Rachel S. Natividad, RN, MSN, NPN212 Medical Surgical Nursing 1

The Respiratory System

Structure and Function

Gas exchange

Changes associated to Aging recoil and compliance

AP diameter

functional alveoli

in Pa02

Respiratory defense mechanisms less effective

Altered respiratory controlsMore gradual response to changes in O2 and Co2 levels in blood

DiagnosticsPulse Oximetry

Chest X-Ray

Computed Tomography (CT scan)

Bronchoscopy

Thoracentesis

Pulmonary Function Tests

Sputum Specimen and Cultures

Diagnostics: Pulse OximetryMeasures arterial oxygen saturation

Pulse oximetry probe on forehead, ears, nose, finger, toes,

False readings

Intermittent or continuous monitoring

Ideal values: 95-100%

When to Notify MD< 91%86% (Medical Emergency)

Diagnostics: Chest X-RayScreen, diagnose, evaluate treatment

Instructions: No metals/jewelry

Diagnostics: Chest X-Ray Cont.Posterior Anterior ViewLeft Lateral ViewNoduleInfiltrates

Diagnostics: Sputum SpecimenTo diagnose; evaluate treatmentSpecimen: ID organisms or abnormal cellsCulture & Sensitivity (C&S)CytologyGram stains (e.g. Acid Fast Bacilli)

Diagnostics: Computed Tomography: CT ScanImages in cross-section view

Uses contrast agents

Instructions:

Right upper Lobe

Diagnostics: Bronchoscopy

Diagnose problems and assess changes in bronchi/bronchioles

Performed to remove foreign body, secretions, or to obtain specimens of tissue or mucus for further study

Procedure Care/Instructions:NPO 6 -8 hrs priorSedation during procedurePost Procedure:HOB elevatedObserve for hemorrhageNPO until gag reflex returns

Diagnostics: Pulmonary Function Test (PFTs)Evaluate lung function

Observe for increased dyspnea or bronchospasm

Instructions:No bronchodilators 6 hours prior

Diagnostics: ThoracentesisSpecimen from pleural fluid

Treat pleural effusion

Assess for complications

Post-Procedure care:CXR after procedure

PositionsSitting on side of bed over bedside table chest elevatedLying on affected sideStraddling a chair

Assessment: Cues to Respiratory Problems

Dyspnea

Cough

Sputum

Pneumonia: Case StudyPathophysiology

Pneumonia: Pathophysiology Cont.

Pneumonia: EtiologyCausebacteria (75%)virusesfungiMycoplasmaParasiteschemicals

Pneumonia: ClassificationsCommunity-acquired pneumonia (CAP)Onset in community or during 1st 2 days of hospitalization (Strep. pneumoniae most common)

Hospital-acquired Pneumonia(HAP/nosocomial)Occurring 48 hrs or longer after hospitalization

Aspiration pneumonia

Pneumonia caused by opportunistic organismsPneumocystis Carinii

Pneumonia: Risk FactorsCAPOlder adultChronic/coexisting conditionRecent history or exposure to viral or influenza infectionsHistory of tobacco or alcohol useHAPOlder adultChronic lung diseaseALOCAspirationET, Trach, NG / GT ImmunocompromisedMechanical ventilation

Pneumonia: Clinical ManifestationsFevers, chills, anorexiaPleuritic chest painSOBCrackles/wheezesCough, sputum productionTachypnea

Pneumonia: Clinical Manifestations-Cont.Mycoplasma (Atypical)feeling tired or weak, headaches, sore throat, or diarrhea. Eventually, most develop a dry cough. They can, also, develop fever, chills, earaches, chest pain

walking pneumonia

Pneumonia: DiagnosisDiagnosis Physical exam crackles, rhonchi/wheezes

CXR area of increased density (infiltrates/ consolidation)

Sputum specimen Gram stainLUL Infiltrates

Pneumonia :Interventions/Tx

Treatment Antibiotics choose based on age, suspected cause & immune status

Supportive care IV fluids, supplemental oxygen therapy, respiratory monitoring, cough enhancement

*may take 6-8 weeks for CXR to normalize

Nursing DiagnosesImpaired gas exchange R/T Pneumonia

Pain R/T infection in lung Pneumonia

Pneumonia: ComplicationsHypoxemia

Pleural effusion

Atelectasis

Pleurisy

AtelectasisPleurisyPleural Effusion

Toxic sprinkles anyone?

