Emphysema Description - Progressive destruction of alveoli related to chronic inflammation - Decreased surface area of respiratory bronchioles, alveoli, and

alveolar ducts available for gas exchange - Airway collapse due to loss of elasticity in respiratory system tissue - A chronic form of obstructive pulmonary disease (COPD) - Group of diseases with the major characteristics of airflow restriction - Common symptom includes difficulty with exhalation caused by airways obstructed by edema or excessive mucus production. - Lung hyperinflation causes alveolar air trapping and leads to frequent pulmonary infections. - Symptoms may be reversible in asthma, but are typically progressive with emphysema, chronic bronchitis, and cystic fibrosis. Etiology and pathophysiology - Cigarette smoking is the primary etiology associated with emphysema. - Contributing factors include chronic respiratory inflammation from air pollution or occupational substances such as coal, glass, and asbestos. - Diagnosis in young and middle-aged adults may be associated with hereditary deficiency of alpha1-antitrypsin, an enzyme that prevents breakdown of lung tissue protein. - Air trapping in respiratory bronchioles, alveoli, and alveolar ducts leads to reacted infections and characteristics barrel chest appearance. - Breathing requires more energy and greater use of accessory muscles. Assessment Clinical manifestation - Pink puffer is a classical clinical description characterized by barrel chest, pursedlip breathing (caused by forced exhalation), obvious use of accessory muscles when breathing, and underweight appearance. - Exertional dyspnea progresses with advancing disease. - Persistent tachycardia is related to inadequate oxygenation. - Lung auscultation yields overall diminished breath sounds, and wheezes or crackles may be present.

Diagnostic and laboratory findings - Arterial blood gas analysis reveals slightly decreased pO2; pCO2 is not elevated until later stages. - Chest x-ray indicates hyperinflated lungs with flattened diaphragm, heart size is normal or small. Priority nursing diagnoses - impaired gas exchange - dyspnea - risk for infection - imbalanced nutrition: less than body requirements - activity intolerance - deficient knowledge - non-compliance (regarding smoking cessation) Planning and implementation - Assists client to develop appropriate nutritional plans to provide adequate calories - Administer supplemental low-flow oxygen as necessary; be prepared to initiate mechanical ventilator support. - Administer and teach clients about antibiotic therapy. - Administer and teach clients about bronchodilator therapy and use of measureddose (metered dose) inhalants. Medication therapy - Immunization against pneumonia and influenza - Antibiotics as needed for concurrent respiratory infection - Bronchodilators controversial use in COPD, but maintenance therapy may be used to reduce dyspnea and attempt to increase FEVI. - Beta-adregenic agonists used as bronchodilators in COPD and administered by nebulizer or metered dose inhaler (MDI). - Anticholinergics ipratropium (Atrovent) administered as a maintenance therapy by inhaler; considered one of the most effective bronchodilators for COPD. - Long-acting theophyline controversial use in COPD but may be beneficial to strengthen diaphragm contractility and decrease work of breathing.

- Corticosteroids controversial use in COPD but may be beneficial for clients with asthma history or with frequent exacerbations unresponsive to therapy with betaantagonists. Therapeutic management - Goals of therapy are to improve ventilation and promote patent airway by removal of secretions. - Remove environmental pollutant and encourage smoking cessation. - Bronchodilator therapy - Beta adrenergic agonists - Corticosteroid therapy - Oxygen therapy and nebulization therapy - Chest physiotherapy - Intermittent positive pressure breathing (IPPE) - Mechanical ventilation - Surgical procedures include bullectomy, lung volume reduction surgery, and lung transplantation. Client education - Cessation of smoking - Maintenance of adequate nutrition with emphasis on higher calorie intake. Chronic Bronchitis Description - A disorder of chronic airway inflammation - Chronic productive cough lasting at least 3 months during 2 years. - A form of chronic obstructive pulmonary Etiology and pathophysiology - Cigarette smoking is the primary etiology of chronic bronchitis. - Contributing factors include chronic respiratory inflammation from air pollution or occupational substances such as coal, glass, and asbestos. - Chronic inflammation of airways produces hyperplasia of mucous glands, resulting in excessive sputum production. - Cilia disappear, and their airway clearance function is lost.

