MEDICAL AND SURGICAL NURSING Respiratory System

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ANATOMY OF RESPIRATORY SYSTEM

Pleural Fluid: prevents pleural friction rub (as seen in pneumonia and pleural effusion)

OXYGENATON: the dynamic interaction of gases in the body for the purpose of delivering adequate oxygen essential for cellular survival RESPIRATORY SYSTEM MAIN FUNCTION: GAS EXCHANGE I. Upper Respiratory Tract A. Functions 1. Filtering 2. Warming and moistening 3. Humidification B. Parts 1. Nose - made up of framework of cartilages; divided into R and L by the nasal septum. 2. Paranasal Sinuses includes four pair of bony cavities that are lined with nasal mucosa and ciliated epithelium. 3. Tubernate Bones ( Conchae ) 4. Pharynx muscular passageway for both food and air Nasopharynx Oropharynx Laryngopharynx 5. Tonsils and Adenoids 6. Larynx voice production, coughing reflex Made up of framework of: Epiglottis valve that covers the opening to the larynx during swallowing. Glottis opening between the vocal cords Hyoid bone u shaped bone in neck Cricoid cartilage

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Bronchi Lobar Bronchi: 3 R and 2 L Segmental Bronchi: 10 R and 8 L Subsegmental Bronchi Bronchioles Terminal Bronchioles Respiratory Bronchioles, considered to be the transitional passageways between the conducting airways and the gas exchange Alveoli functional cellular units or gas-exchange units of the lungs. O2 and CO2 exchange takes place Made up of about 300 million TYPE 1 - provide structure to the alveoli TYPE 2 - secrete SURFACTANT, reduces surface tension; increases alveoli stability & prevents their collapse TYPE 3 alveolar cell macrophages, destroys foreign material, such as bacteria
Lecithin Sphingomyelin L/S ratio indicates lung maturity

2:1 normal 1:2 immature lungs

PULMONARY CIRCULATION Provides for reoxygenation of blood and release of CO2

Thyroid cartilage, forms the Adams apple Arythenoid cartilage

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Speech production and cough reflex Vocal cords Trachea - consists of cartilaginous rings Passageway of air

PULMONARY ARTERIES, carry blood from the heart to the lungs. PULMONARY VEINS, is a large blood vessel of the circulatory system that carries blood from the lungs to the left atrium of the heart.

Site of tracheostomy (4th-6th tracheal ring)

II. Lower respiratory tract A. Function: facilitates gas exchange B. Parts 1. Lungs, are paired elastic structure enclosed in the thoracic cage, which is an airtight chamber with distensible walls. Right 3 lobes, 10 segments Left 2 lobes, 8 segments Client post pneumonectomy affected side to promote expansion Post lobectomy unaffected side to promote drainage

Pleural cavity Parietal Visceral

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DRIVING FORCE FOR AIR FLOW Airflow driven by the pressure difference between atmosphere (barometric pressure) and inside the lungs (intrapulmonary pressure).

RESPIRATORY MUSCLES PRIMARY: diaphragm and external intercostal muscles ACCESORY: sternocleidomastoid (elevated sternum), the scalene muscles (anterior, middle and posterior scalene) and the nasal alae

AIRWAY RESISTANCE Resistance is determined chiefly by the radius size of the airway. Causes of Increased Airway Resistance 1. Contraction of bronchial mucosa Thickening of bronchial mucosa Obstruction of the airway Loss of lung elasticity

PHYSIOLOGY OF RESPIRATORY SYSTEM

VENTILATION: The movement of air in and out of the airways.

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The thoracic cavity is an air tight chamber. the floor of this chamber is the diaphragm. Inspiration: contraction of the diaphragm (movement of this chamber floor downward) and contraction of the external intercostal muscles increases the space in this chamber. lowered intrathoracic pressure causes air to enter through the airways and inflate the lungs. Expiration: with relaxation, the diaphragm moves up and intrathoracic pressure increases. this increased pressure pushes air out of the lungs. expiration requires the elastic recoil of the lungs. Inspiration normally is 1/3 of the respiratory cycle and expiration is 2/3.

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RESPIRATION The process of gas exchange between atmospheric air and the blood at the alveoli, and between the blood cells and the cells of the body. Exchange of gases occurs because of differences in partial pressures. Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body. Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body.

NEUROCHEMICAL CONTROL
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MEDULLA OBLONGATA respiratory center initiates each breath by sending messages to primary respiratory muscles over the phrenic nerve has inspiration and expiration centers PONS has 2 respiration centers that work with the inspiration center to produce normal rate of breathing 1. PNEUMOTAXIC CENTER affects the inspiratory effort by limiting the volume of air inspired 2. APNEUSTIC CENTER prolongs inhalation

pouches uotward due to diaphragmatic descent) causes: diaphragmatic paralysis

NOTE: Chemoreceptors responds to changes in ph, increased PaCO2 = increase RR

RESPIRATORY EXAMINATION AND ASSESSMENT

Background information A. Abnormal patterns of breathing 1. Sleep Apnea cessation of airflow for more than 10 seconds more than 10 times a night during sleep causes: obstructive (e.g. obesity with upper narrowing, enlarged tonsils, pharyngeal soft tissue changes in acromegaly or hypothyroidism) 2. Cheyne-Stokes periods of apnoea alternating with periods of hyperpnoae pathophysiology: delay in medullary chemoreceptor response to blood gas changes causes left ventricular failure brain damage (e.g. trauma, cerebral, haemorrhage) high altitude 3. Kussmaul's (air hunger) deep rapid respiration due to stimulation of respiratory centre causes: metabolic acidosis (e.g. diabetes mellitus, chronic renal failure) 4. Hyperventilation complications: alkalosis and tetany causes: anxiety 5. Ataxic (Biot) irregular in timing and deep causes: brainstem damage 6. Apneustic post-inspiratory pause in breathing causes: brain (pontine) damage

B. Cyanosis 1. Refers to blue discoloration of skin and mucous membranes , is due to presence of deoxygenated haemoglobin in superficial blood vessels 2. Central cyanosis = abnromal amout of deoxygenated haemoglobin in arteries and that blue discoloration is present in parts of body with good circulation such as tongue 3. Peripheral cyanosis = occurs when blood supply to a certain part of body is reduced, and the tissue extracts more oxygen from normal from the circulating blood, e.g. lips in cold weather are often blue, but lips are spared 4. Causes of cyanosis Central cyanosis decreased arterial saturation decreased concentration of inspired oxygen: high altitude lung disease: COPD with cor pulmoale, massive pulmonary embolism right to left cardiac shunt (cyanotic congenital heart disease) polycythaemia haemoglobin abnromalities (rare): methaemoglobinaemia, sulphaemoglobinaemia Peripheral cyanosis all causes of central cyanosis cause peripheral cyanosis exposure to cold reduced cardiac output: left ventricular failure or shock arterial or venous obstruction Position: patient sitting over edge of bed General appearance look for the following Dyspnea normal respiratory rate < 14 each minute tachypnoea = rapid respiratory rate are accessory muscles being used (sternomastoids, platysma, strap muscles of neck) - characteristically, the accessory muscles cause elevation of shoulders with inspiration and aid respiration by increasing chest expansion Cyanosis Character of cough ask patient to cough several times lack of usual explosive beginning may indicate vocal cord paralysis (bovine cough) muffled, wheezy ineffective cough suggests airflow limitation very loose productive cough suggests excessive bronchial secretions due to: - chronic bronchitis - pneumonia - bronchiectasis dry irritating cough may occur with: - chest infection - asthma - carcinoma of bronchus
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Paradoxical the abdomen sucks with respiration (normally, it

