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THE RESPIRATORY SYSTEM
Major function
GAS EXCHANGE
CONSISTS OF:
Nose and Mouth
allow air flow into and out of the body
Paranasal Sinuses
trap particles of foreign matter
Pharynx
passageway of digestive and respiratory tracts.
traps foreign particles
Respiratory System
Larynx
voice box, connects the upper and lower airways
initiates cough reflex w/c is part of the respiratory system’s defense mechanism
Trachea
C-Shaped connector
connects the larynx to the bronchi
Respiratory System
Bronchi
left and right bronchi
large passages that leads to the left and right lungs
Bronchioles
smaller branches of Bronchi
LUNGS
Alveoli
clustered microscopic sacs
where gas exchange occurs
contains a coating of surfactant to reduce tension and keep the them collapsing
Respiratory System
Lobes
How many lobes?
composed of 3 lobes (1 on the right and 2 on the left)
Respiratory System
Bronchoscopy
direct visualization of trachea and bronchial tree through the use of a bronchoscope
Laryngoscopy
uses laryngoscope to directly visualize the larynx
Nursing Management
Preprocedure:
NPO 6-12 hours before
consent
Diagnostic Tests
Post procedure Care:
Check cough and gag reflexes – prone to aspiration
assess respiratory status
NPO until gag reflex returns
monitor for bradycardia and hypotension
vasovagal response
Vagus nerve – 10th cranial nerve
Diagnostic Tests
Chest X-ray
taking a radiographic picture of the lung tissuePulmonary Angiography
injection of radiopaque dye through a catheter
provides radiographic picture of the pulmonary circulation
Sputum Study/ Exam
laboratory test that provides microscopic evaluation of sputum, evaluating it for culture and sensitivity, gram stain and acid-fast bacillus.
Diagnostic Tests
Nursing Management for Sputum Test
Obtain early-morning sterile specimen from suctioning or expectoration
Make sure that the specimen is truly sputum not saliva
Diagnostic Tests
Surgical Puncture of the chest wall, usually with large bore needle
Purpose:For drainage of accumulated fluidTo obtain a sample of intrapleural fluid to
determine to cause of infection or empyema (pus)
Thoracentesis
body cavity containing the lungs; the lungs are surrounded by two serous membranes, the pleurae
outer pleura (parietal pleura) covers and is attached to the chest wall
inner pleura (visceral pleura) covers and is attached to the lung and other structures, i.e. blood vessels, bronchi and nerves
Pleural SpaceSpace between the pleuranormally contains a small amount of
pleural fluid
Pleura
Thoracentesis
Nursing Care:
Beforeconsentreassure patientposition the client
sitting on the edge of the bed
turn the client on his unaffected side with the arm of his affected side raised above his head
After Assess respiratory statusmonitor V/S frequentlyposition the client on the affected side
(seal the punctured site)
Thoracentesis
Pulmonary Function Test (PFT)
non invasive procedure test that measure lung volume, ventilation, and diffusing capacity using a Spirometer
Nursing Mgt:
Ask the client to breath through a mouthpiece following specific directions.
refrain from smoking, or eating a heavy meal 4-6 hours before testing
Diagnostic Tests
ABG (Arterial Blood Gas)
Mantoux Intradermal Skin Test
detects tuberculosis antibodies
Nursing Care:document Hx of positive results in the past or exposure to
BCG immunizationcircle and record the test sitereading – 48-72 hours after injection
Diagnostic Tests
Lung Biopsy
removal of small amount of lung tissue for histologic evaluation.
