RESPIRATORY SYSTEM

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RESPIRATORY SYSTEM

• When you can't breathe,

nothing else matters
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Basic Respiratory Anatomy
Nasopharynx
Oropharynx
Epiglottis
Larynx
Trachea
Carina
Bronchi
Bronchioles
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Lower Respiratory Anatomy

• Bronchioles
• Walls consist entirely of smooth muscle (no
  cartilage)
• Smallest airways

• Alveoli
• Site of O2 CO2 exchange with blood
• Air sacs

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x
John Smith 123 Main Street North Bay,
Ont
1400
130 35 125/85
82 4 5 6 15
A B
123 Main Street Pts Home
Difficulty Breathing
1340
Sudden onset of severe dyspnea, productive cough,
Denied any graduate increase in wheezing or
cough, No CP, no increase in sputum
x
COPD (x5yrs) with 3-4 exacerbations per year,
Smoker (1pk /day/x50 years)
Salbutamol MDI 2 puffs q6h prn, Salmeterol Diskus
50 mg bid
Overnight Home O2 at 2L by NC
X
X
x
75 M
x
x
Pt in obvious respiratory distress, tripod
breathing, use of accessory muscles, sweating,
pink, anxious.
x
WNL
X
X X
X
X
X
X
X
X
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Signs and Symptoms of COPD

• Primary Symptoms include
• cough, sputum production, dyspnea on exertion
• Other symptoms may include
• weight loss (dyspnea interferes with eating)
• decreased exercise tolerance
• barrel chest
• colds that last weeks, not days
• wheezing and shortness of breath
• increase in the amount and thickness of sputum
  produced
• change in color of sputum
• difficulty sleeping
• chest tightness

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What does your Pt Look Like?

• ? Orthopnea
• Barrel Chest ?

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Respiratory Assessments

• Airway
• Ensure Open Airway Maintain Open Airway
• Concious patient can maintain own airway
• Remove False Teeth
• Breathing
• Noisy breathing is obstructed breathing
• Not all obstructed breathing is noisy.

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Respiratory Assessment

• Is the pt moving air?
• Rate
• Is the pt moving air adequately?
• Quality
• Is their blood being oxygenated?
• O2 Sats

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Auscultation - Diagram
http//solutions.3m.com/wps/portal/3M/en_US/Littma
nn/stethoscope/education/heart-lung-sounds/
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RESPIRATORYPatterns
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ER Nursing Interventions

• Vitals O2 Sat
• Oxygen
• IV Fluids to keep hydrated
• 12 lead ECG, CXR
• Labs ABG, CBC, Cardiac Enzymes, Lytes
• Administer medications

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Lab Results for COPD

• ABG on room air 7.34/50/54 (pH/pCO2/pO2) -
  Respiratory Acidosis w/ DC O2 in Blood
• Na 138 K 3.9 Cl 98 HCO3 26 BUN 12 Cr 1.1
• WBC 11.0 with 80 Neutrophils
• CXR- no evidence of pneumonia
• Peak flow rate 120L/min (normal PEFR for a 5'8"
  60year old without COPD is around 520).

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Arterial Blood Gases

• pH 7.35 to 7.45 PaCO2 35 to 45 mmHg
• PaO2 80 to 100 mmHg HCO3 22 to 26 meq/L
• 1. Evaluate each individually
• 2. Determine acidosis or alkalosis
• - Respiratory Acidosis or Alkalosis
• 3. Determine respiratory or metabolic
• - Match ? pH with ? PaCO2 or ? HCO3
• - Think of CO2 as an Acid (Respiratory)
• - Think of HCO3 as a Base (Metabolic)
• 4. Determine extent of compensation

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Arterial Blood Gas Test

• Respiratory Alkalosis
• is characterized by a raised pH and a decreased
  PCO2, is due to over ventilation caused by
  hyperventilating, pain, emotional distress, or
  certain lung diseases that interfere with oxygen
  exchange.

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Arterial Blood Gas Test

• Respiratory Acidosis
• is characterized by a lower pH and an
  increased PCO2 and is due to respiratory
  depression (not enough oxygen in and CO2 out).
  This can be caused by many things, including
  pneumonia, chronic obstructive pulmonary disease
  (COPD)

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CHEST X-RAY

• - Emphysema -
• Chest radiograph shows hyperinflation, flattened
  diaphragm, increased retrosternal space, vertical
  heart, and hyperlucency of the lung parenchyma.

