Chapter 27: Lower Respiratory Problems

What is a pneumothorax?

air in the pleural cavity! - can lead to lung collapse - reduced lung volume - Open: opening in chest wall ​ (Penetrating/sucking CW) - Closed: no external wound

Pneumonia Clinical Manifestations

- Cough: productive or nonproductive​ - Green, yellow, or rust-colored sputum​ - Fever, chills​ - Dyspnea, tachypnea​ - Pleuritic chest pain

Flail Chest Treatment

- Ensure adequate ventilation/lung expansion​ - Adequate oxygenation​ - Pain management​ - Other, if needed: ​ Intubation/mechanical ventilation​, Surgical fixation

Fractured ribs need to know details...

- Most common ribs 5 through 9​ - Can damage pleura, lungs, heart, and other internal organs​ Manifestations​ - Pain with inspiration and coughing​ - Splinting​ - Shallow respirations

pneumothorax treatment

- chest tube with water seal drainage - partial pleurectomy, stapling, or pleurodesis

Pathophysiology of Tuberculosis

- gram-positive, aerobic, acid-fast bacillus - spread airborne - transmission requires close/frequent/prolonged exposure - after inhaled, droplets lodge in bronchioles and alveoli

Types of Pnuemonia: 1. Aspiration 2. Necrotizing 3. Opportunistic A. inflammation and infection of the lower respiratory tract in immunocompromised patients. B. results from abnormal entry of material from the mouth or stomach into the trachea and lungs. C. a rare complication of a bacterial lunch infection.

1. B 2. C 3. A

Which health promotion information should the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination

A, D, E

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select all that apply.) a. Age b. Blood pressure c. Respiratory rate d. O2 saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level

A, B, C, E, F

pneumonia

an acute inflammation of the lung parenchyma, often caused by inhaled pneumococci of the species Streptococcus pneumoniae.

TB Drugs: 1. isoniazid 2. rifampin 3. pyrazinamide 4. ethambutol

ALL are hepatotoxic (avoid alcohol) 1. isoniazid: tingling 2. rifampin: makes you yellow/orange 3. pyrazinamide: joint pain 4. ethambutol: joint pain

Do you remove an impaled object?

no, stabalize!!!!!

Tuberculosis

An infectious disease that may affect almost all tissues of the body, especially the lungs, caused by Mycobacterium tuberculosis (1/3 of world's population has TB) (prevalence in the US decreasing)

How many drugs are used to treat active TB?

FOUR (4) (2 phases)

Pathopsysiology of Pneumonia

Inflammatory response -> alveoli fill with fluid & increased production of mucous -> decreased gas exchange -> resolution of infection

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

Order: A, B, D, C

Pneumothorax manifestations

Small: mild tachycardia, dyspnea Large: respiratory distress, absent lung sounds

Flail chest need to know details...

Three or more consecutive fractured ribs in 2 or more places or fractured sternum and several consecutive ribs​ Causes unstable chest wall and paradoxical movement with breathing​ Rapid, shallow respirations​ Asymmetric chest movement​ Inadequate ventilation​ Splinting​ Crepitus near fractures​

fractured rib treatment

Treatment​ - Reduce Pain: NSAIDs, opioids, nerve blocks​ - Patient teaching​ (Deep breathing, coughing​, Incentive spirometry​) - Appropriate use of analgesics​

Diagnostic Studies for Tuberculosis

Tuberculin skin test (TST)​ Interferon-γ (INF-gamma) release assays (IGRAs)—screening tool​ CXR​ Bacteriologic Studies

acute bronchitis

a self-limiting inflammation of the lower respiratory tract that is usually due to infection caused by viruses.

Community Acquired Pneumonia (CAP)

a type of pneumonia that results from contagious infection outside of a hospital or clinic

tension pneumothorax

a type of pneumothorax in which air that enters the chest cavity is prevented from escaping needle decompression needed ASAP chest tube with water seal drainage

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

a. Auscultate for breath sounds.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

a. Document the amount of drainage every 8 hours.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

a. Increased tactile fremitus

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Respiratory rate is 24 breaths/min when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

a. O2 saturation is 88%.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.

a. Observe for distended neck veins.

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB and has never had a positive TB skin test before. Which information should the occupational health nurse plan to teach the staff nurse? a. Use and side effects of isoniazid b. Standard four-drug therapy for TB c. Need for annual repeat TB skin testing d. Bacille Calmette-Guérin (BCG) vaccine

a. Use and side effects of isoniazid

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/min d. Resting pulse oximetry (SpO2) of 85%

a. Weak cough effort

An older adult is receiving standard multidrug therapy for tuberculosis (TB). Which finding should the nurse report to the health care provider? a. Yellow-tinged sclera b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices

a. Yellow-tinged sclera

Consequence of fractured ribs:

atelectasis and pneumonia

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse? a. "Are you ready to talk with family members about dying?" b. "Can you tell me what makes you think you will die so soon?" c. "Do you think that an antidepressant medication would be helpful?" d. "Would you like to talk to the hospital chaplain about your feelings?"

b. "Can you tell me what makes you think you will die so soon?"

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? a. "I will call my health care provider if I still feel tired after a week." b. "I will continue to do deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I will cancel my follow-up chest x-ray appointment if I feel better next week."

b. "I will continue to do deep breathing and coughing exercises at home."

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 77-yr-old patient with tuberculosis (TB) who has four medications due b. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath c. A 35-yr-old patient with pneumonia who has a temperature of 100.2° F (37.8° d. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled

b. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.

b. A surgical face mask is applied before visiting the patient.

