Respiratory System part 2 second years student Nursing Collage

1
Respiratory Systempart 2second years
studentNursing Collage

• Iman Al Shaweesh
• Sept. 2008
• Al Najah Univesity

2
Health History

• The reason that pt. is seeking health care is,
  dyspnea (shortness of breath), hemoptysis (blood
  spit up from respiratory tract), odema, cough,
  general fatigue, weakness.
• Nurse must identify chief complain , when started
  problem ,how long, duration, severity, assess
  risk factors, identify the impact of ss on the
  patient ability to perform daily activitie.

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• Major ss are dyspnea, cough, wheezing, sputum
  production, chest pain, clubbing of fingers,
  hemoptysis, cyanisis. This SS are related to
  duration severity of disease.

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1-Dyspnea

• difficult or labored breathing, shortness of
  breath. Symptom common to many pulmonary
  cardiac disorders, particularly when there is
  decrease lung compliance or increase airway
  resistance.
• Rt. Ventricle will affect by pulmonary disease
  because it must pump blood through the lung
  against greater resistance.

5

• Sudden dyspnea in health person indicates.
• Pneumothorax (air in pleural cavity).
• Pulmonary embolism
• RDS.
• Acute respiratory obstruction.

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Orthopnea

• (inability to breath easily except in an upright
  position). Found in pt. with COPD, heart disease.
• Dyspnea with an expiratory wheeze occurs with
  COPD.
• Noisy breathing result from narrowing of the
  airway or localized obstruction of major bronchus
  by tumor or foreign body.

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Relieve measures

• high fowlers position, 02 in sever case.
• Ask pt. circumstance that produces dyspnea.
• How much exertion triggers shortness of breath?
• Cough?
• Time of day or night? Occur at rest.
• Shortness sudden or gradual.

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2-Cough

• Result from irritation of the mucous membranes
  any where in the respiratory tract.stimulus many
  arise from an infectious process or irritant as
  smoke, dust, gass.its protect against
  accumulation of secretion in the bronchi
  bronchioles.

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Clinical manifestation

• Cough may indicate serious pulmonary disease.
• Nurse must evaluate character of cough, dry,
  loose, sever, brassy, hacking.
• A dry, irritant cough in characteristics of an
  URTI of viral origin or may be S.E of (ACE)
  inhibitor therapy.
• Laryngotracheitis cause an irritative high
  pitched cough.

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• Tracheal lesions produce a brassy cough.
• A sever or changing cough may indicate
  bronchogenic carcinoma.
• A cough in the morning with sputum production may
  indicate bronchitis.
• A cough that worsen when the pt. is in supine
  position suggest postnasal drip (sinusitis).
• Coughing after food intake may indicate
  aspiration of material into the tracheobronchial
  trea.

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3-sputum production

• pt. who coughs long enough produce sputum.
• Violent coughing cause bronchial spasm
  obstruction irritation of bronchi and may
  result in scope (funting).
• Uncontrolled cough that is non productive is
  exhausting potentially harmful.

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Clinical manifestation

• Thick, yellow, green..Indicate bacterial
  infection.
• Thin, mucoid sputum......Indicate viral.
• Pink tinged mucoid sputum Indicate lung
  tumor.
• Profuse, frothy, pink material ...Indicate
  pulmonary odema.
• Foul-smelling sputum bad breath .Indicate
  lung abscess, infection from anaerobic organism.

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Relieve measure

• Adequate hydration (water).
• Inhalation of nebulizer.
• Stop smoking, because it causes inflammation
  hyperplasia of mucous, and decrease production of
  surfactant.
• If smoking stop sputum will decrease, encourage
  pt. to drink juices to change sputum taste
  select of food that increase the appetite.

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4-chest pain

• may associated with pulmonary or cardiac disease.
• Chest pain with pulmonary may be sharp stabbing
  intermittent or dull, aching persistant
• Pain may refer else where- neck, back, abdomen.

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Clinical manifestation

• Chest pain may occur with pneumonia, pulmonary
  embolism with lung infarction pleurisity.
• It also late symptom of bronchogenic carcinoma.
• Lung disease not always produce pain because lung
  visceral pleura lack sensory nerves
  insensitive to pain stimuli partial pleura has
  rich supply of sensory nerves.

