ncm 103 - oxy respi

The Respiratory SystemAnatomy & Physiology

Airways • Upper Respiratory Tract

▫ Nose Nasal cavity or nares (nostrils) Cilia, mucus

serves as a passageway for air to pass to and from the lungs filters impurities, humidifies and warms the air as it is inhaled Olfaction

▫ Paranasal Sinuses four pairs of bony cavities connected by series of ducts that drain into nasal cavity frontal, ethmoidal, sphenoidal, and maxillary serve as resonating chamber in speech common site of infection

▫ Turbinate Bones (Conchae) increase mucous membrane surface of nasal passages and slightly obstruct air flowing through them

▫ Pharynx (Throat) Connects nasal and oral cavities to larynx Passageway for respiratory and digestive tracts Tonsils

▫ Larynx Voice organ/box - for vocalization Protects lower airways by initiating cough reflex

▫ Trachea Contains C-shaped cartilaginous rings composed of smooth muscle Connects larynx to bronchi

• Lower Respiratory Tract ▫ Lungs

Separated by space called mediastinum Right lung

• 3 lobes • Broader but shorter

Left lung • 2 lobes

Pneumocytes Type I – line alveoli Type II – produce surfactant

Pleura Serous membranes that enclose the lungs Visceral, parietal pleurae & pleural space

▫ Bronchi Large air passages that lead to lungs

Lobar, segmental, subsegmental ▫ Bronchioles

Branch into terminal bronchioles and alveoli ▫ Alveoli

Clustered microscopic sacs enveloped by capillaries Where gas exchange occurs Contain surfactant to reduce surface tension & keep them from collapsing

▫ Thorax Provides protection for lungs, heart & great vessels 12 pair of ribs, sternum, thoracic vertebrae

▫ Diaphragm Main respiratory muscle for inspiration Supplied by phrenic nerve

Accessory Muscles for Inspiration • Sternocleidomastoid • Scalene • Parasternal • Trapezius

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• Pectoralis ▫ Used during increased work of breathing

Respiratory Centers • Medulla oblongata

▫ Primary center • Pons

▫ Pneumotaxic center Rhythmic quality of breathing

▫ Apneustic center Deep, prolonged inspiration

• Carotid & Aortic bodies ▫ Peripheral chemoreceptors ▫ Take up work of breathing when central chemoreceptors in medulla are damaged ▫ Respond to low oxygen concentration in blood & to blood pressure

• Muscles & Joints ▫ Propioceptors ▫ Exercise increases RR

Respiration• Process of gas exchange between the individual & the environment • Three processes

▫ Ventilation ▫ Diffusion ▫ Perfusion

Ventilation • Movement of gases in & out of the lungs

▫ Inhalation – voluntary phase ▫ Exhalation – involuntary phase

Diffusion • Exchange of gases from an area of higher pressure to an area of lower pressure

Perfusion • The availability & movement of blood for transport of gases, nutrients & metabolic waste products • Filling of the pulmonary capillaries with blood

Ventilation Perfusion (V/Q) Balance & Imbalance • Normal Ratio

▫ In a healthy lung, a given amount of blood passes an alveolus and is matched with an equal amount of gas• Low V/Q Ratio (Shunt)

▫ When perfusion exceeds ventilation, a shunt exists ▫ Blood bypasses the alveoli without gas exchange occurring ▫ Seen with obstruction of the distal airways

• pneumonia, atelectasis, tumor, mucus plug• High V/Q ratio (Dead space)

▫ When ventilation exceeds perfusion▫ The alveoli do not have an adequate blood supply for gas exchange to occur

• Pulmonary emboli, pulmonary infarction, and cardiogenic shock• Absent (silent unit)

▫ Absence of or limited ventilation and perfusion • Pneumothorax, severe acute respiratory distress syndrome

Lung Volumes • Tidal volume

▫ Amount of air inhaled and exhaled with each breath• Inspiratory reserve volume

▫ Maximum volume of air that can be inhaled after a normal inhalation • Expiratory reserve volume

▫ Maximum volume of air that can be exhaled forcibly after a normal exhalation• Residual volume

▫ Amount of air that remains in lungs after forceful expiration ▫ Prevents lung collapse


Lung Capacities • Vital Capacity

▫ Maximum volume of air exhaled from the point of maximum inspiration VC = TV + IRV + ERV

• Functional residual capacity ▫ Amount of air that remains in the lungs after normal exhalation

• Total lung capacity ▫ The volume of air in the lungs after a maximum inspiration

TLC = TV + IRV + ERV + RV

Assessment of Clients with Respiratory Disorders

History • Chief Complaint • Post Medical Hx

▫ Childhood, infectious dse ▫ Respiratory immunization ▫ Major illnesses, hospitalization ▫ Medications ▫ Allergies

• Family HX • Psychosocial Hx & Lifestyle

▫ Occupational or environmental exposure ▫ Personal habits – smoking

Physical Examination • Inspection

▫ s/s of respiratory distress ▫ Breathing pattern ▫ Chest wall configuration ▫ Chest movement ▫ Fingers & toes

(-) pallor, cyanosis No clubbing of fingers

• Palpation ▫ Tracheal position ▫ Chest wall configuration ▫ Tactile fremitus

Sensation of sound vibrations produced when pt speaks • Increased fremitus

• Lung consolidation – pneumonia, tumor • Decreased fremitus

• Felt when more air than normal is trapped in lungs or pleural space – emphysema, pneumothorax

