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Respiratory System

Objectives:
Discuss assessment of respiratory system Explain nursing care of patients receiving therapeutic treatments Discuss the pathophysiology, signs & symptoms, and care of patients with bronchitis, pneumonia, pleuritis, pneumothorax, flail chest, pulmonary embolism, and acute respiratory distress syndrome

Objectives:
Discuss the pathophysiology, signs & symptoms, and care of patients with chronic obstructive pulmonary disease and restrictive pulmonary disease Explain the relationship between cigarette smoking and chronic respiratory disorders

General Respiratory Assessment History Chief complaints Dyspnea How much exertion triggers shortness of breath? Is there an associated cough? Other symptoms? Sudden onset or gradual?

General Respiratory Assessment Time of day it occurs most? Worse when flat? Occur at rest? With walking? With climbing stairs? How far can you walk before getting short of breath? Relief measures?

General Respiratory Assessment

Chief Complaints Cough Character Timing Triggers Relief measures Sputum Production Color Odor Consistency Quantity

General Respiratory Assessment Chief Complaints Wheezing Stridor Chest pain

Physical Examination
Inspection Shape Pattern Rate Skin color

Physical Examination
Palpation Trachea Chest wall Percussion Auscultation

Auscultation..
Normal Breath Sounds
Pitch Amplitude Duration Quality Normal Location

Vesicular Low

Soft

Inspiration > Expiration

Breezy

Peripheral lung fields

Bronchial High

Loud

Inspiration < Expiration

Hollow

Trachea

Broncho- Med vesicular

Moderate

Equal

Mixed

Bronchi, between scapula; 1st & 2nd ICS

Abnormal Breath Sounds


Diminished Crackles Fine Coarse Rhonchi Wheezing Sibilant Sonorous Pleural Friction Rub

Diagnostic Test
Pulmonary Function Test Arterial Blood Gas Pulse Oximetry Chest Xray Ventilation-Perfusion Lung Scan Bronchoscopy Thoracentesis

Therapeutic Measures
Thoracentesis Effective Coughing & Deep Breathing Pursed- Lip Breathing Incentive Spirometry Chest Physiotherapy Suctioning Aerosol therapy Oxygen

Oxygen
Ordered in liters per minute or as FiO2 (fraction of inspired air) Nasal Cannula 1 liter = 24% 2 liters = 28% 3 liters= 32% 4 liters= 36% 5 liters = 40%

Oxygen

Masks Simple=30-60% Partial rebreather = 35 -60% Rebreather = 100% Venturi mask = 24-55% with adapters

Complications of Oxygen Therapy


Oxygen toxicity Ocular damage Atelectasis Hypoventilation

Airway Management
Upper airway obstruction Endotracheal intubation Tracheostomy To bypass upper airway obstruction Access for longterm ventilation Prevent aspiration pneumonia

Thoracic Surgery
Thoracotomy opening of chest wall Pneumonectomy remove entire lung Lobectomy remove a lobe Segmental resection large portion removed Wedge resection small wedge

Interventions
Pre-operatively focus on coughing and deep breathing exercises Post-operatively Positioning Keep HOB elevated 2040 degrees Position on unaffected side in immediate postop phase Chest tube care

Interventions
Oxygen Incentive Spirometry / Coughing & Deep Breathing Hydration Pain control

Atelectasis
Collapsed alveoli Causes: Reduced ventilation Blockage of air exchange Anesthesia Smoking Obesity Diagnosis Chest x-ray

Clinical Manifestations of Atelectasis Low grade fever Dyspnea Tachypnea Tachycardia Cyanosis decreased breath sounds, bronchial breath sounds over involved area, crackles

Prevention of Atelectasis
Frequent position changes Early ambulation Proper coughing and deep breathing Incentive spirometry Proper pain control after surgery

Treatment of Atelectasis
Chest Physiotherapy Oxygen Positive pressure treatments Nebulizers Bronchoscopy

Acute Bronchitis
Viral or Bacterial Inflammation of trachea and bronchial tree Increased production of secretions Productive cough-yellow or green Diffuse wheezes Tachypnea Chest discomfort Fever Headache, malaise

Diagnosis of Acute Bronchitis


Clinical presentation Chest x-ray Sputum culture

Management of Acute Bronchitis


Antitussive (codeine; pertussin) Bronchodilator (Brethine; Bronkosol) Broad spectrum antibiotic (ampicillin; erythromycin) Bedrest Vaporizer Hydration

