Respiratory MA.doc

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1.

2.

Nose - made up of framework of cartilages; divided into R and L by the nasal septum.Paranasal Sinuses – includes four pair of bony

collapseTYPE 3 – alveolar cell macrophages, destroys foreign material, such as bacteria

cavities that are lined with nasal mucosa and ciliated

3.epithelium.Tubernate Bones ( Conchae )

Lecithin Sphingomyelin

4. Pharynx – muscular passageway for both food and L/S ratio indicates lung maturity

air 2:1 normal

Nasopharynx 1:2 immature lungs

Oropharynx Laryngopharynx PULMONARY CIRCULATION

New Era University – College of NursingMENTORING ACTIVITY: SY 2014-2015

Mentee: Patricia Joy Guinto, Batch 2016Mentor: Leslie Masaya, Batch 2015

MED-SURG: RESPIRATORY SYSTEM

ANATOMY OF RESPIRATORY SYSTEM

OXYGENATON: the dynamic interaction of gases in the body for the purpose of delivering adequate oxygen essential for cellular survival

RESPIRATORY SYSTEM MAIN FUNCTION:GAS EXCHANGE

I. Upper Respiratory TractA. Functions

1. Filtering2. Warming and moistening3. Humidification

B. Parts

2. Bronchi Lobar Bronchi: 3 R and 2 L Segmental Bronchi: 10 R and 8 L Subsegmental Bronchi

3. Bronchioles Terminal Bronchioles Respiratory Bronchioles, considered to be the

transitional passageways between theconducting airways and the gas exchange

4. Alveoli- functional cellular units or gas-exchange

units of the lungs.- O2 and CO2 exchange takes place- Made up of about 300 million

TYPE 1 - provide structure to the alveoli

TYPE 2 - secrete S URF A CT A N T , reduces surface tension; increases alveoli stability & prevents their

5. Tonsils and Adenoids6. Larynx – voice production, coughing reflex

Made up of framework of: Epiglottis – valve that covers the opening to

the larynx during swallowing. Glottis – opening between the vocal cords Hyoid bone – u shaped bone in neck Cricoid cartilage Thyroid cartilage, forms the Adam’s apple Arythenoid cartilage Speech production and cough reflex Vocal cords

7. Trachea - consists of cartilaginous rings Passageway of air Site of tracheostomy (4th-6th tracheal ring)

II. Lower respiratory tractA. Function: facilitates gas exchange

B. Parts1. Lungs, are paired elastic structure enclosed in the

thoracic cage, which is an airtight chamber with distensible walls.

Right – 3 lobes, 10 segments Left – 2 lobes, 8 segments

Client post pneumonectomy affected side to promote expansionPost lobectomy unaffected side to promote drainage

Pleural cavity Parietal Visceral Pleural Fluid: prevents pleural friction rub

(as seen in pneumonia and pleural effusion)

- Provides for reoxygenation of blood and release of CO2

PULMONARY ARTERIES, carry blood from the heart to the lungs.

PULMONARY VEINS, is a large blood vessel of the circulatory system that carries blood from the lungs to the left atrium of the heart.

RESPIRATORY MUSCLES- PRIMARY: diaphragm and external intercostal muscles- ACCESORY: sternocleidomastoid (elevated sternum), the

scalene muscles (anterior, middle and posterior scalene) and the nasal alae

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PHYSIOLOGY OF RESPIRATORY SYSTEM

VENTILATION: The movement of air in and out of the airways.

• The thoracic cavity is an air tight chamber. the floor of this chamber is the diaphragm.

• Inspiration: contraction of the diaphragm (movement of this chamber floor downward) and contraction of the external intercostal muscles increases the space in this chamber. lowered intrathoracic pressure causes air to enter through the airways and inflate the lungs.

• Expiration: with relaxation, the diaphragm moves up and intrathoracic pressure increases. this increased pressure pushes air out of the lungs. expiration requires the elastic recoil of the lungs.

• Inspiration normally is 1/3 of the respiratory cycle and expiration is 2/3.

DRIVING FORCE FOR AIR FLOWAirflow driven by the pressure difference between atmosphere

(barometric pressure) and inside the lungs (intrapulmonary pressure).

AIRWAY RESISTANCE

Resistance is determined chiefly by the radius size of the airway.

Causes of Increased Airway Resistance1. Contraction of bronchial mucosa2. Thickening of bronchial mucosa3. Obstruction of the airway4. Loss of lung elasticity

RESPIRATION• The process of gas exchange between atmospheric air and

the blood at the alveoli, and between the blood cells and the cells of the body.

• Exchange of gases occurs because of differences in partial pressures.

• Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body.

• Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body.

NEUROCHEMICAL CONTROLMEDULLA OBLONGATA – respiratory center initiates each breath by sending messages to primary respiratory muscles over the phrenic nerve

- has inspiration and expiration centers

PONS – has 2 respiration centers that work with the inspiration center to produce normal rate of breathing1. P NEUMO T A X IC CEN T ER – affects the inspiratory effort by limiting the volume of air inspired2. A P NEUS T IC CEN T ER – prolongs inhalation

NOTE: Chemoreceptors responds to changes in ph, increasedPaCO2 = increase RR

RESPIRATORY EXAMINATION AND

ASSESSMENT

Background information

A. Abnormal patterns of breathing1. Sleep Apnea

cessation of airflow for more than 10 seconds more than 10 times a night during sleep

causes: obstructive (e.g. obesity with upper narrowing, enlarged tonsils, pharyngeal soft tissue changes inacromegaly or hypothyroidism)

2. Cheyne-Stokes periods of apnoea alternating with periods of

hyperpnoae pathophysiology: delay in medullary chemoreceptor

response to blood gas changes causes

left ventricular failure brain damage (e.g. trauma, cerebral,

haemorrhage) high altitude

3. Kussmaul's (air hunger) deep rapid respiration due to stimulation of respiratory

centre causes: metabolic acidosis (e.g. diabetes mellitus,

chronic renal failure)4. Hyperventilation

complications: alkalosis and tetanycauses: anxiety

5. Ataxic (Biot)irregular in timing and deepcauses: brainstem damage

6. Apneusticpost-inspiratory pause in breathingcauses: brain (pontine) damage

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7. Paradoxical the abdomen sucks with respiration (normally, it

pouches uotward due to diaphragmatic descent) causes: diaphragmatic paralysis

B. Cyanosis1. Refers to blue discoloration of skin and mucous

membranes , is due to presence of deoxygenated haemoglobin in superficial blood vessels

2. Central cyanosis = abnromal amout of deoxygenatedhaemoglobin in arteries and that blue discoloration is present in parts of body with good circulation such as tongue

3. Peripheral cyanosis = occurs when blood supply to acertain part of body is reduced, and the tissue extracts more oxygen from normal from the circulating blood, e.g. lips in cold weather are often blue, but lips are spared

