RESPIRATION

Chapter 30 &31

Acute and Chronic Respiratory Disorders1Commonly understood to mean movement of airAccomplished by the pulmonary system, consisting of the airways and lungs, the blood vessels perfusing them, the muscles of the thorax and abdomen, and the innervation of these structuresVENTILATION2the movement of atmospheric air into and out of the lungsdepends on open airways and contractions of muscles to create pressure gradients for air flowventilation is the critical first step in the complex process of respirationPULMONARY VENTILATION3provides oxygen for metabolism in the tissuesremoves carbon dioxide, the waste product of metabolismPrimary functions of the respiratory system4facilitates sense of smellproduces speechmaintains acid-base balancemaintains body water levelsmaintains heat balanceSecondary functions of the respiratory system5THE PROCESS OF AIR ENTERING THE LUNGSALSO CALLED INSPIRATIONINVOLVES ACTIVE CONTRACTION OF THE MUSCLES AND DIAPHRAGMNOTED BY ENLARGEMENT OF THE CHEST CAVITYINHALATION6THE PROCESS OF AIR LEAVING THE LUNGSALSO CALLED EXPIRATIONA PASSIVE PROCESS MUSCLES RELAX AND CHEST RETURNS TO NORMAL SIZEEXHALATION7normally approx 500 ml of air is inhaled and exhaledAPNEA-temp interruption in normal breathing, no air movement occursdyspnea-difficulty breathingorthopnea-difficulty breathing while in a lying positionSee Table 30-1 for types of breathing patternsBREATHING8respiratory center of the brain located just above the spinal cord in the brain stemstimulated by changing levels of CO2 & OxygenChemoreceptors in the aorta and carotid artery monitor the PH and the amount of carbon dioxide and oxygen in the blood stream.

MEDULLA9NOSESINUSESPHARYNXLARYNXEPIGLOTTISUPPER RESPIRATORY TRACT10Humidifies, warms, and filters inspired airNOSE

11air-filled cavities within the hollow bones that surround the nasal passagesprovide resonance during speechSINUSES12located behind the oral and nasal cavitiesdivided into the nasopharynx, oropharynx, laryngopharynxpassageway for both the respiratory and digestive tractsPHARYNX (Throat)13located above the trachea and just below the pharynx at the root of the tonguecontains two pairs of vocal cords, the false and true cordsopening between true vocal cords is the glottisthe glottis plays an important role in coughingcoughing is the most fundamental defense mechanism of the lungsLARYNX (Voice Box)14leaf-shaped elastic structure that is attached alone one end to the top of the larynxit prevents food from entering the tracheobronchial tree by closing over the glottis during swallowingEPIGLOTTIS15TRACHEAMAINSTEM BRONCHIBRONCHIOLESALVEOLAR DUCTS AND ALVEOLI LOWER RESPIRATORY TRACT

16located in front of the esophagusbranches into the right and left mainstem bronchi at the carinapassageway for air to reach the lungsTRACHEA (Windpipe)17begins at the carinaa ridgelike structure between the openings of the right and left bronchusthe right bronchus is slightly wider, shorter, and more vertical than the left bronchusmost foreign bodies from the trachea usually enter the right bronchusthe mainstem bronchi divides into five secondary or lobar bronchi that enter each of the five lobes of the lungMAINSTEM BRONCHI18the bronchi are lined with cilia, which propel mucus up and away from the lower airway to the trachea where it can be expectorated or swallowedMAINSTEM BRONCHI19branch from the secondary bronchi and subdivide into the small terminal and respiratory bronchiolesthey contain no cartilage and depend on the elastic recoil of the lung for patencythe terminal bronchioles contain no cilia and do not participate in gas exchangeBRONCHIOLES20alveolar ducts branch from the respiratory bronchiolesalveolar sacs, which arise from the ducts, contain clusters of alveoli, which are the basic units of gas exchangecells in the walls of the alveoli secrete surfactant, a phospholipid protein that reduces the surface tension in the alveoli, without this alveoli collapseALVEOLAR DUCTS AND ALVEOLI21innervation of the respiratory structures is accomplished by the phrenic nerve, vagus nerve, and thoracic nervesthe parietal pleural lines the inside of the thoracic cavity including the upper surface of the diaphragmthe visceral pleura covers the pulmonary surfacesLUNGS

22a thin fluid layer, which is produced by the cells lining the pleura, lubricates the visceral and parietal pleura, allowing them to glide smoothly and painlessly during respirationblood flows through the lungs occurs via the pulmonary system and the bronchial systemLUNGS CONT23scalene muscleselevate the first two ribssternocleidomastoid musclesraise the sternumtrapezius and pectoralis musclesfix the shouldersaccessory muscles of respiration24the diaphragm descends into the abdominal cavity during inspiration causing negative pressure in the lungsthe negative pressure draws air from the area of greater pressure, the atmosphere, into the area of lesser pressure, the lungsin the lungs, air passes through the terminal bronchioles into the alveoli to oxygenate the body tissuesTHE RESPIRATORY PROCESS25at the end of inspiration, the diaphragm and intercostal muscles relax and the lungs recoilas the lungs recoil, pressure within the lungs becomes greater than atmospheric pressure causing the air that now contains the cellular waste products of carbon dioxide and water to move from the alveoli in the lungs to the atmosphereTHE RESPIRATORY PROCESS26AGE RELATED CHANGESATROPHY (pharynx and larynx)SLACKENING OF VOCAL CORDSLOSS OF ELASTICITY RIGID RIB CAGEDIAPHRAGM FLATTENSDECREASED NUMBER OF ALVEOLI

27reduced chest movementdecreased ability to inhale and exhaleless effective coughincreased work of breathingless tolerance for exercise and stressAGE RELATED CONSEQUENCES28smokingallergiesfrequent respiratory illnesseschest injurysurgeryexposure to chemicals and environmental pollutantscrowded living conditionsfamily history of infectious diseasegeographic residence and travel to foreign countries

RISK FACTORS FOR RESPIRATORY DISEASE

29HEALTH HISTORYWHAT DO YOU NEED TO KNOW?Chief complaint and hx of present illnesspast medical hxreview of systemsfunctional assessment30coughpaindyspneafeversweatingnausea/vomitingeffort to treatresponse to treatment

PRESENT ILLNESS31onset-one week ,activity, lying down? duration-each episode, how long frequency-frequent, occasionally, constantly type-dry hacking, wet productive, irritating and scratchy severity-hard enough to throw up?COUGH:

32 sputum production & characteristicsCOLOR-green, yellow, clear, rusty, blood tingedCONSISTENCY-thick, thin,ODOR-there either is or there isntAMOUNT-scant, copious, large, small pain-does it hurt when you cough?have they tried anything to treat it and has it helpedCOUGH

33 onset duration severity precipitating events associated symptomsDyspnea:

34 location onset duration precipitating events effects on breathing relief measuresassociated symptomsPain:35Coldspneumoniatuberculosis/last TB testchronic bronchitisemphysemaasthmacancer of resp. tractcystic fibrosisimmunizationsSinus infectionsear infections diabetes mellitusheart diseaseallergies / current medstraumasurgerieshospitalizations/ last CXRconditions that suppress the immune systemPAST MEDICAL HISTORY36Family history

Major respiratory conditionssmoking history

37fatigueweaknessfever chillsnight sweatsearachesnasal obstructionsinus painsore throathoarsenessedemadyspneaorthopneaReview of symptoms38occupationexposure to pathogensexposure to respiratory irritantstypical dayusual dietfluid intake

smoking history# yrs smokedX pkg/dthis equals pack yearsrole in familystressorscoping strategies

Functional Assessment39PHYSICAL EXAMbe alert to any unusually rapid or slow breathing and to tachycardia, which may be a sign of hypoxiaremember normal respiratory rate is 16 - 20 breaths per minute40Appearancefacial expressionposturealertnessspeech patternobvious distressVS Ht. & Wt.GENERAL SURVEY

41NOSEpatency of naresnasal flaring(sign of air hunger)swellingdischargebleedingforeign bodiesmucosa should be bright red in colordeviation of nasal septumHEAD AND NECK

42SINUSESpalpate sinuses for tendernessLIPS pursed-lip breathing, common technique for decreasing dyspnea for pts with chronic resp dzinspect lips, tip of nose, top of auricles, gums and under tongue for cyanosis, a bluish color R/t inadequate O2PHARYNXRedness, tonsil exudate or enlargementHEAD AND NECK

43inspect for deviation, can be indicative for a large atelectasis, pleural effusion, aortic aneurysm, enlargement of part of the thyroid gland, and tension pneumothoraxTRACHEA

44THORAXlook for deformities and lesionsobserve breathing pattern and effort, should be regular and symmetricpalpate for lumps and symmetrypalpate for tactile fremitus (What is this?)A tremulous vibration of the chest wall during breathing that is palpable on physical examination. It may indicate inflammation, infection, or congestion.auscultate lungs in systematic manner, usually posterior, sides, anterior45THORAXlisten for normal movement of air and abnormal soundsWHEEZE-high-pitched sound caused by air passing through narrowed passageways, as with asthma or COPD

46THORAXRHONCHUS-dry rattling sound caused by partial bronchial obstructionCRACKLES(RALES)-associated with many cardiac and pulmonary disorders, sounds like rubbing strands of hair between the thumb and forefinger next to the ear47THORAXCOARSE CRACKLES- sounds like a velcro fastener being separatedPLEURAL FRICTION RUB-grating, scratchy noise similar to a creaking shoe

48ABDOMENinspect the abdomen for distention that might interfere with full expansion of the lungs

49EXTREMITIEScheck color of extremities and edemafinger clubbing/chronic resp problems

50HOMANS SIGNdorsiflex pts footsuspect thromboplhlebitis if this elicits pain behind the knee or in the calfimportant to know, the legs and the pelvis are the source of most pulmonary emboli

51NORMAL BREATHING PATTERNSshould have regular patterneven depthrate 12-20 breaths/minthis is the normal respiratory drive

52TACHYPNEAshould have regular patterneven depthrate is faster than 20 breaths/minmay be caused by fever, pain, anxiety, respiratory disorders, shock

53BRADYPNEAshould have regular patterneven depthrate is slower than 12 breaths/minmay be caused by sedatives, narcotics, alcohol; brain, metabolic, and respiratory disorders

