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

Auscultation

(Listening for Normal and Adventitious Breath Sounds)

Palpation and Percussion

Inspection

(client's color, level of consciousness, emotional state)

(Rate, depth, quality, rhythm, effort relating to respiration)

Health History

(allergies, occupation, lifestyle, health habits)

Assessment Review

Vital Signs

Respiratory rate & heart rate WNL

Oxygen saturation of 95% or higher

Assessment Review

Physical 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 positive

airway pressure

(CPAP)

Obstructive Sleep Apnea

Tonsillectomy Adenoidectomy

Obstructive Sleep Apnea

Uvuloplatopharyngopla

sty

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 7.35

HCO3 at or below 24 mmHg

PaCO2 at or below 45 mmHg

PaO2 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, mal

aise

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 & Symptoms

Primary 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

Tuberculosis

Spread through droplet

nuclei:

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

Tuberculosis

If patient has adequate

immune response:

Scar tissue develops around tubercle

Walls off bacilli

Infected, does not develop TB

Inadequate immune

response

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 Regime

INH

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 Regime

Pyrazinamid

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

Thoracentesis

Pre-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 <7.35

HCO3 > 24mm Hg

PCO2 > 45 mm HG

PaO2 < 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 intake

Nursing 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 following

presenting symptom of COPD?

Increased dyspnea

Sputum production

Emphysema

John is medicated with a bronchodilator to reduce

airway obstruction. Assess for

Dysrhythmias

Central nervous system excitement

Tachycardia

Purse Lip Breathing

Recommended 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

Bronchiectasis

A chronic dilation of the

bronchi 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 decreased

to 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 of

heparin is Mrs Perkins receiving each hour?

Heparin Infusion

880 units

20,000 divided by 500 = 40 units

If 22 ml are infused per hour, then 880 units

of heparin are infused each hour

40 x 22 = 880

Heparin Therapy

What nursing interventions should you implement for

Mrs 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 Embolism

Mrs 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 Embolism

The 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