OXYGENATON: the dynamic interaction of gases in the body for the purpose of delivering adequate oxygen essential for cellular survival RESPIRATORY SYSTEM MAIN FUNCTION: GAS EXCHANGE
I. Upper Respiratory TractA. Functions
1. Filtering2. Warming and moistening3. Humidification
B. Parts1. Nose - made up of framework of cartilages; divided
into R and L by the nasal septum. 2. Paranasal Sinuses – includes four pair of bony
cavities that are lined with nasal mucosa and ciliated epithelium.
3. Tubernate Bones ( Conchae )4. Pharynx – muscular passageway for both food and
air Nasopharynx Oropharynx Laryngopharynx
5. Tonsils and Adenoids6. Larynx – voice production, coughing reflex
Made up of framework of: Epiglottis – valve that covers the opening
to the larynx during swallowing. Glottis – opening between the vocal cords Hyoid bone – u shaped bone in neck Cricoid cartilage Thyroid cartilage, forms the Adam’s apple Arythenoid cartilage Speech production and cough reflex Vocal cords
7. Trachea - consists of cartilaginous rings Passageway of air Site of tracheostomy (4th-6th tracheal ring)
II. Lower respiratory tractA. Function: facilitates gas exchangeB. Parts
1. Lungs, are paired elastic structure enclosed in the thoracic cage, which is an airtight chamber with distensible walls. Right – 3 lobes, 10 segments Left – 2 lobes, 8 segments
Client post pneumonectomy affected side to promote expansion Post lobectomy unaffected side to promote drainage
2. Bronchi Lobar Bronchi: 3 R and 2 L Segmental Bronchi: 10 R and 8 L
Subsegmental Bronchi3. Bronchioles
Terminal Bronchioles Respiratory Bronchioles, considered to be
the transitional passageways between the conducting airways and the gas exchange
4. Alveoli - functional cellular units or gas-exchange
units of the lungs.- O2 and CO2 exchange takes place- Made up of about 300 million
TYPE 1 - provide structure to the alveoliTYPE 2 - secrete SURFACTANT, reduces surface tension; increases alveoli stability & prevents their collapseTYPE 3 – alveolar cell macrophages, destroys foreign material, such as bacteria
L/S ratio indicates lung maturity 2:1 normal 1:2 immature lungs
PULMONARY CIRCULATION- Provides for reoxygenation of blood and release of CO2
PULMONARY ARTERIES, carry blood from the heart to the lungs.
PULMONARY VEINS, is a large blood vessel of the circulatory system that carries blood from the lungs to the left atrium of the heart.
the scalene muscles (anterior, middle and posterior scalene) and the nasal alae
PHYSIOLOGY OF RESPIRATORY SYSTEM
VENTILATION: The movement of air in and out of the airways.
• The thoracic cavity is an air tight chamber. the floor of this chamber is the diaphragm.
• Inspiration: contraction of the diaphragm (movement of this chamber floor downward) and contraction of the external intercostal muscles increases the space in this chamber. lowered intrathoracic pressure causes air to enter through the airways and inflate the lungs.
• Expiration: with relaxation, the diaphragm moves up and intrathoracic pressure increases. this increased pressure pushes air out of the lungs. expiration requires the elastic recoil of the lungs.
• Inspiration normally is 1/3 of the respiratory cycle and expiration is 2/3.
DRIVING FORCE FOR AIR FLOWAirflow driven by the pressure difference between
atmosphere (barometric pressure) and inside the lungs (intrapulmonary pressure).
AIRWAY RESISTANCE Resistance is determined chiefly by the radius size of the
airway. Causes of Increased Airway Resistance
1. Contraction of bronchial mucosa2. Thickening of bronchial mucosa3. Obstruction of the airway4. Loss of lung elasticity
RESPIRATION• The process of gas exchange between atmospheric air
and the blood at the alveoli, and between the blood cells and the cells of the body.
• Exchange of gases occurs because of differences in partial pressures.
• Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body.
• Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body.
