Respi System

CARE OF CLIENTS WITH PROBLEMS RELATED TO THE RESPIRATORY SYSTEM Earl Francis R. Sumile, RN Instructor, College of Nursing University of Santo Tomas

Respiration Respiration – process by which cells receive oxygen for cellular metabolism and eliminate carbon dioxide as metabolic waste.

Processes Involved in Respiration 

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1. Ventilation or breathing (inspiration and expiration) – movement of air in and out of the lungs as a result of gas flow from an area of greater pressure to an area of lesser pressure. 2. Diffusion or gas exchange – movement of gasses between the air in the alveoli and blood in the pulmonary capillaries to lower pressure or concentration 3. Perfusion or circulation or blood flow – transport of oxygen and carbon dioxide in the blood and body fluids to body cells.

Respiratory Control 1. Medulla oblongata - primary respiratory center; spontaneous, rhythmic respiration  2. Cerebral cortex – voluntary breathing  3. Pons varoli – involuntary breathing 

Factors Influencing Respiration    

1. BP changes – decreased BP = increased RR 2. Change in body temperature – increased temp = increased RR 3. Drugs – depressants; decreased RR 4. Age – decreases with age  A. Neonate - 35-60/min  B. Infant – 44/min  C. Child (5 years) – 20-25/min  D. Adolescent (10-14 years) – 17-22/min; (15 years) – 20/min  E. Adult – 16-20/min  Older adult – 12-16/min

Nursing Assessment 

1. Respiration    

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Eupnea – normal respiration; rate and depth are equal Tachypnea – fast respiratory rate Bradypnea – slow respiratory rate Dyspnea – difficult or labored breathing; individualized perception of breathlessness (awareness of breathing) Apnea – periods during which there is no breathing Orthopnea – dyspnea that is relieved by upright position Biot’s – respirations of the same depth followed by a period of apnea

Nursing Assessment Cheyne Stokes - gradual increase followed by gradual decrease in the depth of respirations, and then a period of apnea  Kussmaul – deep, rapid and regular breathing  Paroxysmal Nocturnal Dyspnea – sudden onset of dyspnea while sleeping in a recumbent position 2. Cough and secretions  Cough – sudden, explosive expiratory protective reflex to remove an irritant from air passages; may be hacking, croupy, rattling, whooping, barking  Sputum – substance ejected from the lungs by coughing or clearing the throat; may be thick, viscous, tenacious or gelatinous, frothy, mucoid, mucopurulent 

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Nursing Assessment 

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3. Chest pain of pulmonary origin  A. Chest wall – localized, constant and increases with movements  B. Pleura – sharp, abrupt, increased with inspiration or with cough or sneeze  C. Lung parenchyma – dull, constant ache, poorly localized 4. Cyanosis – dusky bluish color of the mucous membranes, skin and nailbeds due to excessive deoxygenation of hemoglobin  A. Peripheral – extremities and nailbeds are blue due to peripheral vasoconstriction; secondary to decreased cardiac output

Nursing Assessment 

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B. Central – bluish discolorization of lips, tongue, face and mucous membrane; secondary to decreased oxygen of blood; always pathological C. Differential – upper part of the body is pink and lower half is blue or vise versa; usually seen in cardiac diseases

5. Breath Sounds 

A. Vesicular – soft, low-pitched sounds heard over the normal lung fields

Nursing Assessment 

B. Adventitious - breath sounds not normally heard in the lungs • Crackles or Rales – discrete, discontinuous inspiratory sounds that have dry or wet crackling quality • Wheezes – continuous sounds originating from small air passages that are narrowed by secretions, swelling or tumors. • Stridor or Stertorous – noisy respiration • Friction Rub – grating sound caused by inflammed pleura rubbing against the chestwall

Diagnostic Assessment 

1. Radiologic  

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A. Chest X-ray – PA, lateral, oblique B. Fluoroscopy – direct viewing without film to view lung expansion and respiratory excursion of diaphragm C. Tomography or stratigraphy – computed tomography permits better visualization of layer or plane of lugs “slices”; done to check cavities, neoplasms, lung densities, stereoscopic – 3D D. Ultrasound or echogram – harmless, high frequency sound wave emitted and penetrates the thorax and bounces back to transducer to picture image

Diagnostic Assessment 

E. Bronchography – visualizes bronchial tree by x-ray after iodize radioplaque liquid is introduced via a metal cannula through the trachea • Prep – NPO, no dentures, sedative, antispasmodic, done with topical spray anesthesia • Post – NPO until gag reflex is back, deep breathing exercises and coughing to clear airway and postural drainage to remove dye

