Assessment of respiratory system Dr.Essmat Gemaey Assistant prof.Psychiatric nursing.
Respiratory Nursing #1
Transcript of Respiratory Nursing #1
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Medical and Surgical Nursing
Respiratory System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
MS Abejo1
MEDICAL AND SURGICAL NURSING
Respirator y System
Lecturer:Mark Fredderick R. Abejo RN,MAN
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Medical and Surgical Nursing
Respiratory System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
MS Abejo3
PHYSIOLOGY OF RESPIRATORY SYSTEM
VENTILATION: The movement of air in and out of the airways.
The thoracic cavity is an air tight chamber. the floor of
this chamber is the diaphragm.
Inspiration: contraction of the diaphragm (movement of
this chamber floor downward) and contraction of the
external intercostal muscles increases the space in this
chamber. lowered intrathoracic pressure causes air to
enter through the airways and inflate the lungs.
Expiration: with relaxation, the diaphragm moves up and
intrathoracic pressure increases. this increased pressure
pushes air out of the lungs. expiration requires the elastic
recoil of the lungs.
Inspiration normally is 1/3 of the respiratory cycle and
expiration is 2/3.
DRIVING FORCE FOR AIR FLOW
Airflow driven by the pressure difference between
atmosphere (barometric pressure) and inside the lungs
(intrapulmonary pressure).
AIRWAY RESISTANCE
Resistance is determined chiefly by the radius size of the
airway.
Causes of Increased Airway Resistance
1. Contraction of bronchial mucosa
2. Thickening of bronchial mucosa
3. Obstruction of the airway
4. Loss of lung elasticity
RESPIRATION
The process of gas exchange between atmospheric air
and the blood at the alveoli, and between the blood cells
and the cells of the body.
Exchange of gases occurs because of differences in
partial pressures.
Oxygen diffuses from the air into the blood at the alveoli
to be transported to the cells of the body.
Carbon dioxide diffuses from the blood into the air at the
alveoli to be removed from the body.
NEUROCHEMICAL CONTROL
MEDULLA OBLONGATA respiratory center
initiates each breath by sending messages to primary
respiratory muscles over the phrenic nerve
- has inspiration and expiration centers
PONS has 2 respiration centers that work with the
inspiration center to produce normal rate of breathing
1. PNEUMOTAXIC CENTER affects the inspiratory
effort by limiting the volume of air inspired
2. APNEUSTIC CENTERprolongs inhalation
NOTE: Chemoreceptors responds to changes in ph, increasedPaCO2 = increase RR
RESPIRATORY EXAMINATION AND
ASSESSMENT
Background information
A. Abnormal patterns of breathing
1. Sleep Apnea
cessation of airflow for more than 10 seconds more
than 10 times a night during sleep
causes:obstructive (e.g. obesity with upper narrowing,enlarged tonsils, pharyngeal soft tissue changes in
acromegaly or hypothyroidism)2.
Cheyne-Stokes
periods of apnoea alternating with periods ofhyperpnoae
pathophysiology:delay in medullary chemoreceptor
response to blood gas changes
causes left ventricular failure brain damage (e.g. trauma, cerebral,
haemorrhage) high altitude
3.
Kussmaul's (air hunger)
deep rapid respiration due to stimulation of respiratorycentre
causes: metabolic acidosis (e.g. diabetes mellitus,
chronic renal failure)
4.
Hyperventilation
complications:alkalosis and tetany
causes:anxiety
5. Ataxic (Biot)
irregular in timing and deep
causes:brainstem damage
6.
Apneustic
post-inspiratory pause in breathing
causes:brain (pontine) damage
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Medical and Surgical Nursing
Respiratory System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
MS Abejo4
7.
Paradoxical
the abdomen sucks with respiration (normally, itpouches uotward due to diaphragmatic descent)
causes: diaphragmatic paralysis
B.
Cyanosis
1.
Refers to blue discoloration of skin and mucousmembranes , is due to presence of deoxygenatedhaemoglobin in superficial blood vessels
2. Central cyanosis= abnromal amout of deoxygenated
haemoglobin in arteries and that blue discoloration ispresent in parts of body with good circulation such astongue
3. Peripheral cyanosis= occurs when blood supply to acertain part of body is reduced, and the tissue extracts
more oxygen from normal from the circulating blood, e.g.lips in cold weather are often blue, but lips are spared
4. Causes of cyanosis
Central cyanosis decreased arterial saturation decreased concentration of inspired oxygen:
high altitude lung disease: COPD with cor pulmoale,
massive pulmonary embolism right to left cardiac shunt (cyanotic congenital
heart disease) polycythaemia haemoglobin abnromalities (rare):
methaemoglobinaemia, sulphaemoglobinaemia
Peripheral cyanosis all causes of central cyanosis cause peripheral
cyanosis exposure to cold reduced cardiac output: left ventricular failure or
shock
arterial or venous obstructionPosition:patient sitting over edge of bed
General appearance
look for the following
Dyspnea
normal respiratory rate < 14 each minute
tachypnoea = rapid respiratory rate
are accessory muscles being used (sternomastoids,
platysma, strap muscles of neck) - characteristically,the accessory muscles cause elevation of shoulderswith inspiration and aid respiration by increasingchest expansion
Cyanosis
Character of coughask patient to cough several times
lack of usual explosive beginning may indicatevocal cord paralysis (bovine cough)
muffled, wheezy ineffective cough suggests airflowlimitation
very loose productive cough suggests excessive
bronchial secretions due to:- chronic bronchitis
- pneumonia- bronchiectasis
dry irritating cough may occur with:
- chest infection
- asthma
- carcinoma of bronchus- left ventricular failure
- interstitial lung disease
- ACE inhibitors
Sputum
volume
type (purulent, mucoid, mucopurulent)presence or absence of blood?
