Medical-Surgical Nursing

Respiratory System

Primary functions
a. provides oxygen for metabolism in the tissues
b. removes carbon dioxide, the waste product of metabolism

2 Main Parts

1. Upper Repiratory Tract

a. Nose
b. Mouth
c. Pharynx
d. Larynx
2. Lower Respiratory Tract
a. Trachea
b. Bronchus
c. Bronchioles
d. Lungs

NOSE
1. Filters, warms and humidifies air
2. First defense against foreign particles
3. Inhalation for deep breathing is to be done via nose
4. Exhalation is done through the mouth
5. Serves as passageway for incoming and outgoing air, filtering, warming, moistening, and chemically examining it.
6. Organ of smell (Olfactory receptors located in the nasal mucosa
7. Aids in phonation

PHARYNX
1. Serves as a passageway and entrance to the respiratory and digestive tracts
2. Aids in Phonation
3. Tonsils function to destroy incoming bacteria and detoxify certain foreign proteins
LARYNX
1. Voice production: during expiration, air passing through the larynx cause the vocal cords to vibrate; short, tense cords
2. Serves as a passageway for air and as the entrance to the lower respiratory tract

TRACHEA”windpipe”
1. tube about 4 inches long
 2. begins just under the larynx (voice box) and runs down behind the breastbone (sternum).
3. divides into two smaller tubes called bronchi: one bronchus for each lung.
4. composed of about 20 rings of tough cartilage
5. widens and lengthens slightly with each breath in, returning to its resting size with each breath out

BRONCHUS
1. a passage of airway in the respiratory tract that conducts air into the lungs
2. branches into smaller tubes, which in turn become bronchioles
3. No gas exchange takes place in this part of the lungs

BRONCHIOLES
1. first passageways by which the air passes through the nose or mouth to the air sacs of the lungs in which branches no longer
contain cartilage or glands in their submucosa
2. they are branches of the bronchi. The bronchioles terminate by entering the circular sacs called alveoli

LUNGS
1. a pair of spongy, air-filled organs located on either side of the chest (thorax).
2. covered by a thin tissue layer called the pleura. The same
3. A thin layer of fluid acts as a lubricant allowing the lungs to slip smoothly as they expand and contract with each breath.

Diagnostic Tests
1. Spirometry
2. Arterial blood gas determination
3. Oximeters
4. Exercise tolerance
5. Radiography
6. Bronchoscopy
7. Culture, sensitivity tests

General Manifestations of Respiratory Disease

1. Sneezing
2. Coughing
– Irritation
– Controlled by medulla
– Constant, dry unproductive vs. productive cough
3. Sputum
– Mucus discharge
– Yellowish-green
– Rusty, dark-colored
– Thick, sticky
– Hemoptysis
Manifestations
1. Breathing patterns and characteristics
– Kussmaul respiration
– Labored respiration, prolonged inspiration/expiration times
– Wheezing
– Stridors
2. Breath sounds
– Rales
– Rhonchi
– Absence

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 inacromegaly or hypothyroidism)

2. Cheyne-Stokes- periods of apnoea alternating with periods of hyperpnoae

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 respiratory centre
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
7. Paradoxical
- the abdomen sucks with respiration (normally, it pouches uotward due to diaphragmatic descent)
causes: diaphragmatic paralysis

Dieases of the Respiratory System

PNEUMONIA
– inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.

High risk
-elderly & children below 5 y/o

Etiologic agents
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Hemophilus pneumoniae(Bronchopneumonia)
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.

Predisposing factors
1. Smoking
2. Air pollution
3. Immuno-compromised
4. Prolonged immobility – CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue

Signs and Symptoms

1. Productive cough –Pathognomonic Sign: greenish to rusty sputum
2. Dyspnea with prolonged respiratory grunt
3. Fever, chills, anorexia, gen body malaise
4. Wt loss
5. Pleuritic friction rub
6. Rales/ crackles
7. Cyanosis
8. Abdominal distension leading to paralytic ileus

Sputum exam – could confirm presence of TB & pneumonia

Diagnostic
1. Sputum (GSCS)- gram staining & culture sensitivity - Reveals (+) cultured microorganism.
2. Chest X-ray – pulmo consolidation
3. CBC – increase WBC
4. Erythrocyte sedimentation rate
5. ABG – PO2 decrease

Nursing Management
1. Enforce Complete Bed Rest
2. Strict respiratory isolation
3. Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides – ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
 4. Force fluids – 2 to 3 L/day
5. Institute pulmonary toilet-
a.) Deep breathing exercise
b.) Coughing exercise
c.) Chest physiotherapy – cupping
d.) Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfortable & humid environment
9. Diet: increase CHO or calories, CHON & Vit. C
10. Postural drainage - To drain secretions using gravity

PULMONARY TUBERCULOSIS (KOCH DSE)

- Inflammation of lung tissue caused by invasion of mycobacterium TB or tubercle
bacilli or acid fast bacilli – gram (+) aerobic, motile & easily destroyed by heat or
sunlight.