MEDULLA OBLONGATA – respiratory center initiates each breath by sending messages to primary respiratory muscles over the phrenic nerve
- has inspiration and expiration centers
PONS – has 2 respiration centers that work with the inspiration center to produce normal rate of breathing1. PNEUMOTAXIC CENTER – affects the inspiratory effort by limiting the volume of air inspired 2. APNEUSTIC CENTER – prolongs inhalation
NOTE: Chemoreceptors responds to changes in ph, increased PaCO2 = increase RR
RESPIRATORY EXAMINATION AND
A. Abnormal patterns of breathing1. Sleep Apnea
cessation of airflow for more than 10 seconds more than 10 times a night during sleep
causes: obstructive (e.g. obesity with upper narrowing, enlarged tonsils, pharyngeal soft tissue changes in acromegaly or hypothyroidism)
2. Cheyne-Stokes periods of apnoea alternating with periods of
hyperpnoae pathophysiology: delay in medullary chemoreceptor
response to blood gas changes causes
left ventricular failure brain damage (e.g. trauma, cerebral,
haemorrhage) high altitude
3. Kussmaul's (air hunger) deep rapid respiration due to stimulation of respiratory
centre causes: metabolic acidosis (e.g. diabetes mellitus,
chronic renal failure) 4. Hyperventilation
complications: alkalosis and tetany causes: anxiety
5. Ataxic (Biot) irregular in timing and deep causes: brainstem damage
6. Apneustic post-inspiratory pause in breathing causes: brain (pontine) damage
7. Paradoxical the abdomen sucks with respiration (normally, it
pouches uotward due to diaphragmatic descent) causes: diaphragmatic paralysis
B. Cyanosis1. Refers to blue discoloration of skin and mucous
membranes , is due to presence of deoxygenated haemoglobin in superficial blood vessels
2. Central cyanosis = abnromal amout of deoxygenated haemoglobin in arteries and that blue discoloration is
present in parts of body with good circulation such as tongue
3. Peripheral cyanosis = occurs when blood supply to a certain part of body is reduced, and the tissue extracts more oxygen from normal from the circulating blood, e.g. lips in cold weather are often blue, but lips are spared
4. Causes of cyanosis Central cyanosis
decreased arterial saturation decreased concentration of inspired oxygen:
high altitude lung disease: COPD with cor pulmoale,
massive pulmonary embolism right to left cardiac shunt (cyanotic congenital
idiopathic (80%) secondary to poliomyelitis (inflammation involving
grey matter of cord) (note: severe thoracic kyphoscoliosis may reduce lung
capacity and increase work of breathing) Lesions of chest wall
scars - previous thoracic operations or chest drains for a previous pneumothorax or pleural effusion
thoracoplasty (was once performed to remove TB, but no longer is because of effective antituberculosis chemotherapy) invovled removal of large number of ribs on one side to achieve permanent collapse of affected lung
erythema and thickening of skin may occur in radiotherapy; there is a sharp demarcation between abnormal and normal skin
Diffuse swelling of chest wall and neck pathophysiology: air tracking from the lungs causes:
pneumothorax rupture of oesopahagus
Prominent veins cause: superior vena caval obstruction
Asymmetry of chest wall movements assess this by inspecting from behind patient, looking
down the clavicles during moderate respiration - diminished movement indicates underlying lung disease
the affected side will showed delayed or decreased movement
causes of reduced chest wall movements on one side are localised: localised pulmonary fibrosis consolidation collapse pleural effusion pneumothroax
causes of bilateral reduced chest wall movements are diffuse: chronic airflow limitation diffuse pulmonary fibrosis
The Chest: palpation
chest expansion place hands firmly on chest wall with fingers extending
around sides of chest (fugyre 4.5) as patient takes a big breath in, the thumbs should move
symmetrically apart about 5 cm reduced expansion on one side indicates a lesion on that
side note: lower lobe expansion is tested here; upper lobe is
tested for on inspection (as above) apex beat
(discussed in cardiac section) for respiratory diseases:
displacement toward site of lesion - can be caused by: collapse of lower lobe localised pulmonary fibrosis
displacement away from site of lesion - can be caused by: pleural effusion tension pneumothorax
apex beat is often impalpable in a chest which is hyperexpanded secondary to chronic airflow limitation
palpate chest wall with palm of hand while patient repeats "99"
front and back of chest are each palpated in 2 comparable positions with palms; in this way differences in vibration on chest wall can be detected
causes of change in vocal fremitus are the same as those for vocal resonance (see later)
ribs gently compress chest wall anteroposteriorly and laterally localised pain suggests a rib fracture (may be secondary to
trauma or spontaneous as a result of tumour deposition or bone disease)
The Chest: percussion
with left hand on chest wall and fingers slightly separated and aligned with ribs, the middle finger is pressed firmly against the chest; pad of right middle finger is used to strike firmly the middle phalanx of middle finger of left hand
percussion of symmetrical areas of: anterior (chest) posterior (back) (ask patient to move elbows forward
across the front of chest - this rotates the scapulae anteriorly, i.e. moves it out of the way)
axillary region (side) supraclavicular fossa
percussion over a solid structure (e.g. liver, consolidated lung) produces a dull note
percusion over a fluid filled area (e.g. pleural effusion) produces an extremely dull (stony dull) note
percussion over the normal lung produces a resonant note percussion over a hollow structure (e.g. bowel, pneumothorax)
produces a hyperresonsant note liver dullness:
upper level of liver dullness is determined by percussing down the anterior cehst in mid-clavicular line
normally, upper level of liver dullness is 6th rib in right mid-clavicular line
if chest is resonant below this level, it is a sign of hyperinflation usually due to emphysema, asthma
cardiac dullness: area of cardiac dullness is uaully present on left side of
chest this may decrease in emphysema or asthma
The Chest: auscultation
breath sounds introduction
one should use the diaphragm of stethoscope to listen to breath sound in each area, comparing each side
remember to listen high up into the axillae remember to use bell of stethoscope to listen to lung
from above the clavicles quality of breath sounds
normal breat sounds are heard with stethoscope over all parts of
chest, produced in airways rather than alveoli (although once they had been thought to arise from alveoli (vesicles) and are therefore called vesicular sounds)
normal (vesicular) breath sounds are louder and longer on inspiration than on expiration; and there is no gap between the inspiratory and expiratory sounds
bronchial breath sounds turbulence in large airways is heard without
being filtered by the alveoli, and therefore
produce a different quality; they are heard over the trachea normally, but not over the lungs
are audible throughout expiration, and often there is a gap between inspiration and expiration
are heard over areas of consolidation since solid lung conducts the sound of turbulence in main airways to peripheral areas without filtering
palpate liver for enlargement due to secondary deposits of tumour from lung, or right heart failure
Permberton's sign ask patient to lift arms over head look for development of facial plethora, inspiratory
stridor, non-pulsatile elevation of jugular venous pressure
occurs in vena caval obstruction Feet
inspect for oedema or cyanosis (clues of cor pulmonale)
look for evidence of deep vein thrombosisd Respiratory rate on exercise and positioning
patients complaining of dyspnoea should have their respiratory rate measured at rest, at maximal tolerated exertion and supine
if dyspnoea is not accompanied by tachypnoea when a patient climbs stairs, one should consider malingering
look for paradoxical inward motion of abdomen during inspiration when patient is uspine (indicating diaphragmatic paralysis)
Temperature: fever may accompany any acute or chronic chest infection
1. Skin Test: Mantoux Test or Tuberculin Skin Test
This is used to determine if a person has been infected or has been exposed to the TB bacillus.
