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  1. 1. OXYGENATION<br />BY:<br />LUDY MAE B. NALZARO, RN, MN<br />
  2. 2. Respiration<br />Respiratory control is tied closely to:<br />Arterial blood and brain CO2 level<br />Arterial blood oxygen level<br />Acute disorders:<br />Colds and flu<br />Pneumonia<br />Chest trauma<br />COPD<br />Respiratory problems are associated with:<br />Allergies<br />Occupational factors<br />Genetic factors<br />Smoking and tobacco use<br />Infection<br />Neuromuscular disorders<br />Chest abnormalities<br />Trauma<br />Pleural conditions<br />Pulmonary vascular abnormalities<br />LUDY MAE B. NALZARO, RN, MN<br />2<br />
  4. 4. RESPIRATORY SYSTEM <br />PRIMARY FUNCTIONS <br />Provides O 2 for metabolism in the tissues <br />Removes CO 2 , the waste product of metabolism <br />SECONDARY FUNCTIONS <br />Facilitates sense of smell <br />Produces speech <br />Maintains acid-base balance <br />Maintains body water levels <br />Maintains heat balance <br />LUDY MAE B. NALZARO, RN, MN<br />4<br />
  5. 5. UPPER RESPIRATORY TRACT<br />NOSE<br />Humidifies, warms & filters inspired air<br />SINUSES<br />Air-filled cavities within the hollow bones that surround <br /> the nasal passages <br />Provide resonance during speech<br /><ul><li>Lighten the skull
  6. 6. Produce mucus that drains into the nasal cavity</li></ul>PHARYNX <br />Located behind the oral & nasal cavities <br />Divided:<br />Nasopharynx<br />oropharynx & <br />laryngopharynx<br />Passageway for both the respiratory & digestive tracts <br />LUDY MAE B. NALZARO, RN, MN<br />5<br />
  7. 7. UPPER RESPIRATORY TRACT<br />LARYNX <br />Located above the trachea & just below the pharynx at the root of the tongue <br />Commonly called the “VOICE BOX” <br />Contains 2 pairs of vocal cords, the false & true cords <br />The opening between the true vocal cords is theGLOTTIS<br />EPIGLOTTIS <br />Leaf-shaped elastic structure that is attached along one end to the top of the larynx <br />Prevents the food from entering the tracheo-bronchial tree by closing over the glottis during swallowing <br />LUDY MAE B. NALZARO, RN, MN<br />6<br />
  8. 8. RESPIRATORY SYSTEM<br />LUDY MAE B. NALZARO, RN, MN<br />7<br />
  9. 9. LOWER RESPIRATORY TRACT <br />TRACHEA <br />Located in front of the esophagus <br />Branches into the right & left mainstem bronchi at the carina<br />From larynx to 7th thoracic vertebra <br />LUDY MAE B. NALZARO, RN, MN<br />8<br />
  10. 10. LOWER RESPIRATORY TRACT <br />LUNGS <br />Located in in the pleural cavity in the thorax <br />above the clavicles to the diaphragm - the diaphragm (the major muscle of respiration)<br />The bronchi are lined with cilia which propel mucus up & away from the lower airway to the trachea where it can be expectorated or swallowed <br />RIGHT LUNG <br />larger than the left<br />divided into 3 lobes: the upper, middle & lower lobes <br />LEFT LUNG <br />narrower than the right lung to accommodate the heart ; <br />divided into 2 lobes <br />LUDY MAE B. NALZARO, RN, MN<br />9<br />
  11. 11. Innervation of the respiratory structures is accomplished by the PHRENIC NERVE (C3), VAGUS NERVE & THORACIC NERVES <br />PARIETAL PLEURA - lines the inside of the thoracic cavity including the upper surface of the diaphragm <br />VISCERAL PLEURA - covers the pulmonary surfaces <br />Pleural cavity contains serous fluid<br />A thin fluid (surfactant) layer produced by the cells lining the pleura, lubricates the visceral & parietal pleura, allowing them to glide smoothly and painlessly during respiration <br />LUDY MAE B. NALZARO, RN, MN<br />10<br />
  12. 12. Lung Volumes<br />Ave total capacity of 5900mL (19 y.o. man)<br />A person cannot exhale all the air from the lungs<br />1200mL of air remains in the lungs even after forceful expiration<br />RESIDUAL VOLUME<br />Prevents collapse of the lung structure during expiration<br />Volume of air that moves in and out with each breath<br />TIDAL VOLUME<br />Usually 500ml<br />The amount of air inhaled during deep breathing (beyond tidal volume)<br />INSPIRATORY RESERVE VOLUME<br />Amount of air exhaled forcibly<br />EXPIRATORY RESERVE VOLUME<br />LUDY MAE B. NALZARO, RN, MN<br />11<br />
  13. 13. Respiratory Tree Divisions<br /><ul><li>Primary bronchi
  14. 14. Secondary (lobar) bronchi
  15. 15. Tertiary bronchi
  16. 16. Bronchioles
  17. 17. Terminal bronchioles</li></ul>LUDY MAE B. NALZARO, RN, MN<br />12<br />
  18. 18. BRONCHI<br />LUDY MAE B. NALZARO, RN, MN<br />13<br />
  19. 19. LOWER RESPIRATORY TRACT <br />BRONCHIOLES <br />Contain no cartilage & depend on the elastic recoil of the lung for patency <br />Terminal bronchioles contain no cilia & don’t participate in gas exchange <br />From nose to terminal bronchioles no gas exchange happens and are considered anatomic dead space<br />ALVEOLAR DUCTS & ALVEOLI <br />used to indicate all structures distal to the terminal bronchiole <br />Alveolar ducts branch from the respiratory bronchioles <br />Alveolar sacs which arise from the ducts contain clusters of alveoli which are basic units of gas exchange <br />Cells in the walls of the alveoli secrete surfactant <br />reduces the surface tension in the alveoli <br />without surfactant the alveoli would collapse <br />LUDY MAE B. NALZARO, RN, MN<br />14<br />
  20. 20.
  21. 21. Ventilation<br />Movement of air in and out of the lungs<br />3 forces:<br />Compliance<br />Refers to ease of the lungs to expand and indicates the relationship between the volume and pressure of the lungs<br />Normal: Lungs are elastic so they recoil<br />Diseases the cause fibrosis of the lungs results in “stiff lungs” with long compliance<br />Requires high inspiratory pressure to achieve the set volume of gas<br />Emphysema that damage the elastic structure of the alveolar wall result in ”floppy lungs” with great compliance but poor recoil<br />LUDY MAE B. NALZARO, RN, MN<br />16<br />
  22. 22. Surface tension<br />Surfactant in the alveolar lining lowers surface tension and increases compliance and aids in ventilation and oxygenation<br />Deficiency of surfactant (premature infants) results to stiff lungs = RDS<br />Muscular effort of inspiratory muscles<br />Contraction of the diaphragm and external intercostal muscles enlarges the size of the thorax<br />LUDY MAE B. NALZARO, RN, MN<br />17<br />
  23. 23. Role of Pulmonary Surfactant<br />Surfactant decreases surface tension which: <br /><ul><li>increases pulmonary compliance (reducing the effort needed to expand the lungs)
  24. 24. reduces tendency for alveoli to collapse </li></ul>LUDY MAE B. NALZARO, RN, MN<br />18<br />
  25. 25. LOWER RESPIRATORY TRACT <br />ACCESSORY MUSCLES OF RESPIRATION<br />SCALENE MUSCLES <br />Elevate the first 2 ribs <br />STERNOCLEIDOMASTOID MUSCLES <br />Raises the sternum <br />TRAPEZIUS & PECTORALIS MUSCLES <br />Fix the shoulders <br />LUDY MAE B. NALZARO, RN, MN<br />19<br />
  26. 26. Movements of the Muscles<br />LUDY MAE B. NALZARO, RN, MN<br />20<br />
  27. 27.
