NCMA 113 – RESPIRATORY AND NURSING CARE

COVERAGE: LUNGS
 Introduction - The human body has two lungs which are the
 Process of Respiration right lung and the left lung.
 Structure of Respiratory System - The lungs share space in the thoracic, or chest
 The Act of Breathing cavity, of the human body with the heart which lies
 Muscle Movement between the left and right lungs, as shown in the
 Factors Affecting the Respiratory System picture above, and above the diaphragm which is
 Assessing the Respiratory System the major breathing muscle of the body and at the
 Respiratory Treatment level of the first rib of the body.
- Like the heart, the lungs are protected with boney
structures like the ribs and the spine.
INTRODUCTION o LEFT LUNG
- Oxygen, a clear, odorless gas that constitutes - Two lobes – superior and inferior
approximately 21% of the air we breathe, is - One fissure – oblique
necessary for proper functioning of all the living - Cardiac notch
cells. - Lingula (like tongue portion of the upper lobe
- The absence of oxygen can lead to cellular, between cardiac notch and oblique fissure)
tissue, and organism death. o RIGHT LING
- Respiration is the process of gas exchange - Three lobes – superior, middle and inferior
between the individual and environment. - Two fissures – horizontal and oblique
- Shorter, wider and heavier compared to left
PROCESS OF RESPIRATION - Deeper diaphragmatic surface due to presence
1. Pulmonary ventilation or breathing: the movement of liver
of air between the atmosphere and the alveoli of - Liver
the lungs as we inhale and exhale
2. Gas exchange, which involves diffusion of oxygen THE ACT OF BREATHING
and carbon dioxide between the alveoli and  Inhalation – the intake of air into the lungs through
pulmonary capillaries expansion of chest volume
3. Transport of oxygen from the lungs to the tissues,  Exhalation – the expulsion of air from the lungs
and carbon dioxide from the tissues to the lungs through contract of chest volume
- The respiratory system is the system in the o Inhalation and exhalation involves muscles
human body that enables us to breathe o Changes in chest volume during inhalation and
exhalation – note that it only shows the
STRUCTURE OF RESPIRATORY SYSTEM movement of the diaphragm, not that of the rib
1. Upper Respiratory Airway muscles.
a. Nasal Cavity 1. Rid muscles = muscle between the ribs in the
b. Pharynx chest
c. Larynx 2. Diaphragm muscle
2. Lower Respiratory Airway
a. Trachea MUSCLE MOVEMENT
b. Bronchi The diaphragm and rib muscles are constantly
c. Alveoli contracting and relaxing (approximately 16 times per
minute), thus causing the chest cavity to increase and
FLOW OF AIR DURING INSPIRATION decrease.
 Nose or mouth Inhalation and exhalation are involuntary and therefore
 Pharynx their control requires an effort.
 Larynx During inhalation – the muscles contract
 Trachea - Contraction of the diaphragm muscle – causes
 The right or left bronchi of the lung the diaphragm to flatten, thus enlarging the chest
 Bronchioles of the lungs cavity.
 Alveoli of the lungs - Contraction of the rib muscles – causes the ribs
to rise, thus increasing the chest volume. The

MG_23 | 1
 NCMA 113 – RESPIRATORY AND NURSING CARE

chest cavity expands, thus reducing air pressure
and causing air to be passively drawn into the
lungs. Air passes from the high pressure outside
the lungs to the low pressure inside the lungs.
During exhalation – the muscles relax
- The muscles are no longer contracting, they are
relaxed.
- The diaphragm curves and rises, the ribs descend
– and chest volume decreases. The chest cavity
contracts thus increasing air pressure and causing
the air in the lungs to be expelled through the
upper respiratory tract. Exhalation, too, is passive.
Air passes from the high pressure in the lungs to
the low pressure in the upper respiratory tract.
RESPIRATORY SYSTEM – ILLUSTRATION
ASSESSING THE RESPIRATORY SYSTEM
Assess the client for signs and symptoms of respiratory
changes:
 Complaints of shortness of breath (dyspnea)
 Bluish or cyanotic appearance of the nail beds, lips,
mucous membranes and skin
 Restlessness, irritability, confusion, decreased level
of consciousness
 Pain during inspiration and expiration
 Labored or difficult breathing
 Orthopnea
 Use of accessory muscles
 Abnormal breath sounds such as wheezes, rhonchi
or rales
 Inability to breathe spontaneously
 Thick, frothy, blood-tinged or copious sputum
production
 Paradoxical chest wall movement

