Nursing Care of Patients With Ventilation Disorders

Chapter 36:
Nursing Care of Patients with Ventilation Disorders
Learning Outcomes:
1. Relate the pathophysiology and manifestations of lower respiratory

infections and inflammation, lung cancer, chest wall disorders, and
trauma to the ability to maintain effective ventilation and respiration
(gas exchange).
a. Suggested Activity: Use anatomical models to review the
anatomy of the lower respiratory tract. Using these models,
explain how the development of pathology in these areas
impairs gas exchange.
b. Suggested Activity: Demonstrate airflow through various sizes
of common tubules, such as soda straws, coffee stirrers, oxygen
tubing, or corrugated oxygen-delivery tubes. Consider having
students inhale through a soda straw or coffee stirrer to
experience the difference in airflow. Relate the pathophysiology
of impairment of airway size to that experience.
2. Compare and contrast the etiology, risk factors, and vulnerable
populations for lower respiratory infections, lung cancer, chest wall
disorders, trauma, and lung cancer
©2015 by Pearson Education, Inc.

LeMone/Burke/Bauldoff/Gubrud, Instructor’s Resource Manual for Medical-Surgical Nursing, 6th Edition
Ch. 36 Nursing Care of Patients with Ventilation Disorders
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a. Suggested Activity: Have students identify clinical patients who
might be at risk for the development of ventilation disorder.
Discuss the care necessary for these patients.
3. Describe interprofessional care and the nursing role in health
promotion and caring for patients with lower respiratory infections,
lung cancer, chest wall disorders, trauma, and lung cancer.
a. Suggested Activity: Divide the class into small groups and
assign each group one of the major categories of disorders
discussed in this chapter. Have each group work through the
nursing process as it would be associated with that disease
process.
4. Discuss surgery and other invasive procedures used to treat lung
cancer, chest wall disorders, trauma, and lung cancer, and nursing
responsibilities in caring for patients undergoing these procedures.
a. Suggested Activity: Ask an RN with trauma training to come to
post-conference to discuss emergency nursing treatment of the
patient with chest wall trauma.
5. Describe the nursing implications for medications used to treat
respiratory disorders and oxygen therapy.

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a. Suggested Activity: Have students identify medications that are
commonly used for treatment of ventilation disorders. Have the
students group the medications by class and identify major
nursing implications in administration.
I. Infections and Inflammatory Disorders

II. The Patient with Acute Bronchitis
A. Pathophysiology
1. Infectious bronchitis: caused by viruses or bacteria
2. Inflammatory bronchitis: inhalation of toxic gases/chemicals
a) Inflammatory cells infiltrate affected mucosa, exudate formation, increased mucus
production
B. Manifestations
1. Inflammatory response to infection or tissue damage
2. Capillary dilation, edema of mucosal lining of bronchi
3. Ciliated epithelium is damaged; ciliary function impaired
4. Nonproductive coughing paroxysms (later productive), substernal chest pain,
moderate fever, general malaise
C. Interprofessional care
1. Diagnosis
a) Based on history and clinical presentation
b) Chest x-ray to rule out pneumonia
2. Treatment
a) Broad-spectrum antibiotic
b) Daytime: expectorant cough medication
c) Nighttime: cough suppressant
D. Nursing care
1. Teaching topics
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a) Increased fluid intake
b) Over-the-counter analgesics and cough preparations, and prescribed medications
c) Smoking cessation
III. The Patient with Pneumonia

A. Pathophysiology
1. Infectious causes: bacteria, viruses, fungi, protozoa, and other microbes
a) Community acquired
(1) Most common: Streptococcus pneumoniae
(2) Other leading causes: Mycoplasma pneumoniae, Haemophilus influenza,
influenza virus, Chlamydia pneumoniae, Legionella pneumophila
b) Nosocomial (hospital acquired)
(1) Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae,
Escherichia coli
c) Opportunistic
(1) Pneumocystis carinii, Mycobacterium tuberculosis, Cytomegalovirus (CMV),
atypical mycobacteria, fungi
2. Noninfectious causes: aspiration of gastric contents and inhalation of toxic or
irritating gases
B. Physiology review
1. Sneezing, swallowing, expectoration, reflex closure of epiglottis and bronchial tree
help maintain sterility of lower respiratory tract
2. Past barriers, organisms rapidly phagocytized by macrophages, then attacked by
inflammatory and immune defenses
a) Aging impairs these immune responses, increases risk
C. Pathophysiology
1. Causes: inhalation of air or water, bloodstream from infection elsewhere, aspiration
of oropharyngeal secretions containing microbes
2. Pathologic process, anatomic location and manifestations vary by organism
3. Acute bacterial pneumonia (Streptococcus pneumoniae)
a) Inflammatory response causes alveolar edema and exudate

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b) Consolidation (solidification) of lung tissue
(1) Lobar pneumonia: large portion consolidation
(2) Bronchopneumonia: patchy consolidation
(3) Interstitial pneumonia
(4) Miliary pneumonia
D. Manifestations
1. Acute bacterial pneumonia
a) Onset: acute, rapid
b) Respiratory: productive cough; chest aching or pleuritic pain; limited breathing
sounds; audible pleural friction rub
c) Systemic: shaking chills, fever
E. Complications
1. Infection of pleura
2. Extensive parenchymal damage with necrosis, lung abscess, and empyema or pleural
effusion
3. Progressive destruction of lung tissue and functional impairment
4. Lung abscess
5. Empyema
a) Identified by chest x-ray or CT scan
b) Bacteremia can lead to meningitis, endocarditis, or peritonitis, thus increasing the
risk of mortality
6. Legionnaire’s Disease
a) Onset: gradual
b) Respiratory manifestations: dry cough, dyspnea
c) Systemic manifestations: chills and fever; general malaise; headache; confusion;
anorexia and diarrhea; myalgias and arthralgias
7. Primary atypical pneumonia
a) Mycoplasma pneumonia
b) Onset: gradual

