Respiratory

RESPIRATORY

I.

General Respiratory Anatomy and Physiology (illustration ) A. The respiratory system is comprised of the upper airway and lower airway structures. B. The upper respiratory system filters, moistens and warms air during inspiration. C. The lower respiratory system enables the exchange of gases to regulate serum PaO2, PaCO2 and Ph.

II.

Physiology (illustration ) A. Basic gas-exchange unit of the respiratory system is the alveoli. B. Alveolar stretch receptors respond to inspiration by sending signals to inhibit inspiratory neurons in the brain stem to prevent lung over distention. C. During expiration stretch receptors stop sending signals to inspiratory neurons and inspiration is ready to start again. D. Oxygen and carbon dioxide are exchanged across the alveolar capillary membrane by process of diffusion. E. Neural control of respirations is located in the medulla. The respiratory center in the medulla is stimulated by the concentration of carbon dioxide in the blood. F. Chemoreceptors, a secondary feedback system, located in the carotid arteries and aortic arch respond to hypoxemia. These chemoreceptors also stimulate the medulla. G. Ph regulation I. Blood Ph (partial pressure of hydrogen in blood): a decrease in blood Ph stimulates respiration hyperventilation, both through the neurons of the brain's respiratory center and through the chemoreceptors in carotid arteries and aortic arch. II. Blood PaCO2 (partial pressure of carbon dioxide in arterial blood): an increase in the PaCO2 results in decreased blood Ph, and stimulates respiration as described above. III. Blood PaO2 (partial pressure of oxygen in arterial blood): a decrease in the PaO2 results in a decreased blood Ph, stimulating respiration as described above. IV. When arterial Ph rises or the arterial PaCO2 falls, hypoventilation occurs.

V.

Disorders of the Upper Respiratory System A. Allergic rhinitis (hay fever) - sensitivity to allergens with whitish or clear nasal discharge

B.

C.

Sinusitis (illustration ) 1. Medical condition a. inflammation of mucus membranes in the sinuses b. may be followed by infection with a yellowish-green discharge 2. Management a. treatment with antibiotics, decongestants, antihistamines b. surgery to drain and open sinuses c. antral irrigation (sinus irrigation) d. Caldwell-Luc procedure Upper airway obstruction (choking) 1. Findings a. stridor (harsh, vibrating breath) b. no sound of air c. both hands of client around the throat

d.

D.

E.

management: emergency treatment (illustration i. Heimlich maneuver ii. cricothyrotomy (cut cricoid cartilage) iii. tracheotomy/tracheostomy

Pharyngitis 1. Inflammation of mucous membranes of pharynx 2. Bacterial, viral, environmental causes 3. Treat findings; if culture shows bacteria, use antibiotics Tonsillitis 1. Inflammation and/or infection of tonsils 2. Acute form is usually bacterial 3. Treat findings; if culture shows bacteria, use antibiotics

)

F.

G.

H.

VI.

Peritonsillar abscess 1. Complication of acute tonsillitis 2. Infection spreads to surrounding tissue 3. If swelling is massive, can endanger airway 4. Treat findings; if culture shows bacteria, use antibiotics Vocal cord disorders 1. Laryngitis a. inflammation of vocal cords and surrounding mucous membranes b. cause: something irritates the larynx c. occurs in viral and bacterial infections d. in children, called croup (larynx blocked by edema, spasm or both) e. treat findings, rest voice, remove irritants, gargle with warm salt water 2. Vocal cord paralysis a. injury, trauma or disease of larynx, laryngeal nerves or vagus nerve b. may result as a complication after thyroidectomy surgery c. assess how well client can protect airway d. can sometimes be surgically treated with Teflon injection Cancer of the larynx 1. Etiology a. most tumors of the larynx are squamous cell carcinoma b. more common among men, age 50 to 65 c. cigarette smoking and alcohol consumption are related 2. Findings a. persistent sore throat b. dyspnea c. dysphagia d. increasing persistent hoarseness e. weight loss f. enlarged cervical lymph nodes 3. Management a. radiation therapy b. chemotherapy c. surgery: removal of all or part of larynx to treat cancer i. total laryngectomy: no voice, permanent stoma in neck with no risk of aspiration from oral cavity ii. radical neck dissection: when cancer has metastasized to surrounding tissues 4. Nursing interventions a. arrange for clients with larnygectomies to meet with members of support groups b. establish a method for communication before surgery c. maintain airway; have suction equipment at bedside d. observe for signs of hemorrhage or infection e. teach about trach and stoma care f. assist with period of grieving