RESPIRATORY TREATMENT
OXYGEN THERAPY
I. Purpose
- To relieve hypoxia and provide adequate tissue
oxygenation.
II. Clinical Indications
A. Any client who is likely to have significant shunt
from:
o Fluid in the alveoli.
a. Pulmonary edema
FACTORS AFFECTING THE RESPIRATORY SYSTEM b. Pneumonia
HMEALS c. Near-drowning
 Health status = diseases in the respiratory system d. Chest trauma
can affect respiratory function o Collapsed alveoli (atelectasis)
 Medications = anti-anxiety drugs and sedative- a. Airway obstruction
hypnotics can decrease the rate and depth of 1. Any client who is unconscious
respirations. (Ex. Diazepam (Valium), Flurazepam 2. Choking
(Dalmane), Barbiturates (Phenobarbital) b. Failure to take deep breaths
 Environment = altitude, heat, cold and air pollution 1. Pain (rib fracture)
affect oxygenation 2. Paralysis of the respiratory muscles (spine
 Age = increase in newborn, slows until adulthood injury)
and decreases for elderly o Depression of the respiratory center (head
 Lifestyle = increase due to physical exercise/ injury, drug overdose)
activity; occupations can predispose individual to a. Collapse of an entire lung (pneumothorax)
lung diseases. Silicosis (sandstone blasters and b. Other gases in the alveoli
potters), asbestosis (asbestos workers), anthracosis c. Smoke inhalation
(coal miners), organic dust disease (farmers/ d. Toxic inhalations
agricultural workers) e. Carbon monoxide poisoning
 Stress = some hyperventilate when stressed, when o Respiratory arrest
stress continues this increase the risk of B. Cardiac arrest
cardiovascular disease C. Shock
D. Shortness of breath
E. Signs of respiratory insufficiency

MG_23 | 2
 NCMA 113 – RESPIRATORY AND NURSING CARE
F. Breathing fewer than 10 times per minute
G. Chest pain
H. Stroke
I. Anemia
III. Precautions:
A. Clients with COPD should receive oxygen at low
flow rates (usually 1 to 3 L/min), to prevent
inhibition of hypoxic respiratory drive.
B. Excessive amounts of oxygen for prolonged
periods of time will cause retrolental fibroplasia
and blindness in infants who are premature.
C. Oxygen delivered without humidification will
result in drying and irritation of respiratory
mucosa, decreased ciliary action, and thickening
of respiratory secretions.
D. Oxygen supports combustion, and fire is a
potential hazard during its administration.
o Ground electrical equipment.
o Prohibit smoking.
o Institute measures to decrease static
electricity.
E. High flow rates of oxygen delivered by
ventilator or cuffed tracheostomy and
endotracheal tubes can produce signs of oxygen
toxicity in 24 to 48 hours:
o Cough sore throat, decreased vital capacity,
and substernal discomfort.
o Pulmonary manifestations due to:
a. Atelectasis
b. Exudation of protein fluids into alveoli
c. Damage to pulmonary capillaries
d. Interstitial hemorrhage
IV. Oxygen Administration:
A. Oxygen is dispensed from cylinder or piped-in
system.
B. Methods of delivering oxygen:
1. Nasal prongs/cannula
- Comfortable and simple, and allows
client to move about in bed
- Delivers 25% to 40% oxygen at flow
rates of 4 to 6 L/min
- Difficult to keep in position unless client
is alert and cooperative
2. Venturi mask
- Allows for accurate delivery of
prescribed concentration of oxygen
- Delivers 24% to 50% oxygen at flow
rates of 4 to 8 L/min
- Useful in long-term treatment of COPD.
3. Simple O2 face mask
- Poorly tolerated—used for short
periods of time; feeling of “suffocation.”
- Delivers 50% to 60% oxygen at flow
rates of 8 to 12 L/min
- Significant rebreathing of carbon
dioxide at low oxygen flow rates
- Hot—may produce pressure sores
around nose and mouth
4. Non-rebreather reservoir mask
- Reservoir bag has one-way valve
preventing the client from exhaling
back into the bag
- Oxygen flow rate prevents collapse of
bag during inhalation
- Delivers 90% to 95% oxygen at flow
rates of 10 to 12 L/min
- Ideal for severe hypoxia, but client may
complain of feelings of suffocation
5. T-tube
- Provides humidification and enriched
oxygen mixtures to tracheostomy or
endotracheal tube
- Delivers up to 100% oxygen at flow
rates at least twice the minute
ventilation
V. Intubation and Mechanical Ventilation:
A. Indications:
- Apnea
- Inadequate upper airway or inability to
clear secretions
- Worsening respiratory acidosis (PaCO2
greater than 50 mm Hg) and
hypoventilation
- PaO2 less than 55 mm Hg
- Absent gag reflex
- Heavy sedation or paralysis
- Imminent respiratory failure
(respiratory rate less than 8 to 10
breaths/min or greater than 30 to 40
breaths/min)
- Chest wall trauma
- Profound shock
- Controlled hyperventilation (e.g.,
increased ICP)
B. Types of positive-pressure ventilators:
- Pressure cycled—gas flows into the
client until a predetermined airway
pressure is reached. Tidal volume is not
constant
- Time cycled—gas flows for a certain
percentage of time during ventilatory
cycle
MG_23 | 3
 NCMA 113 – RESPIRATORY AND NURSING CARE