- Goblet cells develop in abnormal sites of the terminal bronchiole, also increasing sputum production. - Mucosal edema and increased production of thick mucus progressively obstructs airflow. - Work of breathing increases with progressive airway obstruction. - Repeated pulmonary infections results from increased sputum production and ineffective airway clearance. - Polycythemia develops as a compensatory response to chronic hypoxemia. Assessment Clinical manifestations - Frequent cough, occurring during winter season, with foul-smelling sputum. - Classic appearance of blue bloater includes tendency for obesity and bluish-red skin discoloration from cyanosis and polycythemia. - Dyspnea and activity intolerance occurs as disease preogresses. - Increased anterior-posterior chest diameter. Diagnostic and laboratory findings - Elevated red blood cell count; hemoglobin and hematocrit elevated in later stages - Chest x-ray reveals enlarged heart, congested lung fields and normal or flattened diaphragm - Pulmonary infection indicates increased residual volume, decreased vital capacity, FEVI, and FEVI/FVC ratio. Priority nursing diagnosis - Impaired gas exchange - Dyspnea - Ineffective airway clearance - Risk for infection - Imbalanced nutrition: more than body requirements - Activity intolerance - Knowledge deficit Planning and implementation

- Assist client to develop appropriate nutritional plans that provide adequate calories but maintain ideal weight. - Administer supplemental low-flow oxygen as necessary; be prepared to initiate mechanical ventilation. Medical therapy - Immunization against pneumonia and influenza - Antibiotics - Bronchodilators controversial use in COPD, but maintenance therapy may be used to reduce dyspnea and attempt to increase FEVI. - Beta-adregenic agonists used as bronchodilators in COPD and administered by nebulizer or metered dose inhaler (MDI). - Anticholinergics ipratropium (Atrovent) administered as a maintenance therapy by inhaler; considered one of the most effective bronchodilators for COPD. - Long-acting theophyline controversial use in COPD but may be beneficial to strengthen diaphragm contractility and decrease work of breathing. - Corticosteroids controversial use in COPD but may be beneficial for clients with asthma history or with frequent exacerbations unresponsive to beta-antagonists medication Client education - Smoking cessation - Nutritional therapies for adequate energy needs and weight management Asthma Description - Chronic inflammation - Severity and duration of symptoms are unpredictable. - The progressive airway obstruction unresponsive to treatment leads to status asthmaticus, an emergency condition. - It is a form of chronic obstructive pulmonary disease Etiology and pathophysiology - Intrinsic etiologies uncertain causes; physical or psychological stress; exercisesincluded

- Extrinsic etiologies antigen-antibody (allergic) reaction to specific irritants; common triggers include air pollutants, sinusitis, cold and dry air, medications, food additives, hormonal influences, and gastroesophageal reflux - It is characterized by widespread spam of bronchiole smooth muscle with airway edema. - Excessive secretion of thick mucus contributes to airway obstruction. - Lungs become hyperinflated and alveolar air tapping occurs. - Gas exchanges become impaired as ventilation-perfusion mismatching occurs. Assessment Clinical manifestations - Severe dyspnea - Wheezing with expiration; intensity of wheezing is not to severity of airway obstruction; clients with severe airway obstruction may not be able to move enough air to produce wheezing sound - Cough - Feelings of chest tightness - Prolonged expiration are noted - Mild to greatly diminished breath sounds upon auscultation; diminished or absent breath sounds may be related to atelectasis or pneomothorax - Hyperresonant sound or percussion - Increased heart rate and blood pressure - Extreme restlessness, anxiety, agitation - Trachypnea with use of accessory muscles Diagnostic and laboratory findings (during an episode or attack) - Decreased pO2, mild respiratory alkalosis - Elevated eosinophil count - Increased residual volume, decreased vital capacity, decreased forces expiratory volume and peak expiratory flow rate Priority nursing diagnoses - Ineffective breathing pattern - Ineffective airway clearance

