oxygenation

OXYGENAT
RESPIRATORY SYSTEM
ION
Ma. Tosca Cybil A. Torres,
RN, MAN
MTCAT '09

TERMINOLOGIES
VENTILATION – MOVEMENT OF AIR IN & OUT OF
THE LUNGS

RESPIRATION – EXCHANGE OF GASES :
EXTERNAL & INTERNAL

EXTERNAL – BET. ALVEOLI & PULMONARY
CAPILLARIES
INTERNAL – BET. SYSTEMIC CAPILLARIES

PERFUSION – AVAILABILITY & MOVEMENT OF
CAPILLARY BLOOD FOR EXCHANGE OF GASES
MTCAT '09

Anatomy of the Upper
Respiratory System

 Nose
 Sinuses
 Pharynx
 Larynx
 Trachea
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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
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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

 Reflex bronchoconstriction – protects
upper and lower airways.
 Hering breuer reflex – limit lung inflation.
If lung becomes overstretched, HB reflex
is activated.

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Anatomy of the lower
respiratory system
Lungs

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Conducting Zone
structures- serves as
conduit to and from
the respiratory zone

Respiratory
Zone- only site
of gas exchange

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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
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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

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

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

 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

 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

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

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

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

Lung capacities – 2 or more lung volumes
 Vital capacity (VC) = TV+IRV+ERV (amount of
air than can be exhaled from maximal
inspiration) 4600mL
 Inspiratory capacity = TV+IRV (maximum
amount of inhaled air at the beginning of
normal expiration & distending the lungs to its
maximum) 3500mL
 Functional residual capacity = RV+ERV
(amount of air remaining in lungs after normal
expiration) 2300mL
 Total lung capacity = sum of all lung volumes;
total amount of air that the lungs can hold
average pair of human lungs can hold about 8L
of air, but only a small amount of this capacity is
used during normal breathing
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Factors Affecting Lung
Volume
Larger volumes 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)
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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

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.
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 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.
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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

 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

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.

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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.)
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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

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

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

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?
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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

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

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

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

Relief measures (cough)

 Cough suppressants----should be
used with caution
 Smoking cessation
 Drinking warm beverages
 First generation antihistamines with
decongestants

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Sputum production

 The reaction of the lungs to any
constantly recurring irritant
 May be associated with a nasal
discharge

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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

Relief measures (sputum
production)

 Increase OFI
 Nebulization
 Cessation of smoking
 Adequate oral hygiene
 Back clapping/ chest physiotherapy
 Postural drainage
MTCAT '09

Chest pain

 Chest pain associated with pulmonary
conditions may be sharp, stabbing, and
intermittent, or it may be dull, aching, and
persistent

MTCAT '09

Relief measures (chest
pain)
 Analgesics
 NSAIDS
 Regional anesthetic block

MTCAT '09

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

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

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

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

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

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
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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

Physical
Assessment of the
Respiratory System

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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

Inspection

 Normal chest
 Slight retraction of
intercostal spaces
 2x as wide as deep
 Anterior/posterior
diameter
 1:2

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Inspection

 Barrel chest
 Occurs as a result of
over inflation of the
lungs
 Increase in anterior-
posterior diameter of
the thorax
 2:2

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Inspection
 Funnel chest
 (Pectus Excavatum)
 Depression of the
lower portion of the
sternum
 Complications
 Heart damage
 i Cardiac output

MTCAT '09

Inspection
 Pigeon chest
(Pectus Carinatum)
 Displacement of the
sternum
 Sternum protrudes
outward
 h anterior-posterior
diameter

MTCAT '09

Pigeon Chest

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Inspection

 Kyphoscoliosis
 Characterized by
the elevation of
the scapula and a
corresponding S-
shaped spine
 Limits lung
expansion

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Inspection
 Uniform expansion
of the chest
 Pneumonia
 Pleural effusion
 Pneumothorax
 Bulging intercostal
spaces
 Obstruction
 Emphysema
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Inspection

 Marked retraction of
intercostal spaces
 Blockage
 Shoulder rise
 Accessory muscles
 Posture

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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

patterns
Depth
 Hyperpnea
 h depth

 Hyperventilation
 h depth & rate

 Hypoventilation
 i depth & rate
 Shallow irregular
breathing
MTCAT '09

patterns
Depth
 Kussmaul's
 h rate & depth
 Assoc. with severe acidosis
 Apneustic
 Prolonged gasping followed by a short
breath

MTCAT '09

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

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

Inspection:
 Trachea
 Deviation
 Pleural effusion
 Tension pneumothorax
 Atelectasis
 Color
 LOC
 Emotional state

MTCAT '09

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

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

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

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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

Auscultation
Purpose
 Asses air flow
through bronchial
tree
Procedure
 Diaphragm of
stethoscope
 Superior  inferior
 Compare rt to lf
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Auscultation: Results
Normal
 Vesicular
 Lung field
 Soft and low
 Bronchial
 Trachea & bronchi
 Hollow
 Bronchovesicular
 Mixed
 Between scapulae
 Side of sternum
 1st & 2nd intercostal space
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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
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 COPD

 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

 Pleural friction rub
 D/t inflammation of
pleural space
 Grating, creaking
 I&E
 Best heard
 Anterior, Lower,
lateral area

MTCAT '09

 Stridor
 Crowing
 Partial obstruction of
the larynx or trachea

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 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
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 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

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

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

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
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Comparison of a CXR and
a chest MRI

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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

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

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

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

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

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

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

• 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

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

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

Cont…(Bronchoscopy)
 Inform client that spraying of local anesthesia will
cause coughing at first, which will stop as the
anesthetic begins to work
 Inform client that as the anesthesia wears off, the
throat may be scratchy for several days
 Instruct client on NPO 6-12hrs prior (withhold ASA or
Ibuprofen if client takes it on a regular basis or as
ordered)
 Place client on NPO 1-2hrs after the procedure or
until (+) for gag reflex MTCAT '09

Sputum Culture
 Sputum is obtained for analysis to identify
pathogenic organisms and to determine
whether malignant cells are present.
 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

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

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

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.

Levels of Hypoxemia

MILD PaO2 of 60-80mmHg

MODERATE PaO2 of 40-60mmHg

SEVERE PaO2 of less than 40mmHg

MTCAT '09

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

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

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

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

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

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

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

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

Breathing Exercises

 Facilitates respiratory functioning
by increasing lung expansion
and preventing alveolar collapse

MTCAT '09

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

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

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

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

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

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

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.

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

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

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

Suctioning
 Purpose:
 Remove excess mucus secretions to
maintain patent airway
 Collect sputum or secretions for
diagnostic testing

MTCAT '09

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

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

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

 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.

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

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

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

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

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

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

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

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

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

 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

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

Incentive Spirometry

 Purpose
 Improve pulmonary ventilation and
oxygenation
 Loosen respiratory secretions.
 Prevent or treat atelectasis by expanding
collapsed.

MTCAT '09

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

Agent How provided Clinical Notes

MTCAT '09

oxygenation

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