Nursing Dia

Client with Alterations in Respiratory
Function
Nancy Haugen PhD, RN
and Sandra Galura MSN, RN, CCRN, CPAN
Ulrich & Canale's Nursing Care Planning Guides (NANDA), CHAPTER 4, 116-225
Open reading mode
ASTHMA
Asthma is a disorder characterized by intermittent and reversible obstruction of the airways. This
airflow obstruction is caused by bronchial hyperresponsiveness and inflammation of the airway
mucous membranes. Allergens enter the airway and initiate the inflammatory cascade. Mast cells
found in the basement membranes of the bronchial walls degranulate and release inflammation
response mediators, which cause increased capillary permeability and vasodilation, and
recruitment of eosinophils, lymphocytes, and neutrophils. The response leads to the production
of thick, tenacious mucus that blocks the airways. Combined with the bronchial
hyperresponsiveness and capillary vasodilation and permeability, intake of air significantly
decreases, and air is trapped in the lungs below the obstruction. Chronic inflammation leads to
remodeling of the bronchial walls. The bronchial walls hypertrophy, and mucus-producing cells
undergo hyperplasia.
Asthma attacks are variable and unpredictable, range from mild to severe, and differ from client
to client. Clinical manifestations of an asthma attack include dyspnea, wheezing, chest tightness,
tachycardia, sweating, cough, tightening of neck muscles, and use of accessory muscles to
breathe. The client may also have an audible wheezing or whistling on exhalation. Indications
that asthma is becoming worse include an increase in the frequency and severity of asthma
attacks and an increased need to use bronchodilators.
There is no clear indication why some people get asthma and others, exposed to the same
conditions, do not. It is possibly due to a combination of environmental and genetic factors.
Triggers for an asthma attack also vary from client to client and may include airborne allergens
and air pollutants, viral respiratory infections, cold air, stress, medications (i.e., nonsteroidal anti-
inflammatory drugs [NSAIDs]), exercise, gastroesophageal reflex disease, smoke, and
occupational factors.
This care plan focuses on care of the adult client with asthma who is hospitalized during an
exacerbation of the illness. Much of the information is applicable to clients receiving follow-
up care in an extended care facility or home setting.
1
OUTCOME/DISCHARGE CRITERIA
The client will:
1.
Have improved respiratory function
2.
Have vital signs within client's normal range
3.
Tolerate expected level of activity
4.
Verbalize an understanding of medications ordered including rationale, food and drug

interactions, side effects, methods of administering, and importance of taking as
prescribed
5.
Demonstrate appropriate use of inhalers.
2
Nursing Diagnosis IMPAIRED RESPIRATORY
FUNCTION *
* This diagnostic label includes the following nursing
diagnoses: ineffective breathing pattern, ineffective airway
clearance, and impaired gas exchange.
Definition: Inspiration and/or expiration that does not provide adequate ventilation; inability to
clear secretions or obstructions from the respiratory tract to maintain a clear airway
Ineffective breathing pattern NDx
Related to:
Increased rate of respirations associated with fear and anxiety, and feeling of air hunger
Decreased depth of respirations associated with weakness, fatigue, fear, anxiety
Ineffective airway clearance NDx
Related to:
Narrowing of the airways associated with:
Excessive mucus production, inflammation, and bronchospasm
Bronchial wall remodeling with bronchial hypertrophy and hyperplasia of mucus-

secreting cells
3
Stasis of secretions associated with:
Difficulty coughing up secretions resulting from fatigue, weakness, and presence

of tenacious secretions if fluid intake is inadequate
Impaired ciliary function resulting from loss of ciliated epithelium (occurs with
inflammation, destruction, and fibrosis of bronchial walls)
Impaired Gas Exchange NDx
Related to:
Narrowing or obstruction of the small airways
CLINICAL MANIFESTATIONS
Subjective Objective
Rapid, shallow respirations; abnormal breath sounds wheezing;
Reports of restlessness;
cough; use of accessory muscles when breathing; significant
irritability; somnolence;
decrease in oximetry results; abnormal arterial blood gas values;
chronic cough; chest tightness
reduced activity tolerance
RISK FACTORS

Genetics
Smoking
Allergies
4
Environmental factors
DESIRED OUTCOMES
The client will maintain adequate respiratory function as evidenced by:
a.
Usual rate and depth of respiration
b.
Decreased dyspnea
c.
Usual or improved breath sounds
d.
Usual mental status
e.
Oximetry results within normal range for client
f.
Arterial blood gas values within normal range for client
NOC OUTCOMES
Respiratory status; airway patency; respiratory status: ventilation; respiratory status: gas
exchange
NIC INTERVENTIONS
Respiratory monitoring; airway management; chest physiotherapy; cough enhancement; oxygen
therapy; medication administration; ventilation assistance; cough enhancement; fear and anxiety
reduction
5
NURSING ASSESSMENT
RATIONALE
Assess for signs and symptoms Early recognition of signs and symptoms of ineffective
of impaired respiratory function: breathing patterns allows for prompt intervention.
Rapid, shallow
respirations
Rapid, shallow respirations do not provide adequate

ventilatory support. Difficulty with breathing and the need to
sit up to breathe, as well as use of accessory muscles, lead to
Dyspnea, orthopnea client fatigue and further decline in respiratory status.

Use of accessory muscles

when breathing

Changes in the characteristics of breath sounds may be due to
airway obstruction, mucus plugs, or retained secretions in
Abnormal breath sounds larger airways. Wheezing is associated with bronchospasms.
(e.g., wheezes, crackles)

Muscle fatigue/weakness may impair effective clearance of
secretions.
Cough effectiveness

Restlessness, irritability
Restlessness, irritability, and change in mental status
or level of consciousness indicate an oxygen deficiency
and require immediate treatment.
Confusion, somnolence
6
RATIONALE
The bluish discoloration of the skin and mucous

Central cyanosis (a late membranes occur in the presence of deoxygenated
sign) hemoglobin. This occurs when arterial oxygen
saturation falls below 85% to 90%.
Oximetry is a non-invasive method of measuring

arterial oxygen saturation. The results assist in
evaluating respiratory status. Decreasing PaO 2 and
Assess arterial blood gas and
increasing CO 2 are indicators or respiratory problems.
pulse oximetry values and report
abnormal findings.

Allows for evaluation of client's current oxygenation

status, so that appropriate supplemental oxygen
therapy can be implemented.
THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Implement measures to improve respiratory
status.
Positioning in semi-Fowler's position promotes
Place client in a semi-Fowler's position. D optimal gas exchange by enabling chest
expansion and diaphragm excursion.
Instruct client in breathing exercises focusing on These techniques help clients decrease the
hypoventilation, breath holding after exhalation, need for beta 2 -agonists and inhaled
and breathing through the nose. corticosteroids.
Instruct client in exercises involving shoulder
rotations and arm lifts performed in sync with This technique helps to expand the lungs.
breathing.
The irritants in smoke increase mucus
production, impair ciliary function, and can
Discourage smoking. cause inflammation and damage to the
bronchial and alveolar walls; the carbon
monoxide decreases oxygen availability.
Maintain activity restrictions and increase Conservation of energy through activity
activity as allowed and tolerated. restrictions allows energy to be focused on
7
RATIONALE
breathing. Increasing activity as tolerated
helps to mobilize secretions and promotes
deeper breathing.
Perform actions to reduce fear and anxiety (e.g.,
assure client that staff members are nearby;
The experience of anxiety during an asthma
respond to call signal as soon as possible;
attack can exacerbate the attack.
provide calm, restful environment; instruct in
relaxation techniques). D
Maintaining adequate hydration decreases the
Maintain client fluid intake of at least 2500
viscosity of secretions and improves ciliary
mL/day unless contraindicated. D
action in removing secretions.
Dependent/Collaborative Actions
Implement measures to improve respiratory
status.
Beta- 2 agonists are the treatment of choice for
Administer beta- 2 adrenergic agonists inhaled
an asthma attack because they relax airway
during an acute attack and oral for ongoing
smooth muscles and decrease
therapy. D
bronchoconstriction.
Provides support for the respiratory

system until it is able to function
Administer and monitor oxygen as
appropriately.
ordered.
The combination of helium and oxygen
Administer Heliox (a helium/oxygen
is lighter than air and easier to breathe
mixture).
when gas flow is compromised by
bronchospasms.
Corticosteroids decrease airway inflammation

Administer corticosteroids both inhaled and oral.
and thereby improve bronchial airflow.
Consult appropriate health care providers
Notifying the appropriate health care
(respiratory therapist and physician) if signs and
professionals allows for a multifaceted
symptoms of impaired respiratory function
approach to treatment.
persist or worsen.
Nursing Diagnosis ACTIVITY INTOLERANCE NDx

Definition: Insufficient physiological or psychological energy to endure or complete required or
desired daily activities
Related to:
8
Tissue hypoxia associated with impaired gas exchange
Inadequate nutrition status
Difficulty resting and sleeping associated with dyspnea, excessive coughing, fear,
anxiety, frequent assessment and treatments, and side effects of medication therapy (e.g.,
some bronchodilators, corticosteroids)
Increased energy expenditure associated with strenuous breathing efforts and persistent
coughing
Verbal report of Abnormal heart rate or blood pressure (B/P) response to activity; exertional
fatigue or discomfort or dyspnea; electrocardiographic changes reflecting dysrhythmias
weakness or ischemia; unable to speak with physical activity
RISK FACTORS

Smoking
Malnutrition
Allergens
Insomnia
DESIRED OUTCOMES
9
The client will demonstrate an increased tolerance for activity as evidenced by:
a.
Verbalization of feeling less fatigued and weak
b.
Ability to perform ADL without exertional dyspnea, chest pain, diaphoresis, dizziness,
and significant changes in vital signs
NOC OUTCOMES
Activity tolerance; endurance, fatigue level; vital signs; asthma: self-management
NIC INTERVENTIONS
Activity therapy; energy management; oxygen therapy; nutrition management; sleep
enhancement; cardiac care; cardiac rehabilitation; teaching regarding prescribed activity
NURSING ASSESSMENT
RATIONALE
Assess for signs and symptoms of activity intolerance:
Statements of fatigue or weakness
Exertional dyspnea, chest pain, diaphoresis, or dizziness

Early recognition of signs and
symptoms of activity intolerance
allows for prompt intervention.
Abnormal heart rate response to activity (e.g., increase
in rate of 20 beats/min above resting rate, rate not
returning to preactivity level within 3 minutes after
stopping activity, change from regular to irregular rate)
Significant change (15-20 mm Hg) in B/P with activity
10
RATIONALE
Independent Actions
Implement measures to promote rest and/or Cells use oxygen and fat, protein, and
conserve energy (e.g., maintain prescribed activity carbohydrates to produce the energy
restrictions, minimize environmental activity and needed for all body activities. Rest and
noise, provide uninterrupted rest periods, assist with activities that conserve energy result in a
care, keep supplies and personal articles within easy lower metabolic rate, which preserves
reach, limit the number of visitors, use shower chair nutrients and oxygen for necessary
when showering, sit to brush teeth or comb hair). D activities.
Implement measures to promote sleep (e.g., elevate
head of bed and support arms on pillows to facilitate
Sleep replenishes a client's energy and
breathing, maintain oxygen therapy during sleep,
feelings of well-being.
discourage intake of fluids high in caffeine in the
evening, reduce environmental stimuli). D
Altered respiratory function such as
Implement measures to decrease excessive excessive coughing can lead to inadequate
coughing and frequency of asthma attacks (e.g., tissue oxygenation, which results in less
protect client from exposure to irritants such as efficient energy production and a reduced
smoke, flowers, and powder; avoid extremely hot or ability to tolerate activity. Improving
cold foods/fluids). D respiratory status increases the amount of
oxygen available for energy production.
Excessive intake of nicotine and caffeine
Discourage smoking and excessive intake of
can increase cardiac workload and
beverages high in caffeine such as coffee, tea, and
myocardial oxygen utilization, thereby
colas.
decreasing oxygen availability.
Perform actions to improve respiratory status (e.g.,
Improvement of respiratory status is done
place client in semi- to high-Fowler's position;
to relieve dyspnea, decrease frequency of
instruct client to deep breathe or use incentive
asthma attacks, and improve tissue
spirometry every 1 to 2 hours; maintain bed rest as
oxygenation.
ordered; and use oxygen as needed). D
Perform actions to maintain adequate nutritional
status (e.g., increase activity as tolerated potentially
improving appetite; encourage a rest period before Adequate nutritional status is important in
meals to reduce fatigue; assist with oral hygiene order to maintain ADL.
before meals; maintain a clean environment and a
relaxed, pleasant atmosphere). D
Instruct a client to: Changes in a client's activity tolerance
should be reported immediately.
Assessment of the change will allow for
timely diagnosis of the cause and
Report a change in the frequency and subsequent treatment.
consistency of asthma attacks.
11
RATIONALE
Report a decreased tolerance for activity.
Stop any activity that causes increased chest

pain, increased shortness of breath,
dizziness, or extreme fatigue or weakness.
Consult appropriate health care providers (e.g.,
respiratory therapist, physician, dietitian) if signs
provider allows for modification of the
and symptoms of activity intolerance persist or
treatment plan.
worsen.
DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx ;
INEFFECTIVE HEALTH MAINTENANCE NDx ; OR
INEFFECTIVE SELF-HEALTH MANAGEMENT *
* The nurse should select the diagnostic label that is most
appropriate for the client's discharge teaching.
NDx
Definition: Absence or deficiency of cognitive information related to specific topic (lack of
specific information necessary for clients/significant others) to make informed choices regarding
condition/treatment/lifestyle changes; inability to identify, manage, and/or seek out help to
manage health pattern of regulating and integrating into daily living a therapeutic regimen for
treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health
goals
Verbalizes inability to manage illness; verbalizes inability Increased frequency and intensity of
to follow prescribed regimen asthma attacks
12
RISK FACTORS

Cognitive deficit
Financial concerns
Smoking
Inability to care for oneself
Difficulty in modifying personal habits and integrating treatments into lifestyle
NURSING ASSESSMENT
RATIONALE
Assess client readiness

and ability to learn Early recognition of client's readiness to learn and meaning of
their illness allows for implementation of the appropriate
Assess meaning of teaching interventions.
illness to client
NOC OUTCOMES
Knowledge: treatment regimen; knowledge: energy conservation; knowledge: treatment
procedure(s); knowledge: health resources; knowledge: illness care; compliance behavior; health
beliefs; perceived ability to perform: knowledge of treatment regimen
NIC INTERVENTIONS
13
Health system guidance; teaching: individual; teaching: disease process; teaching: prescribed
activity/exercise; teaching: prescribed medication; self-modification assistance; values
clarification; discharge planning; medication management; smoking cessation assistance
RATIONALE
Desired Outcome: The client will identify ways
to prevent or minimize respiratory problems.
Independent Actions
Instruct client in ways to maintain respiratory
health:

Good general health supports the individual's
Maintain overall general good health ability to fight off infection.
(e.g., reduce stress, eat a well-balanced
diet, obtain adequate rest).
Stop smoking.
The irritants in smoke and respiratory irritants

increase mucus production, impair ciliary
Avoid exposure to respiratory irritants function, and can cause inflammation and
such as smoke, dust, aerosol sprays, damage to the bronchial and alveolar walls.
paint fumes, and solvents; wear a mask
or scarf over nose and mouth if exposure
to high levels of these irritants is
unavoidable.

Air pollution in high levels is harmful to
Remain indoors as much as possible persons with existing lung disease.
when air pollution levels are high.
Exposure to extreme hot and cold air may

cause bronchoconstriction, allowing less air
Avoid extremes in hot and cold weather. into and out of the lungs.
14
RATIONALE

Increases a client's potential for a respiratory
Avoid prolonged close contact with infection
persons who have respiratory infection.

Immunizations help to prevent further
Receive immunizations against influenza respiratory disease.
and pneumococcal pneumonia.
Changes in the incidence of asthma attacks

Have client keep a log/diary of the frequency, should be reported to the client's health care
duration, and intensity of asthma attacks, and provider because they may indicate a change in
morning peak flow rates. the disease process, effectiveness of
medications, and/or a concurrent illness.
Involvement of the client's significant others
Include significant others in explanations and
contribute to adherence to the treatment
teaching sessions and encourage their support.
regimen.
RATIONALE
Desired Outcome: The client will verbalize ways
to maintain adherence to the medication regimen
including rationale, food and drug interactions,
side effects, methods of administration, and the
importance of taking medications as prescribed.
Independent Actions
Educate the patient about the disease process and
treatment of asthma:

Understanding of the disease and its
Explain asthma in terms the client can treatment plan provides patients with a sense
understand; stress that adherence to the of control, and they will be more likely to
treatment plan is necessary in order to comply with the treatment regimen.
prevent complications and reactivation of
the disease.
15
RATIONALE
Explain that asthma can be treated, but only

if the client adheres to the prescribed
medication regimen.
Provide written instructions about and

encourage client to participate in the
treatment plan. Written instructions allow the client to refer
to them as needed. The instructions should
include all information needed to
understand disease processes and treatment.
Provide client with written instructions
about disease process, signs and symptoms
to report, medication therapy, and follow-
up appointments.
Knowledge of medications and how they

impact the system improves client adherence
Explain the rationale for side effects of drugs, food and helps enhance the client's understanding
and drug interactions, the importance of taking of the importance of adhering to the
medications as prescribed, and drugs to manage prescribed medication regimen. The client
side effects. must be able to recognize alterations in
functioning related to medication
administration.
Examples of asthma medications: Corticosteroids suppress inflammation and
the normal immune process. Mast cell
stabilizers decrease the frequency and
intensity of allergic reactions.
Corticosteroids Anticholinergics provide adjunctive
management of bronchospasms caused by
asthma. IgE antagonists prevent the release
of mediators of the allergic response.
Mast cell stabilizers Leukotriene modifiers decrease the
inflammatory process. Methylxanthines
promote bronchodilation through relaxing
the airways.
Anticholinergics
16
RATIONALE
IgE antagonists
Leukotriene modifiers
Beta 2 -Adrenergic agonists
Methylxanthines
Assist client to develop a method to promote

adherence to the medication schedule. Knowledge of the medication regimen and
the impact of these medications on the body,
as well as how the medication regimen can
be incorporated into the client's lifestyle,
Assist client to identify ways the allows the client some mechanism of control
medication regimen can be incorporated of his/her disease and the ability to have an
into the client's lifestyle. active part in treatment and care.
Instruct client to take all medications as often as

prescribed and avoid skipping doses or altering the
Consistent use of medication(s) is important
prescribed dose; if a dose is missed, instruct client
in preventing asthma attacks.
to take it as soon as remembered unless it is almost
time for the next dose of the same medication.
Medication is not delivered to the lungs and
Teach the client how to use the different types of remains in the oral pharynx when inhalers
inhalers. are used incorrectly, leading to infections in
the oral pharynx.
Reinforce the need to consult physician before
This is important to prevent exacerbations in
discontinuing any medication or taking additional
asthma attacks.
prescription and nonprescription medications.
Provide information about and encourage Provides for continuum of care and can help
utilization of community resources and social improve client adherence with the
services that can assist client to comply with the medication regimen and possibly financial
medication regimen or to provide financial support assistance for medications.
if needed (e.g., local Department of Health and
Human Services, local chapter of the American
17
RATIONALE
Lung Association, support groups).
RATIONALE
Desired Outcome: The client will state signs and
symptoms to report to the health care provider.
Independent Actions
Instruct client to report the following to the health care
provider:
Persistent or recurrent loss of appetite, nausea,

weakness, fatigue, or weight loss
Fever, chills, continued or increased night sweats

These clinical manifestations
Difficulty breathing, continued or increased cough, indicate an infection or super
or chest pain infection and should be reported to
the health care provider.

Unusual color, amount, and odor of vaginal

secretions; white patches or ulcerated areas in
mouth; stiff neck and headache; hoarseness;
persistent sore throat; bone pain; swollen, red,
painful joints; swollen lymph nodes
Signs and symptoms of adverse effects of

medications
Desired Outcome: The client will verbalize an

understanding of a plan for adhering to recommended
follow-up care including future appointments with health
care provider and graded exercise program.
Independent Actions
18
RATIONALE
Reinforce the importance of keeping appointments for Regular health care appointments
follow-up tests (e.g., blood work, chest radiographs) and are important to determine
physical examinations to determine effectiveness of the effectiveness of the medication
medication regimen and assess for side effects. regimen and assess for side effects.
ADDITIONAL NURSING DIAGNOSES

DISTURBED SLEEP PATTERN* NDx
Related to fear, anxiety, unfamiliar environment, excessive coughing, frequent assessments and
treatments, side effects of medications (e.g., some bronchodilators, corticosteroids), and inability
to assume usual sleep position associated with orthopnea
RISK FOR POWERLESSNESS NDx

Related to physical limitations; disease progression despite efforts to comply with treatment
plan; dependence on others to meet self-care needs; and alterations in roles, lifestyle, and future
plans
FEAR NDx AND ANXIETY NDx

Related to fear associated with difficulty breathing, fear of death during an asthma attack,
potential changes in lifestyle
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic obstructive pulmonary disease (COPD) is a term used to describe a disease state
characterized by the presence of airflow obstruction in the lungs. The airflow obstruction is
chronic, usually progressive, and may be accompanied by airway hyperactivity. Other terms
sometimes used to describe this condition are chronic obstructive lung disease (COLD) and
chronic airflow limitation (CAL). Signs and symptoms usually include dyspnea, cough, and
sputum production that worsen over time and during periodic exacerbations.
The two conditions that comprise COPD are chronic bronchitis and emphysema. Chronic
bronchitis is characterized by a cough that persists at least 3 months of the year for 2 consecutive
years and an excessive production of mucus in the bronchi due to inflammation of the
bronchioles and hypertrophy and hyperplasia of the mucous glands. In contrast, emphysema is
characterized by dyspnea and a mild cough. The impaired airflow that occurs with emphysema is
related to loss of lung elasticity, narrowing of the terminal nonrespiratory bronchioles, and
destructive changes in the walls of the alveolar and/or respiratory bronchioles. Both chronic
bronchitis and emphysema are usually present in the person with COPD, although one of the two
usually predominates.
19
Causative factors of COPD include chronic irritation of the lungs by cigarette smoke, exposure
to air pollution and chemical irritants, and recurrent respiratory tract infections. In a small
percentage of cases of emphysema, the destruction of lung tissue by proteolytic enzymes is a
result of a genetic deficiency of alpha 1 -antitrypsin.
This care plan focuses on care of the adult client with COPD who is hospitalized during an
acute exacerbation. Much of the information is applicable to clients receiving follow-up care
in an extended care facility or home setting.
The client will:
1.
Have improved respiratory function
2.
Tolerate expected level of activity
3.
Have no signs and symptoms of complications
4.
Identify ways to prevent or minimize further respiratory problems
5.
Verbalize ways to maintain an optimal nutritional status
6.
Identify ways to conserve energy and/or reduce dyspnea and fatigue
7.
Demonstrate proper chest physiotherapy and use of respiratory equipment
8.
20
Verbalize an understanding of medications ordered including rationale, food and drug
interactions, side effects, methods of administering, and importance of taking as
prescribed
9.
Identify precautions that should be adhered to when using oxygen
10.
State signs and symptoms to report to the health care provider
11.
Share feelings and thoughts about the effects of COPD on lifestyle and roles
12.
Identify resources that can assist with financial needs, home management, and adjustment
to changes resulting from COPD
13.
Verbalize an understanding of and a plan for adhering to recommended follow-up care

including future appointments with health care provider and graded exercise program.
Nursing Diagnosis IMPAIRED RESPIRATORY

FUNCTION *
* This diagnostic label includes the following nursing
diagnoses: ineffective breathing pattern, ineffective airway
clearance, and impaired gas exchange.
Definition: Inability of an individual to maintain adequate ventilation of the respiratory tract and
perfusion of oxygen (O 2 ) and carbon dioxide (CO 2 ) between the lungs and vascular system to
maintain adequate tissue oxygenation
Related to:
Ineffective breathing pattern NDx
Related to:
21

Increased rate of respirations associated with fear and anxiety
Decreased depth of respirations associated with weakness, fatigue, fear, anxiety, and
presence of a flattened diaphragm (a result of prolonged hyperinflation of the lungs)
Ineffective airway clearance NDx
Related to:
Narrowing of the airways associated with:
Excessive mucus production and inflammation and hyperplasia of the bronchial

walls (especially with chronic bronchitis)
Destruction of the elastic fibers in the walls of the small airways (with
emphysema)
Stasis of secretions associated with:
Difficulty coughing up secretions resulting from fatigue, weakness, and presence

of tenacious secretions if fluid intake is inadequate
Impaired ciliary function resulting from loss of ciliated epithelium (occurs with
inflammation, destruction, and fibrosis of bronchial walls)
Decreased mobility
22
Impaired gas exchange NDx
Related to:
Narrowing or obstruction of the small airways
A decrease in effective lung surface (occurs as a result of collapse or destruction of

alveolar walls)
Rapid, shallow respirations; abnormal breath sounds; chronic cough;
use of accessory muscles when breathing; increased anterior-
Reports of confusion;
posterior diameter; dyspnea; nasal flaring; central cyanosis (late
disorientation; restlessness;
sign); decreased expiratory and inspiratory pressure; decreased
irritability; somnolence;
minute ventilation and vital capacity; significant decrease in
chest tightness
oximetry results; abnormal arterial blood gas values; reduced
activity tolerance
RISK FACTORS

Smoking
Obstruction of airways
Excessive mucous production
Impaired ciliary function
23
Occupational dust and chemicals
Alpha 1 -Antitrypsin deficiency
DESIRED OUTCOMES
The client will maintain adequate respiratory function as evidenced by:
a.
Usual rate and depth of respiration
b.
Decreased dyspnea
c.
Usual or improved breath sounds
d.
Usual mental status
e.
Oximetry results within normal range for client
f.
NOC OUTCOMES
Respiratory status; airway patency; respiratory status: ventilation; respiratory status: gas
exchange
NIC INTERVENTIONS
Respiratory monitoring; airway management; chest physiotherapy; cough enhancement; oxygen
therapy; medication administration; ventilation assistance; cough enhancement; fear and anxiety
reduction
24
NURSING ASSESSMENT
RATIONALE
Assess for signs and symptoms Early recognition of signs and symptoms of ineffective
of impaired respiratory function: breathing patterns allows for prompt intervention.
Rapid, shallow
respirations
Rapid, shallow respirations do not provide adequate

ventilatory support. Difficulty with breathing and the need to
sit up to breathe, as well as use of accessory muscles, lead to
Dyspnea, orthopnea client fatigue and further decline in respiratory status.

Use of accessory muscles

when breathing

Changes in the characteristics of breath sounds may be due to
Abnormal breath sounds airway obstruction, mucus plugs, or retained secretions in
(e.g., diminished or larger airways.
absent, rhonchi, wheezes)

Muscle fatigue/weakness may impair effective clearance of
secretions.
Cough effectiveness
Restlessness, irritability Restlessness, irritability, and change in mental status of level

of consciousness indicate an oxygen deficiency and require
immediate treatment.
The bluish discoloration of the skin and mucous membranes

occurs in the presence deoxygenated hemoglobin. This occurs
when arterial oxygen saturation falls below 85% to 90%.
25
RATIONALE
Central cyanosis (a late

sign)
Oximetry is a noninvasive method of measuring arterial

Assess arterial blood gas and
oxygen saturation. The results assist in evaluating respiratory
pulse oximetry values and report
status. Decreasing PaO 2 and increasing CO 2 are indicators of
abnormal findings.
respiratory problems.
RATIONALE
Independent Actions
Implement measures to improve
respiratory status:
Reduce fear and anxiety.

Prevent shallow and/or rapid breathing that can occur
with fear and anxiety.
Maintain supportive
environment.

The client's anxiety may increase if left alone during
Don't leave client during periods of respiratory distress.
periods of acute respiratory
distress.

Decreases client's feelings of being in an enclosed area,
which can increase anxiety.
Open curtains and doors.
Positioning in semi-Fowler's position promotes optimal

gas exchange by enabling chest expansion. Leaning on
the overbed table decreases dyspnea through pressure
Place client in a semi-Fowler's on the gastric contents and diaphragmatic contraction.
position, and position overbed
table so client can lean on it if
26
RATIONALE
desired. D

These techniques help clients slow their pace of
Instruct client in and assist with breathing, which makes each breath more effective.
diaphragmatic and pursedlip
breathing techniques.
Forced deep breathing and use of incentive spirometry

Instruct client to deep breathe or use will increase expansion of the lungs and improve the
incentive spirometer every 1 to 2 hours. client's ability to clear mucus from the lungs. The
D technique may also improve the amount of oxygen that
is able to penetrate deep into the lungs.

