The Respiratory System and Its Disorders

THE RESPIRATORY SYSTEM

Major function

GAS EXCHANGE

CONSISTS OF:

Nose and Mouth

allow air flow into and out of the body

Paranasal Sinuses

trap particles of foreign matter

Pharynx

passageway of digestive and respiratory tracts.

traps foreign particles

Respiratory System

Larynx

voice box, connects the upper and lower airways

initiates cough reflex w/c is part of the respiratory system’s defense mechanism

Trachea

C-Shaped connector

connects the larynx to the bronchi

Respiratory System

Bronchi

left and right bronchi

large passages that leads to the left and right lungs

Bronchioles

smaller branches of Bronchi

LUNGS

Alveoli

clustered microscopic sacs

where gas exchange occurs

contains a coating of surfactant to reduce tension and keep the them collapsing

Respiratory System

Lobes

How many lobes?

composed of 3 lobes (1 on the right and 2 on the left)

Respiratory System

Bronchoscopy

direct visualization of trachea and bronchial tree through the use of a bronchoscope

Laryngoscopy

uses laryngoscope to directly visualize the larynx

Nursing Management

Preprocedure:

NPO 6-12 hours before

consent

Diagnostic Tests

Post procedure Care:

Check cough and gag reflexes – prone to aspiration

assess respiratory status

NPO until gag reflex returns

monitor for bradycardia and hypotension

vasovagal response

Vagus nerve – 10th cranial nerve

Diagnostic Tests

Chest X-ray

taking a radiographic picture of the lung tissuePulmonary Angiography

injection of radiopaque dye through a catheter

provides radiographic picture of the pulmonary circulation

Sputum Study/ Exam

laboratory test that provides microscopic evaluation of sputum, evaluating it for culture and sensitivity, gram stain and acid-fast bacillus.

Diagnostic Tests

Nursing Management for Sputum Test

Obtain early-morning sterile specimen from suctioning or expectoration

Make sure that the specimen is truly sputum not saliva

Diagnostic Tests

Surgical Puncture of the chest wall, usually with large bore needle

Purpose:For drainage of accumulated fluidTo obtain a sample of intrapleural fluid to

determine to cause of infection or empyema (pus)

Thoracentesis

body cavity containing the lungs; the lungs are surrounded by two serous membranes, the pleurae

outer pleura (parietal pleura) covers and is attached to the chest wall

inner pleura (visceral pleura) covers and is attached to the lung and other structures, i.e. blood vessels, bronchi and nerves

Pleural SpaceSpace between the pleuranormally contains a small amount of

pleural fluid

Pleura

Thoracentesis

Nursing Care:

Beforeconsentreassure patientposition the client

sitting on the edge of the bed

turn the client on his unaffected side with the arm of his affected side raised above his head

After Assess respiratory statusmonitor V/S frequentlyposition the client on the affected side

(seal the punctured site)

Thoracentesis

Pulmonary Function Test (PFT)

non invasive procedure test that measure lung volume, ventilation, and diffusing capacity using a Spirometer

Nursing Mgt:

Ask the client to breath through a mouthpiece following specific directions.

refrain from smoking, or eating a heavy meal 4-6 hours before testing

Diagnostic Tests

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ABG (Arterial Blood Gas)

Mantoux Intradermal Skin Test

detects tuberculosis antibodies

Nursing Care:document Hx of positive results in the past or exposure to

BCG immunizationcircle and record the test sitereading – 48-72 hours after injection

Diagnostic Tests

Lung Biopsy

removal of small amount of lung tissue for histologic evaluation.

