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📚 Your 3rd Semester Subjects (INC/BFUHS Syllabus)

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🫁 Lung Abscess - Complete Study Notes

Medical Surgical Nursing | 3rd Semester (INC/BFUHS Syllabus)

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1. DEFINITION

• Acute lung abscess - duration less than 4-6 weeks
• Chronic lung abscess - duration more than 6 weeks (about 40% of cases)

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2. CLASSIFICATION

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3. ETIOLOGY (Causes)

Most Common Cause - ASPIRATION

• Alcoholism (most common predisposing factor)
• Altered consciousness - coma, drug overdose, seizures, general anesthesia
• Poor oral hygiene / periodontal disease / carious teeth - anaerobic bacteria colonize gingival crevices
• Dysphagia (difficulty swallowing)
• Gastroesophageal reflux disease (GERD)
• Debilitated/bedridden patients with depressed cough reflex

Other Causes

1. Necrotizing pneumonia - caused by S. aureus, Klebsiella pneumoniae, Pseudomonas spp., Streptococcus pyogenes
2. Bronchial obstruction - by tumor (lung cancer), foreign body - impaired drainage leads to abscess
3. Septic emboli - from right-sided infective endocarditis (tricuspid valve) or Lemierre's syndrome (jugular vein thrombophlebitis from Fusobacterium necrophorum)
4. Hematogenous spread - in staphylococcal bacteremia (causes multiple abscesses)
5. Post-procedural - after bronchoscopy, biopsy

Causative Organisms

Important exam tip: Anaerobic bacteria are present in almost all lung abscesses and are the exclusive isolates in 1/3 to 2/3 of cases. - (Robbins & Kumar Basic Pathology)

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4. PATHOPHYSIOLOGY

Aspiration of infected oropharyngeal material
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Bacteria deposit in dependent lung segments
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Pneumonitis develops over 7-14 days
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Necrosis of lung parenchyma
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Cavity formation (lung abscess)
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Cavity communicates with airway → partial drainage
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Air-fluid level visible on X-ray/CT

• Right lung is more commonly affected than left because:
  • Right mainstem bronchus is shorter, larger in diameter, and more vertical
  • Aspirated material goes to right side more easily
• Common locations:
  • Posterior segment of the RIGHT upper lobe
  • Superior (apical) segment of the right lower lobe
  • These are the most dependent segments in a recumbent (lying down) patient

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5. CLINICAL FEATURES (Signs & Symptoms)

Subacute / Indolent Onset (weeks to months - typical of anaerobic)

Physical Examination Findings

• Fever
• Poor dentition (points to aspiration/anaerobic etiology)
• Decreased consciousness (in some)
• On chest examination: crackles, egophony, dullness to percussion if pleural effusion present
• Clubbing of fingers - in chronic cases

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6. INVESTIGATIONS (Diagnostic Studies)

1. Chest X-Ray (CXR)

• Shows a thick-walled cavity with an air-fluid level surrounded by consolidation/infiltrate
• Most common location - right upper or lower lobe posterior/superior segments

2. CT Scan of Chest (most accurate)

• Better definition of the cavity
• Can distinguish lung abscess from:
  • Empyema (lung abscess is round, has ragged/shaggy inner wall, does NOT compress surrounding lung)
  • Malignancy (wall thickness >16 mm, nodular inner wall suggests cancer)
  • Septic emboli (multiple nodules in different stages)
• Features of lung abscess on CT:
  • Air-fluid level
  • Surrounding consolidation/ground-glass opacities
  • Irregular ("shaggy") inner wall

3. Sputum Examination

• Gram stain and aerobic culture
• Putrid-smelling sputum = virtually diagnostic of anaerobic infection
• Note: Anaerobic culture is technically difficult - samples must be transported rapidly

4. Blood Investigations

• CBC - leukocytosis (raised WBC), elevated ESR, CRP
• Blood cultures (especially in secondary abscesses)

5. Bronchoscopy

• To rule out obstruction (foreign body, tumor)
• Bronchoalveolar lavage (BAL) for culture in secondary/immunocompromised cases

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7. COMPLICATIONS

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8. MEDICAL MANAGEMENT

Antibiotic Therapy (Primary Treatment)

