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NurseReview.Org Respiratory System - Presentation Transcript

1. Medical and Surgical Nursing Review The Respiratory System Nurse Licensure Examination Review
2.
3. Outline Of Review Concepts:
oReview of the relevant respiratory anatomy
oReview of the relevant respiratory physiology
oThe respiratory assessment
oCommon laboratory examinations
4. Outline Of Review Concepts:
o Review of the common respiratory problems and the nursing management
o Review of common respiratory diseases
 Upper respiratory conditions
 Lower respiratory conditions
5. Respiratory Anatomy & Physiology
o The respiratory system consists of two main parts - the upper and the lower tracts
o The UPPER respiratory system consists of:
o 1. nose
o 2. mouth
o 3. pharynx
o 4. larynx
o The LOWER respiratory system consists of:
o 1. Trachea
o 2. Bronchus
o 3. Bronchioles
o 4. Respiratory unit
8. Upper Respiratory Tract
9. The Nose
o This is the first part of the upper respiratory system that contains nasal bones and cartilages
o There are numerous hairs called vibrissae
o There are numerous superficial blood vessels in the nasal mucosa
10. The Nose
o The functions of the nose are:
o 1. To filter the air
o 2. To humidify the air
o 3. To aid in phonation
o 4. Olfaction
11. The Pharynx
o The pharynx is a musculo - membranous tube that is composed of three parts
o 1. Nasopharynx
o 2. Oropharynx
o 3. Laryngopharynx
12. The Pharynx
o The pharynx functions :
o 1. As passageway for both air and foods (in the oropharynx)
o 2. To protect the lower airway
13. The Larynx
o Also called the voice box
o Made of cartilage and membranes and connects the pharynx to the trachea
14. The Larynx
o Functions of the larynx:
o 1. Vocalization
o 2. Keeps the patency of the upper airway
o 3. Protects the lower airway
15. The Paranasal sinuses

o These are four paired bony cavities that are lined with nasal mucosa and ciliated pseudostratified
columnar epithelium
o Named after their location - frontal, ethmoidal, sphenoidal and maxillary
16. The Paranasal sinuses
o The function of the sinuses:
o Resonating chambers in speech
17. The Lower Respiratory System
o The lower respiratory system consists of
o 1. Trachea
o 2. Main bronchus
o 3. Bronchial tree
o 4. Lungs- 3R/ 2L
o to the terminal bronchioles is called the conducting airway◊The trachea
o to the alveoli is called the respiratory◊The respiratory bronchioles acinus
18. The Trachea
o A cartilaginous tube measures 10-12 centimeters
o Composed of about 20 C-shaped cartilages, incomplete posteriorly
19. The Trachea
o The function of the trachea is to conduct air towards the lungs
o The mucosa is lined up with mucus and cilia to trap particles and carry them towards the upper airway
20. The Bronchus
o The right and left primary bronchi begin at the carina
o The function is for air passage
21. The Primary Bronchus
o RIGHT BRONCHUS
o Wider
o Shorter
o More Vertical
o LEFT BRONCHUS
o Narrower
o Longer
o More horizontal
22. The Bronchioles
o The primary bronchus further divides into secondary, then tertiary then into bronchioles
o The terminal bronchiole is the last part of the conducting airway
23. The Respiratory Acinus
o The respiratory acinus is the chief respiratory unit
o It consists of
o 1. Respiratory bronchiole
o 2. Alveolar duct
o 3. alveolar sac
o The respiratory acinus is the chief respiratory unit
o The function of the respiratory acinus is gas exchange through the respiratory membrane
o The respiratory membrane is composed of two epithelial cells
o 1.The type 1 pneumocyte - most abundant, thin and flat. This is where gas exchange occurs
o 2. The type 2 pneumocyte - secretes the lung surfactant
o A type III pneomocyte is just the macrophage that ingests foreign material and acts as an important
defense mechanism
27. Accessory Structures
o The PLEURA
o Epithelial serous membrane lining the lung parenchyma
o Composed of two parts- the visceral and parietal pleurae
o The space in between is the pleural space containing a minute amount of fluid for lubrication
o The Thoracic cavity
o The chest wall composed of the sternum and the rib cage
o The cavity is separated by the diaphragm, the most important respiratory muscle

