OXYGENATIONRESPIRATORY SYSTEM

Ma. Tosca Cybil A. Torres, RN, MAN

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TERMINOLOGIESVENTILATION – MOVEMENT OF AIR IN & OUT OF

THE LUNGS

RESPIRATION – EXCHANGE OF GASES : EXTERNAL & INTERNAL

EXTERNAL – BET. ALVEOLI & PULMONARY CAPILLARIES

INTERNAL – BET. SYSTEMIC CAPILLARIES

PERFUSION – AVAILABILITY & MOVEMENT OF CAPILLARY BLOOD FOR EXCHANGE OF GASESMTCAT '09

Anatomy of the Upper Respiratory System

Nose Sinuses Pharynx Larynx Trachea

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Defenses of the Airways & Lungs

Nose- particulates larger than 10 mm are filtered and trapped in the nasal mucosa.

Mucocilliary blanket- 2-10 mm

Mucocilliary escalator system – composed of mucus secreting goblet cells in the bronchi, ciliated epithelia & mucus

Pulmonary alveolar macrophage activityMTCAT '09

Reflexes of the Airways Sneeze Reflex – characterized by a deep

inspiration, followed by a violent expiratory blast through the nose Irritant stimulate the trigeminal nerve May cause HTP

Cough reflex- start with deep inspiration, glottis closes. Maximal intrathoracic and intra-airway pressures are produced to cause the trachea to narrow. Triggers the stimulatory impulse from vagus nerve to

medulla

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Reflex bronchoconstriction – protects upper and lower airways.

Hering breuer reflex – limit lung inflation. If lung becomes overstretched, HB reflex is activated.

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Anatomy of the lower respiratory systemLungs

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Respiratory Zone- only site of gas exchange

Conducting Zone structures- serves as conduit to and from the respiratory zone

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Lungs Lungs lie in the thoracic cavity separated by

mediastinum R lungs – 3 lobes L lungs – 2 lobes

Lungs are further divided into lobules → terminated into alveolar sacs

Parietal pleura– covers the lungs and lines the thoracic wall.

Visceral pleura- covers the surface of each lung

Pleural fluid- slippery serous secretion produced by the pleural membranes which allows the lungs to glide easily over the thorax wall

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Alveoli

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Substance important in Alveolar Expansion

Surfactant – lines the alveolus

- Fatty protein provides surface stability (reduces surface tension) and prevents collapse of the alveolar structures (atelectasis)

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Respiratory Centers

1. Medulla oblangata contains inspiratory and expiratory centers, the main region for respiration–

Dorsal respiratory group -the region responsible for causing the normal, resting inspiration 

Ventral respiratory group is only active when you need to breathe more actively.  For ex. when you are talking

- provide automatic control of unconscious breathing

2. Pons- Pneumotaxic area in the pons, important for regulating the amount of air one takes in with each breath.  When we find ourselves needing to breath faster, the pneumotaxic area tells the dorsal respiratory group to speed it up.  And when we need to take longer breaths, the pneumotaxic area tells the dorsal respiratory group to prolong its bursts.  

Apneustic center stimulates the inspiratory medullary center to promote deep, prolonged inspiration

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Major Muscles of Ventilation

1. Diaphragm –contraction and relaxation causes changes in the size and pressure of the chest cavity.

2. External intercostal muscles – further enlarge thoracic cavity by an upward and outward motion of the lower ribs.

3. Internal intercostal muscles – used in forced expiration to stiffen the intercostal spaces during straining

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4. Abdominal wall muscles – aids to forced expiration. Generate the explosive pressure

that is necessary for coughing. Contract at the end of forced

inspiration in synchrony with glottic closure to limit and stop inspiration abruptly.

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5. Accessory musclea. Scalene- one of the muscles of the

neck responsible for the 1st and 2nd ribs in inspiration

b. Sternocleidomastoid -= used during labored breathing to raise the first 2 ribs and sternum and increase size of thoracic cavity.

c. Trapezius and pectoralis – fix the shoulders

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REVIEW OF PHYSIOLOGY Functions of the Respiratory System

Oxygen transport- o2 is supplied to and CO2 is removed from the cells by way of the circulating blood.

Respiration- the whole process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body.

Ventilation- movement of air in and out of the airways Diffusion – air crosses the alveolar – capillary membrane

and is carried in the plasma bound chemically to hgb. Perfusion – blood is delivered through pulmonary

capillary system past the alveoli for the purpose of gas exchange.

Distribution – Air is delivered by the smaller peripheral airways to the alveoli.

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MECHANICS OF VENTILATION

Physical factors that govern airflow in and out of the lungs which include:- Air pressure variance- air flows from a

region of higher pressure to an area of lower pressure

- Airway resistance- as determined by the size of the airway through which the air is flowing

- Compliance – measure of the elasticity, expandability and distensibility of the lungs.

