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    NurseReview.Org Respiratory System NurseReview.Org Respiratory System Presentation Transcript

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