Anatomy and Physiology:

A. Function of the Lungs

1. Respiration: overall process by which exchange takes place between the atmosphere and the cells
of the body. Normal adult respiratory rate: 12-20 breaths per minute.
2. Ventilation: movement of air in and out of the airways, intermittently replenishing the oxygen and
removing the carbon dioxide from the lungs
3. Dead space: the 150 cc area where there is no air exchange; anatomically from the nose and mouth
to the alveoli. Therefore, 150 cc of the tidal volume is not used in any air exchange.

B. Factors Affecting Airflow

1. Normally airways are open, moist, intact, and not inflamed. Cilia clear foreign substances.
2. Objective of care is to keep the airways healthy by the nursing interventions:
a. Promote adequate fluid intake
b. Prevent exposure to infections
c. Decrease exposure to tobacco smoke
d. Decrease environmental pollutants
e. Avoid triggers which cause inflammation of airways, such as allergens
3. If airways are affected, the diameter of the airways narrows causing an increase in airway
resistance.

C. General Causes of Airway Illnesses Are:

1. Infections which cause mucus and swelling
2. Allergens which cause swelling and bronchospasm
3. Foreign bodies which cause obstruction
4. Obstructive disorders: COPD, bronchiectasis
5. Restrictive disorders: kyphoscoliosis, abdominal distension, edema
6. Trauma: stab wound, surgery

Diagnostic Test

A. Chest X-ray: noninvasive procedure with no special preparation; lead shield for women of
childbearing age
B. Mantoux Test: positive result only indicates client was exposed to Tuberculosis (TB); it is
not diagnostic for active TB
1. Upper 1/3 inner surface forearm
2. Needle bevel up
3. 0.1 ml of purified protein derivative (PPD) subdermal
4. Read in 48-72 hours
5. Measure induration: if 10 mm or greater, it is a positive reading

C. Sputum Examination: first morning specimen preferable, approximately 15 ml required;

always obtain before initiating antibiotics
D. Thoracentesis: aspiration of pleural fluid and/or air from the pleural space
1. Preparation
a. Consent and explanation
b. Position: sitting on side of bed with feet on chair, leaning over bedside table
c. No more than 1,200 ml should be removed at one time
2. Post-procedure
a. Apply pressure to puncture site
b. Use Semi-Fowler's position or puncture site up
c. Monitor for shock, pneumothorax, respiratory arrest, subcutaneous
emphysema
d. Assess breath sounds

E. Bronchoscopy: examination of tracheobronchial tree using a bronchoscope

>> Oscopy = putting a lighted instrument into an opening to view something

1. Preparation
a. Consent and explanation
b. NPO after midnight
c. Assess lung function
1. ABG, oxygen administration (02 saturation), Chest X-ray
2. Post-procedure
a. Keep client NPO until return of gag reflex is confirmed
b. Monitor vital signs until stable
c. Assess for respiratory distress
d. Administer warm saline gargles after gag reflex returns (warm fuzzies)
e. Use Semi-Fowler's position (good aeration)
f. Deep breaths
g. Give water as first fluid
 h. Inform client that it is possible to expectorate some blood tinged mucus
secretions, especially when a biopsy was performed.