Diagnostic Assessment 

F. Lung scan or scintigram or scintiphotography – records the pattern of pulmonary radioactivity after inhalation or IV injection of gamma ray emitting radionucleotides; • Perfusion scan – iodine IV (contrast medium) • Ventilation scan – xenon gas inhaled (contrast medium)

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G. Pulmonary angiography – radiopaque material is injected via catheter in systemic vein to check emboli, congenital or acquired lesions of pulmonary vessels • Prep – dye—radiopaque iodine; check allergy to iodine and seafoods; give 10 gtts of lugol’s solutionn several hours before test to block thyroid uptake of radioactive iodine

Diagnostic Assessment 2. Direct Visualization or Endoscopic

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A. Rhinoscopy – direct visualization and examination of nasal cavity B. Laryngoscopy – direct visualization of larynx • •

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Prep – consent, topical anesthesia, NPO 6-8 hours, atropine sulfate, sedation Post – head of bed elevated, lateral position, ice collar, check gag reflex and hoarseness, tracheostomy tray at bedside because of laryngeal edema or spasm

C. Bronchoscopy – direct examination of trachea, bronchi and larynx • b.

Purposes: Inspect parts of respiratory tract

Diagnostic Assessment Purposes: b. Aspirate secretions and exudates n air passage c. Remove foreign body d. Do biopsy Nursing Care – same as in laryngoscopy 

D. Transllumination – directing a beam of light against frontal or maxilliary sinuses Nursing care – turn overhead lights off

Diagnostic Assessment 

3. Lung biopsy – pleural needle biopsy

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4. Laboratory studies   

A. Hematological studies – CBC, ESR B. Cytologic studies C. Sputum – 4 ml specimen • Methods of taking specimen: endotracheal – through ET tube fiberoptic bronchoscopy – by use of bronchoscope gastric lavage – via NGT transtracheal – surgical opening of trachea

Diagnostic Assessment  

D. Bacteriological – smear and culture E. Thoracentesis – aspiration of fluid and air from pleural cavity; site of insertion: for fluid – 7th to 8th intercostal space midaxillary; for air – 2nd or 3rd intercostal space mid-clavicular prep: consent, no moving, nochoughing, proper positioning, remoe not more than 1500cc within 30 mins (to prevent intravascular shift) post: turned to unaffecte4d side – seal itself; to prevent seepage

Diagnostic Assessment 5. Skin test for TB

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A. PPD – purified protein derivatives  B. OT – old tuberculin Techniques: 

a. b. c. d.

Mantoux test – intracutaneous – for diagnosis Tine test Mono vaccine Heaf screening *b, c, d – multiple puncture test using jet gun

Diagnostic Assessment 

6. Pulmonary Function Test – non-invasive method of assessing the functional capacity of the lungs; ability of gas to diffuse across the alveoli capillary membrane and ratio of ventilated alveoli to perfused capillaries. 

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A. Pulse oximetry – non-invasive technique that measures the oxygen saturation (SaO2) of arterial blood (uses pulse oximeter) B. Spirometry – measures lung capacity, volumes and flow rates with the use of an intrument called spirometer.

Diagnostic Assessment Pulmonary Volumes: b. VT (Tidal volume) = 500 ml; volume of air; inspired with each breath c. IC (Inspiratory Capacity) = 3500 ml; maximum amount of air which can be inhaled in d. IRV (Inspiratory Reserve Volume) = 300 ml; inspiratory capacity in excess of tidal volume e. ERV (Expiratory Reserve Volume) = 100-1100 ml; maximum quantity of air that can be forcibly exhaled after expiration f. RV (Residual Volume) = 1200 ml; air remaining after expiration g. VC (Vital Capacity) = 4000-5000 ml; maximum volume of air expired with inspiration h. TLC (Total Lung Capacity) = 5200-6000 ml; residual volume + vital capacity

Diagnostic Assessment 

7. Arterial Blood Gases – examination of arterial blood to determine the pressure exerted by oxygen and carbon dioxide in the blood; provides objective determination of arterial blood oxygenation, gas exchange, alveolar ventilation and acid-base balance; use heparinized syringe. Sites: radial, brachial, femoral artery PaO2 – measures O2 dissolved in blood – shows efficiency of gas exchange ventilation and perfusion

Diagnostic Assessment PaCO2 – determines the adequacy of ventilation; depends upon the amount of O2 produced and ability of lungs to eliminate; shows effectiveness of ventilation pH – measurement of hydrogen ion concentration SaO2 – measures oxyhemoglobin saturation

