Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer. TNM staging system. TNM staging takes the following factors into account. The size of the Lung Cancer (T). Whether Lung Cancer cells have spread into the lymph nodes (N) whether the Lung Cancer has spread anywhere else in the body – secondary cancer or metastases (M)

Stage of Lung cancer TNM (Tumor, Nodes, Metastases) system of staging

TNM Stage of Lung cancer Description:

Primary tumor (T)

• TX; Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy.
• T0 :  No evidence of primary tumor
• Tis :  Carcinoma in situ
• T1 :  Tumor 3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)
• T2: Tumor with any of the following features of size or extent: 3 cm in greatest dimension. Involves main bronchus, 2 cm distal to the carina Invades the visceral pleura Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung.
• T3 : Tumor of any size that directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinum pleura, parietal pericardium; or          tumor in the main bronchus, 2 cm distal to the carina, but without involvement of          the carina; or associated atelectasis or obstructive pneumonitis of the entire lung
• T4: Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina; or tumor with a malignant pleural or pericardial effusion, b or with satellite tumor nodule(s) within the ipsilateral primary-tumor lobe of the lung

Regional lymph nodes (N)

• NX Regional lymph nodes cannot be assessed
• N0 No regional lymph node metastasis
• N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes involved by direct extension of the primary tumor
• N2 Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s)
• N3 Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral, or contralateral scalene, or supraclavicular lymph node(s)

Distant Metastasis (M)

• MX Presence of distant metastasis cannot be assessed
• M0 No distant metastasis
• M1 Distant metastasis present

Stage grouping (TNM subsets):

• Stage IA (T1 N0 M0), IB (T2 N0 M0). Most common form of early lung cancer located only in the lungs. Detected on routine chest X-ray in patients who present for unrelated medical condition or routine examination. Treatment-surgical resection.
• Stage IIA (T1 N1 M0), IIB (T2 N1 M0, T3 N0 M0). Tumors in the lung and lymph nodes (hilar and bronchopulmonary nodes). Treatment-surgical resection and adjuvant radiation or chemotherapy, or both. Induction chemotherapy before surgery is being investigated. Patients with significant co-morbid disease surgery may not be an option.
• Stage IIIA (T3 N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0) Cancer in the lung and lymph nodes on the same side of the chest.  T3 tumors involving the main stem bronchi produce hemoptysis, Dyspnea, wheezing, atelectasis, and post obstructive pneumonia. T3 tumors involving the pericardium or diaphragm may be symptomatic but those involving the chest wall usually cause pain. Nodal disease is often asymptomatic, if extensive nodal disease may cause compression of the proximal airways and superior vena cava syndrome. Treatment—selected cases surgical resection (T3NO-1), commonly multi-modality therapy with chemotherapy being primary form of treatment; multiple trials of combined chemotherapy, radiation with or without surgery are under investigation.
• Stage IIIB (T4 N0 M0, T4 N1 M0, T4 N2 M0, T1 N3 M0, T2 N3 M0, T3 N3 M0, T4 N3 M0) Cancer has spread to the lymph nodes on the opposite side of the chest. T4 tumors invade the mediastinum structures, and/or malignant pleural effusions. N3—metastases. Treatment—chemotherapy and radiation therapy; in rare exceptions, surgery may be considered.
• Stage IV (Any T Any N M1) Evidence of metastatic disease. Treatment often palliative (to relieve symptoms). Clinical trials may offer some survival benefit.

Like many other neoplasm disease Complications of Lung Cancer occurs when lung cancer metastasized to other organ, outside the Lung. Disease progression and metastasis cause various complications. Early stage and localized disease may be asymptomatic. Symptoms are often medically treated and attributed to conditions such as bronchitis, pneumonia, and chronic obstructive pulmonary disease. Symptoms: cough & wheezing, increased sputum production, hemoptysis, Dyspnea, pneumonia, pleural effusions.

Advanced disease predominant at time of diagnosis related to tumor growth and compression of adjacent structures. When the primary tumor spreads to intrathoracic structures, complications may include tracheal obstruction; esophageal compression with dysphagia; phrenic nerve paralysis with hemidiaphragm elevation and dyspnea; sympathetic nerve paralysis with Horner’s syndrome with ptosis, miosis, hemifacial anhydrosis, clubbing, hypertrophic osteoarthropathy, bone pain, fatigue, dysphagia from esophageal compression, wheezing or stridor, phrenic nerve paralysis with elevated hemidiaphragm, arrhythmias and heart failure (from pericardial involvement), hypoxia related to lymphangitic spread, superior vena cava syndrome (swelling of the face, neck and upper extremities and related to compression of blood vessels in the neck and upper thorax.

Symptoms: chronic cough, Dyspnea, weight loss, increased sputum production, hemoptysis, hoarseness (involvement of the laryngeal nerve), pleural effusions and atelectasis, chronic pain, pain over the shoulder and medial scapula, arm pain with or without muscle wasting along ulnar distribution,

Lung cancer usually cause breathing and heart problems such as:

• Pleural effusion
• Pericardial effusion
• Coughing up large amounts of bloody sputum.
• Collapse of a lung (pneumothorax).
• Blockage of the airway (bronchial obstruction).
• Recurrent infections, such as pneumonia.

Other complications are anorexia and weight loss, sometimes leading to cachexia, digital clubbing, and hypertrophic osteoarthropathy. Endocrine syndromes may involve production of hormones and hormone precursors.

Extra thoracic spread of disease: adrenal glands (50%), liver (30%), brain (20%), bone (20%), kidneys (15%), scalene lymph nodes. Prognosis remains poor and has improved very slightly despite medical advances: <14% combined 5-year survival rate.

A common treatment method of Lung Cancer is Surgery, chemotherapy and radiotherapy is all classified as a treatment for lung cancer. Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer.  Lung cancer accounts for more deaths than prostate, breast, and colon cancer combined. The 1-year survival rate remains approximately 41%, and the 5-year survival rate is 15%. Only 16% of lung cancers are found at an early, localized stage, when the 5-year survival rate is 49%. The survival rate for lung cancer has not improved over the last 10 years.

Common treatment methods of Lung Cancer:

Surgery Treatment for Lung Cancer

The treatment of choice for non-small cell lung cancer, Stage IA, IB, IIA, IIB, and selected cases of stage IIIA : lobectomy (removal of a lobe of the lung), pneumonectomy (removal of one lung), wedge resection or segmentectomy for patients with inadequate pulmonary reserve who cannot tolerate lobectomy, VATS (Video Assisted Thoroscopic Surgery), palliative surgery. Before surgery patient must know the risk factor from Lung Cancer Surgery; Risks from lung cancer surgery include damage to structures in or near the lungs, general risks related to surgery, and risks from general anesthesia

Patient education before surgery: patient understands surgical procedure, incision, placement of chest tubes; smoking cessation before surgery to reduce pulmonary complications pain control; bronchodilators, coughing and deep-breathing exercises, early ambulation after surgery.