• Perscussion ▫ Resonance – heard over normal lung tissue

Loud, low-pitched, long & hollow ▫ Flat – airless tissue

Soft, high-pitched, short & extremely dull ▫ Dull – dense lung tissue or consolidation

Moderate in loudness & pitch, thud-like▫ Tympany

Loud, high-pitched, drumlike ▫ Hyperresonance

Very loud, very low, booming Represents air trapping

• Auscultation ▫ Normal Breath Sounds

Bronchial (tracheal) – heard over manubrium; high-pitched & loud Bronchovesicular – bronchi; moderate pitched & amplitude Vesicular – all over chest but heard best in bases of lungs; low-pitched & soft

• Sonorous rhonchi – low-pitched, musical snoring 3 ncm103/oxygenation/2010

▫ Adventitious Breath Sounds Crackles

• Discrete, noncontinuous sounds that result from delayed reopening of deflated airways• Reflect inflammation or congestion

• pneumonia, bronchitis, heart failure, bronchiectasis, pulmonary fibrosis• Friction rubs

• result from inflammation of the pleural surfaces • crackling, grating sound

Wheezes • a/w bronchial wall oscillation & narrowing of airways • asthma, chronic bronchitis, bronchiectasis

• Sonorous wheezes (rhonchi)• Deep, low-pitched rumbling sounds heard primarily during expiration

• Sibilant wheezes • Continuous, musical, high-pitched, whistlelike sounds heard during inspiration

and expiration

Voice Sounds • Egophony

▫ Say “eee”▫ Auscultated as “a” indicating consolidation

• Whispered pectoriloquy ▫ Whisper “1, 2, 3”▫ Auscultated as muffled 1, 2, 3

• Bronchophony ▫ Say “ninety-nine”▫ Consolidation results in increased resonance & words are heard clearly

Altered Breathing Patterns • Cheyne-Stokes breathing

▫ Regular cycle where rate and depth of breathing increase, then decrease until apnea (about 20 sec) occurs• Hyperventilation

▫ Increased rate and depth of breathing (Kussmaul's respiration if caused by DKA)• Hypoventilation

▫ Shallow, irregular breathing• Biot’s breathing

▫ Periods of normal breathing (3-4 breaths) followed by varying period of apnea (usually 10 sec to 1 min)• Apnea

▫ Period of cessation of breathing; time duration varies

Diagnostic Evaluation

Pulmonary Function Tests • Noninvasive tests that measure lung volume, ventilation, & diffusing capacity using a spirometer

▫ Client is asked to breathe thru mouthpiece ff specific directions while computer calculates volumes • Instruct pt to refrain from smoking or eating a heavy meal 4-6H before test • Document bronchodilators or narcotics used before testing

Arterial Blood Gas Analysis • Lab test that assesses the arterial blood for tissue oxygenation, ventilation & acid-base status• Before test, note pt’s temperature • Document O2 & assissted MV used • After, apply pressure to site for at least 5 mins • Assess puncture site for bleeding

Pulse Oximetry • Noninvasive method of continuously monitoring oxygen saturation of hemoglobin (SpO2 or SaO2)


Sputum Study • Lab test that provides microscopic evaluation of sputum for C&S, Gram stain & AFB

▫ Obtain early morning sterile specimen from suctioning or expectoration ▫ Make sure specimen is sputum, not saliva

Imaging Studies Chest X-ray

• Produces radiographic picture of lung tissue ▫ Detects tumors, inflammation, air, fluid ▫ Monitor equipment – catheters, tubes

Determine client’s ability to inhale & hold his breath Instruct client to remove jewelry from chest

CT Scan • Lungs are scanned in successive layers by a narrow-beam x-ray• Provide a cross-sectional view of the chest

▫ Contrast agent may be used

Magnetic Resonance Imaging • Yield a much more detailed diagnostic image than CT scans by using magnetic fields & radiofrequency signals

Fluoroscopic Studies• Used to assist with procedures like chest needle biopsy to identify lesions• Used to study movement of chest wall, mediastinum, heart, and diaphragm

▫ diaphragm paralysis, lung masses

Pulmonary Angiography • Patient receives injection of radiopaque dye to provide radiographic picture of pulmonary circulation

▫ Note pt’s allergies to iodine, radiopaque dye▫ NPO 8H before test ▫ Informed consent ▫ Possible SE – flushing, burning sensation ▫ Check insertion site for bleeding

Lung Scan • V/Q scan, uses visual inhalation or IV injection of radioisotopes to create an image of blood flow in the lungs

▫ Informed consent ▫ Remove all metal objects before test▫ Determine pt’s ability to lie still for about 1H during procedure ▫ Check catheter insertion site for bleeding

Endoscopic Procedures Bronchoscopy

• Visualization of trachea & bronchial tree with a bronchoscope ▫ Withhold food & fluids 6-12H if possible ▫ Make sure that written, informed consent has been obtained ▫ Check cough & gag reflex; NPO until it returns▫ Assess sputum ▫ Assess respiratory status ▫ Note bradycardia – vasovagal response

Thoracoscopy • Pleural cavity is examined with an endoscope

▫ pleural effusions, pleural disease, tumor staging• Small incisions are made into pleural cavity in an intercostal space


