NCM 112 - MIDTERM

CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
Ainie Balabaran BSN 3D
TOPIC 1 Parts and Functions of the Lower Respiratory System

THE RESPIRATORY SYSTEM

Respiratory system – It is a network of organs and tissues responsible in the

exchange of gases.

Basic functions:
1. Movement of air out of the lungs,
2. Exchange of oxygen and carbon dioxide
3. Helps maintain acid base balance

Apart from gas exchange, the lungs and other pulmonary circulation have
other functions:
1. Pulmonary defense – The lung is consisting of CILIA. Cilia are tiny,
muscular, hair like projections on the cells that lines the airway. It propels a
liquid layer of mucous that covers the airways.
 Mucous layer traps the pathogens, potentially infectious microorganisms
and other particles preventing them from reaching the lungs.
 Alveolar macrophages - it is a type of white blood cells on the surface
of the alveoli. It ingests small, inhaled, infection, toxic or allergic particles
that have evaded the mechanical defenses of the respiratory tract since
alveoli are not protected by mucous or cilia. Further, it also manufactures
surfactant for local use. Surfactant is a mixture of lipids and protein,
which is secreted in the alveolar space by epithelial type 2 cells to lower
the surface tension at the air interface within the alveoli of the lungs.
2. Metabolic function - The respiratory system controls the level of carbon
dioxide. As we all know, carbon dioxide is an acidic gas that needs to be blown
off or removed because excessive amounts of this can be fatal.
3. Pulmonary circulation- The respiratory system also helps in the
oxygenation of blood.
The respiratory system is divided into two parts:
1. Upper respiratory
2. Lower respiratory
Parts and Functions of the Upper Respiratory System
The lower respiratory system is composed of the following:
1. Trachea
2. Bronchi
3. Bronchioles
4. Lungs
 Trachea - It is a five inch long tube made of C shaped hyaline cartilage
rings.
 It connects the larynx to the bronchi, and allows air to pass through
the neck and into the thorax. The rings of the cartilage in the trachea
allow it to remain open to air at all times.
 The main function of the trachea is to provide a clear airway for air
to enter and exit the lungs. In addition, the epithelial lining of the
trachea produces mucus to trap dust and other contaminants, thus
preventing it from reaching the lungs.
 Bronchi - At the inferior end of the trachea, the trachea splits into left
and right branches known as the primary bronchi.
 The primary bronchi branches off into smaller tubes called the
secondary bronchi, and the second bronchi in turn splits into smaller
tubes called the tertiary bronchitis with each lobe, and the tertiary
bronchi splits into smaller tubes called the bronchioles that spreads
throughout the lungs.

 Bronchioles – The presence of smooth muscles and elastin allow the

smaller bronchi and bronchioles to be more flexible and contractile.

 Lungs - the lungs are a pair of large spongy organs found in the thorax
lateral to the heart and superior to the diaphragm.

Each lung is surrounded by a pleural membrane, which are:

 Visceral pleura - or the inner lining
The upper respiratory system is composed of the following:  Parietal pleura - which is the outer lining
1. Nose
2. Nasal cavity
3. Pharynx
4. Larynx

 Nose - functions to protect the lower airway by warming and

humidifying air and filtering small particles before air enters the lung.

 Nasal cavity - is a hollow space within the nose and skull that is lined
with hairs and mucous membranes.
 The function of the nasal cavity is to warm, moisturize and filter
air entering the body before it reaches the lungs.
 Hairs in mucus lining the nasal cavity help to trap dust, mold,
pollen and other environmental contaminants before they can
reach the inner portion of the body.
 Air exiting the body through the nose returns moisture and heat
to the nasal cavity before being exhaled into the environment.
 Pharynx – also known as the throat.
 It is a muscular funnel that extends from the posterior end of the
nasal cavity to the superior end of the esophagus and the larynx.
 Larynx - The larynx is also known as the voice box.
 The epiglottis is a cartilage pieces of the larynx and it serves as a
cover of the larynx during swallowing.
 The space in between the visceral and parietal pleura is called Pleural
Cavity - This contains a thin film of lubricating liquid called the Pleural
Fluid.
 Pleural Fluid - This pleural fluid prevents friction and rubbing of the
pleural membranes while breathing.
 Pleural membranes provide the lung with space to expand, as well as a
negative pressure space relative to the body's external environment.
 The left and the right lungs are slightly different in size and shape due to
the pointing of the heart to the left side of the body. The left lung is
slightly smaller than the right lung, and is made up of two lobes, while
the right lung three lobes.

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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
 Alveoli - The interior of the lung is made up of spongy tissues containing
many capillaries and around 20 million tiny sacs, which is called as the
alveoli.
 The alveoli are cup shaped structures found at the end of terminal
bronchioles and surrounded by capillaries.
 The alveoli are lined with thin, simple squamous epithelium that
allows air entering the other lines to exchange its gases with the
blood passing through the capillaries.
Muscles of Respiration
(Surrounding the lungs are sets of muscles that are able to cause air to be
inhaled or exhaled from the lungs)
 Diaphragm - The diaphragm is a thin sheet of skeletal muscle that forms
the floor of the thorax.
 It is the principal muscle of respiration since 75% of air is produced
by diaphragmatic contractions.
 Intercostal muscles - between the ribs are small, intercostal muscles
that assist the diaphragm with lung expansion and compression.
Physiology of the Respiratory System
Respiratory system performs four major functions:
 PULMONARY VENTILATION - It is a process of moving air into and
out of the lungs to facilitate gas exchange. The respiratory system uses
both a negative pressure system and the contraction of muscles to achieve
pulmonary ventilation.
 EXTERNAL RESPIRATION - is the exchange of gases between the
air filling the alveoli and the blood in the capillaries surrounding the walls
of the alveoli
 INTERNAL RESPIRATION - is the exchange of gases between the
blood in the capillaries and the tissues of the body.
 TRANSPORTATION OF GASES - There are two major respiratory
gases:
 Oxygen
 Carbon dioxide
 They are transported through the body in the blood.
 The blood plasma has the ability to transport some dissolved oxygen
and carbon dioxide, but most of the gases, transported in the blood
are binded to transport molecules.
 An example of transport molecule is the hemoglobin, it is an
important transport molecule found in the red blood cells that
carries almost 99% of the oxygen in the blood.
 Hemoglobin can also carry a small amount of carbon dioxide aside
from the tissues back to the lungs. However, the vast majority of
carbon dioxide is carried in the plasma as Bicarbonate Ion.
Exchange of Gases in the Alveoli
The exchange of gases usually occurs in the alveoli. So how do the alveoli work?
 The alveoli releases oxygen into the blood vessels to supply the cells of
the body and it also takes in carbon dioxide and water from the blood for
expiration.
 The body cells will absorb the oxygen and releases water and carbon
dioxide through the blood vessels, which in turn will be excreted by the
lungs through exhalation.
Pulmonary Ventilation
 Pulmonary ventilation involves physical movement of air in and out of
the lungs.
 The primary function of pulmonary ventilation is to maintain adequate
alveolar ventilation and to prevent buildup of carbon dioxide in the
alveoli and achieves a constant supply of oxygen to the tissues.
 Air flows between the atmosphere and the alveoli of the lungs as a result
of pressure difference created by the contraction and relaxation of the
respiratory muscles.
 The rate of airflow and the effort needed for breathing is influenced by
the alveolar surface tension and integrity of the lungs.
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Two Mechanisms of Respiration:
1. Inspiration - During inspiration or breathing in, the thorax expands and
intrapulmonary pressure falls below atmospheric pressure.
 Because the intrapulmonary pressure is lesser than the atmospheric
pressure, the air will naturally enter the lungs until the pressure
difference no longer exist.
2. Expiration - Breathing out or expiration is also a result of pressure
breaching (?) but it is converse to inhalation that is the pressure in the
lungs is greater than the atmospheric pressure.
 Exhalation is a passive process as no skeletal muscles are involved
during the process.
 The process results from Elastic recall of the chest wall and the
lungs. However, during exercises or activities, exhalation usually
increases and the muscles of exhalation which are abdominals and
intercostal muscles contract, thus increasing the abdominal and
thoracic region.
 As abdominal muscle contract, the inferior ribs moves downwards
and compresses the abdominal viscera and the diaphragm moves
upward.
Factors Affecting Pulmonary Ventilation
1. Surface tension of alveolar fluid - it is the degree or the force exerted
by water molecules on the surface of the land tissue. Surface tension is
provided by the fluid called Surfactant.
 Surfactant - It is a lipoprotein molecule that reduces the force of
surface tension from water molecules on the lung tissue.
 During inhalation, the surface tension must be overcome to expand
the lungs, and it also aids in the lungs’ elastic recoil
2. Airway resistance - This refers to the degree of resistance to the flow of
air through the respiratory tract during inspiration and expiration.
 The degree of resistance depends on many things, particularly the
diameter of the airway.
 The walls of the airways offer some resistance to the flow of air into
and out of the lungs. Alveolar expansion is also dependent on
surfactant.
 During inspiration, the bronchioles dilate because the walls are
pulled together in all directions. The diameter of the airway passage
is also dependent on the smooth muscle.
 Stimulation from the sympathetic nerve fibers causes the smooth
muscles to relax, resulting in bronchodilation and decreased
resistance.
3. Compliance of the lungs - compliance is the ability of the lungs and
pleural cavity to expand and contract based on the changes in pressure.
 The higher the compliance, the less effort is needed in chest and lung
expansion; Low compliance mean that more effort is needed
 Compliance depends on the elasticity and the surface tension of the
lungs.
 Compliance is inversely related to the elastic recoil of the lungs so,
thickening of the lung tissue will decrease lung compliance.
 The lungs must also be able to overcome the force of surface tension
from water on lung tissue during inflation in order to be compliant
and greater surface tension causes lower lung compliance, therefore
surfactants secreted by type 2 epithelial cells increases lung
compliance by reducing the force of surface tension.
 Normal lungs have a high compliance and expand easily because the
elastic fibers are stretched readily and the surfactant in the lungs
reduces the surface tension.
- Lung Volumes - are also known as the respiratory volume.
 It refers to the volume of gas in the lungs at the given time during
the respiratory cycle.
 A healthy adult at rest normally has a respiratory rate of 12-18
breaths/min and with each respiration, a 500 ml of air is moved in
and out of the lungs.
Four standard lung volumes:
1. Tidal Volume (TV) - It is the amount of air that can be inhaled or
exhaled during one respiratory cycle. This depicts the functions of the
respiratory centers, respiratory muscles, and the mechanics of the lungs
and chest wall.
 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
2. Inspiratory Reserve Volume (IRV) – is the additional amount of air that  Chest X ray
can be inhaled after a normal inhalation. IRV is usually kept in reserve,  MRI
but is used during deep breathing.  CT scan and PET scan
3. Expiratory Reserve Volume (ERV) - is the volume of air that can be  CT scans and MRIs are both used to capture images within the
exhaled forcibly after exhalation of normal tidal volume. ERB is usually body. The difference between the two is that MRI or Magnetic
reduced with obesity, ascites or after upper abdominal surgery. Resonance Imaging uses radio waves, while the CT scan or the
Computed Tomography scan uses X-rays.
4. Residual Volume - is the volume of air remaining in the lungs after
 PET scans can give the healthcare provider a view of complex
maximal exhalation. Lung volumes are usually measured by the use of
systemic diseases by showing problems at the cellular level.
spirometer.
5. Sputum Studies - the sputum is collected in order to determine what
General Respiratory Assessment
type of microorganism causes the respiratory problems.
1. History Taking
 The sputum is usually sent to the laboratory for culture and
What should include history taking:
sensitivity.
a. Biographic and demographic data – of the patient
 Culture is done in order to detect and diagnose bacterial and lower
b. Past health history - in relation to the respiratory system.
respiratory tract infection.
c. Family health history - of respiratory problem or disorder.
6. Bronchoscopy - is a nonsurgical procedure used to examine and visualize
2. Physical assessment and examinations - by using the four methods of
the airways and check for any abnormalities.
assessment (IPPA): Inspection, Palpation, Percussion and Auscultation.
 We inspect the patient and observe for signs and symptoms of
7. Spirometry - is the most common type of pulmonary function or
respiratory problems,
breathing test.
 We palpate in order to determine tracheal position.
 It is used to measure how much air the patient can breathe in and
 We also check for fremitus, which is the vibration of the chest wall out of the lungs, as well as how easily and fast the patient can blow
made by vocalization, the air out of the lungs.
 We percuss in order to assess the density or air ratio of the lungs.  This is usually done with the use of Spirometer.
 We auscultate in order to listen to the different adventitious sounds
in the lungs with the aid of the stethoscope. Further discussion on ABG or Arterial Blood Gas:
 It is also important that we take note of this subjective data.
 As what we have mentioned, ABG’s are obtained in order to determine
Subjective data are based on signs and symptoms felt and verbalized
oxygenation status and acid base balance.
by the patient.
 Objective data are the signs and symptoms manifested by the patient  ABG analysis includes measurement of partial pressure of oxygen, partial
as observed by the health practitioner. pressure of carbon dioxide, acidity and bicarbonates in the blood.