Nursing Actions:

BeforeNPO for 8 hoursconsent

After: V/SAssess respiratory statuscheck incision site for bleeding

Diagnostic Tests

Common Respiratory Interventions

Nursing Action:Place in Semi or in high Fowler’s positionUse sterile gloves and sterile suction catheterHyperventilate the client w/ 100% of O2 before and after the

procedureApply suction during withdrawal of the catheterRotate the catheter while applying an intermittent suction

upon withdrawal of the catheterSuctioning should take for only 10 to 15 seconds (Insertion,

intermittent suctioning, and removal of the suction)

Tracheobronchial Suctioning

Percussion, Vibration and Postural Drainage (PVD)dependent nursing interventions

Postural DrainageDrainage by gravity of various lung segments

Percussion

“clapping”

forceful striking of the skin with cupped hands

Percussion over the congested areas of lungs can mechanically dislodge the tenacious secretions from the bronchial wall

ProcedureVerify doctor’s orderAssess accumulation of mucous secretionsPosition to allow expectoration of mucous secretions by gravityPlace the client in each position for 10-15 minutesVibrate and percuss – loosen mucous secretionsBest done 60-90 minutes before meals or in the morning upon awakening and

at bedtime

Chest Physiotherapy

VibrationSeries of vigorous quivering produced by hands that are placed flat

against the client’s chest wallUsed after percussion to increase flow of the exhaled air and thus loosen

the thick secretions

Procedure:Place the hands, palms down on the chest area to be drained , one hand

over the other with the fingers together and extendedAsk the client to inhale deeply and to exhale slowly through the nose or

pursed lipsDuring exhalations, tense all the hand and arm muscles, and using

mostly the heel of the hand, vibrate (Shake) the hands moving then down ward. Stop vibrating when the client inhales

Do 5 vibrations on each affected lung segmentAfter each vibrations, encourage client to cough and expectorate

secretions

Chest Physiotherapy

Thoracostomy Tube (Closed Chest Drainage)

Remove air and/or fluids from the pleural spaceReestablish negative pressure and reexpand the lungs

Indications:Pneumothorax

collection of air or gas in the pleural space Hemothorax

accumulation of blood in the pleural spacePleural Effusion

presence of fluid in the pleural space

Types:

One Bottle System

Two Bottle System

Three Bottle System


One-Bottle SystemThe bottle serves as drainage bottle

and water-seal bottleImmerse the tip of the tube 2-3 cm on

sterile NSS to create water-sealKeep at list 2-3 feet below the level of

the chestNever raise bottle above the level of

the chest


One-Bottle System

Assess patency of the device

fluctuation of fluid on the tube

intermittent bubbling of fluid

Continuous bubbling means air leak

Absence of Fluctuation

obstruction

check for kinks; milk the tubing towards the bottle

consider lung reexpansion

validate w/ chest x-ray


Two- bottle SystemCould be connected or not

connected to a suction apparatus

Not connected 1st bottle is the drainage

bottle2nd bottle water-seal bottle Observe for fluctuation of

fluid along the tube (water-seal bottle) and intermittent bubbling with each respiration


Connected to the suction apparatus

1st bottle is drainage and water-seal bottle; 2nd suction control bottle

continuous bubbling on the suction control bottle; intermittent bubbling and fluctuation in the water-seal

immerse tube in the first bottle 2-3 cm on sterile NSS and 10-20 cm for suction control bottle to stabilize negative pressure


Three-Bottle System1st bottle- drainage bottle, 2nd – water-seal bottle, 3rd-suction

control bottleIntermittent bubbling and fluctuation on water-seal bottle

and continuous bubbling in the suction control bottle


Nursing Management Encourage

DBE and coughing exercises, turning to sides at regular basis, ambulate

Mark the mount of drainage at regular intervalsAvoid frequent milking and clamping to avoid tension

pneumothoraxRemoval of chest tube

Done by the physician

Prepare: petroleum gauze, suture removal kit, sterile gauze, adhesive tape

Place client in semi fowler’s position

Instruct to exhale deeply and do valsalva maneuver as the chest tube is removed

Chest X-ray may be done


DISORDERS

Nose BleedingCauses: Trauma

Nursing care:Sit-up, lean forward, head tipped – prevent

aspiration of bloodPressure over the soft tissue of the nose for at least 5

minutesCold compress/icepacksNotify physician if recurrent

Epistaxis

an inflammation and infection of the sinuses

Etiology:

Streptococcus Pneumoniae, haemophilus influenzae

Sinusitis

URTI

Cigarette Smoking

Allergic rhinitis

Inflammation

Edema of the mucous membrane

Hypersecretion of mucus

Infection

Simple Pathophysiology of Sinusitis

Assessment findings

Pain:

Maxillary – cheek, upper teeth

Frontal – above the eyebrows

Ethmoid – in and around the eyes

Sphenoid – behind the eye, top of the head

General malaiseStuffy noseHAFeverPersistent coughPost nasal discharges

Sinusitis

Nursing Care:RestIncrease fluid intakeAnti-infectivesNasal decongestants

Surgical Management:

Functional Endoscopic Sinus Surgery (FESS)

most common corrective surgery for chronic sinus inflammation

Performed under the magnification of a small telescopic endoscope

remove diseased tissue and bone, polyps to open the sinuses and help to restore the nose and sinus’ health

Sinusitis

Functional Endoscopic Sinus Surgery

Caldwell-Luc Surgery (Radical Antrum Surgery)

“conventional procedure”

involves removal of the diseased lining of the maxillary antrum

left scars and caused significant bruising and discomfort

Sinusitis

Caldwell-Luc Surgery (Radical Antrum Surgery)

Nursing Management after the surgery

Do not chew on the affected sideCaution with oral hygiene Do not wear dentures for 10 daysDo not blow the nose for 2 weeks after removal of packing Avoid sneezing for two weeks after surgery

Sinusitis

Inflammation of the tonsils

Etiology:

Streptococcus - most common

Haemophilus influenzae

Complications:

Otitis media

Pneumonia

Nephritis

Osteomyelitis

Rheumatic fever

Tonsillitis

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Assessment:

Otalgia (referred pain to the ear)

Dysphagia

Malaise

Acutely inflamed mucous membrane with or w/o purulent exudates

Tonsillitis

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Nursing Care:

rest

increase fluid intake

warm saline gargle – relieves discomfort

antimicrobials ,Ibuprofen, lozenges

Surgical Manegement

Tonsillectomy indicated if tonsillitis is recurrent

5-6 times a yearSurgical removal of the tonsils

Tonsillitis

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Tonsillectomy

Pre Operative Care:

Assess URTI. Coughing and sneezing could also cause bleeding

Check PT time. Bleeding is common Post op complication

Surgical Management

POST OPERATIVE CARE

prone, turn head to sides or lateral position until awake

if awake can be positioned in semi Fowler’s position

monitor for hemorrhage specially during the 1st 12-24 hours

inspect the oropharynx and mouth for fresh blood

frequent swallowing

bright red vomitus

increased RR

Promote Comfort

Ice collar, acetaminophen, avoid ASA

Foods and Fluids

Ice-cold Fluids

Refer for pain and administer prescribe medications

Aspirin is contraindicated

Surgical Management

Also known as Respiratory Distress Syndrome

Type of Lung Failure resulting from many different disorders that cause FLUID to ACCUMULATE in the lungs and OXYGEN levels in the blood to be TOO LOW

Medical emergency

ACUTE RESPIRATORY DISTRESS SYNDROME(ARDS)

Air

Lungs

Alveolar capillaries(small blood vessels)

Bloodstream

Inflammation on the lungs

NORMAL ARDS

Increase fluid in the alveoli

prevents the lungs from filling with air and moving enough oxygen into the

bloodstream

Severe respiratory failure

Assessment Findings

SOB/DOB (rapid, shallow breathing)CyanosisRapid HRAnxiety, confusion and restlessnessCrackles and wheezesDecreased breath sounds



Management:

Bed rest

O2 therapy

Monitor respirations, cardiovascular, and neurologic status (hypoxemia)

Monitor pulse oximetry regularly

Monitor Laboratory studies:

Hb and Hgb

WBC

Fowler’s position

Weigh daily – I and O

Encourage to express feelings

Pharmacology

antibiotics

Diuretics

Several disorders that affect the movement of air in and out of the lungs

The airways, the tubes that carry air in and out of the lungs are partly obstructed

Cigarette smoking is the most common cause

Irreversible

Consists Of:Chronic BronchitisAsthmaEmphysema

Chronic Obstructive Pulmonary Disease (COPD)

CHRONIC BRONCHITIS

Inflammation, or irritation of the bronchi

Causes chronic persistent cough with formation of thick mucous secretions

Are called "blue bloaters" because they have cyanosis

Possible Causes:

Cigarette Smoking

RTI

Environmental pollutants


CHRONIC BRONCHITIS

Characterized By:

Increase of submucous glands and goblet cells

- produces mucus

Impaired ciliary function

- reduces mucus clearance


Rapid Increase in Mucus

Obstruction(trapping of

CO2)

Impaired Alveolar ventilation

Derived from the bluish color of the lips and skin

A blue bloater

experiences cyanosis due to a decrease insufficient amounts of oxygen reaching the blood.