- left ventricular failure - interstitial lung disease - ACE inhibitors Sputum volume type (purulent, mucoid, mucopurulent) presence or absence of blood? Stridor croaking noise loudest on inspiration is a sign that requires urgent attention causes: (obstruction of larynx, trachea or large broncus) - acute onset (minutes) inhaled foreign body acute epiglottitis anaphylaxis toxic gas inhalation - gradual onset (days, weeks) laryngeal and pharyngeal tumours crico-arytenoid rheumatoid arthritis bilateral vocal cord palsy tracheal carcinoma paratracheal compression by lymph nodes post-tracheostomy or intubation granulomata Hoarseness causes include: - laryngitis - laryngeal nerve palsy associated with carcinoma of lung - laryngeal carcinoma The Hands Clubbing commonly cause by respiratory disease (but NOT emphysema or chronic bronchitis) occasionally, clubbing is associated with hypertrophic pulmonary osteoarthropathy (HPO) characterised by periosteal inflammation at distal ends of long bones, wrists, ankles, metacarpals and metatarsals sweelling and tenderness over wrists and other involved areas

Horner's syndrome? (constricted pupil, partial ptosis and loss of sweating which can be due to apical lung tumour compressing sympathetic nerves in neck) Nose polpys? (associated with asthma) engorged turbinates? (various allergic conditions) deviated septum? (nasal obstruction) Mouth and tongue look for central cyanosis evidence of upper respiratory tract infection (a reddened pharynx and tonsillar enlargement with or without a coating of pus) broken tooth - may predispose to lung abscess or pneumonia sinusitis is indicated by tenderness over the sinuses on palpation some patients with obstructive sleep apnoea will be obese with a receding chin, a small pharynx and a short thick neck

The Trachea causes of tracheal displacement: toward the side of the lung lesion upper lobe collapse upper lobe fibrosis pneumonectomy upper mediastinal masses, such as retrosternal goitre tracheal tug (finger resting on trachea feels it move inferiorly with each inspiration) is a sign of gross overexpansion of the chest because of airflow obstruction The Chest: inspection Shape and symmetry of chest Barrel shaped anteroposterior (AP) diameter is increased compared with lateral diameter causes: hyperinflation due to asthma, emphysema

Staining staining of fingers - sign of cigarette smoking (caused by tar, not nicotine) Wasting and weakness Pulse rate Flapping tremor (asterixis) - unreliable sign ask patient to dorsiflex wrists and spread out fingers, with arms outstretched flapping tremor may occur with severe carbon dioxide retention (severe chronic airflow limitation) The Face Eyes
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Pigeon chest (pectus carinatum) localised prominence (outward bowing of sternum and costal cartilages) causes: manifestation of chronic childhood illness (due to repeated strong contractions of diaphragm while thorax is still pliable) rickets

Funnel chest (pectus excavatum) developmental defect involving a localised depression of lower end of sternum in severe cases, lung capacity

may be restricted

Harrison's sulcus innar depression of lower ribs just above costal margins at site of attachment of diaphragm causes: severe asthma in childhood rickets Kyphosis , exaggerated forward curvature of spine Scoliosis , lateral bowing Kyphoscoliosis: causes: idiopathic (80%) secondary to poliomyelitis (inflammation involving grey matter of cord) (note: severe thoracic kyphoscoliosis may reduce lung capacity and increase work of breathing) Lesions of chest wall scars - previous thoracic operations or chest drains for a previous pneumothorax or pleural effusion thoracoplasty (was once performed to remove TB, but no longer is because of effective antituberculosis chemotherapy) invovled removal of large number of ribs on one side to achieve permanent collapse of affected lung erythema and thickening of skin may occur in radiotherapy; there is a sharp demarcation between abnormal and normal skin Diffuse swelling of chest wall and neck pathophysiology: air tracking from the lungs causes: pneumothorax rupture of oesopahagus Prominent veins cause: superior vena caval obstruction Asymmetry of chest wall movements assess this by inspecting from behind patient, looking down the clavicles during moderate respiration diminished movement indicates underlying lung disease the affected side will showed delayed or decreased movement causes of reduced chest wall movements on one side are localised: localised pulmonary fibrosis consolidation collapse pleural effusion pneumothroax causes of bilateral reduced chest wall movements are diffuse: chronic airflow limitation diffuse pulmonary fibrosis

place hands firmly on chest wall with fingers extending around sides of chest (fugyre 4.5) as patient takes a big breath in, the thumbs should move symmetrically apart about 5 cm reduced expansion on one side indicates a lesion on that side note: lower lobe expansion is tested here; upper lobe is tested for on inspection (as above) apex beat (discussed in cardiac section) for respiratory diseases: displacement toward site of lesion - can be caused by: collapse of lower lobe localised pulmonary fibrosis displacement away from site of lesion - can be caused by: pleural effusion tension pneumothorax apex beat is often impalpable in a chest which is hyperexpanded secondary to chronic airflow limitation vocal fremitus palpate chest wall with palm of hand while patient repeats "99" front and back of chest are each palpated in 2 comparable positions with palms; in this way differences in vibration on chest wall can be detected causes of change in vocal fremitus are the same as those for vocal resonance (see later) ribs gently compress chest wall anteroposteriorly and laterally localised pain suggests a rib fracture (may be secondary to trauma or spontaneous as a result of tumour deposition or bone disease) The Chest: percussion with left hand on chest wall and fingers slightly separated and aligned with ribs, the middle finger is pressed firmly against the chest; pad of right middle finger is used to strike firmly the middle phalanx of middle finger of left hand percussion of symmetrical areas of: anterior (chest) posterior (back) (ask patient to move elbows forward across the front of chest - this rotates the scapulae anteriorly, i.e. moves it out of the way) axillary region (side) supraclavicular fossa percussion over a solid structure (e.g. liver, consolidated lung) produces a dull note percusion over a fluid filled area (e.g. pleural effusion) produces an extremely dull (stony dull) note percussion over the normal lung produces a resonant note percussion over a hollow structure (e.g. bowel, pneumothorax) produces a hyperresonsant note liver dullness: upper level of liver dullness is determined by percussing down the anterior cehst in mid-clavicular line normally, upper level of liver dullness is 6th rib in right mid-clavicular line if chest is resonant below this level, it is a sign of hyperinflation usually due to emphysema, asthma cardiac dullness: area of cardiac dullness is uaully present on left side of chest

