NCLEX-RN Exam Cram: Caring for the Client with Disorders of the Respiratory System
Date: Dec 27, 2010
Terms you'll need to understand
|
Acute respiratory failure |
|
|
Apnea |
|
|
Asthma |
|
|
Atelectasis |
|
|
Bronchitis |
|
|
Continuous positive airway pressure (CPAP) |
|
|
Cor pulmonale |
|
|
Cyanosis |
|
|
Dyspnea |
|
|
Emphysema |
|
|
Empyema |
|
|
Hemoptysis |
|
|
Hypoxemia |
|
|
Hypoxia |
|
|
Pleural effusion |
|
|
Pleurisy |
|
|
Pneumonia |
|
|
Pulmonary embolus |
|
|
Tachypnea |
Nursing skills you'll need to master
|
Assessing breath sounds |
|
|
Providing tracheostomy care |
|
|
Collecting sputum |
|
|
Teaching proper use of an inhaler (MDI and DPI) |
|
|
Performing chest physiotherapy |
|
|
Assisting with thoracentesis |
|
|
Obtaining a throat culture |
|
|
Performing venipuncture |
|
|
Administering medication |
|
|
Managing chest drainage system |
|
|
Maintaining oxygen therapy |
|
|
Maintaining assisted ventilation |
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) exists when prolonged disease or injury has made the lungs less capable of meeting the body's oxygen needs. Examples of COPD include chronic bronchitis, emphysema, and asthma.
Chronic Bronchitis
Chronic bronchitis, an inflammation of the bronchi and bronchioles, is caused by continuous exposure to infection and non-infectious irritants, such as cigarette smoke. The condition is most common in those ages 40 to 55. Chronic bronchitis may be reversed with the removal of noxious irritants, although it is often complicated by chronic lung infections. These infections, which are characterized by a productive cough and dyspnea, can progress to right-sided heart failure and pulmonary hypertension. Chronic bronchitis and emphysema have similar symptoms that require similar interventions.
Emphysema
Emphysema is the irreversible overdistention of the airspaces of the lungs, which results in destruction of the alveolar walls. Clients with emphysema are classified as pink puffers or blue bloaters. Pink puffers may complain of exertional dyspnea without cyanosis. Blue bloaters develop chronic hypoxia, cyanosis, polycythemia, cor pulmonale, pulmonary edema, and eventually respiratory failure.
Physical assessment reveals the presence of a barrel chest, use of accessory muscles, coughing with the production of thick mucoid sputum, prolonged expiratory phase with grunting respirations, peripheral cyanosis, and digital clubbing.
In identifying emphysema, a chest x-ray reveals hyperinflation of the lungs with flattened diaphragm. Pulmonary studies show that the residual volume is increased while vital capacity is decreased. Arterial blood gases reveal hypoxemia.
Many symptoms of chronic bronchitis and emphysema are the same; therefore, medications for the client with chronic bronchitis and emphysema include bronchodilators, steroids, antibiotics, and expectorants. Oxygen should be administered via nasal cannula at 2–3 liters/minute. Close attention should be given to correcting acid-base imbalances, meeting the client's nutritional needs, avoidance of respiratory irritants, prevention of respiratory infections, providing oral hygiene, and client teaching regarding medications.
Asthma
Asthma is the most common respiratory condition of childhood. Intrinsic (nonallergenic) asthma is precipitated by exposure to cold temperatures or infection. Extrinsic (allergenic or atopic) asthma is often associated with childhood eczema. Both asthma and eczema are triggered by allergies to certain foods or food additives. Introducing new foods to the infant one at a time helps decrease the development of these allergic responses. Easily digested, hypoallergenic foods and juices should be introduced first, including rice cereal and apple juice, which may be given at six months of age. Cow's milk should not be given to the infant before one year of age. Symptoms of asthma include expiratory wheeze; shortness of breath; and a dry, hacking cough, which eventually produces thick, white, tenacious sputum. In some instances an attack may progress to status asthmaticus, leading to respiratory collapse and death.
Management of the client with asthma includes maintenance therapy with mast cell stabilizers and leukotriene modifiers. Treatment of acute asthmatic attacks includes the administration of oral or inhaled short-term or long-term B2 agonist and anti-inflammatories as well as supplemental oxygen. Methylxanthines, such as aminophylline, are rarely used for the treatment of asthma. These drugs, which can cause tachycardia and dysrhythmias, are administered as a last resort. Antibiotics are frequently ordered when a respiratory infection is present.
Acute Respiratory Infections
Acute respiratory infections, such as pneumonia, are among the most common causes of death from infectious diseases in the United States. Pneumonia is the fifth major cause of death in persons over age 65.