• Duration: 4-6 weeks minimum; up to 14 weeks depending on radiological clearance

Why Clindamycin over Penicillin? Because many oral anaerobes produce beta-lactamases that destroy penicillin. Clindamycin has proved superior to penicillin in clinical trials. - (Harrison's Principles of Internal Medicine, 22E)

• For MRSA abscesses: Linezolid (preferred) or Vancomycin
• For MSSA abscesses: Cefazolin, Nafcillin, or Oxacillin

Expected Response to Treatment

• Clinical improvement within 3-4 days
• Fever resolves in 7-10 days
• Antibiotics continue until abscess clears on imaging (CXR/CT)

Surgical Intervention

• Life-threatening hemoptysis
• Bronchopleural fistula
• Empyema
• Cavity >6 cm in diameter
• No response to 12 weeks of antibiotic therapy
• Obstructed bronchus

Percutaneous / CT-Guided Drainage

• For patients who fail antibiotic therapy
• Risks: pneumothorax, bronchopleural fistula

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9. NURSING MANAGEMENT

Assessment

• Monitor vital signs - temperature (fever pattern), respiratory rate, oxygen saturation (SpO2)
• Assess sputum - quantity, colour, odour (foul smell indicates anaerobic infection)
• Assess for hemoptysis - amount and colour of blood
• Assess pain (pleuritic chest pain)
• Assess nutritional status and weight
• Assess oral hygiene and dentition

Nursing Diagnoses (NANDA-based)

1. Ineffective Airway Clearance related to excessive secretions and cavity formation
2. Impaired Gas Exchange related to consolidation and cavitation
3. Acute Pain related to pleuritic chest pain
4. Hyperthermia related to infective process
5. Imbalanced Nutrition: Less than body requirements related to poor appetite, weight loss
6. Risk for Aspiration related to altered consciousness/gag reflex

Nursing Interventions

• Encourage deep breathing and coughing exercises
• Postural drainage - position the patient so the affected lung lobe is uppermost to facilitate drainage by gravity (usually semi-prone or lateral positions)
• Chest physiotherapy (percussion and vibration)
• Adequate hydration (2-3 litres/day) to thin secretions
• Nebulisation as ordered
• Suction if patient cannot cough effectively

• Administer antibiotics as ordered - ensure correct dose, route, timing
• Monitor for antibiotic side effects (e.g., diarrhoea with clindamycin - risk of C. difficile)
• Maintain strict hand hygiene
• Dispose of sputum in covered containers - standard precautions

• Monitor SpO2 continuously
• Administer supplemental oxygen as prescribed
• Position patient - semi-Fowler's (30-45 degrees) to facilitate breathing
• Report any sudden deterioration in respiratory status

• Antipyretics (Paracetamol) for fever as ordered
• Analgesics for pleuritic chest pain
• Oral hygiene care - regular mouth rinses, dental hygiene (this also helps prevent recurrence)
• Encourage high-protein, high-calorie diet to support healing and fight infection

• Explain the disease, its course, and treatment plan
• Emphasize completing the full course of antibiotics (4-6 weeks - very common reason for relapse is stopping early)
• Teach about maintaining good oral hygiene and regular dental check-ups
• Advice on avoiding alcohol and maintaining positioning after meals if aspiration risk
• Educate about warning signs - increased hemoptysis, worsening breathlessness - must report immediately
• Smoking cessation counselling

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10. DIFFERENTIAL DIAGNOSIS

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11. PROGNOSIS

• With antibiotics, mortality has decreased to 15-20%
• In immunocompromised patients, large abscesses (>6 cm), or bronchial obstruction, mortality may be as high as 75% despite treatment
• Before antibiotics were available (pre-1940s), mortality was 32-34%

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Quick Revision Summary (for Exams)

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What I Can Do ✅

• Explain each disease/topic in extreme detail - definition, causes, pathophysiology, signs & symptoms, investigations, medical management, nursing management, complications, prevention
• Pull previous year questions style explanations (long answer, short answer format as per INC/BFUHS pattern)
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• Write everything in clean, copy-paste ready text that you can format into a PDF

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My Strong Recommendation: Disease by Disease 🎯

Pneumonia, Tuberculosis, Lung Abscess, Bronchitis, Bronchiectasis, Asthma, COPD, Pleural Effusion, Pneumothorax, Pulmonary Embolism, Respiratory Failure, ARDS, Cancer of Lung, Tracheostomy care...