A. Chronic Airflow Limitation (CAL): also called Chronic Obstructive Pulmonary Disease (COPD)
1. Definition: a group of chronic lung diseases including pulmonary emphysema, chronic
bronchitis, and bronchial asthma
2. Major diseases
a. Pulmonary emphysema ("pink puffer")
1. Definition: destruction of alveoli, narrowing of small airways (bronchioles)
and the trapping of air resulting in loss of lung elasticity
2. Etiology: cigarette smoking (#1 preventable cause of respiratory problems),
deficiency of alpha anti-trypsin (enzyme that blocks the action of proteolytic
enzymes that are destructive to elastin and other substances in the alveolar
walls)
3. Manifestations
a. Shortness of breath
b. Difficult exhalation
c. Pursed-lip breathing
d. Wheezing, crackles
e. Shallow rapid respirations
f. Hypoxia (deficiency of oxygen)
g. Productive cough (not much sputum)
h. Respiratory acidosis
i. Barrel chest (CO2 is trapped inside lungs; working very hard at
breathing)
j. Anorexia, weight loss
k. Finger clubbing
l. Low flow oxygen (1 liter)
m. Neck vein distention
n. Circumoral cyanosis
o. Increased metabolic rate
p. Lower 02 saturation (95-100)
q. Finger clubbing
4. Nursing Interventions
a. Position sitting up, leaning forward
b. Provide pulmonary toilet
1. Bronchodilator medications via nebulization as ordered
2. Chest physiotherapy/pulmonary drainage (CPT/PD)
3. Assess if effective by checking the breath sounds and the
pulse oximetry on a routine basis.
c. Encourage frequent rest periods
d. Use intermittent positive pressure breathing (IPPB)
e. Administer oxygen at low flow (under most circumstances, limited to
1 liter, but may go no higher than a maximum 3 liters or less): to
prevent CO 2 narcosis
f. Encourage fluids: 2000-3000 cc per day if not contraindicated
g. Administer prophylactic antibiotics, as ordered
h. Provide appropriate nutrition: decrease carbohydrates in order to
decrease carbon dioxide. Increase calories and protein to meet
increased energy requirements. Lower intake of gas forming foods
to decrease dyspnea and SOB.
i. Promote deep breathing exercises
j. Promote energy conservation exercises to enhance rest
k. Provide emotional support to decrease anxiety
l. Address sexual concerns
m. Provide teaching
1. Avoid crowds
2. Diaphragmatic breathing
3. Pursed-lip breathing
4. Report first sign of upper respiratory infection (URI)
5. Avoid allergens (examples: dust, odors, dander, etc.)

b. Chronic bronchitis (blue bloater)

1. Definition: excessive mucus secretions within the airways and recurrent
cough
2. Etiology: heavy cigarette smoking, pollution, infection
3. Manifestations
a. Cough (copious sputum)
b. Dyspnea on exertion, later at rest
c. Hypoxemia resulting in polycythemia: ruddy look to skin,
compensation
d. Crackles, rhonchi
 e. Pulmonary hypertension leading to cor pulmonale and signs of right
heart failure such as peripheral dependent edema

4. Nursing Interventions
a. Prevent exposure to irritants
b. Reduce irritants
c. Increase humidity: 70% is best
d. Relieve bronchospasm through deep breathing and medications
e. Provide chest physiotherapy (CPT)
f. Provide postural drainage (PD)
g. Promote breathing techniques; same as COPD

c. Asthma
1. Definition: condition of abnormal bronchial hyperreactivity to certain
substances
2. Etiology
a. Extrinsic: antigen-antibody reaction triggered by food, drugs, or
inhaled particles
b. Intrinsic: pathophysiological conditions within the respiratory tract,
non-allergic form

3. Manifestations: acute attack

a. Severe, sudden dyspnea
b. Use of accessory muscles; for adults neck muscles; child will get retractions
c. Sitting up
d. Diaphoresis
e. Anxiety, apprehension
f. Wheezing
g. Cyanosis: very late sign
h. Remember, an improvement in wheezes with no improvement in the client's
condition may actually indicate worsening of the condition and tightening of
airways to the point where air flow is diminishing
i. Decrease in tidal volume is measured by a spirometer

4. Nursing Interventions
a. Remain with client
b. Use High-Fowler's position
c. Provide emotional support
d. Monitor respiratory status: ABGs, lung sounds, and pulse oximetry
e. Promote hydration with fluids
f. Administer epinephrine hydrochloride (Adrenalin) subcutaneously and monitor its
effectiveness
g. Administer aminophylline, theophylline and ethylenediamine (Phyllocontin) IV
1. Monitor for side effects such as GI upsets (nausea and vomiting) and
seizures
2. Monitor theophylline level to assure therapeutic action and eliminate toxic
effects: therapeutic serum level is 10-20 mcg/ml

h. Provide bronchodilators via nebulization and metered dose inhalers (MDI)

i. Monitor oxygen therapy
j. Administer corticosteroids: to decrease airway inflammation and open airways