o The Mediastinum
o The space between the lungs, which includes the heart and pericardium, the aorta and the vena
cavae.
30. GENERAL FUNCTIONS OF THE Respiratory System
o Gas exchange through ventilation, external respiration and cellular respiration
o Oxygen and carbon dioxide transport
31. The Assessment
o HISTORY
o Reason for seeking care
o Present illness
o Previous illness
o Family history
o Social history
32. The Assessment
o PHYSICAL EXAMINATION
o Skin- cyanosis, pallor
o Nail clubbing
o Cough and sputum production
o Inspect - palpate - percuss - auscultate the thorax
33. The Assessment
o LABORATORY EXAMINATION
o 1. ABG analysis
o 2. Sputum analysis
o 3. Direct visualization - bronchoscopy
o 4. Indirect visualization - CXR, CT and MRI
o 5. Pulmonary function test
34. ABG Analysis
o This test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an
arterial sample
35. ABG Analysis
o Pre-test: choose site carefully, perform the Allen’s test, secure equipments- syringe, needle, container
with ice
o Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial)
o Post-test: Apply firm pressure for 5 minutes, label specimen correctly, place in the container with ice
36. ABG Analysis
o ABG normal values
o PaO2 80-100 mmHg
o PaCO2 35-45 mmHg
o pH 7.35- 7.45
o HCO3 22- 26 mEq/L
o O2 Sat 95-99%
37. Sputum Analysis
o This test analyzes the sample of sputum to diagnose respiratory diseases, identify organism, and
identify abnormal cells
38. Sputum Analysis
o Pre-test: Encourage to increase fluid intake
o Intra-test: rinse mouth with WATER only, instruct the patient to take 3 deep breaths and force a deep
cough, steam nebulization, collect early morning sputum
o Post-test: provide oral hygiene, label specimen correctly
39. Pulse Oximetry
o Non-invasive method of continuously monitoring the oxygen saturation of hemoglobin
o A sensor or probe is attached to the earlobe, forehead, fingertip or the bridge of the nose
40. Bronchoscopy
o A direct inspection of the trachea and bronchi through a flexible fiber-optic or a rigid bronchoscope
o Done to determine location of pathologic lesions, to remove foreign objects, to collect tissue specimen
and remove secretions/aspirated materials
41. Bronchoscopy
o Pre-test: Consent, NPO x 6h, teaching
o Intra-test: position supine or sitting upright in a chair, administer sedative, gag reflex will be abolished,
remove dentures

o Post-test: NPO until gag reflex returns, position SEMI-fowler’s with head turned to sides, hoarseness
is temporary, CXR after the procedure, keep tracheostomy set and suction x 24 hours
42. Thoracentesis
o Pleural fluid aspiration for obtaining a specimen of pleural fluid for analysis, relief of lung compression
and biopsy specimen collection
43. Thoracentesis
o Pre-test: Consent
o Intra-test: position the patient sitting with arms on a table or side-lying fowler’s, instruct not to cough,
breathe deeply or move
o Post-test: position unaffected side to allow lung expansion of the affected side, CXR obtained,
maintain pressure dressing and monitor respiratory status
44. Pulmonary Function Tests
o Volume and capacity tests aid diagnosis in patient with suspected pulmonary dysfunction
o Evaluates ventilatory function
o Determines whether obstructive or restrictive disease
o Can be utilized as screening test
45. Pulmonary Function Test
o Lung Volumes
o Tidal volume
o Inspiratory reserve volume
o Expiratory reeve volume
o Residual volume
o Lung capacities
o Inspiratory capacity
o Vital capacity
o Functional residual capacity
o Total lung capacity
o Pre-test: Teaching, no smoking for 3 days, only light meal 4 hours before the test
o Intra-test: position sitting, bronchodilator, nose-clip and mouthpiece, fatigue and dyspnea during the
test
o Post-test: adequate rest periods, loosen tight clothing
48. Common Respiratory Problems and the common interventions
49. Dyspnea
o Breathing difficulty
o Associated with many conditions- CHF, MG, GBS, Muscular dystrophy, obstruction, etc…
50. Dyspnea
o General nursing interventions:
o 1. Fowler’s position to promote maximum lung expansion and promote comfort. An alternative position
is the ORTHOPNEIC position
o 2. O2 usually via nasal cannula
o 3. Provide comfort and distractions
51. Cough and sputum production
o Cough is a protective reflex
o Sputum production has many stimuli
o bacterial pneumonia◊Thick, yellow, green or rust-colored
o pulmonary edema◊Profuse, Pink, frothy
o Lung tumor◊Scant, pink-tinged, mucoid
52. Cough and sputum production
o General nursing Intervention
o 1. Provide adequate hydration
o 2. Administer aerosolized solutions
o 3. advise smoking cessation
o 4. oral hygiene
53. Cyanosis
o Bluish discoloration of the skin
o A LATE indicator of hypoxia
o Appears when the unoxygenated hemoglobin is more than 5 grams/dL
o observe color on the undersurface of tongue and lips◊Central cyanosis

o observe the nail beds, earlobes◊Peripheral cyanosis
54. Cyanosis
o Interventions:
 Check for airway patency
 Oxygen therapy
 Positioning
 Suctioning
 Chest physiotherapy
 Check for gas poisoning
 Measures to increased hemoglobin
55. Hemoptysis
o Expectoration of blood from the respiratory tract
o Common causes: Pulmo infection, Lung CA, Bronchiectasis, Pulmo emboli
o acidic pH, coffee ground material◊Bleeding from stomach
56. Hemoptysis
o Interventions:
o Keep patent airway
o Determine the cause
o Suction and oxygen therapy
o Administer Fibrin stabilizers like aminocaproic acid and tranexamic acid
57. Epistaxis
o Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane
o Most common site- anterior septum
o Causes
o 1. trauma
o 2. infection
o 3. Hypertension
o 4. blood dyscrasias , nasal tumor, cardio diseases
58. Epistaxis
o Nursing Interventions
o prevents swallowing◊1. Position patient: Upright, leaning forward, tilted and aspiration
o 2. Apply direct pressure. Pinch nose against the middle septum x 5-10 minutes
o 3. If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foams
o 4. Assist in electrocautery and nasal packing for posterior bleeding
59. CONDITIONS OF THE UPPER AIRWAY
o Upper airway infections
o 1. Rhinitis- allergic, non-allergic and infectious
o 2. Sinusitis- acute and chronic
o 3. Pharyngitis- acute and chronic
o 1. Rhinitis- Assessment findings
o Rhinorrhea
o Nasal congestion
o Nasal itchiness
o Sneezing
o Headache
o 2. sinusitis- Assessment findings
o Facial pain
o Tenderness over the paranasal sinuses
o Purulent nasal discharges
o Ear pain, headache, dental pain
o Decreased sense of smell
o 3. Pharyngitis- Assessment findings

