Medical Surgical Nursing respiratory system

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Lung Volumes & Capacities

Lung volumes – amount of air exchanged during ventilation

Tidal volume (TV) – amount of air that moves in & out of the lungs during normal breathing (500mL)

Inspiratory reserve volume (IRV) – maximum amount of inhaled air in excess of the normal TV (3000mL)

Expiratory reserve volume (ERV) – maximum amount of exhaled air in excess of the normal TV (1100mL)

Residual volume (RV) – amount of air remaining in the lungs after forced expiration; increases with age (1200mL)

Lung capacities – 2 or more lung volumes

Vital capacity (VC) = TV+IRV+ERV (amount of air than can be exhaled from maximal inspiration) 4600mL

Inspiratory capacity = TV+IRV (maximum amount of inhaled air at the beginning of normal expiration & distending the lungs to its maximum) 3500mL

Functional residual capacity = RV+ERV (amount of air remaining in lungs after normal expiration) 2300mL

Total lung capacity = sum of all lung volumes; total amount of air that the lungs can hold

average pair of human lungs can hold about 8L of air, but only a small amount of this capacity is used during normal breathing

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Factors Affecting Lung Volume

Larger volumes

males

taller people

non-smokers

athletes

people living at high altitudes (the body's diffusing capacity increases in order to be able to process more air)

Smaller volumes

Females

shorter people

Smokers

non-athletes

people living at low altitudes (atmosphere is less dense at higher altitude, therefore, the same volume of air contains fewer molecules of all gases

Effects of Aging

Progressive loss of elastic recoil of lungs – due to elastin & collagen fiber changes

Increased respiratory muscle workload – due to calcification of soft tissues in chest wall

Total lung capacity remains constant

Increased residual lung volume – result of changes in aging

Physical Assessment

Inspection:

Symmetry of Chest Expansion

Size of chest (barrel chest, pigeon chest, deformities, flail segment/paradoxical movement)

Signs of Increased Respiratory Effort

Changes in Skin Color (including nail beds)

Clubbing of fingernails

Include listening to patient’s speech

Palpation

Trachea – slightly movable & quickly returns to midline after displacement

Tactile fremitus –transmission of vibration of air movement through chest wall during phonation (99 method)

Thoracic excursion

Percussion:

Resonant – low-pitched hollow (normal lung sound)

Hyperresonant – louder & lower-pitched; presence of increased amount of air (emphysema, pneumothorax)

Dull- thudlike

Tympanic – hollow (tension-pneumothorax)

Flat – soft high-pitched

Auscultation:

Bronchial, bronchovesicular, vesicular

Adventitious Breath sounds:

Stridor - High pitched crowing sound, usually heard on inspiration, indication of a tight upper airway

Wheezing - Whistling sound, usually heard on expiration, indication of narrowing of lower airways (bronchospasm, edema, foreign material)

Ronchi - Rattling sound, caused by mucus in larger airways

Rales - Fine crackling sound, indication of fluid in the alveoli

Diagnostics

Chest X-ray (Chest radiography; Serial chest x-ray)

Visualization of the chest, lungs, heart, large arteries, ribs, and diaphragm while standing in front of the machine

Two views are usually taken:

Antero-posterior view - x-rays pass through the chest from the back

Lateral view - x-rays pass through the chest from one side to the other

Nursing Interventions:

Instruct client to hold his breath while x-ray is taken

Inform client that test is performed in the radiology department (in hospitals, mobile x-rays may be used) & the film plate may feel cold

Instruct client to wear a hospital gown and remove all jewelries

B. Pulmonary Function Tests (PFT)

a group of tests measuring lung function

Measure of diffusion capacity

client breathes in a harmless gas for a very short time (one breath)

the concentration of the gas in the air exhaled is measured

the difference in the amount of gas inhaled and exhaled can help estimate how quickly gas can travel from the lungs into the blood

Body plethysmograph - most accurate

Client sits in a sealed, clear box that looks like a telephone booth while breathing in and out into a mouthpiece

Changes in pressure inside the box help determine the lung volume

Cont…(PFT)

Spirometry test – measures airflow; client will breathe through a tight fitting mouthpiece and will have nose clips

