RESPIRATION

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					1
   Commonly understood to mean movement of air
   Accomplished by the pulmonary system,
    consisting of the airways and lungs, the blood
    vessels perfusing them, the muscles of the thorax
    and abdomen, and the innervation of these
    structures




                                                        2
   the movement of atmospheric air into and out of
    the lungs
   depends on open airways and contractions of
    muscles to create pressure gradients for air flow
   ventilation is the critical first step in the complex
    process of respiration




                                                            3
   provides oxygen for metabolism in the tissues
   removes carbon dioxide, the waste product of
    metabolism




                                                    4
◦   facilitates sense of smell
◦   produces speech
◦   maintains acid-base balance
◦   maintains body water levels
◦   maintains heat balance




                                  5
   THE PROCESS OF AIR ENTERING THE LUNGS
   ALSO CALLED INSPIRATION
   INVOLVES ACTIVE CONTRACTION OF THE MUSCLES AND
    DIAPHRAGM
   NOTED BY ENLARGEMENT OF THE CHEST CAVITY




                                                     6
   THE PROCESS OF AIR LEAVING THE LUNGS
   ALSO CALLED EXPIRATION
   A PASSIVE PROCESS
   MUSCLES RELAX AND CHEST RETURNS TO NORMAL
    SIZE




                                                7
   normally approx 500 ml of air is inhaled and
    exhaled
    ◦ APNEA-temp interruption in normal breathing, no air
      movement occurs
    ◦ dyspnea-difficulty breathing
    ◦ orthopnea-difficulty breathing while in a lying position
    ◦ See Table 30-1 for types of breathing patterns




                                                                 8
◦ respiratory center of the brain located just above the spinal cord in the
  brain stem
◦ stimulated by changing levels of CO2 & Oxygen
◦ Chemoreceptors in the aorta and carotid artery monitor the PH and
  the amount of carbon dioxide and oxygen in the blood stream.




                                                                              9
   NOSE
   SINUSES
   PHARYNX
   LARYNX
   EPIGLOTTIS




                 10
◦ Humidifies, warms, and filters inspired air




                                                11
◦ air-filled cavities within the hollow bones that surround
  the nasal passages
◦ provide resonance during speech




                                                              12
◦ located behind the oral and nasal cavities
◦ divided into the nasopharynx, oropharynx,
  laryngopharynx
◦ passageway for both the respiratory and digestive tracts




                                                             13
   located above the trachea and just below the
    pharynx at the root of the tongue
   contains two pairs of vocal cords, the false and
    true cords
   opening between true vocal cords is the glottis
   the glottis plays an important role in coughing
   coughing is the most fundamental defense
    mechanism of the lungs



                                                       14
   leaf-shaped elastic structure that is attached alone
    one end to the top of the larynx
   it prevents food from entering the tracheobronchial
    tree by closing over the glottis during swallowing




                                                           15
   TRACHEA
   MAINSTEM BRONCHI
   BRONCHIOLES
   ALVEOLAR DUCTS AND ALVEOLI




                                 16
   located in front of
    the esophagus
   branches into the
    right and left
    mainstem bronchi at
    the carina
   passageway for air
    to reach the lungs


                          17
   begins at the carina
    ◦ a ridgelike structure between the openings of the right
      and left bronchus
   the right bronchus is slightly wider, shorter, and more
    vertical than the left bronchus
    ◦ most foreign bodies from the trachea usually enter the
      right bronchus
   the mainstem bronchi divides into five secondary or
    lobar bronchi that enter each of the five lobes of the lung




                                                                  18
   the bronchi are lined with cilia, which propel
    mucus up and away from the lower airway to the
    trachea where it can be expectorated or
    swallowed




                                                     19
   branch from the secondary bronchi and
    subdivide into the small terminal and respiratory
    bronchioles
   they contain no cartilage and depend on the
    elastic recoil of the lung for patency
   the terminal bronchioles contain no cilia and do
    not participate in gas exchange




                                                        20
   alveolar ducts branch from the respiratory
    bronchioles
   alveolar sacs, which arise from the ducts,
    contain clusters of alveoli, which are the
    basic units of gas exchange
   cells in the walls of the alveoli secrete
    surfactant, a phospholipid protein that
    reduces the surface tension in the alveoli,
    without this alveoli collapse


                                                  21
   innervation of the respiratory structures is
    accomplished by the phrenic nerve, vagus nerve,
    and thoracic nerves
   the parietal pleural lines the inside of the thoracic
    cavity including the upper surface of the
    diaphragm
   the visceral pleura covers the pulmonary surfaces




                                                            22
   a thin fluid layer, which is produced by the cells
    lining the pleura, lubricates the visceral and
    parietal pleura, allowing them to glide smoothly
    and painlessly during respiration
   blood flows through the lungs occurs via the
    pulmonary system and the bronchial system




                                                         23
   scalene muscles
    ◦ elevate the first two ribs
   sternocleidomastoid muscles
    ◦ raise the sternum
   trapezius and pectoralis muscles
    ◦ fix the shoulders




                                       24
   the diaphragm descends into the abdominal
    cavity during inspiration causing negative
    pressure in the lungs
   the negative pressure draws air from the area
    of greater pressure, the atmosphere, into the
    area of lesser pressure, the lungs
   in the lungs, air passes through the terminal
    bronchioles into the alveoli to oxygenate the
    body tissues


                                                    25
   at the end of inspiration, the diaphragm and
    intercostal muscles relax and the lungs recoil
   as the lungs recoil, pressure within the lungs
    becomes greater than atmospheric pressure
    causing the air that now contains the cellular
    waste products of carbon dioxide and water to
    move from the alveoli in the lungs to the
    atmosphere



                                                 26
   ATROPHY (pharynx and
    larynx)
   SLACKENING OF VOCAL
    CORDS
   LOSS OF ELASTICITY
   RIGID RIB CAGE
   DIAPHRAGM FLATTENS
   DECREASED NUMBER
    OF ALVEOLI

                           27
   reduced chest movement
   decreased ability to inhale and exhale
   less effective cough
   increased work of breathing
   less tolerance for exercise and stress




                                             28
   smoking
   allergies
   frequent respiratory illnesses
   chest injury
   surgery
   exposure to chemicals and environmental pollutants
   crowded living conditions
   family history of infectious disease
   geographic residence and travel to foreign countries




                                                       29
   WHAT DO YOU NEED TO KNOW?
   Chief complaint and hx of present illness
   past medical hx
   review of systems
   functional assessment




                                                30
   cough
   pain
   dyspnea
   fever
   sweating
   nausea/vomiting
   effort to treat
   response to treatment



                            31
   onset-one week ,activity, lying down?
   duration-each episode, how long
    frequency-frequent, occasionally, constantly
    type-dry hacking, wet productive, irritating and
    scratchy
    severity-hard enough to throw up?




                                                        32
   sputum production & characteristics
    ◦   COLOR-green, yellow, clear, rusty, blood tinged
    ◦   CONSISTENCY-thick, thin,
    ◦   ODOR-there either is or there isn’t
    ◦   AMOUNT-scant, copious, large, small
   pain-does it hurt when you cough?
   have they tried anything to treat it and has it
    helped




                                                          33
   onset
   duration
   severity
   precipitating events
   associated symptoms




                           34
   location
   onset
   duration
   precipitating events
   effects on breathing
   relief measures
   associated symptoms




                           35
   Colds                          Sinus infections
   pneumonia                      ear infections
   tuberculosis/last TB test      diabetes mellitus
   chronic bronchitis             heart disease
   emphysema                      allergies / current meds
   asthma                         trauma
   cancer of resp. tract          surgeries
   cystic fibrosis                hospitalizations/ last CXR
   immunizations                  conditions that suppress
                                    the immune system



                                                                 36
 Major respiratory
  conditions
 smoking history




                      37
   fatigue                sinus pain
   weakness               sore throat
   fever                  hoarseness
   chills                 edema
   night sweats           dyspnea
   earaches               orthopnea
   nasal obstruction



                                          38
   occupation                 smoking history
   exposure to                 ◦ # yrs smokedX pkg/d
    pathogens                   ◦ this equals pack
                                  years
   exposure to
    respiratory irritants      role in family
   typical day                stressors
   usual diet                 coping strategies
   fluid intake

                                                        39
   be alert to any unusually rapid or slow
    breathing and to tachycardia, which may be a
    sign of hypoxia
   remember normal respiratory rate is 16 - 20
    breaths per minute




                                                   40
   Appearance
   facial expression
   posture
   alertness
   speech pattern
   obvious distress
   VS Ht. & Wt.




                        41
   NOSE
    ◦   patency of nares
    ◦   nasal flaring(sign of air hunger)
    ◦   swelling
    ◦   discharge
    ◦   bleeding
    ◦   foreign bodies
    ◦   mucosa should be bright red in color
    ◦   deviation of nasal septum




                                               42
   SINUSES
    ◦ palpate sinuses for tenderness
   LIPS
    ◦ pursed-lip breathing, common technique for
      decreasing dyspnea for pts with chronic resp dz
    ◦ inspect lips, tip of nose, top of auricles, gums and
      under tongue for cyanosis, a bluish color R/t
      inadequate O2
   PHARYNX
    ◦ Redness, tonsil exudate or enlargement




                                                             43
◦ inspect for deviation, can be indicative for a large
  atelectasis, pleural effusion, aortic aneurysm,
  enlargement of part of the thyroid gland, and tension
  pneumothorax




                                                          44
   look for deformities and lesions
   observe breathing pattern and effort, should be
    regular and symmetric
   palpate for lumps and symmetry
   palpate for tactile fremitus (What is this?)
    ◦ A tremulous vibration of the chest wall during breathing that is
      palpable on physical examination. It may indicate
      inflammation, infection, or congestion.
   auscultate lungs in systematic manner, usually
    posterior, sides, anterior




                                                                    45
   listen for normal movement of air and abnormal
    sounds
   WHEEZE-high-pitched sound caused by air
    passing through narrowed passageways, as
    with asthma or COPD




                                                46
   RHONCHUS-dry rattling sound caused by
    partial bronchial obstruction
   CRACKLES(RALES)-associated with many
    cardiac and pulmonary disorders, sounds like
    rubbing strands of hair between the thumb and
    forefinger next to the ear




                                                47
48
   inspect the abdomen for distention that might
    interfere with full expansion of the lungs




                                                    49
   check color of extremities and edema
   finger clubbing/chronic resp problems




                                            50
   dorsiflex pts foot
   suspect thromboplhlebitis if this elicits pain
    behind the knee or in the calf
   important to know, the legs and the pelvis are
    the source of most pulmonary emboli




                                                     51
   should have regular pattern
   even depth
   rate 12-20 breaths/min
   this is the normal respiratory drive




                                           52
   should have regular pattern
   even depth
   rate is faster than 20 breaths/min
   may be caused by fever, pain, anxiety,
    respiratory disorders, shock




                                             53
   should have regular pattern
   even depth
   rate is slower than 12 breaths/min
   may be caused by sedatives, narcotics,
    alcohol; brain, metabolic, and respiratory
    disorders




                                                 54
   should have regular pattern
   uneven depth; periodic deep breaths (more
    than 3 sighs/min)
   rate is 12 to 20 breaths/min
   may be caused by severe anxiety




                                                55
   breaths are progressively deeper, then
    becoming more shallow, followed by period of
    apnea
   may be caused by severe brain pathology




                                                   56
   should have a regular pattern
   deep respirations
   rate is faster than 20 breaths/min
   may be caused by metabolic acidosis, diabetic
    ketoacidosis, renal failure




                                                57
   should have an irregular pattern
   depth varies, sudden periods of apnea
   may be caused by neurologic disorders




                                            58
   gradual rise in end-expiratory level during
    forced rapid breathing
   may be caused by emphysema




                                                  59
   ABG                 MRI
   SPUTUM C&S          PULMONARY
   BRONCHOGRAM          FUNCITON TEST
   CXR                 BRONCOSCOPY
   VENTILATION -       THORACENTESIS
    PERFUSION SCAN      SPIROMETRY: lung
   CT                   volumes and
                         capacity


                                        60
   used to provide information regarding the
    anatomical location and appearance of the lungs
   Pre-procedure: remove all jewelry and other
    metal objects from the chest area, assess ability
    to inhale and hold breath, question females
    regarding pregnancy or the possibility of
    pregnancy
   Post procedure: assist the client to dress



                                                        61
   a specimen obtained by expectoration or tracheal
    suctioning to assist in the identification of
    organisms or abnormal cells




                                                       62
   determine specific purpose of collection and check
    with institutional policy for appropriate collection of
    specimen
   obtain an early morning sterile specimen from
    suctioning or expectoration after a respiratory
    treatment, if prescribed
   obtain 15 mL of sputum




                                                              63
   instruct client to rinse mouth with water before
    collection; instruct client to take several deep
    breaths and then cough deeply to obtain sputum
   ALWAYS collect specimen before starting
    antibiotics




                                                       64
   if culture of sputum is prescribed, transport to
    laboratory immediately
   assist the client with mouth care




                                                       65
   direct visual examination of the larynx, trachea,
    and bronchi with a fiberoptic bronchoscope
   Used to visualize abnormalities, take biopsy
    samples or lesions, or remove foreign bodies.




