Nursing Care of Clients with

Gas Exchange Disorders

DR. MARIA LOURDES CULLA – BAÑAGA RN, MAN

ASSOCIATE PROFESSOR
 PLEURA
• Parietal Pleura – lines the thoracic wall and
superior aspect of the diaphragm
• Visceral Pleura – Covers the lung
• Pleural cavity – Or the space between the
two layers contains a thin layer of
serous fluid
 Bronchiectasis
Permanent enlargement of parts of the airways of the
lungs. Symptoms typically include a chronic cough
productive mucus

Pathophysiology
❑ Chronic infection
❑ Dilation of One or more
❑ Large bronchi
❑ Airway obstruction
Etiology
❑ Secondary to CHF, Asthma, TB
 Bronchiectasis
Signs and Symptoms
❑ Dyspnea = sudden shortness of breath, or
breathing difficulty
❑ Cough
❑ Large amounts of sputum
❑ Anorexia
❑ Recurrent infection
❑ Clubbing
❑ Crackles and wheezes
 Bronchiectasis
Diagnosis
❑ X ray
❑ CT scan
❑ Sputum culture
❑ Test to find underlying cause
Therapeutic intervention
❑ Antibiotics
❑ Mucolytics, Expectorants
❑ Chest Physiotherapy
❑ Oxygen
❑ Surgical Resection
 Pneumonia
Pathophysiology
❑ Acute Lung Infection
❑ Inflammation and alveolar damage
❑ Alveoli filled with exudate
❑ Reduced surface area for gas exchange
Etiology
❑ Bacteria, usually streptococcus pneumoniae
❑ Virus
❑ Fungus
❑ Aspiration
❑ Artificial ventilation (VAP)
❑ Hypostasis
❑ Chemical
 Pneumonia
Prevention
❑ Pneumococcal Vaccine
❑ Flu vaccine
❑ Coughing and deep breathing
❑ Hand washing
❑ Frequent mouth care, continuous suction for
ventilator associated pneumonia
 Pneumonia
Signs and Symptoms
❑ Chest pain
❑ Fever, chills
❑ Cough, dyspnea
❑ Yellow, rusty or Blood – tinged sputum
❑ Crackles, wheezes
❑ Malaise
 Pneumonia
Signs and Symptoms in Elderly
New Onset
❑ Confusion
❑ Lethargy
❑ Fever
❑ Dyspnea
 Pneumonia
Complications
❑ Pleurisy = is an inflammation of the lining of the
lungs and chest (the pleura) that leads to chest
pain when you take a breath or cough
❑ Pleural effusion = excess fluid accumulates in the
pleural cavity, the fluid filled space that surrounds
the lungs. This excess can impair breathing by
limiting the expansion of the lungs
 Pneumonia
❑ Atelectasis = the collapse or closure of a lung
resulting in reduced or absent gas exchange. It
may affect part or all of a lung. It is usually
unilateral

❑ Spread of infection
 Pneumonia

Diagnosis
❑ Chest x ray
❑ Sputum culture
❑ Blood culture
 Pneumonia
Therapeutic Interventions
❑ antibiotic – PO or IV
❑ Antiviral medication (zovirax)
❑ Bronchodilators = open up (dilate) the breathing
passages by relaxing the bronchial smooth muscle
❑ Expectorants = increase bronchial secretions and make
it easier to cough up mucus from the airways and lungs
❑ Oxygen
❑ Fluids – Fluids help minimize mucosal drying and
maximize ciliary action to move secretions. Encourage
increased fluid intake of up to 3000 ml / day
( Some clients cannot tolerate increased fluids because of
underlying disease)
 Tuberculosis
Pathophysiology
❑ AFB Implant or Bronchioles or Alveoli = AFB stands
for Acid Fast Bacilli. It is a test used to diagnosed
Tuberculosis. A sputum specimen is obtained and
tested for AFB. If the specimen is negative, it helps
rule out TB. There are other tests that are also used
in combination with this test to diagnose
Tuberculosis including a chest X ray
 Tuberculosis
Pathophysiology

❑ Tubercle Formed = the bacillus spreads slowly

and widely in the lungs, causing the formation
of hard nodules (tubercles) or large cheese like
masses that break down the respiratory
tissues and form cavities in the lungs.
 Tuberculosis
Pathophysiology
❑ Immune System Keeps in Check = Typically, M.
Tuberculosis remains dormant – immune
system keeps it in check (latent tuberculosis).
If the immune system compromised,
reactivation occur. Active disease classically
presents with fever, weight loss, night sweats
and productive cough ( with or without
hemoptysis) that does not respond to
conventional antibiotic therapy
❑ 5% to 10% Infected become ill
❑ May activate with impaired immunity
 Tuberculosis
At Risk

