Molecular Exchange Of Oxygen And Carbon Dioxide Within The Body’s



Molecular exchange of oxygen and carbon dioxide within the body’s tissues (Mosby,2006)

 The

process by which gases are moved into and out of the lungs (Mosby,2006)

 The

passage of fluid through a specific organ or an area of the body (Polaski and Tatro,1996)



is the process by which oxygen in the air is brought into the lungs and into close contact with the blood, which absorbs it and carries it to all parts of the body

 Chief

complaint  Signs and Symptoms  Past Medical History  Family History  Psychosocial History and Life-style

What are the current respiratory symptoms?  When did each symptom start?  What is the perceived cause of the symptom?  When do the symptoms affect the client?  What helps to relieve the symptoms? 

N.B.: Clients under acute and emergency situations

 Coughs

› › › ›

When did it start? How long? Any pain? Sputum?



Sputum Production › › › ›

Color? (clear, yellow green, rust, bloody) Odor Quality (watery, stringy, frothy, thick) Quantity (teaspoon, tablespoon, cup)

FYI: The tracheobroncial tree normally produces 3 ounces of mucus per day as part of our normal cleansing mechanism

 Hemoptysis

› Blood expectorated from the mouth in

the form of gross blood, frankly bloody sputum, or blood tinged sputum › Lungs, stomach and epistaxis › Result of forceful coughing? › Amount?

 Adventitious

Breath sounds

› Wheezing  Produced when air passes through partially obstructed/ narrowed airways on expiration Inspiratory wheezing Audible /stethoscope When? Relieves itself? Requires medication

› Stridor Produced when air passes through partially obstructed/ narrowed upper airways on inspiration Voice changes? (character, hoarseness) difficulty swallowing sleep related disorders head aches weight gain fluid retention Apnea and restlessness)

 Chest

pains

› Retrosternal pains – burning, constant and

aching sensations

Does the pain/discomfort get better or worse when changing body position?  Is the pain/discomfort better or worse with respirations?  Is the pain/discomfort intense, dull, or knifelike?  Is the pain/discomfort deep or close to the surface? 

Frequent colds, Sinus infections, Nasal trauma, Epistaxis (hypertension)  Childhood and Infectious diseases (TB, Bronchitis, influenza, asthma, pneumonia, URI)  Immunizations – pneumovax (Pneumococcal Pneumonia)/ flu  Major illnesses and Hospitalization  Medications – prescribed/OTC  Allergies 

 Respiratory

diseases (Asthma, emphysema, COPD, lung cancer, respiratory infections, tuberculosis, and allergies)

 Occupational/Environmental

Exposure

and Geographic Location › Home, hobbies, work environment › Exposure to pollutants/ air toxins › Travel to areas where respiratory

diseases are prevalent › Living quarters/ Place

 Smoking

› (years of smoking x packs per day = pack

years)

 Alcoholism

– ciliary action, decrease mucus clearance, depress gag reflex  Drug (Legal/Illegal)Overdose – respiratory failure  Exercise

 Inspection,

Palpation, Percussion and Auscultation

 Tachypnea,

grasping, grunting, central cyanosis, open mouth, flared nares, dyspnea, color of facial skin and lips, use of accessory muscles  IE ratio  Chest wall configuration  Chest movement  Fingers and toes – cyanosis, clubbing

 Trachea

– masses, deviation, etc.  Chest wall - movement, ease and symmetry using the heel/ulnar aspect of the hand  Thoracic Excursion  Tactile fremitus

 Resonant,

Hyper-resonant, dull, tympanic, or flat  Apices, Bases, posterior to lateral areas

 Normal

breath sounds  Adventitious breath sounds  Avoid the bony areas



Arterial Blood Gas Analysis (ABG) › Measures the PaO2,

PaCO2 and pH › Oxygen saturation, HCO3

› PAO2- efficient of gas

exchange (ventilation/perfusion) › PaCO2 – efficiency of ventilation

 Pulmonary

Function Test (PFT)