Stridor
croaking noise loudest on inspiration
is a sign that requires urgent attention
causes: (obstruction of larynx, trachea or largebroncus)
- acute onset (minutes) inhaled foreign body acute epiglottitis anaphylaxis toxic gas inhalation
- gradual onset (days, weeks) laryngeal and pharyngeal tumours crico-arytenoid rheumatoid arthritis bilateral vocal cord palsy tracheal carcinoma paratracheal compression by lymph nodes post-tracheostomy or intubation
granulomata
Hoarseness
causes include:- laryngitis- laryngeal nerve palsy associated with
carcinoma of lung- laryngeal carcinoma
The Hands
Clubbing
commonly cause by respiratory disease (but NOTemphysema or chronic bronchitis)
occasionally, clubbing is associated with hypertrophicpulmonary osteoarthropathy (HPO) characterised by periosteal inflammation at distal ends
of long bones, wrists, ankles, metacarpals andmetatarsals
sweelling and tenderness over wrists and otherinvolved areas
Staining
staining of fingers - sign of cigarette smoking (caused by
tar, not nicotine)
Wasting and weakness
Pulse rate Flapping tremor (asterixis)- unreliable sign
ask patient to dorsiflex wrists and spread out fingers, with
arms outstretched
flapping tremor may occur with severe carbon dioxide
retention (severe chronic airflow limitation)
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Medical and Surgical Nursing
Respiratory System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
MS Abejo6
The Chest:palpation
chest expansion
place hands firmly on chest wall with fingers extendingaround sides of chest (fugyre 4.5)
as patient takes a big breath in, the thumbs should move
symmetrically apart about 5 cm
reduced expansion on one side indicates a lesion on thatside
note: lower lobe expansion is tested here; upper lobe is
tested for on inspection (as above)
apex beat
(discussed in cardiac section)
for respiratory diseases: displacement toward site of lesion - can be caused by:
collapse of lower lobe
localised pulmonary fibrosis displacement away from site of lesion - can be caused
by:
pleural effusion
tension pneumothorax apex beat is often impalpable in a chest which is
hyperexpanded secondary to chronic airflow limitation
vocal fremitus
palpate chest wall with palm of hand while patient repeats"99"
front and back of chest are each palpated in 2 comparablepositions with palms; in this way differences in vibration onchest wall can be detected
causes of change in vocal fremitus are the same as those forvocal resonance (see later)
ribs
gently compress chest wall anteroposteriorly and laterally
localised pain suggests a rib fracture (may be secondary to
trauma or spontaneous as a result of tumour deposition orbone disease)
The Chest:percussion
with left hand on chest wall and fingers slightly separated andaligned with ribs, the middle finger is pressed firmly against
the chest; pad of right middle finger is used to strike firmly themiddle phalanx of middle finger of left hand
percussion of symmetrical areas of: anterior (chest) posterior (back) (ask patient to move elbows forward
across the front of chest - this rotates the scapulaeanteriorly, i.e. moves it out of the way)
axillary region (side) supraclavicular fossa
percussion over a solid structure (e.g. liver, consolidated lung)
produces a dull note
percusion over a fluid filled area (e.g. pleural effusion)
produces an extremely dull (stony dull) note
percussion over the normal lung produces a resonant note
percussion over a hollow structure (e.g. bowel, pneumothorax)produces a hyperresonsant note
liver dullness:
upper level of liver dullness is determined by percussingdown the anterior cehst in mid-clavicular line
normally, upper level of liver dullness is 6th rib in right
mid-clavicular line if chest is resonant below this level, it is a sign of
hyperinflation usually due to emphysema, asthma
cardiac dullness: area of cardiac dullness is uaully present on left side of
chest this may decrease in emphysema or asthma
The Chest:auscultation
breath sounds
introductionone should use the diaphragm of stethoscope to listento breath sound in each area, comparing each side
remember to listen high up into the axillae
remember to use bell of stethoscope to listen to lung
from above the clavicles
quality of breath sounds
normal breat sounds are heard with stethoscope over all parts of
chest, produced in airways rather than alveoli(although once they had been thought to arisefrom alveoli (vesicles) and are therefore calledvesicular sounds)
normal (vesicular) breath sounds are louder and
longer on inspiration than on expiration; andthere is no gap between the inspiratory andexpiratory sounds
bronchial breath sounds turbulence in large airways is heard without
being filtered by the alveoli, and therefore
produce a different quality; they are heard overthe trachea normally, but not over the lungs
are audible throughout expiration, and oftenthere is a gap between inspiration and expiration
are heard over areas of consolidation since solidlung conducts the sound of turbulence in mainairways to peripheral areas without filtering
causes include:
- lung consolidation (lobar pneumonia) -
common- localised pulmonary fibrosis - uncommon
- pleural effusion (above the fluid) -
uncommon- collapsed lung (e.g. adjacent to a pleural
effusion) - uncommon amphoric sound = when breath sounds over a
large cavity have an exaggerated bronchialquality)
intensity of breath sounds
causes of reduced breath sounds include: chronic airflow limitation (especially
emphysema) pleural effusion pneumothorax
pneumonia
large neoplasm pulmonary collapse
added (adventitious) sounds
two types of added sounds: continuous (wheezes) andinterrupted (crackles)
wheezes
may be heard in expiration or inspiration or both
pathophysiology of wheezes - airway narrowing an inspiratory wheeze implies severe airway
narrowing
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Medical and Surgical Nursing
Respiratory System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
MS Abejo7
causes of wheezes include:- asthma (often high pitched) - due to muscle
spasm, mucosal oedema, excessivesecretions
- chronic airflow diseases - due to mucosaloedema and excessive secretions
- carcinoma causing bronchial obstruction -
tends to cause a localised wheeze which ismonophonic and does not clear with
coughing
crackles some terms not to use include rales (low pitched
crackles) and creptitations (high pitchedcrackles)
crackles are due to collapse of peripheralairways on expiration and sudden opening oninspiration
early inspiratory crackles- suggests disease of small airways
- characteristic of chronic airflow limitation- are only heard in early inspiration
late or paninspiratory crackles
-suggests disease confined to alveoli
- may be fine, medium or coarse
- fine crackles - typically caused by
pulmonary fibrosis- medium crackles - typically caused by left
ventricular failure (due to presence of
alveolar fluid)- coarse crackes - tend to change with
coughing; occur with any disease that leadsto retention of secretions; commonly occurin bronchiectasis
pleural friction rub
when thickened, roughened pleural surfaces rubtogether, a continuous or intermittent gratingsound may be heard
suggests pleurisy, which may be secondary topulmonary infarction or pnuemonia
vocal resonanance
gives information about lungs' ability to transmit sounds
consolidated lung tends to transmit high frequencies so
that speech heard through stethoscope takes a bleetingquality (aegophony); when a patient with aegophony says"bee" it sounds like "bay"
listen over each part of chest as patient says "99"; overconsolidated lung, the numbers will become clearlyaudible; over normal lung, the sound is muffled
whispering pectoriloquy - vocal resonance is increased tosuch an extent that whispered speech is distinctly heard
The Heart
lie patient at 45 degrees
measure jugular venous plse for right heart failure
examine preacordium; pay close attention to pulmonary
component of P2 (which is best heard at 2nd intercostalspace on left) and should not be louder than A2; if it islouder, suspect pulmonary hypertension
cor pulmonale (also called pulmonary hypertensive heart
disease) may be due to:
chronic airflow limitation (emphysema)
pulmonary fibrosis
pulmonary thromboembolism
marked obesity
sleep apnoea
severe kyphoscoliosis
The Abdomen
palpate liver for enlargement due to secondary deposits of
tumour from lung, or right heart failure
Other
Permberton's sign ask patient to lift arms over head look for development of facial plethora, inspiratory
stridor, non-pulsatile elevation of jugular venouspressure
occurs in vena caval obstruction
Feet
inspect for oedema or cyanosis (clues of corpulmonale)
look for evidence of deep vein thrombosisd
Respiratory rate on exercise and positioning
patients complaining of dyspnoea should have theirrespiratory rate measured at rest, at maximal toleratedexertion and supine
if dyspnoea is not accompanied by tachypnoea whena patient climbs stairs, one should considermalingering
look for paradoxical inward motion of abdomen
during inspiration when patient is uspine (indicatingdiaphragmatic paralysis)
Temperature: fever may accompany any acute or chronic
chest infection
DIAGNOSTIC EVALUATION
1. Skin Test: Mantoux Test or Tuberculin Skin Test
This is used to determine if a person has been infected orhas been exposed to the TB bacillus.