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The Best Plan for You 📋

1. Send me your syllabus (photo or type it out)
2. I'll list all the topics in order
3. We go one topic at a time, and for each topic I will give you:
   • Full detailed notes
   • Previous year question-style long answers
   • Short note format
   • MCQs (10-15 per topic)
4. At the end of the full unit, I'll compile a unit-level MCQ set (30-50 questions)

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About PDF

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🫁 ATELECTASIS

Complete Study Notes | Medical Surgical Nursing | 3rd Semester (INC/BFUHS Syllabus)

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SECTION 1: DEFINITION

• The affected lung continues to receive blood (perfusion) but has NO ventilation
• This creates a Ventilation-Perfusion (V/Q) mismatch leading to hypoxemia (low oxygen in blood)
• Also called Collapse of the lung
• It may involve an entire lung, a lobe, a segment, or a subsegment

Simple definition for exams: "Atelectasis is the collapse or incomplete expansion of lung tissue resulting in areas of poorly aerated or non-aerated pulmonary parenchyma."

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SECTION 2: TYPES / CLASSIFICATION

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TYPE 1: RESORPTION (OBSTRUCTIVE) ATELECTASIS

• An obstruction BLOCKS air from entering the distal airways
• The air already present DISTAL to the obstruction is gradually resorbed (absorbed) into the blood
• With no new air entering, the alveoli progressively collapse

• Mediastinum SHIFTS TOWARD the affected (collapsed) side - because the lung shrinks and pulls structures toward it

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TYPE 2: COMPRESSION (PASSIVE/RELAXATION) ATELECTASIS

• External pressure is applied on the lung from OUTSIDE, compressing it
• The lung is literally "squashed" and collapses

• Mediastinum SHIFTS AWAY from the affected side - because the space-occupying material pushes structures away

Basal atelectasis - a subtype of compression atelectasis. Occurs at lung bases in bedridden patients due to failure to breathe deeply, abdominal pressure pushing up the diaphragm. Very common post-operatively.

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TYPE 3: CONTRACTION (CICATRIZATION) ATELECTASIS

• Fibrosis (scarring) of the lung or pleura prevents the lung from expanding fully
• The lung is "trapped" in a contracted state by scar tissue
• Cicatrization = scarring

• This is the ONLY IRREVERSIBLE type of atelectasis
• Seen in late-stage tuberculosis, old healed pneumonia, interstitial fibrosis

• Pulmonary fibrosis
• Pleural fibrosis / thickening
• Old tuberculosis with scarring
• Radiation-induced fibrosis

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ADDITIONAL TYPES (also asked in exams)

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SECTION 3: PREDISPOSING / RISK FACTORS

Post-operative Patients (MOST IMPORTANT)

• General anesthesia decreases Functional Residual Capacity (FRC) - the amount of air left in lungs after normal exhalation
• Upper abdominal or thoracic surgery - pain prevents deep breathing; also stimulates GI viscera altering diaphragm function
• Anesthesia impairs mucociliary clearance - the tiny hairs that sweep secretions out of airways stop working
• Patients cannot cough effectively because of pain

Other High-Risk Groups

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SECTION 4: PATHOPHYSIOLOGY

OBSTRUCTION / COMPRESSION / FIBROSIS
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Airway blocked OR lung externally compressed OR restricted by fibrosis
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Air cannot enter distal alveoli (or existing air gets resorbed)
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Alveolar COLLAPSE (atelectasis)
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Lung continues to receive blood supply (perfusion) BUT no ventilation
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V/Q MISMATCH (blood goes through collapsed areas without getting oxygenated)
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HYPOXEMIA (low PaO2 in blood) → Tachypnea, Dyspnea
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If prolonged → Mucus stagnates → BACTERIAL INFECTION → PNEUMONIA

