Unit 1

UNIT 1 NURSING MANAGEMENT OF
PATIENTS WITH COMBION

RESPIRATORY DISORDERS
Structure
1.0 Objectives
1.1 Introduction
1.2 Review of Related Anatomy and Physiology
1.2.1 Upper Respiratory Tract
1.2.2 Lower Respiratory Tract
1.2.3 Respiration
1.3 Assessment of Patients with Respiratory Problems
1.4 Diagnostic Tests
1.4.1 Pulmonary Function Tests
1.4.2 Pulse Oximetry
1.4.3 Arterial Blood Gas Studies
1.4.4 Ventilation-Perfusion Lung Scan
1.5 Radiography
1.5.1 Chest Roentgenogram
1 .5.2 Tomography (Planigraphy)
1.5.3 Computed Tomography
1.5.4 Positron Emission Tomography (PET)
1.5.5 Magnetic Resonance Imaging
1.5.6 Fluoroscopy
1.5.7 Barium Swallow
1.6 Bronchoscopy
1.7 Radioisotope Diagnostic Procedures
1.7.1 Perfusion Lung Scan
1.7.2 Ventilation Scan
1.7.3 Gallium Scan
1.8 Examination of Pleural Fluid and Pleural Biopsy
1.8.1 Thoracentesis
1.8.2 Pleural Biopsy
1.8.3 Lung Biopsy
1.9 Major Health Problems of the Lower Respiratory System
1.9.1 Restricted Lung Diseases
1.9.2 Common Obstructive LungIPulmonary Diseases (COPD)
1.9.3 Respiratory Insuff~ciencyand Respiratory Failure
1.9.4 Trauma and Surgical Conditions
1.10 Related Pharmacology
1.11 Let Us Sum Up
1 .12 Key Words
1.13 Answers to Check Your Progress
1.14 Further Readings .
Respiratory and
Cardiovascular Nursing
After completing this unit, you will be able to:

explain the anatomy and physiology of respiratory system;
describe the signs and symptoms of common respiratory disorder/problems;
explain the nurses role in the diagnostic procedures; and
describe the nursing measures to solve nursing measures involved in
problems of respiratory system.
1.1 INTRODUCTION
Respiration is one of the most vital functions of the body. The purpose of
respiration is to provide oxygen ta the body cells and to remove excess carbon
dioxide from the body cells. Respiratory nursing is a challenging practice area if
you are able to understand the common problems related to respiratory system.
You may need to review the Anatomy and Physiology of the respiratory system
in detail as it is discussed very briefly in this unit.
In this unit you are going to learn about the common problems of patients with
the respiratory disease and nursing measures to be taken to solve the problems.
1.2 REVIEW OF RELATED ANATOMY AND

PHYSIOLOGY
You have already read about anatomy a Physiology a respiratory system in GNM
course in the following text we would discuss the anatomy and physiology.
1.2.1 Upper Respiratory Tract
Fig. 1.1: Structure of upper respiratory tract

I
Nose and Paranasal Sinuses Nursing Management of
Patients with Common
Nose is supported by the nasal bones, nasal processes of the maxillary bones, the Respiratory. Disorders
cartilaginous and bony parts of the septum, and the upper and lower nasal
cartilages. The nasal cavities are located between the roof oi' the mouth and the
frontal, ethmoid and sphenoid bones. The three projections called the turbinate
bones are located on the lateral walls of the nasal cavities and lined with mucous
membrane. These provide a large surface area with a rich blood supply. The
anterior part of the nose is called the vestibule which extends posteriorly a short
distance to a point at which its lining changes from skin to mucous membrane
containing ciliated epithelium. The nasal septum divides the nasal cavity into
right and left. The olfactory epithelium is located in a small area superiorly and
provides the end-organ of smell.
Four sets of paranasal sinuses are located on either side of the head. These
sinuses are air filled spaces in the skull that serve to lighten the head. They are
lined with mucous membrane that is continuous with that of the nose. The
sinuses drain into the nasal cavities through the opening behind the trubinates.
Functions of the nose and nasal sinuses are to warm, moisten and filter incoming
air, to house receptors for olfaction and to promote vocal resonance.
Pharynx
Pharynx is a funnel shaped tube about 13cm long that starts at the internal nares
and extends to the level of the cricoid cartilage. It lies posterior to the nasal and
oral cavities, superior to larynx and just anterior to the cervical vertebrae. Its
walls are composed of skeletal muscles and lined by mucous membrane. Three
parts of pharynx are nasopharynx, oropharynx and laryngopharynx. The
nasopharynx is posterior to nasal cavity. The two internal nares, to eustachian
tubes and the oropharynx are the openings of nasopharynx. Oropharynx lies
posterior to oral cavity, extends from the soft palate inferiorly to the level of
hyoid bone, lined with non-keratinized stratified squamous epithelium. Two pairs
of tonsil are found in oropharynx. Laryngopharyx begins at the layer of hyoid
bone, lined by non-keratinized stratified squamous epithelium, opens into
oesophagus posteriorly and the larynx anteriorly.
Pharynx serves as a passage way for air, food and drink, and provides resonating
chamber for speech sounds.
Larynx
Larynx or voice box is a short passage way that connects the laryngopharynx
with trachea. It lies in the midline of the neck anterior to oesophagus and
corresponds with the levels of cervical 4 to 6 vertebrae. Its wall is composed of
nine pieces of cartilage-3 single-thyroid, epiglottis and cricoid and 3 in pairs-
arytenoid, cuneiform and comiculate cartilages. Arytenoid influencerhe positions
and tensions of vocal folds. Thyroid cartilage, two fused plates of hyaline
cartilage to form the anterior wall of the larynx giving a triangular shape.
Epiglottis is large, leaf shaped having a stem which is attached to the anterior
rim of the thyroid cartilage and hyoid bone and a broad superior 'leaf' portion
unattached and free to move up and down. During swallowing epiglottis moves
down and forms a lid over glottis closing the entrance to larynx to prevent the
entry of food or drink. When small particles of food, drink or dust enter the
larynx a cough reflex occurs to expel the material. The cricoids cartilage, a ring
of hyaline cartilage forming the inferi~rwall of the larynx is connected to
thyroid cartilage by cricothyroid ligament and to the first ring of trachea by the
,-r;~nh-oohn-II;n-mnnt f'r;nrn;rl onrt;lnnn ;a n I-nrlmnrb f ~ mnLinn
r nn pmnrnonrxi
Respiratory and airway. Arytenoid cartilages are two small structures situated on the upper
Cardiovascular Nursing surface of the expanded signet portion of the cricoids cartilage. They give
attachment to the posterior ends of the true vocal cords. The true vocal cords are
fibro elastic bands extending from the posterior aspects of the thyroid cartilage in
front to the arytenoids cartilage behind,. The false vocal cords are two loose
folds of mucous membrane situated above the true cords. Larynx is lined by
mucous membrane which, except over the vocal cords, is covered with ciliated
columnar epithelium.
The chief function of larynx is to serve as passageway for air. Larynx also serves
as a voice box.
1.2.2 Lower Respiratory Tract
Larynx W BRONCHIAL TREE
)le
'ry
Fig. 1.2: Structure of lower respiratory tract

Trachea
Trachea or windpipe is 12 cm long, 2.5 cm in diameter lying in front of the
esophagus and ends opposite the fourth dorsal vertebrae where it divides into
main bronchi. It consists of a number of c-shaped rings of cartilage connected by
fibrous tissues and having the opening of the C posteriorly. The hnction of the
rings of cartilage is to keep trachea open and prevent the collapse of the wall
like those of the esophagus. It is lined with ciliated columnar epithelium and
cells which secrete mucus.
Trachea serves as a passage air way, filter and moisten the air.
Bronchi and Bronchioles Nursing Management of
Trachea ends by bifurcating into right and left bronchi at the carina, the level of Respiratory Disorders
fourth dorsal vertebra. Each bronchus passes to the corresponding lung. From
each main bronchus smaller bronchi are given off, like branches of a tree, and
the smallest bronchi is called bronchioles. The structure of the bronchi is similar
to that of the bronchi, but they contain no cartilaginous loops, instead there are
more muscle fibers. Mucus is secreted by goblet cells interspersed between the
ciliated cells and by sub-mucosal mucus-secreting glands.
Each bronchioles terminate in an alveolar sac made up of number of air pockets
wihc are lined with delicate layer of flattened epithelial cells and are surrounded
by network of capillaries through the walls of which interchange of gasses takes
place. Blood in the capillaries is brought by the pulmonary artery from the right
ventricle and drained into the left atrium through the pulmonary veins. Alveoli
which number 300 millions in adults are minute sacs that arise from the walls of
the respiratory bronchioles and alveolar ducts. The alveolus is composed of a
single layer of squamous epithelium and elastic basement membrane. These two
layers together with the interstitium and the endothelial and basement layers of
the adjacent capillary, from the alveolar-capillary membrane or interface. It is
across this membrane diffusion of carbon dioxide and oxygen occurs. The
structure of millions alveoli provides a large surface area for gaseous diffusion to
occur. In addition to this respiratory hnction the alveoli prevent lung collapse by
producting surfactant, a phospholipid that decreases surface tension and prevents
intersititial fluid from transferring into the lung space (Fig. 1.3).
Pulmonary
arteriole Terminal
Pulmonay bronchiole
venule Lymphatic
vessel
Elastic Blood vessel
connection Respiratory
tissue bronchiole
Respiratory
' Alveolar bronchiole
Pulmonar ducts
(alve?laJ
cap~llary Alveolar
\ ducts
Alveo
Visceral Alveolar Alveolar

pleura sac sacs
Alveoli Visceral
pleura
a) Diagram of a portion of a lobule of the lung b) Lung lobule
Fig. 1.3: Microscopic anatomy of a lobule of the lungs