Nursing Actions:
BeforeNPO for 8 hoursconsent
After: V/SAssess respiratory statuscheck incision site for bleeding
Diagnostic Tests
Common Respiratory Interventions
Nursing Action:Place in Semi or in high Fowler’s positionUse sterile gloves and sterile suction catheterHyperventilate the client w/ 100% of O2 before and after the
procedureApply suction during withdrawal of the catheterRotate the catheter while applying an intermittent suction
upon withdrawal of the catheterSuctioning should take for only 10 to 15 seconds (Insertion,
intermittent suctioning, and removal of the suction)
Tracheobronchial Suctioning
Percussion, Vibration and Postural Drainage (PVD)dependent nursing interventions
Postural DrainageDrainage by gravity of various lung segments
Percussion
“clapping”
forceful striking of the skin with cupped hands
Percussion over the congested areas of lungs can mechanically dislodge the tenacious secretions from the bronchial wall
ProcedureVerify doctor’s orderAssess accumulation of mucous secretionsPosition to allow expectoration of mucous secretions by gravityPlace the client in each position for 10-15 minutesVibrate and percuss – loosen mucous secretionsBest done 60-90 minutes before meals or in the morning upon awakening and
at bedtime
Chest Physiotherapy
VibrationSeries of vigorous quivering produced by hands that are placed flat
against the client’s chest wallUsed after percussion to increase flow of the exhaled air and thus loosen
the thick secretions
Procedure:Place the hands, palms down on the chest area to be drained , one hand
over the other with the fingers together and extendedAsk the client to inhale deeply and to exhale slowly through the nose or
pursed lipsDuring exhalations, tense all the hand and arm muscles, and using
mostly the heel of the hand, vibrate (Shake) the hands moving then down ward. Stop vibrating when the client inhales
Do 5 vibrations on each affected lung segmentAfter each vibrations, encourage client to cough and expectorate
secretions
Chest Physiotherapy
Thoracostomy Tube (Closed Chest Drainage)
Remove air and/or fluids from the pleural spaceReestablish negative pressure and reexpand the lungs
Indications:Pneumothorax
collection of air or gas in the pleural space Hemothorax
accumulation of blood in the pleural spacePleural Effusion
presence of fluid in the pleural space
Types:
One Bottle System
Two Bottle System
Three Bottle System
Thoracostomy Tube (Closed Chest Drainage)
One-Bottle SystemThe bottle serves as drainage bottle
and water-seal bottleImmerse the tip of the tube 2-3 cm on
sterile NSS to create water-sealKeep at list 2-3 feet below the level of
the chestNever raise bottle above the level of
the chest
Thoracostomy Tube (Closed Chest Drainage)
One-Bottle System
Assess patency of the device
fluctuation of fluid on the tube
intermittent bubbling of fluid
Continuous bubbling means air leak
Absence of Fluctuation
obstruction
check for kinks; milk the tubing towards the bottle
consider lung reexpansion
validate w/ chest x-ray
Thoracostomy Tube (Closed Chest Drainage)
Two- bottle SystemCould be connected or not
connected to a suction apparatus
Not connected 1st bottle is the drainage
bottle2nd bottle water-seal bottle Observe for fluctuation of
fluid along the tube (water-seal bottle) and intermittent bubbling with each respiration
Thoracostomy Tube (Closed Chest Drainage)
Connected to the suction apparatus
1st bottle is drainage and water-seal bottle; 2nd suction control bottle
continuous bubbling on the suction control bottle; intermittent bubbling and fluctuation in the water-seal
immerse tube in the first bottle 2-3 cm on sterile NSS and 10-20 cm for suction control bottle to stabilize negative pressure
Thoracostomy Tube (Closed Chest Drainage)
Three-Bottle System1st bottle- drainage bottle, 2nd – water-seal bottle, 3rd-suction
control bottleIntermittent bubbling and fluctuation on water-seal bottle
and continuous bubbling in the suction control bottle
Thoracostomy Tube (Closed Chest Drainage)
Nursing Management Encourage
DBE and coughing exercises, turning to sides at regular basis, ambulate
Mark the mount of drainage at regular intervalsAvoid frequent milking and clamping to avoid tension
pneumothoraxRemoval of chest tube
Done by the physician
Prepare: petroleum gauze, suture removal kit, sterile gauze, adhesive tape
Place client in semi fowler’s position
Instruct to exhale deeply and do valsalva maneuver as the chest tube is removed
Chest X-ray may be done
Thoracostomy Tube (Closed Chest Drainage)
DISORDERS
Nose BleedingCauses: Trauma
Nursing care:Sit-up, lean forward, head tipped – prevent
aspiration of bloodPressure over the soft tissue of the nose for at least 5
