Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 18

NURSING CARE OF THE CLIENT: RESPIRATORY SYSTEM

Respiratory System


Its primary function is delivery of oxygen to the lungs and removal of carbon dioxide from the lungs.

Thoracic Cavity
The inside of the chest cage is called the thoracic cavity.  Contained within the thoracic cavity are the lungs, cone-shaped, porous organs encased in the pleura, a thin, transparent double-layered serous membrane lining the thoracic cavity.


The Physiology of the Lungs

The right lung is larger than the left and is divided into three sections or lobes: upper, middle, and lower.  The left lung is divided into two lobes: upper and lower.  The upper portion of the lungs is the apex; the lower portion is the base.


Conducting Airways
The conducting airways are tubelike structures that provide a passageway for air as it travels to the lungs.  The conducting airways include the nasal passages, mouth, pharynx, larynx, trachea, bronchi, and bronchioles.


Pharynx Larynx Trachea



The conducting airways that connect nasal passages and mouth to the lower parts of the respiratory tract. The passageway for air entering and leaving the trachea and containing the vocal cords. Commonly known as the windpipe, this tube is composed of connective tissue mucosa and smooth muscle supported by C-shaped rings of cartilage.

Bronchi, Bronchioles
Two tubes, the right and left primary bronchi, that each pass into its respective lung.  Within the lungs, the bronchi branch off into increasingly smaller diameter tubes until they become the terminal bronchioles.


Respiration
A process of gas exchange necessary to supply cells with oxygen for carrying on metabolism, and to remove carbon dioxide produced as a waste byproduct.  Two types of respiration: external and internal.


External & Internal Respiration

The exchange of gases between the inhaled air and the blood in the pulmonary capillaries.  The exchange of gases at the cellular level between tissue cells and blood in systemic capillaries.


Signs & Symptoms

1. 2. 3. 4. 5. 6.

Dyspnia Cough Sputum Production Chest Pain Wheezing Hemoptesis

Assessment
Health History (allergies, occupation, lifestyle, health habits)

Inspection (client's color, level of consciousness, emotional state) (Rate, depth, quality, rhythm, effort relating to respiration)

Palpation and Percussion

Auscultation (Listening for Normal and Adventitious Breath Sounds)

Adventitious Breath Sounds

Abnormal sounds and some conditions associated with them:


Fine crackles (dry, highpitched poppingCOPD, CHF, pneumonia) Coarse crackles (moist, lowpitched gurglingpneumonia, edema, bronchitis) Sonorous wheezes (lowpitched snoringasthma, bronchitis, tumor)

Sibilant wheezes (highpitched, musical asthma, bronchitis, emphysema, tumor) Pleural friction rub (creaking, grating pleurisy, tuberculosis, abscess, pneumonia) Stridor (crowingcroup, foreign body obstruction, large airway tumor).

Common Diagnostic Tests for Respiratory Disorders

1.

2.

3.

Laboratory Tests (Hemoglobin; Arterial blood gases; Pulmonary Function Tests; Sputum Analysis& culture). Radiologic Studies (Chest X-ray; Ventilation-perfusion scan; CAT scan; Pulmonary angiography). Other (Pulse oximetry; Bronchoscopy; Thoracentesis; MRI).

Respiratory Care Modilities

O Therapy The administration of O in concentration greater than that found in environmental atmosphere  Indications -change in respiratory rate - hypoxemia - hypoxia


O Therapy


1. 2. 3. 4.


Cautions O toxicity Suppression of ventelation Source of Cross infection Fire Danger Method of Oxygen Administration slide(22-1)

Chest Physiotherapy

1. 2. 3.   

The Goal of chest physiotherapy is :

Remove bronchial secretion Improve Ventilation Increase efficiency of respiratory muscles Postural Drainage Chest Percussion &vibration Breathing exercise &retraining

Air Way Management

  1. 2. 3. 4. 

Emergency management of upper airway obstruction Causes foreign body Secretions Vomiting or food particles Enlarged tissue edema, Ca, &abscesses Assessment Inspection , palpation,& Auscultation

Airway Management


1. 2. 3. 4. 5.

Emergency Measures Opening airway by extend Pt neck back Observe airway Cross finger to clear airway If no passage Abd thrust Use resuscitation bag guide lines p 499

Endotracheal Intubation


Passing endotracheal tube through mouth or nose into the trachea

It is a method of choice in emergency  Providing airway for specific patients  For mechanical ventilation


Tracheastomy


It is a procedure in which an opening is made into the trachea and indwelling tube is inserted into the trachea


1.