This utilizes the PPD (Purified Protein Derivatives). The PPD is injected intradermally usually in the inner
aspect of the lower forearm about 4 inches below theelbow.
The test is read 48 to 72 hours after injection. (+) Mantoux Test is induration of 10 mm or more. But for HIV positive clients, induration of about 5 mm is
considered positive
Signifies exposure to Mycobacterium Tubercle bacilli
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Medical and Surgical Nursing
Respiratory System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
MS Abejo8
2. Pulse Oximeter
Non-invasive method of continuously monitoring heoxygen saturation of hemoglobin
A probe or sensor is attached to the fingertip, forehead,earlobe or bridge of the nose
Sensor detects changes in O2sat levels by monitoring
light signals generated by the oximeter and reflected bythe blood pulsing through the tissue at the probe
Normal SpO2 = 95% - 100% < 85% - tissues are not receiving enough O2 Results unreliable in:
Cardiac arrest Shock Use of dyes or
vasoconstrictors Severe anemia High carbon
monoxide Level
3. Chest X-ray
This is a NON-invasive procedure involving the use of x-rays with minimal radiation.
The nurse instructs the patient to practice the on cue tohold his breath and to do deep breathing
Instruct the client to remove metals from the chest. Rule out pregnancy first.
5. Computed Tomography (CT Scan) and Magnetic Resonance
Imaging ( MRI )
The CT scanis a radiographic procedure that utilizesx-ray machine.
The MRIuses magnetic field to record the H+density ofthe tissue.
It does NOT involve the use of radiation.
The contraindications for this procedure are thefollowing: patients with implanted pacemaker,
patients with metallic hip prosthesis or other metalimplants in the body.
This chest CT scan shows a cross-section of a personwith bronchial cancer. The two dark areas are the lungs. The lightareas within the lungs represent the cancer.
Clear MRI images of lung airways during breathing.
6. Flouroscopy
Studies the lung and chest in motion Involves the continuous observation of an image
reflected on a screen when exposed to radiation in themanner of television screen that is activated by anelectrode beam.
Structures of different densities that intercept the X-raybeam are visualized on the screen in silhouette
7. Indirect Bronchography
A radiopaque medium is instilled directly into thetrachea and the bronchi and the outline of the entire
bronchial tree or selected areas may be visualizedthrough x-ray.
It reveals anomalies of the bronchial treeand isimportant in the diagnosis of bronchiectasis.
Nursing interventions BEFORE Bronchogram
Secure written consent
Check for allergies to sea foods or iodine or
anesthesia NPO for 6 to 8 hours Pre-op meds: atropine SO4and valium,
topical anesthesiasprayed; followed by local
anestheticinjected into larynx. The nurse musthave oxygen and anti spasmodic agents ready.
Nursing interventions AFTER Bronchogram Side-lying position NPO until cough and gag reflexes returned Instruct the client to cough and deep breathe
client
8. Bronchoscopy
This is the direct inspection and observationof thelarynx, trachea and bronchi through a flexible or rigid
bronchoscope. Passage of a lighted bronchoscopeinto the bronchial
tree for direct visualization of the trachea and thetracheobronchial tree.
Diagnostic uses: To examine tissues or collect secretions To determine location or pathologic process
and collect specimen for biopsy
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Medical and Surgical Nursing
Respiratory System Lecture Notes
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MS Abejo9
To evaluate bleeding sites To determine if a tumor can be resected
surgically
Therapeutic uses To Remove foreign objects from
tracheobronchial tree
To Excise lesions To remove tenacious secretions obstructing the
tracheobronchial tree To drain abscess To treat post-operative atelectasis
Nursing interventions BEFORE Bronchoscopy Informed consent/ permit needed Explain procedure to the patient, tell him what
to expect, to help him cope with the unkown Atropine (to diminish secretions) is
administered one hour before the procedure About 30 minutes before bronchoscopy,
Valium is given to sedate patient and allayanxiety.
Topical anesthesia is sprayed followed bylocal anesthesia injected into the larynx
Instruct on NPO for 6-8 hours Remove dentures, prostheses and contact lenses The patient is placed supine with
hyperextended neckduring the procedure
Nursing interventions AFTER Bronchoscopy
Put the patient on Side lying position
Tell patient that the throat may feel sore with . Check for the return of cough and gag reflex. Check vasovagal response. Watch for cyanosis, hypotension, tachycardia,
arrythmias, hemoptysis, and dyspnea. Thesesigns and symptoms indicate perforation ofbronchial tree. Refer the patient immediately!
9. Lung Scan
Procedure using inhalation or I.V. injection of a
radioisotope, scans are taken with a scintillation camera. Imaging of distribution and blood flow in the lungs.
(Measure blood perfusion) Confirm pulmonary embolism or other blood- flow
abnormalities
Nursing interventions BEFORE the procedure: Allay the patients anxiety Instruct the patient to Remain still during the
procedure
Nursing interventions AFTER the procedure Check the catheter insertion site for bleeding Assess for allergies to injected radioisotopes Increase fluid intake, unless contraindicated.
