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Medical and Surgical Nursing

Review
The Respiratory System
Nurse Licensure Examination
Review
Outline Of Review Concepts:
 Review of the relevant respiratory
anatomy
 Review of the relevant respiratory
physiology
 The respiratory assessment
 Common laboratory examinations
Outline Of Review Concepts:
 Review of the common respiratory
problems and the nursing management
 Review of common respiratory diseases
 Upper respiratory conditions
 Lower respiratory conditions
Respiratory Anatomy &
Physiology
 The respiratory system consists of two
main parts - the upper and the lower
tracts
Respiratory Anatomy &
Physiology
 The UPPER respiratory system consists
of:
 1. nose
 2. mouth
 3. pharynx
 4. larynx
Respiratory Anatomy &
Physiology
 The LOWER respiratory system
consists of:
 1. Trachea
 2. Bronchus
 3. Bronchioles
 4. Respiratory unit
Upper Respiratory Tract
The Nose
 This is the first part of the upper
respiratory system that contains nasal
bones and cartilages
 There are numerous hairs called
vibrissae
 There are numerous superficial blood
vessels in the nasal mucosa
The Nose
 The functions of the nose are:
 1. To filter the air
 2. To humidify the air
 3. To aid in phonation
 4. Olfaction
The Pharynx
 The pharynx is a musculo -
membranous tube that is composed of
three parts
 1. Nasopharynx
 2. Oropharynx
 3. Laryngopharynx
The Pharynx
 The pharynx functions :
 1. As passageway for both air and
foods (in the oropharynx)
 2. To protect the lower airway
The Larynx
 Alsocalled the voice box
 Made of cartilage and membranes and
connects the pharynx to the trachea
The Larynx
 Functions of the larynx:
 1. Vocalization
 2. Keeps the patency of the upper
airway
 3. Protects the lower airway
The Paranasal sinuses
 These are four paired bony cavities that
are lined with nasal mucosa and ciliated
pseudostratified columnar epithelium
 Named after their location - frontal,
ethmoidal, sphenoidal and maxillary
The Paranasal sinuses
 Thefunction of the sinuses:
Resonating chambers in speech
The Lower Respiratory System
 The lower respiratory system consists of
 1. Trachea
 2. Main bronchus
 3. Bronchial tree
 4. Lungs- 3R/ 2L
 The trachea to the terminal bronchioles
is called the conducting airway
 The respiratory bronchioles to the
alveoli is called the respiratory acinus
The Trachea
A cartilaginous tube measures 10-12
centimeters
 Composed of about 20 C-shaped
cartilages, incomplete posteriorly
The Trachea
 The function of the trachea is to
conduct air towards the lungs
 The mucosa is lined up with mucus and
cilia to trap particles and carry them
towards the upper airway
The Bronchus
 The right and left primary bronchi begin
at the carina
 The function is for air passage
The Primary Bronchus
 RIGHT BRONCHUS  LEFT BRONCHUS

