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Respiratory TractRespiratory Tract Disorders Disorders
Respiratory TractRespiratory Tract Disorders Disorders
Assessment & Assessment & Management of Patients Management of Patients
WithWith
Lower Respiratory TractLower Respiratory TractLower Respiratory TractLower Respiratory Tract
Trachea Bronchi Bronchioles Alveoli Cilia
Clinical Manifestations Clinical Manifestations 1. Local Manifestations
Cough chronic, paroxysmal, dry , productive
Excessive Nasal Secretion Expectoration of Sputum
mucoid, purulent, mucopurulent, rusty, hemoptysis
Pain pleuritic, intercostal, generalized
chest pain Dyspnea- shortness of breath
2. Systemic Manifestations Hypoxemia
insufficient oxygenation of the blood cyanosis- bluish, grayish discoloration of
skin & mucous membranes Hypoxia
inadequate tissue oxygenation Hypercapnia
CO2 in arterial blood above normal limits Hypocapnia
CO2 in arterial blood below normal limits Respiratory Failure
Clinical ManifestationsClinical Manifestations
Assessment of Respiratory SystemAssessment of Respiratory System
Health History Risk Factors Major Clinical Manifestations
Cough Sputum production Chest pain Wheezing Clubbing of the fingers Cyanosis
Physical ExaminationPhysical Examination
Inspection posture, shape, movement, dimensions of
chest, flared nostrils, use of accessory muscles, skin color, and rate, depth, & rhythm of respiration
Palpation respiratory excursion, masses, tenderness
Percussion flat, dull, resonant, hyperresonant sounds
Auscultation breath sounds, voice sounds, crackles,
wheezes
Assessment of Respiratory Assessment of Respiratory SystemSystem
CracklesCrackles
Diagnostic ProceduresDiagnostic Procedures Sputum Studies
Methods- standard, saline inhalation, gastric washing
Arterial Blood Gases measurements of blood pH , arterial
O2 & CO2 tensions, acid-base balance
Pulse Oximetry Chest X-ray Bronchoscopy Thoracentesis Laryngoscopy
Lower Respiratory Disorders
Lower Respiratory Disorders
PneumoniaPneumonia
Inflammation & infection of lung- infecting organisms typically inhaled- organisms transmitted to lower airways and alveoli causing inflammation- impairs gas exchange
Etiology: bacteria, virus, Mycoplasma, fungus, or from aspiration or inhalation of chemicals or other toxic substances
Risk factors: cigarette smoking, chronic underlying disorders, severe acute illness, suppressed immune system, & immobility
Assessment: Questions to ask Have you been experiencing difficulty
breathing? Are you having pain? Where? Do you have a cough? Have you been running a fever? Have you been feeling tired?
Clinical Manifestations: fever, pleuritic chest pain, tachypnea,
SOB, tachycardia, cough, sputum production- rusty, blood-tingled or yellow-green, fatigue, poor appetite
PneumoniaPneumonia
Diagnostic: Sputum and blood cultures, CBC, ABGs,
CXR, & BronchoscopyNursing Diagnoses: Ineffective airway clearance r/t thick,
tenacious sputum Ineffective breathing pattern r/t tachypnea,
chest pain, & airway inflammation Impaired gas exchange r/t exudate in
alveoli Activity intolerance r/t hypoxemia, fatigue
PneumoniaPneumonia
Planning: Client Outcomes Maintain open & clear airway, normal RR, PO2
level without supplemental O2, complete physical care without frequent rest periods
Interventions Improve airway patency- auscultate lung
sounds, monitor ABGs or pulse oximetry, elevate HOB, C & DB q 2hrs, ambulate , I/S, O2 as needed
Promote fluid intake & promote activity tolerance
Monitor & prevent complications
PneumoniaPneumonia
Pharmacology: Antibiotic therapy based on sputum culture &
sensitivity Levaquin, Tequin, Rocephin, Primaxin,
Zithromax, Ketek, Zinacef, Cipro, Tetracycline Instruct to finish all antibiotics at prescribed
intervals Evaluation:
breathing easier without chest pain temperature normal, activity level increased without frequent rest
periods
PneumoniaPneumonia
TuberculosisTuberculosis
Infectious disease that primarily affects the lungs; may be transmitted to other parts of the body
Pulmonary infiltrates accumulate, cavities develop, & masses of granulated tissue form within the lungs
Primary infectious agent- Mycobacterium Bacilli
Transmitted by inhalation of droplets (talking, coughing, sneezing, & singing)
Risk factors: immune system disorder, preexisting medical conditions, institutionalized, health care workers
Pulmonary Pulmonary TuberculosisTuberculosis
Mycobacterium tuberculosis Airborne transmission Tuberculin skin testing Pharmacologic therapy- multi-drug regimens and prophylaxis
Assessment: Questions to ask - Are you suffering from
night sweats? Have you lost weight? Have you been having low-grade fever? Have you been having SOB and coughing up anything from your lungs? Have you had chest pain? Where? Have you had weight loss?