                                                        66
   obtain informed consent
   NPO from midnight before the procedure ( or 6-
    8 hours)
   obtain vital signs
   monitor coagulation studies
   remove dentures or eyeglasses
   prepare suction equipment
   administer medication for sedation as
    prescribed


                                                67
   have emergency resuscitation equipment readily
    available




                                                     68
   monitor vital signs
   maintain semi-Fowler’s position
   assess gag reflex
   maintain NPO status until gag reflex returns
   monitor for bloody sputum
   monitor respiratory status
   monitor for asymmetric chest movement
   monitor for swelling of face and neck
   monitor for dyspnea, diminished lung sounds


                                                   69
   monitor for complications such as
    brohnchospasm, bacteremia, bronchial perforation
    indicated by facial or neck crepitus, dysrhythmias,
    fever, hemorrhage, hypoxemia, and pneumothorax
   notify physician if fever or difficulty in breathing
    occurs after the procedure




                                                           70
   an invasive fluoroscopic procedure after injection
    of iodine, radiopaque, or contrast material through
    a catheter inserted through the antecubital or
    femoral vein into the pulmonary artery or one of its
    branches




                                                           71
   obtain informed consent
   assess for allergies to iodine, seafood, and other
    radiopaque dyes
   maintain NPO status for 8 hours before the
    procedure
   monitor vital signs
   monitor coagulation studies
   establish an IV access



                                                         72
   administer sedation as prescribed
   instruct client to lie still during the procedure
   instruct client that he or she may feel an urge to
    cough, or flushing, nausea, or salty taste after
    injection of the dye
   have emergency resuscitaiton equipment
    available




                                                         73
   monitor VS
   avoid taking blood pressures in the extremity used
    for injection for 24 hours
   monitor peripheral neurovascular status
   assess insertion site for bleeding
   monitor for delayed reaction to the dye




                                                         74
   Removal of fluid or air from the pleural space via a
    transthoracic aspiration
   Pleural fluid is aspirated and examined for
    pathogens, other abnormal components. Cells
    studied for malignance
   See figure 30-8 page 522




                                                           75
   obtain informed consent
   obtain baseline vital signs
   prepare client for ultrasound or chest x-ray study if
    prescribed before procedure
   assess coagulation studies
   note that client is positioned sitting upright with
    arms and head supported by a table at the
    bedside during the procedure




                                                            76
   if the client cannot sit up, the client is placed lying
    in bed on the unaffected side with the head of the
    bed elevated 45 degrees
   inform client not to cough, breathe deeply, or
    move during the procedure




                                                              77
   monitor VS
   monitor respiratory status
   patient is positioned on the unaffected side after
    the procedure
   apply a sterile, pressure dressing and assess
    puncture site
   monitor for signs of pneumothorax, air embolism,
    and pulmonary edema
   observe for uneven chest movements,
    respiratory distress and hemorrhage
   Document amount and color of fluid removed




                                                         78
   included a number of different tests used to
    evaluate lung mechanics, gas exchange and
    acid-base disturbance through spirometric
    measurements, lung volumes, and arterial
    blood gases
   examples: measures of: total lung capacity,
    forced respiratory volume, functional residual
    capacity, inspiratory capacity, vital capacity,
    forced vital capacity (see table 29-4 for
    definitions)


                                                      79
   used to diagnose pulmonary disease
   monitor disease progression
   evaluate the extent of disability
   assess the effects of medication




                                         80
   determine if an analgesic that may depress the
    respiratory function is being administered
   consult with physician regarding holding
    bronchodilators before testing
   instruct client to void before procedure and to
    wear loose clothing




                                                      81
   remove dentures
   instruct client to refrain from smoking or eating a
    heavy meal for 4 to 6 hours before the test




                                                          82
   resume normal diet and any broncholilators and
    respiratory treatments that were held before the
    procedure




                                                       83
   an instrument that measures the ventilatory
    function of the lungs
   measures volume of air that the lungs can hold
   the rate of flow of air in and out of the lungs
   the compliance (elasticity) of lung tissue
   involves inserting mouthpiece, taking as deep a
    breath as possible and blowing as hard, as fast,
    and as long as possible
   See Table 30-2 for Lung Volumes and Capacities




                                                       84
   noninvasive measurement of arterial oxygen
    saturation
   A beam of light passes through the tissue , and
    the amount of light absorbed by oxygen
    saturated hemoglobin is measured.
   sensor clipped to earlobe or fingertip
   factors that interfere with an accurate reading
    include: hypotension, hypothermia,
    vasoconstriction, and finger movement, also dark
    fingernail polish if it is placed on the nail


                                                       85
   visualizes the bronchial tree
   radiographic procedure
   pts throat and bronchi are anesthetized




                                              86
   dye is instilled into the bronchial tree through a
    catheter or a fiberoptic bronchoscope
   pt is tilted in different positions for dye to spread in
    specific directions
   complications include: pneumonia, delayed
    hypersensitivity reaction and laryngospasm




                                                               87
   a percutaneous lung biopsy is performed to obtain
    tissue for analysis by culture or cytological
    examination
   a needle biopsy is done to identify pulmonary
    lesions, changes in lung tissue, and the cause of
    pleural effusion




                                                        88
   obtain informed consent
   maintain NPO status before the procedure
   inform the client that a local anesthetic will be
    used by that a sensation of pressure during
    needle insertion and aspiration may be felt
   administer analgesics and sedatives as prescribed




                                                        89
   monitor vital signs
   apply a dressing to the biopsy site and monitor
    for drainage or bleeding
   monitor for signs of respiratory distress and
    notify the physician if they occur
   monitor for signs of pneumothorax and air
    emboli and notify physician if they occur
   prepare client for chest x-ray study if prescribed



                                                         90
   Demonstrated lung ventilation and perfusion.
   the ventilation scan determines the patency of
    the pulmonary airways and detects
    abnormalities in ventilation
   Detects pulmonary embolism and other
    obstructive conditions
   a radioactive substance may be inhaled or
    injected for the procedure



                                                     91
92
   obtain informed consent
   assess for allergies to dye, iodine, or seafood
   remove jewelry around the chest area
   review breathing methods that may be required
    during testing
   establish an IV access




                                                      93
   Administer sedation if prescribed
   Usually NPO for 4 hours
   May take 2 hours
   Have emergency resuscitation equipment
    available




                                             94
   monitor client for reaction to the radionuclide for
    1 hour for anaphylaxis
   for 24 hours after the procedure, rubber gloves
    are worn when urine is being discarded; they
    should be washed with soap and water before
    removing, and then the hands should be
    washed after the gloves are removed(
    radioactive material is excreted in the urine)




                                                          95
   Instruct the client to wash hands carefully with
    soap and water for 24 hours after the procedure
    when voiding (lets hope they already do this)




                                                       96
   allows visualization of slices or layers of the chest
   a camera rotates in a circular pattern around the
    body for a three dimensional assessment of the
    thorax
   usually used to look for the presence of lesions or
    tumors
   radioactive dye containing iodine may be injected
    IV




                                                            97
   explain the test to the patient
   they lie on a platform while a special doughnut-
    shaped radiographic scanner rotates around them
   stress the importance of remaining still during the
    scanning
   assess iodine allergy, if contrast is used, if there
    is, report it to the radiologist
   NPO may be required




                                                           98
   note side effects of contrast: nausea, vomiting,
    headache




                                                       99
   similar to CT but without harmful radiation
   doughnut-shaped magnet used
   pt lies on a stretcher that slides into a tubelike
    device
   mechanical clanging noises are heard as machine
    operates




                                                         10
                                                          0
   metal implants such as cardiac pacemakers and
    orthopedic implants may be affected by MRI, but
    are not absolute contraindications
   aneurysm clips, intraocular metal, heart valves
    made before 1964, and middle ear prostheses
    generally contraindicate MRI




                                                      10
                                                       1
   explain test to patient
   get consent form signed
   assess for claustrophobia
   anxious pt may require sedation
   have pt remove metal watch and jewelry




                                             10
                                              2
   safety precautions if sedated; otherwise, no
    special after care is needed




                                                   10
                                                    3
   Determine past or present exposure to
    tuberculosis
   A patient who has ever been vaccinated with
    BCG will test positive regardless of actual
    exposure
    ◦ Bacille Calmette-Guérin (BCG) is a vaccine against
      tuberculosis that is prepared from a strain of the
      attenuated (weakened) live bovine tuberculosis
      bacillus, Mycobacterium bovis, that has lost its
      virulence in humans by being specially cultured in an
      artificial medium for years.




                                                              10
                                                               4
   purified protein derivative or old tuberculin is
    introduced into the skin using a device with four
    tines
   the device is firmly pressed on the anterior
    forearm for 1 sec.
   This site is marked, recorded, and inspected in
    48 to 72 hours for redness and swelling
   a reaction equal to or greater than 2 mm at one
    or more puncture sites is positive


                                                        10
                                                         5
   cleanse puncture site
   tell pt. The procedure causes pain briefly
   stress need to return in 48-72 hr to evaluate
    response
   pt should not scratch site
   tell pt skin reaction may persist for a week




                                                    10
                                                     6
   if PPD is positive this test is done
   old tuberculin is injected intradermally in the lower
    anterior forearm
   this site is marked, recorded and inspected after
    48-72 hr for swelling and redness
   a reaction of 5 mm or more is positive for
    tuberculosis exposure




                                                            10
                                                             7
   tell pt to expect some pain with injection
   return in 48-72 hours for evaluation of response
   swelling may persist up to a week




                                                       10
                                                        8
   May be performed when respiratory disease is
    suspected
   May contain bacterial or malignant cells
   Also examined for volume, consistency, color, and
    odor
   Thick foul smelling, and yellow, green, or rust
    colored sputum usually indicates a bacterial
    infection




                                                        10
                                                         9
   Ordered to determine the presence of bacteria,
    identify the specific organisms and identify
    appropriate antimicrobials
   Collect specimen before antimicrobial therapy is
    begun




                                                       11
                                                        0
   Performed to determine the presence of acid-fast
    bacilli
   Including the bacteria that causes tuberculosis
   Usually collected on 3 consecutive days
   Cover and refrigerate or deliver to lab within 1
    hour
   Use sterile container




                                                       11
                                                        1
   measures pH, PaCO2, PaO2, HCO3 and O2
    saturation
   detects alkalosis or acidosis, and alterations in
    oxygenation status that may occur with many
    respiratory, cardiac, and metabolic disorders




                                                   112
   PH: 7.35 - 7.45
   PaCO2: 35 - 45 mm Hg
   PaO2: 75 - 100 mm Hg
   HCO3: 22 - 26 mEq/L
   O2 saturation: 96 - 100%