o Fiery-red pharyngeal membrane
o White-purple flecked exudates
o Enlarged and tender cervical lymph nodes
o Fever malaise ,sore throat
o Difficulty swallowing
o Cough may be absent
o Upper airway infections- Laboratory tests
o 1. CBC
o 2. Culture
o Upper airway infections: Nursing Interventions
o 1. Maintain Patent Airway
o Increase fluid intake to loosen secretions
o Utilize room vaporizers or steam inhalation
o Administer medications to relieve nasal congestion
o 2. Promote comfort
o Administer prescribed analgesics
o Administer topical analgesics
o Warm gargles for the relief of sore throat
o Provide oral hygiene
o 3. Promote communication
o Instruct patient to refrain from speaking as much as possible
o Provide writing materials
o 4. Administer prescribed antibiotics
o Monitor for possible complications like meningitis, otitis media, abscess formation
o 5. Assist in surgical intervention
o Upper airway infection: Tonsillitis
o Infection and inflammation of the tonsils
o Most common organism- Group A- beta hemolytic streptococcus (GABS)
o ASSESSMENT FINDINGS
o Sore throat and mouth breathing
o Fever
o Difficulty swallowing
o Enlarged, reddish tonsils
o Foul-smelling breath
o Laboratory test
o 1. CBC
o 2. throat culture
o MEDICAL management
o 1. Antibiotics- penicillin
o 2. Tonsillectomy for chronic cases and abscess formation
o NURSING INTERVENTION for tonsillectomy
o 1. Pre-operative care

o Consent
o Routine pre-op surgical care
o 2. POST-operative care
o Position: Most comfortable is PRONE, with head turned to side
o Maintain oral airway, until gag reflex returns
o Apply ICE collar to the neck to reduce edema
o Advise patient to refrain from talking and coughing
o Ice chips are given when there is no bleeding and gag reflex returns
o Notify physician if
o a. Patient swallows frequently
o b. vomiting of large amount of bright red or dark blood
o c. PR increased, restless and Temp is increased
76. Laryngeal Cancer
o A malignant tumor of the larynx
o More frequent in men
o 50-70 years old
o RISK FACTORS
o 1. Smoking
o 2. Alcohol
o 3. Exposure to chemicals
o 4. Straining of voice
o 5. chronic laryngitis
o 6. Deficiency of Riboflavin
o 7. family history
o Growth can be anywhere in the larynx
o 1. Supraglottic- above the vocal cords
o 2. glottic- vocal cord area
o 3. infraglottic- below the vocal cords
o Most tumors are found in the glottic area
o Hoarseness of more than TWO weeks duration
o Cough and sore throat
o Burning and pain in the throat especially after consuming HOT liquids and citrus foods
o Neck lump
o Dysphagia, dyspnea, foul breath, CLAD
o LABORATORY FINDINGS
o 1. Indirect laryngoscopy
o 2. direct laryngoscopy
o 3. Biopsy
o 4. CT and MRI
o Most commonly- squamos carcinoma
o MEDICAL MANAGEMENT
o Radiation therapy

o Chemotherapy
o Surgery
 Partial laryngectomy
 Supraglottic laryngectomy
 Hemilaryngectomy
 Total laryngectomy
o NURSING MANAGEMENT: PRE-operative
o 1. Provide the patient pre-operative teachings
o Clarify misconceptions
o Tell that the natural voice will be lost
o Teach communication alternatives
o Collaborate with other team members
o NURSING MANAGEMENT
o 2. reduce patient ANXIETY
o Provide opportunities for patient and family members to ask questions
o Referrals to previous patients with laryngeal cancers and cancer groups
o NURSING MANAGEMENT: POST-op
o 3. Maintain PATENT Airway
o Position patient: Semi or High Fowler’s
o Suction secretions
o Encourage to deep breath, turn and cough
o 4. Administer care of the laryngectomy tube
o Suction as needed
o Cleanse the stoma with saline
o Administer humidified oxygen
o Laryngectomy tube is usually removed within 3-6 weeks after surgery
o 5. Promote alternative communication methods
o Call bell or hand bell
o Magic Slate
o Hand signals
o Collaborate with speech therapist
o 6. Promote adequate Nutrition
o NPO after operation
o No foods or drinks per orem for 10 days
o IVF, TPN are alternative nutrition routes
o Start oral feedings with thick liquids, avoid sweet foods
o 7. Promote positive body image and self-esteem
o Encourage verbalization of feelings
o Allow independence in self-care
o 8. Monitor for COMPLICATIONS
o Respiratory Distress
 Suction
 Coughing and deep breathing
 Humidified oxygen
 Alert the surgeon