• Normal: Every unit of lung that gets blood flow (Q) also gets ventilation (V) → oxygen properly loaded onto haemoglobin
• In atelectasis: Blood still flows through the collapsed lung units but there is NO air → blood passes through without picking up oxygen → "shunt" → hypoxemia

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SECTION 5: CLINICAL FEATURES (Signs & Symptoms)

Small Atelectasis (subsegmental / plate-like):

• Often ASYMPTOMATIC - discovered incidentally on X-ray
• May cause mild dyspnea

Larger Atelectasis (lobar / whole lung):

Physical Examination Findings:

Exam Tip: In post-operative patients, fever in first 24-48 hours = think atelectasis first! (not infection - that comes later, usually after 48-72 hours).

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SECTION 6: INVESTIGATIONS

1. Chest X-Ray (First-line investigation)

• Loss of lung volume on affected side
• Displacement of lobar fissures toward the collapse
• Tracheal/mediastinal shift toward the collapsed side (in resorption atelectasis)
• Elevated hemidiaphragm on the affected side
• Crowding of ribs on the affected side
• Plate-like (discoid) atelectasis - thin horizontal lines, usually at bases
• Increased opacity (whiteness) in the area of collapse

2. CT Scan of Chest

• More sensitive than CXR
• Can detect early or subtle atelectasis
• Helps identify the underlying CAUSE (mucus plug, mass, lymph nodes)
• Can distinguish atelectasis from pneumonia, pleural effusion, or tumor

3. Bronchoscopy

• When obstruction is suspected
• Can directly visualize the airway obstruction (tumor, mucus plug, foreign body)
• Can also be THERAPEUTIC - remove the obstruction

4. Arterial Blood Gas (ABG)

• Shows hypoxemia (low PaO2)
• May show hypocapnia (low PaCO2) early due to tachypnea (hyperventilation)
• Later: respiratory failure with hypercapnia if large area involved

5. Pulse Oximetry (SpO2)

• SpO2 ≤96% after breathing oxygen via Venturi mask for 30 minutes is a moderately sensitive test for diagnosing post-operative atelectasis
• Quick bedside monitoring tool - nurses use this continuously

6. Bedside Ultrasound

• Increasingly used to detect atelectasis at bedside in ICU patients

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SECTION 7: COMPLICATIONS

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SECTION 8: MEDICAL MANAGEMENT

1. Treat the Underlying Cause

• Relieve the obstruction (mucus plug, foreign body, tumor)
• Drain pleural effusion or pneumothorax (compression type)
• Manage underlying fibrosis (contraction type)

2. Incentive Spirometry

• Patient breathes deeply through a spirometer device to expand collapsed alveoli
• Commonly prescribed post-operatively for prevention and treatment
• Patient takes a slow, deep inhalation, sustains it for 5-6 seconds, then exhales

3. Positive Pressure Breathing

• IPPB (Intermittent Positive Pressure Breathing) - delivers positive pressure during inhalation
• CPAP (Continuous Positive Airway Pressure) / BiPAP (Non-invasive ventilation) - keeps alveoli open by maintaining positive end-expiratory pressure; very effective for post-operative atelectasis
• PEEP (Positive End-Expiratory Pressure) - in mechanically ventilated patients

4. Bronchoscopy

• For obstructive atelectasis
• Suction out mucus plugs
• Remove foreign bodies
• Biopsy tumors

5. Pharmacological Treatment

• Bronchodilators (nebulized Salbutamol, Ipratropium) - dilate airways, facilitate mucus clearance
• Mucolytics (N-Acetylcysteine) - thin out thick secretions
• Antibiotics - if secondary infection / pneumonia develops
• Analgesics - for post-operative patients so pain does not prevent deep breathing

6. Positioning

• Semi-Fowler's (30-45°) or High Fowler's (90°) - reduces compression of lung bases by abdominal organs
• Frequent repositioning every 2 hours - changes dependent areas, redistributes ventilation

7. Oxygen Therapy

• Supplemental oxygen to correct hypoxemia
• Monitor SpO2 continuously

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SECTION 9: NURSING MANAGEMENT

