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OXYGENATIONRESPIRATORY
SYSTEM
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TERMINOLOGIESVENTILATION MOVEMENT OF AIR IN & OUT OF THE
LUNGS
RESPIRATION EXCHANGE OF GASES : EXTERNAL &INTERNAL
EXTERNAL BET. ALVEOLI & PULMONARY CAPILLARIES
INTERNALBET. SYSTEMIC CAPILLARIES
PERFUSION AVAILABILITY & MOVEMENT OFCAPILLARY BLOOD FOR EXCHANGE OF GASES
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CASE STUDY At the emergency room, patient Anna, 39
y.o,came, in respiratory distress, shouting forhelp, because of massive hemoptysis that
she is presently experiencing
Vital signs are:
RR = 30,
HR= 105,
BP=130/80,
T= 36 C
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CASE STUDY Her skin is cold and clammy
You provided oxygen via nasal prong
What other nursing actions would you
do?
What nursing history would you extract?
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CASE STUDY You learned that patient has been experiencing
night sweats, easy fatiguability for about 1
month.
There was on & off cough and fever, and
patient self-medicated with low dose
Amoxycillin
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CASE STUDY With the above history, in which ward is
your patient be admitted?
What are the possible diagnostics herphysician would order?
What are your proposed nursing plan forthe patient?
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REVIEW OF ANATOMYDivisions of the RespiratorySystem
Air Conducting System -
nose . terminal bronchioles
Gas-exchanging lung units
respiratory bronchioles alveolar ducts
alveolar sacs alveoli
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REVIEW OF ANATOMYOrgans of the RespiratorySystem
Each lung has 3 primary components:
Air passages
Blood vessels pulmonary artery (majorsupply), bronchial arteries
Elastic connective tissue
PLEURA Parietal and Visceral
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REVIEW OF PHYSIOLOGY Functions of the Respiratory System
Parameters in the process of breathing
Atmospheric O2 is 21%, normal atmosphericpressure 760 mmHg
Adequate ventilation or perfusion of the
alveoli Inspiration
Expiration
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REVIEW OF PHYSIOLOGY Parameters in the process of breathing
Permeable alveoli-capillary membrane
Adequate pulmonary and systemic circulationSystemic
circulation
Pulmonary
Circulation
Decrease pO2 Vasodilatation vasoconstriction
Mechanism More time for
gas exchange
Shunting of
blood to better
ventilated
arteries
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REVIEW OF PHYSIOLOGY Parameters in the process of breathing
Ability of the blood to transportO2 and CO2 between the
lungs and the tissues Ability of the cells to utilize O2 and eliminate CO2
Neural Control of Respiration
1. Medullary Rhythmicity Area
2. Apneustic Area prolong and deepen respiration3. Pneumotaxic Area inhibit inspiration
Pulmonary Volumes and Capacity
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NURSING PATIENTS WITH THREATSTO VENTILATIONNursing History
Cough
Secretions sputum, phlegm
Dyspnea activity, time of the day, duration,
posture, onset & precipitating factor
Chest pain
Cyanosis
Voice quality
Stridor
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NURSING PATIENTS WITH THREATSTO VENTILATIONNursing History
CYANOSIS TYPES
1. Peripheral extremities, nailbeds
2. Central lips, tongue, face and mucous
membrane
3. Differential
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NURSING PATIENTS WITH THREATSTO VENTILATIONNursing History
CYANOSIS
Factors that alter the presence of Cyanosis
1. Pigmentation and thickness2. Type of light used during assessment
natural light is desirable
3. Absolute amount of reduced hemoglobin4. Observers perception
1. Activity
2. Duration 3. Distribution
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NURSING PATIENTS WITH THREATSTO VENTILATIONPhysical Assessment
Inspection deformities, rate and rhythm of
breathing
Palpation - fremitus Percussion - resonance
Auscultation
Normal breath sounds
1. Vesicular most of the lung
2. Bronchovesicular mainstem bronchi
3. Bronchial/Tubular - trachea