54SIGHING RESPIRATIONSshould have regular patternuneven depth; periodic deep breaths (more than 3 sighs/min)rate is 12 to 20 breaths/minmay be caused by severe anxiety55CHEYNE-STOKES RESPIRATIONS; APNEAbreaths are progressively deeper, then becoming more shallow, followed by period of apneamay be caused by severe brain pathology56KUSSMAULS RESPIRATIONS (WITH HYPERVENTILATION)should have a regular patterndeep respirationsrate is faster than 20 breaths/minmay be caused by metabolic acidosis, diabetic ketoacidosis, renal failure

57BIOTS RESPIRATIONS; APNEAshould have an irregular patterndepth varies, sudden periods of apneamay be caused by neurologic disorders58obstructive breathing, rising end-expiratory level with forced expirations gradual rise in end-expiratory level during forced rapid breathingmay be caused by emphysema59ABGSPUTUM C&SBRONCHOGRAMCXRVENTILATION -PERFUSION SCANCTMRIPULMONARY FUNCITON TESTBRONCOSCOPYTHORACENTESISSPIROMETRY: lung volumes and capacityDIAGNOSTIC PROCEDURES

60used to provide information regarding the anatomical location and appearance of the lungsPre-procedure: remove all jewelry and other metal objects from the chest area, assess ability to inhale and hold breath, question females regarding pregnancy or the possibility of pregnancyPost procedure: assist the client to dress CHEST X-RAY STUDY

61a specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cellsSPUTUM SPECIMEN

62determine specific purpose of collection and check with institutional policy for appropriate collection of specimenobtain an early morning sterile specimen from suctioning or expectoration after a respiratory treatment, if prescribedobtain 15 mL of sputumSPUTUM-PREPROCEDURE63instruct client to rinse mouth with water before collection; instruct client to take several deep breaths and then cough deeply to obtain sputumALWAYS collect specimen before starting antibioticsSPUTUM-PREPROCEDURE64if culture of sputum is prescribed, transport to laboratory immediatelyassist the client with mouth careSPUTUM-POSTPROCEDURE65direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscopeUsed to visualize abnormalities, take biopsy samples or lesions, or remove foreign bodies.BRONCHOSCOPY

66obtain informed consentNPO from midnight before the procedure ( or 6-8 hours)obtain vital signsmonitor coagulation studiesremove dentures or eyeglassesprepare suction equipmentadminister medication for sedation as prescribedBRONCHOSCOPY pre-procedure67have emergency resuscitation equipment readily availableBRONCHOSCOPYpre-procedure

68monitor vital signsmaintain semi-Fowlers positionassess gag reflexmaintain NPO status until gag reflex returnsmonitor for bloody sputummonitor respiratory status monitor for asymmetric chest movementmonitor for swelling of face and neckmonitor for dyspnea, diminished lung soundsBRONCHOSCOPY post procedure69monitor for complications such as brohnchospasm, bacteremia, bronchial perforation indicated by facial or neck crepitus, dysrhythmias, fever, hemorrhage, hypoxemia, and pneumothoraxnotify physician if fever or difficulty in breathing occurs after the procedureBRONCHOSCOPYpost-procedure70an invasive fluoroscopic procedure after injection of iodine, radiopaque, or contrast material through a catheter inserted through the antecubital or femoral vein into the pulmonary artery or one of its branchesPulmonary Angiography71obtain informed consentassess for allergies to iodine, seafood, and other radiopaque dyesmaintain NPO status for 8 hours before the proceduremonitor vital signsmonitor coagulation studiesestablish an IV accessPulmonary Angiography-preprocedure72administer sedation as prescribedinstruct client to lie still during the procedureinstruct client that he or she may feel an urge to cough, or flushing, nausea, or salty taste after injection of the dyehave emergency resuscitaiton equipment availablePulmonary Angiography-preprocedure

73monitor VSavoid taking blood pressures in the extremity used for injection for 24 hoursmonitor peripheral neurovascular statusassess insertion site for bleedingmonitor for delayed reaction to the dyePulmonary angiography-postprocedure74Removal of fluid or air from the pleural space via a transthoracic aspirationPleural fluid is aspirated and examined for pathogens, other abnormal components. Cells studied for malignanceSee figure 30-8 page 522Thoracentesis

75obtain informed consentobtain baseline vital signsprepare client for ultrasound or chest x-ray study if prescribed before procedureassess coagulation studiesnote that client is positioned sitting upright with arms and head supported by a table at the bedside during the procedureThoracentesis-preprocedure76if the client cannot sit up, the client is placed lying in bed on the unaffected side with the head of the bed elevated 45 degreesinform client not to cough, breathe deeply, or move during the procedure

Thoracentesis-preprocedure

77monitor VSmonitor respiratory statuspatient is positioned on the unaffected side after the procedureapply a sterile, pressure dressing and assess puncture sitemonitor for signs of pneumothorax, air embolism, and pulmonary edemaobserve for uneven chest movements, respiratory distress and hemorrhageDocument amount and color of fluid removedThoracentesis-postprocedure78included a number of different tests used to evaluate lung mechanics, gas exchange and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gasesexamples: measures of: total lung capacity, forced respiratory volume, functional residual capacity, inspiratory capacity, vital capacity, forced vital capacity (see table 29-4 for definitions)Pulmonary function test (PFT)79used to diagnose pulmonary diseasemonitor disease progressionevaluate the extent of disabilityassess the effects of medicationPFT

80determine if an analgesic that may depress the respiratory function is being administeredconsult with physician regarding holding bronchodilators before testinginstruct client to void before procedure and to wear loose clothingPFT-preprocedure81remove denturesinstruct client to refrain from smoking or eating a heavy meal for 4 to 6 hours before the testPFT-preprocedure

82resume normal diet and any broncholilators and respiratory treatments that were held before the procedurePFT-post procedure

83an instrument that measures the ventilatory function of the lungsmeasures volume of air that the lungs can holdthe rate of flow of air in and out of the lungsthe compliance (elasticity) of lung tissueinvolves inserting mouthpiece, taking as deep a breath as possible and blowing as hard, as fast, and as long as possibleSee Table 30-2 for Lung Volumes and CapacitiesSpirometry84noninvasive measurement of arterial oxygen saturationA beam of light passes through the tissue , and the amount of light absorbed by oxygen saturated hemoglobin is measured.sensor clipped to earlobe or fingertipfactors that interfere with an accurate reading include: hypotension, hypothermia, vasoconstriction, and finger movement, also dark fingernail polish if it is placed on the nailPulse Oximetry

85visualizes the bronchial treeradiographic procedurepts throat and bronchi are anesthetizedBronchogram

86dye is instilled into the bronchial tree through a catheter or a fiberoptic bronchoscopept is tilted in different positions for dye to spread in specific directionscomplications include: pneumonia, delayed hypersensitivity reaction and laryngospasmBronchogram87a percutaneous lung biopsy is performed to obtain tissue for analysis by culture or cytological examinationa needle biopsy is done to identify pulmonary lesions, changes in lung tissue, and the cause of pleural effusionLung Biopsy88obtain informed consentmaintain NPO status before the procedureinform the client that a local anesthetic will be used by that a sensation of pressure during needle insertion and aspiration may be feltadminister analgesics and sedatives as prescribedLung Biopsy-preprocedure89monitor vital signsapply a dressing to the biopsy site and monitor for drainage or bleedingmonitor for signs of respiratory distress and notify the physician if they occurmonitor for signs of pneumothorax and air emboli and notify physician if they occurprepare client for chest x-ray study if prescribedLung Biopsy-postprocedure90Demonstrated lung ventilation and perfusion.the ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilationDetects pulmonary embolism and other obstructive conditionsa radioactive substance may be inhaled or injected for the procedureVentilation-perfusion lung scan9192

obtain informed consentassess for allergies to dye, iodine, or seafoodremove jewelry around the chest areareview breathing methods that may be required during testingestablish an IV accessVentilation-perfusion lung scan-preprocedure93Administer sedation if prescribedUsually NPO for 4 hoursMay take 2 hoursHave emergency resuscitation equipment availableVentilation-perfusion lung scan-preprocedure94

monitor client for reaction to the radionuclide for 1 hour for anaphylaxisfor 24 hours after the procedure, rubber gloves are worn when urine is being discarded; they should be washed with soap and water before removing, and then the hands should be washed after the gloves are removed( radioactive material is excreted in the urine)Ventilation-perfusion lung scan-postprocedure95Instruct the client to wash hands carefully with soap and water for 24 hours after the procedure when voiding (lets hope they already do this)Ventilation-perfusion lung scan-postprocedure96allows visualization of slices or layers of the chesta camera rotates in a circular pattern around the body for a three dimensional assessment of the thoraxusually used to look for the presence of lesions or tumorsradioactive dye containing iodine may be injected IVCOMPUTED TOMOGRAPHY (CT)97explain the test to the patientthey lie on a platform while a special doughnut-shaped radiographic scanner rotates around themstress the importance of remaining still during the scanningassess iodine allergy, if contrast is used, if there is, report it to the radiologistNPO may be requiredCT preparation98

note side effects of contrast: nausea, vomiting, headacheCT postprocedure

99

similar to CT but without harmful radiationdoughnut-shaped magnet usedpt lies on a stretcher that slides into a tubelike devicemechanical clanging noises are heard as machine operatesMRI100

metal implants such as cardiac pacemakers and orthopedic implants may be affected by MRI, but are not absolute contraindicationsaneurysm clips, intraocular metal, heart valves made before 1964, and middle ear prostheses generally contraindicate MRIMRI101

explain test to patientget consent form signedassess for claustrophobiaanxious pt may require sedationhave pt remove metal watch and jewelryMRI preparation102

safety precautions if sedated; otherwise, no special after care is neededMRI postprocedure103