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c) Respiratory manifestations: pharyngitis or bronchitis, dry, hacking, nonproductive
cough
d) Systemic manifestation: fever, headache, myalgias, and arthralgias
8. Viral pneumonia
a) Influenza and adenovirus
b) Cytomegalovirus (CMV) pneumonia is increasing in immunocompromised people.
c) Onset: sudden or gradual
d) Respiratory manifestations: dry cough
e) Systemic manifestations: flu-like symptoms
9. Pneumocystis pneumonia
a) Opportunistic: people with AIDS and immunocompromise are at risk
b) Abrupt onset with fever, tachypnea, shortness of breath, dry, nonproductive cough
c) Can lead to intercostal retractions and cyanosis
10. Aspiration pneumonia
a) Gastric contents in lungs
b) Risk factors: emergency surgery, depressed coughing reflexes, impaired swallowing
F. Interprofessional care
1. Prevention
a) Focus on early identification, appropriate treatment, and support of respiratory
function
2. Diagnosis
a) Chest x-ray, sputum gram stain, sputum culture and sensitivity
b) Complete blood count (CBC) with white blood cell (WBC) differential
c) Serology: when blood and sputum tests are negative
d) Pulse oximetry: continuously monitor gas exchange
e) Arterial blood gases (ABGs)
f) Fiberoptic bronchoscopy
3. Immunization
a) Pneumococcal vaccine usually imparts lifetime immunity with single dose
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b) Recommended for: people over age 65; those with chronic cardiac or respiratory
conditions, diabetes mellitus, alcoholism, or other chronic diseases;
immunocompromised people
4. Medications
a) Antibiotics to eradicate infection
(1) Specific medications for particular bacteria
b) Bronchodilators to improve ventilation and reduce hypoxia
c) Mucus “break up” agent
5. Treatments
a) Increased fluid intake
b) Incentive spirometry to promote clearance of respiratory secretions
c) Oxygen therapy
(1) For patient who is tachypneic or hypoxemic
(2) Increasing percentage of inspired oxygen
(3) Low-flow or high-flow
(4) Venturi mask; Vapotherm
d) Chest physiotherapy
(1) Percussion: rhythmically striking or clapping the chest wall with cupped hands,
using rapid wrist flexion and extension
(2) Vibration: repeatedly tensing the arm and hand muscles while maintaining firm
but gentle pressure over the affected area with the flat of the hand
(3) Postural drainage: uses gravity to facilitate removal of secretions from a particular
lung segment
6. Complementary therapies
a) Echinacea
b) Ma hung or ephedra (banned in U.S. for safety risks)
G. Nursing care
1. Health promotion
a) Inquire about allergic responses to eggs or previous influenza vaccinations
2. Assessment
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a) Health history
b) Physical examination: presentation, apparent distress, level of consciousness; skin
color, temperature; respiratory excursion, use of accessory muscles of respiration;
lung sounds
3. Diagnoses, outcomes, and interventions
a) Ineffective airway clearance
(1) Assess respiratory status and cough frequently
(2) Monitor arterial blood gas results
(3) Place in Fowler’s or high-Fowler’s position and encourage frequent position
changes and ambulation as allowed
(4) Assist to cough, deep breathe, and use assistive devices
(5) Perform pulmonary hygiene measures
b) Ineffective breathing pattern
(1) Assess respiratory status
(2) Assess for pleuritic discomfort
(3) Provide analgesics as ordered
(4) Teach slow abdominal breathing, meditation, and visualization
c) Activity intolerance
(1) Assess activity tolerance
(2) Assist with self care, bathing
(3) Schedule activities, planning for rest periods
(4) Provide assistive devices
4. Continuity of care
a) Discuss medication, activity level and rest, fluid and nutritional intake, avoiding
smoking, manifestations to report to healthcare provider
b) Refer to community support services
IV. The Patient with Severe Acute Respiratory Syndrome

A. Pathophysiology
1. Coronavirus, spreads primarily by contact with respiratory secretions

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2. Infects cells of respiratory tract
3. Alveolar damage and inflammation of interstitial pulmonary tissues
B. Manifestations and complications
1. 2–7 day average incubation period
2. Fever above 100.4 degrees F (38 degrees C)
3. Nonproductive cough, shortness of breath, dyspnea, hypoxemia
4. In second week, respiratory symptoms may progress to respiratory distress.
1. Diagnosis
a) Serology test, Reverse-transcriptase PCR (RT-PCR), chest x-ray, pulse oximetry,
CBC, sputum specimen, blood culture
b) Creatinine phosphokinase (CPK or CK), ALT, and AST levels may be markedly
increased
2. Medications
a) None at this time have been shown to be consistently effective.
3. Infection control
a) Standard precautions + contact and airborne precautions
b) Healthcare setting: hand hygiene, gown, gloves, eye protection, N95 respirator
c) Community setting:
(1) Patient advised to stay home for 10 days after fever has resolved; cover mouth
and nose when coughing/sneezing; wear surgical mask
(2) Family members wash hands frequently
4. Treatments
a) Supportive
b) Oxygen if hypoxemia is present
c) Intubation/mechanical ventilation for respiratory failure or ARDS
D. Nursing care
1. Health promotion
a) Preventing spread to others; providing respiratory support
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b) Health history: onset; recent international travel and/or exposure
c) Physical assessment
2. Diagnosis, outcomes and interventions
a) Impaired gas exchange
(1) Monitor vital signs, color, oxygen saturation, and arterial blood gases
(2) Safety alert: risk of respiratory failure
b) Risk for infection
(1) Private room with airflow control; discuss importance of isolation
(2) Mask patient when transporting patient; assist in masking visitors
(3) Inform all personnel involved of diagnosis
(4) Teach patient how to limit transmission to others
a) Educate on:
(1) The disease, its origin and transmission
(2) Manifestations of impaired respiratory status to report to the healthcare provider
(3) Techniques for preventing spread of the disease to others
V. The Patient with Lung Abscess

