NSG 3800 EXAM 2 STUDY GUIDE
Unit 3
Infection or Inflammation of the Lungs PPT:
●Aspiration p. 559-600
○Etiology
■Inhalation of foreign material
■Secretions or stomach contents
○Pathophysiology
■Aspiration pneumonia develops after inhalation of colonized oral or
pharyngeal material
■Acute inflammatory response
■Blockage if stomach contents
■Acid gastric juice-destructive to alveoli
○Prevention
■Monitor LOC
■Monitor reflexes and swallowing difficulty
●Impaired gag reflex → risk!
■HOB elevated
■Minimal sedatives → b/c you can aspirate if you decrease LOC
■Enteral tube feeding - confirming location, check residual, avoid if high
risk
●If high risk → avoid bolus feedings
■Ensure swallow study
■ETT cuff pressure maintained
●Ensure the cuff is inflated to seal off the airway
●Sleep Apnea (p. 567-568)
○Neurologic origin
○Obesity
○Large uvula
○Short neck
○Smoking
○Enlarged tonsils or adenoids
○Obstruction by soft palate or tongue
○Treatment *depends on what is causing sleep apnea*
■CPAP
■If tonsils are enlarged or adenoids → surgery
■Obstruction by soft palate → surgery
○S/S
■Loud snoring
1
, ■Excessive daytime sleepiness
■Frequent episodes of obstructed breathing during sleep
■Morning headache
■Unrefreshing sleep
■Dry mouth upon awakening
●Pneumonia (p.587 - 596)
○Types
■Community-acquired
■Health care-associated pneumonia
■Hospital-acquired
■Ventilator-associated
■Aspiration
■Immunocompromised host
○S/S
■Chills, fever pleuritic chest pain, tachypnea, and respiratory distress
■Viral, mycoplasma, or legionella: relative bradycardia
■Headache, low-grade fever, pleuritic pain, myalgia, rash, and pharyngitis
●Low-temperature elevation - viral
●High-temperature elevation - bacterial
●Pleuritic pain - able to distinguish b/c its accompanied with
respirations whereas cardiac pain is constantly present
■Orthopnea, crackles, increased tactile fremitus, purulent sputum
●Orthopnea - tripoding position
●Tactile fremitus - mucus and fluids cause a dull vibration (normal
is strong and clear vibrations)
■Obstruction of bronchioles, decreased gas exchange, increased exudate
■Cough
○Diagnostic Tests
■Sputum Collection
●Nasotracheal suctioning device where you suction and it contains a
sputum trap
○Need patient to do:
■Oral hygiene
■Deep breathing
○Best first thing in the morning is best!
○We have 6 hours to start antibiotic after dx w/ pneumonia
■Chest Xray
■ABGs if in a lot of respiratory distress
■Blood culture
■Bronchoscopy may be used for acute severe infection
2
,●Nursing Diagnosis
○Activity intolerance r/t imbalance b/w o2 supply and demand
○Ineffective airway clearance r/t inflammation and presence of secretions
○Impaired gas exchange r/t decreased functional lung tissue
○Risk for concussion r/t hypoxia
■Patient dx w/ pneumonia and has changes in LOC → Hypoxia in the brain
●Monitor for restlessness, agitated, sudden confusion
○First action to take: check the patient’s pulse ox
○Nursing Process: Assessment
■VS
■Secretions: amount, odor, color
■Cough: frequency and severity
■Tachypnea, SOB
■Inspect and auscultate chest (going to trend them checking if they are
getting better/worse)
■Changes in mental status, fatigue, edema, dehydration, concomitant heart
failure, especially in older adult patients
○Nursing Process: Planning
■Improved airway patency
■Increased activity as tolerated
●So need to assess what “tolerated” means for the patient
■Maintenance of proper fluid volume
■Maintenance of adequate nutrition
■Understanding of the treatment protocol and preventive measures
■Absence of complications
○Medical Mgmt
■Hydration
■Oxygenation w/ humidification
■Antibiotics/ Antivirals
■Bronchodilators
■Anti-inflammatories
■Administration of antibiotic as determined by the results of a culture and
sensitivity
■Supportive treatment includes fluids, oxygen for hypoxia
■Medications
●NSAIDS (as MD prescribed), antitussives (Dextromethorphan,
p608), decongestants (Pseudoephedrine, p604), antihistamines
(Hydroxyzine, p750)
○Nursing Care
■Face mask or nasal cannula
3
, ■Coughing techniques
■Chest physiotherapy
●Percussion
●No postural drainage if they are in acute distress (only when they
stabilize)
■Position changes
■Incentive spirometry
■Nutrition
■Rest
■Activity as tolerated
■Patient teaching
●Take medication as prescribed
●Hand hygiene/ respiratory etiquette
●How to use the incentive spirometer (IS)
●Hydration: what type of fluids they can have (no coffee, tea or cola
b/c diuretics)
●Rest and activity
●Nutrition: high protein diet
■Self-care
■Gerontological Considerations
●Classic s/s of pneumonia may be absent or masked
●Complaint is usually over acute confusion or delirium
○Expected Outcomes
■Improved airway patency
■Rests and conserves energy and then slowly increasing activity
■Maintains adequate hydration, adequate dietary intake
■Verbalizes increased knowledge about mgmt strategies
■Complies w/ mgmt strategies
■Exhibits no complications
○Complications
■Respiratory failure → Require intubation
●Tuberculosis (p. 600-605)
○S/S
■Insidious
■Low-grade fever that occurs in the later afternoon
■Cough; nonproductive or mucopurulent; hemoptysis (Lasting at least 2
weeks)
■Night sweats (cold), fatigue, unexplained weight loss
■Malaise
■Anorexia
4
Unit 3
Infection or Inflammation of the Lungs PPT:
●Aspiration p. 559-600
○Etiology
■Inhalation of foreign material
■Secretions or stomach contents
○Pathophysiology
■Aspiration pneumonia develops after inhalation of colonized oral or
pharyngeal material
■Acute inflammatory response
■Blockage if stomach contents
■Acid gastric juice-destructive to alveoli
○Prevention
■Monitor LOC
■Monitor reflexes and swallowing difficulty
●Impaired gag reflex → risk!