Determine past or present exposure to tuberculosisA patient who has ever been vaccinated with BCG will test positive regardless of actual exposureBacille Calmette-Gurin (BCG) is a vaccine against tuberculosis that is prepared from a strain of the attenuated (weakened) live bovine tuberculosis bacillus, Mycobacterium bovis, that has lost its virulence in humans by being specially cultured in an artificial medium for years. Tuberculin skin tests104

purified protein derivative or old tuberculin is introduced into the skin using a device with four tinesthe device is firmly pressed on the anterior forearm for 1 sec.This site is marked, recorded, and inspected in 48 to 72 hours for redness and swellinga reaction equal to or greater than 2 mm at one or more puncture sites is positiveMultipuncture (tine) test (PPD)105cleanse puncture sitetell pt. The procedure causes pain brieflystress need to return in 48-72 hr to evaluate responsept should not scratch sitetell pt skin reaction may persist for a weekPPD preparation106

if PPD is positive this test is doneold tuberculin is injected intradermally in the lower anterior forearmthis site is marked, recorded and inspected after 48-72 hr for swelling and rednessa reaction of 5 mm or more is positive for tuberculosis exposureMantoux test107

tell pt to expect some pain with injectionreturn in 48-72 hours for evaluation of responseswelling may persist up to a weekMantoux preparation108

May be performed when respiratory disease is suspectedMay contain bacterial or malignant cellsAlso examined for volume, consistency, color, and odorThick foul smelling, and yellow, green, or rust colored sputum usually indicates a bacterial infectionSputum analysis

109

Ordered to determine the presence of bacteria, identify the specific organisms and identify appropriate antimicrobialsCollect specimen before antimicrobial therapy is begunCulture and sensitivity110Performed to determine the presence of acid-fast bacilliIncluding the bacteria that causes tuberculosisUsually collected on 3 consecutive daysCover and refrigerate or deliver to lab within 1 hourUse sterile containerAcid-fast test111ABGs

measures pH, PaCO2, PaO2, HCO3 and O2 saturationdetects alkalosis or acidosis, and alterations in oxygenation status that may occur with many respiratory, cardiac, and metabolic disorders112

ABGs Normal Values for adultsPH: 7.35 - 7.45PaCO2: 35 - 45 mm HgPaO2: 75 - 100 mm HgHCO3: 22 - 26 mEq/LO2 saturation: 96 - 100%113

ABG Preparationtell the patient a blood sample will be drawn from an artery (usually radial)an Allens test should be done before an arterial puncture to ensure that the arteries to the hand are patent (page 465)The patients hand is formed into a fist while the technician compresses the ulnar artery. Compression of the ulnar artery is continued while the fist is opened. If blood perfusion through the radial artery is adequate, the hand should flush and resume a normal pinkish coloration.

114115

ABG postprocedureapply pressure to the puncture site for 5-10 minutesnote the concentration of any oxygen therapy on lab sliptransport the blood gas syringe to the lab in an ice bath within 15 minutesrespiratory therapist will usually take sample and analyze itGo to slide 140- (just had ABGs)116hydrogen ions (H+) are vital to lifeexpressed as pHbodys pH is normally alkaline between 7.35 and 7.45)117ACIDS: Produced as end products of metabolismcontain hydrogen ionsthe number of hydrogen ions in body fluid determines its acidity, alkalinity, or if it is neutral118BASEScontain no H+hydrogen ion acceptorsaccept H+ from acids to neutralize or decrease the strength of a base or to form a weaker acid119Regulating H+ concentration in the bloodBUFFERS: hemoglobin, plasma proteins, carbonic acid/bicarbonate system, phosphate buffer systemLUNGSKIDNEYSPOTASSIUM120Lungs regulating systeminteracts with the buffer system to maintain acid base balancein acidosis: pH goes down and the respiratory rate and depth go up in an attempt to blow off acidsthe carbonic acid created by the neutralizing action of bicarbonate can be carried to the lungs where it is reduced to C)2 and water and exhaled, thus H+ are inactivated and excreted121Lungs regulating systemin alkalosis, the pH goes up and the respiratory rate and depth go down, the CO2 is retained, and the carbonic acid builds to neutralize and decrease the strength of excess bicarbonatethe action of the lungs is reversible in controlling an excess or deficit122Lungs regulating systemthe lungs can hold H+ until the deficit is corrected or can inactivate H+, changing them to water molecules to be exhaled as CO2, thus correcting the excessthe lungs are capable of inactivating only H+ carried by carbonic acid (H2CO3); excess H+ created by other problems must be excreted by the kidneys123Respiratory Acidosisthe total concentration of buffer base is lower than normal, with a relative increasing hydrogen ion (H+) concentration; thus a greater number of H+ are circulating in the blood than can be absorbed by the buffer system124due to primary defects in the function of the lungs or by changes in normal respiratory patterns from secondary problemsremember that any condition that causes an obstruction of the airway or depresses respiratory status can cause respiratory acidosishypoventilationCOPD, CAL, COLDCAUSES OF RESPIRATORY ACIDOSIS125pulmonary edemapneumoniaatelectasisasthmabronchitis or bronchiectasisinfectionmedications such as sedatives, narcotics, or anestheticsCAUSES OF RESPIRATORY ACIDOSIS126brain traumaCAUSES OF RESPIRATORY ACIDOSIS127

in an attempt to compensate, the respiratory rate and depth increasepH less than 7.35 and PCO2 greater than 45 mm Hgmental status changes such as confusiondrowsinessrestlessnessweaknessDATA COLLECTION128dizzinessdyspneahyperkalemiaDATA COLLECTION129maintain patent airwaymonitor for signs of respiratory distressadminister oxygen as prescribedplace client in semi-Fowlers position unless contraindicatedencourage and assist the client to turn, cough, and deep breatheprepare to administer chest physiotherapy and postural drainage as prescribedIMPLEMENTATION130encourage hydration to thin secretions unless excess fluid intake is contraindicatedsuction the client as necessarymonitor electrolyte valuesavoid the use of tranquilizers, narcotics, and hypnotics because they further depress respirationsadminister antibiotics for infection as prescribedIMPLEMENTAION131a deficit of carbonic acid (H2CO3) or a decrease in H+ concentrationresults from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluidsRespiratory alkalosis132due to conditions that cause overstimulation of the respiratory statushyperventilationhypoxemiafeverearly stages of salicylate poisoningreactions to certain medicationspainCauses of respiratory alkalosis133anxietyhysteriaCauses of respiratory alkalosis134initially, the hyperventilation and respiratory stimulation will cause abnormal rapid and deep respirations (tachypnea)in an attempt to compensate, respiratory rate and depth then go downpH is greater than 7.45 and PCO2 is less than 35 mm Hgaltered mental statuspallor around the mouthDATA COLLECTION135tingling of the fingersdizzinessspasms of the muscles of the handshypokalemiaDATA COLLECTION136maintain a patent airwayprovide emotional support and reassurance to the clientencourage appropriate breathing patternsIMPLEMENTATION137provide cautious care with ventilator clients so that the client is not forced to take breaths too deeply or rapidlymonitor electrolyte valuesadminister sedatives as prescribedIMPLEMENTATION138Thoracentesisbreathing exerciseschest physiotherapysuctioninghumidification & aerosoloxygenIPPBartificial airwaysmechanical ventilationchest tubesthoracic surgeryvideo thoracoscopydrug therapyTHERAPUTIC MEASURES139performed to aid in lung expansion and expectoration of respiratory secretionsindicated when pts are immobilized or after general anesthesiaBreathing Exercises140

sit in a semi-Fowlers position for maximal lung expansionplace on hand on the abdomen to feel it rise and fall with breathinginhale deeply through the nose, pause 1 to 3 seconds, and exhale slowly through the mouthDeep Breathing and Coughing141

after 4 to 6 deep breaths, cough deeply from the lungs to aid in the expectoration of sputumafter thoracic or abdominal surgery, splint the incision with a pillow to minimize discomfort and support the incisionDeep Breathing and Coughing142

used to inhibit airway collapse and to decrease dyspnea in pts with chronic lung diseaseinstruct pt to pucker lips as if to whistle, blow out a candle, or blow through a strawthen they should inhale through the nose and slowly exhale through pursed lipsexhalation should last twice as long as inhalationPursed-Lip Breathing143

chest percussion and vibrationpostural drainageChest physiotherapy144

goal is to improve oxygen and carbon dioxide exchange in the lungs by removing excessive mucous secretions with a suction catheterSuctioning145

use strict aseptic techniqueadminister oxygen before inserting the suction catheter because the procedure temporarily interferes with the patients air flowmoisten the catheter in sterile water and insert the catheter through the nose or mouth before applying suctionSuctioning Key Points146

apply suction intermittently as the catheter is rotated and withdrawn from the airwaymaintain the pressure gauge between 80 and 100 mm Hglimit each suction pass to 10 seconds (try holding your breath while you do this)allow the patient to rest briefly, encourage deep breathing, and rinse the catheter with sterile solution between suction attemptsSuctioning Key Points147monitor the patients response to suctioningif tachycardia or increased respiratory distress develops, stop the procedure and give the patient oxygen as ordereddocument the amount, color, odor, and consistency of the patients secretions as well as the patients status before and after the procedureSuctioning Key Points148creates water vapor to raise the relative humidity of inspired gas to 100%there are room humidifiers and medical oxygen is humidified as it bubbles through a container of watersterile water should be used to prevent the spread of bacteriaHumidifiers149suspended liquid particles of bronchodilators or inactive fluids such as water or salinedelivered by devices called nebulizers (pts call them puffers sometimes)can be hand heldmay be connected to an oxygen maskpt should sit upright and slowly inhale, hold the breath briefly and exhale slowlyAerosol therapy150Air in the atmosphere contains approximately 21% oxygen, which is usually sufficientIndividuals with pulmonary disease or injury may need supplemental oxygenOxygen is considered a drug and should be treated as such, you need an order and there may be serious side effects as well as benefitsOxygen therapy151If you observe a patient becoming lethargic or bradypneic, immediately notify a supervisor or physician, these are symptoms of adverse effects of oxygen therapyOxygen is delivered from a bulk system, mounded on the wall of a patients room or it can be delivered from a cylinder unit on wheelsOxygen therapy152A tube is needed to connect the flowmeter to the specific oxygen delivery deviceThis tube is then attached to the patient via nasal cannula or maskOxygen therapy is ordered in liters per minute or FIO2FIO2 mean fraction of inspired oxygenIt is written as 0.30, which means 30% oxygen concentrationOxygen therapy153The most common used delivery device is the nasal cannulaIt fits around the face and directly into the nares by way of two prongsIt is designed to deliver a flow of oxygen from 1 to 6 L/min with approximate FIO2 of 0.24 to 0.44 or 24 to 44% oxygen concentration deliveredOxygen therapy154