A. Lung abscess—local area of lung destruction
B. Pathophysiology
1. Forms after lung tissue becomes consolidated
2. In up to 89% of patients, anaerobic organisms are the cause
3. Consolidated tissue becomes necrotic:
a) Can spread to involve entire bronchopulmonary segment
b) Can progress proximally until it ruptures into a bronchus
c) Can lead to diffuse pneumonia or a syndrome similar to acute respiratory distress
syndrome
C. Manifestations
1. Typically 2 weeks after precipitating event

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2. Early symptoms are those of pneumonia
3. When the abscess ruptures, the patient may expectorate large amounts of foul-
smelling, purulent, and possibly blood-streaked sputum
4. Breathing sounds diminish; crackles in region of abscess; dull percussion tone is
present
D. Interprofessional care
1. Diagnosis
a) Based on history and presentation
b) CBC may indicate leukocytosis
c) Sputum culture may not show organism unless rupture occurs
d) Chest x-ray
2. Treatment
a) Antibiotic therapy: intravenous clindamycin (Cleocin), amoxicillin-clavulanate
(Augmentin), or penicillin
E. Nursing care
1. Diagnoses
a) Risk for ineffective airway clearance
b) Impaired gas exchange
c) Hyperthermia
d) Anxiety
2. Patient and family teaching
a) Importance of completing antibiotic therapy
b) Risk of sepsis
c) For surgery: preoperative teaching and instruction on postoperative care
VI. The Patient with Tuberculosis

A. Chronic, recurrent infectious disease, usually affects lungs
B. Bacteria: Mycobacterium tuberculosis
1. Transmitted through droplet nuclei
C. Pathophysiology
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1. Disease process
a) Bacteria implants in alveolus or respiratory bronchiole, cause local inflammatory
response. Bacteria is isolated but not destroyed
b) Tubercle (sealed-off colony of bacilli) forms
c) Caseation necrosis: infected tissue in tubercle dies
2. If immune response adequate, patient may not develop TB
3. Primary tuberculosis: severe and uncommon in adults
4. Reactivation tuberculosis: previously healed lesion may be reactivated
a) Occurs when immune system is suppressed
b) Risk of death if untreated
5. HIV patients at high risk
D. Manifestations
1. Initial infection typically goes unnoticed
2. Fatigue, weight loss, anorexia, low-grade afternoon fever, night sweats; dry cough,
which later becomes productive of purulent and/or blood-tinged sputum
3. Extrapulmonary tuberculosis
a) Bacilli enter bronchi
b) Disease spread to other organs through blood and lymph system
c) Miliary tuberculosis
(1) Chills, fever, weakness, malaise, progressive dyspnea
(2) With bone marrow involvement: anemia, thrombocytopenia, and leukocytosis
d) Genitourinary tuberculosis
(1) Kidney and genitourinary tract infected
(2) Large portion of renal parenchyma destroyed
(3) Symptoms of UTI, flank pain
(4) Men: manifestations of epididymitis or prostatitis
(5) Women: manifestations of pelvic inflammatory disease, impaired fertility, ectopic
pregnancy
e) Tuberculosis meningitis