Nursing Interventions: Instruct client to:

breathe into a mouthpiece that is connected to an instrument (spirometer)

eat a light meal before the test

not to smoke for 4 - 6 hours before the test

stop using bronchodilators or inhaler medications 6-8hrs prior

Inform client that temporary shortness of breath or light-headedness may be felt

C. Peak Expiratory Flow Rate (PEFR)

measures how fast a person can exhale

it is one of many tests that measure how well the airways work

requires a peak expiratory flow (PEF) monitor, a small handheld device with a mouthpiece at one end and a scale with a moveable indicator (usually a small plastic arrow)

commonly used to diagnose and monitor lung diseases such as asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), & emphysema

Home monitoring helps determine whether treatments are working or detect when your condition is getting worse . This allows anticipation on when breathing will bec ome worse and to take medications or to call hea lth care providers before symptoms become too seve re

A decrease in peak flow indicates blocked or narrowed airways

A significant fall in peak flow can signal the onset of a lung disease esp. when accompanied by persistent coughing, SOB, or wheezing

PEFR measurements are not as accurate as the spirometry

Inform client that repeated efforts may cause lightheadedness

Loosen any tight clothing that might restrict breathing

Sit up straight or stand while performing the tests

Instruct client on proper procedure to do this test:

Breathe in as deeply as possible.

Blow into the instrument's mouthpiece as hard and fast as possible.

Do this 3 times, and record the highest flow rate

D. Throat Culture

Also known as throat swab culture

a laboratory test to isolate and identify organisms that may cause infection in the throat; when throat infection is suspected, particularly strep throat

back of the throat is swabbed with a sterile cotton swab near the tonsils

Instruct client not to use antiseptic mouthwashes before the test

Inform client that he may experience a gagging sensati on when the back of the throat is swabbed

Instru ct to resist gagging and closing the mouth during procedure (test only takes a few seconds)

E. Bronchoscopy (Fiber Optic Bronchoscopy)

views the airways and diagnose lung disease

may also be used during the treatment of some lung conditions

flexible bronchoscope is usually used (less than ½ in wide and about 2ft long)

scope is passed through the mouth or nose, and then into the lungs

rigid bronchoscope requires general anesthesia

flexible bronchoscope uses local anesthesia (spray if via mouth and throat; numbing jelly if via nose)

IV meds may be given to help relax the client

Cont…(Bronchoscopy)

Inform client that spraying of local anesthesia will cause coughing at first, which will stop as the anesthetic begins to work

Inform client that as the anesthesia wears off, the throat may be scratchy for several days

Instruct client on NPO 6-12hrs prior (withhold ASA or Ibuprofen if client takes it on a regular basis or as ordered)

Place client on NPO 1-2hrs after the procedure or until (+) for gag reflex

F. Sputum Culture

Sputum - secretion produced in the lungs and the bronchi; what comes up with deep coughing

This mucus-like secretion may become infected, bloodstained, or contain abnormal cells that may lead to a diagnosis

Drinking a lot of water and other fluids the night before collection may help

Perform back tapping or chest clapping on client to aid in loosening the sputum

Instruct client on proper specimen collection

Collect morning specimen

Gargle with water only before specimen collection cough deeply and spit sputum in a sterile cup

Send specimen to lab ASAP

G. Oximetry

measures oxygen concentration (%) in the blood

used in the evaluation of various medical conditions affecting heart & lung functions

most commonly used = pulse oximeters because they respond only to pulsations, such as those in pulsating capillaries of the area tested

pulse oximeter works by passing a beam of red and infrared light through a pulsating capillary bed

ratio of red to infrared blood light transmitted gives a measure of the oxygen saturation in the blood

Principle: oxygenated blood is bright red while the deoxygenated blood is blue-purple

Other types:

intracardiac oximetry - blood that is within the heart or on whole blood that has been removed from the body

More recently, using a similar technology to oxymetry, carbon dioxide levels can be measured at the skin as well

Pulmonary Tuberculosis

contagious bacterial infection that mainly involves the lungs, but may spread to other organs

Cause: Mycobacterium tuberculosis

Mode of transmission: inhalation of air droplets from a cough or sneeze of an infected person

primary stage of the infection is usually asymptomatic

Pathophysiology Nursinglectures.blogspot.com

High-risk individuals

Elderly

Infants

Immunosuppressed (AIDS, chemotherapy, or antirejection medicines given after a organ transplant)

