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2. o These are four paired bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar epitheliumo Named after their location - frontal, ethmoidal, sphenoidal and maxillary 16. The Paranasal sinuseso The function of the sinuses:o Resonating chambers in speech 17. The Lower Respiratory Systemo The lower respiratory system consists ofo 1. Tracheao 2. Main bronchuso 3. Bronchial treeo 4. Lungs- 3R/ 2Lo to the terminal bronchioles is called the conducting airwayThe tracheao to the alveoli is called the respiratoryThe respiratory bronchioles acinus 18. The Tracheao A cartilaginous tube measures 10-12 centimeterso Composed of about 20 C-shaped cartilages, incomplete posteriorly 19. The Tracheao The function of the trachea is to conduct air towards the lungso The mucosa is lined up with mucus and cilia to trap particles and carry them towards the upper airway 20. The Bronchuso The right and left primary bronchi begin at the carinao The function is for air passage 21. The Primary Bronchuso RIGHT BRONCHUSo Widero Shortero More Verticalo LEFT BRONCHUSo Narrowero Longero More horizontal 22. The Bronchioleso The primary bronchus further divides into secondary, then tertiary then into bronchioleso The terminal bronchiole is the last part of the conducting airway 23. The Respiratory Acinuso The respiratory acinus is the chief respiratory unito It consists ofo 1. Respiratory bronchioleo 2. Alveolar ducto 3. alveolar sac 24. The Respiratory Acinuso The respiratory acinus is the chief respiratory unito The function of the respiratory acinus is gas exchange through the respiratory membrane 25. The Respiratory Acinuso The respiratory membrane is composed of two epithelial cellso 1.The type 1 pneumocyte - most abundant, thin and flat. This is where gas exchange occurso 2. The type 2 pneumocyte - secretes the lung surfactant 26. The Respiratory Acinuso A type III pneomocyte is just the macrophage that ingests foreign material and acts as an important defense mechanism 27. Accessory Structureso The PLEURAo Epithelial serous membrane lining the lung parenchymao Composed of two parts- the visceral and parietal pleuraeo The space in between is the pleural space containing a minute amount of fluid for lubrication 28. Accessory Structureso The Thoracic cavityo The chest wall composed of the sternum and the rib cageo The cavity is separated by the diaphragm, the most important respiratory muscle 3. 29. Accessory Structureso The Mediastinumo The space between the lungs, which includes the heart and pericardium, the aorta and the venacavae. 30. GENERAL FUNCTIONS OF THE Respiratory Systemo Gas exchange through ventilation, external respiration and cellular respirationo Oxygen and carbon dioxide transport 31. The Assessmento HISTORYo Reason for seeking careo Present illnesso Previous illnesso Family historyo Social history 32. The Assessmento PHYSICAL EXAMINATIONo Skin- cyanosis, palloro Nail clubbingo Cough and sputum productiono Inspect - palpate - percuss - auscultate the thorax 33. The Assessmento LABORATORY EXAMINATIONo 1. ABG analysiso 2. Sputum analysiso 3. Direct visualization - bronchoscopyo 4. Indirect visualization - CXR, CT and MRIo 5. Pulmonary function test 34. ABG Analysiso This test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of anarterial sample 35. ABG Analysiso Pre-test: choose site carefully, perform the Allens test, secure equipments- syringe, needle, containerwith iceo Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial)o Post-test: Apply firm pressure for 5 minutes, label specimen correctly, place in the container with ice 36. ABG Analysiso ABG normal valueso PaO2 80-100 mmHgo PaCO2 35-45 mmHgo pH 7.35- 7.45o HCO3 22- 26 mEq/Lo O2 Sat 95-99% 37. Sputum Analysiso This test analyzes the sample of sputum to diagnose respiratory diseases, identify organism, andidentify abnormal cells 38. Sputum Analysiso Pre-test: Encourage to increase fluid intakeo Intra-test: rinse mouth with WATER only, instruct the patient to take 3 deep breaths and force a deepcough, steam nebulization, collect early morning sputumo Post-test: provide oral hygiene, label specimen correctly 39. Pulse Oximetryo Non-invasive method of continuously monitoring the oxygen saturation of hemoglobino A sensor or probe is attached to the earlobe, forehead, fingertip or the bridge of the nose 40. Bronchoscopyo A direct inspection of the trachea and bronchi through a flexible fiber-optic or a rigid bronchoscopeo Done to determine location of pathologic lesions, to remove foreign objects, to collect tissue specimenand remove secretions/aspirated materials 41. Bronchoscopyo Pre-test: Consent, NPO x 6h, teachingo Intra-test: position supine or sitting upright in a chair, administer sedative, gag reflex will be abolished,remove dentures 4. oPost-test: NPO until gag reflex returns, position SEMI-fowlers with head turned to sides, hoarseness is temporary, CXR after the procedure, keep tracheostomy set and suction x 24 hours 42. Thoracentesiso Pleural fluid aspiration for obtaining a specimen of pleural fluid for analysis, relief of lung compression and biopsy specimen collection 43. Thoracentesiso Pre-test: Consento Intra-test: position the patient sitting with arms on a table or side-lying fowlers, instruct not