 Wider  Narrower
 Shorter  Longer
 More Vertical  More horizontal
The Bronchioles
 The primary bronchus further divides
into secondary, then tertiary then into
bronchioles
 The terminal bronchiole is the last part
of the conducting airway
The Respiratory Acinus
 The respiratory acinus is the chief
respiratory unit
 It consists of
 1. Respiratory bronchiole
 2. Alveolar duct
 3. alveolar sac
The Respiratory Acinus
 The respiratory acinus is the chief
respiratory unit
 The function of the respiratory acinus is
gas exchange through the respiratory
membrane
The Respiratory Acinus
 The respiratory membrane is composed
of two epithelial cells
 1.The type 1 pneumocyte - most
abundant, thin and flat. This is where
gas exchange occurs
 2. The type 2 pneumocyte - secretes
the lung surfactant
The Respiratory Acinus
A type III pneomocyte is just the
macrophage that ingests foreign
material and acts as an important
defense mechanism
Accessory Structures
The PLEURA
 Epithelial serous membrane lining the
lung parenchyma
 Composed of two parts- the visceral
and parietal pleurae
 The space in between is the pleural
space containing a minute amount of
fluid for lubrication
Accessory Structures
The Thoracic cavity
 The chest wall composed of the
sternum and the rib cage
 The cavity is separated by the
diaphragm, the most important
respiratory muscle
Accessory Structures
The Mediastinum
 The space between the lungs, which
includes the heart and pericardium, the
aorta and the vena cavae.
GENERAL FUNCTIONS OF THE
Respiratory System
 Gas exchange through ventilation,
external respiration and cellular
respiration
 Oxygen and carbon dioxide transport
The Assessment
HISTORY
 Reason for seeking care
 Present illness
 Previous illness
 Family history
 Social history
The Assessment
PHYSICAL EXAMINATION
 Skin- cyanosis, pallor
 Nail clubbing
 Cough and sputum production
 Inspect - palpate - percuss - auscultate
the thorax
The Assessment
LABORATORY EXAMINATION
 1. ABG analysis
 2. Sputum analysis
 3. Direct visualization - bronchoscopy
 4. Indirect visualization - CXR, CT and
MRI
 5. Pulmonary function test
ABG Analysis
 This
test helps to evaluate gas
exchange in the lungs by measuring the
gas pressures and pH of an arterial
sample
ABG Analysis
 Pre-test: choose site carefully, perform
the Allen’s test, secure equipments-
syringe, needle, container with ice
 Intra-test: Obtain a 5 mL specimen from
the artery (brachial, femoral and radial)
 Post-test: Apply firm pressure for 5
minutes, label specimen correctly, place
in the container with ice
ABG Analysis
ABG normal values
 PaO2 80-100 mmHg
 PaCO2 35-45 mmHg
 pH 7.35- 7.45
 HCO3 22- 26 mEq/L
 O2 Sat 95-99%
Sputum Analysis
 Thistest analyzes the sample of
sputum to diagnose respiratory
diseases, identify organism, and identify
abnormal cells
Sputum Analysis
 Pre-test: Encourage to increase fluid intake
 Intra-test: rinse mouth with WATER only,
instruct the patient to take 3 deep breaths
and force a deep cough, steam nebulization,
collect early morning sputum
 Post-test: provide oral hygiene, label
specimen correctly
Pulse Oximetry
 Non-invasive method of continuously
monitoring the oxygen saturation of
hemoglobin
 A sensor or probe is attached to the
earlobe, forehead, fingertip or the
bridge of the nose
Bronchoscopy
A direct inspection of the trachea and
bronchi through a flexible fiber-optic or
a rigid bronchoscope
 Done to determine location of
pathologic lesions, to remove foreign
objects, to collect tissue specimen and
remove secretions/aspirated materials
Bronchoscopy
 Pre-test: Consent, NPO x 6h, teaching
 Intra-test: position supine or sitting upright in
a chair, administer sedative, gag reflex will be
abolished, remove dentures
 Post-test: NPO until gag reflex returns,
position SEMI-fowler’s with head turned to
sides, hoarseness is temporary, CXR after
the procedure, keep tracheostomy set and
suction x 24 hours
Thoracentesis
 Pleural fluid aspiration for obtaining a
specimen of pleural fluid for analysis,
relief of lung compression and biopsy
specimen collection
Thoracentesis
 Pre-test: Consent
 Intra-test: position the patient sitting with arms
on a table or side-lying fowler’s, instruct not to
cough, breathe deeply or move
 Post-test: position unaffected side to allow
lung expansion of the affected side, CXR
obtained, maintain pressure dressing and
monitor respiratory status
Pulmonary Function Tests
 Volume and capacity tests aid
diagnosis in patient with suspected
pulmonary dysfunction
 Evaluates ventilatory function
 Determines whether obstructive or
restrictive disease
 Can be utilized as screening test
Pulmonary Function Test
Lung Volumes
 Tidal volume
 Inspiratory reserve volume
 Expiratory reeve volume
 Residual volume
Pulmonary Function Test
Lung capacities
 Inspiratory capacity
 Vital capacity
 Functional residual capacity
 Total lung capacity
Pulmonary Function Test
 Pre-test: Teaching, no smoking for 3 days,
only light meal 4 hours before the test
 Intra-test: position sitting, bronchodilator,
nose-clip and mouthpiece, fatigue and
dyspnea during the test
 Post-test: adequate rest periods, loosen tight
clothing
Common Respiratory Problems
and the common interventions
Dyspnea
Breathing difficulty
Associated with many
conditions- CHF, MG, GBS,
Muscular dystrophy,
obstruction, etc…
Dyspnea
General nursing interventions:
 1. Fowler’s position to promote
maximum lung expansion and promote
comfort. An alternative position is the
ORTHOPNEIC position
 2. O2 usually via nasal cannula
 3. Provide comfort and distractions
Cough and sputum production
Cough is a protective reflex
 Sputum production has many stimuli
 Thick, yellow, green or rust-colored
bacterial pneumonia
 Profuse, Pink, frothy pulmonary
edema
 Scant, pink-tinged, mucoid Lung
tumor
Cough and sputum production
General nursing Intervention
 1. Provide adequate hydration
 2. Administer aerosolized solutions
 3. advise smoking cessation
 4. oral hygiene
Cyanosis
 Bluishdiscoloration of the skin
 A LATE indicator of hypoxia
 Appears when the unoxygenated
hemoglobin is more than 5 grams/dL
 Central cyanosis observe color on the
undersurface of tongue and lips
 Peripheral cyanosis observe the nail
beds, earlobes
Cyanosis
 Interventions:
 Check for airway patency
 Oxygen therapy
 Positioning
 Suctioning
 Chest physiotherapy
 Check for gas poisoning
 Measures to increased hemoglobin
Hemoptysis
 Expectoration of blood from the
respiratory tract
 Common causes: Pulmo infection, Lung
CA, Bronchiectasis, Pulmo emboli
 Bleeding from stomach  acidic pH,
coffee ground material
Hemoptysis
Interventions:
 Keep patent airway
 Determine the cause
 Suction and oxygen therapy
 Administer Fibrin stabilizers like
aminocaproic acid and tranexamic acid
Epistaxis
 Bleeding from the nose caused by rupture
of tiny, distended vessels in the mucus
membrane
 Most common site- anterior septum
Causes
 1. trauma
 2. infection
 3. Hypertension
 4. blood dyscrasias , nasal tumor, cardio
diseases
Epistaxis
Nursing Interventions
 1. Position patient: Upright, leaning
forward, tilted prevents swallowing and
aspiration
 2. Apply direct pressure. Pinch nose
against the middle septum x 5-10 minutes
 3. If unrelieved, administer topical
vasoconstrictors, silver nitrate, gel foams
 4. Assist in electrocautery and nasal
packing for posterior bleeding
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections
 1. Rhinitis- allergic, non-allergic and
infectious
 2. Sinusitis- acute and chronic
 3. Pharyngitis- acute and chronic
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections
1. Rhinitis- Assessment findings
 Rhinorrhea
 Nasal congestion
 Nasal itchiness
 Sneezing
 Headache
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections
2. sinusitis- Assessment findings
 Facial pain
 Tenderness over the paranasal sinuses
 Purulent nasal discharges
 Ear pain, headache, dental pain
 Decreased sense of smell
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections
3. Pharyngitis- Assessment findings
 Fiery-red pharyngeal membrane
 White-purple flecked exudates
 Enlarged and tender cervical lymph nodes
 Fever malaise ,sore throat
 Difficulty swallowing
 Cough may be absent
CONDITIONS OF THE UPPER
AIRWAY
 Upper airway infections- Laboratory
tests
 1. CBC
 2. Culture
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections: Nursing Interventions
1. Maintain Patent Airway
 Increase fluid intake to loosen secretions
 Utilize room vaporizers or steam inhalation
 Administer medications to relieve nasal
congestion
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections: Nursing
Interventions
2. Promote comfort
 Administer prescribed analgesics
 Administer topical analgesics
 Warm gargles for the relief of sore
throat
 Provide oral hygiene
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections: Nursing
Interventions
3. Promote communication
 Instruct patient to refrain from speaking
as much as possible
 Provide writing materials
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infections: Nursing
Interventions
4. Administer prescribed antibiotics
 Monitor for possible complications like
meningitis, otitis media, abscess
formation
5. Assist in surgical intervention
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
 Infection and inflammation of the tonsils
 Most common organism- Group A- beta
hemolytic streptococcus (GABS)
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
 ASSESSMENT FINDINGS
 Sore throat and mouth breathing
 Fever
 Difficulty swallowing
 Enlarged, reddish tonsils
 Foul-smelling breath
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
 Laboratory test
 1. CBC
 2. throat culture
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
 MEDICAL management
 1. Antibiotics- penicillin
 2. Tonsillectomy for chronic cases and
abscess formation
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
 NURSING INTERVENTION for
tonsillectomy
 1. Pre-operative care
 Consent
 Routine pre-op surgical care
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
 NURSING INTERVENTION for
tonsillectomy
 2. POST-operative care
 Position: Most comfortable is PRONE,
with head turned to side
 Maintain oral airway, until gag reflex
returns
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
 NURSING INTERVENTION for
tonsillectomy
 2. POST-operative care
 Apply ICE collar to the neck to reduce
edema
 Advise patient to refrain from talking and
coughing
 Ice chips are given when there is no
bleeding and gag reflex returns
CONDITIONS OF THE UPPER
AIRWAY
Upper airway infection: Tonsillitis
 NURSING INTERVENTION for
tonsillectomy
 2. POST-operative care
 Notify physician if
 a. Patient swallows frequently
 b. vomiting of large amount of bright red or
dark blood
 c. PR increased, restless and Temp is
increased