Respiratory and Thorax and Lungs
The lungs, a pair of conical-shaped organs lie in the thoracic cavity, protected by
the bony thorax composed of the sternum and ribs a interiorly and ribs, scapulae
and the vertebral column posteriorly. The apices of lungs lie just above the
clavicles and the concave base posteriorly extends to the 11th or 12th rib. The
lung is described as having a medistinal and a costal surface. The costal surface
is in contact with the wall of the pleural cavity which consist of the ribs and
intercostals muscles forming the thoracic cavity. The thoracic cavity is lined with
pleura. The pleura is a continuous serous membrane; one surface of it lines the
inside of the rib &ge knows as the parietal pleura and the other surface covers
the lungs knows as the visceral pleura. The space between the two surfaces is
known as potential space, containing a few milliliters of serous fluid that
prevents friction between the two surfaces.
The lungs are separated from each other by the mediastinum which contains the
heart and great vessels, the esophagus and, in its upper part the trachea. The
chief feature of the mediastinal surface is the presence of the hilum where the
main bronchus and pulmonary artery enter and pulmonary veins leave the lungs.
Group of lymph glands which drain the lungs are situated at the hylum and at
the bifurcation of trachea. The right and left lungs are divided by deep fissures
into lobes, the right lungs has upper, middle and lower lobes and left lung has
upper and lower. Each lobe is further divided into segments. Air is conducted to
each segment through the bronchioles the smallest branches of the bronchi (Fig.
1.4).
Superior
mediastinnurn f &OphaguS
oesophagus &scending aorta
Fig. 1.4(a): Schematic sagittal section through the throax to Fig. 1,4(b): Schematic coronal section through the throax
10 show subdivisions of the mediastinum to show its main contents
,
i Respiratory Muscles Nuraiag Management of
Patients witb C o m ~ l o n
The important respiratory muscles are the diaphragm, the external and internal Requatory Disorders
intercostals muscles and the scalene muscles. The sternocleidomastoids, the
I pectoralis major and minor the trapezium and the laryngeal muscles are the
accessory muscles of respiration.
1.2.3 Respiration
The process of gas exchange in the body is called respiration. Respiration can be
divided into four major functional events
Pulmonary Ventilation
Pulmonary ventilation is the process by which gasses flow between the
atmosphere and lung alveoli. Air moves into the lungs when air pressure inside
the lungs is less than the air pressure in the atmosphere and out of the lungs
when the pressure inside the lungs is greater than the atmosphere pressure.
Breathing in is called inhalation or inspiration. Just before each inhalation air
pressure inside the alveoli is equal to the atmospheric pressures, 760 rnmHg, and
the intrapleural pressure is 756 mmHg. With inspiration, the cavity of the thorax
is enlarged as external intercostals muscles and the diaphragm contract causing a
decrease in the intrapleural pressure to about 754 mmHg. The parietal pleura
lining the cavity is pulled outward in all direction and the visceral pleura and
lungs are pulled along with it. As the lung volume increases in this way the
pressure inside the lungs i.e. 760 mmHg drops to 758 mmHg. Thus a pressure
difference is established between the atmosphere and alveoli and air flows into
the lungs from the atmosphere. Breathing out or exhalation (expiration) starts
when the inspiratory muscles and diaphragm relaxes, the dome of the diaphragm
moves up, the ribs are depressed leading to decrease in the lung volume and
increase in the lung pressure (763 rnm Hg). Air flows out form the area of higher
pressure to the area of lower pressure in the atmosphere. The elastic recoil of the
chest wall and the lungs is due to the recoil of elastic fibers and the inward pull
of surface tension due to the alveolar fluid. A thin layer of alveolar fluid coats
the surface of the alveoli and exerts a force known as surface tension. Exhalation
is a passive process while inhalation or inspiration is an active process.
External Respiration
Diffusion of oxygen into blood and carbon dioxide into alveoli (external
respiration) is the diffusion of oxygen from air in the alveoli of lungs to blood in
the pulmonary capillaries and diffusion of carbon dioxide in the opposite
direction.
Transport of Oxygen and Carbon Dioxide

Transport of oxygen and carbon dioxide in the blood and body fluids to and
from the cells. 98.5 per cent oxygen bound to haemoglobin in the RBC and 1.5
per cent of oxygen dissolved in the blood plasma is transported to the body cells.
Whereas carbon dioxide from the tissues is diffused into the b1,ood and
transported to the lungs in the form of bicarbonate ions (78 per cent), as
carbamino compounds (13 per cent) and a small percentage (9 per oent)
dissolved in blood plasma. From the lungs carbon dioxide is removed in the
exhalation.
Internal Respiration
This occurs in tissues throughout the body the exchange of oxygen and carbon
dioxide between the systemic capillaries and tissue cells is called the internal
respiration. Partial pressure of oxygen (PO,) in the systemic capillaries is higHer
Respiratory and (100 mtnHg) than the PO, in tissues cells in the tissue cells (40 mmHg) at rest.
Cardiovascular Nursing Due to the pressure difference, oxygen diffises out of the capillaries into the
tissue cells and blood PO, drops to 40 rnm Hg. Tissues are constantly using
oxygen and producing carbon dioxide. Partial Pressure of carbon dioxide (PCO,)
of cells is higher (45 mrnHg) than that of systemic capillary blood (40 mmHg).
As a result carbon dioxide diffise fiom tissue cells into the systemic capillaries
until the PCO, increases to 45 mm Hg.
Control of Respiration
Regulation of Respiration
Normal rate of respiration in adult is 14 to 18 breath per minute. In children the
rate is more. Respiration is controlled by the respiratory center situated in the
Medulla oblongata of the brain and by the chemical composition of the blood.
Factors Necessary to Maintain Normal Breathing
1) Adequate supply of oxygen in the environment.

2) A patent airway
3) Normally functioning chest wall
4) Adequately functioning alveoli and capillaries (terminal respiratory units)
5) Adequate amount of heamoglobin
6) An effective cardiac pump and circulatory system to deliver oxygen to the
tissues
7) A hctioning respiratory center.
Any one or more of these factors if not in optimum functional level, lead to
Nursing Management of
Respiratory Disorders
Activity 1
Draw a diagram of upper respiratory system and lower respiratory system and
mark the parts.
1.3 ASSESSMENT OF PATIENTS WITH

RESPIRATORY PROBLEMS
History of Respiratory Illness
History of illness of present and past of patient and family.
Physical Examination
Physical examination includes inspection, palpation, percussion and auscultation.
i) Inspection
Skin
Assess for any change in the skin colour.
Association with
- Flushed - Fever
- Duskiness or Blueness indicating - Pulmonary of Heart
of cyanosis Diseases,
- Observe beneath tongue, buccal mucosa, - Abnormality of Hb or
lips, ear lobes and nail beds Cold temperature
- Pallor seen in nails, face, conjunctiva - Anaemialdecreased blood
and mouth . flow
Facial Expression
- Anxious, intense or air-hungry - Chronic lung disease
Speech
- Breathlessness during speech - Chronic lung disease
Level of Consciousness may Vary
Note changes in personality, mental activity Chronic lung diseases
and the presence of restlessness
Chest
Note the size, shape and symmetry of the chest. Normally, chest is symmetrical.
Assess the abnormalities, of spine and chest as it may limit thorasic excursion
and compromise ventilatory function.
dbrium of sternum Suprasternal notch
Sternal angle
Body of sternum
2nd rib
2nd interspace
2nd coastal cartilage
Costochondral
junctions
Costal margin
Niphoic
I
Costal angle
Fig. 1.5: Normal anatomy of the rib cage
Shape AbnormaEi~
Scoliosis: Lateral deviation of the spine causing a downward slant of the thorasic
cage on the affected side and an upward tilt of the pelvis on the contralateral
side. '
Kyphoscoliosis: A combination of kyphosis and scoliosis.the shoulder and

scapula appear elevated. One side of the thorax is convex and the interspaces on
this side appear flared.
Interspaces flared
Cross section of thorax Clinical appearance

Fig. 1.6: Thoracic kyphoscoliosis
Barrel Chest: Chest appears approximately round with anteroposterior diameter Nursing Management of
of about 1:l (normal AP: transverse diameter is 1:2 to 5:7) .The ribs are in a Patients with Common
horizontal position. The accessory muscles of respiration in the neck appear
larger than normal. This may develop naturally with ageing or may be associated
with chronic lung disease, particularly emphysema.

Fig. 1.7: Barrel Chest
Funnel Chest (Pectus Excavated): This is a depression of part or all of

sternum. If the depression is deep, the heart and great vessels may be
compressed leading to reduced cardiac output and respiratory compromise.

Fig. 1.8: Funnel chest Qectus carinaturn)
Pigeon. Chest (Pectus Carinatum): This is an anterior protrusion of the chest

producing an increased AP diameter.
sternum
Fig. 1.9: Pigcon chest (pectus carinaturn)
Respiratory and Symmetry of Chest Expansion
Normally, each side of the chest expand to an equal degree. Asymmetrical chest
expansion may be seen in pnemothorax, pleural effusion, after resusction surgery,
pronounced atelectasis and chest injury.
Assess the movement of the main respiratory as well as accessory muscles. In
normal breathing, no straining of the muscles seen.
Breathing
Assess the patterns of breathing. Observe the rate, rhythm, depth and quality of
respiration. Normal respiration is regular, without evidence of distress, rate 60:20
per minute in resting adults.
Assess for signs of respiratory distress such as:

Use of accessory muscles, retraction of the intercostals spaces during inspi-
ration and contraction of abdominal muscles during expiration.
a Nasal flaring
'e Pursed lips during expiration indicating dificulty in exhaling air
1 Leaning forward in a effort to decrease the respiratory distress. Nursing Management of
8 Splinting to decrease the chest wall movement to control pain ,
Respiratory Divrders
ii) Palpation .
Use the ball of one hand and move the hand from one side of the posterior
thorax to other (Fig. 1.10). Note presence of swelling, masses, muscle tone,
fremitus and crepitation. Fremitus is a vibration that can be felt by the hand
through the chest wall. Ask the patient to speak in a normal tone of voice,
repeating "99" or "1, 2, 3" while you palpate the chest. Increased vibration near
the large bronchi is normal. In other areas, an increased fremitus is indicative of
increased density of lung tissue which is seen in consolidation of lung, lobar
pneunomia and pulmonary oedema. Decreased fremitus is normal in patient who
has a soft voice. In other cases, it indicates obstruction of air flow into a portion
of lung, pleural effusion, hemothorax, pneumothorax or a bronchial obstruction.
Crepitatoin is a tactile sensation or a coarse, crackling sound produced by the
compression of skin with air in the underlying subentaneous tissue see in
patients with aurgical emphysema or chest trauma (air leak into subcentarcons
tissue).
Fig. 1.10: ~ e t h o dof Palpation
Palpate the trachea to see it is located in a midline position in the neck. Tracheal
deviation can occur on atilectasis, pneumonectomy, mediastinal mass, large
pleural effusion, tension pneuthorax, unilateral emphysema and neck tumor
r
iii) Percussion
Tapping of the chest wall to crate vibrations in the chest wall and underlying
c tissue. It reveals how much air or solid tissue lies beneath the chest wall and
reflects the density of the underlying lung tissue percus down the anterior chest
at 5 cm intervals. As you percus down the chest wall, the level of the diaphragm
in the normal individual is indicated by the onset of dullness on the right
(margin of lever) and tympany on the left (margin of gastric air bubble). Normal
position of the diaphragm is at the 10th intercostals space posteriorly and the
sixth rib at the anterior midclavicular line.
iv) Ausculation
Vesicular breath sounds created by the vibrations as air enters alveoli is heard
over the infraclavicular region, lateral and posterior thorax. It is a soft, low-
pitched rustling sound. Inspiratory phase is heard longer than the expiratory
Respiratory and phase. Decreased or absent vesicular breath sound may occus in patients with
Cardiovascular Nursing bronchial obstruction, emphysema, pleural effusion, chest surgery, old age
obesity and chest pain. Bronchovesicular sounds are heard between scapula and
over the large mainstem bronchi. They are medium in intensity and pitch
inspiratory and expiratory phase are equal. Broncheal breath sounds are harsh,
loud and high-pitched and are heard over the trachea. Expiratory phase is longer
than inspiratory phase. If this sound is heard over lung tissue, abnormal
consolidation may be present.
Abnormal.breath sounds include rates, rhonchi, wheezes and pleural friction rubs.
Activity ,2
Assess one patient each with bronchial asthma, acute bronchitis, pneumonia and
emphysema and note the findings. Compare it with expected normal finding.
Nursing Managemeut of
1.4 DIAGNOSTIC TESTS Pstients witb C o m o n
The most common pulmonary diagnostic test are: PFT, Pulse Oximetry Arterial
Blood Gas Studies, Ventilation-Perhsion Lung Scan.
1.4.1 Pulmonary Function Tests

