PLT COLLEGE INC.

College of Nursing
Bayombong, Nueva Vizcaya

Nursing Care Management 103 (Care of the Clients with Problems in

Oxygenation)

Functions of the Respiratory System

 Oxygen supplier. The job of the respiratory system is to keep the body constantly
supplied with oxygen.
 Elimination. Elimination of carbon dioxide.
 Gas exchange. The respiratory system organs oversee the gas exchanges that
occur between the blood and the external environment.
 Passageway. Passageways that allow air to reach the lungs.
 Humidifier. Purify, humidify, and warm incoming air.

Anatomy of the Respiratory System

The organs of the respiratory system include the nose, pharynx, larynx, trachea, bronchi,
and their smaller branches, and the lungs, which contain the alveoli.
 Nostrils. During breathing, air enters the nose by passing through the nostrils, or nares.
 Nasal cavity. The interior of the nose consists of the nasal cavity, divided by a
midline nasal septum.
 Olfactory receptors. The olfactory receptors for the sense of smell are located in the
mucosa in the slitlike superior part of the nasal cavity, just beneath the ethmoid
bone.
 Respiratory mucosa. The rest of the mucosal lining, the nasal cavity called the
respiratory mucosa, rests on a rich network of thin-walled veins that warms the air as
it flows past.
 Mucus. In addition, the sticky mucus produced by the mucosa’s glands moistens the
air and traps incoming bacteria and other foreign debris, and lysozyme enzymes in
the mucus destroy bacteria chemically.
 Ciliated cells. The ciliated cells of the nasal mucosa create a gentle current that
moves the sheet of contaminated mucus posteriorly toward the throat, where it is
swallowed and digested by stomach juices.
 Conchae. The lateral walls of the nasal cavity are uneven owing to three mucosa-
covered projections, or lobes called conchae, which greatly increase the surface
area of the mucosa exposed to the air, and also increase the air turbulence in the
nasal cavity.
 Palate. The nasal cavity is separated from the oral cavity below by a partition, the
palate; anteriorly, where the palate is supported by bone, is the hard palate; the
unsupported posterior part is the soft palate.
 Paranasal sinuses. The nasal cavity is surrounded by a ring of paranasal sinuses
located in the frontal, sphenoid, ethmoid, and maxillary bones; theses sinuses lighten
the skull, and they act as a resonance chamber for speech.
Pharynx
Size.
The pharynx is a muscular passageway about 13 cm (5 inches) long that vaguely
resembles a short length of red garden hose.
Function
Commonly called the throat, the pharynx serves as a common passageway for food
and air.
Portions of the pharynx. Air enters the superior portion, the nasopharynx, from the nasal
cavity and then descends through the oropharynx and laryngopharynx to enter the
larynx below.
Pharyngotympanic tube. The pharyngotympanic tubes, which drain the middle ear
open into the nasopharynx.
Pharyngeal tonsil. The pharyngeal tonsil, often called adenoid is located high in the
nasopharynx.
Palatine tonsils. The palatine tonsils are in the oropharynx at the end of the soft palate.
Lingual tonsils. The lingual tonsils lie at the base of the tongue.

Larynx
The larynx or voice box routes air and food into the proper channels and plays a role in
speech.
Structure. Located inferior to the pharynx, it is formed by eight rigid hyaline cartilages
and a spoon-shaped flap of elastic cartilage, the epiglottis.
Thyroid cartilage. The largest of the hyaline cartilages is the shield-shaped thyroid
cartilage, which protrudes anteriorly and is commonly called Adam’s apple.
Epiglottis. Sometimes referred to as the “guardian of the airways”, the epiglottis protects
the superior opening of the larynx.
Vocal folds. Part of the mucous membrane of the larynx forms a pair of folds, called the
vocal folds, or true vocal cords, which vibrate with expelled air and allows us to speak.
Glottis. The slitlike passageway between the vocal folds is the glottis.
Trachea
Length. Air entering the trachea or windpipe from the larynx travels down its length (10
to 12 cm or about 4 inches) to the level of the fifth thoracic vertebra, which is
approximately midchest.
Structure. The trachea is fairly rigid because its walls are reinforced with C-shaped
rings of hyaline cartilage; the open parts of the rings about the esophagus and allow it
to expand anteriorly when we swallow a large piece of food, while the solid portions
support the trachea walls and keep it patent, or open, in spite of the pressure changes
that occur during breathing.

Cilia. The trachea is lined with ciliated mucosa that beat continuously and in a direction
opposite to that of the incoming air as they propel mucus, loaded with dust particles
and other debris away from the lungs to the throat, where it can be swallowed or spat
out.

Main Bronchi
Structure. The right and left main (primary) bronchi are formed by the division of the
trachea.
Location. Each main bronchus runs obliquely before it plunges into the
medial depression of the lung on its own side.
Size. The right main bronchus is wider, shorter, and straighter than the left.

Lungs
Location. The lungs occupy the entire thoracic cavity except for the most central area,
the mediastinum, which houses the heart, the great blood vessels, bronchi, esophagus,
and other organs.
Apex. The narrow, superior portion of each lung, the apex, is just deep to the clavicle.
Base. The broad lung area resting on the diaphragm is the base.
Division. Each lung is divided into lobes by fissures; the left lung has two lobes, and the
right lung has three.

Pleura. The surface of each lung is covered with a visceral serosa called the pulmonary,
or visceral pleura and the walls of the thoracic cavity are lined by the parietal pleura.
Pleural fluid. The pleural membranes produce pleural fluid, a slippery serous secretion
which allows the lungs to glide easily over the thorax wall during breathing movements
and causes the two pleural layers to cling together.
Pleural space. The lungs are held tightly to the thorax wall, and the pleural space is
more of a potential space than an actual one.
Bronchioles. The smallest of the conducting passageways are the bronchioles.
Alveoli. The terminal bronchioles lead to the respiratory zone structures, even smaller
conduits that eventually terminate in alveoli, or air sacs.
Respiratory zone. The respiratory zone, which includes the respiratory bronchioles,
alveolar ducts, alveolar sacs, and alveoli, is the only site of gas exchange.
Conducting zone structures. All other respiratory passages are conducting zone
structures that serve as conduits to and from the respiratory zone.
Stroma. The balance of the lung tissue, its stroma, is mainly elastic connective tissue that
allows the lungs to recoil passively as we exhale.

