MEDICAL AND SURGICAL NURSING

Respiratory System

MS 1

ANATOMY OF RESPIRATORY SYSTEM

OXYGENATON: the dynamic interaction of gases in the body for the purpose of delivering adequate oxygen essential for cellular survival RESPIRATORY SYSTEM MAIN FUNCTION: GAS EXCHANGE

I. Upper Respiratory TractA. Functions

1. Filtering2. Warming and moistening3. Humidification

B. Parts1. Nose - made up of framework of cartilages; divided

into R and L by the nasal septum. 2. Paranasal Sinuses – includes four pair of bony

cavities that are lined with nasal mucosa and ciliated epithelium.

3. Tubernate Bones ( Conchae )4. Pharynx – muscular passageway for both food and

air Nasopharynx Oropharynx Laryngopharynx

5. Tonsils and Adenoids6. Larynx – voice production, coughing reflex

Made up of framework of: Epiglottis – valve that covers the opening

to the larynx during swallowing. Glottis – opening between the vocal cords Hyoid bone – u shaped bone in neck Cricoid cartilage Thyroid cartilage, forms the Adam’s apple Arythenoid cartilage Speech production and cough reflex Vocal cords

7. Trachea - consists of cartilaginous rings Passageway of air Site of tracheostomy (4th-6th tracheal ring)

II. Lower respiratory tractA. Function: facilitates gas exchangeB. Parts

1. Lungs, are paired elastic structure enclosed in the thoracic cage, which is an airtight chamber with distensible walls. Right – 3 lobes, 10 segments Left – 2 lobes, 8 segments

Client post pneumonectomy affected side to promote expansion Post lobectomy unaffected side to promote drainage

Pleural cavity Parietal Visceral Pleural Fluid: prevents pleural friction rub

(as seen in pneumonia and pleural effusion)

2. Bronchi Lobar Bronchi: 3 R and 2 L Segmental Bronchi: 10 R and 8 L

Subsegmental Bronchi3. Bronchioles

Terminal Bronchioles Respiratory Bronchioles, considered to be

the transitional passageways between the conducting airways and the gas exchange

4. Alveoli - functional cellular units or gas-exchange

units of the lungs.- O2 and CO2 exchange takes place- Made up of about 300 million

TYPE 1 - provide structure to the alveoliTYPE 2 - secrete SURFACTANT, reduces surface tension; increases alveoli stability & prevents their collapseTYPE 3 – alveolar cell macrophages, destroys foreign material, such as bacteria

Lecithin Sphingomyelin

L/S ratio indicates lung maturity 2:1 normal 1:2 immature lungs

PULMONARY CIRCULATION- Provides for reoxygenation of blood and release of CO2

PULMONARY ARTERIES, carry blood from the heart to the lungs.

PULMONARY VEINS, is a large blood vessel of the circulatory system that carries blood from the lungs to the left atrium of the heart.

RESPIRATORY MUSCLES- PRIMARY: diaphragm and external intercostal muscles - ACCESORY: sternocleidomastoid (elevated sternum),

the scalene muscles (anterior, middle and posterior scalene) and the nasal alae

PHYSIOLOGY OF RESPIRATORY SYSTEM

VENTILATION: The movement of air in and out of the airways.

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• The thoracic cavity is an air tight chamber. the floor of this chamber is the diaphragm.

• Inspiration: contraction of the diaphragm (movement of this chamber floor downward) and contraction of the external intercostal muscles increases the space in this chamber. lowered intrathoracic pressure causes air to enter through the airways and inflate the lungs.

• Expiration: with relaxation, the diaphragm moves up and intrathoracic pressure increases. this increased pressure pushes air out of the lungs. expiration requires the elastic recoil of the lungs.

• Inspiration normally is 1/3 of the respiratory cycle and expiration is 2/3.

DRIVING FORCE FOR AIR FLOWAirflow driven by the pressure difference between

atmosphere (barometric pressure) and inside the lungs (intrapulmonary pressure).

AIRWAY RESISTANCE Resistance is determined chiefly by the radius size of the

airway. Causes of Increased Airway Resistance

1. Contraction of bronchial mucosa2. Thickening of bronchial mucosa3. Obstruction of the airway4. Loss of lung elasticity

RESPIRATION• The process of gas exchange between atmospheric air

and the blood at the alveoli, and between the blood cells and the cells of the body.

• Exchange of gases occurs because of differences in partial pressures.

• Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body.

• Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body.

NEUROCHEMICAL CONTROL

MEDULLA OBLONGATA – respiratory center initiates each breath by sending messages to primary respiratory muscles over the phrenic nerve

- has inspiration and expiration centers

PONS – has 2 respiration centers that work with the inspiration center to produce normal rate of breathing1. PNEUMOTAXIC CENTER – affects the inspiratory effort by limiting the volume of air inspired 2. APNEUSTIC CENTER – prolongs inhalation

NOTE: Chemoreceptors responds to changes in ph, increased PaCO2 = increase RR

RESPIRATORY EXAMINATION AND

ASSESSMENT

Background information

A. Abnormal patterns of breathing1. Sleep Apnea

cessation of airflow for more than 10 seconds more than 10 times a night during sleep

causes: obstructive (e.g. obesity with upper narrowing, enlarged tonsils, pharyngeal soft tissue changes in acromegaly or hypothyroidism)

2. Cheyne-Stokes periods of apnoea alternating with periods of

hyperpnoae pathophysiology: delay in medullary chemoreceptor

response to blood gas changes causes

left ventricular failure brain damage (e.g. trauma, cerebral,

haemorrhage) high altitude

3. Kussmaul's (air hunger) deep rapid respiration due to stimulation of respiratory

centre causes: metabolic acidosis (e.g. diabetes mellitus,

chronic renal failure) 4. Hyperventilation

complications: alkalosis and tetany causes: anxiety

5. Ataxic (Biot) irregular in timing and deep causes: brainstem damage

6. Apneustic post-inspiratory pause in breathing causes: brain (pontine) damage

7. Paradoxical the abdomen sucks with respiration (normally, it

pouches uotward due to diaphragmatic descent) causes: diaphragmatic paralysis

B. Cyanosis1. Refers to blue discoloration of skin and mucous

membranes , is due to presence of deoxygenated haemoglobin in superficial blood vessels

2. Central cyanosis = abnromal amout of deoxygenated haemoglobin in arteries and that blue discoloration is

MS 3

present in parts of body with good circulation such as tongue

3. Peripheral cyanosis = occurs when blood supply to a certain part of body is reduced, and the tissue extracts more oxygen from normal from the circulating blood, e.g. lips in cold weather are often blue, but lips are spared

4. Causes of cyanosis Central cyanosis

decreased arterial saturation decreased concentration of inspired oxygen:

high altitude lung disease: COPD with cor pulmoale,

massive pulmonary embolism right to left cardiac shunt (cyanotic congenital

heart disease) polycythaemia haemoglobin abnromalities (rare):

methaemoglobinaemia, sulphaemoglobinaemia Peripheral cyanosis

all causes of central cyanosis cause peripheral cyanosis

exposure to cold reduced cardiac output: left ventricular failure or

shock arterial or venous obstruction

Position: patient sitting over edge of bed

General appearance

look for the following Dyspnea

normal respiratory rate < 14 each minute tachypnoea = rapid respiratory rate are accessory muscles being used (sternomastoids,

platysma, strap muscles of neck) - characteristically, the accessory muscles cause elevation of shoulders with inspiration and aid respiration by increasing chest expansion

Cyanosis Character of cough

ask patient to cough several times lack of usual explosive beginning may indicate

vocal cord paralysis (bovine cough) muffled, wheezy ineffective cough suggests airflow

limitation very loose productive cough suggests excessive

bronchial secretions due to:- chronic bronchitis - pneumonia - bronchiectasis

dry irritating cough may occur with:- chest infection - asthma - carcinoma of bronchus - left ventricular failure - interstitial lung disease - ACE inhibitors

Sputum volume type (purulent, mucoid, mucopurulent) presence or absence of blood?

