● Acute Respiratory Disorders:

○ Acute respiratory disorders include rhinitis, sinusitis, influenza, and pneumonia

■ Older adults are more susceptible to infections and have decreased
pulmonary reserves due to normal lung changes (lung elasticity and
thickening alveoli)*
○ Health Promotion and Disease Prevention: perform hand hygiene, encourage
immunizations for pneumonia and influenza in young children and older adults
who have chronic illnesses or are immunocompromised, promote smoking
cessation
○ Arterial Blood Gas as a Diagnostic Procedure: to check oxygen status and
acid-base balance
■ Pre-Op: perform an Allen’s test before arterial puncture to check radial
and ulnar circulation
■ Intra-Procedure: use surgical aseptic technique to perform arterial
puncture and collect the specimen into a heparinized syringe; place the
specimen into a basin of ice to preserve pH + oxygen levels and bring it to
the lab immediately; needle goes in at 90º
■ Post-Op: hold direct pressure for at least 5 minutes onto the site
immediately after arterial puncture; hold pressure for at least 20 minutes if
the patient is on anticoagulants
○ Complications from an ABG Procedure:
■ Hematoma & Arterial Occlusion: blood accumulates at IV site
● Nursing Interventions: observe for changes in temperature,
swelling, color, loss of pulse, or pain; notify provider of changes
■ Air Embolism: air enters the arterial system upon catheter insertion
● Nursing Interventions:
○ Place the patient on the left side in Trendelenburg position
○ Monitor for SOB, decreased SaO2, and chest pain
○ Notify provider of changes and administer O2 therapy
○ Bronchoscopy: conducted to visualize the larynx, trachea, and bronchi with
either a flexible fiber-optic bronchoscope or rigid bronchoscope
■ Purposes: to collect a biopsy, aspirate deep sputum or lung abscesses for
culture and sensitivity
■ Is performed as an outpatient procedure in a surgical setting under general
anesthesia
■ Is performed at the bedside under local anesthesia and moderate sedation
■ Is performed on patients receiving mechanical ventilation by inserting the
scope through the patient’s endotracheal (ET) tube
■ Pre-Procedure:
● Assess for allergies to anesthesia and use of anticoagulants
 ● Ensure a consent form is signed by the patient*
● Remove the patient’s dentures if they have it
● Maintain the patient’s NPO status 4-8 hours before to reduce the
risk of aspiration due to cough reflex being blocked by anesthesia
● Administer pre-procedure medications (viscous lidocaine or local
anesthetic throat spray)
■ Intra-Procedure:
● Position the patient in a sitting or supine position
● Assist in collecting and labeling specimen; ensure delivery to lab
● Monitor vital signs, respiratory patterns, and oxygen status
throughout procedure
■ Post-Procedure:
● Continuously monitor vital signs, respirations, and LOC
● Assess for presence of gag reflex and ability to swallow before
resuming oral intake
● Patient is not discharged from recovery until gag reflex and
respiratory effort is present
● Document patient’s response to procedure (vital signs, gag reflex)
■ Complications of Bronchoscopy: pneumothorax, aspiration (major
complication), laryngospasm (uncontrolled contractions of the vocal cords
impeding the ability to inhale)
● Pneumothorax: a collapsed lung; the lung is accidentally
punctured while inserting the tube
■ Expected Findings: sore throat and blood tinged sputum
○ Thoracentesis: the surgical perforation of the chest wall and pleural space with a
large-bore needle
■ Purposes: obtain specimens for diagnosis, instill medications into pleural
space, remove fluids (effusion) or air from the pleural space, or relief of
pleural pressure
■ The patient should NOT cough or move during the procedure
■ Pre-Procedure:
● Position patient sitting up with arms and shoulders raised, support
with pillows and/or over bed table, and support legs and feet
■ Post-Procedure:
● Apply a dressing over puncture site and assess for bleeding or
drainage
● Monitor vital signs and respiratory status
● Auscultate lungs for reduced breath sounds on the side of
procedure
 ● Obtain a post-procedure chest x-ray to check for resolution of
effusion and to rule out pneumothorax
○ Influenza: occurs in fall and winter months; highly contagious viral infection
■ Adults are contagious from 24 hours before symptoms develop and up to 5
days after they begin
■ Symptoms: severe headache, muscle aches, chills, fatigue, weakness,
severe diarrhea, cough, fever
■ Nursing Interventions:
● Maintain droplet precautions for hospitalized patients
● Monitor hydration status
● Administer fluid therapy as prescribed
● Monitor respiratory status
● Administer medications: Oseltamivir [Tamiflu], Amantadine
[Osmolex], and/or Rimantadine [Flumadine]
■ Patient Education:
● Encourage annual flu shot
● Thoroughly wash hands and follow coughing etiquette
● Avoid places where people gather/large crowds
● Increase fluid intake if flu symptoms develop, rest, and stay home
● Encourage patients to start antiviral meds 24-48 hours after onset
of symptoms
○ Atelectasis: collapse of the alveoli; can be acute or chronic; most common
abnormality on a chest x-ray; high risk for patients that received surgery
■ Obstructive Atelectasis: most common form
■ Causes: foreign body, tumor or growth in an airway, altered breathing
patterns, retained secretions, pain, alteration in small airway function,
prolonged supine positioning, increased abdominal pressure, upper
abdominal surgery, thoracic surgery, or open heart surgery
■ Clinical Findings:
● Tachycardia, tachypnea, pleural pain
● Central cyanosis, insidious onset
● Decreased breath sounds and crackles over affected area
● O2 saturation less than 90%
● Respiratory distress with large area of lung affected
■ Nursing Diagnosis: ineffective airway clearance, ineffective breathing
patterns, impaired gas exchange
■ Nursing Interventions to Prevent Atelectasis:
● Frequently turn the patient
● Early ambulation and mobilization
● Deep breathing
 ● Incentive spirometer
● Suctioning (can be done through the nose or mouth; hit the
patient's back to release secretions)
● Nebulizer treatment and postural drainage/chest percussion
■ Why is a post-op patient at risk for atelectasis? Due to low tidal breathing
pattern and/or monotonous shallow breathing related to pain, anesthesia,
and narcotics for pain relief.
