Respiratory System

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Respiratory System

• NUR 105 ADULT HEALTH
• Shelton State Community College
• Clem Hill

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Respiratory System Learning Objectives

• Define terms associated with the respiratory
• system.
• Describe diagnostic tests for respiratory
• system alterations.
• Describe upper and lower respiratory
• alterations.
• Interpret clinical manifestation to determine
• necessary care for respiratory alterations.

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Respiratory Objectives cont..

• Utilize the nursing process in the care and
• treatment of a client with a respiratory
• alteration.
• Describe the process of tracheotomy care,
• suctioning, and chest physiotherapy.
• Describe the pharmacological agents and
• treatments for respiratory system
• alterations.

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Respiratory System Objectives cont...

• Describe nutritional considerations for
• treating respiratory system alterations.

5
Anatomy and Physiology Review

• Upper Respiratory Tract
• Nose and Sinuses
• Pharynx
• Larynx
• Lower Respiratory Tract
• Trachea
• Mainstem Bronchi
• Lobar, Segmental, and Subsegmental Bronchi
• Bronchioles
• Aveolar Ducts and Aveoli

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• Accessory Muscles of Respiration
• Respiratory Changes Associated With Aging
• Physiologic Changes
• Muscle atrophy of the pharynx and
• larynx
• Slackening of the vocal cords
  
• Loss of elasticity of the laryngeal
  muscles and
• cartilages

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Physiological Changes cont

• Difficulty in respirations due to loss of and
  lung
• elasticity and enlargement of the
• bronchioles, and decrease in the number
• of aveoli.
• Respiratory muscles atrophy, rib cage
• becomes more rigid, and the diaphragm
• flattens resulting in reduced chest
  movement
• and ability to inhale and exhale, less
  effective
• cough, increased work of breathing.

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Assessment Techniques

• Collect history of client data on family,
• personal, smoking, drug use, allergies,
• place of residence, dietary history,
• occupational history, and socioeconomic
• level.
• Assess current health problems such as
• cough, sputum production, chest pain, and
• dyspnea.

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Physical Assessment

• Assessment of the Nose and Sinuses
• Assessment of the pharynx, trachea, and
• larynx.
• Assessment of the lung and thorax
• Inspection
• Palpitation
• Percussion
• Auscultation

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• Normal Breath Sounds include bronchial,
• bronchialvescicular, and vescicular.
• Adventitious breath sounds include, crackle,
  wheeze, rhonchus, and pleural
• friction rub.

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• Other assessment include, voice sound,
• bronchophony, whispered pectoriloguy,
• egophony, skin and mucous membranes,
• general appearance, and endurance.

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Psychosocial Assessment

• Some respiratory problems may be worsened by
  stress.
• Chronic respiratory disease may cause changes in
  family roles, social isolation, and financial
  problems due to unemployment or disability.
• Discuss coping mechanism and offer access to
  support systems

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• Laboratory Test
• Blood Test
• RBC provide data about oxygen transport to
  arterial
  blood the tissues. If hemoglobin deficient,
  hypoxemia results.
• Arterial Blood Gases measured to determine
  the effectiveness of gas exchange ( PaO2 and
  PaCO2 and acid-base balance
• Sputum Tests the mucous membrane
• lining of the lower respiratory tract
  responds to acute
  inflammation by increasing the
  production of secretions, which may contain
  bacterial or malignant cells.

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Diagnostic Test

• Radiographic examination
• Chest radiographic to assess progression of
  disease and response to treatment.
• Digital chest radiography uses less
• radiation and useful to assess lung and
• chest lesions.
• Fluoroscopy radiograph- used to observe deep
  structures in motion.

15

• Imaging Procedures
• CT scan dye is injected to each layer of
  lung is photographed.
• Magnetic Resonance Imaging (MRI) similar to
  CAT scan without harmful radiation.
• Pulmonary Function Studies evaluate volumes and
  capacities, flow rates, diffusion, capacity gas
  exchange, airway resistance, and distribution of
  ventilation.
• Pulse oximetry permits the non-invasive
  measurement of arterial oxygen saturation.

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• Pulmonary Angiography an x-ray exam of the
  pulmonary vessels after intravenous
• administration of a radiopaque dye.
• Ventilation-Perfusion Scan (Lung Scan) a
  radioactive dye is injected IV and scan is done
• to view blood flow to the lungs (perfusion).
• Exercise Testing increases metabolism and gas
  transport as energy is used.
• Skin Test used to identify infectious, virus
  and fungal.

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• Other Invasive Diagnostic Test
• Endoscopic Examinations
• Bronchogram radiopaque dye is
• instilled into the bronchial tree and
• xrays are taken.
• Broncoscopy scope inserted to allow
• visualization of the bronchial tree and
• biopsy of tissue can be done.

