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SECTION 5 Problems of Oxygenation: Ventilation

Oxygen therapy, hydration, nutritional support, and therapeutic

positioning are part of your nursing management.
AMBULATORY AND HOME CARE. Teach the patient about the
importance of taking every dose of the prescribed antibiotic, any
drug-drug and food-drug interactions for the prescribed antibiotic, and the need for adequate rest to maintain progress toward
recovery. Tell patients that it may be several weeks before their

usual vigor and sense of well-being return. A prolonged period

of convalescence is especially necessary for the older adult or
chronically ill patient.
Teaching should also include information about available
influenza and pneumococcal vaccines. Patients can receive the
pneumococcal vaccine and influenza vaccine at the same time
in different arms.

NURSING CARE PLAN 28-1

Patient with Pneumonia
NURSING DIAGNOSIS
PATIENT GOALS

Impaired gas exchange related to fluid and exudate accumulation at the capillary-alveolar membrane as evidenced by
decreased breath sounds, abnormal arterial blood gases, restlessness, confusion, and somnolence.
1. Maintains adequate alveolar oxygen-carbon dioxide exchange
2. Clears lungs of fluids and exudates

OUTCOMES (NOC)
Respiratory Status: Gas Exchange

INTERVENTIONS (NIC) AND RATIONALES

Respiratory Monitoring

Auscultate breath sounds, noting areas of decreased/absent ventilation, and presence of adventitious
sounds to obtain ongoing data on patients response to therapy.
Monitor rate, rhythm, depth, and effort of respirations to determine respiratory status.
Monitor for increased restlessness, anxiety, and air hunger to detect increasing hypoxemia.
Monitor patients ability to cough effectively to promote secretion removal.

PaO2 _____
PaCO2 _____
Oxygen saturation _____
Chest x-ray findings _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range

Dyspnea at rest _____

Dyspnea with mild exertion _____
Restlessness _____
Cyanosis _____

Oxygen Therapy
Administer supplemental oxygen as ordered to promote adequate oxygenation.
Set up oxygen equipment and administer through a heated, humidified system to prevent drying of the
respiratory tract.
Monitor the effectiveness of oxygen therapy (e.g., pulse oximetry, ABGs).
Monitor patients anxiety related to need for oxygen therapy to provide explanations and reassurance.
Periodically check oxygen delivery device to ensure that the prescribed concentration is being delivered.

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

NURSING DIAGNOSIS

Ineffective breathing pattern related to inflammation and pain as evidenced by dyspnea, tachypnea, nasal flaring, altered
chest excursion
Demonstrates effective respiratory rate, rhythm, and depth of respirations

PATIENT GOAL
OUTCOMES (NOC)
Respiratory Status: Ventilation

Respiratory rate _____

Respiratory rhythm _____
Tidal volume _____
Depth of inspiration _____

Measurement Scale
1 = Severe deviation from normal range
2 = Substantial deviation from normal range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range

Dyspnea at rest _____

Restlessness _____
Somnolence _____
Impaired cognition _____

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

INTERVENTIONS (NIC) AND RATIONALES

Ventilation Assistance
Monitor respiratory and oxygenation status to determine change in status.
Position to minimize respiratory efforts (e.g., elevate the head of the bed and provide overbed table
for patient to lean on) to reduce oxygen needs.
Encourage slow deep breathing, turning, and coughing to promote effective breathing pattern.
Monitor for respiratory muscle fatigue to provide additional support if needed.
Assist with incentive spirometer as appropriate to promote alveolar ventilation.
Administer medications (e.g., bronchodilators and inhalers) that promote airway patency and gas
exchange.

CHAPTER 28 Lower Respiratory Problems

553

NURSING CARE PLAN 28-1contd

Patient with Pneumonia
NURSING DIAGNOSIS

Acute pain related to inflammation and ineffective pain management and/or comfort measures as evidenced by patient report
of pleuritic chest pain and presence of pleural friction rub, shallow respirations
Reports control of pain following relief measures

PATIENT GOAL
OUTCOMES (NOC)
Pain Control

Reports pain controlled _____

Described causal factors _____
Uses nonanalgesic relief measures _____
Uses analgesics appropriately _____

Measurement Scale

1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated

INTERVENTIONS (NIC) AND RATIONALES

Pain Management
Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency,
quality, intensity or severity of pain, and precipitating factors to determine appropriate interventions.
Encourage patient to monitor own pain and to intervene appropriately to allow independence and prepare
for discharge.
Teach use of nonpharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction,
and massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and
along with other pain relief measures to relieve pain and reduce the need for analgesia.
Use pain control measures before pain becomes severe because mild to moderate pain is controlled
more quickly.
Medicate before an activity to increase participation, but evaluate the hazard of sedation to help minimize
pain that will be experienced.

