Rachel S. Natividad, RN, MSN, NPRachel S. Natividad, RN, MSN, NPN212 Medical Surgical Nursing 1N212 Medical Surgical Nursing 1

The Respiratory The Respiratory SystemSystem

Structure and FunctionStructure and Function

Gas exchangeGas exchange

Changes associated to AgingChanges associated to Aging ↓ ↓ recoil and compliancerecoil and compliance

AP diameter AP diameter

↓ ↓ functional alveolifunctional alveoli

↓ ↓ in Pa02in Pa02

Respiratory defense Respiratory defense mechanisms less effective mechanisms less effective

Altered respiratory controlsAltered respiratory controls More gradual response to More gradual response to

changes in O2 and Co2 changes in O2 and Co2 levels in bloodlevels in blood

DiagnosticsDiagnostics

Pulse OximetryPulse Oximetry

Chest X-RayChest X-Ray

Computed Tomography Computed Tomography (CT scan)(CT scan)

BronchoscopyBronchoscopy

ThoracentesisThoracentesis

Pulmonary Function Pulmonary Function TestsTests

Sputum Specimen and Sputum Specimen and CulturesCultures

Diagnostics: Pulse OximetryDiagnostics: Pulse Oximetry Measures arterial oxygen Measures arterial oxygen

saturationsaturation

Pulse oximetry probe on Pulse oximetry probe on forehead, ears, nose, finger, forehead, ears, nose, finger, toes, toes,

False readingsFalse readings

Intermittent or continuous Intermittent or continuous monitoring monitoring

Ideal values: 95-100%Ideal values: 95-100%

When to Notify MDWhen to Notify MD < 91%< 91% 86% (Medical Emergency)86% (Medical Emergency)

Diagnostics: Chest X-RayDiagnostics: Chest X-Ray Screen, diagnose, Screen, diagnose,

evaluate treatmentevaluate treatment

Instructions: No Instructions: No metals/jewelrymetals/jewelry

Diagnostics: Chest X-Ray Cont.Diagnostics: Chest X-Ray Cont.

Posterior Anterior View Left Lateral View

Nodule

Infiltrates

Diagnostics: Sputum SpecimenDiagnostics: Sputum Specimen

To diagnose; evaluate treatmentTo diagnose; evaluate treatment Specimen: ID organisms or abnormal Specimen: ID organisms or abnormal

cellscells Culture & Sensitivity (C&S)Culture & Sensitivity (C&S) CytologyCytology Gram stains Gram stains

(e.g. Acid Fast Bacilli)(e.g. Acid Fast Bacilli)

Diagnostics: Computed Diagnostics: Computed Tomography: CT ScanTomography: CT Scan

Images in Images in cross-cross-sectionsection view view

Uses contrast Uses contrast agentsagents

Instructions:Instructions:

Right upper Lobe

Diagnostics: BronchoscopyDiagnostics: Bronchoscopy

Diagnose problems and assess Diagnose problems and assess changes in bronchi/bronchioleschanges in bronchi/bronchioles

Performed to remove foreign Performed to remove foreign body, secretions, or to obtain body, secretions, or to obtain specimens of tissue or mucus for specimens of tissue or mucus for further studyfurther study

Procedure Care/InstructionsProcedure Care/Instructions::NPO 6 -8 hrs priorNPO 6 -8 hrs priorSedation during procedureSedation during procedurePost Procedure:Post Procedure:HOB elevatedHOB elevatedObserve for hemorrhageObserve for hemorrhageNPO until gag reflex returnsNPO until gag reflex returns

Diagnostics: Pulmonary Diagnostics: Pulmonary Function Test (PFTs)Function Test (PFTs)

Evaluate lung functionEvaluate lung function

Observe for increased Observe for increased dyspnea or dyspnea or bronchospasmbronchospasm

Instructions:Instructions: No bronchodilators 6 No bronchodilators 6

hours priorhours prior

Diagnostics: ThoracentesisDiagnostics: Thoracentesis Specimen from Specimen from

pleural fluidpleural fluid

Treat pleural Treat pleural effusioneffusion

Assess for Assess for complicationscomplications

Post-Procedure care:Post-Procedure care: CXR after procedureCXR after procedure

PositionsPositions•Sitting on side of bed over bedside table Sitting on side of bed over bedside table chestchest elevatedelevated•Lying on affected sideLying on affected side•Straddling a chairStraddling a chair

Assessment: Assessment: Cues to Cues to Respiratory ProblemsRespiratory Problems

DyspneaDyspnea

CoughCough

SputumSputum

Pneumonia: Case StudyPneumonia: Case StudyPathophysiologyPathophysiology

Pneumonia: Pathophysiology Cont.Pneumonia: Pathophysiology Cont.

