Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

MEDICAL AND SURGICAL NURSING

R esp
espii r at
atory
ory System
System

Lecturer: Mark F red
redd
deri ck R . Abe
Abejo R N,M AN

MS 1 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

ANATOMY OF RESPIRATORY SYSTEM Pleural Fluid: prevents pleural friction

rub (as seen in pneumonia and pleural
effusion)

OXYGENATON: the dynamic interaction of gases in the body 2.  Bronchi

for the purpose of delivering adequate oxygen essential for   Lobar Bronchi: 3 R and 2 L
cellular survival   Segmental Bronchi:
Bronchi: 10 R and 8 L

  Subsegmental Bronchi
RESPIRATORY SYSTEM MAIN FUNCTION: 3.  Bronchioles
GAS EXCHANGE
EXCHANGE   Terminal Bronchioles
  Respiratory Bronchioles, considered to
I.  Upper Respiratory Tract be the transitional passageways between
A.  Functions the conducting airways and the gas
1.  Filtering exchange
2.  Warming and moistening 4.  Alveoli
3.  Humidification -  functional cellular
cellular units or gas-
B.  Parts exchange units of the lungs.
1.  Nose - made up of framework of cartilages; -  O2 and CO2 exchange takes place
divided into R and L by the nasal septum. -  Made up of about 300 million
2.  Paranasal Sinuses  –   includes four pair of bony TYPE 1 - provide structure
structure to the alveoli
cavities that are lined with nasal mucosa and TYPE 2 - secrete SURFACTANT,
SURFACTANT, reduces
reduces
ciliated epithelium. surface tension; increases alveoli stability &
3.  Tubernate Bones ( Conchae ) prevents their collapse
4.  Pharynx  –   muscular passageway for both food TYPE 3 – 
3 –  alveolar
  alveolar cell macrophages, destroys
and air foreign material, such as bacteria
  Nasopharynx
  Oropharynx   Lecithin
  Laryngopharynx   Sphingomyelin
5.  Tonsils and Adenoids L/S ratio indicates lung maturity
6.  Larynx – 
Larynx  –  voice
  voice production, coughing reflex 2:1 normal
1:2 immature lungs
Made up of framework of:
Epiglottis  –   valve that covers the
opening to the larynx during swallowing. PULMONARY CIRCULATION
Glottis  –   opening between the vocal - Provides for reoxygenation of blood and release of
cords CO2
Hyoid bone – 
bone –  u
  u shaped bone in neck
PULMONARY ARTERIES, carry blood
Cricoid cartilage
from the heart to the lungs.
Thyroid cartilage,
cartilage, forms the Adam’s
apple PULMONARY VEINS, is a large blood
Arythenoid cartilage vessel of the circulatory system that carries
Speech production and cough reflex blood from the lungs to the left atrium of the
Vocal cords heart.
7.  Trachea - consists of cartilaginous
cartilaginous rings
  Passageway of air
  Site of tracheostomy (4 th-6th tracheal ring)

II.  Lower respiratory tract

A.  Function: facilitates gas exchange
B.  Parts
1.  Lungs, are paired elastic structure enclosed in
the thoracic cage, which is an airtight chamber
with distensible walls.
  Right – 
Right  –  3
 3 lobes, 10 segments
  Left – 
Left –  2
 2 lobes, 8 segments

Client post pneumonectom

pneumonectomy y affected side to promote
expansion
Post lobectomy unaffected
unaffecte d side to promote drainage

  Pleural cavity
Parietal
Visceral

MS 2 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

RESPIRATORY MUSCLES 2.  Thickening of bronchial mucosa

- PRIMARY: diaphragm and external intercostal 3.  Obstruction of the airway
muscles 4.  Loss of lung elasticity
- ACCESORY: sternocleidomastoid
sternocleidom astoid (elevated
sternum), the scalene muscles (anterior, middle and RESPIRATION
posterior scalene) and the nasal alae   The process of gas exchange between atmospheric air
•

and the blood at the alveoli, and between the blood

cells and the cells of the body.
•

  Exchange of gases occurs because of differences in

PHYSIOLOGY OF RESPIRATORY SYSTEM partial pressures.
•  Oxygen diffuses from the air into the blood at the
alveoli to be transported to the cells of the body.
VENTILATION :
VENTILATION: The movement of air
air in and out of the
•  Carbon dioxide diffuses from the blood into the air at
airways.
the alveoli to be removed from the body.

•  The thoracic cavity is an air tight chamber. the floor

NEUROCHEMICAL CONTROL
of this chamber is the diaphragm
diaphragm..
MEDULLA OBLONGATA  –   respiratory center
•  Inspiration: contraction of the diaphragm (movement
initiates each breath by sending messages to primary
of this chamber floor downward) and contraction of
respiratory muscles over the phrenic nerve
the external intercostal muscles increases the space in
- has inspiration and expiration centers
this chamber. lowered intrathoracic pressure causes
air to enter through the airways and inflate the lungs.
PONS  –  has
PONS –    has 2 respiration centers that work with the
•  Expiration: with relaxation, the diaphragm moves up
inspiration center to produce normal rate of
and intrathoracic pressure increases. this increased breathing
pressure pushes air out of the lungs. expiration
1. PNEUMOTAXIC CENTER  –   affects the
requires the elastic recoil of the lungs.
inspiratory effort by limiting the volume of air
•  Inspiration normally is 1/3 of the respiratory cycle
inspired
and expiration is 2/3.
2. APNEUSTIC CENTER – 
CENTER –  prolongs
 prolongs inhalation

NOTE: Chemoreceptors
Chemoreceptors responds to changes in
in ph, increased
increased
DRIVING FORCE FOR AIR FLOW
PaCO2 = increase RR
Airflow driven by the pressure difference between
atmosphere (barometric pressure) and inside the lungs
(intrapulmonary pressure). RESPIRATORY EXAMINATION AND

ASSESSMENT

B ac
ackg
kground
round inf
informa
ormation
tion
A.  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 in acromegaly or hypothyroidism)
2.  Cheyne-Stokes
periods of apnoea alternating with periods of
hyperpnoae
 pa
 patho
hopphy
hysiol
siolo
ogy:  delay in medullary chemoreceptor
response to blood gas changes
causes
  left ventricular failure
AIRWAY RESISTANCE   brain damage (e.g. trauma, cerebral,
Resistance is determined chiefly by the radius size of haemorrhage)
the airway.   high altitude
3.  Kussmaul's (air hunger)
Causes of Increased Airway Resistance
deep rapid respiration due to stimulation of
1.  Contraction of bronchial mucosa respiratory centre
MS 3 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

causes: metabolic acidosis (e.g. diabetes mellitus,   Character of cough

chronic renal failure) ask patient to cough several times
4.  Hyperventilation lack of usual explosive beginning may indicate
complications: alkalosis and tetany vocal cord paralysis (bovine cough)
causes:  anxiety muffled, wheezy ineffective cough suggests
5.  Ataxic (Biot) airflow limitation
irregular in timing and deep very loose productive cough suggests excessive
causes:  brainstem damage bronchiall secretions due to:
bronchia
6.  Apneustic - chronic bronchitis
post-inspiratory pause in breathing
post-inspiratory - pneumonia
causes:  brain (pontine) damage - bronchiectasis
dry irritating cough may occur with:
7.  Paradoxical - chest infection
the abdomen sucks with respiration (normally, it - asthma
pouches uotward due to diaphragma
diaphragmatictic descent) - carcinoma of bronchus
causes: diaphragm
diaphragmatic
atic paralysis - left ventricular failure
- interstitial lung disease
B.  Cyanosis - ACE inhibitors
1.  Refers to blue discoloration of skin and mucous   Sputum
membranes , is due to presence of deoxygenated volume
haemoglobin in superficial blood vessels type (purulent, mucoid, mucopurul
mucopurulent)
ent)
2.  Central cyanosis = abnromal amout of deoxygenated presence or absence of blood?
haemoglobin in arteries and that blue discoloration is   Stridor
present in parts of body with good circulation such as croaking noise loudest on inspiration
tongue is a sign that requires urgent attention
3.  Peripheral cyanosis
cyanosis = occurs when blood supply to a
certain part of body is reduced, and the tissue extracts causes:
broncus)(obstruction of larynx, trachea or large
more oxygen from normal from the circulating blood, - acute onset (minutes)
e.g. lips in cold weather are often blue, but lips are   inhaled foreign body
spared   acute epiglottitis
4.  Causes of cyanosis   anaphylaxis
Central cyanosis   toxic gas inhalation
  decreased arterial saturation - gradual onset (days, weeks)
  decreased concentration of inspired   laryngeal and pharyngeal tumours
oxygen: high altitude   crico-aryte
crico-arytenoid
noid rheumatoid arthritis
  lung disease: COPD withw ith cor pulmoale,   bilateral vocal cord palsy
massive pulmonary embolism   tracheal carcinoma
  right to left cardiac shunt (cyanotic   paratracheal compression by lymph
congenitall heart disease)
congenita nodes
  polycythaemia   post-tracheostomy or intubation
  haemoglobin abnromalities (rare): granulomata
methaemoglobinaemia, sulphaemoglobinaemia   Hoarseness