Pneumonia
Pneumonia is an inflammation of the parenchyma of the lungs. Causative organisms include bacteria, viruses, and fungi. Some of these organisms are listed here:
- Pneumococcus
- Group A beta hemolytic streptococcus
- Staphylococcus
- Pseudomonas
- Influenza types A and B
- Cytomegalovirus
- Aspergillus fungiatus
- Pneumocystis carinii
Presenting symptoms depend on the causative organism. The client with viral pneumonia tends to have milder symptoms, whereas the client with bacterial pneumonia might have chills and fever as high as 103°. Clients with cytomegalovirus, pneumocystis carinii, or aspergillus will be acutely ill. General symptoms of pneumonia include
- Hypoxia
- Tachypnea
- Tachycardia
- Chest pain
- Malaise
- Fever
- Confusion (especially in the elderly client)
Care of the client with pneumonia depends on the causative organism. The management of bacterial pneumonias includes antibiotics, antitussives, antipyretics, and oxygen. Antibiotics that may be ordered include penicillin G, tetracycline, garamycin, and erythromycin. Viral pneumonias do not respond to antimicrobial therapy, but are treated with antiviral medication such as Symmetrel (amantadine). Fungal pneumonias are treated with antifungal medication such as Nizoral (ketoconozole). Additional therapies for the client with pneumonia include providing for fluid and nutritional needs, obtaining frequent vital signs, and providing oral hygiene. Supplemental oxygen and chest percussion and drainage should be performed as ordered by the physician
Pleurisy
Pleurisy, an inflammation of the pleural sac, can be associated with upper respiratory infection, pulmonary embolus, thoracotomy, chest trauma, or cancer. Symptoms include
- Sharp pain on inspiration
- Chills
- Fever
- Cough
- Dyspnea
Chest x-ray reveals the presence of air or fluid in the pleural sac. Management of the client with pleurisy includes the administration of analgesics, antitussives, antibiotics, and oxygen therapy. The presence of pleural effusion can require the client to have a thoracentesis. It is the nurse's responsibility to position the client for the procedure and to monitor for signs of complications related to the procedure. The nurse should assess the client's vital signs, particularly changes in respirations and blood pressure, which can reflect impending shock from fluid loss or bleeding. The nurse should also observe the client for signs of a pneumothorax.
Nursing Skill: Positioning the client for a thoracentesis
- Sitting on the edge of the bed with feet supported and with the head and arms resting on a padded over bed table)
- Sitting astride a chair with the arms and head resting on the back of the chair
- Lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (for clients unable to sit upright)
Tuberculosis
Tuberculosis (TB) is a highly contagious respiratory infection caused by the mycobacterium tuberculosis. It is transmitted by droplets from the respiratory tract. Airborne precautions, as outlined by the Centers for Disease Control (CDC), should be used when caring for the client with tuberculosis.
Diagnosis includes the administration of the Mantoux skin test, sometimes referred to as the Purified Protein Derivative (PPD), which is read in 48–72 hours. The presence of a positive Mantoux test indicates exposure to TB but not active infection. A chest x-ray should be ordered for those with a prior positive skin test. A definite diagnosis of TB is made if the sputum specimen is positive for the tubercle bacillus. Factors that can cause a false positive TB skin test include nontuberculous mycobacterium and inoculation with BCG vaccine. Factors that can cause a false negative TB skin test include anergy (a weakened immune system), recent TB infection, age, vaccination with live viruses, overwhelming TB, and poor testing technique. Management of the client with TB includes the use of ultraviolet light therapy and the administration of antimycobacterial drugs. Medication regimens can consist of several drugs including Myambutol (ethambutol), INH (isoniazid), Rifadin (rifampin), and PZA (pyrazinamide). The use of multiple drug therapy has reduced treatment time from two years to as little as six months; however, drug resistant forms may require longer treatment periods. Clients are no longer considered infectious after three negative sputum samples have been obtained. Surgical management may include a wedge resection or lobectomy.
Influenza
Influenza is an acute highly contagious infection that primarily affects the upper respiratory tract. Symptoms of influenza include the following:
- Chills and fever greater than 102° F.
- Sore throat and laryngitis
- Runny nose
- Muscle aches and headache
Complications of influenza include pneumonia, exacerbations of Chronic Obstructive Pulmonary Disease (COPD), and myositis. More serious complications include pericarditis and encephalitis. Children, the elderly, and those with chronic illness are more likely to develop severe complications; therefore, it is recommended that these clients receive annual immunization. The vaccine is given in the fall, prior to the onset of annual outbreaks, which occur in the winter months. The vaccine is produced in eggs; therefore, it should not be given to anyone who is allergic to egg protein. Children age two and older can receive the nasal vaccine as well as adults.
