Respiratory Nursing


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Respiratory Nursing

  1. 1. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN MEDICAL AND SURGICAL NURSING Respiratory System Lecturer: Mark Fredderick R. Abejo RN,MANMS 1 Abejo
  2. 2. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN ANATOMY OF RESPIRATORY SYSTEM 2. Bronchi  Lobar Bronchi: 3 R and 2 L  Segmental Bronchi: 10 R and 8 L  Subsegmental BronchiOXYGENATON: the dynamic interaction of gases in the body for 3. Bronchiolesthe purpose of delivering adequate oxygen essential for cellular  Terminal Bronchiolessurvival  Respiratory Bronchioles, considered to be the transitional passageways between theRESPIRATORY SYSTEM MAIN FUNCTION: conducting airways and the gas exchangeGAS EXCHANGE 4. Alveoli - functional cellular units or gas-exchangeI. Upper Respiratory Tract units of the lungs. A. Functions - O2 and CO2 exchange takes place 1. Filtering - Made up of about 300 million 2. Warming and moistening TYPE 1 - provide structure to the alveoli 3. Humidification TYPE 2 - secrete SURFACTANT, reduces surface B. Parts tension; increases alveoli stability & prevents their 1. Nose - made up of framework of cartilages; divided collapse into R and L by the nasal septum. TYPE 3 – alveolar cell macrophages, destroys 2. Paranasal Sinuses – includes four pair of bony foreign material, such as bacteria cavities that are lined with nasal mucosa and ciliated epithelium.  Lecithin 3. Tubernate Bones ( Conchae )  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 5. Tonsils and Adenoids - Provides for reoxygenation of blood and release of CO2 6. Larynx – voice production, coughing reflex PULMONARY ARTERIES, carry blood from Made up of framework of: the heart to the lungs.  Epiglottis – valve that covers the opening to the larynx during swallowing. PULMONARY VEINS, is a large blood vessel  Glottis – opening between the vocal cords of the circulatory system that carries blood  Hyoid bone – u shaped bone in neck from the lungs to the left atrium of the heart.  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 tract A. Function: facilitates gas exchange B. Parts 1. 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 segmentsClient post pneumonectomy  affected side to promote expansionPost lobectomy  unaffected side to promote drainage RESPIRATORY MUSCLES  Pleural cavity - PRIMARY: diaphragm and external intercostal muscles  Parietal  Visceral - ACCESORY: sternocleidomastoid (elevated sternum),  Pleural Fluid: prevents pleural friction rub the scalene muscles (anterior, middle and posterior (as seen in pneumonia and pleural effusion) scalene) and the nasal alaeMS 2 Abejo
  3. 3. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN • Exchange of gases occurs because of differences in partial pressures. PHYSIOLOGY OF RESPIRATORY SYSTEM • 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 theVENTILATION: The movement of air in and out of the airways. alveoli to be removed from the body. • The thoracic cavity is an air tight chamber. the floor of NEUROCHEMICAL CONTROL this chamber is the diaphragm. MEDULLA OBLONGATA – respiratory center • Inspiration: contraction of the diaphragm (movement of initiates each breath by sending messages to primary this chamber floor downward) and contraction of the respiratory muscles over the phrenic nerve external intercostal muscles increases the space in this - has inspiration and expiration centers chamber. lowered intrathoracic pressure causes air to enter through the airways and inflate the lungs. PONS – has 2 respiration centers that work with the • Expiration: with relaxation, the diaphragm moves up and inspiration center to produce normal rate of breathing intrathoracic pressure increases. this increased pressure 1. PNEUMOTAXIC CENTER – affects the inspiratory pushes air out of the lungs. expiration requires the elastic effort by limiting the volume of air inspired recoil of the lungs. 2. APNEUSTIC CENTER – prolongs inhalation • Inspiration normally is 1/3 of the respiratory cycle and expiration is 2/3. NOTE: Chemoreceptors responds to changes in ph, increased PaCO2 = increase RRDRIVING FORCE FOR AIR FLOW Airflow driven by the pressure difference between RESPIRATORY EXAMINATION ANDatmosphere (barometric pressure) and inside the lungs(intrapulmonary pressure). ASSESSMENT Background information A. Abnormal patterns of breathing 1. 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 in acromegaly 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)AIRWAY RESISTANCE  high altitude 3. Kussmauls (air hunger) Resistance is determined chiefly by the radius size of the deep rapid respiration due to stimulation of respiratory airway. centre Causes of Increased Airway Resistance causes: metabolic acidosis (e.g. diabetes mellitus, 1. Contraction of bronchial mucosa chronic renal failure) 2. Thickening of bronchial mucosa 4. Hyperventilation 3. Obstruction of the airway complications: alkalosis and tetany 4. Loss of lung elasticity causes: anxiety 5. Ataxic (Biot) irregular in timing and deepRESPIRATION causes: brainstem damage • The process of gas exchange between atmospheric air 6. Apneustic and the blood at the alveoli, and between the blood cells post-inspiratory pause in breathing and the cells of the body. causes: brain (pontine) damageMS 3 Abejo
