OXYGENATION CONCEPT

RESPIRATORY SYSTEM

Prepared By: Bongits Amoyen, MAN,RN.

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Information and concepts of this learning material are excerpts from

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 Review of
Anatomy and Learning Outcomes
Physiology
1. Review the anatomy and physiology of respiratory system.
2. Identify different parts of respiratory system.
3. Learn description of various parts of respiratory system.
4. Understand the general and specific functions of respiratory system.

General Function 1. Promote adequate gas exchange of oxygen or carbon dioxide.

2. Bring oxygen into our bodies (called inspiration, or inhalation) and send carbon dioxide out
(called expiration, or exhalation).
3. Pulmonary ventilation, external respiration, transport of respiratory gases and internal
respiration.

Anatomy and Physiology

PARTS DESCRIPTION FUNCTION
Upper Respiratory Tract Structures of the respiratory system, primarily an air conductions system, include
the nose, pharynx and larynx. Air is filtered, warmed and humidified in the upper
airway before passing to lower airway.
1. Nose External nose is a framework of bone and cartilage, internally divided in to two Air enters the system through the nares.
passages or nares (nasal cavities) by the septum. The major functions of the nose are warming, moistening
The septum is covered with a mucous membrane, where the olfactory receptors and filtering the air.
are located. Turbinates, located internally, assist in warming and moistening the
air.

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2. Pharynx Muscular passageway commonly called the throat. Air passes through the nose to the pharynx.
Composed of three sections:

a. Nasopharynx – located above the soft palate of the mouth, contains the
adenoids and openings to the Eustachian tube.
b. Oropharynx – located directly behind the mouth and tongue, contains
palatine tonsils, air and food enter body through oropharynx.
c. Laryngopharynx – extends from the epiglottis to the 6th cervical level.

3. Larynx Sometimes called “voice box”, connects upper and lower airways; framework is Larynx open to allow respirations and closes to prevent
formed by the hyoid bone, epiglottis, and thyroid, cricoids and arytenoids aspirations when food passes through the pharynx.
cartilages. The opening of the larynx called as glottis. Vocal cord of the larynx permit speech and are involved in
the cough reflex.

Lower Respiratory Tract Consists of the trachea, bronchi and branches and lungs and associated
structures.
1. Trachea Extends from the larynx to the 2nd costal cartilage, where it bifurcates and is Air moves from the pharynx to larynx to trachea.
supported by 16 to 20 C-shaped cartilage rings.
The area where trachea divides into 2 branches called the carina.

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2. Bronchi Formed by the division of the trachea into 2 branches.

a. Right Main Stem Bronchus – larger and straighter than the left, further To supply the 3 lobes of right lung.
divides into 3 lobar branches (upper, middle and lower lobar bronchi).
b. Left Main Stem Bronchus – Divides into upper and lower lobar bronchi.
To supply the 2 lobes of left lung.
Bronchiole – A bronchus that is reaches 1mm in diameter is no longer has
connective tissue sheath.

3. Bronchioles In the bronchioles, airway patency is primarily dependent upon elastic recoil Distal to the terminal bronchioles the major function is no
formed by network of smooth muscles. longer air conduction, but gas exchange between blood and
The tracheobronchial tree ends at the terminal bronchioles. alveolar air. The respiratory bronchioles serve as the
transition to the alveolar epithelium.

4. Lungs (left and right) The main organ of respiration, lie within the thoracic cavity on either side of the Where air and gas exchanges take place.
heart.
Broad area of lung resting on diaphragm is called the base, the narrow, superior
portion is the apex.
Three lobes in right lung.
Two lobes in left lung.
Pleura – serous membrane covering the lungs, continuous with the parietal
pleura that line the chest wall.
Lungs associated structures are protected by chest wall.

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5. Chest Wall Includes the rib cage, intercostals muscles and diaphragm.
Parietal pleura lines the chest wall and secretes small amount of lubricating fluid This fluid holds the lung and chest wall together as a single
into the intrapleural spaces (space between visceral and parietal pleura). unit while allowing them to move separately.

The chest is shaped and supported by 12 pairs of ribs and

costal cartilages, the ribs have several attached muscles:

a. Contraction of the external intercostals muscles

raises the rib cage during inspiration and helps
increase the size of thoracic cavity.
b. The internal intercostals muscles tend to pull ribs
down and in and play a role in forced expiration.

Diaphragm – is the major muscle in ventilation (the

exchange of air between atmosphere and the alveoli).
Contraction of muscle fibers causes the dome of the
diaphragm to descend, thereby increasing the volume of
the thoracic cavity. As exertion increases, additional chest
muscles or even abdominal muscles may be employed in
the moving the thoracic cage.
Pulmonary Circulation Pulmonary arteries arise from the right ventricle of the heart and continue to the Provides for re-oxygenation of blood and release of carbon
bronchi and alveoli, gradually decreasing in size to capillaries. dioxide, gas transfer occurs in the pulmonary capillary bed.
The capillaries after contact, with the gas exchange surface of the alveoli, reform
to form the pulmonary veins.
The 2 capillary veins, superior and inferior, empty to the left atrium of the heart.

Gas Exchange Alveolar ducts arise from the respiratory bronchioles and lead to the alveoli. Alveoli are the functional cellular unit of the lungs, about
half a rise directly from the alveolar ducts and are
responsible for about 35% of alveolar gas exchange.

Alveoli produces surfactant, a phospholipid substance

found in the fluid lining the alveolar epithelium. Surfactant
reduces surface tensions and increases the stability of the

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alveoli and prevents their collapse.
Alveolar sacs form that last part of the of the airway,
functionally the same as the alveolar ducts, they are
surrounded by alveoli and are responsible for 65% of the
alveolar gas exchange.

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Diagnostic Learning Outcomes
Tests
1. Identify different diagnostic or laboratory tests that are applicable for respiratory disorders.
2. Understand description of diagnostic and laboratory tests for respiratory disorders.
3. Learn as to how each diagnostic and laboratory tests indicated appropriately.
4. Become skillful in preparing the patient scheduled for diagnostic and laboratory tests through
nursing considerations.

TEST DESCRIPTION INDICATION CONSIDERATION

1. Chest-Xray A chest radiograph, colloquially Detects condition such as atelectasis, 1. Remove metals such as piercings, eye
called a chest x-ray or chest film, is pleural effusion, infiltrates, glasses, buttons and jewelry.
a projection radiograph of the pneumothorax, lesions, mediastinal 2. Inform the physician for any implant
chest used to diagnose conditions shifts, pulmonary edema and chronic devices like pacemaker.
affecting the chest, its contents and obstructive pulmonary disease
nearby structures. (COPD).

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 TEST DESCRIPTION INDICATION CONSIDERATION
2. Computed Tomography Provides 3 dimensional picture Detects lung cancer. 1. Secure consent.
Scan (CT-Scan) that is 100 times more sensitive 2. Asks for seafoods allergies.
than a chest X-ray. 3. Inform the use of contrast medium or
radiopaque dye.
Uses contrast medium. 4. IV insertion with needle gauge of 18 or 19.
5. Prepare PNSS.
6. Inform side effects of contrast medium.
7. Assess for claustrophobia.
8. Instruct patient to lie still while on CT-
scan.
9. Assess for pulses in the injection site.
10. Assess for bleeding.

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 TEST DESCRIPTION INDICATION CONSIDERATION
3. Magnetic Resonance There is the presence of magnetic Identifies obstructed arteries and 1. Assess claustrophobia.
Imaging (MRI) field. tissue perfusion, but movement of 2. Instruct patient to remove all metals.
the heart and lungs reduces the 3. Instruct patient to inform the doctor for
images clarity. implanted metals if there is any.
4. Instruct to lie still while on MRI.
5. Painless.

TEST DESCRIPTION INDICATION CONSIDERATION

4. Collection of Sputum Specimen Analysis or assesses sputum Identify kinds of bacteria. Determine 1. Instruct to cleanse or brush teeth before
quantity, color, viscosity and odor, antibiotic sensitivity and resistance. going to sleep.
microbiological stain, culture and Identify neoplasms. 2. Prepare the sterile container for sputum
sensitivity, and cytologic collection.
examination. 3. Indicate label which includes complete
name and room number.
Culture and Sensitivity 4. Upon waking up the next morning, avoid
cleansing the mouth.
5. Assist patient in performing 3 deep
breathing exercises then cough.
6. Instruct patient and watcher to catch the
sputum by sterile container (1-3ml).
7. Send to laboratory together with the
requisition form.

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 TEST DESCRIPTION INDICATION CONSIDERATION
5. Pulmonary Function It measures lung volume, flow This test allows to measure: 1. Light dinner.
Test (PFT) rates and compliance. 2. Avoid caffeinated drinks or foods.
a. Forced Vital Capacity (FVC) – the 3. Do not smoke.
Spirometry amount of air that the patient forces 4. Avoid strenuous exercises 6 hours before
out of his lungs after a maximum the test.
inspiration. 5. Wear loses clothing.
6. Orient the patient with the use of
b. Forced Expiratory Volume in the spirometry:
first second (FEV1).
6.1. The mouthpiece attached to the
c. Peak Expiratory Flow Rate (PEFR) spirometer will places to patient’s
– how fast the patient can blow out mouth.
the air in his lungs. 6.2. After breathing normally patient
will be asks to slowly blow out
d. Forced Inspiratory Vital Capacity until the lungs are empty.
(FIVC) – the amount of air that 6.3. The patient will take a big deep
patient can take into his lungs. breath to fill up empty lungs
completely.
e. The shape of patient Flow Volume 6.4. As soon as patient’s lungs are full,
Loop (FVC + FIVC) – also provides patient will blow out as hard and
information to patient’s physician. as fast as patient can until lungs
are absolutely empty.
6.5. Patient will be asks to repeat the
test until there are three good
efforts.
TEST DESCRIPTION INDICATION CONSIDERATION
6. Exercise Stress Test Evaluates the ability to transport The test may show exactly where 1. Light breakfast or no food and fluids 2
oxygen and remove carbon dioxide breathing problems begin. They hours before the test.
with increasing metabolic demand. maybe begin in the lungs, heart or 2. No smoking for 8 to 12 hours before the
both. test.
3. No exercise in the morning before the
test.
4. Hold medications.

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 5. Inform the patient that might spirometry
test done.
6. Inform the patient, his blood pressure,
heart rate and breathing are examine.
7. When the test is over, keep the
mouthpiece in place until instructed to
remove it.
8. During the test, blood sample maybe
taken.