Clinical Manifestations- low-grade fever (late afternoon), night sweats, weight loss, anorexia, fatigue, chronic productive cough,pleuritic chest pain, hemoptysis
TuberculosisTuberculosis
Diagnostic: Sputum culture- + acid-fast bacilli (AFB) Skin testing- PPD CBC- WBC elevated CXR Bronchoscopy
Nursing Diagnosis: Ineffective airway clearance r/t thick, tenacious
secretions Ineffective breathing pattern r/t airway
inflammation
TuberculosisTuberculosis
Altered nutrition less than body requirements r/t anorexia and fatigue
Anxiety r/t social isolation secondary to isolation protocols
Planning: Clients Outcomes Maintain clear airway,normal RR, achieve
weight gain, anxiety decreased
Interventions: Maintain respiratory isolation- infectious
period - diversional activities
TuberculosisTuberculosis
Promote airway clearance- bedrest, increase fluid intake, high humidity
Pharmacology First-line meds- INH, Rifampin,
Streptomycin, Ehtambutol, & Pyrazinamide for 4 months
INH and Rifampin continued for an additional 2 months or up to 12 months.
Advocate adherence & prevention Monitor and manage potential complications
Evaluation: Client adheres to isolation precautions, takes
medication as prescribed
TuberculosisTuberculosis
Questions to ask Do you have difficulty breathing- all the
time or is it caused by exertion? Do you cough frequently and is it
productive? Have you had a weight loss? Do you feel tired quite often and are your
activities impaired by SOB or fatigue? Do you have many respiratory infections?
Over what period of time?
TuberculosisTuberculosis
Nursing Diagnosis Ineffective airway clearance r/t thick,
tenacious secretion and fatigue Ineffective breathing pattern r/t fatigue and
obstruction of the bronchial tree Impaired gas exchange r/t increased
sputum production Activity intolerance r/t hypoxemia & fatigue Altered nutrition r/t increased metabolic
demands, fatigue, & anorexia Anxiety r/t inability to breathe effectively
TuberculosisTuberculosis
Diagnostics: ABGs, CBC, sputum culture, CXR, Pulmonary
function tests
Planning: Client Outcomes Effectively clear airway and breathing pattern,
maintain normal ABGs, increase activity with decrease SOB or fatigue, maintain weight, and less anxious with episodes of SOB
TuberculosisTuberculosis
Chronic Obstructive Chronic Obstructive Pulmonary Disease Pulmonary Disease
(COPD)(COPD) A group of chronic, obstructive airflow diseases of
the lungs. Also known as chronic airflow limitation (CAL)
Usually progressive & irreversible; Ciliary cleansing mechanism of the respiratory tract is affected
Involves 3 diseases- Chronic Bronchitis, Asthma, & Emphysema
Risk factors- cigarette smoking, air pollution, occupational exposure, infections, allergens, stress
Inflammation of the bronchi caused by irritants or infection
hypertrophy & hypersecretion of mucous- cause increase in sputum production
increase mucous- decrease airway lumen size- lumen becomes colonized with bacteria.
