NLE Respiratory Nursing — Upper & Lower Respiratory InfectionsRevision Notes

Exam Tips

• NLE FAVOURITE: If a patient with sore throat has tonsillar exudate + fever + swollen anterior cervical nodes + NO cough → think GABHS → give full course penicillin to prevent RHEUMATIC FEVER.
• Viral URTI = NO antibiotics; persistent symptoms (>10 days) or worsening = consider bacterial cause.
• The nurse's most important teaching for GABHS pharyngitis = COMPLETE THE ANTIBIOTIC COURSE.
• Sinusitis worst symptom on bending forward = maxillary or frontal sinus involvement.
• Warm saline gargle is a safe, cheap, non-pharmacological intervention for pharyngitis — very Filipino community health-applicable.

Key Points

• URTIs affect the structures above the larynx: the nose, sinuses, pharynx, and tonsils.
• Most URTIs are VIRAL in origin — antibiotics are NOT routinely indicated.
• Sinusitis: inflammation of the paranasal sinuses, usually viral following a cold; bacterial superinfection is suspected when symptoms persist beyond 10 days or worsen after initial improvement.
• Key sinusitis symptoms: facial pain/pressure worse on bending forward, purulent nasal discharge, nasal congestion, headache, and post-nasal drip.
• Sinusitis management: supportive care (saline irrigation, steam/humidification, decongestants, analgesics); amoxicillin is first-line ONLY for confirmed/persistent bacterial sinusitis.
• Pharyngitis: inflammation of the pharynx; most are viral — ONLY Group A beta-haemolytic Streptococcus (GABHS) requires antibiotics.
• GABHS ('strep throat') clues: sudden sore throat, fever, tonsillar exudate, tender anterior cervical lymph nodes, and ABSENCE OF COUGH (Centor criteria).
• Confirm GABHS with a rapid antigen test or throat culture before starting antibiotics.
• GABHS treatment: full course of PENICILLIN (or amoxicillin); macrolide (e.g., azithromycin) if penicillin-allergic.
• PRIORITY TEACHING for GABHS: complete the ENTIRE antibiotic course — this is the single most important step in preventing RHEUMATIC FEVER and acute glomerulonephritis.
• NANDA nursing diagnosis for pharyngitis: Acute Pain related to pharyngeal inflammation; Risk for Ineffective Health Management related to incomplete antibiotic therapy.
• Maslow's priority for URTIs: Physiological needs (pain, infection control) first; then safety (preventing complications like rheumatic fever).

Definitions

Section Title

Upper Respiratory Tract Infections (URTIs): Sinusitis and Pharyngitis

Common Mistakes

• Prescribing or expecting antibiotics for ALL sore throats — most are viral and do NOT need antibiotics.
• Stopping antibiotic therapy early because symptoms improved — emphasise completing the FULL COURSE for GABHS.
• Confusing sinusitis pain timing: maxillary sinus pain worsens on bending FORWARD (increased pressure), not lying down.
• Forgetting to screen for penicillin allergy before prescribing amoxicillin — use macrolide (azithromycin) as alternative.
• Missing the ABSENCE OF COUGH as a key Centor criterion for GABHS — viral pharyngitis typically includes cough.

Exam Tips

• ABRUPT onset of HIGH FEVER + severe MYALGIA + profound FATIGUE = INFLUENZA (not a common cold).
• OSELTAMIVIR is effective only within 48 HOURS — NLE loves to test this timing.
• Influenza = DROPLET precautions; TB = AIRBORNE precautions (N95, negative pressure room).
• Acute bronchitis management = SUPPORTIVE only; no antibiotics because it is VIRAL.
• Annual influenza vaccine is a cornerstone of prevention — emphasise for elderly and pregnant women in the Philippine context.

