PRESENTED BY:RUMA SENMN(FINAL)

DIAGNOSTIC STUDIES OF THE RESPIRATORY SYSTEM

DISORDERS AND ITS NURSING

RESPONSIBILITIES

INTRODUCTIONRespiratory System Overview

The respiratory system’s primary function is gas exchange.

Acid-base balance is also a function of the respiratory system.

Respiratory System Structure

• Nasal Cavity: Passes air through nose• Mouth: Passes air through• Pharynx: The throat. Cone shaped

passageway leading to trachea. • Trachea: Windpipe. Main tube connecting

nose/mouth to lungs.• Epiglottis: Flap that covers the entrance

to the trachea.• Lungs: Main organ of the

respiratory system.

Respiratory System Structure

• Bronchi: Two tubes inside of lungs that air passes through to the bronchioles.

• Bronchioles: Small branching out tubes divided into alveoli.

• Alveoli: Tiny air sacs that do the oxidation and the exhale of carbon dioxide.

• Capillaries: Blood vessels that are imbedded in the walls of the alveoli. While in the capillaries the blood discharges carbon dioxide into the alveoli and takes up oxygen from the air in the alveoli.

• Cilia: Hair like structures that remove dust and dirt from the air.

REVIEW OF ANATOMY & PHYSIOLOGY

How the Respiratory System Works

Air that flows from the mouth or nasal cavity travels through the pharynx and moves down to the trachea. Then the air moves to the bronchi tubes as they enter the lungs. Once the air gets in the lungs, the air enters separate branches called the bronchiole. Carbon dioxide passes from the blood into the alveoli and is then exhaled.

• Gas exchange occurs by diffusion (O2 passes to the blood and CO2, a by-product of cellular metabolism, passes out of the blood and is channeled away).

• Transport of oxygen to tissues depends on red blood cells and the concentration of hemoglobin, regional blood flow, the arterial oxygen content, and the cardiac output.

• As circulation is continuous, cellular CO2 diffuses into the blood and is eliminated via the pulmonary circulation. For effective gas exchange, ventilation and perfusion at the alveolar level must match closely.

• Contraction and relaxation of the respiratory muscles moves air into and out of the lungs. Normally, inhalation is an active process whereas exhalation is passive.

Nose, sinus, and upper respiratory conditionsThroat conditionsLaryngeal conditionsBronchiolitisAsthmaPneumoniaPleural EffusionEmphysema (COPD)Chronic Bronchitis (COPD)Cystic fibrosisOccupational lung diseasesPulmonary hypertensionPulmonary edemaLung cancer

RISK FACTORS FOR RESPIRATORY DISORDERS

• Smoking• Use of chewing tobacco• Allergies• Frequent respiratory illnesses• Chest injury• Surgery• Exposure to chemicals & environmental

pollutants• Family history of infectious disease• Geographic residence & travel to foreign

countries

DIAGNOSTIC TESTS 1. PULMONARY FUNCTION TEST. 2. ABG ANALYSIS.

3. PULSE OXIMETRY 4. SPUTUM CULTURE5. IMAGING STUDIES a. CHEST X RAY b. COMPUTED TOMOGRAPHY. c. MAGNETIC RESONANCE IMAGING d. PULMONARY ANGIOGRAPHY e. LUNG SCAN- PET SCAN, V/Q SCAN

6. ENDOSCOPIC PROCEDURESa. Bronchoscopy b. Thoracoscopy c. Thoracentesis

7. BIOPSYa. Pleural biopsy d. open biopsy

b. Lung biopsy e. Needle biopsyc. Lymph node biopsy f. Bronchoscopic

biopsy8. Other tests

1. PULMONARY FUNCTION TEST

• Spirometry (meaning the measuring of breath) is the most common of the pulmonary function test (PFTs), measuring lung function, specifically the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled.

• Spirometry is an important tool used for generating pneumotachographs, which are helpful in assessing conditions such as asthma.  

INDICATIONSTo diagnose or manage asthma.

To detect respiratory disease in patients presenting with symptoms of breathlessness, and to distinguish respiratory from cardiac disease as the cause.To diagnose and differentiate between obstructive lung disease and restrictive lung disease.

To follow the natural history of disease. in respiratory conditions.

