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  3. 3. Anatomy of the Upper Respiratory System  Nose  Sinuses  Pharynx  Larynx  Trachea MTCAT '09
  4. 4. Defenses of the Airways & Lungs  Nose- particulates larger than 10 mm are filtered and trapped in the nasal mucosa.  Mucocilliary blanket- 2-10 mm  Mucocilliary escalator system – composed of mucus secreting goblet cells in the bronchi, ciliated epithelia & mucus  Pulmonary alveolar macrophage activity MTCAT '09
  5. 5. Reflexes of the Airways  Sneeze Reflex – characterized by a deep inspiration, followed by a violent expiratory blast through the nose  Irritant stimulate the trigeminal nerve  May cause HTP  Cough reflex- start with deep inspiration, glottis closes. Maximal intrathoracic and intra-airway pressures are produced to cause the trachea to narrow.  Triggers the stimulatory impulse from vagus nerve to medulla MTCAT '09
  6. 6.  Reflex bronchoconstriction – protects upper and lower airways.  Hering breuer reflex – limit lung inflation. If lung becomes overstretched, HB reflex is activated. MTCAT '09
  7. 7. Anatomy of the lower respiratory system Lungs MTCAT '09
  8. 8. Conducting Zone structures- serves as conduit to and from the respiratory zone Respiratory Zone- only site of gas exchange MTCAT '09
  9. 9. Lungs  Lungs lie in the thoracic cavity separated by mediastinum  R lungs – 3 lobes  L lungs – 2 lobes Lungs are further divided into lobules → terminated into alveolar sacs Parietal pleura– covers the lungs and lines the thoracic wall. Visceral pleura- covers the surface of each lung Pleural fluid- slippery serous secretion produced by the pleural membranes which allows the lungs to glide easily over the thorax wall MTCAT '09
  10. 10. MTCAT '09
  11. 11. Alveoli MTCAT '09
  12. 12. Substance important in Alveolar Expansion Surfactant – lines the alveolus - Fatty protein provides surface stability (reduces surface tension) and prevents collapse of the alveolar structures (atelectasis) MTCAT '09
  13. 13. Respiratory Centers 1. Medulla oblangata contains inspiratory and expiratory centers, the main region for respiration– Dorsal respiratory group -the region responsible for causing the normal, resting inspiration Ventral respiratory group is only active when you need to breathe more actively. For ex. when you are talking - provide automatic control of unconscious breathing 2. Pons- Pneumotaxic area in the pons, important for regulating the amount of air one takes in with each breath. When we find ourselves needing to breath faster, the pneumotaxic area tells the dorsal respiratory group to speed it up. And when we need to take longer breaths, the pneumotaxic area tells the dorsal respiratory group to prolong its bursts. Apneustic center stimulates the inspiratory medullary center to MTCAT '09 promote deep, prolonged inspiration
  14. 14. Major Muscles of Ventilation 1. Diaphragm –contraction and relaxation causes changes in the size and pressure of the chest cavity. 2. External intercostal muscles – further enlarge thoracic cavity by an upward and outward motion of the lower ribs. 3. Internal intercostal muscles – used in forced expiration to stiffen the intercostal spaces during straining MTCAT '09
  15. 15.  4. Abdominal wall muscles – aids to forced expiration.  Generate the explosive pressure that is necessary for coughing.  Contract at the end of forced inspiration in synchrony with glottic closure to limit and stop inspiration abruptly. MTCAT '09
  16. 16.  5. Accessory muscle a. Scalene- one of the muscles of the neck responsible for the 1st and 2nd ribs in inspiration b. Sternocleidomastoid -= used during labored breathing to raise the first 2 ribs and sternum and increase size of thoracic cavity. c. Trapezius and pectoralis – fix the shoulders MTCAT '09
  17. 17. REVIEW OF PHYSIOLOGY  Functions of the Respiratory System  Oxygen transport- o2 is supplied to and CO2 is removed from the cells by way of the circulating blood.  Respiration- the whole process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body.  Ventilation- movement of air in and out of the airways  Diffusion – air crosses the alveolar – capillary membrane and is carried in the plasma bound chemically to hgb.  Perfusion – blood is delivered through pulmonary capillary system past the alveoli for the purpose of gas exchange.  Distribution – Air is delivered by the smaller peripheral airways to the alveoli. MTCAT '09