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Lung Volumes & Capacities

Lung volumes – amount of air exchanged during ventilationTidal volume (TV) – amount of air that moves in

& out of the lungs during normal breathing (500mL)

Inspiratory reserve volume (IRV) – maximum amount of inhaled air in excess of the normal TV (3000mL)

Expiratory reserve volume (ERV) – maximum amount of exhaled air in excess of the normal TV (1100mL)

Residual volume (RV) – amount of air remaining in the lungs after forced expiration; increases with age (1200mL)

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Lung capacities – 2 or more lung volumes Vital capacity (VC) = TV+IRV+ERV (amount of

air than can be exhaled from maximal inspiration) 4600mL

Inspiratory capacity = TV+IRV (maximum amount of inhaled air at the beginning of normal expiration & distending the lungs to its maximum) 3500mL

Functional residual capacity = RV+ERV (amount of air remaining in lungs after normal expiration) 2300mL

Total lung capacity = sum of all lung volumes; total amount of air that the lungs can hold

average pair of human lungs can hold about 8L of air, but only a small amount of this capacity is used during normal breathing

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Factors Affecting Lung VolumeLarger volumes

males taller people non-smokers athletes people living at high

altitudes (the body's diffusing capacity increases in order to be able to process more air)

Smaller volumesFemalesshorter peopleSmokersnon-athletespeople living at low

altitudes (atmosphere is less dense at higher altitude, therefore, the same volume of air contains fewer molecules of all gases

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Effects of Aging

Progressive loss of elastic recoil of lungs – due to elastin & collagen fiber changes

Increased respiratory muscle workload – due to calcification of soft tissues in chest wall

Total lung capacity remains constant Increased residual lung volume – result of

changes in aging MTCAT '09

Oxygen is essential for cellular metabolism and have no capability to store it. Without constant delivery of oxygen , tissue hypoxia and anaerobic metabolism result.

Tissue hypoxia – inadequate oxygen supply to meet the needs of the cell.

Hypoxemic hypoxia- a state of low arterial PO2, usually due to inadequate pulmonary gas exchangeIschemic hypoxia – results from inadequate circulation of the blood.Anemic hypoxia – due to anemia and the resulting inability of the blood to carry adequate oxygen.Histotoxic hypoxia – occurs when the tissues are unable to use the oxygen delivered to them because of a metabolic poison. MTCAT '09

O2 is carried in the blood in 2 forms: Physically dissolved oxygen in the plasma In combination with the hemoglobin of the

RBC Each 100 mL of arterial blood carries

0.3 ml of O2 physically dissolved in the plasma and 20 ml of O2 in combination with Hgb in Ferrous Iron

O2 + Hgb = HgbO2Hgb combined with oxygen is called

oxyHGB – whereas oxygen – free hgb is called reduced hgb.

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                                    ErythrocytesErythrocytes, or red blood cells, are the primary carriers of oxygen to the cells and tissues of the body. The biconcave shape of the erythrocyte is an adaptation for maximizing the surface area across which oxygen is exchanged for carbon dioxide. Its shape and flexible plasma membrane allow the erythrocyte to penetrate the smallest of capillaries.

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Red blood cells make up almost 45 percent of the blood volume.

Their primary function is to carry oxygen from the lungs to every cell in the body.

Red blood cells are composed predominantly of a protein and iron compound, called hemoglobin, that captures oxygen molecules as the blood moves through the lungs, giving blood its red color.

As blood passes through body tissues, hemoglobin then releases the oxygen to cells throughout the body. Red blood cells are so packed with hemoglobin that they lack many components, including a nucleus, found in other cells. MTCAT '09

RBC 33% of an rbc cytoplasm is hemoglobin (Hb)

solution There are 280 million molecules of Hb in

each RBC Consists of 4 protein chains called globins,

each chain has heme group.

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Normal range Hematocrit- percentage of whole blood

volume composed of RBCs Male – 42% - 52% Female – 37% - 48%

Hemoglobin – Male -13 to 18 g/dL Female – 12 to 16 g/dL

RBC Male – 4.6 to 6.2 million/mm3

Female – 4.2 – 5.4 million/mm3

Life span – 120 days (4 mos.)

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Assessment: Health History

The major signs and symptoms of respiratory diseases are the ff: Dyspnea Cough Sputum production Chest pain Wheezing Clubbing of the fingers Hemoptysis cyanosis MTCAT '09

Dyspnea

Dyspnea• difficult or labored breathing, breathlessness,

SOB• Symptom common when there is decreased

lung compliance or increased airway resistance

• Maybe related to a lot of different medical conditions

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Levels of DyspneaLevel I Patient can walk 1 mile at own pace

before experiencing shortness of breath

Level II Patient is short of breath after walking 100 yards on level ground or climbing a flight of stairs.

