RESPIRATORY SYSTEM

The respiratory system is that body process which accomplishes pulmonary ventilation. The act of
breathing involves an osmotic and chemical process by which the body takes in oxygen from the
atmosphere and gives off end products, mainly carbon dioxide, formed by oxidation in the alveolar
tissues.

ANATOMY OF RESPIRATORY SYSTEM

Upper Airway
A. Nasal passages:
1. Filter the air.
2. Warm the air.
3. Humidify the air.
B. Nasopharynx
1. Tonsils.
2. Eustachian tube: opens during swallowing to equalize pressure in the middle ear.
C. Oropharynx.
1. Part of both the respiratory and digestive tract.
2. Swallowing reflex initiated here.
3. Epiglottis closes entry to trachea as foodstuff passes enroute to the stomach.

Lower Airway
A. Larynx.
1. Protects the tracheobronchial tree from aspiration of foreign materials.
2. Cough reflex initiated here, whether voluntary or involuntary.
3. Houses the vocal cords, which are considered to be the dividing point between the upper
and lower airways.
B. Trachea.
1. Cylindrical structure.
2. Extend s from the cricoid carthage into the thorax, branching into the right and left main-
stem bronchi.
C. Right lung.
1. Contains three distinct lobes: upper, middle, and lower.
2. Lobes are divided by interlobar fissures.
D. Left lung.
1. Contains two lobes – upper and lower.
2. Lingula is part of the upper lobe but is sometimes referred to as the middle lobe of the left
lung.
3. Lobes are divided by one interlobar fissure.
E. Bronchi.
1. Right mainstem bronchus (RMSB): shorter and wider than left bronchus; nearly vertical to
trachea.
a. Most frequent route for aspirated materials.
 a. Endotracheal tube might enter the RMSB if tube is passed too far.
1. Left mainstem bro nchus (LMS B): b ranches o ff the trachea at a 45-degree angle.
2. The b ro nchi subdivide into b ro nchioles, terminal b ronchio les, respiratory bro nchio les, and
alveo li.
A. Alveoli.
1. Air cells in which gas exchange takes p lace: o xygen, carbo n d io xide.
2. Ho use a substance k nown as surfactant, which k eeps the alveo li expanded. Witho ut
surfactant the alveoli would collap se.
B. Pleura.
1. The p leural flu id is a thin of fluid, encasing each lung, which allows for a smooth, glid ing
mo tio n between the lung and the chest wall.
2. Even though this flu id is film- like, it wo uld be d ifficult to p ull it away fro m the chest wall
(analago us to two glass slides with fluid between them; the slid es mo ve back and forth
easily b ut are d ifficult to pull apart)

PRINCIPLES OF VENTILATION

Respiratio n
Definitio n: A process in which o xygen is transpo rted from the atmosphe re to the cells and carbon
dio xide is carried from the cells to the atmosp here.

A. Resp iratio n is d ivided into fo ur p hases.

1. Pulmo nary ventilatio n.
2. Diffusio n o f o xygen and carbon dioxide between alveoli and blood.
3. Transpo rtatio n o f o xygen and carbon dio xide in b lood to and fro m cells.
4. Regulatio n o f ventilation.
B. Resp irato ry cycle.
1. Inspiration (active process) – d iaphragm descends and external intercostals muscles
contract; alveo lar pressure decreases, allo wing air to flo w into the lungs.
2. Exp iration (normally a passive process) – alveo lar pressure increases, allowing air to flow
fro m the lungs.

Respirato ry Pressures
A. At inspiratio n the intra-alveolar pressure is more negative than the atmospheric pressure.
B. At exp iration the intra-alveolar pressure is more positive, thereby pressing the air o ut o f the
lungs.
C. A negative pressure exists in the intrap leural space and aids in keep ing the visceral p leura of the
lungs against the parietal pleura o f the chest wall. Lung space enlarges as the chest wall
expands.
D. Reco il tendency of the lungs is d ue to the elastic fibers in the lungs and the surfactant.

Surfactant
A. Surface-active material that lines the alveo li and changes the surface tensio n, depend ing on the
area over which it is spread.
B. Surfactant in the lungs allows the smaller alveo li to have lower surface tensio n than the larger
alveo li.
 1. Results in equal p ressures within both and p revents co llapse.
2. Production o f surfactant depends on adequate b lood supply.
A. Conditio ns that decrease surfactant.
1. Hypo xia.
2. Oxygen toxicity
3. Asp iratio n
4. Atelectasis.
5. Pulmonary edema.
6. Pulmonary embo lus.
7. Muco lytic agents.
8. Hyaline membrane d isease.

Comp liance
A. Relatio nship between pressure and vo lume: elastic resistance. This is determined b y d ividing
the tidal vo lume by peak airway p ressure (V, P AP). Tota l co mpliance eq uals chest wall
co mpliance.
B. Conditio ns that decrease chest wall co mp liance.
1. Obesity – excess fatty tissue o ver chest wall and abdo men.
2. Kyp hosco liosis – marked resistance to exp ansio n o f the chest wall.
3. Scleroderma – expansio n of the chest wall limited when the invo lved sk in o ver the chest
wall becomes stiff.
4. Chest wall injury – as in crushing chest wall injuries.
5. Diap hragmatic paralysis – as a result o f surgical damage to the phrenic nerve, or d isease
process invo lving the diaphragm itse lf.
C. Conditio ns that decrease lung compliance.
1. Atelectasis – co llapse o f the alveo li as a result o f obstruction or hypoventilatio n.
2. Pneumo nia – inflammatory p rocess involving the lung tissue.
3. Pulmonary edema – accumulation of fluid in the alveo li.
4. Pleural effusio n – accumulatio n o f p leural fluid in the pleural space co mpressing lung on
the affected side.
5. Pulmonary fibrosis – scar tissue replacing necrosed lung tissue as a result o f infectio n.
6. Pneumo thorax – air present in the p leural cavity; lung is co llapsed as volume o f air
increases.

Airway Resistance
A. Opposition or counterfo rce. Resistance depends on the d iameter and length o f a given tube
(resp iratory tract).
1. Flo w may b e laminar (smooth) or turb ulent.
2. Resistance eq uals p ressure d ivided by flow (Po iseuille’s law).
B. Conditio ns that increase airway resistance.
1. Secretio ns.
2. Bronchial co nstrictio n.

Lung Vo lumes
A. Total lung capacity (TLC) – total vo lume of air that is p resent in the lungs after maximum
insp iratio n.
A. Vital capacity (VC) – vo lume of air that can be e xpelled fo llowing a maximum inspiration.
B. Tidal volume (TV) – volume of a ir with each inspiratio n.
C. Insp iratory reserve vo lume (IRV) – vo lume of air that can be insp ired above the tidal vo lume.
D. Insp iratory capacity (IC) – volume of air with maximum inspiratio n; comprises tidal volume
and inspiratory reserve volume.
E. Exp iratory reserve vo lume (ERV) – vo lume of a ir that ca n be expelled fo llo wing a resting
expiration.
F. Reserve volume (RV) – vo lume o f a ir remaining in the lungs at the end of maximum
expiration.
G. Functional reserve capacity (FRC) – vo lume of a ir remaining in the lungs at the end of resting
expiration; comprises ERV and RV.
H. Forced expiratory vo lume, (F EV), volume of air that is e xpelled within the first second of the
vita l capacity.

Alveo lar Ventila tion

Definition: The rate at which the alveo lar air is renewed each minute b y atmosp heric – the most
important facto r of the entire pulmonary ventilatory process.

A. Rate of alveolar ventilation.

1. Alveolar ventilation is one of the major factors determining the co ncentrations of oxygen
and carbon dio xide in the a lveoli.
2. Alveolar ventilation per minute is the to tal vo lume of new air entering the alveoli each
minute equal to the respiratory rate times the amo unt of new air that enters the alveoli with
each b reath.
B. Dead space.
1. Dead space air is the air that fills the respiratory passages with each breath.
2. The vo lume of a ir that enters the alveo li with each breath is equal to the tidal volume minus
the dead space vo lume.
3. Anatomical dead space refe rs to volume of all spaces o f the respiratory system besid es the
gas exchange area s (the alveo li and terminal d ucts).
4. Physiological de ad space refers to alveolar dead space (occurring because of
no nfunctioning or partially functioning alveo li) included in the total measurement of dead
space.
5. In the no rmal person anato mical and physio lo gical dead space are equal because all a lveoli
are functional.

Oxygen and Carbo n Dioxide Diffusion and Transportation of Respiratory Gases

Ventilation
A. The first phase in respiration is ventilation, which is the constant rep lenishme nt of air in the
lungs.
B. Composition of alveolar air.
1. Alveolar air is only partially replenished by a tmospheric air each inspiratory p hase.
a. Appro ximately 350 cc o f new air (tida l volume minus dead space) is exchanged with the
functio na l residual capacity volume each resp iratory cycle (FRC = 2300 cc ).
 a. Sudde n c ha nges in gaseous co ncentrations are preve nted when alveolar a ir is rep laced
slowly.
1. Alveolar a ir co nta ins more ca rbo n dio xide a nd wa ter vapo r than a tmo sp heric air.
2. Alveolar o xyge n co nce ntratio n depends on the rate o f oxygen abso rbed into the b lood and
the ability of the lungs to take in carbo n d io xide.
3. Carbon dioxide co ntent is likewise a ffec ted b y the ra te carbo n d ioxide is passed into the
a lveo li fro m the blood a nd the ab ility o f the lungs to exp ire it.

Diffusion o f Gases
A. The ne xt phase is move ment o f o xygen fro m the alveolar air to the b lood and mo ve ment o f
carbon dioxid e in the opposite d irectio n.
B. Movement o f gases thro ugh the respiratory me mbra ne depe nds on the following factors.
1. Thickness of me mbra ne.
2. Permeability o f me mbra ne (diffusio n coefficie nt).
3. Surface area of the membra ne.
4. Differe nce s in gas pressures in the alveolar and blood sp aces.
5. Rate o f pulmonary circulatio n.
C. Blood low in carbon d io xide and high in oxyge n lea ves lungs.
D. Thro ugho ut the body there again is exchange o f resp iratory gases in the capillary beds.
1. Oxygen o ut of the blood and into the cells.
2. Carbon dioxide fro m ce lls into the blood.

Oxyge n Transport in the Blood

A. Abo ut 3 percent o f the o xyge n is carried in a d issolved sta te in the wa ter of p lasma and ce lls.
B. Abo ut 97 perce nt is carried in chemica l combination with he mo glob in in red b lood ce lls.
1. The perce nt of o xygen comb ined with eac h he moglobin molecule depends on the p artia l
pressure o f o xygen (pO 2 ).
2. The relatio nship is exp ressed as the o xygen- he mo globin d issociation curve.
a. It shows the pro gre ssive increase in the percent o f the hemo globin that is bo und with
oxyge n as the pO 2 increase.
b. When the pO 2 is high, o xygen b inds with the he mo globin, b ut when pO 2 is low (tissue
cap illaries), o xygen is released fro m hemo globin.
c. This is the basis for oxygen transport fro m the lungs to the tissues.
3. Febrile states and acido sis permit less oxygen to bind with Hb, thereb y limiting the a mo unt
of o xygen available for the tissues.
4. The amo unt of oxyge n that is available to the tissues depe nds o n the oxygen co nte nt o f the
blood and the ca rd iac output.
C. Inad eq uate o xygen tra nspo rt to the tissues – hypoxia.
1. Hypoxic hypoxia: low a rterial pO 2 ,
a. Alveo lar hypo ventilation.
b. Ventilation-perfusion ineq ualitie s.
c. Diffusion defects
d. Fraction of inspired o xygen (FIO 2 ), is le ss tha n atmosphere, such as in high altitudes.
2. Ane mic hypoxia : decrea sed o xygen-carrying capacity to the b lood.
a. Ane mia – less Hb ; there fore, less o xygen is ab le to combine with it.
 a. Carbon mono xide po iso ning – carbon monoxide co mb ines with the Hb, preventing
oxyge n fro m co mb ining with the Hb.
1. Circ ula tory hypoxia: circulatory insuffic iency.
a. Shock – decrease cardiac o utp ut.
b. Congestive heart fa ilure.
c. Arteria l vascular disease – loca lized obstruction to arterial b lood flo w.
d. Tissue need for o xyge n surpasses supp ly a vailab le.
2. Histoto xic hypoxia: prevents tissue s from utilizing o xyge n

Carbon Dio xide Tra nsport in the Blood

A. A sma ll a mount of carbo n d io xide is d isso lved in p lasma and red blood ce lls in the fo rm o f
bicarbonate.
B. Inside the red blood cells, carbo n d ioxide co mbines with water to form carbo nic ac id.
1. It is catalyzed b y the enzyme ca lled carbonic anhydrase.
2. The enzyme accelera tes the rate to a fractio n o f a seco nd.
C. In anothe r fractio n o f a second carbonic acid d issoc iates to form hydro gen io ns and b ica rbo nate
in the red ce lls.
D. Carbon d io xide co mbines with the he mo glob in molec ule.
1. The he mo glob in mo lec ule has give n o ff its o xygen to the tissues, and carbo n d ioxide
attache s itse lf.
2. The ve no us syste m carrie s the co mbined carbo n dioxide back to the lungs where it is
exp ired.

Regula tio n of Resp ira tio n

A. Respirato ry cente rs.
1. Pons – two respiratio n areas: p neumota xic and apneustic.
2. Medulla oblo ngata – major bra in area co ntro lling rhythmic ity o f resp iration.
3. Spinal cord – facilitory role in mainta ining re spiratory center.
4. Hering Breuer reflexes – stre tc h recepto rs located in lung tissue whic h assist in mainta ining
respiratory rhythm a nd preve nt o ver stretc h o f the lung. Afferent fibers are ca rried in the
vagus nerve.
B. Humoral regulatio n o f resp iration (chemica l).
1. Centra l c hemoreceptors.
a. Directly stimulated b y an increase in hydro gen io n conc entra tio n (ac idity) in the
cerebral sp ina l fluid.
b. An increase in arte ria l pCO 2 effects a rap id cha nge in pH of the cerebral spinal fluid,
increase s the depth and rate of respiration, and decreases the pCO 2 level.
c. Changes in hydro ge n io n a nd b icarbo nate ion concentra tio ns are no t as quick ly
recognized as c ha nges in the pCO 2 by the central c he mo recepto rs; respo nses to
metabolic imbala nces are slo wer.
d. Recepto rs are located in the medulla ob lo ngata and adjacent structures.
2. Periphera l che morecep tors.
a. Recepto r cells are loc ated in the carotid bod y at the b ifurcatio n of the commo n caro tid
arteries and a t the aortic arc h.
b. Inpulses from the aortic arch are tra nsmitted to the brain via the vagus nerve.
 a. Imp ulses from the carotid body are transmitted to the brain via the glossopharyngeal
nerve.
b. The periphera l chemoreceptors primarily respond q uickly to a decreased pO 2 (below 50
mm Hg) and to some e xtent to alteration of the pCO 2 and hydrogen ion co nce ntratio n in
the arterial blood.