4. Causes of cyanosis

Central cyanosis decreased arterial saturation

decreased concentration of inspired oxygen:high altitude

lung disease: COPD with cor pulmoale, massive pulmonary embolism

right to left cardiac shunt (cyanotic congenitalheart disease)

polycythaemia haemoglobin abnromalities (rare):

methaemoglobinaemia, sulphaemoglobinaemia

Peripheral cyanosis all causes of central cyanosis cause peripheral

cyanosis exposure to cold reduced cardiac output: left ventricular failure or shock arterial or venous obstruction

Position: patient sitting over edge of bed

General appearance

look for the following Dyspnea

normal respiratory rate < 14 each minute tachypnoea = rapid respiratory rateare accessory muscles being used (sternomastoids, platysma, strap muscles of neck) - characteristically, the accessory muscles cause elevation of shoulders with inspiration and aid respiration by increasing chest expansion

Cyanosis Character of cough

ask patient to cough several timeslack of usual explosive beginning may indicate vocal cord paralysis (bovine cough)

muffled, wheezy ineffective cough suggests airflow limitation

very loose productive cough suggests excessive bronchial secretions due to:

- chronic bronchitis- pneumonia- bronchiectasis

dry irritating cough may occur with:- chest infection

- asthma- carcinoma of bronchus- left ventricular failure- interstitial lung disease- ACE inhibitors

Sputumvolumetype (purulent, mucoid, mucopurulent)presence or absence of blood?

Stridorcroaking noise loudest on inspiration is a sign that requires urgent attentioncauses: (obstruction of larynx, trachea or large broncus)

- acute onset (minutes) inhaled foreign body acute epiglottitis anaphylaxis toxic gas inhalation

- gradual onset (days, weeks) laryngeal and pharyngeal tumours crico-arytenoid rheumatoid arthritis bilateral vocal cord palsy tracheal carcinoma paratracheal compression by lymph nodes post-tracheostomy or intubation

granulomata Hoarseness

causes include:- laryngitis- laryngeal nerve palsy associated with

carcinoma of lung- laryngeal carcinoma

The Hands

Clubbing commonly cause by respiratory disease (but NOTemphysema or chronic bronchitis)

occasionally, clubbing is associated with hypertrophic pulmonary osteoarthropathy (HPO) characterised by periosteal inflammation at distal ends

of long bones, wrists, ankles, metacarpals and metatarsals

sweelling and tenderness over wrists and other involved areas

Staining staining of fingers - sign of cigarette smoking (caused by tar, not

nicotine) Wasting and weakness Pulse rate Flapping tremor (asterixis) - unreliable sign

ask patient to dorsiflex wrists and spread out fingers, with arms outstretched

flapping tremor may occur with severe carbon dioxide retention (severe chronic airflow limitation)

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The Face

Eyes Horner's syndrome? (constricted pupil, partial ptosis and loss

of sweating which can be due to apical lung tumourcompressing sympathetic nerves in neck)

Nosepolpys? (associated with asthma)engorged turbinates? (various allergic conditions)deviated septum? (nasal obstruction)

Mouth and tonguelook for central cyanosisevidence of upper respiratory tract infection (a reddened pharynx and tonsillar enlargement with or without a coating of pus)

broken tooth - may predispose to lung abscess or pneumonia

sinusitis is indicated by tenderness over the sinuses on palpation

some patients with obstructive sleep apnoea will be obesewith a receding chin, a small pharynx and a short thick neck

The Trachea

causes of tracheal displacement: toward the side of the lung lesion

upper lobe collapse upper lobe fibrosis pneumonectomy

upper mediastinal masses, such as retrosternal goitre tracheal tug (finger resting on trachea feels it move inferiorly with

each inspiration) is a sign of gross overexpansion of thechest because of airflow obstruction

The Chest: inspection

Shape and symmetry of chest Barrel shaped

anteroposterior (AP) diameter is increased comparedwith lateral diameter

causes: hyperinflation due to asthma, emphysema

Pigeon chest (pectus carinatum) localised prominence (outward bowing of sternum and

costal cartilages) causes:

manifestation of chronic childhood illness (due to repeated strong contractions of diaphragm while thorax is still pliable)rickets

Funnel chest (pectus excavatum) developmental defect involving a localised depression

of lower end of sternum in severe cases, lung capacity may be restricted

Harrison's sulcus innar depression of lower ribs just above costal margins

at site of attachment of diaphragm causes:

severe asthma in childhood rickets

Kyphosis , exaggerated forward curvature of spineScoliosis , lateral bowingKyphoscoliosis: causes: idiopathic (80%) secondary to poliomyelitis (inflammation involving grey

matter of cord) (note: severe thoracic kyphoscoliosis may reduce lung

capacity and increase work of breathing)

Lesions of chest wall scars - previous thoracic operations or chest drains for a

previous pneumothorax or pleural effusion thoracoplasty (was once performed to remove TB, but no

longer is because of effective antituberculosis chemotherapy) invovled removal of large number ofribs on one side to achieve permanent collapse of affected lung

erythema and thickening of skin may occur in radiotherapy; there is a sharp demarcation betweenabnormal and normal skin

Diffuse swelling of chest wall and neck pathophysiology: air tracking from the lungs causes:

pneumothoraxrupture of oesopahagus

Prominent veins cause: superior vena caval obstruction

Asymmetry of chest wall movements assess this by inspecting from behind patient, looking

down the clavicles during moderate respiration - diminished movement indicates underlying lung disease

the affected side will showed delayed or decreased movement

causes of reduced chest wall movements on one side are localised:

localised pulmonary fibrosis consolidationcollapsepleural effusion pneumothroax

causes of bilateral reduced chest wall movements are diffuse:

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chronic airflow limitation diffuse pulmonary fibrosis

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The Chest: palpation

chest expansion place hands firmly on chest wall with fingers extending

around sides of chest (fugyre 4.5) as patient takes a big breath in, the thumbs should move

symmetrically apart about 5 cm reduced expansion on one side indicates a lesion on that side note: lower lobe expansion is tested here; upper lobe is

tested for on inspection (as above) apex beat

(discussed in cardiac section)for respiratory diseases:

displacement toward site of lesion - can be caused by:collapse of lower lobe localised pulmonary fibrosis

displacement away from site of lesion - can be causedby:

pleural effusion tension pneumothorax

apex beat is often impalpable in a chest which ishyperexpanded secondary to chronic airflow limitation

vocal fremitus palpate chest wall with palm of hand while patient repeats

"99" front and back of chest are each palpated in 2 comparable

positions with palms; in this way differences in vibration on chest wall can be detected

causes of change in vocal fremitus are the same as those for vocal resonance (see later)

ribsgently compress chest wall anteroposteriorly and laterally localised pain suggests a rib fracture (may be secondary to trauma or spontaneous as a result of tumour deposition or bone disease)