Lung Biopsy • Removal of small amount of lung

tissue for histologic evaluation thru surgical exposure or endoscopy

▫ NPO 8H before procedure ▫ Informed consent ▫ Monitor & record vs,

respiratory status s/s

pneumothorax, air embolism, hemorrhage

▫ Check incision site for bleeding

• After procedure, chest tube may be inserted

Thoracentesis • Needle is used to obtain sample of intrapleural fluid to determine the cause of infection; with anesthesia

▫ Informed consent ▫ Position pt properly

sit up or lie on unaffected side with arm of affected side raised above head, elevate HOB 30-45 degrees if possible

▫ Assess vs, respiratory status▫ After, position pt on affected side▫ Check puncture site for fluid leakage

RESPIRATORY DISORDERS

ATELECTASIS refers to closure or collapse of alveoliCommon complication among post-operative or immobilized clients

Etiology/ Pathophysiology:1. Pulmonary secretions and/ or exudates contribute to airway obstruction2. Airway obstruction increases intra-alveolar pressure causing alveolar collapse3. Surface area available for gas exchange is decreased

Clinical Manifestations:1. Low grade fever2. Breath sounds diminished or absent in affected area3. Diminished rate and depth of respiration4. Physical inactivity caused by immobility or pain

Priority Nursing Diagnosis:1. Ineffective Airway clearance2. Ineffective breathing pattern3. Impaired gas exchange

Nursing interventions:1. Monitor respiratory and oxygenation status2. Deep breathing and coughing exercises3. Incentive spiromerty4. Frequent position change5. Ambulation as soon as feasible with client condition6. Maintain adequate hydration and nutrition

Preventing atelectasis:1. Change patient’s position frequently2. Encourage early ambulation from bed to chair followed by early ambulation3. Encourage deep breathing and coughing to mobilize4. Teach/ reinforce appropriate technique for incentive spirometry5. Administer prescribed opioids and sedatives judiciously to prevent respiratory depression6. Perform postural drainage and chest percussion if indicated7. Institute suctioning to remove tracheobronchial secretions

PLEURAL EFFUSIONThe accumulation of fluids in the pleural spaceRarely a primarily disease process but is usually secondary to other diseasesMay be a complication of: heart failure, TB, pneumonia, pulmonary infections (viral), nephrotic syndrome,

pulmonary embolism, neoplastic tumors

Types:1. Transudative pleural effusion2. Exudative3. Empyema


4. Chylothorax

Causes:1. Trauma2. Thoracic surgery3. Positive pressure ventilation4. Thoracentesis5. CVP line insertion6. Emphysema

Clinical Manifestations:1. Sudden, sharp chest pain2. Shortness of breath3. Anxiety/ restlessness4. Tachycardia5. Diminished/ absent breath sounds6. Increased RR7. Chest tightness8. Chest asymmetry9. Cyanosis10. Tympanitic sound on chest percussion

Assessment/ Diagnostic Findings:1. PE2. CXR3. Chest CT scan4. Thoracentesis5. Pleural fluid analysis – gram stain, AFB stain for TB, RBC/WBC, chemistry studies (glucose, amylase, lactic dehydrogenase,

CHON)6. Pleural biopsy

Medical management:1. Thoracentesis2. Chemical pleurodesis3. Surgical pleurectomy4. Pleuroperitoneal shunt

Nursing interventions:1. Remain with patient, stay calm2. High fowler’s position3. Pain management4. O2 therapy5. Chest tube/ thoracentesis6. CXR7. ABG’s8. Monitor for shock

PULMONARY EDEMAAn abnormal accumulation of fluid in the lung tissue and/ or alveolar space

Clinical manifestations:1. Central cyanosis2. Dyspnea3. Air hunger4. Foamy, frothy secretions5. Blood-tinged secretions6. Confused/ stuporous7. Crackles8. Tachycardia9. Increasing hypoxemia

Assessment/ Diagnostic findings:1. CXR


2. Pulse oximetry3. ABG’s

Medical management:1. Cardiac in origin

- Vasodilators- Inotropic medication- Contractility medications

2. Diuretics3. O24. Morphine so4 administration

Nursing management:1. Assist in administration of O22. Administers medication as prescribed3. Monitor patient’s response to medications4. Positioning the patient to promote circulation5. Providing psychological support

ACUTE RESPIRATORY FAILUREA fall in arterial O2 tension (PaCO2) to less than 50mmHg (hypoxemia) and a rise in arterial CO2 tension to greater

than 50mmHg (hypercapnia) with an arterial ph of less than 7.35A sudden and life-threatening deterioration of the gas exchange function of the lungs

Causes:1. Decreased ARF2. Dysfunction of the chest wall3. Dysfunction of lung parenchyma4. Other causes

Clinical manifestations:1. Early signs

- Restlessness- Fatigue- Headache- Dyspnea- Air hunger- Tachycardia

2. Increased BP3. Confusion4. Lethargy5. Tachypnea6. Central cyanosis7. Diaphoresis8. Respiratory arrest9. Respiratory distress

Medical management:1. Treat underlying cause2. Intubation3. Mechanical ventilation

Nursing management:1. Assess patient’s respiratory status2. Monitor patient’s vital signs3. Implement strategies to prevent complications4. Assess the patient’s understanding on the management strategies5. Provide teaching on underlying disorder