Disorders of Lower Respiratory System (LRS): Obstructive A. General facts: process in chronic obstructive pulmonary diseases 1. Block airflow out of lungs 2. Trap air, with impairment of gas exchange 3. Increase the work of breathing B. Emphysema 1. Destroys alveoli 2. Narrows and collapses small airways 3. Overall lung loses elasticity 4. Traps air 5. As alveolar walls die, there is less surface for vital gas exchange C. Chronic bronchitis 1. Definition

2. D.

a. b. Findings a. b.

inflammatory response in the lung affects few alveoli, mostly airways lungs chronically produce fluids inflammation and mucus narrow the airways

Asthma 1. Definition/etiology a. reversible obstruction of airways b. inflammation of airways c. airways hypersensitive to variety of stimuli d. bronchospasm is a minor component e. disease waxes and wanes, remissions and exacerbations 2. Findings a. orthopnea, expiratory wheezing

b. c. d.

e. f.

3.

4.

barrel chest, cyanosis, clubbing of fingers distention of neck veins edema of extremities increased PCO2 and decreased PO2

polycythemia Diagnostics a. physical examination with history of findings b. arterial blood gases c. chest x-ray Complications a. hypoxemia

b.

hypercapnia variety of respiratory infections d. cor pulmonale e. dysrhythmias Management for obstructive disease 1. Antibiotics and corticosteroids for infection or chronic inflammation 2. Bronchodilators 3. Mucolytics 4. Expectorants 5. Respiratory program: postural drainage, exercise, nebulizer, high protein diet (illustration c.

E.

1 illustration 2 ) Nursing interventions common to obstructive diseases 1. Assess client's risk of respiratory failure 2. Assess for degree of respiratory effort for an increased work of breathing or dyspnea 3. Assess oxygenation with pulse oximeter if hemoglobin level is within normal limits 4. Measure arterial blood gases (ABG) to evaluate gas exchange 5. Administer oxygen as indicated 6. If risk of respiratory failure, anticipate ventilation 7. Assist with secretion removal as indicated 8. Pace client activities to reduce oxygen demand 9. Teach diaphragmatic breathing and pursed-lip breathing 10. Position in a high Fowler's to ease breathing effort 11. Provide for nutritional consults as indicated 12. Reinforce the plan for small, frequent high carbohydrate meals 13. Provide referrals for: a. depression associated with disease b. pulmonary rehabilitation c. stop smoking support groups 14. For asthma, teach clients that aspirin or peanuts may stuimulate an asthma attack LRS Disorders: Restrictive A. In general: these disorders prevent full lung expansion via three mechanisms 1. Lung stiffening 2. External compression 3. Muscle weakness F.

VII.

B.

Pulmonary fibrosis- lung stiffening 1. Occupational lung diseases a. coal worker's pneumoconiosis - risk increases with length of exposure to coal dust (>15 years), intensity of exposure, and silica content of dust b. silicosis: workers who will have inhaled silica dust 2. Asbestosis a. inhalation of asbestos fibers b. disease may develop 15 to 20 years after exposure Pulmonary sarcoidosis - lung stiffening 1. Etiology a. unknown origin b. characterized by formation of tubercles, most often in the lungs c. may progress to fibrosis 2. Findings a. dyspnea b. anxiety 3. Diagnostics a. chest x-ray b. biopsy of affected tissue 4. Management a. antitussives b. oxygen therapy c. removal of toxic substances Nursing interventions common to all types of pulmonary fibrosis 1. Prevent infection or exposure to infection 2. Pace clients' activities to reduce oxygen demands and dyspnea 3. Reinforce the need for small, frequent meals 4. Encourage daily activities within pulmonary tolerance a. provide referrals for: I. depression associated with disease II. stop smoking support groups III. occupational rehabilitation

C.