To identify those at risk from pulmonary barotrauma while scuba diving.

to conduct pre-operative risk assessment before anaesthesia or cardiothoracic surgery

IDENTIFYING LUNG VOLUMES.• TIDAL VOLUME: amount of gas inspired or expired

with each breath.• INSPIRATORY RESERVE VOLUME: maximum

amount of additional air which can be inspired at the end of normal inspiration.

• EXPIRATORY RESERVE VOLUME: maximum amount of additional air which can be expired at the end of normal expiration.

• RESIDUAL VOLUME: volume of air remaining in lung after a maximal expiration. This is the only lung volume which cannot be measured by a spirometer.

IDENTIFYING LUNG CAPACITIES

• TOTAL LUNG CAPACITY: The volume of air contained in the lungs at the end of maximal inspiration. TLC= RV+IRV+TV+ERV

• VITAL CAPACITY: maximum volume of air that can be forcefully expelled from the lungs following a maximal inspiration. VC=IRV+TV+ERV

• FUNCTIONAL RESIDUAL CAPACITY: volume of air remaining in lung at the end of a normal expiration. FRC=RV+ERV

• INSPIRATORY CAPACITY:Maximum volume of air that can be inspired after expiration. IC=TV+IRV

The patient is asked to take the deepest breath they can, and then exhale into the sensor as hard as possible, for as long as possible, preferably at least 6 seconds.

It is performed by a technician using a spirometer that has a volume collecting device attached to a recorder that demonstrates time and volume simultaneously.

NORMALOBSTRUCTIVE DISEASE

RESTRICTIVE DISEASE MIXED DISEASE

EXTRA THORACIC OBSTRUCTION

EXERCISE INDUCED ASTHMA

INSTRUCTIONS TO PATIENTS• Do not smoke for one hour before test

• Do not drink alcohol within four hours of test

• Do not eat a large meal within two hours of test

• wear loose clothing• Do not perform vigorous exercise

within 30 minutes of test• Look for physicians instructions

regarding inhaler medications.

2. ARTERIAL BLOOD GAS ANALYSIS

DESCRIPTIONUsed to determine the degree of

oxygenation in blood. PARAMETERS NORMAL VALUES

pH 7.35-7.45P02 80-100mmHg

pCO2 35-45mmHgHCO3 22-27 MeQ/l

ARTERIAL BLOOD GAS ANALYSIS

NURSING CARE• Allens test is done prior to arterial puncture.• Arterial puncture of radial artery, femoral artery, brachial

artery is done.• NOT MORE THAN 3 PRICKS SHOULD BE ATTEMPTED

ON THE SAME ARTERY.• After puncture, pressure dressing must be applied on the site.• Heparinised syringe may be used for withdrawal.• The sample is kept on ice & transported to laboratory as soon

as possible•  

3. PULSE OXIMETRYDescription It is a non invasive method of continuously monitoring

the oxygen saturation of hemoglobin.When oxygen saturation is measured with pulse

oximetry it is known as SpO2.It is an effective method for continuous monitoring of

saturation especially in critical care setting.A probe or sensor is attached to the finger, earlobe.Normal SpO2 :90-100%.

Nursing Intervention• It should be applied on the nail bed.• The nail should not have an impaired

circulation.• The sensor should be working i.e a red light

must be seen,• The probe must be applied to a monitor.

4. SPUTUM CULTURE Description: a specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells.

SPUTUM SPECIMEN

Early morning specimen is preferred.The sample can be collected either by expectoration or by bronchial or tracheal aspiration.The sputum may also be tested for gram stain, AFB stain etc.

Obtain 15 ml of sputum.

Instruct the client to rinse the mouth with water before collection.

Instruct the client to take several deep breaths and then cough deeply to obtain sputum.

Always collect the specimen before client begins antibiotic therapy.

Postprocedure• a. Transport specimen to laboratory STAT.• b. Assist the client with mouth care.

5. IMAGING STUDIES A. CHEST X- RAY

• Chest x-rays are used to identify abnormalities in chest structure and lung tissue.

• Done to detect infection, effusion, foreign body.• It determines degree of air entry to lungs.• It checks Response of patient to treatment.