The Chest: palpation chest expansion

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 this may decrease in emphysema or asthma The Chest: auscultation breath sounds introduction one should use the diaphragm of stethoscope to listen to breath sound in each area, comparing each side remember to listen high up into the axillae remember to use bell of stethoscope to listen to lung from above the clavicles quality of breath sounds normal breat sounds are heard with stethoscope over all parts of chest, produced in airways rather than alveoli (although once they had been thought to arise from alveoli (vesicles) and are therefore called vesicular sounds) normal (vesicular) breath sounds are louder and longer on inspiration than on expiration; and there is no gap between the inspiratory and expiratory sounds bronchial breath sounds turbulence in large airways is heard without being filtered by the alveoli, and therefore produce a different quality; they are heard over the trachea normally, but not over the lungs are audible throughout expiration, and often there is a gap between inspiration and expiration are heard over areas of consolidation since solid lung conducts the sound of turbulence in main airways to peripheral areas without filtering causes include: - lung consolidation (lobar pneumonia) common - localised pulmonary fibrosis - uncommon - pleural effusion (above the fluid) uncommon - collapsed lung (e.g. adjacent to a pleural effusion) - uncommon amphoric sound = when breath sounds over a large cavity have an exaggerated bronchial quality) intensity of breath sounds causes of reduced breath sounds include: chronic airflow limitation (especially emphysema) pleural effusion pneumothorax pneumonia large neoplasm pulmonary collapse added (adventitious) sounds two types of added sounds: continuous (wheezes) and interrupted (crackles) wheezes may be heard in expiration or inspiration or both pathophysiology of wheezes - airway narrowing an inspiratory wheeze implies severe airway narrowing causes of wheezes include: - asthma (often high pitched) - due to muscle spasm, mucosal oedema, excessive secretions
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chronic airflow diseases - due to mucosal oedema and excessive secretions carcinoma causing bronchial obstruction tends to cause a localised wheeze which is monophonic and does not clear with coughing

crackles some terms not to use include rales (low pitched crackles) and creptitations (high pitched crackles) crackles are due to collapse of peripheral airways on expiration and sudden opening on inspiration early inspiratory crackles - suggests disease of small airways - characteristic of chronic airflow limitation - are only heard in early inspiration late or paninspiratory crackles - suggests disease confined to alveoli - may be fine, medium or coarse - fine crackles - typically caused by pulmonary fibrosis - medium crackles - typically caused by left ventricular failure (due to presence of alveolar fluid) - coarse crackes - tend to change with coughing; occur with any disease that leads to retention of secretions; commonly occur in bronchiectasis pleural friction rub when thickened, roughened pleural surfaces rub together, a continuous or intermittent grating sound may be heard suggests pleurisy, which may be secondary to pulmonary infarction or pnuemonia

vocal resonanance gives information about lungs' ability to transmit sounds consolidated lung tends to transmit high frequencies so that speech heard through stethoscope takes a bleeting quality (aegophony); when a patient with aegophony says "bee" it sounds like "bay" listen over each part of chest as patient says "99"; over consolidated lung, the numbers will become clearly audible; over normal lung, the sound is muffled whispering pectoriloquy - vocal resonance is increased to such an extent that whispered speech is distinctly heard The Heart lie patient at 45 degrees measure jugular venous plse for right heart failure examine preacordium; pay close attention to pulmonary component of P2 (which is best heard at 2nd intercostal space on left) and should not be louder than A2; if it is louder, suspect pulmonary hypertension cor pulmonale (also called pulmonary hypertensive heart disease) may be due to: chronic airflow limitation (emphysema) pulmonary fibrosis pulmonary thromboembolism marked obesity sleep apnoea severe kyphoscoliosis

The Abdomen

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palpate liver for enlargement due to secondary deposits of tumour from lung, or right heart failure

A probe or sensor is attached to the fingertip, forehead, earlobe or bridge of the nose Sensor detects changes in O2 sat levels by monitoring light signals generated by the oximeter and reflected by the blood pulsing through the tissue at the probe Normal SpO2 = 95% - 100% < 85% - tissues are not receiving enough O2 Results unreliable in: Cardiac arrest Shock Use of dyes or vasoconstrictors Severe anemia High carbon monoxide Level

Permberton's sign ask patient to lift arms over head look for development of facial plethora, inspiratory stridor, non-pulsatile elevation of jugular venous pressure occurs in vena caval obstruction Feet inspect for oedema or cyanosis (clues of cor pulmonale) look for evidence of deep vein thrombosisd Respiratory rate on exercise and positioning patients complaining of dyspnoea should have their respiratory rate measured at rest, at maximal tolerated exertion and supine if dyspnoea is not accompanied by tachypnoea when a patient climbs stairs, one should consider malingering look for paradoxical inward motion of abdomen during inspiration when patient is uspine (indicating diaphragmatic paralysis) Temperature: fever may accompany any acute or chronic chest infection

3. Chest X-ray This is a NON-invasive procedure involving the use of xrays with minimal radiation. The nurse instructs the patient to practice the on cue to hold his breath and to do deep breathing Instruct the client to remove metals from the chest. Rule out pregnancy first.

5. Computed Tomography (CT Scan) and Magnetic Resonance Imaging ( MRI ) DIAGNOSTIC EVALUATION

1. Skin Test: Mantoux Test or Tuberculin Skin Test This is used to determine if a person has been infected or has been exposed to the TB bacillus. This utilizes the PPD (Purified Protein Derivatives). The PPD is injected intradermally usually in the inner aspect of the lower forearm about 4 inches below the elbow. The test is read 48 to 72 hours after injection. (+) Mantoux Test is induration of 10 mm or more. But for HIV positive clients, induration of about 5 mm is considered positive Signifies exposure to Mycobacterium Tubercle bacilli

The CT scan is a radiographic procedure that utilizes x-ray machine. The MRI uses magnetic field to record the H+ density of the tissue.

It does NOT involve the use of radiation. The contraindications for this procedure are the following: patients with implanted pacemaker, patients with metallic hip prosthesis or other metal implants in the body.

2. Pulse Oximeter Non-invasive method of continuously monitoring he oxygen saturation of hemoglobin

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This chest CT scan shows a cross-section of a person with bronchial cancer. The two dark areas are the lungs. The light areas within the lungs represent the cancer.

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 Therapeutic uses

To evaluate bleeding sites To determine if a tumor can be resected surgically

To Remove foreign objects from tracheobronchial tree To Excise lesions To remove tenacious secretions obstructing the tracheobronchial tree To drain abscess To treat post-operative atelectasis Clear MRI images of lung airways during breathing. 6. Flouroscopy Nursing interventions BEFORE Bronchoscopy Inform ed consent/ permit needed Explain procedure to the patient, tell him what to expect, to help him cope with the unkown

Studies the lung and chest in motion Involves the continuous observation of an image reflected on a screen when exposed to radiation in the manner of television screen that is activated by an electrode beam. Structures of different densities that intercept the X-ray beam are visualized on the screen in silhouette

Atropi ne (to diminish secretions) is administered one hour before the procedure About 30 minutes before bronchoscopy, Valium is given to sedate patient and allay anxiety. Topica l anesthesia is sprayed followed by local anesthesia injected into the larynx Instruct on NPO for 6-8 hours Remov e dentures, prostheses and contact lenses

7. Indirect Bronchography

A radiopaque medium is instilled directly into the trachea and the bronchi and the outline of the entire bronchial tree or selected areas may be visualized through x-ray. It reveals anomalies of the bronchial tree and is important in the diagnosis of bronchiectasis. Nursing interventions BEFORE Bronchogram Secure written consent Check for allergies to sea foods or iodine or anesthesia NPO for 6 to 8 hours

The patient is placed supine with hyperextended neck during the procedure Nursing interventions AFTER Bronchoscopy Put the patient on Side lying position Tell patient that the throat may feel sore with . Check for the return of cough and gag reflex. Check vasovagal response.

Pre-op meds: atropine SO4 and valium, topical anesthesia sprayed; followed by local anesthetic injected into larynx. The nurse must have oxygen and anti spasmodic agents ready.

