Youre probably familiar with chronic obstructive pulmonary disease (COPD) and asthma, diseases that also are

known to the general public. Although not uncommon, restrictive lung disease isn't as well known to health care providers and is almost unknown to the public.

Anatomy and Physiology

Lungs
y y y y y y y y y y y y y

The lungs are paired elastic structures enclosed in the thoracic cage, which is an airtight chamber with distensible walls. Ventilation requires movement of the walls of the thoracic cage and of its floor, the diaphragm. The effect of these movements is alternately to increase and decrease the capacity of the chest. When the capacity of the chest is increased, air enters through the trachea (inspiration) because of the lowered pressure within and inflates the lungs. When the chest wall and diaphragm return to their previous positions (expiration), the lungs recoil and force the air out through the bronchi and trachea. The inspiratory phase of respiration normally requires energy; the expiratory phase is normally passive. Inspiration occurs during the first third of the respiratory cycle, expiration during the latter two thirds The lungs and wall of the thorax are lined with a serous membrane called the PLEURA. The visceral pleura covers the lungs; the parietal pleura lines the thorax. The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath.

Pleura
y y y y y y

Oxygen Transport
y Oxygen is supplied to, and carbon dioxide is removed from, cells y by way of the circulating blood. Cells are in close contact with y capillaries, whose thin walls permit easy passage or exchange of y oxygen and carbon dioxide. Oxygen diffuses from the capillary y through the capillary wall to the interstitial fluid. At this point, it y diffuses through the membrane of tissue cells, where it is used by y mitochondria for cellular respiration. The movement of carbon y dioxide occurs by diffusion in the opposite directionfrom cell y to blood.

Respiration
y After these tissue capillary exchanges, blood enters the systemic y veins (where it is called venous blood) and travels to the y y y y y y y y y y

pulmonary circulation. The oxygen concentration in blood within the capillaries of the lungs is lower than in the lungs air sacs (alveoli). Because of this concentration gradient, oxygen diffuses from the alveoli to the blood. Carbon dioxide, which has a higher concentration in the blood than in the alveoli, diffuses from the blood into the alveoli. Movement of air in and out of the airways (ventilation) continually replenishes the oxygen and removes the carbon dioxide from the airways in the lung. This whole process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body is called respiration.

Ventilation
y During inspiration, air flows from the

environment into the trachea, y bronchi, bronchioles, and alveoli. During expiration, alveolar y gas travels the same route in reverse.

Lung Volumes and Capacities

y Lung function, which reflects the mechanics

of ventilation, is y viewed in terms of lung volumes and lung capacities.

Tidal volume TV the volume of air inhaled and exhaled with each breath. (500ml) Inspiratory Reserve Volume IRV The maximum volume of air that can be inhaled after a normal inhalation. (3000 ml) Expiratory Reserve Volume ERV The maximum volume of air that can be exhaled forcibly after a normal exhalation. (1100 ml) Residual Volume RV the volume of air remaining in the lungs after exhalation. (1200ml)

Vital Capacity VC the maximum volume of air exhaled from the point of maximum inspiration. Inspiratory Capacity IC The maximum volume of air inhaled after normal expiration Functional Residual Capacity FRC The volume of air remaining in the lungs after a normal expiration Total Lung Capacity TLC The volume of air in the lungs after a maximum inspiration

A client was rushed to the ER due to dyspnea. The client complains of a sudden pain in the chest, agravated by coughing. Nasal Flaring, tracheal devation was noted. The current vital sign of the client are: T 37.8 C P 98 bpm R 39 breaths per min BP 90/60 mmHg

Restrictive Lung Disease

Pneumonia

Pleural Effusion

Pneumothorax

Pleurisy

There is LIMITATION to full expansion of the lungs Diagnostics: Pulmonary Function X-Rays CT scans MRI ABG Bronchoscopy Culture and Sensitivities Lung Biopsy

Decreased lung / thoracic compliance Static Lung Volumes are diminished Reduced total lung capacity (TLC), vital capacity, or resting lung volume