                               113
   tell the patient a blood sample will be drawn
    from an artery (usually radial)
   an Allen’s test should be done before an
    arterial puncture to ensure that the arteries to
    the hand are patent (page 465)
    ◦ The patients hand is formed into a fist while the
      technician compresses the ulnar artery.
      Compression of the ulnar artery is continued while
      the fist is opened. If blood perfusion through the
      radial artery is adequate, the hand should flush and
      resume a normal pinkish coloration.
                                                             114
115
   apply pressure to the puncture site for 5-10
    minutes
   note the concentration of any oxygen therapy
    on lab slip
   transport the blood gas syringe to the lab in an
    ice bath within 15 minutes
   respiratory therapist will usually take sample
    and analyze it
   Go to slide 140- (just had ABG’s)
                                                       116
   are vital to life
   expressed as pH
   body’s pH is normally alkaline between 7.35
    and 7.45)




                                                  117
   Produced as end products of metabolism
   contain hydrogen ions
   the number of hydrogen ions in body fluid determines
    its acidity, alkalinity, or if it is neutral




                                                           118
   contain no H+
   hydrogen ion acceptors
   accept H+ from acids to neutralize or decrease
    the strength of a base or to form a weaker acid




                                                      119
   BUFFERS: hemoglobin, plasma proteins,
    carbonic acid/bicarbonate system, phosphate
    buffer system
   LUNGS
   KIDNEYS
   POTASSIUM



                                                  120
   interacts with the buffer system to maintain
    acid base balance
   in acidosis: pH goes down and the respiratory
    rate and depth go up in an attempt to “blow
    off” acids
   the carbonic acid created by the neutralizing
    action of bicarbonate can be carried to the
    lungs where it is reduced to C)2 and water
    and exhaled, thus H+ are inactivated and
    excreted
                                              121
   in alkalosis, the pH goes up and the respiratory
    rate and depth go down, the CO2 is retained,
    and the carbonic acid builds to neutralize and
    decrease the strength of excess bicarbonate
   the action of the lungs is reversible in
    controlling an excess or deficit




                                                       122
   the lungs can hold H+ until the deficit is corrected or can
    inactivate H+, changing them to water molecules to be
    exhaled as CO2, thus correcting the excess
   the lungs are capable of inactivating only H+ carried by
    carbonic acid (H2CO3); excess H+ created by other
    problems must be excreted by the kidneys




                                                                  123
   the total concentration of buffer base is lower than
    normal, with a relative increasing hydrogen ion (H+)
    concentration; thus a greater number of H+ are
    circulating in the blood than can be absorbed by the
    buffer system




                                                     124
   due to primary defects in the function of the
    lungs or by changes in normal respiratory
    patterns from secondary problems
   remember that any condition that causes an
    obstruction of the airway or depresses
    respiratory status can cause respiratory
    acidosis
   hypoventilation
   COPD, CAL, COLD


                                                    12
                                                     5
   pulmonary edema
   pneumonia
   atelectasis
   asthma
   bronchitis or bronchiectasis
   infection
   medications such as sedatives, narcotics, or
    anesthetics



                                                   12
                                                    6
   brain trauma




                   12
                    7
   in an attempt to compensate, the respiratory rate
    and depth increase
   pH less than 7.35 and PCO2 greater than 45 mm
    Hg
   mental status changes such as confusion
   drowsiness
   restlessness
   weakness



                                                        12
                                                         8
   dizziness
   dyspnea
   hyperkalemia




                   12
                    9
   maintain patent airway
   monitor for signs of respiratory distress
   administer oxygen as prescribed
   place client in semi-Fowler’s position unless
    contraindicated
   encourage and assist the client to turn, cough,
    and deep breathe
   prepare to administer chest physiotherapy and
    postural drainage as prescribed

                                                      13
                                                       0
   encourage hydration to thin secretions unless
    excess fluid intake is contraindicated
   suction the client as necessary
   monitor electrolyte values
   avoid the use of tranquilizers, narcotics, and
    hypnotics because they further depress
    respirations
   administer antibiotics for infection as prescribed



                                                         13
                                                          1
   a deficit of carbonic acid (H2CO3) or a decrease
    in H+ concentration
   results from the accumulation of base or from a
    loss of acid without a comparable loss of base in
    the body fluids




                                                        13
                                                         2
   due to conditions that cause overstimulation of the
    respiratory status
   hyperventilation
   hypoxemia
   fever
   early stages of salicylate poisoning
   reactions to certain medications
   pain



                                                          13
                                                           3
   anxiety
   hysteria




               13
                4
   initially, the hyperventilation and respiratory
    stimulation will cause abnormal rapid and
    deep respirations (tachypnea)
   in an attempt to compensate, respiratory rate
    and depth then go down
   pH is greater than 7.45 and PCO2 is less
    than 35 mm Hg
   altered mental status
   pallor around the mouth

                                                      13
                                                       5
   tingling of the fingers
   dizziness
   spasms of the muscles of the hands
   hypokalemia




                                         13
                                          6
   maintain a patent airway
   provide emotional support and reassurance to the
    client
   encourage appropriate breathing patterns




                                                       13
                                                        7
   provide cautious care with ventilator clients so that
    the client is not forced to take breaths too deeply
    or rapidly
   monitor electrolyte values
   administer sedatives as prescribed




                                                            13
                                                             8
   Thoracentesis                 IPPB
   breathing exercises           artificial airways
   chest physiotherapy
                                  mechanical
   suctioning
                                   ventilation
   humidification & aerosol
   oxygen
                                  chest tubes
                                  thoracic surgery
                                  video thoracoscopy
                                  drug therapy

                                                        13
                                                         9
   performed to aid in lung expansion and
    expectoration of respiratory secretions
   indicated when pts are immobilized or after
    general anesthesia




                                                  14
                                                   0
   sit in a semi-Fowler’s position for maximal lung
    expansion
   place on hand on the abdomen to feel it rise and
    fall with breathing
   inhale deeply through the nose, pause 1 to 3
    seconds, and exhale slowly through the mouth




                                                       14
                                                        1
   after 4 to 6 deep breaths, cough deeply from the
    lungs to aid in the expectoration of sputum
   after thoracic or abdominal surgery, splint the
    incision with a pillow to minimize discomfort and
    support the incision




                                                        14
                                                         2
   used to inhibit airway collapse and to decrease
    dyspnea in pts with chronic lung disease
   instruct pt to pucker lips as if to whistle, blow out
    a candle, or blow through a straw
   then they should inhale through the nose and
    slowly exhale through pursed lips
   exhalation should last twice as long as
    inhalation



                                                            14
                                                             3
   chest percussion and vibration
   postural drainage




                                     14
                                      4
   goal is to improve oxygen and carbon dioxide
    exchange in the lungs by removing excessive
    mucous secretions with a suction catheter




                                                   14
                                                    5
   use strict aseptic technique
   administer oxygen before inserting the suction
    catheter because the procedure temporarily
    interferes with the patient’s air flow
   moisten the catheter in sterile water and insert the
    catheter through the nose or mouth before
    applying suction




                                                           14
                                                            6
   apply suction intermittently as the catheter is
    rotated and withdrawn from the airway
   maintain the pressure gauge between 80 and
    100 mm Hg
   limit each suction pass to 10 seconds (try
    holding your breath while you do this)
   allow the patient to rest briefly, encourage deep
    breathing, and rinse the catheter with sterile
    solution between suction attempts


                                                        14
                                                         7
   monitor the patients response to suctioning
   if tachycardia or increased respiratory distress
    develops, stop the procedure and give the patient
    oxygen as ordered
   document the amount, color, odor, and
    consistency of the patient’s secretions as well as
    the patient’s status before and after the procedure




                                                          14
                                                           8
   creates water vapor to raise the relative humidity
    of inspired gas to 100%
   there are room humidifiers and medical oxygen is
    humidified as it bubbles through a container of
    water
   sterile water should be used to prevent the spread
    of bacteria




                                                         14
                                                          9
   suspended liquid particles of bronchodilators or
    inactive fluids such as water or saline
   delivered by devices called nebulizers (pts call
    them puffers sometimes)
   can be hand held
   may be connected to an oxygen mask
   pt should sit upright and slowly inhale, hold the
    breath briefly and exhale slowly



                                                        15
                                                         0
   Air in the atmosphere contains approximately 21%
    oxygen, which is usually sufficient
   Individuals with pulmonary disease or injury may
    need supplemental oxygen
   Oxygen is considered a drug and should be
    treated as such, you need an order and there may
    be serious side effects as well as benefits




                                                       15
                                                        1
   If you observe a patient becoming lethargic or
    bradypneic, immediately notify a supervisor or
    physician, these are symptoms of adverse effects
    of oxygen therapy
   Oxygen is delivered from a bulk system, mounded
    on the wall of a patient’s room or it can be
    delivered from a cylinder unit on wheels




                                                       15
                                                        2
   A tube is needed to connect the flowmeter to the
    specific oxygen delivery device
   This tube is then attached to the patient via
    nasal cannula or mask
   Oxygen therapy is ordered in liters per minute or
    FIO2
   FIO2 mean fraction of inspired oxygen
   It is written as 0.30, which means 30% oxygen
    concentration



                                                        15
                                                         3
   The most common used delivery device is the
    nasal cannula
   It fits around the face and directly into the nares by
    way of two prongs
   It is designed to deliver a flow of oxygen from 1 to
    6 L/min with approximate FIO2 of 0.24 to 0.44 or
    24 to 44% oxygen concentration delivered




                                                             15
                                                              4
   24% @ 1 L/min
   28% @ 2 L/min
   32%@ 3 L/min
   36% @ 4 L/min
   40% @ 5 L/min
   44% @ 6 L/min
   Anything over 6 L/min will not increase the % of
    O2 delivered, using nasal cannulas


                                                       15
                                                        5
   If you notice, anytime you add a liter, you have a
    4% increase in the O2 delivered, you can
    remember 1L will give you 24% then add 4%
    every time you go up a liter




                                                         15
                                                          6
   Used for client with chronic airflow limitation (CAL,
    COPD) and for long-term oxygen use
   The CAL or COPD pt who retains CO2 should
    never receive O2 at a rate higher than 2 to 3
    liters/min
   The potential for apnea or respiratory distress
    occurs




                                                            15
                                                             7
   Place the nasal prongs in the nostrils with the
    openings facing the patient
   Add humidification as prescribed when a flow
    rate higher than 2 liters /min is prescribed
   Check the water level and change the humidifier
    as needed
   Monitor the client for changes in respiratory rate
    or depth



                                                         15
                                                          8
   Assess mucosa as high flow rates have a drying
    effect and increase mucosal irritation
   Monitor skin integrity as the oxygen tubing can
    irritate the skin
   Provide water-soluble jelly to the nares PRN
   Do not use any petroleum based lubricant




                                                      15
                                                       9
   There are 4 types of available
   Simple oxygen mask
   Partial rebreathing mask
   Nonrebreathing mask
   Air entrainment (Venturi) mask




                                     16
                                      0
   Designed to deliver an FIO2 ranging from 0.35 to
    0.55
   Which is 35% to 55%
   It must be 6 L/min at least
   If not 6L/min, CO2 may build up in the mask,
    which would be very dangerous for your patient
   Seen on page 525




                                                       16
                                                        1
   Flow rate must be set to at least 6 L/min
   45%-50% @ 6 L/min
   55%-60% at 8 L/min




                                                16
                                                 2
   Includes a reservoir bag to elevate the potential
    FIO2
   Pt rebreathes part of their own exhaled gas
   Design of the mask allows almost no rebreathed
    gas to contain CO2 from pts lungs, only enriched
    oxygen
   Expected FIO2 range 0.35-0.60 (35 to 60%)
   Flow setting must be at least 6




                                                        16
                                                         3
   None of the pts exhaled gas is rebreathed
   Includes a reservoir bag
   Series of valves to direct fresh supply of gas with each
    breath
   Expected FIO2 should be 1.0(100%)
   Controversy stating only 0.7 (70%)(because
    experimentally the highest F1O2 is approximately 0.7%)
   Also must be 6-10 on flow meter
   Used most often in client who may need to be placed on
    a ventilator




                                                               16
                                                                4
   Provides a specific FIO2
   Usually must place an attachment to the mask
   % of oxygen delivered is determined by the
    color of the attachment, must read the
    manufacture’s instructions
   Example: Pink=50%, Blue=60% etc.
   This mask delivers the highest concentration of
    O2 when compared with the other masks