General Manifestation of Respiratory Problems Values of ABG:

These are the most common signs and symptoms that can be observed to patients with pH 7.35-7.45
respiratory problems: Partial Pressure of Carbon 35-45 mmHg
1. Cough Dioxide (PaCO2)
2. Dyspnea - or difficulty of breathing Partial Pressure of Oxygen 80-100 mmHg
3. Chest pain - which may be brought about by continuous coughing, (PO2)
because continuous and nonstop coughing can decrease oxygen level, Oxygen Saturation (SaO2) 95-100%
causing dyspnea and difficulty of breathing and chest pain. Bicarbonate (HCO3) 22-26 mEq/L
4. Hemoptysis
5. Rapid breathing Acidosis pH is less than 7.35
6. Sputum production Alkalosis pH is more than 7.45
7. Adventitious breath sound Acidosis HCO3 is less than 22
 So what are those different adventitious or abnormal breath sounds Alkalosis HCO3 is more than 26
that can be heard over a patient's lungs? Alkalosis PCO2 is less than 35
 Rhonchi - which is a low pitch breath sounds Acidosis PCO2 is more than 45
 Crackles - a high pitch breath sound
 Wheezing - a high-pitched whistling sound caused by Abnormalities with ABG may cause the following problems :
narrowing of the bronchial tubes.  Respiratory alkalosis
 Stridor - a harsh, vibratory sound caused by narrowing of the  Respiratory acidosis
upper airway.  Metabolic acidosis
 Metabolic alkalosis
Diagnostic Tests
So what are the different diagnostic tests that we can perform in order to assess the
respiratory system?

1. Pulmonary function test - pulmonary function tests are noninvasive

tests that will show how well the lungs are working.
 The test measures the lung volume, capacity, rates of flow and gas
exchange.

2. Pulse oximetry - is a test used to measure the oxygen level or saturation

of the blood with the use of pulse oximeter.

3. Arterial Blood Gas Test (ABG) – are obtained to determine

oxygenation status in acid base balance.
 ABG analysis includes measurements of the partial pressure of
oxygen (PO2), partial pressure of carbon dioxide (PCO2) in arterial
blood, acidity or the pH and bicarbonate.

4. Radiography – includes:

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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
4. Decongestants - These are effective for short term symptom control,
Common Upper Respiratory Problems they decrease nasal discharge and congestion and are available without
1. Allergic Rhinitis prescription.
2. Influenza,
3. Sinusitis. Nursing Management
4. Acute Laryngitis 1. Teach the patient to take note when allergic reactions occur and keep a
diary of activities that precipitate reaction.
A. Allergic Rhinitis - is the inflammation of the nasal mucosa, often in 2. Identification of the allergen.
response to a specific allergen. 3. Teach the patient on how to use nasal spray.
4. Encourage thorough cleaning of the house.
Allergic rhinitis can be classified according to: 5. Encourage medication compliance
 Causative allergens
 Frequency of symptoms B. Influenza - Influenza is a highly contagious airborne disease caused by
influenza A or influenza B virus.
Allergic Rhinitis according to Causative Allergens:  It is an acute febrile illness with variable degrees of systemic
a. Seasonal - usually occurs in the spring and fall. symptoms.
- It is caused by allergies to pollens from trees, flowers, grasses or  Influenza is an acute respiratory illness that produced four global
weeds. pandemics in the last century, the worst of which occurred in 1918
- Attacks may last for several weeks during times when pollen and is known as the Spanish flu.
counts are high and then it disappears and often recurs at the same  The 1918 pandemic was considered as a global disaster, where 500
time of the year. million people were believed to be infected and an estimated death
b. Perennial rhinitis - This occurs year round from exposure to toll reached at least 50 million worldwide.
environmental allergens, such as animal dander, dust, mites,
cockroaches, fungi and molds. Modes of Transmission:
 Direct contact
Allergic Rhinitis according to Frequency of symptoms:  Unhygienic food preparation is on
a. Episode - This refers to the symptoms related to sporadic exposure to
allergens not typically encountered in the patient’s environment.  Aerosol transmission
- Example is exposure to animal dander when visiting your friends  Contact with contaminated objects
home.
When you say Aerosol transmission, sometimes it is also referred
b. Intermittent - It means that the symptoms are present less than four to as airborne. The transmission is similar to droplet infection, meaning the
days a week, or less than four weeks per year. disease can be spread through droplets wherein small bits of saliva or
respiratory fluid that infected individual expel when they cough, sneeze or
c. Persistent - means that the symptoms are present more than four days talk.
a week or more than four weeks per year.
Clinical Manifestations of Influenza:
Early Symptoms of Allergic Rhinitis  Cough and other respiratory symptoms may be initially minimal, but
Sensitization to an allergen occurs with initial honors exposure, frequently progresses as the infection evolve. Patients may report:
which results in the production of antigens or specific immunoglobulin E. 1. Nonproductive cough
After exposure muscles and basophils release histamines, cytokines, 2. Cough related pleuritic chest pain
prostaglandins and leukotrines. This may cause the early symptoms of: 3. Dyspnea
1. Sneezing 4. Fever - may vary widely even among individual patients, with some
2. Itching of nose and eyes having low fevers and other developing fevers as high as 104 degrees
3. Rhinorrhea - rhinorrhea is the free discharged of a thin nasal mucus Celsius. Some patients may report feeling feverish and chills.
fluid or is commonly known as runny nose. 5. Sore throat - may be severe and may last three to five days,
4. Congestion 6. Weakness and severe fatigue may prevent patients from performing
5. Watery eyes, their normal activities or work.
6. Decreased sense of smell.
When are you going to see the doctor?
Treatment of Allergic Rhinitis  Most people who get the flu can treat themselves at home, and often don't
Treatment can be divided into three categories: need to see a doctor. However, if the patient have flu symptoms and are
1. Avoidance of allergens or environmental controls at risk of complications or has difficulty of breathing or seizures, they
2. Medication should be brought to the hospital for treatment.
3. Allergen specific immunotherapy - which can be given in
sublingually or through injection. Diagnostic tests:
a. Viral cultures - This will help identify which virus, it can either be
Medical Management of Allergic Rhinitis: influenza A or influenza B, or other respiratory virus and which viral
1. 2nd generation antihistamines strains are present.

Antihistamines are classified in several ways including: b. Rapid influenza diagnostic tests (RIDT’s) - This can help in the
 Sedating diagnosis by detecting the virus in secretions from the respiratory tract.
 Non-sedating
Medical Management:
 Newer 1. Antiviral medications – These are class of medication used for treating
 Older viral infection.
 First generation - is primarily over the comfort and are included in  Most antiviral medication target specific viruses. Unlike antibiotics,
many combination products such as cold, cough and allergy drugs antiviral drugs do not destroy their target pathogen, instead they
 Second generation inhibit its development and prevent the risk for complication.

2. Intranasal antihistamines - These are agents that are an alternative to 2. Analgesics and antipyretics – are given for pain and fever.
oral antihistamine to treat allergic rhinitis.
Prevention:
3. Corticosteroids - This class of medication is most effective and show to The most effective strategy for managing influenza is prevention.
decrease allergic rhinitis symptoms in more than 90% of patients.

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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
So how do we prevent influenza? 3. Low-grade fever
1. Vaccine - vaccinating healthy people decreases the incidence and risk for 4. Persistent cough
transmitting influenza to those who have less ability to cope with the 5. Feeling of fullness in the throat
effects of the illness.

2 types of Influenza Vaccine:

 Inactivated (injection) - Which contains inactivated or killed virus.
 Live attenuated (nasal spray) - which contains live attenuated virus.
The vaccine is generally effective against influenza virus within two
weeks of administration. The vaccine is only effective against the stains
of the virus that match the vaccines.

C. Sinusitis - is the inflammation or swelling of the air cavities within the

passages of the nose.
 It is usually caused by a virus and often persists even after other
upper respiratory symptoms are gone.
 It can also be caused by infection, allergies and chemical or
particularly irritation of the sinuses.
 Most people do not spread sinus infection to other people.

Sinusitis can be classified as:
 Acute - it begins within one week of an upper respiratory tract
infection, and last less than four weeks.
 Sub-acute – is present when symptoms progress over 4 to 12
weeks,
 Chronic - when there is a persistent infection which is usually
associated with allergies and nasal polyps.
- Usually lasts longer than 12 weeks.
- Generally, this is a result from repeated episodes of an acute
sinusitis that results in irreversible loss of normal ciliated
epithelium lining of the sinus cavity.
Symptoms usually appear suddenly then it increases in severity over
2 to 3 days, and gradually subsides over the next 7 to 10 days as the condition
improves; it totally resolves within 21 days. The diagnosis of laryngitis is
made based on the history, clinical presentation and changes in voice.
Treatment:
1. Supportive - supportive care is the treatment given to prevent, control
or relieve complication and side effects and to improve the patient’s
comfort and quality of life.
 The patient is strongly encouraged to limit the use of the larynx,
including no talking or singing.