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• Pleuritic pain from irritation of partial pleura
  is sharp, pt. describe it as (like the stabbing
  of knife). Pt. comfortable when sleep on affected
  part.
• Nurse must assess quality, intensity, radiation
  of pain, relationship of pain to inspiratory
  expiratory.

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• Relieve measures
• Analgesic medication but not to depress the
  respiratory center or productive cough.
• NSAID for pleurituic pain.
• Regional anesthetic block may be performed to
  decrease extreme pain.

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5-wheesing

• Is often a major finding in pt. with
  bronchoconstriction or airway narrowing.
• Heard with stethoscope depend on location.
• Wheezing is a high pitched, musical sound heard
  mainly on expiration.
• Relieve measure Oral or inhaled bronchodilator.

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6-clubbing of the fingers

• is singe of lung disease found in pt. with
  chronic hypoxic condition, chronic lung
  infections, CA of lung.
• Initially manifested as sponginess the nail bed
  loss of nail bed angle

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7-Hemoptysis

• Expectoration of blood from respiratory tract.
• Is symptom of both pulmonary cardiac disorders.
• Onset is sudden, may be intermittent or
  continious.
• Common cause 1- pulmonary infection.
• 2- CA of lung.
• 3- Abnormalities of
  heart
• blood vesserls.

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• 4- Pulmonary artery or vein
  abnormalities.
• 5- Pulmonary emboli infarction.
• DX. Evaluation
• Chest x-ray.
• Chest angiography.
• Bronchoscopy
• Full history physical examination

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• Inspection of blood, small amount or massive
  hemorrhage. Source of bleeding gums( blood
  appearing in noise).
• Lung (bright red, frothy salty taste haemoptesis.
• Stomach(haemoptesis dark blood).

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8-Cyanosis

• Is a bluish coloring of skin, very late indicator
  of hypoxia.
• Presence or absence of cyanosis is determined by
  amount of unoxygenated hemoglobin in blood. When
  there is 5g/dl of unoxygenated HG. A pt. with
  15g/dl HG will not demonstrate cyanosis until
  5g/dl of HG become unoxygenated.
• Cyanosis is not reliable singe of hypoxia.
  Because anemic pt. rarely manifest cyanosis.

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• In the present of pulmonary condition cyanosis
  assess by tongue lips.
• Peripheral cyanosis results from decrease blood
  flow to certain area not indicate central
  problem.

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Physical assessment of upper respiratory tract

• Noise sinuses
• Inspect external nose for lesion, asymmetry or
  inflammation .ask pt. to tilt head background,
  gently pushing tip of nose inspect mucosa for
  color, swelling, bleeding.nasal Deviation,
  Perforation.
• Nurse inspect inferior middle turbinates then
  nurse palpate frontal maxillary sinuses for
  tenderness using thumb gently pressure. Frontal
  maxillary sinuses can be inspected by
  (transilliumination). If light fails to generate,
  the cavitycantain fluid.

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• Pharynx mouth
• Ask pt to open mouth take breath inspect for
  color, symmetry, ulceration or enlargement.
• Trachea.(position, mobility of trachea).

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Assessment of lower respiratory structures
breathing

• Thorax Inspection of thorax provide information
  about musculoskeletal structure, nutritional
  status respiratory system. Note symmetry.
• Chest configuration. Normal ratio of
  anterioposterior diameter to lateral diameter is
  12. Four deformities of chest associated with
  respiratory disaease.

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• A-Barrel chest.
• Result of overinflation of the lungs
• Increase in anterioposterior diameter of thorax
• Pt. with emphysema, ribs are more wildely spaced
  intercostals spaces tend to blug on expiration.

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Barrel chest
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• B-Funnel chest (pectus excavatum)
• Occur where is depression in lower portion of
  sterum this may compress heart great vessels
  resulting in murmers.
• May occur with rickets or marfans syndrom

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• C-Pigeon chest (pectus carinatum).
• Occur as result of displacement of sternum.
• Increase anterioposterior diameter.
• Rickets , marfans syndrome, sever hyposkoliosis.

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• D-kyphoscoliosis.
• Is characterized by elevated of scapula
  corresponding S- shape spine.
• This limit lung expantion.
• Occure with osteoporosis.

