respiratory nursing

Medical and Surgical Nursing

Respiratory System Lecture Notes

Prepared by: Mark Fredderick R. Abejo RN,, MAN

MS Abejo 1

MEDICAL AND SURGICAL NURSING

Respiratory System

Lecturer: Mark Fredderick R. Abejo RN,MAN




MS Abejo 2

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 Tract

A. Functions 1. Filtering

2. Warming and moistening

3. Humidification

B. Parts 1. 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 Adenoids

6. 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 tract

A. Function: facilitates gas exchange

B. 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 Bronchi

3. 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 alveoli

TYPE 2 - secrete SURFACTANT, reduces surface

tension; increases alveoli stability & prevents their

collapse

TYPE 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




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PHYSIOLOGY OF RESPIRATORY SYSTEM

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

• 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 FLOW

Airflow 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 mucosa

2. Thickening of bronchial mucosa

3. Obstruction of the airway

4. 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 breathing

1. 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 breathing

1. 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




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7. Paradoxical

the abdomen sucks with respiration (normally, it

pouches uotward due to diaphragmatic descent)

causes: diaphragmatic paralysis

B. Cyanosis

1. 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

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)




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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

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




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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

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




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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

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




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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.

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




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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

Informed 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 Bronchoscopy

Put 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.

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




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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


Document bronchodilators or narcotics used

before testing

Allay the patient’s anxiety during the testing

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 exhalation

Residual 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 expiration

Vital 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 COPD

Total 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


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.




MS Abejo 11

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

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 Hypoxemia

o Increased pulse rate

o Rapid, shallow respiration and dyspnea

o Increased restlessness or lightheadedness

o Flaring of nares

o Substernal or intercostals retractions

o 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 LPM

o Simple Face Mask 0-60% 5-8 LPM

o Partial Rebreathing Mask 60-90% 6-10 LPM

o Non-rebreathing Mask 95-100% 6-15 LPM

o Croupette

o 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 Mask

o 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.




MS Abejo 12

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.

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.




MS Abejo 13

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.

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 apparatus

1. 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-seal

5. 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




MS Abejo 14

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

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 Gauze

Suture removal kit

Sterile gauze

Adhesive 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

I. PNEUMONIA – inflammation of the lung parenchyma

leading to pulmonary consolidation because alveoli is filled

with exudates

A. ETIOLOGIC AGENTS

1. Streptococcus pneumoniae (pneumococcal

pneumonia)

2. Hemophilus influenzae (bronchopneumonia)

3. Klebsiella pneumoniae

4. Diplococcus pneumoniae

5. Escherichia coli

6. Pseudomonas aeruginosa




MS Abejo 15

B. HIGH RISK GROUPS

1. Children less than 5 yo

2. Elderly

C. PREDISPOSING FACTORS

1. Smoking

2. Air pollution

3. 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 SYMPTOMS

1. Productive cough, greenish to rusty

2. Dyspnea with prolong expiratory grunt

3. Fever, chills, anorexia, general body malaise

4. Cyanosis

5. Pleuritic friction rub

6. Rales/crackles on auscultation

7. Abdominal distention paralytic ileus

E. DIAGNOSTICS

1. Sputum GS/CS confirmatory; type and sensitivity;

(+) to cultured microorganism

2. CXR – (+) pulmonary consolidation

3. 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 MANAGEMENT

1. Enforce CBR (consistent to all respi disorders)

2. Strict respiratory isolation

3. Administer medications as ordered

Broad spectrum antibiotics

Penicillin – pneumococcal infections

Tetracycline

Macrolides

Azithromycin (OD x 3/days)

1. Too costly

2. Only se: ototoxicity – transient

hearing loss

Anti-pyretics

Mucolytics/expectorants

4. Administer O2 inhalation as ordered

5. Force fluids to liquefy secretions

6. Institute pulmonary toilet – measures to promote

expectoration of secretions

DBE, Coughing exercises, CPT

(clapping/vibration), Turning and repositioning

7. Nebulize and suction PRN

8. Place client of semi-fowlers to high fowlers

9. Provide a comfortable and humid environment

10. Provide a dietary intake high in CHO, CHON,

Calories and Vit C

11. 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

II. 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 FACTORS

1. Malnutrition

2. Overcrowding

3. Alcoholism: Depletes VIT B1 (thiamin) alcoholic

beriberi malnutrition

4. Physical and emotional stress

5. Ingestion of infected cattle with M. bovis

6. Virulence (degree of pathogenecity)

B. MODE OF TRANSMISSION: Airborne droplet

infection

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




MS Abejo 16

C. SIGNS AND SYMPTOMS

1. Productive cough (yellowish)

2. Low grade afternoon fever, night sweats

3. Dyspnea, anorexia, malaise, weight loss

4. Chest/back pain

5. Hemoptysis

D. DIAGNOSTICS

1. 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 bacilli

3. CXR – (+) pulmo infiltrated due to caseous necrosis

4. CBC – elevated WBC

E. NURSING MANAGEMENT

1. Enforce CBR

2. Institute strict respiratory isolation

3. Administer O2 inhalation

4. Forced fluids

5. Encourage DBE and coughing

NO CLAPPING in chronic PTB d/t

hemoptysis may lead to hemorrhage

6. Nebulize and suction PRN

7. Provide comfortable and humid environment

8. 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 nephrotoxicity

1. Monitor liver enzymes

2. 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, Gentamycin

1. common SE: 8th CN damage

tinnitus hearing loss

ototoxicity

2. nephrotoxicity

a. BUN (N = 10-20)

b. CREA (N = 8-10)