Predisposing factors
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle (mycobacterium BOVIS)
5. Virulence
11. Over fatigue

Signs and Symptoms

1. Productive cough – yellowish
2. Low grade fever
3. Night sweats
4. Dyspnea
5. Anorexia, general body malaise, wt loss
6. Chest/ back pain
7. Hempotysis

Diagnosis
1. Skin test – Mantoux test – infection of Purified CHON Derivative PPD
 DOH – 8-10 mm induration
 WHO – 10-14 mm induration
 Result within 48 – 72h
 (+) Mantoux test – previous exposure to tubercle bacilli

Mode of transmission – droplet infection

Nursing Management
1. Complete Bed Rest
2. Strict respiratory isolation
3. O2 inhalation
4. Semi fowler’s position
5. Force fluid to liquefy secretions
6. Nebulize & suction
7. Comfortable & humid environment
8. Diet – increase CHO & calories, CHON, Vits., minerals
9. Short course chemotherapy
a. Isoniazid (INH)
b. Rifampin (RIF)
c. Ethambutol
d. Pyrazinamide
e. Streptomycin

HISTOPLASMOSIS
- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted to birds manure.
Signs and Symptoms
Same as pneumonia & PTB – like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis

Diagnostic
1. Histoplasmin skin test = (+)
2. ABG – pO2 decrease

Nursing Management
1. Complete Bed Rest
2. Meds:
a.) Anti fungal agents
b.) Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 – force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breeding places or kill the bird

COPD – Chronic Obstructive Pulmonary Disease

TYPES
1. Chronic bronchitis
2. Bronchial asthma
3. Bronchiectasis
4. Pulmonary emphysema – terminal stage

For all types of COPD:

 #1 cause is smoking
 Expect doctor to prescribe bronchodilators
 LOW-FLOW OXYGEN only so as not so suppress the respiratory
drive

CHRONIC BRONCHITIS
- called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet mucus producing cells leading to narrowing of
smaller airways.

Predisposing factors
1. Smoking – all COPD types
2. Air pollution

Signs and Symptoms

1. Productive cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmonary HPN
a.)Leading to peripheral edema
b.) Cor pulmonary – respiratory in origin
7. Anorexia, generalized body malaise

Diagnostic
1. ABG
Nursing Management
(Same as emphysema)
 1. Complete Bed Rest
2. Administer medications as ordered
a.) Bronchodilators
b.) Corticosteroids
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
3. O2 – Low inflow
4. Force fluids
5. High fowlers
6. Nebulizer & suction
7. Institute
a. P – posture
b. E – end
c. E – expiratory
d. P – pressure
8. Health Teaching:
a.) Avoid smoking
b.) Prevent complications
1.) Cor pulmonary – R ventricular hypertrophy
2.) CO2 narcosis – lead to coma
3.) Atelectasis
4.) Pneumothorax – air in pleural space
c.) Adhere with the medications

BRONCHIAL ASTHMA
- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller airway

2 Types
1. Extrinsic asthma
a. Acute episodes triggered by type I hypersensitivities
b. Onset in childhood
2. Intrinsic asthma
a. Onset during adulthood
b. Stimuli target hyperresponsive tissue = acute attack

Predisposing factor
1. Extrinsic Asthma – called Atropic/ allergic asthma
a.) Pallor
b.) Dust
c.) Gases
d.) Smoke
e.) Dander
f.) Lints

2. Intrinsic Asthma -
Cause:
a.) Herediatary
b.) Drugs – aspirin, penicillin,  blockers
c.) Food additives – nitrites
d.) Foods – seafood, chicken, eggs, chocolates, milk
e.) Physical/ emotional stress
f.) Sudden change of temp, humidity &air pressure

3. Mixed type: combination of both extrinsic & intristic Asthma

90% cause of asthma

Signs and Symptoms

1. Cough, dyspnea, tight feeling in chest
2. Wheezing
3. Rapid, labored breathing
4. Thick, sticky mucus coughed up
5. Tachycardia and pulse paradoxus
 a. Pulse differs on inspiration and expiration
6. Hypoxia
7. Respiratory acidosis
8. Severe respiratory distress
9. Respiratory failure