The Respiratory Membrane

Wall structure. The walls of the alveoli are composed largely of a single, thin layer of
squamous epithelial cells.
Alveolar pores. Alveolar pores connecting neighboring air sacs and provide alternative
routes for air to reach alveoli whose feeder bronchioles have been clogged by mucus
or otherwise blocked.
Respiratory membrane. Together, the alveolar and capillary walls, their fused basement
membranes, and occasional elastic fibers construct the respiratory membrane (air-
blood barrier), which has gas (air) flowing past on one side and blood flowing past on
the other.
Alveolar macrophages. Remarkably efficient alveolar macrophages sometimes
called “dust cells”, wander in and out of the alveoli picking up bacteria, carbon
particles, and other debris.
Cuboidal cells. Also scattered amid the epithelial cells that form most of the alveolar
walls are chunky cuboidal cells, which produce a lipid (fat) molecule called surfactant,
which coats the gas-exposed alveolar surfaces and is very important in lung function.

Physiology of the Respiratory System

The major function of the respiratory system is to supply the body with oxygen and to
dispose of carbon dioxide. To do this, at least four distinct events, collectively called
respiration, must occur.

Respiration

Pulmonary ventilation. Air must move into and out of the lungs so that gasses in the air
sacs are continuously refreshed, and this process is commonly called breathing.
External respiration. Gas exchange between the pulmonary blood and alveoli must
take place.
Respiratory gas transport. Oxygen and carbon dioxide must be transported to and from
the lungs and tissue cells of the body via the bloodstream.
Internal respiration. At systemic capillaries, gas exchanges must be made between the
blood and tissue cells.

Mechanics of Breathing

Rule. Volume changes lead to pressure changes, which lead to the flow of gasses to
equalize pressure.
Inspiration. Air is flowing into the lungs; chest is expanded laterally, the rib cage is
elevated, and the diaphragm is depressed and flattened; lungs are stretched to the
larger thoracic volume, causing the intrapulmonary pressure to fall and air to flow into
the lungs.
Expiration. Air is leaving the lungs; the chest is depressed and the lateral dimension is
reduced, the rib cage is descended, and the diaphragm is elevated and dome-
shaped; lungs recoil to a smaller volume, intrapulmonary pressure rises, and air flows out
of the lung.
Intrapulmonary volume. Intrapulmonary volume is the volume within the lungs.
Intrapleural pressure. The normal pressure within the pleural space, the intrapleural
pressure, is always negative, and this is the major factor preventing the collapse of the
lungs.
Nonrespiratory air movements. Nonrespiratory movements are a result of reflex activity,
but some may be produced voluntarily such as cough, sneeze, crying, laughing,
hiccups, and yawn.

Respiratory Volumes and Capacities

Tidal volume. Normal quiet breathing moves approximately 500 ml of air into and out of
the lungs with each breath.
Inspiratory reserve volume. The amount of air that can be taken in forcibly over the
tidal volume is the inspiratory reserve volume, which is normally between 2100 ml to
3200 ml.
Expiratory reserve volume. The amount of air that can be forcibly exhaled after a tidal
expiration, the expiratory reserve volume, is approximately 1200 ml.
Residual volume. Even after the most strenuous expiration, about 1200 ml of air still
remains in the lungs and it cannot be voluntarily expelled; this is called residual volume,
and it is important because it allows gas exchange to go on continuously even
between breaths and helps to keep the alveoli inflated.
Vital capacity. The total amount of exchangeable air is typically around 4800 ml in
healthy young men, and this respiratory capacity is the vital capacity, which is the sum
of the tidal volume, inspiratory reserve volume, and the expiratory reserve volume.
Dead space volume. Much of the air that enters the respiratory tract remains in the
conducting zone passageways and never reaches the alveoli; this is called the dead
space volume and during a normal tidal breath, it amounts to about 150 ml.
Functional volume. The functional volume, which is the air that actually reaches the
respiratory zone and contributes to gas exchange, is about 350 ml.
Spirometer. Respiratory capacities are measured with a spirometer, wherein as a person
breathes, the volumes of air exhaled can be read on an indicator, which shows the
changes in air volume inside the apparatus.

External Respiration, Gas Transport, and Internal Respiration

External respiration. External respiration or pulmonary gas exchange involves the

oxygen being loaded and carbon dioxide being unloaded from the blood.
Internal respiration. In internal respiration or systemic capillary gas exchange, oxygen is
unloaded and carbon dioxide is loaded into the blood.

Gas transport. Oxygen is transported in the blood in two ways: most attaches to
hemoglobin molecules inside the RBCs to form oxyhemoglobin, or a very small amount
of oxygen is carried dissolved in the plasma; while carbon dioxide is transported in
plasma as bicarbonate ion, or a smaller amount (between 20 to 30 percent of the
transported carbon dioxide) is carried inside the RBCs bound to hemoglobin.

Control of Respiration

Neural Regulation
Phrenic and intercostal nerves. These two nerves regulate the activity of the respiratory
muscles, the diaphragm, and external intercostals.
Medulla and pons. Neural centers that control respiratory rhythm and depth are
located mainly in the medulla and pons; the medulla, which sets the basic rhythm of
breathing, contains a pacemaker, or self-exciting inspiratory center, and an expiratory
center that inhibits the pacemaker in a rhythmic way; pons centers appear to smooth
out the basic rhythm of inspiration and expiration set by the medulla.
Eupnea. The normal respiratory rate is referred to as eupnea, and it is maintained at a
rate of 12 to 15 respirations/minute.
Hyperpnea. During exercise, we breathe more vigorously and deeply because the
brain centers send more impulses to the respiratory muscles, and this respiratory pattern
is called hyperpnea.