This utilizes the PPD (Purified Protein Derivatives). The PPD is injected intradermally usually in the inner
aspect of the lower forearm about 4 inches below the elbow.
The test is read 48 to 72 hours after injection. (+) Mantoux Test is induration of 10 mm or more. But for HIV positive clients, induration of about 5 mm is
considered positive Signifies exposure to Mycobacterium Tubercle bacilli
2. Pulse Oximeter
Non-invasive method of continuously monitoring he oxygen saturation of hemoglobin
A probe or sensor is attached to the fingertip, forehead, earlobe or bridge of the nose
Sensor detects changes in O2 sat levels by monitoring light signals generated by the oximeter and reflected by the blood pulsing through the tissue at the probe
Normal SpO2 = 95% - 100% < 85% - tissues are not receiving enough O2 Results unreliable in:
Cardiac arrest Shock Use of dyes or
vasoconstrictors Severe anemia High carbon
3. Chest X-ray
This is a NON-invasive procedure involving the use of x-rays with minimal radiation.
The nurse instructs the patient to practice the on cue to hold his breath and to do deep breathing
Instruct the client to remove metals from the chest. Rule out pregnancy first.
5. Computed Tomography (CT Scan) and Magnetic Resonance Imaging ( MRI )
The CT scan is a radiographic procedure that utilizes x-ray machine.
The MRI uses magnetic field to record the H+ density of the tissue. It does NOT involve the use of radiation. The contraindications for this procedure are the
following: patients with implanted pacemaker, patients with metallic hip prosthesis or other metal implants in the body.
This chest CT scan shows a cross-section of a person with bronchial cancer. The two dark areas are the lungs. The light areas within the lungs represent the cancer.
Clear MRI images of lung airways during breathing.
6. Flouroscopy Studies the lung and chest in motion Involves the continuous observation of an image
reflected on a screen when exposed to radiation in the manner of television screen that is activated by an electrode beam.
Structures of different densities that intercept the X-ray beam are visualized on the screen in silhouette
7. Indirect Bronchography A radiopaque medium is instilled directly into the
trachea and the bronchi and the outline of the entire bronchial tree or selected areas may be visualized through x-ray.
It reveals anomalies of the bronchial tree and is important in the diagnosis of bronchiectasis.
Nursing interventions BEFORE Bronchogram
Secure written consent Check for allergies to sea foods or iodine or
anesthesia NPO for 6 to 8 hours Pre-op meds: atropine SO4 and valium,
topical anesthesia sprayed; followed by local anesthetic injected into larynx. The nurse must have oxygen and anti spasmodic agents ready.
Nursing interventions AFTER Bronchogram Side-lying position NPO until cough and gag reflexes returned Instruct the client to cough and deep breathe
8. Bronchoscopy This is the direct inspection and observation of the
larynx, trachea and bronchi through a flexible or rigid bronchoscope.
Passage of a lighted bronchoscope into the bronchial tree for direct visualization of the trachea and the tracheobronchial tree.
Diagnostic uses: To examine tissues or collect secretions To determine location or pathologic process
and collect specimen for biopsy To evaluate bleeding sites To determine if a tumor can be resected
Therapeutic uses To Remove foreign objects from
tracheobronchial tree To Excise lesions To remove tenacious secretions obstructing the
tracheobronchial tree To drain abscess To treat post-operative atelectasis
Nursing interventions BEFORE Bronchoscopy Inform
ed consent/ permit needed
Explain procedure to the patient, tell him what to expect, to help him cope with the unkown
Atropine (to diminish secretions) is administered one hour before the procedure
About 30 minutes before bronchoscopy, Valium is given to sedate patient and allay anxiety.
Topical anesthesia is sprayed followed by local anesthesia injected into the larynx
Instruct on NPO for 6-8 hours Remove dentures, prostheses and contact lenses The patient is placed supine with
hyperextended neck during the procedure
Nursing interventions AFTER BronchoscopyPut the patient on Side lying position Tell patient that the throat may feel sore with . Check for the return of cough and gag reflex.Check vasovagal response.