TEST DESCRIPTION INDICATION CONSIDERATION

7. Lung Scan Demonstrates ventilation and Use primarily to evaluate pulmonary 1. Inform patient to bring radiology results.
perfusion patterns. embolus. 2. Can eat and drink as normal.
3. IV insertion.
A lung scan can be a:

a. Ventilation scan look at how

air moves in and out of the
lungs. In particular, it looks
at how air moves through
the bronchi and bronchioles
within the lungs.

b. Perfusion scan looks at how

blood is flowing within the
lungs. The radioactive tracer
will fill the lungs unless
there is an area where air
cannot move.

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 c. The areas of the lungs where
radioactive tracer collects
greater amounts called “hot
spots”. The areas that do not
absorb the tracer and appear
less bright on the scan image
are referred to as “cold
spots”.
TEST DESCRIPTION INDICATION CONSIDERATION
8. Arterial Blood Gas Assess gas exchange. Decreased PaO2 may indicate 1. Check doctor’s order.
(ABG) Use to measure the partial hypoventilation, ventilation 2. Extract blood from artery.
pressure of oxygen (PaO2), carbon perfusion mismatch or shunting 3. Apply bandage.
pH – 7.35 to 7.45 dioxide (PaCO2), and the pH of an blood away from gas exchange site. 4. Gently rotates sample in test tube to mix
HCO3 – 22 to 26mEq/L arterial blood sample. Oxygen Increased PaCO2 reflects mark heparin with the blood.
PCO2 – 34 to 45mmHg content, oxygen saturation (SaO2) ventilation perfusion mismatch or 5. Send to pulmonary unit with paid
PaO2 – 80 to 100mmHg and bicarbonate (HCO3). hypoventilation. requisition form.
SaO2 – 93 to 100% Decreased PaCO2 reflects increase
alveolar ventilation.
Changes in pH may reflect metabolic
or respiratory dysfunction.

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 TEST DESCRIPTION INDICATION CONSIDERATION
9. Pulse Oximetry Non-invasive assessment of It produces photoplethysmogram. 1. No any special preparation.
arterial oxygen saturation. 2. Check the battery.
97 to 100% Is a medical device that indirectly 3. Check the functions of the device.
monitors the oxygen saturation of
a patient’s blood and changes in
blood volume in the skin.

TEST DESCRIPTION INDICATION CONSIDERATION

10. Bronchoscopy Direct visualization of trachea and It may be used to localize the site of 1. Check the doctor’s order.
mainstream, lobar, segmental and lung hemorrhage, visualizes masses 2. Secure consent.
subsegmental bronchi. in these airways and collect 3. NPO post midnight.
respiratory tract secretions. 4. Hold intake of blood thinner medications.
5. Inform physicians for medication
Serves for biopsy purposes. maintenance.
6. Sedative given as ordered.
Side Effects: 7. Inform the patient on the possibility of
1. Discomfort and coughing coughing. Irritation, short breathing
2. Lung leak or collapse during procedure.
3. Reduced oxygen 8. Inform the patient not to talk while tube is
4. Bleeding inside the lungs.
5. Hoarseness 9. Assess for gag reflex prior to food or water
6. Absence of gag reflex administration.

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 TEST DESCRIPTION INDICATION CONSIDERATION
11. Pleural Biopsy Obtains pleural tissue for Detect lung cancer. 1. Consent.
histologic examination and 2. Assist patient in sitting upright.
culture. 3. Cleanses the skin for biopsy site.
4. Anesthesia injected through the skin and
into the lining of the lungs and chest wall
(pleural membrane).
5. Larger hollow needle is then placed gently
through the skin into the chest cavity
(sometimes with the aid of UTZ or
imaging guide).
6. A smaller cutting needle inside the hollow
one is used to collect tissue samples.
During this part of the procedure, instruct
patient to hum or sya “eee”. This helps
prevent air from getting into the chest
cavity which causes the lung to collapse.
Usually, 3 or more biopsy samples are
taken.
7. When the test is done, bandage or
vaselinized OS is placed over the biopsy
site.
TEST DESCRIPTION INDICATION CONSIDERATION
12. Pulmonary Artery The injection of dye into the Locate pulmonary embolism. 1. Check doctor’s order.
Angiography pulmonary artery. It is done to Show bulging blood vessels. 2. Secure consent.
look at blood vessels that have Arteriovenous malformation. 3. No food and drinks before the procedure.
problems. Heart and blood vessel problems 4. Assess for seafood allergies.
present at birth. 5. IV insertion, PNSS
This is considered the gold Foreign body in a blood vessel. 6. Empty bladder before the procedure.
standard for diagnosing Narrowing of blood vessel wall. 7. Inform patient of the side effects of
pulmonary emboli. contrast medium.
8. Assess for bleeding, nerve injury and
Used of dye. swelling or hematoma at IV site.
9. Check pulses.

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 10. Assess for blood clot.
11. Assess for infection.
12. Inform the doctor for any
taken medicines.
TEST DESCRIPTION INDICATION CONSIDERATION
13. Positron Emission Uses small amount of radioactive Increase uptake of the substance is 1. Check doctor’s order.
Tomography (PET) materials called radiotracers, a seen in malignant cells. 2. Secure consent.
special camera and a computer to 3. Assess allergies to seafood.
help evaluate the organ and tissue 4. Tell the doctor about pregnancy.
functions. 5. Inform the doctor of any maintenance
medication.
6. No food intake 6 hours before the
procedure.
7. Wear loose and comfortable clothing.

TEST DESCRIPTION INDICATION CONSIDERATION

14. Tuberculin Skin Test Intradermal test done to detect
tuberculosis infection; does not
differentiate active from dormant
infections.

Purified protein derivative (PPD) Administered to determine any Read results within 48 – 72 hours, inspect skin
Test previous sensitization to tubercle and circle zone of induration with a
bacillus. pencil,measure diameter in mm.

Mantoux Test 0.1ml solution containing 0.5 Negative: Zone diameter less than 5 mm.
tuberculin units of PPD-tuberculin is Positive: Zone diameter is 10mm or more.
injected into the forearm.

Tine Test A stainless-steel disc with 4 times

impregnated with PPD-tuberculin is
pressed into the skin.

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 TEST DESCRIPTION INDICATION CONSIDERATION
15. Thoracentesis Insertion if a needle through chest For diagnostic evaluation, removal of 1. Secure consent.
wall in to pleural space to obtain pleural fluid accumulation or to 2. Explain the procedure, instruct client not
specimen. instill medication into pleural space. to cough or talk during procedure.
3. Position client side of bed, with upper
torso supported on over bed table, feet
and legs well supported.
4. Assess VS.
5. Posttest: Observe for signs and symptoms
of pneumothorax, shock, leakage at the
puncture site.
6. Auscultate chest to ascertain breath
sounds.

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Therapeutic
Management Learning Outcomes

1. Learn various kinds of therapeutic management that are applicable to respiratory problems.
2. Understand the descriptions of each therapeutic management.
3. Learn as to how each therapeutic management indicated appropriately to bone and muscle
disorders.
4. Improve skills through nursing considerations for each therapeutic management.

MANAGEMENT DESCRIPTION INDICATION CONSIDERATION

Pulmonary Rehabilitation Pulmonary rehabilitation is a Good for patient with chronic lung 1. Supervising exercises as the corner
comprehensive intervention based diseases (COPD). for pulmonary rehabilitation.
on a thorough patient assessment 1.1. Knee extensor training
followed by patient-tailored 1.2. Tai Chi
therapies: 1.3. Non-linear periodised
1. Exercises exercise training
2. Education 1.4. Neuromuscular electrical
3. Behavioral change stimulation
2. Promote adequate rests.
3. Health foods consumption.
4. No smoking.

MANAGEMENT DESCRIPTION INDICATION CONSIDERATION

Oxygen Therapy Most common therapy for clients Indications include arterial hypoxemia,
with respiratory disease. COPD, ARDS, tissue, cellular and
circulatory hypoxia.

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Low Flow System – delivers oxygen a. Nasal Cannula – most a.1. Instruct the client to breathe through the
at variable liter flows designed to common mode of oxygen nose.
add to client’s inspired air. deliver; 100% oxygen through a.2. Remove cannula and clean nares every 8
High Flow System – Client receives 2 prongs, general flow rates 1- hours.
entire inspired gas from the 4L/min. (24 to 40%). a.3. Provide mouth care every 2 to 3 hours.
apparatus, flow rates must exceed a.4. Use gauze pads behind ears to decrease
the volume of air required for a irritation.
person’s minute ventilation. a.5. Assess arterial PaO2 frequently.

b. Standard Mask – simple face b.1. Instruct client to breathe through the
mask that covers the mouth nose.
and nose and provides an b.2. Remove and clean mask every 2 to 3
additional area for oxygen hours.
collection, general ranges is 6 b.3. Monitor carefully in clients who are
to 12L/min (40 to 65%). prone to develop obstructed airways.
b.4. Replace mask with nasal cannula during
meals and reposition mask immediately after
eating.

c. Non-re-breathing Mask – c.1. Instruct client to breathe through the

standard mask with reservoir nose.
bag, general ranges is 6 to c.2. Ensure that the bag does not collapse
15L/min (60 to 90%). completely with each inspiration.
c.3. Remove and clean mask every 2 to 3
hours.

a. Venturi Mask – commonly a.1. Provide supplemental oxygen by cannula

used (24 to 50%). during meals and other activities where mask
interferes.
a.2. Remove and clean mask every 2 to 3
hours.

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 MANAGEMENT DESCRIPTION INDICATION CONSIDERATION
Chest Tube Drainage or Water-seal Drainage Removes air and fluid from the Allows lungs to re-expand to fill the 1. Check doctor’s order.
pleural space. evacuated pleural space. 2. Secure consent.
3. Prepare equipment and materials.
Chest tubes are commonly used for Chest drainage also allows removal of 4. Watch bubbling in water seal
thoracic surgery, penetrating chest pleural fluid for culture. compartment.
wounds, pleural effusion, and 5. Monitor changes in suction pressure.
empyema. Used for evacuation of pneumothorax, 6. Watch for water fluctuation.
hydrothorax, and hemothorax. 7. Secure all connections of tubing.
Sometimes used to instill sclerosing 8. Watch for kinks.
drugs into the pleural space to 9. Have forceps available in the
prevent recurrent malignant pleural bedside.
effusions. 10. Add water to the suction system as
necessary.
Tube Placement: Air removal. 11. Always keep the drainage lower than
a. Between 2nd and 3rd the level of the client’s chest.
intercostals spaces or 12. Encourage coughing and deep
anterior or midaxillary breathing (facilitate removal of air
line. and drainage).
Fluid removal. 13. Does recording.
b. Between 8th and 9th 14. Watch for signs of shock like
intercostals spaces or tachycardia and hypotension.
midaxillary line. 15. Encourage the patient to cough.
16. Passive ROM.
Drainage System: 17. I and O monitoring.
18. Have an extra bottle available in the
1. One-bottle System – client’s room.
Operates by gravity, not
suction. The bottle serves as
both collection chamber
and water seal.
2. Two-bottle System – one
bottle serve as drainage
collection chamber, the
other as water seal.
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3. Three-bottle System – This
system has drainage
collection, a water-seal and
a suction control bottle.
4. Pleur-evac – most popular
commercial water-seal unit.