NURSING INTERVENTION

• Usually taken after deep inspiration.• All metallic objects like jewellery should be removed before

doing X-Ray.• Pregnancy should be ruled out before the test.

B. COMPUTED TOMOGRAPHY• Lungs are scanned in successive layers by narrow

beam Xray.• The images provide a cross sectional view of the

chest.• Can define pulmonary nodules and small tumours

that are not visible on X ray.• It may or may not be done with contrast

NURSING INTERVENTION• Informed consent needs to be taken before

the procedure.• H/O sensitivity to sea foods or iodine needs

to be taken.• Renal function test is done before contrast

administration.

MAGNETIC RESONANCE IMAGING

• It is similar to X ray except that magnetic fields and radiofrequency signals are used.

• It visualizes soft tissues.• It can be used to stage

bronchogenic carcinoma.• Evaluate inflammatory activity in

interstitial lung disease. NURSING INTERVENTIONAssess for any metallic implants

(such as pacemaker, pacemaker wires, or implant). Test will not be performed if present.

PULMONARY ANGIOGRAPHY Investigate thrombo embolic disease of the lung. eg. Pulmonary emboli.It involves rapid injection of radio-opaque agent into vasculature of lungs to study pulmonary vessels.A catheter is inserted into the brachial or femoral artery, threaded into the pulmonary artery, and dye is injected. ECG leads are applied to the chest for cardiac monitoring. Images of the lungs are taken

Nursing Intervention

• Informed consent needs to be taken before the procedure.

• H/O sensitivity to sea foods or iodine needs to be taken.

• Renal function test is done before contrast administration.

• Coagulation profile of the patient is checked before & after the procedure..

• Monitor injection site and pulses distal to the site after the test.

•  

E. LUNG SCAN

A.PET SCANDESCRIPTION NURSING INTERVENTION

it is a radio isotope study to evaluate lung nodules for malignancy.

It can distinguish normal tissue from diseased tissue.

Differentiate viable from dying tissue.

It is more accurate in determining malignancy than CT.

Informed consent required No alcohol, coffee, or tobacco is

allowed for 24 hours prior to the test.

Encourage increased fluid intake post-test to help eliminate the radioactive material.

b. Gallium scan: Is a radio isotope scan to detect inflammatory conditions,

abscesses, adhesions, location and size of tumor.

NURSING INTERVENTION• No special preparation is needed before the test.• Renal function test is done before the test.• Encourage increased fluid intake after the test.

 c. Ventilation/Perfusion(V/Q) SCAN:

DESCRIPTION NURSING INTERVENTION

This test is performed with two nuclear scans to measure breathing (ventilation) and circulation (perfusion) in all parts of the lungs.

A perfusion scan is performed by injecting radioactive albumin into a vein and scanning the lungs.

A ventilation scan is performed by scanning the lungs as the client inhales radioactive gas.

No special preparation is needed before the test.

Test dose of albumin may be given.

Renal function test is done before the test.

Encourage increased fluid intake after the test.

6. ENDOSCOPY A. BRONCHOSCOPY

A bronchoscopy is the direct visualization of the larynx, trachea, and bronchi through a bronchoscope to identify lesions, remove foreign bodies and secretions, obtain tissue for biopsy, and improve tracheobronchial drainage .During the test, a catheter brush or biopsy forceps can be passed to obtain secretions or tissue for examination for cancer.

NURSING MANAGEMENTBEFORE THE TEST

Provide routine preoperative care as ordered. Bronchoscopy is an invasive procedure requiring conscious sedation or anesthesia.

Obtain informed consent.

Coagulation profile may be checked.

Provide mouth care just prior to bronchoscopy. Mouth care reduces oral microorganisms and the risk of introducing them into the lungs. Bring resuscitation and suction equipment to the bedside. Laryngospasm and respiratory distress may occur following the procedure.

POST PROCEDURE

Provide an emesis basin and tissues for expectorating sputum and saliva. Until reflexes have returned, the client may be unable to swallow sputum and saliva safely.Monitor color and character of respiratory secretions. Secretions normally are blood tinged for several hours following bronchoscopy, especially if biopsy has been obtained.

Before discharge assess for the return of gag reflex.

Notify the physician if sputum is grossly bloody. Grossly bloody sputum may indicate a complication such as perforation.

