Medical and Surgical Nursing ReviewRespiratory SystemBY: Jocelyn A. Guzman, Ed.D

Outline of review ConceptsReview of the relevant respiratory anatomyReview of the relevant respiratory physiologyThe respiratory assessmentCommon laboratory examinations

Outline of review ConceptsReview of the common respiratory problems and the nursing managementReview of common respiratory diseasesUpper respiratory conditionsLower respiratory conditions

Respiratory Anatomy & PhysiologyThe respiratory system consists of two main parts- the upper and the lower tracts

Respiratory Anatomy & PhysiologyThe UPPER respiratory system consists of:1. nose2. mouth3. pharynx4. larynx5. trachea

Respiratory Anatomy & PhysiologyThe LOWER respiratory system consists of:1. Bronchi2. Bronchioles3. Respiratory unit alveolar ducts, alveolar sacs, alveoli

Upper respiratory tract

The NoseThis is the first part of the upper respiratory system that contains nasal bones and cartilagesThere are numerous hairs called vibrissaeThere are numerous superficial blood vessels in the nasal mucosa

The NoseThe functions of the nose are:1. To filter the air2. To humidify the air3. To aid in phonation4. Olfaction

The pharynxThe pharynx is a musculo-membranous tube that is composed of three parts1. Nasopharynx2. Oropharynx3. Laryngopharynx

The pharynxThe pharynx functions :1. As passageway for both air and foods (in the oropharynx)2. To protect the lower airway

The larynxAlso called the voice boxMade of cartilage and membranes and connects the pharynx to the trachea

The larynxFunctions of the larynx:1. Vocalization2. Keeps the patency of the upper airway3. Protects the lower airway

The paranasal sinusesThese are four paired bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar epitheliumNamed after their location- frontal, ethmoidal, sphenoidal and maxillary

The paranasal sinusesThe function of the sinuses:Resonating chambers in speech

The Lower Respiratory System1. Trachea2. Main bronchus3. Bronchial tree4. Lungs- 3R/ 2LThe trachea to the terminal bronchioles is called the conducting airwayThe respiratory bronchioles to the alveoli is called the respiratory acinus

TracheaA cartilaginous tube measures 10-12 centimetersComposed of about 20 C-shaped cartilages, incomplete posteriorly

The tracheaThe function of the trachea is to conduct air towards the lungsThe mucosa is lined up with mucus and cilia to trap particles and carry them towards the upper airway

The BronchusThe right and left primary bronchi begin at the carinaThe function is for air passage

The primary bronchusRIGHT BRONCHUSWiderShorterMore VerticalLEFT BRONCHUSNarrowerLongerMore horizontal

The bronchiolesThe primary bronchus further divides into secondary, then tertiary then into bronchiolesThe terminal bronchiole is the last part of the conducting airway

The respiratory AcinusThe respiratory acinus is the chief respiratory unitIt consists of: 1. Respiratory bronchiole2. Alveolar duct3. alveolar sac4. alveoli

The respiratory AcinusThe function of the respiratory acinus is gas exchange through the respiratory membraneThe respiratory membrane is composed of two epithelial cells1.The type 1 pneumocyte- most abundant, thin and flat. This is where gas exchange occurs2. The type 2 pneumocyte- secretes the lung surfactant

The respiratory AcinusA type III pneomocyte is just the macrophage that ingests foreign material and acts as an important defense mechanism

Accessory StructuresThe PLEURAEpithelial serous membrane lining the lung parenchymaComposed of two parts- the visceral and parietal pleuraeThe space in between is the pleural space containing a minute amount of fluid for lubrication

Accessory StructuresThe Thoracic cavityThe chest wall composed of the sternum and the rib cageThe cavity is separated by the diaphragm, the most important respiratory muscle

Accessory StructuresThe MediastinumThe space between the lungs, which includes the heart and pericardium, the aorta and the vena cavae.

GENERAL FUNCTIONS OF THE Respiratory SystemGas exchange through ventilation, external respiration and cellular respirationOxygen and carbon dioxide transport

The AssessmentHISTORYReason for seeking carePresent illnessPrevious illnessFamily historySocial history

The AssessmentPHYSICAL EXAMINATIONSkin- cyanosis, pallorNail clubbingCough and sputum productionInspect-palpate-percuss- auscultate the thorax

Assessment: LABORATORY EXAMINATION1. ABG analysis2. Sputum analysis3. PPD Test4. Pulmonary Function Test5. Direct visualization- bronchoscopy6. Indirect visualization- CXR, CT and MRI7. Pulmonary function test

ABG analysisThis test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an arterial sample

ABG analysisPre-test: choose site carefully, perform the Allens test, secure equipments- 10 mL heparinized syringe, needle, container with iceIntra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial)Post-test: Apply firm pressure for 5 minutes, label specimen correctly, place in the container with ice

What is the significance of Allens test????To assess the adequacy of collateral circulation

ABG analysisABG normal valuesPaO280-100 mmHgPaCO235-45 mmHgpH 7.35- 7.45HCO322- 26 mEq/LO2 Sat95-100%

Sputum AnalysisThis test analyzes the sample of sputum to diagnose respiratory diseases, identify organism, and identify abnormal cells

Sputum AnalysisPre-test: Encourage to increase fluid intakeIntra-test: rinse mouth with WATER only, instruct the patient to take 3 deep breaths and force a deep cough, steam nebulization, collect early morning sputumPost-test: provide oral hygiene, label specimen correctly

PPD (Purified Protein Derivative)IntradermalRead after 48-72 hrs10 mm induration or more = positive5 mm induration or more = + for HIV patientsSignifies exposure to mycobacterium tubercle bacilli

POSITIVE PPD TEST

PULMONARY FUNCTION TESTSTo determine lung volumes and capacitiesVolume and capacity tests aid diagnosis in patient with suspected pulmonary dysfunctionEvaluates ventilatory functionDetermines whether obstructive or restrictive diseaseCan be utilized as screening test