10. Sputum Examination Laboratory test Indicated for microscopic examination of the sputum:
Gross appearance, Sputum C&S, AFB staining, and
for Cytologic examination/ Papanicolaou examination
Nursing interventions: Early morning sputum specimenis to be
collected (suctioning or expectoration) Rinse mouth with plain water Use sterile container. Sputum specimen for C&S is collected before
the first dose of anti-microbial therapy. For AFB staining, collect sputum specimen for
three consecutive mornings.
11. Biopsy of the Lungs
Percutaneous removal of a small amount of lung tissue For histologic evaluation
-Transbronchoscopic biopsydone during bronchoscopy,
- Percutaneous needle biopsy- Open lung biopsy
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Medical and Surgical Nursing
Respiratory System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
MS Abejo10
Nursing interventions BEFORE the procedure:
Withhold food and fluids Place obtained written informed consent in the
patients chart.
Nursing interventions AFTER the procedure:
Observe the patient for signs of Pneumothoraxand air embolism
Check the patient for hemoptysis and
hemorrhage
Monitor and record vital signs Check the insertion site for bleeding Monitor for signs of respiratory distress
12. Lymph Node Biopsy Scalene or cervicomediastinal To assess metastasis of lung cancer
13. Pulmonary Function Test / Studies Non-invasive test Measurement of lung volume, ventilation, and diffusing
capacity Nursing interventions:
Document bronchodilators or narcotics usedbefore testing
Allay the patients anxiety during the testing
LUNG VOLUMES: (ITER)
Inspiratory reserve volume (3000 mL) The maximum volume that can be inhaled following a
normal quiet inhalation.Tidal volume (500 mL)
The volume of air inhaled and exhaled with normal quiet
breathingExpiratory reserve volume (1100 mL)
The maximum volume that can be exhaled following thenormal quiet exhalation
Residual volume (1200 mL) The volume of air that remains in the lungs after forceful
exhalation
LUNG CAPACITIES:
Functional Residual Capacity (ERV 1100 mL + RV 1200 mL =2300 mL)
The volume of air that remains in the lungs after normal,
quiet exhalation
Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500 mL) The amount of air that a person can inspire maximally
after a normal expirationVital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL =4600 mL )
The maximum volume of air that can be exhaled after amaximum inhalation
Reduced in COPDTotal Lung Capacity (IRV 3000 mL + TV 500 mL + ERV 1100mL + RV 1200 mL = 5800 mL)
Total of all four volumes
14. Arterial Blood Gas Laboratory test Indicate respiratory functions
Assess the degree to which the lungs are able to provideadequate oxygen and remove CO2
Assess the degree to which the kidneys are able toreabsorb or excrete bicarbonate.
Assessment of arterial blood for tissue oxygenation,ventilation, and acid-base status
Arterial puncture is performed on areas where goodpulses are palpable (radial, brachial, or femoral).Radial artery is the most common site for withdrawal of
blood specimen
Nursing interventions: Utilize a 10-ml. Pre-heparinized syringe to
prevent clotting of specimen Soak specimen in a container with ice to
prevent hemolysis If ABG monitoring will be done, do Allens
test to assess for adequacy of collateralcirculation of the hand (the ulnar arteries)
15. Pulmonary Angiography
This procedure takes X-ray pictures of the pulmonaryblood vessels (those in the lungs).
Because arteries and veins are not normally seen in an X-ray, a contrast material is injected into one or more
arteries or veins so that they can be seen.
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Medical and Surgical Nursing
Respiratory System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
MS Abejo11
16. Ventilation - Perfusion Scan
Radioactive albumin injection is part of a nuclear scan
test that is performed to measure the supply of bloodthrough the lungs.
After the injection, the lungs are scanned to detect thelocation of the radioactive particles as blood flows
through the lungs.
The ventilation scan is used to evaluate the ability of airto reach all portions of the lungs. The perfusion scanmeasures the supply of blood through the lungs.
A ventilation and perfusion scan is most often performedto detect a pulmonary embolus. It is also used to evaluatelung function in people with advanced pulmonary diseasesuch as COPD and to detect the presence of shunts
(abnormal circulation) in the pulmonary blood vessels.
17. Thoracentesis
Procedure suing needle aspiration of intrapleural fluid or
air under local anesthesia Specimen examination or removal of pleural fluid
Nursing intervention BEFORE Thoracentesis
Secure consent Take initial vital signs Instruct to remain still, avoid coughing during
insertion of the needle Inform patient that pressure sensation will be
felt on insertion of needle
Nursing intervention DURING the procedure: Reassess the patient Place the patient in the proper position:
Upright or sitting on the edge of
the bed
Lying partially on the side,
partially on the back
Nursing interventions after Thoracentesis Assess the patients respiratory status Monitor vital signs frequently Position the patient on the affected side, as
ordered, for at least 1 hour to seal the puncture
site Turn on the unaffected side to prevent leakage
of fluid in the thoracic cavity Check the puncture site for fluid leakage
Auscultate lungs to assess for pneumothorax Monitor oxygen saturation (SaO2) levels Bed rest Check for expectoration of blood
RESPIRATORY CARE MODALITIES
1. Oxygen Therapy
Oxygen is a colorless, odorless, tasteless, and dry gas that
supports combustion Man requires 21% oxygenfrom the environment in order
to survive Indication: Hypoxemia Signs of Hypoxemiao Increased pulse rate
o Rapid, shallow respiration and dyspneao Increased restlessness or lightheadednesso Flaring of nareso Substernal or intercostals retractions
o Cyanosis
Low flow oxygenprovides partial oxygenation with patientbreathing a combination of supplemental oxygen and room air.
Low-flow administration devices:o Nasal Cannula 24-45% 2-6 LPMo Simple Face Mask 0-60% 5-8 LPMo Partial Rebreathing Mask 60-90% 6-10 LPM
o Non-rebreathing Mask 95-100% 6-15 LPMo Croupetteo Oxygen Tent
High flow oxygenprovides all necessary oxygenation, withpatients breathing only oxygen supplied from the mask andexhaling through a one-way vent.