Laryngeal Cancer
A malignant tumor of the larynx
 More frequent in men
 50-70 years old
RISK FACTORS
1. Smoking
2. Alcohol
3. Exposure to chemicals
4. Straining of voice
5. chronic laryngitis
6. Deficiency of Riboflavin
7. family history
Laryngeal Cancer
 Growth can be anywhere in the larynx
 1. Supraglottic- above the vocal cords
 2. glottic- vocal cord area
 3. infraglottic- below the vocal cords

 Most tumors are found in the glottic area
Laryngeal Cancer
 ASSESSMENT FINDINGS
 Hoarseness of more than TWO weeks
duration
 Cough and sore throat
 Burning and pain in the throat especially
after consuming HOT liquids and citrus
foods
 Neck lump
 Dysphagia, dyspnea, foul breath, CLAD
Laryngeal Cancer
 LABORATORY FINDINGS
 1. Indirect laryngoscopy
 2. direct laryngoscopy
 3. Biopsy
 4. CT and MRI

 Most commonly- squamos carcinoma
Laryngeal Cancer
MEDICAL MANAGEMENT
 Radiation therapy
 Chemotherapy
 Surgery
 Partial laryngectomy
 Supraglottic laryngectomy

 Hemilaryngectomy

 Total laryngectomy
Laryngeal Cancer
NURSING MANAGEMENT: PRE-operative
 1. Provide the patient pre-operative
teachings
 Clarify misconceptions
 Tell that the natural voice will be lost
 Teach communication alternatives
 Collaborate with other team members
Laryngeal Cancer
NURSING MANAGEMENT
 2. reduce patient ANXIETY
 Provide opportunities for patient and
family members to ask questions
 Referrals to previous patients with
laryngeal cancers and cancer groups
Laryngeal Cancer
NURSING MANAGEMENT: POST-op
 3. Maintain PATENT Airway
 Position patient: Semi or High Fowler’s
 Suction secretions
 Encourage to deep breath, turn and cough
Laryngeal Cancer
NURSING MANAGEMENT: POST-op
 4. Administer care of the laryngectomy
tube
 Suction as needed
 Cleanse the stoma with saline
 Administer humidified oxygen
 Laryngectomy tube is usually removed
within 3-6 weeks after surgery
Laryngeal Cancer
NURSING MANAGEMENT: POST-op
 5. Promote alternative communication
methods
 Call bell or hand bell
 Magic Slate
 Hand signals
 Collaborate with speech therapist
Laryngeal Cancer
NURSING MANAGEMENT: POST-op
 6. Promote adequate Nutrition
 NPO after operation
 No foods or drinks per orem for 10 days
 IVF, TPN are alternative nutrition routes
 Start oral feedings with thick liquids, avoid
sweet foods
Laryngeal Cancer
NURSING MANAGEMENT: POST-op
 7. Promote positive body image and self-
esteem
 Encourage verbalization of feelings
 Allow independence in self-care
Laryngeal Cancer
NURSING MANAGEMENT: POST-op
 8. Monitor for COMPLICATIONS
 Respiratory Distress
 Suction

 Coughing and deep breathing
 Humidified oxygen

 Alert the surgeon
Laryngeal Cancer
NURSING MANAGEMENT: POST-op
 8. Monitor for Complications
 Hemorrhage
 Monitor for bleeding
 Monitor vital signs