Indication

To bypass an upper airway obstruction 2. To allow removal of tracheobroncheal secretions 3. For long term ventilation 4. To prevent aspiration Complications bleeding, pneumonia, air embolism emphysema pneumothrax

Upper Respiratory Tract Infections/Inflammatory Disorders



 

Rhinitis (coryza, common cold) Allergic rhinitis Sinusitis

  

Pharyngitis Tonsillitis Laryngitis

Upper Respiratory Tract Infections/Inflammatory Disorders

Are the common conditions that affect most people on occasion, some infections are acute and other are chronic

common cold
Often is used when referring to a symptoms of an upper respiratory tract infection ch.ch.by nasal congestion ,sore throat , & cough  Cold referred to a febrile, infectious, acute inflammation,of the mucus membranes of the nasal cavity


common cold


1. 2. 3. 4. 5.

Clinical manifestations Nasal congestion Scratchy or sore throat Sneezing & cough Headache & muscle ache Herpes simplex sore (cold sore )

common cold

1. 2. 3. 4. 5.

Medical Management (symptomatic management)

Fluid intake ,rest ,prevention of chills. Aqueous decongestant,anti histamin, Vit. C. Expectorant as needed Analgesic for aches ,pain , & fever. Antimicrobial to reduce incidence of complications


1.

Nursing Management
Patient teaching of self care & prevention of infection & break chain of infection

Rhinitis


Inflammation of nose by viral , obstructive ,allergic reaction.


1. 2. 3.

Clinical manifestations
Rhinorrhea excessive nasal drainage Nasal congestion, Itching ,& sneezing Headache may occur

Rhinitis


1. 2. 3. 4.

Medical Management Treatment of cause antibiotics Decongestant agents Antihistamine In severe cases corticosteroids

Acute Sinusitis


1. 2. 3.

It is inflammation of sinuses , it is resolved promptly if their opening into nasal cavity . Clinical Manifestations Pressure , pain over the sinus area Tenderness Purulent nasal secretions

Acute Sinusitis

1. 2. 3.

Medical Management
Antimicrobial agent Amoxicillin Oral & Topical Decongestant Heated mist or Saline irrigation


1. 2. 3.

Nursing management Teaching patient self care Complications

Meningitis &osteomylitis Brain abscess Ischemic infarction

Chronic Sinusitis



1. 2. 3. 4.

It is an inflammation of sinuses that persists for more than 8 weeks in adult & or 2 weeks in children Clinical Manifestations
Impaired mucociliary clearness & ventilation Chronic hoarseness & cough Chronic Headache Facial pain

Chronic Sinusitis

1. 2.

Medical Management
Strong antibiotics (for 21 days ) Surgical intervention to remove obstruction cause that cause block of drainage passage


1.
2. 3.

Nursing Management
Increase humidity Increase fluid intake Early signs of sinusitis

Acute Pharyngitis


 1. 2. 3. 4. 5.

It is a febrile inflammation of throat ,caused by virus about 70% , uncomplicated viral infection usually subsided promptly within 310 days Clinical Manifestations Fiery red pharyngeal membrane& tonsils Lymphoid follicles that are swollen Enlarge tender cervical lymph node Fever & malaise Sore throat , hoarseness,& cough

Acute Pharyngitis

1. 2.

Medical Management
Supportive measures for viral infection Pharmacologic therapy antibiotics for 10 days cephalosporinanalgesic for severe sore anti tussive medications Nutritional therapy liquid or soft diet If liquid cant tolerated IV fluid administered Nursing Management (bed rest ,skin assessment, mouth care &normal saline gargle & self care teaching

3.

4.

Chronic Pharyngitis


 1.

2. 3.

Common in adults who work or live in dusty surrounding ,use the voice too excess , suffer from chronic cough , & habitually use alcohol & tobacco Types of pharyngitis Hypertrophic :ch.ch.by general thickening& congestion of pharyngeal mucus membrane Atrophic : probably late stage of first type Chronic Granular : ch.ch.by numerous swollen lymph follicles on the pharyngeal wall

Chronic Pharyngitis

1. 2. 3.

