BACHELOR OF SCIENCE IN NURSING:

NCMB 312 – CARE OF CLIENTS WITH PROBLEMS IN

OXYGENATION, FLUIDS AND ELECTROLYTES,
INFLAMMATORY AND IMMUNOLOGIC RESPONSE, AND
CELLULAR ABERRATION (ACUTE AND CHRONIC)
COURSE MODULE COURSE UNIT WEEK

1 4 4
DISTURBANCES IN OXYGEN EXCHANGE AND UTILIZATION
RESTRICTIVE DISORDERS

✓ Read course and unit objectives

✓ Read study guide prior to class attendance
✓ Read required learning resources
✓ Proactively participate in classroom discussions
✓ Participate in weekly discussion board (Canvas)
✓ Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Identify patients at risk for atelectasis and nursing interventions related to its prevention and
management.
2. Compare the various pulmonary infections with regard to causes, clinical manifestations, nursing
management, complications, and prevention.
3. Use the nursing process as a framework for care of the patient with pneumonia.
4. Relate pleurisy, pleural effusion, and empyema to pulmonary infection.
 5. Describe smoking and air pollution as causes of pulmonary disease.
6. Relate the therapeutic management techniques of acute respiratory distress syndrome to the
underlying pathophysiology of the syndrome.
7. Describe risk factors and measures appropriate for prevention and management of pulmonary
embolism.
8. Describe the complications of chest trauma and their clinical manifestations and nursing
management.
Affective:
1. Demonstrate tact and respect when challenging other people’s opinions and ideas.
2. Accept comments and reactions of classmates on one’s opinions openly and graciously.
3. State outcome criteria for evaluating client responses.
4. Understand treatments and devices used in the nursing care plan.
Psychomotor:
1. Execute and implement a proper care plan for related scenarios such as clients with
restrictive respiratory disorders.
2. Perform correct body mechanics (patient safe handling): safe positioning bed; transfer chair,
ambulation.

Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical
Nursing (14th ed.). Philadelphia: Wolters Kluwer.

Introduction
RESTRICTIVE DISORDERS
Restrictive lung diseases are characterized by reduced lung volumes, either because of an alteration in
lung parenchyma or because of a disease of the pleura, chest wall, or neuromuscular apparatus. Unlike
obstructive lung diseases, such as asthma and chronic obstructive pulmonary disease (COPD), which
show a normal or increased total lung capacity (TLC), restrictive disease are associated with a
decreased TLC. Measures of expiratory airflow are preserved and airway resistance is normal and the
forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio is increased. If caused by
parenchymal lung disease, restrictive lung disorders are accompanied by reduced gas transfer, which
may be marked clinically by desaturation after exercise.

This course unit module discusses the following topics:

1. Pleurisy;
2. Pleural Effusion;
3. Pulmonary Edema;
4. Pulmonary Embolism;
5. Pneumonia;
6. Pulmonary Tuberculosis;
7. Pneumothorax; and
8. Chest Injuries.

I. Pleurisy (pleuritis) Pleurisy refers to inflammation of

both the visceral and parietaln pleurae. When inflamed,
pleural membranes rub together, the result is severe,
sharp, knifelike pain with breathing that is intensified on inspiration. Pleurisy may develop in conjunction
with pneumonia or an upper respiratory tract infection, TB, or collagen disease; after trauma to the
 chest, pulmonary infarction, or pulmonary embolism (PE); in patients with primary or metastatic cancer;
and after thoracotomy.

Clinical Manifestations
• Pain usually occurs on one side and worsens with deep breaths, coughing, or sneezing.
• Pain is decreased when the breath is held. Pain is localized or radiates to the shoulder or abdomen.
• As pleural fluid develops, pain lessens. A friction rub can be auscultated but disappears as fluid
accumulates.

Assessment and Diagnostic Methods

• Auscultation for pleural friction rub
• Chest x-rays
• Sputum culture
• Thoracentesis for pleural fluid examination, pleural
biopsy (less common)

Medical Management
Objectives of management are to discover the
underlying condition causing the pleurisy and to relieve
the pain.
• Patient is monitored for signs and symptoms of pleural effusion: shortness of breath, pain,
assumption of a position that decreases pain, and decreased chest wall excursion.
• Prescribed analgesics, such as NSAIDs, are given to relieve pain and allow effective coughing.
• Applications of heat or cold are provided for symptomatic relief.
• An intercostal nerve block is done for severe pain.

Nursing Management
• Enhance comfort by turning patient frequently on affected side to splint chest wall.
• Teach patient to use hands or pillow to splint rib cage while coughing.