o 8. Monitor for Complications
o Hemorrhage
 Monitor for bleeding
 Monitor vital signs
 Apply direct pressure over the bleeding artery
 Summon assistance and alert the surgeon
o 8. Monitor for COMPLICATIONS
o Wound infection and breakdown
o Monitor for increased temperature, purulent drainage and increased redness/tenderness
o Administer antibiotics
o Clean and change dressing OD
o NURSING MANAGEMENT: HOME CARE
o Humidification system at home is needed
o AVOID swimming
o Cover the stoma with hands or plastic bib over the opening
o Advise beauty salons to avoid hair sprays, powders and loose hair near the opening
o Oral hygiene frequently
92. Acute Respiratory Failure
o Sudden and life-threatening deterioration of the gas-exchange function of the lungs
o Occurs when the lungs no longer meet the body’s metabolic needs
o Defined clinically as:
o 1. PaO2 of less than 50 mmHg
o 2. PaCO2 of greater than 5o mmHg
o 3. Arterial pH of less than 7.35
o CAUSES
o CNS depression- head trauma, sedatives
o CVS diseases- MI, CHF, pulmonary emboli
o Airway irritants- smoke, fumes
o Endocrine and metabolic disorders- myxedema, metabolic alkalosis
o Thoracic abnormalities- chest trauma, pneumothorax
o PATHOPHYSIOLOGY
o Decreased Respiratory Drive
o impair the normal response of◊Brain injury, sedatives, metabolic disorders the brain to normal
respiratory stimulation
o PATHOPHYSIOLOGY
o Dysfunction of the chest wall
o disrupt the impulse◊Dystrophy, MS disorders, peripheral nerve disorders abnormal
ventilation◊transmission from the nerve to the diaphragm
o PATHOPHYSIOLOGY
o Dysfunction of the Lung Parenchyma
o interfere◊Pleural effusion, hemothorax, pneumothorax, obstruction prevent lung
expansion◊ventilation
o Restlessness
o dyspnea
o Cyanosis
o Altered respiration
o Altered mentation
o Tachycardia

o Cardiac arrhythmias
o Respiratory arrest
o DIAGNOSTIC FINDINGS
o Pulmonary function test- pH below 7.35
o CXR- pulmonary infiltrates
o ECG- arrhythmias
100.Acute Respiratory Failure
o MEDICAL TREATMENT
o Intubation
o Mechanical ventilation
o Antibiotics
o Steroids
o Bronchodilators
101.Acute Respiratory Failure
o NURSING INTERVENTIONS
o 1. Maintain patent airway
o 2. Administer O2 to maintain Pa02 at more than 50 mmHg
o 3. Suction airways as required
o 4. Monitor serum electrolyte levels
o 5. Administer care of patient on mechanical ventilation
102.COPD
o These are group of disorders associated with recurrent or persistent obstruction of air passage and
airflow, usually irreversible.
103.COPD
o The most common cause of COPD is cigarette smoking. Asthma, Chronic bronchitis, Emphysema and
Bronchiectasis are the common disorders.
104.COPD
o The general pathophysiology:
o In COPD there is airflow limitation that is both progressive and associated with abnormal inflammatory
response of the lungs to stimuli, usually smoke, particles and dust
105.ASTHMA
o The acute episode of airway obstruction is characterized by airway hyperactivity to various stimuli that
results in recurrent wheezing brought about by edema and bronchospasm
106.Asthma Pathophysiology
o Immunologic/allergic reaction results in histamine release, which produces three main airway
responses
o a. Edema of mucous membranes
o b. Spasm of the smooth muscle of bronchi and bronchioles
o c. Accumulation of tenacious secretions
107.Asthma Assessment Findings
o Assessment findings
o 1. Family history of allergies
o 2. Client history of eczema
o 3. Pulmonary signs and symptoms- Respiratory distress: slow onset of shortness of breath, expiratory
wheeze , prolonged expiratory phase, air trapping (barrel chest if chronic), use of accessory muscles,
irritability (from hypoxia), diaphoresis, cough, anxiety, weak pulse, diaphoresis and change in
sensorium if severe attack
o 4. Use of accessory muscles of respiration, inspiratory retractions, prolonged I:E ratio
o 5. Cardiovascular symptoms: tachycardia, ECG changes, hypertension, decreased cardiac
contractility, pulsus paradoxus
o 6. CNS manifestations: anxiety, restlessness, fear and disorientation
110.Emphysema
o There is progressive and irreversible alveolocapillary destruction with abnormal alveolar enlargement
causing alveolar wall destruction. The result is INCREASED lung compliance, DECREASED oxygen
diffusion and INCREASED airway resistance!
111.Emphysema
o These changes cause a state of carbon dioxide retention, hypoxia, and respiratory acidosis.