• • Closely monitor vital signs and

respiratory status. • Possible complications of

bronchoscopy include laryngospasm, bronchospasm, bronchial perforation with possible pneumothorax or subcutaneous emphysema, hemorrhage, hypoxia, pneumonia or bacteremia, and cardiac stress.

• Instruct to avoid eating or drinking for approximately 2 hours or until fully awake with intact cough and gag reflexes. Suppression of the cough and gag reflexes by systemic and local anesthesia used during the procedure increase the risk for aspiration.

B. THORACOSCOPY

• It is a diagnostic procedure in which the pleural cavity is examined with a endoscope.

• It is indicated in diagnostic evaluation of pleural effusion, pleural diseases etc.

• Patient is constantly monitored for shortness of breath which may indicate pneumothorax.

NURSING INTERVENTION • *SAME AS BRONCHOSCOPY

C. THORACENTESIS

• It is the aspiration of fluid or air from the pleural space.

Purposes include• Aspiration of pleural fluid for analysis.• Pleural biopsy.• Instillation of medication into the pleural space.• Position- sitting on edge of bed with the feet

supported and arms kept on a overbed table or Lying on unaffected side with head end of bed elevated to 30-45 degrees.

NURSING MANAGEMENT

Before the ProcedureCheck the doctor’s order.Identify the client.Asked patient to sign a consent form.Inform that she will be experiencing mild pain on the site where the needle was prickedInform the client that the procedure takes only few minutes, depending primarily on the time it takes for fluid to drain from the pleural cavity.Inform the client not to cough while the needle is inserted in order to avoid puncturing the lungExplain when and where the procedure will occur and who will be present.

The patient may have a diagnostic procedure, such as a chest x-ray, chest fluoroscopy, ultrasound, or CT scan, performed prior to the procedure to assist the physician in identifying the specific location of the fluid in the chest that is to be removed.The patient may receive a sedative prior to the procedure to help the patient relax.Asked the patient to remove any clothing, jewelry, or other objects that may interfere with the procedure.The area around the puncture site may be shaved.Vital signs (heart rate, blood pressure, breathing rate, and oxygen level) are to be monitored before the procedure.

CONTD..

During the Procedure• Support the client verbally and describe the steps

of the procedure as needed.• Vital signs (heart rate, blood pressure, breathing

rate, and oxygen level) are to be monitored during the procedure.

• The patient may receive supplemental oxygen as needed, through a face mask or nasal cannula (tube).

• Observe the client for signs of distress, such as dyspnea, pallor, and coughing

CONTD….• Place the patient in a sitting position with arms raised

and resting on an overbed table. This position aids in spreading out the spaces between the ribs for needle insertion. If the patient is unable to sit, the patient may be placed in a side-lying position on the edge of the bed on unaffected side.

• The skin at the puncture site will be cleansed with an antiseptic solution.

• The patient will receive a local anesthetic at the site where the thoracentesis is to be performed.

• Don’t remove more than 1000 ml of fluid from the pleural cavity within first 30 minutes.

• Place a small sterile dressing over the site of the puncture.

CONTD…After the Procedure• Observe changes in the client’s cough, sputum,

respiratory depth, and breath sounds, & note complaints of chest pain.

• Position the client appropriately• Make  client lie on the unaffected side with the

head of the bed elevated 30 degrees for at least 30 minutes because this position facilitates expansion of the affected lung and eases respirations

• Transport the specimens to the laboratory.

• The dressing over the puncture site will be monitored for bleeding or other drainage.

• Monitor patient’s blood pressure, pulse, and breathing until are stable.

• Document all relevant information. Include date and time performed; the primary care provider’s name; the amount, color, and clarity of fluid drained; and nursing assessments and interventions provided.

7. BIOPSYa.PLEURAL BIOPSY

b. LUNG BIOPSY

c.LYMPH NODE BIOPSY

d. OPEN BIOPSY

e.BRONCHO-SCOPIC BIOPSY

f. NEEDLE BIOPSY.

•Done by needle biopsy of pleura or by pleuroscopy.•Purpose- to examine pleural exudate of undetermined origin.•For culture and gram staining of pleural fluid.

•To obtain lung tissue for examination when Xray findings are inconclusive.•For cytological evaluation of lung lesion.•For identification of pathogenic organism.•It is done under sedation.