Nursing interventions AFTER Bronchogram Side-lying position NPO until cough and gag reflexes returned Instruct the client to cough and deep breathe client

Watch for cyanosis, hypotension, tachycardia, arrythmias, hemoptysis, and dyspnea. These signs and symptoms indicate perforation of bronchial tree. Refer the patient immediately!

8. Bronchoscopy

This is the direct inspection and observation of the larynx, trachea and bronchi through a flexible or rigid bronchoscope. Passage of a lighted bronchoscope into the bronchial tree for direct visualization of the trachea and the tracheobronchial tree. Diagnostic uses: To examine tissues or collect secretions To determine location or pathologic process and collect specimen for biopsy
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9. Lung Scan Procedure using inhalation or I.V. injection of a radioisotope, scans are taken with a scintillation camera.

Imaging of distribution and blood flow in the lungs. (Measure blood perfusion) Confirm pulmonary embolism or other blood- flow abnormalities Nursing interventions BEFORE the procedure: Allay the patients anxiety Instruct the patient to Remain still during the procedure Nursing interventions AFTER the procedure Check the catheter insertion site for bleeding Assess for allergies to injected radioisotopes Increase fluid intake, unless contraindicated.

Nursing interventions BEFORE the procedure: Withhold food and fluids Place obtained written informed consent in the patients chart. Nursing interventions AFTER the procedure:

10. Sputum Examination Laboratory test

Observe the patient for signs of Pneumothorax and air embolism Check the patient for hemoptysis and hemorrhage Monitor and record vital signs Check the insertion site for bleeding Monitor for signs of respiratory distress

Indicated for microscopic examination of the sputum: Gross appearance, Sputum C&S, AFB staining, and for Cytologic examination/ Papanicolaou examination Nursing interventions:

Early morning sputum specimen is to be collected (suctioning or expectoration) Rinse mouth with plain water Use sterile container. Sputum specimen for C&S is collected before the first dose of anti-microbial therapy. For AFB staining, collect sputum specimen for three consecutive mornings.

12. Lymph Node Biopsy Scalene or cervicomediastinal To assess metastasis of lung cancer 13. Pulmonary Function Test / Studies Non-invasive test Measurement of lung volume, ventilation, and diffusing capacity Nursing interventions: Document bronchodilators or narcotics used before testing Allay the patients anxiety during the testing

11. Biopsy of the Lungs Percutaneous removal of a small amount of lung tissue For histologic evaluation Transbronchoscopic biopsydone during bronchoscopy, Percutaneous needle biopsy Open lung biopsy

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Arterial puncture is performed on areas where good pulses are palpable (radial, brachial, or femoral). Radial artery is the most common site for withdrawal of blood specimen Nursing interventions: Utilize a 10-ml. Pre-heparinized syringe to prevent clotting of specimen Soak specimen in a container with ice to prevent hemolysis If ABG monitoring will be done, do Allens test to assess for adequacy of collateral circulation of the hand (the ulnar arteries)

LUNG VOLUMES: (ITER) Inspiratory reserve volume (3000 mL) The maximum volume that can be inhaled following a normal quiet inhalation. Tidal volume (500 mL) The volume of air inhaled and exhaled with normal quiet breathing Expiratory reserve volume (1100 mL) The maximum volume that can be exhaled following the normal quiet exhalation Residual volume (1200 mL)

The volume of air that remains in the lungs after forceful exhalation

15. Pulmonary Angiography This procedure takes X-ray pictures of the pulmonary blood vessels (those in the lungs). Because arteries and veins are not normally seen in an Xray, a contrast material is injected into one or more arteries or veins so that they can be seen. 16. Ventilation - Perfusion Scan Radioactive albumin injection is part of a nuclear scan test that is performed to measure the supply of blood through the lungs. After the injection, the lungs are scanned to detect the location of the radioactive particles as blood flows through the lungs. 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. A ventilation and perfusion scan is most often performed to detect a pulmonary embolus. It is also used to evaluate lung function in people with advanced pulmonary disease such as COPD and to detect the presence of shunts (abnormal circulation) in the pulmonary blood vessels.

LUNG CAPACITIES: Functional Residual Capacity (ERV 1100 mL + RV 1200 mL = 2300 mL ) The volume of air that remains in the lungs after normal, quiet exhalation Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500 mL ) The amount of air that a person can inspire maximally after a normal expiration Vital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL = 4600 mL ) The maximum volume of air that can be exhaled after a maximum inhalation Reduced in COPD Total Lung Capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL + RV 1200 mL = 5800 mL ) Total of all four volumes 14. Arterial Blood Gas Laboratory test Indicate respiratory functions

Assess the degree to which the lungs are able to provide adequate oxygen and remove CO2 Assess the degree to which the kidneys are able to reabsorb or excrete bicarbonate. Assessment of arterial blood for tissue oxygenation, ventilation, and acid-base status
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RESPIRATORY CARE MODALITIES 1. Oxygen Therapy Oxygen is a colorless, odorless, tasteless, and dry gas that supports combustion

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Man requires 21% oxygen from the environment in order to survive Indication: Hypoxemia Signs of Hypoxemia Increased pulse rate Rapid, shallow respiration and dyspnea Increased restlessness or lightheadedness Flaring of nares Substernal or intercostals retractions Cyanosis

17. Thoracentesis Procedure suing needle aspiration of intrapleural fluid or air under local anesthesia Specimen examination or removal of pleural fluid Nursing intervention BEFORE Thoracentesis Secure consent Take initial vital signs Instruct to remain still, avoid coughing during insertion of the needle

Low flow oxygen provides partial oxygenation with patient breathing a combination of supplemental oxygen and room air. Low-flow administration devices: o Nasal Cannula 24-45% 2-6 LPM

Inform patient that pressure sensation will be felt on insertion of needle

Nursing intervention DURING the procedure: Reassess the patient Place the patient in the proper position: Upright or sitting on the edge of the bed Lying partially on the side, partially on the back Nursing interventions after Thoracentesis Assess the patients respiratory status Monitor vital signs frequently

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Simple Face Mask0-60% Non-rebreathing Mask Croupette Oxygen Tent

5-8 LPM 6-10 LPM 95-100% 6-15 LPM

Partial Rebreathing Mask 60-90%

Position the patient on the affected side, as ordered, for at least 1 hour to seal the puncture site Turn on the unaffected side to prevent leakage of fluid in the thoracic cavity Check the puncture site for fluid leakage Auscultate lungs to assess for pneumothorax Monitor oxygen saturation (SaO2) levels Bed rest Check for expectoration of blood

High flow oxygen provides all necessary oxygenation, with patients breathing only oxygen supplied from the mask and exhaling through a one-way vent. High flow administration devices o Venturi Mask 24-40% 4-10 LPM Preferred for clients with COPD because it provides accurate amount of oxygen. o Face Mask o Oxygen Hood* o Incubator / isolette* Note: * can be used for both low and high flow administration The nurse should prevent skin breakdown by checking nares, nose and applying gauze or cotton as necessary Ensure that COPD patients receive only LOW flow oxygen because these persons respond to hypoxia, not increased CO levels.

2. Tracheobronchial suctioning Suction only when necessary not routinely Use the smallest suction catheter if possible

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Client should be in semi or high Fowlers position Use sterile gloves, sterile suction catheter Hyperventilate client with 100% oxygen before and after suctioning Insert catheter with gloved hand (3-5 length of catheter insertion) without applying suction. Three passes of the catheter is the maximum, with 10 seconds per pass. Apply suction only during withdrawal of catheter

The suction pressure should be limited to less than 120 mmHg When withdrawing catheter rotate while applying intermittent suction Suctioning should take only 10 seconds (maximum of 15 seconds) Evaluate: clear breath sounds on auscultation of the chest.