Nursing Assessment

• Monitor vital signs - temperature (especially post-op fever), respiratory rate, SpO2, pulse
• Observe breathing pattern - depth, rate, use of accessory muscles
• Auscultate breath sounds - note any absent/decreased areas
• Assess cough effectiveness - can the patient cough and raise secretions?
• Assess pain level - especially post-operative incisional pain that prevents deep breathing
• Monitor ABG results and SpO2
• Assess level of consciousness and mobility

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Nursing Diagnoses (NANDA)

1. Ineffective Breathing Pattern related to pain, anesthesia, or airway obstruction, manifested by shallow respirations and decreased SpO2
2. Impaired Gas Exchange related to V/Q mismatch secondary to collapsed alveoli, manifested by hypoxemia and dyspnea
3. Ineffective Airway Clearance related to retained secretions, manifested by inability to cough effectively
4. Acute Pain related to surgical incision (post-op patients), manifested by reluctance to breathe deeply (splinting)
5. Risk for Infection related to stagnant secretions in collapsed lung
6. Anxiety related to dyspnea and hypoxemia

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Nursing Interventions

1. AIRWAY CLEARANCE

• Deep breathing exercises - instruct patient to take 5 slow deep breaths, hold for 5-6 seconds, then exhale fully; repeat every 1-2 hours
• Coughing exercises - "Huff coughing" (2-3 short huffs followed by a strong cough) is less painful and more effective than hard coughing
• Splinting technique - teach post-op patients to hold a pillow firmly against the incision while coughing to reduce pain and allow more effective cough
• Incentive spirometry - demonstrate correct use; encourage patient to use every 1-2 hours while awake
• Chest physiotherapy (CPT) - percussion (clapping) and vibration over affected areas to loosen secretions
• Postural drainage - position the affected lung upward/elevated so gravity assists drainage of secretions
• Suction - nasotracheal or tracheal suction if patient cannot clear secretions independently

2. PROMOTING VENTILATION

• Positioning: Elevate head of bed to High Fowler's or Semi-Fowler's position (30-90°) to allow maximum lung expansion
• Ambulation / Early mobilization - encourage early walking post-operatively (within 24 hours if possible)
• Turn and reposition every 2 hours in immobilized patients
• Oxygen therapy as prescribed - monitor SpO2, keep ≥95%
• Assist with CPAP/BiPAP if prescribed

3. PAIN MANAGEMENT (critical in post-op patients)

• Administer prescribed analgesics (paracetamol, NSAIDs, opioids as needed)
• Coordinate deep breathing and coughing exercises to happen after analgesic administration (when pain is controlled)
• Teach splinting technique
• Regional blocks (epidural) may be used by the anaesthesia team

4. HYDRATION

• Encourage oral fluid intake (2-3 litres/day if no contraindication)
• Adequate hydration thins secretions, making them easier to cough up
• Administer IV fluids as ordered

5. MONITORING AND RECORDING

• Monitor SpO2 continuously
• Monitor respiratory rate, depth, and effort every 2-4 hours
• Auscultate breath sounds at least every shift
• Monitor temperature for post-operative fever
• Document any changes in sputum colour, amount, consistency
• Report: SpO2 <94%, RR >25, worsening dyspnea, increasing fever - to the physician immediately

6. PREVENTION OF ATELECTASIS (Pre-operative and Post-operative Nursing)

7. PATIENT AND FAMILY EDUCATION

• Explain what atelectasis is and why it happens (especially to post-op patients/families)
• Demonstrate incentive spirometry use before surgery; observe return demonstration
• Teach deep breathing and huff coughing technique
• Explain importance of early ambulation after surgery
• Tell patient to report any worsening breathlessness, chest pain, or fever
• Explain the purpose of all devices (O2 mask, spirometer, suction)

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SECTION 10: PREVENTION

1. Pre-operative breathing exercises - teach before surgery
2. Incentive spirometry - before and after surgery
3. Early ambulation post-operatively
4. Adequate pain control - so patients can breathe deeply
5. Deep breathing and coughing exercises every 1-2 hours post-op
6. Frequent repositioning - every 2 hours for all immobilized patients
7. Adequate hydration - to prevent thick, sticky secretions
8. Smoking cessation - before elective surgery
9. Avoidance of prolonged supine position
10. Proper management of pleural effusions and pneumothorax

