1. upper respiratory airway
1) [Pediatric] spasmodic laryngitis
2) [Pediatric] epiglottitis
| – bacterial form of croup, which may be caused by Haemophilus influenza type b or Streptococcus pneumoniae | – large, cherry red, edematous epiglottis
– 4D: dyspnea, dysphonia, dysphagia, drooling – tripod positioning : While supporting the body with the hands, the child leans forward, thrusts the chin forward and opens the mouth in an attempt to widen the airway – high fever |
– Avoid placing the child in a supine position. Place the child in tripod position.
– Do not leave the child unattended. Do not restrain the child or take any other measure that may agitate the child. Insertion of an IV line may need to be delayed until an adequate airway is established because this procedure may agitate the child. – Provide cool mist oxygen therapy as prescribed. High humidification cools the airway and decreases swelling. – If epiglottis is suspected, no attempts should be made to visualize the posterior pharynx, obtain a throat culture, or take an oral temperature. – Maintain NPO status. – Isolation precautions should be implemented for a hospitalized child with an upper respiratory infection until the cause of the infection is known. |
3) [Pediatric] laryngo/trachea/bronchitis
| – inflammation of the larynx, trachea, and bronchi
– most common type of croup – RSV: RSV, although not airborne, is highly communicable and is transferred by direct contact with respiratory secretions (contact precaution). The identification of the virus is done via testing of nasal or nasopharyngeal secretions. |
– Provide and encourage fluid intake.
– Teach the parents to avoid administering cough syrups or cold medicines, which may dry and thicken secretions. – Prevention measures include using good hand-washing, avoiding tobacco smoke exposure, administering palivizumab (Synagis), and encouraging breastfeeding. |
4) ★ [Pediatric] otitis media
| – Otitis is an inflammatory disorder usually caused by an infection of the middle ear occurring as a result of a blocked eustachian tube, which prevents normal drainage. It is a common complication of an acute respiratory infection (associated with Hib). It most often occurs between ages 6 to 24 months.
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– fever
– crying – rolling of the head from side to side, pulling on or rubbing the ear
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– Have the child lie with the affected ear down.
– Instruct the child to avoid chewing as much as possible during the acute period because of chewing increases pain. Provide local heat or cold as prescribed to relieve pain. – Instruct the parents to clean drainage from the external ear canal with sterile swabs or gauze. – To administer ear medications in a child younger than age 3 years, pull the ear lobe down and back. In a child older than 3 years, pull the pinna up and back. |
5) [Pediatric] tonsillitis
| – Tonsillitis refers to inflammation and infection of the tonsils, which is lymphoid tissue located in the pharynx.
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– sore throat, difficulty in swallowing, enlarged and bright red tonsils that may be covered with white exudate, an unpleasant mouth odor | – tonsillectomy
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2. lower respiratory airway
1) ★ TB (tuberculosis)
| – Highly communicable disease caused by Mycobacterium tuberculosis
– Via the airborne route by droplet infection. – high risk: HIV, steroid 치료 받는 사람, crowded area에 사는 사람 – After the infected individual has received tuberculosis medication for 2 to 3 weeks, the risk of transmission is reduced greatly. |
– maybe asymptomatic in primary infection
– persistent cough and production of sputum, which is occasionally streaked with blood – chest tightness – low-grade fever, chills, night sweats – fatigue, lethargy, anorexia, weight loss – A sputum culture identifying M. tuberculosis confirms the diagnosis. After medications are started, sputum samples are obtained every 2 to 4 weeks to determine the effectiveness of therapy. Most clients have negative cultures after 3 months of treatment. When the results of three sputum cultures are negative, the client can return to former employment. – QuantiFERON-TB Gold test: a blood analysis test by an ELISA (enzyme), a sensitive and rapid test that assists in diagnosing the client – TST (Tuberculin Skin Test): A positive reaction does not mean that active disease is present but indicates previous exposure to tuberculosis or the presence of inactive (dormant) disease. Induration = 15 or > 15mm, considered positive in any person. Induration = 5 or > 5mm, considered positive in HIV infected persons, recent contact of a person with TB disease, persons with prior TB, persons immunosuppressed for other reasons. TST should not be done at the same time as measles immunization. – A chest x-ray is necessary to rule out active tuberculosis or to detect old healed lesions. |
– The client with active TB is placed under airborne isolation precautions in a negative-pressure room; to maintain negative pressure, the door of the room must be tightly closed. The room should have at least six exchanges of fresh air per hour and should be ventilated to the outside environment, if possible.