 Apply direct pressure over the bleeding artery

 Summon assistance and alert the surgeon
Laryngeal Cancer
NURSING MANAGEMENT: POST-op
 8. Monitor for COMPLICATIONS
 Wound infection and breakdown
 Monitor for increased temperature,
purulent drainage and increased
redness/tenderness
 Administer antibiotics
 Clean and change dressing OD
Laryngeal Cancer
NURSING MANAGEMENT: HOME CARE
 Humidification system at home is needed
 AVOID swimming
 Cover the stoma with hands or plastic bib
over the opening
 Advise beauty salons to avoid hair sprays,
powders and loose hair near the opening
 Oral hygiene frequently
Acute Respiratory Failure

 Sudden and life-threatening
deterioration of the gas-exchange
function of the lungs
 Occurs when the lungs no longer meet
the body’s metabolic needs
Acute Respiratory Failure
 Defined clinically as:
 1. PaO2 of less than 50 mmHg
 2. PaCO2 of greater than 5o mmHg
 3. Arterial pH of less than 7.35
Acute Respiratory Failure
CAUSES
 CNS depression- head trauma, sedatives
 CVS diseases- MI, CHF, pulmonary emboli
 Airway irritants- smoke, fumes
 Endocrine and metabolic disorders-
myxedema, metabolic alkalosis
 Thoracic abnormalities- chest trauma,
pneumothorax
Acute Respiratory Failure
PATHOPHYSIOLOGY
 Decreased Respiratory Drive
 Brain injury, sedatives, metabolic
disorders  impair the normal
response of the brain to normal
respiratory stimulation
Acute Respiratory Failure
PATHOPHYSIOLOGY
 Dysfunction of the chest wall
 Dystrophy, MS disorders, peripheral
nerve disorders disrupt the impulse
transmission from the nerve to the
diaphragm abnormal ventilation
Acute Respiratory Failure
PATHOPHYSIOLOGY
 Dysfunction of the Lung Parenchyma
 Pleural effusion, hemothorax,
pneumothorax, obstruction interfere
ventilation prevent lung expansion
Acute Respiratory Failure
 ASSESSMENT FINDINGS
 Restlessness
 dyspnea
 Cyanosis
 Altered respiration
 Altered mentation
 Tachycardia
 Cardiac arrhythmias
 Respiratory arrest
Acute Respiratory Failure
 DIAGNOSTIC FINDINGS
 Pulmonary function test- pH below 7.35
 CXR- pulmonary infiltrates
 ECG- arrhythmias
Acute Respiratory Failure
 MEDICAL TREATMENT
 Intubation
 Mechanical ventilation
 Antibiotics
 Steroids
 Bronchodilators
Acute Respiratory Failure
 NURSING INTERVENTIONS
 1. Maintain patent airway
 2. Administer O2 to maintain Pa02 at
more than 50 mmHg
 3. Suction airways as required
 4. Monitor serum electrolyte levels
 5. Administer care of patient on
mechanical ventilation
COPD
 These are group of disorders
associated with recurrent or
persistent obstruction of air passage
and airflow, usually irreversible.
COPD
 Themost common cause of COPD is
cigarette smoking. Asthma, Chronic
bronchitis, Emphysema and
Bronchiectasis are the common
disorders.
COPD
The general pathophysiology:
 In COPD there is airflow limitation
that is both progressive and
associated with abnormal
inflammatory response of the lungs
to stimuli, usually smoke, particles
and dust
ASTHMA
 Theacute episode of airway
obstruction is characterized by
airway hyperactivity to various
stimuli that results in recurrent
wheezing brought about by edema
and bronchospasm
Asthma Pathophysiology
 Immunologic/allergic reaction results in
histamine release, which produces
three main airway responses
 a. Edema of mucous membranes
 b. Spasm of the smooth muscle of
bronchi and bronchioles
 c. Accumulation of tenacious secretions
Asthma Assessment Findings
 Assessment findings
 1. Family history of allergies
 2. Client history of eczema
Asthma Assessment Findings
 Assessment findings
 3. Pulmonary signs and symptoms-
Respiratory distress: slow onset of
shortness of breath, expiratory wheeze,
prolonged expiratory phase, air trapping
(barrel chest if chronic), use of accessory
muscles, irritability (from hypoxia),
diaphoresis, cough, anxiety, weak pulse,
diaphoresis and change in sensorium if
severe attack
Asthma Assessment Findings
 Assessment findings
 4. Use of accessory muscles of
respiration, inspiratory retractions,
prolonged I:E ratio
 5. Cardiovascular symptoms: tachycardia,
ECG changes, hypertension, decreased
cardiac contractility, pulsus paradoxus
 6. CNS manifestations: anxiety,
restlessness, fear and disorientation
Emphysema
 There is progressive and
irreversible alveolocapillary
destruction with abnormal
alveolar enlargement causing
alveolar wall destruction. The
result is INCREASED lung
compliance, DECREASED oxygen
diffusion and INCREASED airway
resistance!
Emphysema
These changes cause a
state of carbon dioxide
retention, hypoxia, and
respiratory acidosis.
Emphysema
Cigarette smoking
Heredity, Bronchial asthma
Aging process

Disequilibrium between
ELASTASE & ANTIELASTASE (alpha-1-antitrypsin)

Destruction of distal airways and alveoli
Overdistention of ALVEOLI
Hyper-inflated and pale lungs