Peripheral cyanosis
  all causes of central cyanosis cause peripheral causes include:
- laryngitis
cyanosis - laryngeal nerve palsy associated with
  exposure to cold carcinoma of lung
  reduced cardiac output: left ventricular failure - laryngeal carcinoma
or shock
  arterial or venous obstruction The Hands

Position: patient sitting over edge of bed   Clubbing

commonly cause by respiratory disease (but NOT
General appearance emphysema or chronic bronchitis)
  look for the following
occasionally, clubbing is associated with hypertrophic
  Dyspnea
pulmonary osteoarthropathy
osteoarthropathy (HPO)
  characterised by periosteal inflammation at distal
normal respiratory rate < 14 each minute
ends of long bones, wrists, ankles, metacarpals and
tachypnoea = rapid respiratory rate
metatarsals
are accessory muscles being used
  sweelling and tenderness over wrists and other
(sternomastoids, platysma, strap muscles of
involved areas
neck) - characteristically, the accessory muscles
cause elevation of shoulders with inspiration and
aid respiration by increasing chest expansion
  Cyanosis  

MS 4 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

  Staining
staining of fingers - sign of cigarette smoking (caused Pigeon chest (pectus carinatum)
by tar, not nicotine)   localised prominence (outward bowing of sternum
  Wasting
Wasting and weakness and costal cartilages)
  Pulse rate
  causes:
  Flapping tremor (asterixis) - unreli able
unreliab le sign manifestation of chronic childhood illness (due
manifestation
ask patient to dorsiflex wrists and spread out fingers, to repeated strong contractions of diaphragm
with arms outstretched while thorax is still pliable)
flapping tremor may occur with severe carbon dioxide rickets
retention (severe chronic airflow limitation)

The Face

  Eyes
Horner's syndrome?
syndrome? (constricted pupil, partial ptosis
and loss of sweating which can be due to apical lung
tumour compressing sympathetic nerves in neck)
  Nose
polpys? (associated with asthma) Funnel chest (pectus excavatum)
engorged turbinates? (various allergic conditions)   developmental defect involving a localised
deviated septum? (nasal obstruction) depression of lower end of sternum in severe cases,
  Mouth and tongue lung capacity may be restricted
look for central cyanosis
evidence of upper respiratory tract infection (a
reddened pharynx and tonsillar enlargement with or
without a coating of pus)
broken tooth - may predispose to lung abscess or
pneumonia
  sinusitis is indicated by tenderness over the sinuses on
palpation
  some patients with obstructive sleep apnoea will be obese
with a receding chin, a small pharynx and a short thick
Harrison'ss sulcus
Harrison'
neck
  innar depression of lower ribs just above costal
The Trachea margins at site of attachment of diaphragm
  causes:
  causes of tracheal displacemen
displacement:
t:
severe asthma in childhood
toward the side of the lung lesion rickets
  upper lobe collapse
Kyphosis , exaggerated forward curvature of spine
  upper lobe fibrosis
Scoliosis , lateral bowing
  pneumonectomy
Kyphoscoliosis:  causes:
upper mediastinal masses, such as retrosternal goitre
  idiopathic (80%)
  tracheal tug (finger resting on trachea feels it move
  secondary to poliomyelitis (inflammation involving
inferiorly with each inspiration)
inspiration) is a sign of gross
grey matter of cord)
overexpansion of the chest because of airflow obstruction
  (note: severe thoracic kyphoscoliosis may reduce
The Chest: inspection lung capacity and increase work of breathing)
Lesions of chest wall
  Shape and symmetry of chest
  scars - previous thoracic operations or chest drains
Barrel shaped for a previous pneumothorax or pleural effusion
  anteroposterior (AP) diameter is increased
  thoracoplasty (was once performed to remove TB,
compared with lateral diameter but no longer is because of effective antituberculosis
  causes:  hyperinflation due to asthma, emphysema chemotherapy) invovled removal of large number of
ribs on one side to achieve permanent collapse of

  affected
erythemalung
and thickening of skin may occur in
radiotherapy; there is a sharp demarcation between
abnormal and normal skin

MS 5 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

Diffuse swelling of chest wall and neck to trauma or spontaneous as a result of tumour
  pathophysiology: air tracking from the lungs deposition or bone disease)
  causes:
The Chest: percussio
percussion
n
pneumothorax
rupture of oesopahagus with left hand on chest wall and fingers slightly separated
Prominent veins and aligned with ribs, the middle finger is pressed firmly
  cause:  superior vena caval obstruction against the chest; pad of right middle finger is used to
Asymmetry of chest wall movements strike firmly the middle phalanx of middle finger of left
  assess this by inspecting from behind patient, hand
looking down the clavicles during moderate percussion of symmetrical areas of:
respiration
respiratio n - diminished movement indicates   anterior (chest)
underlying lung disease   posterior (back) (ask patient to move elbows forward
  the affected side will showed delayed or decreased across the front of chest - this rotates the scapulae
across
movement anteriorly, i.e. moves it out of the way)
  causes of reduced chest wall movements on one side   axillary region (side)
are localised:   supraclavicular fossa
localised pulmonary fibrosis percussion over a solid structure (e.g. liver, consolidated
consolidation lung) produces a dull note
collapse percusion over a fluid filled area (e.g. pleural effusion)
pleural effusion produces an extremely dull (stony dull) note
pneumothroax percussion over the normal lung produces a resonant note
causes of bil
bilate
aterr al red
r educed
uced chest wall
wall mo
movem
vements
ents are percussion over a hollow structure (e.g. bowel,
diffuse: pneumothorax) produces a hyperresonsant note
  chronic airflow limitation lilive
verr dullness:
dullness:
  diffuse pulmonary fibrosis   upper level of liver dullness is determined by
percussing down the anterior cehst in mid-clavicular
The Chest: palpation line
  chest expansion   normally, upper level of liver dullness is 6th rib in right
place hands firmly on chest wall with fingers extending mid-clavicular line
around sides of chest (fugyre 4.5)   if chest is resonant below this level, it is a sign of

as patient takes a big breath in, the thumbs should move hyperinflation usually due to emphysema, asthma
symmetrically apart about 5 cm carr diac dullness:
ca dullness:
  area of cardiac dullness is uaully present on left side of
reduced expansion on one side indicates a lesion on that
side chest
  this may decrease in emphysema or asthma
note: lower lobe expansion is tested here; upper lobe is
tested for on inspection (as above) The Chest: auscultation
  apex beat
(discussed in cardiac section)   breath sounds
for respiratory diseases: introduction
  displacemen
displacementt toward site of lesion - can be caused one should use the diaphragm of stethoscope to
by: listen to breath sound in each area, comparing
collapse of lower lobe each side
localised pulmonary fibrosis remember to listen high up into the axillae
  displacement away from site of lesion - can be remember to use bell of stethoscope to listen to
caused by: lung from above the clavicles
pleural effusion quality of breath sounds
tension pneumothorax normal breat sounds
  apex beat is often impalpable in a chest w hich is   are heard with stethoscope over all parts of
hyperexpanded secondary to chronic airflow chest, produced in airways rather than alveoli
limitation (although once they had been thought to arise
  vocal fremitus from alveoli (vesicles) and are therefore called
palpate chest wall with palm of hand while patient vesicular sounds)
  normal (vesicular) breath sounds are louder
repeats "99"
and longer on inspiration than on expiration;
front and back of chest are each palpated in 2
and there is no gap between the inspiratory
comparablee positions with palms; in this way differences
comparabl
and expiratory sounds
in vibration on chest wall can be detected
bronchial breath sounds
causes of change in vocal fremitus are the same as those
  turbulence in large airways is heard without
for vocal resonance (see later)
being filtered by the alveoli, and therefore
 
ribsgently compress chest wall anteroposteriorly and produce a different quality; they are heard
over the trachea normally, but not over the
laterally
lungs
localised pain suggests a rib fracture (may be secondary
  are audible throughout expiration, and often

