Respiratory System

1. Respiratory System NUR 105 ADULT HEALTH Shelton State Community College Clem Hill

2. 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.

3. 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.

4. 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

6. 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

7. 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.

8. 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.

9. 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

10. Normal Breath Sounds include bronchial, bronchialvescicular, and vescicular. Adventitious breath sounds include, crackle, wheeze, rhonchus, and pleural friction rub. Crackles (rales) � Fine, short, interrupted crackling sounds. Best heard on inspiration Wheeze � continuous, high pitched squeaky musical sounds. Best heard on expiration. Not usually altered by coughing. Rhonchus (rhonchi) Continuous low-pitched, course, gurgling, harsh, louder sounds with moaning or snoring quality. Best heard on expiration but can be heard on both inspiration and expiration. May be altered by coughing. Friction rub � Superficial grating or creaking sounds heard during inspiration. Not relieved by coughing.Crackles (rales) � Fine, short, interrupted crackling sounds. Best heard on inspiration Wheeze � continuous, high pitched squeaky musical sounds. Best heard on expiration. Not usually altered by coughing. Rhonchus (rhonchi) Continuous low-pitched, course, gurgling, harsh, louder sounds with moaning or snoring quality. Best heard on expiration but can be heard on both inspiration and expiration. May be altered by coughing. Friction rub � Superficial grating or creaking sounds heard during inspiration. Not relieved by coughing.

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

12. 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

13. 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.

14. 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. dd

16. 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.

17. 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.

18. 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.

19. 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.

20. 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

21. 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 Pursed lip breathing helps client develop control over breathing. Client purses the lips as if to whistle and breathes out slowly and gently, tightening the abdominal muscle to exhale more effectively. Inhale to a count of 3 and exhale to a count of 7. Pursed lip breathing helps client develop control over breathing. Client purses the lips as if to whistle and breathes out slowly and gently, tightening the abdominal muscle to exhale more effectively. Inhale to a count of 3 and exhale to a count of 7.

22. Oxygen Therapy Delivered in L/min or FIO2 Low Flow Oxygen Therapy Nasal Cannula � 24-44 FIO2 @ 1- 6 liters/min Simple Face Mask � 40% - 60 % FIO2 5-8L/min Partial Rebreather Mask � 60-75% @ 6-11L/min Non-Rebreather Mask � 80% 95% FIO2 @ Simple face mask � the minimum flow rate of 6L/min is necessary to prevent any chance of CO2 buildup from occuring. Partial Rebreather � the reservoir bag to elevate the potential FIO2. The patient actually rebreathes part of the exhaled gas in the system. Non- rebreather mask � unstable status. Simple face mask � the minimum flow rate of 6L/min is necessary to prevent any chance of CO2 buildup from occuring. Partial Rebreather � the reservoir bag to elevate the potential FIO2. The patient actually rebreathes part of the exhaled gas in the system. Non- rebreather mask � unstable status.

23. High-flow o2 Delivery System Venturi Mask (Venti Mask) Aerosol Mask Face Mask Tracheostomy Collar T-piece Venti mask delivers the most accurate 02 conc. Aerosol, face tent, trach collar and t-piece all provide high humidity with delivery dial on the humidification source regulates the 02 level.Venti mask delivers the most accurate 02 conc. Aerosol, face tent, trach collar and t-piece all provide high humidity with delivery dial on the humidification source regulates the 02 level.

24.  High-flow 02 Delivery System Venturi Mask (Venti Mask) Aerosol Mask Face Mask Tracheostomy Collar T-piece Venti mask delivers the most accurate 02 conc. Aerosol, face tent, trach collar and t-piece all provide high humidity with delivery dial on the humidification source regulates the 02 level.Venti mask delivers the most accurate 02 conc. Aerosol, face tent, trach collar and t-piece all provide high humidity with delivery dial on the humidification source regulates the 02 level.

25. Drug Therapy Antihistamines Expectorants Antitussives Bronchodilators Corticosteroids Mast Cell Stabilizers

26. 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 Want to improve the flow of air. Ice to decrease discoloration, bleeding, and discomfortWant to improve the flow of air. Ice to decrease discoloration, bleeding, and discomfort

27. 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). Minor deviations cause no symptoms Major deviations can obstruct the nasal passagewayMinor deviations cause no symptoms Major deviations can obstruct the nasal passageway

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

29. 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. Resemble white grapes Most have multiple polyps Surgical proc done to limit new growths Polypectomy can be done under local or general anesthesiaResemble white grapes Most have multiple polyps Surgical proc done to limit new growths Polypectomy can be done under local or general anesthesia

30. 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.

