Chapter 23 - Management of Patients With Chest and Lower Respiratory Tract1

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A baker is exposed to dust from flour. A quarry worker is exposed to rock
dust and silica. A welder is exposed to gases and fumes that can be
inhaled and result in silicosis. A banker, nurse, and mechanic may have
work hazards but not specific to the development of silicosis.
Factors associated with the development of ARDS include aspiration
related to near drowning or vomiting; drug ingestion/overdose;
hematologic disorders such as disseminated intravascular coagulation or
massive transfusions; direct damage to the lungs through prolonged
smoke inhalation or other corrosive substances; localized lung infection;
metabolic disorders such as pancreatitis or uremia; shock; trauma such
as chest contusions, multiple fractures, or head injury; any major surgery;
embolism; and septicemia. Smoke inhalation does not increase the risk
for lung cancer, bronchitis, and tracheobronchitis
The nurse should use strict hand hygiene to help minimize the client's
exposure to infection, which could lead to pneumonia. The head of the
bed should be kept at a minimum of 30 degrees. The client should be
turned and repositioned at least every 2 hours to help promote secretion
drainage. Oral hygiene should be performed every 4 hours to help
decrease the number of organisms in the client's mouth that could lead
to pneumonia.
For a patient with a lung abscess the nurse encourages a diet that is high
in protein and calories to ensure proper nutritional intake. A
carbohydrate-dense diet or diets with limited fats are not advisable for a
patient with a lung abscess.
The client has developed a pneumothorax, and the best action is to
prevent further deflation of the affected lung by placing an airtight
dressing over the wound. A vented dressing would be used in a tension
pneumothorax, but because air is heard moving in and out, a tension
pneumothorax is not indicated. Applying direct pressure is required if
active bleeding is noted.
The client demonstrates understanding of how to prevent relapse when
he states that he must continue taking the antibiotics for the prescribed
10-day course. Although the client should keep the follow-up appointment
with the physician and turn and reposition himself frequently, these
interventions don't prevent relapse. The client should drink 51 to 101 oz
(1,500 to 3,000 ml) per day of clear liquids.
Bubbling in the water-seal chamber occurs in the early postoperative
period. If bubbling is excessive, the nurse checks the system for any kind
of leaks. Fluctuation of the fluid in the water-seal chamber is initially

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present with each respiration. Fluctuations cease if the chest tube is
clogged or a kink develops in the tubing. If the suction unit malfunctions,
the suction control chamber, not the water-seal chamber, will be affected.
Clamping can result in a tension pneumothorax. The other options would
not occur if the chest tube was clamped during transportation.
For a patient with pleural effusion, a diet rich in protein and calories is
pivotal. A carbohydrate-dense diet or diets with limited fat are not
advisable for a patient with lung abscess.
A client with drug-resistant tuberculosis isn't contagious when he's had a
negative acid-fast test. A client with nonresistant tuberculosis is no longer
considered contagious when he shows clinical evidence of decreased
infection, such as significantly decreased coughing and fewer organisms
on sputum smears. The medication may not produce negative acid-fast
test results for several days. The client won't have a clear chest X-ray for
several months after starting treatment. Night sweats are a sign of
tuberculosis, but they don't indicate whether the client is contagious.
The cardinal physiologic abnormalities of acute respiratory failure are
hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on
resolving these problems.
The clinical manifestations of pulmonary contusions are based on the
severity of bruising and parenchymal involvement. The most common
signs and symptoms are crackles, decreased or absent bronchial breath
sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged
secretions, hypoxemia, and respiratory acidosis. Patients with moderate
pulmonary contusions often have a constant, but ineffective cough and
cannot clear their secretions.
Clients are encouraged to perform passive or active exercises, as
tolerated, to prevent the development of a thrombus from forming.
Constrictive, tight-fitting clothing is a risk factor for the development of a
pulmonary embolism in postoperative clients. Clients at risk for a DVT or
a pulmonary embolism are encouraged to drink throughout the day to
avoid dehydration. Estrogen replacement is a risk factor for the
development of a pulmonary embolism.
Early signs and symptoms of pulmonary sarcoidosis may include
dyspnea, cough, hemoptysis, and congestion. Generalized symptoms
include anorexia, fatigue, and weight loss.
The client requires additional teaching if he states that coworkers need to
be checked regularly. Such casual contacts needn't be tested for