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 MANAGEMENT DESCRIPTION INDICATION CONSIDERATION
Mechanical Ventilation This is with the use of mechanical Helps patient to breath by assisting the 1. Maintain patent airway clearances.
ventilator which attach to inhalation of oxygen into the lungs and 2. Assess functions of the machines.
tracheostomy or endotracheal tube. the exhalation of carbon dioxide. 3. Check wirings or electric outlet.
It can support or completely control 4. Perform weaning as ordered.
Ventilator Settings: patient’s breathing. 5. Monitor for GI problem (stress
a. FIO2 ulcer).
b. Rate 6. Monitor ABG.
c. Tidal Volume 7. Administer relaxants, tranquilizers
d. Sensitivity or analgesics to increase client
e. Peak Flow machine synchrony.
f. Inspiratory and expiratory
time.
g. Cycling
h. Limit

Ventilator Modes
a. A/C
b. CPAP
c. SIMV
d. PCV or PC
e. PSV or PS
f. PEEP

Ventilator Alarms
a. High Airway Pressure
alarms
b. Low Airway Pressure
alarms
c. High and Low-Rate alarms
d. High and Low Volume
alarms

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 MANAGEMENT DESCRIPTION INDICATION CONSIDERATION
Chest Physiotherapy Includes chest assessment, effective Deep Breathing: 1. Assess patient if chest physiotherapy
coughing and breathing exercises, is advisable.
postural drainage, percussion, 2. Assess presence of fractures.
vibration and evaluation. Purse-lip Breathing: 3. Inform the patient of the purposes of
doing chest physiotherapy.
4. Auscultate patient’s chest before and
Segmental Breathing: after chest physiotherapy.
5. Perform the procedure before or 3
hours after meals.
Coughing: 6. Administer bronchodilators about 20
minutes before the procedure.
7. Remove constricting or tight
Postural Drainage: clothing.
8. Have equipment available like
tissues, emesis basin, towel and
Percussion: paper bag.

Vibration:

MANAGEMENT DESCRIPTION INDICATION CONSIDERATION

Tracheobronchial Suctioning Suction removal of secretions from Maintain patent airway. 1. Promote adequate gas exchange of
the tracheobronchial tree using a oxygen or carbon dioxide.
sterile catheter inserted into the 2. Substitute for effective coughing.
airway. 3. Obtain a specimen for analysis.
4. Assess patient for absence of
Catheter maybe inserted to various dyspnea, cyanosis, improved breath
routes such as nasopharyngeal, sounds.
oropharyngeal or via an artificial 5. ABG analysis.
airway.

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 MANAGEMENT DESCRIPTION INDICATION CONSIDERATION
Tracheostomy Care Performed to avoid bacterial Maintain patent airway. 1. Promote adequate gas exchange of
contamination and obstruction of oxygen or carbon dioxide.
tracheostomy tube; frequency varies 2. Substitute for effective coughing.
depending on amount of secretions. 3. Obtain a specimen for analysis.
4. Assess patient for absence of
dyspnea, cyanosis, improved breath
sounds.
5. ABG analysis.

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 MANAGEMENT DESCRIPTION INDICATION CONSIDERATION
Endotracheal tube/Intubation Tracheal intubation, usually simply to maintain an open airway or to serve 1. Suctioning
referred to as intubation, is the as a conduit through which to 2. Check for obstruction or clogging.
placement of a flexible plastic tube administer certain drugs. 3. Check placement (cuff).
into the trachea (windpipe). 4. Check security of plasters of tagging.
Depressed level of conditions 5. Auscultate chest regularly.
It is frequently performed in
critically injured, ill, or anesthetized Hypoxemia
patients to facilitate ventilation of
the lungs, including mechanical Respiratory Arrest
ventilation, and to prevent the
possibility of asphyxiation or airway Surgical operation
obstruction.

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 MANAGEMENT DESCRIPTION INDICATION CONSIDERATION
Suctioning When patients are unable to Maintain airway patency. 1. Hyperventilate.
mobilize their secretions, you may 2. After inserting the catheter the
need to suction any secretions from measured distance initiate
the oropharynx and/or trachea to suctioning as you retract the catheter
maintain a patent airway. in a sweeping motion. The maximum
Suctioning may be done through an suction time should only be 15
endotracheal tube, tracheostomy seconds. After suctioning, re-
tube or through the nose or mouth oxygenate the patient.
into the trachea. 3. Promote adequate gas exchange of
oxygen or carbon dioxide.
Long term complications 4. Substitute for effective coughing.
include: 5. Obtain a specimen for analysis.
6. Assess patient for absence of
• Acute airway obstruction. dyspnea, cyanosis, improved breath
• Blocked tube. sounds.
• Infection (localised to 7. ABG analysis
stoma or tracheo-bronchial)
• Aspiration.
• Tracheal trauma.
• Dislodged tube.
• Stomal or tracheal
granulomation tissue.
• Tracheal stenosis

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Respiratory Learning Outcomes
Disorders
1. Identify various respiratory disorders including its descriptions.
2. Able to trace factors contributed to the development of respiratory disorders as well as it
how causes impact to involve anatomy and physiology.
3. Appreciate the importance of including the nursing process in the discussions of respiratory
disorders.
4. Improvement of rendering quality nursing care by appropriately understanding medical
management, surgical management and nursing management for respiratory disorders.

DISORDER DESCRIPTION FACTOR NURSING PROCESS MANAGEMENT

(ADPIE) Medical Surgical Nursing
Respiratory Distress Also called as Hyaline Weak intercostal Assessment Chest X-ray Implementation:
Syndrome Membrane Disease, is muscle. 1. Alveolar collapse or 1. Closely monitor blood
the most common atlectasis ABG gases.
cause of neonatal Immature alveolar 2. Hypoxemia 2. Monitor I and O.
mortality. capillary system. 3. Acidosis Chest auscultations 3. Watch for infection.
4. Rapid shallow 4. Evaluate the progress
Occurs in premature Lack of surfactant respirations with Humidified oxygen or assess skin color,
neonates. intercostal, subcostal depth of respirations,
or sterna retractions. Intubation severity of retractions,
5. Nasal flaring nostril flaring,
6. Audible expiratory Radiant warmer or frequency of expiratory
grunting. Incubator grunting, frothing at
the lips and
Complications: Mechanical ventilation restlessness.
1. Pneumothorax 5. Maintain airway
2. Pneumo-mediastinum IV fluid patency.

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 3. Pneumo-pericardium 6. Check mechanical
4. BPD Tube feeding ventilation.
5. ROP
6. Delayed mental Administration of Evaluation:
development. surfactant. 1. Have adequate
ventilation and be
Diagnosis: maintained.
1. Impaired gas 2. Maintenance of patent
exchange airway.
2. Ineffective airway 3. Effective breathing
clearance patterns and be
3. Ineffective breathing maintained.
pattern 4. Client will
4. Impaired verbal communicate in
communication effective manner.
5. Activity intolerance 5. Demonstrate increased
6. Anxiety tolerance for activity.
7. Altered nutrition: less 6. Reduction of anxiety.
than body 7. Adequate nutrition
requirements status and be
8. Risk for infection maintained.
8. Remains free from
Planning: infections.
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate

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 increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
DISORDER DESCRIPTION FACTOR NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
Sudden Infant Death Also called as “crib Putting on stomach Assessment: Autopsy Intervention:
Syndrome (SIDS) death”. position. 1. Suffocation 1. Make sure that the
2. Aspiration Resuscitation parents are present
Unexpected sudden Occurs commonly on 3. Bluish discoloration when the child’s death
death of an infant winter months. is announced.
younger than the age Diagnosis: 2. Let the parents see the
of 1. Preterm neonates 1. Impaired gas child in a private room,
exchange allow them to express
Reasons for the death Failure to seek 2. Ineffective airway feelings. Reassure
remained unexplained prenatal care. clearance them that they were
even after an autopsy. 3. Ineffective breathing not to blame.
Neonates born in pattern 3. Offer to call clergy,
poor condition and 4. Impaired verbal relatives or friends.
poverty. communication 4. After the parents and
5. Activity intolerance family have recovered
6. Anxiety from their initial
7. Altered nutrition: less shock, explain the
than body necessity for autopsy.
requirements 5. Educate parents with
8. Risk for infection newborn baby to
position their child on
Planning: their back.
1. Have adequate
ventilation and be

Page | 29
 maintained. Evaluation:
2. Maintenance of patent 1. Have adequate
airway. ventilation and be
3. Effective breathing maintained.
patterns and be 2. Maintenance of patent
maintained. airway.
4. Client will 3. Effective breathing
communicate in patterns and be
effective manner. maintained.
5. Demonstrate 4. Client will
increased tolerance for communicate in
activity. effective manner.
6. Reduction of anxiety. 5. Demonstrate increased
7. Adequate nutrition tolerance for activity.
status and be 6. Reduction of anxiety.
maintained. 7. Adequate nutrition
8. Remains free from status and be
infections. maintained.
8. Remains free from
infections.
DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
Croup It is a severe Viral infection Assessment: Throat culture and Intervention:
inflammation and (Parainfluenza, 1. Inflammation in sensitivity. 1. Monitor and support
obstruction of the adenoviruses, laryngeal area. respiration and control
upper airway, respiratory syncytial 2. Inflammation in Antibiotics fever.
occurring as acute virus, and measles subglottic tissue. 2. Monitor cough and
laryngotracheo- virus). 3. Inspiratory stridor Chest X-ray breath sounds.
bronchitis (most 4. Hoarseness or muffled 3. Assess for severe
common), laryngitis Bacterial infection vocal sounds. Laryngoscopy retractions, inspiratory
and acute spasmodic 5. Laryngeal obstruction. stridor, cyanosis,
laryngitis. Inhaled irritants 6. Respiratory distress. Cool mist respiratory rate.
7. Sharp-barking cough. humidification 4. Monitor labor
8. Laryngitis breathing, restlessness,