31. 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

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

33. 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.

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

35. 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.

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

37. 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.

38. 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.

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

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

41. 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

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

44. 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

46. 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

47. 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.

48. 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 PSG (Polysomnography) � Pt is directly observed. NPPV � Noninvasive positive-pressure ventilation BiPAP � bilevel positive pressure airway pressureCPAP � nasal continuous positive airway pressurePSG (Polysomnography) � Pt is directly observed. NPPV � Noninvasive positive-pressure ventilation BiPAP � bilevel positive pressure airway pressureCPAP � nasal continuous positive airway pressure

49. 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.

50. 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.

51. 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

52. 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

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

54. Interventions for Clients with Noninfectious Problems of the Lower Respiratory Tract

55. 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.

56. Asthma Intermittent and reversible airflow obstruction affects only the airways, not the alveoli. Airway obstruction occurs due to inflammation and airway hyperresponsiveness. Extrinsic Asthma also called atopic of allergic asthma, is characterized by hypersensitivity to materials such as molds, animal dander, and pollens. These are external antigens that cause an antigen-antibody reaction in the sensitive patient. When the patient comes in contact with the allergen, immunoglobulin E (IgE) antibodies cause mast cells and basophils to release chemical mediators that constrict bronchial smooth muscle and cause edema in the airways. People with intrinsic asthma also called nonatopic or nonallergic asthma, respond to non-immunologic stimuli such as infection, irritating chemical vapors, emotional stress, cold air, and even exercise. The asthmatic symptoms are caused by the release of acetylcholine in response to parasympathetic stimulation. Acetylcholine causes bronchoconstriction, which is aggravated by the effects of sympathetic stimulation of the mast cells. Extrinsic Asthma also called atopic of allergic asthma, is characterized by hypersensitivity to materials such as molds, animal dander, and pollens. These are external antigens that cause an antigen-antibody reaction in the sensitive patient. When the patient comes in contact with the allergen, immunoglobulin E (IgE) antibodies cause mast cells and basophils to release chemical mediators that constrict bronchial smooth muscle and cause edema in the airways. People with intrinsic asthma also called nonatopic or nonallergic asthma, respond to non-immunologic stimuli such as infection, irritating chemical vapors, emotional stress, cold air, and even exercise. The asthmatic symptoms are caused by the release of acetylcholine in response to parasympathetic stimulation. Acetylcholine causes bronchoconstriction, which is aggravated by the effects of sympathetic stimulation of the mast cells.

58. 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 Leukotriene � chemical that stimulates an allergic response.Leukotriene � chemical that stimulates an allergic response.

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

60. 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) S&PS&P

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

62. 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

63. 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. Sentences and phrases Sentences and phrasesSentences and phrases Sentences and phrases

64. 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) Pg 589 list all of these classifications.Pg 589 list all of these classifications.

65. Drug Therapy (Continued) Methylxanthines Anti-inflammatory agents Corticosteroids Inhaled anti-inflammatory agents Mast cell stabilizers Monoclonal antibodies Leukotriene agonists

66. 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. Sentence and phraseSentence and phrase

67. 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. Status asthmaticus is treated with inhaled and intravenous bronchodilators and oxygen therapy. Endotracheal intubation and mechanical ventilation are sometimes necessary.Status asthmaticus is treated with inhaled and intravenous bronchodilators and oxygen therapy. Endotracheal intubation and mechanical ventilation are sometimes necessary.

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) Emphysema is a degenerative nonreversible disease characterized by the breaking down of the aveolar walls. Main symptom is dyspnea on exertion. As the disease progresses, the pt may have dyspnea when at rest. Pts are often thin and may be observed using accessory muscles of respiration. Increased anteroposterior diameter of the chest creates a barrel chest. Despite dyspnea, pts who have emphysema without chronic bronchitis often have normal arterial blood gases until the disease is very advanced. The skin color may be normal, which explains the term pink puffer, used to describe the pt with emphysema. Depression and irritability are common in pts with COPD.Emphysema is a degenerative nonreversible disease characterized by the breaking down of the aveolar walls. Main symptom is dyspnea on exertion. As the disease progresses, the pt may have dyspnea when at rest. Pts are often thin and may be observed using accessory muscles of respiration. Increased anteroposterior diameter of the chest creates a barrel chest. Despite dyspnea, pts who have emphysema without chronic bronchitis often have normal arterial blood gases until the disease is very advanced. The skin color may be normal, which explains the term pink puffer, used to describe the pt with emphysema. Depression and irritability are common in pts with COPD.