The Chest: percussion

with left hand on chest wall and fingers slightly separated and aligned with ribs, the middle finger is pressed firmly against the chest; pad of right middle finger is used to strike firmly the middle phalanx of middle finger of left hand

percussion of symmetrical areas of: anterior (chest) posterior (back) (ask patient to move elbows forward across

the front of chest - this rotates the scapulae anteriorly, i.e. moves it out of the way)

axillary region (side) supraclavicular fossa

percussion over a solid structure (e.g. liver, consolidated lung)produces a dull note

percusion over a fluid filled area (e.g. pleural effusion)produces an extremely dull (stony dull) notepercussion over the normal lung produces a resonant note percussion over a hollow structure (e.g. bowel, pneumothorax) produces a hyperresonsant note

liver dullness: upper level of liver dullness is determined by percussing down

the anterior cehst in mid-clavicular line normally, upper level of liver dullness is 6th rib in right

mid-clavicular line if chest is resonant below this level, it is a sign of

hyperinflation usually due to emphysema, asthma

cardiac dullness: area of cardiac dullness is uaully present on left side of chest this may decrease in emphysema or asthma

The Chest: auscultation

breath sounds introduction

one should use the diaphragm of stethoscope to listen to breath sound in each area, comparing each side remember to listen high up into the axillaeremember to use bell of stethoscope to listen to lung from above the clavicles

quality of breath sounds

normal breat sounds are heard with stethoscope over all parts of

chest, produced in airways rather than alveoli (although once they had been thought to arise from alveoli (vesicles) and are therefore called vesicular sounds)

normal (vesicular) breath sounds are louder and longer on inspiration than on expiration; and there is no gap between the inspiratory and expiratory sounds

bronchial breath sounds turbulence in large airways is heard without being

filtered by the alveoli, and therefore produce a different quality; they are heard over the trachea normally, but not over the lungs

are audible throughout expiration, and often there is a gap between inspiration and expiration

are heard over areas of consolidation since solid lung conducts the sound of turbulence in main airways to peripheral areas without filtering

causes include:- lung consolidation (lobar pneumonia) -

common- localised pulmonary fibrosis - uncommon- pleural effusion (above the fluid) -

uncommon- collapsed lung (e.g. adjacent to a pleural

effusion) - uncommon amphoric sound = when breath sounds over a large

cavity have an exaggerated bronchial quality) intensity of breath sounds

causes of reduced breath sounds include: chronic airflow limitation (especially

emphysema) pleural effusion pneumothorax pneumonia large neoplasm pulmonary collapse

added (adventitious) sounds two types of added sounds: continuous (wheezes) and

interrupted (crackles)

wheezes may be heard in expiration or inspiration or both pathophysiology of wheezes - airway narrowing an inspiratory wheeze implies severe airway

narrowing

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causes of wheezes include:- asthma (often high pitched) - due to muscle

spasm, mucosal oedema, excessivesecretions

- chronic airflow diseases - due to mucosal oedema and excessive secretions The Abdomen

pulmonary thromboembolism marked obesitysleep apnoeasevere kyphoscoliosis

- carcinoma causing bronchial obstruction -tends to cause a localised wheeze which is monophonic and does not clear with coughing

Other

palpate liver for enlargement due to secondary deposits of tumour from lung, or right heart failure

crackles some terms not to use include rales (low pitched

crackles) and creptitations (high pitched crackles)

crackles are due to collapse of peripheral airways on expiration and sudden opening on inspiration

early inspiratory crackles- suggests disease of small airways- characteristic of chronic airflow limitation- are only heard in early inspiration

late or paninspiratory crackles- suggests disease confined to alveoli- may be fine, medium or coarse- fine crackles - typically caused by

pulmonary fibrosis- medium crackles - typically caused by left

ventricular failure (due to presence ofalveolar fluid)

- coarse crackes - tend to change with coughing; occur with any disease that leadsto retention of secretions; commonly occurin bronchiectasis

pleural friction rub when thickened, roughened pleural surfaces rub

together, a continuous or intermittent grating sound may be heard

suggests pleurisy, which may be secondary to pulmonary infarction or pnuemonia

vocal resonanancegives information about lungs' ability to transmit sounds consolidated lung tends to transmit high frequencies so that speech heard through stethoscope takes a bleeting quality (aegophony); when a patient with aegophony says "bee" it sounds like "bay"

listen over each part of chest as patient says "99"; over consolidated lung, the numbers will become clearly audible; over normal lung, the sound is muffled

whispering pectoriloquy - vocal resonance is increased to such an extent that whispered speech is distinctly heard

The Heart

lie patient at 45 degreesmeasure jugular venous plse for right heart failure examine preacordium; pay close attention to pulmonary component of P2 (which is best heard at 2nd intercostal space on left) and should not be louder than A2; if it is louder, suspect pulmonary hypertension

cor pulmonale (also called pulmonary hypertensive heart disease) may be due to:

chronic airflow limitation (emphysema)pulmonary fibrosis

Permberton's sign ask patient to lift arms over head look for development of facial plethora, inspiratory

stridor, non-pulsatile elevation of jugular venous pressure

occurs in vena caval obstruction

Feet inspect for oedema or cyanosis (clues of cor

pulmonale) look for evidence of deep vein thrombosisd

Respiratory rate on exercise and positioning patients complaining of dyspnoea should have their

respiratory rate measured at rest, at maximal tolerated exertion and supine

if dyspnoea is not accompanied by tachypnoea when a patient climbs stairs, one should consider malingering

look for paradoxical inward motion of abdomenduring inspiration when patient is uspine (indicating diaphragmatic paralysis)

Temperature: fever may accompany any acute or chronic chest infection

DIAGNOSTIC EVALUATION

1. Skin Test: Mantoux Test or Tuberculin Skin Test

This is used to determine if a person has been infected or has been exposed to the TB bacillus.

This utilizes the PPD (Purified Protein Derivatives). The PPD is injected intradermally usually in the inner aspect

of the lower forearm about 4 inches below theelbow.

The test is read 48 to 72 hours after injection. ( + ) M a n t o u x T e st is induration of 10 mm or more. But for HIV positive clients, induration of about 5 mm is

considered positive Signifies exposure to Mycobacterium Tubercle bacilli

This is the direct inspection and observation of thelarynx, trachea and bronchi through a flexible or rigidbronchoscope.

Passage of a lighted bronchoscope into the bronchialtree for direct visualization of the trachea and thetracheobronchial tree.

This chest CT scan shows a cross-section of a person

Diagnostic uses: To examine tissues or collect secretions

with bronchial cancer. The two dark areas are the lungs. The lightareas within the lungs represent the cancer.

To determine location or pathologic processand collect specimen for biopsy

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2. Pulse Oximeter Non-invasive method of continuously monitoring he

oxygen saturation of hemoglobin A probe or sensor is attached to the fingertip, forehead,

earlobe or bridge of the nose Sensor detects changes in O2 sat levels by monitoring light

signals generated by the oximeter and reflected by the blood pulsing through the tissue at the probe

Normal SpO2 = 95% - 100% < 85% - tissues are not receiving enough O2 Results unreliable in:

Cardiac arrest Shock Use of dyes or

vasoconstrictors Severe anemia High carbon

monoxide Level

3. Chest X-ray

This is a NON-invasive procedure involving the use of x- rays with minimal radiation.