Any Questions?

*Resp. System divided into two parts: upper resp and lower resp. tractsCarina located at level of manubriosternal junction- or angle of louis it is where the trachea bifurcates into r and L main stem bronchiSeparates upper and lower resp tracts.

Note: R main stem bronchi straighter than left aspiration more likely to occur in right lung than in Left lung

Bronchioles wrapped by smooth muscles that constrict and dilate in response to stimuli.Narrowing or widening of bronchioles due to contraction and relaxation of muscles determine the diameter of airwaysAlveoli small sacs- functionial unit of lungs

*Alveolar capillary membrane where gas exchange occursPulmonary edema- excess fluid fills alveoli and interstitial spaces- imapairing exchange of O2 and C02Gas exchange by diffusion*Respiratory defense mechanisms less effective (formation of antibodies and cough reflex)

Altered respiratory controls- more gradual response to changes in blood )2 and C02 levels.

From the ages of 20 to 80, our vital capacity declines linearly. The amount of residual air left in our lungs after each breath increases from about 20 percent of the total lung capacity when we are 20 to 35 percent at age 60. Also, slightly less oxygen is absorbed from air that is breathed in. In people who do not smoke or have a lung disorder, the muscles of breathing and the lungs continue to function well enough to meet the needs of the body during ordinary daily activities. But these changes may make exercising vigorously and breathing at high altitudes more difficult.The lungs become less able to fight infection, in part because the cells that sweep debris out of the airways are less able to do so. Cough, which also helps clear the lungs, tends to be weaker.The AirwaysThe trachea (windpipe) and large airways increase in diameter as we age. Enlargement at the lung end of the airways results in a decreased surface area of the lung.Maximum breathing (vital) capacity may decline by about 40 percent between the ages of 20 and 70.Lung ElasticityDecreased lung elasticity and the resulting increase in lung volume and reduced surface area causes the chest to expand and the diaphragm to descend. As our ribs calcify to our breastbone the chest wall stiffens, increasing the workload of the respiratory muscles.The DiaphragmThe muscles used in breathing, such as the diaphragm, tend to weaken.Pulmonary Aging From 20 to age 80 reduces the elasticity of the aveoli by 30%. Blood Oxygen LevelsDecreases, largely as the result of impaired matching of blood flow with the parts of the lung that contain air. Aging does not cause any problems in our ability to get rid of carbon dioxide.PreventionEndurance training can produce stunning increases in the lung capacity of sedentary older persons, with well-conditioned older people possessing lung function exceeding those of much younger people. Smoking accelerates aging changes.The stiffer the lung, the less the compliance. compliance is reduced by diseases which cause an accumulation of fibrous tissue in the lung or by oedema in the alveolar spaces. It is increased in pulmonary emphysema and also with age, probably because of alterations in the elastic tissue in both cases.

*Arthur is a 68-year old African American male who came in with complaints of severe congestion, coughing, and shortness of breath. Arthurs pulse oximetry reading (SpO2) was 92%. The physician diagnosed him with acute bronchitis and sent him home with an inhaler and a course of antibiotics. He continued to have severe coughing and become progressively weak with intermittent episodes of shortness of breath. He had a low grade fever of 100.1, P 98, BP 128/84, R 22 at the time of the second doctors visit. The physician ordered a chest x-ray and sputum for culture and sensitivity. The chest X-ray revealed a suspicious nodule or mass on the right upper lobe. The sputum specimen was inconclusive. The MD ordered a CT scan to investigate further. The Ct scan revealed a tumor on the anterior mediastinum of the right upper lobe. The pulmunologist recommended a bronchoscopy and scheduled pulmonary function tests. The result of the biopsy showed malignant cells and surgery was recommended. *Oximetry- which patients do you need to monitor pulse oximetry on?Arterial and venous O2 SatDevice attach t earlobe, finger, or nose, or foot (babies)Continuously monitored in ICU or 24 hours after sx; spot checks in med-surg ptsAlteredresults with motion, low perfusion, acrylic nailsNotify MD if < 90%, r 92-93% (follow agency protocol or MD specific order if any)

IGGY: Medical emerg 86%; call md if less thatn 91%*Screen for TB, diagnose pneumonia, evaluate txCommon views AP and Lateral

Remove any metal or jewelry between neck and waist*The standard chest examination consists of a PA (posterioranterior) and lateral chest x-ray. The films are read together. The PA exam is viewed as if the patient is standing in front of you with their right side on your left. The patient is facing towards the left on the lateral view.

