NURSING CARE OF THE CLIENT: RESPIRATORY SYSTEM

Nursing Dx: Respiratory Dysfunction

Ineffective Airway Clearance

Impaired Gas Exchange Ineffective Breathing

Pattern Impaired Verbal

Communication

Activity Intolerance

Anxiety Altered Nutrition:

Less than body requirement

Risk for Infection

Respiratory System Its primary

function is delivery of oxygen to the lungs and removal of carbon dioxide from the lungs.

Respiration Process of gas exchange Supply cells with oxygen for carrying on

metabolism Remove carbon dioxide produced as a

waste by-product. Two types of respiration: external and

internal.

Respiratory Assessment

A u scu lta tion(L is te n ing fo r N o rm a l a n d A d ve n tit io u s B rea th S o un d s)

P a lpa tion a nd P ercuss ion

In sp e ction(c lie n t 's co lo r, le ve l o f con sc iou sn ess , em o tion a l sta te )

(R a te , d ep th , q u a lity, rh ythm , e ffo rt re la tin g to resp ira tio n )

H e a lth H is to ry(a lle rg ie s , o ccup a tion , lifes tyle , h e a lth ha b its)

Assessment Review

Vital Signs Respiratory rate & heart rate WNL

Oxygen saturation of 95% or higher

Assessment ReviewPhysical Assessment Speak a sentence of 12 words without

stopping for breath Walk and talk without stopping for breath No cyanosis, pallor, or jaundice Oral mucus membrane & nail beds pink with

rapid capillary refill

Assessment Review Fingertips and nails normal shape, no

clubbing Anterior & posterior diameter of chest 2/3

smaller than lateral diameter Space between each rib larger than breath

of patient’s finger Breathes in through nose & out through

mouth & nose

Assessment Review Breathing quiet Air movement heard in all lobes of both

lungs Sputum production minimal, clear or

white Muscle development even with no

muscle loss on arms & legs Weight proportionate to height; not

underweight

Assessment Review

Psychological Assessment Oriented, not confused

Energy level good, can engage in desired work, recreational & personal activities

Assessment Review

Laboratory Assessment RBC Hemoglobin Hematocrit WBC

WNL for age & gender

Assessment: Inadequate Oxygenation

Resp rapid & shallow Respirations noisy Cannot speak >4 or 5 words without

pausing for breath Change in cognition, acute confusion Decreased oxygen saturation by pulse ox

Assessment: Inadequate Oxygenation

Skin cyanosis or pallor (lighter-skinned pts)

Cyanosis or pallor of lips or oral mucus membranes (pts of any skin color)

Tachycardia Appears to strain to catch breath Fatigue

Physical Assessment: Inadequate O2 Take vital signs Auscultate all lung fields Monitor O2 sat Check recent Hgb, Hct, ABGs Assess cognition Assess use of accessory muscles

Physical Assessment: Inadequate O2 Assess presence of thick or excessive

secretions Assess ability to cough and clear airway

Intervention: Inadequate Oxygenation

Apply O2 & assess response Elevate HOB 30 degrees Suction if needed Notify MD Priortize & pace activities to prevent

fatique

Assessing Lung Sounds

Adventitious Breath Sounds Fine crackles (dry, high-pitched popping…

COPD, CHF, pneumonia)

Coarse crackles (moist, low-pitched gurgling…pneumonia, edema, bronchitis)

Sonorous wheezes (low-pitched snoring…asthma, bronchitis, tumor)

Adventitious Breath Sounds Sibilant wheezes (high-pitched, musical …

asthma, bronchitis, emphysema, tumor)

Pleural friction rub (creaking, grating… pleurisy, tuberculosis, abscess, pneumonia)

Stridor (crowing…croup, foreign body obstruction, large airway tumor)

