ALTERATION IN RESPIRATORY SYSTEM
Tidal Volume: -volume of air inspired or expired with each normal breath, about 500ml 2. Inspiratory Reserve Volume -extra volume of air than can be inspired over & beyond the normal tidal volume, about 3000ml
3. Vital Capacity -equals IRV + TV + ERV or 1C + ERV -maximum amount of air that a person can expel from the lungs after filling the lungs to their maximum extent & expiring to the maximum extent 4. Total Lung Capacity -maximum volume to which the lungs can be expanded with the greatest possible effort
NOT CLINICALLY measured !
Residual volume 2. Functional residual volume 3. Total lung capacity
Expiratory Reserve Volume -amount of air that can still be expired by forceful expiration after the end of a normal tidal expiration 4. Residual Volume -volume of air still remaining in the lungs after the most forceful expiration
1. Inspiratory Capacity -equals TV + IRV -amount of air that a person can breathe beginning at the normal expiratory level & distending his lungs to maximum amount 2. Functional Residual Capacity -equals ERV + RV -about amount of air remaining in the lungs at the end of normal expiration
FACTORS AFFECTING RESPIRATORY FUNCTIONS
AGE -Infants have more rapid respiratory rate. They have primary respiratory activity that is abdominal -Changes of aging affect the breathing pattern. These include loss of elasticity, decreased reflex/cilia action, fragile mucous membrane, osteoporosis, decreased immune system and gastrogastroesophageal reflux.
- Altitude, heat, cold, air pollution affect oxygenation
- Physical exercise increases the rate and depth of respiration -Sedentary lifestyle will cause decreased alveolar expansion -Smokers are prone to develop COPD
STATUS -Healthy persons have intact respiratory functions -Diseases of the lungs affect oxygenation. -People with chronic illnesses often have muscle wasting and poor muscle tone.
-Sedatives, Hypnotics, tranquilizers, barbiturates and narcotics greatly depress respiratory drive.
-Physiologic and Psychological responses to stress can affect respiration. -Hyperventilation, lightheadedness, numbness and tingling sensation may result.
-Fetus and amniotic sac grow large enough to displace the diaphragm upward. -The mother¶s respiratory rate becomes faster and the breath becomes shallower. -µLightening¶ improves client¶s breathing
Normal Breathing pattern
1212-20 respiratory rate Active inspiration with contraction of diaphragm Passive expiration with relaxation of diaphragm Steady rhythm and regular rate and size I:E ratio is 1:2 (inspiration is half that of expiration)
DEVIATIONS FROM THE NORMAL RESPIRATORY FUNCTION
-A condition of insufficient oxygen in the lungs and the body. -Signs of Hypoxia may be the following: Tachycardia, Tachypnea, Dyspnea, Restlessness, LightLightheadedness, Flaring of nostrils, Intercostal retractions, changes in sensorium and Cyanosis.
-Inadequate alveolar ventilation, which can lead to hypoxia. -When CO2 accumulates in the blood, there is HYPERCARBIA.
-Bluish discoloration of the skin, nail beds and mucus membrane due to reduced hemoglobin-oxygen hemoglobinsaturation. -There must be about 5 grams or more of unoxygenated blood per 100 ml for this to manifest externally.
BREATHING PATTERNS -Breathing patterns refer to the rate, volume, rhythm and relative ease or effort of respiration. -Altered breathing can be related to rate, rhythm and position
ALTERED BREATHING PATTERNS: RATE EUPNEAEUPNEA- normal respiration which is quiet and effortless TACHYPNEATACHYPNEA- rapid breathing, more than 20 breaths per minute BRADYPNEABRADYPNEA- abnormally slow respiration (less than 12) APNEAAPNEA- cessation of breathing
ALTERED BREATHING PATTERNS: RHYTHM KUSSMAUL¶S BREATHING- Deep and rapid BREATHINGrespiration seen in metabolic acidosis(DM) CHEYNE-STOKES Respiration- Marked rhythmic CHEYNERespirationwaxing and waning of respiration from very deep to very shallow breathing and temporary apnea. Usually seen in cases of CHF, increased ICP and drug overdose. BIOT¶S respiration- Shallow breaths interrupted by respirationapnea, seen in patients with CNS disorders.