High flow administration devices
o Venturi Mask 24-40% 4-10 LPM Preferred for clients with COPD because it
provides accurate amount of oxygen.
o
Face Masko Oxygen Hood*o Incubator / isolette*
Note: * can be used for both low and high flow administration
The nurse should prevent skin breakdown by checkingnares, nose and applying gauze or cotton as necessary
Ensure that COPDpatients receive only LOW flowoxygenbecause these persons respond to hypoxia, not
increased CO levels.
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Medical and Surgical Nursing
Respiratory System Lecture Notes
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MS Abejo12
2. Tracheobronchial suctioning
Suction only when necessary not routinely
Use the smallest suction catheter if possible Client should be in semi or high Fowlersposition Use sterile gloves, sterile suction catheter Hyperventilate client with 100% oxygen before and
after suctioning
Insert catheter with gloved hand (3-5 length of catheterinsertion) without applying suction. Three passes of thecatheter is the maximum, with 10 seconds per pass.
Apply suction only during withdrawal of catheter The suction pressure should be limited to less than 120
mmHg When withdrawing catheter rotate while applying
intermittent suction Suctioning should take only 10 seconds (maximum of 15
seconds) Evaluate: clear breath sounds on auscultation of the chest.
3. Bronchial Hygiene Measures Suctioning: oropharyngeal; nasopharyngeal
a. Steam inhalation The purpose of steam inhalation are as follows:
- to liquefy mucous secretions
- to warm and humidify air- to relieve edema of airways- to soothe irritated airways- to administer medication
It is a dependent nursing function Inform the client and explain the purpose of the procedure Place the client in Semi-Fowlers position Cover the clients eyes with washcloth to prevent irritation Check the electrical device before use Place the steam inhalator in a flat, stable surface. Place the spout 1218 inchesaway from the clients nose or
adjust distance as necessary CAUTION: avoid burns. Cover the chest with towel to
prevent burns due to dripping of condensate from the steam.Assess for redness on the side of the face which indicatesfirst degree burns.
To be effective, render steam inhalation therapy for 1520
minutes Instruct the client to perform deep breathing and coughing
exercises after the procedure to facilitate expectoration ofmucous secretions.
Provide good oral hygiene after the procedure. Do after-care of equipment.
b. Aerosol inhalation
done among pediatric clients to administer brochodilators ormucolytic-expectorants.
.
c. Medimist inhalation
done among adult clients to administer bronchodilators ormucolytic-expectorants.
4. Chest Physiotheraphy ( CPT )
Includes postural drainage, chest percussion and vibration,and breathing retraining. Effective coughing is also animportant component.
Goals are removal of bronchial secretions, improvedventilation, and increased efficiency of respiratory
muscles. Postural drainage uses specific positions to use gravity to
assist in the removal of secretions. Vibration loosens thick secretions by percussion or
vibration.
Breathing exercises and breathing retraining improveventilation and control of breathing and decrease thework of breathing.
These are procedures for patients with respiratorydisorders like COPD, cystic fibrosis, lung abscess, and
pneumonia. The therapy is based on the fact that mucuscan be knocked or shaken from airways and helped to
drain from the lungs.
Postural drainage Use of gravity to aid in the drainage of secretions. Patient is placed in various positions to promote flow of
drainage from different lung segments using gravity. Areas with secretions are placed higher than lung
segments to promote drainage.
Patient should maintain each position for 5-15 minutesdepending on tolerability.
Percussion Produces energy wave that is transmitted through the
chest wall to the bronchi. The chest is struck rhythmically with cupped hands over
the areas were secretions are located.
Avoid percussion over the spine, kidneys, breast orincision and broken ribs. Areas should be percussed for1-2 minutes
Vibration Works similarly to percussion, where hands are placed on
clients chest and gently but firmly rapidly vibrate handsagainst thoracic wall especially during clients exhalation.
This may help dislodge secretions and stimulate cough. This should be done at least 5-7 times during patient
exhalation.
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Suctioning
Nursing Interventions in CPT Verify doctors order Assess areas of accumulation of mucus secretions. Position to allow expectoration of mucus secretions
by gravity Place client in each position for 5-10 to 15 minutes
Percussion and vibration done to loosen mucussecretions
Change position gradually to prevent posturalhypotension
Client is encouraged to cough up and expectorate
sputum Procedure is best done 60 to 90 minutes before
meals or in the morning upon awakening and atbedtime.
Provide good oral care after the procedure
5. Incentive Spirometry
Types: volume and flow
Device ensures that a volume of air is inhaled and thepatient takes deep breaths.
Used to prevent or treat atelectasis To enhance deep inhalation
Nursing care Positioning of patient, teach and encourage use,
set realistic goals for the patient, and record theresults.
6. Closed Chest Drainage ( Thoracostomy Tube ) Chest tube is used to drain fluid and air out of the
mediastinum or pleural space into a collection chamberto help re-establish normal negative pressure for lung re-
expansion.Purposes To remove air and/or fluids from the pleural space To reestablish negative pressure and re-expand the
lungs
Procedure
The chest tube is inserted into the affected chestwall at the level of 2ndto 3rdintercostals space torelease air or in the fourth intercostals space toremove fluid.
Types of Bottle Drainage
One-bottle system
The bottle serves as drainage and water-seal Immerse tip of the tube in 2-3 cm of sterile NSS to
create water-seal. Keep bottle at least 2-3 feet below the level of the
chest to allow drainage from the pleura by gravity. Never raise the bottle above the level of the heart
to prevent reflux of air or fluid. Assess for patency of the device Observe for fluctuation of fluid along the tube. The
fluctuation synchronizes with the respiration. Observe for intermittent bubbling of fluid;
continues bubbling means presence of air-leak
In the absence of fluctuation:
Suspect obstruction of the deviceAssess the patient first, then if patient is stableCheck for kinks along tubing;Milk tubing towards the bottle (If the hospital allows the
nurse to milk the tube)
If there is no obstruction, consider lung re-expansion;
(validated by chest x-ray)Air vent should be open to air.
Two-bottle system
If not connected to the suction apparatus The first bottle is drainage bottle; The second bottle is water-seal bottle Observe for fluctuation of fluid along the tube
(water-seal bottle or the second bottle) andintermittent bubbling with each respiration.
NOTE! IF connected to suction apparatus
1. The first bottle is the drainage and water-seal bottle;2. The second bottle is suction control bottle.
3.