Page | 30
Childhood disease, Complications: Antipyretics fever and cardiac rate.
affecting more boys 1. Respiratory distress (Acetaminophen) 5. Avoid sedation.
than girls 2. Respiratory arrest Fluid replacement 6. Isolate patient
3. Epiglottis suspected with RSV.
4. Bacterial Tracheitis Oxygen therapy 7. TSB.
5. Atelectasis 8. Relieve sore throat.
6. Dehydration Intubation 9. Maintain calm, quiet
environment.
Diagnosis: Mechanical ventilation
1. Impaired gas Evaluation:
exchange Racemic epinephrine 1. Have adequate
2. Ineffective airway ventilation and be
clearance Corticosteroids maintained.
3. Ineffective breathing 2. Maintenance of patent
pattern Give DPT airway.
4. Impaired verbal 3. Effective breathing
communication patterns and be
5. Activity intolerance maintained.
6. Anxiety 4. Client will
7. Altered nutrition: less communicate in
than body effective manner.
requirements 5. Demonstrate increased
8. Risk for infection tolerance for activity.
6. Reduction of anxiety.
Planning: 7. Adequate nutrition
1. Have adequate status and be
ventilation and be maintained.
maintained. 8. Remains free from
2. Maintenance of patent infections.
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in

Page | 31
 effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
Epiglottiditis Also known as Haemophilus Assessment: ET Intubation Intervention:
epiglotitis, an acute Influenzae type B 1. Preceded by upper 1. Hyperextend the neck,
inflammation of the (HiB) respiratory infection. Tracheostomy sit-up and lean
epiglottis that tends to 2. Laryngeal obstruction forward with the
cause airway Pneumococci 3. Epiglotis edema Mechanical Ventilator mouth open, tongue
obstruction. 4. High fever protruding and nostrils
Streptococci 5. Stridor flaring as tried to
A critical emergency 6. Sore throat breath.
or fatal, unless 7. Dysphagia 2. Assist during
recognized and treated 8. Irritability intubation.
immediately. 9. Restlessness 3. Explain to significant
10. Drooling others about
11. Rhonchi intubation and
12. Inspiratory retractions mechanical ventilator.
4. Administer medication
Diagnosis: as ordered.
1. Impaired gas 5. Maintain airway
exchange patency.
2. Ineffective airway
clearance Evaluation:
3. Ineffective breathing 1. Have adequate
pattern ventilation and be

Page | 32
 4. Impaired verbal maintained.
communication 2. Maintenance of patent
5. Activity intolerance airway.
6. Anxiety 3. Effective breathing
7. Altered nutrition: less patterns and be
than body maintained.
requirements 4. Client will
8. Risk for infection communicate in
effective manner.
Planning: 5. Demonstrate increased
1. Have adequate tolerance for activity.
ventilation and be 6. Reduction of anxiety.
maintained. 7. Adequate nutrition
2. Maintenance of patent status and be
airway. maintained.
3. Effective breathing 8. Remains free from
patterns and be infections.
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.

Page | 33
 ACUTE DISORDER DESCRIPTION FACTOR NURSING PROCESS MANAGEMENT
MEDICAL SURGICAL NURSING
1. Acute Respiratory A form of pulmonary Shock Assessment: ABG Intervention:
Distress Syndrome insufficiency more 1. Dyspnea 1. Assessment of lungs.
(ARDS) commonly Trauma 2. Cough Chest X-ray 2. Elevate head and
encountered in adults 3. Tachypnea chest.
with no previous lung Infection 4. Intercostal retraction 3. Monitor mechanical
disorders than in 5. Rales or rhonchi ventilator.
those with existing Fluid overload 6. Disorientation 4. Assist chest physical
lung disease. 7. Tachycardia therapy as ordered.
Aspiration 8. Cyanosis (rare) 5. Monitor ABG.
Initial damage to the 6. Promote rest by
alveolar capillary Oxygen toxicity Diagnosis: spacing activities and
membrane with 1. Impaired gas treatments.
subsequent leakage of Smoke inhalation exchange 7. Maintain fluid and
fluid into interstitial 2. Ineffective airway electrolyte balance.
spaces and alveoli, Pneumonia clearance
resulting in 3. Ineffective breathing Evaluation:
pulmonary edema and DIC pattern 1. Have adequate
impaired gas 4. Impaired verbal ventilation and be
exchange. Drug allergies communication maintained.
5. Activity intolerance 2. Maintenance of patent
There is cell damage, Drug overdoses 6. Anxiety airway.
decreased surfactant 7. Altered nutrition: less 3. Effective breathing
production and Neurologic injuries than body patterns and be
atelectasis, which in requirements maintained.
turn produce Fat emboli 8. Risk for infection 4. Client will
hypoxemia, decreased communicate in
compliance and Planning: effective manner.
increased work of 1. Have adequate 5. Demonstrate increased
breathing. ventilation and be tolerance for activity.
maintained. 6. Reduction of anxiety.
Also called as “shock 2. Maintenance of patent 7. Adequate nutrition
lung”. airway. status and be

Page | 34
 3. Effective breathing maintained.
patterns and be 8. Remains free from
maintained. infections.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
2. Pulmonary Edema Is a condition in which 2ndary causes like Assessment: Chest X-ray CTT Intervention:
the lungs fill with TB, lung diseases, 1. Give medication as
fluid. lung abscess, Long term pulmonary edema: ABG ordered to treat
pneumonia, COPD, 1. Shortness of breath underlying causes.
Also called as lung and cardiogenic. 2. Difficulty in breathing ECG 2. Avoid smoking.
congestion. when lying down. 3. Avoid recreational
Sepsis 3. Shortness of breath Oxygen therapy medications.
through physical 4. Get regular exercises.
Chemical inhalation activities. Preload Reducers: 5. Eat healthy foods.
4. Wheezing _______________ 6. Maintain normal
Heart, kidney and 5. Waking up at night _______________ weight.
liver failure with a breathless _______________ 7. Reducing intake of
feeling and goes away _______________ salt.
Chest trauma by a sitting upright _______________ 8. Lowering cholesterol
position. levels.
Chest injuries 6. Weight gain
7. Leg edema

Page | 35
Aspiration 8. Swelling in the lower Afterload Reducers: Evaluation:
part of the body _______________ 1. Have adequate
Car accident 9. Fatigue _______________ ventilation and be
_______________ maintained.
High altitude pulmonary _______________ 2. Maintenance of patent
edema: _______________ airway.
1. HA 3. Effective breathing
2. Irregular and rapid Pneumonia Vaccine patterns and be
heartbeats. maintained.
3. Shortness of breath Heart Medications 4. Client will
after exertion and communicate in
during rest. Dexamethasone effective manner.
4. Coughing 5. Demonstrate increased
5. Fever tolerance for activity.
6. Difficulty walking 6. Reduction of anxiety.
uphill and on flat 7. Adequate nutrition
surfaces. status and be
maintained.
Emergency symptoms: 8. Remains free from
1. Extreme breathing infections.
difficulties.
2. Shortness of breath
like suffocating.
3. Inability to breath.
4. Anxiety related to
trouble breathing.
5. Cough produces mix
of saliva and mucus
(frothy).
6. Chest pain
7. Blue or gray skin tone.
8. Sweating along with
breathing difficulties
9. Tachycardia

Page | 36
Complication:
1. CHF
2. Heart attack
3. Pneumonia
4. Kidney failure
5. Lung damage

Diagnosis:
1. Impaired gas
exchange
2. Ineffective airway
clearance
3. Ineffective breathing
pattern
4. Impaired verbal
communication
5. Activity intolerance
6. Anxiety
7. Altered nutrition: less
than body
requirements
8. Risk for infection

Planning:
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.

Page | 37
 5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
3. Legionnaire’s A severe form of Bacterium Legionella Assessment: Antibacteria Intervention:
Disease pneumonia, lung pneumophilia that 1. HA (Tetracyclines, 1. Clean most of the time
inflammation usually can be harbor by 2. Muscle pain Ketolides, Quinolones) the sources of mist.
caused by infection. breathing in a mist 3. Chills 2. Preventing the build
with the bacteria 4. Fever Chest X-ray up of biofilm.
No to person-to- coming from air- 5. Cough (mucus and Sputum analysis 3. Preventing water
person transmission. condition, hot tubs, sometimes blood stagnation in any
and showers, grocery content) Urinalysis pipes.
Usually develops 2 to stores mist 6. Shortness of breath 4. Periodic disinfection of
10 days after exposure machines, decorative 7. Chest pain Blood test the system (water
to legionella bacteria. fountains, swimming 8. N and V system, air-condition
pools, physical 9. Diarrhea etc.)
Pontiac Fever – mild therapy equipment, 10. Disorientation
form of legionnaire’s water system in Evaluation:
disease. Does not hotels, hospitals and Pontiac Fever: 1. Have adequate
infect the lungs and nursing homes. 1. Fever ventilation and be
symptoms usually 2. Chills maintained.
clears within 2 to 5 Old age and person 3. HA 2. Maintenance of patent
days. with weak immune 4. Muscle ache airway.
system are 3. Effective breathing
susceptible. Complication: patterns and be
1. Respiratory failure maintained.
2. Septic shock 4. Client will

Page | 38
 3. Acute kidney failure communicate in
effective manner.
Diagnosis: 5. Demonstrate increased
1. Impaired gas tolerance for activity.
exchange 6. Reduction of anxiety.
2. Ineffective airway 7. Adequate nutrition
clearance status and be
3. Ineffective breathing maintained.
pattern 8. Remains free from
4. Impaired verbal infections.
communication
5. Activity intolerance
6. Anxiety
7. Altered nutrition: less
than body
requirements
8. Risk for infection

Planning:
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition

Page | 39
 status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
4. Atelectasis Collapse of part or all Obstruction (foreign Assessment: Chest X-ray Intervention:
of a lung due to objects, mucus, 1. Dyspnea 1. Turn to sides every 2
bronchial obstruction. secretions, tumors 2. Decreased breath ABG hours.
and bronchospasm). sounds on the affected 2. Promote increase oral
side. Bronchoscopy fluid intake.
3. Decreased RR 3. Humidification
4. Dullness to flatness 4. Prevent abdominal
upon percussion. distention.
5. Cyanosis 5. Avoid large doses of
6. Tachycardia sedatives
7. Tachypnea administration.
8. Elevated body 6. Give antibiotic as
temperature. prophylactic to prevent
9. Weakness respiratory infection.
10. Pain over affected
area. Evaluation:
1. Have adequate
Diagnosis: ventilation and be
1. Impaired gas maintained.
exchange 2. Maintenance of patent
2. Ineffective airway airway.
clearance 3. Effective breathing
3. Ineffective breathing patterns and be
pattern maintained.
4. Impaired verbal 4. Client will
communication communicate in
5. Activity intolerance effective manner.
6. Anxiety 5. Demonstrate increased