Pulmonary functions tests (PFTs) provide information about a clients manifestation
by measuring lung volumes, lung mechanics, and diffusion capabilities of the
lungs. PFTs peribrmed in a pulmonary function laboratory can measure respiratory
volumes and capabilities. On the other hand, PFTs done outside of a laboratory are
modified to include ventilation tests of forced expiratory volume, vital capacity,
and maximal voluntary ventilation measures. A handheld measure of inspiratory
flow is called a peak flow. Many clients with asthma use a peak flowmeter at home
to monitor changes in their condition and responses to treatment.
Education about the purpose, procedure, and implications of the test is performed
by the nurse and reinforced by the examiner. Explicit instructions of each
maneuver are given during the testing. Instruct clients that it is normal to feel
short of breath after the test. Clients should not smoke or use a bronchodilator 6
hours before undergoing a PFT.
1.4.2 Pulse Oximetry

Procedure: Pulse Oximetry is a safe and simple method of assessing
oxygenation. An advantage is that this method is noninvasive and continuous.
Previously, the most common method of assessing oxygenation was the use of
arterial blood gases. Pulse Oximetry was originally used in surgery. The pulse
oximeter passes a beam of light through the tissue, and a sensor attached to the
fingertip, toe, or ear lobe measures the amount of light absorbed by the oxygen-
saturated hemoglobin. The oximeter then gives a reading of the percentage of
hemoglobin that is saturated with oxygen. Saturated oxygen has a close relation
with the saturations obtained from the pulse oximeter if it is above 70 per cent.
The table below provides a quick guide for comparison of saturated oxygen and
partial pressure of arterial oxygen.
50 per cent , 25 mm Hg Life threatening hypoxemia

75 per cent 40 mrn Hg Moderate hypoxemia
4
I
180 per cent I 55 rnm Hg 1 MiM hypoxemia I
Nurses' Responsibility
The nurse should continue to assess the whole patient and not just the oxygen
saturation monitor. If values fall below preset norms, (usually 90 per cent) the
client shonld be instructed to deep breathe (if appropriate). Sometimes the
amount of inspired oxygen is increased(titrated) to keep oxygen saturation above
90 per cent. Instruct the client that an infrared light probe will be attached to a
finger, toe, or ear lobe. The client should avoid moving the sensor because
movement disrupts the sensor and gives false readings.
1.4.3 Arterial Blood Gas Studies

Purpose
1) A measurement of partial pressure of oxygen and carbon dioxide in arterial
blood, as well as the pH of the blood.
Respiratory and 2) ~ h e ' ~ a r t i apressure
1 of oxygen, together with hemoglobin, is a measurement
Cardiovascular,Nursing of the amount of oxygen in the arterial blood.
3) Provide a means of assessing the adequacy oxygenation and ventilation (i.e.,
the lungs supplying oxygen to the body and removing carbon dioxide.)
"
4) Help assess the acid-base status of the body-whether acidosis or alkalosis is
present and to what degree.
Clinical Uses of Arterial Blood Gas Studies
1) Unexplained tachypnea, dyspnea,(especially in patients with cardiovascular
or pulmonary disease).
2) Unexplained restlessness, anxiety, drowsiness, or confusion in patients at
risk for respiratory insufficiency br respiratory failure.
3) Assessment of preoperative pulmonary status.
4) Assessment before and during long-term oxygen therapy and during
mechanical ventilator support.
5) Potential or actual impairment in acid-base balance.
6) Assessment of disease progression or reversibility
1.4.4 Ventilation-Perfusion Lung Scan
Ventilation-prefusion (VIQ) scbnning is used to assess lung ventilation and lung-
perfusion. VIQ scans are valuable in diagnosing pulmonary embolism,
pulmonary infarction, emphysema, fibrosis, and bronchiectasis. Quantitative
perfbsion scans may be helpful in preoperative assessment of clients undergoing
surgical resection of thoracic malignancy.
1.5 RADIOGRAPHY
You have read in GNM courses about radiographical examination. In this text the
discussion will be on the following radiographical tests. ,
1.5.1 Chest Roentgenogram

Normal pulmonary tissue is radiolucent. Thus densities produced by tumors,
foreign bodies, etc. can be detected.
Shows position of normal structures, displacement and presence of abnormal
shadows.
Chest X-rays may reveal extensive pathology in the lungs in the absence of
symptoms.
1.5.2 Tomography (Planigraphy)

Provides films of sections of lungs at different levels within the thorax.
Useful in demonstrating presence of small, solid lesions, calcification, or
cavitation within a lesion.
1.5.3 Computed Tomography

An imaging method in which the lungs are scanned in successive layers by a
nmow beam x-ray. A computer printout is obtained of the absorption values of
the tissues in the plane that is being scanned.
It may be used to defipe pulmonary nodules, small tumors adjacent to pleural Nursing Management of
surfaces (which may be invisible on routine roentgenograms), and to demonstrate
mediastinal abnormalities and hilar adenopathy.
1.5.4 Positron Emission Tomography (PET)

Uses high-energy physics and computer techniques to study lung function; useful
for quantitative measurement of regional puImonary perhsion and for studying
ventilation-perfusion relationships.
1.5.5 Magnetic Resonance Imaging

Magnetic Resonance Imaging (MRI) is the use of magnetic fields rather than
radiation to create images of body structures. MRI is used much like CT scan.
The MRI is more definitive than CT because it creates more detailed images of
anatomic structures.
1.5.6 Fluoroscopy
Enables roentgenologist to view heart, lungs, and diaphragm in the dynamic
(moving) state.
1.5.7 Barium Swallow

Outlines the esophagus and reveals displacement of esophagus and encroachment
on its lumen by cardiac, pulmonary, and mediastinal abnormalities. The
procedure has already been discussed in BNSL-106.
1.6 BRONCHOSCOPY
Bronchoscopy is the passage of lighted bronchoscope into the bronchial tree.
Bronchoscopy may be performed with rigid steel of flexible fiberoptic
instruments. Bronchoscopy may be performed for diagnostic or therapeutic
purposes. The diagnostic purpose include: 1) Examination of tissue 2) further
evaluation of a tumor for potential surgical resection, 3) collection of tissue
specimens for diagnosis, and 4) evaluation of bleeding sites. Therapeutic
bronchoscopy is used to: 1) remove foreign bodies, 2) remove thick viscous
secretions, 3) treat postoperative atelectasis, and 4) destroy and remove lesions.
Preprocedure Care
Explain the procedure to the 'client and family and obtain an informed consent.
Instruct the client not to eat or drink anything 6 hours before the test. The client
is told that his or her throat may be sore after bronchoscopy, and some initial
difficulty in swallowing will be present. Before preprocedural sedation, dentures,
contact lenses, and other prostheses are removed. The client undresses and puts
on a gown. Local anesthesia and intravenous sedation are used to suppress the
cough, and to relieve anxiety. A topical anesthetic is also sprayed into the back
of the throat. The test takes 30-45 minutes to complete.
During the procedure, the client lies in supine position with the head
hyperextended. The nurse monitors vital signs, talks to and reassures the client,
and assists the physician a necessary.
Post Procedure Care
After the procedure, vital signs are monitored. Observe the client for signs of
respiratory distress, including dyspnea, changes in or absent lung sounds.
Expectorated secretions are inspected for evidence of hemoptysis. Nothing is
Respiratory and given by mouth until the cough and swallow reflex have returned, which is
Cardiovascular Nursing usually in 1-2 hours. Once the client can swallow, feeding may begin with ice
chips and small sips of water. Lung sounds are monitored for 24 ours.
Development of asymmetrical or adventitious sounds should be reported to the
physician. Pneumothorax has been noted after bronchoscopy.
1.7 RADIOISOTOPE DIAGNOSTIC PROCEDURES

Radioisotope diagnostic procedures include perfusion, ventilation and
gallium scan.
1.7.1 Perfusion Lung Scan

Following injection of a radioactive isotope, scans are made with a scintillation
camera.
1) Measures blood perfusion through the lungs; evaluates lung function on a
regional basis.
2) Useful in perfhion (vascular) abnormalities-pulmonary embolism.
1.7.2 Ventilation Scan .