❑ Elderly
❑ Alcoholics
❑ Those living in crowded conditions
❑ Mew immigrants
❑ Those with HIV
 Tuberculosis
Signs and Symptoms
❑ Cough
❑ Blood tinged sputum
❑ Night sweats
❑ Anorexia and weight loss
❑ Low grade fever
❑ Dyspnea, chest pain (late)
 Tuberculosis
Diagnostic Tests
❑ PPD skin test
❑ Chest X ray
❑ Sputum cultures
❑ QuatifFERON – TB Gold – simple blood test, aids in
detection of Mycobacterium tuberculosis, QTF is an
interferon – gamma (IFN-Y) release assay and used
as modern alternative to TB skin test (TST, PPD on
Mantoux). QTF is highly specific and sensitive: a
positive result is strongly predictive of true infection
with M. Tuberculosis. It cannot distinguish between
active tuberculosis disease and latent
 TB Diagnosis
❑ A definite diagnosis of tuberculosis can only be made by
culturing Mycobacterium Tuberculosis organism from a
specimen taken from the patient (most often sputum,
but may also include pus, CSF, biopsied tissue). A
diagnosis made other than by culture may only be
classified as “ probable” or “presumed”
❑ The Mantoux tuberculin skin test (TST) or TB blood test
can be used to test for M. Tuberculosis infection.
Additional test are required to confirm TB disease.
 TB Diagnosis
❑ A posterior – anterior chest radiograph is used to detect
chest abnormalities. However, a chest radiograph may be
used to rule out the possibility of pulmonary TB in a
person who has had a positive reaction to a TST or TB
blood and no symptoms of disease
❑ The presence of acid – fast - bacilli (AFB) on a sputum
smear or other specimen often indicates TB disease, but it
does not confirm a diagnosis of TB because some acid-
fast- bacilli are not M. Tuberculosis. A positive culture for
M. Tuberculosis confirms the diagnosis of TB disease.
 Tuberculosis
Therapeutic Interventions

For all patients, the initial M. Tuberculosis isolate

should be tested for drug resistance
❑ Combination of Drugs for 6 to 24 months
• INH
• Rifampicin
• Streptomycin
• Ethambutol
 Tuberculosis
Therapeutic Interventions
❑ Occasional Surgical Removal – surgery is rarely used
to treat TB; it may be used to treat extensively drug-
resistant TB (XDR – TB) or to treat complications of an
infection in the lungs or another part of the body.
When used: it can help repair lung damage like serious
bleeding that can’t be stopped other ways, or for
repeated lung infections other than TB or to remove a
pocket of bacteria that cannot be killed with long-term
medicine treatment.
❑ Isolation
 Nursing Diagnosis:
Lower Respiratory Disorders

❑ Impaired Gas Exchange

❑ Ineffective Airway Clearance
❑ Ineffective Breathing Pattern
❑ Activity Intolerance
 Impaired Gas Exchange
❑ Monitor ❑ Position
• Lung Sounds, • Fowler’s
Respiratory Rate and • Good Lung Down
effort ❑ Administer Oxygen
• Dyspnea ❑ Teach Breathing Exercises
• Mental Status ❑ Discourage Smoking
• SpO2, ABGs
 Ineffective Airway Clearance
❑ Monitor ❑ Administer Expectorants
• Lung sounds ❑ Turn every 2 hours Daily or
• Sputum ambulate
❑ Encourage ❑ Suction PRN
• Fluids ❑ Consider CPT or Mucus
• Deep Breathing Clearance Device
• Coughing
 Ineffective Breathing Pattern
❑ Monitor ❑ Position
• Respiratory Rate, Depth, ❑ Teach Diaphragmatic Breathing
Effort
• ABGs, SpO2
❑ Determine / Treat Cause
 Activity Intolerance
❑ Monitor Response to ❑ Allow Rest between activities
Activity ❑ Obtain Bedside commode
• Vital signs ❑ Increase Activity slowly
• SpO2 ❑ Refer to Pulmonary
❑ Use Portable O2 for Rehabilitation
Ambulation
 Additional Diagnosis for TB
❑ Risk for ineffective self health management
❑ Teach patient and family
• Consider visiting nurse / DOT
❑ Risk for infection transmission
• Teach patient and family
• Maintain isolation precautions
 Prevention of TB Spread

❑ Clean, well ventilated living areas

❑ Isolation of patients who have active TB
❑ High efficiency filtration masks
❑ Gowns, gloves, goggles if contact with sputum
likely
 Restrictive Disorders
❑ Diseases that restrict lung expansion, resulting in a
decreased lung volume, an increased work of
breathing and inadequate ventilation and / or
oxygenation
❑ Examples of restrictive lung diseases: Asbestosis,
Sarcoidosis and Pulmonary Fibrosis
❑ Reduced Compliance – the lung’s ability to stretch
and expand
❑ Limited Chest wall expansion
 Pleurisy