•The scalene lymph nodes over the scalenus anterior muscle may show histopathological changes from intra thoracic disease.•It helps in diagnosis or prognosis of sarcoidosis, tuberculosis , carcinoma etc.

The surgeon makes an incision over the lung area, a procedure called thoracotomy.• Some lung tissue is removed and the incision is closed with sutures. Chest tubes are placed.•A chest x ray is performed immediately after the procedure

During the bronchoscopy, , the physician views the airways, and is able to clear mucus from blocked airways, and collect cells or tissue samples for laboratory analysis.

•The patient is mildly sedated, but awake during the needle biopsy procedure.•The patient is asked to take a deep breath and hold it while the physician inserts the biopsy needle through the incision into the lung tissue to be biopsied

NURSING CARE

BEFORE BIOPSY. • A chest x ray or CT scan of the chest is used to identify the

area to be biopsied.• About an hour before the biopsy procedure, the patient

receives a sedative. Medication may also be given to dry up airway secretions.

• For at least 12 hours before the biopsy, the patient should not eat or drink anything.

• Prior to these procedures, an intravenous line is placed in a vein in the patient's arm to deliver medications or fluids as necessary.

• Informed consent must be taken • Bring resuscitation and suction equipment to the bedside.

Laryngospasm and respiratory distress may occur following the procedure.

AFTER BIOPSY

• Closely monitor vital signs and respiratory status. • A chest XRAY may be done.• Monitor for complications- laryngospasm,

bronchospasm, bronchial perforation etc

• Monitor color and character of respiratory secretions. Notify the physician if sputum is grossly bloody. Grossly bloody sputum may indicate a complication such as perforation.

• The patient should rest at home for a day or two before returning to regular activities, and should avoid strenuous activities for one week after the biopsy.

8. OTHER TESTSCBC- leukocyte countBlood culture- to identify causative

organismNasal swab analysis- H1N1 VIRUSThroat swab analysis- streptococcusMantoux test to detect tuberculosisLaryngoscopy- to visualize larynx,

pharynx, epiglottis.Sinus puncture & aspiration- acute

rhinosinusitisPolymerase chain reaction- to detect

herpes simplex virus infection

SKIN TESTDescription: A skin test is an intra dermal injection used to assist in diagnosing various infectious diseases Pre procedure: Determine hypersensitivity or previous reactions to skin tests Procedure

a. Use test injection test that is free of excessive body hair, dermatitis, and blemishes.

b. Apply the injection at the upper one third of inner surface of the left arm

c. Circle and mark the test sited. Document the date, time, and test site

Post procedure a. Advise the client not to scratch the test site so as to prevent

infection and abscess formationb. Instruct the client to avoid washing the test site.c. Interpret the reaction at the injection site 48 to72 hours after

administration of the test antigend. Assess the test site for the amount of induration (hard swelling)

in millimeters and for the presence of erythema and vesiculation (small blisterlike elevations)

End Tidal CO2 (EtCO2) MONITORING

• Capnogram: A graphical waveform display of carbon dioxide concentration over time.

• Capnometry: Continuous and non-invasive measurement and graphical display of EtCO2.

• Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO2) in the respiratory gases.

Clinical Applications for the use of EtCO2 in the Intensive Care Unit• To confirm proper placement of an advanced

airway• Monitor the quality of compressions during

CPR . • Monitor the respirations in patients at risk for

respiratory depression due to recent sedation, narcotics, or respiratory compromise

• Intermittent nurse monitoring of postoperative patients may not pick up on ventilatory depression

• Monitor respirations in patients with sleep apnea

• Assist with successful ventilator weaning• Identify loss of advanced airway during long-

term mechanical ventilation in the inpatient setting

Normal

Hyper ventilation

Hypoventilation

SUMMARY

Respiratory health assessment includes a detailed history collection, inspection, palpation, percussion & auscultation. A keen observation is required for early diagnosis & treatment. Dignostic tests are also important in differentiating, staging of various respiratory disorders. Its been found that diagnostic tests are more threatening to a patient than the diagnosis itself. Nurses play a key role in various diagnostic tests as mentioned above to facilitate these tests as well as to avoid complications.

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