70. 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 Pg 586 Panlobular � more often caused by a hereditary deficiency of an enzyme inhibitor called alpha-antitrypsin. Centrilobular � affects mainly the respiratory bronchioles and is associated with cigarette smoking. Pg 586 Panlobular � more often caused by a hereditary deficiency of an enzyme inhibitor called alpha-antitrypsin. Centrilobular � affects mainly the respiratory bronchioles and is associated with cigarette smoking.

71. 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 Chronic bronchitis � characterized by increased production of mucus and chronic cough that persist for at least 3 months of the year for 2 consecutive years. Chronic Bronchitis pts have dyspnea on exertion and wheezing. With Chronic hypoxemia, the red blood cell count is typically elevated to compensate for the inadequate oxygen in the blood. Chronic bronchitis � characterized by increased production of mucus and chronic cough that persist for at least 3 months of the year for 2 consecutive years. Chronic Bronchitis pts have dyspnea on exertion and wheezing. With Chronic hypoxemia, the red blood cell count is typically elevated to compensate for the inadequate oxygen in the blood.

72. Complications Chronic bronchitis Hypoxemia and acidosis Respiratory infections Cardiac failure, especially cor pulmonale Cardiac dysrhythmias The pt with chronic bronchitis develops with cor pulmonale demonstrates signs and symptoms of heart failure including increasing dyspnea, cyanosis, and peripheral edema. The pt with chronic bronchitis develops with cor pulmonale demonstrates signs and symptoms of heart failure including increasing dyspnea, cyanosis, and peripheral edema.

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 The work of breathing is increased with COPD, which in turns increases the pts caloric needs requirements. Some COPD pts have difficulty maintaining adequate nutritional Intake. Hi-calorie, high protein supplement. The work of breathing is increased with COPD, which in turns increases the pts caloric needs requirements. Some COPD pts have difficulty maintaining adequate nutritional Intake. Hi-calorie, high protein supplement.

75. 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 02 therapy must be used cautiously. The goal of oxygen is to maintain the Pa02 between 50 and 60 mmHg High levels of 02 are not adminstered because COPD pts may rely on hypoxia drive to breathe. 02 therapy must be used cautiously. The goal of oxygen is to maintain the Pa02 between 50 and 60 mmHg High levels of 02 are not adminstered because COPD pts may rely on hypoxia drive to breathe.

77. Drug Therapy Beta-adrenergic agents Cholinergic antagonists Methylxanthines Corticosteroids Cromolyn sodium/nedocromil Leukotriene modifiers Mucolytics Cromolyn sodium a mast cell stabolizer used to prevent asthma allergies, rhinitis.Cromolyn sodium a mast cell stabolizer used to prevent asthma allergies, rhinitis.

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

83. 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. Sentences and phrasesSentences and phrases

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. Sentences and phrasesSentences and phrases

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 Mucus in the lungs lead to infections, emphysema and atelectasisMucus in the lungs lead to infections, emphysema and atelectasis

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 Prostacyclin agents � a potent vasodilators and inhibitor of platelet aggregation.Prostacyclin agents � a potent vasodilators and inhibitor of platelet aggregation.

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 Sentences and phrasesSentences and phrases

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 Sarcoidosis may affect the skin, eyes, lungs, liver, spleen, bones, salivary glands, joints, and heart. S/S About one third of all pts have no symptoms, others experience dry cough, dyspnea, chest pain, hemoptysis, fatigue, weakness, weight loss, and fever.Sarcoidosis may affect the skin, eyes, lungs, liver, spleen, bones, salivary glands, joints, and heart. S/S About one third of all pts have no symptoms, others experience dry cough, dyspnea, chest pain, hemoptysis, fatigue, weakness, weight loss, and fever.

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 Sentences and phrasesSentences and phrases

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 Sentences and phrasesSentences and phrases

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) Cigarette smoking is the leading cause of lung cancer. The risk is increased even more for smokers who are exposed to other carcinogenic substances, such as arsenic, asbestos and radioactive materials. Evidence is increasing that secondhand smoke Poses a threat to nonsmokers as well. Air pollution may be an additional risk factor. Cigarette smoking is the leading cause of lung cancer. The risk is increased even more for smokers who are exposed to other carcinogenic substances, such as arsenic, asbestos and radioactive materials. Evidence is increasing that secondhand smoke Poses a threat to nonsmokers as well. Air pollution may be an additional risk factor.

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. There are four major types of lung cancer: small cell (�oat cell�) carcinoma, Squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. There are four major types of lung cancer: small cell (�oat cell�) carcinoma, Squamous cell carcinoma, adenocarcinoma, and large cell carcinoma.