                                                      165
   Be sure mask fits securely over nose and
    mouth, as a poorly fitting mask reduces the FIO2
    delivered
   Monitor the skin and provide skin care to the
    area covered by the mask because pressure
    and moisture under the bag may cause skin
    breakdown
   Monitor the client closely for risk of aspiration
    because the mask limits the client’s ability to
    clear the mouth, especially if vomiting occurs

                                                        166
   Provide emotional support to decrease anxiety to
    the client who feels claustrophobic
   Consult with physician regarding switching the
    client from a mask to a nasal cannula during
    eating
   With a reservoir bag, make sure it does not twist
    or kink, which results in a deflated bag




                                                        167
   Fits over the client’s chin, with the top extending
    halfway across the face
   O2 content varies
   Useful instead of a tight-fitting mask for the client
    who has facial trauma and burns




                                                            168
   Can be used to deliver high humidity and the
    desired oxygen to the client with a tracheostomy
   Special adapter called the T piece can be used
    to deliver any desired FIO2 to the client with a
    tracheostomy, laryngecotmy, or endotracheal
    tube
   Oxygen delivered 24% to 100% with flow rates
    at least 10L/min



                                                       16
                                                        9
   Change delivery system to a nasal cannula during
    mealtimes
   Ensure that aerosol mist escapes from the vents of the
    delivery system during inspiration and expiration
   Empty condensation from the tubing to prevent the client
    from being lavaged with water and to promote an
    adequate flow rate
   Ensure that there is sufficient water in canister and
    change the aerosol water container as needed
   Keep the exhalation port on T-piece open and
    uncovered(if occluded, the client can suffocate)



                                                               17
                                                                0
   Monitor the liter flow to be sure it is as
    prescribed
   Assess the patient’s response to therapy;
    monitor reports of blood gas analyses
   Inspect the tubing for kinks, obstructions, loose
    connections, listen for hissing sound in O2
    mask: feel for adequate O2 flow
   Maintain sterile water in the humidifier reservoir




                                                         17
                                                          1
   Clean and replace oxygen therapy equipment
    according to agency policy
   Post a no smoking sign and advise the patient and
    visitors that smoking is not allowed because
    oxygen supports combustion




                                                        17
                                                         2
   Assess color and vital signs before and during
    treatment
   Place an “oxygen in use” sign at client’s bedside
   Assess for presence of chronic lung problems
   Humidify the oxygen




                                                        17
                                                         3
   Intermittent Positive Pressure Breathing
    Treatments
   Used to achieve maximal lung expansion
   The IPPB equipment delivers humidified gas
    with positive pressure, which forces air into
    the lungs with inhalation and allows passive
    exhalation.
   Facilitates maximal exchange of oxygen and
    carbon dioxide gases in the alveoli and
    promotes a productive cough.
   Mucolytics and bronchodilators common

                                                    17
                                                     4
   Oral airway
   Nasal airway
   Endotracheal tube
   Tracheostomy




                        17
                         5
   Orotracheal
   Nasotracheal




                   17
                    6
   Used to maintain a patent airway
   Indicated when the client needs mechanical ventilation
   If client requires artificial airway for longer than 10 to 14
    days, a tracheostomy may be created to avoid mucosal
    and vocal cord damage than can be caused by the
    endotracheal tube
   The cuff located at the distal end of the tube, when
    inflated, produces a seal between the trachea and the
    cuff to prevent aspiration and ensure delivery of a set
    tidal volume when mechanical ventilation is used, an
    inflated cuff also prevents air from passing to the vocal
    cords, nose or mouth



                                                                    17
                                                                     7
   Allows use of a larger diameter tube and
    reduces the work of breathing
   Indicated when the client has a nasal
    obstruction or a predisposition to epistaxis
   Uncomfortable and can be manipulated by the
    tongue causing airway obstruction; an oral
    airway may be needed to keep the client from
    biting on the tube



                                                   17
                                                    8
   Smaller-sized tube increased resistance and
    increases client’s work of breathing
   Discouraged in clients with bleeding disorders
   More comfortable for the client, and the client is
    unable to manipulate with tongue




                                                         17
                                                          9
   Placement is confirmed by chest x-ray study
    (correct placement is 1 to 2 cm above carina)
   Placement is assessed by auscultating both
    sides of chest while manually ventilating with
    resuscitation bag
   If breath sounds and chest wall movement are
    absent on the left side, the tube may be in the
    right mainstem bronchus



                                                      18
                                                       0
   Auscultation over the stomach is performed to rule
    out esophageal intubation
   If the tube is in the stomach, louder breath sounds
    will be heard over the stomach than over the
    chest, and abdominal distention will be present
   Secure the tube immediately after intubation with
    adhesive tape




                                                          18
                                                           1
   Monitor position of tube at lip or nose
   Monitor skin and mucous membranes
   Suction only when needed (Why)




                                              18
                                               2
   The oral tube needs to be moved to the opposite
    side of the mouth daily to prevent pressure and
    necrosis of the lip and mouth area, prevent nerve
    damage, and facilitate inspection and cleaning of
    the mouth; moving the tube to the opposite side of
    the mouth should be done by two health care
    providers




                                                         18
                                                          3
   Prevent pulling or tugging on the tube to prevent
    dislodgement; suction, coughing and speaking
    attempts by the client place extra stress on the
    tube and can cause dislodgement
   Keep a resuscitation (Ambu) bag at bedside at
    all times
   Assess pilot balloon to ensure cuff is inflated




                                                        184
   Hyperoxygenate the client and suction the
    endotracheal tube and the oral cavity
   Place client in semi-Flower’s position
   The cuff is deflated and the tube is removed at
    peak inspiration
   Instruct the client to cough and deep breathe to
    assist in removing accumulated secretions in the
    throat




                                                       185
   apply oxygen therapy as prescribed
   Monitor respiratory status for signs of obstruction
    and notify physician if they occur
   Inform client that hoarseness or a sore throat is
    normal and to limit talking if it occurs




                                                          186
   A tracheotomy is a surgical incision made into the
    trachea to establish an airway
   A tracheostomy is the stoma or opening that
    results from the tracheotomy
   The tracheostomy can be temporary or permanent




                                                         187
   Monitor respirations
   Monitor ABGs and pulse oximetry
   Encourage coughing and deep breathing
   Maintain a semi-to high-Fowler’s postion




                                               188
   Monitor for bleeding, difficulty breathing, absence
    of breath sounds, and crepitus, which are
    indications of hemorrhage, pneumothorax, and
    subcutaneous emphsema




                                                          189
   provide respiratory treatments as prescribed
   Suction as needed: hyperoxygenate the client
    before suctioning
   If client is allowed to eat, sit the client up for meals
    and ensure that the cuff is inflated(if the tube is not
    capped) for meals, and for 1 hour after meals




                                                               190
   Assess the stoma and secretions for blood or
    purulent drainage
   Follow physician’s orders and agency policy for
    cleaning the tracheostomy site and inner
    cannula; usually half-strength hydrogen
    peroxide is used
   Administer humidified oxygen as prescribed as
    the normal humidificaiton process is bypassed in
    a client with a tracheostomy


                                                       191
   Obtain assistance in changing tracheostomy ties:
    cut and remove old ties holding the tracheostomy
    in place
   Keep a resuscitation (Ambu) bag, obturator, and a
    tracheotomy set at the bedside




                                                        192
   Tube obstruction
   Tube dislodgement
   Pneumothorax
   Subcutaneous emphysema
   Bleeding
   Infection
   Tracheal stenosis
   Tracheoesophageal fistula
   Trachea-innominate artery fistula




                                        193
   Used to overcome the client’s inability to ventilate
    or oxygenate adequately
   It may be intermittent or continuous, short or long
    term




                                                           194
   Depending on the patients needs, ventilators may be
    programmed to control or assist the rate of ventilation.
   Ventilators deliver oxygen ranging in concentration from
    21% oxygen to 100% oxygen. (Oxygen concentration =
    FI02)
   Tidal volume is the present amount of oxygenated air
    delivered during each ventilator breath (usually 10 –
    15ml/kg)
   Respiratory rate setting is the total number of breaths
    delivered per minute.
   Positive end expiratory pressure may be prescribed to
    keep the pressure in the lungs above the atmospheric
    pressure at he end of expiration.
    ◦ This reduces collapse of small airways and alveoli, increasing the
      functional residual capacity and improving ventilation.

                                                                           19
                                                                            5
   Assess the client first and the ventilator second
   Assess vital signs, respiratory status, and
    breathing patterns
   Monitor color, particularly in the lips and nail beds
   Monitor the chest for bilateral expansion
   Obtain a pulse oximetry reading




                                                            196
   Assess the need for suctioning and observe type,
    color, and amount of secretions
   Ensure that the alarms are set
   If a cause of an alarm cannot be determined,
    ventilate the client manually with a resuscitation
    bag until the problem is corrected




                                                         197
   Empty ventilator tubings when moisture collects
   Turn client at least every 2 hours or get client
    out of bed as prescribed to prevent
    complications of immobility
   Have resuscitation equipment available at the
    bedside
   Establish an alternate method of communication
    because the patient cannot speak while
    intubated


                                                       198
   Increased secretions in the airway
   Wheezing or bronchospasm causing decreased
    airway size
   Displacement of the endotracheal tube
   Obstructed endotracheal tube because of water or
    a kink in the tubing
   Client coughs, gags, or bites on the tube
   Client is anxious or fights the ventilator




                                                       199
   Disconnection or leak in the ventilator or in the
    client’s airway cuff
   The client stops spontaneous breathing




                                                        200
   Hypotension caused by the application of positive
    pressure, which increases intrathoracic pressure
    and inhibits blood return to the heart
   Respiratory complications such as pneumothorax
    or subcutaneous emphysema as a result of
    positive pressure




                                                        20
                                                         1
   Gastrointestinal alterations as stress ulcers
   Malnutrition
   Infections
   Muscular deconditioning
   Ventilator dependence or inability to wean




                                                    202
   The process of going from ventilator dependence
    to spontaneous breathing




                                                      203
   Continuous positive airway pressure
   Maintains positive pressure in the airway during
    sleep
   Avoids apnea
   Small and have a nose mask that is worn during
    sleeping




                                                       204
   Inserted to drain air or fluid from the “PLEURAL
    SPACE” of the lungs
   Permits re-expansion of a collapsed lung
   Used in pts with hemothorax, pneumothorax or
    pleural effusion
   Inserted under sterile conditions by physician
   Page 523




                                                       205
   Performed in OR or at bedside/ED
   Small incision made to insert tube
   Fourth intercostal space to remove air
    (pneumothorax)
   Eigth or ninth intercostal space to remove fluids
    (hemothorax)
   Tubes are sutured in place at insertion and an
    air tight, sterile dressing is applied



                                                        206
   The other end of the plastic chest tube (distal end)
    is connected to a rubber tubing that leads to a
    pleural drainage device
   This device has three chambers:
    ◦ The collection chamber
    ◦ The water seal chamber
    ◦ The suction chamber




                                                           207
   Chest fluid and air drain into the collection
    chamber
   Air is diverted to the water seal chamber
   When the drainage chamber is full, it can be
    changed without changing out the whole device
   The collection chamber just twists out and a new
    one is twisted in




                                                       208
   Air is diverted here
   It can be seen bubbling up through the water
   It should not be a constant bubbling, more like an
    intermittent bubbling
   If it is constant there may be an air leak




                                                         209
   Agency policy may permit the chest tubing to be
    clamped for 10 seconds while the leak is found
   Check your connections and your dressing at the
    site of insertion
   You should have hemostats in the room for just
    this purpose




                                                      210
   Suction pressure is controlled here
   Gentle bubbling is expected in the suction
    chamber
   Inside the chamber is a tube that is partially
    submerged in water
   The depth of the tube in the water regulates the
    amount of suction