Watch for cyanosis, hypotension, tachycardia, arrythmias, hemoptysis, and dyspnea. These signs and symptoms indicate perforation of bronchial tree. Refer the patient immediately!
9. Lung Scan Procedure using inhalation or I.V. injection of a
radioisotope, scans are taken with a scintillation camera. Imaging of distribution and blood flow in the lungs.
(Measure blood perfusion) Confirm pulmonary embolism or other blood- flow
Nursing interventions BEFORE the procedure: Allay the patient’s anxiety Instruct the patient to Remain still during the
Nursing interventions AFTER the procedure Check the catheter insertion site for bleeding Assess for allergies to injected radioisotopes Increase fluid intake, unless contraindicated.
10. Sputum Examination Laboratory test Indicated for microscopic examination of the sputum:
Gross appearance, Sputum C&S, AFB staining, and for Cytologic examination/ Papanicolaou examination
Nursing interventions: Early morning sputum specimen is to be
collected (suctioning or expectoration) Rinse mouth with plain water Use sterile container. Sputum specimen for C&S is collected before
the first dose of anti-microbial therapy. For AFB staining, collect sputum specimen for
three consecutive mornings.
11. Biopsy of the Lungs Percutaneous removal of a small amount of lung tissue
For histologic evaluation- Transbronchoscopic biopsy—done during bronchoscopy, - Percutaneous needle biopsy - Open lung biopsy
Nursing interventions BEFORE the procedure: Withhold food and fluids Place obtained written informed consent in the
Nursing interventions AFTER the procedure: Observe the patient for signs of Pneumothorax
and air embolism Check the patient for hemoptysis and
hemorrhage Monitor and record vital signs Check the insertion site for bleeding Monitor for signs of respiratory distress
12. Lymph Node Biopsy Scalene or cervicomediastinal To assess metastasis of lung cancer
13. Pulmonary Function Test / Studies Non-invasive test Measurement of lung volume, ventilation, and diffusing
capacity Nursing interventions:
Document bronchodilators or narcotics used before testing
Allay the patient’s anxiety during the testing
LUNG VOLUMES: (ITER)
Inspiratory reserve volume (3000 mL) The maximum volume that can be inhaled following a
normal quiet inhalation.Tidal volume (500 mL)
The volume of air inhaled and exhaled with normal quiet breathing
Expiratory reserve volume (1100 mL) The maximum volume that can be exhaled following the
normal quiet exhalationResidual volume (1200 mL)
The volume of air that remains in the lungs after forceful exhalation
Functional Residual Capacity (ERV 1100 mL + RV 1200 mL = 2300 mL )
The volume of air that remains in the lungs after normal, quiet exhalation
Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500 mL ) The amount of air that a person can inspire maximally
after a normal expirationVital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL = 4600 mL )
The maximum volume of air that can be exhaled after a maximum inhalation
Reduced in COPDTotal Lung Capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL + RV 1200 mL = 5800 mL )
Total of all four volumes
14. Arterial Blood Gas Laboratory test Indicate respiratory functions Assess the degree to which the lungs are able to provide
adequate oxygen and remove CO2
Assess the degree to which the kidneys are able to reabsorb or excrete bicarbonate.
Assessment of arterial blood for tissue oxygenation, ventilation, and acid-base status
Arterial puncture is performed on areas where good pulses are palpable (radial, brachial, or femoral).
Radial artery is the most common site for withdrawal of blood specimen
Nursing interventions: Utilize a 10-ml. Pre-heparinized syringe to
prevent clotting of specimen Soak specimen in a container with ice to
prevent hemolysis If ABG monitoring will be done, do Allen’s
test to assess for adequacy of collateral circulation of the hand (the ulnar arteries)
15. Pulmonary Angiography This procedure takes X-ray pictures of the pulmonary
blood vessels (those in the lungs). Because arteries and veins are not normally seen in an X-
ray, a contrast material is injected into one or more arteries or veins so that they can be seen.
16. Ventilation - Perfusion Scan Radioactive albumin injection is part of a nuclear scan
test that is performed to measure the supply of blood through the lungs.
After the injection, the lungs are scanned to detect the location of the radioactive particles as blood flows through the lungs.
The ventilation scan is used to evaluate the ability of air to reach all portions of the lungs. The perfusion scan measures the supply of blood through the lungs.
A ventilation and perfusion scan is most often performed to detect a pulmonary embolus. It is also used to evaluate lung function in people with advanced pulmonary disease such as COPD and to detect the presence of shunts (abnormal circulation) in the pulmonary blood vessels.