  4. 4. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN - asthma 7. Paradoxical - carcinoma of bronchus the abdomen sucks with respiration (normally, it - left ventricular failure pouches uotward due to diaphragmatic descent) - interstitial lung disease causes: diaphragmatic paralysis - ACE inhibitors  SputumB. Cyanosis volume 1. Refers to blue discoloration of skin and mucous type (purulent, mucoid, mucopurulent) membranes , is due to presence of deoxygenated presence or absence of blood? haemoglobin in superficial blood vessels  Stridor 2. Central cyanosis = abnromal amout of deoxygenated croaking noise loudest on inspiration haemoglobin in arteries and that blue discoloration is is a sign that requires urgent attention present in parts of body with good circulation such as causes: (obstruction of larynx, trachea or large tongue broncus) 3. Peripheral cyanosis = occurs when blood supply to a - acute onset (minutes) certain part of body is reduced, and the tissue extracts  inhaled foreign body more oxygen from normal from the circulating blood, e.g.  acute epiglottitis lips in cold weather are often blue, but lips are spared  anaphylaxis 4. Causes of cyanosis  toxic gas inhalation Central cyanosis - gradual onset (days, weeks)  decreased arterial saturation  laryngeal and pharyngeal tumours  decreased concentration of inspired oxygen:  crico-arytenoid rheumatoid arthritis high altitude  bilateral vocal cord palsy  lung disease: COPD with cor pulmoale,  tracheal carcinoma massive pulmonary embolism  paratracheal compression by lymph nodes  right to left cardiac shunt (cyanotic congenital  post-tracheostomy or intubation heart disease) granulomata  polycythaemia  Hoarseness  haemoglobin abnromalities (rare): causes include: methaemoglobinaemia, sulphaemoglobinaemia - laryngitis Peripheral cyanosis - laryngeal nerve palsy associated with  all causes of central cyanosis cause peripheral carcinoma of lung cyanosis - laryngeal carcinoma  exposure to cold  reduced cardiac output: left ventricular failure or The Hands shock  Clubbing  arterial or venous obstruction commonly cause by respiratory disease (but NOTPosition: patient sitting over edge of bed emphysema or chronic bronchitis) occasionally, clubbing is associated with hypertrophicGeneral appearance pulmonary osteoarthropathy (HPO)  look for the following  characterised by periosteal inflammation at distal ends  Dyspnea of long bones, wrists, ankles, metacarpals and normal respiratory rate < 14 each minute metatarsals tachypnoea = rapid respiratory rate  sweelling and tenderness over wrists and other are accessory muscles being used (sternomastoids, involved areas 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 times  Staining lack of usual explosive beginning may indicate staining of fingers - sign of cigarette smoking (caused by vocal cord paralysis (bovine cough) tar, not nicotine) muffled, wheezy ineffective cough suggests airflow  Wasting and weakness limitation  Pulse rate very loose productive cough suggests excessive  Flapping tremor (asterixis) - unreliable sign bronchial secretions due to: ask patient to dorsiflex wrists and spread out fingers, with - chronic bronchitis arms outstretched - pneumonia flapping tremor may occur with severe carbon dioxide - bronchiectasis retention (severe chronic airflow limitation) dry irritating cough may occur with: - chest infectionMS 4 Abejo
  5. 5. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MANThe Face Funnel chest (pectus excavatum)  developmental defect involving a localised depression  Eyes of lower end of sternum in severe cases, lung capacity Horners syndrome? (constricted pupil, partial ptosis and may be restricted loss of sweating which can be due to apical lung tumour compressing sympathetic nerves in neck)  Nose polpys? (associated with asthma) engorged turbinates? (various allergic conditions) deviated septum? (nasal obstruction)  Mouth and tongue look for central cyanosis evidence of upper respiratory tract infection (a reddened pharynx and tonsillar enlargement with or without a coating of pus) Harrisons sulcus broken tooth - may predispose to lung abscess or  innar depression of lower ribs just above costal margins pneumonia at site of attachment of diaphragm  sinusitis is indicated by tenderness over the sinuses on  causes: palpation severe asthma in childhood  some patients with obstructive sleep apnoea will be obese rickets with a receding chin, a small pharynx and a short thick neck Kyphosis , exaggerated forward curvature of spineThe Trachea Scoliosis , lateral bowing Kyphoscoliosis: causes: causes of tracheal displacement:  idiopathic (80%) toward the side of the lung lesion  secondary to poliomyelitis (inflammation involving  upper lobe collapse grey matter of cord)  upper lobe fibrosis  (note: severe thoracic kyphoscoliosis may reduce lung  pneumonectomy capacity and increase work of breathing) upper mediastinal masses, such as retrosternal goitre Lesions of chest wall tracheal tug (finger resting on trachea feels it move inferiorly  scars - previous thoracic operations or chest drains for a with each inspiration) is a sign of gross overexpansion of the previous pneumothorax or pleural effusion chest because of airflow obstruction  thoracoplasty (was once performed to remove TB, but no longer is because of effective antituberculosisThe Chest: inspection chemotherapy) invovled removal of large number of Shape and symmetry of chest ribs on one side to achieve permanent collapse of Barrel shaped affected lung  anteroposterior (AP) diameter is increased