Clinical Manifestations: Medical Management:

 Sinus pain are slight 1. Acetaminophen – given in order to relive pain.
2. Antitussives/cough depressants – relieve cough by blocking the cough
 Pus like nasal discharge,
reflex.
 Nasal congestion, 3. Throat lozenges – also known as cough drop; is a small typically
 Sinus headaches - which can be on either or both cheekbones, medicated tablet intended to be dissolved slowly in the mouth to
forehead or bridge of the nose, temporarily stop coughs, lubricate and soothe irritated tissues of the
 Throat irritation, throat.
 Sore throat 4. Use of humidifier – is used to loosen secretions.
 Hoarseness of voice 5. Antibiotics – given if the cause of sinusitis is a bacterial infection.
 Cough
Nursing Management:
Nursing Intervention: 1. Have the patient increase fluid intake
1. Advice a patient to rest to help body fight infection and promote 2. Avoid caffeine and alcohol
recovery. 3. Stop smoking
2. Instruct to drink at least 6 to 8 glasses of water per day to loosen
secretions. E. Pharyngitis – medical term for sore throat
3. Take hot showers  It is the inflammation of the pharynx.
4. Apply warm, damp towels around nose cheeks, and eyes to ease facial
pain. Cause: Virus – Streptococcus
5. Sleep with head elevated to help sinuses drain and reduce Signs and Symptoms:
congestion. 1. Sneezing
6. Perform nasal saline washes once or twice a day to wash sinuses. 2. Runny nose
3. Headache
Medical Management: 4. Cough
1. Analgesics – to relieve pain 5. Fatigue
2. Decongestant /expectorant - to relieve swelling. 6. Body aches
3. Antibiotics - as prescribed for infection and 7. Chills
4. Nasal spray – to relieve congestion. 8. Fever

D. Acute Laryngitis - it is the swelling and inflammation of the voice box Medical Management:
or the larynx caused by a virus. 1. Antibiotics – such as amoxicillin and penicillin; they are the most
commonly prescribed treatment for sore throat.
Other causes: - It is important that the client should take the entire course of
 Inflammatory or infectious condition of the upper respiratory tract antibiotic to prevent infection from returning or worsening.
 Overuse of the voice - An entire course of this antibiotic usually lasts 7-10 days.
2. Throat lozenges
 Exposure to smoke-filled environments
 Chemicals inhalation Nursing Management:
Home remedies may include:
Classic Hallmark Signs of Acute Laryngitis: 1. Drink plenty of fluids to prevent dehydration
1. Tingling or burning sensation at the back of the throat 2. Eat/drink warm broth
2. Persistent need to clear the throat

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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
3. Gargle with warm salt water – is done by placing one teaspoon of cellular exudation and edema of the mucous membrane and diminish
salt per ounces of warm water. bronchial mucociliary function
4. Use a humidifier  Consequently, the air passages become clogged by the debris and
5. Rest irritation increases
 In response, copious are higher secretion of the mucus develops
TOPIC 2 resulting to persistent cough

LOWER AIRWAY DISORDERS

 Bronchitis
 Pneumonia
 Chronic Obstructive Pulmonary Disease (COPD)
 Asthma
 Covid-19
 Acute Respiratory Distress Syndrome (ARDS)

A. BRONCHITIS
- Is a self-limiting inflammation of the bronchi in the lower
respiratory tract.

SIGNS AND SYMPTOMS OF BRONCHITIS

TYPES OF BRONCHITIS
1. ACUTE BRONCHITIS
- Most people with acute bronchitis recover after a few days or
weeks
- Common cause by viral infection such as cold or flu are usually
the common cause of acute bronchitis
- Other causes:
 Air pollution  Cough – one of the bodies defense mechanism to get rid or expel
 Dust microorganism that can enters the lungs
 Inhalation of chemicals  Production of mucus – mucus production in the airway is normal, for it
 Smoking keeps the tissue small, for it helps trap small particles of foreign matter
 Chronic sinusitis that enters the lungs. Without it, the airway become dry and malfunction,
 Asthma But sometimes the mucus is produced in excess and changes in nature.
This results in the urge to cough and expectorate this mucus termed as
- AB are usually goes away without any treatment, however
sputum.
antibiotics are given if bacterial infection is present
- If pt. w/ acute bronchitis develop fever, difficulty of breathing or  Fatigue – is caused by lack of oxygen supply and lack of sleep due to
have symptoms lasts longer than 4 weeks, they should see and coughing
consult w/ the pulmonologists  Slight Fever – is brought by infection
- Sometimes over the counter medicines that loosens the mucous or  Shortness of Breath & Chest Discomfort – is caused by lack of oxygen
a non-steroidal anti-inflammatory drug or NSAID such as supply due to the inflammation of the bronchiole tubes.
ibuprofen can help manage AB
 Diagnosis of Bronchitis is based on the assessment.
2. CHRONIC BRONCHITIS  Assessment may reveal normal breath sounds or crackles or wheezes,
- It is an ongoing cough that lasts for several months and comes usually on expiration and exertion
back two or more consecutive years.  However, consolidation which occurs when doing accumulating in the
- In CB, the lining of the airway stays constantly inflame. lungs is absent with bronchitis, that is the reason why chest x-ray results
- This causes the line to swell and produce more mucous which can are normal and not needed unless pneumonia or some other pulmonary
make a hard to breath disorders is suspected
- CB is often part of a serious condition called chronic obstructive
TREATMENT
pulmonary disease.
Goal of treatment: to relieve the symptoms and prevent pneumonia.
- Causes:
 Chronic exposure to smoke The treatment for bronchitis is said to be supportive – the treatment given to
 Cigarette smoking help the pt. manage their symptoms, although they do not treat underlying
 Exposure to pollutants or hazardous airbone substances cause of the disease
PATHOPHYSIOLOGY OF BRONCHITIS What are those supportive care?
 During an episode of acute bronchitis, the cells of the bronchial-lining 1. Cough suppressants – it is given to block coughing reflex.
tissue are irritated and the mucous membrane becomes hyperemic and EX: dextromethorphan and robitussin
edematous or inflamed. 2. Throat lozenges – it helps to temporarily stop cough, lubricate in
 The inflammation of the bronchial linings stimulates the release of 3 soothe irritated tissues of the throat
substances such as bradykinin, histamine, and prostaglandin. 3. Bronchodilators – are beta-agonist inhalers, this will promote
 These 3 substances are said to be the major mediator of inflammation and dilation of the bronchial passages, and it is used for pt w/ wheezes or
allergic responses causing pulmonary vasodilation underlying pulmonary condition
 Pulmonary Vasodilation need to increase capillary permeability 4. Paracetamol – is given for fever
wherein the fluid leaks from the capillary which results to fluid or
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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
5. Antibiotics – maybe given to pt w/ underlying chronic conditions
who have prolong infection associated w/ systemic symptoms. These
are not prescribed for viral infections bc they have side effects and
promote antibiotic resistant.
6. Antiviral – if bronchitis is due to influenza virus, treatment with
antiviral drugs maybe started.
NURSING INTERVENTION
1. Encourage oral fluid intake
2. Advise to drink hot tea and honey – this may help to relieve cough
3. Encourage pt to stop smoking or not to smoke
4. Avoid secondhand smoke
5. Wash hands often
6. Use of humidifier – adds moisture to the air to prevent dryness of the
nose and the throat. It also helps in nitrifying secretion.
B. PNEUMONIA
- Despite the remarkable progress in the development of the antibiotic
to treat pneumonia, it is still associated w/ significant morbidity and
mortality.
- Pneumonia is an acute infection of the lung parenchyma
- More likely to occur when defense mechanisms become incompetent
or are overwhelmed by the virulence or quantity of infectious agents.
- Virulence – it is a pathogens or microbes ability to infect or damage
the organs of the body.
- Causes:
 Bacteria – most common type of bacterial pneumonia, and it is
called focal pneumonia which is caused by streptococcus
pneumoniae that lives in the upper respiratory tract. Bacterial
pneumonia can occur on its own or develop after a viral cold or
flu. Bacterial pneumonia often affects just one part or lobe of
a lung.
Risk for bacterial pneumia:
o People recovering from surgery
o People w/ respiratory disease or viral infection
o People who have weakened immune systems
 Viruses – that effects the upper respiratory tract may cause
pneumonia. Most viral pneumonias are not serious and lasts a
shorter time than bacterial pneumonia. The influenza virus
is the most common cause of viral pneumonia in adult. Viral
pneumonia cause by the influenza may be severe sometimes
fatal. The virus invades the lungs and it multiplies in the lungs.
It is most common in people with:
o People who have pre-existing heart or lung disease
o Pregnant women
 Fungi – fungal pneumonia is most common in people with:
o Chronic health problems or weakened immune systems
o Exposed to large doses of certain fungi from contaminated
soil or bird droppings.
The pathogens that causes pneumonia reach in the lungs in 3 ways
 ASPIRATION – it is the abnormal entry of material or food particles
from the mouth or stomach into the trachea in the lungs.
 INHALATION – it is the breathing in of airborne particles or microbes
present in air
 HEMATOGENOUS SPREAD – it is a spread of a primary infection
elsewhere in the body through the bloodstream. Ex: streptococci &
staphylococcus aureus from infective endocarditis.
CLASSIFICATION OF PNEUMONIA
 Actually there is no universally accepted classification system for the
pneumonia.
7
 These classification helps the healthcare provider identify the causes and
the choice of antimicrobial therapy.
 The most widely recognize effective way to classify pneumonia is the
place where it is acquired. Which can be:
1. Community-acquired – pneumonia that is acquired outside the hospital.
- Streptococcus pneumonia & Haemophilus influenza are most often
responsible for community-acquired pneumonia in adults.
2. Hospital-acquire pneumonia – also known as nosocomial pneumonia.
- Defined as a concept of pneumonia contracted by a pt in a hospital
at least 48-78 hours after being admitted.
TYPES OF PNEUMONIA
Some suggest classifying pneumonia according to the causative pathogens
such as bacterial, viral and fungal pneumonia. How it reaches the lungs. The
characteristics of the disease or radiographic appearance on chest x-ray.
1. Viral Pneumonia – is a common type of pneumonia. It occurs in one
third of all pneumonia cases. This pneumonia is most serious in people
who have pre-existing heart or lung disease and pregnant women.
2. Bacterial Pneumonia – is an inflammation of the lungs due to bacterial
infection. Bacterial pneumonia can occur on its own or develop after a
viral cold or flu. Bacterial pneumonia often affects just one part or lobe of
a lung.
3. Aspiration Pneumonia – results from the entry of solid foods, liquids,
saliva or vomitus into the lungs instead of going down into the esophagus
and the stomach. Conditions that increases the risk for aspiration
includes, decrease level of consciousness, difficulty of swallowing and
insertion of nasogastric tubes w/ or w/out feeding. With loss of
consciousness the gag and cough reflex are depress and aspiration is more
likely to occur.
4. Necrotizing pneumonia – it is a rare and severe complication of bacterial
community-acquired pneumonia (CAP). It causes lung tissue to turn
into a thick, liquid mass.
5. Opportunistic Pneumonia – it is the inflammation of the lower
respiratory tract in immunocompromised pt. Persons at risk includes
with altered immune responses such as HIV or AIDS
PNEUMONIA
PATHOPHYSIOLOGY OF PNEUMONIA
 When bacteria enter the lungs, it will invade the host’s defense
mechanism
 It will invade the spaces between cells and alveoli
 Macrophages (specialized cells involved in defection, phagocytosis, and
destruction of bacteria and other harmful organisms) will inactivate the
bacteria and neutrophils will stimulate the release of cytokines that
signals the body to activate the general activation of the immune system,
telling the body to do its job to fight infection and to eliminate bacteria
causing fever, chills, and fatigue
 Fever – is a defensive reaction of the body against
infectious disease
 When bacteria or viruses invade the body and causes
tissue injury, one of the immune system responses is to
produce pyrogens
 Pyrogens – substances that causes fever
 The virulence of the bacteria (when the bacteria enter the lungs) may
overwhelmed macrophages resulting the release of fibrin rich exudate
that fills the infective and neighboring alveolar spaces causing them to
stick together wondering them airless.
 The inflammatory response also results in the proliferation of
neutrophils causing damage to the lung tissue leading to fibrosis and
pulmonary edema which impairs lung expansion. Thus, causing
pleuritic chest pain, cough, and dyspnea.
 The inflammatory response can also lead to the development of pleural
effusion which is thought to complicate up to 40% of cases of pneumonia
 These changes results in reduce gas exchange. As a result, the vital
organs becomes oxygen deprived and the respiratory effort required
with each breath is increased as a result of disturbance in normal
physiology.
 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
4. Antipyretics
- For fever
5. Cough suppressant.
- These are also called antitussives. It blocks the coughing reflex
6. Bronchodilators
- It relaxes the muscles in the lungs and opens the airway or the
bronchi.
7. Mucolytics
- Medicines that tints the mucous, making it less safe and sticky and
easier to cough out.
8. Corticosteroids
- medicine that decreases
9. Antihistamine
- may provide benefit by reducing sneezing and rhinorrhea or runny
nose.
10. Nasal decongestant
- may also use to treat symptoms such as sneezing and rhinorrhea

