ALTERATION IN RESPIRATORY SYSTEM

Pulmonary "Volumes”Pulmonary "Volumes”

1. 1. Tidal Volume:Tidal Volume:

-volume of air inspired or expired with -volume of air inspired or expired with each normal breath, about 500mleach normal breath, about 500ml

2. 2. Inspiratory Reserve VolumeInspiratory Reserve Volume-extra volume of air than can be -extra volume of air than can be

inspired over & beyond the normal inspired over & beyond the normal tidal volume, about 3000mltidal volume, about 3000ml

3. Vital Capacity3. Vital Capacity

-equals IRV + TV + ERV or 1C + ERV-equals IRV + TV + ERV or 1C + ERV

-maximum amount of air that a person can -maximum amount of air that a person can expel from the lungs after filling the lungs expel from the lungs after filling the lungs to their maximum extent & expiring to the to their maximum extent & expiring to the maximum extentmaximum extent

4. Total Lung Capacity4. Total Lung Capacity

-maximum volume to which the lungs can be -maximum volume to which the lungs can be expanded with the greatest possible effortexpanded with the greatest possible effort

NOT CLINICALLY measured !

1. Residual volume1. Residual volume2. Functional residual volume2. Functional residual volume3. Total lung capacity3. Total lung capacity

3. Expiratory Reserve Volume3. Expiratory Reserve Volume

-amount of air that can still be expired -amount of air that can still be expired by forceful expiration after the end of by forceful expiration after the end of a normal tidal expirationa normal tidal expiration

4. Residual Volume4. Residual Volume

-volume of air still remaining in the -volume of air still remaining in the lungs after the most forceful lungs after the most forceful expirationexpiration

Pulmonary "Capacities:"

1. Inspiratory Capacity1. Inspiratory Capacity

-equals TV + IRV-equals TV + IRV

-amount of air that a person can breathe -amount of air that a person can breathe beginning at the normal expiratory level & beginning at the normal expiratory level & distending his lungs to maximum amountdistending his lungs to maximum amount

2. Functional Residual Capacity2. Functional Residual Capacity

-equals ERV + RV-equals ERV + RV

-about amount of air remaining in the lungs -about amount of air remaining in the lungs at the end of normal expirationat the end of normal expiration

FACTORS AFFECTING RESPIRATORY FUNCTIONS

AGEAGE -Infants have more rapid respiratory rate. -Infants have more rapid respiratory rate.

They have primary respiratory activity that They have primary respiratory activity that is abdominalis abdominal

-Changes of aging affect the breathing -Changes of aging affect the breathing pattern. These include loss of elasticity, pattern. These include loss of elasticity, decreased reflex/cilia action, fragile decreased reflex/cilia action, fragile mucous membrane, osteoporosis, mucous membrane, osteoporosis, decreased immune system and gastro-decreased immune system and gastro-esophageal reflux.esophageal reflux.

ENVIRONMENTENVIRONMENT

- Altitude, heat, cold, air pollution affect - Altitude, heat, cold, air pollution affect oxygenationoxygenation

LIFESTYLELIFESTYLE

- Physical exercise increases the rate - Physical exercise increases the rate and depth of respirationand depth of respiration

-Sedentary lifestyle will cause -Sedentary lifestyle will cause decreased alveolar expansiondecreased alveolar expansion

-Smokers are prone to develop COPD-Smokers are prone to develop COPD

HEALTH STATUSHEALTH STATUS

-Healthy persons have intact -Healthy persons have intact respiratory functionsrespiratory functions

-Diseases of the lungs affect -Diseases of the lungs affect oxygenation. oxygenation.

-People with chronic illnesses often -People with chronic illnesses often have muscle wasting and poor have muscle wasting and poor muscle tone. muscle tone.

MEDICATIONSMEDICATIONS

-Sedatives, Hypnotics, tranquilizers, -Sedatives, Hypnotics, tranquilizers, barbiturates and narcotics greatly barbiturates and narcotics greatly depress respiratory drive.depress respiratory drive.

STRESSSTRESS

-Physiologic and Psychological -Physiologic and Psychological responses to stress can affect responses to stress can affect respiration. respiration.

-Hyperventilation, lightheadedness, -Hyperventilation, lightheadedness, numbness and tingling sensation may numbness and tingling sensation may result.result.

PREGNANCYPREGNANCY -Fetus and amniotic sac grow large -Fetus and amniotic sac grow large

enough to displace the diaphragm enough to displace the diaphragm upward. upward.

-The mother’s respiratory rate -The mother’s respiratory rate becomes faster and the breath becomes faster and the breath becomes shallower. becomes shallower.

-‘Lightening’ improves client’s -‘Lightening’ improves client’s breathingbreathing

Normal Breathing pattern

12-20 respiratory rate12-20 respiratory rate Active inspiration with contraction of Active inspiration with contraction of

diaphragmdiaphragm Passive expiration with relaxation of Passive expiration with relaxation of

diaphragm diaphragm Steady rhythm and regular rate and sizeSteady rhythm and regular rate and size I:E ratio is 1:2 (inspiration is half that of I:E ratio is 1:2 (inspiration is half that of

expiration)expiration)

DEVIATIONS FROM THE NORMAL RESPIRATORY FUNCTIONHYPOXIAHYPOXIA

-A condition of insufficient oxygen in -A condition of insufficient oxygen in the lungs and the body. the lungs and the body.

-Signs of Hypoxia may be the -Signs of Hypoxia may be the following: Tachycardia, Tachypnea, following: Tachycardia, Tachypnea, Dyspnea, Restlessness, Light-Dyspnea, Restlessness, Light-headedness, Flaring of nostrils, headedness, Flaring of nostrils, Intercostal retractions, changes in Intercostal retractions, changes in sensorium and Cyanosis.sensorium and Cyanosis.

HYPOVENTILATIONHYPOVENTILATION

-Inadequate alveolar ventilation, which -Inadequate alveolar ventilation, which can lead to hypoxia. can lead to hypoxia.

-When CO2 accumulates in the blood, -When CO2 accumulates in the blood, there is HYPERCARBIA.there is HYPERCARBIA.