Level III Patient is short of breath while talking or performing ADL

Level IV Patient is short of breaths during periods of inactivity

Orthopnea Shortness of breath when lying downMTCAT '09

Important questions to ask:

How much exertion triggers SOB? is there an associated cough? Is the SOB related to other symptoms? Was the onset of SOB sudden or gradual? At what time of the day does SOB occur? Is the SOB worse when the patient is lying flat

in bed? Does the SOB occur at rest? With exercise?

Running? Climbing stairs?MTCAT '09

Relief measures (dyspnea)

The mgt of dyspnea is aimed at identifying and correcting its cause.

Relief is sometimes achieved by: Placing the patient at rest Assisting in high fowler’s position Administration of O2

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Cough Results from irritation of the mucous

membranes anywhere in the respiratory tract

Stimulus may arise from an infectious process or from an airborne irritant

Persistent and frequent cough can be exhausting and cause pain

Cough may indicate a serious pulmonary disease

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Cough Assess for character of cough to know

cause. Describe as:

Dry –may indicate URTI of viral origin or side effect of ACE inhibitor therapy

Hacking – colds Brassy – tracheal lesions Wheezing- cystic fibrosis Loose- bronchitis Severe – bronchogenic carcinoma

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Cough Note time of onset:

Coughing at night may herald onset of left sided heart failure or bronchial asthma

Cough in the morning with sputum production may indicate bronchitis

Cough worsens while in supine position may indicate sinusitis

Coughing after food intake may be caused by aspiration

Cough of recent onset is usually from an acute infection MTCAT '09

Relief measures (cough)

Cough suppressants----should be used with caution

Smoking cessation Drinking warm beverages First generation antihistamines with

decongestants

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Sputum production

The reaction of the lungs to any constantly recurring irritant

May be associated with a nasal discharge

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Assess character of sputum Purulent sputum (thick and yellow, green or

rust-colored)- common sign of bacterial infection Thin, mucoid sputum- viral bronchitis Gradual increase of sputum over time- chronic

bronchitis or bronchiectasis Pink-tinged mucoid sputum- lung cancer Profuse, frothy, pink material- pulmonary

edema Foul smelling sputum and bad breath- lung

abscess, bronchiectasisMTCAT '09

Relief measures (sputum production)

Increase OFI Nebulization Cessation of smoking Adequate oral hygiene Back clapping/ chest physiotherapy Postural drainage

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Chest pain

Chest pain associated with pulmonary conditions may be sharp, stabbing, and intermittent, or it may be dull, aching, and persistent

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Relief measures (chest pain)

Analgesics NSAIDS Regional anesthetic block

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Wheezing

Major finding in a patient with bronchoconstriction or airway narrowing

High-pitched, musical sound heard mainly on expiration

Oral or inhalant bronchodilators reverse wheezing most of the time

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Clubbing of fingers

A sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung

May be manifested initially as sponginess of the nail bed and loss of the nail bed angle

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Hemoptysis

Coughing up of blood arising from a pulmonary hemorrhage

Blood- alkaline pH (greater than 7.0) Symptom of both pulmonary and cardiac problems Onset is usually sudden, intermittent or continuous Most common causes:

Pulmonary infection Carcinoma of the lung Abnormalities of the heart or blood vessels Pulmonary embolus and infarction Pulmonary vein or artery abnormalitiesMTCAT '09

Determine source of bleeding

Bloody sputum from the nose is usually preceded by considerable sniffing, with blood possibly appearing in the nose

Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include: Tickling sensation in the throat A salty taste A burning or bubbling sensation in the chest Chest pain

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Cyanosis

Bluish coloring of the skin Very late indication of hypoxia Determined by the amount of

unoxygenated hgb in the blood Appears when there is at least 5g/dl of

unoxygenated hgb

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CYANOSIS

Factors that alter the presence of Cyanosis1. Pigmentation and thickness2. Type of light used during assessment –

natural light is desirable3. Absolute amount of reduced hemoglobin4. Observer’s perception

1. Activity 2. Duration 3. Distribution

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OBJECTIVE DATA

In addition to the subjective information obtained through nursing history, OBJECTIVE, measurable data must be obtained.

PHYSICAL ASSESSMENT

primary techniques - IPPA

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Physical Assessment of the Respiratory System

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INSPECTION

observe for the rate and pattern of breathing

To accurately assess the resting pt’s RR

1. count the number of times the chest rise and fall in 1 full minute.