II. Pleural effusion- a collection of fluid in the pleural space, is usually secondary to other diseases (eg,
pneumonia, pulmonary infections, nephrotic syndrome, connective tissue disease, neoplastic tumors,
congestive HF). The effusion can be relatively clear fluid (a transudate or an exudates) or it can be
blood or pus. Pleural fluid accumulates due to an
imbalance in hydrostatic or oncotic pressures
(transudate) or as a result of inflammation by bacterial
products or tumors (exudate).

Clinical Manifestations
Some symptoms are caused by the underlying
disease. Pneumonia causes fever, chills, and pleuritic
chest pain. Malignant effusion may result in dyspnea
and coughing. The size of the effusion, the speed of
its formation, and the underlying lung disease
determine the severity of symptoms.
• Large effusion: shortness of breath to acute
respiratory distress.
• Small to moderate effusion: Dyspnea may not be
present.
• Dullness or flatness to percussion over areas of
fluid, minimal or absence of breath sounds, decreased
fremitus, and tracheal deviation away from the
affected side.
Assessment and Diagnostic Methods
• Physical examination
• Chest x-rays (lateral decubitus)
• Chest CT scan
• Thoracentesis
• Pleural fluid analysis (culture, chemistry, cytology)
• Pleural biopsy

Medical Management
Objectives of treatment are to discover the underlying cause; to prevent reaccumulation of fluid; and to
relieve discomfort, dyspnea, and respiratory compromise. Specific treatment is directed at the
underlying cause.
• Thoracentesis is performed to remove fluid, collect specimen for analysis, and relieve dyspnea.
• Chest tube and water-seal drainage may be necessary for drainage and lung reexpansion.
• Chemical pleurodesis: Adhesion formation is promoted when drugs are instilled into the pleural
space to obliterate the space and prevent further accumulation of fluid.
• Other treatment modalities include surgical pleurectomy (insertion of a small catheter attached to a
drainage bottle) or implantation of a pleuroperitoneal shunt.

Nursing Management
• Implement medical regimen: Prepare and position patient for thoracentesis and offer support
throughout the procedure.
• Monitor chest tube drainage and water-seal system; record amount of drainage at prescribed
intervals.
• Administer nursing care related to the underlying cause of the pleural effusion.
• Assist patient in pain relief. Assist patient to assume positions that are least painful. Administer pain
medication as prescribed and needed to continue frequent turning and ambulation.
• If the patient is to be managed as an outpatient with a pleural catheter for drainage, educate the
patient and family about management and care of the catheter and drainage system.

• Thoracentesis
o Removal of excess air and fluid from the pleural cavity
o Prevent infection:
o
✓ Sterile technique
o Site of insertion:
✓ Depending on the MD’s assessment
✓ Chest X-ray: best method to pinpoint the
site
o POSITION:
✓ Sitting on the edge of the bed with feet
supported and arms on a padded over-
bed table
✓ Straddling a chair with arms and head
resting on the back of the chair
✓ If the patient cannot sit:
▪ Lying on the unaffected side with the
head of the bed elevated 30-450
▪ Kozier: sitting with arms above the
head
o Secure the consent:
✓ Obtained by: MD
 ✓ Secured by: RN
✓ Given by: patient
o Instruction upon insertion:
✓ Exhale and hold
✓ Watch out for:
▪ Respiratory distress
▪ Hypotension
o Prevent hypotension:
✓ Do not remove >1000 mL for the first 30 mins
o Post-procedure:
✓ Apply vaselinized or petrolatum gauze
o Position post-procedure:
✓ Side-lying on the unaffected side
o Emergency!
✓ If the client expectorate blood (may mean accidental puncture of the lungs) NOTIFY the MD!
✓ Rule-out pneumothorax: Chest X-Ray
o Health teaching post procedure:
✓ Avoid coughing
✓ Deep breathing
✓ Straining

III. Pulmonary edema is the abnormal accumulation of fluid in the interstitial spaces of the lungs that
diffuses into the alveoli. Pulmonary edema is an acute event that results from left ventricular failure.
With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The
patient quickly develops pulmonary edema, sometimes called “flash pulmonary edema,” from the blood
volume overload in the lungs. Pulmonary edema can also be caused by noncardiac disorders, such as
renal failure and other conditions that cause the body to retain fluid. The pathophysiology is similar to
that seen in HF, in that the left ventricle cannot handle the volume overload and blood volume and
pressure build up in the left atrium. The rapid increase in atrial pressure results in an acute increase in
pulmonary venous pressure, which produces an increase in hydrostatic pressure that forces fluid out of
the pulmonary capillaries into the interstitial spaces and alveoli. Lymphatic drainage of the excess fluid
is ineffective.