Increased fluid intake promotes thinning of secretions
Maintain client's fluid intake of and reduces dryness of the respiratory mucous
at least 2500 mL/day unless membranes.
contraindicated. D
Suctioning removes secretions from the large airways. It

also stimulates coughing, which helps clear airways of
Perform suctioning if needed. D mucus and foreign matter.
Instruct client to avoid intake of Gas-forming foods and carbonated beverages can cause
large meals, gas-forming foods abdominal bloating, which places pressure on the
(i.e., cauliflower, beans, diaphragm and reduces lung expansion.
cabbage, onions, etc.), and
carbonated beverages.
The irritants in smoke increase mucus production,

impair ciliary function, and can cause inflammation and
damage to the bronchial and alveolar walls; the carbon
Discourage smoking. monoxide decreases oxygen availability.
Conservation of energy through activity restrictions
allows energy to be focused on breathing. Increasing
activity as tolerated helps to mobilize secretions and
27
RATIONALE
Maintain activity restrictions

and increase activity as allowed promotes deeper breathing.
and tolerated. D
respiratory status:
Assist with administration of Mucolytics and diluent or hydrating agents help to

mucolytics and diluent or liquefy secretions for more effective removal.
hydrating agents via nebulizer if
ordered. D

CNS depressants further depress respiratory status,
Avoid use of central nervous exacerbating the client's condition.
system (CNS) depressants. D
Oxygen should be administered at low doses. Question

orders for high concentration, since many persons with
Administer and monitor oxygen COPD are depending on hypoxemia as a stimulus to
as ordered. D breathe.
Bronchodilators relax smooth muscles of the airway,

thus improving air exchange in the lungs.
Corticosteroids decrease airway inflammation and
Administer the following thereby improve bronchial airflow. Antimicrobials may
medications if ordered: be given to prevent or treat pneumonia. Administration
of alpha 1 -proteinase inhibitor may be required if the
cause of emphysema is a genetic deficiency of alpha 1
-antitrypsin.
Bronchodilators
Corticosteroids
28
RATIONALE
Antimicrobials
Alpha 1 -Proteinase inhibitor
Consult appropriate health care

providers (respiratory therapist and
Notifying the appropriate health care professionals
physician) if signs and symptoms of
allows for a multidisciplinary approach to treatment.
impaired respiratory function persist or
worsen.
Nursing Diagnosis IMBALANCED NUTRITION: LESS

THAN BODY REQUIREMENTS NDx
Definition: Inability of the individual to maintain adequate nutrition due to increased
expenditure of energy to support the work of breathing
Related to:
Decreased oral intake associated with:
Dyspnea, weakness, and fatigue
Nausea (can occur in response to noxious stimuli such as the sight of expectorated
sputum and as a side effect of some medications)
Early satiety resulting from compression of the stomach by flattened diaphragm
29
Increased metabolic needs associated with increased energy expenditure resulting from
strenuous breathing efforts and persistent coughing
Weight loss; weight less than normal for client's age, height, and body
Report of painful
frame; abnormal blood urea nitrogen (BUN) and low serum prealbumin
oral mucous
levels; inflamed mucous membranes; pale conjunctiva; excessive hair loss;
membrane
poor muscle tone
RISK FACTORS

Lack of appetite
Shortness of breath causing difficulty with eating
Poor diet
Lack of resources
DESIRED OUTCOMES
The client will maintain adequate nutrition status as evidenced by:
a.
Weight within normal range for client
b.
Normal BUN and serum prealbumin and albumin levels
c.
Usual strength and activity tolerance

30
d.
Healthy oral mucous membrane
NOC OUTCOMES
Nutritional status
NIC INTERVENTIONS
Nutritional monitoring; nutrition management; nutrition therapy; nausea management
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and Early recognition of signs and symptoms of malnutrition
symptoms of malnutrition: allows for prompt intervention.
Weight significantly below a
client's usual weight or less than
normal for client's age, height, and
body frame
Abnormal BUN and low

serum prealbumin and
albumin levels
Inadequate nutritional intake may be exhibited by significant
weight loss or a weight that is less than normal for a client's
age, height, and body frame. If a significant amount of
Increased weakness and weight loss occurs in a short period of time, this may be an
fatigue indication of another disease process occurring.
Sore, inflamed oral

mucous membranes
Pale conjunctiva
31
RATIONALE
Independent Actions
Monitor percentage of meals and snacks
Monitoring a client's intake helps to identify when a
client consumes. Report a pattern of
patient is at risk for inadequate nutrition.
inadequate intake. D
Implement measures to maintain an
adequate nutritional status:

Interventions that relieve dyspnea allow the
Perform actions to improve oral patient to eat a meal without interruption or
intake: need to rest.
o Appropriate scheduling of treatments assists

in decreasing nausea.
Implement measures to
improve respiratory status. Activity usually promotes a sense of well-
being and can help improve an individual's
o appetite.
Schedule treatments that Rest before a meal helps to minimize fatigue

assist in mobilizing mucus during a meal.
(e.g., aerosol treatments,
postural drainage therapy) Noxious sites and odors can inhibit the
at least 1 hour before or
feeding center in the hypothalamus. By
after meals.
eliminating them, the client's intake may
improve.
o
Increase activity as allowed

and tolerated. D Oral hygiene moistens the mouth, which
makes it easier to chew and swallow; it also
o removes unpleasant tastes, which often
improves the taste of foods and fluids.
Encourage a rest period
before meals. D Because a person cannot swallow and
breathe at the same time, relief of dyspnea
o increases the likelihood of maintaining a
good oral intake. Foods that require little or
Eliminate noxious sights no chewing are easier to eat and help to
and odors from the maintain a client's nutritional status.
environment; provide client
with an opaque, covered Providing small rather than large meals can
32
RATIONALE
container for expectorated enable a client who is weak or fatigues easily

sputum. D to finish a meal. Also, a client who has a poor
appetite is often more willing to attempt to
o eat smaller meals because they seem less
overwhelming than larger ones. If smaller
Maintain a clean meals are served, the number of meals per
environment and a relaxed, day should be increased to help ensure
pleasant atmosphere. D adequate nutrition.
o Because a person cannot swallow and

breathe at the same time, relief of dyspnea
Provide oral hygiene before increases the likelihood of maintaining a
meals. D good oral intake.
o Clients who feel rushed during meals tend to

become anxious, lose their appetite, and stop
Assist the client who is eating. Appetite is also suppressed if
dyspneic in selecting foods foods/fluids normally served hot or warm
that require little or no become cold and do not appeal to the client.
chewing.
When the stomach becomes distended, its
o volume receptors stimulate the satiety center
in the hypothalamus and clients reduce their
Serve frequent, small meals oral intake. Drinking liquids with meals
rather than large ones if distends the stomach and may cause satiety
client is weak, fatigues before an adequate amount of food is
easily, or has a poor consumed.
appetite. D
Place client in a high-

Fowler's position for meals.
D
Allow adequate time for

meals; reheat foods/fluids if
necessary. D
33
RATIONALE
Limit fluid intake with

meals (unless the fluid has

Clients must consume a diet that is well balanced
Ensure that meals are well and high in essential nutrients in order to meet their
balanced and high in essential nutritional needs. Dietary supplements are often
nutrients; offer dietary supplements needed to help accomplish this.
if indicated.
Implement measures to maintain an
adequate nutritional status:
Perform actions to improve oral

intake:
o
Supplemental oxygen therapy relieves
dyspnea and the client's anxiety about and
Provide supplemental
preoccupation with breathing efforts and
oxygen during meals. D
increases the ability to focus on eating and
drinking.
o
Obtain a dietary consult to
professionals allows for a multidisciplinary
assist the client in selecting
approach to treatment.
foods/fluids that meet
nutritional needs, are
appealing, and adhere to
personal and cultural
preferences.

Administration of vitamins and minerals help to
Administer vitamins and minerals maintain nutritional status.
if ordered. D
Perform a calorie count if ordered. Report A calorie count provides information about the
34
RATIONALE
caloric and nutritional value of the foods/fluids the
client consumes. The information obtained helps the
information to dietitian and physician.
dietitian and physician determine whether an
alternative method of nutritional support is needed.
Consult physician about an alternative
method of providing nutrition (e.g., If the client's oral intake is inadequate, an
parenteral nutrition, tube feedings) if client alternative method of providing nutrients needs to be
does not consume enough food or fluids to implemented.
meet nutritional needs.
Nursing Diagnosis ACTIVITY INTOLERANCE NDx

Definition: Insufficient physiological or psychological energy to endure or complete required or
desired daily activities
Related to:
Tissue hypoxia associated with impaired gas exchange
Inadequate nutrition status
Difficulty resting and sleeping associated with dyspnea, excessive coughing, fear,
anxiety, frequent assessment and treatments, and side effects of medication therapy (e.g.,
some bronchodilators, corticosteroids)
Increased energy expenditure associated with strenuous breathing efforts and persistent
coughing
Abnormal heart rate or B/P response to activity; exertional discomfort or
Verbal report of
dyspnea; electrocardiographic changes reflecting dysrhythmias or ischemia;
fatigue or weakness
unable to speak with physical activity
35
RISK FACTORS

Exertional dyspnea
Dyspnea during rest and sleep
Anxiety and fear
Increased energy expenditurecoughing and breathing efforts
DESIRED OUTCOMES
The client will demonstrate an increased tolerance for activity as evidenced by:
a.
Verbalization of feeling less fatigued and weak
b.
Ability to perform activities of daily living without exertional dyspnea, chest pain,
diaphoresis, dizziness, and significant changes in vital signs
NOC OUTCOMES
Activity tolerance; endurance; fatigue level; vital signs; self-care: activities of daily living;
energy conservation
NIC INTERVENTIONS
Activity therapy; energy management; oxygen therapy; nutrition management; sleep
enhancement; cardiac care; cardiac rehabilitation; teaching regarding prescribed activity
NURSING ASSESSMENT
36
RATIONALE
Assess for signs and symptoms of activity intolerance:
Statements of fatigue or weakness
Exertional dyspnea, chest pain, diaphoresis, or

dizziness
Early recognition of signs and
symptoms of activity intolerance
allows for prompt intervention and
Abnormal heart rate response to activity (e.g., treatment.
increase in rate of 20 beats/min above resting rate,
rate not returning to preactivity level within 3
minutes after stopping activity, change from regular
to irregular rate)
Significant change (15-20 mm Hg) in B/P with

activity
RATIONALE
Independent Actions
Implement measures to promote rest and/or
conserve energy (e.g., maintain prescribed activity Cells use oxygen and fat, protein, and
restrictions, minimize environmental activity and carbohydrates to produce the energy needed
noise, provide uninterrupted rest periods, assist for all body activities. Rest and activities
with care, keep supplies and personal articles that conserve energy result in a lower
within easy reach, limit the number of visitors, use metabolic rate, which preserves nutrients
shower chair when showering, sit to brush teeth or and oxygen for necessary activities.
comb hair). D
Implement measures to promote sleep (e.g.,
elevated head of bed and support arms on pillows
Sleep replenishes a client's energy and
to facilitate breathing, discourage intake of fluids
feeling of well-being.
high in caffeine in the evening, and reduce
environmental stimuli). D
Implement measures to decrease excessive Altered respiratory function such as
coughing (e.g., protect client from exposure to excessive coughing can lead to inadequate
37
RATIONALE
tissue oxygenation, which results in less
efficient energy production and a reduced
irritants such as smoke, flowers, and powder; avoid
ability to tolerate activity. Improving
extremely hot or cold foods/fluids). D
respiratory status increases the amount of
oxygen available for energy production.
Excessive intake of nicotine and caffeine
Discourage smoking and excessive intake of
can increase cardiac workload and
beverages high in caffeine such as coffee, tea, and
myocardial oxygen utilization, thereby
colas.
decreasing oxygen availability.
Perform actions to improve respiratory status (e.g.,
place client in semi- to high-Fowler's position;
Improvement of respiratory status through
assist client to deep breathe or use incentive
increased lung expansion.
spirometry every 1 to 2 hours; maintain bed rest as
ordered; and use oxygen as needed). D
Perform actions to maintain adequate nutritional
status (e.g., increase activity as tolerated,
potentially improving appetite; encourage a rest Adequate nutritional status is important in
period before meals to reduce fatigue; assist with order to maintain ADL.
oral hygiene before meals; maintain a clean
environment and a relaxed pleasant atmosphere). D
Gradual increase will slowly improve
Increase client's activity gradually as allowed and
strength and ability in performance of
tolerated. D
activities.
Instruct a client to:
Report a decreased tolerance for activity.

Changes in a client's activity tolerance
should be reported immediately. Assessment
of the change will allow for timely diagnosis
of the cause and subsequent treatment.
Stop any activity that causes increased chest
pain, increased shortness of breath,
dizziness, or extreme fatigue or weakness.
Consult appropriate health care providers (e.g.,
respiratory therapist, physician, dietitian) if signs
provider allows for modification of the
and symptoms of activity intolerance persist or
treatment plan.
worsen.
Nursing Diagnosis RISK FOR INFECTION NDx

(PNEUMONIA)
38
Definition: At increased risk for the lungs being invaded by pathogens
Related to:
Stasis of secretions in the lungs (secretions provide a good medium for bacterial growth)
Inhalation of pathogens (especially if client is using respiratory equipment or medication

delivery devices that are not being cleaned adequately or routinely)
Increased respiratory rate; dyspnea; abnormal breath sounds (crackles, rales);
Verbalization of productive cough with purulent green or rust-colored sputum; chills and
pleuritic pain diaphoresis; fever; elevated white blood cell (WBC) count; significant
decrease in pulse oximetry values; worsening arterial blood gas values
RISK FACTORS

Stasis of secretions
Inhalation of pathogens
Debilitated state
Smoking
DESIRED OUTCOMES
The client will not develop pneumonia as evidenced by:
a.
39
Usual breath sounds and percussion note over lungs
b.
Absence of tachypnea
c.
Cough productive of clear mucus only
d.
Afebrile status
e.
WBC count within normal range
f.
g.
Negative sputum culture
h.
Ability to perform ADL without increased dyspnea, chest pain, diaphoresis, dizziness,
and a significant change in vital signs
NOC OUTCOMES
Infection severity; immune status
NIC INTERVENTIONS
Infection protection; infection control; cough enhancement; airway management
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of pneumonia: Early recognition of signs and
symptoms of pneumonia allows for
40
RATIONALE
prompt intervention.

Abnormal breath sounds (e.g., crackles [rales],

pleural friction rub, bronchial breath sounds,
diminished or absent breath sounds)
Dull percussion note over affected lung area
Increase in respiratory rate
Cough productive of purulent, green, or rust-

colored sputum
Chills and fever
Pleuritic pain
Elevated WBC count
Significant decrease in oximetry results
Worsening of arterial blood gas values
Positive sputum culture results
41
RATIONALE
Chest radiograph results indicative of pneumonia
RATIONALE
Independent Actions
Implement measures to prevent pneumonia:
Positioning the client in semi- to high-

Fowler's position promotes optimal gas
Perform actions to improve respiratory exchange by enabling chest expansion.
status (e.g., place client in semi- to high- Forced deep breathing and use of incentive
Fowler's position; assist client to deep spirometry will increase expansion of the
breathe or use incentive spirometer every lungs and improve the client's ability to clear
1 to 2 hours; improve activity tolerance; mucus from the lungs. Maintaining fluid
maintain fluid intake of at least 2500 intake will help to liquefy secretions for
mL/day unless contraindicated). D expectoration.
The potential for illness is decreased through

avoidance of persons with respiratory
Protect client from persons with infections and crowds during the cold and flu
respiratory tract infections. D season.
Frequent oral hygiene helps to decrease the

rate of infection through removal of
Encourage and assist client to perform pathogens and secretions that could be
frequent oral hygiene. D aspirated.

Equipment that is inadequately or
incompletely cleaned after use harbors
Replace or cleanse equipment used for bacteria may lead to an respiratory infection.
respiratory care as often as needed.
Inhaled medication devices only deliver a

certain percentage of the medication to the
lungs. The rest of the medication is deposited
42
RATIONALE
Instruct and assist client to rinse and clean

medication delivery devices (e.g., dry in the oropharynx, which with some
powder inhaler, metered-dose inhaler, medications, increases the risk for infection,
spacer) according to manufacturer's dysphonia, and/or candidiasis.
instructions.
Early administration of antibiotics at the first
If signs and symptoms of pneumonia occur,
sign of infection can decrease the impact and
administer antimicrobials as ordered. D
duration of the infection.
Consult other health care providers at the first Notifying the appropriate health care provider
signs and symptoms of an infection. allows for modification of the treatment plan.
43
BOOK CHAPTER
Respiratory Disorders
Frances D. Monahan PhD, RN, ANEF
, Marianne Neighbors EdD, RN
and Carol J. Green PhD, MN, RN, CNE
Manual of Medical-Surgical Nursing, CHAPTER 2, 57-94
Open reading mode

Section OneAcute Respiratory Disorders
Acute respiratory disorders are short-term diseases or acute complications of chronic
conditions. They can occur once and respond to treatment or recur to further complicate
an underlying disease process.
Atelectasis
Overview/Pathophysiology
Atelectasis is a spontaneous collapse of alveolar lung tissue secondary to persistent
hypoinflation. It is most common following major abdominal or thoracic surgery and
results from hypoventilation of dependent portions of the lungs or inadequate clearing
of secretions. Atelectasis can be an acute or a chronic condition and occurs most often in
individuals with COPD. Postoperatively, atelectasis can be precipitated by the effects of
anesthesia, sedation, and decreased mobility. Other precipitating factors include mucus
plugs, foreign objects in the airways, pleural effusion, bronchogenic carcinoma, history
of smoking, and obesity. Atelectasis can lead to pulmonary infection.
Assessment
The clinical picture is determined by the site of collapse, rate of development, and size of
the affected area.
Signs and symptoms/physical findings

Pleuritic chest pain, tachypnea, shortness of breath, fever, dyspnea, decreased chest wall
movement on affected side, dullness to percussion, decreased or absent breath sounds,
crackles (rales) persisting after deep inspiration or cough, restlessness, agitation, change
in level of consciousness (LOC), cyanosis.
Diagnostic Tests
Oximetry
Bedside oximetry may demonstrate decreased O 2 saturation (92% or less).
Chest x-ray examination
44
Reveals higher density in affected lung, elevation of the hemidiaphragm on affected side,
and compensatory hyperinflation of adjacent lobes on the opposite side.
Arterial blood gas (ABG) values

May reveal acute respiratory acidosis, with pH less than 7.35 and Pa co 2 greater than
45 mm Hg. Pa o 2 may be less than 80 mm Hg, which is consistent with hypoxemia.
Collaborative Management
Management is aimed at preventing this condition in all patients. If atelectasis occurs
and is left untreated, the affected lung area eventually may become infected, fibrotic,
and functionless.
Deep-breathing and coughing exercises

Expand alveoli deep in the lungs and mobilize/clear secretions.
Chest physiotherapy
Mobilizes secretions.
Hyperinflation therapy
Expands partially collapsed lung areas and thereby improve gas exchange. Incentive
spirometry may be used at the bedside.
Analgesics
Reduce pain and thereby facilitate production of an effective cough.
Bronchoscopy
Patient is intubated and a fiberoptic scope is passed into the bronchi to visualize the
area and remove mucous plugs, retained secretions, or foreign objects.
O therapy
2
Maintains Pa o 2 greater than 80 mm Hg or within patient's normal baseline range.
Chest tube insertion

Provides reinflation of collapsed areas of the lung through a small-bore (8F-14F) tube
connected to a one-way flutter valve or to a closed chest-drainage system if drainage of
fluid is significant.
Nursing Diagnoses and Interventions

For Patients at Risk for Atelectasis
Ineffective breathing pattern
45
related to decreased lung expansion secondary to inactivity or omission of deep
breathing
Desired outcomes
Patient demonstrates deep breathing and effective coughing at least hourly and is
eupneic (respiratory rate [RR] 12-20 breaths/min with normal depth and pattern) at all
other times. Auscultation of patient's lungs reveals no adventitious sounds.
Nursing Interventions

Auscultate breath sounds at least q2-4h (or as indicated by patient's condition) and
during hyperinflation therapy. Report any decrease in breath sounds or presence
of/increase in adventitious breath sounds.
Instruct patient in use of hyperinflation device (e.g., incentive spirometer) to expand the
lungs maximally.
Inhale slowly and deeply 2 normal tidal volume.
Hold breath at least 5 sec at the end of inspiration.
Do this 10 per hr to maintain adequate alveolar inflation.
Deep breathing expands the alveoli and aids in mobilizing secretions to the airways,
and coughing further mobilizes and clears the secretions. Monitor patient's progress
and document in nurses' notes.
Administer analgesics as prescribed to reduce pain and thereby facilitate coughing and
deep-breathing exercises.
When appropriate, teach methods of splinting wounds or painful areas to enable

coughing and deep breathing.
46
Instruct patients who are unable to cough effectively in technique of cascade cough (i.e.,
succession of short and more forceful exhalations).
Encourage frequent position changes and other activity as prescribed to help mobilize
secretions and promote effective airway clearance. Use upright sitting position if
permitted to promote good chest expansion.
When not contraindicated, instruct patient to increase fluid intake (to more than
2.5 L/day) to decrease viscosity of pulmonary secretions and facilitate their
mobilization.
When appropriate, coordinate deep-breathing and coughing exercises with peak

effectiveness of bronchodilator therapy to maximize potential for mobilization of
secretions.
Patient-Family Teaching and Discharge Planning

Provide verbal and written information about the following:
Use of hyperinflation device if patient is to continue this therapy at home. Conduct a

predischarge check of patient's technique and document assessment in progress notes.
Importance of maintaining activity level as prescribed.
Importance of maintaining fluid intake of more than 2.5 L/day.
Medications, including drug name, purpose, dosage, schedule, precautions, and

potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.
Pain management techniques, such as medications and splinting.
47
Precipitating factors in the development of atelectasis.
Importance of notifying health care provider if signs and symptoms recur.
Importance of medical follow-up. Review date and time of next appointment.
Pneumonia
Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung
parenchyma (alveolar spaces and interstitial tissue). As a result of the inflammation,
involved lung tissue becomes edematous and air spaces fill with exudate (consolidation),
gas exchange cannot occur, and nonoxygenated blood is shunted into the vascular
system, with resulting hypoxemia. Bacterial pneumonias involve all or part of a lobe,
whereas viral pneumonias appear diffusely throughout the lungs.
Influenza, which can cause pneumonia, is the most serious viral airway infection for
adults. Patients more than 65 yr old, residents of extended care facilities, and
individuals with chronic health conditions have the highest mortality from influenza.
Pneumonias usually are classified into two general types: community acquired and
hospital associated (nosocomial). A third type now recognized is pneumonia in the
immunocompromised individual.
Community acquired
Individuals with community-acquired pneumonia, the most common type, generally do
not require hospitalization unless an underlying medical condition, such as chronic
obstructive pulmonary disease (COPD), cardiac disease, or diabetes mellitus, or an
immunocompromised state complicates the illness.
Hospital associated (nosocomial)

Nosocomial pneumonias usually occur following aspiration of oropharyngeal flora or
stomach contents in an individual whose resistance is altered or whose coughing
mechanisms are impaired (e.g., a patient who has decreased level of consciousness
(LOC), dysphagia, diminished gag reflex, or a nasogastric tube or who has undergone
thoracoabdominal surgery or is on mechanical ventilation). Bacteria invade the lower
respiratory tract via three routes: (1) gastric acid aspiration (the most common route),
which causes toxic injury to the lung and makes it susceptible to bacterial growth; (2)
partial obstruction of airway by a foreign body or fluids contaminated with bacteria; and
(3) outright infection (rare occurrence). Gram-negative pneumonias are associated with
a high mortality rate, even with appropriate antibiotic therapy. If the alveolar-capillary
48
membrane is affected, acute respiratory distress syndrome (ARDS) (formerly known as
adult respiratory distress syndrome) may develop.
Pneumonia in the immunocompromised individual

Immunosuppression and neutropenia are predisposing factors in the development of
nosocomial pneumonias from both common and unusual pathogens. Severely
immunocompromised patients are affected not only by bacteria but also by
fungi (Candida, Aspergillus) , viruses (cytomegalovirus), and protozoa ( Pneumocystis
jiroveci , formerly known as P. carinii ). Most commonly, P. jiroveci is seen in persons
with human immunodeficiency virus (HIV) disease or in persons who are
immunosuppressed therapeutically following organ transplants.
Assessment
Findings are influenced by patient's age, extent of the disease process, underlying
medical condition, and pathogen involved. Generally, any factor that alters integrity of
the lower airways, thereby inhibiting ciliary activity, increases the likelihood of
developing pneumonia ( TABLE 2-1 ).
TABLE 2-1
ASSESSMENT GUIDELINES BY PNEUMONIA TYPE
TYPE/PATHOGEN RISK ONSET DEFINING COMPLICATIONS/C

GROUPS CHARACTE OMMENTS
RISTICS
Community-Acquired
Pneumococcal(Str Persons Abrupt Single Pleural effusions,
eptococcus older than shaking chill, empyema, impaired
pneumoniae) 40 yr, fever, liver function,
especially pleuritic bacteremia,
men; risk chest pain, meningitis; incidence
increased severe of pneumococcal
with cough, pneumonia peaks in
alcoholism shortness of winter and early
and breath, rust- spring; mortality
debilitating colored increases if more
diseases sputum, than one lobe
(e.g., COPD, diaphoresis; involved
heart failure, many
multiple patients also
myeloma, have herpes
sickle cell labialis,
disease); abdominal
often pain and
preceded by distention,
viral URIs and paralytic
49
RISTICS
ileus
Mycoplasma School-aged Gradual Cough, sore Persistent cough
(Mycoplasma children to throat, fever, and sinusitis
pneumoniae) young adults headache, possible; pulse-
(5-30 yr); chills, temperature
intrafamilial malaise, dissociation
spread anorexia, common;
common nausea, Occurrence rare
vomiting,
diarrhea; in
children
arthralgias
involving
large joints
common
Legionnaires'(Legi Middle-aged, Abrupt Malaise, Respiratory failure,
onella elderly headache hypotension, shock,
pneumophila) populations within 24 hr, acute renal failure
(men at fever with
increased normal HR,
risk); shaking
smokers; chills,
individuals progressive
with dyspnea,
malignant cough that
disease, may become
immunosupp productive;
ression, or GI
chronic renal symptoms,
failure; including
exposure to anorexia,
contaminate vomiting,
d diarrhea;
construction arthralgias,
site myalgias
Viral influenza A Elderly 1 wk after Severe Rapid course
persons with onset of dyspnea; leading frequently to
chronic influenza cyanosis; acute respiratory
diseases symptoms scant failure; develops as
(e.g., COPD, sputum, secondary bacterial
50
RISTICS
diabetes occasionally pneumonia
mellitus, with blood;
heart failure); fever;
pregnant persistent
women and dry
cough
Haemophilus Adults 2-6 wk after Fever, chills, Fever may be
influenzae (especially URI dyspnea, minimal or absent;
50 yr of age cough, HR and RR may be
or older) with nausea, normal
chronic vomiting,
diseases pain
(e.g.,
diabetes
mellitus,
COPD,
chronic
alcohol
ingestion)
Nosocomial
Klebsiella Men older Abrupt Chills, fever, Lung abscess and
(Klebsiella than 40 yr, productive empyema,
pneumoniae); also alcoholic cough necrotizing
may be acquired in patients; (copious pneumonitis with
the community patients with purulent cavitation, acute
diabetes green or respiratory failure;
mellitus, currant jelly high mortality
COPD, or sputum), (greater than 50%);
heart severe aspiration of
disease; pleuritic oropharyngeal flora
those chest pain, is responsible for
previously dyspnea, both nosocomial and
treated with cyanosis, community-acquired
antibiotics or jaundice, cases
ET intubation vomiting,
diarrhea
Pseudomonas;also Patients who Gradual Fever, chills, Rare in previously
may be acquired in are confusion, healthy adults; high
the community neutropenic delirium, mortality
from bradycardia,
51
RISTICS
chemotherap purulent
y or sputum
immunosupp (green, foul
ressed smelling)
secondary to
cortisone
therapy or
other
illnesses
Proteus Older adults Abrupt High fever, Occurrence rare;
with chills, localizes to areas
debilitating pleuritic already damaged;
underlying chest pain occurs as a mixed
diseases infection; associated
with four pathogenic
species with differing
antibiotic
susceptibilities
Staphylococcus Patients with Abrupt with Cough, chills, Pulmonary
aureus debilitating community high fever, abscesses,
diseases acquired; pleuritic pain, empyema, pleural
(e.g., insidious with progressive effusions; slow
diabetes hospital dyspnea, response to
mellitus, associated cyanosis, antibiotics
renal failure, bloody
liver disease, sputum
COPD);
those with a
prior viral or
influenza
infection;
injecting drug
users
Aspiration of Patients with Gradual; Fever, Physiologic
gastric contents impaired latent period wheezes, response depends
gag/cough between crackles on pH contents of
reflexes; aspiration (rales), material aspirated:
general and onset of rhonchi, 2.5 or higher, little
anesthesia; symptoms dyspnea, necrosis occurs; less
presence of cyanosis than 2.5, atelectasis,
52
RISTICS
NG/ET tube pulmonary edema,
hemorrhage, and
necrosis can occur
Immunocompromised Patient
Pneumocystis (Pn Patients with Insidious Several Bronchoscopy with
eumocystis AIDS or weeks of transbronchial
jiroveci; formerly organ fever, biopsy usually
known as P. carinii) transplants nonproductiv required for
e cough, diagnosis
night sweats,
dyspnea;
hypoxemia
with few
auscultatory
signs
Aspergillosis(Aspe Patients with Abrupt with High fever; Cavitation frequent;
rgillus) AIDS, immunosupp fungal ball hematogenous
COPD, and ression; within lung spread common in
transplants insidious with cyst or cavity; immunocompromise
(especially COPD nonproductiv d patient
autologous e cough;
bone marrow pleuritic
transplant); chest pain
also those
receiving
cytotoxic
agents or
steroids
View full size
note: Enterobacter and Serratia are enteric organisms that cause pneumonia with the same clinical
pattern as Klebsiellaorganisms.
AIDS, Acquired immunodeficiency syndrome; COPD, chronic obstructive pulmonary
disease; ET, endotracheal; GI,gastrointestinal; HR, heart rate; NG, nasogastric; RR, respiratory
rate; URI, upper respiratory infection.
Cough (productive and nonproductive), increased sputum production (rust colored,
discolored, purulent, bloody, or mucoid), fever, pleuritic chest pain (more common in
community-acquired bacterial pneumonias), dyspnea, chills, headache, myalgia,
restlessness; anxiety; decreased skin turgor and dry mucous membranes secondary to
dehydration; presence of nasal flaring and expiratory grunt; use of accessory muscles of
53
respiration (scalene, sternocleidomastoid, external intercostals); decreased chest
expansion caused by pleuritic pain; dullness on percussion over affected (consolidated)
areas; tachypnea (respiratory rate [RR] more than 20 breaths/min); tachycardia (heart
rate [HR] more than 90 beats per minute [bpm]); increased vocal fremitus; egophony
(e to a change) over area of consolidation; decreased breath sounds; high-pitched
and inspiratory crackles (rales) (increased by or heard only after coughing); low-pitched
inspiratory crackles (rales) caused by airway secretions; and circumoral cyanosis (a late
finding). Older adults may be confused or disoriented and have low-grade fevers but
may present with few other signs and symptoms.
Diagnostic Tests
Confirms presence of pneumonia (i.e., infiltrate appearing on the film).
Sputum for Gram stain and culture and sensitivity tests

Sputum is obtained from lower respiratory tract by endotracheal aspiration, protected
catheter brush, or bronchoalveolar lavage (BAL) before initiation or change of antibiotic
therapy to identify causative organism in cases of hospital-acquired pneumonia. For
community-acquired pneumonias, this approach is recommended only if organism
resistant to usual antibiotic therapy is suspected.
WBC count
Increased (more than 12,000/mm 3 ) in the presence of bacterial pneumonias. Normal or
low WBC (less than 4000/mm 3 ) count may be seen with viral or mycoplasma
pneumonias.
Chemistry panel
Detects presence of hypernatremia and/or hyperglycemia.
Blood culture and sensitivity

Determine presence of bacteremia and aid in identification of causative organism. Used
in cases of hospital-acquired pneumonia and in seriously ill patients with community-
acquired pneumonia.
Oximetry
May reveal decreased O 2 saturation (92% or less).