❑ Pathophysiology
• Inflammation of Visceral and Parietal Pleurae
• Friction Between Pleurae on Inspiration
❑ Etiology
• Secondary to Pneumonia, TB, CA, PE
 Pleurisy
Signs and Symptoms
❑ Sharp pain on inspiration
❑ Shallow breathing
❑ Fever, elevated WBC
❑ Friction Rub
Therapeutic Interventions
❑ Pain management
❑ Treat underlying causes
Diagnostic Tests
❑ Chest X ray
❑ CBC
❑ FVC, FEV1= The FEV1 ratio, also
called Tiffeneau-Pinelli index, is a
calculated ratio used to diagnose
obstructive and restrictive lung
disease.
❑ It represents the proportion of a
person’s vital capacity that they are
able to expire in the first second of
forced expiration to the full vital
capacity
❑ Test to determine Cause
 PLEURAL EFFUSION - FLUID
IN THE PLEURAL CAVITY

• Hydrothorax – Serous fluid

• Empyema – Pus
• Chylothorax – Lymph
• Hemothorax - Blood
❑ Pathophysiology
• Excess fluid between visceral and parietal
pleurae ( Parietal pleura is the pleura which lines
the inside of the chest wall. Visceral pleura is the
pleura which covers the surface of the lung)
• Pleural fluid not reabsorbed
• May collapse lung
 Etiology
❑ Transudative – In transudative effusions, fluid
pressure in the blood vessels increases; and pressure
exerted by blood proteins, such as albumin, may also
be decreased. These circumstances may cause fluid
from the blood vessels to move into the pleural
space; most common causes of transudative pleural
effusions in the United States are heart failure and
cirrhosis. Systemic issue
• Heart failure
• Liver or Kidney Disease
 Etiology
❑ Exudative – a buildup of protein-rich fluid in
the cavity around the lungs, caused by local
injuries to the tissue in and around the lungs;
impairs breathing by limiting the expansion of
the lungs. Common causes are Cancer,
trauma, infections
• Pneumonia
• TB
• CA
 Pleural Effusion
Signs and Symptoms Diagnostic Tests
❑ Dyspnea ❑ Analgesics
❑ Pain ❑ Chest x ray
❑ Cough ❑ Thoracentesis – invasive
❑ Tachypnea procedure to remove fluid or air
❑ Diminished Lung Sounds from the pleural space
❑ Chest tube
❑ Test to determine cause
 Pulmonary Fibrosis
Lungs become scarred, thickened, stiff tissue,
they are damaged. The accumulation of excess
fibrous connective tissue, leads to thicken of the
the walls and causes reduced oxygen supply in
the blood
 Pulmonary Fibrosis

❑ Pathophysiology ❑ Etiology
• Injury to alveoli • Heredity
• Scarring, Fibrosis • Virus
• Impaired Gas Exchange • Environmental / Occupational
Exposure
❑ Signs and Symptoms • Immune Dysfunction
• Progressive Dyspnea • Idiopathic
• Crackles
• Chronic Cough
• Clubbing
 Diagnosis
❑ Chest X ray
❑ CT Scan
❑ Bronchoscopy – examines the lower airways,
including the larynx, trachea, bronchi and
bronchioles; used to examine the mucosal surface
of the airways for abnormalities that might be
associated with a variety of lung diseases
❑ Lung Biopsy
❑ ANA Titer – A positive ANA Titer blood test
indicates the presence of an autoimmune disease
 Therapeutic Interventions
❑ Glucocorticoids - to stop the inflammation resulting
in tissue damage, prednisone
❑ Immune Suppressants – azathioprine or
cyclophosphamide to slow progression of lung
scarring
❑ Smoking Cessation
❑ Oxygen
❑ Flu / Pneumonia Vaccines
❑ Pulmonary Rehabilitation
❑ Lung transplant
 Atelectasis

❑ Pathophysiology ❑ Etiology
• Collapse of Alveoli – Atelectasis • Hypoventilation
is a collapse of lung tissue
affecting part or all of one lung.
Tiny sacs in your lungs, called
alveoli, don’t inflate
 Atelectasis
❑ Collapse or airless condition of alveoli caused by
hypoventilation, obstruction to airways, or
compression
❑ Causes: bronchial obstruction by secretions due
to impaired cough mechanism or conditions that
restrict normal lung expansion on inspiration
❑ Postoperative patients at high risk
 Atelectasis

❑ Symptoms: insidious, include cough,

sputum production, low grade fever
❑ Respiratory distress, anxiety, symptoms of
hypoxia occur if large areas of lung are
affected
 Atelectasis
Signs and Symptoms Therapeutic Interventions
❑ Fine crackles ❑ Prevention
❑ Diminished Breath Sounds • Cough and Deep Breathe
❑ Dyspnea • Incentive Spirometer
• Turn
• Ambulate
 Nursing Diagnosis:
Restrictive Disorders