- Risk for infection - Anxiety Planning and implementation - Allergy desentization therapy if appropriate - Diagnostic testing during non-acute period includes chest x-ray, pulmonary function studies, allergy skin testing, serum eosinophils, and IgE. Medication therapy - Short-acting beta-antagonist inhaler used for mild symptoms occurring twice weekly or less; also used for intermittent symptomatic relief and may be combined with long-active medications. - Anti-inflammatory inhaler plus medium-dose corticosteroid inhaler symptoms occurring daily or more often. - Anti-inflammatory inhaler plus long-acting bronchodilator plus oral corticosteroid used for severe symptoms occurring daily or more often. Therapeutic management - Acute episodes are managed with inhaled beta agonists, bronchodilators, antiinflammatory agents, corticosteroids, and oxygen therapy; In severe cases, mechanical ventilation many be instituted. - Chronic management includes administration of drugs described in the medication section. Client education - Teach client/family about proper use of metered-dose inhaler. - Instruct client regarding the use of peak flow meter for self-assessment of asthma status. Restrictive Diseases refer to those respiratory diseases that restrict movement of the thorax and or lungs and may be associated with pathologic or neurologic factors. Types: - Neuromuscular Disorder myasthenia gravis characterized by the development of generalized muscular weakness causing difficulty in swallowing, which prevents patients from managing their normal oral secretions. A tracheostomy and mechanical ventilator is necessary as disease progresses. bulbar poliomyelitis a viral infection involving the 9th-12th cranial nerves. It affects the pharynx resulting to paralysis of laryngeal muscles. Often tracheostomized

 spinal type it affects the muscle of respiration causing weakness and eventually failure. Guillian-Barre Syndrome acute infectious polyneuritis characterized by headache. aching limbs, general malaise, and slight fever. As disease progresses, sensations of numbness and tingling in the fingers and toes and muscular weakness and paralysis may be noticed. thoracic deformity - kyphocoliosis abnormal convex curvature of the spine - pectus excavatum funnel chest, a concave deformity resulting from the depression of the sternum Restriction to Lung and/or Alveolar Expansion Pneumothorax air accumulation in the pleural space 1. Spontaneous rupture of air-filled bleb that allows pathway for air movement between respiratory system and pleural space; collapse of involved tissue may seal leak with minimal client symptoms; air leak may progress until pressure between thoracic cavity and atmosphere equalizes and client is symptomatic. - Primary spontaneous ruptures of bleb in otherwise healthy individual; occurs more often in tall, slender males aged 20 to 40. - Secondary rupture of overly distended alveolus/alveoli; occurs in individuals with known COPD; severity of symptoms varies with size of pneumothorax. 2. Tension disruption of the chest wall or lungs causes air accumulation in th pleural space; pressure on the mediastinum causes pressure on the other lung and interrupts venous return to the heart. It is a medical emergency that requires emergency that requires emergency placement of chest tube to relieve increase pressure in the thoracic cavity to restore adequate cardiac output. 3. Traumatic disruption of the pleura, bronchi, or lung tissue caused by blunt or penetrating trauma with air accumulation in the pleural spaces. 4. Iatrogenic disruption of the pleura, bronchi or lung tissue during instrumentation for central venous line placement, lung biopsy, thoracentesis produces unintentional air leak within the respiratory system; clinical manifestations and treatment are the same as for spontaneous. Hydrothorax presence of serous fluid in the pleural space due to lymphatic obstruction or by CHF 1. Assessment

Clinical manifestations - Worsening dyspnea - Diminished or absent breath sounds on affected side - Chest wall pain - Fever, persistent cough, night sweats, and weight loss empyema Diagnostic and Laboratory test findings - Visible on chest x-ray if greater than 250 mL fluid accumulates 2. Priority nursing diagnoses - Ineffective breathing pattern - Pain - Risk for infections - Hyperthermia - Impaired gas exchange 3. Planning and implementation - Physician performs thoracentesis; thoracostomy of indicated - Provide adequate nutrition with focus on adequate protein intake Medication therapy - Analgesics - Antipyretics - Intravenous lipids, if chylothorax is present Therapeutic management - Thoracentesis for drainage - Antibiotic therapy - Surgical procedure may include decortications, or the separation of the pleural membranes Client education - Instruct about purpose of thoracentesis/thoracostomy Hemothorax presence of free blood in the pleural space, usually traumatic in origin

