Respiratory System(Oxygenation)

I. Overview of the Anatomy and PhysiologyA. Upper Respiratory Tract

Structures of the respiratory system, primarily an air conduction system, include the nose, pharynx, and larynx. Air is filtered, warmed, and humidified in the upper airway before passing to lower airway.1. Nose

- External nose is a framework of bone and cartilage, internally divided into two passages or nares (nasal cavities) by the septum; air enters the system through the nares.

- The septum is covered with a mucous membrane, where the olfactory receptors are located.

- Turbinates, located internally, assist in warming and moistening the air.The major functions of the nose are warming, moistening, and filtering the air.2. Pharynx

Muscular passageway commonly called the throat.Air passes through the nose to the pharynx, composed of three sections:* Nasopharynx: located above the soft palate of the mouth, contains the adenoids and openings to the Eustachian tubes.* Oropharynx: located directly behind the mouth and tongue, contains the palatine tonsils; air and food enter body through oropharynx.* Laryngopharynx: extends from the epiglottis to the sixth cervical level.

3. Larynx- Sometimes called “voicebox,” connects upper and lower airways;

framework is formed by the hyoid bone, epiglottis, and thyroid, cricoids, and arytenoids cartilages.

- The opening of the larynx is called the glottis.Larynx opens to allow respiration and closes to prevent aspiration when food passes through the pharynx. Vocal cords of the larynx permit speech and are involved in the cough reflex.

B. Lower Respiratory TractConsists of the trachea, bronchi and branches, and the lungs and

associated structures.Trachea1. Air moves from the pharynx to larynx to trachea (length 11-13cm, diameter 1.5-2.5cm in adult).2. Extends from the larynx to the second costal cartilage, where it bifurcates and is supported by 16-20 C-shaped cartilage ring.3. The area where the trachea divides into two braches is called carina.

• Bronchi1. Formed by the division of the trachea into two brances (bronchi)

a. Left mainstem bronchus: larger and straighter than the left; further divides into three lobar branches (upper, middle, and lower lobar bronchi) to supply the three lobes of right lung.

b. Left mainstem bronchus: divides into the upper and lower lobar bronchi, to supply two lobes of left lung.2. At the point a bronchus reaches about 1 mm in diameter it no longer has a connective tissue sheath and is called a bronchiole.3. In the bronchioles, airway patency is primarily dependent upon elastic recoil formed by network of smooth muscles.4. The tracheobroncial tree ends at the terminal bronchioles. Distal to the terminal bronchioles the major function is no longer air conduction, but gas exchange between blood and alveolar air.The respiratory bronchioles serve as the transition to the alveolar epithelium.

• Lungs (Right and Left)- Main organs of respiration, lie within the thoracic cavity on either

side of the heart.- Broad area of lung resting on diaphragm is called the base; the

narrow , superior portion is the apex.- Each lung is divided into lobes: three in the right lung, two in the

left.- Pleura: serous membrane covering the lungs; continuous with the

parietal pleura that lines in the chest wall.-Lungs and associated structures are protected by the chest wall.

* Chest wall

-Includes the rib cage, intercostal muscles,and diaphragm.-Parietal pleura lines the chest wall and secretes small amounts of

lubricating fluid into the intrapleural space (space between the visceral and parietal pleura).

-This fluid holds the lung and chest wall together as a single nit while allowing them to move separately.

-The chest is shaped and supported by 12 pairs of ribs and costal cartilages; the ribs have several attached muscles.

a. Contraction of the external intercostals muscles raises the rib cage during inspiration and helps increase the size of the thoracic cavity.

b. The internal intercostals muscles tend to pull ribs down and in and play a role in forced expiration.

- The diaphragm is the major muscle of ventilation (the exchange of air between the atmosphere and the alveoli).

- Contraction of muscle fibers causes the dome of the diaphragm to descend, thereby, increasing the volume of the thoracic cavity.

- As exertion increases, additional chest muscles may be employed in moving the thoracic cage.

C. Pulmonary Circulation-Provides for reoxygenation of blood and release of CO2; gas transfer occurs in

the pulmonary capillary bed.-Pulmonary arteries arise from the right ventricle of the heart and continue to

the bronchi and alveoli, gradually decreasing in size to capillaries.-The capillaries, after contact with the gas-exchange surface of the alveoli,

reform to form the pulmonary veins.-The two pulmonary veins, superior and inferior, empty into the left atrium.