compared  erythema and thickening of skin may occur in with lateral diameter radiotherapy; there is a sharp demarcation between  causes: hyperinflation due to asthma, emphysema abnormal and normal skin Diffuse swelling of chest wall and neck  pathophysiology: air tracking from the lungs  causes: pneumothorax rupture of oesopahagus Prominent veins  cause: superior vena caval obstruction Asymmetry of chest wall movements Pigeon chest (pectus carinatum)  assess this by inspecting from behind patient, looking  localised prominence (outward bowing of sternum and down the clavicles during moderate respiration - costal cartilages) diminished movement indicates underlying lung disease  causes:  the affected side will showed delayed or decreased manifestation of chronic childhood illness (due to movement repeated strong contractions of diaphragm while  causes of reduced chest wall movements on one side are thorax is still pliable) localised: rickets localised pulmonary fibrosis consolidation collapse pleural effusion pneumothroax causes of bilateral reduced chest wall movements are diffuse:  chronic airflow limitation  diffuse pulmonary fibrosisMS 5 Abejo
  6. 6. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MANThe Chest: palpation cardiac dullness:  area of cardiac dullness is uaully present on left side of chest expansion chest place hands firmly on chest wall with fingers extending  this may decrease in emphysema or asthma around sides of chest (fugyre 4.5) as patient takes a big breath in, the thumbs should move The Chest: auscultation symmetrically apart about 5 cm  breath sounds reduced expansion on one side indicates a lesion on that introduction side one should use the diaphragm of stethoscope to listen note: lower lobe expansion is tested here; upper lobe is to breath sound in each area, comparing each side tested for on inspection (as above) remember to listen high up into the axillae apex beat (discussed in cardiac section) remember to use bell of stethoscope to listen to lung from above the clavicles for respiratory diseases:  displacement toward site of lesion - can be caused by: quality of breath sounds collapse of lower lobe normal breat sounds  are heard with stethoscope over all parts of localised pulmonary fibrosis chest, produced in airways rather than alveoli  displacement away from site of lesion - can be caused (although once they had been thought to arise by: from alveoli (vesicles) and are therefore called pleural effusion vesicular sounds) tension pneumothorax  normal (vesicular) breath sounds are louder and  apex beat is often impalpable in a chest which is longer on inspiration than on expiration; and hyperexpanded secondary to chronic airflow limitation there is no gap between the inspiratory and vocal fremitus expiratory sounds palpate chest wall with palm of hand while patient repeats bronchial breath sounds "99"  turbulence in large airways is heard without front and back of chest are each palpated in 2 comparable being filtered by the alveoli, and therefore positions with palms; in this way differences in vibration on produce a different quality; they are heard over chest wall can be detected the trachea normally, but not over the lungs causes of change in vocal fremitus are the same as those for  are audible throughout expiration, and often vocal resonance (see later) there is a gap between inspiration and expiration ribs  are heard over areas of consolidation since solid gently compress chest wall anteroposteriorly and laterally lung conducts the sound of turbulence in main localised pain suggests a rib fracture (may be secondary to airways to peripheral areas without filtering trauma or spontaneous as a result of tumour deposition or  causes include: bone disease) - lung consolidation (lobar pneumonia) -The Chest: percussion common - localised pulmonary fibrosis - uncommon with left hand on chest wall and fingers slightly separated and - pleural effusion (above the fluid) - aligned with ribs, the middle finger is pressed firmly against uncommon the chest; pad of right middle finger is used to strike firmly the - collapsed lung (e.g. adjacent to a pleural middle phalanx of middle finger of left hand effusion) - uncommon percussion of symmetrical areas of:  amphoric sound = when breath sounds over a  anterior (chest) large cavity have an exaggerated bronchial  posterior (back) (ask patient to move elbows forward quality) across the front of chest - this rotates the scapulae intensity of breath sounds anteriorly, i.e. moves it out of the way) causes of reduced breath sounds include:  axillary region (side)  chronic airflow limitation (especially  supraclavicular fossa emphysema) percussion over a solid structure (e.g. liver, consolidated lung)  pleural effusion produces a dull note  pneumothorax percusion over a fluid filled area (e.g. pleural effusion)  pneumonia produces an extremely dull (stony dull) note  large neoplasm percussion over the normal lung produces a resonant note  pulmonary collapse percussion over a hollow structure (e.g. bowel, pneumothorax) added (adventitious) sounds produces a hyperresonsant note two types of added sounds: continuous (wheezes) and liver dullness: interrupted (crackles)  upper level of liver dullness is determined by percussing wheezes down the anterior cehst in mid-clavicular line  may be heard in expiration or inspiration or both  normally, upper level of liver dullness is 6th rib in right  pathophysiology of wheezes - airway narrowing mid-clavicular line  an inspiratory wheeze implies severe airway  if chest is resonant below this level, it is a sign of narrowing hyperinflation usually due to emphysema, asthmaMS 6 Abejo