Non-neural Factors Influencing Respiratory Rate and Depth

Physical factors. Although the medulla’s respiratory centers set the basic rhythm of
breathing, there is no question that physical factors such as talking, coughing, and
exercising can modify both the rate and depth of breathing, as well as an increased
body temperature, which increases the rate of breathing.
Volition (conscious control). Voluntary control of breathing is limited, and the respiratory
centers will simply ignore messages from the cortex (our wishes) when the oxygen
supply in the blood is getting low or blood pH is falling.
Emotional factors. Emotional factors also modify the rate and depth of breathing
through reflexes initiated by emotional stimuli acting through centers in
the hypothalamus.
Chemical factors. The most important factors that modify respiratory rate and depth
are chemical- the levels of carbon dioxide and oxygen in the blood; increased levels of
carbon dioxide and decreased blood pH are the most important stimuli leading to an
increase in the rate and depth of breathing, while a decrease in oxygen levels become
important stimuli when the levels are dangerously low.
Hyperventilation. Hyperventilation blows off more carbon dioxide and decreases the
amount of carbonic acid, which returns blood pH to normal range when carbon
dioxide or other sources of acids begin to accumulate in the blood.
Hypoventilation. Hypoventilation or extremely slow or shallow breathing allows carbon
dioxide to accumulate in the blood and brings blood pH back into normal range when
blood starts to become slightly alkaline.

Glossary

1. Barrel Chest: A rounded, barrel shape of the chest wall that may indicate an
underlying medical condition, such as chronic obstructive pulmonary disease
(COPD). The diameter of the chest is increased.
2. Bronchial breath sounds: Normal sounds heard over the upper half of the sternum.
3. Bronchophony: Muffled and indistinguishable word sounds heard when listening to
the chest wall with a stethoscope, while the patient vocalizes a repetitive phrase
such as "ninety-nine."
4. Bronchovesicular breath sounds: Normal sounds heard over the trachea.
5. Consolidation: Areas of consolidation in the lungs occur when lung tissue are filled
with fluid.
6. Crepitus: Grating, crackling or popping sensation felt on palpation. Also known as
subcutaneous emphysema, and is caused by air trapped in tissues under the skin
covering the chest wall or neck.
7. Diaphoretic: Excessive perspiration.
8. Dullness: A dull sound usually heard over a solid mass, such as a tumor.
9. Dyspnea: Difficulty breathing or shortness of breath (SOB).
10.Egophony: The distortion of sound due to lung pathology.
11.Flatness: Flat sound heard when dense tissue is palpated.
12. Fremitus: A vibration felt on palpation. Usually indicates some pathology.
13.Hyperresonance: A long, low-pitched hollow sound heard over areas with trapped
gas, of increased air such as pneumothorax or emphysema.
14.Inspiratory: Expiratory ratio: The ratio of the length of time spent on inhaling air,
compared to the length of time spent on exhaling air.
15.Nasal Turbinates: A long, narrow and curled bone shelf which protrudes into the
breathing passage of the nose.
16.Orthopnea: Shortness of breath (SOB) when lying flat.
17.Palpation: Process of using the hands to explore underlying organs to determine
pathology.
18.Paroxysmal Nocturnal Dyspnea (PND): Intermittent, recurrent episodes of shortness of
breath that usually occur while lying down at night.
19.Pectus carinatum: Anterior protrusion of the sternum.
20.Pectus excavatum: Posterior depression of all or part of the sternum
21.Resonance: Normal sound heard on percussion over healthy lung tissue.
22.Scoliosis and kyphosis: Abnormal lateral curvatures of the spine may affect expansion
of the thoracic cage.
23.Transport: Refers to the carrying of oxygen and carbon dioxide throughout the
circulatory system.
24.Ventilation: The exchange of air between the atmosphere and the alveoli.
25. Vesicular breath sounds: Normal sounds heard over most of the lungs.
26.Wheezing: A continuous, coarse, whistling sound produced in the respiratory airways
during breathing.
27.Whispered Pectoriloquy: A whispered phrase is muffled when heard through dense
lung tissue. Ask the patient to whisper a phrase such as "one-two-three". If the sounds
are muffled, some degree of pathology is present.

Adult Pulmonary Assessment

When conducting a focused pulmonary assessment on an adult, it is important to

begin with a thorough history of chest or pulmonary complaints.

Elicit any information about any experienced signs or symptoms of chest disease.
Chest disease usually manifests as the presence of any of the following:
• Cough • Sputum • Dyspnea • Wheezing • Chest pain

Assessment of Cough Duration

An acute cough usually represents a viral infection or allergic response. Chronic

cough may be more ominous. Chronic coughs may manifest from underlying disease
processes such as gastroesophageal reflux disease, asthma, chronic allergies,
bronchitis, tuberculosis, or cancer. Certain drugs may produce a side effect of a
cough. Therefore, a thorough medication history is also warranted.

Type

A productive cough usually indicates some infection or inflammatory process.

Chronic bronchitis presents with a history of productive cough for 3 months of the
 year, for 2 years in a row. A dry or non-productive cough may indicate an “atypical”
pneumonia, such as mycoplasma pneumonia which presents with a hacking cough,
early heart failure which presents with a dry, non-productive cough or croup which
has a characteristic barking sound.

Severity:
Ask your patient to rank their cough on a scale of 1 - 10 to determine their
perception of the severity of their cough. Most patients can use a numerical rating
scale to quantify their symptom. When using a numerical scale, you should ask the
patient to rate their cough on a scale from 0 to 10. Zero means no cough. Ten means
the worst cough they have ever experienced.

Irritants and Aids:

Coughs that increase in severity and frequency at night may indicate an underlying
cardiac condition. Coughs that increase after meals may indicate
gastroesophageal reflux disease. A cough that is worse upon waking may indicate
bronchitis and is sometimes termed a “smokers cough.”

Assessment of Sputum Production

If your patient has a productive cough, investigate the characteristics of their
sputum. Begin by asking your patient about the following:

1. How long have you been coughing up sputum?

-This will help you quantify the severity of the symptoms.

2. What color is your sputum?

• Pink-tinged, frothy sputum may indicate pulmonary edema, which is a respiratory
emergency.
• Purulent, rust-colored sputum may indicate tuberculosis or pneumococcal
pneumonia (Jarvis, 2012).
• Green sputum may indicate a viral process or pseudomonas.
• Yellow sputum is usually indicative of a bacterial infection.
• Black sputum may be consistent with occupational pneumoconiosis or “black
lung.”
• Clear to mucoid sputum that occurs in the mornings is consistent with colds,
bronchitis and other viral infections (Jarvis, 2012).