■ ICOUGH Program for Atelectasis Management:
● Incentive spirometer
● Coughing and deep breathing
● Oral care
● Understanding (patient, family, staff education)
● Get moving (ambulation, mobilization)
● Head of bed elevated
■ Last Resort Management: use when all other breathing exercises have
been done or the patient cannot deep breathe and is still symptomatic
● PEEP: an oxygen mask with varying amounts of expiratory
resistance; stands for positive end-expiratory pressure
● CPAB: continuous positive airway breathing
● Bronchoscopy: to diagnose lung disease and open airway
● CPT: chest physiotherapy
● Endotracheal intubation and mechanical ventilation
● Thoracentesis to relieve compression
○ Pneumonia: inflammation of the lung parenchyma; patients can’t blow out CO2
■ Causes: bacteria, mycobacteria, fungi, viruses
■ Classification: community acquired (CAP), healthcare associated
(HCAP), hospital acquired (HAP), ventilator associated (VAP)
● Hospital acquired is difficult to treat because it is resistant to
antibiotics/medications
● If a patient gets VAP, oral care was not done every 4 hours
■ Risk Factors: elderly patients are most at risk*
● Heart failure, diabetes, alcoholism, COPD, AIDS, influenza, cystic
fibrosis, chronic lung disease
● Extremely young or old age
● Lack of up-to-date immunizations
● Mechanical ventilation
● Immunocompromised status
■ Symptoms: anxiety, fatigue, weakness, chest discomfort, fever, chills,
flushed face, diaphoresis, confusion from hypoxia, SOB, difficulty
 breathing, tachypnea, sharp pleural chest pain, yellow-tinged sputum,
crackles, wheezes, coughing, dull chest percussion, decreased O2 sat
● Confusion from hypoxia is the most common symptom in older
adults; a UTI may also occur and the patient can become septic
(organs start to fail in septic shock)
■ Laboratory and Diagnostic Tests for Pneumonia:
● CBC: to check for elevated WBCs (might not be present in elderly)
● ABGs: to check for hypoxemia (patients with pneumonia have
respiratory acidosis)
● Blood Culture: to rule out organisms in the blood
● Sputum Culture: obtain before starting antibiotic therapy; the
patient must deeply cough and collection must be done in the
morning; use suctioning to obtain a specimen if the patient is
unable to cough
○ To check for the specific organism; a broad-spectrum
antibiotic can be given after obtaining the specimen while
still waiting for the results
○ Penicillin and cephalosporins are most common*
○ Antibiotics are given IV initially then switched to oral
● Chest X-Ray: will show consolidation or infiltration (looks white)
○ Important for diagnosis especially since early symptoms
are vague or absent in older adults
● Pulse Oximetry: their usual O2 sat will be less than 95%
■ Nursing Interventions:
● Position the patient in high Fowler’s unless contraindicated
● Encourage coughing or suction to remove secretions
● Administer humidified O2 therapy as prescribed
○ Monitor for skin breakdown around nose, mouth, and ears
from O2 device
○ Humidified O2 loosens secretions
● Encourage deep breathing with incentive spirometer to prevent
atelectasis
● Promote adequate nutrition and fluid intake
○ Additional calories are needed due to increased work of
breathing; encourage fluid intake of 2-3 L/day to promote
hydration and thin secretions
○ Proper nutrition also aids in preventing secondary
respiratory infections
● Provide rest for patients who have dyspnea
 ● Administer supportive treatment: fluids, oxygen, antipyretics,
decongestants, antihistamines
● Administer bronchodilators to reduce bronchospasm and irritation
● Administer anti-inflammatories to decrease airway inflammation
(glucocorticoids)
● Activity as tolerated and patient self-care
● Chest physiotherapy
■ Nursing Interventions for Antibiotic Therapy:
● Observe patients taking cephalosporins for frequent stools
● Monitor kidney functions, especially in older adults taking
penicillin or cephalosporin
● Encourage patients to take penicillin with food
■ Patient Education:
● Importance of continuing medications for pneumonia treatment
● Encourage rest periods, up-to-date pneumonia and flu
vaccinations, and to avoid large crowds
● Promote smoking cessation if needed
● Remind patient that treatment and recovery takes time
■ Complications:
● Sepsis and Septic Shock: occurs when pathogens enter the blood
● Acute respiratory distress syndrome
● Atelectasis: from airway inflammation and edema; increases risk
of hypoxemia
● Aspiration pneumonia
■ Nursing Diagnosis: ineffective airway clearance, impared gas exchange,
acute pain, deficient knowledge, acute pain, ineffective breathing pattern,
risk for infection
■ Prevention: pneumococcal vaccination
● Reduces incidence of pneumonia, hospitalization for cardiac
conditions, and deaths in older adults
● Recommended for adults 65 years of age or older and people 19
years of age or older with conditions weakening the immune
system
■ Expected Outcomes: improved airway patency; rests and conserves
energy; slowly increases activity; maintains hydration and nutrition;
complies with treatment; has no complications; has increased knowledge
○ Aspiration Pneumonia: inhalation of foreign material into the lungs such as
food, saliva, liquids, vomit, stomach contents
■ Symptoms: tachycardia, dyspnea, central cyanosis, hypertension,
hypotension, and potential death
 ■ Risk Factors: coma, alcoholics, general anesthesia, poor gag reflex,
problems with swallowing
● Common in patients on tube feedings because the head of the bed
is usually not elevated
○ Check for the placement of the NG tube before using:
push air in and listen for a sound; can also aspirate to see
if stomach contents come out; X-Ray to see the placement is
the most reliable
■ Nursing Interventions:
● Keep the head of the bed elevated to 30º and above
● Avoid stimulating the gag reflex with suctioning and procedures
● Check for placement of the nasogastric tube before tube feedings
○ 60 cc’s forced air over stomach area to check patency
● Give thickened fluids for swallowing problems (thin liquids cause
choking and are harder to swallow)
○ Pulmonary Embolism: occurs when a substance enters venous circulation and
forms a blockage in the pulmonary vasculature
■ A medical emergency because it impedes blood flow and causes hypoxia
■ Causes: tumors, bone marrow, amniotic fluids, air, foreign matter, DVT
● Deep vein thrombosis are the most common cause of a PE
■ Risk Factors: long-term immobility, oral contraceptives, estrogen therapy,
pregnancy, tobacco use, obesity, surgery (espec. orthopedic of the lower
extremities or pelvis), heart failure, chronic A-Fib, cancer, trauma, old age
■ Symptoms: anxiety, feeling of impending doom, pressure in the chest,
pain upon inspiration, chest wall tenderness, dyspnea, cough, air hunger,
hemoptysis, pleural friction rub, hypotension, low-grade fever, petechiae
over chest and axillae, abnormal liver function tests, cal
■ Diagnostic Procedures:
● ABGs: respiratory alkalosis which will progress to acidosis
● D-Dimer: blood test measuring substances released when a clot
breaks up; normal range is 0.4 mcg/mL or less; it will be elevated
● CT Scan or CT angiogram: stands for computed tomography
● MRI: magnetic resonance imaging
● Doppler Ultrasound: to visualize blood flow
● Echocardiogram
● Pulmonary Angiogram: a catheter is inserted into the vena cava to
visualize the PE
○ The gold standard test and most thorough but it is invasive
and expensive*
 ○ Nursing Interventions for PA: verify that informed
consent was obtained and monitor vitals, SaO2, anxiety,
and bleeding during and after the procedure
■ Nursing Interventions for a PE:
● Position the patient in high Fowler’s position
● Administer O2 therapy
● Initiate and maintain IV access
● Assess respiratory status every 30 minutes
● Provide emotional support and comfort anxiety
● Monitor changes in LOC and mental status
■ Prevention: exercise to avoid venous stasis, early ambulation,
anti-embolism stockings (only in the absence of a clot)
■ Treatment: measures to improve respiratory and vascular status,