These are procedures for patients with respiratory disorders like COPD, cystic fibrosis, lung abscess, and pneumonia. The therapy is based on the fact that mucus can be knocked or shaken from airways and helped to drain from the lungs.

Postural drainage

3. Bronchial Hygiene Measures Suctioning: oropharyngeal; nasopharyngeal a. Steam inhalation The purpose of steam inhalation are as follows: - to liquefy mucous secretions - to warm and humidify air - to relieve edema of airways - to soothe irritated airways - to administer medication

Use of gravity to aid in the drainage of secretions. Patient is placed in various positions to promote flow of drainage from different lung segments using gravity. Areas with secretions are placed higher than lung segments to promote drainage. Patient should maintain each position for 5-15 minutes depending on tolerability.

Percussion

It is a dependent nursing function Inform the client and explain the purpose of the procedure Place the client in Semi-Fowlers position Cover the clients eyes with washcloth to prevent irritation Check the electrical device before use Place the steam inhalator in a flat, stable surface. Place the spout 12 18 inches away from the clients nose or adjust distance as necessary CAUTION: avoid burns. Cover the chest with towel to prevent burns due to dripping of condensate from the steam. Assess for redness on the side of the face which indicates first degree burns. To be effective, render steam inhalation therapy for 15 20 minutes Instruct the client to perform deep breathing and coughing exercises after the procedure to facilitate expectoration of mucous secretions. Provide good oral hygiene after the procedure. Do after-care of equipment.

Produces energy wave that is transmitted through the chest wall to the bronchi. The chest is struck rhythmically with cupped hands over the areas were secretions are located. Avoid percussion over the spine, kidneys, breast or incision and broken ribs. Areas should be percussed for 1-2 minutes

Vibration

Works similarly to percussion, where hands are placed on clients chest and gently but firmly rapidly vibrate hands against thoracic wall especially during clients exhalation. This may help dislodge secretions and stimulate cough. This should be done at least 5-7 times during patient exhalation.

b. Aerosol inhalation done among pediatric clients to administer brochodilators or mucolytic-expectorants. . c. Medimist inhalation done among adult clients to administer bronchodilators or mucolytic-expectorants. 4. Chest Physiotheraphy ( CPT ) Includes postural drainage, chest percussion and vibration, and breathing retraining. Effective coughing is also an important component. Goals are removal of bronchial secretions, improved ventilation, and increased efficiency of respiratory muscles. Postural drainage uses specific positions to use gravity to assist in the removal of secretions. Vibration loosens thick secretions by percussion or vibration. Breathing exercises and breathing retraining improve ventilation and control of breathing and decrease the work of breathing.

Suctioning Nursing Interventions in CPT Verify doctors order Assess areas of accumulation of mucus secretions. Position to allow expectoration of mucus secretions by gravity Place client in each position for 5-10 to 15 minutes Percussion and vibration done to loosen mucus secretions
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Change position gradually to prevent postural hypotension Client is encouraged to cough up and expectorate sputum Procedure is best done 60 to 90 minutes before meals or in the morning upon awakening and at bedtime. Provide good oral care after the procedure

5. Incentive Spirometry Types: volume and flow Device ensures that a volume of air is inhaled and the patient takes deep breaths. Used to prevent or treat atelectasis To enhance deep inhalation Nursing care Positioning of patient, teach and encourage use, set realistic goals for the patient, and record the results. Types of Bottle Drainage One-bottle system The bottle serves as drainage and water-seal Immerse tip of the tube in 2-3 cm of sterile NSS to create water-seal. Keep bottle at least 2-3 feet below the level of the chest to allow drainage from the pleura by gravity. Never raise the bottle above the level of the heart to prevent reflux of air or fluid. Assess for patency of the device Observe for fluctuation of fluid along the tube. The fluctuation synchronizes with the respiration. Observe for intermittent bubbling of fluid; continues bubbling means presence of air-leak In the absence of fluctuation: Suspect obstruction of the device Assess the patient first, then if patient is stable Check for kinks along tubing;

6. Closed Chest Drainage ( Thoracostomy Tube ) Chest tube is used to drain fluid and air out of the mediastinum or pleural space into a collection chamber to help re-establish normal negative pressure for lung reexpansion. Purposes To remove air and/or fluids from the pleural space To reestablish negative pressure and re-expand the lungs Procedure

Milk tubing towards the bottle (If the hospital allows the nurse to milk the tube)

If there is no obstruction, consider lung re-expansion; (validated by chest x-ray) Air vent should be open to air. Two-bottle system If not connected to the suction apparatus

The first bottle is drainage bottle; The second bottle is water-seal bottle Observe for fluctuation of fluid along the tube (water-seal bottle or the second bottle) and intermittent bubbling with each respiration.

The chest tube is inserted into the affected chest wall at the level of 2nd to 3rd intercostals space to release air or in the fourth intercostals space to remove fluid.

NOTE! IF connected to suction apparatus 1. The first bottle is the drainage and water-seal bottle; 2. The second bottle is suction control bottle. 3. Expect continuous bubbling in the suction control bottle; 4. Intermittent bubbling and fluctuation in the water-seal 5. Immerse tip of the tube in the first bottle in 2 to 3 cm of sterile NSS 6. Immerse the tube of the suction control bottle in 10 to 20 cm of sterile NSS to stabilize the normal negative pressure in the lungs. 7. This protects the pleura from trauma if the suction pressure is inadvertently increased

MS

14

Three-bottle system

The first bottle is the drainage bottle; The second bottle is water seal bottle The third bottle is suction control bottle. Observe for intermittent bubbling and fluctuation with respiration in the water- seal bottle Continuous GENTLE bubbling in the suction control bottle. These are the expected observations. Suspect a leak if there is continuous bubbling in the WATER seal bottle or if there is VIGOROUS bubbling in the suction control bottle. The nurse should look for the leak and report the observation at once. Never clamp the tubing unnecessarily.

In the event the tube accidentally is pulled out, the nurse obtains vaselinized gauze and covers the stoma. She should immediately contact the physician.

Removal of chest tubedone by physician The nurse Prepares: Petrolatum Gauze Suture removal kit Sterile gauze Adhesive tape Place client in semi-Fowlers position Instruct client to exhale deeply, then inhale and do valsalva maneuver as the chest tube is removed. Chest x-ray may be done after the chest tube is removed Asses for complications: subcutaneous emphysema; respiratory distress 7. Artificial Airway a. Oral airways- these are shorter and often have a larger lumen. They are used to prevent the tongue form falling backward. b. Nasal airways- these are longer and have smaller lumen Which causes greater airway resistance c. Tracheostomy- this is a temporary or permanent surgical opening in the trachea. A tube is inserted to allow ventilation and removal of secretions. It is indicated for emergency airway access for many conditions. The nurse must maintain tracheostomy care properly to prevent infection.

If there is NO fluctuation in the water seal bottle, it may mean TWO things

Either the lungs have expanded or the system is NOT functioning appropriately. In this situation, the nurse refers the observation to the physician, who will order for an X-ray to confirm the suspicion.