5. Status Asthmaticus: attack lasting more than 24 hours; medical emergency

h. Use High-Fowler's position
i. Monitor vital signs for signs of hypoxia
j. Monitor respiratory status
k. Administer aminophylline (Phyllocontin) IV as ordered
l. Administer bronchodilator therapy as ordered
m. Provide emotional support

B. Complications of CAL

1. Cor Pulmonale (form of heart failure)

a. Definition: right ventricular hypertrophy or failure secondary to disease of the lungs,
pulmonary vessels or chest wall
b. Etiology: causes increased pressure and pulmonary hypertension
1. Decrease in the size of the pulmonary vascular bed from destruction of the
pulmonary capillaries
2. Increased resistance of pulmonary capillary bed
3. Shunting of unaerated blood across the collapsed alveoli
 c. Manifestations: signs of heart failure; initially the right heart fails, then the left heart fails
because of decreased cardiac output
1. Right heart failure
a. Peripheral edema (dependent)
b. Jugular vein distension
2. Left heart failure
a. Dyspnea
b. Cyanosis
c. Cough
d. Substernal pain
e. Syncope on exertion
f. Paroxysmal nocturnal dyspnea (PND)and orthopnea

d. Nursing Interventions
1. Promote bed rest
2. Monitor oxygen therapy
3. Maintain low-sodium diet
4. Monitor for side effects of digitalis (Digoxin) and diuretics

2. Carbon dioxide narcosis/oxygen toxicity

a. Definition: near comatose state secondary to increased CO 2 due to chronic retention
b. Etiology: carbon dioxide retention and secondary to excessive oxygen delivery
c. Manifestations: signs of hypoxia
1. Drowsy
2. Irritable
3. Hallucinations
4. Coma
5. Paralysis
6. Convulsions
7. Tachycardia
8. Arrythmias
9. Poor ventilation

d. Nursing Interventions
1. Avoid high concentrations of oxygen -keep below 3 L. per minute, no more than
70% oxygen delivered. Make sure you know the approximate concentration
delivered by the oxygen delivery method you are using Cannula: 40%; mask: 60%;
rebreather mask: 100%.
2. Monitor response to oxygen therapy; monitor blood gases. If pCO 2 level is above
normal, it is not preferable to have the oxygen at normal level because it will shut
off the hypoxic drive which is triggered by a low O 2 level. This will cause client to
go into respiratory arrest.

3. Pneumothorax
a. Definition: collection of air or fluid in the pleural space. Can come from outside chest wall
or inside the lung.
b. Etiology
1. Trauma: gunshot, stabbing
2. Thoracic surgery: open thoracotomy
3. Positive pressure ventilation: causes segment of the lung to rip open, expose
pleural space.
4. Iatrogenic (something that occurs as a result of something else), adverse effects of
a. Thoracentesis = putting needles
b. Central venous pressure line insertion
c. Unknown cause
c. Types
1. Spontaneous
2. Tension: due to build up of pressure. Results in a shift of the major organs and
vessels in the chest cavity.
3. Open: from trauma such as a gunshot or stab wound

d. Manifestations: depend on severity

1. Spontaneous
a. Sudden, sharp chest pain
b. Sudden shortness of breath with violent attempts to breathe
c. Hypotension
d. Tachycardia
e. Hyperresonance and decreased breath sounds over the affected lung
f. Anxiety, diaphoresis, restlessness
2. Tension
a. Subcutaneous emphysema (crepitus), dyspnea
b. Cyanosis
 c. Acute chest pain
d. Tympany on percussion
3. Mediastinal shift: contents of mediastinum pushed to unaffected side
1. Cyanosis
2. Tracheal deviation-away from injured side
3. Cardiovascular compromise: may have signs and symptoms depending on degree
of deviation