PULMONARY FUNCTION TESTSLung Volumes

1. Tidal volume TV2. Inspiratory Reserve Volume- IRV3. Expiratory Reserve Volume- ERV4. Residual volume- RV

Lung Capacities

1. Inspiratory Capacity- IC2. Functional Residual Capacity- FRC3. Vital capacity- VC4. Total Lung capacity- TLC

PULMONARY FUNCTION TESTSPre-test: Teaching, no smoking for 3 days, only light meal 4 hours before the test

Intra-test: position sitting, bronchodilator, nose-clip and mouthpiece, fatigue and dyspnea during the test

Post-test: adequate rest periods, loosen tight clothing

LUNG VOLUMES1. Tidal volume volume of air inspired or expired with each normal breath, about 500ml2. Inspiratory Reserve Volume (IRV)- extra volume of air than can be inspired over & beyond the normal tidal volume, about 3000ml

LUNG VOLUMES3. Expiratory Reserve Volume (ERV)-amount of air that can still be expired by forceful expiration after the end of a normal tidal expiration-about 1100ml4. Residual Volume (RV)-volume of air still remaining in the lungs after the most forceful expiration, averages about 1200ml

Pulmonary Capacities

1. Inspiratory Capacity-equals TV + IRV, about 3500ml-amount of air that a person can breathe beginning at the normal expiratory level & distending his lungs to maximum amount2. Functional Residual Capacity-equals ERV + RV-about amount of air remaining in the lungs at the end of normal expiration, about 2300ml

Pulmonary Capacities3. Vital Capacity-equals IRV + TV + ERV or 1C + ERV, about 4600ml-maximum amount of air that a person can expel from the lungs after filling the lungs to their maximum extent & expiring to the maximum extent4. Total Lung Capacity-maximum volume to which the lungs can be expanded with the greatest possible effort-volume of air in the lungs at this level is equal to FRC (2300ml) in young adult

Pulse OximetryNon-invasive method of continuously monitoring the oxygen saturation of hemoglobinA sensor or probe is attached to the earlobe, forehead, fingertip or the bridge of the nose

BronchoscopyA direct inspection of the trachea and bronchi through a flexible fiber-optic or a rigid bronchoscopeDone to determine location of pathologic lesions, to remove foreign objects, to collect tissue specimen and remove secretions/aspirated materials

Bronchoscopy: NSG Resp.Pre-test: ConsentNPO x 6hTeachingRemove dentures, prostheses, contact lenses

Intra-test:position supine or sitting upright in a chairadminister sedative, gag reflex will be abolished

Post-test:NPO until gag reflex returnsposition SEMI-fowlers with head turned to sideshoarseness is temporaryCXR after the procedure as orderedkeep tracheostomy set and suction x 24 hoursWatch out for DOB, hypotension, tachycardia, cyanosis

ThoracentesisPleural fluid aspiration for obtaining a specimen of pleural fluid for analysis, relief of lung compression and biopsy specimen collection

Thoracentesis: NSG Resp.Pre-test: ConsentInitial VSIntra-test:position the patient sitting with arms on a table or side-lying fowlersinstruct not to cough breathe deeply or move during insertion of the needlePost-test: position unaffected side to allow lung expansion of the affected sideCXR obtainedmaintain pressure dressingmonitor respiratory status

CHEST X-RAYProvides information regarding the anatomic location and appearance of the lungsPREPROCEDURE1.Remove all jewelry and other metal objects from the chest area2.Assess the clients ability to inhale and hold breathQuestion females regarding pregnancy or the possibility of pregnancy

Indirect VisualizationCT scan Painless, non-invasive, x-ray procedureMechanism: distinguish density of tissues

MRI SCANPainless, non-invasive, no radiationCreates a magnetic fieldContraindications:(+) pacemaker(+) metal prosthesisClient teaching:Lie still during the procedure for 60-90 minutesEarplugs to reduce noise discomfortCheck if the pt. has ClaustrophobiaNo radiation

Common Respiratory problemsand the common interventions

DyspneaBreathing difficultyAssociated with many conditions- CHF, MG, GBS, Muscular dystrophy, obstruction, etc

DyspneaGeneral nursing interventions:1. Fowlers position to promote maximum lung expansion and promote comfort. An alternative position is the ORTHOPNEIC position2. O2 usually via nasal cannula 3. Provide comfort and distractions

Cough and sputum productionCough is a protective reflexSputum production has many stimuliThick, yellow, green or rust-colored bacterial pneumoniaProfuse, Pink, frothy pulmonary edemaScant, pink-tinged, mucoid Lung tumor

Cough and sputum productionGeneral nursing Intervention1. Provide adequate hydration2. Administer aerosolized solutions3. advise smoking cessation4. oral hygiene

CyanosisBluish discoloration of the skinA LATE indicator of hypoxiaAppears when the unoxygenated hemoglobin is more than 5 grams/dLCentral cyanosis observe color on the undersurface of tongue and lipsPeripheral cyanosis observe the nail beds, earlobes

CyanosisInterventions:Check for airway patencyPositioningOxygen therapySuctioningChest physiotherapyCheck for gas poisoningMeasures to increased hemoglobin

HemoptysisExpectoration of blood from the respiratory tractCommon causes: Pulmo infection, Lung CA, Bronchiectasis, Pulmo emboliBleeding from stomach acidic pH, coffee ground material

HemoptysisInterventions:Keep patent airwayDetermine the causeSuction and oxygen therapyAdminister Fibrin stabilizers like aminocaproic acid and tranexamic acid

EpistaxisBleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane Most common site- anterior septumCauses1. trauma2. infection3. Hypertension4. blood dyscrasias , nasal tumor, cardio diseases

EpistaxisNursing Interventions1. Position patient: Upright, leaning forward, tilted prevents swallowing and aspiration2. Apply direct pressure. Pinch nose against the middle septum x 5-10 minutes3. If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foams4. Assist in electrocautery and nasal packing for posterior bleeding

CONDITIONS OF THE UPPER AIRWAYUpper airway infections1. Rhinitis- allergic, non-allergic and infectious2. Sinusitis- acute and chronic3. Pharyngitis- acute and chronic