MS 6 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

there is a gap between inspiration and pulmonary fibrosis

expiration - medium crackles - typically caused by
  are heard over areas of consolidation since left ventricular failure (due to presence
solid lung conducts the sound of turbulence in of alveolar fluid)
main airways to peripheral areas without - coarse crackes
crackes - tend to change with
filtering coughing; occur with any disease that
  causes include: leads to retention of secretions;
- lung consolidation (lobar pneumonia) - commonly occur in bronchiectasis
common pleural friction rub
localised pulmonary fibrosis -   when thickened, roughened pleural surfaces
- uncommon rub together, a continuous or intermittent
- pleural effusion (above the fluid) - grating sound may be heard
uncommon   suggests pleurisy, which may be secondary to
- collapsed lung (e.g. adjacent to a pleural pulmonary infarction or pnuemonia
effusion) - uncommon
  amphoric sound = when breath sounds over a   vocal resonanance
large cavity have an exaggerated bronchial gives information about lungs' ability to transmit
quality) sounds
i nte
ntensi
nsity
ty of breath
breath sounds consolidated lung tends to transmit high frequencies
causes of reduced breath sounds include: so that speech heard through stethoscope takes a
  chronic airflow limitation (especially bleeting quality (aegophony); when a patient with
emphysema) aegophony says "bee" it sounds like "bay"
  pleural effusion listen over each part of chest as patient says "99";
  pneumothorax over consolidated lung, the numbers will become
  pneumonia clearly audible; over normal lung, the sound is
  large neoplasm muffled
 pulmonary collapse whispering pectoriloquy - vocal resonance is
added (adventitious) sounds increased to such an extent that whispered speech is
two types of added sounds: continuous (wheezes)
(w heezes) distinctly heard
and interrupted (crackles)
The Heart
wheezes
  may be heard in expiration or inspiration or lie patient at 45 degrees
both measure jugular venous plse for right heart failure
  pathophysiol
pathophysiology
ogy of wheezes - airway examine preacordium; pay close attention to
narrowing pulmonary component of P2 (which is best heard at
  an inspiratory wheeze implies severe airway
2nd intercostal space on left) and should not be louder
narrowing than A2; if it is louder, suspect pulmonary
hypertension
  causes of wheezes include:
cor pulmonale (also called pulmonary hypertensive
- asthma (often high pitched) - due to
heart disease) may be due to:
muscle spasm, mucosal oedema,
chronic airflow limitation (emphysema)
excessive secretions
pulmonary fibrosis
- chronic airflow diseases - due to mucosal
oedema and excessive secretions pulmonary thromboembolism
- carcinoma causing bronchial obstruction marked obesity
- tends to cause a localised wheeze which sleep apnoea
is monophonic and does not clear with severe kyphoscoliosis
coughing The Abdomen
crackles
  some terms not to use include rales (low palpate liver for enlargement due to secondary
pitched crackles) and creptitation
creptitationss (high
( high deposits of tumour from lung, or right heart failure
pitched crackles)
Other
  crackles are due to collapse of peripheral
airways on expiration and sudden opening on Permberton's sign
Permberton's
inspiration   ask patient to lift arms over head
  early inspiratory crackles   look for development of facial plethora,
- suggests disease of small airways inspiratory stridor, non-pulsatile elevation of
- character
characteristic
istic of chronic airflow  jugular venous
venous pressure
pressure
limitation   occurs in vena caval obstruction
- are only heard in early inspiration
  late or paninspiratory crackles Feet
  inspect for oedema or cyanosis (clues of cor
- suggests disease confined to alveoli pulmonale)
- may be fine, medium or coarse   look for evidence of deep vein thrombosisd
- fine crackles - typically caused by
MS 7 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

Respiratory rate on exercise and positioning

  patients complaining of dyspnoea should have
their respiratory rate measured at rest, at
maximal tolerated exertion and supine
  if dyspnoea is not accompanied by tachypnoea
when a patient climbs stairs, one should consider
malingering
  look for paradoxical inward motion of abdomen
during inspiration when patient is uspine
(indicating diaphragmatic paralysis)
Temperature: fever may accompany any acute or
chronic chest infection
3. Chest X-ray
  This is a NON-invasive procedure involving
involving the use of
x-rays with minimal radiation.
  The nurse instructs the patient to practice the on cue
to hold his breath and to do deep breathing
  Instruct the client to remove metals from the chest.
  Rule out pregnancy first.
5. Computed Tomography
Tomography (CT Scan) and Magnetic Resonance
Resonance
Imaging ( MRI )

  The CT scan is a radiographic procedure that utilizes

x-ray machine.
+
DIAGNOSTIC EVALUATION   The MRI uses magnetic field to record the H  density
of the tissue.
It does NOT involve the use of radiation.
1. Skin Test: Mantoux Test or Tuberculin Skin Test The contraindications
contraindications for this procedure are the
following: patients with implanted pacemaker,
pacemaker,
  This is used to determine if a person has been infected patients with metalli
metallicc hip prosthesis or other
or has been exposed to the TB bacillus. metal implants in the body.
  This utilizes the PPD (Purified Protein Derivatives).
  The PPD is injected intradermally usually in the inner
aspect of the lower forearm about 4 inches below the
elbow.
  The test is read 48 to 72 hours after injection.
  (+) Mantoux Test is induration of 10 mm or more.
  But for HIV positive clients, induration of about 5
mm is considered positive
  Signifies exposure to Mycobacterium Tubercle bacilli

This chest CT scan shows a cross-section of a person

with bronchial cancer. The two dark areas are the lungs. The
2. Pulse Oximeter light areas within the lungs represent the cancer.

  Non-invasive method of continuously monitoring he

oxygen saturation of hemoglobin
  A probe or sensor is attached to the fingertip,
forehead, earlobe
earlobe or bridge of the
t he nose
  Sensor detects changes in O2 sat levels by monitoring
light signals generated by the oximeter and reflected
by the blood pulsing through the tissue at the probe
  Normal SpO2 = 95% - 100%
  < 85% - tissues are not receiving enough O2
  Results unreliable in:
  Cardiac arrest
  Shock
  Use of dyes or
vasoconstrictors
  Severe anemia
  High carbon
Clear MRI images of lung airways during breathing . 
monoxide Level

6. Flourosco
Flouroscopy
py

MS 8 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

  Studies the lung and chest in motion   Atropine (to diminish secretions) is
  Involves the continuous observation of an image administered one hour before the procedure
reflected on a screen when exposed to radiation in the   About 30 minutes before bronchoscopy,
bronchoscopy,
manner of television screen that is activated by an Valium is given to sedate patient and allay
electrode beam. anxiety.
  Structures of different densities that intercept the X-   Topical anesthesia is sprayed followed by
ray beam are visualized on the screen in silhouette local anesthesia injected into the larynx
  Instruct on NPO for 6-8 hours
7. Indirect Bronchography   Remove dentures, prostheses and contact
  A radiopaque medium is instilled directly into the lenses
trachea and the bronchi and the outline of the entire   The patient is placed supine with
bronchial tree or selected areas may be visualized hyperextended neck during the procedure
through x-ray.
  It reveals anomalies of the bronchial tree and is   Nursing interventions AFTER Bronchosco
Bronchoscopy
py
important in the diagnosis of bronchiectasis.   Put the patient on Side lying position
  Tell patient that the throat may feel sore
  Nursing
Nur sing inte
interve
rvent
ntions
ions BE F ORE B ronc
roncho
hogr
graam w
  Secure written consent i
  Check for allergies to sea foods or iodine or t
anesthesia h
  NPO for 6 to 8 hours  
  Pre-op meds: atropine SO4 and valium, .
topical anesthesia sprayed; followed by local   Check for the return of cough and gag reflex.
anesthetic injected into larynx. The nurse   Check vasovagal response.
must have oxygen and anti spasmodic agents   Watch for cyanosis, hypotension,
ready. tachycardia, arrythmias, hemoptysis, and
dyspnea. These signs and symptoms indicate
  Nursing
Nur sing inte
interve
rvent
ntions
ions AF TE R Br onc
ncho
hogr
graam perforation of bronchial tree. Refer the
  Side-lying position patient immediately!
  NPO until cough and gag reflexes returned
  Instruct the client to cough and deep breathe
client

8. Bronchosco
Bronchoscopy
py
  This is the direct inspection and observatio
observationn of the
larynx, trachea and bronchi through a flexible or
rigid bronchoscope
bronchoscope..
  Passage of a lighted bronchoscope into the bronchial
tree for direct visualization of the trachea and the
tracheobronchial
tracheobron chial tree.