                                                       211
   This tube is hollow and will have a water in it
   There will be a rise and fall of water in this tube
    during inspiration and expiration (tidaling)
   During chest tube insertion, the water is added
    to the control chamber and how much is instilled
    is determined by the physician depending on the
    amount of suctioning required




                                                          212
   A chest radiograph is obtained to confirm
    placement of the tube




                                                213
   Monitor VS and breath sounds frequently
   Assess dressing to be sure a tight seal is
    maintained
   Tape tubing connections and inspect frequently to
    detect air leaks
   Coil extra tubing on the bed to avoid kinks




                                                        214
   Keep drainage system on the floor
   Monitor drainage for blood clots or lung tissue
    which could clog the tube




                                                      215
   Observe the water seal chamber for bubbling, it
    is usually seen unless the lung has reexpanded
    or the tubing is occluded
   After checking for kinks or occlusion of the
    tubing, notify the charge nurse or physician of
    reexpansion
   Always chart the bubbling and if there is no
    bubbling, checking for occlusion and finding
    none and then notifying the physician or CN


                                                      216
   Drainage is monitored by marking the drainage
    level on the drainage receptacle, do this on your
    first assessment of the patient and chart it!
   You will then have the correct amount of drainage
    that occurred by the end of your shift, which you
    will chart as output




                                                        217
   An alternate to the large chest drainage system
   The valve is a disposable unit that is attached to
    the chest tube and to a sterile drainage
    receptacle
   air and fluid can flow in but cannot flow
    backward into the chest
   This is good for the client who can ambulate




                                                         218
   Thoracotomy
    ◦ The surgical opening of the chest wall
    ◦ Reasons for thoracic surgery
      To evaluate chest trauma
      Removal of tumors and cysts




                                               219
   Pneumonectomy
   Lobectomy
   Segmental resection
   Wedge resection




                          220
   The removal of an entire lung




                                    221
   The removal of one lobe of a lung




                                        222
   The extensive dissection and removal of a section
    of the lung




                                                        223
   The removal of a small, triangular section of lung
    tissue




                                                         224
   Stripping of the membrane that covers the visceral
    pleura




                                                         225
   The removal of ribs




                          226
   Everything that goes along with any type of
    surgery
   What you want to stress are breathing exercises
    and explanation of a chest tube if one may be
    required




                                                      227
   Everything that goes with any type of surgery
   What you want to stress
    ◦   Vital signs
    ◦   Lung sounds
    ◦   Mental state
    ◦   Dressings
    ◦   Chest tube function and drainage




                                                    228
View table on page 532 - 533
Decongestants are adrenergic agents
   Mimic the action of epinephrine and norephinephrine
   Cause constriction of nasal blood vessels and reduce
    the swelling of mucous membranes
   Sudafed (common over the counter)
   With systemic vasoconstriction they may elevate the
    blood pressure
   Systemic effects are less severe with topical drops
    and sprays
   People with hypertension, heart disease, and
    hyperthyroidism should not take over the counter cold
    remedies without talking to the Dr or pharmacist.


                                                            231
Antitussives suppress the cough reflex
   When a cough is nonproductive, creates pain and
    interferers with sleep or wound healing cough
    suppression may be indicated
   Codeine is effective (but is an opioid with many
    side effect)
   Dextromethorphan is commonly used
   Be careful suppressing the cough because it is a
    protective mechanism.




                                                       233
Antihistamines are also called
         histamine 1 blockers
   They block the effects of histamine(one of the
    chemicals that causes allergic symptoms)
   Prescription and over the counter
   Dry nasal secretions
   Benadryl - common first generation antihistamine
   May cause dizziness, dry mouth, constipation,
    blurred vision, urinary retention, tachycardia,
    drowsiness and impaired judgment




                                                       235
   Second generation
   Claritin – less likely to cause drowsiness




                                                 236
Thin respiratory secretions
   Thin respiratory secretions so they are more
    readily mobilized and cleared from the airways




                                                     238
Kill or inhibit the growth of
bacteria, viruses, or fungi
   Usually treat only bacterial infections because
    they are not effective against viruses or fungi
   Specific antimicrobials are best selected after
    culture and sensitivity tests are performed on a
    specimen of respiratory secretions
   Instruct on proper self medications




                                                       240
Relax smooth muscle in the bronchial airways
                          and blood vessels
   Asthma and COPD
   Primary drawback is their tendency to cause
    cardiac and CNS stimulation
   Some bronchodilators act primarily to prevent
    bronchial constriction where as other relieve it.




                                                        242
Anti-inflammatory drugs
   Parenterally, orally, inhalation
   Reduce inflammation and edema in the respiratory
    tract
   Less commonly used to treat COPD
   Do no discontinue steroid therapy abruptly




                                                       244
Used to prevent acute asthma attacks
   Intal
   Tilade
   Not useful in stopping an attack after it starts




                                                       246
Leukotriens Mediate allergic responses
   Useful in the treatment of asthma – they inhibit the
    allergic response helping to prevent but not
    interrupt acute asthmatic attacks
   Accolate
   Zyflo
   Singulair




                                                           24
                                                            8
Reduce the viscosity and elasticity of mucus
   Mucomyst is used as an inhalant to thin the
    secretions
   Important for the patient to remain well hydrated




                                                        250
Dissolve blood clots
   Streptase
   Abbokinase
   Alteplase
   Activase




                 25
                  2
9 Lung Herbs For Colds and
          Respiratory Help

   Mullein is a soothing expectorant that makes the
    mucous more fluid and less sticky, hence it can be
    coughed up more easily. It also helps relax the
    muscles in the bronchial passage. It is used for
    bronchitis, colds, persistent coughs, tuberculosis,
    pleurisy, and whooping cough




                                                          254
   Angelica is a warming remedy that is good for the
    digestive system as well as the respiratory
    system. It is an expectorant, which means it will
    encourage coughing and the elimination of excess
    mucous. It helps strengthen the lungs when they
    are weakened, and was traditionally used for
    many types of infections.




                                                        255

   Ginger is great in cases of excess phlegm, and
    bronchitis, and can also be used at the beginning
    of a cold. Like many of these lung herbs, its great
    for the digestive system also. Ginger is often used
    for nausea, and helps circulation.




                                                          256
   Garlic has been studied a lot for its immune benefits.
    Its great both in the digestive system, and the lungs. It
    helps 'sterilize' the bronchial passage in the lungs, and
    has been used in bronchial infections like tuberculosis.
    It's great for the 'common cold', and garlic capsules
    can be bought. Kyolic garlic is excellent. even though
    its an aged garlic. Fresh garlic, consumed within 15
    minutes of being cut open, in a tea with honey and
    lemon juice, is also an excellent remedy, with very
    strong antibacterial and antimicrobial benefits. It's
    great for tonsillitis, throat infections, and similar. As
    well as its cleansing effect on the lungs, garlic helps
    encourage mucous to coughed up.



                                                                257
   Cinnamon should not be used in pregnancy. As a
    lung herb it's more warming than angelica, and
    can be used at the beginning of chesty colds. Mills
    suggests making a tea of powdered cinnamon and
    fresh ginger. It is also used in chest infections.
    Cinnamon is also great for the digestive system,
    and was also traditionally used in convalescence.




                                                          25
                                                           8
   This is a great lung herb for getting rid of excess
    mucous through coughing. It is very soothing,
    however, and the types of coughs it encourages
    are not dry hacking coughs that just produce more
    irritation. Its great for chronic bronchitis in the
    elderly, or for those who are weakened physically
    in some way. It can also be used for nervous
    coughing, and is a digestive tonic similar to
    angelica



                                                          259
   Coltsfoot is also an expectorant. It's great for dry
    coughs, and because of its mucilage content, is
    very soothing when the bronchial passages are
    irritated.




                                                           260

   More than a seasoning for cooking, this lung herb
    has antiseptic properties as well as being an
    expectorant and digestive tonic. It helps 'disinfect'
    the air passages, and also has a calming effect on
    the bronchial tube. It is generally used for more
    asthmatic conditions and dry coughs, but not
    really for bronchitis. Large amounts of thyme
    should not be taken during pregnancy.



                                                            261
   This lung herb is used as a cough suppressant,
    which as indicated above, should only be used
    under some circumstances. But it is used in
    helping treat strong and incessant coughing to the
    point of exhaustion.




                                                         262
263
264
   Last 2 - 14 days,      Fatigue
   first 3 days most      lethargic
    contagious             Fever and chills in
   headache                severe cases
   sneezing
   stuffiness
   sore throat
   runny nose

                                                  265
HISTORY AND EXAM
   Rest              Antivirals
   fluids             (not commonly
   diet               used)
   antipyretics      Vitamin C
   analgesics        antihistamines
                      decongestants




                                        267
26
 8
   Follows a cold or the flu
   usually viral
   Bacterial: Streptococcus pneumoniae,
    haemophilus influenzae
   Irritation and inflammation : increase mucous




                                                    269
   FEVER
   COUGH
   YELLOW OR GREEN SPUTUM
   RAPID BREATHING
   OCCASIONALLY CHEST PAIN




                              270
     HEALTH HISTORY
ASSESSMENT FINDINGS
BROAD SPECTRUM ANTIBIOTIC FOR
                   7 - 10 DAYS
273
   Acute viral respiratory infection
   Several types then subtypes (A,B,C)
   Most susceptible:
    ◦   very young
    ◦   elderly
    ◦   institutionalized
    ◦   chronic disease
    ◦   you




                                          274
   Bronchitis              myocarditis
   Viral or Bacterial      pericarditis
    Pneumonia               Rye Syndrome
                            confusion
                            Guillain-Barre’
                            toxic shock
                            Myositis (swelling of the
                             muscles)
                            renal failure


                                                     275
   Chills
   fever
   muscle pain
   headache
   dry hacking cough




                        276
  SYMPTOMS
ASSESSMENT
   Rest              Antivirals
   fluids             (Symmetrel,
   diet               Flumadine, Tamiflu,
   analgesics         Relenza for type A &
                       B)
   antipyretics
                      prevention; flu shot




                                          278
279
   Inflammation of the        Nosocomial
    alveoli & bronchioles       ◦ poor hand washing
   infectious                  ◦ poor sterile technique
    ◦ Psuedomonas               ◦ contaminated
    ◦ Candidia                    equipment
    noninfectious              ◦ contact
    ◦ fumes
    ◦ dust
    ◦ chemicals


                                                       280
   SMOKERS
   ALTERED CONSCIOUSNESS
   IMMUNOSUPRESSED
   CHRONICALLY ILL
   PROLONGED IMMOBILITY




                            281
   Lobar Pneumonia              Gram + bacteria
    ◦ one or more lobes           ◦ pneumococcal
   Bronchopneumonia              ◦ staphylococcal
    ◦ bronchioles & alveoli       ◦ streptococcal
   Interstitial pneumonia       Gram - bacteria
    ◦ lung tissue                 ◦ pseudomonas
      surrounding the             ◦ influenza
      alveoli                     ◦ legionnaires’ disease
                                 Viral


                                                            282
   PLEURISY         LUNG ABCESS
   PLEURAL          DELAYED
                      RESOLUTION
    EFFUSION
                     EMPYEMA
   ATELECTASIS
                     SYSTEMIC
                      COMPLICATIONS
                      ◦ pericarditis
                      ◦ arthritis
                      ◦ meningitis
                      ◦ endocarditis

                                       283
   Fever
   chills
   sweats
   chest pain
   cough
   sputum production
   hemoptysis
   dyspnea
   headache




                        284
   BACTERIAL                     VIRAL
    ◦ abrupt onset                 ◦ burning or searing
    ◦ severe shaking chills          chest pain in sternal
    ◦ sharp stabbing lateral         area
      chest pain                   ◦ continuous barking
    ◦ intermittent cough             hacking cough with
      productive of rusty            small amount of
      sputum                         sputum production
                                   ◦ headache



                                                             285
   History
   exam
   CXR
   sputum gm. Stain
   sputum C&S
   CBC
   Blood culture




                       286
   3L of fluid/24 hours      Vaccine
   bedrest                    ◦ not recommended for
                                 children under age 2
   analgesics
                               ◦ only given once in a
   antipyretics                 lifetime/There have
   oxygen                       been some questions
   IPPB                         regarding the once in
                                 a lifetime
   antibiotics