e. Nursing Interventions
1. Remain with client and remain calm
2. Position in High-Fowler's
3. Assess vital signs and breath sounds
4. Provide oxygen therapy as ordered
5. Prepare for chest x-ray
6. Provide thoracentesis tray to reestablish negative pressure or relieve pressure with
tension pneumothorax
7. Monitor ABGs
8. Monitor for shock
9. Assist with insertion of chest tubes
a. At the bedside or in operating room by physician
b. Aseptic technique
c. Local anesthetic, stab wound
1. Upper for evacuation of air
2. Lower for evacuation of fluid
d. Occlusive dressing

Closed Chest Drainage

1. Purposes
a. Remove fluid and/or air from the pleural space
b. Reestablish normal negative pressure in the pleural space
c. Promote re-expansion of the lung
d. Prevent reflux of air/fluid into pleural space from the drainage apparatus
e. Used commonly after thoracic surgery or pneumothorax

2. General Principles: the nurse must ask the following when confronted with any chest drainage
system:
a. Where is the water seal? How can it be maintained?
b. What controls the suction in the system? Is it gravity or is it a negative pressure? What is
the setting?
c. Where does the drainage collect, and how can I maintain the patency of this system? How
can I measure the drainage?
3. Usage: the most commonly used today are disposable chest tube systems (Pleur-evac,Thora-
seal)
a. Replacing two and three-bottle systems, these are made of molded plastic to form three
chambers.
1. Suction control chamber (closest to suction): when on should be continuously
bubbling. Amount is usually determined by a water level in the suction control
chamber.
2. Water seal chamber is middle seal; intermittent bubbling occurs if there is air in the
chest. In this area you will observe the rise and fall of fluid in the system with
respirations This is called tidaling.
3. Drainage collection (closest to chest tube)
b. Suction is controlled by the amount of water in the suction control chamber. Make sure
evaporation does not change the amount of suction by lowering the water level.

4. Nursing Interventions
a. Check for bubbling and fluctuation
b. Assess respiratory status
c. Turn client; ask client to cough, deep breathe
d. Mark the amount of drainage at the beginning of each shift. Should see a decrease in the
amount over time.
e. Note character of drainage
f. Be sure tubing is without kinks, coiled on the bed
g. Keep bottles below level of heart
h. Maintain water seal
i. Maintain dry, sterile, occlusive dressing
j. Do not strip tubes, avoid milking
k. Obtain STAT Chest x-ray (CXR)
5. Removal of chest tubes: done by physician
a. Provide equipment: suture removal kit, sterile gauze, petroleum gauze, adhesive tape
b. Use Semi-Fowler's or High-Fowler's position
 c. Instruct client on that removal of tubes will be done during expiration or at end of full
inspiration
d. Apply air-occlusive dressing immediately
e. Obtain STAT Chest x-ray
f. Assess for complications: subcutaneous emphysema, respiratory distress. Major
complication is pneumothorax

D. Infectious Pulmonary Diseases

1. Tuberculosis
a. Reportable, communicable, infectious, inflammatory disease that can occur in any
part of the body
b. Etiology: mycobacterium tuberculosis (nonmo-tile, aerobic, killed by heat and
ultraviolet light); droplet nuclei spread by laughing, sneezing, coughing. Can
spread to other areas of the body and is called miliary TB. Causes caseation in the
lungs and Ghon tubercles which can stay with the client for years, lay dormant
then open again and reinfect the client.
c. Risk factors
1. Overcrowded, poor living conditions
2. Poor nutritional status
3. Previous infection
4. Inadequate treatment of primary infection leads to multi-drug resistant
organisms
5. Close contact with infected person
6. Immune dysfunction or HIV
7. Long-term care facilities, prisons
8. Elderly
9. Substance abuse