Stridor croaking noise loudest on inspiration is a sign that requires urgent attention causes: (obstruction of larynx, trachea or large

broncus)

- acute onset (minutes) inhaled foreign body acute epiglottitis anaphylaxis toxic gas inhalation

- gradual onset (days, weeks) laryngeal and pharyngeal tumours crico-arytenoid rheumatoid arthritis bilateral vocal cord palsy tracheal carcinoma paratracheal compression by lymph nodes post-tracheostomy or intubation

granulomata Hoarseness

causes include:- laryngitis - laryngeal nerve palsy associated with

carcinoma of lung - laryngeal carcinoma

The Hands

Clubbing commonly cause by respiratory disease (but NOT

emphysema or chronic bronchitis) occasionally, clubbing is associated with hypertrophic

pulmonary osteoarthropathy (HPO) characterised by periosteal inflammation at distal ends

of long bones, wrists, ankles, metacarpals and metatarsals

sweelling and tenderness over wrists and other involved areas

Staining staining of fingers - sign of cigarette smoking (caused by

tar, not nicotine) Wasting and weakness Pulse rate Flapping tremor (asterixis) - unreliable sign

ask patient to dorsiflex wrists and spread out fingers, with arms outstretched

flapping tremor may occur with severe carbon dioxide retention (severe chronic airflow limitation)

The Face

Eyes Horner's syndrome? (constricted pupil, partial ptosis and

loss of sweating which can be due to apical lung tumour compressing sympathetic nerves in neck)

Nose polpys? (associated with asthma) engorged turbinates? (various allergic conditions) deviated septum? (nasal obstruction)

Mouth and tongue look for central cyanosis evidence of upper respiratory tract infection (a reddened

pharynx and tonsillar enlargement with or without a coating of pus)

broken tooth - may predispose to lung abscess or pneumonia

sinusitis is indicated by tenderness over the sinuses on

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palpation some patients with obstructive sleep apnoea will be obese with

a receding chin, a small pharynx and a short thick neck

The Trachea

causes of tracheal displacement: toward the side of the lung lesion

upper lobe collapse upper lobe fibrosis pneumonectomy

upper mediastinal masses, such as retrosternal goitre tracheal tug (finger resting on trachea feels it move inferiorly

with each inspiration) is a sign of gross overexpansion of the chest because of airflow obstruction

The Chest: inspection

Shape and symmetry of chest Barrel shaped

anteroposterior (AP) diameter is increased compared with lateral diameter

causes: hyperinflation due to asthma, emphysema

Pigeon chest (pectus carinatum) localised prominence (outward bowing of sternum and

costal cartilages) causes:

manifestation of chronic childhood illness (due to repeated strong contractions of diaphragm while thorax is still pliable)

rickets

Funnel chest (pectus excavatum) developmental defect involving a localised depression

of lower end of sternum in severe cases, lung capacity may be restricted

Harrison's sulcus innar depression of lower ribs just above costal margins

at site of attachment of diaphragm causes:

severe asthma in childhood rickets

Kyphosis , exaggerated forward curvature of spine

Scoliosis , lateral bowing Kyphoscoliosis: causes:

idiopathic (80%) secondary to poliomyelitis (inflammation involving

grey matter of cord) (note: severe thoracic kyphoscoliosis may reduce lung

capacity and increase work of breathing) Lesions of chest wall

scars - previous thoracic operations or chest drains for a previous pneumothorax or pleural effusion

thoracoplasty (was once performed to remove TB, but no longer is because of effective antituberculosis chemotherapy) invovled removal of large number of ribs on one side to achieve permanent collapse of affected lung

erythema and thickening of skin may occur in radiotherapy; there is a sharp demarcation between abnormal and normal skin

Diffuse swelling of chest wall and neck pathophysiology: air tracking from the lungs causes:

pneumothorax rupture of oesopahagus

Prominent veins cause: superior vena caval obstruction

Asymmetry of chest wall movements assess this by inspecting from behind patient, looking

down the clavicles during moderate respiration - diminished movement indicates underlying lung disease

the affected side will showed delayed or decreased movement

causes of reduced chest wall movements on one side are localised: localised pulmonary fibrosis consolidation collapse pleural effusion pneumothroax

causes of bilateral reduced chest wall movements are diffuse: chronic airflow limitation diffuse pulmonary fibrosis

The Chest: palpation

chest expansion place hands firmly on chest wall with fingers extending

around sides of chest (fugyre 4.5) as patient takes a big breath in, the thumbs should move

symmetrically apart about 5 cm reduced expansion on one side indicates a lesion on that

side note: lower lobe expansion is tested here; upper lobe is

tested for on inspection (as above) apex beat

(discussed in cardiac section) for respiratory diseases:

displacement toward site of lesion - can be caused by: collapse of lower lobe localised pulmonary fibrosis

displacement away from site of lesion - can be caused by: pleural effusion tension pneumothorax

apex beat is often impalpable in a chest which is hyperexpanded secondary to chronic airflow limitation

vocal fremitus

MS 5

palpate chest wall with palm of hand while patient repeats "99"

front and back of chest are each palpated in 2 comparable positions with palms; in this way differences in vibration on chest wall can be detected

causes of change in vocal fremitus are the same as those for vocal resonance (see later)

ribs gently compress chest wall anteroposteriorly and laterally localised pain suggests a rib fracture (may be secondary to

trauma or spontaneous as a result of tumour deposition or bone disease)

The Chest: percussion

with left hand on chest wall and fingers slightly separated and aligned with ribs, the middle finger is pressed firmly against the chest; pad of right middle finger is used to strike firmly the middle phalanx of middle finger of left hand

percussion of symmetrical areas of: anterior (chest) posterior (back) (ask patient to move elbows forward

across the front of chest - this rotates the scapulae anteriorly, i.e. moves it out of the way)

axillary region (side) supraclavicular fossa

percussion over a solid structure (e.g. liver, consolidated lung) produces a dull note

percusion over a fluid filled area (e.g. pleural effusion) produces an extremely dull (stony dull) note

percussion over the normal lung produces a resonant note percussion over a hollow structure (e.g. bowel, pneumothorax)

produces a hyperresonsant note liver dullness:

upper level of liver dullness is determined by percussing down the anterior cehst in mid-clavicular line

normally, upper level of liver dullness is 6th rib in right mid-clavicular line

if chest is resonant below this level, it is a sign of hyperinflation usually due to emphysema, asthma

cardiac dullness: area of cardiac dullness is uaully present on left side of

chest this may decrease in emphysema or asthma

The Chest: auscultation

breath sounds introduction

one should use the diaphragm of stethoscope to listen to breath sound in each area, comparing each side

remember to listen high up into the axillae remember to use bell of stethoscope to listen to lung

from above the clavicles quality of breath sounds

normal breat sounds are heard with stethoscope over all parts of

chest, produced in airways rather than alveoli (although once they had been thought to arise from alveoli (vesicles) and are therefore called vesicular sounds)

normal (vesicular) breath sounds are louder and longer on inspiration than on expiration; and there is no gap between the inspiratory and expiratory sounds