Clinical Manifestations
Constant sense of irritation or fullness in throat Mucus expelled by coughing Difficulty in swallowing


1.

Medical Management
Relieving symptoms Avoiding exposure to irritant Correct respiratory & cardiac conditions

Chronic Pharyngitis
2. Antihistamine drugs 3. Decongestant 4. Controlling malaise

1. 2. 3. 4.

Nursing Management
Patient teaching of self care Avoid alcohol , tobacco , exposure to cold Face mask to avoid pollutant Warm fluids,&warm saline gargle

Tonsillitis


  

The tonsils are composed of lymphatic tissue & situated on each side of the oropharynx ,they frequently are the site of acute infection (tonsillitis) Clinical Manifestations Tonsils : sore throat, fever , snoring & difficulty of swallowing Adenoids : ear ache , mouth breathing , drainage ear ,frequent cold , bronchitis, noisy respiration, foul smelling breath &voice impairment

Tonsillitis

1. 2. 3.

Medical Management
For recurrent tonsillitis tonsillectomy Conservative or symptomatic therapy Antimicrobial therapy penicillin for 7 days


1.

Nursing Management
Provide post op. care :V/S ,hemorrhage , position head turned to side,water or ice chips Teaching patient :S&S of hemorrhage Avoid too much talking or coughing Liquid or semi liquid diet for several days Alkaline mouth washing with warm saline

2. 3. 4. 5.

Laryngitis


 

It is an inflammation of larynx ,often occur as a result of voice abuse or exposure to dust , chemicals , smoke , & other pollutants Common in winter & easily transmitted The cause of infection is almost virus


1. 2.

Clinical Manifestations
Hoarseness or aphonia Severe cough

Laryngitis

1. 2. 3. 4.  1. 2. 3.

Medical Management
Resting voice & avoid smoking Inhale cool steam or an aerosol Conservative treatment Antibiotics for bacterial organisms Nursing Management Rest voice Maintain a well humidified environment Daily fluid intake

Pleurisy/Pleural Effusion
Pleurisy is a painful condition that arises from inflammation of the pleura, or sac that encases the lung.  Pleural effusion occurs when the inflamed pleura secretes increased amounts of pleural fluid into the pleural cavity.


Atelectasis
  1. 2. 3. 4. 5.

Collapse or airless condition of the alveoli caused byhypoventilation,obstruction of airway or compression Clinical Manifestations Cough & sputum production Dyspnea ,tachypnea ,tachycardia Sings of pulmonary infection may present Fever Central cyanosis

Atelectasis
 1.

2. 3. 4. 5.

Management First line measures :(turning , early ambulation , lung volume expansion , coughing, spirometry ,breathing exercises If there is no response : (PEEP , IPPB) Bronchoscopy Postural Drainage & percussion If cause is compression remove the cause

Acute Tracheobronchitis


An inflammation of the mucus membrane of the trachea & the bronchial tree , often follow upper respiratory tract infection


1. 2. 3. 4. 5.

Clinical Manifestations
Dry irritating cough expectorate sputum Sternal soreness from coughing Fever ,stress , night sweating Headache & general malaise As the infection progress the patient develop (shortness of breath, noisy breath ,&purulent sputum

Acute Tracheobronchitis

1. 2. 3. 4. 5.

Medical Management
Antibiotics depend on symptoms & culture Expectorant may be prescribed Increase fluid intake Rest & cool therapy Suctioning & Bronchoscopy


1. 2. 3. 4. 5.

Nursing Management
Patient teaching Encourage fluid intake Coughing exercises to remove secretions Complete antibiotics course, Prevent over exertion

Pneumonia


An inflammation of the lung tissue that is caused by microbial agent


1. 2. 3. 4. 5.

Community Acquired Pneumonia (CAP)

Occurs either in community setting or within the first 48 hrs of hospitalization Most common in people younger than 60 yrs Most prevalent during winter & spring Caused by pneumococcus & H influenza Virus the cause in infants & children

Pneumonia


    

Hospital Acquired Pneumonia (HAP) the onset of pneumonia symptoms more than 48 hrs after admission to hospital. Also called nosocomial infection Common organism E.colli ,Klebsiella ,S.aurious It occurs when host defense impaired in certain conditions Pneumonia in the Immuno compressed host Caused by organisms also observed in CAP,HAP. Has subtle onset with progressive dyspnea , fever , &productive cough

Pneumonia

1. 2. 3. 4. 5. 6. 7. 8. 9.