Pneumonia
Inflammatory process Can be bacterial, viral, fungal, protozoan, mycoplasms, aspiration Individuals at risk Smokers After anesthesia Immunosuppressed Immobile Malnourished Altered level of consciousness Impaired swallowing Tube feedings Endotracheal tubes

Complications of Pneumonia
Pleural effusion Atelectasis Lung abcess Pericarditis Endocarditis Adult Respiratory Distress Syndrome

Clinical Manifestations of Pneumonia


Fever and chills Chest discomfort Productive cough Crackles Dyspnea Hemoptysis Headache Fatigue Elderly atypical presentation

Management of Pneumonia
Increase hydration 3 liters/day Bedrest to limited activity Antipyretics Analgesics Nebulizer treatments Antibiotics for bacterial Effective coughing, but antitussives also

Management of Pneumonia
Change positions; HOB elevated Oxygen Small, more frequent meals; high protein, soft Good oral care

Pleuritis
Inflammation of pleura Common causes Pneumonia Tuberculosis Trauma Tumors Virus Spontaneous

Clinical Manifestations of Pleurisy


Sharp inspiratory pain on one side of chest Can usually be localized May radiate to shoulder Can develop into pleural effusion If effusion develops, fever, cough Not shown on chest xray Pleural friction rub

Management of Pleurisy
NSAIDS Splinting Heat Antitussives if coughing Encourage coughing & deep breathing HOB elevated Antibiotic may be used Nerve block around vertebrae to block intercostal nerves in area Effusion oxygen, thoracentesis may be needed

Pneumothorax
Complete or partial collapse of lung Air enters pleural space interrupting negative pressure Causes: Injury Spontaneous Severe coughing

Types of Pneumothorax

Tension No escape of air, air enters pleural space and keeps building Pressure forces collapse Heart, trachea, esophagus shift to the unaffected side mediastinal shift

Types of Pneumothorax
Open Air moves in and out Collapse on affected side Heart, trachea, esophagus move back and forth

Signs & Symptoms of Pneumothorax


Dyspnea Tachypnea Tachycardia Restlessness Pain Anxiety Asymmetrical movement of chest wall Decreases breath sounds on one side

Management of Pneumothorax
Chest tube insertion Oxygen Semi-fowlers or fowlers position Deep breathing & coughing Monitor closely for complications, especially infection

Pulmonary Embolus

Blood clots, air, fat, foreign body Risk factors: Surgery on pelvis, legs Trauma to pelvis, legs Immobility Obesity Deep vein thrombosis

Clinical Manifestations of PE
Sudden chest pain Tachypnea Dyspnea Tachycardia Apprehension Diaphoresis Cough Hemoptysis

Diagnosis of PE
History Clinical presentation VQ scan Spiral CT ABGs Pulmonary angiogram

Management of PE
Anticoagulant therapy IV Heparin followed by Coumadin therapy for up to 6 months Oxygen IV morphine for pain control and anxiety relief Bedrest Adequate hydration Embolectomy Vena cava filters as prevention

Acute Respiratory Distress Syndrome ARDS Complication of some other process Result of any pulmonary insult either direct or indirect Increased permeability of alveolar capillary bed Fluid leaks into alveoli and interstitial space Pulmonary edema and hypoxia Pulmonary hypertension Pulmonary hemorrhage

Clinical Manifestation of ARDs


Manifests anywhere from 1- 96 hours after insult Tachypnea Fine crackles Restlessness, confusion Cough Tachycardia Progressive worsening can go into respiratory arrest

Diagnosis of ARDs

Chest xrays ABGs hypoxia < 70, respiratory acidosis Clinical presentation

Management of ARDs
Mechanical Ventilation Sedation Treat cause Corticosteroids Nutritional support

Asthma
Chronic inflammatory disease of the airways Results in hyperresponsiveness, mucosal edema, mucous production Allergens

Clinical Manifestations
Dyspnea Cough Wheezing Chest tightness Tachycardia Hypoxia Anxiety

Diagnosis and Management


Clinical presentation Response to bronchodilators Spirometry Low oxygen saturations Inhaled beta2 agonists Steroids Oxygen

Maintenance Management
Leukotriene inhibitors Anti-inflammatory Theophylline Long acting bronchodilator Education Know triggers Purse-lip breathing Hydration Monitor peak flows Know when to call physician