Page | 40
 7. Altered nutrition: less tolerance for activity.
than body 6. Reduction of anxiety.
requirements 7. Adequate nutrition
8. Risk for infection status and be
maintained.
Planning: 8. Remains free from
1. Have adequate infections.
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
5. Respiratory Acidosis Respiratory acidosis COPD Assessment: Treatment to Intervention:
develops when air 1. HA underlying causes. 1. Maintain healthy
exhaled out of the Metabolic acidosis 2. Sleep disturbances respiratory function.
lungs does not
3. Anxiety Mechanical ventilation 2. Maintain patent
adequately exchange
the carbon dioxide Kidney failure 4. Personality changes airway.
formed in the body for 5. Drowsiness Sodium Bicarbonate 3. Manage or treat

Page | 41
 the inhaled oxygen in 6. Confusion underlying causes like
air. 7. Stupor COPD.
8. Muscle jerking 4. No to smoking.
9. Hypotension
Evaluation:
Diagnosis: 1. Have adequate
1. Impaired gas ventilation and be
exchange maintained.
2. Ineffective airway 2. Maintenance of patent
clearance airway.
3. Ineffective breathing 3. Effective breathing
pattern patterns and be
Types: 4. Impaired verbal maintained.
communication 4. Client will
a. Acute Respiratory Acute Respiratory 5. Activity intolerance communicate in
Acidosis Acidosis – due to 6. Anxiety effective manner.
respiratory failure and 7. Altered nutrition: less 5. Demonstrate increased
needs an emergent
than body tolerance for activity.
restoration of
healthful respiration, requirements 6. Reduction of anxiety.
acid-base balance and 8. Risk for infection 7. Adequate nutrition
treatment. status and be
Planning: maintained.
1. Have adequate 8. Remains free from
b. Chronic Without dangerously
Respiratory ventilation and be infections.
acidic level in the
Acidosis blood because body’s maintained.
able to compensate 2. Maintenance of patent
through kidney airway.
system, kidneys get rid 3. Effective breathing
of more acid and patterns and be
reabsorb more base to maintained.
try and create a
4. Client will
balance.
communicate in
effective manner.
5. Demonstrate
increased tolerance for

Page | 42
 activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
6. Respiratory Alkalosis Occurs when patient Hyperventilation and Assessment: Treating the Intervention:
breath too fast or too causes hyperven- 1. Dizziness underlying cause 1. Upright position
deep and carbon tilation to happen? 2. Bloating 2. Purse lip breathing
dioxide levels drop to 1. Heart attack 3. Lightheaded 3. Paper bag
low. 2. Pain 4. Numbness
3. Drug use 5. Muscle spasms Evaluation:
Blood pH is rise and 4. Asthma 6. Chest discomfort 1. Have adequate
become too alkaline. 5. Fever 7. Confusion ventilation and be
6. COPD 8. Dry mouth maintained.
7. Infection 9. Tingling in the arms 2. Maintenance of patent
8. Pulmonary 10. Tachycardia airway.
embolism 11. Shortness of breath 3. Effective breathing
patterns and be
Diagnosis: maintained.
1. Impaired gas 4. Client will
exchange communicate in
2. Ineffective airway effective manner.
clearance 5. Demonstrate increased
3. Ineffective breathing tolerance for activity.
pattern 6. Reduction of anxiety.
4. Impaired verbal 7. Adequate nutrition
communication status and be
5. Activity intolerance maintained.
6. Anxiety 8. Remains free from
7. Altered nutrition: less infections.

Page | 43
 than body
requirements
8. Risk for infection

Planning:
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
7. Pneumonia An inflammation of D. Pneumoniae Assessment: Chest X-ray Intervention:
the alveolar spaces of 1. Coughing 1. Facilitate adequate
the lungs, resulting in S. Aureus 2. Greenish to rust WBC ventilation.
the consolidation of colored of sputum. 2. Facilitate removal of
lung tissue as the E. Coli 3. Rapid and shallow ABG secretions.
alveoli fill with breathing. 3. Monitor ABG.
exudates. H. Influenzae 4. Nasal flaring Sputum analysis 4. Observe characteristics

Page | 44
 Types of pneumonia is 5. Use of accessory. of sputum.
according to the cause. Droplet 6. Dullness to flatness 5. Complete bed rest,
upon percussion to the 6. Give antibiotic as
affected area. ordered.
7. Pleural friction rub 7. Prevent transmission.
8. Rales or crackles 8. Monitor VS.
9. Hoarseness of voice 9. Provide teaching and
10. Tachycardia discharge planning
11. Cyanosis such as medication
12. Profuse perspiration regimen, adequate
13. Abdominal distention rest, nutritious foods,
continuity of deep
Diagnosis: breathing and
Types: 1. Impaired gas coughing, availability
exchange of vaccines, and
1. Inflammation of 2. Ineffective airway regular check-up.
the upper lobe of clearance
the lung. 3. Ineffective breathing Evaluation:
2. Inflammation of pattern 1. Have adequate
middle lobe of the 4. Impaired verbal ventilation and be
lung. communication maintained.
3. Inflammation of 5. Activity intolerance 2. Maintenance of patent
the lower lobe of 6. Anxiety airway.
the lung. 7. Altered nutrition: less 3. Effective breathing
than body patterns and be
requirements maintained.
8. Risk for infection 4. Client will
communicate in
Planning: effective manner.
1. Have adequate 5. Demonstrate increased
ventilation and be tolerance for activity.
maintained. 6. Reduction of anxiety.
2. Maintenance of patent 7. Adequate nutrition
airway. status and be
3. Effective breathing maintained.

Page | 45
 patterns and be 8. Remains free from
maintained. infections.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
8. Idiopathic A rare inflammatory Cause is unknown Assessment: Chest X-ray Lung transplant Intervention:
Bronchiolitis lung disorder. 1. Flu like – rare. 1. Give medication as
Obliterans with Radiation therapy 2. Sore throat Pulmonary function ordered.
Organizing Also referred as 3. Non-productive cough test 2. Manage the sign and
Pneumonia (BOOP) Epler’s Pneumonia Chemical exposures 4. Shortness of breath symptoms.
during exertion. HRCT 3. Healthy diet
Bronchiolitis Obli- 5. Wheezing and consumptions.
terans – refers to hemoptysis are rare. Corticosteroid
swirls or plug of 6. Fatigue (Prednisone) Evaluation:
fibrous, granulation 7. Weight loss 1. Have adequate
tissue filling the small ventilation and be
bronchiole airway. Diagnosis: maintained.
1. Impaired gas 2. Maintenance of patent
Organizing Pneu- exchange airway.
monia – refers to 2. Ineffective airway 3. Effective breathing
organized swirls of clearance patterns and be
inflammatory tissue 3. Ineffective breathing maintained.
filling the small pattern 4. Client will

Page | 46
spherical units of the 4. Impaired verbal communicate in
lungs –referred to as communication effective manner.
alveoli and alveolar 5. Activity intolerance 5. Demonstrate increased
ducts. 6. Anxiety tolerance for activity.
7. Altered nutrition: less 6. Reduction of anxiety.
than body 7. Adequate nutrition
requirements status and be
8. Risk for infection maintained.
8. Remains free from
Planning: infections.
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.

Page | 47
 ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
9. Pulmonary Describes the blockage Blood clot Assessment: Anticoagulation Embolectomy Intervention:
Embolism of a pulmonary artery (thrombus) 1. Chest pain Pre-Operative
or one of its branches 2. Shortness of breath Oxygen Thrombectomy 1. Obtain a baseline
by a blood clot or Prolonged 3. Cough that sometimes vascular assessment.
foreign material. immobilization with blood 2. Administer antico-
4. Tachycardia agulants as prescribed.
Blood stasis 5. Anxiety 3. Administer throm-
6. Tachypnea bolytics as prescribed.
Birth control pills 7. Cyanosis 4. Place a bed cradle on
8. Hypotension the bed.
Smoking 5. Avoid bumping or
Complication: jarring the bed.
Tumor 1. Cardiogenic shock 6. Maintain the extremity
2. Circulatory shock in a slightly dependent
DVT 3. Respiratory arrest position.
4. Cardiac arrest
Pregnancy Post-Operative
Diagnosis: 1. Assess cardiac, respi-
Surgery 1. Impaired gas ratory, and neurological
status.
exchange
2. Monitor affected
Damage to blood 2. Ineffective airway extremity for color,
vessel walls clearance temperature, and pulse.
3. Ineffective breathing 3. Assess sensory and
Pulmonary embolus pattern motor function of the
4. Impaired verbal affected extremity.
communication 4. Monitor for signs and
symptoms of new
5. Activity intolerance
thrombi or emboli.
6. Anxiety 5. Administer oxygen as
7. Altered nutrition: less prescribed.
than body 6. Monitor pulse oximetry.
requirements 7. Monitor for complica-
8. Risk for infection tions caused by reperfu-
sion of the artery, such
Page | 48
Planning: as spasms and swelling
1. Have adequate of the skeletal muscles.
ventilation and be 8. Monitor for signs of
swollen skeletal muscles
maintained.
such as edema, pain on
2. Maintenance of patent passive movement, poor
airway. capillary refill,
3. Effective breathing numbness, and muscle
patterns and be tenseness.
maintained. 9. Maintain bed rest
4. Client will initially, with the client
in a semi-Fowler's
communicate in
position.
effective manner. 10. Place a bed cradle on
5. Demonstrate the bed.
increased tolerance for 11. Check the incision site
activity. for bleeding or
6. Reduction of anxiety. hematoma.
7. Adequate nutrition 12. Administer
anticoagulants as
status and be
prescribed.
maintained. 13. Monitor laboratory
8. Remains free from values related to
infections. anticoagulant therapy.
14. Instruct the client to
recognize the signs and
symptoms of infection
and edema.
15. Instruct the client to
avoid prolonged sitting
or crossing the legs
when sitting.
16. Instruct the client to
elevate the legs when
sitting.
17. Instruct the client to
wear antiembolism
stockings as prescribed
and how to remove
and reapply the

Page | 49
 stockings.
18. Instruct the client to
ambulate daily.
19. Instruct the client about
anticoagulant therapy
and the hazards
associated with
anticoagulants