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NURSING PATIENTS WITH THREATSTO VENTILATIONPhysical Assessment
Abnormal Breath Sounds
1. Rales moisture in the tracheobronchial tree;heard on inspiration
2. Wheeze continuous, musical sound heard
with movement of air through narrowed
passage; heard on expiration
3. Friction Rubs grating sound from inflammed
pleura
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NURSING PATIENTS WITH THREATSTO VENTILATIONDiagnostic AssessmentRADIOGRAPHIC
1. Chest Xray2. Tomography
3. Fluoroscopy
4. Pulmonary Angiography pulmonary embolism
EVALUATION
5. Bronchography size,shape and number of
bronchi
6. Pulmonary
Scintiphotography
7. Sinus Xray
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NURSING PATIENTS WITH THREATSTO VENTILATIONDiagnostic Assessment
EXAMINATION BY DIRECT
1. Rhinoscopy
2. Laryngoscopy indirect,
direct
3. Bronchoscopy
4. Bronchofiberoscopy
VISUALIZATION
5. Mediastinoscopy
6. Transillumination
7. Lung Biopsy
transtracheobronchial,
transthoracic8. Pleural Biopsy
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NURSING PATIENTS WITH THREATSTO VENTILATIONDiagnostic Assessment
LABORATORY STUDIES
1. Hematologic
2. Cytological sputum, tracheobronchial
secretions, pleural fluid
3. Bacteriological studies
1. sputum studies : C & S, cytology
2. thoracentesis
3. skin test for TB
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NURSING PATIENTS WITH THREATSTO VENTILATIONDiagnostic Assessment
THORACENTESIS
Site :
Air : 2nd
/3rd
ICS, MCL Fluid : 7th/8th ICS,
PAL
Position :
over a bed table
straddling in achair,
seated in bedwith affectedhand raisedover the head
NursingManagement
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NURSING PATIENTS WITH THREATSTO VENTILATIONDiagnostic Assessment
SKIN TEST FOR P.T.B.
1. Mantoux test
2. PPD
3. Multiple Puncture Test
4. Von Pirquet Scratch Test
5. Volmer Patch Test
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NURSING PATIENTS WITH THREATSTO VENTILATIONASSESSMENT OF PULMONARY
FUNCTION
1. SPIROMETRY2. ARTERIAL BLOOD GAS
1. Ph
2. pCO23. pO2
4. H2CO3
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NURSING PATIENTS WITH THREATSTO VENTILATIONSPIROMETRY
PULMONARY FUNCTION TEST
LUNG CAPACITIES Vital Capacity
Normal Lung Capacity
Total Lung Capacity
Inspiratory Capacity
Functional Residual Capacity
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NURSING PATIENTS WITH THREATSTO VENTILATIONPULMONARY FUNCTION TEST
LUNG VOLUMES
Tidal Volume
Inspiratory Reserve Volume
Expiratory Reserve Volume
Residual Volume Minute Volume
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
1. Planning for Health Promotion
2. Planning for Health Restoration and
Maintenance1. Maintaining Patent Airway
1. Coughing techniques
2. Suctioning2. Reducing Metabolic Demands
3. Preventing and Controlling Infection
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
4. Oxygen Therapy
5. Incentive Spirometry
6. Aerosol Therapy7. IPPB (Intermittent Positive Pressure Breathing)
8. Artificial Airway
9. Mechanical Ventilation10.Chest Surgery
11.Chest Drainage
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
OXYGEN THERAPY
Hypoxemia
Hypoxia Types : Hypoxic hypoxia
Anemic hypoxia
Ischemic hypoxia
Histotoxic hypoxia
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
OXYGEN THERAPY
Assessment for need for oxygen
Planning for oxygen therapy Promoting psychological and physical comfort
Promoting safety
Maintaining Adequate Oxygen Supply : Low flow system nasal cannula, face mask
High Flow system non-rebreathing mask, Venturrimask
Other ways: tracheostomy, portable oxygen, special
room, hyperbaric oxygen
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
AEROSOL THERAPY
1. Distilled water and NSS
2. Detergents
3. Mucolytics
4. Others : bronchodilators, steroids
Devices used to generate aerosols :
1. Nebulizer
2. Humidifier
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
ARTIFICIAL AIRWAY
Types:
1. Oropharyngeal Airway2. Endotracheal : orotracheal, nasotracheal
3. Tracheostomy : 3 main principles of care:
1. Maintain patent airway ( signs of occlusion)
2. Prevent Infection
3. Prevent drying and crusting of the mucosa
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
