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Respiratory System2
 

Respiratory System2

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    Respiratory System2 Respiratory System2 Presentation Transcript

    • RESPIRATORY SYSTEM Ma. Victoria J. Recinto RN, USRN University of the Philippines-Manila Philippine General Hospital
    • OVERVIEW
      • Basic Process of Oxygenation
        • Ventilation- degree of compliance, airway resistance, accessory muscles (Respiratory System)
        • Diffusion- thickness of membranes (Hematologic System)
        • Perfusion- integrity of transport system (CV and Hematologic System)
    • OVERVIEW
      • Function: Respiratory System
        • Obtains O2, removes CO2
        • Filters particles from incoming air
        • Control T and water content
        • Role in sense of smell
        • Regulates blood pH
    • OVERVIEW
    • OVERVIEW
      • Upper Respiratory Tract
        • Filtering of air, warming, moistening
        • Humidification
      • A. Nose
      • Framework of cartilage
      • 2 septum/nostril
      • Anastomosis of capillaries (Keisselbach)
      • B. Pharynx (Throat)- organ of GI and RT
      • Muscular pasageway for food and air
      • Nasopharynx
      • Oropharynx
      • Laryngopharynx
    • OVERVIEW
      • C. Larynx (Voicebox)
      • Phonation (speech production)
      • Cough reflex
      • Frameworks
      • Arythenoid and cricoid cartilage
      • Thyroid gland
      • Hyoid bone
      • Glottis
      • Epiglottis
        • Opens: passage of air
        • Closes: passage of food
    • Upper Respiratory Tract
    • OVERVIEW
      • Lower Respiratory System
        • Gas exchange
        • A. Trachea (windpipe)
        • Cartilaginous rings, ‘U’ shape
        • Site of permanent artificial airway (tracheostomy)
        • B. Carina- area of bifurcation of bronchi
        • C. Bronchi
        • R main bronchus- wider straighter
        • L main bronchus
    • OVERVIEW
      • Lower Respiratory System
        • D. Lungs- covered by serous membrane
        • R- 3 lobes
        • L- 2 lobes
        • Pleural cavity
          • Parietal- with 20 cc of fluid to prevent friction, with nerve endings
          • Visceral- without nerve endings
          • Pleural space
    • OVERVIEW
      • Lower Respiratory System
        • D. Lungs
        • Terminal bronchioles
          • Alveoli (Acinar cells)- site of gas exchange (CO2 and O2)
          • Type II cells- secretes SURFACTANT (phospholipid lipoprotein)   surface tension
    • PNEUMONIA
      • Inflammation of lung parenchyma  pulmonary consolidation as the alveoli are filled with exudates
      • Causative Agents
        • Streptococcus pneumoniae (Pneumococcal pneumonia)
        • Hemophilus influenzae (Bronchopneumonia)
        • E. Coli
        • Klebsiella
        • Pseudomonas aeruginosa
    • PNEUMONIA
    • Predisposing Factors: PNEUMONIA
      • Excessive smoking
      • Air pollution
      • Over fatigue
      • Prolonged immobility  hypostatic pneumonia
      • Aspiration
      • Immunocompromised state
        • AIDS- Pneumocystis carinii taking Zidovudine (AZT)
        • Bronchogenic CA
    • Signs and Symptoms: PNEUMONIA
      • Productive cough (greenish to rusty sputum)
      • Dyspnea with prolonged expiratory grunt
      • Fever, chills, anorexia, N/V, weight loss
      • Pleuritic friction rub
      • Rales, crackles, Bronchial wheezing
      • Cyanosis
      • Chest pain
      • Abdominal distension  paralytic ileus (most feared Cx)
    • Diagnostic Procedures: PNEUMONIA
      • Sputum C/S
      • Gram-staining C/S
      • Chest X-Ray- reveals pulmonary consolidation
      • ABG-  pO2
      • CBC-  WBC,  ESR
    • Nursing Management: PNEUMONIA
        • CBR
        • Place pt. on semi-fowler’s
        • Low flow O2 as ordered
        • Give comfortable and humid environment
        • Diet:  CHON,  CHO,  Vit C
        • Force fluids to liquefy secretions
        • Importance of receiving immunization as recommended
    • Nursing Management: PNEUMONIA
        • Administer meds as ordered
          • Broad spectrum antibiotics
            • Penicillin, Tetracycline, Macrolides
          • Antipyretics
          • Mucolytics/ Expectorants (Guiafenesin, Glycerine, Guiacolate)
    • Nursing Management: PNEUMONIA
        • Institute pulmonary toilet
          • DBE
          • Coughing
          • Chest physiotherapy (CPT)
          • Turning and repositioning
        • Nebulize and suction prn
    • Chest Physiotherapy
    • Nursing Management: PNEUMONIA
        • Institute postural drainage as ordered
          • Pt is placed on various positions to promote drainage of secretions, stay for 20-30 minutes
          • Best done before breakfast, or 2-3 hrs p.c.