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• Thoracentesis aspiration of pleural fluid or
  air from the pleural space.
• Client preparation for stinging sensation
• feeling of pressure.
• Correct position instruct client not to
• move or cough during procedure.
• After procedure, sterile dressing applied
• to puncture site and client positioned on
• unaffected side.
• Monitor for complications air embolism,
  hemothorax, pneumothorax, and pulmonary edema.

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• Lung Biopsy Performed to obtain tissue for
  histologic analysis, culture, or cytologic exam.
• Percutnaneous lung biopsy may be done at
  bedside or in radiology. Fluoroscopy, CT, or
  ultrasound often done to visualize area of
  biopsy.
• Thoracotomy can be done to open the lung to
  obtain tissue specimens.

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• Care after biopsy include
• Assess VS, breath sounds at least q4h
• for 24hrs
• Assess for respiratory distress
• Report reduced or absent breath imme.
  
• Monitor for hemoptysis

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• Breathing Exercises
• Deep breathing and coughing
• Pursed-lip breathing
• Chest Physiotherapy chest percussion,
  vibration, and postural drainage.
• Suctioning
• Humidification and Aerosol Therapy
• Oxygen Therapy
• Intermittent Positive-Pressure Breathing
  Treatment
• Mechanical Ventilation

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• Oxygen Therapy
• Delivered in L/min or FIO2
• Low Flow Oxygen Therapy
• Nasal Cannula 24-44 FIO2 _at_ 1- 6
• liters/min
• Simple Face Mask 40 - 60 FIO2
• 5-8L/min
• Partial Rebreather Mask 60-75 _at_
• 6-11L/min
• Non-Rebreather Mask 80 95 FIO2 _at_

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• High-flow o2 Delivery System
• Venturi Mask (Venti Mask)
• Aerosol Mask
• Face Mask
• Tracheostomy Collar
• T-piece

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• High-flow 02 Delivery System
• Venturi Mask (Venti Mask)
• Aerosol Mask
• Face Mask
• Tracheostomy
• Collar
• T-piece

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• Drug Therapy
• Antihistamines
• Expectorants
• Antitussives
• Bronchodilators
• Corticosteroids
• Mast Cell Stabilizers

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• Fractured Nose resulting from injury.
• Tx
• Rhinoplasty removal of excess
• cartilage and tissue from nose with
• correction of septal defect if needed.
  
• Packing following surg.
• Place pt in semi-fowlers position to
• decrease local swelling.
• Ecchymosis and swelling around eyes/nose
• Apply cool mist, ice compresses

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• Tx cont..
• Limit Valsava movement
• Laxative or stool softners
• Avoid ASA, and NSAIDS
• Prophylatic antibiotics
• Humidifiers
• SMR Submucous (Nasoseptoplasty) -
• the deviated the nasal mucosa removed (an
  incision is made in the nasal mucosa).

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• Epistaxis bleeding from nose.
• First aid Pt sit down and lean
• forward. Direct pressure applied for
• 3 to 5 minutes
• 
  
  

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• Nasal Polyps Swollen masses of sinus or nasal
  mucosa and connective tissue.
• Tend to grow and recur
• Exact cause unk
• TX
• Surgical removal
• Caldwell-Luc procedure or
  ethmoidectomy-
• an incision is made in the upper gum
  line above the teeth. An opening
  is made between both the sinus
  and the nose to remove the polyps.
• Polypectomy -
• Inhaled Steroids
• Nursing Care monitor for bleeding
• Pt will usually have a packing for 24
  hrs.

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• Cancer of the Nose and Sinuses
• _ Cancer of the nose or sinuses is rare
  and can be
• benign or malignant.
• _ Onset is slow and manisfestations
  resemble sinusitis.
• _ Local lymph enlargement often occurs
• on the side with the tumor mass.
• _ Radiation therapy is the main
  treatment surgery is also form of treatment.
  

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• Facial Trauma
• _ La Fort I nasoethmoid complex fracture
• _ Le Fort II maxillary and nosethmoid
• complex fracture
• _ Le Fort III combination of I and II plus
• an orbitalzygoma fracture, often called
• craniofacial disjunction
• _ First assessment airway

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• Facial Trauma Interventions
• _ Anticipate the need for emergency
• intubation, tracheotomy, and
• cricothyroidotomy.
• _ Control hemorrhage.
• _ Assess for extent of injury.
• _ Treat shock.
• _ Stabilize the fracture.

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• Obstructive Sleep Apnea
• _ Breathing disruption during sleep that
• last at least 10 seconds and occurs a
• minimum of five times in an hour.
• _ Excessive daytime sleepiness, inability
• to concentrate, and irritability.
• _ Nonsurgical management and change
• of sleep position.
• _ Surgical management and change of sleep
• position.

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• Disorders of the Larynx
• _ Vocal cord paralysis
• _ Vocal cord nodules and polyps
• _ Laryngeal trauma

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• Upper Airway Obstruction
• _ Life-threatening emergency in which an
• interruption in airflow through the
• nose, mouth, pharynx, or larynx
• occurs.
• _ Early recognition is essential to prevent
• further complications, including
• respiratory arrest.