D.

E.

Disorders of fluid in pleurae 1. Pleural fluid disorders - all treated with water seal chest drainage systems

2.

Pneumothorax: air between the pleurae a. open pneumothorax: hole in the chest wall, communicates with the lung b. closed pneumothorax: hole in lung, chest wall intact c. tension pneumothorax - a nursing and medical emergency i. closed pneumothorax ii. air is forced into the pleural space with a continued pressure build up

iii. iv. v.

shifts mediastinum away from affected side with results of a compressed heart treated with chest tube insertion cardiac and respiratory arrest if not treated

d. examples of the above (illustration ) Pleural effusion a. fluid (transudate or exudate) in the pleural space b. if small, no treatment c. if larger, treated with chest tube insertion 4. Hemothorax a. blood in the pleural space b. treated with thoracentesis or chest tube 5. Empyema a. purulent drainage in the pleural space b. often from a chronic condition such as lung cancer c. treated with chest tube inserton 6. Chylothorax a. lymphatic fluid in pleural space b. treated with thoracentesis or chest tube Musculoskeletal diseases associated with difficulty breathing 2. Guillain-Barre syndrome - follows a viral infection a. ascending paralysis that may affect muscles of respiration as paralysis ascends b. muscles so weak that client cannot breathe deeply, a nursing and medical emergency c. may progress to respiratory failure i. may require intubation ii. mechanical ventilation iii. course of illness varies from a few months to years 3. Myasthenia gravis a. sporadic, progressive weakness of skeletal muscle b. cause: lack of acetylcholine with results of a myoneural junction malfunction c. may not be able to chew and swallow well i. may aspirate ii. may lose protective airway reflexes d. repeated muscle movements, especially towards days end, can exacerbate acute respiratory failure 3.

6.

All of these musculoskeletal disorders EXCEPT Guillain-Barre feature the letter M: -Myasthenia gravis -Poliomyelitis -Amyotrophic Lateral Sclerosis -Muscular dystrophies

3.

4.

Poliomyelitis a. viral infection b. if disease strikes the respiratory muscles the result may be respiratory failure c. may not swallow well i. may aspirate ii. may lose protective airway reflexes Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease) a. affects motor neurons; autonomic, sensory and mental function unchanged b. manifests as a chronic, progressive irreversible disorder c. begins usually in distal ends of upper extremities

d. e.

5.

6.

often leads to respiratory failure within two to five years results in ethical issue i. whether clients want mechanical ventilation ii. whether nutritional support is desired iii. if they would rather die when disease becomes this severe f. results in clients' inability to communicate or physically move from voluntarily and/or clients lack involuntary reflexes, such as blinking or gag reflex Muscular dystrophies a. progressive symmetrical wasting of voluntary muscles with no nerve effect b. as thoracic muscles weaken, breathing becomes more difficult c. may not swallow well; risk for aspiration with loss of protective airway reflexes Interventions common to musculoskeletal disorders a. monitor carefully for changes in condition

b. c. d. e. f. g. h. i. 2.

j. LRS Disorders: Infectious

1.

assess regular swallowing and ability to protect the upper airway discuss chances of mechanical ventilation or nutritional support: does client wish it? assist with coughing and secretion clearance as indicated prevent infection assess for with appropriate referrals for depression that is often associated with these diseases administer medications specific to the disease condition assist/provide occupational or/and physical rehibilitation as indicated maintain adequate nutrition with terminal disorders, provide for referrals for family