  18. 18. MECHANICS OF VENTILATION Physical factors that govern airflow in and out of the lungs which include: - Air pressure variance- air flows from a region of higher pressure to an area of lower pressure - Airway resistance- as determined by the size of the airway through which the air is flowing - Compliance – measure of the elasticity, expandability and distensibility of the lungs. MTCAT '09
  19. 19. 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) MTCAT '09
  20. 20. 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 MTCAT '09
  21. 21. Factors Affecting Lung Volume Larger volumes Smaller volumes  males  Females  taller people  shorter people  non-smokers  Smokers  athletes  non-athletes  people living at high  people living at low altitudes (the body's altitudes (atmosphere diffusing capacity is less dense at higher increases in order to altitude, therefore, the same volume of air be able to process contains fewer more air) MTCAT '09 molecules of all gases
  22. 22. 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 MTCAT '09
  23. 23. Oxygen is essential for cellular metabolism and have no capability to store it. Without constant delivery of oxygen , tissue hypoxia and anaerobic metabolism result. Tissue hypoxia – inadequate oxygen supply to meet the needs of the cell. Hypoxemic hypoxia- a state of low arterial PO2, usually due to inadequate pulmonary gas exchange Ischemic hypoxia – results from inadequate circulation of the blood. Anemic hypoxia – due to anemia and the resulting inability of the blood to carry adequate oxygen. Histotoxic hypoxia – occurs when the tissues are unable to use the oxygen delivered to them because of a metabolic poison. MTCAT '09
  24. 24.  O2 is carried in the blood in 2 forms:  Physically dissolved oxygen in the plasma  In combination with the hemoglobin of the RBC  Each 100 mL of arterial blood carries 0.3 ml of O2 physically dissolved in the plasma and 20 ml of O2 in combination with Hgb in Ferrous Iron  O2 + Hgb = HgbO2 Hgb combined with oxygen is called oxyHGB – whereas oxygen – free hgb is called reduced hgb. MTCAT '09
  25. 25. Erythrocytes Erythrocytes, or red blood cells, are the primary carriers of oxygen to the cells and tissues of the body. The biconcave shape of the erythrocyte is an adaptation for maximizing the surface area across which oxygen is exchanged for carbon dioxide. Its shape and flexible plasma membrane allow the erythrocyte to penetrate the smallest of capillaries. MTCAT '09
  26. 26.  Red blood cells make up almost 45 percent of the blood volume.  Their primary function is to carry oxygen from the lungs to every cell in the body.  Red blood cells are composed predominantly of a protein and iron compound, called hemoglobin, that captures oxygen molecules as the blood moves through the lungs, giving blood its red color.  As blood passes through body tissues, hemoglobin then releases the oxygen to cells throughout the body. Red blood cells are so packed with hemoglobin that they lack many components, including a nucleus, found in other cells. MTCAT '09
  27. 27. RBC  33% of an rbc cytoplasm is hemoglobin (Hb) solution  There are 280 million molecules of Hb in each RBC  Consists of 4 protein chains called globins, each chain has heme group. MTCAT '09
  28. 28. Normal range  Hematocrit- percentage of whole blood volume composed of RBCs  Male – 42% - 52%  Female – 37% - 48%  Hemoglobin –  Male -13 to 18 g/dL  Female – 12 to 16 g/dL  RBC  Male – 4.6 to 6.2 million/mm3  Female – 4.2 – 5.4 million/mm3  Life span – 120 days (4 mos.) MTCAT '09
  29. 29. Assessment: Health History  The major signs and symptoms of respiratory diseases are the ff:  Dyspnea  Cough  Sputum production  Chest pain  Wheezing  Clubbing of the fingers  Hemoptysis  cyanosis MTCAT '09
  30. 30. Dyspnea Dyspnea • difficult or labored breathing, breathlessness, SOB • Symptom common when there is decreased lung compliance or increased airway resistance • Maybe related to a lot of different medical conditions MTCAT '09
  31. 31. Levels of Dyspnea Level I Patient can walk 1 mile at own pace before experiencing shortness of breath Level II Patient is short of breath after walking 100 yards on level ground or climbing a flight of stairs. Level III Patient is short of breath while talking or performing ADL Level IV Patient is short of breaths during periods of inactivity Orthopnea Shortness of breath when lying down MTCAT '09
  32. 32. Important questions to ask:  How much exertion triggers SOB?  is there an associated cough?  Is the SOB related to other symptoms?  Was the onset of SOB sudden or gradual?  At what time of the day does SOB occur?  Is the SOB worse when the patient is lying flat in bed?  Does the SOB occur at rest? With exercise? Running? Climbing stairs? MTCAT '09
