combinations such as Rifadin or Rifamate. Client will be treated as an outpatient; may need to go to clinic for directly observed therapy (DOT) to ensure compliance with this long-term medication regimen.
    b. The following may need to take 300 mg of INH daily for 1 year as prophylactic measure: positive skin test reactors, including contacts; persons who have diseases or are receiving therapies that affect the immune system; persons who have leukemia, lymphoma, or uncontrolled diabetes or who have had a gastrectomy.
    c. Avoid direct contact with sputum.
    (1) Use good hand-washing technique after contact with client, personal articles.
    (2) Have client cover mouth and nose when coughing and sneezing, and use disposable tissues to collect sputum.
    d. Provide good circulation of fresh air. (Changes of air dilute the number of organisms. This plus chemotherapy provide protection needed to prevent spread of disease.)
    e. Implement airborne or droplet precautions.
  • Goal: promote nutrition.
    a. Increased protein, calories to aid in tissue repair and healing.
    b. Small, frequent feedings.
    c. Increased fluids, to liquefy secretions so they can be expectorated.
  • Goal: promote increased self-esteem.
    a. Encourage client and family to express concerns regarding long-term illness and treatment protocol.
    b. Explain methods of disease prevention, and encourage contacts to be tested and treated if necessary.                                                                                          c. Encourage client to maintain role in family while home treatment is ongoing and to return to work and social contacts as soon as it is determined safe for progress of treatment plan.
  • Goal: health teaching.
    a. Desired effects and side effects of medications:
    (1) INH may affect memory and ability to concentrate. May result in peripheral neuritis, hepatitis, rash, or fever.
    (2) Streptomycin may cause eighth cranial nerve damage and vestibular ototoxity, causing hearing loss; may cause labyrinth damage, manifested by vertigo and staggering; also may cause skin rashes, itching, and fever.
    (3) Important for client to know that medication regimen must be adhered to for entire course of treatment.
    (4) Discontinuation of therapy may allow organism to flourish and make the disease more difficult to treat.
    b. Need for follow-up, long-term care, and contact identification.
    c. Importance of nutritious diet, rest, avoidance of respiratory infections.
    d. Identify community agencies for support and follow-up.
    e. Inform that this communicable disease must be reported.

F. Evaluation/outcome criteria:

  • Complies with medication regimen.
  • Lists desired effects and side effects of medications prescribed.
  • Gains weight, eats food high in protein and carbohydrates.
  • Sputum culture becomes negative.
  • Retains role in family.
  • No complications (i.e., no hemorrhage, bacillus not spread to others).

VIII. EMPHYSEMA: chronic disease with excessive inflation of the air spaces distal to the terminal bronchioles, alveolar ducts, and alveoli; characterized by increased airway resistance and decreased diffusing capacity. Emphysema and chronic bronchitis together constitute chronic obstructive pulmonary disease (COPD).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: imbalance between proteases, which break down lung tissue, and α1-antitrypsin, which inhibits the breakdown. Increased airway resistance during expiration results in air trapping and hyperinflation →increased residual volumes. Increased dead space → unequal ventilation →perfusion of poorly ventilated alveoli → hypoxia and carbon dioxide retention (hypercapnia). Chronic hypercapnia reduces sensitivity of respiratory center; chemoreception in aortic arch and carotid sinus become principal regulators of respiratory drive (respond to hypoxia).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Smoking.
  • Air pollution: long-term exposure to environmental irritants, fumes, dust.
  • Antienzymes and α1-antitrypsin deficiencies.
  • Destruction of lung parenchyma.
  • Family history and increased age.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:
    a. Weakness, lethargy.
    b. History of repeated respiratory infections, shortness of breath.
    c. Long-term smoking.
    d. Irritability.
    e. Inability to accept medical diagnosis and treatment plan.
    f. Refusal to stop smoking.
    g. Dyspnea on exertion, dyspnea at rest (Differentiating Between Causes of Dyspnea).

Objective data:
a. Increased BP.
b. Increased pulse. Decreased O2 saturation.
c. Nostrils: flaring.
d. Cough: chronic, productive.
e. Episodes of wheezing, crackles.
f. Increased anterior-posterior diameter of chest (barrel chest).
g. Use of accessory respiratory muscles, abdominal and neck.
h. Asymmetrical thoracic movements, decreased diaphragmatic excursion.                                                                                                                                                   i. Position: sits up, leans forward to compress abdomen and push up diaphragm, increasing intrathoracic pressure, producing more efficient expiration.
j. Pursed lips for greater expiratory breathing phase (“pink puffer”).
k. Weight loss due to hypoxia.
l. Skin: ruddy color, nail clubbing; when combined with bronchitis: cyanosis (“blue bloater”).
m. Respiratory: early disease—alkalosis; late disease—acidosis, respiratory failure.
n. Spontaneous pneumothorax.
o. Cor pulmonale (emergency cardiac condition involving right ventricular failure due to increased pressure within pulmonary artery).
p. X-ray: hyperinflation of lung, flattened diaphragm; lung scan differentiates between ventilation and perfusion.                                                                                          q. Pulmonary function tests:
(1) Prolonged rapid, forced exhalation.
(2) Decreased: vital capacity (<4,000 mL); forced expiratory volume.
(3) Increased: residual volume (may be 200%); total lung capacity.
r. Laboratory data:
(1) PaO2 less than 80 mm Hg, pH less than 7.35.
(2) PaCO2 greater than 45 mm Hg.                                                                                                                                                                                                                  Note: In clients whose compensatory mechanisms are functioning, laboratory values may be out of the normal range, but if a 20:1 ratio of bicarbonate to carbonic acid is maintained, then appropriate acid-base balance also will be maintained. (Carbonic acid value can be obtained by multiplying the PCO2 value by 0.003.)

