Respiratory

Medical – Surgical Nursing P10B

Nasal Cavity

• Location– Btw mouth & cranium

• Function– Remove foreign bodies– Warm – Moisten – Olfactory

Nasal Cavity

• Contains– Cilia

• Hair-like – Sensitive nerve

endings:• Sneeze

Para-Nasal Sinuses

• Description– 4 pairs– Facial area– Continuous w/ nasal

cavity

• Function:– Speech

Pharynx (throat)

• Passageway– Food & liquids

• Digestive tract

– Air • Respiratory tract

• Lowest portion– Opens into 2 space

Pharynx (throat)

• Location– Behind nasal cavity

• Contains– Adenoids– Tonsils

• Lymph system

– Eustachian tubes

Larynx (voice box)

• Location– Btw pharynx & trachea

• Function– Vocalization– Facilitates

cough/sneeze

Larynx (voice box)

• Epiglottis– Gateway / trap door– Flap of elastic cartilage

• Thyroid cartilage– Adam’s apple

Larynx (voice box)

• Vocal cords– Speech

Trachea (Windpipe):

• Location– Btw larynx & bronchi

• Description– 4-5 inches long– Palpate• Above sternal notch

– C-shaped rings of cartilage

Trachea (Windpipe):

• Function– Conduct air

Bronchi

• Location– Below trachea– Center of chest– Behind the heart– Branches into 2 tubes

• Rt – diameter– More vertical– Shorter in length

Question?

Mr. Henderson had a CVA 5 days ago and is having some difficulty swallowing. There is some question that he may have aspirated some food and developed pneumonia. What side pneumonia would you except him to have?

A. Right sidedB. Left sided

Lungs

• Location– Thoracic cage

• Description• Airtight • Mult. Air sacs– Rt• 3 lobes– Lf• 2 lobes

Lungs

• Bronchi – Bronchial tree

• Bronchioles– No cilia– No cartilage– Patency d/t

• elastic recoil of the smooth muscles

• alveolar pressure

Lungs

• Alveolar ducts– Smallest tubes

• Alveoli– Functional unit– Air sacs– Gas exchange– Surrounded by pulm.

Capillaries

Lungs

• Alveoli– Thin membrane– Tendency to

collapse• Alveolar Pressure• surfactant

Pleural membrane

• Location– Surrounds surface of

lung & interior wall of thorax

• Function– Protects– Neg. pressure– Allows movement (

friction)

Pleural membrane

• Pleural space/cavity– Btw– Contains fluid

Mediastinum

• Location– Space btw lungs

• Contains– Heart– Large blood vessels– Esophagus– Trachea– Bronchi

Diaphragm

• Location– Muscle btw lungs & abd.

Cavity• Aids in resp

Skeletal System

• Ribs– 12 pairs– Thoracic cage

• Sternum

Pulmonary circulation

• Main function of resp. system is to deviler O2 to the blood & remove CO2 from it.

• Pulm. Art. – CO2 / deoxygenated

• Pulm vein– O2 / oxygenated

Blood flow: heart and lungs

• Inf/sup vena cave• Rt atrium

– Tricuspid • Rt ventricle

– Pulm • Pulm art• Pulm cap• Pulm vein• Lt atrium

– Bicuspid / mitral• Left venticle• Aorta

Small Group Questions

• Name the structures that air flows past on its way to the lungs

• What is the function of the epiglottis?• What are the supporting structures of the

trachea?• Where in the circulation of blood do you find

deoxygenated blood?

• How many lobes do the rt and lf lungs each have?• What is the purpose of the serous fluid btw the

pleural membranes?

Processes of respirationsVentilation• Movement of air in & out of the the tracheobronchial tree.