Bronchial wall becomes scarred - leads to stenosis & airway obstruction
Defined as a productive cough that lasts 3 months a year for 2 consecutive years with other causes excluded.
Cough in the morning with sputum production is indicative of Chronic Bronchitis
Chronic BronchitisChronic Bronchitis
Risk Factors: cigarette smoking, exposure to pollution,
hazardous airborne substances
Clinical Manifestations: productive cough, dyspnea esp. on exertion, wheezing, use of accessory muscles to breathe, cyanosis- “blue bloater”, clubbed fingers
Interventions: Assess patency of airway- suction if cough ineffective,
RR, accessory muscle use, lung sounds, skin color changes, ABGs
Encourage high fluid intake & instruct in effective breathing & coughing
Monitor oxygen administration & aerosol therapy
Chronic BronchitisChronic Bronchitis
Encourage to report sputum changes or worsening of symptoms
Encourage exercise to improve resp. fitness Counsel to avoid respiratory irritants and stop
smoking Immunize against common flu and pneumonia
Pharmacology: Antibiotic therapy- Tequin, Levaquin Bronchodilators- Albuterol, Combivent,
Theophylline Corticosteroids- Prednisone, SoluMedrol
Chronic BronchitisChronic Bronchitis
Chronic inflammatory disease of the airways - bronchial linings overreact to various stimuli- causes episodic smooth muscle spasms that severely constrict the airway - thickened secretions & mucosal edema further block the airways.
Acute symptoms last from minutes to hours, to days and then periods without symptoms
Most common chronic disease of childhood
Risk Factors: allergy, chronic exposure to airway irritants of allergens, stress, exertion, sinusitis
AsthmaAsthma
AsthmaAsthmaClinical Manifestations: cough with or without
sputum production, SOB & wheezing, generalized chest tightness, expiration requires effort & becomes prolonged, tachycardia, tachypnea, increased restlessness
Interventions: Immediate care depends on severity of asthma
symptoms- assess resp. status, ABGs monitoring, oxygen therapy
Administered prescribed therapy & monitor response
Fluids & antibiotics Minimize anxiety Teach preventive measures- exercise
Pharmacology: Bronchodilators
Beta-agonists- Albuterol, Serevent Xanthines- Theophylline
Corticosteroids Prednisone, SoluMedrol Inhalers- Flovent, Vanceril, Beclovent,
Advair, Azmacort Anticholinergics- Atrovent, Combivent Leukotriene modifiers- SingulairMay be treated as outpatient or require
hospitalization & intensive care
AsthmaAsthma
EmphysemaEmphysema Enlargement of air spaces distal to airways
that conduct air to the alveoli
Enlarged spaces causes breakdown in alveoli
walls- increases in airway size on inspiration-
decreases alveolar membrane for gas exchange
Small airways collapse on exhalation- air
trapped in alveolar spaces
Theses changes- products destruction of
elastin in distal airways and alveoli
Distinguishing characteristic- airflow limitation
caused by lack of elastic recoil in the lungs
COPD-COPD-EmphysemaEmphysema
No trouble inhaling, but with hyperinflated lungs & small airways- exhaling becomes more difficult
Risk Factors: smoking, occupational exposure, heredity
Most common in fifth decade of life
EmphysemaEmphysema
Clinical Manifestations: SOB on exertion, use of
accessory muscles to breath, late cough after onset of
SOB (if productive sputum- scanty & mucoid), “pink
puffer”, barrel chest (increase in anterior-posterior
diameter of chest), thin in appearance, diminished
breath sounds & prolonged expiration, speaks in short
jerky sentences, anxious
Interventions:
Improve gas exchange- oxygen therapy
Achieve airway clearance- aerosol therapy
Encourage adequate hydration
Prevent infections- immunizations
EmphysemaEmphysema
Minimize anxiety
Physical therapy
Patient teaching
Pharmacology: Beta-agonists- Albuterol, Theophylline Anticholinergics- Atrovent Antibiotic therapy- Levaquin, Tequin Corticosteroids
EmphysemaEmphysema
Evaluation: Improved gas exchange, achieves airway
clearance, breathing pattern improved, achieves activity tolerance, acquires effective coping mechanisms, and adheres to therapeutic program.