EVALUATION
The expected outcomes for the patient with pneumonia are presented in NCP 28-1.

TUBERCULOSIS
Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. It usually involves the lungs, but can also
occur in other parts of the body. TB is the worlds second most
common cause of death from infectious disease, after HIV/
acquired immunodeficiency syndrome (AIDS).1 Worldwide,
TB occurs disproportionately in the poor, the underserved,
and minorities. In the United States persons at risk include the
homeless, residents of inner-city neighborhoods, foreign-born
persons, older adults, those in institutions (long-term care facilities, prisons), IV injecting drug users, persons at poverty level,
and those with poor access to health care.12 Immunosuppression from any etiology (e.g., HIV infection, malignancy, longterm corticosteroid use) increases the risk of TB infection. The
prevalence of TB is higher in areas of the United States where
there is a large population of Native Americans, such as Arizona
and New Mexico (see Cultural and Ethnic Health Disparities
box). Health care workers with increased exposure to TB are
considered at high risk.
The incidence of TB worldwide declined until the mid-1980s
when HIV disease emerged. The major factors that have contributed to the resurgence of TB have been (1) high rates of TB
among patients with HIV infection and (2) the emergence of
multidrug-resistant (MDR) strains of M. tuberculosis. The rates
of TB are now slowly declining again.
Once a strain of M. tuberculosis develops resistance to isoniazid and rifampin, it is defined as multidrug-resistant tuberculosis
(MDR-TB). Resistance results from several problems, including
incorrect prescribing, lack of public health case management,
and patient nonadherence to the prescribed regimen.13

Etiology and Pathophysiology

M. tuberculosis is a gram-positive, acid-fast bacillus that is usually spread from person to person via airborne droplets produced by speaking and coughing. Brief exposure to a few tubercle
bacilli rarely causes an infection. TB is more commonly spread
by repeated close contact (within 6 inches of the persons mouth)

CULTURAL AND ETHNIC HEALTH

DISPARITIES
Tuberculosis
Of the reported TB cases in the United States, 82% occur in racial and
ethnic minorities.
Asians have the highest TB rate of any ethnic group in the United
States. Native Hawaiian and other Pacific Islanders have the secondhighest TB rate.
African Americans have 45% of the TB cases in U.S.-born persons.
Of all the TB cases in the United States, 59% occur in foreign-born
persons. This rate is 10 times higher than U.S.-born persons.
The percentage of foreign-born persons with multidrug-resistant TB
has increased from 25% in 1993 to 77% in 2008.
Eleven U.S. states (California, Connecticut, Hawaii, Iowa, Massachusetts, Minnesota, Nebraska, New Hampshire, New Jersey, Utah, and
Vermont) have 70% of their total cases of TB among foreign-born
persons.
Source: Centers for Disease Control and Prevention: Reported tuberculosis
in the United States. Available at www.cdc.gov/tb/statistics/reports/2008/
default.htm.

with the infected person. TB is not highly infectious, and transmission usually requires close, frequent, or prolonged exposure.
The disease cannot be spread by hands, books, glasses, or dishes.
The very small droplets, 1 to 5 m in size, contain M. tuberculosis. Because they are so small, the particles remain airborne
indoors for minutes to hours. Once inhaled, these small particles
lodge in the bronchiole and alveolus. Factors that influence the
likelihood of transmission include the (1) number of organisms expelled into the air, (2) concentration of organisms (small
spaces with limited ventilation would mean higher concentration), (3) length of time of exposure, and (4) immune system of
the exposed person. M. tuberculosis replicates slowly and spreads
via the lymphatic system. The organisms find favorable environments for growth primarily in the upper lobes of the lungs, kidneys, epiphyses of the bone, cerebral cortex, and adrenal glands.

Classification
The classification system for TB14 is presented in Table 28-8. TB
infection occurs when the bacteria are inhaled but there is an
effective immune response and the bacteria become inactive.
The majority of people mount effective immune responses to