The Blue Bloater

Nursing Care for Chronic BronchitisStop SmokingAvoid hair sprays, aerosols – irritates the lungsExercise at least 3 times a week O2 therapyBronchodilators“pursed-lip breathing“

slows down the fast breathing

take a deep breath and then breathe out slowly through the mouth while holding the lips as if you're going to kiss someone


ASTHMA

Airways of people with asthma are extra sensitive to allergens and to other irritating things in the air (irritants)

Inflammation of the lining of the airways (swelling and narrowing)

Spasm including narrowing of airways


ASTHMA

Assessment Findings:

Dyspneic and have marked respiratory effort

Nasal flaring

Pursed-lip breathing with use of accessory muscles

Wheezing (Expiration)

ABSENT WHEEZING

indicate that the small airways are too constricted to allow any air flow

Low Oxygen Saturation (normal 95-99%)


NURSING CARE ON ASTHMA

Assess for manifestations of airway distressAsk the client to rate dyspnea on a scale of 0 to 10Avoid allergens and irritantsMedications – prevent asthma attack

inhaled corticosteriods

Azmacort, AeroBid, Flovent


Nursing Management:

Demonstrate to the client the correct use of inhalers and/or nebulizers

Assist the client in identifying the cause of acute bronhial attack

Teach about the METERED DOSE INHALERS (MDI)When 2 puffs are needed,, 2-3 minutes should lapse

between 2 puffsA spacer may be used to increase the delivery of the

medication

Pharmacology

MDI AND SPACER

Shake the inhaler for five to 10 seconds (about three to five times).

Hold the inhaler upright with the mouthpiece end facing down.

Press down on the inhaler firmly to release the medication as you start to breathe in.

Breathe in slowly and completely for three to five seconds- count 1 one thousand, 2 one thousand, 3 one thousand.

Pharmacology

Hold your breath for 10 seconds if possible to allow the medication to go deeply into your lungs.

Exhale slowly through your mouth. Repeat puffs as prescribed. Wait one minute between puffs

to permit the inhaler to reload with medication, and shake before using again.

Replace the cap on your inhaler/spacer. The inhaler and spacer should be cleaned often to prevent

buildup

Pharmacology

STATUS ASTHMATICUS

Severe, life threatening complication of asthmaAcute episode of bronchospasm that tends to

intensifyWorkload breathing increases 5 to 10 timesCan lead to severe state to hypoxemia, acidosis and

DEATH


EMPHYSEMA

Disorder in which the alveolar walls are destroyed that leads to PERMANENT OVERDISTENTION of the air spaces


Destruction of the connective tissues in the

lungs

Obstruction of Airway

Passages

Inefficient Delivery of O2

Assessment Findings:

Shortness of breath on exertion and later at rest, hyperventilation, and an expanded chest.

Mild emphysema sufferers often maintain adequate blood oxygen levels by hyperventilating, and so are sometimes called "pink puffers”

Chronic Cough

Dyspneic with use of accessory muscles

Sputum production

Emphysema

Assessment Findings

Adventitious breath sounds

Pursed-lip breathing

Tends to assume upright, leaning forward position

Alteration in LOC, Skin color, Skin temperature

Decreased metabolism

Weakness, fatigue, anorexia, weight loss

Peripheral cyanosis


BARREL CHEST

Alteration in thoracic anatomy

CLUBBING OF FINGERS

caused by chronically low blood levels of oxygen

distortion of the normal angle of nail bed


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Nursing Management

Rest - O2

Increase fluid intake – Liquefy mucus secretions

Good oral care – remove sputum and prevent infection

DIET:

High in calorie, High CHON and Decrease CHO

Calorie

energy source

CHON

maintain the integrity of the alveolar walls

Low CHO

Limits CO2 production (End product)


Nursing Management

O2 therapy 1-3 lpm (2 lpm is safest)

Why do you have not to give high concentration of O2?