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PREVIOUS YEAR-STYLE QUESTIONS WITH ANSWERS

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LONG ANSWER QUESTIONS (10-15 marks)

• Definition (see Section 1)
• Types with diagram: Resorption, Compression, Contraction (see Section 2)
• Causes for each type (see Section 3)
• Clinical features (see Section 5)
• Nursing Management in detail (see Section 9)

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• Why post-op patients are at risk (anesthesia, pain, reduced FRC)
• Assessment (SpO2, breath sounds, temperature, pain level)
• Nursing diagnoses
• Interventions: deep breathing, incentive spirometry, pain management, early ambulation, positioning, splinting technique, chest physiotherapy
• Patient education
• Monitoring and reporting criteria

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SHORT ANSWER QUESTIONS (5 marks)

• Obstruction of airway → air distal to obstruction gets absorbed → alveolar collapse
• Mediastinum shifts TOWARD affected side
• Causes: mucus plugs (most common), foreign body aspiration

• Device that provides visual feedback during slow, deep inhalation
• Patient inhales slowly, ball/float rises to target, hold for 5-6 sec
• Expands collapsed alveoli by creating negative intrathoracic pressure
• Used every 1-2 hours post-operatively for prevention and treatment

• General anesthesia reduces FRC
• Mucociliary clearance is impaired
• Inadequate deep breathing due to pain causes secretion retention
• Secretions pool in dependent lung zones → alveoli collapse (atelectasis)
• Collapsed lung with stagnant secretions triggers an inflammatory response → fever
• This typically occurs in the first 24-48 hours post-operatively
• Treatment: deep breathing exercises, early ambulation, incentive spirometry - NOT antibiotics (no infection yet)

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MCQs ON ATELECTASIS (15 Questions)

• A) Inflammation of the lung parenchyma
• B) Loss of lung volume due to inadequate expansion of air spaces ✅
• C) Accumulation of fluid in the pleural space
• D) Overinflation of air spaces

• A) Compression atelectasis
• B) Contraction atelectasis
• C) Resorption (obstructive) atelectasis ✅
• D) Rounded atelectasis

• A) Away from the affected side
• B) Toward the affected side ✅
• C) Does not shift
• D) Shifts downward only

• A) Wound infection
• B) Urinary tract infection
• C) Atelectasis ✅
• D) Deep vein thrombosis

• A) Resorption atelectasis
• B) Compression atelectasis
• C) Contraction atelectasis ✅
• D) Plate-like atelectasis

• A) Applying positive pressure during exhalation
• B) Encouraging slow, deep inhalation to expand alveoli ✅
• C) Vibrating the chest wall to loosen secretions
• D) Delivering nebulized bronchodilators

• A) Administering antibiotics prophylactically
• B) Keeping patient in supine position for 24 hours
• C) Deep breathing exercises and early ambulation ✅
• D) Restricting oral fluids to prevent secretions

• A) Toward the affected side
• B) Away from the affected side ✅
• C) Does not shift
• D) Superiorly

• A) Hyperresonance
• B) Tympany
• C) Dullness ✅
• D) Normal resonance

• A) Hypercapnia
• B) Hypoxemia ✅
• C) Metabolic acidosis
• D) Hyperglycemia

• A) Applying a brace to the surgical site
• B) Holding a pillow against incision while coughing to reduce pain ✅
• C) Tying the patient's legs together post-operatively
• D) Applying external pressure to reduce lung expansion

• A) Tuberculosis
• B) Foreign body aspiration
• C) Asbestos-related pleural disease ✅
• D) Right heart failure

• A) Oxygen ✅ (along with other gases already present distal to obstruction)
• B) Carbon dioxide only
• C) Nitrogen only
• D) Helium

• A) Round opacity near the pleura
• B) Thin horizontal lines, usually at lung bases ✅
• C) Homogeneous opacity of an entire lobe
• D) Cavitary lesion with air-fluid level

• A) Supine (flat)
• B) Trendelenburg (head down)
• C) High Fowler's or Semi-Fowler's ✅
• D) Left lateral decubitus

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QUICK REVISION TABLE

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