Clinical Manifestations
• As a result of decreased cerebral oxygenation,
the patient becomes increasingly restless and
anxious.
• Along with a sudden onset of breathlessness
and a sense of suffocation, the patient’s hands
become cold and moist, the nail beds become
cyanotic (bluish), and the skin turns ashen
(gray).
• The pulse is weak and rapid, and the neck veins
are distended.
• Incessant coughing may occur, producing
increasing quantities of foamy sputum.
• As pulmonary edema progresses, the patient’s
anxiety and restlessness increase; the patient
becomes confused, then stuporous.
• Breathing is rapid, noisy, and moist-sounding;
the patient’s oxygen saturation is significantly
decreased.
• The patient, nearly suffocated by the blood-tinged, frothy fluid filling the alveoli, is literally drowning
 in secretions. The situation demands emergent action.

Assessment and Diagnostic Methods

• Diagnosis is made by evaluating the clinical manifestations resulting from pulmonary congestion.
• Abrupt onset of signs of left-sided HF (eg, crackles on auscultation of the lungs) may occur without
evidence of right-sided HF (eg, no jugular venous distention [JVD], no dependent edema).
• Chest x-ray reveals increased interstitial markings.
• Pulse oximetry to assess ABG levels.

Medical Management
Goals of medical management are to reduce volume overload, improve ventricular function, and
increase respiratory exchange using a
combination of oxygen and medication
therapies.

Oxygenation
• Oxygen in concentrations adequate to
relieve hypoxia and dyspnea
• Oxygen by intermittent or continuous
positive pressure, if signs of hypoxemia
persist
• Endotracheal intubation and mechanical
ventilation, if respiratory failure occurs
• Positive end-expiratory pressure (PEEP)
• Monitoring of pulse oximetry and ABGs

Pharmacologic Therapy
• Morphine given intravenously in small
doses to reduce anxiety and dyspnea;
contraindicated in cerebral vascular
accident, chronic pulmonary disease, or
cardiogenic shock; have naloxone
hydrochloride (Narcan) available for excessive respiratory depression
• Diuretics (eg, furosemide) to produce a rapid diuretic effect
• Vasodilators such as IV nitroglycerin or nitroprusside (Nipride) may enhance symptom relief

Nursing Management
• Assist with administration of oxygen and intubation and mechanical ventilation.
• Position patient upright (in bed if necessary) or with legs and feet down to promote circulation.
Preferably position patient with legs dangling over the side of bed.
• Provide psychological support by reassuring patient. Use touch to convey a sense of concrete
reality. Maximize time at the bedside.
• Give frequent, simple, concise information about what is being done to treat the condition and what
the responses to treatment mean.
• Monitor effects of medications. Observe patient for excessive respiratory depression, hypotension,
and vomiting. Keep a morphine antagonist available (eg, naloxone hydrochloride).
• Insert and maintain an indwelling catheter if ordered or provide bedside commode.
• The patient receiving continuous IV infusions of vasoactive medications requires ECG monitoring
and frequent measurement of vital signs.

IV. Pulmonary Embolism PE refers to the obstruction of the pulmonary artery or one of its branches by a
thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart.
Gas exchange is impaired in the lung mass supplied by the obstructed vessel. Massive PE is a life-
threatening emergency; death commonly occurs within 1 hour after the onset of symptoms. It is a
common disorder associated with trauma, surgery (orthopedic, major abdominal, pelvic, gynecologic),
pregnancy, HF, age more than 50 years, hypercoagulable states, and prolonged immobility. It also may
occur in apparently healthy people. Most thrombi originate in the deep veins of the legs.

Clinical Manifestations
Symptoms depend on the size of the thrombus and the area of the pulmonary artery occlusion.
• Dyspnea is the most common symptom. Tachypnea is the most frequent sign.
• Chest pain is common, usually sudden in onset and pleuritic in nature; it can be substernal and may
mimic angina pectoris or a myocardial infarction.
• Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, syncope, shock, and
sudden death may occur.
• Clinical picture may mimic that of bronchopneumonia or HF.
• In atypical instances, PE causes few signs and symptoms, whereas in other instances it mimics
various other cardiopulmonary disorders.