May vary, depending on presence of underlying pulmonary or other debilitating disease.
May demonstrate hypoxemia (Pa o 2 less than 80 mm Hg) and hypocarbia (Pa co 2 less
than 32-35 mm Hg), with resultant respiratory alkalosis (pH more than 7.45), in the
absence of underlying pulmonary disease.
54
Serologic studies
Acute and convalescent antibody titers drawn to diagnose viral pneumonia. A relative
rise in antibody titers suggests viral infection.
Acid-fast stains and cultures

Rule out tuberculosis (TB).
O therapy
2
Administered when O 2 saturation or ABG results demonstrate hypoxemia. Goal is to

maintain Pa o 2 at 60 mm Hg or higher. Special consideration must be given to patients
with chronic CO 2 retention because their respiratory drive is stimulated by
low/decreasing Pa o 2 levels and not by increasing Pa co 2 levels as is normal. Therefore
high concentrations of O 2 can depress respiration in these patients so O 2 is delivered in
low concentrations initially, and O 2 saturations or ABG levels are monitored closely. If
O 2 saturation or Pa o 2 does not rise to acceptable levels (greater than 92% or 60 mm Hg
or more, respectively), fraction of inspired O 2 (FI o 2) is increased in small increments,
with concomitant checks of ABG values or O 2 saturations.
Antibiotic agents
Prescribed empirically based on presenting signs and symptoms, clinical findings, and
chest x-ray results until sputum or blood culture results are available. Many organisms
responsible for nosocomial pneumonias are resistant to multiple antibiotics. Proper
identification of the organism and determination of sensitivity to specific antibiotics are
critical for determining appropriate therapy.
A macrolide or levofloxacin is used for empirical out-patient treatment of community-

acquired pneumonia; cephalosporins plus a macrolide and doxycycline are used for
patients who are not in the ICU; IV beta-lactam and an IV quinolone or IV azithromycin
are used for ICU patients.
Hospital-acquired pneumonia is empirically treated with IV ceftriaxone, or levofloxacin,

or ampicillin/sulbactam or ertapenem if it is early onset and the patient has no risk
factors for multidrug-resistant (MDR) disease; all other cases are treated initially with
multiagent regimens. Vancomycin is added if risk of methicillin-
resistantStaphylococcus aureus (MRSA) exists.
Hydration
IV fluids may be necessary to replace fluids lost from insensible sources (e.g., tachypnea,
diaphoresis, fever) and decreased oral intake.
Percussion and postural drainage

Indicated if deep breathing and coughing are ineffective in mobilizing secretions.
55
Hyperinflation therapy
Prescribed for patients with inadequate inspiratory effort. (See p. 58 )
Antitussives
Given in the absence of sputum production if coughing is continuous and exhausting to
the patient.
Antipyretics and analgesics

Prescribed to reduce fever and provide relief from pleuritic pain or pain from coughing.
Vaccines
Pneumococcal vaccine
Administered to patients who have chronic health conditions and to those who are more
than 65 yr old and/or are residents of an extended care facility and who have not
received the vaccine within the last 5 yr. Vaccine history should be assessed on
admission, and vaccine should be given to patients who meet criteria without
contraindications (allergy).
Influenza vaccine
Administered to patients with chronic health conditions and to those who are more than
50 yr old and/or are residents of an extended care facility and who have not received the
vaccine within the year. Influenza vaccines are routinely administered from October
through March. Vaccine history should be assessed on admission, and vaccine should be
given to patients who meet criteria without contraindications (e.g., allergy, history of
Guillain-Barr syndrome).
Infection control
See discussion in Appendix 1 , p. 743 .

For Patients with Pneumonia
Impaired gas exchange
related to altered O 2 supply and alveolar-capillary membrane changes secondary to
inflammatory process in the lungs
Desired outcomes
Hospital discharge based on patient exhibiting at least five of the following indicators:
temperature 37.8 C or less, HR 100 bpm or less, RR 24 breaths/min or less, SBP
90 mm Hg or more, O 2 saturation 90% or more, and ability to maintain oral intake.
56

Administer antibiotics within 4 hr of hospital admission to reduce risk of death.
Observe for restlessness, anxiety, mental status changes, shortness of breath, tachypnea,
and use of accessory muscles of respiration, all of which are indicators of respiratory
distress . Remember that cyanosis of the lips and nail beds may be a late indicator of
hypoxia.
Monitor and document VS q2-4h. Be alert to a rising temperature and other changes in
VS that may indicate infection (e.g., increased HR, increased RR).
Auscultate breath sounds at least q2-4h or as indicated by patient's condition. Monitor

for decreased or adventitious sounds (e.g., crackles, wheezes).
Monitor oximetry readings; report O 2 saturation 92% or less because this can indicate a
need for O 2therapy.
Monitor ABG results. A decreasing Pa o 2 often indicates need for O 2 therapy.
Position patient for comfort (usually semi-Fowler's position) to promote diaphragmatic

descent, maximize inhalation, and decrease work of breathing (WOB) . In patients with
unilateral pneumonia, positioning on unaffected side (i.e., good side down) promotes
ventilation/perfusion matching.
Deliver O 2 with humidity as prescribed; monitor oximetry or inspired concentration of

oxygen (FI o 2 ) to ensure that oxygen is within prescribed concentrations . Be aware
that patients with COPD may not tolerate O 2 at a delivery greater than 2 L/min, which
can suppress the centrally mediated respiratory drive.
Facilitate coordination among health care providers to provide rest periods between
care activities to decrease O 2 demand . Allow 90 min for undisturbed rest.
57
Ineffective airway clearance
related to presence of tracheobronchial secretions secondary to infection or related to
pain and fatigue secondary to lung consolidation
Desired outcomes
Patient demonstrates effective cough. Following intervention, patient's airway is free of
adventitious breath sounds.

Maintain a patent airway and ensure that secretions are removed. Suction as
indicated/prescribed.
Auscultate breath sounds q2-4h (or as indicated by patient's condition), and report
changes in patient's ability to clear pulmonary secretions.
Inspect sputum for quantity, odor, color, and consistency; document findings. As
patient's condition worsens, sputum can change in color from clear white yellow
green, or it may show other discoloration characteristic of underlying bacterial infection
(e.g., rust colored, currant jelly).
Ensure that patient performs deep-breathing with coughing exercises at least q2h. Assist
patient into position of comfort, usually semi-Fowler's position, to facilitate
effectiveness and ease of these exercises.
Assess need for hyperinflation therapy (i.e., patient's inability to take deep breaths).
Report complications of hyperinflation therapy to health care provider, including
hyperventilation, gastric distention, headache, hypotension, and signs and symptoms of
pneumothorax (shortness of breath, sharp chest pain, unilateral diminished breath
sounds, dyspnea, cough).
Teach patient to splint chest with pillow, folded blanket, or crossed arms when
coughing, to reduce pain.
58
Ensure that patient receives prescribed chest physiotherapy. Document patient's
response to treatment.
Assist patient with position changes q2h to help mobilize secretions. If the patient is
ambulatory, encourage ambulation to patient's tolerance.
When not contraindicated, encourage fluid intake (2.5 L/day or more) to decrease
sputum viscosity.
For other interventions, see Atelectasis for Ineffective breathing pattern, p. 58 .
Deficient fluid volume

related to increased insensible loss secondary to tachypnea, fever, or diaphoresis
Desired outcomes
At least 24 hr before hospital discharge, patient is normovolemic as evidenced by urine
output 30 mL/hr or more, stable weight, HR less than 100 bpm, SBP greater than
90 mm Hg, fluid intake approximating fluid output, moist mucous membranes, and
normal skin turgor.

Monitor I&O. Consider insensible losses if patient is diaphoretic and tachypneic. Be

alert to urinary output less than 30 mL/hr or 0.5 mL/kg/hr; report urinary output less
than 30 mL/hr.
Weigh patient daily at the same time of day and on the same scale; record weight.
Report weight decreases of 1-1.5 kg/day.
Encourage fluid intake (at least 2.5 L/day in the unrestricted patient) to ensure
adequate hydration.
Maintain IV fluid therapy as prescribed.
59

Promote oral hygiene, including lip and tongue care, to moisten dried tissues and
mucous membranes.
Provide humidity for O 2 therapy to decrease convective losses of moisture.
For Patients at Risk for Developing Pneumonia

Risk for infection (nosocomial pneumonia)
related to inadequate primary defenses (e.g., decreased ciliary action), invasive
procedures (e.g., intubation), and/or chronic disease
Desired outcome
Patient is free of infection as evidenced by normothermia, WBC count 12,000/mm 3 or
less, and sputum clear to whitish.

Perform good handwashing technique before and after contact with patient (even
though gloves are worn).
Identify presurgical candidate who is at increased risk for nosocomial pneumonia

because of the following: older adult (more than 70 yr), obesity, COPD, other chronic
pulmonary conditions (e.g., asthma), history of smoking, abnormal pulmonary function
tests (PFTs; especially decreased forced expiratory flow rate), intubation, and upper
abdominal/thoracic surgery.
Provide preoperative teaching; explain and demonstrate the following pulmonary

activities that will be used postoperatively to prevent respiratory infection: deep
breathing, coughing, turning in bed, splinting wounds, ambulating, maintaining
adequate oral fluid intake, and using hyperinflation device. Make sure that patient
verbalizes knowledge of the exercises and their rationale and returns demonstrations
appropriately.
Advise patients who smoke to discontinue smoking, especially during preoperative and
postoperative periods. Refer to a community-based smoking cessation program as
60
needed. When appropriate, discuss possibility of health care provider's prescription of
transdermal nicotine patches to facilitate smoking cessation.
Administer analgesics hr before deep-breathing exercises to control pain, which

interferes with lung expansion. Scheduled analgesics also promote pain control.
Support (splint) surgical wound with hands, pillows, or folded blanket placed firmly
across site of incision.
Identify patients who are at increased risk for aspiration: individuals with depressed
LOC, dysphagia, or nasogastric (NG) or enteral tube in place. Maintain head of bead
(HOB) at 30-45-degree elevation, and turn patient onto side rather than back. When
patient receives enteral alimentation, recommend continuous rather than bolus
feedings. Hold feedings when patient is lying flat.
Recognize risk factors for patients with tracheostomy: presence of underlying lung
disease or other serious illness, increased colonization of oropharynx or trachea by
aerobic gram-negative bacteria, greater access of bacteria to lower respiratory tract, and
cross-contamination caused by manipulation of tracheostomy tube.
Wear gloves on both hands until tracheostomy wound has healed or formed granulation
tissue around the tube or when handling mechanical ventilation tubing.
Suction prn rather than on a routine basis because frequent suctioning increases risk of
trauma and cross-contamination.
Use sterile catheter for each suctioning procedure. Consider use of closed suction
system to further minimize risk of contamination ; replace closed suction system if
soiled, for mechanical failure, or per agency policy. Always avoid reusing a suction
system for subsequent patients. Avoid saline instillation during suctioning. If patient
has tenacious secretions, increase heat and humidity to loosen them.
Always wear gloves on both hands to suction.
61
Recognize the ways in which nebulizer reservoirs can contaminate patient: introduction
of nonsterile fluids or air, manipulation of nebulizer cup, or backflow of condensate
from delivery tubing into reservoir or into patient when tubing is manipulated.
Use only sterile fluids and dispense them using sterile technique.
Replace (rather than replenish) solutions and equipment at frequent intervals. For
example, empty reservoir completely and refill with sterile solution q8-24h, per agency
protocol.
Change breathing circuits every week unless circuits are soiled, mechanical failure
occurs, or agency policy states otherwise.
Fill fluid reservoirs immediately before use (not far in advance).
Discard any fluid that has condensed in tubing; do not allow fluid to drain back into
reservoir or into patient.
Techniques that mobilize secretions and promote gas.
Medications, including drug names, purpose, dosage, frequency or schedule,

precautions, and potential side effects, particularly of antibiotics. Also discuss
drug/drug, herb/drug, and food/drug interactions. Instruct patient to complete full
regimen of antibiotics to prevent reinfection and subsequent readmission.
62
Signs and symptoms of pneumonia and importance of reporting them promptly if they
recur. Teach patient's significant others that changes in mental status may be the only
indicator of pneumonia if patient is elderly.
Importance of preventing fatigue by pacing activities and allowing frequent rest periods.
Importance of avoiding exposure to individuals known to have flu and colds.

Recommend that patient receive pneumococcal vaccination and annual influenza
vaccination.
Minimizing factors that can cause reinfection, including close living conditions, poor
nutrition, and poorly ventilated living quarters or work environment.
Importance of smoking cessation education and community resources to assist in

cessation.
Phone numbers to call if questions or concerns arise about therapy or disease after
discharge. Additional general information can be obtained from the American Lung
Association at www.lungusa.org .
Information about the free brochures that discuss ways to stop smoking such as the
following:
o How to Help Your Patients Stop Using Tobacco: A National Cancer

Institute Manual for the Oral Health Team, from the Smoking and Tobacco
Control Program of the National Cancer Institute; call (800) 4-CANCER.
Pleural Effusion
A pleural effusion is an accumulation of fluid (blood, pus, chyle, serous fluid) in the
pleural space. Generally, fluid gravitates to the most dependent area of the thorax, and
the adjacent lung becomes compressed. Pleural effusion is rarely a disease in itself, but
rather it is caused by a number of inflammatory, circulatory, or neoplastic diseases.
Transudate effusion results from changes in hydrodynamic forces in the circulation and
63
usually is caused by heart failure (increased hydrostatic pressure) or cirrhosis
(decreased colloidal osmotic pressure). Exudate effusion results from irritation of the
pleural membranes secondary to inflammatory, infective, or malignant processes. More
exact nomenclature can be used once the nature of the fluid in the pleural effusion has
been identified, that is, hydrothorax (a transudate or exudate of serous fluid), pyothorax
or empyema (collection of purulent material), hemothorax (bloody fluid), or chylothorax
(effused chyle).
Assessment
Clinical indicators of pleural effusion are related to the underlying disease. Patients with
a small effusion (less than 300 mL) may be asymptomatic.

Pleuritic chest or shoulder pain, diaphoresis, cough, fever, dyspnea, orthopnea,
decreased breath sounds, dullness to percussion, decreased tactile fremitus, egophony
(e to a change) over effusion site, tracheal deviation away from affected side, and
pleural friction rub.
Diagnostic Tests
Shows evidence of effusion if more than 300 mL of fluid is in the pleural space. With
effusion greater than 1000 mL, the x-ray film may show mediastinal shift away from the
affected lung.
Chest computed tomography (CT)

Enables imaging of the entire pleural space, pulmonary parenchyma, and mediastinum
simultaneously. CT assists in differentiation between lung consolidation and pleural
effusion.
Thoracentesis
Removal of fluid from the pleural space for examination to provide definitive diagnosis
and determine type of effusion.
Percutaneous pleural biopsy

Aids in diagnosing cause of effusion especially when tuberculosis (TB) or malignant
disease is suspected.
Therapeutic thoracentesis
Removes fluid and thereby allows lung to reexpand. Rate of recurrence and time span
for return of symptoms are recorded.
Chest tube insertion

64
Provides continuous drainage of larger effusions through 26F-30F catheter connected to
closed chest-drainage system.
Sclerosing pleurodesis
Produces pleural fibrosis and symphysis (line of fusion between visceral and parietal
pleural layers) by instillation of sclerosing agent (tetracycline, bleomycin, or nitrogen
mustard) via chest tube.

related to decreased lung expansion secondary to fluid accumulation in the pleural
space
Desired outcome
Following intervention, patient's breathing pattern moves toward eupnea.

Auscultate breath sounds q2-4h (or as indicated by patient's condition), and monitor for
decreasing breath sounds or presence of pleural friction rub.
Monitor oximetry readings; report O 2 saturation 92% or less because this can indicate
need for O 2therapy .
Ensure patency of chest drainage system (see guidelines, p. 79 , in

Pneumothorax/Hemothorax ).
Position patient for maximum chest expansion, generally semi-Fowler's position.
If hyperinflation therapy is prescribed, instruct patient in its use and document patient's
progress.
For patients with gross pleural effusion, provide the following instructions for apical
expansion breathing exercise:
65
o
Sit upright.
Position fingers just below the clavicles.
Inhale and attempt to push upper chest wall against pressure of the fingers.
Hold breath for a few seconds, and then exhale passively.
When performed at frequent intervals, this exercise will help expand the involved lung
tissues, minimize flattening of the upper chest, and mobilize secretions.
Importance of smoking cessation. Provide patient with resources related to community

smoking cessation programs. When appropriate, discuss possibility of health care
provider's prescription of transdermal nicotine patches to facilitate smoking cessation.
Signs of respiratory distress, such as restlessness, mental status changes, agitation,

changes in behavior, and complaints of shortness of breath or dyspnea, and importance
of rapidly notifying health care provider if these signs occur.
Use of equipment at home (e.g., hyperinflation device, nebulizer, O 2 ).
Medications, including drug names, dosage, purpose, schedule, precautions, and

66
Pulmonary Embolism
The most common pulmonary perfusion abnormality is pulmonary embolism (PE). PE
is caused by passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into
the pulmonary artery or its branches, with resulting obstruction of the blood supply to
lung tissue and subsequent collapse. The most common source is a dislodged blood clot
from the systemic circulation, typically the deep veins of the legs or pelvis. Thrombus
formation is the result of the following factors: blood stasis, alterations in clotting
factors, and injury to vessel walls. A fat embolus is the most common nonthrombotic
cause of pulmonary perfusion disorders (see p. 74 ).
Total obstruction leading to pulmonary infarction is rare because the pulmonary

circulation has multiple sources of blood supply. Early diagnosis and appropriate
treatment reduce mortality to less than 10%. Although most cases of PE resolve
completely with no residual deficits, some patients may be left with chronic pulmonary
hypertension.
Assessment
Often nonspecific and variable, depending on extent of obstruction and whether patient
has infarction as a result of the obstruction.
Sudden onset of dyspnea and sharp chest pain, restlessness, anxiety, nonproductive
cough or hemoptysis, palpitations, nausea, syncope, tachypnea, tachycardia,
hypotension, crackles (rales), decreased chest wall excursion secondary to splinting,
S 3 and S 4 gallop rhythms, transient pleural friction rub, jugular venous distention,
diaphoresis, edema, and cyanosis.
If infarction has occurred, fever, pleuritic chest pain, and hemoptysis are common.
History and risk factors

Immobility
Especially significant when it coexists with surgical or nonsurgical trauma, carcinoma,
or cardiopulmonary disease. Risk increases as duration of immobility increases.
Cardiac disorders
Atrial fibrillation, heart failure, myocardial infarction, rheumatic heart disease.
Surgery
Risk increases in postoperative period, especially for patients with orthopedic, pelvic,
thoracic, or abdominal surgery and for those with extensive burns or musculoskeletal
injuries of the hip or knee.
67
Pregnancy
Especially during postpartum period.
Chronic pulmonary and infectious diseases

Trauma
Especially lower extremity fractures and burns. Degree of risk is related to severity, site,
and extent of trauma.
Mechanical ventilation
Risk increases because of immobility and inflammatory processes.
Carcinoma
Particularly neoplasms involving the breast, lung, pancreas, and genitourinary and
alimentary tracts.
Obesity
A 20% increase in ideal body weight is associated with increased incidence of PE.
Varicose veins or prior thromboembolic disease

Age
Risk of thromboembolism is greatest for patients 55-65 yr of age.
Diagnostic Tests
Hypoxemia (Pa o 2 less than 80 mm Hg), hypocarbia (Pa co 2 less than 35 mm Hg), and
respiratory alkalosis (pH more than 7.45) usually are present. Normal values do not rule
out PE.
D-dimer
A degradation product produced by plasmin-mediated proteolysis of cross-linked fibrin
and measured by enzyme-linked immunosorbent assay (ELISA). The higher the result
(with less than 250 ng/mL considered negative in most laboratories), the more likely it
is patient has PE. This test is not sensitive or specific enough to diagnose PE, but it may
be used in conjunction with other diagnostic tests.
Cardiac troponin level

Elevated in PE as a result of right ventricular dilation and myocardial injury.

Initially findings are usually normal, or elevated hemidiaphragm may be present. After
24 hr, x-ray examination may reveal small infiltrates secondary to atelectasis that result
68
from the decrease in surfactant. If pulmonary infarction is present, infiltrates and
pleural effusions may be seen within 12-36 hr.
ECG results
Abnormal in 85% of patients with PE.
Spiral or helical computed tomography (CT)

Images pulmonary arteries (PAs) during a single breath. Spiral CT is rapidly becoming
the test of choice in diagnosing PE because of its higher specificity and sensitivity.
Pulmonary ventilation/perfusion scan

Used to detect abnormalities of ventilation or perfusion in the pulmonary system.
Radiopaque agents are inhaled and injected peripherally. Images of distribution of both
agents throughout the lung are scanned. If the scan shows a mismatch of ventilation and
perfusion (i.e., pattern of normal ventilation with decreased perfusion), vascular
obstruction is suggested.
Pulmonary angiography
Definitive study for PE: An invasive procedure that involves catheterization of right side
of the heart and injection of dye into the PA to visualize pulmonary vessels. Abrupt
vessel cutoff may be seen at the site of embolization. Usually, filling defects are seen.
More specific findings are abnormal blood vessel diameters (i.e., obstruction of right PA
would cause dilation of left PA) and abnormal blood vessel shapes (i.e., affected blood
vessel may taper to a sharp point and disappear).
The three goals of therapy are (1) prophylaxis for individuals at risk for development of
PE, (2) treatment during acute embolic event, and (3) prevention of future embolic
events in individuals who have experienced PE.
O therapy
2
Delivered at appropriate concentration to maintain a Pa o 2 of more than 60 mm Hg or

O 2 saturation greater than 90%.
Anticoagulation
Low molecular weight heparin (LMWH) or unfractionated heparin (UFH)
therapy
Started immediately in patients without bleeding or clotting disorders and in whom PE
is strongly suspected with the aim of inhibiting further thrombus growth, promoting
resolution of the formed thrombus, and preventing further embolus formation.
Continued for at least 5 days to allow for depletion of thrombin.
LMWH
69
Preferred to UFH because of more predictable dosing, fewer side effects, once- or twice-
daily subcutaneous administration, and lack of need to monitor activated partial
thromboplastin time. Dose is weight based and differs for various LMWH preparations.
Dose must be adjusted for individuals with renal impairment because most LMWH is
excreted by the kidneys. LMWH has been shown to be safe if given during pregnancy.
UFH
Has shorter half-life than LMWH and effect is completely reversible with protamine.
Ideally, dosage is weight based (e.g., IV bolus of 80 units/kg followed by a maintenance
dose of 18 units/kg/hr). Alternatively, an initial IV bolus of 5000-10,000 units followed
by continuous infusion of 1000 units/hr may be given. Effect is monitored by activated
partial thromboplastin time (aPTT) measurements every 6 hr after initial dose until the
goal of 1.5 to 2.5 control value is consistently established.
Oral anticoagulant (warfarin sodium) therapy

Begun on initiation of heparin therapy and given simultaneously to allow time for
warfarin to inhibit vitamin Kdependent clotting factors before heparin or LMWH is
discontinued. Used long term (3-6 mo, longer if significant risk factors are present).
Initial dose, usually 10 mg/day, is based on prothrombin time (PT) with the goal of 1.25-
1.50 normal or international normalized ratio (INR) of 2.0-3.0. When an INR of 2.0-
3.0 is obtained, UFH or LMWH can be discontinued. PT measurements are monitored
daily.
Vitamin K (vitamin K , [phytonadione]or K [menadione])

1 3
Reverses effects of warfarin in 24-36 hr. Fresh frozen plasma may be required in cases
of serious bleeding. Warfarin crosses the placental barrier and can cause spontaneous
abortion and birth defects.
Thrombolytic therapy
May be given in the first 24-48 hr after diagnosis of PE to speed the process of clot lysis
via conversion of plasminogen to plasmin. Thrombolytic therapy may be preferred for
initial treatment of PE in patients with hemodynamic compromise, with greater than
30% occlusion of pulmonary vasculature, and in whom therapy has been initiated no
later than 3 days after onset of PE. Thrombin time is measured q4h during therapy to
ensure adequate response, which should be 2-5 normal. Partial thromboplastin time
(PTT) can be used instead of thrombin time and should be 2-5 control. Once
thrombolytic therapy is stopped, thrombin time or PTT should be checked frequently
until values fall to less than 2 normal. When this occurs, heparin therapy is started
and continued as described earlier. As many as 33% of patients receiving thrombolytic
therapy have hemorrhagic complications.
Contraindications to thrombolytic therapy include active internal bleeding, recent

stroke, intracranial bleeding within 2 mo of PE, intraspinal surgery, trauma,
arteriovenous malformation, aneurysm, uncontrolled hypertension (DBP higher than
70
110 mm Hg or SBP higher than 185 mm Hg), pregnancy, and status less than 10 days
post partum.
Surgical interventions
Used only in select cases because anticoagulant therapy is usually successful.
Vena Caval Interruption

Uses a filter approved by the U.S. Food and Drug Administration (FDA) to prevent
passage of venous thrombi through the inferior vena cava. The following FDA-approved
filters may be used: Greenfield, Venatech, Simon Nitinol, and Bird's Nest.
Pulmonary Embolectomy
Removes clots from the pulmonary circulation. Generally, use of thrombolytic agents
eliminates need for this procedure.

related to altered O 2 supply secondary to ventilation/perfusion mismatch
Desired outcomes
Following intervention/treatment, patient exhibits adequate gas exchange and
ventilatory function as evidenced by respiratory rate (RR) of 12-20 breaths/min with
normal pattern and depth (eupnea); no significant changes in mental status; and
orientation to person, place, and time. At least 24 hr before hospital discharge, patient
has O 2saturation greater than 90% or Pa o 2 80 mm Hg or higher, Pa co 2 35-45 mm Hg,
and pH 7.35-7.45 (or values consistent with patient's acceptable baseline parameters).

Monitor for signs and symptoms of increasing respiratory distress: RR increased from
baseline; increasing dyspnea, anxiety, restlessness, confusion, and cyanosis.
As indicated, monitor oximetry readings; report O 2 saturation 90% or less because this
can indicate need for O 2 therapy.
Position patient for comfort and optimal gas exchange. Ensure that area of the lung
affected by embolus is not dependent when patient is in lateral decubitus position.
Elevate head of bed (HOB) 30 degrees to improve ventilation .
71

Avoid positioning patient with knees bent (i.e., gatching bed) because this impedes
venous return from legs and can increase risk of PE. Instruct patient not to cross legs
when lying in bed or sitting in a chair.
Limit or pace patient's activities and procedures to decrease metabolic demands for O 2 .
Ensure that patient performs deep-breathing and coughing exercises 3-5 q2h to
maximize ventilation.
Ensure delivery of prescribed concentrations and humidity of O 2 .
Monitor serial ABG values and assess for desired response to treatment. Report lack of
response to treatment or worsening ABG values.
Ineffective protection
related to risk of prolonged bleeding or hemorrhage secondary to anticoagulation
therapy
Desired outcomes
Patient is free of frank or occult bleeding; body secretions/excretions test negative for
blood.

Monitor VS for indicators of profuse bleeding or hemorrhage resulting from

anticoagulant therapy: hypotension, tachycardia, tachypnea.
At least once each shift inspect wounds, oral mucous membranes, any entry site of an
invasive procedure, and nares for evidence of bleeding.
At least once each shift inspect torso and extremities for petechiae or ecchymoses.
72

To prevent hematoma formation, do not give intramuscular (IM) injection unless it is

unavoidable. If parenteral medications are mandatory, attempt to administer
subcutaneously using a small-gauge needle.
Apply pressure to all venipuncture or arterial puncture sites until bleeding stops
completely.
Ensure easy access to the following antidotes for prescribed treatment:
Protamine sulfate: 1 mg counteracts 100 units of heparin, so 1 mg of protamine sulfate

is administered for every 100 units of heparin in the body.
Vitamin K (vitamin K 1 [phytonadione] or K 3 [menadione]): Low doses2.5 mg PO or

0.5-1 mg IVare generally used to control bleeding without hindering restoration of
anticoagulation.
Fresh frozen plasma.
If patient is receiving heparin therapy, monitor serial aPTT (desired range is 1.5-2.5
control). If patient is receiving warfarin therapy, monitor serial PT (desired range is
1.25-1.5 control, or INR value of 2.0-3.0). Report values outside desired range.
To prevent negative interactions with anticoagulants or thrombolytic

therapy, establish compatibility of all drugs before administering them.
Heparin: Digitalis, tetracycline, nicotine, and antihistamines decrease the effect of

heparin therapy. Consult pharmacist about compatibility before infusing other IV drugs
through heparin IV line.
73
Warfarin sodium: Numerous drugs decrease or increase response to treatment with
warfarin. Consult pharmacist to obtain specific information about patient's medication
profile. Antibiotics routinely increase INR levels, check with the pharmacist for drug
interactions.
Thrombolytic therapy: Consult pharmacist before infusing any other medication

through the same IV line.
Because aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) are platelet

aggregation inhibitors and can prolong episodes of bleeding, use these medications
cautiously.
Discuss with patient and significant others the importance of reporting promptly the
presence of bleeding from any of the following sources: hematuria, melena, frank
bleeding from the mouth, epistaxis, hemoptysis, excessive vaginal bleeding
(menometrorrhagia).
Teach necessity of using sponge-tipped applicators and mouthwash for oral care to
minimize risk of gum bleeding. Instruct patient to shave with electric rather than
straight or safety razor.
If patient is restless and combative, provide a safe environment. Use extreme care when
moving patient to avoid bumping patient's extremities into side rails and causing
bleeding.
Deficient knowledge
related to oral anticoagulant therapy, potential side effects, and foods and medications
to avoid during therapy
Desired outcome
Before hospital discharge, patient verbalizes knowledge of prescribed anticoagulant
drug, potential side effects, and foods and medications to avoid while receiving oral
anticoagulant therapy.