  28. 28. Driving Force for Air Flow<br />Airflow driven by:<br /> the pressure difference between<br />atmosphere (barometric pressure) <br />&<br />inside the lungs (intrapulmonary pressure).<br />
  29. 29. atmospheric pressure<br />= 760 mmHg<br />Before inspiration<br />
  30. 30. atmospheric pressure<br />= 760 mmHg<br />
  31. 31. atmospheric pressure<br />= 760 mmHg<br />
  32. 32. Mechanism for the Change in Intrapulmonary pressure<br />Boyle’s Law:<br /> Volume x Pressure = Constant<br />Inspiration:<br />Expiration:<br /> Volume  Pressure<br /> Volume  Pressure<br />
  33. 33. Respiration<br />The process of gas exchange between<br />atm air and the blood at the alveoli<br />the blood cells and the cells of the body<br />Exchange of gases occurs because of differences in partial pressures. <br />Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body.<br />Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body.<br />
  34. 34. Inspiration<br />Contraction of<br />1) diaphragm<br />2) external intercostal muscles<br /><br />The lungs are carried along.<br /><br /> Lung volume<br /><br /> pressure<br /><br /> Air flows in.<br />Forced Expiration<br />Relaxation of<br />diaphragm<br />external intercostal muscles<br />and<br />Contraction of<br />abdominal, internal intercostal and other accessory respiratory muscles.<br /><br /> Lung volume<br /><br /> pressure<br /><br /> Air flows out.<br />Resting Expiration<br />Relaxation of<br />1) diaphragm<br />2) external intercostal muscles<br /><br />The lungs shrink.<br /><br /> Lung volume<br /><br /> pressure<br /><br /> Air flows out.<br />
  35. 35. Ventilation-Perfusion Ratios:A- Normal RatioB- Shunts C- Dead SpaceD- Silent Unit <br />
  36. 36. Airway resistance<br />Resistance is determined chiefly by the radius size of the airway.<br />Causes of Increased Airway Resistance<br /><ul><li>Contraction of bronchial mucosa
  37. 37. Thickening of bronchial mucosa
  38. 38. Obstruction of the airway
  39. 39. Loss of lung elasticity</li></li></ul><li>Blood Supply<br />Blood supply to the lungs. <br />a.Pulmonary arteries to pulmonary capillaries to alveoli, where exchange of gas occurs. <br />b.Bronchial arteries supply the nutrients to the lung tissue and do not participate in gas exchange. <br />LUDY MAE B. NALZARO, RN, MN<br />31<br />
  40. 40.
  41. 41. pulmonary circulation<br />Pulmonary Arteries<br />Pulmonary Veins<br />
  42. 42.
  43. 43. Oxygen Transport<br />LUDY MAE B. NALZARO, RN, MN<br />35<br />
  45. 45. Center in the medulla oblongata<br />1) inspiratorycenter<br />- stimulates inspiration muscles.<br />2) expiratory center<br /><ul><li>inhibits the inspiratorycenter,
  46. 46. stimulates expiration muscles. </li></li></ul><li>Pneumotaxic Center<br /><ul><li> responsible for the rythmic quality of breathing</li></ul>Apneustic Center<br /><ul><li> responsible for deep, prolonged inspiration</li></li></ul><li>Gas Exchange and Respiratory Function <br />
  47. 47. RISK FACTORS FOR RESPIRATORY DISEASE <br />Smoking <br />Use of chewing tobacco <br />Allergies <br />Frequent respiratory illnesses <br />Chest injury <br />Surgery <br />Exposure to chemicals & environmental pollutants <br />Family history of infectious disease <br />Geographic residence & travel to foreign countries <br />LUDY MAE B. NALZARO, RN, MN<br />40<br />
  48. 48. ASSESSMENT<br />
  49. 49. HEALTH HISTORY <br />Medical and family history<br />Age <br />Changes in lung capacities and respiratory function<br />Smoking history<br />Assess pack years (# of packs per day multiply # of yrs smoked)<br />Medication use<br />Allergies<br />Travel and area of residence<br />Diet history<br />Hx of previous URI<br />Occupations hx and socioeconomic status<br />Current healthproblems<br />Restlessness<br />Irritability<br />Confusion<br />Hoarseness<br />Dysrhythmias<br />LUDY MAE B. NALZARO, RN, MN<br />42<br />
  50. 50. Dyspnea<br />Also known as: <br />DIFFICULTY OR LABORED BREATHING<br />BREATHLESSNESS<br />SHORTNESS OF BREATH<br />subjective symptom and a reflection of the client’s judgment of the degree of work of breathing he/she exerts for a given task<br />Occur when there is decrease lung compliance or increased airway resistance<br />Sudden dyspnea in healthy person, indicate PNEUMOTHORAX or ACUTE RESPIRATORY OBSTRUCTION<br />LUDY MAE B. NALZARO, RN, MN<br />43<br />
  51. 51. Dyspnea<br />Orthopnea or the inability to breathe easily except in an upright position may be noted in clients with chronic obstructive pulmonary disorder. <br /> The following should be assessed further to determine what produces dyspnea: <br />a. Exertion that triggers the shortness of breath <br /> b. Presence of cough <br /> c. Relation of dyspnea to other symptoms <br /> d. Onset of shortness of breath <br /> e. Time of day or night dyspnea occurs <br />f. Position of client that worsen/relieves shortness of breath <br />g. Activity of the client when shortness of breath occurs (e.g., at rest, walking, running, climbing the stairs, or exercising) <br />LUDY MAE B. NALZARO, RN, MN<br />44<br />
  52. 52. LUDY MAE B. NALZARO, RN, MN<br />45<br />Assessment Flowchart<br />
  53. 53. Dyspnea<br />Other assessment in dyspnea that should be noted: <br />a. Client’s rating of the intensity of breathlessness <br /> b. Effort required to breath <br /> c. Severity of breathlessness or dyspnea<br />LUDY MAE B. NALZARO, RN, MN<br />46<br />
  54. 54. Dyspnea<br /><ul><li>shortness of breath on lying fl at (orthopnoea): </li></ul> ‘Do you get breathless in bed? <br /> What do you do then? <br /> Does it get worse or better on sitting up?<br />How many pillows do you use? Can you sleep without them?’<br />– waking up breathless: <br /> ‘Do you wake at night with any symptoms?<br /> Do you gasp for breath? <br />What do you do then?’<br />Orthopnoea<br /> - breathless when lying flat <br />paroxysmal nocturnal dyspnoea<br /> - waking up breathless, relieved on sitting up) are features of left heart failure.<br />LUDY MAE B. NALZARO, RN, MN<br />47<br />
  55. 55. Cough<br />Results from irritation of the mucous membranes anywhere in the respiratory tract. <br />May be triggered by:<br />infectious process <br />from an airborne irritant <br />(e.g., smoke, smog, dust, or gas). <br />May indicate serious pulmonary disease <br />May also be caused by a variety of other problems:<br />Cardiac disease<br />Medications<br />Smoking<br />Gastroesophageal reflux<br />LUDY MAE B. NALZARO, RN, MN<br />48<br />
  56. 56. Cough<br />Conduct a symptom analysis on the characteristics of cough by noting the following: <br />a. How and when the cough began, and how long it <br />has been present <br />b. Frequency of cough <br />c. Time of the day when cough is better or worse <br />d. Describe the cough using client’s own words <br />e. A cough may be described as hacking, dry, hoarse, <br />congested, barking, wheezy, or babbling <br />f. Medications or treatments the client used for the <br />cough <br />g. Precautions used to prevent the spread of infection <br />LUDY MAE B. NALZARO, RN, MN<br />49<br />
  57. 57. Sputum Production<br />This is a reaction of the lungs to any constantly recurring irritant; may be associated with nasal discharge. <br />Sources of sputum may be from:<br />tracheobronchial tree, or <br />secretion from: <br />Oral <br />Nasopharyngeal area <br />Sinuses. <br />LUDY MAE B. NALZARO, RN, MN<br />50<br />
  58. 58. Sputum Production<br />3. Characteristics of the sputum: <br />Odor <br />Quality/consistency<br />Color<br />Quantity <br />Tsp, tbsp, cup<br />Location <br />Clearing throat – sinuses<br />Deep, full cough – respiratory tree<br />4. Note any change in color, odor, quality/quantity in the client’s chart<br />LUDY MAE B. NALZARO, RN, MN<br />51<br />
  59. 59. Sputum Production<br />Quality/ Consistency<br />Frothy <br />caused by surfactant in the lung alveoli<br />indicates that the sputum had contact with the lung alveoli or originated from this site.<br />pulmonary edema<br />lung cancer<br />LUDY MAE B. NALZARO, RN, MN<br />52<br />Photograph: Frothy secretions of negative pressure pulmonary edema (NPPE). <br />
  60. 60. Sputum Production<br />2. Mucoid/<br /> sticky <br />COPD<br />Bronchitis<br />asthma<br />LUDY MAE B. NALZARO, RN, MN<br />53<br />
  61. 61. Sputum Production<br />3. Thick, purulent, with foul odor<br />greater mucus production coupled with pus in the purulent types.<br />Lung abscess<br />Bronchiectasis<br />Mucopurulent<br /> - sign of respiratory tract infection<br /> - acute bronchitis and pneumonia<br />LUDY MAE B. NALZARO, RN, MN<br />54<br />
  62. 62. Sputum Production<br />4. Tenacious<br /><ul><li>tending to adhere or cling especially to another substance</li></ul>Asthma<br />COPD<br />LUDY MAE B. NALZARO, RN, MN<br />55<br />