❑ Impaired Gas Exchange

❑ Ineffective Breathing Pattern
❑ Acute Pain
 Obstructive Disorders

❑ Airway Obstruction
❑ Difficult Exhalation
AIRWAY OBSTRUCTION IN ASTHMA
• Inflammatory Mediators
➢ Airway Inflammation
- Increased mucociliary function
- Edema
- Epithelial Injury
➢ Increased Airway Responsiveness
- Bronchospasm
- Airflow limitation
 EXTRINSIC (ATOPIC) ASTHMA
• Type I Hypersensitivity
• Allergen
- Mast cells release inflammatory mediators
Cause acute response within 10 to 29 minutes
- WBCs enter region and release more
inflammatory mediators
• Airway inflammation causes late phase response in
4 to 8 hours
INTRINSIC (NONATOPIC) ASTHMA
• Respiratory Infections
- Epithelial damage, IgE production
• Exercise, hyperventilation, cold air
- Loss of heat and water may cause bronchospasm
• Inhaled irritants
- Inflammation, Vagal reflex
• Aspirin and other NSAIDs
- Abnormal arachnoid acid metabolism
 Asthma
❑ Pathophysiology
• Inflames and narrows the
airways
- Inflammation of Bronchial
Mucosa
- Spasm of Bronchial Smooth
Muscles
- Air Trapping
- Usually Reversible
- Airway remodeling – Asthma is a
chronic disease that can lead to
permanent lung damage. Permanent
changes in the airways appear to
result from repeated asthmatic
events causing recurrent bouts of
inflammation of the bronchi, which
in turn can ultimately led to airway
fibrosis (scarring) and permanent
narrowing of the airways (
remodeling)
 Asthma

Etiology Triggers
❑ Heredity ❑ Smoking
❑ Airborne Allergies ❑ Allergens
❑ Pollution ❑ Infection
❑ Smoking ❑ Sinusitis
❑ Stress
❑ GERD
 Asthma
Signs and Symptoms Complication
❑ Dyspnea ❑ Status Asthmaticus
❑ Wheezing • Severe, Sustained Asthma
❑ Cough • Worsening Hypoxemia
❑ Sputum • Respiratory Alkalosis Progresses
❑ Use of accessory muscle to Respiratory Acidosis
❑ May be worse at night • May be life threatening
 Asthma

Diagnostic Tests Therapeutic Interventions

❑ History and physical ❑ Monitor with Peak Flow Meter
examination ❑ Avoid Triggers
❑ Spirometry – measuring ❑ Avoid Smoking
of breath
❑ ABGs
❑ Allergy skin testing
 Therapeutic Interventions
Bronchodilators
❑ Adrenergic (Albuterol) beta2 – dilates bronchi by
a direct action on the beta2- receptors on the
bronchial smooth muscle to relax the muscles
❑ Leukotriene Inhibitors ( Accolate, Singular) not
used for acute asthma attacks; helps reduce
inflammation in airways, inhibits leukotriene
production
 Therapeutic Interventions
❑ Leukotriene, causes nasal passages to swell and
make excess mucus. It is also responsible for
tightening airways in an asthma attack, making it
harder to breathe.
❑ Theophylline ( Rare) bronchodilator – relaxes
muscles in lungs and chest, making the lungs less
sensitive to allergens and other causes of
bronchospasm; used to treat symptoms such as
wheezing or shortness of breath caused by
asthma, bronchitis, emphysema and other
breathing problems

Beta 1 heart Beta 2 Lungs ( 1 heart, 2 lungs)

 Therapeutic Interventions
❑ Corticosteroids - decrease inflammation
• Inhaled, IV, PO
❑ Mast Cell Inhibitors (Exercise Induced) – stops release
of histamine and related mediators; used to prevent
or control certain allergic disorders. Blocks mast cell
degranulation, stabilizing the cell
❑ Antihistamine
❑ Oxygen PRN
 CHRONIC OBSTRUCTIVE
PULMONARY DISORDERS
• Emphysema
- Enlargement of air spaces and destruction of
lung tissue
• Chronic bronchitis
- Obstruction of small airways
• Bronchiectasis
- Infection and inflammation destroy smooth
muscle in airways permanent dilation
 Pathophysiology
❑ Chronic Bronchitis
• Chronic inflammation
• Low grade infection
• Hypertrophied Mucus Glands in
Bronchi
• Impaired Ciliary Function
• Ineffective Airway Clearance
❑ Diagnosed after ILL 3 months of
year for 2 consecutive years
❑ Emphysema
• Destruction of Alveolar Walls
• Loss of Elastic Recoil
• Damage to Pulmonary Capillaries
• Air trapping
• Impaired gas Exchange
 MECHANISM OF COPD
• Inflammation and fibrosis of the bronchial wall
• Hypertrophied mucous glands excess mucus
- Obstructed airflow
• Loss of alveolar tissue
- Decreased surface area for gas exchange
• Loss of elastic lung fibers
- Airway collapse, obstructed exhalation, air
trapping
 COPD Etiology
❑ Smoking
❑ Passive Smoke Exposure
❑ Pollutants
❑ Familial Predisposition
❑ A1AT Deficiency ( Emphysema) – Alpha 1 antitrypsin
deficiency6 is a genetic disorder that may result in
lung diseases or liver disease. Onset of lung
problems is typically between 20 to 50 years old.
This may result in shortness of breath, wheezing or
an increase risk of lung infections. Complications
may include COPD
Signs and Symptoms