Assessment of Sputum Production Presence of foul odor:

- An odor to sputum usually indicates an infectious process. Presence of blood in
the sputum: If blood is present, further investigation is needed to determine if the
blood is pulmonary in origin or from the gastrointestinal tract. Often the patient
will perceive that they have “coughed up blood” when the blood actually
traveled up through their esophagus to the carina, which causes the patient to
cough. Blood tinged sputum may indicate tuberculosis.

- Assessment of Dyspnea Diseases associated with dyspnea include:

• Congestive heart failure • Chronic bronchitis
• Asthma • Emphysema
• Airway obstruction • Tuberculosis
• HIV-related pulmonary disorders • Pulmonary fibrosis
• Infectious or inflammatory processes
If your patient complains of shortness of breath (SOB):
 Paroxysmal nocturnal dyspnea (PND) wakes the patient up at night.
 Orthopnea (shortness of breath when lying flat) may be present, and may
indicate an underlying cardiac condition.

Chest Pain

Describe your chest pain.

• Cardiac chest pain is usually squeezing or gripping in nature.
• Esophageal or gastric chest pain is usually increased or decreased depending on
food intake or antacid ingestion.
• Tracheal chest pain burns during inhalation.
• Chest wall or rib pain is easily localized and recurs with palpation.
• Pleural chest pain is usually described as “stabbing.”
• Pain associated with lung diseases such as tuberculosis and cancer may be
described as boring, dull, and aching.

Mnemonic For Assessing Chest Pain & Pulmonary Symptoms

P: Provocative or Palliative: What makes the pain or symptom(s) better or worse?
Q: Quality: Describe the pain or symptom(s) (burning, dull, sharp).
R: Radiation: Where in the body does the pain or symptom(s) occur? Is there
radiation or extension of the pain or symptom(s) to another area of the chest?
S: Severity: On a scale of 1-10, (10 being the worst) how bad is the pain or
symptom(s)?
T: Timing: Does it occur in association with something else (e.g. eating, exertion,
movement)?

Data Collection:
Medical History It is important to document a comprehensive medical history that
includes details about:
• Current symptoms
• Previous hospitalizations
• Chronic medical conditions, especially any respiratory conditions
• Acute medical conditions presenting at the time of the examination
• Allergies
• Trauma or surgeries

Data Collection:
Family History After eliciting information about any experienced signs or symptoms
of chest disease, the healthcare provider should obtain a detailed and thorough
medical history, including a family history, social history, occupational history,
communicable disease risk, and medications.

Ask about hereditary disorders such as: cystic fibrosis, alpha 1 antitrypsin deficiency,
asthma, and allergies.

Data Collection:
Social History Smoking:
 Cigarette smoking has been identified as the most important source of
preventable morbidity and premature mortality worldwide (American Lung
Association, 2014).
 Cigarette smoke contains over 4,800 chemicals, 69 of which are known to
cause cancer (American Lung Association, 2014). Nicotine is an addictive drug,
and a social activity, which makes it a difficult habit to break (American Lung
Association, 2014). Ascertain the pack per year smoking history. This is done by
multiplying the number of years your patient has smoked with the number of
packs per day they have smoked. Smokers or past-smokers that have over a 30-
year-pack history have the greatest risk of developing lung cancer (Cancer
Treatment Centers of America, 2014).
 Smokers Pack Per Day History
2 packs per day x 10 years = 20 pack-year history
1 pack per day x 20 years = 20 pack-year history
3 packs per day x 7 years = 21 pack-year history

Data Collection:
Social History Work-related Risk Factors:
 Ask your patient about environment or work-related risk factors for
pulmonary disease. Have they worked in a glass factory, coal mine or
around asbestos?
 Also, ask about the amount and duration of their exposure to fumes in the
workplace.

Communicable Disease Risk:

- Establish any previous exposure to tuberculosis, and the patient's HIV status
or risk.
- Review personal living conditions, presence of birds in the home, and
possible travel.

Data Collection:
Medication History Completing a detailed medication history is important to
determine a possible relationship between medication use and clinical
symptoms. More than 100 medications are known to affect the lungs adversely.

Symptoms of adverse medication interactions or side effects of drug therapy

may manifest in several different ways: • Cough • Asthma • Interstitial
pneumonitis • Non-cardiac pulmonary edema • Pleural effusions

Cardiovascular drugs that most commonly produce pulmonary problems

include amiodarone, angiotensin-converting enzyme (ACE) inhibitors, and
beta-blockers.

The Physical Exam: Inspection of the Chest

When you are using inspection as a physical exam tool, examine your patient
and observe with all your senses. Examples of conditions you will want to
inspect are:
Skin color | location of lesions | bruises or rash | symmetry | size of body parts
sounds, and odors.

Note any abnormal findings. As you inspect the thoracic cage, pay particular
attention to the symmetry of expansion during inspiration and expiration and
note the anterior-posterior (A/P) diameter of the chest. Unequal symmetry of
expansion during inspiration and expiration may indicate a pneumothorax or
flail chest.

The Physical Exam: Inspection of the Chest

• Barrel chest – A rounded, barrel-shaped appearance of the chest. The lateral
diameter of the chest is increased and may be related to advancing age or an
underlying disease processes, such as Chronic Obstructive Pulmonary Disease
(COPD).
• Scoliosis and kyphosis – Abnormal lateral curvatures of the spine may affect
expansion of the thoracic cage.
• Pectus carinatum – Anterior protrusion of the sternum.
• Pectus excavatum – Posterior depression of all or part of the sternum. The

Physical Exam: Inspection of Respiration

Note the rate and depth of respirations. In the healthy adult:

• A normal respiratory rate is 12-20 breaths/minute.
• A normal inspiratory to expiratory ratio (I:E) is 1:2.
(Patients with COPD have a prolonged expiratory phase of about 3-4 seconds.)
• Normal pulse oximetry is 95% - 100%.

