1

Course Number : NCM 112-n

Course Title : Care of clients with Problems in Oxygenation, Fluid and
Electrolytes, Infectious, Inflammatory and Immunologic Response,
Cellular Aberrations, Acute, and Chronic
Instructor : Raul I. Gambalan, RN, MAN

The Individual Client with Problems in Oxygenation

DEFINITION OF TERMS

Apnea Temporary cessation of breathing.

Bronchophony Abnormal increase in clarity of transmitted voice sounds.
Direct examination of larynx, trachea, and bronchi using an
Bronchoscopy endoscope.
Short hairs that provide a constant whipping motion that serves to
Cilia propel mucus and foreign substances away from the lung toward
the larynx.
Compliance measure of the force required to expand or inflate the lungs.
Soft, high-pitched, discontinuous popping sounds during
Crackles inspiration caused by delayed reopening of the airways.
Exchange of gas molecules from areas of high concentration to
Diffusion areas of low concentration.
Dyspnea labored breathing or shortness of breath.
Abnormal change in tone of voice that is heard when auscultating
Egophony lungs.
Fremitus Vibrations of speech felt as tremors of chest wall during palpation.
Hemoptysis Expectoration of blood from the respiratory tract.
Hypoxemia Decrease in arterial oxygen tension in the blood.
hypoxia Decrease in oxygen supply to the tissues and cells.
Obstructive Temporary absence of breathing during sleep secondary to
Sleep Apnea transient upper airway obstruction.
Orthopnea Inability to breathe easily except in an upright position.
Oxygen
Saturation Percentage of hemoglobin that is bound to oxygen.
Physiologic Portion of the tracheobronchial tree that does not participate in
Dead Space gas exchange.
Pulmonary
Perfusion Blood flow through the pulmonary vasculature.
Gas exchange between atmospheric air and the blood and between
Respiration the blood and cells of the body.
Low-pitched wheezing or snoring sound associated with partial
Rhonchi airway obstruction, heard on chest auscultation.
Harsh high-pitched sound heard on inspiration, usually without
Stridor need of stethoscope, secondary to upper airway obstruction.
Tachypnea Abnormally rapid respirations.
Volume of air inspired and expired with each breath during normal
Tidal Volume breathing.
Ventilation Movement of air in and out of airways.
Continuous musical sounds associated with airway narrowing or
Wheezes partial obstruction.
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Review of Anatomy and Physiology: Respiratory System

Functions of the Respiratory System

1. Provides oxygen for metabolism in the tissues
2. Removes carbon dioxide, the waste product of metabolism
3. Facilitates sense of smell
4. Produces speech
5. Maintains acid-base balance
6. Maintains body water levels
7. Maintains heat balance
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The Upper Respiratory Tract

Nose: Humidifies, warms, and filters inspired air

Sinuses: Air-filled cavities within the hollow bones that surround the nasal passages
and provide resonance during speech

Pharynx:
1. Divided into the nasopharynx, oropharynx, and laryngopharynx
2. Passageway for the respiratory and digestive tracts located behind the oral
and nasal cavities

Larynx (Voice Box):

1. Located above the trachea, just below the pharynx at the root of the tongue.
2. Contains two pairs of vocal cords, the false and true cords
3. The opening between the true vocal cords is the glottis.
4. The glottis plays an important role in coughing, which is the most
fundamental defense mechanism of the lungs.

Epiglottis:
1. Leaf-shaped elastic structure attached along one end to the top of the larynx
2. Prevents food from entering the tracheobronchial tree by closing over the
glottis during swallowing.
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The Lower Respiratory Tract

Trachea: Located in front of the esophagus; branches into the right and left
mainstem bronchi at the carina.

Mainstem Bronchi:
1. Begin at the carina
2. The right bronchus is slightly wider, shorter, and more vertical than the left
bronchus.
3. The mainstem bronchi divide into secondary or lobar bronchi that enter each
of the five lobes of the lung.
4. The bronchi are lined with cilia, which propel mucus up and away from the
lower airway to the trachea, where it can be expectorated or swallowed.

Bronchioles:
1. Branch from the secondary bronchi and subdivide into the small terminal and
respiratory bronchioles.
2. The bronchioles contain no cartilage and depend on the elastic recoil of the
lung for patency.
3. The terminal bronchioles contain no cilia and do not participate in gas
exchange.

Lungs:
1. Located in the pleural cavity in the thorax
2. Extend from just above the clavicles to the diaphragm, the major muscle of
inspiration
3. The right lung, which is larger than the left, is divided into three lobes: the
upper, middle, and lower lobes.
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4. The left lung, which is narrower than the right lung to accommodate the
heart, is divided into two lobes.
5. The respiratory structures are innervated by the phrenic nerve, the vagus
nerve, and the thoracic nerves.
6. The parietal pleura lines the inside of the thoracic cavity, including the
upper surface of the diaphragm.
7. The visceral pleura covers the pulmonary surfaces.
8. A thin fluid layer, which is produced by the cells lining the pleura, lubricates
the visceral pleura and the parietal pleura, allowing them to glide smoothly and
painlessly during respiration.
9. Blood flows throughout the lungs via the pulmonary circulation system.

Alveolar Ducts and Alveoli:

1. Acinus (plural acini) is a term used to indicate all structures distal to the
terminal bronchiole.
2. Alveolar ducts branch from the respiratory bronchioles.
3. Alveolar sacs, which arise from the ducts, contain clusters of alveoli, which
are the basic units of gas exchange.
4. Type II alveolar cells in the walls of the alveoli secrete surfactant, a
phospholipid protein that reduces the surface tension in the alveoli and without
surfactant, the alveoli would collapse.
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Accessory Muscles of Respiration:

1. Scalene muscles - which elevate the first 2 ribs
2. Sternocleidomastoid muscles - which raise the sternum
3. Trapezius and pectoralis muscles - which fix the shoulders

The Respiratory Process:

1. The diaphragm descends into the abdominal cavity during inspiration,

causing negative pressure in the lungs.
2. The negative pressure draws air from the area of greater pressure, the
atmosphere, into the area of lesser pressure, the lungs.
3. In the lungs, air passes through the terminal bronchioles into the alveoli and
diffuses into surrounding capillaries, then travels to the rest of the body to
oxygenate the body tissues.
4. At the end of inspiration, the diaphragm and intercostal muscles relax and
the lungs recoil.
5. As the lungs recoil, pressure within the lungs becomes higher than
atmospheric pressure, causing the air, which now contains the cellular waste
products carbon dioxide and water, to move from the alveoli in the lungs to the
atmosphere.
6. Effective gas exchange depends on distribution of gas (ventilation) and blood
(perfusion) in all portions of the lungs.
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The Client Health Assessment:

HISTORY TAKING - Subjective Cues

1. Reason for seeking care (chief complaints) c/c
2. Present Illness/ History of Present Health Concern

Ask For? Rationale

a. Difficulty of Breathing
(Do you ever experience difficulty
breathing or a loss of breath? If the
client answers YES, use COLDSPA to
explore the symptom.)
Characteristics: Dyspnea (difficulty breathing)
can indicate a number of health
Describe the difficulty breathing problems including pulmonary disorders,
Congestive Heart Failure (CHF),
Coronary Heart Disease (CHD),
Myocardial Ischemia, and Myocardial
Infarction (MI).

Chronic Obstructive Pulmonary Disease

(COPD): may describe their dyspnea as
not being able to “breathe or take a deep
breath.”

Anxious clients may describe their

dyspnea as feeling like they are
suffocating or may have tingling in the
lips due to a decrease in carbon dioxide
level.
Onset: It may occur during rest, sleep, or with
mild, moderate, or extreme exertion.
When did it begin?
Gradual onset of dyspnea is usually
indicative of lung changes such as
emphysema.

Sudden onset is associated with viral or

bacterial infections.
Location: Locate the exact location.
Duration: They may have continuous coughing
(“smoker’s cough”) with lots of sputum,
How long did the dyspnea last? shortness of breath with everyday
activities, and wheezing.

Common symptoms of Asthma are

wheezing, frequent cough with or
without mucous, shortness of breath,
and chest tightness.