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• Upper Airway Obstruction Interventions
• _ Interventions include
• - Assessment for cause of the
• obstruction.
• _ Maintenance of patent airway and
• ventilation.
• - Cricothyroidotomy
• - Endotracheal intubation
• - Tracheostomy

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• Neck Trauma
• _ Neck trauma may be caused by a knife,
• gunshot, or traumatic accident.
• _ Assess for other injuries including
• cardiovascular, respiratory, intestinal,
• and neurologic damage.
• _ Assess for patent airway.
• _ Assess carotid artery and esophagus.
• _ Assess for cervical spine injuries and
  prevent
• excess neck movement.

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• Head and Neck Cancer
• _ Head and neck cancer can disrupt
• breathing, eating, facial appearance,
• self-image, speech, and
• communication.
• _ In laryngeal cancer, hoarsness may
• occur because of tumor bulk and
• inability of the vocal cords to come
• together for normal phonation.

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• Ineffective Breathing Pattern
• _ Interventions include
• - Treatment goal to remove or
• eradicate the cancer while preserving
• as much normal function as possible.
• - Nonsurgical management
• - Chemotherapy

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• Surgical Management
• _ Laryngectomy (total and partial)
• _ Tracheostomy
• _ Oropharyngeal cancer resection
• _ Cordal stripping
• _ Cordectomy

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• Preoperative Care
• _ Client and family teaching about the
• tumor
• _ Self-care of airway
• _ Methods of communication
• _ Suctioning
• _ Pain control methods
• _ Critical care environment
• _ Nutritional support
• _ Goals for discharge

42

• Postoperative Care
• _ Monitor airway patency, vital signs,
• hemodynamic status, comfort level.
• _ Monitor for hemorrhage.
• _ Assess for complications.
• - Airway obstruction
• - Hemorrhage
• - Wound breakdown
• - Tumor recurrence

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• Pain Management
• _ Morphine
• _ Acetaminophen with codeine
• _ Acetaminophen alone
• _ Nonsteroidal anti-inflammatory drugs

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• Nutrition
• _ Nasogastric
• _ Gastrostomy
• _ Jejunostomy
• _ Parenteral nutrition until the
• gastrointestinal tract recovers from the
  
• effects of anesthesia
• _ No aspiration after total laryngectomy
  because
• the airway and esophagus are completely
• separated.

45

• Speech Rehabilitation
• _ Writing or using picyure board
• _ Artificial larynx
• _ Esophageal speech sound produced by
• burping the air is swallowed or
• injected into the esophageal pharynx
• and shaping the words in the mouth.
• _ Mechanical devices ( electrolaynges)
• _ Traceoesophageal fistula

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• Risk for aspiration
• _ Interventions include
• _ Dynamic swallow study
• _ Enteral feedings
• _ Routine reflux precautions
• - elevation of the head of bed
• - Strict adherence to tube feeding
• regimen
• - No bolus feeding at night
• - Checking residual feeding

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• Obstructive Sleep Apnea breathing disruption
  during sleep lasting 10 sec. occurring at least 5
  times in an hr.
• Contributing Factors include obesity, a large
  uvula, short neck, smoking, enlarged tonsils or
  adenoids, and edema of oropharyngeal.

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• S/S Pt c/o persistent daytime sleepiness or
  c/o waking up tired. Irritability and personality
  changes.
• Diagnostic test include a PSG which is a study
  of sleep at night.
• Tx include nonsurgical and surgical management.
• Nonsurgical NPPV, BiPAP, CPAP

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• Drug Therapy Xyrem, a CNS depressant inducing
  sleep.
• Provigil promotes daytime wakefulness.
• Surgical Tx Adenoidectomy, Uvulectomy,
  Remodeling of the entire posterior oropharynx
  called a Uvulopalatopharyngoplasty (UPP)
• Tracheostomy may be done if needed.

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• Vocal Cord Nodules and Polyps
• Tx aimed at educating the pt and family about
  smoking hazard and smoking-cessation programs and
  the importance of voice rest.
• No whispering and avoid straining.
• Speech therapy
• Laser or surgical resection to remove nodules
  and polyps.

