The Respiratory SystemCorrelated to the Roy Adaptation Model and Nursing ProcessSandy Marks, RN, BSN, MS(HCA)

N212 Medical Surgical Nursing 1Spring 2008

Course Packet (2007), p 104

Journey through Roy Adaptation Model(RAM) Roy Adaptation Model →

Patients primarily with alterations inphysiological mode →

oxygenation →

respiratory system

Objectives - 1

Review the anatomy and physiology of the respiratory system

Describe the respiratory changes associated with aging

Objectives - 2 Discuss the purpose and interventions

(preparation, explanation, procedure, postcare) for the following diagnostic tests: X-rays: chest, bronchogram, CT, lung scan Direct visualization: bronchoscopy Sputum specimen Thoracentesis Pulmonary function tests (PFT) Oximetry Magnetic resonance imaging (MRI) Cultures

Objectives - 3

Describe the nursing assessment of the following cardinal signs and symptoms:

cough sputum dyspnea

Discuss the pathophysiology, nursing assessment, interventions, and evaluation for Pneumonia

dscherer.com

The Art of Caring

Respiratory Review Purpose =1. provide oxygen for tissue metabolism (O2)2. remove carbon dioxide (CO2)

Influences functions of:1. acid-base balance2. speech3. sense of smell4. fluid balance5. temperature control

Chabner, 2007

Review the anatomy and physiology of

the respiratory system1. upper respiratory tract

2. lower respiratory tract

divided by trachea (windpipe)

bronchi bronchioles alveolar ducts alveoli

trachea

bronchi

alveoli

bronchioles

Chabner, 2007

Gas Exchange

occurs at alveolar capillary membrane

occurs by diffusion

Pulmonary edema =1. excess fluid fills alveoli

spaces2. impairs exchange of O2

and CO2 capillary

Chabner, 2007

Normal lung tissue 300 million alveoli surface area = tennis

court

Right bronchus slightly wider shorter more vertical increases problems with1. intubation2. aspiration

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Physiologic changes associated with aging

Alveoli

alveolar surface area decreases diffusion capacity decreases elastic recoil decreases bronchioles and alveolar ducts dilate ability to cough decreases airways close early

Lungs

residual volume increases vital capacity decreases efficiency of oxygen and carbon dioxide

exchange decreases elasticity decreases

Pharynx and Larynx

muscles atrophy vocal cords become slack laryngeal muscles lose elasticity and

cartilage

Pulmonary Vasculature

increased vascular resistance to blood flow through pulmonary vascular system occurs

pulmonary capillary blood volume decreases risk of hypoxia increases

Exercise Tolerance andMuscle Strength Exercise Tolerance

body’s response to hypoxia and hypercapnea decreases

Muscle Strengthrespiratory muscle strength, especially the diaphragm and intercostals, decreases

Susceptibility to Infection

effectiveness of the cilia increases immunoglobulin A decreases alveolar macrophages are altered

Chest Wall

anteroposterior (AP) diameter increases thorax becomes shorter progressive kyphoscoliosis occurs chest wall compliance (elasticity) decreases mobility may decrease osteoporosis is possible

Summary on effects of aging ↓ ↓ recoil and compliancerecoil and compliance

AP diameter AP diameter

↓ ↓ functional alveolifunctional alveoli

↓ ↓ in Pa02in Pa02

Respiratory defense mechanisms less effective Respiratory defense mechanisms less effective

Altered respiratory controlsAltered respiratory controls More gradual response to changes in O2 and Co2 More gradual response to changes in O2 and Co2

levels in bloodlevels in blood

Diagnostic Tests

X-rays: chest, bronchogram, CT, lung scan Direct visualization: bronchoscopy Sputum specimen and Cultures Thoracentesis Pulmonary function tests (PFT) Oximetry Magnetic resonance imaging (MRI)

Chest X-RayChest X-Ray Screen, diagnose, Screen, diagnose,

evaluate treatmentevaluate treatment

Instructions:Instructions:

Chabner, 2007

X-ray Positions

Chest X-Ray Chest X-Ray (Cont.)(Cont.)