To screen (for TB), diagnose (pneumonia, pulmonary edema (CHF); evaluate treatmnet treat 9to see if pneumonia or pulm edema resolved)

http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\radio\images\large\35983598RUL_NODULE.JPG&fzi=1*Assess presence of abnormal cells

Evaluate treatment: TB- AFB stainsAcid fast Bacilli - TB Culture and sensitivity; AFB; gram stain, cytologyCollected in a sterile container

Instruct pt how to produce a good specimen; deep breathe then cough deeply and expectorate (not spit)

Sputum specimenCultre and sensitivity; AFB; gram-stain (+/-); cytologyCollect in a sterile containerTo diagnose bacterial infection, to assess presence of abnormal cells; to evaluate treatment (TB) AFB stainsInstruct pt on how to produce a good specimen; deep breath then cough deeply then expectorate (ex. Pt spits only)

*images are shown in cross-section Used to dx px difficult to access by usual x-rays Nursing responsibility-same for x-rayDiagnose problems difficult to access by usual X-rays (mediastinum (area underneath the sternum or breast bone) and pleura, hilum)

*Visualization (using fiberoptic tube bronchoscope- athin flexible fiberoptic telescope) of the tracheobronchila tree via a scope advanced through the mouth or nose into the bronchiPerformed to remove foreign body, secretions, or to obtain specimens of tissue or mucus for further studyNursing care: obtain an informed consentKeep NPO for six hours to eight hours before procedureAdminister ordered procedure medications (e.g. Valium) to produce sedation and decrease anxietyInform the client to expect some soreness, dysphagia, hemoptysis after the procedureAdvice client to avoid coughing or clearing throatObserve for signs of hemorrhage and /or respiratory distress; keep HOB elevatedMonitor VS until stableDo not allow fluids until gag reflex returns

Post-op care- keep NPO until gag reflex return and monitor for laryngeal edema; keep HOB elevatedMonitor for hemorrhage and pneumothorax

The endoscope 1) is inserted through the nose or mouth, then through the trachea 2) and finally into the bronchial tubes 3). During the examination it is possible, without the patient feeling anything, to extract secretion for analysis of bacteria. Additionally its possible to take smalltissue samples with biopsy forceps. During the examination the patient will receive a sedative medicament. Post-op: NPO for 6-12 hoursuntil gag reflex returns Monitor for laryngeal edema; hemorrhage and pneumothoraxKeep HOB elevated

One type of lung collapse, known medically as a pneumothorax, occurs when air leaks into the area between your lungs and chest wall (pleural space). The pressure of the air against the lung causes it to give way, often leading to mild to severe chest pain and shortness of breath. A pneumothorax can be caused by a chest injury, certain medical treatments, lung disease or a break in an air blister on the lung's surface.A lung collapses in proportion to the amount of air that leaks into your chest cavity. Although the entire lung can collapse, a partial collapse is much more common. A small, uncomplicated pneumothorax may heal on its own in a week or two, but when the pneumothorax is more severe, the excess air is usually removed by inserting a tube or needle between your ribs into the pleural space.If air continues to build up, the increasing pressure can push your heart and blood vessels toward the uncollapsed lung, compressing both your lung and heart. Called a tension pneumothorax, this condition is life-threatening and requires immediate medical care.

*Tidal volume, forced inspiratory volume

Use of spirometer- to show air movement as pt performs prescribed maneuvers- by RT

PFT- Done by RTTo evaluate lung functionUses a fancy spirometer, blows hard, fast and as long as possible into the mouthpieceProvide rest after procedureNo bronchodilators for 6 hours prior to procedure

These are tests that assess your lung function or capacity. They involve taking normal and deep breaths, as well as breathing out as hard as you can into a tube. Occasionally, you will be asked to briefly hold your breath. Your results are adjusted based on your age, gender, race, and height. Pulmonary function tests provide one measure of how well controlled your asthma is. Your physician will use your results, along with your symptoms, to assess the severity of your asthma, as well as your response to treatment.