Observe the patient for:

• A change in rate, rhythm and depth of respirations.
• A change in the I:E ratio.
• Nasal flaring.
• Pursed lip breathing.
• Retractions of the intercostal space during inspiration.
• Diaphoresis and clamminess.
• Inability to talk easily.

Lung Volume Terminology Tidal Volume (VT): The normal volume of air inhaled
or exhaled with each breath. About 500 ml is the normal value in a healthy
young male. Comparative value = about 2 cups.
Inspiratory Reserve Volume (IRV): The volume of air inhaled during maximum
inspiration beyond normal tidal volume. About 3,000 ml is the normal value in a
healthy young male. Comparative value = 1 and ½ 2 liter bottles of soda.
Inspiratory Capacity (IR): The maximum volume of air that can be expired after
the end of normal quiet inhalation. About 3,500 ml is the normal value in a
healthy young male. Comparative value = Just under 1 gallon.
Expiratory Reserve Volume (ERV): The volume of air that can be forcefully
exhaled beyond normal tidal volume. About 1,000 ml is the normal value in a
healthy young male. Comparative value = Approximately 1 quart.
Residual Volume (RV): The amount of air left in the lungs after a forced
exhalation. About 1,200 ml is the normal value in a healthy young male.
Functional Residual Capacity (FRC): The amount of air remaining in the lungs at
the end of quiet exhalation. About 2,200 ml is the normal value in a healthy
young male. Comparative value = A bit more than a 2 Liter bottle of soda.
Total Lung Capacity (TLC): The total volume of air in the upper and lower
conducting airways and alveoli at the end of maximum inspiration. About 5,700
ml is the normal value in a healthy young male.
 Vital Capacity (VC): The maximum amount of air that can be exhaled after
maximal inspiration. About 4,500 ml is the normal value in a healthy young
male. Comparative value = About the same as 6 bottles of wine.
Minute Ventilation (VE): Total expired volume of air after one minute (This equals
the VT times respiratory rate). About 6,000 ml is the normal value in a healthy
young male.

The Physical Exam: Palpation

- Palpation is another commonly used physical exam technique that requires you
to touch your patient with different parts of your hand using different strengths
and pressures.
- During light palpation, you press the skin about 1/2 inches to 3/4 inches with the
pads of your fingers. When using deep palpation, use your finger pads and
compress the skin about 1.5 to 2 inches.
- Palpation allows you to evaluate fremitus (a palpable vibration that should feel
the same on both sides), estimate thoracic chest expansion and assess the skin
and subcutaneous tissues of the chest (Kaplow & Hardin, 2007).
- When palpating the thoracic cage, you will want to confirm symmetry of chest
expansion and note any unusual crepitations of the chest wall that may occur
with subcutaneous emphysema.

The Physical Exam: Palpation

Fremitus is a palpable vibration, generated from the larynx and transmitted
through the patient’s bronchi and lung parenchyma to the chest wall. You may
ask your patient to repeat a phrase such as “ninety-nine” or “blue moon” as you
palpate their chest wall. Increased fremitus may be noted over areas of
consolidation, such as lobar pneumonia where the consolidation extends to the
lung surface. Decreased fremitus occurs with any condition that would
decrease this sound transmission. Some of these conditions include obstructed
bronchus, pleural effusion, fibrosis, pneumothorax, and emphysema (Stephen et
al., 2010).
Crepitus, also known as subcutaneous emphysema, is palpable air trapped in
tissues under the skin covering the chest wall or neck. When palpated, it
produces a coarse, crackling sensation as gas moves under the skin. Crepitus
may result after thoracic surgery or trauma to the chest.

The Physical Exam: Percussion

- is the process of tapping on a surface to evaluate the size and density of the
underlying structure (Kaplow & Hardin, 2007). Percussion is performed by placing
the distal portion of the middle finger of the non-dominant hand firmly on the
chest wall, and using the fingers of the dominant hand to strike the middle finger
behind the nail bed, and evaluate the sound emitted (Kaplow & Hardin, 2007).
Sounds produced by percussion include:
• Resonance: Normal sound heard on percussion over healthy lung tissue.
• Hyperresonance: A long, low-pitched hollow sound heard over areas with
trapped gas, of increased air such as pneumothorax or emphysema.
• Dullness: A dull sound usually heard over a solid mass, such as a tumor.
• Flatness: Is heard over dense tissues.

The Physical Exam: Auscultation

When auscultating, ensure your room is quiet, use a stethoscope to auscultate
over bare skin, and listen to one sound at a time. The bell or diaphragm of the
 stethoscope should be placed firmly enough to leave a slight ring on the skin
when removed. Be aware that excessive chest hair may also interfere with true
identification of certain sounds.
Auscultate the anterior and posterior chest. Have your patient breathe slightly
deeper than normal through their mouth, then, auscultate from C-7 to
approximately T-10, in a left to right comparative sequence. You should
auscultate laterally from the axilla down to the 7th or 8th rib, listening between
each rib.

Listen for normal breath sounds, which are:

• Vesicular breath sounds: normal sounds heard over most of the lungs.
• Bronchial breath sounds: normal sounds heard over the upper half of the
sternum.
• Bronchovesicular breath sounds: normal sounds heard over the trachea.

Adventitious Breath Sounds/Abnormal Breath Sounds

These are added sounds that are not normally heard in the lungs. If present, they
are heard as being superimposed on normal breath sounds. They are caused by
moving air colliding with secretions in the tracheobronchial passages or by the
popping open of previously deflated airways (Jarvis, 2012).

These are some of the most common adventitious breath sounds heard.
 Crackles: High-pitched sound heard on inspiration. Also known as rales or
crepitation, and is noted as a "popping" sound. May be fine or coarse
crackles. Usually caused by pulmonary edema or pneumonia.
 Wheeze: Musical high-pitched sound heard mainly during expiration. Occurs
in conditions in which the airways are narrowed, such as asthma or
aspiration.
 Stridor: Loud, high-pitched crowing heard in the upper airways, due to an
obstruction or croup. Is usually an emergent situation.
 Rhonchi: A low-pitched wheeze that occurs when there are large amounts
of secretions in the airways.
 Pleural friction rub: Coarse, grating sounds created when inflammation of the
parietal or visceral pleura cause a decrease in the normal lubricating fluid.
As the opposing surfaces rub together during breathing, a coarse grating
sound is heard (Jarvis, 2012).

