Management of Patients with
Lower Respiratory Problems

Chapter 28

Acute Bronchitis
An inflammation of the bronchi in the lower
respiratory tract
Clinical Manifestations
Cough, Headache, Malaise, SOB, Fever, Dyspnea,
Normal Breath Sounds or Wheezes, Chest Pain
Nursing Care
Supportive i.e. fluids, rest, cough suppressants,
bronchodilators, inhaled corticosteroids

Pneumonia
• Acute inflammation of the lung parenchyma

Types of Pneumonia
• Community Acquired (CAP)
– Before hospitalization

• Medical Care-Associated (MCAP)
– Encompasses 3 forms (HAP, VAP, & HCAP)

• Hospital Acquired (HAP)
– Within 48 hrs or longer after admission

• Ventilator associated pneumonia (VAP)

–

48-72 hours after intubation

• Health Care-Associated (HCAP)
– In hospital for 2 days/longer w/in 90 days, resided in long-term care facility, IV anti bx, chemo, or wound care w/in 30 days, attended hospital or dialysis clinica

Types of Pneumonia-cont
• Aspiration-pathogens in oral mucosa, loss of
consciousness
• Opportunistic-altered immune system
– Cytomegalovirus (CMV)
– Pneumocystis jiroveci (PCP)

Pneumonia
Predisposition: Normal defense mechanisms
overwhelmed by a virus or infectious agent
??What Are the Risk Factors??

Case Study
iStockphoto/Thinkstock

• D.T. is an 88-year-old woman who lives
alone.
• She has been feeling weaker over past 2
days.
• Last night became confused and
disoriented.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
iStockphoto/Thinkstock

• Her housekeeper notified her daughter, who
brought D.T. to the clinic.
• She complains of coughing over the past 3 days.
• She has a history of mild heart failure that is
treated medically but has no other significant
health disorders.
• She last saw her health care provider 4 months
ago.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
iStockphoto/Thinkstock

1.What are D.T.’s risk factors for
pneumonia?
2.Based on her history, what type of
pneumonia would you suspect D.T. has?

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
iStockphoto/Thinkstock

1. What clinical manifestations of
pneumonia is D.T. displaying?
2. For what other clinical manifestations
would you assess D.T. ?
3. What diagnostic tests would you expect
the nurse practitioner in the clinic to
order?

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Pneumonia
Clinical Manifestations:
• Most Common
–

•
•

Cough, fever, shaking, chills, dyspnea, tachypnea, pleuritic chest pain, sputum (green, yellow, rust-colored)

Change in mentation for older or debilitated patients
Physical Exam Findings:
–

Rhonchi and crackles,
– Bronchial breath sounds
– Egophony

– ↑ Fremitus
– Dullness to percussion if pleural effusion present

Pneumonia
• Diagnostic Tests:
–
–
–
–
–
–

History
Physical examination
Chest x-ray
Sputum analysis
CBC with differential
Pulse oximetry or ABGs

–Blood cultures
–Thoracentesis
–Bronchoscopy with
washings
–Biologic markers to guide
clinical decisions:
• C-reactive protein (CRP)
• Procalcitonin

Case Study
iStockphoto/Thinkstock

• D.T.’s chest x-ray reveals consolidation in
her left lower lobe, consistent with
pneumonia.
• Her WBC is 17,000/μL (17 × 109/L) with an
increased number of bands.
• Her electrolytes and BNP are within
normal limits.
• Sputum gram stain shows gram-positive
diplococci and many WBCs.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
iStockphoto/Thinkstock

• Because of her age and altered mentation, the
health care provide...

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