1) Inhalation of radioactive gas (xenon, krypton), which diffuses throughout the
lungs.
2) Useful in detecting ventilation abnormalities (emphysema).
1.7.3 Gallium Scan

Radioisotope lung scan used to detect inflammatory conditions of the lungs.
1.8 EXAMINATION OF PLEURAL FLUID AND

PLEURAL BIOPSY
Pleural fluid can be oxamined by doing the theracentasis. The preparation of
pitient for thoracentesis and pleural biopsy is discussed in the following leaf.
1.8.1 Thoracentesis
Thoracentesis is the aspiration of fluid or air form the pleural Space. It may be
diagnostic or therapeutic procedure.
Purpose
1) To remove air or fluid form the pleural cavity in pleural effusion.
2) To obtain diagnostic aspiration of pleural fluid.
3) To obtain pleural biopsy.
4) To instill medication in the pleural cavity.
Pleural fluid is continuously produced and reabsorbed, with a thin layer of fluid
normally in the pleural space; abnormal accumulation of pleural fluid (effusion)
occurs in diseases of the pleura, heart, or lymphatics. The pleural fluid is studies
along with other tests to determine underlying cause.
1) Pleural fluid is obtained by aspiration (thoracentesis) or by tube

thoracotomy.
2) Pleural fluid is examined for cell count, differential, specific gravity, Nursing Management of
cytology, protein, glucose, pH, LDH, and amylase. Patients with Common
a) Pleural fluid usually is light straw colour.
b) Purulent fluid-suggests empyema.
c) Blood tinged fluid-pulmonary infection, neoplastic disease.
d) Milky fluid (chy1othorax)-invasion of thoracic duct b i tumor or
inflammatory process; traumatic rupture of thoracic duct.
3) Observe and record total amount of fluid withdrawn, nature of fluid, and its
color and viscosity.
4) Prepare sample of fluid for laboratory evaluation if prescribed.
1.8.2 Pleural Biopsy .
Pleural biopsy is one of the diagnostic procedure which may cause lot of anxiety
i
t
in the patient.
Procedure
Pleural biopsies may be preformed surgically through a small thoracotomy
incision or during thoracentesis, using a cope needle. Needle biopsy is a
relatively safe, simple diagnostic procedure that is useful for determining the
cause of pleural effusions. The needle removes a small fragment of parietal
pleura, which is used for microscopic cellular examination and culture. If
bacteriologic studies are needed, the biopsy specimen should be obtained before
chemotherapy is begun.
Procedure Care
Obtain informed consent and instruct the client as to the need and purpose of the
test. The preparation and positioning of a client for pleural biopsy is similar to that
for thoracentesis. The test is painful, and the client will need to hold still. Assist
the client and reassure him or her. The test takes 15-30 minutes to complete.
Postprocedure Care
Rare complications include temporary pain form intercostals nerve injury,
pneumothorax, and hemothorax. After the biopsy procedure, observe for
indications of complications (e.g. dyspnea, pallor, diaphoresis, excessive pain). A
pneumothorax associated with needle biopsy may develop. Chest tubes and chest
X-ray studies are usually done after the procedure. The development of
hemothorax is indicated by a substantial increase in fluid in the pleural space and
requires immediate thoracentesis.
1.8.3 Lung Biopsy
As with pleural biopsy, lung biopsy may be done by surgical exposure of the
lung (open lung biopsy) with or without endoscopy using a needle designed to
remove a core of lung tissui. Tissue is then examined for abnormal cellular
structure and bacteria. Lung biopsies are most often done to identify pulmonary
tumors or parenchymal changes (e.g. sarcoidosis).
Aspiration Biopsy of Chest Lesions
Procedure
Needle PUnCbR [a$p~~k~on'' biopsy of chest lesions is done under fluoroscopy.

After a lesion is found on a chest X-ray and localized under fluoroscopy, topical
anesthesia is and the needle is inserted through the chest wall into
: , microscopic
a rmall ramole of cells is aspirated *for >-c.,;+;x,p
diagnosis of malignant neoplasms, granulomas or ther nonmalignant growths.
Respiratory and
Cardiovascular Nursing 1
Possible complications of needle aspiration lung bi psy are hemoptysis,
haemothorax, and pneumothorax.
Postprocedure Care
After the procedure, examine any sputum closely for evidence of blood. Observe
for respiratory distress (may indicate pneumothorax). Monitor the clients vital
signs, breath sounds, skin colour, and temperature.
1.9 MAJOR HEALTH PROBLEMS OF THE LOWER

RESPIRATORY SYSTEM
Disorders at'fecting lung and respiration can be divided into restrictive and
obstructive diseases. In restrictive lung disease, there is restriction in lung
e reduction i r ~lung comp,liaace, As a
~ i u m and result there is a reduction in total
In contrast, there is an increase in airway resistance in prolonged exhalation in Nursing Management of
obstructive lung diseases. Panerrxa \&HI Comirron
Kespiratmy Uisurners
1.9.1 Restricted Lun.g Diseases

Restricted lung disease are classified into the following:
Parenchymal inflammation. This can be due to infection e.g. pneumonia
acute bronchitis tuberculosis.
Space occupying leisions e.g. turnours both benign and malignant.
Occupational lung diseases e.g. Silicosis.

Pleural diseases e.g. pleural effusion.
Lung collapse e.g. Atelectasis, Pneumlothorax
Resectional surgery e.g. Pneumonectomy
Neuromuscular disorders e.g. poliomyelitis, Guillain-Barr'e syndrome,
myasthenia gravis.
CNS depression. Narcotics, cerebral odema.
Limitation of thoracic mobility e.g. abdominal tumours ascites.
Change in bony thdrax. Kyphoscoliosis.
Parenchymal Inflammation
Parenchymal inflammation can be due to infectious diseases or acute bronchitis
or pneumonia discussion will be mainly on pneumania in the following text:
Infectious disease
Acute bronchitis
Pneumonia
Tuberculosis
Bronchitis can be acute or chronic. Acute bronchitis is an inflammation of the
bronchi due to primarily viral infection but may also arise form bacterial agents
such as haemophilus influenza and streptococcus pneumonia.
Clinical Manifestions : - Dyspnoea, fever, tachypnoea, productive
cough, clear to purulent sputums.
- Pleuritic chest pain occasionally.
- Diffise ronchi and crackles heard on
auscultation
Diagnosis : Assessment, X-ray chest
Management : - Symptomatic treatment-fever reduction
measures, cough relief measures, medication
for bronchodilation, hydration and
humidification.
- Antibiotics as prescribed
- Chest physiotherapy
Respiratory and Pneumonia
~ardiovascularNursing
Pneumonia is an inflammatory process in which there is consolidation in lung
caused by exudates filing the alveolar spaces. Gas exchange cannot take place in
the consolidated areas and blood in shunted around the non-functioning alveoli.
Hypoxemia may occur depending on how much lung tissue is involved. Patients
may develop pleural effusion and some times emphyema. The signs a symptoms
and drug therapy of pneumonia given in Table 1.3.
Care of patient with respiratory disease is discussed following.

Nursing Process [sample nursing care plan for respiratory disease (Table 1.4)]
Assessment (You may Refer BNSL- 106)
History
Physical examination
Observation, palpation, percussion, auscultation
Review of records and reports of investigation Nursing Management of
• Monitor vital signs Respiratory Disorders
r:e~piratoryand Complications ,
f rrd~o\a$cularhursing
Atelectasis, delayed resolution, pleural effusion, emphyema, pericarditis and relapse.
Tuberculosis
Tuberculosis is caused by a Bacillus-mycobacterium tuberculosis, a gram-
positive and acid-fast organism. It is communicable disease.
Mode of Transmission
By inhalation of tubercle-laden droplet nuclei. When a person with tuberculosis
speaks, coughs, sneezes, minute tubercle laden droplet get sprayed into the
atmosphere and that remain suspended in the air. Person who breathe the air,
inhale these droplets into their respiratory passages.
Primary Tubercle (Ghon Tubercle)
When an individual with no previous exposure to tuberclosis inhale a sufficient
number of tubercle bacilli into the alveoli, tuberculosis infection occurs.
Inflammation occurs within the parenchyma of the lungs. Body counteracts the
infection with the natural body defenses. Lymph nodes in the hilar region of
the lung become enlarged as they filter drainage form the infected site. The
inflammatroy process and cellular reaction produce a small, firm white nodule
called the primary tubercle.
Calcifid Nodule or Chon Tubercle
The center of the primary tubercles contains tubercle bacilli. Cells gather around
the center, and usually the outer portion becomes fibrosed. As blood vessels get
compressed interfering with nutrition of the tubercle, necrosis occurs at the center.
The area becomes walled off by fibrotic tissue around the outside, and the center
gradually becomes soft and cheesy in consistency. This process is known as
caseation necrosis. This material may become calcified (Ghon tubercle). Most
people who are exposed to tuberculosis and develop infection do not have active
tuberculosis. X-ray shows the calcified nodule. The hilar lymph nodes and a Ghon
tubercle seen is X-ray is referred as the primary complex. Person who have
primary complex will show positive result in'~antouxtest. However a nurse needs
to explain to the clients that a positive tuberculin test does not mean that helshe has
tuberculosis. Body's reaction to the organism. A person who has been unless with
tubercle bacilli harbours the organism for the remainder of he person's life unless
he or she has received prophylactic isonizid. When a person is under physical or
emotional stress, the bacilli lying dormant in the lungs become active.
Assessment
On assessment the clinical manifestations, identified are:
Early in the course of the disease the person may be asymptomatic.
Later cough with sputum production, afternoon elevation of temperature,
night sweat.
Blood-streaked sputum, weight loss, loss of appetite, heamoptysis.
X-ray shows pulmonary infiltrate and mantoux test shows induration 10 rnm
or more.
Nursing Diagnosis
Ineffective airway clearance .
Impaired thermoregulation
Altered nutrition
Fear
Knowledge deficit about the disease-spread and treatment
Medications Nursing Management of
Patknts witb Comnlon
INH,Rifampin, Ethambutol (EMB), Pyrazinamide (PZA) Streptomycine. At least Respiratory Msorders
two drugs are given together to prevent the development of resistant Strains of
tubercle bacilli. Treatment is to be continued with a prescribed combination of
drugs for the prescribed duration. (duration may prolong 6 to 9 months).
. .
Interventions
,
Educate the patient about the importance of taking the medicines as prescribed
and for the prescribed duration, the possible side effects and the precautions and
regular follow up.
Methods to Prevent Spread of lnfecCion
Cover mouth and nose with disposable tissues when coughing, sneezing or laughing.
Place the sued tissue in paper bag and bum, Disinfect sputum before disposing.
Symptomatic interventions as needed. Plenty of oral fluids, nourishing diet,
specially high protein and vitamins and calcium.
Genera2 Preventing Measures
Screening the susceptible community for early detection and treatment, following
up to see that the complete course of treatment taken.
Adult Respiratory Distress Syndrome (ARDS)

ARDS is a syndrome of acute hypoxemic respiratory failure without hypercapnoea.
Causes
Shock of all types, trauma, infection of the pulmonary system, disseminated
intravascular coagulation (DIC), fat emboli, near drowning, aspiration of high
acidic gastric contents, inhalation of toxic agents, oxygen toxicity, narcotic drug
abuse.
Clinical Manifesha&ms
When the lung tissue get destroyed the normal cells are replaced by non surfactant
producing cells which in turn leads to edema and decreased lung compliance.
There is increased capillary wall permeability and the plasma contents infiltrate
into interstitial and alveolar spaces resulting in hypoxemia, alveolar
hyperventilation and respiratory acidosis. Acute respiratory .distress, tachypnoea
dyspnoea, accessory muscle breathing, hypoxemia, diffused pulmonary
infiltrations after lung injury in previously healthy person. On auscultation fine
crackles heard throughout the lung tissue. Dry cough and fever may develop in a
few hours or days. Patients may become confused, agitated, comatossed.
Diagnosis
Chest X-ray shows difise, bilateral and usually symmetric infiltrations. ABG-
Decrease in PaO, and paCO, increase pH (respiratory alkalosis). End stage:
hyperapnia and respiratory acidosis.
Management
- To be managed in ICU.
Focus is on: oxygenation-initially may need to administer highest concentration .
of oxygen using a face mask. This can lead to oxygen toxicity and can worsen
the already existing ARDS pat ti^!^^;^. Better.to reduce oxygen to 50 per cent by
using positive end expiratory pressure (PEEP) to open the closed alveoli for
increased ventilation. As the arterial PaO, is stabilized gradually, reduce FiO,
while maintaining adequate arterial oxygen level. 29
Respiratory and Ventilatory support: if oxygen therapy is unsuccessful, patient is intubated and
Cardlovascular Nursing . placed on a mechanical ventilator, preferably a volume limited one and is set to
provide tidal volume equal to 10-12mVkg body weight, respiratory rate 10-141
mt.and FiO, 50 per cent, PEEP used. If patient's spontaneous respiration is
adequate, intermittent mandatory ventilation (IMV) mode or CPAP is used.
Fluid volume: Monitor pulmonary artery pressure through a balloon tipped
catheter. Diuretics, fluid volume expanders, and hypotensive medicatioris are
administered. .'
Treat underlying causes of ARDS.