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• Airway Obstruction Disorders
• Tongue edema
• Occlusion of the tongue
• Laryngeal edema
• Peritonsillar and laryngeal abscess
• Head and neck cancer
• Thick secretions
• Stroke and cerebral edema
• Smoke inhalation edema
• Facial, tracheal, or laryngeal trauma
• Foreign-body aspiration
• Burns of head and neck
• Anaphylaxis

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• Management include observe for signs of
  respiratory distress such as hypoxia,
  hypercarbia, restlessness, increasing anxiety,
  sternal retractions, a seesawing chest,
  abdominal movements, or a feeling of impending
  
• doom related to air hunger
• Pulse oximeter 02 sat monitoring

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• Management cont
• Assess cause of obstruction
• May require emergency procedure
• Cricothyroidotomy a stab wound at
• the cricothyroid membrane between
• the thyroid

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• Interventions for Clients with Noninfectious
  Problems of the Lower Respiratory Tract

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Chronic Airflow Limitation

• Chronic lung diseases of chronic airflow
  limitation include
• Asthma
• Chronic bronchitis
• Pulmonary emphysema
• Chronic obstructive pulmonary disease includes
  emphysema and chronic bronchitis characterized by
  bronchospasm and dyspnea.

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Asthma

• Intermittent and reversible airflow obstruction
  affects only the airways, not the alveoli.
• Airway obstruction occurs due to inflammation and
  airway hyperresponsiveness.

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Aspirin and Other NonsteroidalAnti-Inflammatory
Drugs

• Incidence of asthma symptoms after taking aspirin
  and other nonsteroidal anti-inflammatory drugs
  (NSAIDs)
• However, response not a true allergy
• Results from increased production of leukotriene
  when other inflammatory pathways are suppressed

59
Collaborative Management

• Assessment
• History
• Physical assessment and clinical manifestations
• No manifestations between attacks
• Audible wheeze and increased respiratory rate
• Use of accessory muscles
• Barrel chest from air trapping

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Laboratory Assessment

• Assess arterial blood gas level.
• Arterial oxygen level may decrease in acute
  asthma attack.
• Arterial carbon dioxide level may decrease early
  in the attack and increase later indicating poor
  gas exchange.
• (Continued)

61
Laboratory Assessment (Continued)

• Atopic asthma with elevated serum eosinophil
  count and immunoglobulin E levels
• Sputum with eosinophils and mucous plugs with
  shed epithelial cells

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Pulmonary Function Tests

• The most accurate measures for asthma are
  pulmonary function tests using spirometry
  including
• Forced vital capacity (FVC)
• Forced expiratory volume in the first second
  (FEV1)
• Peak expiratory rate flow (PERF)
• Chest x-rays to rule out other causes

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Interventions

• Client education asthma is often an intermittent
  disease with guided self-care, clients can
  co-manage this disease, increasing symptom-free
  periods and decreasing the number and severity of
  attacks.
• Peak flow meter can be used twice daily by
  client.
• Drug therapy plan is specific.

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Drug Therapy

• Pharmacologic management of asthma can involve
  the use of
• Bronchodilators
• Beta2 agonists
• Short-acting beta2 agonists
• Long-acting beta2 agonists
• Cholinergic antagonists
• (Continued)

65
Drug Therapy (Continued)

• Methylxanthines
• Anti-inflammatory agents
• Corticosteroids
• Inhaled anti-inflammatory agents
• Mast cell stabilizers
• Monoclonal antibodies
• Leukotriene agonists

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Other Treatments for Asthma

• Exercise and activity is a recommended therapy
  that promotes ventilation and perfusion.
• Oxygen therapy is delivered via mask, nasal
  cannula, or endotracheal tube in acute asthma
  attack.

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Status Asthmaticus

• Status asthmaticus is a severe, life-threatening
  acute episode of airway obstruction that
  intensifies once it begins and often does not
  respond to common therapy.
• If the condition is not reversed, the client may
  develop pneumothorax and cardiac or respiratory
  arrest.
• Emergency department treatment is recommended.

68
Emphysema

• In pulmonary emphysema, loss of lung elasticity
  and hyperinflation of the lung
• Dyspnea and the need for an increased respiratory
  rate
• Air trapping, loss of elastic recoil in the
  alveolar walls, overstretching and enlargement of
  the alveoli into bullae, and collapse of small
  airways (bronchioles)

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Classification of Emphysema

• Panlobular destruction of the entire alveolus
• Centrilobular openings occurring in the
  bronchioles that allow spaces to develop as
  tissue walls break down
• Paraseptal confined to the alveolar ducts and
  alveolar sacs

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Chronic Bronchitis

• Inflammation of the bronchi and bronchioles
  caused by chronic exposure to irritants,
  especially tobacco smoke
• Inflammation, vasodilation, congestion, mucosal
  edema, and bronchospasm
• Affects only the airways, not the alveoli
• Production of large amounts of thick mucus

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Complications

• Chronic bronchitis
• Hypoxemia and acidosis
• Respiratory infections
• Cardiac failure, especially cor pulmonale
• Cardiac dysrhythmias

73
Physical Assessment and Clinical Manifestations

• Unplanned weight loss loss of muscle mass in the
  extremities enlarged neck muscles slow moving,
  slightly stooped posture sits with forward-bend
• Respiratory changes
• Cardiac changes

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Laboratory Assessment

• Status of arterial blood gas values for abnormal
  oxygenation, ventilation, and acid-base status
• Sputum samples
• Hemoglobin and hematocrit blood tests
• Serum alpha1-antitrypsin levels drawn
• Chest x-ray
• Pulmonary function test