› Evaluation of the lungs (lung volumes, lung

mechanisms, diffusion capabilities of the lungs) › Determines: Presence of pulmonary disease or abnormality of the lung function, extent of abnormalities, Severity of impairment, Progression of the disorder, appropriate treatment

 Pulse

Oximetry

› Measures oxygen saturation › Noninvasive, uses a beam of light ›

 Chest

X-ray

› consolidation

 Thoracentesis

– air/fluid in the pleural

space  Biopsy  Sputum Collection

 Subjective

› Verbalizations  Objective

› Physical  Short term – uneasiness, dizzyness, pale skin, nailbeds, acute hearing, use of accessory muscles, impaired breathing pattern Long term – unequal chest expansion, cyanosis, fainting, comatose, death

• A sensation of difficult or uncomfortable breathing or a feeling of not getting enough air. • No standard definition exists for difficulty breathing



Inadequate supply of 02 › › › ›

High altitudes Smoke inhalation Carbon Monoxide poisoning Dilution of inspired air with inert gases

 Interference

airway

› Mechanical Obstruction  Children – aspiration  Unconscious adults – tongue, aspirated vomitus, dentures, mucus



Abnormal functioning bellows motion of chest wall and diaphragm › Trauma to chest wall › Muscle or nerve trauma or impairment

ex. Hiatial hernia  Adequate number of terminal resp. units for diffusion › Emphysema, Pulmonary edema, damage

alveolar-capillary membrane, Physiologic shunts, Adult respiratory distress syndrome

•Inadequate amount of hemoglobin Ex. Severe anemia, Carbon Monoxide poisoning, Methemoglobinemia

•Non-functioning/Impaired respiratory center Depression of respiratory center Increased intracranial pressure



Impaired circulatory system and ineffective heart pump › Heart arrhythmias › Congestive heart › › › ›

failure (CHF) Heart arrhythmias Coronary artery disease Heart attack Hemmorage



Positioning and Posture › Chest and head are elevated – expansion of

lungs and improves efficiency of resp. muscles › Semi-Fowler’s – moderate resp. distress › Sitting upright position leaning on a padded overbed table with arms resting on the table – improve secondary inspiratory muscles › Standing – straight posture while leaning forward



Environmental Conrol › Air pollution › Smoking › Allergens

 Activity

and Rest  Oral Hygiene › Clear secretions › Breathing through the mouth – dry oral

mucosa – risk of stomatitis (yeast) › Essential after administration of mucolytics, steroids, antibiotics, and enzymes › Improve appetite and promote well being › No gas forming foods

 Hydration

and Suctioning

› Liquefy bronchopulmonary secretions › Prevents constipation and fluid imbalances › 3000-4000 ml of fluid per day

Oral (Yankauer) suction tube.

A wall suction unit.

Pneumostat. It uses a one-way valve and has a small collection chamber.

 Infection

prevention and Control  Psychosocial Support › Anxiety = worsen symptoms (dyspnea and

bronchospasm)

CLASS

EXAMPLE

USE

Antimicrobials

Penicillins, Cephalosporins, Tetracyclines, Aminoglycosides,

Bactericidals and Bacteristatics

Cough Preparations

Expectorants ,

Facilitate productive cough

Decongestants

Reduce allergy and symptoms

CLASS

EXAMPLE

USE

Bronchodilators

Beta-Allergenics, Theophylline

Symptomatic relief of asthma and bronchial spasms

Adrenal glucocorticoids

Predisone, Beclomethasone

Symptomatic relief and preventive care of asthma

Antitussives

Narcotics: Codiene Non Narcotics: dextromethorphan

To treat dry, non productive cough that interfere with sleep/activites

Mucolytics

Water acetylcycteine

Thin mucus

Antiallergenics

Cromolyn sodium

Chronic pulmonary conditions that lead to dry sputum

Antihistamines

Diphenyhydramine Relieve symptoms HCl, terfenadine of allergies

 Oxygen

Administration  Facilitating Effective coughing  Artificial Airways  Mechanical Ventilators