Severity:
Palliative/Aggravating factors:
What aggravates or relieves the
dyspnea?
Do any specific activities cause
the difficulty breathing?
Do you have difficulty breathing when
you are resting?
Do you have difficulty breathing when
you sleep?
Do you use more than one pillow or
elevate the head of the bed when you
sleep?
Do you snore when you sleep?
Have you been told that you stop
breathing at night when you snore?
Associated Factors:
Do you experience any other symptoms
when you have difficulty breathing?
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Dyspnea with exercise or heavy
activities is normal if the dyspnea
subsides with
resting from the activity.
Dyspnea will occur with typical
nonstrenuous activities (such as walking
one block or climbing two stairs) of daily
living in clients with lung disease.
Dyspnea can occur with stress and
anxiety.
GERIATRIC CONSIDERATION:
1. Older adults may experience dyspnea with
certain activities related to aging changes of the
lungs (loss of elasticity, fewer functional
capillaries, and loss of lung resiliency).
Associated symptoms provide clues to
the underlying problem.
Certain associated symptoms suggest
problems in other body systems.
For example:
1.Edema or Angina
that occurs with dyspnea may indicate a
cardiovascular problem.
2.Orthopnea (difficulty breathing when
lying supine) may be associated with
heart failure.
3. Paroxysmal Nocturnal Dyspnea
(severe dyspnea that awakens the
person from sleep) also may be
associated with heart failure.
Changes in sleep patterns may cause the

Chest Pain
Do you have chest pain?
Is the pain associated with a
cold, fever, or deep breathing?
Cough
Do you have a cough?
When and how often does it
occur?
Do you produce any sputum when you
cough? If so, what color is the sputum?
How much sputum do you
cough up?
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client to feel fatigued during the day.
Sleep apnea (periods of breathing
cessation during sleep) may be the
source of snoring and gasping sounds.
Generally, sleep apnea diminishes the
quality of sleep, which may account for
fatigue or excessive tiredness,
depression, irritability, loss of memory,
lack of energy, and a risk for automobile
and workplace accidents.
Pain-sensitive nerve endings are located
in the parietal pleura, thoracic muscles,
and tracheobronchial tree, but not in the
lungs. Chest pain associated with a
pulmonary origin may be a late sign of
pulmonary disease.
NURSING ALERT:
Immediately assess any reports of chest pain
further to determine if it is due to cardiac
ischemia, which is a medical emergency requiring
immediate assessment and intervention.
GERIATRIC CONSIDERATION:
Chest pain related to pleuritis may be absent in
older clients because of age-related alterations in
pain perception.
Continuous coughs are usually
associated with acute infections, whereas
those occurring only early in the morning
are often associated with chronic
bronchial inflammation or smoking.
Coughs late in the evening may be the
result of exposure to irritants during
the day.
Coughs occurring at night are often
related to postnasal drip or sinusitis.
GERIATRIC CONSIDERATION:
The ability to cough effectively may be decreased
in the older client because of weaker muscles
and increased rigidity of the thoracic wall.
Nonproductive coughs are often
associated with upper respiratory
irritations and early congestive heart
failure (CHF).
White or mucoid sputum is often seen

Has this amount increased or decreased
recently?
Does the sputum have an odor?
Do you wheeze when you cough or when
you are active?
b. Gastrointestinal (GI) Symptoms
Do you have any gastrointestinal
symptoms such as heartburn, frequent
hiccups, or chronic cough?
3. Previous Illness/Personal Health History
Have you had prior respiratory
problems?
Have you ever had any thoracic surgery,
biopsy, or trauma?
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with common colds, viral infections, or
bronchitis.
Yellow or green sputum is often
associated with bacterial infections.
Blood in the sputum (hemoptysis) is
seen with more serious respiratory
conditions.
Rust-colored sputum is associated with
tuberculosis or pneumococcal
pneumonia.
Pink, frothy sputum may be indicative of
pulmonary edema.
An increase in the amount of sputum is
often seen in an increase in exposure to
irritants, chronic bronchitis, and
pulmonary abscess.
Clients with excessive, tenacious
secretions may need instruction on
controlled coughing and measures to
reduce viscosity of secretions.
Wheezing indicates narrowing of the
airways due to spasm or obstruction.
Wheezing is associated with CHF,
asthma (reactive airway disease), or
excessive secretions.
According to Cleveland Clinic study
conducted in 2008, shown that up to
75% of clients with asthma have
gastroesophageal reflux disease (GERD)
or are more susceptible to GERD.
A history of respiratory disease increases
the risk for a recurrence. In addition,
some respiratory diseases may imitate
other disorders.
Example: Asthma symptoms may mimic
symptoms commonly associated with
emphysema or heart failure.
Previous surgeries may alter the
appearance of the thorax and cause
changes in respiratory sounds.
Trauma to the thorax can result in lung

Have you been tested for or diagnosed
with allergies?
Are you currently taking medications for
breathing problems or other medications
(prescription or over the counter/OTC)
that affect your breathing?
Do you use any other treatments at
home for your respiratory problems?
Have you ever had a chest x-ray,
tuberculosis (TB) skin test, or influenza
immunization?
Have you had any other pulmonary
studies in the past?
Have you recently traveled outside the
country?
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tissue changes.
Many allergic responses are manifested
with respiratory symptoms such as
dyspnea, cough, or hoarseness.
Clients may need education on
controlling the amount of allergens in
their environment.
Consider all medications when
determining if respiratory problems could
be attributed to adverse reactions.
Certain medications.
These medications are contraindicated
with some respiratory problems such as
asthma.
Medications associated with the side
effect of persistent cough.
Example:
1. Beta-adrenergic antagonists (beta
blockers):
Atenolol (Tenormin)
Metoprolol (Lopressor)
2. Angiotensin-Converting Enzyme (ACE)
Inhibitors:
Enalapril (Vasotec)
Lisinopril (Zestril)
These medications are contraindicated
with some respiratory problems such as
asthma.
If the client is using oxygen or other
respiratory therapy at home, it is
important to evaluate knowledge of
proper use and precautions as well as
the client’s ability to afford the therapy.
Information on previous chest x-rays, TB
skin tests, influenza immunizations, and
the like is useful for comparison with
current findings, and provides insight on
self-care practices and possible teaching
needs
Travel to high-risk areas exposes to
potential respiratory diseases.

4. Family History
Is there a history of lung disease in your
family?
Did any family members in your home
smoke when you were growing up?
Is there a history of other pulmonary
illnesses/disorders in the family like
asthma?
5. Social History/Lifestyle and Health Practices
Describe your usual dietary intake
Have you ever smoked cigarettes or other Smoking is linked to a number of
tobacco products?
Do you currently smoke? At what age did
you start?
How much do you smoke and how much
have you smoked in the past?
What activities do you usually associate
with smoking? Have you ever tried to
quit?
Are you exposed to any environmental
conditions that affect your breathing?
Where do you work?
Are you around smokers?
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The risk for lung cancer is thought to be
partially based on genetics.
A history of certain respiratory diseases
(asthma, emphysema) in a family may
increase the risk for development of the
disease.
Exposure to viral or bacterial respiratory
infections in the home increases the risk
for development of these conditions.
Second-hand smoke puts clients at risk
for COPD (including emphysema and
chronic bronchitis) or lung cancer later
in life.
Some pulmonary disorders, such as
asthma, tend to run in families.
Poor nutritional status (both weight loss
and obesity) is frequently seen in clients
with COPD and is a predictor of
mortality.
respiratory conditions, including lung
cancer.
The number of years a person has
smoked and the number of cigarettes
per day influence the risk for developing
smoking-related respiratory problems.
Information on smoking behavior and
previous efforts to quit may be helpful
later in identifying measures to assist
with smoking cessation.
Exposure to certain environmental
inhalants can result in an increased
incidence of certain respiratory
conditions.
Environmental irritants commonly
associated with occupations include coal
dust, insecticides, paint, pollution,
asbestos fibers, and the like.
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Example:
1. Inhaling dust contaminated with
Histoplasma capsulatum may cause
histoplasmosis, a systemic fungal
disease.

Histoplasma capsulatum: this disease is

common in the rural midwestern United
States.

Second-hand smoke is another irritant

that can seriously affect a person’s
respiratory health.
Do you have difficulty performing your Respiratory problems can negatively
usual daily activities? Describe any affect a person’s ability to perform the
difficulties usual ADLs/Activities of Daily Living.
What kind of stress are you experiencing Shortness of breath can be a
at this time? manifestation of stress.

How does it affect your breathing?
Have you used any herbal medicines or
alternative therapies to manage colds or
other respiratory problems?
Client may need education about
relaxation techniques.
Many people use herbal therapies, such
as Echinacea, or alternative therapies,
such as zinc lozenges, to decrease cold
symptoms.

Knowing what clients are using enables

you to check for side effects or adverse
interactions with prescribed
medications.