  7. 7. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN  causes of wheezes include: pulmonary thromboembolism - asthma (often high pitched) - due to muscle marked obesity spasm, mucosal oedema, excessive sleep apnoea secretions severe kyphoscoliosis - chronic airflow diseases - due to mucosal oedema and excessive secretions The Abdomen - carcinoma causing bronchial obstruction - palpate liver for enlargement due to secondary deposits of tends to cause a localised wheeze which is tumour from lung, or right heart failure monophonic and does not clear with coughing Other crackles  some terms not to use include rales (low pitched Permbertons sign crackles) and creptitations (high pitched  ask patient to lift arms over head crackles)  look for development of facial plethora, inspiratory  crackles are due to collapse of peripheral stridor, non-pulsatile elevation of jugular venous airways on expiration and sudden opening on pressure inspiration  occurs in vena caval obstruction  early inspiratory crackles Feet - suggests disease of small airways  inspect for oedema or cyanosis (clues of cor - characteristic of chronic airflow limitation pulmonale) - are only heard in early inspiration  look for evidence of deep vein thrombosisd  late or paninspiratory crackles Respiratory rate on exercise and positioning - suggests disease confined to alveoli  patients complaining of dyspnoea should have their - may be fine, medium or coarse respiratory rate measured at rest, at maximal tolerated - fine crackles - typically caused by exertion and supine pulmonary fibrosis  if dyspnoea is not accompanied by tachypnoea when - medium crackles - typically caused by left a patient climbs stairs, one should consider ventricular failure (due to presence of malingering alveolar fluid)  look for paradoxical inward motion of abdomen - coarse crackes - tend to change with during inspiration when patient is uspine (indicating coughing; occur with any disease that leads diaphragmatic paralysis) to retention of secretions; commonly occur Temperature: fever may accompany any acute or chronic in bronchiectasis chest infection pleural friction rub  when thickened, roughened pleural surfaces rub together, a continuous or intermittent grating sound may be heard DIAGNOSTIC EVALUATION  suggests pleurisy, which may be secondary to pulmonary infarction or pnuemonia 1. Skin Test: Mantoux Test or Tuberculin Skin Test  vocal resonanance gives information about lungs ability to transmit sounds  This is used to determine if a person has been infected or consolidated lung tends to transmit high frequencies so has been exposed to the TB bacillus. that speech heard through stethoscope takes a bleeting  This utilizes the PPD (Purified Protein Derivatives). quality (aegophony); when a patient with aegophony says  The PPD is injected intradermally usually in the inner "bee" it sounds like "bay" aspect of the lower forearm about 4 inches below the listen over each part of chest as patient says "99"; over elbow. consolidated lung, the numbers will become clearly  The test is read 48 to 72 hours after injection. audible; over normal lung, the sound is muffled  (+) Mantoux Test is induration of 10 mm or more. whispering pectoriloquy - vocal resonance is increased to  But for HIV positive clients, induration of about 5 mm is such an extent that whispered speech is distinctly heard considered positive  Signifies exposure to Mycobacterium Tubercle bacilliThe Heart lie patient at 45 degrees measure 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 fibrosisMS 7 Abejo
  8. 8. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN2. 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 Clear MRI images of lung airways during breathing. monoxide Level 6. Flouroscopy  Studies the lung and chest in motion3. Chest X-ray  Involves the continuous observation of an image reflected on a screen when exposed to radiation in the  This is a NON-invasive procedure involving the use of x- manner of television screen that is activated by an rays with minimal radiation. electrode beam.  The nurse instructs the patient to practice the on cue to  Structures of different densities that intercept the X-ray hold his breath and to do deep breathing beam are visualized on the screen in silhouette  Instruct the client to remove metals from the chest.  Rule out pregnancy first. 7. Indirect Bronchography  A radiopaque medium is instilled directly into the5. Computed Tomography (CT Scan) and Magnetic Resonance trachea and the bronchi and the outline of the entireImaging ( MRI ) bronchial tree or selected areas may be visualized through x-ray.  The CT scan is a radiographic procedure that utilizes  It reveals anomalies of the bronchial tree and is x-ray machine. important in the diagnosis of bronchiectasis.  The MRI uses magnetic field to record the H+ density of the tissue.  Nursing interventions BEFORE Bronchogram It does NOT involve the use of radiation.  Secure written consent The contraindications for this procedure are the  Check for allergies to sea foods or iodine or following: patients with implanted pacemaker, anesthesia patients with metallic hip prosthesis or other metal  NPO for 6 to 8 hours implants in the body.  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  This is the direct inspection and observation of the larynx, trachea and bronchi through a flexible or rigid bronchoscope.  Passage of a lighted bronchoscope into the bronchial tree for direct visualization of the trachea and the tracheobronchial tree.  Diagnostic uses: This chest CT scan shows a cross-section of a person  To examine tissues or collect secretionswith bronchial cancer. The two dark areas are the lungs. The light  To determine location or pathologic processareas within the lungs represent the cancer. and collect specimen for biopsyMS 8 Abejo
