Respiratory Course Audit

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The Respiratory System ANGEL LYNN R. SANTOS, MD­RN

Organs of the Respiratory system • Nose • Pharynx • Larynx • Trachea • Bronchi • Lungs – alveoli Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Figure 13.1

Slide 13.1

Function of the Respiratory System • Oversees gas exchanges between the blood and external environment • Exchange of gasses takes place within the lungs in the alveoli • Passageways to the lungs purify, warm, and humidify the incoming air

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.2

The Nose • The only externally visible part of the respiratory system • Air enters the nose through the external nares (nostrils) • The interior of the nose consists of a nasal cavity divided by a nasal septum

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.3a

Upper Respiratory Tract

Figure 13.2 Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.3b

Anatomy of the Nasal Cavity • Olfactory receptors are located in the mucosa on the superior surface • The rest of the cavity is lined with respiratory mucosa • Moistens air • Traps incoming foreign particles

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.4a

Anatomy of the Nasal Cavity • Lateral walls have projections called conchae • Increases surface area • Increases air turbulence within the nasal cavity

• The nasal cavity is separated from the oral cavity by the palate • Anterior hard palate (bone) • Posterior soft palate (muscle) Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.4b

Paranasal Sinuses • Cavities within bones surrounding the nasal cavity • Frontal bone • Sphenoid bone • Ethmoid bone • Maxillary bone Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.5a

Paranasal Sinuses • Function of the sinuses • Lighten the skull • Act as resonance chambers for speech • Produce mucus that drains into the nasal cavity

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.5b

Pharynx (Throat) • Muscular passage from nasal cavity to larynx • Three regions of the pharynx • Nasopharynx – superior region behind nasal cavity • Oropharynx – middle region behind mouth • Laryngopharynx – inferior region attached to larynx • The oropharynx and laryngopharynx are common passageways for air and food Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.6

Structures of the Pharynx • Auditory tubes enter the nasopharynx • Tonsils of the pharynx • Pharyngeal tonsil (adenoids) in the nasopharynx • Palatine tonsils in the oropharynx • Lingual tonsils at the base of the tongue Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.7

Larynx (Voice Box) • Routes air and food into proper channels • Plays a role in speech • Made of eight rigid hyaline cartilages and a spoon-shaped flap of elastic cartilage (epiglottis) Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.8

Structures of the Larynx • Thyroid cartilage • Largest hyaline cartilage • Protrudes anteriorly (Adam’s apple)

• Epiglottis • Superior opening of the larynx • Routes food to the larynx and air toward the trachea Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.9a

Structures of the Larynx

• Vocal cords (vocal folds) • Vibrate with expelled air to create sound (speech)

• Glottis – opening between vocal cords

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Slide 13.9b

Trachea (Windpipe) • Connects larynx with bronchi • Lined with ciliated mucosa • Beat continuously in the opposite direction of incoming air • Expel mucus loaded with dust and other debris away from lungs

• Walls are reinforced with C-shaped hyaline cartilage Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.10

Primary Bronchi • Formed by division of the trachea • Enters the lung at the hilus (medial depression) • Right bronchus is wider, shorter, and straighter than left • Bronchi subdivide into smaller and smaller branches Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.11

Lungs • Occupy most of the thoracic cavity • Apex is near the clavicle (superior portion) • Base rests on the diaphragm (inferior portion) • Each lung is divided into lobes by fissures • Left lung – two lobes • Right lung – three lobes Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.12a

Lungs

Figure 13.4b Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.12b

Coverings of the Lungs • Pulmonary (visceral) pleura covers the lung surface • Parietal pleura lines the walls of the thoracic cavity • Pleural fluid fills the area between layers of pleura to allow gliding Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.13

Respiratory Tree Divisions • Primary bronchi • Secondary bronchi • Tertiary bronchi • Bronchioli • Terminal bronchioli Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.14

Bronchioles

• Smallest branches of the bronchi Figure 13.5a Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.15a

Bronchioles

• All but the smallest branches have reinforcing cartilage Figure 13.5a Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.15b