9. Health teaching and d/c planning

Avoidance of precipitating factors : alcoholism,

overcrowding


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


III. 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

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


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 Bronchitis

2. Bronchial Asthma

3. Bronchiectasis

4. Pulmonary Emphysema




MS Abejo 17

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


1. Smoking

2. Air pollution

B. SIGNS AND SYMPTOMS

1. Consistent productive cough

2. Dyspnea on exertion with prolonged expiratory

grunt

3. Anorexia and generalized body malaise

4. Cyanosis

5. Scattered rales/rhonchi

6. Pulmonary hypertension

Peripheral edema

Cor pulmonale

C. DIAGNOSTICS

1. ABG analysis: decreased PO2, increased PCO2,

respiratory acidosis; hypoxemia cyanosis

D. NURSING MANAGEMENT

1. Enforce CBR


Bronchodilators

Antimicrobials

Corticosteroids


3. Low inflow O2 admin; high inflow will cause

respiratory arrest

4. Force fluids

5. Nebulize and suction client as needed



avoidance of smoking

prevent complications

CO2 narcosis coma

Cor pulmonale

Pleural effusion

Pneumothorax

Regular adherence to meds


II. BRONCHIAL ASTHMA – reversible inflammatory lung

condition caused by hypersensitivity to allergens leading to

narrowing of smaller airways


1. Extrinsic (Atopic/Allergic Asthma)

Pollens, dust, fumes, smoke, fur, dander, lints

2. 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


1. Cough that is productive

2. Dyspnea

3. Wheezing on expiration

4. Tachycardia, palpitations and diaphoresis

5. Mild apprehension, restlessness

6. Cyanosis

C. DIAGNOSTICS

1. PFT decreased vital lung capacity

2. ABG analysis PO2 decreased


1. Enforce CBR


Bronchodilators administer first to facilitate

absorption of corticosteroids

Inhalation

MDI

Corticosteroids


Mucomyst

Antihistamine

3. Administer oxygen inhalation as ordered

4. Forced fluids

5. Nebulize and suction patient as necessary

6. Encourage DBE and coughing

7. Provide a comfortable and humid environment


Avoidance of precipitating factors





MS Abejo 18

Status asthmaticus

DOC: Epinephrine

Aminophylline drip

Emphysema

Regular adherence to medications


III. BRONCHIECTASIS – permanent dilation of the bronchus

due to destruction of muscular and elastic tissue of the

alveolar walls (subject to surgery)


1. Recurrent lower respiratory tract infection

Histoplasmosis

2. Congenital disease

3. Presence of tumor

4. Chest trauma


1. Consistent productive cough

2. Dyspnea

3. Presence of cyanosis

4. Rales and crackles

5. Hemoptysis


C. DIAGNOSTICS

1. ABG analysis reveals low PO2

2. 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 set

D. SURGERY

1. Segmental lobectomy

2. Pneumonectomy

Most feared complications

Atelectasis

Cardiac tamponade: muffled heart sounds,

pulsus paradoxus, HPN


1. Enforce CBR


respiratory arrest


Bronchodilators

Antimicrobials

Corticosteroids (5-10 minutes after

bronchodilators)


4. Force fluids




Avoidance of smoking


Atelectasis

CO2 narcosis coma

Cor pulmonale

Pleural effusion

Pneumothorax



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 Abejo 19


1. Smoking

2. Air pollution

3. Hereditary: involves alpha-1 antitrypsin for

elastase production for recoil of the alveoli

4. Allergy

5. High risk group elderly degenerative

decreased vital lung capacity and thinning of

alveolar lobes


1. Productive cough

2. Dyspnea at rest

3. Prolonged expiratory grunt

4. Resonance to hyperresonance

5. Decreased tactile fremitus

6. Decreased breath sounds ( if (-) BS lung collapse)

7. Barrel chest


9. Rales or crackles

10. Alar flaring

11. Pursed-lip breathing (to eliminate excess CO2)

C. DIAGNOSTICS

1. 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


1. Enforce CBR


Bronchodilators

Antimicrobials

Corticosteroids



respiratory arrest and oxygen toxicity

4. Force fluids

5. Pulmonary toilet


7. Institute PEEP in mechanical ventilation

PEEP – positive end expiratory pressure

allows for maximum alveolar diffusion

prevent lung collapse


9. Diet modifications: high calorie, CHON, CHO,

vitamins and minerals


Avoidance of smoking


Atelectasis

CO2 narcosis coma

Cor pulmonale

Pleural effusion

Pneumothorax



RESTRICTIVE LUNG DISEASE

V. PNEUMOTHORAX – partial or complete collapse of the

lungs due to accumulation of air in pleural space

A. TYPES

1. Spontaneous – air enters pleural space without an

obvious cause

Ruptured blebs (alveolar – filled sacs)

inflammatory lung conditions

2. 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 FACTORS

1. Chest trauma

2. Inflammatory lung condition

3. tumors

C. SIGNS AND SYMPTOMS

1. Sudden sharp chest pain, dyspnea, cyanosis

2. Diminished breath sounds

3. Cool, moist skin

4. Mild restlessness and apprehension

5. Resonance to hyperresonance

D. DIAGNOSTICS

1. ABG analysis: PO2 decreased

2. CXR – confirms collapse of lungs


1. Assist in endotracheal intubation

2. Assist in thoracentesis

3. Administer meds as ordered

Narcotic analgesics – Morphine sulfate

Antibiotics

4. Assist in CTT to H20 sealed drainage

respiratory nursing

Health & Medicine