Air traping, decreased gas exchange and Retention of CO2

Hypoxia Respiratory acidosis
Emphysema Assessment
1. Anorexia, fatigue, weight
loss
2. Feeling of breathlessness,
cough, sputum production,
flaring of the nostrils, use of
accessory muscles of
respiration, increased rate and
depth of breathing, dyspnea
Emphysema Assessment
 3. Decreased respiratory
excursion, resonance to hyper-
resonance, decreased breath
sounds with prolonged
expiration, normal or decreased
fremitus
 4. Diagnostic tests: pCO2
elevated or normal; PO2 normal
or slightly decreased
Chronic bronchitis
 Chronic inflammation of the
bronchial air passageway
characterized by the presence of
cough and sputum production for at
least 3 months in each 2 consecutive
years.
 Excessive production of mucus in
the bronchi with accompanying
persistent cough.
Chronic Bronchitis
pathophysiology
 Characteristic changes include
hypertrophy/ hyperplasia of the
mucus-secreting glands in the
bronchi, decreased ciliary
activity, chronic inflammation,
and narrowing of the small
airways.
Chronic Bronchitis Assessment
 I.Productive (copious) cough,
dyspnea on exertion, use of
accessory muscles of respiration,
scattered rales and rhonchi
 2. Feeling of epigastric fullness,
cyanosis, distended neck veins,
ankle edema
 3. Diagnostic tests: increased pCO2
decreased PO2
Bronchiectasis
 Permanent abnormal
dilation of the bronchi
with destruction of
muscular and elastic
structure of the bronchial
wall
Bronchiectasis
 Caused by bacterial infection;
recurrent lower respiratory
tract infections; congenital
defects (altered bronchial
structures); lung tumors
Bronchiectasis
 1. Chronic cough with production of
mucopurulent sputum, hemoptysis,
exertional dyspnea, wheezing
 2. Anorexia, fatigue, weight loss
 3. Diagnostic tests
 a. Bronchoscopy reveals sources and sites
of secretions
 b. Possible elevation of WBC
COPD Management
Independent and Collaborative
Management
 1. Rest-To reduce oxygen
demands of tissues
 2. Increase fluid intake-To liquefy
mucus secretions
 3. Good oral care-To remove
sputum and prevent infection
COPD Management
Independent and Collaborative Management
4. Diet:
 High caloric diet provides source of
energy
 High protein diet helps maintain integrity
of alveolar walls
 Moderate fats
 Low carbohydrate diet limits carbon
dioxide production (natural end product).
The client has difficulty exhaling carbon
dioxide.
COPD Management
 Independent and Collaborative
Management
5. O2 therapy 1 to 3 lpm (2 lpm is
safest)
 Do not give high concentration
of oxygen. The drive for
breathing may be depressed.
COPD Management
 Independent and Collaborative
Management
 6. Avoid cigarette smoking, alcohol,
and environmental pollutants-These
inhibit mucociliary function.
 7. CPT –percussion, vibration,
postural drainage
COPD Management
 Independent and Collaborative
Management
 8. Bronchial hygiene measures
 Steam inhalation
 Aerosol inhalation
 Medimist inhalation
COPD Management
 Pharmacotherapy
 1. Expectorants (guaiafenessin)/ mucolytic
(mucomyst/mucosolvan)
 2. Antitussives
 Dextrometorphan
 Codeine
 Observe for drowsiness
 Avoid activities that involve mental
alertness, e.g driving, operating electrical
machines
 Cause decrease peristalsis thereby
constipation
COPD Management
 Pharmacotherapy
 3.Bronchodilators
 Aminophylline (Theophylline)
 Ventolin (Salbutamol)
 Bricanyl (Terbutaline)
 Alupent (Metaproterenol)
 Observe for tachycardia
COPD Management
 Pharmacotherapy
 4. Antihistamine
 Benadryl (Diphenhydramine)
 Observe for drowsiness
 5. Steroids
 Anti-inflammatory effect
 6. Antimicrobials
Flail Chest

Complication of chest trauma
occurring when 3 or more
adjacent ribs are fractured at
two or more sites, resulting in
free-floating rib segments.
Flail Chest
Chest wall is no longer able
to provide the bony structure
necessary to maintain
adequate ventilation;
consequently
the flail portion and
underlying tissue move
paradoxically (in opposition)
to the rest of the chest cage
and lungs.
Flail Chest
 The flail portion is sucked in on
inspiration and bulges out on
expiration.
 Result is hypoxia, hypercarbia, and
increased retained secretions.
 Caused by trauma (sternal rib
fracture with possible costochondral
separations).
Flail Chest
 PATHOPHYSIOLOGY
 During inspiration, as the chest expands,
the detached part of the rib segment (flail
segment) moves in a “paradoxical”
manner
 The chest is pulled INWARD during
inspiration, reducing the amount of air that
can be drawn into the lungs
 The chest bulges OUTWARD during
expiration because the intrathoracic
pressure exceeds atmospheric pressure.
The patient has impaired exhalation
Flail Chest
This paradoxical action will lead to:
 Increased dead space