EmphysemaEmphysema
AtelectasisAtelectasis Inadequate ventilation Mucus plugs Pleural effusion Pneumothorax Hemothorax
Pleural Pleural EffusionEffusion
PneumothoraxPneumothorax
Condition in which air or gas exists in the pleural space
Normally negative pressure (suction) between the visceral and parietal pleura- any injury that allows air or positive pressure to enter pleural space- prevents the lung from remaining inflated
Air in pleural space- increased intrapleural pressure- partial or total collapse of the lung
Types: Simple, Traumatic, or Tension
PneumothoraPneumothoraxx
PneumothoraxPneumothorax Simple (Closed or spontaneous)Simple (Closed or spontaneous)
Air enters the pleural space from the lung in the absence of disease
Occurs in men ages 20 to 40 & result of rupture of small blister on the apex of the lung
If occurs from trauma or pulmonary disease- referred to as secondary or complicated
Basic symptoms: SOB & chest pain
Treatment of Simple Treatment of Simple PneumothoraxPneumothorax
PneumothoraPneumothoraxx
PneumothoraxPneumothorax Traumatic (Open)Traumatic (Open)
A hole in the chest wall allows atmospheric air to flow into the pleural space
Air in the pleural space - increased intrapleural pressure- resulting in partial or total collapse of the lung
Results from a penetrating injury, a therapeutic procedure, or insertion of a CVC or pulmonary artery catheter
A sucking sound audible on inspiration as the chest wall rises & varying degrees of resp. distress
PneumothoraxPneumothorax TensionTension
Injury allows air to leak into pleural space during inspiration- prevents air from leaking out during expiration
Each inspiration-amount of air increases- becomes trapped to point causing increased thoracic pressure- pushes the heart, vena cava, and aorta out of position (mediastinum shift)- results in poor venous return to heart - leads to poor cardiac output
Medical emergency- disruption of cardiac output & respiratory distress
PneumothoraxPneumothorax Etiology:
Blunt chest trauma (MVAs and falls), penetrating traumas (gunshot and knife injuries), rib fractures, & flail chest
Assessment: Questions to ask Are you having difficulty breathing? Do you have pain in your chest? Point to your
pain with one finger. Clinical Manifestations:
SOB, CP, tachypnea, tachycardia, cyanosis, diminished breath sounds, hyper-resonance on affected side, neck vein engorgement, paradoxical movement of the chest, deviated trachea, cardiogenic shock & anxiety
PneumothoraxPneumothorax Diagnostic:
ABGs, CXR Nursing Diagnosis:
Ineffective breathing pattern r/t decreased lung expansion
Impair gas exchange r/t collapse of an area of the lung
Anxiety r/t inability to ventilate effectively
Planning: Client Outcomes RR & ABGs within normal limits, client states
rationale for treatment & procedures, & client rests without behavioral signs of excessive anxiety
Nursing Interventions: Comprehensive respiratory assessment- airway
patency, RR, lung sounds, chest rise & fall symmetrically, ABGs, blood counts, electrolytes, cardiac status, urinary output, chest wall
Maintain semi-Fowler’s position Encourage deep breathing & coughing Administer oxygen therapy Medicate for pain as needed Explain all procedures- calm & reassure about
overall treatment & condition as needed Encourage use of relaxation techniques Medical- Mechanical Ventilation & Chest tubes
PneumothoraPneumothoraxx
Chest TubesChest Tubes
Chest Drainage SystemChest Drainage System
Inserted after most thoracic & cardiac surgeries
Consists of chest tube attached to valve mechanism- allow air or fluid to drain out of the chest cavity
Include one, two, and three-bottle systems and the one-piece, three chamber, disposable plastic systems
Purpose of Chest Drainage SystemPurpose of Chest Drainage System
Removes air, blood, & other fluids from pleural space or mediastinal space
Facilitates re-expansion of the lungs and restore negative pressure in thoracic cavity
Indications forIndications forChest Drainage SystemChest Drainage System