Evaluation:
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will communicate
in effective manner.
5. Demonstrate increased
tolerance for activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
10. Sarcoidosis Is an inflammatory Unknown cause Assessment: Chest radiograph Intervention:
disease that affects 1. Asymptomatic 1. Manage the signs and
multiple organs in the Occupational factors 2. Fatigue (unrelieved by Ct Scan symptoms.
body, but mostly lungs sleep) 2. Encourage regular
and lymph glands. Environmental 3. Lack of energy PET Scan check-up
factors 4. Weight loss
Page | 50
 Involving abnormal 5. Joint aches Bronchoscopy with Evaluation:
collections of inflam- Infections 6. Pain biopsy 1. Have adequate
matory cells that form 7. Dry eyes ventilation and be
lumps know as 8. Erythema Nodosum NSAIDs maintained.
granulomas. 9. Maculo popular 2. Maintenance of patent
It usually begins in the eruptions Glucocorticoids airway.
lungs, skin, lymph 3. Effective breathing
nodes. Diagnosis: Antimetabolites patterns and be
1. Impaired gas maintained.
exchange Corticosteroids 4. Client will
2. Ineffective airway communicate in
clearance effective manner.
3. Ineffective breathing 5. Demonstrate increased
pattern tolerance for activity.
4. Impaired verbal 6. Reduction of anxiety.
communication 7. Adequate nutrition
5. Activity intolerance status and be
6. Anxiety maintained.
7. Altered nutrition: less 8. Remains free from
than body infections.
requirements
Types: 8. Risk for infection
____________________
____________________ Planning:
____________________ 1. Have adequate
____________________ ventilation and be
____________________ maintained.
____________________ 2. Maintenance of patent
____________________ airway.
____________________ 3. Effective breathing
____________________ patterns and be
____________________ maintained.
____________________ 4. Client will
____________________ communicate in
_______. effective manner.

Page | 51
 5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
11. Severe Acute Potentially deadly Coronavirus Assessment: Blood test Intervention:
Respiratory illness that quickly 1. High fever 1. Report any suspected
Syndrome (SARS) spread around the Cough 2. Cough Nasal Secretion Test infected person with
world in 2003. 3. Muscle aches SARS.
Sneezing 4. Chest pain Viral Culture 2. Cover mouth, use
5. Difficulty in breathing mask.
Person to person 3. Frequent handwashing
contact Complication: 4. Avoid touching the
1. Pneumonia eyes, mouth or nose
Sharing utensils 2. Death with unclean hands.
5. Covering the mouth
Hugging and kissing Diagnosis: when coughing,
1. Impaired gas sneezing, yawning.
Speaking with a exchange
distance of 3 feet 2. Ineffective airway Evaluation:
clearance 1. Have adequate
3. Ineffective breathing ventilation and be
pattern maintained.
4. Impaired verbal 2. Maintenance of patent
communication airway.
5. Activity intolerance 3. Effective breathing
6. Anxiety patterns and be
7. Altered nutrition: less maintained.

Page | 52
 than body 4. Client will
requirements communicate in
8. Risk for infection effective manner.
5. Demonstrate increased
tolerance for activity.
Planning: 6. Reduction of anxiety.
1. Have adequate 7. Adequate nutrition
ventilation and be status and be
maintained. maintained.
2. Maintenance of patent 8. Remains free from
airway. infections.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
12. Lung Abscess Lung abscess is a type Microbial infection Assessment: Clindamycin CTT Intervention:
of liquefactive necrosis 1. Fever 1. Postural position.
of the lung tissue and Aspiration 2. Chilling Sputum analysis Lobectomy 2. Secure the bottle
formation of cavities 3. Cough drainages.
(more than 2cm) Alcoholism 4. Night sweats Bronchoscopy 3. Manage the signs and
containing necrotic 5. Dyspnea symptoms.

Page | 53
debris or fluid. Underlying causes 6. Wt. loss CT Scan 4. Provide medications as
7. Fatigue ordered.
Intubation 8. Chest pain
9. Sometimes anemia Evaluation:
Tracheostomy 10. Productive cough 1. Have adequate
Heart disease Complication: ventilation and be
complication 1. Empyema maintained.
2. Fistula 2. Maintenance of patent
Respiratory disease 3. Lung bleeding airway.
complications 4. Spreading of 3. Effective breathing
infections patterns and be
Dental infections maintained.
Diagnosis: 4. Client will
Elderly 1. Impaired gas communicate in
exchange effective manner.
Bacteria 2. Ineffective airway 5. Demonstrate increased
clearance tolerance for activity.
Viruses 3. Ineffective breathing 6. Reduction of anxiety.
pattern 7. Adequate nutrition
4. Impaired verbal status and be
communication maintained.
5. Activity intolerance 8. Remains free from
6. Anxiety infections.
7. Altered nutrition: less
than body
requirements
8. Risk for infection

Planning:
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing

Page | 54
 patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
13. Pneumothorax and Partial or complete Chest Trauma Assessment: Chest X-ray Thoracentesis Intervention:
Hemothorax lung collapse due to 1. Sudden sharp chest 1. Maintain airway
accumulation of air Stab Wound pain ABG patency.
and fluid or blood in
2. Dyspnea 2. Restore or promote
the pleural space.
Gunshot wound 3. Diminished or absent Intubation or respiratory function.
breath sound on the tracheostomy 3. Provide pain control.
Blunt trauma affected side. 4. Assist in thoracentesis
4. Decreased expiratory procedure.
excursion. 5. Position patient
5. Hyperresonance on comfortably.
percussion.
6. Tracheal shift to the Evaluation:
opposite side. 1. Have adequate
7. Weak, rapid pulse. ventilation and be
8. Anxiety maintained.
9. Diaphoresis 2. Maintenance of patent
Types:
1. Spontaneous P. airway.
The most common
3. Effective breathing
type of closed

Page | 55
 pneumothorax. Air Diagnosis: patterns and be
accumulates within 1. Impaired gas maintained.
the pleural space exchange 4. Client will
without an obvious
2. Ineffective airway communicate in
cause. Rupture of
small bleb on the clearance effective manner.
visceral pleura most 3. Ineffective breathing 5. Demonstrate increased
Blfrequently produces pattern tolerance for activity.
this type of 4. Impaired verbal 6. Reduction of anxiety.
pneumothorax. communication 7. Adequate nutrition
5. Activity intolerance status and be
2. Open P. Air enters the pleural
6. Anxiety maintained.
space through an
opening in the chest 7. Altered nutrition: less 8. Remains free from
wall. than body infections.
requirements
3. Tension P. Air enters the pleural 8. Risk for infection
space with each
inspiration but cannot Planning:
escape, causes
1. Have adequate
increased intra-
thoracic pressure and ventilation and be
shifting of mediastinal maintained.
contents to the 2. Maintenance of patent
unaffected side airway.
(mediastinal shift). 3. Effective breathing
patterns and be
4. Hemothorax Accumulation of blood
in the pleural space, maintained.
frequently found with 4. Client will
an open communicate in
pneumothorax re- effective manner.
sulting in hemo- 5. Demonstrate
pneumothorax. increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status.
8. Free from infections.

Page | 56
 ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
14. Pulmonary Pulmonary hyper- Assessment: Treatment of Intervention:
Hypertension tension is abnormally 1. Shortness of breath underlying causes. 1. Manage underlying
elevated pressure in and worsen during cause.
the pulmonary
activity. Oxygen therapy 2. Manage signs and
circulation.
2. Rapid breathing symptoms.
3. Louder sounds of Blood thinners 3. Monitor side effects of
heart beat. blood thinners.
4. Elevation of chest Bronchodilators
wall. Evaluation:
Liver disease 5. NVE 1. Have adequate
Pulmonary occlusive ventilation and be
disease Diagnosis: maintained.
Congenital defects 1. Impaired gas 2. Maintenance of patent
exchange airway.
2. Ineffective airway 3. Effective breathing
clearance patterns and be
3. Ineffective breathing maintained.
Classification:
pattern 4. Client will
Group 1: Pulmonary Arterial Associated with Left heart diseases 4. Impaired verbal communicate in
Hypertension narrowing of the mall (heart failure, communication effective manner.
blood vessels in the valvular diseases). 5. Activity intolerance 5. Demonstrate increased
lungs. Also called as COPD 6. Anxiety tolerance for activity.
Pulmonary Arterial Congenital lung 7. Altered nutrition: less 6. Reduction of anxiety.
Hypertension (PAH). defects.
than body 7. Adequate nutrition
requirements status and be
Group 2: Pulmonary Produces long term COPD 8. Risk for infection maintained.
Hypertension Due to Left problems since left 8. Remains free from
Heart Disease heart is affected. Planning: infections.
1. Have adequate
ventilation and be
Group 3: Pulmonary Related to chronic Clots
Hypertension Due to Lung maintained.
lung diseases
Disease or Chronic Hypoxia 2. Maintenance of patent

Page | 57
Group 4: Pulmonary Obstruction airway.
hypertension Due to Blood 3. Effective breathing
Clots in the Lungs patterns and be
maintained.
Group 5: Pulmonary Blood disorders, GIT diseases 4. Client will
Hypertension Due to Blood systemic disorders, Kidney Diseases communicate in
and Other Disorders and metabolic effective manner.
disorders 5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
15. Pleural Effusion Collection of fluid in Liver and kidney Assessment: Antibiotic Thoracentesis Intervention:
the pleural space. disease 1. Dyspnea 1. Assist in thoracentesis.
2. Dullness Analgesics CTT 2. Prepare materials for
Pneumonia
3. Absent or decreased specimen collection for
TB breath sounds. Anticoagulant analysis.
4. Pleuritic pain 3. Assist in administering
Lung abscess 5. Dry cough Chest X-ray medication through
6. Pleural friction rub thoracentesis.
Bronchial carcinoma Biopsy 4. Place client in high
Diagnosis: fowler’s position.
Leukemia
1. Impaired gas
Chest Trauma exchange Evaluation:
2. Ineffective airway 1. Have adequate
Pulmonary edema clearance ventilation and be
3. Ineffective breathing maintained.
Systemic infection pattern 2. Maintenance of patent

Page | 58
Classification: 4. Impaired verbal airway.
communication 3. Effective breathing
1. Transudate Accumulation of 5. Activity intolerance patterns and be
protein-poor and cell
6. Anxiety maintained.
poor fluid.
7. Altered nutrition: less 4. Client will
2. Supporative Accumulation of pus than body communicate in
(empyema) in the pleural space. requirements effective manner.
8. Risk for infection 5. Demonstrate increased
tolerance for activity.
Planning: 6. Reduction of anxiety.
1. Have adequate 7. Adequate nutrition
ventilation and be status and be
maintained. maintained.
2. Maintenance of patent 8. Remains free from
airway. infections.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.