  9. 9. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN  To evaluate bleeding sites 9. Lung Scan  To determine if a tumor can be resected  Procedure using inhalation or I.V. injection of a surgically radioisotope, scans are taken with a scintillation camera.  Imaging of distribution and blood flow in the lungs.  Therapeutic uses (Measure blood perfusion)  To Remove foreign objects from  Confirm pulmonary embolism or other blood- flow tracheobronchial tree abnormalities  To Excise lesions  To remove tenacious secretions obstructing the  Nursing interventions BEFORE the procedure: tracheobronchial tree  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  Nursing interventions AFTER the procedure  Informed consent/ permit needed  Check the catheter insertion site for bleeding  Explain procedure to the patient, tell him what  Assess for allergies to injected radioisotopes to expect, to help him cope with the unkown  Increase fluid intake, unless contraindicated.  Atropine (to diminish secretions) is administered one hour before the procedure 10. Sputum Examination  About 30 minutes before bronchoscopy,  Laboratory test Valium is given to sedate patient and allay  Indicated for microscopic examination of the sputum: anxiety. Gross appearance, Sputum C&S, AFB staining, and  Topical anesthesia is sprayed followed by for Cytologic examination/ Papanicolaou examination local anesthesia injected into the larynx  Instruct on NPO for 6-8 hours  Nursing interventions:  Remove dentures, prostheses and contact lenses  Early morning sputum specimen is to be  The patient is placed supine with collected (suctioning or expectoration) hyperextended neck during the procedure  Rinse mouth with plain water  Use sterile container.  Nursing interventions AFTER Bronchoscopy  Sputum specimen for C&S is collected before  Put the patient on Side lying position the first dose of anti-microbial therapy.  Tell patient that the throat may feel sore with .  For AFB staining, collect sputum specimen for  Check for the return of cough and gag reflex. three consecutive mornings.  Check vasovagal response.  Watch for cyanosis, hypotension, tachycardia, 11. Biopsy of the Lungs arrythmias, hemoptysis, and dyspnea. These  Percutaneous removal of a small amount of lung tissue signs and symptoms indicate perforation of  For histologic evaluation bronchial tree. Refer the patient immediately! - Transbronchoscopic biopsy—done during bronchoscopy, - Percutaneous needle biopsy - Open lung biopsyMS 9 Abejo
  10. 10. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN  Nursing interventions BEFORE the procedure: LUNG CAPACITIES:  Withhold food and fluids  Place obtained written informed consent in the Functional Residual Capacity (ERV 1100 mL + RV 1200 mL = patient’s chart. 2300 mL )  The volume of air that remains in the lungs after normal,  Nursing interventions AFTER the procedure: quiet exhalation  Observe the patient for signs of Pneumothorax Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500 mL ) and air embolism  The amount of air that a person can inspire maximally  Check the patient for hemoptysis and after a normal expiration hemorrhage Vital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL =  Monitor and record vital signs 4600 mL )  Check the insertion site for bleeding  The maximum volume of air that can be exhaled after a  Monitor for signs of respiratory distress maximum inhalation  Reduced in COPD12. Lymph Node Biopsy Total Lung Capacity (IRV 3000 mL + TV 500 mL + ERV 1100  Scalene or cervicomediastinal mL + RV 1200 mL = 5800 mL )  To assess metastasis of lung cancer  Total of all four volumes13. Pulmonary Function Test / Studies 14. Arterial Blood Gas  Non-invasive test  Laboratory test  Measurement of lung volume, ventilation, and diffusing  Indicate respiratory functions capacity  Assess the degree to which the lungs are able to provide  Nursing interventions: adequate oxygen and remove CO2  Document bronchodilators or narcotics used  Assess the degree to which the kidneys are able to before testing reabsorb or excrete bicarbonate.  Allay the patient’s anxiety during the testing  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)LUNG VOLUMES: (ITER)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 15. Pulmonary AngiographyExpiratory reserve volume (1100 mL)  This procedure takes X-ray pictures of the pulmonary  The maximum volume that can be exhaled following the blood vessels (those in the lungs). normal quiet exhalation  Because arteries and veins are not normally seen in an X-Residual volume (1200 mL) ray, a contrast material is injected into one or more  The volume of air that remains in the lungs after forceful arteries or veins so that they can be seen. exhalationMS 10 Abejo