2. Observe the breathing pattern and effort

3. Actual volume can be measured by a spirometer.

4. Note relative length of inspiration and exhalation.

Prolonged inspiration indicates obstruction of the upper airways (Croup, epiglotitis)

Long exhalation indicates air trapping (asthma,emphysema)5. Note use of accessory muscles6. Observe for color (cyanosis)7. Check for deformities

Physical Assessment

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Inspection

Normal chest Slight retraction of

intercostal spaces 2x as wide as deep Anterior/posterior

diameter 1:2

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Inspection

Barrel chest Occurs as a result of

over inflation of the lungs

Increase in anterior-posterior diameter of the thorax 2:2

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Inspection

Funnel chest (Pectus Excavatum)

Depression of the lower portion of the sternum

Complications Heart damage i Cardiac output

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Inspection

Pigeon chest (Pectus Carinatum) Displacement of the

sternum Sternum protrudes

outward h anterior-posterior

diameter

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Pigeon Chest

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Inspection

Kyphoscoliosis Characterized by

the elevation of the scapula and a corresponding S-shaped spine

Limits lung expansion

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Inspection

Uniform expansion of the chest Pneumonia Pleural effusion Pneumothorax

Bulging intercostal spaces Obstruction Emphysema

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Inspection

Marked retraction of intercostal spaces Blockage

Shoulder rise Accessory muscles Posture

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Inspection: Breathing patterns

Rate Eupnea

Normal 12-20 / min

Tachypnea rapid shallow breathing >24CPM Pnuemonia, pulm edema, acidosis, septicemia, pain

Bradypnea <10CPM, with normal depth and regular rhythm h ICP, drug OD

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Inspection: Breathing patterns

Depth Hyperpnea

h depth

Hyperventilation h depth & rate

Hypoventilation i depth & rate Shallow irregular

breathingMTCAT '09

Inspection: Breathing patterns

Depth Kussmaul's

h rate & depth Assoc. with severe acidosis

Apneustic Prolonged gasping followed by a short

breath

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Inspection: Breathing patterns

Rhythm Apnea

Cessation breathing Cheyne-stokes

Regular cycle with increasing rate and depth, then decrease until apnea (usually about 20 secs) occur

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Inspection: Breathing patterns

Rhythm Biot’s

Periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10-60 secs)

Assoc w/ h ICP

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Inspection:

Trachea Deviation

Pleural effusion Tension pneumothorax Atelectasis

Color LOC Emotional state

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PALPATIONUses hands to assess:

Trachea – slightly movable & quickly returns to midline after displacement

Tactile fremitus –transmission of vibration of air movement through chest wall during phonation (99 method)

Thoracic excursion

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Palpation

TML Tenderness (T) Masses (M) Lesions (L)

Sinuses Palpate below eyebrow & Cheekbone

Crepitus Subcutaneous emphysema Air leaks into the sub-c tissue

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Percussion

Rational To determine if

underlying tissue is filled with air or solid material

Procedure Pt sitting Tap starting at shoulder compare rt to lf

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PERCUSSION RESULT

Resonant – low-pitched hollow (normal lung sound)

Hyperresonant – louder & lower-pitched; presence of increased amount of air (emphysema, pneumothorax)

Dull- thudlike Tympanic – hollow (tension-

pneumothorax) Flat – soft high-pitched

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Auscultation

Purpose Asses air flow

through bronchial tree

Procedure Diaphragm of

stethoscope Superior inferior Compare rt to lf

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Auscultation: Results

Normal Vesicular

Lung field Soft and low

Bronchial Trachea & bronchi Hollow

Bronchovesicular Mixed Between scapulae Side of sternum 1st & 2nd intercostal space

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Auscultation: ResultsAdventitious Crackles

Soft, high pitched, discontinuing popping sounds that occur during inspiration

air bronchi with secretions Fine crackles Discontinuous popping sounds heard in late

inspiration Sounds like hair rubbing together Originates in the alveoli Etiology: pneumonia, bronchitis

Course Crackles Discontinuous popping sounds heard in early

inspiration Harsh, Moist sound originating in the large

bronchi COPD

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Auscultation: Results

Wheezes Sonorous wheezes (rhonchi)

Deep low pitched Snoring > E Caused by air narrowed tracheobronchial

passages Etiology: h secretions

Sibilant Wheezes Continuous,

musical, High pitched

Whistle-like I & E Caused by air

narrowed passages, partially obstructed

May clear with coughing

Etiology: Asthma bronchospasm Build-up of

secretions

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Auscultation: Results

Pleural friction rub D/t inflammation of

pleural space Grating, creaking I & E Best heard

Anterior, Lower, lateral area

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Auscultation: Results

Stridor Crowing Partial obstruction of

the larynx or trachea

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A child with difficulty breathing and a “barking” cough id displaying signs associated with which condition?

A. Asthma

B. Croup

C. Cystic fibrosis

D. Epiglottitis

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When assessing the lung sounds of a child with asthma, which sound are you most likely to hear?