Page | 59
 ACUTE DISORDER DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
16. Pleurisy Involves inflammation Underlying diseases Assessment: Antibiotic CTT Intervention:
of the tissue layers 1. Chest pain (knife like) 1. Instruct patient to
(pleura) lining and Infections 2. Shortness of breathing Chest X-ray Thoracentesis perform self-splinting.
inner chest wall. 3. Stabbing sensation UTZ 2. Assist on MHBR or
Inhaled chemical HBR.
Describes the substance Diagnosis: 3. Assist in thoracentesis
syndrome charac- 1. Impaired gas or CTT procedures.
terized by a sharp pain Cancers exchange 4. Secure drainages.
in chest cavity that 2. Ineffective airway 5. Monitor drainages.
worsen with breathing Tumors clearance
(inspiration). 3. Ineffective breathing Evaluation:
Pulmonary embolism pattern 1. Have adequate
Pleural Effusion – 4. Impaired verbal ventilation and be
accumulation of fluid Obstruction communication maintained.
between visceral and 5. Activity intolerance 2. Maintenance of patent
parietal layers. Chest Trauma 6. Anxiety airway.
7. Altered nutrition: less 3. Effective breathing
Pleurisy – often Chest Injuries than body patterns and be
associated with the requirements maintained.
accumulation of fluid 8. Risk for infection 4. Client will
between the two layers communicate in
of pleura Planning: effective manner.
1. Have adequate 5. Demonstrate increased
ventilation and be tolerance for activity.
maintained. 6. Reduction of anxiety.
2. Maintenance of patent 7. Adequate nutrition
airway. status and be
3. Effective breathing maintained.
patterns and be 8. Remains free from
maintained. infections.
4. Client will
communicate in

Page | 60
 effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections
CHRONIC DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
DISORDERS MEDICAL SURGICAL NURSING
1. COPD Refers to respiratory
conditions that
produce obstruction of
air flow; includes
emphysema, bron-
chitis, bronchiectasis
and asthma.

a. Emphysema Enlargement and Smoking Assessment: ABG Intervention:

destruction of the 1. Air trapping 1. Administer medication
alveolar, bronchial Infection 2. Thoracic over Chest X-ray as ordered.
and bronchiolar tissue distention 2. Facilitate removal of
with resultant loss of Inhalant irritant 3. Sputum accumulation Bronchodilators: secretions.
recoil. 4. Loss of diaphragmatic 1. Amino- 3. Improve ventilation.
Heredity muscle tone phylline 4. Provide client teaching
5. Carbon dioxide 2. Isopro-terenol and discharge
Allergic factors retention (Isuprel) planning pertaining to
6. Hypoxia 3. Terbutaline prevention of recurrent
Aging 7. Respiratory acidosis (Brethine) infections, control of
8. Anorexia 4. Metapro- environment,
9. Fatigue terenol avoidance of inhaled
10. Weight loss (Alupent) irritants, and

Page | 61
 11. Feeling of 5. Theophylline increasing activity
breathlessness 6. Isoetharine intolerance.
12. Cough (Bronkosol)
13. Sputum production
14. Flaring of nostrils
15. Use of accessory
muscles of respiration
16. Increase RR
17. Depth of breathing
18. Dyspnea
19. Decreased breath
sounds

b. Bronchitis Excessive production Smoking Assessment: ABG Intervention:

of mucus in the 1. Productive cough 1. Administer medication
bronchi with Infection 2. Dyspnea on sertion Chest X-ray as ordered.
accompanying per- 3. Use of accessory 2. Facilitate removal of
sistent cough. Inhalant irritant muscles of respiration. Expectorants secretions.
4. Scattered rales and (Robitussin) 3. Improve ventilation.
Characteristic changes Heredity rhonchi. 4. Provide client teaching
include hypertrophy 5. Feeling of epigastric Antimicrobials and discharge
or hyperplasia of the Allergic factors fullness. planning pertaining to
mucus secreting 6. Slight cyanosis Bronchodilators: prevention of recurrent
glands in the bronchi, Aging 7. Distended neck veins 1. Amino- infections, control of
decreased ciliary 8. Ankle edema phylline environment,
activity, chronic 2. Isopro-terenol avoidance of inhaled
inflammation and (Isuprel) irritants, and
narrowing of small 3. Terbutaline increasing activity
airways. (Brethine) intolerance.
4. Metapro-
terenol
(Alupent)
5. Theophylline
6. Isoetharine
(Bronkosol)

Page | 62
c. Bronchiectasis Permanent abnormal Bacterial infection Assessment: Bronchoscopy Intervention:
dilation of bronchi 1. Chronic cough 1. Administer medication
with destruction of Recurrent lower 2. Production of sputum Chest X-ray as ordered.
muscular and elastic respiratory tract 3. Hemoptysis 2. Facilitate removal of
structure of the infection. 4. Exertional dyspnea ABG secretions.
bronchial wall. 5. Wheezing 3. Improve ventilation.
Congenital defects 6. Fatigue Sputum analysis 4. Provide client teaching
7. Anorexia and discharge
Lung tumors 8. Weight loss WBC or CBC planning pertaining to
prevention of recurrent
Thick and tenacious Expectorants infections, control of
secretions (Robitussin) environment,
avoidance of inhaled
Antimicrobials irritants, and
increasing activity
Bronchodilators: intolerance.
1. Amino-
phylline
2. Isopro-terenol
(Isuprel)
3. Terbutaline
(Brethine)
4. Metapro-
terenol
(Alupent)
5. Theophylline
6. Isoetharine
(Bronkosol)

Page | 63
d. Asthma Obstructive disease of Allergic reaction Assessment: ABG Intervention:
the lower respiratory (environment) 1. Shortness of breath 1. Administer medication
tract. resulting to the 2. Expiratory wheeze Oxygen therapy as ordered.
production of 3. Prolong expiratory 2. Facilitate removal of
Most common in histamine causes phase Bronchodilators: secretions.
children, young edema of mucus 4. Air trapping 1. Beta- 3. Improve ventilation.
children and too old. membrane, spasm of 5. Use of accessory adrenergic 4. Provide client teaching
the smooth muscle of muscles 2. Theo-phylline and discharge
Status Asthmaticus – bronchi and 6. Irritability planning pertaining to
occurs when there is bronchioles and 7. Diaphoresis Corticosteroids prevention of recurrent
little response to accumulation of 8. Change in sensorium infections, control of
treatment and tenacious secretions. Cromolyn Sodium environment,
symptoms persist. Diagnosis: avoidance of inhaled
Family history of 1. Impaired gas Physical therapy irritants, and
allergies exchange increasing activity
2. Ineffective airway Chest physiotherapy intolerance.
Client history of clearance
eczema 3. Ineffective breathing Exercise
pattern Evaluation:
4. Impaired verbal 1. Have adequate
communication ventilation and be
5. Activity intolerance maintained.
6. Anxiety 2. Maintenance of patent
7. Altered nutrition: less airway.
than body 3. Effective breathing
requirements patterns and be
8. Risk for infection maintained.
4. Client will
Planning: communicate in
1. Have adequate effective manner.
ventilation and be 5. Demonstrate increased
maintained. tolerance for activity.
2. Maintenance of patent 6. Reduction of anxiety.
airway. 7. Adequate nutrition
3. Effective breathing status and be

Page | 64
 patterns and be maintained.
maintained. 8. Remains free from
4. Client will infections.
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
CHRONIC DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
DISORDER (ADPIE) MEDICAL SURGICAL NURSING
2. Idiopathic Is a type of chronic Unknown cause Assessment: Chest X-ray Lung Intervention:
Pulmonary Fibrosis lung disease charac- 1. Dry, non-productive transplantation 1. Reduces the
terized by a Smoking cough. Treatment of symptoms.
progressive and Chemical substances 2. Shortness of breath underlying causes 2. Administer oxygen and
irreversible decline in with activity. follow range of liters
lung function. Occupational 3. Crackles Pulmonary function administration.
exposure to asbestos, 4. Clubbing of fingers test 3. Encourage patient to
wood dust, coal dust, 5. Abnormal pulmonary verbalize feelings.
silica, stone dust etc. function test. Oxygen therapy 4. Instruct on follow-ups.
6. Hypoxemia
Pulmonary emboli 7. Cyanosis Prednisone Evaluation:
1. Have adequate
Complication: Anticoagulant ventilation and be
1. Pulmonary maintained.
hypertension 2. Maintenance of patent
2. Heart failure airway.
3. Pneumonia 3. Effective breathing
4. Pulmonary embolism patterns and be

Page | 65
Diagnosis: maintained.
1. Impaired gas 4. Client will
exchange communicate in
2. Ineffective airway effective manner.
clearance 5. Demonstrate increased
3. Ineffective breathing tolerance for activity.
pattern 6. Reduction of anxiety.
4. Impaired verbal 7. Adequate nutrition
communication status and be
5. Activity intolerance maintained.
6. Anxiety 8. Remains free from
7. Altered nutrition: less infections.
than body
requirements
8. Risk for infection

Planning:
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status.
8. Free from infections.