to cough, breathe deeply or moveo Post-test: position unaffected side to allow lung expansion of the affected side, CXR obtained, maintain pressure dressing and monitor respiratory status 44. Pulmonary Function Testso Volume and capacity tests aid diagnosis in patient with suspected pulmonary dysfunctiono Evaluates ventilatory functiono Determines whether obstructive or restrictive diseaseo Can be utilized as screening test 45. Pulmonary Function Testo Lung Volumeso Tidal volumeo Inspiratory reserve volumeo Expiratory reeve volumeo Residual volume 46. Pulmonary Function Testo Lung capacitieso Inspiratory capacityo Vital capacityo Functional residual capacityo Total lung capacity 47. Pulmonary Function Testo Pre-test: Teaching, no smoking for 3 days, only light meal 4 hours before the testo Intra-test: position sitting, bronchodilator, nose-clip and mouthpiece, fatigue and dyspnea during the testo Post-test: adequate rest periods, loosen tight clothing 48. Common Respiratory Problems and the common interventions 49. Dyspneao Breathing difficultyo Associated with many conditions- CHF, MG, GBS, Muscular dystrophy, obstruction, etc 50. Dyspneao General nursing interventions:o 1. Fowlers position to promote maximum lung expansion and promote comfort. An alternative position is the ORTHOPNEIC positiono 2. O2 usually via nasal cannulao 3. Provide comfort and distractions 51. Cough and sputum productiono Cough is a protective reflexo Sputum production has many stimulio bacterial pneumoniaThick, yellow, green or rust-coloredo pulmonary edemaProfuse, Pink, frothyo Lung tumorScant, pink-tinged, mucoid 52. Cough and sputum productiono General nursing Interventiono 1. Provide adequate hydrationo 2. Administer aerosolized solutionso 3. advise smoking cessationo 4. oral hygiene 53. Cyanosiso Bluish discoloration of the skino A LATE indicator of hypoxiao Appears when the unoxygenated hemoglobin is more than 5 grams/dLo observe color on the undersurface of tongue and lipsCentral cyanosis 5. o observe the nail beds, earlobesPeripheral cyanosis 54. Cyanosiso Interventions: Check for airway patency Oxygen therapy Positioning Suctioning Chest physiotherapy Check for gas poisoning Measures to increased hemoglobin 55. Hemoptysiso Expectoration of blood from the respiratory tracto Common causes: Pulmo infection, Lung CA, Bronchiectasis, Pulmo embolio acidic pH, coffee ground materialBleeding from stomach 56. Hemoptysiso Interventions:o Keep patent airwayo Determine the causeo Suction and oxygen therapyo Administer Fibrin stabilizers like aminocaproic acid and tranexamic acid 57. Epistaxiso Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membraneo Most common site- anterior septumo Causeso 1. traumao 2. infectiono 3. Hypertensiono 4. blood dyscrasias , nasal tumor, cardio diseases 58. Epistaxiso Nursing Interventionso prevents swallowing1. Position patient: Upright, leaning forward, tilted and aspirationo 2. Apply direct pressure. Pinch nose against the middle septum x 5-10 minuteso 3. If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foamso 4. Assist in electrocautery and nasal packing for posterior bleeding 59. CONDITIONS OF THE UPPER AIRWAYo Upper airway infectionso 1. Rhinitis- allergic, non-allergic and infectiouso 2. Sinusitis- acute and chronico 3. Pharyngitis- acute and chronic 60. CONDITIONS OF THE UPPER AIRWAYo Upper airway infectionso 1. Rhinitis- Assessment findingso Rhinorrheao Nasal congestiono Nasal itchinesso Sneezingo Headache 61. CONDITIONS OF THE UPPER AIRWAYo Upper airway infectionso 2. sinusitis- Assessment findingso Facial paino Tenderness over the paranasal sinuseso Purulent nasal dischargeso Ear pain, headache, dental paino Decreased sense of smell 62. CONDITIONS OF THE UPPER AIRWAYo Upper airway infectionso 3. Pharyngitis- Assessment findings 6. o Fiery-red pharyngeal membrane o White-purple flecked exudates o Enlarged and tender cervical lymph nodes o Fever malaise ,sore throat o Difficulty swallowing o Cough may be absent 63. CONDITIONS OF THE UPPER AIRWAYo Upper airway infections- Laboratory testso 1. CBCo 2. Culture 64. CONDITIONS OF THE UPPER AIRWAYo Upper airway infections: Nursing Interventionso 1. Maintain Patent Airwayo Increase fluid intake to loosen secretionso Utilize room vaporizers or steam inhalationo Administer medications to relieve nasal congestion 65. CONDITIONS OF THE UPPER AIRWAYo Upper airway infections: Nursing Interventionso 2. Promote comforto Administer prescribed analgesicso Administer topical analgesicso Warm gargles for the relief of sore throato Provide oral hygiene 66. CONDITIONS OF THE UPPER AIRWAYo Upper airway infections: Nursing Interventionso 3. Promote communicationo Instruct patient to refrain from speaking as much as possibleo Provide writing materials 67. CONDITIONS OF THE UPPER AIRWAYo Upper airway infections: Nursing Interventionso 4. Administer prescribed antibioticso Monitor for possible complications like meningitis, otitis media, abscess formationo 5. Assist in surgical intervention 68. CONDITIONS OF THE UPPER AIRWAYo Upper airway infection: Tonsillitiso Infection and inflammation of the tonsilso Most common organism- Group A- beta hemolytic streptococcus (GABS) 69. CONDITIONS OF THE UPPER AIRWAYo Upper airway infection: Tonsillitiso ASSESSMENT FINDINGSo Sore