Position ORTHOPNEAORTHOPNEA- inability to breathe in a supine position. DYSPNEADYSPNEA- difficulty or uncomfortable breathing
AIRWAY Upper airway obstruction involves the nose, pharynx and larynx. -The most common clinical cause is the tongue! tongue! Lower airway obstruction involves the trachea, bronchi and lungs.
MISMATCH -When mismatching occurs, some alveolar regions will be well ventilated but poorly perfused (a condition known as DEADSPACE), -While others may be well perfused but poorly ventilated (known as SHUNTING)
1. ABG analysis 2. Sputum analysis 3. Direct visualization- bronchoscopy visualization4. Indirect visualization- CXR, CT and MRI visualization5. Pulmonary function test
test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an arterial sample
choose site carefully, secure equipmentsequipments- syringe, needle, container with ice Intra-test: Obtain a 5 mL specimen from Intrathe artery (brachial, femoral and radial) Post-test: Apply firm pressure for 5 Postminutes, label specimen correctly, place in the container with ice
normal values PaO2 80-100 mmHg 80PaCO2 35-45 mmHg 35pH 7.35- 7.45 7.35HCO3 22- 26 mEq/L 22O2 Sat 98-100% 98-
test analyzes the sample of sputum to diagnose respiratory diseases, identify organism, and identify abnormal cells
Encourage to increase fluid
intake Intra-test: rinse mouth with WATER Intraonly, 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 Postspecimen correctly
method of continuously monitoring the oxygen saturation of hemoglobin by photospectrometry A sensor or probe is attached to the earlobe, forehead, fingertip or the bridge of the nose
direct inspection of the trachea and bronchi through a flexible fiber-optic or a fiberrigid bronchoscope Done to determine location of pathologic lesions, to remove foreign objects, to collect tissue specimen and remove secretions/aspirated materials
PrePre-test: Consent, NPO x 6h, teaching IntraIntra-test: position supine or sitting upright in a chair, administer sedative, gag reflex will be abolished, remove dentures PostPost-test: NPO until gag reflex returns, position SEMI-fowler¶s with head turned to SEMIsides, hoarseness is temporary, CXR after the procedure, keep tracheostomy set and suction x 24 hours
fluid aspiration for obtaining a specimen of pleural fluid for analysis, relief of lung compression and biopsy specimen collection
Consent Intra-test: position the patient sitting with Intraarms on a table or side-lying fowler¶s, sideinstruct not to cough, breathe deeply or move Post-test: position unaffected side to Postallow lung expansion of the affected side, CXR obtained, maintain pressure dressing and monitor respiratory status
Pulmonary Function Tests
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: Spirometry Lung volumes Gas transfer Bronchial chalenge
Teaching, no smoking for 3 days, only light meal 4 hours before the test Intra-test: position sitting, bronchodilator, Intranosenose-clip and mouthpiece, fatigue and dyspnea during the test Post-test: adequate rest periods, loosen Posttight clothing
Airway Clearance Ineffective Breathing Pattern Impaired Gas Exchange Activity Intolerance Ineffective tissue perfusion Disturbed sleep pattern Acute pain Anxiety
The Overall goals for a client with oxygenation problems are to: Maintain patent airway Improve comfort and ease of breathing Maintain or improve pulmonary ventilation and oxygenation Demonstrate improved gas exchanges Improve ability to participate in physical activities
Oxygenation Positioning the client to allow for maximum chest expansion Encouraging or providing frequent changes in position- usually Q2H position Encouraging ambulation Giving pain medications before deep breathing and coughing
Deep breathing and coughing exercises These measures allow for the removal of secretions from the airway. Breathing exercises are frequently indicated for the clients with restricted chest expansion such as COPD and post-thoracic surgical postpatients.
Hydration This maintains the moisture of the respiratory mucous membrane. Increased fluid intake as tolerated Milk should be avoided as it increases the viscosity of secretions. Use of humidifiers Use of nebulizers or aerosol therapy
Positioning and Ambulation Ambulation and the ability to change position frequently are two natural means for keeping the lungs open and clear of secretions. Movements help shift respiratory secretions in the airway. Mucus tends to pool in the lungs of people who cannot move around.