d. Manifestations: same as other pulmonary inflammations and infections

1. Productive cough
2. Night sweats, low-grade fever
3. Hemoptysis
4. Dyspnea
5. Malaise
6. Weight loss
7. Anorexia, vomiting, indigestion
8. Pallor

e. Diagnostic tests
1. Mantoux test
2. Sputum for acid-fast bacillus, x3
3. Chest x-ray
4. History and physical exam

f. Treatment
1. Chemotherapy (all are hepatotoxic)
a. Ethambutol (Myambutol): impairs RNA synthesis; side effects: optic
neuritis, skin rash
b. Rifampicin (Rifadin): impairs RNA synthesis; side effects: red-
orange color to urine and feces; negates birth control pill; nausea,
vomiting, thrombocytopenia
c. Isoniazid (INH): interferes with DNA synthesis used in prophylactic
treatment; side effects: peripheral neuritis, hepatotoxicity, GI upset;
must take vitamin B6 (pyridoxine) (Beesix) in conjunction with this
therapy to prevent peripheral neuritis
d. Streptomycin; side effects: 8th nerve damage, use with caution in
renal disease. Should have hearing tests done routinely.

1. Nursing Interventions
a. Teaching plan includes:
1. Preventive measures to avoid catching viral infections (infection control)
2. Drugs must be taken in combination to avoid bacterial resistance
3. Drugs should be taken either once each day or 2-3 times per week, but always at
the same time of day and on an empty stomach
4. Drugs must be taken for 6-12 months
5. Maintaining adequate nutritional status
6. Promoting yearly checkups
7. Make sure the client knows to have liver function tests.
b. Hospital care
1. Teaching: hand washing, cover nose and mouth when sneezing, coughing
2. Wear special particulate respirator mask when in the client's room
 3. Isolation room ventilated to outside (negative pressure room); discontinued when
client no longer considered infectious
4. Psychological support: reinforcement of the need to take medications. Many
clients choose to stop drug therapy.

POINTS TO REMEMBER:

1. Obtain sputum specimens before drug therapy is initiated

2. Multiple drug therapy is necessary to prevent the development of resistant
organisms
3. Give drugs in a single daily dose
4. Drug therapy must be continued for 6-12 months even though the x-ray,
sputum specimens, and manifestations are within normal limits
5. Client is generally considered noninfectious after 1-2 weeks of continuous
drug therapy
6. Avoid use of alcohol during drug therapy to reduce risk of hepatotoxicity

2. Pneumonia
a. Definition: inflammation of the lung parenchyma caused by infectious agents
b. Etiology: classified as community acquired or hospital acquired (nosocomial)
1. Community acquired
a. Streptococcus pneumoniae or pneumococcal
b. Haemophilus influenzae
c. Legionella pneumonia
d. Atypical pneumonia: most commonly seen in children; usual organism is
mycoplasma pneumoniae; differs from the others in that minimal mucus is
produced
2. Hospital acquired
c. Staphylococcus aureus
d. Klebsiella pneumoniae
e. Pseudomonas pneumoniae
f. Fungi (various types, i.e., histoplasmosis)

c. Persons at risk
a. Elderly
b. Infants
c. Substance abusers
d. Cigarette smokers
e. Postoperative clients or those on prolonged bed rest
f. Clients with chronic illnesses such as COPD;CAL
g. Clients with AIDS - Pneumocystis carinii pneumonia (PCP)
h. Other immunosuppressed clients

d. Common manifestations
1. Sudden onset of chills, fever
2. Cough: dry and painful at first, later produces rusty colored sputum
3. Dyspnea
4. Flushed cheeks
5. Pallor, cyanosis
6. Pleuritic pain that increases with respiration
7. Tachypnea, tachycardia

e. Nursing Interventions
1. Administer drug therapy as ordered
1. Cough suppressants (be careful giving to children and clients who have
chest congestion; generally only given to them for sleep), expectorants
2. Bronchodilators; teach use of metered dose inhaler
3. Antibiotics as ordered
4. Mild analgesic - to decrease pain and enable client to deep breathe
2. Encourage ambulation as tolerated
3. Provide pulmonary toilet
4. Assess for sputum thickness, color
5. Administer oxygen to maintain oxygen saturations >95%
6. Provide small frequent meals, increase fluid intake
7. Maintain fluid and electrolyte balance
8. Isolate as indicated
9. Provide oral hygiene