Adventitious Breath Sounds Found in Various Pulmonary Disorders

 Crackles- Lobar pneumonia, bronchitis, heart failure & TB
 Wheeze- Emphysema
 Bilateral Wheezing on Expiration-Asthma
 Crackles & Rhonchi- Acute Respiratory Distress Syndrome (ARDS)

Abnormal Voice Sounds

- Auscultate voice sounds including bronchophony, egophony, and whispered
pectoriloquy: Bronchophony: When a patient vocalizes a repetitive phrase such
as "ninety-nine," the patient's voice remains loud at the periphery of the lungs or
sounds louder than usual, over a distinct area of consolidation.

 Bronchophony is a repetitive phrase that sounds louder than normal,over a

consolidated area.
  Egophony: The distortion of sound due to lung pathology. The "eee-eee"
sound is heard as "aaa-aaa" when heard through dense lung tissue.
 Whispered Pectoriloquy: A whispered phrase is muffled when heard through
dense lung tissue. Ask the patient to whisper a phrase such as "one-two-
three." If the sounds are muffled, some degree of pathology is present.

DIAGNOSTIC TESTS/LABORATORY TESTS

1. Computed tomography (CT) scan, also known as computerized axial

tomography (CAT), or CT scanning computerized tomography is a painless, non-
invasive diagnostic imaging procedure that produces cross-sectional images of
several types of tissue not clearly seen on a traditional X-ray.

CT scans may be performed with or without contrast medium. A contrast may

either be an iodine-based or barium-sulfate compound that is taken orally,
rectally, or intravenously which can enhance the visibility of specific tissues,
organs, or blood vessels. The duration of the procedure will depend on the area
being scanned.

CT scan of the chest aids in determining the cause of an

unexplained cough, fever, difficulty of breath, chest pain, and other respiratory
symptoms. It is recommended for screening of possible lung cancer in its early,
curable stage.
Indication Abnormal Results

 Diagnose a dissection or leak of

an aortic aneurysm or aortic arch
aneurysm
 Diagnose the invasion of a neck mass in
the thorax
 Differentiate emphysema or broncho-
pleural fistula from a lung abscess
 Distinguish tumors adjacent to
the aorta from aortic aneurysms  Accumulation of fluid, blood, or fat
 Differentiate tumors from calcified  Aortic aneurysms
lesions (signifies tuberculosis)  Cysts
 Detect the mediastinal lymph nodes  Enlarged lymph nodes
 Assess primary malignancy that may  Nodules
metastasize to the lungs, especially in  Pleural effusion
the patient with a primary bone tumor,  Tumors
soft-tissue sarcoma, or melanoma
 Identify the extent of lung diseases such
as bronchiectasis, emphysema, and
diffuse interstitial lung disease
 Locate observed neoplasms (e.g.,
Hodgkin’s disease), especially with the
mediastinal involvement
 Plan radiation therapy
 Contraindication

 Pregnant patient (absolute contraindication)

 Patients with a known allergy to iodine
 Patients with claustrophobia
 Patients with renal impairment unless the benefits outweigh the risks
 Patients with hyperthyroidism or toxic goiter (induce thyrotoxic crisis)
 Patients with complications after a previous administration of a contrast
 Patients with severe obesity (usually more than 300 pounds)

Interfering Factors

 Retained oral or I.V. contrast material from previous diagnostic studies may
affect the visibility of the images.
 Metal objects including eyeglasses, dentures, jewelry, and hairpins

Nursing Responsibilities for CT Scan

Before the procedure

 Informed Consent. Obtain an informed consent properly signed.

 Look for allergies. Assess for any history of allergies to iodinated dye or shellfish if
contrast media is to be used.
 Get health history. Ask the patient about any recent illnesses or other medical
conditions and current medications being taken. The specific type of CT scan
determines the need for an oral or I.V. contrast medium
 Check for NPO status. Instruct the patient to not to eat or drink for a period
amount of time especially if a contrast material will be used.
 Get dressed up. Instruct the patient to wear comfortable, loose-fitting clothing
during the exam.
 Provide information about the contrast medium. Tell the patient that a mild
transient pain from the needle puncture and a flushed sensation from an I.V.
contrast medium will be experienced.
 Instruct the patient to remain still. During the examination, tell the patient to
remain still and to immediately report symptoms of itching, difficulty breathing or
swallowing, nausea, vomiting, dizziness, and headache.
 Inform about the duration of the procedure. Inform the patient that the
procedure takes from five (5) minutes to one (1) hour depending on the type of
CT scan and his ability to relax and remain still.

After the procedure

 Diet as usual. Instruct the patient to resume the usual diet and activities unless
otherwise ordered.
 Encourage the patient to increase fluid intake (if a contrast is given). This is so to
promote excretion of the dye.

2. Chest X-ray (Chest radiography, CXR) is one of the most frequently performed
radiological examination. A chest x-ray is a painless, non-invasive test uses
electromagnetic waves to produce visual images of the heart, lungs, bones,
and bloodvessels of the chest. Air spaces normally seen in the lungs appear dark
on the chest films. A basic chest x-ray includes posteroanterior (PA) view, in
which x-rays pass from the back to the front of the body, and a left lateral view.