- Volume cycled—most common Oropharyngeal and Nasopharyngeal suctioning

ventilators used; tidal volume is  Assess indications for suctioning:
determined, and a fixed volume is o audible secretions during respiration
delivered with each breath o adventitious breath sounds
C. Ventilator modes:  Position
- Controlled—machine delivers a breath o Conscious: Semi- fowler’s
at a fixed rate regardless of client’s o Unconscious: Lateral
effort or demands  Pressure of suction equipment to prevent
- Assist-controlled—machine senses a trauma to mucous membrane of airways
client’s efforts to breathe and delivers a  Appropriate size of sterile suction catheter
fixed tidal volume with each effort SIZE OF WALL UNIT PORTABLE
- Intermittent mandatory ventilation CATHETER UNIT
(IMV)— breaths are delivered by the ADULT Fr. 12-18 100-120 10-15 mmHg
machine, but the client may also mmHg
breathe spontaneously without CHILD Fr. 8-10 95-110 5-10 mmHg
machine assistance mmHg
- Pressure support—client breathes INFANT Fr. 5-8 50-95 mmHg 2-5 mmHg
spontaneously and determines  Don sterile gloves (sterile technique)
ventilator rate. Tidal volume  Length of catheter
determined by inflation pressure and o Nose-Earlobe (13 cm) or 5 inches
client’s lung-thorax compliance.  Lubricate
D. Minute ventilation—determined by the o Naso- water soluble lubricant
respiratory rate and the tidal volume. A o Oro- sterile water or NSS
respiratory rate of 10 to 15 breaths/min is
considered appropriate. Close monitoring is
required to achieve desired (not necessarily
normal) PaCO2.
E. Positive end-expiratory pressure (PEEP)—
maintenance of positive airway pressure at the
end of expiration. Applied in the form of
continuous positive airway pressure (CPAP) for
the client breathing spontaneously or
continuous positive-pressure ventilation (CPPV)
for the client receiving mechanical breaths.
Applied in 3- to 5-cm H2O increments. Levels
greater than 10 to 15 cm H2O are associated
with cardiovascular dysfunction and
hemodynamic compromise

Suctioning

MG_23 | 4
 NCMA 113 – RESPIRATORY AND NURSING CARE

rapid heart rate which can indicate hypoxemia

or suddenly bloody secretions which can
indicate damage to the mucosa.
 Can lead to trauma to airways, nosocomial
infection, cardiac dysrhythmia, hypoxia and
even death.
 Decrease complications by:
o Hyperinflation
o Hyperoxygenation
o Hyperventilation
o Gently rotate catheter, withdraw while
suctioning, suction for 5-10 seconds
 Can irritate the mucosa.
 Removes oxygen from the respiratory tract
possibly causing hypoxemia (insufficient oxygen
in blood)
 Important to oxygenate the pt. before
suctioning, by applying supplemental O2 and
taking deep breaths.
 When performed correctly, provides comfort by
relieving respiratory distress.
 When performed incorrectly, can increase
anxiety and pain and cause respiratory arrest.
 Uncomfortable procedure, can be painful.

 Indicated to maintain a patent airway and to

remove saliva, pulmonary secretions, blood,
vomitus, or foreign material from the pharynx.
 Suctioning of the nasopharynx or oropharynx
may be indicated if the pt. is able to raise
secretions from the airways but unable to clear
from the mouth, or suctioning of the tracheal
when unable to raise secretions from the
airways.
 Frequency varies with amount of secretions, but
should be done often enough to keep
ventilation effective and as effortless as
possible.
 Wear gloves, googles and mask, and gown if
necessary.
 Aspirating secretions through a catheter
connected to suction machine or wall suction
outlet.
 Assess for signs of respiratory distress.
 Asses for client inability to cough up and
expectorate secretions, dyspnea, poor skin
color, bubbling or rattling breath sounds,
decreased O2 saturation.
 Monitor pt.’s color and heart rate, color,
amount and consistency of secretions. Stop
immediately, administer O2 and notify
physician if pt. is cyanotic, excessively slow or

MG_23 | 5