■HOB elevated
■Minimal sedatives → b/c you can aspirate if you decrease LOC
■Enteral tube feeding - confirming location, check residual, avoid if high
risk
●If high risk → avoid bolus feedings
■Ensure swallow study
■ETT cuff pressure maintained
●Ensure the cuff is inflated to seal off the airway
●Sleep Apnea (p. 567-568)
○Neurologic origin
○Obesity
○Large uvula
○Short neck
○Smoking
○Enlarged tonsils or adenoids
○Obstruction by soft palate or tongue
○Treatment *depends on what is causing sleep apnea*
■CPAP
■If tonsils are enlarged or adenoids → surgery
■Obstruction by soft palate → surgery
○S/S
■Loud snoring
1
, ■Excessive daytime sleepiness
■Frequent episodes of obstructed breathing during sleep
■Morning headache
■Unrefreshing sleep
■Dry mouth upon awakening
●Pneumonia (p.587 - 596)
○Types
■Community-acquired
■Health care-associated pneumonia
■Hospital-acquired
■Ventilator-associated
■Aspiration
■Immunocompromised host
○S/S
■Chills, fever pleuritic chest pain, tachypnea, and respiratory distress
■Viral, mycoplasma, or legionella: relative bradycardia
■Headache, low-grade fever, pleuritic pain, myalgia, rash, and pharyngitis
●Low-temperature elevation - viral
●High-temperature elevation - bacterial
●Pleuritic pain - able to distinguish b/c its accompanied with
respirations whereas cardiac pain is constantly present
■Orthopnea, crackles, increased tactile fremitus, purulent sputum
●Orthopnea - tripoding position
●Tactile fremitus - mucus and fluids cause a dull vibration (normal
is strong and clear vibrations)
■Obstruction of bronchioles, decreased gas exchange, increased exudate
■Cough
○Diagnostic Tests
■Sputum Collection
●Nasotracheal suctioning device where you suction and it contains a
sputum trap
○Need patient to do:
■Oral hygiene
■Deep breathing
○Best first thing in the morning is best!
○We have 6 hours to start antibiotic after dx w/ pneumonia
■Chest Xray
■ABGs if in a lot of respiratory distress
■Blood culture
■Bronchoscopy may be used for acute severe infection
2
,●Nursing Diagnosis
○Activity intolerance r/t imbalance b/w o2 supply and demand
○Ineffective airway clearance r/t inflammation and presence of secretions
○Impaired gas exchange r/t decreased functional lung tissue
○Risk for concussion r/t hypoxia
■Patient dx w/ pneumonia and has changes in LOC → Hypoxia in the brain
●Monitor for restlessness, agitated, sudden confusion
○First action to take: check the patient’s pulse ox
○Nursing Process: Assessment
■VS
■Secretions: amount, odor, color
■Cough: frequency and severity
■Tachypnea, SOB
■Inspect and auscultate chest (going to trend them checking if they are
getting better/worse)
■Changes in mental status, fatigue, edema, dehydration, concomitant heart
failure, especially in older adult patients
○Nursing Process: Planning
■Improved airway patency
■Increased activity as tolerated
●So need to assess what “tolerated” means for the patient
■Maintenance of proper fluid volume
■Maintenance of adequate nutrition
■Understanding of the treatment protocol and preventive measures
■Absence of complications
○Medical Mgmt
■Hydration
■Oxygenation w/ humidification
■Antibiotics/ Antivirals
■Bronchodilators
■Anti-inflammatories
■Administration of antibiotic as determined by the results of a culture and
sensitivity
■Supportive treatment includes fluids, oxygen for hypoxia
■Medications
●NSAIDS (as MD prescribed), antitussives (Dextromethorphan,
p608), decongestants (Pseudoephedrine, p604), antihistamines
(Hydroxyzine, p750)
○Nursing Care
■Face mask or nasal cannula
3
, ■Coughing techniques
■Chest physiotherapy
●Percussion
●No postural drainage if they are in acute distress (only when they
stabilize)
■Position changes
■Incentive spirometry
■Nutrition
■Rest
■Activity as tolerated
■Patient teaching
●Take medication as prescribed
●Hand hygiene/ respiratory etiquette
●How to use the incentive spirometer (IS)
●Hydration: what type of fluids they can have (no coffee, tea or cola
b/c diuretics)
●Rest and activity
●Nutrition: high protein diet
■Self-care
■Gerontological Considerations
●Classic s/s of pneumonia may be absent or masked
●Complaint is usually over acute confusion or delirium
○Expected Outcomes
■Improved airway patency
■Rests and conserves energy and then slowly increasing activity
■Maintains adequate hydration, adequate dietary intake
■Verbalizes increased knowledge about mgmt strategies
■Complies w/ mgmt strategies
■Exhibits no complications
○Complications
■Respiratory failure → Require intubation
●Tuberculosis (p. 600-605)
○S/S
■Insidious
■Low-grade fever that occurs in the later afternoon
■Cough; nonproductive or mucopurulent; hemoptysis (Lasting at least 2
weeks)
■Night sweats (cold), fatigue, unexplained weight loss
■Malaise
■Anorexia
4
