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NurseReview.Org Respiratory System

  1. 1. Medical and Surgical Nursing Review The Respiratory System Nurse Licensure Examination Review
  2. 3. Outline Of Review Concepts: <ul><li>Review of the relevant respiratory anatomy </li></ul><ul><li>Review of the relevant respiratory physiology </li></ul><ul><li>The respiratory assessment </li></ul><ul><li>Common laboratory examinations </li></ul>
  3. 4. Outline Of Review Concepts: <ul><li>Review of the common respiratory problems and the nursing management </li></ul><ul><li>Review of common respiratory diseases </li></ul><ul><ul><li>Upper respiratory conditions </li></ul></ul><ul><ul><li>Lower respiratory conditions </li></ul></ul>
  4. 5. Respiratory Anatomy & Physiology <ul><li>The respiratory system consists of two main parts - the upper and the lower tracts </li></ul>
  5. 6. Respiratory Anatomy & Physiology <ul><li>The UPPER respiratory system consists of: </li></ul><ul><li>1. nose </li></ul><ul><li>2. mouth </li></ul><ul><li>3. pharynx </li></ul><ul><li>4. larynx </li></ul>
  6. 7. Respiratory Anatomy & Physiology <ul><li>The LOWER respiratory system consists of: </li></ul><ul><li>1. Trachea </li></ul><ul><li>2. Bronchus </li></ul><ul><li>3. Bronchioles </li></ul><ul><li>4. Respiratory unit </li></ul>
  7. 8. Upper Respiratory Tract
  8. 9. The Nose <ul><li>This is the first part of the upper respiratory system that contains nasal bones and cartilages </li></ul><ul><li>There are numerous hairs called vibrissae </li></ul><ul><li>There are numerous superficial blood vessels in the nasal mucosa </li></ul>
  9. 10. The Nose <ul><li>The functions of the nose are: </li></ul><ul><li>1. To filter the air </li></ul><ul><li>2. To humidify the air </li></ul><ul><li>3. To aid in phonation </li></ul><ul><li>4. Olfaction </li></ul>
  10. 11. The Pharynx <ul><li>The pharynx is a musculo - membranous tube that is composed of three parts </li></ul><ul><li>1. Nasopharynx </li></ul><ul><li>2. Oropharynx </li></ul><ul><li>3. Laryngopharynx </li></ul>
  11. 12. The Pharynx <ul><li>The pharynx functions : </li></ul><ul><li>1. As passageway for both air and foods (in the oropharynx) </li></ul><ul><li>2. To protect the lower airway </li></ul>
  12. 13. The Larynx <ul><li>Also called the voice box </li></ul><ul><li>Made of cartilage and membranes and connects the pharynx to the trachea </li></ul>
  13. 14. The Larynx <ul><li>Functions of the larynx: </li></ul><ul><li>1. Vocalization </li></ul><ul><li>2. Keeps the patency of the upper airway </li></ul><ul><li>3. Protects the lower airway </li></ul>
  14. 15. The Paranasal sinuses <ul><li>These are four paired bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar epithelium </li></ul><ul><li>Named after their location - frontal, ethmoidal, sphenoidal and maxillary </li></ul>
  15. 16. The Paranasal sinuses <ul><li>The function of the sinuses: </li></ul><ul><li>Resonating chambers in speech </li></ul>
  16. 17. The Lower Respiratory System <ul><li>The lower respiratory system consists of </li></ul><ul><li>1. Trachea </li></ul><ul><li>2. Main bronchus </li></ul><ul><li>3. Bronchial tree </li></ul><ul><li>4. Lungs- 3R/ 2L </li></ul><ul><li>The trachea  to the terminal bronchioles is called the conducting airway </li></ul><ul><li>The respiratory bronchioles  to the alveoli is called the respiratory acinus </li></ul>
  17. 18. The Trachea <ul><li>A cartilaginous tube measures 10-12 centimeters </li></ul><ul><li>Composed of about 20 C-shaped cartilages, incomplete posteriorly </li></ul>
  18. 19. The Trachea <ul><li>The function of the trachea is to conduct air towards the lungs </li></ul><ul><li>The mucosa is lined up with mucus and cilia to trap particles and carry them towards the upper airway </li></ul>
  19. 20. The Bronchus <ul><li>The right and left primary bronchi begin at the carina </li></ul><ul><li>The function is for air passage </li></ul>
  20. 21. The Primary Bronchus <ul><li>RIGHT BRONCHUS </li></ul><ul><li>Wider </li></ul><ul><li>Shorter </li></ul><ul><li>More Vertical </li></ul><ul><li>LEFT BRONCHUS </li></ul><ul><li>Narrower </li></ul><ul><li>Longer </li></ul><ul><li>More horizontal </li></ul>
  21. 22. The Bronchioles <ul><li>The primary bronchus further divides into secondary, then tertiary then into bronchioles </li></ul><ul><li>The terminal bronchiole is the last part of the conducting airway </li></ul>
  22. 23. The Respiratory Acinus <ul><li>The respiratory acinus is the chief respiratory unit </li></ul><ul><li>It consists of </li></ul><ul><li>1. Respiratory bronchiole </li></ul><ul><li>2. Alveolar duct </li></ul><ul><li>3. alveolar sac </li></ul>
  23. 24. The Respiratory Acinus <ul><li>The respiratory acinus is the chief respiratory unit </li></ul><ul><li>The function of the respiratory acinus is gas exchange through the respiratory membrane </li></ul>
  24. 25. The Respiratory Acinus <ul><li>The respiratory membrane is composed of two epithelial cells </li></ul><ul><li>1.The type 1 pneumocyte - most abundant, thin and flat. This is where gas exchange occurs </li></ul><ul><li>2. The type 2 pneumocyte - secretes the lung surfactant </li></ul>
  25. 26. The Respiratory Acinus <ul><li>A type III pneomocyte is just the macrophage that ingests foreign material and acts as an important defense mechanism </li></ul>
  26. 27. Accessory Structures <ul><li>The PLEURA </li></ul><ul><li>Epithelial serous membrane lining the lung parenchyma </li></ul><ul><li>Composed of two parts- the visceral and parietal pleurae </li></ul><ul><li>The space in between is the pleural space containing a minute amount of fluid for lubrication </li></ul>
  27. 28. Accessory Structures <ul><li>The Thoracic cavity </li></ul><ul><li>The chest wall composed of the sternum and the rib cage </li></ul><ul><li>The cavity is separated by the diaphragm, the most important respiratory muscle </li></ul>
  28. 29. Accessory Structures <ul><li>The Mediastinum </li></ul><ul><li>The space between the lungs, which includes the heart and pericardium, the aorta and the vena cavae. </li></ul>
  29. 30. GENERAL FUNCTIONS OF THE Respiratory System <ul><li>Gas exchange through ventilation, external respiration and cellular respiration </li></ul><ul><li>Oxygen and carbon dioxide transport </li></ul>
  30. 31. The Assessment <ul><li>HISTORY </li></ul><ul><li>Reason for seeking care </li></ul><ul><li>Present illness </li></ul><ul><li>Previous illness </li></ul><ul><li>Family history </li></ul><ul><li>Social history </li></ul>
  31. 32. The Assessment <ul><li>PHYSICAL EXAMINATION </li></ul><ul><li>Skin- cyanosis, pallor </li></ul><ul><li>Nail clubbing </li></ul><ul><li>Cough and sputum production </li></ul><ul><li>Inspect - palpate - percuss - auscultate the thorax </li></ul>
  32. 33. The Assessment <ul><li>LABORATORY EXAMINATION </li></ul><ul><li>1. ABG analysis </li></ul><ul><li>2. Sputum analysis </li></ul><ul><li>3. Direct visualization - bronchoscopy </li></ul><ul><li>4. Indirect visualization - CXR, CT and MRI </li></ul><ul><li>5. Pulmonary function test </li></ul>
  33. 34. ABG Analysis <ul><li>This test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an arterial sample </li></ul>
  34. 35. ABG Analysis <ul><li>Pre-test: choose site carefully, perform the Allen’s test, secure equipments- syringe, needle, container with ice </li></ul><ul><li>Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial) </li></ul><ul><li>Post-test: Apply firm pressure for 5 minutes, label specimen correctly, place in the container with ice </li></ul>