Nursirag Process '
Assessment
History of illness from family members, clinical manifestations, reports and
records and physical examination.
Occupatioaal Lung Diseases Nurshg Management of
Patienb with Common
The common occupational lung diseases include silicosis due to inhalation of
inorganic dust, allergic alveolitis due to inhalation of organic dust. In silicosis
the common manifestation is breathlessness when exercise. In case of allergic
alveolitis wheezing is the major problem. In both the condition preventive
measures are important. People should protect themselves from inhaling dust to
different types specially for people working in silica mines. People have to use
protective barriers in the occupational site to prevent inhaling the dust.
Cancer Lung
Incidence of cancer lung is more in persons who smoke. Environmental and
industrial pollution is also a risk factor in the inerease in incidence.
Clinical Manifestation
Most new growths in the lungs arise from the bronchi and hence known as
bronchogenic carcinoma. Asymptomatic in few persons initially. The disease is
identified in a chest X-ray.
a Cough, Hemoptysis.
a Shortness of breath and a Unilateral Wheeze.
a Pain on inspiration if pleura is affected.
a Friction rub, plural effusion.
a Clubbing of fingers.
a Fatigue.
Diagnosis
a Chest X-ray, Sputum Cytology Test
Fibro Optic Bronchoscopy and Biopsy
a In later stage of diseaseweight loss, Debility indicating metastasis Staging
of Cancer (refer BNS- 106, Block 4)
Management
a ~ h e m o t h e r a ~ ~ / R a d i o t halone
era~~ is not sufficient. Surgical measures are '
the choice of treatment in early detected cases (BNS-106, Block 4).
a Management of Breathing
1.9.2 Common Obstructive LungIPulmonary Diseases (COPD)

COPD refers to diseases that produced obstruction of air flow. They are chronic
bronchitis, pulmonary emphysema and bronchial asthma.
Chronic Bronchitis
Chronic Bronchitis is defined clinically as hypersecretion of mucus and recurrent
episode of productive cough for a period of 3 months per year at least two
consecutive years.
Pathophysiology
First there is glandular hypertrophy.. Mucous gland hypertrophy and hyperplasia
from chronic irritations cause excessive mucus production. The excessive mucus
Respiratory and and impaired ciliary movement associated with chronic bronchitis increase
Cardiovascular Nursing susceptibility to infection. As infection progress, the epithelial cells produce a
mucopurulent exudates in the lumen or the disease may progress to ulceration
and destruction of the bronchial wall. The peribronchial fibrosis and the presence
of granulation tissue result in stenosis and airway obstruction.
Second the bronchial wall tissue changes, mucosal ocdema and excessive mucus
production, all increase airway resistance in persons with chronic bronchitis.
Excess mucus may also cause bronchospasm.
Third the pathophysiologic changes may impair the ability of lungs to exchange
0, and CO, leading to ventilation-perfusion mismatching at the alveolar-capillary
membrane. Obstructed airways may lead to atelectasis which further diminishes
the surface are a available for respiration.
Fourth the right ventricular decompensation or corpulmonale may result.
Clinical Manifestiarions
Early Symptoms
Symptoms are episodic in nature or continuous with very little response to
bronchodialators.
Productive cough especially on awakening which many people specially the cigarette
smokers often ignore. Grayish white sputum, when infected, yellowish' sputum.
Inspiratory Crackles (Rales)
Late Symptoms
Significant physical incapacity, breathlessness even when walking on a flat
surface, noticeable shortness of breath (SOB). As disease progresses in severity,
symptoms are present constantly. Increased dyspnea using accessory muscles to
breathe. Chronic hypoxemia leads to cyanosis. Increased pulmonary vascular
resistance caused by respiratory acidosis and hypoxemia increases pressure on
right heart resulting right heart failke (Cor pulmonale). The person appears stout
or overweight fiom edema, dusky skin. Rt. Side heart failure may be indicated
by jugular venous distention, hepatomegaly, peripheral edema. Respiratory
acidosis, hypoxemia, polycythemia, tachycardia, cynosis.
Chronic bronchitis complicated by corpulmonale often have chronic respiratory
failure (gradual onset of PaO,< 50, and PaCO,> 50) may develop acute
respiratory failure.
Pulmonary Function Test Findings
a Decreased expiratory flow rate
a Decreased vital capacity
. '
a Increased residual volume
Total lung capacity usually within normal limits
Deatment and Management
biagnosis
a History, physical examination
'a Radiological examination+hest X-ray
8 Sputum studies, CIS, smear,
a ABG analysis-resting PaO, low, elevated PaCO,. during exercises PaCo, Nursing Management of
PatientE with Common
increase. Respiratory Disorders
a Complete blood Picture,
a DFI
Medical Therapy
a Symptomatic treatment
a Supportive measures
a Educate patient and family.
a No smoking, avoid other inhaled irritants
a Keep away from people with URI
a Control environmental temperature and humidity
Good nutrition,
Proper ventilation
Specifc Therapy
a Bronchodilators-Terbutaline, Aminophylline, Theophylline, Adrenaline,
Isoproternol
a Antimicrobial or antibiotics
a Corticosteroids in acute symptoms
a Digitalis in heart failure.
a Cough expectorant
Respiratoly Therapy
Aerosol therapy: bronchodialator through metered hand-held nebulisers 0,
therapy 1-2 L. of 0, by nasal prong.
Relaxation Exercises
Meditation
a Breathing Exercises
a Respiratory muscle rehabilitation
Nursing Process
Histow
Character of onset and duration of cough, sputum production, dyspnea, pain in
right upper quarant.
a Smoking history.
a Past illness - Influenza pneumonia, repeated R.T.I., Chronic sinusitis
a Past or present exposure to environmental irritants at home or at work
a Self-care used to treat symptoms
Medication taken and their effectiveness.
Respiratory and Physical Examination
Assess - General appearance
Overweight or bloated
Dependent ocdema
Distended jugular veinslneck veins
Hepatomegaly
Vital signs
Pulmonary Assessment
Posture, use of accessory muscle for breath, clubbing of fingers, central
cynosis and altered sensorium.
8 Increased tactile fiemitus
On auscultation -inspiratory crackles (rales), inspiratory and expiratory

rhonchi
..
Assess Lab Findings
ABG for respiratory acidosis and hypoxemia
Hematology; increased Hb and PCV, increased' WBC count
PFT; decreased FEV,
Emphysema
Emphysema is destructive changes in alveolar walls and enlargement of air
spaces distal to the terminal non-respiratory bronchioles. It is characterized
physiologically by decreased lung compliance, decreased diffising capacity, and
increased airway resistance.
Respiratory and Etiology
Not known, Continued cigarette smoking increases chances of developing this. It
is seen as familiar disease.
Primary Preventions
Protect self fiom polluted atmosphere
No smoking
Pathophysiology
Distension and damage of the respiratory .bronchioles selectively occur. Opening
develops in the walls of the bronchioles.and they become enlarged and confluent
and tend to from a single space as the walls enlarge. Distribution is uneven but
more severe in upper portions in centrilobular emphysema (CLE). In panlobular
Emphysema (PLE) more uniform enlargement and destruction of alveoli, more
diffuse and more severe in lower lung.
Signs and Symptoms
Increased lung compliance, loss of elastic recoil resulting firm destruction of
elastin in lung parenchyma causes the lungs to become permanently distended.
Increased airway resistance. Distribution of elastic lung tissue causes the small
airway to either collapse or narrow particularly during expiration. Thus, air
becomes trapped in the distal airspaces. More pressure on diaphragm fiom
distended lungs, so more use of accessory muscles to force the trapped air out of
lungs leading to intra pleural pressure that hicreases the airway collapse. Altered
02/C02exchange.
Clinical Manifeslation .
Early onset of dyspnea on exertion (DOE) which progresses to continuous

dyspnea. Rhonchi, crackles , accessory muscle breathing, Increased rate of
breathing, prolonged expiratory phase, spontaneous exhibition of pursed-lip
breathing, decreased FEV, and vital capacity with no response to
bronchodilators.
Scanty sputum or absent.
Normal or mild hypoxemia-respiratory alkalosis; late stage hypoxemia
respiratory acidosis.
Increased AP diameter (barrel chest), decreased lateral expansion, diaphragmatic
-
movement, complaint of epigastric fullness.