After surgery : assess respiratory function (respiratory rate, level of dyspnea, use of accessory muscles, and arterial blood gases); monitor chest tube drainage and air leaks, monitor oxygen saturation at rest and ambulation, assess pain control, chest physical therapy (bronchial drainage positions, deep breathing, coughing)  early ambulation,monitor for atrial arrhythmias ; discharge planning and home care arrangements.

Chemotherapy Treatment for Lung Cancer

Researchers are continually looking at different ways of combining new and old drugs for advanced non-small cell lung cancer.

Chemotherapy Treatment for Non-Small Cell Lung Cancer

1. Customize treatment: Erlotinib (Tarceva) for people whose tumors have epidermal growth factor receptors, a genetic mutation. Gefitinib (Iressa) effective in people whose lung tumors have similar genetic mutations.
2. Targeted treatments for advanced non-small cell lung cancer; Sunitinib (Sutent) works by cutting off blood supply and blockingnthe cancer cells their ability to grow. Sorafenib (Nexavar) suppresses receptors for vascular endothelial growth factor platelet derived growth factor—plays a critical role in the growth of blood vessels that feed the cancer (angiogensis).
3. Combined methods are the treatment of choice for selected cases of stage IIIA and IIIB;  Cispatin, Paclitaxel and Gemcitabine, Gemcitabine and Vinorelbine, Carboplatin and Paclitaxel and radiation, Cisplatin and Vinblastine and radiation
4. Stage IV; Carboplatin and Paclitaxel, Carboplatin and Gemcitabine, Cisplatin and Vinorelbine, Docetaxel and Gemcitabine, Pemetrexed, Chemotherapy combined with Cetuximab (Erbitux): Cetuximab binds to epidermal growth factor receptors (EGFR), preventing a series of reactions in the cell that lead to lung cancer.
5. Progression of disease: Single-agent Docetaxel, Gemcitabine, Paclitaxel
6. Investigational New treatment approaches are being investigated all the time. Mage-A3 vaccine and non-small cell lung cancer, Bortezomib (Velcade) proteasome inhibitors destroys cancer cells

Chemotherapy Treatment for Small-Cell Lung Cancer

1. Limited-stage disease;  Pulmonary resection stage I or stage II, Etoposide and Cisplatin and Radiation, Etoposide and Carboplatin
2. Extensive stage disease: Etoposide and Carboplatin +/− Paclitaxel, Adriamycin, Cyclophosphamide
3. Investigational: Vaccine-autologous dendritic cell-adenovirus p53

Chemotherapy treatment Complications, Myelosuppression (infection, anemia, bleeding), nephrotoxicity, nausea and vomiting, mucositis (inflammation of the mucous membranes), fatigue, SIADH and hyponatremia, hypotension, anaphylaxis, alopecia (hair loss), neurotoxicity (peripheral neuropathies, central nervous system toxicity), cardiomyopathy, arrhythmias, congestive heart failure, myocardial infarction, pneumonitis or pulmonary fibrosis, taste changes.

Patient education (chemotherapy): chemotherapeutic agents, treatment schedule, adverse effects of drugs.

Radiation therapy Treatment for Lung Cancer

1. External beam radiotherapy used as an adjunct to surgery to decrease tumor size, to cure patients considered inoperable for medical or pathologic reasons, or to decrease symptoms. Radiation after surgery: to improve resectability of tumor & to sterilize microscopic disease. Radiation after surgery: to treat disease confined to one hemi thorax with hilar or mediastinum nodal metastasis & to reduce local recurrence (if positive surgical margins exist). Prophylactic cranial irradiation: limited disease small-cell lung cancer to reduce reoccurrence in CNS.
2. Brachytherapy placement of radioactive sources (seeds or catheter) directly into or adjacent to a tumor. Intraoperative: reduce local recurrence. Symptom palliation (relief of pain from bone metastases, hemoptysis, superior vena cave syndrome, airway obstruction).

Complications of radiation therapy: Dyspnea, cough, initial increase in mucus production, and then dry cough, fatigue, skin erythema, esophagitis and dysphagia, pneumonitis, lung fibrosis.

Patient education: radiation therapy: indelible markings, treatment schedule, site-specific adverse effects (within treatment field).

Treatment alternatives

Neoadjuvant is therapy given before the primary therapy to improve effectiveness (e.g., chemotherapy or radiation before surgery). Adjuvant treatments are equally beneficial and often given concurrently or immediately following one another to maximize effectiveness (e.g., surgery and adjuvant chemotherapy after surgery), multimodality is therapy that combines more than one method of treatment (e.g. concurrent chemotherapy and radiation, such as, adjuvant and Neoadjuvant)

Home care considerations

After lung surgery: smoking cessation, control of incision pain, wound care, breathing exercises and coughing, pursed lip breathing exercises, maintain fluid intake, maintaining your nutrition, resume activity, regaining arm and shoulder function.

During and after radiation therapy: monitor side effects of radiation therapy and report any change in.

Symptoms: Dyspnea, fatigue is common lasting 4–6 weeks after therapy, good nutrition, liquid diet supplement during periods of esophagitis, avoid wearing tight clothes, skin care.

During and after chemotherapy, advise patients:

• To identify all treatment related side effects and report changes
• Fatigue may last weeks to months
• To plan their day, and allow for periods of rest
• Try activities such as yoga, exercise, meditation, and guided imagery
• Keep a diary and document symptoms, activity level, nutrition, treatments, and emotions
• To monitor effectiveness of pain medications
• To monitor for any signs of infection, such as an increased temperature, redness or swelling, and that the latter symptoms may not be present during weeks of impaired immunity following chemotherapy administration
• Monitor weight change and appetite
• Nutritional supplements

Pulmonary rehabilitation programs: exercise strengthening, breathing exercises, walking program, nebulizers/aerosol medication delivery, disease specific instruction and support. Support groups: Lung Cancer specific, Better Breathers Club a support group sponsored by the American Lung Association for patients with chronic lung disease. Hospice: dignified dying, pain management, end of life issues, patient/family support.