PHYSICAL EXAMINATION – Objective Cues

1. General Survey
a. Inspection
Assessment Normal Findings Abnormal Findings
Inspect for nasal flaring Nasal flaring is not observed. Nasal flaring is seen
and pursed lip with labored
breathing. Normally the diaphragm and the respirations (especially
external intercostal muscles do in small children) and is
most of the work of breathing. indicative of hypoxia.

This is evidenced by outward Pursed lip breathing

expansion of the abdomen and
lower ribs on inspiration as well
as return to resting position on
expiration.
may be seen in asthma,
emphysema, or CHF as
a physiologic response
to help slow down
expiration and keep
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alveoli open longer

Observe color of face, The client has evenly colored Ruddy to purple
lips, and chest. skin tone, without unusual or complexion may be
prominent discoloration. seen in clients with
COPD or CHF as a
result of polycythemia.
Cyanosis may be seen
if client is cold or
hypoxic.

CULTURAL
CONSIDERATIONS:
Cyanosis makes white skin
appear blue-tinged,
especially in the perioral,
nailbed, and conjunctival
areas. Dark
skin appears blue, dull, and
lifeless in the same areas.
Inspect color and shape Pink tones should be seen in the Pale or cyanotic nails
of nails nailbeds. may indicate hypoxia.

There is normally a 160-degree Early clubbing (180-

angle between the nail base and degree angle) and late
the skin. clubbing (greater than
a 180-degree angle)
can occur from hypoxia.

2. Physical Examination – Posterior Thorax

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Normal Findings Abnormal Findings

a. Inspection Scapulae are symmetric and Spinous processes that
non-protruding. deviate laterally in the
While the client sits thoracic area may
with arms at the sides, Shoulders and scapulae are at indicate scoliosis.
stand behind the client equal horizontal positions. The
and observe the ratio of anteroposterior to Spinal configurations
position of scapulae transverse diameter is 1:2. may have respiratory
and the shape and implications. Ribs
configuration of the Spinous processes appear appearing horizontal at
chest wall. straight, and thorax appears an angle greater than
symmetric, with ribs sloping 45 degrees with the
NOTE: downward at approximately a spinal column is
Some clinicians prefer to 45-degree angle in relation to frequently the result of
inspect the entire thorax
first, followed by palpation
the spine. an increased ratio
of the anterior and posterior between the
thorax, then percussion and GERIATRIC CONSIDERATION: anteroposterior-
auscultation of the anterior Kyphosis (an increased curve of the transverse diameter
and posterior thorax. thoracic spine) is common in older
clients.
(barrel chest).

It results from a loss of lung resiliency This condition is

and a loss of skeletal muscle. It may commonly the result of
be a normal finding. emphysema due to
hyperinflation of the
lungs.
CULTURAL CONSIDERATIONS: Trapezius, or shoulder,
The size of the thorax, which
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affects pulmonary function, differs by muscles are used to

race. facilitate inspiration in
Compared with African Americans,
cases of acute and
Asians and Native Americans, adult chronic airway
Caucasians have a larger thorax and obstruction or
greater lung capacity. atelectasis.
Observe use of The client does not use Tripod Position:
Accessory Muscles. accessory (trapezius/shoulder) Client leans forward
muscles to assist breathing. and uses arms to
Watch as the client support weight and lift
breathes and note use The diaphragm is the major chest to increase
of muscles. muscle at work. breathing capacity.

This is evidenced by expansion

of the lower chest during
inspiration.
Inspect the client’s Client should be sitting up and Tender or painful areas
positioning. relaxed, breathing easily with may indicate inflamed
arms at sides or in lap. fibrous connective
Note the client’s tissue.
posture and ability to Pain over the
support weight while intercostal spaces may
breathing comfortably be from inflamed
pleurae.
Pain over the ribs,
especially at the costal
chondral junctions, is a
symptom of fractured
ribs.
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Tripod Position

b. Palpation Client reports no Muscle soreness from exercise

tenderness, pain, or or the excessive work of
Palpate for tenderness unusual sensations. breathing (as in
and sensation.
Temperature should be COPD) may be palpated as
Palpation may be equal bilaterally. tenderness.
performed with one or
both hands, but the Increased warmth may be
sequence of palpation is related to local infection.
established.

Use your fingers to

palpate for tenderness,
warmth, pain, or other
sensations.

Start toward the midline

at the level of the left
scapula (over the apex
of the left lung) and
move your hand left to
right, comparing
findings bilaterally.

Move systematically
downward and out to
cover the lateral
portions of the lungs at
the bases.
Palpate for crepitus. The examiner finds no Crepitus can be palpated if air
Crepitus palpable crepitus. escapes from the lung or
Subcutaneous other airways into the
Emphysema subcutaneous tissue, as
occurs after an open thoracic
A crackling sensation injury, around a chest
(like bones or hairs tube/tracheostomy.
rubbing
against each other) that It also may be palpated in
occurs when air passes areas of extreme
through fluid or congestion/consolidation.
exudate.
In such situations, mark
Use your fingers and margins and monitor to note
follow the sequence any decrease or increase in
when palpating. the crepitant area.
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Sequence for Palpating the Posterior Thorax

Palpate surface Skin and subcutaneous A physician or other

characteristics. tissue are free of appropriate professional
lesions and masses. should evaluate any unusual
Put on gloves and use palpable mass.
your fingers to palpate
any lesions that you
noticed during
inspection.

Feel for any unusual

masses.
Palpate for fremitus. Fremitus is symmetric Unequal fremitus is usually
and easily identified the result of consolidation
Following the sequence in the upper regions of (which increases fremitus) or
described previously, the lungs. bronchial obstruction, air
use the ball or ulnar trapping in emphysema,
edge of one hand to If fremitus is not pleural effusion, or
assess for fremitus palpable on either side, pneumothorax (which all
(vibrations of air in the the client may need to decrease fremitus).
bronchial tubes speak louder.
transmitted to the chest Diminished fremitus even with
wall). A decrease in the a loud spoken voice may
intensity of fremitus is indicate an obstruction of the
As you move your hand normal as the examiner tracheobronchial tree
to each area, ask the moves toward the base

client to say “ninety-
nine.” Assess all areas
for symmetry and
intensity of vibration.
NOTE:
The ball of the hand is best
for assessing tactile fremitus
because the area is
especially sensitive to
vibratory sensation.
Assess chest expansion.
Place your hands on the
posterior chest wall with
your thumbs at the level
of T9 or T10 and
pressing together a
small skin fold. As the
client takes a deep
breath, observe the
movement of your
thumbs.
of the lungs.
Fremitus should remain
symmetric for bilateral
positions.
When the client takes a
deep breath, the
examiner’s thumbs
should move 5 to 10 cm
apart symmetrically.
GERIATRI CONSIDERATIONS:
Calcification of the costal
cartilages and loss of the
accessory musculature, the
older client’s thoracic
expansion may be decreased,
although it should still be
symmetric.
19
Unequal chest expansion can
occur with severe atelectasis
(collapse or incomplete
expansion), pneumonia, chest
trauma, or pneumothorax (air
in the pleural space).
Decreased chest excursion at
the base of the lungs is
characteristic of COPD. This is
due to decreased
diaphragmatic function.
 20

Starting position for assessing symmetry of chest expansion.

c. Percussion Resonance is the Hyperresonance is elicited

percussion tone elicited in cases of trapped air
Percuss for tone. over normal lung tissue. such as in emphysema or
Start at the apices of pneumothorax.
the scapulae and percuss Percussion elicits flat tones
across the tops of both over the scapula.
shoulders.

Then percuss the

intercostal spaces across
and down, comparing
sides.

Percuss to the lateral

aspects at the bases
of the lungs, comparing
sides.