                                                     287
   Ineffective airway clearance R/T
    ◦ Increased sputum production
    ◦ Thick secretions
    ◦ Ineffective cough




                                       288
   What can a nurse do?
    ◦ Decrease production of sputum and promote expectoration by
      administering antimicrobials, decongestants and expectorants as
      ordered
    ◦ Teach and encourage deep breathing and coughing
    ◦ Change positions at least every 2 hours to help mobilize
      secretions
    ◦ Chest physiotherapy and aerosol therapy
    ◦ Suctioning if needed
    ◦ Provide tissues and receptacle
    ◦ Chart amount, color, consistency of secretions
    ◦ Ausculate lung sounds frequently to assess the effects of
      interventions




                                                                        289
   Edema and secretions with pneumonia may
    interfere with gas exchange
   Pt may have hypoxemia-low O2 in blood or
    hypercapnia-accumulation of CO2 in blood
   Need to improve gas exchange




                                               290
   What’s a nurse to do?
   Monitor vital signs, lung sounds and skin color to assess
    gas exchange
   Be alert for signs of hypoxemia: restlessness,
    tachycardia and tachypnea
   Report abnormal ABGs
   Check hemoglobin values, signals less O2 carrying
    ability
   Mobilize secretions as mentioned before
   Elevate HOB
   Administer O2 as ordered



                                                                291
   Activity usually restricted but may range from
    bed rest to BRP
   Schedule nursing care to prevent over tiring
   Allow periods of uninterrupted rest
   Provide assistance until pt is able to do self-care
   Encourage visitors not to tire pt with long visits
   Evaluate ability to tolerate ADLs




                                                          292
   What’s a nurse to do?
    ◦ Assess pts usual dietary habits
    ◦ Monitor weight by weighing pt before breakfast using same scale
    ◦ Monitor albumin and lymphocyte blood counts to detect low levels
      that are common with inadequate protein
    ◦ Typical diet: high protein, soft
    ◦ Assist pt with meal if needed
    ◦ Document intake
    ◦ Provide oral care before meals
    ◦ Elevate HOB arrange tray in attractive and convenient manner
    ◦ Nasal cannula recommended during meals
    ◦ If pt tires, more frequent smaller meals would be better




                                                                         29
                                                                          3
   Fever, mouth breathing and inadequate intake
    may increase the risk for this diagnosis
   Dehydration causes secretions to be thicker and
    more difficult to expectorate




                                                      29
                                                       4
   Decreased skin turgor
   Concentrated urine
   Dry mucous membranes
   Elevated hemoglobin and hematocrit




                                         29
                                          5
   What’s a nurse to do?
    ◦ Encourage 3L of fluid daily unless contraindicated
    ◦ Administer IV fluids as ordered
    ◦ If permitted give hard candy which stimulates thirst and
      fluid intake
    ◦ Record intake and output




                                                                 296
◦   Monitor temp q2-4h
◦   Administer antipyretics as ordered
◦   Keep pt dry and lightly covered
◦   Keep room comfortable temp, avoid chilling
◦   Tepid sponge baths for fevers as ordered
◦   Hypothermia blanket as ordered to reduce temp




                                                    297
   Administer analgesics as ordered
   Position pt for comfort
   Encourage splinting painful areas during deep
    breathing and coughing
   Massage to promote comfort
   Notify the physician if pain is unrelieved or
    worsens




                                                    298
   Gradually increase activities as you recover,
    fatigue may persist for several weeks
   Avoid people with colds or other infections
   Get plenty of rest, good nutrition and 3 L of fluids
    each day unless contraindicated
   Complete any prescribed drugs after discharge
   Nursing Care Plan page 539
   Teaching Plan for Pneumonia 540
   Nutrition Concepts page 540


                                                           299
PREVENTION
301
   Keep suction equipment on hand
   Position upright with neck in neutral position
   Thinken liquids




                                                     302
   Elevate the head of bed if enteral feeding
   Measure residual before each bolus feeding
   If greater than 100ml with hold the feeding and
    notify the physician
   Stop continuous feeding for 20-30 min before
    lowering the patients head
   If they must be kept flat then place on right side
   Check the residual every 4 hours and if more than
    20% of hourly rate consult the physician


                                                         303
Inflammation of the pleura
   Pneumonia
   tuberculosis
   chest wall injury
   pulmonary infarction
   Tumors




                           305
   Abrupt and severe pain
   one side of the chest
   breathing and coughing aggravate the pain




                                                306
 UNDERLYING            DISORDER
 PAIN     RELIEF
   Analgesics
   anti-inflammatory
   antitussives
   antimicrobials
   local heat




                                   307
   Pain R/T inflammation
   Ineffective breathing pattern R/T splinting, pleural
    effusion




                                                           308
   When reported, obtain complete description
    ◦   Location
    ◦   Severity
    ◦   Precipitating factors
    ◦   Alleviating factors
    ◦   Use pain scale




                                                 309
   Administer ordered analgesics
   Splinting for the affected side
   Splint rib cage when coughing
   Apply heat if ordered
   Give antitussives if ordered to decrease painful
    coughing
   If on bed rest, assist pt with regular position
    changes
   Administer NSAIDs as ordered to reduce pain
    and inflammation



                                                       310
   Monitor breathing pattern, pay attention to chest
    symmetry during breathing
   Encourage pt to turn, take deep breaths and couth
   Encourage to ambulate if permitted
   Elevate HOB




                                                        31
                                                         1
   If pleural effusion develops, progressive dyspnea,
    decreased or absent breath sounds in the affected
    area and decreased chest wall movement on the
    affected side, a thoracentesis may be done to
    remove accumulated fluid
   If done at bedside you, the nurse will assist
   So be ready!!!




                                                         312
313
   PENETRATING                 NONPENETRATING
   Gunshot, stab                ◦   MVA, Falls, Blast
    wounds                       ◦   rib fx
    ◦ pneumothorax               ◦   pneumothorax
    ◦ tears of aorta, vena       ◦   pulmonary contusions
      cava, other major          ◦   cardiac contusions
      vessels




                                                            314
   Obvious trauma          decreased blood
   chest pain               pressure
   dyspnea                 tracheal deviation
   asymmetrical chest      distended neck
    wall movement            veins
   cyanosis                bloodshot or bulging
   weak rapid pulse         eyes



                                                315
   Stabilization              VS
   prevention                 LOC
   dressing tape three        O2
    sides(called a vented      semi-fowlers
    dressing)
   An airtight dressing
    could cause a tension
    pneumothorax
   do not remove impaled
    objects

                                               316
  An accumulation of air in the pleural cavity that results in
          complete or partial collapse of a lung.




Air enters the space between the chest wall and the lung either
    through a hole in the chest wall or through a tear in the
                bronchus, bronchioles, or alveoli.

                                                                  317
   Tension                   Open
   air is repeatedly         chest wound
    entering the pleural      air moves in and out
    space                      freely
   lung on affected          lung on affected
    side collapses             side collapses
   mediastinal shift         medistinal flutter



                                                  318
   Dyspnea                    Asymmetric chest
   tachypnea                   movement
   tachycardia                diminished breath
   restlessness                sounds
   pain anxiety               progressive cyanosis
   decreased movement         chest wound
    of the involved chest      sucking chest wound
    wall                        (air can be heard or
                                felt from wound)

                                                       319
   Needle aspiration of fluid/air from pleural space
   chest tube insertion
   surgical repair of a tear
   If persistent air leak( variety being studied)
    ◦ intrapleural tetracycline
    ◦ blood patches
    ◦ fibrin glue




                                                        320
   If chest tube: monitor insertion site
   Document amount and characteristics of
    drainage
   Add to I&O
   Give chest tube care
   Monitor for increasing respiratory distress:
    ◦   Tachycardia
    ◦   Dyspnea
    ◦   Cyanosis
    ◦   Restlessness
    ◦   Anxiety



                                                   321
   Inspect trachea for deviation which may be
    caused by mediastinal shift
    ◦ occurs when a lung collapses and the heart, trachea,
      esophagus, and great blood vessels shift toward the
      unaffected side
   Mediastinal flutter
    ◦ Occurs with an open pneumothorax, everything may
      shift back and forth toward the unaffected side with
      inspiration then toward the affected side with expiration




                                                                  322
   Check ABGs for hypoxemia and hypercapnia
   Immediately report deteriorating respiratory status
   Protect chest tube and monitor its function




                                                          323
   Position pt for comfort in a Fowler’s or semi-
    Fowler’s position, avoid side-lying until affected
    lung has re-expanded, could cause mediastinal
    shift
   Support and encourage pt to deep breath and
    cough q2h while awake
   Administer O2 as ordered




                                                         324
   Speak calmly to pt, explain every procedure
   Tell pt about chest tube
   Give pt opportunity to ask questions and express
    fear




                                                       325
   Monitor pulse and blood pressure
   If blood pressure falls and pulse rate increases,
    you should suspect mediastinal shift, notify
    physician immediately, this could be fatal




                                                        32
                                                         6
   Monitor for signs of pain
   Document characteristics of pain
   Administer analgesics as ordered
   Document the effects of drug therapy
   Rate pain on 0-10 scale
   Use positioning, massage, distraction etc.
   Notify physician if measures fail and pain is not
    relieved



                                                        327
   Monitor for signs and symptoms of infection
    ◦   Fever
    ◦   Increased pulse and respirations
    ◦   Foul drainage from tube insertion site
    ◦   Elevated WBC




                                                  328
   Use sterile technique for invasive procedures
    and dressing changes
   Administer prescribed antimicrobials
   Monitor hydration status and promote fluid
    intake of 2 to 3 L/d unless contraindicated
   Before discharge instruct pt on chest tube care
    and to notify physician of S/S of infection
    ◦ Fever or increasing redness, swelling, or drainage
      from insertion site




                                                           329
   Accumulation of blood between the chest wall
    and the lung
   Pressure around the lung increases, causing
    partial or complete collapse of the lung
   Results from lacerated or torn blood vessel, lung
    malignancy, pulmonary embolus
   May also be caused by anticoagulation therapy




                                                        330
   Essentially like a pneumothorax, nursing care is
    similar
   Surgical intervention may be necessary to control
    bleeding
   Pt is at risk for decreased cardiac output due to
    hemorrhage




                                                        331
        Most common chest injuries
 blunt injury/MVA-hit steering wheel
Ribs 4 to 9 most commonly affected
         Takes approx 6 wks to heal
   Pain at injury site (especially during inspiration)
   bruising
   Swelling
   Visible bone fragments at site of injury
   shallow breathing
   protective holding of the chest




                                                          333
   Pain relief to allow adequate chest expansion
   intercostal nerve blocks
   no binders or rib belts restricts expansion of chest
   encourage deep breathing every four hours
   Complication: pneumonia or atelectasis due to
    inadequate chest expansion




                                                           334
   Goal: effective breathing pattern
   Breathing exercises to prevent pulmonary complications
   Instruct splinting while deep breathing and coughing
   Adequate pain control is essential, monitor q2h, rate
    pain on scale 0-10
   Administer prescribed analgesics
   Provide a calm environment
   Encourage pt to rest
   Evaluate effects of pain measures
   Inform physician if pain isn’t controlled




                                                             335
 Two adjacent ribs on the same side of the chest are
broken in two or more places. Results in paradoxical
                                          movement
   Severe dyspnea
   cyanosis
   tachypnea
   tachycardia
   paradoxical movement-affected part will move in
    with inspiration and moves out with expiration-
    opposite of how it should be




                                                      33
                                                       7
   History
   Exam CXR
   ABG




               338
   Adequate oxygenation
    ◦ Cough & deep breathing
    ◦ IPPB
    ◦ pain management
   Respiratory Distress
    ◦ intubation
    ◦ ventilator




                               339
   Foreign substance carried through the blood
   Usually blood clots but may be fat, air, tumors,
    bone marrow, amniotic fluid or clumps of
    bacteria
   Ventilation-perfusion mismatch.
   Alveoli are ventilated + no blood flow= no gas
    exchange



                                                   340
   If a large pulmonary vessel is obstructed, alveoli
    collapse, cardiac output falls, there is constriction
    of the bronchi and the pulmonary artery, and
    sudden death may ensue.