A. MurmursB. Sonorous WheezingC. Sibilant WheezingD. CracklesE. Pleural friction rub

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Diagnostics: Imaging Studies

A. Chest X-ray (Chest radiography; Serial chest x-ray)

Visualization of the chest, lungs, heart, large arteries, ribs, and diaphragm while standing in front of the machine

Two views are usually taken: 1. Antero-posterior view - x-rays pass

through the chest from the back 2. Lateral view - x-rays pass through

the chest from one side to the other

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B. Computed tomography• CT scan is an imaging

method in which the lungs are scanned in successive layers by a narrow-beam x-ray.

• Distinguishes fine tissue density

• Used to define pulmonary nodules and small tumors adjacent to pleural surfaces which are not visible on routine CXRs

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C. Magnetic Resonance imaging (MRI) Similar to CT scan except that magnetic

fields and radiofrequency are used instead of narrow beam x-rays

Used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease

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Comparison of a CXR and a chest MRI

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D. Flouroscopic studies Used to assist with

invasive procedures such as chest needle biopsy or transbronchial biopsy.

It may be used to study the movement of the chest wall, mediastinum, heart, and diaphragm.

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E. Pulmonary Angiography Most commonly used to

investigate thromboembolic disease of the lungs

It involves the rapid injection of a radiopaque agent into the vasculature of the lungs.

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F. Radioisotope Diagnostic Procedures

V/Q scan (ventilation/perfusion scan)- used clinically to measure the integrity of the pulmonary vessels relative to blood flow and to evaluate blood flow abnormalities

Gallium scan- used to detect inflammatory conditions, abscesses, adhesions, and the presence, location, and size of tumors. Used to stage bronchogenic Ca.

Positron Emission Tomography (PET) scan- used to evaluate lung nodules for malignancy.

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Pulmonary Function Tests (PFT)

• a group of tests measuring lung function• Measure of diffusion capacity

• client breathes in a harmless gas for a very short time (one breath)

• the concentration of the gas in the air exhaled is measured

• the difference in the amount of gas inhaled and exhaled can help estimate how quickly gas can travel from the lungs into the blood

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Body plethysmograph - most accurate

• Client sits in a sealed, clear box that looks like a telephone booth while breathing in and out into a mouthpiece

• Changes in pressure inside the box help determine the lung volume

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Cont…(PFT)Spirometry test – measures airflow;

client will breathe through a tight fitting mouthpiece and will have nose clips

Nursing Interventions: Instruct client to:

a. breathe into a mouthpiece that is connected to an instrument (spirometer)

b. eat a light meal before the testc. not to smoke for 4 - 6 hours

before the testd. stop using bronchodilators or

inhaler medications 6-8hrs prior

e. Inform client that temporary shortness of breath or light-headedness may be felt

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Peak Expiratory Flow Rate (PEFR)

• measures how fast a person can exhale• it is one of many tests that measure how well the

airways work • requires a peak expiratory flow (PEF) monitor, a

small handheld device with a mouthpiece at one end and a scale with a moveable indicator (usually a small plastic arrow)

• commonly used to diagnose and monitor lung diseases such as asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), & emphysema

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• A decrease in peak flow indicates blocked or narrowed airways

• A significant fall in peak flow can signal the onset of a lung disease esp. when accompanied by persistent coughing, SOB, or wheezing

• PEFR measurements are not as accurate as the spirometry

• Nursing Interventions:• Inform client that repeated efforts may cause

lightheadedness• Loosen any tight clothing that might restrict breathing• Sit up straight or stand while performing the tests• Instruct client on proper procedure to do this test:• Breathe in as deeply as possible.• Blow into the instrument's mouthpiece as hard and fast

as possible.• Do this 3 times, and record the highest flow rate

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Throat Culture

Also known as throat swab culturea laboratory test to isolate and identify

organisms that may cause infection in the throat; when throat infection is suspected, particularly strep throat

back of the throat is swabbed with a sterile cotton swab near the tonsils

Nursing Interventions:Instruct client not to use antiseptic mouthwashes

before the testInform client that he may experience a gagging

sensation when the back of the throat is swabbedInstruct to resist gagging and closing the mouth

during procedure (test only takes a few seconds)

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Bronchoscopy (Fiber Optic Bronchoscopy)

views the airways and diagnose lung disease

may also be used during the treatment of some lung conditions

flexible bronchoscope is usually used (less than ½in wide and about 2ft long)

scope is passed through the mouth or nose, and then into the lungs

rigid bronchoscope requires general anesthesia

flexible bronchoscope uses local anesthesia (spray if via mouth and throat; numbing jelly if via nose)

IV meds may be given to help relax the client

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Cont…(Bronchoscopy)

Nursing Interventions:Inform client that spraying of local anesthesia will

cause coughing at first, which will stop as the anesthetic begins to work

Inform client that as the anesthesia wears off, the throat may be scratchy for several days

Instruct client on NPO 6-12hrs prior (withhold ASA or Ibuprofen if client takes it on a regular basis or as ordered)

Place client on NPO 1-2hrs after the procedure or until (+) for gag reflex MTCAT '09

Sputum CultureSputum is obtained for analysis to identify

pathogenic organisms and to determine whether malignant cells are present.