bronchial breath sounds turbulence in large airways is heard without

being filtered by the alveoli, and therefore

produce a different quality; they are heard over the trachea normally, but not over the lungs

are audible throughout expiration, and often there is a gap between inspiration and expiration

are heard over areas of consolidation since solid lung conducts the sound of turbulence in main airways to peripheral areas without filtering

causes include:- lung consolidation (lobar pneumonia) -

common - localised pulmonary fibrosis - uncommon - pleural effusion (above the fluid) -

uncommon - collapsed lung (e.g. adjacent to a pleural

effusion) - uncommon amphoric sound = when breath sounds over a

large cavity have an exaggerated bronchial quality)

intensity of breath sounds causes of reduced breath sounds include:

chronic airflow limitation (especially emphysema)

pleural effusion pneumothorax pneumonia large neoplasm pulmonary collapse

added (adventitious) sounds two types of added sounds: continuous (wheezes) and

interrupted (crackles) wheezes

may be heard in expiration or inspiration or both pathophysiology of wheezes - airway narrowing an inspiratory wheeze implies severe airway

narrowing

causes of wheezes include:- asthma (often high pitched) - due to muscle

spasm, mucosal oedema, excessive secretions

- chronic airflow diseases - due to mucosal oedema and excessive secretions

- carcinoma causing bronchial obstruction - tends to cause a localised wheeze which is monophonic and does not clear with coughing

crackles some terms not to use include rales (low pitched

crackles) and creptitations (high pitched crackles)

crackles are due to collapse of peripheral airways on expiration and sudden opening on inspiration

early inspiratory crackles- suggests disease of small airways - characteristic of chronic airflow limitation - are only heard in early inspiration

late or paninspiratory crackles- suggests disease confined to alveoli - may be fine, medium or coarse - fine crackles - typically caused by

pulmonary fibrosis - medium crackles - typically caused by left

ventricular failure (due to presence of alveolar fluid)

- coarse crackes - tend to change with

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coughing; occur with any disease that leads to retention of secretions; commonly occur in bronchiectasis

pleural friction rub when thickened, roughened pleural surfaces rub

together, a continuous or intermittent grating sound may be heard

suggests pleurisy, which may be secondary to pulmonary infarction or pnuemonia

vocal resonanance gives information about lungs' ability to transmit sounds consolidated lung tends to transmit high frequencies so

that speech heard through stethoscope takes a bleeting quality (aegophony); when a patient with aegophony says "bee" it sounds like "bay"

listen over each part of chest as patient says "99"; over consolidated lung, the numbers will become clearly audible; over normal lung, the sound is muffled

whispering pectoriloquy - vocal resonance is increased to such an extent that whispered speech is distinctly heard

The Heart

lie patient at 45 degrees measure jugular venous plse for right heart failure examine preacordium; pay close attention to pulmonary

component of P2 (which is best heard at 2nd intercostal space on left) and should not be louder than A2; if it is louder, suspect pulmonary hypertension

cor pulmonale (also called pulmonary hypertensive heart disease) may be due to:

chronic airflow limitation (emphysema) pulmonary fibrosis pulmonary thromboembolism marked obesity sleep apnoea severe kyphoscoliosis

The Abdomen

palpate liver for enlargement due to secondary deposits of tumour from lung, or right heart failure

Other

Permberton's sign ask patient to lift arms over head look for development of facial plethora, inspiratory

stridor, non-pulsatile elevation of jugular venous pressure

occurs in vena caval obstruction Feet

inspect for oedema or cyanosis (clues of cor pulmonale)

look for evidence of deep vein thrombosisd Respiratory rate on exercise and positioning

patients complaining of dyspnoea should have their respiratory rate measured at rest, at maximal tolerated exertion and supine

if dyspnoea is not accompanied by tachypnoea when a patient climbs stairs, one should consider malingering

look for paradoxical inward motion of abdomen during inspiration when patient is uspine (indicating diaphragmatic paralysis)

Temperature: fever may accompany any acute or chronic chest infection

DIAGNOSTIC EVALUATION

1. Skin Test: Mantoux Test or Tuberculin Skin Test

This is used to determine if a person has been infected or has been exposed to the TB bacillus.

This utilizes the PPD (Purified Protein Derivatives). The PPD is injected intradermally usually in the inner

aspect of the lower forearm about 4 inches below the elbow.

The test is read 48 to 72 hours after injection. (+) Mantoux Test is induration of 10 mm or more. But for HIV positive clients, induration of about 5 mm is

considered positive Signifies exposure to Mycobacterium Tubercle bacilli

2. Pulse Oximeter

Non-invasive method of continuously monitoring he oxygen saturation of hemoglobin

A probe or sensor is attached to the fingertip, forehead, earlobe or bridge of the nose

Sensor detects changes in O2 sat levels by monitoring light signals generated by the oximeter and reflected by the blood pulsing through the tissue at the probe

Normal SpO2 = 95% - 100% < 85% - tissues are not receiving enough O2 Results unreliable in:

Cardiac arrest Shock Use of dyes or

vasoconstrictors Severe anemia High carbon

monoxide Level

3. Chest X-ray

This is a NON-invasive procedure involving the use of x-rays with minimal radiation.

The nurse instructs the patient to practice the on cue to hold his breath and to do deep breathing

Instruct the client to remove metals from the chest. Rule out pregnancy first.

5. Computed Tomography (CT Scan) and Magnetic Resonance Imaging ( MRI )

The CT scan is a radiographic procedure that utilizes x-ray machine.

MS 7

The MRI uses magnetic field to record the H+ density of the tissue. It does NOT involve the use of radiation. The contraindications for this procedure are the

following: patients with implanted pacemaker, patients with metallic hip prosthesis or other metal implants in the body.

This chest CT scan shows a cross-section of a person with bronchial cancer. The two dark areas are the lungs. The light areas within the lungs represent the cancer.

Clear MRI images of lung airways during breathing.

6. Flouroscopy Studies the lung and chest in motion Involves the continuous observation of an image

reflected on a screen when exposed to radiation in the manner of television screen that is activated by an electrode beam.

Structures of different densities that intercept the X-ray beam are visualized on the screen in silhouette

7. Indirect Bronchography A radiopaque medium is instilled directly into the

trachea and the bronchi and the outline of the entire bronchial tree or selected areas may be visualized through x-ray.

It reveals anomalies of the bronchial tree and is important in the diagnosis of bronchiectasis.

Nursing interventions BEFORE Bronchogram

Secure written consent Check for allergies to sea foods or iodine or

anesthesia NPO for 6 to 8 hours Pre-op meds: atropine SO4 and valium,

topical anesthesia sprayed; followed by local anesthetic injected into larynx. The nurse must have oxygen and anti spasmodic agents ready.

Nursing interventions AFTER Bronchogram Side-lying position NPO until cough and gag reflexes returned Instruct the client to cough and deep breathe

client

8. Bronchoscopy This is the direct inspection and observation of the

larynx, trachea and bronchi through a flexible or rigid bronchoscope.

Passage of a lighted bronchoscope into the bronchial tree for direct visualization of the trachea and the tracheobronchial tree.

Diagnostic uses: To examine tissues or collect secretions To determine location or pathologic process

and collect specimen for biopsy To evaluate bleeding sites To determine if a tumor can be resected

surgically

Therapeutic uses To Remove foreign objects from

tracheobronchial tree To Excise lesions To remove tenacious secretions obstructing the

tracheobronchial tree To drain abscess To treat post-operative atelectasis

Nursing interventions BEFORE Bronchoscopy Inform

ed consent/ permit needed

Explain procedure to the patient, tell him what to expect, to help him cope with the unkown

Atropine (to diminish secretions) is administered one hour before the procedure

About 30 minutes before bronchoscopy, Valium is given to sedate patient and allay anxiety.