Key Points

• Influenza is an acute viral illness (Influenza A and B) with ABRUPT onset — distinguishing it from the gradual onset of the common cold.
• Classic flu triad: high fever + myalgia (muscle aches) + profound fatigue, with dry cough and headache.
• Influenza complications: viral or secondary bacterial PNEUMONIA — high risk in elderly, pregnant women, immunocompromised, and those with chronic disease.
• Antiviral treatment: OSELTAMIVIR (Tamiflu) — most effective within 48 HOURS of symptom onset.
• Influenza precautions: DROPLET precautions (not airborne) — surgical mask for nurse within 1 meter, private room preferred.
• Prevention: annual influenza vaccination (especially for high-risk groups), proper hand hygiene, cough etiquette.
• Acute bronchitis: inflammation of the bronchi, most often VIRAL and self-limiting; usually follows a URTI.
• Bronchitis hallmark: cough initially dry then becomes productive, lasting UP TO 3 WEEKS; may have low-grade fever and chest discomfort.
• ANTIBIOTICS ARE NOT INDICATED for acute bronchitis (viral) — overuse promotes antibiotic resistance.
• Bronchitis management: supportive — fluids (2–3 L/day), rest, humidification, antipyretics/analgesics.
• Teach warning signs that may indicate progression to pneumonia: HIGH FEVER, dyspnoea, pleuritic chest pain.
• NANDA for bronchitis: Ineffective Airway Clearance; Acute Pain; Deficient Knowledge regarding disease process and antibiotic misuse.
• Smoking cessation is an important teaching point for both bronchitis and all respiratory conditions.

Definitions

Section Title

Influenza and Acute Bronchitis

Common Mistakes

• Giving oseltamivir AFTER 48 hours and expecting it to be effective — it loses most efficacy after the 48-hour window.
• Using AIRBORNE precautions for influenza — influenza is DROPLET, not airborne (TB is airborne — classic NLE distractor).
• Expecting antibiotics for acute bronchitis — it is viral; antibiotics only worsen antimicrobial resistance.
• Confusing influenza (abrupt, systemic, with myalgia) with the common cold (gradual, localised, nasal symptoms).
• Forgetting to identify high-risk groups for influenza complications: elderly, pregnant women, immunocompromised, chronic disease patients.

Exam Tips

• PRIORITY in pneumonia = AIRWAY and OXYGENATION (Maslow's physiological need) → HIGH-FOWLER'S position is first nursing action.
• RUST-COLOURED sputum = Streptococcus pneumoniae (pneumococcal) — CAP first-line = amoxicillin or macrolide.
• ELDERLY with new confusion, lethargy, or unexplained fall → SUSPECT PNEUMONIA even without classic fever.
• Collect sputum culture BEFORE starting antibiotics — preserves diagnostic accuracy.
• INCREASED tactile fremitus + dullness to percussion + bronchial breath sounds = CONSOLIDATION (pneumonia); DECREASED fremitus + dullness = pleural effusion.
• Fluoroquinolones (levofloxacin) risk = TENDON RUPTURE + QT prolongation — use with caution in elderly; this is a favourite NLE pharmacology distractor.

Key Points

• Pneumonia is an infection of the lung PARENCHYMA causing inflammation and CONSOLIDATION of alveoli with exudate, impairing gas exchange.
• CLASSIFICATION: Community-acquired pneumonia (CAP) — most common cause is Streptococcus pneumoniae; Hospital-acquired/ventilator-associated (>48h after admission); Aspiration pneumonia (risk: impaired swallowing, decreased LOC, NG feeding).
• PATHOPHYSIOLOGY: Pathogens in alveoli → inflammatory exudate fills alveoli (consolidation) → reduced gas exchange surface area → HYPOXAEMIA.
• CLASSIC SIGNS: fever and chills, productive cough with PURULENT or RUST-COLOURED sputum (rust = pneumococcal), pleuritic chest pain, dyspnoea, tachypnoea.
• PHYSICAL EXAM FINDINGS over consolidation: crackles (rales), bronchial breath sounds, DULLNESS to percussion, INCREASED tactile fremitus, positive egophony (E → A sound change).
• ATYPICAL PRESENTATION IN ELDERLY: confusion, lethargy, and falls may be the ONLY signs — blunted fever is common. HIGH-YIELD NLE POINT.
• DIAGNOSTICS: Chest X-ray (infiltrates/consolidation), sputum Gram stain and culture (collect BEFORE antibiotics), CBC (leukocytosis), blood cultures if severe, pulse oximetry/ABG.
• PRIORITY NURSING INTERVENTION: Maintain PATENT AIRWAY and ADEQUATE OXYGENATION — this is Maslow's Level 1 (physiological survival need).
• POSITIONING: HIGH-FOWLER'S position to maximise lung expansion and facilitate breathing.
• AIRWAY CLEARANCE: Encourage deep breathing and coughing, incentive spirometry, hydration (2–3 L/day unless contraindicated) to loosen secretions.
• Give ANTIBIOTICS PROMPTLY AND ON TIME to maintain therapeutic blood levels; monitor treatment response.
• Monitor for COMPLICATIONS: pleural effusion/empyema, sepsis/septic shock, respiratory failure/ARDS, atelectasis, lung abscess.
• NANDA diagnoses: Impaired Gas Exchange; Ineffective Airway Clearance; Activity Intolerance; Risk for Infection (spread); Deficient Knowledge.
• PREVENTION: Pneumococcal vaccine (PCV13, PPSV23) and annual influenza vaccine for at-risk groups (elderly, chronic illness).