Treatment of influenza is aimed at controlling symptoms and preventing complications. Interventions for the client with influenza include bed rest, increased fluid intake, decongestant nasal sprays, antitussives with codeine, and antipyretics. Antibiotics are indicated if the client develops bacterial pneumonia. Antiviral medication such as Relenza (zanamivir) and Tamiflu (oseltamivir) are used for the prevention as well as the treatment of influenza A and B and can be used to reduce the duration and severity of symptoms. Symmetrel (amantadine) or Flumadine (rimantadine) are also used to prevent or decrease symptoms of the flu.
Acute Respiratory Failure
Acute respiratory failure can be defined as the lungs' failure to meet the body's oxygen requirements. One acute respiratory condition you need to be familiar with is acute respiratory distress syndrome, commonly known as ARDS.
Acute Respiratory Distress Syndrome
Acute respiratory distress syndrome, commonly known as ARDS or noncardiogenic pulmonary edema, occurs mostly in otherwise healthy persons. ARDS can be the result of anaphylaxis, aspiration, pulmonary emboli, inhalation burn injury, or complications from abdominal or thoracic surgery. ARDS may be diagnosed by a chest x-ray that will reveal emphysematous changes and infiltrates that give the lungs a characteristic appearance described as ground glass. Assessment of the client with ARDS reveals
- Hypoxia
- Sternal and costal retractions
- Presence of rales or rhonchi
- Diminished breath sounds
- Refractory hypoxemia
Care of the client with ARDS involves
- Use of assisted ventilation
- Monitoring of arterial blood gases
- Attention to nutritional needs
- Frequent change in position, placement in high Fowler's position, prone position, or use of specialized beds to minimize consolidation of infiltrates in large airways
- Investigational therapies, including the use of vitamins C and E, aspirin, interleukin, and surfactant replacements
Pulmonary Embolus
Pulmonary embolus refers to the obstruction of the pulmonary artery or one of its branches by a clot or some other undissolved matter, such as fat or a gaseous substance. Clots can originate anywhere in the body but are most likely to migrate from a vein deep in the legs, pelvis, kidney, or arms. Fat emboli are associated with fractures of the long bones, particularly the femur. Air emboli, which are less common, can occur during the insertion or removal of a central line. Common risk factors for the development of pulmonary embolus include immobilization, fractures, trauma, cigarette smoking, use of oral contraceptives, and history of clot formation.
Symptoms of a pulmonary embolus depend on the size and location of the clot or undissolved matter. Symptoms include
- Chest pain
- Dyspnea
- Syncope
- Hemoptysis
- Tachycardia
- Hypotension
- Sense of apprehension
- Petechiae over the chest and axilla
- Distended neck veins
Diagnostic tests to confirm the presence of pulmonary embolus include chest x-ray, pulmonary angiography, lung scan, and ECG to rule out myocardial infarction. Management of the client with a pulmonary embolus includes
- Placing the client in high Fowler's position
- Administering oxygen via mask
- Giving medication for chest pain
- Using thrombolytics/anticoagulants
Antibiotics are indicated for those with septic emboli. Surgical management using umbrella-type filters is indicated for those who cannot take anticoagulants as well as for the client who has recurrent emboli while taking anticoagulants. Clients receiving anticoagulant therapy should be observed for signs of bleeding. PT, INR, and PTT are three tests used to track the client's clotting time. You can refer to Chapter 13, "Caring for the Client with Disorders of the Cardiovascular System," for a more complete discussion of these tests.
Emerging Infections
The CDC (1994) defines emerging infections as diseases of infectious origin with human incidences occurring within the past two decades. Emerging illnesses are likely to increase in incidence in the near future. Two respiratory conditions listed as emerging infections are Severe Acute Respiratory Syndrome (SARS) and Legionnaire's disease.
Severe Acute Respiratory Syndrome
Severe Acute Respiratory Syndrome (SARS) is caused by a coronavirus. Symptoms include
- Fever
- Dry cough
- Hypoxemia
- Pneumonia
In identifying SARS, a chest x-ray reveals "ground glass" infiltrates with bilateral consolidation occurring sometimes within 24–48 hours, thus suggesting the rapid development of acute respiratory failure. SARS has occurred with greater frequency in Asia, although cases have also been confirmed in Canada, Switzerland, and Germany; therefore, a history of recent travel is significant
The SARS virus can be found in nasopharyngeal and oropharyngeal secretions, blood, and stool. Diagnostic tests for SARS include
- Sputum cultures for Influenza A, B, and RSV
- Serum tests to detect antibodies IgM and IgG
- Reverse transcriptase polymerase chain reaction tests performed to detect RNA of SARS CoV
Two tests on two different specimens must be positive to confirm the diagnosis. Test results are considered negative if no SARS CoV antibodies are found 28 days after the onset of symptoms.
