The obstruction, which occurs at the level of the larger or smaller bronchus, can be caused by a foreign body, tumor, or mucous plugging. Nonobstructive atelactasis is caused by loss of contact between the parietal and the visceral pleurae, as well as compression, loss of surfactant, and replacement of parenchymal tissue by scarring or infiltrative disease. Abnormal breathing patterns, such as hypoventilation and a slow respiratory rate, can also lead to Atelectasis. In such cases, the lung does not fully expand, which causes the lower airways to collapse.
Causes of Atelectasis
Atelectasis occurs most frequently after surgery and is a major concern for acute care nurses.
Patients with abdominal and/or thoracic surgery are the most susceptible, especially in the older age group. The duration of the surgery is also a risk factor. Patients in surgery for more than 4 hours have a 50% incidence of severe atelectasis, compared with a 19% incidence for those in surgery for 2 hours. Other causes of atelectasis are mucous plugs in patients who smoke heavily and inflammation from inflammatory lung disease. Atelectasis also occurs in patients with central nervous system depression following a drug overdose or a critical cerebral event such as a cerebrovascular accident.
Nursing care plan assessment and examination
Assess the patient for such preoperative risk factors as obesity, pre-existing respiratory problems, and smoking. Because surgical patients are at risk, be alert for component of the postoperative history that may contribute to atelectasis: a decrease in total lung volume because of pain and splinting, changes in breathing patterns from incisional discomfort or medications, advanced age, and a need for an increased fraction of inspired oxygen (FiO2). Other factors include use of narcotic analgesics that depress the respiratory drive, immobility, a decrease in consciousness, muscular weakness, hypotension, sepsis, and use of a nasogastric tube.
The patient may appear asymptomatic if small areas of the lung are involved, or they may appear acutely ill with extreme shortness of breath and clinical signs of oxygen deficit such as confusion, agitation, rapid heart rate, and even combative behavior when large areas are affected. Suprasternal, substernal, and intercostal retractions may be present, depending on the severity of atelectasis. Percussion reveals a dullness over the affected lung area. When the patient’s breath sounds are auscultated, you may hear decreased breath sounds or even find breath sounds to be absent. In addition, many patients have fine, late inspiratory crackles and coarse crackles or wheezes with airway obstruction.
The patient with atelectasis may be very anxious if breathing becomes too difficult. If the atelectasis is a result of foreign body aspiration by a child, the parents may be upset and guilty. Determine the patient’s and parents’ abilities to cope with the stressful situation.
Nursing care plan primary nursing diagnosis Ineffective airway clearance related to obstruction and lung collapse.
Nursing care plan intervention and treatment plan
Patients in pain, especially following abdominal and thoracic surgery, tend to breathe shallowly to decrease their discomfort. Pain medications allow them to breathe more deeply and expand their lungs. Use caution in overmedicating patients, however, because that will reduce respiratory excursion. In the immediate postoperative period, narcotic analgesia is often prescribed because it is readily reversible by naloxone (Narcan).
Incentive spirometry, chest percussion, and postural drainage may be prescribed by the physician to increase gas exchange and to decrease the risk of atelectasis. Oxygen may be delivered with humidification to improve clearance of mucus. If atelectasispersists, the physician may prescribe a mask with continuous positive airway pressure (CPAP). With the use of a CPAP mask, positive airway pressure is maintained throughout the respiratory cycle. In addition, CPAP prevents and reverses airway closure, thus expanding the lung volumes and reestablishing the functional residual capacity (FRC). If atelectasis persists and hypoxemia becomes life-threatening, endotracheal intubation and mechanical ventilation with positive-pressure ventilation and positive end-expiratory pressure (PEEP) may be necessary, but these aggressive therapies are usually not needed.
Instruct the preoperative patient on coughing and deep-breathing exercises prior to surgery, before incisional pain makes learning difficult. Teach the patient breathing exercises, such as pursed-lip breathing and abdominal breathing to expand the lungs. As soon as the patient is awake and alert after surgery, with a patent airway and adequate breathing, encourage him or her to cough and breathe deeply to help expand the lung. If the patient has abdominal or thoracic incisions, use a pillow to splint the incision to reduce discomfort during breathing exercises. Encourage the patient to use the incentive spirometer at the bedside every 2 hours when she or he is awake.
Encourage the patient to ambulate as soon as possible to reduce complications of immobility, which cause retention of secretions and decreased lung volumes. Seating the patient upright allows the patient to breathe more deeply because the lungs can expand better. Turn patients on bedrest at least every 2 hours.
Encourage patients who can expectorate secretions to cough; place a paper bag on the side rails of the bed for sanitary tissue disposal. If the patient is not on fluid restriction, explain that he or she should drink at least 2 to 3 L of fluid a day to liquefy secretions. If the patient is unresponsive, suction the patient endotracheally to remove sputum and to stimulate coughing.
If a child has developed atelectasis because of foreign-body obstruction, teach the parents to maintain a safe environment. The most commonly aspirated objects are safety pins and hard foods such as corn, raisins, and peanuts. Parents should not allow children to run or walk while eating because activity predisposes the child to aspiration. Teach the patient and family to evaluate all toys for removable parts; explain that coins are commonly aspirated and should not be given to children. Explain to parents that they should not allow a young child to play with baby powder during diaper changes because if the top is altered and powder spills onto the child’s face, the child can inhale it.
Nursing care plan discharge and home health care guidelines
To prevent atelectasis, instruct the patient prior to surgery about coughing, deep breathing, and early ambulation. Encourage the patient to request and take pain medications to assist with deep-breathing exercises. Explain that an adequate fluid intake is important to help loosen secretions and aid in their removal.
Instruct patients regarding the use of any medications they are to take at home. Discuss the indications for use and any adverse effects. If patients are placed on antibiotics, instruct them to finish all of the antibiotics even if they feel better before the prescription is completed.