Respiratory Systempart 2second years studentNursing Collage Iman Al Shaweesh Sept. 2008 Al NajahUnivesity
Health History • The reason that pt. is seeking health care is, dyspnea (shortness of breath), hemoptysis (blood spit up from respiratory tract), odema, cough, general fatigue, weakness. • Nurse must identify chief complain , when started problem ,how long, duration, severity, assess risk factors, identify the impact of s&s on the patient ability to perform daily activitie.
Major s&s are dyspnea, cough, wheezing, sputum production, chest pain, clubbing of fingers, hemoptysis, cyanisis. This S&S are related to duration & severity of disease.
1-Dyspnea • difficult or labored breathing, shortness of breath. Symptom common to many pulmonary & cardiac disorders, particularly when there is decrease lung compliance or increase airway resistance. • Rt. Ventricle will affect by pulmonary disease because it must pump blood through the lung against greater resistance.
Sudden dyspnea in health person indicates. • Pneumothorax (air in pleural cavity). • Pulmonary embolism • RDS. • Acute respiratory obstruction.
Orthopnea • (inability to breath easily except in an upright position). Found in pt. with COPD, heart disease. • Dyspnea with an expiratory wheeze occurs with COPD. • Noisy breathing result from narrowing of the airway or localized obstruction of major bronchus by tumor or foreign body.
Relieve measures • high fowlers position, 02 in sever case. • Ask pt. circumstance that produces dyspnea. • How much exertion triggers shortness of breath? • Cough? • Time of day or night? Occur at rest. • Shortness sudden or gradual.
2-Cough • Result from irritation of the mucous membranes any where in the respiratory tract.stimulus many arise from an infectious process or irritant as smoke, dust, gass……….its protect against accumulation of secretion in the bronchi & bronchioles.
Clinical manifestation • Cough may indicate serious pulmonary disease. • Nurse must evaluate character of cough, dry, loose, sever, brassy, hacking. • A dry, irritant cough in characteristics of an URTI of viral origin or may be S.E of (ACE) inhibitor therapy. • Laryngotracheitis cause an irritative high pitched cough.
Tracheal lesions produce a brassy cough. • A sever or changing cough may indicate bronchogenic carcinoma. • A cough in the morning with sputum production may indicate bronchitis. • A cough that worsen when the pt. is in supine position suggest postnasal drip (sinusitis). • Coughing after food intake may indicate aspiration of material into the tracheobronchial trea.
3-sputum production • pt. who coughs long enough produce sputum. • Violent coughing cause bronchial spasm obstruction & irritation of bronchi and may result in scope (funting). • Uncontrolled cough that is non productive is exhausting & potentially harmful.
Clinical manifestation • Thick, yellow, green………………..Indicate bacterial infection. • Thin, mucoid sputum……………......Indicate viral. • Pink tinged mucoid sputum ……………Indicate lung tumor. • Profuse, frothy, pink material ……………...Indicate pulmonary odema. • Foul-smelling sputum & bad breath ……….Indicate lung abscess, infection from anaerobic organism.
Relieve measure: • Adequate hydration (water). • Inhalation of nebulizer. • Stop smoking, because it causes inflammation & hyperplasia of mucous, and decrease production of surfactant. • If smoking stop sputum will decrease, encourage pt. to drink juices to change sputum taste &select of food that increase the appetite.
4-chest pain • may associated with pulmonary or cardiac disease. • Chest pain with pulmonary may be sharp stabbing & intermittent or dull, aching & persistant • Pain may refer else where- neck, back, abdomen.
Clinical manifestation • Chest pain may occur with pneumonia, pulmonary embolism with lung infarction & pleurisity. • It also late symptom of bronchogenic carcinoma. • Lung disease not always produce pain because lung & visceral pleura lack sensory nerves & insensitive to pain stimuli & partial pleura has rich supply of sensory nerves.
Pleuritic pain from irritation of partial pleura is sharp, pt. describe it as (like the stabbing of knife). Pt. comfortable when sleep on affected part. • Nurse must assess quality, intensity, radiation of pain, relationship of pain to inspiratory & expiratory.
Relieve measures • Analgesic medication but not to depress the respiratory center or productive cough. • NSAID for pleurituic pain. • Regional anesthetic block may be performed to decrease extreme pain.
5-wheesing: • Is often a major finding in pt. with bronchoconstriction or airway narrowing. • Heard with stethoscope & depend on location. • Wheezing is a high pitched, musical sound heard mainly on expiration. • Relieve measure: Oral or inhaled bronchodilator.
