MEDICAL-SURGICAL NURSING: MIDTERMS OVERVIEW

MEDICAL-SURGICAL NURSING
| MARK DARYL A. MISUARI | CLINICAL INSTRUCTOR: MILKY ADAJAR
ESCOBER| SEM 1 | A.Y. 2022 – 2023 |

fibrinogen: protein converted into

ASSESSMENT OF HEMATOLOGIC
fibrin to form thrombus and clot
FUNCTION AND TREATMENT
MODALITIES fibrinolysis: process of breakdown of
fibrin clot
anemia: decreased red blood cell
granulocyte: granulated WBC (i.e.,
(RBC) count
neutrophil, eosinophil, basophil)
band cell: slightly immature
hematocrit: percentage of total
neutrophil
blood volume consisting of RBCs
blast cell: primitive white blood cell
hematopoiesis: complex process of
(WBC)
the formation and maturation of
cytokines: proteins produced by blood cells
leukocytes that are vital to
hemoglobin: iron-containing protein
regulation of hematopoiesis,
of RBCs; delivers oxygen to tissues
apoptosis, and immune responses
hemostasis: intricate balance
differentiation: development of
between clot formation and clot
functions and characteristics that
dissolution
are different from those of the
parent stem cell leukocyte: one of several cellular
components of blood involved in
erythrocyte: a cellular component of
defense of the body; subtypes
blood involved in the transport of
include neutrophils, eosinophils,
oxygen and carbon dioxide
basophils, monocytes, and
(synonym: red blood cell [RBC])
lymphocytes (synonym: white blood
erythropoiesis: process of the cell [WBC])
formation of RBCs
leukopenia: less-than-normal
erythropoietin: hormone produced amount of WBCs in circulation
primarily by the kidney; necessary for
lymphocyte: form of WBC involved in
erythropoiesis
immune functions
fibrin: filamentous protein; basis of
lymphoid: pertaining to lymphocytes
thrombus and blood clot
macrophage: reticuloendothelial
cells capable of phagocytosis
monocyte: large WBC that becomes
a macrophage when it leaves the
circulation and moves into body
tissues
myeloid: pertaining to nonlymphoid
blood cells that differentiate into
RBCs, platelets, macrophages, mast
cells, and various WBCs
myelopoiesis: formation and
maturation of cells derived from
myeloid stem cell
natural killer (NK) cells: lymphocytes
that defend against microorganisms
and malignant cells
neutrophil: fully mature WBC
capable of phagocytosis; primary
defense against bacterial infection
oxyhemoglobin: combined form of
oxygen and hemoglobin; primarily
found in arterial blood
phagocytosis: process of cellular
ingestion and digestion of foreign
bodies
plasma: liquid portion of blood
plasminogen: protein converted to
plasmin to dissolve thrombi and clots
platelet: a cellular component of
blood involved in blood coagulation
(synonym: thrombocyte) red blood
cell (RBC): a cellular component of
blood involved in the transport of
oxygen and carbon dioxide
(synonym: erythrocyte)
reticulocytes: slightly immature RBCs,
usually only 1% of total circulating
RBCs
reticuloendothelial system: complex
system of cells throughout the body
capable of phagocytosis
serum: portion of blood remaining
after coagulation occurs stem cell:
primitive cell, capable of self-
replication and differentiation into
myeloid or lymphoid stem cell
stroma: component of the bone
marrow not directly related to
hematopoiesis but serves important
supportive roles in this process
thrombocyte: a cellular component
of blood involved in blood
coagulation (synonym: platelet)
white blood cell (WBC): one of
several cellular components of
blood involved in defense of the
body; subtypes include neutrophils,
eosinophils, basophils, monocytes,
and lymphocytes (synonym:
leukocyte)
Hematologic System -Marrow is one of the largest organs
of the body, making up 4% to 5% of
Bone Marrow
total body weight.
Blood Cells
Hemostasis (body’s natural Red Marrow
reaction to an injury that stops Yellow Marrow
bleeding and repairs the
-can develop either into myeloid or
damage.
lymphoid stem cells
Plasma
-lymphoid stem cells produce either T
Blood Functions
or B lymphocytes
Carries O2 and nutrients to cells
Myeloid stem cells differentiate into
Remove wastes (CO2 and
three broad cell types: erythrocytes,
metabolic wastes)
leukocytes, and platelets
Hormone transport
Immune and inflammatory Blood Cells
responses
Temperature regulation -can be classified as erythrocytes
F/E balance (Fluid and (RBC), leukocytes (WBC), and
electrolyte) thrombocytes (platelets)
Acid/Base balance
-they take 40-45% of the blood
CBC Test volume

-most common type of blood -average lifespan of RBCs are 120

diagnostic test (complete blood
count test) that measures several
components and features of your
blood.
Homeostasis
days
-the need for the body to replenish
its supply of cells is continuous; this
process is termed hematopoiesis
(primary site is the bone marrow)

-the maintenance of a constant Leukocytes are classified as:

internal equilibrium in a biologic
Granulocytes (neutrophils,
system
eosinophils, and basophils)
Bone Marrow Agranulocytes
o Monocytes (mononuclear
-is the site of hematopoiesis, or blood leuokocytes)
cell formation o Lymphocytes (T and B cells)
Neutrophils- pink to violet hue Blood Groups

Eosinophils- bright-red granules -ABO typing

-Rh typing
Basophils- stain deep blue

Platelets
Type A Anti- B (A-antigen)
- are not technically cells; rather,
Type B Anti- A (B-antigen)
they are granular fragments of giant
cells in the bone marrow called Type AB+ Universal Recipient
megakaryocytes (A and B-antigen)

Platelets play an essential role in the Type O- Universal Donor (Anti

control of bleeding. They circulate
freely in the blood in an inactive
state, where they nurture the
endothelium of the blood vessels,
maintaining the integrity of the
vessel.
Plasma
– A and B-antigen)
ABO Incompatibility
-happens when the mother’s blood
type is O and her baby’s blood type
is A or B
-First pregnancy (usually occurs)

-90 percent of it is water and the -Mild cases (subsequent

remainder of it consists primarily pregnancies)
plasma proteins; clotting factors
(particularly fibrinogen); and small Rh Typing
amounts of other substances, such
-identifies presence/absence of RH
as nutrients, enzymes, waste
antigen
products, and gases. If allowed to
clot, the remaining fluid is called -Anti-Rh antibodies not automatically
serum. formed

It contains: Rh Incompatibility

-Albumin (produced by the liver) - Rh- (mother), Rh+ (infant)

- Harmful to subsequent
-Globulins (alpha, beta, gamma)
pregnancies
-Fibrinogen
The placenta carries:
-Prothrombin
N- utrients
O- xygen

W- astes

A- ntibodies

Rhogam

-Given to 1st baby if Rh+ and mother

is Rh- (within 72 hours)

Blood Coagulation

-process by which a blood clot is

formed on a bleeding site

Hemostasis

-intricate balance between clot

formation and clot dissolution

Coagulation Phase

- Fibrinogen Fibrin
- Activation of clot factors and
formation
- Fibrinolysis (clot breakdown)

Management of Patients with
Nonmalignant Hematologic
Disorders
lack of nutrients, including iron,
vitamin B12 and folic acid
Hemolytic anemias

an abnormality within the

Blood Disorders
erythrocyte itself (e.g., sickle cell
Hematologic disorders vary widely in disease [SCD],
their etiologies and manifestations. glucose-6-phosphate
dehydrogenase [G-6-PD]
While some are malignant, most deficiency),
hematologic disorders are benign. within the plasma e.g., immune
Disease processes can be quite hemolytic anemias),
complex, so a comprehensive from direct injury to the
understanding of the processes erythrocyte within the circulation
involved is important so that nurses (e.g., hemolysis caused by a
may effectively assess, intervene, mechanical heart valve).
monitor, and educate patients
about their conditions. ASSESSMENT/CLINICAL MANIFESTATIONS:

dyspnea
chest pain
Anemia is a condition characterized muscle pain
by a lower-than-normal hemoglobin cramping
concentration. Fewer than the slight tachycardia on exertion
normal number of red blood cells fatigue
(RBCs), also called erythrocytes, are
present in the circulation. COMPLICATIONS:

CAUSES: heart failure,

paresthesias
Hypoproliferative anemias delirium

bone marrow damage from DIAGNOSTIC TESTS:

