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Respiratory System (2)

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  • 1. Respiratory Tract Disorders Assessment & Management of Patients With
  • 2. Lower Respiratory Tract
    • Trachea
    • Bronchi
    • Bronchioles
    • Alveoli
    • Cilia
  • 3. Clinical Manifestations
    • 1. Local Manifestations
      • Cough
        • chronic, paroxysmal, dry , productive
      • Excessive Nasal Secretion
      • Expectoration of Sputum
        • mucoid, purulent, mucopurulent, rusty, hemoptysis
      • Pain
        • pleuritic, intercostal, generalized chest pain
      • Dyspnea- shortness of breath
  • 4.
      • 2. Systemic Manifestations
        • Hypoxemia
          • insufficient oxygenation of the blood
          • cyanosis- bluish, grayish discoloration of skin & mucous membranes
        • Hypoxia
          • inadequate tissue oxygenation
        • Hypercapnia
          • CO2 in arterial blood above normal limits
        • Hypocapnia
          • CO2 in arterial blood below normal limits
        • Respiratory Failure
    Clinical Manifestations
  • 5. Assessment of Respiratory System
    • Health History
      • Risk Factors
      • Major Clinical Manifestations
        • Cough
        • Sputum production
        • Chest pain
        • Wheezing
        • Clubbing of the fingers
        • Cyanosis
  • 6. Physical Examination
    • Inspection
      • posture, shape, movement, dimensions of chest, flared nostrils, use of accessory muscles, skin color, and rate, depth, & rhythm of respiration
    • Palpation
      • respiratory excursion, masses, tenderness
    • Percussion
      • flat, dull, resonant, hyperresonant sounds
    • Auscultation
      • breath sounds, voice sounds, crackles, wheezes
    Assessment of Respiratory System
  • 7. Crackles
  • 8. Diagnostic Procedures
    • Sputum Studies
      • Methods- standard, saline inhalation, gastric washing
    • Arterial Blood Gases
      • measurements of blood pH , arterial O2 & CO2 tensions, acid-base balance
    • Pulse Oximetry
    • Chest X-ray
    • Bronchoscopy
    • Thoracentesis
    • Laryngoscopy
  • 9.
    • Lower
    • Respiratory
    • Disorders
  • 10. Pneumonia
    • Inflammation & infection of lung- infecting organisms typically inhaled- organisms transmitted to lower airways and alveoli causing inflammation- impairs gas exchange
    • Etiology: bacteria, virus, Mycoplasma, fungus, or from aspiration or inhalation of chemicals or other toxic substances
    • Risk factors: cigarette smoking, chronic underlying disorders, severe acute illness, suppressed immune system, & immobility
  • 11.  
  • 12.
    • Assessment: Questions to ask
      • Have you been experiencing difficulty breathing?
      • Are you having pain? Where?
      • Do you have a cough?
      • Have you been running a fever?
      • Have you been feeling tired?
    • Clinical Manifestations:
      • fever, pleuritic chest pain, tachypnea, SOB, tachycardia, cough, sputum production- rusty, blood-tingled or yellow-green, fatigue, poor appetite
    Pneumonia
  • 13.
    • Diagnostic:
    • Sputum and blood cultures, CBC, ABGs, CXR, & Bronchoscopy
    • Nursing Diagnoses:
    • Ineffective airway clearance r/t thick, tenacious sputum
    • Ineffective breathing pattern r/t tachypnea, chest pain, & airway inflammation
    • Impaired gas exchange r/t exudate in alveoli
    • Activity intolerance r/t hypoxemia, fatigue
    Pneumonia
  • 14.
    • Planning: Client Outcomes
    • Maintain open & clear airway, normal RR, PO2 level without supplemental O2, complete physical care without frequent rest periods
    • Interventions
    • Improve airway patency- auscultate lung sounds, monitor ABGs or pulse oximetry, elevate HOB, C & DB q 2hrs, ambulate , I/S, O2 as needed
    • Promote fluid intake & promote activity tolerance
    • Monitor & prevent complications
    Pneumonia
  • 15.