The client suspected of having SARS should be cared for using airborne and contact precautions. Management includes the use of antibiotics to treat secondary or atypical pneumonia. Antivirals or retrovirals can be used to inhibit replication. Respiratory support, closed system for suctioning, and the use of surfactant replacement may be ordered.
Legionnaire's Disease
Legionnaire's disease is caused by gram negative bacteria found in both natural and manmade water sources. Bacterial growth is greater in stored water maintained at temperatures ranging from 77° to 107° F. Risk factors include
- Immunosuppression
- Diabetes
- Pulmonary disease
Legionnaire's involves the lungs and other organs. The symptoms include
- Productive cough
- Dyspnea
- Chest pain
- Diarrhea
- Fever
Diagnostic tests include a urinary antigen test that remains positive after initial antibiotic therapy. Management includes the use of antibiotics, oxygen, provision of nutrition, and hydration. The drug of choice for treating Legionnaire's disease is Zithromax (azithromycin). Transmission-based precautions are not necessary when caring for the client with Legionnaire's disease because there is no indication of human-to-human transmission.
Diagnostic Tests for Review
These are simply some of the tests that are useful in diagnosing pulmonary disorders. You should review the normal lab values as well as any special preparations for the client undergoing those tests. In addition, think about the care given to clients after the procedures have been completed. For instance, the client who has undergone a bronchoscopy will have a depressed gag reflex, which increases the chance of aspiration. No food or fluid should be given until the gag reflex returns. The tests for diagnosing pulmonary disorders are as follows:
- CBC
- Chest x-ray
- Pulmonary function tests
- Lung scan
- Bronchoscopy
Pharmacology Categories for Review
The client with a respiratory disorder should be managed with several categories of medications. The client with an acute respiratory condition, such as bacterial pneumonia, is given an antibiotic to fight the infection, antipyretic medication for fever and body aches, and an antitussive for relief of cough. The client with a chronic respiratory condition may receive many of the same medications, with the addition of a steroid or bronchodilator. The following list contains the most commonly prescribed categories of medications used to treat clients with respiratory conditions:
- Antibiotics
- Antivirals
- Antituberculars
- Antitussives
- Antipyretics
- Bronchodilators
- Expectorants
- Leukotriene modifiers
- Mast-cell stabilizers
- Steroids
Exam Prep Questions
-
When performing an assessment on the client with emphysema, the nurse finds that the client has a barrel chest. The alteration in the client's chest is due to:
A.
Collapse of distal alveoli
B.
Hyperinflation of the lungs
C.
Long-term chronic hypoxia
D.
Use of accessory muscles
-
The nurse notes that a client with COPD demonstrates more dyspnea in certain positions. Which position is most likely to alleviate the client's dyspnea?
A.
Lying supine with a single pillow
B.
Standing or sitting upright
C.
Side lying with the head elevated
D.
Lying with head slightly lowered
-
When reviewing the chart of a client with long standing lung disease, the nurse should pay close attention to the results of which pulmonary function test?
A.
Residual volume
B.
Total lung capacity
C.
FEV1/FVC ratio
D.
Functional residual capacity
-
The physician has ordered O2 at 3 liters/minute via nasal cannula. O2 amounts greater than 3 liters / minute are contraindicated in the client with COPD because:
A.
Higher concentrations result in severe headache.
B.
Hypercapnic drive is necessary for breathing.
C.
Higher levels will be required later to raise the pO2.
D.
Hypoxic drive is needed for breathing.
-
The client taking a bronchodilator tells the nurse that he is going to begin a smoking cessation program when he is discharged. The nurse should tell the client to notify the doctor if his smoking pattern changes because he will:
A.
Need his medication dosage adjusted
B.
Require an increase in antitussive medication
C.
No longer need annual influenza immunization
D.
Not derive as much benefit from inhaler use
-
Lab results indicate that the client's serum aminophylline level is 17mcg/mL. The nurse recognizes that the aminophylline level is:
A.
Within therapeutic range
B.
Too high and should be reported
C.
Questionable and should be repeated
D.
Too low to be therapeutic
-
The morning weight for a client with emphysema indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD?
A.
Polycythemia
B.
