Acute Disorders of the Lower Respiratory Tract
Lobectomy: During a lobectomy, an incision is made in the chest wall for removal of a lung lobe.
Therefore, the nurse should instruct the client to expect to have a pleural chest tube to drain air and
fluid from the chest cavity and to promote lung expansion.
It is the nurse’s responsibility to acknowledge the client’s statement, to encourage verbalization, and to
explore the client’s feelings.
Bronchoscopy: Check for gag reflex
The priority action the nurse should take when using the airway, breathing, circulation approach to
client care is to confirm that the client has a gag reflex. Absence of the gag reflex places the client at risk
for impaired airway from aspiration.
Tuberculosis: Place a surgical mask on the client prior to exiting the room.
Clients who have TB can infect others because the bacteria travel into the air through normal respiration
or by cough. Therefore, to protect others from harm the nurse should place a surgical mask on the client
anytime the client is preparing to exit his room.
Rifampin will turn the urine and other secretions a harmless reddish-orange color. This includes sputum,
tears, and sweat.
A positive result does not always indicate active disease
A positive tuberculin skin test response indicates that the client has developed an immune response to
the bacillus due to exposure to the mycobacterium tuberculosis but does not confirm active disease. The
client will require further testing, such as x-ray examination, to confirm whether infection is present.
Pneumothorax:
Signs and symptoms: Dyspnea, tachypnea (respirations above 20 breaths/min), tachycardia,
restlessness, pain, anxiety, decreased movement of the involved chest wall, asymmetric chest wall
movement, diminished breath sounds on the injured side, and progressive cyanosis
A client who has a pneumothorax will have diminished or absent breath sounds on the affected side due
to partial or total collapse of the lung.
Medical treatment: Physician may insert an 18-gauge needle through chest wall into pleural space and
aspirate accumulated air or fluid, then insert a chest tube
Maintain the drainage container below the level of the client's chest.
If air is entering the pleural space from a tear in the lung or bronchus, surgery may be needed to repair
the tear
The nurse should securely tape all connections on the client’s chest tube to maintain a closed system
and prevent a break in the connection.
Lobectomy: During a lobectomy, an incision is made in the chest wall for removal of a lung lobe.
Therefore, the nurse should instruct the client to expect to have a pleural chest tube to drain air and
fluid from the chest cavity and to promote lung expansion.
It is the nurse’s responsibility to acknowledge the client’s statement, to encourage verbalization, and to
explore the client’s feelings.
Bronchoscopy: Check for gag reflex
The priority action the nurse should take when using the airway, breathing, circulation approach to
client care is to confirm that the client has a gag reflex. Absence of the gag reflex places the client at risk
for impaired airway from aspiration.
Tuberculosis: Place a surgical mask on the client prior to exiting the room.
Clients who have TB can infect others because the bacteria travel into the air through normal respiration
or by cough. Therefore, to protect others from harm the nurse should place a surgical mask on the client
anytime the client is preparing to exit his room.
Rifampin will turn the urine and other secretions a harmless reddish-orange color. This includes sputum,
tears, and sweat.
A positive result does not always indicate active disease
A positive tuberculin skin test response indicates that the client has developed an immune response to
the bacillus due to exposure to the mycobacterium tuberculosis but does not confirm active disease. The
client will require further testing, such as x-ray examination, to confirm whether infection is present.
Pneumothorax:
Signs and symptoms: Dyspnea, tachypnea (respirations above 20 breaths/min), tachycardia,
restlessness, pain, anxiety, decreased movement of the involved chest wall, asymmetric chest wall
movement, diminished breath sounds on the injured side, and progressive cyanosis
A client who has a pneumothorax will have diminished or absent breath sounds on the affected side due
to partial or total collapse of the lung.
Medical treatment: Physician may insert an 18-gauge needle through chest wall into pleural space and
aspirate accumulated air or fluid, then insert a chest tube
Maintain the drainage container below the level of the client's chest.
If air is entering the pleural space from a tear in the lung or bronchus, surgery may be needed to repair
the tear
The nurse should securely tape all connections on the client’s chest tube to maintain a closed system
and prevent a break in the connection.