Nursing Interventions:Drinking a lot of water and other fluids

the night before collection may helpPerform back tapping or chest clapping

on client to aid in loosening the sputum Instruct client on proper specimen

collectionCollect morning specimenGargle with water only before

specimen collection cough deeply and spit sputum in a sterile cup

Send specimen to lab ASAP

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Oximetry

measures oxygen concentration (%) in the blood pulse oximeter- most commonly used; because they respond

only to pulsations, such as those in pulsating capillaries of the area tested

pulse oximeter works by passing a beam of red and infrared light through a pulsating capillary bed

ratio of red to infrared blood light transmitted gives a measure of the oxygen saturation in the blood

Normal o2 saturation: 95%-100%, <85% indicates that the tissues are not receiving enough oxygen

Principle: oxygenated blood is bright red while the deoxygenated blood is blue-purple

Other types: intracardiac oximetry - blood that is within the heart or on

whole blood that has been removed from the body More recently, using a similar technology to oxymetry, carbon

dioxide levels can be measured at the skin as well MTCAT '09

THORACENTESIS- aspiration of pleural fluid for diagnostic purposes

Site : Air : 2nd /3rd ICS, MCL Fluid : 7th/8th ICS, PAL

Position : over a bed table straddling in a chair seated in bed with affected hand raised over the

head

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ARTERIAL BLOOD GASES

ALLEN’S TESTARTERIAL PUNCTURE

ABG studies aid in assessing the ability of the lungs to provide oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH.MTCAT '09

Levels of Hypoxemia

MILD PaO2 of 60-80mmHg

MODERATE PaO2 of 40-60mmHg

SEVERE PaO2 of less than 40mmHg

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NORMAL ACID-BASE BALANCE

Estimated HCO3 concentration after fully oxygenated arterial blood has been equilibrated with CO2 at a PCO2 of 40 mmHg at 38C; eliminates the influence of respiration on the plasma HCO3 concentration

22-26 mEq/LStandard HCO3

Partial pressure of CO2 in the arterial blood:

PCO2<35 mmHg = respiratory alkalosis

PCO2>45 mmHg = respiratory acidosis35-45 mmHgPaCO2

Identifies whether there is acidemia or alkalemia:

pH<7.35 = acidosis; pH>7.45 = alkalosis7.35-7.45pH

Partial pressure of oxygen in arterial blood (decreases with age)

In adults < 60 years:

60-80 mmHg = mild hypoxemia

40-60 mmHg = moderate hypoxemia

< 40 mmHg = severe hypoxemia

80-100 HgPaO2

Definition and ImplicationsNormal ValueParameter

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Nursing Diagnosis

INEFFECTIVE BREATHING PATTERN

The state in which an individual’s inhalation and/or exhalation pattern does not enable adequate pulmonary inflation or emptying.

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Defining characteristics:

dyspnea

tachypnea

abnormal ABG values

cough

respiratory depth changes

assumption of three- point position

pursed lip breathing

used of accessory muscles

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INEEFECTIVE AIRWAY CLEARANCE

The state in which an individual is unable to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Defining characteristics:Abnormal breath soundschanges in rate and depth of respirationtachypnea effective or ineffective coughcyanosisdyspnea

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IMPAIRED GAS EXCHANGE

The state in which an individual experiences a decreased passage of oxygen and/or CO2 between the alveoli of the lungs and the vascular system.

Defining Characteristics:

restless

irritability

inability to move secretions

hypercapnia

hypoxiaMTCAT '09

GOALS/ OBJECTIVES/ PLANNING

1. Patient will demonstrate knowledge regarding prevention of respiratory dysfunction.

2. Patient’s tissues will have adequate oxygenation.

3. Patient will mobilize secretions.

4. Patient will effectively cope with changes in self-concept and lifestyle.

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NURSING PATIENTS WITH THREATS TO VENTILATION

1. Planning for Health Promotion

2. Planning for Health Restoration and Maintenance

a. Maintaining Patent Airway1. Coughing techniques

2. Nebulization

3. Steam inhalation

4. Suctioning

5. Chest physiotherapy(CPT)/ Chest mucus mobilization

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NURSING PATIENTS WITH THREATS TO VENTILATION

b. Breathing Exercises

c. Preventing and Controlling Infection

d. Oxygen Therapy

e. Incentive Spirometry

f. Appropriate pharmacologic agents

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Breathing Exercises

Facilitates respiratory functioning by increasing lung expansion and preventing alveolar collapse

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Breathing exercises

Pursed-lip breathing Involves deep inspiration and prolonged

expiration through pursed lips to prevent alveolar collapse.