CONDITIONS OF THE UPPER AIRWAY1.RHINITIS Assessment findingsRhinorrheaNasal congestionNasal itchinessSneezingHeadache

CONDITIONS OF THE UPPER AIRWAYUpper airway infections2. sinusitis- Pathophysio:URTI, Cigarette smoking, Allergic Rhinitis inflammation edema of te mucous membranes hypersecration of mucus infection

Assessment:PainMaxillary: Cheek & upper teethFrontal: above eyebrowsEthmoid: in & around eyesSphenoid: behind eye, occiput, top of headGeneral malaiseStuffy noseHeadache Post nasal dripPersistent coughfever

NSG resp:RestIncrease OFIHot wet packsCodeine, avoid ASA D/T increase devt of nasal polypsAnti-inffectivesNasal decongestant for 72 hrsIrrigation of maxillary sinus w/ warm NSS

CONDITIONS OF THE UPPER AIRWAY3. PHARYNGITIS- Assessment findings

Fiery-red pharyngeal membraneWhite-purple flecked exudatesEnlarged and tender cervical lymph nodesFever malaise ,sore throatDifficulty swallowingCough may be absent

CONDITIONS OF THE UPPER AIRWAYUpper airway infections- Laboratory tests1. CBC2. Culture

CONDITIONS OF THE UPPER AIRWAYUpper airway infections: Nursing Interventions1. Maintain Patent AirwayIncrease fluid intake to loosen secretionsUtilize room vaporizers or steam inhalationAdminister medications to relieve nasal congestion

CONDITIONS OF THE UPPER AIRWAYUpper airway infections: Nursing Interventions2. Promote comfortAdminister prescribed analgesicsAdminister topical analgesicsWarm gargles for the relief of sore throatProvide oral hygiene

CONDITIONS OF THE UPPER AIRWAYUpper airway infections: Nursing Interventions3. Promote communicationInstruct patient to refrain from speaking as much as possibleProvide writing materials

CONDITIONS OF THE UPPER AIRWAYUpper airway infections: Nursing Interventions4. Administer prescribed antibioticsMonitor for possible complications like meningitis, otitis media, abscess formation5. Assist in surgical intervention

TonsillitisInfection and inflammation of the tonsilsMost common organism- Group A- beta hemolytic streptococcus (GABS)

CONDITIONS OF THE UPPER AIRWAYUpper airway infection: TonsillitisASSESSMENT FINDINGSSore throat and mouth breathingFeverDifficulty swallowingEnlarged, reddish tonsilsFoul-smelling breath

CONDITIONS OF THE UPPER AIRWAYUpper airway infection: TonsillitisLaboratory test1. CBC2. throat culture

NSG interventionRestIncrease OFIWarm saline gargleAnalgesic as orderedAntimicrobialsSurgery is indicated if + recurrence of 5-6 times in a year

NURSING INTERVENTION for tonsillectomy1. Pre-operative careConsentAssess for URTI. Coughing & sneezing post op may cause bleeding and septicemiaCheck PTT

2. POST-operative carePosition: Most comfortable is PRONE, with head turned to side or lateral(awake: semi-fowlers)Maintain oral airway, until gag reflex returns Monitor for hemorrhageFrequent swallowingBright red vomitusIncrease PRPromote comfortIce collarAcetaminophenNo ASAFoods/fluidsIce cold Bland diet

Teachings:Avoid clearing of throat, coughing, sneezing, blowing of nose for 1-2 weeks2-3 L of fluid until mouth odor disappearsReport S/Sx of bleedingThroat discomfort b/n 4-8 days is expectedAvoid crowded places

CONDITIONS OF THE UPPER AIRWAYUpper airway infection: TonsillitisNURSING INTERVENTION for tonsillectomy2. POST-operative careApply ICE collar to the neck to reduce edemaAdvise patient to refrain from talking and coughingIce chips are given when there is no bleeding and gag reflex returns

Laryngeal CancerA malignant tumor of the larynxMore frequent in men50-70 years oldRISK FACTORS1. Smoking2. Alcohol3. Exposure to chemicals4. Straining of voice5. chronic laryngitis6. Deficiency of Riboflavin7. family history

Laryngeal CancerGrowth can be anywhere in the larynx1. Supraglottic- above the vocal cords2. glottic- vocal cord area3. infraglottic- below the vocal cords

Most tumors are found in the glottic area

Laryngeal CancerASSESSMENT FINDINGSHoarseness of more than TWO weeks durationCough and sore throat Burning and pain in the throat especially after consuming HOT liquids and citrus foodsNeck lumpDysphagia, dyspnea, foul breath, CLAD

Laryngeal CancerLABORATORY FINDINGS1. Indirect laryngoscopy2. direct laryngoscopy3. Biopsy4. CT and MRI

Most commonly- squamous carcinoma

Laryngeal CancerMEDICAL MANAGEMENTRadiation therapyChemotherapySurgeryPartial laryngectomySupraglottic laryngectomyHemilaryngectomyTotal laryngectomy absolute loss of voicePermanent tracheostomyLoss of sense of smellInability to blow, sip soup or star, whistle, gargle, do valsalva manuever (lift heavy objects, constipation)NR: establish means of communication

Laryngeal CancerNURSING MANAGEMENT: PRE-operative1. Provide the patient pre-operative teachingsClarify misconceptionsTell that the natural voice will be lostTeach communication alternativesCollaborate with other team members

Laryngeal CancerNURSING MANAGEMENT2. reduce patient ANXIETYProvide opportunities for patient and family members to ask questionsReferrals to previous patients with laryngeal cancers and cancer groups

Laryngeal CancerNURSING MANAGEMENT: POST-op3. Maintain PATENT AirwayPosition patient: Semi or High FowlersSuction secretionsEncourage to deep breath, turn and coughPrevent infectionTracheostomy carePsychological support