System Assessment

A. Check fo r airway patency.

1. Clear out secretio ns.
2. Insert o ral airway if necessary.
3. Positio n client on side if the re is no cervical spine injury.
4. Pla ce hand or cheek over nose and mo uth of client to feel if client is ventilating.
B. Listen to lung so unds.
1. Absence of breath so unds: ind icate s lungs not e xpanding, due either to obstructio n or
deflation.
2. Rales (crackling sounds): indicate vibratio ns of fluid in lungs.
3. Rho nchi (coarse sounds): indicate pa rtial ob struction o f airwa y.
4. Decreased breath so unds: indicate poo rly-ventilated lungs.
5. Detectio n of bro nchial so unds that are deviated from normal position: indicates mediastinal
shift d ue to collapse of lung.
C. Determine level of co nsciousness; decreased sensorium can ind icate hypo xia.
D. Observe sp utum or trachea l secretio ns; bloody sputum can indicate contusions of lung or injury
to trachea and other a natomica l structures.
E. Evaluate vital signs for temperature, resp iratory rate, p ulse, a nd changes in skin co lor.
F. Evaluate fo r tightness or fullness in chest.
G. Determine degree of pain client is exp eriencing.
H. Observe for PVCs if client is on monitor.
I. Assess for resp iratory co mplications.
1. Assess for ab normal breathing pa tterns.
a. Dyspnea – labored or difficult breathing.
b. Hyperpnea – ab normal deep brea thing.
c. Hypopnea – reduced depth o f breathing.
d. Orthop ne a – difficulty breathing in other than upright positio n. Observe f
e. Tac hypnea – rapid breathing.
f. Stridor – no isy respirations as air is forced thro ugh a partially obstructed airway.
2. Eva luate cough.
a. Normally a protective mechanism utilized to keep the trachebronchial tree free of
secretions.
b. Common sympto m of respira tory d isease.
3. Assess bronchospasm.
a. Bro nchi narrow and secretions may be retained.
b. Conditio n may lead to infection.
4. Observe for hemoptysis – expectoratio n of blood or blood-tinged sp utum.
5. Assess for cyanosis – la te sign of hypoxia, due to large amounts o f reduced hemoglobin in
the blood (PaO 2 , of about 50 mm Hg).
 1.Observe for hypoxia (anoxia) – deficie ncy of o xygen in body tissues.
2.Evaluate for hypercapnia.
a. Occurs when carbon dioxide is reta ined.
b. High levels o f oxygen depress and/or paralyze the medullary respiratory center.
c. Perip heral chemoreceptors (sensitive to oxygen) become the stimuli for breathing.
3. Assess for presence o f respiratory alkalosis or acidosis.
A. Assess for o ther system comp lications.
1. Evaluate for polycythemia – increase in RBCs as a compensatory response to hypoxemia.
2. Observe for clubbing of fingers. Patho genesis is not well understood.
3. Evaluate for or pulmonale – enlargement o f the right ventricle as a result of pulmonary
arterial hypertension follo wing respiratory patho logy.
4. Evaluate for chest pain,
5. Assess for atelectasis.
6. Check fo r abdominal distentio n.
7. Assess for hypertension.
8. Evaluate cardiac status: CHF, cerebral edema, arrhythmias.
9. Assess for trauma to thorax.
B. Assess oxygen concentratio n with noninvasive pulse oximetry.
1. Senso r probe on earlobe, finger or toe registers light passing thro ugh vascular bed.
2. Allows continual monitoring o f arte rial oxygen saturatio n.
C. Assess for co nd itions associated with resp irato ry failure.
1. Infectious diseases: tuberculosis, pneumo nia.
2. Obstruction of airway: p ulmo nary embo lism, chronic bro nchitis, bronchiectasis,
emphysema, asthma, cardiac disorders leading to p ulmo nary congestion.
3. Restric tive lung d isease: pleural effusio n, pneumonthorax, atelectasis, p ulmo nary tumors,
obesity.
4. CNS depression: drugs, head injury, CNS infection.
5. Chest wall trauma: fail chest, neuromuscular d isease, congenital deformities.

Diagnostic P roced ures

Radio logic S tudies

A. Chest x-ray
B. Lung scintrigrap hy: measures concentration or gamma rays from lung after intak e of isotope.
C. Perfusion studies: o utline p ulmonary vascular structures after intake o f radioactive isotopes IV.
D. Bronchography.
1. An opaq ue substance is inse rted into trachea, and an x-ray is taken of the tracheobronchial
tree and lungs.
2. Client is n.p.o. to p revent dangers of regurgitation and aspiration.

Bronchoscopy

A. A tube- like lighted scope to visualize the inte rior of the tracheobro nchial tree.
B. Used as a therapeutic tool to remo ve foreign materials.
C. Procedure and nursing care
 1. Pla ce client supine with neck hyperextended.
2. Post procedure: check client’s ab ility to co ntrol secretions.
3. Observe for potential complicatio ns of laryngospasm, laryngeal edema, anesthesia
co mplications, subcutaneous emphysema.
4. Inform client to expect noarseness and sore throat.

Biopsy o f Respiratory Tissue

A. May be done by needle, via bro ncho scope, or an open lung procedure biopsy.
B. Nursing care: observe for h e mothorax and / or p neumothorax.

Thoracentesis
A. A needle p uncture through the chest wall to remove air or fluid.
B. Used for dia gnostic and / or therapeutic purposes.
C. Nursing care: observe for possible pneumothorax post procedure.

Pulmo nary Function Tests

A. Measure body’s ability to mechanica lly ventilate and to effect gaseous exchange.
B. See Lung Vo lumes under Princip les of Ventilation.

Tuberculin Skin Test

A. Mantoux intradermal test (more reliable).
1. Tuberculin injected intradermal, intermed iate PPD.
2. Test read 48 to 72 ho urs postintradermal wheal production.
3. Erythema not important
4. Area of ind uration more than 10 mm: ind icates positive reac tion (client has had co ntact with
the tubercle bacillus).
5. Reactions of 5 to 9 mm require retest.
B. Tine test.
1. Not recommended for diagnosis.
2. Test read on third day.
3. Mantoux test if induration more than 2 mm.

Arterial Blood Stud ies

A. Arterial blood ga ses.
1. Ind icate respira tory function b y measuring:
a. Oxygen (pO 2 )
b. Carbon Dioxide (pCO 2 )
c. pH
d. Oxygen saturatio n and bicarbo nate (HCO 2 )
2. Determine state of acid-base balance.
3. Reveal the adequacy of the lungs to p rovide oxygen and to remove carbon dioxide.
4. Assess degree to which kidneys can maintain a normal pH.
B. Normal arterial values.
1. Oxygen saturation: 93 to 98 percent.
2. PaO 2 : 95 mm Hg.
3. Arterial pH: 7.35 to 7.45 (7.4).
 1. pCO 2 : 35 to 45 mm Hg (40).
2. HCO 3 content: 23 to 27 mEq (25).
3. Base exce ss: - 3 to + 3 (0).

System P lanning and Analysis

A. breath so unds clearer to auscultation. Decreased rales and / or rho nchi. No advent itio us so unds
ausc ultated.
B. Shortness of breath reduced.
C. Coughing is more productive/effective.
D. Respiratory rate decreased; ve ntilation and air exchange increased.
E. Potential comp lications minimized.
F. Correction o f hypo xic conditio n so that client is adequately oxygenated.
1. Arterial pO 2 returns to normal range.
2. Improved vital capacity and pulmo nary ventilation.
3. Increased tissue o xygenatio n (pink colo r).
G. Client’s energy is conserved.
1. Abdominal breathing is more auto matic and respirations are more efficie nt and relaxed.
2. Clie nts with chronic lung diseases experience increased comfort and breathing efficiency.
H. Closed water-seal drainage is maintained, dra inage is evacuated, and lung reexpanded.
I. If necessary, a route is established for mechanical ventilatio n.
J. An artificial airway is provided when upper airway is ob structed.
K. For clients with chronic obstructive lung disease, a route is estab lished for long-term
ventillatory assistance.
1. Anatomic dead space is decrea sed.
2. Pulmonary toilet with hyperinflatio n o f lungs is acco mp lished.
3. Effective treatment fo r atelectasis or other p ulmo nary complicatio ns is pro vided.

System Imp lementation

A. Maintain patent airway.

1. Suctio n
2. Intubation.
a. Oral airway.
b. Endotracheal intubatio n.
B. Maintain adequate ventilation.
1. If client need s help b reathing, a ventilatory may be used.
a. Ventilator simulates breathing action usually pro vided by d iaphra gm and thoracic cage.
b. Type o f ventilato r depe nds on specific needs o f client.
2. Ventilators are classified by function based on cyc les and de livery.
C. Administer oxygen therapy using specific oxygen equip ment accord ing to the percentage o f
oxygen req uired by client.
D. Monitor b lood gases to determine how well client’s o xygen needs are being met.
E. Maintain fluid and electrolyte bala nce.
 1. Whe n b lood a nd fluid loss is replaced, watch carefully for fluid o verload, which can
lead to p ulmonary edema.
2. Record intake and output.
A. Mainta in ac id-base bala nce; make frequent b lood gas determination as acid-base imba lances
occur read ily with co mpromised resp irations or with mechanical ventilation.
B. Provide for relief o f pain.
1. Analgesics should be used with caution as they dep ress respirations. (Demerol is the drug of
cho ice).
2. Atropine, mo rphine sulfate, and barb iturates sho uld be avoided.
3. Nerve block may be used.
C. Administer electrocardio gram to establish if there is associated cardiac damage.
D. Provide for chest p hysiotherapy.
E. Mainta in hydration status.
1. Necessary to liquefy secretio ns or prevent fo rmation o f thick, tenacious secretions.
2. Monitor oral intak e of fluids, IV administratio n of fluids, or humidification to
tracheobronchial tree.
F. Administer appropriate drug therapy for resp iratory co nd ition.

System Evaluatio n

A. Resp iratory status is maintained.

B. Vital capacity and pulmonary ventilation are impro ved, and tissue o xygenation is increased.
C. Client’s energy is conserved.
D. Secretions are loosened, and lungs are fully e xpanded.
E. Client is able to breathe deep ly, and shortness of breath is reduced.
F. Breath sounds are clear to auscultation with no appa rent adventitious sounds.
G. Client is able to cough without assistance, and coughing is p roductive.
H. Arteria l pO 2 , returns to normal range, and correctio n of hypo xic co ndition occurs.
I. Client experiences increased comfort, and anxiety level is decreased.

INFECTIOUS DIS EASES

Pulmonary Tuberculosis

Definition: Airborned, infectious, communicable d isease thought to be caused by Mycobacterium

tuberc ulosis. May affect any part of the body, but is most common in the lungs. Disease may be
acute or chronic.

Characteristics
A. Tuberc le bacilli is rod-shaped and gram-positive, acid fast.
B. Diagnostic findings.
1. Early Am sputum for stain a nd culture: positive acid- fast bacillus.
2. Fiberoptic bronchoscopy and chest x-ray (to determine p resence and extent of TB).
3. Inc reased WBC and ESR.
4. Manto ux skin test: positive.
a. Purified protein derivative (PP D) tub erculin antigen.
 a. PPD tuberculin injected intrade rmally to form whe al 6-10 mm.
b. Test read 48 – 72 ho urs: significant ind uration is 10 mm d ia meter or more. Results
mea n c lie nt ha s had co ntac t – does not signify active disease is prese nt. Insignificant
reaction is ind uration less that 10 mm.
A. Most peop le infec ted do not deve lop clinical illness beca use the immune system b rings
infectio n under co ntro l.
B. PErsos at risk : persons with HIV, the elderly, certain mino rity groups, persons in close co ntact
with infec tious TB, or who ha ve live dormant bac illi fro m an initial infectio n acquired years
befo re.
C. Pathop hysiology.
1. Inhaled droplets conta ining the bacteria infect the alveoli that become the foc us of infec tio n.
2. After e ntrance o f tubercle bac illi, the bod y a ttempts to wall off the organism by
phagoc ytosis a nd lymp hocytosis.
3. Macrophages surround the bacilli and form tub ercle s.
4. Tubercles go thro ugh the process o f caseat io n – a necro tic proc ess. (Ce lls beco me an
a morp ho us cheese- like mass and ma be encapsulated to fo rm a nod ule).
5. Caseous nodule erode s and sp utum is released lea ving a n a ir- filled ca vity.
6. Initia l lesio n may dissemina te by exte nsio n, via bloodstrea m or lymph system, and thro ugh
bronc hi.

Assessme nt
A. Evalua te p ulmo nary sympto ms.
1. Cough (at cavitation stage)
2. Sputum productio n – initia lly dry, then p urule nt.
3. Dysp nea.
4. He mop tysis
5. Pleuritic pa in (with p leural invo lveme nt).
6. Ra les.
B. Evalua te systemic symptoms.
1. Fatigue, malaise.
2. Night swea ts, low-grade fe ver in afternoo n.
3. Wight loss.
4. Anore xia.
5. Irritab ility, la ssitude.
6. Tac hycard ia.
C. Comp lete p hysica l exa mination.
D. Comp lete soc ia l a nd med ical history.
E. Examine sp utum – takes 3 – 8 weeks for results c heck tube rculin test.