Expect continuous bubbling in the suction control bottle;4. Intermittent bubbling and fluctuation in the water-seal
5. Immerse tip of the tube in the first bottle in 2 to 3 cm ofsterile NSS
6. Immerse the tube of the suction control bottle in 10 to 20cm of sterile NSS to stabilize the normal negative
pressure in the lungs.7. This protects the pleura from trauma if the suction
pressure is inadvertently increased
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Three-bottle system
The first bottle is the drainage bottle; The second bottle is water seal bottle The third bottle is suction control bottle.
Observe for intermittent bubbling andfluctuation with respiration in the water- seal
bottle Continuous GENTLE bubbling in the suction
control bottle. These are the expected observations. Suspect a leak if there is continuous bubbli ng in
the WATER seal bottle or if there is VIGOROUS
bubbling i n the suction control bottle. The nurse should look for the leak and report the
observation at once. Never clamp the tubingunnecessarily.
If there is NO fluctuation in the water seal bottle, it may meanTWO things
Either the lungs have expanded or the system is NOTfunctioning appropriately.
In this situation, the nurse refers the observation to the
physician, who will order for an X-ray to confirm thesuspicion.
Important Nursing considerations
Encourage doing the following to promote drainage: Deep breathing and coughing exercises Turn to sides at regular basis Ambulate ROM exercise of arms Mark the amount of drainage at regular intervals Avoid frequent milking and clamping of the tube to
prevent tension pneumothorax
What the nurse should do if: If there is continuous bubbling:
The nurse obtains a toothless clamp
Close the chest tube at the point where it exits the chestfor a few seconds.
If bubbling in the water seal bottle stops, the leak is
likely in the lungs, But if the bubbling continues, the leak is between the
clamp and the bottle chamber.
Next, the nurse moves the clamp towards the bottle checking thebubbling in the water seal bottle.
If bubbling stops, the leak is between the clampand the distal part including the bottle.
But if there is persistent bubbling, it means that thedrainage unit is leaking and the nurse must obtain
another set. In the event that the water seal bottle breaks, thenurse temporarily kinks the tube and must obtain a
receptacle or container with sterile water andimmerse the tubing.
She should obtain another set of sterile bottle asreplacement. She should NEVER CLAMP the tube
for a longer time to avoid tension pneumothorax. In the event the tube accidentally is pulled out, the
nurse obtains vaselinized gauze and covers thestoma.
She should immediately contact the physician.
Removal of chest tubedone by physician
The nurse Prepares:
Petrolatum GauzeSuture removal kit
Sterile gauzeAdhesive tape
Place client in semi-Fowlers position
Instruct client to exhale deeply, then inhale and dovalsalva maneuver as the chest tube is removed.
Chest x-ray may be done after the chest tube is
removed Asses for complications: subcutaneous emphysema;
respiratory distress
7. Artificial Airway
a. Oral airways- these are shorter and often have a larger lumen.They are used to prevent the tongue form falling backward.
b. Nasal airways- these are longer and have smaller lumen Whichcauses greater airway resistance
c. Tracheostomy- this is a temporary or permanent surgicalopening in the trachea. A tube is inserted to allow ventilation andremoval of secretions. It is indicated for emergency airway accessfor many conditions. The nurse must maintain tracheostomy care
properly to prevent infection.
RESPIRATORY DISEASES AND
DISORDERS
I. PNEUMONIA inflammation of the lung parenchyma
leading to pulmonary consolidation because alveoli is filledwith exudates
A. ETIOLOGIC AGENTS
1. Streptococcus pneumoniae (pneumococcalpneumonia)
2. Hemophilus influenzae (bronchopneumonia)3. Klebsiella pneumoniae4. Diplococcus pneumoniae5. Escherichia coli
6. Pseudomonas aeruginosa
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B.
HIGH RISK GROUPS
1. Children less than 5 yo
2. Elderly
C.
PREDISPOSING FACTORS
1. Smoking
2. Air pollution
3.
Immunocompromised (+) AIDS
Kaposis Sarcoma
Pneumocystis Carinii Pneumonia
DOC: Zidovudine (Retrovir) Bronchogenic Ca
4. Prolonged immobility (hypostatic pneumonia)5. Aspiration of food (aspiration pneumonia)6. Over fatigue
D. SIGNS AND SYMPTOMS
1. Productive cough, greenish to rusty2. Dyspnea with prolong expiratory grunt3. Fever, chills, anorexia, general body malaise
4. Cyanosis
5.
Pleuritic friction rub6. Rales/crackles on auscultation7. Abdominal distentionparalytic ileus
E. DIAGNOSTICS
1. Sputum GS/CSconfirmatory; type and sensitivity;(+) to cultured microorganism
2. CXR(+) pulmonary consolidation3. CBC
Elevated ESR (rate of erythropoeisis) N = 0.5-1.5% (compensatory mech to decreased O2)
Elevated WBC4. ABGPO2 decreased (hypoxemia)
F.
NURSING MANAGEMENT
1. Enforce CBR (consistent to all respi disorders)
2. Strict respiratory isolation3. Administer medications as ordered
Broad spectrum antibioticsPenicillinpneumococcal infections
TetracyclineMacrolides
Azithromycin (OD x 3/days)
1. Too costly2. Only se: ototoxicity transient
hearing loss Anti-pyretics
Mucolytics/expectorants
4. Administer O2 inhalation as ordered
5.
Force fluids to liquefy secretions6. Institute pulmonary toilet measures to promote
expectoration of secretions DBE, Coughing exercises, CPT
(clapping/vibration), Turning and repositioning7. Nebulize and suction PRN
8. Place client of semi-fowlers to high fowlers9. Provide a comfortable and humid environment10. Provide a dietary intake high in CHO, CHON,
Calories and Vit C
11. Assist in postural drainage Patient is placed in various position to drain
secretions via force of gravity
Usually, it is the upper lung areas which aredrained
Nursing management:Monitor VS and BS
Best performed before meals/breakfast or2-3 hours p.c. to prevent gastroesophageal
reflux or vomiting (pagkagising maraming
secretions diba? Nakukuha?)Encourage DBEAdminister bronchodilators 15-30 minutes
before procedureStop if pt. cant tolerate the procedureProvide oral care after procedure as it mayaffect taste sensitivity
Contraindications:
Unstable VS
Hemoptysis
Increased ICP
Increased IOP (glaucoma)
12. Provide pt health teaching and d/c planning Avoidance of precipitating factors
Prevention of complicationsAtelectasisMeningitis
Regular compliance to medications Importance of ffup care
II. PULMONARY TUBERCULOSIS (KOCHS DISEASE)
infection of the lung parenchyma caused by invasion ofmycobacterium tuberculosis or tubercle bacilli (gram negative,acid fast, motile, aerobic, easily destroyed by heat/sunlight)
A.