Laryngeal CancerNURSING MANAGEMENT: POST-op4. Administer care of the laryngectomy tubeSuction as neededCleanse the stoma with salineAdminister humidified oxygenLaryngectomy tube is usually removed within 3-6 weeks after surgery

Laryngeal CancerNURSING MANAGEMENT: POST-op5. Promote alternative communication methodsCall bell or hand bellMagic SlateHand signalsCollaborate with speech therapist

Laryngeal CancerNURSING MANAGEMENT: POST-op6. Promote adequate NutritionNPO after operationNo foods or drinks per orem for 10 daysIVF, TPN are alternative nutrition routesStart oral feedings with thick liquids, avoid sweet foods

Laryngeal CancerNURSING MANAGEMENT: POST-op7. Promote positive body image and self-esteemEncourage verbalization of feelingsAllow independence in self-care

Laryngeal CancerNURSING MANAGEMENT: POST-op8. Monitor for COMPLICATIONSRespiratory DistressSuctionCoughing and deep breathingHumidified oxygenAlert the surgeon

Laryngeal CancerNURSING MANAGEMENT: POST-op8. Monitor for ComplicationsHemorrhageMonitor for bleeding Monitor vital signsApply direct pressure over the bleeding arterySummon assistance and alert the surgeon

Laryngeal CancerNURSING MANAGEMENT: POST-op8. Monitor for COMPLICATIONSWound infection and breakdownMonitor for increased temperature, purulent drainage and increased redness/tendernessAdminister antibioticsClean and change dressing OD

Laryngeal CancerNURSING MANAGEMENT: HOME CAREHumidification system at home is neededAVOID swimmingCover the stoma with hands or plastic bib over the openingAdvise beauty salons to avoid hair sprays, powders and loose hair near the openingOral hygiene frequently

Acute Respiratory Failure

Sudden and life-threatening deterioration of the gas-exchange function of the lungsOccurs when the lungs no longer meet the bodys metabolic needs

Acute Respiratory Failure Defined clinically as:1. PaO2 of less than 50 mmHg2. PaCO2 of greater than 5o mmHg3. Arterial pH of less than 7.35

Acute Respiratory Failure CAUSESCNS depression- head trauma, sedativesCVS diseases- MI, CHF, pulmonary emboliAirway irritants- smoke, fumesEndocrine and metabolic disorders- myxedema, metabolic alkalosisThoracic abnormalities- chest trauma, pneumothorax

Acute Respiratory Failure PATHOPHYSIOLOGYDecreased Respiratory DriveBrain injury, sedatives, metabolic disorders impair the normal response of the brain to normal respiratory stimulation

Acute Respiratory Failure PATHOPHYSIOLOGYDysfunction of the chest wallDystrophy, MS disorders, peripheral nerve disorders disrupt the impulse transmission from the nerve to the diaphragm abnormal ventilation

Acute Respiratory Failure PATHOPHYSIOLOGYDysfunction of the Lung ParenchymaPleural effusion, hemothorax, pneumothorax, obstruction interfere ventilation prevent lung expansion

Acute Respiratory Failure ASSESSMENT FINDINGSRestlessnessdyspneaCyanosisAltered respirationAltered mentationTachycardiaCardiac arrhythmiasRespiratory arrest

Acute Respiratory Failure DIAGNOSTIC FINDINGSPulmonary function testABG - pH below 7.35CXR- pulmonary infiltratesECG- arrhythmias

Acute Respiratory Failure MEDICAL TREATMENTIntubationMechanical ventilationAntibioticsSteroidsBronchodilators

Acute Respiratory Failure NURSING INTERVENTIONS1. Maintain patent airway 2. Administer O2 to maintain Pa02 at more than 50 mmHg3. Suction airways as required4. Monitor serum electrolyte levels5. Administer care of patient on mechanical ventilation

COPDThese are group of disorders associated with recurrent or persistent obstruction of air passage and airflow, usually irreversible.

COPDThe most common cause of COPD is cigarette smoking. Asthma, Chronic bronchitis, Emphysema and Bronchiectasis are the common disorders.

COPD The general pathophysiology: In COPD there is airflow limitation that is both progressive and associated with abnormal inflammatory response of the lungs to stimuli, usually smoke, particles and dust

ASTHMAThe acute episode of airway obstruction is characterized by airway hyperactivity to various stimuli that results in recurrent wheezing brought about by edema and bronchospasm

Asthma PathophysiologyImmunologic/allergic reaction results in histamine release, which produces three main airway responsesa. Edema of mucous membranesb. Spasm of the smooth muscle of bronchi and bronchiolesc. Accumulation of tenacious secretions

Asthma Assessment Findings Assessment findings1. Family history of allergies2. Client history of eczema

Asthma Assessment Findings3.Respiratory distressslow onset of shortness of breathexpiratory wheezeprolonged expiratory phaseair trapping (barrel chest if chronic)use of accessory musclesirritability (from hypoxia)DiaphoresisCoughAnxietyweak pulseDiaphoresischange in sensorium if severe attack

inspiratory retractionsprolonged I:E ratio5. Cardiovascular symptoms: tachycardia, ECG changes, hypertension, decreased cardiac contractility, pulsus paradoxus6. CNS manifestations: anxiety, restlessness, fear and disorientation

EmphysemaThere is progressive and irreversible alveolocapillary destruction with abnormal alveolar enlargement causing alveolar wall destruction. The result is INCREASED lung compliance, DECREASED oxygen diffusion and INCREASED airway resistance!

EmphysemaThese changes cause a state of carbon dioxide retention, hypoxia, and respiratory acidosis.

Emphysema Cigarette smokingHeredity, Bronchial asthmaAging process Disequilibrium betweenELASTASE & ANTIELASTASE (alpha-1-antitrypsin) Destruction of distal airways and alveoliOverdistention of ALVEOLIHyper-inflated and pale lungs Air traping, decreased gas exchange and Retention of CO2 HypoxiaRespiratory acidosis

Emphysema Assessment1. Anorexia, fatigue, weight loss2. Feeling of breathlessness, cough, sputum production, flaring of the nostrils, use of accessory muscles of respiration, increased rate and depth of breathing, dyspnea

Emphysema Assessment3. Decreased respiratory excursion, resonance to hyper-resonance, decreased breath sounds with prolonged expiration, normal or decreased fremitus4. Diagnostic tests: pCO2 elevated or normal; PO2 normal or slightly decreased

Chronic bronchitisChronic inflammation of the bronchial air passageway characterized by the presence of cough and sputum production for at least 3 months in each 2 consecutive years.Excessive production of mucus in the bronchi with accompanying persistent cough.