Important Nursing considerations Encourage doing the following to promote drainage: Deep breathing and coughing exercises Turn to sides at regular basis Ambulate ROM exercise of arms Mark the amount of drainage at regular intervals Avoid frequent milking and clamping of the tube to prevent tension pneumothorax What the nurse should do if:

RESPIRATORY DISEASES AND DISORDERS

RESPIRATORY INFECTION 1. Rhinitis 2. Sinusitis 3. Pharyngitis 4. Tonsilitis & Adenoiditis 5. Laryngitis 6. Tracheobronchitis 7. Pneumonia 8. Pulmonary Tuberculosis 9. Histoplasmosis

If there is continuous bubbling: The nurse obtains a toothless clamp Close the chest tube at the point where it exits the chest for a few seconds. If bubbling in the water seal bottle stops, the leak is likely in the lungs, But if the bubbling continues, the leak is between the clamp and the bottle chamber.

Next, the nurse moves the clamp towards the bottle checking the bubbling in the water seal bottle. If bubbling stops, the leak is between the clamp and the distal part including the bottle. But if there is persistent bubbling, it means that the drainage unit is leaking and the nurse must obtain another set. In the event that the water seal bottle breaks, the nurse temporarily kinks the tube and must obtain a receptacle or container with sterile water and immerse the tubing. She should obtain another set of sterile bottle as replacement. She should NEVER CLAMP the tube for a longer time to avoid tension pneumothorax.
MS 15

I.

RHINITIS - inflammation and irritation of the mucous membrane of the nose. Allergic Non allergic Allergic A. ETIOLOGIC FACTOR 1. Changes in temperature or humidity 2. Odors 3. Foods 4. Infection 5. Age 6. Systemic disease 7. Drugs (cocaine ) 8. OTC drugs

Note: The presence of fewer than two symptoms R/O acute sinusitis and four or more suggest acute sinusitis. B. CLINICAL MANIFESTATION 1. Excessive nasal drainage 2. Runny nose 3. Nasal congestion 4. Nasal discharge 5. Sneezing 6. Headache 7. Low grade fever 8. Tearing watery eyes 9. General malaise NURSING MANAGEMENT 1. Identify the cause of infection through the history and physical examination. 2. Administer medications as ordered: Antihistamine Diphenhydramine (Benadryl) Chlorpheniramine Loratidine Nasal Decongestant Cromolyn ( Nasalcrom ) Health Teaching: Instruct the patient to avoid or reduce exposure to allergens and irritants such as dusts, molds, animals, fumes, odors, powders etc.. Teach the patient to read drug labels and possible reaction to OTC drugs Proper technique in administering nasal medications Practice hand hygiene Chronic 1. Impaired mucociliary clearance and ventilation 2. Cough with thick discharge 3. Chronic hoarseness 4. Chronic headache 5. Chronic facial pain 6. Fatigue and nasal congestion C. NURSING MANAGEMENT 1. Perform a careful and physical assessment of the head and neck, particularly the nose, ears, teeth, sinuses, pharynx and chest. 2. Administer medications as ordered: Antibiotic Amoxicillin Ampicillin Trimethoprim / sulfamethoxazole ( Bactrim , Septral ) Macrolides (clarithromycin) , Azithromycin ( zithromax ) and Quinolones such as levofloxacin (levaquin) if the patient has allergy to penicillin Nasal Decongestant Topical decongestant is used only by adults and should not be used for longer than 3 4 days. Oral decongestant must be used cautiously in patient with HPN 3. Health Teaching: Instruct the patient to immediately consult a MD if periorbital edema and severe pain on palpation occur. Instruct the patient about the methods to promote drainage of sinuses, including humidification of the air in the home and use of steam inhalation and warm compress to relieve pressure. Avoid swimming , diving and air travel Immediately STOP SMOKING Emphasized the importance of completing the antibiotic regimen.

C.

3.

II.

SINUTIS inflammation of the sinuses A. ETIOLOGIC FACTORS 1. Allergies 2. Structural abnormalities, such as a deviated septum, small sinus ostia or a concha bullosa 3. Nasal polyps 4. carrying the cystic fibrosis gene 5. Second hand smoke is the cause of about 40% of chronic rhinosinusitis. 6. Bacterial organism ( streptococcus and haemophilus) CLINICAL MANIFESTATION Acute 1. Facial pain 2. Pressure over the affected sinus 3. Nasal obstruction 4. Fatigue 5. Purulent nasal discharge 6. Fever 7. Headache 8. Ear pain 9. Decreased sense of smell

III. PHARYNGITIS
A.

- inflammation of the throat

B.

ETIOLOGIC FACTORS 1. Viral infection ( adenovirus, influenza virus, Epstein-barr and herpes simplex 2. Bacterial infection ( group A beta hemolytic streptococci, N. gonorrhoeao, H. influenza and Mycoplasma )

B. CLINICAL MANIFESTATION Acute 1. Fiery red pharyngeal membrane and tonsils 2. Lymphoid follicles swollen and freckled with white-purple exudates. 3. Cervical lymph nodes enlarged and tender 4. Fever, malaise and sore throat 5. Hoarseness
16

MS

Chronic 1. Constant sense of irritation or fullness in the throat 2. Mucus that collects in the throat 3. Difficulty in swallowing

C.

ASSESSMENT and DIAGNOSTIC METHODS 1. Rapid screening test for streptococcal antigens 2. Optical immunoassay (OIA ) 3. Nasal swabbings 4. Blood cultures

D. NURSING MANAGEMENT 1. Encourage bed rest during febrile stage of illness. 2. Administer medications as ordered: Antibiotics ( same as sinusitis ) Analgesic Antitussive medication (dextromethorphan ) - for persistent and painful cough 3. Secure nasal swabbings and throat and blood specimens for culture as needed. 4. Administer warm saline gargles or irrigations to ease pain. 5. Perform mouth care 6. Advise patient of importance of taking the full course of antibiotic therapy. 7. Instruct patient to avoid alcohol, tobacco, 2nd hand smoke, exposure to cold and environmental and occupational pollutants. 8. Encourage patient to drink plenty of fluids IV. TONSILLITIS & ADENODITIS Tonsillitis inflammation and infection of the tonsils ( palatine and lingual ) Adenoditis - inflammation of the adenoid or the pharyngeal tonsils. A. CLINICAL MANIFESTATION Tonsilitis 1. Sore throat 2. Fever 3. Snorring 4. Difficulty swallowing

A.

ETIOLOGIC AGENTS 1. Streptococcus pneumoniae (pneumococcal pneumonia) 2. Hemophilus influenzae (bronchopneumonia) 3. Klebsiella pneumoniae 4. Diplococcus pneumoniae 5. Escherichia coli 6. Pseudomonas aeruginosa HIGH RISK GROUPS 1. Children less than 5 yo 2. Elderly PREDISPOSING FACTORS 1. Smoking 2. Air pollution 3. Immunocompromised (+) AIDS Kaposis Sarcoma Pneumocystis Carinii Pneumonia DOC: Zidovudine (Retrovir)

B.

C.

4. 5. 6.
D.

Bronchogenic Ca

Prolonged immobility (hypostatic pneumonia) Aspiration of food (aspiration pneumonia) Over fatigue

V.

PNEUMONIA inflammation of the lung parenchyma leading to pulmonary consolidation because alveoli is filled with exudates E.

