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Respiratory Disorders

 James R. Tekiko R.N.,M.A.N.

Bronchoscopy – direct examination of trachea, bronchi and larynx

Purposes:  Inspect parts of respiratory tract

b. Aspirate secretions and exudates n air passage c. Remove foreign body d. Do biopsy  MAJOR FUNCTION: Gas Exchange • During gas exchange, air is taken into the body by inhalation and travels through respiratory passages to the lungs. In the lungs, O2 diffuses into the blood and CO2 is removed by exhalation Sense of smell, speech, acid base balance, body water levels and maintains heat balance Thoracentesis – Aspiration of fluid and air from pleural cavity; site of insertion: for fluid – 7th to 8th intercostal space mid-axillary; for air – 2nd or 3rd intercostal space midclavicular prep: consent, no moving, no coughing, proper positioning, remoe not more than 1500cc within 30 mins (to prevent intravascular shift) post: turned to unaffected side – seal itself; to prevent seepage Pulmonary Function Test – non-invasive method of assessing the functional capacity of the lungs; ability of gas to diffuse across the alveoli capillary membrane and ratio of ventilated alveoli to perfused capillaries.  A. Pulse oximetry – noninvasive technique that measures the oxygen Prep – consent, topical anesthesia, NPO 6-8 hours, atropine sulfate, sedation Post – head of bed elevated, lateral position, , check gag reflex and hoarseness,

DIAGNOSTIC TESTS  Skin testing : mantoux test ( PPD)ID – read 48 -72 hrs, +10mm up indurration exp.to Myco T Chest X-ray Sputum examination- C &S AFB 3xAM Lung biopsy – needle biopsy, open lung, VATS Computed Tomography permits better visualization of layer or plane of lungs “slices”; done to check cavities, neoplasms, lung densities, stereoscopic – 3D D. Ultrasound or echogram – harmless, high frequency sound wave emitted and penetrates the thorax and bounces back to transducer to picture image

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saturation (SaO2) of arterial blood (uses pulse oximeter)  B. Spirometry – measures lung capacity, volumes and flow rates with the use of an instrument called spirometer.

pCO2 Normal HCO3

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pCO2 Normal HCO3

ABG PROFILE IN METABOLIC ACIDOSIS or ALKALOSIS ACIDOSIS Decreased pH Decreased HCO3 Decreased BE Normal pCO2 MET <7.4> <24> <0> 40 ALKALOSIS Increased pH Increased HCO3 Increased BE Normal pCO2

. Arterial Blood Gases – provides objective determination of arterial blood oxygenation, gas exchange, alveolar ventilation and acid-base balance; use heparinized 2ml syringe.

Signs and Symptoms of AcidBase Imbalances:
 Acidosis – increased CO – depression of CNS – decrease in mental capacity –delirium, coma or death Alkalosis – increased O2 – overexcitability or irritability of CNS – extreme nervousness, over excitability, tetany or convulsions

Sites: radial, brachial, femoral artery PaO2 – measures O2 dissolved in blood – shows efficiency of gas exchange ventilation and perfusion PaCO2 – determines the adequacy of ventilation; depends upon the amount of O2 produced and ability of lungs to eliminate; shows effectiveness of ventilation pH – measurement of hydrogen ion concentration SaO2 – measures oxyhemoglobin saturation

Common Upper Respiratory Problems Epistaxis (nosebleeding)
– usually originates from the blood vessels in the anterior part of the septum Causes: 1. Trauma to nasal mucosa from foreign object 2. Picking of the nose 3. Local irritation of the mucous membrane from lack of humidity in the air (O2 cannula) 4. Violent sneezing or blowing of the nose

ACID BASE BALANCE
COMPARISON OF ARTERIAL or VENOUS BLOOD GASES pH pO2 pCO2 SaO2 HCO3 Base ex ARTERIAL 7.35-7.45 80-100 mmHg 35-45 96-98% 22-26 -2+2 VENOUS 7.31-7.41 35-49 mmHg 41-51 70-75% 23-25 -2+2