The nurse instructs the patient to practice the on cue tohold his breath and to do deep breathing

Instruct the client to remove metals from the chest. Rule out pregnancy first.

5. Computed Tomography (CT Scan) and Magnetic ResonanceImaging ( MRI )

The CT scan is a radiographic procedure that utilizes x-ray machine.

The MRI uses magnetic field to record the H+ density of the tissue.

It does NOT involve the use of radiation.The contraindications for this procedure are the following: patients with implanted pacemaker, patients with metallic hip prosthesis or other metal implants in the body.

Clear MRI images of lung airways during breathing.

6. Flouroscopy Studies the lung and chest in motion Involves the continuous observation of an image reflected

on a screen when exposed to radiation in themanner of television screen that is activated by an electrode beam.

Structures of different densities that intercept the X-ray beam are visualized on the screen in silhouette

7. Indirect Bronchography A radiopaque medium is instilled directly into the

trachea and the bronchi and the outline of the entire bronchial tree or selected areas may be visualizedthrough x-ray.

It reveals anomalies of the bronchial tree and is important in the diagnosis of bronchiectasis.

Nursing interventions BEFORE Bronchogram Secure written consent Check for allergies to sea foods or iodine or

anesthesia NPO for 6 to 8 hours Pre-op meds: atropine SO4 and valium, topical

anesthesia sprayed; followed by local anesthetic injected into larynx. The nurse must have oxygen and anti spasmodic agents ready.

Nursing interventions AFTER Bronchogram Side-lying position NPO until cough and gag reflexes returned Instruct the client to cough and deep breathe

client

8. Bronchoscopy

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To evaluate bleeding sites To determine if a tumor can be resected

surgically

Therapeutic uses To Remove foreign objects from

9. Lung Scan Procedure using inhalation or I.V. injection of a

radioisotope, scans are taken with a scintillation camera. Imaging of distribution and blood flow in the lungs.

(Measure blood perfusion) Confirm pulmonary embolism or other blood- flow

tracheobronchial tree abnormalities To Excise lesions To remove tenacious secretions obstructing the

tracheobronchial tree Nursing interventions BEFORE the procedure:

Allay the patient’s anxiety To drain abscess Instruct the patient to Remain still during the To treat post-operative atelectasis procedure

Nursing interventions BEFORE Bronchoscopy Informed consent/ permit needed Explain procedure to the patient, tell him what to

expect, to help him cope with the unkown Atropine (to diminish secretions) is

administered one hour before the procedure About 30 minutes before bronchoscopy,

Valium is given to sedate patient and allay anxiety.

Topical anesthesia is sprayed followed bylocal anesthesia injected into the larynx

Instruct on NPO for 6-8 hours Remove dentures, prostheses and contact lenses The patient is placed supine with

hyperextended neck during the procedure

Nursing interventions AFTER Bronchoscopy Put the patient on Side lying position Tell patient that the throat may feel sore with . Check for the return of cough and gag reflex. Check vasovagal response. Watch for cyanosis, hypotension, tachycardia,

arrythmias, hemoptysis, and dyspnea. Thesesigns and symptoms indicate perforation ofbronchial tree. Refer the patient immediately!

Nursing interventions AFTER the procedure Check the catheter insertion site for bleeding Assess for allergies to injected radioisotopes Increase fluid intake, unless contraindicated.

10. Sputum Examination Laboratory test Indicated for microscopic examination of the sputum:

Gross appearance, Sputum C&S, AFB staining, and for Cytologic examination/ Papanicolaou examination

Nursing interventions: Early morning sputum specimen is to be

collected (suctioning or expectoration) Rinse mouth with plain water Use sterile container. Sputum specimen for C&S is collected before the

first dose of anti-microbial therapy. For AFB staining, collect sputum specimen for

three consecutive mornings.

11. Biopsy of the Lungs Percutaneous removal of a small amount of lung tissue For histologic evaluation- Transbronchoscopic biopsy—done during bronchoscopy,- Percutaneous needle biopsy- Open lung biopsy

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Nursing interventions BEFORE the procedure: Withhold food and fluids Place obtained written informed consent in the

patient’s chart.

Nursing interventions AFTER the procedure: Observe the patient for signs of Pneumothorax

and air embolism Check the patient for hemoptysis and

hemorrhage Monitor and record vital signs Check the insertion site for bleeding Monitor for signs of respiratory distress

12. Lymph Node Biopsy Scalene or cervicomediastinal To assess metastasis of lung cancer

13. Pulmonary Function Test / Studies Non-invasive test Measurement of lung volume, ventilation, and diffusing

capacity Nursing interventions:

Document bronchodilators or narcotics used before testing

Allay the patient’s anxiety during the testing

LU N G V O LU M E S : (ITE R ) Inspiratory reserve

volume (3000 mL) The maximum volume that can be inhaled following a normal

quiet inhalation.Tidal volume (500 mL)

The volume of air inhaled and exhaled with normal quiet breathing

Expiratory reserve volume (1100 mL) The maximum volume that can be exhaled following the normal

quiet exhalationResidual volume (1200 mL)

The volume of air that remains in the lungs after forceful exhalation

LU N G C A PAC I TI E S :

Functional Residual Capacity (ERV 1100 mL + RV 1200 mL =2300 mL )

The volume of air that remains in the lungs after normal, quiet exhalation

Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500 mL ) The amount of air that a person can inspire maximally after

a normal expirationVital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL =4600 mL )

The maximum volume of air that can be exhaled after a maximum inhalation

Reduced in COPDTotal Lung Capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL + RV 1200 mL = 5800 mL )

Total of all four volumes

14. Arterial Blood Gas Laboratory test Indicate respiratory functions Assess the degree to which the lungs are able to provide

adequate oxygen and remove CO2 Assess the degree to which the kidneys are able to

reabsorb or excrete bicarbonate. Assessment of arterial blood for tissue oxygenation,

ventilation, and acid-base status Arterial puncture is performed on areas where good

pulses are palpable (radial, brachial, or femoral).Radial artery is the most common site for withdrawal of blood specimen

Nursing interventions: Utilize a 10-ml. Pre-heparinized syringe to

prevent clotting of specimen Soak specimen in a container with ice to

prevent hemolysis If ABG monitoring will be done, do Allen’s

test to assess for adequacy of collateral circulation of the hand (the ulnar arteries)

15. Pulmonary Angiography This procedure takes X-ray pictures of the pulmonary blood

vessels (those in the lungs). Because arteries and veins are not normally seen in an X- ray, a

contrast material is injected into one or morearteries or veins so that they can be seen.