To categorize lung cancers visible Pathologic features on light microscopy, are used. Lung cancers are divided into two major groups, Small Cell Lung Cancer and Non–Small Cell Lung Cancer

Non-Small Cell Lung Cancer

1. Squamous cell (epidermoid forms in the lining of the bronchial tubes). Most common type of lung cancer in men. Decreasing incidence in last two decades.  Typically develops in segmental bronchi, causing bronchial obstruction and regional lymph node involvement. Symptoms are related to obstruction : nonproductive cough, pneumonia, atelectasis, that is, a collapsed lung, chest pain is a late symptom associated with bulky tumor, Pancoast Tumor, or pulmonary sulcus tumor, begins in the upper portion of the lung and commonly spreads to the ribs and spine causing classic shoulder pain that radiates down the ulnar nerve distribution. Treatment: surgical resection is preferred before the development of metastatic disease, chemotherapy and radiation therapy to decrease the incidence of recurrence.
2. Adenocarcinoma. Most common form in Unites States, Increasing incidence in females. Occurs in non smokers. adenocarcinoma develops in the periphery of the lungs and frequently metastasizes to brain, bone, and liver. Symptoms: no symptoms with small peripheral lesions, Identifi ed by routine chest radiograph/CT scan. Treatment: surgical resection and chemotherapy and radiation therapy to decrease the incidence of recurrence.
3. Bronchioalveolar (BAC). Form near the lung’s air sacs. BAC may have abnormal gene in their tumor cells. Targeted chemotherapy treatment appears to be effective.
4. Large cell. Large cell: 10% of all lung cancer cases. Bulky peripheral tumor. Metastasizing to brain, bone, adrenal glands, or liver. Symptoms related to obstruction or metastatic spread pneumonitis and pleural effusions. Treatment: surgical resection (limited because of the often aggressive course of this tumor type) and chemotherapy and radiation therapy (palliative role to minimize symptoms of advanced disease).

Small-Cell Lung Cancer

Patients with SCLC often have widespread disease at the time of diagnosis. Rapid clinical deterioration in patients with chest masses often indicates SCLC

1. Oat cell carcinoma Oat cell carcinoma: 13% of all lung cancers. Most aggressive type, greater tendency to metastasize than Non-Small Cell Lung Cancer Strongly related to cigarette smoking often occurs within the mainstem bronchi and segmental bronchi; 80% of cases have hilar and mediastinal node involvement. Symptoms: Paraneoplastic syndrome: syndrome of inappropriate antidiuretic hormone (SIADH), Hyponatremia, fluid retention, weakness, and fatigue, Ectopic adrenocorticotropic hormone (ACTH) production, Hypokalemia, hyponatremia, hyperglycemia, lethargy, and confusion. Treatment for Oat cell carcinoma, Surgery rarely indicated even in those with limited stage disease because of the need for immediate systemic therapy and chemotherapy and radiation therapy offers the best hope for prolonged survival and quality of life. Majority of the patients respond to chemotherapy and radiation therapy but recurrence rate is very high. Two-thirds of patients demonstrate evidence of extensive disease at the time of diagnosis.
2. Non-Bronchogenic Carcinomas. Undifferentiated non-small cell lung cancer (NSCLC). Non-bronchogenic carcinomas undifferientated non-small cell lung cancer (NSCLC) : <5% of all lung cancers combined: Mesothelioma a rare tumor of the parietal pleura, Mesothelioma is another rare type of cancer which affects the covering of the lung (the pleura). It is often caused by exposure to asbestos, bronchial adenoma (carcinoid), fibrosarcoma.

Definition of Pneumothorax (collapsed lung), Pneumothorax is is defined as the presence of air in the pleural space. Air in the pleural space occurring spontaneously or from trauma. In patients with chest trauma, it is usually the result of a laceration to the lung parenchyma, tracheobronchial tree, or esophagus. The patient’s clinical status depends on the rate of air leakage and size of wound. The amount of air or gas trapped in the intrapleural space determines the degree of lung collapse.

Classification of Pneumothorax

• Spontaneous Pneumothorax sudden onset of air in the pleural space with deflation of the affected lung in the absence of trauma.
• Open Pneumothorax (sucking wound of chest) implies an opening in the chest wall large enough to allow air to pass freely in and out of thoracic cavity with each attempted respiration.
• Tension Pneumothorax buildup of air under pressure in the pleural space resulting in interference with filling of both the heart and lungs.
• Traumatic Pneumothorax; Traumatic Pneumothorax may result from insertion of a central venous line, thoracic surgery, or a penetrating chest injury, such as a gunshot or knife wound, or it may follow a transbronchial biopsy. It may also occur during thoracentesis or a closed pleural biopsy. When traumatic Pneumothorax follows a penetrating chest injury, hemothorax (blood in the pleural space) may also occur.

Other classification of Pneumothorax :

• Primary spontaneous Pneumothorax
• Secondary spontaneous Pneumothorax
• Iatrogenic Pneumothorax
• Traumatic Pneumothorax

Clinical Manifestations of Pneumothorax

• Hyperresonance; diminished breath sounds.
• Reduced mobility of affected half of thorax.
• Tracheal deviation away from affected side in tension pneumothorax
• Clinical picture of open or tension pneumothorax is one of air hunger, agitation, hypotension, and cyanosis
• Mild to moderate dyspnea and chest discomfort may be present with spontaneous pneumothorax

Pneumothorax Etiology

• Primary spontaneous: rupture of pleural blebs typically occurs in young people without parenchymal lung disease or occurs in the absence of traumatic injury to the chest or lungs
• Secondary spontaneous: occurs in the presence of lung disease, primarily emphysema, but can also occur with tuberculosis (TB), sarcoidosis, cystic fibrosis, malignancy, and pulmonary fibrosis
• Iatrogenic: complication of medical or surgical procedures, such as therapeutic thoracentesis, tracheostomy, pleural biopsy, central venous catheter insertion, positive pressure mechanical ventilation, inadvertent intubation of right mainstem bronchus
• Traumatic: most common form of pneumothorax and hemothorax, caused by open or closed chest trauma related to blunt or penetrating injuries

Complications

• Acute respiratory failure.
• Cardiovascular collapse with tension Pneumothorax
• Hypoxemia

Pneumothorax Treatment. Treatment is conservative for spontaneous pneumothorax in which no signs of increased pleural pressure appear (indicating tension Pneumothorax), lung collapse is less than 30%, and the patient shows no signs of Dyspnea or other indications of physiologic compromise.  Such treatment consists of bed rest, careful monitoring of blood pressure, pulse rate, and respirations, oxygen administration, and  needle aspiration.

If more than 30% of the lung is collapsed, treatment to reexpand the lung includes placing a thoracostomy tube in the second or third intercostal space in the midclavicular line, connected to an underwater seal or low-pressure suction.