CYANOSISCYANOSIS

-Bluish discoloration of the skin, nail -Bluish discoloration of the skin, nail beds and mucus membrane due to beds and mucus membrane due to reduced hemoglobin-oxygen reduced hemoglobin-oxygen saturation.saturation.

-There must be about -There must be about 5 grams or more5 grams or more of unoxygenated blood per 100 ml for of unoxygenated blood per 100 ml for this to manifest externally.this to manifest externally.

ALTERED BREATHING PATTERNSALTERED BREATHING PATTERNS

-Breathing patterns refer to the rate, -Breathing patterns refer to the rate, volume, rhythm and relative ease or volume, rhythm and relative ease or effort of respiration.effort of respiration.

-Altered breathing can be related to -Altered breathing can be related to rate, rhythm and positionrate, rhythm and position

ALTERED BREATHING PATTERNS: RATEALTERED BREATHING PATTERNS: RATE

EUPNEAEUPNEA- normal respiration which is quiet and - normal respiration which is quiet and effortlesseffortless

TACHYPNEATACHYPNEA- rapid breathing, more than 20 - rapid breathing, more than 20 breaths per minutebreaths per minute

BRADYPNEABRADYPNEA- abnormally slow respiration (less - abnormally slow respiration (less than 12)than 12)

APNEAAPNEA- cessation of breathing- cessation of breathing

ALTERED BREATHING PATTERNS: RHYTHM ALTERED BREATHING PATTERNS: RHYTHM KUSSMAUL’S BREATHING-KUSSMAUL’S BREATHING- Deep and rapid Deep and rapid

respiration seen in metabolic acidosis(DM)respiration seen in metabolic acidosis(DM)CHEYNE-STOKES Respiration-CHEYNE-STOKES Respiration- Marked rhythmic Marked rhythmic

waxing and waning of respiration from very deep waxing and waning of respiration from very deep to very shallow breathing and temporary apnea. to very shallow breathing and temporary apnea. Usually seen in cases of CHF, increased ICP and Usually seen in cases of CHF, increased ICP and drug overdose.drug overdose.

BIOT’S respiration-BIOT’S respiration- Shallow breaths interrupted by Shallow breaths interrupted by apnea, seen in patients with CNS disorders.apnea, seen in patients with CNS disorders.

ALTERED BREATHING PATTERNS: ALTERED BREATHING PATTERNS: Position Position

ORTHOPNEA- inability to breathe in a ORTHOPNEA- inability to breathe in a supine position.supine position.

DYSPNEA- difficulty or uncomfortable DYSPNEA- difficulty or uncomfortable breathing breathing

OBSTRUCTED AIRWAYOBSTRUCTED AIRWAY

Upper airway obstruction involves the Upper airway obstruction involves the nose, pharynx and larynx. nose, pharynx and larynx.

-The most common clinical cause is the -The most common clinical cause is the tonguetongue!!

Lower airway obstruction involves the Lower airway obstruction involves the trachea, bronchi and lungs.trachea, bronchi and lungs.

VENTILATION-PERFUSION VENTILATION-PERFUSION MISMATCHMISMATCH

-When mismatching occurs, some -When mismatching occurs, some alveolar regions will be well ventilated alveolar regions will be well ventilated but poorly perfused (a condition but poorly perfused (a condition known as DEADSPACE), known as DEADSPACE),

-While others may be well perfused but -While others may be well perfused but poorly ventilated (known as poorly ventilated (known as SHUNTING)SHUNTING)

The AssessmentThe Assessment

LABORATORY EXAMINATIONLABORATORY EXAMINATION

1. ABG analysis1. ABG analysis

2. Sputum analysis2. Sputum analysis

3. Direct visualization- bronchoscopy3. Direct visualization- bronchoscopy

4. Indirect visualization- CXR, CT and MRI4. Indirect visualization- CXR, CT and MRI

5. Pulmonary function test5. Pulmonary function test

ABG analysis

This test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an arterial sample

Pre-test: choose site carefully, secure Pre-test: choose site carefully, secure equipments- syringe, needle, container equipments- syringe, needle, container with icewith ice

Intra-test: Obtain a 5 mL specimen from Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial)the artery (brachial, femoral and radial)

Post-test: Apply firm pressure for 5 Post-test: Apply firm pressure for 5 minutes, label specimen correctly, place minutes, label specimen correctly, place in the container with icein the container with ice

ABG normal valuesABG normal values

PaO2PaO2 80-100 mmHg80-100 mmHg

PaCO2PaCO2 35-45 mmHg35-45 mmHg

pHpH 7.35- 7.457.35- 7.45

HCO3HCO3 22- 26 mEq/L22- 26 mEq/L

O2 SatO2 Sat 98-100%98-100%

Sputum AnalysisSputum Analysis

This test analyzes the sample of sputum This test analyzes the sample of sputum to diagnose respiratory diseases, identify to diagnose respiratory diseases, identify organism, and identify abnormal cells organism, and identify abnormal cells

Pre-test: Encourage to increase fluid Pre-test: Encourage to increase fluid intakeintake

Intra-test: rinse mouth with WATER Intra-test: rinse mouth with WATER only, instruct the patient to take 3 deep only, instruct the patient to take 3 deep breaths and force a deep cough, steam breaths and force a deep cough, steam nebulization, collect early morning nebulization, collect early morning sputumsputum

Post-test: provide oral hygiene, label Post-test: provide oral hygiene, label specimen correctlyspecimen correctly

Pulse OximetryPulse Oximetry

Non-invasive method of continuously Non-invasive method of continuously monitoring the oxygen saturation of monitoring the oxygen saturation of hemoglobin by photospectrometryhemoglobin by photospectrometry

A sensor or probe is attached to the A sensor or probe is attached to the earlobe, forehead, fingertip or the bridge earlobe, forehead, fingertip or the bridge of the noseof the nose

BronchoscopyBronchoscopy

A direct inspection of the trachea and A direct inspection of the trachea and bronchi through a flexible fiber-optic or a bronchi through a flexible fiber-optic or a rigid bronchoscoperigid bronchoscope

Done to determine location of pathologic Done to determine location of pathologic lesions, to remove foreign objects, to lesions, to remove foreign objects, to collect tissue specimen and remove collect tissue specimen and remove secretions/aspirated materialssecretions/aspirated materials

