Respiratory System Assessment & Disorders 26/10/2009 1.
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Transcript of Respiratory System Assessment & Disorders 26/10/2009 1.
Respiratory System
Assessment & Disorders
26/10/2009 1
Upper Respiratory System
Noses and Sinuses
NoseBegin respiratory system
Filter and warm air
SinusesOpenings in facial bones
Lighten skull
Assist in speech
Produce mucus
Pharynx and Larynx
PharynxNasopharynx
Oropharynx
Laryngopharynx
LarynxConnects laryngopharynx to trachea
Routes air and food to proper passageway
Lower Respiratory system
Lungs
Separated by mediastinum
Composed of elastic connective tissue
Divided into lobes which are further divided into segments
Bronchi and Alveoli
Trachea divides into right and left mainstem bronchi
Bronchi continue to branch and get smaller (bronchioles) and end as alveoli
Air moves through passageways to alveoli where gas exchange occurs
Bronchioles and Alveoli
Pulmonary Circulation
Pulmonary arteries
Pulmonary veins
Pulmonary capillary network
Pleura
Double-layered membrane that covers lungs
Parietal
Visceral
Hold lungs out to chest wall
Rib Cage and Intercostal Muscles
Protect lungs
12 pairs ribs
Intercostal muscles are between ribsAssist with process of breathing
Ventilation
Divided into inspiration and expiration
Normal is 12–20 breaths per minute
Inspiration
Lasts 1–1.5 seconds
Diaphragm contracts and flattens
Intercostal muscles contractIncreases size of chest cavity
Lungs stretch and volume increases
Pressure in lungs slightly less than atmospheric
Causes air to rush in
Expiration
Lasts 2 to 3 seconds
Passive
Muscles relax
Diaphragm rises
Ribs descend
Lungs recoil
Pressure in chest cavity increases (compressing alveoli)
Pressure in lungs higher than atmospheric causes gases to flow out of the lungs
Factors Affecting Respiration
Respiratory center of the brain
Chemoreceptors in the brain, aortic arch, and carotid arteries
Airway resistance
Compliance
Elasticity
Surface tension of alveoli
Respiratory Changes Associated with Aging
Cartilage that connects ribs to sternum and spinal cord calcifies
Anterior-posterior diameter of chest increases
Respiratory muscles weaker
Cough and laryngeal reflexes less effective
Respiratory Changes Associated with Aging
Size of lungs decreases
Alveoli less elastic
Older client at greater risk for developing respiratory infections
Assessment
SubjectiveCurrent complaint or existing condition
Onset or duration of symptoms
Ability to maintain ADL
Nasal congestion, nosebleeds
Sore throat, difficulty swallowing
Changes in voice quality
Difficulty breathing, orthopnea
Pain on breathing
Assessment (continued)
SubjectivePresence of cough frequency, duration, productive or unproductive
Sputum amount, color, and consistency
Exposure to infections (colds or influenza)
History of chronic lung conditions
Occupational exposure to chemicals, smoke, asbestos
Assessment (continued)
SubjectiveHistory of previous respiratory problems
Allergies to medication or environmental allergens
Use of tobacco, chewing tobacco, marijuana, cocaine, injected drugs, and alcohol
Assessment (continued)
ObjectiveAssess state of health
Color
Ease of breathing
Note respiratory rate and pattern
Observe nasal flaring
Use of accessory muscles for breathing
Listen for hoarseness in client’s speech
Assessment (continued)
ObjectiveInspect mucosa of nose, mouth, and oropharynx
Inspect neck, position of trachea
Inspect anterior/posterior diameter of chest
Palpate lips for nodules, chest for tenderness or swelling
Assessment (continued)
ObjectiveAuscultate breath sounds, note absence or presence and quality
Note adventitious breath sounds (wheezing or crackles)
Pulse Oximetry
Monitors oxygen saturation (SpO2)
Amount of arterial hemoglobin that is combined with oxygen
Nursing CareApply to fingertip, forehead, earlobe, or nose
Remove nail polish when using fingertip
Arterial Blood Gases
Nursing careApply pressure to site 2–5 minutes following arterial puncture
Serum Alpha1-Antitrypsin
Deficiency in this serum protein contributing factor in emphysema and COPD
Normal value in adults 150–350 mg/dL
Fasting specimen obtained in client with elevated cholesterol or triglycerides
Sputum and Tissue
Throat or nose swab
Sputum specimen
Culture and sensitivity
Gram’s stain
Acid-fast stain
Cytology
Imaging Techniques
X-rays
CT scans
Ventilation perfusion scans
Nursing care and client teaching
If contrast used remember to ask about allergies, especially iodine and seafood
Pulmonary Function Tests
Measure lung volume and capacity
Smoking, caffeine, and bronchodilators interfere with results
Nursing care and client teachingInstruct client to stop bronchodilators 4–6 hours prior to test
Instruct client not to smoke or drink caffeinated drinks prior to test
Lung Volumes and Capacities
Direct Visualization
Direct or indirect laryngoscopyUsed to identify and evaluate laryngeal tumors
Nursing care and client teachingMake sure consent form has been signed
Remove dentures, partial plates, bridges prior to procedure
NPO before procedure
NPO after procedure until gag reflex returns
Bronchoscopy
Visualize trachea, bronchi and bronchioles
Tumors and structural disorders
Obtain tissue biopsy
Obtain sputum specimen
Removal of foreign body
Nursing care and teaching
25/10/2010 34
Asthma and COPD
Dr Ibrahim Bashayreh, RN, PhD.