chemicals (e.g., benzene)
medication (e.g., Hemoglobin levels
chloramphenicol), Hematorcrit levels
lack of important factors that Reticulocyte count
promote erythrocyte production RBC indices
such as erythropoietin, Mean corpuscular volume (MCV)
Red cell distribution width (RDW)
 Serum iron level
Total iron-binding capacity (TIBC)
Percent saturation
Ferritin levels
Serum vitamin B12
Folate levels
Haptoglobin
Erythropoietin levels
Colonoscopy
Upper endoscopy
MEDICAL MANAGEMENT
Management of anemia is directed
toward correcting or controlling the
cause of the anemia; if the anemia is
severe, the erythrocytes that are lost
or destroyed may be replaced with
a transfusion of packed red blood
cells (PRBCs).
NURSING MANAGEMENT
Assisting the patient to prioritize
activities to establish a balance
between activities and rest that is
acceptable to the patient.
The nurse should advise the
patient that alcohol can interfere
with utilization of some essential
nutrients and recommend limited
alcohol intake.
Dietary education involving family
members when possible should
be individualized to address
specific needs and include
cultural preferences for food
preparation and selection.
Dietary supplements (e.g.,
vitamins and iron) may be
prescribed.
Lost volume can be replaced
with transfusions or intravenous
fluids based on symptoms and
laboratory test results.
Monitoring the patient’s vital signs
and pulse oximetry, especially
with activity, is an important
nursing action.
Medications, including
antihypertensive drugs, may need
to be adjusted or withheld based
IRON DEFICIENCY ANEMIA
Iron deficiency anemia results when
the intake of dietary iron is
inadequate for synthesis of
hemoglobin. The body is able to
store about one fourth to one third of
its iron requirements, and it is not until
those stores are depleted that iron
deficiency anemia develops.
CAUSES:
Blood loss
GI bleeding from ulcers, gastritis,
tumors, or inflammatory bowel
disease
Menorrhagia (excessive
menstrual bleeding)
Pregnancy with inadequate iron
intake
Chronic alcohol abuse
Too much use of NSAIDs
Iron malabsorption
ASSESSMENT/CLINICAL MANIFESTATIONS:
Normal symptoms of anemia (as
stated above)
Smooth, red tongue
Brittle and ridged nails
Angular cheilosis
DIAGNOSTIC TEST:
Bone marrow aspiration
Ferritin level
Mean corpuscular volume (MCV)
Hematocrit and RBC levels
Total iron-binding capacity (TIBC)
Serum iron level
MEDICAL MANAGEMENT:
Oral iron supplementation (ferrous
sulfate, ferrous gluconate, ferrous
fumarate)
Ferric maltol
If oral iron is poorly absorbed or
poorly tolerated, or large
amounts of supplemental iron are
needed, intravenous (IV) iron may
be given in repeated doses.
NURSING MANAGEMENT:
Food sources rich in iron include
organ meats (e.g., beef or calf’s
liver, chicken liver), other meats,
beans (e.g., pinto, black, and
garbanzo beans), leafy green
vegetables, raisins, and molasses.
Eating iron-rich foods with a
source of vitamin C (e.g., orange
juice) improves iron absorption.
The nurse assists the patient in
selecting healthy diet options.
Nutritional counseling can be
provided for those who have an
inadequate diet.
The nurse also encourages the
patient to continue the
prescribed therapy for as long as
needed to replenish iron stores
even when fatigue and other
symptoms have resolved.
IV supplementation may be used
when the patient’s iron stores are
very low, if the patient cannot
tolerate oral forms of iron, or both.
The nurse must be aware of the
type of parenteral formulation of
iron ordered so that risk for
anaphylaxis can be determined.
The nurse must assist the patient in
understanding the need for
repeated doses to replenish iron
stores or to maintain iron stores in
the setting of chronic blood loss,
such as hemodialysis or chronic
GI bleeding.
APLASTIC ANEMIA
-is a rare disease caused by a
decrease in or damage to bone
marrow stem cells, damage to the
microenvironment within the bone
marrow, and replacement of
marrow with fat.
CAUSES:
Certain medications
Chemicals
 Radiation damage Transfusions with PRBCs and
Certain toxic materials, including platelets are frequently required
inorganic arsenic, glycol ethers, Prophylaxis against invasive
plutonium, and radon, have also fungal infection is needed for
been suggested as possible patients who are severely
causes. neutropenic.
Nonviral hepatitis Patients who become
Congenital anomaly lymphopenic after ATG require
prophylaxis for pneumocystis
ASSESSMENT/CLINICAL MANIFESTATIONS:
pneumonia.
Infection and symptoms of
NURSING MANAGEMENT:
anemia
Fatigue Thorough assessment for signs of
Pallor infection and bleeding are
Dyspnea critical.
Purpura (bruising) Monitoring for side effects of
Lymphadenopathy therapy, including hypersensitivity
Splenomegaly reactions while administering
Retinal hemorrhages ATG.
Patients who require long-term
DIAGNOSTIC TESTS:
cyclosporine therapy should be
CBC reveals pancytopenia monitored for long-term effects,
Bone marrow biopsy including renal and liver
Neutrophil counts less than dysfunction, hypertension,
1,500/mm3, hemoglobin less than pruritus, visual changes, tremor,
10 g/dL, and platelet counts less and skin cancer.
than 50,000/mm3 Education regarding drug–drug
interactions between ATG and
MEDICAL MANAGEMENT: many other drugs is necessary.
Hematopoietic stem cell Patients should be informed that
transplant stopping immunosuppressive
Immunosuppressive therapy using therapy abruptly is not
antithymocyte globulin (ATG) and recommended.
androgens or cyclosporine PERNICIOUS ANEMIA
Corticosteroids may be beneficial
in the short-term - A type of anemia that is
characterized by a deficient
amount of vitamin B12.
- Absence of intrinsic factor also
impairs vitamin B12 absorption.
When associated with lack of
intrinsic factor, the anemia is
referred to as pernicious anemia.
CAUSES:
Inadequate dietary intake
Can occur in people who follow
a vegan diet and do not
NURSING MANAGEMENT:
consume any meat or dairy
products
Impaired absorption from the GI
tract
ASSESSMENT/CLINICAL MANIFESTATIONS:
Signs and symptoms of anemia
Weakness
Listlessness
Fatigue
Smooth, sore, red tongue
Mild diarrhea
Pale particularly in the mucous
membranes
Confusion
Paresthesias
Difficulty in maintaining their
balance because of spinal cord
damage
DIAGNOSTIC TESTS:
Serum levels of both folic acid
and vitamin B12 are analyzed.
Schilling test
Vitamin B12 assay
MEDICAL MANAGEMENT:
Vitamin B12 replacement
Oral supplements with vitamins or
fortified soy milk
Replacement is typically given by
monthly intramuscular injections
Intranasal sprays and gels are
also available options to avoid
the need for intramuscular
injections
Careful neurologic assessment is
important to identify neurologic
complications. Assessment should
include tests of position, vibration
sense, and cognitive function.
The nurse should pay close
attention to the patient’s gait and
stability with ambulation. Physical
and occupational therapy
referrals may be needed to assist
in obtaining assistive devices and
making sure patients are
instructed in their use
The nurse may instruct the patient
to choose soft bland foods that
are less likely to cause further
discomfort.
Education for patients with
pernicious anemia must include
the chronic nature of this
condition and the necessity of
monthly vitamin B12 injections or
daily oral vitamin B12
supplements even when
symptoms have resolved.
FOLIC ACID DEFICIENCY ANEMIA
-is characterized by having too little
folate (vitamin B9) in your blood.
-Folic acid is stored in the body as
compounds known as folates. Folate
stores are smaller than those of
vitamin B12 and can be depleted
within months if dietary intake of
folate is deficient.
CAUSES:
Alcohol abuse
Dietary intake of folate is deficient
Small bowel diseases such as
celiac disease may interfere with
normal absorption of folic acid
ASSESSMENT/CLINICAL MANIFESTATIONS:
Signs and symptoms of anemia
Weakness
Listlessness
Fatigue
Smooth, sore, red tongue
Mild diarrhea
Pale particularly in the mucous
membranes
Confusion
Paresthesias
Difficulty in maintaining their
balance because of spinal cord
damage
DIAGNOSTIC TESTS:
Serum levels of both folic acid
and vitamin B12 are analyzed.
Measurement of the amount of
folate within the red blood cells is
a more sensitive test to determine
true folate deficiency although it
is not commonly performed.
MEDICAL MANAGEMENT:
Increase amount of folic acid in
the diet and taking 1 mg of folic
acid daily as a supplement
IM injectable of folic acid can be
given for malabsorption
When folate deficiency is
associated with alcohol abuse,
supplementation should continue
as long as the patient is
consuming alcohol.
NURSING MANAGEMENT:
Careful neurologic assessment is
important to identify neurologic
complications. Assessment should
include tests of position, vibration
sense, and cognitive function.
The nurse should pay close
attention to the patient’s gait and
stability with ambulation. Physical
and occupational therapy
referrals may be needed to assist
in obtaining assistive devices and
making sure patients are
instructed in their use
The nurse may instruct the patient
to choose soft bland foods that
are less likely to cause further
discomfort.
Education for patients with
pernicious anemia must include
the chronic nature of this
condition and the necessity of
monthly vitamin B12 injections or
 daily oral vitamin B12 stroke, kidney injury, impotence,
supplements even when and pulmonary hypertension.
symptoms have resolved.
DIAGNOSTIC TESTS:
SICKLE CELL DISEASE
The patient with SC has a low
SCD is an autosomal recessive hematocrit and sickled cells on
disorder caused by inheritance of the blood smear. The white blood
the sickle hemoglobin (HbS) gene. It cell count and platelet count are
is associated with severe hemolytic often elevated as a result of a
anemia. chronic inflammatory state.
Abnormal hemoglobin is
CAUSES:
identified by hemoglobin
Defective sickle hemoglobin electrophoresis.
gene (HbS gene)
MEDICAL MANAGEMENT:
The HbS gene is inherited primarily
in people of African descent. It Continued research is still ongoing
may also be seen to a lesser and aggressive management of
degree in people of Middle symptoms, including pain, and
Eastern and Mediterranean complication, there are a few
descent, and some tribal primary treatment modalities.
populations in India. HSCT may cure SCD. However,
this treatment modality is
ASSESSMENT/CLINICAL MANIFESTATIONS:
available to only a small subset of
S/Sx of anemia affected patients, either due to a
Jaundice lack of compatible donors or due
Enlargement of the bones in the to severe organ damage (e.g.,
face and skull renal, liver, lung) that may be
Tachycardia already present in the patient.
Cardiac murmurs Hydroxyurea is a
Cardiomegaly chemotherapeutic agent that is
Arrythmias effective in increasing levels of
Heart failure fetal hemoglobin (i.e.,
Patients with SCD are particularly hemoglobin F), which in turn
susceptible to infections, decreases the formation of
especially pneumonia and sickled cells.
osteomyelitis. Additional RBC transfusions have been
complications of SCD include shown to be highly effective in
several situations: in an acute
 exacerbation of anemia, in the Nursing care focuses on
prevention of severe monitoring patients for signs and
complications from anesthesia symptoms of infection. Prescribed
and surgery in improving the antibiotics should be
response to infection, in the case administered as soon as possible.
of acute chest syndrome and If oral antibiotics are prescribed
multiple organ dysfunction at home, patients and caregivers
syndrome, and in thwarting the must understand the importance
cerebral edema from a stroke. of completing the entire course of
Hydration is critical during a antibiotics.
painful crisis. Oral hydration may Maximizing nutrition, hydration,
be sufficient if the patient is able adequate sleep, and tissue
to maintain adequate intake. IV perfusion can all help to minimize
hydration may be needed if the fatigue.
patient is unable to consume 2 to Patients with SCD benefit greatly
3 L of fluid during a crisis episode. from understanding the
Supplemental oxygen may also circumstances that may
be needed. precipitate a sickle cell crisis and
the steps they can take to
NURSING MANAGEMENT:
prevent or diminish the symptoms
Swollen joints should be they may experience during a
supported and elevated until crisis.
swelling subsides. Relaxation Nurses in outpatient facilities or
techniques, breathing exercises, home health nurses may need to
yoga, and self-hypnosis may be provide follow-up care for
helpful to some patients in coping patients with vascular access
with pain. devices.
Following acute pain episodes, THALASSEMIA
aggressive measures should be
taken to preserve joint function. - Are a group of hereditary
Physical therapy, whirlpool baths, anemias characterized by
and transcutaneous electrical hypochromia (an abnormal
nerve stimulation (TENS) are decrease in the hemoglobin
among modalities that may be content of erythrocytes), extreme
used. While heat packs may be microcytosis (smaller than normal
helpful, cold packs and ice size erythrocytes), hemolysis, and
should be avoided as cold may variable degrees of anemia.
precipitate sickling.
CAUSES:
It is caused by mutations in the
DNA of cells that make
hemoglobin.
ASSESSMENT/CLINICAL MANIFESTATIONS:
Severe anemia
Profound hemolysis
Ineffective erythropoiesis
Cognitive dysfunction
Peripheral neuropathy
Cerebrovascular disease
*Words that are typed in blue-
colored letters are complications of
the specific disease* Go on! :)
DIAGNOSTIC TESTS:
CBC Test (quantity and size of the
RBCs)
Reticulocyte count (a measure of
young red blood cells)
Hemoglobin electrophoresis is
used to diagnose beta
thalassemia.
Genetic testing
MEDICAL MANAGEMENT:
HSCT offers a chance of cure.
When this is not possible,
treatment consists of PRBC
transfusion and iron chelation
therapy, as needed.
NURSING MANAGEMENT:
Patient education for adolescents
and young adult should include
preconception counseling about
the risk of thalassemia major in
offspring.
GLUCOSE-6-PHOSPHATE
DEHYDROGENASE DEFICIENCY
(G6PD DEFICIENCY)
-it is the lack of an enzyme (glucose-
6-phosphate dehydrogenase) in the
bloodstream.
CAUSES:
The Glucose-6-Phosphate
Dehydrogenase (G-6-PD) gene is
responsible for the abnormality
seen in this disorder. The gene
produces an enzyme within the
erythrocyte that is necessary to
stabilize the cell membrane.
Defection of the specific gene.
ASSESSMENT/CLINICAL MANIFESTATIONS:
Asymptomatic and normal
hemoglobin levels and
reticulocyte counts increases,
and symptoms of hemolysis.
Pallor
Jaundice
Hemoglobinuria
DIAGNOSTIC TESTS:
Screening test for the deficiency
or by quantitative assay of G-6-
PD.
MEDICAL MANAGEMENT:
 Treatment requires CAUSES:
discontinuation of the offending
Malignant change in the genetic
agent. Transfusion is not usually
material (DNA) within a single cell
necessary unless severe hemolysis
of the bone marrow (clonal
is present, as may be seen in the
disorder).
Mediterranean variety of G-6-PD
deficiency. ASSESSMENT/CLINICAL MANIFESTATIONS:

NURSING MANAGEMENT: Neurologic symptoms such as

headache, dizziness, vision
Patients should be educated
changes, and transient ischemic
about the disease and provided
attacks (TIAs);
with a list of medications and
Abdominal symptoms such as
other substances to be avoided.
early satiety, abdominal
Patients with G-6-PD deficiency
discomfort/pain (that can also be
should always seek medical
associated with splenomegaly);
advice before taking any new
cardiovascular symptoms
medication or supplement.
including ruddy complexion,
Patients should be advised to
angina, claudication, dyspnea,
wear Medic-Alert bracelets that
hypertension, and
identify that they have G-6-PD
thrombophlebitis;
deficiency. Genetic counseling
Constitutional symptoms such as
may also be indicated.
fatigue and night sweats.
POLYCYTHEMIA VERA
DIAGNOSTIC TESTS:
- Refers to an increased volume of
Diagnosis is based upon the
RBCs. The term is used when the
evaluation of clinical symptoms
hematocrit is elevated (more
and laboratory findings as well as
than 55% in males and 50% in
the presence of a mutation of the
females).
JAK2 gene
- It is the most common of the
three Philadelphia chromosome- MEDICAL MANAGEMENT:
negative myeloproliferative
disorders. In polycythemia vera Phlebotomy is considered the
the bone marrow is hypercellular, mainstay of therapy and is used
and the erythrocyte, leukocyte, to maintain the hematocrit level
and platelet counts in the at less than 45%
peripheral blood are often Low-dose aspirin prevents
elevated. vascular thrombosis without
 increasing the risk of bleeding The patient needs to be
and is recommended for all instructed to avoid iron
patients with polycythemia vera supplements, including those in
Cytoreductive therapy over-the-counter multivitamin
Interferon-alfa is another first-line supplements, because the iron
cytoreductive agent that can be can further stimulate RBC
selected; it is indicated in patients production.
younger than 60 years of age, or
in patients who are pregnant or HEMOPHILIA
intolerant of hydroxyurea There are two forms of hemophilia:
Ruxolitinib is a JAK2 inhibitor; it is hemophilia A and hemophilia B. Both
used in patients who are resistant are clinically similar but are
or unable to tolerate hydroxyurea distinguishable by laboratory tests.
and for whom interferon-alfa is
not indicated Hemophilia A is caused by a genetic
defect that results in deficient or
NURSING MANAGEMENT: defective factor VIII.

Management of fatigue can Hemophilia B, also known as

include pharmacologic agents Christmas disease, is due to a
(e.g., erythropoiesis-stimulating genetic defect that causes a
agents, antidepressant drugs, deficiency or defect in factor IX.
stimulants such as caffeine or
amphetamines) and CAUSES:
nonpharmacologic treatments
Lacking of blood clotting factors
(e.g., exercise, yoga, and
(Factor VIII and IX)
optimizing sleep).
Gene mutation
The nurse may recommend
bathing in tepid water, avoiding ASSESSMENT/CLINICAL MANIFESTATIONS:
vigorous toweling off after
Hemorrhages
bathing, and using cocoa butter
Spontaneous bleeding
or oatmeal-based lotions.
Trauma
Adopting or maintaining a
Hemarthroses
healthy lifestyle should be
Hematomas
encouraged.
Pain
Patients should be educated
Swelling and limitation of
about the signs and symptoms of
movement
thrombosis.
Recurrent joint hemorrhages
 Joint arthropathy risk for hemorrhage and
Spontaneous hematuria complications associated with
GI bleeding bleeding.
Clot formation and wound Safety at home and at work
healing are often poor should be emphasized.
Nurses can help patients and
MEDICAL MANAGEMENT:
families understand the
Concentrates are used when potential benefits of prophylactic
patients are actively bleeding; it is therapy while helping them to
important that treatment is minimize the disadvantages.
initiated as soon as possible to Patients with hemophilia are also
reduce risk for bleeding instructed to avoid agents that
complications. can interfere with platelet
Immunosuppressive therapy in the aggregation that can add
form of corticosteroids, IVIG or additional risk for bleeding.
cyclophosphamide may be used Additionally, patients and families
to remove inhibitors. should have a written emergency
Emicizumab is a new bispecific plan that includes measures to be
humanized monoclonal antibody taken in specific situations along
that is effective in preventing with names and telephone
bleeding in patients with numbers for emergency contacts.
hemophilia A.
DISSEMINATED INTRAVASCULAR
Aminocaproic acid inhibits
COAGULATION (DIC)
fibrinolysis and subsequently
stabilizes blood clots.
Disseminated intravascular
NURSING MANAGEMENT: coagulation (DIC) is a systemic
syndrome that is characterized by
Helping patients cope with their
microthromboses and bleeding.
condition, assisting them to
identify positive aspects of their CAUSES:
lives, and encouraging
Sepsis
independence and self-
Trauma
sufficiency are important nursing
Cancer
activities.
Shock
The nurse must provide these
Abruption placentae
patients with extensive education
Allergic reactions
to understand activity restrictions
Infection or malignancy
and self-care strategies to reduce
ASSESSMENT/CLINICAL MANIFESTATIONS: Laboratory values must be
monitored frequently to assess for
Progressive decrease in the
trends over time as well as for
platelet count
changes in values.
Thrombosis
Suctioning should be performed
Bleeding in GI and urinary tracts
as gently as possible to diminish
DIAGNOSTIC TESTS: the risk of additional bleeding.
CNS involvement can be
thromboelastography manifested as headache, visual
platelet count changes, and alteration in level
fibrin degradation products of consciousness.
PT and fibrinogen level
THROMBOCYTOPENIA
MEDICAL MANAGEMENT:
Thrombocytopenia (low platelet
increasing tissue oxygenation level) can result from a variety of
replacing fluids factors, including reduced
correcting electrolyte production of platelets in the bone
abnormalities, marrow, increase destruction of
administering vasopressor platelets, or increased consumption
medications of platelets.
heparin infusion
Recombinant forms of CAUSES:
thrombomodulin were believed
reduced production of platelets
to inactivate thrombin, the main
in the bone marrow,
culprit in inciting the
increased destruction of platelets,
coagulopathy that undergirds
increased consumption of
DIC.
platelets
NURSING MANAGEMENT:
ASSESSMENT/CLINICAL MANIFESTATIONS:
Nurses need to identify patients at
Bleeding
risk for DIC (see previous
Petechiae
discussion on precipitating
Nasal and gingival bleeding
factors). It is important to assess
Excessive menstrual bleeding
patients frequently and
Excessive bleeding from surgery
thoroughly for signs and
Excessive bleeding in dental
symptoms of thrombi and
extractions
bleeding and monitor for
progression of these signs.
 Spontaneous and fatal bleeding purpura, and immune
in the CNS and GI tract thrombocytopenia.