Turn on the unaffected side to prevent leakage The nurse should prevent skin breakdown by checkingof fluid in the thoracic cavity nares, nose and applying gauze or cotton as necessary

Check the puncture site for fluid leakage Ensure that COPD patients receive only LOW flow Auscultate lungs to assess for pneumothorax oxygen because these persons respond to hypoxia, not Monitor oxygen saturation (SaO2) levels increased CO levels.

Bed restCheck for expectoration of blood 12



16. Ventilation - Perfusion Scan Radioactive albumin injection is part of a nuclear scan

test that is performed to measure the supply of blood through the lungs.

After the injection, the lungs are scanned to detect the location of the radioactive particles as blood flowsthrough the lungs.

The ventilation scan is used to evaluate the ability of air to reach all portions of the lungs. The perfusion scan measures the supply of blood through the lungs.

A ventilation and perfusion scan is most often performed to detect a pulmonary embolus. It is also used to evaluate lung function in people with advanced pulmonary disease such as COPD and to detect the presence of shunts(abnormal circulation) in the pulmonary blood vessels.

17. Thoracentesis Procedure suing needle aspiration of intrapleural fluid or

air under local anesthesia Specimen examination or removal of pleural fluid

Nursing intervention BEFORE Thoracentesis Secure consent Take initial vital signs Instruct to remain still, avoid coughing during

insertion of the needle Inform patient that pressure sensation will be

felt on insertion of needle

Nursing intervention DURING the procedure: Reassess the patient Place the patient in the proper position:

Upright or sitting on the edge of the bed

Lying partially on the side, partially on the back

Nursing interventions after Thoracentesis Assess the patient’s respiratory status Monitor vital signs frequently Position the patient on the affected side, as

ordered, for at least 1 hour to seal the puncturesite

RESPIRATORY CARE MODALITIES

1. Oxygen Therapy Oxygen is a colorless, odorless, tasteless, and dry gas that

supports combustion Man requires 21% oxygen from the environment in order to

survive Indication: Hypoxemia

Signs of Hypoxemiao Increased pulse rateo Rapid, shallow respiration and dyspneao Increased restlessness or lightheadednesso Flaring of nareso Substernal or intercostals retractionso Cyanosis

Low flow oxygen provides partial oxygenation with patient breathing a combination of supplemental oxygen and room air. Low-flow administration devices:

o Nasal Cannula 24-45% 2-6 LPMo Simple Face Mask 0-60% 5-8 LPMo Partial Rebreathing Mask 60-90% 6-10 LPMo Non-rebreathing Mask 95-100% 6-15 LPMo Croupetteo Oxygen Tent

High flow oxygen provides all necessary oxygenation, with patients breathing only oxygen supplied from the mask and exhaling through a one-way vent.High flow administration devices

o Venturi Mask 24-40% 4-10 LPM Preferred for clients with COPD because it

provides accurate amount of oxygen.o Face Masko Oxygen Hood*o Incubator / isolette*

Note: * can be used for both low and high flow administration

The purpose of steam inhalation are as follows:- to liquefy mucous secretions Percussion- to warm and humidify air Produces energy wave that is transmitted through the- to relieve edema of airways chest wall to the bronchi.- to soothe irritated airways The chest is struck rhythmically with cupped hands over- to administer medication the areas were secretions are located.

It is a dependent nursing function Avoid percussion over the spine, kidneys, breast or Inform the client and explain the purpose of the procedure incision and broken ribs. Areas should be percussed for Place the client in Semi-Fowler’s position 1-2 minutes Cover the client’s eyes with washcloth to prevent irritation Check the electrical device before use Vibration Place the steam inhalator in a flat, stable surface. Works similarly to percussion, where hands are placed on Place the spout 12 – 18 inches away from the client’s nose or client’s chest and gently but firmly rapidly vibrate hands

adjust distance as necessary against thoracic wall especially during client’s exhalation. CAUTION: avoid burns. Cover the chest with towel to This may help dislodge secretions and stimulate cough.

prevent burns due to dripping of condensate from the steam. This should be done at least 5-7 times during patientAssess for redness on the side of the face which indicates exhalation.first degree burns.

To be effective, render steam inhalation therapy for 15 – 20

minutesInstruct the client to perform deep breathing and coughingexercises after the procedure to facilitate expectoration ofmucous secretions.

Provide good oral hygiene after the procedure. Do after-care of equipment.

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2. Tracheobronchial suctioning Suction only when necessary not routinely Use the smallest suction catheter if possible Client should be in semi or high Fowler’s position Use sterile gloves, sterile suction catheter Hyperventilate client with 100% oxygen before and after

suctioning Insert catheter with gloved hand (3-5― length of catheter

insertion) without applying suction. Three passes of the catheter is the maximum, with 10 seconds per pass.

Apply suction only during withdrawal of catheter The suction pressure should be limited to less than 120

mmHg When withdrawing catheter rotate while applying

intermittent suction Suctioning should take only 10 seconds (maximum of 15

seconds) Evaluate: clear breath sounds on auscultation of the chest.

3. Bronchial Hygiene Measures Suctioning: oropharyngeal; nasopharyngeal

a. Steam inhalation

Goals are removal of bronchial secretions, improved ventilation, and increased efficiency of respiratory muscles. Postural drainage uses specific positions to use gravity to assist

in the removal of secretions. Vibration loosens thick secretions by percussion or

vibration. Breathing exercises and breathing retraining improve

ventilation and control of breathing and decrease the work of breathing.

These are procedures for patients with respiratory disorders like COPD, cystic fibrosis, lung abscess, and pneumonia. The therapy is based on the fact that mucus can be knocked or shaken from airways and helped todrain from the lungs.

Postural drainage Use of gravity to aid in the drainage of secretions. Patient is placed in various positions to promote flow of

drainage from different lung segments using gravity. Areas with secretions are placed higher than lung

segments to promote drainage. Patient should maintain each position for 5-15 minutes

depending on tolerability.

b. Aerosol inhalation done among pediatric clients to administer brochodilators or

mucolytic-expectorants..

c. Medimist inhalation done among adult clients to administer bronchodilators or

mucolytic-expectorants.

4. Chest Physiotheraphy ( CPT ) Includes postural drainage, chest percussion and vibration, and

breathing retraining. Effective coughing is also an important component.

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Suctioning Nursing Interventions in CPT

Verify doctor’s order Assess areas of accumulation of mucus secretions. Position to allow expectoration of mucus secretions by

gravity Place client in each position for 5-10 to 15 minutes Percussion and vibration done to loosen mucus

secretions Change position gradually to prevent postural

hypotension Client is encouraged to cough up and expectorate

sputum Procedure is best done 60 to 90 minutes before

meals or in the morning upon awakening and at bedtime.

Provide good oral care after the procedure

5. Incentive Spirometry• Types: volume and flow• Device ensures that a volume of air is inhaled and the

patient takes deep breaths.• Used to prevent or treat atelectasis• To enhance deep inhalation

• Nursing care– Positioning of patient, teach and encourage use, set

realistic goals for the patient, and record the results.