          • Pt. should be well hydrated, knows how to cough
            • Prone with pillow on abdomen- drains lower part of the lungs
            • Supine with buttocks up- drains upper part of the lungs
    • Postural Drainage
    • Postural Drainage
    • Nursing Management: PNEUMONIA
        • Institute postural drainage as ordered
          • Monitor VS, breath sounds
          • Administer bronchodilators 15-30 minutes prior
          • Encourage DBE
          • Stop if pt can’t tolerate the procedure
          • Give oral care post procedure
          • No to pt with: hemoptysis, unstable VS,  ICP,  IOP
    • Nursing Management: PNEUMONIA
        • Discharge Health Teaching
          • Stop smoking
          • Regular adherence to meds
          • Dietary modification
          • Follow-up care
          • Prevent Cx: atelectasis and meningitis
    • PULMONARY TUBERCULOSIS
      • Or Koch’s Disease
      • Causative agent: MTB- acid-fast, non-motile
      • Predisposing Factors
        • Malnutrition
        • Overcrowding
        • Alcoholism
        • Ingestion of affected cattle (with M. bovis)
        • Virulence of the microorganism
    • PULMONARY TUBERCULOSIS
    • Signs and Symptoms: PTB
        • Productive cough- yellowish secretions > 2 wks
        • Dyspnea
        • Low grade afternoon fever- Pathognomonic Sign
        • Night sweats- Classical Sign
        • Anorexia, general body malaise
        • Weight loss
        • Chest pain
        • Hemoptysis
    • Diagnostic Procedures: PTB
        • Mantoux Test- skin test, injection of PPD
          • Reading: after 48-72 hrs
          • (+) exposure to PTB:
            • DOH: 8-10 mm induration
            • WHO: 10-14 mm induration
    • Diagnostic Procedures: PTB
        • Sputum AFB- (+) MTB
        • Chest X-ray- pulmonary infiltrates (caseous necrosis)
        • CBC-  WBC
    • PULMONARY TUBERCULOSIS
      • Nursing Management
        • CBR
        • Comfortable environment
        • O2 inhalation as ordered
        • Force fluids to liquefy secretions
        • NO CPT, only DBE and coughing
        • Nebulize and suction prn
        • Place on semi-fowler’s
        • Diet:  CHON,  CHO,  Vit C
    • PULMONARY TUBERCULOSIS
      • Short Course Chemotherapy
        • I. Intensive Phase
          • INH- given for 4 mos., taken a.c.
            • S/E: peripheral neuritis- give Vit B6
          • Rifampicin- given for 4 mos., taken a.c.
            • S/E: all body secretions turned red-orange
          • PZA- given for 2 mos., taken p.c.
