Respiratory Tract DisordersRespiratory Tract Disorders

Assessment & Assessment & Management of Patients Management of Patients

WithWith

Lower Respiratory TractLower Respiratory Tract

Trachea Bronchi Bronchioles Alveoli Cilia

Respiratory anatomy

Alveoli at the terminal end of the lower airway

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

Function

Gases are moved in and out of the lung

through pressure changes.

Intrapleural pressure is negative (less than atmospheric pressure – 760mmHg)

Please refer to suggested reading notes

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 Manifestations

Medical Terminology (Respiratory conditions)

Respiratory Failure: The inability of the cardovascular and pulmonary systems to maintain an adequate exchange of oxygen and carbondioxide in the lungs .

Maybe caused by a failure in oxygen or in ventilation.

Can be hypoxemic or hypercapneic.

Medical terminology cont.

Ventilation: the process of moving gases into and out of the lungsWork of Breathing: The effort required for expanding and contracting of the lungs. The influencing factors: the rate and depth of breathing, the ease in which the lungs can be expanded and airway resistance

Assessment of Respiratory System

Health History Risk Factors Major Clinical Manifestations

Cough Sputum production Chest pain Wheezing Clubbing of the fingers Cyanosis

Physical 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 System

Crackles

Diagnostic 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

Pneumonia 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

Pneumonia

Diagnostic: Sputum and blood cultures, CBC, ABGs, CXR,

& BronchoscopyNursing Diagnoses: Ineffective airway clearance sec. to thick,

tenacious sputum Ineffective breathing pattern sec.to

tachypnea, chest pain, & airway inflammation Impaired gas exchange sec. to exudate in

alveoli Activity intolerance sec. to hypoxemia, fatigue Acute pain sec.to disease process

Pneumonia

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 , O2 as needed

Promote fluid intake & promote activity tolerance Monitor & prevent complications High fowler’s positioning to facilitate air exchange

Pneumonia

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 Short acting beta 2 agonist such as Salbutamol Corticosteroids ,Prednisolone to decrease

inflammation Influenza vaccine, pneumococcal vaccine

Pneumonia

Period of bed rest Promote adequate nutrition Provide support Evaluation:

breathing easier without chest pain temperature normal, activity level increased without frequent

rest periods

ARDS

Acute Respiratory Disease Syndrome

A form of Acute Lung InjuryDiffused alveolar injury

An acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia

Build up fluid in alveolar

ARDS - Causes

Breathing vomit into lungs (aspirations)

Inhaling chemicalsLung transplannt

PneumoniaSeptic shock (infection thru body)

Trauma

ARDS -Characterstics

Stiff heavy lungs(decreases the lungs ability to expand)

The level of oxygen in the blood can stay dangerously low (even if oxygen is

given via a ventilator)

ARDS - Symptoms

Symptoms usually develop 24 to 48 hrs of illness or injury

DyspnoeaLow blood pressure (infection) and

organ failureRapid breathing

ARDS - Diagnostics

Arterial Blood GasBlood Tests

Blood and Urine culturesBronchoscopy

Chest x-raySputum culture and analysis

ARDS - Treatment

Intensive Care AdmissionAntibiotic therapy

Steroid therapyDiuretics

Ventilatory support

PULMONARY EMBOLISM

Is a complication of an underlying venous thrombosis

Patient may not show classic signs and symptoms

PE – SIGNS AND SYMPTOMS

Classic presentation:Pleuretic chest pain

DyspnoeaHypoxia

PE – Signs and symptomsSeizuresSyncope

Abdominal painFever

Productive coughWheezing

Altered level of consciousness

PE – Signs and Symptoms

New onset of atrial fibrillationHemoptysis

Flank painDelirium

PE - Diagnosis

ECGChest xray, CT, MRI, Echo, VQ scan

Blood tests –Dimer, coagulation profile, Arterial blood gas

PE - Management

Anticoagulation (warfarin, heparin, retaplse)

Surgical intervention :Emoblectomy

Vena Cava filters

TUBERCULOSIS 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 Tuberculosis

Mycobacterium tuberculosisAirborne transmissionTuberculin skin testingPharmacologic therapy- multi-drug regimens and prophylaxis

TuberculosisAssessment: 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

Diagnostic: Sputum culture- + acid-fast bacilli (AFB) Skin testing CBC- WBC elevated CXR BronchoscopyNursing Diagnosis: Ineffective airway clearance r/t thick, tenacious

secretions Ineffective breathing pattern r/t airway

inflammation

Tuberculosis

Altered nutrition less than body requirements sec. to anorexia and fatigue

Fatigue sec. to disease process Anxiety sec. to social isolation secondary

to isolation protocolsPlanning: Clients Outcomes Maintain clear airway,normal RR, achieve

weight gain, anxiety decreasedInterventions: Maintain respiratory isolation- infectious

period - diversional activities Barrier protection should be used

Tuberculosis

Evaluation: Client adheres to isolation precautions,

takes medication as prescribed Complications Miliary TB The organism invade the blood stream

and can spread to multiple body organ Meningitis Pericarditis

Promote airway clearance- bedrest, increase fluid intake, high humidity

Pharmacology First-line meds- Isoniazid, Rifampin,

Ehtambutol, & Pyrazinamide for 4 months Isoniazid and Rifampin continued for an

additional 2 months or up to 12 months. Advocate adherence & prevention Monitor and manage potential

complications Adequate nutrition Provide client and family education Provide emotional support

Tuberculosis

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?

Tuberculosis

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

Tuberculosis

Diagnostics: ABGs, CBC, sputum culture, CXR, Pulmonary

function testsPlanning: 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

Tuberculosis

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

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

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 Bronchitis

Bronchiolitis:Bronchiolitis is a common illness of the respiratory tract

usually caused by viral infection. It affects

the tiny airways, called the bronchioles,

that lead to the lungs. As these airways

become inflamed, they swell and fill with

mucus, making breathing difficult.

The variable degrees of obstruction

produced in air passage by these changes

lead to hyperpnoea & progressive

emphysema.

Bronchiolitis:Nursing Assessment

Sometimes more severe respiratory difficulties gradually develop:

Rapid, shallow breathing .

Drawing in of the neck and chest with each breath, known as retractions.

Flaring of the nostrils.

Irritability, with difficulty sleeping and signs of fatigue or lethargy.

BronchiolitisNursing care:

Follow strict precautions to prevent spread of infection.

Administer high humidified oxygen.

Clear nasal congestion, try a bulb syringe and saline (saltwater) nose

drops.

Provide adequate Ng. Care for vomiting, fever, & diarrhea.

Small frequent diet, & increase fluid intake.

A lung abscess is a localized area of lung destruction

liquefaction necrosis usually related to pyogenic bacteria

Cavity formation

Clinical manifestation Dyspnoea Chest pain Tachycardia

Lung abscess

Diagnosis Method CT Chest X ray 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