Diagnosing Respiratory Disorders

Laboratory Tests Hemoglobin Arterial blood

gases Pulmonary

Function Tests Sputum Analysis

Radiologic Studies Chest X-ray Ventilation-

perfusion scan CAT scan Pulmonary

angiography

Respiratory Disorders

Other diagnostic tests Pulse oximetry Bronchoscopy Thoracentesis MRI

Assessment: Upper Airway Problems Voice changes

nasal quality if above palate“breathy” or “whispery” if larynx or trachea

Snoring Mouth breathing

Assessment: Upper Airway Problems Change in cognition or LOC or acute

confusion Decreased O2 sat Skin cyanosis or pallor Cyanosis or pallor of lips or oral mucus

membranes Tachycardia & dysrhythmia

Physical Assessment: Upper Airway Problems

Take vital signs Monitor O2 sat Assess for presence of thick or excessive

secretions Assess ability to cough and clear airway Assess nasal drainage & sputum for

color & blood

Physical Assessment: Upper Airway Problems

Check WBC & ABG levels Assess cognition Assess hydration status

Intervention: Upper Airway Problems Suction Apply o2 & assess response Keep HOB elevated 30 degrees Notify MD Ensure venous access

Obstructive Sleep Apnea Intermittent absence of airflow through

mouth & nose during sleep

Occlusion of the oropharyngeal airway

Obstruction causes O2 sat, pO2, and pH to rise & pCO2 to rise

Obstructive Sleep Apnea

Obstructive Sleep Apnea Loud storing

during sleep Excessive daytime

drowsiness Irritability Restless sleep

Obstructive Sleep Apnea Restore airflow Prevent adverse

effects of disorder

Weight reduction Alcohol abstinence Improve nasal

patency Avoid prone

sleeping position

Obstructive Sleep Apnea Treatment of

Choice:Continous positiveairway pressure

(CPAP)

Obstructive Sleep Apnea Tonsillectomy Adenoidectomy

Obstructive Sleep Apnea Uvuloplatopharyngo

plasty

Obstructive Sleep Apnea Disturbed Sleep Pattern Fatigue Ineffective Breathing Pattern Impaired Gas Exchange Risk for Injury Risk for Sexual Dysfunction

Tracheostomy Bypass upper

airway obstruction 1. esophagus 2. trachea 3. tracheostomy tube

Tracheostomy Facilitate removal

of secretions

Tracheostomy

Manage long-term mechanical ventilation

Assessment: Infectious Resp Problems Resp shallow & rapid Decreased O2 sat Skin cyanosis or pallor Cyanosis or pallor of lips & oral mucus

membranes Tachycardia Work hard to inhale & exhale Restless anxious or confused

Physical Assessment: Infections Vital signs Auscultate all lung fields Monitor O2 sat Assess cognition Assess sputum Assess ability to cough & clear airway

Lab Values: Infections Elevated WBC ABG:

pH lower than 7.35HCO3 at or below 24 mmHgPaCO2 at or below 45 mmHgPaO2 below 90 mm Hg

Interventions: Infectious Resp Problems

Administer O2 Upright position with arms resting on

table or armrests Chest physiotherapy/pulmonary hygiene Pace activities to prevent fatigue

Interventions: Infectious Resp Problems

Administer IV, oral, or inhaled drugs Respiratory therapy treatments Reassess resp status after resp therapy Ensure fluid intake 3 liters/day

Sinusitis

Sinusitis

Pain & tenderness Headache, fever,

malaise Nasal congestion Purulent nasal

discharge Bad breath

Sinusitis: Medication Therapy Antibiotics

Oral or topical decongestants

Antihistamines

Saline nose drops or sprays

Systemic mucolytic agents

Sinusitis: Interdisciplinary Care Drain obstructed

sinuses Control infection Relieve pain Prevent

complications

Sinusitis Endoscopic sinus surgery

Sinus Surgery: Caldwell Luc procedure

Sinus Surgery: Antral irrigation

Sinusitis: Health Promotion Promote nasal drainage Encourage liberal fluid intake Judicious use of nasal decongestants Treat any obstructive process