Bronchioles

• Terminal bronchioles end in alveoli Figure 13.5a Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.15c

Respiratory Zone • Structures • Respiratory bronchioli • Alveolar duct • Alveoli

• Site of gas exchange

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Slide 13.16

Alveoli • Structure of alveoli • Alveolar duct • Alveolar sac • Alveolus • Gas exchange takes place within the alveoli in the respiratory membrane

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.17

Respiratory Membrane (Air-Blood Barrier) • Thin squamous epithelial layer lining alveolar walls • Pulmonary capillaries cover external surfaces of alveoli

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Slide 13.18a

Respiratory Membrane (Air-Blood Barrier)

Figure 13.6

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Slide 13.18b

Gas Exchange • Gas crosses the respiratory membrane by diffusion • Oxygen enters the blood • Carbon dioxide enters the alveoli

• Macrophages add protection • Surfactant coats gas-exposed alveolar surfaces Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.19

Events of Respiration

• Pulmonary ventilation – moving air in and out of the lungs • External respiration – gas exchange between pulmonary blood and alveoli

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.20a

Events of Respiration • Respiratory gas transport – transport of oxygen and carbon dioxide via the bloodstream • Internal respiration – gas exchange between blood and tissue cells in systemic capillaries

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Slide 13.20b

Mechanics of Breathing (Pulmonary Ventilation) • Completely mechanical process • Depends on volume changes in the thoracic cavity • Volume changes lead to pressure changes, which lead to the flow of gases to equalize pressure Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.21a

Mechanics of Breathing (Pulmonary Ventilation) • Two phases • Inspiration – flow of air into lung • Expiration – air leaving lung

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Slide 13.21b

Inspiration • Diaphragm and intercostal muscles contract • The size of the thoracic cavity increases • External air is pulled into the lungs due to an increase in intrapulmonary volume

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.22a

Inspiration

Figure 13.7a Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.22b

Exhalation • Largely a passive process which depends on natural lung elasticity • As muscles relax, air is pushed out of the lungs • Forced expiration can occur mostly by contracting internal intercostal muscles to depress the rib cage Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.23a

Exhalation

Figure 13.7b

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Slide 13.23b

Accessory Muscles of Respiration

Pressure Differences in the Thoracic Cavity • Normal pressure within the pleural space is always negative (intrapleural pressure) • Differences in lung and pleural space pressures keep lungs from collapsing

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Slide 13.24

Nonrespiratory Air Movements • Can be caused by reflexes or voluntary actions • Examples • Cough and sneeze – clears lungs of debris • Laughing • Crying • Yawn • Hiccup Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.25

Respiratory Volumes and Capacities • Normal breathing moves about 500 ml of air with each breath (tidal volume [TV]) • Many factors that affect respiratory capacity • A person’s size • Sex • Age • Physical condition • Residual volume of air – after exhalation, about 1200 ml of air remains in the lungs Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.26

Respiratory Volumes and Capacities • Inspiratory reserve volume (IRV) • Amount of air that can be taken in forcibly over the tidal volume • Usually between 2100 and 3200 ml

• Expiratory reserve volume (ERV) • Amount of air that can be forcibly exhaled • Approximately 1200 ml Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.27a

Respiratory Volumes and Capacities

• Residual volume • Air remaining in lung after expiration • About 1200 ml

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.27b

Respiratory Volumes and Capacities • Vital capacity • The total amount of exchangeable air • Vital capacity = TV + IRV + ERV • Dead space volume • Air that remains in conducting zone and never reaches alveoli • About 150 ml Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.28

Respiratory Volumes and Capacities • Functional volume • Air that actually reaches the respiratory zone • Usually about 350 ml

• Respiratory capacities are measured with a spirometer

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.29

Respiratory Capacities

Figure 13.9 Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.30

The Respiratory System DRA. JULIE C, YU-SANTOS

Respiratory Sounds • Sounds are monitored with a stethoscope • Bronchial sounds – produced by air rushing through trachea and bronchi • Vesicular breathing sounds – soft sounds of air filling alveoli Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.31