74
Assess patient's facility with language; engage an interpreter or language-appropriate
written materials if necessary.
Determine patient's knowledge of oral anticoagulant therapy. As appropriate, discuss

drug name, purpose, dose, schedule, precautions, and potential side effects. Also discuss
food/drug, herb/drug, and drug/drug interactions.
Teach potential side effects/complications of anticoagulant therapy: easy bruising,

prolonged bleeding from cuts, spontaneous nosebleeds, bleeding gums, black and tarry
or bloody stools, vaginal bleeding, and blood in urine and sputum.
Discuss importance of laboratory testing and follow-up visits with health care provider.
Explain importance of informing all health care providers (including dentist) that
patient is taking an anticoagulant. Suggest that patient wear a MedicAlert tag or
otherwise carry identification to alert health care providers about the anticoagulant
therapy.
Teach patient to notify doctor if diet contains large amounts of foods high in vitamin K
(e.g., fish, bananas, dark-green vegetables, tomatoes, cauliflower), which can interfere
with anticoagulation .
Caution patient that soft-bristled rather than hard-bristled toothbrush and electric
rather than straight or safety razor should be used during anticoagulant therapy to
minimize risk of injury that could cause bleeding.
Instruct patient to consult health care provider before taking over-the-counter (OTC) or
prescribed drugs that were used before initiating anticoagulant therapy. Aspirin,
cimetidine, trimethaphan, and macrolides are among the many drugs that enhance
response to warfarin. Drugs that decrease response include antacids, diuretics, oral
contraceptives, and barbiturates.
75
Reinforce patient teaching about oral anticoagulant therapy (see Deficient knowledge ).
Also provide verbal and written information about the following:
Risk factors related to development of thrombi and embolization and preventive

measures to reduce the risk.
Signs and symptoms of thrombophlebitis: calf swelling; tenderness or warmth in the

involved area; possible presence of pain in affected calf when ankle is dorsiflexed; slight
fever; and distention of distal veins, coolness, edema, and pale color in the distal
affected leg.
Signs and symptoms of PE: sudden onset of dyspnea, anxiety, nonproductive cough or
hemoptysis, palpitations, nausea, syncope.
Importance of preventing impairment of venous return from the lower extremities by

avoiding prolonged sitting, crossing legs, and wearing constrictive clothing.
Fat Embolism
Fat embolism is the most common type of nonthrombotic PE. Free fatty acids cause
toxic vasculitis, followed by thrombosis and obstruction of small pulmonary arteries by
fat.
Assessment
Typically, patient is asymptomatic for 12-24 hr following embolization. This period ends
with sudden cardiopulmonary and neurologic deterioration: apprehension, restlessness,
mental status changes, confusion, delirium, coma, dyspnea, tachypnea, tachycardia, and
hypertension; fever; petechiae, especially of conjunctivae, neck, upper torso, axillae, and
proximal arms; inspiratory crowing; pulmonary edema; profuse tracheobronchial
secretions; fat globules in sputum; and expiratory wheezes.

Multiple long bone fractures, especially fractures of the femur and pelvis; trauma to
adipose tissue or liver; burns; osteomyelitis; sickle cell crisis.
Diagnostic Tests
ABG values
76
Should be determined in patients at risk for fat embolus for the first 48 hr following
injury because early hypoxemia indicative of fat embolus is apparent only with
laboratory assessment. Hypoxemia (Pa o 2 less than 80 mm Hg) and hypercarbia
(Pa co 2 more than 45 mm Hg) are present with respiratory acidosis (pH less than 7.35).

Pattern similar to that in acute respiratory distress syndrome (ARDS) is seen: diffuse,
extensive bilateral interstitial and alveolar infiltrates.
Complete blood count (CBC)

May reveal decreased hemoglobin (Hgb) and hematocrit (Hct) secondary to hemorrhage
into the lung. In addition, thrombocytopenia (platelets 150,000/mm 3 or less) is
indicative of fat embolism.
Serum lipase
Value rises with fat embolism.
Urinalysis
May reveal fat globules following fat embolus.
O 2
Concentration of O 2 is based on clinical picture, ABG results, and patient's prior

respiratory status. Intubation and mechanical ventilation may be required.
Diuretics
Approximately 30% of patients with fat emboli develop pulmonary edema that
necessitates use of diuretics.

See Impaired gas exchange on p. 72 .
Pneumothorax/Hemothorax
Overview/Pathophysiology of Pneumothorax
Pneumothorax is an accumulation of air in the pleural space that leads to increased
intrapleural pressure. Risk factors include blunt or penetrating chest injury, chronic
obstructive pulmonary disease (COPD), previous pneumothorax, and positive-pressure
ventilation. The three types of pneumothorax are as follows:
Spontaneous
Also referred to as closed pneumothorax because the chest wall remains intact with no
leak to the atmosphere. It results from rupture of a bleb or bulla on the visceral pleural
77
surface, usually near the apex. Generally, the cause of the rupture is unknown, although
it may result from a weakness related to a respiratory infection or from an underlying
pulmonary disease (e.g., COPD, tuberculosis (TB), malignant neoplasm). The affected
individual is usually young (20-40 yr), previously healthy, and male. Onset of symptoms
usually occurs at rest rather than with vigorous exercise or coughing. Potential for
recurrence is great; the second pneumothorax occurs an average of 2-3 yr after the first.
Traumatic
Can be open or closed. An open pneumothorax occurs when air enters the pleural space
from the atmosphere through an opening in the chest wall, such as with a gunshot
wound, stab wound, or invasive medical procedure (e.g., thoracentesis or placement of a
central line into a subclavian vein). A sucking sound may be heard over the area of
penetration during inspiration, a feature that accounts for the classic wound description
as a sucking chest wound. A closed traumatic pneumothorax occurs when the visceral
pleura is penetrated but the chest wall remains intact with no atmospheric leak. This
usually occurs following blunt trauma that results in rib fracture and dislocation. It also
may occur from use of positive end-expiratory pressure (PEEP) or after
cardiopulmonary resuscitation (CPR).
Tension
Generally occurs with closed pneumothorax; also can occur with open pneumothorax
when a flap of tissue acts as a one-way valve. Air enters the pleural space through the
pleural tear when the individual inhales, and it continues to accumulate but cannot
escape during expiration because the tissue flap closes. With tension pneumothorax, as
pressure in the thorax and mediastinum increases, it produces a shift in the affected
lung and mediastinum toward the unaffected side that further impairs ventilatory
efforts. The increase in pressure also compresses the vena cava. This compression
impedes venous return and leads to a decrease in cardiac output and ultimately to
circulatory collapse if the condition is not diagnosed and treated quickly. Tension
pneumothorax is a life-threatening medical emergency.
Overview/pathophysiology of hemothorax
Hemothorax is an accumulation of blood in the pleural space. Hemothorax generally
results from blunt trauma to the chest wall, but it also can occur following thoracic
surgery, after penetrating gunshot or stab wounds, as a result of anticoagulant therapy,
after insertion of a central venous catheter, or following various thoracoabdominal
organ biopsies. Mediastinal shift, ventilatory compromise, and lung collapse can occur,
depending on the amount of blood accumulated.
Assessment
Signs and symptoms/physical findings vary, depending on type and size of the
pneumothorax or hemothorax (TABLE 2-2 ).
TABLE 2-2
SIGNS AND SYMPTOMS/PHYSICAL FINDINGS WITH PNEUMOTHORAX OR HEMOTHORAX
78
SPONTANEOUS OR TRAUMATIC
PNEUMOTHORAX
CLOSED OPEN TENSION HEMOTHORAX
PNEUMOTHORAX
Signs and Symptoms
Shortness of breath, Shortness of Dyspnea, chest pain Dyspnea, chest
cough, chest breath, sharp chest pain
tightness, chest pain pain
Physical Assessment
Tachypnea, Agitation, Anxiety, tachycardia, Tachypnea, pallor,
decreased thoracic restlessness, cyanosis, jugular vein cyanosis, dullness
movement, tachypnea, distention, tracheal over affected side,
cyanosis, cyanosis, presence deviation toward the tachycardia,
subcutaneous of chest wound, unaffected side, hypotension,
emphysema, hyperresonance absent breath sounds diminished or
hyperresonance over affected area, on affected side, absent breath
over affected area, sucking sound on distant heart sounds, sounds, change
diminished breath inspiration, hypotension, change mental status
sounds, paradoxical diminished breath in mental status
movement of chest sounds, change in
wall (may signal flail mental status
chest), change in
mental status
View full size
Diagnostic Tests
Reveals presence of air or blood in the pleural space on the affected side,
pneumothorax/hemothorax size, and any shift in the trachea and mediastinum.

Hypoxemia (Pa o 2 less than 80 mm Hg) may be accompanied by hypercarbia
(Pa co 2 greater than 45 mm Hg) with resultant respiratory acidosis (pH less than 7.35).
Arterial O 2 saturation may be decreased initially but usually returns to normal within
24 hr.
Oximetry
Reveals decreased O 2 saturation (90% or less).
CBC
May reveal decreased Hgb proportionate to amount of blood lost in the hemothorax.
79
Management is determined by signs and symptoms. A small pneumothorax (less than
20%) may heal itself via reabsorption of the free air and may thereby render invasive
procedures unnecessary unless an underlying disease process or injury is present.
Hemothorax nearly always requires intervention.
O therapy
2
Administered when ABG values or oximetry demonstrates presence of hypoxemia,

which usually occurs when the pneumothorax/hemothorax is large. 100% O 2 may be
administered to speed reabsorption of a pneumothorax.
Thoracentesis/air aspiration
Used for hemothorax to remove blood from the pleural space. For cases of tension
pneumothorax, thoracentesis/air aspiration is performed immediately to remove air
from the pleural space. A large-bore needle is inserted in the second intercostal space,
midclavicular line, which correlates to the superior portion of the anterior axillary lobe.
A sudden rushing out of air confirms the diagnosis of tension pneumothorax. Following
release of entrapped air, chest tubes are inserted. Air aspiration may be done when a
pneumothorax is large enough to allow lung reexpansion; if only partial reexpansion
occurs, a one-way valve may be attached to the thoracentesis catheter to allow for
outpatient management.
Chest tube placement (tube thoracostomy)

A chest tube (thoracic catheter) may be inserted in any patient who is symptomatic.
During insertion the patient should be in an upright position so that the lung falls away
from the chest wall. Thoracic catheter positioning depends on whether air, fluid, or both
are to be drained. The thoracic catheter must be connected to an underwater-seal
drainage system, dry suction system, or one-way flutter valve device. Suction may be
used, depending on size of the pneumothorax or hemothorax, patient's condition, and
amount of drainage. If drainage is minimal and no suction is required, a one-way flutter
valve may be used instead of an underwater-seal drainage system or dry suction. After
chest tube insertion and removal of air or fluid from the pleural space, the lung begins to
reexpand. A chest tube may produce pleural inflammation, causing pleuritic pain, slight
temperature elevation, and pleural friction rub.
Thoracotomy
Often indicated in patients who have had two or more spontaneous pneumothoraces on
one side because of risk of continuous recurrence or if pneumothorax does not resolve
within 7 days. With hemothorax, thoracotomy is performed to locate the source and
control bleeding if blood loss is excessive. Thoracotomy may include mechanical
abrasion of the pleural surfaces with a dry sterile sponge or chemical abrasion via an
agent such as tetracycline solution or talc, which results in pleural adhesions
(pleurodesis) that help prevent recurrence of pneumothorax. Partial pleurectomy may
be performed instead of mechanical or chemical abrasion.
80
Video-assisted thoracic surgery (VATS)
Performed in the operating room while patient is under general anesthesia. A small
thoracoscope is inserted through a small chest incision. Pleural fluid is removed and
pleural biopsy samples may be obtained. A chest tube is inserted and connected to
suction for further drainage.
Chemical pleurodesis
Instillation of a sclerosing agent (e.g., tetracycline, talc) into the pleural cavity to
produce adhesions and a line of fusion between visceral and parietal pleural layers.
IV therapy
Administered if significant loss of fluids or blood occurs.
Analgesia
Because of rich innervation of the pleura, chest tube placement or pleurodesis is painful,
and significant analgesia is usually required.

related to altered O 2 supply secondary to ventilation/perfusion mismatch
Desired outcomes
Following treatment/intervention, patient exhibits adequate gas exchange and
ventilatory function as evidenced by respiratory rate (RR) 20 breaths/min or less with
normal depth and pattern (eupnea); no significant mental status changes; and
orientation to person, place, and time. At a minimum of 24 hr before hospital discharge,
patient's ABG values are as follows: Pa o 2 80 mm Hg or more and Pa co 2 35-45 mm Hg
(or values within patient's acceptable baseline parameters), or oximetry readings
demonstrate O 2 saturation greater than 90%.

Monitor serial ABG results to detect decreasing Pa o 2 and increasing Pa co 2 , which can
signal impending respiratory compromise , or monitor oximetry readings for
O 2 saturation 90% or less. Report significant findings.
Observe for increased restlessness, anxiety, tachycardia, and changes in mental status.
Cyanosis may be a late sign. These signs indicate hypoxia.
81
Assess VS and breath sounds q2h or as indicated by patient's condition.
Following tube or exploratory thoracotomy, check q15min until stable for increased RR,
diminished or absent movement of chest wall on affected side, paradoxical movement of
the chest wall, increased work of breathing (WOB), use of accessory muscles of
respiration, complaints of increased dyspnea, unilateral diminished breath sounds, and
cyanosis, which indicates respiratory distress. Evaluate heart rate (HR) and BP for
indications of shock (i.e., tachycardia and hypotension).
Position patient to allow for full expansion of unaffected lung. Semi-Fowler's position
usually provides comfort and allows adequate expansion of chest wall and descent of
diaphragm.
Change patient's position q2h to promote drainage and lung reexpansion and facilitate
alveolar perfusion.
Encourage patient to take deep breaths and provide necessary analgesia to decrease
discomfort during deep-breathing exercises . Instruct patient in splinting thoracotomy
site with arms, pillow, or folded blanket. Deep breathing promotes full lung expansion
and decreases risk of atelectasis. Coughingfacilitates mobilization of tracheobronchial
secretions, if present.
Deliver and monitor O 2 and humidity as indicated.
Ineffective breathing pattern (or risk for same)

related to decreased lung expansion secondary to malfunction of chest drainage system
Desired outcome
Following intervention, patient becomes eupneic.

Monitor patient at frequent intervals (q2-4h, as appropriate) to assess breathing pattern

while chest-drainage system is in place. Auscultate breath sounds, reporting diminished
82
sounds; be alert for and report signs of respiratory distress, including tachycardia,
restlessness, anxiety, and changes in mental status.
Assess and maintain closed chest-drainage system as follows:
Tape all connections and secure chest tube to thorax with tape. Avoid all tubing kinks,
and ensure that the bed and equipment are not compressing any component of the
system.
Eliminate all dependent loops in tubing. These may impede removal of air and fluid
from the pleural space.
Maintain fluid in underwater-seal chamber and suction chamber at appropriate levels.
Be aware that the suction apparatus does not regulate amount of suction applied to
closed chest-drainage system. The amount of suction is determined by water level in the
suction control chamber. Minimal bubbling in this chamber is acceptable and desirable.
Dial the level of dry suction per health care provider's recommendation. Suction aids in
lung reexpansion, but removing suction for short periods, such as for transporting, will
not be detrimental or disrupt the closed chest-drainage system.
Avoid stripping of chest tubes. This mechanism for maintaining chest-tube patency is
controversial and has been associated with creating high negative pressures in the
pleural space, which can damage fragile lung tissue. Squeezing alternately hand over
hand along the drainage tube may generate sufficient pressure to move fluid along the
tube. Use of mechanical or handheld tube-stripping devices should be avoided.
Be aware that fluctuations in the underwater-seal chamber are characteristic of a patent

chest tube. Fluctuations stop when either the lung has reexpanded or there is a kink or
obstruction in the chest tube as follows:
83
Bubbling in the underwater-seal chamber occurs on expiration and is a sign that air is
leaving the pleural space. Continuous bubbling in the underwater-seal chamber may be
a signal that air is leaking into the drainage system. Locate and seal the system's air leak,
if possible.
Keep the following necessary emergency supplies at the bedside:
Petrolatum gauze pad to apply over insertion site if the chest tube becomes dislodged ;
use of this dressing provides an airtight seal to prevent recurrent pneumothorax.
Bottle of sterile water in which to submerge the chest tube if it becomes disconnected
from the underwater-seal system.
Never clamp a chest tube without a specific directive from health care provider;
clamping may lead to tension pneumothorax because air in the pleural space no longer
can escape.
Acute pain
related to impaired pleural integrity, inflammation, or presence of a chest tube
Desired outcomes
Within 1 hr of intervention, patient's subjective perception of pain decreases, as
documented by pain scale. Objective indicators, such as grimacing, are absent or
diminished.

At frequent intervals, assess patient's degree of discomfort by using an appropriate pain

rating scale such as 0 (no pain) to 10 (worst pain), as well as patient's verbal and
nonverbal cues.
Medicate with analgesics as prescribed and use pain scale to evaluate and document
medication effectiveness . Encourage patient to request analgesic before pain becomes
severe.
84

Premedicate patient 30 min before initiating coughing, exercising, or repositioning, to

minimize pain .
Teach patient to splint affected side when coughing, moving, or repositioning, to

minimize pain .
Facilitate coordination among health care providers to provide rest periods between
care activities to decrease O 2 demand . Allow 90 min for undisturbed rest.
Stabilize chest tube to reduce pull or drag on latex connector tubing. Tape chest tube
securely to thorax. Position tube to ensure there are no dependent loops.
For additional interventions, see Pain, p. 13 , in Chapter 1 .
Purpose of chest tube and its maintenance.
Potential for and symptoms of recurrence of spontaneous pneumothorax and

importance of seeking medical care immediately.
Medications, including drug names, purpose, dosage, schedule, precautions, and

Pulmonary Tuberculosis
85
Tuberculosis (TB) is an infectious disease caused primarily by Mycobacterium
tuberculosis. In the United States an estimated 10 to 15 million persons are infected
with this organism, most of whom have latent TB infection (LTBI) in which the bacteria
are in the body (usually the lungs) in a dormant form that neither causes disease nor is
communicable to other persons. A small proportion of persons (about 10%) with LTBI
will develop active TB in their lifetimes.
For many years (from 1953 to 1984), reported cases of TB in the United States decreased
by almost 6% each year, and the general perception was that TB was no longer a
problem. This decline was due to many factors, including improved living conditions
(less crowding and better ventilation), better nutrition, and antituberculosis drugs. As a
result, the public health infrastructure to support TB control weakened as other
diseases, for example, human immunodeficiency virus (HIV)/acquired
immunodeficiency syndrome (HIV/AIDS), became more prominent. It was not until the
late 1980s that a link between TB and HIV/AIDS became apparent, as was manifested
partly by multidrug-resistant (MDR) TB outbreaks occurring in seven hospitals between
1990 and 1992 and resulting in many cases of LTBI, TB disease, and death. In addition,
reported cases of TB increased 20% between 1985 and 1992. After the hospital
outbreaks and other changes in administrative and legislative support to control TB,
cases have steadily declined again in most areas of the country. In 2003, fewer than
15,000 cases of TB were reported in the United States, more than half of which were
among foreign-born persons. Worldwide, TB remains a leading cause of death in
developing countries; the World Health Organization (WHO) estimates that
approximately one third of the world's population is infected with M. tuberculosis.
M. tuberculosis is transmitted by the airborne route via minute, invisible particles called
droplet nuclei. When individuals with TB disease of the lungs or throat cough, sneeze,
speak, or sing, TB organisms harboring in their respiratory secretions are expelled into
the air and transform quickly into tiny droplet nuclei that can remain suspended in air
for several hours, depending on the environment (especially within ventilation systems).
To become infected, another person must breathe the air containing the droplet nuclei.
A person's natural defenses of the nose and upper airway and immune system often
prevent sufficient numbers of organisms from reaching the alveoli to cause infection. It
generally takes 5 to 200 bacilli implanted in the alveoli to cause LTBI. When bacilli
reach the alveoli, these organisms are ingested by macrophages. Some of these bacilli
spread through the bloodstream when the macrophages die; however, the immune
system response usually prevents the individual from developing TB disease. Although
most TB cases are pulmonary (85%), TB can occur in almost any part of the body or as
disseminated disease. About half the people with LTBI who develop active TB (5%) will
do so within the first year or two after infection. The remainder (5%) will develop active
TB within their lifetimes.
Close contacts of patients require identification so that they can undergo evaluation for
the presence of LTBI. TB is reportable to the public health department.
Assessment
86
For an accurate diagnosis of TB, a complete medical and psychosocial history is needed
along with a physical examination that includes a tuberculin skin test [TST], chest x-ray
examination, and sputum examination (including acid-fast bacillus [AFB] smears,
cultures, and drug sensitivity studies).

Productive prolonged cough, dyspnea, fever, night sweats, chest pain, hemoptysis, chills,
loss of appetite, unintended weight loss over a short period of time, and tiredness.
History/risk factors for developing active TB

Immunocompromised state, especially HIV infection; injection drug use; radiographic
evidence of prior, healed TB; weight loss of 10% or more of ideal body weight; and other
medical conditions, including diabetes mellitus, silicosis, end-stage renal disease, some
types of cancers, and certain immunosuppressive therapies. Persons who have
emigrated from areas of the world with high rates of TB are also more likely to have
LTBI than are persons born in the United States.
Diagnostic Tests
Sputum culture
Three sputum cultures are obtained 8 to 24 hr apart and are sent for AFB smear and
culture to ascertain presence of M. tuberculosis. Results of sputum culture are negative
in persons with LTBI.
Acid-fast stain
Detection of AFB in stained smears examined under a microscope usually provides the
first bacteriologic clue of TB. Smear results should be available within 24 hr of specimen
collection. AFB in the smear may be mycobacteria other than M. tuberculosis; many
patients can have TB and still have a negative smear. Specimens are generally collected
by asking patient to expectorate sputum into a cup; however, tracheal washing,
thoracentesis of pleural fluid, and lung biopsy are other options.

Involvement is most characteristically evident in the apex and posterior segments of the
upper lobes. Although not diagnostically definitive, x-ray examination reveals
calcification at original site, enlargement of hilar lymph nodes, parenchymal infiltrate,
pleural effusion, and cavitation. Patients with HIV infection may have an atypical
radiographic presentation of TB. Any abnormality on a chest x-ray film of a patient with
AIDS should be considered possible TB until ruled out.
TST or intradermal injection of antigen

This test uses a purified protein derivative (PPD) of mycobacterial organisms that is
administered intradermally and interpreted as positive or negative using measured
millimeters of induration. The test is considered positive when an area of induration
10 mm or greater is present within 48-72 hr after injection. Tests in patients in high-risk
87
categories such as HIV-infected and recently HIV-exposed patients are considered
positive with 5 mm or greater induration. Those who are immunocompromised and
some patients with active TB may have a negative PPD test, even in the presence of
active TB disease. A positive PPD test indicates LTBI and is not diagnostic for active
disease.
QuantiFERON-TB (QFT) blood test

Whole-blood interferon gamma assay that requires only one patient visit for a blood
specimen to assess for LTBI (rather than for active disease); use is currently limited
because of laboratory requirements for specimen evaluation.
Common drug regimens for treatment of LTBI
For persons suspected of having LTBI, treatment should not begin until active TB
disease has been excluded. The standard regimen (American Thoracic Society/Centers
for Disease Control and Prevention [ATS/CDC]) for LTBI treatment is 6 to 9 mo of
isoniazid (INH) or 4 mo of rifampin. Although these regimens are broadly applicable,
modifications should be considered under special circumstances that include HIV
infection, suspected drug resistance, pregnancy, and liver problems. Adequate LTBI
treatment reduces risk for development of active TB by about 70% (i.e., from a lifetime
risk of 10% to 3%).
Treatment for TB disease

For persons with TB disease, treatment with a single drug can lead to development of
bacterial resistance to that drug; thus all TB disease treatment regimens must contain
multiple drugs to which the organisms are susceptible. For most patients, the preferred
regimen consists of initiation of a 2-mo phase of four drugsrifampin, INH,
pyrazinamide, and ethambutol (RIPE), followed by a continuation phase of INH and
rifampin of at least 4 mo, for a minimal total treatment duration of 6 mo. TB treatment
regimens may need to be altered for persons infected with HIV who are on antiretroviral
therapy (ART), as well as when drug-susceptibility tests become available or when
disease is severe and patient's response is less than adequate.
Directly observed therapy (DOT) adherence-enhancing strategy

Treatment success is often enhanced by using DOT for medication administration. DOT
is achieved by having a trained health care worker or other specially trained person
watch a patient swallow each dose of medication and record dates that the DOT was
observed. In the United States DOT is the standard of care for all patients with TB
disease and should be used for all doses during the course of therapy for TB disease and
for LTBI whenever feasible.
Administrative, environmental, and respiratory controls for selected settings

Inpatient settings/patient rooms
88
Patient is placed in an airborne-infection isolation (AII) room until antimicrobial
therapy is successful and patient is determined to be no longer infectious as indicated by
AFB smear. AII requires a private room with special ventilation that dilutes and
removes airborne contaminants and controls the direction of airflow so that air pressure
inside the room is negative to the air pressure in the hallway. To enable adequate
function of this negative airflow system, the door to the room should be closed as much
as possible and the negative pressure monitored consistent with hospital policy. Persons
entering the AII room should wear N-95 respirators designed to provide a tight face seal
and filter particles in the 1- to 5-m range. Patients should wear a standard surgical
mask if it is necessary for them to leave the room.
Ambulatory care settings and medical offices

In these settings where patients with TB disease are treated, at least one room should
meet requirements for an AII room. When a person with diagnosed or suspected TB
enters the office, he/she should put on a surgical mask as soon as possible and shortly
thereafter be placed in the AII room. When the person with TB leaves the AII room,
sufficient time should elapse for adequate removal of air contaminated with M.
tuberculosis (usually 30 min to 2 hr, depending on number of air changes and
ventilation efficiency) before another patient is placed in the room. For staff and others
entering the AII room with the TB patient and in the 30-120 min after patient leaves the
room, an N-95 disposable respirator should be worn.

Deficient knowledge
relate to the spread of TB and procedure for airborne-infection isolation
Desired outcome
Following instruction, patient and significant others verbalize how TB is spread and
measures necessary to prevent the spread.

Assess patient's facility with language; engage an interpreter or language-appropriate

written materials if necessary.
Teach patient about TB and the mechanism by which it is spread (respiratory droplet
nuclei).
Explain AII to patient and significant others. Post appropriate notice of

isolation/airborne precautions on patient's room door.
89

Remind staff and visitors of need to keep door closed to enable effective function of the
ventilation system.
Explain to staff and visitors the importance of wearing N-95 or other high-efficiency
respirators, including proper fit and use. Provide appropriate respirators at doorway or
other convenient place.
Teach patient importance of covering mouth and nose with tissue when sneezing or
coughing and of disposing used tissue in appropriate waste container.

Antituberculosis medications, including drug name, purpose, dosage, schedule,

precautions, and potential side effects. Also discuss drug/drug, herb/drug, and
food/drug interactions. Remind patient that medications are to be taken without
interruption for the prescribed period. Remind patient of the need for continued
laboratory monitoring for complications of pharmacotherapy. Describe DOT if that is
the medication administration method selected.
Importance of periodic reculturing of sputum.
Importance of basic hygiene measures, including handwashing, covering cough with

tissues, and proper disposal of contaminated items.
discharge.
Additional general information can be obtained at the following websites:
90
o Division of Tuberculosis Elimination at the Centers for Disease Control
and Prevention,www.cdc.gov/tb
o American Lung Association, www.lungusa.org
o American Thoracic Society, www.thoracic.org
o University of Medicine and Dentistry of New Jersey, New Jersey Medical

School National Tuberculosis Center, www.umdnj.edu/ntbcweb
o National Tuberculosis Curriculum Consortium at the University of

California San Diego,http://NTCC.ucsd.edu
Section TwoAcute Respiratory Failure

Acute respiratory failure (ARF) develops when the lungs are unable to exchange O 2 and
CO 2 adequately. Clinically, respiratory failure exists when Pa o 2 is less than 50 mm Hg
with the patient at rest and breathing room air. Pa co 2 50 mm Hg or more or pH less
than 7.35 is significant for respiratory acidosis, which is the common precursor to ARF.
Although a variety of disease processes can lead to development of respiratory failure

( BOX 2-1 ), four basic mechanisms are involved.
BOX 2-1
DISEASE PROCESSES LEADING TO DEVELOPMENT OF RESPIRATORY FAILURE
Impaired Alveolar Ventilation

Chronic obstructive pulmonary disease (emphysema, bronchitis, cystic fibrosis, obesity)
Restrictive pulmonary disease (interstitial fibrosis, asthma, pleural effusion,

pneumothorax, kyphoscoliosis, diaphragmatic paralysis)
Neuromuscular defects (Guillain-Barr syndrome, myasthenia gravis, multiple sclerosis,

muscular dystrophy, polio, brain/spinal cord injury)
Depression of respiratory control centers (drug-induced cerebral infarction, acute or

nave narcotic use in large doses, drug/toxic agents)
91

Chest trauma (rib fractures)
Ventilation or Perfusion Disturbances

Pulmonary emboli
Atelectasis
Pneumonia
Emphysema
Chronic bronchitis
Bronchiolitis
Acute lung injury
Acute respiratory distress syndrome (ARDS)formerly known as adult respiratory

distress syndrome
Diffusion Disturbances

Pulmonary/interstitial fibrosis
Pulmonary edema
92

ARDS
Acute lung injury *
* Progression of respiratory failure in certain diagnoses can lead to acute lung injury and acute
respiratory distress syndrome. Acute lung injury is characterized by bilateral pulmonary
infiltrates on chest x-ray; noncardiogenic pulmonary edema; and a Pa o 2 /FI o 2 (P/F) ratio of
less than 300. P/F ratio is the relationship of arterial blood gas (Pa o 2 ) to inspired
O 2 concentration (FIo 2 ). Normal P/F ratio is approximately 500 (100/0.20). In a patient with
Pa o2 of 80 mm Hg and FI o 2 of 0.40, the P/F ratio would be 200 (80/0.40).
Anatomic loss of functioning lung tissue (tumor pneumonectomy)
ARDS is characterized by all of the above criteria with a P/F ratio of less than 200. Acute
lung injury is most often seen as part of a systemic inflammatory response, usually
sepsis or other direct lung injury. The inflammatory response causes widespread
destruction of alveolar capillary endothelia, extravasculation of protein-rich fluid, and
interstitial edema in the alveoli. As a result, alveolar membranes become damaged by
fluid filling the alveoli, with resulting destruction of surfactant production. This leads to
refractory hypoxemia (increased O 2 requirements that necessitate a large amount of
inspired oxygen), noncompliant lungs, and a profound ventilation/perfusion mismatch.
Nursing management should be focused on monitoring and anticipation of intubation

with mechanical ventilation.
From Bernard GR, Artigas A, Brigham KL et al: The American-European

Consensus Conference on ARDS: definitions, mechanisms, relevant outcomes,
and clinical trial coordination, Am J Respir Crit Care Med 149(3Pt1):818-824, 1994.
Alveolar hypoventilation
Occurs secondary to reduction in alveolar minute ventilation. Because differential
indicators (cyanosis, somnolence) occur late in the process, the condition may go
unnoticed until tissue hypoxia is severe.
Ventilation/perfusion mismatch
Considered the most common cause of hypoxemia. Normal alveolar ventilation occurs at
a rate of 4 L/min, with normal pulmonary vascular blood flow occurring at a rate of
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5 L/min. Normal ventilation/perfusion ratio is 0.8:1. Any disease process that
interferes with either side of the equation upsets physiologic balance and can lead to
respiratory failure as a result of reduction in arterial O 2 levels.
Diffusion disturbances
Processes that physically impair gas exchange across the alveolar-capillary membrane.
Diffusion is impaired because of the increase in anatomic distance the gas must travel
from alveoli to capillary and capillary to alveoli.
Right-to-left shunt
Occurs when the previously mentioned processes go untreated. Large amounts of blood
pass from the right side of the heart to the left and out into the general circulation
without adequate ventilation; therefore blood is poorly oxygenated. This mechanism
occurs when alveoli are atelectatic or fluid filled, inasmuch as these conditions interfere
with gas exchange. Unlike the first three responses, hypoxemia secondary to right-to-left
shunting does not improve with O 2 administration because despite the increare in
inspired oxygen concentration (FI o 2 ) the additional oxygen is unable to cross the
alveolar-capillary membrane.
Assessment
Clinical indicators of ARF vary according to the underlying disease process and severity
of the failure. ARF is one of the most common causes of impaired level of consciousness
(LOC). Often it is misdiagnosed as heart failure, pneumonia, or stroke.