DIAGNOSTIC TESTS: CAUSES:

Bone marrow aspiration H.pylori

Bone marrow biopsy HIV
ethylenediaminetetraacetic acid Hepatitis
for peripheral smear Leukemia
Sepsis
MEDICAL MANAGEMENT:
Trauma
Splenectomy drugs (e.g., cephalosporins,
Platelet transfusion sulfonamides, furosemide)
Bone marrow transplant autoimmune disorders (e.g.,
antiphospholipid antibody
NURSING MANAGEMENT: syndrome)
The nurse considers the cause of ASSESSMENT/CLINICAL MANIFESTATIONS:
the thrombocytopenia, the likely
duration, and overall condition of Low platelet count
the patient. Easy bruising
Education is an important Heavy menses
intervention to promote safety Petechiae
and should include fall Wet purpura
prevention, particularly for older Spontaneous bleeding
adults and those who are frail. DIAGNOSTIC TESTS:
Interventions for patients with
secondary thrombocytopenia are Careful history and physical
the same as those for a patient examination
with cancer who is at risk for Bone marrow aspiration
bleeding. Blood smears

MEDICAL MANAGEMENT:
IMMUNE THROMBOCYTOPENIC
PURPURA Quinine, sulfa-containing drugs
The mainstay of short-term
ITP is a condition that affects people therapy is the use of
of all ages but is most common in immunosuppressive agents. These
children and young women. This agents block the binding
disorder is also referred to as
idiopathic thrombocytopenic
 receptors on macrophages to Patient and family education
reduce platelet destruction. should address signs of
IVIG is commonly used to treat exacerbation (e.g., petechiae
ITP. It renders its effect by binding and ecchymoses), how to
to the receptors on macrophages contact appropriate health care
Aminocaproic acid, a fibrinolytic personnel, the name and type of
enzyme inhibitor that slows the medications inducing ITP (if
dissolution of blood clots, may be appropriate) current medical
useful for patients with significant treatment (name of medications,
mucosal bleeding that is resistant side effects, tapering schedule, if
to other treatments. indicated), frequency of
Potential treatment side effects, monitoring for the platelet count,
the patient’s lifestyle, activity and follow-up appointments.
level, concurrent use of The patient should be instructed
medications, and treatment to avoid all agents that interfere
preferences are also considered. with platelet function, including
herbal therapies and OTC
NURSING MANAGEMENT:
medications.
Nursing care includes a thorough Patients who are receiving long-
assessment of the patient’s term corticosteroids should
lifestyle to determine risks for understand that they are at
bleeding associated with increased risk for complications
activities. including osteoporosis, proximal
Careful medication history should muscle wasting, cataract
also be obtained, including use of formation, and dental caries.
over-the-counter (OTC)
medications, herbs, and
nutritional supplements.
The nurse must be alert to sulfa-
containing medications and
others that may interfere with
platelet function (e.g., aspirin,
NSAIDs).
The nurse must assess for a history
of recent viral illness and reports
of headache, visual disturbances,
and other symptoms that may
indicate intracranial bleeding.
GLOSSARY FOR CHAPTER 29 hemolysis: destruction of RBCs with
release of cellular components into
absolute neutrophil count (ANC): a
the circulation; may occur within or
calculation of the number of
outside the vasculature
circulating neutrophils, derived from
the total number of white blood cells hemosiderin: iron-containing
(WBCs) and the percentage of pigment derived from the
neutrophils counted in a microscope breakdown of hemoglobin
’s visual field
hypochromia: pallor within the RBCs
anemia: decreased red blood cell caused by decreased hemoglobin
(RBC) count content

aplasia: lack of cellular leukemia: uncontrolled proliferation

development (e.g., of cells within the of WBCs
bone marrow)
lymphopenia: a lymphocyte count
cytokines: proteins produced by less than 1500/mm3
leukocytes that are critical for
megaloblastic anemia: a type of
regulation of hematopoiesis,
anemia characterized by abnormalY
apoptosis, and immune responses
large, nucleated RBCs
erythrocyte: a cellular component of
microcytosis: smaller-than normal
blood essential to the transport of
RBCs
oxygen and carbon dioxide
(synonym: RBC) neutropenia: lower-than-normal
number of neutrophils
erythroid cells: any cell that is or will
become a mature RBC normochromic: normal RBC color,
indicating normal amount of
erythropoietin: hormone produced
hemoglobin
primarily by the kidneys in response
to cellular hypoxia that is necessary normocytic: normal size of RBC
for erythropoiesis
pancytopenia: abnormal decrease
haptoglobin: blood protein in WBCs, RBCs, and platelets
synthesized by the liver; binds free
hemoglobin released from petechiae: tiny capillary
erythrocytes which is then removed hemorrhages
by the reticuloendothelial system poikilocytosis: variation in shape of
RBCs
polycythemia: excess RBCs