PFT shows increased residual volume, fuoctional residual capacity and total lung
volume, decreased diffusing capacity, decreased forced expiratory volume (FEV),
vital capacity may be normal or slightly reduced later in the disease, thus FEVII
VC rate is decreased. Bronchodilators fail to show ihProvement is
PFT(significant- differentiating findings)
ABG is often near normal
Medical Management
Diagnosis History, Chest X-ray, A B 4 P ~ T sputum
, for CIS.
Other management is same for chronic bronchitis.
Nursing Process Nursing Management of
Assessment History of dyspnea, cough, sputum production, Respiratory Disorders
smoking history
Exposure to environmental irritant.
Family history of illness.
Medications or other modalities of treatment.,
Observation : Thin, barrel chest, tachycardia, tachypnea.
Use of accessory muscles for breathing. Forward leaning-
pursed-lip breathing, prolonged expiration.
Palpation : Decreased lateral expansion and decreased fremitus.
Percussion : Hyperresonance.
Auscultation : Decreased breath sounds and heart sounds, rhonchi,
inspiratory crackles.
Diagnostic Test Findings
ABG early stages - respiratory alkalosis
Later stages - respiratory acidosis
PFT - decreased FEV,, decreased VC, and decreased diffusing
Capacity, increased total lung capacity, increased FRC and RV
Nursing Diagnosis and Interventions
Same as for chronic bronchitis.
Bronchial Asthma
Bronchial Asthma is characterized by increased responsiveness of the trachea and
bronchi to various stimuli that cause narrowing of the airways and dificulty in
breathing. Its onset is sudden and it is intermittent.
Predisposing Factors
Environmental Factors
/ Change in temperature, especially cold air.
Change in humidity-dry air
Atmospheric pollutants, Pollens
Cigarette and industrial smoke, Ozone Sulphur Dioxide
I Formaldehyde vapour.
Strong odors-perfume
Allergens
- Feathere, rtnirn~ldander, ducrt mitea. molds allergens, foods tret&xl with
eulfites(beer, wine, fruit juices, mack foods, s~ltads,potateee, rkellfleih a d
frosk and dried Ruita).
!
I
Rasplratory and Exercise
@rirdiovascularYursing
Stress or emotional upset
Medications
0 Aspirin, non-steroidal antiinflammatory drugs(NSAIDs), beta-
blockers(inc1uding eye drops), cholinergic drugs.
0 Enzymes - including those in laundry detergents.
Chemicals
- Solvents, paints, rubber and plastics.
Pathophysiology
Asthma result from several physiological alterations, including altered
immunologic response, increased airways resistance, increased lung-compliance,
impaired mucociliary function. Asthma resulting from the antigen-antibody
reaction in which chemical mediators such as histamine, eosinophilic factor etc.
caused constriction of smooth muscles of both the large and small airways
resulting in bronchospasm, increased capillary permeability resulting in mucosal
oedema and increased mucus production.
Bronchospams causes increased airway resistance and obstruction to air flow in
and out of lungs. The lung become hyperinflated resulting in increased lung
compliance. The increased mucus production can cause formation of mucus
plugged which can further block the airway. Impaired mucocilliary function,
hypertrophy of mucus-secreting glands, thickened mucus and slowed ciliary
movement are common findings in persons with asthma. During an attack,
increased mucus production combined with slowed clearance of mucus due to
decreased ciliary movement results in increased water loss from mucus. Mucus
becomes viscous, forming a mucus plug which may block airways.
Increased airway resistance and hyperinflation can increase the work of
respiratory muscles resulting in muscle fatigue and exhaustion. Resulting
hypoventilation in severe cases lead to respiratory acidosis, and even death.
Clinical Manifestations
Can be chronic to acute, mild to severe. Acute attack often occur at night.
During an acute attack, audible inspiratory and expiratory wheezing. Patient
appears to be in acute respiratory distress. Tachypnea, use of accessory muscles
for breathing, nasal flaring, apprehensive, sweating. If treatment is successful,
the attack ends with continue up of large quantities of thick tenacious sputum,
repeated attack may continue in case of infection.
Persons with severe asthatic attack that are difficult to control with usual
medications may be developing status asthmaticus. In this condition, air trapping
in the distal airspace leads to respiratory muscle exhaustion and severe
ventilation-perfusion abnormalities with resultant respiratory failure and
hypoxemia.
Patient with status asthmaticus is unable to talk due to severe respiratory distress,
becomes cyanosed and changed sensorium.
This is a medical emergency.
Emergency Room Management
Patient may needs intubation and ventilatory support tiil such time that patient is
able to breathe normally. In some cases: patient is administered muscle relaxants
and put on complete artificial ventila!ion.
Repeated attack to status asthmaticus may cause irreversible emphysema, Nursing Management of
resulting in abperrnanentdecrease in total breathing capacity. Patients with Common
Respiratory Disorderq
PFT characteristics of Asthma-show reduction in FEVI to less than 25 per cent
of predicted. FEV is markedly reduced in proportion to the FCV, although the
FVC may be decreased. Improved flow rates after medication indicates reversible
bronchospasm which is a characteristic finding with asthma.
ABG may very from respiratory alkalosis with mild hypoxemia to severe
respiratory acidosis, with profound hypoxemia depending on the severity and
duration of attack.
Medical Management
Objective
a Promote normal functioning of the individual.
a Prevent recurrent symptoms
a Prevent severe attack.
a Prevent side effect.
Chief Aim
a To provide the patient immediate, progressive ongoing bronchial relaxation.
Medicines Prescribed
a Aminophylline 4 to 6 mglkg. Over 15 to 30 minutes IV diluted in 5 per cent
dextrose (250 mg in 50 to 100 ml). When stabilized, oral may be started.
a By inhalation-beta-agonist such as Albutnol Sulphate or Metaproterenol
Sulphate (Alupent, Metaprel) in normal saline or in metered hand-held
nebuliser.
If not effective, then TV Methylprednisolone 60 to 125 every 6 hourly, when
stabilized can be started on oral, dose is tapered off gradually.
Nursing Process
History, precipitating factors, current medication, medication used to relieve

asthma symptoms. Any recent changes in medication regimen. Self-care methods
used to relieve symptoms.
! a General appearance-apprehensive, sensorium, altered or not.
a Vitals: Tachycardia, Tachypnea, pulses paradoxus
k
I Pulmonary Examination
Use of accessory muscles to breath.
!
b a Posture-forward breathing.
a Dyspnea
Prolonged expiration
Cynosis
a Decreased lateral expansion
Respiratory and Decreased tremitus
Cardlovaecular Nursing
Hyperresonance
Decreased diaphragmatic excursion
9 Inspiratory and expiratory wheezing
e Rhonchi (as patient gets exhausted due to dyspnea, breath sounds and
adventious founds may be absent or faint).
Assess Lab Findings
ABG-moderate attack-respiratory alkalosis with mild hypoxemia.
Prolonged or severe attack-respiratory acidosis with severe hypoxemia.
Sputum : for eosinophilia
PFT: decrease FEV (forced expiratory volume) and VC.
1.9.3 Respiratory Insufficiency and Respiratory Failure Patients with Common
Respira+oryDisorders
Respiratory insufficiency usually indicate inadequate exchange of oxygen and
carbondioxide to meet the needs of the body during normal activities.
Respiratory Failure: When ventilation is insufficient to achieve gas exchange
eve11 at rest.
Disorders which can lead to or associated with respiratory insufficiency and
failure:
Pulmonary Disorders
Infection
Pulmonary oedema
Embolus
COPD
ARDS
Cancer
Chest Trauma
Severe atelectasis
Non-Pulmonary Disorders
CNS disturbance due to drug overdose, anaesthesia, head injury.
Neuromuscular disorders-Guillain-Barre's Syndrome, Myasthenia gravis,
Multiple sclerosis, spinal cord injury, poliomyelitis,muscular dystrophy.
Post-Operation Complication
Prolonged mechanical ventilation.
Pathophysiology
With inadequate ventilation arterial PO, falls and tissue becomes hypoxic.
PCO, increases, leading to fall in pH and patient becomes acidotic.
Criteria for Diagnosis of Respiratory Failure
PaO, < 60 rnm Hg when breathing room air.
PaCO, > 50 mm Hg.
Vital Capacity < 15 mllkg
Respiration > 301min or below 8lmin.
Management
Goals
Improve oxygenations and ventilation to restore the personls Pa,- 0,. and
Pa( '0, to their previous levels.
Understand the underlying cause.
Remove the cause or improve.
Respiratory and Treated with low-flow or controlled flowloxygen (inspired 0, concentration)
Cardiovascular Nursing in the patient between 24 per cent to 30 per cent) by using ventury mask or
two pronged nasal cannula with 1-2 liters flow rate. This will increase the
amount of 0, carried by Hb without increasing the PaO,.
Patient with other causes can have higMow rates of 0, (5 to 10 Llmt).
Hazards of 0,Therapy
Exposure to greater than 60 per cent 0, for a period of more than 36 hours, or
exposure to 100 per cent 0, for a period of more than 6 hours, results in
atelectasis 'and alveolar collapse. Breathing very high concentration of 0, (80 to
100 per cent) for prolonged periods (24 hours or more) is often associated with
development of ARDS.
,Airway Management
' . To improved ventilation, suctioning, IPPB, Ultrasonic mist therapy and postural
drainage with clapping and vibrating are all employed to halt the progress of
insufficiency. If these are not sufficient, then artificial airway.
For short-tem-endotracheal intubation. An endotacheal.
Tube is passed through either the nose or mouth into the trachea.
For ling-term-1f the artificial airway is to be maintained for a prolonged period
-of time, a tracheostomy is to be done and a tracheostomy tube is inserted. (For
care of patient with intubation and tracheostomy (refer BNSL-106, Block 3).
Tracheostomy Care
A tracheostomy is an external opening made into the trachea in order to provide
an artificial airway (an opening is made in the 2nd and 3rd or 4th tracheal rings).
Nursing Responsibility in Managing a Tracheostomy Patient
1) Maintain,a patient airway.
2) Observe the patient for any complications.
3) Observe strict aseptic technique.
4) Ensure humidification.
5) Provide communication facilities to the patient.
6) Change the dressing pm. and the keep the area clean and dry.
7) Provide frequent mouth care.
8) Provide psychological support.
9) Understand the patient and his problems.
Procedure of Suctioning
Purpose: To maintain a patient airway.
Equipment
1) Sterile disposable catheter (size of the catheter should be not more than 21
3rd of lumen of tracheostomy tube).
2) Sterile gloves.
3) Sterile saline.
4) Sterile gauze piece. '
5) Sterile syringe. Nursinb MaIkilgCmeIIt cf
Patienix n:th t"v!nrr~u~
6 ) paper'bag or kidney tray. Respir~luqDisorders
7) Suction apparatus.
Procedure
Use strict aseptic technique. Use mask.
Explain to the patient.
Put on glove.
Lubricate the catheter with normal saline.
Insert catheter with suction turned off (open end of Y connection).
Pass tube into the trachea as long as it goes without giving initation to
patient and gradually open suction. ( close they connection).
a Remove the catheter rotating between fingers (thumb and forefingers).
Time should be only 10-15 seconds.
a If the secretion is tenacious, instill sterile saline 2 cc.
Repeat suctioning (if patient is connected to ventilator, then after instilling
saline connect the patient to respirator, give 3 to 4 respiration and then
disconnect and do suction).
a Giving coughing and breathing exercise of chest physiotherapy (can be
given by the assistant).
Ausculate chest to know whether there is any accumulation of secretion in
some part-give change of position.
Clean the catheter by suctioning saline into it. Outside of catheter can be
cleaned by the sterile gauze.
Note the amount of colour of secretion as well as time. Tdeal is to use fiesh
catheter for each time.
Make the patient comfortable.
a Suction as often as necessary maintaining asceptic principles.
Provide mouth care and maintain oral hygiene.
a Maintain nutritional needs- nasogastric feed in case of endotracheal intuba-
tion.
Ensure adequate ventilation by assessing lung sounds regularly.
Secure endotracheal tube or tracheostomy tube in position.
Assess lung volumes at regular intervals.
Change patient's position every two hours.
Perform postural drainage, cuppinglclapping and vibrating as appropriate.
Provide safely and comfort.
Maintain the cuff of the tube inflated.
Assess the tube placement at regular intervals.
Change the tapeslties whenever soiled.
Keep spare sterile tube at the bedside.
Minimise sensory deprivation - lighting, time of the day.
Respiratory and a Plan acceptable mode of communication for the patient such as "Yes" or
Casdiovasculor Nursing "No" response, non-verbal mode or use of m8gic slate.
a Explain procedure and talk to patient.
a Encourage family members to talk to patient.
Reinforce ability of the patient to Hpeak by reassuring speech will return.
Provide adequate rest for any distress during immediate extubation.
1.9.4 Trauma and Surgical Conditions