Chronic Bronchitis pathophysiologyCharacteristic changes include hypertrophy/ hyperplasia of the mucus-secreting glands in the bronchi, decreased ciliary activity, chronic inflammation, and narrowing of the small airways.

Chronic Bronchitis AssessmentI. Productive (copious) cough, dyspnea on exertion, use of accessory muscles of respiration, scattered rales and rhonchi2.Feeling of epigastric fullness, cyanosis, distended neck veins, ankle edema3.Diagnostic tests: increased pCO2 decreased PO2

BronchiectasisPermanent abnormal dilation of the bronchi with destruction of muscular and elastic structure of the bronchial wall

BRONCHIAL TUBE

Bronchiectasis Caused by bacterial infection; recurrent lower respiratory tract infections; congenital defects (altered bronchial structures); lung tumors

Bronchiectasis1. Chronic cough with production of mucopurulent sputum, hemoptysis, exertional dyspnea, wheezing2. Anorexia, fatigue, weight loss3. Diagnostic testsa. Bronchoscopy reveals sources and sites of secretionsb. Possible elevation of WBC

COPD ManagementIndependent and Collaborative Management1. Rest-To reduce oxygen demands of tissues2. Increase fluid intake-To liquefy mucus secretions3. Good oral care-To remove sputum and prevent infection

COPD ManagementIndependent and Collaborative Management 4. Diet: High caloric diet provides source of energyHigh protein diet helps maintain integrity of alveolar wallsModerate fatsLow carbohydrate diet limits carbon dioxide production (natural end product). The client has difficulty exhaling carbon dioxide.

COPD ManagementIndependent and Collaborative Management5. O2 therapy 1 to 3 lpm (2 lpm is safest)Do not give high concentration of oxygen. The drive for breathing may be depressed.

COPD ManagementIndependent and Collaborative Management6. Avoid cigarette smoking, alcohol, and environmental pollutants-These inhibit mucociliary function.7. CPT percussion, vibration, postural drainage

COPD ManagementIndependent and Collaborative Management8. Bronchial hygiene measuresSteam inhalationAerosol inhalationMedimist inhalation

COPD ManagementPharmacotherapy1. Expectorants (guaifenesin)/ mucolytic (mucomyst/mucosolvan)2. AntitussivesDextrometorphanCodeineObserve for drowsinessAvoid activities that involve mental alertness, e.g driving, operating electrical machinesCause decrease peristalsis thereby constipation

COPD ManagementPharmacotherapy3. BronchodilatorsAminophylline (Theophylline)Ventolin (Salbutamol)Bricanyl (Terbutaline)Alupent (Metaproterenol)Observe for tachycardia

COPD ManagementPharmacotherapy4. AntihistamineBenadryl (Diphenhydramine)Observe for drowsiness5. SteroidsAnti-inflammatory effect6. Antimicrobials

Flail Chest

Complication of chest trauma occurring when 3 or more adjacent ribs are fractured at two or more sites, resulting in free-floating rib segments.

Flail Chest

Chest wall is no longer able to provide the bony structure necessary to maintain adequate ventilation; consequentlythe flail portion and underlying tissue move paradoxically (in opposition) to the rest of the chest cage and lungs.

Flail ChestThe flail portion is sucked in on inspiration and bulges out on expiration.Result is hypoxia, hypercapnea, and increased retained secretions.Caused by trauma (sternal rib fracture with possible costochondral separations).

Flail Chest: PATHOPHYSIOLOGYDuring inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner The chest is pulled INWARD during inspiration, reducing the amount of air that can be drawn into the lungsThe chest bulges OUTWARD during expiration because the intrathoracic pressure exceeds atmospheric pressure. The patient has impaired exhalation

Flail ChestThis paradoxical action will lead to:Increased dead spaceReduced alveolar ventilationDecreased lung complianceHypoxemia and respiratory acidosisHypotension, inadequate tissue perfusion can also follow

Flail Chest: Assessment1. Severe dyspnea; rapid, shallow, grunty breathing; paradoxical chest motion. The chest will move INWARDS on inhalation and OUTWARDS on exhalation.2. Cyanosis, possible neck vein distension, tachycardia, hypotension3. Diagnostic testsa. PO2 decreasedb. pCO2 elevatedc. pH decreased

Nursing interventions1. Maintain an open airway: suction secretions, blood from nose, throat, mouth, and via endotracheal tube; note changes in amount, color, and characteristics.2. Monitor mechanical ventilation 3. Encourage turning, coughing, and deep breathing.4. Monitor for signs of shock: HYPOTENSION, TACHYCARDIA

Flail ChestMedical management: SUPPORTIVE1. Internal stabilization with a volume-cycled ventilator2. Drug therapy (narcotics, sedatives)

PneumothoraxPartial or complete collapse of the lung due to an accumulation of air or fluid in the pleural space

Pneumothorax

Typesa. Spontaneous pneumothorax: the most common type of closed pneumothorax; air accumulates within the pleural space without an obvious cause. Rupture of a small bleb on the visceral pleura most frequently produces this type of pneumothorax.

Pneumothorax

Typesb. Open pneumothorax: air enters the pleural space through an opening in the chest wall; usually caused by stabbing or gunshot wound.

PneumothoraxTypesc. Tension pneumothorax: air enters the pleural space with each inspiration but cannot escape; causes increased intrathoracic pressure and shifting of the mediastinal contents to the unaffected side (mediastinal shift).