Pneumonia (illustration ) 3. Definition/etiology a. acute infection of lung parenchyma b. cause: bacterium, virus, protozoan, mycobacterium, mycoplasma, or rickettsia c. pneumonia is the leading cause of death from infectious causes d. may affect only a region of lung: lobar pneumonia, bronchopneumonia e. may be the result of: i. primary infection ii. secondary to other lung damage iii. aspiration 4. Risk factors for pneumonia a. pre-existing pulmonary disease b. abdominal and thoracic surgery c. mechanical ventilation d. advanced age e. decreased ability to protect airway or cough effectively f. artificial airway g. chronic illness and debilitation h. depressed immune function i. cancer 5. Diagnostics a. chest radiograph b. sputum culture, sensitivity and microscopic analysis, Gram stain, cytology c. ABG as indicated by clinical condition 6. Management a. antimicrobials, depending on pathogen b. antipyretic c. expectorants d. antitussives e. supplemental oxygen, as indicated f. IV fluids to treat dehydration 7. Nursing interventions a. monitor finger oximeter if hemoglobin levels within normal limits

b. c. d. e. f.

8.

2.

promote hydration to liquify secretions teach effective coughing techniques to minimize energy expenditure suction if necessary teach the need to continue entire course of antimicrobial therapy which is usually seven to ten days teach that findings are expected to be less within 48 to 72 hours of initial therapy

Pulmonary tuberculosis (PTB) (illustration ) a. Etiology i. mycobacterium tuberculosis ii. bacilli lodge in alveoli iii. pulmonary infiltrates iv. can spread throughout body via blood v. multi-drug resistant PTB is becoming more prevalent vi. PTB incidence is rising with increasing homelessness and AIDS b. Findings i. weakness with fatigue ii. anorexia with weight loss iii. night sweats iv. chest pain v. productive cough c. Diagnostics i. sputum and gastric contents, analysis for the presence of acid-fast bacilli ii. chest x-ray for presence of active or calcified lesions, "coin" lesions iii. tuberculin testing 1. tine, mantoux tests 1. checked 48 to 72 hours for induration 2. positive if >10 mm induration in healthy persons iv. establishes if there is an antibody response to the tubercle bacillus v. if positive, indicates prior exposure to bacillus, not an active disease d. Management i. long-term, six to 24 months, antimicrobial therapy with isoniazid (INH) (Hyzyd) or rifampin (Rifadin), with ethambutol HCL (Etibi) in some cases ii. bed rest or chair rest until findings abate iii. surgical resection of involved lung if medication is not effective iv. high carbohydrate, high protein diet with frequent small meals e. Nursing interventions i. with active infection, client must be isolated with airborne precautions when in the hospital ii. teach client 1. proper techniques to prevent spread of infection: hand washing, etc. 2. to report bloody sputum 3. not to use over the counter (OTC) medications without health care provider's approval 4. importance of taking medications as prescribed 1. adherence to treatment regimen 2. return at scheduled times for lab testing of liver enzymes 3. an increase in B6 to minimize peripheral neuropathies, a common side effect of drug therapy Lung abscess 3. Localized area of lung infection 4. Usually follows pneumonia, TB or aspiration 5. Treatment consists of draining and culturing abscess and antimicrobial therapy

IX.

LRS Disorders: Miscellaneous

A.

B.

Pulmonary embolism 1. Definition/etiology a. clot blocks blood from the "bed" of arteries that feed the lung b. client is breathing but gases are not exchanged - ventilation without perfusion c. hypoxemia results d. can be mild or immediately fatal, based on the size and location of clot(s) e. usually clot has traveled from deep veins in the leg or pelvis 2. Diagnostics a. ventilation/perfusion (V/P) scan, also called V/Q scan b. ABG c. EKG 3. Management a. oxygen via mask b. anticoagulation - heparin in acute and coumadin for chronic risk c. thrombolytics d. filter surgically placed in vena cava for long term care Acute respiratory distress syndrome (ARDS) 1. Definition/etiology a. alveolar capillary membrane becomes more permeable to fluids b. increased extravascular lung fluid c. pulmonary compliance decreases d. intrapulmonary shunt increases e. refractory hypoxemia f. usually seen after lung injury or massive multi-system organ disease 2. Findings a. restlessness, anxiety b. dyspnea c. tachycardia d. cyanosis e. intercostal retractions 3. Diagnostics a. clinical presentation and history of findings b. hypoxemia on ABG despite increasing inspired oxygen level c. chest x-ray shows diffuse infiltrates 4. Management a. optimize oxygenation I. mechanical ventilation II. sedation may be required III. paralytic agents may be necessary