  11. 11. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN16. 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 flows through 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. 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 Hypoxemia o Increased pulse rate o Rapid, shallow respiration and dyspnea o Increased restlessness or lightheadedness o Flaring of nares17. Thoracentesis o Substernal or intercostals retractions  Procedure suing needle aspiration of intrapleural fluid or o Cyanosis air under local anesthesia  Specimen examination or removal of pleural fluid Low flow oxygen provides partial oxygenation with patient  Nursing intervention BEFORE Thoracentesis breathing a combination of supplemental oxygen and room air.  Secure consent Low-flow administration devices:  Take initial vital signs o Nasal Cannula 24-45% 2-6 LPM  Instruct to remain still, avoid coughing during o Simple Face Mask 0-60% 5-8 LPM insertion of the needle o Partial Rebreathing Mask 60-90% 6-10 LPM  Inform patient that pressure sensation will be o Non-rebreathing Mask 95-100% 6-15 LPM felt on insertion of needle o Croupette o Oxygen Tent  Nursing intervention DURING the procedure:  Reassess the patient High flow oxygen provides all necessary oxygenation, with  Place the patient in the proper position: patients breathing only oxygen supplied from the mask and  Upright or sitting on the edge of exhaling through a one-way vent. the bed High flow administration devices  Lying partially on the side, o Venturi Mask 24-40% 4-10 LPM partially on the back  Preferred for clients with COPD because it provides accurate amount of oxygen.  Nursing interventions after Thoracentesis o Face Mask  Assess the patient’s respiratory status o Oxygen Hood*  Monitor vital signs frequently o Incubator / isolette*  Position the patient on the affected side, as ordered, for at least 1 hour to seal the puncture Note: * can be used for both low and high flow administration site  Turn on the unaffected side to prevent leakage  The nurse should prevent skin breakdown by checking of 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 rest  Check for expectoration of bloodMS 11 Abejo
  12. 12. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN2. Tracheobronchial suctioning  Goals are removal of bronchial secretions, improved  Suction only when necessary not routinely ventilation, and increased efficiency of respiratory  Use the smallest suction catheter if possible muscles.  Client should be in semi or high Fowler’s position  Postural drainage uses specific positions to use gravity to  Use sterile gloves, sterile suction catheter assist in the removal of secretions.  Hyperventilate client with 100% oxygen before and  Vibration loosens thick secretions by percussion or after suctioning vibration.  Insert catheter with gloved hand (3-5― length of catheter  Breathing exercises and breathing retraining improve insertion) without applying suction. Three passes of the ventilation and control of breathing and decrease the catheter is the maximum, with 10 seconds per pass. work of breathing.  Apply suction only during withdrawal of catheter  These are procedures for patients with respiratory  The suction pressure should be limited to less than 120 disorders like COPD, cystic fibrosis, lung abscess, and mmHg pneumonia. The therapy is based on the fact that mucus  When withdrawing catheter rotate while applying can be knocked or shaken from airways and helped to intermittent suction drain from the lungs.  Suctioning should take only 10 seconds (maximum of 15 seconds) Postural drainage  Evaluate: clear breath sounds on auscultation of the chest.  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.3. Bronchial Hygiene Measures  Areas with secretions are placed higher than lung  Suctioning: oropharyngeal; nasopharyngeal segments to promote drainage.  Patient should maintain each position for 5-15 minutesa. Steam inhalation depending on tolerability.  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 patient Assess for redness on the side of the face which indicates exhalation. first degree burns.  To be effective, render steam inhalation therapy for 15 – 20 minutes  Instruct the client to perform deep breathing and coughing exercises after the procedure to facilitate expectoration of mucous secretions.  Provide good oral hygiene after the procedure.  Do after-care of equipment.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.MS 12 Abejo
  13. 13. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MANSuctioning 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. Types of Bottle Drainage  Provide good oral care after the procedure One-bottle system  The bottle serves as drainage and water-seal5. Incentive Spirometry  Immerse tip of the tube in 2-3 cm of sterile NSS to • Types: volume and flow create water-seal. • Device ensures that a volume of air is inhaled and the  Keep bottle at least 2-3 feet below the level of the patient takes deep breaths. chest to allow drainage from the pleura by gravity. • Used to prevent or treat atelectasis  Never raise the bottle above the level of the heart • To enhance deep inhalation to prevent reflux of air or fluid.  Assess for patency of the device • Nursing care  Observe for fluctuation of fluid along the tube. The – Positioning of patient, teach and encourage use, fluctuation synchronizes with the respiration. set realistic goals for the patient, and record the  Observe for intermittent bubbling of fluid; results. 