Imp le me nta tion

A. Mainta in resp ira tory preca utions.
1. Client no t conside red infectio us 2-4 weeks after initiation o f chemotherapy.
2. Teac h clie nt methods to p reve nt spread of d rop le ts whe n co ughing.
B. Monitor ad ministration of med icatio ns.
A co mb inatio n o f drugs used to destro y variable microbia l organisms.
 1. Current regimen is 2 months o f iso niazid (INH) rifamp in (RIF), and p yrazinamide (PYZ)
fo llo wed b y 4 months of iso niazid and rifampin. Streptomycin and Ethambutol are also
reco mmended for initial treatment.
a. Six mo nths o f d rug therap y is usually sufficient for k illing the bacilli. Treatment may
continue fo r 1 year, at least 9 mo nths for HIV positive.
b. Sputum smears obtained every 2-4 weeks until negative (sp utum cultures beco me negative
in 3-5 mo nths).
2. Second- line drugs used fo r resistant clients: capreomycin, kanamycin, para-aminosalicylic
acid, and cyclo serine.
3. Drugs more effective when ad ministered in single daily dose.
4. Drug resistance is a prob lem, esp ecially in Asians.
5. Corticosteroids may be used to gether with antituberculosis agents in severe cases to red uce
symptoms.
A. Chemop rop hylaxis.
1. Isoniazid and vitamin B6 therapy for 6 mo nths to 1 year given to those infected with
tubercle bacillus witho ut the d isease or to tho se at high risk for develop ment of the d isease.
2. Evaluate for potential co mp licatio ns o f INH therap y: liver dysfunctio n and liver damage.
a. Check for fatigue, loss o f appetite, joint pain, dark, urine, fever, right upper quad rant
tenderness, nausea, and vo miting.
b. Enco urage client to report for frequent prescribed liver function stud ies.
B. Work with client to maintain comp liance – the major prob lem in eliminating TB.
1. Strict co mp liance to drug regimen.
2. Monthly fo llow-up visits fo r sp utum smear until conversio n.
C. Instruct client in ways to prevent spread o f d isease.
1. Cover nose and mo uth with a few layers o f d ispo sab le tissue when sneezing o r coughing.
2. Expecto rate into a disposable sp utum container.
3. Maintain adeq uate air ventilatio n.
D. Deco ntaminate infected air b y no nrecircula ted air or ultravio let rays.
E. Provide well-balanced d iet: high carbo hydrate, high protein, high vitamin B6 .
F. Provide frequent oral hygiene.

Pneumonia
Definitio n: An acute inflammatory process o f the alveo lar paces resulting in a lung consolidatio n as
the alveo li fill with exudate.

Assessment
A. Evaluate fo r type of p neumo nia.
1. Bacterial p neumonias.
a. Lobar.
(1) Pneumococcus is the most co mmo n organism.
(2) Communicab le d isease.
(3) Yo ung males mo st affected.
(4) Clinical manifestatio ns.
(a) Rap id o nset, severe chills, high temperature (1030 to 1060 F, reduced b y crisis).
(b) Constant dry, hacking co ugh.
 (a) Pleuritic pain.
(b) Anxiety.
(c) Dysp nea.
(d) Sputum –wa tery to rust-colored.
a. Bronc hop neumo nia.
(1) Strep and stap h co mmo n organis ms.
(2) Asp iratio n freq uently of this type (food, chemica l, smoke, o il).
(3) Secondary to other co nd itio ns such as age, deb ilitatio n, stasis.
(4) Commo n in very yo ung and very old.
(5) Clinical manifestatio ns.
(a) Temperature – 1010 to 1030 F (red uced b y lysis ).
(b) Cough prod uctive – yello w or gree n sp utum.
1. Atyp ical p neumonia.
a. Known etio lo gy – rick ettsial: Q fever, Rock y Mo untain spotted fever, psittacosis.
b. Nonspecific etio lo gy – k nown as walk ing p neumo nia.
(1) Found in co mmo n liv ing co nd itio ns.
(2) Most co mmo n in yo ung ad ults.
(3) Te mperature not usually abo ve 990 F reduced b y lysis).
(4) Clinical manifestatio ns.
a) Malaise.
b) Fatigue.
c) Chills.
d) Cough – usually no nprod uctive (“goose ho nk ”)
e) Sputum – clear or white (if prod uctive).
A. Assess fo r exacerbatio n of c hro nic ob structive e p ulmo na ry disease as resp irato ry infectio ns
precip itate this co nd itio n.
B. Observe for a n increase in the a mo unt o f sp utum.
1. Change in the c haracter o f sp utum (particularly co lor – yello w to green).
2. Onset o f ma la is e ore feb rility ma y ind icate infectio n.

Imp le mentatio n
A. Maintain bed re st until tempe rature is norma l.
B. Limit visitors.
C. Force fluids to 3000 cc or mo re to p ro vide hydratio n.
D. Observe and record type and amo unt o f sp utum .
E. Ad minister antibio tics as ord ered.
1. Given fo r a period o f 10 to 14 da ys.
2. Antib iotics most co mmo nly used a re amp icillin and tetracyc line.
F. Provide p hysio therap y as ordered.
G. Obtain throa t, sputum, and blood cultures for spec ific organisms.
H. Ad minister o xygen at 6 1/minute unless COPD.
I. Ad minister antipyretic d rugs.

Hypo xic Co nd itio n

Definitio n: O xygen defic ie ncy – the primary ind icatio n fo r initatio n o f o xygen therap y.
Assessment
A. Check to see if client has a patent airway.
B. Assess client’s vital signs.
C. Observe existence of P VC s if client is on monitor.
D. Observe client for any of the following signs. If these signs are evident, yo u may need to
administer oxygen.
1. Tachycardia.
2. Gasping and/or irregular respirations (dyspnea).
3. Restlessness.
4. Flarig nostrils.
5. Cyanosis.
6. Subternal o r intercostal retractions.
7. Increased b lood pressure followed by decreased blood pressure.
8. Abnormal ABGs.
E. Evaluate for stages of hypoxia.
1. Early symp to ms.
a. Restlessness.
b. Headache, visual disturbances
c. Slight confusion
d. Hyperventilation.
e. Tachycardia.
f. Hypertension.
g. Dyspnea
2. Late symptoms
a. Hypotension.
b. Bradycardia.
c. Metabolic acidosis (production of lac tic acid).
3. Chronic oxygen lack.
a. Polycythemia.
b. Clubbing of fingers and toes.
c. Thrombosis.
F. Assess for side effects of oxygen therapy.
1. Atelectasis.
a. Nitrogen is washed out of the lungs when a high FIO 2 is delivered to client.
b. In alveoli free of nitrogen, oxygen diffuses out of the alveoli into the blood faster than
ventilation brings oxygen into the alveoli.
c. This results in a collapse (atelectasis) of the affected alveo li.
2. Pulmonary oxygen toxicity.
a. High FIO 2 delivered over a long period of time (48 hours) results in destruction of the
pulmonary cap illaries and lung tissue.
b. The clinical picture resembles that of pulmonary edema.
3. Retrolental fibroplasia
a. Blindness resulting from high FIO 2 delivered to premature infants.
b. This condition is seen in prolonged F IO 2 of 100 percent when high levels of oxygen not
needed.
4. Carbon dioxide narcosis.
 a. Carbon dioxide narcosis can develop if hypoxic d rive is removed by administering FIO 2
to return the arterial pO 2 to normal range.
b. Symp to ms o f carbo n d ioxide narcosis.
(1) Comatose.
(2) Flushed, pink sk in.
(3) Flaccid (sometimes twitching) extre mities.
(4) Shallow breathing.
A. Evaluate client for clinical manifestations of COPD.
1. Ve ntila tory drive is hypoxemic.
2. Oxyge n ad ministration requires critical observatio n. Start at 2 1/minute.

Imp lementation
A. Monitor lung sounds for adeq uate ventilatio n.
B. Monitor client for signs of oxygen to xicity.
C. Provide skin care fo r areas surrounding oxygen eq uipment.
D. Administer oxygen a t appropriate flo w with specified eq uipment.
1. Nasal prongs and cannula.
a. Easily tolerated by clients.
b. The FIO 2 will vary dep end ing on the flow.
(1) FIO 2 : 24-28%. Flow: 1-2 1.
(2) FIO 2 : 30-35%. Flow: 3-4 1.
(3) FIO 2 : 38-44%. Flow: 5-6 1.
2. Mask without reservo ir bag.
a. Requires fairly high flows to prevent re breathing of carbon d io xide.
b. Accurate FIO2 difficult to estimate.
(1) FIO 2 : 35 – 45%. Flow: 8-12 1.
(2) FIO 2 : 45 – 55%. Flow: 8-12 1.
(3) FIO 2 : 55 – 65%. Flow: 8-12 1.
3. Mask with reservoir bag.
a. Higher F IO2 is delivered b ecause of the re servior
b. At flows less than 6 1/minute, risk o f rebreathing carbon dio xide increases.
(1) FIO 2 : 50 – 60%. Flow: 6 1.
(2) FIO 2 : 60 – 70%. Flow: 7 1.
(3) FIO 2 : 70 – 100%. Flow: 8-10 1.
4. Ve nturi ma sk.
a. Delivers fixed or pred icted FIO2 .
b. Utilized effectively in clients with COPD when acc ura te FIO 2 is necessary fo r proper
treatment.
(1) FIO 2 : 24%. Flow: 2-4 1.
(2) FIO 2 : 28%. Flow: 4-6 1.
(3) FIO 2 : 35%. Flow: 6-8 1.
5. Face tent.
a. Well-to lerated by clients b ut sometimes difficult to keep in place.
b. Convenie nt for providing humidificatio n with compressed air in co njunctio n with nasal
prongs.
c. FIO 2 : 35 – 50%. Flow: 8-10 1.
 1. Oxygen hood.
a. Hood fits o ver child’s head.
b. Provides warm, humidified o xygen at high co ncentratio ns.
c. FIO 2 : 40 – 35%. Flo w: 5-12 1.
2. Intratracheal o xygen device for lo ng=-term

CHRONIC OBSTRUCTIVE
PULMONAR Y DISEASE (COPD)

Definition: A functional catego ry applied to resp iratory d iso rders that obstruct the pathway of
normal alveolar ventilatio n either b y spasm o f the airways, mucus secretions, or changes in
airway and/or alveo li.

Chronic B ronchitis

Definition: A lo ng-term inflammatio n o f the muco us membrane o f the bronchial tubes with
recurrent co ugh and sp utum prod uction.

Cha racteristics
A. Cigarette smok ing is probably the biggest culprit, inhib iting the ciliary activity o f the
bronchi, and resulting I increased stimu latio n o f the muco us glands to secrete mucus.
B. Immuno lo gical factors and familial p red isposition may also be implicated fo r those
ind ivid uals who do not smoke.

Assessment
A. assess fo r bro nchoco nstrictio n.
B. Evaluate mal;aise.
C. Check fo r exertional d ysp nea.
D. Assess for hemoptysis.
E. Evaluate co ugh – may not be p rod uctive but may be p urulent.
F. Assess for hypoxia
1. Atelectasis.
2. Percussion – hyperreso nant.
3. Tactile fremitus decreased.
4. Pro lo nged expiratory p hase.
5. Expansion decreased.
6. Trachea mid line.
7. Wheezes, rales.

Implementatio n
A. Ad minister antibio tics when infectio n occurs,.
B. Ad minister bro nchodilators to relieve bro ncho-spasm and facilitate mucus expectoration.
C. Force fluids to 3000 cc daily
D. Provide chest p hysio therapy.
E. Monitor o xygen therap y.
Bronchiectasis
Definition: Though to develop following airway obstruction or atelectasis as a result of disease,
such as tuberculosis, or infection, such a pneumonia.

Assessment
A. Evaluate for frequent, servere paroxysms of coughing.
B. Assess for hemoptysis.
C. Check for fetid breath.
D. Assess or thick, profuse sputum.
E. Observe for breathlessness, fatigue.
F. Assess for profuse night sweats.
G. Assess for weight loss, anorexia,.
H. Evalu7ate lung filed and chest for the following:
1. Trachea deviates to the affected side.
2. Decreased expansion.
3. Percussion – dull.
4. Vocal fremitus and breath sounds absent if bronchus occluded.
5. Vocal fremitus increase; bronchovesicular / bronchial breath sounds if bronchus open.
6. Rales, rhonchi.

Implementation
A. Ad minis ter antibiotics as ordered. Usually given for 7 to 10 days,.
B. Provide chest physiotherapy.
C. Ad minister bronchodilator to assist in removal of secretions.
D. Monitor oxygen therapy if hypoxia occurs.
E. Prepare client for surgery if servere hemoptysis occurs.
F. Encourages client to rest by providing quiet environment.
G. Provide high-protein diet with increased fluid in take.
H. Provide frequent mouth care.

Emphysema
Definition: the permanent overdistention of the alveoli with resulting destruction of the alveolar
walls (Emphysema is a Greek word meaning “overin- flated.”)

Assessment
A. Alpha, antitrypsin deficiency causes condition to develop at a younger age.
B. Observe for dyspnea – chief complaint.
C. Assess sputum production.
D. Observe for weight loss.
E. Assess for hypoxia, hypercapnia.
F. Observe for barrel chest.
G. Observe if expansion decreased.
H. Assess for flat d iaphragm.
I. Observe if accessory muscles of respiration are used.
J. Assess for decreased tactile fremitus
K. Percuss for hyperresonance.
 A. Auscultate for d istant brea th so unds.
B. Asswes fo r pro lo nged exp iratory p hase.
C. Assess for wheezes, forced exp iratory rho nchi.
1. Pulmo nary hypertensio n.
2. Right-sided heart failure.
3. Spontaneo us p neumo thorax.

Implementatio n
A. Monitor for signs o f impe nd ing hypo xia.
B. Monitor for alteratio ns in lung so unds.
C. Instruct o n p ursed lip breathing exercises.
D. Ad minister lo w co ncentratio n o xygen. Usually 21 /min.
E. Monitor for signs o f carbo n d io xide narcosis.
F. Provide hydratio n.
1. Necessary to liq uefy se cretio ns prese nt, or to pre vent formatio n o f thick, tenacio us
secretio ns in clients with p ulmo nary d isease.
2. Modalities.
a. Oral intak e o f fluids/
b. IV ad ministratio n o f fluids.
c. Humid ificatio n to tracheob ro nchial tre e via face tent or aeroso l mask, using
co mpressed air.
3. Humid ificatio n and aero so l therap y.
a. Humid ity.
(1) Water co ntent o f a gas at a given temperature.
(2) Humid ificatio n can be delivered thro ugh humid ifier or neb ulizer.
b. Aeroso l.
(1) Suspensio n o f water particles in a gas med ium
(2) Nebulizers deliver aero so ls.
c. Clinical imp licatio ns.
(1) Relief o f b ro nchopasm and muco sal edema.
(2) Mob ilizatio n o f secretio ns.
(3) Ad ministratio n o f med icatio ns such as b ro nchod ilators, muco lytics, detergents,
and selecte4d antib io tics.
(4) Humid ificatio n o f the tracheobro nchial tree.