Early
Restlessness, changes in mental status, anxiety, headache, fatigue, cool and dry skin,
increased BP, tachycardia, cardiac dysrhythmias.
Intermediate
Confusion, increased agitation, and increased O 2 requirements with decreased
O 2 saturations. Patients who have hypoventilation respiratory failure often exhibit
lethargy and bradypnea. Patients with ventilation/perfusion mismatch often exhibit
tachypnea.
Late
Cyanosis, diaphoresis, coma, respiratory arrest.
Diagnostic Tests
Arterial blood gas (ABG) analysis
Assesses adequacy of oxygenation and effectiveness of ventilation and is the most
important diagnostic tool. Typical results are Pa o 2 60 mm Hg or less, Pa co 2 45 mm Hg
or more, and pH less than 7.35, findings consistent with severe respiratory acidosis.
94
Ascertains presence of underlying pathophysiology or disease process that may be
contributing to the failure.
Treatment is aimed at correcting the acid-base disturbance while treating underlying
pathophysiology in an effort to prevent or correct ARF. Although the general rule is to
bring the Pa o 2 to greater than 60 mm Hg and the Paco 2 to 35-45 mm Hg, patients with
chronic obstructive pulmonary disease (COPD) may be clinically stable with
Pa co 2 greater than 45 mm Hg; therefore determination of pH is critical in these
individuals. For example, patients with chronically high Pa co 2 whose pH drops to less
than baseline are at risk for ARF.
O therapy
2
As determined by ABG values. O 2 therapy at an FI o 2 of 0.5 or less and pharmacotherapy

(e.g., bronchodilators, steroids, antibiotics) often improve ABGs sufficiently to get
patient out of danger, depending on ARF cause. Persistent respiratory acidosis following
medical intervention may indicate need for intubation and mechanical ventilation.
Bronchodilator therapy
Delivered via nebulizer or noninvasive positive-pressure ventilation (NIPPV). It may
eliminate necessity for intubation and mechanical ventilation.
Coughing/deep-breathing exercises
Mobilize secretions and promote full lung expansion. If cough is ineffective, suctioning
may be necessary to stimulate cough reflex and clear secretions. Intermittent positive-
pressure breathing (IPPB) may be used for patients who are unable to use incentive
spirometer to assist with lung expansion.
Intubation and mechanical ventilation

Patient may require intubation and mechanical ventilation to provide adequate
respiratory function and stabilize ABGs if ARF progresses. Mechanical support is used
until underlying cause of the failure can be corrected and patient can resume ventilatory
efforts independently.
Prophylaxis for gastric stress ulceration and deep vein thrombosis/pulmonary

embolism (DVT/PE)
Every patient with ARF is at risk for these complications.

See Psychosocial Support, p. 31 . See Pneumonia for Impaired gas exchange, p.
64 , and Deficient fluid volume, p. 66 . Also see Pleural Effusion , p. 68 ; Pulmonary
Embolus , p. 69 ; Pneumothorax/Hemothorax , p. 75 ; Asthma , p. 91 ; Multiple
95
Sclerosis, p. 229 ; and Guillain-Barr Syndrome, p. 238 , because these disorders may
be precursors to ARF.

ARF is an acute condition that is symptomatically treated during patient's
hospitalization. Discharge planning and teaching should be directed at educating patient
and significant others about underlying pathophysiology and treatment specific for that
process. See sections in this chapter that relate specifically to the underlying
pathophysiology contributing to development of ARF.
Section ThreeChronic Obstructive Pulmonary Disease

COPD is the fourth leading cause of death in the United States. It is a disease state
characterized by airflow limitation that is not fully reversible. Airflow limitation usually
is progressive and associated with an abnormal inflammatory response of the lungs to
noxious particles or gases and characterized by chronic inflammation throughout the
airways, parenchyma, and pulmonary vasculature.
In the central airways, inflammatory cells infiltrate the surface epithelium. Enlarged
mucus-secreting glands and an increased number of goblet cells lead to mucus
hypersecretion. In smaller airways, chronic inflammation leads to repeated cycles of
injury to the airway wall. Repair of the airway wall results in increased collagen content
and scar tissue formation that narrow the lumen and produce fixed airway obstruction.
Destruction of lung parenchyma in patients with COPD typically occurs as emphysema,

which involves dilation and destruction of the bronchioles. An imbalance of proteinases
and antiproteinases in the lungs is believed to be a major mechanism causing these
changes.
Assessment
Chronic cough (usually the first symptom) followed by dyspnea (usually reason for
seeking health care) with a prolonged expiratory phase. As lung function deteriorates,
perceived increase in work of breathing (WOB), wheezing, chest tightness, use of
accessory muscles of respiration, digital clubbing, decreased thoracic expansion, barrel
chest appearance, dullness over areas of consolidation, adventitious breath sounds
(especially coarse rhonchi and wheezing). Signs of COPD-related right-sided heart
failure: include ankle edema, distended neck veins, hepatic congestion, and bloated
appearance. See BOX 2-2 .
BOX 2-2
INDICATORS FOR DIAGNOSING COPD
Chronic Cough
96

Present intermittently or every day
Often present throughout the day
Seldom only nocturnal
Chronic Sputum

Any pattern of sputum production
Dyspnea

Progressive (worsens over time)
Persistent (present every day)
Described by patient as increased effort to breathe, heaviness, air hunger, or gasping
Worse with exercise
Worse during respiratory infections
History of Exposure to Risk Factors

Tobacco smoke
Occupational dust and chemicals
97

Smoke from home cooking and heating fuels

Cigarette smoking is the primary causative factor. Genetic factors (e.g., hereditary
deficiency of alpha-1 antitrypsin) and exposure to outdoor/indoor air pollutants may
also contribute.
Diagnostic Tests
Chest x-ray
Rules out other causes of airway obstruction and lung cancer.
Computed tomography (CT) scan

Assesses for presence and extent of emphysema.

Important in advanced COPD and should be obtained when there are signs of right-
sided (diastolic) heart failure (e.g., jugular vein distention, peripheral edema) or
respiratory failure (Pa o 2 less than 60 mm Hg with or without Pa co 2 greater than
50 mm Hg).
Oximetry
Alpha-1 antitrypsin deficiency screen

Performed in patients who develop COPD at a young age (less than 45 years) or who
have a strong family history of the disease.
Spirometry
Confirms diagnosis of COPD. Clinical indicators and the forced expiratory volume in
1 sec (FEV 1 ) diagnose and classify severity of COPD. See TABLE 2-3 . Should be
monitored annually and during acute illness.
TABLE 2-3
CLASSIFICATION OF COPD SEVERITY
STAGE CHARACTERISTICS
0: At risk Normal spirometry
Chronic symptoms (cough, sputum production)
I: Mild FEV 1 /FVC less than 70%
98
STAGE CHARACTERISTICS
FEV 1 80% or more predicted
With or without chronic symptoms (cough, sputum production)
II: Moderate FEV 1 /FVC less than 70%
50% FEV 1 less than 80% predicted
III: Severe FEV 1 /FVC less than 70%
30% FEV 1 less than 50% predicted
IV: Very FEV 1 /FVC less than 70%
severe
FEV 1 less than 30% predicted or FEV 1 less than 50% predicted plus
chronic respiratory failure
View full size
FEV 1 , Forced expiratory volume in 1 second; FVC, forced vital capacity.
Sputum culture
May reveal presence of infective organisms. Sputum specimens are best collected when
the patient first wakes in the morning.
Differential diagnosis
COPD may mimic many other diseases such as asthma, heart failure, bronchiectasis,
tuberculosis (TB), obliterative bronchiolitis, and diffuse bronchiolitis.
O therapy
2
To treat hypoxemia. It is used cautiously in patients with chronic CO 2 retention for

whom hypoxemia, rather than hypercapnia, stimulates the respiratory drive. Long-term
O 2 therapy has been shown to slow progression of COPD and reduce mortality.
Long-term O 2 therapy is generally introduced in patients with Pa o 2 less than

60 mm Hg. O 2 delivered at 2 L/min via nasal cannula generally results in acceptable
Pa o 2 levels of 65-80 mm Hg.
Smoking cessation
Single most effective way of reducing risk of development and progression of COPD.
Nicotine replacement therapy also should be considered to assist with withdrawal from
tobacco.
99
Pulmonary rehabilitation
A comprehensive program includes exercise training, nutrition counseling, and
education. Patients who have completed a pulmonary rehabilitation program have been
shown to have improved quality of life and slowed progression of the disease.
Pharmacotherapy
Inhaled bronchodilators
Open airways by relaxing smooth muscles of the airways. The resultant increased
airflow may help loosen mucus.
Inhaled steroids
Result in a small, one-time increase in FEV 1 , decrease frequency and severity of
exacerbations, and reduce mortality.
Oral steroids (prednisone)

Used short term (10-14 days) for severe exacerbations to decrease inflammation and
thereby increase airflow.
Antibiotics
Prescribed based on presence of infiltrate on chest x-ray film and other signs of
infection.
IV or oral fluids
Administered to promote adequate hydration.
Diuretics or Na restriction
+
Prescribed to reduce fluid overload in the presence of cardiac complications, such as

heart failure.

Ineffective airway clearance
related to decreased energy, which results in ineffective cough, or related to presence of
increased tracheobronchial secretions
Desired outcomes
Following intervention, patient coughs appropriately and has effective airway clearance
as evidenced by absence of adventitious breath sounds.

100
Auscultate breath sounds q2-4h (or as indicated by patient's condition) and after
coughing. Be alert to and report changes in adventitious breath sounds.
Teach patient the double cough technique to prevent small airway collapse, which can
occur with forceful coughing.
Sit upright with upper body flexed forward slightly.
Take 2-3 breaths and exhale passively.
Inhale again, but only to the midinspiratory point.
Exhale by coughing quickly 2-3 .
When not otherwise indicated, encourage fluid intake (2.5 L/day or more) to decrease
sputum viscosity.
Imbalanced nutrition: less than body requirements

related to decreased intake secondary to fatigue and anorexia
Desired outcome
For a minimum of 24 hr before hospital discharge, patient has adequate nutrition as
evidenced by stable weight, positive N balance, and serum albumin 3.5-5.5 g/dL.

Monitor food and fluid intake. If indicated, obtain dietary consultation for calorie
counts.
Provide diet in small, frequent meals that are nutritious and easy to consume.
101
Request consultation with dietitian so that patient can verbalize food likes and dislikes.
Unless otherwise indicated, provide calories more from unsaturated fat sources ( BOX 2-
3 ) than from carbohydrate sources. During the process of carbohydrate metabolism,
the body uses O 2 and produces CO2 , which is then excreted by the lungs. Patients with
COPD take in less O 2 and retain CO 2 . A high-fat diet minimizes this problem because
fat generates the least amount of CO 2 for a given amount of O 2 used, whereas
carbohydrates generate the most.
BOX 2-3
RECOMMENDED CALORIE SOURCES FOR PATIENTS WITH COPD
Foods High in Fat
o
Cheese
Cream
Cream soups
Custards
Evaporated milk
Fish
Margarine
Mayonnaise
102
Meat
Nuts
Poultry
Salad and cooking oils
Whole milk
Foods to Avoid
o
Cakes
Cookies
Jams
Pastries
Sugar-concentrated snacks
Discuss with patient and significant others the importance of good nutrition in the
treatment of COPD.

related to decreased lung expansion secondary to chronic airflow limitations
Desired outcome
103
Following treatment/intervention, patient's breathing pattern improves as evidenced by
reduction in or absence of dyspnea and movement toward a state of eupnea.

Assess respiratory status q2-4h and be alert for indicators of respiratory distress (i.e.,
agitation, restlessness, changes in mental status, decreased level of consciousness
(LOC), use of accessory muscles of respiration). Auscultate breath sounds; report a
decrease in breath sounds or an increase in adventitious breath sounds.
Teach pursed-lip breathing, which increases intraluminal air pressure and thus
promotes internal stability of the airways and may prevent airway collapse during
expiration. Record patient's response to breathing technique.
Sit upright with hands on thighs, or lean forward with elbows propped on over-the-bed
table.
Inhale slowly through nose with mouth closed.
Form lips in an O shape as though whistling.
Exhale slowly through pursed lips. Exhalation should take twice as long as inhalation
(e.g., count to 5 on inhalation; count to 10 on exhalation).
Administer bronchodilator therapy as prescribed. Monitor for side effects, including

tachycardia and dysrhythmias.
Monitor patient's response to prescribed O 2 therapy. Be aware that high concentrations

of O 2 can depress the respiratory drive in individuals with chronic CO 2 retention.
104
Monitor oximetry readings; report O 2 saturation 92% or less because this can indicate
Monitor serial ABG values. Patients with chronic CO 2 retention may have chronically
compensated respiratory acidosis with low normal pH (7.35-7.38) and Pa co 2 greater
than 45 mm Hg.
Activity intolerance
related to imbalance between O 2 supply and demand secondary to inefficient work of
breathing
Desired outcome
Patient reports decreasing dyspnea during activity or exercise and rates perceived
exertion at 3 or less on a 0-10 scale.

Maintain prescribed activity levels and explain rationale to patient.
Monitor patient's respiratory response to activity. Activity intolerance is indicated by

excessively increased respiratory rate (RR) (e.g., more than 10 breaths/min higher
than baseline) and depth, dyspnea, and use of accessory muscles of respiration. Ask
patient to rate perceived exertion (see p. 90 for a description). If activity intolerance is
noted, instruct patient to stop the activity and rest.
Facilitate coordination among health care providers to ensure rest periods between care
activities to decrease O 2 demand. Allow 90 min for undisturbed rest.
Assist patient with active ROM exercises to build stamina and prevent complications of
decreased mobility . For more information, see Risk for activity intolerance in
Prolonged Bed Rest, p. 23 .
105

Use of home O 2 , including when to use it, importance of not increasing prescribed flow
rate, precautions, and community resources for O 2 replacement when necessary.
Request respiratory therapy consultation to assist with teaching related to O 2 therapy, if
indicated.
Medications, including drug names, route, purpose, dosage, schedule, precautions, and
potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions. If
patient will be taking oral corticosteroids while at home, provide instructions
accordingly to ensure patient takes the correct amount, particularly during the period in
which medication will be tapered.
Signs and symptoms of heart failure that necessitate medical attention: increased
dyspnea, fatigue, and coughing; changes in amount, color, or consistency of sputum;
swelling of ankles and legs; fever; and sudden weight gain. For more information, see
Heart Failure, p. 107 .
Importance of avoiding contact with infectious individuals, especially those with

respiratory infections.
Recommendation that patient receive a pneumococcal vaccination and annual influenza

vaccination.
Review of Na + -restricted diet (see Box 4-1 , p. 165 ) and other dietary considerations as
indicated.
Importance of pacing activity level to conserve energy.
Follow-up appointment with health care provider; confirm date and time of next
appointment.
106
Introduction to pulmonary rehabilitation programs.
Section FourAsthma
Asthma is a chronic disorder characterized by an exaggerated bronchoconstrictive
response to selective stimuli, recurrent and reversible obstruction of airflow in the
bronchioles and smaller bronchi, and inflammation. Infiltration of the airways by
inflammatory cells such as activated lymphocytes and eosinophils, denudation of the
epithelium, deposition of collagen in the membrane, and presence of mast cells are often
found in mild and moderate asthma. Severe asthma can lead to occlusion of the
bronchial lumen by mucus, hyperplasia, and hypertrophy of the bronchial smooth
muscles and hyperplasia of goblet cells. Over time, this inflammation can lead to
remodeling and damage to the airways.
Approximately 12 million Americans have asthma. Mortality rates are estimated at

around 4500 deaths/yr, an overall decline since 1995. Asthma mortality is nearly 3
higher in black male than in white male patients and is 2.5 higher in black female than
in white female patients.
Assessment
Tachypnea, dyspnea, orthopnea, wheezing, coughing (often worse at night and in the
morning), chest tightness, increased sputum production, tachycardia, anxiety, agitation,
prolonged expiratory phase, use of accessory muscles of respiration, chest retractions
(supraclavicular area, intercostal and suprasternal spaces), hyperexpansion of the
thorax, hyperresonance, pulsus paradoxus, diaphoresis, and pallor.
Symptoms occur or worsen in the presence of exercise, viral infections, animals with fur
or feathers, house-dust mites, mold, smoke (tobacco, wood), pollen, changes in weather,
strong emotional expression (crying), airborne chemicals or dusts, and menses. If
symptoms are left untreated, an acute asthmatic attack can progress to status
asthmaticus (SA), a severe and unrelenting asthma attack. SA is an exhausting condition
that results in respiratory insufficiency and hypoxia, and it may result in death if
untreated.
Diagnostic Tests
Oximetry

Acute respiratory acidosis (Pa co 2 more than 45 mm Hg and pH less than 7.35) typically
is present during an acute asthma attack.
107
Usually normal; lung hyperinflation may be seen with severe asthma.
CBC
May show increased WBCs with concurrent infection. Differential may show increased
eosinophils, which indicates an allergic response.
Sputum
Gross examination may reveal increased viscosity or actual mucus plugs. Culture and
sensitivity may reveal microorganisms if infection was the precipitating event.
Spirometry
Evaluates degree of airflow obstruction. Partially reversible obstruction (a more than
12% increase and 200 mL in FEV 1 after inhaling a short-acting bronchodilator or after
receiving a short course of oral corticosteroids) is diagnostic.
Peak expiratory flow rate (PEFR)

Provides objective measurement of lung function via a small handheld gauge called a
peak flowmeter. Patient is instructed to inhale deeply and then forcibly exhale rapidly
into the flowmeter, to provide a reading in L/min. The higher the number, the better the
airflow. Normal peak flow rates vary across individuals and are based on gender, height,
and age. Each patient should monitor daily morning PEFRs to determine normal values.
A peak flowmeter is included in the asthma action plan to monitor therapy for asthmatic
patients.
ECG results
Sinus tachycardia is an important baseline indicator because use of some
bronchodilators may produce cardiac stimulant effects and dysrhythmias. Prominent P
waves appear in chronic asthma.
Primarily, management is directed toward monitoring for and preventing acute asthma
attacks.
Quick Relief or Symptomatic Therapy

O therapy
2
Generally, these patients experience mild to moderate hypoxemia. Low-flow (1-3 L/min)
O 2 is delivered via nasal cannula with humidity for O 2 saturation of less than 90%.
Pharmacotherapy
Initiated to relieve bronchospasm and continued until wheezing subsides and PFTs
return to baseline.
108
Bronchodilators
Dilate smooth muscles of the airways. Nebulizer/aerosolized bronchodilators are used
for acute exacerbation of symptoms.
Corticosteroids
Inhibit the inflammatory response. Acute adrenal insufficiency can develop in patients
who take steroids routinely at home if these drugs are not given to the patient during
hospitalization.
IV Steroids (Methylprednisolone)
Used to gain control of inflammation in severe attacks. Dosage varies according to
severity of the episode and whether patient is currently taking steroids.
Oral Steroids
Once stabilized, the patient in acute phase begins taking oral steroids. Steroids are used
cautiously in patients with tuberculosis (TB), diabetes, and peptic ulcer.
Antibiotics
Initiated if there is concurrent fever, leukocytosis, purulent sputum, or unsuspected
bacterial sinusitis.
Fluid replacement
Needed to maintain adequate hydration.
Long-Term Control
Nebulizer/aerosolized bronchodilators
Usually prescribed for short-term use for acute exacerbations of symptoms. However,
some patients require maintenance doses to prevent recurrent attacks.
Steroids
Systemic corticosteroids (prednisone or methylprednisolone)
Usually, patients are gradually weaned from steroids over 2-3 wk. Some patients may
require low-dose steroids indefinitely.
Inhaled steroids
Mainstay of interim therapy to prevent or reduce the incidence of acute asthmatic
attacks. Dosage is commonly 2-4 inhalations 2-4 /day. Some patients use inhalant
bronchodilators simultaneously with steroid inhalers. To maximize effectiveness of the
steroid inhaler, these patients should be taught to use the bronchodilator as prescribed,
wait 10-15 min, and then use the steroid inhaler. Use of steroid inhalers may result in
fungal overgrowth of the mouth or pharynx; patient should rinse mouth after each dose.
109
Nonsteroidal antiinflammatory inhalers (cromolyn, nedocromil sodium)
These agents are believed to mediate endothelial response to allergens and thus prevent
bronchospasm. Cromolyn is believed to inhibit secretion of the slow-reacting substance
of anaphylaxis (SRS-A) from mast cells. Not all patients benefit from cromolyn. Usual
dosage is 2-4 inhalations 2-4/day.
Leukotriene modifiers (zafirlukast, zileuton)

Inhibit effects of leukotrienes, which are potent inflammatory mediators that cause
smooth muscle bronchoconstriction, increased vascular permeability, and mucus
production. These modifiers are used in conjunction with antiinflammatory agents.
Methylxanthines (aminophylline, theophylline)

Although methylxanthines were once first-line therapeutic agents, they are now
considered third-line therapy. Methylxanthines have relatively weak bronchodilating
properties and no effect on inflammatory response. When used, their dosage is carefully
monitored by blood levels of theophylline.

related to altered O 2 supply secondary to decreased alveolar ventilation as a result of
narrowed airways
Desired outcomes
Following treatment/intervention, patient has adequate gas exchange as evidenced by a
respiratory rate (RR) of 12-20 breaths/min (or values consistent with patient's
baseline). Before hospital discharge, patient's ABG values are as follows:
Pa o 2 80 mm Hg or higher, Pa co 2 35-40 mm Hg, and pH 7.35-7.45, or oximetry
readings demonstrating O 2 saturation greater than 90%. Patient reports decreased
dyspnea and diminished to no wheezes.

Observe for signs and symptoms of hypoxia (e.g., agitation, mental status changes,
anxiety, restlessness, changes in mental status or level of consciousness (LOC)).
Remember that cyanosis of the lips and nail beds is a late indicator of hypoxia.
Position patient for comfort and to promote optimal gas exchange.
110
Auscultate breath sounds q2-4h or more frequently as indicated by patient's condition.
Monitor for decreased or adventitious sounds (e.g., crackles [rales], rhonchi, wheezes).
Monitor oximetry readings; report O 2 saturation 90% or less because this can indicate a
The goal of asthma education is self-management to prevent unnecessary

hospitalizations from acute exacerbations. Therefore teaching focuses on symptom
control, an action plan for crisis management, and monitoring techniques. Verbal and
written information should be provided about the following:
Control of factors contributing to asthma severity: irritants or allergens that can

precipitate an attack and importance of reducing exposure to these irritants from
patient's environment.
Need for regular exercise.
Signs and symptoms of acute exacerbation (e.g., increased cough; increased dyspnea,
especially at night or during activity; wheezing).
Medications, including drug names, route, purpose, dosage, precautions, and potential
side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.
Proper use of metered-dose inhalers, including use of a spacer (if indicated) to facilitate
medication inhalation. Document adequate return demonstration by the time of
hospital discharge. Remind patient that over-the-counter (OTC) inhalers contain
medications that can interfere with prescribed therapy. Instruct patient to contact
health care provider before taking any OTC medications.
111
If patient will take corticosteroids while at home, provide instructions accordingly to
ensure that patient takes the correct amount, particularly during the period in which the
medication will be tapered.
Proper use of peak flowmeters; document return demonstration. Patient should

measure and document PEFR, usually twice a day. Peak flowmeters should never be
used alone to diagnose exacerbation. Peak flowmeter readings along with assessment of
symptoms and use of inhalers will help determine severity.
Development of an asthma action plan, which includes peak flow readings, symptoms,
and use of rescue medications. An asthma action plan is a risk-stratified outline for
steps to take if patient experiences an asthma attack. Many action plans also list
emergency medications and contact information.
Smoking cessation: the single most effective way to reduce asthma attacks. With every
interaction, patients should be asked about their smoking status and advised of the
importance of quitting, even if they have quit within the past year. A counseling session
should include social support and scheduled follow-up visits. Nicotine replacement
therapy also should be considered to assist with withdrawal from tobacco.
Recommendation that patient receive a pneumococcal vaccination and annual influenza

vaccination.
Importance of follow-up care. Confirm date and time of next appointment.
discharge. Additional general information can be obtained from the following resource:
o National Asthma Education and Prevention Program Expert Panel

Report 2: Guidelines for the Diagnosis and Management of Asthma, National
Heart, Lung, and Blood Institute, Department of Health and Human Services,
National Institutes of Health. Available
atwww.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
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Copyright 2017 Elsevier, Inc. All rights reserved.
113
The Client with Alterations in Hematologic and
Immune Function
Nancy Haugen PhD, RN
and Sandra Galura MSN, RN, CCRN, CPAN
Ulrich & Canale's Nursing Care Planning Guides (NANDA), CHAPTER 7, 449-484
Open reading mode

HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION
AND ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)
Acquired immune deficiency syndrome (AIDS) is an infectious disease of the immune
system and is considered to be the last phase of the clinical spectrum of infection by the
human immunodeficiency virus (HIV). HIV is a retrovirus that affects the cells in the
body that have a CD4 receptor on their surface. The types of cells that have the CD4
receptor and can be infected by the virus include lymphocytes, monocytes,
macrophages, glial cells, bone marrow progenitors, and gut-associated lymphoid tissue.
The CD4 + T lymphocytes (also called T4 or T-helper cells) have the greatest number of
CD4 receptors and are consequently the major target of HIV. These lymphocytes are
ultimately destroyed by HIV, which results in severely impaired cell-mediated immunity
in the host. Humoral immune function is also impaired because the B lymphocytes are
unable to respond appropriately to the presence of a new antigen without the help of
normal CD4 + T lymphocytes. The effect of HIV on the monocyte and macrophage
further depresses immune system function.
HIV has been isolated from all body fluids, but at this point, transmission has been
associated only with blood, semen, amniotic fluid, vaginal secretions, and breast milk.
The known routes of transmission are by intimate sexual contact, mucous membrane or
percutaneous exposure to infected blood or blood products, and perinatal transmission
from mother to child. The four high-risk groups for acquiring HIV infection are
heterosexuals with multiple sexual partners, men who have sex with men, intravenous
drug users, and recipients of blood/blood products. Treating HIV-infected women
during pregnancy with an antiretroviral agent (e.g., zidovudine) has significantly
reduced the transmission of HIV from mother to child.
Infection with HIV tends to follow a particular course, with the clinical expression being
attributed to either the effects of the virus itself or the consequences of CD4 + T-
lymphocyte depletion. The initial event in the course of the disease is acute retroviral
infection, which occurs about 1 to 6 weeks after exposure to HIV. The person
experiences symptoms such as fever, headache, myalgias, lymphadenopathy, rash,
fatigue, and sore throat that may persist for a week or longer. Then, the HIV-infected
person enters the chronic infection stage. In the early period of chronic infection, the
person may be asymptomatic or continue to experience mild symptoms such as fatigue,
headache, and lymphadenopathy. This early period often lasts as long as 10 to 12 years,
114
depending on the rate of viral replication and the rapidity of CD4 + T-lymphocyte
destruction. The symptomatic stage of HIV infection develops when the CD4 + T-
lymphocyte count drops below 500 cells/mm 3 and the HIV viral load rises above
10,000 copies/mL. In the early symptomatic stage, the person has various nonspecific
symptoms (e.g., unexplained fever and weight loss, fatigue, night sweats, peripheral
neuropathy, persistent diarrhea) and persistent, localized viral or fungal infections.
AIDS is the last stage of HIV infection. In addition to the symptoms experienced in the
previous stage, AIDS is heralded by immune suppression (serologically defined as a
CD4 + T-lymphocyte count < 200 cells/mm 3 ) and the presence of a condition that
meets the criteria for definition of an AIDS case as specified by the Centers for Disease
Control and Prevention (CDC). These AIDS-indicator conditions include HIV-related
encephalopathy, HIV wasting syndrome, opportunistic infections (e.g.,Pneumocystis
jiroveci pneumonia [formerly known as pneumocystis carinii PCP]; candidiasis of
esophagus or bronchi, trachea, or lungs; Mycobacterium
tuberculosis , Mycobacterium avium complex [MAC]; extrapulmonary
cryptococcosis; cytomegalovirus infection; Toxoplasma encephalitis;
coccidioidomycosis), and AIDS-related cancers (e.g., Kaposi's sarcoma, non-Hodgkin's
lymphoma, invasive cervical cancer).
At this time, there is no cure for HIV infection. However, there have been significant
advances in antiretroviral therapy and prevention of opportunistic infections that have
increased the long-term survival of persons with HIV infection. Earlier treatment and
the use of highly active antiretroviral therapy (HAART), which consists of a combination
of at least three antiretroviral agents, have made significant differences in sustaining
viral suppression, slowing disease progression, and reducing drug resistance. Because of
the side effects of the antiretroviral agents and lack of adherence to the drug regimen,
current federal guidelines suggest that treatment be offered early, but that it can be
delayed until higher levels of immune suppression are observed.
The antiretroviral agents used to control viral replication of HIV include nucleoside
reverse transcriptase inhibitors (e.g., zidovudine, lamivudine, zalcitabine, abacavir,
didanosine, stavudine), protease inhibitors (e.g., saquinavir, ritonavir, indinavir,
amprenavir, nelfinavir), nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine,
delavirdine, efavirenz), and fusion inhibitors (e.g., enfuvirtide). Chemoprophylactic
therapy to prevent AIDS-defining opportunistic infections has also led to a significant
decline in the incidence of certain diseases such as PCP, MAC, tuberculosis, and
toxoplasmosis.
This care plan focuses on the adult client with HIV infection hospitalized
for treatment of a probable opportunistic infection. Much of the
information is applicable to clients receiving follow-up care in an
extended care facility or home setting.
The client will:
1.
115
Have an adequate respiratory status
2.
Have an adequate or improved nutritional status
3.
Be able to perform activities of daily living without undue fatigue or dyspnea
4.
Demonstrate evidence that opportunistic infection is resolving
5.
Be effectively managing the signs and symptoms of neurological dysfunction
6.
Have discomfort at a manageable level
7.
Show evidence that skin and oral mucous membranes are intact or healing appropriately
8.
Have fewer episodes of diarrhea
9.
Identify ways to prevent the spread of HIV
10.
Identify ways to decrease the risk for developing opportunistic infections
11.
Verbalize ways to maintain an optimal nutritional status
12.
13.
116
Share feelings about changes in mental and physical functioning and the social isolation
and loneliness that may result from having AIDS
14.
Identify resources that can assist with financial needs and adjustment to changes
resulting from the diagnosis of AIDS
15.