24% @ 1 L/min28% @ 2 L/min32%@ 3 L/min36% @ 4 L/min40% @ 5 L/min44% @ 6 L/minAnything over 6 L/min will not increase the % of O2 delivered, using nasal cannulasNasal Cannula (nasal prongs)155

If you notice, anytime you add a liter, you have a 4% increase in the O2 delivered, you can remember 1L will give you 24% then add 4% every time you go up a literNasal Cannula (nasal prongs)156

Used for client with chronic airflow limitation (CAL, COPD) and for long-term oxygen useThe CAL or COPD pt who retains CO2 should never receive O2 at a rate higher than 2 to 3 liters/minThe potential for apnea or respiratory distress occursNasal Cannula (nasal prongs)157

Place the nasal prongs in the nostrils with the openings facing the patientAdd humidification as prescribed when a flow rate higher than 2 liters /min is prescribedCheck the water level and change the humidifier as neededMonitor the client for changes in respiratory rate or depthImplementation158Assess mucosa as high flow rates have a drying effect and increase mucosal irritationMonitor skin integrity as the oxygen tubing can irritate the skinProvide water-soluble jelly to the nares PRNDo not use any petroleum based lubricantImplementation159There are 4 types of availableSimple oxygen maskPartial rebreathing maskNonrebreathing maskAir entrainment (Venturi) maskMasks160

Designed to deliver an FIO2 ranging from 0.35 to 0.55 Which is 35% to 55% It must be 6 L/min at leastIf not 6L/min, CO2 may build up in the mask, which would be very dangerous for your patientSeen on page 525Simple mask161

Flow rate must be set to at least 6 L/min45%-50% @ 6 L/min55%-60% at 8 L/minSimple mask162

Includes a reservoir bag to elevate the potential FIO2Pt rebreathes part of their own exhaled gasDesign of the mask allows almost no rebreathed gas to contain CO2 from pts lungs, only enriched oxygenExpected FIO2 range 0.35-0.60 (35 to 60%)Flow setting must be at least 6Partial rebreathing mask163

None of the pts exhaled gas is rebreathedIncludes a reservoir bagSeries of valves to direct fresh supply of gas with each breathExpected FIO2 should be 1.0(100%)Controversy stating only 0.7 (70%)(because experimentally the highest F1O2 is approximately 0.7%)Also must be 6-10 on flow meterUsed most often in client who may need to be placed on a ventilatorNonrebreathing mask164

Provides a specific FIO2Usually must place an attachment to the mask% of oxygen delivered is determined by the color of the attachment, must read the manufactures instructionsExample: Pink=50%, Blue=60% etc.This mask delivers the highest concentration of O2 when compared with the other masksAir entrainment mask (Venturi)165

Be sure mask fits securely over nose and mouth, as a poorly fitting mask reduces the FIO2 deliveredMonitor the skin and provide skin care to the area covered by the mask because pressure and moisture under the bag may cause skin breakdownMonitor the client closely for risk of aspiration because the mask limits the clients ability to clear the mouth, especially if vomiting occursImplementation166Provide emotional support to decrease anxiety to the client who feels claustrophobicConsult with physician regarding switching the client from a mask to a nasal cannula during eatingWith a reservoir bag, make sure it does not twist or kink, which results in a deflated bagImplementation167Fits over the clients chin, with the top extending halfway across the faceO2 content variesUseful instead of a tight-fitting mask for the client who has facial trauma and burnsFace tent168

Can be used to deliver high humidity and the desired oxygen to the client with a tracheostomySpecial adapter called the T piece can be used to deliver any desired FIO2 to the client with a tracheostomy, laryngecotmy, or endotracheal tubeOxygen delivered 24% to 100% with flow rates at least 10L/minTracheostomy collar and T piece169

Change delivery system to a nasal cannula during mealtimesEnsure that aerosol mist escapes from the vents of the delivery system during inspiration and expirationEmpty condensation from the tubing to prevent the client from being lavaged with water and to promote an adequate flow rateEnsure that there is sufficient water in canister and change the aerosol water container as neededKeep the exhalation port on T-piece open and uncovered(if occluded, the client can suffocate)Implementation170Monitor the liter flow to be sure it is as prescribedAssess the patients response to therapy; monitor reports of blood gas analysesInspect the tubing for kinks, obstructions, loose connections, listen for hissing sound in O2 mask: feel for adequate O2 flowMaintain sterile water in the humidifier reservoirKey points with oxygen therapy171Clean and replace oxygen therapy equipment according to agency policyPost a no smoking sign and advise the patient and visitors that smoking is not allowed because oxygen supports combustionKey points with oxygen therapy172

Assess color and vital signs before and during treatmentPlace an oxygen in use sign at clients bedsideAssess for presence of chronic lung problemsHumidify the oxygenImplementation173Intermittent Positive Pressure Breathing TreatmentsUsed to achieve maximal lung expansionThe IPPB equipment delivers humidified gas with positive pressure, which forces air into the lungs with inhalation and allows passive exhalation.Facilitates maximal exchange of oxygen and carbon dioxide gases in the alveoli and promotes a productive cough.Mucolytics and bronchodilators common

IPPB174Oral airwayNasal airwayEndotracheal tubeTracheostomyArtificial Airways175

OrotrachealNasotrachealEndotracheal tubes176

Used to maintain a patent airwayIndicated when the client needs mechanical ventilationIf client requires artificial airway for longer than 10 to 14 days, a tracheostomy may be created to avoid mucosal and vocal cord damage than can be caused by the endotracheal tubeThe cuff located at the distal end of the tube, when inflated, produces a seal between the trachea and the cuff to prevent aspiration and ensure delivery of a set tidal volume when mechanical ventilation is used, an inflated cuff also prevents air from passing to the vocal cords, nose or mouthEndotracheal tubes177Allows use of a larger diameter tube and reduces the work of breathingIndicated when the client has a nasal obstruction or a predisposition to epistaxisUncomfortable and can be manipulated by the tongue causing airway obstruction; an oral airway may be needed to keep the client from biting on the tubeOrotracheal178Smaller-sized tube increased resistance and increases clients work of breathingDiscouraged in clients with bleeding disordersMore comfortable for the client, and the client is unable to manipulate with tongueNasotracheal179

Placement is confirmed by chest x-ray study (correct placement is 1 to 2 cm above carina)Placement is assessed by auscultating both sides of chest while manually ventilating with resuscitation bagIf breath sounds and chest wall movement are absent on the left side, the tube may be in the right mainstem bronchusImplementaion180Auscultation over the stomach is performed to rule out esophageal intubationIf the tube is in the stomach, louder breath sounds will be heard over the stomach than over the chest, and abdominal distention will be presentSecure the tube immediately after intubation with adhesive tapeImplementaion181Monitor position of tube at lip or noseMonitor skin and mucous membranesSuction only when needed (Why)Implementaion182The oral tube needs to be moved to the opposite side of the mouth daily to prevent pressure and necrosis of the lip and mouth area, prevent nerve damage, and facilitate inspection and cleaning of the mouth; moving the tube to the opposite side of the mouth should be done by two health care providersImplementaion183Prevent pulling or tugging on the tube to prevent dislodgement; suction, coughing and speaking attempts by the client place extra stress on the tube and can cause dislodgementKeep a resuscitation (Ambu) bag at bedside at all timesAssess pilot balloon to ensure cuff is inflatedImplementaion184Hyperoxygenate the client and suction the endotracheal tube and the oral cavityPlace client in semi-Flowers positionThe cuff is deflated and the tube is removed at peak inspirationInstruct the client to cough and deep breathe to assist in removing accumulated secretions in the throatExtubation185apply oxygen therapy as prescribedMonitor respiratory status for signs of obstruction and notify physician if they occurInform client that hoarseness or a sore throat is normal and to limit talking if it occursExtubation186A tracheotomy is a surgical incision made into the trachea to establish an airwayA tracheostomy is the stoma or opening that results from the tracheotomyThe tracheostomy can be temporary or permanentTracheostomy187

Monitor respirationsMonitor ABGs and pulse oximetryEncourage coughing and deep breathingMaintain a semi-to high-Fowlers postionImplementation188Monitor for bleeding, difficulty breathing, absence of breath sounds, and crepitus, which are indications of hemorrhage, pneumothorax, and subcutaneous emphsemaImplementation189provide respiratory treatments as prescribedSuction as needed: hyperoxygenate the client before suctioningIf client is allowed to eat, sit the client up for meals and ensure that the cuff is inflated(if the tube is not capped) for meals, and for 1 hour after mealsImplementation190Assess the stoma and secretions for blood or purulent drainageFollow physicians orders and agency policy for cleaning the tracheostomy site and inner cannula; usually half-strength hydrogen peroxide is usedAdminister humidified oxygen as prescribed as the normal humidificaiton process is bypassed in a client with a tracheostomyImplementation191Obtain assistance in changing tracheostomy ties: cut and remove old ties holding the tracheostomy in placeKeep a resuscitation (Ambu) bag, obturator, and a tracheotomy set at the bedsideImplementation192Tube obstructionTube dislodgementPneumothoraxSubcutaneous emphysemaBleedingInfectionTracheal stenosisTracheoesophageal fistulaTrachea-innominate artery fistulaComplications of a Tracheostomy193Used to overcome the clients inability to ventilate or oxygenate adequatelyIt may be intermittent or continuous, short or long termMechanical Ventilation194

Depending on the patients needs, ventilators may be programmed to control or assist the rate of ventilation.Ventilators deliver oxygen ranging in concentration from 21% oxygen to 100% oxygen. (Oxygen concentration = FI02)Tidal volume is the present amount of oxygenated air delivered during each ventilator breath (usually 10 15ml/kg)Respiratory rate setting is the total number of breaths delivered per minute.Positive end expiratory pressure may be prescribed to keep the pressure in the lungs above the atmospheric pressure at he end of expiration.This reduces collapse of small airways and alveoli, increasing the functional residual capacity and improving ventilation.