Positio ns fo r Chest Physiothera py

 To affect RUL and LUL, p lace clie nt in up right po sitio n.
 To affect RML, po sitio n client o n left sid e with head sla nted do wn, right sho ulder o ne-
quarter turn o nto p illow. C up anteriorly o ver left nipp le.
 To affect lingual LL, positio n client o n right side with head slanted down, left sho ulde r o ne-
quarter turn o nto p illow. C up anteriorly o ver left nipp le.
 To a ffect RLL and LLL, p lace client in Trendele nb urg’s positio n, alternatuing sides, or
prone.

G. Provide for chest p hysio therap y.

1. Postural d rainage.
 a. Positions are utilized to pro mote gravitational drainage and mob ilizatio n of
secretio ns o f affected lung segments.
b. This allo ws the client to expectorate them
c. They may also be asp irated thro ugh a sterile suctioning proced ure
2. Cupp ling and vibration.
a. Valuab le and necessary ad junct to postural drainage.
b. Vibratio n o f the chest is performed only d uring the exp iratory phase o f resp iratio n.
3. Deep breathing and co ughing.
a. Sho uld be enco uraged often.
b. Clients with COPD should be taught the mechanics of an effective co ugh.
(1) Contract intercostal muscles.
(2) Contract diap hragm.
(3) Fill lungs with air.
4. Breathing exercises or exercise regimen – and integral part in the management o f clients
with p ulmonary disease.
a. Diaphragmatic breathing.
(1) Breathe in via nose.
(2) Exhale through slightly p ursed lips
(3) Contract abdo minal muscles while exhaling.
(4) Chest sho uld not mo ve, b ut abdo men sho uld do the moving (Abdo men contracts
at exp iration
(5) Exer5cises can be learned with client flat o n back and then do ne in o ther
positio ns.
b. Accelerate d iap hragmatic breathing.
c. Chest expansio n – ap ical, lateral (unilateral, bilateral), basal.
d. Controlled b reathing with daily activities and grad ed exercises to impro ve general
physical fitness.
e. Relaxatio n and stretching.
f. General relaxation.
5. Intermittent positive p ressure breathing (IPPB).
a. Purposes.
(1) Impro ve oxygenatio n to the lungs
(2) Impro ve alveolar ventilatio n
(3) Deliver aerosolized bro nchod ilators.
(4) Decrease the work of b reathing.
(5) Mobilize secretio ns.
(6) Impro ve or prevent atelectasis.
(7) Treat pulmo nary edema.
b. IPPB treatments should be ad min istered b y a resp iratory therap ist or trained nursing
perso nnel.
c. Client should not be left unattended during the IPPB treatments.
d. Postural drainage, cupping and vibratio n, and coughing and deep breathing should
fo llo w each trea tment.
B. Monitor carefully for co mp licatio ns of right-sided heart failure (cor p umo nale) and left-
sided failure.
Chronic Asthma
Definition: A conditio n ma nifested b y d ifficult b reathing and c ha racterized by ge nera lized
broncho co nstric tion, excess muc us secre tio n, a nd mucosa l ede ma.

Assessment
A. Assess for type o f asthma.
1. Extrinsic – early o nset in life and o ften assoc iated with history of a llergy.
2. intrinsic – usually ad ult o nset a nd o ften assoc iated with enviro nme nta l factors.
B. Eva lua te fo r prec ipitating factors.
1. Etio lo gy unknown.
2. Emo tio n.
3. Infectio n.
4. Seasonal changes.
5. Pets.
6. Smok ing.
7. Family histo ry.
8. Occupatio nal expo sure to d usts or chemica l irritants.
9. Drugs.
C. Eva lua te fo r resp ira tory proble ms.
1. Resp irato ry d istress.
2. Air hunger
3. Tachypnea
4. Prolonged e xp iratory p hase.
5. Cough ma y be no nprod uctive or ve ry p urule nt.
6. Tachycad ia.
7. Hypo xia, cyab nosis, hypercap nia.
8. Assess p hysical signs.
a. Retractio n o f intercostal a nd sternal muscles.
b. Percussion – hype rresona nt.
c. Distant b reath so unds.
d. Rho nchi, wheezes, ra le s.

Imple mentatio n
A. Provide supportive respirato ry case.
B. Ad minister drug therap y.
1. Bronc hod ila tors.
a. Ep inephrine and derivative s.
b. Aminop hyline a nd derivatives.
c. Cromo lyn (Intal).
d. Isoetha rine (Bro nko so l).
2. Corticostero ids.
C. Sedatives and narcotics sho uld be used with cautio n.
D. Ad minister o xyge n via nasa l ca nnula.
E. Force fluids to 3000 cc daily.
F. Monitor IPPB treatments.
CHRONIC R ESTRICTIVE
DISORDERS

Pleural Effusion
Definition: A collection of non-purulent fluid in the pleural space. Many pathological processes can
irritate the pleurae and cause effusion, but in older clients cancer is a common cause.

Assessment
A. Assess for dyspnea
B. Check fatigue level.
C. Assess fir elevated temperature
D. Assess for dry cough.
E. Assess for pleural pain.
F. Assess physical signs.
1. Absence of movement on side of effusion.
2. Percussion – dull.
3. Decreased breath sounds.
4. Pleural friction rub occurs in dry pleurisy, but as effusion develops, the friction rub
disappears.
5. Collapse of lung – when fluid increases in amount.
6. Mediastinal structures shift position.
7. Cardiac tamponade.

Implementation
A. Assist with thoracentesis, which is used to aid in diagnosis and to relieve pressure by
draining excess fluid.
1. Explain procedure to client.
2. Instruct client to tell you any compromising symptoms such as difficulty in breathing or
discomfort.
3. Give client reassurance during procedure.
B. Monitor vital signs.
C. Following removal of fluid, observe for bradycardia, hypotension, pain, or pulmonary
edema.
D. Monitor administration of drugs if ordered for empyema.
E. Administer oxygen as ordered.
F. Teach deep-breathing exercises to increase lung expansion.
G. Monitor chest rubes ad drainage.

Pneumothorax
Definition: A collection of air in the pleural cavity. As the air collects in the pleural space, the lung
is collapsed and respiratory distress ensues. The condition occurs as a result of chest wall
Characteristics
A. Tension p neumothorax is a med ica l emergency.
1. The mediastinum shifts away from the side of the p neumothorax co mp ressing the
unaffected lung.
2. A large-bore need le is introduced into the p leural cavity to re lease the pressure.
3. A tube toracosto my is then performed.
B. A small pne umothorax may reabsorb on its own.
1. If the penumotho rax is large or increasing in size, closed tube toraco sto my is performed.
2. Water-seal is utilized to reexpand the lung.
C. Hemothorax occurs with pne umotho rax, especially if trauma is the causative fac tor.
D. Trea tme nt: e va cuate the blood thro ugh c hest tube insertio n.

Assessment
A. Assess for sharp, sudden chest pain.
B. Check anxiety, vertigo.
C. Assess for hypo te nsion.
D. Assess for gasping respiratio ns, dypnea.
E. Look for pallo r.
F. Evaluate co ugh.
G. Check ta chycardia.
H. Evaluate elevated temperature, diapho resis.
I. Assess for hypo xia, hypercapnia.
J. Assess for p hysical signs.
1. Paradoxical or dimin ished movement o n the affec ted side.
2. Percussion – hyperresonant.
3. Absent breath so unds.
4. Tactile fre mitus decreased.

Imple mentatio n
A. Monitor vital signs frequently for impending shock.
B. Ausculate lungs freq uently.
C. Monitor for respiratory d istress.
D. Assist c lient to semi-or high-Fowler’s positio n.
E. Reassure client who will be anxious.

Cancer of the Lung

Definition: P ulmo nary tumo rs are either primary or meta static and interrupt the normal
physioco lo gica l functioning of the lung.

Characteristics
A. Classification of lung cancer is designated b y an-atomic locatio n o r by histological pa ttern.
1. Anatomic classification.
a. Central lesions involve the tracheobrionchial tube up to the vital b ronchi.
b. Perip heral lesions extend from the d istal b ronchi and includes the borncioles.
 1. Four histologic types.
a. Squamous cell (epidermoid).
(1) Most frequent lung lesions.
(2) Affects more men than women.
(3) Associated with cigarette smoking.
(4) Lesion usually starts in bronchial are and extends.
b. Adenocarcinoma.
(1) Usually develops in peripheral tissue (smaller bronchi)
(2) Metastasizes by blood route.
(3) May be associated with focal lung scars.
(4) Affects more women than men.
c. Bronchiole-alveolar cell.
(1) Rare multimodular lesion.
(2) Affects bronchiolar or alveolar linings.
d. Undifferentiated carcinoma.
(1) Metastisez early.
(2) Affects younger age group.
(3) Affects more men than women.
B. Detection – pulmonary lesions are not usually detected by physical exam, and symptoms do
not occur until process is extensive. Chest x-ray is very helpful in diagnosis.

Assessment
A. Assess for pulmonary symptoms.
1. Persistent cough
2. Dyspnea
3. Bloody sputum.
4. Long-term pulmonary infection.
5. Atelectasis.
6. Bronchiectasis.
7. Chest pain.
8. Chills, fever.
B. Assess for systemic symptoms.
1. Weakness.
2. Weight loss.
3. Anemia.
4. Anorexia.
5. Metabolic syndromes
a. Hypercalcemia.
b. Inappropriate ADH.
c. Cushing’s syndrome
d. Gynecomastia.
6. Neromuscular changes.
a. Peripheral neuropathy
b. Corticocerebellar degeneration.
7. Connective tissue abnormalities.
a. Clubbing
 a. Arthralgias.
2. Dermato lo gic ab normalities
3. Vascular changes.

Implementatio n
A. Comprehensive suppo rtive care o f client in the pre-operative and postoperative state. (see
sectio n o n care of the operative client.)
B. Give app ropriate informatio n to client to allay anxiety and clarify expectatio ns.
C. Instruct client in postoperative pro cedures to minimize co mplicatio ns
D. Give psycho lo gical suppo rt.

THORACUIC TRAUMA

Tra uma Assessment

A. Check fo r airway patency.
1. Clear o ut secretions.
2. Insert oral airway if necessary.
3. Positio n client o n side if there is no cervical sp ine injury.
4. Place hand or cheek o ver nose and mouth o f client to feel if client is breathing.
B. Inspect thoracic cage for injury.
1. Inspect for co ntusio ns, ab rasio ns, and symmetry o f chest movement.
2. If open wound of chest, seal o ff immed iately with a pressure dressing to prevent air
fro m entering thoracic cavity.
3. Watch for symmetrical movement o f chest. Asymmetrical movement ind icate.
a. Flail chest.
b. Tensio n p neumo thorax.
c. Hemothorax
d. Fracture ribs.
4. Observe co lor; cyanosis ind icates decreased o xygenatio n.
5. Observe type of b reathing; stertorous b reathing usually ind icates obstructed respiratio n.
C. Auscultate lung so unds.
1. Absence o f b reath so unds: indicate vib rations o f fluid in lungs.
2. Rales (crack ling sounds): indicate vibratio ns of fluid in lungs.
3. Rho nchi (coarse sounds): indicate partial ob structio n of airway.
4. Decreased breath so unds: ind icate poorly-ventilated lungs.
5. Detectio n o f bronchial so unds which are deviated from normal positio n: indicates
mediastinal shift d ue to collapse of lung.
D. Determine level o f conscio usness; decreased sensorium can ind icate hypoxia.
E. Observe sp utum or tracheal secretio ns; b loody sp utum can ind icate co ntusio ns of lung or
injury to trachea and other anatomical structures

Tra uma Implementation

A. Take history frio m client to aid in total evaluatio n o f client’s co nd itio n.

B. Ad minister electrocard io gram to establish if there is associated cardiac damage.
 A. Maintain patent a irway.
1. Suctio n.
2. Intubatio n.
a. Oral airway
b. Endotracheal intubation.
B. Maintain adequate ventilatio n.
C. Maintain fluid and electrolyte balance.
1. When blood and flu id loss is rep laced, watch carefully for fluid overload, which can
lead to pulmo nary edema.
2. Record intake a nd o utp ut.
D. Maintain acid-base balance; make frequent blood gas determinations as acid-base
imbalances occur readily with co mpromised respiratio ns or with mechanical ventilation.
E. Provide for re lief of pa in.
1. Analgesics sho uld be used with cautio n as they depress resp irations. (Demerol is the
drug o f cho ice.)
2. Atropine, mo rp hine sulfate, and barbiturate s should be avoided.
3. Nerve block may be used.

TYPES OF TRAUMATIC
INJURIES

Open Wounds of the Chest

Assessment
A. Evaluate if a ir from the atmosphere entered the pleural cavity causing co llap se o f lung.
B. Assess for air entering and leaving the wound d uring insp iration and exp iratio n.
C. Evaluate if intrap leural negative pressure is lost, thereb y embarrassing respiratio ns, leading
to hypoxia. Death can occur if not corrected promptly.

Impleme ntatio n
A. Apply Vaseline gauze to wound with pressure dressing.
B. Place c lient o n assisted ventilatio n if nec essary.
C. Prepare for insertio n of chest tubes.
D. Place client in high-Fowler’s positio n (unless contraind icated) to assist in adeq uate
ventilatio n.

Hemothorax or Pneumothorax
Definition: Hemothorax refers to b lood in pleural space. Pneumothorax re fers to air in p le ural
space, positive pressure is built up, collapsing the lung.