❑ Cough
❑ Sputum production
❑ Dyspnea
❑ Prolonged expiration
❑ Barrel Chest –trapped air
❑ Activity Intolerance
 Complications of COPD
❑ Cor Pulmonale – a condition that causes the right side
of the heart to fail. Long term high blood pressure in the
arteries of the lung and right ventricle of the heart can
lead to cor pulmonale. High blood pressure in the
arteries of the lungs is called pulmonary hypertension
❑ Weight Loss
 Complications of COPD
❑ Pneumothorax – an abnormal collection of air in the
pleural space between the lung and the chest wall
❑ Respiratory Failure – inadequate gas exchange by the
respiratory system, with the result that levels of arterial
oxygen, carbon dioxide or both cannot be maintained
within their normal ranges. A drop in blood oxygenation
is known as hypoxemia; a rise in arterial carbon dioxide
levels is called hypercapnia
 HYPOXEMIA
• PO2 greater than 60 mmHg
- Cyanosis
• Impaired function of vital centers
- Agitated or combative behavior,
euphoria, impaired judgement,
convulsions, delirium, stupor, coma
- Retinal hemorrhage
- Hypotension and bradycardia
• Activation of compensatory mechanisms
- Sympathetic system activation
 HYPERCAPNIA
• PCO2 greater than 50 mmHg
• Respiratory acidosis
- Increased respiration
- Decreased nerve activity
* Carbon dioxide narcosis
* Disorientation, somnolence, coma
- Decreased muscle contraction
* Vasodilation
- Headache; warm flushed skin
 PNEUMOTHORAX
• Air enters the pleural cavity
• Air takes up space, restricting lung expansion
• Partial or complete collapse of the affected lung:
- Spontaneous : Air filled blister on the lung
ruptures
- Traumatic: Air enters through chest injuries
* Tension: Air enters pleural cavity
through wound on inhalation, cannot leave on
exhalation
* Open: Air enters pleural cavity through
the wound on inhalation and leaves on
exhalation
 PNEUMOTHORAX
Pathophysiology
Air in the Intrapleural Space
❑ Complete or partial collapse of the lung
❑ Intrapleural space = the pressure within the pleural
cavity. Normally, the pressure within the pleural cavity
is slightly less than the atmospheric pressure, in what
is known as negative pressure.
❑ When pleural cavity is damaged / ruptured and the
intrapleural pressure becomes equal to or exceeds the
atmospheric pressure, pneumothorax may ensure
 Types of Pneumothorax
❑ A spontaneous pneumothorax is
when part of your lung collapses.
It happen if air collects in the
pleural space ( the space
between your lungs and chest
wall). The trapped air in the
pleural space prevents your lung
from filling with air, and the lung
collapses.
❑ A traumatic pneumothorax is
caused by an injury that tears
your lung and allows air to enter
the pleural space. This is the area
between your lungs and your
chest wall. The air trapped in your
pleural space prevents your lung
from filling with air, which causes
it to collapse.
 Types of Pneumothorax

❑ Tension Pneumothorax. A pneumothorax is a

condition in which air becomes trapped in the
pleural space. This is usually caused by trauma
to the lung, or a “punctured” lung. The patient
continues to breathe, pulling air into the injured
lungs, but the air escapes into the chest cavity.
 PNEUMOTHORAX
Signs and Symptoms

❑ Shallow, Rapid Respirations

❑ Asymmetrical Chest Expansion
❑ Dyspnea
❑ Chest Pain
❑ Absent Breath Sounds over Affected Area
 Tension Pneumothorax
Signs and Symptoms

❑ Tracheal Deviation
❑ Bradycardia
❑ Cyanosis
❑ Shock and Death if untreated
 PNEUMOTHORAX
Diagnostic Tests

❑ History and Physical Examination

❑ Bedside Ultrasound
❑ Chest Xray
❑ ABGs, ApO2
 Therapeutic Interventions
❑ Monitor ABGs and Respiratory Status
❑ Chest Tube to water seal drainage
❑ Pleurodesis (Sclerosis) for recurrent collapse
❑ Pleurodesis – performed to prevent recurrence of
pneumothorax or recurrent pleural effusion. Uses
medicine to adhere lung to chest wall, seals up space
between the outer lining of lung and chest wall
(pleural cavity) to prevent fluid or air from continually
building up around lungs
❑ Can be done chemically or surgically
❑ Involves the adhesion of the two pleurae
 Nursing Care