(a)Sequence for percussing the (b)Normal percussion tones heard from

posterior thorax the posterior thorax

Percuss for diaphragmatic Excursion should be equal Dullness is present when

excursion. bilaterally and measure 3– fluid or solid tissue
5 cm in adults. replaces air in the lung or

“Ask the client to exhale
forcefully and hold the
breath”.
Beginning at the scapular
line (T7), percuss the
intercostal spaces of the
right posterior chest wall.
Percuss downward until
the tone changes from
resonance to dullness.
Mark this level and allow
the client to breathe.
Next ask the client to
inhale deeply and hold it.
Percuss the intercostal
spaces from the mark
downward until resonance
changes to dullness. Mark
the level and allow the
client to breathe.
Measure the distance
between the two marks.
Perform this assessment
technique on both
sides of the posterior
thorax.
Measuring diaphragmatic excursion
The level of the diaphragm
may be higher on the right
because of the position of
the liver.
In well-conditioned clients,
excursion can measure up
to 7 or 8 cm.
21
occupies the pleural
space, such as in lobar
pneumonia, pleural
effusion, or tumor.
Diaphragmatic descent
may be limited by
atelectasis of the lower
lobes or by emphysema,
in which diaphragmatic
movement
and air trapping are
minimal.
The diaphragm remains in
a low position on
inspiration and expiration.
Other possible causes for
limited descent can be
pain or abdominal changes
such as extreme ascites,
tumors, or pregnancy.
Uneven excursion may be
seen with inflammation
from unilateral
pneumonia, damage to
the phrenic nerve, or
splenomegaly

d. Auscultation
Auscultate for breath
sounds.
To best assess lung
sounds, you will need to
hear the sounds as
directly as possible.
Do not attempt to listen
through clothing or a
drape, which may produce
additional sound or muffle
lung sounds that exist.
To begin, place the
diaphragm of the
stethoscope firmly
and directly on the
posterior chest wall at
the apex of the lung at
C7.
Ask the client to breathe
deeply through the mouth
for each area of
auscultation (each
placement of the
stethoscope) in the
auscultation sequence
so that you can best hear
inspiratory and
expiratory sounds.
Be alert to the client’s
comfort and offer times
for rest and normal
breathing if fatigue is
becoming a problem.
GERIATRIC CONSIDERATION:
Deep breathing may be
especially difficult for the older
client, who may fatigue easily.
Offer rest as needed.
Three types of normal
breath sounds may be
auscultated—bronchial,
bronchovesicular, and
vesicular.
Bronchial sounds are
present over the large
airways in the anterior
chest near the second and
third intercostal spaces.
Sounds are more tubular
and hollow-sounding than
vesicular sounds, but not
as harsh as tracheal
breath sounds.
Sounds are loud and high
in pitch with a short pause
between inspiration and
expiration. Expiratory
sounds last longer than
inspiratory sounds.
Bronchovesicular sounds
are heard in the posterior
chest between the
scapulae and in the center
part of the anterior chest.
Sounds are softer than
bronchial sounds, but have
a tubular quality.
Sounds are about equal
during inspiration and
expiration.
Differences in pitch and
intensity are often more
easily detected during
expiration.
Vesicular sounds are soft,
blowing, or rustling sounds
normally heard throughout
most of the lung fields.
Sounds are normally heard
throughout inspiration,
22
Diminished or absent
breath sounds often
indicate that little or no air
is moving in or out of the
lung area being
auscultated.
This may indicate
obstruction within the
lungs as a result of
secretions, mucus plug, or
a foreign object.
It may also indicate
abnormalities of the
pleural space such as
pleural thickening, pleural
effusion, or
pneumothorax.
In cases of emphysema,
the hyperinflated nature of
the lungs, together with a
loss of elasticity of lung
tissue, may result in
diminished inspiratory
breath sounds.
Increased (louder) breath
sounds often occur when
consolidation or
compression results
in a denser lung area that
enhances the transmission
of sound.

Auscultate from the apices
of the lungs at C7 to the
bases of the lungs at T10
and laterally from the
axilla down to the seventh
or eighth rib.
Listen at each site for at
least one complete
respiratory cycle.
Location of breath sounds for the
posterior thorax. V, vesicular sounds the
BV, bronchovesicular sounds
Auscultate for adventitious
sounds.
23
continue without pause
through expiration, and
then fade away about one
third of the way through
expiration.
NOTE:
Breath sounds are considered
normal only in the area
specified.
Heard elsewhere, they are
considered abnormal sounds.
Example: Bronchial breath
sounds are abnormal if heard
over the peripheral lung fields.
Sometimes breath sounds
may be hard to hear with
obese or heavily muscled
clients due to increased
distance to underlying lung
tissue.
Sequence for auscultating
posterior thorax
No adventitious sounds, Adventitious lung sounds,
such as crackles (discrete such as crackles (formerly
and discontinuous sounds) called rales) and wheezes
 24

Adventitious sounds are or wheezes (musical and (formerly called rhonchi)

sounds added or continuous), are are evident.
superimposed over normal auscultated.
breath sounds and heard NOTE:
during auscultation. If you hear an abnormal sound
during auscultation, always
have the client cough, then
Be careful to note the listen again and note any
location on the chest wall change.
where adventitious sounds Coughing may clear the lungs.
are heard as well as the
location of such sounds
within the respiratory
cycle.

Adventitious Lung/Breath Sources Conditions

Sounds
1. Discontinuous Sounds
a. Crackles (fine): Inhaled air suddenly Crackles occurring late in
High-pitched, short, opens the small, deflated inspiration are associated
popping sounds heard air passages that are with restrictive diseases
during inspiration and not coated and sticky with such as pneumonia and
cleared with coughing. exudate. congestive heart failure.

Sounds are discontinuous Crackles occurring early in

and can be simulated by inspiration are associated
rolling a strand of hair with obstructive disorders
between your fingers near such as bronchitis,
your ear. asthma, or emphysema.
b. Crackles (coarse) Inhaled air comes into May indicate pneumonia,
Low-pitched, bubbling, contact with secretions pulmonary edema (PE),
moist sounds that may in the large bronchi and and pulmonary fibrosis
persist from early trachea. (PF).
inspiration to early
expiration. “Velcro rales” of
pulmonary fibrosis are
Described as softly heard louder and closer to
separating Velcro. Stethoscope.

Usually do not change

location, and are more

2. Continuous Sounds
a. Pleural Friction Rub:
Low-pitched, dry, grating
sound; sound is much
like crackles, only more
superficial and occurring
during both inspiration
and expiration.
b. Wheeze (sibilant):
High-pitched, musical
sounds heard primarily
during expiration but may
also be heard on
inspiration.
c. Wheeze (sonorous):
Low-pitched snoring or
moaning sounds heard
primarily during expiration
but may be heard
throughout the respiratory
cycle. These wheezes may
clear with coughing.
Auscultate Voice Sounds.
a. Bronchophony:
Ask the client to repeat
the phrase “ninety-nine”
while you auscultate the
chest wall.
b. Egophony:
Ask the client to repeat
the letter “E” while you
listen over the chest wall.
c. Whispered pectoriloquy:
Ask the client to
whisper the phrase “one–
two–three” while
you auscultate the chest
wall.
3. Physical Examination – Anterior Thorax
a. Inspection
Inspect for shape and The anteroposterior
Sound is the result of
rubbing of two inflamed
pleural surfaces.
Air passes through
constricted passages
(caused by swelling,
secretions, or tumor).
Same as sibilant wheeze.
The pitch of the wheeze
cannot be correlated to
the size of the passageway
that generates it.
Voice transmission is soft,
muffled, and indistinct.
The sound of the voice
may be heard but the
actual phrase cannot be
distinguished.
Voice transmission will be
soft and muffled but the
letter “E” should be
distinguishable.
Transmission of sound is
very faint and muffled. It
may be inaudible.
25
common in clients with
long-term COPD.
Pleuritis
Sibilant wheezes are often
heard in cases of acute
asthma or chronic
emphysema.
Sonorous wheezes are
often heard in cases of
bronchitis or single
obstructions and snoring
before an episode of sleep
apnea. Stridor is a
harsh, honking wheeze
with severe
broncholaryngospasm,
such as occurs with croup.
The words are easily
understood and louder
over areas of increased
density. This may indicate
consolidation from
pneumonia, atelectasis, or
tumor.
Over areas of
consolidation or
compression, the sound is
louder and sounds like
“A.”
Over areas of
consolidation or
compression, the sound is
transmitted clearly and
distinctly. In such areas, it
sounds as if the client is
whispering directly into
the stethoscope.
Anteroposterior equals

configuration. Have the
client sit with arms at the
sides. Stand in front of the
client and assess shape
and configuration.
Inspect position of the
sternum. Observe the
sternum from an anterior
and lateral viewpoint.
diameter is less than the
transverse diameter. The
ratio of anteroposterior
diameter to the transverse
diameter is 1:2.
Sternum is positioned at
midline and straight.
GERIATRIC CONSIDERATIONS:
The sternum and ribs may be
more prominent in the older
client because of loss of
subcutaneous fat.
26
transverse diameter,
resulting in a barrel chest
This is often seen in
emphysema because of
hyperinflation of the
lungs.
Pectus excavatum (funnel
chest) is a markedly
sunken sternum and
adjacent cartilages. It is a
congenital malformation
that seldom causes
symptoms other than self-
consciousness.
Pectus carinatum (pigeon
chest) is a forward
protrusion of the sternum
causing the adjacent ribs
to slope backward. Both
conditions may restrict
expansion of the lungs and
decrease lung capacity.