reticulocytes: slightly immature RBCs,

usually 1% of total number of
circulating RBCs

spherocytes: small, spherically

shaped RBCs

thrombocytopenia: lower-than-
normal platelet count

thrombocytosis: higher-than-normal
platelet count
 Management of Patients with
Hematologic Neoplasms
LEUKEMIA
The term leukocytosis refers to an
increase of leukocytes (WBCs) in the
circulation. Typically, only one
specific cell type is increased.
Because the proportions of several
types of leukocytes (e.g., eosinophils,
basophils, monocytes) are small, an
increase in other types can be great
enough to elevate the total
leukocyte count, particularly the
neutrophils or lymphocytes.
ACUTE MYELOID LEUKEMIA
Acute myeloid leukemia (AML)
originates due to a series of genetic
mutation in the myeloid HSC leading
to clonal development of abnormal
blast cells.
AML is the most common form of
leukemia, as well as most commo
cause of death from all leukemias.
AML can affect any age group.
However, the incidence of this
disease increases with age, with the
median age at time of diagnosis
being about 68 years.
CAUSES:
The exact cause of AML is unclear,
but there are several known risk
factors. In addition to increasing
age, males have a higher incidence
than females.
Other risks include having been
exposed to chemicals such as
benzene or pesticides or exposed to
ionizing radiation; and a history of
prior treatment with
chemotherapeutic drugs, such as
alkylating agents or topoisomerase
inhibitors, tobacco smoking, other
blood disorders (e.g.,
myeloproliferative diseases), and
several genetic disorders (e.g., Down
syndrome, Trisomy 8, or Fanconi
anemia)
ASSESSMENT/CLINICAL MANIFESTATIONS:
pallor,
fatigue,
weakness,
dyspnea on exertion, and
dizziness
ecchymoses (bruises),
petechiae (pinpoint red or purple
hemorrhagic spots on the skin),
epistaxis (nosebleeds), and
gingival bleeding
Lymphadenopathy (enlargement
of lymph nodes) or;
Splenomegaly (enlargement of
the spleen) is rare.
Fevers may occur and are not
always due to infection.
DIAGNOSTIC TESTS:
 CBC Test (commonly shows a
decrease in both erythrocytes
and thrombocytes)
AML can be further classified into
seven different subgroups, based
on cytogenetics, histology, and
morphology of the blasts, as well
as the presence of genetic
mutations.
MEDICAL MANAGEMENT:
Chemotherapy: induction and
consolidation
Induction therapy: doses of
cytarabine and either
daunorubicin, idarubicin, or
mitoxantrone; etoposide
Hematopoietic stem cell
transplant
Allogeneic stem cell transplant
Supportive care
Hydroxyurea or hypomethylating
agents such as azacitidine may
be used briefly to control the
increase of blast cells
NURSING MANAGEMENT:
The disease process can increase
the patient’s metabolic rate and
nutritional requirements.
Nutritional intake is often reduced
because of pain and discomfort
associated with stomatitis.
Encouraging or providing mouth
care before and after meals and
administering analgesic agents
before eating can help increase
intake.
Patients with acute leukemia
need to maintain some physical
activity and exercise to prevent
the deconditioning that results
from inactivity. The use of a high-
efficiency particulate air (HEPA)
filter mask can permit the patient
to ambulate outside the room
despite severe neutropenia.
Physical therapy can also be
beneficial.
Patients with acute leukemia may
require hospitalization for
extensive nursing care (either
during induction or consolidation
therapy or during resultant
complications); sleep deprivation
frequently results.
Nurses need to implement
creative strategies that permit
uninterrupted sleep for at least a
few hours while still administering
necessary medications on
schedule.
Intake and output need to be
measured accurately, and daily
weights should also be monitored.
The patient should be assessed
for signs of dehydration as well as
fluid overload, with particular
attention to pulmonary status and
the development of dependent
edema.
CHRONIC MYELOID LEUKEMIA
Chronic myeloid leukemia (CML)
arises from a mutation in the myeloid
stem cell. Normal myeloid cells
continue to be produced, but there
is a pathologic increase in the
production of forms of blast cells.
CAUSES:
CML results from a chromosomal
translocation, where a section of
deoxyribonucleic acid (DNA) is
shifted from chromosome 22 to
chromosome 9, forming what is
known as a “fusion gene” that is
abnormal. The specific fused
gene found in all patients with
CML is the BCR-ABL gene, which
occurs when the BCR gene from
chromosome 22 switches places
with the ABL gene from
chromosome 9.
ASSESSMENT/CLINICAL MANIFESTATIONS:
Fatigue
Anemia
Splenomegaly
Dyspnea
Decreased perfusion to the lungs
and brain from leukostasis
Enlarged and tender liver
Lymphadenopathy
MEDICAL MANAGEMENT:
TKIs work by blocking the signals
within the leukemic cells that
express the BCR-ABL protein. This
inhibition prevents a series of
chemical reaction that cause the
cells to grow and divide, thus
inducing complete remission at
the cellular level.
TKI imatinib mesylate is
considered to be standard of
care for patients with CML.
Allogeneic HSCT
Induction therapy
NURSING MANAGEMENT:
It is extremely important for the
nurse to educate the patient
about the medication regimen,
how to manage side effects, drug
interactions, and safe handling.
The nurse should also monitor the
patient for adverse signs and
symptoms of therapy, such as
decreased urinary output,
changes in the
electrocardiogram (ECG; TKIs can
cause arrhythmias and prolonged
QT intervals), and
myelosuppression (e.g., fevers,
chills, changes in the CBC)
ACUTE LYMPHOCYTIC LEUKEMIA
ALL results from an uncontrolled
proliferation of immature cells
(lymphoblasts) derived from the
lymphoid stem cell.
CAUSES:
Older age (especially over 70)
Prior exposure to chemotherapy
or radiation therapy
Genetic conditions (e.g.,
especially Down syndrome; also
 neurofibromatosis, Klinefelter before eating can help increase
syndrome, and Fanconi anemia) intake.
Patients with acute leukemia
ASSESSMENT/CLINICAL MANIFESTATIONS:
need to maintain some physical
Nonspecific or no symptoms activity and exercise to prevent
initially. the deconditioning that results
The CNS is frequently a site for from inactivity. The use of a high-
leukemic cells; thus, patients may efficiency particulate air (HEPA)
exhibit cranial nerve palsies or filter mask can permit the patient
headache, vomiting because of to ambulate outside the room
meningeal involvement. despite severe neutropenia.
Manifestations of leukemic cell Physical therapy can also be
infiltration into other organs are beneficial.
more common with ALL than with Patients with acute leukemia may
other forms of leukemia and require hospitalization for
include pain from an enlarged extensive nursing care (either
liver or spleen as well as bone during induction or consolidation
pain. therapy or during resultant
complications); sleep deprivation
MEDICAL MANAGEMENT: frequently results.
Intrathecal chemotherapy Nurses need to implement
TKIs (imatinib) creative strategies that permit
Conventional chemotherapy uninterrupted sleep for at least a
Corticosteroids (corticosteroid few hours while still administering
dexamethasone) necessary medications on
Allogeneic HSCT schedule.
Nursing interventions should focus
NURSING MANAGEMENT: on assisting the patient to
establish a balance between
The disease process can increase
activity and rest. Patients with
the patient’s metabolic rate and
acute leukemia need to maintain
nutritional requirements.
some physical activity and
Nutritional intake is often reduced
exercise to prevent the
because of pain and discomfort
deconditioning that results from
associated with stomatitis.
inactivity.
Encouraging or providing mouth
Nutritional supplements are
care before and after meals and
frequently used. Daily body
administering analgesic agents
weight (as well as intake and
 output measurements) is useful in organisms (e.g., Haemophilus
monitoring fluid status. Both influenzae)
calorie counts and more formal
MEDICAL MANAGEMENT:
nutritional assessments are often
useful. Parenteral nutrition may be Targeted therapy
required to maintain adequate Immunotherapy
nutrition. Single immunotherapy agent
administered in combination with
CHRONIC LYMPHOCYTIC LEUKEMIA
chemotherapeutic agents, such
Chronic lymphocytic leukemia (CLL) as an immunotherapeutic
is a common malignancy of older antibody against the B-
adults, and the most prevalent type lymphocyte antigen CD20 (e.g.,
of adult leukemia in the Western rituximab, ofatumumab,
world. obinutuzumab) with
chemotherapeutic agents (e.g.,
CAUSES:
fludarabine, cyclophosphamide,
The exact cause of chronic bendamustine, chlorambucil) as
lymphocytic leukemia is not initial therapy.
known. TKIs such as ibrutinib or idelalisib
The disease can occur in 10% of may be used as either
those with a first- or second- monotherapy or in combination
degree relative with the same with other agents.
diagnosis. Veterans of the
NURSING MANAGEMENT:
Vietnam War who were exposed
to Agent Orange (herbicide) may IV treatment with immunoglobulin
be at risk for developing this (IVIG) may be given to select
disease, but there is no definitive patients with recurrent infection.
link to other pesticides or Patients with CLL should receive
exposure to chemicals. both pneumonia and flu
vaccinations as indicated.
ASSESSMENT/CLINICAL MANIFESTATIONS:
Live vaccines should be avoided.
Splenomegaly
LYMPHOMA
Lymphadenopathy
Viral infections such as herpes The lymphomas are neoplasms of
zoster cells of lymphoid origin. These tumors
increased risk of developing usually start in lymph nodes but can
infection with encapsulated involve lymphoid tissue in the spleen,
GI tract (e.g., the wall of the Lymphadenopathy on the
stomach), liver, or bone marrow. cervical nodes
Mediastinal mass
HODGKIN LYMPHOMA However, other nodes that can
Hodgkin lymphoma is a relatively be affected include the
rare malignancy that has a high cure supraclavicular and mediastinal
rate. It is somewhat more common in nodes; involvement of the iliac or
males than in females and has two inguinal nodes or spleen is much
peaks of incidence: one from ages less common.
15 to 34 and the other after 60 years Pruritus
of age. Extreme distress
Fatigue
CAUSES: Decreased appetite
Abdominal pain
The cause of Hodgkin lymphoma
Splenomegaly
is unknown.
Occasional pain in affected
However, several risk factors have
lymph node
been identified, which include
Impaired cellular immunity
age, a history of viral infections
All organs are vulnerable to
(particularly the Epstein–Barr virus,
invasion by tumor cells. Clinical
human immune deficiency virus
manifestations result from
[HIV], or human herpesvirus 8
compression of organs by the
[HHV8]), having a family history,
tumor, such as:
and being exposed to cytotoxic
 Cough
agents.
 Pulmonary effusion
Additionally, Hodgkin lymphoma
 Jaundice
is seen more commonly in
 Abdominal pain
patients receiving long-term
 Mild anemia
immunosuppressive therapy (e.g.,
organ transplant recipients) and DIAGNOSTIC TESTS:
in veterans who were exposed to
the herbicide Agent Orange. Excisional lymph node biopsy and
the presence of Reed-Sternberg
ASSESSMENT/CLINICAL MANIFESTATIONS: cells.
Enlargement of one or more A chest x-ray and a computed
lymph nodes on one side of the tomography (CT) scan of the
neck. chest, abdomen, and pelvis are
crucial to identify the extent of
 lymphadenopathy within these increase the risk of developing
regions. second cancers, such as use of
A positron emission tomography tobacco and alcohol and
(PET) scan is the most sensitive exposure to environmental
imaging test and is carcinogens and excessive
recommended for initial staging sunlight.
to help determine the extent of Screening for late effects of
disease as well as later for treatment, such as
evaluation of response to chemotherapy is necessary.
treatment. In addition, the nurse should
Laboratory tests include CBC with provide education about
differential; serum electrolytes, relevant self-care strategies and
blood urea nitrogen (BUN) and disease management.
creatinine; ESR; liver and renal
function studies; NON-HODGKIN LYMPHOMA
immunohistochemistry and The NHLs are a heterogeneous group
cytogenetic evaluation; HIV of cancers that originate from the
testing; and hepatitis B and C neoplastic growth of lymphoid tissue.
testing. Similar to CLL, the neoplastic cells
are thought to arise from a single
MEDICAL MANAGEMENT:
clone of lymphocytes; however, in
Patients with early disease (stage NHL, the cells may vary
I-II) may receive one of the morphologically.
following combination
CAUSES:
chemotherapy regimens: ABVD
(doxorubicin [trade name Although no common etiologic
Adriamycin], bleomycin, factor has been identified, the
vinblastine, and dacarbazine) or incidence of NHL is increased in
Stanford V (doxorubicin, patients who have immune
vinblastine, mechlorethamine, deficiencies or autoimmune
etoposide, vincristine, bleomycin, disorders; had prior treatment for
and prednisone) cancer; been an organ
Chemotherapy transplant recipient; had a history
Radiation Therapy of viral infections (e.g., Epstein–
Barr virus, HIV, HHV8); and been
NURSING MANAGEMENT:
exposed to herbicides, pesticides,
The nurse should encourage solvents, dyes, and defoliating
patients to reduce factors that agents, such as Agent Orange.
ASSESSMENT/CLINICAL MANIFESTATIONS: chain reaction (PCR); CT scans of
the chest, abdomen, and pelvis;
Painless swelling in one or more
PET scan; MUGA or ECG (if
lymph nodes in the neck, axillary
patient is to receive
region, or groin.
anthracycline-based regimen);
An abdominal mass may
and bone marrow biopsy and
compromise the bowel or ureters,
aspirate (if marrow involvement is
leading to acute kidney injury or
suspected).
bowel obstruction.
Splenomegaly can cause MEDICAL MANAGEMENT:
abdominal pain, nausea, early
satiety, and weight loss. If the disease is indolent and
A mass in the mediastinum can localized, the treatment of
cause: choice may be radiation therapy
 Cough alone.
 Dyspnea For aggressive subtypes of NHL,
 Chest pain that may lead combination chemotherapy is
to cardiovascular or typically indicated. One of the
respiratory distress most common combinations is
CHOP. A MoAb (e.g., rituximab,
DIAGNOSTIC TESTS: obinutuzumab) may be given
along with the chemotherapy.
incisional or excisional lymph
When NHL has relapsed or is
node biopsy is required for
refractory to standard treatments,
immunophenotyping and
other single agent or combination
cytogenetic analysis testing.
chemotherapy regimens may be
Flow cytometry is commonly
used. For instance, the ICE
performed to determine the
regimen (i.e., ifosfamide,
specific antigen on the malignant
carboplatin, and etoposide) may
cell.
be implemented; or agents such
Another test that may be
as bendamustine, brentuximab
performed is fluorescence in situ
vedotin, romidepsin, or
hybridization (FISH), which
axicabtagene may be tried.
analyzes the DNA and RNA of the
Autologous HSCT (AuHSCT) is
biopsy or blood sample for
another treatment option for
chromosomal abnormalities.
relapsed or refractory NHL,
In addition, there may be testing
particularly in patients younger
for viruses (e.g., Epstein–Barr,
than 60 years.
HHV8, hepatitis B); polymerase
NURSING MANAGEMENT: The etiology of multiple myeloma
is not known, but risk factors are
Patients need to be educated to
identified:
minimize the risks of infection, to
 Age: rarely occurs in those
recognize signs of possible
less than 35 years of age;
infection, and to contact their
risks increase with
primary provider if such signs
increasing age
develop.
 African Americans have
Survivors should be encouraged
twice the risk of Whites
to have regular follow-up
 Exposure to radiation,
appointments and be screened
petroleum products,
for the signs and symptoms of
benzenes, and Agent
possible secondary malignancies.
Orange
Additionally, patients should be
 Family history, particularly
evaluated for cardiovascular and
among first-degree
fertility concerns with each
relatives (e.g., siblings,
patient visit.
parents)
The ACS (2019b) developed
 Men have slightly higher
health behavior
risks than women
recommendations for cancer
 Overweight or obesity
survivors, which include avoiding
 Plasma cell disease history:
or stopping smoking, maintaining
o Monoclonal
a normal body weight, practicing
gammopathy of
good nutrition habits (i.e.,
undetermined
consuming fruits and vegetables),
significance (MGUS)
and engaging in a minimum of
o Plasmacytoma
150 minutes of exercise per week.
ASSESSMENT/CLINICAL MANIFESTATIONS:
MULTIPLE MYELOMA
Hypercalcemia
Multiple myeloma is a malignant Renal dysfunction
disease of the most mature form of B Anemia
lymphocyte—the plasma cell. Bone destruction
Plasma cells secrete Bone lesions
immunoglobulins, which are proteins Bone pain
necessary for antibody production to
fight infection. DIAGNOSTIC TESTS:

CAUSES: CBC with differential, BUN, serum

creatinine, creatinine clearance,
 serum electrolytes (especially lenalidomide, pomalidomide, or
calcium and albumin), LDH, and thalidomide) and the
beta-2 microglobulin analyzed. corticosteroid dexamethasone.
Serum protein electrophoresis or Lenalidomide is recommended as
free light chain assay should be maintenance therapy for patients
performed to detect the following an AuHSCT and after
presence of M protein. the initial 8 to 12 cycles of primary
Additionally, cytogenetic studies therapy for patients who have
are performed to see if any of not received an HSCT.
several chromosomal Bisphosphonates have been
abnormalities typically found in shown to strengthen bone by
patients with multiple myeloma diminishing survival of osteoclasts,
are present. thus controlling bone pain and
Radiographic evaluation (CT potentially preventing bone
scan, MRI, and PET scan) should fractures.
be performed to determine the
NURSING MANAGEMENT:
presence of lytic bone lesions.
Bone marrow aspiration and Nursing care should focus on
biopsy are conducted to assessing for signs and symptoms
evaluate bone marrow plasma of hypercalcemia.
cell abnormalities. Patient education should include
methods to prevent and minimize
MEDICAL MANAGEMENT:
the risk of infection, reportable
There is no cure for multiple signs and symptoms, medication
myeloma; the aims of treatment side effects, and pain
are to reduce symptoms and to management.
prolong disease progression. Another key nursing responsibility
Patients who present with is to assess for and provide
symptomatic disease are emotional/psychological support.
evaluated for eligibility for an Educating patients about
autologous HSCT (AuHSCT), effective coping skills to aid in
based on age, presence of dealing with multiple myeloma
comorbidities, and risk and its treatment is a key
stratification. intervention.
Proteasome inhibitor–based
bortezomib regimen, which
commonly includes an
immunomodulatory drug (e.g.,
absolute neutrophil count (ANC): a
calculation of the number of
circulating neutrophils, derived from
the total white blood cells (WBCs)
and the percentage of neutrophils
counted in a microscope’s visual
field
angiogenesis: formation of new
blood vessels
apoptosis: programmed cell death
blast cells: immature leukocytes
clone: proliferation from same cell of
origin so that descendent cells are
identical to the cell of origin
cytokines: proteins produced by
leukocytes that are vital to
regulation of hematopoiesis,
apoptosis, and immune responses;
also called biochemical or
inflammatory mediators
erythrocyte sedimentation rate (ESR):
laboratory test that measures the
rate of settling of red blood cells
(RBCs); elevation is indicative of
inflammation; also called the sed
rate
erythromelalgia: a burning, painful
sensation and erythema in the
fingers or toes
hematopoiesis: complex process of
the formation and maturation of
blood cells
indolent: when in reference to a
neoplasm refers to a slow-growing
cancer that often remains localized
or causes few symptoms
leukemia: uncontrolled proliferation
of WBCs, often immature
lymphadenopathy: enlargement of
a lymph node or lymph nodes
lymphoid: pertaining to lymphocytes
myeloid: pertaining to nonlymphoid
blood cells that differentiate into
RBCs, platelets, macrophages, mast
cells, and various WBCs
neutropenia: lower-than-normal
number of neutrophils
pancytopenia: abnormal decrease
in WBCs, RBCs, and platelets
petechiae: tiny capillary
hemorrhages
phagocytosis: process of cellular
ingestion and digestion of foreign
bodies
reticulocytes: slightly immature RBCs,
usually only 1% of total circulating
RBCs
splenomegaly: enlargement of the
spleen
stem cell: primitive cell, capable of
self-replication and differentiation
into myeloid or lymphoid stem cell
thrombocythemia: higher-than-
normal platelet count that occurs
without a known cause

thrombocytopenia: lower-than-
normal platelet count

thrombocytosis: higher-than-normal
platelet count that results because
of a disease or disorder
 Allergen specific immunoglobulin
Management of Patients with E antibody test
Upper Respiratory Tract Disorders Allergy tests may be performed to
identify possible allergens.