                                                            341
   Surgery of the pelvis or lower legs
   Immobility
   Obesity
   Estrogen therapy
   Clotting abnormalities
   If a large pulmonary vessel is obstructed, alveoli
    collapse, cardiac output falls, there is
    constriction of the bronchi and the pulmonary
    artery, and sudden death may occur



                                                         342
   Sudden chest pain      cough
    worsens with           hemoptysis
    breathing              Crackles may be
   tachypena               heard on
   dyspnea                 auscultation
   apprehensive           fever
   diaphoretic            tachycardia



                                              343
   History and physical
   ABG
   EKG
   lung scan
   Pulmonary angiogram




                           344
   MEDICAL                      SURGICAL
    ◦ Heparin to establish       embolectomy
      and maintain (PTT 2 -
      2.5 times the normal
                                 vena cava
      rate)                       interruption
    ◦ Coumadin 6 months          venous
    ◦ Fibrinolytics               thrombectomy
    ◦ oxygen
    ◦ intubation                 See pg 546 for
    ◦ ventilation                 pictures of filters

                                                        345
   Must monitor risk factors that led to the embolism
   Homans’ sign assessed in each leg




                                                         346
   Monitor respiratory rate and effort
   Breath sounds
   Skin color
   Pulse
   Blood pressure




                                          347
   ABGs report abnormalities to physician
   Elevate HOB
   Administer O2 as prescribed
   Administer prescribed IV fluids
   Document I&O
   Active/passive ROM
   Early ambulation after surgery
   Antiembolism and pneumatic compression
    stockings




                                             348
   Remain calm
   Tell pt what is being done
   Explain equipment and procedures in terms pt can
    understand
   Encourage pt to express concerns and ask
    questions
   Permit family member to remain with the patient




                                                       349
   See patient teaching plan page 547 for pulmonary
    embolism




                                                       350
Acute Respiratory Distress Syndrome




                                      351
   Progressive             Cardiac dysrhythmias
    pulmonary disorder      renal failure
    that follows lung       stress ulcers
    trauma.                 thrombocytopenia
   Infiltrate              DIC (disseminated
                             intravascular
    development              coagulation)
   fluid shift             oxygen toxicity
   pulmonary edema         sepsis
   atelectasis

                                                    352
   Increased                 Dyspnea with
    respiratory rate           retractions
   fine crackles             cyanosis
   restless                  diaphoresis
   agitated                  diffuse crackles and
   confused                   rhonchi
   increased pulse rate
   cough

                                                  353
   History
   exam
   CXR
   ABG
   pH increases Co2 falls
   O2 falls despite O2
   pH decreases respiratory acidosis




                                        354
   Intubation with ventilator
   treat underlying cause
   corticosteroids debatable issue




                                      355
   Characterized by interstitial hemorrhage
    associated with intraalveolar hemorrhage resulting
    in decreased pulmonary compliance
   The major complication is acute respiratory
    distress syndrome (ARDS)




                                                         356
   Dyspnea
   Hypoxemia
   Increased bronchial secretions
   Hemoptysis
   Restlessness
   Decreased breath sounds
   Rales and wheezes




                                     357
   Maintain airway and ventilation
   Place client in high Fowler’s position
   Administer oxygen as prescribed
   Monitor for increased respiratory distress
   Maintain bed rest and limit activity to reduce
    oxygen demands
   Prepare for mechanical ventilation as prescribed




                                                       358
   Occurs when the client cannot eliminate carbon
    dioxide from the alveoli
   The carbon dioxide retention results in
    hypoxemia
   Oxygen reaches the alveoli but cannot be
    absorbed or used properly
   The lungs can move air sufficiently but cannot
    oxygenate the pulmonary blood properly



                                                     359
   Respiratory failure occurs as a result of
    mechanical abnormality of the lungs or chest wall,
    a defect in the respiratory control center in the
    brain, or an impairment in the function of the
    respiratory muscles




                                                         360
   Dyspnea
   Headache
   Confusion
   Restlessness
   Tachycardia
   Cyanosis
   Dysrhythmias
   Decreased level of consciousness
   Alterations in respirations and breath sounds




                                                    361
   Identify and treat the cause
   Administer O2 as prescribed to maintain the
    PaO2 level above 60 mm Hg
   Place the client in high Fowler’s position
   Encourage deep breathing
   Administer bronchodilators as prescribed
   Prepare the client for mechanical ventilation if
    supplemental O2 cannot maintain acceptable
    PaO2 levels



                                                       362
   The collection of fluid in the pleural space
   Any condition that interferes with either secretion
    or drainage of this fluid will lead to pleural effusion




                                                              363
   Pleuritic pain that is sharp and increases with
    inspiration
   Dyspnea on exertion
   Dry nonproductive cough caused by bronchial
    irritation or mediastinal shift
   Malaise




                                                      364
   Tachycardia
   Elevated temperature
   Decreased breath sounds
   CXR shows pleural effusion and a mediastinal
    shift away from the fluid




                                                   365
   Identify and treat underlying cause
   Monitor vital signs
   Monitor breath sounds
   Place client in high Fowler’s position
   Encourage coughing and deep breathing
   Prepare client for thoracentesis




                                             366
5th leading cause of death in US
   A combination of asthma, chronic bronchitis,
    & emphysema.

   May see only one or two, but usually all three.

   COLD- Chronic Obstructive Lung Disease

   CAL – Chronic Airflow Limitation



                                                      368
   Pulmonary function test common diagnostic
    procedure
   Provides info about airway dynamics, lung
    volumes, and diffusing capacity
    ◦ Airway dynamics – patients ability to inhale or exhale by
      force
    ◦ Diffusing capacity – ability of gases to diffuse across the
      alveolar capillary membrane

    ◦ Test are effort dependent – patient must be mentally
      alert, cooperative and able to follow directions.

                                                                    36
                                                                     9
Reactive Airway Disease




                          370
   Early /acute episode:
   Begins when triggers ( allergens, irritants, infections,
    exercise) activate the inflammatory process
   Airway constrict & becomes edematous
   Mucus secretions increases, forming plugs in the
    ariways
   Tenacious sputum is produced
   Usually occur within 30-60 minutes after exposure to the
    trigger and resolve some 30-60 minutes later
          Fig 31-1 page 551




                                                               371
   Late Phase
   Begins 5-6 hours after the early phase
   Red & white blood cells infiltrate the swollen
    tissues of the airways
   Lasts several hours or days
   Risk for another acute episode until the phase
    subsides




                                                     372
   Constriction of the bronchi & broncioles.
   Results in a ventilation perfusion mismatch
    ◦ Severe, persistent bronchospasm is called status
      asthmaticus




                                                         373
   CAN RESULT IN:
   RIGHT SIDED HEART FAILURE
   PNUEMOTHORAX
   ACIDOSIS
   RESPIRATORY ARREST
   CARDIAC ARREST

   Medical Emergency!



                                374
   DYSPNEA
   PRODUCTIVE COUGH
   USE OF ACCESSORY MUSCLES
   AUDIBLE EXPIRATORY WHEEZE
   TACHYCARDIA
   TACHYPENA




                                375
   HISTORY
   PHYSICAL EXAM
   PFT : DECREASED EXPIRATORY AIR VOLUME
   ABG’s if moderate to severe symptoms




                                            376
   PREVENTION OF ATTACK
   REMOVING THE CAUSATIVE AGENT
   BRONCHODIALTORS
   ANTI-INFLAMMAROTY DRUGS




                                   377
   RELIEVERS – RELIEVE ACUTE SYMPTOMS
   CONTROLLERS – PROVIDE LONG TERM
    CONTROL
   Beta 2 receptor agonists are the most often
    used relievers
   Controllers: inhaled glucocorticoids, leukotriene
    inhibitors, long acting beta 2 receptor agonists,
    mast cell stabilizers and xanthines.




                                                        378
   BRONCHIAL INFLAMATION THAT RESULTS
    FROM INHALED IRRITANTS WHICH RESULTS
    INCREASED MUCOUS PORDUCTION.
   MUST HAVE A CHRONIC COUGH FOR 3
    MONTHS OR LONGER FOR
       TWO CONSECETIVE YEARS
        Figure 31-3 page 553




                                           379
   Inflammation caused by inhaled irritants,
    including cigarette smoke
   At first, only large airways are affected, but
    smaller airways are eventually involved.
   Mucus obstructs the airway, causing air to be
    trapped in distal portions of the lungs
   Alveolar ventilation is impaired and
        hypoxemia may develop
   See Teaching Plan page 561 for Chronic Bronchitis and Emphysema




                                                                      380
   Right sided heart failure secondary to pulmonary
    disease.




                                                       381
   Centrilobar
    ◦ cigarette smoking
    ◦ Affects mainly the respiratory bronchioles
   Panlobular
    ◦ hereditary deficiency of alpha 1 -antitrypsin
    ◦ Affects the respiratory bronchioles and the alveoli.

    ◦ May have both at the same time

Figure 31-4 Page 554



                                                             382
   Alveolar walls breakdown cause permanent
    distention of air spaces & decrease in elastic
    recoil. Partially collapsed airways. Bullae &
    blebs develop




                                                     383
   Heart failure
   Respiratory failure
   Increased PaCO2
   Decreased PaO2




                          384
   Infection
   air pollution
   smoking
   adverse drug reaction
   Left ventricular failure
   MI
   PE
   Spontaneous Pneumothorax


                               38
                                5
   Bronchitis
   Productive Cough
   External Dyspnea
   Wheezing
   Elevated RBC
   Cor Pulmonale- dyspnea, cyanosis, peripheral
    edema, “blue bloater”




                                                   38
                                                    6
   Dyspnea on exertion, then on rest
   thin patients
   use accessory muscles
   increase in chest diameter “barrel chest”
   “Pink Puffers”




                                                387
   Diagnosis: History & exam, PFT
   decrease in forced expiratory volume and forced
    vital capacity
   increase in residual capacity and volume and total
    lung capacity




                                                         388
   Drug therapy
   oxygen therapy
   Chest physiotherapy
   Exercise
   Nutrition
   Surgical Treatment (lung volume reduction
    surgery) LVRS




                                                389
Up to 30% of the hyperinflated lung tissue is excised to
improve the mechanics of breathing, enabling the patient to
breath more deeply



             •Effectiveness  still being evaluated
                  •Recovery period is long
                   •Mortality rate 5%-10%
   Abnormal dilation and distortion of bronchi &
    bronchioles, usually confined to one lung lobe or
    segment.
   Typically follows recurrent inflammatory conditions
    infections or obstruction.
   Some times congenital.