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.

b. Administer the prescribed morphine.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) suppository

b. Blood cultures from two sites

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax.

b. Continue to monitor the collection device.

Which action should the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.

b. Place a patient with altered consciousness in a side-lying position.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions in a private hospital room c. Monitoring patient serology results to identify the infecting organism d. Titrating the O2 flowrate as prescribed to keep the O2 saturation over 90%

b. Placing the patient on droplet precautions in a private hospital room

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will take the bus instead of driving." b. "I will stay indoors whenever possible." c. "My spouse will sleep in another room." d. "I will keep the windows closed at home."

c. "My spouse will sleep in another room."

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Tell me what you know about the treatments available." d. "Surgery is the treatment of choice for stage I lung cancer."

c. "Tell me what you know about the treatments available."

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site

c. 400 mL of blood in the collection chamber

After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion. d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101° F (38.3° C).

c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home O2 therapy

c. Appropriate use of cough suppressants

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of chronic alcohol use. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Repeat warnings about the high risk for infecting others several times. b. Give the patient written instructions about how to take the medications. c. Arrange for a daily meal and drug administration at a community center. d. Arrange for the patient's friend to administer the medication on schedule.

c. Arrange for a daily meal and drug administration at a community center.

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about drug-resistant TB. b. Schedule directly observed therapy. c. Ask the patient whether medications have been taken as directed. d. Discuss the need for an injectable antibiotic with the health care provider.

c. Ask the patient whether medications have been taken as directed.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? a. Ask the patient about any visual changes in red-green color discrimination. b. Question the patient about experiencing shortness of breath, hives, or itching. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.

c. Explain that orange discolored urine and tears are normal while taking this medication.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction

c. Frequent use of an incentive spirometer

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.

c. Help the patient to splint the chest when coughing.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

c. Medicate the patient with prescribed morphine.

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a. Report of chest wall pain b. Heart rate of 110 beats/min c. Paradoxical chest movement d. Large bruised area on the chest

c. Paradoxical chest movement

Which finding indicates to the nurse that the administered nifedipine (Procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH)? a. Heart rate is between 60 and 100 beats/min. b. Patient's chest x-ray indicates clear lung fields. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg.

c. Patient reports a decrease in exertional dyspnea.

Which action should the nurse take to prepare a patient with a pleural effusion for a thoracentesis? a. Remind the patient not to eat or drink 6 hours. b. Start a peripheral IV line to administer sedation. c. Position the patient sitting up on the side of the bed. d. Obtain a collection device to hold 3 liters of pleural fluid.

c. Position the patient sitting up on the side of the bed.

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.

c. Require the use of protective equipment.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach the patient about providing specimens for 3 consecutive days. d. Instruct the patient to collect several separate sputum specimens today.

c. Teach the patient about providing specimens for 3 consecutive days.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics

c. Teaching patients about the need for adult pertussis immunizations

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse? a. The O2 saturation is 90%. b. The blood pressure is 98/56 mm Hg. c. The epoprostenol (Flolan) infusion is disconnected. d. The international normalized ratio (INR) is prolonged.

c. The epoprostenol (Flolan) infusion is disconnected.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 6000/μL. d. Increased tactile fremitus is palpable over the right chest.

c. The patient's white blood cell (WBC) count is 6000/μL.

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is important for the nurse to ask before the skin test? a. "Do you take any over-the-counter (OTC) medications?" b. "Do you have any family members with a history of TB?" c. "How long has it been since you moved to the United States?" d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates that the teaching has been effective? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

d. "I will call the health care provider right away if I develop a fever."

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

d. "I will use the incentive spirometer every hour or two during the day."

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction

d. Chest tube connected to suction

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

d. Elevate the head of the bed to a semi-Fowler's position.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem should the nurse assign as the priority? a. Fatigue b. Hyperthermia c. Impaired mobility d. Impaired gas exchange

d. Impaired gas exchange

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

d. Piperacillin/tazobactam (Zosyn)

A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Sputum smears for acid-fast bacilli are negative.

d. Sputum smears for acid-fast bacilli are negative.

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.

d. Tape a nonporous dressing on three sides over the wound.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Assist the patient with chest physiotherapy and postural drainage. b. Teach the patient to avoid the use of over-the-counter expectorants. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest x-ray showed infiltrates in the lower lobes. c. The patient has a cough that is productive of blood-tinged mucus. d. The patient is being treated with antiretrovirals for HIV infection.

d. The patient is being treated with antiretrovirals for HIV infection.

The nurse supervises unlicensed assistive personnel (UAP) providing care for a patient who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene? a. UAP assists the patient to ambulate to the bathroom. b. UAP helps splint the patient's chest during coughing. c. UAP transfers the patient to a bedside chair for meals. d. UAP lowers the head of the patient's bed to 15 degrees.

d. UAP lowers the head of the patient's bed to 15 degrees.

Clinical Manifestations of Tuberculosis

fatigue, weight loss, low grade fever, night sweats. Cough - non-productive at first, then productive (purulent) sputum, develops over weeks. Late: dyspnea and hemoptysis

Hospital Acquired Pneumonia (HAP)

pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization.

pertussis

whooping cough; highly contagious bacterial infection of the pharynx, larynx, and trachea caused by Bordetella pertussis

Diagnostic Studies for Pneumonia

• History and physical examination • Chest x-ray (Fig. 27-3) • Thoracentesis and/or bronchoscopy • Pulse oximetry • Arterial blood gases (ABGs) • Sputum gram stain, culture & sensitivity • Ideally before antibiotics started • Blood cultures • CBC with differential