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.6. Closed Chest Drainage ( Thoracostomy Tube )  Chest tube is used to drain fluid and air out of the NOTE! IF connected to suction apparatus mediastinum or pleural space into a collection chamber 1. The first bottle is the drainage and water-seal bottle; to help re-establish normal negative pressure for lung re- 2. The second bottle is suction control bottle. expansion. 3. Expect continuous bubbling in the suction control bottle; Purposes 4. Intermittent bubbling and fluctuation in the water-seal  To remove air and/or fluids from the pleural space 5. Immerse tip of the tube in the first bottle in 2 to 3 cm of  To reestablish negative pressure and re-expand the sterile NSS lungs 6. Immerse the tube of the suction control bottle in 10 to 20 Procedure cm of sterile NSS to stabilize the normal negative  The chest tube is inserted into the affected chest pressure in the lungs. wall at the level of 2nd to 3rd intercostals space to 7. This protects the pleura from trauma if the suction release air or in the fourth intercostals space to pressure is inadvertently increased remove fluid.MS 13 Abejo
  14. 14. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN Three-bottle system Removal of chest tube—done by physician  The first bottle is the drainage bottle;  The nurse Prepares:  The second bottle is water seal bottle Petrolatum Gauze  The third bottle is suction control bottle. Suture removal kit Sterile gauze  Observe for intermittent bubbling and Adhesive tape fluctuation with respiration in the water- seal  Place client in semi-Fowler’s position bottle  Instruct client to exhale deeply, then inhale and do  Continuous GENTLE bubbling in the suction valsalva maneuver as the chest tube is removed. control bottle. These are the expected observations.  Chest x-ray may be done after the chest tube is  Suspect a leak if there is continuous bubbling in removed the WATER seal bottle or if there is VIGOROUS  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. Never clamp the tubing 7. Artificial Airway unnecessarily. a. Oral airways- these are shorter and often have a larger lumen.If there is NO fluctuation in the water seal bottle, it may mean They are used to prevent the tongue form falling backward.TWO things  Either the lungs have expanded or the system is NOT b. Nasal airways- these are longer and have smaller lumen Which functioning appropriately. causes greater airway resistance  In this situation, the nurse refers the observation to the physician, who will order for an X-ray to confirm the c. Tracheostomy- this is a temporary or permanent surgical suspicion. opening in the trachea. A tube is inserted to allow ventilation and removal of secretions. It is indicated for emergency airway accessImportant Nursing considerations for many conditions. The nurse must maintain tracheostomy care  Encourage doing the following to promote drainage: properly to prevent infection.  Deep breathing and coughing exercises  Turn to sides at regular basis  Ambulate  ROM exercise of arms RESPIRATORY DISEASES AND  Mark the amount of drainage at regular intervals DISORDERS  Avoid frequent milking and clamping of the tube to prevent tension pneumothoraxWhat the nurse should do if: I. PNEUMONIA – inflammation of the lung parenchyma  If there is continuous bubbling: leading to pulmonary consolidation because alveoli is filled  The nurse obtains a toothless clamp with exudates  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 leak is likely in the lungs,  But if the bubbling continues, the leak is between the clamp and the bottle chamber.Next, the nurse moves the clamp towards the bottle checking thebubbling 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 the drainage 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 a receptacle or container with sterile water and A. ETIOLOGIC AGENTS immerse the tubing. 1. Streptococcus pneumoniae (pneumococcal  She should obtain another set of sterile bottle as pneumonia) replacement. She should NEVER CLAMP the tube 2. Hemophilus influenzae (bronchopneumonia) for a longer time to avoid tension pneumothorax. 3. Klebsiella pneumoniae  In the event the tube accidentally is pulled out, the 4. Diplococcus pneumoniae nurse obtains vaselinized gauze and covers the 5. Escherichia coli stoma. 6. Pseudomonas aeruginosa  She should immediately contact the physician.MS 14 Abejo
  15. 15. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN B. HIGH RISK GROUPS  Usually, it is the upper lung areas which are 1. Children less than 5 yo drained 2. Elderly  Nursing management:  Monitor VS and BS C. PREDISPOSING FACTORS  Best performed before meals/breakfast or 1. Smoking 2-3 hours p.c. to prevent gastroesophageal 2. Air pollution reflux or vomiting (pagkagising maraming 3. 