anticoagulant and thrombolytic therapy
■ Thrombolytic Therapy: Alteplase [Activase] and tissue plasminogen
activators [TPA] (a group of clot busters, includes alteplase) are used to
dissolve blood clots and restore pulmonary blood
● A clot buster is only given when there is a definitive diagnosis of a
PE; it is NOT first-line because of a high risk of internal bleeding
■ Anticoagulant Therapy: Heparin [Hep-Lock], Lovenox [Enoxaparin], and
Warfarin [Coumadin] to prevent clots from getting larger or additional
clots from forming; liver produces clotting factors; protamine sulfate is
the antidote to heparin
● Nursing Interventions for Anticoagulant Therapy:
○ Assess for contraindications: active bleeding, peptic ulcer
disease, history of stroke, recent trauma
○ Monitor bleeding times:
■ Prothrombin time (PT) and INR for warfarin (INR
should be 2-3; vitamin K is the antidote to warfarin)
■ Partial thromboplastin time (aPTT) for heparin
■ Complete blood count
○ If patients on warfarin regularly eat green leafy vegetables,
they have to eat the same amount as they always do;
nothing more, nothing less
■ Therapeutic Procedures:
● Embolectomy: surgical removal of embolus
● Vena Cava Filter: filter inserted to prevent further emboli from
reaching the pulmonary vasculature
● Nursing Interventions for Both:
○ Maintain an NPO status and verify informed consent
 ○ Monitor vital signs, incision drainage, and pain
management post-procedure
■ Patient Education:
● Promote smoking cessation
● Encourage patient to avoid long periods of immobility
● Encourage patient to wear compression stocking for circulation
● Advise the patient to monitor intake of foods high in vitamin K
(green leafy vegetables) if taking warfarin
○ Vitamin K reduces anticoagulant effects of warfarin
● Advise patient to adhere to a schedule for monitoring PT and INR
and weekly blood draws, and follow medication dosage adjustment
● Tell the patient to avoid taking aspirin unless specified by the
provider
● Encourage the patient to check his mouth and skin daily for
bleeding and bruising
● Encourage the patient to use a electric shavers and soft-bristled
toothbrushes
● Instruct patient to avoid blowing nose hard and to gently apply
pressure is nosebleeds occur; do NOT hold in a sneeze
● Prevention of PE during travel: stand up for 5 minutes every
hour, wear support stocking, remain hydrated, perform active
ROM exercises when sitting
■ Nursing Diagnosis: impaired gas exchange, ineffective breathing pattern,
knowledge deficit, risk for bleeding

● Chronic Respiratory Disorders:

○ Anything chronic is occurring for 3 months or more
○ Assessment for Chronic Pulmonary Disease: impact on ADLs, orthopnea,
dyspnea with expiratory wheeze, fear, anxiety
○ Risk Factors for Chronic Pulmonary Disease: smoking, environmental
exposure, depressed immune system, family history, genetic makeup
○ Oxygen Therapy:
■ Is administered to maintain an O2 sat of 95% and above, decrease work of
breathing, and reduce stress on the myocardium
■ A provider’s order is needed except in an emergency situation, where a
nurse can administer up to 2 L of oxygen
■ The lowest amount of oxygen possible should be used without putting the
patient at risk for complications
■ The concentration of room air is 21%
○ Oxygen Delivery Devices: the percentage of oxygen is expressed as the fraction
of inspired oxygen (FiO2)
■ Low Flow Oxygen Delivery:
● Nasal Cannula: FiO2 24-44% at flow rate of 1-6 L/min
○ Advantages: safe/easy to apply, comfortable, well tolerated;
patient is able to eat, talk, and ambulate
○ Disadvantages: extended use leads to skin breakdown and
drying of the mucous membranes; tube gets dislodged
● Simple Face Mask: covers the nose and mouth; FiO2 40-60% at
flow rates of 5-8 L/min (5 L/min = CO2 flushing from mask)
○ Advantages: easy to apply; more comfortable than cannula
○ Disadvantages: flow rates less than 5L/min results in
rebreathing CO2; poorly tolerated by patients with anxiety
and claustrophobia; eating, drinking, talking is impaired;
moisture and pressure under masks causes skin breakdown
● Non-Rebreather Mask: Fi02 80-95% at flow rate of 10-15 L/min;
it keeps the reservoir bag ⅔ full during inspiration and expiration
○ Advantages: delivers the highest possible O2 concentration
(except for intubation)
○ Disadvantages: eating and drinking are impaired; poorly
tolerated by patients with anxiety and claustrophobia; valve
and flap on the mask must be intact and functional during
each breath
■ High Flow Oxygen Delivery: aerosol mask/face tent, T-piece, trach collar
● Venturi Mask: covers mouth and nose; FiO2 24-50% at flow rate
of 4-10 L/min via different size adapters that allows specific
amount of air to mix with oxygen; given to patients with COPD
○ Advantages: delivers the most precise O2 concentration;
humidification is not required; best suited for patients with
chronic lung disease
○ Disadvantages: it’s expensive
○ Oxygen Toxicity: occurs because of too much oxygen (greater than 50%), long
duration of oxygen therapy (more than 24-48 hours), and the patient’s degree of
lung disease
■ Symptoms: non-productive cough, substernal pain, nasal stuffiness,
nausea, vomiting, fatigue, headache, sore throat, and hypoventilation
■ Early Signs: tachycardia, tachypnea, restlessness, pale skin/mucus
membranes, elevated BP, symptoms of respiratory distress (use of
accessory muscles, nasal flaring, adventitious lung sounds)
 ■ Late Signs: confusion, stupor, cyanotic skin, bradypnea, hypotension,
dysrhythmias
■ Nursing Interventions:
● Use the lowest level of oxygen possible to maintain O2
● Monitor ABGs
● Use an oxygen mask with continuous positive airway (CPAP or
BIPAP) if ordered
● Use positive end-expiratory (PEEP) while the patient is on a
ventilator to decrease the amount of oxygen needed and/or to
prevent or reverse atelectasis
○ Hypoxemia: decrease in the arterial oxygen tension of the blood; leads to hypoxia
■ Manifestations:
● Changes in mental status: impaired judgment, restlessness (early
sign), agitation, disorientation, confusion (early sign), lethargy
(early sign), coma
● Dyspnea, dysrhythmias
● Increased blood pressure
● Changes in heart rate
● Central cyanosis (late sign)
● Diaphoresis and cool extremities
○ Hypoxia: decrease in oxygen supply to the tissue and cells; can be
life-threatening; is not only due to respiratory issues
○ Chronic Obstructive Pulmonary Disease (COPD): emphysema and chronic
bronchitis; typically affects middle-aged to older adults; retain CO2
■ Most patients with emphysema also have chronic bronchitis
■ It is irreversible and is managed with lifestyle changes and medications
■ Most common cause is environmental irritants inhaled into the lungs
■ Risk Factors: advanced age, cigarette smoking (#1 risk), air pollution
■ Chronic Bronchitis: “Blue Bloaters”
● Inflammation of the bronchi and bronchioles due to smoking and
environmental irritants; also causes hypersecretion of mucus
● Diagnosis: presence of cough and sputum production for at least 3
months in each of 2 consecutive years
● Manifestations: ciliary function is reduced, bronchial walls
thicken, bronchial airways narrow, mucus may plug airways,
cyanosis, HR is high, dependent edema, crackles in the lungs
● The patient is more susceptible to respiratory infections
● Increased pulmonary artery pressure may cause right-sided heart
failure (cor pulmonale)- more common in this than emphysema
■ Emphysema: “Pink Puffers”
 ● Loss of alveoli elasticity and hyperinflation of the lung tissue
(causes the diaphragm to flatten)
● Causes destruction of the alveoli (become stiff/hard) leading to
decreased surface area for gas exchange, carbon dioxide retention,
and respiratory acidosis
● Manifestations: impaired oxygen and carbon dioxide exchange,
hypoxemia; they will not become cyanotic
● Increased pulmonary artery pressure may cause right-sided heart
failure (cor pulmonale)
● Patients with emphysema need frequent meals packed with calories
and protein