Clinical Manifestations
Sudden onset of shaking chills Rapidly increase in body temperature 38-40 C Chest pluratic pain increased by deep breathing Patient looks severely ill with marked tachypnea Shortness of breath Orthopnea Poor appetite Diaphoresis &tires easily Purulent sputum

Pneumonia

1. 2. 3. 4. 5. 6. 

Medical Management
Appropriate antibiotics depend on culture result Hydration (increase fluid intake ) Antipyretic for fever & Headache Warm moist inhalation to relieve irritation Antihistamine to relieve sneezing & rhinorrhea Oxygen & respiratory supportive measures Complications : Shock & respiratory failure , Atelectasis & plural effusion Super infection

Chronic Obstructive pulmonary Disease (COPD)

 

Disease state in which air flow is obstructed by emphysema or bronchitis or both The airway obstruction is usually progressive & irreversible


1. 2. 3.

Clinical Manifestations
Cough Increase work of breathing Severe dyspnea that interfere with patient activity

Chronic Obstructive pulmonary Disease (COPD)


1. 2. 3.

Medical Management
Inhaled bronchodilators to improve airway Oxygen therapy as prescribed Pulmonary rehabilitation emotional & physiologic needs ,breathing exercises ,&methods of symptoms elevation

Chronic Obstructive pulmonary Disease (COPD)


 1. 2. 3. 4. 
1. 2. 3. 4.

Nursing Management
Patient Education About COPD Breathing exercise Inspiratory muscles training Self care activity Coping measures

Complications
Pneumonia Atelectasis Pneumothrax Respiratory insufficiency & failure

Chronic Bronchitis


1. 2.

It is a productive cough that lasts in each of 2 consecutive years in a patient whom other causes of cough is excluded Clinical Manifestations Chronic productive cough in winter Increase frequency of respiratory infection

Chronic Bronchitis
 1. 2. 3. 4. 5. 6.

Medical Management the objective of treatment are to keep the bronchioles opened & functioning Antibiotics therapy for recurrent infection Bronchodilators to remove secretion Postural Drainage & chest percussion Hydration & fluid intake Corticosteroid may be used Smoker patient should stop smoking

Emphysema
 

A complex and destructive lung disease wherein air accumulates in the tissues of the lungs. Smoking is the major cause of Emphysema


1. 2.

Classification
Panlobular : destruction of the respiratory bronchiole,alevular duct &alveoli Centrilobular : pathogenic changes take place mainly in the center of secondary lobule

Emphysema


1. 2. 3. 4. 5.

Clinical Manifestations Increase dyspnea on exertion Anoroxia & Weight loss Weakness & Inactivity Pursed lip- breathing Increase cough wheezing purulent sputum & occasionally fever

Emphysema


1. 2. 3. 4. 5. 6.

Medical Management Bronchodilators Antimicrobial Agents Oxygen therapy Pulmonary rehabilitation Smoking cessation corticosteroids

Asthma
A condition characterized by intermittent airway obstruction in response to a variety of stimuli. inflammatory  Asthma differ from COPD in that it is reversible process either spontaneously or with treatment  Allergy is the strongest predisposing factor for the development of asthma


Asthma


1.

2.

Clinical Manifestations The most three common symptoms are: a- coug b- dyspnea c- wheezing Hypoxemia may occur along with
a- cyanosis b- diaphoresis tachycardia d- widened pulse pressure c-

Asthma


1. 2. 3. 4.

Prevention : allergic test to identify the substances cause the symptoms and avoid it as possible Complications Asthmaticus Rib fracture Pneumonia Atelectases

Asthma

 1. 2. 3.

Medical Management
Pharmacologic Therapy (long term) Corticosteroid :most effective ant inflammatory medication (inhaled form) Long-acting beta2adrenergic agonist mild to moderate bronchodilator (theophilline Quick relive medications (short acting beta2 adrenergic

4.

agonists Peak flow monitoring

Asthma
 1. 2. 3. 4. 5. 6.

Nursing Management Immediate care based on severity of symptoms Assessment & Allergic History Administer medication & observe patient response Antibiotics as prescribed for infection Assist in intubations procedure if needed Psychological support for patient & his family

Acute Respiratory Failure

Conditions wherein there is a failure of the respiratory system as a whole.  It is a sudden & life threatening deterioration of gas exchange function of the lung  Acute : a fall in arterial PaO2 to less than 50mmHg &a rise in arterial PaCo2to greater than 50mmHg


Acute Respiratory Failure



1. 2. 3. 4.