            • S/E: skin rashes, nephro and hepatotoxicity
          • PZA is replaced by Ethambutol
            • S/E: optic neuritis (visual disturbance)
    • PULMONARY TUBERCULOSIS
      • Short Course Chemotherapy
        • II. Standard Regimen
          • Streptomycin IM (Aminoglycoside)
            • S/E: Ototoxicity due to damage to CN VIII  temporary hearing loss
            • Nephrotoxicity- monitor BUN and Crea levels
    • PULMONARY TUBERCULOSIS
      • Discharge Health Teaching
        • Avoid precipitating factors
        • Take meds religiously
          • If missed 1 day’s meds, NEVER  the dose on the next day, simply let the pt continue taking the meds
        • Prevent Cx: Atelectasis and Miliary TB
        • Follow-up care
    • HISTOPLASMOSIS
      • Acute fungal infection characterized by inhalation of contaminated dust with Histoplasma capsulatum from bird’s manure
    • HISTOPLASMOSIS
      • S/Sx: PTB, Pneumonia-like
        • Productive cough
        • Dyspnea
        • Cyanosis
        • Hemoptysis
        • Fever, chills, anorexia, general body malaise
        • Chest and joint pain
    • HISTOPLASMOSIS
      • Diagnostic Procedure
      • (+) Histoplasmin skin test
      • (+) agglutination test
      •  WBC
      • ABG-  pO2
      • CXR- (+) infiltrates
    • HISTOPLASMOSIS
      • Nursing Management
        • CBR, semi Fowler’s position
        • O2 inhalation as ordered
        • Force fluids
        • Encourage coughing & DBE
        • Nebulize and suction prn
    • HISTOPLASMOSIS
      • Nursing Management
        • Administer meds as ordered
          • Antifungal agent: Amphotericin B (Fungizone)
            • S/E: nephrotoxicity and hypoK+
          • Corticosteroids
          • Antipyretics
          • Antihistamines
          • Mucolytics/expectorants
    • HISTOPLASMOSIS
      • Nursing Management
        • Spraying of breeding places
        • Prevent Cx: Atelectasis and Bronchiectasis
    • SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
      • Cause: Coronavirus
      • Begins with fever, body aches, mild respiratory Sxs
      • After 2-7 days, dry cough & dyspnea develops
      • MOT: close person-to-person contact (direct contact with infectious secretions and soiled articles)
      • Prevention: avoiding contact with those suspected of having SARS, avoiding travel to countries with SARS outbreak, frequent hand washing
    • INHALATION INJURIES: CO poisoning
      • CO: colorless, odorless, tasteless, with affinity for Hgb 200X greater than O2, forming carboxyHgb  tissue hypoxia
      Blood Level Assessment 1-10% Impaired visual acuity 11-20% Flushing, HA 21-30% N/, impaired dexterity 31-40% Vom,dizziness,syncope 41-50%  HR,  RR >50% Coma, death
    • INHALATION INJURIES: CO poisoning
      • Interventions
        • Remove victim from exposure
        • Administer 100% O2
        • Assess need for CPR
        • Monitor VS and CO levels
    • OCCUPATIONAL LUNG DISEASE: SILICOSIS
      • Or Asbestosis or Coal Workers’ Pneumoconiosis
      • Fibrotic lung disease caused by inhalation or organic dusts over long periods of time
      • Common among miners & sandblasters
    • OCCUPATIONAL LUNG DISEASE: SILICOSIS
      • S/Sx
        • Uncomplicated or simple: asymptomatic with evidence of fibrosis on CXR
        • Chronic complicated: malaise, A/, wt loss, severe dyspnea on exertion, massive fibrosis on CXR
    • OCCUPATIONAL LUNG DISEASE: SILICOSIS
      • Interventions
        • Eliminate the toxic substance
        • O2 as ordered
        • Coughing and DBE
        • Administer antitussives for cough & anti-TB meds as ordered (Cx: PTB)
    • COPD
      • Types
      • Chronic Bronchitis
      • Bronchial Asthma
      • Bronchiectasis
      • Pulmonary Emphysema
    • COPD-Chronic Bronchitis
      • Inflammation of bronchi  hyperplasia of goblet mucus-producing cells  narrowing of smaller airways
    • COPD-Chronic Bronchitis
      • Predisposing Factors
        • Excessive, chronic smoking
        • Air pollution
    • COPD-Chronic Bronchitis
      • S/Sx
        • Productive cough
        • Dyspnea at exertion
        • Prolonged expiratory grunt
        • Scattered rales, rhonchi
        • Anorexia, general body malaise