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) Early detection is the key to survival of lung cancer, but this is difficult because metastasis often occurs before the lesions can be seen on x-ray. Treatment decision made on the basis of tumor type, lymph node involvement, evidence of metastasis, and the pts general state of health. Radiotherapy, ChemotherapyEarly detection is the key to survival of lung cancer, but this is difficult because metastasis often occurs before the lesions can be seen on x-ray. Treatment decision made on the basis of tumor type, lymph node involvement, evidence of metastasis, and the pts general state of health. Radiotherapy, Chemotherapy

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 Pleurodesis � production of adhesions between the parietal and visceral pleura, usually done surgically or by installation of drugs or chemicals. Used to treat pneumothorax.Pleurodesis � production of adhesions between the parietal and visceral pleura, usually done surgically or by installation of drugs or chemicals. Used to treat pneumothorax.

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 This allergic response release of chemicals, including histamine, causes vasodilation and increased capillary permeability. Fluid leaks from the capillaries causing swelling of the nasal mucosa. These cahanges can be triggered by overuse of decongestant nose drops or sprays.This allergic response release of chemicals, including histamine, causes vasodilation and increased capillary permeability. Fluid leaks from the capillaries causing swelling of the nasal mucosa. These cahanges can be triggered by overuse of decongestant nose drops or sprays.

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) The most common cause causative microorganisms are staph and strep. The infection spreads from the nasal passageway into the sinuses.The most common cause causative microorganisms are staph and strep. The infection spreads from the nasal passageway into the sinuses.

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 Caldwell-Luc procedure involves an incision in the upper gum line above the teeth. An opening is made between the affected sinus and the nose. This allows secretions to drain, relieving the pressure. The cavity is packed, and the packing is left in place for 48 hrs and removed by the physician. Caldwell-Luc procedure involves an incision in the upper gum line above the teeth. An opening is made between the affected sinus and the nose. This allows secretions to drain, relieving the pressure. The cavity is packed, and the packing is left in place for 48 hrs and removed by the physician.

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. Usually occurs with acute rhinitis or sinusitis. Usually occurs with acute rhinitis or sinusitis.

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 Sentences and phrasesSentences and phrases

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

116. 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. Sentences and phrases+Sentences and phrases+

117. 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 Sentences and phrasesSentences and phrases

118. Laboratory Assessment Gram stain, culture, and sensitivity testing of sputum Complete blood count Arterial blood gas level Serum blood, urea nitrogen level Electrolytes Creatinine Sentences and phrasesSentences and phrases

119. 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 spirometer�chest physiotherapy if complicated. Prevent dehydration. (Continued) Sentences and phrasesSentences and phrases

121. 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. Sentences and phrasesSentences and phrases

122. 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 Sentences and phrasesSentences and phrases

123. 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 Sentences and phrasesSentences and phrases

124. 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.

125. Clinical Manifestations of TB Progressive fatigue Lethargy Nausea Anorexia Weight loss Irregular menses Low-grade fever, night sweats Cough, mucopurulent sputum, blood streaks

126. 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) Sentences and phrasesSentences and phrases

127. Diagnostic Assessment (Continued) Positive reaction does not mean that active disease is present, but does indicate exposure to TB or dormant disease.

128. Interventions Combination drug therapy strict adherence Isoniazid Rifampin Pyrazinamide Ethambutol or streptomycin Negative sputum culture indicative of client no longer being infectious Sentences and phrasesSentences and phrases

129. Health Teaching Follow exact drug regimen. Proper nutrition must be maintained. Reverse weight loss and severe lethargy. Educate client about the disease. Sentences and phrasesSentences and phrases

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

131. 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.

132. 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.

133. 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

134. Interventions for Critically Ill Clients with Respiratory Problems

135. Pulmonary Embolism A collection of particulate matter�solids, liquids, or gases�enters 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. Sentence and phraseSentence and phrase

136. Etiology Prolonged immobilization Central venous catheters Surgery Obesity Advancing age Hypercoagulability History of thromboembolism Cancer diagnosis

137. 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.

143. Acute Respiratory Failure Pressure of arterial oxygen < 60 mm Hg Pressure of arterial carbon dioxide > 50 mm Hg pH < 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 brain�s respiratory control center Impaired ventilatory muscle function S&PS&P

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 inadequate�too little oxygen reaches the blood and carbon dioxide is retained.

147. 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

148. 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 Sentences and phrasesSentences and phrases

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

155. 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

158. Chest Trauma About 25% of traumatic deaths result from chest injuries: Pulmonary contusion Rib fracture Flail chest Pneumothorax Tension pneumothorax Hemothorax Tracheobronchial trauma