Causes Decrease respiratory derive brain Dysfunction of chest wall nerves & muscles Dysfunction of lung parenchyma expansion Postoperative & inadequate ventilation

Acute Respiratory Failure

 1. 2. 3. 4. 5. 6. 7.

Clinical Manifestations Impaired oxygenation & may be include restlessness Fatigue & headache Dyspnea & air hunger Tachycardia &hypertension Confusion & lethargy Diaphoresis Respiratory Arrest Uses of accessory muscles

Acute Respiratory Failure

Medical management: Intubations and mechanical ventilation may be required to maintain adequate ventilation and oxygenation while the case corrected


Acute Respiratory Failure



1. 2. 3. 4. 5.

Nursing management: Monitoring patient responses and arterial blood gases Monitoring vital sign turning ,mouth car , skin care , and rang of motion . Teaching about the underlying disorders Assists in intubations procedure

Pulmonary Embolism
    1. 2. 3. 4.

Obstruction of a pulmonary artery by a bloodborne substance. Deep vein thrombosis is a common cause of pulmonary embolism. Other types (Air , Fat , Septic ) Clinical Manifestations Dyspnea & Tachypnea Sudden & pluretic chest pain Fever & cough & hemoptesis Apprehension Diaphoresis & syncope

Pulmonary Embolism
 1. i. ii. iii. iv. v. vi.

Medical Management Emergency Management Nasal O2 IV infusion for Medication Perfusion Scan ABGs &ECG Small dose of Morphine Intubation & mechanical Ventilation

Pulmonary Embolism
Pharmacologic Management i. Anticoagulant therapy heparin 500010000 bolus then 18u/kg/hrs warfarin for three months ii. Thrombolytic therapy (STK , Actylase (TPA)) iii. Surgical Management (Surgical Embolectomy)

Pulmonary Embolism


1. 2. 3. 4. 5. 6.

Nursing Management Preventing thrombus formation Monitoring thrombolytic therapy Providing post operative nursing care Managing O2 therapy Preventing anxiety Monitor for complications+

Pneumothorax/Hemothorax


1. 2. 3.

Traumatic disorders of the respiratory tract wherein the underlying lung tissue is compressed and eventually collapses. Types Simple Pnuemothrax Traumatic Pnuemothorax Tension

Pneumothorax/Hemothorax
 1. 2. 3. 4. 5. 6. 7.

Clinical Manifestations Sudden pluretic pain Anxious patient , dyspnea & air hunger Increase use of accessory muscles Central cyanosis Tympanic sound in percussion Absent of breath sound & tactile fremetus Agitation Diaphoresis & hypotension

Pneumothorax/Hemothorax
 1. 2. 3. 4. 5. 6. 7.

Medical Management High concentration supplemental O2 Chest tube for drainage In emergency anything may be use to fill the chest wound Heavy dressing Needle aspiration thoracenthesis Connecting chest tube to water seal drainage An emergency thoractomy may also performed

Pulmonary Edema
A life-threatening condition characterized by a rapid shift of fluid from plasma into the pulmonary interstitial tissue and the aveoli, resulting in markedly impaired gas exchange.  Can result from severe left ventrical failure, rapid administration of I.v. fluids, inhalation of noxious gases, or opiate or barbiturate overdose.


Adult Respiratory Distress Syndrome

A life-threatening condition characterized by severe dyspnea, hypoxemia, and diffuse pulmonary edema.  Usually follows major assault on multiple body systems or severe lung trauma.


Bronchiectasis
A chronic dilation of the bronchi.  Main causes of this disorder are pulmonary TB infection, chronic upper respiratory tract infections, and complications of other respiratory disorders of childhood, particularly cystic fibrosis.


Neoplasms of the Respiratory Tract

Benign neoplasms.  Lung cancer.  Cancer of the larynx.


Epistaxis
A hemorrhage of the nares or nostrils.  May be unilateral (most common) or bilateral.  Blood loss can be minimal to severe.


Smoking


Cigarette smoking is indicated as a major causative factor in the development of respiratory disorders, such as lung cancer, cancer of the larynx, emphysema, and chronic bronchitis.