Respiratory System (2)

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Respiratory TractRespiratory Tract Disorders Disorders

Assessment & Assessment & Management of Patients Management of Patients

WithWith

Lower Respiratory TractLower Respiratory TractLower Respiratory TractLower Respiratory Tract

Trachea Bronchi Bronchioles Alveoli Cilia

Clinical Manifestations Clinical Manifestations 1. Local Manifestations

Cough chronic, paroxysmal, dry , productive

Excessive Nasal Secretion Expectoration of Sputum

mucoid, purulent, mucopurulent, rusty, hemoptysis

Pain pleuritic, intercostal, generalized

chest pain Dyspnea- shortness of breath

2. Systemic Manifestations Hypoxemia

insufficient oxygenation of the blood cyanosis- bluish, grayish discoloration of

skin & mucous membranes Hypoxia

inadequate tissue oxygenation Hypercapnia

CO2 in arterial blood above normal limits Hypocapnia

CO2 in arterial blood below normal limits Respiratory Failure

Clinical ManifestationsClinical Manifestations

Assessment of Respiratory SystemAssessment of Respiratory System

Health History Risk Factors Major Clinical Manifestations

Cough Sputum production Chest pain Wheezing Clubbing of the fingers Cyanosis

Physical ExaminationPhysical Examination

Inspection posture, shape, movement, dimensions of

chest, flared nostrils, use of accessory muscles, skin color, and rate, depth, & rhythm of respiration

Palpation respiratory excursion, masses, tenderness

Percussion flat, dull, resonant, hyperresonant sounds

Auscultation breath sounds, voice sounds, crackles,

wheezes

Assessment of Respiratory Assessment of Respiratory SystemSystem

CracklesCrackles

Diagnostic ProceduresDiagnostic Procedures Sputum Studies

Methods- standard, saline inhalation, gastric washing

Arterial Blood Gases measurements of blood pH , arterial

O2 & CO2 tensions, acid-base balance

Pulse Oximetry Chest X-ray Bronchoscopy Thoracentesis Laryngoscopy

Lower Respiratory Disorders

PneumoniaPneumonia

Inflammation & infection of lung- infecting organisms typically inhaled- organisms transmitted to lower airways and alveoli causing inflammation- impairs gas exchange

Etiology: bacteria, virus, Mycoplasma, fungus, or from aspiration or inhalation of chemicals or other toxic substances

Risk factors: cigarette smoking, chronic underlying disorders, severe acute illness, suppressed immune system, & immobility

Assessment: Questions to ask Have you been experiencing difficulty

breathing? Are you having pain? Where? Do you have a cough? Have you been running a fever? Have you been feeling tired?

Clinical Manifestations: fever, pleuritic chest pain, tachypnea,

SOB, tachycardia, cough, sputum production- rusty, blood-tingled or yellow-green, fatigue, poor appetite

PneumoniaPneumonia

Diagnostic: Sputum and blood cultures, CBC, ABGs,

CXR, & BronchoscopyNursing Diagnoses: Ineffective airway clearance r/t thick,

tenacious sputum Ineffective breathing pattern r/t tachypnea,

chest pain, & airway inflammation Impaired gas exchange r/t exudate in

alveoli Activity intolerance r/t hypoxemia, fatigue

PneumoniaPneumonia

Planning: Client Outcomes Maintain open & clear airway, normal RR, PO2

level without supplemental O2, complete physical care without frequent rest periods

Interventions Improve airway patency- auscultate lung

sounds, monitor ABGs or pulse oximetry, elevate HOB, C & DB q 2hrs, ambulate , I/S, O2 as needed

Promote fluid intake & promote activity tolerance

Monitor & prevent complications

PneumoniaPneumonia

Pharmacology: Antibiotic therapy based on sputum culture &

sensitivity Levaquin, Tequin, Rocephin, Primaxin,

Zithromax, Ketek, Zinacef, Cipro, Tetracycline Instruct to finish all antibiotics at prescribed

intervals Evaluation:

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

periods

PneumoniaPneumonia

TuberculosisTuberculosis

Infectious disease that primarily affects the lungs; may be transmitted to other parts of the body

Pulmonary infiltrates accumulate, cavities develop, & masses of granulated tissue form within the lungs

Primary infectious agent- Mycobacterium Bacilli

Transmitted by inhalation of droplets (talking, coughing, sneezing, & singing)

Risk factors: immune system disorder, preexisting medical conditions, institutionalized, health care workers

Pulmonary Pulmonary TuberculosisTuberculosis

Mycobacterium tuberculosis Airborne transmission Tuberculin skin testing Pharmacologic therapy- multi-drug regimens and prophylaxis

Assessment: Questions to ask - Are you suffering from

night sweats? Have you lost weight? Have you been having low-grade fever? Have you been having SOB and coughing up anything from your lungs? Have you had chest pain? Where? Have you had weight loss?