Definitions

Section Title

Pneumonia — Pathophysiology, Assessment, and Nursing Management

Common Mistakes

• Forgetting that the ELDERLY may present WITHOUT classic fever — confusion or a fall may be the only sign of pneumonia.
• Collecting sputum AFTER starting antibiotics — sputum culture must be done BEFORE the first antibiotic dose for accurate results.
• Placing patient in SUPINE position instead of HIGH-FOWLER'S — this worsens breathing effort and gas exchange.
• Confusing increased tactile fremitus (consolidation in pneumonia) with decreased fremitus (pleural effusion or pneumothorax).
• Restricting fluids in pneumonia — adequate hydration (2–3 L/day) is essential to thin secretions and facilitate airway clearance.
• Forgetting that right lower lobe is most common in aspiration pneumonia (gravity-dependent, wider right mainstem bronchus).

Exam Tips

• CAP mild = AMOXICILLIN or MACROLIDE; severe = FLUOROQUINOLONE or beta-lactam + macrolide.
• FLUOROQUINOLONE = TENDON RUPTURE + QT prolongation (NLE pharmacology classic).
• MACROLIDE = GI upset + QT prolongation.
• PARACETAMOL is first-line for fever in pneumonia — monitor liver function with prolonged use.
• Pneumococcal + influenza vaccines = PRIMARY PREVENTION for high-risk patients — key health promotion NLE item.

Key Points

• CAP FIRST-LINE: Amoxicillin or a MACROLIDE (azithromycin, clarithromycin) for mild/outpatient cases.
• CAP SEVERE CASES or COMORBIDITIES: Respiratory FLUOROQUINOLONE (levofloxacin) OR a beta-lactam + macrolide combination.
• MACROLIDES (azithromycin, clarithromycin): Common side effect = GI upset (nausea, diarrhoea); IMPORTANT — monitor for QT PROLONGATION on ECG.
• FLUOROQUINOLONES (levofloxacin): Risk of TENDON RUPTURE (especially Achilles tendon) and QT prolongation; can cause blood glucose fluctuations (hypo or hyperglycaemia); use with caution in the elderly.
• ANTIPYRETICS/ANALGESICS: Paracetamol (acetaminophen) for fever management and pleuritic chest pain — avoid NSAIDs if there is risk of bleeding or renal impairment.
• PREVENTION PHARMACOLOGY: Pneumococcal vaccine (PCV13 for children; PPSV23 for adults ≥65, immunocompromised) and annual influenza vaccine.
• Always give antibiotics ON TIME and at the SCHEDULED INTERVAL to maintain therapeutic blood levels.
• Monitor for therapeutic response: decreasing fever, improving oxygenation, reduced cough, improving chest X-ray findings.

Definitions

Section Title

Pneumonia — Pharmacology and Drug Therapy

Common Mistakes

• Giving fluoroquinolones without assessing for tendon pain or advising rest — teach patients to report any tendon pain immediately.
• Overlooking QT prolongation risk when combining macrolides and fluoroquinolones with other QT-prolonging drugs.
• Skipping pneumococcal vaccine in elderly patients ≥65 — this is a primary prevention strategy endorsed in the Philippine healthcare context.
• Confusing the antibiotic regimens: amoxicillin is for CAP; NOT automatically used for hospital-acquired pneumonia (requires broader spectrum).

Exam Tips

• Philippine NTP FIRST-LINE diagnostic = GENEXPERT MTB/RIF (detects TB + rifampicin resistance in ~2 hours).
• TB screening trigger in the Philippines = COUGH ≥ 2 WEEKS → refer to DOTS facility.
• Mantoux: inject intradermally → read at 48–72 HOURS → measure INDURATION only (not redness).
• LATENT TB = no symptoms, not infectious; ACTIVE TB = symptomatic, infectious — know this distinction.
• Extrapulmonary TB on the spine = POTT'S DISEASE — classic extrapulmonary TB scenario in NLE.