ABG PROFILE IN RESPIRATORY ACIDOSIS or ALKALOSIS ACIDOSIS Decreased pH Increased RESP 7.4 40 ALKALOSIS Increased pH Decreased

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Causes: 1. Viral – influenza, adenovirus, staphylococcus aureus 2. Bacterial – streptococcus pneumonia, haemophilus influenzae 3. Allergic – seasonal

Nursing Management: 1. Patient sits up leaning forward with head tipped downward 2. Compress soft tissues of nose against septum with fingers and maintain pressure for at least five minutes 3. Apply ice or cold compress to nose to constrict blood vessels 4. If bleeding does not stop with direct pressure, place cotton ball soaked in topical vasoconstrictor (neo-synephrine) into nose and apply pressure (dependent nursing function) 5. Instruct not to blow nose for several hours after nose bleed 6. Silver nitrate stick or electrocautery (dependent nursing function) 7. Post nasal pack (dependent nursing function)

Signs and Symptoms: 1. Fever and malaise 2. Stuffy nose 3. Slowly developing pressure over the involved sinus 4. Persistent cough 5. Post nasal drip 6. Headache

Sinusitis –URTI Allergic Rhinitis
    Rest increase fluid intake hot wet packs anti-infectives or antihistamines depending on the cause of sinusitis Nasal decongestantsDimetapp, Sudafed irrigation with warm NSS

SINUSITIS
 inflammation of air filled cavities that lines the mucous membranes of the sinuses

Cald-wel-luc surgery (radical antrum operation) – incision made under the

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upper lip to treat chronic maxillary sinusitis Priority Nursing Care: a. Proper oral hygiene done with caution to avoid injury to the incision b. Don’t chew on affected side c. No dentures for ten days d. No blowing of nose for two weeks e. No sneezing (if you must sneeze, keep mouth open)

1. Rest and increase fluid intake 2. Warm saline throat irrigation 3. Ice collar to relieve discomfort 4. Analgesic and antipyretics 5. Antibiotics 6. Surgery – tonsillectomy 7. Avoid carbonated and citrus juices- irritate the incision - Ice chips, small sips of cold fluid, popsicles (1st day) - Soft foods on 2nd day

TONSILITIS
 Inflammation of the tonsils

Tonsillectomy
Pre-op Care: a. Check for loose tooth Post-op Care: a. HOB to 45° elevated to reduce e b. Monitor for hemorrhage – frequent swallowing, bright red vomitus, rapid pulse, and restlessness c. Comfort – apply ice collar to neck; use acetaminophen in place of aspirin d. Food and fluids – no milk. Avoid carbonated and citrus juices- irritate the incision

Signs and Symptoms: 1. Sore throat 2. Pain on swallowing 3. Fever and chills 4. General muscle aching and malaise Nursing Management:

- Ice chips, small sips of cold fluid, popsicles (1st day) - Soft foods on 2nd day

Post Tonsillectomy
Patient teaching No clearing of throat

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No coughing, sneezing, vigorous nose bleeding and vigorous exercise for one to two weeks Drink fluids two to three liters a day Avoid hard and scratchy foods such as popcorn and pretzels Expect stools to be black or dark for a few days

Head of bed elevated 45o Assist patient in communicating – provide writing materials, etc  Post partial laryngectom y – patient will be able to talk Post total laryngectom y – no voice; artificial larynx now available

Laryngitis
 Inflammation and swelling of mucous membrane of larynx Cause: Infection, improper use of voice, smoking Manifestations:  

Hoarse voice, throat irritation, dry, non-productive cough Treatment: ATB Stop smoking Removal of cause

Practice swallowing

Chronic Obstructive Pulmonary Disease
 disease state characterized by airflow limitation that is progressive and associated with an abnormal inflammatory response of the lungs to noxious particle or gases ( smoking) that is not fully reversible Chronic Bronchitis Emphysema Risk Factors include environmental exposures and host factors Primary symptoms are cough, sputum production and dyspnea