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Diagnosis of COPD Exacerbation

• Indication for hospitalization
• Advanced Age
• Increased dyspnea, cough
• Inability to eat and sleep due to
• exacerbation of the illness
• Worsening hypoxemia

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What COPD is

• The American Thoracic Society has defined COPD
  as a disease state characterized by the presence
  of airflow obstruction due to chronic bronchitis
  (and/or) emphysema the airflow obstruction is
  generally progressive, may be accompanied by
  airway hyperresponsiveness, and may be partially
  reversible.

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Spirometry Test

• Is used to evaluate air flow obstruction, which
  is determined by the ratio of FEV1 (volume of air
  in which the pt can forcibly exhale in 1 second)
  to forced vital capacity (FVC).
• With obstruction the pt either has difficulty
  exhaling or cannot forcibly exhale air from the
  lungs reducing the FEV1.
• Obstructive lung disease is defined as FEV1/FVC
  ratio less than 70

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Stages of COPD 1 2

• Mild COPD
• Often no symptoms
• S.O.B. with mild to moderate activity
• Frequent cough and regular sputum
• Mild to Moderate COPD
• Occasionally no symptoms
• S.O.B. with moderate activity
• Regular thick, yellow sputum
• Wheezing when exhaling
• Excessive inflation of the lungs

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Stages of COPD - 3

• Severe COPD
• Exaggerated symptoms of moderate COPD plus
• S.O.B. and tightening of the chest at rest or
  with min. activity
• Inactive lifestyle
• Frequent exacerbations with resp. failure and
  heart complications
• Requiring long term O2 therapy and/or
  hospitalization
• Swelling of ankles
• Cyanosis
• Weight loss

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Differentiation of COPD from Asthma
Differentiation Criteria COPD ASTHMA
Age of Onset Usually 5th-6th decade Variable
Role of Smoking Directly related Not directly related, but may adversely affect asthma
Evolution Slow, progressive Episodic
History of Allergy Infrequent Over 50 of patients
Inflammatory cells Neutrophils Eosinophils
Diffusing Capacity Decreased, especially with emphysema Normal
Reversibility of Airflow Obstruction Obstruction is chronic and persistent. FEV1 is persistently reduced if disease is significant. Obstruction is episodic and usually reversible with therapy. FEV1 usually normal between attacks
Spirometry May have improvement with spirometry, but not universally seen Usually marked improvement on spirometry with bronchodilators or steroids.
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Chronic Bronchitis vs Emphysema

• Emphysema destruction of alveoli, loss of lung
  elasticity
• increased work of breathing, air trapping
• Chronic Bronchitis irritation and inflammation
  of the lining of bronchial tubes, wheezing,
  mucus, congestion

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Chronic Bronchitis vs Emphysema
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Medications / Treatment

• O2 at 1L/min via nasal cannula
• Salbutamol 2.5mg q 1-2 hours via nebulizer.
• Ipratropium 250 mg every 6 hours via nebulizer.
• Pulmicort 0.5 mg q12h via nebulizer
• Methylprednisolone 50 mg IV q8h

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BRONCHODILATORS

• Act to decrease muscle tone in both small and
  large airways in the lungs. Include
• Beta-adrenergic
• Anticholinergic
• Methylxanthines

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ß2 agonists

• Salbutamol Short-acting ß2 agonist. Used in
  treatment of bronchospasm. Selectively stimulates
  beta2-adrenergic receptors of the lungs.
  Bronchodilation results from relaxation of
  bronchial smooth muscle, which relieves
  bronchospasm and reduces airway resistance.
• Salmeterol Long-acting ß2 agonist. More
  convenient than short-acting, but also more
  expensive.

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Anticholinergic

• Ipratropium Bromide (Atrovent) Inhibits vagally
  mediated reflexes by antagonizing action of
  acetylcholine, specifically with the muscarinic
  receptor on bronchial smooth muscle.

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Corticosteroids

• Important anti-inflammatory therapy effective
  in accelerating recovery from acute COPD
  exacerbations.
• Methylprednisolone (Solu-Medrol, Depo-Medrol) --
  Usually given IV in ED for initiation of
  corticosteroid therapy, although PO should
  theoretically be equally effective.