including regular laboratory studies, future appointments with health care providers,
and medications prescribed.
Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION *
* This diagnostic label includes the following nursing diagnoses: ineffective

breathing pattern, ineffective airway clearance, and impaired gas exchange.
Definition: Inspiration and/or expiration that does not provide adequate ventilation;
inability to clear secretions or obstructions from the respiratory tract to maintain a clear
airway
Ineffective breathing pattern NDx related to:
Decreased depth of respirations associated with fear, anxiety, weakness, fatigue, and
chest pain if present
Increased rate of respirations associated with fear, anxiety, and the increase in
metabolic rate that occurs with infection
Ineffective airway clearance NDx related to:
Increased production of secretions associated with some opportunistic infections of the

lungs
Stasis of secretions associated with decreased activity and poor cough effort resulting
from fatigue and pain
117
Impaired gas exchange NDx related to a decrease in effective lung surface associated
with:
The presence of infiltrates and/or cavities in the lung tissue resulting from opportunistic
infection of the lungs (e.g., PCP, pneumococcal pneumonia, tuberculosis,
histoplasmosis)
Compression and/or replacement of lung tissue if an AIDS-related cancer such as

Kaposi's sarcoma or non-Hodgkin's lymphoma is present
Reports of difficulty vocalizing; Dyspnea; orthopnea; diminished breath sounds;
verbal reports of restlessness adventitious breath sounds; cough; change in
respiratory rate and rhythm
View full size
RISK FACTORS

Pulmonary infection
Immunosuppression
Pneumocystis jiroveci pneumonia
Mycobacterium tuberculosis
DESIRED OUTCOMES
The client will experience adequate respiratory function as evidenced by:
a.
Normal rate and depth of respirations
b.
118
Decreased dyspnea
c.
Improved breath sounds
d.
Symmetrical chest excursion
e.
Usual mental status
f.
Oximetry results within normal range
g.
Arterial blood gas values within normal range
NOC OUTCOMES
Respiratory status: airway patency; respiratory status: ventilation; respiratory status:
gas exchange
NIC INTERVENTIONS
Respiratory monitoring; airway management; chest physiotherapy; cough
enhancement; ventilation assistance; oxygen therapy; medication administration
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and Early recognition of signs and symptoms
symptoms of impaired respiratory function: of impaired respiratory function allows for
Rapid, shallow respirations
Dyspnea, orthopnea
119
RATIONALE
Use of accessory muscles when breathing
Abnormal breath sounds (e.g., diminished,

bronchial, crackles [rales], wheezes)
Asymmetrical chest excursion
Cough (can be productive or dry and

nonproductive depending on the
opportunistic disease present)
Monitor arterial blood gas values, chest x-

ray results.
View full size
RATIONALE
Independent Actions
respiratory status: D
High-Fowler's position allows for maximum
diaphragmatic excursion and lung
Place client in a semi- to high-Fowler's expansion. Prevention of slumping is
position unless contraindicated; position essential because slumping causes
with pillows to prevent slumping. abdominal contents to be pushed up.
Instruct client to breathe slowly if

hyperventilating.
Repositioning helps to mobilize secretions.
If client must remain flat in bed, assist

with position change at least every 2
120
RATIONALE
hours.
Deep breathing and use of an incentive

spirometer promote maximal inhalation and
Instruct client to deep breathe or use lung expansion.
incentive spirometer every 1 to 2 hours.
Perform actions to promote removal of

pulmonary secretions.
Coughing or huffing accelerates airflow

through the airways, which helps mobilize
Instruct and assist client to cough or and clear mucus and foreign matter from
huff every 1 to 2 hours. the respiratory tract.

Discourage smoking. cause damage to the bronchial and alveolar
walls; the carbon monoxide decreases
oxygen availability.
respiratory status:

Maintain activity restrictions as ordered

to reduce oxygen needs.
Positive pressure airway techniques

increase intrapulmonary (alveolar) pressure,
Assist with positive airway pressure which helps reexpand alveoli and prevent
techniques (e.g., continuous positive further alveolar collapse.
airway pressure [CPAP], bilevel positive
airway pressure [BiPAP], flutter/positive
expiratory pressure [PEP] device) if
ordered
121
RATIONALE
Perform actions to promote removal of
pulmonary secretions:
Adequate hydration and humidified inspired

air help thin secretions, which facilitates the
Implement measures to thin tenacious mobilization and expectoration of
secretions and reduce dryness of the secretions.
respiratory mucous membrane:
Maintain a fluid intake of at least

2500 mL/day unless contraindicated.
Humidify inspired air as ordered.
Mucolytics and diluent or hydrating agents

are mucokinetic substances that reduce the
Assist with administration of viscosity of mucus, thus making it easier for
mucolytics (e.g., acetylcysteine) and the client to mobilize and clear secretions
diluent or hydrating agents (e.g., from the respiratory tract.
water, saline) via nebulizer if ordered.
Assist with or perform postural

drainage therapy (PDT) if ordered.
Perform suctioning if ordered.
Administer expectorants (e.g.,

guaifenesin) if ordered.
Reducing pain enables the client to breathe
122
RATIONALE
more deeply and participate in activities to
improve respiratory status.
Perform actions to reduce pain and
fatigue:
Administer analgesics before activities

and procedures that can cause pain
and before pain becomes severe.
Maintain oxygen therapy as ordered. D
Central nervous system depressants such

as opioid narcotics cause depression of the
Administer central nervous system respiratory center and cough reflex. This
depressants judiciously; hold medication can result in stasis of secretions and
and consult physician if respiratory rate hypoventilation with impaired gas exchange.
is less than 12 breaths/min.
Administer the following medications if

ordered:
Bronchodilators dilate terminal airways,

improving oxygen and ventilation.delivery
Bronchodilators
Antimicrobials may be given to prevent

pneumonia. Corticosteroids decrease
Antimicrobials pulmonary inflammation and are usually
reserved for moderate to severe cases of
PCP because of the risk for further
immunosuppression.
Corticosteroids
Consult appropriate health care provider Consulting the appropriate health care
(e.g., respiratory therapist, physician) if provider allows for modification of the
signs and symptoms of impaired treatment plan.
123
RATIONALE
respiratory function persist or worsen.
View full size
Nursing Diagnosis ACUTE/CHRONIC PAIN NDx

Definition: Pain is whatever the experiencing person says it is, existing whenever the
person says it does. It is an unpleasant sensory and emotional experience arising from
actual or potential tissue damage. Acute pain has a duration of less than 6 months, while
chronic pain recurs at intervals for months or years
Oral, pharyngeal, and/or esophageal pain related to the presence of aphthous

ulcers in the mouth and/or infections involving the oropharyngeal and esophageal
mucosa (e.g., candidiasis, herpes simplex)
Abdominal pain related to nonspecific gastritis and opportunistic infection or

neoplastic involvement of the intestine
Neuropathic pain related to the effect of HIV, some opportunistic infections, and
some medications (e.g., didanosine, zalcitabine, isoniazid) on the peripheral nerves
Headache related to:
Cranial inflammation/pressure associated with an opportunistic infection involving the

sinuses or brain or the presence of a cerebral neoplasm
Vasoactive cytokines that are present with HIV infection
Chest pain related to:
Inflammation of the parietal pleura associated with an opportunistic infection of the

lungs
124
Muscle strain associated with excessive coughing if present
Skin and local tissue pain related to:
Skin lesions associated with opportunistic infection and/or Kaposi's sarcoma
Skin breakdown in perianal area associated with diarrhea
Verbal report of pain Inability to breathe deeply, ambulate, sleep, or perform
identifying the level of activities of daily living; crying; muscle rigidity;
intensity using a pain rating diaphoresis; blood pressure (B/P) or pulse changes;
scale; loss of appetite increase in the rate and depth of breathing
View full size
RISK FACTORS

Chronic physical disability
Chronic psychosocial disability
Injury agents
DESIRED OUTCOMES
The client will experience diminished pain as evidenced by:
a.
Verbalization of a decrease in or absence of pain
b.
Relaxed facial expression and body positioning
c.
125
Increased participation in activities
d.
Stable vital signs
NOC OUTCOMES
Comfort level; pain control; pain: disruptive effects
NIC INTERVENTIONS
Pain management; environmental management: comfort; analgesic administration
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms Early recognition of signs and symptoms
of pain: of acute or chronic pain allows for prompt
intervention.
Verbalization of pain
Grimacing
Reluctance to move or breathe deeply
Rubbing head
Reluctance to eat
Restlessness
Diaphoresis
126
RATIONALE

Increased B/P
Tachycardia
Assess client's perception of the

severity of pain using a pain intensity rating
scale.
Assess the client's pain pattern:
Location
Quality
Onset
Duration
Precipitating factors
Aggravating factors
Alleviating factors
Ask the client to describe previous pain

experiences and methods used to manage
127
RATIONALE
pain effectively.
View full size
RATIONALE
Independent Actions
Implement measures to reduce pain: D
Actions help promote relaxation and
subsequently increase the client's
Perform actions to reduce fear and anxiety threshold and tolerance for pain.
about the pain experience:
Assure client the need for pain relief is

understood.
Plan methods for achieving pain control

with client.
Perform actions to reduce fear and anxiety:
Instruct client in relaxation techniques and

encourage participation in diversional
activities.
Administer analgesics before activities and

procedures that can cause pain and before
pain becomes severe.
Actions help to increase the client's
128
RATIONALE
threshold and tolerance for pain.
Perform actions to reduce fatigue:
Organize nursing care to allow for

uninterrupted periods of rest.
Provide or assist with nonpharmacological

methods for pain relief.
Position change
Progressive relaxation exercises
Guided imagery
Restful environment
Diversional activities such as watching

television, reading, or conversing
Collaborating with clients regarding pain

control strategies can assist them in
Plan methods for achieving pain control maintaining a sense of control over the
with client. pain experience.
129
RATIONALE

Perform actions to prevent and treat oral

mucous membrane and skin lesions:
Lubricate lips frequently
Have client rinse mouth frequently with

salt and warm water.
Implement measures to reduce pain:

Administer the following if ordered:
Nonopioid analgesics are thought to

interfere with the of pain impulses by
Nonopioid (nonnarcotic) analgesics such inhibiting prostaglandin
as salicylates and other nonsteroidal anti- synthesistransmission
inflammatory agents
Opioid analgesics act by altering the

clients perception of pain and emotional
Opioid (narcotic) analgesics response to the pain experience
Tricyclic antidepressants are used to

treat painful neuropathies.
Tricyclic antidepressants (e.g.,
amitriptyline) and/or anticonvulsants (e.g.,
carbamazepine, gabapentin)
Topical anesthetics help alleviate skin

and superficial neuropathic pain.
Topical anesthetic/analgesic ointments
130
RATIONALE
(e.g., capsaicin)
Anesthetic agents help control pain by

inhibiting the initiation and conduction of
Oral anesthetic and/or protective agents pain impulses along sensory pathways.
(e.g., sucralfate, viscous xylocaine mixed
with diphenhydramine elixir and a
magnesium or aluminum antacid)
Corticosteroids may be utilized to relieve

pain associated with central nervous
Corticosteroids system lesions, sinusitis, and peripheral
neuropathies.some
These agents may be given to treat HIV
infection and/or opportunistic disease(s)
Antimicrobials and/or antineoplastic causing the pain.
agents
Consult appropriate health care provider if Consulting the appropriate health care
adequate pain relief cannot be achieved provider allows for modification of the
with the above measures. treatment plan.
View full size
Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN
BODY REQUIREMENTS NDx
Definition: Intake of nutrients insufficient to meet metabolic demands
Related to:
Decreased oral intake associated with:
Anorexia resulting from malaise, fatigue, fear, anxiety, pain, depression, increased levels
of certain cytokines that depress appetite (e.g., tumor necrosis factor [TNF]), and some
antiretroviral agents
Nausea, dyspnea, and cognitive impairment if present
131
o
Oral pain and/or dysphagia resulting from opportunistic lesions in the mouth, pharynx,
and esophagus
Impaired utilization of nutrients associated with:
Accelerated and inefficient metabolism of nutrients resulting from an increased resting

energy expenditure that occurs with infection and increased levels of certain cytokines
(e.g., TNF, interleukin-1)
Decreased absorption of nutrients if HIV and/or opportunistic infection involve the

intestine
Loss of nutrients associated with persistent diarrhea and vomiting if present
Self report of inadequate Body weight 20% or more under ideal body weight; loss
food intake; reported lack of of weight with adequate food intake; weakness of
food; aversion to eating; lack muscles required for swallowing or chewing; sore,
of interest in food inflamed buccal cavity; hyperactive bowel sounds;
diarrhea; excessive hair loss
View full size
RISK FACTORS

Inability to digest food
Inability to absorb nutrients
Biological factors
132
DESIRED OUTCOMES
The client will maintain an adequate nutritional status as evidenced by:
a.
Weight within normal range for client
b.
Normal blood urea nitrogen (BUN) and serum albumin, prealbumin, hematocrit (Hct),
and hemoglobin (Hgb) levels and lymphocyte count
c.
Usual strength and activity tolerance
d.
Healthy oral mucous membranes
NOC OUTCOMES
Appetite; nutritional status
NIC INTERVENTIONS
Nutritional monitoring; nutritional management; nutritional therapy; exercise
promotion: strength training; nausea management
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and Early recognition of signs and symptoms of
symptoms of malnutrition: malnutrition allows for prompt intervention.

Weight significantly below client's

usual weight or below normal for
client's age, height, and body
frame
Weakness and fatigue
133
RATIONALE
Sore, inflamed oral mucous
membrane
Pale conjunctiva
Lower-than-normal
anthropomtrie measurements:
Skinfold thickness
Body circumferences (e.g., hip,

waist, mid-upper arm)
Bioelectrical impedance analysis
Monitor percentage of meals and

snacks client consumes.
Report a pattern of inadequate
intake.
Monitor BUN, serum prealbumin, Abnormal BUN, low serum prealbumin,
albumin, Hct, and Hgb levels albumin, Hct, and Hgb levels may indicate
malnutrition. Because of the long (20 day) half-life
of albumin, the value is a late indicator of
malnutrition.
Prealbumin has a half-life of 2 days and is a

more timely. sensitive indicator of protein status.
View full size

134
RATIONALE
Independent Actions
Implement measures to maintain an adequate nutritional status:
Actions help to reduce
oral/pharyngeal pain and improve
Perform actions to improve oral intake: swallowing.
Implement measures to prevent breakdown

of the oral mucous membrane and promote
healing of existing lesions:
Lubricate lips frequently. D
Rinse mouth frequently with salt and warm

water; baking soda and warm water; or a
solution of salt, baking soda, and warm
water.D
Implement measures to reduce nausea:
Encourage client to eat dry foods when

nauseated.
Avoid serving foods with an overpowering

aroma.
135
RATIONALE
Implement measures to reduce pain.
Activity promotes a sense ofwell-

being, which can improve appetite.
Increase activity as tolerated.
If client is having difficulty swallowing, assist

him/her to select foods that are easily
chewed and swallowed (e.g., eggs, custard,
macaroni and cheese, baby foods) and avoid
serving foods that are sticky (e.g., peanut
butter, soft bread).
Encourage a rest period before meals to

minimize fatigue.
Maintain a clean environment and a relaxed,

pleasant atmosphere. D
Oral hygiene moistens the mouth,

which may make it easier to chew and
Provide oral hygiene before meals. D swallow; it also removes unpleasant
tastes, which often improves the taste
of foods/fluids.

Serve frequent, small meals rather than large

ones if client is weak, fatigues easily, and/or
has a poor appetite.
If client is dyspneic, place in a high-Fowler's

position for meals and provide supplemental
136
RATIONALE
oxygen therapy during meals.
If client's sense of taste is altered, suggest

adding extra sweeteners and
flavorings/seasonings to foods.
Encourage significant others to bring in

client's favorite foods and eat with him/her.
Assist client with meals if indicated. D
Allow adequate time for meals; reheat

foods/fluids as necessary.
Action will assist client in selecting

foods/fluids that meet nutritional
Perform actions to control diarrhea: needs, are appealing, and adhere to
personal and cultural preferences.

Instruct client to avoid foods/fluids that may

stimulate or irritate the bowel or cause the
stool to be more liquid.
Implement measures to maintain an adequate Decreases nausea
nutritional status:

Perform actions to improve oral intake:
137
RATIONALE

Administer prescribed antiemetics.
Obtain a dietary consult if necessary.
Ensure that meals are well balanced and high

in essential nutrients; offer high-protein, high-
calorie dietary supplements:
Elemental formulas
Nutrient-dense candy bars and soups if

indicated
Vitamins and minerals
Appetite stimulants
Anabolic agents
Cytokine inhibitors help to improve
138
RATIONALE
appetite and promote weight gain by
suppressing TNF- production (use of
Cytokine inhibitors (e.g., Thalidomide) thalidomide is reserved for persons
with severe HIV-related wasting).
Perform a calorie count if ordered. Report
information to dietitian and physician.
Consult physician or physical therapist about a Exercise is necessary to promote the
progressive exercise program. maintenance/buildup of lean body
mass and help prevent wasting.
Consult physician about an alternative method Consulting the appropriate health
of providing nutrition if client does not care provider allows for modification
consume enough food or fluids to meet of the treatment plan.
nutritional needs:

Parenteral nutrition
Tube feedings
View full size

Nursing Diagnosis RISK FOR IMBALANCED FLUID
VOLUME NDx AND RISK FOR ELECTROLYTE
IMBALANCE NDx
Definition: At risk for decrease, increase, or rapid shift from one to the other of
intracellular, interstitial and/or extracellular fluid; at risk for imbalance of electrolytes
Related to:
Deficient fluid volume NDx related to:
Excessive loss of fluid associated with diarrhea, diaphoresis, and vomiting if present
139
Decreased oral intake associated with anorexia, weakness, nausea, and oropharyngeal
pain
Hypokalemia related to:
Excessive loss of potassium associated with diarrhea and vomiting if present
Decreased oral intake
Hyponatremia related to:
Excessive loss of sodium associated with diarrhea, profuse diaphoresis, and vomiting if
present
Excessive loss of sodium associated with diarrhea, profuse diaphoresis, and vomiting if
present
Water retention associated with increased antidiuretic hormone (ADH) output resulting
from opportunistic disease involvement of the lungs or central nervous system
Verbal reports of Change in mental status; decreased skin turgor; postural
weakness; hypotension; weak, rapid pulse; decreased urine output; cardiac
confusion dysrhythmias; nausea and vomiting; absent bowel sounds
View full size
RISK FACTORS

Abdominal ascites
140
Sepsis
DESIRED OUTCOMES
The client will maintain fluid and electrolyte balance as evidenced by:
a.
Normal skin turgor
b.
Moist mucous membranes
c.
Stable weight
d.
B/P and pulse within normal range for client and stable with position change
e.
Capillary refill time less than 2 to 3 seconds
f.
Usual mental status
g.
Balanced intake and output
h.
Usual muscle strength
i.
Soft, nondistended abdomen with normal bowel sounds
j.
Absence of nausea, vomiting, abdominal cramps, and seizure activity
k.
BUN, Hct, and serum potassium and sodium levels within normal range
141
NOC OUTCOMES
Fluid balance; hydration; electrolyte and acid-base balance
NIC INTERVENTIONS
Fluid management; electrolyte management: hypokalemia; electrolyte management:
hyponatremia
NURSING ASSESSMENT
RATIONALE
symptoms of: imbalanced fluid and electrolytes allow for

Deficient fluid volume:
Decreased skin turgor, dry mucous

membranes, thirst
Weight loss of 2% or greater over a

short period
Postural hypotension and/or low B/P
Weak, rapid pulse
Capillary refill time greater than 2 to 3

seconds
Change in mental status
142
RATIONALE
Decreased urine output (reflects an
actual rather than potential fluid
deficit)
Hypokalemia
Cardiac dysrhythmias
Postural hypotension
Muscle weakness
Nausea and vomiting
Abdominal distention
Hypoactive or absent bowel sounds
Hyponatremia
Nausea and vomiting
Abdominal cramps
143
RATIONALE
Lethargy
Confusion
Weakness
Seizures
Monitor serum electrolyte, BUN,

creatinine levels
View full size
RATIONALE
Independent Actions
Implement measures to prevent or treat
imbalanced fluid and electrolytes:
Persistent or severe diarrhea
results in excessive loss of
Perform actions to control diarrhea: gastrointestinal fluid.
Foods or fluids that stimulate the

bowel lead to increased intestinal
Instruct client to avoid foods/fluids that may motility and excessive mucous
stimulate or irritate the bowel or cause the production that increases the liquidity of
stool to be more liquid. the intestinal contents.

Perform actions to improve oral intake (e.g.,

prevent breakdown of oral mucous
membrane).
Perform actions to reduce fever (e.g., tepid

sponge bath, cool cloths to groin and
144
RATIONALE
axillae).
Encourage intake of foods/fluids high in

potassium:
Bananas
Avocado
Potatoes
Raisins
Cantaloupe
Encourage intake of foods/fluids high in

sodium
Processed cheese
Canned soups
Canned vegetables
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RATIONALE
Bouillon
imbalanced fluid and electrolytes:
Nausea often causes the client to
have decreased fluid intake. Preventing
Administer antiemetics if ordered to control vomiting results in excessive loss of
vomiting. fluid.
Adequate fluid intake needs to be

provided to ensure adequate hydration.
Maintain a fluid intake of at least 2500
mL/day unless contraindicated; if oral intake Serum electrolytes such as
is inadequate or contraindicated, maintain sodium and potassium, with narrow
intravenous and/or enterai therapy as therapeutic ranges, must be kept within
ordered. normal limits for normal body functions
to occur.

Administer electrolyte replacements if

ordered.
Consult physician if signs and symptoms of Consulting the appropriate health care
imbalanced fluid and electrolytes persist or provider allows for modification of the
worsen. treatment plan.
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Nursing Diagnosis HYPERTHERMIA NDx
Definition: Body temperature elevated above normal range
Related to: Stimulation of the thermoregulatory center in the hypothalamus by

endogenous pyrogens that are released in an infectious process
Verbal reports of Increase in body temperature above normal range; flushed skin;
headache warm to touch; increased respiratory rate; tachycardia; seizures;
convulsions
View full size
RISK FACTORS
146

Increased metabolic rate
Illness
Medications
Dehydration
DESIRED OUTCOMES
The client will experience resolution of hyperthermia as evidenced by:
a.
Skin usual temperature and color
b.
Pulse rate between 60 and 100 beats/min
c.
Respiratory rate 12 to 20 breaths/min
d.
Normal body temperature
NOC OUTCOMES
Thermoregulation
NIC INTERVENTIONS
Fever treatment
NURSING ASSESSMENT
RATIONALE
Assess for signs and Early recognition of signs and symptoms of hyperthermia
147
RATIONALE
symptoms of hyperthermia: allows for prompt intervention.

Warm, flushed skin
Tachycardia
Tachypnea
Elevated temperature
Monitor and record all Excessive fluid loss that may occur with hyperthermia
sources of fluid loss. can potentiate the loss of fluid and electrolytes.
Monitor laboratory studies: Hyperthermia may be a symptom of infection. Monitoring
laboratory studies helps to identify possible contributing
factors.
Arterial blood gas values
Serum electrolyte levels
Urinalysis
Chest x-ray results
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RATIONALE
Independent Actions
Implement measures to While hyperthermia/fever is an important defense
reduce fever: mechanism, the stress of fever is great. Fever increases
148
RATIONALE
demands on the cardiorespiratory system. A prolonged
fever may weaken a client by exhausting energy stores.
Perform actions to resolve If the source of the fever is a potential respiratory
the infectious process: infection, appropriate interventions that mobilize
secretions must be implemented.

promote rest.
maintain an adequate
nutritional status.
promote removal of
pulmonary secretions if a
respiratory infection is
present.
Administer tepid sponge

bath and/or apply cool
cloths to groin and axillae if
indicated.
Use a room fan to provide

cool circulating air. D
Apply cooling blanket if

ordered. D
Implement measures to Fever may be accompanied by diaphoresis, which can
reduce fever: result in excessive loss of fluid.
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RATIONALE

Perform actions to resolve

the infectious process:
Maintain a fluid intake of at

least 2500 mL/day unless
contraindicated.
Administer antimicrobials
as ordered.
Administer antipyretics if
ordered.
Consult physician if Consulting the appropriate health care provider allows for
temperature remains modification of the treatment plan.
higher than 38.5C
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Nursing Diagnosis FATIGUE NDx
Definition: An overwhelming sustained sense of exhaustion and decreased capacity for
physical and mental work at usual level
Related to:
Difficulty resting and sleeping
Increased energy utilization associated with the elevated metabolic rate that is present
with infection
Malnutrition
150

Tissue hypoxia associated with:
Impaired alveolar gas exchange if respiratory infection is present
Anemia resulting from:
HIV or opportunistic disease involvement of erythroid precursors in the bone marrow
Treatment with medications that can cause bone marrow depression or red blood cell
(RBC) hemolysis (e.g., zidovudine, antineoplastic agents, trimethoprim-
sulfamethoxazole [TMP-SMX])
Vitamin B 12 or folate deficiency (a result of malabsorption if intestinal involvement is

present)
Overwhelming emotional demands associated with the diagnosis of AIDS
Side effects of some medications client may be receiving (e.g., narcotic [opioid]
analgesics, antiemetics, antianxiety or antipsychotic agents)
Verbalization of overwhelming lack of energy; Lethargic or listless; drowsy;
tired; increase in physical complaints; compromised concentration;
compromised libido; inability to restore energy disinterest in surroundings;
even after sleep decreased performance
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RISK FACTORS

151
Stress
Depression
Anemia
Malnutrition
DESIRED OUTCOMES
The client will experience a reduction in fatigue as evidenced by:
a.
Verbalization of feelings of increased energy
b.
Ability to perform usual activities of daily living
c.
Increased interest in surroundings and ability to concentrate
NOC OUTCOMES
Endurance; energy conservation; rest; psychomotor energy
NIC INTERVENTIONS
Energy management; exercise promotion: strength training; nutrition management;
sleep enhancement; mood management
NURSING ASSESSMENT
RATIONALE
Assess for signs and symptoms of Early recognition and reporting of signs and
fatigue: symptoms of fatigue allow for prompt
intervention.
Verbalization of lack of energy and
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RATIONALE
inability to maintain usual routines
Lack of interest in surroundings
Decreased ability to concentrate
Lethargy
Assist client to identify personal

patterns of fatigue:

Time of day
After certain activities
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RATIONALE
Independent Actions
Inform client that a feeling of Any physical illness that causes pain or
persistent fatigue is not unusual and discomfort can result in fatigue. A client needs
is a result of the disease itself as to be reassured that this is not unusual.
well as a side effect of certain
medications the client may be
taking.
Plan activities so that times of great Do not plan activities for nursing convenience
fatigue are avoided. such as evening hours.
Implement measures to increase
strength and reduce fatigue:
D Schedule activities, treatments, or procedures
for times when the client is awake in order to
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RATIONALE
maximize the client's participation

Perform actions to promote rest

and/or conserve energy:
Maintain activity restrictions if

ordered.
Minimize environmental activity

and noise.
Organize nursing care to allow

for periods of uninterrupted rest.
Assist client with self-care activities

as needed.
Keep supplies and personal

articles within easy reach.
Instruct client in energy-saving

techniques:
Using shower chair when
154
RATIONALE
showering
Sitting to brush teeth or comb

hair
Implement measures to reduce

fear and anxiety and assist the
client to adjust to and cope with
the diagnosis of AIDS.
Implement measures to reduce

pain.
Implement measures to promote

sleep:
Encourage relaxing diversional

activities in the evening.
Allow client to continue usual

sleep practices unless
contraindicated.
Reduce environmental stimuli.
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RATIONALE
Increase client's activity as allowed

and tolerated.
Infection is a great source of stress and should

be resolved to reduce the incidence of fatigue.
Perform actions to resolve the
infectious process.
Encourage rest periods before

meals to minimize fatigue.
Adequate nutrition is needed to maintain

optimal function of the immune system.
Perform actions to maintain
adequate nutritional status.
Perform actions to improve

respiratory status:
Maintain activity restrictions as

ordered to reduce oxygen needs.
Clients with respiratory disorders should be

positioned to promote effective breathing.
Position the client for effective
ventilation:
Sitting upright in bed propped with

pillows
Nicotine and caffeine can increase cardiac
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RATIONALE
workload and myocardial oxygen utilization,
thereby decreasing oxygen availability.
Discourage smoking and
excessive intake of beverages high
in caffeine such as coffee, tea, and
colas.
Implement measures to increase
strength and reduce fatigue:

Perform actions to promote rest

and/or conserve energy:
Sedatives/hypnotics are central nervous

system depressants that promote sleep.
Administer prescribed sedative-
hypnotics. Adequate sleep can reduce the
incidence of fatigue.
Anemia is a reduction of the number of

circulating erythrocytes or a decrease in the
Administer the following if ordered to quality or quantity of hemoglobin. With anemia,
treat anemia: oxygen-carrying capacity of the blood is
reduced causing tissue hypoxia, resulting in
symptoms of weakness and fatigue.