 Administering

Oxygen

› Require when hypoxemia occurs of

expected to occur › Does not cure › Indications: Reduced arterial blood oxygen, increased work of breathing, and decreased myocardial workload

Oxygen Induced Hypoventilation › Primary resp. centers(medulla and pons) – inc. CO2 › Secondary resp. centers (carotid bodies, arch of aorta) – dec. in O2 › Administration of oxygen would decrease ventilation 

 Oxygen

Toxicity

› Prolonged exposure to high conc. of › ›

› ›

oxygen Pathologic: 24-48 hours Symptoms: mild tracheobronchitis, substernal soreness, nasal congestion, pain on inspiration, and inc. coughing May cause structural damage to lung tissue; impair transport of 02 ABG monitoring

 Ocular

Damage

› Exposure of cornea and lens to 100 %

oxygen › tearing, of retina, edema and visual impairment

 Familiar

with various methods of 02

admin.  Knowledgeable of 02 therapy – administer and detect equipment malfunction

 Masks,

nasal cannulas, face tent, ventilator, or nebulizer

A nasal cannula.

A simple face mask.

A partial rebreather mask.

A nonrebreather mask.

A Venturi mask. – inspired air + fixed oxygen conc.

oxygen face tent.

Pediatric oxygen tent.

oxygen tank on a wheeled stand

 Low

flow - supplement  High flow – meet/ exceeds the clients inspiratory flow rate – accurate delivery of inspired oxygen  Oxygen

and compressed gases are dry

 Humidity

– water vapor in air  Aerosol – suspension of solid/liquid particles in a flow of gas

 Addition

of water vapor to inspired gas

› Prevents drying and irritation › Prevents drying and thickening of

secretions › Loosens secretions

Insert flow meter into the wall unit.

This flow meter is set to deliver 2 L/minute.

    



Used to hydrate the airways Administer of aerosolized medication Therapy for mobilization of secretions Water, isotonic saline and 0.25 to 0.45% saline May be done before Intermittent Positive pressure breathing treatments and postural drainage (Mist Therapy) After tracheostomy

*May have bronchospasm – bronchodilator therapy

A tracheostomy mist collar.

 Effective

Coughing

› Augments the ciliary clearance

mechanisms, thus maintaining patent airways › Uses the diaphragm, proper posture, slow and deep stacked breaths, and short expulsive blasts of air to , mobilize and expectorate secretions

 Ineffective

coughing

› Collapse of airways › Rupture of thin walled alveoli › Pneumothorax › Dangerous for unstable cardiac and

cerebral function

Assume a position that will facilitate effective use of abdominal muscles – sitting position with knees slightly flexed  Take slow, deep inspirations, diaphragmatic breathing  Do a Valsalva type maneuver  Exhale through pursed lips – movement of secretions tracheobroncal cough reflex centers  Learn cough technique before it is intended 

 Encourages

maximal breathing  Involves visualization of amount of volume of inspired air on the spirometer  Goal or volume is set by practitioner

 Exhale

to a point of comfort  Place the mouthpeice  Inhale through the mouth only until goal is attained  Hold for 3 to 5 seconds  Exhale normally  Rest  Repeat

 Diaphragm

is used, not accessory

muscles  Increased tidal volume, decreased RR, inc. exercise tolerance and inc. in alveolar ventilation  Abdomen rises when inhalation  Contracts upon exhalation

Position the patient (Semi-Fowlers with knees bent)  Place thumbs in the epigastric notch, spread fingers around lower ribs  Inhale; press the thumbs against abdominal wall with slight pressure  Pause naturally (smooth ventilation pattern, even distribution of air)  Exhale; press inward and upward (Contract abdominal muscle, pursed lip)  Ideally, the length of IE ratio is 1:2 