Delivering O2 to the alveoli & removing CO2Perfusion• Blood flow in the capillary bed in the lungsDiffusion• Movement of gases (O2 & CO2) across the alveoli membrane• Flows from area of greater concentration to lesser

concentration

Patient airway

• Choking

Changes assoc. with aging

• Cartilage hardens• Muscles weaker• cough reflex• elasticity

Assessment: Subjective

• Nasal Congestion• Sore throat• Change in voice• Difficulty breathing• Orthopnea• Pain

• Cough• Sputum• Affect on ADL’s

History

• Physical problems• Function problems• Life style• Smoking• Family Hx• Occupation hx• Allergens / environment• Anxiety

Inspection

• Normal chest– 2x as wide as deep– Anterior/posterior

diameter• 1:2

Inspection

• Barrel chest– D/t over inflation of

lungs– anterior-posterior

diameter • 2:2

Inspection

• Kyphosis– AKA

• Hunchback

– Abnormal curvature of the thoracic spine

Inspection

• Lordosis– AKA

• Sway-back

– Abnormal curvature of the lumbar spine

Inspection

• Uniform expansion of the chest

• Intercostal spaces

Inspection

• Shoulder rise• Accessory muscles• Posture

Inspection:

• Trachea– midline

• Color• LOC• Emotional state

Inspection: Breathing patterns

Rate• Eupnea– Normal– 12-20 / min

• Tachypnea– rate

• Bradypnea– rate

Inspection: Breathing patterns

Depth• Hyperventilation– depth & rate

• Hypoventilation– depth & rate

Auscultation

Purpose• Asses air flow through

bronchial treeProcedure• Diaphragm of

stethoscope• Superior inferior• Compare rt to lf

Auscultation: Results

Normal• Vesicular

– Lung field– Soft and low

• Bronchial– Trachea & bronchi– Hollow

Auscultation: Results

Adventitious• Crackles– air bronchi with

secretions

• Fine crackles– Air suddenly

reinflated

• Course Crackles– Moist

Auscultation: Results

• Wheezes– Sonorous wheezes

• Deep low pitched• Snoring• Caused by air

narrowed passages• D/t secretions

– Sibilant Wheezes• High pitched• Whistle-like• Caused by air

narrowed passages• D/t constriction

– Asthma

Early & late signs of hypoxia

• Anxiety• Bradycardia• Cyanosis• Depressed respirations• Diaphoresis• Disorientation• Dyspnea

• Restlessness• Headache• Agitation• Poor judgment• Retraction• Tachycardia• Tachypnea

Dyspnea

• Definition– SOB

–SOB, flat affect, BS x 4

Dyspnea

• Significance– Common with cardiac & resp. disease

Dyspnea

• Orthopnea– Sit up to breath• COPD• CHF

Dyspnea

• Right ventricle– If chronic airway resistance – pressure – Rt ventricle work – Rt. Vent damage

Dyspnea

• Nrs Management– Find cause– Give O2

– HOB – Communication• KISS

Cough

• Definition– To expel air from the lungs suddenly– Irritation of mucous membrane

Cough

• Significance– Infection– Irritants– Protective mechanism

Cough

• Nrs management– Assess– Describe – Directed – Pain control• Splinting

– Infection control– Suppressants / Anti-tussives

Sputum Production

Definition• Matter discharged

from resp. track that contains mucus and pus, blood, fibrin, or bacteria

Sputum Production

Significance• Purulent– Thick, yellow/green – Bacteria

Sputum Production

Nrs Management• Thick– Hydrate

• water• Nebulizer• Humidifier

• TCDB• No smoking• Oral care• Appetite

Do You Know?????

What breath sound would you expect to hear on a patient with increased sputum production?

A. VesicularB. CracklesC. Sonorous wheezesD. Sibilant wheezes

Obtaining a sputum specimen

• Explain– From lungs

• Sterile cup• Deep breath x 3 • Cough deeply• Expectorate • Best time for

specimen collection?– AM

Chest pain

Significance• Cardiac or pulmonary

Chest pain

Nrs Management• Assess• Analgesics OK, but…• Position for pain– Affected side– Splint

Hemoptysis

Definition• Expectoration of blood

from the respiratory tract

Hemoptysis

Significance• Pulm or cardiac

Hemoptysis

• Hemoptysis– Definition?