throat and mouth breathingo Fevero Difficulty swallowingo Enlarged, reddish tonsilso Foul-smelling breath 70. CONDITIONS OF THE UPPER AIRWAYo Upper airway infection: Tonsillitiso Laboratory testo 1. CBCo 2. throat culture 71. CONDITIONS OF THE UPPER AIRWAYo Upper airway infection: Tonsillitiso MEDICAL managemento 1. Antibiotics- penicillino 2. Tonsillectomy for chronic cases and abscess formation 72. CONDITIONS OF THE UPPER AIRWAYo Upper airway infection: Tonsillitiso NURSING INTERVENTION for tonsillectomyo 1. Pre-operative care 7. oConsent oRoutine pre-op surgical care 73. CONDITIONS OF THE UPPER AIRWAYo Upper airway infection: Tonsillitiso NURSING INTERVENTION for tonsillectomyo 2. POST-operative careo Position: Most comfortable is PRONE, with head turned to sideo Maintain oral airway, until gag reflex returns 74. CONDITIONS OF THE UPPER AIRWAYo Upper airway infection: Tonsillitiso NURSING INTERVENTION for tonsillectomyo 2. POST-operative careo Apply ICE collar to the neck to reduce edemao Advise patient to refrain from talking and coughingo Ice chips are given when there is no bleeding and gag reflex returns 75. CONDITIONS OF THE UPPER AIRWAYo Upper airway infection: Tonsillitiso NURSING INTERVENTION for tonsillectomyo 2. POST-operative careo Notify physician ifo a. Patient swallows frequentlyo b. vomiting of large amount of bright red or dark bloodo c. PR increased, restless and Temp is increased 76. Laryngeal Cancero A malignant tumor of the larynxo More frequent in meno 50-70 years oldo RISK FACTORSo 1. Smokingo 2. Alcoholo 3. Exposure to chemicalso 4. Straining of voiceo 5. chronic laryngitiso 6. Deficiency of Riboflavino 7. family history 77. Laryngeal Cancero Growth can be anywhere in the larynxo 1. Supraglottic- above the vocal cordso 2. glottic- vocal cord areao 3. infraglottic- below the vocal cordso Most tumors are found in the glottic area 78. Laryngeal Cancero ASSESSMENT FINDINGSo Hoarseness of more than TWO weeks durationo Cough and sore throato Burning and pain in the throat especially after consuming HOT liquids and citrus foodso Neck lumpo Dysphagia, dyspnea, foul breath, CLAD 79. Laryngeal Cancero LABORATORY FINDINGSo 1. Indirect laryngoscopyo 2. direct laryngoscopyo 3. Biopsyo 4. CT and MRIo Most commonly- squamos carcinoma 80. Laryngeal Cancero MEDICAL MANAGEMENTo Radiation therapy 8. oChemotherapy oSurgery Partial laryngectomy Supraglottic laryngectomy Hemilaryngectomy Total laryngectomy 81. Laryngeal Cancero NURSING MANAGEMENT: PRE-operativeo 1. Provide the patient pre-operative teachingso Clarify misconceptionso Tell that the natural voice will be losto Teach communication alternativeso Collaborate with other team members 82. Laryngeal Cancero NURSING MANAGEMENTo 2. reduce patient ANXIETYo Provide opportunities for patient and family members to ask questionso Referrals to previous patients with laryngeal cancers and cancer groups 83. Laryngeal Cancero NURSING MANAGEMENT: POST-opo 3. Maintain PATENT Airwayo Position patient: Semi or High Fowlerso Suction secretionso Encourage to deep breath, turn and cough 84. Laryngeal Cancero NURSING MANAGEMENT: POST-opo 4. Administer care of the laryngectomy tubeo Suction as neededo Cleanse the stoma with salineo Administer humidified oxygeno Laryngectomy tube is usually removed within 3-6 weeks after surgery 85. Laryngeal Cancero NURSING MANAGEMENT: POST-opo 5. Promote alternative communication methodso Call bell or hand bello Magic Slateo Hand signalso Collaborate with speech therapist 86. Laryngeal Cancero NURSING MANAGEMENT: POST-opo 6. Promote adequate Nutritiono NPO after operationo No foods or drinks per orem for 10 dayso IVF, TPN are alternative nutrition routeso Start oral feedings with thick liquids, avoid sweet foods 87. Laryngeal Cancero NURSING MANAGEMENT: POST-opo 7. Promote positive body image and self-esteemo Encourage verbalization of feelingso Allow independence in self-care 88. Laryngeal Cancero NURSING MANAGEMENT: POST-opo 8. Monitor for COMPLICATIONSo Respiratory Distress Suction Coughing and deep breathing Humidified oxygen Alert the surgeon 89. Laryngeal Cancer 9. oNURSING MANAGEMENT: POST-op o8. Monitor for Complications oHemorrhage Monitor for bleeding Monitor vital signs Apply direct pressure over the bleeding artery Summon assistance and alert the surgeon 90. Laryngeal Cancero NURSING MANAGEMENT: POST-opo 8. Monitor for COMPLICATIONSo Wound infection and breakdowno Monitor for increased temperature, purulent drainage and increased redness/tendernesso Administer antibioticso Clean and change dressing OD 91. Laryngeal Cancero NURSING MANAGEMENT: HOME CAREo Humidification system at home is neededo AVOID swimmingo Cover the stoma with hands or plastic bib over the openingo Advise beauty salons to avoid hair sprays, powders and loose hair near the openingo Oral hygiene frequently 92. Acute Respiratory Failureo Sudden and life-threatening deterioration of the gas-exchange function of the lungso Occurs when the lungs no longer meet the bodys metabolic needs 93. Acute Respiratory Failureo Defined clinically as:o 1. PaO2 of less than 50 mmHgo 2. PaCO2 of greater than 5o mmHgo 3. Arterial pH of less than 7.35 94. Acute Respiratory Failureo CAUSESo CNS depression- head trauma, sedativeso CVS diseases- MI, CHF, pulmonary embolio Airway