  63. 63. Sputum Production<br />5. Watery<br />Common colds<br />allergy<br />LUDY MAE B. NALZARO, RN, MN<br />56<br />
  64. 64. Sputum Production<br />Color: <br />1. Rust<br />pneumococcal infection <br />implies the breakdown of RBCs and their phagocytosis by alveolar macrophages <br />e.g., chronic pulmonary edema<br />LUDY MAE B. NALZARO, RN, MN<br />57<br />Rusty <br />Hemoptysis<br />
  65. 65. Sputum Production<br />2. Yellow-green colored sputum<br />bacterial infection<br />LUDY MAE B. NALZARO, RN, MN<br />58<br />
  66. 66. Sputum Production<br />3. Pink colored<br />pulmonary edema <br />4. White colored<br />asthma <br />5. Gray colored<br />bronchitis <br />LUDY MAE B. NALZARO, RN, MN<br />59<br />
  67. 67. Sputum Production<br />6. Brick red colored sputum <br />Klebsiella infection<br />LUDY MAE B. NALZARO, RN, MN<br />60<br />
  68. 68. Sputum Production<br />7. Salmon colored sputum <br />staphylococcal infection<br />LUDY MAE B. NALZARO, RN, MN<br />61<br />
  69. 69. Sputum Production<br />8. Brown <br />aspergillosis<br />9. Anchovy-chocolate <br />amebic abscess <br />10. Red sputum and saliva <br />rifampin use <br />LUDY MAE B. NALZARO, RN, MN<br />62<br />
  70. 70. Hemoptysis<br />Refers to the blood expectorated from the mouth in the form of gross blood, frankly blood sputum, or blood-tinged sputum. <br />Identify whether the source of blood are the lungs, a nosebleed, or the stomach. <br />Obtain an estimate of the amount of blood expectorated using specifications (i.e., teaspoon, tablespoon, or cup). <br />Pulmonary causes of hemoptysis include:<br />Chronic bronchitis<br />Bronchiectasis<br />Pulmonary tuberculosis<br />Cystic fibrosis<br />Pulmonary embolism<br />Pneumonia<br />Lung cancer<br />Lung abscess. <br />LUDY MAE B. NALZARO, RN, MN<br />63<br />
  71. 71. Wheezing <br />A high-pitched, musical sound produced when air passes through partially obstructed or narrowed airways on inspiration or expiration. <br />Could be heard with or without the use of a stethoscope. <br /> A client may not complain of wheezing but take note when the client reports chest tightness or chest discomfort. <br />Ask the client when the wheezing occurs and whether it resolves spontaneously or is relieved by medication. <br />LUDY MAE B. NALZARO, RN, MN<br />64<br />
  72. 72. Wheezing <br />This manifestation is not always caused by asthma but may also be caused by :<br />mucosal edema<br />airway secretions<br />collapsed airways<br />foreign objects <br />tumors partially obstructing air flow. <br />LUDY MAE B. NALZARO, RN, MN<br />65<br />
  73. 73. Stridor<br /> High-pitched sound produced when air passes through a partially obstructed or narrowed upper airway upon inspiration. <br />Associated with respiratory distress and can be life threatening due to compromised airway. <br />Commonly seen in:<br />Epiglottitis<br />Sleep apnea<br />Heart failure<br />Aspiration <br />Ask client about:<br />Changes in voice character, <br />Hoarseness <br />Difficulty swallowing<br />Sleep-related disorders<br />Early morning headaches<br />Weight gain<br />Fluid retention<br />Apne<br />Restlessness. <br />LUDY MAE B. NALZARO, RN, MN<br />66<br />
  74. 74. Chest Pain<br />occur with:<br />Pneumonia<br />pulmonary embolism with lung infarction<br />Pleurisy<br />bronchogenic carcinoma. <br />Assess the quality, intensity, and radiation of pain. <br />Identify and explore precipitating factors . <br />Note the relationship of pain to the inspiratory and expiratory phases of respiration. <br />Ask client whether activity, coughing, or movement brings pain and what relieves pain. <br />LUDY MAE B. NALZARO, RN, MN<br />67<br />
  75. 75. CHEST PAIN:<br />The most common causes of chest pain are:<br />– ischaemic heart disease: severe constricting, central chest pain<br />– pleuritic pain: sharp, localized pain, usually lateral; worse on<br />inspiration or cough<br />– anxiety or panic attacks: a very common cause of chest pain<br />Inquire about circumstances that bring on an attack.<br />SOB:<br />The degree of exercise that brings on the symptoms<br />must be noted (e.g. climbing one flight of stairs, after 0.5 km (1/4<br />mile) walk).<br />LUDY MAE B. NALZARO, RN, MN<br />68<br />
  76. 76. Symptom Analysis<br />Things to assessed when client describes a specific respiratory manifestation:<br />Onset = when it begin<br />Location = where<br />Duration = how long<br />Characteristics<br />Ask in common language, note about amnt, size, # and extent of chief complaint<br />Aggravating and relieving factors<br />Factors that precipitate/worsen/alleviate a manifestation<br />Associated manifestation<br />s/sx that occur in conjunction with chief complaint<br />LUDY MAE B. NALZARO, RN, MN<br />69<br />
  77. 77. Timing<br />Both onset & period during which problem has occurred<br />Setting<br />Time, place or particular situation in which the client experiences the complaint<br />Severity <br />Scale of 1-10 (1 as the least and 10 as the most)<br />LUDY MAE B. NALZARO, RN, MN<br />70<br />
  78. 78. Gather information based on Gordon’s, giving emphasis on the following:<br />Current Respiratory Problems:<br />Ask regarding recent changes in the breathing pattern.<br />Perception on activities that might cause the changes/symptoms<br />Number of pillows used when sleeping at night<br />LUDY MAE B. NALZARO, RN, MN<br />71<br />
  79. 79. Hx of Respiratory Disease<br />Colds, allergies, asthma, TB, bronchitis, pneumonia or emphysema<br />Frequency of the disease occurrence, duration, and tx/mgt of the disease<br />Exposure to any pollutants<br />LUDY MAE B. NALZARO, RN, MN<br />72<br />
  80. 80. Assessment<br />Collecting Objective Data: PE<br />Client preparation<br />Equipment and supplies:<br />exam gown and drape<br />Gloves<br />Stethoscope<br />light source<br />Mask<br />Skin marker<br />Metric ruler<br />
  81. 81. Key assessment points:<br />Provide privacy for the client<br />Keep your hands warm to promote client’s comfort during exam<br />Remain nonjudgmental about client’s habits and lifestyle, particularly smoking<br />
  82. 82. Cyanosis<br />Central Cyanosis<br />Peripheral Cyanosis<br />
  83. 83. Assessment of the Hands<br />Clubbing of the fingernails<br />
  84. 84. Assessment of the Hands<br />Staining<br />Wasting and weakness<br />Pulse rate<br />Flapping Tremor<br />
  85. 85. Assessment of the Face<br />Eyes<br />Horner's syndrome? (constricted pupil, partial ptosis and loss of sweating which can be due to apical lung tumour compressing sympathetic nerves in neck) <br />Nose<br />polpys? (associated with asthma) <br />engorged turbinates? (various allergic conditions) <br />deviated septum? (nasal obstruction) <br />Mouth and tongue<br />look for central cyanosis <br />evidence of upper respiratory tract infection (a reddened pharynx and tonsillar enlargement with or without a coating of pus) <br />broken tooth - may predispose to lung abscess or pneumonia <br />
  86. 86. Inspect:<br />For nasal flaring and pursed lip breathing<br />Color and shape of nails<br />Observe color of face, lips, and chest<br />
  87. 87. Shape and symmetry of chest<br />Barrel Shaped<br />
  88. 88. Shape and symmetry of chest<br />Pigeon Chest ( Pectus Carinatum )<br />
  89. 89. Shape and symmetry of chest<br />Funnel Chest<br />
  90. 90. Shape and symmetry of chest<br />Kyphosis<br />Scoliosis<br />Kyphoscoliosis<br />
  91. 91. Posterior Thorax<br />Inspect configuration and client’s positioning<br />Observe for use of accessory muscles and assess chest expansion<br />
  92. 92. Posterior Thorax<br />Palpate for: <br />Tenderness<br />Sensation<br />Crepitus<br />Surface characteristics<br />Fremitus<br />
  93. 93. Posterior Thorax<br />Auscultate for breath sounds, adventitious sounds<br />Auscultate voice sounds: bronchophony, egophony, whispered pectoriloquy<br />
  94. 94.
  95. 95. Normal Breath Sounds<br />
  96. 96. ASSESSING BREATH SOUNDS<br />LUDY MAE B. NALZARO, RN, MN<br />89<br />
  97. 97. Abnormal Breath Sounds<br />
  98. 98. Anterior Thorax<br />Inspect for:<br />shape and configuration<br />position of sternum<br />slope of ribs<br />intercostal spaces,<br />Observe for:<br />quality and pattern of respiration<br />use of accessory muscles<br />
  99. 99. Anterior Thorax<br />Palpate for:<br />Tenderness<br />Sensation<br />Surface masses<br />Fremitus<br />Anterior chest expansion<br />
  100. 100.
  101. 101. Anterior Thorax<br />Percuss for tone<br />
  102. 102.
  103. 103. Anterior Thorax<br />Auscultate for anterior breath sounds, adventitious sounds, and voice sounds<br />
  104. 104.