minutesCold compress/icepacksNotify physician if recurrent
Epistaxis
an inflammation and infection of the sinuses
Etiology:
Streptococcus Pneumoniae, haemophilus influenzae
Sinusitis
URTI
Cigarette Smoking
Allergic rhinitis
Inflammation
Edema of the mucous membrane
Hypersecretion of mucus
Infection
Simple Pathophysiology of Sinusitis
Assessment findings
Pain:
Maxillary – cheek, upper teeth
Frontal – above the eyebrows
Ethmoid – in and around the eyes
Sphenoid – behind the eye, top of the head
General malaiseStuffy noseHAFeverPersistent coughPost nasal discharges
Sinusitis
Nursing Care:RestIncrease fluid intakeAnti-infectivesNasal decongestants
Surgical Management:
Functional Endoscopic Sinus Surgery (FESS)
most common corrective surgery for chronic sinus inflammation
Performed under the magnification of a small telescopic endoscope
remove diseased tissue and bone, polyps to open the sinuses and help to restore the nose and sinus’ health
Sinusitis
Functional Endoscopic Sinus Surgery
Caldwell-Luc Surgery (Radical Antrum Surgery)
“conventional procedure”
involves removal of the diseased lining of the maxillary antrum
left scars and caused significant bruising and discomfort
Sinusitis
Caldwell-Luc Surgery (Radical Antrum Surgery)
Nursing Management after the surgery
Do not chew on the affected sideCaution with oral hygiene Do not wear dentures for 10 daysDo not blow the nose for 2 weeks after removal of packing Avoid sneezing for two weeks after surgery
Sinusitis
Inflammation of the tonsils
Etiology:
Streptococcus - most common
Haemophilus influenzae
Complications:
Otitis media
Pneumonia
Nephritis
Osteomyelitis
Rheumatic fever
Tonsillitis
Assessment:
Otalgia (referred pain to the ear)
Dysphagia
Malaise
Acutely inflamed mucous membrane with or w/o purulent exudates
Tonsillitis
Nursing Care:
rest
increase fluid intake
warm saline gargle – relieves discomfort
antimicrobials ,Ibuprofen, lozenges
Surgical Manegement
Tonsillectomy indicated if tonsillitis is recurrent
5-6 times a yearSurgical removal of the tonsils
Tonsillitis
Tonsillectomy
Pre Operative Care:
Assess URTI. Coughing and sneezing could also cause bleeding
Check PT time. Bleeding is common Post op complication
Surgical Management
POST OPERATIVE CARE
prone, turn head to sides or lateral position until awake
if awake can be positioned in semi Fowler’s position
monitor for hemorrhage specially during the 1st 12-24 hours
inspect the oropharynx and mouth for fresh blood
frequent swallowing
bright red vomitus
increased RR
Promote Comfort
Ice collar, acetaminophen, avoid ASA
Foods and Fluids
Ice-cold Fluids
Refer for pain and administer prescribe medications
Aspirin is contraindicated
Surgical Management
Also known as Respiratory Distress Syndrome
Type of Lung Failure resulting from many different disorders that cause FLUID to ACCUMULATE in the lungs and OXYGEN levels in the blood to be TOO LOW
Medical emergency
ACUTE RESPIRATORY DISTRESS SYNDROME(ARDS)
Air
Lungs
Alveolar capillaries(small blood vessels)
Bloodstream
Inflammation on the lungs
NORMAL ARDS
Increase fluid in the alveoli
prevents the lungs from filling with air and moving enough oxygen into the
bloodstream
Severe respiratory failure
Assessment Findings
SOB/DOB (rapid, shallow breathing)CyanosisRapid HRAnxiety, confusion and restlessnessCrackles and wheezesDecreased breath sounds
ACUTE RESPIRATORY DISTRESS SYNDROME(ARDS)
ACUTE RESPIRATORY DISTRESS SYNDROME(ARDS)
Management:
Bed rest
O2 therapy
Monitor respirations, cardiovascular, and neurologic status (hypoxemia)
Monitor pulse oximetry regularly
Monitor Laboratory studies:
Hb and Hgb
WBC
Fowler’s position
Weigh daily – I and O
Encourage to express feelings
Pharmacology
antibiotics
Diuretics
Several disorders that affect the movement of air in and out of the lungs
The airways, the tubes that carry air in and out of the lungs are partly obstructed
Cigarette smoking is the most common cause
Irreversible
Consists Of:Chronic BronchitisAsthmaEmphysema
Chronic Obstructive Pulmonary Disease (COPD)
CHRONIC BRONCHITIS
Inflammation, or irritation of the bronchi
Causes chronic persistent cough with formation of thick mucous secretions
Are called "blue bloaters" because they have cyanosis
Possible Causes:
Cigarette Smoking
RTI
Environmental pollutants
Chronic Obstructive Pulmonary Disease (COPD)
CHRONIC BRONCHITIS
Characterized By:
Increase of submucous glands and goblet cells
- produces mucus
Impaired ciliary function
- reduces mucus clearance
Chronic Obstructive Pulmonary Disease (COPD)
Rapid Increase in Mucus
Obstruction(trapping of
CO2)
Impaired Alveolar ventilation
Derived from the bluish color of the lips and skin
A blue bloater
experiences cyanosis due to a decrease insufficient amounts of oxygen reaching the blood.