Packed red blood cells
Erythropoiesis-stimulating growth
factor to stimulate RBC production
(e.g., epoetin alfa)
Stimulants act by stimulating the central

nervous system. Stimulants may be used to
prevent or reverse fatigue or sleep.
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RATIONALE
Administer stimulants if ordered(e.g.,
dextroamphetamine).
Consult appropriate health care Consulting the appropriate health care provider
provider (e.g., rehabilitation allows for modification of the treatment plan.
therapist, psychiatric nurse clinician,
fatigue worsen.
View full size
Nursing Diagnosis DISTURBED THOUGHT PROCESSES NDx
Definition: Disruption in cognitive operations and activities
Related to: HIV encephalopathy associated with:
AIDS dementia complex resulting from a direct effect of HIV on the central nervous
system
Opportunistic infections and/or neoplasms involving the central nervous system (e.g.,
toxoplasmic encephalitis, cryptococcal meningitis, progressive multifocal
leukoencephalopathy, cytomegalovirus [CMV] encephalitis, primary central nervous
system lymphoma)
Imbalanced fluid and electrolytes and hypoxemia if present
Verbalization of hallucinations; Inaccurate interpretation of the environment;
delusions; memory distractibility; inappropriate social behavior;
deficit/problems decreased ability to make decisions
View full size
RISK FACTOR

Cerebral abscess
158
DESIRED OUTCOMES
The client will experience improvement in thought processes as evidenced by:
a.
Improved verbal response time
b.
Longer attention span
NOC OUTCOMES
Cognitive orientation; cognition; information processing
NIC INTERVENTIONS
Dementia management; behavior modification; medication administration
NURSING ASSESSMENT
RATIONALE
Assess client for disturbed thought Early recognition and reporting of signs and
processes: symptoms of disturbed thought processes
allow for prompt intervention.
Slowed verbal responses
Decreased ability to concentrate
Impaired memory
Poor reasoning
Apathy
159
RATIONALE
Agitation
Hallucinations
Confusion
Ascertain from significant others

client's usual level of cognitive and
emotional functioning.
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RATIONALE
Independent Actions
If client shows evidence of altered thought Actions help to maintain a safe
processes: and therapeutic environment.

Reorient client to person, place, and time as

necessary; avoid repeatedly asking questions
about orientation that client cannot answer.
Address client by name.
Place familiar objects, clock, and calendar within

client's view.
Approach client in a slow, calm manner; allow

adequate time for communication.
Repeat instructions as necessary using clear,
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RATIONALE
simple language and short sentences.
Keep environmental stimuli to a minimum
Avoid touch and proximity if this appears to

increase anxiety.
Maintain a consistent and fairly structured routine

and write out schedule of activities for client to refer
to if desired.
Have client perform only one activity at a time and

allow adequate time for performance of activities
Encourage client to make lists of planned activities,

questions, and concerns.
Use distraction rather than confrontation to manage

negative behavior.
Set limits on negative behavior and avoid arguing

about the established limits.
If client is confused or experiencing hallucinations,

allow significant others to remain with client in order
to provide constant reassurance.
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RATIONALE
Encourage significant others to be supportive of
client; instruct them in methods of dealing with
client's disturbed thought processes.
Discuss physiological basis for disturbed thought

processes with client and significant others; inform
them that cognitive and emotional functioning may
improve with drug therapy

Implement measures to improve client's thought

processes:
Decreased tissue oxygenation to

the cerebral tissues can lead to
Perform actions to improve tissue oxygenation. alterations in normal thought
processes.
Electrolyte imbalances such as
alterations in normal sodium
Perform actions to prevent or treat imbalanced fluid levels can cause alterations in
and electrolytes. normal thought processes.
Administer the following medications if ordered:
Antimicrobials to treat HIV and opportunistic

infections
Antineoplastic agents to treat neoplastic

conditions affecting the central nervous system
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RATIONALE

Antipsychotic agents (e.g., haloperidol,

perphenazine, risperidone, chlorpromazine) to
reduce restlessness, agitation, or hallucinations
Antimania/mood-stabilizing agents (e.g., lithium;

anticonvulsants such as carbamazepine, valproic
acid, and gabapentin)
Central nervous system stimulants (e.g.,

dextroamphetamine sulfate, methylphenidate
[Ritalin]) to reduce apathy and withdrawn behavior
Diagnostic studies may be done

to determine the cause of
Toxoplasma and cryptococcal serology studies disturbed thought processes.
Cerebrospinal fluid analysis
Brain biopsy
Neuropsychological tests
Consult appropriate health care provider (e.g., Consulting the appropriate health
psychiatric nurse clinician, physician) if disturbed care provider allows for
thought processes persist or worsen. modification of the treatment
plan.
View full size
Nursing Diagnosis RISK FOR
INFECTION NDx (OPPORTUNISTIC INFECTION OR SEPSIS)
Definition: At increased risk for being invaded by pathogenic organisms
163
Related to:
Decreased resistance to infection associated with:
Cellular and humoral immune deficiencies present in HIV infection
Inadequate nutritional status
Depletion of immune mechanisms resulting from presenting infection and treatment

with antimicrobial agents
Myelosuppression resulting from certain medications (e.g., zidovudine, antineoplastic

agents, trimethoprim-sulfamethoxazole, ganciclovir, pyrimethamine)
Stasis of respiratory secretions and/or urinary stasis if mobility is decreased
Break in integrity of skin associated with frequent venipunctures or placement of a

central venous catheter
Impaired integrity of skin or mucous membranes if present
CLINICAL MANIFESTATIONS *
* Specific objective and subjective symptoms will depend on site of infection and causative organism.
Verbal reports of pain at areas of Fever, chills, tachycardia, warm discharge over
impaired skin integrity areas of impaired skin integrity
View full size
DESIRED OUTCOMES
164
The client will remain free of additional opportunistic infection and sepsis as evidenced
by:
1.
Return of temperature toward client's normal range
2.
Decrease in episodes of chills and diaphoresis
3.
B/P within normal limits and pulse rate returning toward normal range
4.
Normal or improved breath sounds
5.
Absence or resolution of dyspnea
6.
Stable or improved mental status
7.
Voiding clear urine without reports of frequency, urgency, and burning
8.
Absence or resolution of painful, pruritic skin lesions
9.
Stable or gradual increase in body weight
10.
No reports of increased weakness and fatigue
11.
Absence of visual disturbances
12.
165
Absence or resolution of heat, pain, redness, swelling, and unusual drainage in any area
13.
Absence or resolution of oral mucous membrane irritation and ulceration
14.
Ability to swallow without difficulty
15.
White blood cell (WBC) and differential counts returning toward normal range
16.
Negative results of cultured specimens
NOC OUTCOMES
Immune status; infection severity
NIC INTERVENTIONS
Infection control; infection protection
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of additional Early recognition of
opportunistic infection and sepsis (be alert to subtle changes signs and symptoms
in client since the signs of infection may be minimal as a of infection allows for
result of immunosuppression; also be aware that some signs prompt intervention.
and symptoms vary depending on the site of infection, the
causative organism, and the age of the client):

Increase in temperature above client's usual level
Increase in episodes of chills and diaphoresis
Hypotension (a symptom of sepsis)
166
RATIONALE

Increased pulse rate
Development or worsening of abnormal breath sounds
Development or worsening of dyspnea
Development or worsening of cough
Decline in mental status
Cloudy urine
Reports of frequency, urgency, or burning when urinating
Urinalysis showing a WBC count greater than 5, positive

leukocyte esterase or nitrites, or presence of bacteria
Vesicular lesions particularly on face, lips, and perianal area
New or increased reports of pain in and/or itching of skin

lesions and surrounding tissue
Further increase in weight loss, fatigue, or weakness
167
RATIONALE

Visual disturbances
New or increased heat, pain, redness, swelling, or unusual

drainage in any area
New or increased irritation or ulceration of oral mucous

membrane
Development of or increased dysphagia
Significant change in WBC count and/or differential
Positive results of cultured specimens (e.g., urine, vaginal

drainage, stool, sputum, blood, drainage from lesions)
Assess results of complete blood cell count (CBC) with

differential, and of all cultured specimens for positive results.
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RATIONALE
Independent Actions
Implement measures to prevent further infection:

Use good hand hygiene and encourage client to

do the same.
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RATIONALE
Protect client from others with infection.
The use of sterile technique

reduces the risk of introduction of
Maintain sterile technique during all invasive pathogens into the body.
procedures:
Urinary catheterization
Venous and arterial punctures
Injections
Change peripheral intravenous line sites according

to hospital policy.
Securing catheters and tubings

helps to reduce trauma to the
Anchor catheters/tubings: tissues and the risk for
introduction of pathogens
associated with the in-and-out
movement of the tubing.

Urinary
Intravenous
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RATIONALE
Change equipment, tubings, and solutions used
for treatments such as intravenous infusions,
respiratory care, irrigations, and enterai feedings
according to hospital policy.
Maintain a closed system for drains (e.g., urinary

catheter) and intravenous infusions whenever
possible.
Provide a low-microbe diet (e.g., thoroughly

cooked foods, fruits and vegetables that have
been washed thoroughly).
Perform actions to prevent stasis of respiratory

secretions:
Assist client to turn, cough, and deep breathe.
Increase activity as allowed and tolerated.
Instruct and assist client to perform good perineal

care routinely and after each bowel movement.
Reducing stress helps to prevent

an increase in secretion of cortisol
Perform actions identified in this care plan to (cortisol interferes with some
reduce stressors, such as discomfort, dyspnea, immune responses).
and fear and anxiety.
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RATIONALE

Perform actions to prevent breakdown of oral

mucous membrane and promote healing of
existing lesions:
Salt water/baking soda mouth

rinses help to alkalinize the
Have client rinse mouth frequently with salt and mouth, which reduces bacteria,
warm water; baking soda and warm water; or a as bacteria thrive in acidic
solution of salt, baking soda, and warm water. environments.
Healthy, intact skin reduces the

risk of infection.
Perform actions to prevent or treat skin
breakdown.
Implement measures to relieve pruritus.
If client has open lesions, perform actions to

prevent wound infection:
Maintain sterile technique during wound care.
Instruct client to avoid touching wounds.
A client experiencing urinary

retention is at increased risk for a
Perform actions to prevent urinary retention: urinary tract infection because the
accumulated urine creates an
environment conducive to the
growth and colonization of
organisms.
171
RATIONALE

Instruct client to urinate when the urge is first felt.
Promote relaxation during voiding attempts.
If client has a central venous catheter, instruct and

assist the client with proper care of the exit site.
Implement measures to prevent further infection:

Agents to reduce the rate of

replication of HIV
Antiretroviral agents
Agents to stimulate
production/enhance activity of the
Immunomodulating agents (e.g., interleukin-2, WBCs
colony-stimulating factors such as filgrastim and
sargramostim)
Agents to treat current infection or

prevent additional opportunistic
Antimicrobial agents (prophylaxis infection
forPneumocystis
carinii pneumonia,Mycobacterium
tuberculosis,toxoplasmosis, and Mycobacterium
avium complex is recommended for all patients
with a CD4+ cell count below a critical level)
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RATIONALE
Vaccines (e.g., hepatitis A, hepatitis B,
pneumococcal pneumonia, influenza)
Maintain a fluid intake of at least 2500 mL/day

unless contraindicated.
Perform actions to maintain an adequate

nutritional status:
Obtain a dietary consult if necessary to assist

client in selecting foods/fluids that meet
nutritional needs.
View full size

DISCHARGE TEACHING/CONTINUED CARE
Nursing Diagnosis DEFICIENT KNOWLEDGE NDx ;
INEFFECTIVE FAMILY THERAPEUTIC REGIMEN
MANAGEMENT; OR INEFFECTIVE HEALTH
MAINTENANCE *
* The nurse should select the diagnostic label that is most appropriate for the client's
discharge teaching needs.
NDx
Definition: Absence or deficiency of cognitive information related to specific topic
(lack of specific information necessary for clients/significant others to make informed
choices regarding condition/treatment/lifestyle changes); pattern of regulating and
integrating into family processes a program for treatment of illness and the sequelae of
illness that is unsatisfactory for meeting specific health goals; inability to identify,
manage, and/or seek out help to manage health
173
Verbalization of the desire to Failure to include treatment in daily routines; failure
manage illness; verbalization of to take action to reduce risk factors; makes choices
difficulty with prescribed in daily living ineffective for meeting health goals;
regimen inadequate follow through of instruction
View full size
RISK FACTORS

Cognitive limitations
Lack of recall
Unfamiliarity with information, resources
NOC OUTCOMES
Knowledge: disease process; knowledge: treatment regimen; knowledge: health
behavior; knowledge: health resources; knowledge: infection control
NIC INTERVENTIONS
Health system guidance; teaching: disease process; teaching: prescribed diet; teaching:
prescribed medication; communicable disease management; financial resource
assistance
NURSING ASSESSMENT
RATIONALE
Assess the client's baseline Understanding the client's baseline
understanding of: knowledge allows for implementation of the
appropriate interventions.
Disease process
Therapeutic regimen
174
RATIONALE
Health prevention measures
Assess the client's access to Early identification of barriers to therapeutic

resources to help with successful regimen management allows for
implementation of the treatment plan. implementation of the appropriate
interventions.
View full size
RATIONALE
Desired Outcome: The client will
identify ways to prevent the spread of
HIV.
Independent Actions
Instruct client in ways to prevent the HIV is a fragile virus that can be transmitted
spread of HIV to others: only under specified conditions in which a
client comes in contact with infected body
fluids including blood, vaginal secretions, and
breast milk. HIV is transmitted through sexual
intercourse with an infected partner, exposure
to infected blood or blood products, and
perinatal transmission during pregnancy, at
the time of delivery, or through breast-feeding.
HIV is inactivated rapidly after being exposed
to commonly used chemical germicides such
If a spill of blood or other body fluids as household bleach.
occurs, cleanse area with hot, soapy
water or a household detergent and
then disinfect with a solution of 1 part
bleach to 10 parts water.
Dispose of water used to clean up

body fluid spills in the toilet.
Do not share eating utensils,

toothbrushes, razors, enema
175
RATIONALE
equipment, or sexual devices.
Avoid getting pregnant, but if

pregnancy occurs, consult health care
provider about antiretroviral therapy
(e.g., zidovudine) to reduce the risk of
perinatal transmission of HIV to infant.
Do not breast-feed infant.
Do not donate blood, sperm, or body

organs.
Drug use in and of itself does not cause HIV.
If an intravenous drug user:
The major risk for HIV infection with drug use

is the sharing of drug paraphernalia that may
Get involved in a needle and syringe contain the blood of an infected individual.
exchange program.
Do not share drug-injecting

equipment (e.g., needles, syringes,
cookers, cotton, rinse water).
Discard disposable needles and

syringes after one use or clean them
with household bleach and rinse
thoroughly with water.
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RATIONALE
Safe sexual activity eliminates the risk of
exposure to HIV in semen and vaginal
If sexually active with a partner: secretions. Abstinence is the most effective
method.

Avoid multiple sexual partners and

partners with risky sexual behaviors;
be honest with desired partner about
HIV infection.
Modify techniques so that both

partners are protected from contact
with body fluids.
Avoid unsafe sexual practices:
Sharing sex toys
Allowing ejaculate to come in

contact with broken skin or mucous
membranes
Intercourse without a condom
Any activity that could cause tears

in lining of vagina, rectum, or penis
177
RATIONALE

Mouth contact with penis, vagina,

or anal area
Avoid vaginal intercourse during

menstruation (the contact with blood
increases the risk of HIV
transmission).
Barriers should be used when engaging in

insertive sexual activity.
Instruct the client in effective use of
condoms:
The effectiveness of male condoms is 80% to

90%.
Always use a barrier (male and/or
female condom) during anal,
vaginal, and oral penetration
(condom should be applied before
time a body orifice is entered
because HIV is found in preseminal
fluid).
Use latex or polyurethane condoms

(HIV can penetrate other types of
materials).
Use condoms with a receptacle tip

to reduce the risk of spillage of
semen; if that type is unavailable,
create a receptacle for ejaculate by
pinching tip of condom as it is
rolled on erect penis.
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RATIONALE

Lubricate outside of condom and

area to be penetrated to minimize
possibility of condom breakage.
Avoid lubricants made of mineral oil

or petroleum distillates such as
Vaseline or baby oil (these
products weaken latex).
Hold condom at base of penis

during withdrawal and use caution
during removal of condom to
prevent spillage of semen (penis
should be withdrawn and condom
removed before the penis has
totally relaxed).
Dispose of condom immediately

after use (a new one should be
used for subsequent sexual
activity).
Store condoms in a cool place to

prevent them from drying out and
breaking during use.
Do not use a condom if the

expiration date on the package has
passed, the package looks worn or
punctured, or if the condom looks
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RATIONALE
brittle or discolored or is sticky.
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RATIONALE
Desired Outcome: The client will identify ways to
decrease the risk for developing opportunistic
infections.
Independent Actions
Instruct client in ways to decrease risk for HIV disease progression
developing an opportunistic infection: may be delayed by promoting a
healthy immune system.
Cleanse kitchen and bathroom surfaces regularly Actions that result in

with a disinfectant to prevent growth of avoiding exposure to new
pathogens. infections are useful.
If respiratory equipment (e.g., inhalers, humidifier)

is used at home, cleanse it as instructed and
change water in humidifier daily.
Wear gloves when gardening and when in contact

with human or pet excreta (e.g., cleaning litter
boxes, bird cages, and aquariums).
Avoid exposure to body fluids during sexual

activity and use latex or polyurethane condoms
during sexual intercourse.
Reduce the risk of food-borne illness.
Thoroughly wash hands and food preparation
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RATIONALE
items and surfaces (e.g., knives, cutting board,
countertop) before and after cooking, especially
when working with raw meat, poultry, and fish.
Avoid intake of foods/fluids with a high

microorganism content (e.g., raw or undercooked
poultry, seafood, meats, or eggs; unwashed fruits
and vegetables; unpasteurized dairy products or
fruit juices; raw seed sprouts; soft cheeses;
anything that has passed its expiration date).
Cook leftover foods or ready-to-eat foods (e.g.,

hot dogs) until steaming hot before eating.
Avoid foods from delicatessen counters (e.g.,

prepared meats, salads, cheeses) and
refrigerated pts and other meat spreads, or
reheat these foods until steaming before eating.
Do not drink water directly from lakes or rivers.
Boil water for a full minute if a community boil

water advisory is issued.
Old buildings, damp areas

may be source of molds or
Avoid activities such as cleaning, remodeling, or environmental contaminants.
demolishing old buildings; exploring caves; Other areas may be considered to
disturbing soil beneath bird-roosting sites or be endemic areas for
cleaning chicken coops; being around disturbed histoplasmosis and
native soil at building excavation sites or dust coccidioidomycosis.
storms.
Action reduces the risk of
exposure to environmental
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RATIONALE
contaminants that may lead to
viral or bacterial infection.
Wash hands after handling pets and avoid contact
with reptiles (e.g., snakes, lizards, turtles), baby
chickens, and ducklings.
Avoid swimming in lakes, rivers, and public pools.
Keep living quarters well ventilated and change

furnace filters regularly to reduce exposure to
airborne disease.
Many vaccines are composed of

live viruses and create a health
Avoid contact with persons who have an infection risk for those with compromised
and those who have been recently vaccinated. immune systems.
Maintain an adequate balance between activity

and rest.
Inform all health care providers of HIV infection so

that drugs that further suppress the immune
system (e.g., corticosteroids,
immunosuppressants) will not be prescribed
unnecessarily.
Drink at least 10 glasses of liquid each day unless

contraindicated.
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RATIONALE
Desired Outcome: The client will verbalize
182
RATIONALE
ways to maintain optimal nutritional status.
Independent Actions
Provide instructions regarding ways to Proper nutrition is essential to maintain
maintain an optimal nutritional status: body mass and ensure the necessary
levels of vitamins and nutrients.
Eat foods that are high in protein and

calories.
Try to eat a snack or a small meal, or drink

a nutritional supplement every 2 to 3 hours.
Take prescribed vitamins, appetite

stimulants (e.g., megestrol acetate), and
anabolic agents (e.g., oxandrolone).
Participate in a progressive exercise

program if possible.
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RATIONALE
Desired Outcome: The client will state
signs and symptoms to report to the
health care provider.
Independent Actions
Stress importance of notifying the health Clients must notify the health care provider
care provider if the following signs and of signs and symptoms of disease
symptoms occur or if these existing progression or the development of
signs and symptoms worsen: opportunistic infections so the treatment
plan can be modified.
Persistent fever or chills
183
RATIONALE

Night sweats
Persistent headache or different type of

headache
Swollen glands
Skin lesions or significant rash
Reddish purple patches or nodules on

any body area
Ulcerations or white patches in the

mouth
Difficulty swallowing
Persistent diarrhea or vomiting
Perianal or vulvovaginal itching and/or

pain
Frequency urgency or burning on

urination
184
RATIONALE

Cloudy or foul-smelling urine
Dry cough or a cough productive of

purulent, green, or rust-colored sputum
Progressive shortness of breath
Increasing weakness, fatigue, or weight

loss
Change in vision, spots that appear to

drift in front of eye (floaters)
Decline in mental function or level of

consciousness
Loss of strength and coordination in

extremities
Inability to maintain an adequate fluid

intake
Yellow discoloration of skin
Bleeding from rectum that is not related
185
RATIONALE
to hemorrhoids
Severe depression or anxiousness or

feeling of being a danger to self or
others
Seizures
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RATIONALE
Desired Outcome: The client will identify resources that
can assist with financial needs and adjustment to
changes resulting from the diagnosis of AIDS.
Independent Actions
Provide information to client and significant others Provides client and family
about state and federally funded financial programs and with knowledge of
resources that can assist in adjustment to the diagnosis resources to sustain
of AIDS (e.g., American Foundation for AIDS Research, therapeutic regimen during
National Association of People with AIDS, hospice times of financial crisis.
programs, community support groups, CDC National
AIDS Hotline, Project Inform, counselors).
Initiate referral for state and federally funded

financial programs if indicated.
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RATIONALE
Desired Outcome: The client will verbalize an
understanding of and a plan for adhering to
recommended follow-up care including regular
laboratory studies, future appointments with health
care providers, and prescribed medications.
Independent Actions
186
RATIONALE
Stress the importance of adhering to the Adherence to the prescribed
prescribed treatment regimen. regimen can reduce
hospitalization, improve
Reinforce the importance of keeping scheduled outcomes, and aid in
follow-up appointments for laboratory studies and with maintaining optimal health
health care providers. status.
Explain the rationale for, side effects of, and

importance of taking medications prescribed (e.g.,
antiretroviral agents, antimicrobial agents,
hematopoietic agents, anabolic agents, appetite
stimulants). Inform client of pertinent food and drug
interactions.
Reinforce the importance of strictly adhering to

the antiretroviral regimen prescribed (usually consists
of a combination of at least three antiretroviral
agents). Explain that not adhering to the prescribed
regimen will limit the effectiveness of subsequent
regimens.
Explain the importance of taking the full dose of

any antimicrobial agents prescribed. Reinforce the
possibility that lifelong treatment with antimicrobials
(e.g., trimethoprim-sulfamethoxazole [TMP-SMX])
may be necessary to prevent some opportunistic
infections if the CD4+ cell count is critically low.
Implement measures to improve client compliance:

Include significant others in teaching sessions if

possible.
Encourage questions and allow time for reinforcement

and clarification of information provided.
Provide written instructions regarding scheduled

appointments with health care providers and
laboratory, medications prescribed, signs and
187
RATIONALE
symptoms to report, and ways to prevent infection.
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DIARRHEA NDx
Related to:
A direct effect of HIV on the intestine or opportunistic disease involvement of the

intestine (e.g., Mycobacterium avium-intracellulare, Cryptosporidium, Salmonella,
cytomegalovirus, Escherichia coli, Clostridium difficile, Entamoeba histolytica, Giardia,
Kaposi's sarcoma)
Side effect of some antiretroviral agents (e.g., protease inhibitors, didanosine)
ALTERED COMFORT: CHILLS AND EXCESSIVE DIAPHORESIS

Related to persistent or recurrent fever associated with HIV and opportunistic infections
ALTERED COMFORT: PRURITUS

Related to:
Dry skin associated with deficient fluid volume (can occur as a result of decreased oral
intake, excessive diaphoresis, and/or persistent diarrhea)
Pruritic folliculitis (e.g., staphylococcal folliculitis, eosinophilic folliculitis)
Dermatological disorders such as seborrheic dermatitis, photodermatitis, and psoriasis
Side effect of some antimicrobials (e.g., TMP-SMX).
188
Vulvovaginal candidiasis
IMPAIRED ORAL MUCOUS MEMBRANE NDx

Related to:
Malnutrition and deficient fluid volume
Infections such as candidiasis, herpes simplex, oral hairy leukoplakia, and bacterial
gingivitis/periodontitis
Kaposi's sarcoma or lymphoma in the oral cavity
ACTUAL/RISK FOR IMPAIRED SKIN INTEGRITY NDx

Related to:
Presence of cutaneous infections such as folliculitis, herpes zoster or simplex, bullous

impetigo, bacillary angiomatosis, molluscum contagiosum, and/or abscesses
Presence of certain skin disorders (e.g., seborrheic dermatitis, photodermatitis,

psoriasis)
Skin lesions associated with Kaposi's sarcoma if present
Excessive scratching associated with pruritus (can occur with certain skin disorders or
as a side effect of some medications such as TMP-SMX)
Increased skin fragility associated with malnutrition
189
Persistent contact with irritants associated with diarrhea
Damage to the skin and/or subcutaneous tissue associated with prolonged pressure on
tissues, friction, or shearing if mobility is decreased
RISK FOR INJURY NDx

Falls related to:
Weakness and fatigue
Decline in cognitive, behavioral, and/or motor function resulting from HIV-associated

involvement of the brain and spinal cord (e.g., AIDS dementia complex, vacuolar
myelopathy) and/or opportunistic infection or neoplastic involvement of the central
nervous system (CNS)
Visual impairment if present (can result from cytomegalovirus retinitis or from an

infection and/or neoplasm involving the CNS)
Burns related to:
Diminished sensation associated with peripheral neuropathy if present (can be a result

of the effect of HIV and some opportunistic infections on the peripheral nerves and/or a
side effect of some antiretroviral agents)
FEAR/ANXIETY NDx
Related to:
Threat of permanent worsening of health status and possible disability and death
Threat to self-concept associated with changes in physical and mental functioning (e.g.,
wasting syndrome, gait difficulty, poor coordination, dementia)
190

Stigma associated with having AIDS
Financial concerns
Separation from support system
Possibility of transmitting disease to others
INEFFECTIVE COPING NDx

Related to:
Depression, fear, anxiety, and ongoing grieving associated with the diagnosis of AIDS
and poor prognosis
Need for permanent change in lifestyle associated with impaired immune system
functioning and potential for disease transmission to others
Uncertainty of disease course and feelings of powerlessness over course of disease
Need for disclosure of diagnosis with possibility of subsequent rejection and/or

distancing by others and loss of employment and health benefits
Guilt associated with past behavior (if it was a factor in contracting HIV) and/or
possibility of having transmitted HIV to others
Lack of personal resources to deal with disability and premature death associated with
youth (a significant number of clients are in their 20s or 30s and are not
191
developmentally prepared to acknowledge and cope with disability and their own
mortality)
Multiple losses (e.g., death of close friends with AIDS; loss of normal body functioning,
family support, financial security, and/or usual lifestyle and roles)
Chronic symptoms (e.g., pain, diarrhea, fatigue) if present
RISK FOR LONELINESS NDx

Related to:
Fear of associating with others because of possibility of contracting an infection
Stigma and discrimination associated with the diagnosis of AIDS and others' fear of
contracting HIV
Decreased participation in usual activities because of weakness, pain, fatigue, and fear of
falls
Withdrawal from others associated with fear of embarrassment resulting from decline in
physical and mental functioning
INTERRUPTED FAMILY PROCESSES NDx

Related to:
Diagnosis of terminal, communicable disease in family member
Fear of disclosure of diagnosis with subsequent rejection of family unit
192
Change in family roles and structure associated with progressive disability and eventual
death of family member
Financial burden associated with extended illness and progressive disability of client
Fear of contracting disease from client
Decisions made by client and his/her partner about such issues as treatment plan, life
support, and disposition of property that may be in conflict with the client's family of
origin
Anticipatory grief
SELF-CARE DEFICIT NDx

Related to:
Cognitive and/or motor impairments if present (can result from HIV or opportunistic
disease involvement of the CNS)
Fatigue, weakness, and dyspnea
Depression
Visual impairment if present (can result from cytomegalovirus retinitis or from an

infection and/or neoplasm involving the CNS)
DISTURBED SLEEP PATTERN NDx

Related to fear, anxiety, depression, frequent assessments and treatments, pain,
diarrhea, pruritus, chills, night sweats, coughing and dyspnea (may occur if respiratory
193
infection is present), unfamiliar environment, and the effect of some medications (e.g.,
zidovudine)
INEFFECTIVE SEXUALITY PATTERNS NDx

Related to:
Rejection by desired partner associated with his/her fear of contracting AIDS
Need to disclose to new partner(s) the diagnosis of AIDS
Decreased sexual desire associated with fatigue, pain, weakness, anxiety, depression,
and fear of transmitting or contracting disease
RISK FOR POWERLESSNESS NDx

Related to:
The disabling and terminal nature of AIDS
Increasing dependence on others to meet basic needs
Changes in roles, relationships, and future plans
GRIEVING NDx
Related to:
Having an incurable illness with an uncertain course and a high probability of

premature death
Changes in body functioning, appearance, lifestyle, and roles associated with the disease
process
194
SEPSIS
Sepsis is a systemic response to infection. It is defined by the American College of Chest
Physicians and Society of Critical Care Medicine as a documented infection with a
finding of at least two of the four systemic inflammatory response criteria (i.e.,
temperature > 38C or below 36C; heart rate > 90 beats/min; respiratory rate > 20
breaths/min or partial pressure of carbon dioxide in arterial blood [Paco 2 ] < 32 mm
Hg; white blood cell [WBC] count > 12,000/mm 3 , < 4000/mm 3 , or > 10% immature
neutrophils).
Sepsis has become a leading cause of death in the United States. The increase in the
number of cases of sepsis is attributed to a number of factors including the increased
number of elderly persons and persons who are immunocompromised as a result of HIV
infection, more aggressive treatment with chemotherapy and radiation for cancer, and
treatment with corticosteroids and immunosuppressive agents. The increased use of
invasive diagnostic and therapeutic procedures has also led to increased exposure to
pathogens. In addition, the emergence of resistant organisms is making infections more
difficult to treat.
Gram-positive bacteria (e.g., Staphylococcus aureus, Staphylococcus

epidermidis, enterococci, Streptococcus pneumoniae ) and gram-negative
bacteria (e.g., Escherichia coli, Haemophilus influenzae, Klebsiella
pneumoniae, Pseudomonas aeruginosa, Serratia, Proteus, Enterobacter,
Neisseria meningitides ) are the primary organisms that cause sepsis. The most
common sites of infection that lead to sepsis are the lungs, blood, abdominal/pelvic
cavity, and the urinary tract.
Once the causative organism enters the blood (referred to as septicemia or bacteremia),
the toxins produced by the pathogens initiate a widespread inflammatory and immune
response commonly referred to as the systemic inflammatory response syndrome
(SIRS). This inflammatory response is designed to be a protective process but if
uncontrolled, triggers the release of many inflammatory mediators that subsequently
cause widespread vasodilation, injury to the endothelium, and increased capillary
permeability. This chain of events can lead to maldistribution of circulating blood with
hypotension, hypoperfusion, and organ dysfunction. Septic shock, disseminated
intravascular coagulation (DIC), and multiple organ dysfunction syndrome (MODS) can
develop if this chain of events is not reversed.
This care plan focuses on care of the adult client hospitalized for
treatment of sepsis.
The client will:
1.
Demonstrate evidence that the infection is resolving
195
2.
Have stable vital signs and evidence of adequate organ perfusion
3.
Have no signs and symptoms of complications
4.
Verbalize an understanding of ways to promote continued resolution of the existing

infection
5.
Identify ways to reduce the risk for recurrent infections
6.
7.

including future appointments with health care provider, medications prescribed, and
activity limitations.
Nursing Diagnosis IMPAIRED GAS EXCHANGE NDx

Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the
alveolar capillary membrane
Related to: Decreased pulmonary blood flow associated with a reduction in systemic
tissue perfusion resulting from inflammatory-mediated vasodilation, the fluid shift that
occurs with increased capillary permeability, and selective vasoconstriction
Loss of effective lung surface associated with:
Atelectasis resulting from hypoventilation and the decrease in surfactant production

that occurs when blood flow to the lungs is diminished
196
Accumulation of secretions in the lungs resulting from decreased mobility, poor cough
effort, and an increased production of secretions if a respiratory tract infection is
present
Accumulation of fluid in the lungs resulting from the generalized endothelial damage
and increase in capillary permeability that occur with a systemic inflammatory response
to severe infection
Verbal reports of shortness of Confusion; restlessness; dyspnea; irritability;
breath; visual disturbances; somnolence; abnormal arterial blood gas values;
headache upon awakening abnormal skin color; abnormal rate and depth of
breathing; tachycardia; diaphoresis; polycythemia
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RISK FACTORS

Alveolar capillary membrane changes
Ventilation perfusion abnormalities
DESIRED OUTCOMES
The client will experience adequate oxygen/carbon dioxide exchange as evidenced by:
a.
Usual mental status
b.
Unlabored respirations at 12 to 20 breaths/min
c.
Oximetry results within normal range
d.
Arterial blood gas values within normal range
197
NOC OUTCOMES
Respiratory status: gas exchange
NIC INTERVENTIONS
Respiratory monitoring; cough enhancement; chest physiotherapy; oxygen therapy
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of Early recognition of signs and
impaired gas exchange: symptoms of impaired gas exchange
allows for prompt intervention.
Restlessness, irritability
Tachypnea, dyspnea
Significant decrease in oximetry results
Decreased partial pressure of arterial oxygen

(PaO 2 ) and/or increased partial pressure of
arterial carbon dioxide (PaCO 2 )
Monitor pulse oximetry results.
Monitor arterial blood gas values.
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RATIONALE
Independent Actions
Implement measures to improve gas exchange: D
198
RATIONALE
Improves lung expansion
Place client in a semi- to high-Fowler's

position unless contraindicated.
Instruct and assist client to change

position, deep breathe, and cough at
least every 2 hours.