C.

b. antibiotics, as indicated c. corticosteroids 5. Nursing interventions a. plan for frequent rest periods b. monitor trends in oxygenation status, ABGs, respiratory effort c. observe for behavioral changes and vital signs; confusion and hypertension may indicate cerebral hypoxia Lung cancer 1. Definition/etiology a. types of lung cancer

I. II. III. IV.

2.

3.

squamous cell carcinoma small-cell (oat cell) carcinoma adenocarcinoma

large cell carcinoma b. prognosis is generally poor c. largely preventable if smokers stop and nonsmokers avoid second hand smoke Findings a. hoarse voice b. changes in breathing c. persistent cough or change in cough d. blood-streaked or bloody sputum e. chest pain or tightness in chest wall f. recurring pneumonia, pleural effusion g. weight loss Diagnostics a. medical imaging examinations b. cytological sputum analysis c. bronchoscopy d. biopsy

SQUAMOUS CELL CARCINOMA

A. B.

C.

Risk factors 1. Is most often associated with cigarette smoking 2. Exposure to environmental carcinogens e.g. uranium, asbestos Characteristics 1. Accounts for 30-35% of lung cancer cases 2. Is more common among men 3. Findings occur earlier because of bronchial obstructive characteristics (arises from bronchial epithelium) 4. Causes cavitating pulmonary lesions 5. Usually metastasizes locally Therapy 1. Life expectancy is better than small cell carcinoma 2. Surgical resection is often attempted

SMALL CELL CARCINOMA

A.

Risk Factors 1. Cigarette smoking

B.

C.

2. Environmental carcinogens Characteristics 1. Accounts for 15% to 25% of lung cancers 2. Spreads early 3. Very malignant form 4. Is often associated with endocrine disturbances Therapy 1. Poorest prognosis 2. Average survival is less than one year

ADENOCARCINOMA

A.

B.

C.

Risk Factors 1. Not related to cigarette smoking 2. Lung scarring 3. Chronic interstitial fibrosis Characteristics 1. More common among women 2. Accounts for about half of all lung cancers 3. Usually located in peripheral section of lungs 4. Often no clinical signs or findings until well advanced Treatment 1. Does not respond well to chemotherapy 2. Most often, surgical resection is attempted

LARGE CELL CARCINOMA

A. B.

C.

Risk Factors 1. Cigarette smoking 2. Environmental carcinogens Characteristics 1. Occurs in 15-25% of all lung cancers 2. Frequently metastases via blood 3. Usually peripheral rather than centrally located in the lung lobes Therapy 1. Usually client is not a candidate for surgery due to the high frequency of metastasis 2. Tumors often responds to radiation therapy but frequently recurs A. Management A. nonsurgical A. chemotherapy B. radiation therapy C. laser therapy to de-bulk tumor D. thoracentesis and pleurodesis B. surgical A. thoracotomy A. wedge resection - part of a lobe B. segmental resection- part of a lobe C. lobectomy - one or more lobes D. pneumonectomy - entire right or left lung B. Nursing interventions A. post-operative care A. chest drainage B. routine post operative care A. monitor respiratory status frequently B. teach effective deep breathing and cough techniques

C.

C. D. E. F. 3.

refer to physical therapy for exercises for shoulder on affected side D. relieve pain optimize oxygenation provide opportunities for the client to talk about cancer; as needed, refer to support groups teach information as based on treatment plan and prognosis optimize nutritional status

Cor pulmonale A. Definition/etiology A. right ventricular hypertrophy and subsequent chronic heart failure B. cause: heart must pump against great resistance from lung's blood vessels: called increased pulmonary vascular resistance (PVR) C. increased PVR results from chronic lung disease D. may be due to primary pulmonary hypertension as well B. Diagnostics

A.