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Breathing pattern respiratory rates

• Normal breath 12-18 b/m, regular in depth
  rythem. This descripe as eupnea.
• Bradycardia slow breathing associated with
  increase ICP , brain injury, drug overdose.
• Tachypnea- rapid breathing. Pt with pneumonia,
  metabolic acidosis, pulmonary odema, septicemia.
• Hyperventilation shallow, irregular breathing.
  hyperventilation associated with sever acidosis
  is called ( kussmauls respiration

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• Hyperpnea increase depth of respiration.
• Hyperventilation increase in rate depth .
  inspiration expiration are equal in duration.
• 1-Thoracic palpation
• The nurse palpates the thorax for tenderness,
  masses, lesion, vocal fremitus, and respiratory
  excursion. Nurse performs direct palpation with
  finger tips or ball of the hand (for deeper
  masses).

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• A-Respiratory excursion
• Is an estimation of thoracic expansion may
  dissolve significant information about thoracic
  movement during breathimg.
• Pt. instructed to inhale deeply while the
  movement of nurse thumbs. This movement is
  normally symmetry. Asymmetric excursion due to
  fracture rib, trauma, unilateral bronchial
  obstruction.
• Decrease chest excursion due to chronic fibrotic
  disease.

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• B-Tactile fremitus
• Sound generated by the larynx travels distally a
  lone the bronchial tree to test the chest wall in
  resonant motion. Pt asks to repeat 99.
• Pt. with emphesema- rupture of aloveoli
  trapping of air, exhibit no tactile fremitus.
• Tactile fremitus increase over lob affected with
  pneumonia.

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• C-Thoracic percussion
• Nurse use percussion to determine a whether
  underlying tissues are filled with air, fluid or
  solid material.also used to estimate size,
  location certain structure with thorax. (heart.
  Diaphragm).

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• D-diaghragmatic excusion
• Normal resonance of the lung stops at the
  diaphragm, the position of diaphragm is different
  in inspection expiration.
• Assess position motion of diaphragm by
  ask pt. to take breath hold it, nurse
• marked with pen. Distance between the two
  markings indicates range of motion.
• 8-10cm in healthy, 5-7 most people. The
  diaphragm is about 2cm. higher in Rt.
• Because position of heart.

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DX.Evaluation

• Pulmonary function test. Routinely used in pt.
  with chronic respiratory disorders, test should
  measurements of lung volume, ventilatory function
  mechanism of breathing diffusion gas
  exchange.
• Arterial blood gas study. Aid in assessing the
  ability of the lungs to provide adequate o2
  remove co2. the ability of kidney to reabsorb
  excrete bicarbonate ions to maintain body normal
  PH. ABGs are obtained through an arterial
  puncture at radial, brachial, femoral, or
  indwelling arterial catheter.

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• Pulse oximetry. Non invasive method of
  continuously monitoring o2 sat. of hemoglin.
  Aprobe or sensor is attached to the fingertip
  forehead, earlobe, bridge of nose. Normal
  95-100, decrease 85 indicate that tissue are not
  receiving enough o2.
• Culture. Throat culture to identify pathogenic
  organism, drug sensitivity testing. Specimen to
  lab must be within 2 hr.s (overgrowth of
  organisim). Specimen taken at morning.

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• Imagining studies. Include X- ray, CT, MRI
  (magnetic resonance imagimg, radioscopic
  diagnostic scans.
• 1-Chest x-ray normal pulmonary tissue is
  radiolucent, there for densties produced by
  fluid, tumors, foreign bodies pathogenic
  condition can be detected by x-ray.
• 2-CT used to identify pulmonary nodules small
  tumors that are not visible on routine chest
  x-ray.

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• 3-MRI are more diagnostic image than CT..to
  characterized pulmonary bodules.
• 4-Fluoroscopic studies used to assess with
  invasive procedures as chest needle biopsy. To
  study movement of chest wall, heartr,
  diaphragm.To detect , diaphragm paralysis lung
  masses.

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• 5-Pulmonary angiography used to investigate
  thromboembolic disease of the lung as congenital
  abnormalities of pulmonary vascular tree.( it
  involve rapid injection of radiopaque agent (
  from femoral vein, arm vein) into the vascular of
  the lungs for radiographic study of pulmonary
  vessels

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• 6-Radioisotope DX. Procedures (lung
  scan).Ventilation- perfusion lung scan is first
  performed by injecting a radioactive agent into a
  peripheral vein then obtaining a scan of the
  chest into detects radiation.Used clinically to
  measure the integrity pf pulmonary vessels
  relative to blood flow to evaluate blood flow
  abnormalities as seen in pulmonary emboli. It
  takes 20-40 minute.