Pre-test: Consent, NPO x 6h, teachingPre-test: Consent, NPO x 6h, teaching Intra-test: position supine or sitting upright in a Intra-test: position supine or sitting upright in a

chair, administer sedative, gag reflex will be chair, administer sedative, gag reflex will be abolished, remove denturesabolished, remove dentures

Post-test: NPO until gag reflex returns, Post-test: NPO until gag reflex returns, position SEMI-fowler’s with head turned to position SEMI-fowler’s with head turned to sides, hoarseness is temporary, CXR after the sides, hoarseness is temporary, CXR after the procedure, keep tracheostomy set and suction procedure, keep tracheostomy set and suction x 24 hoursx 24 hours

ThoracentesisThoracentesis

Pleural fluid aspiration for obtaining a Pleural fluid aspiration for obtaining a specimen of pleural fluid for analysis, specimen of pleural fluid for analysis, relief of lung compression and biopsy relief of lung compression and biopsy specimen collectionspecimen collection

Pre-test: ConsentPre-test: Consent Intra-test: position the patient sitting with Intra-test: position the patient sitting with

arms on a table or side-lying fowler’s, arms on a table or side-lying fowler’s, instruct not to cough, breathe deeply or instruct not to cough, breathe deeply or movemove

Post-test: position unaffected side to Post-test: position unaffected side to allow lung expansion of the affected allow lung expansion of the affected side, CXR obtained, maintain pressure side, CXR obtained, maintain pressure dressing and monitor respiratory statusdressing and monitor respiratory status

Pulmonary Function Tests

Volume and capacity tests aid diagnosis Volume and capacity tests aid diagnosis in patient with suspected pulmonary in patient with suspected pulmonary dysfunctiondysfunction

Evaluates ventilatory functionEvaluates ventilatory functionDetermines whether obstructive or Determines whether obstructive or

restrictive diseaserestrictive diseaseCan be utilized as screening testCan be utilized as screening test

Pulmonary function test:Pulmonary function test:

SpirometrySpirometryLung volumesLung volumesGas transferGas transfer

Bronchial chalengeBronchial chalenge

Pre-test: Teaching, no smoking for 3 Pre-test: Teaching, no smoking for 3 days, only light meal 4 hours before the days, only light meal 4 hours before the testtest

Intra-test: position sitting, bronchodilator, Intra-test: position sitting, bronchodilator, nose-clip and mouthpiece, fatigue and nose-clip and mouthpiece, fatigue and dyspnea during the test dyspnea during the test

Post-test: adequate rest periods, loosen Post-test: adequate rest periods, loosen tight clothingtight clothing

DiagnosesDiagnoses

Ineffective Airway ClearanceIneffective Airway Clearance Ineffective Breathing PatternIneffective Breathing Pattern Impaired Gas ExchangeImpaired Gas ExchangeActivity IntoleranceActivity Intolerance Ineffective tissue perfusionIneffective tissue perfusionDisturbed sleep patternDisturbed sleep patternAcute painAcute painAnxietyAnxiety

PlanningPlanning

The Overall goals for a client with The Overall goals for a client with oxygenation problems are to:oxygenation problems are to:

Maintain patent airwayMaintain patent airway Improve comfort and ease of breathingImprove comfort and ease of breathing Maintain or improve pulmonary ventilation Maintain or improve pulmonary ventilation

and oxygenationand oxygenation Demonstrate improved gas exchangesDemonstrate improved gas exchanges Improve ability to participate in physical Improve ability to participate in physical

activities activities

ImplementationImplementation

Promoting OxygenationPromoting OxygenationPositioning the client to allow for Positioning the client to allow for

maximum chest expansionmaximum chest expansionEncouraging or providing frequent Encouraging or providing frequent

changes in position- usually Q2Hchanges in position- usually Q2HEncouraging ambulationEncouraging ambulationGiving pain medications before deep

breathing and coughing

Deep breathing and coughing exercisesDeep breathing and coughing exercisesThese measures allow for the removal These measures allow for the removal

of secretions from the airway.of secretions from the airway.Breathing exercises are frequently Breathing exercises are frequently

indicated for the clients with indicated for the clients with restricted chest expansion such as restricted chest expansion such as COPD and post-thoracic surgical COPD and post-thoracic surgical patients.patients.

HydrationHydrationThis maintains the moisture of the This maintains the moisture of the

respiratory mucous membrane. respiratory mucous membrane. Increased fluid intake as toleratedIncreased fluid intake as toleratedMilk should be avoided as it increases Milk should be avoided as it increases

the viscosity of secretions. the viscosity of secretions. Use of humidifiers Use of humidifiers Use of nebulizers or aerosol therapyUse of nebulizers or aerosol therapy

Positioning and AmbulationPositioning and AmbulationAmbulation and the ability to change Ambulation and the ability to change

position frequently are two natural position frequently are two natural means for keeping the lungs open means for keeping the lungs open and clear of secretions.and clear of secretions.

Movements help shift respiratory Movements help shift respiratory secretions in the airway. secretions in the airway.

Mucus tends to pool in the lungs of Mucus tends to pool in the lungs of people who cannot move around. people who cannot move around.

Pursed-lip breathingPursed-lip breathingThis is a special measure to be used This is a special measure to be used

along with deep breathing.along with deep breathing. Patients with COPD should be taught Patients with COPD should be taught

this technique to aid in the release of this technique to aid in the release of trapped air from the obstructed trapped air from the obstructed airways. airways.

Prevents AIR- TRAPPINGPrevents AIR- TRAPPING

Respiratory medicationsRespiratory medicationsBronchodilators, anti-inflammatory Bronchodilators, anti-inflammatory

drugs, expectorants, mucolytics and drugs, expectorants, mucolytics and cough suppressants may be used to cough suppressants may be used to treat respiratory problemstreat respiratory problems

Chest PhysiotherapyChest Physiotherapy These are DEPENDENT nursing actions These are DEPENDENT nursing actions

performed with a physician’s order.performed with a physician’s order. Chest physiotherapy is based on the fact Chest physiotherapy is based on the fact

that mucus can be knocked or shaken form that mucus can be knocked or shaken form the walls of the airways and helped to drain the walls of the airways and helped to drain from the lungs. from the lungs.