MECHANICAL VENTILATION THERAPY
TYPES:
1. Pressure Cycled2. Volume Cycled
ACCESSORY ATTACHMENTS
1. Intermittent Mandatory Ventilation2. Continuous Positive Airway Pressure
3. Positive End Expiratory Pressure
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
CHEST SURGERY
CHEST DRAINAGE
Principle of negative pressure (NP)
Vacuum is needed to reestablish NP
Closed water-sealed drainage
Types: 1- bottle, 2-bottle, 3-bottle Purpose: remove air and fluid, lung
reexpansion
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
CHEST DRAINAGE
Nursing Resposibilities
1-BOTTLE operates by gravity only, fluctuation/oscillation stops : lung has
reexpanded, or tube is kinked
intermittent bubbling normal with expiration
Continuous bubbling air leak Rapid bubbling consid loss of air
Chest Xray - reexpansion
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
CHEST DRAINAGE
Nursing Responsibilities
2 OR 3 BOTTLE SYSTEM Suction necessary
Periodic emptying of fluid/ bubbling in the
control tube indic proper fxning No Fluctuation with expiration in water-
sealed bottle
Continuous bubbling air leak
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NURSING PATIENTS WITH THREATSTO VENTILATIONPlanning
CHEST DRAINAGE
REMOVAL OF CATHETER
1. Premedication
2. During expiration or end of inspiration
3. Wound covered with skin
clips/PETROLEUM GAUZE
PLEUREVAC
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COMMON REPIRATORYPROBLEMS - NOSENOSE
Epistaxis
causes : picking of the nose, DHF, HPN,
cancer, sinusitis, deviated/perforated septum
mgt: elevate, promote vasoconstriction, external
control. Ice collar, drugs - neosynephrine
Nasal Polyp - overgrowth of mucous membranecauses : allergy, chronic sinusitis
Deviated Septum
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COMMON REPIRATORYPROBLEMS - SINUSES,THROAT
SINUSES
Sinusitis
causes
s/sx : pain, nasal congestion,general malaise,fever
treatment : bed rest, medications,
surgery : Caldwell-Luc operation
THROAT Tonsilitis
S/Sx
Mgt
Surgery : Tonsillectomy
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TONSILLECTOMYNursing Care
PRE-OP: no fever,evaluate hemostasis,ATROPINESULFATE
POST-OP1. Patient may have postnasal pack
2. HOB 45 degreeslocal; prone with head to 1 side
general
3. Temp axilla, rectal4. Avoid clearing of throat or cough bleeding
5. Aspirin, narcotics, ice collar
6. Vomiting small amnt of blood
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TONSILLECTOMY7. Blood trickling down the throat/ FREQUENT
SWALLOWING Hemorrhage
8. If conscious, no acidic drinks (burning sensation),give ice chips and cold liquids
9. NO STRAW sucking can cause bleeding
10.Alkaline mouthwash
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COMMON REPIRATORYPROBLEMS - LARYNXLARYNX
Laryngitis
Cancer of the Larynx Predisposing factor : heavy smoking and
drinking, family hx, chronic laryngitis, vocal
abuse
S/Sx persistent hoarseness -1ST AND EARLY,cough,enlarged cervical LN, pain in the Adams
apple that radiates to the ear
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COMMON REPIRATORYPROBLEMS - LARYNX Cancer of the Larynx
Diagnostics : Laryngoscopy, biopsy
Mgt : Early : LaryngofissureAdvanced : Laryngectomy, Radiation
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TOTAL LARYNGECTOMYNURSING CARE PreOp- Assist the physician in telling the patient:1. He will loose the following :
1. voice,
2. normal means of breathing,
3. sense of smell, blowing of nose,4. blowing of air from mouth,
5. sip soup,sucka straw,
6. gargle,
7. whistle
8. lift heavy object2. Breath through a permanent tracheostomy
3. Know other methods of speech
4. Visit a speech therapist
5. Tube feedings after surgery,temporary
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TOTAL LARYNGECTOMYNURSING CARE Post Op1. Constant attendance; no IV for the dominant arm
2. Avoid:1. raising tone of voices
2. completing sentences verbally that the patient started towrite
3. talking nervously and excessively
3. Elevate HOB to:
1. promote drainage2. facilitate respiration
3. prevent strain on suture line
4. minimize edema
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TOTAL LARYNGECTOMY4. Avoid dusts or fumes , tracheostomy stoma has no