External Respiration • Oxygen movement into the blood • The alveoli always has more oxygen than the blood • Oxygen moves by diffusion towards the area of lower concentration • Pulmonary capillary blood gains oxygen

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.32a

External Respiration • Carbon dioxide movement out of the blood • Blood returning from tissues has higher concentrations of carbon dioxide than air in the alveoli • Pulmonary capillary blood gives up carbon dioxide

• Blood leaving the lungs is oxygen-rich and carbon dioxide-poor Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.32b

Gas Transport in the Blood • Oxygen transport in the blood • Inside red blood cells attached to hemoglobin (oxyhemoglobin [HbO2]) • A small amount is carried dissolved in the plasma

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Slide 13.33a

Gas Transport in the Blood • Carbon dioxide transport in the blood • Most is transported in the plasma as bicarbonate ion (HCO3–) • A small amount is carried inside red blood cells on hemoglobin, but at different binding sites than those of oxygen

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Slide 13.33b

Internal Respiration • Exchange of gases between blood and body cells • An opposite reaction to what occurs in the lungs • Carbon dioxide diffuses out of tissue to blood • Oxygen diffuses from blood into tissue Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.34a

Internal Respiration

Figure 13.11

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.34b

External Respiration, Gas Transport, and Internal Respiration Summary

Figure 13.10 Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.35

Neural Regulation of Respiration • Activity of respiratory muscles is transmitted to the brain by the phrenic and intercostal nerves • Neural centers that control rate and depth are located in the medulla • The pons appears to smooth out respiratory rate • Normal respiratory rate (eupnea) is 12–15 respirations per minute • Hypernia is increased respiratory rate often due to extra oxygen needs Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.36

Neural Regulation of Respiration

Figure 13.12 Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.37

Factors Influencing Respiratory Rate and Depth • Physical factors • Increased body temperature • Exercise • Talking • Coughing

• Volition (conscious control) • Emotional factors Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.38

Factors Influencing Respiratory Rate and Depth • Chemical factors • Carbon dioxide levels • Level of carbon dioxide in the blood is the main regulatory chemical for respiration • Increased carbon dioxide increases respiration • Changes in carbon dioxide act directly on the medulla oblongata Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.39a

Factors Influencing Respiratory Rate and Depth • Chemical factors (continued) • Oxygen levels • Changes in oxygen concentration in the blood are detected by chemoreceptors in the aorta and carotid artery • Information is sent to the medulla oblongata

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.39b

Respiratory Disorders: Chronic Obstructive Pulmonary Disease (COPD) • Exemplified by chronic bronchitis and emphysema • Major causes of death and disability in the United States

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Slide 13.40a

Respiratory Disorders: Chronic Obstructive Pulmonary Disease (COPD) • Features of these diseases • Patients almost always have a history of smoking • Labored breathing (dyspnea) becomes progressively more severe • Coughing and frequent pulmonary infections are common Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.40b

Respiratory Disorders: Chronic Obstructive Pulmonary Disease (COPD) • Features of these diseases (continued) • Most victimes retain carbon dioxide, are hypoxic and have respiratory acidosis • Those infected will ultimately develop respiratory failure

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.40c

Emphysema • Alveoli enlarge as adjacent chambers break through • Chronic inflammation promotes lung fibrosis • Airways collapse during expiration • Patients use a large amount of energy to exhale • Overinflation of the lungs leads to a permanently expanded barrel chest • Cyanosis appears late in the disease Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.41

Chronic Bronchitis • Mucosa of the lower respiratory passages becomes severely inflamed • Mucus production increases • Pooled mucus impairs ventilation and gas exchange • Risk of lung infection increases • Pneumonia is common • Hypoxia and cyanosis occur early Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.42

Chronic Obstructive Pulmonary Disease (COPD)

Figure 13.13 Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.43

Lung Cancer • Accounts for 1/3 of all cancer deaths in the United States • Increased incidence associated with smoking • Three common types • Squamous cell carcinoma • Adenocarcinoma • Small cell carcinoma Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.44