Assessment and Diagnostic Methods

• Because the symptoms of PE can vary from few to severe, a diagnostic workup is performed to rule
out other diseases.
• The initial diagnostic workup may include chest x-ray, ECG, ABG analysis, and ventilation–
perfusion scan.
• Pulmonary angiography is considered the best method to diagnose PE; however, it may not be
feasible, cost-effective, or easily performed, especially with critically ill patients.
• Spiral CT scan of the lung, D-dimer assay (blood test for evidence of blood clots), and pulmonary
arteriogram may be warranted.

Prevention
• Ambulation or leg exercises in patients on bed rest
• Application of sequential compression devices
• Anticoagulant therapy for patients whose hemostasis is adequate and who are undergoing major
elective abdominal or thoracic surgery

Medical Management
Immediate objective is to stabilize the cardiopulmonary system.
• Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central
cyanosis.
• IV infusion lines are inserted to establish routes for medications or fluids that will be needed.
• A perfusion scan, hemodynamic measurements, and ABG determinations are performed. Spiral
(helical) CT or pulmonary angiography may be performed.
• Hypotension is treated by a slow infusion of dobutamine (Dobutrex), which has a dilating effect on
the pulmonary vessels and bronchi, or dopamine (Intropin).
• The ECG is monitored continuously for dysrhythmias and right ventricular failure, which may occur
suddenly.
• Digitalis glycosides, IV diuretics, and antiarrhythmic agents are administered when appropriate.
• Blood is drawn for serum electrolytes, complete blood cell count, and hematocrit.
• If clinical assessment and ABG analysis indicate the need, the patient is intubated and placed on a
mechanical ventilator.
• If the patient has suffered massive embolism and is hypotensive, an indwelling urinary catheter is
inserted to monitor urinary output.
• Small doses of IV morphine or sedatives are administered to relieve patient anxiety, to alleviate
chest discomfort, to improve tolerance of the endotracheal tube, and to ease adaptation to the
mechanical ventilator.
Anticoagulation Therapy
• Anticoagulant therapy (heparin, warfarin sodium [Coumadin]) has traditionally been the primary
method for managing acute DVT and PE (numerous specific options for treatment are available).
• Patients must continue to take some form of anticoagulation for at least 3 to 6 months after the
embolic event.
• Major side effects are bleeding anywhere in the body and anaphylactic reaction resulting in shock
or death. Other side effects include fever, abnormal liver function, and allergic skin reaction.

Thrombolytic Therapy
• Thrombolytic therapy may include urokinase, streptokinase, and alteplase. It is reserved for PE
affecting a significant area and causing hemodynamic instability.
• Bleeding is a significant side effect; nonessential invasive procedures are avoided.

Surgical Management
• A surgical embolectomy is rarely performed but may be indicated if the patient has a massive PE or
hemodynamic instability or if there are contraindications to thrombolytic therapy.
• Transvenous catheter embolectomy with or without insertion of an inferior vena caval filter (eg,
Greenfield).

Nursing Management
Minimizing the Risk of PE
The nurse must have a high degree of suspicion for PE in all patients, but particularly in those with
conditions predisposing to a slowing of venous return.

Preventing Thrombus Formation

• Encourage early ambulation and active and passive leg exercises.
• Instruct patient to move legs in a “pumping” exercise.
• Advise patient to avoid prolonged sitting, immobility, and constrictive clothing.
• Do not permit dangling of legs and feet in a dependent position.
• Instruct patient to place feet on floor or chair and to avoid crossing legs.
• Do not leave IV catheters in veins for prolonged periods.

Monitoring Anticoagulant and Thrombolytic Therapy

• Advise bed rest, monitor vital signs every 2 hours, and limit invasive procedures.
• Measure international normalized ratio (INR) or activated partial thromboplastin time (PTT) every 3
to 4 hours after thrombolytic infusion is started to confirm activation of fibrinolytic systems.
• Perform only essential ABG studies on upper extremities, with manual compression of puncture site
for at least 30 minutes.

Minimizing Chest Pain, Pleuritic

• Place patient in semi-Fowler’s position; turn and reposition frequently.
• Administer analgesics as prescribed for severe pain.

Managing Oxygen Therapy

• Assess the patient frequently for signs of hypoxemia and monitors the pulse oximetry values.
• Assist patient with deep breathing and incentive spirometry.
• Nebulizer therapy or percussion and postural drainage may be necessary for management of
secretions.

Alleviating Anxiety
• Encourage patient to express feelings and concerns.
• Answer questions concisely and accurately.
• Explain therapy, and describe how to recognize untoward effects early.
 Monitoring for Complications
Be alert for the potential complication of cardiogenic shock or right ventricular failure subsequent to the
effect of PE on the cardiovascular system.