– The nurse wears a particulate respirator (a special individually fitted air-purifying N95 or N100 mask) when caring for the client and a gown when the possibility of clothing contamination exists. – If the client needs to leave the room for a test or procedure, the client is required to wear a surgical mask. |
– client education: Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand. Advise the client that the medication regimen is continued over 6 to 12 months depending on the situation. Advise the client of the side/adverse effects of the medication and ways of minimizing them to ensure compliance. Inform the client to resume activities gradually. Instruct the client about the need for adequate nutrition and a well-balanced diet to promote healing and to prevent recurrence of the infection. Instruct the client to increase the intake of foods rich in iron, protein, and vitamin C. Inform the client and family that respiratory isolation is not necessary because family members already have been exposed. TB 환자가 뱉은 가래는 tissue에 뱉은 후 plastic bag에 봉인 후 정해진 곳에.
2) ★ pneumonia
| – Infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles.
– Viral pneumonia, aspiration pneumonia is needed standard precaution. Bacterial pneumonia, primary atypical pneumonia is needed droplet precaution. – high risk: old age, smoking, alcohol, immobility, COPD, asthma, DM, immunodeficiency – complication: acute respiratory failure, shock, meningitis, pericarditis, endocarditis |
– inflammation + hypoxia
– sputum production (productive cough), use of accessory muscles for breathing (retraction) – pleuritic pain – chills, elevated temperature, HR ↑, RR ↑, BP ↓ – rhonchi and wheezes, crackle – The chest x-ray film shows lobar or segmental consolidation, pulmonary infiltrates, or pleural effusion. – A sputum culture identifies the organism. 가래 검사가 확진임. – The white blow cell count and the erythrocyte sedimentation rate are elevated. – M/S change – tactile fremitus ↑, bronchial sound, dullness |
– Place the client in a semi-Fowler’s position to facilitate breathing and lung expansion. Encourage the client to lie on the affected side to splint the chest and reduce the discomfort caused by pleural rubbing.
– Encourage coughing and deep breathing and use of the incentive spirometer. Provide PCT. M/S 없으면 suction. – Provide a balance of rest and activity, increasing activity gradually. – Administer oxygen as prescribed. – Administer antibiotics as prescribed. Administer antipyretics, bronchodilators, cough suppressants, mucolytic agents, and expectorants as prescribed. – Perform nasotracheal suctioning if the client is unable to clear secretions. |
– client education: Prevent the spread of infection by hand washing and the proper disposal of secretions. Provide a high- calorie, high-protein diet with small frequent meals. Encourage fluids, up to 3L/day, to thin secretions unless contraindicated. To avoid chilling and exposure to individuals with respiratory infections or viruses. To notify the HCP if chills, fever, dyspnea, hemoptysis, or increased fatigue occurs.
3) 폐농양
4) atelectasis
| – A postoperative complication that usually occurs 1 to 2 days after surgery. A collapsed or airless state of the lung that may be the result of airway obstruction caused by accumulated secretions of failure of the client to deep-breathe or ambulate about after surgery. |
5) [Pediatric] cystic fibrosis
| – The mucus produced by the exocrine glands is abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs, particularly in the respiratory, gastrointestinal, and reproductive systems. This is a chronic multisystem disorder, characterized by exocrine gland dysfunction.
– autosomal recessive disease |
– Common symptoms are associated with progressive chronic lung disease as a result of infection, pancreatic enzyme deficiency, and pancreatic fibrosis caused by duct blockage and sweat gland dysfunction resulting in increased sodium and chloride sweat concentrations.
– clubbing of the fingers, barrel chest – steatorrhea – Sweat chloride test |
– Goals of treatment include preventing and treating pulmonary infection by improving aeration, removing secretions, and administering antibiotic medications.
– A child with cystic fibrosis requires a high-calorie, high-protein, and well-balanced diet to meet energy and growth needs. Multivitamins and vitamins A, D, E, and K are also administered. Increase in fluids. |
3. ★ COPD (Chronic Obstructive Pulmonary Disease)
| – COPD is a disease state characterized by airflow obstruction caused by emphysema or chronic bronchitis. Progressive airflow limitation occurs, associated with an abnormal inflammatory response of the lungs that is not completely reversible.
– high risk: smoking, air pollution, chronic respiratory infection, genetic factor, a-1 antitrypsin – complication : pneumonia (rusty + productive cough), pulmonary hypertension, cor-pulmonale |
– exertional dyspnea, prolonged expiration (inhale : exhale = 1 : 3), use of accessory muscles for breathing, orthopnea, cough with sputum production
– wheezing and crackles – barrel chest: increased AP diameter – weight loss – ABG: respiratory acidosis, hypoxemia – polycythemia = erythrocytosis – X-ray: congestion and hyperinflation – pulmonary function test: decreased vital capacity |
– Place the client in a Fowler’s position and leaning forward to aid in breathing.