ACUTE RESPIRATORY DISTRESS SYNDROMEA clinical syndrome characterized by a sudden and progressive pulmonary edema, increasing bilateral infiltrates on

CXR, hypoxemia refractory to O2 supplementation, and reduced lung compliance

Etiologic factors:8 ncm103/oxygenation/2010

1. Aspiration2. Drug ingestion and overdose3. Hematologic disorders4. Prolonged inhalation of high concentrations of O2, smoke, or corrosive substances5. Localized infection6. Metabolic disorders7. Shock8. Trauma9. Major surgery10. Fat or air embolism11. Systemic sepsis

Clinical manifestations:1. Increased RR2. Dyspnea3. Retractions4. Central cyanosis5. Dry cough6. Fine crackles7. Fever8. Alteration in LOC9. ABG’s- decreased PaO2, increased PaCO2

Medical management:1. Supplemental O22. ABG analysis3. Pulse oximetry4. Bedside pulmonary function testing5. PEEP6. Intravenous crystalloid solutions administration7. Pharmacologic therapy

- human recombinant interleukin -1 receptor antagonist- neutrophil inhibitors- Antisepsis agents- surfactant replacement therapy- corticosteroids

8. Nutritional therapy

Nursing management:1. Close monitoring on patient2. Nursing responsibilities in different respiratory modalities3. Frequent assessment of the patient’s status4. Turning the patient frequently5. Explain all the procedures to be done to the patient6. PEEP

- Administer morphine- Monitor patient- Pain medication- Comfort

PULMONARY HYPERTENSIONA condition in which there is raised BP within the blood vessels supplying the lungs

Causes:1. Primary/ Idiopathic2. Secondary

Clinical Manifestations:1. Dyspnea2. Substernal chest pain3. Weakness4. Fatigue5. Syncope


6. Occasional hemoptysis7. Signs of right-sided heart failure

- Peripheral edema- Ascites- Distended neck veins- Liver engorgement- Crackles- Heart murmur

Assessment/ Diagnostic findings:1. PE2. CXR3. Pulmonary function studies4. ECG5. Echocardiogram6. VQ scan7. Cardiac catheterization

Medical management:1. Supplemental oxygenation2. Cardiac glycosides3. Fluid restriction4. Diuretics5. Ca channel blockers6. Vasodilators7. Anti-coagulants

Nursing management:1. Identify patient’s at high-risk for pulmonary HPN2. Be alert for s/sx3. Administer O2 appropriately4. Instruct patients and their families on O2 usage at home5. Administer medication as prescribed6. Assess patient’s status regularly

PULMONARY HEART DISEASEA condition in which the right ventricle of the heart enlarges as a result of diseases that affect the structure or

function of the lung or its vasculature

Clinical manifestations:1. Increasing edema of the feet / legs2. Distended neck veins3. Enlarged palpable liver4. Pleural effusion5. Ascites6. Heart murmur7. Headache8. Confusion 9. Somnolence10. Increasing SOB11. Wheezing12. Cough13. Fatigue

Medical management:1. Supplemental oxygenation2. ABG analysis3. Pulse oximetry4. ECG monitoring5. Endotracheal intubation6. Bed rest, Na restriction, diuretic therapy7. Digitalis

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Nursing management:1. Assess the patient’s respiratory and cardiac status2. Administer medications as prescribed3. Close monitoring for:

- Fluid retention- Weight gain- Edema

PULMONARY EMBOLISMEmboli lodge in pulmonary vasculature and obstruct adequate blood flow through pulmonary capillaries

Clinical manifestations:1. Restlessness, anxiety, agitation2. Altered V/S- tachy, tachy, hypotension, fever3. Chest pain4. Hemoptysis5. Mental status changes6. Decreasing LOC7. Cyanosis8. Recent history of thromboembolism9. Lung crackles

Assessment/ Diagnostic findings:1. CXR2. Atrial Fibrillation3. Pulmonary angiogram4. ABG analysis

Medical management:1. O2 therapy2. Anticoagulant3. Embolectomy4. Thrombolytic therapy5. Intracaval filter

Nursing management:1. Maintain patent airway2. Supplemental O23. Be prepared to initiate intubation4. Maintain IV access5. Circulatory support as indicated6. Placement of vena cava filter7. Pain management8. Pulmonary embolectomy9. Avoid immobility as much as feasible10. Teach s/sx of venous occlusion11. Instruct client/ family in anticoagulant therapy as indicated

Chest Trauma

WHY LIFE-THREATENING?Disrupts airway > Hypoxemia from injury, massive hemorrhage, collapsed lung and pneumothorax

Injures thoracic contents > Hypovolemia & Cardiac Failure

Ergo, TIME is very critical in tx of Chest trauma

Blunt Chest Trauma Results from sudden compression or positive pressure inflicted to the chest wallMore common but often difficult to identify extent of damage; symptoms may be generalized and vague

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Usually from MVA (steering wheel, seatbelt), falls & bicycle crashes

1. Simple Rib Fracture Clinical Manifestations

Pain, especially on inspiration Point tenderness & bruising at injury site Splinting on shallow respirations Apprehensiveness

Diagnostics Chest X-ray reveals area and degree of fracture ABG analysis (↑ pCO2, ↓pO2) Pulse oximetry (decreased lung volumes & capacities)