  105. 105. EFFECTS OF AGING<br />Aging<br />Affects the mechanical aspects of ventilation by decreasing chest wall compliance and elastic recoil of the lungs<br />Changes in these properties reduce ventilatory reserve<br />Aging causes the oxygen to decrease but no effect on carbon dioxide.<br />LUDY MAE B. NALZARO, RN, MN<br />98<br />
  106. 106. DIAGNOSTIC TESTS <br />
  107. 107. IMAGING STUDIES<br />X - ray<br />CT Scan<br />MRI<br />Fluoroscopy<br />Pulmonary Angiography<br />Ventilation - Perfusion Scan<br />Gallium Scan<br />PET<br />
  108. 108. information on the anatomic location & appearance <br />Evaluates:<br />lung fields, clavicle and ribs, cardiac border, mediastinum, diaphragm, and thoracic spine<br />Air trapping, consolidation, cavity formation or presence of tumors<br />LUDY MAE B. NALZARO, RN, MN<br />101<br /><ul><li>PRE-PROCEDURE NURSING CARE
  109. 109. Instruct on the purpose of the procedure and the location
  110. 110. Procedures takes approx 15 minutes
  111. 111. No restriction on food, fluid, or medication prior to the procedure
  112. 112. No sedation or anesthetic
  113. 113. Remove all jewelry & other metal objects
  114. 114. Lead apron for men and women of childbearing age
  115. 115. Assess ability to inhale & hold the breath
  116. 116. Question regarding pregnancy of possibility of pregnancy </li></ul>CHEST X-RAY (CXR) FILM (RADIOGRAPH) <br />
  117. 117. Chest X-Ray<br />
  118. 118. Front View Side View<br />
  119. 119. Computed Tomography Scan<br />
  120. 120. <ul><li>chest CT scan shows a cross-section of a person with bronchial cancer.
  121. 121. The two dark areas are the lungs. The light areas within the lungs represent the cancer. </li></ul>Computed Tomography Scan<br />
  122. 122. Magnetic Resonance Imaging<br /><ul><li>Similar to CT scan
  123. 123. except that magnetic fields and radiofrequency signals are used instead of narrow beam-xray.</li></li></ul><li>Fluoroscopy<br /><ul><li>a study of moving body structures - similar to an x-ray "movie."
  124. 124. A continuous x-ray beam is passed through the body part being examined, and is transmitted to a TV-like monitor so that the body part and its motion can be seen in detail.
  125. 125. Used to assist with invasive procedures (chest needle biopsy) performed to identify lesions.
  126. 126. Used to study the movement of the chest wall, mediastinum, heart and diaphragm to detect paralysis and to locate lung masses.</li></li></ul><li>PULMONARY ANGIOGRAPHY<br />used to detect blood clots in the lungs & congenital abnormalities in the lungs. <br />Local anaesthetic is given to numb the area.<br />Contrast media is injected into the pulmonary arteries via the antecubital or femoral vein into the pulmonary artery <br />it involves iodine or radiopaque or contrast material <br />Definitive for pulmonary embolism<br />Procedure takes ½ an hour. <br />Patient will be on bed rest for 3hrs<br />LUDY MAE B. NALZARO, RN, MN<br />108<br />
  127. 127. PULMONARY ANGIOGRAPHY<br />PRE-PROCEDURE NURSING CARE <br />Informed consent <br />Assess for allergies to iodine, seafood & dyes <br />NPO prior to procedure <br />V/S <br />Assess coagulation studies <br />Establish an IV <br />Administer sedation <br />Client must lie still during the procedure<br />LUDY MAE B. NALZARO, RN, MN<br />109<br />
  128. 128. PULMONARY ANGIOGRAPHY<br />PRE-PROCEDURE NURSING CARE<br />Urge to cough<br />Emergency equipment available <br />POST-PROCEDURE NURSING CARE<br />V/S <br />No BP for 24 hrs in the affected extremity <br />Monitor peripheral neurovascular status <br />Assess for bleeding <br />Monitor dye reaction <br />LUDY MAE B. NALZARO, RN, MN<br />110<br />
  129. 129. PULMONARY ANGIOGRAPHY<br />Contraindication:<br />Pregnancy<br />Dye allergies<br />Unstable client<br />Uncooperative client<br />Complications:<br />Cardiac dysrthymias<br />Anaphylatic reactions to dye <br />Risk for death<br />LUDY MAE B. NALZARO, RN, MN<br />111<br />
  130. 130. Radioisotope Diagnostic Procedure (Lung Scan)<br />Types:<br />Ventilation-perfusion scan<br />Gallium scan<br />Positron emission tomography<br />Used to detect normal lung functioning, pulmonary vascular supply and gas exchange<br />LUDY MAE B. NALZARO, RN, MN<br />112<br />
  131. 131. Ventilation - Perfusion Scan<br /><ul><li>Radioactive albumin injection in peripheral vein
  132. 132. performed to measure the supply of blood through the lungs.
  133. 133. After the injection, the lungs are scanned to detect the location of the radioactive particles as blood flows through the lungs.</li></li></ul><li>Ventilation - Perfusion Scan<br /><ul><li>The ventilation scan is used to evaluate the ability of air to reach all portions of the lungs. The perfusion scan measures the supply of blood through the lungs.
  134. 134. Imaging 20-40 minutes
  135. 135. Indication:
  136. 136. to detect a pulmonary embolus (ventilation without perfusion)
  137. 137. to evaluate lung function in COPD
  138. 138. to detect the presence of shunts (abnormal circulation) in the pulmonary blood vessels.
  139. 139. Lung cancer</li></li></ul><li>Gallium Scan<br /><ul><li>It is a type of nuclear scan involving radioactive gallium
  140. 140. determine whether a patient has inflammation in the lungs, abscess, adhesions, presence of tumor (sarcoidosis).
  141. 141. Used to stage bronchogenic cancer and record tumor regression after chemotherapy
  142. 142. Gallium is injected in a vein and a series of x-rays are taken to identify where the gallium has accumulated in the lungs. </li></li></ul><li>Indirect Bronchography<br /><ul><li>A radiopaque medium is instilled directly into the trachea and the bronchi
  143. 143. the outline of the entire bronchial tree or selected areas may be visualized through x-ray.
  144. 144. reveals anomalies of the bronchial tree and is important in the diagnosis of bronchiectasis. </li></li></ul><li><ul><li>Nursing interventions BEFORE Bronchogram
  145. 145. Secure written consent
  146. 146. Check for allergies to sea foods or iodine or anesthesia
  147. 147. NPO for 6 to 8 hours
  148. 148. Pre-op meds:
  149. 149. Atropine SO4
  150. 150. Valium
  151. 151. Topical anesthesiasprayed
  152. 152. followed by local anesthetic injected into larynx.
  153. 153. Oxygen and antispasmodic agents must be ready.
  154. 154. Nursing interventions AFTER Bronchogram
  155. 155. Side-lying position
  156. 156. NPO until cough and gag reflexes returned
  157. 157. Instruct the client to cough and deep breathe client</li></li></ul><li>Positron Emission Tomography<br />
  158. 158. Positron Emission Tomography<br />Used to evaluate lung nodules for malignancy<br />Can detect and siplay metabolic changes in tissue, distinguish normal from abnormal, viable from dead cells<br />LUDY MAE B. NALZARO, RN, MN<br />119<br />
  159. 159. Positron Emission Tomography<br />
  160. 160. Lung Scan<br /><ul><li> Procedure using inhalation or I.V. injection of radioisotope, scans are taken with a scintillation camera.
  161. 161. Imaging of distribution and blood flow in the lungs. (Measure blood perfusion)
  162. 162. Confirm pulmonary embolism or other blood- flow abnormalities</li></li></ul><li>Nursing interventions BEFORE the procedure:<br /><ul><li>Allay the patient’s anxiety
  163. 163. Instruct the patient to Remain still during the procedure</li></ul>Nursing interventions AFTER the procedure<br /><ul><li>Check the catheter insertion site for bleeding
  164. 164. Assess for allergies to injected radioisotopes
  165. 165. Increase fluid intake, unless contraindicated. </li></li></ul><li>Endoscopic Procedure<br />Bronchoscopy<br />Endoscopic Thoracoscopy<br />Thoracenthesis<br />
  166. 166. BRONCHOSCOPY <br />Purposes of diagnostic bronchoscopy are: <br />(1) to examine tissues or collect secretions, <br />(2) to determine the location and extent of the pathologic process and to obtain a tissue sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy),<br />(3) to determine if a tumor can be resected surgically, and<br />(4) to diagnose bleeding sites (source of hemoptysis).<br />Therapeutic bronchoscopy is used to: <br />(1) remove foreign bodies from the tracheobronchial tree, <br />(2) remove secretions obstructing the tracheobronchial tree when the patient cannot clear them, <br />(3) treat postoperative atelectasis, and <br />(4) destroy and exciselesions.<br />LUDY MAE B. NALZARO, RN, MN<br />124<br />
  167. 167. BRONCHOSCOPY <br />visual examination of the larynx, trachea & bronchi with a fiber-optic bronchoscope <br />PRE-PROCEDURE NURSING CARE <br />Informed consent <br />NPO 6-8hrs prior <br />Explain procedure to reduce fear and decrease anxiety <br />Assess coagulation studies <br />Remove dentures or eyeglasses <br />Prepare suction <br />Have resuscitation equipment available <br />LUDY MAE B. NALZARO, RN, MN<br />125<br />
  168. 168. <ul><li>Atropine (to diminish secretions) is administered one hour before the procedure
  169. 169. About 30 minutes before bronchoscopy.