기침 시 베개를 배에. – Instruct the client in diaphragmatic or abdominal breathing techniques and pursed-lip breathing techniques, which increase airway pressure and keep air passages open, promoting maximal carbon dioxide expiration. Huff coughing. – Allow activity as tolerated. Adhere to activity limitations, alternating rest periods with activity. – Administer a low concentration of oxygen (1∼2L/min) as prescribed; the stimulus to breathe is a low arterial PO2 instead of an increased PCO2. – Administer bronchodilators as prescribed, and instruct the client in the use of oral and inhalant medications. Administer corticosteroids (for exacerbations), mucolytics, antibiotics as prescribed. |
– client education: Stop smoking. Encourage small, frequent meals to maintain nutrition and prevent dyspnea. Provide a high-calorie, high-protein, high-fat, and low-carbohydrate diet with supplements. Avoid eating gas-producing foods, spicy foods, and extremely hot or cold foods. Encourage fluid intake up to 3000mL/day to keep secretions thin, unless contraindicated. Avoid exposure to individuals with infections and avoid crowds. Avoid fireplaces, pets, feather pillows, and other environmental allergens. 환자가 퇴원하기 전에 미리 집 청소. Avoid extremes in temperatures. When dusting, use a wet cloth. 규칙적 운동. 매년 influenza 예방접종.
1) chronic bronchitis
2) bronchiectasis
| – dyspnea, chronic cough, purulent sputum, hemoptysis, foul breathing
– wheezing, crackles, rhonchi – fatigue, anorexia – clubbing finger |
3) emphysema
4) empyema
| – Collection of pus within the pleural cavity | – dyspnea, cough
– chest pain – anorexia – elevated temperature, night sweats |
– Place the client in a semi-Fowler’s or high Fowler’s position.
– Instruct the client to splint the chest as necessary. – Encourage coughing and deep breathing. – Administer antibiotics as prescribed. -Assist with thoracentesis or chest tube insertion to promote drainage and lung expansion. – If marked pleural thickening occurs, prepare the client for decortication. |
4. pleural cavity
1) pleurisy
| – Inflammation of the visceral and parietal membranes; may be caused by pulmonary infarction or pneumonia. | – dyspnea
– knifelike pain aggravated on deep breathing and coughing |
– Instruct the client to lie on the affected side to splint the chest.
– Encourage coughing and deep breathing. – Administer analgesics as prescribed. |
2) pleural effusion
| – pleural effusion is the collection of fluid in the pleural space. | – progressive dyspnea, non-productive cough
– pleuritic pain – decreased breath sounds over the affected area |
– Place the client in a Fowler’s position.
– Encourage coughing and deep breathing. – Prepare the client for thoracentesis. – If pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as prescribed. |
5. cancer
1) laryngeal cancer
2) lung cancer
6. trauma
1) epistaxis
2) rib fracture
| – pain at the injury site that increases with inspiration
– shallow respirations – client splints chest – tenderness at the site |
– Note that the ribs usually reunite spontaneously.
– Place the client in a Fowler’s position. |
3) flail chest
| – severe pain in the chest
– paradoxical respiration, dyspnea, cyanosis – shallow respiration, diminished breath sounds – tachycardia, hypotension |
– Maintain the client in Fowler’s position.
– Encourage coughing and deep breathing. – Maintain bed rest and limit activity to reduce oxygen demands. – Administer humidified oxygen as prescribed. – Prepare for mechanical ventilation with PEEP if required. |
4) pulmonary contusion
| – dyspnea
– decreased breath sounds – hemoptysis, increased bronchial secretions |
– similar to flail chest nursing |
5) ★ pneumothorax
| – accumulation of atmospheric air in the pleural space
– spontaneous pneumothorax open pneumothorax tension pneumothorax: trachea deviated to the unaffected side |
– sharp chest pain
– dyspnea, cyanosis – absent breath sounds on the affected side, tactile fremitus ↓, excursion ↓ hyper resonance – tachycardia, BP ↓, RR ↑, JVD – open pneumothorax 시 sucking sound |
– Maintain the client in Fowler’s position.
– Administer oxygen as prescribed. – Prepare for chest tube placement. – Monitor the chest tube drainage system. |
7. acute
1) ★ asthma: completely reversible
| – Chronic inflammatory disorder of the airways that causes varying degrees of obstruction in the airways
– Status asthmaticus is a severe life-threatening asthma episode that is refractory to treatment and may result in pneumothorax, acute cor pulmonale, or respiratory arrest. |
– tachypnea with hyperventilation,
prolonged exhalation, wheezing or crackles, dyspnea, nonproductive cough diminished lung sounds, use of accessory muscles for breathing, cyanosis – tachycardia – restlessness – diaphoresis – ventilatory failure and asphyxia (질식) |
– Position the client in a high Fowler’s position or sitting to aid in breathing.