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Impaired gas exchange related to thick pulmonary secretions.
  • Ineffective breathing pattern related to hyperinflated alveoli.
  • Ineffective airway clearance related to pulmonary secretions.
  • Altered nutrition, less than body requirements, related to weight loss due to hypoxia.
  • Infection related to chronic disease process and decreased ciliary action.
  • Activity intolerance related to increased energy demands used for breathing.
  • Sleep pattern disturbance related to changes in body positions necessary for breathing.
  • Anxiety related to disease progression.
  • Knowledge deficit (learning need) related to disease, treatment, and self-care needs.
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E. Nursing care plan/implementation:

  • Goal: promote optimal ventilation.
    a. Institute measures designed to decrease airway resistance and enhance gas exchange.
    b. Position: Fowler’s or leaning forward to encourage expiratory phase.
    c. Oxygen with humidification, as ordered—no more than 2 L/min to prevent depression of hypoxic respiratory drive. May need long-term oxygen therapy as disease progresses, to improve quality of life and reduce risk of complications.
    d. Intermittent positive-pressure breathing (IPPB) with nebulization as ordered. Small-volume nebulizer treatment.
    e. Assisted ventilation.
    f. Postural drainage, chest physiotherapy.
    g. Medications, as ordered:
    (1) Bronchodilators to increase airflow through bronchial tree: inhaled: beta2-adrenergic agonists (albuterol, metaproterenol); anticholinergic agent: ipratropium (Atrovent); aminophylline, theophylline, terbutaline, isoproterenol (Isuprel).
    (2) Antimicrobials to treat infection (determined by sputum cultures and sensitivity): trimethoprim and sulfamethoxazole (Bactrim, Septra); doxycycline, erythromycin, amoxicillin, cephalosporins, and macrolides (condition deteriorates with respiratory infections).                                                                                    (3) Corticosteroids to decrease inflammation, mucosal edema, improve pulmonary function during exacerbation; systemic: prednisone, methylprednisolone sodium succinate (Solu-Medrol); inhaled: triamcinolone acetonide (Azmacort), beclomethasone (Beclovent, Vanceril), flunisolide (AeroBid).
    (4) Expectorants (increase water intake to achieve desired effect): glyceryl guaiacolate (Robitussin).
    (5) Bronchial detergents/liquefying agents (Mucomyst).
    h. Immunotherapy: helps ward off life-threatening influenza and pneumonia. Flu vaccination every October or November. Pneumococcal vaccination routinely one dose; revaccinate 5 years later if high risk.
  • Goal: employ comfort measures and support other body systems.
    a. Oral hygiene prn; frequently client is mouth breather.
    b. Skin care: waterbed, air mattress, foam pads to prevent skin breakdown.
    c. Active and passive ROM exercises to prevent thrombus formation; antiembolic stocking or woven elastic (Ace) bandages may be applied.
    d. Increase activities to tolerance.
    e. Adequate rest and sleep periods to prevent mental disturbances due to sleep deprivation and to reduce metabolic rate.
  • Goal: improve nutritional intake.
    a. High-protein, high-calorie diet to prevent negative nitrogen balance.
    b. Give small, frequent meals.
    c. Supplement diet with high-calorie drinks.
    d. Push fluids to 3,000 mL/day, unless contraindicated—helps moisten secretions.
  • Goal: provide emotional support for client and family.
    a. Identify factors that increase anxiety:
    (1) Fears related to mechanical equipment.
    (2) Loss of body image.
    (3) Fear of dying.
    b. Assist family coping:
    (1) Do not reinforce denial or encourage over concern.
    (2) Give accurate, up-to-date information on client’s condition.
    (3) Be open to questioning.
    (4) Encourage client–family communication.
    (5) Provide appropriate diversional activities.
  • Goal: health teaching.
    a. Breathing exercises, such as pursed-lip breathing and diaphragmatic breathing.
    b. Stress-management techniques.
    c. Methods to stop smoking.
    d. Importance of avoiding respiratory infections.                                                                                                                                                                                    e. Desired effects and side effects of prescribed medications, possible interactions with over the- counter drugs.
    f. Purposes and techniques for effective bronchial hygiene therapy.
    g. Rest/activity schedule that increases with ability.
    h. Food selection for high-protein, high-calorie diet.
    i. Importance of taking 2,500 to 3,000 mL fluid per day (unless contraindicated by another medical problem).
    j. Importance of medical follow-up.

F. Evaluation/outcome criteria:

  • Takes prescribed medication.
  • Participates in rest/activity schedule.
  • Improves nutritional intake, gains appropriate weight for body size.
  • No complications of respiratory failure, cor pulmonale.
  • No respiratory infections.
  • Acid-base balance maintained through compensatory mechanisms, acidosis prevented.

Physiological Integrity: Nursing Care of the Adult Client

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