SIGNS AND SYMPTOMS OF PNEUMONIA Nursing management

- Pneumonia varies in the signs and symptoms depending on the A. improve airway patency
organism and the patient’s underlying disease, but the most common How do we maintain airway patency?
presenting symptoms of pneumonia are: 1. Administer oxygen as prescribed.
 Cough – maybe productive or dry because the air sacs are - Using a high humidity face mask delivers warm, humidified air to
filled with fluid or purulent material causing cough with the tracheobronchial tree helps liquefy secretions and relieve
phlegm. The sputum is maybe green, yellow, rust-color, tracheobronchial irritation.
or bloody 2. Remove secretions
 Sudden chills rapidly rising fever with shivering - removing secretions can be done by encouraging the patient to
 Pleuritic chest pain – which is aggravated by respiration cough out the secretions or to do suctioning
and coughing - Removing secretions is important because the retained secretions
 Myalgia/Muscle ache interfere with gas exchange and may slow recovery.
 Abdominal pain - The nurse should encourage the patient to take 2-3 liters of water
 Headache per day if not contraindicated, because adequate hydration loosens
 Nausea and vomiting pulmonary secretions
4. Deep Breathing and coughing exercises
COMPLICATIONS OF PNEUMONIA - by using incentives spirometer this is to promote lung function
1. Atelectasis – lung collapse 5. Provide CPT or chest physical therapy
2. Pleurisy – inflammation of the pleura - This will help loosen and mobilize the secretion.
3. Pleural effusion – fluid in the pleural space, in most cases effusion is
sterile and is reabsorbed in 1-2 weeks. Sometimes effusion is for B. promoting rest and conserving energy.
aspiration by thoracentesis 1. Avoid overexertion
4. Bacteremia – bacterial infection in the blood - The nurse should instruct the patient to avoid over exertion this is
5. Pneumothorax – collection of air in the pleural space causing the to decrease oxygen demand
lungs to collapse 2. Semi Fowler's position
6. Acute respiratory failure – leading cause of death in patients with - Position the client in semi Fowler's to facilitate breathing in lung
severe pneumonia. Failure occurs when pneumonia damages the expansion.
lungs’ ability to retain oxygen and carbon dioxide across the alveolar C. Maintenance of adequate nutrition
capillary membrane. 1. Provide a high calorie, high protein diet with small frequent meal
- A diet rich in protein is beneficial for patients suffering from
DIAGNOSTIC TESTS
pneumonia, foods like nuts, beans, white meats and cold water fishes
1. CHEST X-RAY
like salmon and sardines have an anti-inflammatory properties.
- Often shows patterns, characteristics of the infecting pathogens and
- They're also important in repairing the damaged tissues and
pleural effusion
building new tissues in the body.
2. ARTERIAL BLOOD GASES
D. promote patient’s Knowledge.
- Maybe obtain to assess for hypoxemia 1. Understanding of the treatment protocol and preventive measures
3. COMPLETE BLOOD COUNT
- So the nurse should make the patient understand the treatment and
- To check for white blood cell protocols and the preventive measures of pneumonia
- Leukocytes increase in WBC will indicate pneumonia E. Monitor respiratory rate status
4. SPUTUM CULTURE AND GRAM STAIN 1. Record color, consistency, and amount of sputum
- To identify microorganism before beginning an antibiotic therapy. 2. Assess progression of signs and symptoms.
However, antibiotic administration should not be delayed if the - The nurses should monitor the respiratory status such as labored
specimen cannot be obtain. respirations or cyanosis and cold clammy skin
- Delays in antibiotic therapy can increase the risk for morbidity and F. Prevent Complications
mortality
C. COPD
Medical management
What are the medical management of pneumonia? D. ASTHMA
1. Antibiotics - it is a chronic inflammatory disease of the airways that causes airway
- Macrolide antibiotics are given for preferred treatment for children hyper responsiveness, mucosal edema and mucus production
and adults with pneumonia. - Asthma cannot be cured but its symptoms can be controlled.
- Macrolide include azithromycin and Clarithromycin, it is most - It isn't clear why some people get Asthma and others don't. But it's
effective for patients with bacterial pneumonia. probably due to the combination of environmental and inherited
2. Oxygen therapy factors.
- Oxygen therapy is given to treat hypoxemia
3. Analgesic
- To relieve chest pain
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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
What are the causes of asthma? 2. Complete blood count
 Airborne allergens - In complete blood count we check for elevated levels of eosinophil.
- such as pollen, dust, mites, molds, pet dander or particles of Elevated level of eosinophil indicates presence of allergies
cockroach waste. 3. Serum levels of immunoglobulin E
 Respiratory infections - May be elevated if allergy is pressing.
- such as common colds 4. Arterial blood gas analysis
 Physical activity 5. Pulse oximetry
 Cold weather  Arterial blood gas analysis and pulse oximetry will help death or mean
 Air pollutants and irritants hypoxemia during asthma attack
- such as smoke
 Certain medications Medical management.
- Such as beta blockers, aspirin and non-steroidal anti-inflammatory 1. Long acting medications
drugs, and naproxen sodium - To achieve and maintain control or persistent asthma.
 Stress - Corticosteroids
 food Allergies - It is used to decrease inflammation of the airways, an example of
 Gastro esophageal reflux disease. (GERD) - is a condition in which which is prednisone.
the stomach acid is backed up into the throat. - Long acting beta adrenergic agents (LABA)
- Taken on a daily basis to relax the muscles lining that carries air to
PATHOPHYSIOLOGY OF ASTHMA the lungs.
 Asthma symptoms are related to a combination of inflammation and - This allows the tube to remain open making breathing easier.
airway hyper responsiveness. - LABA should be taken only with the combination with a
 While the extra cause of asthma is unknown, studies have shown that corticosteroid to treat asthma. Example is volmaxand serevent.
the development of asthma is a combination of a genetic tendency - Xanthine Derivatives
towards an IgE or immunoglobulin E mediated overreaction to - Medication that use to dilate the airways or sometimes this called as
external triggers, a familial tendency and exposure to certain childhood bronchodilator
upper respiratory infections, or allergens. Example of Xanthine derivatives are aminophylline and theophylline
 When the allergen or triggers and enters the lungs, it stimulates the - Leukotriene modifiers or inhibitors
muscles of the lungs to produce several chemical mediator such as - It inhibits the actions of Leukotriene.
histamine and leukotriene
- LEUKOTRIENE are substances released by the muscles during
asthma attack which causes bronchoconstriction
 Example of Leukotriene inhibitors are montelukast and zyrtec

2. Quick relief medication

- is given for immediate treatment of asthma symptoms and
exacerbation

Example of Quick relief medication is anticholinergic.

- Anticholinergics
- Prevent the release of acetylcholine.
- Examples of anticholinergic is atrovent.
- Acetylcholine
- It is a neurotransmitter that causes bronchoconstriction, increased
mucus secretion and inflammation.