Procedure suing needle aspiration of intrapleural fluid or air under local anesthesia
Specimen examination or removal of pleural fluid Nursing intervention BEFORE Thoracentesis
Secure consent Take initial vital signs Instruct to remain still, avoid coughing during
insertion of the needle Inform patient that pressure sensation will be
felt on insertion of needle
Nursing intervention DURING the procedure: Reassess the patient Place the patient in the proper position:
Upright or sitting on the edge of the bed
Lying partially on the side, partially on the back
Nursing interventions after Thoracentesis Assess the patient’s respiratory status Monitor vital signs frequently Position the patient on the affected side, as
ordered, for at least 1 hour to seal the puncture site
Turn on the unaffected side to prevent leakage of fluid in the thoracic cavity
Check the puncture site for fluid leakage Auscultate lungs to assess for pneumothorax Monitor oxygen saturation (SaO2) levels Bed rest Check for expectoration of blood
RESPIRATORY CARE MODALITIES
1. Oxygen Therapy Oxygen is a colorless, odorless, tasteless, and dry gas that
supports combustion Man requires 21% oxygen from the environment in order
to survive Indication: Hypoxemia Signs of Hypoxemiao Increased pulse rateo Rapid, shallow respiration and dyspneao Increased restlessness or lightheadednesso Flaring of nareso Substernal or intercostals retractionso Cyanosis
Low flow oxygen provides partial oxygenation with patient breathing a combination of supplemental oxygen and room air. Low-flow administration devices:
High flow oxygen provides all necessary oxygenation, with patients breathing only oxygen supplied from the mask and exhaling through a one-way vent.High flow administration devices
o Venturi Mask 24-40% 4-10 LPM Preferred for clients with COPD because it
provides accurate amount of oxygen.o Face Masko Oxygen Hood*o Incubator / isolette*
Note: * can be used for both low and high flow administration
The nurse should prevent skin breakdown by checking nares, nose and applying gauze or cotton as necessary
Ensure that COPD patients receive only LOW flow oxygen because these persons respond to hypoxia, not increased CO levels.
2. Tracheobronchial suctioning Suction only when necessary not routinely Use the smallest suction catheter if possible Client should be in semi or high Fowler’s position Use sterile gloves, sterile suction catheter Hyperventilate client with 100% oxygen before and
after suctioning Insert catheter with gloved hand (3-5“ length of catheter
insertion) without applying suction. Three passes of the catheter is the maximum, with 10 seconds per pass.
Apply suction only during withdrawal of catheter The suction pressure should be limited to less than 120
mmHg When withdrawing catheter rotate while applying
intermittent suction Suctioning should take only 10 seconds (maximum of 15
seconds) Evaluate: clear breath sounds on auscultation of the chest.
a. Steam inhalation The purpose of steam inhalation are as follows:
- to liquefy mucous secretions- to warm and humidify air- to relieve edema of airways- to soothe irritated airways- to administer medication
It is a dependent nursing function Inform the client and explain the purpose of the procedure Place the client in Semi-Fowler’s position Cover the client’s eyes with washcloth to prevent irritation Check the electrical device before use Place the steam inhalator in a flat, stable surface.
Place the spout 12 – 18 inches away from the client’s nose or adjust distance as necessary
CAUTION: avoid burns. Cover the chest with towel to prevent burns due to dripping of condensate from the steam. Assess for redness on the side of the face which indicates first degree burns.
To be effective, render steam inhalation therapy for 15 – 20 minutes
Instruct the client to perform deep breathing and coughing exercises after the procedure to facilitate expectoration of mucous secretions.
Provide good oral hygiene after the procedure. Do after-care of equipment.
b. Aerosol inhalation done among pediatric clients to administer brochodilators or
c. Medimist inhalation done among adult clients to administer bronchodilators or
4. Chest Physiotheraphy ( CPT ) Includes postural drainage, chest percussion and
vibration, and breathing retraining. Effective coughing is also an important component.
Goals are removal of bronchial secretions, improved ventilation, and increased efficiency of respiratory muscles.
Postural drainage uses specific positions to use gravity to assist in the removal of secretions.
Vibration loosens thick secretions by percussion or vibration.
Breathing exercises and breathing retraining improve ventilation and control of breathing and decrease the work of breathing.
These are procedures for patients with respiratory disorders like COPD, cystic fibrosis, lung abscess, and pneumonia. The therapy is based on the fact that mucus can be knocked or shaken from airways and helped to drain from the lungs.
Postural drainage Use of gravity to aid in the drainage of secretions. Patient is placed in various positions to promote flow of
drainage from different lung segments using gravity. Areas with secretions are placed higher than lung
segments to promote drainage. Patient should maintain each position for 5-15 minutes
depending on tolerability.
Percussion Produces energy wave that is transmitted through the
chest wall to the bronchi. The chest is struck rhythmically with cupped hands over
the areas were secretions are located. Avoid percussion over the spine, kidneys, breast or
incision and broken ribs. Areas should be percussed for 1-2 minutes
Vibration Works similarly to percussion, where hands are placed on
client’s chest and gently but firmly rapidly vibrate hands against thoracic wall especially during client’s exhalation.
This may help dislodge secretions and stimulate cough.
This should be done at least 5-7 times during patient exhalation.
Suctioning Nursing Interventions in CPT
Verify doctor’s order Assess areas of accumulation of mucus secretions. Position to allow expectoration of mucus secretions
by gravity Place client in each position for 5-10 to 15 minutes Percussion and vibration done to loosen mucus
secretions Change position gradually to prevent postural
hypotension Client is encouraged to cough up and expectorate
sputum Procedure is best done 60 to 90 minutes before
meals or in the morning upon awakening and at bedtime.