RHINITIS

DEFINITION: Rhinitis is a group of NURSING INTERVENTION:

disorders characterized by
avoid or reduce exposure to
inflammation and irritation of the
allergens and irritants, such as
mucous membranes of the nose.
dusts, molds, animals, fumes,
CAUSE: odors, powders, sprays, and
tobacco smoke
changes in temperature or
The nurse instructs the patient
humidity
about the importance of
odors
controlling the environment at
infection
home and at work
age
infectious rhinitis, the nurse
systemic disease
reviews hand hygiene technique
use of over-the-counter (OTC)
with the patient as a measure to
and prescribed nasal
prevent transmission of organisms.
decongestants
Saline nasal sprays or aerosols
and the presence of a foreign
may be helpful in soothing
body.
mucous membranes, softening
The most common cause of non-
crusted secretions, and removing
allergic rhinitis is the common
irritants
cold
MEDICAL INTERVENTION:
ASSESSMENT:
Viral rhinitis, medications may be
rhinorrhea (excessive nasal
prescribed to relieve the
drainage, runny nose)
symptoms.
nasal congestion
In allergic rhinitis, allergy tests may
nasal discharge (purulent with
be performed to identify possible
bacterial rhinitis)
allergens.
sneezing
Depending on the severity of the
pruritus of the nose, roof of the
allergy, desensitizing
mouth, throat, eyes, and ears.
immunizations and
DIAGNOSTIC TEST: corticosteroids may be required
If symptoms suggest a bacterial
Percutaneous skin test
infection, an antimicrobial agent
is used
 Patients with nasal septal tearing watery eyes,
deformities or nasal polyps may “scratchy” or sore throat,
be referred to an ear, nose, and general malaise,
throat specialist. chills,
and often headache and muscle
aches.
Viral Rhinitis (Common Cold) In some people, the virus
exacerbates herpes simplex,
DEFINITION:
commonly called a cold sore
Viral rhinitis is the most frequent viral
NURSING INTERVENTION:
infection in the general population.
The term common cold often is used Implementation of appropriate
when referring to a URI that is self- hand hygiene measures
limited and caused by a virus. The nurse educates the patient
about how to break the chain of
CAUSE:
infection with appropriate hand
Rhinoviruses (early fall and spring). hygiene
Other viruses tend to cause winter The nurse instructs the patient
colds. about methods to treat symptoms
Colds are caused by as many as of the common cold and
200 different viruses (coronavirus, provides both verbal and written
adenovirus, respiratory syncytial information to assist in the
virus, influenza virus, and prevention and management of
parainfluenza virus.) URIs.
MEDICAL INTERVENTION:
adequate fluid intake,
DIAGNOSTIC TEST:
rest,
Percutaneous skin test prevention of chilling,
Allergen specific immunoglobulin and the use of expectorants as
E antibody test needed.
Allergy tests may be performed to Warm salt-water gargles soothe
identify possible allergens. the sore throat,
nonsteroidal antiinflammatory
drugs (NSAIDs), such as aspirin or
ASSESSMENT:
ibuprofen, relieve aches and
low-grade fever, pains.
nasal congestion, Antihistamines are used to relieve
rhinorrhea and nasal discharge, sneezing, rhinorrhea, and nasal
halitosis, congestion.
sneezing,
 Petroleum jelly can soothe cloudy or colored nasal
irritated, chapped, and raw skin discharge congestion, blockage,
around the nares or stuffiness as well as a localized
or diffuse headache.

high fever (i.e., 39°C [102°F] or

Acute Rhinosinusitis
higher).
DEFINITION: NURSING INTERVENTION:

Acute rhinosinusitis is classified as The nurse instructs the patient

acute bacterial rhinosinusitis about symptoms of complications
(ABRS) or acute viral rhinosinusitis that require immediate follow-up.
(AVRS). The nurse instructs the patient
Recurrent acute rhinosinusitis is about methods to promote
characterized by four or more drainage of the sinuses,
acute episodes of ABRS per year The patient is advised to avoid
and is discussed with chronic swimming, diving, and air travel
rhinosinusitis (CRS). Patients using tobacco are
instructed to immediately stop
CAUSE:
smoking or using any form of
abnormal structures of the nose, tobacco
enlarged adenoids, The nurse also educates the
diving and swimming, patient about the side effects of
tooth infection, prescribed and OTC nasal sprays
trauma to the nose, and about rebound congestion
tumors, (rhinitis medicamentosa).
and the pressure of foreign
objects.
MEDICAL INTERVENTION:
DIAGNOSTIC TEST:
Antibiotics should be given as
CT SCANS complication or soon as the diagnosis of ABRS is
alternative diagnosis is suspected established. Amoxicillin–
clavulanic acid (Augmentin) is
ASSESSMENT:
the antibiotic of choice.
ABRS: purulent nasal drainage Treatment of AVRS typically
(anterior, posterior, or both) involves nasal saline lavage and
accompanied by nasal 1567 decongestants
obstruction or a combination of Treatment of AVRS typically
facial pain-pressure-fullness involves nasal saline lavage and
pressure, decongestants
or a sense of fullness
Chronic Rhinosinusitis and Recurrent The patient is instructed to blow
Acute Rhinosinusitis the nose gently and to use tissue
to remove the nasal drainage.
DEFINITION: Elevating the head of the bed
It is diagnosed when the patient has promote drainage of the sinuses
Patients are cautioned to avoid
experienced 12 weeks or longer of
caffeine and alcohol, which can
two or more of the following
cause dehydration.
symptoms: mucopurulent drainage,
nasal obstruction, facial pain–
pressure–fullness, or hyposmia MEDICAL INTERVENTION:
(decreased sense of smell).
Prescribed antibiotics may
include amoxicillin-clavulanic
acid, erythromycin–sulfisoxazole
CAUSE: (Eryzole), second- or third-
generation cephalosporins such
Mechanical obstruction in the ostia
as cefuroxime or cefixime, or
of the frontal, maxillary, and anterior
newer fluoroquinolones such as
ethmoid sinuses (known collectively
moxifloxacin
as the ostiomeatal complex) is the
usual cause of CRS and recurrent
acute rhinosinusitis Pharyngitis
Acute Pharyngitis
DIAGNOSTIC TEST:
DEFINITION:
x-ray,
Acute pharyngitis is a sudden painful
sinoscopy,
inflammation of the pharynx, the
ultrasound, CT scanning,
back portion of the throat that
MRI
includes the posterior third of the
nasal endoscopy allows for
tongue, soft palate, and tonsils. It is
visualization of the posterior nasal
commonly referred to as a sore
cavity, nasopharynx, and sinus
throat.
drainage
ASSESSMENT:
CAUSE:
nasal stuffiness,
nasal discharge, Viral infection
facial pain.
Responsible viruses
Vision loss,
include the adenovirus, influenza
headache, virus, Epstein–Barr virus, and
awakening in the morning herpes
Fatigue simplex virus.
nasal congestion
DIAGNOSTIC TEST:
NURSING INTERVENTION:
 Rapid antigen detection testing common in adults who work in dusty
(RADT) surroundings, use their voice to
excess, suffer from chronic cough, or
ASSESSMENT: habitually use alcohol and tobacco
fiery-red *Hypertrophic
pharyngeal membrane and
tonsils, lymphoid follicles that are *Atrophic
swollen and flecked with white-
purple exudate, enlarged and *Chronic granular
tender cervical lymph nodes, and CAUSE:
no cough.
Fever (higher than 38.3°C [101°F]), Inadequate dental hygiene
malaise, and Irritants and pollutants
sore throat also may be present. Overuse of voice
NURSING INTERVENTION: DIAGNOSTIC TEST:
nurse instructs the patient to stay Physical examination
in bed during the febrile stage of RADT
illness and to rest frequently once
up and about. ASSESSMENT:
examine the skin once or twice Hoarseness
daily for possible rash, a tired voice
warm saline gargles or throat swollen glands in the neck
irrigations are used difficulty swallowing
the nurse instructs the patient
about preventive measures NURSING INTERVENTION:

MEDICAL INTERVENTION: The nurse recommends

avoidance of alcohol, tobacco,
Viral pharyngitis is treated with secondhand smoke
supportive measures because
exposure to cold or to
antibiotics have no effect on the
environmental or occupational
causal organism. Bacterial
pollutants.
pharyngitis is treated with a
variety of antimicrobial agents The patient may minimize
exposure to pollutants by wearing
a disposable facemask.
Chronic Pharyngitis The nurse encourages the patient
to drink plenty of fluids
DEFINITION:
MEDICAL INTERVENTION:
Chronic pharyngitis is a persistent
antihistamine decongestant
inflammation of the pharynx. It is
medications
 prescribed orally every 4 to 6 course of any prescribed
hours. Aspirin (for patients older antibiotic for the first
than 20 years) or acetaminophen postoperative week
is recommended for its analgesic The patient should eat an
properties. adequate diet with soft foods,
tonsillectomy which are more easily swallowed
than hard foods.
The patient should avoid spicy,
Tonsillitis and Adenoiditis hot, acidic, or rough foods. Milk
and milk products (ice cream
DEFINITION:
and yogurt) may be restricted
Infection of the adenoids frequently The nurse instructs the patient
accompanies acute tonsillitis. about the need to maintain good
Frequently occurring bacterial hydration.
pathogens include GABHS, the most The patient is advised to avoid
common organism. vigorous tooth brushing or
gargling
CAUSE:
MEDICAL INTERVENTION:
Bacterial and viral infections
Exposure to allergens or pollutants Bacterial infections - penicillin
(first-line therapy) or
DIAGNOSTIC TEST:
cephalosporins.
RADT Viral tonsillitis is not effectively
throat swab culture treated with antibiotic therapy
thorough physical examination tonsillectomy
adenoidectomy
ASSESSMENT:

sore throat,
fever, Peritonsillar Abscess
snoring,
DEFINITION:
difficulty swallowing
is the most common major
NURSING INTERVENTION:
suppurative complication of sore
Continuous nursing observation is throat accounting for roughly 30% of
required in the immediate soft tissue head and neck abscesses.
postoperative
CAUSE:
Monitor symptoms of
complications Streptococcus Pyogenes
The nurse informs the patient
DIAGNOSTIC TEST:
about the need to take the full
 Intraoral ultrasound patient with a peritonsillar abscess
transcutaneous cervical presents with acute airway
ultrasound obstruction and requires
immediate airway management.
ASSESSMENT:
 Procedures may include
a severe sore throat,
intubation, cricothyroidotomy,
fever,
or tracheotomy
trismus (inability to open the
mouth),
drooling. Laryngitis
raspy voice,
DEFINITION:
odynophagia (a severe sensation
of burning, squeezing pain while an inflammation of the larynx, often
swallowing), occurs as a result of voice abuse or
dysphagia (difficulty swallowing), exposure to dust, chemicals, smoke,
and and other pollutants or as part of a
otalgia (pain in the ear). URI
NURSING INTERVENTION: CAUSE:
-the nurse assists with the procedure voice abuse or exposure to dust,
and provides support to the patient chemicals,
before, during, and after the smoke,
procedure. and other pollutants or as part of
a URI.
-The nurse also observes the patient
the pathogens that cause the
for complications
common cold and pharyngitis;
-Instructs the patient about signs and the most common cause is a
symptoms of complications that virus, and laryngitis is often
require prompt attention by the associated with allergic rhinitis or
patient’s primary provider. pharyngitis
MEDICAL INTERVENTION DIAGNOSTIC TEST:

Antimicrobial agents and Laryngoscopy

corticosteroid therapy are used
ASSESSMENT:
for the treatment of peritonsillar
abscess. hoarseness or aphonia (loss of
Intramuscular administration of voice)
clindamycin (Cleocin) can be severe cough
used in the outpatient setting,
NURSING INTERVENTION:
-The nurse instructs the patient to rest
the voice and to maintain a well-
humidified environment.
-The nurse instructs the patient about
the importance of taking prescribed
medications
-the nurse informs the patient that
the symptoms of laryngitis often
extend a week to 10 days after
completion of antibiotic therapy
MEDICAL INTERVENTION:
-resting the voice, avoiding irritants
(including smoking), resting, and
inhaling cool steam or an aerosol
-For chronic laryngitis, the treatment
includes resting the voice,
eliminating any primary respiratory
tract infection, eliminating smoking,
and avoiding secondhand smoke.
-Corticosteroids, such as
beclomethasone, may be given.
Obesity or excess weight
Neck circumference
male gender,
postmenopausal status,
and advanced age.
DIAGNOSTIC TEST:
electroencephalogram (EEG),
electro-oculogram,
chin electromyogram (EMG).
electrocardiogram (ECG)
ASSESSMENT:
-frequent and loud snoring with
breathing cessation for 10 seconds
or longer
-awakening abruptly with a loud
snort as the blood oxygen level
drops
-“3S’s”—namely, snoring, sleepiness,
and significant-other report of sleep
apnea episodes

Excessive daytime sleepiness

OBSTRUCTION AND TRAUMA OF THE
UPPER RESPIRATORY AIRWAY Frequent nocturnal awakening
Obstructive Sleep Apnea Insomnia

DEFINITION: Loud snoring

a disorder characterized by Morning headaches
recurrent episodes of upper airway
NURSING INTERVENTION:
obstruction and a reduction in
ventilation. It is defined as cessation -explains the disorder in terms that
of breathing (apnea) during sleep are understandable to the patient
usually caused by repetitive upper and relates symptoms (daytime
airway obstruction. sleepiness) to the underlying
disorder.
CAUSE:
-The nurse also instructs the patient
and family about treatments,
including the correct and safe use of
CPAP, BiPAP, MAD, and oxygen
therapy, if prescribed.
-The nurse educates the patient
about the risk of untreated OSA and
the benefits of treatment
approaches
MEDICAL INTERVENTION:
Weight loss,
avoidance of alcohol,
positional therapy (using devices
that prevent patients from sleeping
on their backs),
and oral appliances such as
mandibular advancement devices
(MADs) are the first steps
Epistaxis (Nosebleed)
DEFINITION:
Epistaxis, a hemorrhage from the
nose, is caused by the rupture of tiny,
distended vessels in the mucous
membrane of any area of the nose.
CAUSES:
-sinuses or adenoids
-fragile blood vessels that bleed
easily
-an infection of the nose lining
ASSESSMENT:
-Bleeding from one or both nostrils
-bleeding down the back of the
throat with spitting
-coughing or vomiting of blood
DIAGNOSTIC:
-CBC
-Prothrombin Time
-Partial Thromboplastin time –PTP
NURSING MANAGEMENT:
-The nurse monitors the patient’s vital
signs,
-assists in the control of bleeding,
-provides tissues and an emesis basin
to allow the patient to expectorate
any excess blood
-Assuring the patient in a calm
-the nurse instructs the patient to
avoid vigorous exercise for several
days and to avoid hot or spicy foods
and tobacco, because this may
cause vasodilation and increase the
risk of rebleeding.
MEDICAL MANAGEMENT:
-applying direct pressure.
-The patient sits upright with the
head tilted forward to prevent
swallowing and aspiration of blood
and is directed to pinch the soft
outer portion of the nose against the
midline septum for 5 or 10 minutes
continuously
-Application of nasal decongestant
-The search for the bleeding site -The patient is also instructed about
the signs and symptoms of bleeding
and infection and when to contact
NASAL OBSTRUCTION the primary provider.