Clinical Manifestations- low-grade fever (late afternoon), night sweats, weight loss, anorexia, fatigue, chronic productive cough,pleuritic chest pain, hemoptysis

Diagnostic: Sputum culture- + acid-fast bacilli (AFB) Skin testing- PPD CBC- WBC elevated CXR Bronchoscopy

Nursing Diagnosis: Ineffective airway clearance r/t thick, tenacious

secretions Ineffective breathing pattern r/t airway

inflammation

Altered nutrition less than body requirements r/t anorexia and fatigue

Anxiety r/t social isolation secondary to isolation protocols

Planning: Clients Outcomes Maintain clear airway,normal RR, achieve

weight gain, anxiety decreased

Interventions: Maintain respiratory isolation- infectious

period - diversional activities

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

Pharmacology First-line meds- INH, Rifampin,

Streptomycin, Ehtambutol, & Pyrazinamide for 4 months

INH and Rifampin continued for an additional 2 months or up to 12 months.

Advocate adherence & prevention Monitor and manage potential complications

Evaluation: Client adheres to isolation precautions, takes

medication as prescribed

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?

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

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

function tests

Planning: Client Outcomes Effectively clear airway and breathing pattern,

maintain normal ABGs, increase activity with decrease SOB or fatigue, maintain weight, and less anxious with episodes of SOB

Chronic Obstructive Chronic Obstructive Pulmonary Disease Pulmonary Disease

(COPD)(COPD) A group of chronic, obstructive airflow diseases of

the lungs. Also known as chronic airflow limitation (CAL)

Usually progressive & irreversible; Ciliary cleansing mechanism of the respiratory tract is affected

Involves 3 diseases- Chronic Bronchitis, Asthma, & Emphysema

Risk factors- cigarette smoking, air pollution, occupational exposure, infections, allergens, stress

Inflammation of the bronchi caused by irritants or infection

hypertrophy & hypersecretion of mucous- cause increase in sputum production

increase mucous- decrease airway lumen size- lumen becomes colonized with bacteria.

Bronchial wall becomes scarred - leads to stenosis & airway obstruction

Defined as a productive cough that lasts 3 months a year for 2 consecutive years with other causes excluded.

Cough in the morning with sputum production is indicative of Chronic Bronchitis

Chronic BronchitisChronic Bronchitis

Risk Factors: cigarette smoking, exposure to pollution,

hazardous airborne substances

Clinical Manifestations: productive cough, dyspnea esp. on exertion, wheezing, use of accessory muscles to breathe, cyanosis- “blue bloater”, clubbed fingers

Interventions: Assess patency of airway- suction if cough ineffective,

RR, accessory muscle use, lung sounds, skin color changes, ABGs

Encourage high fluid intake & instruct in effective breathing & coughing

Monitor oxygen administration & aerosol therapy

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 inflammatory disease of the airways - bronchial linings overreact to various stimuli- causes episodic smooth muscle spasms that severely constrict the airway - thickened secretions & mucosal edema further block the airways.

Acute symptoms last from minutes to hours, to days and then periods without symptoms

Most common chronic disease of childhood

Risk Factors: allergy, chronic exposure to airway irritants of allergens, stress, exertion, sinusitis

AsthmaAsthma

AsthmaAsthmaClinical Manifestations: cough with or without

sputum production, SOB & wheezing, generalized chest tightness, expiration requires effort & becomes prolonged, tachycardia, tachypnea, increased restlessness

Interventions: Immediate care depends on severity of asthma

symptoms- assess resp. status, ABGs monitoring, oxygen therapy

Administered prescribed therapy & monitor response

Fluids & antibiotics Minimize anxiety Teach preventive measures- exercise

Pharmacology: Bronchodilators

Beta-agonists- Albuterol, Serevent Xanthines- Theophylline

Corticosteroids Prednisone, SoluMedrol Inhalers- Flovent, Vanceril, Beclovent,

Advair, Azmacort Anticholinergics- Atrovent, Combivent Leukotriene modifiers- SingulairMay be treated as outpatient or require

hospitalization & intensive care

AsthmaAsthma

EmphysemaEmphysema Enlargement of air spaces distal to airways

that conduct air to the alveoli

Enlarged spaces causes breakdown in alveoli

walls- increases in airway size on inspiration-

decreases alveolar membrane for gas exchange

Small airways collapse on exhalation- air

trapped in alveolar spaces

Theses changes- products destruction of

elastin in distal airways and alveoli

Distinguishing characteristic- airflow limitation

caused by lack of elastic recoil in the lungs

COPD-COPD-EmphysemaEmphysema

No trouble inhaling, but with hyperinflated lungs & small airways- exhaling becomes more difficult