  35. 36. ABG Analysis <ul><li>ABG normal values </li></ul><ul><li>PaO2 80-100 mmHg </li></ul><ul><li>PaCO2 35-45 mmHg </li></ul><ul><li>pH 7.35- 7.45 </li></ul><ul><li>HCO3 22- 26 mEq/L </li></ul><ul><li>O2 Sat 95-99% </li></ul>
  36. 37. Sputum Analysis <ul><li>This test analyzes the sample of sputum to diagnose respiratory diseases, identify organism, and identify abnormal cells </li></ul>
  37. 38. Sputum Analysis <ul><li>Pre-test: Encourage to increase fluid intake </li></ul><ul><li>Intra-test: rinse mouth with WATER only, instruct the patient to take 3 deep breaths and force a deep cough, steam nebulization, collect early morning sputum </li></ul><ul><li>Post-test: provide oral hygiene, label specimen correctly </li></ul>
  38. 39. Pulse Oximetry <ul><li>Non-invasive method of continuously monitoring the oxygen saturation of hemoglobin </li></ul><ul><li>A sensor or probe is attached to the earlobe, forehead, fingertip or the bridge of the nose </li></ul>
  39. 40. Bronchoscopy <ul><li>A direct inspection of the trachea and bronchi through a flexible fiber-optic or a rigid bronchoscope </li></ul><ul><li>Done to determine location of pathologic lesions, to remove foreign objects, to collect tissue specimen and remove secretions/aspirated materials </li></ul>
  40. 41. Bronchoscopy <ul><li>Pre-test: Consent, NPO x 6h, teaching </li></ul><ul><li>Intra-test: position supine or sitting upright in a chair, administer sedative, gag reflex will be abolished, remove dentures </li></ul><ul><li>Post-test: NPO until gag reflex returns, position SEMI-fowler’s with head turned to sides, hoarseness is temporary, CXR after the procedure, keep tracheostomy set and suction x 24 hours </li></ul>
  41. 42. Thoracentesis <ul><li>Pleural fluid aspiration for obtaining a specimen of pleural fluid for analysis, relief of lung compression and biopsy specimen collection </li></ul>
  42. 43. Thoracentesis <ul><li>Pre-test: Consent </li></ul><ul><li>Intra-test: position the patient sitting with arms on a table or side-lying fowler’s, instruct not to cough, breathe deeply or move </li></ul><ul><li>Post-test: position unaffected side to allow lung expansion of the affected side, CXR obtained, maintain pressure dressing and monitor respiratory status </li></ul>
  43. 44. Pulmonary Function Tests <ul><li>Volume and capacity tests aid diagnosis in patient with suspected pulmonary dysfunction </li></ul><ul><li>Evaluates ventilatory function </li></ul><ul><li>Determines whether obstructive or restrictive disease </li></ul><ul><li>Can be utilized as screening test </li></ul>
  44. 45. Pulmonary Function Test <ul><li>Lung Volumes </li></ul><ul><li>Tidal volume </li></ul><ul><li>Inspiratory reserve volume </li></ul><ul><li>Expiratory reeve volume </li></ul><ul><li>Residual volume </li></ul>
  45. 46. Pulmonary Function Test <ul><li>Lung capacities </li></ul><ul><li>Inspiratory capacity </li></ul><ul><li>Vital capacity </li></ul><ul><li>Functional residual capacity </li></ul><ul><li>Total lung capacity </li></ul>
  46. 47. Pulmonary Function Test <ul><li>Pre-test: Teaching, no smoking for 3 days, only light meal 4 hours before the test </li></ul><ul><li>Intra-test: position sitting, bronchodilator, nose-clip and mouthpiece, fatigue and dyspnea during the test </li></ul><ul><li>Post-test: adequate rest periods, loosen tight clothing </li></ul>
  47. 48. Common Respiratory Problems and the common interventions
  48. 49. Dyspnea <ul><li>Breathing difficulty </li></ul><ul><li>Associated with many conditions- CHF, MG, GBS, Muscular dystrophy, obstruction, etc… </li></ul>
  49. 50. Dyspnea <ul><li>General nursing interventions: </li></ul><ul><li>1. Fowler’s position to promote maximum lung expansion and promote comfort. An alternative position is the ORTHOPNEIC position </li></ul><ul><li>2. O2 usually via nasal cannula </li></ul><ul><li>3. Provide comfort and distractions </li></ul>
  50. 51. Cough and sputum production <ul><li>Cough is a protective reflex </li></ul><ul><li>Sputum production has many stimuli </li></ul><ul><li>Thick, yellow, green or rust-colored  bacterial pneumonia </li></ul><ul><li>Profuse, Pink, frothy  pulmonary edema </li></ul><ul><li>Scant, pink-tinged, mucoid  Lung tumor </li></ul>
  51. 52. Cough and sputum production <ul><li>General nursing Intervention </li></ul><ul><li>1. Provide adequate hydration </li></ul><ul><li>2. Administer aerosolized solutions </li></ul><ul><li>3. advise smoking cessation </li></ul><ul><li>4. oral hygiene </li></ul>
  52. 53. Cyanosis <ul><li>Bluish discoloration of the skin </li></ul><ul><li>A LATE indicator of hypoxia </li></ul><ul><li>Appears when the unoxygenated hemoglobin is more than 5 grams/dL </li></ul><ul><li>Central cyanosis  observe color on the undersurface of tongue and lips </li></ul><ul><li>Peripheral cyanosis  observe the nail beds, earlobes </li></ul>
  53. 54. Cyanosis <ul><li>Interventions: </li></ul><ul><ul><li>Check for airway patency </li></ul></ul><ul><ul><li>Oxygen therapy </li></ul></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><li>Suctioning </li></ul></ul><ul><ul><li>Chest physiotherapy </li></ul></ul><ul><ul><li>Check for gas poisoning </li></ul></ul><ul><ul><li>Measures to increased hemoglobin </li></ul></ul>
  54. 55. Hemoptysis <ul><li>Expectoration of blood from the respiratory tract </li></ul><ul><li>Common causes: Pulmo infection, Lung CA, Bronchiectasis, Pulmo emboli </li></ul><ul><li>Bleeding from stomach  acidic pH, coffee ground material </li></ul>
  55. 56. Hemoptysis <ul><li>Interventions: </li></ul><ul><li>Keep patent airway </li></ul><ul><li>Determine the cause </li></ul><ul><li>Suction and oxygen therapy </li></ul><ul><li>Administer Fibrin stabilizers like aminocaproic acid and tranexamic acid </li></ul>
  56. 57. Epistaxis <ul><li>Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane </li></ul><ul><li>Most common site- anterior septum </li></ul><ul><li>Causes </li></ul><ul><li>1. trauma </li></ul><ul><li>2. infection </li></ul><ul><li>3. Hypertension </li></ul><ul><li>4. blood dyscrasias , nasal tumor, cardio diseases </li></ul>
  57. 58. Epistaxis <ul><li>Nursing Interventions </li></ul><ul><li>1. Position patient: Upright, leaning forward, tilted  prevents swallowing and aspiration </li></ul><ul><li>2. Apply direct pressure. Pinch nose against the middle septum x 5-10 minutes </li></ul><ul><li>3. If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foams </li></ul><ul><li>4. Assist in electrocautery and nasal packing for posterior bleeding </li></ul>
  58. 59. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infections </li></ul><ul><li>1. Rhinitis- allergic, non-allergic and infectious </li></ul><ul><li>2. Sinusitis- acute and chronic </li></ul><ul><li>3. Pharyngitis- acute and chronic </li></ul>
  59. 60. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infections </li></ul><ul><li>1. Rhinitis- Assessment findings </li></ul><ul><li>Rhinorrhea </li></ul><ul><li>Nasal congestion </li></ul><ul><li>Nasal itchiness </li></ul><ul><li>Sneezing </li></ul><ul><li>Headache </li></ul>
  60. 61. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infections </li></ul><ul><li>2. sinusitis- Assessment findings </li></ul><ul><li>Facial pain </li></ul><ul><li>Tenderness over the paranasal sinuses </li></ul><ul><li>Purulent nasal discharges </li></ul><ul><li>Ear pain, headache, dental pain </li></ul><ul><li>Decreased sense of smell </li></ul>