Trauma to the chest may affect the bony chest cage, pleura and lungs, diaphragm
or mediastinal contents. Injuries to chest are classified into two groups blunt and
penetrating.
Blunt or Non-penetrating Injury
When body is struck by a blunt object such as steering wheel or blows to chest
with blunt object. External injury may appear minor but the impact may cause
severe life threatening internal injuries.
Penetrating trauma occurs when a foreign body passes through the body tissues.
It usually result from gun shot or stab injuries.
Types of chest trauma due to:
Blunt Injury
Closed penumothorax
a Tension pneumothorax
a Tracheobronchial injury
a Fracture ribs and flail chest
a Mediastinal injury
Penetrating Injury
a Open pneumothorax (sucking chest wound)
a Hemothorax
Tracheobrochiaf injury
a Pulmonary contusion
a Mediastinal injury
Emergency Management of Chest Injury
Possible Assessment Findings
a Obvious trauma to chest wall (e.g. brushing, open wound).
Chest pain.
Dyspnea, shortness of breath. difficulty in breathing.
Cough (with or without hemoptysis).
a Asymmetric chest movement.
a Cyanosis of mouth, face, nail beds, mucous membranes.
a Rapid, weak pulse.
Decreased blood pressure.
Deviation of trachea. Nurslig Minagement of
Distended neck veins. Respiratory Disorders
Audible air escaping for chest.
Subcutaneous emphysema.
Decreased breath founds on side of injury.
Muffled heart sounds.
Management
Establish and maintain airway. Anticipate need for intubation if resgiratory
distress evident.
Administer high humidified 0, using non-rebreather mask.
Establish IV access with two large gauge catheters.
Remove clothing to assess i n j u j sites.
Monitor vital signs, level of consciousness, oxygen saturation, urinary
output.
Assess for tension pneurnothorax and, if present, do a needle thoracotomy.
Dress sucking chest wound with non-porous dressing taped on three sides.
Do not remove impaled objects; stabilize them with bulky dressings.
Assess for other injuries such as bleeding and treat appropriately.
Put patient in a semi-Fowler's position or lay patient on the injured side if
breathing is easier.
Pneumothorax
Entry of air in the pleural cavity is called pneurnothorax. It may be spontaneous,
result of penetrating or non-penetrating injuries.
Closed Pneurnothorax
Caused by blunt injury resulting in fractured ribs piercing the pleural membrane
or by a sudden compression of the rib cage. Air enters the pleural space
increasing intra pleural pressure which collapse the lung.
Spontaneous Pneumoihorax
Result from the rupture of an emphysematous bleb on the lung surface or that
may follow severe bouts of coughing in persons with pulmonary disease.
Tension Pneumothorax
When air leak into the intra pleural space and it cannot escape during expiration.
This can be a result-of closed pneurnothorax and also of penetrating chest injury.
The accumulated air buildup positive pressure in the chest cavity resulting in
lung collapse on the affected side, mediastinal shift towards unaffected side and
compression of mediastinal organs resulting in decreased cardiac output and
decreased venous return, '
Open pneumothorax occurs when a penetrating chest wound opens the intra
pressure, AS patient inspires, air is sucked into the
pleural space to . . ....- b;,. .,,,,n Blood may also leak into the pleural
Respiratory and Signs and Symptoms
Closed pneumothorax: Small one-may not show any symptoms.
Absence : Larger or rapidly developing one-sharp pain on in
inspiration, increasing dyspnoea, restlessness,
diaphoresis, hypotension, tachicardia absence of chest
movement on affected side, of breath sounds and hyper
resonance on affected side.
Spontaneous : Sudden unexplained shortness of breath inpatient
pneumothorax with chronic pulmonary disease.
Open peumothorax : Sucking sounds at wound site with respiration. Trachea
shifted towards unaffected side during inspiration and
return towards midline with expiration.
Tension pneumothorax : Severe dyspnoea, restlessness, trachea shifted form
affected midline towards unaffected side. Absence of chest
movement on side, hypotension, tachycardia, absence of
breath sounds on affected side diminished heart sounds.
Diagnosis
History of injury, Assessment and chest X-ray
Management of Pneumofhorax
In closed one monitor vital signs, 0, supplement needle aspiration of air or
Water seal chest drainage.
In spontaneous, tension and open pneumothorax surgical intervention along with
above measure may be required.
Nursing Process
Assessment-history of illness or injury, physical examination, reports and records.
Nursing Diagnosis
Cardiac output decreased
Gas exchange impaired
Breathing pattern ineffective
Comfort altered
Knowledge deficit
Interventions
Semi-fowlers position
Oxygen therapy
Observe for cardiac disrrhythmia
Palpate for subcutaneous emphysema
Prepare and assist for thoracentesis
Care of water-seal drainage.
Fracture Rib
Causes
Blows, crushing injuries or strain caused by severe coughing to sneezing spells.
If rib is splintered, or the fiac&J-e-djsplacedsharp segments may penetrate the
n l ~ ,...A~ tLL.~ v ~
Common Signs and Symptoms Nursing Management of
Pain at the sight of the injury increasing on respiration, localized tenderness and Respiratory Disorders
crepitus on palpation, splinting of the chest and shallow breaths.
Diagnosis
Clinical features, X-ray chest.
Management
Stabilisation of the fractured site. Analgesics as needed.
Flail Chest
It is a condition in which multiple ribs of the sternum are, fractured in more than
one place and a portion of the chest wall becomes separated form the chest cage.
The chest wall no longer provides the rigid bony support required for the normal
ventilation. The dislocated segment is pulled inward on inspiration and outward
on expiration. This is known as paradoxical respiration. (Fig. 1.12)
I
Fig. 1.12: Normal respiration. A, Inspiration; B; Expiration. Paradoxical motion: C,

Inspiration, area of lung underlying unstable chest wall sucks in on inspiration. D,
Same area balloons out on expiration. Note movement of mediastinum toward
opposite lung on inspiration
Other manifestions of flail chest are localized atelectasis, hypoxemia, due to

decreased ventilation, hypercapnea and respiratory acidosis. Restlessness.
Signs and Symptoms .
Severe pain which increases with each respiration, decreased breath sounds on
auscultation, paradoxical movement of the flail segment, increased pulse and
respiratory rate, hypotension.
Diagnosis
.-,
CJ;,, chest X-ray, ABG analysis.
Respiratory and Management
Stabilise the fail segment, intubation and place patient on a volume controlled
positive pressure mechanical ventilation for internal stabilization of the chest and
to decrease the work of breathing, provide supplemental oxygen, correct acid
base balance, provide analgesis for pain control.
Penetrating Chest Wounds
When knife, bullet etc. enters the chest, a penetrating wound occurs. This type of
injury cause trauna to the lungs and pleura leading to pneumothorax,
hemothorax and collapse of lung and interferes with cardiac action.
Assessment Findings
Nature of injury and, time, signs of shock, breathing difficulty, trachea deviated
from mid-line.
Dilrgn osis
History, assessment findings, chest X-ray, ABG analysis
Meriical Management
If there is a sucking wound of the chest, strap a wound to prevent air entry into
pleural cavity. If a knife is struck, not to remove it. Shift to emergency or
hospital. Place in an upright position in emergency. Start oxygen therapy.
Intubate, if needed. Check for air or blood collection in pleural cavity.
Thoracentesis, ifneeded. Connect patient to eater-seal closed drainage. Surgical
exploration, if needed. Monitor for hypovolemia-monitor CVP to detect cardiac
tarnponade. Administer IV fluid and blood in needed.
Nursing Process
Assessment
Nature of the injury, when it occurred, pain at site of injury that increased on
respiration, area tender to touch, patient splints chest and takes shallow breath.
Any parr?~doxical breathing, distended neck vein, restlessness, position of trachea,
temperature, pulse, respiration, any open chest wound.
Care of Patient with Chest Tube and Water-seal Drainage Nursing Management o f
After chest injuries and resectional surgery of the lung (except pneumonectomy) Respiratory Disorders
one or two drainage tubes are inserted into the pleural space. Each tube is
connected to a water seal drainage bottle containing 1 to 2 cms of sterile water or
to another negative pressure suction system. The glass rod connected to the chest
tube is under water. This seal the chest tube, allowing air and fluid to drain from
the pleural space into the water seal bottle and preventing air of fluid from entering
the pleural space. In resectional surgery except in pneumonectomy, the remaining
portions of the lung must overexpand and fill the space left by the resected portion.
The removal of air and fluid from the pleural space accomplishes two basic
purposes i.e. aid in expansion of the remaining portion of the lung as air and fluid
escapes through the drainage tubes, and reestablish negative pressure in the pleural
space. Because the drainage system is closed, air is prevented from entering the
chest tubes and collapsing the lung (refer BNSL-106).
Surgical Procedures of Chest (Other than Cardiac Surgeries)
Chest surgery is preformed for a variety of reasons, some of which are unrelated
to respiratory problems. For example, a thoractomy is performed for heat and
esophageal surgery.
Types of Chest Surgeries
Closed procedures
Thoracentaesis To remove fluid from the pleural
cavity.
Diagnostic purpose.
Tracheobronchial lung biospy Pleuritis
Pleural biopsy Malignant and non-malignant growth.
Needle puncture Small nodules less than lcm size
which in inaccessible to percutaneous
needle aspiratin biopsy or patient
unable to stand a standard
thoracotomy.
Video assisted thoracic surgery To confirm diagnosis or to obtain
biopsy.
Open Thoracic Surgery
Exploratory Thoracotomy Bronchogenic Carcinoma, TB
Resectional Pulmonary Surgeries
Pneumonectomy (Removal of Bronchogenic Carcinoma confined to
Lung) a Lobe, Bronchiectasis, Lung absess,
Cyst, Metastatic Ca.
Lobectomy (Removal of Lobe) Bronchoiectasis, lung abscess,
metastatic Ca.
Segmental Resection .(Removal of Benign tumour, localized '
one segment of lung) inflammatory disease, lung biopsy,
excision of small nodules.
Wedge resection (removal of small Chronic empyema
localised lesion that occupies only
part of a segement.
Decortication (removal of a fibrous . Residual air space after surgery,
peel from the visceral pleura) Chronic emphysema.
Respiratnry and Thoracoplasty (removal of ribs Chest deformity.
Cardiovascular Nursing without entering pleura. Usually
three ribs are removed. When there
is space in the chest that cannot be
obliterated by other means).
Pulmonary embolectomy Pulmonary embolism.
Heart Lung transplantation End stage of pulmonary diseases e.g.
Unilateral ling transplant COPD, Interstitial fibrosis in children,
cystic fibrosis.
Surgery of the Pleura
Excision of tumors of the pleura End stage of Cancer lung.
Pre-operative Managemeitt
a) Early Pre-operative Management
a Admission
a History taking.
Physical examination.
Diagnostic measures
i) Lab tests-blood, urine sputum, ABG analysis.
ii) Non-invasive respiratory monitoring techniques-pulse oximetry,
capnography, PFT
iii) Radiological and sonographic studies.-chest C-ray, Fluroscopy, CAT
Scan, pulmonary angiography, bronchography, sonography.
iv) MRI
v) Ventilation perfusion scanning.
vi) Endoscopic studies.
vii) Invasive procedures-thoracentesis, biopsy
Evaluation of patient's emotional and nutritional status and corrective meas-
ures.
a Control of infection.
Pre-operative teaching--chest physiotherapy, breathing exercise,
diaphragmatic and pursed lip breathing, coughing exercise, postural drain-
age, percussion and vibration, coughing, spirometry, arm and shoulder
exercise. Orientation to OT, ICU and recovery room. Explanation about
anaesthesia, operative procedure, chest drainage, oxygen therapy, IV fluid
and pain medication. Discuss the bad effects of smoking and no smoking
atleast 24 hours before surgery.
Blood requirement.
b) : Previous Day of Surgery
Legal aspect-informed consent taken.
r Pre-anaesthetic check-up.
r Skin preparation.
. Pre-operative antibiotics after sensitivity testhg.
Fasting for 6-8 hour before surgery. Respiratory Disorders
I
Provide comfortable invironment for rest and sleep.
c) On the Day of Surgeiy
Earl morning care.
Hospital clothes, removal of ornaments and artificial dentures.
Monitor vital signs and pre-medication.
I
Check and complete all the records and shift the patient to OT with all
records.
Post-operative Management
Goal: Promote ventilation and expansion of lungs by maintaining clear airway.
Promote comfort by relieving pain Promote re-expansion of the lung by proper
maintenance of water-seal drainage system, promoting arm exercise to maintain
full use of the patient's arm on the operated side. Promote hydration and
nutrition. Monitor incision for bleeding and subcutaneous emphysema.
a) Immediate Post-operative Care (On the Day of Surgery)
Prepare the recovery roornIICU to receive the patient.
Receive the patient and position his appropriately (semi-Fowler's if con-
scious).
Maintain a patent a k a y , administer oxygen
Assess pulse, respiration, BP,CVP every 15 minutes for two hours and then
hourly till patient is stabilized and then four hours.
Assess and maintain the fluid therapy - blood /plasma or dextrose saline.
- Monitor hourly urine output.
- Maintain intake output.
Chest X-ray 4 hourly, ABG hourly.
Care of the chest drainage tube.
- Location of the chest drainage apparatus.
- Position of the person.
- Maintain patency of the chest drainage tubing.
- Prevent infection.
- Activity with chest drainage.
- Clamping chest drainage tubing.
- Chest X-ray should be taken.
Medication- administer the prescribed medication and observe the effect and for
any side effects.
b) Later Post-operative Care
i) 1st Post-Operation Day
Check the level of consciousness.