D. Gas exchange

-Alveolar ducts arise from the respiratory bronchioles and lead to the alveoli.-Alveoli are the functional cellular units of the lungs; about half arise directly

from the alveolar ducts and are responsible for about 35% of alveolar exchange.-Alveoli produce surfactant, a phopholipid substance found in the fluid ining

the alveolar epithelium. Surfactant reduces surface tension and increases the ability of the alveoli and prevents their collapse.

-Alveolar sacs from the last part of the airway; functionally the same as the alveolar ducts, they are surrounded by alveoli and are responsible for 65% of the alveolar gas exchange.

II. ASSESSMENT A. Health History 1. Biographical Data (name, age, gender,race, date of birth, address, marital status, religion, etc) 2. Chief complaint/Presenting Problem

- Nose/nasal sinuses: symptoms may include colds, discharge, epistaxis, sinus problems (swelling,pain)

- Throat: symptoms may include sore throat, hoarseness, difficulty swallowing, etc.

- Lungs: symptoms may include - Cough: note duration, frequency: type(dry, hacking, bubbly, barky,

hoarse, congested); sputum (productive or nonproductive); circumstances related to cough (time of day, positions, talking, anxiety); treatment.

- Dyspnea: note onset, severity, duration, efforts to treat, whether associated with radiation., if accompanied by cough or diaphoresis, time of day when it most likely occurs, interference with ADL, whether precipitated by any specific acivities, whether accompanied y cyanosis.

- Wheezing, chest pain, hemoptysis - Relief measures

3. Past Medical History- immunization, allergies (foods, drugs, contact or inhalant allergens,

precipitating factors, specific treatment, desensitization), surgeries, other medical illnesses, nutrition/diet, etc.

4. Family History Assessment- Assess family histories of respiratory impairment.- Assess family history for individuals with early-onset chronic

pulmonary disease, and other communicable respiratory diseases.- Assess family history of genetically-linked diseases.

5. Lifestyle- smoking (note type, duration, number per day, number of years of

smoking, inhalation); substance abuse, occupation (work conditions that could irritate respiratory system), geographical location, type and frequency of exercise.

B. Physical Examination of the Upper Respiratory Tract1. Nose – straight, without flaring or discharge, nares patent; mucosa pink and moist; septum midline, without masses or perforation2. Sinuses – transilluminate 3. Trachea

- note the position and mobility of the trachea by direct palpation

- inspect for enlarged lymph nodes

C. Physical Assessment of the Lower Respiratory Tract1. Thorax (skin color, turgor, evidence of loss of subcutaneous tissue, and note for asymmetry)2. Chest Configuration

- normally, the ratio of the anteroposterior diameter to the lateral diameter is !:2. There are four main deformities of the cheast with respiratory problems:

a. Barrel chest – occurs as the result of overinflation of the lungs. More evident in patient’s with emphysema; in which the ribs are wider in space and intercostal spaces tend to bulge on expirationb. Funnel chest (Pectus excavatum) – occurs when there is a depression in the lower portion of the sternum. This may occur in clients with rickets or Marfari’s syndrome.;c. Pigeon’s chest (Pectus carinatum) – occurs as a result of displacement of the sternum. There is an increase in anteroposterior diameter. This may occur with rickets, Marfari’s syndrome, or severe kyphoscoliosis.d. Kyphoscoliosis – is characterized by elevation of the scapula and a corresponding S-shaped spine. Tyhis may occur with osteoorosis and other skeletal disorders that affect the thorax.

3. Breathing Patterns and Respiratory Ratesa. Eupnea – breathing at 12-18 breaths/minb. bradypnea – slower than normal rate (<10 breaths per min) with normal depth and regular rhythmc. Tacypnea – rapid, shallow breathing (>25 breaths/min)d. Hypoventilation – shallow, irregular breathinge. Hyperventilation – increased rate and depth of

breathing (called Kussmaul’s respiration, if caused by DKA)f. Apnea – period of cessation of breathing.g.Cheyne-Stokes – regular cycle where the rate and depth of

breathing increase, then decrease until apnea (usually about 20 seconds) occurs.

h. Biot’s respiration – periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10 seconds to

1 minute).