Providing Postoperative Nursing Care

• Measure pulmonary arterial pressure and urinary output.
• Assess insertion site of arterial catheter for hematoma formation and infection.
• Maintain blood pressure to ensure perfusion of vital organs.
• Encourage isometric exercises, antiembolism stockings, and walking when permitted out of bed;
elevate foot of bed when patient is resting.
• Discourage sitting; hip flexion compresses large veins in the legs.

V. Pneumonia- is an ordinary infection, if it is not treated at an initial stage, it may spread to others. Also it
may cause lot of complications to the infected person which may be sometimes fatal. Hence it is always
better to identify the cause of infection and get it treated. Pneumonia is a general term that refers to an
infection of the lungs, which can be caused by a variety of microorganisms, like viruses, bacteria, fungi,
and parasites. Pneumonia is a common illness, occurs in all age groups, and is a leading cause of
death among the elderly and people who are suffering from long time illness. It is a very
old disease well known to our ancestors. Hippocrates, the ancient Greek physician known as the father
of Medicine had described the signs and symptoms of pneumonia accurately as early as 4th century
B.C.

Types of Pneumonia: It can be classified in

several different ways. They are:
1. Acute pneumonia: It is a type which
usually develops rapidly and lasts for 2 to
3 weeks. It is spread easily and can cause
symptoms very soon.
2. Chronic pneumonia: These
develop gradually over a period of weeks
to months. This type pneumonia does not
spread easily.
3. Community acquired pneumonia is a
common seen in people with an underlying
pathology. Streptococcus is the most
common bacterial cause of community-
acquired pneumonia. This occurs most
commonly in very young and very old
people.
4. Hospital-acquired pneumonia is an
infection that patients get while they’re in the hospital. This means the infection is not present at
the time a patient is admitted to the hospital.
5. Aspiration pneumonia is an inflammation of the lungs and bronchial tubes caused by inhaling
foreign material, usually food, drink, vomit, or secretions from the mouth into the lungs.
6. Severe Acute Respiratory Syndrome (SARS): SARS is a highly contagious and deadly type
of pneumonia which first occurred in 2002 after initial outbreaks in China. SARS is caused by a
virus called as coronavirus.
7. Chemical pneumonia: Chemical pneumonia is caused by chemical toxins such as pesticides,
which may enter the body by inhalation or by skin contact.
 Causative organisms: It is caused by different types of microorganisms, including bacteria,
viruses, fungi, and parasites.
1. Viruses: Some viruses that cause pneumonia are adenoviruses, rhinovirus, influenza virus (flu),
respiratory syncytial virus (RSV), and parainfluenza virus.
2. Bacteria : The bacterium Streptococcus pneumoniae, a common cause of pneumonia. Bacteria
typically enter the lung when airborne droplets are inhaled, but they can also reach the lung
through the bloodstream when there is an infection in another part of the body. Many bacteria
live in parts of the upper respiratory tract, such as the nose, mouth and sinuses, and can easily
be inhaled into the alveoli.
3. Fungi: Fungal pneumonia is uncommon, but it may occur in individuals with reduced immune
system due to AIDS or other medical problems.
4. Parasites: A variety of parasites can affect the lungs. These parasites typically enter the body
through the skin or by being swallowed. Once inside the body, they travel to the lungs, usually
through the blood and cause disease.

Inflammation of LUNG PARENCHYMA

• Etiology:
o Strep. Pneumoniae
o H. influenza
o E.coli
o Klebsiella
• S/Sx:
o RUSTY/PRUNE JUICE-colored
sputum (pathognomonic sign)
o Dyspnea
o Fever
o Pleuritic chest pain
o Crackles
• Dx:
o CXR
o CBC (leukocytosis)
• Mngt:
o ANTIBIOTICS
o Oxygen
o Force fluids
o CPT
o Nebulization
o Semi-fowler’s position

VI. Pulmonary Tuberculosis

Tuberculosis (TB), an infectious disease primarily
affecting the lung parenchyma, is most often
caused by Mycobacterium tuberculosis. It may
spread to almost any part of the body, including
the meninges, kidney, bones, and lymph nodes.
The initial infection usually occurs 2 to 10 weeks
after exposure. The patient may then develop
active disease because of a compromised or
inadequate immune system response. The active
process may be prolonged and characterized by long remissions when the disease is arrested, only to
be followed by periods of renewed activity. TB is a worldwide public health problem that is closely
associated with poverty, malnutrition, overcrowding, substandard housing, and inadequate health care.
Mortality and morbidity rates continue to rise.
TB is transmitted when a person with active pulmonary disease expels the organisms. A susceptible
person inhales the droplets and becomes infected. Bacteria are transmitted to the alveoli and multiply.
An inflammatory reaction results in exudate in the alveoli and bronchopneumonia, granulomas, and
fibrous tissue. Onset is usually insidious.