Watch for sternal
retractions.
Inspect slope of the ribs.
Assess the ribs from an
anterior and lateral
viewpoint.
Observe quality and
pattern of respiration.
Note breathing
characteristics as well
as rate, rhythm, and
depth.
NOTE: When assessing
respiratory patterns, it is more
objective to describe the
breathing pattern, rather than
just labeling the pattern.
Respiration Patterns
Retractions not observed.
Ribs slope downward with
symmetric intercostal
spaces. Costal angle is
within 90 degrees.
Respirations are relaxed,
effortless, and quiet. They
are of a regular rhythm
and normal depth at a rate
of 10–20 per minute in
adults.
Tachypnea and bradypnea
may be normal in some
clients.
27
Sternal retractions are
noted, with severely
labored breathing.
Barrel-chest configuration
results in a more
horizontal position of the
ribs and costal angle of
more than 90 degrees.
This often results from
long-standing
emphysema.
Labored and noisy
breathing is often seen
with severe asthma or
chronic bronchitis.
Abnormal breathing
patterns include
tachypnea, bradypnea,
hyperventilation,
hypoventilation,
Cheyne-Stokes
respiration, and Biot’s
respiration.
 28

Type Description Indication

1. Normal 12–20 breaths/min and Normal breathing pattern
Regular (cpm-cycles per
minute)
*16-20 breaths/minute
2. Tachypnea More than 24 breaths/min May be a normal response
and shallow to fever, anxiety, or
Tachy-high, increase exercise.

Can occur with respiratory

insufficiency, alkalosis,
pneumonia, or Pleurisy.
3. Bradypnea Less than 10 breaths/min May be normal in well-
and regular conditioned athletes.

Brady-low, decrease Can occur with

medication-induced
depression of the
respiratory center,
diabetic coma, neurologic
damage.
4. Hyperventilation Increased rate and Usually occurs with
increased depth extreme exercise, fear,
or anxiety.
Hyper- high, increase
Causes of hyperventilation
include disorders of the
central nervous system,
an overdose of the drug
salicylate, or severe
anxiety.

Respiration Patterns

Type Description Indication

5. Kussmaul Rapid, deep, labored A type of hyperventilation
associated with diabetic
ketoacidosis (DKA)
6. Hypoventilation Decreased rate, decreased Usually associated with
depth, irregular pattern overdose of narcotics or
Hypo- low, decrease anesthetics.
7. Cheyne-Stokes Regular pattern May result from severe
respiration characterized by congestive heart failure,
alternating periods of drug overdose, increased
deep, rapid breathing intracranial pressure, or
followed by periods of renal failure.
apnea
May be noted in elderly
persons during sleep, not

8. Biot’s respiration
9. Ataxic
10. Air trapping
3. Physical Examination – Anterior Thorax
a. Inspection
Inspect intercostal spaces.
Ask the client to breathe
normally and observe the
intercostal spaces.
Irregular pattern
characterized by varying
depth and rate of
respirations followed by
periods of apnea
Significant disorganization
with irregular and varying
depths of respiration
Increasing difficulty in
getting breath out
No retractions or bulging
of intercostal spaces are
noted.
29
related to any disease
process.
May be seen with
meningitis or severe
brain damage.
A more extreme
expression of Biot’s
respirations indicating
respiratory compromise.
In chronic obstructive
pulmonary disease, air is
trapped in the lungs
during forced expiration.
Retraction of the
intercostal spaces
indicates an increased
inspiratory effort.
This may be the result of
an obstruction of the
respiratory tract or
atelectasis.
Bulging of the intercostal
spaces indicate trapped air
such as in emphysema or
asthma.

3. Physical Examination – Anterior Thorax
a. Inspection
Observe for use of
accessory muscles.
Ask the client to breathe
normally and observe for
use of accessory muscles.
30
Use of accessory muscles Neck muscles
(sternomastoid and (sternomastoid, scalene,
rectus abdominis) is not and trapezius) are used to
seen with normal facilitate inspiration in
respiratory effort. cases of acute or chronic
airway obstruction or
After strenuous exercise atelectasis.
or activity, clients with
normal respiratory The abdominal muscles
status may use neck and the internal intercostal
muscles for a short time muscles are used to
to enhance breathing. facilitate expiration in
COPD.
 31

b. Palpation
Palpate for tenderness,
sensation, and surface
masses.
Use your fingers to
palpate for tenderness and
sensation.
No tenderness or pain is Tenderness over thoracic
palpated over the lung muscles can result from
area with respirations. exercising (e.g., pushups)
especially in a previously
sedentary client.

Start with your hand

positioned over the left
clavicle (over the apex of
the left lung) and move
your hand left to right,
comparing findings
bilaterally.

Move your hand

systematically downward
toward the midline at the
level of the breasts and
outward at the base to
include the lateral aspect
of the lung.

Anterior Thoracic Palpation

NOTE: Anterior thoracic palpation is best for

assessing the right lung’s middle lobe.

b. Palpation
Palpate for tenderness at
costochondral junctions of
ribs.
Palpate for crepitus as you
would on the posterior
thorax
Palpate for any surface
masses or lesions.
Palpate for fremitus. Using
the sequence for the
anterior chest described
previously, palpate for
fremitus using the same
technique as for the
posterior thorax.
32
Palpation does not elicit GERIATRIC CONSIDERATIONS:
tenderness. Tenderness or pain at the
costochondral junction of the
ribs is seen with fractures,
especially in older clients with
osteoporosis.
No crepitus is palpated. In areas of extreme
congestion or
consolidation,
crepitus may be palpated,
particularly in clients with
lung disease.
No unusual surface Surface masses or lesions
masses or lesions are may indicate cysts or
palpated. tumors.
Fremitus is symmetric and Diminished vibrations,
easily identified in even with a loud spoken
the upper regions of the voice, may indicate an
lungs. obstruction of the
tracheobronchial tree.
A decreased intensity of
fremitus is expected Clients with emphysema
toward the base of the may have considerably
lungs. However, fremitus decreased fremitus as a
should be symmetric result of air trapping.
bilaterally.
 33

NOTE:
When you assess for fremitus
on the female client, avoid
palpating the breast.

Breast tissue dampens the

vibrations.
Palpate anterior chest
expansion.
Place your hands on the
client’s anterolateral wall
with your thumbs along
the costal margins and
pointing toward the
xiphoid process
Thumbs move outward in Unequal chest expansion
a symmetric fashion can occur with severe
from the midline. atelectasis, pneumonia,
chest trauma, pleural
effusion, or
pneumothorax.
Decreased chest excursion
at the bases of the lungs
is seen with COPD.

Palpating anterior chest expansion.


c. Percussion
Percuss for tone. Resonance is the
percussion tone elicited
Percuss the apices above over normal lung tissue.
the clavicles.
Percussion elicits dullness
Then percuss the over breast tissue, the
intercostal spaces across heart, and the liver.
and down, comparing
sides. Tympany is detected over
the stomach, and flatness
is detected over the
muscles and bones.
Sequence for percussing the anterior thorax.
34
Hyperresonance is elicited
in cases of trapped air
such as in emphysema or
pneumothorax.
Dullness may characterize
areas of increased density
such as consolidation,
pleural effusion, or tumor.
 35

Normal percussion tones heard from the anterior thorax.

Location of breath sounds for the anterior thorax. B, bronchial sounds;

V, vesicular sounds; BV, broncho-vesicular sounds.
 36

d. Auscultation
Auscultate for anterior
breath sounds,
adventitious sounds, and
voice sounds.
Refer to text in the Presence of adventitious
posterior thorax section breath sounds.
for normal voice sounds.

Place the diaphragm of the

stethoscope firmly and
directly on the anterior
chest wall.

Auscultate from the apices

of the lungs slightly above
the clavicles to the bases
of the lungs at the sixth
rib.

Ask the client to breathe

deeply through the mouth
in an effort to avoid
transmission of sounds
that may occur with nasal
breathing.
NOTE:
Do not attempt to listen
Be alert to the client’s through clothing or other
comfort and offer times for materials.
rest and normal breathing
if fatigue is becoming a However, if the client has a
problem, particularly for large amount of hair on the
chest, listening through a thin
the older client. T-shirt can decrease extraneous
sounds that may be
Listen at each site for at misinterpreted as crackles.
least one complete
respiratory cycle.