4. Thoracic Palpation- palpates the thorax for tenderness, masses, lesions,

respiratory excursion, and vocal/tactile fremitus. * respiratory excursion – is an estimation of thoracic expansion and may disclose significant information about thoracic movement during breathing. (Decreased chest excursion may be due to chronic fibrotic disease. Asymmetric excursion may be due to splinting secondary to pleurisy, fractured ribs, trauma, or unilateral bronchial obstruction. * tactile fremitus – is the detection of the resulting vibration on the chest wall by touch while patient is asked to repeat consonant sounds.5. Thoracic Percussion

- normally, the nurse should find resonance over lung tissues: note for hyperresonance which may signify emphysema and pnumothorax.

- assess for the diaphragmatic excursion (normal distance between levels of dullness on full expiration and inspiration is 6 – 12 cm)

6. Thoracic Auscultation- normal breath sounds are distinguished by their location over a specific area

of the lung and as follows:a. vesicular – soft, relatively low-pitched sound which is heard over the entire

lung field except over the sternum and between the scapulae.b. bronchovesicular – intermediately-low pitched sound often heard in the 1st and 2nd interspaces anteriorly and between the scapulae over the main bronchus.c. bronchial – Loud, high-pitched sound heard over the manubrium.d. tracheal – Loud, high-pitched sound heard over the trachea in the neck.

assess for presence of adventitious sounds: 1. Crackles (formerly called rales):a. Crackles in general – soft, high-pitched, discontinuous popping sounds that

occur during inspiration. This may be due to the fluid in the airways or alveoli.

b. Coarse crackles – Discontinuous popping sounds heard in early inspiration, harsh, moist sound originating in the large bronchi. This may occur in clients with obstructive pulmonary disease.c. Fine crackles – Discontinuous popping sounds heard in late inspiration; sounds like hair rubbing together; originates in the alveoli. This is associated with interstitial pneumonia, and restrictive pulmonary disease.

2. Wheezes a. Sonorous wheeze (ronchi) – deep, low-pitched rumbling sounds heard primarily during expiration caused by air moving through narrowed tracheobronchial passages. This is associated with excessive mucous secretions and tumor growth. b. Sibilant wheeze – Continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways. This may be due to bronchospasm, asthma and buil dup of secretions3. Friction rubs – harsh, crackling sound, like two pieces of leather being rubbed together. This is associated with inflammation and loss of lubricating pleural fluid.4. Stridor – a shrill, harsh sound heard during inspiration with laryngeal spasm or obstruction.

III. Diagnostic Tests A. Arterial blood gases (ABGs) – measures base excess/deficit, blood pH, CO2, total CO2, O2 content, O2 saturation (SaO2), pCO2 (partial pressure of carbon dioxide), pO2 (partial pressure of oxygen). * Nursing Responsibilities:

a. If drawn by arterial stick, place a 4x4 bandage over puncture site after withdrawal of needle and maintain pressure with two fingers for at least 2 minutes.

b. Gently rotate sample in test tube to mix heparin with the blood.c. Place sample in ice-water container until it can be analyzed.

B. Pulmonary function studies1. Evaluation of lung volume and capacities by spirometry: tidal volume (TV), vital capacity (VC), inspiratory and

expiratory reserve volume (IRV and ERV), residual v olume (RV), inspiratory capacity (IC), functional residual capacity (FRC).

2. Involves use of spirometer to diaphragm movement of air as client performs various respiratory maneuvers; shows restriction or obstruction to airflow, or both.

* Nursing Care 1. Carefully explaining procedure will help allay anxiety and ensure cooperation. 2. Perform tests before meals. 3. Withhold medication that may alter respiratory function unless otherwise ordered. 4. After procedure assess pulse and provide for rest period C. Hematologic studies (ESR, Hgb, Hct, WBC, etc)D. Sputum culture and sensitivity

Culture: isolation and identification of specific microorganism from a specimen

Sensitivity: determination of antibiotic agent effective against organism (sensitive or resistant) *Nursing Care: 1. Explain necessity of effective coughing. 2. If client unable to cough, heated aerosol will assist with obtaining a specimen. 3. Collect specimen in a sterile container that can be capped afterwards. 4. Volume need not exceed 1 – 3 ml. 5. Deliver specimen to lab rapidly.

E. Tuberculin Skin Test – intradermal test done to detect tuberculosis infection; does not differentiate active from dormant infections 1. Purified purine derivative (PPD) tuberculin is administered to determine any previous desensitization to tubercle bacillus. 2. Methods of administration:

- Mantoux test : 0.1 ml solution containing 0.5 tuberculin units of PPD – tuberculin is injected itno the forearm.