Oxygen therapy and mechanical ventilation are prescribed as needed. Surgical interventions include removing the penetrating object, exploratory thoracotomy if necessary, thoracentesis, and thoracotomy for patients with two or more episodes of spontaneous pneumothorax or patients with pneumothorax that does not resolve within 1 week.

Spontaneous Pneumothorax

• Treatment is generally nonoperative if Pneumothorax is not too extensive; Observe and allow for spontaneous resolution for less than 50% pneumothorax in otherwise healthy person, Needle aspiration or chest tube drainage may be necessary to achieve reexpansion of collapsed lung if greater than 30% pneumothorax.
• Surgical intervention by pleurodesis or thoracotomy with resection of apical blebs is advised for patients with recurrent spontaneous pneumothorax.

Tension Pneumothorax

• Immediate decompression to prevent cardiovascular collapse by thoracentesis or chest tube insertion to let air escape.
• Chest tube drainage with underwater-seal suction to allow for full lung expansion and healing

Open Pneumothorax

• Close the chest wound immediately to restore adequate ventilation and respiration. Patient is instructed to inhale and exhale gently against a closed glottis (Valsalva maneuver) as a pressure dressing (petroleum gauze secured with elastic adhesive) is applied. This maneuver helps to expand collapsed lung.
• Chest tube is inserted and water-seal drainage set up to permit evacuation of fluid/air and produce reexpansion of the lung.
• Surgical intervention may be necessary to repair trauma.

Recurring spontaneous pneumothorax treated by instilling a sclerosing agent through a thoracostomy tube or during thoracostomy. Thoracotomy and pleurectomy are other procedures that prevent recurrence by causing the lung to adhere to the parietal pleura. Traumatic and tension pneumothoraces require chest tube drainage. Traumatic Pneumothorax may also require surgical repair.

Nursing Diagnosis Pneumothorax
Nursing Assessment Pneumothorax

Patient History, Obtain history for chronic respiratory disease, trauma, and onset of symptoms. The patient history reveals sudden, sharp, pleuritic pain. The patient may report that chest movement, breathing, and coughing exacerbate the pain. He may also report shortness of breath.

Ask about chest pain; determine its onset, intensity, and location. Ask if the patient has shortness of breath or difficulty in breathing or fatigue. Elicit a history of COPD or emphysema or if the patient has had a thoracotomy, thoracentesis, or insertion of a central line. Ask if the patient smokes cigarettes

For patients who have experienced chest trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. Specify the type of trauma (blunt or penetrating).

Physical Examination

The severity of the symptoms depends on the extent of any underlying disease and the amount of air in the pleural space. Examine the patient’s chest for a visible wound that may have been caused by a penetrating object. Patients with an open Pneumothorax also exhibit a sucking sound on inspiration.

Inspection typically reveals asymmetrical chest wall movement with overexpansion and rigidity on the affected side. The patient may appear cyanotic. In tension pneumothorax, he may have distended neck veins and pallor, and he may exhibit anxiety. Observe whether the patient has a flail chest. Examine the thorax area, including the anterior chest, posterior chest, and axillae, for contusions, abrasions, hematomas, and penetrating wounds. Note that even small penetrating wounds can be life-threatening if vital structures are perforated. Observe the patient carefully for pallor. Take the patient’s blood pressure and pulse rate, noting the early signs of shock or massive bleeding, such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill. Continue to monitor the vital signs frequently during periods of instability to determine changes in the condition or the development of complications.

Palpation, note any tracheal deviation toward the unaffected side, subcutaneous emphysema (also known as crepitus; a dry, crackling sound caused by air trapped in the subcutaneous tissues), or decreased to absent tactile fremitus over the affected area. Percussion may elicit a hyperresonant or tympanitic sound.

Auscultation reveals decreased or absent breath sounds over the affected area and no adventitious sounds other than a possible pleural rub. Auscultate chest for diminished breath sounds and percuss for hyperresonance.

Percussion may reveals hyperresonance on the affected side

Diagnostic Test For Pneumothorax

Blood Tests

• Arterial blood gases (ABGs): Measures oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia.
• Hemoglobin/hematocrit (Hgb/Hct): Assesses relationship of red blood cells (RBCs) to fluid volume or viscosity.

Other Diagnostic Studies

• Chest x-ray: Evaluates organs or structures within the chest and is the initial study of choice in blunt force chest trauma.
• Thoracic computed tomography (CT): Enhance anatomic views of the chest and locates abnormalities. Early CT may influence therapeutic management.
• Thoracic ultrasound: Assists in determining abnormalities in the chest.
• Thoracentesis: Performed to relieve the intrathoracic pressure due to accumulation of fluid in the pleural space.

Nursing diagnosis Pneumothorax

Common Nursing Diagnosis That Could Be Found In Patient with Pneumothorax:

• Ineffective Breathing Pattern
• Risk for Trauma/Suffocation
• Deficient Knowledge [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs
• Acute pain
• Anxiety
• Fear
• Impaired gas exchange related to decreased oxygen diffusion capacity
• Ineffective coping
• Ineffective tissue perfusion: Cardiopulmonary
• Risk for infection

Common Nursing Diagnosis That Could Be Found In Nursing care plans for Pneumothorax:  Ineffective Breathing Pattern, Risk for Trauma/Suffocation, Deficient Knowledge,  Acute pain, Anxiety,  Fear, Impaired gas exchange, Ineffective coping,  Ineffective tissue perfusion: Cardiopulmonary,  Risk for infection.

Nursing diagnosis:

Ineffective Breathing Pattern related to: Decreased lung expansion due to air or fluid accumulation, musculoskeletal impairment, Pain and anxiety, inflammatory process

Nursing Interventions Nursing Diagnosis Ineffective Breathing Pattern

Respiratory Monitoring

1. Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation.
2. Evaluate respiratory function, noting rapid or shallow respirations, Dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.
3. Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.
4. Auscultate breath sounds.
5. Note chest excursion and position of trachea.
6. Assess fremitus.

Ventilation Assistance

1. Assist client with splinting painful area when coughing, or during deep breathing.
2. Maintain position of comfort, usually with head of bed elevated. Turn to affected side.  Encourage client to sit up as much as possible.
3. Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations.

Tube Care: Chest

1. If thoracic catheter is disconnected or dislodged: Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once.
2. After thoracic catheter is removed: Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage.

Ventilation Assistance

1. Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements.
2. Administer supplemental oxygen via cannula, mask, or mechanical ventilation, as indicated.
3. Administer analgesics and sedatives, as indicated.