Posterior Anterior View Left Lateral View

www.fotosearch.com

Bronchogram Slightly

oblique

Computed Tomography: CT Computed Tomography: CT ScanScan Images in Images in cross-cross-

sectionsection view view

Uses contrast Uses contrast agentsagents

Instructions:Instructions:

Right upper Lobe

www.ucl.ac.uk

Lung Scan most to detect emboli

no food restrictions breathes radioactive

material through a tube for 5 minutes

6 ventilation images taken

radioactive injection same 6 images

retaken compare images

www.diiradiology.com www.washingtonhospital.org

Ventilation- air distribution in lungPerfusion- blood supply to & within lung

BronchoscBronchoscopyopy

Diagnose problems and assess Diagnose problems and assess changes in bronchi / bronchioleschanges in bronchi / bronchioles

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

Post-Procedure Care / Instructions:Post-Procedure Care / Instructions:

Sputum SpecimenSputum Specimen

To diagnose; evaluate treatmentTo diagnose; evaluate treatment Specimen: ID organisms or abnormal Specimen: ID organisms or abnormal

cellscells Culture & Sensitivity (C&S)Culture & Sensitivity (C&S) CytologyCytology Gram stains Gram stains

(e.g. Acid Fast Bacilli)(e.g. Acid Fast Bacilli)

ThoracentThoracentesisesis

Specimen from Specimen from pleural fluidpleural fluid

Treat pleural effusionTreat pleural effusion

Assess for Assess for complicationscomplications

Post-Procedure care:Post-Procedure care:PositionsPositions

•Sitting on side of bed over bedside table Sitting on side of bed over bedside table chest elevated chest elevated•Lying on affected sideLying on affected side•Straddling a chairStraddling a chair

Chabner, 2007

Pneumothorax

Pulmonary Function Test Pulmonary Function Test (PFTs)(PFTs)

Evaluate lung functionEvaluate lung function

Observe for increased Observe for increased dyspnea or dyspnea or bronchospasmbronchospasm

Instructions:Instructions:

Pulse Pulse OximetryOximetry Measures arterial Measures arterial

oxygen saturationoxygen saturation Pulse oximetry probe Pulse oximetry probe

on ears, nose, finger, on ears, nose, finger, toes, foreheadtoes, forehead

False readingsFalse readings Intermittent or Intermittent or

continuous monitoring continuous monitoring Ideal valuesIdeal values When to Notify MDWhen to Notify MD

Chabner, 2007

MRI Frontal View White masses =

Hodgkin Disease lesions

Chabner, 2007

MRI – transverse view – same patient

Nursing Assessment:Cardinal Signs and Symptoms of:

1. Cough2. Sputum3. Dyspnea

Cough – Main Sign of Lung Disease how long present occurs at a specific time (smokers = upon

wakening in AM) related to activity productive vs nonproductive congested dry tickling hacking

Sputum – normally 3 oz produced/day important symptom associated with coughing

Check: 1. duration – long term, short term2. color – rust colored3. consistency – thick, thin, watery, frothy4. odor- foul 5. amount – describe in tsp, or fractions of cup

and if increasing (external or internal cause)

Dyspnea – subjective data (perception) difficulty in breathing or breathlessness Check:1. onset – slow or abrupt2. duration - # of hours, time of day3. relieving factors – position change, med,

stop activity4. wheezing, crackles, rales, or stridor occur

with breathlessness Quantify by assessing if interferes with ADL PND or orthopnea

Lung sounds wheezing crackles stridor

auscultation – sequence pg. 534, Iggy

bronchial = trachea & mainstem bronchi bronchovesicular = branching bronchi vesicular = small bronchiole periphery

Pneumonia: Case StudyPneumonia: Case Study

Course Packet (2007), pgs 115-117

Nursing Student Tools

Concept Map – Pneumonia Medical-Surgical Map (Medimap) Nursing Map

PathophysiologyPathophysiology

Toxic sprinkles anyone?Toxic sprinkles anyone?