 These chemical triggers inflammatory response or inflammation of the
airways
 leak of fluid from the vasculature and bronchoconstriction which results
to hypersecretion of mucous, airway muscle contraction and swelling of
the bronchial membranes, causing the narrowing of the air passages,
thus resulting to wheezing, shortness of breath and chest tightness.
Signs and Symptoms of asthma
Three most common signs and symptoms of asthma
1. Cough
- with or without mucous
2. Dyspnea and chest tightness
- which is caused by narrowing and inflammation of the airways
3. Wheezing
- There may be a generalized wheezing, which is the sound of air flows
through a narrowed airways. First an expiration, then possibly
during inspiration as well.
In some instances, cough may be the only symptom
Asthma attacks often occur at night or early in the morning, possibly
due to the circadian variations that influence airway receptor
pressure,
Diagnostic Test of Asthma
1. Sputum test or sputum culture
- This is done in order to determine what type of microorganism
causes asthma,
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Nursing management
The immediate nursing care of the patients with asthma depends on the
severity of the symptoms.
1. Promote the rest.
2. Maintain the nutrition
3. Avoid allergens,
4. Promote patients knowledge about the disease process,
5. Prevent and manage complications.
The patient treated successfully as an outpatient if asthma symptoms are
relatively mild for you or he may require hospitalization and intensive care for
acute and severe asthma,
E. COVID – 19
F. Acute Respiratory Distress Syndrome or ARDS
- It is previously called as adult respiratory distress syndrome,
- It is characterized by non-cardiogenic inflammatory lung edema
with severe hypoxemia.
- It is a life threatening lung condition that occurs when the fluid
accumulates in the air sacs of the lungs or, the alveoli
- It is the most severe form of acute lung injury (ALI).
- Occurs as a result of inflammatory trigger that initiates the release
of cellular and chemical mediators causing injury to the alveolar
capillary membrane, which results in the leakage of fluid in the
alveolar interstitial spaces and alterations in the capillary.
Etiologic Factors
- are the common causes of acute respiratory distress syndrome
 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
1. Aspiration of gastric secretion - To determine the microorganism causing acute respiratory
2. smoke and chemical inhalation, distress syndrome.
3. chest trauma,
4. oxygen toxicity, Medical Management of Acute Respiratory Distress Syndrome
5. over dosage of sedatives Supportive Care
- Refers to the treatment given to help the patient manage their
Risk Factor symptoms, although they do not treat the underlying cause of the
1. Age-over 65 years old disease.
2. Chronic lung disease
3. history of alcohol abuse and smoking, Supportive Care:
1. Supplemental oxygen
PATHOPHYSIOLOGY OF ACUTE RESPIRATORY DISTRESS - Since patients with ARDS are severely hypoxemic. It is important
SYNDROME. to improve their arterial oxygen saturation by using high fractions
 Injury to the lungs causes damage of the alveolar cells and stimulate the of inspired oxygen and decreasing oxygen consumption.
muscles to release bradykinin and histamine. The damage to the
alveolar cells results in the decrease of surfactant production. 2. mechanical ventilator
- Is the machine used to help patients breathe or ventilate when
What is surfactant? there's spontaneous ventilation is inadequate.
 It is a chemical produced by the alveoli that lowers or decrease the surface
tension of the lungs. 3. Fluid therapy
 The decrease in the amount of surfactant resource to decrease alveolar - The goal of fluid therapy is to maintain intravascular volume and
compliance perfusion to the different vital organs of the body.
 the ability of the alveoli to expand and stretch to accommodate air that
enters the lungs, which results to lung collapse or atelectasis resulting 4. Nutritional support.
to decrease lung compliance and impaired gas exchange. Thus developing - Patients with a ARDS are intensely catabolic, and nutritional
the different signs and symptoms of acute respiratory distress syndrome. support may help to offset catabolic losses.
 The release of bradykinin increases memory membrane permeability - If gastrointestinal tract is available for nutritional intake enteral
causing the leakage of vascular fluid, while histamine and inflammatory feedings are preferred
chemical causes bronchoconstriction, vascular narrowing and - Possible advantage of entero route include, fewer intravascular
obstruction, infection, thus GI bleeding because of gastric buffering, and
 The increase in membrane permeability, bronchoconstriction, vascular preservation of the intestinal mucosal barrier
narrowing and obstruction will resultt to pulmonary edema causing
impaired gas exchange 5. Positioning strategies
- Thus development of signs and symptoms of acute respiratory - Placed the patient in Semi Fowler's position to promote lung
distress syndrome. expansion.
- However, some studies show that it is most helpful if the patient is
positioned to prone to facilitate drainage or separations and improve
our arterial oxygenation.
This can be done by using the VOLLMAN PRONE POSITIONER or
what we call the rotoprone, these are example of beds use to position the
patient.

Clinical Manifestation of patients with acute respiratory distress syndrome

1. Rapid onset of severe dyspnea, usually 12 to 48 hours after the initial
event,
2. Intercostal retraction and crackles
3. arterial hypoxemia
Hypoxemia - decrease in oxygen level in the blood, which is not responsive
to oxygen supplementation. That is why patients are put on ventilators, Medications for patients with ARDS
4. labored breathing and tachypnea 1. Antibiotic
- the patient also has an increase of alveolar dead space and decreased - is given when that cause of ARDS bacteria.
pulmonary compliance which results to the stiffness of the lungs - This will inhibit the bacterial cell wall synthesis and prevents the
growth of bacteria.
Assessment and Diagnostic Evaluation 2. Anti-inflammatory drugs used to decrease inflammation of the
1. History Taking airways
2. Physical examination (objective and the subjective data). 3. Diuretics
3. Tests: - These are medications used to increase urine flow.
ABG - It is given to decrease pulmonary edema since ARDS is particularly
- To determine hypoxemia in partial pressure of oxygen and characterized by pulmonary edema caused by an increase in
carbon dioxide, pulmonary capillary permeability,
CHEST X-RAY OR CT SCAN 4. Anti-anxiety drugs,
- Will show bilateral infiltrates and pulmonary edema. 5. Muscle relaxants/ sedatives
BRONCHOSCOPY - This will decrease patient’s anxiety, since the patient is intubated
- to visualize the airways 6. Bronchodilators
SPUTUM CULTURE ANALYSIS - Will help open the airway.
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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
Nursing Management  Ex. Acid-base balance, Body temperature, Fluid acid-base
1. Facilitate respiratory management such as: balance
- Positioning of the client.
- Monitoring the oxygen level, 3. Protection from blood loss, infection, and diseases (by maintaining the
- ensure that the Endotracheal intubation is intact and patent homeostasis of blood coagulation, combating invasion of
- perform suctioning microorganisms)
- possibly check the mechanical ventilator for any problems
especially in the delivery of the oxygen 2 Major Components of Blood
2. Performed chest physiotherapy 1. Plasma
3. Minimize anxiety. - The clear, straw-colored liquid portion of blood that remains when
4. Rest RBC, WBC, platelets and other cellular components are removed.
- This is to minimize or to decrease oxygen consumption. - Single largest component of human blood about 55% of blood is
plasma
- Composed of 90% water - contains proteins, electrolytes, gases,
TOPIC 2 nutrients, and waste.
- It is transporting medium of cells and other substances vital to the
OXYGENATION-TRANSPORT DISORDER human body.
- Also carries out a variety of functions in the body such as blood
HEMATOLOGIC DISORDERS clotting and fighting infections and diseases.
Anemia
● Anemia caused by Decreased Erythrocyte Production Important Components of Plasma
 Iron-Deficiency Anemia a. Serum
 Thalassemia - A circulating carrier of exogenous and endogenous liquids in the
 Megaloblastic Anemias blood.
 Aplastic Anemia - It helps in the transportation of fatty acids and thyroid hormones
● Anemia Caused by Blood Loss which acts on most of the cells found in the body.
 Acute Blood Loss
 Chronic Blood Loss b. Plasma Proteins
● Anemia Caused by Increased Erythrocyte Destruction - Help maintain the colloidal osmotic pressure
 Sickle Cell Disease - Include albumin, globulin, and clotting factors (mostly fibrinogen).
 Disseminated Intravascular Coagulation - The liver makes most of the plasma protein

c. Albumin
- S protein that helps maintain oncotic pressure in the blood
ANATOMY AND PHYSIOLOGY OF HEMATOLOGIC SYSTEM
2. Blood Cells
Hematology - Also called hematopoietic cells hemocyte or hematocyte
 It is the study of blood and blood-forming tissues. - It is a cell produce through hematopoiesis and found mainly in the
 A functioning hematologic system is needed to support the patient blood
ability to transport O2 and CO2, maintain intravascular volume, - About 45% of the blood is composed of formed elements, or blood
coagulate blood and combat infection. cells.

Structures and Functions of Hematologic System 3 Types of Blood Cells

1. Bone Marrow a. Erythrocytes (RBCs)
2. Blood - Responsible in the transportation of gases.
3. Spleen - Assist in maintaining acid-base balance
4. Lymph System - Flexible cells with a unique biconcave shape, this flexibility allows
the cells to change its shape so that it can easily pass through the
1. Bone Marrow tiny capillaries.
- Soft material that fills the central core of bones responsible in blood - The cell membrane is thin to facilitate the diffusion of gases.
cell production (hematopoiesis). - RBCs are primarily composed of large molecules called
- The bone marrow response by a negative feedback system to the hemoglobin.
need for specific blood cells, by increasing blood cell production.
 Hemoglobin
2 Types of Bone Marrow o a complex protein-iron compound composed of heme
1. Yellow (adipose) (iron) and globin (a simple protein)
2. Red (hematopoietic) o As RBC circulates throughout the capillaries surrounding
- actively makes blood cells the alveoli within the lungs, the O2 attaches to the iron on
- Red blood Cells (RBC), White Blood Cells (WBC), Platelets the hemoglobin where refer this oxygen bound
- In adults, red marrow is found primarily in the flat and irregular hemoglobin as oxyhemoglobin.
bone such as end of long bones, pelvic bones, vertebrae and scapulae.
 Erythropoiesis
2. Blood o The process of RBC production is controlled by
- Fluid that constantly circulates to provide the body with nutrition, erythropoietin.
oxygen, and waste removal.
 Erythropoietin
3 Major Functions of Blood o A glycoprotein growth released by the kidney to
1. Transportation of gases, nutrients and waste products, hormones and stimulate the bone marrow to increase RBC production.
heat.
 Ex. O2 from lungs to cells, nutrients from GI tract to cells, b. Leukocytes (WBCs)
metabolic waste products such as carbon dioxide from the cells - Appears white when separated from blood.
to the lungs, kidneys, and liver. - Originates from the stem cells within the bone marrow.
- Serves to protect the body from infection.
2. Regulation of acid and base balances