Complete Sample Nursing Care Plans for Pneumothorax

Patient teaching for Pneumothorax

Patient teaching Discharge and home healthcare guidance for patient with Pneumothorax; Review all follow-up appointments, which often involve chest x-rays, arterial blood gas analysis, and a physical exam. Refer for counseling, if necessary. Teach the patient when to notify the physician of complications and to report any sudden chest pain or difficulty breathing

Patient teaching Discharge and home healthcare guidance for patient with Pneumothorax

• Reassure the patient. Explain what Pneumothorax is, what causes it, and all diagnostic tests and procedures.
• If the patient is having surgery or chest tubes inserted, explain why he needs these procedures. Reassure him that the chest tubes are inserted to make him more comfortable.
• Encourage the patient to perform deep-breathing exercises every hour when awake.
• Discuss the potential for recurrent spontaneous Pneumothorax, and review its signs and symptoms. Emphasize the need for immediate medical intervention if these should occur.
• Instruct patient to continue use of the incentive spirometer at home.
• For patients with spontaneous Pneumothorax, there is an increased risk for repeat occurrence; therefore, encourage these patients to report sudden Dyspnea immediately.

copd

Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible, sometimes referred to as chronic airway obstruction or chronic obstructive lung disease. The airflow limitation is generally progressive and is normally associated with an inflammatory response of the lungs due to irritants. COPD includes chronic bronchitis and pulmonary emphysema. Chronic bronchitis is a chronic inflammation of the lower respiratory tract characterized by excessive mucous secretion, cough, and Dyspnea associated with recurring infections of the lower respiratory tract. Pulmonary emphysema is a complex lung disease characterized by destruction of the alveoli, enlargement of distal airspaces, and a breakdown of alveolar walls. There is a slowly progressive deterioration of lung function for many years before the development of illness.

Clinical Manifestations Chronic Obstructive Pulmonary Disease (COPD)

Chronic Bronchitis (usually insidious, developing over a period of years) :

1. Presence of a productive cough lasting at least 3 months a year for 2 successive years.
2. Production of thick, gelatinous sputum; greater amounts produced during superimposed infections.
3. Wheezing and dyspnea as disease progresses

Emphysema (Gradual in onset and steadily progressive):

1. Dyspnea, decreased exercise tolerance.
2. Cough may be minimal, except with respiratory infection.
3. Sputum expectoration mild.
4. Increased anteroposterior diameter of chest (barrel chest) due to air trapping with diaphragmatic flattening.

Causes for Chronic Obstructive Pulmonary Disease (COPD)

The etiology of Chronic Obstructive Pulmonary Disease COPD includes:

• Cigarette smoking.
• Air pollution, occupational exposure.
• Allergy, autoimmunity.
• Infection.
• Genetic predisposition, aging.

Etiology of emphysema includes:

• Exposure to tobacco smoke due to smoking preventable cause
• Secondhand smoke or passive smoking: nitric oxide, component of smoke, is a potent bronchodilator
• Ambient air pollution
• Alpha 1 -antitrypsin deficiency: genetic abnormality accounts for less than 1% of Chronic Obstructive Pulmonary Disease (COPD)

Etiology of chronic bronchitis includes:

• Exposure to tobacco smoke due to cigarette smoking
• Secondhand smoke or passive smoking
• Ambient air pollution and occupational irritants
• Sex, race, and socioeconomic status: higher prevalence of respiratory symptoms in men, higher mortality rates in whites, and higher morbidity and mortality in blue-collar workers.
• Occupational dusts and chemicals: vapors, irritants and fumes, particulate matter, organic dust

Complications for Chronic Obstructive Pulmonary Disease (COPD)

• Dyspnea
• Cor pulmonale
• Respiratory failure
• Pneumothorax
• Bronchiectasis: recurrent bouts of bronchitis
• Decreased quality of life and functional status
• Decreased independence due to difficulty breathing and increased oxygen demands resulting in fatigue
• Assistance with activities of daily living (ADLs) as disease progresses
• Pneumonia, overwhelming respiratory infection.
• Right-sided heart failure, Dysrhythmias
• Depression
• Skeletal muscle dysfunction

Stages of COPD Based on the Global Initiative for Chronic Obstructive Lung Disease

Treatment for Chronic Obstructive Pulmonary Disease (COPD)

Treatment for Chronic Obstructive Pulmonary Disease (COPD) is designed to relieve symptoms and prevent complications. Because most COPD patients receive outpatient treatment, they need comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. If programs in pulmonary rehabilitation are available, encourage the patient to enroll.

If the patient is to continue oxygen therapy at home, teach the patient  how to use the equipment correctly. Patients with COPD rarely require more than 3 L/minute to maintain adequate oxygenation. Higher flow rates will further increase the partial pressure of arterial oxygen, but patients whose ventilatory drive is largely based on hypoxemia commonly develop a markedly increased partial pressure of arterial carbon dioxide. In such patients, chemoreceptors in the brain are relatively insensitive to the increase in carbon dioxide.

Treatment for Chronic Obstructive Pulmonary Disease (COPD) includes:

• Smoking cessation.
• Inhaled bronchodilators reduce Dyspnea and bronchospasm; delivered by metered dose inhalers (MDI) or handheld or mask nebulizer devices.
• Methylxanthines, such as theophylline (Theo-Dur), given orally as sustained-release formulation for chronic maintenance therapy (less commonly used).
• Inhaled corticosteroids are recommended for patients with symptomatic COPD with documented spirometric improvement from glucocorticosteroids, or in those with an FEV₁ that is less than 50% of the predicted value and repeated exacerbations requiring treatment with antibiotics and/or oral glucocorticosteroids.
• Antibiotics help treat respiratory tract infections. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures.
• Oral corticosteroids are used in acute exacerbations for anti-inflammatory effect; may also be given I.V. in severe cases.
• Chest physical therapy, including postural drainage for secretion clearance and breathing retraining for improved ventilation and control of dyspnea.
• Supplemental oxygen therapy for patients with hypoxemia. CO₂ must be monitored to determine increased CO₂ retention.
• Pulmonary rehabilitation to improve function, strength, symptom control, disease self-management techniques, independence, and quality of life.
• Antimicrobial agents for episodes of respiratory infection.
• Lung volume reduction surgery is under investigation for treatment of heterogeneous emphysema.
• Treatment for alpha₁-antitrypsin deficiency:
• Prevent damage to lungs by quitting smoking.
• Lung transplantation may be considered for people with severely disabling alphaantitrypsin disease.