  61. 62. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infections </li></ul><ul><li>3. Pharyngitis- Assessment findings </li></ul><ul><li>Fiery-red pharyngeal membrane </li></ul><ul><li>White-purple flecked exudates </li></ul><ul><li>Enlarged and tender cervical lymph nodes </li></ul><ul><li>Fever malaise ,sore throat </li></ul><ul><li>Difficulty swallowing </li></ul><ul><li>Cough may be absent </li></ul>
  62. 63. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infections- Laboratory tests </li></ul><ul><li>1. CBC </li></ul><ul><li>2. Culture </li></ul>
  63. 64. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infections: Nursing Interventions </li></ul><ul><li>1. Maintain Patent Airway </li></ul><ul><li>Increase fluid intake to loosen secretions </li></ul><ul><li>Utilize room vaporizers or steam inhalation </li></ul><ul><li>Administer medications to relieve nasal congestion </li></ul>
  64. 65. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infections: Nursing Interventions </li></ul><ul><li>2. Promote comfort </li></ul><ul><li>Administer prescribed analgesics </li></ul><ul><li>Administer topical analgesics </li></ul><ul><li>Warm gargles for the relief of sore throat </li></ul><ul><li>Provide oral hygiene </li></ul>
  65. 66. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infections: Nursing Interventions </li></ul><ul><li>3. Promote communication </li></ul><ul><li>Instruct patient to refrain from speaking as much as possible </li></ul><ul><li>Provide writing materials </li></ul>
  66. 67. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infections: Nursing Interventions </li></ul><ul><li>4. Administer prescribed antibiotics </li></ul><ul><li>Monitor for possible complications like meningitis, otitis media, abscess formation </li></ul><ul><li>5. Assist in surgical intervention </li></ul>
  67. 68. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infection: Tonsillitis </li></ul><ul><li>Infection and inflammation of the tonsils </li></ul><ul><li>Most common organism- Group A- beta hemolytic streptococcus (GABS) </li></ul>
  68. 69. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infection: Tonsillitis </li></ul><ul><li>ASSESSMENT FINDINGS </li></ul><ul><li>Sore throat and mouth breathing </li></ul><ul><li>Fever </li></ul><ul><li>Difficulty swallowing </li></ul><ul><li>Enlarged, reddish tonsils </li></ul><ul><li>Foul-smelling breath </li></ul>
  69. 70. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infection: Tonsillitis </li></ul><ul><li>Laboratory test </li></ul><ul><li>1. CBC </li></ul><ul><li>2. throat culture </li></ul>
  70. 71. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infection: Tonsillitis </li></ul><ul><li>MEDICAL management </li></ul><ul><li>1. Antibiotics- penicillin </li></ul><ul><li>2. Tonsillectomy for chronic cases and abscess formation </li></ul>
  71. 72. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infection: Tonsillitis </li></ul><ul><li>NURSING INTERVENTION for tonsillectomy </li></ul><ul><li>1. Pre-operative care </li></ul><ul><li>Consent </li></ul><ul><li>Routine pre-op surgical care </li></ul>
  72. 73. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infection: Tonsillitis </li></ul><ul><li>NURSING INTERVENTION for tonsillectomy </li></ul><ul><li>2. POST-operative care </li></ul><ul><li>Position: Most comfortable is PRONE, with head turned to side </li></ul><ul><li>Maintain oral airway, until gag reflex returns </li></ul>
  73. 74. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infection: Tonsillitis </li></ul><ul><li>NURSING INTERVENTION for tonsillectomy </li></ul><ul><li>2. POST-operative care </li></ul><ul><li>Apply ICE collar to the neck to reduce edema </li></ul><ul><li>Advise patient to refrain from talking and coughing </li></ul><ul><li>Ice chips are given when there is no bleeding and gag reflex returns </li></ul>
  74. 75. CONDITIONS OF THE UPPER AIRWAY <ul><li>Upper airway infection: Tonsillitis </li></ul><ul><li>NURSING INTERVENTION for tonsillectomy </li></ul><ul><li>2. POST-operative care </li></ul><ul><li>Notify physician if </li></ul><ul><li>a. Patient swallows frequently </li></ul><ul><li>b. vomiting of large amount of bright red or dark blood </li></ul><ul><li>c. PR increased, restless and Temp is increased </li></ul>
  75. 76. Laryngeal Cancer <ul><li>A malignant tumor of the larynx </li></ul><ul><li>More frequent in men </li></ul><ul><li>50-70 years old </li></ul><ul><li>RISK FACTORS </li></ul><ul><li>1. Smoking </li></ul><ul><li>2. Alcohol </li></ul><ul><li>3. Exposure to chemicals </li></ul><ul><li>4. Straining of voice </li></ul><ul><li>5. chronic laryngitis </li></ul><ul><li>6. Deficiency of Riboflavin </li></ul><ul><li>7. family history </li></ul>
  76. 77. Laryngeal Cancer <ul><li>Growth can be anywhere in the larynx </li></ul><ul><li>1. Supraglottic- above the vocal cords </li></ul><ul><li>2. glottic- vocal cord area </li></ul><ul><li>3. infraglottic- below the vocal cords </li></ul><ul><li>Most tumors are found in the glottic area </li></ul>
  77. 78. Laryngeal Cancer <ul><li>ASSESSMENT FINDINGS </li></ul><ul><li>Hoarseness of more than TWO weeks duration </li></ul><ul><li>Cough and sore throat </li></ul><ul><li>Burning and pain in the throat especially after consuming HOT liquids and citrus foods </li></ul><ul><li>Neck lump </li></ul><ul><li>Dysphagia, dyspnea, foul breath, CLAD </li></ul>
  78. 79. Laryngeal Cancer <ul><li>LABORATORY FINDINGS </li></ul><ul><li>1. Indirect laryngoscopy </li></ul><ul><li>2. direct laryngoscopy </li></ul><ul><li>3. Biopsy </li></ul><ul><li>4. CT and MRI </li></ul><ul><li>Most commonly- squamos carcinoma </li></ul>
  79. 80. Laryngeal Cancer <ul><li>MEDICAL MANAGEMENT </li></ul><ul><li>Radiation therapy </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Surgery </li></ul><ul><ul><li>Partial laryngectomy </li></ul></ul><ul><ul><li>Supraglottic laryngectomy </li></ul></ul><ul><ul><li>Hemilaryngectomy </li></ul></ul><ul><ul><li>Total laryngectomy </li></ul></ul>
  80. 81. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: PRE-operative </li></ul><ul><li>1. Provide the patient pre-operative teachings </li></ul><ul><li>Clarify misconceptions </li></ul><ul><li>Tell that the natural voice will be lost </li></ul><ul><li>Teach communication alternatives </li></ul><ul><li>Collaborate with other team members </li></ul>
  81. 82. Laryngeal Cancer <ul><li>NURSING MANAGEMENT </li></ul><ul><li>2. reduce patient ANXIETY </li></ul><ul><li>Provide opportunities for patient and family members to ask questions </li></ul><ul><li>Referrals to previous patients with laryngeal cancers and cancer groups </li></ul>
  82. 83. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: POST-op </li></ul><ul><li>3. Maintain PATENT Airway </li></ul><ul><li>Position patient: Semi or High Fowler’s </li></ul><ul><li>Suction secretions </li></ul><ul><li>Encourage to deep breath, turn and cough </li></ul>
  83. 84. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: POST-op </li></ul><ul><li>4. Administer care of the laryngectomy tube </li></ul><ul><li>Suction as needed </li></ul><ul><li>Cleanse the stoma with saline </li></ul><ul><li>Administer humidified oxygen </li></ul><ul><li>Laryngectomy tube is usually removed within 3-6 weeks after surgery </li></ul>
  84. 85. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: POST-op </li></ul><ul><li>5. Promote alternative communication methods </li></ul><ul><li>Call bell or hand bell </li></ul><ul><li>Magic Slate </li></ul><ul><li>Hand signals </li></ul><ul><li>Collaborate with speech therapist </li></ul>
  85. 86. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: POST-op </li></ul><ul><li>6. Promote adequate Nutrition </li></ul><ul><li>NPO after operation </li></ul><ul><li>No foods or drinks per orem for 10 days </li></ul><ul><li>IVF, TPN are alternative nutrition routes </li></ul><ul><li>Start oral feedings with thick liquids, avoid sweet foods </li></ul>