• Coughed up blood

– From?• Pulm hemorrhage

– Description• Pink, red, mixed with

sputum

• Hematemesis– Definition?

• Vomited blood

– From?• Stomach / GI

– Description• “Coffee ground”

Hemoptysis

Nrs Management• Determine source• Serious

Cyanosis

Definition• Bluish coloring of skin

Dx tests

Pulse Oximeter

Purpose• Noninvasive O2 SatNormal• 95-100%• <85% – Tissue is not receiving

enough O2

Pulse oximeter

Not reliable in…• Cardiac arrest• Dyes• Anemia

Radiographic exams• Chest x-ray• CT scan• Angiography• Bronchoscopy• Thoracoscopy • Thoracentesis

Chest x-ray

Description• 2-d image Purpose• Fluid• Tumor• Foreign bodies

Chest – X-ray

Nrs management

• Normal heart size & clear lung field

CT Scan

Description• Computerize Tomography• With or without contrast

mediumPurpose• Tissue• Tumor• Foreign bodies• Fluid

CT scan

Nrs management• Without contrast

medium– No prep

• With contrast medium– NPO 6 hrs– Assess for allergies

Angiography

Purpose• Visualize Pulm.

CirculationDescription• Dye• Femoral vein • Heart • Pulm Arteries

AngiographyNrs. Management• Pre-op

– NPO– Check Allergies

• Shellfish/iodine

• Post-op– Lie flat 8 hrs– Sandbag– Check pedal pulses– Assess hemorrhaging– Push fluids

Bronchoscopy

Description• Direct inspection of

larynx, trachea & bronchi via flexible tube (fiberoptic)

Purpose• Examine• Tissue sample

Bronchoscopy

• Nrs Management• Pre-op– NPO 6-8 hrs– Sedation

• Lung CA obstruction

Bronchoscopy

Nrs management• Post-op– Side-ling until gag back– NPO till gag back– Check gag– Check bleeding

• Glottis stenosis

• http://video.search.yahoo.com/search/video;_ylt=A0oGdXBnY59OcnwAuNNXNyoA?ei=UTF-8&p=bronchoscopy&fr2=tab-web&fr=moz2-ytff-

Thoracentesis

Purpose• Remove fluid

Thoracentesis

Nrs Management• Position patient• Support• Post-op

– Vital signs q 15

• http://video.search.yahoo.com/search/video;_ylt=A0oGdWeLZJ9OvQsAZ1lXNyoA?ei=UTF-8&p=thoracentesis&fr2=tab-web&fr=moz2-ytff-

Sputum studies

• Check for– Pathogens

• C&S

White Blood Cell Count

• Normal– 5,000 – 10,000 cell/mm3

• Elevated– Bacterial infection

• Decreased– Viral infection

Hemoglobin

Normal• Female: 12-16 g/dl• Male:14-18 g/dlElevated• COPD• DehydrationDecreased• Anemia• Hemorrhaging

Hematocrit

Normal• Female: 37-47%• Male: 42-52%Elevated• Dehydration• Burns• COPDDecreased• Anemia• Leukemia

PTT/PT Partial Thromboplastin Time

• Prolonged– Anticoagulant

Quiz?

• The main function of platelets is to…A. Provide oxygen to tissueB. Fight viral infectionsC. Fight bacterial infectionsD. Form a blood clot

Platelets adhere to one another and play a very important role in coagulation

Deep Breathing & Coughing

• Airway clearance– Nrs Dx

• Ineffective airway clearance

– fluids– Splinting– Infection Control

Oxygen therapy

• Goal– Provide adequate

transport of O2– work– stress to myocardium

• Need for O2 based on– ABG’s– Clinical assessment

Oxygen therapy

• Cautions on O2 tx–Med!• Except in an emergency situation is

administered only with Dr. order• Give O2 only to bring the pt back to baseline– ***COPD–WHY?