Assessment
A. Evaluate pa in.
B. Ausculate for decreased breath sounds.
C. Observe for tracheal shift to unaffected side.
D. Observe for dyspnea and resp iratory embarra ssment.
Implementation
A. Assist with the insertion of a number 18 needle into the second intercostal space,
midclavicular line, followed by aspiratio n of the fluid or air by means of a thoracentesis.
B. Assist with insertio n o f chest tubes and connectio n to closed-chest drainage.
C. Continuously observe vital signs for comp licatio ns such as shock an card iac failure.

Fracture Ribs

Assessment
A. Eva luate pain and tenderness over fracture area.
B. Observe for bruising at injury site.
C. Eva luate respiratory embarra ssment occurring from sp linters puncturing lung and causing
pneumothorax
D. Observe c lient for splinting o f c hest causing shallow respiratio ns. Sp linting causes a
reduction in lung compliance as well as respiratory acido sis.

Implementation
A. Administer mild analgesic, suc h as small doses of Demerol, for pain relief. (Caution:
Narcotics can depress respiration and the cough reflex).
B. Encourage deep breathing and coughing to prevent resp iratory complications such as
atelectasis and pneumonia.
C. Observe for signs of hemorrhage such as atelectasis and p neumo nia.
D. Assist with intercostal nerve b lock if necessary to decrease pain.

Flail Chest
Definition: Multip le rib fractures that result in an unstable chest wall.

Assessment
A. Eva luate for pain.
B. Observe for dysp nea leading to cyanosis.
C. Assess if detached portion o f flail chest is mo ving in opposition to other areas o f chest cage
and lung.
1. On inspiration, the affe cted chest area is dep ressed ; it is bulging outward.
2. This causes poor expansion of lungs, which results in carbon dio xide rete ntion and
respiratory ac idosis
D. Eva luate ability to co ugh effectively. Inab ility lead to accumulation of flu ids a nd respiratory
complications such as pneumonia and atelectasis.
E. Assess for sings of cardia fa ilure due to impaired filling of right side of heart. This
cond ition results fro m high venous pressure caused by paradoxical breathing.
F. Observe for rapid, shallow, and no isy resp iratio ns.

Implementation
A. Prepare fo r tracheotomy with a c uffed trach tube.
B. Place client on volume-set respirator. (MA-I), which delivers the same amount of tidal
volume with each breath and is not dependent on client’s resp iratio ns.
C. Suction freque ntly to prevent resp iratory complications
 A. Preve nt pain by ad ministering nerve b lock or Demerol as o rdered
B. Observe for sings of shock a nd hemo rrhage.
C. For c lient on ventilator, use nasogastric tube to pre ve nt abdo minal d iste ntio n and eme sis,
whic h can lead to aspiratio n.
D. For c lie nt not o n mechanical ventilator:
1. Enco urage turning, co ughing, and hype rve ntila ting every hour.
2. Administer oxyge n.
3. Mainta in IPP B
4. Suction as need ed.

Ca rdiac Ta mpo na de

Definition: Acute acc umulatio n of b lood or flu id in the perica rdial sac. Can occur fro m blunt or
penetra ting chest wounds (interferes with diastolic filling.

Assessment
A. Assess for increa sed CVP.
B. Assess for decreased b lood pressure.
C. Assess for narro wed p ulse p ressure.
D. Eva luate paradoxica l p ulse (p ulse d isappea rs o n inspiratio n and ins weak o n exp ira tion
because o f cha nged intracthorac ic p ressure)
1. Paradoxica l p ulse is an exa ggeratio n o f the normal fall in arteria l BP o n insp ira tion.
2. defined as a fa ll in systo lic a rteria l BP to 10-20 mm Hg o r more o n insp ira tion.
E. Observe for d istended neck veins (jugular vein cannot e mpty properly).
F. Auscula te fo r dista nt heart so unds.
G. Observe for a gitation.
H. Observe for c ya nosis.

Imple mentatio n
A. Assist with needle inse rtion. Large need le (16-18 gauge) is inserted by physic ian into
pericard ium, and b lood is withdra wn.
B. Maintain card iac mo nito ring to observe for arrhythmias due to myocard ia l irritability.
C. Ha ve cardiac de fibrillator a nd e merge ncy drugs a va ilab le to tre at ca rd iac arrhythmias.
D. Monitor vital signs a nd watc h for shock.

TREATMENT FOR TRAUMATIC

INJURY

Chest Tube

Assessme nt
A. Eva luate c lient’s safety while tubes inserted.
B. Assess patency o f chest tubes.
C. Observe for med iastinal shift.
D. Auscula te bre ath sounds for air flow.
E. Observe for b ilateral c hest expansion.
 A. Eva luate c hest drainage.

Implementation
A. Assist p hysician in placement of tubes.
1. Tubes placed in pleural cavity fo llowing thoracic surge ry.
2. Provides for remo val of air and serosanguineo us fluid fro m p leural space.
B. Attach to water-seal suc tion – maintains closed system.
1. Tape a ll connectors.
2. Ensure that all stoppers in bottles are tigh fitting.
C. Apply suctio n.
1. Keep bottles b elow level of bed.
2. Keep suc tio n level where ordered (be sure that b ubbling is not exce ssive in the pressure-
regulating bottle).
3. Maintain water level in bottle.
D. Maintain patency.
1. Milk chest tub es every 30 to 60 minute s.
a. Milk away from client toward the drainage receptab le (P leur-evac o r bottles).
b. Pinch tub ing close to the chest with o ne hand as the other hand milk s the tube.
Continue going down tube in this method until co ming to the drainage receptacle.
2. Milking may be o rdered – stripping should be avoid ed.
E. Maintain safety-clamp for less than a minute.
1. Keep rubber-tipped hemostats at bedside to clamp tube. (If air leak develops in tube,
lung may collapse. ) C lamp ing is contro versial – che ck hospital po licy.
2. Check that all co nnectors are taped.
F. Clamp chest tube o nly for fo llowing reaso ns.
1. To locate so urce of air leak when bubb ling occurs in water-seal chamber. Begin
clamping close to chest – when clamp is between air leak and water-seal, b ubbling will
stop – leak is abo ve it.
2. To pre vent air fro m entering p leural space; clamp while replacing draina ge until due to
breaka ge or full collectio n chamber.
3. To verify that client is ready to have chest tubes remo ved.
4. Do not clamp to get client out o f bed o f it tubing comes apart (p lace end in sterile water
as temporary seal).
a. Clean tube ends and reco nnect.
b. Ha ve client exha le to rid p leural space of air.

Wate r-Seal Chest Draina ge

Cha racteristics

A. Three types – one, two-, or three-bottle drainage.

B. General principles.
1. Used after so me intrathoracic procedures.
2. Chest tubes p laced intrapleurally.
 1. Brea thing mechanism operates on p rinciple of negative pre ssure (pressure in c hest
cavity is lo wer than p ressure o f atmosp here, ca using a ir to rush into chest cavity whe n
injury such as stab wo und occurs).
2. Whe n c hest has been ope ned, vacuum must be applied to c hest to reestab lish ne ga tive
pressure.
3. Closed wa ter-sea l drainage is method of reestablishing ne gative pressure.
a. Water acts as a sea l a nd k eeps the air from be ing drawn back into p leural space.
b. Open drainage syste m wo uld allow a ir to be sucked back into chest ca vity and
co llapse lung.
4. Closed dra ina ge is established b y plac ing c atheter into pleura l space and a llowing it to
drain under water.
a. The e nd o f the draina ge tub e is a lwa ys kept under wa ter.
b. Air will not be dra wn up thro ugh catheter into ple ura l spa ce when the tube is unde r
wate r.

Assessment
A. Assess client’s respiratory ra te, rhythm, and b reath sounds fo r sings o f resp iratory d istress.
B. Check tha t a ll co nnections o n tub ing a re airtight and suction contro l is connected.
C. Exa mine syste m to see if it is set up a nd functio ning p roperly,.
D. Identify a ny ma lfunc tio ns in syste m, i.e., air leak s negative pre ssure or obstruction.

Implementatio n

A. Ma inta in o ne-bottle suctio n syste m.

One -Bottle Suctio n System

- Fro m C lient

- Water-Seal Tube

- Insp iration

- Expiration

Wate r-Se al and D rainage Bottle

1. There is o nly o ne bottle ; it functio ns a s a collection bottle for dra ina ge as we ll as a pressure
regulato r
2. As the d raina ge increases in a mo unt, the water-sea l tube (immersed in the dra inage ) is
pulled up slightly to decrease the amount of fo rce that is req uired to permit the flu id to be
dra ined from the p le ura l space.
3. The dep th to whic h the water-sea l tube is immersed belo w the fluid in the bottle de termines
the pressure exerted by the water
4. Dra inage is measure in the sa me way as two-bottle suctio n.
A. Maintain two-bottle suctio n system.

Two-Bottle Suction System

- From C lient
- Inspiration
- Exp iration

Water-Seal Bottle Drainage Bottle

#2 #1

1. Two-bottle suction
a. Same as three-bottle suction except that the bottle connected to mechanica l suction is
not inc luded.
b. Draina ge bottle (bottle number one) is connected from client and is betwee n the client
and the water-seal bo ttle (or bottle numb er two).
(1) Short tube goes fro m client into d rainage bottle (not to extend belo w drainage level).
(2) Mark drainage level on o utside of bottle.
(3) Short tube with rubber tubing goes from the drainage bottle to water-seal bo ttle.
(4) This tube exte nds below water level in the water-sea l bottle.
2. Bottle number two.
a. The long tube extends below water level (fro m bottle number one).
b. A seco nd sho rt tube provide s an air vent.
c. Water in this bottle goes up the tube when c lient inhales and down the tube when client
exhales.
d. Water in this bottle should not b ubble co nsta ntly.
B. Maintain three-bottle suction syste m.

Three-Bottle Suction System

1. Third bottle is connected to suc tion motor-called mec hanical suction.

2. Bottle number three regulates the amount of negative pre ssure in the syste m
3. Three tubes.
a. Short tube, above water level, comes from water-sea l bottle.
b. Short tube connected to suctio n mo tor.
c. Third tube, below water le ve l in bo ttle, opens to the atmosp here o utside o f the
bottle.
d. The depth to which third tube is subme rged in the water determines the suction
pressure within the drainage syste m
4. When drainage syste m pressure beco mes too low, outside air is sucked into the
system. Results in consta nt b ubbling in the p ressure.
5. Whenever the moto r is o ff, drainage system must be open to the atmosphe re.
a. Intrap leural air can escape fro m the system.
b. Detach the third bottle tub ing fro m the suction motor to provide the air vent.
Me chanical Ve ntilatio n

Assessment
A. Assess resp iratory status for need to use mecha nica l ve ntilatio n.
B. Identify type o f mechanical ventilatio n needed.
1. Negative pressure ventilator.
a. Help ful in p rob lems of a ne uromuscular nature .
b. Not effective in the treatme nt o f increased airwa y resistance.
c. Types— full bod y, chest, a nd chest-abdo men.
2. Positive pressure ventila tor.
a. Uses positive pressure (p ressure grea ter than atmosphe ric) to inflate lungs.
b. Types
(1) Pressure cycle.
(a) Pressure ranges from 10 to 30 cm o f wa ter pre ssure.
(b) Air is active ly forced into lungs.
(c) Expiration is pa ssive.
(2) Vo lume cyc le.
(a) Uses p hysio lo gical limits.
(b) Predetermined total vo lume is delivered irrespective or a irwa y pressure.
(c) Positive end e xp iratory pressure (P EEP) utilized to ma inta in positive
pressure be twee n exp iration a nd beginning of inspiration.
C. Assess for co mp licatio ns of positive pressure therap y.
1. Resp irato ry a lkalosis.
2. Gastric d iste ntion and p ara lytic ileus.
3. Gastrointestinal b leed ing.
4. Diffuse a telec tasis.
5. Infection
6. Circ ulatory collapse
7. Pne umo thora x pro gressive alveolar cap illary b lock.
8. Sudden ventricular fibrillation.

Impleme ntation
A. Monitor ventilator for comp lica tio ns.
B. Suctio n c lient or check for k inks in tubing whe n pressure a larm sounds.
C. Monitor b lood gas values freque nt ly.
D. Maintain fluid therapy.
1. IV ro ute.
2. Oral ro ute if c lient ab le to swa llow.
E. Monitor intake and o utp ut.

Thoracic S urgical Pro ced ures

Assessment
A. Identify type o f proced ure done.
1. Explo ratory thoraco to my: inc isio n o f the thorac ic wa ll, performed to locate b leed ing,
injuries, tumors.
 1. Thoracop lasty: removal o f ribs or portio ns o f ribs to red uce the size of the thoracic spac e.
2. Pne umo nectomy: remova l o f a lobe of the lung
3. Lobecto my: re mo val o f a lobe o f the lung (three lobes o n right side, two o n the left).
4. Segmented re section: remo va l of o ne or more segme nts o f the lung (right lung has ten
segme nts and left lung has e ight).
5. Wedge resection: remova l o f a sma ll, loca lized area o f d isease near the surface of the lung.
A. Eva lua te time o f client care req uired.