 Reduced alveolar ventilation

 Decreased lung compliance

 Hypoxemia and respiratory
acidosis
 Hypotension, inadequate tissue
perfusion can also follow
Flail Chest
Assessment findings
 1. Severe dyspnea; rapid, shallow, grunty
breathing; paradoxical chest motion. The
chest will move INWARDS on inhalation
and OUTWARDS on exhalation.
 2. Cyanosis, possible neck vein
distension, tachycardia, hypotension
 3. Diagnostic tests
 a. PO2 decreased
 b. pCO2 elevated
 c. pH decreased
Flail Chest
Nursing interventions
 1. Maintain an open airway: suction
secretions, blood from nose, throat,
mouth, and via endotracheal tube; note
changes in amount, color, and
characteristics.
 2. Monitor mechanical ventilation
 3. Encourage turning, coughing, and
deep breathing.
 4. Monitor for signs of shock:
HYPOTENSION, TACHYCARDIA
Flail Chest
Medical management:
SUPPORTIVE
 1. Internal stabilization with a
volume-cycled ventilator
 2. Drug therapy (narcotics,
sedatives)
Pneumothorax
Partial or complete collapse
of the lung due to an
accumulation of air or fluid in
the pleural space
Pneumothorax
Types
 a. Spontaneous pneumothorax: the
most common type of closed
pneumothorax; air accumulates
within the pleural space without an
obvious cause. Rupture of a small
bleb on the visceral pleura most
frequently produces this type of
pneumothorax.
Pneumothorax
Types
 b. Open pneumothorax: air enters
the pleural space through an
opening in the chest wall; usually
caused by stabbing or gunshot
wound.
Pneumothorax
Types
 c. Tension pneumothorax: air enters
the pleural space with each
inspiration but cannot escape;
causes increased intrathoracic
pressure and shifting of the
mediastinal contents to the
unaffected side (mediastinal shift).
Pneumothorax
Assessment findings
 1. Sudden sharp pain in the chest,
dyspnea, diminished or absent breath
sounds on affected side, tracheal shift to
the opposite side (tension pneumothorax
accompanied by mediastinal shift)
 2. Weak, rapid pulse; anxiety; diaphoresis
Pneumothorax
Assessment findings
 3. Diagnostic tests
 a. Chest x-ray reveals area and degree of
pneumothorax
 b. pCO2 elevated
 c. pH decreased
Pneumothorax
Nursing interventions
1. Provide nursing care for the client
with an endotracheal tube: suction
secretions, vomitus, blood from
nose, mouth, throat, or via
endotracheal tube; monitor
mechanical ventilation.
Pneumothorax
Nursing interventions
2. Restore/promote adequate
respiratory function.
 a. Assist with thoracentesis and
provide appropriate nursing care.
 b. Assist with insertion of a chest
tube to water- seal drainage and
provide appropriate nursing care.
 c. Continuously evaluate respiratory
patterns and report any changes.
Pneumothorax
Nursing interventions
3. Provide relief/control of pain.
 a. Administer
narcotics/analgesics/sedatives as
ordered and monitor effects.
 b. Position client in high-Fowler’s
position.
Atelectasis
 Collapse of part or all of a lung due
to bronchial obstruction
 May be caused by
 intrabronchial obstruction
 tumors, bronchospasm
 foreign bodies
 extrabronchial compression (tumors,
enlarged lymph nodes); or
 endobronchial disease (bronchogenic
carcinoma, inflammatory structures)
Atelectasis
Assessment findings
 1. Signs and symptoms may be absent
depending upon degree of collapse
and rapidity with which bronchial
obstruction occurs
 2. Dyspnea, decreased breath sounds
on affected side, decreased respiratory
excursion, dullness to flatness upon
percussion over affected area
Atelectasis
Assessment findings
 3. Cyanosis, tachycardia,
tachypnea, elevated temperature,
weakness, pain over affected area
Atelectasis
Assessment findings
4. Diagnostic tests
 a. Bronchoscopy: may or may not
reveal an obstruction
 b. Chest x-ray shows diminished size
of affected lung and lack of radiance
over atelectatic area
 c. pO2 decreased
Pleural Effusion

 Defined broadly as a collection of
fluid in the pleural space
 A symptom, not a disease; may be
produced by numerous conditions
Pleural Effusion
General Classification
Transudative effusion:
accumulation of protein-poor,
cell-poor fluid

Exudative effusion:
accumulation of protein rich
fluid
Pleural Effusion
Assessment findings
 1. Dyspnea, dullness over affected
area upon percussion, absent or
decreased breath sounds over
affected area, pleural pain, dry
cough, pleural friction rub
 2. Pallor, fatigue, fever, and night
sweats (with empyema)
Pleural Effusion
Assessment findings
3. Diagnostic tests
 a. Chest x-ray positive if greater than
250 cc pleural fluid
 b. Pleural biopsy may reveal
bronchogenic carcinoma
 c. Thoracentesis may contain blood if
cause is cancer, pulmonary infarction,
or tuberculosis; positive for specific
organism in empyema.
Pleural Effusion
Nursing interventions: In general:
 1. Assist with repeated thoracentesis.
 2. Administer narcotics/sedatives as
ordered to decrease pain.
 3. Assist with instillation of medication
into pleural space (reposition client every
15 minutes to distribute the drug within
the pleurae).
 4. Place client in high-Fowler’s position to
promote ventilation.
Pleural Effusion
Medical management
 1. Identification and treatment of the
Underlying cause
 2. Thoracentesis
 3. Drug therapy
 a. Antibiotics: either systemic or inserted
directly into pleural space
 b. Fibrinolytic enzymes: trypsin,
streptokinase-. streptodornase to decrease
thickness of pus and dissolve fibrin clots
 4. Closed chest drainage
 5. Surgery: open drainage
Pneumonia
An inflammation of the alveolar spaces
of the lung, resulting in
consolidation of lung tissue as the
alveoli fill with exudates
 The various types of pneumonias are
classified according to the offending
organism.
 Pneumonia can also be classified as
COMMUNITY Acquired Pneumonia
(CAP) and Hospital acquired
pneumonia (HAP)
Pneumonia
PATHOPHYSIOLOGIC FINDINGS ARE:
 HYPERTROPHY OF MUCOUS
MEMBRANE
 Increased sputum production
 Wheezing
 Dyspnea
 Cough
 Rales
 Ronchi
Pneumonia
PATHOPHYSIOLOGIC FINDINGS ARE:
 INCREASED CAPILLARY
PERMEABILITY
 Increased Fluid Exudation
 Consolidation-tissue that solidifies as a
result of collapsed alveoli
 Hypoxemia
Pneumonia
PATHOPHYSIOLOGIC FINDINGS ARE:
INFLAMMATION OF THE PLEURA
 Chest pain
 Pleural effusion
 Dullness
 Decreased Breath sounds
 Increased tactile fremitus
Pneumonia
PATHOPHYSIOLOGIC FINDINGS ARE:
HYPOVENTILATION
 Decreased Chest expansion
 Respiratory acidosis