The usual SEQUENCE is as follows- The usual SEQUENCE is as follows- POSITIONING, Percussion, Vibration, and POSITIONING, Percussion, Vibration, and removal of secretions by SUCTIONING or removal of secretions by SUCTIONING or Coughing followed lastly by oral hygiene Coughing followed lastly by oral hygiene

Oxygen therapyOxygen therapyUse of cannula, face mask and venturi Use of cannula, face mask and venturi

maskmask

Use of Artificial AirwaysUse of Artificial AirwaysThese artificial airways are inserted to These artificial airways are inserted to

maintain patent air passages for maintain patent air passages for clients whose airway have become or clients whose airway have become or may become obstructed. may become obstructed.

These are devices that provide a more These are devices that provide a more direct route to the lungs than the direct route to the lungs than the natural airway natural airway

SuctioningSuctioningThis is a mechanical aspiration of the This is a mechanical aspiration of the

airways involving the use of a catheter airways involving the use of a catheter inserted through the nose, mouth or inserted through the nose, mouth or tracheal tubetracheal tube

The catheter is attached to a portable The catheter is attached to a portable or wall unit SUCTION machine. or wall unit SUCTION machine. Secretions are drawn up by a vacuum.Secretions are drawn up by a vacuum.

Care of patients with chest tubes and Care of patients with chest tubes and drainage systemsdrainage systems

Assists in emergency interventions Assists in emergency interventions like removal of airway obstruction (by like removal of airway obstruction (by Heimlich maneuver), and initiating Heimlich maneuver), and initiating CPRCPR

EvaluationEvaluation

Nurses must collect data to evaluate Nurses must collect data to evaluate the effectiveness of interventions. the effectiveness of interventions.

The nurse works with the patient to The nurse works with the patient to develop goals develop goals

Common Respiratory problemsCommon Respiratory problems

DyspneaDyspnea

-Breathing difficulty-Breathing difficulty

-Associated with many conditions- -Associated with many conditions- CHF, MG, GBS, Muscular dystrophy, CHF, MG, GBS, Muscular dystrophy, obstruction, etc…obstruction, etc…

General nursing interventions:General nursing interventions:

1. Fowler’s position to promote 1. Fowler’s position to promote maximum lung expansion and maximum lung expansion and promote comfort. An alternative promote comfort. An alternative position is the ORTHOPNEIC positionposition is the ORTHOPNEIC position

2. O2 (1-3 lpm) usually via nasal 2. O2 (1-3 lpm) usually via nasal cannulacannula

3. Provide comfort 3. Provide comfort

Cough and sputum productionCough and sputum productionCough is a protective reflexCough is a protective reflexSputum production has many stimuliSputum production has many stimuli

-Thick, yellow, green or rust-colored-Thick, yellow, green or rust-colored bacterial pneumoniabacterial pneumonia

-Profuse, Pink, frothy-Profuse, Pink, frothy pulmonary edemapulmonary edema

-Scant, pink-tinged, mucoid-Scant, pink-tinged, mucoid Lung tumorLung tumor

General nursing InterventionGeneral nursing Intervention

1. Provide adequate hydration1. Provide adequate hydration

2. Administer aerosolized solutions2. Administer aerosolized solutions

3. advise smoking cessation3. advise smoking cessation

4. oral hygiene 4. oral hygiene

CyanosisCyanosis Bluish discoloration of the skinBluish discoloration of the skin A LATE indicator of hypoxiaA LATE indicator of hypoxia Appears when the unoxygenated hemoglobin Appears when the unoxygenated hemoglobin

is more than 5 grams/dLis more than 5 grams/dL Central cyanosisCentral cyanosis observe color on the observe color on the

undersurface of tongue and lipsundersurface of tongue and lips Peripheral cyanosisPeripheral cyanosis observe the nail beds, observe the nail beds,

earlobesearlobes

Interventions:Interventions:Check for airway patencyCheck for airway patencyOxygen therapyOxygen therapyPositioningPositioningSuctioningSuctioningChest physiotherapyChest physiotherapyCheck for gas poisoningCheck for gas poisoningMeasures to increased hemoglobin

HemoptysisHemoptysisExpectoration of blood from the Expectoration of blood from the

respiratory tractrespiratory tractCommon causes: Pulmo infection, Lung Common causes: Pulmo infection, Lung

CA, Bronchiectasis, Pulmo emboliCA, Bronchiectasis, Pulmo emboliBleeding from stomach Bleeding from stomach acidic pH, acidic pH,

coffee ground materialcoffee ground material

Interventions:Interventions:Keep patent airwayKeep patent airwayDetermine the causeDetermine the causeSuctioning prnSuctioning prnOxygen therapyOxygen therapyAdminister Fibrin stabilizers like Administer Fibrin stabilizers like

aminocaproic acid and tranexamic acidaminocaproic acid and tranexamic acid

EpistaxisEpistaxis Bleeding from the nose caused by rupture of tiny, Bleeding from the nose caused by rupture of tiny,

distended vessels in the mucus membrane distended vessels in the mucus membrane Most common site- anterior septumMost common site- anterior septum

CausesCauses1. trauma1. trauma2. infection2. infection3. Hypertension3. Hypertension4. blood dyscrasias , nasal tumor, cardio diseases4. blood dyscrasias , nasal tumor, cardio diseases

Nursing InterventionsNursing Interventions 1. Position patient: Upright, leaning forward, 1. Position patient: Upright, leaning forward,

tiltedtilted prevents swallowing and aspiration prevents swallowing and aspiration 2. Apply direct pressure. Pinch nose against 2. Apply direct pressure. Pinch nose against

the middle septum x 5-10 minutesthe middle septum x 5-10 minutes 3. If unrelieved, administer topical 3. If unrelieved, administer topical

vasoconstrictors, silver nitrate, gel foamsvasoconstrictors, silver nitrate, gel foams 4. Assist in electrocautery and nasal packing 4. Assist in electrocautery and nasal packing

for posterior bleedingfor posterior bleeding

CONDITIONS OF THE UPPER CONDITIONS OF THE UPPER AIRWAYAIRWAY

Upper airway infectionsUpper airway infections Pharyngitis and tonsillitis Pharyngitis and tonsillitis - Assessment findings- Assessment findings Fiery-red pharyngeal membraneFiery-red pharyngeal membrane White-purple flecked exudatesWhite-purple flecked exudates Enlarged and tender cervical lymph nodesEnlarged and tender cervical lymph nodes Fever malaise ,sore throatFever malaise ,sore throat Difficulty swallowingDifficulty swallowing Cough may be absentCough may be absent