Topical anesthesia is sprayed followed by local anesthesia injected into the larynx

Instruct on NPO for 6-8 hours Remove dentures, prostheses and contact lenses The patient is placed supine with

hyperextended neck during the procedure

Nursing interventions AFTER BronchoscopyPut the patient on Side lying position Tell patient that the throat may feel sore with . Check for the return of cough and gag reflex.Check vasovagal response.

MS 8

Watch for cyanosis, hypotension, tachycardia, arrythmias, hemoptysis, and dyspnea. These signs and symptoms indicate perforation of bronchial tree. Refer the patient immediately!

9. Lung Scan Procedure using inhalation or I.V. injection of a

radioisotope, scans are taken with a scintillation camera. Imaging of distribution and blood flow in the lungs.

(Measure blood perfusion) Confirm pulmonary embolism or other blood- flow

abnormalities

Nursing interventions BEFORE the procedure: Allay the patient’s anxiety Instruct the patient to Remain still during the

procedure

Nursing interventions AFTER the procedure Check the catheter insertion site for bleeding Assess for allergies to injected radioisotopes Increase fluid intake, unless contraindicated.

10. Sputum Examination Laboratory test Indicated for microscopic examination of the sputum:

Gross appearance, Sputum C&S, AFB staining, and for Cytologic examination/ Papanicolaou examination

Nursing interventions: Early morning sputum specimen is to be

collected (suctioning or expectoration) Rinse mouth with plain water Use sterile container. Sputum specimen for C&S is collected before

the first dose of anti-microbial therapy. For AFB staining, collect sputum specimen for

three consecutive mornings.

11. Biopsy of the Lungs Percutaneous removal of a small amount of lung tissue

For histologic evaluation- Transbronchoscopic biopsy—done during bronchoscopy, - Percutaneous needle biopsy - Open lung biopsy

Nursing interventions BEFORE the procedure: Withhold food and fluids Place obtained written informed consent in the

patient’s chart.

Nursing interventions AFTER the procedure: Observe the patient for signs of Pneumothorax

and air embolism Check the patient for hemoptysis and

hemorrhage Monitor and record vital signs Check the insertion site for bleeding Monitor for signs of respiratory distress

12. Lymph Node Biopsy Scalene or cervicomediastinal To assess metastasis of lung cancer

13. Pulmonary Function Test / Studies Non-invasive test Measurement of lung volume, ventilation, and diffusing

capacity Nursing interventions:

Document bronchodilators or narcotics used before testing

Allay the patient’s anxiety during the testing

MS 9

LUNG VOLUMES: (ITER)

Inspiratory reserve volume (3000 mL) The maximum volume that can be inhaled following a

normal quiet inhalation.Tidal volume (500 mL)

The volume of air inhaled and exhaled with normal quiet breathing

Expiratory reserve volume (1100 mL) The maximum volume that can be exhaled following the

normal quiet exhalationResidual volume (1200 mL)

The volume of air that remains in the lungs after forceful exhalation

LUNG CAPACITIES:

Functional Residual Capacity (ERV 1100 mL + RV 1200 mL = 2300 mL )

The volume of air that remains in the lungs after normal, quiet exhalation

Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500 mL ) The amount of air that a person can inspire maximally

after a normal expirationVital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL = 4600 mL )

The maximum volume of air that can be exhaled after a maximum inhalation

Reduced in COPDTotal Lung Capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL + RV 1200 mL = 5800 mL )

Total of all four volumes

14. Arterial Blood Gas Laboratory test Indicate respiratory functions Assess the degree to which the lungs are able to provide

adequate oxygen and remove CO2

Assess the degree to which the kidneys are able to reabsorb or excrete bicarbonate.

Assessment of arterial blood for tissue oxygenation, ventilation, and acid-base status

Arterial puncture is performed on areas where good pulses are palpable (radial, brachial, or femoral).

Radial artery is the most common site for withdrawal of blood specimen

Nursing interventions: Utilize a 10-ml. Pre-heparinized syringe to

prevent clotting of specimen Soak specimen in a container with ice to

prevent hemolysis If ABG monitoring will be done, do Allen’s

test to assess for adequacy of collateral circulation of the hand (the ulnar arteries)

15. Pulmonary Angiography This procedure takes X-ray pictures of the pulmonary

blood vessels (those in the lungs). Because arteries and veins are not normally seen in an X-

ray, a contrast material is injected into one or more arteries or veins so that they can be seen.

16. Ventilation - Perfusion Scan Radioactive albumin injection is part of a nuclear scan

test that is performed to measure the supply of blood through the lungs.

After the injection, the lungs are scanned to detect the location of the radioactive particles as blood flows through the lungs.

The ventilation scan is used to evaluate the ability of air to reach all portions of the lungs. The perfusion scan measures the supply of blood through the lungs.

A ventilation and perfusion scan is most often performed to detect a pulmonary embolus. It is also used to evaluate lung function in people with advanced pulmonary disease such as COPD and to detect the presence of shunts (abnormal circulation) in the pulmonary blood vessels.

17. Thoracentesis

MS 10

Procedure suing needle aspiration of intrapleural fluid or air under local anesthesia

Specimen examination or removal of pleural fluid Nursing intervention BEFORE Thoracentesis

Secure consent Take initial vital signs Instruct to remain still, avoid coughing during

insertion of the needle Inform patient that pressure sensation will be

felt on insertion of needle

Nursing intervention DURING the procedure: Reassess the patient Place the patient in the proper position:

Upright or sitting on the edge of the bed

Lying partially on the side, partially on the back

Nursing interventions after Thoracentesis Assess the patient’s respiratory status Monitor vital signs frequently Position the patient on the affected side, as

ordered, for at least 1 hour to seal the puncture site

Turn on the unaffected side to prevent leakage of fluid in the thoracic cavity

Check the puncture site for fluid leakage Auscultate lungs to assess for pneumothorax Monitor oxygen saturation (SaO2) levels Bed rest Check for expectoration of blood

RESPIRATORY CARE MODALITIES

1. Oxygen Therapy Oxygen is a colorless, odorless, tasteless, and dry gas that

supports combustion Man requires 21% oxygen from the environment in order

to survive Indication: Hypoxemia Signs of Hypoxemiao Increased pulse rateo Rapid, shallow respiration and dyspneao Increased restlessness or lightheadednesso Flaring of nareso Substernal or intercostals retractionso Cyanosis

Low flow oxygen provides partial oxygenation with patient breathing a combination of supplemental oxygen and room air. Low-flow administration devices:

o Nasal Cannula 24-45% 2-6 LPMo Simple Face Mask0-60% 5-8 LPMo Partial Rebreathing Mask 60-90% 6-10 LPMo Non-rebreathing Mask 95-100% 6-15 LPMo Croupetteo Oxygen Tent

High flow oxygen provides all necessary oxygenation, with patients breathing only oxygen supplied from the mask and exhaling through a one-way vent.High flow administration devices

o Venturi Mask 24-40% 4-10 LPM Preferred for clients with COPD because it

provides accurate amount of oxygen.o Face Masko Oxygen Hood*o Incubator / isolette*

Note: * can be used for both low and high flow administration

The nurse should prevent skin breakdown by checking nares, nose and applying gauze or cotton as necessary

Ensure that COPD patients receive only LOW flow oxygen because these persons respond to hypoxia, not increased CO levels.