  Diagnostic uses:
  To examine tissues or collect secretions

  To determine location or pathologic process

and collect specimen for biopsy
  To evaluate bleeding sites
  To determine if a tumor can be resected
surgically

  Therapeutic uses
  To Remove foreign objects from
tracheobronchial
tracheobro nchial tree
  To Excise lesions
  To remove tenacious secretions
s ecretions obstructing
the tracheobronchial tree
  To drain abscess 9. Lung Scan
  To treat post-operative atelectasis   Procedure using inhalation or I.V. injection of a
radioisotope,
radioisotope, scans are taken with a scintillation
  Nursing interventions BEFORE Bronchosco
Bronchoscopy
py camera.
  Informed consent/ permit needed   Imaging of distribution and blood flow in the lungs.

  Explain procedure to the patient, tell him  

(Measure blood perfusion)
Confirm pulmonary embolism or other blood- flow
what to expect, to help him cope with the
unkown abnormalities

MS 9 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

  Nursing interventions BEFORE the procedure:

  Allay the patient’s anxiety 
anxiety      Nursing interventions AFTER the procedure:
  Instruct the patient to Remain still during   Observe the patient for signs of
the procedure Pneumothorax
Pneumothora x and air embolism
  Check the patient for hemoptysis and
  Nursing interventions AFTER the procedure hemorrhage
  Check the catheter insertion site for bleeding   Monitor and record vital signs
  Assess for allergies to injected radioisotopes   Check the insertion site for bleeding
  Increase fluid intake, unless contraindicated.   Monitor for signs of respirator
respiratory
y distress

10. Sputum Examination 12. Lymph Node Biopsy

  Laboratory test   Scalene or cervicomediastinal
  Indicated for microscopic examination
examination of the
t he sputum:   To assess metastasis of lung cancer
Gross appearance, Sputum C&S, AFB staining, and
for Cytologic examination/ Papanicolaou examination 13. Pulmonary Function Test / Studies
  Non-invasiv
Non-invasivee test
  Nursing interventions:   Measurement of lung volume, ventilation, and
  Early morning sputum specimen is to be diffusing capacity
collected (suctioning or expectorati
expectoration)
on)   Nursing interventions:
  Rinse mouth with plain water   Document bronchodilators or narcotics used
  Use sterile container. before testing
  Sputum specimen for C&S is collected   Allay the patient’s anxiety during the testing 
testing  
before the first dose of anti-microbial
therapy.
  For AFB staining, collect sputum specimen
for three consecutive mornings.

11. Biopsy of the Lungs

  Percutaneous removal of a small amount of lung
tissue
  For histologic evaluation
- Transbronchoscopic
Transbroncho scopic biopsy — done
done during
bronchoscopy,
- Percutaneous needle biopsy
- Open lung biopsy

LUNG VOLUMES: (ITER)

Inspiratory reserve volume (3000 mL)

  The maximum volume that can be inhaled following a
normal quiet inhalation.
Tidal volume (500 mL)
  The volume of air inhaled and exhaled with normal
quiet breathing
Expiratory reserve volume (1100 mL)
  The maximum volume that can be exhaled following
the normal quiet exhalation
Residual volume (1200 mL)
  The volume of air that remains in the lungs after
forceful exhalation


  Nursing interventions BEFORE the procedure: LUNG CAPACITIES:
  Withhold food and fluids
  Place obtained written informed consent in
Functional Residual Capacity (ERV 1100 mL + RV 1200 mL =
the patient’s chart. 2300 mL )

MS 10 Abejo

Medical and Surgical Nursing
Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  
  The volume of air that remains in the lungs after
normal, quiet exhalation
Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500 mL )
  The amount of air that a person can inspire
maximally after a normal expiration
Vital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL =
4600 mL )
  The maximum volume of air that can be exhaled after
a maximum inhalation
  Reduced in COPD
Total Lung Capacity (IRV 3000 mL + TV 500 mL + ERV 1100
mL + RV 1200 mL = 5800 mL )
  Total of all four volumes
14. Arterial Blood Gas
  Laborator
Laboratory y test
  Indicate respiratory functions
  Assess the degree to which the lungs are able to
provide adequate oxygen and remove CO 2 
  Assess the degree to which the kidneys are able to
reabsorb or excrete bicarbonate.
  Assessment of arterial blood for tissue oxygenation,
oxygenation,
ventilation, and acid-base status
  Arterial puncture is performed on areas where good
pulses are palpable (radial, brachial, or femoral).
Radial artery is the most common site for withdrawal
w ithdrawal
of blood specimen
   Nursing interventions:
  Utilize a 10-ml. Pre-heparinized syringe to
prevent clotting of specimen
  Soak specimen in a container with ice to
prevent hemolysis
  If ABG monitoring will be done, do Allen’s
test to assess for adequacy of collateral
circulation
circulatio n of the hand (the ulnar arteries)
15. Pulmonary Angiogra
A ngiography
phy
  This procedure takes X-ray pictures of the pulmonary
blood vessels (those in the lungs).
  Because arteries and veins are not normally seen in an
X-ray, a contrast material is injected into one or more
arteries or veins so that they can be seen.
16. Ventilation - Perfusion Scan
  Radioactive albumin injection is part of a nuclear
scan test that is performed to measure the supply of
blood through the lungs.
MS
  After the injection, the lungs are scanned to detect the
location of the radioactive particles as blood flows
through the lungs.
  The ventilation scan is used to evaluate the ability of
air to reach all portions of the lungs. The perfusion
scan measures the supply of blood through the lungs.
  A ventilation and perfusion scan is most often
performed to detect a pulmonary embolus. It is also
used to evaluate lung function in people with
advanced pulmonary
pulmonary disease such as COPD and to
detect the presence of shunts (abnormal circulation)
in the pulmonary blood vessels.
17. Thoracentesis
  Procedure suing needle aspiration of intrapleural
fluid or air under local anesthesia
  Specimen examination or removal of pleural fluid
  Nursing intervention BEFORE Thoracen
Thoracentesis
tesis
  Secure consent
  Take initial vital signs
  Instruct to remain still, avoid coughing
during insertion of the needle
  Inform patient that pressure sensation will
be felt on insertion of needle
  Nursing intervention DURING the procedure:
  Reassess the patient
  Place the patient in the proper position:
  Upright or sitting on the edge of
the bed
  Lying partially on the side,
partially on the back
  Nursing interventions after Thoracentesis
  Assess the patient’s respiratory status 
status 
  Monitor vital signs frequently
  Position the patient on the affected side, as
ordered, for at least 1 hour to seal the
puncture site
  Turn on the unaffected side to t o prevent
leakage of fluid in the thoracic cavity
  Check the puncture site for fluid leakage
  Auscultate lungs to assess for pneumothorax
  Monitor oxygen saturation (SaO2) levels
  Bed rest
  Check for expectoration of blood
11 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

2. Tracheobronchial
Tracheobronchial suctioning
  Suction only when necessary not routinely
  Use the smallest suction catheter if possible
  Client should be in semi or high Fowler’s position
  Use sterile gloves, sterile suction catheter
  Hyperventilate client with 100% oxygen before and
after suctioning
  Insert catheter with gloved hand (3-5―
(3-5― length of
catheter insertion) without applying suction. Three
passes of the catheter is the maximum
maximum,, with 10
seconds per pass.
  Apply suction only during withdrawal
w ithdrawal of catheter
  The suction pressure should be limited to less than
120 mmHg
  When withdrawing catheter rotate while applying
intermittent suction
RESPIRATORY CARE MODALITIES   Suctioning should take only 10 seconds (maximum of
15 seconds)
  Evaluate:: clear breath sounds on auscultation of the
Evaluate
1. Oxygen Therapy chest.
  Oxygen is a colorless, odorless, tasteless, and dry gas
that supports combustion
  Man requires 21% oxygen from the environment in 3. Bronchial Hygiene Measures
order to survive   Suctioning: oropharyngeal; nasopharynge
nasopharyngeal
al
  Indication: Hypoxemia
  Signs of Hypoxemia a. Steam inhalation
o
  Increased pulse rate   The purpose of steam inhalation are as follows:
- to liquefy mucous secretions
o  Rapid, shallow respiration and dyspnea
o  Increased restlessness or lightheadedness - to warm and humidify air
o  Flaring of nares - to relieve edema of airways
o  Substernal or intercostals retractions - to soothe irritated airways
o  Cyanosis - to administer medication
medication
  It is a dependent nursing function
Low flow oxygen provides partial oxygenation with patient   Inform the client and explain the purpose of the
breathing a combination of supplemental oxygen and room air. procedure
Low-flow administration devices:   Place the client in Semi-Fowler’s
Semi-Fowler’s position 
position 
o  Nasal Cannula 24-45% 2-6 LPM   Cover the client’s eyes withwith washcloth to prevent
o  Simple Face Mask 0-60% 5-8 LPM irritation
o  Partial Rebreathing Mask 60-90% 6-10 LPM
LPM   Check the electrical device before use
o  Non-rebreathing
Non-rebreath ing Mask 95-100% 6-15 LPM   Place the steam inhalator in a flat, stable surface.
o  Croupette   Place the spout 12 – 
12 –  18
 18 inches away from the client’s nose
o  Oxygen Tent or adjust distance as necessary
  CAUTION: avoid burns. Cover the chest with w ith towel to
High flow oxygen provides all necessary oxygenation, with prevent burns due to dripping of condensate from the
patients breathing only oxygen supplied from the mask and steam. Assess for redness on the side of the face which
exhaling through a one-way vent. indicates first degree burns.
H i gh flow adm
admii ni
nistrat
stratii on de
devices   To be effective, render steam inhalation therapy for 15  –  
o  Venturi Mask 24-40% 4-10 LPM 20 minutes
  Preferred for clients with COPD because it   Instruct the client to perform deep breathing and
provides accurate amount of oxygen. coughing exercises after the procedure to facilitate
o  Face Mask expectoration of mucous secretions.
o  Oxygen Hood*   Provide good oral hygiene after the procedure.
o  Incubator / isolette*   Do after-care of equipment.