                                                          391
   Coughing.
   Production of purulent sputum in large
    quantities.
   Fever
   hemoptysis
   nasal stuffiness
   sinus drainage
   Fatigue
   weakness




                                             392
   Control symptoms
   prevent spread.
   Antibiotics
   oxygen therapy
   chest physiotherapy




                          393
Hereditary disorder
   Hereditary disorder
   Dysfunction of the exocrine gland
   Production of thick tenacious mucous
   Obstruction of the pancreatic ducts so that
    pancreatic enzymes cannot be delivered to the
    GI tract
   Stools bulky and foul smelling
   Women have reduced fertility
   Males often have vas deferens absent



                                                    396
   Infection.
   Emphysema.
   Atelectasis.




                   397
   Pancreatic enzyme replacement
   Chest physiotherpay
   Aerosol & nebulizer treatments
   Bronchodilators
   Anti-inflammatory agents
   Inhaled deoxyribonuclease
       Lung transplantation




                                     398
   GOAL:
    ◦   Effective airway clearance
    ◦   Prevention/treatment of infection
    ◦   Adequate nutrition
    ◦   Effective therapeutic regimen management




                                                   399
   TB
   Sarcoidosis
   pneumoconiosis
   Interstitial fibrosis
   Lung cancer




                            400
   A highly communicable disease caused by
    Mycobacterium tuberculosis
   A nonmotile, nonsporulating, acid-fast rod that
    secrets niacin; and when the bacillus reaches a
    susceptible site, it multiplies freely




                                                      401
   Because it is an aerobic bacterium, it primarily
    affects the pulmonary system, especially the
    upper lobes where oxygen content is greatest, but
    can also affect other areas of the body such as the
    brain, intestines, peritoneum, kidney, joints, and
    liver




                                                          402
   An exudative-type response causes a nonspecific
    pneumonitis and development of granulomas in
    the lung tissue
   Has an insidious onset, and many clients are not
    aware of symptoms until the disease is well
    advanced




                                                       403
   A multidrug-resistant strain (MDR-TB) of TB can
    exist as a result of improper or noncompliant use
    of treatment programs and the development of
    mutations in the tubercle bacilli
   The goal of treatment is to prevent transmission,
    control symptoms and prevent progression of the
    disease




                                                        404
   Alcoholism
   Intravenous drug use
   Malnutrition
   Infection
   The elderly
   The homeless




                           405
   Refugees
   Minority groups
   Individuals from a lower socioeconomic group
   Children younger than 5 years old
   Individuals living in crowded areas such as long-
    term care facilities, prisons, and mental health
    facilities




                                                        40
                                                         6
   Individuals in constant, frequent contact with an
    untreated or undiagnosed individual
   Individuals with immune dysfunction, human
    immunodeficiency virus (HIV), or who are
    immunosuppressed from medication therapy
   Drinking unpasteurized milk if the cows are
    infected with bovine TB




                                                        407
   Via aerosolization or airborne route by droplet
    infection
   When an infected individual coughs, laughs,
    sneezes, or sings, droplet nuclei containing TB
    bacteria enter the air and may be inhaled by
    others




                                                      408
   Identification of those individuals in close contact with
    the infected individual is important so that they can be
    tested and treated as necessary
   When contacts have been identified, these people are
    assessed with a tuberculin test and chest x-ray study to
    determine infection with TB
   After the infected individual has received TB medication
    for 2 to 3 weeks, the risk of transmission is greatly
    reduced




                                                                409
   Droplets enter the lungs and the bacteria form a
    tubercle lesion
   The body’s defense systems encapsulate the
    tubercle, leaving a scar
   If encapsulation does not occur, bacteria may
    enter the lymph system, travel to the lymph
    nodes, and cause an inflammatory response
    called granulomatous inflammation



                                                       410
   Primary lesions form; the primary lesions may
    become dormant, but can be reactivated and
    become a secondary infection when reexposed
    to the bacterium
   In an active phase, TB can cause necrosis in
    the lesions, leading to rupture and the spread
    of necrotic tissue, and damage to various parts
    of the body



                                                 411
   Past exposure to TB
   Client’s country of origin and travel to foreign
    countries in which there is a high incidence of TB
   Recent history of influenza, pneumonia, febrile
    illness, cough, and foul-smelling sputum
    production




                                                         412
   Previous tests for TB and what the results were
   Recent bacille Galmette-Guerin (BCG) vaccine (a
    vaccine containing attenuated tubercle bacilli that
    may be given to people in foreign countries or to
    persons traveling to foreign countries to produce
    increased resistance to TB)




                                                          413
   An individual who has received BCG will have a
    positive skin test and should be evaluated for TB
    with a chest x-ray study




                                                        414
   May be asymptomatic in primary infection
   Fatigue
   Lethargy
   Anorexia
   Weight loss




                                               415
   Low-grade fever
   Chills
   Night sweats
   Persistent cough and the production of
    mucopurulent sputum, which is occasionally
    streaked with blood, or rust colored
   Chest tightness and a dull, aching chest pain
    may accompany the cough



                                                    416
   Physical exam of chest does not provide
    conclusive evidence of TB
   Chest XR study is not definitive, but the presence
    of multinodular infiltrates with calcification in the
    upper lobes suggests TB
   If the disease is active, inflammation may be seen
    on the chest XR




                                                            417
   Dullness with percussion over involved
    parenchymal areas, bronchial breath sounds,
    rhonchi, and /or crackles
   Partial obstruction of a bronchus, caused by
    endobronchial disease or compression by lymph
    nodes, may produce localized wheezing and
    dyspnea




                                                    418
   Sputum specimens are obtained for an acid-fast
    smear
   A sputum culture identifying M. tuberculosis
    confirms the diagnosis
   After medications are started, sputum samples
    are obtained again to determine the
    effectiveness of therapy
   Most clients have negative cultures after 3
    months of compliance to medication therapy



                                                     419
   The client with active TB is placed on respiratory
    isolation precautions in a well-ventilated negitive
    pressure room
   The room should have at least six exchanges of
    fresh air per hour and should be ventilated to the
    outside environment if possible




                                                          420
   The nurse wears a particulate respirator (a special
    individually fitted mask -N-95) when caring for the
    client and a gown when there is a possibility of
    contamination of clothing
   Hands are always thoroughly washed before and
    after caring for the client




                                                          421
   If the client needs to leave the room for a test or
    procedure, the client is required to wear a mask
   Isolation is discontinued when the client is no
    longer considered infectious




                                                          422
   After the infected individual has received TB
    medication for 2 to 3 weeks, the risk of
    transmission is greatly reduced
   When the results of three sputum cultures are
    negative, the client is no longer considered
    infectious




                                                    423
   Provide the client and family with information
    about TB and ally concerns about the contagious
    aspect of the infection
   Instruct the client to follow the medication regimen
    exactly as prescribed and always to have a supply
    of the medication on hand




                                                           424
   Advise the client of the side effects of the
    medication and ways of minimizing them to ensure
    compliance
   Reassure the client that after 2 to 3 weeks of
    medication therapy, it is unlikely that the client will
    infect anyone
   Inform the client that activities should be resumed
    gradually




                                                              425
   Instruct about need for adequate nutrition to
    promote healing
   Instruct to increase foods rich in iron, protein,
    vitamin C
   Respiratory isolation not necessary, family have
    already been exposed




                                                        426
   Cover mouth and nose when coughing, sneezing;
    put used tissues in plastic bag
   Teach handwashing
   Inform client sputum culture is needed q 2-4 wks
    once medication is initiated




                                                       427
   Inform client when results of 3 sputum cultures are
    negative, client is no longer infectious and can
    return to employment
   Avoid excessive exposure to silicone or dust, con
    cause further lung damage
   Instruct importance on treatment and follow-up
    care
   See Patient Teaching Plan on page 565




                                                          428
   Isoniazid (INH)
    ◦ Do not skip doses and take for full length of prescribed
      therapy
    ◦ Do not take with any other medication
    ◦ Avoid alcohol
    ◦ Take on empty stomach with 8 oz glass of water
    ◦ Avoid taking antacids with medication
    ◦ Avoid tyramine containing foods
    ◦ Notify doc if vision changes occur



                                                                 42
                                                                  9
   Rifampin
    ◦ Do not skip doses and take full prescribed therapy
    ◦ Do not take with any other medication
    ◦ Avoid alcohol
    ◦ Take on empty stomach with 8 oz glass of water, no
      antacids
    ◦ Urine, feces, sweat and tears will be red-orange in
      color, soft contact lenses can become permanently
      discolored
    ◦ Notify physician if jaundice develops




                                                            430
 Several conditions in which there is inflammation of the lower
respiratory tract and thickening and fibrosis of the alveolar walls


May be cause by:
•Inhaled substances
•Connective tissue disorders
•No specific cause
   Formation of scar tissue in the lung tissue after
    inflammation or irritation
    ◦ Cigarette smoking
    ◦ Frequent aspiration
    ◦ Exposure to environmental or occupation substances




                                                           43
                                                            2
   Pulmonary hypertension (increased pressure in
    the pulmonary artery caused by obstruction to
    blood flow in pulmonary vessels)
   Cor pulmonale
   Ventilatory failure




                                                    43
                                                     3
   Nonproductive cough
   Progressive dyspnea
   Inspirational crackles
   Clubbing of fingertips

Medical Treatment
   Corticosteriods
   Bronchodilators
   O2
   Lung Transplant for end stage

                                    43
                                     4
Inhalation of various particles in the work setting
   Dust
   Ammonia
   Chlorine
   Plant and animal proteins
   Silica
   Asbestos
   Coal dust




                                43
                                 6
   Ammonia or chlorine causes acute respiratory
    irritation
   Usually temporary
   Maybe develop pulmonary edema or alveolar
    damage if lower airways affected
   Cough
   Wheezing
   Dyspnea
   Tx focuses on the management of symptoms and
    avoidance of future exposure

                                                   437
   Plant or animal proteins may cause allergic
    reaction
   Tx same for bronchial asthma
   Usually last only a few hours
   May have hyperactive airway for years




                                                  43
                                                   8
   Allergic inflammatory response of the alveoli to
    inhaled organic particles
   Few days or may contract pulmonary edema with
    permanent effects
   Corticosteroids and avoidance of the irritants is
    recommended
   May need respiratory support if severe




                                                        439
   Inhalation of various dusts
   Response to repeated exposure to silica,
    asbestos, or coal dust
   Characterized by diffuse pulmonary fibrosis and
    restrictive lung disease




                                                      44
                                                       0
Inflammatory condition that may affect the skin, eyes,
lungs, liver, spleen, bones, salivary glands, joints, and
                          heart
   Cause is unknown
   Unknown factor triggers a series of immune
    processes leading to the formation of clusters of
    cells and debris in affected tissues called
    granulomas
   May have periods of remissions and
    exacerbations




                                                        442
   Dry cough
   Dyspnea
   Chest pain
   Hemoptysis
   Fatigue
   Weakness
   Weight loss
   Fever




                  443
   Administer corticosteroids as prescribed to control
    symptoms
   Lung transplant is the only option for patients with
    end stage pulmonary disease




                                                           444
   Focuses on monitoring the patient for progressive
    dysfuncions




                                                        44
                                                         5
   A pulmonary fungal infection caused by spores of
    Histoplasma capsulatum
   Transmission occurs by the inhalation of spores,
    which are commonly located in contaminated soil
   Spores are also usually found in bird droppings




                                                       446
   Dyspnea
   Chills
   Chest px
   Elevated temperature
   Pulmonary infiltrates on chest XR




                                        447
   Elevated WBC count
   Positive skin test
   Positive agglutination test
   Splenomegaly
   Hepatomegaly




                                  448
   Administer oxygen as prescribed
   Administer antiemetics, antihistamines,
    antipyretics, and steroids as prescribed
   Administer fungicidal medications as prescribed
   Encourage coughing and deep breathing




                                                      449
   Place client in semi-Fowler’s position
   Monitor vital signs
   Monitor respiratory status
   Monitor for nephrotoxicity from fungicidal
    medications
   Instruct client to spray area with water before
    sweeping barn and chicken coups




                                                      450
   Known as asbestosis and coal workers’
    pneumoconiosis
   Fibrotic disease of lungs caused by inhalation of
    inorganic dusts over long periods
   Common in miners and sandblasters
   Tuberculosis (TB) is frequent complication




                                                        451
   Frequent respiratory infections
   Blood-streaked sputum
   Cough
   Nodular lesions in lungs seen on CXR




                                           452
   Administer antitussive as prescribed for cough
   Administer medications for TB as prescribed
   Eliminate toxic substances
   Administer oxygen as prescribed
   Encourage coughing and deep breathing




                                                     453
Leading cause of death in the US
   Two major categories
   Small (oat cell) lung carcinoma
   Non small cell lung carcinoma




                                      45
                                       5
   Persistent cough
   Hemoptysis
   Chest pain
   Recurring pneumonia
   Recurring bronchitis
   Dyspnea
   Wt loss
   Pain in the shoulder arm or hand



                                       45
                                        6
   CXR
   CT
   MRI
   Fibroptic bronchoscopy
   Sputum cytology
   Biopsy




                             45
                              7
   Early detection is the key
   Radiotherapy
   Chemotherapy
   Targeted Biologic Therapies
   Surgical (see pulmonary resection figure 31-9
    page 567)




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459

				
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