Provide good oral care after the procedure
5. Incentive Spirometry• Types: volume and flow• Device ensures that a volume of air is inhaled and the
patient takes deep breaths. • Used to prevent or treat atelectasis • To enhance deep inhalation
• Nursing care– Positioning of patient, teach and encourage use,
set realistic goals for the patient, and record the results.
6. Closed Chest Drainage ( Thoracostomy Tube ) Chest tube is used to drain fluid and air out of the
mediastinum or pleural space into a collection chamber to help re-establish normal negative pressure for lung re-expansion.
Purposes To remove air and/or fluids from the pleural space To reestablish negative pressure and re-expand the
The chest tube is inserted into the affected chest wall at the level of 2nd to 3rd intercostals space to release air or in the fourth intercostals space to remove fluid.
Types of Bottle Drainage One-bottle system
The bottle serves as drainage and water-seal Immerse tip of the tube in 2-3 cm of sterile NSS to
create water-seal. Keep bottle at least 2-3 feet below the level of the
chest to allow drainage from the pleura by gravity. Never raise the bottle above the level of the heart
to prevent reflux of air or fluid. Assess for patency of the device Observe for fluctuation of fluid along the tube. The
fluctuation synchronizes with the respiration. Observe for intermittent bubbling of fluid;
continues bubbling means presence of air-leak
In the absence of fluctuation: Suspect obstruction of the device
Assess the patient first, then if patient is stable Check for kinks along tubing; Milk tubing towards the bottle (If the hospital allows
the nurse to milk the tube) If there is no obstruction, consider lung re-expansion;
(validated by chest x-ray) Air vent should be open to air.
Two-bottle system If not connected to the suction apparatus The first bottle is drainage bottle; The second bottle is water-seal bottle Observe for fluctuation of fluid along the tube
(water-seal bottle or the second bottle) and intermittent bubbling with each respiration.
NOTE! IF connected to suction apparatus1. The first bottle is the drainage and water-seal bottle; 2. The second bottle is suction control bottle.3. Expect continuous bubbling in the suction control bottle; 4. Intermittent bubbling and fluctuation in the water-seal5. Immerse tip of the tube in the first bottle in 2 to 3 cm of
sterile NSS 6. Immerse the tube of the suction control bottle in 10 to 20
cm of sterile NSS to stabilize the normal negative pressure in the lungs.
7. This protects the pleura from trauma if the suction pressure is inadvertently increased
Three-bottle system The first bottle is the drainage bottle; The second bottle is water seal bottle The third bottle is suction control bottle.
Observe for intermittent bubbling and fluctuation with respiration in the water- seal bottle
Continuous GENTLE bubbling in the suction control bottle. These are the expected observations.
Suspect a leak if there is continuous bubbling in the WATER seal bottle or if there is VIGOROUS bubbling in the suction control bottle.
The nurse should look for the leak and report the observation at once. Never clamp the tubing unnecessarily.
If there is NO fluctuation in the water seal bottle, it may mean TWO things
Either the lungs have expanded or the system is NOT functioning appropriately.
In this situation, the nurse refers the observation to the physician, who will order for an X-ray to confirm the suspicion.
Important Nursing considerations Encourage doing the following to promote drainage: Deep breathing and coughing exercises Turn to sides at regular basis Ambulate ROM exercise of arms Mark the amount of drainage at regular intervals
Avoid frequent milking and clamping of the tube to prevent tension pneumothorax
What the nurse should do if: If there is continuous bubbling: The nurse obtains a toothless clamp Close the chest tube at the point where it exits the chest
for a few seconds. If bubbling in the water seal bottle stops, the leak is
likely in the lungs, But if the bubbling continues, the leak is between the
clamp and the bottle chamber.
Next, the nurse moves the clamp towards the bottle checking the bubbling in the water seal bottle.
If bubbling stops, the leak is between the clamp and the distal part including the bottle.
But if there is persistent bubbling, it means that the drainage unit is leaking and the nurse must obtain another set.
In the event that the water seal bottle breaks, the nurse temporarily kinks the tube and must obtain a receptacle or container with sterile water and immerse the tubing.
She should obtain another set of sterile bottle as replacement. She should NEVER CLAMP the tube for a longer time to avoid tension pneumothorax.
In the event the tube accidentally is pulled out, the nurse obtains vaselinized gauze and covers the stoma.
She should immediately contact the physician.
Removal of chest tube—done by physician The nurse Prepares:
Place client in semi-Fowler’s position Instruct client to exhale deeply, then inhale and do
valsalva maneuver as the chest tube is removed. Chest x-ray may be done after the chest tube is
removed Asses for complications: subcutaneous
emphysema; respiratory distress
7. Artificial Airway
a. Oral airways- these are shorter and often have a larger lumen. They are used to prevent the tongue form falling backward.
b. Nasal airways- these are longer and have smaller lumen Which causes greater airway resistance
c. Tracheostomy- this is a temporary or permanent surgical opening in the trachea. A tube is inserted to allow ventilation and removal of secretions. It is indicated for emergency airway access for many conditions. The nurse must maintain tracheostomy care properly to prevent infection.