    • Pharmacology:
      • Antibiotic therapy based on sputum culture & sensitivity
        • Levaquin, Tequin, Rocephin, Primaxin, Zithromax, Ketek, Zinacef, Cipro, Tetracycline
        • Instruct to finish all antibiotics at prescribed intervals
    • Evaluation:
      • breathing easier without chest pain
      • temperature normal,
      • activity level increased without frequent rest periods
    Pneumonia
  • 16. Tuberculosis
    • Infectious disease that primarily affects the lungs; may be transmitted to other parts of the body
    • Pulmonary infiltrates accumulate, cavities develop, & masses of granulated tissue form within the lungs
    • Primary infectious agent- Mycobacterium Bacilli
    • Transmitted by inhalation of droplets (talking, coughing, sneezing, & singing)
    • Risk factors: immune system disorder, preexisting medical conditions, institutionalized, health care workers
  • 17. Pulmonary Tuberculosis
    • Mycobacterium tuberculosis
    • Airborne transmission
    • Tuberculin skin testing
    • Pharmacologic therapy- multi-drug regimens and prophylaxis
  • 18.
    • Assessment:
    • Questions to ask - Are you suffering from night sweats? Have you lost weight ? Have you been having low-grade fever? Have you been having SOB and coughing up anything from your lungs? Have you had chest pain? Where? Have you had weight loss?
    • Clinical Manifestations- low-grade fever (late afternoon), night sweats, weight loss, anorexia, fatigue, chronic productive cough,pleuritic chest pain, hemoptysis
    Tuberculosis
  • 19.
    • Diagnostic:
    • Sputum culture- + acid-fast bacilli (AFB)
    • Skin testing- PPD
    • CBC- WBC elevated
    • CXR
    • Bronchoscopy
    • Nursing Diagnosis:
    • Ineffective airway clearance r/t thick, tenacious secretions
    • Ineffective breathing pattern r/t airway inflammation
    Tuberculosis
  • 20.
    • Altered nutrition less than body requirements r/t anorexia and fatigue
    • Anxiety r/t social isolation secondary to isolation protocols
    • Planning: Clients Outcomes
    • Maintain clear airway,normal RR, achieve weight gain, anxiety decreased
    • Interventions:
    • Maintain respiratory isolation- infectious period - diversional activities
    Tuberculosis
  • 21.
    • Promote airway clearance- bedrest, increase fluid intake, high humidity
    • Pharmacology
      • First-line meds- INH, Rifampin, Streptomycin, Ehtambutol, & Pyrazinamide for 4 months
      • INH and Rifampin continued for an additional 2 months or up to 12 months.
    • Advocate adherence & prevention
    • Monitor and manage potential complications
    • Evaluation:
    • Client adheres to isolation precautions, takes medication as prescribed
    Tuberculosis
  • 22.
    • Questions to ask
      • Do you have difficulty breathing- all the time or is it caused by exertion?
      • Do you cough frequently and is it productive?
      • Have you had a weight loss?
      • Do you feel tired quite often and are your activities impaired by SOB or fatigue?
      • Do you have many respiratory infections? Over what period of time?
    Tuberculosis
  • 23.
    • Nursing Diagnosis
    • Ineffective airway clearance r/t thick, tenacious secretion and fatigue
    • Ineffective breathing pattern r/t fatigue and obstruction of the bronchial tree
    • Impaired gas exchange r/t increased sputum production
    • Activity intolerance r/t hypoxemia & fatigue
    • Altered nutrition r/t increased metabolic demands, fatigue, & anorexia
    • Anxiety r/t inability to breathe effectively
    Tuberculosis
  • 24.
    • Diagnostics:
    • ABGs, CBC, sputum culture, CXR, Pulmonary function tests
    • Planning: Client Outcomes
    • Effectively clear airway and breathing pattern, maintain normal ABGs, increase activity with decrease SOB or fatigue, maintain weight, and less anxious with episodes of SOB
    Tuberculosis
  • 25.  
  • 26. Chronic Obstructive Pulmonary Disease (COPD)
    • A group of chronic, obstructive airflow diseases of the lungs. Also known as chronic airflow limitation (CAL)
    • Usually progressive & irreversible; Ciliary cleansing mechanism of the respiratory tract is affected
    • Involves 3 diseases- Chronic Bronchitis, Asthma, & Emphysema
    • Risk factors- cigarette smoking, air pollution, occupational exposure, infections, allergens, stress
  • 27.