Risk Factors: smoking, occupational exposure, heredity

Most common in fifth decade of life

EmphysemaEmphysema

Clinical Manifestations: SOB on exertion, use of

accessory muscles to breath, late cough after onset of

SOB (if productive sputum- scanty & mucoid), “pink

puffer”, barrel chest (increase in anterior-posterior

diameter of chest), thin in appearance, diminished

breath sounds & prolonged expiration, speaks in short

jerky sentences, anxious

Interventions:

Improve gas exchange- oxygen therapy

Achieve airway clearance- aerosol therapy

Encourage adequate hydration

Prevent infections- immunizations

EmphysemaEmphysema

Minimize anxiety

Physical therapy

Patient teaching

Pharmacology: Beta-agonists- Albuterol, Theophylline Anticholinergics- Atrovent Antibiotic therapy- Levaquin, Tequin Corticosteroids

EmphysemaEmphysema

Evaluation: Improved gas exchange, achieves airway

clearance, breathing pattern improved, achieves activity tolerance, acquires effective coping mechanisms, and adheres to therapeutic program.

EmphysemaEmphysema

AtelectasisAtelectasis Inadequate ventilation Mucus plugs Pleural effusion Pneumothorax Hemothorax

Pleural Pleural EffusionEffusion

PneumothoraxPneumothorax

Condition in which air or gas exists in the pleural space

Normally negative pressure (suction) between the visceral and parietal pleura- any injury that allows air or positive pressure to enter pleural space- prevents the lung from remaining inflated

Air in pleural space- increased intrapleural pressure- partial or total collapse of the lung

Types: Simple, Traumatic, or Tension

PneumothoraPneumothoraxx

PneumothoraxPneumothorax Simple (Closed or spontaneous)Simple (Closed or spontaneous)

Air enters the pleural space from the lung in the absence of disease

Occurs in men ages 20 to 40 & result of rupture of small blister on the apex of the lung

If occurs from trauma or pulmonary disease- referred to as secondary or complicated

Basic symptoms: SOB & chest pain

Treatment of Simple Treatment of Simple PneumothoraxPneumothorax

PneumothoraxPneumothorax Traumatic (Open)Traumatic (Open)

A hole in the chest wall allows atmospheric air to flow into the pleural space

Air in the pleural space - increased intrapleural pressure- resulting in partial or total collapse of the lung

Results from a penetrating injury, a therapeutic procedure, or insertion of a CVC or pulmonary artery catheter

A sucking sound audible on inspiration as the chest wall rises & varying degrees of resp. distress

PneumothoraxPneumothorax TensionTension

Injury allows air to leak into pleural space during inspiration- prevents air from leaking out during expiration

Each inspiration-amount of air increases- becomes trapped to point causing increased thoracic pressure- pushes the heart, vena cava, and aorta out of position (mediastinum shift)- results in poor venous return to heart - leads to poor cardiac output

Medical emergency- disruption of cardiac output & respiratory distress

PneumothoraxPneumothorax Etiology:

Blunt chest trauma (MVAs and falls), penetrating traumas (gunshot and knife injuries), rib fractures, & flail chest

Assessment: Questions to ask Are you having difficulty breathing? Do you have pain in your chest? Point to your

pain with one finger. Clinical Manifestations:

SOB, CP, tachypnea, tachycardia, cyanosis, diminished breath sounds, hyper-resonance on affected side, neck vein engorgement, paradoxical movement of the chest, deviated trachea, cardiogenic shock & anxiety

PneumothoraxPneumothorax Diagnostic:

ABGs, CXR Nursing Diagnosis:

Ineffective breathing pattern r/t decreased lung expansion

Impair gas exchange r/t collapse of an area of the lung

Anxiety r/t inability to ventilate effectively

Planning: Client Outcomes RR & ABGs within normal limits, client states

rationale for treatment & procedures, & client rests without behavioral signs of excessive anxiety

Nursing Interventions: Comprehensive respiratory assessment- airway

patency, RR, lung sounds, chest rise & fall symmetrically, ABGs, blood counts, electrolytes, cardiac status, urinary output, chest wall

