Module C

Respiratory

Roy Model- Oxygenation

Required Readings-

Lewis, Heitkemper, Dirksen. Medical-Surgical Nursing (current Ed.) Mosby,

a. Respiratory Review – understanding of the normal respiratory system
b. Acid-Base – ABG’s
c. Acute respiratory complications such as ARDS/ ARF
d. Ventilators- management, trouble shooting

Additional required articles as found on Etudes

Recommended Readings-
Pathophysiology book review and drugs affecting the respiratory system

Theory Objectives
1. Review the anatomical structures and physiological functions of the
respiratory tract.
2. Review age related changes in the respiratory system and differences in
assessment findings.
3. Describe the significance of arterial blood gas values and the oxyhemoglobin
dissociation curve in relation to respiratory function.
4. Analyze and interpret blood gas results.
5. Apply the Roy Model nursing process to perioperative care of a client
undergoing chest surgery.
6. Explain the etiology, pathophysiology, diagnostic evaluation, clinical
manifestations, nursing and collaborative management for respiratory failure,
and acute respiratory distress syndrome (ARDS)
7. Discuss indications for, types, and modes of mechanical ventilation.
8. Define key ventilator controls and settings
9. Discuss nursing responsibilities of a client receiving mechanical ventilation.
10. Discuss the role of the respiratory therapist in management of the ventilator
client.

Clinical Component-
Objectives
1. Assist with physical care and assessment of clients in an intensive care
setting with respiratory dysfunction.
2. Care for clients on ventilator support, airway maintenance
3. Assist with tracheostomy, endotracheal, nasal or oral suctioning.
4. Monitor ventilator settings and/ or oxygen support.
Drugs
Steroids (Solu-Cortef, Solu-Medrol), Diuretics, Bronchodilators (Terbutaline,
Theophylline), Inhalers (IPPB, HHN, Nebulized), Neuromuscular blocking agents

Diet
High calorie, high protein and/or restriction or force of fluids

Laboratory
ABG’s, Hematology and other CXR, Lung Scans, Sputum studies, Oxygen
saturation bedside monitoring

Critical Thinking Question

1. A patient is returning to the nursing unit after chest surgery with an
endotracheal tube, a chest tube, and two IV’s in place. Identify the
priorities of assessment and interventions for this patient.
2. A 55 year old client in the ICU on mechanical ventilation postoperative
for open heart surgery, now at day 2 of recovery. Develop a checklist and
a general plan of care based on this client’s stage of recovery. Prioritize!
3. A client presents to the clinic c/o chest pain. He appears acutely ill, and
you begin your assessment immediately. What manifestations will the
client exhibit that will help to differentiate among a pulmonary embolus,
myocardial infarction, and pneumonia? What necessary equipment and/
or responses are necessary in each of these disorders? What diagnostic
tests can you anticipate?
 Module B
Respiratory Supplement

Review Key Concepts

The major function of the respiratory system is gas exchange. During gas
exchange, air is taken into the body through inhalation and travels through respiratory
passages to the lungs. In the lungs, oxygen is attached to the red blood cells and carbon
dioxide is given off.

Respiratory Assessment and Function

Respiratory Assessment
1. Review Structures and Functions of the Respiratory System
2. Physiology of Respiration
a. ABG’s
b. Manifestations of inadequate oxygenation
3. Other
a. control of respiration
b. defense mechanisms
4. Geriatric Considerations
5. Assessment
a. Shunting
b. Adventitious Sounds
c. Other disease manifestations

Diagnostic Procedures
1. Chest radiology (CXR) – PA/ LAT
2. Tomography – plane of a section (solid lesion)
3. Computerized Tomography (CT/ CAT)- cross sectional views
4. PET – radioactive- more specific views of perfusion
5. Angiography radioactive- (vessels)
6. Endoscopic Procedures
7. Biopsy
8. Sputum
9. Thoracentesis
10. Review Pulmonary Function Test
11. Lung Scans

Acid/ Base Balance with Respiratory Conditions

1. Types of Hypoxia
2. Be familiar with most reliable and accurate oxygen administration devices
3. Oxygen – is a drug- how do you know it is working or causing a problem
4. Treatment modalities- advantages/ disadvantages
a. IPPB- intermittent positive pulmonary breathing
b. Nebulizer Therapy
c. Incentive Therapy- Chest PhysiotherapyPostural Drainage/ Percussion-
Vibration
 d. Artificial Airways- i.e. Intubation
5. Preventive complications for pt’s with artificial airways
a. Early- bleeding, pneumothorax, air embolism, aspiration, recurrent laryngeal
nerve damage, subcutaneous or mediastinal emphysema, penetration of the
wall
b. Later- infection, rupture of the innominate artery, dysphagia,
tracheoesophageal fistula, tracheal deviation, tracheal ischemia/ necrosis
c. Airway removal- vocal cord paralysis/ nerve damage or tracheal stenosis
6. Respiratory Acidosis-
a. Characterized by excess of carbon dioxide, reduced alveolar ventilation
b. Assess- CV- tachycardia, HTN, atria/ ventricular arrhythmias, hypotension
with vasodilation
c. Treatment- endotracheal intubation, dialysis to remove toxic drugs, antibiotics
if pneumonia, bronchodilators, Sodium Bicarb- for severe cases only.
7. Respiratory Alkalosis
a. Characterized by deficiency of carbon dioxide in blood , alveolar
hyperventilation
b. Assess- agitation, cardiac arrhythmias fail to respond to tx, circumoral/
peripheral paresthesias, deep rapid breathing (40+), light headedness/
dizziness (especially watchful of neurological, neuromuscular, or
cardiovascular change)
c. Treatment- consists of treating the underlying condition (CNS disease, fever/
sepsis), relaxation techniques, breathing into a bag during panic attack.