76
Impaired Gas Exchange

• Interventions for chronic obstructive pulmonary
  disease
• Airway management
• Monitoring client at least every 2 hours
• Oxygen therapy
• Energy management

77
Drug Therapy

• Beta-adrenergic agents
• Cholinergic antagonists
• Methylxanthines
• Corticosteroids
• Cromolyn sodium/nedocromil
• Leukotriene modifiers
• Mucolytics

78
Surgical Management

• Lung transplantation for end-stage clients
• Preoperative care and testing
• Operative procedure through a large midline
  incision or a transverse anterior thoracotomy
• Postoperative care and close monitoring for
  complications

79
Ineffective Breathing Pattern

• Interventions for the chronic obstructive
  pulmonary disease client
• Assessment of client
• Assessment of respiratory infection
• Pulmonary rehabilitation therapy
• Specific breathing techniques
• Positioning to help alleviate dyspnea
• Exercise conditioning
• Energy conservation

80
Ineffective Airway Clearance (Continued)

• Postural drainage in sitting position when
  possible
• Tracheostomy

81
Imbalanced Nutrition

• Interventions to achieve and maintain body
  weight
• Prevent protein-calorie malnutrition through
  dietary consultation.
• Monitor weight, skin condition, and serum
  prealbumin levels.
• Address food intolerance, nausea, early satiety,
  loss of appetite, and meal-related dyspnea

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Anxiety

• Interventions for increased anxiety
• Important to have client understand that anxiety
  will worsen symptoms
• Plan ways to deal with anxiety

84
Health Teaching

• Instruct the client
• Pursed-lip and diaphragmatic breathing
• Support of family and friends
• Relaxation therapy
• Professional counseling access
• Complementary and alternative therapy

85
Activity Intolerance

• Interventions to increase activity level
• Encourage client to pace activities and promote
  self-care.
• Do not rush through morning activities.
• Gradually increase activity.
• Use supplemental oxygen therapy.

86
Health Teaching

• Instruct the client
• Pursed-lip and diaphragmatic breathing
• Support of family and friends
• Relaxation therapy
• Professional counseling access
• Complementary and alternative therapy

87
Activity Intolerance

• Interventions to increase activity level
• Encourage client to pace activities and promote
  self-care.
• Do not rush through morning activities.
• Gradually increase activity.
• Use supplemental oxygen therapy.

88
Potential for Pneumonia or Other Respiratory
Infections

• Risk is greater for older clients
• Interventions include
• Avoidance of large crowds
• Pneumonia vaccination
• Yearly influenza vaccine

89
Cystic Fibrosis

• Genetic disease affecting many organs, lethally
  impairing pulmonary function
• Present from birth, first seen in early childhood
  (many clients now live to adulthood)
• Error of chloride transport, producing mucus with
  low water content
• Problems in lungs, pancreas, liver, salivary
  glands, and testes

90
Nonpulmonary Manifestations

• Adults usually smaller and thinner than average
  owing to malnutrition
• Abdominal distention
• Gastroesophageal reflux, rectal prolapse,
  foul-smelling stools, steatorrhea
• Vitamin deficiencies
• Diabetes mellitus

91
Pulmonary Manifestations

• Respiratory infections
• Chest congestion
• Limited exercise tolerance
• Cough and sputum production
• Use of accessory muscles
• Decreased pulmonary function
• Changes in chest x-ray result
• Increased anteroposterior diameter of chest

92
Exacerbation Therapy

• Avoid mechanical ventilation
• Airway clearance
• Increased oxygenation
• Antibiotic therapy
• Heliox (50 oxygen, 50 helium) therapy
• Bronchodilator and mucolytic therapies

93
Surgical Therapy

• Lung and/or pancreatic transplantation do not
  cure the disease the genetic defect in chloride
  transport and the thick, sticky mucus remain.
• Transplantation extends life by 10 to 20 years.
• Single-lung transplant as well as double-lung
  transplantation is possible.

94
Primary Pulmonary Hypertension

• The disorder occurs in the absence of other lung
  disorders, and its cause is unknown although
  exposure to some drugs increases the risk.
• The pathologic problem is blood vessel
  constriction with increasing vascular resistance
  in the lung.
• The heart fails (cor pulmonale).
• Without treatment, death occurs within 2 years.