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Asthma
Asthma is a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways
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Asthma
Asthma is a chronic (long-term) disease that makes it hard to breathe. Asthma can't be cured, but it can be managed. With proper treatment, people with asthma can lead normal, active lives.
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Etiology
Cause of asthma is unknown but many factors play a part:
Genetic factors: Asthma tends to run in the family
Environmental factors: pollen, dust, mold, tobacco smoke
Occupational exposure: chemicals and gases
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Normal bronchiole/ Asthmatic bronchiole
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How asthma works
If you have asthma, your airways (breathing passages) are extra sensitive. When you are around certain things, your extra-sensitive airways can:
Become red and swollen - your airways get inflamed inside. They fill up with mucus. The swelling and mucus make your airways narrower, so it's harder for the air to pass through.
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Cont.
Become "twitchy" and go into spasm - the muscles around your airways squeeze together and tighten. This makes your airways narrower, leaving less room for the air to pass through.The more red and swollen your airways are, the more twitchy they become.
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Symptoms
Hard breathing caused by irritants
Asthma inducers: If you breathe in something you're allergic to- for example, dust or pollen- or if you have a viral infection- for example, a cold or the flu- your airways can become inflamed (red and swollen).
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Cont.
Asthma triggers: If you breathe in an asthma trigger like cold air or smoke, or if you exercise, the muscles around your airways can go into spasm and squeeze together tightly. This leaves less room for air to pass through.
It's important for every person with asthma to know what they triggers and inducers are.
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What are the Triggering Factors?
Domestic dust mites
Air pollution
Tobacco smoke
Occupational irritants
Animal with fur
Pollen
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Triggering Factors ( cont.)
Respiratory (viral) infections
Chemical irritants
Strong emotional expressions
Drugs ( aspirin, beta blockers)
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Asthma: Early Clinical Manifestations
Expiratory & inspiratory wheezing
Dry or moist non-productive cough
Chest tightness
Dyspnea
Anxious &Agitated
Prolonged expiratory phase
Increased respiratory & heart rate
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Asthma: Early Clinical Manifestations
Wheezing
Chest tightness
Dyspnea
Cough
Prolonged expiratory phase [1:3 or 1:4]
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Asthma: Severe Clinical Manifestations
HypoxiaConfusionIncreased heart rate & blood pressure Respiratory rate up to 40/minute & pursed lip breathingUse of accessory musclesDiaphoresis & pallor Cyanotic nail beds Flaring nostrils
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Classification
At risk- breathing test normal, mild symptoms
Mild- breathing test shows mild limitation, increasing symptoms
Moderate- person will typically seek care for symptoms, shortness of breath with significant exertion, lung tests abnormal
Severe- shortness of breath with limited activity, lung tests abnormal
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Asthma: Diagnostic Tests
Pulmonary Function Tests FEV1 decreased
Increase of 12% - 15% after bronchodilator indicative of asthma
PEFR decreased
Symptomatic patient eosinophils > 5% of total WBC
Increased serum IgE
Chest x-ray shows hyperinflation
ABGs Early: respiratory alkalosis, PaO2 normal or near-normal
severe: respiratory acidosis, increased PaCO2,
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Asthma: Nursing Diagnoses
Ineffective airway clearance r/t bronchospasm, ineffective cough, excessive mucus
Anxiety r/t difficulty breathing, fear of suffocation
Ineffective therapeutic regimen management r/t lack of information about asthma
Knowledge deficit
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Medical Management of Asthmatic Patient
Limit exposure triggering agents
Medications such as: inhaled corticosteroids, inhaled beta2 adrenergic agonist, and cromolyn sodium
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Asthma Medications: Anti-inflammatory
Corticosteroids Not useful for acute attack Beclomethasone: vanceril, beclovent, qvar
Cromolyn & nedocromil Inhibits immediate response from exercise and allergens
Prevents late-phase response Useful for premedication for exercise, seasonal asthma Intal, Tilade
Leukotriene modifiers Interfere with synthesis or block action of leukotrienes
Have both bronchodilation and anti-inflammatory propertiesNot recommended for acute asthma attacks Should not be used as only therapy for persistent asthma Accolate, Singulair, Zyflo
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Asthma Medications: Bronchodilators
2-adrenergic agonistsRapid onset: quick relief of bronchoconstriction