  170. 170. Valium is given to sedate patient and allay anxiety.
  171. 171. To inhibit vagal stimulation (prevent bradycardia, dysrhthmias and hypotension)
  172. 172. Topical anesthesia is sprayed followed by local anesthesia injected into the larynx
  173. 173. The patient is placed supine with hyperextended neck during the procedure</li></ul>Nursing interventions BEFORE Bronchoscopy<br />
  174. 174. DIAGNOSTIC TESTS <br />POST-PROCEDURE NURSING CARE <br />V/S <br /> Fowler’s position <br />Assess gag reflex (+, may offer ice chips)<br />NPO until gag reflex returns <br />Monitor for bloody sputum <br />Monitor respiratory status <br />Monitor for complications: bronchospasm, bronchial perforation, crepitus, dysrhythmia, fever, hemorrhage, hypoxemia, and pneumothorax <br />Notify the MD if complications occur <br />LUDY MAE B. NALZARO, RN, MN<br />127<br />
  175. 175. Endoscopic Thoracoscopy<br />
  176. 176. Endoscopic Thoracoscopy<br />Pleural cavity is examined with endoscope<br />Small incision into pleural cavity in an intercostal space<br />Indicated:<br />Pleural effusion<br />Pleural diseases<br />Tumor staging <br />LUDY MAE B. NALZARO, RN, MN<br />129<br />
  177. 177. LUNG BIOPSY <br />a percutaneous lung biopsy - culture or cytologicexamination <br />Invasive technique involving entering the lung or pleura to obtain tissue for analysis<br />Used to make a definite dx regarding the type of malignancy, infection, inflammation, or other type of lung disease<br />PRE-PROCEDURE NURSING CARE <br />Informed consent <br />NPO prior <br />Local anesthetic <br />Pressure during insertion and aspiration <br />Administer analgesics & sedatives as Rx <br />LUDY MAE B. NALZARO, RN, MN<br />130<br />
  178. 178. DIAGNOSTIC TESTS <br />LUNG BIOPSY <br />POST-PROCEDURE NURSING CARE <br />V/S <br />Pressure dressing <br />Monitor for hemoptysis/bleeding <br />Monitor for respiratory distress <br />Monitor for complications: pneumothorax and air emboli <br />Prepare for CXR <br />Chest tube management for open lung biopsy<br />LUDY MAE B. NALZARO, RN, MN<br />131<br />
  179. 179. Nursing interventions BEFORE the procedure:<br /><ul><li>Withhold food and fluids
  180. 180. Place obtained written informed consent in the patient’s chart. </li></ul>Nursing interventions AFTER the procedure:<br /><ul><li>Observe the patient for signs of Pneumothorax and air embolism
  181. 181. Check the patient for hemoptysis and hemorrhage
  182. 182. Monitor and record vital signs
  183. 183. Check the insertion site for bleeding
  184. 184. Monitor for signs of respiratory distress</li></li></ul><li>THORACENTESIS<br />Involves needle aspiration of pleural fluid or air from the pleural space for diagnostic and therapeutic purposes.<br />A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia<br />No more than 1200ml should be removed at one time<br />CONTRAINDICATION:<br />An uncooperative patient <br />coagulation disorder that can not be corrected with emphysema), <br />only one functioning lung <br />(due to diminished reserve, aspiration should not exceed 1L as there is a risk of development of pulmonary edema.<br />LUDY MAE B. NALZARO, RN, MN<br />133<br />
  185. 185. Thoracenthesis<br />
  186. 186. COMPLICATIONS<br />pneumothorax (3-30%), <br />hemopneumothorax, <br />hemorrhage, <br />hypotension (low blood pressure due to a vasovagal response) <br />reexpansion pulmonary edema.<br />LUDY MAE B. NALZARO, RN, MN<br />135<br />
  187. 187. DIAGNOSTIC TESTS <br />PRE-PROCEDURE NURSING CARE <br />Informed consent <br />V/S <br />CXR or U/A prior to the procedure <br />Assess coagulation studies <br />Upright ( sitting on the side of the bed with the feet on a stool, leaning over the bedside table)<br />Do not cough, breath deeply, or move during the procedure <br />LUDY MAE B. NALZARO, RN, MN<br />136<br />
  188. 188. DIAGNOSTIC TESTS <br />POST-PROCEDURE NURSING CARE <br />Apply pressure on the puncture site<br />Use semi-fowlers or puncture site up<br />Monitor V/S, respiratory status <br />Assess site for bleeding and crepitus<br />Monitor for signs of PNEUMOTHORAX, AIR EMBOLISM & PULMONARY EDEMA<br />Determine if MD wants a follow up CXR <br />LUDY MAE B. NALZARO, RN, MN<br />137<br />
  189. 189. DIAGNOSTIC TESTS <br />SPUTUM SPECIMEN <br />obtained by expectoration or tracheal suctioning <br />identify organisms or abnormal cells <br />PRE-PROCEDURE NURSING CARE <br />Determine specific purpose <br />Early morning sterile specimen <br />5-15 ml of sputum <br />Rinse the mouth with water prior to collection <br />Take several deep breaths and then cough forcefully <br />Collect the specimen before antibiotic therapy<br />LUDY MAE B. NALZARO, RN, MN<br />138<br />
  190. 190. LUDY MAE B. NALZARO, RN, MN<br />139<br />
  191. 191. DIAGNOSTIC TESTS <br />SUCTIONING PROCEDURE IN OBTAINING SPUTUM SPECIMEN <br />Aseptic technique <br />Hyperoxygenate<br />Lubricate the catheter with sterile water <br />Tracheal suctioning : 4 inches <br />Nasotracheal suctioning : insert to induce cough reflex <br />Don’t apply suction while inserting <br />Suction intermittently for 10-15 seconds <br />Rotate and withdraw <br />Hyperoxygenate & deep breaths <br />LUDY MAE B. NALZARO, RN, MN<br />140<br />
  192. 192. DIAGNOSTIC TESTS <br />SPUTUM SPECIMEN <br />POST-PROCEDURE NURSING CARE <br />Label the container<br />Transport specimen to lab stat <br />Mouth care <br />LUDY MAE B. NALZARO, RN, MN<br />141<br />
  193. 193. Skin Test: Mantoux Test or Tuberculin Skin Test<br />This is used to determine if a person has been infected or has been exposed to the TB bacillus. <br />This utilizes the PPD (Purified Protein Derivatives). <br />The PPD is injected intradermallyusually in the inner aspect of the lower forearm about 4 inches below the elbow. <br />The test is read 48 to 72 hours after injection.<br />(+) Mantoux Test is induration of 10 mm or more. <br />But for HIV positive clients, induration of about 5 mm is considered positive<br />Signifies exposure to Mycobacterium Tubercle bacilli<br />
  194. 194.
  195. 195.