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(1) Spread to the subarachnoid space
(2) Manifestations: listlessness, irritability, anorexia, and fever; headache and
behavior changes
f) Skeletal tuberculosis
(1) Most likely to occur in childhood
(2) Collapse of vertebral bodies, significant kyphosis, spinal cord compression
(3) Involved joint is painful, warm, tender
E. Incidence and prevalence
1. Factors for resurgence: HIV/AIDS epidemic, emergence of multiple-drug-resistant
(MDR) strains of TB, social factors such as immigration, poverty, homelessness, and
drug abuse
2. TB rates have been dropping since 1993
3. Worldwide: still a significant health problem
4. Affects mostly disadvantaged populations
5. Risk factors
a) Poor ventilation, less-than-optimal immune function, prolonged contact, injection
drug use, HIV infection, alcoholism
F. Nursing care for the older adult
a) Presenting symptoms are vague, including coughing, weight loss, anorexia, or
periodic fevers
b) Purified protein derivative (PPD) often required by law
c) Teach home care
d) Teach possible side effects of prescribed medications
G. Interprofessional care
1. Focus: early detection, accurate diagnosis, effective treatment, preventing TB spread
2. Hospitalization is rarely required
3. Screening
a) Tuberculin test
(1) Positive response indicates that infection and a cellular (T-cell) response have
developed; does not mean that active disease is present or that the patient is
infectious to others
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(2) Screen those with:
(a) HIV infection or risk
(b) Exposed to TB
(c) With medical risk factors
(d) Born in countries with high prevalence of TB
(e) Medically underserved low-income populations
(f) Alcoholics and injection drug users
(g) Residents and staff of long-term residential facilities, such as long- term care
and mental health facilities, correctional institutions
(3) Methods for tuberculin testing
(a) Intradermal PPD (Mantoux) test; multiple-puncture (tine) test
4. Diagnosis
a) A positive tuberculin test alone does not indicate active disease
b) Sputum smear is microscopically examined for acid-fast bacilli
c) Sputum culture positive for M. tuberculosis provides the definitive diagnosis
d) Automated radiometric culture systems (Bactec) allow for much faster detection
e) Sensitivity testing to determine appropriate drug therapy
f) Polymerase chain reaction (PCR)-rapid detection of M. tuberculosis DNA
g) Chest x-ray; liver function tests
5. Medications
a) Chemotherapeutic medications both to prevent and treat
b) Prophylactic treatment: Isoniazid (INH), bacilli Calmette-Guérin (BCG) vaccine
c) Initial regimen of four oral antitubercular drugs for 2 months
(1) Isoniazid (INH), rifampin, pyrazinamide, and ethambutol
d) 4 additional months of therapy with isoniazid and rifampin
e) In the presence of HIV infection, treatment is continued for at least 9 months
f) Many adverse and toxic effects
g) Patients often do not comply with prescriptions
H. Nursing care
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1. Health promotion
a) Threat to public health
b) Education and screening
c) Early diagnosis
2. Assessment
a) Health history
b) Physical examination
c) Diagnostic tests
a) Deficient knowledge
(1) Assess knowledge about the disease process; identify misperceptions and
emotional reactions
(2) Assess ability and interest in learning, developmental level, and obstacles to
learning
(3) Identify support systems, and include significant others in teaching
b) Ineffective therapeutic regimen management
(1) Assess self-care abilities and support systems
(2) Work collaboratively to identify barriers to managing the prescribed treatment;
assist in developing a plan for managing prescribed regimen; provide verbal and
written instructions that are clear and appropriate
(3) Active intervention for homeless people
(4) Refer patients who are unlikely to comply with treatment regimen to public health
department for management and follow-up
c) Risk for infection
(1) Use standard precautions and TB isolation techniques
a) Discuss with patient and family:
(1) Screening and prevention of spread
(2) Medication regiment
(3) Nutrition and dietary guidelines

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(4) Manifestations of complications to report
(5) Community support services
VII. The Patient with Inhalation Anthrax

A. Pathophysiology
1. Bacillus anthracis, the spore-forming rod responsible for causing anthrax
2. Potential biologic weapon threat
B. Manifestations
1. Flu-like symptoms, followed by an abrupt onset of severe dyspnea, stridor, and
cyanosis
2. Lymph nodes in the mediastinum and thorax become inflamed and enlarged
3. Septic shock and/or meningitis may develop
4. Untreated, death results from hemorrhagic thoracic lymphadenitis and hemorrhagic
mediastinitis
5. 45% mortality rate
C. Diagnosis
1. Blood culture/chest x-ray
2. Because of risk of death, people suspected of exposure are treated prophylactically
D. Treatments
1. Ciprofloxacin (Cipro) is used to both prevent and treat inhalation anthrax
2. Doxycycline (Vibramycin) is an alternative to ciprofloxacin
3. Vaccine is considered experimental
VIII. The Patient with a Fungal Infection

A. Pathophysiology and manifestations
1. Histoplasmosis: most common fungal lung infection in U.S.
a) Found in soil, bird droppings, and bats
b) Most infections lead to latent asymptomatic disease, or primary acute histoplasmosis,
a mild, self-limiting influenza-like illness
c) Chronic progressive disease, usually seen in older adults

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d) Immunocompromised host: macrophages remove fungi, but are unable to destroy
them, resulting in disseminated histoplasmosis (often fatal)
2. Coccidioidomycosis: Coccidioides immitis mold grows in arid soil of Southwest,
Mexico, Central/South America
a) Typically causes an acute, self-limiting pulmonary infection that often is
asymptomatic and goes unrecognized
3. Blastomycosis: Blastomyces dermatitidis fungus grow in Midwestern U.S./Canada
a) Lungs are primary site for disease
b) Pulmonary symptoms include fever, dyspnea, pleuritic chest pain, and cough, which
may become productive of bloody or purulent sputum
c) Fatal if untreated
4. Paracoccidioidomycosis
a) Also known as Brazilian blastomycosis or Lutz-Spendore-Almeida disease
b) Caused by Paracoccidioides brasiliensis fungus
c) The pulmonary presentation includes lobar pneumonia or pleurisy that continues past
the ninth day
5. Aspergillus
a) Aspergillus spores are common in the environment, but rarely cause disease except in
the immunocompromised
b) When infection occurs, Aspergillus species invade blood vessels and produce hyphae
that branch at acute angles, frequently causing venous or arterial thrombosis
c) Dyspnea, nonproductive cough, pleuritic chest pain, chills, and fever
d) If the organism invades a pulmonary blood vessel, hemoptysis or massive pulmonary
hemorrhage can occur
B. Interprofessional care
1. Microscopic examination of a sputum specimen
2. Blood cultures, cerebrospinal fluid cultures, chest x-ray
3. Acute pulmonary histoplasmosis and acute pulmonary coccidioidomycosis
a) Usually resolve without treatment
b) Antifungal drugs may shorten the disease course
(1) Oral itraconazole (Sporanox) for histoplasmosis

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4. Intravenous amphotericin B. for other fungal infections
5. Surgery (lobectomy) for severe hemoptysis associated with aspergillosis
C. Nursing care
1. Education
a) Antifungal drugs
b) Pregnancy and birth control
2. Monitor carefully during infusion and therapy
IX. The Patient with Pleuritis (Pleurisy)