mechanism for filtering and cooling air neck bib
5. Observe post-op complications:1. Fistula formation
2. carotid artery rupture3. Stenosis of tracheostomy
4. Atelectasis and pneumonia
5. Shock
6. Hemorrhage
6. IV,tube feeding, analgesic, antibiotic
7. Care of Gomco or Hemovac drainage catheter:remove fluid from potetial deadspace (space for larynx)
8. If catheter not used, ressure dressin .
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TOTAL LARYNGECTOMY9. Minimal postop pain; narcotics contraindicated
in Head & neck surgery
10.Self care teachings:
1. NGT, instruct self-feeding.2. Instruct removing and replacing laryngostomy
tube : breath in, hold, insert and resume normal
resp.
3. Caution when shaving : it takes 6 months for cut
nerve endings to regenerate
Laryngostomy tube stays for 3-8 wks until stoma becomes
permamnently formed
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TOTAL LARYNGECTOMY11.Rehabilitation : aeg wear ID stating he has no
vocal cord
12. Not smoke
13. Speech Rehab- A.S.A. mucous membrane
and muscles are completely healed
14. Artificial Respiration :
mouth to neck stoma breathing
O2 administration to tracheostomy
patients head should not be turned- may obstruct
trach
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CONDITIONS AFFECTINGTHE CHEST2 CLASSIFICATIONS :
1. OBSTRUCTION in the pathways of normalalveolar ventilation by:
1. spasm2. mucus secretions
3. morphologic changes
2. RESTRICTION in the movement of thorax orlungs associated with :
1. Pathologic factors
2. Neurologic factors
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All Im asking for is a beautiful hair cut
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CHRONIC OBSTRUCTIVEPULMONARY DISEASE (COPD)1. EMPHYSEMA
2. BRONCHIAL ASTHMA
3. BRONCHIECTASIS
4. CHRONIC BRONCHITIS
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C.O.P.D. - EMPHYSEMAStretching and overdistention of the alveoli
Loss of intralveolar septa, pulmonary elasticity
and alveolar capillary surface
Loss of pulmonary compliance + partial obstruction
No effective inhalation
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C.O.P.D. - EMPHYSEMAPredisposing Factors :
1. Cigarette smoking
2. Pollution
3. Chronic long term infection
S/Sx1. Cough
2. Weakness
3. Lethargy
4. Barrel chest5. Bronchospasms
6. Asthma
7. Forced expirations
C O P D -
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C.O.P.D. - BRONCHIALASTHMA Viral respiratory Infection/ allergens Bronchial spasm and bronchial constriction
STATUS ASTHMATICUS
S/Sx :
dyspnea,
cough,
wheezing
prolonged expiration
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These lungs appear essentially normal, but arenormal-appearing because they are the hyperinflated
lungs of a patient who died with status asthmaticus.
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This cast of the bronchial tree is formed of inspissated
mucus and was coughed up by a patient during anasthmatic attack. The outpouring of mucus from
hypertrophied bronchial submucosal glands, the
bronchoconstriction, and dehydration all contribute to the
formation of mucus plugs that can block airways in
asthmatic patients.