        • Cyanosis- Blue Bloaters
        • Feeling of breathlessness
        • Pulmonary HTN leading to peripheral edema and Cor Pulmonale (most feared Cx)
    • Cor Pulmonale
    • COPD-Bronchial Asthma
      • Reversible inflammatory disorder of lung tissue due to hypersensitivity to allergens  narrowing of smaller airways
      • Predisposing Factors (based on 3 types)
        • Extrinsic (Atopic/Allergic)
          • Pollen, dust, furs, fumes, gases, smoke, danders, lints
    • COPD-Bronchial Asthma
        • Intrinsic (Non-Atopic/Non-Allergic)
          • Hereditary
          • Drugs: ASA, Pen, Phenylbutazone, Beta blockers
          • Foods: seafoods, eggs, chicken, chocolate, milk and its products
          • Food additives- nitrates (also can cause CA)
          • Sudden change in T, air pressure and humidity
          • Extreme emotion
          • Physical stress
        • Mixed- combination of the 2
          • Most common type (90% of cases)
    • COPD-Bronchial Asthma
    • COPD-Bronchial Asthma
      • S/Sx
        • Non-productive cough
        • Dyspnea
        • Wheezing on expiration
        • Slight cyanosis
        • Mild restlessness and apprehension
        • Tachycardia and palpitation
        • Diaphoresis
    • COPD-Bronchial Asthma
      • Diagnostic Procedures
        • ABG-  pO2
        • PFT-  vital lung capacity (max. vol. of air that can be exhaled with the deepest breath possible)
    • COPD-Bronchial Asthma
      • Nursing Management
        • Administer meds as ordered
          • Bronchodilators- inhalation or metered dose inhaler (pump)
          • Corticosteroids
          • Mucolytics/Expectorants
          • Anti-histamine
        • O2 as ordered
    • COPD-Bronchial Asthma
    • COPD-Bronchial Asthma
      • Nursing Management
        • Force fluids
        • Nebulize and suction prn
        • Comfortable and humid environment
    • COPD-Bronchial Asthma
        • Discharge Health Teaching
          • Avoid precipitating factors
          • Regular adherence to meds
            • Sudden withdrawal to corticosteroids  status asthmaticus
          • Prevent Complications
            • Emphysema
            • Status asthmaticus- Drug of Choice: Epinephrine
    • COPD-Bronchiectasis
      • Permanent dilatation of bronchus  destruction of elastic and muscular tissues of the alveolar walls
    • COPD-Bronchiectasis
      • Predisposing Factors
        • Recurrent URTI and LRTI
        • Congenital anomalies (LTB)
        • Lung tumor
      • Signs and Symptoms
        • Productive cough
        • Dyspnea
        • Anorexia, general body malaise
        • Cyanosis
        • Hemoptysis
    • COPD-Bronchiectasis
      • Diagnostic Procedures
        • ABG-  pO2
        • Bronchoscopy
    • COPD-Bronchiectasis
      • Bronchoscopy: Nursing Management
        • Pre-op: informed consent, maintain on NPO, monitor VS
        • Post-op
          • Feed when gag reflex returns
          • Avoid talking, coughing, smoking  chronic irritation
          • Monitor for S/ of gross/frank bleeding
          • WOF laryngospasm and edema  DOB, SOB  prepare trache set at bedside
    • COPD-Bronchiectasis
      • Nursing Management
        • Same as in pulmonary emphysema
        • Assist in surgical procedure
          • Pneumonectomy
            • Position post-op: lie on affected side
          • Segmental wedge lobectomy
            • Position post-op: lie on unaffected side
    • Pneumonectomy vs. Lobectomy
    • COPD-Pulmonary Emphysema
      • Irreversible, end-stage stage of COPD characterized by inelasticity of alveolar wall  air trapping  maldistribution of gases  over distension of thoracic cavity   A:P diameter (Barrel-chest)
    • COPD-Pulmonary Emphysema
    • COPD-Pulmonary Emphysema
      • Predisposing Factors
        • Excessive, chronic smoking
        • Allergy
        • Air pollution
        • Hereditary- deficiency of alpha-1 anti-trypsin  elastase/elastin  alveolar recoil (Northern European origin)
        • Elderly- high risk group
    • COPD-Pulmonary Emphysema
      • Types
        • Centrilobular/Panlobular
          • Blue Bloaters
          • pCO2  , pO2  , resp. acidosis with hypoxemia
        • Centriacinar/Panacinar
          • Pink Puffers