*These tubes, inserted in your chest during the thoracentesis, will remove air, blood, or fluid from the area around your lungs. Removal of fluid or air from pleural space; performed for diagnostic purposes or to alleviate respiratory distress; a needle biopsy of the pleura may be doneNo more than 1000 mL of fluid should be removed at the time (may result in sudden fluid shift: pulmonary edema); fluid withdrawn should be sent to the lab for C&S, analysis of lgucose, protein and pHComplications include pneumothorax from trauma to the lung and pulmonary edema resulting from sudden fluid shifts

Nursing care: Obtain informed consentEnsure a CXR is done before and after the procedure ( to check for pneumothorax)Support the client in the sitting positionInform the client not to cough during the procedure to prevent trauma to the lungsAssess pulse and respirations before during and after the procedure

Obtain specimen of pleural fluid for dx; sometime tx for pleural effusion if excessive amountsLarge bore needle into pleural spaceSTAT CXR always after procedure to check for pneumothorax ( d/t possibility of puncturing the visceral pleura)Three different possible positionssitting on side of bed over bedside table chest elevatedlying on affected sidestraddling a chair

Effusion without a secure clinical diagnosis (e.g., CHF) or small quantity Thoracentesis is a diagnostic procedure done in patients who have abnormal amounts of fluid accumulation in the pleural space. The procedure is usually done at the bedside under local anesthesia. The needle is placed through the chest wall into the pleural space and fluid is then withdrawn into a syringe. infection and bleeding at site, reaccumulation of pleural fluid,

Pneumothorax is a condition in which air gets between your lungs and your chest wall. Pneumothorax is one cause of a collapsed lung a serious, sometimes life-threatening, condition.Normally, two thin layers of moist tissue (pleura) separate your lungs and chest wall. Any air that leaks through lung tissue into this space (pleural space) will cause the lung tissue to collapse in proportion to the amount of air that enters the pleural cavity.Air can collect in the pleural space for many reasons, including:An injury that damages the chest wall, such as a stab or gunshot wound A broken rib that punctures the lung A procedure or surgery that involves the lung or chest wall Spontaneous pneumothorax, which is thought to be due to the rupture of an air-filled blister on the surface of the lung In many cases, the cause of a pneumothorax can't be determined. People with underlying lung disease, such as asthma or cystic fibrosis, may be at increased risk of pneumothorax.Signs and symptoms of pneumothorax include:Sudden, sharp chest pain Shortness of breath Chest tightness A doctor can confirm a diagnosis of pneumothorax by a chest X-ray. Occasionally, the air leak seals itself. Depending on the severity, a doctor can remove the air from the pleural space with a tube inserted between the ribs and attached to a suction device. Surgery may be needed when suction isn't effective or for recurrent pneumothorax.If air continues to enter the pleural space, tension pneumothorax occurs. The large amount of air may push the center of the chest (mediastinum) toward the other lung, compressing it. This is life-threatening and requires immediate insertion of a chest tube between the ribs to relieve the increased pressure.

*Table 25-6 = p. 552 resp px and descriptionsDyspnea- at rest or exertion? Difficulty breathing in certain position? E.g. lying down and better when sitting up?To assess the degree- ask how it affects ADLs

Wheezing- inspiratory or expiratory or both? Precipitating factors, meds/palliative factors.Pain- chest, pleuritic type (pain with inspiration)?, scale, palliative (lying down? pericarditis)Cough evaluate quality (barking, dry, productove, moist); onset and chronicity; pattern (regular, paroxysmal, in am, certain activities, taking deep breaths); OTCs

CoughPrecipitating factors: activity, position changes, smoking, weather, anxiety, vocalizationDuration, timing, frequency:chronicacutetime of day it is worse and related cause: AM bronchitis, Nights LVFQualitynonproductive vs productivechronic productivewheezingbarking: epiglottal disease e.g. croupstridor (loud harsh): tracheal obstructionmorning smokers coughSputum amount, color, consistency, and odornomral- clear or slightly white