    • Inflammation of the bronchi caused by irritants or infection
    • hypertrophy & hypersecretion of mucous- cause increase in sputum production
    • increase mucous- decrease airway lumen size- lumen becomes colonized with bacteria.
    • Bronchial wall becomes scarred - leads to stenosis & airway obstruction
    • Defined as a productive cough that lasts 3 months a year for 2 consecutive years with other causes excluded.
    • Cough in the morning with sputum production is indicative of Chronic Bronchitis
    Chronic Bronchitis
  • 28.  
  • 29.
    • Risk Factors: cigarette smoking, exposure to pollution, hazardous airborne substances
    • Clinical Manifestations: productive cough, dyspnea esp. on exertion, wheezing, use of accessory muscles to breathe, cyanosis- “blue bloater”, clubbed fingers
    • Interventions:
    • Assess patency of airway- suction if cough ineffective, RR, accessory muscle use, lung sounds, skin color changes, ABGs
    • Encourage high fluid intake & instruct in effective breathing & coughing
    • Monitor oxygen administration & aerosol therapy
    Chronic Bronchitis
  • 30.
    • Encourage to report sputum changes or worsening of symptoms
    • Encourage exercise to improve resp. fitness
    • Counsel to avoid respiratory irritants and stop smoking
    • Immunize against common flu and pneumonia
    • Pharmacology:
    • Antibiotic therapy- Tequin, Levaquin
    • Bronchodilators- Albuterol, Combivent, Theophylline
    • Corticosteroids- Prednisone, SoluMedrol
    Chronic Bronchitis
  • 31.
    • Chronic inflammatory disease of the airways - bronchial linings overreact to various stimuli- causes episodic smooth muscle spasms that severely constrict the airway - thickened secretions & mucosal edema further block the airways.
    • Acute symptoms last from minutes to hours, to days and then periods without symptoms
    • Most common chronic disease of childhood
    • Risk Factors: allergy, chronic exposure to airway irritants of allergens, stress, exertion, sinusitis
    Asthma
  • 32.  
  • 33. Asthma
    • Clinical Manifestations: cough with or without sputum production, SOB & wheezing, generalized chest tightness, expiration requires effort & becomes prolonged, tachycardia, tachypnea, increased restlessness
    • Interventions:
    • Immediate care depends on severity of asthma symptoms- assess resp. status, ABGs monitoring, oxygen therapy
    • Administered prescribed therapy & monitor response
    • Fluids & antibiotics
    • Minimize anxiety
    • Teach preventive measures- exercise
  • 34.  
  • 35.
    • Pharmacology:
    • Bronchodilators
      • Beta-agonists- Albuterol, Serevent
      • Xanthines- Theophylline
    • Corticosteroids
      • Prednisone, SoluMedrol
      • Inhalers- Flovent, Vanceril, Beclovent, Advair, Azmacort
    • Anticholinergics- Atrovent, Combivent
    • Leukotriene modifiers- Singulair
    • May be treated as outpatient or require hospitalization & intensive care
    Asthma
  • 36. Emphysema
    • Enlargement of air spaces distal to airways that conduct air to the alveoli
    • Enlarged spaces causes breakdown in alveoli walls- increases in airway size on inspiration- decreases alveolar membrane for gas exchange
    • Small airways collapse on exhalation- air trapped in alveolar spaces
    • Theses changes- products destruction of elastin in distal airways and alveoli
    • Distinguishing characteristic- airflow limitation caused by lack of elastic recoil in the lungs
  • 37. COPD-Emphysema
  • 38.  
  • 39.
    • No trouble inhaling, but with hyperinflated lungs & small airways- exhaling becomes more difficult
    • Risk Factors: smoking, occupational exposure, heredity
    • Most common in fifth decade of life
    Emphysema
  • 40.
    • Clinical Manifestations: SOB on exertion, use of accessory muscles to breath, late cough after onset of SOB (if productive sputum- scanty & mucoid), “pink puffer”, barrel chest (increase in anterior-posterior diameter of chest), thin in appearance, diminished breath sounds & prolonged expiration, speaks in short jerky sentences, anxious
    • Interventions:
    • Improve gas exchange- oxygen therapy
    • Achieve airway clearance- aerosol therapy
    • Encourage adequate hydration
    • Prevent infections- immunizations
    Emphysema
  • 41.  
  • 42.