Note: * can be used for both low and high flow administration b. Aerosol inhalation
  done among pediatric clients to administer
  The nurse should prevent skin breakdown by brochodilators or mucolytic-expectorants.
checking nares, nose and applying gauze or cotton as .
necessary c. Medimist inhalation
  Ensure that COPD patients receive only LOW flow   done among adult clients to administer bronchodilators
oxygen because these persons respond to hypoxia, not or mucolytic-expectorants.
increased CO levels.
4. Chest Physiotheraphy
Physiotheraphy ( CPT
CPT )

MS 12 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

  Includes postural drainage, chest percussion and

vibration, and breathing retraining. Effective
coughing is also an important component.
  Goals are removal of bronchial secretions, improved
ventilation, and increased efficiency of respiratory
muscles.
  Postural drainage uses specific positions to use gravity
to assist in the removal of secretions.
  Vibration loosens thick secretions by percussion or
Suctioning
vibration. Nursing Interventions in CPT
  Breathing exercises and breathing retraining improve
  Verify doctor’s order 
order 
ventilation and control of breathing and decrease the
  Assess areas of accumulation of mucus
work of breathing.
secretions.
  These are procedures for patients w ith respiratory
  Position to allow expectoration of mucus
disorders like COPD, cystic fibrosis, lung abscess,
secretions by gravity
and pneumonia. The therapy is based on the fact that
  Place client in each position for 5-10 to 15
mucus can be knocked or shaken from airways and
helped to drain from the lungs. minutes
  Percussion and vibration done to loosen mucus
secretions
Postural drainage
  Change position gradually to prevent postural
  Use of gravity to aid in the drainage of secretions.
  Patient is placed in various positions to promote flow
hypotension
  Client is encouraged to cough up and
of drainage from different lung segments using
gravity. expectorate
expectora te sputum
  Procedure is best done 60 to 90 minutes before
  Areas with secretions are placed higher than lung
segments to promote drainage. meals or in the morning upon awakening and at

  Patient should maintain each position for 5-15   bedtime.

Provide good oral care after the procedure
minutes depending on tolerability.

Percussion 5. Incentive Spirometry

  Produces energy wave that is transmitted through the
•  Types: volume and flow
chest wall to the bronchi. •  Device ensures that a volume of air is inhaled and the
  The chest is struck rhythmically with cupped hands
patient takes deep breaths.
over the areas were secretions are located. •  Used to prevent or treat atelectasis
  Avoid percussion over the spine, kidneys, breast or
•  To enhance deep inhalation
incision and broken ribs. Areas should be percussed
for 1-2 minutes •  Nursing care
  Positioning of patient, teach and encourage
 – 

use, set realistic goals for the patient, and

Vibration
record the results.
  Works similarly to percussion, where hands are
placed on client’s chest and gently but firmly rapidly
vibrate hands against thoracic wall especially during
client’s exhalation.
exhalation.
  This may help dislodge secretions and stimulate cough.
  This should be done at least 5-7 times during patient
exhalation.

6. Closed Chest Drainage ( Thoracostomy Tube )

  Chest tube is used to drain fluid and air out of the

mediastinum or pleural space into a collection

chamber to help re-establish normal negative
pressure for lung re-expansion.
Purposes

MS 13 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

  To remove air and/or fluids from the pleural 1.  The first bottle is the drainage and water-seal bottle;
space 2.  The second bottle is suction control bottle.
  To reestablish negative pressure and re-expand 3.  Expect continuous bubbling in the suction control
the lungs bottle;
Procedure 4.  Intermittent bubbling and fluctuation in the water-
  The chest tube is inserted into the
t he affected chest seal
nd rd
wall at the level of 2  to 3  intercostals space to 5.  Immerse tip of the tube in the first bottle in 2 to 3 cm
release air or in the fourth intercostals space to of sterile NSS
remove fluid. 6.  Immerse the tube of the suction
s uction control bottle in 10 to
20 cm of sterile NSS to stabilize the normal negative
pressure in the lungs.
7.  This protects the pleura from trauma if the suction
pressure is inadvertently increased

Three-bottle system
  The first bottle is the drainage bottle;
  The second bottle is water seal bottle
  The third bottle is suction control bottle.

  Observe for intermittent bubbling and

fluctuation with respiration in the water- seal
bottle
  Continuous GENTLE bubbling in the suction
control bottle. These are the expected
observations.
  Suspect a leak if there is cocontinuous
ntinuous bubbling
bubbling i n
Types of Bottle Drainage
the WATE
WAT E R se seal
al bot
bottle
tle or if there is VIGOROUS
One-bottle system
bubbli
bub bling
ng i n the suction control bottle
bottle.
  The bottle serves as drainage and water-seal
  The nurse should look for the leak and report
  Immerse tip of the tube in 2-3 cm of sterile NSS
the observation at once. Never clamp the tubing
to create water-seal.
unnecessarily.
  Keep bottle at least 2-3 feet below the level of
the chest to allow drainage from the pleura by
If there is NO fluctuation in the water seal bottle, it may mean
gravity.
TWO things
  Never raise the bottle above the level of the
  Either the lungs have expanded or the system is NOT
heart to prevent reflux of air or fluid.
functioning appropriatel
appropriately.
y.
  Assess for patency of the device
  In this situation, the nurse refers the observation to
  Observe for fluctuation of fluid along the tube.
the physician, who will order for an X-ray to confirm
The fluctuation synchronizes with the
the suspicion.
respiration.
  Observe for intermittent bubbling of fluid;
Important Nursing considerations
continues bubbling means presence of air-leak   Encourage doing the following to promote drainage:
  Deep breathing and coughing exercises
In the absence of fluctuation:
  Turn to sides at regular basis
Suspect obstruction of the device
  Ambulate
 Assess the patient first, then if patient is stable
  ROM exercise of arms
 Check for kinks along tubing;
  Mark the amount of drainage at regular intervals
 Milk tubing towards the bottle
bottle (If the hospital allows
allows
  Avoid frequent milking and clamping of the tube to
the nurse to milk the tube)
prevent tension pneumothorax
 If there is no obstruction, consider lung re-expansion;
re-expansion;
(validated by chest x-ray)
What the nurse should do if:
 Air vent should be open to air.
  If there is continuous bubbling:
  The nurse obtains a toothless clamp
Two-bottle system
  Close the chest tube at the point where it exits the
  If not connected to the suction apparatus
chest for a few seconds.
  The first bottle is drainage bottle;
  If bubbling in the water seal bottle stops, the leak is
  The second bottle is water-seal bottle
likely in the lungs,
  Observe for fluctuation of fluid along the tube
  But if the bubbling continues, the leak is between the
(water-seal bottle or the second bottle) and clamp and the bottle chamber.
intermittent bubbling with each respiration.
Next, the nurse moves the clamp towards the bottle checking
NOTE! IF connected to suction apparatus the bubbling in the water
w ater seal bottle.

MS 14 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

  If bubbling stops, the leak is between the clamp

and the distal part including the bottle. I.  RHINITIS - inflammation
inflammation and irritation
irritation of
of the mucous
mucous
  But if there is persistent bubbling, it means that membrane of the nose.
the drainage unit is leaking and the nurse must Allergic
obtain another set. Non allergic
  In the event that the
t he water seal bottle breaks, Allergic
the nurse temporarily kinks the tube and must
obtain a receptacle or container with sterile A.  ETIOLOGIC FACTOR
water and immerse the tubing. 1.  Changes in temperature or humidity
  She should obtain another set of sterile bottle as 2.  Odors
replacement.
replacem ent. She should
s hould NEVER CLAMP the 3.  Foods
tube for a longer time to avoid tension 4.  Infection
pneumothorax. 5.  Age
  In the event the tube
tu be accidentally is pulled out, 6.  Systemic disease
the nurse obtains vaselinized gauze and covers 7.  Drugs (cocaine )
the stoma. 8.  OTC drugs
  She should immediately contact the physician.