  33. 33. Relief measures (dyspnea)  The mgt of dyspnea is aimed at identifying and correcting its cause.  Relief is sometimes achieved by:  Placing the patient at rest  Assisting in high fowler’s position  Administration of O2 MTCAT '09
  34. 34. Cough  Results from irritation of the mucous membranes anywhere in the respiratory tract  Stimulus may arise from an infectious process or from an airborne irritant  Persistent and frequent cough can be exhausting and cause pain  Cough may indicate a serious pulmonary disease MTCAT '09
  35. 35. Cough  Assess for character of cough to know cause.  Describe as:  Dry –may indicate URTI of viral origin or side effect of ACE inhibitor therapy  Hacking – colds  Brassy – tracheal lesions  Wheezing- cystic fibrosis  Loose- bronchitis  Severe – bronchogenic carcinoma MTCAT '09
  36. 36. Cough  Note time of onset:  Coughing at night may herald onset of left sided heart failure or bronchial asthma  Cough in the morning with sputum production may indicate bronchitis  Cough worsens while in supine position may indicate sinusitis  Coughing after food intake may be caused by aspiration  Cough of recent onset is usually from an acute infection MTCAT '09
  37. 37. Relief measures (cough)  Cough suppressants----should be used with caution  Smoking cessation  Drinking warm beverages  First generation antihistamines with decongestants MTCAT '09
  38. 38. Sputum production  The reaction of the lungs to any constantly recurring irritant  May be associated with a nasal discharge MTCAT '09
  39. 39. Assess character of sputum  Purulent sputum (thick and yellow, green or rust-colored)- common sign of bacterial infection  Thin, mucoid sputum- viral bronchitis  Gradual increase of sputum over time- chronic bronchitis or bronchiectasis  Pink-tinged mucoid sputum- lung cancer  Profuse, frothy, pink material- pulmonary edema  Foul smelling sputum and bad breath- lung abscess, bronchiectasis '09 MTCAT
  40. 40. Relief measures (sputum production)  Increase OFI  Nebulization  Cessation of smoking  Adequate oral hygiene  Back clapping/ chest physiotherapy  Postural drainage MTCAT '09
  41. 41. Chest pain  Chest pain associated with pulmonary conditions may be sharp, stabbing, and intermittent, or it may be dull, aching, and persistent MTCAT '09
  42. 42. Relief measures (chest pain)  Analgesics  NSAIDS  Regional anesthetic block MTCAT '09
  43. 43. Wheezing  Major finding in a patient with bronchoconstriction or airway narrowing  High-pitched, musical sound heard mainly on expiration  Oral or inhalant bronchodilators reverse wheezing most of the time MTCAT '09
  44. 44. Clubbing of fingers  A sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung  May be manifested initially as sponginess of the nail bed and loss of the nail bed angle MTCAT '09
  45. 45. Hemoptysis  Coughing up of blood arising from a pulmonary hemorrhage  Blood- alkaline pH (greater than 7.0)  Symptom of both pulmonary and cardiac problems  Onset is usually sudden, intermittent or continuous  Most common causes:  Pulmonary infection  Carcinoma of the lung  Abnormalities of the heart or blood vessels  Pulmonary embolus and infarction  Pulmonary vein or artery abnormalities MTCAT '09
  46. 46. Determine source of bleeding  Bloody sputum from the nose is usually preceded by considerable sniffing, with blood possibly appearing in the nose  Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include:  Tickling sensation in the throat  A salty taste  A burning or bubbling sensation in the chest  Chest pain MTCAT '09
  47. 47. Cyanosis  Bluish coloring of the skin  Very late indication of hypoxia  Determined by the amount of unoxygenated hgb in the blood  Appears when there is at least 5g/dl of unoxygenated hgb MTCAT '09
  48. 48. CYANOSIS Factors that alter the presence of Cyanosis 1. Pigmentation and thickness 2. Type of light used during assessment – natural light is desirable 3. Absolute amount of reduced hemoglobin 4. Observer’s perception 1. Activity 2. Duration 3. Distribution MTCAT '09
  49. 49. OBJECTIVE DATA In addition to the subjective information obtained through nursing history, OBJECTIVE, measurable data must be obtained. PHYSICAL ASSESSMENT primary techniques - IPPA MTCAT '09
  50. 50. Physical Assessment of the Respiratory System MTCAT '09