Imp le mentation
A. Provide postoperative nursing ma nageme nt.
1. Closed c hest dra ina ge is e mp lo yed in all but p ne umo nectomy. In pneumonecto my, it is
desirab le that the fluid acc umulate in e mp ty thorac ic space. Eve ntually the thorac ic space
fills with sero us exudate, whic h co nso lid ates to pre vent extensive med ia stina l shifts.
2. Maintain pate nt c hest tube d raina ge b y chest tube milk ing – milk a wa y fro m client toward
draina ge bo ttle.
3. Maintain resp ira tory functio n.
a. Have c lie nt turn, co ugh, and deep brea the
b. Suctio n if necessary.
c. Provide o xygen the rapy.
d. Provide IPP B therap y.
e. Ventilate mechanica lly if necessary.
4. Ambulate early to enco urage adeq ua te ve ntilatio n and pre vent postoperative co mp licatio ns.
(Amb ulate clients with p ne umonecto mies in two or three da ys to facilitate card iop ulmo nary
adjustment).
5. Provide range-of- motion exerc ises to a ll e xtro mities to p ro mo te adequate circ ula tio n.
6. Monitor ce ntra l veno us pressure with vital signs – watch for indications o f impa ired
ve nto us return to heart.
7. Positio n client correctly.
a. Use semi-Fo wler’s po sitio n whe n vita l signs are stab le to facilitate lung expansion.
b. Turn every one to two ho urs.
c. Pneumo necto my
(1) No chest tubes inserted. F luid le ft in space to co nso lidate.
(2) Positio n o n operative side.
(3) Some physicia ns will allow positioning o n e ither side a fter twenty-fo ur ho urs.
d. Segmental resec tio n o r wed ge rese4 ctio n: positio n on back or unoperative side (a ids in
expand ing rema ining p ulmo nary tissue ).
e. Lobecto my: turn to either side (can exp and lung tissue o n both sides).
8. Maintain fluid intake as to le rated. Watch for o verload in p ne umo nectomy c lie nts.
9. Provide arm a nd sho uld er postoperative exe rcises – preve nt ad hesio n formation.
a. Put a ffected arm thro ugh both active a nd pa ssive ra nge o f motion every fo ur ho urs.
b. Start e xercises within fo ur hours after clie nt has returned to room follo wing surgery.
B. Monitor for postoperative co mp licatio ns.
1. Respirato ry co mp licatio ns.
a. Causes of inadequate ve ntilatio n.
(1) Airwa y obstruc tio n d ue to secretio n acc umulatio n.
 (1) Atelectasis due to underexpansio n of lungs and anesthetic agents d uring surgery.
(2) Hypoventilation and carbo n d ioxide b uild up d ue to incisional splinting because of
pain.
(3) Depressio n of CNS fro m overuse o f med icatio ns.
a. Tension p neumo thorax.
(1) Caused b y air leak through p leural incisio n lines.
(2) Can cause med iastina l shift.
b. Pulmo nary embolism.
c. Bronchopulmonary fistula
(1) Air escapes into pleural space and is forced into subcutaneo us tissue around
incision, causing subcutaneous emp hysema.
(2) Caused b y inadeq uate closure of bro nchus when resectio n is do ne.
(3) Another ca use is alveolar or bronchiolar tears in surface o f lung (p artic ularly
follo wing pneumo nectomy).
d. Atelectasis and /or pneumonia: caused b y a irway obstruction or as result of anesthe sia.
e. Respiratory arrest can occur.
1. Circulatory comp lications.
a. Hypo volemia: due to fluid or blood loss.
b. Arrhythmias: due to underlying myocard ial disease.
c. Cardiac arrest: ca n occur from either of these conditio ns.
d. Pulmo nary edema: can occur d ue to fluid overload o f circulatory system.

Tracheostomy

Assessment
A. Determine need for tracheostomy as co mpared to less intrusive methods of pro vid ing patent
airway.
B. Assess client’s level o f consciousness to determine client’s ab ility to understand exp lanatio n
and instructions.
C. Observe c lient’s resp iratory status: shortness of breath, severe dyspnea, tachyp nea, or
tac hycard ia.
D. Auscultate for presence and forced exp iration of rhonchi, rales, o r wheezes.
E. Observe for dried or mo ist secretio ns surrounding cannula or on tracheal dressing.
F. Observe for excessive expectoration of secretions.
G. Assess result of ro utine trac heal care to determine if routine care is adeq uate for this client.
H. Observe client’s ability to sustain resp iratory function b y ab ility to breath through normal
airway
I. Assess respira tory status: breath sounds, respirato ry rate, use of accesso ry muscles for breathing
while tracheal tube is p lugged.
J. Assess for labored b reathing, flaring of nares, retractio ns, and co lor of nail beds.

Imp lementation
A. Provide tracheal suction as ordered or p. r. n.
1. Always app ly oral or nasal suction first so that when cuff is deflated, secretio ns will no t fall
into lung from area abo ve c uff.
 1. Catheter must be changed be fore do ing trachea l suctio ning.
A. Provide humid ity by using trach mist mask, if client is not on ventilator.
B. Monitor for hemorrhage aro und tracheostomy site.
C. Change dressings (nonraveling type) and c lea nse surro unding area with hydrogen peroxide at
least every four ho urs.
D. Provide case for cuffed tracheosto my tube.
1. Hyperventilate c lient before and after cuff is deflated with ambu bag.
2. Deflate tracheal cuff.
a. Suction airway before de flating c uff.
b. Attac h 10 cc syringe to d istal end of inflatab le cuff, making sure seal is tight.
c. Slowly withdraw 5 cc o f air. Amount of air withdrawn is determined by type of cuff
used and whether air leak is utilized.
d. Keep syringe attached to e nd of cuff.
e. Suction if co ugh reflex stimulated.
f. Assess resp irations, if labored reinflate cuff.
g. If high vo lume/low pressure cuff is used, cuff is not routinely deflated. (In fact,
deflating c uff does not help tracheal lining. The poo led secretio ns abo ve the tracheal
cuff are the problem).
3. Inflate cuff.
a. Suction airway before inflating cuff.
b. If syringe is no t already attached, attach 10 cc syringe to d istal end of inflatab le cuff,
mak ing sure seal is tight.
c. Inflate prescribed a mount of a ir to create leak free system. C uff is inflated correctly
when you cannot he ar the client’s voice or any air movement fro m nose or mouth.
d. Remove syringe and app ly rubb er-tipped forceps to maintain air in cuff.
e. If high volume/low pressure cuff is used, cuff is no t routinely d eflated.
E. Administer inner cannula tracheal clea ning.
1. Suction be fore cleaning tracheal tube.
2. Unlock the inner cannula by turning the lock to the right about 90 degrees and secure the
outer cannula o f the neck p la te with your left ind ex finger and thumb.
3. Gently pull the inner cannula slightly upwa rd and out towards you.
4. Wash cannula thoro ughly with cool, sterile water, saline, or hydro gen peroxide to remove
secretio ns. (Tapwater may be used if hosp ital po licy a llows). Soak the cannula in a
hydrogen-pero xide filled sterile bowl to further re move dried secretio n.
5. Rinse cannula thoro ughly with sterile water or saline, and dry tube thoro ughly with
absorbent pape r.
6. Rep lace the inner cannula carefully by grasp ing the outer flange o f the cannula with your
left hand as you insert the cannula. Lock the inner ca nnula by turning the lock to the left so
that it is in an upright positio n.
7. Clea nse arund the incision site with applica tor sticks soaked in normal sa line and/or
hydrogen pero xide (one-half strength). Apply antib iotic ointment around incision site if
ordered.
8. Apply trac h dressing aro und insertio n site, and change trach ties if needed.
9. IF trach ties are to be c hanged, ask anothe r person to hold the tracheal tube in p lace while
you change the ties. This procedure prevents accidenta l extuba tio n if the c lient co ughs.
F. Provide instillation o f normal saline.
 1.Attach ste rile catheter to suction machine tub ing.
2.Dra w up norma l sa line (usually 3 to 5 cc) in syringe.
3.Remove needle fro m syringe.
4.Turn on o xyge n supp ly to resuse rta tion bag.
5.Turn on suction eq uip ment.
6.Remove needle be fore injecting saline into tube.
7.Instill presc ribed amo unt of normal sa line into tracheosto my or endotrac hea l tube with
ungloved ha nd.
8. Give client 3 to 5 breaths with resuscitation ba g if client ca n tole rate this proced ure.
9. Put on sterile glo ve a nd be gin deep suctioning. C lie nt ma y be hyperve ntilated with
resusc itato r bag a fter suctio ning.
A. Provide tracheosto my plugging.
1. Suctio n nasop ha rynx.
2. Change suction ca theters, and suctio n trache a.
3. Deflate tracheal cuff; suc tio n aga in if necessary.
4. Place trac hea l p lug in either the inner cannula or o uter ca nnula with inner ca nnula remo ved
5. Observe c lie nt for resp iratory distre ss.

Suctio ning
Assessment
A. Dete rmine need for suctioning.
B. Observe vita l signs for increa ses in pulse and resp iratio n and fo r changes in sk in co lor.
C. Ausc ultate so unds to e va luate lung fie ld.
D. Dete rmine le ve l o f consc io usness to assess hypo xia.

Imple me nta tio n

A. Provide naso tracheal suction
1. Gather eq uip ment
a. Sterile suction ca theter, usua lly No. 14 or No. 16 French.
b. Sterile sa line.
c. Suctio n ma chine.
d. Sterile glo ves.
2. Complete suctioning procedure.
a. Preoxyge nate be fore suctioning.
b. Lubricate c athe ter with no rmal sa line.
c. Insert cathe ter into nose for 15 to 20 c m.
d. Do not app ly suctio n while introd ucing catheter.
e. When ad va nced as far as possib le, be gin suctioning b y withdra wing cathe ter slowly,
rotating it with pressure app lied. (Usua lly a whistle tip ca theter or Y co nnecto r tube is
used to app ly pressure).
f. Withdraw catheter slightly if co ugh re fle x is stimulated.
g. Re me mber that hypo xia can occur if suctio ning is done inco rrectly.
(1) Excess o f 10 seco nds suctio ning – o xygen decreased in re spiratory tree.
(2) Causes c hemoreceptors to respo nd b y increasing ventilation rate.
h. Posto xygenate after suctioning.
A. Provide trac heosto my suctio ning.
1. Gather equip ment.
a. Same equip ment as for nasotracheal.
b. Sterile syringe (5 cc ) and terile saline fo r instilla tion into trach tube.
2. Comp lete suctioning procedure.
a. Be sure that suction catheter is not more than half the dia meter o f tracheostomy tub e.
b. Preoxygenate before suctio ning.
c. Lubricate with ste rile saline, then insert catheter thro ugh tracheostomy tube fo r 20 to 30
cm with suctio n turned off.
d. Do not suction for more than 10 seco nds.
e. Rotate catheter while withdrawing it.
f. Do not repeat procedure fo r at least three minutes unless necessary to withdraw more
secretio ns to p ermit adequate ventilation.
g. If secretio ns are very te nacious, 3 to 5 cc o f sterile saline may be inserted thro ugh tube
and allowed to remain for a few seconds before suctioning.
h. To remo ve secretio ns from right bro nchus, turn client’s head to left; to remove
secretio ns from le ft b ro nchus, turning client’s head to right may help.

Pulmo nary Medications

Sympatho mimetic Bronchod ilators

A. Ep inephrine (Adre naline).

1. Beta and alpha stimulant; relaxes bro nchial smooth musc le.
2. Ro utes: subq, IV, MDI (metered dose inha lant).
3. Used to treat asthma and for anaphylaxis.
4. May cause arrhythmias, increased BP, urinary retention, increased b lood sugar, headache.
B. Ep hedrine sulfate.
1. Relaxes smooth muscle of the tracheobro nchial tree.
2. Ro ute: p.o.
3. Used fo r mild bronchospasm.
4. Similar side effects as epinephrine.
C. Isoproterenol (Isuprel).
1. Pure beta agonist; re laxes smooth muscle of tracheobronchial tree ; relieves bronchospasms.
2. Ro utes: IV, MDI.
3. May cause ma rked ta chycard ia, arrhythmias, angina, palpitations.
D. Albutero l (Proventil, Vento lin)
1. Very selective beta2 agonist.
2. Ro utes: p.o. MDI.
3. Minimal cardiovascular side effects.
E. Isoetharine (BRo nkoso l, Bronko meter).
1. More beta2 specific than Isuprel; relaxes smooth muscle o f the tracheobro nchial tree; less
potent.
2. Ro ute: Nebulized so lution or MDI.
3. Side effects similar to Isuprel, b ut appear less frequently, may cause tachycardia.
 1. To lerance to bronchod ilating effect may develop with too frequent use o f medicatio n.
A. Metaprotereno l (Alupent).
1. Relieves bronchospasm.
2. Ro utes: p.o. MDI.
3. Side effects same as isoetharine.
B. Terb utaline (Bricanyl, Brethine)
1. Beta-adrenergic-receptor ago nis t; bro nchodilator; relieves bro nchospasms associated with
COPD, asthma.
2. Ro utes: subq, p.o. Breathaire b y MDI.
3. May cause nervo usness, palpitations; nausea if taken on an empty sto mach.

Anticholinergic Bro nchodilators

A. Ipratropium bro mide (Atro vent).
1. Bronchod ilating e ffect primarily local and site sp ecific: more potent than
sympathomimetics in COPD.
2. Ro ute: MDI.
3. Minimal side effects.

Methylxanthine Bronchodilators
A. Aminophyline.
1. Relaxes smoo th muscle o f the tacheobronchial tree; bronchod ilator
2. Ro utes: p.o., IV, rectal suppository.
3. Therapeutic serum level 8-20 mcg/ml.
4. May cause tachycard ia, hyptensio n, arrhythmias
5. To xic levels cause arrhythmias, seizures.
B. Theop hylline.
1. Relaxes smoo th muscle o f the bro nchi and pulmo nary vessels.
2. Ro utes: p.o., rectally.
3. Therapeutic serum level 10-20 mcg/ml.
4. Side effects similar to Amino phylline
C. Oxtriphyllinwe (C ho ledyl).
1. Similar to other bro nchodilators
2. Ro ute: p.o.
3. Less GI irritation than Aminop hylline.

Antime diators/Antiinfla mma to ry Agents

A. Cromolyn Sod ium

1. Used fo r yo unger clients with asthma.
2. Ro ute: MDI.
3. Prevents bronchospasm when used before exercise or exposure to co ld air.
B. Corticostero ids
1. Used in co njunction with bro nchod ilators for treatment o f bronchosp asms. Aerosol use
prevents
2. Ro utes:
a. Prednisone p.o.
 a. Methylprednisolone, hydrocortisone IV.
b. Beclomethasone diproprionate (Beclovent, Venceril) MDI.
c. Thiamcinolo ne (Azmacort) MDI.
2. Instruct client to rinse mouth a fter use to prevent oral ca ndid iasis.
3. Side effects include increased appetite, euphoria and ps ychosis.

Mucokinetic Agents

A. Acetylcysteine (Mucomyst)
1. Used to loose n secretions; reduces viscosity.
2. Routes: inhaled or instilled.
3. May cause bronchospasms, na usea.
4. Instruct client to rinse mouth a fter use.
B. Quaia fenesin
1. Commo nly used expectorant.
2. Route: p.o.
C. Iodide preparatio ns (SSKI, Organidin).
1. Expecto rant liquefies tenacious bronchial secretions.
2. Route: p.o., bitter taste, give with juice or milk.
3. Do not administer if a llergic to iodine or hype rthyroid.

Pulmo nary Embolis m

Definition: The mo vement of a thrombus fro m site of origin to lung.