The Blue Bloater
Nursing Care for Chronic BronchitisStop SmokingAvoid hair sprays, aerosols – irritates the lungsExercise at least 3 times a week O2 therapyBronchodilators“pursed-lip breathing“
slows down the fast breathing
take a deep breath and then breathe out slowly through the mouth while holding the lips as if you're going to kiss someone
Chronic Obstructive Pulmonary Disease (COPD)
ASTHMA
Airways of people with asthma are extra sensitive to allergens and to other irritating things in the air (irritants)
Inflammation of the lining of the airways (swelling and narrowing)
Spasm including narrowing of airways
Chronic Obstructive Pulmonary Disease (COPD)
ASTHMA
Assessment Findings:
Dyspneic and have marked respiratory effort
Nasal flaring
Pursed-lip breathing with use of accessory muscles
Wheezing (Expiration)
ABSENT WHEEZING
indicate that the small airways are too constricted to allow any air flow
Low Oxygen Saturation (normal 95-99%)
Chronic Obstructive Pulmonary Disease (COPD)
NURSING CARE ON ASTHMA
Assess for manifestations of airway distressAsk the client to rate dyspnea on a scale of 0 to 10Avoid allergens and irritantsMedications – prevent asthma attack
inhaled corticosteriods
Azmacort, AeroBid, Flovent
Chronic Obstructive Pulmonary Disease (COPD)
Nursing Management:
Demonstrate to the client the correct use of inhalers and/or nebulizers
Assist the client in identifying the cause of acute bronhial attack
Teach about the METERED DOSE INHALERS (MDI)When 2 puffs are needed,, 2-3 minutes should lapse
between 2 puffsA spacer may be used to increase the delivery of the
medication
Pharmacology
MDI AND SPACER
Shake the inhaler for five to 10 seconds (about three to five times).
Hold the inhaler upright with the mouthpiece end facing down.
Press down on the inhaler firmly to release the medication as you start to breathe in.
Breathe in slowly and completely for three to five seconds- count 1 one thousand, 2 one thousand, 3 one thousand.
Pharmacology
Hold your breath for 10 seconds if possible to allow the medication to go deeply into your lungs.
Exhale slowly through your mouth. Repeat puffs as prescribed. Wait one minute between puffs
to permit the inhaler to reload with medication, and shake before using again.
Replace the cap on your inhaler/spacer. The inhaler and spacer should be cleaned often to prevent
buildup
Pharmacology
STATUS ASTHMATICUS
Severe, life threatening complication of asthmaAcute episode of bronchospasm that tends to
intensifyWorkload breathing increases 5 to 10 timesCan lead to severe state to hypoxemia, acidosis and
DEATH
Chronic Obstructive Pulmonary Disease (COPD)
EMPHYSEMA
Disorder in which the alveolar walls are destroyed that leads to PERMANENT OVERDISTENTION of the air spaces
Chronic Obstructive Pulmonary Disease (COPD)
Destruction of the connective tissues in the
lungs
Obstruction of Airway
Passages
Inefficient Delivery of O2
Assessment Findings:
Shortness of breath on exertion and later at rest, hyperventilation, and an expanded chest.
Mild emphysema sufferers often maintain adequate blood oxygen levels by hyperventilating, and so are sometimes called "pink puffers”
Chronic Cough
Dyspneic with use of accessory muscles
Sputum production
Emphysema
Assessment Findings
Adventitious breath sounds
Pursed-lip breathing
Tends to assume upright, leaning forward position
Alteration in LOC, Skin color, Skin temperature
Decreased metabolism
Weakness, fatigue, anorexia, weight loss
Peripheral cyanosis
Chronic Obstructive Pulmonary Disease (COPD)
BARREL CHEST
Alteration in thoracic anatomy
CLUBBING OF FINGERS
caused by chronically low blood levels of oxygen
distortion of the normal angle of nail bed
Chronic Obstructive Pulmonary Disease (COPD)
Nursing Management
Rest - O2
Increase fluid intake – Liquefy mucus secretions
Good oral care – remove sputum and prevent infection
DIET:
High in calorie, High CHON and Decrease CHO
Calorie
energy source
CHON
maintain the integrity of the alveolar walls
Low CHO
Limits CO2 production (End product)
Chronic Obstructive Pulmonary Disease (COPD)
Nursing Management
O2 therapy 1-3 lpm (2 lpm is safest)
Why do you have not to give high concentration of O2?