Oxygen therapy

• COPD & O2– Normal - CO2 indicator to breath– COPD – O2 indicator to breath• d/t CO2 levels “burned” medulla sensor for CO2• Medulla uses O2 to initiate breath

COPD & O2

• COPD + O2 • Resp

Oxygen therapy

• Precautions– Catalyst for combustion– “No smoking” sign– Tanks missiles– No friction toys

Smoker's home destroyed and neighbor injured

• Kalispell MO, 15 July 2004 A home on Kalispell's west side was extensively damaged Wednesday morning by a fire that was probably started by a cigarette and was accelerated by oxygen from medical oxygen tanks. A neighbor, who was trying to help was knocked down by the explosion of one oxygen tank, which also caused temporary hearing loss for a police officer.

• A report by F. Ray Ruffatto of the fire department's prevention division said that while the exact cause of the fire is still undetermined, "initial investigation indicates the fire may be the result of carelessly discarded smoking materials."

Smoker dies in house fireHudson MA 21 July 2004—• The victim of yestrerday's fire died after suffering second- and third-

degree burns from a devastating blaze at her Manning Street home Sunday.

• The resident was a smoker, according to State Fire Marshal Stephen Coan, and he said the combination of cigarettes and the multiple oxygen tanks in the home either caused or exacerbated the fire.

• She was in critical condition after being pulled from the house by a neighbor and then died yesterday at UMass Memorial Medical Center, University Campus in Worcester.

• The combination of oxygen tanks and cigarettes have sparked fires that since 1997 have killed 16 people in the state and caused severe burns or smoke inhalation in 20, said Coan.

The nurse is to teach a client with Chronic Obstructed Pulmonary Disease safety precautions for using oxygen at home. The nurse knows that the client understands the safety principles discussed when he says the following:

A. "Smoking is permitted when oxygen is in use." B. "Fire extinguishers do not need to be stored." C. "Acetone, oil, and alcohol are appropriate substances

to use with clients who are using oxygen." D."Avoid materials that generate static electricity."

A client is being discharged and will receive oxygen therapy at home. The nurse is teaching the client and family oxygen safety measures. Which of the following statements by the cleint indicated the need for further teaching?

A. I realize that I should check the oxygen level of the portable tank on a consistent basis

B. I will keep my scented candles within 5 feet of my oxygen tank

C. I will not sit in front of my wood-burning fireplace with my oxygen on.

D. I will call the physician if I experience any shortness of breath

A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen, the first nursing action would be to…

A. Wait until the client’s lab work is done (ABG’s)B. Not administer oxygen unless ordered by the

physicianC. Administer oxygen at 2 Liters flow per minuteD.Administer oxygen at 10 Liters flow per minute and

check the client’s nail beds frequently

Oxygen

Side effects• O2 • Hyper or hypo

ventilation?– Hypoventilation

Method of O2 Administration

Nasal Cannula• Flow rate– 1-6 L/min

• FiO2– 20-40%

• Nrs– Talk & eat– Comfort– Nose breather

Method of O2 Administration

Simple Mask• Flow rate– 6-10 L/min

• FiO2– 40-60%

• Nrs– Higher flow rate

Method of O2 Administration

Partial Re-breather Mask (Reservoir)

• Flow rate– 6-10 L/min

• FiO2– 60-100%

• Nrs– Uses reservoir to capture

some exhaled gas for rebreathing

– Vents allow room air to mix with O2

Method of O2 Administration

Non-rebreather Mask• Flow rate– 6-10 L/min

• FiO2– 70-100%

Method of O2 Administration

• Nrs– Side vents closed– Reservoir vent closed

for I, open for E– Reservoir bag stores

O2 for I but does not allow E air in

– Reservoir never collapse to <½

Method of O2 Administration

Venturi • Flow rate– 4-8 %

• FiO2– 20-40%

• Nrs.– Precise % of O2– i.e. COPD

• Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the clients ear?A. Artificial nailsB. VasodilationC. HypothermiaD. Movement of the head

A nurse is having difficulty setting up humidified oxygen at 40% per Venturi mask and does not know how many liters of flow she should use. Which of the following actions is most appropriate to ensure safe oxygen administration?

A. Consult with a respiratory therapist. B. Look at the package directions and try to figure it

out. C. Ask the nursing assistant how to set it up. D.Use a regular oxygen mask.

