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					Respiratory System

    NUR 105 ADULT HEALTH
Shelton State Community College
            Clem Hill
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.
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.
Respiratory System Objectives cont...
Describe nutritional considerations for
treating respiratory system alterations.
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
   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
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.
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.
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
 Normal Breath Sounds include bronchial,
  bronchialvescicular, and vescicular.
 Adventitious breath sounds include,
  crackle, wheeze, rhonchus, and pleural
  friction rub.
   Other assessment include, voice sound,
    bronchophony, whispered pectoriloguy,
    egophony, skin and mucous membranes,
    general appearance, and endurance.
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
   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.
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.
   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.
   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.
   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.
   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.
   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.
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
   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
   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 @
   High-flow o2 Delivery System
    Venturi Mask (Venti Mask)
     Aerosol Mask
     Face Mask
     Tracheostomy Collar
     T-piece
   High-flow 02 Delivery System
    Venturi Mask (Venti Mask)
    Aerosol Mask
    Face Mask
    Tracheostomy
     Collar
    T-piece
   Drug Therapy
    Antihistamines
    Expectorants
    Antitussives
    Bronchodilators
    Corticosteroids
    Mast Cell Stabilizers
   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
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).
   Epistaxis – bleeding from nose.
     First aid – Pt sit down and lean
     forward. Direct pressure applied for
     3 to 5 minutes
   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.
   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.
   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
   Facial Trauma Interventions
    _ Anticipate the need for emergency
      intubation, tracheotomy, and
      cricothyroidotomy.
    _ Control hemorrhage.
    _ Assess for extent of injury.
    _ Treat shock.
    _ Stabilize the fracture.
   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.
   Disorders of the Larynx
    _ Vocal cord paralysis
    _ Vocal cord nodules and polyps
    _ Laryngeal trauma
   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.
   Upper Airway Obstruction Interventions
    _ Interventions include:
      - Assessment for cause of the
        obstruction.
    _ Maintenance of patent airway and
      ventilation.
       - Cricothyroidotomy
       - Endotracheal intubation
       - Tracheostomy
   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.
   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.
   Ineffective Breathing Pattern
    _ Interventions include:
      - Treatment goal: to remove or
        eradicate the cancer while preserving
        as much normal function as possible.
      - Nonsurgical management
      - Chemotherapy
   Surgical Management
    _ Laryngectomy (total and partial)
    _ Tracheostomy
    _ Oropharyngeal cancer resection
    _ Cordal stripping
    _ Cordectomy
   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
   Postoperative Care
    _ Monitor airway patency, vital signs,
      hemodynamic status, comfort level.
    _ Monitor for hemorrhage.
    _ Assess for complications.
      - Airway obstruction
      - Hemorrhage
      - Wound breakdown
      - Tumor recurrence
   Pain Management
    _ Morphine
    _ Acetaminophen with codeine
    _ Acetaminophen alone
    _ Nonsteroidal anti-inflammatory drugs
   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.
   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
   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
    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.
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
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.
   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.
   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
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
Management cont…
Assess cause of obstruction
May require emergency procedure
  Cricothyroidotomy – a stab wound at
   the cricothyroid membrane between
   the thyroid
Interventions for Clients
   with Noninfectious
 Problems of the Lower
   Respiratory Tract
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.
Asthma
   Intermittent and reversible airflow obstruction affects only
    the airways, not the alveoli.
   Airway obstruction occurs due to inflammation and airway
    hyperresponsiveness.
Aspirin and Other Nonsteroidal
Anti-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
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
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)
Laboratory Assessment (Continued)
 Atopic asthma with elevated serum
  eosinophil count and immunoglobulin
  E levels
 Sputum with eosinophils and mucous
  plugs with shed epithelial cells
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
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.
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)
Drug Therapy (Continued)
 Methylxanthines
 Anti-inflammatory agents
 Corticosteroids
 Inhaled anti-inflammatory agents
 Mast cell stabilizers
 Monoclonal antibodies
 Leukotriene agonists
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.
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.
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)
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
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
Complications
 Chronic bronchitis
 Hypoxemia and acidosis
 Respiratory infections
 Cardiac failure, especially cor
  pulmonale
 Cardiac dysrhythmias
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
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
Impaired Gas Exchange
   Interventions for chronic obstructive
    pulmonary disease:
       Airway management
       Monitoring client at least every 2 hours
       Oxygen therapy
       Energy management
Drug Therapy
 Beta-adrenergic agents
 Cholinergic antagonists
 Methylxanthines
 Corticosteroids
 Cromolyn sodium/nedocromil
 Leukotriene modifiers
 Mucolytics
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
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
Ineffective Airway Clearance
(Continued)
     Postural drainage in sitting position when
      possible
     Tracheostomy
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
Anxiety
   Interventions for increased anxiety:
       Important to have client understand that
        anxiety will worsen symptoms
       Plan ways to deal with anxiety
Health Teaching
   Instruct the client:
       Pursed-lip and diaphragmatic breathing
       Support of family and friends
       Relaxation therapy
       Professional counseling access
       Complementary and alternative therapy
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.
Health Teaching
   Instruct the client:
       Pursed-lip and diaphragmatic breathing
       Support of family and friends
       Relaxation therapy
       Professional counseling access
       Complementary and alternative therapy
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.
Potential for Pneumonia or Other
Respiratory Infections
Risk is greater for older clients
 Interventions include:
       Avoidance of large crowds
       Pneumonia vaccination
       Yearly influenza vaccine
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
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
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
Exacerbation Therapy
 Avoid mechanical ventilation
 Airway clearance
 Increased oxygenation
 Antibiotic therapy
 Heliox (50% oxygen, 50% helium)
  therapy
 Bronchodilator and mucolytic
  therapies
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.
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.
Interventions
 Warfarin therapy
 Calcium channel blockers
 Prostacyclin agents
 Digoxin and diuretics
 Oxygen therapy
 Surgical management
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
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
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
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
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)
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.
Manifestations of Lung Cancer
 Often nonspecific, appearing late in
  the disease process
 Chills, fever, and cough
 Assess sputum
 Breathing pattern
 Palpation
 Percussion
 Auscultation
Surgical Management
 Lobectomy
 Pneumonectomy
 Segmentectomy (wedge resection)
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.
Interventions for Palliation
 Oxygen therapy
 Drug therapy
 Radiation therapy
 Laser therapy
 Thoracentesis and pleurodesis
 Dyspnea management
 Pain management
 Interventions for
    Clients with
Infectious Problems
    of the Lower
 Respiratory Tract
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
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)
Sinusitis (Continued)
   Nonsurgical management
       Broad-spectrum antibiotics
       Analgesics
       Decongestants
       Steam humidification
       Hot and wet packs over the sinus area
       Nasal saline irrigations
Surgical Management
 Antral irrigation
 Caldwell-Luc procedure
 Nasal antral window procedure
 Endoscopic sinus surgery
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.
   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.
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
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
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
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.
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
Laboratory Assessment
 Gram stain, culture, and sensitivity
  testing of sputum
 Complete blood count
 Arterial blood gas level
 Serum blood, urea nitrogen level
 Electrolytes
 Creatinine
Impaired Gas Exchange
   Interventions include:
       Cough enhancement
       Oxygen therapy
       Respiratory monitoring
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)
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.
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
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
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.
Clinical Manifestations of TB
  Progressive fatigue
  Lethargy
  Nausea
  Anorexia
  Weight loss
  Irregular menses
  Low-grade fever, night sweats
  Cough, mucopurulent sputum, blood
   streaks
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)
Diagnostic Assessment (Continued)
   Positive reaction does not mean that
    active disease is present, but does
    indicate exposure to TB or dormant
    disease.
Interventions
 Combination drug therapy strict
  adherence
 Isoniazid
 Rifampin
 Pyrazinamide
 Ethambutol or streptomycin
 Negative sputum culture indicative of
  client no longer being infectious
Health Teaching
 Follow exact drug regimen.
 Proper nutrition must be maintained.
 Reverse weight loss and severe
  lethargy.
 Educate client about the disease.
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
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.
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.
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
 Interventions for
Critically Ill Clients
 with Respiratory
      Problems
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.
Etiology
 Prolonged immobilization
 Central venous catheters
 Surgery
 Obesity
 Advancing age
 Hypercoagulability
 History of thromboembolism
 Cancer diagnosis
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
Interventions
•   Evaluate chest pain
•   Auscultate breath sounds
•   Encourage good ventilation and relaxation