Rhinitis(coryza,common cold)

Allergic rhinitis Sinusitis

Pharyngitis Tonsillitis Laryngitis

-Viral

-Exposure to allergens

-Bacterial (strep,pneumo.) viral

-Bacterial/viral

-Bacterial(strep)

Irritation due to excessive use of voice,exposure to irritants(cigarette smoke)

Extension of rhinitis

Upper airway infection: TonsillitisUpper airway infection: Tonsillitis

-Infection and inflammation of the -Infection and inflammation of the tonsilstonsils

Most common organism- Group A- Most common organism- Group A- beta hemolytic streptococcus (GABS)beta hemolytic streptococcus (GABS)

Laboratory testsLaboratory tests1. CBC1. CBC2. Culture2. Culture

MEDICAL managementMEDICAL management

1. Antibiotics- penicillin1. Antibiotics- penicillin

2. Tonsillectomy for chronic cases and 2. Tonsillectomy for chronic cases and abscess formation abscess formation

Nursing InterventionsNursing Interventions

1. Maintain Patent Airway1. Maintain Patent Airway

-Increase fluid intake to loosen -Increase fluid intake to loosen secretionssecretions

-Utilize room vaporizers or steam -Utilize room vaporizers or steam inhalationinhalation

-Administer medications to relieve -Administer medications to relieve nasal congestionnasal congestion

2. Promote comfort2. Promote comfort

-Administer prescribed analgesics-Administer prescribed analgesics

-Administer topical analgesics-Administer topical analgesics

-Warm gargles for the relief of sore -Warm gargles for the relief of sore throatthroat

-Provide oral hygiene-Provide oral hygiene

3. Promote communication3. Promote communication

-Instruct patient to refrain from speaking as -Instruct patient to refrain from speaking as much as possiblemuch as possible

-Provide writing materials-Provide writing materials

4. Administer prescribed antibiotics4. Administer prescribed antibiotics

-Monitor for possible complications like -Monitor for possible complications like meningitis, otitis media, abscess formationmeningitis, otitis media, abscess formation

5. Assist in surgical intervention5. Assist in surgical intervention

ASSESSMENT FINDINGSASSESSMENT FINDINGSSore throat and mouth breathingSore throat and mouth breathingFeverFeverDifficulty swallowingDifficulty swallowingEnlarged, reddish tonsilsEnlarged, reddish tonsilsFoul-smelling breathFoul-smelling breath

NURSING INTERVENTION for NURSING INTERVENTION for tonsillectomytonsillectomy

1. Pre-operative care1. Pre-operative careConsentConsentRoutine pre-op surgical careRoutine pre-op surgical care

2. POST-operative care2. POST-operative care Position: Most comfortable is Lateral Decubitus Position: Most comfortable is Lateral Decubitus

for drainagefor drainage Maintain oral airway, until gag reflex returns Maintain oral airway, until gag reflex returns Apply ICE collar to the neck to reduce edemaApply ICE collar to the neck to reduce edema Advise patient to Advise patient to refrain from talking and refrain from talking and

coughingcoughing Ice chipsIce chips are given when there is no bleeding and are given when there is no bleeding and

gag reflex returns then oral feeding follows.gag reflex returns then oral feeding follows.

Notify physician ifNotify physician ifa. a. Patient swallows frequentlyPatient swallows frequentlyb. vomiting of large amount of bright b. vomiting of large amount of bright

red or dark bloodred or dark bloodc. PR increased, restless and Temp is c. PR increased, restless and Temp is

increasedincreasedHemorrhage is the most serious Hemorrhage is the most serious

complication usually 12-24hrs post opcomplication usually 12-24hrs post op

Acute Respiratory Failure Acute Respiratory Failure

Sudden and life-threatening Sudden and life-threatening deterioration of the gas-exchange deterioration of the gas-exchange function of the lungsfunction of the lungs

Occurs when the lungs no longer Occurs when the lungs no longer meet the body’s metabolic needsmeet the body’s metabolic needs

Defined clinically as:Defined clinically as:

1. PaO2 of less than 50 mmHg1. PaO2 of less than 50 mmHg

2. PaCO2 of greater than 50 mmHg2. PaCO2 of greater than 50 mmHg

3. Arterial pH of less than 7.353. Arterial pH of less than 7.35

CAUSESCAUSESCNS depression- head trauma, CNS depression- head trauma,

sedativessedativesCVS diseases- MI, CHFCVS diseases- MI, CHFAirway irritants- smoke, fumesAirway irritants- smoke, fumesEndocrine and metabolic disorders- Endocrine and metabolic disorders-

myxedema, metabolic alkalosismyxedema, metabolic alkalosisThoracic abnormalities- chest traumaThoracic abnormalities- chest trauma

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Decreased Respiratory DriveDecreased Respiratory Drive

Brain injury, sedatives, metabolic Brain injury, sedatives, metabolic disorders disorders impair the normal impair the normal response of the brain to normal response of the brain to normal respiratory stimulationrespiratory stimulation

Dysfunction of the chest wallDysfunction of the chest wallDystrophy, MS disorders, peripheral Dystrophy, MS disorders, peripheral

nerve disordersnerve disorders disrupt the impulse disrupt the impulse transmission from the nerve to the transmission from the nerve to the diaphragmdiaphragm abnormal ventilation abnormal ventilation

Dysfunction of the Lung ParenchymaDysfunction of the Lung ParenchymaPleural effusion, hemothorax, Pleural effusion, hemothorax,

pneumothorax, obstructionpneumothorax, obstruction interfere ventilationinterfere ventilation prevent lung prevent lung expansion expansion

ASSESSMENT FINDINGSASSESSMENT FINDINGS RestlessnessRestlessness DyspneaDyspnea CyanosisCyanosis Altered respirationAltered respiration Altered mentationAltered mentation TachycardiaTachycardia Cardiac arrhythmiasCardiac arrhythmias Respiratory arrestRespiratory arrest