2. Tracheobronchial suctioning Suction only when necessary not routinely Use the smallest suction catheter if possible Client should be in semi or high Fowler’s position Use sterile gloves, sterile suction catheter Hyperventilate client with 100% oxygen before and

after suctioning Insert catheter with gloved hand (3-5“ length of catheter

insertion) without applying suction. Three passes of the catheter is the maximum, with 10 seconds per pass.

Apply suction only during withdrawal of catheter The suction pressure should be limited to less than 120

mmHg When withdrawing catheter rotate while applying

intermittent suction Suctioning should take only 10 seconds (maximum of 15

seconds) Evaluate: clear breath sounds on auscultation of the chest.

3. Bronchial Hygiene Measures Suctioning: oropharyngeal; nasopharyngeal

a. Steam inhalation The purpose of steam inhalation are as follows:

- to liquefy mucous secretions- to warm and humidify air- to relieve edema of airways- to soothe irritated airways- to administer medication

It is a dependent nursing function Inform the client and explain the purpose of the procedure Place the client in Semi-Fowler’s position Cover the client’s eyes with washcloth to prevent irritation Check the electrical device before use Place the steam inhalator in a flat, stable surface.

MS 11

Place the spout 12 – 18 inches away from the client’s nose or adjust distance as necessary

CAUTION: avoid burns. Cover the chest with towel to prevent burns due to dripping of condensate from the steam. Assess for redness on the side of the face which indicates first degree burns.

To be effective, render steam inhalation therapy for 15 – 20 minutes

Instruct the client to perform deep breathing and coughing exercises after the procedure to facilitate expectoration of mucous secretions.

Provide good oral hygiene after the procedure. Do after-care of equipment.

b. Aerosol inhalation done among pediatric clients to administer brochodilators or

mucolytic-expectorants..

c. Medimist inhalation done among adult clients to administer bronchodilators or

mucolytic-expectorants.

4. Chest Physiotheraphy ( CPT ) Includes postural drainage, chest percussion and

vibration, and breathing retraining. Effective coughing is also an important component.

Goals are removal of bronchial secretions, improved ventilation, and increased efficiency of respiratory muscles.

Postural drainage uses specific positions to use gravity to assist in the removal of secretions.

Vibration loosens thick secretions by percussion or vibration.

Breathing exercises and breathing retraining improve ventilation and control of breathing and decrease the work of breathing.

These are procedures for patients with respiratory disorders like COPD, cystic fibrosis, lung abscess, and pneumonia. The therapy is based on the fact that mucus can be knocked or shaken from airways and helped to drain from the lungs.

Postural drainage Use of gravity to aid in the drainage of secretions. Patient is placed in various positions to promote flow of

drainage from different lung segments using gravity. Areas with secretions are placed higher than lung

segments to promote drainage. Patient should maintain each position for 5-15 minutes

depending on tolerability.

Percussion Produces energy wave that is transmitted through the

chest wall to the bronchi. The chest is struck rhythmically with cupped hands over

the areas were secretions are located. Avoid percussion over the spine, kidneys, breast or

incision and broken ribs. Areas should be percussed for 1-2 minutes

Vibration Works similarly to percussion, where hands are placed on

client’s chest and gently but firmly rapidly vibrate hands against thoracic wall especially during client’s exhalation.

This may help dislodge secretions and stimulate cough.

This should be done at least 5-7 times during patient exhalation.

Suctioning Nursing Interventions in CPT

Verify doctor’s order Assess areas of accumulation of mucus secretions. Position to allow expectoration of mucus secretions

by gravity Place client in each position for 5-10 to 15 minutes Percussion and vibration done to loosen mucus

secretions Change position gradually to prevent postural

hypotension Client is encouraged to cough up and expectorate

sputum Procedure is best done 60 to 90 minutes before

meals or in the morning upon awakening and at bedtime.

Provide good oral care after the procedure

5. Incentive Spirometry• Types: volume and flow• Device ensures that a volume of air is inhaled and the

patient takes deep breaths. • Used to prevent or treat atelectasis • To enhance deep inhalation

• Nursing care– Positioning of patient, teach and encourage use,

set realistic goals for the patient, and record the results.

MS 12

6. Closed Chest Drainage ( Thoracostomy Tube ) Chest tube is used to drain fluid and air out of the

mediastinum or pleural space into a collection chamber to help re-establish normal negative pressure for lung re-expansion.

Purposes To remove air and/or fluids from the pleural space To reestablish negative pressure and re-expand the

lungs Procedure

The chest tube is inserted into the affected chest wall at the level of 2nd to 3rd intercostals space to release air or in the fourth intercostals space to remove fluid.

Types of Bottle Drainage One-bottle system

The bottle serves as drainage and water-seal Immerse tip of the tube in 2-3 cm of sterile NSS to

create water-seal. Keep bottle at least 2-3 feet below the level of the

chest to allow drainage from the pleura by gravity. Never raise the bottle above the level of the heart

to prevent reflux of air or fluid. Assess for patency of the device Observe for fluctuation of fluid along the tube. The

fluctuation synchronizes with the respiration. Observe for intermittent bubbling of fluid;

continues bubbling means presence of air-leak

In the absence of fluctuation: Suspect obstruction of the device

Assess the patient first, then if patient is stable Check for kinks along tubing; Milk tubing towards the bottle (If the hospital allows

the nurse to milk the tube) If there is no obstruction, consider lung re-expansion;

(validated by chest x-ray) Air vent should be open to air.

Two-bottle system If not connected to the suction apparatus The first bottle is drainage bottle; The second bottle is water-seal bottle Observe for fluctuation of fluid along the tube

(water-seal bottle or the second bottle) and intermittent bubbling with each respiration.

NOTE! IF connected to suction apparatus1. The first bottle is the drainage and water-seal bottle; 2. The second bottle is suction control bottle.3. Expect continuous bubbling in the suction control bottle; 4. Intermittent bubbling and fluctuation in the water-seal5. Immerse tip of the tube in the first bottle in 2 to 3 cm of

sterile NSS 6. Immerse the tube of the suction control bottle in 10 to 20

cm of sterile NSS to stabilize the normal negative pressure in the lungs.

7. This protects the pleura from trauma if the suction pressure is inadvertently increased

Three-bottle system The first bottle is the drainage bottle; The second bottle is water seal bottle The third bottle is suction control bottle.

Observe for intermittent bubbling and fluctuation with respiration in the water- seal bottle

Continuous GENTLE bubbling in the suction control bottle. These are the expected observations.

Suspect a leak if there is continuous bubbling in the WATER seal bottle or if there is VIGOROUS bubbling in the suction control bottle.

The nurse should look for the leak and report the observation at once. Never clamp the tubing unnecessarily.

If there is NO fluctuation in the water seal bottle, it may mean TWO things

Either the lungs have expanded or the system is NOT functioning appropriately.

In this situation, the nurse refers the observation to the physician, who will order for an X-ray to confirm the suspicion.

Important Nursing considerations Encourage doing the following to promote drainage: Deep breathing and coughing exercises Turn to sides at regular basis Ambulate ROM exercise of arms Mark the amount of drainage at regular intervals

MS 13

Avoid frequent milking and clamping of the tube to prevent tension pneumothorax

What the nurse should do if: If there is continuous bubbling: The nurse obtains a toothless clamp Close the chest tube at the point where it exits the chest

for a few seconds. If bubbling in the water seal bottle stops, the leak is

likely in the lungs, But if the bubbling continues, the leak is between the

clamp and the bottle chamber.

