RESPIRATORY DISORDERS

NIO CRUZADA NOVENO, RN

 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Respiratory Therapy

1. Suctioning
❑ Secretions too thick to cough out; inability of pt
❑ O2 prior suction; no more than 15 sec
❑ Position pt w/ extended head & neck
❑ R bronchus [15 to vertical]; L bronchus [25-35]
2. Tracheostomy Care
3. IPPB
❑ O2 & air mixture is forced into pt’s lung during
inspiration
❑  alveolar ventilation; promotes coughing of
secretion; deep adm’n of aerosol meds

RESPIRATORY 2
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Mechanical Ventilation [Respirators]

➢ Ventilation by mechanical means in those who are

unable to maintain N levels of O2 & CO2 in blood
➢ COPD, neuromuscular dse, ARDS, thoracic
trauma..

❑ Modes
✓ Assist/control mode
✓ Intermittent mandatory ventilation (IMV)
✓ Positive end expiratory pressure (PEEP)
✓ Continuous positive airway pressure (CPAP)

RESPIRATORY 3
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Mechanical Ventilation [Respirators]

❑ Nursing Care
Assess for:
✓ Intermittent mandatory ventilation (IMV)
✓ Positive end expiratory pressure (PEEP)
✓ Continuous positive airway pressure
(CPAP)

RESPIRATORY 4
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Mechanical Ventilation [Respirators]

❑ Nursing Care
✓ Assess for  cardiac output
✓ Monitor for (+) water balance [I&O, daily
wts, peripheral edema, auscultate BS]
✓ Monitor for barotrauma
▪ Assess ventilator setting q 4hrs
▪ BS q 2hrs
▪ ABGs
▪ Pulmonary PE q shift
✓ Monitor GI problems (stress ulcer)

RESPIRATORY 5
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Endotracheal Tube [Artificial Airway]

➢ cuffed tube inserted by anesthesiologist

➢ Suction frequently
➢ deflate cuff 3-5 min q 1-2hrs

❑ Assessment
✓ ABGs
✓ Hypoventilation & hyperventilation
[Expiration is longer than insp. cycle – N]
❑ Nursing Care
✓ Oral hygiene
✓ Suctioning [frequent]
✓ Humidification
RESPIRATORY 6
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Oxygen Therapy

➢ most common therapy with respiratory problems

❑ Indications
✓ Arterial hypoxemia [COPD,ARDS]
✓ Tissue, cellular & circulatory hypoxia
❑ Methods
✓ Masks – 25-35%
✓ Cannula prong 30-40% at 6-8L/min
✓ Catheter
❑ O2 toxicity
✓ Eye blindness;lung atelectasis; convulsion

RESPIRATORY 7
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Chest Physiotherapy

➢ Postural drainage
➢ Percussion
➢ Vibration

❑ Nursing Care
✓ Perform before or 3-4hrs after meal
✓ Bronchodilators 15-20 min before
✓ Remove all tight clothings
✓ Percuss on area approx 3min during I& E
✓ Vibrate on area during E of 4-5 deep
✓ Assist pt in coughing positioning
✓ Provide good oral hygiene
RESPIRATORY 8
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Chest Tubes [Water-Seal Drainage Systems]

➢ Insertion of catheter into the intrapleural

space for evacuation of fluid or air
➢ 2nd or 3rd IC space anterior or mid-axillary line
[air]; 8th or 9th IC space [fluid]

❑ Types
✓ One-Bottle system [collection chamber
& water seal]
✓ Two-Bottle system [ 1 bottle – drainage
collection chamber; 1 bottle – water
seal]
✓ Three-Bottle system [drainage collection,
RESPIRATORY water seal and suction control bottle] 9
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Chest Tubes [Water-Seal Drainage Systems]

❑ Nursing Care
✓ Bottles are always kept below chest level
✓ Check for kinks and leaks
Water-seal bottle:
Fluid fluctuates up w/ Insp, down w/ Exp;
Intermittent bubbling – N w/ exhalation,
coughing or sneezing;
No fluctuation/intermittent bubbling –
reexpansion of lung or blockage
Continuous bubbling – air leak
Suction control bottle:
Air bubbles gently and continuously from
submerged tube
RESPIRATORY 10
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Chest Tubes [Water-Seal Drainage Systems]

❑ Characteristics of chest drainage

✓ Initially very bloody
✓ 500-1000ml in 1st 24hrs
✓ When lung is expanded fluid fluctuation
ceases in water seal bottle
✓ Closed chest drainage is usually required
for 2-3 days postOP
❑ Removal of chest tube
✓ Instruct pt to perform Valsalva
maneuver; apply vaseline pressure
dressing to site
✓ Pt is given pain meds prior to removal
RESPIRATORY ✓ Observe air leak after removal 11
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Thoracic Surgical Procedures