DEFINITION: MEDICAL MANAGEMENT:

The passage of air through the -removal of the obstruction,

nostrils is frequently obstructed by a
-Commonly used medications
deviation of the nasal septum,
include nasal corticosteroids
hypertrophy of the turbinate bones,
or the pressure of nasal polyps. -antibiotics for the treatment of
underlying infection or antihistamines
CAUSES:
for the management of allergies.
-chronic sinusitis
-sinus infection
Fractures of the nose
-cold or flu
DEFINITION:
-allergic rhinitis
The most common facial fracture
ASSESSMENT: and the most common fracture in
the body.
-sneezing
CAUSES:
-headache
-direct Assault
-inability to smell
-contact sports
-eye itching or watering
-physical fight
-postnasal discharge
-motor vehicle accidents
DIAGNOSTIC:
ASSESSMENT:
-computed tomography
-pain
NURSING MANAGEMENT:
-deformity
-the nurse elevates the head of the
bed to promote drainage and to -nasal obstruction
alleviate discomfort from edema.
-swelling of the soft tissue
-the patient is instructed to avoid
DIAGNOSTIC:
blowing the nose with force during
the postoperative recovery period. -intranasal examination
-radiography “x-ray”
NURSING MANAGEMENT: Recent throat pain or recent
fever
-the nurse applies ice and
Tobacco consumption
encourages the patient to keep the
head elevated.
ASSESSMENT:
-The nurse instructs the patient to
apply ice packs to the nose to lowered oxygen saturation
decrease swelling shortness of breath
chronic cough
-the nurse carefully inspects the
mucosa for lacerations or a septal DIAGNOSTIC:
hematoma.
Laryngoscopy
-The nurse instructs the patient to
avoid sports activities for 6 weeks
NURSING MANAGEMENT:
MEDICAL MANAGEMENT:
-Optimal positioning
-Cold compresses are used to
prevent or reduce edema -Use of pillow or hand splints when
coughing
-Uncomplicated nasal fractures may
be treated initially with antibiotics, -Use of abdominal muscles for more
analgesic agents, and a forceful cough
decongestant nasal spray.
MEDICAL MANAGEMENT:
-rhinoplasty to reshape the external
-Emergent maneuvers to clear an
appearance of the nose.
airway obstruction
-A septorhinoplasty is performed
-Tracheotomy
when the nasal septum needs to be
repaired. -administration of subcutaneous
epinephrine and a corticosteroid
Laryngeal Obstruction

DEFINITION:
Cancer of the Larynx
Obstruction of the larynx because of
edema is a serious condition that DEFINITION:
may be fatal without swift, decisive
Cancer of the larynx accounts for
intervention.
approximately half of all head and
CAUSES: neck cancers. Cancer of the larynx is
most common in people older than
Heavy alcohol consumption
65 years and is four times more
Histories of allergies
common in men
CAUSES:
Tobacco (smoke, smokeless, e-
cigarettes, hookahs) Combined
effects of alcohol
tobacco Asbestos
Secondhand smoke
Unhealthy diet
ASSESSMENT:
voice may sound harsh, raspy,
and lower in pitch
persistent cough or sore throat
pain and burning in the throat,
especially when consuming hot
liquids or citrus juices
DIAGNOSTIC:

fine-needle aspiration
(FNA)biopsy,
barium swallow,
endoscopy,
CT or MRI scan,
a positron emission tomography
(PET) scan
NURSING MANAGEMENT:
-support for therapies, pain control
-promoting nutrition, emotional
support
MEDICAL MANAGEMENT:
surgery, radiation therapy, and
adjuvant chemo radiation therapy.
alaryngeal communication:
alternative modes of speaking that
do not involve the normal larynx;
used by patients whose larynx has
been surgically removed
aphonia: impaired ability to use one
’s voice due to disease or injury to
the larynx
apnea: cessation of breathing
dysphagia: difficulty swallowing
epistaxis: hemorrhage from the nose
due to rupture of tiny, distended
vessels in the mucous membrane of
any area of the nose
rhinitis medicamentosa: rebound
nasal congestion commonly
associated with overuse of over-the-
counter nasal decongestants
rhinorrhea: drainage of a large
amount of fluid from the nose
rhinosinusitis: inflammation of the
nares and paranasal sinuses,i
ncluding frontal, ethmoid, maxillary,
and sphenoid sinuses; replaces the
term sinusitis
tonsillitis: inflammation of the tonsils
xerostomia: dryness of the mouth

herpes simplex: a cutaneous viral

infection with painful vesicles and
erosions on the tongue, palate,
gingiva, buccal membranes, or lips
(synonym: cold sore)

laryngectomy: surgical removal of all

or part of the larynx and surrounding
structures

laryngitis: inflammation of the larynx;

may be caused by voice abuse,
exposure to irritants, or infectious
organisms

nuchal rigidity: stiffness of the neck

or inability to bend the neck

pharyngitis: inflammation of the

throat

rhinitis: inflammation of the mucous

membranes of the nose

Management of Patients with
Chronic Pulmonary Disease
Although chronic bronchitis is a
clinically and epidemiologically
useful term, it does not reflect the
major impact of airflow limitation on
morbidity and mortality in COPD.

EMPHYSEMA
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE (COPD)
Emphysema is the impaired
oxygen and carbon dioxide
Chronic obstructive pulmonary exchange results from destruction of
disease (COPD) is a preventable and the walls of overdistended alveoli.
treatable slowly progressive Emphysema is a pathologic term
respiratory disease of airflow that describes an abnormal
obstruction involving the airways, distention of the airspaces beyond
pulmonary parenchyma, or both. the terminal bronchioles and
destruction of the walls of the alveoli.
COPD may include diseases that
cause airflow obstruction (e.g., CAUSES
emphysema, chronic bronchitis) or  Exposure to tobacco smoke
any combination of these disorders. accounts for an estimated 80–
Other diseases such as cystic fibrosis 90% of cases of chronic
(CF), bronchiectasis, and asthma are obstructive pulmonary disease
classified as chronic pulmonary  Secondhand smoke
disorders.  Increased age
 Occupational exposure—dust,
Asthma is considered a distinct, chemicals
separate disorder and is classified as  Indoor and outdoor air pollution
an abnormal airway condition  Genetic abnormalities, including
characterized primarily by reversible a deficiency of alpha1-
inflammation. antitrypsin, an enzyme inhibitor
CHRONIC BRONCHITIS that normally counteracts the
destruction of lung tissue by
Chronic Bronchitis a disease of certain other enzymes
the airways is defined as the  ENDS; e.g., e-cigarettes, e-pens,
presence of cough and sputum e-pipes, e-hookahs, e-cigars
production for at least 3 months in ASSESSMENT/CLINICAL MANIFESTATIONS
each of 2 consecutive years.
 Three primary symptoms: chronic increases long-term smoking
cough, sputum production, and abstinence rates—comes in a
dyspnea variety of forms (gum, inhaler,
nasal spray, transdermal patch,
 Weight loss
sublingual tablet, or lozenge).
 respiratory insufficiency
 Bupropion SR and nortriptyline
 respiratory infections or COPD
(antidepressants to increase long-
exacerbation
term quit rates)
 “Barrel Chest” Thorax
 Varenicline, a nicotinic
Configuration
acetylcholine receptor partial
Complications
agonist, may assist in smoking
 Pneumonia cessation
 Chronic atelectasis,  Oxygen Therapy
 Pneumothorax,  Oxygen Administration Devices
 Pulmonary arterial hypertension o Cannula (nasal and
(cor pulmonale) reservoir)
DIAGNOSTIC TESTS o Nasal (oropharyngeal)
catheter
 Pulmonary function studies o Simple masks
 Spirometry o Partial Rebreathing masks
 Arterial blood gas o Nonrebreathing masks
measurements/tests o Venturi masks
 Screening for alpha1-antitrypsin o Transtracheal oxygen
deficiency catheter
Imaging studies: o Aerosol mask
o Tracheostomy collar
 Chest x-ray (alternative diagnosis)
o T-piece
 CT Scan particularly high-
o Face tent
resolution CT Scan
Pharmacologic Therapy
MEDICAL MANAGEMENT
 Bronchodilators (Pressurized
 Promoting smoking cessation as
metered-dose inhaler [pMDI], dry
appropriate
powder inhaler, small-volume
 Providing supplemental oxygen
nebulizer [SVN], or via the oral
therapy as indicated,
route in pill or liquid form)
 Prescribing medications, and
 Beta-2-adrenergic agonists,
managing exacerbations
Corticosteroids
 Nicotine replacement—a first-line
(formoterol/budesonide,
pharmacotherapy that reliably
 vilanterol/fluticasone furoate, and  Encourage patient to begin to
salmeterol/fluticasone) bathe self, dress self, walk, and
 Anticholinergics (ipratropium drink fluids. Discuss energy
bromide, tiotropium bromide, conservation measures.
umeclidinium)  Support patient in establishing a
 Antitrypsin augmentation therapy regular regimen of exercise using
 Antibiotic agents treadmill and exercise bicycle,
 Mucolytic agents walking, or other appropriate
 Antitussive agents exercises, such as mall walking.
 Vasodilators  Enroll patient in pulmonary
 Opioids rehabilitation program where
 Vaccination (influenza vaccine) available.
Surgical Management  Monitor respiratory status,
including rate and pattern or
 Bullectomy
respirations, breath sounds, signs
 Lung volume reduction surgery
and symptoms of respiratory
 Lung transplantation
distress, and pulse oximetry.
Pulmonary Rehabilitation
 Chest physiotherapy (CPT)
 Patient Education o Postural Drainage (Segmented
 Nutritional Therapy Bronchial Drainage)
Palliative Care o Chest Percussion and Vibration
o Breathing Retraining
o
BRONCHIECTASIS
NURSING MANAGEMENT
Bronchiectasis is a chronic,
 Assessment involves obtaining
irreversible dilation of the bronchi
information about current
and bronchioles that results from
symptoms as well as previous
destruction of muscles and elastic
disease manifestations.
connective tissue.
 The nurse and the patient need
to achieve airway clearance CAUSES
(adequate hydration, teach
breathing techniques, avoid  Recurrent respiratory infections
irritants exposure)  Cystic Fibrosis
 Improvement in breathing  Rheumatic and other systemic
pattern (diaphragmatic or diseases
pursed-lip breathing)  Primary ciliary dysfunction
 Tuberculosis
 Immune deficiency disorders  Patients and families are taught
ASSESSMENT/CLINICAL MANIFESTATIONS to perform postural drainage and
to avoid exposure to people with
 Chronic cough
upper respiratory or other
 Production of sputum in copious
infections.
amounts
 If the patient experiences fatigue
 Hemoptysis
and dyspnea, they are informed
 Clubbing of the fingers
about strategies to conserve
 Repeated episodes of pulmonary
energy while maintaining as
infection
active a lifestyle as possible.
DIAGNOSTIC TESTS
 The patient is educated about
 CT Scan the early signs of respiratory
 High-resolution CT scan infection and the progression of
 Sputum test for tubercle bacilli the disorder so that appropriate
MEDICAL MANAGEMENT treatment can be implemented
promptly.
 Chest physiotherapy  The patient’s nutritional status is
 Bronchoscopy (mucopurulent assessed and strategies are
sputum) implemented to ensure an
 Smoking cessation adequate diet.
 Antibiotics
ASTHMA
 Antimicrobial therapy
 Nebulized mucolytics or nebulized is a heterogeneous disease,
hypertonic saline usually characterized by chronic
 Bronchodilators airway Inflammation.
Surgical Management
CAUSES
 Segmental resection
 Female gender
 Lobectomy
 Atopy
 Pneumonectomy
 Exposure to indoor and outdoor
 Video-assisted surgery
allergens
NURSING MANAGEMENT
 Respiratory infections
 Patient education targets  Air pollution
eliminating smoking and other  Active/passive smoking
factors that increase the  Diet, small size at birth
production of mucus and hamper ASSESSMENT/CLINICAL MANIFESTATIONS
its removal.
 Wheezing
 Cough
 Dyspnea (shortness of breathing) budesonide, ciclesonide,
 Chest tightness flunisolide)
 “Choking” sensation during  Long-acting beta-2
exercise adrenergic agonists (LABAs)
 Asthma exacerbation (salmeterol, formoterol)
 Diaphoresis  Leukotriene modifiers
 Tachycardia (inhibitors), or antileukotrienes
 Widened pulse pressure (montelukast, zafirlukast,
 Hypoxemia zileuton)
 Central cyanosis  Phosphodiesterase inhibitors
Complications (Theophylline)
 Immunomodulators
 status asthmaticus
(omalizumab, mepolizumab,
 respiratory failure,
reslizumab, benralizumab, and
 pneumonia
dupilumab)
 atelectasis
Peak Flow Monitoring - measure the
DIAGNOSTIC TESTS
highest airflow during a forced
 Sputum and Blood tests expiration.
 Arterial blood gas tests
NURSING MANAGEMENT
 Pulse oximetry
 Spirometry (lung function)  Obtains a history of allergic
MEDICAL MANAGEMENT reactions to medications before
administering medications.
 Identifies medications the patient
Pharmacologic Therapy is taking.
 Administers medications as
Quick-Relief Medications prescribed and monitors the
patient’s responses to those
 Short-acting beta-2-
medications. These medications
adrenergic agonists (SABAs)
may include an antibiotic if the
(albuterol, levalbuterol,
patient has an underlying
pirbuterol)
respiratory infection.
 Anticholinergics (ipratropium)
 Administers fluids if the patient is
 Corticosteroids
dehydrated.
(methylpredisnolone,
 Nurses who have contact with
prednisolone, prednisone)
patients with asthma in any
 Inhaled Corticosteroids
setting use the opportunity to
(beclomethasone,
assess the patient’s respiratory
 status and ability to manage self-  Respiratory failute
care to prevent serious  Asphyxia
exacerbations. DIAGNOSTIC TESTS
 Nurses refer patients to
 General assessment of the
community support groups. In
patient’s (degree of
addition, nurses remind patients
breathlessness, ability to talk,
and families about the
positioning of patient, level of
importance of health promotion
alertness or cognitive function)
strategies and recommended
 Physical assessment (respiratory
health screening.
rate, the use of accessory
muscles, presence of central
STATUS ASTHMATICUS
cyanosis, auscultatory findings,
pulse, and pulsus paradoxus)
The term status asthmaticus is
 Peak expiratory flow after a
sometimes used to describe rapid
bronchodilator
onset, severe, and persistent asthma
 PaO2 and PaCO2
that does not respond to
 Pulse Oximetry
conventional therapy. The attacks
 Pulmonary Function Studies
can occur with little or no warning
 Arterial Blood Gas Measurements
and can progress rapidly to
MEDICAL MANAGEMENT
asphyxiation.
 Close monitoring of the patient
CAUSES
 Objective reevaluation for
 Infection response to therapy
 Anxiety  Oxygen Therapy
 Inhaler abuse Pharmacologic Therapy
 Dehydration
 Beta-2-adrenergic agonists
 Increased adrenergic blockage
 Corticosteroids
 Nonspecific irritants
 Inhaled short-acting beta-2-
 Hypersensitivity to medications
adrenergic agonists
such as aspirin, beta-blockers,
 IV fluids for hydration
and NSAIDs.
 Bronchodilators (pMDI, SVN)
ASSESSMENT/CLINICAL MANIFESTATIONS
 Supplemental O2 using a
 Labored breathing nonrebreathing mask or partial
 Prolonged exhalation non rebreathing mask
 Distended neck veins
 Wheezing
 Magnesium Sulfate (calcium
agonist to relax smooth muscle
and cause bronchodilation)
Bronchial thermoplasty is the first
nondrug therapy for the treatment of
severe, uncontrolled asthma. It
consists of controlled radiofrequency
heating of the central airways
through a bronchoscope.
NURSING MANAGEMENT
 The nurse vigilantly monitors the
patient for the first 12 to 24 hours,
or until the severe exacerbation
resolves.
 The nurse also assesses the
patient’s skin turgor for signs of
dehydration.
 Nurses administer IV fluids as
prescribed, up to 3 to 4 L/day,
unless contraindicated.
 Blood pressure and cardiac
rhythm should be monitored
continuously during the acute
phase and until the patient
stabilizes and responds to
therapy.
CYSTIC FIBROSIS
CF is the most common fatal
autosomal recessive disease among
Caucasians. It is less frequently found
among Hispanic, Asian, and African
Americans.
CAUSES
 Mutations or dysfunction in the
protein cystic fibrosis
transmembrane conductance
regulator (CFTR)
 The most common mutation is
ΔF508; however, researchers
have identified more than 1700
mutations of the disease
ASSESSMENT/CLINICAL MANIFESTATIONS
 Productive cough
 Wheezing
 Hyperinflation of the lung fields on
chest x-ray and pulmonary
function test results consistent with
obstructive disease of the airways
 Chronic respiratory inflammation
and infection due to mucus
clearance
 Sinusitis
 Nasal Polyps
 pancreatic insufficiency
 recurrent abdominal pain
 biliary cirrhosis
 vitamin deficiencies
 recurrent pancreatitis
 weight loss
 CF-related diabetes
 Genitourinary problems (males
and female infertility)
DIAGNOSTIC TESTS
 Clinical picture consistent with the
CF phenotype and laboratory
evidence of CFTR dysfunction
MEDICAL MANAGEMENT
 Multimodal antibiotic regimens
(oral, inhaled, and IV)
 Airway clearance measures
(mucolytics such as dornase alfa)
 Inhaled hypertonic saline (for and dietary intake to promote
mucus expectoration) removal of secretions and to
 Bronchodilators ensure an adequate nutritional
 CFTR modulators status
 Nutritional support  As with any chronic disease,
 Exercise palliative care and end-of-life
 Antibiotics (depending on sputum issues and concerns need to be
cultures results) addressed with the patient when
 Dornase aflfa (nebulized warranted.
medication given to degrade the
large amount of
deoxyribonucleic acid [DNA] that
accumulates within CF mucus)
 Nebulized and IV antibiotics or a
combination may be used to
treat chronic colonization of the
lung.
NURSING MANAGEMENT