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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
c. Thrombocytes (platelets) LABORATORY & DIAGNOSTIC TESTS
- Promotes blood coagulation 1. Complete Blood Count with Peripheral Smear
- Responsible in the clotting process. a. RBC count – however the total RBC count is not fully reliable in
- One third of the platelets in the body are stored in the spleen. determining the adequacy of RBC function. We must also
evaluate hemoglobin and hematocrit. Normal value of some RBC
test are different from men and women because normal values are
3. Spleen based on the body mass.
- Largest lymphoid organ in the body located in the upper left b. Hgb count – Hgb count usually reduce in cases of anemia and
quadrant of the abdomen. hemorrhage.
c. WBC - increase in WBC indicates infection, inflammation, tissue
4 Major Functions of the Spleen: injury or death and cancer. WBC elevation doesn’t necessarily
1. Hematopoietic predict the severity of illness, however it can give clues to the
cause. Extreme high WBC count occurs in certain type of
- The spleen has the ability to make RBC during fetal development
Leukemia. A decrease in WBC count or Leukopenia is associated
with bone marrow depression; severe or chronic illness; and other
2. Filtration
types of Leukemia.
- The spleen is capable of removing the old and detective RBC from d. Platelet count - decrease in platelet count is called
the circulation through mononuclear phagocytosis.
thrombocytopenia, and people with thrombocytopenia is prone
- Can also catabolized hemoglobin released by hemolysis and return to bleeding. Increase in platelet count is called thrombocytosis
the iron part of the hemoglobin to the bone marrow for reuse. which indicates inflammation or cancer.
- Spleen plays vital role in filtering circulating bacteria especially e. Peripheral Smear - used to look at the morphology, shape, and
encapsulated microorganisms such as gram-positive cocci. appearance of the blood cells and may help with the diagnosis. For
example: Many immature WBC may indicate acute leukemia.
3. Immunologic 2. Bone Marrow Examination - it is important in evaluating many
- The spleens rich supply of lymphocytes, monocytes, and stores hematologic problems it involves aspiration or aspiration with biopsy.
immunoglobulin plays a role in its immunologic function. 3. Lymph Node Biopsy
- Used to determine if the cancer cells have invaded the lymph node.
4. Storage Helps determine the extent of metastasis and cancer.
- Its storage function is reflected in its role as a storage site for RBC
and platelet. Different Hematologic Disorders
- Spleen can store more than 300 ml of blood Anemia
- It stores about one third of the platelet. - A deficiency in the number or erythrocytes (RBC, the quantity or
quality of hemoglobin, and/or volume of packed RBC (Hematocrit).
4. Lymph System - Not a specific disease, rather a manifestation of pathologic process.
- Carries fluid from the interstitial spaces of the blood
- Also returns excess interstitial fluid to the blood. Clinical Manifestation:
1. Pallor, Jaundice, and Pruritus
Consist of: - Pallor results from reduce amount of hemoglobin that reduce blood
a) Lymph fluid flow to the skin
b) Lymphatic capillaries and ducts - Jaundice occurs when there is an excessive breakdown of RBC or
c) Lymph nodes hemolysis causing an increase number or amount of serum bilirubin.
- Filtration of pathogens and foreign particles. - Hemolysis also causes pruritus because of increase serum and bile
- Through the lymph, proteins and pass from the GI tract and salt concentration in the skin.
hormones can return to the circulatory system. 2. Easy fatigability - not enough O2 supply
3. Shortness of breath - decrease O2 supply
Assessment of Hematologic System  Easy fatigability and shortness of breath is brought about by
 It is based on a thorough health history and presenting Signs and the lack of O2 supply to the different organs of the body. The
symptoms: circulatory system cannot provide enough O2 to meet the
demands of body for O2. Due to lack of O2 to the heart, the
A. Subjective Data heart will compensate to provide the body with oxygen by
pumping harder causing tachycardia.
Important Health Information: 4. Tachycardia
1. Past Health History – determine if the patient had prior hematologic
problems. Ask the patient about problems with anemia, bleeding Medical Management:
problems, and blood disorders. 1. Blood Transfusions
2. Medications taken - many medications may interfere with normal - increase and replaced RBC
hematologic functions. Those on long term anti-coagulant therapy 2. Drug Therapy
such as Warfarin are at risk for bleeding problems. Chemotherapeutic - Erythropoietin to correct anemia by stipulating the bone
drugs used to treat cancer, anti-retroviral agent used to treat HIV may marrow to produce RBC
cause bone marrow depression. - Iron supplement – Iron is an essential element for blood
3. Surgery and other treatments – ask the patient about specific surgical transfusion
procedures. This includes splenectomy or surgical incision of the 3. O2 Therapy
duodenum where iron absorption occurs. - To stabilize the patient especially with those severe anemia to
4. Elimination Patterns – ask if there’s blood in urine or stool because it prevent lung collapse and cardiac problem.
might indicate bleeding.
5. Activity-exercise pattern - fatigue is the most prominent signs and Nursing Intervention
symptoms in many hematologic problem.  Goal of Therapy - correct the cause of the anemia
B. Objective Data 1. Encourage alternate rest and activity periods
1. Physical Examination (IPPA) 2. Help the patient prioritize activities – to accommodate energy levels
 skin 3. Provide information about nutritional needs – and how to meet them
 spleen 4. Increase the patients’ intake of essential nutrients
 lymph nodes
 liver

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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
ANEMIA CAUSED BY DECREASED ERYTHROCYTE
PRODUCTION
1. IRON-DEFICIENCY ANEMIA
- Is the most common nutritional disorder
- Caused by inadequate dietary intake or iron rich food,
malabsorption, blood loss, or hemolysis.
RISK FACTORS:
 Poor diet
 Women in their reproductive years (prone to have this anemia due to
blood loss during their monthly period thus Iron supplementation should be
given)
CAUSES:
 Blood loss
 Lack of Iron in the diet
 Inability to absorb Iron
o An intestinal disorder such as Celiac Disease which affects the
intestines ability to absorb nutrients from the digested foods
can lead to Iron-deficiency anemia. Thus, it is important that
we need to take the surgical history of the patient for this will
help in managing the disease.
 Pregnancy
o Iron-deficiency anemia occurs in many pregnant women
because their iron stores need to serve their own increase blood
volume, as well as the source of hemoglobin for the growing
fetus.
CLINICAL MANIFESTATION (SEVERE)
 In the early course of Iron-deficiency anemia the patient may have any
symptom, as the diseases becomes chronic any of the general
manifestations of anemia may develop such as:
1. Blurring of Vision - due to lack oxygen supply in the eyes.
2. Anorexia
3. Pallor - due to decrease hemoglobin level
4. Lethargy – lack of oxygen in the brain
5. Sensitivity to cold due to decrease RBCs that help regulate the
body temperature.
6. Icteric sclera – yellowish discoloration of the sclera due to
excessive breakdown of the RBCs.
2. THALASSEMIA
- Group of hereditary hemolytic anemia involving inadequate
production of normal hemoglobin, which decreases RBC
production.
- It is marked by a deficit in the production of hemoglobin.
- Caused by mutations in the DNA of cells that makes up
hemoglobin (hgb) resulting to absent or decrease hemoglobin
level.
- Because thalassemia affects hemoglobin production, it also
impairs RBCs or RBC synthesis.
- Globulin Protein is one of the major blood proteins which is
important in blood clotting. It is characterized by defected
synthesis in one or more polypeptide chains necessary for the
hemoglobin production
2 Types of Thalassemia
a. Alpha-thalassemia
b. Beta-thalassemia
Risk factors:
 Family history of thalassemia – Thalassemia is past from parents
to children through mutated hemoglobin gene.
 Certain ancestry – occurs most often in African and American and
in people of Mediterranean and Southeast Asia.
Signs and Symptoms of Thalassemia
1. Fatigue and weakness
2. Pale or yellowish discoloration of the skin
3. Facial bone deformities – which are due to bone changes associated
with ineffective erythropoiesis causing over expansion of the bone
marrow and the bones become thinner and pathological fracture may
occur.
4. Slow growth
13
5. Abdominal enlargement – is due to inflammation of the liver and the
spleen. Splenomegaly may be associated with an overactive spleen or
o Hypersplenism - a condition that can develop because too many
cells build up are destroyed within the spleen.
6. Dark urine - due to inability of the kidney to filter urine which may be
brought about by the lack of oxygen supply to the kidney
MEDICAL MANAGEMENT
 There are no specific drug or diet therapies which are effective in treating
thalassemia. Thalassemia minor does not need treatment because the
body adapts to the reduction of normal hemoglobin. The care of patients
with thalassemia is supportive.
1. Blood transfusion or exchange transfusions if there is a decrease in
the hemoglobin level in conjunction with chelating agents.
o Chelating agents – this will help reduce the iron overloading
that occurs with chronic transfusion therapy. Chelation
therapy aims to balance iron accumulation from blood
transfusion by increasing iron excretion in the urine.
2. Ascorbic acid supplements may be needed during chelation therapy
- since they increase urinary excretion of iron. Ascorbic acid should only
be taken with chelation therapy because it increases the absorption of
dietary iron.
3. Zinc supplements maybe needed since zinc is reduced with chelation
therapy.
NOTE: Iron supplements should not be given because it may result to
excess iron which can collect in the many areas of the body causing organ
damage.
NURSING MANAGEMENT
1. Teach the patient how to prevent infection.
2. Observe and assess carefully for reactions when the patient is on
treatment such as BT or oral therapy.
3. Encourage the patient to drink plenty of fluids.
4. Provide emotional support
5. Help the patient and his family to cope for chronic nature of the
disease and explain the need for lifelong transfusions.
3. MEGALOBLASTIC ANEMIA
- A condition in which the bone marrow produces unusually large,
structurally abnormal, immature red blood cells (megaloblasts).
CAUSES:
1. Hypovitaminosis
a. Cobalamin (Vitamin B12)
b. Folic Acid
 These two play a vital role in the production of RBC.
2. Suppression of DNA synthesis by drugs
3. Inborn errors of cobalamin and folic acid metabolism
SIGNS AND SYMPTOMS OF MEGALOBLASTIC ANEMIA
 Shortness of Breath
 Muscle Weakness
 Abnormal Paleness of the Skin
 Gastrointestinal manifestations are also common which includes:
o Glossitis or swollen tongue
o Anorexia or loss of appetite/weight loss
o Diarrhea
o Nausea
 Neurologic Manifestations are also common which includes
Peripheral Neuropathy such as:
o Tingling in the hands and feet
o Numbness in extremities
o Gait instability
DIAGNOSTIC TESTS:
1. (CBC) Complete Blood Count – to check the RBC and the
hemoglobin level.
2. Schilling Test – is a medical procedure used to determine whether
the body is properly absorbing vit.B12.
o How is it performed? The patient usually has to take
small supplements of radioactive B12 then retake the
 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
radioactive B12 again after 24 hours a urine example will 3. Fatigue
be collected for analysis. 4. Pallor
 Low platelet count will also result to:
MEDICAL MANAGEMENT 5. Increased risk of bleeding even if in minor injuries or
1. Cobalamin Therapy - is given intramuscularly daily for 2 weeks and mucosal areas such as :
weekly until the hematocrit value is normal and then monthly for life. 6. Petechiae or rashes
2. Folate Therapy – given however it should not be given to those  Decreased in WBC results to body’s inability to fight against infections
patients with megaloblastic anemia if cobalamin deficiency has not resulting to:
been definitively ruled out. Although folic acid will help improve 7. Sepsis or Recurrent infections
anemia, but neurological disorder cause by cobalamin deficiency will
worsen. DIAGNOSTIC TESTS
1. CBC – usually reveals decrease in RBC, WBC, PLATELET, and
NURSING MANAGEMENT RETICULOCYTE (young RBC), and increase in
1. Teach the patient on how to prevent infection ERYTHROPOEITIN.
2. Encourage the patient to drink plenty of fluids  Erythropoietin are foremost released by the kidney, which is
3. Provide emotional support responsible in blood production. Since there is a decrease in RBC, the
4. Instruct patients to increase intake of food rich in folic acid kidney will produce more and more protein to compensate for the
 Asparagus decreasing RBC and Reticulocyte which resulted to decrease RBC
 Broccoli production.
 Spinach 2. Bleeding time - is usually decreased due to decreased platelet
 Lettuce count.
 Lemon 3. Bone Marrow Biopsy – this is done to determine if there is
 Banana decrease in hematopoietic stem cells, malignancy, and cell
 Liver morphology. Morphology refers to the size, shape, and the
 Mushroom structure of the cell.
 To prevent loss of folic, food should not be cooked excessively and
should not be diluted in large amount of water. MEDICAL MANAGEMENT
 To prevent cobalamin deficiency, vegetarians should include dietary  Depends on the:
products and egg in their meals. 1. Age of the patient
 Patients should know that goat milk contains little folate.  <50 yrs old – can undergo stem cell transplant
 >50 yrs old – immunosuppressive therapy is given such as
4. APLASTIC ANEMIA the use of glucocorticoids and cyclosporine increase
- A disease in which the body fails to produce sufficient amount of hematopoietic stem cells such as stem cell injection
blood cells such as RBCs, WBCs, and platelets, and hypocellular  Blood transfusion is also given in severe cases.
bone marrow. 2. Clinical history
- Can be mild or severe  If the cause of the disease is due to exposure to toxins or radiations,
this can be removed or avoided immediately.
Hypocellular Bone Marrow
- Decrease in the number of the normal cells. TOPIC 3