  51. 51. Physical Assessment INSPECTION observe for the rate and pattern of breathing To accurately assess the resting pt’s RR 1. count the number of times the chest rise and fall in 1 full minute. 2. Observe the breathing pattern and effort 3. Actual volume can be measured by a spirometer. 4. Note relative length of inspiration and exhalation. Prolonged inspiration indicates obstruction of the upper airways (Croup, epiglotitis) Long exhalation indicates air trapping (asthma,emphysema) 5. Note use of accessory muscles 6. Observe for color (cyanosis) MTCAT '09 7. Check for deformities
  52. 52. Inspection  Normal chest  Slight retraction of intercostal spaces  2x as wide as deep  Anterior/posterior diameter  1:2 MTCAT '09
  53. 53. Inspection  Barrel chest  Occurs as a result of over inflation of the lungs  Increase in anterior- posterior diameter of the thorax  2:2 MTCAT '09
  54. 54. Inspection  Funnel chest  (Pectus Excavatum)  Depression of the lower portion of the sternum  Complications  Heart damage  i Cardiac output MTCAT '09
  55. 55. Inspection  Pigeon chest (Pectus Carinatum)  Displacement of the sternum  Sternum protrudes outward  h anterior-posterior diameter MTCAT '09
  56. 56. Pigeon Chest MTCAT '09
  57. 57. Inspection  Kyphoscoliosis  Characterized by the elevation of the scapula and a corresponding S- shaped spine  Limits lung expansion MTCAT '09
  58. 58. Inspection  Uniform expansion of the chest  Pneumonia  Pleural effusion  Pneumothorax  Bulging intercostal spaces  Obstruction  Emphysema MTCAT '09
  59. 59. Inspection  Marked retraction of intercostal spaces  Blockage  Shoulder rise  Accessory muscles  Posture MTCAT '09
  60. 60. Inspection: Breathing patterns Rate  Eupnea  Normal  12-20 / min  Tachypnea  rapid shallow breathing >24CPM  Pnuemonia, pulm edema, acidosis, septicemia, pain  Bradypnea  <10CPM, with normal depth and regular rhythm  h ICP, drug OD MTCAT '09
  61. 61. Inspection: Breathing patterns Depth  Hyperpnea  h depth  Hyperventilation  h depth & rate  Hypoventilation  i depth & rate  Shallow irregular breathing MTCAT '09
  62. 62. Inspection: Breathing patterns Depth  Kussmaul's  h rate & depth  Assoc. with severe acidosis  Apneustic  Prolonged gasping followed by a short breath MTCAT '09
  63. 63. Inspection: Breathing patterns Rhythm  Apnea  Cessation breathing  Cheyne-stokes  Regular cycle with increasing rate and depth, then decrease until apnea (usually about 20 secs) occur MTCAT '09
  64. 64. Inspection: Breathing patterns Rhythm  Biot’s  Periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10-60 secs)  Assoc w/ h ICP MTCAT '09
  65. 65. Inspection:  Trachea  Deviation  Pleural effusion  Tension pneumothorax  Atelectasis  Color  LOC  Emotional state MTCAT '09
  66. 66. PALPATION Uses hands to assess:  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 MTCAT '09
  67. 67. Palpation  TML  Tenderness (T)  Masses (M)  Lesions (L)  Sinuses  Palpate below eyebrow & Cheekbone  Crepitus  Subcutaneous emphysema  Air leaks into the sub-c tissue MTCAT '09
  68. 68. Percussion Rational  To determine if underlying tissue is filled with air or solid material Procedure  Pt sitting  Tap starting at shoulder  compare rt to lf MTCAT '09
  69. 69. PERCUSSION RESULT  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 MTCAT '09
  70. 70. Auscultation Purpose  Asses air flow through bronchial tree Procedure  Diaphragm of stethoscope  Superior  inferior  Compare rt to lf MTCAT '09
  71. 71. Auscultation: Results Normal  Vesicular  Lung field  Soft and low  Bronchial  Trachea & bronchi  Hollow  Bronchovesicular  Mixed  Between scapulae  Side of sternum  1st & 2nd intercostal space MTCAT '09
  72. 72. Auscultation: Results Adventitious  Crackles  Soft, high pitched, discontinuing popping sounds that occur during inspiration  air  bronchi with secretions  Fine crackles  Discontinuous popping sounds heard in late inspiration  Sounds like hair rubbing together  Originates in the alveoli  Etiology: pneumonia, bronchitis  Course Crackles  Discontinuous popping sounds heard in early inspiration  Harsh, Moist sound originating in the large bronchi MTCAT '09  COPD
  73. 73. Auscultation: Results  Sibilant Wheezes  Wheezes  Continuous, musical,  Sonorous wheezes High pitched (rhonchi)  Whistle-like  I&E  Deep low pitched  Caused by air   Snoring narrowed passages,  >E partially obstructed  Caused by air   May clear with narrowed coughing tracheobronchial  Etiology: passages  Asthma  Etiology: h secretions  bronchospasm MTCAT '09  Build-up of secretions
  74. 74. Auscultation: Results  Pleural friction rub  D/t inflammation of pleural space  Grating, creaking  I&E  Best heard  Anterior, Lower, lateral area MTCAT '09
  75. 75. Auscultation: Results  Stridor  Crowing  Partial obstruction of the larynx or trachea MTCAT '09