Risk Factors
• Close contact with someone who has active TB
• Immunocompromised status (eg, elderly, cancer, corticosteroid therapy, and HIV)
• Injection drug use and alcoholism
• People lacking adequate health care (eg, homeless or impoverished, minorities, children, and
young adults)
• Preexisting medical conditions, including diabetes, chronic renal failure, silicosis, and
malnourishment
• Immigrants from countries with a high incidence of TB (eg, Haiti, southeast Asia)
• Institutionalization (eg, long-term care facilities, prisons)
• Living in overcrowded, substandard housing
• Occupation (eg, health care workers, particularly those performing high-risk activities)

Clinical Manifestations
• Low-grade fever, cough, night sweats, fatigue, and weight loss
• Nonproductive cough, which may progress to mucopurulent sputum with hemoptysis

Assessment and Diagnostic Methods

• TB skin test (Mantoux test); QuantiFERON-TB Gold (QFT-G) test
• Chest x-ray
• Acid-fast bacillus smear
• Sputum culture

Gerontologic Considerations
Elderly patients may have atypical manifestations, such as unusual behavior or disturbed mental status,
fever, anorexia, and weight loss. TB is increasingly encountered in the nursing home population. In
many elderly people the TB skin test produces no reaction.

Medical Management
Pulmonary TB is treated primarily with antituberculosis agents for 6 to 12 months. A prolonged
treatment duration is necessary to ensure eradication of the organisms and to prevent relapse.

Pharmacologic Therapy
• First-line medications: isoniazid or INH (Nydrazid), rifampin (Rifadin), pyrazinamide, and ethambutol
(Myambutol) daily for 8 weeks and continuing for up to 4 to 7 months
• Second-line medications: capreomycin (Capastat), ethionamide (Trecator), para aminosalicylate
sodium, and cycloserine (Seromycin)
• Vitamin B (pyridoxine) usually administered with INH

Nursing Management
Promoting Airway Clearance
• Encourage increased fluid intake.
• Instruct about best position to facilitate drainage.

Advocating Adherence to Treatment Regimen

• Explain that TB is a communicable disease and that taking medications is the most effective way of
preventing transmission.
 • Instruct about medications, schedule, and side effects; monitor for side effects of anti-TB
medications.
• Instruct about the risk of drug resistance if the medication regimen is not strictly and continuously
followed.
• Carefully monitor vital signs and observe for spikes in temperature or changes in the patient’s
clinical status.
• Teach caregivers of patients who are not hospitalized to monitor the patient’s temperature and
respiratory status; report any changes in the patient’s respiratory status to the primary health care
provider.

Promoting Activity and Adequate Nutrition

• Plan a progressive activity schedule with the patient to increase activity tolerance and muscle
strength.
• Devise a complementary plan to encourage adequate nutrition. A nutritional regimen of small,
frequent meals and nutritional supplements may be helpful in meeting daily caloric requirements.
• Identify facilities (eg, shelters, soup kitchens, Meals on Wheels) that provide meals in the patient’s
neighborhood may increase the likelihood that the patient with limited resources and energy will
have access to a more nutritious intake.

Preventing Spreading of TB Infection

• Carefully instruct the patient about important hygiene measures, including mouth care, covering the
mouth and nose when coughing and sneezing, proper
disposal of tissues, and handwashing.
• Report any cases of TB to the health department so that
people who have been in contact with the affected patient
during the infectious stage can undergo screening and
possible treatment, if indicated.
• Instruct patient about the risk of spreading TB to other
parts of the body (spread or dissemination of TB infection
to nonpulmonary sites of the body is known as miliary TB).
• Carefully monitor patient for military TB: Monitor vital signs
and observe for spikes in temperature as well as changes
in renal and cognitive function; few physical signs may be
elicited on physical examination of the chest, but at this
stage the patient has a severe cough and dyspnea.
Treatment of miliary TB is the same as for pulmonary TB.