PRECIPITATING FACTORS
1. Malnutrition
2.
Overcrowding3. Alcoholism: Depletes VIT B1 (thiamin)alcoholic
beriberimalnutrition4. Physical and emotional stress5. Ingestion of infected cattle with M. bovis6. Virulence (degree of pathogenecity)
B. MODE OF TRANSMISSION: Airborne dropletinfection
Tracheostomy usually done at bedside, 10-20 minutes
Stress test: 30 minutes
Mammography: 10-20 minutes
LARYNGOSPASMtracheostomy STAT
OR Tracheostomy: laryngeal, thyroid, neck CA
DIAPHRAGMprimary muscle for respiration
INTERCOSTAL MUSCLESsecondary muscle for respiration
ALVEOLI (Acinar cells) functional unit of the lungs; site for gas
exchange (via diffusion)
VENTILATIONmovement of air in and out of the lungs RESPIRATIONlungs to cells
Internal
External
RETROLENTAL FIBROPLASIA retinopathy/blindness in
immaturity d/t high O2 flow in pedia patients
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C.
SIGNS AND SYMPTOMS
1. Productive cough (yellowish)
2. Low grade afternoon fever, night sweats3. Dyspnea, anorexia, malaise, weight loss
4. Chest/back pain5. Hemoptysis
D.
DIAGNOSTICS1. Skin testing
Mantoux testPPD
Induration width (within 48-72 h)
8-10 mm (DOH)
10-14 mm (WHO)
5 mm in AIDS patients is +indicates previous exposure to tubercle
bacilli2. Sputum AFB (+) tubercle bacilli3. CXR(+) pulmo infiltrated due to caseous necrosis4. CBCelevated WBC
E.
NURSING MANAGEMENT1. Enforce CBR
2. Institute strict respiratory isolation3. Administer O2 inhalation4. Forced fluids5. Encourage DBE and coughing
NO CLAPPING in chronic PTB d/t
hemoptysis may lead to hemorrhage
6. Nebulize and suction PRN7. Provide comfortable and humid environment
8. Institute short course chemotherapy
Intensive phase
INH
SE: peripheral neuritis (increase vit
B6 or pyridoxine
Rifampicin SE: red orange color of bodily
secretionsPZA
May be replaced with Ethambutol
(SE: optic neuritis) if (+)hypersensitivity to drug
SE: allergic reactions; hepatotoxicity
and nephrotoxicity1. Monitor liver enzymes2. Monitor BUN and CREA
INH given for 4 months, PZA andRifampicin is given for 2 months, A.C. tofacilitate absorptionThese 3 drugs are given simultaneously to
prevent development of resistance
Standard Regimen
Streptomycin injection (aminoglycosides)
Neomycin, Amikacin, Gentamycin
1. common SE: 8thCN damage tinnitus hearing loss ototoxicity
2. nephrotoxicitya. BUN (N = 10-20)
b. CREA (N = 8-10)9. Health teaching and d/c planning
Avoidance of precipitating factors : alcoholism,overcrowding
Prevention of complicationsAtelectasis
Military TB (extrapulmonary TB:meningeal, Potts, adrenal glands, skin,
cornea)
Strict compliance to medicationsNever double the dose! Continue takingthe meds if missed a day)
Diet modifications: increased CHON, CHO,Calories, Vit C
Importance of ffup care
III. HISTOPLASMOSIS acute fungal infection caused byinhalation of contaminated dust with Histoplasma capsulatumfrom birds manure
A.
PREDISPOSING FACTORS Inhalation of contaminated dust
2.
SIGNS AND SYMPTOMS
PTB like symptoms Productive cough Fever, chills, anorexia, generalized body
malaise Cyanosis Chest and joint pains Dyspnea Hemoptysis
3.
DIAGNOSTICS
Histoplasmin skin test is (+) ABG analysis reveals pO2 low
4.
NURSING MANAGEMENT
Enforce CBG
Administer meds as orderedAntifungal agents
Amphotericin B (Fungizone) SE:nephrotoxicity and hypokalemia
Monitor transaminases, BUN and
CREACorticosteroidsAnti-pyretics
Mucolytics/expectorants Administer oxygen inhalation as ordered Forced fluids Nebulize and suction as necessary
Prevent complications
Bronchiectasis, atelectasis
Prevention of spreadSpraying of breeding places
Kill bird and owner! Hehe!
CHRONIC OBSTRUCTIVE PULMONARY DISEASES
1. Chronic Bronchitis
2. Bronchial Asthma
3.
Bronchiectasis
4.
Pulmonary Emphysema
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I. CHRONIC BRONCHITIS (Blue Bloaters) Inflammationof the bronchi due to hypertrophy or hyperplasia of goblet
mucous producing cells leading to narrowing of smallerairways
A. PREDISPOSING FACTORS
1.
Smoking2. Air pollution
B.
SIGNS AND SYMPTOMS
1. Consistent productive cough2. Dyspnea on exertion with prolonged expiratory
grunt3. Anorexia and generalized body malaise4. Cyanosis5. Scattered rales/rhonchi
6. Pulmonary hypertension Peripheral edema Cor pulmonale
C.
DIAGNOSTICS
1.
ABG analysis: decreased PO2, increased PCO2,respiratory acidosis; hypoxemia cyanosis
D.
NURSING MANAGEMENT
1. Enforce CBR2. Administer medications as ordered
Bronchodilators Antimicrobials Corticosteroids Mucolytics/expectorants
3. Low inflow O2 admin; high inflow will causerespiratory arrest
4. Force fluids5. Nebulize and suction client as needed6. Provide comfortable and humid environment
7.
Health teaching and d/c planning avoidance of smoking prevent complications
CO2 narcosiscomaCor pulmonale
Pleural effusionPneumothorax
Regular adherence to meds Importance of ffup care
II. BRONCHIAL ASTHMA reversible inflammatory lungcondition caused by hypersensitivity to allergens leading to
narrowing of smaller airways
A. PREDISPOSING FACTORS
1. Extrinsic(Atopic/Allergic Asthma)
Pollens, dust, fumes, smoke, fur, dander, lints2. Intrinsic(Non-Atopic/Non-Allergic)
Drugs (aspirin, penicillin, B-blockers) Foods (seafoods, eggs, chicken, chocolate) Food additives (nitrates, nitrites) Sudden change in temperature, humidity and
air pressure Genetics Physical and emotional stress
3. Mixed typecombination of both
B.