❑ Monitor Respiratory Status

❑ Monitor Chest Drainage System
❑ Report Changes Promptly
 RIB FRACTURES

Etiology Care
❑ Trauma ❑ Control Pain
❑ Cough ❑ Encourage Coughing
❑ CPR and Deep Breathing
❑ Promote Adequate
ventilation
 FAIL CHEST
❑ Life threatening condition that occurs when a segment of
the rib cage breaks due to trauma and becomes detached
from the rest of the chest wall
❑ Causes multiple rib fractures
❑ Ribcage not able to maintain bellows action
❑ Part of the chest wall moves independently, the chest
cannot expand properly and cannot properly draw air into
the lungs
❑ Care
❑ Monitor ABGs
❑ Mechanical Ventilation
Nursing Diagnoses: Chest Trauma
❑ Impaired Gas Exchange
❑ Ineffective Breathing Pattern
❑ Acute Pain
 ACUTE RESPIRATORY FAILURE
Pathophysiology Etiology
❑ Hypoventilation ❑ COPD
❑ Unable to maintain ABGs ❑ Aspiration
❑ Any impairment in oxygenation ❑ Neurological Disease
or ventilation in which the
arterial oxygen tension falls
below 60mmHg and/ or the
carbon dioxide tension rises
above 50mmHg and the pH drops
below 7.35.
Signs and Symptoms Diagnostic Test
❑ Worsening ABGs ❑ ABGs
❑ Increasing Dyspnea • PaO2 <60 mmHg
❑ Restlessness, Confusion • PaO2 > 50mmHg
❑ Lethargy ❑ Test to determine cause
❑ Coma and Death
 Therapeutic Interventions
❑ Oxygen
❑ Bronchodilators
❑ Correct Underlying cause
❑ Intubation and Ventilation
• Check advance directives
 ACUTE RESPIRATORY
DISTRESS SYNDROME
• Exudate enters the alveoli
- Blocks gas exchange
- Makes inhalation more difficult

• Neutrophils enter the alveoli

- release inflammatory mediators,
proteolytic enzymes, reactive oxygen species
 ACUTE RESPIRATORY
DISTRESS SYNDROME (ARDS)
Pathophysiology
❑ Alveolocapillary Membrane Damage (A thin layer tissue
that mediates the exchange of gases between the alveoli
and the blood in the pulmonary capillaries) PULMONARY
GAS EXCHANGE occurs across this membrane. All
disorders causing ARDS cause massive pulmonary
inflammation that injures the alveolocapillary membrane
and produces severe pulmonaryedema, shunting and
hypoxemia
❑ Pulmonary Edema
❑ Alveolar Collapse
❑ Lungs Stiff and noncompliant
❑ Lungs may hemorrhage
 ACUTE RESPIRATORY
DISTRESS SYNDROME (ARDS)
Etiology Signs and Symptoms
❑ Acute lung injury ❑ Dyspnea
• Sepsis ❑ Elevated RR
• Shock ❑ Fine crackles
• Aspiration ❑ Respiratory Acidosis
❑ Not usually in patients ❑ Restlessness, Confusion
with chronic respiratory ❑ Death Rate 45% to 50 %
disease
 ACUTE RESPIRATORY
DISTRESS SYNDROME (ARDS)
Diagnostic Tests Therapeutic Interventions
❑ ABGs ❑ Oxygen
❑ Chest Xray ❑ Intubation
❑ Tests to determine cause ❑ Mechanical ventilation
❑ Treat underlying cause
❑ Supportive Care
 ACUTE RESPIRATORY
DISTRESS SYNDROME (ARDS)
Nursing Diagnosis: Respiratory Failure
❑ Impaired Gas Exchange
❑ Ineffective Airway Clearance
❑ Ineffective Breathing Pattern
❑ Activity Intolerance
❑ Anxiety
❑ Disturbed Thought Processes
❑ Self care Deficit
CAUSES OF RESPIRATORY FAILURE
• Hypoventilation — hypercapnia, hypoxia
- Depression of the respiratory center
- Diseases of respiratory nerves or muscles

• Ventilation / perfusion mismatching

• Impaired diffusion – hypoxemia but not hypercapnia
- Interstitial lung disease
- ALI / ARDS
- Pulmonary Edema
- Pneumonia
 COPD
Diagnostic Test
❑ Chest X ray
❑ CT Scan
❑ ABGs
❑ CBC
❑ Spirometry
❑ Sputum Analysis
 COPD