irritants- smoke, fumeso Endocrine and metabolic disorders- myxedema, metabolic alkalosiso Thoracic abnormalities- chest trauma, pneumothorax 95. Acute Respiratory Failureo PATHOPHYSIOLOGYo Decreased Respiratory Driveo impair the normal response ofBrain injury, sedatives, metabolic disorders the brain to normalrespiratory stimulation 96. Acute Respiratory Failureo PATHOPHYSIOLOGYo Dysfunction of the chest wallo disrupt the impulseDystrophy, MS disorders, peripheral nerve disorders abnormalventilationtransmission from the nerve to the diaphragm 97. Acute Respiratory Failureo PATHOPHYSIOLOGYo Dysfunction of the Lung Parenchymao interferePleural effusion, hemothorax, pneumothorax, obstruction prevent lungexpansionventilation 98. Acute Respiratory Failureo ASSESSMENT FINDINGSo Restlessnesso dyspneao Cyanosiso Altered respirationo Altered mentationo Tachycardia 10. oCardiac arrhythmias oRespiratory arrest 99. Acute Respiratory Failureo DIAGNOSTIC FINDINGSo Pulmonary function test- pH below 7.35o CXR- pulmonary infiltrateso ECG- arrhythmias 100.Acute Respiratory Failureo MEDICAL TREATMENTo Intubationo Mechanical ventilationo Antibioticso Steroidso Bronchodilators 101.Acute Respiratory Failureo NURSING INTERVENTIONSo 1. Maintain patent airwayo 2. Administer O2 to maintain Pa02 at more than 50 mmHgo 3. Suction airways as requiredo 4. Monitor serum electrolyte levelso 5. Administer care of patient on mechanical ventilation 102.COPDo These are group of disorders associated with recurrent or persistent obstruction of air passage andairflow, usually irreversible. 103.COPDo The most common cause of COPD is cigarette smoking. Asthma, Chronic bronchitis, Emphysema andBronchiectasis are the common disorders. 104.COPDo The general pathophysiology:o In COPD there is airflow limitation that is both progressive and associated with abnormal inflammatoryresponse of the lungs to stimuli, usually smoke, particles and dust 105.ASTHMAo The acute episode of airway obstruction is characterized by airway hyperactivity to various stimuli thatresults in recurrent wheezing brought about by edema and bronchospasm 106.Asthma Pathophysiologyo Immunologic/allergic reaction results in histamine release, which produces three main airwayresponseso a. Edema of mucous membraneso b. Spasm of the smooth muscle of bronchi and bronchioleso c. Accumulation of tenacious secretions 107.Asthma Assessment Findingso Assessment findingso 1. Family history of allergieso 2. Client history of eczema 108.Asthma Assessment Findingso Assessment findingso 3. Pulmonary signs and symptoms- Respiratory distress: slow onset of shortness of breath, expiratorywheeze , prolonged expiratory phase, air trapping (barrel chest if chronic), use of accessory muscles,irritability (from hypoxia), diaphoresis, cough, anxiety, weak pulse, diaphoresis and change insensorium if severe attack 109.Asthma Assessment Findingso Assessment findingso 4. Use of accessory muscles of respiration, inspiratory retractions, prolonged I:E ratioo 5. Cardiovascular symptoms: tachycardia, ECG changes, hypertension, decreased cardiaccontractility, pulsus paradoxuso 6. CNS manifestations: anxiety, restlessness, fear and disorientation 110.Emphysemao There is progressive and irreversible alveolocapillary destruction with abnormal alveolar enlargementcausing alveolar wall destruction. The result is INCREASED lung compliance, DECREASED oxygendiffusion and INCREASED airway resistance! 111.Emphysemao These changes cause a state of carbon dioxide retention, hypoxia, and respiratory acidosis. 11. 112.Emphysema o Cigarette smoking o Heredity, Bronchial asthma o Aging process o oDisequilibrium between oELASTASE & ANTIELASTASE (alpha-1-antitrypsin) oDestruction of distal airways and alveoli oOverdistention of ALVEOLI oHyper-inflated and pale lungs oAir traping, decreased gas exchange and Retention of CO2 o oHypoxia Respiratory acidosis 113.Emphysema Assessment o 1. Anorexia, fatigue, weight loss o 2. Feeling of breathlessness, cough, sputum production, flaring of the nostrils, use of accessorymuscles of respiration, increased rate and depth of breathing, dyspnea 114.Emphysema Assessment o 3. Decreased respiratory excursion, resonance to hyper-resonance, decreased breath sounds withprolonged expiration, normal or decreased fremitus o 4. Diagnostic tests: pCO2 elevated or normal; PO2 normal or slightly decreased 115.Chronic bronchitis o Chronic inflammation of the bronchial air passageway characterized by the presence of cough andsputum production for at least 3 months in each 2 consecutive years. o Excessive production of mucus in the bronchi with accompanying persistent cough. 116.Chronic Bronchitis pathophysiology o Characteristic changes include hypertrophy/ hyperplasia of the mucus-secreting glands in the bronchi,decreased ciliary activity, chronic inflammation, and narrowing of the small airways. 