Maintain semi-Fowler’s position Encourage deep breathing & coughing Administer oxygen therapy Medicate for pain as needed Explain all procedures- calm & reassure about

overall treatment & condition as needed Encourage use of relaxation techniques Medical- Mechanical Ventilation & Chest tubes

Chest TubesChest Tubes

Chest Drainage SystemChest Drainage System

Inserted after most thoracic & cardiac surgeries

Consists of chest tube attached to valve mechanism- allow air or fluid to drain out of the chest cavity

Include one, two, and three-bottle systems and the one-piece, three chamber, disposable plastic systems

Purpose of Chest Drainage SystemPurpose of Chest Drainage System

Removes air, blood, & other fluids from pleural space or mediastinal space

Facilitates re-expansion of the lungs and restore negative pressure in thoracic cavity

Indications forIndications forChest Drainage SystemChest Drainage System

After thoracic & cardiac surgery Traumatic injury- Fractured Rib Intrapleural- pneumothorax, hemothorax,

& pleural effusion Mediastinal- cardiac surgery, chest

trauma Complication from procedures:

CVC insertion Lung biopsy

Types of Chest Drainage Types of Chest Drainage SystemsSystems

Water-seal Remove air or fluid from pleural space or

mediastinum Mechanism for collection of drainage One-way mechanism to keep air from getting

back into the pleural space Water-seal acts = one-way valve

Allows air to leave pleural space- but not to return-maintaining negative pressure

Waterless Valve to regulate suction Valve can be opened for air & liquid drainage to

move out Remain closed to prevent air from entering

pleural space

Autotransfusion Variation of water-seal system Attached container so that blood drained from

chest can be salvaged for autotransfusion

Types of Chest Drainage Types of Chest Drainage SystemsSystems

AssessmentAssessment

Respiratory status S&S of extended pneumothorax or hemothorax Function of drainage system every 1 hr:

System below level of patient’s chest Tube free of kinks, or external obstruction All connections secured Color and amount of drainage Fluctuation of fluid level in water-seal chamber Constant bubbling in water-seal chamber

Anxiety level & understanding

Pt with Chest Drainage SystemsPt with Chest Drainage Systems

Nursing Diagnosis Ineffective breathing pattern related to decreased

lung expansion as evidence by:

Planning: Patient Outcomes Breath sounds are normal Respiration unlabored & occur at rate of 16 to 20

breaths per minute ABG values approaching normal Lung re-expansion seen on chest x-ray film

Chest Drainage SystemsChest Drainage Systems

Nursing Interventions: Maintain airtight, patent, functioning chest

drainage system Re-tape all connections as needed Re-tape or reinforce chest-tube dressing Tubing free of kinks, loops & external pressure Place roll towel under chest- protect tubing from

body weight Encourage cough and deep breathe & position

change frequently Keep occlusive petrolatum jelly dressing at

bedside

Chest Drainage Chest Drainage SystemsSystems

Mark amount of drainage in collection container at 1 to 4 hour intervals

Check water levels in suction control & water-seal pressure chambers

Notify MD of constant bubbling in water-seal or drainage becoming bright red or increases suddenly

Reassure the patient that staff is nearby- call light in reach

Documentation for chest drainage systems Assist with chest tube insertion or removal

Evaluation: RR & ABGs within normal limits Decreased difficulty breathing Chest pain diminished Equal lung sounds Bilateral chest movement Decreased chest tube drainage Client able to verbalize rationale for treatment

and procedures Client rests without behavioral signs of

excessive anxiety

Older Adult AlertOlder Adult Alert

1. Be concern about any changes in orientation. This may be a first indication of pneumonia in older adults.

2. Be cautious in fluid administration. Overhydration may initiate CHF.

3. Older clients may become confused with multiple drug therapies and may not follow the regimen correctly. Theses clients may need assistance to ensure proper administration. In older clients, the thoracic muscles are weaker which may make the older adult unable to tolerate the increased work of breathing required of COPD.

4. Older adult clients have fewer alveoli than younger adults- oxygen exchange will be even more impaired in older adult clients with COPD.

5. The weaker thoracic muscles in older adults will also make coughing more difficult, and thus, retained secretions will be a problem in many cases.

6. Older adults high risk for infection due to decreased immune response. Chest injuries evaluated carefully for signs of infection. Temperature of 99 degrees F may indicate an initial infection.

7. Cough will be impaired due to decreased muscle strength- older adults greater risk for atelectasis and pneumonia after a chest injury.

Older Adult AlertOlder Adult Alert

Respiratory System (2)

Health & Medicine