  196. 196. DIAGNOSTIC TESTS <br />PULSE OXIMETRY <br />a non-invasive test that registers arterial O 2 saturation (SaO 2 ) <br />NORMAL VALUE: 95%-100% <br />alert hypoxemia before clinical signs occurs <br />PROCEDURE <br />A sensor is placed: finger, toe, nose, earlobe or forehead<br />Don’t select an extremity with an impediment to blood flow <br />>91% - immediate treatment <br />SaO2 >85% - hypo-oxygenation <br />SaO2is  70% - life-threatening <br />LUDY MAE B. NALZARO, RN, MN<br />145<br />
  197. 197. <ul><li>unreliable in:
  198. 198. Cardiac arrest
  199. 199. Shock
  200. 200. Use of dyes or vasoconstrictors
  201. 201. Severe anemia
  202. 202. High carbon monoxide Level</li></li></ul><li>PULMONARY FUNCTION TEST (PFTs) <br />used to evaluate lung mechanics, gas exchange, & acid-base disturbance thru spirometric measurements, lung volumes, and arterial blood gases <br />PRE-PROCEDURE NURSING CARE <br />Determine if an analgesic that may depress the respiratory function is being administered <br />Consult with MD regarding holding bronchodilators prior to testing <br />Instruct the client to void prior to procedure and to wear loose clothing <br />Remove dentures <br />Instruct the client to refrain from smoking or eating a heavy meal for 4-6 hrs prior to the test <br />LUDY MAE B. NALZARO, RN, MN<br />147<br />
  203. 203. POST-PROCEDURE NURSING CARE <br />Resume normal diet and any bronchodilators & respiratory treatments that were held prior to the procedure <br />Observe for increased dyspnea or bronchospasm after the testing<br />LUDY MAE B. NALZARO, RN, MN<br />148<br />PULMONARY FUNCTION TEST (PFTs) <br />
  204. 204. Determine pH, oxygen and carbon dioxide concentrations<br />the ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation <br />aid in assessing:<br />the ability of the lungs to provide adequate oxygen and remove carbon dioxide <br />the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH.<br />LUDY MAE B. NALZARO, RN, MN<br />149<br />ARTERIAL BLOOD GASES (ABGs) <br />
  205. 205. PRE-PROCEDURE NURSING CARE <br />Inform client on the procedure<br />Perform Allen’s test prior to drawing radial artery specimens <br />Have the client rest for 30 mins prior to specimen collection <br />Avoid suctioning prior to drawing ABGs <br />Don’t turn off O 2 unless the ABGs are ordered to be drawn at room air <br />LUDY MAE B. NALZARO, RN, MN<br />150<br />
  206. 206. POST-PROCEDURE NURSING CARE<br />Apply pressure on the puncture site for 5-10 mins & longer if the client is on anticoagulant therapy or has bleeding disorder <br />Be sure that no air bubbles in the specimen<br />Place the specimen on ice <br />Note the client’s temperature on the laboratory form <br />Note the O 2 & type of ventilation that the client is receiving on the laboratory form <br />Transport the specimen to the laboratory within 15 mins<br />LUDY MAE B. NALZARO, RN, MN<br />151<br />ARTERIAL BLOOD GASES (ABGs) <br />
  207. 207. ACID-BASE BALANCE <br />Respiratory System: CO2 (acid) <br />Metabolic acidosis – (Lungs) excrete CO2 <br />Metabolic alkalosis – (Lungs) retain CO2 <br />Renal or Metabolic System: H ion(acid) ; HCO3(base) <br />Respi. acidosis – (Kidney) excrete H+ ; retain HCO3 <br />Respi. alkalosis – (Kidney) retain H+ ; excrete HCO3 <br />Normal ABG Values : <br />Ph : 7.35 – 7.45 <br />PCO2 : 35 – 45 mgHG<br />HCO3 : 22-26 meq/L <br />PO2 : 80-100 mgHg<br />Base excess : (+2 or –2) <br />LUDY MAE B. NALZARO, RN, MN<br />152<br />ARTERIAL BLOOD GASES (ABGs) <br />
  208. 208. ARTERIAL BLOOD GAS SITE: Radial Artery TEST: Allens Test <br /> Ph  acidosis <br /> alkalosis <br /> PCO2  alkalosis <br /> acidosis <br /> HCO3 acidosis <br /> alkalosis <br />LUDY MAE B. NALZARO, RN, MN<br />153<br />ARTERIAL BLOOD GASES (ABGs) <br />
  209. 209. ARTERIAL BLOOD GAS <br />1. Assess ph, PCO2 & HCO3 <br />2. Identify imbalance. If ph is normal use 7.4 <br />7.4 – acidosis <br /> 7.4 – alkalosis <br />3. Identify if compensated or uncompensated <br />uncompensated- if one component is normal & the other is abnormal <br />compensated – if both PCO2 & HCO3 are abnormal in <br />opposite directions <br />4. If compensated, identify if partially or fully <br />partially – if ph is abnormal <br />fully - if ph is normal <br />LUDY MAE B. NALZARO, RN, MN<br />154<br />ARTERIAL BLOOD GASES (ABGs) <br />
  210. 210. RESPIRATORY TREATMENTS <br />LUDY MAE B. NALZARO, RN, MN<br />155<br />
  211. 211. CHEST PHYSIOTHERAPY (CPT) <br />Percussion and vibration over the thorax to loosen secretions in the affected areas of the lungs<br />NURSING CARE <br />Best time - morning upon arising, 1 hr before meals or 2-3hrs after meals <br />Stop if pain occurs <br />Provide mouth care <br />CONTRAINDICATIONS <br /> respiratory distress <br />Hx of fractures <br />Chest incisions <br />If procedure increases bronchospasm<br />Obese <br />LUDY MAE B. NALZARO, RN, MN<br />156<br />RESPIRATORY TREATMENTS <br />
  212. 212. CHEST PHYSIOTHERAPY (CPT) <br />PROCEDURE<br />Use cupped hands or percussion device<br />Stop if painful<br />Effective 1st thing in the morning or 1 hr before or 2-3hrs after meals<br />Instruct to take a deep breaths and cough during the procedure<br />Administer the bronchodilator (if prescribed) 15 minutes before the procedure.<br />POST PROCEDURE<br />Asses oxygenation status<br />Offer oral hygiene<br />LUDY MAE B. NALZARO, RN, MN<br />157<br />
  213. 213. POSTURAL DRAINAGE<br />use of the gravity to drain the secretions from segments of the lungs<br />May combined with CPT<br />NURSING CARE <br />Consent <br />Position the client <br />Best time – A.M. upon arising, 1 hr before meals, 2-3 hrs after meals <br />Stop if cyanosis or exhaustion occurs <br />Maintain position 5-20 mins after <br />Provide mouth care after the procedure <br />LUDY MAE B. NALZARO, RN, MN<br />158<br />
  214. 214. nionoveno@yc<br />respi disorders<br />159<br />Chest PhysiotherapyPostural Drainage<br />
  215. 215. Chest PhysiotherapyPostural Drainage<br />CONTRAINDICATIONS OF POSTURAL DRAINAGE <br />Unstable V/S <br />Increased ICP <br />LUDY MAE B. NALZARO, RN, MN<br />160<br />
  216. 216. Incentive Spirometer<br />Type: Flow and Volume<br />Device ensures that a volume of air is inhaled and the patient takes deep breaths.<br />Used to prevent or treat atelectasis<br />
  217. 217. Volume Oriented<br />Flow Oriented<br />
  218. 218. CLIENT INSTRUCTIONS<br />Use the lips to form seal around the mouth piece <br />Inspire deeply <br />Hold inspiration for a few seconds <br />Forcefully exhale <br />Avoid the use of spirometry at mealtimes <br />it may cause nausea <br />LUDY MAE B. NALZARO, RN, MN<br />163<br />
  219. 219. Nebulizer Therapy<br />A hand-held apparatus <br />disperses a moisturizing agent or medication such as a bronchodilator into the lungs. <br />device must make a visible mist.<br />Nursing care: instruct patient in use. <br />breathe with slow, deep breaths through mouth and hold a few seconds at the end of inspiration. <br />Coughing exercises may be encouraged to mobilize secretions after a treatment. <br />Assess patient before treatment and evaluate patient response after treatment.<br />
  220. 220. OXYGEN THERAPY<br />LUDY MAE B. NALZARO, RN, MN<br />165<br />
  221. 221. Delivery Devices<br />Nasal cannula<br />Simple face mask<br />Partial rebreather mask<br />Non-rebreather mask<br />Venturi mask<br />Small volume nebulizer<br />
  222. 222. OXYGEN (O 2 ) ADMINSITRATION <br />NURSING CARE <br />V/S <br />OXYGEN IN USE sign <br />Humidify the O 2 <br />LUDY MAE B. NALZARO, RN, MN<br />167<br />
  223. 223. NASAL CANNULA (NASAL PRONGS) <br />flow rates of 1-6L/min; 24% (at 1L/min) to 44% (at 6L/min) <br />flow rates higher than 6L/min don’t significantly increase oxygenation <br />NOTE: Client who retains CO2 should never receive O2 at rates higher than 2-3 L/min unless on a mechanical ventilator <br />effective O2 concentration can be delivered to both nose breathers & mouth breathers with the use of a nasal cannula<br />LUDY MAE B. NALZARO, RN, MN<br />168<br />
  224. 224. Nasal Cannula<br />It delivers a relatively low concentration of oxygen (24% - 45% ) at flow rate of 2 – 6 L/min.<br />
  225. 225. Nasal Cannula<br />Indication<br />Low FiO2<br />Long term therapy<br />Contraindications<br />Apnea<br />Mouth breathing<br />Need for High FiO2<br />
  226. 226. NASAL CANNULA (NASAL PRONGS)<br />Fraction of Inspired Oxygen (FiO2) DELIVERED VIA NASAL CANNULA <br />24% at 1L/min <br />28% at 2L/min <br />32% at 3L/min <br />36% at 4L/min <br />40% at 5L/min <br />44% at 6L/min <br />LUDY MAE B. NALZARO, RN, MN<br />171<br />