6. Closed Chest Drainage ( Thoracostomy Tube ) Chest tube is used to drain fluid and air out of the

mediastinum or pleural space into a collection chamberto help re-establish normal negative pressure for lung re- expansion.

Purposes To remove air and/or fluids from the pleural space To reestablish negative pressure and re-expand the

lungs Procedure

The chest tube is inserted into the affected chest wall at the level of 2nd to 3rd intercostals space to release air or in the fourth intercostals space to remove fluid.

Types of Bottle DrainageOne-bottle system

The bottle serves as drainage and water-seal Immerse tip of the tube in 2-3 cm of sterile NSS to

create water-seal. Keep bottle at least 2-3 feet below the level of the

chest to allow drainage from the pleura by gravity. Never raise the bottle above the level of the heart to

prevent reflux of air or fluid. Assess for patency of the device Observe for fluctuation of fluid along the tube. The

fluctuation synchronizes with the respiration. Observe for intermittent bubbling of fluid;

continues bubbling means presence of air-leak

In the absence of fluctuation:Suspect obstruction of the device

Assess the patient first, then if patient is stable Check for kinks along tubing; Milk tubing towards the bottle (If the hospital allows the nurse

to milk the tube) If there is no obstruction, consider lung re-expansion;

(validated by chest x-ray) Air vent should be open to air.

Two-bottle system If not connected to the suction apparatus The first bottle is drainage bottle; The second bottle is water-seal bottle Observe for fluctuation of fluid along the tube

(water-seal bottle or the second bottle) and intermittent bubbling with each respiration.

NOTE! IF connected to suction apparatus1. The first bottle is the drainage and water-seal bottle;2. The second bottle is suction control bottle.3. Expect continuous bubbling in the suction control bottle;4. Intermittent bubbling and fluctuation in the water-seal5. Immerse tip of the tube in the first bottle in 2 to 3 cm of

sterile NSS6. Immerse the tube of the suction control bottle in 10 to 20 cm

of sterile NSS to stabilize the normal negativepressure in the lungs.

7. This protects the pleura from trauma if the suction pressure is inadvertently increased

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Three-bottle system Removal of chest tube—done by physician

The first bottle is the drainage bottle; The second bottle is water seal bottleThe third bottle is suction control bottle.

The nurse Prepares:Petrolatum Gauze Suture removal kit Sterile gauze

Observe for intermittent bubbling and fluctuation with respiration in the water- seal bottle

Adhesive tape Place client in semi-Fowler’s position Instruct client to exhale deeply, then inhale and do

Continuous GENTLE bubbling in the suctioncontrol bottle. These are the expected observations.

valsalva maneuver as the chest tube is removed. Chest x-ray may be done after the chest tube is

Suspect a leak if there is continuous bubbling inthe WATER seal bottle or if there is VIGOROUS

removed Asses for complications: subcutaneous emphysema;

bubbling in the suction control bottle. respiratory distress The nurse should look for the leak and report the

observation at once. N eve r c la m p t h e t ub i n g 7. Artificial Airwayunn ece s sa ri l y .

If there is NO f l u c t u a t io n i n t h e w a ter s ea l bo t t l e , it may meanTWO things

Either the lungs have expanded or the system is NOTfunctioning appropriately.

In this situation, the nurse refers the observation to the physician, who will order for an X-ray to confirm the suspicion.

Important Nursing considerations Encourage doing the following to promote drainage: Deep breathing and coughing exercises Turn to sides at regular basis Ambulate ROM exercise of arms Mark the amount of drainage at regular intervals Avoid frequent milking and clamping of the tube to

prevent tension pneumothorax

What the nurse should do if: If there is continuous bubbling: The nurse obtains a toothless clamp Close the chest tube at the point where it exits the chest for a

few seconds. If bubbling in the water seal bottle stops, the le a k is

l i ke l y in t h e l un g s , But if the bubbling continues, the le a k is b e tw ee n t h e c l a m p

a n d t h e b o t t le c h a m b e r .

Next, the nurse moves the clamp towards the bottle checking the bubbling in the water seal bottle.

If bubbling stops, the leak is between the clamp and the distal part including the bottle.

But if there is persistent bubbling, it means that thedrainage unit is leaking and the nurse must obtain another set.

In the event that the water seal bottle breaks, the nurse temporarily kinks the tube and must obtain areceptacle or container with sterile water and immerse the tubing.

She should obtain another set of sterile bottle as replacement. She should NEVER CLAMP the tubefor a longer time to avoid tension pneumothorax.

In the event the tube accidentally is pulled out, the nurse obtains vaselinized gauze and covers the stoma.

She should immediately contact the physician.

a. Oral airways- these are shorter and often have a larger lumen.They are used to prevent the tongue form falling backward.

b. Nasal airways- these are longer and have smaller lumen Which causes greater airway resistance

c. Tracheostomy- this is a temporary or permanent surgical opening in the trachea. A tube is inserted to allow ventilation and removal of secretions. It is indicated for emergency airway access for many conditions. The nurse must maintain tracheostomy care properly to prevent infection.

RESPIRATORY DISEASES AND DISORDERS

I. PNEUMONIA – inflammation of the lung parenchyma leading to pulmonary consolidation because alveoli is filled with exudates

A. ETIOLOGIC AGENTS1. Streptococcus pneumoniae (pneumococcal

pneumonia)2. Hemophilus influenzae (bronchopneumonia)3. Klebsiella pneumoniae4. Diplococcus pneumoniae5. Escherichia coli6. Pseudomonas aeruginosa

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B. HIGH RISK GROUPS1. Children less than 5 yo

Usually, it is the upper lung areas which are drained

2. Elderly Nursing management: Monitor VS and BS

C. PREDISPOSING FACTORS Best performed before meals/breakfast or1. Smoking 2-3 hours p.c. to prevent gastroesophageal2. Air pollution reflux or vomiting (pagkagising maraming3. Immunocompromised secretions diba? Nakukuha?)

(+) AIDS Encourage DBE Kaposi’s Sarcoma Administer bronchodilators 15-30 minutes Pneumocystis Carinii Pneumonia before procedure

DOC: Zidovudine (Retrovir) Stop if pt. can’t tolerate the procedure

4. Bronchogenic CaProlonged immobility (hypostatic pneumonia)

Provide oral care after procedure as it mayaffect taste sensitivity

5. Aspiration of food (aspiration pneumonia) Contraindications:6. Over fatigue Unstable VS

D. SIGNS AND SYMPTOMS1. Productive cough, greenish to rusty2. Dyspnea with prolong expiratory grunt3. Fever, chills, anorexia, general body malaise4. Cyanosis5. Pleuritic friction rub6. Rales/crackles on auscultation7. Abdominal distention paralytic ileus

E. DIAGNOSTICS1. Sputum GS/CS confirmatory; type and sensitivity;

Hemoptysis Increased ICP

Increased IOP (glaucoma)12. Provide pt health teaching and d/c planning

Avoidance of precipitating factors Prevention of complications

Atelectasis Meningitis

Regular compliance to medications Importance of ffup care

2.3.