6-clubbing of the fingers • is singe of lung disease found in pt. with chronic hypoxic condition, chronic lung infections, CA of lung. • Initially manifested as sponginess the nail bed & loss of nail bed angle
7-Hemoptysis: • Expectoration of blood from respiratory tract. • Is symptom of both pulmonary & cardiac disorders. • Onset is sudden, may be intermittent or continious. • Common cause: 1- pulmonary infection. 2- CA of lung. 3- Abnormalities of heart & blood vesserls.
4- Pulmonary artery or vein abnormalities. 5- Pulmonary emboli & infarction. DX. Evaluation: • Chest x-ray. • Chest angiography. • Bronchoscopy • Full history & physical examination
Inspection of blood, small amount or massive hemorrhage. Source of bleeding gums( blood appearing in noise). • Lung (bright red, frothy salty taste haemoptesis. • Stomach(haemoptesis dark blood).
8-Cyanosis • Is a bluish coloring of skin, very late indicator of hypoxia. • Presence or absence of cyanosis is determined by amount of unoxygenated hemoglobin in blood. When there is 5g/dl of unoxygenated HG. A pt. with 15g/dl HG will not demonstrate cyanosis until 5g/dl of HG become unoxygenated. • Cyanosis is not reliable singe of hypoxia. Because anemic pt. rarely manifest cyanosis.
In the present of pulmonary condition cyanosis assess by tongue & lips. • Peripheral cyanosis results from decrease blood flow to certain area & not indicate central problem.
Physical assessment of upper respiratory tract Noise & sinuses • Inspect external nose for lesion, asymmetry or inflammation .ask pt. to tilt head background, gently pushing tip of nose& inspect mucosa for color, swelling, & bleeding.nasal Deviation, Perforation. • Nurse inspect inferior & middle turbinates then nurse palpate frontal & maxillary sinuses for tenderness using thumb & gently pressure. Frontal & maxillary sinuses can be inspected by (transilliumination). If light fails to generate, the cavitycantain fluid.
Pharynx & mouth • Ask pt to open mouth & take breath inspect for color, symmetry, ulceration or enlargement. • Trachea.(position, mobility of trachea).
Assessment of lower respiratory structures & breathing • ThoraxInspection of thorax provide information about musculoskeletal structure, nutritional status & respiratory system. Note symmetry. • Chest configuration. Normal ratio of anterioposterior diameter to lateral diameter is 1:2. Four deformities of chest associated with respiratory disaease.
A-Barrel chest. • Result of overinflation of the lungs • Increase in anterioposterior diameter of thorax • Pt. with emphysema, ribs are more wildely spaced & intercostals spaces tend to blug on expiration.
B-Funnel chest (pectus excavatum) • Occur where is depression in lower portion of sterum this may compress heart & great vessels resulting in murmers. • May occur with rickets or marfans syndrom
C-Pigeon chest (pectus carinatum). • Occur as result of displacement of sternum. • Increase anterioposterior diameter. • Rickets , marfans syndrome, sever hyposkoliosis.
D-kyphoscoliosis. • Is characterized by elevated of scapula & corresponding S- shape spine. • This limit lung expantion. • Occure with osteoporosis.
Breathing pattern & respiratory rates • Normal breath 12-18 b/m, regular in depth & rythem. This descripe as eupnea. • Bradycardia – slow breathing associated with increase ICP , brain injury, drug overdose. • Tachypnea- rapid breathing. Pt with pneumonia, metabolic acidosis, pulmonary odema, septicemia. • Hyperventilation – shallow, irregular breathing. hyperventilation associated with sever acidosis is called ( kussmauls respiration
Hyperpnea – increase depth of respiration. • Hyperventilation – increase in rate & depth . inspiration & expiration are equal in duration. • 1-Thoracic palpation: • The nurse palpates the thorax for tenderness, masses, lesion, vocal fremitus, and respiratory excursion. Nurse performs direct palpation with finger tips or ball of the hand (for deeper masses).
A-Respiratory excursion: • Is an estimation of thoracic expansion & may dissolve significant information about thoracic movement during breathimg. • Pt. instructed to inhale deeply while the movement of nurse thumbs. This movement is normally symmetry. Asymmetric excursion due to fracture rib, trauma, & unilateral bronchial obstruction. • Decrease chest excursion due to chronic fibrotic disease.