B. HIGH RISK GROUPS1. Children less than 5 yo2. Elderly
C. PREDISPOSING FACTORS1. Smoking2. Air pollution3. Immunocompromised
(+) AIDS Kaposi’s Sarcoma Pneumocystis Carinii Pneumonia
DOC: Zidovudine (Retrovir) Bronchogenic Ca
4. Prolonged immobility (hypostatic pneumonia)5. Aspiration of food (aspiration pneumonia)6. Over fatigue
D. SIGNS AND SYMPTOMS1. Productive cough, greenish to rusty2. Dyspnea with prolong expiratory grunt3. Fever, chills, anorexia, general body malaise4. Cyanosis5. Pleuritic friction rub6. Rales/crackles on auscultation7. Abdominal distention paralytic ileus
E. DIAGNOSTICS1. Sputum GS/CS confirmatory; type and
Azithromycin (OD x 3/days)1. Too costly2. Only se: ototoxicity – transient
hearing loss Anti-pyretics Mucolytics/expectorants
4. Administer O2 inhalation as ordered5. Force fluids to liquefy secretions6. Institute pulmonary toilet – measures to promote
expectoration of secretions DBE, Coughing exercises, CPT
(clapping/vibration), Turning and repositioning7. Nebulize and suction PRN8. Place client of semi-fowlers to high fowlers9. Provide a comfortable and humid environment10. Provide a dietary intake high in CHO, CHON,
Calories and Vit C11. Assist in postural drainage
Patient is placed in various position to drain secretions via force of gravity
Usually, it is the upper lung areas which are drained
Nursing management: Monitor VS and BS Best performed before meals/breakfast or
2-3 hours p.c. to prevent gastroesophageal reflux or vomiting (pagkagising maraming secretions diba? Nakukuha?)
Encourage DBE Administer bronchodilators 15-30 minutes
before procedure Stop if pt. can’t tolerate the procedure Provide oral care after procedure as it may
affect taste sensitivity Contraindications:
Unstable VS Hemoptysis Increased ICP Increased IOP (glaucoma)
12. Provide pt health teaching and d/c planning Avoidance of precipitating factors Prevention of complications
Regular compliance to medications Importance of ffup care
VI. PULMONARY TUBERCULOSIS (KOCH’S DISEASE) – infection of the lung parenchyma caused by invasion of mycobacterium tuberculosis or tubercle bacilli (gram negative, acid fast, motile, aerobic, easily destroyed by heat/sunlight)
A. PRECIPITATING FACTORS1. Malnutrition2. Overcrowding3. Alcoholism: Depletes VIT B1 (thiamin)
alcoholic beriberi malnutrition4. Physical and emotional stress5. Ingestion of infected cattle with M. bovis6. Virulence (degree of pathogenecity)
B. MODE OF TRANSMISSION: Airborne droplet infection
C. SIGNS AND SYMPTOMS1. Productive cough (yellowish)2. Low grade afternoon fever, night sweats3. Dyspnea, anorexia, malaise, weight loss4. Chest/back pain5. Hemoptysis
D. DIAGNOSTICS1. Skin testing
Mantoux test – PPD Induration width (within 48-72 h)
8-10 mm (DOH) 10-14 mm (WHO) 5 mm in AIDS patients is +
indicates previous exposure to tubercle bacilli
2. Sputum AFB (+) tubercle bacilli3. CXR – (+) pulmo infiltrated due to caseous necrosis4. CBC – elevated WBC
E. NURSING MANAGEMENT1. Enforce CBR2. Institute strict respiratory isolation3. Administer O2 inhalation4. Forced fluids5. Encourage DBE and coughing
NO CLAPPING in chronic PTB d/t hemoptysis may lead to hemorrhage
6. Nebulize and suction PRN7. Provide comfortable and humid environment8. Institute short course chemotherapy
Intensive phase INH
SE: peripheral neuritis (increase vit B6 or pyridoxine
Rifampicin SE: red orange color of bodily
May be replaced with Ethambutol (SE: optic neuritis) if (+) hypersensitivity to drug
SE: allergic reactions; hepatotoxicity and nephrotoxicity1. Monitor liver enzymes2. Monitor BUN and CREA
INH given for 4 months, PZA and Rifampicin is given for 2 months, A.C. to facilitate absorption
These 3 drugs are given simultaneously to prevent development of resistance
Standard Regimen Streptomycin injection (aminoglycosides)
Neomycin, Amikacin, Gentamycin1. common SE: 8th CN damage
tinnitus hearing loss ototoxicity
2. nephrotoxicitya. BUN (N = 10-20)b. CREA (N = 8-10)
9. Health teaching and d/c planning Avoidance of precipitating factors : alcoholism,
overcrowding Prevention of complications
Atelectasis Military TB (extrapulmonary TB:
meningeal, Pott’s, adrenal glands, skin, cornea)
Strict compliance to medications Never double the dose! Continue taking
the meds if missed a day) Diet modifications: increased CHON, CHO,
Calories, Vit C Importance of ffup care
VII. HISTOPLASMOSIS – acute fungal infection caused by inhalation of contaminated dust with Histoplasma capsulatum from birds’ manure