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C.O.P.D. - BRONCHIECTASIS Dilation of medium-sized bronchi Loss of bronchial elasticity
Excessive mucus
Chronic productive cough
S/Sx :
Abundant sputum maybe blood-tinged ( trauma
to bronchial walls)
C O P D
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C.O.P.D.CHRONIC BRONCHITIS Inflammation of bronchioles
Causes : infection, respiratory irritants
S/Sx : cough
Excessive mucus production and retention
Dyspnea Hyperinflated chest
Concurrent emphysema
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COPD - MANAGEMENT
IMPROVINGVENTILATION
Oxygen,
IPPB,
nebulization,
suctioning secretions
Medications:
bronchodilators, steroids
STRENGTHENING
RESPIRATORY
MUSCLES
Breathing exercises
OTHER CONCERNS : hydration,
prevention or treatment
of infection(antibiotics)
cough medications,
nutrition,
providing emotional and
physical rest
Incentive spirometry
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RESTRICTIVE DISEASESCLASSIFICATION : NEUROMUSCULAR
THORACIC DEFORMITY
RESTRICTION TO LUNG OR ALVEOLAREXPANSION
INFILTRATIVE DISEASE
OBESITY LOSS OF FUNCTIONING PULMONARY TISSUE
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RESTRICTIVE DISEASENEUROMUSCULAR DISORDERS
1. MYASTHENIA GRAVIS Generalized muscular weakness
There is difficulty in swallowing aspiration
Respiratory muscle paralysis with dse progression
Tracheostomy and mech ventilator
2. BULBAR POLIOMYELITIS
Viral infection 9th 12th CN paralysis of laryngeal musclestrach
SPINAL TYPEparalysis of respiratory muscles
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RESTRICTIVEDISEASESNEUROMUSCULAR DISORDERS3. GUILLAIN BARRE SYNDROME
Acute infectious polyneuritis
Headache, aching limbs, gend bodymalaise, fever
Progression:
numbness and tingling of digits
muscular weakness and paralysis
RESTRICTIVE DISEASES
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RESTRICTIVE DISEASES
THORACIC DEFORMITY
1. KYPHOSCOLIOSIS
Abnormal convex curvature of the spine
2. PECTUS EXCAVATUM
funnel chest
Concave deformity resulting from
depression of the sternum
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RESTRICTIONTO LUNG and/or ALVEOLAREXPANSIONDISEASES OF THE PLEURA
1. PNEUMOTHORAX Spontaneous: primary, secondary
Traumatic Causes : unknown, pulmonary lesion, iatrogenic
Dyspnea, cough, chest pain, decreased chestmovements, mediastinal shift to affected side
2. HYDROTHORAX Serous fluid; lymphatic obstruction
3. HEMOTHORAX traumatic
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RESTRICTIONTO LUNG and/or ALVEOLAREXPANSION
4. PLEURISY
Inflammation of the pleura with changes in its
serous secretion
Types :
Pleural effusion
Empyema
Fibrinous
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PLEURISY
PLEURAL EFFUSION
Sero-fibrinous fluidDyspnea, limited movement of chest
Mediastinal shift away from affected side
TB, Pneumonia, malignancy, cardiacfailure
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PLEURISY
EMPYEMA
Purulent exudate From preexisting infections in the lung,ribs or
subphrenic space
Lung collapse of affected sideDull pain and persistent tenderness
limited chest movements
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The pleural surface at the lower
left demonstrates areas of yellow-
tan purulent exudate. Pneumonia
may be complicated by a pleuritis.Initially, there may just be an
effusion into the pleural space.
There may also be a fibrinous
pleuritis. However, bacterial
infections of lung can spread to the
pleura to produce a purulent
pleuritis. A collection of pus in the
pleural space is known as
empyema.