Nursing Diagnoses Pain, acute r/t nerve compression from thoracic injury AEB apprehensiveness, verbalization of pain (PS 10/10),

splinting on shallow respirations, point tenderness Ineffective breathing pattern Impaired skin integrity Anxiety

Medical Management Medications:

Pain relievers (non-opioids IV, intercostal nerve blocks)Mild sedatives

Nursing interventions Provide pain relief

Analgesics as orderedAssist to position of comfortIce compress

Monitor client closely for s/s of complicationsBloody sputums/s of pneumothorax & hemothorax

2. Flail Chest Frequently a complication of blunt chest trauma from a steering wheel injury Usually occurs when 3 or more adjacent ribs (multiple contiguous ribs) are fractured at 2 or more sites, resulting in free-

floating rib segments May also result as a combination fracture of ribs and costal cartilages or sternum

Pathophysiology Normally,

During INSPIRATION ATM Pressure > IT Pressure During EXPIRATION IT Pressure > ATM Pressure

During inspiration, as the chest expands, the flail segment is pulled inward, reducing the amount of air that can be drawn into the lungs. On expiration, because the ITP exceeds AP, the flail segment bulges outward, impairing patient’s ability to exhale.

The mediastinum then shifts back to the affected side.

Pathognomonic sign! PARADOXICAL Chest Movement

Clinical Manifestations Severe dyspnea with rapid, shallow grunty breathing Paradoxical chest motion Cyanosis, tachycardia, hypotension, JVD Chest wound, rush of air through trauma site Crepitus over trauma site Mediastinal shift & lateral deviation of trachea towards unaffected side Pneumothorax & hemothorax Hemoptysis Anxiety & restlessness

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Diagnostics Chest X-ray reveals area and degree of fracture ABG analysis (↑ pCO2, ↓pO2, ↓pH) Pulse oximetry (decreased lung volumes & capacities)

Nursing Diagnoses Ineffective airway clearance Impaired gas exchange Ineffective breathing pattern Pain, Acute Anxiety

Medical Management Medications:

Pain relievers (non-opioids IV, intercostal nerve blocks) Low doses of sedatives

Nursing interventions Restore adequate ventilation and prevent further air from entering pleural cavity : MEDICAL EMERGENCY

In emergency situation: Place air-occlusive dressing or hand over the wound; position patient’s body on affected side

Administer oxygen, maintain open airway Assist ET tube insertion Hook patient to ventilator Assist with thoracentesis and insertion of Closed Tube Thoracostomy Monitor s/s of shock, ABG’s

Administer pain medications as ordered Encourage coughing, turning & DBE

3. Pulmonary Contusion Damage to the lung tissues resulting in hemorrhage and localized edema a/w chest trauma when there is rapid compression and decompression to the chest wall May not be evident initially on examination but will develop in the posttraumatic period

Pathophysiology The primary pathologic defect is an abnormal accumulation of fluid in the interstitial and intra-alveolar spaces Injury to lung parenchyma and its capillary network → Leakage of serum protein and plasma → Exerts osmotic

pressure that enhances loss of fluid from capillaries → Blood, edema, and cellular debris (cellular response to injury) enter lung and accumulate in bronchioles and alveolar surface where they interfere with gas exchange

Occasionally, a contused lung occurs on the other side of the point of body impact; this is called a contrecoup contusion

Clinical Manifestations Mild, moderate, or severe

o tachypnea, tachycardia, pleuritic chest pain, hypoxemia, and blood-tinged secretions, crackles, frank bleeding, severe hypoxemia, and respiratory acidosis

o Changes in sensorium, including increased agitation or combative irrational behavioro s/symptoms of ARDS: central cyanosis, agitation, combativeness, productive cough with frothy, bloody secretions

Assessment & Diagnostic Findings Pulse oximetry ABG Analysis CXR – pulmonary infiltration (changes may not appear for 1 or 2 days after the injury)

Medical Management Treatment priorities include maintaining the airway, providing adequate oxygenation, and controlling pain

Mild Adequate hydration via IVF and OFI; Monitor fluids to avoid hypervolemia

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Volume expansion techniques, PD, CPT including coughing, suctioning Pain – intercostals nerve blocks, opioids via PCA Antimicrobial therapy – damaged lung is susceptible to infection Supplemental oxygen by mask or cannula for 24 to 36 hours

Moderate Bronchoscopy to remove secretions; intubation and MV with PEEP to keep lungs inflated Diuretics to reduce edema NGT is inserted to relieve GI distention

Severe ET intubation and MV support, diuretics, and fluid restriction Colloids and crystalloid solutions to treat hypovolemia Antimicrobial medications for treatment of pulmonary infection

PENETRATING TRAUMAOccurs when foreign object penetrates chest wall (POE & POX present)Usually from GSW & SW Appearance of the external wound may be very deceptive

Diagnostics Chest x-ray Blood chemistry profile ABG analysis Pulse oximetry, ECG Blood typing and cross-matching

Medical Management Immediate Goal: Restore and maintain cardiopulmonary function IFC to monitor UO NGT to prevent aspiration & decompress GIT Shock – colloids, crystalloids, or blood Chest tube – lung re-expansion, complete evacuation of blood and air Penetrating wound of heart and great vessels, esophagus, tracheobronchial tree – surgery

PNEUMOTHORAXTypes

1. Spontaneous pneumothorax aka closed or simple pneumothorax RF: subpleural bleb rupture, tuberculous focus, carcinoma, lung abcess, pulmonary infarction, severe

coughing attack, blunt chest trauma2. Traumatic pneumothorax

aka open pneumothorax Causes: GSW, stab wounds may occur with invasive thoracic procedures

(ie, thoracentesis, transbronchial lung biopsy, insertion of a subclavian line) in which the pleura is inadvertently punctured,or with barotrauma from mechanical ventilation).