Dyspnea and/or Tachypnea

Oxygen therapy as ordered Deep Breathing Exercises

Ineffective airway clearance related to SECRETIONS

Airway management Suctioning Chest Physiotherapy: Coughing Techniques Chest Hygiene techniques Increase fluids Humidification

Altered Comfort: PAIN

Pain Management Measures: Relaxation Techniques Diversional Activities Heat and Cold Applications Pharmacologic Pain Measure: NSAIDS Intercostal Nerve Block

Fatigue

Instruct the client to rest and avoid overexertion Comfort Positioning Change positions frequently Engage only in moderate activity

Malnutrition

Fluids with Calories and Electrolytes Nutritionally enriched drinks Shakes Parenteral Nutrition as needed Consultation with Dietician/ Nutritionist

Deficient Knowledge related to treatment

Teach the client and family on the risk factors, prevention disease process, Self care activities, the medications, the treatment procedures. Answer any query about the condition the client may have

Disease Specific Concerns

Pathogenic Organism: Risk Factors:

Impaired Host Defenses Smoking Prolonged Immobility Shallow breathing pattern Depressed Cough Reflex NPO; NGT; Orotracheal tube; endotracheal tube Advanced age Respiratory therapy with improperly cleaned equipment
Streptococcus pneumoniae Legionella pneumophilla Pseudomona aeruginosa Staphylococcus areus

Clinical Manifestations: FEVER Chills Pleuritic Chest pain aggravated with coughing Tachypnea Shortness of breath Use of accessory muscles Rapid Pulse Expectoration of Sputum Orthopnea

Community Acquired Pneumonia -acquired in the community or within 48 hours of hospitalization

Hospital Acquired Pneumonia - Acquired 48 hours after hospitalization

Bronchopneumonia Lobar pneumonia

Medical management Appropriate Antibiotic Therapy

Complications Shock Respiratory Failure Atelectasis from obstruction of bronchial secretions Pleural Effussions Superinfections

Nursing Interventions

Improving Airway Patency:

Removing secretions Encourage hydration Humidification

Promoting rest and Conserving Energy

Comfort measures Position Changes Instruct client not to overexert

Promote Fluid Intake

To make up for the insensible fluid loses brought by tachypnea and fever

Maintaining Nutrition
Calorie filled fluids Nutritionally enriched drinks and shakes

Promoting Patients Knowledge

Clients should be instructed on the management of the illness

Monitor for Possible Complications

Heart Failure

TB

Pneumonia

Pulmonary Infections

Collection of fluid in the pleural space

Clear Bloody Purulent

Transudative

Exudative

Clinical Manifestations Usually S/S of the underlying disease Depending on the size of the effusion , the degree of dyspnea may be noted

Medical Management Objective of treatment is to discover the underlying cause, to prevent accumulation of fluid, and to relieve discomfort, dyspnea and respiratory compromise Thoracentesis is performed to remove the fluid, obtain specimen, to relieve dyspnea and respiratory compromise. This maybe performe with ultrasound guidance Depending on the size of the effusion, the fluid may be treated by thoracentesis or by inserting a chest tube connected to a water seal drainage system or suction to evacuate the pleural space and to re-expand the lung Pleurodesis may be performed to obliterate the pleural space in case of recurring effusions Nursing Intervention The nurse assist in thoracentesis and offers support throughout the procedure Pain Management: comfort measure positioning, medications Monitoring of Chest tube and water-seal drainage system Nursing care directed to the underlying cause Education of client in the care of drainage system

Simple Pneumothorax -or spontaneous, occurs when air

enters the pleural space through a breach of either the parietal or visceral pleura. Most commonly this occurs through the rupture of a bleb or bronchopleural fistula.