Mechanical Ventilation195Assess the client first and the ventilator secondAssess vital signs, respiratory status, and breathing patternsMonitor color, particularly in the lips and nail bedsMonitor the chest for bilateral expansionObtain a pulse oximetry readingImplementation196Assess the need for suctioning and observe type, color, and amount of secretionsEnsure that the alarms are setIf a cause of an alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is correctedImplementation197Empty ventilator tubings when moisture collectsTurn client at least every 2 hours or get client out of bed as prescribed to prevent complications of immobilityHave resuscitation equipment available at the bedsideEstablish an alternate method of communication because the patient cannot speak while intubatedImplementation198Increased secretions in the airwayWheezing or bronchospasm causing decreased airway sizeDisplacement of the endotracheal tubeObstructed endotracheal tube because of water or a kink in the tubingClient coughs, gags, or bites on the tubeClient is anxious or fights the ventilatorCauses of high pressure alarms199Disconnection or leak in the ventilator or in the clients airway cuffThe client stops spontaneous breathingCauses of low pressure alarms200Hypotension caused by the application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heartRespiratory complications such as pneumothorax or subcutaneous emphysema as a result of positive pressureComplications of ventilation therapy201Gastrointestinal alterations as stress ulcersMalnutritionInfectionsMuscular deconditioningVentilator dependence or inability to weanComplications of ventilation therapy202The process of going from ventilator dependence to spontaneous breathingWeaning203Continuous positive airway pressureMaintains positive pressure in the airway during sleepAvoids apneaSmall and have a nose mask that is worn during sleepingCPAP204Inserted to drain air or fluid from the PLEURAL SPACE of the lungsPermits re-expansion of a collapsed lungUsed in pts with hemothorax, pneumothorax or pleural effusionInserted under sterile conditions by physicianPage 523Chest Tubes ( watched video)205

Performed in OR or at bedside/EDSmall incision made to insert tubeFourth intercostal space to remove air (pneumothorax)Eigth or ninth intercostal space to remove fluids (hemothorax)Tubes are sutured in place at insertion and an air tight, sterile dressing is appliedChest Tubes206The other end of the plastic chest tube (distal end) is connected to a rubber tubing that leads to a pleural drainage deviceThis device has three chambers:The collection chamberThe water seal chamberThe suction chamberChest Tubes207

Chest fluid and air drain into the collection chamberAir is diverted to the water seal chamberWhen the drainage chamber is full, it can be changed without changing out the whole deviceThe collection chamber just twists out and a new one is twisted inCollection chamber208

Air is diverted hereIt can be seen bubbling up through the waterIt should not be a constant bubbling, more like an intermittent bubblingIf it is constant there may be an air leakWaterseal chamber209Agency policy may permit the chest tubing to be clamped for 10 seconds while the leak is foundCheck your connections and your dressing at the site of insertionYou should have hemostats in the room for just this purposeWaterseal chamber210Suction pressure is controlled hereGentle bubbling is expected in the suction chamberInside the chamber is a tube that is partially submerged in waterThe depth of the tube in the water regulates the amount of suctionSuction Control Chamber211This tube is hollow and will have a water in itThere will be a rise and fall of water in this tube during inspiration and expiration (tidaling)During chest tube insertion, the water is added to the control chamber and how much is instilled is determined by the physician depending on the amount of suctioning requiredSuction Control Chamber212A chest radiograph is obtained to confirm placement of the tubeChest Tubes213

Monitor VS and breath sounds frequentlyAssess dressing to be sure a tight seal is maintainedTape tubing connections and inspect frequently to detect air leaksCoil extra tubing on the bed to avoid kinksImplementation214Keep drainage system on the floorMonitor drainage for blood clots or lung tissue which could clog the tubeImplementation215Observe the water seal chamber for bubbling, it is usually seen unless the lung has reexpanded or the tubing is occluded After checking for kinks or occlusion of the tubing, notify the charge nurse or physician of reexpansionAlways chart the bubbling and if there is no bubbling, checking for occlusion and finding none and then notifying the physician or CNImplementation216Drainage is monitored by marking the drainage level on the drainage receptacle, do this on your first assessment of the patient and chart it!You will then have the correct amount of drainage that occurred by the end of your shift, which you will chart as outputImplementation217An alternate to the large chest drainage systemThe valve is a disposable unit that is attached to the chest tube and to a sterile drainage receptacleair and fluid can flow in but cannot flow backward into the chestThis is good for the client who can ambulateHeimlich Flutter Valve218

ThoracotomyThe surgical opening of the chest wallReasons for thoracic surgeryTo evaluate chest traumaRemoval of tumors and cystsThoracic Surgery219

PneumonectomyLobectomySegmental resectionWedge resectionSurgical procedures on the Lungs220

The removal of an entire lungPneumonectomy

221The removal of one lobe of a lungLobectomy222

The extensive dissection and removal of a section of the lungSegmental resection223The removal of a small, triangular section of lung tissue

Wedge resection224

Stripping of the membrane that covers the visceral pleura

Decortication225

The removal of ribsThoracoplasty

226Everything that goes along with any type of surgeryWhat you want to stress are breathing exercises and explanation of a chest tube if one may be requiredPreoperative nursing care227Everything that goes with any type of surgery What you want to stressVital signsLung soundsMental stateDressingsChest tube function and drainagePostoperative nursing care228Drug Therapy View table on page 532 - 533

DecongestantsDecongestants are adrenergic agents

Mimic the action of epinephrine and norephinephrineCause constriction of nasal blood vessels and reduce the swelling of mucous membranesSudafed (common over the counter)With systemic vasoconstriction they may elevate the blood pressureSystemic effects are less severe with topical drops and spraysPeople with hypertension, heart disease, and hyperthyroidism should not take over the counter cold remedies without talking to the Dr or pharmacist. 231DecongestantsAntitusivesAntitussives suppress the cough reflex

When a cough is nonproductive, creates pain and interferers with sleep or wound healing cough suppression may be indicatedCodeine is effective (but is an opioid with many side effect)Dextromethorphan is commonly usedBe careful suppressing the cough because it is a protective mechanism.

233Antitussives

AntihistaminesAntihistamines are also called histamine 1 blockers

They block the effects of histamine(one of the chemicals that causes allergic symptoms)Prescription and over the counterDry nasal secretionsBenadryl - common first generation antihistamineMay cause dizziness, dry mouth, constipation, blurred vision, urinary retention, tachycardia, drowsiness and impaired judgment

235Antihistamines

Second generation Claritin less likely to cause drowsiness236Antihistamines

ExpectorantsThin respiratory secretions

Thin respiratory secretions so they are more readily mobilized and cleared from the airways238ExpectorantsAntimicrobialsKill or inhibit the growth of bacteria, viruses, or fungi

Usually treat only bacterial infections because they are not effective against viruses or fungiSpecific antimicrobials are best selected after culture and sensitivity tests are performed on a specimen of respiratory secretionsInstruct on proper self medications

240Antimicrobials

BronchodilatorsRelax smooth muscle in the bronchial airways and blood vessels

Asthma and COPDPrimary drawback is their tendency to cause cardiac and CNS stimulationSome bronchodilators act primarily to prevent bronchial constriction where as other relieve it.

242Bronchodilators

CorticosteroidsAnti-inflammatory drugsParenterally, orally, inhalationReduce inflammation and edema in the respiratory tractLess commonly used to treat COPDDo no discontinue steroid therapy abruptly

244Corticosteroids

Mast Cell StabilizersUsed to prevent acute asthma attacks

IntalTiladeNot useful in stopping an attack after it starts246Mast Cell StabilizersLeukotriene InhibitorsLeukotriens Mediate allergic responses

Useful in the treatment of asthma they inhibit the allergic response helping to prevent but not interrupt acute asthmatic attacksAccolateZyfloSingulair248Leukotriene Inhibitors

mucolyticsReduce the viscosity and elasticity of mucus

Mucomyst is used as an inhalant to thin the secretions Important for the patient to remain well hydrated250mucolyticsThrombolyticsDissolve blood clots

StreptaseAbbokinaseAlteplaseActivase

252Thrombolytics

Lung Herbs9 Lung Herbs For Colds and Respiratory Help

Mullein is a soothing expectorant that makes the mucous more fluid and less sticky, hence it can be coughed up more easily. It also helps relax the muscles in the bronchial passage. It is used for bronchitis, colds, persistent coughs, tuberculosis, pleurisy, and whooping cough

254MulleinAngelica is a warming remedy that is good for the digestive system as well as the respiratory system. It is an expectorant, which means it will encourage coughing and the elimination of excess mucous. It helps strengthen the lungs when they are weakened, and was traditionally used for many types of infections.

255Angelica

Ginger is great in cases of excess phlegm, and bronchitis, and can also be used at the beginning of a cold. Like many of these lung herbs, its great for the digestive system also. Ginger is often used for nausea, and helps circulation.

256GingerGarlic has been studied a lot for its immune benefits. Its great both in the digestive system, and the lungs. It helps 'sterilize' the bronchial passage in the lungs, and has been used in bronchial infections like tuberculosis. It's great for the 'common cold', and garlic capsules can be bought. Kyolic garlic is excellent. even though its an aged garlic. Fresh garlic, consumed within 15 minutes of being cut open, in a tea with honey and lemon juice, is also an excellent remedy, with very strong antibacterial and antimicrobial benefits. It's great for tonsillitis, throat infections, and similar. As well as its cleansing effect on the lungs, garlic helps encourage mucous to coughed up.

257Garlic

Cinnamon should not be used in pregnancy. As a lung herb it's more warming than angelica, and can be used at the beginning of chesty colds. Mills suggests making a tea of powdered cinnamon and fresh ginger. It is also used in chest infections. Cinnamon is also great for the digestive system, and was also traditionally used in convalescence.

258Cinnamon

This is a great lung herb for getting rid of excess mucous through coughing. It is very soothing, however, and the types of coughs it encourages are not dry hacking coughs that just produce more irritation. Its great for chronic bronchitis in the elderly, or for those who are weakened physically in some way. It can also be used for nervous coughing, and is a digestive tonic similar to angelica

259Elecampane

Coltsfoot is also an expectorant. It's great for dry coughs, and because of its mucilage content, is very soothing when the bronchial passages are irritated.

260Coltsfoot

More than a seasoning for cooking, this lung herb has antiseptic properties as well as being an expectorant and digestive tonic. It helps 'disinfect' the air passages, and also has a calming effect on the bronchial tube. It is generally used for more asthmatic conditions and dry coughs, but not really for bronchitis. Large amounts of thyme should not be taken during pregnancy.

261ThymeThis lung herbis used as a cough suppressant, which as indicated above, should only be used under some circumstances. But it is used in helping treat strong and incessant coughing to the point of exhaustion.