CANCER OF THE LARYNX
Risk factors – Carcinogens – smoking, alcohol, cement/ wood dust,petrol/paint fumes Others – straining the voice, chronic laryngitis,60 and up, men, african american, family history S/S  Hoarseness for more than 2 weeks cough, Sore throat Lump on the throat. dysphagia Pain in the Adam's apple that radiates to the ear Dyspnea, enlarged cervical nodes and cough 

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COPD
Chronic bronchitis  Excessive mucous production and recurrent productive cough for at least 3 months in each of the two consecutive two years or more Causes:

TX – Radiation, Laryngectomy

Post Op Laryngectomy
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Smoking and pollutants Viral or bacterial infections

irritants, control of environmental temperature, proper nutrition, adequate hydration

EMPHYESEMA
• Destructive changes in alveolar walls and enlargement of air spaces distal to bronchioles; loss of recoil and air trapping Over distended and non functional alveoli leading to rupture retention of CO2 and hypoxia leading to respiratory acidosis

Normal VS Chronic Bronchitis

Predisposing factors: • • Smoking Alpha1 antitrypsin deficiency( enzyme inhibitor that protects the lung parenchyma from injury) – for Caucasians Familial tendency the stimulus to breathe is a low pO2 instead of an increased pCO2

S/S Chronic Bronchitis • • • • • • Chronic productive cough “cigarette cough” Grayish white sputum Dyspnea Cyanosis, tachycardia Respiratory acidosis Ankle edema, distended neck vein “Blue bloaters”

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Signs and symptoms: • • • • Uses accessory muscles to breathe Ruddy collor No cyanosis Thin with “barrel-chest”

Nursing management:   Pursed-lip breathing Forward – leaning position Low O2 concentration

Management of Chronic Bronchitis • Pharmacotherapeutics – mucolytic, expectorants, antitussives, antihistamines Supportive measures – avoid smoking, inhaled

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Fluid intake to 3L/day if not contraindicated (What condition?) O2 @ 2-3L/min Diet high in CHON, vitamin C, calories, nitrogen

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Nursing Management • Monitor VS and respiratory status. Administer low flow O2 (24-28%). Monitor pulse oximetry Monitor CV status to detect arrhythmias related to hypoxia Encourage to drink plenty of fluids if not contraindicated Instruct in diaphragmatic or abdominal and pursed lip breathing techniques Suction if necessary to clear airway of secretions Position in high fowlers position and leaning forward to aid in breathing • • • • • • Encourage small, frequent feedings to prevent dyspnea Encourage activity as tolerated to prevent fatigue Encourage to stop smoking Avoid exposure to persons with infections Avoid allergens and pollution Receive immunizations: influenza (flu shot)

• • Assessment: • • • Anatomic changes: barrel chest and clubbing Cor pulmonale (R sided HF) Cough (character, frequency, time of day) exertional dyspnea Wheezing and crackles Weight loss Sputum production (amount, color consistency) Use of accessory muscles for breathing Posturing (leaning forward) Prolonged expiration Pursed lip breathing •

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Diagnostic Exams: • • CXR- congestion and hyperinflation ABG- respiratory acidosis and hypoxemia

MEDICAL MANAGEMENT  Risk reduction- smoking cessation Bronchodilators Corticosteroids

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Treatment: • CPT, Postural drainage, IS

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Influenza and pneumococcal vaccination Oxygen therapy

Environmental factors – change in temperature or humidity Atmospheric pollutants – cigarettes, industrial smoke Strong odors – perfume, insecticides Allergens – feathers, dust, food, pollens, laundry detergents Exercise Stress or emotional upset Medications – aspirin, NSAIDs