EtiologyEtiology

CauseCause bacteria (75%)bacteria (75%) virusesviruses fungifungi MycoplasmaMycoplasma parasitesparasites chemicalschemicals

ClassificatiClassificationsons

Community-acquired pneumonia (CAP)Community-acquired pneumonia (CAP) Onset in community or during 1Onset in community or during 1stst 2 days of hospitalization 2 days of hospitalization

(Strep. pneumoniae most common)(Strep. pneumoniae most common)

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

Aspiration pneumoniaAspiration pneumonia

Pneumonia caused by opportunistic organismsPneumonia caused by opportunistic organisms Pneumocystis CariniiPneumocystis Carinii

Risk FactorsRisk Factors

CAPCAP Older adultOlder adult Chronic/coexisting Chronic/coexisting

conditioncondition Recent history or Recent history or

exposure to viral or exposure to viral or influenza infectionsinfluenza infections

History of tobacco or History of tobacco or alcohol usealcohol use

HAPHAP Older adultOlder adult Chronic lung diseaseChronic lung disease ALOCALOC AspirationAspiration ET, Trach, NG / GT ET, Trach, NG / GT ImmunocompromisedImmunocompromised Mechanical ventilationMechanical ventilation

Clinical Manifestations - 1Clinical Manifestations - 1 Fevers, chills, anorexiaFevers, chills, anorexia Pleuritic chest painPleuritic chest pain SOBSOB Crackles / wheezesCrackles / wheezes Cough, sputum productionCough, sputum production TachypneaTachypnea

Clinical Manifestations - 2Clinical Manifestations - 2

Mycoplasma (Atypical)Mycoplasma (Atypical) feeling tired or weak, feeling tired or weak,

headaches, sore throat, or headaches, sore throat, or diarrhea. diarrhea.

Eventually, most develop a Eventually, most develop a dry cough.  They can, also, dry cough.  They can, also, develop fever, chills, develop fever, chills, earaches, chest painearaches, chest pain

““walking pneumonia”walking pneumonia”

DiagnoDiagnosissis

Diagnosis Diagnosis →→ Physical exam → crackles, Physical exam → crackles,

rhonchi / wheezesrhonchi / wheezes

CXR → area of increased CXR → area of increased density density

(infiltrates / consolidation)(infiltrates / consolidation)

Sputum specimen – Sputum specimen – Gram stainGram stain

LUL Infiltrates

www.med.wayne.edu

CXR- LUL Pneumonia

Interventions and TreatmentInterventions and Treatment TreatmentTreatment

Antibiotics → choose based on age, suspected Antibiotics → choose based on age, suspected cause & immune statuscause & immune status

Supportive care → IV fluids, supplemental oxygen Supportive care → IV fluids, supplemental oxygen therapy, respiratory monitoring, cough therapy, respiratory monitoring, cough enhancementenhancement

*may take 6-8 weeks for CXR to normalize*may take 6-8 weeks for CXR to normalize

Nursing Diagnoses…Nursing Diagnoses… Impaired gas exchange R/T Impaired gas exchange R/T

PneumoniaPneumonia

Pain R/T infection in lung Pain R/T infection in lung PneumoniaPneumonia

ComplicatiComplicationsons

HypoxemiaHypoxemia

Pleural effusionPleural effusion

AtelectasisAtelectasis

PleurisyPleurisy

Atelectasis Pleurisy

Pleural Effusion

Chabner, 2007

Atelectasis

A = obstruction

B = accumulation of fluid of air

Additional learning resources NANDA approved nursing diagnoses specific

to respiratory system: p125 of study packet Skills Lab:

Heart and Lung Sounds Trainer Learning Lung Sounds, Cardionics CD Audio-visual material

Resources Beers, M. & Berkow, R. (Ed.). (2000). The Merck

Manual of Geriatrics (3rd ed.). Whitehouse Station: Merck & Co., Inc.

Chabner (2007). The Language of Medicine (8th ed.). St. Louis: Saunders.

Ignatavicius, D. & Workman, L. (2006). Medical-Surgical Nursing Critical Thinking for

Collaborative Care (5th ed.). St. Louis: Elsevier Saunders.

Scherer, D. (2008). Pictures retrieved March 31 and available at dscherer.com

dscherer.com