112.Emphysema
o Cigarette smoking
o Heredity, Bronchial asthma
o Aging process
o
o Disequilibrium between
o ELASTASE & ANTIELASTASE (alpha-1-antitrypsin)
o Destruction of distal airways and alveoli
o Overdistention of ALVEOLI
o Hyper-inflated and pale lungs
o Air traping, decreased gas exchange and Retention of CO2
o
o Hypoxia Respiratory acidosis
113.Emphysema Assessment
o 1. Anorexia, fatigue, weight loss
o 2. Feeling of breathlessness, cough, sputum production, flaring of the nostrils, use of accessory
muscles of respiration, increased rate and depth of breathing, dyspnea
114.Emphysema Assessment
o 3. Decreased respiratory excursion, resonance to hyper-resonance, decreased breath sounds with
prolonged expiration, normal or decreased fremitus
o 4. Diagnostic tests: pCO2 elevated or normal; PO2 normal or slightly decreased
115.Chronic bronchitis
o Chronic inflammation of the bronchial air passageway characterized by the presence of cough and
sputum production for at least 3 months in each 2 consecutive years.
o Excessive production of mucus in the bronchi with accompanying persistent cough.
116.Chronic Bronchitis pathophysiology
o Characteristic changes include hypertrophy/ hyperplasia of the mucus-secreting glands in the bronchi,
decreased ciliary activity, chronic inflammation, and narrowing of the small airways.
117.Chronic Bronchitis Assessment
o I. Productive (copious) cough, dyspnea on exertion, use of accessory muscles of respiration, scattered
rales and rhonchi
o 2. Feeling of epigastric fullness, cyanosis, distended neck veins, ankle edema
o 3. Diagnostic tests: increased pCO2 decreased PO2
118.Bronchiectasis
o Permanent abnormal dilation of the bronchi with destruction of muscular and elastic structure of the
bronchial wall
119.Bronchiectasis
o Caused by bacterial infection; recurrent lower respiratory tract infections; congenital defects (altered
bronchial structures); lung tumors
120.Bronchiectasis
o 1. Chronic cough with production of mucopurulent sputum, hemoptysis, exertional dyspnea, wheezing
o 2. Anorexia, fatigue, weight loss
o 3. Diagnostic tests
 a. Bronchoscopy reveals sources and sites of secretions
 b. Possible elevation of WBC
121.COPD Management
o Independent and Collaborative Management
o 1. Rest- To reduce oxygen demands of tissues
o 2. Increase fluid intake -To liquefy mucus secretions
o 3. Good oral care- To remove sputum and prevent infection
122.COPD Management
o 4. Diet:
o High caloric diet provides source of energy
o High protein diet helps maintain integrity of alveolar walls
o Moderate fats
o Low carbohydrate diet limits carbon dioxide production (natural end product). The client has difficulty
exhaling carbon dioxide.
123.COPD Management
o 5. O2 therapy 1 to 3 lpm ( 2 lpm is safest )

o Do not give high concentration of oxygen. The drive for breathing may be depressed.
124.COPD Management
o 6 . Avoid cigarette smoking, alcohol, and environmental pollutants-These inhibit mucociliary function.
o 7. CPT –percussion, vibration, postural drainage
125.COPD Management
o 8. Bronchial hygiene measures
o Steam inhalation
o Aerosol inhalation
o Medimist inhalation
126.COPD Management
o Pharmacotherapy
o 1. Expectorants (guaiafenessin)/ mucolytic (mucomyst/mucosolvan)
o 2. Antitussives
o Dextrometorphan
o Codeine
o Observe for drowsiness
o Avoid activities that involve mental alertness, e.g driving, operating electrical machines
o Cause decrease peristalsis thereby constipation
127.COPD Management
o Pharmacotherapy
o 3. Bronchodilators
o Aminophylline (Theophylline)
o Ventolin (Salbutamol)
o Bricanyl (Terbutaline)
o Alupent (Metaproterenol)
 Observe for tachycardia
128.COPD Management
o Pharmacotherapy
o 4. Antihistamine
o Benadryl (Diphenhydramine)
o Observe for drowsiness
o 5. Steroids
o Anti-inflammatory effect
o 6. Antimicrobials
129.Flail Chest
o Complication of chest trauma occurring when 3 or more adjacent ribs are fractured at two or more
sites, resulting in free-floating rib segments.
130.Flail Chest
o Chest wall is no longer able to provide the bony structure necessary to maintain adequate ventilation;
consequently
o the flail portion and underlying tissue move paradoxically (in opposition) to the rest of the chest cage
and lungs.
131.Flail Chest
o The flail portion is sucked in on inspiration and bulges out on expiration.
o Result is hypoxia, hypercarbia, and increased retained secretions.
o Caused by trauma (sternal rib fracture with possible costochondral separations).
132.Flail Chest
o PATHOPHYSIOLOGY
o During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in
a “paradoxical” manner
o The chest is pulled INWARD during inspiration, reducing the amount of air that can be drawn into the
lungs
o The chest bulges OUTWARD during expiration because the intrathoracic pressure exceeds
atmospheric pressure. The patient has impaired exhalation
133.Flail Chest
o This paradoxical action will lead to:
 Increased dead space
 Reduced alveolar ventilation