Nursing Diagnosis Chronic Obstructive Pulmonary Disease (COPD)

Nursing diagnosis Nursing Care Plans Chronic Obstructive Pulmonary Disease (COPD) determine with the data that we collect in nursing assessment

Nursing Assessment Chronic Obstructive Pulmonary Disease (COPD)

The typical patient with Chronic Obstructive Pulmonary Disease (COPD), have a long-term cigarette smoker, remains asymptomatic until middle age. His ability to exercise or do strenuous work gradually starts to decline, and he begins to develop a productive cough. These signs are subtle at first, but become more pronounced as the patient gets older and the disease progresses. Eventually the patient may develop Dyspnea on minimal exertion, frequent respiratory infections, intermittent or continuous hypoxemia, and grossly abnormal pulmonary function studies.

Patient History:

• Exposure to risk factors
• Past medical history including asthma, allergy sinusitis, or nasal polyps
• Family history of COPD or other chronic respiratory disease
• Chronic cough: length of time, daily or intermittent, seldom noc turnal
• Chronic sputum production: characteristics of sputum, change with the season amount produced
• Dyspnea that is progressive, persistent, worse with exercise, worse during respiratory infections
• History of exposure to tobacco smoke, occupational dusts and chemicals, smoke from home cooking and heating fuels
• Smoking history: pack years (number of packs per day multiplied by number of years smoking)
• Age when fi rst noticed symptoms
• Current functional status and ability to perform ADLs
• Limitation of activities
• Pneumonia and other respiratory illnesses
• Use of oxygen: liter flow and years of usage
• Weight loss or weight gain
• Sleep pattern and position during sleep: number of pillows used

Physical Examination

Potential abnormal physical exam findings (will vary based on severity of illness):

• Assessment of severity based on level of symptoms
• Severity of spirometric abnormalities
• Characteristics of respiratory pattern: rate, depth, symmetry, and synchrony; breathlessness due to airway narrowing and bronchoconstriction
• Use of pursed lip breathing
• Breath sounds: normal and adventitious: crackles, rhonchi and wheezes; hyperresonant lung fields; may be distant due to hyperinflation
• Cough due to increased sputum production: usually worse in the morning
• Sputum production: color, amount; usually increased with chronic bronchitis
• Shortness of breath with speech: two or three words per breath
• Dyspnea on exertion
• Barrel chest as a result of increased RV
• Use of accessory muscles
• Resting pulse oximetry with potential drop with activity
• Presence of complications such as respiratory failure and right heart failure
• Cor pulmonale: right-sided heart failure to include edema, heart rate, blood pressure, jugular venous pressure (JVP)
• Check for presence of murmurs, gallops, rubs, lifts, heaves, and/or thrills
• Fluid retention and edema
• Overall appearance: thin with muscle wasting and barrel chest or overweight with barrel chest
• Enlarged abdominal girth or cachetic appearance
• Enlarged liver with right-sided heart failure
• Posture: hunched over with rolled shoulders
• Pallor skin color
• Generalized edema

Diagnostic Test Chronic Obstructive Pulmonary Disease (COPD)

• Chest X-ray: air trapping; hyperinfl ation; increased A-P diameter; flattened diaphragms
• Postbronchodilator FEV 1
• Pulmonary function test: show decreased FEV 1 (up to 50% loss) and decreased FEF 25%–75%; increased functional residual capacity (FRC) due to air trapping and hyperinflation
• Arterial blood gases: may show increased CO 2 due to inability to expel all of the air (air trapping) and low O 2 levels due to ventilation/ perfusion mismatch
• Assess Dyspnea using a valid tool such as the Modified Borg scale or the Visual Analog Scale
• Oxygen saturation at rest and with activity
• Quality-of-life measure: baseline measurement
• Six-minute walk distance: baseline measurement

Nursing Diagnosis That Could Be Found In Patient with COPD

Common nursing diagnosis found in Nursing care plans for Chronic Obstructive Pulmonary Disease (COPD):

1. Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection
2. Impaired Gas Exchange related to chronic pulmonary obstruction, abnormalities due to destruction of alveolar capillary membrane
3. Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles
4. Deficient Knowledge [Learning Need] regarding condition, treatment, self-care, and discharge needs related to lack of information or unfamiliarity with information resources, Information misinterpretation, Lack of recall or cognitive limitation

Common nursing diagnosis found in Nursing care plans Chronic Obstructive Pulmonary Disease (COPD): Ineffective Airway Clearance, Impaired Gas Exchange, Imbalanced Nutrition: Less Than Body Requirements, Deficient Knowledge.

Nursing diagnosis:

Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection

Goal

Respiratory Status: Airway Patency Effective

Nursing interventions NCP COPD:

• Auscultate breath sounds. Note adventitious breath sounds such as wheezes, crackles, or rhonchi.
• Assess and monitor respiratory rate. Note inspiratory-toexpiratory ratio.
• Note presence and degree of dyspnea, for example, reports of “air hunger,” restlessness, anxiety, respiratory distress, and use of accessory muscles. Use a 0 to 10 scale or American Thoracic Society’s Grade of Breathlessness Scale to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of chronic dyspnea.
• Assist client to maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of bed.
• Keep environmental pollution from sources such as dust, smoke, and feather pillows to a minimum according to individual situation.
• Encourage and assist with abdominal or pursed-lip breathing exercises.
• Observe for persistent, hacking, or moist cough. Assist with measures to improve effectiveness of cough effort.
• Increase fluid intake to 3,000 mL/day within cardiac tolerance.
• Provide warm or tepid liquids. Recommend intake of fluids between, instead of during, meals.
• Administer medications, as indicated indicated, for example: Beta-agonists.
• Provide supplemental humidification, such as ultrasonic nebulizer and aerosol room humidifier.
• Assist with respiratory treatments, such as spirometry and chest physiotherapy.
• Monitor and graph serial ABGs, pulse oximetry, and chest x-ray.

Sample Nursing care plans Chronic Obstructive Pulmonary Disease (COPD)

Most Chronic Obstructive Pulmonary Disease COPD patients receive outpatient treatment, so provide comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease.

Patient Teaching For Patient With Chronic Obstructive Pulmonary Disease COPD:

General Health

• Teach the patient and his family how to recognize early signs of infection; warn the patient to avoid contact with people with respiratory infections. Encourage good oral hygiene to help prevent infection. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures
• Help the patient and his family adjust their lifestyles to accommodate the limitations imposed by this debilitating chronic disease. Instruct the patient to allow for daily rest periods and to exercise daily as directed.
• Teach good habits of well-balanced, nutritious intake.
• Encourage high-protein diet with adequate mineral, vitamin, and fluid intake.
• Advise against excessive hot or cold fluids and foods, which may provoke an irritating cough.
• Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods, which cause distention and restrict diaphragmatic movement.
• Encourage five to six small meals daily to ease shortness of breath during and after meals.
• Suggest rest periods before and after meals if eating produces shortness of breath. Warn against potassium depletion. Patients with COPD tend to have low potassium levels; also, patient may be taking diuretics; Watch for weakness, numbness, tingling of fingers, leg cramps, Encourage foods high in potassium include bananas, dried fruits, dates, figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes.
• Advise patient on restricting sodium as directed.
• Limit carbohydrates if CO₂ is retained by patient, because they increase CO₂.
• Use community resources, such as Meals On Wheels or a home care aide if energy level is low.