Are in frequent contact with people who have the disease

Live in crowded or unsanitary living conditions

Have poor nutrition

The appearance of drug-resistant strains of TB

S/Sx

Limited to minor cough

Fever and night sweats

Fatigue

Unintentional weight loss

Excessive sweating, especially at night

Coughing up blood

Phlegm-producing cough

Wheezing

Chest pain

Breathing difficulty

Cont…(PTB)

Dx:

Chest x-ray – seen on upper lobes (due to higher O 2 concentration)

Sputum cultures (Acid-Fast Stain) – confirmatory test

Tuberculin skin test (Mantoux Test) – ID purified protein derivative (PPD)

48-72hrs interpretation

(+) = 15mm induration (5mm for immunosuppressed clients)

Bronchoscopy

Thoracentesis (very rare occasions)

Chest CT Scan

Complications:

Miliary TB - widespread dissemination of Mycobacterium tuberculosis from hematogenous spread

Pleural Effusion – collection of fluid in the pleural cavity

Empyema – purulent drainage It results from an untreated pleural-space infection

Nursinglectures.blogspot.com Empyema

Cont…

Tx: Multi-drug therapy = to prevent development of resistance ( RIPES )

R ifampicin – inhibits RNA synthesis of the bacilli

I soniazid – remarkably potent to the bacilli; prophylaxis; given with Vit. B 6

P yrazinamide (PZA) – inhibits cell growth

E thambutol – inhibits cell growth

S treptomycin – 1 st drug found to be effective against PTB; given by injection

Nursing Management:

Give meds before meals

Maintenance therapy = after 6months

Client not communicable after 2wks

Rifampicin’s SE: reddish/orange body secretions (urine)

PZA prone to hyperuricemia so ↑ oral fluids

Ethambutol - A/E: optic neuritis so √ vision/visual changes

C/I: pedia – cannot report any visual disturbances

Streptomycin – A/E: ototoxic (√ tinnitus)

nephrotoxic = √ oliguria

neurotoxic = seizure precautions

Asthma

Chronic inflammatory airway disease

Exposure to allergens (dust, smoke,

animal dander, pollen, volatile organic

compounds, food, meds, etc)

Cold air, exercise, & emotional upset

can produce bronchospasm

Pathophysiology:

allergens -> immune response (mast cells, eosinophils, T lymphocytes) -> mucus production -> bronchospasm -> inflammation -> excessive mucus production -> narrowing of airways -> bronchoconstriction -> asthma attack

Manifestations: (asthma attacks differ from 1

person to another)

Episodic wheezing

Feelings of chest tightness

Cough may be accompanied by wheezing

Prolonged expiration

Increased RR

Severe attacks = severe dyspnea (use of accessory muscles)

Distant breath sounds (due to air trapping)

Loud wheezing

Fatigue develops

Moist skin

Anxiety/panic attack

Client is able to speak 1-2 words before taking a breath

Complication: respiratory failure (onset marked by inaudible breath sounds, diminished wheezing, coughing becomes ineffective

Cont…

Dx: careful Hx & physical assessment

Spirometry

Inhalation challenge test – measures the level of airway responsiveness (histamine, or exposure to non-pharmacologic agent)

Tx/ Nursing Management: goal = prevention of attack episodes

Pharmacologic

Quick-relief – not for daily use; relaxes bronchial muscles (albuterol, terbutaline via MDI or nebulizer)

Long-term meds – taken on daily basis; anti-inflammatory (cromolyn via MDI), corticosteroids (budesonide via MDI), bronchodilators (theophylline)

Mgt:

B ronchodilators

R est & relaxation techniques

O 2 = low flow (1-2Lpm)

N ebulize

C hest physiotherapy & controlled breathing (IPPB)

H igh-fowler’s/ orthopneic

I mmunotherapy

A void allergens

L iberal fluid intake

Meds:

A minophylline

S teroids

T heophylline – relaxes bronchial muscles

H istamine antagonist

M ucolytics – acetylcysteine (Fluimucil)

A ntibiotics

Chronic Obstructive Pulmonary Disease (COPD)

clinical syndrome of chronic dyspnea as a result of expiratory airflow obstruction due to chronic bronchitis or emphysema (often both)

Causes: long-term smoking (leading cause) & Alpha1-antitrypsin deficiency (only known inherited form of the disease)