Sudden Infant Death syndrome (SIDS) • Apparently healthy infant stops breathing and dies during sleep • Some cases are thought to be a problem of the neural respiratory control center • One third of cases appear to be due to heart rhythm abnormalities Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.45

Asthma

• Chronic inflamed hypersensitive bronchiole passages • Response to irritants with dyspnea, coughing, and wheezing

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.46

BRONCHIAL TUBE

Developmental Aspects of the Respiratory System • Lungs are filled with fluid in the fetus • Lungs are not fully inflated with air until two weeks after birth • Surfactant that lowers alveolar surface tension is not present until late in fetal development and may not be present in premature babies Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.47a

Developmental Aspects of the Respiratory System • Important birth defects • Cystic fibrosis – oversecretion of thick mucus clogs the respiratory system • Cleft palate

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Slide 13.47b

Aging Effects • Elasticity of lungs decreases • Vital capacity decreases • Blood oxygen levels decrease • Stimulating effects of carbon dioxide decreases • More risks of respiratory tract infection Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.48

Respiratory Rate Changes Throughout Life • Newborns – 40 to 80 respirations per minute • Infants – 30 respirations per minute • Age 5 – 25 respirations per minute • Adults – 12 to 18 respirations per minute • Rate often increases somewhat with old age Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Slide 13.49

RESPIRATORY DISORDERS DRA. JULIE C. YU-SANTOS

OBSTRUCTIVE DISORDERS 1. MECHANICAL OBSTRUCTION a. Foreign Bodies b. Tongue Falling 2. ALLERGIES a. Hay Fever (Allergic Rhinitis) b. Bronchial Asthma

3. INFECTIONS (LRTI) a. Laryngitis b. Tracheitis c. Bronchitis d. Bronchiolitis e. Pneumonitis 4. TUMORS a. BenignTumors b. Lung Cancer

DIFFUSIVE DISORDERS A. Loss of Aerating Surface B.  Pulmonary Perfusion

ALVEOLAR INFEC.  Pneumonia  PTB  Histoplasmosis FLUIDS IN ALVEOLI  Pulmonary Edema  A.R.D.S. ATELECTASIS  IRDS  Pneumothorax

OVERSTRETCHING  ( Compliance,  Recoil)  Pulmonary Emphysema  Bronchiectasis  COMPLIANCE  PTB Fibrosis  Consolidations (Pneumonia, Tumors)  Pneumothorax

I.RESTRICTION or PARALYSIS OF RESP. M:  Poliomyelitis  Myasthenia Gravis II.LOSS OF NORMAL  Guillain-Barre’ Synd NEGATIVE  Multiple Sclerosis PRESSURE:  Amyotropic Lateral  Pneumothorax Sclerosis (ALS)  Hemothorax  Scleroderma  Pleural Effusion  Kyphoscoliosis  Empyema Thoracis  Obesity  Multiple Rib  Brain/SC Injury Fracture (Flail  Gen. Anes./ Narcotic O. Chest)

RESTRICTIVE DISORDERS

DIFFUSIVE DISORDERS

= Disorders affecting Alveolar Diffusion 

LOSS OF AERATING SURFACE



PULMONARY PERFUSION

LOSS OF AERATING SURFACE 

ALVEOLAR INFEC.



OVERSTRETCHING ( Compliance, Recoil) *Pul. Emphysema *Bronchiectasis



COMPLIANCE *PTB Fibrosis *Consolidations: (Tumors, Pneumonias) *Pneumothorax

*Pneumonia *PTB *Histoplasmosis

FLUIDS IN ALVEOLI *Pulmonary Edema *A.R.D.S.