117.Chronic Bronchitis Assessment o I. Productive (copious) cough, dyspnea on exertion, use of accessory muscles of respiration, scatteredrales and rhonchi o 2. Feeling of epigastric fullness, cyanosis, distended neck veins, ankle edema o 3. Diagnostic tests: increased pCO2 decreased PO2 118.Bronchiectasis o Permanent abnormal dilation of the bronchi with destruction of muscular and elastic structure of thebronchial wall 119.Bronchiectasis o Caused by bacterial infection; recurrent lower respiratory tract infections; congenital defects (alteredbronchial structures); lung tumors 120.Bronchiectasis o 1. Chronic cough with production of mucopurulent sputum, hemoptysis, exertional dyspnea, wheezing o 2. Anorexia, fatigue, weight loss o 3. Diagnostic tests a. Bronchoscopy reveals sources and sites of secretions b. Possible elevation of WBC 121.COPD Management o Independent and Collaborative Management o 1. Rest- To reduce oxygen demands of tissues o 2. Increase fluid intake -To liquefy mucus secretions o 3. Good oral care- To remove sputum and prevent infection 122.COPD Management o Independent and Collaborative Management o 4. Diet: o High caloric diet provides source of energy o High protein diet helps maintain integrity of alveolar walls o Moderate fats o Low carbohydrate diet limits carbon dioxide production (natural end product). The client has difficultyexhaling carbon dioxide. 123.COPD Management o Independent and Collaborative Management o 5. O2 therapy 1 to 3 lpm ( 2 lpm is safest ) 12. o Do not give high concentration of oxygen. The drive for breathing may be depressed. 124.COPD Management o Independent and Collaborative Management o 6 . Avoid cigarette smoking, alcohol, and environmental pollutants-These inhibit mucociliary function. o 7. CPT percussion, vibration, postural drainage 125.COPD Management o Independent and Collaborative Management o 8. Bronchial hygiene measures o Steam inhalation o Aerosol inhalation o Medimist inhalation 126.COPD Management o Pharmacotherapy o 1. Expectorants (guaiafenessin)/ mucolytic (mucomyst/mucosolvan) o 2. Antitussives o Dextrometorphan o Codeine o Observe for drowsiness o Avoid activities that involve mental alertness, e.g driving, operating electrical machines o Cause decrease peristalsis thereby constipation 127.COPD Management o Pharmacotherapy o 3. Bronchodilators o Aminophylline (Theophylline) o Ventolin (Salbutamol) o Bricanyl (Terbutaline) o Alupent (Metaproterenol) Observe for tachycardia 128.COPD Management o Pharmacotherapy o 4. Antihistamine o Benadryl (Diphenhydramine) o Observe for drowsiness o 5. Steroids o Anti-inflammatory effect o 6. Antimicrobials 129.Flail Chest o Complication of chest trauma occurring when 3 or more adjacent ribs are fractured at two or moresites, resulting in free-floating rib segments. 130.Flail Chest o Chest wall is no longer able to provide the bony structure necessary to maintain adequate ventilation;consequently o the flail portion and underlying tissue move paradoxically (in opposition) to the rest of the chest cageand lungs. 131.Flail Chest o The flail portion is sucked in on inspiration and bulges out on expiration. o Result is hypoxia, hypercarbia, and increased retained secretions. o Caused by trauma (sternal rib fracture with possible costochondral separations). 132.Flail Chest o PATHOPHYSIOLOGY o During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves ina paradoxical manner o The chest is pulled INWARD during inspiration, reducing the amount of air that can be drawn into thelungs o The chest bulges OUTWARD during expiration because the intrathoracic pressure exceedsatmospheric pressure. The patient has impaired exhalation 133.Flail Chest o This paradoxical action will lead to: Increased dead space Reduced alveolar ventilation 13. Decreased lung compliance Hypoxemia and respiratory acidosis Hypotension, inadequate tissue perfusion can also follow 134.Flail Chest o Assessment findings o 1. Severe dyspnea; rapid, shallow, grunty breathing; paradoxical chest motion. The chest will moveINWARDS on inhalation and OUTWARDS on exhalation. o 2. Cyanosis, possible neck vein distension, tachycardia, hypotension o 3. Diagnostic tests a. PO2 decreased b. pCO2 elevated c. pH decreased 135.Flail Chest o Nursing interventions o 1. Maintain an open airway: suction secretions, blood from nose, throat, mouth, and via endotrachealtube; note changes in amount, color, and characteristics. o 2. Monitor mechanical ventilation o 3. Encourage turning, coughing, and deep breathing. o 4. Monitor for signs of shock: HYPOTENSION, TACHYCARDIA 136.Flail Chest o Medical management: SUPPORTIVE o 1. Internal stabilization with a volume-cycled ventilator o 2. Drug therapy (narcotics, sedatives) 137.Pneumothorax o Partial or complete collapse of the lung due to an accumulation of air or fluid in the pleural space 138.Pneumothorax o Types o a . Spontaneous pneumothorax : the most common type of closed pneumothorax; air accumulateswithin the pleural space without an obvious cause. Rupture of a small bleb on the visceral pleura mostfrequently produces this type of pneumothorax. 139.Pneumothorax o Types o b. Open pneumothorax : air enters the pleural space through an opening in the chest wall; usuallycaused by stabbing or gunshot wound. 140.Pneumothorax o Types o c. Tension pneumothorax : air enters the pleural space with each inspiration but cannot escape;causes increased intrathoracic pressure and shifting of the mediastinal contents to the unaffected side(mediastinal shift ). 