          • pCO2  , pO2  , resp. alkaosis with hyperoxemia
    • Blue Bloater vs. Pink Puffer
    • The Blue Bloater
    • COPD-Pulmonary Emphysema
      • Signs and Symptoms
        • Productive cough
        • Dyspnea at rest
        • Anorexia, general body malaise
        • On lung percussion- resonance to hyperresonance
    • COPD-Pulmonary Emphysema
      • Signs and Symptoms
        • (+) alar flaring
        • rales, rhonchi
        •  breath sounds, vocal fremiti
        • Barrel chest- Pathognomonic Sign
        • (+) pursed-lip breathing
    • COPD-Pulmonary Emphysema
      • Nursing Management
        • CBR
        • Administer meds as ordered
          • Bronchodilator
          • Corticosteroid
          • Antibiotics
          • Mucolytics/expectorants
    • COPD-Pulmonary Emphysema
      • Nursing Management
        • Low flow, Fixed concentration O2 inhalation as ordered not to remove the Hypoxic Drive
    • COPD-Pulmonary Emphysema
      • Nursing Management
        • Force fluids
        • Diet:  CHON,  Vit & min.,  CHO
        • DBE- pursed-lip, cascade coughing, CPT
        • Nebulize and suction secretions prn
    • COPD-Pulmonary Emphysema
        • Discharge Health Teaching
          • Stop smoking
          • Regular adherence to meds
          • Prevent Complications
            • Atelectasis
            • Cor Pulmonale
            • CO2 narcosis- severe disorientation/confusion  coma
            • Pneumothorax
          • Follow-up care
    • Restrictive Lung Disorders
      • Pneumothorax
      • Partial/complete collapse of the lungs due to accumulation of air in the pleural space
    • Pneumothorax
      • 3 types
        • Spontaneous- without obvious cause
          • e.g. rupture of bleb (alveolar fluid sac) in recurrent lung inflammation and infection
        • Open- thru chest opening
          • e.g. stab, gunshot wounds
        • Tension- from blunt chest injury or from mech. vent. With PEEP air enters pleural space with each inspiration and cannot escape  thoracic cavity  mediastinal shift
            • E.g. flail chest (with paradoxical breathing)
    • Pneumothorax
      • Predisposing Factors
        • Chest trauma
        • Recurrent inflammatory lung condition
        • Lung tumors
    • Pneumothorax
      • Signs and Symptoms
        • Cool, moist skin (beginning of shock)
        • Sharp, chest pain
        • Unexplained dyspnea
        •  breath sounds  lung collapse
        •  lung expansion
        • Cyanosis
    • Pneumothorax
      • Signs and Symptoms
        • Mild restlessness/apprehension
        • On lung percussion- resonance to hyperresonance
        • SQ emphysema (crepitus on palpation)
        • Tracheal deviation to unaffected side
    • Pneumothorax
      • Diagnostic Procedure
        • ABG-  pO2
        • Chest X-ray- partial or complete lung collapse
    • Nursing Management: Pneumothorax
        • Assist in intubation
        • Administer meds as ordered
          • Narcotic analgesic
          • Antibiotics
    • Nursing Management: Pneumothorax
        • Assist in thoracentesis/ chest tube thoracostomy
          • Remove air- insert at 2 nd -3 rd ICS
          • Remove fluid- insert laterally near base, posteriorly at 8 th -9 th ICS
          • Pt position: struggling to a chair, pt exhales and hold breath during insertion (under local anesthesia)
    • Thoracentesis
    • Nursing Management: Pneumothorax
          • Attach tube to water-seal drainage
            • Objectives:
              • To reestablish (-) pressure in the lungs
              • To promote lung expansion
              • To drain air, fluid and blood and to prevent its reflux
    • Nursing Management: Water Seal Drainage
        • Monitor VS, I/O, breath sounds
        • DBE
        • Administer meds as ordered
        • Maintain strict asepsis
    • Nursing Management: Water Seal Drainage
        • Prepare at bedside:
          • vaselinized gauze
          • Hemostan clamp
          • Extra bottle with water
    • Nursing Management: Water Seal Drainage
        • Monitor for oscillation and fluctuation
          • N- (+) intermittent bubbling,  with inspiration,  expiration
          • Check for leakage