Removal of chest tube — done

done by physician
  The nurse Prepares:
Petrolatum Gauze B.  CLINICAL MANIFESTATION
Suture removal kit 1.  Excessive nasal drainage
Sterile gauze 2.  Runny nose
Adhesive tape 3.  Nasal congestion
  Place client in semi-Fowler’s
semi-Fowler’s position
position 4.  Nasal discharge
  Instruct client to exhale deeply, then inhale and 5.  Sneezing
do valsalva maneuver as the chest tube is 6.  Headache
removed. 7.  Low grade fever
  Chest x-ray may be done after the chest tube is 8.  Tearing watery eyes
removed 9.  General malaise
  Asses for complica
complications:
tions: subcutaneous
emphysema;; respiratory distress
emphysema C.  NURSING MANAGEMENT
1.  Identify the cause of infection through the
7. Artificial Airway history and physical examination.
2.  Administer medications as ordered:
a. Oral airways- these are shorter and often have a larger   Antihistamine
lumen. They are used to prevent the tongue form falling   Diphenhydram
Diphenhydramineine (Benadryl)
backward.   Chlorpheniramine
  Loratidine
b. Nasal airways- these are longer and have smaller lumen   Nasal Decongestant
Which causes greater airway resistance   Cromolyn ( Nasalcrom )
3.  Health Teaching:
c. Tracheostomy- this is a temporary or permanent surgical   Instruct the patient to avoid or reduce
opening in the trachea. A tube is inserted to allow ventilation exposure to allergens and irritants such as
and removal of secretions. It is indicated for emergency airway dusts, molds, animals, fumes, odors,
access for many conditions. The nurse must maintain powders etc..
tracheostomy
tracheostom y care properly to prevent infection.   Teach the patient to read drug labels and
possible reaction to OTC drugs
  Proper technique in administering nasal
medications
RESPIRATORY DISEASES AND   Practice hand hygiene
DISORDERS
II.  SINUTIS
SINUTIS – 
 –  inflammation
 inflammation of the sinuses
RESPIRATORY INFECTION
1.  Rhinitis A.  ETIOLOGIC FACTORS
2.  Sinusitis 1.  Allergies
3.  Pharyngitis 2.  Structural abnormalities, such as a deviated
4.  Tonsilitis & Adenoiditis septum, small sinus ostia or a concha bullosa
5.  Laryngitis 3.  Nasal polyps
6.  Tracheobronchitis 4.  carrying the cystic fibrosis gene
7.  Pneumonia 5.  Second hand smoke is the cause of about 40% of
8.  Pulmonary Tuberculosis chronic rhinosinusitis.
9.  Histoplasmosis
MS 15 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

6.  Bacterial organism ( streptococcus and

haemophilus) A.  ETIOLOGIC FACTORS
1.  Viral infection ( adenovirus, influenza virus,
B. CLINICAL MANIFESTATION Epstein-barr and herpes simplex
2.  Bacterial infection ( group A beta hemolytic
Acute streptococci, N. gonorrhoeao, H. influenza and
1.  Facial pain Mycoplasma )
2.  Pressure over the affected sinus
3.  Nasal obstruction B.  CLINICAL MANIFESTATION
4.  Fatigue
5.  Purulent nasal discharge Acute
6.  Fever 1.  Fiery red pharyngeal membrane and tonsils
7.  Headache 2.  Lymphoid follicles swollen and freckled with
8.  Ear pain white-purple exudates.
9.  Decreased sense of smell 3.  Cervical lymph nodes enlarged and tender
4.  Fever, malaise and sore throat
Note: The presence
presence of fewer than two symptoms
symptoms R/O 5.  Hoarseness
acute sinusitis and four or more suggest acute sinusitis.
Chronic
Chronic 1.  Constant sense of irritation or fullness in the
1.  Impaired mucociliary clearance and ventilation throat
2.  Cough with thick discharge 2.  Mucus that collects in the throat
3.  Chronic hoarseness 3.  Difficulty in swallowing
sw allowing
4.  Chronic headache
5.  Chronic facial pain
6.  Fatigue and nasal congestion C.  ASSESSMENT and DIAGNOSTIC METHODS
1.  Rapid screening test for streptococca
streptococcall antigens
C.  NURSING MANAGEMENT 2.  Optical immunoassay
immunoassay (OIA )
1.  Perform a careful and physical assessment of the 3.  Nasal swabbings
head and neck, particularly the nose, ears, teeth, 4.  Blood cultures
sinuses, pharynx and chest.
2.  Administer medications as ordered: D.  NURSING MANAGEMENT
  Antibiotic 1.  Encourage bed rest during febrile stage of
  Amoxicillin illness.
  Ampicillin 2.  Administer medications as ordered:
  Trimethoprim / sulfamethoxazole   Antibiotics ( same as sinusitis )
( Bactrim , Septral )   Analgesic
  Macrolides (clarithromycin) ,   Antitussive medication (dextromethorphan
(dextromethorphan )
Azithromycin ( zithromax ) and - for persistent and painful cough
Quinolones such as levofloxacin 3.  Secure nasal swabbings and throat and blood
(levaquin) if the patient has allergy to specimens for culture as needed.
penicillin 4.  Administer warm saline gargles or irrigations to
  Nasal Decongestant ease pain.
  Topical decongestant is used only by 5.  Perform mouth care
adults and should not be used for 6.  Advise patient of importance of taking the full
longer tha
than
n 3 –  4
 4 days. course of antibiotic therapy.
  Oral decongestant must be used 7.  Instruct patient to avoid alcohol, tobacco, 2 nd 
cautiously
cautiously in patient
patient with HPN
H PN hand smoke, exposure to cold and
3.  Health Teaching: environmental
environm ental and occupational pollutants.
  Instruct the patient to immediately 8.  Encourage patient to drink plenty of fluids
consult a MD if periorbital edema and
severe pain on palpation occur. IV.  TONSILLITIS & ADENODITIS
  Instruct the patient about the methods
to promote drainage of sinuses, Tonsillitis  –   inflammation and infection of the tonsils
including humidification of the air in ( palatine and lingual )
the home and use of steam inhalation Adenoditis - inflammation
inflammation of the adenoid or the
and warm compress to r elieve pressure. pharyngeall tonsils.
pharyngea
  Avoid swimming , diving and air travel
  Immediately STOP SMOKING A.  CLINICAL MANIFESTATION
  Emphasized the importance of
completing the antibiotic regimen. Tonsilitis
1.  Sore throat
2.  Fever
III.  PHARYNGITIS - inflamm
inflammation
ation of the throat 3.  Snorring