141.Pneumothorax o Assessment findings o 1. Sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side ,tracheal shift to the opposite side (tension pneumothorax accompanied by mediastinal shift) o 2. Weak, rapid pulse; anxiety; diaphoresis 142.Pneumothorax o Assessment findings o 3. Diagnostic tests a. Chest x-ray reveals area and degree of pneumothorax b. pCO2 elevated c. pH decreased 143.Pneumothorax o Nursing interventions o 1. Provide nursing care for the client with an endotracheal tube: suction secretions, vomitus, bloodfrom nose, mouth, throat, or via endotracheal tube; monitor mechanical ventilation. 144.Pneumothorax o Nursing interventions o 2. Restore/promote adequate respiratory function. o a. Assist with thoracentesis and provide appropriate nursing care. o b. Assist with insertion of a chest tube to water- seal drainage and provide appropriate nursing care. o c. Continuously evaluate respiratory patterns and report any changes. 145.Pneumothorax 14. oNursing interventions o3. Provide relief/control of pain. oa. Administer narcotics/analgesics/sedatives as ordered and monitor effects. ob. Position client in high-Fowlers position. 146.Atelectasis o Collapse of part or all of a lung due to bronchial obstruction o May be caused by intrabronchial obstruction tumors, bronchospasm foreign bodies extrabronchial compression (tumors, enlarged lymph nodes); or endobronchial disease (bronchogenic carcinoma, inflammatory structures) 147.Atelectasis o Assessment findings o 1. Signs and symptoms may be absent depending upon degree of collapse and rapidity with whichbronchial obstruction occurs o 2. Dyspnea, decreased breath sounds on affected side, decreased respiratory excursion, dullness toflatness upon percussion over affected area 148.Atelectasis o Assessment findings o 3. Cyanosis, tachycardia, tachypnea, elevated temperature, weakness, pain over affected area 149.Atelectasis o Assessment findings o 4. Diagnostic tests o a. Bronchoscopy: may or may not reveal an obstruction o b. Chest x-ray shows diminished size of affected lung and lack of radiance over atelectatic area o c. pO2 decreased 150.Pleural Effusion o Defined broadly as a collection of fluid in the pleural space o A symptom, not a disease; may be produced by numerous conditions 151.Pleural Effusion o General Classification Transudative effusion: accumulation of protein-poor, cell-poor fluid Exudative effusion: accumulation of protein rich fluid 152.Pleural Effusion o Assessment findings o 1. Dyspnea, dullness over affected area upon percussion, absent or decreased breath sounds overaffected area, pleural pain, dry cough, pleural friction rub o 2. Pallor, fatigue, fever, and night sweats (with empyema) 153.Pleural Effusion o Assessment findings o 3. Diagnostic tests o a. Chest x-ray positive if greater than 250 cc pleural fluid o b. Pleural biopsy may reveal bronchogenic carcinoma o c. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or tuberculosis; positivefor specific organism in empyema. 154.Pleural Effusion o Nursing interventions: In general: o 1. Assist with repeated thoracentesis. o 2. Administer narcotics/sedatives as ordered to decrease pain. o 3. Assist with instillation of medication into pleural space (reposition client every 15 minutes todistribute the drug within the pleurae). o 4. Place client in high-Fowlers position to promote ventilation. 155.Pleural Effusion o Medical management o 1. Identification and treatment of the Underlying cause o 2. Thoracentesis o 3. Drug therapy a. Antibiotics: either systemic or inserted directly into pleural space 15. b. Fibrinolytic enzymes: trypsin, streptokinase-. streptodornase to decrease thickness of pus anddissolve fibrin clots o 4. Closed chest drainage o 5. Surgery: open drainage 156.Pneumonia o An inflammation of the alveolar spaces of the lung, resulting in consolidation of lung tissue as the alveoli fill with exudates o The various types of pneumonias are classified according to the offending organism. o Pneumonia can also be classified as COMMUNITY Acquired Pneumonia (CAP) and Hospital acquired pneumonia (HAP) 157.Pneumonia o PATHOPHYSIOLOGIC FINDINGS ARE: o HYPERTROPHY OF MUCOUS MEMBRANE Increased sputum production Wheezing Dyspnea Cough Rales Ronchi 158.Pneumonia o PATHOPHYSIOLOGIC FINDINGS ARE: o INCREASED CAPILLARY PERMEABILITY Increased Fluid Exudation Consolidation-tissue that solidifies as a result of collapsed alveoli Hypoxemia 159.Pneumonia o PATHOPHYSIOLOGIC FINDINGS ARE: o INFLAMMATION OF THE PLEURA o Chest pain o Pleural effusion o Dullness o Decreased Breath sounds o Increased tactile fremitus 160.Pneumonia o PATHOPHYSIOLOGIC FINDINGS ARE: o HYPOVENTILATION o Decreased Chest expansion o Respiratory acidosis o Depressed PROTECTIVE MECHANISM o Increased WBC (leukocytosis) o Increased RR and Fever 161.Pneumonia o Assessment findings o Cough with greenish to rust-colored sputum production o rapid, shallow respirations with an expiratory grunt o nasal flaring; intercostal rib retraction; use of accessory muscles of respiration o rales or crackles (early) progressing to coarse (later). o Tactile fremitus is INCREASED! 162.Pneumonia o Assessment findings o Fever, chills, chest pain, weakness, generalized malaise o Tachycardia, cyanosis, profuse perspiration, abdominal distension o Rapid shallow breathing 163.Pneumonia o Diagnostic tests o a. Chest x-ray shows consolidation over affected areas o b. WBC increased o c. pO2 decreased o d. Sputum specimen- culture reveal particular causative organism 16. 