  86. 87. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: POST-op </li></ul><ul><li>7. Promote positive body image and self-esteem </li></ul><ul><li>Encourage verbalization of feelings </li></ul><ul><li>Allow independence in self-care </li></ul>
  87. 88. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: POST-op </li></ul><ul><li>8. Monitor for COMPLICATIONS </li></ul><ul><li>Respiratory Distress </li></ul><ul><ul><li>Suction </li></ul></ul><ul><ul><li>Coughing and deep breathing </li></ul></ul><ul><ul><li>Humidified oxygen </li></ul></ul><ul><ul><li>Alert the surgeon </li></ul></ul>
  88. 89. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: POST-op </li></ul><ul><li>8. Monitor for Complications </li></ul><ul><li>Hemorrhage </li></ul><ul><ul><li>Monitor for bleeding </li></ul></ul><ul><ul><li>Monitor vital signs </li></ul></ul><ul><ul><li>Apply direct pressure over the bleeding artery </li></ul></ul><ul><ul><li>Summon assistance and alert the surgeon </li></ul></ul>
  89. 90. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: POST-op </li></ul><ul><li>8. Monitor for COMPLICATIONS </li></ul><ul><li>Wound infection and breakdown </li></ul><ul><li>Monitor for increased temperature, purulent drainage and increased redness/tenderness </li></ul><ul><li>Administer antibiotics </li></ul><ul><li>Clean and change dressing OD </li></ul>
  90. 91. Laryngeal Cancer <ul><li>NURSING MANAGEMENT: HOME CARE </li></ul><ul><li>Humidification system at home is needed </li></ul><ul><li>AVOID swimming </li></ul><ul><li>Cover the stoma with hands or plastic bib over the opening </li></ul><ul><li>Advise beauty salons to avoid hair sprays, powders and loose hair near the opening </li></ul><ul><li>Oral hygiene frequently </li></ul>
  91. 92. Acute Respiratory Failure <ul><li>Sudden and life-threatening deterioration of the gas-exchange function of the lungs </li></ul><ul><li>Occurs when the lungs no longer meet the body’s metabolic needs </li></ul>
  92. 93. Acute Respiratory Failure <ul><li>Defined clinically as: </li></ul><ul><li>1. PaO2 of less than 50 mmHg </li></ul><ul><li>2. PaCO2 of greater than 5o mmHg </li></ul><ul><li>3. Arterial pH of less than 7.35 </li></ul>
  93. 94. Acute Respiratory Failure <ul><li>CAUSES </li></ul><ul><li>CNS depression- head trauma, sedatives </li></ul><ul><li>CVS diseases- MI, CHF, pulmonary emboli </li></ul><ul><li>Airway irritants- smoke, fumes </li></ul><ul><li>Endocrine and metabolic disorders- myxedema, metabolic alkalosis </li></ul><ul><li>Thoracic abnormalities- chest trauma, pneumothorax </li></ul>
  94. 95. Acute Respiratory Failure <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>Decreased Respiratory Drive </li></ul><ul><li>Brain injury, sedatives, metabolic disorders  impair the normal response of the brain to normal respiratory stimulation </li></ul>
  95. 96. Acute Respiratory Failure <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>Dysfunction of the chest wall </li></ul><ul><li>Dystrophy, MS disorders, peripheral nerve disorders  disrupt the impulse transmission from the nerve to the diaphragm  abnormal ventilation </li></ul>
  96. 97. Acute Respiratory Failure <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>Dysfunction of the Lung Parenchyma </li></ul><ul><li>Pleural effusion, hemothorax, pneumothorax, obstruction  interfere ventilation  prevent lung expansion </li></ul>
  97. 98. Acute Respiratory Failure <ul><li>ASSESSMENT FINDINGS </li></ul><ul><li>Restlessness </li></ul><ul><li>dyspnea </li></ul><ul><li>Cyanosis </li></ul><ul><li>Altered respiration </li></ul><ul><li>Altered mentation </li></ul><ul><li>Tachycardia </li></ul><ul><li>Cardiac arrhythmias </li></ul><ul><li>Respiratory arrest </li></ul>
  98. 99. Acute Respiratory Failure <ul><li>DIAGNOSTIC FINDINGS </li></ul><ul><li>Pulmonary function test- pH below 7.35 </li></ul><ul><li>CXR- pulmonary infiltrates </li></ul><ul><li>ECG- arrhythmias </li></ul>
  99. 100. Acute Respiratory Failure <ul><li>MEDICAL TREATMENT </li></ul><ul><li>Intubation </li></ul><ul><li>Mechanical ventilation </li></ul><ul><li>Antibiotics </li></ul><ul><li>Steroids </li></ul><ul><li>Bronchodilators </li></ul>
  100. 101. Acute Respiratory Failure <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>1. Maintain patent airway </li></ul><ul><li>2. Administer O2 to maintain Pa02 at more than 50 mmHg </li></ul><ul><li>3. Suction airways as required </li></ul><ul><li>4. Monitor serum electrolyte levels </li></ul><ul><li>5. Administer care of patient on mechanical ventilation </li></ul>
  101. 102. COPD <ul><li>These are group of disorders associated with recurrent or persistent obstruction of air passage and airflow, usually irreversible. </li></ul>
  102. 103. COPD <ul><li>The most common cause of COPD is cigarette smoking. Asthma, Chronic bronchitis, Emphysema and Bronchiectasis are the common disorders. </li></ul>
  103. 104. COPD <ul><li>The general pathophysiology: </li></ul><ul><li>In COPD there is airflow limitation that is both progressive and associated with abnormal inflammatory response of the lungs to stimuli, usually smoke, particles and dust </li></ul>
  104. 105. ASTHMA <ul><li>The acute episode of airway obstruction is characterized by airway hyperactivity to various stimuli that results in recurrent wheezing brought about by edema and bronchospasm </li></ul>
  105. 106. Asthma Pathophysiology <ul><li>Immunologic/allergic reaction results in histamine release, which produces three main airway responses </li></ul><ul><li>a. Edema of mucous membranes </li></ul><ul><li>b. Spasm of the smooth muscle of bronchi and bronchioles </li></ul><ul><li>c. Accumulation of tenacious secretions </li></ul>
  106. 107. Asthma Assessment Findings <ul><li>Assessment findings </li></ul><ul><li>1. Family history of allergies </li></ul><ul><li>2. Client history of eczema </li></ul>
  107. 108. Asthma Assessment Findings <ul><li>Assessment findings </li></ul><ul><li>3. Pulmonary signs and symptoms- Respiratory distress: slow onset of shortness of breath, expiratory wheeze , prolonged expiratory phase, air trapping (barrel chest if chronic), use of accessory muscles, irritability (from hypoxia), diaphoresis, cough, anxiety, weak pulse, diaphoresis and change in sensorium if severe attack </li></ul>
  108. 109. Asthma Assessment Findings <ul><li>Assessment findings </li></ul><ul><li>4. Use of accessory muscles of respiration, inspiratory retractions, prolonged I:E ratio </li></ul><ul><li>5. Cardiovascular symptoms: tachycardia, ECG changes, hypertension, decreased cardiac contractility, pulsus paradoxus </li></ul><ul><li>6. CNS manifestations: anxiety, restlessness, fear and disorientation </li></ul>
  109. 110. Emphysema <ul><li>There is progressive and irreversible alveolocapillary destruction with abnormal alveolar enlargement causing alveolar wall destruction. The result is INCREASED lung compliance, DECREASED oxygen diffusion and INCREASED airway resistance! </li></ul>
  110. 111. Emphysema <ul><li>These changes cause a state of carbon dioxide retention, hypoxia, and respiratory acidosis. </li></ul>
  111. 112. Emphysema <ul><li>Cigarette smoking </li></ul><ul><li>Heredity, Bronchial asthma </li></ul><ul><li>Aging process </li></ul><ul><li> </li></ul><ul><li>Disequilibrium between </li></ul><ul><li>ELASTASE & ANTIELASTASE (alpha-1-antitrypsin) </li></ul><ul><li>Destruction of distal airways and alveoli </li></ul><ul><li>Overdistention of ALVEOLI </li></ul><ul><li>Hyper-inflated and pale lungs </li></ul><ul><li>Air traping, decreased gas exchange and Retention of CO2 </li></ul><ul><li> </li></ul><ul><li>Hypoxia Respiratory acidosis </li></ul>