ATELECTASIS *IRDS *Pneumothorax

Loss of alveolar tissues Pulmonary Resectional Surgeries  Lobectomies--removal of lobe/s but not the entire lung  Pneumonectomy—removal of a lung  Segmental Resection—removal of segments but not entire lobe  Wedge Resection—removal of wedges but not entire segment; commonly done for open lung biopsy Nursing Diagnosis: Gas Exchange, Impaired

BRONCHIAL ASTHMA

BRONCHIAL Asthma Inappropriate response of the immune system to allergens or foreign proteins  Allergy involving the lower respiratory tract  Non-infectious  Inflammatory Predisposing Etiology: @ Heredity Precipitating Etiology: @Extrinsic allergens @Intrinsic allergens 

Types of Asthma A. Extrinsic or Atopic Asthma: r/t external allergens such as:  -contactants: dust, chemicals, soaps, perfumes, lotions, make-up  -inhalants: dust, hay, scents, smoke, sprays  -ingestants: food, milk, chicken, beef, pork, eggs, etc.  -Sudden changes in temperature

Types of Asthma B. Intrinsic or Non-Atopic Asthma= not r/t external allergens Stress Fatigue Lack of Sleep Anxiety C. MIXED type of Asthma= both types present

Bronchial Asthma:  Heredity  Release

+ Allergens

of IgE from B lymphocytes

 IgE

+ Mast cells of respiratory tract = damage to mast cells

 Release

of: Histamine, Bradykinin, Serotonin, Leukotriennes, Prostaglandins, ECF-A, SRS-A from damaged mast cells to respiratory membranes

Bronchial Asthma: Pathophysiology  Inflammatory

reaction @ linings of

the airway  S-welling  H-eat  A-airway obstruction  R-edness  P-ain (Back pains)

Bronchial Asthma  =S-ecretions:

copious, viscous, sticky, stringy, whitish  =S-pasms: laryngo-tracheobronchial spasm  =S-welling: edema of the airway





Airway Obstruction Dyspnea

Signs and Symptoms: Asthma

 Successive

episodes of coughing: dry, hacking, non-productive cough  Increased respiratory secretions: whitish, stringy  Wheezing on expiration  Prolonged expiration  Dry lips and mucous membranes (mouth)  Dyspnea, Tachypnea, Tachycardia  Apprehension and restlessness

NCP: Bronchial Asthma Nsg. Dx.#1: Ineffective Airway Clearance r/t Secretions, Spasms and Swelling of airway ass’d w/ allergy of the LRT  Goals: Long-term Goal: Patient will achieve an open airway and adequate ventilation as manifested by normal VS and relief of symptoms Short-term Objectives: 

e. f. g.

Liquify secretions Easily expectorate and drain secretions Relieve spasms

NCP: Bronchial Asthma Nursing Actions:  1. Liquify secretions. = Increase fluid intake @ 2-3 l/day = Nebulization = Steam inhalation = Avoid creams, milk = Humidify room = Mucolytics as ordered Bromhexine HCl… (Bisolvon) Ambroxol…(Solmux Broncho; Broncho fluid) Guiafenesin…(Robitussin) Carboxycisteine… (Loviscol) Ammonium Citrate… (Citrex) 

NCP: Bronchial Asthma  2.

Drain and easily expectorate secretions = Deep breathing = Coughing = Vibration = Percussion = Postural Drainage  3. Relieve bronchospasm and swelling of airways = Administer Bronchodilators = Administer anti-histaminics

BRONCHODILATORS: A. Direct bronchodilators = Xanthine bronchodilators (Theophyllines: Aminophyllines, Nuelin, Marax, Brolexin, AsmaSolon, etc.) = Sympathomimetic bronchodilators (Adrenaline, Ephedrine SO4, Neosynephrine, Phenylephrine HCl, Bronkosol, Isoproterenol) = New generation bronchodilators (Salbutamol-Ventolin; Terbutaline-Bricanyl; ) B. Indirect bronchodilators = antibiotics = steroids  ANTI-HISTAMINICS.  Diphenhydramine HCl-(Benadryl),  Chlorpheniramine Maleate-(Chlortrimeton),  Brompheniramine Maleate-(Dimetapp),  Terfenadine HCl-(Teldane),  Loratadine HCl-(Claritin) 

NCP: Bronchial Asthma  Nsg.

Dx. #2: Impaired Breathing Pattern r/t airway obstruction  Goal: = Improve ventilation = Relieve signs of dyspnea  Actions:  Administer O2 @ 2-3 l/min via nasal cannula  Fowler’s or orthopneic position

NCP: Bronchial Asthma  Nsg.