PursedPursed-lip breathing This is a special measure to be used along with deep breathing. Patients with COPD should be taught this technique to aid in the release of trapped air from the obstructed airways. Prevents AIR- TRAPPING AIR-
Respiratory medications Bronchodilators, anti-inflammatory antidrugs, expectorants, mucolytics and cough suppressants may be used to treat respiratory problems
Chest Physiotherapy These are DEPENDENT nursing actions performed with a physician¶s order. Chest physiotherapy is based on the fact that mucus can be knocked or shaken form the walls of the airways and helped to drain from the lungs. The usual SEQUENCE is as followsfollowsPOSITIONING, Percussion, Vibration, and removal of secretions by SUCTIONING or Coughing followed lastly by oral hygiene
Oxygen therapy Use of cannula, face mask and venturi mask
Use of Artificial Airways These artificial airways are inserted to maintain patent air passages for clients whose airway have become or may become obstructed. These are devices that provide a more direct route to the lungs than the natural airway
Suctioning This is a mechanical aspiration of the airways involving the use of a catheter inserted through the nose, mouth or tracheal tube The catheter is attached to a portable or wall unit SUCTION machine. Secretions are drawn up by a vacuum.
of patients with chest tubes and drainage systems Assists in emergency interventions like removal of airway obstruction (by Heimlich maneuver), and initiating CPR
must collect data to evaluate the effectiveness of interventions. The nurse works with the patient to develop goals
Common Respiratory problems
-Breathing difficulty -Associated with many conditionsconditionsCHF, MG, GBS, Muscular dystrophy, obstruction, etc«
nursing interventions: 1. Fowler¶s position to promote maximum lung expansion and promote comfort. An alternative position is the ORTHOPNEIC position 2. O2 (1-3 lpm) usually via nasal (1cannula 3. Provide comfort
and sputum production Cough is a protective reflex Sputum production has many stimuli -Thick, yellow, green or rust-colored rustbacterial pneumonia -Profuse, Pink, frothy pulmonary edema -Scant, pink-tinged, mucoid Lung tumor pink-
nursing Intervention 1. Provide adequate hydration 2. Administer aerosolized solutions 3. advise smoking cessation 4. oral hygiene
Cyanosis Bluish discoloration 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
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
Interventions: Keep patent airway Determine the cause Suctioning prn 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 siteCauses 1. trauma 2. infection 3. Hypertension 4. blood dyscrasias , nasal tumor, cardio diseases
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 5 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 Pharyngitis and tonsillitis - Assessment findings Fiery-red pharyngeal membrane Fiery White-purple flecked exudates White Enlarged and tender cervical lymph nodes Fever malaise ,sore throat Difficulty swallowing Cough may be absent
Rhinitis(coryza,common cold) Allergic rhinitis Sinusitis
Pharyngitis Tonsillitis Laryngitis
-Viral -Exposure to allergens -Bacterial (strep,pneumo.) viral -Bacterial/viral -Bacterial(strep) Irritation due to excessive use of voice,exposure to irritants(cigarette smoke) Extension of rhinitis
airway infection: Tonsillitis -Infection and inflammation of the tonsils Most common organism- Group AorganismAbeta hemolytic streptococcus (GABS)
Laboratory tests 1. CBC 2. Culture
management 1. Antibiotics- penicillin Antibiotics2. Tonsillectomy for chronic cases and abscess formation
Interventions 1. Maintain Patent Airway -Increase fluid intake to loosen secretions -Utilize room vaporizers or steam inhalation -Administer medications to relieve nasal congestion
2. Promote comfort -Administer prescribed analgesics -Administer topical analgesics -Warm gargles for the relief of sore throat -Provide oral hygiene
3. Promote communication -Instruct patient to refrain from speaking as much as possible -Provide writing materials 4. Administer prescribed antibiotics -Monitor for possible complications like meningitis, otitis media, abscess formation 5. Assist in surgical intervention
ASSESSMENT FINDINGS Sore throat and mouth breathing Fever Difficulty swallowing Enlarged, reddish tonsils Foul-smelling breath Foul-
INTERVENTION for tonsillectomy 1. Pre-operative care Pre Consent Routine pre-op surgical care pre-
2. POST-operative care POST Position: Most comfortable is Lateral Decubitus for drainage Maintain oral airway, until gag reflex returns 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 then oral feeding follows.
