Editing Medical-Surgical Nursing (section)

== Respiratory Disorders ==

=== Chronic Obstructive Pulmonary Disease ===

Chronic obstructive pulmonary disease encompasses emphysema, in which alveolar walls are destroyed and air trapping occurs, and chronic bronchitis, in which airway inflammation and mucus production dominate. Findings include a prolonged expiratory phase, barrel chest, use of accessory muscles, wheezes and diminished breath sounds, chronic productive cough, clubbing, and weight loss.

Nursing interventions: teach pursed-lip breathing to prevent airway collapse on exhalation, diaphragmatic breathing, tripod positioning, energy conservation, adequate hydration to thin secretions, small frequent high-calorie meals because eating is tiring and a full stomach worsens dyspnea, and smoking cessation, which is the only intervention that slows disease progression.

Nursing application: many patients with advanced disease are chronic carbon dioxide retainers. Oxygen is titrated to the lowest effective flow, commonly targeting an oxygen saturation of about eighty-eight to ninety-two percent, because excessive oxygen can worsen ventilation-perfusion mismatch and blunt respiratory drive. Oxygen is never withheld from a hypoxemic patient, but it is given deliberately and monitored.

=== Asthma ===

Asthma is reversible airway inflammation, bronchospasm, and mucus plugging. Findings include wheezing, chest tightness, cough that is often worse at night, prolonged expiration, and decreased peak expiratory flow.

Nursing application: a sudden absence of wheezing in a patient who is still in distress is ominous, not reassuring. It means airflow has become too limited to generate sound and signals impending respiratory failure. Escalate immediately.

Medication teaching: use the short-acting beta agonist rescue inhaler first, wait the recommended interval, then use the inhaled corticosteroid, and rinse the mouth after the corticosteroid to prevent oral candidiasis. A spacer improves delivery. Peak flow in the green zone is eighty to one hundred percent of personal best, yellow is fifty to seventy-nine percent and signals caution, and red is below fifty percent and requires rescue medication and prompt help.

=== Pneumonia ===

Pneumonia is infection and inflammation of lung parenchyma with consolidation. Findings include fever, chills, productive cough, pleuritic chest pain, tachypnea, crackles, bronchial breath sounds over consolidated areas, dullness to percussion, increased tactile fremitus, and hypoxemia.

Nursing interventions: obtain sputum cultures before starting antibiotics when possible, give antibiotics promptly, encourage fluids, provide incentive spirometry and coughing and deep breathing, position with the good lung down when one lung is affected to optimize perfusion to the better lung, and mobilize the patient early.

Nursing application: in older adults the presenting sign of pneumonia is frequently new confusion, a fall, or decreased appetite rather than fever and cough. Treat new confusion in an older adult as a red flag requiring investigation.

=== Tuberculosis ===

Tuberculosis is caused by ''Mycobacterium tuberculosis'' and spreads by the airborne route. Findings include a cough lasting more than three weeks, hemoptysis, night sweats, low-grade afternoon fever, fatigue, and unintentional weight loss.

Infection control: place the patient in an airborne infection isolation room with negative pressure, wear a fitted N95 respirator or higher, keep the door closed, and place a surgical mask on the patient during transport outside the room. Diagnosis is confirmed by sputum acid-fast bacillus smears and culture; a positive skin test indicates exposure, not active disease.

Medications: rifampin turns urine, sweat, and tears orange and reduces the effectiveness of oral contraceptives. Isoniazid is hepatotoxic and causes peripheral neuropathy, which is why pyridoxine (vitamin B6) is given with it. Pyrazinamide is hepatotoxic and raises uric acid. Ethambutol can cause optic neuritis, so the patient reports any change in vision or color discrimination. Therapy lasts many months, and adherence, often by directly observed therapy, is the central nursing concern.

=== Pulmonary Embolism ===

A thrombus, usually from a deep vein thrombosis, occludes pulmonary arterial flow. Onset is sudden: dyspnea, pleuritic chest pain, tachypnea, tachycardia, anxiety, and sometimes hemoptysis or syncope. Massive embolism causes hypotension and cardiac arrest.

Nursing interventions: raise the head of the bed, give oxygen, notify the rapid response team or provider immediately, obtain intravenous access, and anticipate computed tomography pulmonary angiography, anticoagulation, and in severe cases thrombolysis or embolectomy. Prevention through early ambulation, sequential compression devices, and prophylactic anticoagulation is the highest-value nursing action.

=== Acute Respiratory Distress Syndrome ===

Diffuse alveolar-capillary membrane injury causes noncardiogenic pulmonary edema. The hallmark is refractory hypoxemia, meaning the oxygen saturation does not improve despite increasing supplemental oxygen, with bilateral infiltrates on chest imaging and no evidence of cardiogenic cause. Management is mechanical ventilation with low tidal volume lung-protective settings, positive end-expiratory pressure, prone positioning in selected patients, and treatment of the underlying cause, commonly sepsis, aspiration, trauma, or pancreatitis.

=== Chest Tubes ===

A chest tube drains air, blood, or fluid from the pleural space and restores negative pressure so the lung can reexpand.

Expected findings include gentle tidaling, which is fluctuation of the fluid level in the water seal chamber with respiration, and intermittent bubbling in the water seal only when the patient coughs or exhales in the case of a pneumothorax. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires assessment of connections and the insertion site. Cessation of tidaling can mean the lung has reexpanded or that the tubing is obstructed or kinked.

Nursing application: keep the drainage system upright and below chest level, do not routinely clamp the tube because clamping can create a tension pneumothorax, do not strip or milk the tubing, and keep sterile occlusive dressing supplies at the bedside. If the tube becomes disconnected from the drainage system, place the end in sterile water. If the tube is pulled out of the chest, cover the site with a dressing taped on three sides and notify the provider immediately.