262Wild Cherry Bark

DISORDERS OF THE RESPIRATORY SYSTEM

263ACUTE VIRAL RHINITISTHE COLD

264Last 2 - 14 days, first 3 days most contagiousheadache sneezingstuffinesssore throat runny noseFatiguelethargicFever and chills in severe casesSIGNS AND SYMPTOMS

265DIAGNOSISHISTORY AND EXAMRestfluidsdietantipyreticsanalgesicsAntivirals (not commonly used)Vitamin CantihistaminesdecongestantsTREATMENT

267Acute Bronchitis

268Follows a cold or the fluusually viralBacterial: Streptococcus pneumoniae, haemophilus influenzaeIrritation and inflammation : increase mucous ETIOLOGY AND RISK FACTORS269FEVER COUGHYELLOW OR GREEN SPUTUMRAPID BREATHINGOCCASIONALLY CHEST PAINSIGNS AND SYMPTOMS270DIAGNOSISHEALTH HISTORY ASSESSMENT FINDINGSMEDICAL TREATMENTBROAD SPECTRUM ANTIBIOTIC FOR7 - 10 DAYS

INFLUENZA273

Acute viral respiratory infectionSeveral types then subtypes (A,B,C)Most susceptible:very youngelderlyinstitutionalizedchronic disease you

Etiology and Risk Factors274

BronchitisViral or Bacterial PneumoniamyocarditispericarditisRye SyndromeconfusionGuillain-Barretoxic shockMyositis (swelling of the muscles)renal failureCOMPLICATIONS275

Chills fevermuscle painheadachedry hacking coughSIGNS AND SYMPTOMS

276MEDICAL DIAGNOSISSYMPTOMSASSESSMENTRestfluidsdietanalgesicsantipyreticsAntivirals (Symmetrel, Flumadine, Tamiflu, Relenza for type A & B)prevention; flu shotTREATMENT278PNEUMONIA

279

Inflammation of the alveoli & bronchioles infectiousPsuedomonasCandidia noninfectiousfumesdustchemicalsNosocomialpoor hand washingpoor sterile techniquecontaminated equipmentcontactEtiology and Risk Factors280SMOKERSALTERED CONSCIOUSNESSIMMUNOSUPRESSEDCHRONICALLY ILLPROLONGED IMMOBILITYThose at risk281Lobar Pneumoniaone or more lobesBronchopneumoniabronchioles & alveoliInterstitial pneumonialung tissue surrounding the alveoli

Gram + bacteriapneumococcalstaphylococcalstreptococcalGram - bacteriapseudomonasinfluenzalegionnaires diseaseViralPATHOPHYSIOLOGY282PLEURISYPLEURAL EFFUSIONATELECTASISLUNG ABCESSDELAYED RESOLUTIONEMPYEMASYSTEMIC COMPLICATIONSpericarditisarthritismeningitisendocarditisCOMPLICATIONS283Feverchillssweatschest paincoughsputum productionhemoptysisdyspneaheadacheSIGNS & SYMPTOMS

284BACTERIALabrupt onsetsevere shaking chillssharp stabbing lateral chest painintermittent cough productive of rusty sputum VIRALburning or searing chest pain in sternal areacontinuous barking hacking cough with small amount of sputum productionheadache

SIGNS & SYMPTOMS285HistoryexamCXRsputum gm. Stainsputum C&SCBCBlood cultureDIAGNOSIS286

3L of fluid/24 hoursbedrestanalgesics antipyreticsoxygenIPPBantibioticsVaccinenot recommended for children under age 2only given once in a lifetime/There have been some questions regarding the once in a lifetimeTREATMENT287Ineffective airway clearance R/TIncreased sputum productionThick secretionsIneffective coughNursing diagnoses288

What can a nurse do?Decrease production of sputum and promote expectoration by administering antimicrobials, decongestants and expectorants as orderedTeach and encourage deep breathing and coughingChange positions at least every 2 hours to help mobilize secretionsChest physiotherapy and aerosol therapySuctioning if neededProvide tissues and receptacleChart amount, color, consistency of secretionsAusculate lung sounds frequently to assess the effects of interventionsIneffective airway clearance289Edema and secretions with pneumonia may interfere with gas exchangePt may have hypoxemia-low O2 in blood or hypercapnia-accumulation of CO2 in bloodNeed to improve gas exchangeImpaired gas exchange290

Whats a nurse to do?Monitor vital signs, lung sounds and skin color to assess gas exchangeBe alert for signs of hypoxemia: restlessness, tachycardia and tachypneaReport abnormal ABGsCheck hemoglobin values, signals less O2 carrying abilityMobilize secretions as mentioned beforeElevate HOBAdminister O2 as orderedImpaired gas exchange291Activity usually restricted but may range from bed rest to BRPSchedule nursing care to prevent over tiringAllow periods of uninterrupted restProvide assistance until pt is able to do self-careEncourage visitors not to tire pt with long visitsEvaluate ability to tolerate ADLsActivity intolerance292

Whats a nurse to do?Assess pts usual dietary habitsMonitor weight by weighing pt before breakfast using same scaleMonitor albumin and lymphocyte blood counts to detect low levels that are common with inadequate proteinTypical diet: high protein, softAssist pt with meal if neededDocument intakeProvide oral care before mealsElevate HOB arrange tray in attractive and convenient mannerNasal cannula recommended during mealsIf pt tires, more frequent smaller meals would be betterAltered nutrition: less than body requirments293Fever, mouth breathing and inadequate intake may increase the risk for this diagnosisDehydration causes secretions to be thicker and more difficult to expectorateRisk for fluid volume deficit294Decreased skin turgorConcentrated urineDry mucous membranesElevated hemoglobin and hematocritSigns and symptoms of fluid volume deficit295Whats a nurse to do?Encourage 3L of fluid daily unless contraindicatedAdminister IV fluids as orderedIf permitted give hard candy which stimulates thirst and fluid intakeRecord intake and outputFluid volume deficit296

Monitor temp q2-4hAdminister antipyretics as orderedKeep pt dry and lightly coveredKeep room comfortable temp, avoid chillingTepid sponge baths for fevers as orderedHypothermia blanket as ordered to reduce tempFluid volume deficit297Administer analgesics as orderedPosition pt for comfortEncourage splinting painful areas during deep breathing and coughingMassage to promote comfortNotify the physician if pain is unrelieved or worsensPain298Gradually increase activities as you recover, fatigue may persist for several weeksAvoid people with colds or other infectionsGet plenty of rest, good nutrition and 3 L of fluids each day unless contraindicatedComplete any prescribed drugs after dischargeNursing Care Plan page 539Teaching Plan for Pneumonia 540 Nutrition Concepts page 540

What to teach regarding pneumonia299ASPIRATION PNEUMONIAPREVENTIONPREVENTING ASPIRATION301

Keep suction equipment on handPosition upright with neck in neutral positionThinken liquids

302Prevention measures: Elevate the head of bed if enteral feeding Measure residual before each bolus feedingIf greater than 100ml with hold the feeding and notify the physicianStop continuous feeding for 20-30 min before lowering the patients headIf they must be kept flat then place on right sideCheck the residual every 4 hours and if more than 20% of hourly rate consult the physician

303Prevention of Aspiration Pneumonia

PLEURISYInflammation of the pleuraPneumoniatuberculosischest wall injurypulmonary infarctionTumorsCommon Causes305Abrupt and severe painone side of the chestbreathing and coughing aggravate the painSymptoms306UNDERLYING DISORDERPAIN RELIEFAnalgesicsanti-inflammatoryantitussivesantimicrobialslocal heatTREATMENT307Pain R/T inflammationIneffective breathing pattern R/T splinting, pleural effusionNursing diagnoses for pleurisy308When reported, obtain complete descriptionLocationSeverityPrecipitating factorsAlleviating factorsUse pain scaleInterventions for pain309Administer ordered analgesicsSplinting for the affected sideSplint rib cage when coughingApply heat if orderedGive antitussives if ordered to decrease painful coughingIf on bed rest, assist pt with regular position changesAdminister NSAIDs as ordered to reduce pain and inflammationInterventions for pain310Monitor breathing pattern, pay attention to chest symmetry during breathingEncourage pt to turn, take deep breaths and couthEncourage to ambulate if permittedElevate HOBIneffective breathing pattern311If pleural effusion develops, progressive dyspnea, decreased or absent breath sounds in the affected area and decreased chest wall movement on the affected side, a thoracentesis may be done to remove accumulated fluidIf done at bedside you, the nurse will assistSo be ready!!!

Complications312CHEST TRAUMA

313PENETRATINGGunshot, stab woundspneumothoraxtears of aorta, vena cava, other major vessels NONPENETRATINGMVA, Falls, Blastrib fxpneumothoraxpulmonary contusionscardiac contusionsCATEGORIES OF CHEST TRAUMA

314Obvious traumachest paindyspneaasymmetrical chest wall movementcyanosisweak rapid pulse

decreased blood pressuretracheal deviationdistended neck veinsbloodshot or bulging eyes

SIGNS & SYMPTOMS315Stabilizationpreventiondressing tape three sides(called a vented dressing)An airtight dressing could cause a tension pneumothoraxdo not remove impaled objectsVSLOCO2semi-fowlersMEDICAL TREATMENT316PNEUMOTHORAX

An accumulation of air in the pleural cavity that results in complete or partial collapse of a lung.Air enters the space between the chest wall and the lung either through a hole in the chest wall or through a tear in the bronchus, bronchioles, or alveoli.317Tensionair is repeatedly entering the pleural spacelung on affected side collapsesmediastinal shiftOpenchest woundair moves in and out freelylung on affected side collapsesmedistinal flutterTENSION / OPEN PNEUMO318Dyspneatachypneatachycardiarestlessnesspain anxiety decreased movement of the involved chest wallAsymmetric chest movementdiminished breath soundsprogressive cyanosischest woundsucking chest wound (air can be heard or felt from wound)

SIGNS & SYMPTOMS319Needle aspiration of fluid/air from pleural spacechest tube insertionsurgical repair of a tearIf persistent air leak( variety being studied) intrapleural tetracyclineblood patchesfibrin glueTREATMENT320If chest tube: monitor insertion siteDocument amount and characteristics of drainageAdd to I&OGive chest tube careMonitor for increasing respiratory distress:TachycardiaDyspneaCyanosisRestlessnessAnxietyNursing care321Inspect trachea for deviation which may be caused by mediastinal shiftoccurs when a lung collapses and the heart, trachea, esophagus, and great blood vessels shift toward the unaffected sideMediastinal flutterOccurs with an open pneumothorax, everything may shift back and forth toward the unaffected side with inspiration then toward the affected side with expirationNursing care322Check ABGs for hypoxemia and hypercapniaImmediately report deteriorating respiratory statusProtect chest tube and monitor its functionNursing care/ineffective breathing pattern323