3. Tension pneumothorax “one-way leak” Air enters the pleural space with each inspiration but cannot escape

Clinical Manifestations Sudden sharp pain in chest with dyspnea Diminished or absent breath sounds on affected side Decreased respiratory excursion on affected side Hyperresonance on percussion Decreased vocal fremitus Tracheal and mediastinal shift

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Weak, rapid pulse Diaphoresis Anxiety & restlessness

Diagnostics1. Chest X-ray reveals area and degree of pneumothorax, air in pleural space2. ABG analysis (↑ pCO2, ↓pO2, ↓pH)3. Pulse oxymetry (decreased lung volumes & capacities)

Nursing interventions1. Restore adequate ventilation and prevent further air from entering pleural cavity : MEDICAL EMERGENCY

Place air-occlusive dressing or hand over the wound; position patient’s body on affected side Administer oxygen, maintain open airway Assist with thoracentesis Monitor s/s of shock, ABG’s

2. Promote respirations3. Administer pain medications as ordered4. Encourage coughing, turning & DBE5. Prepare client for CTT6. Care for a patient with CTT

Care for a client with Closed Tube ThoracostomyGoal: to reestablish negative intrapleural pressureChest drainage system

1. Single- bottle system The end of the drainage tube from the patient’s chest is submerged in water.

2. Two-bottle system Single-bottle system plus a fluid collection bottle

3. Three-bottle system Two-bottle system plus a third bottle to control the amount of suction applied

Chest drainage system1. Bottle #1: Drainage compartment2. Bottle #2: Water seal chamber; prevents re-collapse of the lungs3. Bottle #3: Suction control connected to wall suction

Nursing interventions Sterile technique is used when changing dressing around the tube insertions Promote respirations Administer pain medications as ordered Encourage coughing & DBE Have on hand an air-occlusive dressing & tape, clamp, sterile bottleBottle #1

Mark level of water in bottle Never raise the bottle above the level of the chest

Bottle #2 Expect for continuous air bubbles in water for the first 24-48 hours Persistent large amounts of air bubbles indicate an air leak Clamp tube to verify a leak; replace a broken, cracked, or full unit If seal becomes disconnected:

Place tubing in sterile water If dislodged from chest:

Seal insertion immediately using sterile occlusive dressing Fluctuations of the fluid level is expected Milking the tubes will prevent blockage of the tube from clots or debris Drainage of more than 100ml in 1 hour should be reported to the physician

Bottle #3 Air should continuously bubble through this unit when suction is on Maintain the ordered level of water in the unit – AVOID EVAPORATION

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ASTHMAChronic, reversible, obstructive airway disease, characterized by wheezingCaused by spasm of the bronchial tubes, or the swelling of the bronchial mucosa, after exposure to various stimuli

INCIDENCEAsthma is the most common chronic disease in childhood. Most children experience their first symptoms by 5 years of age.

ETIOLOGY Asthma commonly results from hyperresponsiveness of the trachea and bronchi to irritants Allergy influences both the persistence and the severity of asthma, and atopy or the genetic predisposition for the

development of an IgE-mediated response to common airborne allergens is the most predisposing factor for the development of asthma.

CLASSIFICATION1. Extrinsic Asthma (Atopic/allergic asthma) Caused by allergen/antigen – foreign particle which enters the body

o Cockroach particleso Cat hair and salivao Dog hair and salivao House dust miteso Mold or yeast sporeso Metabisulfite, used as a preservative in many beverages and some foodso Pollen

2. Intrinsic asthma (non-allergic asthma) - not allergy-related, caused by anything except an allergy May be caused by inhalation of chemicals such as cigarette smoke or cleaning agents, taking aspirin, chest infection, stress,

laughter, exercise, cold air, food preservativeso Smokeo Exerciseo Gas, wood, coal, and kerosene heating unitso Natural gas, propane, or kerosene used as cooking fuelo Fumeso Smogo Viral respiratory infectionso Wood smokeo Weather changes

SIGNS AND SYMPTOMS1. Non Productive to Productive Cough2. Dyspnea3. Wheezing on expiration4. Cyanosis5. Mild apprehension and restlessness6. Tachycardia and palpitation7. Diaphoresis

PATHOPHYSIOLOGY Initial release of inflammatory mediators from bronchial mast cells, epithelial cells, and macrophages, followed by

activation of other inflammatory cells Alteration of autonomic neural control of airway tone and epithelial integrity Increased responsiveness in airways smooth muscle

Bronchial spasm Inflammation and edema of the mucosa Production of thick mucus, which results in increased airway resistance, premature closure of airways, hyperinflation,

increased work of breathing, and impaired gas exchange-If not treated promptly, status asthmaticus may occur

CLINICAL MANIFESTATIONS1. Increased respiratory rate2. Wheezing (intensifies as attack progresses)3. Cough (productive)

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4. Use of accessory muscles5. Distant breath sounds6. Fatigue7. Moist skin8. Anxiety and apprehension9. Dyspnea