When oxygen therapy via nasal cannula is ordered for a patient, the first action by the nurse is to:

A. Post an “oxygen in use” sign on the door to the room

B. Adjust the oxygen level before applying the cannulaC. Explain the rules of fire safety and oxygen useD. Lubricate the nares with water-soluble jelly

The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the chart for pulse oximetry reading for the last 8

hours.

Time 7am 9am 11am 1am 3am

Reading 95% 90% 90% 85% 80%

The pulse oximetry reading at 3:30 PM is 75%. What should the nurse do first?

A.Administer oxygen via maskB.Swaddle the neonate in heated blanketsC.Reassess the oximetry reading in 30

minutesD.Draw blood gases for oxygen and carbon

dioxide levels.

Nebulizer Mist Treatment

• Deliver Moisture OR medication directly into the lungs

• Topical – systemic S/E

• Indications:– Must be able to deep

breath

Nebulizer Mist Treatment

Meds:• Bronchodilators– Albuteral (ventolin)

• Corticosteroids• Mucolytic agents– Acetylcysteine

• Antibiotics

Metered Dose Inhaler

• Admin. Topical meds directly into the lungs

• systemic S/E• Meds:– Corticosteroids– Bronchodilators– Mast cell inhibitors

Metered Dose Inhaler

Procedure• Canister into unit

correctly• Shake gently• Hold inhaler – breath

out slowly (not into inhaler)

Metered Dose Inhaler

• Place mouthpiece into your mouth

• Close lips around it• Tilt head back• Keep tongue out of way• Press top of the canister

firmly & breath in through your mouth

Metered Dose Inhaler

• Remove inhaler from mouth

• Hold breath for several seconds

• Breath out slowly

Metered Dose Inhaler

Rinse your mouth afterward to help reduce unwanted side effects

The nurse is teaching a client with asthma about the proper use of a metered-dose inhaler. Which statement by the client indicates that the teaching was effective?

A. "I'll flex my head forward and breathe out forcefully before inhaling the drug."

B. "As I press down on the canister, I'll inhale slowly over 10 seconds."

C. "I'll hold my breath for 5 seconds after inhaling the drug to allow the drug to reach my lungs."

D."I'll wait one minute between puffs."

Incentive Spirometry

• Device enc. Deep breath

• Prevent & tx Atelectasis

• Procedure– Inhale!

Nursing Diagnosis- Respiration

• Airway Clearance, ineffective• Aspiration, risk for• Breathing Pattern, ineffective• Gas Exchange, impaired

Ineffective Airway Clearance

• R/T– Artificial airway– Excessive or thick secretions– Inability to cough effectiviely– Infection– Obstruction / restriction– Pain– Other

Ineffective Airway Clearance

• AMB (AEB)– Ineffective cough– Inability to remove airway secretions– Abnormal breath sounds– Abnormal respiratory rate, rythm depth

Ineffective Airway Clearance

• Plan / Outcome / Goal– Maintain patent airway AEB• Clear breath sounds • Respiratory easy and unlabored• Normal respiratory rate

Ineffective Airway ClearanceNursing interventions

• Assess respiratory rate, depth, rhythm, effort and breath sounds

• Position: HOB elevated• Promote optimum level of activity

for best possible lung expansion• Ambulate / Chair• Turn/reposition• Suction prn

• Encourage fluids• Facilitate airway clearance

– Deep breathing– Pursed lips– Incentive spirometry– Cough Aerosol therapy

• Chest physiotherapy

COPD - overview

COPD?– Chronic Obstructive Pulmonary Disease

• Broad classifications of disease

COPD

• Characterized by – airflow limitation – Irreversible– Dyspnea on exertion– Progressive– Abn. inflammatory response of the lungs to

noxious particles or gases

Pathophysiology

• Noxious particles of gas • Inflammatory response • Narrowing of airway

Pathophysiology

• Inflammation • Thickening of the wall of the pulmonary

capillaries• (Smoke damage & inflammatory process)