 Specific measures include

strategies that promote removal
of pulmonary secretions, CPT
(including postural drainage,
chest percussion, and vibration),
and breathing exercises
 The patient is reminded of the
need to reduce risk factors
associated with respiratory
infections (e.g., exposure to
crowds or to people with known
infections)
 The patient is taught the early
signs and symptoms of respiratory
infection and disease progression
that indicate the need to notify a
primary provider
 The nurse emphasizes the
importance of an adequate fluid
air trapping: incomplete emptying of
alveoli during expiration due to loss
of lung tissue elasticity (emphysema),
bronchospasm (asthma), or airway
obstruction
alpha1-antitrypsin deficiency:
genetic disorder resulting from
deficiency of alpha1-antitrypsin, a
protective agent for the lung;
increases patient’s risk for
developing panacinar emphysema
even in the absence of smoking
asthma: a heterogeneous disease,
usually characterized by chronic
airway inflammation; defined by
history of symptoms such as wheeze,
shortness of breath, chest tightness,
and cough that vary over time and
in intensity
bronchiectasis: chronic, irreversible
dilation of the bronchi and
bronchioles that results from the
destruction of muscles and elastic
connective tissue; dilated airways
become saccular and are a
medium for chronic infection
chest percussion: manually cupping
hands over the chest wall and using
vibration to mobilize secretions by
mechanically dislodging viscous or
adherent secretions in the lungs
chest physiotherapy (CPT): therapy
used to remove bronchial secretions,
improve ventilation, and increase
the efficiency of the respiratory
muscles; types include postural
drainage, chest percussion, and
vibration, and breathing retraining
chronic bronchitis: a disease of the
airways defined as the presence of
cough and sputum production for at
least a combined total of 3 months
in each of 2 consecutive years
chronic obstructive pulmonary
disease (COPD): disease state
characterized by airflow limitation
that is not fully reversible; sometimes
referred to as chronic airway
obstruction or chronic obstructive
lung disease
desaturate: a precipitous drop in the
saturation of hemoglobin with
oxygen
dry-powder inhaler (DPI): a
compact, portable inspiratory flow–
driven inhaler that delivers dry-
powder medications into the patient
’s lungs
emphysema: a disease of the
airways characterized by destruction
of the walls of overdistended alveoli
flutter valve: portable handheld
mucous clearance device;
consisting of a tube with an
oscillating steel ball inside; upon
expiration, highfrequency oscillations
facilitate mucous expectoration

fraction of inspired oxygen (FiO2):

concentration of oxygen delivered
(e.g., 1.0 equals to 100% oxygen)

hypoxemia: decrease in arterial

oxygen tension in the blood

hypoxia: decrease in oxygen supply

to the tissues and cells
 Assessment of Respiratory the dust and organisms in the
Function inhaled air.