Diagnostic

Pulmonary function test – decrease lung capacity

1. ABG – PO2 decrease

Nursing Management
1. Complete Bed Rest for all types of COPD
2. Meds-
a.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids
b.) Corticosteroids – due inflammatory. Given 10 min after administration of bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist – at bedside put suction machine.
e.) Antihistamine
3. Force fluid
4. O2 – all COPD low inflow to prevent respiratory distress
5. Nebulize & suction
6. Semifowler – all COPD except emphysema due late stage
7. Health teachings
a.) Avoid predisposing factors
b.) Complications:
a.) Status astmaticus- give epinephrine & bronchodilators
b.) Emphysema
c.) Adherence to medications

BRONCHIECTASIS – abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.
Predisposing factors
1. Recurrent upper & lower RI
2. Congenital anomalies
3. Tumors
4. Trauma

Signs and Symptoms

1. Productive cough
2. Dyspnea
3. Anorexia, gen body malaise- all energy are used to
increase respiration.
4. Cyanosis
5. Hemoptisis

Diagnostic
1. ABG – PO2 decrease
2. Bronchoscopy – direct visualization of bronchus using
fiberscope
Nsg Mgt: before bronchoscopy
1. Consent, explain procedure – MD/
lab explain RN
2. NPO
3. Monitor VS
Nsg Mgt after bronchoscopy
1. Feeding after return of gag reflex
2. Instruct client to avoid talking, smoking or coughing
3. Monitor signs of frank or gross bleeding
4. Monitor of laryngeal spasm
 DOB
 Prepare at bedside tracheostomy set

Management: same as emphysema except Surgery

Pneumonectomy – removal of affected lung
Segmental lobectomy – position of pt – unaffected side

PULMONARY EMPHYSEMA
– irreversible terminal stage of COPD
– Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases.
– Body will compensate over distension of thoracic cavity
– Barrel chest

Predisposing factor
1. Smoking
2. Allergy
3. Air pollution
4. High risk – elderly
5. Hereditary

Signs and Symptoms

1. Productive cough
2. Dyspnea at rest
3. Anorexia & generalized body malaise
4. Rales/ rhonchi
5. Bronchial wheezing
6. Decrease tactile fremitus
7. Resonance to hyperresonance – percussion
8. Decreased or diminished breath sounds
9. Pathognomonic: Barrel chest – increase post/ anterior diameter of chest
10. Purse lip breathing – to eliminated PCO2
11. Flaring of alai nares

Diagnosis
1. Pulmonary function test – decrease vital lung capacity
2. ABG

Nursing Management
1. Complete Bed Rest
2. Administer medications as ordered
a. Bronchodilators
b. Corticosteroids
c. Antimicrobial agents
d. Mucolytics/ expectorants
3. O2 – Low inflow
4. Force fluids
5. High fowlers
6. Nebulize & suction
7. Institute
P – posture
E – end
E – expiratory
P – pressure
8. Health teachings
a.) Avoid predisposing factors
b.) Complications:
c.) Status astmaticus- give epinephrine & bronchodilators
d.) Emphysema
c.) Adherence to medications

RESTRICTIVE LUNG DISORDER

PNEUMOTHORAX
– partial / or complete collapse of lungs due to entry or air in pleural space.

Types:
1. Spontaneous Pneumothorax – entry of air in pleural space without obvious cause
Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
Eg. open pneumothorax – air enters pleural space through an opening in chest wall
 -Stab/ gun shot wound
2. Tension Pneumothorax – air enters plural space with at inspiration & can’t escape leading to over distension of thoracic cavity
resulting to shifting of mediastinum content to unaffected side.
Eg. flail chest – “paradoxical breathing”

Predisposing factors
1.Chest trauma
2.Inflammatory lung conditions
3.Tumor

Signs and Symptoms

1. Sudden sharp chest pain
2. Dyspnea
3. Cyanosis
4. Diminished breath sound of affected lung
5. Cool moist skin
6. Mild restlessness/ apprehension
7. Resonance to hyper resonance

Diagnosis
1. ABG – pO2 decrease –
2. Chest X-ray – confirms pneumothorax

Nursing Management
1. Endotracheal intubation
2. Thoracenthesis
3. Meds – Morphine SO4
- Anti microbial agents
4. Assist in test tube thoracotomy

Nursing Mgt if pt is on Chest Physiotherapy attached to

H2O drainage
1. Maintain strict aseptic technique
2. Prepare at bedside
a.) Petroleum gauze pad if dislodged Hemostan
b.) If with air leakage – clamp
c.) Extra bottle
3. Meds – Morphine SO4
Antimicrobial
4. Monitor & assess for oscillation fluctuations or bubbling
a.) If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
1. Check for loop, clots, and kink
2. Milk towards H2O seal
3. Indicates re-expansion of lungs
When will MD remove chest tube:
1. If (-) fluctuations
2. (+) Breath sounds
3. CXR – full expansion of lungs

Nursing Mgt of removal of chest tube

1. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space.
2. Apply vaselinated air occlusive dressing
- Maintain dressing dry & intact