Medications - Bronchodilators- Salbutamol and theophylline- Instruct on the use of both oral and inhalant medications - Steroids- to reduce inflammation Pred. - mast cell stabilizers (Cromolyn Na) - Mucolytics- to thin secretions Carbocysteine - Expectorants- Guaifenesin (Robitussin) - Antihistamine- Diphenhydramine - Antibiotics, SURGICAL MNGMT  Bullectomy- bullae are enlarged airspace occupy space in the thorax but do not help in ventilation (emphysema) Lung Volume Reduction Surgery- removal of diseased lung tissue allowing expansion of the normal cell Lung Transplantation -

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Asthma \patho

Signs and symptoms:   Episodic dyspnea Accessory muscle breathing Inspiratory or expiratory wheezing Respiratory alkalosis Status asthmaticus – respiratory acidosis

Asthma
 Bronchial spasms and constrictions characterized by expiratory wheezing Causes:     Genetic Immunologic  Allergic Environmental 

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Nursing management: Bronchodilators – epinephrine, theophylline, aminophylline, proventil, terbutaline

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Corticosteroids – solumedrol, dexamethanol

BRONCHIECTASIS
 Chronic, irreversible dilation of bronchi and bronchioles Pred. Fac – recurrent resp inf.,PTB Inflam process with pulm infect, damage the bronchial wall result thick sputum obstructing the bronchi S/S Chronic cough and purulent sputum production TX -Postural drainage promotes clearing of secretions. Antibiotics may be prescribed. Stop smoking

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Atelactasis Pneunonia - Refers to bacterial, viral, parasitic or fungal infection that causes inflammation of alveolar spaces & increase in alveolar fluid. Ventilations decreases as secretion thicken

Pneumonia
• The edema associated with inflammation stiffens the lungs, decreases lung compliance and vital capacity and causes hypoxemia

CYSTIC FIBROSIS
 Autosomal recessive disease CF gene Viscous secretions in lungs, intestine, reproductive tract, pancreas. . Increase salt in sweat. Airflow obstruction is key feature

Causes: Aspiration (NGT feedings) , chemical irritants, bacteria, virus CLASSIFICATION  Community Acquired Pneumonia (CAP)1st 48hr Hospital Acquired Pneumonia(HAP) after 48hr Lobar and Broncho

Medical Management:  antibiotics, bronchodilators, inhaled mucolytic agents

Nursing Management: chest physiotherapy, fluid and dietary intake, reduce risk for infection 

PNEUMONIA ASSESSMENT  Chills, fever SOB, tachypnea, accessory muscle use  sputum (rusty, green or bloody with pneumococcal pneumonia and yellow green with bronchopneumonia)

CHEST AND LOWER RESPIRATORY TRACT DISORDERS

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crackles, rhonchi, pleural friction rub on auscultation, cough, malaise

 restlessness (hypoxia) Diagnostic exam: CXR shows diffuse patches throughout the lungs or consolidation in a lobe Sputum culture identifies the organism Nursing management: Standard airborne precautions Diet high in CHO, CHON, B6, C and calories No CPT, no PD and IS Provide negative pressure room to prevent spread of infection Mask

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Treatment: CPT, ATB, IS Diet: High CHON, high calorie (to offset hypermetabolic state) , force fluids Administer O2 and respiratory treatments Position in semi-fowler’s position to facilitate breathing and lung expansion Change position frequently and ambulate as tolerated to mobilize secretions

TB Medications Administer medications (MDT) 6 months Rifampicin- reddish orange secretions INH- peripheral neuritisparesthesia Vit B6

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Tuberculosis
• • Airborne, infectious, communicable disease Poor nutrition, overworked, overcrowded places with poor ventilation, immunosuppressed

* Both hepatotoxic- avoid ALCOHOL! PZA - inc. uric acid Ethambutol – optic neuritis -blindness Streptomycin- ototoxic and nephrotoxic Drugs to be taken on empty stomach.