95
Interventions

• Warfarin therapy
• Calcium channel blockers
• Prostacyclin agents
• Digoxin and diuretics
• Oxygen therapy
• Surgical management

96
Interstitial Pulmonary Disease

• Affects the alveoli, blood vessels, and
  surrounding support tissue of the lungs rather
  than the airways
• Restrictive disease thickened lung tissue,
  reduced gas exchange, stiff lungs that do not
  expand well
• Slow onset of disease
• Dyspnea common

97
Sarcoidosis

• Granulomatous disorder of unknown cause that can
  affect any organ, but the lung is involved most
  often
• Autoimmune responses in which the normally
  protective T-lymphocytes increase and damage lung
  tissue
• Interventions (corticosteroids) lessen symptoms
  and prevent fibrosis

98
Idiopathic Pulmonary Fibrosis

• Common restrictive lung disease
• Example of excessive wound healing
• Inflammation that continues beyond normal healing
  time, causing extensive fibrosis and scarring
• Mainstays of therapy corticosteroids, which slow
  the fibrotic process and manage dyspnea

99
Occupational Pulmonary Disease

• Can be caused by exposure to occupational or
  environmental fumes, dust, vapors, gases,
  bacterial or fungal antigens, or allergens
• Worsened by cigarette smoke
• Interventions special respirators that ensure
  adequate ventilation

100
Lung Cancer

• A leading cause of cancer deaths worldwide
• Metastasizes at late-stage diagnosis
• Paraneoplastic syndromes
• Staged to assess size and extent of disease
• Etiology and genetic risk
• (Continued)

101
Lung Cancer (Continued)

• Incidence and prevalence make lung cancer a major
  health problem.
• Health promotion and illness prevention is
  primarily through education strategies and
  reduced tobacco smoking.

102
Manifestations of Lung Cancer

• Often nonspecific, appearing late in the disease
  process
• Chills, fever, and cough
• Assess sputum
• Breathing pattern
• Palpation
• Percussion
• Auscultation

103
Surgical Management

• Lobectomy
• Pneumonectomy
• Segmentectomy (wedge resection)

104
Chest Tubes

• Placement after thoracotomy
• Drainage system
• Care required
• Monitor hourly to ensure sterility and patency.
• Tape tubing junctions.
• Keep occlusive dressing at insertion site.
• Position correctly to prevent kinks and large
  loops.

105
Interventions for Palliation

• Oxygen therapy
• Drug therapy
• Radiation therapy
• Laser therapy
• Thoracentesis and pleurodesis
• Dyspnea management
• Pain management

106

• Interventions for Clients with Infectious
  Problems of the Lower Respiratory Tract

107
Rhinitis

• Inflammation of the nasal mucosa
• Often called hay fever or allergies
• Interventions include
• Drug therapy antihistamines and decongestants,
  antipyretics, antibiotics
• Complementary and alternative therapy
• Supportive therapy

108
Sinusitis

• Inflammation of the mucous membranes of the
  sinuses
• S/S include pain or feeling of heaviness over the
  affected area.
• Pain may seem like a toothache.
• Headache is common.
• (Continued)

109
Sinusitis (Continued)

• Nonsurgical management
• Broad-spectrum antibiotics
• Analgesics
• Decongestants
• Steam humidification
• Hot and wet packs over the sinus area
• Nasal saline irrigations

110
Surgical Management

• Antral irrigation
• Caldwell-Luc procedure
• Nasal antral window procedure
• Endoscopic sinus surgery

111
Pharyngitis

• Sore throat is common inflammation of the mucous
  membranes of the pharynx.
• Assess for odynophagia, dysphagia, fever, and
  hyperemia.
• Strep throat can lead to serious medical
  complications.
• Epiglottitis is a rare complication of
  pharyngitis.

112

• Treatment include rest, fluids, analgesics, and
  throat gargles or irrigations.
• A soft diet may be ordered because of painful
  swallowing.
• Humidifier to increase moisture in the room
  air.
• Antibiotics, usually penicillin or
  erythromycin while awaiting results of cultures.

113
Tonsillitis

• Inflammation and infection of the tonsils and
  lymphatic tissues located on each side of the
  throat
• Contagious airborne infection, usually bacterial
• Antibiotics therapy for 7 to 10 days.
• Analgesics and anesthetic lozenges for pain
• Warm saline gargles or irrigations
• Surgical intervention

114
Peritonsillar Abscess

• Complication of acute tonsillitis
• Pus behind the tonsil, causing one-sided swelling
  with deviation of the uvula
• Trismus and difficulty breathing
• Percutaneous needle aspiration of the abscess
• Completion of antibiotic regimen

115
Laryngitis

• Inflammation of the mucous membranes lining the
  larynx, possibly including edema of the vocal
  cords
• Acute hoarseness, dry cough, difficulty
  swallowing, temporary voice loss (aphonia)
• Voice rest, steam inhalation, increased fluid
  intake, throat lozenges
• Therapy relief and prevention

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Influenza

• Flu is a highly contagious acute viral
  respiratory infection.
• Manifestations include severe headache, muscle
  ache, fever, chills, fatigue, weakness, and
  anorexia.
• Vaccination is advisable.
• Antiviral agents may be effective.