Pneumothorax

Assessment findings1. Sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side, tracheal shift to the opposite side (tension pneumothorax accompanied by mediastinal shift)2. Weak, rapid pulse; anxiety; diaphoresis

Pneumothorax

Assessment findings3. Diagnostic testsa. Chest x-ray reveals area and degree of pneumothoraxb. pCO2 elevatedc. pH decreased

PneumothoraxNursing interventionsHigh-fowlersPain mngt.O2 therapyCXrayABGThoracentesisMonitor for shock

Thoracentesis: NRAspiration of fluid / air from the pleural spaceNR Before:ConsentInitial VSUpright leaning on overbed tableRemain still, no coughing or deep breathing during insertionNR AFTER:Position to unaffected side to prevent leakage in the thoracic cavityBed rest until VS are stableNotify Dr. for expectoration of blood

T H O R A C E N T E S I S

Chest Thoracostomy Tube (CTT)Removes air / fluids from the pleural spaceReestablishes negative pressure & reexpands the lungsTYPES:1-bottle systemDrainage bottle and water sealKeep 2-3 ft below the level of the chestAir vent should be open to airintermittent fluctuation

2-bottle systemNot connected to suction1st bottle drainage2nd bottle water-seal; intermittent fluctuationConnected to suction1st drainage & water seal, immerse tip 2-3 cm of NSS; intermittent fluctuation2nd suction; 10-20 cm of of sterile NSS; continuous bubbling

3- bottle system1st drainage bottle2nd water seal; immerse tip 2-3 cm of NSS; intermittent fluctuation3rd suction bottle; tip @ 10-20 cm of of sterile NSS; continuous bubbling

Nsg resp.Encourage DBE, coughing exercisesTurn to sidesAmbulateROM of armsMark the amount of drainage at regular intervalsAvoid milking or clamping to prevent tension pneumonthorax if not orderedIf + continuous bubbling @ water seal indicates air leak check the connection tube, clamp+ absence of fluctuation Check for obstruction kinks, milk towards thetube as orderedNo obstruction CXray - reexpansion

Removal of CTT: NRPreparePetroleum gauzeSuture removal kitSterile gauzeAdhesive tapeSemi-fowlersInstruct to do valsalva maneuver as CTT is being removedCxrayAssess for subcutaneous emphysema, respi. distress

Pleural EffusionDefined broadly as a collection of fluid in the pleural spaceA symptom, not a disease; may be produced by numerous conditions

Pleural EffusionGeneral ClassificationTransudative effusion: accumulation of protein-poor, cell-poor fluid

Exudative effusion: accumulation of protein rich fluid

Pleural EffusionAssessment findings1. Dyspnea, dullness over affected area upon percussion, absent or decreased breath sounds over affected area, pleural pain, dry cough, pleural friction rub2. Pallor, fatigue, fever, and night sweats (with empyema)

Pleural EffusionAssessment findings3. Diagnostic testsa. Chest x-ray positive if greater than 250 cc pleural fluidb. Pleural biopsy may reveal bronchogenic carcinomac. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or tuberculosis; positive for specific organism in empyema.

Pleural EffusionNursing interventions: In general:1. Assist with repeated thoracentesis.2. Administer narcotics/sedatives as ordered to decrease pain.3. Assist with instillation of medication into pleural space (reposition client every 15 minutes to distribute the drug within the pleurae).4. Place client in high-Fowlers position to promote ventilation.

AtelectasisCollapse of part or all of a lung due to bronchial obstructionMay be caused by intrabronchial obstructiontumors, bronchospasm foreign bodies extrabronchial compression (tumors, enlarged lymph nodes); orendobronchial disease (bronchogenic carcinoma, inflammatory structures)

AtelectasisAssessment findings1. Signs and symptoms may be absent depending upon degree of collapse and rapidity with which bronchial obstruction occurs2. Dyspnea, decreased breath sounds on affected side, decreased respiratory excursion, dullness to flatness upon percussion over affected area

AtelectasisAssessment findings3. Cyanosis, tachycardia, tachypnea, elevated temperature, weakness, pain over affected area

AtelectasisAssessment findings4. Diagnostic testsa. Bronchoscopy: may or may not reveal an obstructionb. Chest x-ray shows diminished size of affected lung and lack of radiance over atelectatic areac. pO2 decreased

Pleural EffusionMedical management1. Identification and treatment of the Underlying cause2. Thoracentesis3. Drug therapya. Antibiotics: either systemic or inserted directly into pleural spaceb. Fibrinolytic enzymes: trypsin, streptokinase- to decrease thickness of pus and dissolve fibrin clots4. Closed chest drainage5. Surgery: open drainage

PneumoniaAn inflammation of the alveolar spaces of the lung, resulting in consolidation of lung tissue as the alveoli fill with exudatesThe various types of pneumonias are classified according to the offending organism.Pneumonia can also be classified as COMMUNITY Acquired Pneumonia (CAP) and HOSPITAL acquired pneumonia (HAP)

PneumoniaPATHOPHYSIOLOGIC FINDINGS ARE: HYPERTROPHY OF MUCOUS MEMBRANEIncreased sputum productionWheezingDyspneaCoughRales/CracklesRonchi

PneumoniaPATHOPHYSIOLOGIC FINDINGS ARE: INCREASED CAPILLARY PERMEABILITYIncreased Fluid ExudationConsolidation-tissue that solidifies as a result of collapsed alveoliHypoxemia

PneumoniaPATHOPHYSIOLOGIC FINDINGS ARE: INFLAMMATION OF THE PLEURAChest painPleural effusionDullnessDecreased Breath soundsIncreased tactile fremitus

PneumoniaPATHOPHYSIOLOGIC FINDINGS ARE: HYPOVENTILATIONDecreased Chest expansionRespiratory acidosisDepressed PROTECTIVE MECHANISMIncreased WBC (leukocytosis)Increased RR and Fever

PneumoniaAssessment findingsCough with greenish to rust-colored sputum productionrapid, shallow respirations with an expiratory gruntnasal flaring; intercostal rib retraction; use of accessory muscles of respirationFine rales or crackles (early) progressing to coarse rales or crackles (later).Tactile fremitus is INCREASED!