Steps of Clinical and Diagnostic as per National Asthma Education and Prevention ProgramMild Intermittent Asthma

Symptoms ? 2 times per week Brief exacerbations Nighttime symptoms ? 2 times a month Asymptomatic and normal PEF (peak expiratory flow) between exacerbations PEF or FEV, (forced expiratory volume in 1 second) ? 80% of predicted value PEF variability < 20%

Mild Persistent Asthma Symptoms > 2 times/week, but less than once a day Exacerbations may affect activity Nighttimes symptoms > 2 times a month PEF/FEV ? 80% of predicted value PEF variability 20%-30%

Moderate Persistent Asthma Daily Symptoms Daily use of inhaled short-acting ?2 - agonists Exacerbations affect activity Exacerbations ? 2 times a week Exacerbations may last days Nighttime symptoms > once a week PEF/FEV > 60%-<80% of predicted value PEF variability > 30%

Severe Persistent Asthma Continual symptoms Frequent exacerbations Frequent nighttime symptoms Limited physical activity PEF or FEV ? 60% of predicted value PEF variability > 30 %

LABORATORY AND DIAGNOSTIC FINDINGS:Spirometry will detect:

a. Decreased for expiratory volume (FEV)b. Decreased peak expiratory flow rate (PEFR)c. Diminished forced vital capacity (FVC)d. Diminished inspiratory capacity (IC)

NURSING MANAGEMENT1. Assess respiratory status by closely evaluating breathing patterns and monitoring vital signs2. Administer prescribed medications, such as bronchodilators, anti-inflammatories, and antibiotics3. Promote adequate oxygenation and a normal breathing pattern4. Explain the possible use of hyposensitization therapy5. Help the child cope with poor self-esteem by encouraging him to ventilate feelings and concerns. Listen actively as the child

speaks, focus on the child’s strengths, and help him to identify the positive and negative aspects of his situation.6. Discuss the need for periodic PFTs to evaluate and guide therapy and to monitor the course of the illness.7. Provide child and family teaching. Assist the child and family to name signs and symptoms of an acute attack and

appropriate treatment measures8. Refer the family to appropriate community agencies for assistance.

Chronic Obstructive Pulmonary Disease (COPD) Disease state characterized by airflow limitation that is not fully reversible (Global Initiative for Chrnonic Obstructive Lung

Disease [GOLD], World Health Organization [WHO] & National Heart, Lung and Blood Institute [NHLBI], 2004)

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Include diseases that cause airflow obstruction (e.g., Emphysema, chronic bronchitis) or any combination of these disorders

INCIDENCE Currently, COPD is the fourth leading cause of mortality and the 12th leading cause of disability. However, by the year 2020

it is estimated that COPD will be the third leading cause of death and the fifth leading cause of disability (Sin, McAlister, Man. Et al., 2003). People with COPD commonly become symptomatic during the middle adult years, and the incidence of the disease increases with age.

PREDISPOSING FACTORS Environmental exposures Host factors Cigarette smoking

CHRONIC BRONCHITIS Lung damage and inflammation in the large airways Cough with sputum production on most days for 3 months of a year, for 2 consecutive years

PATHOPHYSIOLOGY

Hallmark: Hyperplasia and hypertrophy of goblet cells and mucous glands of the airway COMPLICATION : Cor pulmonale

PHYSICAL MANIFESTATIONS Shortness of breath (dyspnea) Persistent cough Sputum or mucus production, wheezing Chest tightness, and tiredness Respiratory failure Cyanosis Headaches, drowsiness or twitching (asterixis) Tachypnea Crackles Active use of muscles in the neck to help with breathing

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http://nursingcrib.com/chronic-bronchitis/

EMPHYSEMA Characterized by loss of elasticity (increased pulmonary compliance) of the lung tissue caused by destruction of structures

feeding the alveoli, owing to the action of alpha-1 antitrypsin deficiency Small airways collapse during forced exhalation, as alveolar collapsibility has decrease Airflow is impeded and air becomes trapped in the lungs

ETIOLOGY Exposure to toxic chemicals, including long-term exposure to tobacco smoke

PHYSICAL MANIFESTATIONS Pursed-lipped breathing Central cyanosis Finger clubbing Hyperresonance, particularly just above the liver; difficulty to palpate apex beat Decreased breath sounds Expiratory wheeze Signs of fluid overload – pitting peripheral edema Ruddy complexion of face (w/ secondary polycythemia) Asterixis (metabolic flap) at the wrist

DIAGNOSTIC EVALUATION1. PFTs demonstrative airflow obstruction – reduced forced vital capacity (FVC), FEV1, FEV1 to FVC ration; increased residual

volume to total lung capacity (TLC) ratio, possibly increased TLC.2. ABG levels – decreased PaO2, pH, and increased CO2.3. Chest X-ray – in late stages, hyperinflation, flattened diaphragm, increased rettrosternal space, decreased vascular

markings, possible bullae.4. Alpa1-antitrypsin assay – useful in identifying genetically determined deficiency in emphysema.

TREATMENT The goals of COPD treatment are

1) to prevent further deterioration in lung function2) to alleviate symptoms3) to improve performance of daily activities and quality of life.