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 Hemorrhage is the most serious complication usually 12-24hrs post op 12-
Acute Respiratory Failure
and life-threatening lifedeterioration of the gas-exchange gasfunction of the lungs Occurs when the lungs no longer meet the body¶s metabolic needs
Defined clinically as: 1. PaO2 of less than 50 mmHg 2. PaCO2 of greater than 50 mmHg 3. Arterial pH of less than 7.35
CAUSES CNS depression- head trauma, depressionsedatives CVS diseases- MI, CHF diseases Airway irritants- smoke, fumes irritants Endocrine and metabolic disordersdisordersmyxedema, metabolic alkalosis Thoracic abnormalities- chest trauma abnormalities-
Respiratory Drive Brain injury, sedatives, metabolic disorders impair the normal response of the brain to normal respiratory stimulation
Dysfunction of the chest wall Dystrophy, MS disorders, peripheral nerve disorders disrupt the impulse transmission from the nerve to the diaphragm abnormal ventilation
Dysfunction of the Lung Parenchyma Pleural effusion, hemothorax, pneumothorax, obstruction interfere ventilation prevent lung expansion
ASSESSMENT FINDINGS Restlessness Dyspnea Cyanosis Altered respiration Altered mentation Tachycardia Cardiac arrhythmias Respiratory arrest
DIAGNOSTIC FINDINGS Pulmonary function test ABG=pH below 7.35; hypoxia CXR- pulmonary infiltrates CXR ECG- arrhythmias ECG-
MEDICAL TREATMENT Intubation Mechanical ventilation Antibiotics Steroids Bronchodilators
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
are group of disorders associated with recurrent or persistent obstruction of air passage and airflow, usually irreversible. Asthma Chronic bronchitis Emphysema Bronchiectasis
most common and significant risk factor of COPD is cigarette smoking. Others- fumes, air pollution, recurrent Othersrespi. Infection, genetics
The general pathophysiology In COPD there is airflow limitation that is both progressive and associated with abnormal inflammatory response of the lungs
The acute episode of REVERSIBLE airway obstruction is characterized by airway hyperactivity to various stimuli Factors: Extrinsic Intrinsic
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
findings: history 1. Family history of allergies 2. Client history of eczema
Respiratory distress Shortness of breath Expiratory wheeze Use of accessory muscles Irritability diaphoresis, cough, anxiety, weak pulse
There is progressive and irreversible alveolar destruction with abnormal alveolar enlargement The result is INCREASED lung compliance, compliance, DECREASED oxygen diffusion and INCREASED airway resistance!
These changes cause a state of carbon dioxide retention, hypoxia, and respiratory acidosis.
Cigarette smoking Heredity, Bronchial asthma Aging process Disequilibrium between ELASTASE & ANTIELASTASE (alpha-1-antitrypsin) (alpha-
Destruction of distal airways and alveoli Overdistention of ALVEOLI HyperHyper-inflated and pale lungs
Air trapping, decreased gas exchange and Retention of CO2 Hypoxia Respiratory acidosis
fatigue, weight loss Feeling of breathlessness, cough sputum production, flaring of the nostrils Dyspnea Barrel chest
in percussion, decreased breath sounds with prolonged expiration Diagnostic tests: pCO2 elevated, PO2 normal or slightly decreased
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.
Characteristic changes include: Hypertrophy/ hyperplasia of the mucusmucus-secreting glands in the bronchi Decreased ciliary activity, chronic inflammation Narrowing of the small airways.
Assessment 1. Productive (copious) cough, dyspnea on cough, exertion, use of accessory muscles of respiration, scattered rales and rhonchi 2. Feeling of epigastric fullness, cyanosis, distended neck veins, edema 3. Diagnostic tests: increased pCO2 decreased PO2
Permanent abnormal dilation of the bronchi with destruction of muscular and elastic structure of the bronchial wall
Caused by bacterial infection or recurrent lower respiratory tract infections congenital defects (altered bronchial structures) lung tumors
assessment Chronic cough with production of mucopurulent sputum, hemoptysis, exertional dyspnea, wheezing Anorexia, fatigue, weight loss Diagnostic tests Bronchoscopy reveals sources and sites of secretions
1. Rest- To reduce oxygen demands of tissues Rest2. Increase fluid intake- To liquefy mucus secretions intake3. Good oral care- To remove sputum and prevent infection care4. 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).