– Administer oxygen as prescribed. – Administer bronchodilators, corticosteroids as prescribed. – Stay with the client to decrease anxiety. – Record the amount, color, and consistency of sputum, if any. – Auscultate lung sounds before, during, and after treatments. – CPT strengthens the respiratory musculature and produces more efficient breathing patterns. However, CPT is not recommended during an acute exacerbation. |
– Client education: On the intermittent nature of symptoms and the need for long-term management. To identify possible triggers and measures to prevent episodes. Teach the child and parents about measures to prevent and reduce exposure to allergens. Avoid extremes of environmental temperature. Encourage adequate rest, sleep, and a well-balanced diet. Instruct the child on the importance of adequate fluid intake to liquefy secretions. Assist in developing an exercise program. About the management of medication and proper administration. About the correct use of a peak flow meter. About developing an asthma action plan with the primary HCP and what to do if an asthma episode occurs.
2) acute respiratory failure
| – This occurs when insufficient oxygen is transported to the blood or inadequate carbon dioxide is removed from the lungs and the client’s compensatory mechanisms fail. In oxygenation failure or hypoxemic respiratory failure, oxygen may reach the alveoli but cannot be absorbed or used properly, resulting in a PaO2 lower than 60mmHg, SaO2 lower than 90%, or PaCO2 greater than 50mmHg occurring with acidemia. | – dyspnea, alterations in respirations and breath sounds
– headache, restlessness, confusion, decreased level of consciousness – tachycardia, dysrhythmias – hypertension |
– Maintain the client in Fowler’s position.
– Encourage deep breathing. – Administer oxygen to maintain the PaO2 level higher than 60 to 70mmHg. – Prepare the client for mechanical ventilation. – Administer bronchodilators as prescribed. |
3) ARDS (Acute Respiratory Distress Syndrome)
| – A form of acute respiratory failure that occurs as a complication of some other condition; it is caused by a diffuse lung injury and leads to extravascular lung fluid. | – earliest sign: tachypnea
– dyspnea, deteriorating ABG levels, decreased breath sounds, pulmonary infiltrates – late sign: crackle |
– Maintain the client in Fowler’s position.
– Administer oxygen as prescribed. – Prepare the client for mechanical ventilation using PEEP. – Restrict fluid intake as prescribed. – Administer diuretics, anticoagulants, or corticosteroids as prescribed. |
4) ★ pulmonary embolism
| – Occurs when a thrombus forms (most commonly in a deep vein), detaches, travels to the right side of the heart, and then lodges in a branch of the pulmonary artery. | – cough with blood-tinged sputum, dyspnea, cyanosis, tachypnea
– chest pain (특히 흡기 시) – apprehension and restlessness, feeling of impending doom, diaphoresis – distended neck veins, JVD, hypotension, tachycardia – petechiae over the chest and axilla – crackles and wheezes – BT ↑ |
– Notify the RRT.
– Reassure the client. – Elevate the head of the bed. – Prepare to administer oxygen. – Obtain V/S and check lung sounds. – Prepare to obtain an ABG. – Prepare for the administration of heparin therapy or other therapies, such as embolectomy or placement of a vena cava filter if necessary. – Finally, the nurse documents the event, interventions are taken, and the client’s response to treatment. |
5) pulmonary HTN
| – short of breath, non-productive cough
– chest pain – dizziness, lethargy, fatigue – swelling leg, peripheral edema |
8. infection
1) influenza (also known as the flu)
| – highly contagious acute viral respiratory infection
– high risk: 어린아이, 노인, 면역력 감소, 단체 생활 |
– acute onset of fever
– sore throat, cough, rhinorrhea – headache, muscle aches, myalgia – fatigue, weakness, anorexia, nausea, vomiting, malaise – facial pain은 아님: 이 경우는 중이염 등의 complication |
– Yearly vaccination is recommended to prevent the disease. The vaccination is contraindicated in the individual with egg allergies.
– Additional prevention measures include avoiding those who have developed influenza, frequent and proper handwashing, and cleaning and disinfecting surfaces that have become contaminated with secretions. – Encourage rest. – Administer antiviral medications as prescribed. Provide supportive therapy. – Encourage fluids to prevent pulmonary complications. |
2) Legionnaire’s disease
| – Acute bacterial infection caused by Legionella pneumophila. Sources of the organism include contaminated cooling tower water and warm stagnant water supplies, including water vaporizers, water sonicators, whirlpool spas, and showers. |
3) histoplasmosis
| – Pulmonary fungal infection caused by spores of Histoplasma capsulatum. Spores are usually found in bird droppings. | – Positive skin test for histoplasmosis
– Positive agglutination test |
4) sarcoidosis
| – Presence of epithelioid cell tubercles in the lung.
– The cause is unknown, but a high titer of Epstein-Barr virus may be noted. |
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