  76. 76.  A child with difficulty breathing and a “barking” cough id displaying signs associated with which condition? A. Asthma B. Croup C. Cystic fibrosis D. Epiglottitis MTCAT '09
  77. 77.  When assessing the lung sounds of a child with asthma, which sound are you most likely to hear? A. Murmurs B. Sonorous Wheezing C. Sibilant Wheezing D. Crackles E. Pleural friction rub MTCAT '09
  78. 78. Diagnostics: Imaging Studies A. 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: 1. Antero-posterior view - x-rays pass through the chest from the back 2. Lateral view - x-rays pass through the chest from one side to the other MTCAT '09
  79. 79. B. Computed tomography • CT scan is an imaging method in which the lungs are scanned in successive layers by a narrow-beam x- ray. • Distinguishes fine tissue density • Used to define pulmonary nodules and small tumors adjacent to pleural surfaces which are not visible on routine CXRs MTCAT '09
  80. 80. C. Magnetic Resonance imaging (MRI)  Similar to CT scan except that magnetic fields and radiofrequency are used instead of narrow beam x-rays  Used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease MTCAT '09
  81. 81. Comparison of a CXR and a chest MRI MTCAT '09
  82. 82. D. Flouroscopic studies  Used to assist with invasive procedures such as chest needle biopsy or transbronchial biopsy.  It may be used to study the movement of the chest wall, mediastinum, heart, and diaphragm. MTCAT '09
  83. 83. E. Pulmonary Angiography  Most commonly used to investigate thromboembolic disease of the lungs  It involves the rapid injection of a radiopaque agent into the vasculature of the lungs. MTCAT '09
  84. 84. F. Radioisotope Diagnostic Procedures  V/Q scan (ventilation/perfusion scan)- used clinically to measure the integrity of the pulmonary vessels relative to blood flow and to evaluate blood flow abnormalities  Gallium scan- used to detect inflammatory conditions, abscesses, adhesions, and the presence, location, and size of tumors. Used to stage bronchogenic Ca.  Positron Emission Tomography (PET) scan- used to evaluate lung nodules for malignancy. MTCAT '09
  85. 85. 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 MTCAT '09
  86. 86. 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 MTCAT '09
  87. 87. Cont…(PFT) Spirometry test – measures airflow; client will breathe through a tight fitting mouthpiece and will have nose clips Nursing Interventions: Instruct client to: a. breathe into a mouthpiece that is connected to an instrument (spirometer) b. eat a light meal before the test c. not to smoke for 4 - 6 hours before the test d. stop using bronchodilators or inhaler medications 6-8hrs prior e. Inform client that temporary shortness of breath or light- headedness may be felt MTCAT '09
  88. 88. 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 MTCAT '09
  89. 89. • 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 • Nursing Interventions: • 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 MTCAT '09
  90. 90. 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  Nursing Interventions:  Instruct client not to use antiseptic mouthwashes before the test  Inform client that he may experience a gagging sensation when the back of the throat is swabbed  Instruct to resist gagging and closing the mouth during procedure (test only takes a few seconds) MTCAT '09
  91. 91. 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 ½in 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 MTCAT '09
  92. 92. Cont…(Bronchoscopy)  Nursing Interventions:  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 MTCAT '09
  93. 93. Sputum Culture  Sputum is obtained for analysis to identify pathogenic organisms and to determine whether malignant cells are present.  Nursing Interventions:  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 MTCAT '09
  94. 94. Oximetry  measures oxygen concentration (%) in the blood  pulse oximeter- most commonly used; 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  Normal o2 saturation: 95%-100%, <85% indicates that the tissues are not receiving enough oxygen  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, MTCAT '09 carbon dioxide levels can be measured at the skin as well
  95. 95. THORACENTESIS- aspiration of pleural fluid for diagnostic purposes  Site :  Air : 2nd /3rd ICS, MCL  Fluid : 7th/8th ICS, PAL  Position :  over a bed table  straddling in a chair  seated in bed with affected hand raised over the head MTCAT '09
  96. 96. ARTERIAL BLOOD GASES ARTERIAL PUNCTURE ALLEN’S TEST ABG studies aid in assessing the ability of the lungs to provide oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body '09 MTCAT pH.