(+) to cultured microorganismCXR – (+) pulmonary consolidationCBC

Tracheostomy usually done at bedside, 10-20 minutesStress test: 30 minutesMammography: 10-20 minutes

Elevated ESR (rate of erythropoeisis) N = 0.5-1.5% (compensatory mech to decreased O2)

LARYNGOSPASM – tracheostomy STATOR Tracheostomy: laryngeal, thyroid, neck CA

Elevated WBC DIAPHRAGM – primary muscle for respiration4. ABG – PO2 decreased (hypoxemia) INTERCOSTAL MUSCLES – secondary muscle for respiration

ALVEOLI (Acinar cells) –functional unit of the lungs; site for gas

F. NURSING MANAGEMENT1. Enforce CBR (consistent to all respi disorders)2. Strict respiratory isolation3. Administer medications as ordered

Broad spectrum antibiotics Penicillin – pneumococcal infections Tetracycline Macrolides

Azithromycin (OD x 3/days)1. Too costly2. Only se: ototoxicity – transient

hearing loss

exchange (via diffusion) VENTILATION – movement of air in and out of the lungs RESPIRATION – lungs to cells

Internal External

RETROLENTAL FIBROPLASIA – retinopathy/blindness in immaturity d/t high O2 flow in pedia patients

II. PULMONARY TUBERCULOSIS (KOCH’S DISEASE) – infection of the lung parenchyma caused by invasion of mycobacterium tuberculosis or tubercle bacilli (gram negative,acid fast, motile, aerobic, easily destroyed by heat/sunlight)

Anti-pyretics Mucolytics/expectorants

4. Administer O2 inhalation as ordered5. Force fluids to liquefy secretions6. Institute pulmonary toilet – measures to promote

expectoration of secretions DBE, Coughing exercises, CPT

(clapping/vibration), Turning and repositioning7. Nebulize and suction PRN8. Place client of semi-fowlers to high fowlers9. Provide a comfortable and humid environment10. Provide a dietary intake high in CHO, CHON, Calories

and Vit C

11. Assist in postural drainage Patient is placed in various position to drain

secretions via force of gravity

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A. PRECIPITATING FACTORS1. Malnutrition2. Overcrowding3. Alcoholism: Depletes VIT B1 (thiamin) alcoholic beriberi

malnutrition4. Physical and emotional stress5. Ingestion of infected cattle with M. bovis6. Virulence (degree of pathogenecity)

B. MODE OF TRANSMISSION: Airborne droplet infection

Monitor transaminases, BUN and

CREA

Corticosteroids

Anti-pyreticsMucolytics/expectorants

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C. SIGNS AND SYMPTOMS1. Productive cough (yellowish)2. Low grade afternoon fever, night sweats3. Dyspnea, anorexia, malaise, weight loss4. Chest/back pain5. Hemoptysis

D. DIAGNOSTICS1. Skin testing

Mantoux test – PPD Induration width (within 48-72 h)

8-10 mm (DOH) 10-14 mm (WHO) 5 mm in AIDS patients is +

indicates previous exposure to tubercle bacilli

2. Sputum AFB (+) tubercle bacilli3. CXR – (+) pulmo infiltrated due to caseous necrosis4. CBC – elevated WBC

E. NURSING MANAGEMENT1. Enforce CBR2. Institute strict respiratory isolation3. Administer O2 inhalation4. Forced fluids5. Encourage DBE and coughing

NO CLAPPING in chronic PTB d/t hemoptysis may lead to hemorrhage

6. Nebulize and suction PRN7. Provide comfortable and humid environment8. Institute short course chemotherapy

Intensive phase INH

SE: peripheral neuritis (increase vitB6 or pyridoxine

Rifampicin SE: red orange color of bodily

secretions PZA

May be replaced with Ethambutol (SE: optic neuritis) if (+) hypersensitivity to drug

SE: allergic reactions; hepatotoxicity and nephrotoxicity1. Monitor liver enzymes2. Monitor BUN and CREA

INH given for 4 months, PZA and Rifampicin is given for 2 months, A.C. to facilitate absorption

These 3 drugs are given simultaneously to prevent development of resistance

Standard Regimen Streptomycin injection (aminoglycosides)

Neomycin, Amikacin, Gentamycin1. common SE: 8th CN damage

tinnitus hearing loss ototoxicity2. nephrotoxicity

a. BUN (N = 10-20)b. CREA (N = 8-10)

9. Health teaching and d/c planning

Avoidance of precipitating factors : alcoholism, overcrowding

Prevention of complications Atelectasis

Military TB (extrapulmonary TB:meningeal, Pott’s, adrenal glands, skin,

cornea) Strict compliance to medications

Never double the dose! Continue taking the meds if missed a day)

Diet modifications: increased CHON, CHO, Calories, Vit C

Importance of ffup care

III. HISTOPLASMOSIS – acute fungal infection caused by inhalation of contaminated dust with Histoplasma capsulatum from birds’ manure

A. PREDISPOSING FACTORS Inhalation of contaminated dust

2. SIGNS AND SYMPTOMS PTB like symptoms Productive cough Fever, chills, anorexia, generalized body

malaise Cyanosis Chest and joint pains Dyspnea Hemoptysis

3. DIAGNOSTICS Histoplasmin skin test is (+) ABG analysis reveals pO2 low

4. NURSING MANAGEMENT Enforce CBG Administer meds as ordered

Antifungal agents Amphotericin B (Fungizone) SE:

nephrotoxicity and hypokalemia

Administer oxygen inhalation as ordered Forced fluids Nebulize and suction as necessary Prevent complications

Bronchiectasis, atelectasis Prevention of spread

Spraying of breeding places Kill bird and owner! Hehe!

CHRONIC OBSTRUCTIVE PULMONARY DISEASES

1. Chronic Bronchitis2. Bronchial Asthma3. Bronchiectasis4. Pulmonary Emphysema

CO2 narcosis coma AntihistamineAdminister oxygen inhalation as orderedForced fluidsNebulize and suction patient as necessary

Cor pulmonale 3. Pleural effusion 4. Pneumothorax 5.