Depressed PROTECTIVE MECHANISM
 Increased WBC (leukocytosis)
 Increased RR and Fever
Pneumonia
Assessment findings
 Cough with greenish to rust-colored
sputum production
 rapid, shallow respirations with an
expiratory grunt
 nasal flaring; intercostal rib retraction; use
of accessory muscles of respiration
 rales or crackles (early) progressing to
coarse (later).
 Tactile fremitus is INCREASED!
Pneumonia
Assessment findings
 Fever, chills, chest pain,
weakness, generalized malaise
 Tachycardia, cyanosis, profuse
perspiration, abdominal
distension
 Rapid shallow breathing
Pneumonia
Diagnostic tests
 a. Chest x-ray shows consolidation
over affected areas
 b. WBC increased
 c. pO2 decreased
 d. Sputum specimen- culture
reveal particular causative
organism
Pneumonia
1. Facilitate adequate ventilation.
 a. Administer oxygen as needed and assess
its effectiveness.
 b. Place client in Fowler’s position.
 c. Turn and reposition frequently clients who
are immobilized/obtunded.
 d. Administer analgesics as ordered to relieve
pain associated with breathing
 e. Auscultate breath sounds every 2—4
hours.
 f. Monitor ABGs.
Pneumonia
GENERAL Nursing interventions
2. Facilitate removal of secretions
 general hydration
 deep breathing and coughing
 Suctioning
 Expectorants
 aerosol treatments via nebulizer,
humidification of inhaled air
 chest physical therapy
Pneumonia
GENERAL Nursing interventions
3. Observe color, characteristics of
sputum and report any changes;
encourage client to perform good
oral hygiene after expectoration.
Pneumonia
GENERAL Nursing interventions
4. Provide adequate rest and relief/control of
pain.
 a. Provide bed rest with limited physical
activity.
 b. Limit visits and minimize conversations.
 c. Plan for uninterrupted rest periods.
 d. Institute nursing care in blocks to ensure
periods of rest.
 e. Maintain pleasant and restful environment
Pneumonia
GENERAL Nursing interventions
5. Administer antibiotics as ordered.
Monitor effects and possible toxicity.
6. Prevent transmission (respiratory
isolation may be required for clients with
staphylococcal pneumonia).
7. Control fever and chills: monitor
temperature and administer
 antipyretics as ordered, maintain increased
fluid intake, provide frequent clothing and
linen changes.
Pneumonia
GENERAL Nursing interventions
8. Provide client teaching and discharge
planning concerning prevention of
recurrence.
 a. Medication regimen/antibiotic therapy
 b. Need for adequate rest,
 c. Need to continue deep breathing and coughing
Pneumonia
GENERAL Nursing interventions
8. Provide client teaching and discharge
planning concerning prevention of
recurrence.
 d. Availability of vaccines
 e. Techniques that prevent transmission (use of
tissues when coughing, adequate disposal of
secretions)
 f. Avoidance of persons with known respiratory
infections
 g. Need to report signs and symptoms of
respiratory infection
Lung Cancer
Primary pulmonary tumors arise from the
bronchial epithelium and are therefore
referred to as bronchogenic carcinomas.