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Medical Floor

• For a Patient with Dyspnea (SOB)
• Place pt in a position that facilitates breathing
• Assess vital signs, auscultate for adventitious
  sounds and quality of air movement
• If hyperventilating, encourage slow deep
  breathing
• Have pt perform pursed lips breathing
• Notify physician or NP and respiratory therapist
• Assess oxygenation status by evaluating changes
  in mental status
• Give any PRN medications that will help to
  facilitate breathing
• Continue to monitor Vital signs and support
  effort to breathe

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Medical Floor

• For a Patient with Ineffective Breathing Pattern
• Attempt to arouse pt with physical stimulation to
  enhance breathing
• Assess airway for obstruction
• Assess vitals signs, auscultate chest noting
  depth and quality
• Assess skin colour for cyanosis, and moistness
• Administer supplemental O2 with a simple mask up
  to 10L/min (60) Oxygen
• Administer bronchodilators if ordered
• Notify physician and respiratory therapist

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Nursing Student

• Respiratory assessment vitals
• Student is not happy with O2 sats (low 90s) so
  increases amt of O2 from 2L to 6L.
• Humidifies increased O2 leaves at end of shift
• Next morning on new shift

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New Signs Symptoms

• Sudden onset of shaking chills
• Rapidly rising fever (? 39oc)
• Pleuritic CP aggrevated by deep breathing
  coughing,
• Purulent sputum
• Tachypnea (25-45bpm), SOB, use of accessory
  muscles for breathing
• Orthopnea
• Pulse rapid bounding

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Relevant Nursing Assessments

• Auscultation
• Coarse Crackles
• Percussion (dull sound over the right lower lobe
  of lungs)

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Doctors Orders

• Chest X Ray
• Labs ABG, CBC, Sputum C S,
• Meds Antibiotics

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CHEST X-RAY

• Right
• Lower Lobe
• Pneumonia

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Pneumonia Labs

• ABG
• PaO2 55 mm Hg
• Sputum culture confirms gram-negative organisms.
• CBC indicates leukocytosis (WBC 20000/mm3)

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Pneumonia Meds

• Fluoroquinolones
• Moxifloxacillin 400 mg IV od

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Respiratory Failure

• Monitor Respiratory status, rate and pattern of
  respirations, breath sounds and signs and
  symptoms of acute respiratory distress (early
  recognition can avert further complications)
• Monitor pulse oximetry and ABGs (finding changes
  will guide in correcting and preventing
  complications)
• Administer O2 therapy and initiate mechanisms for
  mechanical ventilation (Acute respiratory failure
  is a medical emergency! Administration of O2 and
  mechanical ventilation are critical to survival)

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Pt Transferred to ICU

• ABG interpretation more often.
• Pulmonary auscultation q 2-4 hours
• Suction ET tube as needed
• Keep tubes clear free from tugging
• Oral care frequently b/c primary source of
  contamination
• Active or Passive ROM, Up to chair whenever
  possible
• Communication
• Comfort, inform, explain, keep involved.
• Evaluate for spontaneous pneumothorax or tension
  pneumothorax from vent.

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Pursed Lips Breathing

• Improves ventilation
• Releases trapped air in the lungs
• Keeps the airways open longer and decreases the
  work of breathing
• Prolongs exhalation to slow the breathing rate
• Relieves shortness of breath
• Causes general relaxation

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Pursed Lips Breathing

• Relax your neck and shoulder muscles.
• Inhale slowly through your nose for two counts,
  keeping your mouth closed.
• Pucker or "purse" your lips as if you were going
  to whistle or gently flicker the flame of a
  candle.
• Exhale slowly and gently through your pursed lips
  while counting to four.

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Diaphragmatic Breathing

• With COPD air often becomes trapped in the lungs,
  pushing down on the diaphragm.
• Increased use of accessory muscles.
• Helps to
• Strengthen the diaphragm
• Decrease the work of breathing by slowing your
  breathing rate
• Decrease oxygen demand
• Use less effort and energy to breathe

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Diaphragmatic Breathing
Lie on your back on a flat surface  or in bed,
with your knees bent and your head supported.
Place one hand on your  upper chest and the other
just below your rib cage. Breathe in slowly
through your nose so that your stomach moves out
against your hand. The hand on your chest should
remain as still as possible.
Tighten your stomach muscles, letting them fall
inward as you exhale through pursed lips. The
hand on your upper chest must remain as still as
possible.
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Discharge to Community

• Pulmonary Rehab Training Video http//video.google
  .ca/videoplay?docid-492365751703873903qCOPD

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Home Care

• Nurses job at the home includes
• Assessment of physical status, vitals chest
  assessment
• Teaching pt self care
• Performing Chest physiotherapy
• Encourage compliance with current therapy
• Report to the pts physician any deterioration in
  the pts physical status or inability to clear
  secretions.
• Home Teaching Smoking Cessation, annual Flu shot
  Pneumonia shot.

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Chest Physiotherapy

• Percussion
• Is carried out by cupping the hands and lightly
  stroking the chest wall in a rhythmic fashion
• Vibration
• is the technique of applying manual compression
  and tremor to the chest wall during the
  exhalation phase of respirations.