■ Health Promotion and Disease Prevention: smoking cessation, avoid
exposure to secondhand smoke, use protective equipment (mask), ensure
proper ventilation while working in environments with carcinogens or
particles in the air, flu and pneumonia vaccinations
■ Manifestations: They breathe when their CO2 is high, not O2
● Dyspnea on exertion, tripod position, decreased O2 sat
● Productive cough (severe in the morning upon rising)
● Hypoxemia and use of accessory muscles
● Crackles, wheezes, rapid and shallow respirations
● Barrel chest, increased chest diameter
● Poor nutrition, weight loss (emphysema), unable to tolerate
activities
● Hyperresonance on percussion (with emphysema)
● Clubbing of fingers and toes (late stage of disease)
● Increased hematocrit and hemoglobin due to more blood being
made as the heart works harder
● Pallor and cyanosis of nail beds and mucous membranes (late stage
of disease)
● Dependent edema secondary to right-sided heart failure
■ Lab and Diagnostic Tests:
● ABGs: for oxygen status and acid-base balance
○ Hypoxemia = decreased PaCO2 less than 80 mmHg
○ Hypercapnia = increased PaCO2 greater than 45 mmHg
● Hematocrit: will be increased due to low oxygen levels
● Sputum and WBC Cultures: to diagnose infection
● Pulmonary Function Test: measures forced expiratory volume
(FEV) and forced vital capacity (FVC)
● Chest X-Ray: shows hyperinflation of the alveoli and a flattened
diaphragm in the late stage of emphysema
 ● Pulse Oximetry: patients with COPD have a normal O2 sat
between 88-93%
○ They are stimulated to breathe from a low O2 level rather
than a high CO2 level
■ Nursing Interventions and Patient Education:
● Administer oxygen therapy and monitor O2 levels
● Administer proper medication
● Advise the patient to avoid large crowds and other people with
respiratory infections
● Patient should practice breathing techniques to control dyspnea
● COPD patients need 2-4 L/min of O2 via nasal cannula or up to
40% via venturi mask
● Educate patient to eat high calories and protein in small frequent
meals and to keep hydrated
● Encourage smoking cessation
● Flu vaccine annually and pneumonia vaccine every 5 years
● Diaphragmatic (abdominal) Breathing:
○ Take deep breaths from the diaphragm
○ Lie on back with knees bent
○ Rest hand over abdomen to create resistance
○ If the patient’s hand rises and lowers upon inhalation and
exhalation, the breathing is performed correctly
● Pursed-Lip Breathing:
○ Form a mouth as if preparing to whistle
○ Take a deep breath in through the nose and out through the
mouth
○ Do not puff cheeks
○ Take breaths deep and slow
■ Medications:
● Albuterol [ProAir, Salbutamol]: bronchodilator
○ A short-acting beta agonist (SABA) that provides rapid
relief in emergency situations
○ Monitor patient’s HR for palpitations and monitor for
tremors and tachycardia
● Ipratropium [Atrovent]: anticholinergic
○ Increases bronchodilation and decreases pulmonary
secretions; sympathetic NS response
○ Monitor HR for palpitations because it is a sign of toxicity
○ Observe patient for dry mouth and encourage them to
suck on hard candies to moisten their mouth
 ● Theophylline [Elixophyllin]: methylxanthines; bronchodilator
○ Relaxes bronchial smooth muscle
○ Has a narrow therapeutic range and needs close monitoring
○ Monitor serum levels for toxicity (10-20 mcg/mL)
○ Adverse Effects: tachycardia, nausea, diarrhea
● Prednisone [Deltasone] and Methylprednisolone [Solumedrol]:
○ Are corticosteroids that decreases airway inflammation and
mucus production
○ *Patient must rinse out their mouth after inhaling and
use a spacer to decrease risk of developing oral thrush*
○ Side Effects: immunosuppression, fluid retention,
hyperglycemia (glucose must be checked), easy bruising,
osteoporosis, hypokalemia, poor wound healing
● Acetylcysteine [Mucomyst, Acetadote], Dornase Alfa
[Pulmozyme], and Guaifenesin [Mucinex]: mucolytic agents
○ Thins secretions to make them easier to expel
○ Acetylcysteine and Dornase Alfa are nebulized
○ Mucinex is oral; it can be taken in combination with
Dextromethorphan [Robitussin, Delsym] to loosen mucus
■ Complications of COPD:
● Respiratory Infections: due to increased mucus production and
poor oxygenation levels
● Right Sided Heart Failure (Cor Pulmonale): air trapping, airway
collapse, and stiff alveoli lead to increased pulmonary pressure;
blow flow is difficult; the increased workload leads to enlargement
and thickening of the right atrium and ventricle
■ Nursing Diagnosis: impaired gas exchange, ineffective airway clearance,
ineffective breathing pattern, self-care deficit, activity intolerance,
ineffective coping, deficient knowledge, risk for infection, fatigue
○ Asthma: chronic inflammatory disorder of the airways, resulting in intermittent,
reversible airflow obstruction of the bronchioles; cause is unknown
■ Obstruction is due to either inflammation or airway hyperresponsiveness
■ Manifestations: mucosal edema, bronchoconstriction, excess mucus
production, use of accessory muscle, barrel chest, wheezing, increased
chest diameter
● Hypocapnia (low CO2 in the blood) due to hyperventilation
■ Symptoms: dyspnea, chest tightness, anxiety, stress, coughing, wheezing,
mucus production, prolonged exhalation, poor oxygen saturation, chest
retraction
■ Health Promotion and Patient Education:
 ● Smoking cessation and regular exercise
● Use a protective mask and ensure proper ventilation while in an
environment with carcinogens or particles in the air
● Flu and pneumonia vaccines
● Teach patient how to administer medications
● Recognize and avoid triggers (strong odors, household cleaners,
seasonal allergens like grass, pollen, trees, humidity, temperature
changes, medications such as beta blockers)
● Instruct patient to use hot water to eliminate dust mites in bed
linens
■ Diagnostic Categories: based on how often symptoms arise
● Mild Intermittent: more than twice a week
● Mild Persistent: more than twice a week but not daily
● Moderate Persistent: daily and occurs with exacerbations 2x a
week
● Severe Persistent: occurs continually with frequent exacerbations
that limit physical activity and quality of life
■ Risk Factors: family history of asthma, smoking, secondhand smoke
exposure, environmental allergies, exposure to chemical irritants or dust,
pet dander, strong smells like perfume, gastroesophageal reflux disease
(GERD), older adults due to lung changes
■ Lab and Diagnostic Tests:
● ABGs: for oxygen saturation and acid-base balance
○ Hypoxemia: decreased PaCO2 less than 80 mmHg
○ Hypocapnia: decreased PaCO2 less than 35 mmHg (early
in attack)
○ Hypercapnia: increased PaCO2 greater than 45 mmHg (late
in attack)
● Pulmonary Function Tests: most accurate test to diagnose asthma
and its severity*
● Chest X-Ray: diagnoses changes in lung structure over time
■ Nursing Interventions:
● Place patient in high Fowler’s position
● Administer oxygen therapy and medications as prescribed
● Monitor HR and rhythm for changes during acute attacks (can be
irregular, tachycardic or with PVCs)
● Provide rest for older adults with dyspnea
● Monitor severity of symptoms and reduce fear and anxiety
● Assess breath sounds, peak flow, pulse oximetry, vital signs, and
fluid balance
 ● Obtain a history of allergic reactions and environmental exposures
■ Patient Education:
● Encourage prompt medical attention for infections
● Encourage vaccinations
● Educate on how to adhere to action plan and use flow meters
● Teach patient how to avoid triggers and know the warning signs of
an attack
● Teach how to use a peak flow meter and when and how to seek
help
■ Asthma Action Plan:
● Green Zone: use preventive medication
○ Breathing is good, no cough or wheeze, sleeps through the
night, can work and play
● Yellow Zone: add quick-relief meds on top of green zone meds
○ First signs of a cold, exposure to triggers, cough, mild
wheeze, tight chest, coughing at night
● Red Zone: get immediate help from a doctor
○ Medicine is not helping, breathing is hard and fast, nose
opens wide, trouble speaking, ribs show (in children)
■ Medications:
● Albuterol [ProAir, Salbutamol]: bronchodilator
○ Provides rapid relief of acute symptoms and
exercise-induced asthma; not a daily treatment
○ It is a rescue medication
○ Monitor patient’s HR for palpitations and monitor for
tremors and tachycardia
● Ipratropium [Atrovent]: anticholinergic
○ Increases bronchodilation and decreases pulmonary
secretions; long acting and prevents bronchospasm
○ Monitor HR for palpitations because it is a sign of toxicity
○ Observe patient for dry mouth and encourage them to
suck on hard candies to moisten their mouth
● Theophylline [Elixophyllin]: methylxanthines; bronchodilator
○ Relaxes bronchial smooth muscles; given orally
○ Avoid caffeine while taking this medication
○ Monitor serum levels for toxicity*
○ Adverse Effects: tachycardia, nausea, diarrhea
● Salmeterol [Serevent Diskus]: bronchodilators
○ Used only to prevent an asthma attack
 ○ Used with corticosteroids, never alone* (take this med first
then the corticosteroid)
○ May cause tachycardia and nervousness
○ It is a preventative medication
● Combination Agents: a bronchodilator and an anti-inflammatory
○ If it is prescribed separately for inhalation, administer at the
same time
○ The bronchodilator is administered first to increase the
absorption of the anti-inflammatory agent
● Prednisone [Deltasone], Methylprednisolone [Solumedrol], and
Beclomethasone [Qvar Redihaler]: anti-inflammatory
○ Decreases airway inflammation
○ *Patient must rinse out their mouth after inhaling and
use a spacer to decrease risk of developing oral thrush*
○ Side Effects: immunosuppression, fluid retention,
hyperglycemia, hypokalemia, osteoporosis, poor wound
healing
○ Watch for decreased immunity function, monitor for
hyperglycemia, observe for fluid retention and weight gain
■ Patient Teaching for Anti-Inflammatory Medications:
● Drink plenty of fluids for hydration
● Take prednisone with food
● Use to prevent an attack, NOT at the onset of an attack
● Avoid people with respiratory infections
● Do not discontinue abruptly, it needs to be tapered
● Have good oral care
■ Nursing Diagnosis: anxiety, activity intolerance, deficient knowledge,
impaired gas exchange, impaired oral mucous membrane, ineffective
airway clearance, ineffective breathing pattern, ineffective coping
■ Complications:
● Respiratory Failure: due to persistent hypoxemia from asthma
○ Nursing Interventions:
■ Monitor oxygen levels and acid-base (ABGs)*
■ Prepare for intubation and mechanical ventilation*
● Status Asthmaticus: life-threatening episode of airway obstruction
that is often unresponsive to treatment
○ Symptoms: extreme wheezing, labored breathing, use of
accessory muscles, distended neck veins
○ Creates a risk for cardiac and/or respiratory arrest
○ Nursing Interventions:
 ■ Prepare for emergency intubation*
■ Administer IV fluids, oxygen, bronchodilators, and
epinephrine*
■ Initiate systemic steroids therapy
○ Exercise-Induced Bronchoconstriction (EIB): exercise induced asthma
■ Narrowing of the airways, increasing difficulty moving air during exercise
■ Symptoms are worse in cold dry air because it causes bronchoconstriction
■ Symptoms: shortness of breath, coughing, wheezing, tight chest
■ Patient Education:
● Warm up 10-15 minutes before exercising
● Take a short-acting beta agonist before exercising (ex: albuterol)
● Do not exercise when sick or with respiratory illness
● Breathe through the nose to warm up the air
○ Using a Peak Flow Meter:
■ Stand up straight and take a deep breath, filling the lungs up all the way
■ Blow out as hard and fast as you can in a single blow. Your first burst of
air is the most important, so blowing for a longer time will not affect
your result
■ If you coughed or did not do the steps right, do it over again
■ Find Your Personal Best: patient breathes 3 times and the highest of the 3
numbers is your peak flow number
● If their personal best is not reached that day, that indicates an
attack is starting
○ Endotracheal Intubation: inserted through the patient’s nose or mouth into the
trachea; allows for emergency airway management (ex: patient having recurrent
seizures)
■ Cannot be in place for more than 2 weeks, then the patient will need a
tracheostomy
■ Mouth intubation: easiest and quickest form; often performed in ED
■ Nasal intubation: performed when the patient has facial or oral trauma;
not used if the patient has a clotting problem
■ Placement:
● Placed by an anesthetist, anesthesiologist, or pulmonologist
● Chest x-ray verifies the correct placement
● It is cuffed or uncuffed:
○ Cuffed: on the tracheal end of the tube; inflated to ensure
proper placement and form a seal between the cuff and
tracheal wall; patient cannot talk when cuff is inflated
● Seal: ensures adequate tidal volume is delivered by the mechanical
ventilator when attached to the external end of the tube
 ● There is a number on the tube to indicate where the tube ends at
the lip, if it changes, that means the tube moved
■ Medication: Succinylcholine [Anectine] is given to anesthetize the patient
■ Nursing Interventions:
● Have resuscitation equipment (including ambu bag) ready at the
bedside at all times
● Monitor vital signs and check tube placement
● Auscultate for breath sounds bilaterally after intubation and
observe for symmetric chest movement
● Ensure intubation attempts last no longer than 30 seconds and
re-oxygenate patient before each attempt
● Stabilize the tube with a tube holding device or secure with tape
● Keep rotating the tube to different sides of the mouth to prevent
sores
● Monitor for hypoxemia, dysrhythmias, and spiration
○ Tracheostomy: surgical procedure where an opening is made in the trachea
■ Indwelling tube inserted into the trachea is called a tracheostomy tube
■ Suctioning: necessary to remove secretions due to decreased coughing
mechanism; performed when adventitious breath sounds are present or
secretions are obviously present
■ Preventing Complications for Tracheostomy and ET Tube:
● Administer adequate warmed humidity
● Maintain cuff pressure at appropriate level
● Suction as needed per assessment findings
● Maintain skin integrity by changing tape and dressing as needed
or per protocol
● Auscultate lung sounds
● Monitor for signs and symptoms of infection, including
temperature and white blood cell count
● Administer prescribed oxygen and monitor oxygen saturation
● Monitor for cyanosis
● Maintain adequate hydration of the patient
● Use sterile technique when suctioning and performing
tracheostomy care
■ Guidelines for Suctioning:
● All equipment coming in direct contact with the patients lower
airway must be sterile
● Use only the amount of suctioning needed to remove secretions
 ● Administer 100% oxygen before and during the procedure to
prevent decreased O2 saturation; 30-60 seconds before and after
suction
● Suction for 10-15 seconds
● Suction pressure should be between 120-140 mmHg
● Leave the patient connected to the ventilator
● Do NOT exceed 2-4 passess per suctioning procedure and allow
enough time to pass between each pass
● The patient should have a lot of fluids so the mucus can breakdown
● Insert the end of the catheter into 0.9% sodium chloride or sterile
water and suction up the solution until the suction tubing is clear
● Verify that FIO2 is returned to previous levels
● *If you want to see the thorough procedure instructions, google
“suctioning tracheostomy and ET tube elsevier”
○ Mechanical Ventilation: provides breathing support until lung functions restored
■ Delivers warm (37 C) 100% humidified oxygen at FiO2 levels between
21-100%
■ Positive Pressure Ventilator: delivers air into the lungs under pressure
throughout inspiration and/or expiration to keep the alveoli open during
inspiration and to prevent alveolar collapse during expiration
■ Benefits: forced/enhanced lung expansion, improves gas exchange,
decreases work of breathing
■ Nursing Interventions:
● Assess ET tube position, document placement, suction oral and
tracheal secretions
● Have resuscitation bag with face mask at bedside at all times in