Risk factors:

Exposure to certain gases or fumes in the workplace

Exposure to heavy amounts of second hand smoke and pollution

Frequent use of cooking gas without proper ventilation

Low socioeconomic status

Male

Living in heavily industrialized urban areas

Recurrent respiratory illnesses

Family history of chronic bronchitis and emphysema (e.g., alpha1-antitrypsin deficiency)

Emotional stress and repressed emotions have also been shown to contribute

Chronic Bronchitis (“Blue Bloaters”)

chronic cough, resulting from excessive tracheobronchial mucus production and impaired mucus elimination, on most days for 3 months of a year, for 2 consecutive years

Some people, even those with severe COPD, have few or no symptoms

Pathophysiology:

hallmarked by hyperplasia (increased number) and hypertrophy (increased size) of the goblet cells (mucous gland) of the airway -> increase mucus secretion -> airway obstruction -> cyanosis

infiltration of the airway walls with inflammatory cells (neutrophils) -> scarring -> airway wall thickening -> narrowing of the small airway -> metaplasia (abnormal change in the tissue) & fibrosis (further thickening and scarring) of lower airway -> limitation of airflow -> cyanosis

Chronic Bronchitis Illustration Nursinglectures.blogspot.com

Emphysema (Pink Puffers)

enlarged air spaces distal to the terminal bronchioles with destruction of the alveolar walls; there is also a loss of elastic recoil in the lung

Pathophysiology:

exact mechanism for the development of emphysema is not understood, although it is known to be linked with smoking and age

enlarged air sacs (alveoli) of the lungs -> reduces lung surface area -> ↓ lung elasticity -> small bronchioles collapse -> dead air space formation (blebs) -> air trapping -> dyspnea

Emphysema Illustrations Nursinglectures.blogspot.com

Emphysema vs. Chronic Bronchitis

Characteristic Pink Puffers Blue Bloaters

Definition - alveolar wall - inflammation of bronchi ->

destruction leads ↑ mucus prod uction (goblet

to air spaces (blebs) cells) & chronic cough

Smoking Hx - usual - usual

Age of onset - 40-50y/o - 30-40y/o; mid-age disability

Clinical Features

Color - acyanotic - cyanosis w/ edema

Barrel Chest - dramatic - may be present

Weight loss - severe (advanced) - infrequent (often overweight)

SOB - compensatory - predominant early symptom

pursed-lip breathing

Sputum - may be absent - copious sputum production

Lung x-ray - overinflated lucent - “dirty lungs”

Heart involvement - none, late cor pulmonale - cor pulmonale (RV)

ABGs - mild-mod hypoxemia - (+)hypoxemia

Dx: physical assessment

Chest x-ray or Chest CT Scan = confirmatory

PFTs, TST

Lab: Arterial Blood Gas (ABG)

Below Above

Acidosis pH = 7.35 – 7.45 Alkalosis

Acidosis HCO 3 = 22 – 26mEq/L Alkalosis

Alkalosis PCO 2 = 35 – 45mmHg Acidosis

R espiratory Compensation

A lternate arrows pH compensatory system

M etabolic uncompensated abnormal no change

S ame arrows partially abnormal change

Fully normal change

Management: STOP SMOKING

Improve oxygenation

Monitor respiratory patterns & assess breath sounds

Low flow O 2 (1-3Lpm)

High fowler’s position

Energy conservation techniques

Decrease CO 2 retention (airway clearance)

facilitate coughing

pursed-lip breathing technique

Maintain adequate hydration & room humidity

Meds: bronchodilators - to increase airflow and reduce dyspnea

sometimes theophylline - requires frequent blood monitoring for toxicity

inhaled steroids

Antibiotics - during flare-ups of symptoms

Alpha1-antitrypsin replacement therapy

Pleurisy

inflammation of the lining of the lungs that ca uses pain when you take a breath or cough

normally smooth lining of the lungs (the pleura) become rough, they rub together with each breath, and may produce a rough, grating sound called a "friction rub."