  112. 113. Emphysema Assessment <ul><li>1. Anorexia, fatigue, weight loss </li></ul><ul><li>2. Feeling of breathlessness, cough, sputum production, flaring of the nostrils, use of accessory muscles of respiration, increased rate and depth of breathing, dyspnea </li></ul>
  113. 114. Emphysema Assessment <ul><li>3. Decreased respiratory excursion, resonance to hyper-resonance, decreased breath sounds with prolonged expiration, normal or decreased fremitus </li></ul><ul><li>4. Diagnostic tests: pCO2 elevated or normal; PO2 normal or slightly decreased </li></ul>
  114. 115. Chronic bronchitis <ul><li>Chronic inflammation of the bronchial air passageway characterized by the presence of cough and sputum production for at least 3 months in each 2 consecutive years. </li></ul><ul><li>Excessive production of mucus in the bronchi with accompanying persistent cough. </li></ul>
  115. 116. Chronic Bronchitis pathophysiology <ul><li>Characteristic changes include hypertrophy/ hyperplasia of the mucus-secreting glands in the bronchi, decreased ciliary activity, chronic inflammation, and narrowing of the small airways. </li></ul>
  116. 117. Chronic Bronchitis Assessment <ul><li>I. Productive (copious) cough, dyspnea on exertion, use of accessory muscles of respiration, scattered rales and rhonchi </li></ul><ul><li>2. Feeling of epigastric fullness, cyanosis, distended neck veins, ankle edema </li></ul><ul><li>3. Diagnostic tests: increased pCO2 decreased PO2 </li></ul>
  117. 118. Bronchiectasis <ul><li>Permanent abnormal dilation of the bronchi with destruction of muscular and elastic structure of the bronchial wall </li></ul>
  118. 119. Bronchiectasis <ul><li>Caused by bacterial infection; recurrent lower respiratory tract infections; congenital defects (altered bronchial structures); lung tumors </li></ul>
  119. 120. Bronchiectasis <ul><li>1. Chronic cough with production of mucopurulent sputum, hemoptysis, exertional dyspnea, wheezing </li></ul><ul><li>2. Anorexia, fatigue, weight loss </li></ul><ul><li>3. Diagnostic tests </li></ul><ul><ul><li>a. Bronchoscopy reveals sources and sites of secretions </li></ul></ul><ul><ul><li>b. Possible elevation of WBC </li></ul></ul>
  120. 121. COPD Management <ul><li>Independent and Collaborative Management </li></ul><ul><li>1. Rest- To reduce oxygen demands of tissues </li></ul><ul><li>2. Increase fluid intake -To liquefy mucus secretions </li></ul><ul><li>3. Good oral care- To remove sputum and prevent infection </li></ul>
  121. 122. COPD Management <ul><li>Independent and Collaborative Management </li></ul><ul><li>4. Diet: </li></ul><ul><li>High caloric diet provides source of energy </li></ul><ul><li>High protein diet helps maintain integrity of alveolar walls </li></ul><ul><li>Moderate fats </li></ul><ul><li>Low carbohydrate diet limits carbon dioxide production (natural end product). The client has difficulty exhaling carbon dioxide. </li></ul>
  122. 123. COPD Management <ul><li>Independent and Collaborative Management </li></ul><ul><li>5. O2 therapy 1 to 3 lpm ( 2 lpm is safest ) </li></ul><ul><li>Do not give high concentration of oxygen. The drive for breathing may be depressed. </li></ul>
  123. 124. COPD Management <ul><li>Independent and Collaborative Management </li></ul><ul><li>6 . Avoid cigarette smoking, alcohol, and environmental pollutants-These inhibit mucociliary function. </li></ul><ul><li>7. CPT –percussion, vibration, postural drainage </li></ul>
  124. 125. COPD Management <ul><li>Independent and Collaborative Management </li></ul><ul><li>8. Bronchial hygiene measures </li></ul><ul><li>Steam inhalation </li></ul><ul><li>Aerosol inhalation </li></ul><ul><li>Medimist inhalation </li></ul>
  125. 126. COPD Management <ul><li>Pharmacotherapy </li></ul><ul><li>1. Expectorants (guaiafenessin)/ mucolytic (mucomyst/mucosolvan) </li></ul><ul><li>2. Antitussives </li></ul><ul><li>Dextrometorphan </li></ul><ul><li>Codeine </li></ul><ul><li>Observe for drowsiness </li></ul><ul><li>Avoid activities that involve mental alertness, e.g driving, operating electrical machines </li></ul><ul><li>Cause decrease peristalsis thereby constipation </li></ul>
  126. 127. COPD Management <ul><li>Pharmacotherapy </li></ul><ul><li>3. Bronchodilators </li></ul><ul><li>Aminophylline (Theophylline) </li></ul><ul><li>Ventolin (Salbutamol) </li></ul><ul><li>Bricanyl (Terbutaline) </li></ul><ul><li>Alupent (Metaproterenol) </li></ul><ul><ul><li>Observe for tachycardia </li></ul></ul>
  127. 128. COPD Management <ul><li>Pharmacotherapy </li></ul><ul><li>4. Antihistamine </li></ul><ul><li>Benadryl (Diphenhydramine) </li></ul><ul><li>Observe for drowsiness </li></ul><ul><li>5. Steroids </li></ul><ul><li>Anti-inflammatory effect </li></ul><ul><li>6. Antimicrobials </li></ul>
  128. 129. Flail Chest <ul><li>Complication of chest trauma occurring when 3 or more adjacent ribs are fractured at two or more sites, resulting in free-floating rib segments. </li></ul>
  129. 130. Flail Chest <ul><li>Chest wall is no longer able to provide the bony structure necessary to maintain adequate ventilation; consequently </li></ul><ul><li>the flail portion and underlying tissue move paradoxically (in opposition) to the rest of the chest cage and lungs. </li></ul>
  130. 131. Flail Chest <ul><li>The flail portion is sucked in on inspiration and bulges out on expiration. </li></ul><ul><li>Result is hypoxia, hypercarbia, and increased retained secretions. </li></ul><ul><li>Caused by trauma (sternal rib fracture with possible costochondral separations). </li></ul>
  131. 132. Flail Chest <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a “paradoxical” manner </li></ul><ul><li>The chest is pulled INWARD during inspiration, reducing the amount of air that can be drawn into the lungs </li></ul><ul><li>The chest bulges OUTWARD during expiration because the intrathoracic pressure exceeds atmospheric pressure. The patient has impaired exhalation </li></ul>
  132. 133. Flail Chest <ul><li>This paradoxical action will lead to: </li></ul><ul><ul><li>Increased dead space </li></ul></ul><ul><ul><li>Reduced alveolar ventilation </li></ul></ul><ul><ul><li>Decreased lung compliance </li></ul></ul><ul><ul><li>Hypoxemia and respiratory acidosis </li></ul></ul><ul><ul><li>Hypotension, inadequate tissue perfusion can also follow </li></ul></ul>
  133. 134. Flail Chest <ul><li>Assessment findings </li></ul><ul><li>1. Severe dyspnea; rapid, shallow, grunty breathing; paradoxical chest motion. The chest will move INWARDS on inhalation and OUTWARDS on exhalation. </li></ul><ul><li>2. Cyanosis, possible neck vein distension, tachycardia, hypotension </li></ul><ul><li>3. Diagnostic tests </li></ul><ul><ul><li>a. PO2 decreased </li></ul></ul><ul><ul><li>b. pCO2 elevated </li></ul></ul><ul><ul><li>c. pH decreased </li></ul></ul>
  134. 135. Flail Chest <ul><li>Nursing interventions </li></ul><ul><li>1. Maintain an open airway: suction secretions, blood from nose, throat, mouth, and via endotracheal tube; note changes in amount, color, and characteristics. </li></ul><ul><li>2. Monitor mechanical ventilation </li></ul><ul><li>3. Encourage turning, coughing, and deep breathing. </li></ul><ul><li>4. Monitor for signs of shock: HYPOTENSION, TACHYCARDIA </li></ul>
  135. 136. Flail Chest <ul><li>Medical management: SUPPORTIVE </li></ul><ul><li>1. Internal stabilization with a volume-cycled ventilator </li></ul><ul><li>2. Drug therapy (narcotics, sedatives) </li></ul>