Dx. #3: Gas Exchange, impaired r/t increased physiologic shunting defect.  Goal: Improve gas exchange as shown by normal ABGs  Actions:  Monitor ABG findings  Intubate as needed  Connect to artificial ventilator  Continue with bronchodilators and steroids  IVF to kvo.

LUNG CANCER

Lung Cancer: Definition malignant

growth in airways , alveolar tissues or interstitial spaces in the lungs Atypical cells growing in a very fast pace resulting to tumors

Lung Cancer: Incidence In Adults: Leading Cause of Death in U.S. in both men and women  Highest in age 60 and up  Seldom seen in age group below 40  Approx. 180,000 Americans will 

Incidence As to Types:  Adenocarcinoma

…………....35-40%  Epidermoid/Squam ous cell...………3035%  Oat cell……20-25%  Large cell…15-20%

Classification: LUNG CANCER 

According to Location: I. Centrally-located Tumors Bronchogenic Carcinoma II. Peripherally located Tumors Lung Carcinoma 

According to Origin

1. Primary Tumorprimary lesion originated from lungs 2. Secondary or Metastatic Tumor- original tumor from other parts of

Classification: Histology 1. ADENOCARCINOMA=  not associated with any known cause  Incidence equal among smokers and non-smokers  Increasing incidence among women  Peripherally-located : broncho-alveolar area  Incidence: 2003 Statistics……………………..35-40% 2. EPIDERMOID CARCINOMA  Squamous Cell Type  Entirely associated with heavy smoking  History: > 1p/y  Highest incidence among Males > 40  Most common cause of death among males in US today  Centrally located in large bronchi  Incidence: 2003 Statistics……………………..30-35%

Classification: Histology 3. OAT-CELL Ca  Fusiform, polygonal  Oat-like, small cells  Highly metastatic  Peripherally-located  Usually not operable at time of diagnosis  Poor Prognosis  Incidence: 2003 Statistics……20-25%

   

4. LARGE-CELL Ca Large cells Slow-growing Prognosis: Good

METASTASES: LUNG CA Lymph nodes  Bones  Brain  Contralateral Lung  Adrenals  Kidneys  Liver  Peritoneal organs 

Diagnostic Exams: Lung Ca Chest X-ray  Tomography 

Signs and Symptoms: Lung Ca 1. COUGH Persistent for 2-3 weeks  Changing quality  From hacking and nonproductive to thick and purulent sputum 2. HEMOPTYSIS- esp in am 3. UNILATERAL WHEEZE on expiration (partial obstruction) 4. CHX IN VOICE QUALITY = from hoarseness to aphonia (laryngeal n. compression) 

5. CHEST PAINS/Tightness= spread to regional lymph nodes 6. Dysphagia= spread to esophagus, trachea 7. Head & neck edema=spread to esophagus and lymphatic structures 8. Dyspnea 9. Anorexia, Weight loss, Anemia, 10. Infections=Fever, chills

Recurring Pneumonia

11. Dx:

PULMONARY EMPHYSEMA

Pulmonary Emphysema Terminal stage : C.A.L. (Chronic Airway Limitation)  Old Name: COPD  Chief characteristics: – Chronic airway obstruction – Poor entry of O2 – Poor removal of CO2 – Air trapping – Overstretching of alveolar walls – Inc Compliance, Dec Recoil – Formation of emphysematous blebs or bullae 

Etiology:Pulmonary Emphysema

Predisposing Factors:  A=uto-Immunity  H=eredity = lack or absence of alpha-1 & 2 anti-trypsin  A=ging Precipitating Factors:  S=moking  P=ollution  A=llergies  I=nfections

Pathophysiology: Pul. Emphysema 

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Chronic airway obstruction O2 intake

 Hypoxemia 

Overdilation  Hypoxia

CO2 removal Air trapping Hypercapnea Resp. Acidosis

Blebs

CHEST XRAY

 Provides

information regarding the anatomic location and appearance of the lungs  PREPROCEDURE  1.Remove all jewelry and other metal objects from the chest area  2.Assess the client’s ability to inhale and hold breath  Question females regarding pregnancy or the possibility of pregnancy