MS 16 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

4.  Difficulty swallowing   Elevated ESR (rate of erythropoeisis) N =

0.5-1.5% (compensatory mech to decreased
O2)
V.  PNEUMONIA  –   inflammation of the lung parenchyma   Elevated WBC
leading to pulmonary consolidation because alveoli is filled 4.  ABG – 
ABG –  PO2
  PO2 decreased (hypoxemia)
with exudates
F.  NURSING MANAGEMENT
1.  Enforce CBR (consistent to all respi disorders)
2.  Strict respiratory isolation
3.  Administer medications as ordered
  Broad spectrum antibiotics
Penicillin – 
Penicillin  –  pneumococcal
 pneumococcal infections
Tetracycline
Macrolides
  Azithromycin (OD x 3/days)
1.  Too costly
2.  Only se: ototoxicity
ototoxicity – 
 –  transient
 transient
hearing loss
  Anti-pyretics
  Mucolytics/expectorants
4.  Administer O2 inhalation as ordered
A.  ETIOLOGIC AGENTS 5.  Force fluids to liquefy secretions
1.  Streptococcus pneumoniae (pneumococcal 6.  Institute pulmonary toilet – 
toilet  –  measures
  measures to promote
pneumonia) expectoration of secretions
2.  Hemophilus influenzae (bronchopneum
(bronchopneumonia)
onia)   DBE, Coughing exercises, CPT
3.  Klebsiella pneumoniae (clapping/vibration), Turning and
4.  Diplococcu
Diplococcuss pneumoniae repositioning
5.  Escherichia coli 7.  Nebulize and suction PRN
6.  Pseudomonas aeruginosa 8.  Place client of semi-fowlers to high fowlers
9.  Provide a comfortable and humid environment
10.  Provide a dietary intake high in CHO, CHON,
B.  HIGH RISK GROUPS Calories and Vit C
1.  Children less than 5 yo 11.  Assist in postural drainage
2.  Elderly   Patient is placed in various position to drain
secretions via force of gravity
C.  PREDISPOSING FACTORS   Usually, it is the upper lung areas which are
1.  Smoking drained
2.  Air pollution   Nursing managem
management: ent:
3.  Immunocompromised Monitor VS and BS
  (+) AIDS Best performed before meals/breakfast
Kaposi’s Sarcoma 
Sarcoma  or 2-3 hours p.c. to prevent
Pneumocystis Carinii Pneumonia gastroesophageal reflux or vomiting
  DOC: Zidovudine (Retrovir) (pagkagising maraming secretions diba?
  Bronchogenic Ca Nakukuha?)
4.  Prolonged immobility (hypostatic pneumonia) Encouragee DBE
Encourag
5.  Aspiration of food (aspiration pneumonia) Administer bronchodilators 15-30
6.  Over fatigue minutes before procedure
Stop if pt. can’t tolerate the procedure 
procedure 
D.  SIGNS AND SYMPTOMS Provide oral care after procedure as it
1.  Productive cough, greenish to rusty may affect taste sensitivity
2.  Dyspnea with prolong expiratory grunt Contraindications:
3.  Fever, chills, anorexia, general body malaise   Unstable VS
4.  Cyanosis   Hemoptysis
5.  Pleuritic friction rub   Increased ICP
6.  Rales/cra
Rales/crackles
ckles on auscultation   Increased IOP (glaucoma)
7.  Abdominal distention paralytic ileus 12.  Provide pt health teaching and d/c planning
  Avoidance of precipitating factors
E.  DIAGNOSTICS   Prevention of complications
1.  Sputum GS/CS confirmatory;
confirmato ry; type and Atelectasis
sensitivity; (+) to cultured microorganism
microorganism
2.  CXR
CXR – 
 –  (+)
 (+) pulmonary consolidation
consolidation Meningitis
  Regular compliance to medications
3.  CBC   Importance of ffup care

MS 17 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

  Tracheostomy usually done at bedside, 10-20 minutes

VI.  PULMONARY TUBERCULOSIS (KOCH’S DISEASE)  DISEASE)   –     Stress test: 30 minutes
infection of the lung parenchyma caused by invasion of   Mammography: 10-20 minutes
mycobacterium tuberculosis or tubercle bacilli (gram   LARYNGOSPASM – 
LARYNGOSPASM  –  tracheostomy
 tracheostomy STAT
  OR Tracheostomy: laryngeal, thyroid, neck CA
negative, acid fast, motile, aerobic, easily destroyed by
  DIAPHRAGM – 
DIAPHRAGM  –  primary
 primary muscle for respiration
heat/sunlight)
  INTERCOSTAL MUSCLES – 
MUSCLES –  secondary
 secondary muscle for respiration
  ALVEOLI (Acinar cells) – 
cells)  – functional
functional unit of the lungs; site for gas
A.  PRECIPITATING FACTORS exchange (via diffusion)
1.  Malnutrition   VENTILATION –  movement
VENTILATION –   movement of air in and out of the lungs
2.  Overcrowding   RESPIRATION – 
RESPIRATION  –  lungs
 lungs to cells
3.  Alcoholism: Depletes VIT B1 (thiamin)   Internal
alcoholic beriberi malnutrition   External
  RETROLENTAL FIBROPLASIA  –   retinopathy/blindness in
4.  Physical and emotional stress
immaturity d/t high O2 flow in pedia patients
5.  Ingestion of infected cattle with M. bovis
6.  Virulence (degree of pathogenecity)    May be replaced with Ethambutol
(SE: optic neuritis) if (+)
B.  MODE OF TRANSMISSION: Airborne droplet hypersensitivity
hypersensitiv ity to drug
infection   SE: allergic reactions;
hepatotoxicity and nephrotoxicity
1.  Monitor liver enzymes
2.  Monitor BUN and CREA
C.  SIGNS AND SYMPTOMS INH given for 4 months, PZA and
1.  Productive cough (yellowish) Rifampicin is given for 2 months, A.C.
2.  Low grade afternoon fever, night sweats
sw eats to facilitate absorption
3.  Dyspnea, anorexia, malaise, weight loss These 3 drugs are given simultaneously
4.  Chest/back pain to prevent development of resistance
5.  Hemoptysis   Standard Regimen
Streptomycin injection
D.  DIAGNOSTICS (aminoglycosides)
1.  Skin testing
  Neomycin, Amikacin, Gentamycin
  Mantoux test – 
test –  PPD
 PPD
1.  common SE: 8   CN damage
th
Induration width (within 48-72 h)
tinnitus hearing loss
  8-10 mm (DOH) ototoxicity
  10-14 mm (WHO) 2.  nephrotoxicity
  5 mm in AIDS patients is + a.  BUN (N = 10-20)
indicates previous exposure to tubercle b.  CREA (N = 8-10)
bacilli 9.  Health teaching and d/c planning
2.  Sputum AFB (+) tubercle bacilli   Avoidance of precipitating factors :
3.  CXR  –   (+) pulmo infiltrated due to caseous alcoholism, overcrowding
necrosis   Prevention of complications
4.  CBC
CBC – 
 –  elevated
  elevated WBC Atelectasis
Military TB (extrapulmonary TB:
meningeal, Pott’s, adrenal glands, skin,
E.  NURSING MANAGEMENT cornea)
1.  Enforce CBR   Strict compliance to medicatio
medications ns
2.  Institute strict respiratory isolation Never double the dose! Continue taking
3.  Administer O2 inhalation the meds if missed a day)
4.  Forced fluids   Diet modifications: increased CHON, CHO,
5.  Encourage DBE and coughing Calories, Vit C
  NO CLAPPING in chronic PTB d/t   Importance of ffup care
hemoptysis may lead to hemorrhage
6.  Nebulize and suction PRN VII. HISTOPLASMOSIS  –   acute fungal infection caused by
7.  Provide comfortable and humid environm
environment
ent inhalation of contaminated dust with Histoplasma
8.  Institute short course chemotherapy capsulatum from birds’ manure 
manure 
  Intensive phase
INH A.  PREDISPOSING FACTORS
  SE: peripheral neuritis (increase   Inhalation of contaminated dust
vit B6 or pyridoxine
 
Rifampicin 2. SIGNS
  PTBAND
likeSYMPTOMS
symptoms
  SE: red orange color of bodily
secretions   Productive cough
PZA   Fever, chills, anorexia, generalized body
malaise
MS 18 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

  Cyanosis 1.  Consistent productive cough

  Chest and joint pains 2.  Dyspnea on exertion with prolonged expiratory
  Dyspnea grunt
  Hemoptysis 3.  Anorexia and generalized body malaise
4.  Cyanosis
3.  DIAGNOSTICS 5.  Scattered rales/rhonchi
  Histoplasmin
Histoplasmin skin test is (+) 6.  Pulmonary
Pulmonar y hypertension
  ABG analysis reveals pO2 low   Peripheral edema
  Cor pulmonale
4.  NURSING MANAGEMENT
  Enforce CBG C.  DIAGNOSTICS
  Administer meds as ordered 1.  ABG analysis: decreased PO2, increased PCO2,
Antifungal agents respiratory acidosis; hypoxemia cyanosis
  Amphotericin B (Fungizone) SE:
nephrotoxicity and hypokalemia D.  NURSING MANAGEMENT
  Monitor transaminases, BUN and 1.  Enforce CBR
CREA 2.  Administer medications as ordered
Corticosteroids   Bronchodilators
Anti-pyretics   Antimicrobials
Mucolytics/expectorants   Corticosteroids
  Administer oxygen inhalation as ordered   Mucolytics/expectorants
  Forced fluids 3.  Low inflow O2 admin; high inflow will cause
  Nebulize and suction as necessary respiratory arrest
  Prevent complications 4.  Force fluids
Bronchiectasis,
Bronchiecta sis, atelectasis 5.  Nebulize and suction client as needed
  Prevention of spread 6.  Provide comfortable
comfortable and humid environment
Spraying of breeding places 7.  Health teaching and d/c planning
Kill bird and owner! Hehe!   avoidance of smoking
  prevent complications
CO2 narcosis coma
Cor pulmonale
CHRONIC OBSTRUCTIVE PULMONARY DISEASES
Pleural effusion
Pneumothorax
1.  Chronic Bronchitis   Regular adherence to meds
2.  Bronchiall Asthma
Bronchia   Importance of ffup care
3.  Bronchiectasis
4.  Pulmonary Emphysema II.  BRONCHIAL ASTHMA  –   reversible inflammatory lung
condition caused by hypersensitivity to allergens leading to
I.  CHRONIC BRONCHITIS (Blue Bloaters) – 
Bloaters) –   Inflammati
Inflammation
on narrowing of smaller airways
of the bronchi due to hypertrophy or hyperplasia of goblet
mucous producing cells leading to narrowing of smaller
airways