  136. 137. Pneumothorax <ul><li>Partial or complete collapse of the lung due to an accumulation of air or fluid in the pleural space </li></ul>
  137. 138. Pneumothorax <ul><li>Types </li></ul><ul><li>a . Spontaneous pneumothorax : the most common type of closed pneumothorax; air accumulates within the pleural space without an obvious cause. Rupture of a small bleb on the visceral pleura most frequently produces this type of pneumothorax. </li></ul>
  138. 139. Pneumothorax <ul><li>Types </li></ul><ul><li>b. Open pneumothorax : air enters the pleural space through an opening in the chest wall; usually caused by stabbing or gunshot wound. </li></ul>
  139. 140. Pneumothorax <ul><li>Types </li></ul><ul><li>c. Tension pneumothorax : air enters the pleural space with each inspiration but cannot escape; causes increased intrathoracic pressure and shifting of the mediastinal contents to the unaffected side (mediastinal shift ). </li></ul>
  140. 141. Pneumothorax <ul><li>Assessment findings </li></ul><ul><li>1. Sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side , tracheal shift to the opposite side (tension pneumothorax accompanied by mediastinal shift) </li></ul><ul><li>2. Weak, rapid pulse; anxiety; diaphoresis </li></ul>
  141. 142. Pneumothorax <ul><li>Assessment findings </li></ul><ul><li>3. Diagnostic tests </li></ul><ul><ul><li>a. Chest x-ray reveals area and degree of pneumothorax </li></ul></ul><ul><ul><li>b. pCO2 elevated </li></ul></ul><ul><ul><li>c. pH decreased </li></ul></ul>
  142. 143. Pneumothorax <ul><li>Nursing interventions </li></ul><ul><li>1. Provide nursing care for the client with an endotracheal tube: suction secretions, vomitus, blood from nose, mouth, throat, or via endotracheal tube; monitor mechanical ventilation. </li></ul>
  143. 144. Pneumothorax <ul><li>Nursing interventions </li></ul><ul><li>2. Restore/promote adequate respiratory function. </li></ul><ul><li>a. Assist with thoracentesis and provide appropriate nursing care. </li></ul><ul><li>b. Assist with insertion of a chest tube to water- seal drainage and provide appropriate nursing care. </li></ul><ul><li>c. Continuously evaluate respiratory patterns and report any changes. </li></ul>
  144. 145. Pneumothorax <ul><li>Nursing interventions </li></ul><ul><li>3. Provide relief/control of pain. </li></ul><ul><li>a. Administer narcotics/analgesics/sedatives as ordered and monitor effects. </li></ul><ul><li>b. Position client in high-Fowler’s position. </li></ul>
  145. 146. Atelectasis <ul><li>Collapse of part or all of a lung due to bronchial obstruction </li></ul><ul><li>May be caused by </li></ul><ul><ul><li>intrabronchial obstruction </li></ul></ul><ul><ul><li>tumors, bronchospasm </li></ul></ul><ul><ul><li>foreign bodies </li></ul></ul><ul><ul><li>extrabronchial compression (tumors, enlarged lymph nodes); or </li></ul></ul><ul><ul><li>endobronchial disease (bronchogenic carcinoma, inflammatory structures) </li></ul></ul>
  146. 147. Atelectasis <ul><li>Assessment findings </li></ul><ul><li>1. Signs and symptoms may be absent depending upon degree of collapse and rapidity with which bronchial obstruction occurs </li></ul><ul><li>2. Dyspnea, decreased breath sounds on affected side, decreased respiratory excursion, dullness to flatness upon percussion over affected area </li></ul>
  147. 148. Atelectasis <ul><li>Assessment findings </li></ul><ul><li>3. Cyanosis, tachycardia, tachypnea, elevated temperature, weakness, pain over affected area </li></ul>
  148. 149. Atelectasis <ul><li>Assessment findings </li></ul><ul><li>4. Diagnostic tests </li></ul><ul><li>a. Bronchoscopy: may or may not reveal an obstruction </li></ul><ul><li>b. Chest x-ray shows diminished size of affected lung and lack of radiance over atelectatic area </li></ul><ul><li>c. pO2 decreased </li></ul>
  149. 150. Pleural Effusion <ul><li>Defined broadly as a collection of fluid in the pleural space </li></ul><ul><li>A symptom, not a disease; may be produced by numerous conditions </li></ul>
  150. 151. Pleural Effusion <ul><li>General Classification </li></ul><ul><ul><li>Transudative effusion: accumulation of protein-poor, cell-poor fluid </li></ul></ul><ul><ul><li>Exudative effusion: accumulation of protein rich fluid </li></ul></ul>
  151. 152. Pleural Effusion <ul><li>Assessment findings </li></ul><ul><li>1. Dyspnea, dullness over affected area upon percussion, absent or decreased breath sounds over affected area, pleural pain, dry cough, pleural friction rub </li></ul><ul><li>2. Pallor, fatigue, fever, and night sweats (with empyema) </li></ul>
  152. 153. Pleural Effusion <ul><li>Assessment findings </li></ul><ul><li>3. Diagnostic tests </li></ul><ul><li>a. Chest x-ray positive if greater than 250 cc pleural fluid </li></ul><ul><li>b. Pleural biopsy may reveal bronchogenic carcinoma </li></ul><ul><li>c. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or tuberculosis; positive for specific organism in empyema. </li></ul>
  153. 154. Pleural Effusion <ul><li>Nursing interventions: In general: </li></ul><ul><li>1. Assist with repeated thoracentesis. </li></ul><ul><li>2. Administer narcotics/sedatives as ordered to decrease pain. </li></ul><ul><li>3. Assist with instillation of medication into pleural space (reposition client every 15 minutes to distribute the drug within the pleurae). </li></ul><ul><li>4. Place client in high-Fowler’s position to promote ventilation. </li></ul>
  154. 155. Pleural Effusion <ul><li>Medical management </li></ul><ul><li>1. Identification and treatment of the Underlying cause </li></ul><ul><li>2. Thoracentesis </li></ul><ul><li>3. Drug therapy </li></ul><ul><ul><li>a. Antibiotics: either systemic or inserted directly into pleural space </li></ul></ul><ul><ul><li>b. Fibrinolytic enzymes: trypsin, streptokinase-. streptodornase to decrease thickness of pus and dissolve fibrin clots </li></ul></ul><ul><li>4. Closed chest drainage </li></ul><ul><li>5. Surgery: open drainage </li></ul>
  155. 156. Pneumonia <ul><li>An inflammation of the alveolar spaces of the lung, resulting in consolidation of lung tissue as the alveoli fill with exudates </li></ul><ul><li>The various types of pneumonias are classified according to the offending organism. </li></ul><ul><li>Pneumonia can also be classified as COMMUNITY Acquired Pneumonia (CAP) and Hospital acquired pneumonia (HAP) </li></ul>
  156. 157. Pneumonia <ul><li>PATHOPHYSIOLOGIC FINDINGS ARE: </li></ul><ul><li>HYPERTROPHY OF MUCOUS MEMBRANE </li></ul><ul><ul><li>Increased sputum production </li></ul></ul><ul><ul><li>Wheezing </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>Rales </li></ul></ul><ul><ul><li>Ronchi </li></ul></ul>
  157. 158. Pneumonia <ul><li>PATHOPHYSIOLOGIC FINDINGS ARE: </li></ul><ul><li>INCREASED CAPILLARY PERMEABILITY </li></ul><ul><ul><li>Increased Fluid Exudation </li></ul></ul><ul><ul><li>Consolidation-tissue that solidifies as a result of collapsed alveoli </li></ul></ul><ul><ul><li>Hypoxemia </li></ul></ul>
  158. 159. Pneumonia <ul><li>PATHOPHYSIOLOGIC FINDINGS ARE: </li></ul><ul><li>INFLAMMATION OF THE PLEURA </li></ul><ul><li>Chest pain </li></ul><ul><li>Pleural effusion </li></ul><ul><li>Dullness </li></ul><ul><li>Decreased Breath sounds </li></ul><ul><li>Increased tactile fremitus </li></ul>
  159. 160. Pneumonia <ul><li>PATHOPHYSIOLOGIC FINDINGS ARE: </li></ul><ul><li>HYPOVENTILATION </li></ul><ul><li>Decreased Chest expansion </li></ul><ul><li>Respiratory acidosis </li></ul><ul><li>Depressed PROTECTIVE MECHANISM </li></ul><ul><li>Increased WBC (leukocytosis) </li></ul><ul><li>Increased RR and Fever </li></ul>