case of malfunction or accidental extubation
● Monitor ventilator alarms that signal that the patient is not
receiving the correct ventilation and never turn off the alarms
○ Volume (low pressure) Alarm: indicates a low exhaled
volume due to disconnection, cuff leak, and or tube
displacement
○ Pressure (high pressure) Alarm: indicates excessive
secretions, patient biting the tube, kinks in the tube,
pulmonary edema, pneumothorax, patient is coughing
○ Apnea Alarm: indicates that the ventilator does not detect
spontaneous respiration in a preset time period
● Monitor adequate volume in the cuff of the ET tube; assess the cuff
quality every 8 hours and maintain a pressure of 20 mmHg or
below to reduce the risk of tracheal necrosis
 ● Assess for air leak around the cuff (patient speaking, air hissing,
decreased SaO2)
● Reposition the ET tube every 24 hours or according to protocol and
assess skin breakdown
● Enhance Gas Exchange: use analgesics for pain without
suppressing respiratory drive, frequent repositioning, monitor fluid
balance (I&O, daily weight, presence of peripheral edema), give
meds for primary disease
● Promote Effective Airway Clearance: assess lung sounds every
2-4 hours, humidification of airway, administer medications
○ To clear the airway: use suction, position changes, promote
increased mobility, and CPT (chest physiotherapy)
● Prevent Trauma and Infection: do tube care, infection control
measures, elevate the head of the bed, cuff management
○ Oral care must be done every 4 hours and the patient
needs to be turned and repositioned
■ Other Interventions: do ROM exercises, ambulate the patient,
communication methods, stress reduction techniques, promote coping,
family teaching, and emotional support of the family
■ Medications to Give:
● Analgesics: Morphine and Fentanyl
● Sedatives: Propofol [Diprivan], Diazepam [Valium], Lorazepam
[Ativan]
● Ulcer-Preventing Agents: Famotidine [Pepcid], Pantoprozole
[Protonix], Lansoprazole [Prevacid]
■ Assessment: in-depth respiratory assessment including indicators of
oxygen status, neurologic status, effective coping and emotional needs,
and comfort level
■ Planning: maintain patient airway, optimal gas exchange, absence of
trauma or infection, attainment of optimal mobility, adjustment to
nonverbal methods of communication, successful coping measures
■ Diagnosis: impaired gas exchange, ineffective airway clearance, risk for
trauma, impaired physical mobility, impaired verbal communication,
defensive coping, powerlessness
■ Potential Complications: ventilator issues, alterations in cardiac function,
barotrauma, pulmonary infection, sepsis, delirium, pneumothorax
○ Extubation:
■ Have resuscitation equipment with face mask and O2 available at bedside
■ Have reintubation equipment at bedside
■ Suction the oropharynx and trachea well to avoid aspiration
 ■ Deflate the cuff on the ET tube and remove it during peak inspiration
■ Never extubate when the patient is still on sedation or is high from it
■ After Extubation:
● Monitor for signs of respiratory distress or airway obstruction
(ineffective cough, dyspnea, and stridor)
● Assess SpO2 and vital signs every 5 minutes
● Patient should NOT speak for a long period of time to promote
proper gas exchange
● Encourage coughing, deep breathing, use of incentive spirometer

● Musculoskeletal Issues:
○ Risk Factors for Bone Fracture: osteoporosis, falls, motor vehicle crashes,
substance use disorder, disease (bone cancer), contact sports, age, physical abuse
○ Findings of a Bone Fracture:
■ Pain and reduced movement at the area of fracture
■ Crepitus (grating sounds by the rubbing of bone fragments)
■ Deformity (internal rotation of extremity, shortened extremity, or visible
bone if it’s an open fracture)
■ Muscle spasm (due to pulling forces of unaligned bone)
■ Edema or swelling starts immediately
■ Ecchymosis (discoloration of the skin from bleeding, usually by bruise)
○ Closed or Simple Fracture: no break in the skin surface
○ Open or Compound/Complex Fracture: disrupts skin integrity, causing an open
wound and tissue injury with a risk of infection; graded on extent of tissue injury
■ Grade I: minimal skin damage
■ Grade II: damage includes skin and muscle contusions but without
extensive soft tissue injury
■ Grade III: damage to skin, muscle, nerves, and blood vessels is excessive
■ *Must put a sterile dressing if the bone is poking out of the skin to
prevent osteomyelitis*
○ Comminuted Fracture: bone is broken into miniature fragments (will hear
crepitus)
○ Oblique Fracture: is slanted across the bone shaft
○ Spiral Fracture: occurs from twisting motion around the bone shaft (common
with physical abuse)
○ Greenstick Fracture: occurs on one side but does not extend completely through
the bone (most often in children)
○ Health Promotion and Disease Prevention: recommended intake of calcium in
developmental stage of life, adequate vitamin D intake and exposure to sunlight,
 weight-bearing exercise on a regular basis, prevent falls or accidents, use seatbelts
and helmet to prevent injury
■ Take a bisphosphonate if prescribed to slow bone resorption and treat
osteoporosis: Alendronate [Fosamax]
○ Diagnostic Procedures: x-ray, CT scan, and MRI
○ Interventions for an Acute Fracture:
■ Provide emergency care at the time of injury
■ Keep patient NPO until evaluated by a physician (a priority action)
■ Administer pain medication
■ Stabilize the injury including joints above and below the fracture by using
a splint and avoiding unnecessary movements
■ Maintain proper body alignment of the affected extremity
■ Elevate the limb above the heart and apply ice
■ Assess for bleeding and apply pressure if needed
■ Cover open wounds with sterile dressing to avoid osteomyelitis
■ Initiate and continue neurovascular checks hourly
■ Monitor the 6 P’s: pain, pallor, paralysis, paresthesia, pulselessness,
poikilothermia
● Pain is the FIRST sign of compartment syndrome, especially upon
movement
○ Immobilization Interventions: casts, splints/immobilizers, traction, external
fixation, and internal fixation
■ Prevents injury, promotes healing/circulation, reduces pain, and corrects
the deformity
○ Casts: are circumferential immobilizers that are applied once the swelling has
subsided (to avoid compartment syndrome)
■ More effective than splints/immobilizers because the patient can’t remove
it
■ If there is swelling after cast application and it causes unrelieved pain, the
cast can be split on one side (univalve) or on both sides (bivalve)
■ Widow: can be placed in an area of the cast for skin inspection
■ Moleskin: used over any rough area of the cast (on the edges of the cast)
that can rub against the patient’s skin; tell them not to remove it
■ Materials Used:
● Plaster of Paris: it is heavy, not water resistant, and takes 24-72
hours to dry
● Synthetic Fiberglass: light, stronger, water resistant, and dries very
quickly (in 30 minutes)
■ Types of Casts: short and long arm, short and long leg casts, body casts
 ● Walking Casts: a rubber walking pad on the sole of the cast that
assists the patient in ambulating when weight bearing is allowed
● Spica Casts: a portion of the truck and one or two extremities,
typically used in children who have congenital hip dysplasia
■ Nursing Interventions:
● Monitor neurovascular status every hour for the first 24 hours
○ By testing capillary refill and having the patient wiggle toes
● Assess for pain and apply ice for the first 24-48 hours to reduce
swelling
● Handle a plaster cast with the palm of your hands NOT your
fingertips (it prevents the cast from denting and causing pressure
ulcers); you may use your fingertips when its dry*
● After the cast is applied, position the patient so that warm, dry air
circulates around and under the cast for faster drying and to
prevent pressure from changing the shape of the cast (you can
rotate the patient’s arm so it dries evenly)
● Elevate the cast above the level of the heart during the first 24-48
hours to prevent edema to the affected extremity