SIGNS AND SYMPTOMS 1. Productive cough, greenish to rusty 2. Dyspnea with prolong expiratory grunt 3. Fever, chills, anorexia, general body malaise 4. Cyanosis 5. Pleuritic friction rub 6. Rales/crackles on auscultation 7. Abdominal distention paralytic ileus DIAGNOSTICS 1. Sputum GS/CS confirmatory; type sensitivity; (+) to cultured microorganism 2. CXR (+) pulmonary consolidation 3. CBC

and

4.
F.
MS 17

Elevated ESR (rate of erythropoeisis) N = 0.51.5% (compensatory mech to decreased O2) Elevated WBC

ABG PO2 decreased (hypoxemia)

NURSING MANAGEMENT

1.
2. 3.

4. 5.

6.

Enforce CBR (consistent to all respi disorders) Strict respiratory isolation Administer medications as ordered Broad spectrum antibiotics Penicillin pneumococcal infections Tetracycline Macrolides Azithromycin (OD x 3/days) 1. Too costly 2. Only se: ototoxicity transient hearing loss Anti-pyretics Mucolytics/expectorants Administer O2 inhalation as ordered Force fluids to liquefy secretions Institute pulmonary toilet measures to promote expectoration of secretions

A.

PRECIPITATING FACTORS 1. Malnutrition 2. Overcrowding 3. Alcoholism: Depletes VIT B1 (thiamin) alcoholic beriberi malnutrition 4. Physical and emotional stress 5. Ingestion of infected cattle with M. bovis 6. Virulence (degree of pathogenecity) MODE OF TRANSMISSION: Airborne droplet infection

B.

C.

7. 8. Place client of semi-fowlers to high fowlers 9. Provide a comfortable and humid environment 10. Provide a dietary intake high in CHO, CHON,
Calories and Vit C 11. Assist in postural drainage Patient is placed in various position to drain secretions via force of gravity Usually, it is the upper lung areas which are drained

DBE, Coughing exercises, CPT (clapping/vibration), Turning and repositioning Nebulize and suction PRN D.

SIGNS AND SYMPTOMS 1. Productive cough (yellowish) 2. Low grade afternoon fever, night sweats

3.
4. 5.

Dyspnea, anorexia, malaise, weight loss Chest/back pain Hemoptysis

DIAGNOSTICS 1. Skin testing Mantoux test PPD Induration width (within 48-72 h) 8-10 mm (DOH) 5 mm in AIDS patients is + indicates previous exposure to tubercle bacilli Sputum AFB (+) tubercle bacilli CXR (+) pulmo infiltrated due to caseous necrosis CBC elevated WBC

10-14 mm (WHO)

Nursing management: Monitor VS and BS

Best performed before meals/breakfast or 2-3 hours p.c. to prevent gastroesophageal reflux or vomiting (pagkagising maraming secretions diba? Nakukuha?) Encourage DBE Administer bronchodilators 15-30 minutes before procedure Stop if pt. cant tolerate the procedure Provide oral care after procedure as it may affect taste sensitivity Contraindications: Unstable VS Hemoptysis Increased ICP Increased IOP (glaucoma) 12. Provide pt health teaching and d/c planning Avoidance of precipitating factors Prevention of complications Atelectasis Meningitis Regular compliance to medications Importance of ffup care

2.
3. 4. E.

NURSING MANAGEMENT 1. Enforce CBR

2. 3. 4. 5. 6. 7.

Institute strict respiratory isolation Administer O2 inhalation Forced fluids Encourage DBE and coughing

NO CLAPPING in chronic PTB d/t hemoptysis may lead to hemorrhage Nebulize and suction PRN Provide comfortable and humid environment

Tracheostomy usually done at bedside, 10-20 minutes Stress test: 30 minutes Mammography: 10-20 minutes LARYNGOSPASM tracheostomy STAT OR Tracheostomy: laryngeal, thyroid, neck CA DIAPHRAGM primary muscle for respiration INTERCOSTAL MUSCLES secondary muscle for respiration ALVEOLI (Acinar cells) functional unit of the lungs; site for gas exchange (via diffusion) VENTILATION movement of air in and out of the lungs RESPIRATION lungs to cells Internal External RETROLENTAL FIBROPLASIA retinopathy/blindness immaturity d/t high O2 flow in pedia patients in

VI. PULMONARY TUBERCULOSIS (KOCHS DISEASE)

infection of the lung parenchyma caused by invasion of mycobacterium tuberculosis or tubercle bacilli (gram negative, acid fast, motile, aerobic, easily destroyed by heat/sunlight)
MS

18

8.

Institute short course chemotherapy Intensive phase INH SE: peripheral neuritis (increase vit B6 or pyridoxine Rifampicin SE: red orange color of bodily secretions PZA May be replaced with Ethambutol (SE: optic neuritis) if (+) hypersensitivity to drug

3.

Hemoptysis

DIAGNOSTICS Histoplasmin skin test is (+) ABG analysis reveals pO2 low NURSING MANAGEMENT Enforce CBG Administer meds as ordered Antifungal agents Amphotericin B (Fungizone) SE: nephrotoxicity and hypokalemia Monitor transaminases, BUN and CREA Corticosteroids Anti-pyretics Mucolytics/expectorants Administer oxygen inhalation as ordered Forced fluids Nebulize and suction as necessary Prevent complications

4.

SE: allergic reactions; hepatotoxicity and nephrotoxicity 1. Monitor liver enzymes 2. Monitor BUN and CREA

INH given for 4 months, PZA and Rifampicin is given for 2 months, A.C. to facilitate absorption These 3 drugs are given simultaneously to prevent development of resistance Standard Regimen

Streptomycin injection (aminoglycosides)

Neomycin, Amikacin, Gentamycin

9.

common SE: 8th CN damage tinnitus hearing loss ototoxicity 2. nephrotoxicity a. BUN (N = 10-20) b. CREA (N = 8-10) Health teaching and d/c planning

1.

Bronchiectasis, atelectasis Prevention of spread Spraying of breeding places Kill bird and owner! Hehe!

CHRONIC OBSTRUCTIVE PULMONARY DISEASES

Avoidance of precipitating factors : alcoholism, overcrowding Prevention of complications Atelectasis

1. 2. 3. 4.

Chronic Bronchitis Bronchial Asthma Bronchiectasis Pulmonary Emphysema CHRONIC BRONCHITIS (Blue Bloaters) Inflammation of the bronchi due to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways

I.

Military TB (extrapulmonary TB: meningeal, Potts, adrenal glands, skin, cornea) Strict compliance to medications Never double the dose! Continue taking the meds if missed a day) Diet modifications: increased CHON, CHO, Calories, Vit C Importance of ffup care

VII.

HISTOPLASMOSIS acute fungal infection caused by inhalation of contaminated dust with Histoplasma capsulatum from birds manure A. PREDISPOSING FACTORS Inhalation of contaminated dust 2. SIGNS AND SYMPTOMS PTB like symptoms Productive cough Fever, chills, anorexia, generalized body malaise Cyanosis Chest and joint pains Dyspnea
19

A.

PREDISPOSING FACTORS 1. Smoking 2. Air pollution SIGNS AND SYMPTOMS 1. Consistent productive cough

B.

2.

Dyspnea on exertion with prolonged expiratory grunt

MS

3.
4. 5. 6.

Anorexia and generalized body malaise Cyanosis Scattered rales/rhonchi Pulmonary hypertension Peripheral edema Cor pulmonale B.

3.

Sudden change in temperature, humidity and air pressure Genetics Physical and emotional stress Mixed type combination of both

C.