Anemia+Leukocytopenia+Thrombocytopenia =PANCYTOPENIA CARDIOVASCULAR SYSTEM

 Anemia – decrease in RBCs
 Leukocytopenia – decrease in WBCs
 Thrombocytopenia – decrease in the number of plaletes
ETIOLOGY
 Autoimmune destruction of hematopoietic stem cells
o Hematopoietic Stems cells – responsible for the renewal and
production of the blood
 Autoimmune destruction of hematopoietic stem cells results in the
alteration in the appearance of hematopoietic stem cells – making it a
NON-SELF ANTIGEN,
o As we all know ANTIGEN are toxins or substances, foreign
substances that stimulate the immune response in the body.
Since the hematopoietic stem cells become a non-self antigen,
the body will sense them as foreign so the immune system will
destroy hematopoietic stem cells resulting in decrease blood
cells
CAUSES OF APLASTIC ANEMIA
1. Radiation or other toxic agents that contains benzene
2. Drugs
 Chemotherapeutic agent
 Anti-seizure
 Anti-inflammatory – not for long term use since it can cause aplastic
anemia. It should be used only when needed.
 Antibiotics
3. Infectious Agents such as HIV
- It is also called as the circulatory system whose function is to
circulation and transport of nutrients oxygen hormones to and from
the cells in the body to nourish it.
CIRCULATORY SYSTEM IS COMPOSED OF THE FOLLOWING
1. Heart
- It is a four chambered hollow muscular organ normally about the
size of a fist.
- It is composed of three layers; a thin lining the endocardium, the
muscular layer the myocardium, and an outer layer the epicardium.
- The heart is primarily responsible for pumping blood and
distributing oxygen and nutrients throughout the.
3. Lungs
- It is the organ responsible for gas exchange.
4. Blood vessels
- These are tubes through which the blood circulate in the body.
3 types of blood vessels:
a. Arteries
- Carry oxygenated blood from the heart to the body.
b. Veins
- Carries unoxygenated blood from the body to the heart
c. Capillaries
- Which is responsible in the exchange of nutrients and wastes between
the blood and tissue cells.

SIGNS AND SYMPTOMS PHYSIOLOGY OF CIRCULATION

 Decrease in RBC causes decrease oxygenation in the tissues causing the  Your heart is a pump it's a muscular organ about the size of your fist and
heart to pump harder resulting to: is located slightly left to center in your chest. Your heart is divided into
1. Chest pain the right and left side.
2. Shortness of breath  The division protects oxygen-rich blood from mixing with oxygen poor
blood, together your heart and blood vessels comprise your
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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
cardiovascular system which circulate blood and oxygen around your
body.
 In fact your heart pumps about 5 quarts of blood every minute.
 It beats about 100,000 times in one day that's about 35 million times in a
year.
 Oxygen-poor blood blue blood returns to the heart after circulating
through your body. The right side of the heart composed of the right
atrium and ventricle collects and pumps the blood to the lungs through
the pulmonary arteries. The lungs refresh the blood with a new supply of
oxygen making it turn red oxygen-rich blood, red blood then enters the
left side of the heart composed of the left atrium and ventricle and is
pumped through the aorta to the body to supply tissues with oxygen for
vowels within your heart keep your blood moving the right way.
 The tricuspid, mitral, pulmonary, and aortic valves work like gates on
offense they open only one way and only when pushed on each valve
opens and closes once per heartbeat or about once every second. A
beating heart contracts and relaxes.
 Contraction is called systole and relaxing is called diastole. During
systole your ventricles contract forcing blood into the vessels going to
your lungs and body much like ketchup being forced out of a squeeze
bottle. The right ventricle contracts a little bit before the left ventricle
does. Your ventricles then it will rocks during diastolic and are filled with
blood coming from the upper chambers. That left and right atria then the
cycle starts over again. Your heart is nurishing by blood to blood vessels
called coronary arteries. Extend over the surface of your heart and branch
into smaller capillaries. A network of blood vessels that feed your heart
with oxygen-rich blood your heart also has electrical wiring which keeps
repeating electrical impulses. Begin high in the right atrium and travel
through specialized pathways to the ventricles delivering the signal to
pump. Conduction system keeps your heart beating in a coordinated and
normal rhythm which in turn keeps blood circulating.
 The continuous exchange of oxygen rich blood with oxygen poor blood
is what keeps you alive.
GENERAL CLINICAL MANIFESTATIONS OF CV SYSTEM
DISORDER
 Angina and chest pain
 Pain in both arms that radiates from the left shoulder, neck, jaw, or
back
 Shortness of breath
 Dizziness
 Tachycardia
 Nausea
 Dysrhythmia/ abnormal rate and rhythm of the heart
 Easy fatigability
ASSESSMENT
1. Physical examination (IPPA)
- Using the four assessment method which are inspection, palpation,
percussion, and auscultation.
- Nurses collect objective data through observation of the signs and
symptoms. And subjective data through interview.
2. Personal and family history
- Because most of the cardiovascular problems are inherited.
DIAGNOSIS AND LABORATORY FINDINGS
1. Blood tests
 CBC - to check for hemoglobin and RBC level.
 Lipid profile - this includes total cholesterol, High Density
Lipoprotein or HDL (good cholesterol), and Low Density
Lipoprotein or LDL (bad cholesterol) and triglycerides.
- Elevation in triglycerides and LDL are strongly associated with
coronary artery disease.
- Increased HDL level is associated with decreased risk of coronary
artery disease. HDL serves as a protective role by mobilizing
cholesterol from tissues.
 Blood chemistry - includes fasting blood sugar – this is to check for
the presence of sugar in the blood.
- SGOT helps determine how well the liver is functioning.
- SGPT to detect heart and liver damage.
- BUN and creatinine to determine kidney functioning
- Uric Acid detects gout or kidney problems.
2. Troponin-I – this are heart muscle protein which is released when there is
cardiac injury such as myocardial infarction.
15
3. CPK-MB enzymes- are found in the heart. Levels begins to increase 3 to 6
hours after symptom onset; peak in 12 to 24 hours and returned to baseline
within 12 to 48 hours after myocardial infarction.
4. ECG or electrocardiogram – helps detect health problems by measuring
the electrical activity generated by the heart as it contracts.
5. Echocardiogram (2D echo) - it is used to see the actual motion of the heart
structure. It also checked how the heart’s chambers and valves are pumping
blood through the heart.
6. HOLTER MONITOR - it captures and display the performance of the
heart and determines if the heart is working properly for 24 to 48 hours only.
7. Event monitor or loop recorder - it is a type of ECG monitoring device
that records the activities of the heart. An event monitor is a portable unit that
uses electrodes to store ECG data.
2 types of event monitor:
 External - is usually worn for a month. They require electrodes
that is continuously placed on the skin. They must be activated by
the patient when symptoms occur.
 Implantable - is used for patient who may have serious yet
infrequent dysrhythmia. This small recorder is implanted
through a small incision into the chest wall. It continuously
monitors heart activity.
8. Imaging tests
 Chest X-ray- this is to check for the enlargement of the heart.
 CT scan - can detect heart disease using x-ray.
 MRI – medical imaging technique that uses a magnetic field and
computer generated radio waves to create detailed images of the
heart and the tissues in the body.
FUNCTIONAL STUDIES
1.) Exercise or stress test - it is used to evaluate the hearts response to
physical stress. This helps to assess cardiovascular disorder and set limits for
exercise program. Exercise testing is used for person who can walk unassisted
or use a bike.
2.) 6-Minute Walk test - it is a general test of cardiac fitness often use with
older adults used to measure the distance the patient can walk on a flat surface
in 6 minutes.
3.) Noninvasive Hemodynamic Monitoring - it is provides information
about cardiovascular status changes such as peripheral oxygen saturation,
blood pressure, and heart measurement.
CARDIOVASCULAR DISEASES
HYPERTENSION (HIGH BLOOD PRESSURE)
- One of the most important modifiable risk factors that can lead to
development of cardiovascular disease.
- As BP increases so does the risk for myocardial infarction, heart failure,
stroke and renal disease.
Blood Pressure
 Is the force exerted why the blood against the walls of the blood
vessels. It must be adequate to maintain tissue perfusion during
activity and rest. It is typically represented by two numbers. The
top number as systolic - it is the arterial pressure when the heart
contracts. The lower numbers are the diastolic or the arterial
pressure when the heart is relaxing. Both numbers in a blood
pressure reading are important, but after age 50, the systolic
reading is even more significant.
STAGES OF HPN
 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
ETIOLOGY PATHOPHYSIOLOGY
1. Primary Hypertension
 Also known as essential or idiopathic hypertension.
 Is the elevation of blood pressure without any identifiable cause.
 It accounts for 90 to 95% of all cases of hypertension. Although the
exact reason for primary hypertension is unknown, there are
multiple contributing factors.

Risk Factors:
 Overproduction of sodium retaining hormones
 Increased sodium intake
 Obesity
 Diabetes
 intake of sodium
 age
 family history
 smoking
 excess alcohol intake  A fall ib BP causes a pressurese sensitive neuron of the aortic arch and
carotic sinuses to release BARORECEPTORS. They will send impulses
2. Secondary Hypertension to the SNS activating the beta receptors in the heart causing an increase
 Is a high blood pressure caused by other condition or diseases. in cardiac output. Further, the presence of baroreceptors, stimulate the
 This type of hypertension accounts for 5% to 10% of hypertension release of alpha 1 adrenaline in the blood vessels causing vasoconstriction
in adults. and increase peripheral vascular resistance causing high BP.
 This can become resistant causing cardiovascular complications if
left untreated. Conditions that may cause secondary hypertension
includes:
 Kidney disease such as chronic renal failure, acute
glomerulonephritis.
 Adrenal diseases such Addison’s disease also known as
primary adrenal insufficiency and Cushing’s
syndrome. CUSHING’S SYNDROME - a hormonal
disorder caused by high level hormores cortisol in the body.
 Thyroid problems such as hyperthyroidism and
 Obstructive sleep apnea - is condition in which the
breathing stops involuntarily for brief periods of time during
sleep.