❑ Stop Smoking!!! ❑ Mechanical ventilation

❑ Oxygen 1 to 2 L/m ❑ End of life planning
❑ Supportive Care
❑ Pulmonary rehab Medications
❑ Surgery ❑ Bronchodilators
❑ Endobronchial Valve – is an ❑ Corticosteroids
implantable medical device – a ❑ Expectorants
small, one-way valve, which is
implanted in an airway in the
pulmonary system to treat one of
several lung conditions
 EMPHYSEMA
• Neutrophils in the alveoli secrete trypsin
- Increased neutrophil numbers due to inhaled
irritants can damage alveoli
• a1- antitrypsin inactivates the trypsin before it
can damage the alveoli
- A genetic defect in a1 – antitrypsin synthesis
leads to alveolar damage
 EMPHYSEMA

Sign and Symptoms

❑ Diminished Breath Sounds

❑ Dyspnea
❑ Progressive Activity Intolerance
 CHRONIC BRONCHITIS
❑ Chronic irritation of airways
- Increased number of mucous cells
- Mucus hyper secretion
❑ Productive cough

Signs and Symptoms

❑ Wheezing, crackles
❑ Chronic Cough
❑ Dyspnea
❑ Thick, Tenacious Sputum
❑ Increased susceptibility to infection
❑ Mucous Plugs
 PINK PUFFERS VERSUS
BLUE BLOATERS
• Pink puffers ( usually emphysema)
- Increase respiration to maintain oxygen levels
- Dyspnea; increased ventilatory effort
- Use accessory muscles; pursed – lip breathing

• Blue bloaters ( usually bronchitis)

- Cannot increase respiration enough to maintain
oxygen levels
- Cyanosis and polycythemia
- Cor pulmonale
 CYSTIC FIBROSIS
• Recessive disorder in chloride transport proteins
- High concentrations of NaCL in the sweat
- Less Na+ and water in respiratory mucus and in
pancreatic secretions
Mucus is thicker
* Obstructs airways
* Obstructs the pancreatic and biliary ducts
 Cystic Fibrosis
Pathophysiology Signs and Symptoms
❑ Exocrine Gland Disorder ❑ Thick, Tenacious Sputum
❑ Thick Tenacious ❑ Frequent Respiratory Infections
Secretions ❑ Finger Clubbing
❑ Blocked Pancreatic ❑ Malabsorption
Enzymes ❑ Fatty, Foul smelling Stools
❑ Death from antibiotic resistant
Etiology infection
❑ Heredity
 Diagnostic Tests
❑ “Kiss Your Baby” Campaign – the sponsors of the
campaign said if your baby tasted salty when
kissed have the child checked for CF
❑ Sweat Chloride Test – a common and simple test
used to evaluate a patient who is suspected of
having cystic fibrosis… Patients with cystic fibrosis
produced larger quantities of sweat chloride than
normal individuals
Therapeutic Interventions
❑ Hydration
❑ Inhaled Mucolytic Medication
❑ Bronchodilators, Corticosteroids
❑ Expectorants
❑ Chest Physiotherapy
❑ Antibiotics
❑ Prevent Infection
❑ Pancreatic Enzyme Replacement ( Pancrease,
Viokase)
 Therapeutic Interventions
❑ Ibuprofen May Slow Lung Deterioration - High dose
Ibuprofen May Slow Cystic Fibrosis Lung Disease;
Inflammation increases damage done to the lungs;
the use of high doses has also raised concerns about
the potential for unwanted effects, which has limited
the use of these drugs in cystic fibrosis
❑ Lung Transplant
PULMONARY EMBOLISM
 PULMONARY EMBOLISM
❑ Pathophysiology
• Blood clot in pulmonary artery
• Ventilation – perfusion mismatch – a condition
in which one or more areas of the lung receive
oxygen but no blood flow, or they receive blood
flow but no oxygen due to some diseases and
disorders
• Impaired Gas Exchange
• Lung infarction – Death of one or more sections
of lung tissue due to deprivation of an adequate
blood supply
 PULMONARY EMBOLISM
Etiology Prevention
❑ DVT Most common cause of PE ❑ Regular ambulation
❑ Fat emboli from compound ❑ Prompt treatment of DVT
fracture ❑ In high risk patients:
❑ Amniotic fluid emboli during • Warfarin (Coumadin)
labor and delivery • Enoxaparin
• Heparin
PULMONARY EMBOLISM
Signs and Symptoms
❑ Sudden Onset Dyspnea
❑ Tachycardia
❑ Tachypnea
❑ Cough
❑ Crackles
❑ Hemoptysis
 PULMONARY EMBOLISM
Diagnosis
❑ Spiral CT scan
❑ Lung Scan
❑ Angiogram – used to visualize the inside, or
lumen of blood vessels and organs of the body
❑ D – Dimer – a blood test that measures a
substance released when a blood clot breaks up.
Ordered without lab tests and imaging scans, to
help check for blood clotting problems
 PULMONARY EMBOLISM
Therapeutic Interventions
❑ Thrombolytics
❑ Heparin
❑ Warfarin (Coumadin)
❑ Oxygen
❑ Embolectomy (Rare) – the emergency surgical
removal of emboli which are blocking blood
circulation; an emergency procedure often as
the last resort
❑ Jugular or femoral filter for recurrent PE
 PULMONARY EMBOLISM
Nursing Diagnosis