Position pt for comfort in a Fowlers or semi-Fowlers position, avoid side-lying until affected lung has re-expanded, could cause mediastinal shiftSupport and encourage pt to deep breath and cough q2h while awakeAdminister O2 as orderedNursing care/ineffective breathing pattern324Speak calmly to pt, explain every procedureTell pt about chest tubeGive pt opportunity to ask questions and express fearNursing care/fear325Monitor pulse and blood pressureIf blood pressure falls and pulse rate increases, you should suspect mediastinal shift, notify physician immediately, this could be fatalNursing care/risk for decreased cardiac output326Monitor for signs of painDocument characteristics of painAdminister analgesics as orderedDocument the effects of drug therapyRate pain on 0-10 scaleUse positioning, massage, distraction etc.Notify physician if measures fail and pain is not relievedNursing care/pain327Monitor for signs and symptoms of infectionFeverIncreased pulse and respirationsFoul drainage from tube insertion siteElevated WBCNursing care/risk for infection328Use sterile technique for invasive procedures and dressing changesAdminister prescribed antimicrobialsMonitor hydration status and promote fluid intake of 2 to 3 L/d unless contraindicatedBefore discharge instruct pt on chest tube care and to notify physician of S/S of infectionFever or increasing redness, swelling, or drainage from insertion siteNursing care/risk for infection329Accumulation of blood between the chest wall and the lungPressure around the lung increases, causing partial or complete collapse of the lungResults from lacerated or torn blood vessel, lung malignancy, pulmonary embolusMay also be caused by anticoagulation therapyHEMOTHORAX330Essentially like a pneumothorax, nursing care is similarSurgical intervention may be necessary to control bleedingPt is at risk for decreased cardiac output due to hemorrhageHemothorax treatment331RIB FRACTURESMost common chest injuriesblunt injury/MVA-hit steering wheelRibs 4 to 9 most commonly affectedTakes approx 6 wks to heal

Pain at injury site (especially during inspiration)bruisingSwellingVisible bone fragments at site of injuryshallow breathingprotective holding of the chestSIGNS & SYMPTOMS333Pain relief to allow adequate chest expansionintercostal nerve blocksno binders or rib belts restricts expansion of chestencourage deep breathing every four hoursComplication: pneumonia or atelectasis due to inadequate chest expansionTREATMENT334Goal: effective breathing patternBreathing exercises to prevent pulmonary complicationsInstruct splinting while deep breathing and coughingAdequate pain control is essential, monitor q2h, rate pain on scale 0-10Administer prescribed analgesicsProvide a calm environmentEncourage pt to restEvaluate effects of pain measuresInform physician if pain isnt controlledNursing care335FLAIL CHESTTwo adjacent ribs on the same side of the chest are broken in two or more places. Results in paradoxical movementSevere dyspneacyanosistachypneatachycardiaparadoxical movement-affected part will move in with inspiration and moves out with expiration-opposite of how it should beSIGNS & SYMPTOMS337HistoryExam CXRABGDIAGNOSIS338Adequate oxygenation Cough & deep breathingIPPBpain managementRespiratory Distressintubationventilator

TREATMENT339PULMONARY EMBOLUSForeign substance carried through the bloodUsually blood clots but may be fat, air, tumors, bone marrow, amniotic fluid or clumps of bacteriaVentilation-perfusion mismatch.Alveoli are ventilated + no blood flow= no gas exchange340If a large pulmonary vessel is obstructed, alveoli collapse, cardiac output falls, there is constriction of the bronchi and the pulmonary artery, and sudden death may ensue.341Surgery of the pelvis or lower legsImmobilityObesityEstrogen therapyClotting abnormalitiesIf a large pulmonary vessel is obstructed, alveoli collapse, cardiac output falls, there is constriction of the bronchi and the pulmonary artery, and sudden death may occurEtiology and risk factors342Sudden chest pain worsens with breathingtachypenadyspneaapprehensivediaphoreticcough hemoptysisCrackles may be heard on auscultation fevertachycardiaSIGNS & SYMPTOMS343History and physicalABGEKGlung scanPulmonary angiogramDIAGNOSIS344MEDICALHeparin to establish and maintain (PTT 2 -2.5 times the normal rate)Coumadin 6 monthsFibrinolyticsoxygenintubationventilationSURGICALembolectomyvena cava interruption venous thrombectomy

See pg 546 for pictures of filtersTREATMENT345Must monitor risk factors that led to the embolismHomans sign assessed in each legNursing care346

Monitor respiratory rate and effortBreath soundsSkin colorPulseBlood pressureNursing care/altered cardiopulmonary tissue perfusion347

ABGs report abnormalities to physicianElevate HOB Administer O2 as prescribedAdminister prescribed IV fluidsDocument I&OActive/passive ROMEarly ambulation after surgeryAntiembolism and pneumatic compression stockings

Nursing care/altered cardiopulmonary tissue perfusion348Remain calmTell pt what is being doneExplain equipment and procedures in terms pt can understandEncourage pt to express concerns and ask questionsPermit family member to remain with the patientNursing care/anxiety349See patient teaching plan page 547 for pulmonary embolism350

ARDSAcute Respiratory Distress Syndrome351

Progressive pulmonary disorder that follows lung trauma. Infiltrate development fluid shiftpulmonary edemaatelectasisCardiac dysrhythmiasrenal failurestress ulcersthrombocytopeniaDIC (disseminated intravascular coagulation)oxygen toxicitysepsisETIOLOGY & RISK FACTORS352Increased respiratory ratefine cracklesrestlessagitatedconfusedincreased pulse ratecoughDyspnea with retractionscyanosisdiaphoresisdiffuse crackles and rhonchiSIGNS & SYMPTOMS353HistoryexamCXRABGpH increases Co2 fallsO2 falls despite O2pH decreases respiratory acidosisDIAGNOSIS354Intubation with ventilatortreat underlying causecorticosteroids debatable issueTREATMENT355

Characterized by interstitial hemorrhage associated with intraalveolar hemorrhage resulting in decreased pulmonary complianceThe major complication is acute respiratory distress syndrome (ARDS)Pulmonary Contusion356DyspneaHypoxemiaIncreased bronchial secretionsHemoptysisRestlessnessDecreased breath soundsRales and wheezesSigns and Symptoms357Maintain airway and ventilationPlace client in high Fowlers positionAdminister oxygen as prescribedMonitor for increased respiratory distressMaintain bed rest and limit activity to reduce oxygen demandsPrepare for mechanical ventilation as prescribedImplementation358Occurs when the client cannot eliminate carbon dioxide from the alveoliThe carbon dioxide retention results in hypoxemiaOxygen reaches the alveoli but cannot be absorbed or used properlyThe lungs can move air sufficiently but cannot oxygenate the pulmonary blood properlyRespiratory failure359Respiratory failure occurs as a result of mechanical abnormality of the lungs or chest wall, a defect in the respiratory control center in the brain, or an impairment in the function of the respiratory musclesRespiratory failure360DyspneaHeadacheConfusionRestlessnessTachycardiaCyanosisDysrhythmiasDecreased level of consciousnessAlterations in respirations and breath soundsRespiratory failure/Signs and Symptoms361Identify and treat the causeAdminister O2 as prescribed to maintain the PaO2 level above 60 mm HgPlace the client in high Fowlers positionEncourage deep breathingAdminister bronchodilators as prescribedPrepare the client for mechanical ventilation if supplemental O2 cannot maintain acceptable PaO2 levelsRespiratory failure/what to do?362The collection of fluid in the pleural spaceAny condition that interferes with either secretion or drainage of this fluid will lead to pleural effusionPleural effusion363Pleuritic pain that is sharp and increases with inspirationDyspnea on exertionDry nonproductive cough caused by bronchial irritation or mediastinal shiftMalaisePleural effusion/signs and symptoms364TachycardiaElevated temperatureDecreased breath soundsCXR shows pleural effusion and a mediastinal shift away from the fluidPleural effusion/signs and symptoms365Identify and treat underlying causeMonitor vital signsMonitor breath soundsPlace client in high Fowlers positionEncourage coughing and deep breathingPrepare client for thoracentesisImplementation366Chronic Obstructive Pulmonary Disease (COPD)5th leading cause of death in US

A combination of asthma, chronic bronchitis, & emphysema.

May see only one or two, but usually all three.

COLD- Chronic Obstructive Lung Disease

CAL Chronic Airflow Limitation

CHRONIC OBSTUCTIVE PULMONARY DISEASE368Pulmonary function test common diagnostic procedureProvides info about airway dynamics, lung volumes, and diffusing capacityAirway dynamics patients ability to inhale or exhale by forceDiffusing capacity ability of gases to diffuse across the alveolar capillary membrane

Test are effort dependent patient must be mentally alert, cooperative and able to follow directions. 369CHRONIC OBSTUCTIVE PULMONARY DISEASEReactive Airway Disease

ASTHMA370

Early /acute episode:Begins when triggers ( allergens, irritants, infections, exercise) activate the inflammatory processAirway constrict & becomes edematousMucus secretions increases, forming plugs in the ariwaysTenacious sputum is producedUsually occur within 30-60 minutes after exposure to the trigger and resolve some 30-60 minutes laterFig 31-1 page 551

Asthma Attacks371Late PhaseBegins 5-6 hours after the early phaseRed & white blood cells infiltrate the swollen tissues of the airwaysLasts several hours or daysRisk for another acute episode until the phase subsides

Asthma372Constriction of the bronchi & broncioles.Results in a ventilation perfusion mismatchSevere, persistent bronchospasm is called status asthmaticus

Bronchospasm373CAN RESULT IN:RIGHT SIDED HEART FAILUREPNUEMOTHORAXACIDOSISRESPIRATORY ARRESTCARDIAC ARREST

Medical Emergency!