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Chest Physiotherapy

• Percussion and Vibration
• Alternating Percussion and Vibration is
  beneficial because it helps to loosen mucus and
  increase the velocity of air expired from the
  small airways
• Alternating the two for 3-5 minutes for each
  postural drainage position (There are 6) is the
  best way to clear a large amount of sputum
• Evaluate breath sounds before and after the
  procedure

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Self Care

• Self Care Includes
• Practice slow and rhythmical breathing in a
  relaxed manner
• Minimize the amount of dust and other particles
  in the air by removing drapes, dusting and
  vacuuming regularly
• Ensure adequate diet nutrition. Small frequent
  meals and snacks. Promotes gas exchange and
  increases energy levels

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Quiz

1. Name the site of gas exchange in the respiratory
   system
2. Name 3 symptoms of COPD
3. What is the name for body-position dependant
   breathing
4. Name the most significant contributing factor to
   COPD
5. Describe the difference in the alveoli b/w
   Emphysema Chronic Bronchitis
6. Name three signs symptoms of pneumonia
7. Name some of the doctors orders you would expect
   for a pneumonia patient
8. What are the two types of breathing to teach the
   patient?
9. Name the two types of chest physiotherapy
10. Name one of the self-care responsibilities the
    patient has

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References

• Bare, G., Smeltzer, C. Brunner and Suddarths
  (2004). Textbook of medical surgical nursing
  (10th ed.). Philadelphia PA, Lippincott.
• Deglin, J., Vallerand, A. (2004). Daviss Drug
  Guide for Nurses (9th ed). Philadelphia, PA
  Davis.
• McCance, K.L., Huether, S.E. (2002)
  Pathophysiology (4th ed.) St. Louis, MO Mosby
• Zator Estes, M.E. (2002) Health Assessment
  Physical Examination (2nd ed.) New York Thompson
  Learning
• Limmer, OKeefe, Grant, Murray, Bergeron.
  Emergency Care (9th ed.) (2001) New Jersey
  Prentice Hall
• Shade, Rothenberg, Wertz, Jones, Collins. (2002)
  EMT-Intermediate Textbook (2nd ed.) Philadelphia,
  PA Mosbys.
• ABG Article Assessing ABG
• Laschinger, H.K. (1984) Demystifying Arterial
  Blood Gases. The Canadian Nurse.
• Balter, M. et al (2003)  Canadian guidelines for
  the management of acute exacerbations of chronic
  bronchitis Executive summary. Canadian
  Respiratory Journal, 10(5), retrieved
  on September 21, 2006 from http//www.pulsus.com/R
  espir/10_05/balt_ed.htm
• Kleinschmidt, P. (2005) Chronic bronchitis and
  emphysema. Retrieved on September 21, 2006 from
  http//www.emedicine.com/emerg/topic99.htm      
• Sharma, S. (2006)   Pneumonia, Bacterial.
  Retrieved on September 21, 2006 from
   http//www.emedicine.com/MED/topic1852.htm      

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Atelectasis

• Potential Problem Atelectasis (collapsed
  alveoli)
• Monitor respiratory status (tachypnea, dyspnea,
  diminished or absent breath sounds may indicate
  atelactasis)
• Encourage diaphragmatic breath and effective
  coughing (improves lung expansion and gas
  exchange)
• Promote use of lung expansion techniques ie. Deep
  breathing and incentive spirometry (promotes
  maximal lung expansion)

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Pneumothorax

• Air outside the lungs
• 1. Monitor respiratory status (dyspnea,
  tachypnea, acute pleuritic chest pain, tracheal
  diviation, absence of breath sounds may indicate
  pneumothorax)
• 2. Assess pulse (tachycardia is often associated
  with pneumothorax)
• 3. Assess for chest pain (often associated with
  pneumothorax)
• 4. Palpate for tracheal deviation from the
  affected side
• 5. Monitor ABGs
• 6. Administer prescribed O2 therapy (to correct
  hypoxemia
• 7. Administer prescribed analgesics for chest
  pain (pain interferes with deep breathing,
  required for lung expanion)
• 8. Assist with chest tube expansion (removal of
  air from the pleural space will allow lung to
  reexpand)

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Pneumothorax X-ray
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Oxygen Therapy Prescription

• Prescription tells you
• Oxygen dose (L/min)
• The number of hours/day that oxygen therapy is
  required
• The dose required during sleep/exercise
• The oxygen supply system
• The delivery device (ie. Nasal cannula, etc.)