Additional work on inspiratory muscles during diaphragmatic breathing  Inspiratory muscle strength and endurance is improved  Flow resistor with a one way valve  Inhale; closes with resistance  Exhale; opens with minimal resistance 

 Prevents

airway collapse  Helps empty the lungs more completely  Inhale through the nose  Exhale through pursed lips

Combination of percussion over the chest wall, vibration, coughing, deep breathing  Usually done by physiotherapists  Done to mobilize secretions, inc. exercise tolerance, improve ventilation and restore effective breathing patterns  Should be done 2 hours before meal to avoid vomiting and aspiration 

 Percussion – indirect clapping on chest wall with cupped hands Vibration- energy waves from the hand are used to move secretions from affected lung areas during expiration 

 Positioning

a client so that gravity is used to drain specific lung segments or retained secretions  Pillows and towels used to support joints  5 to 10 mins.  Discontinue if cyanosis, dyspnea, change in VS, no more secretions, non productive cough occurs

 Maintain  Oral

airway patency

(Oropharyngeal)  Nasal (Nasolpharyngeal, Nasal Trumpets)  Endotracheal  Tracheostomy

› Length: distance between lips › › ›

›

and the angle of the jaw Too long; gagging Too short; increase airway obstruction (tongue) Contraindication: Consciousness, facial fractures, or foreign body in the oral cavity Short term



Hollow, soft rubber tube  Nares to the base of the tongue  Length: Nose to the Earlobe  Diameter: smaller than the nostril  Patients who cannot tolerate oral airways, frequent nasotracheal suctioning(avoid trauma to mucus membranes)  Should be rotated every 8 hours  If longer than a week, use endotracheal tracheostomy tubes instead 

 Long,

slender, and hollow tube  Inserted to the trachea (carina) via mouth or nose  Passes to the vocal cords  Oral – short term  Nasal – long term, more secure, more comfortable, risk for sinusitis



Surgical opening made into the trachea › Avoid complication in the upper airways, stable, easy

suctioning and ready attachment of equip. › Can eat and talk



Indications: › › › › › › › ›

Need long term artificial airway Upper airway obstruction Upper airway bleeding Altered level of consciousness Inability to clear lower airway secretions Continuous mechanical ventilations Sleep apnea Airway burns

Block

 Ventilates

the lungs  Indications: Inadequate ventilation and hypoxemia › Intermittent Positive-Pressure Breathing › Positive End-Expiratory Pressure and

Continuous Airway Pressure › Pressure support Ventilation › High Frequency Ventilation › Unilateral Lung Ventilation

 Assisted

(Person Cycled)  Controlled (Machine Cycled)

Pressure cycled ventilator to deliver pressurized breaths to a spontaneously breathing client  10 to 20 mins 



Adjusts and controls the inspiratory flow pressure and flow rates to match the particular degree of an individual patient's condition

 maintenance

of positive pressure at the end of expiration, increasing the opportunity for gas exchange



Disadvantage: increase in intrathoracic pressure

 Augments

spontaneous resp. effort with a preset level of positive airway pressure

 For

patients with severe noncompliant lungs

 Required

tracheal intubation that permits separate ventilation for each lung; different volume per lung

 



 

Mosby A., (1991) Medical-Surgical Nursing: Concepts and Clinical Practice, 4th ed. Mosby Year Book,Inc. ;USA Mosby E.,(2006) Mosby’s Pocket Dictionaryof Medicine, Nursing and Health Professions.5th ed. Elseviier Pte.Lte. ; Singapore Polaski A. and Tatro S., Luckman’s Core Principles and Practice of Medical-Surgical Nursing, W.B. Saunders Co.; USA www.pdfcoke.com/doc/14097540/NCP-of-Difficulty-of-Breathing Retrieved on Sept. 7,2009 www.accrn.org/dob Retrieved on Sept. 7,2009