Drive for breathing is low level of CO2

Avoid smoking, alcohol, environmental pollutants

CPT

Bronchial hygiene measures

steam and aerosol inhalation


PHARMACOLOGY:

expectorants

antitussives

CODIENE

Observe for drowsiness

avoid activities that involve mental alertness

causes dec peristalsis thereby constipation

Bronchodilators (Aminophylline, ventolin, Bricanyl)

Antihistamine

Steriods

Antimicrobials


Pleural effusion

accumulation of fluids in the pleural space

pneumothorax - air

Types of Plerual Effusion

Hemothorax – blood

Pyothorax – pus

Hydrothorax - water

Pleural Effusion and Pneumothorax

CAUSES:

trauma

thoracic surgery

thoracentesis

Emphysema

Assessment:

Sudden sharp chest pain

SOB

Anxiety, restlessness

Inc. PR and RR

Chest tightness

cyanosis


Nursing Interventions:

remain with patient

High-Fowler’s position

pain management

O2

chest tube drainage or thoracentesis

chest x-ray

ABG monitoring

monitor for S/Sx of Shock


Most common cause of death among men and womenCan be:

Primary Lung Cancer - originated in the lung cells

Secondary Lung Cancer – metastasis

Causes:Cigarette smoking – 90% of casesExposure to carcinogens like asbestos, radiation, arsenic,

nickel.Air pollutionTB and other pervious lung disease

Lung Cancer

Signs and Symptoms:Persistent cough – first and most common signHymoptysis Wheezing due to narrowed airwaysSOBFeverChest painLoss of appetiteWeight lossFatigue and weaknessPleural effusions

Lung Cancer

Diagnosis:Chest X-ray (may determine most lung tumors but may

miss small tumors)CT Scan Needle Biopsy

obtaining a specimen by inserting a needle through the skin

Lung Cancer

Medical Management:Radiation TheraphyChemotheraphy

Indicated for:

clients whom surgery poses an unacceptably high risk

clients who have technically inoperable tumors

clients who refuse surgerySurgical Resection – treatment of choice

Lung Cancer

Surgical Management:Laser Surgery

Palliative measure to relief the endobronchial obstruction that are not resectable

PULMONARY RESECTION

Wedge Resection

removal of a small, localized area near the diseased tissue

Lobectomy

removal of the entire lobe of the lung

After surgery, the remaining lung overexpands to fill the open portion of the thoracic space

Pneumonectomy

removal of the entire lung

the involved side of the thoracic cavity is an empty space

Lung Cancer

Nursing Management of the Surgical Client:

Preoperative Care:Aimed at reducing the client’s anxiety levelPostoperative self-care activities

respiratory exercises (use of incentive spirometry)

splinting technique to promote effective coughing and deep breathing

leg exercises to prevent thrombophlebitis

Lung Cancer


Splinting Technique:Place one hand around the client’s back and the other

around the incision areaSupport the area below the incision with one hand while

exerting downward pressure on the shoulder on the affected side with the other

Have the client hug a pillow during forced expiratory cough

Lung Cancer


Postoperative Care:Monitor for manifestations of respiratory failure

(increased RR, use of accessory muscles, cyanosis, decreased PaO2 and increased PaCO2, restlessness)

Monitor IV flow rates (IVF should not exceed 125ml/hr)Monitor cardiac functionsAssess dressing and incision area every 4 hours for bleeding;

assess closed chest drainage system for bleedingPlace client in semi fowler once VS are stableAssist the client in coughing and deep breathing exercises administer pain medication as ordered

Lung Cancer


Postoperative Care:Position the client as indicated by phase of recovery and

surgical procedure:

Nonoperative Side – Lying position may be used until consciousness is regained

Semi-Fowler Position – recommended once VS is stableMaintain supplemental oxygenProvide opportunity to express feelings

Lung Cancer

TuberculosisPulmonary EmbolismPneumoniaIntubation

Study the Following Cases

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The Respiratory System and Its Disorders