Pneumonia Inflammation of lung parenchyma Infectious: Bacteria, viruses, fungal

protozoa Noninfectious: aspiration of gastric

contents, inhalation of toxic or irritating gases

Can be classified as community acquired, nosocomial, or opportunistic

Pneumonia: Signs & SymptomsPrimary Atypical PNA Fever Headache Myalgias Arthralgias Dry, hacking, non

productive cough

Viral PNA Flu-like symptoms Headache Fever Fatigue Malaise Muscle aches

Pneumonia: Signs & Symptoms

Pneumocystis PNA

Opportunistic infection

Abrupt onset Fever Tachypnea SOB

Dry, nonproductive cough

Respiratory distress

Intercostal retractions

Cyanosis

Pneumonia

Interdisciplinary care

Prevention Pneumococcal

vaccine Influenza vaccine

Medications Antibiotics Bronchodilators Agents to liquefy

mucus

Pneumonia

Treatment Oxygen therapy Chest

physiotherapy

Nursing Diagnosis Ineffective airway

clearance Ineffective

breathing pattern Activity

intolerance

Theresa A 20 year old college student Lives in a small dormitory with 30 other

students. Four weeks into the Spring semester, she

was diagnosed with bacterial pneumonia Admitted to the hospital

Teresa: High Priority Intervention Specimens for culture are taken prior to

beginning the antibiotic

Administering prior to cultures may make it impossible to determine the actual agent causing the pneumonia.

Theresa: Bacterial Pneumonia

Sputume culture results most frequent strain of found in

community-acquired pneumonia Streptococcus pneumoniae

Teresa: Clinical Manifestations Fever

stabbing or pleuritic chest pain

tachypnea

Elderly Weakness Fatigue lethargy Confusion poor appetite

without classic s & s

Treatment: Bacterial Pneumonia Started on Penicillin G

Response between 1 & 2 days

Complications of Pneumonia Atelectasis

Hypotension & shock

Pleural effusion

Impaired gas exchange

Pneumonia: Impaired Gas Exchange Results in hypoxia

Earliest sign and symptom of which is a change in the level of consciousness.

Interventions Oxygen by nasal cannula Plan for periods of rest during activities

of daily living. Monitor pulse oximetry readings every 4

hours. What oxygen delivery system would be

most effective for Theresa?

Nasal Cannula

Low flow delivery device 2 l/min = ~28% Higher flow rates (>5 l/min) dry nasal

membranes

Simple Face Mask

Flow rates 6-12 l/min Delivers 35-50% O2 Pt comfort issues (Maybe used for

Mr. Howe if SOB)

Non-Rebreathing Mask

Delivers accurate, high concentrations of oxygen

Achieves 60-90% O2 delivery

Oxygen Conserving Cannula

Built in oxygen reservoir

30-50% O2 delivery Increased comfort

Nebulizers/Humidifiers 02 is drying to mucous membranes Nebulizers

Bubble-through humidifier >4 l/min

Humidifiers Heated water

Tuberculosis Infection of the

lung tissue

Mycobacterium tuberculosis

TuberculosisSpread through

dropletnuclei: Coughing Sneezing Speaking Singing

Tuberculosis: Risk Factors Overcrowded, poor

living conditions Poor nutritional status Previous infection Inadequate treatment

of primary infection leads to multi-drug resistant organisms

Close contact to infected person

Immune dysfunction; HIV infection

LTC facilities, Prisons

Elderly Substance abuse

Tuberculosis

Caseation necrosis Inhaled bacteria multiply Tubercle is formed Infected tissue dies Cheeselike center forms

TuberculosisIf patient has adequateimmune response: Scar tissue develops

around tubercle Walls off bacilli Infected, does not

develop TB

Inadequate immuneresponse TB can develop

rapidly

Reactivation TB

Suppressed immune system due to Age Disease Use of immunosuppressive drugs

Tuberculosis: Signs & Symptoms Fatigue Weight loss Anorexia pm fever

Dry cough Later productive,

purelent/blood tingled

Night sweats

Tuberculosis: Interdisciplinary Care Early detection Accurate diagnosis Effective disease

treatment Preventing spread

to others

Tuberculin test Intradermal PPD

(Mantoux) test Multiple-puncture

(tine) testing

TB: Goals of Medication Treatment Make the disease noncommunicable to

others

Reduce symptoms of the disease

Affect a cure in the shortest possible time

Tuberculosis: Nursing Diagnosis Deficient Knowledge

Ineffective Therapeutic Regimem Management

Risk for Infection

Mr. Howe c/o dyspnea progressive wt

loss for several months

Productive cough Night sweats

“wringing wet”

Dx: R/O TB What additional

questions should you ask about Mr. Howe’s cough?