1. Exporatory thoracotomy: incision of the thoracic

wall, performed to locate bleeding, injuries,
tumors

2. Thoracoplasty: removal of ribs or portion of ribs to

reduce the size of the thoracic space

3. Pneumonectomy: removal of entire lung

[Bronchogenic Ca]

RESPIRATORY 12
DISORDERS (NCN)
 OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS

Thoracic Surgical Procedures

4. Lobectomy: removal of a lobe of the lung

[bronhiectasis, bronchogenic Ca,
emphysematous blebs, lung abscess]
5. Segmented resection: removal of one or more
segments of the lung [bronchiectasis]
6. Wedge resection: removal of a small, localized
area of disease near the surface of the lung or
lesion that occupies only part of a segment of
lung tissue [excision of nodules for biopsy]
7. Decortication: stripping off the fibrous membrane
that covers the pleura

RESPIRATORY 13
DISORDERS (NCN)
 OXYGENATION (Respiratory)

ACID-BASE BALANCE

Acids
❑ Proton donors
❑ Give H+ in solution
❑ Electron acceptors

Bases
❑ Proton acceptors
❑ Give OH- in solution
❑ Electron donors

RESPIRATORY 14
DISORDERS (NCN)
 OXYGENATION (Respiratory)

ACID-BASE BALANCE

Role of Acid-Base Balance

❑ Acids & bases must be balanced to

maintain homeostasis in the body’s fluids

❑ Homeostasis is crucial for all life processes to

occur [eg. cellular metabolism, nerve &
muscle conduction, smooth muscle &
cardiac muscle contraction]

❑ Acid-base balances cause changes in the

performance of certain body functions
[eg. respiratory stimulation, changing
electrolyte levels]
RESPIRATORY 15
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Metabolic Production of Acids and Bases

Acids
❑ CO2 (H2CO3) [metabolism of fats & CHO]
❑ Sulfuric acids [S-containing amino acid]
❑ Hydrochloric acid [cationic amino acid]
❑ Phosphoric acid [oxidation of phospholipids &
phosphoproteins]
❑ Organic acids [lactic acid, acetoacetic acid]
❑ Fecal loss of HCO3-

Bases
❑ HCO3- [metabolism of anionic amino a.,
citrates]
Production of non-volatile acids is highly dependent on the diet
RESPIRATORY 16
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Mechanism of pH Regulation

❑ Neutralization by buffer systems in the blood,

lymph, interstitial & intracellular fluids

❑ Regulation of CO2 excretion by the lungs

❑ Excretion of acids & bases by the kidneys

❑ Synthesis of ammonia by the kidneys

RESPIRATORY 17
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Buffer Systems

❑ Bicarbonate BS
✓ major EC buffer; 1st line defense
✓ Regulated by both kidneys & lungs
✓ N ratio of [HCO3-]/pCO2 = 20:1 → pH 7
❑ Hemoglobin BS
✓ 2nd major BS in the plasma
✓ Neutralizes and disposes CO2 in the lungs
❑ Phosphate BS
✓ major intracellular BS
❑ Plasma Protein
✓ Minor role in the plasma

RESPIRATORY 18
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Acid-Base Disturbances

❑ Three steps to identify the acid-base imbalance:

✓ Determine arterial blood pH [acidosis,
alkalosis]
✓ Determine CO2 level [respiratory]
✓ Determine HCO3- level [metabolic]

❑ Normal Values: ABG

✓ Arterial pH [7.35-7.45]
✓ Bicarbonate (HCO3-) [24-28 mEq/L]
✓ Carbon dioxide (PCO2) [35-45 mmHg]
✓ Oxygen (PO2) [95%]
✓ O2 saturation [93-98%]

RESPIRATORY 19
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Acid-Base Disturbances

Disturbance pH PaCO2 [HCO3-] Compensation

(mEq/L) (mmHg)

Respiratory acidosis < 7.35  N  HCO3-

Respiratory alkalosis > 7.45  N  HCO3-

Metabolic acidosis < 7.35 N   pCO2

Hypervent
Metabolic alkalosis > 7.45 N   pCO2
Hypovent

RESPIRATORY 20
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Acid-Base Disturbances

Example: pH = 7.30
pCO2 = 50 mmHg
[HCO3- ]= 25 mEq/L
Disturbance: Respiratory acidosis
Compensation:  HCO3- absorption
[kidneys]
Example: pH = 7.31
pCO2 = 38 mmHg
[HCO3- ] = 20 mEq/L
Disturbance: Metabolic acidosis
Compensation:  pCO2 , hypoventilation
[lungs]
RESPIRATORY 21
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Respiratory Acidosis [ pH,  pCO2]