Causes:

may develop when you have lung inflammation due to infections such as pneumonia or tuberculosis

Asbestos-related disease

Certain cancers

Chest trauma

Pulmonary embolus - blockage of an artery in the lungs by fat, air, blood clot, or tumor cells

Respiratory tract infections

S/Sx: main symptom = chest pain

Some people feel the pain in the shoulder

Deep breathing, coughing, and chest movement makes the pain worse

fluid may collect inside the chest cavity & may cause the following:

Coughing

Cyanosis

Shortness of breath, tachypnea

Dx: Complete Blood Count (CBC)

Activity intolerance (fatigue) RBC = 4.5M – 5.4M Risk for injury (CVA/Thrombosis)

Risk for infection WBC = 5K – 10K Actual infection

Risk for injury (bleeding) Platelets = Risk for injury (CVA- 150k – 450k clot formation)

Fluid volume deficit Hematocrit = Fluid volume excess

(dehydration) 35 – 45%

Thoracentesis - procedure to remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest; local anesthesia

Pleural Biopsy - procedure to remove a sample of the tissue lining the lungs and the inside of the chest wall to check for disease or infection

Ultrasound of the chest or Chest x-ray

Sputum exam

Tx: depends on what is causing the pleurisy

Bacterial infections = antibiotics (some bacterial infections require a surgical procedure to drain all the infected fluid)

acetaminophen or anti-inflammatory drugs such as ibuprofen (for pain control)

Thoracentesis

Complications: Collapsed lung due to thoracentesis

Complications from the original illness

Nursing Management:

Health teachings (infection, work environment, splinting ribcage with pillow)

Position client on affected side

Thoracentesis: Instruct client not to cough, breathe de eply, or move during the test to lung puncture

Instruct to report SOB &/or chest pain during procedure

Apply pressure on puncture site & monitor for bleeding

Tracheostomy

Tracheostomy – used for severe lung disorder , neurological problem, or infection makes it impossible to breathe,

to keep the windpipe open and supply air

a small opening (stoma) through the skin on the throat

a breathing tube is directly inserted into the windpipe (trachea).

The trache tube is sometimes sewn to the skin around the stoma

It can also be held in place with trache ties

Some trache tubes have an inflatable cuff near the outer end to keep it from coming out and to prevent air leaks

trache tube parts

Obturator - used to pass the trache into the windpipe

outer cannula (tube) - has a plastic "trache plate" that lies against the skin of the neck and holds the trache in place

Inner cannula that fits inside the outer one and locks into place

Obturator and clamp should always be at bedside

Tracheostomy Care

clean the inner cannula on a daily basis

Observe proper precautions & handwashing before & after care

Whenever the tube threatens to become clogged with mucus, suction it clear

Materials:

kidney basin

a small brush (like a toothbrush) or twisted OS

H 2 O 2 &/or sterile NSS

4x4 gauze pad

scissors

Procedures:

Place a “trache bib” under the trache plate with a gauze pad (upright “U”)

Unlock the inner cannula and remove it by pulling it gently out and down

Put a clean wet inner cannula (if reserve is available) as replacement & lock in place

Clean the dirty cannula by soaking it in H 2 O 2

Scrub it with the small brush when bubbling stops

Rinse well the inner cannula by pouring the sterile NSS

Return in place & lock if client has no reserve

Endotracheal (ET) Tube

most common artificial airway used for short-term airway management or mechanical ventilation

may be inserted either orally or nasally

has a cuff that is inflated with air to hold the tube in place in the trachea

amount of air in the cuff should be checked every 8hrs to ensure that the cuff is not exerting too much pressure on the trachea walls

client with ET tube must be closely monitored:

to ensure that the tube remains patent

that skin breakdown does not occur from the tube (either the oral or nasal cavity)

infection is prevented

Intubation Illustrations Nursinglectures.blogspot.com 2 Intubation 3 ET tube Placement 4 Securing the ET tube 1 ET tubes

Securing Apparatuses for ET Tube Nursinglectures.blogspot.com ETAD Thomas Tube Holder

Nursing Management

RNs prepare all needed materials needed for in tubation &/or assist in placement by securing p at ient’s position (head tilted on supine)

Sterile suction kit, a bottle of sterile NSS, sterile gloves, a clean bite block if necessary, and tape already torn into appropriately-sized pieces, laryngoscope

Documentation (note also tube distance at client’s lips)

All waste should be properly disposed

Complete airway check every 8hrs & prn

The insertion point (in cm) of the ET tube should be confirmed to be the same as prior to the procedure, unless the purpose of the procedure was to change the depth of the tube (via X-ray)

Cont…