164.Pneumonia o 1. Facilitate adequate ventilation. o a. Administer oxygen as needed and assess its effectiveness. o b. Place client in Fowlers position . o c. Turn and reposition frequently clients who are immobilized/obtunded. o d. Administer analgesics as ordered to relieve pain associated with breathing o e. Auscultate breath sounds every 24 hours. o f. Monitor ABGs. 165.Pneumonia o GENERAL Nursing interventions o 2. Facilitate removal of secretions o general hydration o deep breathing and coughing o Suctioning o Expectorants o aerosol treatments via nebulizer, humidification of inhaled air o chest physical therapy 166.Pneumonia o GENERAL Nursing interventions o 3. Observe color, characteristics of sputum and report any changes; encourage client to perform good oral hygiene after expectoration. 167.Pneumonia o GENERAL Nursing interventions o 4. Provide adequate rest and relief/control of pain. o a. Provide bed rest with limited physical activity. o b. Limit visits and minimize conversations. o c. Plan for uninterrupted rest periods. o d. Institute nursing care in blocks to ensure periods of rest. o e. Maintain pleasant and restful environment 168.Pneumonia o GENERAL Nursing interventions o 5. Administer antibiotics as ordered. Monitor effects and possible toxicity. o 6. Prevent transmission (respiratory isolation may be required for clients with staphylococcal pneumonia). o 7. Control fever and chills: monitor temperature and administer antipyretics as ordered, maintain increased fluid intake, provide frequent clothing and linenchanges. 169.Pneumonia o GENERAL Nursing interventions o 8. Provide client teaching and discharge planning concerning prevention of recurrence. a. Medication regimen/antibiotic therapy b. Need for adequate rest, c. Need to continue deep breathing and coughing 170.Pneumonia o GENERAL Nursing interventions o 8. Provide client teaching and discharge planning concerning prevention of recurrence. d. Availability of vaccines e. Techniques that prevent transmission (use of tissues when coughing, adequate disposal ofsecretions) f. Avoidance of persons with known respiratory infections g. Need to report signs and symptoms of respiratory infection 171.Lung Cancer o Primary pulmonary tumors arise from the bronchial epithelium and are therefore referred to as bronchogenic carcinomas. o FACTORS: Possibly caused by inhaled carcinogens (primarily cigarette smoke but also asbestos, nickel, iron oxides, air silicone pollution; preexisting pulmonary disorders PTB, COPD) 172.Lung Cancer o Assessment findings o Persistent cough (may be productive or blood tinged) o chest pain 17. o dyspnea o unilateral wheezing, friction rub, possible unilateral paralysis of the diaphragm o Fatigue, anorexia, nausea, vomiting, pallor 173.Lung Cancer o Diagnostic tests. o a. Chest x-ray may show presence of tumor or evidence of metastasis to surrounding structures o b. Sputum for cytology reveals malignant cells o c. Bronchoscopy: biopsy reveals malignancy o d. Thoracentesis: pleural fluid contains malignant cells o e. Biopsy of lymph nodes may reveal metastasis 174.Lung Cancer o 1. Provide support and guidance to client as needed. o 2. Provide relief/control of pain. o 3. Administer medications as ordered and monitor effects/side effects. o 4. Control nausea: administer medications as ordered, provide good oral hygiene, provide small and more frequent feedings. 175.Lung Cancer o 5. Provide nursing care for a client with a thoracotomy. o 6. Provide client teaching and discharge planning concerning a. Disease process, diagnostic and therapeutic interventions b. Side effects of radiation and chemotherapy c. Realistic information about prognosis 176.Lung Cancer o Medical management o 1. Radiation therapy o 2. Chemotherapy: usually includes cyclophosphamide, methotrexate, vincristine, doxorubicin, and procarbazine; concurrently in some combination o 3. Surgery: when entire tumor can be removed 177.Lung Cancer o Quick Notes on Bronchogenic Cancer o Predisposing factors o Cigarette smoking o Asbestosis o Emphysema o Smoke from burnt wood o Types o Squamous cell Ca- with good prognosis o Adenocarcinoma- with good prognosis o Oat cell Ca- with good prognosis o Undifferentiated Ca- with poor prognosis 178.Lung Cancer o Quick Notes on Bronchogenic Cancer o Nursing Interventions o Patent airway o O2 / Aerosol therapy o Deep breathing exercises o Relief of pain o Protection from infection o Adequate nutrition o Chest tube management 179.Lung Cancer o Quick Notes on Bronchogenic Cancer o Surgery o Pneumonectomy= Removal of a lung (either left or right) o Lobectomy =Removal of a lobe. o Segmentectomy= Removal of a segment. o Wedge resection =Removal of the entire tumor regardless of the segment. o Decortication= Stripping off of fibrinous membrane enclosing the lung 18. oThoracoplasty= Removal of rib/s. Usually done after pneumonectomy, to reduce the size of the empty thorax thereby prevent mediastinal shift. 