STATUS ASTHMATICUS374

DYSPNEAPRODUCTIVE COUGHUSE OF ACCESSORY MUSCLESAUDIBLE EXPIRATORY WHEEZETACHYCARDIA TACHYPENA

SIGNS & SYMPTOMS375HISTORYPHYSICAL EXAMPFT : DECREASED EXPIRATORY AIR VOLUMEABGs if moderate to severe symptoms

DIAGNOSIS376

PREVENTION OF ATTACKREMOVING THE CAUSATIVE AGENTBRONCHODIALTORSANTI-INFLAMMAROTY DRUGS

TREATMENT377

RELIEVERS RELIEVE ACUTE SYMPTOMSCONTROLLERS PROVIDE LONG TERM CONTROLBeta 2 receptor agonists are the most often used relieversControllers: inhaled glucocorticoids, leukotriene inhibitors, long acting beta 2 receptor agonists, mast cell stabilizers and xanthines.MEDICATIONS378BRONCHIAL INFLAMATION THAT RESULTS FROM INHALED IRRITANTS WHICH RESULTS INCREASED MUCOUS PORDUCTION.MUST HAVE A CHRONIC COUGH FOR 3 MONTHS OR LONGER FOR TWO CONSECETIVE YEARSFigure 31-3 page 553

CHRONIC BRONCHITISBlue Bloater379Inflammation caused by inhaled irritants, including cigarette smokeAt first, only large airways are affected, but smaller airways are eventually involved.Mucus obstructs the airway, causing air to be trapped in distal portions of the lungsAlveolar ventilation is impaired and hypoxemia may developSee Teaching Plan page 561 for Chronic Bronchitis and Emphysema

Chronic Bronchitis380Right sided heart failure secondary to pulmonary disease.

Cor-Pulmonale381

Centrilobarcigarette smokingAffects mainly the respiratory bronchiolesPanlobularhereditary deficiency of alpha 1 -antitrypsinAffects the respiratory bronchioles and the alveoli.

May have both at the same timeFigure 31-4 Page 554

Emphysema ( Pink Puffer)382Alveolar walls breakdown cause permanent distention of air spaces & decrease in elastic recoil. Partially collapsed airways. Bullae & blebs develop

Emphysema383

Heart failureRespiratory failureIncreased PaCO2Decreased PaO2

Complications384Infectionair pollutionsmokingadverse drug reactionLeft ventricular failureMIPESpontaneous Pneumothorax

Factors Leading to Complications385BronchitisProductive CoughExternal DyspneaWheezingElevated RBCCor Pulmonale- dyspnea, cyanosis, peripheral edema, blue bloater

Signs & Symptoms386Dyspnea on exertion, then on restthin patientsuse accessory musclesincrease in chest diameter barrel chestPink Puffers

Emphysema387

Diagnosis: History & exam, PFTdecrease in forced expiratory volume and forced vital capacityincrease in residual capacity and volume and total lung capacity

Emphysema without Chronic Bronchitis388Drug therapyoxygen therapyChest physiotherapyExercise NutritionSurgical Treatment (lung volume reduction surgery) LVRS

Treatment389Lung Volume Reduction SurgeryUp to 30% of the hyperinflated lung tissue is excised to improve the mechanics of breathing, enabling the patient to breath more deeply

Effectiveness still being evaluatedRecovery period is longMortality rate 5%-10%Abnormal dilation and distortion of bronchi & bronchioles, usually confined to one lung lobe or segment.Typically follows recurrent inflammatory conditions infections or obstruction.Some times congenital.

Bronchiectasis391Coughing.Production of purulent sputum in large quantities.Feverhemoptysisnasal stuffinesssinus drainageFatigue weaknessSigns and Symptoms392Control symptomsprevent spread.Antibioticsoxygen therapychest physiotherapy

Treatment393Cystic FibrosisHereditary disorder

Cystic FibrosisHereditary disorderDysfunction of the exocrine glandProduction of thick tenacious mucousObstruction of the pancreatic ducts so that pancreatic enzymes cannot be delivered to the GI tractStools bulky and foul smellingWomen have reduced fertilityMales often have vas deferens absentCystic Fibrosis396Infection.Emphysema.Atelectasis.

Complications397

Pancreatic enzyme replacementChest physiotherpayAerosol & nebulizer treatmentsBronchodilatorsAnti-inflammatory agentsInhaled deoxyribonucleaseLung transplantation

Treatment of Cystic Fibrosis398GOAL:Effective airway clearancePrevention/treatment of infectionAdequate nutritionEffective therapeutic regimen management

Nursing Care

399

TBSarcoidosispneumoconiosis Interstitial fibrosisLung cancer

Restrictive pulmonary disordersReduce lung volumes

400A highly communicable disease caused by Mycobacterium tuberculosisA nonmotile, nonsporulating, acid-fast rod that secrets niacin; and when the bacillus reaches a susceptible site, it multiplies freelyTuberculosis (TB)401Because it is an aerobic bacterium, it primarily affects the pulmonary system, especially the upper lobes where oxygen content is greatest, but can also affect other areas of the body such as the brain, intestines, peritoneum, kidney, joints, and liverTuberculosis (TB)402

An exudative-type response causes a nonspecific pneumonitis and development of granulomas in the lung tissueHas an insidious onset, and many clients are not aware of symptoms until the disease is well advancedTuberculosis (TB)403

A multidrug-resistant strain (MDR-TB) of TB can exist as a result of improper or noncompliant use of treatment programs and the development of mutations in the tubercle bacilliThe goal of treatment is to prevent transmission, control symptoms and prevent progression of the diseaseTuberculosis (TB)404AlcoholismIntravenous drug useMalnutritionInfectionThe elderlyThe homelessTuberculosis (TB)/risk factors405RefugeesMinority groupsIndividuals from a lower socioeconomic groupChildren younger than 5 years oldIndividuals living in crowded areas such as long-term care facilities, prisons, and mental health facilitiesTuberculosis (TB)/risk factors406Individuals in constant, frequent contact with an untreated or undiagnosed individualIndividuals with immune dysfunction, human immunodeficiency virus (HIV), or who are immunosuppressed from medication therapyDrinking unpasteurized milk if the cows are infected with bovine TBTuberculosis (TB)/risk factors407Via aerosolization or airborne route by droplet infectionWhen an infected individual coughs, laughs, sneezes, or sings, droplet nuclei containing TB bacteria enter the air and may be inhaled by othersTB-Transmission408Identification of those individuals in close contact with the infected individual is important so that they can be tested and treated as necessaryWhen contacts have been identified, these people are assessed with a tuberculin test and chest x-ray study to determine infection with TBAfter the infected individual has received TB medication for 2 to 3 weeks, the risk of transmission is greatly reducedTuberculosis (TB) transmission409Droplets enter the lungs and the bacteria form a tubercle lesionThe bodys defense systems encapsulate the tubercle, leaving a scarIf encapsulation does not occur, bacteria may enter the lymph system, travel to the lymph nodes, and cause an inflammatory response called granulomatous inflammationTB-Disease progression410Primary lesions form; the primary lesions may become dormant, but can be reactivated and become a secondary infection when reexposed to the bacteriumIn an active phase, TB can cause necrosis in the lesions, leading to rupture and the spread of necrotic tissue, and damage to various parts of the bodyTB-Disease progression411Past exposure to TBClients country of origin and travel to foreign countries in which there is a high incidence of TBRecent history of influenza, pneumonia, febrile illness, cough, and foul-smelling sputum productionTB-client history412Previous tests for TB and what the results wereRecent bacille Galmette-Guerin (BCG) vaccine (a vaccine containing attenuated tubercle bacilli that may be given to people in foreign countries or to persons traveling to foreign countries to produce increased resistance to TB)TB-client history413An individual who has received BCG will have a positive skin test and should be evaluated for TB with a chest x-ray studyTB-client history414

May be asymptomatic in primary infectionFatigueLethargyAnorexiaWeight lossTB-clinical manifestations415

Low-grade feverChillsNight sweatsPersistent cough and the production of mucopurulent sputum, which is occasionally streaked with blood, or rust coloredChest tightness and a dull, aching chest pain may accompany the coughTB-clinical manifestations416Physical exam of chest does not provide conclusive evidence of TBChest XR study is not definitive, but the presence of multinodular infiltrates with calcification in the upper lobes suggests TBIf the disease is active, inflammation may be seen on the chest XRChest assessment417Dullness with percussion over involved parenchymal areas, bronchial breath sounds, rhonchi, and /or cracklesPartial obstruction of a bronchus, caused by endobronchial disease or compression by lymph nodes, may produce localized wheezing and dyspneaAdvanced disease418Sputum specimens are obtained for an acid-fast smearA sputum culture identifying M. tuberculosis confirms the diagnosisAfter medications are started, sputum samples are obtained again to determine the effectiveness of therapyMost clients have negative cultures after 3 months of compliance to medication therapySputum cultures419The client with active TB is placed on respiratory isolation precautions in a well-ventilated negitive pressure roomThe room should have at least six exchanges of fresh air per hour and should be ventilated to the outside environment if possibleThe hospitalized TB client420

The nurse wears a particulate respirator (a special individually fitted mask -N-95) when caring for the client and a gown when there is a possibility of contamination of clothingHands are always thoroughly washed before and after caring for the clientThe hospitalized TB client421If the client needs to leave the room for a test or procedure, the client is required to wear a maskIsolation is discontinued when the client is no longer considered infectiousThe hospitalized TB client422

After the infected individual has received TB medication for 2 to 3 weeks, the risk of transmission is greatly reducedWhen the results of three sputum cultures are negative, the client is no longer considered infectiousThe hospitalized TB client423Provide the client and family with information about TB and ally concerns about the contagious aspect of the infectionInstruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on handThe client at home424

Advise the client of the side effects of the medication and ways of minimizing them to ensure complianceReassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyoneInform the client that activities should be resumed graduallyThe client at home425Instruct about need for adequate nutrition to promote healingInstruct to increase foods rich in iron, protein, vitamin CRespiratory isolation not necessary, family have already been exposedThe client at home426

Cover mouth and nose when coughing, sneezing; put used tissues in plastic bagTeach handwashingInform client sputum culture is needed q 2-4 wks once medication is initiatedThe client at home427Inform client when results of 3 sputum cultures are negative, client is no longer infectious and can return to employmentAvoid excessive exposure to silicone or dust, con cause further lung damageInstruct importance on treatment and follow-up careSee Patient Teaching Plan on page 565The client at home42