Assessing Cough How it feels How bad it is What makes it better or worse When it started Amount, color, odor, and consistency of

sputum

Mr. Howe Diagnostic test

expected for patient

Mantoux test Sputum for acid-

fast bacillus Chest X-ray History and

Physical Examination

Mantoux Test Positive result only indicate exposure or

has received BCG immunization

BCG immunization: Eastern Europe and countries where TB is endemic

Is not diagnostic for active TB

Mantoux Test Give upper 1/3 surface of the forearm Needle is inserted with bevel up 0.1 ml of purified derivative (PPD) inserted

intradermally) Read 48-78 hrs Induration 1.5 mm or greater is + (HIV or

immunosuppressed pts 5 mm or greater +

Sputum Studies Sputum Samples

Expectoration tracheal suction

Bronchoscopy Used to

identify infecting organisms

Confirm presence of malignant cells

early morning 15 ml required Obtain prior to

antibiotics Ask pt to rinse

mouth before collecting specimen

Mr. Howe: Bronchoscopy ordered

Preparation Informed consent NPO after midnight Explain procedure, obtain baseline vs &

ABG Atropine may be ordered to dry secretions

Bronchoscopy

Mr. Howe: Post Bronchoscopy

Complications Aspiration

Infection

Pneumothorax

Mr. Howe: Post Bronchoscopy Care NPO until gag reflex Monitor vital signs Assess for dyspnea, hemoptysis, & tachycardia Notify MD if fever, difficulty breathing Semi-Fowler’s position Give H2O as first fluid Inform pt of possible expectoration of blood

tingled mucus

Tuberculosis: Drug Therapy

Mr. Howe’s Medication Regime Chemotherapy are

all Hepatotoxic

Ethambutol optic neuritis skin rash

Rifampicin n/v Thrombocytopenia turns all bodily

secretions a red-orange color (tears, sweat, etc)

Mr. Howe’s Medication RegimeINH peripheral neuritis

(take Vitamin B 6 in conjunction to prevent)

hepatotoxicity GI upset

Streptomycin 8th cranial nerve

damage routine hearing

test caution in renal

disease

Mr. Howe’s Medication RegimePyrazinamid Heptoxicity hyperuricemia monitor uric acid & hepatic function

Mr. Howe’s Hospital Care Teach handwashing, cover nose and

mouth when coughing, sneezing Droplet Isolation-negative pressure room Special particulate respirator mask Psychosocial support-reinforce need to

take medication

Mr. Howe’s Teaching Plan Preventive measures to avoid catching

viral infections Taken drugs in combination to avoid

bacterial resistance Take meds at the same time of day on an

empty stomach Follow med regimen 6-12 months as

prescribed

Mr. Howe’s Teaching Plan Adequate nutritional status Annual check-up Annual Check-up: liver function tests Notify MD if signs of hepatitis,

hepatoxicity, neurotoxicity, & visual changes occur

Thoracentesis Used to obtain pleural fluid

for analysis Needle inserted between

ribs second and third intercostal spaces

Fluid withdrawn with syringe or tubing connected to sterile vacuum bottle

ThoracentesisPre-Procedure Informed consent-

explained & signed

Inform about pressure sensations that will be experienced during the procedure

Baseline vital signs

Make sure that a CXR has been completed

Thoracentesis: Positioning Lying on the unaffected side with the

bed elevated 30 – 40 degrees Sitting on the edge of the bed with her

feet supported and her arms and head on a padded overbed table.

Straddling a chair with her arms and head resting on the back of the chair.