PneumoniaAssessment findingsFever, chills, chest pain, weakness, generalized malaiseTachycardia, cyanosis, profuse perspiration, abdominal distensionRapid shallow breathing

PneumoniaDiagnostic testsa. Chest x-ray shows consolidation over affected areasb. WBC increasedc. pO2 decreasedd. Sputum specimen- culture reveal particular causative organism

1. Facilitate adequate ventilation.a. Place client in Fowlers position.B.Administer oxygen as needed and assess its effectiveness.c. Turn and reposition frequently clients who are immobilized/obtunded.d. Administer analgesics as ordered to relieve pain associated with breathinge. Auscultate breath sounds every 24 hours.f. Monitor ABGs.

Nursing interventions2. Facilitate removal of secretionsgeneral hydrationdeep breathing and coughingSuctioningExpectorantsaerosol treatments via nebulizer, humidification of inhaled airchest physical therapy

3. Observe color, characteristics of sputum and report any changes; encourage client to perform good oral hygiene after expectoration. 4.Provide adequate rest and relief/control of pain.a. Provide bed rest with limited physical activity.b. Limit visits and minimize conversations.c. Plan for uninterrupted rest periods.d. Institute nursing care in blocks to ensure periods of rest.e. Maintain pleasant and restful environment

5. Administer antibiotics as ordered. Monitor effects and possible toxicity.6. Prevent transmission (respiratory isolation may be required for clients with staphylococcal pneumonia).7. Control fever and chills: monitor temperature and administer antipyretics as ordered, maintain increased fluid intake, provide frequent clothing and linen changes.

8. Provide client teaching and discharge planning concerning prevention of recurrence.a. Medication regimen/antibiotic therapyb. Need for adequate rest, c. Need to continue deep breathing and coughing d. Availability of vaccinese. Techniques that prevent transmission (use of tissues when coughing, adequate disposal of secretions)f. Avoidance of persons with known respiratory infectionsg. Need to report signs and symptoms of respiratory infection

Lung CancerPrimary pulmonary tumors arise from the bronchial epithelium and are therefore referred to as bronchogenic carcinomas.

FACTORS: Possibly caused by inhaled carcinogens (primarily cigarette smoke but also asbestos, nickel, iron oxides, air silicone pollution; preexisting pulmonary disorders PTB, COPD)

Assessment findings Persistent cough (may be productive or blood tinged)chest paindyspneaunilateral wheezing, friction rub, possible unilateral paralysis of the diaphragmFatigue, anorexia, nausea, vomiting, pallor

Diagnostic testsa. Chest x-ray may show presence of tumor or evidence of metastasis to surrounding structuresb. Sputum for cytology reveals malignant cellsc. Bronchoscopy: biopsy reveals malignancyd. Thoracentesis: pleural fluid contains malignant cellse. Biopsy of lymph nodes may reveal metastasis

NSG responsibility1. Provide support and guidance to client as needed.2. Provide relief/control of pain.3. Administer medications as ordered and monitor effects/side effects.4. Control nausea: administer medications as ordered, provide good oral hygiene, provide small and more frequent feedings.

5. Provide nursing care for a client with a thoracotomy.6. Provide client teaching and discharge planning concerninga. Disease process, diagnostic and therapeutic interventionsb. Side effects of radiation and chemotherapyc. Realistic information about prognosis

Medical management1. Radiation therapy2. Chemotherapy: usually includes cyclophosphamide, methotrexate, vincristine, doxorubicin, and procarbazine; concurrently in some combination3. Surgery: when entire tumor can be removed

Predisposing factorsCigarette smokingAsbestosisEmphysemaSmoke from burnt woodTypesSquamous cell Ca- with good prognosisAdenocarcinoma- with good prognosisOat cell Ca- with good prognosisUndifferentiated Ca- with poor prognosis

Nursing InterventionsPatent airwayO2 / Aerosol therapyDeep breathing exercisesRelief of painProtection from infectionAdequate nutrition Chest tube management

SurgeryPneumonectomy=Removal of a lung (either left or right)NR:Semi-fowlers, turned slightly on affected side for lung expansionAvoid full side lying to prevent mediastinal shiftNo CTT

Lobectomy=Removal of a lobe.Segmentectomy=Removal of a segment.Wedge resection=Removal of the entire tumor regardless of the segment.Decortication=Stripping off of fibrinous membrane enclosing the lungThoracoplasty=Removal of rib/s. Usually done after pneumonectomy, to reduce the size of the empty thorax thereby prevent mediastinal shift.

NR:+ CTT care w/ a CTTSemi-fowlersUnaffected side for expansion of affected lung

Pulmonary EmbolismThis refers to the obstruction of the pulmonary artery or one of its branches by a blood clot (thrombus) that originates somewhere in the venous system or in the right side of the heart.Most commonly, pulmonary embolism is due to a clot or thrombus from the deep veins of the lower legs.

Pulmonary EmbolismCausesFat embolism. Air embolismMultiple traumaPVDs Abdominal surgeryImmobilityHypercoagulability

PATHOPHYSIOLOGYThe thrombus that travels from any part of the venous system obstructs either completely or partially. Then the lungs will have inadequate blood supply, with resultant increase in dead space in the lungsGas exchange will be impaired or absent in the involved area

Pulmonary EmbolismPATHOPHYSIOLOGYThe regional pulmonary vasculature will constrict causing increased resistance, increased pulmonary arterial pressure and then increase workload of the right side of the heart.