Cor pulmonale
C.
Left ventricular failure
D.
Compensated acidosis
-
The nurse is teaching the client the appropriate way to use a metered dose inhaler. Which action indicates the client needs additional teaching?
A.
The client takes a deep breath while depressing the inhaler.
B.
The client places the inhaler two fingers from the mouth.
C.
The client waits 15 seconds before using the inhaler a second time.
D.
The client exhales slowly using purse lipped breathing.
-
The client with COPD may lose weight despite having adequate caloric intake. When counseling the client in ways to maintain an optimal weight, the nurse should tell the client to:
A.
Continue the same caloric intake and increase the amount of fat intake
B.
Increase his activity level to stimulate his appetite
C.
Increase the amount of complex carbohydrates and decrease the amount of fat intake
D.
Decrease the amount of complex carbohydrates while increasing calories, protein, vitamins, and minerals
-
The client has been receiving garamycin 65 mg IVPB every 8 hours for the past 6 days. Which lab result indicates an adverse reaction to the medication?
A.
WBC 7500
B.
Serum glucose 92
C.
Protein 3.5
D.
Serum creatinine 2.0
Answer Rationales
- Answer B is correct. Clients with emphysema develop a barrel chest due to the trapping of air in the lungs, causing them to hyperinflate. Answers C and D are common in those with emphysema but do not cause the chest to become barrel shaped. Answer A does not occur in emphysema.
- Answer B is correct. The client with chronic obstructive pulmonary disease has increased difficulty breathing when lying down. His respiratory effort is improved by standing or sitting upright or by having the bed in high Fowler's position. Answers A, C, and D do not alleviate the client's dyspnea; therefore they are incorrect.
- Answer C is correct. The FEV1/FVC ratio indicates disease progression. As COPD worsens, the ratio of FEV1 to FVC becomes smaller. Answers A and B reflect loss of elastic recoil due to narrowing and obstruction of the airway. Answer D is increased in clients with obstructive bronchitis.
- Answer D is correct. In clients with COPD, respiratory effort is stimulated by hypoxemia. Answers A and C are incorrect because higher levels would rob the client of the drive to breathe. Answer B is an incorrect statement.
- Answer A is correct. Changes in smoking patterns should be discussed with the physician because they have an impact on the amount of medication needed. Answer B is incorrect because clients with COPD are placed on expectorants, not antitussives. Answer C is incorrect because an annual influenza vaccine is recommended for all those with lung disease. Answer D is incorrect because benefits from inhaler use should be increased when the client stops smoking.
- Answer A is correct. The therapeutic range for aminophylline is 10–20 mcg/ml. Answers B and D are incorrect. There are no indications that the results are questionable; therefore, repeating the test as offered by answer C is incorrect.
- Answer B is correct. Cor pulmonale, or right sided heart failure, is a possible complication of emphysema. Answers A and D do not cause weight gain, so they're incorrect. Answer C would be reflected in pulmonary edema, so it's incorrect.
- Answer C is correct. The client should wait 60 seconds before using the inhaler a second time. The client's wait time of 15 seconds indicates that the client needs further teaching. Answers A, B, and D indicate that the client understands the correct use of the inhaler.
- Answer D. The client with COPD needs additional calories, protein, vitamins, and minerals. Answer A is incorrect because the client needs more calories but not more fat. Answer B is not feasible, will increase the O2 demands, and will result in further weight loss. Answer C leads to excess acid production and an increased respiratory workload.
- Answer D is correct. The serum creatinine is elevated, indicating renal impairment. Answers A, B, and C are within normal limits.
Suggested Readings and Resources
- Centers for Disease Control and Prevention: www.cdc.gov.
- American Lung Association: www.lungusa.org.
- The Pathology Guy: www.pathguy.com.
- Health24: www.health24.com.
- Ignatavicius, D., and Workman, S. Medical Surgical Nursing: Critical Thinking for Collaborative Care. 6th ed. Philadelphia: Elsevier, 2008.
- Brunner, L., and Suddarth, D. Textbook of Medical Surgical Nursing. 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2009.
- LeMone, P., and Burke, K. in Medical Surgical Nursing: Critical Thinking in Client Care. 4th ed. Upper Saddle River, NJ: Pearson Prentice Hall, 2008.
- Lewis, S., Heitkemper, M., Dirksen, S., O'Brien, P,. and Bucher, L. Medical Surgical Nursing: Assessment and Management of Clinical Problems. 7th ed. Philadelphia: Elsevier, 2007.
- Lehne, R. Pharmacology for Nursing Care. 7th ed., Philadelphia: Elsevier, 2009.