Sequence for auscultating the anterior thorax.

 37

LABORATORY EXAMINATIONS

1. Arterial Blood Gases (ABGs): Measurement of the dissolved oxygen and carbon
dioxide in the arterial blood helps indicate the acid-base state and how well oxygen is
being carried to the body.

Normal Arterial Blood Gas Values

pH: 7.35 to 7.45 PCO2: 35 to 45 mm Hg
HCO3: 22 to 27 mEq/L PO2: 80 to 100 mm Hg
O2 saturation: 95% to 100%

Nursing Management before procedure:

1. Perform Allen’s test before drawing radial artery specimens.
2. Have the client rest for 30 minutes before specimen collection to ensure accurate
measurement of body oxygenation.
3. Do not turn off oxygen unless the ABG sample is prescribed to be drawn with the
client breathing room air.

Nursing Management after procedure:

1. Place the specimen on ice.
2. Note the client’s temperature on the laboratory form.
3. Note the oxygen and type of ventilation that the client is receiving on the
laboratory form.
4. Apply pressure to the puncture site for 5 to 10 minutes or longer if the client is
receiving anticoagulant therapy or has a bleeding disorder.
5. Transport the specimen to the laboratory within 15 minutes.

2. Sputum Specimen Analysis: Specimen obtained by expectoration or tracheal

suctioning to assist in the identification of organisms or abnormal cells.

Nursing Management before procedure:

1. Determine specific purpose of collection and check with institutional policy for
appropriate method for collection of a specimen.
2. Obtain an early morning sterile specimen from suctioning or expectoration after a
respiratory treatment if a treatment is prescribed.
3. Instruct the client to rinse the mouth with water before collection.
4. Obtain 15 mL of sputum.
5. Instruct the client to take several deep breaths and then cough deeply to obtain
sputum.
6. Always collect the specimen before the client begins antibiotic therapy.

Nursing Management after procedure:

1. If a culture of sputum is prescribed, transport the specimen to the laboratory
immediately.
2. Assist the client with mouth care.
 38

3. Direct Visualization Laryngoscopy and Bronchoscopy: Direct visual

examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope

Nursing Management before procedure:

1. Obtain informed consent.
2. Maintain Nothing Per Orem (NPO) status for the client from midnight before the
procedure.
3. Obtain vital signs.
4. Assess the results of coagulation studies.
5. Remove dentures and eyeglasses.
6. Prepare suction equipment.
7. Establish an intravenous (IV) access as necessary and administer medication for
sedation as prescribed.
8. Have emergency resuscitation equipment readily available.

Nursing Management after procedure:

1. Monitor vital signs.
2. Maintain the client in a semi-Fowler’s position.
3. Assess for the return of the gag reflex.
4. Maintain NPO status until the gag reflex returns.
5. Have an emesis basin readily available for the client to expectorate sputum.
6. Monitor for bloody sputum.
7. Monitor respiratory status, particularly if sedation has been administered.
8. Monitor for complications, such as bronchospasm or bronchial perforation,
indicated by facial or neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and
pneumothorax.
9. Notify the physician if fever, difficulty in breathing, or other signs of complications
occur following the procedure.

4. Chest X-ray (Radiograph): Provides information regarding the anatomical

location and appearance of the lungs.

Nursing Manage before and after procedure:

1. Remove all jewelry and other metal objects from the chest area.
2. Assess the client’s ability to inhale and hold his or her breath.
3. Help the client get dressed after the procedure.

5. Computed Tomography Scanning (CT-Scan) of the Chest:

(a.) CT scan is a type of imaging test. It uses X-ray and computer technology to
make detailed pictures of the organs and structures inside your chest.
(b.) These images are more detailed than regular X-rays. They can give more
information about injuries or diseases of the chest organs.
(c.) In a CT scan, an X-ray beam moves in a circle around your body. It takes many
images, called slices, of the lungs and inside the chest.
(d.) A computer processes these images and displays it on a monitor.
 39

Importance of Chest CT-Scan:

1. CT scan of the chest may be done to check the chest and its organs for blockages,
injuries, intrathoracic bleeding, infections, tumors and other lesions, and unexplained
chest pain.
2. CT scan may be done when another type of exam, such as an X-ray or physical
exam, is not conclusive.
3. CT scan may also be used to guide needles during biopsies (a small piece of tissue
is removed so it can be examined in the laboratory) of thoracic organs or tumors.
4. CT scan can also be done to help remove a sample of fluid from the chest. They
are useful in keeping an eye on tumors and other conditions of the chest before and
after treatment.

Risks of a CT scan of the Chest:

1. Pregnant: Inform your healthcare provider. Radiation exposure during pregnancy
may lead to birth defects.
2. Breast Feeding: Let your healthcare provider know. Ask if you should pump and
save breastmilk to use after the procedure.
3. Contrast Dye: There is a risk you may have an allergic reaction to the dye. Inform
your healthcare provider if you have ever had a reaction to any contrast dye, or if
you’ve had any kidney problems.
4. Kidney Failure/Problem: Inform your healthcare provider. In some cases, the
contrast dye can cause kidney failure. It will add more insult injuries if the patient has
underlying kidney problems or is dehydrated. People with kidney disease are more
prone to kidney damage after contrast exposure.
5. Diabetic Patient taking Metformin: You are at risk for developing metabolic
acidosis. This is a condition where you have an unsafe change in blood pH.

Nursing Management before CT-Scan:

1. If you are pregnant or think you may be pregnant, please check with your doctor
before scheduling the exam. Other options will be discussed with you and your
doctor.
2. Ask the client to change into a patient gown. Please remove all piercings and leave
all jewelry and valuables at home.
3. Assess the patient if he/she has pacemaker or any metallic objects or if the patient
has history of recent barium studies because it can alter the accuracy of the results.
4. Ask if the patient has hypersensitivity to iodine because contrast media can cause
allergy to the person.
5. Secure informed consent with regards the procedures whether it will involve
contrast or not.
6. Secure a patent intravenous line for the contrast media or for any emergency
situations.
7. NPO/Nothing Per Orem Status:
(a.) If your doctor ordered a CT scan without contrast, you can eat, drink and
take your prescribed medications prior to your exam.
(b.) If your doctor ordered a CT scan with contrast, do not eat anything three
hours prior to your CT scan.
(c.) You are encouraged to drink clear liquids.
(d.) You may also take your prescribed medications prior to your exam.
 40

8. Medications:
(a.) All patients can take their prescribed medications as usual as per doctor’s
advised.
(b.) Diabetics should eat a light breakfast or lunch three hours prior to the scan
time. Depending on your oral medication for diabetes, you may be asked to
discontinue use of the medication for 48 hours after the CT scan, as per doctor’s
advised.

Nursing Management after CT-Scan:

1. The client may be watched for a period of time for any side effects or reactions to
the contrast dye. These include itching, swelling, rash, or trouble breathing.
2. Alert your healthcare provider if you notice any pain, redness, or swelling at the IV
site after you return home. These could be signs of an infection or other type of
reaction.
3. Inform the client if contrast was given by mouth, he/she may have diarrhea or
constipation after the procedure.
4. If the client had CT-scan without contrast, he/she may go back to usual diet and
activities unless the healthcare provider tells differently.

6. Magnetic Resonance Imaging (MRI)of the Chest:

(a.) Magnetic resonance imaging (MRI) is a type of noninvasive imaging test that
uses magnets and radio waves to create pictures of the inside of your body.
(b.) MRI produces no damaging radiation and is considered a safer alternative,
especially for pregnant women.
(c.) In a chest MRI, magnets and radio waves create black-and-white images of your
chest.
(d.) Images allow your doctor to check your tissues and organs for abnormalities
without making an incision.
(e.) MRIs also create images that see beyond your bones and include soft tissue.

Purposes of MRI of the Chest:

1. The healthcare provider may order an MRI scan if they suspect that something is
wrong in your chest area and the cause of the problem can’t be determined through a
physical examination.
2. Your doctor may want to order a chest MRI to see if you have blocked blood
vessels, cancer, disease affecting your organs, heart problems, injury, a source
causing pain,
tumors, problems affecting your lymph system.