180.Pulmonary Embolism o This refers to the obstruction of the pulmonary artery or one of its branches by a blood clot (thrombus) that originates somewhere in the venous system or in the right side of the heart. o Most commonly, pulmonary embolism is due to a clot or thrombus from the deep veins of the lower legs. 181.Pulmonary Embolism o Causes o Fat embolism. Air embolism o Multiple trauma o PVDs o Abdominal surgery o Immobility o Hypercoagulability 182.Pulmonary Embolism o PATHOPHYSIOLOGY o The thrombus that travels from any part of the venous system obstructs either completely or partially . Then the lungs will have inadequate blood supply, with resultant increase in dead space in the lungs o Gas exchange will be impaired or absent in the involved area 183.Pulmonary Embolism o PATHOPHYSIOLOGY o The regional pulmonary vasculature will constrict causing increased resistance, increased pulmonary arterial pressure and then increase workload of the right side of the heart. 184.Pulmonary Embolism o PATHOPHYSIOLOGY o When the work of the right side of the heart exceeds its capacity, right ventricular failure will result, leading to a decrease in cardiac output followed by decreased systemic perfusion and eventually, SHOCK 185.Pulmonary Embolism o Assessment o Restlessness (cardinal initial sign) o Dyspnea o Stabbing chest pain o Cyanosis o Tachycardia o Dilated pupils o Apprehension/ fear o Diaphoresis o Dysrhythmias o Hypoxia 186.Pulmonary Embolism o Diagnostic Tests: o Ventilation-perfusion scan o Pulmonary arteriography o CXR o ECG o ABG 187.Pulmonary Embolism o Nursing Interventions o Oxygen therapy STAT o Early ambulation postop o Monitor obese patient o Do not massage legs o Relieve pain- analgesics o HOB elevated o Heparin (2 weeks) then Coumadin (3-6 months) 188.Pulmonary Embolism o Patient Teaching for prevention of Pulmonary Embolism o Active leg exercises to avoid venous stasis 19. o Early ambulation o Use of elastic compression stockings o Avoidance of leg-crossing and sitting for prolonged periods o Drink fluids 189.Surgical Aspect of Respiratory Care o Thoracic Surgery o a. Exploratory thoracotomy : anterior or posterolateral incision through the fourth, fifth, sixth, or seventh intercostal spaces to expose and examine the pleura and lung 190.Surgical Aspect of Respiratory Care o Thoracic Surgery o b. Lobectomy : removal of one lobe of a lung; treatment for bronchiectasis, bronchogenic carcinoma, emphysematous blebs, lung abscesses 191.Surgical Aspect of Respiratory Care o Thoracic Surgery o c. Pneumonectomy : removal of an entire lung; most commonly done as treatment for bronchogenic carcinoma 192.Surgical Aspect of Respiratory Care o Thoracic Surgery o d. Segmental resection : removal of one or more segments of lung; most often done as treatment for bronchiectasis 193.Surgical Aspect of Respiratory Care o Thoracic Surgery o e. Wedge resection : removal of lesions that occupy only part of a segment of lung tissue; for excision of small nodules or to obtain a biopsy 194.Surgical Aspect of Respiratory Care o Nursing interventions: PREOPERATIVE o 1. Provide routine pre-op care. o 2. Perform a complete physical assessment of the lungs to obtain baseline data. o 3. Explain expected post-op measures: care of incision site, oxygen, suctioning, chest tubes (except if pneumonectomy performed) 195.Surgical Aspect of Respiratory Care o Nursing interventions: PREOPERATIVE o 4. Teach client adequate splinting of incision with hands or pillow for turning, coughing, and deep breathing. o 5. Demonstrate ROM exercises for affected side. o 6. Provide chest physical therapy to help remove secretions. 196.Surgical Aspect of Respiratory Care o Nursing interventions: POSTOPERATIVE o 1. Provide routine post-op care. o 2. Promote adequate ventilation. o a. Perform complete physical assessment of lungs and compare with pre-op findings. o b. Auscultate lung fields every 12 hours. o c. Encourage turning, coughing, and deep breathing every 12 hours after pain relief obtained. 197.Surgical Aspect of Respiratory Care o Nursing interventions: POSTOPERATIVE o 2. Promote adequate ventilation. o d. Perform tracheobronchial suctioning if needed. o e. Assess for proper maintenance of chest drainage system (except after pneumonectomy). o f. Monitor ABGs and report significant changes. o g. Place client in semi-Fowlers position 198.Surgical Aspect of Respiratory Care o Nursing interventions: POSTOPERATIVE o If pneumonectomy is performed, follow surgeons orders about positioning, often on back or OPERATIVE SIDE o If Lobectomy , patient is usually positioned on the UNOPERATIVE SIDE 199.Surgical Aspect of Respiratory Care o Nursing interventions: POSTOPERATIVE o 3. Provide pain relief. o a. Administer narcotics/analgesics prior to turning, coughing, and deep breathing. o b. Assist with splinting while turning, coughing, deep breathing. 200.Surgical Aspect of Respiratory Care 20. o Nursing interventions: POSTOPERATIVE o 4. Provide client teaching and discharge planning concerning o a. Need to continue with coughing/deep breathing for 68 weeks post-op and to continue ROM exercises o b. Importance of adequate rest with gradual increases in activity levels 201.Surgical Aspect of Respiratory Care o Nursing interventions: POSTOPERATIVE o 4. Provide client teaching and discharge planning concerning o c. High-protein diet with inclusion of adequate fluids o d. Chest physical therapy o e. Good oral hygiene o f. Need to avoid persons with known upper respiratory infection o g. Adverse signs and symptoms o h. Avoidance of crowds and poorly ventilated areas.