Avoid Exposure to Respiratory Irritants

• Advise patient to stop smoking and avoid exposure to second-hand smoke.
• Advise patient to avoid sweeping, dusting, and exposure to paint, aerosols, bleaches, ammonia, and other respiratory irritants.
• Advise patient to keep entire house well-ventilated.
• Warn patient to stay out of extremely hot/cold weather to avoid bronchospasm and dyspnea.
• Instruct patient to humidify indoor air in winter; maintain 30% to 50% humidity for optimal mucociliary function.
• Suggest the use of a HEPA air cleaner to remove dust, pollen, and other particulates; this is controversial as to the benefit to the patient.

Breathing Exercises

• Explain that goal is to strengthen and coordinate muscles of breathing to lessen work of breathing and help lung empty more completely.
• To promote ventilation and reduce air trapping, teach the patient to breathe slowly, prolong expirations to two to three times the duration of inspiration, and to exhale through pursed lips.
• Stress the importance of controlled breathing.
• Teach diaphragmatic breathing and pursed-lip breathing for episodes of dyspnea and stress.
• To help mobilize secretions, teach the patient how to cough effectively. If the patient with copious secretions has difficulty mobilizing secretions, teach his family how to perform postural drainage and chest physiotherapy. If secretions are thick, encourage the patient to drink 12 to 15 glasses of fluid per day.
• Encourage muscle toning by regular exercise.
• If the patient use oxygen therapy at home, teach him how to use the equipment correctly.

Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose, and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis.

Causes Bronchiectasis

The primary etiology in the development of ordinary acquired Bronchiectasis is inflammatory destruction of the elastic tissue, smooth muscle, and cartilage of bronchial walls usually due to severe preceding infection(s). Fewer cases are caused by genetic or immune deficiencies or result from inhalation injury.

Bronchiectasis results from conditions associated with repeated damage to bronchial walls and with abnormal mucociliary clearance, which causes a breakdown of supporting tissue adjacent to the airways. Such conditions include:

Predisposing factors:

• Bronchopulmonary infection— Mycobacterium species, bacterial (e.g., Staphylococcus aureus, Bordetella pertussis, Klebsiella pneumoniae, H. influenza ), viral (e.g., measles, HIV, adenovirus, influenza), fungal (histoplasmosis, coccidiomycosis), recurrent aspiration pneumonia.
• Bronchial obstruction—foreign body aspiration, lung or bronchogenic neoplasm, airway nodules, hilar adenopathy (e.g., sarcoidosis), mucus impaction (e.g., allergic bronchopulmonary aspergllosis), broncholith, external compression by vascular aneurysm.
• Immunodefi ciency states—hypogammaglobulinemia, IgG subclass deficiency, selective IgA deficiency.
• Other congenital syndromes—cystic fibrosis, alpha1-antitrypsin deficiency, primary ciliary dyskinesia (e.g., Kartagener’s syndrome), Young’s syndrome (azoospermia and chronic sinopulmonary infections).
• Inhalation injury—smoke, ammonia, sulfur or nitrogen dioxide.
• Rheumatologic disease—rheumatoid arthritis, Sjogren’s syndrome
• Anatomic defects—bronchomalacia, Swyer-James syndrome, bronchial cartilage deficiency (Williams-Campbell syndrome), tracheobronchomegaly (Mounier-Kuhn syndrome)

Complications Bronchiectasis

1. Hemoptysis occurs in nearly 50% of patients with bronchiectasis (Mysliwiec & Pina, 1999); major pulmonary hemorrhage and death from exsanguination are rare (Swartz, 1998).
2. Empyema, lung abscess, and pneumothorax are serious but rare complications of acute infections in bronchiectasis (Luce, 1994).
3. Progressive respiratory insuffi ciency and cor pulmonale complicate severe bronchiectasis associated with deteriorating pulmonary function and hypoxemia.

TREATMENT FOR BRONCHIECTASIS

a. Medical interventions

1. Inhaled bronchodilators may be helpful in diffuse small airway disease; beta adrenergic agents dilate airways and improve ciliary activity (Swartz, 1998).
2. Antimicrobial therapy for treatment of acute infectious exacerbations is based on results of sputum gram stain and culture.
3. Corticosteroids reduce the airway infl ammatory response in bronchiectasis.
4. Oxygen therapy is prescribed as indicated for patients with hypoxemia at rest, during sleep, and/or with activity.
5. Gamma globulin replacement for immunoglobulin defi ciency may be effective in reducing the frequency and severity of sinopulmonary infections (George et al., 1995).
6. Effective reduction and removal of bronchial secretions by a variety of available methods is critical in patients with bronchiectasis. The approach selected should be based upon an individual’s self-care abilities, motivation, breath control, neuromuscular status, preferences, needs, and financial resources (Langenderfer, 1998).

• Effective cough
• Percussion and postural drainage
• Autogenic drainage
• Positive expiratory pressure (PEP) therapy
• Flutter valve
• Vest therapy
• Humidifi cation (by cold water, jet nebulizers) as an adjunct to chest physiotherapy enhanced sputum production (Conway, Fleming, Perring, & Holgate, 1992).

1. Aerosolized recombinant human DNase may lyse the DNA that causes the sputum to be highly viscous. Initial studies for cystic fibrosis are promising, but this therapy is not FDA approved in non-CF bronchiectasis (O’Donnell, Barker, Ilowite, & Fick, 1998; Wills et al., 1996).
2. Non-invasive intermittent positive pressure ventilation (NIPPV) is an alternative to tracheostomy for respiratory failure due to advanced bronchiectasis.

b. Surgical intervention

1. Surgical resection
2. Lung or heart-lung transplantation

Nursing diagnosis Bronchiectasis

Nursing diagnosis for Bronchiectasis determine from data that we collect from nursing assessment and from the test diagnostic results.

Nursing assessment for Bronchiectasis

Patient’s history of recurrent bronchopulmonary infections and symptoms of chronic productive cough are hallmark features of bronchiectasis. Pain and dyspnea are also common.