 Decreased lung compliance
 Hypoxemia and respiratory acidosis
 Hypotension, inadequate tissue perfusion can also follow
134.Flail Chest
o 1. Severe dyspnea; rapid, shallow, grunty breathing; paradoxical chest motion. The chest will move
INWARDS on inhalation and OUTWARDS on exhalation.
o 2. Cyanosis, possible neck vein distension, tachycardia, hypotension
 a. PO2 decreased
 b. pCO2 elevated
 c. pH decreased
135.Flail Chest
o Nursing interventions
o 1. Maintain an open airway: suction secretions, blood from nose, throat, mouth, and via endotracheal
tube; note changes in amount, color, and characteristics.
o 2. Monitor mechanical ventilation
o 3. Encourage turning, coughing, and deep breathing.
o 4. Monitor for signs of shock: HYPOTENSION, TACHYCARDIA
136.Flail Chest
o Medical management: SUPPORTIVE
o 1. Internal stabilization with a volume-cycled ventilator
o 2. Drug therapy (narcotics, sedatives)
137.Pneumothorax
o Partial or complete collapse of the lung due to an accumulation of air or fluid in the pleural space
138.Pneumothorax
o Types
o a . Spontaneous pneumothorax : the most common type of closed pneumothorax; air accumulates
within the pleural space without an obvious cause. Rupture of a small bleb on the visceral pleura most
frequently produces this type of pneumothorax.
139.Pneumothorax
o Types
o b. Open pneumothorax : air enters the pleural space through an opening in the chest wall; usually
caused by stabbing or gunshot wound.
140.Pneumothorax
o Types
o c. Tension pneumothorax : air enters the pleural space with each inspiration but cannot escape;
causes increased intrathoracic pressure and shifting of the mediastinal contents to the unaffected side
(mediastinal shift ).
141.Pneumothorax
o 1. Sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side ,
tracheal shift to the opposite side (tension pneumothorax accompanied by mediastinal shift)
o 2. Weak, rapid pulse; anxiety; diaphoresis
142.Pneumothorax
 a. Chest x-ray reveals area and degree of pneumothorax
 b. pCO2 elevated
 c. pH decreased
143.Pneumothorax
o 1. Provide nursing care for the client with an endotracheal tube: suction secretions, vomitus, blood
from nose, mouth, throat, or via endotracheal tube; monitor mechanical ventilation.
144.Pneumothorax
o 2. Restore/promote adequate respiratory function.
o a. Assist with thoracentesis and provide appropriate nursing care.
o b. Assist with insertion of a chest tube to water- seal drainage and provide appropriate nursing care.
o c. Continuously evaluate respiratory patterns and report any changes.
145.Pneumothorax

o 3. Provide relief/control of pain.
o a. Administer narcotics/analgesics/sedatives as ordered and monitor effects.
o b. Position client in high-Fowler’s position.
146.Atelectasis
o Collapse of part or all of a lung due to bronchial obstruction
o May be caused by
 intrabronchial obstruction
 tumors, bronchospasm
 foreign bodies
 extrabronchial compression (tumors, enlarged lymph nodes); or
 endobronchial disease (bronchogenic carcinoma, inflammatory structures)
147.Atelectasis
o 1. Signs and symptoms may be absent depending upon degree of collapse and rapidity with which
bronchial obstruction occurs
o 2. Dyspnea, decreased breath sounds on affected side, decreased respiratory excursion, dullness to
flatness upon percussion over affected area
148.Atelectasis
o 3. Cyanosis, tachycardia, tachypnea, elevated temperature, weakness, pain over affected area
149.Atelectasis
o a. Bronchoscopy: may or may not reveal an obstruction
o b. Chest x-ray shows diminished size of affected lung and lack of radiance over atelectatic area
o c. pO2 decreased
150.Pleural Effusion
o Defined broadly as a collection of fluid in the pleural space
o A symptom, not a disease; may be produced by numerous conditions
o General Classification
 Transudative effusion: accumulation of protein-poor, cell-poor fluid
 Exudative effusion: accumulation of protein rich fluid
o 1. Dyspnea, dullness over affected area upon percussion, absent or decreased breath sounds over
affected area, pleural pain, dry cough, pleural friction rub
o 2. Pallor, fatigue, fever, and night sweats (with empyema)
o a. Chest x-ray positive if greater than 250 cc pleural fluid
o b. Pleural biopsy may reveal bronchogenic carcinoma
o c. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or tuberculosis; positive
for specific organism in empyema.
o Nursing interventions: In general:
o 1. Assist with repeated thoracentesis.
o 2. Administer narcotics/sedatives as ordered to decrease pain.
o 3. Assist with instillation of medication into pleural space (reposition client every 15 minutes to
distribute the drug within the pleurae).
o 4. Place client in high-Fowler’s position to promote ventilation.
o Medical management
o 1. Identification and treatment of the Underlying cause
o 2. Thoracentesis
o 3. Drug therapy
 a. Antibiotics: either systemic or inserted directly into pleural space

 b. Fibrinolytic enzymes: trypsin, streptokinase-. streptodornase to decrease thickness of pus and
dissolve fibrin clots
o 4. Closed chest drainage
o 5. Surgery: open drainage
156.Pneumonia
o An inflammation of the alveolar spaces of the lung, resulting in consolidation of lung tissue as the
alveoli fill with exudates
o The various types of pneumonias are classified according to the offending organism.
o Pneumonia can also be classified as COMMUNITY Acquired Pneumonia (CAP) and Hospital acquired
pneumonia (HAP)
157.Pneumonia
o PATHOPHYSIOLOGIC FINDINGS ARE:
o HYPERTROPHY OF MUCOUS MEMBRANE
 Increased sputum production
 Wheezing
 Dyspnea
 Cough
 Rales
 Ronchi
158.Pneumonia
o INCREASED CAPILLARY PERMEABILITY
 Increased Fluid Exudation
 Consolidation-tissue that solidifies as a result of collapsed alveoli
 Hypoxemia
159.Pneumonia
o INFLAMMATION OF THE PLEURA
o Chest pain
o Pleural effusion
o Dullness
o Decreased Breath sounds
o Increased tactile fremitus
160.Pneumonia
o HYPOVENTILATION
o Decreased Chest expansion
o Respiratory acidosis
o Depressed PROTECTIVE MECHANISM
o Increased WBC (leukocytosis)
o Increased RR and Fever
161.Pneumonia
o Cough with greenish to rust-colored sputum production
o rapid, shallow respirations with an expiratory grunt
o nasal flaring; intercostal rib retraction; use of accessory muscles of respiration
o rales or crackles (early) progressing to coarse (later).
o Tactile fremitus is INCREASED!
162.Pneumonia
o Fever, chills, chest pain, weakness, generalized malaise
o Tachycardia, cyanosis, profuse perspiration, abdominal distension
o Rapid shallow breathing
163.Pneumonia
o Diagnostic tests
o a. Chest x-ray shows consolidation over affected areas
o b. WBC increased
o c. pO2 decreased
o d. Sputum specimen- culture reveal particular causative organism