    • Minimize anxiety
    • Physical therapy
    • Patient teaching
    • Pharmacology:
    • Beta-agonists- Albuterol, Theophylline
    • Anticholinergics- Atrovent
    • Antibiotic therapy- Levaquin, Tequin
    • Corticosteroids
    Emphysema
  • 43.
    • Evaluation:
    • Improved gas exchange, achieves airway clearance, breathing pattern improved, achieves activity tolerance, acquires effective coping mechanisms, and adheres to therapeutic program.
    Emphysema
  • 44. Atelectasis
    • Inadequate ventilation
    • Mucus plugs
    • Pleural effusion
    • Pneumothorax
    • Hemothorax
  • 45. Pleural Effusion
  • 46. Pneumothorax
    • Condition in which air or gas exists in the pleural space
    • Normally negative pressure (suction) between the visceral and parietal pleura- any injury that allows air or positive pressure to enter pleural space- prevents the lung from remaining inflated
    • Air in pleural space- increased intrapleural pressure- partial or total collapse of the lung
    • Types: Simple, Traumatic, or Tension
  • 47. Pneumothorax
  • 48. Pneumothorax Simple (Closed or spontaneous)
    • Air enters the pleural space from the lung in the absence of disease
    • Occurs in men ages 20 to 40 & result of rupture of small blister on the apex of the lung
    • If occurs from trauma or pulmonary disease- referred to as secondary or complicated
    • Basic symptoms: SOB & chest pain
  • 49. Treatment of Simple Pneumothorax
  • 50. Pneumothorax
  • 51. Pneumothorax Traumatic (Open)
    • A hole in the chest wall allows atmospheric air to flow into the pleural space
    • Air in the pleural space - increased intrapleural pressure- resulting in partial or total collapse of the lung
    • Results from a penetrating injury, a therapeutic procedure, or insertion of a CVC or pulmonary artery catheter
    • A sucking sound audible on inspiration as the chest wall rises & varying degrees of resp. distress
  • 52. Pneumothorax Tension
    • Injury allows air to leak into pleural space during inspiration- prevents air from leaking out during expiration
    • Each inspiration-amount of air increases- becomes trapped to point causing increased thoracic pressure- pushes the heart, vena cava, and aorta out of position (mediastinum shift)- results in poor venous return to heart - leads to poor cardiac output
    • Medical emergency- disruption of cardiac output & respiratory distress
  • 53.  
  • 54.  
  • 55. Pneumothorax
    • Etiology:
      • Blunt chest trauma (MVAs and falls), penetrating traumas (gunshot and knife injuries), rib fractures, & flail chest
    • Assessment: Questions to ask
      • Are you having difficulty breathing?
      • Do you have pain in your chest? Point to your pain with one finger.
    • Clinical Manifestations:
      • SOB, CP, tachypnea, tachycardia, cyanosis, diminished breath sounds, hyper-resonance on affected side, neck vein engorgement, paradoxical movement of the chest, deviated trachea, cardiogenic shock & anxiety
  • 56. Pneumothorax
    • Diagnostic:
      • ABGs, CXR
    • Nursing Diagnosis:
      • Ineffective breathing pattern r/t decreased lung expansion
      • Impair gas exchange r/t collapse of an area of the lung
      • Anxiety r/t inability to ventilate effectively
    • Planning: Client Outcomes
      • RR & ABGs within normal limits, client states rationale for treatment & procedures, & client rests without behavioral signs of excessive anxiety
  • 57.