While sitting up, the client is instructed to take a deep breath and to exhale slowly through pursed lips, as if blowing through a straw.

Clients need to control exhalation phase so that it is longer than inhalation.

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Pursed lip breathing Instruct client to breathe in slowly through

the nose for 1 count Purse lips as if going to whistle Breathe out gently through pursed lips for 2

slow counts (breathe out twice as slowly as when breathing in). Let the air escape naturally

Keep doing pursed lip breathing until no longer short of breath

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Breathing exercises

Diaphragmatic breathing Requires the client to relax intercostal

and accessory respiratory muscles while taking deep inspirations.

The client concentrates on expanding the diaphragm during controlled inspiration.

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Diaphragmatic breathing

The client is taught to place one hand flat below the breast bone above the waist and the other hand 2-3 cm below the first hand.

The client is asked to inhale while the lower hand moves outward during inspiration

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Preventing and Controlling Infections

HEATH TEACHING can limit both exposure to and occurrence of ARTI such as influenza and pneumonia. Promote optimal immune function by

encouraging good nutrition Remind client to avoid exposure to known

infected people or large crowds during peak flu seasons

Good hygiene practices Advising high-risk people to receive annual

flu vaccination MTCAT '09

Coughing

No single measure controls respiratory secretions more effectively than a strong cough that pushes secretions upward.

To cough effectively, the client must be able to take deep breath and generate rapid airflow.

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Controlled Coughing exercise

Assist client in a comfortable sitting position Instruct client to lean head forward slightly while placing both feet

firmly on the ground. Breathe in deeply using diaphragmatic breathing Instruct to hold breath for three seconds. While keeping the mouth slightly open, instruct to cough out twice.

The client should feel his diaphragm pushed upward while doing this. The first cough should bring up the phlegm, and the second cough should move it towards the throat.

Instruct to spit the phlegm out into a tissue. Remember to check the colour; if the phlegm is yellow, green or brown, or has blood in it.

Allow client to rest and repeat these steps once or twice if necessary. MTCAT '09

Nebulization Nebulization – a process of adding moisture or

medications to inspired air by mixing particles of varying sizes with air. A nebulizer uses the aerosol principle to suspend a maximum number of water drops or particles of the desired size in inspired air. Moisture added to the RS through nebulization improves clearance of pulmonary secretions.

Often used for administration of bronchodilators and mucolytic agents.

The client inhales deeply and holds each breath for a moment, which allows for more effective aerosol deposition into distant portions of the airways.

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Steam Inhalation

Purpose: To liquefy mucus secretions To warm and humidify inspired air To relieve edema of airways To soothe irritated airways To administer medications

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Steam Inhalation Place client in semi fowler’s position. Cover client’s eyes with wash cloth. Check electrical device before use Place steam inhalator in a flat, stable surface Place the spout 12-18 inches away from the

client’s nose or adjust the distance as necessary. Cover chest with a towel Render steam inhalation for 15-20 minutes for

effectivity Instruct client to perform DBE and coughing

exercises after the procedure Provide good oral hygiene after the procedure. Document MTCAT '09

SuctioningPurpose:

Remove excess mucus secretions to maintain patent airway

Collect sputum or secretions for diagnostic testing MTCAT '09

Suctioning (Oropharyngeal and Nasopharyngeal) Assess indications for suctioning:

• audible secretions during respiration • adventitious breath sounds

Position: • conscious: Semi-Fowler’s position • unconscious: lateral position facing the

nurse

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Pressure of suction equipment, to prevent trauma to mucus membrane of airways• Wall unit:

Adult: 100-120 mmHg Child: 95-110 mmHg Infant: 50-95 mmHg

• Portable unit: Adult 10-15 mmHg Child 5-10 mmHg Infant 2-5 mmHg MTCAT '09

Appropriate size of sterile suction catheter, to prevent trauma to mucus membranes of airways• Adult Fr. 12-18• Child Fr. 8-10• Infant Fr. 5-8

Don sterile gloves. Length of catheter:

• Measure from the tip of the client’s nose to the earlobe or about 13 cm(5 in) for an adult)

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Lubricate catheter, to reduce friction o Nasopharyngeal suction tip- water soluble lubricant o Oropharyngeal suction tip- sterile water or NSS

Apply suction during withdrawal of the suction catheter (never during insertion). Withdraw catheter in a rotating manner.