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  Bronchogenic Ca  Provide oral care after procedure as it may 4. Prolonged immobility (hypostatic pneumonia) affect taste sensitivity 5. Aspiration of food (aspiration pneumonia)  Contraindications: 6. Over fatigue  Unstable VS  Hemoptysis D. SIGNS AND SYMPTOMS  Increased ICP 1. Productive cough, greenish to rusty  Increased IOP (glaucoma) 2. Dyspnea with prolong expiratory grunt 12. Provide pt health teaching and d/c planning 3. Fever, chills, anorexia, general body malaise  Avoidance of precipitating factors 4. Cyanosis  Prevention of complications 5. Pleuritic friction rub  Atelectasis 6. Rales/crackles on auscultation  Meningitis 7. Abdominal distention  paralytic ileus  Regular compliance to medications  Importance of ffup care E. DIAGNOSTICS 1. Sputum GS/CS  confirmatory; type and sensitivity; (+) to cultured microorganism  Tracheostomy usually done at bedside, 10-20 minutes 2. CXR – (+) pulmonary consolidation  Stress test: 30 minutes 3. CBC  Mammography: 10-20 minutes  Elevated ESR (rate of erythropoeisis) N = 0.5-  LARYNGOSPASM – tracheostomy STAT 1.5% (compensatory mech to decreased O2)  OR Tracheostomy: laryngeal, thyroid, neck CA  Elevated WBC  DIAPHRAGM – primary muscle for respiration 4. ABG – PO2 decreased (hypoxemia)  INTERCOSTAL MUSCLES – secondary muscle for respiration  ALVEOLI (Acinar cells) –functional unit of the lungs; site for gas exchange (via diffusion) F. NURSING MANAGEMENT  VENTILATION – movement of air in and out of the lungs 1. Enforce CBR (consistent to all respi disorders)  RESPIRATION – lungs to cells 2. Strict respiratory isolation  Internal 3. Administer medications as ordered  External  Broad spectrum antibiotics  RETROLENTAL FIBROPLASIA – retinopathy/blindness in  Penicillin – pneumococcal infections immaturity d/t high O2 flow in pedia patients  Tetracycline  Macrolides  Azithromycin (OD x 3/days) II. PULMONARY TUBERCULOSIS (KOCH’S DISEASE) – 1. Too costly infection of the lung parenchyma caused by invasion of 2. Only se: ototoxicity – transient mycobacterium tuberculosis or tubercle bacilli (gram negative, hearing loss acid fast, motile, aerobic, easily destroyed by heat/sunlight)  Anti-pyretics  Mucolytics/expectorants A. PRECIPITATING FACTORS 4. Administer O2 inhalation as ordered 1. Malnutrition 5. Force fluids to liquefy secretions 2. Overcrowding 6. Institute pulmonary toilet – measures to promote 3. Alcoholism: Depletes VIT B1 (thiamin)  alcoholic expectoration of secretions beriberi  malnutrition  DBE, Coughing exercises, CPT 4. Physical and emotional stress (clapping/vibration), Turning and repositioning 5. Ingestion of infected cattle with M. bovis 7. Nebulize and suction PRN 6. Virulence (degree of pathogenecity) 8. Place client of semi-fowlers to high fowlers 9. Provide a comfortable and humid environment B. MODE OF TRANSMISSION: Airborne  droplet 10. Provide a dietary intake high in CHO, CHON, infection Calories and Vit C 11. Assist in postural drainage  Patient is placed in various position to drain secretions via force of gravityMS 15 Abejo
  16. 16. Medical and Surgical NursingRespiratory System Lecture NotesPrepared by: Mark Fredderick R. Abejo RN,, MAN C. SIGNS AND SYMPTOMS  Avoidance of precipitating factors : alcoholism, 1. Productive cough (yellowish) overcrowding 2. Low grade afternoon fever, night sweats  Prevention of complications 3. Dyspnea, anorexia, malaise, weight loss  Atelectasis 4. Chest/back pain  Military TB (extrapulmonary TB: 5. Hemoptysis meningeal, Pott’s, adrenal glands, skin, cornea) D. DIAGNOSTICS  Strict compliance to medications 1. Skin testing  Never double the dose! Continue taking  Mantoux test – PPD the meds if missed a day)  Induration width (within 48-72 h)  Diet modifications: increased CHON, CHO,  8-10 mm (DOH) Calories, Vit C  10-14 mm (WHO)  Importance of ffup care  5 mm in AIDS patients is +  indicates previous exposure to tubercle III. HISTOPLASMOSIS – acute fungal infection caused by bacilli inhalation of contaminated dust with Histoplasma capsulatum 2. Sputum AFB  (+) tubercle bacilli from birds’ manure 3. CXR – (+) pulmo infiltrated due to caseous necrosis 4. CBC – elevated WBC A. PREDISPOSING FACTORS  Inhalation of contaminated dust E. NURSING MANAGEMENT 2. SIGNS AND SYMPTOMS 1. Enforce CBR  PTB like symptoms 2. Institute strict respiratory isolation  Productive cough 3. Administer O2 inhalation  Fever, chills, anorexia, generalized body 4. Forced fluids malaise 5. Encourage DBE and coughing  Cyanosis  NO CLAPPING in chronic PTB  d/t  Chest and joint pains hemoptysis  may lead to hemorrhage  Dyspnea 6. Nebulize and suction PRN  Hemoptysis 7. Provide comfortable and humid environment 8. Institute short course chemotherapy 3. DIAGNOSTICS  Intensive phase  Histoplasmin skin test is (+)  INH  ABG analysis reveals pO2 low  SE: peripheral neuritis (increase vit 4. NURSING MANAGEMENT B6 or pyridoxine  Enforce CBG  Rifampicin  Administer meds as ordered  SE: red orange color of bodily  Antifungal agents secretions  Amphotericin B (Fungizone) SE:  PZA nephrotoxicity and hypokalemia  May be replaced with Ethambutol  Monitor transaminases, BUN and (SE: optic neuritis) if (+) CREA hypersensitivity to drug  Corticosteroids  SE: allergic reactions; hepatotoxicity  Anti-pyretics and nephrotoxicity  Mucolytics/expectorants 1. Monitor liver enzymes  Administer oxygen inhalation as ordered 2. Monitor BUN and CREA  Forced fluids  INH given for 4 months, PZA and  Nebulize and suction as necessary Rifampicin is given for 2 months, A.C. to  Prevent complications facilitate absorption  Bronchiectasis, atelectasis  These 3 drugs are given simultaneously to  Prevention of spread prevent development of resistance  Spraying of breeding places  Standard Regimen  Kill bird and owner! Hehe!  Streptomycin injection (aminoglycosides)  Neomycin, Amikacin, Gentamycin 1. common SE: 8th CN damage  CHRONIC OBSTRUCTIVE PULMONARY DISEASES tinnitus  hearing loss  ototoxicity 2. nephrotoxicity 1. Chronic Bronchitis a. BUN (N = 10-20) 2. Bronchial Asthma b. CREA (N = 8-10) 3. Bronchiectasis 9. Health teaching and d/c planning 4. Pulmonary EmphysemaMS 16 Abejo