● Make sure the cast is not too tight (1 finger should fit in between)
■ Patient Education:
● Instruct the patient not to place any objects inside the cast to avoid
trauma to the skin
○ *Relieve itching by blowing cool air from the hair dryer
into the cast*
● Encourage the patient to report any area under cast that is painful,
has increased drainage, hot spots (warm-dry), and/or has a foul
odor (these indicate infection)
○ Splints and Immobilzers: provides support, controls movement, and prevents
additional injury
■ Splints are removable and allow for monitoring of skin swelling and
integrity
■ Splints can support fractured/injured areas until casting occurs and
swelling is decreased
■ Nursing Interventions and Patient Education:
● Ensure that the patient is aware of application protocol regarding
full-time or part-time use
● Instruct the patient to observe for skin breakdown at pressure
straps
● Patient must follow the doctor’s instruction for wear time
○ External Fixation Devices: immobilizes fracture using percutaneous pins and
wires that are attached to a rigid external frame; high risk for osteomyelitis
■ Provides support for complicated or comminuted fractures with extensive
soft tissue damage
■ Nursing Interventions:
● Elevate the extremity to reduce edema
● Patient needs reassurance because of the appearance of the device
● Perform pin care every shift or 8-12 hours; use a q-tip to clean
each pin then discard; do NOT use the same q-tip for another pin
● Early mobility may be anticipated and discomfort is usually
minimal
● Monitor for complications such as infection
■ Patient Education: pin care and teach strategies to prevent complications
○ Open Reduction and Internal Fixation:
■ Open Reduction: the visualization of a fracture through an incision in the
skin
■ Internal Fixation: plates, screws, pins, rods, and prosthetics are placed as
needed
● Pins, rods, and plates are used internally to surgically place bones
back to its original state
■ After the bone heals, the hardware may or may not be removed (depends
on the location and type of hardware)
○ Traction: uses a pulling force to promote and maintain alignment of the injured
area; never remove without a doctor’s order
■ Prescription for Traction Includes: the type of traction, amount of
weight, and whether it can be removed for nursing care
■ It is a short-term intervention until other interventions can be used
■ A trapeze is used to change the patient’s body position during muscle
spasms; if that doesn’t work, anti-spasm medication will be given
■ Purposes: prevent soft tissue injury, realign the bone, decrease muscle
spasms and pain, correct or prevent further deformities
■ Types of Traction:
● Skin Traction: primary purpose is to decrease muscle spasms and
immobilize the extremity prior to surgery
○ A pulling force is applied by weights that are attached by
rope to the patient’s skin with tape, straps, boots, or cuffs
● Buck Extension: used preoperatively for hip fractures for
immobilization in adult patients
 ● Skeletal Traction: screws are inserted into the bone (ex: halo
traction); can use heavier weights (15-30 lbs) and longer traction
time to realign the bone
○ Frequent pin and skin care is needed to prevent infection*
○ Perform pin care every 8-12 hours; use a q-tip to clean
each pin then discard; do NOT use the same q-tip for
another pin
■ Principles for Effective Traction:
● A counterforce must be applied (usually the patient’s body weight
and positioning in bed)
● Traction must be continuous to reduce and immobilize fractures
● *Skeletal traction is never interrupted*
● Weights are not removed unless intermittent traction is prescribed
● Any factor that reduces pull must be eliminated
● Ropes must be unobstructed and weights must hang freely and not
of the floor
● Knots or the footplate must not touch the foot of the bed
■ Nursing Interventions for Skin Traction: proper application and
maintenance
● Monitor for skin breakdown, nerve damage, and circulation
impairment
○ Inspect skin at least 3 times a day
○ Palpate traction tapes to assess for tenderness
○ Assess sensation and movement
○ Assess pulses, color, capillary refill, and temperature of
fingers and toes
○ Assess for indicators of DVT, skin breakdown, and
infection
■ Nursing Interventions for Skeletal Traction:
● Evaluate traction apparatus and patient position
● Maintain alignment of the body
● Report pain promptly
● Trapeze to help with movement
● Assess pressure points in skin every 8 hours
● Regular shifting in position
● Special mattresses or other pressure reduction devices
● Perform active foot exercises and leg exercises every hour
● Elastic hose, pneumatic compression hose, or anticoagulant
therapy may be prescribed
 ● Pin Care: typically provided once a shift, 1-2 times a day, or per
protocol; done frequently to prevent and monitor for infection
○ Signs of Infection: drainage (color, amount, odor),
redness, loosening of pins and tenting of skin at pin site
(skin rising up to cover the pins)
○ Complications:
■ Compartment Syndrome: affects extremities and occurs when pressure
within one or more of the muscle compartments of the extremity
compromises circulation resulting in ischemia-edema cycle
● Capillaries dilate in an attempt to pull oxygen into the tissue;
increased capillary permeability from histamine release leads to
edema
● Increased edema causes pressure on the nerve endings causing pain
● Pressure can result from external sources such as a tight cast or a
constrictive bulky dressing
● Assess using the 6 P’s: pain, paralysis, paresthesia, pallor,
pulselessness, and poikilothermia
● If compartment syndrome is untreated, necrosis can result and
neuromuscular damage occurs within 4-6 hours
● Manifestations:
○ Increased pain, especially with movement, that is
unrelieved with elevation or by pain medication (first sign)
○ Paresthesia or numbness, burning, and tingling is an early
manifestation due to nerve compromise
○ Paralysis indicates major nerve damage and is a late
manifestation
○ Color of tissue and nailbeds is pale; always compare it with
an unaffected extremity
○ Pulselessness is a late manifestation (necrosis develops)
○ Compare the temperature of both extremities: it is cold
because there is no blood supply
○ The tissue will die if nothing is done in 4-6 hours
● Nursing Interventions for Prevention:
○ Assess the neurovascular status frequently
○ Notify the provider when compartment syndrome is
suspected
○ Loosen the constrictive dressing or cut the bandage or tape
○ Keep the extremity at heart level to improve arterial
pressure
 ○ If the cast is too tight, call the provider to bivalve the cast
to relieve pressure
○ Fasciotomy: surgical incision is made through the
subcutaneous tissue and fascia of the affected compartment
to relieve pressure and restore circulation (after all
interventions have been done and failed)
■ Fat Embolism:
● Adults older than 70 are at increased risk
● Hip and pelvic fractures are common causes
● Occurs usually within 12-48 hours following long bone fractures
or with total joint arthroplasty
● Fat globules from bone marrow are released into the vasculature
and travel to the small blood vessels, including the lungs (results in
acute respiratory insufficiency and impaired organ perfusion)
● Early Manifestations: dyspnea, increased respiratory rate,
decreased oxygen saturation, headache, decreased mental acuity,
confusion, tachycardia, chest pain
● Late Manifestations: cutaneous petechiae (pinpoint-sized
hemorrhage occurring on the neck, chest, upper arm, and
abdomen); this is what separates it from a pulmonary embolism
● Nursing Interventions:
○ Maintain the patient on bedrest
○ Immobilization of fractures of the long bones and minimal
manipulation during turning can prevent it, if
immobilization procedures have not yet been performed
● Treatment: oxygen for respiratory compromise, corticosteroids to
decrease cerebral edema, vasopressors and fluid replacement for
shock, pain and antianxiety medications