DIAGNOSTIC FINDINGSDIAGNOSTIC FINDINGSPulmonary function testPulmonary function testABG=pH below 7.35; hypoxiaABG=pH below 7.35; hypoxiaCXR- pulmonary infiltratesCXR- pulmonary infiltratesECG- arrhythmiasECG- arrhythmias

MEDICAL TREATMENTMEDICAL TREATMENT IntubationIntubationMechanical ventilationMechanical ventilationAntibioticsAntibioticsSteroidsSteroidsBronchodilatorsBronchodilators

NURSING INTERVENTIONSNURSING INTERVENTIONS1. Maintain patent airway 1. Maintain patent airway 2. Administer O2 to maintain Pa02 at 2. Administer O2 to maintain Pa02 at

more than 50 mmHgmore than 50 mmHg3. Suction airways as required3. Suction airways as required4. Monitor serum electrolyte levels4. Monitor serum electrolyte levels5. Administer care of patient on

mechanical ventilation

COPDCOPD

These are group of disorders These are group of disorders associated with recurrent or associated with recurrent or persistent obstruction of air passage persistent obstruction of air passage and airflow, usually irreversible. and airflow, usually irreversible.

AsthmaAsthmaChronic bronchitisChronic bronchitisEmphysemaEmphysemaBronchiectasisBronchiectasis

The most common and significant The most common and significant risk factor of COPD is cigarette risk factor of COPD is cigarette smoking.smoking.

Others- fumes, air pollution, recurrent Others- fumes, air pollution, recurrent respi. Infection, geneticsrespi. Infection, genetics

The general pathophysiologyThe general pathophysiology In COPD there is In COPD there is airflow limitationairflow limitation

that is both progressive and that is both progressive and associated with associated with abnormal abnormal inflammatoryinflammatory response of the lungs response of the lungs

ASTHMAASTHMA

The acute episode of REVERSIBLE The acute episode of REVERSIBLE airway obstruction is characterized by airway obstruction is characterized by airway hyperactivity to various stimuliairway hyperactivity to various stimuli

Factors:Factors:

ExtrinsicExtrinsic

IntrinsicIntrinsic

Asthma PathophysiologyAsthma Pathophysiology Immunologic/allergic reactionImmunologic/allergic reaction results in results in

histamine release, which produces histamine release, which produces three three main airway responsesmain airway responses

a. a. EdemaEdema of mucous membranes of mucous membranes

b. b. SpasmSpasm of the smooth muscle of bronchi of the smooth muscle of bronchi and bronchiolesand bronchioles

c. Accumulation of tenacious c. Accumulation of tenacious secretionssecretions

Assessment findings: historyAssessment findings: history

1. Family history of allergies1. Family history of allergies

2. Client history of eczema2. Client history of eczema

Respiratory distressRespiratory distressShortness of breathShortness of breathExpiratory wheezeExpiratory wheezeUse of accessory musclesUse of accessory muscles IrritabilityIrritabilitydiaphoresis, cough, anxiety, weak diaphoresis, cough, anxiety, weak

pulsepulse

Emphysema

There is progressive and irreversible There is progressive and irreversible alveolar destruction with abnormal alveolar destruction with abnormal alveolar enlargementalveolar enlargement

The result is The result is INCREASED lung INCREASED lung compliancecompliance, DECREASED oxygen , DECREASED oxygen diffusion and INCREASED airway diffusion and INCREASED airway resistance!resistance!

These changes cause a state of These changes cause a state of carbon dioxide retention, hypoxia, carbon dioxide retention, hypoxia, and respiratory acidosis.and respiratory acidosis.

Cigarette smokingCigarette smokingHeredity, Bronchial asthmaHeredity, Bronchial asthma

Aging processAging process

Disequilibrium betweenDisequilibrium between

ELASTASE & ANTIELASTASE (alpha-1-antitrypsin)ELASTASE & ANTIELASTASE (alpha-1-antitrypsin)

Destruction of distal airways and alveoliDestruction of distal airways and alveoliOverdistention of ALVEOLIOverdistention of ALVEOLI

Hyper-inflated and pale lungsHyper-inflated and pale lungs

Air trapping, decreased gas exchange and Retention of CO2Air trapping, decreased gas exchange and Retention of CO2

HypoxiaHypoxia Respiratory acidosisRespiratory acidosis

Anorexia, fatigue, weight lossAnorexia, fatigue, weight lossFeeling of breathlessness, coughFeeling of breathlessness, coughsputum production, flaring of the sputum production, flaring of the

nostrilsnostrilsDyspneaDyspneaBarrel chest Barrel chest

Hyper-resonance in percussion, Hyper-resonance in percussion, decreased breath sounds with decreased breath sounds with prolonged expirationprolonged expiration

Diagnostic tests: pCO2 elevated, Diagnostic tests: pCO2 elevated, PO2 PO2 normal or slightly decreasednormal or slightly decreased

Chronic bronchitisChronic bronchitis

Chronic inflammation of the bronchial Chronic inflammation of the bronchial air passageway characterized by the air passageway characterized by the presence of cough and presence of cough and sputum sputum production for at least 3 months in production for at least 3 months in each 2 consecutive years.each 2 consecutive years.

Characteristic changes include:Characteristic changes include:Hypertrophy/ hyperplasia of the Hypertrophy/ hyperplasia of the

mucus-secreting glands in the mucus-secreting glands in the bronchibronchi

Decreased ciliary activity, chronic Decreased ciliary activity, chronic inflammationinflammation

Narrowing of the small airways.Narrowing of the small airways.