Next, the nurse moves the clamp towards the bottle checking the bubbling in the water seal bottle.

If bubbling stops, the leak is between the clamp and the distal part including the bottle.

But if there is persistent bubbling, it means that the drainage unit is leaking and the nurse must obtain another set.

In the event that the water seal bottle breaks, the nurse temporarily kinks the tube and must obtain a receptacle or container with sterile water and immerse the tubing.

She should obtain another set of sterile bottle as replacement. She should NEVER CLAMP the tube for a longer time to avoid tension pneumothorax.

In the event the tube accidentally is pulled out, the nurse obtains vaselinized gauze and covers the stoma.

She should immediately contact the physician.

Removal of chest tube—done by physician The nurse Prepares:

Petrolatum GauzeSuture removal kitSterile gauzeAdhesive tape

Place client in semi-Fowler’s position Instruct client to exhale deeply, then inhale and do

valsalva maneuver as the chest tube is removed. Chest x-ray may be done after the chest tube is

removed Asses for complications: subcutaneous

emphysema; respiratory distress

7. Artificial Airway

a. Oral airways- these are shorter and often have a larger lumen. They are used to prevent the tongue form falling backward.

b. Nasal airways- these are longer and have smaller lumen Which causes greater airway resistance

c. Tracheostomy- this is a temporary or permanent surgical opening in the trachea. A tube is inserted to allow ventilation and removal of secretions. It is indicated for emergency airway access for many conditions. The nurse must maintain tracheostomy care properly to prevent infection.

RESPIRATORY DISEASES AND DISORDERS

RESPIRATORY INFECTION1. Rhinitis2. Sinusitis3. Pharyngitis4. Tonsilitis & Adenoiditis5. Laryngitis6. Tracheobronchitis7. Pneumonia8. Pulmonary Tuberculosis9. Histoplasmosis

I. RHINITIS - inflammation and irritation of the mucous membrane of the nose. Allergic Non allergic Allergic

A. ETIOLOGIC FACTOR1. Changes in temperature or humidity2. Odors3. Foods4. Infection5. Age6. Systemic disease7. Drugs (cocaine )8. OTC drugs

B. CLINICAL MANIFESTATION1. Excessive nasal drainage2. Runny nose3. Nasal congestion4. Nasal discharge5. Sneezing6. Headache7. Low grade fever8. Tearing watery eyes9. General malaise

C. NURSING MANAGEMENT1. Identify the cause of infection through the history

and physical examination.2. Administer medications as ordered:

Antihistamine Diphenhydramine (Benadryl) Chlorpheniramine Loratidine

Nasal Decongestant Cromolyn ( Nasalcrom )

3. Health Teaching: Instruct the patient to avoid or reduce

exposure to allergens and irritants such as dusts, molds, animals, fumes, odors, powders etc..

Teach the patient to read drug labels and possible reaction to OTC drugs

Proper technique in administering nasal medications

Practice hand hygiene

II. SINUTIS – inflammation of the sinuses

A. ETIOLOGIC FACTORS

MS 14

1. Allergies2. Structural abnormalities, such as a deviated septum,

small sinus ostia or a concha bullosa3. Nasal polyps4. carrying the cystic fibrosis gene5. Second hand smoke is the cause of about 40% of

chronic rhinosinusitis.6. Bacterial organism ( streptococcus and

haemophilus)

B. CLINICAL MANIFESTATION

Acute1. Facial pain2. Pressure over the affected sinus3. Nasal obstruction4. Fatigue5. Purulent nasal discharge6. Fever7. Headache8. Ear pain9. Decreased sense of smell

Note: The presence of fewer than two symptoms R/O acute sinusitis and four or more suggest acute sinusitis.

Chronic1. Impaired mucociliary clearance and ventilation2. Cough with thick discharge3. Chronic hoarseness4. Chronic headache5. Chronic facial pain6. Fatigue and nasal congestion

C. NURSING MANAGEMENT1. Perform a careful and physical assessment of the

head and neck, particularly the nose, ears, teeth, sinuses, pharynx and chest.

2. Administer medications as ordered: Antibiotic

Amoxicillin Ampicillin Trimethoprim / sulfamethoxazole

( Bactrim , Septral ) Macrolides (clarithromycin) ,

Azithromycin ( zithromax ) and Quinolones such as levofloxacin (levaquin) if the patient has allergy to penicillin

Nasal Decongestant Topical decongestant is used only

by adults and should not be used for longer than 3 – 4 days.

Oral decongestant must be used cautiously in patient with HPN

3. Health Teaching: Instruct the patient to immediately consult

a MD if periorbital edema and severe pain on palpation occur.

Instruct the patient about the methods to promote drainage of sinuses, including humidification of the air in the home and use of steam inhalation and warm compress to relieve pressure.

Avoid swimming , diving and air travel Immediately STOP SMOKING

Emphasized the importance of completing the antibiotic regimen.

III. PHARYNGITIS - inflammation of the throat

A. ETIOLOGIC FACTORS1. Viral infection ( adenovirus, influenza virus,

Epstein-barr and herpes simplex2. Bacterial infection ( group A beta hemolytic

streptococci, N. gonorrhoeao, H. influenza and Mycoplasma )

B. CLINICAL MANIFESTATION

Acute1. Fiery red pharyngeal membrane and tonsils2. Lymphoid follicles swollen and freckled with

white-purple exudates.3. Cervical lymph nodes enlarged and tender4. Fever, malaise and sore throat5. Hoarseness

Chronic1. Constant sense of irritation or fullness in the throat2. Mucus that collects in the throat3. Difficulty in swallowing

C. ASSESSMENT and DIAGNOSTIC METHODS1. Rapid screening test for streptococcal antigens2. Optical immunoassay (OIA )3. Nasal swabbings4. Blood cultures

D. NURSING MANAGEMENT1. Encourage bed rest during febrile stage of illness.2. Administer medications as ordered:

Antibiotics ( same as sinusitis ) Analgesic Antitussive medication (dextromethorphan )

- for persistent and painful cough3. Secure nasal swabbings and throat and blood

specimens for culture as needed.4. Administer warm saline gargles or irrigations to

ease pain.5. Perform mouth care6. Advise patient of importance of taking the full

course of antibiotic therapy.7. Instruct patient to avoid alcohol, tobacco, 2nd hand

smoke, exposure to cold and environmental and occupational pollutants.

8. Encourage patient to drink plenty of fluids

IV. TONSILLITIS & ADENODITIS

Tonsillitis – inflammation and infection of the tonsils ( palatine and lingual )Adenoditis - inflammation of the adenoid or the pharyngeal tonsils.