SIGNS AND SYMPTOMS
1. Cough that is productive2. Dyspnea3. Wheezing on expiration
4.
Tachycardia, palpitations and diaphoresis5. Mild apprehension, restlessness6. Cyanosis
C.
DIAGNOSTICS
1. PFTdecreased vital lung capacity2. ABG analysisPO2 decreased
D.
NURSING MANAGEMENT
1. Enforce CBR
2. Administer medications as ordered Bronchodilators administer first to facilitate
absorption of corticosteroids
InhalationMDI
Corticosteroids Mucolytics/expectorants Mucomyst Antihistamine
3. Administer oxygen inhalation as ordered4. Forced fluids5. Nebulize and suction patient as necessary
6. Encourage DBE and coughing7. Provide a comfortable and humid environment8. Health teaching and d/c planning
Avoidance of precipitating factors Prevention of complications
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Status asthmaticus
DOC: Epinephrine
Aminophylline drip
Emphysema Regular adherence to medications Importance of ffup care
III.
BRONCHIECTASIS permanent dilation of the bronchusdue to destruction of muscular and elastic tissue of thealveolar walls (subject to surgery)
A.
PREDISPOSING FACTORS
1. Recurrent lower respiratory tract infection
Histoplasmosis2. Congenital disease
3. Presence of tumor4. Chest trauma
B. SIGNS AND SYMPTOMS
1. Consistent productive cough2. Dyspnea3. Presence of cyanosis4. Rales and crackles
5. Hemoptysis6. Anorexia and generalized body malaise
C.
DIAGNOSTICS
1.
ABG analysis reveals low PO22. Bronchoscopy direct visualization of bronchilining using a fibroscope Pre-op
Secure consentExplain procedure
NPO 4-6 hoursMonitor VS and breath sounds
Post-operativeFeeding initiated upon return of gag reflexInstruct client to avoid talking, coughingand smoking as it may irritate respiratorytract
Monitor for s/sx of frank or gross bleedingMonitor for signs of laryngeal spasm
DOB and SOB prepare trache set
D.
SURGERY
1. Segmental lobectomy
2. Pneumonectomy Most feared complications
AtelectasisCardiac tamponade: muffled heart sounds,
pulsus paradoxus, HPN
E.
NURSING MANAGEMENT
1. Enforce CBR2. Low inflow O2 admin; high inflow will cause
respiratory arrest
3. Administer medications as ordered Bronchodilators Antimicrobials Corticosteroids (5-10 minutes after
bronchodilators) Mucolytics/expectorants
4.
Force fluids5. Nebulize and suction client as needed6. Provide comfortable and humid environment
7. Health teaching and d/c planning Avoidance of smoking Prevent complications
Atelectasis
CO2 narcosiscomaCor pulmonalePleural effusionPneumothorax
Regular adherence to meds Importance of ffup care
IV. PULMONARY EMPHYSEMA terminal and irreversible
stage of COPD characterized by : Inelasticity of alveoli Air trapping Maldistribution of gasses (d/t increased air trapping)
Overdistention of thoracic cavity (Barrel chest) compensatory mechanismincreased AP diameter
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A.
PREDISPOSING FACTORS
1. Smoking2. Air pollution
3. Hereditary: involves alpha-1 antitrypsin forelastase productionfor recoil of the alveoli
4. Allergy
5.
High risk group elderly degenerative decreased vital lung capacity and thinning ofalveolar lobes
B. SIGNS AND SYMPTOMS
1. Productive cough2. Dyspnea at rest
3. Prolonged expiratory grunt4. Resonance to hyperresonance5. Decreased tactile fremitus6. Decreased breath sounds ( if (-) BS lung collapse)
7. Barrel chest8. Anorexia and generalized body malaise9. Rales or crackles10. Alar flaring
11.
Pursed-lip breathing (to eliminate excess CO2)
C.
DIAGNOSTICS
1. ABG analysis reveal Panlobular, centrilobular PO2 elevation and
PCO2 depression respiratory acidosis (bluebloaters)
Panacinar/centriacinar PCO2 depression and
PO2 elevation (pink puffershyperaxemia)2. Pulmo function testdecreased vital lung capacity
D.
NURSING MANAGEMENT
1. Enforce CBR
2. Administer medications as ordered Bronchodilators
Antimicrobials Corticosteroids Mucolytics/expectorants
3. Low inflow O2 admin; high inflow will causerespiratory arrest and oxygen toxicity
4. Force fluids
5. Pulmonary toilet6. Nebulize and suction client as needed7. Institute PEEP in mechanical ventilation
PEEPpositive end expiratory pressure allows for maximum alveolar diffusion prevent lung collapse
8. Provide comfortable and humid environment9. Diet modifications: high calorie, CHON, CHO,
vitamins and minerals10. Health teaching and d/c planning Avoidance of smoking Prevent complications
AtelectasisCO2narcosiscomaCor pulmonalePleural effusion
Pneumothorax Regular adherence to meds Importance of ffup care
RESTRICTIVE LUNG DISEASE
V. PNEUMOTHORAX partial or complete collapse of thelungs due to accumulation of air in pleural space
A. TYPES
1. Spontaneous air enters pleural space without an
obvious cause Ruptured blebs (alveolar filled sacs)
inflammatory lung conditions
2. Openair enters pleural space through an openingin pleural wall (most common) Gun shot wounds Multiple stab wounds
3. Tensionair enters pleural space during inspirationand cannot escape leading to overdistention of thethoracic cavity mediastinal shift to the affectedside (ie. Flail chest) paradoxical breathing
B.
PREDISPOSING FACTORS
1. Chest trauma2. Inflammatory lung condition
3.
tumors
C.
SIGNS AND SYMPTOMS
1. Sudden sharp chest pain, dyspnea, cyanosis2. Diminished breath sounds
3. Cool, moist skin4. Mild restlessness and apprehension5. Resonance to hyperresonance
D.
DIAGNOSTICS
1. ABG analysis: PO2 decreased2. CXRconfirms collapse of lungs
E. NURSING MANAGEMENT
1. Assist in endotracheal intubation
2.
Assist in thoracentesis3. Administer meds as ordered Narcotic analgesicsMorphine sulfate Antibiotics
4. Assist in CTT to H20 sealed drainage