164.Pneumonia
o 1. Facilitate adequate ventilation.
o a. Administer oxygen as needed and assess its effectiveness.
o b. Place client in Fowler’s position .
o c. Turn and reposition frequently clients who are immobilized/obtunded.
o d. Administer analgesics as ordered to relieve pain associated with breathing
o e. Auscultate breath sounds every 2—4 hours.
o f. Monitor ABGs.
165.Pneumonia
o GENERAL Nursing interventions
o 2. Facilitate removal of secretions
o general hydration
o deep breathing and coughing
o Suctioning
o Expectorants
o aerosol treatments via nebulizer, humidification of inhaled air
o chest physical therapy
166.Pneumonia
o 3. Observe color, characteristics of sputum and report any changes; encourage client to perform good
oral hygiene after expectoration.
167.Pneumonia
o 4. Provide adequate rest and relief/control of pain.
o a. Provide bed rest with limited physical activity.
o b. Limit visits and minimize conversations.
o c. Plan for uninterrupted rest periods.
o d. Institute nursing care in blocks to ensure periods of rest.
o e. Maintain pleasant and restful environment
168.Pneumonia
o 5. Administer antibiotics as ordered. Monitor effects and possible toxicity.
o 6. Prevent transmission (respiratory isolation may be required for clients with staphylococcal
pneumonia).
o 7. Control fever and chills: monitor temperature and administer
 antipyretics as ordered, maintain increased fluid intake, provide frequent clothing and linen
changes.
169.Pneumonia
o 8. Provide client teaching and discharge planning concerning prevention of recurrence.
 a. Medication regimen/antibiotic therapy
 b. Need for adequate rest,
 c. Need to continue deep breathing and coughing
170.Pneumonia
o 8. Provide client teaching and discharge planning concerning prevention of recurrence.
 d. Availability of vaccines
 e. Techniques that prevent transmission (use of tissues when coughing, adequate disposal of
secretions)
 f. Avoidance of persons with known respiratory infections
 g. Need to report signs and symptoms of respiratory infection
171.Lung Cancer
o Primary pulmonary tumors arise from the bronchial epithelium and are therefore referred to as
bronchogenic carcinomas.
o FACTORS: Possibly caused by inhaled carcinogens (primarily cigarette smoke but also asbestos,
nickel, iron oxides, air silicone pollution; preexisting pulmonary disorders PTB, COPD)
172.Lung Cancer
o Persistent cough (may be productive or blood tinged)
o chest pain

o dyspnea
o unilateral wheezing, friction rub, possible unilateral paralysis of the diaphragm
o Fatigue, anorexia, nausea, vomiting, pallor
173.Lung Cancer
o Diagnostic tests.
o a. Chest x-ray may show presence of tumor or evidence of metastasis to surrounding structures
o b. Sputum for cytology reveals malignant cells
o c. Bronchoscopy: biopsy reveals malignancy
o d. Thoracentesis: pleural fluid contains malignant cells
o e. Biopsy of lymph nodes may reveal metastasis
174.Lung Cancer
o 1. Provide support and guidance to client as needed.
o 2. Provide relief/control of pain.
o 3. Administer medications as ordered and monitor effects/side effects.
o 4. Control nausea: administer medications as ordered, provide good oral hygiene, provide small and
more frequent feedings.
175.Lung Cancer
o 5. Provide nursing care for a client with a thoracotomy.
o 6. Provide client teaching and discharge planning concerning
 a. Disease process, diagnostic and therapeutic interventions
 b. Side effects of radiation and chemotherapy
 c. Realistic information about prognosis
176.Lung Cancer
o Medical management
o 1. Radiation therapy
o 2. Chemotherapy: usually includes cyclophosphamide, methotrexate, vincristine, doxorubicin, and
procarbazine; concurrently in some combination
o 3. Surgery: when entire tumor can be removed
177.Lung Cancer
o Quick Notes on Bronchogenic Cancer
o Predisposing factors
o Cigarette smoking
o Asbestosis
o Emphysema
o Smoke from burnt wood
o Types
o Squamous cell Ca- with good prognosis
o Adenocarcinoma- with good prognosis
o Oat cell Ca- with good prognosis
o Undifferentiated Ca- with poor prognosis
178.Lung Cancer
o Patent airway
o O2 / Aerosol therapy
o Deep breathing exercises
o Relief of pain
o Protection from infection
o Adequate nutrition
o Chest tube management
179.Lung Cancer
o Surgery
o Pneumonectomy= Removal of a lung (either left or right)
o Lobectomy =Removal of a lobe.
o Segmentectomy= Removal of a segment.
o Wedge resection =Removal of the entire tumor regardless of the segment.
o Decortication= Stripping off of fibrinous membrane enclosing the lung