VII. Pneumothorax
• Accumulation of
atmospheric air in
pleural space which
results in rise in intra-
throracic pressure
• TYPES:
o SIMPLE
pneumothorax
✓ Breach in the
visceral or
parietal pleura
o TENSION
pneumothorax
✓ Laceration or
hole in the
 lungs
• S/Sx:
o Dyspnea
o Dec. or Absent breath sound on the affected side
o Dec. chest expansion
o Tracheal deviation to the unaffected side (CXR)
✓ Exclusive for TENSION pneumothorax
• Mngt:
o Thoracentesis

Chest tubes and drainage system

• Aims to restore negative pressure of the pleural cavity and drain collected fluid/blood
• Components:
o Suction control chamber
o Water seal chamber
o Closed collection chamber
• Assessment of the site:
o At least every 4 hours for:
✓ Excessive or abnormal drainage
✓ Cracking sound upon palpation for subcutaneous emphysema
• R
e
p
o
s
i
t
i
o
n
i
n
g
:
o E
v
e
r
y

h
o
u
r
s
✓ If lying on the affected side
▪ (put a rolled towel beside the tubing)
• Remember:
o Keep the collection device below the client’s chest level
• Oscillations or fluctuations on water seal:
 o NORMAL
o ABSENCE:
✓ Re-expansion of the lungs
✓ Obstruction
o Mngt:
✓ Notify the MD for CXR
✓ Obstruction: (no milking and stripping)
▪ SQUEEZE (hand-over-hand)
• Presence of bubbling:
o Drainage Bottle: NO BUBBLING
o Water Seal Bottle: INTERMITTENT BUBBLING
o Suction Control Bottle: CONTINOUS GENTLE BUBBLING
• Abnormal bubbling:
o Water Seal Bottle: CONTINOUS BUBBLING
o Suction Control Bottle: VIGOROUS BUBBLING
✓ ALERT: LEAKAGE!!!
• Management:
o CLAMP the tube and TAPE the leak (allowed for short periods)
o PROLONGED CLAMPING: can cause tension pneumothorax
• Absence of bubbling
o Water Seal Bottle
o Suction Control Bottle
✓ May mean:
▪ Lung Re-expansion
▪ Obstruction
✓ Mngt:
▪ The same
• Points to remember:
o TUBE PULLED FROM THE
SITE
✓ Cover with DRY
STERILE dressing
✓ If air is leaking ensure
that the dressing is not
occlusive
✓ If not available in the
choices:
▪ Vaselinized gauze
▪ Petrolatum gauze
o TUBE DISCONNECTED or
WATER SEAL BOTTLE
BREAKS:
✓ Submerge the end in 1
in. of sterile saline or
water
✓ Reconnect

VIII. Chest Injuries

Major chest trauma may occur alone or in combination with multiple other injuries. Chest trauma
is classified as either blunt or penetrating. Blunt chest trauma results from sudden compression
or positive pressure inflicted to the chest wall. Penetrating trauma occurs when a foreign object
penetrates the chest wall.
• Rib Fracture
o Fracture resulting from direct blunt
chest trauma
o S/Sx:
✓ Pain at the site (increases with
respiration)
o Mngt:
✓ Unite spontaneously
✓ High fowler’s position
• Flail chest
o Fracture or 3 or more ribs resulting
from direct blunt chest trauma
o S/Sx:
✓ PARADOXICAL BREATHING
o Mngt:
✓ Oxygen
✓ WOF respiratory distress
✓ High fowler’s position

1. acute lung injury: an umbrella term for hypoxemic, respiratory failure; acute respiratory distress
syndrome is a severe form of acute lung injury
2. acute respiratory distress syndrome: nonspecific pulmonary response to a variety of pulmonary
and nonpulmonary insults to the lung; characterized by interstitial infiltrates, alveolar hemorrhage,
atelectasis, decreased compliance, and refractory hypoxemia
3. asbestosis: diffuse lung fibrosis resulting from exposure to asbestos fibers
4. atelectasis: collapse or airless condition of the alveoli caused by hypoventilation, obstruction to
the airways, or compression
5. consolidation: lung tissue that has become more solid in nature due to collapse of alveoli or
infectious process (pneumonia)
6. empyema: accumulation of purulent material in the pleural space
7. hemoptysis: the coughing up of blood from the lower respiratory tract
8. hemothorax: partial or complete collapse of the lung due to blood accumulating in the pleural
space; may occur after surgery or trauma
9. induration: an abnormally hard lesion or reaction, as in a positive tuberculin skin test
10. nosocomial: pertaining to or originating from a hospitalization; not present at the time of hospital
admission
11. open lung biopsy: biopsy of lung tissue performed through a limited thoracotomy incision
12. orthopnea: shortness of breath when reclining or in the supine position
13. pleural effusion: abnormal accumulation of fluid in the pleural space
14. pleural friction rub: localized grating or creaking sound caused by the rubbing together of
inflamed parietal and visceral pleurae
15. pneumothorax: partial or complete collapse of the lung due to positive pressure in the pleural
space
16. pulmonary edema: increase in the amount of extravascular fluid in the lung
17. pulmonary embolism: obstruction of the pulmonary vasculature with an embolus; embolus may
be due to blood clot, air bubbles, or fat droplets
18. purulent: consisting of, containing, or discharging pus
19. restrictive lung disease: disease of the lung that causes a decrease in lung volumes
20. tension pneumothorax: pneumothorax characterized by increasing positive pressure in the
 pleural space with each breath; this is an emergency situation and the positive pressure needs to
be decompressed or released immediately
21. thoracentesis: insertion of a needle into the pleural space to remove fluid that has accumulated
and decrease pressure on the lung tissue; may also be used diagnostically to identify potential
causes of a pleural effusion