❑ Impaired Gas Exchange

❑ Risk for Injury Related to Anticoagulant use
 PULMONARY VENOUS
HYPERTENSION
• Secondary
- Elevation of pulmonary venous pressure
- Increased pulmonary blood flow
- Pulmonary vascular obstruction
- Hypoxemia

• Primary
- Blood vessel walls thicken and constrict
 PULMONARY ARTERIAL
HYPERTENSION
Pathophysiology Signs and Symptoms
❑ Elevated pressure in ❑ Dyspnea
pulmonary arteries ❑ Fatigue
❑ Right ventricular failure ❑ Crackles
❑ Cyanosis
Etiology ❑ Tachypnea
❑ Unknown
❑ Secondary; CAD, Valve
disease
 PULMONARY ARTERIAL
HYPERTENSION
Diagnostic Test Therapeutic Interventions
❑ ABG’s ❑ Low sodium diet
❑ Cardiac Catheterization ❑ Diuretics
❑ ECG ❑ Vasodilators
❑ Additional Tests to find ❑ Oxygen
cause ❑ Warfari
 PULMONARY ARTERIAL
HYPERTENSION
Nursing Care

❑ Monitor Respiratory Status

❑ Bedrest
❑ Positioning
❑ Comfort Measures
 COR PULMONALE
• Right sided heart failure secondary to lung diseases
or pulmonary hypertension
- Decreased lung ventilation
- Pulmonary vasoconstriction
- Increased workload on the right heart
- Decreased oxygenation
- Kidney releases erythropoietin more RBCs
made Polycythemia makes blood more
viscous
- Increased workload on the heart
 LUNG CANCER
❑ Small Cell Lung Cancer
❑ Large Cell Carcinoma
❑ Adenocarcinoma
❑ Squamous Cell Carcinoma
 LUNG CANCER

Etiology Signs and Symptoms

❑ Smoking - smokers 13 times ❑ None until late
more likely to develop cancer as ❑ Productive cough
nonsmokers ❑ Recurrent infection
❑ Environmental Tobacco Smoke ❑ Dyspnea
❑ Other Carcinogens ❑ Hemoptysis
• Asbestos ❑ Anorexia and weight loss
• Arsenic ❑ Pain
• Pollution ❑ Wheezing / Stridor
 LUNG CANCER
Complications Diagnostic Tests
❑ Pleural effusion ❑ Chest X ray
❑ Superior vena cava ❑ CT Scan
syndrome ❑ Sputum analysis
❑ Ectopic hormone secretion ❑ Biopsy
• ADH ❑ Additional test to find metastasis
• ACTH ( cushing’s syndrome)
• PTH ( hypercalcemia)
❑ Actelectasis
❑ Metastasis
 LUNG CANCER
Therapeutic Interventions Nursing Diagnoses: Lung Cancer
❑ Stage (TNM System) ❑ Impaired Gas Exchange
❑ Chemotherapy ( usually ❑ Ineffective Airway Clearance
palliative) ❑ Imbalanced Nutrition
❑ Radiation ( usually ❑ Pain
palliative) ❑ Constipation
❑ Anticipatory Grieving
❑ Activity Intolerance
 THORACIC SURGERY
❑ Pneumonectomy – or pneumectomy is a surgical
procedure to remove a lung
❑ Lobectomy – Removal of just one lobe of the lung is
specifically referred to as a lobectomy
❑ Resection – a segment of the lung as a wedge resection (
or segmentectomy)
❑ VATS – video assisted thoracic surgery – minimally
invasive surgical procedure used to access the chest cavity
to operate on the lung, mediastinum and pleura; to treat
conditions such as cancer, pneumothorax, infection, cysyts
and other thoracic disorders
❑ Transplant
 THORACIC SURGERY

Preoperative Care Postoperative Care

❑ Monitor respiratory status ❑ Invasive care setting
❑ Teach ❑ Monitor
• Routine pre op teaching • Vital signs
• What to expect • SpO2, ABGs
• Visit SICU • Hemodynamic Parameters
• Include Family • Lung sounds
❑ Ventilator
❑ Chest tubes
 THORACIC SURGERY

Nursing Diagnoses
❑ Ineffective Airway Clearance
❑ Impaired Gas Exchange
❑ Acute Pain
❑ Impaired Physical Mobility
❑ Risk for Infection