A.  PREDISPOSING FACTORS

1.  Extrinsic (Atopic/Allergic Asthma)
  Pollens, dust, fumes, smoke, fur, dander,
A.  PREDISPOSING FACTORS lints
1.  Smoking 2.  Intrinsic (Non-Atopic/Non-Al
(Non-Atopic/Non-Allergic)
lergic)
2. Air pollution   Drugs (aspirin, penicillin, B-blockers)
  Foods (seafoods, eggs, chicken, chocolate
chocolate))
B.  SIGNS AND SYMPTOMS   Food additives (nitrates, nitrites)

MS 19 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

  Sudden change in temperature, humidity

and air pressure
  Genetics
  Physical and emotional stress
3.  Mixed type combination
combination of both

B.  SIGNS AND SYMPTOMS

1.  Cough that is productive
2.  Dyspnea
3.  Wheezing on expiration
4.  Tachycardia,
Tachycard ia, palpitations and diaphoresis
5.  Mild apprehension, restlessness
6.  Cyanosis

C.  DIAGNOSTICS
1.  PFT decreased vital lung capacity
2.  ABG analysis PO2 decreased

D.  NURSING MANAGEMENT

1.  Enforce CBR
2.  Administer medications as ordered
  Bronchodilators
Bronchodi lators administer first to
facilitate absorption of corticostero
corticosteroids
ids
Inhalation
MDI A.  PREDISPOSING FACTORS
  Corticosteroids 1.  Recurrent lower respiratory tract infection

  Mucolytics/expectorants   Histoplasmosis
  Mucomyst 2.  Congenital disease
  Antihistamine 3.  Presence of tumor
3.  Administer oxygen inhalation as ordered 4.  Chest trauma
4.  Forced fluids
5.  Nebulize and suction patient as necessary B.  SIGNS AND SYMPTOMS
6.  Encourage DBE and coughing 1.  Consistent productive cough
7.  Provide a comfortable and humid environment 2.  Dyspnea
8.  Health teaching and d/c planning 3.  Presence of cyanosis
  Avoidance of precipitating factors 4.  Rales and crackles
  Prevention of complications 5.  Hemoptysis
Status asthmaticus 6.  Anorexia and generalized body malaise
  DOC: Epinephrine
C.  DIAGNOSTICS
  Aminophylline
Aminophylli ne drip
1.  ABG analysis reveals low PO2
Emphysema
2.  Bronchoscopy  –   direct visualization of bronchi
  Regular adherence to medications
lining using a fibroscope
  Importance of ffup care
Pre-op
 
Secure consent
III.  BRONCHIECTASIS – 
BRONCHIECTASIS –  permanent
 permanent dilation of the bronchus
Explain procedure
due to destruction of muscular and elastic tissue of the
NPO 4-6 hours
alveolarr walls (subject to surgery)
alveola
Monitor VS and breath sounds
  Post-operative
Feeding initiated upon return of gag
reflex
Instruct client to avoid talking,
coughing and smoking as it may irritate
respiratory
respirator y tract
Monitor for s/sx of frank or gross
bleeding
Monitor for signs of laryngeal spasm
  DOB and SOB prepare trache
set
D.  SURGERY
1.  Segmental lobectomy
2.  Pneumonectomy
  Most feared complications
Atelectasis

MS 20 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

Cardiac tamponade: muffled heart 5.  High risk group elderly degenerative
sounds, pulsus paradoxus, HPN decreased vital lung capacity and thinning of
alveolar lobes

E.  NURSING MANAGEMENT B.  SIGNS AND SYMPTOMS

1.  Enforce CBR 1.  Productive cough
2.  Low inflow O2 admin; high inflow will cause 2.  Dyspnea at rest
respiratory
respiratory arrest 3.  Prolonged expiratory grunt
3.  Administer medications as ordered 4.  Resonance to hyperresonance
  Bronchodilators 5.  Decreased tactile fremitus
  Antimicrobials 6.  Decreased breath sounds ( if (-) BS lung
  Corticosteroids (5-10 minutes after collapse)
bronchodilators) 7.  Barrel chest
  Mucolytics/expectorants 8.  Anorexia and generalized body malaise
4.  Force fluids 9.  Rales or crackles
5.  Nebulize and suction client as needed 10.  Alar flaring
6.  Provide comfortable and humid environment 11.  Pursed-lip breathing (to eliminate excess CO2)
7.  Health teaching and d/c planning
  Avoidance of smoking C.  DIAGNOSTICS
  Prevent complications 1.  ABG analysis reveal
Atelectasis   Panlobular,, centrilobular PO2 elevation and
Panlobular
CO2 narcosis coma PCO2 depression respiratory acidosis
Cor pulmonale (blue bloaters)
Pleural effusion   Panacinar/centriacinar PCO2 depression
Pneumothorax and PO2 elevation (pink puffers  –  
  Regular adherence to meds hyperaxemia)
  Importance of ffup care 2.  Pulmo function test  –   decreased vital lung
capacity

IV.  PULMONARY EMPHYSEMA – 

EMPHYSEMA –  terminal
  terminal and irreversible D.  NURSING MANAGEMENT
stage of COPD characterized by : 1.  Enforce CBR
  Inelasticity of alveoli 2.  Administer medications as ordered
  Air trapping   Bronchodilators
  Maldistribution of gasses (d/t increased air   Antimicrobials
trapping)   Corticosteroids
  Overdistention of thoracic cavity (Barrel chest)   Mucolytics/expectorants
compensatory mechanism increased AP 3.  Low inflow O2  admin; high inflow will cause
diameter respiratory arrest and oxygen toxicity
4.  Force fluids
5.  Pulmonary toilet
6.  Nebulize and suction client as needed
7.  Institute PEEP in mechanica
mechanicall ventilation
  PEEP – 
PEEP  –  positive
 positive end expiratory pressure
  allows for maximum alveolar diffusion
  prevent lung collapse
8.  Provide comfortable
comfortable and humid environment
9.  Diet modifications: high calorie, CHON, CHO,
vitamins and minerals
10.  Health teaching and d/c planning
  Avoidance of smoking
  Prevent complicati
complications
ons
Atelectasis
CO2 narcosis coma
Cor pulmonale
Pleural effusion
Pneumothorax
  Regular adherence to meds
  Importance of ffup care
A.  PREDISPOSING FACTORS
 
1.
2.  Smoking
Air pollution RESTRICTIVE LUNG DISEASE
3.  Hereditary: involves alpha-1 antitrypsin for
elastase productio
productionn for recoil of the alveoli V.  PNEUMOTHORAX – 
PNEUMOTHORAX  –   partial or complete collapse of the
4.  Allergy lungs due to accumulation of air in pleural space

MS 21 Abejo
 

Medical and Surgical Nursing

Respiratory System
System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN  

A.  TYPES
1.  Spontaneous  –   air enters pleural space without
an obvious cause
  Ruptured blebs (alveolar  –   filled sacs)
inflammatory
inflamm atory lung conditions
2.  Open  –   air enters pleural space through an
opening in pleural wall (most common)
  Gun shot wounds
  Multiple stab wounds
3.  Tension  –   air enters pleural space during
inspiration and cannot escape leading to
overdistention of the thoracic cavity
mediastinal shift to the affected side (ie. Flail
chest) paradoxicall breathing
paradoxica

B.  PREDISPOSING FACTORS

1.  Chest trauma
2.  Inflammato
Inflammatoryry lung condition
3.  tumors
C.  SIGNS AND SYMPTOMS
1.  Sudden sharp chest pain, dyspnea, cyanosis
2.  Diminished breath sounds
3.  Cool, moist skin
4.  Mild restlessness and apprehension
5.  Resonance to hyperresona
hyperresonance
nce

D.  DIAGNOSTICS
1.  ABG analysis: PO2 decreased
2.  CXR
CXR – 
 –  confirms
 confirms collapse of lungs

E.  NURSING MANAGEMENT

1.  Assist in endotracheal intubation
2.  Assist in thoracentesis
3.  Administer meds as ordered
  Narcotic analgesics – 
analgesics –  Morphine
 Morphine sulfate
  Antibiotics
4.  Assist in CTT to H20 sealed drainage

MS 22 Abejo