                                    (Continued)
Interventions (Continued)
 •   Monitor the following:
     –   respiratory pattern
     –   tissue oxygenation
     –   symptoms of respiratory failure
     –   laboratory values
     –   effects of anticoagulant medications
 •   Surgery
Decreased Cardiac Output
   Interventions include:
       Intravenous fluid therapy
       Drug therapy
           Positive inotropic agents
           Vasodilators
Anxiety
   Interventions include:
       Oxygen therapy
       Communication
       Drug therapy: antianxiety agents
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.
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
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
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.
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.
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
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
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.
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
Interventions
 Endotracheal intubation and
  mechanical ventilation with positive
  end-expiratory pressure or
  continuous positive airway pressure
 Drug therapy
 Nutrition therapy; fluid therapy
 Case management
Endotracheal Intubation
 Components of the endotracheal tube
 Preparation for intubation
 Verifying tube placement
 Stabilizing the tube
 Nursing care
Mechanical Ventilation
   Types of ventilators:
       Negative-pressure ventilators
       Positive-pressure ventilators
           Pressure-cycled ventilators
           Time-cycled ventilators
           Microprocessor ventilators
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
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
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.
Complications
   Complications can include:
       Lung
       Cardiac
       Gastrointestinal and nutritional
 Infection
 Muscular complications
 Ventilator dependence
Chest Trauma
   About 25% of traumatic deaths result
    from chest injuries:
       Pulmonary contusion
       Rib fracture
       Flail chest
       Pneumothorax
       Tension pneumothorax
       Hemothorax
       Tracheobronchial trauma

				
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