1. Etiology and pathophysiology - Normal intrapleural pressure is negative compared to atmospheric air pressure - Pressure difference between the thoracic cavity and the atmosphere is one of the stimuli of breathing - Intrapleural presence equalizes with atmospheric air, removing one of the stimuli for breathing - The lung collapses as pressure increases in the thoracic cavity - Excessive pressure is placed on the chest; output is compromised - Preload decreases and cardiac output is compromised 2. Assessment Clinical manifestation - Dyspnea - Tracheal deviation toward unaffected side - Diminished breath sounds on affected side - Unequal chest expansion (reduced on affected side) - Crepitus over the chest Diagnostic and Laboratory test findings - Chest x-ray reveals pneumothorax - ABG shows decreased pO2 3. Priority nursing diagnoses - Impaired gas exchange - Risk for injury - Ineffective breathing pattern - Decreased cardiac output - Risk for infection - Pain - Anxiety 4. Planning and implementation - Care of the client with a chest tube

- Maintain infection control practices Therapeutic management - In mild cases, no chest tubes is required; if the pneumothorax is significant, a chest tube is inserted - Placement of chest tube with water seal drainage - Spontaneous pneumothorax in otherwise health client may resolve without invasive treatment - If spontaneous pneumothorax occurs repeatedly, pleurodosis may be required, which is the instillation of an agent (such as tetracycline) in the pleural spaces to allow the pleural to adhere together; other procedures include partial pleurectomy; stapling; or laser pleurodosis for pleural sealing Medication therapy: analgesics and antibiotics Pleurisy Inflammation of the pleural cavity and can be accompanied by the presence of serofibrinous fluid, pus or replacement of serous secretion of the pleural with fibrinous exudates. Types: 1. fibrinous pleurisy (dry pleurisy) lack of lubricating serous secretion on the pleural and the presence of fibrinous exudates in the pleural cavity cause friction rubs during respiratory movements. Signs and symptoms are pain, rapid and shallow respiration; limited motion in the affected side due partly to voluntary splinting, restricted ventilatory efficiency. 2. pleural infection a. b. Description: Accumulation of fluid in the pleural space Etiology and pathophysiology Transudative pleural effusion - Pleural fluid contains a small quantity of protein. - Fluid moves from capillaries into pleural space - Most common cause is increased hydrostatic pressure, such as what occurs with heart failure. - Decreased oncotic pressure caused by an inadequate albumin level occurs more frequently with chronic renal and liver disease. Exudative pleural infusion - Pleural fluid contains a large quantity of protein.

- Inflammatory responses causes increased capillary permeability with fluid shift out of capillaries. - Exudation is associated with pulmonary tumors, pulmonary infections, pulmonary emboli, pancreatitis, and ruptured esophagus. Empyema - Pleural fluid containing pus - Empyema is associated with infectious process such as pneumonia, lung abscess, and tubercolosis. Cylothorax - Disruption of pulmonary lymph vessels caused by surgery or trauma can lead to abnormal accumulation of lymph fluid in pleural space - Produces fat malabsorption from GI tract c. Assessment Clinical manifestation Worsening dyspnea Diminished or absent breath sounds on affected side Dullness to percussion on affected side Chest wall pain Fever, persistent cough, night sweats, and weigh loss with empyema Diagnostic and Laboratory test findings Visible on chest x-ray if greater than 250 ml fluid accumulates d. Priority nursing diagnoses - Ineffective breathing pattern - Pain - Risk for infection - Hyperthermia - Impaired gas exchange e. Planning and implementation - Physician performs thoracentesis; thoracostomy if indicated - Provide adequate nutrition with focus on adequate protein intake.