a Chest X-ray every 4 hourly I
Respiratory and ABG analysis, weaning from ventilator or 0,.
Vitals 4 hourly.
Deep breathing and coughing exercise 2 hourly.
Check operative site for bleeding, assess the dressing.
Milking the chest drainage tubes and check for patency of chest drainage.
Encowage a m and shoulder exercise.
Start oral feed after test feed.
ii) 2nd Post Operation Day
Encourage the person to take orally normal diet.
Record intake output chart.
Remove the drainage tube if secretion is below 50 ml
Shift the person to post-operative ward.
Give steam inhalation. Encourage the person to do all breathing exercise,
ambulation.
Administer analgesis as prescribed for pain. Continue other medication.
iii) 3rd Post Operation Day
Encourage the person to walk and to take normal diet.
Administer medications.
Encourage self-care activities, breathing exercise and postural drainage.
Steam inhalation.
Laxatives or protoclysis enema if needed.
Check the operated site for swelling and redness.
Asses for any complication.
iv) 4th Post Operation Day
Shift the person to respective wards.
Check vitals record
Intake and output.
Chest physiotherapy.
Change wound dressing.
Prepare the patient for discharge and follow-up.
V) Fifth Post-operative day onwards
Usually dressing can be changed on the 4th or 5th Post-Op. Day. Discharge on
7th or 8th Post-Op. Day, if no coinplications.
Discharge counseling: importance of continuing with the breathing exercise,
physiotherapy, abstinance from smoking, about the medication regine, infection
preventive measures, good nutritious diet and follow-up regime.
.. .
Cornplicatjons
Respiratory Insufiiciency
Atelectasis and Pneumothorax
Tension Pneurnothorax . Nursing Management of
Pulmonary Embolism Respiratory Disorders
Subcutaneous Emphysema
Residual Pleural Space
Broncho-pleural fistulla
Acute Pulmonary edema
Respiratory Arrest
Gastric Distension
Cardiac Arhythrnias
Infection
Adrenal Exhaustion
Respiratory and
Activity 3 '
Make a list of respiratory prablems with which patients are admitted in your
hospital. Do nursing assessment and prepare nursing care plan for patients with
pneumonia,COPD and patient with a surgery involving respiratory system.
Nursi~agManagemtnt of
1.10 RELATED PHARMACOLOGY Patients w ~ t hCommon
The common drugs used in the treatment of respiratory disorders are antibodies
in case of infection, bronchidilators, and cough syrups. Antibodies are prescribed
on the basis of the identified infective agents and their sensitivity.
We will discuss about bronchodilators and the cough syrups.
Bronchodilators
Main action of various bronchodilators is to relax the bronchial smooth muscles.
Indications
Bronchodilator are used for bronchial asthma, bronchospasm associated with
bronchitis, emphysema or other obstructive pulmonary diseases. They are also
used in exercise induced asthma.
Contraindications
Person with hypersensitivity to syrnpathommitics, tachy dysrhythmias, narrow
angle glaucoma.
Insomia, tremors, anxiety, nausea, vomiting, irritation in throat, headache,

tachycardia, palpitation.
Nursing Implications
Assess respiratory function, pulse rate and rhythm-baseline data. Teach patient
the method of using inhalor-shake well, exhale, place mouth piece in mouth, take
deep breath through mouth while squeezing, releasing a puff of medication, hold
breath for 3 to 4 second at all inspiration, remove mouth piece and exhale
slowly, rinse mouth after completing treatment, wash inhalor with warm water,
dry and keep safely, patient to stop smoking. Administer oral medication to
prevent gastric irritation. Evaluate therapeutic response. Keep medication in safe
light-resistant container in cool environment.
Respiratory and
Cardiovascular Nursing ,

Unit 1

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Unit 1

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UNIT 1 NURSING MANAGEMENT OF

PATIENTS WITH COMBION

After completing this unit, you will be able to:

1.2 REVIEW OF RELATED ANATOMY AND

1.2.1 Upper Respiratory Tract

Fig. 1.1: Structure of upper respiratory tract

1.2.2 Lower Respiratory Tract

Larynx W BRONCHIAL TREE

Fig. 1.2: Structure of lower respiratory tract

Visceral Alveolar Alveolar

a) Diagram of a portion of a lobule of the lung b) Lung lobule

Fig. 1.3: Microscopic anatomy of a lobule of the lungs

oesophagus &scending aorta

Transport of Oxygen and Carbon Dioxide

Factors Necessary to Maintain Normal Breathing

1) Adequate supply of oxygen in the environment.

1.3 ASSESSMENT OF PATIENTS WITH

dbrium of sternum Suprasternal notch

2nd coastal cartilage

Fig. 1.5: Normal anatomy of the rib cage

Kyphoscoliosis: A combination of kyphosis and scoliosis.the shoulder and

Cross section of thorax Clinical appearance

Cross section of thorax Clinical appearance

Funnel Chest (Pectus Excavated): This is a depression of part or all of

Cross section of thorax Clinical appearance

Pigeon. Chest (Pectus Carinatum): This is an anterior protrusion of the chest

Assess for signs of respiratory distress such as:

Fig. 1.10: ~ e t h o dof Palpation

1.4.1 Pulmonary Function Tests

1.4.2 Pulse Oximetry

50 per cent , 25 mm Hg Life threatening hypoxemia

1.4.3 Arterial Blood Gas Studies

1.5.1 Chest Roentgenogram

1.5.2 Tomography (Planigraphy)

1.5.3 Computed Tomography

1.5.4 Positron Emission Tomography (PET)

1.5.5 Magnetic Resonance Imaging

1.5.7 Barium Swallow

1.7 RADIOISOTOPE DIAGNOSTIC PROCEDURES

1.7.1 Perfusion Lung Scan

1.7.2 Ventilation Scan .

1.7.3 Gallium Scan

1.8 EXAMINATION OF PLEURAL FLUID AND

1) Pleural fluid is obtained by aspiration (thoracentesis) or by tube

Needle PUnCbR [a$p~~k~on'' biopsy of chest lesions is done under fluoroscopy.

1.9 MAJOR HEALTH PROBLEMS OF THE LOWER

1.9.1 Restricted Lun.g Diseases

Occupational lung diseases e.g. Silicosis.

Care of patient with respiratory disease is discussed following.

Adult Respiratory Distress Syndrome (ARDS)

Treat underlying causes of ARDS.

1.9.2 Common Obstructive LungIPulmonary Diseases (COPD)

On auscultation -inspiratory crackles (rales), inspiratory and expiratory

Early onset of dyspnea on exertion (DOE) which progresses to continuous

movement, complaint of epigastric fullness.

History, precipitating factors, current medication, medication used to relieve

1.9.4 Trauma and Surgical Conditions

Fig. 1.12: Normal respiration. A, Inspiration; B; Expiration. Paradoxical motion: C,

Other manifestions of flail chest are localized atelectasis, hypoxemia, due to

Check the level of consciousness.

Residual Pleural Space

Acute Pulmonary edema

We will discuss about bronchodilators and the cough syrups.