Respiratory Problems

Acute Respiratory Distress Syndrome (ARDS)

In ARDS fluids builds up in the lungs and causes them to stiffen. This
impairs breathing, thereby reducing the amount of oxygen in the capillaries that
supply the lungs. When severe, the syndrome can cause an unmanageable and
ultimately fatal lack of oxygen. However, clients who recover may have little or
no permanent lung damage.
Pneumonic-
A- assault to the pulmonary system
R- respiratory distress
D- decreased lung compliance
S- Severe respiratory failure
Risk Factors
Aspiration Decreased Surfactant production
Fat Emboli Fluid overload
Neurological injuries Oxygen toxicity
Respiratory infection Sepsis, shock, or Trauma

Assessment/ Diagnostics
Priority assessment- with a minimum of 3 s/sx clustered together
Priority diagnostics to prove suspicion of the problem
Nursing Diagnosis
Impaired gas exchange r/t (disease state/ situation ) m/b (cluster of 3 s/sx)
Ineffective breathing pattern r/t (disease state/ situation ) m/b (cluster of 3 s/sx)
Ineffective tissue perfusion: Cardiopulmonary r/t (disease state/ situation ) m/b (cluster of
3 s/sx)
Outcome- measureable and time sensitive

Interventions: (AIDC)
Assessment:
1. Priority Assessment r/t problem i.e. respiratory, cardiovascular and neurological
status noting signs/ symptoms of respiratory distress
2. Significant Patient History r/t problem and /or Situational Issue
3. Priority Diagnostics/ Laboratory Tests
Independent
Group r/t function/ purpose/ rationale i.e. To facilitate Respiratory Enhancement
1. To facilitate Respiratory Oxygen Enchange
a. Re-assess client q …… to evaluate for respiratory compromise
b. What Bed rest is best? ( prone position/ high fowler’s)
c. Suction as needed to reduce secretions
d. Evaluate dietary changes (depending on work of breathing,
ventilator?) to meet demands
e. Provide respiratory toileting by Chest physiotherapy, postural
drainage, TCDB, I/S
f. Organize nursing care with rest periods to conserve energy and avoid
overexertion and fatigue
g. Administer Medications to optimize respiratory (please list the specific
ones and why)
2. Prevent Respiratory complications
a. Monitor oxygen therapy effectiveness by pulse oximetry at or above
90%
b. Monitor laboratory values (H/H, WBC/ platelets, Coagulation panels,
fibrinogen levels)
c. Monitor Hemodynamic devices, I/O, IV’s (may include TPN as well
as other medications), daily weight
3. Initiate VAP protocol- If patient is ventilated, then Evidence-Based
Practice (EBP)
i. List all the key components of VAP protocol
Dependent
List all the specific orders needed to fix the problem/ nursing diagnosis
Collaborative
Who and why

Acute Respiratory Failure

In acute respiratory failure, the respiratory system can’t adequately supply the
body with the oxygen it needs or adequately remove carbon dioxide. A pt is considered
in failure when the PaO2 is less than or equal to 50 mm Hg with a pH of less than 7.25.
 Risk Factors
Abdominal/ thoracic surgery ARDS Anesthesia
Atelectasis Brain tumors COPD
Drug overdose Encephalitis Flail chest
Guillain-Barre syndrome Head trauma Multiple sclerosis
Muscular dystrophy Myasthenia gravis Pleural effusion

Assessment, Nursing Diagnosis, Interventions

Follow above sample

Mechanical Ventilation
Negative Pressure Vent’s – External
(Similar to spontaneous ventilation)
Positive Pressure Vent’s – Internal to Lung
 Pressure Cycle (specific pressure/ rest- no rate)
 Timed cycle (newborns, depends on expired air)
 Volume cycle (volume/ rate/ inspire-expire/ constant)
Common problems with vent’s
Disconnected tubes Hypotension Dec. phasing
Dec. gas exchange Dec. LOC Tachycardia/ pnea
Infection Inc. secretion Leaky tubes
Ventilator dependence Powerless Dec. communication
Dislodgement Atelectasis Pneumothorax
Poor ABG’s Mucus plug
Respiratory Weaning
What are the criteria used to determine a patient is reading for weaning?
How do you know the patient is not tolerating weaning?