Chronic Obstructive Pulmonary Disease


Umbrella term Obstructive bronchitis Emphysema Asthma Progressive and irreversible air flow obstruction

Risk Factors for COPD


Smoking Second-hand smoke Occupational exposure Air pollution Heredity Chronic respiratory infections

Pathophysiology
Bronchitis Excess mucous blocks airways Chronic cough Emphysema Impaired gas exchange due to destruction of the alveolar walls Air trapping

Complications of COPD
Cor pulmonale Right sided heart failure secondary to pulmonary disease Respiratory Failure Progressive debilitation

Clinical Manifestations of COPD


Dyspnea Cough Increased work of breathing Weight loss Activity intolerance Cyanosis Diminished breath sounds Adventitious breath sounds

Complications
Pneumonia Acute respiratory failure Spontaneous pneumothorax Cor pulmonale

Management of COPD
Oxygen Pulmonary hygiene Bronchodilators Steroids Preventing infection Adequate hydration and nutrition Energy conservation Pulmonary rehabilitation Psychological support

Tuberculosis
Mycobacterium tuberculosis Airborne transmission Risk factors: Exposure Health care workers IV drug abusers Crowded, substandard living conditions Homeless Immunocompromised HIV

Pathophysiology
Mycobacterium bacilli is inhaled Bacilli causes inflammatory response Neutrophils and macrophages engulf the bacteria Exudate forms causing bronchopneumonia

Pathophysiology
Macrophages surround the granulomas Granulomas turn into fibrous tissue with a center called a Ghon tubercle Bacteria and macrophages become necrotic creating a cheesy mass Mass calcifies

Factors for re-activation of disease


Age HIV infection Immunosuppression Prolonged corticosteroid therapy Malabsorption Low body weight Substance abuse Co-existing diseases Genetic predisposition

Clinical Manifestations of TB
Low grade fever Cough Anorexia Night sweats Dyspnea Hemoptysis Chest discomfort

Diagnostic Tests for TB


Mantoux test Purified protein derivative Chest xray Acid-fast bacillus smear and culture

Management of TB
Antituberculin agents Determine any drug resistance Primary drug resistance Secondary or acquired resistance Multi-drug resistance Start high First-line drugs Isoniazid (INH) Rifampin (Rifadin)

Management of TB
Hospitalized clients need to be in a negative-pressure ventilation room Particulate respirators Compliance with long term medication regimen Education and follow-up

Isoniazid Preventive Therapy


Prevents infection in people exposed Converted TB test but no signs of active disease Significant TB test results and abnormal chest xray Positive TB test and increased risk Younger than 35 with positive TB test, no risk factors and normal chest x-ray

Tuberculosis outside the lungs


Extrapulmonary tuberculosis (XPTB) Bacilli travels through the lymph and blood systems Renal system, bone growth plates, meninges Disseminated TB seen more in HIV Vague symptoms Can be more difficult to treat

Lung Tumors
Benign or malignant Benign tumors hamartoma; fibroma; hemangioma; lipoma; papiloma Surgical intervention Malignant classified according to cell type Small cell carcinoma (oat cell carcinoma) Squamous cell carcinoma (epidermoid) Adenocarcinoma Large cell carcinoma

Risk Factors for Lung Cancer


Cigarette smoking Second-hand smoke Occupational exposure (asbestos, motor vehicle emissions, pollutants, radon) Genetics Low level radiation Smoking and low intake of beta carotene

Clinical Manifestations of Lung Cancer


Cough Dyspnea Change in breathing pattern Hemoptysis Rust-colored sputum Unexplained weight loss Chest or shoulder pain

Diagnosis of TB
Chest xray CT scan / MRI Monoclonal antibody tagging Bronchoscopy Fine needle aspiration under CT scan Staging based on TumorNode-Metastasis system

Management of Lung Cancer


Radiation Therapy Used to reduce size of tumor When surgical resection is not an option In combination with surgery Relieve symptoms Chemotherapy Depends on cell type Small cell lung cancers respond well Combination approach works best

Surgical Management of Lung Cancer


Preoperative PFTs Antibiotics, bronchodilators Control anxiety Education Operative Laser surgery Pulmonary resection Wedge resection Segmental resection Lobectomy Pneumonectomy

Surgical Management of Lung Cancer


Post-operative Stringent pulmonary care Pain control Ambulation Management of closed chest drainage