Assessment

A. Assess for mild conditio n (involves smalle r arteries).

1. Signs mimic pleurisy or bronchial pneumonia.
2. Transient dysp nea.
3. Mild pleuritic pain.
4. Tachycardia.
5. Increased temperature.
6. Cough with hemoptysis.
B. Assess for servere co ndition (invo lves p ulmonary artery).
1. Chest p ain.
2. Severe d yspnea leading to air hunger.
3. Shallow, rap id breathing.
4. Sharp substernal chest pain.
5. Vertigo leading to syncope.
6. Hypovo lemia.
7. Card iac arrhythmias.
8. Generalized weakness.
9. Feelings of doom.
10. Hypotension.
Implementation

A. Provide patent airway.

1. Place in semi-to high-Fowler’s position if vital signs allow.
2. Administer oxygen as needed (nasal cannula).
3. Assist with intubation as needed.
4. Ausculate breath sounds every one to two hours.
5. Obtain arterial b lood gases to ascertain acid-base imbalance.
6. Check sp utum fo r presence o f blood or b lood-tinged muc us.
7. Administer diuretics or card iotonics, as necessary.
8. Observe for sings of shock.
B. Administer anticoagulants (check lab values each day befo re administering medication,
fo llowing initial anticoagula tio n).
C. Give narcotics for pain (watch for respiratory depressio n).
D. Take vital signs every two to fo ur hours.
E. Turn as directed by physicia n; do not do percussio n or clapping o r ad minister back rubs.
F. Enco ura ge client to cough and deep breath every one to two ho urs.
G. Maintain bed re st; have client avoid sudden move ments.
H. Give emotional support and prepare for lung scan.
I. Observe for possible extension of emboli or for occurrence o f other emboli.
1. Check urine for hematuria o r oliguria.
2. Check legs, especially calf.
J. Prepare fo r surgical intervention.
1. Surgical interventio n carries high risk.
2. Types o f surgery.
a. Femoral vein ligatio n.
b. Ligation of ionferio r vena cava.
c. Pulmonary embolectomy.

Disseminated Intravascula r
Coagulatio n (DIC)
Definition: S imultaneous activation of the thombin (clotting) and fib rino lytic system.

Characteristics
A. Excessive intravascular thrombin is produced, which co nverts fibrinogen to fibrin clo t.
B. After fibrinogen is used up, circulating thrombin continues to be present and will co ntinue to
convert any form o f fib rino gen to fibrin.
C. Fib rino gen enters system b y transfusio n or b y body production o f fibrinoge4n. this process
intesifies the hemorrhage state.
D. DIC is a ssociated with extracorporeal circulation and obstetric co mplications.
E. Arterials hypotensio n results in arterial vasoco mstrictio n and capillary dilatation; this causes
shunting of blood which leads to acidotic blood formed from blood stagna tio n.
F. Stress is the primary ca use o f increased fibrinolysis.
Assessment

A. Observe for excessive bleeding (caused by depletion of clotting factors) through genitourinary
tract, following injections, etc.
B. Evaluate lab results for low hemoglobin, low platelets.
C. Evaluate arterial blood gases for acidosis.
D. Observe for skin lesions, such as petechiae, purpura, subcutaneous hematomas.

Implementation

A. Treat cause of DIC symptomatically.

1. Antibiotics for infections.
2. Fluids and colloids for shock.
3. Steroid for endotoxins
4. Dialysis for renal failure.
B. Administer heparin IV to stop cycle of thrombosis—hemorrhage.
1. Neutralizes free circulating thrombin
2. Inhibits blood clotting in vivo, due to effect in factor IX.
3. Prevents extension of thrombi.
4. Keep clotting time two to three times normal.
5. Give 10,000 to 20,000 units every two to four hours.
C. Give transfusion of platelets and fresh- frozen plasma to replace clotting factors.
D. Administer oxygen as needed.
E. Take precautions to prevent additional hemorrhage.
1. Avoid chest tube “milking.”
2. Take temperature orally or axillary, not rectally.
3. Avoid administration of parenteral medications if possible.
4. Avoid trauma to muxcous membranes.
5. If nasogastric tube inserted, prevent bleeding by administering antacids and keeping NG
tube connected to low suction. Do not irrigate unless absolutely necessary.
POS TOPERATIVE COMPLICATIONS

POTENTIAL
PATIENTS AT RISK INDICATIVE FINDINGS
COMPLICATION
Atelectasis: co llapse of All with genera l a nesthesia Fever to 102o F
a lveoli; ma y be d iffuse a nd Special risk clients: Tac hyca rd ia
invo lve a segment or lobe, or Smokers Restlessness
lung Chro nic bro nchitis Tac hyp ness
Emp hysema Altered breath so und
Obesity Dullk ness to p ercussion
Elderly Diminished or abse nt breath
Upper abdo minal surgery sounds
Chest surgery Ra le s
Abdo mina l d istentio n ABGs: d ecreased PaO 2
Pne umo nia : infla mmatory Clients with unresolved Client co mplains o f dysp nea;
process in which a lveo li are ate lec tasis Tac hyca rd ia; increasing
filled with e xudate Following aspiration te mperature productive co ugh
Potential onset: Smoker and increasing amount of
First 36 to 48 ho urs Elderly sputum beco ming te nac io us,
Chro nic bro nchitis rusty, or p urule nt
Emp hysema Tactile fremitus
Heart fa ilure Dullness to p ercussio n
Debilitated Bro nchial breath sounds
Alco ho lic Increased wet ra le s or rhonc hi
Immob ile Vo ice so unds present
Cough suppressa nt Bro nchophony
medica tio ns Egop hony
Resp iratory depressa nt Whispered pe rto rilo guy
medica tio ns ABGs: d ecreased PaO 2
Pulmo na ry Embolis m: Superficial ve in thro mbosis: Only 10 perce nt reco gnized
fo re ign object has migrated to rare deep ve in thro mbosis: 40 c linica lly
branch of p ulmo nary a rte ry to 60 Pain sharp and stabb ing,
Potential onset: Perce nt a ir e mbo li: occurs with breathing;
Seve nth to te nth da y intraperitoneal surgery lo calized (right lo wer lobe
Fat e mbo li; lo ng bone mo st freque nt)
Massive embolism: fracture, split sternum Increased resp irato ry ra te
Pulmo nary hyperte nsio n, Increased he art rate
dysp nea, right he art failure, Restlessness
shock, ABGs: decreased PaO 2 ,
increased PaCO 2
Pulmo na ry Infa rc tio n: Pulmo nary embo lism He mop tysis
nec rosis of lung tissue d ue to Cough
occlusion o f b lood supp ly Fever 101o to 102o F
(less than 10 perc ent de velop) Pleura l frictio n rub
Pleuric pain
Potential onset:
Pulmo na ry Infa rctio n: Pulmo nary embo lism Hemop tysis
necrosis o f lung tissue d ue to Cough
occlusio n o f b lood supp ly Fever 101o to 102o F
(less than 10 percent develop) Ple ural frictio n rub
Ple uric pain
Potential onset:
2 to 72 hrs. after a rterial
obstructio n

Preventio n INTERVENTION DRUG THERAPY

Preoperative: ha ve client Increase effectiveness of Analgesics: pa in co ntro l
practice turning, co ughing, pulmo nary to ilet Bro nchod ilators (neb ulized
and deep b reathing Ad minister supplemental thro ugh IPPB): liq uefy
Discuss impo rtance of oxyge n as o rdered secretio ns
exercises Monitor for o nset of Water or saline (neb ulized
Postoperative clients at risk: pneumo nia thro ugh IPPB): liq uefy
Turn q30 min. If entire lobe o f lung is secretio ns
Deep breathe and co ugh invo lved, prepare for
Other clients: broncho scope to remo ve p lug
Initiate turning and deep
breathing exercises
Q1-2hrs.
Amb ulate as soo n as possib le
Med icate to red uce pain,
sp linting, and resistance to
treatment
Provide vigoro us treatment o f Turn, co ugh, a nd deep b reathe Antib iotics: Cephalospo rin or
atelec tasis q1 hr. amp icillin p rop hylactically for
Preve nt asp iratio n May need to stimu late co ugh 48 ho urs for high risk patients
with nasotracheal suctio ning Cephalo sporin IV or
Send sp utum for culture and parenteral fo r infectio ns
sensitivity Antip yretics: d ecrease
Freque nt mo uth care for temperature
co mfort
Ad minister o xygen as o rdered
Increase flu id intake
Monitor fo r respo nse to
treatment
Provide range o f mo tio n Ad minister o xygen to relieve Anticoa gulatio n therap y: low-
Enco urage early amb ulatio n hypo xia dose herpain o r warfarin
Prevent tho mbop hleb itis Red uce anxiety Sodium prop hylactically for
Do no t massage a potential or Positio n client o n left side high risk p atie nts
susp ected thro mbop hleb itic with head dependent to Streptok inase” thro mbo lytic
area prevent air embo lus effect (24 ho urs)
Prevent recurrent Heparin therap y: d ecrease
embolizatio n; prepare for clotting time analgesics:
Prevent thromboembolic Describe ind icative findings to Antibiotics: infection control
pulmonary artery occlusion. physician
See preventio n of Institute relaxation techniq ues
thro mbophlebitis to decrease cleint’s anxiety
Administer o xygen
Su0port and comfort client

ACQUIR ED CARDIAC DISEASE

Rheumatic Fever

Definition: A systemic inflammatory (collagen) disease that usually follo ws a gro up A beta -
hemolytic

Assessment

A. Utilizes Jo nes criteria for diagnosis (there is no single clinical pattern)

B. Two major criteria, or one major and two minor criteria, are necessary for a diagnosis.
1. Major criteria.
a. Assess for carditis.
b. Check for polyaarthritis
c. Evaluate if chorea is present.
d. Assess for erythema marginatum.
e. Ascertain if subcutaneous nodules are present.
2. Minor criteria.
a. Assess for fever.
b. Check for arthralgia.
c. Determine if child has had rheumatic fever or rheumatic heart disease.
d. Evaluate for elevated erythrocyte sed imentation rate.
e. Check for positive C-reaction protein.
f. Determine if P-R interval is prolonged.
C. Evaluate suppo rting evidence.
1. Recent scarlet fever.
2. Positive throat culture for group A streptococci.
3. Increase streptococcal antibodies.

Implementatio n
A. Provide antibio tic therap y against any remaining streptococci.
B. Administer aspirin for joint symptoms.
C. Ensure sufficient bed rest.
D. Prevent further infection.
E. Instruct on use of long-term antibacterial prophylaxis.

Subacute Bacterial Endocarditis

Assessme nt
A. Look for insid io us o nset o f symp to ms.
B. Assess for fever.
C. Check fo r lethargic be ha vio r and general ma laise.
D. Assess for ano re xia.
E. Eva luate fo r spleno mega ly.
F. Assess for retina l he morrhages.

Impleme ntation
A. Provide la rge doses o f antib io tic therap y, usually p enic illin.
B. Ensure adeq uate bed rest.
C. Monitor erythrocyte sed ime ntatio n rate a nd increased leukocytes.
D. Repeat b lood culture s as ordered.

HIGH OBS TRUC TIVE RESPIRATORY CONDITONS

Laryngo trac heobro nc hitis

De finitio n: Viral gro up is a syndrome ca used b y a variety o f infla mmatory conditio ns o f the upper
a irway. Vira l croup is the most common, a nd b acterial croup is the most serio us.

Assessme nt
A. Ascertain if rhinitis a nd cough ha ve preceded croup fo r se ve ral days.
B. Assess for grad ual o nset, the n bark ing co ugh and insp iratory stridor – usually fo r 3 to 7 days.
C. Look for symp to ms in childre n less than three years o ld.
D. Assess for mild e leva tio n in tempera ture (be lo w 102 0 F).
E. Observe for hypoxe mia which results in anxiety a nd restlessness.
F. Assess for cya no sis, a late sign, which may ind ica te co mp lete airway obstructio n.

Impleme ntation
A. Plan for ho me treatme nt if nor insp irato ry stridor.
1. Instruc t pare nts in signs o f airwa y ob structio n.
a. Tachyp nea.
b. Cya nosis.
c. Inc reased a nxiety.
2. Instruc t pare nts in using the showe r fo r warm mist therap y. (Coo l mist is pre ferable b ut
usua lly not a vailab le at ho me).
B. Provide hospita l care fo r ac ute o nset with inspria tory stridor.
1. Monitor vita l signs every 1-2 ho urs; check te mpe rature e very 2 hours while in coo l mist
te nt.
2. Check re sp iratory status e very 1-2 ho urs, depend ing upo n seve rity o f d istress.
3. Monitor acco mpa nying signs and sympto ms.
a. RR (resp iratory rate).
b. GFR (grunting, flaring, retracting).
c. Stridor.
d. Color.
e. Auscultatio n o f breath so nd s.
 a. Restlessness.
b. Use o f accessory muscles.
1. Obtain base line ABG/C BC.
2. Place in cool mist o xygen te nt e very 4-6 hours, depend ing o n se verity o f distres s.
3. Monitor hyd ratio n status.
a. If RR>60 and NPO, start intra ve no us fluids; if RR<60 and will take fluids, give c lear
liq uid s only as to lerated.
b. Monitor urinary o utp ut, spec ific gravity, and sk in turgo r.
c. Ma inta in patenc y o f IV.
4. Place o n card io-resp iratory mo nitor if signs o f hypoxia or re spiratory failure.

Ep iglottitis
Definition: An acute vira l o r bacteria l infectio n o f the epiglo ttis. Usually caused b y Hemop hillus
influenza type B or pneumococci streptococci.

Assessme nt
A. Observe that illness occ urs mo st freque ntly in yo ung c hild re n, 3-7 years of a ge.
B. Ascertain if illness was preceded by an upper resp irato ry infe ctio n.
C. Assess for rap id o nse t with insp irato ry strido r a nd re tractio ns, co ugh, muffled vo ice.
D. Assess for high te mperature (1000 – 1040 F)
E. Assess for resp irato ry d istress.
F. Evaluate d iffic ulty in swallo wing as ma nifested b y excessive droo ling and re fusa l to take
liq uids.