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tuberculosis. However, a person in close contact with a person who's
infectious is at risk and should be checked. The client demonstrates
effective teaching if he states that he'll take his medications for 9 to 12
months, that coworkers don't need medication, and that he requires
laboratory tests while on medication. Coworkers not needing
medications, taking the medication for 9 to 12 months, and having
scheduled laboratory tests are all appropriate statements.
Vitamin B6 (pyridoxine) is usually administered with INH to prevent INHassociated peripheral neuropathy. Vitamins C, D, and E are not
appropriate.
In ALS, an early sign of respiratory distress is increased restlessness,
which results from inadequate oxygen flow to the brain. As the body tries
to compensate for inadequate oxygenation, the heart rate increases and
blood pressure drops. A decreased LOC is a later sign of poor tissue
oxygenation in a client with respiratory distress.

For a client with chest trauma, a diagnosis of Impaired gas exchange

takes priority because adequate gas exchange is essential for survival.
Although the other nursing diagnoses Anxiety, Decreased cardiac
output, and Ineffective tissue perfusion (cardiopulmonary) are possible
for this client, they are lower priorities than Impaired gas exchange.
Nasogastric, orogastric, and endotracheal tubes increase the risk of
pneumonia because of the risk of aspiration from improperly placed
tubes. Frequent oral hygiene and checking tube placement help prevent
aspiration and pneumonia. Although a client who smokes is at increased
risk for pneumonia, the risk decreases if the client has stopped smoking.
Ambulation helps prevent pneumonia. A client who receives opioids, not
acetaminophen, has a risk of developing pneumonia because respiratory
depression may occur.
Asbestosis is caused by inhalation of asbestos dust, which is frequently
encountered during construction work, particularly when working with
older buildings. Laws restrict asbestos use, but old materials still contain
asbestos. Inhalation of silica may cause silicosis, which results from
inhalation of silica dust and is seen in workers involved with mining,
quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and
other dusts may cause black lung disease. Pollen may cause an allergic
reaction, but is unlikely to cause pneumoconiosis.
Factors associated with the development of ARDS include aspiration

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related to near drowning or vomiting; drug ingestion/overdose;
hematologic disorders such as disseminated intravascular coagulation or
massive transfusions; direct damage to the lungs through prolonged
smoke inhalation or other corrosive substances; localized lung infection;
metabolic disorders such as pancreatitis or uremia; shock; trauma such
as chest contusions, multiple fractures, or head injury; any major surgery;
embolism; and septicemia.
Under normal conditions, approximately 5 to 15 mL of fluid between the
pleurae prevent friction during pleural surface movement. Under normal
conditions, there is approximately 5 to 15 mL of fluid between the
pleurae. This amount would exceed the normal amount. Under normal
conditions, there is approximately 5 to 15 mL of fluid between the
pleurae. This amount would exceed the normal amount. Fluid between
the pleurae functions to prevent friction during pleural surface
movement.
A cough that changes in character is one of the hallmark signs of lung
cancer. Low-grade fever, hoarseness, and weight loss may be attributed
to other disease processes and don't necessarily indicate lung cancer.
A cough that changes in character is one of the hallmark signs of lung
cancer. Low-grade fever, hoarseness, and weight loss may be attributed
to other disease processes and don't necessarily indicate lung cancer.

As the acute phase of bacterial pneumonia subsides, normal lung

function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg.
A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2
retention common during the acute phase of pneumonia. Restlessness
and confusion indicate hypoxia, not an improvement in the client's
condition. Bronchial breath sounds over the affected area occur during
the acute phase of pneumonia; later, the affected area should be clear on
auscultation.
SARS, a highly contagious viral respiratory illness, is spread by close
person-to-person contact. Contained in airborne respiratory droplets, the
virus is easily transmitted by touching surfaces and objects contaminated
with infectious droplets. The nurse should give top priority to instituting
infection-control measures to prevent the spread of infection to
emergency department staff and clients. After isolation measures are
carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-