FACTORS:
Possibly caused by inhaled carcinogens
(primarily cigarette smoke but also
asbestos, nickel, iron oxides, air silicone
pollution; preexisting pulmonary disorders
PTB, COPD)
Lung Cancer
Assessment findings
 Persistent cough (may be productive
or blood tinged)
 chest pain
 dyspnea
 unilateral wheezing, friction rub,
possible unilateral paralysis of the
diaphragm
 Fatigue, anorexia, nausea, vomiting,
pallor
Lung Cancer
Diagnostic tests.
 a. Chest x-ray may show presence of tumor or
evidence of metastasis to surrounding
structures
 b. Sputum for cytology reveals malignant cells
 c. Bronchoscopy: biopsy reveals malignancy
 d. Thoracentesis: pleural fluid contains
malignant cells
 e. Biopsy of lymph nodes may reveal
metastasis
Lung Cancer
1. Provide support and guidance to
client as needed.
2. Provide relief/control of pain.
3. Administer medications as ordered
and monitor effects/side effects.
4. Control nausea: administer
medications as ordered, provide good
oral hygiene, provide small and more
frequent feedings.
Lung Cancer
5. Provide nursing care for a client with
a thoracotomy.
6. Provide client teaching and discharge
planning concerning
 a. Disease process, diagnostic and
therapeutic interventions
 b. Side effects of radiation and
chemotherapy
 c. Realistic information about prognosis
Lung Cancer
Medical management
 1. Radiation therapy
 2. Chemotherapy: usually includes
cyclophosphamide, methotrexate,
vincristine, doxorubicin, and
procarbazine; concurrently in some
combination
 3. Surgery: when entire tumor can be
removed
Lung Cancer
Quick Notes on Bronchogenic Cancer
Predisposing factors
 Cigarette smoking
 Asbestosis
 Emphysema
 Smoke from burnt wood
Types
 Squamous cell Ca- with good prognosis
 Adenocarcinoma- with good prognosis
 Oat cell Ca- with good prognosis
 Undifferentiated Ca- with poor prognosis
Lung Cancer
Quick Notes on Bronchogenic Cancer
Nursing Interventions
 Patent airway
 O2 / Aerosol therapy
 Deep breathing exercises
 Relief of pain
 Protection from infection
 Adequate nutrition
 Chest tube management
Lung Cancer
Quick Notes on Bronchogenic Cancer
Surgery
 Pneumonectomy=Removal of a lung (either left or
right)
 Lobectomy=Removal of a lobe.
 Segmentectomy=Removal of a segment.
 Wedge resection=Removal of the entire tumor
regardless of the segment.
 Decortication=Stripping off of fibrinous membrane
enclosing the lung
 Thoracoplasty=Removal of rib/s. Usually done after
pneumonectomy, to reduce the size of the empty
thorax thereby prevent mediastinal shift.
Pulmonary Embolism
This refers to the obstruction of the
pulmonary artery or one of its
branches by a blood clot (thrombus)
that originates somewhere in the
venous system or in the right side of
the heart.
 Most commonly, pulmonary
embolism is due to a clot or
thrombus from the deep veins of the
lower legs.
Pulmonary Embolism
Causes
 Fat embolism. Air embolism
 Multiple trauma
 PVD’s
 Abdominal surgery
 Immobility
 Hypercoagulability
Pulmonary Embolism
PATHOPHYSIOLOGY
 The thrombus that travels from any
part of the venous system obstructs
either completely or partially. Then
the lungs will have inadequate blood
supply, with resultant increase in
dead space in the lungs
 Gas exchange will be impaired or
absent in the involved area
Pulmonary Embolism
PATHOPHYSIOLOGY
 The regional pulmonary vasculature
will constrict causing increased
resistance, increased pulmonary
arterial pressure and then increase
workload of the right side of the
heart.
Pulmonary Embolism
PATHOPHYSIOLOGY
 When the work of the right side of
the heart exceeds its capacity, right
ventricular failure will result, leading
to a decrease in cardiac output
followed by decreased systemic
perfusion and eventually, SHOCK
Pulmonary Embolism
Assessment
 Restlessness (cardinal initial sign)
 Dyspnea
 Stabbing chest pain
 Cyanosis
 Tachycardia
 Dilated pupils
 Apprehension/ fear
 Diaphoresis
 Dysrhythmias
 Hypoxia
Pulmonary Embolism
Diagnostic Tests:
Ventilation-perfusion scan
Pulmonary arteriography
CXR
ECG
ABG
Pulmonary Embolism
Nursing Interventions
 Oxygen therapy STAT
 Early ambulation postop
 Monitor obese patient
 Do not massage legs
 Relieve pain- analgesics
 HOB elevated
 Heparin (2 weeks) then Coumadin (3-6
months)
Pulmonary Embolism
Patient Teaching for prevention of
Pulmonary Embolism
 Active leg exercises to avoid venous
stasis
 Early ambulation
 Use of elastic compression stockings
 Avoidance of leg-crossing and sitting
for prolonged periods
 Drink fluids
Surgical Aspect of Respiratory
Care
Thoracic Surgery
 a. Exploratory thoracotomy: anterior or
posterolateral incision through the
fourth, fifth, sixth, or seventh intercostal
spaces to expose and examine the
pleura and lung
Surgical Aspect of Respiratory
Care
Thoracic Surgery
 b. Lobectomy: removal of one lobe of a
lung; treatment for bronchiectasis,
bronchogenic carcinoma,
emphysematous blebs, lung abscesses
Surgical Aspect of Respiratory
Care
Thoracic Surgery
 c. Pneumonectomy: removal of an
entire lung; most commonly done as
treatment for bronchogenic carcinoma
Surgical Aspect of Respiratory
Care
Thoracic Surgery
 d. Segmental resection: removal of one
or more segments of lung; most often
done as treatment for bronchiectasis
Surgical Aspect of Respiratory
Care
Thoracic Surgery
 e. Wedge resection: removal of lesions
that occupy only part of a segment of
lung tissue; for excision of small
nodules or to obtain a biopsy
Surgical Aspect of Respiratory
Care
Nursing interventions: PREOPERATIVE
 1. Provide routine pre-op care.
 2. Perform a complete physical
assessment of the lungs to obtain
baseline data.
 3. Explain expected post-op measures:
care of incision site, oxygen, suctioning,
chest tubes (except if pneumonectomy
performed)
Surgical Aspect of Respiratory
Care
Nursing interventions: PREOPERATIVE
 4. Teach client adequate splinting of
incision with hands or pillow for
turning, coughing, and deep
breathing.
 5. Demonstrate ROM exercises for
affected side.
 6. Provide chest physical therapy to
help remove secretions.
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
 1. Provide routine post-op care.
 2. Promote adequate ventilation.
 a. Perform complete physical assessment of
lungs and compare with pre-op findings.
 b. Auscultate lung fields every 1—2 hours.
 c. Encourage turning, coughing, and deep
breathing every 1—2 hours after pain relief
obtained.
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
 2. Promote adequate ventilation.
 d. Perform tracheobronchial suctioning if
needed.
 e. Assess for proper maintenance of chest
drainage system (except after
pneumonectomy).
 f. Monitor ABGs and report significant
changes.
 g. Place client in semi-Fowler’s position
Surgical Aspect of Respiratory
Care
Nursing interventions:
POSTOPERATIVE
If pneumonectomy is performed,
follow surgeon’s orders about
positioning, often on back or
OPERATIVE SIDE
If Lobectomy, patient is usually
positioned on the UNOPERATIVE
SIDE
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
3. Provide pain relief.
 a. Administer narcotics/analgesics
prior to turning, coughing, and deep
breathing.
 b. Assist with splinting while turning,
coughing, deep breathing.
Surgical Aspect of Respiratory
Care
Nursing interventions:
POSTOPERATIVE
4. Provide client teaching and
discharge planning concerning
 a. Need to continue with
coughing/deep breathing for 6—8
weeks post-op and to continue ROM
exercises
 b. Importance of adequate rest with
gradual increases in activity levels
Surgical Aspect of Respiratory
Care
Nursing interventions: POSTOPERATIVE
4. Provide client teaching and discharge
planning concerning
 c. High-protein diet with inclusion of
adequate fluids
 d. Chest physical therapy
 e. Good oral hygiene
 f. Need to avoid persons with known upper
respiratory infection
 g. Adverse signs and symptoms
 h. Avoidance of crowds and poorly ventilated
areas.