Post Thoracentesis Apply pressure to

puncture site Assess bleeding &

crepitus Semi-fowlers or

puncture site up

Monitor for blood-tingled mucus

Assess for hypoxemia,

Assess for tachycardia

Assess breath sounds

Why is a chest x-ray ordered post procedure?

Assessment: Lower Resp Problems Resp shallow and rapid Decreased oxygen saturation Skin cyanosis or pallor Cyanosis or pallor of lips & mucus

membranes Tachycardia Work hard to inhale & exhale

Assessment: Lower Resp Problems Restless & anxious Thin compared to height Muscles of neck appear thick Arm & leg muscles appear thin Clubbed fingers Chest is barrel shaped Rib space more than a finger breath apart

Physical Assessment: Lower Resp Problems

Take vital signs Monitor O2 sat Assess cognition Assess sputum Assess ability to cough & clear airway

Lab Values: Lower Resp Problems Elevated RBC, HCT, HGB Elevated WBC ABGs

ph <7.35HCO3 > 24mm HgPCO2 > 45 mm HGPaO2 < 80 mm Hg

Interventions: Lower Resp Problems Upright position Chest Physiotherapy O2 low to maintain resp of 16 breaths minute Pace activities Administer inhaled drugs Respiratory therapy Fluid intake at least 3L daily

Bronchitis Common in adults

Risk factors Impaired immune

defenses Cigarette smoking

Acute bronchitis follows a viral URI

Chronic bronchitis is a component of COPD

Bronchitis Viral, bacterial

or inflammatory Irritants cause

increased mucus production and mucosal irritation

Acute Bronchitis

Bronchitis: Signs & Symptoms Non-productive

cough

Later becomes productive

Paroxysmal cough

Chest pain

Moderate fever

General malaise

Bronchitis

Treatment Symptomatic Rest Increased fluid

intakeNursing Intervention teaching

Medications ASA or tylenol Broad spectrum

antibiotic Cough

expectorant

Asthma Chronic inflammatory disorder of the

airways

Brief (acute asthma fatal)

Persistent irritation of the airways

Asthma: Risk Factors Allergies Family history occupational exposure Respiratory viruses Exercise in cold air Emotional stress

Asthma: Triggers Allergens Resp tract infection Exercise Inhaled irritants Secondhand smoke Medications

Asthma: Acute/early response Vasoconstriction

Edema

Mucus production

Asthma: Patho Inflammatory

mediators released

Activation of inflammatory cells

Bronchoconstriction

Airway edema

Impaired mucus clearing

SOB trapping of air

impairs gas exchange

Asthma: Signs & Symptoms Chest tightness Cough, dyspnea,

sheezing Tachycardia,

tachypnea, prolonged expiration

Fatigue, anxiety apprenhension

Respiratory failure Breath sounds

may improve right before failure

Asthma: Treatment Control symptoms Prevent acute

attacks Restore airway

patency Restore alveolar

ventilation

Long term control Anti-infammatory

agents Long acting

bronchodialators Leukotriene

modifiers

Asthma: Treatment

Quick relief Short acting

adrenergic stimulants

Anticholinergic drugs

Methylxanthines

Administration methods

Metered-dose inhaler (MDI)

Dry powder inhaler (DPI)

Nebulizer

Chronic Obstructive Pulmonary Disease

A collective term used to refer to chronic lung disorders

Air flow into or out of the lungs is limited

John Emphysema for 25 years

H/O smoking Diagnosis: Bronchitis

John: Cigarette Smoking Major causative factor in the

development of respiratory disorders lung cancer cancer of the larynx Emphysema chronic bronchitis

During assessment you note the presence of a “barrel chest”.

“air trapping” in the lungs

Barrel Chest

Slow progressive obstruction of airways Airways narrow Resistance to airflow increase Expiration slow and difficult Result: mismatch between alveolar

ventilation and perfusion, leading to impaired gas exchange

Major symptoms to assess John for

You should be alert for the followingpresenting symptom of COPD?