Medication therapy - analgesics - antipyretics - intravenous lipids, if chylothorax present Therapeutic management - Thoracentesis for drainage of the pleural cavity - Antibiotic therapy - Surgical procedure may include decortications, or the separation of the pleural membranes Client education - Instruct about purposes of thoracentesis/thoracostomy Infiltrative Diseases - Bronchogenic carcinoma Description - Lung cancer is the leading cause of death resulting from malignancy Etiology and pathophysiology - Cigarette smoking is the leading cause; cancer risk increases with length of smoking exposure. - Some individuals have a genetic predisposition to bronchogenic carcinoma Assessment Clinical manifestation - Symptom onset is often late in the course of disease. - Persistent cough with or without hemoptysis - Localized chest pain - Dyspnea - Unilateral wheeze upon auscultation - Swallowing difficulty - Anorexia - Weight loss

- Enlarged neck lymph nodes Diagnostic and laboratory findings - Mass visible on chest x-ray - Sputum for cytology reveals tumor cells Priority nursing diagnoses - anticipatory grieving - anxiety - pain - knowledge deficit - ineffective airway clearance - ineffective breathing pattern - impaired gas exchange - powerlessness - hopelessness Planning and implementation - Administration of oxygen therapy as prescribed - Provide care of chest tubes as previously discussed Medication therapy - opioid analgesics - immunotherapy - chemotherapy - antiemetics Therapeutic management - surgical resection - laser therapy - chemotherapy - immunotherapy - radiation therapy

- Obesity Types: Pickwickian syndrome refers to a group of clinical features found in patients with extreme obesity Abdominal ascites mean abnormal accumulation of fluid in the peritoneal cavity - Loss of Functioning of Pulmonary Tissue the human organism experiences respiratory distress only after there has been change to large amounts of the alveolar capillary surfaces. It does not only decrease the surfaces for blood-gas but also reduce the production of surfactant, resulting in alveolar collapse and possible atelectasis. Types: Pulmonary Infarction is necrotic loss of pulmonary tissue due to occlusion of a pulmonary artery by an embolus that most frequently arises from deep veins of the legs. Pulmonary embolism - Description Emboli lodged in pulmonary vasculature and obstruct adequate blood flow through pulmonary capillaries. Ventilation perfusion mismatch a clinical significant imbalance between volume of air and volume of blood circulating in the gas exchange area of the lungs; causes impaired gas exchange. Pulmonary embolism is a frequent complication of hospitalized clients Etiology and pathophysiology - Most common sites for origin of emboli include venous thromboses in the deep veins of lower extremities, pelvis, or right side of the heart. - Risk factors for pulmonary embolism include immobility, hypercoagulability, trauma to endothelial layer of blood vessels, and long bone fractures. - Dislodgement of venous thromboses occurs with movement into pulmonary vasculature; fat emboli travel from site of long vessels. - Emboli obstruct small to large areas of the pulmonary vasculature, preventing adequate perfusions and gas exchange. - A massive obstructed tissue leads to pulmonary infarction. - Severe impairment of gas exchange can be rapidly fatal. Assessment

Clinical manifestation - Restlessness, anxiety, agitation - Vital signs: tachycardia, trachypnea, hypotension, and fever - Chest pain - Hemoptysis - Mental status changes - Decreasing level of consciousness - Cyanosis - Recent history of thromboembolism and/or long bone fractures - Lung crackles upon auscultation Diagnostic and Laboratory test findings - Atrial fibrillation - Chest x-ray may be normal - Pulmonary angiogram reveals pulmonary embolism. - Ventilation perfusion scan indicates areas of mismatch - Abnormal arterial blood gases Priority nursing diagnoses - Ineffective breathing pattern - Impaired gas exchange - Anxiety - Pain - Impaired physical mobility Planning and implementation - Be prepared to initiate mechanical ventilation - Maintain IV access - Circulatory support as indicated - Placement of vena cava filter - Pulmonary embolecomy

Medication therapy - Thrombolytic therapy - Anticoagulant therapy - Opioid analgesics - Anti-anxiety agents Therapeutic management - Oxygen therapy - Anticoagulant therapy - Embolectomy - Thrombolytic therapy - To prevent future emboli, an intracaval filter may be inserted into the inferior vena cava to trap emboli from a known source. Lung Abscess is a necrosis of any tissue caused by aspiration of a foreign body; bronchial obstruction, or pneumonia. Pulmonary Fibrosis is a pathological increase of connective tissue in the lung parenchyma and may be either be localized or diffused that is secondary to other diseases like TB, pneumonia, chronic bronchitis, silicolisis, emphysema. Pneumococoniosis is a chronic fibrotic pulmonary disease caused by inhalation of irritating dust as in silica, asbestos and coal dust for a long period of time. Pneumonia an acute pulmonary infection caused streptococcus, hemophilus influenzas and the viruses. Description - Acute inflammatory of lung parenchyma (alveoli and respiratory bronchioles) - Classified as viral versus bacterial, community-acquired versus hospitalacquired, atypical, pneumocystis Etiology and pathophysiology - Causative agent can be infectious (bacteria, viruses, fungi, and other microbes) or non-infectious (aspirated or inhaled substances) - Most common organism for both community-acquired and hospital-acquired is the Gram-positive bacteria, Streptococcus pneumoniae - Other common organisms associated with community-acquired pneumonia include Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, Haemophilus influenzae, and othew influenzae viruses by pneumonococcus,