Discourage smoking. damage the bronchial and alveolar walls; the
carbon monoxide decreases oxygen
availability.
Implement measures to improve gas Maintaining adequate tissue perfusion
exchange: helps to ensure adequate pulmonary blood
flow.
Perform actions to maintain adequate The massive vasodilation that occurs

tissue perfusion: during sepsis results in a relative
hypovolemia or distributive shock. Adequate
volume replacement must occur first. If B/P
remains low after volume has been replaced,
Administer intravenous fluids vasopressors and/or inotropes may be added
(colloids/crystalloids) as ordered. to support circulation. Adequate tissue
perfusion promotes delivery of oxygen at the

tissue level.
Administer vasopressors and positive
All actions help to open up terminal
inotropic agents if ordered to maintain
airways/alveoli, increasing the surface area
adequate perfusion pressure and
available for gas exchange to occur, resulting
cardiac output.
in improved oxygenation.

Restricting activity lowers the body's
Assist with positive airway pressure oxygen requirements.
techniques (e.g., continuous positive
airway pressure [CPAP], bilevel Antimicrobial agents help to resolve
positive airway pressure [BiPAP], the infectious process and control the
flutter/positive expiratory pressure systemic inflammatory response.
199
RATIONALE
[PEP] device) if ordered.
Maintain activity restrictions as

ordered; increase activity gradually as
allowed and tolerated.
Administer antimicrobial agents as

ordered.
Consult appropriate health care Allows for modification of the treatment plan
provider (respiratory therapist,
impaired gas exchange persist or
worsen.
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Nursing Diagnosis INEFFECTIVE TISSUE PERFUSION NDx
Definition: Decrease in oxygen resulting in failure to nourish the tissues at the
capillary level. NANDA International identifies five types of ineffective tissue perfusion:
renal, gastrointestinal, peripheral, cerebral, and cardiopulmonary
Related to:
Maldistribution of circulating blood associated with vasodilation, fluid shift that occurs
with increased capillary permeability, and selective vasoconstriction that occur in
response to inflammatory mediators (e.g., cytokines, complement, histamine, kinins)
released in a serious infection
Hypovolemia associated with deficient fluid volume resulting from decreased fluid
intake, excessive loss of fluid (can occur with diaphoresis, hyperventilation, vomiting,
and/or diarrhea if present), and the fluid shift that occurs with increased capillary
permeability
200
Decreased cardiac output (occurs late in severe sepsis and shock) associated with the
depressant effect of acidosis, myocardial depressant factor, and some inflammatory
mediators (e.g., cytokines) on myocardial contractility
Restlessnes Decreased B/P; confusion; cool extremities; pallor or cyanosis of
s extremities; diminished or absent peripheral pulses; slow capillary refill;
edema; oliguria
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RISK FACTORS

Smoking
Hyperlipidemic
Sedentary lifestyle
DESIRED OUTCOMES
The client will maintain adequate tissue perfusion as evidenced by:
a.
B/P within normal range for client
b.
Usual mental status
c.
Extremities warm with absence of pallor and cyanosis
d.
Palpable peripheral pulses
e.
201
f.
Absence of edema
g.
Urine output at least 30 mL/h
NOC OUTCOMES
Circulation status; tissue perfusion: abdominal organs; tissue perfusion: cardiac; tissue
perfusion: cerebral; tissue perfusion: peripheral; tissue perfusion: pulmonary
NIC INTERVENTIONS
Circulatory care: arterial insufficiency; circulatory care: venous insufficiency; cerebral
perfusion promotion; hypovolemia management; cardiac care: acute
NURSING ASSESSMENT
RATIONALE
symptoms of diminished tissue ineffective tissue perfusion allows for prompt
perfusion: intervention.

Decreased B/P
Confusion
Cool extremities
Pallor or cyanosis of extremities
Diminished or absent peripheral

pulses
202
RATIONALE
Slow capillary refill
Edema
Oliguria
Monitor hemodynamic status:

Vital signs
Urine output
Central venous pressure (if

applicable)
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RATIONALE
Maintaining adequate tissue perfusion helps to
ensure adequate pulmonary blood flow. The
Perform actions to maintain massive vasodilation that occurs during sepsis
adequate tissue perfusion: results in a relative hypovolemia or distributive
shock. Adequate volume replacement must occur
first. If B/P remains low after volume has been
replaced, vasopressors and/or inotropes may be
Administer intravenous fluids added to support circulation. Adequate tissue
(colloids/crystalloids) as ordered. perfusion promotes delivery of oxygen at the
tissue level.

Administer vasopressors and

positive inotropic agents if
203
RATIONALE
ordered to maintain adequate
perfusion pressure and cardiac
output.
Perform actions to prevent or treat

deficient fluid volume:
Control diarrhea if present.
Reduce nausea and vomiting if

present.
Antimicrobial agents help to resolve the infectious

process and control the systemic inflammatory
Administer antimicrobial agents response.
as ordered.
Consult appropriate health care Allows for modification of the treatment plan
provider if signs and symptoms of
diminished tissue perfusion
persist or worsen.
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Nursing Diagnosis RISK FOR DEFICIENT FLUID
VOLUME NDx
Definition: At risk for experiencing vascular, cellular, or intracellular dehydration
Related to:
Decreased oral intake associated with anorexia, fatigue, and nausea if present
Increased insensible fluid loss associated with diaphoresis and hyperventilation if

present
204

Excessive loss of fluid associated with vomiting and/or diarrhea if present with initial
infection or as a side effect of antimicrobial therapy
Fluid shifting from the intravascular to extravascular space associated with the
increased capillary permeability that occurs with a systemic inflammatory response
Subjectiv Objective
e
N/A Decreased B/P; decreased pulse pressure; decreased skin turgor; dry
mucous membranes; increased pulse rate; elevated Hct; increased body
temperature; decreased urine output; increased urine concentration
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DESIRED OUTCOMES
The client will not experience deficient fluid volume as evidenced by:
a.
Normal skin turgor
b.
Moist mucous membranes
c.
Stable weight
d.
B/P and pulse rate within normal range for client and stable with position change
e.
Usual mental status
f.
BUN and Hct values within normal range
g.
205
Balanced intake and output
h.
Urine specific gravity within normal range
NOC OUTCOMES
Fluid balance; hydration
NIC INTERVENTIONS
Fluid monitoring; fluid management; hypovolemia management; intravenous therapy;
fever treatment; diarrhea management; nausea management
NURSING ASSESSMENT
RATIONALE
symptoms of deficient fluid volume: deficient fluid volume allows for prompt
intervention.
Decreased skin turgor
Dry mucous membranes, thirst
Weight loss of 2% or greater over a

short period
Postural hypotension and/or low B/P
Weak, rapid pulse
Neck veins flat when client is supine
206
RATIONALE
Change in mental status
Decrease in urine output with

increased specific gravity
Monitor BUN, Hct values.

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RATIONALE
deficient fluid volume:

Perform actions to reduce nausea and

vomiting if present:
Administer antimicrobial agents with food

Administer prescribed antiemetics.
Perform actions to control diarrhea if present:
Consult physician about another

antimicrobial agent if onset of diarrhea
seems related to initiation of antimicrobial
therapy.
207
RATIONALE
Administer prescribed antidiarrheal agents.
Actions help to reduce

insensible fluid loss associated with
Perform actions to reduce fever. diaphoresis and hyperventilation.
Decreasing the release of

inflammatory mediators associated with
Administer antimicrobial agents as ordered to infection decreases capillary
treat the infection and decrease the release permeability and the resultant fluid
of inflammatory mediators. shift.

Maintain a fluid intake of at least 2500

mL/day unless contraindicated; if oral intake
is inadequate or contraindicated, maintain
intravenous fluid therapy as ordered.
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Nursing Diagnosis HYPERTHERMIA NDx
Definition: Body temperature elevated above normal range as a result of either fever
or hyperthermia
Related to: Stimulation of the thermoregulatory center in the hypothalamus by

endogenous pyrogens that are released in an infectious process
Report of Flushed skin; increase in body temperature; tachycardia; tachypnea;
chills warm to touch
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RISK FACTORS

Illness
Increased metabolic rate
208

Dehydration
DESIRED OUTCOMES
The client will experience resolution of hyperthermia as evidenced by:
a.
Skin usual temperature and color
b.
Pulse rate between 60 and 100 beats/min
c.
Respiratory rate 12 to 20 breaths/min
d.
Normal body temperature
NOC OUTCOMES
Thermoregulation
NIC INTERVENTIONS
Fever treatment
NURSING ASSESSMENT
RATIONALE
Assess for signs and Early recognition and reporting of signs and symptoms
symptoms of hyperthermia: of hyperthermia allow for prompt intervention.

Warm, flushed skin
Tachycardia
209
RATIONALE
Tachypnea
Elevated temperature
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RATIONALE
Independent Actions
Implement measures to reduce fever:

Perform actions to resolve the infectious process: D
Implement measures to promote rest (assist client with

activities of daily living, provide uninterrupted rest periods,
limit visitors).
Helps to fight off infection
Encourage client to eat a well-balanced diet high in

essential nutrients.
Decreases hyperthermia
Administer tepid sponge bath and/or apply cool cloths to

groin and axillae if indicated.
Use a room fan to provide cool, circulating air.
Implement measures to reduce fever:

210
RATIONALE
Perform actions to resolve the infectious process:
Maintain a fluid intake of at least 2500 mL/day unless

contraindicated.
Treats/prevents infection
Administer antimicrobials as ordered.
Decreases fever
Apply cooling blanket if ordered
Administer antipyretics if ordered.
Consult physician if temperature remains higher than Allows for prompt

38.5C. alteration in interventions
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Nursing Diagnosis RISK FOR
INFECTION NDx (SUPERINFECTION)
Definition: At risk for being invaded by pathogenic organisms
Related to:
Decreased resistance to infection associated with depletion of immune mechanisms

resulting from the current infection and treatment with antimicrobial agents
Stasis of respiratory secretions and/or urinary stasis if mobility is decreased
211
Break in skin integrity associated with frequent venipunctures or presence of invasive
lines (e.g., intravenous catheter, hemodynamic monitoring devices)
Verbal reports of pain at areas Increased body temperature; redness, warmth
of impaired skin integrity discharge over areas of impaired skin integrity
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DESIRED OUTCOMES
The client will have resolution of existing infection and remain free of superinfection as
evidenced by:
a.
Return of temperature toward normal range
b.
Decrease in episodes of chills and diaphoresis
c.
Pulse rate returning toward normal range
d.
Normal or improved breath sounds
e.
Absence or resolution of dyspnea and cough
f.
Stable or improved mental status
g.
Voiding clear urine without reports of frequency, urgency, and burning
h.
No reports of increased weakness and fatigue
i.
212
Absence or resolution of heat, pain, redness, swelling, and unusual drainage in any area
j.
Absence of oral mucous membrane lesions and ulceration
k.
Absence or resolution of diarrhea and abdominal pain and cramping
l.
WBC and differential counts returning toward normal range
m.
Negative results of cultured specimens
NOC OUTCOMES
Immune status; infection severity
NIC INTERVENTIONS
Infection control; infection protection
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of superinfection Early recognition of
(be alert to subtle changes in client since the signs of signs and symptoms of
infection maybe minimal as a result of immunosuppression; an infection allows for
also be aware that some signs and symptoms vary prompt intervention.
depending on the site of the infection, the causative
organism, and the age of the client):

Increase in temperature
Increase in episodes of chills and diaphoresis
Increased pulse rate
213
RATIONALE

Development or worsening of abnormal breath sounds
Development or worsening of dyspnea and/or cough
Decline in mental status
Cloudy urine; reports of frequency, urgency, burning when

urinating
Further increase in fatigue or weakness
New or increased heat, pain, redness, swelling, or unusual

drainage in any area
Development or worsening of lesions or ulceration of oral

mucous membrane
New or increased episodes of diarrhea and abdominal

cramping or pain
Monitor CBC with differential; culture results;

urinalysis; chest x-ray results.
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RATIONALE
Independent Actions
214
RATIONALE
Implement measures to prevent
superinfection:
Prevents spread of infection
Use good hand hygiene and encourage

client to do the same.
Decreases client's potential for infection
Protect client from others with infection.
Necessary to produce cells that fight

infection
Encourage client to eat a well-balanced
diet high in essential nutrients; provide
dietary supplements if indicated.
Prevents entrance of pathogens into the

body
Maintain sterile technique during all
invasive procedures.
Decreases potential for infection
Change intravenous insertion sites

Securely anchoring tubes/catheters

reduces trauma to the tissues and the risk
Anchor catheter/tubings securely. for introduction of pathogens associated
with the in-and-out movement of the
tubing.

Change equipment, tubings, and

solutions used for treatments such as
intravenous infusions, respiratory care,
irrigations, and enterai feedings
215
RATIONALE
Prevents introduction of pathogens into the
body
Maintain a closed system for drains (e.g.,
urinary catheter) and intravenous
infusions whenever possible.
Perform actions to prevent stasis of

respiratory secretions:
Improves lung expansion and motility of

secretions
Assist client to turn, cough, and deep
breathe.
Increase activity as allowed and

tolerated.
Perform actions to prevent urinary

retention/stasis:
Prevents stasis of urine, which increases

the potential for infection
Urinate when urge is felt.
Prevents contamination from bacteria from

the rectum
Promote relaxation when voiding.
Instruct and assist client to perform good

perineal care routinely and after each
bowel movement.
216
RATIONALE

If client has open lesions or wound

drains, perform actions to prevent wound
infection:
Maintain sterile technique during wound

care.
Instruct client to avoid touching

wounds.
Implement measures to prevent
superinfection:

Maintain a fluid intake of 2500 mL/day

Consult physician about discontinuing

urinary catheter if one is present.
Consult physician about:
Maintains nutritional status. TPN has a

high glucose content, which provides a rich
Enteral feeding rather than total medium for bacterial growth.
parenteral nutrition (TPN) if nutritional
replacement is necessary
217
RATIONALE
Use of sucralfate rather than antacids

and histamine 2 -receptor antagonists
These agents increase the pH of the

stomach contents, which promotes
Administer antimicrobial agents as bacterial overgrowth; aspiration of gastric
ordered. contents with a high bacteria content
increases the risk for pneumonia.
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POTENTIAL COMPLICATIONS OF SEPSIS
COLLABORATIVE DIAGNOSIS
SEPTIC SHOCK
Definition: Sepsis-induced hypotension or the requirement for vasopressors or
inotropes to maintain B/P despite adequate fluid volume resuscitation along with the
presence of perfusion abnormalities that may include lactic acidosis, oliguria, or acute
alteration in mental status
Related to: Systemic hypoperfusion associated with maldistribution of circulating

blood, deficient fluid volume, and decreased myocardial contractility resulting from an
uncontrolled systemic inflammatory response to severe infection
Reports of Low arterial pressure; low systemic vascular resistance; systemic
confusion edema; tachycardia; temperature instability
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DESIRED OUTCOMES
The client will not develop septic shock as evidenced by:
a.
Systolic B/P equal to or higher than 90 mm Hg
b.
Usual mental status
c.
218
d.
Extremities warm and usual color
e.
f.
Palpable peripheral pulses
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of Early recognition of signs and
septic shock: symptoms of septic shock allows for
Hyperdynamic or compensatory phase
Widened pulse pressure with the diastolic

pressure dropping and little change in the
systolic pressure
Restlessness
Tachycardia
Warm, flushed skin
Hypodynamic or progressive phase
219
RATIONALE
Systolic B/P less than 90 mm Hg or a
reduction of greater than 40 mm Hg from
baseline
Cool, clammy skin
Change in level of consciousness
Decreased urine output
Rapid, shallow breathing
Rapid, thready pulse
Monitor serum lactate levels.

View full size
RATIONALE
Implement measures to maintain Maintains intravascular volume
adequate tissue perfusion:

Administer intravenous fluids

(crystalloids/colloids) as ordered.
If signs and symptoms of septic Treatment for septic shock focuses on the
shock occur: expansion of circulating volume to improve tissue
perfusion. Oxygenation and perfusion must be
maintained to prevent extreme lactic acidosis. The
Maintain intravenous fluid therapy patient often requires transfer to a critical care unit
as ordered. for invasive monitoring of hemodynamic status
220
RATIONALE
Maintain oxygen therapy (Swan Ganz catheter; central venous pressure;
as ordered. arterial line.)
Administer antimicrobials as
ordered.
Administer vasopressors and

positive inotropic agents as
ordered to maintain adequate
perfusion pressure and cardiac
output.
Prepare client for transfer to

critical care unit.
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RISK FOR DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
Definition: A systemic thrombohemorrhagic disorder seen in association with well-
defined clinical situations and laboratory evidence
Related to: Widespread inflammation and the resulting endothelial damage associated
with sepsis results in inappropriate triggering of the coagulation cascade due to the
presence of tissue factor that is released by damaged or dead tissues
Reports of Bleeding: rapid development of oozing from
restlessness; agitation; venipuncture sites, arterial lines, surgical wounds; ecchymotic
confusion lesions; bleeding in conjunctiva, nose, and gums
Thrombosis: cyanosis of fingers/toes, nose, breast;

symptoms of organ failure
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DESIRED OUTCOMES
221
The client will not develop DIC as evidenced by:
a.
Absence of petechiae, ecchymoses, and frank or occult bleeding
b.
Usual color and temperature of extremities
c.
Usual mental status
d.
Fibrin degradation products (FDP) and D-dimer results within normal range
e.
Fibrinogen level, platelet count, activated partial thromboplastin time (APTT),

prothrombin time (PT), and thrombin time within normal range
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of DIC: Early recognition of signs and
symptoms of DIC allows for
Petechiae, ecchymoses
Frank or occult bleeding (e.g., oozing from

venipuncture sites or surgical incisions, epistaxis,
hematuria, gingival bleeding)
Cool, mottled extremities
Restlessness, agitation, confusion
Monitor results of PT/PTT; FDP; fibrinogen level,
222
RATIONALE
D-dimer.
View full size
RATIONALE
Independent Actions
If DIC occurs:
The body has depleted its clotting
factors; thus, after any invasive
Implement safety precautions to prevent further procedure, excessive bleeding may
bleeding: occur.
Avoid injections.
Avoid invasive procedures.
Discontinue any invasive lines with extreme

caution.
Use electric rather than straight-edge razor for

shaving.
Implement measures to control infection and Treat/prevent infections
reduce the risk for an uncontrolled systemic
inflammatory response in order to reduce the
risk for DIC:

Administer antimicrobial agents as ordered.
223
RATIONALE
Perform actions to reduce the risk for
superinfection.
If DIC occurs:
Improves blood's clotting
ability
Administer fresh frozen plasma, platelets, and/or
cryoprecipitate if ordered. Blood products identified help
to enhance clotting and stop
bleeding.
Administer medications to interrupt clotting:
Heparin
Antithrombin III
Heparin is contraindicated if platelet count is

less than 50,000.
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RISK FOR ORGAN ISCHEMIA/DYSFUNCTION (MULTIPLE ORGAN
DYSFUNCTION SYNDROME)
Definition: The progressive dysfunction of two or more organ systems resulting from
an uncontrolled inflammatory response to severe illness or injury
Relation to:
Hypoperfusion of major organs associated with shock
Microvascular thrombosis associated with DIC
224
Subjectiv Objective
e
N/A Low-grade fever; tachycardia; dyspnea; altered mental status; individual
organ failure
View full size
RISK FACTORS

Malnutrition
Corticosteroids
Bowel infarction
Inadequate or delayed resuscitation
Multiple blood transfusions
Persistent infection
Significant tissue injury
Burns
Trauma
Acute pancreatitis
225

Circulatory shock
Adult respiratory distress syndrome
Necrotic tissue
DESIRED OUTCOMES
The client will not develop organ ischemia/dysfunction as evidenced by:
a.
Usual mental status
b.
c.
Unlabored respirations at 12 to 20 breaths/min
d.
Audible breath sounds without an increase in adventitious sounds
e.
Absence of new or increased abdominal pain, distention, nausea, vomiting, and diarrhea
f.
BUN, creatinine, aspartate aminotransferase (AST), alanine aminotransferase (ALT),

and lactate dehydrogenase (LDH) levels within normal range
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of: Early recognition of signs and
symptoms of multiple organ
dysfunction syndrome (MODS)
226
RATIONALE
Cerebral ischemia (e.g., change in mental allows for prompt intervention.
status)
Urine output less than 30 mL/h (elevated BUN

and creatinine levels)
Acute respiratory distress syndrome (e.g.,

dyspnea, increase in respiratory rate, low
arterial oxygen saturation [SaO 2 ], crackles)
Gastrointestinal ischemia (e.g., hypoactive or

absent bowel sounds, abdominal pain and
distention, nausea, vomiting, diarrhea,
hematemesis, blood in stool)
Liver dysfunction (e.g., increased AST, ALT, and

LDH levels; jaundice)
Monitor results of chest x-ray and complete

metabolic panel.
View full size
RATIONALE
reduce the risk for organ
ischemia/dysfunction:

Perform actions to maintain

adequate tissue perfusion.
227
RATIONALE
Perform actions to prevent

and treat DIC.
This medication has been found to have antithrombotic,

antiinflammatory, and profibrinolytic activity and may
Administer recombinant reduce the risk of MODS; it is only used in persons with
activated protein C severe sepsis who are not having symptoms of DIC.
(drotrecogin alfa [Xigris]) if Because of the risks associated with this drug and the
ordered. patient's critical state, transfer to intensive care is
indicated.
If signs and symptoms of
organ ischemia/MODS
occur:

Maintain oxygen therapy.
Prepare client for transfer to

critical care unit.
View full size

FEAR/ANXIETY NDx
Related to:
Unfamiliar environment
Separation from significant others
Severity of current condition
228

Threat of death
DEFICIENT KNOWLEDGE NDx ; INEFFECTIVE THERAPEUTIC

REGIMEN MANAGEMENTNDx ; OR INEFFECTIVE HEALTH
MAINTENANCE* NDx
SPLENECTOMY
Splenectomy is the surgical removal of the spleen. The most common indication for the
surgery is rupture of the spleen. Causes of rupture include penetrating or blunt trauma
to the spleen, operative trauma to the spleen during surgery on nearby organs, and
damage to the spleen as a result of disease (e.g., mononucleosis, tuberculosis of the
spleen). A splenectomy may also be indicated if the spleen is removing excessive
quantities of platelets, erythrocytes, or leukocytes from the circulation (hypersplenism).
Conditions associated with hypersplenism include leukemia, idiopathic
thrombocytopenic purpura, Felty's syndrome, thalassemia major, lymphoma, and
hereditary spherocytosis. Additionally, splenectomy may be performed to treat splenic
cysts and neoplasm. When feasible, a partial splenectomy is performed so that some of
the spleen's immunological function is maintained.
This care plan focuses on the adult client hospitalized for a splenectomy.
The care plan will need to be individualized according to the client's
underlying disease process or the extensiveness of abdominal trauma
necessitating the surgery.
The client will:
1.
Have surgical pain controlled
2.
Have evidence of normal healing of surgical wound
3.
Have no signs and symptoms of infection
4.
Have no signs and symptoms of postoperative complications
229
5.
Identify appropriate safety measures to follow because of increased risk for infection
6.
7.

including future appointments with health care provider, medications prescribed,
wound care, and activity level.
For a full, detailed care plan on this topic, go

to http://evolve.elsevier.com/Haugen/careplanning/ .
NDx = NANDA-I Diagnosis
D = Delegatable Action
= UAP
= LVN/LPN
= Go to for animation
230

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Client with Alterations in Respiratory

and Sandra Galura MSN, RN, CCRN, CPAN

Open reading mode

Have improved respiratory function

Have vital signs within client's normal range

Tolerate expected level of activity

Verbalize an understanding of medications ordered including rationale, food and drug

Demonstrate appropriate use of inhalers.

Ineffective breathing pattern NDx

Decreased depth of respirations associated with weakness, fatigue, fear, anxiety

Ineffective airway clearance NDx

Narrowing of the airways associated with:

Excessive mucus production, inflammation, and bronchospasm

Bronchial wall remodeling with bronchial hypertrophy and hyperplasia of mucus-

Difficulty coughing up secretions resulting from fatigue, weakness, and presence

Impaired Gas Exchange NDx

Narrowing or obstruction of the small airways

Usual rate and depth of respiration

Usual or improved breath sounds

Usual mental status

Oximetry results within normal range for client

Arterial blood gas values within normal range for client

Use of accessory muscles

The bluish discoloration of the skin and mucous

Oximetry is a non-invasive method of measuring

Allows for evaluation of client's current oxygenation

Provides support for the respiratory

Corticosteroids decrease airway inflammation

Nursing Diagnosis ACTIVITY INTOLERANCE NDx

Inadequate nutrition status

Verbalization of feeling less fatigued and weak

Statements of fatigue or weakness

Exertional dyspnea, chest pain, diaphoresis, or dizziness

Significant change (15-20 mm Hg) in B/P with activity

Report a decreased tolerance for activity.

Stop any activity that causes increased chest

DISCHARGE TEACHING/CONTINUED CARE

Inability to care for oneself

Difficulty in modifying personal habits and integrating treatments into lifestyle

Assess client readiness

The irritants in smoke and respiratory irritants

Exposure to extreme hot and cold air may

Changes in the incidence of asthma attacks

Explain that asthma can be treated, but only

Provide written instructions about and

Knowledge of medications and how they

Beta 2 -Adrenergic agonists

Assist client to develop a method to promote

Instruct client to take all medications as often as

Persistent or recurrent loss of appetite, nausea,

Fever, chills, continued or increased night sweats

Unusual color, amount, and odor of vaginal

Signs and symptoms of adverse effects of

Desired Outcome: The client will verbalize an

ADDITIONAL NURSING DIAGNOSES

RISK FOR POWERLESSNESS NDx

FEAR NDx AND ANXIETY NDx

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Have improved respiratory function

Tolerate expected level of activity

Have no signs and symptoms of complications

Identify ways to prevent or minimize further respiratory problems

Verbalize ways to maintain an optimal nutritional status

Identify ways to conserve energy and/or reduce dyspnea and fatigue