A. Pleura: thin membrane of two layers overlying lungs and chest wall
B. Pleural cavity: between layers of the pleura, contains serous fluid
C. Pathophysiology and manifestations
1. Inflammation of pleura
2. Abrupt onset, unilateral, well localized, sharp or stabbing pain
3. Often occurs following a viral respiratory illness, pneumonia, or rib injury
D. Interprofessional care
1. Diagnosis based on manifestations
a) Chest x-ray/ECG to rule out other causes of chest pain
2. Treatment
a) Symptomatic
3. Care focused on promoting comfort
E. Nursing care
1. Teach patient and family
a) Pleuritis is generally self-limited and of short duration
b) Discuss symptoms to report to the healthcare provider: increased fever, productive
cough, difficulty breathing, or shortness of breath
X. The Patient with a Pleural Effusion


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1. Excess pleural fluid, may be either transudate or exudate
2. Precipitating factors: heart failure, renal failure, nephrosis, liver failure, malignancy
3. Large pleural effusion compresses adjacent lung tissue
a) Manifestation of dyspnea; pain may develop
b) Breath sounds are diminished or absent
c) Dull percussion tone heard over affected area; chest wall movement may be limited
1. Chest x-rays, CT scan, ultrasonography used to localize and differentiate effusions
2. Thoracentesis: fluid removed from pleural space
a) Analyzed for appearance, cell counts, protein and glucose content, the presence of
enzymes such as LDH and amylase, abnormal cells, and culture
3. Treatment
a) Focuses on underlying disorder
b) An empyema may require repeated drainage, as well as high doses of parenteral
antibiotics
c) Thoracotomy and surgical excision may be necessary
C. Nursing care
1. Supporting respiratory function and assisting with procedures to evacuate collected
fluid
2. Teaching for home care: symptoms of recurrent effusion or complications following
thoracentesis to report to healthcare provider (increasing dyspnea or shortness of
breath, cough, and hemoptysis)
XI. The Patient with Pneumothorax

A. Pathophysiology
1. When either the visceral or parietal pleura is breached, air enters the pleural space,
equalizing this pressure
2. Lung expansion is impaired; recoil tendency collapses lung
3. Spontaneous pneumothorax
a) Primary (simple) pneumothorax: affects previously healthy people, usually tall,
slender men between ages 16 and 24; cause unknown

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b) Secondary (complicated) pneumothorax: generally caused by overdistention and
rupture of an alveolus, is more serious and potentially life threatening
4. Traumatic pneumothorax
a) Blunt or penetrating trauma of the chest wall and pleura, fracture of the trachea and
a ruptured bronchus or esophagus can lead to closed pneumothorax
b) Open pneumothorax (sucking chest wound): penetrating chest trauma
c) Iatrogenic pneumothorax: results from puncture or laceration of the visceral pleura
during central-line placement, thoracentesis, or lung biopsy
(1) Alveoli can become overdistended and rupture during anesthesia, resuscitation
procedures, or mechanical ventilation
5. Tension pneumothorax
a) Air enters the pleural space but is prevented from escaping
b) Ventilation is severely compromised, and venous return to the heart is impaired
c) Medical emergency requiring immediate intervention to preserve respiration and
cardiac output
B. Manifestations
1. Spontaneous pneumothorax
a) Depends on size of pneumothorax, extent of lung collapse, and any underlying lung
disease
b) Pleuritic chest pain, shortness of breath, heart rate and respiratory increase,
asymmetrical chest-wall movement (affected side is hyperresonant to percussion, and
breath sounds may be diminished or absent)
c) Hypoxemia may develop (more pronounced in secondary)
d) Decreased breath sounds and hyperresonant percussion tone on affected side,
unequal lung excursion, tachypnea, tachycardia
2. Traumatic pneumothorax
a) Pain and dyspnea
b) Chest wall movement on the affected side is diminished, and breath sounds are
absent; if penetrating wound is present, air may be heard and felt moving through it
with respiratory efforts
c) Pain, dyspnea, tachypnea, tachycardia, decreased respiratory excursion, absent
breath sounds in affected area
d) Hemothorax frequently accompanies traumatic pneumothorax
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e) The manifestations of iatrogenic pneumothorax are similar to those of spontaneous
pneumothorax
3. Tension pneumothorax
a) Hypotension, shock, distended neck veins, severe dyspnea, tachypnea, tachycardia,
decreased respiratory function, absent breath sound on affected side, tracheal
deviation toward unaffected side
1. Treatment depends on severity
2. Thoracostomy may be necessary
3. Diagnosis
a) Oxygen saturation measurements, chest x-rays, and ABGs
4. Treatments
a) Chest tubes (closed-chest catheter) allows lung to reexpand
(1) Protocol and systems of chest tubes
b) Pleurodesis: adhesions between the parietal and visceral pleura
(1) To prevent recurring pneumothorax
c) Surgery: for patients at high risk of recurrence
(1) Thoracostomy
D. Nursing care
1. Health promotion
2. Assessment
a) Health history
b) Physical assessment
c) Diagnostic tests: chest x-rays, arterial blood gases
3. Diagnosis, outcomes, and interventions
a) Impaired gas exchange
(1) Assess and document vital signs and respiratory status
(2) Evaluate chest wall movement, position of the trachea, and neck veins frequently;
place in Fowler’s or high-Fowler’s position
(3) Administer oxygen
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(4) Assess chest tube, system function, and drainage at least every 2 hours
b) Risk for injury
(1) Secure a loop of drainage tubing to the sheet or gown
(2) When turning to the affected side, ensure that neither the chest tube nor drainage
tubing is kinked or occluded under the patient
(3) Teach the patient how to ambulate with the drainage system
(4) Ensure all tubing connections are taped per hospital policy or provider preference
a) Education about future risk
b) Stress the importance of follow-up care and monitoring
c) Teach manifestations to report to healthcare provider
XII. The Patient with Hemothorax (Blood in Pleural Space)