Indications of Chest X-ray

 Assist in the diagnosis of diaphragmatic hernia, lung tumors, and metastasis
 Detect known or suspected pulmonary, cardiovascular, and skeletal
disorders
 Identify the presence of chest trauma
 Confirm correct placement and position of the endotracheal
tube, tracheostomytube, chest tubes, central venous catheters, nasogastric
feeding tube, pacemakerwires, intraortic balloon pump, Swan-Ganz
catheters, and automatic implantable cardioverter defibrillator
 Evaluate positive purified protein derivative (PPD) or Mantoux test
for pulmonary tuberculosis.
 Monitor progressions, resolutions, or maintenance of disease
 Evaluate the patient’s response to a therapeutic regimen
(antibiotic, chemotherapy)

Contraindication
Patients who are pregnant or suspected of being pregnant unless the potential
benefits of a procedure using radiation outweigh the risk of maternal and fetal
damage

Interfering Factors
 Presence of metallic objects within the area of examination
 Excessive or unnecessary movements made by the patient during the
procedure
 Incorrect position of the patient, which may produce poor exposure of the
area to be examined
 Inability of the patient to take full inspiration
 Improper adjustment of the radiographic equipment to serve thin or obese
patients, which can result in underexposure or overexposure of the films

Nursing Responsibilities for Chest X-ray

Before Chest X-ray
The following are the nursing interventions prior to chest x-ray:

 Remove all metallic objects. Items such as jewelry, pins, buttons etc can
hinder the visualization of the chest.
 No preparation is required. Fasting or medication restriction is not needed
unless directed by the health care provider.
 Ensure the patient is not pregnant or suspected to be pregnant. X-rays are
usually not recommended for pregnant women unless the benefit
outweighs the risk of damage to the mother and fetus.
 Assess the patient’s ability to hold his or her breath. Holding one’s breath
after inhaling enables the lungs and heart to be seen more clearly in the x-
ray.
 Provide appropriate clothing. Patients are instructed to remove clothing
from the waist up and put on an X-ray gown to wear during the procedure.
 Instruct patient to cooperate during the procedure. The patient is asked to
remain still because any movement will affect the clarity of the image.
 After Chest X-ray
The nurse should note of the following nursing interventions after chest x-ray:
 No special care. Note that no special care is required following the
procedure
 Provide comfort. If the test is facilitated at the bedside, reposition the
patient properly.

3. Complete Blood Count

Red Blood Cells (RBC)

- Red blood cells or erythrocytes transport oxygen from the lungs to the bodily
tissues. RBCs are produced in the red bone marrow, can survive in the peripheral
blood for 120 days, and are removed from the blood through the bone marrow,
liver, and spleen.

Normal values for red blood cell count:

Male adult: 4.5 – 6.2 million/mm3
Female adult: 4.5 – 5.0 million/mm3

Indications of RBC count:

Helps in diagnosing anemia and blood dyscrasia.

Hemoglobin (Hgb)
- Hemoglobin is the protein component of red blood cells that serves as a vehicle
for oxygen and carbon dioxide transport. It is composed of a pigment (heme)
which carries iron, and a protein (globin). The hemoglobin test is a measure of
the total amount of hemoglobin in the blood.

Normal values chart for hemoglobin count:

Male adult: 14 – 16.5 g/dL
Female adult: 12 – 16 g/dL

Indications of Hemoglobin count:

Hemoglobin count is indicated to help measure the severity of anemia (low
hemoglobin) or polycythemia (high hemoglobin).

Monitor the effectiveness of a therapeutic regimen.

Increased Hemoglobin Levels Decreased Hemoglobin Levels
Chronic obstructive pulmonary disease Anemia
Congenital heart disease Cancer
Congestive heart disease Chronic hemorrhage
Dehydration Hemolysis
Hemoconcentration of the blood Kidney disease
High altitudes Lymphoma
Polycythemia vera Neoplasia
Severe burns Nutritional deficiency
Sarcoidosis
Severe hemorrhage
Sickle cell anemia
Splenomegaly
 Systemic lupus erythematosus

Hematocrit (Hct)
Hematocrit or packed cell volume (Hct, PCV, or crit) represents the percentage
of the total blood volume that is made up of the red blood cell (RBC).

Normal values for hematocrit count:

Male adult: 42 – 52%
Female adult: 35 – 47%

Increased Hematocrit Levels Decreased Hematocrit Levels

Burns Anemia
Chronic obstructive pulmonary disease Bone marrow failure
Congenital heart disease Hemoglobinopathy
Dehydration Hemolytic reaction
Eclampsia Hemorrhage
Erythrocytosis Hyperthyroidism
Polycythemia Vera Leukemia
Severe dehydration Liver cirrhosis
Malnutrition
Multiple myelomas
Normal pregnancy
Nutritional deficiency
Rheumatoid arthritis
Red Blood Cell Indices
Red blood cell indicates (RBC Indices) determine the characteristics of an RBC. It
is useful in diagnosing pernicious and iron deficiency anemias and other liver
diseases.

Mean corpuscular volume (MCV): The average size of the individual RBC.
Mean corpuscular hemoglobin (MCH): The amount of Hgb present in one cell.
Mean corpuscular hemoglobin concentration (MCHC): The proportion of each
cell occupied by the Hgb.

Normal Lab Values for RBC Indices are:

Mean corpuscular volume (MCV): Male: 78 – 100 μm3; Female: 78 – 102 μm3
Mean corpuscular hemoglobin (MCH): 25 – 35pg
Mean corpuscular hemoglobin concentration (MCHC): 31 – 37%

Serum Iron (Fe)

Iron is essential for the production of blood helps transport oxygen from the lungs
to the tissues and carbon dioxide from the tissues to the lungs.

Normal lab values for serum iron:

Male adult: 65 – 175 mcg/dL
Female adult: 50 – 170 mcg/dL

Indication of serum iron:

Helps in diagnosing anemia and hemolytic disorder.
Increased Serum Iron Levels Decreased Serum Iron Levels
 Hemochromatosis Chronic blood loss
Hemosiderosis Chronic gastrointestinal blood loss
Hemolytic anemia Chronic hematuria
Hepatic necrosis Chronic pathologic menstruation
Hepatitis Inadequate absorption of iron
Iron poisoning Iron deficiency anemia
Lead toxicity Lack of iron in the diet
Massive transfusion Neoplasia
Pregnancy (late stages)
Nursing considerations for serum iron:
Recent intake of a meal containing high iron content may affect the results.

Drugs that may cause decreased iron levels include adrenocorticotropic

hormone, cholestyramine, colchicine, deferoxamine, and testosterone.

Drugs that may cause increased iron levels include dextrans, ethanol, estrogens,
iron preparations, methyldopa, and oral contraceptives.

Erythrocyte Sedimentation Rate (ESR)

Erythrocyte sedimentation rate (ESR) is a measurement of the rate at which
erythrocytes settle in a blood sample within one hour.