    • Nursing Interventions:
      • Comprehensive respiratory assessment- airway patency, RR, lung sounds, chest rise & fall symmetrically, ABGs, blood counts, electrolytes, cardiac status, urinary output, chest wall
      • Maintain semi-Fowler’s position
      • Encourage deep breathing & coughing
      • Administer oxygen therapy
      • Medicate for pain as needed
      • Explain all procedures- calm & reassure about overall treatment & condition as needed
      • Encourage use of relaxation techniques
      • Medical- Mechanical Ventilation & Chest tubes
    Pneumothorax
  • 58. Chest Tubes
  • 59. Chest Drainage System
    • Inserted after most thoracic & cardiac surgeries
    • Consists of chest tube attached to valve mechanism- allow air or fluid to drain out of the chest cavity
    • Include one, two, and three-bottle systems and the one-piece, three chamber, disposable plastic systems
  • 60. Purpose of Chest Drainage System
    • Removes air, blood, & other fluids from pleural space or mediastinal space
    • Facilitates re-expansion of the lungs and restore negative pressure in thoracic cavity
  • 61. Indications for Chest Drainage System
    • After thoracic & cardiac surgery
    • Traumatic injury- Fractured Rib
    • Intrapleural- pneumothorax, hemothorax, & pleural effusion
    • Mediastinal- cardiac surgery, chest trauma
    • Complication from procedures:
      • CVC insertion
      • Lung biopsy
  • 62. Types of Chest Drainage Systems
    • Water-seal
      • Remove air or fluid from pleural space or mediastinum
      • Mechanism for collection of drainage
      • One-way mechanism to keep air from getting back into the pleural space
      • Water-seal acts = one-way valve
        • Allows air to leave pleural space- but not to return-maintaining negative pressure
  • 63.
    • Waterless
      • Valve to regulate suction
      • Valve can be opened for air & liquid drainage to move out
      • Remain closed to prevent air from entering pleural space
    • Autotransfusion
      • Variation of water-seal system
      • Attached container so that blood drained from chest can be salvaged for autotransfusion
    Types of Chest Drainage Systems
  • 64. Assessment
    • Respiratory status
    • S&S of extended pneumothorax or hemothorax
    • Function of drainage system every 1 hr:
      • System below level of patient’s chest
      • Tube free of kinks, or external obstruction
      • All connections secured
      • Color and amount of drainage
      • Fluctuation of fluid level in water-seal chamber
      • Constant bubbling in water-seal chamber
    • Anxiety level & understanding
    Pt with Chest Drainage Systems
  • 65.  
  • 66.
    • Nursing Diagnosis
      • Ineffective breathing pattern related to decreased lung expansion as evidence by:
    • Planning: Patient Outcomes
      • Breath sounds are normal
      • Respiration unlabored & occur at rate of 16 to 20 breaths per minute
      • ABG values approaching normal
      • Lung re-expansion seen on chest x-ray film
    Chest Drainage Systems
  • 67.
    • Nursing Interventions:
      • Maintain airtight, patent, functioning chest drainage system
      • Re-tape all connections as needed
      • Re-tape or reinforce chest-tube dressing
      • Tubing free of kinks, loops & external pressure
      • Place roll towel under chest- protect tubing from body weight
      • Encourage cough and deep breathe & position change frequently
      • Keep occlusive petrolatum jelly dressing at bedside
    Chest Drainage Systems
  • 68.
      • Mark amount of drainage in collection container at 1 to 4 hour intervals
      • Check water levels in suction control & water-seal pressure chambers
      • Notify MD of constant bubbling in water-seal or drainage becoming bright red or increases suddenly
      • Reassure the patient that staff is nearby- call light in reach
      • Documentation for chest drainage systems
      • Assist with chest tube insertion or removal
    Chest Drainage Systems
  • 69.
    • Evaluation:
      • RR & ABGs within normal limits
      • Decreased difficulty breathing
      • Chest pain diminished
      • Equal lung sounds
      • Bilateral chest movement
      • Decreased chest tube drainage
      • Client able to verbalize rationale for treatment and procedures
      • Client rests without behavioral signs of excessive anxiety
    Chest Drainage Systems
  • 70. Older Adult Alert
    • Be concern about any changes in orientation. This may be a first indication of pneumonia in older adults.
    • Be cautious in fluid administration. Overhydration may initiate CHF.
    • Older clients may become confused with multiple drug therapies and may not follow the regimen correctly. Theses clients may need assistance to ensure proper administration. In older clients, the thoracic muscles are weaker which may make the older adult unable to tolerate the increased work of breathing required of COPD.
    • Older adult clients have fewer alveoli than younger adults- oxygen exchange will be even more impaired in older adult clients with COPD.
  • 71.
    • The weaker thoracic muscles in older adults will also make coughing more difficult, and thus, retained secretions will be a problem in many cases.
    • Older adults high risk for infection due to decreased immune response. Chest injuries evaluated carefully for signs of infection. Temperature of 99 degrees F may indicate an initial infection.
    • Cough will be impaired due to decreased muscle strength- older adults greater risk for atelectasis and pneumonia after a chest injury.
    Older Adult Alert

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