1. Causes: chest trauma, tumors, pulmonary infarction, infections such as TB
2. With significant hemorrhage, a risk of shock exists
3. Symptoms similar to pneumothorax or pleural effusion
4. Chest x-ray confirms diagnosis
B. Treatment
1. Thoracentesis or thoracostomy with chest tube drainage is used to remove blood from
the pleural space
C. Nursing care
1. Focuses on maintaining adequate respiratory function and cardiac output
2. When hemothorax develops rapidly and hemorrhage is significant, additional priority
3. Diagnoses
a) Decreased cardiac output
b) Risk for deficient fluid volume
XIII. Trauma of the Chest or Lung

A. Chest injury is a leading cause of death from trauma
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B. Traumatic injury to the chest may involve both the chest wall and
underlying thoracic structures, including the lungs, heart, great vessels,
and esophagus
XIV. The Patient with a Thoracic Injury
1. Most common: acceleration-deceleration injury and direct mechanisms of injury (e.g.,
crush injuries)
2. Rib fracture
a) Generally well tolerated
b) Complications can occur for older adult or person with lung disease
c) Displaced fractured ribs can penetrate the pleura, leading to pneumothorax and
possible hemothorax
d) Intrathoracic vessels may be damaged or torn with fractures of the first and second
ribs; fractures of the seventh through tenth ribs may cause liver or spleen injuries
3. Flail chest
a) Paradoxic movement
b) Significantly affects ventilation, and consequently, gas exchange
c) Dyspnea and pain, especially on inspiration; unequal chest expansion; palpable
crepitus; breath sounds diminished; crackles may be heard on auscultation
4. Pulmonary contusion
a) May occur unilaterally or bilaterally
b) Alveoli and pulmonary arterioles rupture, causing intra-alveolar hemorrhage and
interstitial and bronchial edema; resulting inflammatory response increases capillary
permeability, leading to local or general edema
c) Manifestations of pulmonary contusion may not be apparent until 12 to 24 hours
after the injury
d) Increasing shortness of breath, restlessness, apprehension, and chest pain are early
signs; copious sputum, which may be blood tinged, is present
e) Later manifestations: tachycardia, tachypnea, dyspnea, and cyanosis
f) Even with appropriate treatment, pulmonary contusion can lead to acute respiratory
distress and potential death
Page 23 of 33
1. Chest x-ray
2. Rib fracture: providing adequate analgesia to promote breathing, coughing, and
movement is primary intervention
3. Flail chest: intercostal nerve blocks or continuous epidural analgesia to manage the
pain associated
a) Intubation and mechanical ventilation
4. Pulmonary contusion patients often are critically ill, requiring intensive care
management
a) Treatment is supportive, directed at maintaining adequate ventilation and alveolar gas
exchange
b) Endotracheal intubation and mechanical ventilation
c) Although adequate hydration is necessary to prevent shock, overhydration can
increase pulmonary edema
d) Unilateral pulmonary contusion—unique management problem
(1) Mechanical ventilation with positive end-expiratory pressure (PEEP) to maintain
open alveoli and adequate gas exchange can damage the unaffected lung
(2) Intubation with a double-lumen endotracheal tube that permits independent
ventilation of each lung may be used
C. Nursing care
1. Health promotion
2. Health history
3. Physical examination
a) Acute pain
(1) Frequently assess pain; administer analgesics by patient-controlled analgesia or
on a schedule
b) Ineffective airway clearance
(1) Assess lung sounds and respiratory rate, depth, and effort frequently
(2) Encourage to cough, deep breathe, and change position every 1 to 2 hours, and
use the incentive spirometer
(3) Teach splinting with pillow when coughing

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(4) Elevate the head of the bed
c) Impaired gas exchange
(1) Expected outcomes: improved ventilation and adequate oxygenation as evidenced
by blood gas levels within normal limits for the individual patient
(2) Monitor vital signs, color, oxygen saturation, and arterial blood gases
(3) Assess for manifestations such as anxiety or apprehension, restlessness, confusion
or lethargy, or complaints of headache
(4) Maintain oxygen therapy and mechanical ventilation as ordered. Hyperoxygenate
prior to suctioning
a) Teaching for home care includes: pain management and its importance in preventing
respiratory complications; importance of coughing and deep breathing; reasons for
not taping or wrapping the chest continuously
b) Symptoms to report to the healthcare provider; importance of avoiding respiratory
irritants
XV. The Patient with Inhalation Injury