  227. 227. NASAL CANNULA (NASAL PRONGS)<br />NURSING CARE <br />Add humidification <br />Monitor humidifier <br />Assess RR <br />Assess the mucosa <br />high flow rates have a drying effect & increase mucosal irritation <br />Assess the skin integrity <br />O2 tubing can irritate the skin <br />Provide water-soluble jelly <br />LUDY MAE B. NALZARO, RN, MN<br />172<br />
  228. 228. SIMPLE FACE MASK <br />40%-60% for short term O 2 therapy or to deliver O 2 in an emergency <br />minimal flow rate of 5L/min - to prevent the rebreathing of exhaled air <br />NURSING CARE <br />Be sure the mask fits <br />Provide skin care <br />pressure & moisture under the mask may cause skin breakdown <br />Monitor for aspiration <br />the mask limits the client’s ability to clear the mouth esp if vomiting occurs <br />Provide emotional support to decrease anxiety in the client who feels claustrophobic <br />LUDY MAE B. NALZARO, RN, MN<br />173<br />
  229. 229. Simple Face Mask<br />Volumes greater that 10 LPM does not increase O2 delivery<br />Indications<br />Moderate FiO2<br />Contraindications<br />Apnea<br />Need for High FiO2<br />
  230. 230. Simple Face Mask<br />It delivers oxygen concentrations from 40% - 60% at liter flows of 5 - 8 L/min<br />
  231. 231. F I 0 2 DELIVERED <br />VIA <br />SIMPLE FACE MASK <br />40% at 5L/min <br />45% to 50% at 6L/min <br />55% to 60% at 8L/min <br />NOTE: <br />PYRAMID POINT : <br />Flow rate must be set to at least 5L/min to flush the mask of CO2 <br />LUDY MAE B. NALZARO, RN, MN<br />176<br />
  232. 232. PARTIAL REBREATHER MASK <br />70%-90% with flow rates of 6-15L/min <br />the client rebreathes 1/3 of the exhaled tidal volume<br />NURSING CARE <br />Make sure that the reservoir does not twist or kink <br />Keep the reservoir bag inflated 2/3 full during inspiration <br />deflation results in decreased O 2 delivered & rebreathingof exhaled air <br />LUDY MAE B. NALZARO, RN, MN<br />177<br />
  233. 233. Partial Rebreather<br />Indications<br />Moderate FiO2<br />Contraindications<br />Apnea<br />Need for High FiO2<br />
  234. 234. Non-Rebreather Mask<br /> 90% <br />most frequently use in deteriorating respiratory status requiring intubation<br />has a one-way valve between the mask & reservoir and two flaps over the exhalation ports <br />entire quantity of O 2 from the reservoir bag <br />the flaps prevent room air from entering thru the exhalation ports <br />LUDY MAE B. NALZARO, RN, MN<br />179<br />
  235. 235. Non-Rebreather Mask<br />Range 80-95% at 15 LPM<br />Indications<br />Delivery of high FiO2<br />Contraindications<br />Apnea<br />Poor respiratory effort<br />
  236. 236. Non-Rebreather Mask<br />F IO2 DELIVERED: 60% to 100% <br />F IO2 at a liter flow that maintains the bag 2/3 full <br />NURSING CARE <br />Remove the mucus or saliva from the mask <br />Assess the client <br />Ensure the valve & flaps are functional <br />Valves should open during expiration & close during inspiration <br />Monitor for kinks & twisting <br />LUDY MAE B. NALZARO, RN, MN<br />181<br />
  237. 237. HIGH-FLOW OXYGEN DELIVERY SYSTEM <br />24% to 100% at 8-15L/min <br />high-flow systems include:<br />Venturi mask<br />aerosol mask<br />face tent<br />tracheostomy collar, and <br />T-piece <br />deliver a consistent and accurate O 2 concentration <br />LUDY MAE B. NALZARO, RN, MN<br />182<br />
  238. 238. VENTURI MASK <br />give accurate O 2 concentration <br />an adapter is located between the bottom of the mask & the O 2 source <br />the adapter contains holes of different sizes that allow only specific amounts of air to mix with the O 2 <br />the adapter allows selection of the amount of O 2 desired <br />LUDY MAE B. NALZARO, RN, MN<br />183<br />
  239. 239. VENTURI MASK <br />F IO 2 DELIVERED: 24% to 55% F IO 2 with flow rates of 4-10L/min <br />NURSING CARE <br />Monitor closely to ensure an accurate flow rate <br />Keep the orifice for the Venturi adapter open uncovered to ensure adequate oxygen delivery <br />Ensure the mask fits snugly & that tubing is free of kinks <br />Monitor mucous membranes <br />LUDY MAE B. NALZARO, RN, MN<br />184<br />
  240. 240. FACE TENT <br />fits over the client’s chin, with top extending halfway across the face <br />the O 2 concentration varies <br />useful for the client who has facial trauma or burns because it is not tight <br />AEROSOL MASK <br />used for the client who has thick secretions <br />TRACHEOSTOMY COLLAR OR T-PIECE <br />the tracheostomy collar can be used to deliver high humidity & the desired O 2 to the client with a tracheostomy <br />a special adapter, called T-piece can be used to deliver any desired FIO 2 to the client with a tracheostomy, laryngectomy or endotracheal tube <br />LUDY MAE B. NALZARO, RN, MN<br />185<br />
  241. 241. Venturi Mask, Nonrebreathing Mask, Partial Rebreathing Mask <br />
  242. 242. FACE TENT, AEROSOL MASK, TRACHEOSTOMY COLLAR & T-PIECE <br />F IO 2 DELIVERED: 24% to 100% F IO 2 with flow rates of at least 10L/min <br />NURSING CARE <br />Change to nasal cannula during meals <br />Empty condensation <br />Monitor water in the canister & change the aerosol water container as needed <br />Keep the exhalation port in the T-piece open <br />Position the T-piece so that it does not pull on the tracheostomy or endotracheal tube <br />it may cause erosion of the skin at the tracheostomy insertion site <br />LUDY MAE B. NALZARO, RN, MN<br />187<br />
  243. 243. T-Piece and Tracheostomy Collar<br />
  244. 244. Oxygen Therapy Safety Precautions<br />リPlace cautionary signs reading “ No SMOKING: Oxygen in Use”<br /><ul><li>client’s door
  245. 245. at the foot or head of the bed
  246. 246. on the oxygen equipment</li></ul>Note:<br />Oxygen is colorless, odorless, tasteless and a dry gas that support combustion, therefore leakage cannot be detected.<br />
  247. 247. Oxygen Therapy Safety Precautions<br />リInstruct the client and visitors about the hazard of smoking with oxygen in use.<br />リMake sure that electric device are in good condition in order to prevent the occurrence of short-circuit sparks.<br />リAvoid materials that generate static electricity, such as woolen blankets and synthetic fibers. Cotton blankets should be used.<br />リAvoid the use of volatile, flammable materials such as oils, greases, alcohol and acetone near clients receiving oxygen.<br />リMake known the location of fire extinguishers<br />LUDY MAE B. NALZARO, RN, MN<br />190<br />
  248. 248. Complications of Oxygen Therapy<br />Oxygen toxicity<br />Reduction of respiratory drive in patients with chronic low oxygen tension<br />Fire<br />
  249. 249. Oxygen Toxicity<br />Oxygen concentrations>50% for extended periods of time (longer than 48 hours) <br />cause an overproduction of free radicals, which can severely damage cells. <br />Symptoms include:<br />substernal discomfort<br />Paresthesias<br />Dyspnea<br />Restlessness<br />Fatigue<br />Malaise<br />Progressive respiratory difficulty<br />Refractory hypoxemia<br />Alveolar atelectasis, and alveolar infiltrates on x-ray.<br />Prevention:<br />Use lowest effective concentrations of oxygen.<br />
  250. 250. ARTIFICIAL AIRWAY<br />Endotracheal Tube <br />Purpose: <br />Tracheal Suctioning <br />Positive Pressure Breathing<br />Nsg. Care: <br />Humidify air <br />Suction PRN <br />NGT <br />Promote Communication <br />Confirm placement <br />Monitor the cuff <br />LUDY MAE B. NALZARO, RN, MN<br />193<br />
  251. 251. TRACHEOSTOMY TUBE <br />PURPOSE : SAME AS ET <br />TYPES : <br />Plastic <br />Metal <br />PARTS: <br />Outer Cannula<br />Inner Canula<br />Obsturator<br />LUDY MAE B. NALZARO, RN, MN<br />194<br />
  252. 252. TRACHEOSTOMY TUBE <br />NSG. CARE: <br />Asepsis <br />No sedative <br />Suction PRN <br />Hemostats <br />NGT, TPN & Oral nutrition <br />Wash the stoma <br />Tub bath <br />Avoid swimming <br />Weaning <br />LUDY MAE B. NALZARO, RN, MN<br />195<br />
  253. 253. Tracheostomy<br />
  254. 254. Tracheostomy<br />Bypasses the upper airway to bypass an obstruction, allow removal of secretions, permit long-term mechanical ventilation, prevent aspirations of secretions, or replace an endotracheal tube<br />Complications include:<br />Bleeding<br />Pneumothorax<br />Aspiration<br />Subcutaneous or mediastinal emphysema<br />Laryngeal nerve damage<br />Posterior tracheal wall penetration.<br />Long-term complications include:<br />airway obstruction, <br />infection,<br />rupture of the in nominate artery, <br />dysphagia,<br />fistula formation, <br />tracheal dilatation, and <br />tracheal ischemia and necrosis.<br />
  255. 255. Tracheostomy Tubes<br />
  256. 256. Nursing Diagnoses: Patients with Endotracheal Intubation or Tracheostomy <br />Communication<br />Anxiety<br />Knowledge deficit<br />Ineffective airway clearance<br />Potential for infection<br />
  257. 257. Care Issues for the Tracheostomy Client<br /><ul><li>Prevention of tissue damage
  258. 258. Cuff pressure can cause mucosal ischemia.