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VI.Endoscopic procedure

• Bronchoscopy is direct inspection examination
  of the larynx, trachea, bronchi through either
  a flexible fiberoptic scope or rigidf
  bronchoscope.
• Purpose of DX. Bronchoscopy.
• To examine tissue or collect secreations.
• To determine location obtain tissue.
• To determine if tumor can be resected surgically.
• To DX. Bleeding site.

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• Thepaputic bronchoscopy is used to
• Remove foreign bodies.
• Remove recreation obstruction the
  tracheobronchial tree.
• Treat post operative atelactasis.
• Destroy excise lesion.

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• Complication
• Reaction to local anesthesia.
• Infection
• Aspiration
• Bronchoscopy
• Hypoxemia

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• NSG intervention
• consent form, NPO, explain procedure,
  preoperative medication ( atropine,
  sedation)..as prescribed to inhibit vagal
  stimulation, suppress cough. Also pt. must remove
  dentures.
• Post op. pt. must be NPO until the cough reflex
  returns. Ice-chips fluid given.
• Observe v/s, hypoxia, bleeding, hypotention,
  tachycardia, dysarythmia.

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Thoracoscopy

• (DX. Treat biobsy).
• Is DX procedure in which the pleural cavity is
  examined with an endoscope. Small incisions are
  made into the pleural cavity.
• Chest tube may be inserted pleural cavity is
  drained by negative- pressure water seal drainage.

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• NSG intervention
• Monitor shortness of breath (which may indicate
  pneumothorax).
• Monitor chest drainage if chest tube is in place.
• Monitor activity restriction.

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Thoracenteses.

• A thin layer of pleural fluid normally remains in
  the pleural space. An accumulation.
• may occur in some disorders. Sample can obtain by
  (aspiration of pleural fluid for DX. To
  therapeutic purposes).
• Needle biobsy can be performed at same time.
  Study includes grams stain culture sensitivity,
  acid- fast staining, PH..

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Biopsy

• The excision of small amount of tissue, may be
  performed to permit examination of cells from the
  pharynx, larynx.
• Pleural biopsy is accomplished by needle biopsy
  of the pleura or by pleuroscipy. Visual
  exploration through a fiberoptic bronchoscopy.
• Lung biobsy procedures is performed to obtain
  lung tissue for examination to identify the
  nature of lesion.

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• There are several non-surgical technique as
• transcantheter bronchial brushing
• trans brachial lung biopsy
• percutanous.
• NSG intervention same as bronchoscopy, monitor
  shortness of breath, bleeding, infection, report
  pain, redness of biopsy, site, pus..
• Lymph node biopsy scalene node biopsy may
  performed to detect lymph spread of pulmonary
  disease as hodgkins carcinoma.

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Management of pt.s with upper respiratory tract
disorder

• 1-Rhinitis is a group of disorder characterizes
  by inflammation irritation of the mucous
  membranes of the nose. It may be classified as
  non allergic allergic.
• Patghophysiolopgy
• Non allergic rhinitis may be caused by a variety
  of factors including.
• Environmental factors such as change temp.
  Humidity odors, foods, infection, age, systemic
  disease, drugs (cocaine). Or prescribed
  medication, foreign body.

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• SS
• Rinorrhea (excessive nasal drainage, runny
  nose), nasal congestion, discharge itching,
  sneezing, and headach.
• RX.
• Depend on cause if viral, medication given to
  reduce symptoms.
• In allergic rhinitis tests may perform,
  corticosteroid desensitizing immunization may
  require.

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• If bacterial infection- antimicrobial agent.
• Antihistamine for allergy for sneezing, itching,
  rhinrrhea.
• Oral decongestant agent.

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• NSG Manegement.
• Avoid or decrease exposure to allergens
  irritants.
• Controlling environment.
• Technique of administer nasal medication.
• Hygiene, blow the nose before medication.
• Treat symptom.
• In elderly, nurse discusses value of vaccine in
  the fall to achieve immunity prior the beginning
  of flu season.