A. PREDISPOSING FACTORS Inhalation of contaminated dust
2. SIGNS AND SYMPTOMS PTB like symptoms Productive cough Fever, chills, anorexia, generalized body
malaise Cyanosis Chest and joint pains Dyspnea Hemoptysis
Tracheostomy usually done at bedside, 10-20 minutes Stress test: 30 minutes Mammography: 10-20 minutes LARYNGOSPASM – tracheostomy STAT OR Tracheostomy: laryngeal, thyroid, neck CA DIAPHRAGM – primary muscle for respiration INTERCOSTAL MUSCLES – secondary muscle for respiration ALVEOLI (Acinar cells) –functional unit of the lungs; site for gas
exchange (via diffusion) VENTILATION – movement of air in and out of the lungs RESPIRATION – lungs to cells
RETROLENTAL FIBROPLASIA – retinopathy/blindness in immaturity d/t high O2 flow in pedia patients
Histoplasmin skin test is (+) ABG analysis reveals pO2 low
4. NURSING MANAGEMENT Enforce CBG Administer meds as ordered
Antifungal agents Amphotericin B (Fungizone) SE:
nephrotoxicity and hypokalemia Monitor transaminases, BUN and
3. Administer oxygen inhalation as ordered4. Forced fluids5. Nebulize and suction patient as necessary6. Encourage DBE and coughing7. Provide a comfortable and humid environment8. Health teaching and d/c planning
Avoidance of precipitating factors Prevention of complications
Status asthmaticus DOC: Epinephrine Aminophylline drip
Emphysema Regular adherence to medications Importance of ffup care
III. BRONCHIECTASIS – permanent dilation of the bronchus due to destruction of muscular and elastic tissue of the alveolar walls (subject to surgery)
A. PREDISPOSING FACTORS1. Recurrent lower respiratory tract infection
Histoplasmosis2. Congenital disease3. Presence of tumor4. Chest trauma
B. SIGNS AND SYMPTOMS
1. Consistent productive cough2. Dyspnea3. Presence of cyanosis4. Rales and crackles5. Hemoptysis6. Anorexia and generalized body malaise
C. DIAGNOSTICS1. ABG analysis reveals low PO22. Bronchoscopy – direct visualization of bronchi
lining using a fibroscope Pre-op
Secure consent Explain procedure NPO 4-6 hours Monitor VS and breath sounds
Post-operative Feeding initiated upon return of gag reflex Instruct client to avoid talking, coughing
and smoking as it may irritate respiratory tract
Monitor for s/sx of frank or gross bleeding Monitor for signs of laryngeal spasm
DOB and SOB prepare trache setD. SURGERY
1. Segmental lobectomy2. Pneumonectomy
Most feared complications Atelectasis Cardiac tamponade: muffled heart sounds,
pulsus paradoxus, HPN
E. NURSING MANAGEMENT1. Enforce CBR 2. Low inflow O2 admin; high inflow will cause
respiratory arrest3. Administer medications as ordered
Bronchodilators Antimicrobials Corticosteroids (5-10 minutes after
4. Force fluids5. Nebulize and suction client as needed6. Provide comfortable and humid environment7. Health teaching and d/c planning
Avoidance of smoking Prevent complications
Atelectasis CO2 narcosis coma Cor pulmonale Pleural effusion Pneumothorax
Regular adherence to meds Importance of ffup care
IV. PULMONARY EMPHYSEMA – terminal and irreversible stage of COPD characterized by :
Inelasticity of alveoli Air trapping Maldistribution of gasses (d/t increased air trapping) Overdistention of thoracic cavity (Barrel chest)
compensatory mechanism increased AP diameter
A. PREDISPOSING FACTORS1. Smoking2. Air pollution3. Hereditary: involves alpha-1 antitrypsin for
elastase production for recoil of the alveoli4. Allergy5. High risk group elderly degenerative
decreased vital lung capacity and thinning of alveolar lobes
B. SIGNS AND SYMPTOMS1. Productive cough2. Dyspnea at rest3. Prolonged expiratory grunt4. Resonance to hyperresonance5. Decreased tactile fremitus6. Decreased breath sounds ( if (-) BS lung
collapse)7. Barrel chest8. Anorexia and generalized body malaise9. Rales or crackles10. Alar flaring11. Pursed-lip breathing (to eliminate excess CO2)
3. Tension – air enters pleural space during inspiration and cannot escape leading to overdistention of the thoracic cavity mediastinal shift to the affected side (ie. Flail chest) paradoxical breathing
B. PREDISPOSING FACTORS1. Chest trauma2. Inflammatory lung condition3. tumors
C. SIGNS AND SYMPTOMS1. Sudden sharp chest pain, dyspnea, cyanosis2. Diminished breath sounds3. Cool, moist skin4. Mild restlessness and apprehension5. Resonance to hyperresonance
D. DIAGNOSTICS1. ABG analysis: PO2 decreased2. CXR – confirms collapse of lungs
E. NURSING MANAGEMENT1. Assist in endotracheal intubation2. Assist in thoracentesis3. Administer meds as ordered