ACID BASE BALANCE Regulated by 

1. Chemical Buffer system – substance that can act as a chemical sponge, either by soaking up or releasing H2 ions to stabilize pH • A. Carbonic acid – bicarbonate system – lungs (CO2); kidneys (bicarbonate) • B. Phosphate buffer system – kidneys – mop up H2 ions • C. Protein buffer system – plasma and intracellular fluid, protein hemoglobin

ACID BASE BALANCE 

2. Respiratory control of pH (medulla) • 1. Decreased pH (acidic) = increased RR and depth increased CO2 (lungs) decreased CO2, pH = alkaline • 2. Increased pH = decreased RR and depth of resp, increased CO2, pH = acidic

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3. Renal regulation of pH – kidney make permanent adjustments in pH control of the retention or excretion of bicarbonate and H2 ions • 1. In acidosis, excess H2 ions are excreted in kidney tubules via urine. • 2. In alkalosis, bicarbonate ions enter tubules and excreted in urine.

ACID BASE BALANCE 

Compensation • Kidneys attempt to compensate for changes in blood bicarbonate • Lungs attempt to maintain 20:1 ratio • Shifting of H2 ions from extracellular fluid to intracellular fluid and vice versa

ACID BASE BALANCE COMPARISON OF ARTERIAL or VENOUS BLOOD GASES ARTERIAL

VENOUS

pH

7.35-7.45

7.31-7.41

pO2

80-100 mmHg

35-40 mmHg

pCO2

35-45

41-51

SaO2

96-98%

70-75%

HCO3

22-26

23-25

Base ex

-2+2

-2+2

ACID BASE BALANCE ABG PROFILE IN RESPIRATORY ACIDOSIS or ALKALOSIS ACIDOSIS

RESP

ALKALOSIS

Decreased pH

7.4

Increased pH

Increased pCO2

40

Decreased pCO2

Normal HCO3

24

Normal HCO3

ACID BASE BALANCE ABG PROFILE IN METABOLIC ACIDOSIS or ALKALOSIS ACIDOSIS

MET

ALKALOSIS

Decreased pH

<7.4>

Increased pH

Decreased HCO3

<24>

Increased HCO3

Decreased BE

<0>

Increased BE

Normal pCO2

40

Normal pCO2

Signs and Symptoms of Acid-Base Imbalances: 

Acidosis – increased CO – depression of CNS – decrease in mental capacity –delirium, coma or death

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Alkalosis – increased O2 – overexcitability or irritability of CNS – extreme nervousness, over excitability, tetany or convulsions

Respiratory Management 

1. Pharmacotherapeutics     

A. bronchodilators – relaxes smooth muscles of respiratory tract B. prednisone – decreases edema of the respiratory tract C. mucolytic – reduces thickness of secretions D. antitussive – depresses cough reflex E. antihistamines – blocks histamine; antiinflammatory

Respiratory Management 

2. Surgery – with chest tube to water sealed drain post operatively  A. exploratory thoracotomy – done to confirm a suspected diagnosis of chest disease; to determine bleeding in chest trauma  B. pneumonectomy – removal of an entire lung to treat bronchogenic cancer, tuberculosis, bronchiectasis and lung abscess; postoperatively, positioned to affected side  C. lobectomy – one lobe is removed; postoperatively with chest tube and positioned to affected side

Respiratory Management 

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D. segmental resection – segmentectomy; one or more segment/s is/are removed following pulmonary tuberculosis or bronchiectasis E. wedge resection – removal of pie-shaped or a well circumscribed section from the surface of the lung F. decortication – removal of fibrous peel from visceral pleura; done in empyema, pleural effusion, prolonged hemothorax G. thoracoplasty – removal of ribs; extrapleural procedure

Respiratory Management 

3. Therapeutic Modalities   

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A. O2 therapy B. deep breathing and coughing exercises – support post-op site with pillow C. postural drainage – use of specific positions so that force of gravity can ssist in the removal of bronchial secretions from the affected bronchioles into bronchi and trachea by means of expectoration; percussion and vibration; best done uppon akin in the morining or ½ to 1 hour ac D. incentive spiromentry – uses spirometer to maximize voluntary lung inflation; prevents or treats atelectasis

Respiratory Management 

4. Mechanical Ventilation 

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A. IPPB (intermittent positive pressure breathing) – supplies air or oxygen under positive pressure (above atmosphere) during inspiration B. PEEP (positive end expiratory pressure) – ventilator mode that increases and maintains positive pressure at the end of expiration C. CPAP (continuous positive airway pressure) – technique that maintains positive pressure in the lung during spontaneous ventilation (T-piece)