The treatment strategies include1) quitting cigarette smoking2) taking medications to dilate airways (bronchodilators) and decrease airway inflammation3) vaccinating against flu influenza and pneumonia4) regular oxygen supplementation and 5) pulmonary rehabilitation.

Metered dose inhalers (MDIs)o Used to deliver bronchodilatorso Pressurized canister containing a medication that is released when the canister is compressed

Spacerso Tube-like chambers attached to the outlet of the MDI canistero Can hold released medications long enough for patients to inhale them slowly and deeply into the lungs

Other treatments Pulmonary rehabilitation

-Cornerstone in the management of moderate to severe COPD-Program of education regarding lung function and dysfunction, proper breathing techniques (diaphragmatic breathing, pursed lip breathing), and proper use of respiratory equipment and medications

Lung volume reduction surgery (LVRS) -Surgical procedure used to treat some patients with COPD

o Over-inflated portions of lung are removed surgically so the compressed lung may expand and function better

PHARMACOLOGIC INTERVENTIONS Beta-agonists

o Have the bronchodilating effects of adrenaline without many of its unwanted side effects albuterol (Ventolin, Proventil)

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metaproterenol (Alupent) pirbuterol (Maxair) terbutaline (Brethaire), isoetharine (Bronkosol) Levalbuterol (Xopenex) is a recently approved Beta-2 agonist.

o Side effects: anxiety, tremor, palpitations or fast heart rate, and low blood potassium.

Anti-cholinergic Agentso Dilate airways by blocking the receptors for acetylcholine on the muscles of the airways and preventing them from

narrowing Ipratropium bromide (Atrovent)

Methylxanthineso Theophylline (Theo-Dur, Theolair, Slo-Bid, Uniphyl, Theo-24) and aminophylline are examples of methylxanthines.

Methylxanthines are administered orally or intravenously

Corticosteroidso When airway inflammation (which causes swelling) contributes to airflow obstruction, anti-inflammatory

medications (more specifically, corticosteroids) may be beneficialo Prednisone and Prednisoloneo Side effects: osteoporosis, bone fractures, diabetes mellitus, high blood pressure, thinning of the skin and easy

bruising, insomnia, emotional changes, and weight gain

o Inhaled corticosteroids have many fewer side effects than long term oral corticosteroids beclomethasone dipropionate (Beclovent, Beconase, Vancenase, and Vanceril), triamcinolone acetonide

(Azmacort), fluticasone (Flovent), budesonide (Pulmicort), mometasone furoate (Asmanex) and flunisolide (Aerobid).

Treatment of Alpha-1 antitrypsin deficiencyo Emphysema can develop at a very young age in some patients with severe alpha-1 antitrypsin deficiency (AAT).

Replacement of the missing or inactive AAT by injection can help prevent progression of the associated emphysema. This therapy is of no benefit in other types of COPD.

COMPLICATIONS1. Respiratory failure2. Pneumonia, overwhelming respiratory infection3. Right-sided heart failure, dysrhythmias4. Depression5. Skeletal muscle dysfunction

NURSING INTERVENTIONSMonitoring

1. Monitor for adverse effects of bronchodilators – tremulousness, tachycardia, cardiac arrhythmias, central nervous system stimulation, hypertension.

2. Monitor condition after administration of aerosol bronchodilators to assess for improved aeration, reduced adventitious sounds, reduced dyspnea.

3. Monitor serum theophylline level, as ordered, to ensure therapeutic level and prevent toxicity.4. Monitor oxygen saturation at rest and with activity.

Supportive Care1. Eliminate all pulmonary irritants, particularly cigarette smoke. Smoking cessation usually reduces pulmonary irritation,

sputum production, and cough. Keep the patient’s room as dust-free as possible.2. Use postural drainage positions to help clear secretions responsible for airway obstructions.3. Teach controlled coughing.4. Encourage high level of fluid intake ( 8 to 10 glasses; 2 to 2.5 liters daily) within level of cardiac reserve.5. Give inhalations of nebulized saline to humidify bronchial tree and liquefy sputum. Add moisture (humidifier, vaporizer) to

indoor air.6. Avoid dairy products if these increases sputum production.7. Encourage the patient to assume comfortable position to decrease dyspnea.8. Instruct and supervise patient’s breathing retraining exercises.9. Use pursed lip breathing at intervals and during periods of dyspnea to control rate and depth of respiration and improve

respiratory muscle coordination.10. Discuss and demonstrate relaxation exercises to reduce stress, tension, and anxiety.

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11. Maintain the patient’s nutritional status.12. Reemphasize the importance of graded exercise and physical conditioning programs.13. Encourage use of portable oxygen system for ambulation for patients with hypoxemia and marked disability.14. Train the patient in energy conservation technique.15. Assess the patient for reactive-behaviors such as anger, depression and acceptance.

Education and health maintenance1. Review with the patient the objectives of treatment and nursing management.2. Advise the patient to avoid respiratory irritants. Suggest that high efficiency particulate air filter may have some benefit.3. Warn patient to stay out of extremely hot or cold weather and to avoid aggravating bronchial obstruction and sputum

obstruction.4. Warn patient to avoid persons with respiratory infections, and to avoid crowds and areas with poor ventilation.5. Teach the patient how to recognize and report evidence of respiratory infection promptly such as chest pain, changes in

character of sputum (amount, color and consistency), increasing difficulty in raising sputum, increasing coughing and wheezing, increasing of shortness of breath.

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