▪ Ignatavicius, D.D., Workman, M.L., & Rebar, C.R. (2018). Medical-Surgical Nursing: Concepts
for Interprofessional Collaborative Care (9th ed.). St. Louis: Elsevier.
▪ LeMone, P., Burke, K.M., Bauldoff, G., & Gubrud, P. (2015). Medical-Surgical Nursing: Critical
Reasoning in Patient Care (6th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall.
▪ Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-
Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis:
Elsevier.
▪ Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019). Essentials for Nursing Practice (9th
ed.). St. Louis: Elsevier.
▪ Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2017). Fundamentals of Nursing (9th ed.).
St. Louis: Elsevier/Mosby.
▪ Wilkinson, J.M., Treas, L.S., Barnett, K.L., & Smith, M.H. (2016). Fundamentals of Nursing:
Volume 1- Theory, Concepts, and Applications; Volume 2- Thinking, Doing, and Caring. (3rd
ed.). Philadelphia: F.A. Davis Co.

Answer the following questions:

1. You are caring for a 34-year-old patient who experienced blunt chest trauma in a motor vehicle
crash. A chest tube was inserted to treat a simple pneumothorax and hemothorax. The chest
drainage system has drained 400ml of light red fluid during the 1st 6 hours after insertion. The
patient has become increasingly short of breath during the past hour.. What physical assessment
skills and strategies would you use to determine potential changes in the patient’s respiratory
condition? What are potential causes of this increasing shortness of breath? What would you do to
prepare for an emergency situation in this patient? (30pts)
2. Consider the scenario and answer the following questions.
Case Study: Community Acquired Pneumonia
Teresa, a 20 year old college student, lives in a small dormitory with 30 other students. Four weeks
after start of classes, she was diagnosed as having bacterial pneumonia and was admitted to the
hospital. (20 pts, 5 pts each)
A. What intervention can the nurse provide to decrease the viscosity of secretions?
B. The nurse is assessing Teresa during the admission process. What manifestations of
bacterial pneumonia does the nurse expect to find?
C. The nurse assesses Teresa for arterial hypoxemia. What does the nurse understand is the
reason why this complication develops?
D. The nurse is assessing vital signs and lung sounds every 4 hours. What complications
should the nurse monitor for?

Books
 Collaborative Staging Task Force of the American Joint Committee on Cancer. (2007).
Collaborative staging manual and coding instructions. NIH Publication Number 04-5496. U.S.
Department of Health and Human Services, National Institutes of Health, National Cancer Institute.
Wilkins, R. L., Dexter, J. R. & Gold, P. M. (2007). Respiratory disease: A case study approach to
patient care (3rd ed.). Philadelphia: F. A. Davis Company.

Journals and Electronic Documents

American Lung Association. (2005). Occupational lung disease fast fact sheet. Available at:
www.lungusa.org
Wilson, K. C. & Hollingsworth, H. (2007). What’s new in pulmonary, critical care and sleep
medicine. Up to Date. Available at: www.uptodate.com

Online
Agency for Healthcare Quality and Research, www.ahrq.gov
American Association for Respiratory Care, www.aarc.org
American College of Chest Physicians, www.chestnet.org
American Lung Association, www.lungusa.org
American Thoracic Society, www.thoracic.org
Centers for Disease Control and Prevention, www.cdc.gov
National Heart, Lung and Blood Institute, www.nhlbi.nih.gov
Occupational Safety and Health Administration (OSHA), www.osha.gov
Pulmonary Hypertension Association (PHA), www.phassociation.org
Respiratory Nursing Society, www.respiratorynursingsociety.org