After thoracic & cardiac surgery Traumatic injury- Fractured Rib Intrapleural- pneumothorax, hemothorax,
& pleural effusion Mediastinal- cardiac surgery, chest
trauma Complication from procedures:
CVC insertion Lung biopsy
Types of Chest Drainage Types of Chest Drainage SystemsSystems
Water-seal Remove air or fluid from pleural space or
mediastinum Mechanism for collection of drainage One-way mechanism to keep air from getting
back into the pleural space Water-seal acts = one-way valve
Allows air to leave pleural space- but not to return-maintaining negative pressure
Waterless Valve to regulate suction Valve can be opened for air & liquid drainage to
move out Remain closed to prevent air from entering
pleural space
Autotransfusion Variation of water-seal system Attached container so that blood drained from
chest can be salvaged for autotransfusion
Types of Chest Drainage Types of Chest Drainage SystemsSystems
AssessmentAssessment
Respiratory status S&S of extended pneumothorax or hemothorax Function of drainage system every 1 hr:
System below level of patient’s chest Tube free of kinks, or external obstruction All connections secured Color and amount of drainage Fluctuation of fluid level in water-seal chamber Constant bubbling in water-seal chamber
Anxiety level & understanding
Pt with Chest Drainage SystemsPt with Chest Drainage Systems
Nursing Diagnosis Ineffective breathing pattern related to decreased
lung expansion as evidence by:
Planning: Patient Outcomes Breath sounds are normal Respiration unlabored & occur at rate of 16 to 20
breaths per minute ABG values approaching normal Lung re-expansion seen on chest x-ray film
Chest Drainage SystemsChest Drainage Systems
Nursing Interventions: Maintain airtight, patent, functioning chest
drainage system Re-tape all connections as needed Re-tape or reinforce chest-tube dressing Tubing free of kinks, loops & external pressure Place roll towel under chest- protect tubing from
body weight Encourage cough and deep breathe & position
change frequently Keep occlusive petrolatum jelly dressing at
bedside
Chest Drainage Chest Drainage SystemsSystems
Mark amount of drainage in collection container at 1 to 4 hour intervals
Check water levels in suction control & water-seal pressure chambers
Notify MD of constant bubbling in water-seal or drainage becoming bright red or increases suddenly
Reassure the patient that staff is nearby- call light in reach
Documentation for chest drainage systems Assist with chest tube insertion or removal
Chest Drainage SystemsChest Drainage Systems
Evaluation: RR & ABGs within normal limits Decreased difficulty breathing Chest pain diminished Equal lung sounds Bilateral chest movement Decreased chest tube drainage Client able to verbalize rationale for treatment
and procedures Client rests without behavioral signs of
excessive anxiety
Chest Drainage SystemsChest Drainage Systems
Older Adult AlertOlder Adult Alert
1. Be concern about any changes in orientation. This may be a first indication of pneumonia in older adults.
2. Be cautious in fluid administration. Overhydration may initiate CHF.
3. Older clients may become confused with multiple drug therapies and may not follow the regimen correctly. Theses clients may need assistance to ensure proper administration. In older clients, the thoracic muscles are weaker which may make the older adult unable to tolerate the increased work of breathing required of COPD.
4. Older adult clients have fewer alveoli than younger adults- oxygen exchange will be even more impaired in older adult clients with COPD.
5. The weaker thoracic muscles in older adults will also make coughing more difficult, and thus, retained secretions will be a problem in many cases.
6. Older adults high risk for infection due to decreased immune response. Chest injuries evaluated carefully for signs of infection. Temperature of 99 degrees F may indicate an initial infection.
7. Cough will be impaired due to decreased muscle strength- older adults greater risk for atelectasis and pneumonia after a chest injury.
Older Adult AlertOlder Adult Alert