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normal saline and obtain nasopharyngeal and sputum specimens.
ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less
than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide
tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial
pH of less than 7.35.
The nurse places the client in semi-Fowler's position to aid breathing and
increase the amount of air taken with each breath. Increased fluid intake
is important to encourage because it helps to loosen secretions and
replace fluids lost through fever and increased respiratory rate. The nurse
monitors fluid intake and output, skin turgor, vital signs, and serum
electrolytes. He or she administers antipyretics as indicated and ordered.
Antibiotics are not given for viral pneumonia. The client's activity level is
ordered by the physician, not decided by the nurse.
Class 1 is exposure, but no evidence of infection. Class 0 is no exposure
and no infection. Class 2 is a latent infection, with no disease. Class 4 is
disease, but not clinically active.
After thoracic surgery, draining secretions, air, and blood from the
thoracic cavity is necessary to allow the lungs to expand. This makes
options B, C, and D are incorrect.
The Mantoux test doesn't differentiate between active and dormant
infections. If a positive reaction occurs, a sputum smear and culture as
well as a chest X-ray are necessary to provide more information. Although
the area of redness is measured in 3 days, a second test may be needed;
neither test indicates that tuberculosis is active. In the Mantoux test, an
induration 5 to 9 mm in diameter indicates a borderline reaction; a larger
induration indicates a positive reaction. The presence of a wheal within 2
days doesn't indicate active tuberculosis.
Pneumothorax (air in the pleural space) is a potential complication of all
central venous access devices. Signs and symptoms include chest pain,
dyspnea, shoulder or neck pain, irritability, palpitations, lightheadedness, hypotension, cyanosis, and unequal breath sounds. A chest
X-ray reveals the collapse of the affected lung that results from
pneumothorax. Triple-lumen catheter insertion through the subclavian
vein isn't associated with pulmonary embolism, MI, or heart failure.
Chemical irritation from noxious fumes, gases, and air contaminants
induces acute bronchitis. Aspiration related to near drowning or vomiting,
drug ingestion or overdose, and direct damage to the lungs are factors
associated with the development of acute respiratory distress syndrome.

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In a client with bacterial pneumonia, retained secretions cause dyspnea,
and respiratory tract inflammation causes wheezing. Bacterial pneumonia
also produces a productive cough and fever, rather than a nonproductive
cough and normal temperature. Sore throat occurs in pharyngitis, not
bacterial pneumonia. Abdominal pain is characteristic of a GI disorder,
unlike chest pain, which can reflect a respiratory infection such as
pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.
A tension pneumothorax causes the lung to collapse and the heart, the
great vessels, and the trachea to shift toward the unaffected side of the
chest (mediastinal shift). A traumatic pneumothorax occurs when air
escapes from a laceration in the lung itself and enters the pleural space
or enters the pleural space through a wound in the chest wall. A simple
pneumothorax most commonly occurs as air enters the pleural space
through the rupture of a bleb or a bronchopleural fistula. Cardiac
tamponade is compression of the heart resulting from fluid or blood
within the pericardial sac.
Chemical irritation from noxious fumes, gases, and air contaminants can
induce acute tracheobronchitis. Aspiration related to near drowning or
vomiting, drug ingestion or overdose, and direct damage to the lungs are
factors associated with the development of acute respiratory distress
syndrome.
Because lung cancer produces few early symptoms, its mortality rate is
high. Lung cancer has increased in incidence due to increase in number
of women smokers, growing aging population, and exposure to pollutants
but not indicative of mortality rates.
Ineffective airway clearance is the priority nursing diagnosis for this
client. Pneumonia involves excess secretions in the respiratory tract and
inhibits air flow to the capillary bed. A client with pneumonia may not
have an Ineffective breathing pattern, such as tachypnea, bradypnea, or
Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity
aren't priority diagnoses for this client.
The acute phase of ARDS is marked by a rapid onset of severe dyspnea
that usually occurs less than 72 hours after the precipitating event
Chest percussion reveals dullness over the involved area. The nurse may
note diminished or absent breath sounds over the involved area when
auscultating the lungs and may also hear a friction rub. Chest
radiography and computed tomography (CT) scan show fluid in the
involved area.

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Subcutaneous emphysema is the result of air leaking between the
subcutaneous layers not serious complication but is notable and
reportable. Pink skin and blood in the collection chamber are normal
findings. When two tubes are inserted, the posterior or lower tube drains
fluid,whereas the anterior or upper tube is for air removal.