Assessment : cough, hemoptysis, dyspnea, low grade fever, night sweats, fatigue, malaise, anorexia, weight loss Diagnostic exam: Mantoux test, Sputum culture for AFB, CXR

LUNG ABSCESS
 Complication of bacterial pneumonia or caused by aspiration or oral anaerobes Localized necrotic lesion of the lung parenchyma containing purulent material that collapses and form cavity Productive cough with copious amount of foul smelling sputum

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DX Chest X Ray,Sputum MC&S,FOB TX IV antibiotics high dose, CPT,high CHON and calories

Pleural Conditions
 Pleurisy – inflammation of visceral and parietal pleura

=secondary to pneumonia, infection =plueritic pain(one lung) aggravated by deep breathing, coughing, sneezing then pain decreases as fluid accumulates DX – CXR, Ausculation TX – analgesics, turn to affected side to splint chest wall, splinting chest when coughing, treat underlying condition

EMPYEMA
 Accumulation of thick, purulent fluid withing the pleural space.  2 to lung abscess/bacterial pneumonia Assessment: Pleuritic chest pain that is sharp and increases with inspiration Dyspnea, decreased breath sounds, fever, malaise Dry, non-productive cough caused by bronchial irritation or mediastinal shift to unaffected side

 s/s of pneumonia/ chest infection  DX – Chest CT, ausc – dec breath sounds, thoracentesis  TX – drain fluid( home on chest drain), IV antibiotics(4-6wks) PLEURAL EFFUSION • • Excess of fluid in the pleural space Normally the pleural space contains small amount of extracellular fluid to lubricate itincreased production or inadequate removal results in effusion DX – CXR,CT, Pleural fluid C&S

Treatment of Pleural Effusion Thoracentesis – UTZ guided Thoracotomy with chest drain insertion- drain and re expand the lungs Talc pleurodesis – recurrent effusion done when pleural space is drained A chemical irritant eg talc is instillled in the pleural space via the chest drain. After instillling the talc chest drain is clamp for 60 to 90 mins and client is

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asked to change positions to promote distribution of the talc and maximize contact with pleural space. ( promote adhesion of visceral and parietal pleura)

Nursing Management -Pneumothorax  Apply dressing over open chest wound Position in high fowler’s position Prepare for chest tube placement until the lung has fully expanded Monitor for hypotension, tachycardia and tachypnea Assess for pain and medicate as ordered Administer O2 Assist in turning, coughing, deep breathing and IS to prevent atelectasis and mobilize secretions Monitor chest tube drainage system

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Pneumothorax
 Occurs when there is accumulation of air in the pleural space 

TYPES  Simple/Spontaneous – rupture of bleb Open – chest trauma Tension – wound in chest wall, lacerated lung

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 Open VS Tension Pneumothorax

Chest Tubes
• • Returns negative pressure to intrapleural space Used to remove abnormal accumulations of air and fluid from pleural space Collection chamber – drainage Water seal chamber- tip of tube is underwater allowing fluid and air to drain and prevents air from entering the pleural space Water oscillates (moves up when patient inhales and moves down as patient exhales) Suction control chamber- gentle continuous bubbling normal

• Assessment of pneumothorax • • • • Dyspnea, diminished or absent breath sounds unilaterally sharp pain that increases with exertion, dullness on percussion tracheal shift to unaffected side (tension) decreased chest expansion unilaterally, diaphoresis, subcutaneous emphysema, sucking sound with open chest wound • •

Placement of Tube

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Malignant tumor of the lungs (primary/ metastatic) #1 type of cancer

Causes: - Smoking ( 10 x prone) , 5 yrs off smoking less risk Pack year history- # of packs/day x # years smoked -exposure to environmental and occupational pollutants ( more in urban than rural places) - genetics – 2-3x prone than general population - diet – low in fruit and veg. beta carotene ? Important ASSESSMENT Nursing Management Monitor for drainage (amount, color) Keep tubes free of obstruction Change position frequently Do not strip or milk tubes Maintain the drainage system below chest level to maintain water seal and prevent reflux Cough, dyspnea, hoarseness, hemoptysis, chest pain, anorexia and weight loss, weakness Diagnostics CXR, CT(small nodules not seen by CXR),FOB, MRI,VATS Classification Non small cell 75%– Squamous cell central, Adenocarcinoma – peripheral (most common) Large cell ca- peripheral, grows fast Small cell 25% - arise in major bronchi Nursing Management: • • • Assess for tracheal deviation Place in fowler’s position for ease in breathing Administer O2 and humidification to moisten and loosen secretions Administer corticosteroids and bronchodilators Provide high calorie, high CHON, high vitamin diet