Traumatic Pneumothorax -occurs when air escapes from a

laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. It can occur with blunt trauma or penetrating chest trauma (stabs, or gunshots) and from diaphragmatic tears

Clinical Manifestations: S/s associated depend on the size and cause Pain is sudden and maybe pleuritic Pt. may only have minimal resp. distress with slight chest discomfort and tachypnea with a small simple or uncomplicated pneumothorax. If Large and the lung collapses totally. Acute respiratory distress occurs., Anxiety, dyspnea, air hunger, increased use of acessory muscles, may develop cyanosis, severe hypoxemia Severe chain pain may occur, accompanied by tachypnea, decreased movement of the affected side of thorax, tympany of percussion, decreased or absent breath sounds and tactile fremitus on affected side

Medical Management Depends on the cause and severity Goal of Tx is to evacuate the air or blood from the pleural space. Chest tube is inserted near the second intercostal space Once the test tubes are inserted and suction is applied (20mmHg) effective decompression of the pleural cavity occurs. If an excessive amount of blood enters the chest tube in a relatively short period, an autotransfusion may be needed. (blood from the drainage is used.) Traumatic Open Pneumothorax calls for emergency interventions. Stopping the flow of air through the opening in the chest wall is a life-saving measure. Anything may be used that is large enough to fill the chest wound. If conscious, the Pt. is instructed to exhale and strain against a closed glottis. This action assist in expanding the lung and ejecting the air from the thorax Antibiotics are also prescribed to combat infection from contamination. The chest wall is opened(Thoracotomy) when more than 1500 ml of blood initially by thoracentesis or when chest tube output continues at greater than 200 ml /hour

Tension Pneumothorax Occurs when air is drawn into the pleural space from a lacerated lung or through a small hole in the chest wall. This may be a complication of other types of pneumothorax. In contrast to open pneumothorax, the air that enters the chest cavity with each inspiration is trapped; it can not be expelled during expiration through the air passages or the hole in the chest wall. A one-way valve effect occurs

Clinical Manifestations Air hunger Agitation Increasing hypoxemia, central cyanosis, hypotension, tachycardia and profuse diaphoresis Medical Management High concentration of supplemental Oxygen to treat the hypoxemia Pulse oxymetry shiuld be used to monitor oxygen saturation In an emergency situatio, a tension pneumothorax can be decompressed or quickly converted to a simple pneumothorax by inserting a large bore needle.

Or Pleuritis -refers to inflammation of both layers of the pleura (parietal and visceral). Collagen Disease Pulmonary Embolism Metastatic Cancer Post thoracotomy

URTI

TB

Clinical Manifestation Pleuritic pain in relation to respiratory movement (deep breathing, coughing or sneezing worsens pain) Pain maybe minimal or absent when the breath is held or it may be localized or radiate to the shoulder or abdomen. Later as pleural fluid develops, the pain decreases. Assessment Pleural Friction Rub can be heard with the stethoscope, it disappears when more fluid accumulates Dx: Xrays, sputum examinations, thoracentesis

Medical Management The objectives of tx are to discover the underlying conditon causing the pleurisy and to relieve the pain. When the underlying disease is treated, the pleuritic inflammation usually resolves. Pharmacologic pain measures may be utilized.

Nursing Management The nurse can offer suggestion in pain management and enhance comfort: turning frequently to the side affected side to splint the chest wall and reduce stretching of the pleura The nurse can also teach the patient to use the hands or pillow to splint the rib cage while coughing.

Nurses Roles

Direct Care Provider Teacher

y Teaching about the disease process and care of the

client.

Counselor
y Your patient may feel depressed, fearful, and

anxious because of the debilitating effects of the lung restriction and ever-present dyspnea. Encourage him to talk about his feelings and seek spiritual counsel if he wishes, coach him in coping skills

Patient Advocate
y The nurse can speak for the client in terms of having

the clients rights to safe and quality care

Mans Uniqueness

The patient and family will have unique learning needs, it is the nurses role to provide for this uniqueness. The care and teaching should be individualized. Although the care principles given are often generalized, the nurse should tailor this to the individual client. The nurse should also note that all person have their own unique culture. Communication is also part of the uniqueness of man, the nurse should note on the verbal and non verbal communication aspects of the client.