1. Smoke inhalation: pulmonary injury due to inhalation of hot air, toxic gases, or
particulate matter is the leading cause of death in burn injury
2. Three mechanisms significantly impair normal respiratory function
a) Thermal damage to the airways, leading to impaired ventilation
b) Carbon monoxide or cyanide poisoning, resulting in tissue hypoxia
c) Chemical damage to the lung from noxious gases, which can impair gas exchange
d) Asphyxiation
e) Carbon monoxide or cyanide inhalation—immediate threat to life
(1) Hemoglobin bound to carbon monoxide reduces the oxygen-carrying capacity of
blood and oxygen delivery to cells of the body
(2) Suspected if the burn occurred in a closed space, if there is evidence of inhalation
injury, or if dyspnea develops
f) Manifestations: depend on level of carboxyhemoglobin saturation
(1) When hemoglobin is 10% to 20% saturated with carbon monoxide, symptoms
include headache, dizziness, dyspnea, and nausea
Page 25 of 33
(a) A characteristic “cherry-red” skin color
(2) With increasing levels, confusion, visual disturbances, irritability, hallucinations,
hypotension, seizures, and coma develop
(3) Permanent neurologic deficit can occur in survivors of severe acute carbon
monoxide poisoning
(4) Pneumonia is common following smoke inhalation
3. Near-drowning
a) Asphyxiation and aspiration are primary problems
b) Laryngeal spasm causes asphyxia
c) Most often asphyxia and hypoxemia are the result of fluid aspiration
d) The dive reflex may prolong survival
e) Water aspiration can cause delayed death from near-drowning
f) Respiratory and systemic effects differ between freshwater and saltwater
g) Manifestations
(1) May include altered level of consciousness, restlessness, and apprehension;
headache or chest pain; vomiting, possible cyanosis, apnea, tachypnea, and
wheezing
(2) Other manifestations include tachycardia, dysrhythmias, hypotension, shock, and
cardiac arrest. Hypothermia may be present
1. Safety and prevention
2. Administering effective cardiopulmonary resuscitation
a) Hypoxemia progresses rapidly until breathing is restored; reversal of tissue hypoxia
depends on adequate circulation
3. Diagnosis
a) ABGs
b) Carboxyhemoglobin levels are drawn in suspected carbon monoxide poisoning
c) Serum electrolytes and osmolality levels vary in near-drowning, depending on the type
of water aspirated
d) Chest x-ray

Page 26 of 33
e) Bronchoscopy may be ordered to inspect damaged lung tissue, particularly with
smoke inhalation and possible thermal injury
4. Treatments
a) Supportive
b) Endotracheal intubation and mechanical ventilation
c) Supplemental oxygen
d) Hyperbaric oxygen therapy may be used for carbon monoxide poisoning
(1) Risks include: oxygen toxicity and potential trauma to lung tissues, sinuses, and
ears due to the increased pressures
e) Bronchodilator therapy to manage bronchospasm
f) Intravenous fluids may be ordered; if significant hemolysis has occurred, packed red
blood cells may be given
g) With near-drowning victims, measures such as inducing hypothermia or barbiturate-
induced coma and administering corticosteroids and osmotic diuretics may be
employed to help prevent neurologic damage
h) Careful monitoring for complications such as pneumonia and acute respiratory
distress syndrome is vital throughout the course of treatment
C. Nursing care
1. Health promotion
a) Prevention of inhalation injuries
b) Teaching value of safety procedures in the home
c) Teaching swimming safety
d) CPR training
2. Health history
3. Physical examination
4. Diagnostic tests
a) Ineffective airway clearance
(1) Assess lung and breath sounds and respiratory rate, depth, and effort
(2) Assist to cough frequently; suction the intubated patient as needed to remove
secretions; elevate head of bed
Page 27 of 33
b) Impaired gas exchange
(1) Monitor vital signs, color, oxygen saturation, mental status
(2) Monitor exhaled carbon monoxide, arterial blood gases, and pulmonary artery
pressures
c) Ineffective tissue perfusion: cerebral
(1) Monitor vital signs and neurologic status frequently
(2) A change in level of consciousness or behavior is typically the earliest sign of
increased intracranial pressure (IICP)
(3) Maintain effective ventilation and oxygenation; hypercapnia and hypoxemia
increase cerebral edema
(4) Administer sedation, osmotic diuretics, or corticosteroids as ordered to reduce
cerebral edema
a) Teach non-hospitalized patients about symptoms that may indicate a complication
b) Provide resources for patients who have neurologic damage
XVI. The Patient with Lung Cancer

A. Pathophysiology
1. Damaged bronchial epithelial cells mutate over time to become neoplastic
2. Bronchogenic carcinoma: vast majority of primary lung lesions
a) Types: small-cell carcinomas, non-small-cell carcinomas
3. Each cell type differs in its incidence, presentation, and manner of spread
B. Manifestations
1. Related to the location and spread of the tumor
2. Chronic cough, hemoptysis, wheezing, shortness of breath
3. Dull chest pain with spread to mediastinum
4. Pleuritic pain with pleura invasion
5. Systemic and paraneoplastic manifestations
a) Weight loss, anorexia, fatigue, and weakness
b) Bone pain, tenderness, and swelling; clubbing of the fingers and toes

Page 28 of 33
c) Various endocrine, neuromuscular, cardiovascular, and hematologic symptoms
C. Complications and course
1. Superior vena cava syndrome: obstruction of superior vena cava
2. Paraneoplastic syndromes
a) Syndrome of inappropriate ADH secretion (SIADH) with fluid retention,
hyponatremia, edema, Cushing’s syndrome related to abnormal ACTH production,
and hypercalcemia
3. Procoagulation factors, increasing the risk for venous thrombosis, pulmonary
embolism, and thrombotic endocarditis
D. Incidence and risk factors
1. Risk increases with age
2. Genetics
3. Tobacco smoking or exposure to tobacco smoke
4. Dose–response relationship between smoking and lung cancer
E. Interprofessional care
1. Prevention is primary goal
2. Diagnosis
a) Chest x-ray, sputum specimen, bronchoscopy; CT scan
b) Cytologic examination and biopsy
c) CBC, liver function studies, serum electrolytes
d) Tuberculin test
e) Pulmonary function tests (PFTs)
f) Arterial blood gases
g) Lung cancer is staged by the tumor size, location, degree of invasion of the primary
tumor, and the presence of metastatic disease
(1) Stage 0 to Stage IV
3. Medications
a) Combination chemotherapy, often combined with radiation therapy and/or surgery
b) Bronchodilators to reduce airway obstruction