AssessmentAssessment

1. 1. Productive (copious) coughProductive (copious) cough, dyspnea on , dyspnea on exertion, use of accessory muscles of exertion, use of accessory muscles of respiration, scattered rales and rhonchirespiration, scattered rales and rhonchi

2.2. Feeling of epigastric fullness, cyanosis, Feeling of epigastric fullness, cyanosis, distended neck veins, distended neck veins, edemaedema

3.3. Diagnostic tests: increased pCO2 Diagnostic tests: increased pCO2 decreased PO2decreased PO2

Bronchiectasis

Permanent abnormal dilation of the Permanent abnormal dilation of the bronchi with bronchi with destruction of muscular destruction of muscular and elastic structure of the bronchial and elastic structure of the bronchial wallwall

Caused by Caused by bacterial infection or recurrent lower bacterial infection or recurrent lower

respiratory tract infectionsrespiratory tract infectionscongenital defects (altered bronchial congenital defects (altered bronchial

structures)structures) lung tumorslung tumors

assessment assessment Chronic cough with production of Chronic cough with production of

mucopurulent sputum, mucopurulent sputum, hemoptysis,hemoptysis, exertional dyspnea, wheezingexertional dyspnea, wheezing

Anorexia, fatigue, weight lossAnorexia, fatigue, weight lossDiagnostic testsDiagnostic testsBronchoscopy reveals sources and Bronchoscopy reveals sources and

sites of secretionssites of secretions

COPD ManagementCOPD Management

1. Rest- 1. Rest- To reduce oxygen demands of tissuesTo reduce oxygen demands of tissues

2. Increase fluid intake- 2. Increase fluid intake- To liquefy mucus secretionsTo liquefy mucus secretions3. Good oral care- To remove sputum and prevent infection3. Good oral care- To remove sputum and prevent infection4. Diet 4. Diet -High caloric diet-High caloric diet provides source of energy provides source of energy-High protein-High protein diet helps maintain integrity of alveolar walls diet helps maintain integrity of alveolar walls-Moderate fats-Moderate fats-Low carbohydrate-Low carbohydrate diet limits carbon dioxide production diet limits carbon dioxide production

(natural end product).(natural end product).

5. O2 therapy 1 to 3 lpm (5. O2 therapy 1 to 3 lpm (2 lpm is 2 lpm is safest)safest)Do not give high concentration Do not give high concentration of oxygen. The drive for breathing of oxygen. The drive for breathing may be depressedmay be depressed

6. Avoid cigarette smoking, alcohol, 6. Avoid cigarette smoking, alcohol, and environmental pollutants.and environmental pollutants.

7. CPT –percussion, vibration, postural 7. CPT –percussion, vibration, postural drainagedrainage

8. Bronchial hygiene measures8. Bronchial hygiene measures

Steam inhalationSteam inhalation

Aerosol inhalationAerosol inhalation

Medimist inhalationMedimist inhalation

PharmacotherapyPharmacotherapy

1. Expectorants (guaiafenessin)/ 1. Expectorants (guaiafenessin)/ mucolytic (mucomyst/mucosolvan)mucolytic (mucomyst/mucosolvan)

2. Antitussives2. AntitussivesDextrometorphanDextrometorphanCodeineCodeine

3. Bronchodilators3. BronchodilatorsAminophylline (Theophylline)Aminophylline (Theophylline)Ventolin (Salbutamol)Ventolin (Salbutamol)Bricanyl (Terbutaline)Bricanyl (Terbutaline)Alupent (Metaproterenol)Alupent (Metaproterenol)Observe for tachycardiaObserve for tachycardia

4. Antihistamine4. AntihistamineBenadryl (Diphenhydramine)Benadryl (Diphenhydramine)Observe for drowsinessObserve for drowsiness

5. Steroids5. SteroidsAnti-inflammatory effectAnti-inflammatory effect

6. Antimicrobials6. Antimicrobials

PneumothoraxPneumothorax

Partial or complete collapse of the Partial or complete collapse of the lung due to an accumulation of air or lung due to an accumulation of air or fluid in the pleural spacefluid in the pleural space

1. Spontaneous pneumothoraxSpontaneous pneumothoraxRupture of a small bleb on the Rupture of a small bleb on the

visceral pleuravisceral pleura

2. 2. Open pneumothoraxOpen pneumothorax air enters the pleural space through air enters the pleural space through

an opening in the chest wall; usually an opening in the chest wall; usually caused by stabbing or gunshot caused by stabbing or gunshot wound.wound.

3. Tension pneumothoraxTension pneumothorax air enters the pleural space with each air enters the pleural space with each

inspiration but cannot escapeinspiration but cannot escape causes increased intrathoracic causes increased intrathoracic

pressure pressure shifting of the mediastinal contents to shifting of the mediastinal contents to

the unaffected side (mediastinal the unaffected side (mediastinal shift).shift).

Assessment findingsAssessment findings

1. Sudden sharp pain in the chest, 1. Sudden sharp pain in the chest, dyspnea, diminished or dyspnea, diminished or absent breath absent breath sounds on affected sidesounds on affected side, , tracheal tracheal shift to the opposite sideshift to the opposite side

2. Weak, rapid pulse; anxiety; 2. Weak, rapid pulse; anxiety; diaphoresisdiaphoresis

3. Diagnostic tests3. Diagnostic tests

a. Chest x-ray reveals area and degree a. Chest x-ray reveals area and degree of pneumothoraxof pneumothorax

b. pCO2 elevatedb. pCO2 elevated

c. pH decreasedc. pH decreased

Nursing interventionsNursing interventionsProvide nursing care for the client Provide nursing care for the client

with an endotracheal tubewith an endotracheal tubeSuction secretions, vomitus, blood Suction secretions, vomitus, blood

from nose, mouth, throat, or via from nose, mouth, throat, or via endotracheal tubeendotracheal tube

Monitor mechanical ventilation.Monitor mechanical ventilation.

4. Restore/promote adequate 4. Restore/promote adequate respiratory function.respiratory function.

a. Assist with thoracentesis and a. Assist with thoracentesis and provide appropriate nursing care. provide appropriate nursing care.

b. Assist with insertion of a chest b. Assist with insertion of a chest tube to water- seal drainagetube to water- seal drainage

c. Continuously evaluate respiratory c. Continuously evaluate respiratory patterns and report any changes.patterns and report any changes.

5. Provide relief/control of pain.5. Provide relief/control of pain.a. Administer a. Administer

narcotics/analgesics/sedatives as narcotics/analgesics/sedatives as ordered and monitor effects.ordered and monitor effects.

b. Position client in high-Fowler’s b. Position client in high-Fowler’s position.position.