          • If (-) bubbling: check for kinks, obstruction- milk towards drainage bottle, or lungs are fully expanded
    • Water Seal Drainage
    • Nursing Management: Water Seal Drainage
      • 3 parameters to remove chest tube
        • (-) bubbling/fluctuations
        • (+) symmetrical breath sounds
        • Chest X-ray confirms full lung expansion
    • Nursing Management: Water Seal Drainage
      • Before, During and After Removal of Chest Tube
        • Encourage DBE
        • Monitor VS, breath sounds
        • Give analgesic prior to removal
        • Instruct pt to perform Valsalva maneuver for easy removal and to prevent air entry to pleural space
        • Apply vaselinized occlusive dressing, WOF bleeding
    • PLEURAL EFFUSION
      • Collection of fluid in the pleural space
      • S/Sx
        • Pleuritic pain that is sharp &  with inspiration
        • Dyspnea on exertion
        • Dry, nonproductive cough caused by bronchial irritation or mediastinal shift
        •  HR,  T
        •  breath sounds
        • CXR: confirms the dx & shows mediastinal shift
    • PLEURAL EFFUSION
      • Interventions
        • Identify & tx the underlying cause
        • Monitor breath sounds
        • High Fowler’s position
        • Coughing & DBE
        • Prepare the pt for thoracentesis
    • PLEURAL EFFUSION
      • Interventions
        • If recurrent, prepare the pt for:
      • Pleurectomy: surgically stripping parietal away from visceral pleura to promote adhesion of the 2 layers during healing
      • Pleurodesis: instilling sclerosing substance into pleural space via thoracotomy tube
    • EMPYEMA
      • Collection of pus in the pleural cavity (thick, opaque, foul-smelling)
      • Causes: pulmonary infection, lung abscess due to thoracic surgery or chest trauma
      • Goal of tx: emptying empyema cavity, reexpanding the lung, controlling infection
    • EMPYEMA
      • S/Sx of infection +  chest wall mov’t & pleural exudate on CXR
      • Interventions
        • Semi or High Fowler’s position
        • Monitor breath sounds
        • Coughing and DBE
        • Splint the chest if in pain
        • Antibiotics as ordered
    • EMPYEMA
      • Interventions
        • Assist in chest tube insertion
        • If (+) marked pleural thickening, prepare the pt for Decortication: surgical removal of restrictive mass of fibrin & inflammatory cells
    • PLEURISY
      • Inflammation of the visceral & parietal pleura, rubbing together during breathing causing pain
      • May be caused by pulmonary infarction or pneumonia
      • Usually occurs on one side of the chest (lower lateral portion)
    • PLEURISY
      • S/Sx
        • Knifelike pain aggravated by deep breathing & coughing
        • Dyspnea
        • Pleural friction rub on auscultation
        • Apprehension
    • PLEURISY
      • Interventions
        • Identify and tx the cause
        • Monitor breath sounds
        • Hot or cold applications as ordered
        • Encourage coughing & DBE
        • Lie on affected side to splint the chest
        • Analgesics as ordered
    • ACUTE RESPIRATORY DISTRESS SYNDROME
      • A form of acute respiratory failure as a complication of other condition, caused by diffuse lung injury  extravascular lung fluid  compression of terminal airways   lung vol. & compliance
      • ABG= resp. acidosis & hypoxemia not responding to  O2 concentration
      • CXR= interstitial edema
    • ACUTE RESPIRATORY DISTRESS SYNDROME
      • Predisposing factors
        • Sepsis
        • Fluid overload
        • Shock
        • Trauma
        • Neuro injuries
        • Burns
        • DIC
        • Drug ingestion
        • Toxic substance inhalation
    • ACUTE RESPIRATORY DISTRESS SYNDROME
      • S/Sx
        •  HR
        • Dyspnea
        •  breath sounds
        • Deteriorating blood gas levels
        • Hypoxemia despite high O2 concentration
        •  pulm. compliance
        • Pulm. infiltrates
    • ACUTE RESPIRATORY DISTRESS SYNDROME
      • Interventions
        • Identify & tx the cause
        • O2 as ordered
        • High Fowler’s position
        • Fluid restriction as ordered
        • Diurretics, anticoagulants, corticosteroids as ordered
        • Prepare for intubation and mechanical ventilation with PEEP