5. O2 therapy 1 to 3 lpm (2 lpm is (2 safest)Do safest)Do not give high concentration of oxygen. The drive for breathing may be depressed 6. Avoid cigarette smoking, alcohol, and environmental pollutants. 7. CPT ±percussion, vibration, postural drainage
8. Bronchial hygiene measures Steam inhalation Aerosol inhalation Medimist inhalation
Pharmacotherapy 1. Expectorants (guaiafenessin)/ mucolytic (mucomyst/mucosolvan) 2. Antitussives Dextrometorphan Codeine
3. Bronchodilators Aminophylline (Theophylline) Ventolin (Salbutamol) Bricanyl (Terbutaline) Alupent (Metaproterenol) Observe for tachycardia
4. Antihistamine Benadryl (Diphenhydramine) Observe for drowsiness 5. Steroids Anti-inflammatory effect Anti6. Antimicrobials
Partial or complete collapse of the lung due to an accumulation of air or fluid in the pleural space
1. Spontaneous pneumothorax Rupture of a small bleb on the visceral pleura 2. Open pneumothorax air enters the pleural space through an opening in the chest wall; usually caused by stabbing or gunshot wound.
3. Tension pneumothorax air enters the pleural space with each inspiration but cannot escape causes increased intrathoracic pressure shifting of the mediastinal contents to the unaffected side (mediastinal shift).
Assessment findings 1. Sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side, tracheal shift side, to the opposite side 2. Weak, rapid pulse; anxiety; diaphoresis
3. Diagnostic tests a. Chest x-ray reveals area and degree xof pneumothorax b. pCO2 elevated c. pH decreased
Nursing interventions 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.
4. 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 water c. Continuously evaluate respiratory patterns and report any changes.
5. Provide relief/control of pain. a. Administer narcotics/analgesics/sedatives as ordered and monitor effects. b. Position client in high-Fowler¶s highposition.
Defined broadly as a collection of fluid in the pleural space
General Classification Transudative effusion: accumulation of proteinprotein-poor, cell-poor fluid ( cancers ) cellExudative effusion: accumulation of protein rich fluid ( infections )
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)
Diagnostic tests a. Chest x-ray positive x b. Pleural biopsy may reveal bronchogenic carcinoma c. Thoracentesis
Serous fluid in the
pleural cavity Hemothorax- Blood in the cavity Hemothorax ___________- Pus in the cavity ___________ ___________- Lymph in the cavity ___________-
Serous fluid in the
pleural cavity Hemothorax- Blood in the cavity Hemothorax Pyothorax- Pus in the cavity Pyothorax Chylothorax- Lymph in the cavity Chylothorax-
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)
Assessment findings Persistent cough (blood tinged) chest pain dyspnea unilateral wheezing, friction rub, possible unilateral paralysis of the diaphragm Fatigue, anorexia, nausea, vomiting, pallor
Diagnostic tests Chest x-ray may show presence of tumor xor evidence of metastasis to surrounding structures Sputum for cytology reveals malignant cells Bronchoscopy: biopsy reveals malignancy Thoracentesis: pleural fluid contains malignant cells
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
Quick Notes on Bronchogenic Cancer
factors Cigarette smoking Asbestosis CPD Smoke from burnt wood
Types Squamous cell Ca- with good Caprognosis Adenocarcinoma- with good Adenocarcinomaprognosis Oat cell Ca- with good prognosis Ca Undifferentiated Ca- with poor Caprognosis
Nursing Interventions Patent airway O2 / Aerosol therapy Deep breathing exercises Relief of pain Protection from infection Adequate nutrition Chest tube management
Surgery Pneumonectomy=Removal of a lung (either left or right) Lobectomy=Removal of a lobe.
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.
Causes Fat embolism Air embolism Multiple trauma PVD¶s Abdominal surgery Immobility Hypercoagulability
Assessment Restlessness (cardinal initial sign) Dyspnea Stabbing chest pain Cyanosis Tachycardia Dilated pupils Apprehension/ fear Diaphoresis Dysrhythmias Hypoxia
Diagnostic Tests: Ventilation-perfusion scan Ventilation Pulmonary arteriography CXR ECG ABG
Nursing Interventions Oxygen therapy STAT Early ambulation postop Monitor obese patient Do not massage legs Relieve pain- analgesics pain HOB elevated Heparin (2 weeks) then Coumadin (3-6 (3months)