A. CLINICAL MANIFESTATION

Tonsilitis1. Sore throat2. Fever

MS 15

3. Snorring4. Difficulty swallowing

V. PNEUMONIA – inflammation of the lung parenchyma leading to pulmonary consolidation because alveoli is filled with exudates

A. ETIOLOGIC AGENTS1. Streptococcus pneumoniae (pneumococcal

pneumonia)2. Hemophilus influenzae (bronchopneumonia)3. Klebsiella pneumoniae4. Diplococcus pneumoniae5. Escherichia coli6. Pseudomonas aeruginosa

B. HIGH RISK GROUPS1. Children less than 5 yo2. Elderly

C. PREDISPOSING FACTORS1. Smoking2. Air pollution3. Immunocompromised

(+) AIDS Kaposi’s Sarcoma Pneumocystis Carinii Pneumonia

DOC: Zidovudine (Retrovir) Bronchogenic Ca

4. Prolonged immobility (hypostatic pneumonia)5. Aspiration of food (aspiration pneumonia)6. Over fatigue

D. SIGNS AND SYMPTOMS1. Productive cough, greenish to rusty2. Dyspnea with prolong expiratory grunt3. Fever, chills, anorexia, general body malaise4. Cyanosis5. Pleuritic friction rub6. Rales/crackles on auscultation7. Abdominal distention paralytic ileus

E. DIAGNOSTICS1. Sputum GS/CS confirmatory; type and

sensitivity; (+) to cultured microorganism2. CXR – (+) pulmonary consolidation3. CBC

Elevated ESR (rate of erythropoeisis) N = 0.5-1.5% (compensatory mech to decreased O2)

Elevated WBC

4. ABG – PO2 decreased (hypoxemia)

F. NURSING MANAGEMENT1. Enforce CBR (consistent to all respi disorders)2. Strict respiratory isolation3. Administer medications as ordered

Broad spectrum antibiotics Penicillin – pneumococcal infections Tetracycline Macrolides

Azithromycin (OD x 3/days)1. Too costly2. Only se: ototoxicity – transient

hearing loss Anti-pyretics Mucolytics/expectorants

4. Administer O2 inhalation as ordered5. Force fluids to liquefy secretions6. Institute pulmonary toilet – measures to promote

expectoration of secretions DBE, Coughing exercises, CPT

(clapping/vibration), Turning and repositioning7. Nebulize and suction PRN8. Place client of semi-fowlers to high fowlers9. Provide a comfortable and humid environment10. Provide a dietary intake high in CHO, CHON,

Calories and Vit C11. Assist in postural drainage

Patient is placed in various position to drain secretions via force of gravity

Usually, it is the upper lung areas which are drained

Nursing management: Monitor VS and BS Best performed before meals/breakfast or

2-3 hours p.c. to prevent gastroesophageal reflux or vomiting (pagkagising maraming secretions diba? Nakukuha?)

Encourage DBE Administer bronchodilators 15-30 minutes

before procedure Stop if pt. can’t tolerate the procedure Provide oral care after procedure as it may

affect taste sensitivity Contraindications:

Unstable VS Hemoptysis Increased ICP Increased IOP (glaucoma)

12. Provide pt health teaching and d/c planning Avoidance of precipitating factors Prevention of complications

Atelectasis Meningitis

Regular compliance to medications Importance of ffup care

MS 16

VI. PULMONARY TUBERCULOSIS (KOCH’S DISEASE) – infection of the lung parenchyma caused by invasion of mycobacterium tuberculosis or tubercle bacilli (gram negative, acid fast, motile, aerobic, easily destroyed by heat/sunlight)

A. PRECIPITATING FACTORS1. Malnutrition2. Overcrowding3. Alcoholism: Depletes VIT B1 (thiamin)

alcoholic beriberi malnutrition4. Physical and emotional stress5. Ingestion of infected cattle with M. bovis6. Virulence (degree of pathogenecity)

B. MODE OF TRANSMISSION: Airborne droplet infection

C. SIGNS AND SYMPTOMS1. Productive cough (yellowish)2. Low grade afternoon fever, night sweats3. Dyspnea, anorexia, malaise, weight loss4. Chest/back pain5. Hemoptysis

D. DIAGNOSTICS1. Skin testing

Mantoux test – PPD Induration width (within 48-72 h)

8-10 mm (DOH) 10-14 mm (WHO) 5 mm in AIDS patients is +

indicates previous exposure to tubercle bacilli

2. Sputum AFB (+) tubercle bacilli3. CXR – (+) pulmo infiltrated due to caseous necrosis4. CBC – elevated WBC

E. NURSING MANAGEMENT1. Enforce CBR2. Institute strict respiratory isolation3. Administer O2 inhalation4. Forced fluids5. Encourage DBE and coughing

NO CLAPPING in chronic PTB d/t hemoptysis may lead to hemorrhage

6. Nebulize and suction PRN7. Provide comfortable and humid environment8. Institute short course chemotherapy

Intensive phase INH

SE: peripheral neuritis (increase vit B6 or pyridoxine

Rifampicin SE: red orange color of bodily

secretions PZA

May be replaced with Ethambutol (SE: optic neuritis) if (+) hypersensitivity to drug

SE: allergic reactions; hepatotoxicity and nephrotoxicity1. Monitor liver enzymes2. Monitor BUN and CREA

INH given for 4 months, PZA and Rifampicin is given for 2 months, A.C. to facilitate absorption

These 3 drugs are given simultaneously to prevent development of resistance

Standard Regimen Streptomycin injection (aminoglycosides)

Neomycin, Amikacin, Gentamycin1. common SE: 8th CN damage

tinnitus hearing loss ototoxicity

2. nephrotoxicitya. BUN (N = 10-20)b. CREA (N = 8-10)

9. Health teaching and d/c planning Avoidance of precipitating factors : alcoholism,

overcrowding Prevention of complications

Atelectasis Military TB (extrapulmonary TB:

meningeal, Pott’s, adrenal glands, skin, cornea)

Strict compliance to medications Never double the dose! Continue taking

the meds if missed a day) Diet modifications: increased CHON, CHO,

Calories, Vit C Importance of ffup care

VII. HISTOPLASMOSIS – acute fungal infection caused by inhalation of contaminated dust with Histoplasma capsulatum from birds’ manure

A. PREDISPOSING FACTORS Inhalation of contaminated dust

2. SIGNS AND SYMPTOMS PTB like symptoms Productive cough Fever, chills, anorexia, generalized body

malaise Cyanosis Chest and joint pains Dyspnea Hemoptysis

3. DIAGNOSTICS

MS

Tracheostomy usually done at bedside, 10-20 minutes Stress test: 30 minutes Mammography: 10-20 minutes LARYNGOSPASM – tracheostomy STAT OR Tracheostomy: laryngeal, thyroid, neck CA DIAPHRAGM – primary muscle for respiration INTERCOSTAL MUSCLES – secondary muscle for respiration ALVEOLI (Acinar cells) –functional unit of the lungs; site for gas

exchange (via diffusion) VENTILATION – movement of air in and out of the lungs RESPIRATION – lungs to cells

Internal External

RETROLENTAL FIBROPLASIA – retinopathy/blindness in immaturity d/t high O2 flow in pedia patients

17

Histoplasmin skin test is (+) ABG analysis reveals pO2 low

4. NURSING MANAGEMENT Enforce CBG Administer meds as ordered

Antifungal agents Amphotericin B (Fungizone) SE:

nephrotoxicity and hypokalemia Monitor transaminases, BUN and

CREA Corticosteroids Anti-pyretics Mucolytics/expectorants

Administer oxygen inhalation as ordered Forced fluids Nebulize and suction as necessary Prevent complications

Bronchiectasis, atelectasis Prevention of spread

Spraying of breeding places Kill bird and owner! Hehe!