- Tine Test: a stainless steel disc with 4 tines impregnated with PPD-tuberculin is pressed into the skin

3. Results: read within 48-72 hours; inspect skin and circle zone of induration with a pen; measure diameter in mm:- Negative: zone diameter less than 5 mm- doubtful or probable: zone diameter within 5m – 10 mm (investigate for other underlying medical condition)- Positive: zone diameter of 10mm or more

F. Thoracentesis – insertion of a needle through the chest wall into the pleural space to obtain the specimen for diagnostic evaluation; removal of pleural fluid accumulation, or to instill medication into the pleural space.

* Nursing Care: prior to procedurea. Confirm that a signed permit has been obtainedb. Explain procedure; instruct client not to cough or talk during

procedure.c. Position client at side of bed, with upper torso supported on

overbed table, feet and legs well supported.d. assess vital signs.

* Nursing care: following procedurea. Observe for signs and symptoms of pneumothorax, shock, leakage at puncture site.b. Auscultate chest to ascertain breath sounds.

G. Bronchoscopy – insertion of a fiberoptic scope into the bronchi for diagnosis, biopsy, specimen collection, examination of structures/tissues, removal of foreign bodies.*Nursing care: prior to procedure

a. Confirm that a signed permit has been obtainedb. Explain procedure, remove dentures, and provide

good oral hygiene.c. Keep client NPO 6-12 hours pretest.

*Nursing care: following procedure:a. Position client on side or in semi-Fowler’sb. Keep on NPO until return of gag reflex.c. assess for and report for frank bleedingd. Apply ice bags to throat for comfort; discourage talking, coughing, smoking for a few hours to decrease throat irritation.

H. Imaging Studies

a. X-ray studiesb. Ventilation-perfusion lung scan (Radioisotope Diagnostic Procedurec. CT scand. MRIe. Fluoroscopic studiesf. Pulmonary angiography

IV. ANALYSIS AND NURSING DIAGNOSIS

1. Ineffective breathing pattern2. Impaired gas exchange3. Altered tissue perfusion (peripheral)4. Activity Intolerance5. Pain6. Risk for infection7. Anxiety8. Ineffective individual coping9. Knowledge deficit

V. OUTOME IDENTIFICATION AND PLANNING

Goals for management of respiratory problems focus on improved breathing patterns, gas exchange and tissue perfusion, increased activity intolerance, pain relief, decreased anxiety, improved coping, and increased knowledge of disease process and therapeutic management.

VI. IMPLEMENTATION1. Assess respiratory status and tissue perfusion (respiratory rate, depth and effort; level of consciousness; lung sounds; buccal and peripheral cyanosis; capillary refill time; color and consistency of sputum; and pulse oximetry.2. Improve breathing patterns.

a. Encourage upright position (semi-Fowler or high-Fowler position) at least 30 to 45 degrees.b. Encourage the client to increase fluid intake to at least 2 to 3

liters of fluid each day, unless contraindicated as in pulmonary congestion.

3. Promote gas exchangea. Collaborate with a respiratory therapist when administering

oxygen therapy. Analyze ABG values and pulse oximetry to determine need for oxygen therapy. Assist in administering nebulizer, metered dose inhaler, or

intermittent positive-pressure breathing treatment and mechanical ventilation.

b. Encourage effective coughing. Instruct client to take three deep breaths in through the nose and out through the mouth, and on the third breath pull in the abdominal muscles and cough twice forcefully with mouth open. Encourage the client to lie on the affected side to splint the area if there is pain qwhen coughing.c. Encourage the client to eliminate or minimize exposure to all

pulmonary irritants, and advise the client to quit smoking.

4. Improve activity tolerance- Enourage client to alternate rest with activity to prevent over

exertion trhat may exacerbate symptoms and to increase activity gradually.

5. Provide pain managementa. assess the client for pain, and exclude other potential

complications.b. Instruct the client about splinting when the client has chest

pain.

6. Promote infection control measuresa. Instruct the client to avoid crowds of people with known colds, flu or respiratory infectionb. Implement the standard precautions and droplet or airborne

precautions as indicated.7. Promote coping and minimize anxiety.

a. support the client in dealing with emotional stress by discussing positive coping strategies (i.e., relaxation

techniques, guided imagery, and enrolment in pulmonary rehabilitation center).b. Reassure the client, give him concise explanations, and remain calm to reduce the client’s anxiety and thereby decrease oxygen need.

8. Provide client and family teaching.a. Instruct the client to report danger signs and symptoms, including a change in color of the sputum, numbness and tingling in extremities, and difficulty with breathing.