POSTPROCEDURE  Assist

the client to dress

SPUTUM SPECIMEN A specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells 

1. PREPROCEDURE

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A. Determine specific purpose of collection and check with institutional policy for appropriate collection of specimen B. Obtain an early morning sterile specimen from suctioning or expectoration after a respiratory treatment, if a treatment is prescribed C. Obtain 15 ml of sputum D. Instruct the client to rinse the mouth with water prior to collection E. Instruct the client to take several deep breaths and then cough deeply to obtain

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  

 POSTPROCEDURE  A.

If a culture of sputum is prescribe, transport specimen to laboratory immediately  B. Assist the client with mouth care

BRONCHOSCOPY          

1. Direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope PREPROCEDURE A. Obtain informed consent B. NPO from midnight prior to the procedure C. Obtain vital signs D. Assess the results of coagulation studies E. Remove dentures or eyeglasses F. Prepare suction equipment G. Administer medication for sedation as prescribed H. Have emergency resuscitation equipment readily available

POSTPROCEDURE        

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A. Monitor vitals signs B. Maintain semi-fowler’s position C. Assess for the return of gag reflex D. Maintain NPO status until gag reflex returns E. Have an emesis basin readily available for client to expectorate sputum F. Monitor for bloody sputum G. Monitor respiratory status, particularly if sedation was administered H. Monitor for complications, such as bronchospasm , bronchial perforation indicated by facial or neck crepitus, dysrhythmias, fever, bacteremia, hemorrhage, hypoxemia, and pneumothorax I. Notify the physician if fever, difficulty of

PULMONARY ANGIOGRAPHY

1. An invasive fluoroscopic procedure in which a catheter is inserted through the antecubital or femoral vein into the pulmonary artery or one of its branches  2. Involves an injection of iodine or radiopaque or contrast material  PREPROCEDURE 

     

A. Obtain informed consent B. Assess for allergies to odine, seafood, or other radioopaque dyes C. Maintain NPO status for 8 hours prior to the procedure D. Monitor vital signs E. Assess results of coagulation studies F. Establish an IV access

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  

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PREPROCEDURE (CONT.) H. Instruct the client that he or she must lie still during the procedure I. Instuct the client that she or he may feel an urge to cough, flushing, nausea, or a salty taste following injection of the dye J. Have emergency resuscitation equipment available POSTPROCEDURE A. Monitor vital signs B. Avoid taking blood pressures for 24 hours in the extremity used for the injection C. Monitor peripheral neurovascular status

THORACENTESIS

Removal of fluid or air from the pleural space via a transthoracic aspiration  PREPROCEDURE 

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A. Obtain consent B. Obtain vital signs C. Prepare the client for ultrasound or chest radiograph, if prescribed, prior to procedure D. Assess results of coagulation studies E. Note that the client is positioned sitting upright, with the arms and head supported by a table at the bedside during the procedure F. 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 G. Instruct the client not to cough, breath

 POSTPROCEDURE  A.

Monitor vital signs  B. Monitor respiratory status  C. Apply a pressure dressing, and assess the puncture site for bleeding and crepitus  D. Monitor for signs of pneumothorax, air embolism, and pulmonary edema

PULMONARY FUNCTION TEST -

Include 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

PREPROCEDURE C. D. E. F. G.