Pulmonary EmbolismPATHOPHYSIOLOGYWhen the work of the right side of the heart exceeds its capacity, right ventricular failure will result, leading to a decrease in cardiac output followed by decreased systemic perfusion and eventually, SHOCK

AssessmentRestlessness (cardinal initial sign)DyspneaStabbing chest pain with petecchial rashCyanosisTachycardiaDilated pupilsApprehension/ fearDiaphoresisDysrhythmiasHypoxia

Pulmonary EmbolismDiagnostic Tests:Ventilation-perfusion scanPulmonary arteriographyCXRECGABG

Pulmonary EmbolismNursing InterventionsOxygen therapy STATEarly ambulation postopMonitor obese patientDo not massage legsRelieve pain- analgesicsHOB elevatedHeparin (2 weeks) then Coumadin (3-6 months)

Patient Teaching for preventionActive leg exercises to avoid venous stasisEarly ambulationUse of elastic compression stockingsAvoidance of leg-crossing and sitting for prolonged periodsDrink fluids Stop smokingavoid contact sports, constipationObserve for bleedingUse soft bristled toothbrushEvaluate use of contraceptives to physician

Surgical Aspect of Respiratory CareThoracic Surgerya. Exploratory thoracotomy: anterior or posterolateral incision through the fourth, fifth, sixth, or seventh intercostal spaces to expose and examine the pleura and lung

Surgical Aspect of Respiratory CareThoracic Surgeryb. Lobectomy: removal of one lobe of a lung; treatment for bronchiectasis, bronchogenic carcinoma, emphysematous blebs, lung abscesses

Surgical Aspect of Respiratory CareThoracic Surgeryc. Pneumonectomy: removal of an entire lung; most commonly done as treatment for bronchogenic carcinoma

Surgical Aspect of Respiratory CareThoracic Surgeryd. Segmental resection: removal of one or more segments of lung; most often done as treatment for bronchiectasis

Surgical Aspect of Respiratory CareThoracic Surgerye. Wedge resection: removal of lesions that occupy only part of a segment of lung tissue; for excision of small nodules or to obtain a biopsy

Surgical Aspect of Respiratory CareNursing interventions: PREOPERATIVE1. Provide routine pre-op care.2. Perform a complete physical assessment of the lungs to obtain baseline data.3. Explain expected post-op measures: care of incision site, oxygen, suctioning, chest tubes (except if pneumonectomy performed)

Surgical Aspect of Respiratory CareNursing interventions: PREOPERATIVE4. Teach client adequate splinting of incision with hands or pillow for turning, coughing, and deep breathing.5. Demonstrate ROM exercises for affected side.6. Provide chest physical therapy to help remove secretions.

Surgical Aspect of Respiratory CareNursing interventions: POSTOPERATIVE1. Provide routine post-op care.2. Promote adequate ventilation.a. Perform complete physical assessment of lungs and compare with pre-op findings.b. Auscultate lung fields every 12 hours.c. Encourage turning, coughing, and deep breathing every 12 hours after pain relief obtained.

Surgical Aspect of Respiratory CareNursing interventions: POSTOPERATIVE2. Promote adequate ventilation.d. Perform tracheobronchial suctioning if needed.e. Assess for proper maintenance of chest drainage system (except after pneumonectomy).f. Monitor ABGs and report significant changes.g. Place client in semi-Fowlers position

Surgical Aspect of Respiratory CareNursing interventions: POSTOPERATIVEIf pneumonectomy is performed, follow surgeons orders about positioning, often on back or OPERATIVE SIDEIf Lobectomy, patient is usually positioned on the UNOPERATIVE SIDE

Surgical Aspect of Respiratory CareNursing interventions: POSTOPERATIVE3. Provide pain relief.a. Administer narcotics/analgesics prior to turning, coughing, and deep breathing.b. Assist with splinting while turning, coughing, deep breathing.

Surgical Aspect of Respiratory CareNursing interventions: POSTOPERATIVE4. Provide client teaching and discharge planning concerninga. Need to continue with coughing/deep breathing for 68 weeks post-op and to continue ROM exercisesb. Importance of adequate rest with gradual increases in activity levels

Surgical Aspect of Respiratory CareNursing interventions: POSTOPERATIVE4. Provide client teaching and discharge planning concerningc. High-protein diet with inclusion of adequate fluids d. Chest physical therapye. Good oral hygienef. Need to avoid persons with known upper respiratory infectiong. Adverse signs and symptoms h. Avoidance of crowds and poorly ventilated areas.

TuberculosisReportable, communicable disease

Classification of TBClass 0 no exposureClass 1 - +exposure; - infectionClass 2 - +infection; - disease (no clinical evidence of active TB)Class 3 - +disease, clinically activeClass 4 - + disease; not clinically activeClass 5 suspected; dx pending

Infectious, may be cured by medicationAirborne special maskCover nose & mouth when coughing, sneezing & laughingHand hygieneMay lie dormant for many years & reactivated during stress

Mantoux (PPD)ID @ forearmRead in 48-72 hrs10mm = positive5 mm = + for pts. w/ HIVTine / multiple puncture testRead in 48-72 hrsScreening test onlyPositive reaction is verified by PPD

Nsg ResponsibilityNotify health departmentINHNot recommended >35 y/o who are at low risktuberculostatic

EthambutolSE: optic neuritis, skin rashOpthalmologic exam @ regular basisPZASE: most hepatotoxicHighly specific to mycobacterium tubercleTake anti-TB drugs in combination to prevent resistanceTake on empty stomachPts are not infectious after 2 weeks of treatmentEvaluate drugs effectiveness through sputum cultureAvoid excessive exposure to dust & siliconeMust take full course of medsGood nutritionEvaluate household contacts

HistoplasmosisSystemic fungal disease by inhalation of dust contaminated by histoplasma capsulatumEtiology:Pigeon / chicken manureNot spread from human to humanS/SXCough FeverJoint painMalaiseSometimes asymptomatic

Dx:CXrayHistoplasmin skin test (like PPD)Mngt:Amphoteracin BNephrotoxic, adrenal failure, headache, fever & chillsWet down chicken manure before shoveling so fungal spores will not become airborne

Exam!!!!1.A client with AIDS & PTB which management will be prescribed?A. INH, RifampicinB.ethambutol, PZA, INHC.INH, Rifampicin, PZA, EthambutolD.etham, ciprofloxacin, streptomycin, INH

Ans: CA 21-day course of tx is required to identify the sensitivity of TB organism to meds. Ethambutol & streptomycin are not given together for this pt.

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