Increased dyspnea Sputum production

EmphysemaJohn is medicated with a bronchodilator to reduceairway obstruction. Assess for Dysrhythmias Central nervous system excitement Tachycardia

Purse Lip BreathingRecommended for John to: Decrease respiratory

rate

Increase alveolar ventilation

Reduce functional residual capacity

Venturi Mask is prescribed for John because: Moderate Oxygen Flow Delivers precise, high-

flow rates 24%-50%

Humidification available Requires face mask

BronchiectasisA chronic dilation of thebronchi caused by: pulmonary TB

infection chronic upper

respiratory tract infections

complications of other respiratory disorders

Obstruction of a pulmonary artery by a bloodborne substance

Pulmonary Embolism:

Common Cause: Deep vein

thrombosis

Pulmonary Embolism

Other sources of Pulmonary Emboli Fat Emboli

From fractured long bones Air Emboli

From IVs Amniotic fluid Tumors

Mrs. Perkins Mrs Perkins is suspected of having a

pulmonary embolus.

What diagnostic test confirms this diagnosis?

Pulmonary Embolism The plasma D-dimer test is highly specific for

the presence of a thrombus. An elevated d-dimer indicates a thrombus

formation and lysis.

What assessment data would support that Mrs. Perkins has experienced a pulmonary embolus?

Clinical Manifestations of Pulmonary Embolus

Sudden, unexplained dyspnea, tachypnea or tachycardia

Cough Chest pain Hemoptysis Sudden changes in mental status

(hypoxia)

Diagnosing Pulmonary Embolism Ventilation-Perfusion Scan

Nuclear imaging test Determines percentage of each lung that is

functioning normally

Pulmonary Angiography

Pulmonary Embolism

Mrs. Perkins pulse oximetry has decreasedto 90%. What does this indicate?

The normal pulse oximeter reading is 93% - 100%.

A reading of 90% indicates Mrs Perkins has an

arterial oxygen level of about 60

Pulmonary Embolism

With a diagnosis of PE, what intervention is crucial for

Mrs. Perkins?

Institute and maintain bedrest Bedrest reduces metabolic demands and

tissue needs for oxygen.

Management: Pulmonary Emboli Anticoagulation therapy

Heparin Coumadin for ~6 months

Thrombolytic therapy Use very cautiously only for acute, massive

PE Urokinase, Streptokinase & tPA

Inferior Vena Cava filter

Mrs. Perkins

Mrs. Perkins is receiving a heparin drip.The bag hanging is 20,000 units/500 ml of D5W infusing at 22 ml/hr. How many units

ofheparin is Mrs Perkins receiving each

hour?

Heparin Infusion 880 units20,000 divided by 500 = 40 units

If 22 ml are infused per hour, then 880 units

of heparin are infused each hour40 x 22 = 880

Heparin TherapyWhat nursing interventions should you implement forMrs Perkins receiving Heparin? Keep protamine sulfate readily available Assess for overt & covert signs of bleeding Avoid invasive procedures and injections Administer stool softeners as ordered

Pulmonary EmbolismMrs Perkins PT is 12.9 and PTT is 98. What are your implications for administering heparin to Mrs

Perkins?

A normal PTT is 39 seconds 58-78 is 1.5 to 2 times the normal value and is

within the normal therapeutic range A PTT of 98 means Mrs Perkins is not clotting;

medication should be held.

Pulmonary EmbolismThe doctor has ordered Coumadin for Mrs.Perkins. PT = 22 PTT = 39 INR = 2.8

What action should you implement Give the Coumadin because the

theurapeutic INR level is 2-3. What is the antidote for Coumadin?

Pulmonary Embolism: Teaching Use a soft bristle toothbrush to reduce the

risk of bleeding

Avoid aspirin Aspirin is an antiplatlet which may

increase bleeding tendencies.

Pulmonary Embolism: Teaching Wear a medic alert band

Increase fluid intake to 2-3L day (increases fluid volume which prevents DVT the common cause of PE)

IVC Filters

Greenfield Filter

Bird’s Nest Filter