Treatment of choice for acute attacks If used too much causes tremors, anxiety, tachycardia, palpitations, nausea Too-frequent use indicates poor control of asthma Short-acting
Albuterol[proventil]; metaproterenol [alupent]; bitolterol [tornalate]; pirbuterol [maxair]
Long-acting
Useful for nocturnal asthma
Not useful for quick relief during an acute attack Salmeterol [serevent]
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Asthma Medications: Bronchodilators con’t
Methylxanthines Less effective than beta-adrenergics
Useful to alleviate bronchoconstriction of early and late phase, nocturnal asthma Does not relieve hyperresponsiveness Side effects: nausea, headache, insomnia, tachycardia, arrhythmias, seizures Theophylline, aminophylline
Anticholinergics Inhibit parasympathetic effects on respiratory system
Increased mucus
Smooth muscle contraction Useful for pts w/adverse reactions to beta-adrenergics or in combination w/beta-adrenergics
Ipratropium [atrovent]
Ipratropium + albuterol [Combivent]
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Management of Asthmatic Patient
Identify and assess statusAvoid precipitating factorsBring inhaler for each appointmentDrug considerations: Avoid ASA, NSAIDs, barbiturates, and narcoticsDrug interactions with asthmatic medications (ex. Theophylline vs. Antibiotics, Cimetidine)Chronic corticosteroid users may require steroid supplementationFor sedation, nitrous oxide/oxygen and/or small doses of oral diazepam is recommended
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Asthma: Client Teaching
Correct use of medications
Signs & symptoms of an attackDyspnea, anxiety, tight chest, wheezing, cough
Relaxation techniques
When to call for help, seek treatment
Environmental control
Cough & postural drainage techniques
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COPD
Chronic obstructive pulmonary disease is a slowly progressive disease that is characterized by a gradual loss of lung function
COPD includes chronic bronchitis, chronic obstructive bronchitis, or emphysema, or combinations of these conditions
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Epidemiology
20.3 million Americans report having asthma
5,000 deaths annually from asthma
12.1 million Americans reported being diagnosed with COPD
119,000 deaths annually from COPD
COPD is the 4th leading cause of death in the U.S.
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Chronic Bronchitis
Inflammation of the main airway passages (bronchi) to the lungs, which results in the production of excess mucous, a reduction in the amount of airflow in and out of the lungs, and shortness of breath
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Emphysema
A respiratory disease characterized by breathlessness brought on by the enlargement, or over-inflation of, the air sacs (alveoli) in the lungs
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Signs and symptoms
Wheezing
Coughing
Sputum production
Shortness of breath
Chest tightness
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Diagnosis
Clinical symptoms
Chest x-ray
Lung function tests
ABGs
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Nursing diagnosisIneffective airway clearance r/t secretionsImpaired gas exchange r/t altered supply O2Altered health maintenance r/t ineffective individual copingRisk for infection r/t inadequate defense systemKnowledge deficit of COPDAltered role performance r/t changes in role
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Nursing DX
Ineffective breathing pattern r/t musculoskeletal impairment , decreased energyInability to sustain spontaneous ventilation r/t muscle fatigueActivity intolerance r/t imbalance of O2 supply
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Clinical Features of COPD Patients
Mild COPD: no abnormal signs, smokers cough, little or no breathlessness
Moderate COPD: breathlessness with/without wheezing, cough with/without sputum
Severe COPD: breathlessness on any exertion/at rest, wheeze and cough prominent, lung inflation usual, cyanosis, peripheral edema, and polycythemia in advanced disease
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Diagnosis
SpirometryBreathing test which measures the amount and rate at which air can pass through the airways
Bronchodilator Reversibility TestingRelaxing tightened muscles around the airways and opening up airways quickly to ease breathing
Other pulmonary function testingDiffusion capacity
Chest X-ray
Arterial Blood GasShows oxygen level in blood
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Medical Management of COPD Patient
Smoking cessation and elimination of environmental pollutants
Palliative measure such as regular exercise, good nutrition, flu and pneumonia vaccines
Bronchodilators, corticosteroids, anticholinergics, and NSAIDs
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Management of COPD Patient
Review history for concurrent heart disease
Avoid treatment if upper respiratory tract infection is present
Treat in upright position
Avoid rubber dam in severe cases
Use pulse oximetry (if pulse ox <91%, use low flow 2-3L/min)
Avoid Nitrous oxide/oxygen in severe cases
Avoid barbiturates, narcotics, antihistamines, and anticholinergics
If patient is on steroid regimen, supplement as needed
Drug interactions with COPD medication
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