■ Osteomyelitis: an infection in the bone that begins as inflammation within
the bone secondary to penetration by infectious organism
● Symptoms: localized pain, edema, erythema, fever, drainage
● Patients with chronic osteomyelitis may have a low grade fever
that occurs in the afternoon or evening
● Treatment: (a) long course (3 months) IV (through a PICC line) or
oral antibiotics, (b) surgical debridement, (c) unsuccessful
treatment can result in amputation
○ Vancomycin [Vancocin] is typically given: must know the
peak and trough levels (trough = 5-15 mcg/mL and peak =
20-40 mcg/mL)
 ● Nursing Interventions:
○ Administer antibiotics to maintain a constant blood level
○ Administer analgesics PRN
○ Conduct neurovascular assessments if debridement is done
○ If the wound is left open to heal, standard precautions are
adequate and clean technique can be used during dressing
change
○ Amputation is needed if all treatments fail
○ Joint Replacements: treats severe joint pain and disability for repair and
management of joint fractures or joint necrosis
■ Hip, knee, and finger joints are frequently replaced
■ Patients with Hip Replacement Surgery:
● Prevent Dislocation of Hip Prosthesis:
○ Correct positioning using splint, wedge, pillows
○ Keep hip in abduction when turning; adduction when
transferring
○ Limit flexing of the hip; less than 90 degrees
● Mobility and Ambulation:
○ Begin ambulation within 1 day after surgery using walkers
or crutches
○ Weight bearing as prescribed by physician
○ Apply ice to the surgical site following ambulation for pain
● Drain Usage Postoperatively: assess for bleeding and fluid
accumulation
● Prevent Infection:
○ Remove drain within 24-48 hours
○ Strict hygiene practices
○ Patient is at risk for up to 2 years (24 months)
○ Prophylactic antibiotics may be given to prevent post-op
infection
● Prevent DVT:
○ Use prophylactic measures (early ambulation, ROM,
anticoagulants, SCDs)
○ Monitor closely for clinical signs of the development of
DVT and PE (calf pain, warm to the touch, chest pain,
SOB, low oxygen sat)
● Patient Education for Hip Replacement:
○ Instruct patient about raised toilet seats and care items
(long-handled shoe horn)
○ Patient should NOT bend all the way down
 ○ Avoid dislocations by:
■ Use elevated seating and a raised toilet
■ Do NOT cross legs and avoid low chairs
■ Avoid turning to the operative side, unless
prescribed
■ Avoid flexion of hip greater than 90 degrees
■ Use an abduction pillow (wedges in between both
legs spreading them out)
■ Patients with Knee Replacement:
● Postoperative Interventions:
○ Compression bandage on knee
○ Assess neurovascular status every 2-4 hours
○ Monitor for complications (VTE, infection, bleeding)
○ Patients with knee replacements are at risk for hip
contractions: patient should be prone for 30 minutes to
avoid flexion and should not sit for long periods of time
● Wound Suction Drain:
○ Remove in 24-48 hours as long as there is not a lot of
drainage
○ Prophylactic antibiotics
○ Autotransfusion of extensive bleeding
● Continuous Passive Motion (CPM):
○ Promote range of motion, circulation, and healing
○ Prevent scar tissue formation in knee
○ Patient is placed in device immediately after surgery
● Physical Therapy:
○ Strength and ROM
○ Assistive devices
○ Ambulate patient on first post-op day
● Acute Rehabilitation:
○ Starts in 1-2 weeks
○ Total recovery is 6 weeks
○ ***Remember rehabilitation starts on admission***
○ Lower Back Pain: occurs along the lumbosacral area of the vertebral column
■ Can be acute (self-limiting) or chronic (3 months or repeated pain
episodes)
■ Patients with back pain can also experience foot, ankle, and leg weakness
or burning/stabbing pain radiating to the leg or foot
■ It is the leading cause of work disability; prevalent in ages 30-60
 ■ Risk Factors: smoking, obesity, scoliosis, osteoporosis, muscle
strain/spasm, herniated disk, compression fracture
■ Prevention:
● Exercise to keep back healthy and strong
● Use proper body mechanics and lifting techniques
● Maintain correct postures and a healthy weight
● Wear low-heeled shoes
● Smoking cessation (smoking is linked to disk degeneration)
● Avoid prolonged sitting/standing
● Adequate intake of calcium and vitamin D
■ Medications:
● Analgesics: Acetaminophen [Tylenol]
● NSAIDs: Ibuprofen [Advil] and Naproxen [Aleve]
● Muscle Relaxants: Cyclobenzaprine Hydrochloride [Flexeril] and
Methocarbamol [Robaxin]
■ Patient Education:
● Proper body alignment and balanced rest with activity
● Encourage use of thermal application (dry or moist to alleviate
pain and ice for acute inflammation)
● Use of complementary and alternative therapies (acupuncture, tai
chi, music therapy)
● Daily schedule for activities to promote independence (high-energy
activities in the morning)
● Encourage a well-balanced diet and ideal body weight
● Assistive devices to promote safety and independence (shoe-horn,
elevated toilet seat)
○ Osteoporosis: most prevalent bone disease in the world; bones are brittle and
fragile, and breaks easy under stress
■ Normal bone turnover is altered and the rate of bone resorption
(osteoclasts) is greater than the rate of bone formation (osteoblasts),
resulting in total bone loss
■ Frequently results in compression fractures of the spine, fractures of the
neck, or fractures of the intertrochanteric region of the femur*
■ A loss of height is associated with osteoporosis, but is also normal with
aging
■ Prevention:
● Ensure the patient’s diet includes adequate calcium and vitamin D
○ Vitamin D-Rich Foods: fish, egg yolk, fortified milk, cereal
○ Calcium-Rich Foods: milk products, green vegetables,
fortified orange juice and cereal, red and white beans, figs
 ○ Patient should take calcium supplements with vitamin D
○ **You NEED vitamin D to absorb calcium**
● Encourage patient to limit the amount of carbonated beverages,
which contains phosphates and cause calcium loss
● Engage in weight bearing exercise (walking, lifting weights)
○ Amputations: the removal of a body part; commonly an extremity
■ Can be elective due to complications of peripheral vascular disease and
atherosclerosis, congenital deformities, chronic osteomyelitis, malignant
tumor, or traumatic due to an accident
■ An amputation is described in regard to the extremity and whether they are
located above or below the designated joint (ex: above or below the knee
amputation)
■ Risk Factors: traumatic injury (motor vehicle crashes, industrial
equipment and war-related injuries); thermal injury (frostbite, burns);
peripheral vascular disease, diabetes mellitus, infection, malignancy
● *Diabetes is one of the most common reasons for amputation*
● If a bone is accidentally severed, place the extremity in a bag and
stick it in ice water
■ Signs an Amputation is Needed: gangrene and necrosis
■ Expected Findings: decreased tissue perfusion, cyanosis, history of injury
or disease process precipitating amputation, altered peripheral pulse,
differences in tempt, infection, gangrenes, open wounds
■ Nursing Interventions:
● Prevent postoperative complications (hypovolemia, pain, infection)
● Assess surgical site for bleeding and monitor vital signs frequently
● Monitor tissue perfusion at the end of residual limb
● Monitor and treat pain; differentiate between phantom limb and
incisional pain
○ Incisional Pain: treated with analgesics
○ Phantom Limb Pain: sensation of pain in location of the
extremity following the amputation; treated with
antiepileptics such as Gabapentin [Neurontin] to relieve
sharp, stabbing, and burning phantom limb pain
■ Must treat phantom pain because the patient
actually feels it
■ Preparing the Limb for Prosthesis:
● Residual limb MUST be shaped and shrunk to fit a prosthetic limb
● Shrinkage Interventions:
○ Wrap the stump in a figure 8 with elastic bandages to
prevent restricted blood flow, decrease edema, and create a
cone shape
○ Use the stump shrinker sock (easier for patient to apply)
○ Use an air splint (plastic inflatable device) to protect and
shape the residual limb and for easy access to inspect the
wound