  97. 97. Levels of Hypoxemia MILD PaO2 of 60-80mmHg MODERATE PaO2 of 40-60mmHg SEVERE PaO2 of less than 40mmHg MTCAT '09
  98. 98. NORMAL ACID-BASE BALANCE Parameter Normal Value Definition and Implications Partial pressure of oxygen in arterial blood (decreases with age) In adults < 60 years: PaO2 80-100 Hg 60-80 mmHg = mild hypoxemia 40-60 mmHg = moderate hypoxemia < 40 mmHg = severe hypoxemia Identifies whether there is acidemia or pH 7.35-7.45 alkalemia: pH<7.35 = acidosis; pH>7.45 = alkalosis Partial pressure of CO2 in the arterial blood: PaCO2 35-45 mmHg PCO2<35 mmHg = respiratory alkalosis PCO2>45 mmHg = respiratory acidosis Estimated HCO3 concentration after fully Standard HCO3 22-26 mEq/L oxygenated arterial blood has been equilibrated with CO2 at a PCO2 of 40 mmHg at 38C; eliminates the influence of respiration on the plasma HCO3 concentration MTCAT '09
  99. 99. Nursing Diagnosis INEFFECTIVE BREATHING PATTERN The state in which an individual’s inhalation and/or exhalation pattern does not enable adequate pulmonary inflation or emptying. MTCAT '09
  100. 100. Defining characteristics: dyspnea tachypnea abnormal ABG values cough respiratory depth changes assumption of three- point position pursed lip breathing used of accessory muscles MTCAT '09
  101. 101. INEEFECTIVE AIRWAY CLEARANCE The state in which an individual is unable to clear secretions or obstructions from the respiratory tract to maintain airway patency. Defining characteristics: Abnormal breath sounds changes in rate and depth of respiration tachypnea effective or ineffective cough cyanosis dyspnea MTCAT '09
  102. 102. IMPAIRED GAS EXCHANGE The state in which an individual experiences a decreased passage of oxygen and/or CO2 between the alveoli of the lungs and the vascular system. Defining Characteristics: restless irritability inability to move secretions hypercapnia hypoxia MTCAT '09
  103. 103. GOALS/ OBJECTIVES/ PLANNING 1. Patient will demonstrate knowledge regarding prevention of respiratory dysfunction. 2. Patient’s tissues will have adequate oxygenation. 3. Patient will mobilize secretions. 4. Patient will effectively cope with changes in self-concept and lifestyle. MTCAT '09
  104. 104. NURSING PATIENTS WITH THREATS TO VENTILATION 1. Planning for Health Promotion 2. Planning for Health Restoration and Maintenance a. Maintaining Patent Airway 1. Coughing techniques 2. Nebulization 3. Steam inhalation 4. Suctioning 5. Chest physiotherapy(CPT)/ Chest mucus mobilization MTCAT '09
  105. 105. NURSING PATIENTS WITH THREATS TO VENTILATION b. Breathing Exercises c. Preventing and Controlling Infection d. Oxygen Therapy e. Incentive Spirometry f. Appropriate pharmacologic agents MTCAT '09
  106. 106. Breathing Exercises  Facilitates respiratory functioning by increasing lung expansion and preventing alveolar collapse MTCAT '09
  107. 107. Breathing exercises  Pursed-lip breathing  Involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse.  While sitting up, the client is instructed to take a deep breath and to exhale slowly through pursed lips, as if blowing through a straw.  Clients need to control exhalation phase so that it is longer than inhalation. MTCAT '09
  108. 108. Pursed lip breathing  Instruct client to breathe in slowly through the nose for 1 count  Purse lips as if going to whistle  Breathe out gently through pursed lips for 2 slow counts (breathe out twice as slowly as when breathing in). Let the air escape naturally  Keep doing pursed lip breathing until no longer short of breath MTCAT '09
  109. 109. Breathing exercises  Diaphragmatic breathing  Requires the client to relax intercostal and accessory respiratory muscles while taking deep inspirations.  The client concentrates on expanding the diaphragm during controlled inspiration. MTCAT '09
  110. 110. Diaphragmatic breathing  The client is taught to place one hand flat below the breast bone above the waist and the other hand 2-3 cm below the first hand.  The client is asked to inhale while the lower hand moves outward during inspiration MTCAT '09
  111. 111. Preventing and Controlling Infections  HEATH TEACHING can limit both exposure to and occurrence of ARTI such as influenza and pneumonia.  Promote optimal immune function by encouraging good nutrition  Remind client to avoid exposure to known infected people or large crowds during peak flu seasons  Good hygiene practices  Advising high-risk people to receive annual MTCAT '09 flu vaccination
  112. 112. Coughing  No single measure controls respiratory secretions more effectively than a strong cough that pushes secretions upward.  To cough effectively, the client must be able to take deep breath and generate rapid airflow. MTCAT '09
  113. 113. Controlled Coughing exercise  Assist client in a comfortable sitting position  Instruct client to lean head forward slightly while placing both feet firmly on the ground.  Breathe in deeply using diaphragmatic breathing  Instruct to hold breath for three seconds.  While keeping the mouth slightly open, instruct to cough out twice. The client should feel his diaphragm pushed upward while doing this. The first cough should bring up the phlegm, and the second cough should move it towards the throat.  Instruct to spit the phlegm out into a tissue. Remember to check the colour; if the phlegm is yellow, green or brown, or has blood in it.  Allow client to rest and repeat these steps once or twice if MTCAT '09 necessary.