Key Points

• TB is caused by Mycobacterium tuberculosis, an ACID-FAST BACILLUS (AFB) spread by AIRBORNE DROPLET NUCLEI when an infected person coughs, sneezes, or talks.
• The Philippines has one of the HIGHEST TB burdens in the world — TB is the leading infectious disease killer nationally.
• PATHOPHYSIOLOGY: Inhaled bacilli → lodge in alveoli → immune system walls them off → GRANULOMA (Ghon complex) → LATENT TB INFECTION (LTBI).
• LATENT TB: Person is INFECTED but NOT INFECTIOUS, ASYMPTOMATIC; positive TST/PPD; no active disease signs.
• ACTIVE TB: Bacilli reactivate (triggered by immunosuppression, HIV, diabetes, malnutrition, ageing) → tissue destruction, cavitation, and systemic symptoms.
• EXTRAPULMONARY TB: Can affect lymph nodes, bone (Pott's disease = TB spine), meninges (TB meningitis), and kidneys.
• CLASSIC MANIFESTATIONS: Chronic productive cough ≥2 WEEKS, low-grade AFTERNOON fever, NIGHT SWEATS, unexplained weight loss, fatigue, anorexia, haemoptysis.
• SCREENING TRIGGER in the Philippine setting: COUGH OF ≥2 WEEKS — refer immediately to nearest DOTS facility.
• DIAGNOSTICS (Philippine NTP first-line): GENEXPERT MTB/RIF is the PRIMARY diagnostic test — detects M. tuberculosis AND rifampicin resistance in approximately 2 HOURS.
• SPUTUM AFB SMEAR MICROSCOPY (DSSM): Still used for monitoring treatment response; previously the initial test but now secondary to GeneXpert.
• CHEST X-RAY: Supports diagnosis (upper-lobe infiltrates, cavitation) but NOT CONFIRMATORY alone.
• TUBERCULIN SKIN TEST (Mantoux/PPD): Read at 48–72 HOURS; measure INDURATION (not redness); indicates infection/exposure, not necessarily active disease; can be positive in prior BCG-vaccinated individuals.
• NANDA diagnoses for TB: Ineffective Airway Clearance; Impaired Gas Exchange; Activity Intolerance; Social Isolation; Ineffective Health Maintenance; Deficient Knowledge (DOTS, drug regimen).
• Maslow's priority for TB: Physiological (oxygenation) → Safety (infection control, preventing spread) → Love/belonging (social isolation) → Self-esteem (stigma reduction).

Definitions

Section Title

Tuberculosis (TB) — Philippine Priority Topic: Pathophysiology, Assessment, and Diagnostics

Common Mistakes

• Reading the Mantoux test at the WRONG TIME (not 48–72 hours) or measuring REDNESS instead of INDURATION.
• Forgetting that LATENT TB is not infectious — only ACTIVE pulmonary TB poses a transmission risk.
• Using chest X-ray as CONFIRMATORY for TB — it supports diagnosis but is not definitive alone; GeneXpert is the first-line confirmatory test in the Philippine NTP.
• Thinking a BCG-vaccinated patient cannot have TB — BCG reduces severity but does NOT guarantee complete protection; TST can be positive post-BCG.
• Confusing the screening trigger: cough of ≥2 WEEKS in the Philippine setting → refer for TB workup, not just treat as bronchitis.

Exam Tips

• TB = AIRBORNE → NEGATIVE PRESSURE ROOM + N95 for nurse (surgical mask on PATIENT during transport) — the #1 NLE distractor.
• RIPE mnemonic: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol — 2 months intensive (all 4) + 4 months continuation (R + I only) = 6 MONTHS TOTAL.
• DRUG TOXICITY MNEMONICS: R = Red (orange urine); I = Injury to nerves (peripheral neuropathy → B6); P = Pain in joints (gout/uric acid); E = Eye damage (optic neuritis).
• R, I, P = HEPATOTOXIC — monitor LFTs, report jaundice, dark urine, RUQ pain; AVOID ALCOHOL.
• GENEXPERT = FIRST-LINE diagnostic for Philippine NTP (TB + rifampicin resistance in 2 hours).
• DOTS = watch patient SWALLOW every dose — prevents MDR-TB.
• Patient on effective TB therapy = non-infectious after ~2–3 weeks of treatment — but NEVER STOP EARLY.
• RIFAMPICIN reduces oral contraceptive efficacy — counsel to use additional barrier contraception.
• ISONIAZID → always pair with PYRIDOXINE (B6) — this is a guaranteed NLE answer.