  160. 161. Pneumonia <ul><li>Assessment findings </li></ul><ul><li>Cough with greenish to rust-colored sputum production </li></ul><ul><li>rapid, shallow respirations with an expiratory grunt </li></ul><ul><li>nasal flaring; intercostal rib retraction; use of accessory muscles of respiration </li></ul><ul><li>rales or crackles (early) progressing to coarse (later). </li></ul><ul><li>Tactile fremitus is INCREASED! </li></ul>
  161. 162. Pneumonia <ul><li>Assessment findings </li></ul><ul><li>Fever, chills, chest pain, weakness, generalized malaise </li></ul><ul><li>Tachycardia, cyanosis, profuse perspiration, abdominal distension </li></ul><ul><li>Rapid shallow breathing </li></ul>
  162. 163. Pneumonia <ul><li>Diagnostic tests </li></ul><ul><li>a. Chest x-ray shows consolidation over affected areas </li></ul><ul><li>b. WBC increased </li></ul><ul><li>c. pO2 decreased </li></ul><ul><li>d. Sputum specimen- culture reveal particular causative organism </li></ul>
  163. 164. Pneumonia <ul><li>1. Facilitate adequate ventilation. </li></ul><ul><li>a. Administer oxygen as needed and assess its effectiveness. </li></ul><ul><li>b. Place client in Fowler’s position . </li></ul><ul><li>c. Turn and reposition frequently clients who are immobilized/obtunded. </li></ul><ul><li>d. Administer analgesics as ordered to relieve pain associated with breathing </li></ul><ul><li>e. Auscultate breath sounds every 2—4 hours. </li></ul><ul><li>f. Monitor ABGs. </li></ul>
  164. 165. Pneumonia <ul><li>GENERAL Nursing interventions </li></ul><ul><li>2. Facilitate removal of secretions </li></ul><ul><li>general hydration </li></ul><ul><li>deep breathing and coughing </li></ul><ul><li>Suctioning </li></ul><ul><li>Expectorants </li></ul><ul><li>aerosol treatments via nebulizer, humidification of inhaled air </li></ul><ul><li>chest physical therapy </li></ul>
  165. 166. Pneumonia <ul><li>GENERAL Nursing interventions </li></ul><ul><li>3. Observe color, characteristics of sputum and report any changes; encourage client to perform good oral hygiene after expectoration. </li></ul>
  166. 167. Pneumonia <ul><li>GENERAL Nursing interventions </li></ul><ul><li>4. Provide adequate rest and relief/control of pain. </li></ul><ul><li>a. Provide bed rest with limited physical activity. </li></ul><ul><li>b. Limit visits and minimize conversations. </li></ul><ul><li>c. Plan for uninterrupted rest periods. </li></ul><ul><li>d. Institute nursing care in blocks to ensure periods of rest. </li></ul><ul><li>e. Maintain pleasant and restful environment </li></ul>
  167. 168. Pneumonia <ul><li>GENERAL Nursing interventions </li></ul><ul><li>5. Administer antibiotics as ordered. Monitor effects and possible toxicity. </li></ul><ul><li>6. Prevent transmission (respiratory isolation may be required for clients with staphylococcal pneumonia). </li></ul><ul><li>7. Control fever and chills: monitor temperature and administer </li></ul><ul><ul><li>antipyretics as ordered, maintain increased fluid intake, provide frequent clothing and linen changes. </li></ul></ul>
  168. 169. Pneumonia <ul><li>GENERAL Nursing interventions </li></ul><ul><li>8. Provide client teaching and discharge planning concerning prevention of recurrence. </li></ul><ul><ul><li>a. Medication regimen/antibiotic therapy </li></ul></ul><ul><ul><li>b. Need for adequate rest, </li></ul></ul><ul><ul><li>c. Need to continue deep breathing and coughing </li></ul></ul>
  169. 170. Pneumonia <ul><li>GENERAL Nursing interventions </li></ul><ul><li>8. Provide client teaching and discharge planning concerning prevention of recurrence. </li></ul><ul><ul><li>d. Availability of vaccines </li></ul></ul><ul><ul><li>e. Techniques that prevent transmission (use of tissues when coughing, adequate disposal of secretions) </li></ul></ul><ul><ul><li>f. Avoidance of persons with known respiratory infections </li></ul></ul><ul><ul><li>g. Need to report signs and symptoms of respiratory infection </li></ul></ul>
  170. 171. Lung Cancer <ul><li>Primary pulmonary tumors arise from the bronchial epithelium and are therefore referred to as bronchogenic carcinomas. </li></ul><ul><li>FACTORS: Possibly caused by inhaled carcinogens (primarily cigarette smoke but also asbestos, nickel, iron oxides, air silicone pollution; preexisting pulmonary disorders PTB, COPD) </li></ul>
  171. 172. Lung Cancer <ul><li>Assessment findings </li></ul><ul><li>Persistent cough (may be productive or blood tinged) </li></ul><ul><li>chest pain </li></ul><ul><li>dyspnea </li></ul><ul><li>unilateral wheezing, friction rub, possible unilateral paralysis of the diaphragm </li></ul><ul><li>Fatigue, anorexia, nausea, vomiting, pallor </li></ul>
  172. 173. Lung Cancer <ul><li>Diagnostic tests. </li></ul><ul><li>a. Chest x-ray may show presence of tumor or evidence of metastasis to surrounding structures </li></ul><ul><li>b. Sputum for cytology reveals malignant cells </li></ul><ul><li>c. Bronchoscopy: biopsy reveals malignancy </li></ul><ul><li>d. Thoracentesis: pleural fluid contains malignant cells </li></ul><ul><li>e. Biopsy of lymph nodes may reveal metastasis </li></ul>
  173. 174. Lung Cancer <ul><li>1. Provide support and guidance to client as needed. </li></ul><ul><li>2. Provide relief/control of pain. </li></ul><ul><li>3. Administer medications as ordered and monitor effects/side effects. </li></ul><ul><li>4. Control nausea: administer medications as ordered, provide good oral hygiene, provide small and more frequent feedings. </li></ul>
  174. 175. Lung Cancer <ul><li>5. Provide nursing care for a client with a thoracotomy. </li></ul><ul><li>6. Provide client teaching and discharge planning concerning </li></ul><ul><ul><li>a. Disease process, diagnostic and therapeutic interventions </li></ul></ul><ul><ul><li>b. Side effects of radiation and chemotherapy </li></ul></ul><ul><ul><li>c. Realistic information about prognosis </li></ul></ul>
  175. 176. Lung Cancer <ul><li>Medical management </li></ul><ul><li>1. Radiation therapy </li></ul><ul><li>2. Chemotherapy: usually includes cyclophosphamide, methotrexate, vincristine, doxorubicin, and procarbazine; concurrently in some combination </li></ul><ul><li>3. Surgery: when entire tumor can be removed </li></ul>
  176. 177. Lung Cancer <ul><li>Quick Notes on Bronchogenic Cancer </li></ul><ul><li>Predisposing factors </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Asbestosis </li></ul><ul><li>Emphysema </li></ul><ul><li>Smoke from burnt wood </li></ul><ul><li>Types </li></ul><ul><li>Squamous cell Ca- with good prognosis </li></ul><ul><li>Adenocarcinoma- with good prognosis </li></ul><ul><li>Oat cell Ca- with good prognosis </li></ul><ul><li>Undifferentiated Ca- with poor prognosis </li></ul>
  177. 178. Lung Cancer <ul><li>Quick Notes on Bronchogenic Cancer </li></ul><ul><li>Nursing Interventions </li></ul><ul><li>Patent airway </li></ul><ul><li>O2 / Aerosol therapy </li></ul><ul><li>Deep breathing exercises </li></ul><ul><li>Relief of pain </li></ul><ul><li>Protection from infection </li></ul><ul><li>Adequate nutrition </li></ul><ul><li>Chest tube management </li></ul>
  178. 179. Lung Cancer <ul><li>Quick Notes on Bronchogenic Cancer </li></ul><ul><li>Surgery </li></ul><ul><li>Pneumonectomy= Removal of a lung (either left or right) </li></ul><ul><li>Lobectomy =Removal of a lobe. </li></ul><ul><li>Segmentectomy= Removal of a segment. </li></ul><ul><li>Wedge resection =Removal of the entire tumor regardless of the segment. </li></ul><ul><li>Decortication= Stripping off of fibrinous membrane enclosing the lung </li></ul><ul><li>Thoracoplasty= Removal of rib/s. Usually done after pneumonectomy, to reduce the size of the empty thorax thereby prevent mediastinal shift. </li></ul>