  259. 259. Use minimal leak technique and occlusive technique.
  260. 260. Check cuff pressure often.
  261. 261. Prevent tube friction and movement.
  262. 262. Prevent and treat malnutrition, hemodynamic instability, or hypoxia.</li></li></ul><li>Tracheostomy Care<br /><ul><li>Assessment of the client
  263. 263. Secure tracheostomy tubes in place
  264. 264. Prevent accidental decannulation
  265. 265. Suction
  266. 266. Remove old Dressing
  267. 267. Sterile procedure: H2O, H2O2, brush, q-tip, 2X2s
  268. 268. Turn and remove inner cannula; clean, rinse, replace; turn and click into place
  269. 269. Clean around stoma</li></li></ul><li>Tracheostomy Care Procedure (continued)<br /><ul><li>Replace trach ties– ONE SIDE AT A TIME!
  270. 270. Tracheostomy care is delivered at least q 8 hrs; or more often as needed
  271. 271. Tracheostomy dressings are pre-cut to fit around trach and protect neck and skin from secretions</li></li></ul><li>Air Warming and Humidification<br /><ul><li>The tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter the air.
  272. 272. Air must be humidified.
  273. 273. Maintain proper temperature.
  274. 274. Ensure adequate hydration.</li></li></ul><li>Tracheostomy Suctioning<br /><ul><li>Suctioning maintains a patent airway and promotes gas exchange.
  275. 275. Assess need for suctioning from the client who cannot cough adequately.
  276. 276. Suctioning is done through the nose or the mouth.
  277. 277. Suctioning can cause:
  278. 278. Hypoxia (see causes to follow)
  279. 279. Tissue (mucosal) trauma
  280. 280. Infection
  281. 281. Vagal stimulation and bronchospasm
  282. 282. Cardiac dysrhythmias from hypoxia caused by suctioning</li></li></ul><li>Things to Remember about Suctioning<br /><ul><li>80 – 120 mmHg suction
  283. 283. Less is better
  284. 284. Hyperoxygenate before suctioning
  285. 285. Instill NS only if secretions are dry or to induce cough
  286. 286. Insert tube until resistance, then withdraw 1-2 cm
  287. 287. Must be past end of artificial airway
  288. 288. Less than 10 seconds
  289. 289. Twist catheter as it is withdrawn
  290. 290. Any suctioning causes mucosal damage </li></li></ul><li>Causes of Hypoxia in Clients with Tracheostomy<br /><ul><li>Ineffective oxygenation before, during, and after suctioning
  291. 291. Use of a catheter that is too large for the artificial airway
  292. 292. Prolonged suctioning time
  293. 293. Excessive suction pressure
  294. 294. Too frequent suctioning</li></li></ul><li>Weaning from a Tracheostomy Tube<br /><ul><li>Weaning is a gradual decrease in the tube size and ultimate removal of the tube.
  295. 295. Cuff is deflated as soon as the client can manage secretions and does not need assisted ventilation.
  296. 296. Change from a cuffed to an uncuffed tube.
  297. 297. Size of tube is decreased by capping; use a smaller fenestrated tube.
  298. 298. Tracheostomy button has a potential danger of getting dislodged.</li></li></ul><li>Mechanical Ventilation<br />Positive or negative pressure breathing device to maintain ventilation or oxygenation<br />Indications<br />Negative pressure<br />“Iron lung,” chest cuirass<br />Positive pressure<br />Pressure-cycled<br />Time-cycled<br />Volume-cycled<br />
  299. 299. Ventilators<br />
  300. 300. Suctioning<br />using negative pressure to remove excessive mucous secretion <br />to maintain patent airway<br />to collect specimen for diagnostic testing <br />Procedure: <br />Use appropriate catheter size: F 5-8 for infants, F 8-10 for children and F12-18 for adult. <br />Position client in fowlers( for those with intact gag reflex), side lying (for unconscious) to prevent aspiration <br />Adult pressure: 50-75 mmhg in infants, 100-120 mmhg in adults <br />Preoxygenate client <br />Lubricate catheter tip by immersing in cup of saline solution <br />Insert catheter through during inspiration (when epiglottis is open) without exerting the suction yet (OPEN PORT) until you feel resistance. <br />Retract catheter by 1 cm before exerting suction <br />Exert suction by CLOSE PORT, withdrawing catheter in rotating motion within 5-10 seconds only!!!! <br />Hyper oxygenate for a full minute between subsequent suctioning. Encourage deep breathing! <br />LUDY MAE B. NALZARO, RN, MN<br />210<br />
  301. 301. NURSING PRIORITIES<br />LUDY MAE B. NALZARO, RN, MN<br />211<br />
  302. 302. NURSING PRIORITY <br />GOAL: To promote adequate respiratory function<br />Adequate O2 supply from the environment. <br />Man requires 21% of O2 from the environment in order to survive. <br />Deep breathing and coughing exercises. <br />To promote maximum lung expansion and to loosen mucous secretions. <br />Positioning. <br />The semi-fowler’s or high fowlers position promotes maximum lung expansion. <br />LUDY MAE B. NALZARO, RN, MN<br />212<br />
  303. 303. NURSING PRIORITY <br />Patent airway. <br />To promote gaseous exchange from the person and the environment. <br />Causes of airway obstruction: <br />mucus secretions<br />edema of airways<br />spasms of airways<br />foreign bodies. <br />Airway obstruction is characterized by noisy breathing. <br />Adequate hydration.<br />To maintain moisture of the mucus membrane lining the respiratory tract. This is necessary to prevent irritation and infection. <br />LUDY MAE B. NALZARO, RN, MN<br />213<br />
  304. 304. NURSING PRIORITY <br />Avoid environmental pollutants, alcohol and smoking. <br />These factors inhibit mucociliary function. <br />Chest physiotherapy (CPT)- percussion, vibration, and postural drainage (PVD). These procedures are dependent nursing function. <br />LUDY MAE B. NALZARO, RN, MN<br />214<br />
  305. 305. NURSING PRIORITY <br />Postural drainage <br />is expulsion of secretions various segments by gravity. <br />involves placing the client in different positions so that the area of the lung congestion will be in vertical position with the bronchus. This facilitates drainage by gravity. <br />LUDY MAE B. NALZARO, RN, MN<br />215<br />
  306. 306. NURSING PRIORITY <br />Steam inhalation <br />Purposes: <br />To liquefy mucous secretions <br />To warm and humidify air <br />To relieve edema of airways <br />To soothe irritated airways <br />To administer medications <br />LUDY MAE B. NALZARO, RN, MN<br />216<br />
  307. 307. NURSING PRIORITY <br />Coughing<br />single most effective measure to control respiratory secretions upward. <br />Deep breathing<br />expands the alveoli and mobilizes secretions. <br />Pursed lip breathing<br />Allows a gradual decline of pressure hence preventing lung collapse <br />LUDY MAE B. NALZARO, RN, MN<br />217<br />
  308. 308. ALTERED BREATHING PATTERNS <br />Tachypnea<br />rapid respiratory rate <br />Bradypnea<br />slow respiratory rate <br />Apnea<br />cessation of breathing <br />LUDY MAE B. NALZARO, RN, MN<br />218<br />
  309. 309. Hyperventilation<br />excessive amount of air in the lungs. It results from deep, rapid respirations. <br />Cheyne-stokes<br />marked rhythmic waxing and waning of respirations from very deep or very shallow breathing and temporary apnea. <br />Biot’s<br />shallow breathes interrupted by apnea <br />LUDY MAE B. NALZARO, RN, MN<br />219<br />
  310. 310. LUDY MAE B. NALZARO, RN, MN<br />220<br />
  311. 311. LUDY MAE B. NALZARO, RN, MN<br />221<br />
  312. 312. LUDY MAE B. NALZARO, RN, MN<br />222<br />
  313. 313. ALTERED BREATHING PATTERNS <br />Kussmauls<br />increased rate and depth, seen in metabolic acidosis and renal failure. <br />Apneustic<br />prolonged gasping inspiration followed by a very short, usually inefficient expiration. <br />Dypsnea<br />difficult or labored breathing. <br />Orthopnea<br />inability to breathe except in an upright or sitting position. <br />LUDY MAE B. NALZARO, RN, MN<br />223<br />
  314. 314. CLASSIFICATION OF PULMONARY DISORDERS<br /> Restrictive disorders<br />Pneumonia<br />PTB<br />Laryngeal Carcinoma<br />Lung Cancer<br />Chronic obstructive pulmonary disease<br />Emphysema<br />Chronic Bronchitis<br />Bronchial Asthma<br />Pulmonary vascular disorders<br />Pulmonary Embolism<br />ARD<br />