Drive for breathing is low level of CO2
Avoid smoking, alcohol, environmental pollutants
CPT
Bronchial hygiene measures
steam and aerosol inhalation
Chronic Obstructive Pulmonary Disease (COPD)
PHARMACOLOGY:
expectorants
antitussives
CODIENE
Observe for drowsiness
avoid activities that involve mental alertness
causes dec peristalsis thereby constipation
Bronchodilators (Aminophylline, ventolin, Bricanyl)
Antihistamine
Steriods
Antimicrobials
Chronic Obstructive Pulmonary Disease (COPD)
Pleural effusion
accumulation of fluids in the pleural space
pneumothorax - air
Types of Plerual Effusion
Hemothorax – blood
Pyothorax – pus
Hydrothorax - water
Pleural Effusion and Pneumothorax
CAUSES:
trauma
thoracic surgery
thoracentesis
Emphysema
Assessment:
Sudden sharp chest pain
SOB
Anxiety, restlessness
Inc. PR and RR
Chest tightness
cyanosis
Pleural Effusion and Pneumothorax
Nursing Interventions:
remain with patient
High-Fowler’s position
pain management
O2
chest tube drainage or thoracentesis
chest x-ray
ABG monitoring
monitor for S/Sx of Shock
Pleural Effusion and Pneumothorax
Most common cause of death among men and womenCan be:
Primary Lung Cancer - originated in the lung cells
Secondary Lung Cancer – metastasis
Causes:Cigarette smoking – 90% of casesExposure to carcinogens like asbestos, radiation, arsenic,
nickel.Air pollutionTB and other pervious lung disease
Lung Cancer
Signs and Symptoms:Persistent cough – first and most common signHymoptysis Wheezing due to narrowed airwaysSOBFeverChest painLoss of appetiteWeight lossFatigue and weaknessPleural effusions
Lung Cancer
Diagnosis:Chest X-ray (may determine most lung tumors but may
miss small tumors)CT Scan Needle Biopsy
obtaining a specimen by inserting a needle through the skin
Lung Cancer
Medical Management:Radiation TheraphyChemotheraphy
Indicated for:
clients whom surgery poses an unacceptably high risk
clients who have technically inoperable tumors
clients who refuse surgerySurgical Resection – treatment of choice
Lung Cancer
Surgical Management:Laser Surgery
Palliative measure to relief the endobronchial obstruction that are not resectable
PULMONARY RESECTION
Wedge Resection
removal of a small, localized area near the diseased tissue
Lobectomy
removal of the entire lobe of the lung
After surgery, the remaining lung overexpands to fill the open portion of the thoracic space
Pneumonectomy
removal of the entire lung
the involved side of the thoracic cavity is an empty space
Lung Cancer
Nursing Management of the Surgical Client:
Preoperative Care:Aimed at reducing the client’s anxiety levelPostoperative self-care activities
respiratory exercises (use of incentive spirometry)
splinting technique to promote effective coughing and deep breathing
leg exercises to prevent thrombophlebitis
Lung Cancer
Nursing Management of the Surgical Client:
Splinting Technique:Place one hand around the client’s back and the other
around the incision areaSupport the area below the incision with one hand while
exerting downward pressure on the shoulder on the affected side with the other
Have the client hug a pillow during forced expiratory cough
Lung Cancer
Nursing Management of the Surgical Client:
Postoperative Care:Monitor for manifestations of respiratory failure
(increased RR, use of accessory muscles, cyanosis, decreased PaO2 and increased PaCO2, restlessness)
Monitor IV flow rates (IVF should not exceed 125ml/hr)Monitor cardiac functionsAssess dressing and incision area every 4 hours for bleeding;
assess closed chest drainage system for bleedingPlace client in semi fowler once VS are stableAssist the client in coughing and deep breathing exercises administer pain medication as ordered
Lung Cancer
Nursing Management of the Surgical Client:
Postoperative Care:Position the client as indicated by phase of recovery and
surgical procedure:
Nonoperative Side – Lying position may be used until consciousness is regained
Semi-Fowler Position – recommended once VS is stableMaintain supplemental oxygenProvide opportunity to express feelings
Lung Cancer
TuberculosisPulmonary EmbolismPneumoniaIntubation
Study the Following Cases