Key Points

• DOTS (Directly Observed Treatment, Short-course): A trained treatment partner or health worker DIRECTLY WATCHES the patient SWALLOW every dose — the backbone of the Philippine National TB Control Program (NTP).
• DOTS core principle: ensures ADHERENCE and prevents MULTIDRUG-RESISTANT TB (MDR-TB), which develops from incomplete treatment.
• Under the Philippine NTP, TB diagnosis and the full drug regimen are provided FREE through DOTS facilities in public health centres.
• STANDARD RIPE REGIMEN (drug-susceptible TB): 6 MONTHS TOTAL.
• INTENSIVE PHASE: 2 months on 4 drugs — Rifampicin (R) + Isoniazid (I) + Pyrazinamide (P) + Ethambutol (E).
• CONTINUATION PHASE: 4 months on 2 drugs — Rifampicin (R) + Isoniazid (I) only.
• TB drugs are taken as a SINGLE DAILY DOSE, preferably on an EMPTY STOMACH for best absorption (unless GI upset requires food).
• RIFAMPICIN: ~10 mg/kg/day (450–600 mg). SIGNATURE: turns body fluids (urine, sweat, tears) ORANGE-RED — harmless but must be taught. TOXICITIES: hepatotoxic; potent enzyme INDUCER (REDUCES oral contraceptive efficacy — advise barrier method).
• ISONIAZID (INH): ~5 mg/kg/day (300 mg). SIGNATURE toxicity: PERIPHERAL NEUROPATHY — prevented by giving PYRIDOXINE (Vitamin B6). Also HEPATOTOXIC.
• PYRAZINAMIDE: ~25 mg/kg/day. TOXICITY: HEPATOTOXIC; raises URIC ACID → HYPERURICAEMIA/GOUT (joint pain, especially in toes and ankles).
• ETHAMBUTOL: ~15 mg/kg/day. SIGNATURE toxicity: OPTIC NEURITIS — causes DECREASED VISUAL ACUITY and RED-GREEN COLOUR BLINDNESS. TEACH: report any visual changes IMMEDIATELY; baseline and periodic vision checks required.
• SHARED TOXICITY (R, I, P): ALL THREE are HEPATOTOXIC — monitor LFTs; teach jaundice, dark urine, nausea, RUQ pain = stop drugs and report immediately.
• INFECTION CONTROL (TB — Maslow Safety Priority): AIRBORNE PRECAUTIONS — NEGATIVE-PRESSURE ISOLATION ROOM + N95 RESPIRATOR for staff (surgical mask on patient during transport).
• TB is AIRBORNE (droplet nuclei <5 microns, remain suspended in air) — NOT droplet. This is the most common NLE distractor.
• A patient on effective TB therapy is generally considered NON-INFECTIOUS after roughly 2–3 WEEKS of treatment with clinical improvement and reduced cough — but TREATMENT MUST CONTINUE for the full 6 months.
• CONTACT TRACING: Household contacts must be screened; infants receive BCG per national immunisation schedule.
• NANDA nursing diagnoses for TB management: Ineffective Therapeutic Regimen Management; Risk for Injury (drug toxicity); Social Isolation; Impaired Nutrition: Less Than Body Requirements.

Definitions

Section Title

Tuberculosis (TB) — DOTS, RIPE Regimen, Drug Toxicities, and Nursing Management

Common Mistakes

• Using DROPLET precautions (surgical mask) instead of AIRBORNE precautions (N95 respirator + negative-pressure room) for TB — the most classic NLE distractor.
• Forgetting to give PYRIDOXINE (B6) with isoniazid — students must memorise this pairing.
• Not teaching patients about ORANGE-RED URINE from rifampicin — patients panic and stop the drug.
• Stopping TB drugs after 2 months when symptoms improve — treatment MUST continue for the FULL 6 MONTHS.
• Failing to assess VISION BASELINE before starting ethambutol — optic neuritis can be missed if not monitored.
• Confusing drug toxicities: Pyrazinamide → GOUT (uric acid); Ethambutol → OPTIC NEURITIS; Isoniazid → PERIPHERAL NEUROPATHY; Rifampicin → ORANGE URINE + reduces OCP efficacy.
• Thinking all three (R, I, P) are hepatotoxic but forgetting that ETHAMBUTOL is NOT primarily hepatotoxic — its key toxicity is optic neuritis.
• Prescribing TB drugs with food routinely — they should be taken on EMPTY STOMACH for best absorption (unless GI intolerance occurs).