COPD

• Includes– Emphysema– Chronic bronchitis

• Does not include– Asthma

COPD - FYI

• COPD 4th leading cause of death in the US• 12th leading cause of disability• Death from COPD is on the rise while death

from heart disease is going down

COPD

Risk Factors for COPD• Exposure to tobacco smoke – 80-90% of COPD

• Passive smoking• Occupational exposure• Air pollution

COPD risk factors

• #1– Smoking

• Why is smoking so bad??– ↓ phagocytes– ↓ cilia function– ↑ mucus production

Chronic Bronchitis

• Disease of the airway• Definition:– cough + sputum production – > 3 months

Chronic Bronchitis

Pathophysiology• Pollutant irritates airway • Inflammation• secretion of mucus

Chronic Bronchitis

• Plugs become areas for bacteria to grow and chronic infections which increases mucus secretions and eventually, areas of focal necrosis and fibrosis

Chronic Bronchitis

• Bronchial walls thicken– Bronchial Lumen narrows– Mucus plugs airway

• Alveoli/bronchioles become damaged• ↑ susceptibility to LRI

What do you think?

Exacerbation of Chronic bronchitis is most likely to occur during?

A.Fall B.SpringC.SummerD.Winter

Emphysema

Pathophysiology• Affects alveolar membrane– Destruction of alveolar wall– Loss of elastic recoil– Over distended alveoli

Emphysema

Pathophysiology• Over distended alveoli– Damage to adjacent pulmonary capillaries– dead space– Impaired passive expiration

• Impaired gas exchange

Emphysema

• Impaired gas exchange– impaired expiration• Hypoxemia• CO2

Emphysema

• Damaged pulmonary capillary bed– pulmonary pressure – work load for right ventricle – Right side heart failure

COPD Compare and contrast

• Chronic Bronchitis is a disease of the ___________?– Airway

• Emphysema is a disease affecting the ___________?– Alveoli

C.O.P.D.

• Risk factors, S&S, treatment, Dx, Rx - same for Chronic Bronchitis & Emphysema

C.O.P.D.

Clinical Manifestation (primary)

1. Cough2. Sputum production3. Dyspnea on exertion(Secondary)• Wt. loss• Resp. infections• Barrel chest

C.O.P.D.Nrs. Assessment

• Risk factors• Past Hx / Family Hx• Pattern of development• Presence of comobidities• Current Tx• Impact

• ABG’s– Baseline PaO2

• Rule out other diseases– CT scan– X-ray

C.O.P.D. Medical Management

• Risk reduction– Smoking cessation!• (The only thing that slows down the progression of the

disease!)

C.O.P.D. Rx. therapy

Primary• Bronchodilators• CorticosteriodsSecondary• Antibiotics• Mucolytic agents• Anti-tussive agents

Bronchodilators• Action:– Relieve bronchospasms– Reduce airway obstruction–↑ ventilation

Bronchodilators

• Examples– Albuterol (Proventil, Ventolin, Volmax)– Metaproterenol (Alupent)– Ipratropium bromide (Atrovent)– Theophylline (Theo-Dur)*

* Oral

Glucocorticoids

• Action– Potent anti-inflammatory agent

Corticsteriods

• S/E– Cushing• Moon face• Na+ & H20 retention

– Never discontinue abruptly

• What affect do corticosteroids have of blood sugar levels?

Glucocorticoids

• Examples– Prednisone– Methyprednisone– Beclovent

C.O.P.D. Medical Management

• Treatment– O2• When PaO2 < 60 mm Hg

– Pulmonary rehab• Breathing exercises• Pulmonary hygiene

Nursing Management

• Impaired gas exchange• Ineffective airway clearance• Ineffective breathing patterns• Activity intolerance• Deficient knowledge about self-care• Ineffective coping

Exercise has which of the following effects on clients with asthma,

chronic bronchitis and emphysema?

A. It enhances cardiovascular fitnessB. It improves respiratory muscle strengthC. It reduces the number of acute attacksD. It worsens respiratory function and is

discouraged