Determine if an analgesic that may depress the respiratory function is being administered Consult with the physician regarding holding bronchodilators prior to testing Instruct the client to void prior to procedure and to wear loose clothing Remove denture Instruct the client to refrain from smoking or eating a heavy meal for 4 to 6 hours prior to the test

POSTPROCEDURE

LUNG BIOPSY

1. A percutaneous lung biopsy is performed to obtain tissue for analysis by culture or cytologic examination  2. A needle biopsy is done to identify pulmonary lesions, changes in lung tissue, and the cause of pleural effusion 

PREPROCEDURE  A. Obtain informed consent  B. Maintain NPO status prior to the procedure  C. Inform the client that a local anesthetic will be used but that a sensation of pressure during needle insertion and aspiration may be felt 

 POSTPROCEDURE

A. Monitor vital signs  B. Apply a dressing to the biopsy site and monitor for drainage or bleeding  C. Monitor for signs of respiratory distress, and notify the physician if they occur  D. Monitor for signs of pneumothorax and air emboli, and notify the physician if they occur  E. Prepare the client for chest x-ray film if prescribed 

VENTILATION PERFUSION LUNG SCAN 1. In the perfusion scan, blood flow to the lungs is evaluated  2. The ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation  3. A radionuclide may be injected for the procedure  PREPROCEDURE 

   

A. Obtain informed consent B. Assess for allergy to dye, iodine, or seafood C. Remove jewelry around the chest area D. Review breathing methods that may be required during testing

 POSTPROCEDURE

A. Monitor client for reaction to the radionulide  B. For 24 hours following the procedure, rubber gloves worn when urine is being discarded should be washed with soap and water before removing; then the hands should be washed after the gloves are removed  C. Instruct client to wash hands carefully with soap and water for 24 hours following the procedure 

SKIN TESTS An intradermal injection used to assist in diagnosing various infectious diseases  PREPROCEDURE  Determine hypersensitivity or previous reactions to skin tests  PROCEDURE  A. Use a test site that is free of excessive body hair , dermatitis, and blemishes  B. Apply at the upper one third of inner surface of left arm  C. Circle and mark the injection test site  D. Document the date, time, and test site 

POSTPROCEDURE  A. Advise the client not to scratch the test site, to prevent infection and abscess formation  B. Instruct the client to avoid washing the test site  C. Interpret the reaction of the injection site 24 to 72 hours after administration of the test antigen  D. Assess the test site for the amount of induration (hard swelling) in millimeters and the presense of erythema and vesiculation (small blister like elevations) 

ARTERIAL BLOOD GASSES Measure the dissolved oxygen and carbon dioxide in the arterial blood and reveal the acid-base state and how the oxygen is being carried to the body  NORMAL ABG VALUES  Ph: 7.35 to 7.45  Pco2: 35 to 45 mm Hg  HCO3: 22 to 27 mEq/L  Po2: 80 to 100 mm Hg  O2 saturation: 96% to 100%  Oxyhemoglobin dissociation curve: no shift 

PREPROCEDURE  A. Perform Allen’s test prior to drawing radial artery specimens  B. Have the client rest for 30 minutes prior to specimen collection  C. Avoid suctioning prior to drawing ABGs  D. Do not turn off oxygen unless the ABGs are ordered to be drawn at room air 

POSTPROCEDURE  A. Place the specimen on ice  B. Note the client’s temperature on laboratory form  C. Note the oxygen and type of ventilation that the client is receiving on the laboratory form  D. Apply pressure to the puncture site for 5 to 10 minutes and longer if the client is on anticoagulant therapy or has a bleeding disorder  E. Transport the specimen to the 

PULSE OXIMETRY

1. A non invasive test the registers the oxygen saturation of the client’s hemoglobin  2. This arterial oxygen saturation (SaO2) is recorded as a percentage  3. The normal value is 95% to 100%  4. After a hypoxic client uses up the readily available oxygen (measured as the arterial oxygen pressure, PaO2, on arterial blood gas testing) the reserve oxygen, that oxygen attached to the hemoglobin (SaO2), is drawn on to provide oxygen to the tissues  5. A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur 

PROCEDURE  A. A sensor is placed on the client’s finger, toe, nose, earlobe, or forehead to measure oxygen saturation, which is then displayed on a monitor  B. Maintain the transducer at heart level  C. Do not select an extremity with an impediment to blood flow  D. Results lower than 91% necessitate immediate treatment  E. If the SaO2 is below 85%, the body’s tissues have a difficult time becoming oxygenated; an SaO2 of less than 70% is life threatening 