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Pneumonia

• Excess of fluid in the lungs resulting from an
  inflammatory process
• Inflammation triggered by infectious organisms
  and inhalation of irritants
• Community-acquired infectious pneumonia
• Nosocomial or hospital-acquired
• Atelectasis
• Hypoxemia

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Laboratory Assessment

• Gram stain, culture, and sensitivity testing of
  sputum
• Complete blood count
• Arterial blood gas level
• Serum blood, urea nitrogen level
• Electrolytes
• Creatinine

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Impaired Gas Exchange

• Interventions include
• Cough enhancement
• Oxygen therapy
• Respiratory monitoring

120
Ineffective Airway Clearance

• Interventions include
• Help client to cough and deep breathe at least
  every 2 hours.
• Administer incentive spirometerchest
  physiotherapy if complicated.
• Prevent dehydration.
• (Continued)

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Potential for Sepsis

• Primary intervention is prescription of
  anti-infectives for eradication of organism
  causing the infection.
• Drug resistance is a problem, especially among
  older people.
• Interventions for aspiration pneumonia aimed at
  preventing lung damage and treating infection.

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Severe Acute Respiratory Syndrome (SARS)

• A virus from a family of virus types known as
  coronaviruses
• Virus infection of cells of the respiratory
  tract, triggering inflammatory response
• No known effective treatment for this infection
• Prevention of spread of infection

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Pulmonary Tuberculosis

• Highly communicable disease caused by
  Mycobacterium tuberculosis
• Most common bacterial infection
• Transmitted via aerosolization
• Initial infection multiplies freely in bronchi or
  alveoli
• Secondary TB
• Increase related to the onset of HIV

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Assessment

• Diagnosis of TB considered for any client with a
  persistent cough or other compatible symptoms
  (weight loss, anorexia, night sweats, hemoptysis,
  shortness of breath, fever, or chills)
• Bacillus Calmette-Guerin vaccine within previous
  10 years produces positive skin test,
  complicating interpretation of TB test.

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Clinical Manifestations of TB

• Progressive fatigue
• Lethargy
• Nausea
• Anorexia
• Weight loss
• Irregular menses
• Low-grade fever, night sweats
• Cough, mucopurulent sputum, blood streaks

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Diagnostic Assessment

• Manifestation of signs and symptoms
• Positive smear for acid-fast bacillus
• Confirmation of diagnosis by sputum culture of M.
  tuberculosis
• Tuberculin test (Mantoux test) purified protein
  derivative given intradermally in the forearm
• Induration of 10 mm or greater diameter
  indicative of exposure
• (Continued)

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Diagnostic Assessment (Continued)

• Positive reaction does not mean that active
  disease is present, but does indicate exposure to
  TB or dormant disease.

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Interventions

• Combination drug therapy strict adherence
• Isoniazid
• Rifampin
• Pyrazinamide
• Ethambutol or streptomycin
• Negative sputum culture indicative of client no
  longer being infectious

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Health Teaching

• Follow exact drug regimen.
• Proper nutrition must be maintained.
• Reverse weight loss and severe lethargy.
• Educate client about the disease.

130
Lung Abscess

• Localized area of lung destruction caused by
  liquefaction necrosis, usually related to
  pyogenic bacteria
• Pleuritic chest pain
• Interventions
• Antibiotics
• Drainage of abscess
• Frequent mouth care for Candida albicans

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Health Promotion and Illness Prevention

• Stop smoking.
• Reduce weight.
• Increase physical activity.
• If traveling or sitting for long periods, get up
  frequently and drink plenty of fluids.
• Refrain from massaging or compressing leg muscles.

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Inhalation Anthrax

• Bacterial infection is caused by the
  gram-positive, rod-shaped organism Bacillus
  anthracis from contaminated soil.
• Fatality rate is 100 if untreated.
• Two stages are the prodromal stage and the
  fulminant stage.
• Drug therapy includes ciprofloxacin, doxycycline,
  and amoxicillin.

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Pulmonary Empyema

• A collection of pus in the pleural space
• Most common cause pulmonary infection, lung
  abscess, and infected pleural effusion
• Interventions include
• Emptying the empyema cavity
• Re-expanding the lung
• Controlling the infection

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• Interventions for Critically Ill Clients with
  Respiratory Problems

135
Pulmonary Embolism

• A collection of particulate mattersolids,
  liquids, or gasesenters venous circulation and
  lodges in the pulmonary vessels.
• In most people with pulmonary embolism, a blood
  clot from a deep vein thrombosis breaks loose
  from one of the veins in the legs or the pelvis.