Normal lab values for erythrocyte sedimentation rate:

0 – 30 mm/hour (value may vary depending on age)

Indication for Erythrocyte Sedimentation Rate:

Assist in the diagnosis of conditions related to acute and chronic infection,
inflammation, and tissue necrosis or infarction.

Increased ESR Levels Decreased ESR Levels

Bacterial infection Hypofibrinogenemia
Chronic renal failure Polycythemia vera
Hyperfibrinogenemia Sickle cell anemia
Inflammatory disease Spherocytosis
Macroglobulinemia
Malignant diseases
Severe anemias such as vitamin B12
deficiency or iron deficiency

Nursing consideration
Fasting is not required
Fatty meal prior extraction may cause plasma alterations

White Blood Cells and Differential

The normal laboratory value for WBC count has two components: the total
number of white blood cells and differential count.

White Blood Cells (WBC)

- act as the body’s first line of defense against foreign bodies, tissues, and other
substances. WBC count assesses the total number of WBC in a cubic millimeter
of blood. White blood cell differential provides specific information on white
blood cell types:

Neutrophils are the most common type of WBC and serve as the primary defense
against infection.

Lymphocytes play a big role in response to inflammation or infection.

Monocytes are cells that respond to infection, inflammation, and foreign bodies
by killing and digesting the foreign organism (phagocytosis).

Eosinophils respond during an allergic reaction and parasitic infections.

Basophils are involved during an allergic reaction, inflammation, and

autoimmune diseases.

Bands are immature WBCs that are first released from the bone marrow into the
blood.

Normal lab values for white blood cell count and WBC differential:
WBC Count: 4,500 to 11,000 cells/mm³
Neutrophils: 55 – 70% or 1,800 to 7,800 cells/mm³
Lymphocytes: 20 – 40% or 1,000 to 4,800 cells/mm³
Monocytes: 2 – 8% or 0.0 to 800 cells/mm³
Eosinophils: 1 – 4% or 0.0 to 450 cells/mm³
Basophils: 0–2% or 0.0 to 200 cells/mm³
Bands: 0–2 % or 0.0 to 700 cells/mm³

Increased WBC Count (Leukocytosis) Decreased WBC Count (Leukopenia)

Inflammation Autoimmune disease
Infection Bone marrow failure
Leukemic neoplasia Bone marrow infiltration (e.g.,
Stress myelofibrosis)
Tissue necrosis Congenital marrow aplasia
Trauma Drug toxicity (e.g., chloramphenicol)
Nutritional deficiency
Severe infection
Nursing consideration for WBC count:
A low total WBC count with a left shift means a recovery from bone
marrow depression or an infection of such intensity that the demand for
neutrophils in the tissue is greater than the capacity of the bone marrow to
release them into the circulation.

Platelets (PLT)
Platelets are produced in the bone marrow and play a role in hemostasis.
Platelets function in hemostatic plug formation, clot retraction, and coagulation
factor activation.

Normal values for platelet count:

150,000 to 400,000 cells/mm³
 Increased platelet count Decreased platelet count
(thrombocytosis) (thrombocytopenia)
Iron deficiency anemia Cancer
Malignant disorder Chemotherapy
Polycythemia vera Disseminated intravascular coagulation
Postsplenectomy syndrome Hemolytic anemia
Rheumatoid arthritis Hemorrhage
Hypersplenism
Immune thrombocytopenia
Infection
Inherited thrombocytopenia disorders
such as Bernard-Soulier, Wiskott-Aldrich,
or Zieve syndromes
Leukemia and other myelofibrosis
disorders
Pernicious anemia
Systemic lupus erythematosus
Thrombotic thrombocytopenia
Nursing considerations for Platelet counts:
 High altitudes, persistent cold temperature, and strenuous exercise increase
platelet counts.
 Assess the venipuncture site for bleeding in clients with known
thrombocytopenia.
 Bleeding precautions should be instituted in clients with a low platelet count.

4. Arterial Blood Gas

are measured in a laboratory test to determine the extent of compensation by
the buffer system. It measures the acidity (pH) and the levels of oxygen and
carbon dioxide in arterial blood. Blood for an ABG test is taken from an artery
whereas most other blood tests are done on a sample of blood taken from a
vein.
Normal Lab Values for Arterial Blood Gases
pH: 7.35 – 7.45
HCO3: 22 – 26 mEq/L
PCO2: 35 – 45 mmHg
PaO2: 80 – 100 mmHg
SaO2: >95
Increased pH levels (Alkalosis)
Metabolic alkalosis Respiratory alkalosis
Aldosteronism Acute and severe pulmonary disease
Chronic vomiting Anxiety neuroses
Chronic and high-volume gastric suction Carbon monoxide poisoning
Hypochloremia Chronic heart failure
Hypokalemia Cystic fibrosis
Mercurial diuretics Pain
Pregnancy
Pulmonary emboli
Shock
Decreased pH (Acidosis)
Metabolic acidosis Respiratory acidosis
 Ketoacidosis Respiratory failure
Lactic acidosis
Renal failure
Severe diarrhea
Pco2
Increased Pco2 levels Decreased Pco2 levels
Chronic obstructive pulmonary disease Anxiety
Head trauma Hypoxemia
Overoxygenation in a patient with COPD Pain
Oversedation Pregnancy
Pickwickian syndrome Pulmonary emboli

Po2 and O2 content

Increased Po2, increased O2 content
Hyperventilation
Increased inspired O2
Decreased Po2, increased O2 content
Adult respiratory distress syndrome
Anemias
Atelectasis
Atrial or ventricular cardiac septal defects
Bronchospasm
Emboli
Inadequate oxygen in inspired air
(suffocation)Mucus plug
Pneumothorax
Pulmonary edema
Restrictive lung disease
Severe hypoventilation (e.g., neurologic
somnolence, oversedation)

HCO3
Increased HCO3 levels
Aldosteronism
Chronic and high-volume gastric suction
Chronic vomiting
Chronic obstructive pulmonary disease
Use of mercurial diuretics
Decreased HCO3 levels
Acute renal failure
Chronic and severe diarrhea
Chronic use of loop diuretics
Diabetic ketoacidosis
Starvation

Good things come to people who wait,

but better things come to those who
go out and get them.

-prince rener pera