Pleural Effusion

Defined broadly as a collection of fluid in Defined broadly as a collection of fluid in the pleural spacethe pleural space

General ClassificationGeneral Classification Transudative effusion: accumulation of Transudative effusion: accumulation of

protein-poor, cell-poor fluid ( cancers )protein-poor, cell-poor fluid ( cancers ) Exudative effusion: accumulation of Exudative effusion: accumulation of

protein rich fluid ( infections )protein rich fluid ( infections )

Assessment findingsAssessment findings1. Dyspnea, dullness over affected 1. Dyspnea, dullness over affected

area upon percussion, absent or area upon percussion, absent or decreased breath sounds over decreased breath sounds over affected area, pleural pain, dry cough, affected area, pleural pain, dry cough, pleural friction rubpleural friction rub

2. Pallor, fatigue, fever, and night 2. Pallor, fatigue, fever, and night sweats (with empyema)sweats (with empyema)

Diagnostic testsDiagnostic testsa. Chest x-ray positive a. Chest x-ray positive b. Pleural biopsy may reveal b. Pleural biopsy may reveal

bronchogenic carcinomabronchogenic carcinomac. Thoracentesisc. Thoracentesis

CLINICAL Correlation:

Hydrothorax- Serous fluid in the Hydrothorax- Serous fluid in the pleural cavitypleural cavity

Hemothorax- Blood in the cavityHemothorax- Blood in the cavity___________- Pus in the cavity___________- Pus in the cavity___________- Lymph in the cavity___________- Lymph in the cavity

Hydrothorax- Serous fluid in the Hydrothorax- Serous fluid in the pleural cavitypleural cavity

Hemothorax- Blood in the cavityHemothorax- Blood in the cavityPyothorax- Pus in the cavityPyothorax- Pus in the cavityChylothorax- Lymph in the cavityChylothorax- Lymph in the cavity

Lung CancerLung Cancer

Primary pulmonary tumors arise from Primary pulmonary tumors arise from the bronchial epithelium and are the bronchial epithelium and are therefore referred to as bronchogenic therefore referred to as bronchogenic carcinomas.carcinomas.

FACTORSFACTORSPossibly caused by inhaled Possibly caused by inhaled carcinogenscarcinogens (primarily cigarette (primarily cigarette smoke but also asbestos, nickel, iron smoke but also asbestos, nickel, iron oxides, air silicone pollution; oxides, air silicone pollution; preexisting pulmonary disorders PTB, preexisting pulmonary disorders PTB, COPD)COPD)

Assessment findingsAssessment findings Persistent cough (blood tinged)Persistent cough (blood tinged) chest painchest pain dyspneadyspnea unilateral wheezing, friction rub, possible unilateral wheezing, friction rub, possible

unilateral paralysis of the diaphragmunilateral paralysis of the diaphragm Fatigue, anorexia, nausea, vomiting, pallorFatigue, anorexia, nausea, vomiting, pallor

Diagnostic testsDiagnostic tests Chest x-ray may show presence of tumor Chest x-ray may show presence of tumor

or evidence of metastasis to surrounding or evidence of metastasis to surrounding structuresstructures

Sputum for cytology reveals malignant Sputum for cytology reveals malignant cellscells

Bronchoscopy: biopsy reveals malignancyBronchoscopy: biopsy reveals malignancy Thoracentesis: pleural fluid contains Thoracentesis: pleural fluid contains

malignant cellsmalignant cells

Medical managementMedical management1. Radiation therapy1. Radiation therapy2. Chemotherapy: usually includes 2. Chemotherapy: usually includes

cyclophosphamide, methotrexate, cyclophosphamide, methotrexate, vincristine, doxorubicin, and vincristine, doxorubicin, and procarbazine; concurrently in some procarbazine; concurrently in some combinationcombination

3. Surgery: when entire tumor can be 3. Surgery: when entire tumor can be removedremoved

Quick Notes on Bronchogenic Quick Notes on Bronchogenic CancerCancer

Predisposing factorsPredisposing factorsCigarette smokingCigarette smokingAsbestosisAsbestosisCPDCPDSmoke from burnt woodSmoke from burnt wood

TypesTypesSquamous cell Ca- with good Squamous cell Ca- with good

prognosisprognosisAdenocarcinoma- with good Adenocarcinoma- with good

prognosisprognosisOat cell Ca- with good prognosisOat cell Ca- with good prognosisUndifferentiated Ca- with poor Undifferentiated Ca- with poor

prognosisprognosis

Nursing InterventionsNursing InterventionsPatent airwayPatent airwayO2 / Aerosol therapyO2 / Aerosol therapyDeep breathing exercisesDeep breathing exercisesRelief of painRelief of painProtection from infectionProtection from infectionAdequate nutrition Adequate nutrition Chest tube managementChest tube management

SurgerySurgeryPneumonectomy=Removal of a lung Pneumonectomy=Removal of a lung

(either left or right)(either left or right)Lobectomy=Removal of a lobe.Lobectomy=Removal of a lobe.

Pulmonary EmbolismPulmonary Embolism

This refers to the obstruction of the This refers to the obstruction of the pulmonary artery or one of its pulmonary artery or one of its branches by a blood clot (thrombus) branches by a blood clot (thrombus) that originates somewhere in the that originates somewhere in the venous system or in the right side of venous system or in the right side of the heart.the heart.

CausesCausesFat embolismFat embolismAir embolismAir embolismMultiple traumaMultiple traumaPVD’s PVD’s Abdominal surgeryAbdominal surgery ImmobilityImmobilityHypercoagulabilityHypercoagulability

AssessmentAssessment Restlessness (cardinal initial sign)Restlessness (cardinal initial sign) DyspneaDyspnea Stabbing chest painStabbing chest pain CyanosisCyanosis TachycardiaTachycardia Dilated pupilsDilated pupils Apprehension/ fearApprehension/ fear DiaphoresisDiaphoresis DysrhythmiasDysrhythmias HypoxiaHypoxia

Diagnostic Tests:Diagnostic Tests:Ventilation-perfusion scanVentilation-perfusion scanPulmonary arteriographyPulmonary arteriographyCXRCXRECGECGABGABG

Nursing InterventionsNursing Interventions Oxygen therapy STATOxygen therapy STAT Early ambulation postopEarly ambulation postop Monitor obese patientMonitor obese patient Do not massage legsDo not massage legs Relieve pain- analgesicsRelieve pain- analgesics HOB elevatedHOB elevated Heparin (2 weeks) then Coumadin (3-6 Heparin (2 weeks) then Coumadin (3-6

months)months)