SputumQuality: color, consistency, amount, odor (may contain cellular debris, mucus, pus, blood)mucoid non infectious (allergies)mucopurulent viral infectionsyellow or green bacterial infectionspink, blood tinged streptococcal, staphylococcal, pneumonia, cancer, TBpink, frothy - pulmonary edemaprofuse, colorless - alveolar cell cancerbloody pulmonary emboli, bronchiectasis, abcess, TB, tumor, bleeding disordersthick, tenacious emphysema, chronic bronchitis

Wheezing: air passing through narrowed airwaysPrecip factors:Qualityexpiratory wheeze: obstructive disease in peripheral airwaysWheezing resp: local obstruction of major airwayInspiratory stridor: partial obstruction at laryngeal or tracheal levelCyanosisCentral: inadequate gas exchange in the lungs(decreased arterial O2 < 80%) Assess in warm parts of the body- mucous membranes, inside lips, mouthPeripheral: excessive extraction of O2 in periphery; assess in cold parts of the body (fingers, toes, nose, outside of lips)Associated factors: cough, SOB, bleeding

*Pneumonia is a serious infection causing inflammation to one or both lungs. The air sacs (alveoli) in the lungs fill with fluid and pus, making it difficult for the person affected to breathe. When the air sacs in the lungs' fill it impairs their main function, which is to get oxygen from the air into the bloodstream

organism reaches lower resp tractOutpouring of inflammatory exudate and cellsWBCs phagocytize the organisms and release enzymesPortions of the lungs fill with exudate and inflammatory cells - consolidation

*Inhalation of pathogens in air dropletsAspiration of infected secretions from the upper respiratory tractAspiration of infected particles from gastric contents, food, or debrisHematogenous spread*What causes pneumonia?Pneumonia can be caused by bacteria, viruses, fungal infections or chemical exposure, sometimes the exact cause of pneumonia is never known. The most common types of pneumonia are as follows:Bacterial pneumonia develops when bacteria that normally live harmlessly in the throat enter the lungs. This usually happens when the body's immune system is weakened in some way. This usually occurs after an upper respiratory infection, such as influenza. The lungs are damaged enough to allow the bacteria to infect the area. Bacterial pneumonia is usually caused by bacteria called either pneumococcus or streptococcus pneumoniae. The pneumonia 'Legionnaire's disease' is caused by the bacterium Legionella pneumophila and is found in faulty air conditioning units of large buildings e.g. hospitals or hotels. The bacteria can survive in warm, moist, air conditioning units and if present can cause an outbreak of the disease. The name comes from an epidemic in 1976, when 29 American Legion members all mysteriously died after staying at the same hotel. However, the disease is usually mild and is treated with antibiotics. Viral pneumonia is caused by simple viral organisms which, are often similar to those responsible for the common cold. Viral pneumonia is also a common complication of other illnesses such as colds, influenza, measles, herpes and chickenpox. Viral pneumonia is usually milder than bacterial pneumonia and lasts a shorter period of time. Mycroplasma pneumonia is caused by a micro-organism of the same name. Mycroplasma pneumonia is spread by close contact with an infected person and is more common in young adults. Some people who are infected with this type of pneumonia may never experience any symptoms. If the infected person is in good health, the illness is not as serious as normal pneumonia and there are rarely any complications. Aspiration pneumonia is caused when bacteria enters into the lungs from the mouth or stomach during vomiting. This type is usually more common in alcoholics. Pneumocystis Carinii Pneumonia (P.C.P.) is caused by a micro-organism that may live harmlessly in normal lungs. P.C.P. often develops as a secondary infection in patients whose immune system is weakened by illnesses such as cancer and HIV. P.C.P. can be the first sign of illness in people with HIV. What are the symptoms of pneumonia?Symptoms of both bacterial and viral pneumonia are similar and usually last about 2 weeks. Symptoms may include any of the following:High temperature. Severe shaking and chills. Cough that worsens over time and is often accompanied by phlegm. Severe chest pain or tightness in the chest. Shortness of breath. Loss of appetite. Tiredness and fatigue. General muscle aches. If you believe you might have pneumonia or have a persistent cough, then you should visit your doctor for further advice.Am I at risk of getting pneumonia?Anyone can get pneumonia, even the young. However, it is more common and more serious if you: Are elderly. Have had your spleen removed. Are an alcoholic. Suffer with asthma, heart conditions, lung diseases or diabetes. Smoke. Have a weak immune system (caused by long term illness such as cancer or HIV). How is pneumonia diagnosed?Your doctor can usually diagnose pneumonia by listening to you breathe with a stethoscope. If he/she suspects you have pneumonia, you will usually be referred to a hospital for a chest X-ray to see how bad the condition is. If the condition is severe the doctor will take a sample of your phlegm to examine under a microscope. The doctor will then try to grow the organism that is causing the infection, to find out which type of pneumonia you have. What treatment is there for pneumonia?If you have bacterial pneumonia your doctor will prescribe antibiotics, if however, you have viral pneumonia it will get better on its own. With both types of pneumonia you should get plenty of bed rest, take painkillers to reduce the fever and drink 8 glasses of juice or water a day. If pneumonia is severe you may need to be hospitalized for treatment. Treatments you receive in hospital may include; supplementary oxygen to help with breathing, physiotherapy to help clear mucus and/or antibiotics given directly into the vein. However, the majority of people with pneumonia will not need to be hospitalized.*CAP: Important infection worldwideMost common in the winter months