o Thoracoplasty= Removal of rib/s. Usually done after pneumonectomy, to reduce the size of the empty
thorax thereby prevent mediastinal shift.
180.Pulmonary Embolism
o This refers to the obstruction of the pulmonary artery or one of its branches by a blood clot (thrombus)
that originates somewhere in the venous system or in the right side of the heart.
o Most commonly, pulmonary embolism is due to a clot or thrombus from the deep veins of the lower
legs.
o Causes
o Fat embolism. Air embolism
o Multiple trauma
o PVD’s
o Abdominal surgery
o Immobility
o Hypercoagulability
o PATHOPHYSIOLOGY
o The thrombus that travels from any part of the venous system obstructs either completely or partially .
Then the lungs will have inadequate blood supply, with resultant increase in dead space in the lungs
o Gas exchange will be impaired or absent in the involved area
o PATHOPHYSIOLOGY
o The regional pulmonary vasculature will constrict causing increased resistance, increased pulmonary
arterial pressure and then increase workload of the right side of the heart.
o PATHOPHYSIOLOGY
o When the work of the right side of the heart exceeds its capacity, right ventricular failure will result,
leading to a decrease in cardiac output followed by decreased systemic perfusion and eventually,
SHOCK
o Assessment
o Restlessness (cardinal initial sign)
o Dyspnea
o Stabbing chest pain
o Cyanosis
o Tachycardia
o Dilated pupils
o Apprehension/ fear
o Diaphoresis
o Dysrhythmias
o Hypoxia
o Diagnostic Tests:
o Ventilation-perfusion scan
o Pulmonary arteriography
o CXR
o ECG
o ABG
o Oxygen therapy STAT
o Early ambulation postop
o Monitor obese patient
o Do not massage legs
o Relieve pain- analgesics
o HOB elevated
o Heparin (2 weeks) then Coumadin (3-6 months)
o Patient Teaching for prevention of Pulmonary Embolism
o Active leg exercises to avoid venous stasis

o Early ambulation
o Use of elastic compression stockings
o Avoidance of leg-crossing and sitting for prolonged periods
o Drink fluids
189.Surgical Aspect of Respiratory Care
o Thoracic Surgery
o a. Exploratory thoracotomy : anterior or posterolateral incision through the fourth, fifth, sixth, or
seventh intercostal spaces to expose and examine the pleura and lung
o Thoracic Surgery
o b. Lobectomy : removal of one lobe of a lung; treatment for bronchiectasis, bronchogenic carcinoma,
emphysematous blebs, lung abscesses
o Thoracic Surgery
o c. Pneumonectomy : removal of an entire lung; most commonly done as treatment for bronchogenic
carcinoma
o Thoracic Surgery
o d. Segmental resection : removal of one or more segments of lung; most often done as treatment for
bronchiectasis
o Thoracic Surgery
o e. Wedge resection : removal of lesions that occupy only part of a segment of lung tissue; for excision
of small nodules or to obtain a biopsy
o Nursing interventions: PREOPERATIVE
o 1. Provide routine pre-op care.
o 2. Perform a complete physical assessment of the lungs to obtain baseline data.
o 3. Explain expected post-op measures: care of incision site, oxygen, suctioning, chest tubes (except if
pneumonectomy performed)
o Nursing interventions: PREOPERATIVE
o 4. Teach client adequate splinting of incision with hands or pillow for turning, coughing, and deep
breathing.
o 5. Demonstrate ROM exercises for affected side.
o 6. Provide chest physical therapy to help remove secretions.
o Nursing interventions: POSTOPERATIVE
o 1. Provide routine post-op care.
o 2. Promote adequate ventilation.
o a. Perform complete physical assessment of lungs and compare with pre-op findings.
o b. Auscultate lung fields every 1—2 hours.
o c. Encourage turning, coughing, and deep breathing every 1—2 hours after pain relief obtained.
o 2. Promote adequate ventilation.
o d. Perform tracheobronchial suctioning if needed.
o e. Assess for proper maintenance of chest drainage system (except after pneumonectomy).
o f. Monitor ABGs and report significant changes.
o g. Place client in semi-Fowler’s position
o If pneumonectomy is performed, follow surgeon’s orders about positioning, often on back or
OPERATIVE SIDE
o If Lobectomy , patient is usually positioned on the UNOPERATIVE SIDE
o 3. Provide pain relief.
o a. Administer narcotics/analgesics prior to turning, coughing, and deep breathing.
o b. Assist with splinting while turning, coughing, deep breathing.

o a. Need to continue with coughing/deep breathing for 6—8 weeks post-op and to continue ROM
exercises
o b. Importance of adequate rest with gradual increases in activity levels
o c. High-protein diet with inclusion of adequate fluids
o d. Chest physical therapy
o e. Good oral hygiene
o f. Need to avoid persons with known upper respiratory infection
o g. Adverse signs and symptoms
o h. Avoidance of crowds and poorly ventilated areas.

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