Common Respiratory Problems 

Epistaxis (nosebleeding) – usually originates from the blood vessels in the anterior part of the septum Causes: 2. Trauma to nasal mucosa from foreign object 3. Picking o fhte nose 4. Local irritation of the mucous membrane from lack of humidity in the air 5. Chronic infection 6. Violent sneezing or blowing of the nose

Common Respiratory Problems Nursing Management: 2. Patient sits up leaning forward with head tipped downward 3. Compress soft tissues of nose against septum with fingers and maintain pressure for at least five minutes 4. Apply ice or cold copress to nose to constrict blood vessels 5. If bleeding does not stop with direct pressure, place cotton ball soaked in topical vasoconstrictor (neo-synephrine) into nose and apply pressure (dependent nursing function) 6. Instrut not to blow nose for several hours after nose bleed 7. Silver nitrate stick or electrocautery (dependent nursing function) 8. Post nasal pack (dependent nursing function)

Common Respiratory Problems 

Sinusitis – inflammation of air filled cavities that lines the mucous membranes of the sinuses Causes: 2. Viral – influenza, adenovirus, staphyloccocus aureus 3. Bacterial – streptococcus pneumoniae, haemophilus influenzae 4. Allergic – seasonal

Common Respiratory Problems Signs and Symptoms: 2. Fever and malaise 3. Stuffy nose 4. Slowly developing pressure over the involved sinus 5. Persistent cough 6. Post nasal drip 7. Headache

Common Respiratory Problems Nursing Management: 2. Positioning – to drain secretions a. Proetz – supine position with 3 head pillows, head on neutral position; for ethmoidal and sphenoidal sinusitis b. Parkinsons – supine position with 3 head pillows, head turned to sides; for frontal and maxillary sinusitis 3. 4. 5.

Analgesics and antipyretics Decongestants Antibiotics

Common Respiratory Problems 5. Cald-wel-luc surgery (radical antrum operation) – incision made under the upper lip to treat chronic maxillary sinusitis Priority Nursing Care: b. Proper oral hygiene done with caution to avoid injury to the incision c. Don’t chew on affected side d. No dentures for ten days e. No blowing of nose for two weeks f. No sneezing (if you must sneeze, keep mouth open)

Common Respiratory Problems 

Tonsilitis – inflammation of the tonsils and their crypts Signs and Symptoms: 2. Sore throat 3. Pain on swallowing 4. Fever and chills 5. General muscle aching and malaise

Common Respiratory Problems Nursing Management: 3. 4. 5. 6. 7. 8.

Rest and increase fluid intake Warm saline throat irrigation Ice collar to relieve discomfort Analgesic and antipyretics Antibiotics Surgery – tonsillectomy

Tonsillectomy Pre-op Care: b. Check for loose tooth Post-op Care:  Position on side until fully awake than to mid-fowler’s  Monitor for hemorrhage – frequent swallowing, bright red vomitus, rapid pulse, and restlessness  Comfort – apply ice collar to neck; use acetaminophen in place of aspirin  Food and fluids – give cold fluids and bland foods; no milk

Tonsillectomy e. Patient teaching No clearing of throat No coughing, sneezing, vigorous nose bleeding and vigorous exercise for one to two weeks Drink fluids two to three liters a day Avoid hard and scratchy foods such as popcorn and pretzels Expect stools to be black or dark for a few days

Common Respiratory Problems 

Laryngeal Cancer 

Predisposing factors: • Overuse of voice • Teachers • Singers • Family predisposition to cancer

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Signs and Symptoms: • Persistent hoarseness associated with otalgia and dysphagia • Lump on the throat • Pain in the adam’s apple that radiates to the ear • Dyspnea, enlarged cervical nodes and cough

Common Respiratory Problems 

Surgical Management: • Partial laryngectomy • Total laryngectomy • Tracheostomy – temporary or permanent

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Post-operative Care: • Head of bed elevated 45o • Assist patient in communicating – provide writing materials, etc • Post partial laryngectomy – patient will be able to talk • Post total laryngectomy – no voice; artificial larynx now available

• Practice swallowing • Loss of sense of smell

Common Respiratory Problems 

Tracheostomy Care: • Immediate postop; wound or stoma care – aseptic technique • In case of accidental removal of the tracheostomy tube, the following should be at bedside • Sterile forceps – to open the stoma • Sterile set of tracheostomy tube – to be inserted by the physician • Provide adequate humidity – cool moist humidifier • Cover the stoma during the day and remoisten it when it dries. Use scarf, bib or turtleneck • Wash stoma with washcloth and warm water and soap daily • Aspirate secretions if cough mechanism is not effective

Common Respiratory Problems • Instill 3-5 ml of normal saline to loosen mucous plugs before suctioning • Hyperoxygenate before and after suctioning • Take bath with caution making sure water or soap does not enter the stoma. No swimming is allowed.