  114. 114. Nebulization  Nebulization – a process of adding moisture or medications to inspired air by mixing particles of varying sizes with air. A nebulizer uses the aerosol principle to suspend a maximum number of water drops or particles of the desired size in inspired air. Moisture added to the RS through nebulization improves clearance of pulmonary secretions.  Often used for administration of bronchodilators and mucolytic agents.  The client inhales deeply and holds each breath for a moment, which allows for more effective aerosol deposition into distant portions of the airways. MTCAT '09
  115. 115. Steam Inhalation  Purpose:  To liquefy mucus secretions  To warm and humidify inspired air  To relieve edema of airways  To soothe irritated airways  To administer medications MTCAT '09
  116. 116. Steam Inhalation  Place client in semi fowler’s position.  Cover client’s eyes with wash cloth.  Check electrical device before use  Place steam inhalator in a flat, stable surface  Place the spout 12-18 inches away from the client’s nose or adjust the distance as necessary.  Cover chest with a towel  Render steam inhalation for 15-20 minutes for effectivity  Instruct client to perform DBE and coughing exercises after the procedure  Provide good oral hygiene after the procedure.  Document MTCAT '09
  117. 117. Suctioning  Purpose:  Remove excess mucus secretions to maintain patent airway  Collect sputum or secretions for diagnostic testing MTCAT '09
  118. 118. Suctioning (Oropharyngeal and Nasopharyngeal)  Assess indications for suctioning: • audible secretions during respiration • adventitious breath sounds  Position: • conscious: Semi-Fowler’s position • unconscious: lateral position facing the nurse MTCAT '09
  119. 119. Pressure of suction equipment, to prevent trauma to mucus membrane of airways • Wall unit:  Adult: 100-120 mmHg  Child: 95-110 mmHg  Infant: 50-95 mmHg • Portable unit:  Adult 10-15 mmHg  Child 5-10 mmHg MTCAT '09  Infant 2-5 mmHg
  120. 120. Appropriate size of sterile suction catheter, to prevent trauma to mucus membranes of airways • Adult Fr. 12-18 • Child Fr. 8-10 • Infant Fr. 5-8 Don sterile gloves. Length of catheter: • Measure from the tip of the client’s nose to the earlobe or about 13 cm(5 in) for an adult) MTCAT '09
  121. 121.  Lubricate catheter, to reduce friction o Nasopharyngeal suction tip- water soluble lubricant o Oropharyngeal suction tip- sterile water or NSS  Apply suction during withdrawal of the suction catheter (never during insertion). Withdraw catheter in a rotating manner.  Apply suction for 5-10 seconds (max 15 seconds)  Pre oxygenate client with 100% oxygen. Hyperventilate with manual resuscitaiton bag before and after suctioning  Allow 20-30 second interval between each suction  Provide oral and nasal care  Dispose contaminated equipment safely.  Assess effectiveness of suctioning MTCAT '09  Document.