Risks of a MRI scan of the Chest:

1. If the client has a pacemaker or metal implant from previous surgeries or injuries,
be sure to tell the doctor beforehand and find out whether you can have an MRI. It’s
possible for these implants to complicate a scan or even malfunction during the scan.
2. The dye used for the test can cause an allergic reaction or worsen kidney function
if you have kidney disease and these are unlikely side effects.
3. Claustrophobia (difficulty being in enclosed spaces), you may feel uncomfortable
while in the MRI machine. Rest assured that there is nothing to fear. The healthcare
 41

provider may prescribe an anti-anxiety medication to help with your discomfort. In

some cases, you might be sedated for the process.

Nursing Management/Client Education about MRI Scan:

1. Before the procedure, the client should inform the healthcare provider if they have
a pacemaker. Depending on type of pacemaker, the doctor may suggest another
route for inspection, such as a CT scan. Some pacemaker models can be
reprogrammed before an MRI so they aren’t disrupted by the examination.
2. MRI uses magnets, which can attract metals. The client should inform the doctor if
he/she has any type of metal implanted from previous surgeries, such as artificial
heart valves, clips, implants, pins, plates, screws, staples, and stents.
3. The client may need to fast for four to six hours before the exam as per doctor’s
advised.
4. Contrast Dye: The healthcare provider may require the use of a special dye to
highlight an area of concern. This dye, gadolinium, is administered through an IV. It’s
different from the dye used during a CT scan. While allergic reactions to the dye are
rare, alert your doctor of any concerns before the dye is injected.

7. Pulmonary Function Tests (PFT): Tests used to evaluate lung mechanics, gas
exchange, and acid-base disturbance through spirometric measurements, lung
volumes, and arterial blood gas levels.

Nursing Management before procedure:

1. Determine whether an analgesic that may depress the respiratory function is being
administered.
2. Consult with the physician regarding holding bronchodilators before testing.
3. Instruct the client to void before the procedure and to wear loose clothing.
4. Remove dentures.

5. Instruct the client to refrain from smoking or eating a heavy meal for 4 to 6 hours
before the test.

Nursing Management after procedure:

1. Client may resume normal diet and any bronchodilators and respiratory treatments
that were held before the procedure.

8. Pulse Oximetry:
(a.) A noninvasive test that registers the oxygen saturation of the client’s
hemoglobin.
(b.) The capillary oxygen saturation (SaO2) is recorded as a percentage.
(c.) The normal value is 95% to 100%.
(d.) After a hypoxic client uses up the readily available oxygen (measured as the
arterial oxygen pressure, PaO2, on ABG testing), the reserve oxygen, that oxygen
attached to the hemoglobin (SaO2), is drawn on to provide oxygen to the tissues.
(e.) A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs
occur.
 42

Nursing Management:
1. A sensor is placed on the client’s finger, toe, nose, ear lobe, or forehead to
measure oxygen saturation, which then is displayed on a monitor.
2. Maintain the transducer at heart level.
3. Do not select an extremity with an impediment to blood flow.

9. Thoracentesis: Removal of fluid or air from the pleural space via a transthoracic
aspiration.

Nursing Management before procedure:

1. Obtain informed consent.
2. Obtain vital signs.
3. Prepare the client for ultrasound or chest radiograph, if prescribed, before
procedure.
4. Assess results of coagulation studies.
5. Note that the client is positioned sitting upright, with the arms and shoulders
supported by a table at the bedside during the procedure.
6. If the client cannot sit up, the client is placed lying in bed toward the unaffected
side, with the head of the bed elevated.
7. Instruct the client not to cough, breathe deeply, or move during the procedure.

Nursing Management after procedure:

1. Monitor vital signs.
2. Monitor respiratory status.
3. Apply a pressure dressing, and assess the puncture site for bleeding and crepitus.
4. Monitor for signs of pneumothorax, air embolism, and pulmonary edema.

10. Mantoux Skin Test/Tuberculin Skin Test:

(a.) A positive Mantoux reaction does not mean that active disease is present but
indicates previous exposure to tuberculosis or the presence of inactive (dormant)
disease.
(b.) Once the test result is positive, it will be positive in any future tests.
(c.) Purified protein derivative (PPD) containing 5 tuberculin units is administered
intradermally in the forearm.
(d.) An area of induration measuring 10 mm or more in diameter, 48 to 72 hours
after injection, indicates that the individual has been exposed to tuberculosis.
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Common Respiratory Problems

1. Dyspnea
(a.) Breathing difficulty.
(b.) Associated with many conditions- CHF, MG, GBS, Muscular dystrophy, and
obstruction.

General Nursing Interventions:

1. Fowler’s position to promote maximum lung expansion and promote comfort.
An alternative position is an ORTHOPNEIC position.
2. O2 usually via nasal cannula.
3. Provide comfort and distractions.

2. Cough and Sputum Production

General Nursing Interventions:

1. Fowler’s position to promote maximum lung expansion and promote comfort.
An alternative position is an ORTHOPNEIC position.
2. Oxygen usually via nasal cannula.
3. Provide comfort and distractions.
4. Provide adequate hydration.
5. Administer aerosolized solutions.
6. Advise smoking cessation.
7. Oral hygiene.

3. Cyanosis
(a.) Bluish discoloration of the skin.
(b.) A LATE indicator of hypoxia.
(c.) Appears when the unoxygenated hemoglobin is more than 5 grams/dL.
(d.) Central cyanosis - observe color on the undersurface of tongue and lips.
(e.) Peripheral cyanosis - observe the nail beds, earlobes.

General Nursing Interventions:

1. Check for airway patency
2. Oxygen therapy
3. Positioning
4. Suctioning
5. Chest physiotherapy
6. Check for gas poisoning
7. Measures to increase hemoglobin

4. Hemoptysis
(a.) Expectoration of blood from the respiratory tract.
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(b.) Common causes: pulmonary infection, Lung CA, Bronchiectasis, Pulmonary

emboli.
(c.) Bleeding from the stomach - acidic pH, coffee ground material.

General Nursing Interventions:

1. Keep patent airway.
2. Determine the cause.
3. Suction and oxygen therapy.
4. Administer Fibrin stabilizers like aminocaproic acid and tranexamic acid.

5. Epistaxis
(a.) Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus
membrane.
(b.) Most common site- anterior septum.

Causes of Epistaxis:
1. trauma
2. infection
3. Hypertension
4. blood dyscrasias, nasal tumor, cardio/heart diseases

General Nursing Interventions:

1. Position patient: Upright, leaning forward, tilted: Prevents swallowing and
aspiration.
2. Apply direct pressure. Pinch nose against the middle septum for 5-10 minutes.
3. If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foams.
4. Assist in electrocautery and nasal packing for posterior bleeding.

CONDITIONS OF THE UPPER AIRWAY

1. Upper Airway Infection: Tonsillitis

Assessment Findings/Clinical Manifestations/Signs and Symptoms

1. Sore throat and mouth breathing
2. Fever
3. Difficulty swallowing
4. Enlarged, reddish tonsils
5. Foul-smelling breath

NURSING INTERVENTION for Tonsillectomy

1. Pre-operative Care:
(a.) Complete any blood work or other doctor appointments, as directed by your
surgeon, in a timely manner.
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(b.) Do not take aspirin or ibuprofen-containing medications within 7 days of the

operation.
(c.) You may not eat or drink anything, including water, after midnight on the day of
the operation.
(d.) You may, or take medications with a sip of water the day of the operation if
directed specifically by your doctor.
2. Post-operative Care:
(a.) Apply ICE collar to the neck to reduce edema.
(b.) Advise patient to refrain from talking and coughing.
(c.) Ice chips are given when there are no bleeding and gag reflex returns.
(d.) Notify physician if:
d1: Patient swallows frequently.
d2: vomiting of a large amount of bright red or dark blood.
d3: Pulse Rate increased, restless and Temp is increased.
d4: Bleeding and gag reflex returns.

ACUTE RESPIRATORY FAILURE

(a.) Sudden and life-threatening deterioration of the gas-exchange function of the
lungs.
(b.) Occurs when the lungs no longer meet the body’s metabolic needs.
(c.) Defined clinically as:
PaO2 of less than 50 mmHg
PaCO2 of greater than 5o mmHg
Arterial pH of less than 7.35

Causes of Acute Respiratory Failure:

1. CNS depression: Head trauma, Sedatives
2. CVS diseases: Myocardial Infarction (MI), Congestive Heart Failure (CHF),
Pulmonary Emboli
3. Airway irritants: Smoke, Fumes
4. Endocrine and metabolic disorders- myxedema, metabolic alkalosis
5. Thoracic/chest abnormalities and injuries

Disease Process/Pathophysiology:
1. Decreased Respiratory Drive
Brain injury, sedatives, metabolic disorders Impair the normal response of the
brain to normal respiratory stimulation.