DIAGNOSTICS 1. ABG analysis: decreased PO2, increased PCO2, respiratory acidosis; hypoxemia cyanosis NURSING MANAGEMENT 1. Enforce CBR

D.

SIGNS AND SYMPTOMS 1. Cough that is productive 2. Dyspnea 3. Wheezing on expiration 4. Tachycardia, palpitations and diaphoresis 5. Mild apprehension, restlessness 6. Cyanosis DIAGNOSTICS 1. PFT decreased vital lung capacity

2.

Administer medications as ordered Bronchodilators Antimicrobials Corticosteroids

C.

2.
D.

ABG analysis PO2 decreased

3. 4. 5. 6. 7.

Mucolytics/expectorants

Low inflow O2 admin; high inflow will cause respiratory arrest Force fluids Nebulize and suction client as needed Provide comfortable and humid environment Health teaching and d/c planning avoidance of smoking prevent complications

NURSING MANAGEMENT 1. Enforce CBR 2. Administer medications as ordered

CO2 narcosis coma Cor pulmonale Pleural effusion Pneumothorax Regular adherence to meds Importance of ffup care

3. 4. 5. 6. 7.

II.

8.

BRONCHIAL ASTHMA reversible inflammatory lung condition caused by hypersensitivity to allergens leading to narrowing of smaller airways

Bronchodilators administer first to facilitate absorption of corticosteroids Inhalation MDI Corticosteroids Mucolytics/expectorants Mucomyst Antihistamine Administer oxygen inhalation as ordered Forced fluids Nebulize and suction patient as necessary Encourage DBE and coughing Provide a comfortable and humid environment Health teaching and d/c planning Avoidance of precipitating factors Prevention of complications Status asthmaticus DOC: Epinephrine Aminophylline drip Emphysema Regular adherence to medications Importance of ffup care

III. BRONCHIECTASIS

permanent dilation of the bronchus due to destruction of muscular and elastic tissue of the alveolar walls (subject to surgery)

A.

PREDISPOSING FACTORS 1. Extrinsic (Atopic/Allergic Asthma) Pollens, dust, fumes, smoke, fur, dander, lints 2. Intrinsic (Non-Atopic/Non-Allergic) Drugs (aspirin, penicillin, B-blockers) Foods (seafoods, eggs, chicken, chocolate) Food additives (nitrates, nitrites)
20

MS

E.

NURSING MANAGEMENT 1. Enforce CBR 2. Low inflow O2 admin; high inflow will cause respiratory arrest 3. Administer medications as ordered Bronchodilators Antimicrobials

4. 5.

6.
7.

Corticosteroids (5-10 minutes bronchodilators) Mucolytics/expectorants Force fluids Nebulize and suction client as needed Provide comfortable and humid environment Health teaching and d/c planning Avoidance of smoking Prevent complications Atelectasis

after

A. PREDISPOSING FACTORS 1. Recurrent lower respiratory tract infection Histoplasmosis 2. Congenital disease 3. Presence of tumor 4. Chest trauma SIGNS AND SYMPTOMS 1. Consistent productive cough 2. Dyspnea 3. Presence of cyanosis 4. Rales and crackles 5. Hemoptysis 6. Anorexia and generalized body malaise DIAGNOSTICS 1. ABG analysis reveals low PO2 2. Bronchoscopy direct visualization of bronchi lining using a fibroscope Pre-op Secure consent Explain procedure

CO2 narcosis coma Cor pulmonale Pleural effusion Pneumothorax Regular adherence to meds Importance of ffup care

IV. PULMONARY

B.

EMPHYSEMA terminal and irreversible stage of COPD characterized by : Inelasticity of alveoli Air trapping

Maldistribution of gasses (d/t increased air trapping) Overdistention of thoracic cavity (Barrel chest) compensatory mechanism increased AP diameter

C.

NPO 4-6 hours Monitor VS and breath sounds Post-operative Feeding initiated upon return of gag reflex Instruct client to avoid talking, coughing and smoking as it may irritate respiratory tract Monitor for s/sx of frank or gross bleeding Monitor for signs of laryngeal spasm A. PREDISPOSING FACTORS 1. Smoking 2. Air pollution 3. Hereditary: involves alpha-1 antitrypsin for elastase production for recoil of the alveoli 4. Allergy

D.

DOB and SOB prepare trache set SURGERY 1. Segmental lobectomy 2. Pneumonectomy Most feared complications Atelectasis Cardiac tamponade: muffled heart sounds, pulsus paradoxus, HPN
21

MS

5.

High risk group elderly degenerative decreased vital lung capacity and thinning of alveolar lobes

V.

PNEUMOTHORAX partial or complete collapse of the lungs due to accumulation of air in pleural space A. TYPES 1. Spontaneous air enters pleural space without an obvious cause

B.

SIGNS AND SYMPTOMS 1. Productive cough 2. Dyspnea at rest 3. Prolonged expiratory grunt 4. Resonance to hyperresonance 5. Decreased tactile fremitus 6. Decreased breath sounds ( if (-) BS lung collapse) 7. Barrel chest 8. Anorexia and generalized body malaise

2.

9. Rales or crackles 10. Alar flaring 11. Pursed-lip breathing (to eliminate excess CO2)
C. DIAGNOSTICS 1. ABG analysis reveal B.

3.

Ruptured blebs (alveolar filled sacs) inflammatory lung conditions Open air enters pleural space through an opening in pleural wall (most common) Gun shot wounds Multiple stab wounds Tension air enters pleural space during inspiration and cannot escape leading to overdistention of the thoracic cavity mediastinal shift to the affected side (ie. Flail chest) paradoxical breathing

2.
D.

Panlobular, centrilobular PO2 elevation and PCO2 depression respiratory acidosis (blue bloaters)

C.

Panacinar/centriacinar PCO2 depression and PO2 elevation (pink puffers hyperaxemia) Pulmo function test decreased vital lung capacity

PREDISPOSING FACTORS 1. Chest trauma 2. Inflammatory lung condition 3. tumors SIGNS AND SYMPTOMS 1. Sudden sharp chest pain, dyspnea, cyanosis 2. Diminished breath sounds 3. Cool, moist skin 4. Mild restlessness and apprehension

NURSING MANAGEMENT 1. Enforce CBR 2. Administer medications as ordered Bronchodilators Antimicrobials Corticosteroids

5.
D.

Resonance to hyperresonance

DIAGNOSTICS 1. ABG analysis: PO2 decreased 2. CXR confirms collapse of lungs NURSING MANAGEMENT 1. Assist in endotracheal intubation 2. Assist in thoracentesis 3. Administer meds as ordered Narcotic analgesics Morphine sulfate Antibiotics 4. Assist in CTT to H20 sealed drainage

E.

3.

Mucolytics/expectorants

Low inflow O2 admin; high inflow will cause respiratory arrest and oxygen toxicity 4. Force fluids 5. Pulmonary toilet 6. Nebulize and suction client as needed 7. Institute PEEP in mechanical ventilation PEEP positive end expiratory pressure allows for maximum alveolar diffusion prevent lung collapse 8. Provide comfortable and humid environment 9. Diet modifications: high calorie, CHON, CHO, vitamins and minerals 10. Health teaching and d/c planning Avoidance of smoking Prevent complications Atelectasis

CO2 narcosis coma Cor pulmonale Pleural effusion Pneumothorax Regular adherence to meds Importance of ffup care

RESTRICTIVE LUNG DISEASE

MS 22