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2-Viral rhinitis (common cold).

• Is used when referring to an URTI is self-
  limited caused by a virus (viral rhinituis).
• nasal congestion, rhinorrhea, sneezing, sore
  throat general malaise characterize it.
• Cold are highly contagious because virus is shed
  for about two days befot the symptoms appear.

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• The 6 viruses known to produce SS of viral
  rhinitis are rhiniuvirus, parainfluenza virus,
  corona virus, resp. syncytial virus influenza,
  adenovirus. Each one have multiple strain.(e.g
  100 strains of rhinivirus, which account of 50
  of al colds.

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• SS
• Nasal congestion, runny nose, sneezing, nasal
  discharge, nasal itching, tearing watery eyes,
  scratchy or sore throat, general malaise.
• Low grade fever, chills, headache, muscle aches.
• In some people it exacerbates to herpes simplex.
• Symptom last 1-2 wk.s.

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Treatment

• Consist of symptomatic therapy, no specific
  treatment.
• Adequate fluid intake.
• Rest, increase intake of vitamin C, use
  expectorant.
• Warm salt water gargles
• NSAID as aspirin, ibuprofen relieves the aches,
  pain, fever.

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• Some research suggests Zink lozenges, may
  decrease duration of cold symptoms if taken
  within 1st 24 hr.s of onset.
• Antibiotic should not be used.
• NSG Manegement
• Teach pt. how to break the chain of infection,
  hand washing (most effective).
• Teach method to treat symptom prevent measure.

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3-Acute sinusitis

• The sinuses, mucus lined cavities filled with air
  that drain normally into the nose, are involved
  in a high proportion of URTI.
• If opening to nasal are clear, the infection
  resolve promptly.
• Some individual are more prone to sinusitis
  because of their occupation as paint.

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• Patghophysiolopgy
• Acute sinusitis is an infection of the Para nasal
  sinuses.
• It frequently developa as aresult of an URTI.
• Nasal congestion caused by inflammation, odema,
  transudation of fluid, lead to obstraction of the
  sinus cavity.
• This provide an excellent modium for bacterial
  growth.
• .

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• Bacterial organism account for 60 of acute
  sinusitis as streptococcus pneumonia, hemophilus
  influenza, moraxella catarrbalis.
• Dental infection associated with acute sinusitis

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• SS
• Facial pain, nasal obstruction, fatigue,
  purulent nasal discharge, fever, headache, facial
  ear pain fullness, dental pain, cough, decrease
  sense pf smell, sore throat, eyelid edema.

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Assessment DX finding

• History physical examination.
• Tenderness over the infected sinus
  area.transilluminated (decrease transmission of
  air).
• Sinus x-ray. (Fluid level, mucisal thikining).
• Computed tomograghy scanning is most effective DX
  tool.

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• Complication
• If not treated lead to meningitis brain abscess,
  ischemic infarction, osteomyelitis, sever orbital
  cellulites.
• RX.
• Goal to treat infection, shrink the nasal mucosa
  relieve pain.
• Antimicrobial, first lineamoxicillin,
  erythromycin, bactrim.

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• Mucolytic agent, decease nasal congestion.
• Antihistamine
• If pt. continues to have symptom 7-10 days, the
  sinuses may need to be irrigated hospital may
  be required.
• NSG Management
• Teach method to promot drasinage as inhaling
  system, increase fluid intake, local heat.

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• Inform pt. about S.E of nasal spray body
  receptors depened on spray to keep nasal passage
  open. (rebond congestion).
• Teach early signe of a sinus infection
  recommended preventive measures as following
  health practices, avoid contact with people have
  URTI.
• Explain the fever nuchal rigidity, sever headach
  as signe of potential complication.

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Chronic Sinusitis

• Is an inflammation of sinuses that persists for
  more than 3 wk.s in adult 2 wk.s in children.
  Estimated that 32 millions develop/year.
• Is an inflammation of sinuses that persists for
  more than 3 wk.s in adult 2 wk.s in children.
  Estimated that 32 millions develop/year.
• Blockage that persist for greater 3 wk. may occur
  because of infection, allergy, or structural
  abnormalities.

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• This result in stagnant recreation, an ideal
  medium for infection.
• Organism as acute immunocompremized at risk of
  fungal.