Common Respiratory Problems 

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COPD – Chronic obstructive pulmonary disease OAD – Obstructive airway disease CAL – Chronic airway limitation

Chronic bronchitis 

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Excessive mucous production and recurrent productive cough for two years or longer Causes:  

Inhalation of physical or chemical irritants Viral or bacterial infections

Chronic bronchitis 

Signs and Symptoms:       

Chronic productive cough “cigarette cough” Grayish white sputum Dyspnea Cyanosis, tachycardia Respiratory acidosis Ankle edema, distended neck vein “Blue bloaters”

Chronic bronchitis 

Nursing management: 

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Pharmacotherapeutics – mucolytic, expectorants, antitussives, antihistamines Supportive measures – avoid smoking, inhaled irritants, control of environmental temperature, proper nutrition, adequate hydration

Emphysema 

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Destructive changes in alveolar walls and enlargement of air spaces distal to bronchioles; loss of recoil and air trapping Causes – unknown Predisposing factors:   

Smoking Alpha antitrypsin deficiency Familial tendency

Emphysema 

Signs and symptoms:    

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Uses accessory muscles to breathe Ruddy collor No cyanosis Thin with “barrel-chest”

Nursing management:   

Pursed-lip breathing Forward – leaning position Low O2 concentration

Asthma 

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Bronchial spasms and constrictions characterized by expiratory wheezing Causes:    

Genetic Immunologic Allergic Environmental

Asthma 

Common Factors that Triggers an Attack: 

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Environmental factors – change in temperature or humidity Atmospheric pollutants – cigarettes, industrial smoke Strong odors – perfume, insecticides Allergens – feathers, dust, food, pollens, laundry detergents Exercise Stress or emotional upset Medications – aspirin, NSAIDs

Asthma 

Signs and symptoms:     

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Episodic dyspnea Accessory muscle breathing Inspiratory or expiratory wheezing Respiratory alkalosis Status asthmaticus – respiratory acidosis

Nursing management:  

Bronchodilators – epinephrine, theophylline, aminophylline, proventil, terbutaline Corticosteroids – solumedrol, dexamethanol

Common Respiratory Problems 

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Pneumohemohydrothorax – presence of air, blood or water in the thoracic cavity Flail Chest – multiple rib fracture characterized by paradoxical breathing

Flail Chest 

Nursing Management: 

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CTT – Chest tube or closed thoracotomy tube; surgical introduction of tube into the 7th and 8th intercostal space midaxillary to remove water or blood (hydrothorax or hemothorax) and 2nd or 3rd intercostal space mid-clavicular to get rid of air (pneumothorax) Water sealed drainage

Flail Chest 

Nursing Care of Clients with CTT to H2O sealed drain: 

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Maintain patency of tube by milking or stripping away from the patient towards the drainage bottle Fasten tubing to bed to prevent dependent loops

Flail Chest 

If fluid is not fluctuating in the water seal chamber: • Be sure patient is not lying on tubes • Check connections to be sure chest tube system is intact • Ask patient to cough or change position to see if fluctuation is restored • Fluctuation will stop when lung has reexpanded

Flail Chest 

Keep 2 hemostats with rubber prongs at the bedside so that the chest tube can be clamped if the system becomes disconnected or broken

Flail Chest 

An alternative method with no clamping of tubes is to keep a liter bottle of sterile water at bedside at all times. If the patient’s chest drainage unit breaks or cracks: • Insert the end of the pt’s chest tube into the bottle of sterile water • Remove any of the cracked or broken system • Obtain new system as soon as possible

Flail Chest 

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Never lift the closed drainage system above the pt’s chest because this will allow fluid to be pulled into the pleural space When transporting a patient, chest tubes should not be clamped unless it is necessary for few minutes; bottles placed below the chest level

Flail Chest 

If chest tube is accidentally pulled out of chest: • Apply gloves, pinch skin opening together with fingers • Apply petrolatum jelly gauze and sterile 4x4 dressing • Cover dressing with adhesive tape and call surgeon immediately