- Spread of microbes in alveoli activates the inflammatory and immune response - Antigen-antibody response damages mucous membranes of bronchioles and alveoli resulting to edema - Microbe cellular debris and exudates fill alveoli and can impair gas exchange Assessment a. Viral - Fever: low-grade - Cough: non-productive - White blood cell count: normal to low elevation - Chest x-ray: minimal changes evident - Clinical course: less severe than pneumonia of bacterial origin b. Bacterial - Fever: high - Cough: productive - White blood cell count: high elevation - Chest x-ray: obvious infiltrates - Clinical course: More severe than pneumonia of viral origin Priority nursing diagnoses - impaired gas exchange - ineffective airway clearance - ineffective breathing pattern - imbalanced nutrition: less than body requirements - activity intolerance - anxiety - pain - hyperthermia Planning and implementation - Maintain patent airway.

- Monitor respiratory oxygenation status. - Provide supplemental oxygen as indicated - Be prepared to initiate mechanical ventilator support. - Administer antimicrobials as prescribed. - Provide pain management. - Provide nutritional support and fluids via appropriate route. - Provide adequate opportunities for physical rest. - For all hospitalized clients, take measures to prevent pneumonia. Medication therapy - antibiotics as indicated - other antimicrobials as indicated - analgesics -antipyretics Therapeutic management - Antibiotic therapy, analgesics, antipyretics - Oxygen therapy to treat hypoxemia Client education - Immunization against influenza and pneumococcal pneumonia - Activity limitations and importance of rest - Pulmonary tubercolosis a serious health hazard caused by mycobasterium tubercolosis, characterized by cough, hemoptysis, malaise, weight loss, easy fatigability, low grade afternoon fever, night sweats, generally low resistance - Pulmonary edema a condition characterized by excessive amount of fluid in the alveoli and pulmonary interstitial tissues, which tends to block the blood gas exchange - Thoracic trauma Description alteration of breathing mechanics and/or gas exchange caused by respiratory trauma a. Blunt trauma injury to chest wall without disruption of pleura - rib fractures

- flail chest - soft tissue rupture: diaphragm, trachea, bronchi and major blood vessels - tension pneumothorax - contusions: lungs; heart b. Penetrating trauma injury involves disruption of peura - Internal wounds communicate with external atmosphere - Open air-sucking wounds - Pneumothorax/hemothorax - Tissue wounds heart, lungs, major blood vessels Pathophysiology varies related to the specific injury - rib fracture is most common type of chest trauma a. Flail chest - Multiple rib fractures in 2 places (separated from bony skeleton) - Chest wall unstable with paradoxical chest expansion (flail segment moves inward with inhalation and outward exhalation) - Ventilation-perfusion mismatch b. Rupture of diaphragm - Abdominal contents dislocate upward into thoracic cavity - Decrease in diaphragmatic control of breathing Assessment Clinical manifestation - chest pain (may be severe, such as with flail chest) - shallow breathing with splinting - possible unequal chest expansion - tachycardia, tachypnea, hypotension - crepitus over the chest Diagnostic and laboratory test findings - Chest x-ray findings show white opacifications - ABGs reveal hypoxemia

 Priority nursing diagnoses - Pain - Ineffective breathing pattern - Ineffective airway clearance - Impaired gas exchange - Decreased cardiac output - Anxiety Planning and implementation - Placement of chest tube with water seal drainage may be indicated Medication therapy: oioid analgesics, epidural analgesia may be appropriate Client education - Pain management patient-controlled analgesia may be appropriate - Prevention of thromboembolic phenomena