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PLEURISYFIBRINOUS / DRY PLEURISY
Lack of lubricating serous secretion
Fibrinous exudates causes frictionrubs
Pain
rapid shallow respiration
Restricted ventilatory efficiency
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PLEURISYFIBRINOUS / DRY PLEURISY
MANAGEMENTThoracentesis
Chest Tube
Pleurodesis
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RESTRICTIVE DISEASES
INFILTRATIVE DISEASES
Pulmonary Tuberculosis
Bronchogenic Carcinoma OBESITY
Pickwickian Syndrome extreme obesity
Ascites -
RESTRICTION DUE TO
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LOSS OF FUNCTIONING
PULMONARY TISSUE
CHANGE IN ALVEOLAR CAPILLARY SURFACES
DECREASED SURFACES FOR BLD GASES &DECREASED PRODUCTION OF SURFACTANT
ALVEOLAR COLLAPSE
ATELECTASIS
RESTRICTION DUE TO
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LOSS OF FUNCTIONINGPULMONARY TISSUE
1. PULMONARY INFARCTION
2. LUNG ABSCESS
3. BRONCHOGENIC CARCINOMA4. PULMONARY FIBROSIS
5. PNEUMOCONIOSES
6. PNEUMONIA
7. PULMONARY TUBERCULOSIS
8. PULMONARY EDEMA
PULMONARY INFARCTION
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PULMONARY INFARCTION
Loss of pulmonary tissue from occlusion ofpulmonary artery by an embolus
Long bone fracture; obstetric patients
LUNG ABSCESS
Aspiration of foreign body Lung obstruction
Pneumonia
BRONCHOGENIC CARCINOMA
Smoking, pollutants
Cough, wheeze, hemoptysis, dyspnea
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This is a rare finding that may complicate a term
pregnancy at delivery. Seen here in a pulmonary arterybranch is an amniotic fluid embolus that has layers of fetal
squames. Amniotic fluid embolization can have the same
outcome
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This is a squamous cell
carcinoma of the lung that is
arising centrally in the lung (asmost squamous cell
carcinomas do). It is
obstructing the right main
bronchus. The neoplasm isvery firm and has a pale white
to tan cut surface.
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PNEUMONIA
Acute pulmonary infection
Pneumococcus, Streptococcus, Haemophilus
Thi i l b i i
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This is a lobar pneumonia in
which consolidation of the
entire left upper lobe has
occurred. This pattern ismuch less common than the
bronchopneumonia pattern.
In part, this is due to the fact
that most lobar pneumoniasare due to Streptococcus
pneumoniae
(pneumococcus)
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PULMONARY FIBROSIS
Pathological increase in lung connective
tissue Diffuse / localized
Secondary to other pulmonary diseases
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Regardless of the etiology for restrictive lung diseases, many
eventually lead to extensive fibrosis. The gross appearance, asseen here in a patient with organizing diffuse alveolar damage, is
known as "honeycomb" lung because of the appearance of the
irregular air spaces between bands of dense fibrous connective
tissue.
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PNEUMOCONIOSES
Chronic, fibrotic
Inhalation of irritant dusts: Silica
Asbestos
Coal
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PULMONARY TUBERCULOSIS
Mycobacterium TB
Cough, hemoptysis, malaise, weight loss,low grade afternoon fever easy
fatigability, night sweats
Anti TB drugs, quadruple therapy
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Here is the gross appearance of
a lung with tuberculosis.
Scattered tan granulomas are
present, mostly in the upperlung fields. Some of the larger
granulomas have central
caseation. Granulomatous
disease of the lung grossly
appears as irregularly sizedrounded nodules that are firm
and tan. Larger nodules may
have central necrosis known as
caseation--a process of
necrosis that includes elements
of both liquefactive and
coagulative necrosis).
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On closer inspection, the
granulomas have areas of
caseous necrosis. This is very
extensive granulomatousdisease. This pattern of
multiple caseating granulomas
primarily in the upper lobes is
most characteristic of
secondary (reactivation)tuberculosis. However, fungal
granulomas (histoplasmosis,
cryptococcosis,
coccidioidomycosis) can mimic
this pattern as well.
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The Ghon complex is seen here at closer range. Primary
tuberculosis is the pattern seen with initial infection with
tuberculosis in children. Reactivation, or secondary
tuberculosis, is more typically seen in adults.
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PULMONARY EDEMA
Excessive amount of fluid in the alveoli
and pulmonary interstitial tissues Congestive Heart Failure, Chronic Renal
Failure
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MANAGEMENT RESTRICTIVE LUNG DISEASE Antibiotics
Oxygenation
Hemodynamic monitoring Diuresis /phlebotomy pulmonary edema
Ventilatory support
The nurse enters the room of a client who
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The nurse enters the room of a client who
has a chest tube attached to a water-seal
drainage system & noticed the chest tube is
dislodged from the chest. The most
appropriate nursing intervention is to:
a. Notify the physicianb. Insert a new chest tube
c. Cover the insertion site with petroleum gauze
d. Instruct client to breathe deeply until helparrives
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