Regular adherence to meds 6. Encourage DBE and coughing Importance of ffup care 7. Provide a comfortable and humid environment

8. Health teaching and d/c planning Avoidance of precipitating factors Prevention of complications19



I. CHRONIC BRONCHITIS (Blue Bloaters) – Inflammation of the bronchi due to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways

II. BRONCHIAL ASTHMA – reversible inflammatory lung condition caused by hypersensitivity to allergens leading to narrowing of smaller airways

A. PREDISPOSING FACTORSA. PREDISPOSING FACTORS 1. Extrinsic (Atopic/Allergic Asthma)

1. Smoking2. Air pollution 2.

Pollens, dust, fumes, smoke, fur, dander, lintsIntrinsic (Non-Atopic/Non-Allergic) Drugs (aspirin, penicillin, B-blockers)

B. SIGNS AND SYMPTOMS Foods (seafoods, eggs, chicken, chocolate)

1. Consistent productive cough2. Dyspnea on exertion with prolonged expiratory grunt3. Anorexia and generalized body malaise4. Cyanosis5. Scattered rales/rhonchi6. Pulmonary hypertension

Peripheral edema Cor pulmonale

C. DIAGNOSTICS1. ABG analysis: decreased PO2, increased PCO2,

respiratory acidosis; hypoxemia cyanosis

D. NURSING MANAGEMENT1. Enforce CBR2. Administer medications as ordered

Bronchodilators Antimicrobials Corticosteroids Mucolytics/expectorants

3. Low inflow O2 admin; high inflow will cause respiratory arrest

4. Force fluids5. Nebulize and suction client as needed6. Provide comfortable and humid environment7. Health teaching and d/c planning

avoidance of smoking prevent complications

Food additives (nitrates, nitrites) Sudden change in temperature, humidity and air

pressure Genetics Physical and emotional stress

3. Mixed type combination of both

B. SIGNS AND SYMPTOMS1. Cough that is productive2. Dyspnea3. Wheezing on expiration4. Tachycardia, palpitations and diaphoresis5. Mild apprehension, restlessness6. Cyanosis

C. DIAGNOSTICS1. PFT decreased vital lung capacity2. ABG analysis PO2 decreased


Bronchodilators administer first to facilitate absorption of corticosteroids

Inhalation MDI

Corticosteroids Mucolytics/expectorants Mucomyst

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Status asthmaticus DOC: Epinephrine Aminophylline drip

Emphysema Regular adherence to medications Importance of ffup care

III. BRONCHIECTASIS – permanent dilation of the bronchus due to destruction of muscular and elastic tissue of the alveolar walls (subject to surgery)

A. PREDISPOSING FACTORS1. Recurrent lower respiratory tract infection

Histoplasmosis2. Congenital disease3. Presence of tumor4. Chest trauma

B. SIGNS AND SYMPTOMS1. Consistent productive cough2. Dyspnea3. Presence of cyanosis4. Rales and crackles5. Hemoptysis6. Anorexia and generalized body malaise

C. DIAGNOSTICS1. ABG analysis reveals low PO22. Bronchoscopy – direct visualization of bronchi lining

using a fibroscope Pre-op

Secure consent Explain procedure NPO 4-6 hours Monitor VS and breath sounds

Post-operative Feeding initiated upon return of gag reflex Instruct client to avoid talking, coughing and

smoking as it may irritate respiratory tract

Monitor for s/sx of frank or gross bleeding Monitor for signs of laryngeal spasm

DOB and SOB prepare trache setD. SURGERY

1. Segmental lobectomy2. Pneumonectomy

Most feared complications Atelectasis Cardiac tamponade: muffled heart sounds,

pulsus paradoxus, HPN

E. NURSING MANAGEMENT1. Enforce CBR2. Low inflow O2 admin; high inflow will cause

respiratory arrest3. Administer medications as ordered

Bronchodilators Antimicrobials Corticosteroids (5-10 minutes after

bronchodilators) Mucolytics/expectorants

4. Force fluids5. Nebulize and suction client as needed6. Provide comfortable and humid environment7. Health teaching and d/c planning

Avoidance of smoking Prevent complications

Atelectasis CO2 narcosis coma Cor pulmonale Pleural effusion Pneumothorax

Regular adherence to meds Importance of ffup care

IV. PULMONARY EMPHYSEMA – terminal and irreversible stage of COPD characterized by :

Inelasticity of alveoli Air trapping Maldistribution of gasses (d/t increased air trapping) Overdistention of thoracic cavity (Barrel chest)

compensatory mechanism increased AP diameter

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A. PREDISPOSING FACTORS1. Smoking2. Air pollution3. Hereditary: involves alpha-1 antitrypsin for

elastase production for recoil of the alveoli4. Allergy5. High risk group elderly degenerative

decreased vital lung capacity and thinning of alveolar lobes

B. SIGNS AND SYMPTOMS1. Productive cough2. Dyspnea at rest3. Prolonged expiratory grunt4. Resonance to hyperresonance5. Decreased tactile fremitus6. Decreased breath sounds ( if (-) BS lung collapse)7. Barrel chest8. Anorexia and generalized body malaise9. Rales or crackles10. Alar flaring11. Pursed-lip breathing (to eliminate excess CO2)

C. DIAGNOSTICS1. ABG analysis reveal

Panlobular, centrilobular PO2 elevation and PCO2 depression respiratory acidosis (blue bloaters)

Panacinar/centriacinar PCO2 depression andPO2 elevation (pink puffers – hyperaxemia)

2. Pulmo function test – decreased vital lung capacity


Bronchodilators Antimicrobials Corticosteroids Mucolytics/expectorants

3. Low inflow O2 admin; high inflow will cause respiratory arrest and oxygen toxicity

4. Force fluids5. Pulmonary toilet6. Nebulize and suction client as needed7. Institute PEEP in mechanical ventilation

PEEP – positive end expiratory pressure allows for maximum alveolar diffusion prevent lung collapse

8. Provide comfortable and humid environment9. Diet modifications: high calorie, CHON, CHO,

vitamins and minerals10. Health teaching and d/c planning

Avoidance of smoking Prevent complications

Atelectasis CO2 narcosis coma

Cor pulmonale Pleural effusion Pneumothorax

Regular adherence to meds Importance of ffup care

RESTRICTIVE LUNG DISEASE

V. PNEUMOTHORAX – partial or complete collapse of the lungs due to accumulation of air in pleural space

A. TYPES1. Spontaneous – air enters pleural space without an

obvious cause Ruptured blebs (alveolar – filled sacs)

inflammatory lung conditions2. Open – air enters pleural space through an opening in

pleural wall (most common) Gun shot wounds Multiple stab wounds

3. Tension – air enters pleural space during inspiration and cannot escape leading to overdistention of the thoracic cavity mediastinal shift to the affected side (ie. Flail chest) paradoxical breathing

B. PREDISPOSING FACTORS1. Chest trauma2. Inflammatory lung condition3. tumors

C. SIGNS AND SYMPTOMS1. Sudden sharp chest pain, dyspnea, cyanosis2. Diminished breath sounds3. Cool, moist skin4. Mild restlessness and apprehension5. Resonance to hyperresonance

D. DIAGNOSTICS1. ABG analysis: PO2 decreased2. CXR – confirms collapse of lungs

E. NURSING MANAGEMENT1. Assist in endotracheal intubation2. Assist in thoracentesis3. Administer meds as ordered

Narcotic analgesics – Morphine sulfate Antibiotics

4. Assist in CTT to H20 sealed drainage

Respiratory MA.doc

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