Page 29 of 33
c) Analgesics and pain management
4. Surgery
a) Can cure non-small-cell lung cancer
b) Most types inoperable at time of diagnosis
c) Laser bronchoscopy: bronchoscopy-guided laser used to resect tumor
d) Mediastinoscopy: visualization of the mediastinum using an endoscope passed
through a suprasternal incision
e) Thoracotomy: incision into the chest wall
f) Wedge resection: removal of a small section of peripheral lung tissue
g) Segmental resection: removal of an individual bronchovascular segment of a lobe
h) Sleeve resection: resection of a section of a major bronchus with reconstruction of
remaining normal bronchus
i) Lobectomy: removal of a single lung lobe
j) Pneumonectomy: removal of an entire lung
5. Radiation therapy
a) Used alone or in combination with surgery or chemotherapy
b) Treatment goal may be either cure or symptom relief (palliative)
c) Prior to surgery, radiation therapy is used to “debulk” tumors
d) Complications of lung cancer may be treated with radiation
F. Nursing care
1. Health promotion
2. Priorities of care
a) Health history
b) Physical examination
c) Laboratory tests and diagnostic studies
a) Ineffective breathing pattern
(1) Assess and document respiratory status every 4 hours; more frequently
postoperatively or as needed

Page 30 of 33
(2) Frequently assess and document pain level
(3) Elevate head of bed to 60 degrees; assist to turn, cough, and deep breathe and use
incentive spirometry; help splint the chest with a pillow or blanket when coughing
b) Activity intolerance
(1) Assess activity tolerance
(2) Assist postoperative patient to increase activities gradually
(3) Teach measures to conserve energy while performing ADLs
c) Pain
(1) Assess and document pain
(2) Maintain medication schedule using narcotic, nonsteroidal anti-inflammatory
drugs, and other medications as ordered
(3) Provide or assist with comfort measures
(4) Spend as much time with the patient as possible; allow family members to remain
with the patient
d) Anticipatory grieving
(1) Spend time with the patient and family
(2) Answer questions honestly
(3) Encourage the patient and family to express their feelings, fears, and concerns
a) Discuss the disease, expected prognosis, and planned treatment strategies
b) Importance of quitting smoking
c) Strategies to cope with noxious effects of radiation or chemotherapy
d) Activities and exercises to improve strength and regain function for the postoperative
patient
e) The need to continue coughing and deep-breathing exercises at home
f) Symptoms to report to the healthcare provider
g) Use of analgesics and other pain relief measures for postoperative or cancer pain
h) Information about hospice services, home health, local cancer support groups for
patients and caregivers, and American Cancer Society services
XVII. Chapter Highlights

Page 31 of 33
A. Pneumonia, inflammation of the respiratory bronchioles and alveoli,
usually is bacterial in origin. Different organisms commonly are found in
hospital-acquired pneumonia than in community acquired pneumonia.
Nursing care focuses on promoting airway clearance, supporting effective
gas exchange, and promoting rest.
B. Infection control measures, including standard, airborne, and contract
precautions, are vital to prevent the spread of viral severe acute
respiratory syndrome (SARS).
C. Tuberculosis affects many people worldwide. In the United States, the
primary affected populations are immigrants, people with compromised
immunity, and people living in crowded or unsanitary conditions.
D. The tuberculin test (PPD) detects a cellular immune response to M. tb,
indicating infection, but not necessarily active disease.
E. Effective tuberculosis treatment is a public health concern, requiring
therapy and compliance monitoring, contact follow-up, and assessment for
adverse treatment effects.
F. Fungal lung infections tend to have a geographic pattern of distribution.
People with compromised immune status are more likely to be affected.
Their manifestations resemble those of pneumonia or tuberculosis.
G. Disorders of the pleura, such as pleural effusion and pneumothorax, can
affect lung expansion, ventilation, and gas exchange when significant.
H. Tension pneumothorax develops when air enters the pleural space but is
unable to escape, collapsing the lung on the affected side and placing
pressure on the unaffected lung and mediastinum. Ventilation, gas
exchange, venous return, and cardiac output can be significantly affected.
I. Trauma may affect the chest wall, or the airways and alveoli. Flail chest
and pulmonary contusion often occur concurrently; hemothorax also
frequently develops with chest trauma. Chest trauma can endanger
effective ventilation and gas exchange.
J. Lung cancer, the leading cause of cancer deaths, typically is advanced
when diagnosed. Surgery, radiation therapy, and chemotherapy are used
to treat lung cancer, often in combination.

Page 32 of 33
K. Superior vena cava syndrome and paraneoplastic syndromes may
complicate lung cancer.

Page 33 of 33

Nursing Care of Patients With Ventilation Disorders

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Nursing Care of Patients With Ventilation Disorders

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Chapter 36:

Nursing Care of Patients with Ventilation Disorders

1. Relate the pathophysiology and manifestations of lower respiratory

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

I. Infections and Inflammatory Disorders

III. The Patient with Pneumonia

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

IV. The Patient with Severe Acute Respiratory Syndrome

©2015 by Pearson Education, Inc.

V. The Patient with Lung Abscess

©2015 by Pearson Education, Inc.

VI. The Patient with Tuberculosis

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©2015 by Pearson Education, Inc.

VII. The Patient with Inhalation Anthrax

VIII. The Patient with a Fungal Infection

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©2015 by Pearson Education, Inc.

IX. The Patient with Pleuritis (Pleurisy)

X. The Patient with a Pleural Effusion

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XI. The Patient with Pneumothorax

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XII. The Patient with Hemothorax (Blood in Pleural Space)

XIII. Trauma of the Chest or Lung

©2015 by Pearson Education, Inc.

XV. The Patient with Inhalation Injury

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XVI. The Patient with Lung Cancer

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©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

XVII. Chapter Highlights

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

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