Pneumonia: EtiologyPneumonia: Etiology

CauseCause bacteria (75%)bacteria (75%) virusesviruses fungifungi MycoplasmaMycoplasma ParasitesParasites chemicalschemicals

Pneumonia: ClassificationsPneumonia: Classifications

Community-acquired pneumonia (CAP)Community-acquired pneumonia (CAP) Onset in community or during 1Onset in community or during 1stst 2 days of hospitalization 2 days of hospitalization

(Strep. pneumoniae most common)(Strep. pneumoniae most common)

Hospital-acquired Pneumonia(HAP/nosocomial)Hospital-acquired Pneumonia(HAP/nosocomial) Occurring 48 hrs or longer after hospitalizationOccurring 48 hrs or longer after hospitalization

Aspiration pneumoniaAspiration pneumonia

Pneumonia caused by opportunistic organismsPneumonia caused by opportunistic organisms Pneumocystis CariniiPneumocystis Carinii

Pneumonia: Risk FactorsPneumonia: Risk Factors

CAPCAP Older adultOlder adult Chronic/coexisting Chronic/coexisting

conditioncondition Recent history or Recent history or

exposure to viral or exposure to viral or influenza infectionsinfluenza infections

History of tobacco or History of tobacco or alcohol usealcohol use

HAPHAP Older adultOlder adult Chronic lung diseaseChronic lung disease ALOCALOC AspirationAspiration ET, Trach, NG / GT ET, Trach, NG / GT ImmunocompromisedImmunocompromised Mechanical ventilationMechanical ventilation

Pneumonia: Clinical Pneumonia: Clinical ManifestationsManifestations

Fevers, chills, anorexiaFevers, chills, anorexia Pleuritic chest painPleuritic chest pain SOBSOB Crackles/wheezesCrackles/wheezes Cough, sputum productionCough, sputum production TachypneaTachypnea

Pneumonia: Clinical Pneumonia: Clinical Manifestations-Cont.Manifestations-Cont.

Mycoplasma (Atypical)Mycoplasma (Atypical) feeling tired or weak, feeling tired or weak,

headaches, sore throat, headaches, sore throat, or diarrhea. or diarrhea.

Eventually, most develop Eventually, most develop a dry cough.  They can, a dry cough.  They can, also, develop fever, chills, also, develop fever, chills, earaches, chest painearaches, chest pain

““walking pneumonia”walking pneumonia”

Pneumonia: DiagnosisPneumonia: Diagnosis

Diagnosis Diagnosis →→ Physical exam → Physical exam →

crackles, crackles, rhonchi/wheezesrhonchi/wheezes

CXR →area of increased CXR →area of increased density density

(infiltrates/ consolidation)(infiltrates/ consolidation)

Sputum specimen – Sputum specimen – Gram stainGram stain

LUL Infiltrates

Pneumonia :Interventions/TxPneumonia :Interventions/Tx TreatmentTreatment

Antibiotics → choose based on age, Antibiotics → choose based on age, suspected cause & immune statussuspected cause & immune status

Supportive care → IV fluids, supplemental Supportive care → IV fluids, supplemental oxygen therapy, respiratory monitoring, cough oxygen therapy, respiratory monitoring, cough enhancementenhancement

*may take 6-8 weeks for CXR to normalize*may take 6-8 weeks for CXR to normalize

Nursing Diagnoses…Nursing Diagnoses…

Impaired gas exchange R/T Impaired gas exchange R/T PneumoniaPneumonia

Pain R/T infection in lung Pain R/T infection in lung PneumoniaPneumonia

Pneumonia: ComplicationsPneumonia: Complications

HypoxemiaHypoxemia

Pleural effusionPleural effusion

AtelectasisAtelectasis

PleurisyPleurisy

Atelectasis Pleurisy

Pleural Effusion

Toxic sprinkles anyone?Toxic sprinkles anyone?

Any Questions?Any Questions?