Apply suction for 5-10 seconds (max 15 seconds) Pre oxygenate client with 100% oxygen.

Hyperventilate with manual resuscitaiton bag before and after suctioning

Allow 20-30 second interval between each suction Provide oral and nasal care Dispose contaminated equipment safely. Assess effectiveness of suctioning Document. MTCAT '09

Chest Physiotherapy (CPT)

Chest physiotherapy- a group of therapies in combination to mobilize pulmonary secretions.

Is based on the premise that mucus can be shaken from the walls of the airways and helped drain form the lungs.

CPT should be followed by productive coughing and suctioning of the client who has decreased ability to cough.

CPT is recommended for clients who produce greater than 30 ml of sputum per day or have evidence of atelectasis by CXR exam.

Includes: Postural drainage Chest percussion Vibration

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Guidelines for CPT

Know the clients normal range of VS Know the client’s medications Know the client’s medical history Know the client’s level of cognitive

function Be aware of the client’s exercise

tolerance

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Chest percussion Involves striking the chest wall over the area

being drained. The hand is positioned so that the fingers and

thumb touch and the hands are cupped. Percussion of the chest wall sends waves of

varying amplitude and frequency through the chest, changing the consistency and location of the sputum.

Take care to avoid striking over the spine or kidneys, on female breasts, or on incisions or broken ribs.

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Vibration

In this technique, use hands like a gentle jack hammer: place hands on the client’s chest and rapidly and vigorously vibrate them while the client exhales.

This technique may help dislodge secretions and stimulate a cough.

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Postural Drainage

Postural drainage uses gravity to assist in the movement of secretions.

The client is assisted in various positions to facilitate mucus flow from different segments of the lungs.

Note that not all postural drainage positions are well tolerated by all clients.

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OXYGEN THERAPY Administration of Supplemental Oxygen Indication: hypoxemia Signs of hypoxemia:

Restlessness (initial sign) Increased PR Rapid, shallow respiration and dyspnea Light headedness Flaring of nares Substernal or intercostals retractions Cyanosis (late sign)

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Oxygen systems1. Low flow administration devices

Nasal cannula (24-45% at 2-6 LPM) May be used in clients with COPD at 2-3 LPM if

venturi mask is not available

Simple face mask (40-60% at 5-8 LPM) Partial Rebreathing Mask (60-90 % at 6-10

LPM) Non-Rebreathing Mask (95-100% at 6-15

LPM) Croupette Oxygen Tent

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2. High flow administration devices• Venturi mask (24%-50%). Low-

concentration venture- type mask is preferred for clients with COPD because it provides accurate amount of oxygen. They require 2-3 LPM or 28% oxygen

• Face mask. • Oxygen hood. Can be used for low and

high flow concentration• Incubator/Isolette. Can be used for low

and high flow concentration. MTCAT '09

Oxygen Therapy Assess signs and symptoms of hypoxemia Check doctor’s orders Position patient, preferably in semi-Fowler’s. Open source of oxygen before insertion of oxygen

device. Regulate oxygen flow accurately. Excessive

administration of oxygen can cause oxygen narcosis (respiratory alkalosis)

Place a “NO SMOKING” sign at bedside Strictly enforce this warning Oxygen greatly accelerates combustion

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Avoid use of oil, greases, alcohol, and ether near the client receiving oxygen.

Humidify oxygen. Place sterile water into the oxygen humidifier.

Provide food oronasal hygiene. Lubricate nares with water-soluble lubricant to

soothe the mucus membrane. Do not use oil. Assess effectiveness of oxygen therapy. Check

VS, especially RR; note quality of respiration. Make relevant documentation.

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Incentive Spirometry The incentive spirometry motivates the

client to breathe deeply by offering the incentive of measuring progress.

The client is visually motivated to take increasingly deeper breaths.

A reasonable therapy schedule is 8-10 breaths hourly during waking hours

To avoid hyperventilation, encourage client to perform the exercises slowly.

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Incentive Spirometry

Purpose Improve pulmonary ventilation and

oxygenation Loosen respiratory secretions. Prevent or treat atelectasis by expanding

collapsed.

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Common Medications for clients with Respiratory

ConditionsAgent How Provided Clinical Notes

BronchodilatorsTerbutaline (Bricanyl)Albuterol (Ventolin)Ipratropium (Atrovent)

Theophylline, aminophylline

Unit dose packs; solution for administration via hand held nebulizer; some solutions for injection

Oral via tabs and liquids; injectable intravenous solution

•Used to treat wheezing from asthma, COPD•May cause nervousness and tremors•May cause tachycardia

•SE include nausea. Headache, agitation•Toxic levels may include cardiac dysrhythmias and seizures•Wide variety of available preparation; use extra caution in administration

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Agent How provided Clinical Notes

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