  179. 180. Pulmonary Embolism <ul><li>This refers to the obstruction of the pulmonary artery or one of its branches by a blood clot (thrombus) that originates somewhere in the venous system or in the right side of the heart. </li></ul><ul><li>Most commonly, pulmonary embolism is due to a clot or thrombus from the deep veins of the lower legs. </li></ul>
  180. 181. Pulmonary Embolism <ul><li>Causes </li></ul><ul><li>Fat embolism. Air embolism </li></ul><ul><li>Multiple trauma </li></ul><ul><li>PVD’s </li></ul><ul><li>Abdominal surgery </li></ul><ul><li>Immobility </li></ul><ul><li>Hypercoagulability </li></ul>
  181. 182. Pulmonary Embolism <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>The thrombus that travels from any part of the venous system obstructs either completely or partially . Then the lungs will have inadequate blood supply, with resultant increase in dead space in the lungs </li></ul><ul><li>Gas exchange will be impaired or absent in the involved area </li></ul>
  182. 183. Pulmonary Embolism <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>The regional pulmonary vasculature will constrict causing increased resistance, increased pulmonary arterial pressure and then increase workload of the right side of the heart. </li></ul>
  183. 184. Pulmonary Embolism <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>When the work of the right side of the heart exceeds its capacity, right ventricular failure will result, leading to a decrease in cardiac output followed by decreased systemic perfusion and eventually, SHOCK </li></ul>
  184. 185. Pulmonary Embolism <ul><li>Assessment </li></ul><ul><li>Restlessness (cardinal initial sign) </li></ul><ul><li>Dyspnea </li></ul><ul><li>Stabbing chest pain </li></ul><ul><li>Cyanosis </li></ul><ul><li>Tachycardia </li></ul><ul><li>Dilated pupils </li></ul><ul><li>Apprehension/ fear </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Dysrhythmias </li></ul><ul><li>Hypoxia </li></ul>
  185. 186. Pulmonary Embolism <ul><li>Diagnostic Tests: </li></ul><ul><li>Ventilation-perfusion scan </li></ul><ul><li>Pulmonary arteriography </li></ul><ul><li>CXR </li></ul><ul><li>ECG </li></ul><ul><li>ABG </li></ul>
  186. 187. Pulmonary Embolism <ul><li>Nursing Interventions </li></ul><ul><li>Oxygen therapy STAT </li></ul><ul><li>Early ambulation postop </li></ul><ul><li>Monitor obese patient </li></ul><ul><li>Do not massage legs </li></ul><ul><li>Relieve pain- analgesics </li></ul><ul><li>HOB elevated </li></ul><ul><li>Heparin (2 weeks) then Coumadin (3-6 months) </li></ul>
  187. 188. Pulmonary Embolism <ul><li>Patient Teaching for prevention of Pulmonary Embolism </li></ul><ul><li>Active leg exercises to avoid venous stasis </li></ul><ul><li>Early ambulation </li></ul><ul><li>Use of elastic compression stockings </li></ul><ul><li>Avoidance of leg-crossing and sitting for prolonged periods </li></ul><ul><li>Drink fluids </li></ul>
  188. 189. Surgical Aspect of Respiratory Care <ul><li>Thoracic Surgery </li></ul><ul><li>a. Exploratory thoracotomy : anterior or posterolateral incision through the fourth, fifth, sixth, or seventh intercostal spaces to expose and examine the pleura and lung </li></ul>
  189. 190. Surgical Aspect of Respiratory Care <ul><li>Thoracic Surgery </li></ul><ul><li>b. Lobectomy : removal of one lobe of a lung; treatment for bronchiectasis, bronchogenic carcinoma, emphysematous blebs, lung abscesses </li></ul>
  190. 191. Surgical Aspect of Respiratory Care <ul><li>Thoracic Surgery </li></ul><ul><li>c. Pneumonectomy : removal of an entire lung; most commonly done as treatment for bronchogenic carcinoma </li></ul>
  191. 192. Surgical Aspect of Respiratory Care <ul><li>Thoracic Surgery </li></ul><ul><li>d. Segmental resection : removal of one or more segments of lung; most often done as treatment for bronchiectasis </li></ul>
  192. 193. Surgical Aspect of Respiratory Care <ul><li>Thoracic Surgery </li></ul><ul><li>e. Wedge resection : removal of lesions that occupy only part of a segment of lung tissue; for excision of small nodules or to obtain a biopsy </li></ul>
  193. 194. Surgical Aspect of Respiratory Care <ul><li>Nursing interventions: PREOPERATIVE </li></ul><ul><li>1. Provide routine pre-op care. </li></ul><ul><li>2. Perform a complete physical assessment of the lungs to obtain baseline data. </li></ul><ul><li>3. Explain expected post-op measures: care of incision site, oxygen, suctioning, chest tubes (except if pneumonectomy performed) </li></ul>
  194. 195. Surgical Aspect of Respiratory Care <ul><li>Nursing interventions: PREOPERATIVE </li></ul><ul><li>4. Teach client adequate splinting of incision with hands or pillow for turning, coughing, and deep breathing. </li></ul><ul><li>5. Demonstrate ROM exercises for affected side. </li></ul><ul><li>6. Provide chest physical therapy to help remove secretions. </li></ul>
  195. 196. Surgical Aspect of Respiratory Care <ul><li>Nursing interventions: POSTOPERATIVE </li></ul><ul><li>1. Provide routine post-op care. </li></ul><ul><li>2. Promote adequate ventilation. </li></ul><ul><li>a. Perform complete physical assessment of lungs and compare with pre-op findings. </li></ul><ul><li>b. Auscultate lung fields every 1—2 hours. </li></ul><ul><li>c. Encourage turning, coughing, and deep breathing every 1—2 hours after pain relief obtained. </li></ul>
  196. 197. Surgical Aspect of Respiratory Care <ul><li>Nursing interventions: POSTOPERATIVE </li></ul><ul><li>2. Promote adequate ventilation. </li></ul><ul><li>d. Perform tracheobronchial suctioning if needed. </li></ul><ul><li>e. Assess for proper maintenance of chest drainage system (except after pneumonectomy). </li></ul><ul><li>f. Monitor ABGs and report significant changes. </li></ul><ul><li>g. Place client in semi-Fowler’s position </li></ul>
  197. 198. Surgical Aspect of Respiratory Care <ul><li>Nursing interventions: POSTOPERATIVE </li></ul><ul><li>If pneumonectomy is performed, follow surgeon’s orders about positioning, often on back or OPERATIVE SIDE </li></ul><ul><li>If Lobectomy , patient is usually positioned on the UNOPERATIVE SIDE </li></ul>
  198. 199. Surgical Aspect of Respiratory Care <ul><li>Nursing interventions: POSTOPERATIVE </li></ul><ul><li>3. Provide pain relief. </li></ul><ul><li>a. Administer narcotics/analgesics prior to turning, coughing, and deep breathing. </li></ul><ul><li>b. Assist with splinting while turning, coughing, deep breathing. </li></ul>
  199. 200. Surgical Aspect of Respiratory Care <ul><li>Nursing interventions: POSTOPERATIVE </li></ul><ul><li>4. Provide client teaching and discharge planning concerning </li></ul><ul><li>a. Need to continue with coughing/deep breathing for 6—8 weeks post-op and to continue ROM exercises </li></ul><ul><li>b. Importance of adequate rest with gradual increases in activity levels </li></ul>
  200. 201. Surgical Aspect of Respiratory Care <ul><li>Nursing interventions: POSTOPERATIVE </li></ul><ul><li>4. Provide client teaching and discharge planning concerning </li></ul><ul><li>c. High-protein diet with inclusion of adequate fluids </li></ul><ul><li>d. Chest physical therapy </li></ul><ul><li>e. Good oral hygiene </li></ul><ul><li>f. Need to avoid persons with known upper respiratory infection </li></ul><ul><li>g. Adverse signs and symptoms </li></ul><ul><li>h. Avoidance of crowds and poorly ventilated areas. </li></ul>