➢ Involve “hypoventilation” leading to retention of

Paco2

❑ Symptoms:
✓ Slow, shallow, weak respirations
✓ Declining level of consciousness
✓ Mental lethargy, confusion, disorientation
✓ Associated signs of impaired oxygenation

RESPIRATORY 22
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Respiratory Acidosis [ pH,  pCO2]

❑ Associated disease or conditions:

✓ COPD (Emphysema)
✓ Pneumonia
✓ Head trauma → damage to respiratory
center
✓ Overdose → depression of respiratory
center
✓ Barbiturates, anesthetics, narcotics
✓ Respiratory or cardiac arrest

❑ Nursing Management:
✓ Assess the cause, correct it
✓ Provide O2 & support for ventilation
✓ Administer NaHCO3 as ordered
RESPIRATORY ✓ Monitor pts mental status & serial ABGs 23
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Respiratory Alkalosis [ pH,  pCO2]

➢ involve “hyperventilation” leading to excessive

loss of Paco2

❑ Symptoms:
✓ Rapid, deep, “blowing” respirations
✓ Acute excitation, trembling nervousness
✓ Neuromuscular irritability
✓ Numbness & tingling of extremities

RESPIRATORY 24
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Respiratory Alkalosis [ pH,  pCO2]

❑ Associated disease or conditions:

✓ Asthma (acute bronchial constriction)
✓ Brain injury (+) resp. center
✓ Overdose of ASA, cocaine
✓ Acute anxiety (“fight” or “flight” response)
✓ High altitude (hyperventilation)

❑ Nursing Management:
✓ Assess the cause, correct it
✓ Coaching pt’s breathing pattern to slow,
deep respiration, coaching breathing,
breath holding and paper bag breathing
✓ Reduce anxiety [anxiolytics/sedatives]

RESPIRATORY 25
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Metabolic Acidosis [ pH,  loss of HCO3-]

❑ Symptoms:
✓ CNS depression [cardiac dysrhythmia,
apathy & lethargy, disorientation, coma]
✓ Kussmaul breathing
✓ Acetone breathe [DM]
✓ Oliguria or anuria [renal failure]

❑ Anion Gap = [Na+ + K+] – [Cl- + HCO3-]

= 12-16 mEq/L
 Anion gap acidosis – normochloremic

 Anion gap acidosis – hypoalbuminemia

[1gm/dl  albumin = 2mEq/L  AG]
N Anion gap - hyperchloremic
RESPIRATORY 26
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Metabolic Acidosis [ pH,  HCO3-] -  loss of HCO3-

❑ Associated disease or conditions

✓ Severe or prolonged diarrhea
✓ Prolonged fasting [anorexia]
✓ Normochloremic acidosis
▪ Diabetid ketoacidosis [ BHBA, AA]
▪ Alcoholic acidosis [ BHBA, AA]
▪ Shock, sepsis, CHF [ Lactic acid]
▪ Methanol poisoning [ Lactic acid]
✓ Hypoalbuminemia, hypercalcemia,
hypermagnesemia, hyperkalemia, lithium
toxicity, IgG myeloma
✓ GI HCO3- losses, defects in renal
acidification [N anion gap]

RESPIRATORY 27
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Metabolic Acidosis [ pH,  HCO3-] -  loss of HCO3-

❑ Nursing Management:
✓ Assess the cause, correct it
✓ Reversal of acidotic state;
NaHCO3 administration [pH < 7.2]
✓ Close watch on VS & level of
consciousness
✓ Cardiac monitoring
✓ Serial ABGs

RESPIRATORY 28
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Metabolic Alkalosis [ pH,  HCO3-]

❑ Symptoms:
✓ CNS excitement [irritability, disorientation,
muscular twitching, seizures]
✓ Dysrhythmia

❑ Associated disease or conditions:

✓ Gastric loss of HCl [vomiting, mechanical
darinage,]
✓ Use of diuretics
✓ Endo/exogenous mineralocorticoid excess
[hypokalemia]
✓ Acetated in parenteral alimentation
✓ Citrate in fresh whole blood [BT]

RESPIRATORY 29
DISORDERS (NCN)
 OXYGENATION (ACID-BASE BALANCE)

Metabolic Alkalosis [ pH,  loss of HCO3-]

❑ Nursing Management
✓ Assess the cause, correct it
✓ Reversal of alkalotic state;
✓ Volume expansion w/ NaCl
[vomiting/diuretic induced]
✓ K+ repletion
✓ Carbonic anhydrase inhibitor
✓ Monitor VS
✓ Serial ABGs

RESPIRATORY 30
DISORDERS (NCN)
RESPIRATORY DISORDERS

NIO CRUZADA NOVENO, RN