Implementation
A. Prepare for lateral neck films STAT to co nfirm d ia gnosis. Keep child in upright positio n.
Sup ine po sition ma y ca use occlusio n o f the a irway and respiratory arre st.
B. Never use restraints; never use a to ngue b lade.
C. Do not elicit a ga g reflex – ma y ca use further spasm of epiglottis.
D. Prepare c hild fo r OR if elective intubatio n is to be do ne.
E. Ma inta in trac heoto my set/intubation tray at b edside.
F. Provide coo l o xyge n mist at all times.
G. Monitor vita l signs with resp iratory sta tus e very 1 ho ur with co ntinuo us clo se observatio n.
1. Monitor resp iratory ra te, grunting, re tracting, stridor, co lor, restlessness.
2. Auscultate breath so unds; e valuate use of a ccessory muscles.
H. Monitor hyd ratio n status. Keep child NPO.
1. Start IV. C heck urinary o utp ut, sp ec ific gra vity, sk in turgor, tears.
2. Ma inta in patenc y o f IV.
I. Monitor temp erature every 2 ho urs – give Tyle no l for te mperature > 1000 F as ordered.
J. Place o n card ioresp iratory monitor.
K. Iso late for 24 ho urs after start o f antib iotic therapy.
L. Prepare fo r intub atio n.
1. Ma inta in child in up right position.
2. Ad minister humid ified oxyge n – assist with CPAP or mec ha nical ve ntilatio n as
necessary.
 1. Check e very 1 hour to ma intain tube pate nc y.
2. Restrain child well to p revent a ccidenta l e xtubatio n (re ma ins intubated 12 -48 ho urs).
A. Monitor signs prior to extubation.
1. Ab ility to swallow.
2. Reso lution o f sepsis.
3. Temperature within normal limits for 12 ho urs.
4. Reso lution o f swelling.
5. NPO 4 hours prior to e xtubatio n.

Tonsillitis a nd Adenoiditis
Definitio n: Infectio n and infla mma tio n of the palatine to nsils and adenoid s. Primary ca uses are
Gro up A beta-he molytic streptococcus a nd viruses.

Assessment
A. Assess for to nsillitis.
1. Observe for fe ver, sore throat, and anorexia.
2. Assess for genera l malaise a nd d iffic ulty in swa llowing.
B. Assess for adenoid itis.
1. Eva luate for stertoro us breathing.
2. Assess for pain in ear and recurring otitis med ia.
C. Evaluate if ind ications fo r surge ry are p resent.
1. Surge ry is performed only when abso lutely nec essary because tonsils are tho ught to have
importa nt p rotective immuno logic func tions.
2. Assess for repeat4ed episode s o f to nsillitis, which indicate s infection.
3. Assess for difficulty in swa llowing, whic h ind ica tes enlargement of to nsils o r adenoid s.
4. Observe for interference with breathing.
5. Eva luate for blocked Eustac hian tube. (C hronic otitis media).

Implementa tion
PREOP ERATIVE INTERVENTIONS
A. Take samp les for blood tests (CBC, Hgb, Hc t, b leed ing and c lo tting time), sero lo gic te sts, and
throat culture.
B. Obtain co mp lete hea lth history, includ ing history of a lle rgies.
C. Provide e motio nal support for the c hild.
1. Separatio n from fa mily.
2. Hospita lizatio n procedure.
3. Physical la yo ut of surgery roo m.
4. Ind uc tio n of a nesthesia.
5. Reco very roo m pro ced ure.
6. Postoperative pain.
7. Postoperative activity level (p la y therapy use ful).
D. Provide routine preopera tive care.

POSTOPERATIVE IN TERVENTIONS
A. Ma inta in in pro ne o r S ims’ positio n until fully awake to facilitate draina ge of secretions and
prevent asp iration. The n cha nge to semi-Fowle r’s.
A. Avo id suctio ning a nd co ughing to pre ve nt he mo rrhage.
B. Observe for signs of shock.
1. Restlessness.
2. Alterations in vita l signs (increased p ulse, decreased b lood pressure, incre ased re sp iratio n).
3. Frequent swallowing.
4. Excessive thirst.
5. Vo miting of b lood.
6. Pallor
C. Ma inta in calm, q uiet enviro nme nt to p re vent anxiety, whic h can lead to shock.
D. Provide ice collar
E. Force fluids.
1. Enco urage co ld fluids, pop sic les, ice c hip s.
2. Avoid use o f c itrus juices, mild, hot liq uids.
3. Do not use straws.
F. Ad minister Tyleno l for p ain as ordered.

ASSOCIATED CONDITIONS
Definition: C ystic fibrosis is a ge netic d iso rder in whic h the muc us-prod uc ing gla nds, particularly
tho se of the lungs and pa ncreas, are abno rmal. They prod uce thick and visco us muc us. Ab norma l
mucus p rod uctio n in the pancre as leads to pancreatic insufficie ncy and, in the lungs, to
emp hysemato us c hanges.

Assessme nt
A. Assess weight ga in because infants with high ca loric intake do not ga in we ight.
B. Evaluate for recurrent, se vere resp iratory infec tio ns ca used b y thick mucous a nd bronchial
plugs, whic h can ca use atelecta sis.
C. Assess for mild d iarrhea with greasy, ma lodorous stoo ls ca used b y malab sorptio n of fats and
prote ins.
D. Evaluate d iagno stic tests, inc luding the sweat test for sod ium co ntent and trypsin te st. (Trypsis
is absent in cystic fibro sis)

Imp lementatio n
A. Provide adequa te nutritio nal ma intenance.
1. Pancreatic enzyme s, Viokase and Cota zym, prior to mea ls.
2. Water-solub le vita mins.
3. Fat-soluble vitamins A, D, a nd E in water- miscib le form.
4. Die t high in calories and p rotein and lo w in fat.
5. Sodium ba lance.
B. Provide adequa te respiratory maintena nce. Ma jor objective is to keep lungs c le ar of muc us.
1. IPPB muco mist.
2. Mist te nt a t night to lique fy secretio ns.
3. Postura l d ra inage t. i.d. fo llowing IPP B.
4. Breathing e xercises. (C hildren tend to breathe shallowly).
C. Ad minister antibio tic s as ordered to p reve nt infectio n.
D. Provide pare ntal ed ucation.
 1. Informatio n abo ut the d isease and its lo ng term effect.
2. Genetic co unseling.
3. Reso urce centers such as Natio nal Fo undatio n for C ystic F ibrosis a nd local organizatio ns.
4. Care o f the child at home.
a. Normal family ro utine.
b. Children are irritab le, frightened, and insecure.
c. Children need attentio n, d iscip line, and reassurance.

Sudden Infant Death S ynd ro me (SIDS )

Definitio n: The sudden, unexp lainab le death o f an infant d uring sleep.

Characteristics
A. Most freq uent cause o f death after neo natal pe riod.
B. Peak incidence fro m 2 to 4 mo nths o f age. No danger first mo nth; rare after 6 mo nths.
C. Higher incid ence in winter, June and July, and in lo w- inco me gro ups.
D. On autopsy, inflammatio n o f upper resp irato ry tract is fo und.
E. Maternal factors: SIDS more co mmo n in unwed mothers, yo unger mothers, multiparo us
mo thers with sho rter between-pregnancy intervals, cigarette-smok ing mo thers, and mo thers
who do not fully utilize health care facilities or use them later in pregnancy.
F. Infant facto rs: S IDS more co mmo n in prematures and small- for-gestatio nal-age infants; infant’s
gro wth after b irth is slo wer than average.
G. Sleep : mo t deaths are unob served ; death d uring sleep is co mmo n altho ugh not universal.
H. Feed ing: bottle- feed ing mo re prevalent in SIDS, but breast- fed infants are not immune.
I. Familial recurrence: greater than no rmal pop ulatio n, b ut o nly 1-2 percent risk. No evidence of
genetic link.
J. Specificity: occurrence rate o f S IDS parallels the rate for general infant mo rtality.
K. Etiology unknown and co ntro versial. Theories invo lve carbo n d io xid e, sensitivity, massive
virus, a llergic reactio n and poor respo nse to stimu lus.

Assessment
1. Assess age o f infant and remaining ep idemio lo gic find ings.
2. Assess for p re maturity/low b irth weight infa nt.
3. Check fo r resp iratory pauses, sleep ap nea.
4. Check for gastroesop hageal reflux/ap nea assoc iated with re gurgitatio n after feed ing, o r tiring
during feed ing.
5. Assess for past histo ry o f o xygen ad ministratio n.
6. Assess for histo ry o f allergic respo nse.

Imp lementatio n
A. Ap ne ic ep isode d isco vered : infant respo nd when stimu lated (near- miss SIDS). Instruct parents
in care.
1. Shake/stimu late infant. If no respo nse, immed iately begin CPR.
2. Take infant to p hysician or nearest emergency roo m.
a. Record accurate histo ry fro m parents: time o f d isco very o f infant, co lor o f infant, skin
temperature, spo ntaneo us resp iratio ns after stimu latio n.
 a. Ask relevant q uestions: Wa s CPR begun? How lo ng a fter? How long was it co ntinued?
Did infa nt respond? Did there appe ar to b e regurgita tio n o f formula when infant was
disco vered? W hen d id infa nt last eat?
1. Assist p hysic ian to do co mp lete ne urolo gical, developme ntal, and p hysical exam o f infa nt,
inc lud ing lab work.
2. Teach parents CPR.
3. Instruc t parents abo ut care o f a c hild o n a ho me monitor.
4. give parents p ho ne numbers for resp ite c are and suppo rt gro ups.
5. Suggest to pare nts tha t infant jo in sleep stud y pro gram (polygrap h monito ring o f near-miss
SIDS infants).
A. Infant d ies; upo n a utopsy, S IDS is dia gnosed.
1. Support pa re nts thro ugh loss a nd grieving proce ss. Reassure pare nts that they d id
eve rything right for the child. Emp hasize b la me lessne ss of pare nts and sib lings.
2. Inform p are nts o f re sult o f a utop sy as soo n a possib le so grie ving p rocess may begin.
3. Refer pare nts to Natio na l Fo undatio n for SIDS.
4. If other infa nts in ho me, suggest they be tested for possib le sleep ap nea.

Kawasaki Dise ase

Definitio n: A c hildren’s d isease, most freq uently see n in boys und er two o f Asia n a nc estry. It
respo nds like a vira l disease o f lymp h nodes, but has an unkno wn cause.

Assessment
A. Assess for a ge, sex, and a ncestry to determine if c hild fits usua l profile.
B. Assess for vira l symp toms: fever, ra sh, swo lle n hands and feet, red ness o f the eyes, swo lle n
lymp h glands in the neck, inflamma tion o f mouth, lip s, and thro at.
C. Assess for pote ntia l heart invo lve ment (ane urysm, b locked coro nary artery lead ing to a he art
attack, myocard itis or pericard itis; arrhythmias ca n also occ ur).

Trea tment
A. Sinc e cause is unknown, no spec ific trea tme nt is o rdered.
B. Monitor asp irin to red uce feve r, pain, a nd inflammatio n; intraveno us ga mma globulin may
prevent coronary artery d isease if given early.

Sick le Cell Anemia

Definitio n: An hered itary d iso rder in whic h red blood ce lls sickle whe n under low oxygen tensio n.
Usua lly co nfined to Bla cks, it is co nsidered to be inherited as a n autoso mal recessive disorder.

Assessment
A. Assess ma jor sympto ms.
1. Severe c hro nic a nemia – pa llor.
2. Period ic crises with abdominal a nd joint pa in.
3. Lethargy and listlessness.
4. Irritab ilty.
5. High fe ver.
 1. Enlarged sp leen fro m inc reased ac tivity.
2. Jaundice fro m exce ssive blood cell destruction.
3. Wide ning of the marrow space s of the bones.
4. Gallstone s.
A. Assess periods o f crisis.
1. Thro mbotic crises.
a. Most freq uent type.
b. Caused b y occlusio n of the sma ll b lood vessels prod uc ing distal ischemia and
infarction.
c. Beginning o f crises may be characterized by the swelling of the hand and feet or
decreased appetite, irritability, or fever.
d. May experie nce pain and swe lling in abdome n.
2. Sequestra tion crises.
a. Occurs usua lly in c hildren under five.
b. Caused by poo ling o f b lood in splee n.
c. Enlargeme nt of sp lee n a nd circulatory collapse.

Imple me ntatio n
A. Alleviate pa in with a na lge sics.
B. Prevent de hydration with intrave nous infusio n, if necessary, a nd increased fluid intake.
C. Keep child wa rm.
D. Offe r parents genetic co unse ling.
E. Counsel the fa mily o n p hysiolo gy and pro gno sis o f disease.
F. During sequestration crises, supervise b lood tra nsfusions.

Hemop hilia
Definitio n: A sex-linked d iso rder in which certain factors necessary for coagulatio n of the b lood
are missing. Tra nsmissio n o f sex- linked trait are passed fro m unaffected carrier females to a ffected
males.

Characteristics
A. Hemophilia A-Factor VIII defic iency: treated with cryoprecip itate or fresh- fro ze n plasma.
B. Hemophilia B – Factor IX deficienc y (Christmas disease ): treated with cryoprec ipitate o r fresh
froze n pla sma.
C. Hemophilia C – Factor XI deficie nc y: trea ted with fresh- fro ze n plasma.

Assessment
A. Assess for type A or B.
1. Possib le bleed ing tende ncy in neonata l period beca use factors are not pa ssed thro ugh t he
place nta.
2. Excessive bruising.
3. Large he matomas from mino r trauma.
4. Persistent b leeding from mino r injuries.
5. Hema rthro sis with joint pain, swe lling, and limited move ment.
6. Possib le progressive degenera tive c hanges with osteoporosis, muscle atrop hy, and fized
joints.
A. Assess for type C.
1. Usually appears as a mild bleeding disorder.
2. Autosomal dominant trait with both sexes affected.

Implementation
A. Prevent bleeding
1. Protect child from environment by padding crib and playpen.
2. Supervise child carefully when child is learning to walk.
B. Observe for signs of blood transfusion reaction.
C. Observe for signs of volume overload with plasma administration.
D. Treatment if bleeding occurs:
1. Apply cold compresses and pressure.
2. Hemarthrosis (effusion of blood into joint).
a. Immobilize joint initially.
b. Initiate passive range of motion within forty-eight hours to prevent stiffness.
3. Immobilize site of bleeding.