1. The history of acute, even if delayed, onset of bronchiectasis can sometimes be traced to a defi nite illness, pneumonia, or aspiration event in patients with postobstructive or infectious bronchiectasis. Those patients with underlying congenital or immune disorders usually demonstrate a more insidious disease onset (Luce, 1994).
2. Cough is present in 90% of patients (Nicotra et al., 1995).
3. Daily (often purulent) sputum production occurs in 75% of patients and varies in volume from 10–500 ml (Nicotra et al., 1995).
4. Pleuritic chest pain represents distended peripheral airways or distal pneumonitis adjacent to a visceral pleural surface. This symptom occurs in 50% of bronchiectasis patients (Barker, 2002).
5. Repeated episodes of fever, pleurisy, and/or sinusitis are also common.
6. Weakness, dyspnea, and weight loss are seen in patients during infectious exacerbations or those with extensive disease.
7. The St. George’s Respiratory Questionnaire (SGRQ) has been validated as a useful tool for assessment of health-related quality of life in patients with bronchiectasis (Wilson, Jones, O’Leary, Cole, & Wilson, 1997). Test items are divided into three major areas: symptomatology; activity tolerance; and impact of the condition on daily life including employment, need for medications, and sense of control or panic over one’s health.

Physical examination findings are neither sensitive nor specific for bronchiectasis.

1. Crackles are the most common adventitious auscultatory finding, followed in frequency by wheezing, rhonchi, and a pleural friction rub (Barker, 2002; Mysliwiec & Pina, 1999; Nicotra et al., 1995).
2. Digital clubbing is rare (Barker, 2002; Mysliwiec & Pina, 1999).
3. Nasal polyps and sinusitis may also be evident (Luce, 1994).
4. Patients may have fetid breath chronically or solely during episodes of purulent sputum production.
5. Generalized weight loss and use of accessory muscles accompany severe disease.

Diagnostic Test for Bronchiectasis

1. Radiographic imaging studies are the principal diagnostic tools for Bronchiectasis (chest roentgenogram, non-contrast computed tomography (HRCT) and spiral volumetric scans.
2. Bronchoscopy is used to examine airways for obstructing tumors or foreign bodies, to evaluate the degree and site of hemoptysis, and to detect or remove inspissated secretions (Barker & Bardana, 1988; George, Matthay, Light, & Matthay, 1995).
3. Functional assessment of the bronchiectasis patient includes pulmonary function testing with spirometry and lung volumes, and arterial blood gas analysis.
4. Laboratory studies are important in the diagnosis and follow-up of patients:

• The complete blood count with cell differential may reveal leukocytosis or increased neutrophil levels during acute exacerbations; anemia may be present in chronic infections (Swartz,1998).
• Quantitative serum immunoglobulin levels of IgA, IgM, IgE, IgG
• Sputum smear reveals large numbers of white blood cells and both gram-positive and gram-negative organisms
• Sweat chloride testing is used to screen for cystic fibrosis in young adults with no identifiable predisposing cause for bronchiectasis.
• Aspergillus titers are indicated when an Aspergillus organism is cultured or if radiographic exam (chest X-ray or HRCT) demonstrates central bronchiectasis (Barker & Bardana, 1988).

Nursing Diagnosis That Could Be Found In Patient with Bronchiectasis

1. Impaired gas exchange related to ventilation–perfusion inequality
2. Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, bronchopulmonary infection, and other complications
3. Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants
4. Self-care deficits related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation
5. Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns
6. Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, and the inability to work
7. Deficient knowledge about self-management to be performed at home.

Nursing Care Plans Bronchiectasis
Nursing Care Plans Bronchiectasis. Common nursing diagnosis found in nursing care plans for Bronchiectasis: Impaired gas exchange, Ineffective airway clearance, Ineffective breathing pattern, Self-care deficits, Activity intolerance, Ineffective coping, and Deficient knowledge.

Below is Sample nursing care plans Bronchiectasis:

Bronchiectasis, Patient Teaching & Home Health Guidance

Patient Teaching & Home Health Guidance for Patient With Bronchiectasis. Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis.

Patient Teaching & Home Health Guidance for Patient with Bronchiectasis:

• Instruct on early signs of pulmonary or sinus infection: change in amount or color of sputum or nasal drainage, Hemoptysis, increased Dyspnea, fever, chills, fatigue, headache, chest pain.
• Emphasize importance of completing full course of antimicrobial therapy to prevent relapse or development of resistant strains of organisms; include education on proper delivery of intravenous and/or aerosolized antibiotics.
• Teach patient and significant other effective airway clearance techniques to remove secretions and optimize ventilation. In addition to postural drainage and chest percussion, the patient may be instructed on proper use of the Flutter or PEP devices. The Vest is an alternative to chest percussion.
• Encourage the patient to drink plenty of fluids to thin secretions and aid expectoration
• Educate on avoidance of potential lung irritants: secondhand smoke, dust, noxious fumes, occupational exposures, and respiratory infections.
• Instruct the patient to avoid air pollutants and people with known upper respiratory tract infections.
• Inform patient of variety of pharmacologic and non-pharmacologic smoking cessation strategies and aids.
• If appropriate, advise the patient to stop smoking because it stimulates secretions and irritates the airways.

Respiratory System

Nursing diagnosis pneumonia. Pneumonia, acute infection of the lung parenchyma that often impairs gas exchange. Pneumonia is an inflammatory condition of the interstitial lung tissue in which fluid and blood cells escape into the alveoli. The inflammatory process causes the lung tissue to stiffen, thus resulting in a decrease in lung compliance and an increase in the work of breathing. The fluid-filled alveoli cause a physiological shunt, and venous blood passes  unventilated portions of lung tissue and returns to the left atrium unoxygenated, patient begins to exhibit the signs and symptoms of hypoxemi

Focused Nursing assessment in  pneumonia care plans

• Vital sign: blood pressure,  body temperature, the pulse or rate of heartbeats, the respiration or rate of breathing
• Crackles, wheezing, or rhonchi over the affected lung area
• Dullness when you percuss
• Presence of cyanosis, and presence of dyspnea or tachypnea

Common nursing diagnosis found in pneumonia

Impaired gas exchange, Ineffective coping, Risk for deficient fluid Volume, Risk for infection Ineffective airway clearance, Acute pain, Anxiety, Hyperthermia, Imbalanced nutrition: Less than body requirements,

Nursing diagnosis for pneumonia base in nursing priority

1. Ineffective airway clearance
2. Impaired gas exchange
3. Imbalanced nutrition: Less than body requirements
4. Acute pain
5. Hyperthermia
6. Anxiety
7. Ineffective coping
8. Risk for deficient fluid volume
9. Risk for infection