POINTS TO REMEMBER:

1. Most pneumonias have a sudden onset

 2. Penicillin remains the drug of choice for pneumococcal pneumonias (unless
allergic to PCN)
3. Antibiotics must be given on time to maintain blood levels
4. Watch for side effects of penicillin therapy - especially allergies

E. Cancer of the Lungs (see also under oncology)

1. Definition: primary or secondary (metastatic from a primary site) malignant tumor located
in the lung or bronchi
2. Etiology: cigarette smoking, exposure to asbestos and other carcinogens (coal dust,
uranium, nickel)
3. Manifestations:
a. Asymptomatic in the early stages
b. Later stages:
1. Coughing
2. Wheezing
3. Dyspnea
4. Hemoptysis
5. Weight loss
6. Anorexia
7. Fever

c. Nursing Interventions
1. Support cessation of smoking
2. Postoperative care for lung excision
a. Pneumonectomy: removal of an entire lung (reasons: cancer, abscess); postop:
dorsal recumbent or Semi-Fowler's position on affected side; range of motion to
affected shoulder; no chest tube. Make sure nursing interventions are instituted to
prevent infection in the other lung.
b. Lobectomy: removal of a lobe for TB or abscess; postop: chest tube
c. Segmentectomy: removal of a lobe(reason: infection in localized area); postop:
chest tube
d. Wedge resection: removal of a small portion of lung tissue (reason: small localized
area of disease near the surface of the lung); postop: chest tube
3. Encourage turn, cough, deep breathe
4. Administer oxygen
5. Provide pain interventions so that client will be able to move and deep breathe
6. Promote fluids to maintain thin respiratory tract secretions
7. Instruct client to splint chest incision when coughing
8. Teach client exercises for arm on affected side to prevent frozen shoulder
9. Place needed articles on side of surgery so client will move arm to get them
10. Assess wound for infection

Pulmonary Therapies

A. Chest Physiotherapy (CPT) (using cupped hands)

1. Definition: percussion and vibration over the thorax to loosen secretions in the affected
areas of the lung
2. Procedure
a. Keep a layer of material (gown or pajamas) between your hands and the client's
skin
b. Stop if pain occurs
c. Best time to do is in the morning upon rising, 1 hour before meals or 2-3 hours
after meals
d. Client must be instructed to deep breathe and cough during the procedure
e. Should be followed with oral hygiene
3. Contraindications
d. When bronchospasm is increased by its use
e. History of pathological fractures, rib fractures, or osteoporosis
f. Obesity
g. New incisions in the chest area or upper abdominal area
h. Pain in the chest
B. Postural Drainage
0. Definition: use of gravity to drain secretions from segments of the lung; may be combined
with chest PT
1. Nursing Interventions
a. Proper positioning (lung segment to be drained is uppermost)
b. Stop if cyanosis or exhaustion increases
c. Provide mouth care after procedure; best time is in the morning upon rising, 1 hour
before meals or 2-3 hours after meals
d. Maintain position 5-20 minutes or as tolerated
2. Contraindications
a. Unstable vital signs
b. Increased intracranial pressure
C. Pulmonary Toilet
0. Cough
1. Breathe deeply
2. Chest PT
3. Turn and position

1. Bronchodilators
a. Relax airways and opens diameter thereby decreasing airway resistance
b. Common side effects include tachycardia and headache
c. Types:
1. Albuterol (Proventil)
2. Isoetharine (Bronkosol)
3. Terbutaline (Brethine)
4. Salmeterolxinafoate (Serevent)
d. Used for long-term maintenance therapy of asthma
e. Prevents bronchospasm
f. Cannot be used to treat acute symptoms