Page | 66
 CHRONIC DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
DISORDER (ADPIE) MEDICAL SURGICAL NURSING
3. Pulmonary Bacterial infectious Mycobacterium Assessment: Rifampicin Intervention:
Tuberculosis disease. tuberculosis an acid- 1. Cough Isoniazid 1. Prevent transmission.
fast bacillus spread 2. Yellow mucoid Pyrazinamide 2. Promote adequate
via droplet and sputum Ethambutol nutrition.
airborne. 3. Dyspnea Streptomycin 3. Prevent social
4. Hemoptysis isolation.
Living in crowded 5. Rales or crackles 4. Vary client’s routine to
areas. 6. Anorexia prevent boredom.
7. Body malaise 5. Discuss client’s
Sharing of utensils. 8. Weight loss feelings and assess for
9. Afternoon low-grade boredom, depression,
Exposes to person fever anxiety, fatigue or
with TB 10. Pallor apathy, allow
11. Pain expression of concerns.
12. Fatigue 6. Provide client teaching
13. Night sweats and discharge
planning like
Diagnosis: medication regimen,
1. Impaired gas transmission
exchange prevention, and
2. Ineffective airway regular check-up.
clearance
3. Ineffective breathing Evaluation:
pattern 1. Have adequate
4. Impaired verbal ventilation and be
communication maintained.
5. Activity intolerance 2. Maintenance of patent
6. Anxiety airway.
7. Altered nutrition: less 3. Effective breathing
than body patterns and be
requirements maintained.
8. Risk for infection 4. Client will

Page | 67
 Planning: communicate in
1. Have adequate effective manner.
ventilation and be 5. Demonstrate increased
maintained. tolerance for activity.
2. Maintenance of patent 6. Reduction of anxiety.
airway. 7. Adequate nutrition
3. Effective breathing status and be
patterns and be maintained.
maintained. 8. Remains free from
4. Client will infections.
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
CHRONIC DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
DISORDER (ADPIE) MEDICAL SURGICAL NURSING
4. Histoplasmosis A systemic fungal Histoplasma Assessment: Chest X-ray Intervention:
disease caused by capsulatum 1. Cough Histoplasmin skin test 1. Monitor respiratory
inhalation of dust transmitted by bird 2. Fever status.
contaminated by manure, which 3. Joint pain Antifungal - Ampho- 2. Give medications as
histoplasma cap- contaminates dust. 4. Malaise tericin B ordered.
sulatum 5. Sometimes
asymptomatic Acetaminophen

Diagnosis: Benadryl Evaluation:

1. Impaired gas 1. Have adequate
exchange Steroids ventilation and be

Page | 68
 2. Ineffective airway maintained.
clearance 2. Maintenance of patent
3. Ineffective breathing airway.
pattern 3. Effective breathing
4. Impaired verbal patterns and be
communication maintained.
5. Activity intolerance 4. Client will
6. Anxiety communicate in
7. Altered nutrition: less effective manner.
than body 5. Demonstrate increased
requirements tolerance for activity.
8. Risk for infection 6. Reduction of anxiety.
7. Adequate nutrition
Planning: status and be
1. Have adequate maintained.
ventilation and be 8. Remains free from
maintained. infections.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.

Page | 69
PNEUMOCONIOSES DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
DISORDER (ADPIE) MEDICAL SURGICAL NURSING
1. Silicosis Also known as miner’s Occupation hazard Assessment: Chest X-ray Lung Intervention:
phthisis, grinder’s (silica dust) 1. Asymptomatic transplantation 1. Wear mask at all times,
asthma, and potter’s 2. Dyspnea Pulmonary function have reservation of
rot. 3. Cough, often test masks.
persistent and 2. Avoid too much
Permanent disease sometimes severe. CT-Scan exposue to silicosis
with no cure. 4. Fatigue Cough suppressants dusts.
5. Tachypnea 3. Increase OFI.
6. Anorexia Antibiotics (as 4. Manage signs and
7. Fever necessary) symptoms.
8. Chest pain 5. No to smoking
9. Gradual darkening of Oxygen therapy
the skin. Evaluation:
10. Gradual dark shallow Bronchodilators 1. Have adequate
rifts in nails. ventilation and be
11. Cyanosis Corticosteroids maintained.
12. Pallor 2. Maintenance of patent
13. Respiratory airway.
insufficiency. 3. Effective breathing
patterns and be
Diagnosis: maintained.
1. Impaired gas 4. Client will
exchange communicate in
2. Ineffective airway effective manner.
clearance 5. Demonstrate increased
3. Ineffective breathing tolerance for activity.
pattern 6. Reduction of anxiety.
4. Impaired verbal 7. Adequate nutrition
communication status and be
5. Activity intolerance maintained.
6. Anxiety 8. Remains free from
7. Altered nutrition: less infections.

Page | 70
 than body
requirements
8. Risk for infection

Planning:
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
PNEUMOCONIOSES DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
DISORDER (ADPIE) MEDICAL SURGICAL NURSING
2. Asbestosis Asbestos is a naturally Prolong exposure to Assessment: CT-Scan Lung Intervention:
occurring mineral Asbestos transplantation 1. Eat well balanced diet.
substance that can be Asbestos Causes Changes MRI 2. Adequate sleep and
pulled into a fluffy in Pleura rest.
consistency. 1. Pleural plaques Chest X-ray 3. Exercise regularly.
It is soft and flexible 2. Diffuse pleural Oxygen 4. Increase OFI.
and yet resistant to thickening 5. Prevent respiratory

Page | 71
heat, electricity and 3. Benign asbestos Pulmonary infections.
chemical corrosion. pleural effusions Rehabilitation 6. Avoid pollution.
4. Rounded atelectasis
It can mix to cloth, (folded lung) Evaluation:
cement, paper, plastic 1. Have adequate
and other materials to Signs and Symptoms: ventilation and be
make them stronger. 1. Chest pain maintained.
2. Dyspnea 2. Maintenance of patent
Asbestosis – chronic 3. Persistent dry cough airway.
lung disease caused by 4. Fatigue 3. Effective breathing
scarring of lung tissue. 5. Chest tightness patterns and be
6. Anorexia maintained.
7. Wt. loss 4. Client will
communicate in
Diagnosis: effective manner.
1. Impaired gas 5. Demonstrate increased
exchange tolerance for activity.
2. Ineffective airway 6. Reduction of anxiety.
clearance 7. Adequate nutrition
3. Ineffective breathing status and be
pattern maintained.
4. Impaired verbal 8. Remains free from
communication infections.
5. Activity intolerance
6. Anxiety
7. Altered nutrition: less
than body
requirements
8. Risk for infection

Planning:
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent

Page | 72
 airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
PNEUMOCONIOSES DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
DISORDER (ADPIE) MEDICAL SURGICAL NURSING
3. Coal Worker’s Also known as “black Long term exposure Assessment: Chest X-ray Intervention:
Pneumoconiosis lung disease”. to coal dusts. 1. Inflammation 1. Eliminating exposures
(CWP) 2. Fibrosis CT-Scan to coal dusts.
Cannot be removed by 3. Necrosis 2. Wear masks.
the body the inhaled 4. Often Asymptomatic MRI 3. Increase oral fluid
coal dusts. 5. Dyspnea intake.
6. Tahcypnea History Assessment 4. No smoking.

Complication: Oxygen therapy Evaluation:

1. Chronic Bronchitis 1. Have adequate
Pulmonary ventilation and be
Diagnosis: rehabilitation maintained.
1. Impaired gas 2. Maintenance of patent
exchange Influenza vaccine airway.
2. Ineffective airway 3. Effective breathing
clearance patterns and be

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 3. Ineffective breathing maintained.
pattern 4. Client will
4. Impaired verbal communicate in
communication effective manner.
5. Activity intolerance 5. Demonstrate increased
6. Anxiety tolerance for activity.
7. Altered nutrition: less 6. Reduction of anxiety.
than body 7. Adequate nutrition
requirements status and be
8. Risk for infection maintained.
8. Remains free from
Planning: infections.
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.

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 CHEST TRAUMA DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
1. Fractured Ribs Most common chest Blunt trauma Assessment: Chest X-ray Intervention:
injury resulting from 1. Pain during 1. Provide pain relief or
blunt trauma. inspiration. ABG control.
2. Point tenderness 2. Monitor closely for
Ribs 4 to 8 are most 3. Bruising at injury site Narcotics complication
commonly fractured 4. Splinting with shallow
because they are least respirations Intercostal nerve block Evaluation:
protected by chest 5. Apprehensiveness 1. Have adequate
muscles. ventilation and be
Diagnosis: maintained.
Splintered or dis- 1. Impaired gas 2. Maintenance of patent
placed fractured ribs exchange airway.
may penetrate the 2. Ineffective airway 3. Effective breathing
pleura and lungs. clearance patterns and be
3. Ineffective breathing maintained.
pattern 4. Client will
4. Impaired verbal communicate in
communication effective manner.
5. Activity intolerance 5. Demonstrate increased
6. Anxiety tolerance for activity.
7. Altered nutrition: less 6. Reduction of anxiety.
than body 7. Adequate nutrition
requirements status and be
8. Risk for infection maintained.
8. Remains free from
Planning: infections.
1. Have adequate
ventilation and be
maintained.
2. Maintenance of patent
airway.
3. Effective breathing

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 patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.
CHEST TRAUMA DESCRIPTION FACTORS NURSING PROCESS MANAGEMENT
(ADPIE) MEDICAL SURGICAL NURSING
2. Flail Chest Fracture of several Trauma Assessment: Chest X-ray Intervention:
ribs and resultant 1. Severe dyspnea 1. Maintain patent
instability of the Car Accidents 2. Rapid shallow ABG airway.
affected chest wall. breathing 2. Monitor mechanical
Falls 3. Grunty breathing ventilator
The flail portion 4. Paradoxical chest 3. Turn to sides every 2
sucked in during motion hours.
inspiration and bulges 5. Cyanosis 4. Encourage coughing
out on expiration. 6. Neck vein distention and deep breathing
7. Tachycardia exercises.
8. Hypotension 5. Monitor for signs of
shock.
Diagnosis:
1. Impaired gas Evaluation:
exchange 1. Have adequate
2. Ineffective airway ventilation and be
clearance maintained.
3. Ineffective breathing 2. Maintenance of patent

Page | 76
 pattern airway.
4. Impaired verbal 3. Effective breathing
communication patterns and be
5. Activity intolerance maintained.
6. Anxiety 4. Client will
7. Altered nutrition: less communicate in
than body effective manner.
requirements 5. Demonstrate increased
8. Risk for infection tolerance for activity.
6. Reduction of anxiety.
Planning: 7. Adequate nutrition
1. Have adequate status and be
ventilation and be maintained.
maintained. 8. Remains free from
2. Maintenance of patent infections.
airway.
3. Effective breathing
patterns and be
maintained.
4. Client will
communicate in
effective manner.
5. Demonstrate
increased tolerance for
activity.
6. Reduction of anxiety.
7. Adequate nutrition
status and be
maintained.
8. Remains free from
infections.

Page | 77
References

Doherty, Christi (2020). Med-Surg Success: NCLEX-Style Q&A Review, F.A. Davis Publishing 2020. ISBN: 1719645442.
Hinkle, Janice & Cheever, Kerry (2022). Brunner & Suddarth’s textbook of Medical Surgical Nursing Vol. 1&2 + Study Guide for Brunner & Suddarth’s Textbook
of Medical Surgical Nursing (Strictly Set), 15th Edition. Lippincott Williams & Wilkins Publishing 2022. ISBN: 888882200141.
Ignatavicius, Donna, Rebar, Cherie & Heimgartner, Nicole (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th
Edition, Elsevier Publishing 2023. ISBN: 032387827X.
Honan, Linda (2023). Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition, Lippincott Williams & Wilkins Publishing 2023. ISBN: 1975190963.
Nedu (2020). ABG Interpretation fir Nurses: Everything You Need to Know to Interpret Arterial Blood Gases. Illustrated Edition, NEDU LLC Publisher, 2020.
ISBN: 1952914000.

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