Care of drain • If drainage bottle accidentally breaks, immerse tube in sterile water , remove broken system and replace with new one If chest tube accidentally pulled out, pinch skin together, apply sterile occlusive dressing and CALL MD When chest tube is removed, patient asked to take a deep breath and hold it and tube is removed; a petrolatum dressing or dry dressing is placed

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LUNG CANCER
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Treatment/Mngmt • • • • Provide activity with rest periods Radiation therapy Chemotherapy SURGERY

Anticoagulation therapy – Heparin iv

ACUTE RESPIRATORY FAILURE
Exists when gas exchange can not keep up with rate of O2 consumption Pa O2 – less 50 PaCO2 –less than 50 mm  Decreased respiratory drivemultiple sclerosis, sedatives, severe hypothyroidism Dysfunction of the chest wall – myasthenia gravis, guillain barre Dysfunction of lung parenchyma- pnemonia, Ptb, asthma, pulm edema/embolism Treat underlying causeintubation

Lung resection     Lobectomy Bilobectomy Pneumonectomy Segmentectomy – segment of the lung is removed Wedge resection – removal of pie shaped area of the segment

PULMONARY EDEMA
 Most often occurs as result of abnormal cardiac function – shifting of fluid bec of poor LV Crackles, dyspnea, central cyanosis, frothy sputum(fluid mix with air in the alveoli) Treat underlying disease. Diuretics, O2

PULMONARY HYPERTENSION
 Systolic pulmonary artery pressure > 30 mm Hg. or mean pulmonary artery pressure >25 mm Hg. Primary is idiopathic Secondary results from existing cardiac or pulmonary diseaseCOPD, chronic thrombotic/embolic dse. Manage underlying disease S/S – dyspnea with exertion then at rest., chest pain, weakness, right sided failure DX – Echo, Right Heart Catheterization, PFT,CXR, ECG TX –treat underlying disease Digoxin, Warfarin, Lung Transplant, IVC filter then PTE

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PULMONARY EMBOLISM
 Obstruction of pulmonary artery or one of its branches by a thrombus or embolus( DVT’s) Dyspnea,tachypnea, and chest pain occur suddenly DX – CXR, D dimer assay, Doppler UTZ Prevention of deep vein thrombosis   

Emergency management  Thrombolytic therapy – Streptokinase iv then ---

IVC Filter

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DX – CXR, D dimer assay, Doppler UTZ Prevention of deep vein thrombosis

Emergency management  PAH Meds  Bosentan- vasodilator of pulmonary artery. Thrombolytic therapy – Streptokinase iv then --Anticoagulation therapy – Heparin iv

S/E – hypotension. Monitor Liver Func. test  Prostacyclin- Epoprostenol (Flolan) – relaxes vascular smooth muscle(lungs),plt deagregator

reduce pulmonary vascular resistance & pressure  half life is only 3 mins – continous IV thru hickman lineS/E hypotension, jaw pain, redness, head-ache  done every 12 hours.

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EPOPROSTENOL Trepostinil (Remodulin) – prostacyclin analogue. Longer half life than FlolanDone every 48 hrs SC Iloprost (Ventavis) – inhaled, synthetic form of prostacyclin. Done 7 times a day.

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PULMONARY EMBOLISM
 Obstruction of pulmonary artery or one of its branches by a thrombus or embolus( DVT’s) Dyspnea,tachypnea, and chest pain occur suddenly

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