B-Tactile fremitus • Sound generated by the larynx travels distally a lone the bronchial tree to test the chest wall in resonant motion. Pt asks to repeat 99. • Pt. with emphesema- rupture of aloveoli & trapping of air, exhibit no tactile fremitus. • Tactile fremitus increase over lob affected with pneumonia.
C-Thoracic percussion • Nurse use percussion to determine a whether underlying tissues are filled with air, fluid or solid material.also used to estimate size, location certain structure with thorax. (heart. Diaphragm).
D-diaghragmatic excusion Normal resonance of the lung stops at the diaphragm, the position of diaphragm is different in inspection & expiration. Assess position & motion of diaphragm by ask pt. to take breath & hold it, nurse marked with pen. Distance between the two markings indicates range of motion. 8-10cm in healthy, 5-7 most people. The diaphragm is about 2cm. higher in Rt. Because position of heart.
DX.Evaluation • Pulmonary function test. Routinely used in pt. with chronic respiratory disorders, test should measurements of lung volume, ventilatory function & mechanism of breathing diffusion & gas exchange. • Arterial blood gas study. Aid in assessing the ability of the lungs to provide adequate o2 & remove co2. the ability of kidney to reabsorb & excrete bicarbonate ions to maintain body normal PH. ABGs are obtained through an arterial puncture at radial, brachial, femoral, or indwelling arterial catheter.
Pulse oximetry. Non invasive method of continuously monitoring o2 sat. of hemoglin. Aprobe or sensor is attached to the fingertip forehead, earlobe, bridge of nose. Normal 95-100%, decrease 85 indicate that tissue are not receiving enough o2. • Culture. Throat culture to identify pathogenic organism, drug sensitivity testing. Specimen to lab must be within 2 hr.s (overgrowth of organisim). Specimen taken at morning.
Imagining studies. Include X- ray, CT, MRI (magnetic resonance imagimg, radioscopic diagnostic scans. 1-Chest x-ray: normal pulmonary tissue is radiolucent, there for densties produced by fluid, tumors, foreign bodies & pathogenic condition can be detected by x-ray. 2-CT : used to identify pulmonary nodules & small tumors that are not visible on routine chest x-ray.
3-MRI:are more diagnostic image than CT…..to characterized pulmonary bodules. 4-Fluoroscopic studies: used to assess with invasive procedures as chest needle biopsy. To study movement of chest wall, heartr, diaphragm.To detect , diaphragm paralysis & lung masses.
5-Pulmonary angiography: used to investigate thromboembolic disease of the lung as congenital abnormalities of pulmonary vascular tree.( it involve rapid injection of radiopaque agent ( from femoral vein, arm vein) into the vascular of the lungs for radiographic study of pulmonary vessels
6-Radioisotope DX. Procedures (lung scan).Ventilation- perfusion lung scan is first performed by injecting a radioactive agent into a peripheral vein & then obtaining a scan of the chest into detects radiation.Used clinically to measure the integrity pf pulmonary vessels relative to blood flow to evaluate blood flow abnormalities as seen in pulmonary emboli. It takes 20-40 minute.
VI.Endoscopic procedure • Bronchoscopy is direct inspection & examination of the larynx, trachea, & bronchi through either a flexible fiberoptic scope or rigidf bronchoscope. • Purpose of DX. Bronchoscopy. • To examine tissue or collect secreations. • To determine location & obtain tissue. • To determine if tumor can be resected surgically. • To DX. Bleeding site.
Thepaputic bronchoscopy is used to: • Remove foreign bodies. • Remove recreation obstruction the tracheobronchial tree. • Treat post operative atelactasis. • Destroy & excise lesion.
Complication: • Reaction to local anesthesia. • Infection • Aspiration • Bronchoscopy • Hypoxemia
NSG intervention: • consent form, NPO, explain procedure, preoperative medication ( atropine, sedation)…..as prescribed to inhibit vagal; stimulation, suppress cough. Also pt. must remove dentures. • Post op. pt. must be NPO until the cough reflex returns. Ice-chips & fluid given. • Observe v/s, hypoxia, bleeding, hypotention, tachycardia, dysarythmia.
Thoracoscopy (DX. Treat & biobsy). • Is DX procedure in which the pleural cavity is examined with an endoscope. Small incisions are made into the pleural cavity. • Chest tube may be inserted & pleural cavity is drained by negative- pressure water seal drainage.
NSG intervention: • Monitor shortness of breath (which may indicate pneumothorax). • Monitor chest drainage if chest tube is in place. • Monitor activity restriction.