  122. 122. Chest Physiotherapy (CPT)  Chest physiotherapy- a group of therapies in combination to mobilize pulmonary secretions.  Is based on the premise that mucus can be shaken from the walls of the airways and helped drain form the lungs.  CPT should be followed by productive coughing and suctioning of the client who has decreased ability to cough.  CPT is recommended for clients who produce greater than 30 ml of sputum per day or have evidence of atelectasis by CXR exam.  Includes:  Postural drainage  Chest percussion  Vibration MTCAT '09
  123. 123. Guidelines for CPT  Know the clients normal range of VS  Know the client’s medications  Know the client’s medical history  Know the client’s level of cognitive function  Be aware of the client’s exercise tolerance MTCAT '09
  124. 124. Chest percussion  Involves striking the chest wall over the area being drained.  The hand is positioned so that the fingers and thumb touch and the hands are cupped.  Percussion of the chest wall sends waves of varying amplitude and frequency through the chest, changing the consistency and location of the sputum.  Take care to avoid striking over the spine or kidneys, on female breasts, or on incisions or broken ribs. MTCAT '09
  125. 125. Vibration  In this technique, use hands like a gentle jack hammer: place hands on the client’s chest and rapidly and vigorously vibrate them while the client exhales.  This technique may help dislodge secretions and stimulate a cough. MTCAT '09
  126. 126. Postural Drainage  Postural drainage uses gravity to assist in the movement of secretions.  The client is assisted in various positions to facilitate mucus flow from different segments of the lungs.  Note that not all postural drainage positions are well tolerated by all clients. MTCAT '09
  127. 127. MTCAT '09
  128. 128. OXYGEN THERAPY  Administration of Supplemental Oxygen  Indication: hypoxemia  Signs of hypoxemia:  Restlessness (initial sign)  Increased PR  Rapid, shallow respiration and dyspnea  Light headedness  Flaring of nares  Substernal or intercostals retractions  Cyanosis (late sign) MTCAT '09
  129. 129. Oxygen systems 1. Low flow administration devices  Nasal cannula (24-45% at 2-6 LPM)  May be used in clients with COPD at 2-3 LPM if venturi mask is not available  Simple face mask (40-60% at 5-8 LPM)  Partial Rebreathing Mask (60-90 % at 6-10 LPM)  Non-Rebreathing Mask (95-100% at 6-15 LPM)  Croupette  Oxygen Tent MTCAT '09
  130. 130. 2. High flow administration devices • Venturi mask (24%-50%). Low- concentration venture- type mask is preferred for clients with COPD because it provides accurate amount of oxygen. They require 2-3 LPM or 28% oxygen • Face mask. • Oxygen hood. Can be used for low and high flow concentration • Incubator/Isolette. Can be used for low and high flow concentration. MTCAT '09
  131. 131. Oxygen Therapy  Assess signs and symptoms of hypoxemia  Check doctor’s orders  Position patient, preferably in semi-Fowler’s.  Open source of oxygen before insertion of oxygen device.  Regulate oxygen flow accurately. Excessive administration of oxygen can cause oxygen narcosis (respiratory alkalosis)  Place a “NO SMOKING” sign at bedside  Strictly enforce this warning  Oxygen greatly accelerates combustion MTCAT '09
  132. 132.  Avoid use of oil, greases, alcohol, and ether near the client receiving oxygen.  Humidify oxygen. Place sterile water into the oxygen humidifier.  Provide food oronasal hygiene.  Lubricate nares with water-soluble lubricant to soothe the mucus membrane. Do not use oil.  Assess effectiveness of oxygen therapy. Check VS, especially RR; note quality of respiration.  Make relevant documentation. MTCAT '09
  133. 133. Incentive Spirometry  The incentive spirometry motivates the client to breathe deeply by offering the incentive of measuring progress.  The client is visually motivated to take increasingly deeper breaths.  A reasonable therapy schedule is 8-10 breaths hourly during waking hours  To avoid hyperventilation, encourage client to perform the exercises slowly. MTCAT '09
  134. 134. Incentive Spirometry  Purpose  Improve pulmonary ventilation and oxygenation  Loosen respiratory secretions.  Prevent or treat atelectasis by expanding collapsed. MTCAT '09
  135. 135. Common Medications for clients with Respiratory Conditions Agent How Provided Clinical Notes Bronchodilators Unit dose packs; solution •Used to treat wheezing Terbutaline (Bricanyl) for administration via from asthma, COPD Albuterol (Ventolin) hand held nebulizer; •May cause nervousness Ipratropium (Atrovent) some solutions for and tremors injection •May cause tachycardia Theophylline, Oral via tabs and liquids; •SE include nausea. aminophylline injectable intravenous Headache, agitation solution •Toxic levels may include cardiac dysrhythmias and seizures •Wide variety of available preparation; use extra caution in administration MTCAT '09
  136. 136. Agent How provided Clinical Notes MTCAT '09
  137. 137. MTCAT '09