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Clinical Manifestation

• Impaired mucocilliary clearance ventilation,
  cough, chronic hoarseness, chronic headach in
  periorbital area, facial pain.
• Fatigue, nasal stuffness, decrease smell taste,
  fullness in the ears.
• Symptoms are generally pronounced on awakening.

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DX finding assessment

• History, computed tomography scan or MRI if
  fungal suspected.
• Rule out other systemic disorders as tumor.
• Nasal endoscopy.
• Complication
• Uncommon.
• sever orbital cellulites
• meningitis, encephalitis
• cavenous sinus thrombosis

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Treatment of chronic sinusitis

• As acute course 3-4 wk.s)
• Surgical management when medical failed incision
  drainage sinus, removing tumor, correct
  structural deformities (excise fungal ball
  necrotic tissue drain sinus).
• Topical corticosteroid, antimicrobial agents are
  administer before after surgery.

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• NSG Management
• Nurse teaches pt. how to promote sinus drainage
  at home by increase envoromental humidity.
• Increase fluid, follow medication regime.
• Instrucr signe of sinus infection.

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4-Acute Pharyngitis

• Is an inflammation or infection in the throat
  usually causing symptoms of a sore throat.
• Pathophysiology
• Most cases of acute pharyngitis are caused by
  viral infection.
• When group.A beta-hemolytic streptococcus- most
  common cause acute pharyngitis the condition know
  as strep throat.

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• Body response by triggering an inflammatory
  response in the pharynx, this results in pain,
  fever, vasodilation, edema, tissue damage,
  manifested by redness swelling in the tonsillar
  pillars, uvula soft palate, creamy exudates may
  be presented in tonsillar pairs.
• If a beta- hemolytic streptococci is a more sever
  illness.

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• Complication include, sinasitus, OM,
  peritonsillar abscess, mastoiditis cervical
  adenitis.
• In rare case meningitis, pneumonia.
• SS
• Afiery red pharyngitis membrane tonsils
  lymphoid follicles those are swollen flacked
  with white purple exudates. Enlarge tender
  cervical lumph nodes.
• Fever, malaise, sore throat may present.

80
Assessment DX.

• Latex agglutination (LA) / strep antigen
• ELISA
• Throat culture
• Nasal swab blood culture
• RX
• Viralsupportive measures
• Bacterial.. penicillin, erythromycin,
  cephalosporin (10 day).
• analgesia, aspirin, acamol.
• Antitussive med. Codian
• Nutritional therapy, liquid, soft, in sever case
  IV

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NSG Management

• Stay in bed during febril stage.
• Disposed of tissue to decrease spread infection.
• Examin skin for rash, because pharungitis may
  precede some communicable disease as rubella.
• Warm saline gargles or irrigation.
• Ice collar can relieve sever throats.

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• Mouth care.
• Full course of antibiotics, A beta-hemolytic
  strep. Infection possible develop complication as
  nephritis, RF, which may have onset 2-3 wk.s of
  pharyngitis.
• Nurse must instruct the important of take full
  course of med.)

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Chronic Pharyngitis

• Is a persistent inflammation of the pharynx, its
  common in adults who work or live in dusty
  surrounding, use their voice to excess, suffer
  from chronic cough, use alcohol.
• Three type of chronic pharyngitis
• Hypertrophic general thickening congestion of
  the pharyngeal mucusemembrane.
• B. Atrophic late stage of type one membrane is
  thin, whitish, glistening.

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• C. Chronic granular(clergymanas sore throat),
  characterized by numerous swollen lymph follicles
  on the pharynx.
• SS
• Pt. sense, constant sense of irritation or
  fullness on throat.
• Mucous that collects in the throat can be
  expelled by coughing difficulty swallowing.

85
Treatment

• Rx based on relieving symptoms avoid exposure to
  irritants.
• Nasal congestion- nasal spray contain ephedrine
  sulfate
• Aspirin or acetaminiphil.
• Analgesic, antihistamin q 4-6 hr.

86
NSG Management

• Avoid contact with other.
• Alcohol, tobacco, smoke, exposure to cold are
  avoided.
• Drink plenty of fluids
• Gargelling with worm saline may relieve throat
  discomfort.
• Lozenges will keep throat moistened.