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Etiology

• Prolonged immobilization
• Central venous catheters
• Surgery
• Obesity
• Advancing age
• Hypercoagulability
• History of thromboembolism
• Cancer diagnosis

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Clinical Manifestations

• Assess the client for
• Respiratory manifestations dyspnea, tachypnea,
  tachycardia, pleuritic chest pain, dry cough,
  hemoptysis
• Cardiac manifestations distended neck veins,
  syncope, cyanosis, hypotension, abnormal heart
  sounds, abnormal electrocardiogram findings
• Low-grade fever, petechiae, symptoms of flu

138
Interventions

• Evaluate chest pain
• Auscultate breath sounds
• Encourage good ventilation and relaxation
• (Continued)

139
Interventions (Continued)

• Monitor the following
• respiratory pattern
• tissue oxygenation
• symptoms of respiratory failure
• laboratory values
• effects of anticoagulant medications
• Surgery

140
Decreased Cardiac Output

• Interventions include
• Intravenous fluid therapy
• Drug therapy
• Positive inotropic agents
• Vasodilators

141
Anxiety

• Interventions include
• Oxygen therapy
• Communication
• Drug therapy antianxiety agents

142
Risk for Injury (Bleeding)

• Interventions include
• Protect client from situations that could lead to
  bleeding.
• Closely monitor amount of bleeding.
• Assess often for bleeding, ecchymoses, petechiae,
  or purpura.
• Examine all stool, urine, nasogastric drainage,
  and vomitus and test for occult blood.

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Acute Respiratory Failure

• Pressure of arterial oxygen lt 60 mm Hg
• Pressure of arterial carbon dioxide gt 50 mm Hg
• pH lt 7.3
• Ventilatory failure, oxygenation failure, or a
  combination of both ventilatory and oxygenation
  failure

144
Ventilatory Failure

• Type of mismatch in which perfusion is normal but
  ventilation is inadequate
• Thoracic pressure insufficiently changed to
  permit air movement into and out of the lungs
• Mechanical abnormality of the lungs or chest wall
• Defect in the brains respiratory control center
• Impaired ventilatory muscle function

145
Oxygenation Failure

• Thoracic pressure changes are normal, and air
  moves in and out without difficulty, but does not
  oxygenate the pulmonary blood sufficiently.
• Ventilation is normal but lung perfusion is
  decreased.

146
Combined Ventilatory and Oxygenation Failure

• Hypoventilation involves poor respiratory
  movements.
• Gas exchange at the alveolar-capillary membrane
  is inadequatetoo little oxygen reaches the blood
  and carbon dioxide is retained.

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Dyspnea

• Encourage deep breathing exercises.
• Assess for
• Perceived difficulty breathing
• Orthopnea client finds it easier to breathe when
  in upright position
• Oxygen
• Position of comfort
• Energy-conserving measures
• Pulmonary drugs

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Acute Respiratory Distress Syndrome

• Hypoxia that persists even when oxygen is
  administered at 100
• Decreased pulmonary compliance
• Dyspnea
• Noncardiac-associated bilateral pulmonary edema
• Dense pulmonary infiltrates seen on x-ray

149
Causes of Lung Injury in Acute Respiratory
Distress Syndrome

• Systemic inflammatory response is the common
  pathway.
• Intrinsically the alveolar-capillary membrane is
  injured from conditions such as sepsis and shock.
• Extrinsically the alveolar-capillary membrane is
  injured from conditions such as aspiration or
  inhalation injury.

150
Diagnostic Assessment

• Lower PaO2 value on arterial blood gas
• Poor response to refractory hypoxemia
• Ground-glass appearance to chest x-ray
• No cardiac involvement on ECG
• Low to normal PCWP

151
Interventions

• Endotracheal intubation and mechanical
  ventilation with positive end-expiratory pressure
  or continuous positive airway pressure
• Drug therapy
• Nutrition therapy fluid therapy
• Case management

152
Endotracheal Intubation

• Components of the endotracheal tube
• Preparation for intubation
• Verifying tube placement
• Stabilizing the tube
• Nursing care

153
Mechanical Ventilation

• Types of ventilators
• Negative-pressure ventilators
• Positive-pressure ventilators
• Pressure-cycled ventilators
• Time-cycled ventilators
• Microprocessor ventilators

154
Modes of Ventilation

• The ways in which the client receives breath from
  the ventilator include
• Assist-control ventilation (AC)
• Synchronized intermittent mandatory ventilation
  (SIMV)
• Bi-level positive airway pressure (BiPAP) and
  others

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Ventilator Controls and Settings

• Tidal volume
• Rate breaths per minute
• Fraction of inspired oxygen
• Sighs
• Peak airway (inspiratory) pressure
• Continuous positive airway pressure
• Positive end-expiratory pressure

156
Nursing Management

• First concern is for the client second for the
  ventilator.
• Monitor and evaluate response to the ventilator.
• Manage the ventilator system safely.
• Prevent complications.

157
Complications

• Complications can include
• Lung
• Cardiac
• Gastrointestinal and nutritional
• Infection
• Muscular complications
• Ventilator dependence

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Chest Trauma

• About 25 of traumatic deaths result from chest
  injuries
• Pulmonary contusion
• Rib fracture
• Flail chest
• Pneumothorax
• Tension pneumothorax
• Hemothorax
• Tracheobronchial trauma

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