MECHANISM IN THE CONTROL OF BLOOD PRESSURE

 This will also help us further understand how the medication work.
 There are multiple organs involved in the control of blood pressure these
are heart, the blood vessels, kidneys, liver, and the lungs.
The two major processes involved in the control of blood pressure:
1. BARORECEPTORS AND A SYMPATHETIC NERVOUS
SYSTEM
- Baroreceptor are specialized mechanoreceptor in the walls of
the blood vessels.
- They send impulses to the SNS when changes in BP occurs.
- They communicate to the brain weather the blood pressure is
too low or too high so that does brain can adjust the blood flow
accordingly.
2. RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM (RAAS)
- Hormone that regulates BP and fluid/electrolyte balance and
systemic vascular resistance.
- It is a hormone system that regulates blood pressure and the
fluid and electrolytes. The RENIN-ANGIOTENSIN-
ALDOSTERONE also plays an important role in regulating
blood volume and systemic vascular resistance which together
influence cardiac output and atrial pressure.
THREE IMPORTANT COMPONENTS IN THE SYSTEM
1. Renin - released primarily by the kidney which stimulates the formation
of angiotensin in the blood and tissues which in turns stimulates the
release of aldosterone from the adrenal cortex.
2. Angiotensin
3. Aldosterone.
 As mentioned, the kidneys play an important role in the regulation of
blood volume. When BP falls, the pressure sensitive neuron in aortic
arch and carotid sinuses will release baroreceptors stimulating the beta
cells and baroreceptors found in the kidneys which will stimulate the
reease of RENIN.
 RENIN is a protease that converts angiotensinogen found in the liver to
angiotensin 1 which is converted to angiotensin 2 in the lungs by ACE
(angiotensin converting enzyme).
 Angiotensin 2 is a potent vasoconstrictor causing vasoconstriction of
arteries and veins resulting to increased vascular resistance, thus
increasing BP.
 The release of angiotensin 1 will stimulate the aldosterone secretion by
the kidneys causing Na reabsorption and increase blood volume, thus
increasing BP.
CLINICAL MANIFESTATIONS
 Hypertension is often called the silent killer because it is often
asymptomatic until it becomes severe and target organ disease occurs. A
patient with severe hypertension may have a variety of symptoms
secondary to the effects on the blood vessels in the various organs and
tissue or to the increase workload of the heart.
 fatigue
 dizziness
 angina or chest pain,
 dyspnea,
 Severe headache.

 One of the most important parameter in determining hypertension is the

blood pressure measurement. The blood pressure generally should be
measured in both arms to determine if there is a difference. It is important
to use an appropriate sized arm cuff.

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 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
MEDICAL MANAGEMENT TREATMENT
The goal of treatment for hypertension is to lower blood pressure and to
protect important organs like the brain, the kidneys from damage.
Medication that are commonly given are:
1. Alpha 1 beta blockers - which inhibit the smooth muscle contraction
causing a decrease in vascular resistance.
Example is processing. Further, it will block the stimulation of
 Alpha 1 receptor in the kidney suppressing the release of renin,
decrease angiotensin, and decrease aldosterone production resulting
in decreased blood pressure. Example: CARVEDILOL
2. Beta-blockers
- can be selected. Selective beta-blocker blocks the beta
receptors of the heart decreasing cardiac output thereby
decreasing blood pressure. An example of beta blockers
selective is METOPROLOL.
- Beta-blocker can be also be non-selective. This blocks the
alpha 1 receptor causing decreased cardiac output and
decreased vascular resistance causing increase blood pressure.
3. Centrally acting adrenergic drugs
- This blocks the sympathetic activity in the brain. Examples are
CLONIDINE AND METHYLDOPA. This also decreases the release
of catecholamine by the parasympathetic nervous system causing
decreased vascular resistant and cardiac output resulting to decrease
in blood pressure.
4. Calcium channel blockers
- This inhibits muscular contraction of the blood vessels which leads to
decreased vascular resistance or resistance to blood flow, thus lowering
blood pressure.
- Examples are AMLODIPINE AND NIFEDIPINE. Since this drugs
causes vasodilation, the side effects may include dizziness, edema,
swelling of gums and headache.
5. Diuretics
- This helps reducing the reabsorption of serum sodium in the kidneys
leading to significant dialysis resulting to less volume in the vascular
space thus decreasing cardiac output.
6. Ace Inhibitors
- Angiotensin Converting Enzyme Inhibitors
- This inhibits the conversion of angiotensin 1 to angiotensin 2. As
mention or your angiotensin 2 is a potent vasoconstrictor.
NURSING MANAGEMENT
1. Lifestyle changes or modifications
 Lose weight
 Quit smoking
 Healthy diet
 Reduce sodium and fats in the diet
 Regular exercise
 Limit or avoid alcohol intake
2. Compliance to medication
RHEUMATIC HEART DISEASE (RHD)
- Condition in which the heart valves are permanently damaged by
rheumatic fever.
- Result of untreated streptococcal infection such as sore throat or
scarlet fever.
- An immune response causes an inflammatory condition in the body
which can result in on-going valve damage.
- RHD is caused by rheumatic fever – an inflammatory disease that can
affect many connective tissue especially in the heart, joint, skin, or
brain.
- The heart valves can be inflamed and become scarred over time. This
can result in narrowing or leaking of the heart valve making it harder
for the heart to function normally. This may take years to develop and
can result in heart failure.
RISK FACTORS
 Children who get repeated strep throat infection
17
CLINICAL MANIFESTATION
1. fever
2. swollen, tender, red and painful joints particularly in the limbs and
ankle
3. nodules under the skin
4. red, raised, lattice-like rash usually in the chest, back, and abdomen
5. shortness of breath
6. chest discomfort
7. uncontrolled movements of arms, legs, or facial muscles
8. weakness
COMMON COMPLICATION
 CARDITIS- inflammation of the heart
DIAGNOSTICS
1. 2D echocardiogram - To show valvular insufficiency and peru
cardinal fluid or thickening
2. Chest X-ray - Show an enlargement of the heart
3. Electrocardiogram (ECG) - Longer PR interval
TREATMENT
1. Drug therapy
- Antibiotics doesn’t change the course of the acute disease or the
development of the the carditis, however it can eliminate residual
group A of streptococci in the tonsils and in the pharynx and prevent
the spread of microorganism to other persons
2. Supportive measures
- As what we have mentioned, supportive measures will help relieve
the different signs and symptoms
 NSAIDS
 Corticosteroids - these are anti-inflammatory agents use to
control fever and decreased joint pain and manifestation
- Treatments depend on how much damage has been done to the heart
valves
3. Mitral valve replacement
- Surgery to replace or re pair a badly damage valve
CONGESTIVE HEART FAILURE
 Cardiac failure of Heart Failure
 The inability of the heart to pump sufficient blood to meet the needs
of the tissues for oxygenation and nutrients.
 Heart failure doesn’t mean that the heart stop working rather it
means that the heart work less efficiently than normal due to the
various possible causes. Blood moves through the heart and the body
at a slow rate and the pressure in the increases. As a result, the heart
can’t pump enough oxygen and nutrients to meet the body’s needs.
 The chamber of the heart may respond by stretching to hold more
blood to pump through the body or becoming stiff or thickened, this
helps the body moving but the heart muscles walls may eventually
weakened and will not be able to pump efficiently. And this is formally
known as CONGESTIVE HEART FAILURE
ETIOLOGIC FACTORS
1. CORONARY ARTERY DISEASE
- This occurs when the cholesterol and fatty deposits build up in the
heart arteries, less blood can reach the heart. This build up is known
as ASTEROCLEROSIS.
2. PAST HEART ATTACK (MI)
- Wherein, the part of the muscle tissue essentially dies.
3. HIGH BLOOF PRESSURE (HTP or HBP)
- Uncontrolled HBP is a major risk factor for developing heart failure,
when the pressure in the blood vessel is too high, the heart must pump
harder than normal to keep the blood circulating.
4. ABNORMAL HEART VALVES
- When the heart doesn’t open or close completely during each
heartbeat, the heart muscle has to pump harder to keep the blood
moving. If the workload becomes still great, heart failure will result
 NCM 112 - MIDTERM
CARE OF CLIENTS W/ PROBLEMS IN OXYGENATION, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE & CHRONIC
Prof. Joyce C. Bisnar RN, RM, MAN
 Enlarged liver and spleen
o May be secondary to chronic pulmonary problems
 Distended jugular veins
 Anorexia and other gastrointestinal distress
 Weight gain caused by edema.

DIAGNOSTIC TESTS
 Chest X-ray to check lung condition, this is to identify if congestive
heart failure is right sided or left sided.
 Echocardiogram or 2d echo, it helps determine the ejection
fraction of the heart and how well the heart is functioning?
 Central Venous Pressure (CVP), it is a blood pressure in the vena
cave near the right atrium of the heart.
o it is usually elevated in right sided heart failure
o CVP test the amount of blood returning to the heart and the
ability of the heart to pump the blood back into the arterial
CHF CAN BE:
system
1. LEFT SIDED HEART FAILURE  Electrocardiogram (ECG)
 Stress test
- The most common Heart Failure
- Usually occurs when the oxygenated blood from the left ventricle
MEDICAL MANAGEMENT
cannot pump the blood out in the chamber causing the blood to backup
1. Angiotensin-converting enzyme or (ACE) inhibitors
or return to the lungs resulting to respiratory problems or signs and
symptoms such as: - It causes vasodilation by inhibiting the conversion of angiotensin
I to angiotensin II
 Paroxysmal nocturnal dyspnea it is difficulty of breathing that
- (Angiotensin II) is a potent vasoconstrictor
worsens at night.
 Elevated pulmonary capillary wedge pressure 2. Angiotensin II receptor blockers
 Pulmonary congestion which may be manifested by - The action of this medication is almost exactly the same with
o Cough Angiotensin-converting enzyme or (ACE) inhibitors.
o Crackles - It is also causes vasodilation
o Wheezes
- It is an alternative for people who can’t tolerate ACE inhibitor.
o Blood-tinged sputum
o Tachypnea.
4. Beta blockers
 Restlessness - Inhibit smooth muscle contraction causing a decrease in vascular
 Confusion brought about by lack of oxygen in the brain resistance
 Orthopnea is difficulty of breathing when lying down
 Tachycardia results from the overwork load of the heart to 5. Diuretics
compensate for the need of oxygen. - Also called as the water pills.
 Exertional dyspnea - It reduces the reabsorption of serum sodium in the kidneys leading
 Fatigue to decrease volume in the vascular space thus decreasing cardiac
 Cyanosis is due to lack of circulating oxygenated blood Since output.
most of the blood oxygenated by the lungs returns to the lungs
instead to the aorta for circulation Nursing Management
1. Auscultate the lungs
- Check for the presence of crackles, wheezes, and S3 heart sounds
2. Promote physical activities
- A total of 30 minutes of physical activity everyday should be
encouraged
- The nurse and the physician should collaborate to develop a
schedule that promotes ___________ and prioritization of
activities
3. Decrease anxiety
- The nurse should promote physical comfort and provide
psychological support and begin teaching ways to control anxiety
and avoid anxiety provoking situations or conditions.
4. Manage fluid volume
- Patient’s fluid statue should be monitored closel. Auscultating the
lungs, monitoring daily body weight and assisting the patient to
adhere to a low sodium diet.
6. Prevent complications
- It is very important that we have to educate the patient on the
importance of compliance to medication and other treatment, this
2. RIGHT SIDED HEART FAILURE / RIGHT SIDED CARDIAC
is to prevent complications.
FAILURE

- Right sided heart failure usually occurs when the right side of the
heart cannot eject blood and cannot accommodate all the blood that
normally returns to it from the venous circulation.
- Instead of pushing the blood into the pulmonary artery for
oxygenation, some of the unoxygenated blood return to the
circulation causing the following SIGNS AND SYMPTOMS:
 Fatigue
 Increased peripheral venous pressure
 Ascites

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