2. Trauma, pneumothorax
Dysfunction of the chest wall
Dystrophy, MS disorders, peripheral nerve disorders disrupt the impulse
transmission from the nerve to the diaphragm abnormal ventilation

3. Dysfunction of the Lung Parenchyma

Pleural effusion, hemothorax, pneumothorax, obstruction interfere ventilation
prevent lung expansion.
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Assessment Findings/Clinical Manifestations/Signs and Symptoms

1. Dyspnea
2. Headache
3. Restlessness
4. Confusion
5. Tachycardia
6. Hypertension
7. Dysrhythmias
8. Decreased level of consciousness
9. Alterations in respirations and breath sounds

Diagnostic Test Findings:

1. Pulmonary function test: pH below 7.35
2. Chest X-Ray: pulmonary infiltrates
3. Electrocardiogram: arrhythmias

Nursing Management/Interventions:
1. Identify and treat the cause of the respiratory failure.
2. Administer oxygen to maintain the PaO2 level higher than 60 to 70 mm Hg.
3. Place the client in a Fowler’s position.
4. Encourage deep breathing.
5. Suction airways as required
6. Monitor serum electrolyte levels
7. Administer bronchodilators as prescribed.
8. Prepare the client for mechanical ventilation if supplemental oxygen cannot
maintain acceptable PaO2 and PaCo2 levels.

Chronic Obstructive Pulmonary Disease (C.O.P.D)

(a.) Also known as chronic obstructive lung disease and chronic airflow limitation
(b.) Chronic obstructive pulmonary disease is a disease state characterized by airflow
obstruction caused by emphysema or chronic bronchitis.
(c.) Progressive airflow limitation occurs, associated with an abnormal inflammatory
response of the lungs that is not completely reversible.
(d.) Chronic obstructive pulmonary disease leads to pulmonary insufficiency,
pulmonary hypertension, and cor pulmonale.

Types of COPD and Manifestations

1. Chronic Bronchitis (Blue Bloaters) - Cyanosis with Edema

(a.) Inflammation of the bronchi, which causes increase mucous production and
chronic cough.
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(b.) Bronchioles narrowed as a result of thickened membrane and with inflammation

of surrounding tissue.
(c.) Persistent cough, copious sputum production, dyspnea and shortness of breath.
(d.) "Dirty Lung" appearance in chest x-ray.
(e.) Enlarged heart (cor pulmonale-right ventricle).
(f.) Increased PaCO2 and hypoxemia is usually present.
(g.) Ages 45- to 65-year-old with long history of smoking.
2. Pulmonary Emphysema (Pink Puffer) - Acyanotic with compensatory
pursed-lip breathing
(a.) Destruction of alveolar wall leading to permanent over distention of dead air
spaces (blebs and bullaes).
(b.) Lung tissue becomes inelastic and lungs enlarged with small bronchioles collapse
that leads to air trapping.
(c.) Persistent shortness of breath, progressive dyspnea, diminished breath sounds
and barrel chest (enlarged antero-posterior diameter of thorax).
(d.) Over inflated lucent lungs in x-ray.
(e.) No cardiac problems involvement but late cor pulmonale.
(f.) Usually, Low PaCO2 and mild to moderate hypoxemia.
(g.) Ages 65- to 75-year-old with history of smoking.

Nursing Management/Interventions:
1. Monitor vital signs.
2. Administer a concentration of oxygen based on Arterial Blood Gas (ABG) values
and oxygen saturation by pulse oximetry as prescribed.
3. Monitor pulse oximetry.
4. Provide respiratory treatments and chest physiotherapy (CPT).
5. Instruct the client in diaphragmatic or abdominal breathing techniques and pursed-
lip breathing techniques, which increase airway pressure and keep air passages open,
promoting maximal carbon dioxide expiration.
6. Record the color, amount, and consistency of sputum.
7. Suction the client’s lungs, if necessary, to clear the airway and prevent infection.
8. Monitor weight.
9. Encourage small, frequent meals to maintain nutrition and prevent dyspnea.
10. Provide a high-calorie, high-protein diet with supplements.
11. Encourage fluid intake up to 3000 mL/day to keep secretions thin, unless
contraindicated.
12. Place the client in a Fowler’s position and leaning forward to aid in breathing.
13. Allow activity as tolerated.
14. Administer bronchodilators as prescribed, and instruct the client in the use of oral
and inhalant medications.
15. Administer corticosteroids as prescribed for exacerbations.
16. Administer mucolytics as prescribed to thin secretions.
17. Administer antibiotics for infection if prescribed.

ATELECTASIS: The collapse of part or all of a lung due to bronchial obstruction.

Possible Causes of Atelectasis:

1. Intrabronchial obstruction
2. Tumors, Bronchospasm
3. Foreign bodies
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4. Extra bronchial compression (tumors, enlarged lymph nodes)

5. Endobronchial disease (bronchogenic carcinoma, inflammatory structures)

Assessment Findings/Clinical Manifestations/Signs and Symptoms

1. Signs and symptoms may be absent depending upon the degree of collapse and
rapidity with which bronchial obstruction occurs
2. Dyspnea, decreased breath sounds on the affected side, decreased respiratory
excursion, dullness to flatness upon percussion over the affected area
3. Cyanosis, tachycardia, tachypnea, elevated temperature, weakness, pain over the
affected area.

Diagnostic Test Findings:

a. Bronchoscopy: may or may not reveal an obstruction.
b. Chest x-ray shows the diminished size of affected lung and lack of radiance over an
atelectatic area.
c. Partial pressure of oxygen (pO2) decreased
Normal Range: 75 to 100 millimeters of mercury (mm Hg), or
10.5 to 13.5 kilopascal (kPa)

PNEUMONIA
(a.) An inflammation of the alveolar spaces of the lung, resulting in consolidation of
the lung tissue as the alveoli fill with exudates
(b.) The various types of pneumonia are classified according to the offending
organism.
(c.) Pneumonia can also be classified as COMMUNITY Acquired Pneumonia (CAP) and
Hospital-acquired pneumonia (HAP).

Pathophysiologic Findings of Pneumonia:

1. Hypertrophy of the mucus membrane
2. Increased sputum production
3. Wheezing
4. Dyspnea
5. Cough
6. Rales
7. Ronchi

Assessment Findings/Clinical Manifestations/Signs and Symptoms

1. Cough with greenish to rust-colored sputum production.
2. Rapid, shallow respirations with an expiratory grunt
3. Nasal flaring, Intercostal rib retraction and use of accessory muscles of respiration.
4. Rales or crackles (early) progressing to coarse (later).
5. Increased Tactile fremitus.
6. Fever, chills, chest pain, weakness, generalized malaise.
7. Tachycardia, cyanosis, profuse perspiration, abdominal distension.
8. Rapid shallow breathing.
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Nursing Management/Interventions:
1. Facilitate Adequate Ventilation.
a. Administer oxygen as needed and assess its effectiveness.
b. Place the client in Fowler’s position.
c. Turn and reposition frequently clients who are immobilized/obtunded.
d. Administer analgesics as ordered to relieve pain associated with breathing.
e. Auscultate breath sounds every 2-4 hours.
f. Monitor Arterial Blood Gas (ABGs).

2. Facilitate removal of secretions.

3. General hydration.
4. Deep breathing and coughing.
5. Perform gentle suctioning as required.
6. Administer Expectorants as ordered.
7. Administer aerosol treatments via nebulizer, humidification of inhaled air as
ordered.
8. Schedule and assist chest physiotherapy (CPT).
9. Observe color, characteristics of sputum and report any changes.
10. Encourage the client to perform good oral hygiene after expectoration.

Nursing Diagnoses Taxonomy Pertinent to problems/ Alterations in

Oxygenation.
1. Ineffective Breathing Pattern
2. Ineffective Airway Clearance
3. Impaired Gas Exchange
4. Inability to sustain spontaneous ventilation
5. Dysfunctional ventilatory weaning response
6. Decreased Cardiac Output
7. Altered Tissue perfusion

Reference:

1. Smeltzer, Suzanne C, et.al.,2010. Brunner and Suddarth’s Textbook of Medical and

Surgical Nursing. 12th Edition. Wolters Kluwer Health / Lippincott Williams & Wilkins.

2. Weber, Janet R and Kelley, Jane H. 2104. Health Assessment in Nursing. 5 th

Edition. Wolters Kluwer Health | Lippincott Williams & Wilkins.
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