HAPDeveloping >2 days after arrival in hospitalIncreased risk in: assisted ventilationpre-existing lung diseaseaspiration or anyone immunocompromised

Aspiration- form aspiration of secretions and substances into lower resp airways from mouth or stomach into trachea dn then to lngs

At risk: loss of consciousness: alcoholic, stroke, seizures, anesthesia, coma-where cough and gag reflex depressed

Opportunistic- HIV pts. Pneumocystis carinii, cytomegalovirus, fungi in immunocompormised pts*Walking Pneumonia is an infection of the lungs that stems from a bacterial infection (Mycoplasma Pneumonia), mostly affecting people under the age of 40. The patient may have symptoms lasting from days to weeks. Once a diagnosis is made, proper treatment is with antibiotics. It is called "walking Pneumonia" because people do not appear to be very sick, even though they have Pneumonia. Usually begin with vague symptoms such as feeling tired or weak, headaches, sore throat, or diarrhea. Eventually, most develop a dry cough. They can, also, develop fever, chills, earaches, chest pain, enlarged lymph nodes in the neck, and muscle or joint pains. A few patients may feel short of breath.

**always obtain both PA & Lateral films

For complicated pneumonia- gram stain and ID the infecting organism

Rapid Diagnostic studiesThe infectious agent is the most valuable piece of information in managing a complicated pneumonia.Gram stain - bacteriaAcid fast - mycobacteriaDFA - Pneumocystis, influenza, legionellaPCR - chlamydia, mycoplasma, mycobacteria, legionella, hantavirusEIA - influenza, RSV

Treatments: hydration, proper nutrition, support 02; ABX IV, HHN tx, analgesics

Treat with abx based on source of infection (com vs hosp acquired;) type of org present; and severity

New antibioticsCephalosporinsMacrolides/ketolidesFluoroquinolonesRoute of administrationOralIntravenousIntramuscular

Admission decisions related to :hypoxia, inadequate oral intake, lack of home care support

Antibiotic Decision Making: Severity of disease, Microbiology environment, Patient, Host status, Individual considerations

*Impaired gas exchange RT inflammatory exudate in alveolar spacePain rt infection in lungHyperthermia rt infectionAnxiety rt dyspnea*Pleurisy inflammation of pleura (pleuritis); common px occurs with PneumoniaPleural effusion usually sterile and is absored in 1-2 weeks; but can be aspirated with thoracentesis if too severeAtelectasis collapsed lung; airless alveoli; on one or part of lobe; clear with good TCDBWhich stimulates surfactant for lung expansionDelayed resolution results from persistent infection and is seen on x-ray as residual consolidation: in older people, manouished, COPDs, alcoholicsEmpyema accumulation of purulent exudate in pleura; infreq; need abx and chest tube drainage Lung abcess in Staph areus and gram neg pneum; not a common complicationPeridarditis from spread of MO from infected pleura

Rheumatic heart disease- endocarditis, pericarditis