Anatomic and Physiologic
Overview
Anatomy of the Respiratory System
Upper Respiratory Tract
Upper airway structures consist of the
nose; paranasal sinuses; pharynx,
tonsils, and adenoids; larynx; and
trachea.
Nose
The nose serves as a passageway for
air to pass to and from the lungs. It
filters impurities and humidifies and
warms the air as it is inhaled.
The anterior nares (nostrils) are the
external openings of the nasal
cavities.
The turbinate bones are also called
conchae (the name suggested by
their shell-like appearance).
Air entering the nostrils is deflected
upward to the roof of the nose, and
it follows a circuitous route before it
reaches the nasopharynx. It comes
into contact with a large surface of
moist, warm, highly vascular, ciliated
mucous membrane (called nasal
mucosa) that traps practically all of
Paranasal Sinuses
The paranasal sinuses include four
pairs of bony cavities that are lined
with nasal mucosa and ciliated
pseudostratified columnar
epithelium.
The sinuses are named by their
location:
frontal,
ethmoid
sphenoid
maxillary
A prominent function of the sinuses is
to serve as a resonating chamber in
speech. The sinuses are a common
site of infection.
Pharynx, Tonsils, and Adenoids
The pharynx, or throat, is a tubelike
structure that connects the nasal
and oral cavities to the larynx. It is
divided into three regions: nasal,
oral, and laryngeal.
The nasopharynx is located posterior
to the nose and above the soft
palate. The oropharynx houses the
faucial, or palatine, tonsils.
The adenoids, or pharyngeal tonsils,
are located in the roof of the
nasopharynx. The tonsils, the
adenoids, and other lymphoid tissue
encircle the throat.
Larynx
The larynx, or voice box, is a
cartilaginous epithelium-lined organ
that connects the pharynx and the
trachea and consists of the
following:
Epiglottis: a valve flap of cartilage
that covers the opening to the larynx
during swallowing
Glottis: the opening between the
vocal cords in the larynx
Thyroid cartilage: the largest of the
cartilage structures; part of it forms
the Adam’s apple
Cricoid cartilage: the only complete
cartilaginous ring in the larynx
(located below the thyroid cartilage)
Arytenoid cartilages: used in vocal
cord movement with the thyroid
cartilage
Vocal cords: ligaments controlled by
muscular movements that produce
sounds; located in the lumen of the
larynx
Although the major function of the
larynx is vocalization, it also protects
the lower airway from foreign
substances and facilitates coughing;
it is, therefore, sometimes referred to
as the “watchdog of the lungs”
Trachea
The trachea, or windpipe, is
composed of smooth muscle with C-
shaped rings of cartilage at regular
intervals.
The trachea serves as the passage
between the larynx and the right
and left main stem bronchi, which
enter the lungs through an opening
called the hilus.
Lower Respiratory Tract
The lungs are paired elastic
structures enclosed in the thoracic
cage, which is an airtight chamber
with distensible walls.
The right lung has upper, middle, and
lower lobes, whereas the left lung
consists of upper and lower lobes.
Pleura
The lungs and wall of the thoracic
cavity are lined with a serous
membrane called the pleura.
The visceral pleura cover the lungs;
the parietal pleura line the thoracic
cavity, lateral wall of the
mediastinum, diaphragm, and inner
aspects of the ribs.
Mediastinum
The mediastinum is in the middle of
the thorax, between the pleural sacs
that contain the two lungs.
Bronchi and Bronchioles
There are several divisions of the
bronchi within each lobe of the lung.
First are the lobar bronchi (three in
the right lung and two in the left
lung).
Lobar bronchi divide into segmental
bronchi (10 on the right and 8 on the
left); these structures facilitate
effective postural drainage in the
patient.
Segmental bronchi then divide into
subsegmental bronchi. These
bronchi are surrounded by
connective tissue that contains
arteries, lymphatics, and nerves.
Alveoli
The lung is made up of about 300
million alveoli, constituting a total
surface area between 50 and 100
m2.
There are three types of alveolar
cells. Type I and type II cells make
up the alveolar epithelium.
Type I cells account for 95% of the
alveolar surface area and serve as a
barrier between the air and the
alveolar surface; type II cells
account for only 5% of this area but
are responsible for producing type I
cells and surfactant.
Alveolar macrophages, the third
type of alveolar cells, are
phagocytic cells that ingest foreign
matter and, as a result, provide an
important defense mechanism.
Function of the Respiratory System
Oxygen Transport
Oxygen is supplied to, and carbon
dioxide is removed from, cells by
way of the circulating blood through
the thin walls of the capillaries.
Oxygen diffuses from the capillary
through the capillary wall to the
interstitial fluid.
Respiration
Movement of air in and out of the
airways continually replenishes the
oxygen and removes the carbon
dioxide from the airways and the
lungs.
This whole process of gas exchange
between the atmospheric air and
the blood and between the blood
and cells of the body is called
respiration.
Ventilation
Ventilation requires movement of the
walls of the thoracic cage and of its
floor, the diaphragm.
The effect of these movements is
alternately to increase and
decrease the capacity of the chest.
When the capacity of the chest is
increased, air enters through the
trachea (inspiration) and moves into
the bronchi, bronchioles, and alveoli,
and inflates the lungs.
When the chest wall and the
diaphragm return to their previous
positions (expiration), the lungs recoil
and force the air out through the
bronchi and the trachea.
Pulmonary Diffusion and Perfusion
Pulmonary diffusion is the process by
which oxygen and carbon dioxide
are exchanged from areas of high
concentration to areas of low
concentration at the air–blood
interface.
Pulmonary perfusion is the actual
blood flow through the pulmonary
vasculature. The blood is pumped
into the lungs by the right ventricle
through the pulmonary artery.
Ventilation and Perfusion Balance
and Imabalance
Adequate gas exchange depends
on an adequate ventilation–
perfusion (V./Q.) ratio. In different
areas of the lung, the (V./Q.) ratio
varies. Airway blockages, local
changes in compliance, and gravity
may alter ventilation. V./Q.
imbalance occurs as a result of
inadequate ventilation, inadequate
perfusion, or both. There are four
possible (V./Q.) states in the lung:
normal (V./Q.) ratio, low (V./Q.) ratio
(shunt), high (V./Q.) ratio (dead
space), and absence of ventilation
and perfusion (silent unit).
Gas Exchange
The air we breathe is a gaseous
mixture consisting mainly of nitrogen
(78%), oxygen (21%), argon (1%),
and trace amounts of other gases
including carbon dioxide, methane,
and helium, among other gases.
The amount of oxygen that
combines with hemoglobin depends
on both the amount of hemoglobin
in the blood and on PaO2, although
only up to a PaO2 of about 150 mm
Hg. This is measured as oxygen
saturation (SaO2), the percentage of
the O2 that could be carried if all the
hemoglobin held the maximum
possible amount of O2.
Common Symptoms
The major signs and symptoms of
respiratory disease are dyspnea,
cough, sputum production, chest
pain, wheezing, and hemoptysis.
During the health history, the nurse
should also consider non-pulmonary
diseases when evaluating symptoms,
as these symptoms may occur with a
variety of other illnesses.
Dyspnea
The official American Thoracic
Society Statement (2012) defines
dyspnea as a subjective feeling of
discomfort while breathing; its
causes may include multiple
physiologic, psychological,
environmental, or social factors.
Dyspnea and tachypnea
(abnormally rapid
respirations) accompanied by
progressive hypoxemia (low blood
oxygen level) in a person who has
recently experienced lung trauma,
shock, cardiopulmonary bypass, or
multiple blood transfusions may
signal ARDS.
Orthopnea (shortness of breath when
lying flat, relieved by sitting or
standing) may be found in patients
with heart disease and occasionally
in patients with chronic obstructive
pulmonary disease (COPD); dyspnea
with an expiratory wheeze occurs
with COPD.
Cough
Cough is a reflex that protects the
lungs from the accumulation of
secretions or the inhalation of foreign
bodies. Its presence or absence can
be a diagnostic clue because some
disorders cause coughing and others
suppress it.
Sputum Production
Sputum production is the reaction of
the lungs to any constantly recurring
irritant and often results from
persistent coughing. It may also be
associated with a nasal discharge.
Chest pain
Chest pain or discomfort may be
associated with pulmonary, cardiac,
gastrointestinal, or musculoskeletal
disease or anxiety. Chest pain
associated with pulmonary
conditions may be sharp, stabbing,
and intermittent, or it may be dull,
aching, and persistent.
Wheezing
Wheezing is a high-pitched, musical
sound which is continuous, meaning
it is heard on either expiration
(asthma) or inspiration (bronchitis).
Hemoptysis
Hemoptysis is the expectoration of
blood from the respiratory tract. It
can present as small to moderate
blood-stained sputum to a large
hemorrhage and always warrants
further investigation.
The most common causes are:
Pulmonary infection
Carcinoma of the lung
Abnormalities of the heart or
blood vessels
Pulmonary artery or vein
abnormalities
PE or infarction
Physical Assessment of the
Respiratory System
General Appearance
The patient’s general appearance
may give clues to respiratory status.
In particular, the nurse inspects for
clubbing of the fingers and notes skin
color.
Clubbing of the Fingers
Clubbing of the fingers is a change
in the normal nail bed. It appears as
sponginess of the nail bed and loss
of the nail bed angle.
It is a sign of lung disease that is
found in patients with chronic
hypoxic conditions, chronic lung
infections, or malignancies of the
lung.
Cyanosis
Cyanosis, a bluish coloring of the
skin, is a very late indicator of
hypoxia. The presence or absence of
cyanosis is determined by the
amount of unoxygenated
hemoglobin in the blood.
Chest Configuration
Barrel Chest. Barrel chest occurs as
a result of overinflation of the lungs,
which increases the anteroposterior
diameter of the thorax. It occurs with
aging and is a hallmark sign of
emphysema and COPD.
Funnel Chest (Pectus Excavatum).
Funnel chest occurs when there is a
depression in the lower portion of the
sternum. This may compress the
heart and great vessels, resulting in
murmurs.
Pigeon Chest (Pectus Carinatum). A
pigeon chest occurs as a result of
the anterior displacement of the
sternum, which also increases the
anteroposterior diameter.
Kyphoscoliosis. Kyphoscoliosis is
characterized by elevation of the
scapula and a corresponding S-
shaped spine.
Thoracic Palpation
The nurse palpates the thorax for
tenderness, masses, lesions,
respiratory excursion, and vocal
fremitus. If the patient has reported
an area of pain or if lesions are
apparent, the nurse performs direct
palpation with the fingertips (for skin
lesions and subcutaneous masses) or
with the ball of the hand (for deeper
masses or generalized flank or rib
discomfort).
Respiratory Excursion
Respiratory excursion is an estimation
of thoracic expansion and may
disclose significant information about
thoracic movement during
breathing.
Tactile Fremitus
Tactile fremitus describes vibrations
of the chest wall that result from
speech detected on palpation.
Thoracic Percussion
Percussion produces audible and
tactile vibration and allows the nurse
to determine whether underlying
tissues are filled with air, fluid, or solid
material.
Diaphragmatic Excursion
The normal resonance of the lung
stops at the diaphragm. The position
of the diaphragm is different during
inspiration and expiration.
Thoracic Auscultation
Assessment concludes with Egophony- describes voice sounds
auscultation of the anterior, that are distorted. It is best
posterior, and lateral thorax. appreciated by having the patient
repeat the letter E. The distortion
Auscultation helps the nurse assess
produced by consolidation
the flow of air through the bronchial
transforms the sound into a clearly
tree and evaluate the presence of
heard A rather than E.
fluid or solid obstruction in the lung.
Type of Breath Sounds
Breath Sounds
Vesicular
Normal breath sounds are
Bronchovesicular
distinguished by their location over a
Bronchial
specific area of the lung and are
Tracheal
identified as vesicular,
bronchovesicular, and bronchial Whispered pectoriloquy
(tubular) breath sounds.
Whispered pectoriloquy describes
Adventitious Sounds the ability to clearly and distinctly
hear whispered sounds that should
An abnormal condition that affects
not normally be heard.
the bronchial tree and alveoli may
produce adventitious (additional) Tidal Volume
sounds. Some adventitious sounds
The volume of each breath is
are divided into two categories:
referred to as the tidal volume. A
crackles, or nonmusical, spirometer is an instrument that can
discontinuous sounds; and wheezes, be used at the bedside to measure
or continuous musical sounds volumes.
Rhonchi, a type of wheezing, are Minute Ventilation
lower-pitched continuous sounds
heard over the lungs in partial airway Because respiratory rates and tidal
obstruction. volumes vary widely from breath to
breath, these data alone are
Voice Sounds unreliable indicators of adequate
ventilation. However, the tidal
The sound heard through the
volume multiplied by the respiratory
stethoscope as the patient speaks is
rate provides what is called minute
known as vocal resonance.
ventilation or minute volume, the
volume of air exchanged per
Bronchophony- describes vocal minute.
resonance that is more intense and
Vital Capacity
clearer than normal.
Vital capacity is measured by having
the patient take in a maximal breath
and exhale fully through a
spirometer. The normal value
depends on the patient’s age,
gender, body build, and weight.
Inspiratory Force
Inspiratory force evaluates the effort
the patient is making during
inspiration. It does not require patient
cooperation and, therefore, is a
useful measurement in the patient
who is unconscious.
Diagnostic Evaluation
Pulmonary Function Tests
Pulmonary function tests (PFTs) are
routinely used in patients with
chronic respiratory disorders to aid
diagnosis.
They are performed to assess
respiratory function and to
determine the extent of dysfunction,
response to therapy, and as
screening tests in potentially
hazardous industries, such as coal
mining and those that involve
exposure to asbestos and other
noxious irritants.
Arterial Blood Gas Studies
Arterial blood gas (ABG) studies aid
in assessing the ability of the lungs to
provide adequate oxygen and
remove carbon dioxide, which
reflects ventilation, and the ability of
the kidneys to reabsorb or excrete
bicarbonate ions to maintain normal
body pH, which reflects metabolic
states.
Venous Blood Gas Studies
Venous blood gas (VBG) studies
provide additional data on oxygen
delivery and consumption. VBG
levels reflect the balance between
the amount of oxygen used by
tissues and organs and the amount
of oxygen returning to the right side
of the heart in the blood.
Pulse Oximetry
Pulse oximetry, or SpO2, is a
noninvasive method of continuously
monitoring the oxygen saturation of
hemoglobin (SaO2).
End-Tidal Carbon Dioxide
End-tidal carbon dioxide (ETCO2)
monitoring is a noninvasive method
of monitoring partial pressure of
carbon dioxide (CO2) at end
exhalation.
Cultures
Throat, nasal, and nasopharyngeal
cultures can identify pathogens
responsible for respiratory infections,
such as pharyngitis.
Throat cultures are performed in
adults with severe or ongoing sore
throats accompanied by fever and
lymph node enlargement and are
most useful in detecting
streptococcal infection.
Sputum Studies
Sputum is obtained for analysis to
identify pathogenic organisms and
to determine whether malignant
cells are present.
Periodic sputum examinations may
be necessary for patients receiving
antibiotics, corticosteroids, and
immunosuppressive medications for
prolonged periods because these
agents are associated with
opportunistic infections.
Sputum samples ideally are
obtained early in the morning before
the patient has had anything to eat
or drink!!!!!
Imaging Studies
Chest X-Ray
Chest x-ray may reveal an extensive
pathologic process in the lungs. The
routine chest x-ray consists of two
views: the posteroanterior projection
and the lateral projection. Chest x-
rays are usually obtained after full
inspiration because the lungs are
best visualized when they are well
aerated.
Computed Tomography
A CT of the chest is an imaging
method in which the lungs,
mediastinum, and vascular structures
within the chest are scanned in
successive layers by a narrow-beam
x-ray.
Pulmonary Angiography
Pulmonary angiography is used to
investigate congenital abnormalities
of the pulmonary vascular tree, and
less frequently PE, when less invasive
tests are inconclusive.
Magnetic Resonance Imaging
MRI is similar to a CT scan except
that magnetic fields and
radiofrequency signals are used
instead of radiation. MRI is able to
better distinguish between normal
and abnormal tissues than CT and,
therefore, yields a much more
detailed diagnostic image.
MRI is used to characterize
pulmonary nodules; to help stage
bronchogenic carcinoma
(assessment of chest wall invasion);
and to evaluate inflammatory
activity in interstitial lung disease,
acute PE, and chronic thrombolytic
pulmonary hypertension.
Fluoroscopic Studies
Fluoroscopy, which allows live x-ray
images to be generated via a
camera to a video screen, is used to
assist with invasive procedures, such
as a chest needle biopsy or
transbronchial biopsy, that are
performed to identify lesions.
Radioisotope Diagnostic Procedures
(Lung Scans)
Several types of lung scans—V./Q.
scan, gallium scan, and positron
emission tomography (PET)—are
performed to assess normal lung
functioning, pulmonary vascular
supply, and gas exchange. Pleural Biopsy
Pregnancy is a contraindication for
Pleural biopsy is accomplished by
these scans.
needle biopsy of the pleura,
Endoscopic Procedures thoracoscopy, or pleuroscopy, a
visual exploration through a
Bronchoscopy
fiberoptic pleuroscope inserted into
Bronchoscopy is the direct the pleural space or through a
inspection and examination of the thoracotomy.
larynx, trachea, and bronchi through
Lung Biopsy Procedures
either a flexible fiberoptic
bronchoscope or a rigid Lung biopsy is performed to obtain
bronchoscope. tissue for examination when other
diagnostic testing indicates potential
Thoracoscopy
interstitial lung disease, such as
Thoracoscopy is a diagnostic cancer, infection, or sarcoidosis.
procedure in which the pleural
Lymph Node Biopsy
cavity is examined with an
endoscope and fluid and tissues can The scalene lymph nodes, which are
be obtained for analysis. enmeshed in the deep cervical pad
of fat overlying the scalenus anterior
Thoracentesis
muscle, drain the lungs and
Thoracentesis (aspiration of fluid and mediastinum and may show
air from the pleural space) is histologic changes from
performed for diagnostic or intrathoracic disease.
therapeutic reasons.

Purposes of the procedure include

removal of fluid and, very rarely, air
from the pleural cavity; aspiration of
pleural fluid for analysis; pleural
biopsy; and instillation of medication
into the pleural space.
Biopsy
Biopsy—the excision of a small
amount of tissue—may be
performed to permit examination of
cells from the upper and lower
respiratory structures and adjacent
lymph nodes.
apnea: temporary cessation of
breathing
bronchophony: abnormal increase in
clarity of transmitted voice sounds
heard when auscultating the lungs
bronchoscopy: direct examination of
the larynx, trachea, and bronchi
using an endoscope
cilia: short, fine hairs that provide a
constant whipping motion that
serves to propel mucus and foreign
substances away from the lung
toward the larynx
compliance: measure of the force
required to expand or inflate the
lungs
crackles: nonmusical, discontinuous
popping sounds during inspiration
caused by delayed reopening of the
airways heard on chest auscultation
dyspnea: subjective experience that
describes an uncomfortable or
painful breathing sensation when
either at rest or while walking or
climbing stairs; also commonly
referred to as shortness of breath
egophony: abnormal change in
tone of voice that is heard when
auscultating the lungs
fremitus: vibrations of speech felt as
tremors of the chest wall during
palpation
hemoptysis: expectoration of blood
from the respiratory tract
hypoxemia: decrease in arterial
oxygen tension in the blood
hypoxia: decrease in oxygen supply
to the tissues and cells
obstructive sleep apnea: temporary
absence of breathing during sleep
secondary to transient upper airway
obstruction
orthopnea: shortness of breath when
lying flat; relieved by sitting or
standing
oxygen saturation: percentage of
hemoglobin that is bound to oxygen
physiologic dead space: portion of
the tracheobronchial tree that does
not participate in gas exchange
pulmonary diffusion: exchange of
gas molecules (oxygen and carbon
dioxide) from areas of high
concentration to areas of low
concentration
pulmonary perfusion: blood flow
through the pulmonary vasculature
respiration: gas exchange between
atmospheric air and the blood and
between the blood and cells of the
body
rhonchi: deep, low-pitched snoring
sound associated with partial airway
obstruction, heard on chest
auscultation
stridor: continuous, high-pitched,
musical sound heard on inspiration,
best heard over the neck; may be
heard without use of a stethoscope,
secondary to upper airway
obstruction.

tachypnea: abnormally rapid

respirations

tidal volume: volume of air inspired

and expired with each breath during
normal breathing

ventilation: movement of air in and

out of the airways
wheezes: continuous musical sounds
associated with airway narrowing or
partial obstruction

whispered pectoriloquy: whispered

sounds heard loudly and clearly
upon thoracic auscultation

Trust yourself. You have

survived a lot, and you will survive
whatever more challenges there are
to come. Good luck everyone and
God bless! :)