CHRONIC OBSTRUCTIVE PULMONARY DISEASES

1. Chronic Bronchitis2. Bronchial Asthma3. Bronchiectasis4. Pulmonary Emphysema

I. CHRONIC BRONCHITIS (Blue Bloaters) – Inflammation of the bronchi due to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways

A. PREDISPOSING FACTORS1. Smoking2. Air pollution

B. SIGNS AND SYMPTOMS1. Consistent productive cough2. Dyspnea on exertion with prolonged expiratory

grunt3. Anorexia and generalized body malaise4. Cyanosis5. Scattered rales/rhonchi6. Pulmonary hypertension

Peripheral edema Cor pulmonale

C. DIAGNOSTICS1. ABG analysis: decreased PO2, increased PCO2,

respiratory acidosis; hypoxemia cyanosis

D. NURSING MANAGEMENT1. Enforce CBR2. Administer medications as ordered

Bronchodilators Antimicrobials Corticosteroids Mucolytics/expectorants

3. Low inflow O2 admin; high inflow will cause respiratory arrest

4. Force fluids5. Nebulize and suction client as needed6. Provide comfortable and humid environment7. Health teaching and d/c planning

avoidance of smoking prevent complications

CO2 narcosis coma Cor pulmonale Pleural effusion Pneumothorax

Regular adherence to meds Importance of ffup care

II. BRONCHIAL ASTHMA – reversible inflammatory lung condition caused by hypersensitivity to allergens leading to narrowing of smaller airways

A. PREDISPOSING FACTORS1. Extrinsic (Atopic/Allergic Asthma)

Pollens, dust, fumes, smoke, fur, dander, lints2. Intrinsic (Non-Atopic/Non-Allergic)

Drugs (aspirin, penicillin, B-blockers) Foods (seafoods, eggs, chicken, chocolate) Food additives (nitrates, nitrites) Sudden change in temperature, humidity and

air pressure Genetics Physical and emotional stress

3. Mixed type combination of both

B. SIGNS AND SYMPTOMS1. Cough that is productive2. Dyspnea3. Wheezing on expiration4. Tachycardia, palpitations and diaphoresis5. Mild apprehension, restlessness6. Cyanosis

MS 18

C. DIAGNOSTICS1. PFT decreased vital lung capacity2. ABG analysis PO2 decreased

D. NURSING MANAGEMENT1. Enforce CBR2. Administer medications as ordered

Bronchodilators administer first to facilitate absorption of corticosteroids Inhalation MDI

Corticosteroids Mucolytics/expectorants Mucomyst Antihistamine

3. Administer oxygen inhalation as ordered4. Forced fluids5. Nebulize and suction patient as necessary6. Encourage DBE and coughing7. Provide a comfortable and humid environment8. Health teaching and d/c planning

Avoidance of precipitating factors Prevention of complications

Status asthmaticus DOC: Epinephrine Aminophylline drip

Emphysema Regular adherence to medications Importance of ffup care

III. BRONCHIECTASIS – permanent dilation of the bronchus due to destruction of muscular and elastic tissue of the alveolar walls (subject to surgery)

A. PREDISPOSING FACTORS1. Recurrent lower respiratory tract infection

Histoplasmosis2. Congenital disease3. Presence of tumor4. Chest trauma

B. SIGNS AND SYMPTOMS

1. Consistent productive cough2. Dyspnea3. Presence of cyanosis4. Rales and crackles5. Hemoptysis6. Anorexia and generalized body malaise

C. DIAGNOSTICS1. ABG analysis reveals low PO22. Bronchoscopy – direct visualization of bronchi

lining using a fibroscope Pre-op

Secure consent Explain procedure NPO 4-6 hours Monitor VS and breath sounds

Post-operative Feeding initiated upon return of gag reflex Instruct client to avoid talking, coughing

and smoking as it may irritate respiratory tract

Monitor for s/sx of frank or gross bleeding Monitor for signs of laryngeal spasm

DOB and SOB prepare trache setD. SURGERY

1. Segmental lobectomy2. Pneumonectomy

Most feared complications Atelectasis Cardiac tamponade: muffled heart sounds,

pulsus paradoxus, HPN

E. NURSING MANAGEMENT1. Enforce CBR 2. Low inflow O2 admin; high inflow will cause

respiratory arrest3. Administer medications as ordered

Bronchodilators Antimicrobials Corticosteroids (5-10 minutes after

bronchodilators) Mucolytics/expectorants

4. Force fluids5. Nebulize and suction client as needed6. Provide comfortable and humid environment7. Health teaching and d/c planning

Avoidance of smoking Prevent complications

Atelectasis CO2 narcosis coma Cor pulmonale Pleural effusion Pneumothorax

Regular adherence to meds Importance of ffup care

IV. PULMONARY EMPHYSEMA – terminal and irreversible stage of COPD characterized by :

Inelasticity of alveoli Air trapping Maldistribution of gasses (d/t increased air trapping) Overdistention of thoracic cavity (Barrel chest)

compensatory mechanism increased AP diameter

MS 19

A. PREDISPOSING FACTORS1. Smoking2. Air pollution3. Hereditary: involves alpha-1 antitrypsin for

elastase production for recoil of the alveoli4. Allergy5. High risk group elderly degenerative

decreased vital lung capacity and thinning of alveolar lobes

B. SIGNS AND SYMPTOMS1. Productive cough2. Dyspnea at rest3. Prolonged expiratory grunt4. Resonance to hyperresonance5. Decreased tactile fremitus6. Decreased breath sounds ( if (-) BS lung

collapse)7. Barrel chest8. Anorexia and generalized body malaise9. Rales or crackles10. Alar flaring11. Pursed-lip breathing (to eliminate excess CO2)

C. DIAGNOSTICS1. ABG analysis reveal

Panlobular, centrilobular PO2 elevation and PCO2 depression respiratory acidosis (blue bloaters)

Panacinar/centriacinar PCO2 depression and PO2 elevation (pink puffers – hyperaxemia)

2. Pulmo function test – decreased vital lung capacity

D. NURSING MANAGEMENT1. Enforce CBR2. Administer medications as ordered

Bronchodilators Antimicrobials Corticosteroids Mucolytics/expectorants

3. Low inflow O2 admin; high inflow will cause respiratory arrest and oxygen toxicity

4. Force fluids5. Pulmonary toilet6. Nebulize and suction client as needed7. Institute PEEP in mechanical ventilation

PEEP – positive end expiratory pressure

allows for maximum alveolar diffusion prevent lung collapse

8. Provide comfortable and humid environment9. Diet modifications: high calorie, CHON, CHO,

vitamins and minerals10. Health teaching and d/c planning

Avoidance of smoking Prevent complications

Atelectasis CO2 narcosis coma Cor pulmonale Pleural effusion Pneumothorax

Regular adherence to meds Importance of ffup care

RESTRICTIVE LUNG DISEASE

V. PNEUMOTHORAX – partial or complete collapse of the lungs due to accumulation of air in pleural space

A. TYPES1. Spontaneous – air enters pleural space without an

obvious cause Ruptured blebs (alveolar – filled sacs)

inflammatory lung conditions2. Open – air enters pleural space through an opening

in pleural wall (most common) Gun shot wounds Multiple stab wounds

3. Tension – air enters pleural space during inspiration and cannot escape leading to overdistention of the thoracic cavity mediastinal shift to the affected side (ie. Flail chest) paradoxical breathing

B. PREDISPOSING FACTORS1. Chest trauma2. Inflammatory lung condition3. tumors

C. SIGNS AND SYMPTOMS1. Sudden sharp chest pain, dyspnea, cyanosis2. Diminished breath sounds3. Cool, moist skin4. Mild restlessness and apprehension5. Resonance to hyperresonance

D. DIAGNOSTICS1. ABG analysis: PO2 decreased2. CXR – confirms collapse of lungs

E. NURSING MANAGEMENT1. Assist in endotracheal intubation2. Assist in thoracentesis3. Administer meds as ordered

Narcotic analgesics – Morphine sulfate Antibiotics

4. Assist in CTT to H20 sealed drainage

MS 20