4.

pulmonary artery pressure readings via a catheter (illustration ) B. echocardiogram C. chest radiograph D. ABG E. EKG C. Management A. administer oxygen as ordered B. if hemoglobin within normal limits (WNL), monitor oxygenation with finger or pulse oximeter C. bed rest, as needed D. monitor effects of medications A. cardiac glycosides B. pulmonary artery vasodilator C. diuretics D. restricted fluid intake as indicated E. nursing interventions A. monitor for changes in oxygenation status B. pace activities in clients who tire easily Respiratory failure A. Definition: lungs cannot maintain arterial oxygen levels or eliminate carbon dioxide A. PaCO2 > 50 mm Hg

B. C.

B.

Etiology

A.

lung diseases that harden the alveolar-capillary membrane to trap O2 neuro-muscular or musculoskeletal disorders A. respiratory drive dulled or blunted B. muscles too weak to breathe C. Diagnostics: ABG D. Management A. oxygen per mask B. mechanical ventilation C. monitor for improvement in the underlying cause for the respiratory failure Oxygen is essential for life. So, before all else, keep airways open and ease breathing effort. Clients with chronic lung disease use more oxygen and energy to breathe. This can create a vicious cycle in which the client works harder, and continually requires more oxygen and more energy. Nursing interventions for clients with chronic lung disease should include pacing of activities, because these clients have little reserve for exertion. Quality of life for clients can be significantly improved if clients routinely use diaphragmatic breathing and pursed-lip breathing. B.

D. E. F. G.

PaO2 < 50 mm Hg clients with chronic lung disease precautions A. look for drop from baseline function B. this is a nursing and medical emergency C. clients are always hypoxemic

H.

Clients with asthma must understand the different types of inhalers and when to use each type. Some rescue inhalers are for acute dyspnea. Other inhalers are for maintenance or preventative types of drugs. I. A finger or pulse oximeter reading is simply one element of an assessment. It is not the whole picture. J. Cyanosis, a late finding, is determined by oxygenation and hemoglobin content. K. Clients with anemia may be severely hypoxemic and never turn blue, but rather "ashen". L. Clients with polycythemia may be cyanotic with adequate tissue oxygenation. M. The serious public health issue of pulmonary TB requires control and reporting of any incidence and recent contacts that the client had so prophalactic therapy for two to three months can be initiated. N. When caring for a client after a chest tube insertion, an occlusive dressing is placed around the chest tube insertion site and the connections of the chest tube system are taped to prevent air leaks at connections. An occlusive dressing is one that is totally covered, as well as the edges with non-porous tape. This dressing is typically not changed and not expected to have any drainage on it.

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• • • • • •

When caring for a client on a ventilator, if an alarm sounds, first, assess the client. See if the alarm resets or if the cause is obvious. If the alarm continues to sound and the client develops distress, disconnect the client from the ventilator, use a manual resuscitation bag to ventilate with 100% oxygen and page or call the respiratory therapist immediately. If the ventilator tube disconnects, the low pressure alarm will sound. If the high pressure alarm sounds on the ventilator, the nurse should check for some type of obstruction or occlusion of the airway: mucous plugs, biting of the tube by the client, tube slips into right main stem bronchus, or increased secretions. To maximize therapeutic effect of inhalers, the key is technique. It is critical to teach clients the right technique and observe how well they use the inhaler. Smoking cessation is critical to reduce the risk and severity of lung disease. Second-hand smoke enhances the risk of children to develop asthma or other chronic lung diseases. Best approach to pulmonary embolus is prevention. The use of intermittent compression stockings prevents clots in the deep veins. Clients with pulmonary TB need intensive community follow up to ensure that they continue with pharmacological treatment once discharged from the hospital. Clients who stop therapy too soon are the source for the more deadly multi-drug resistant forms of pulmonary TB. Acidosis Alkalosis Antibiotic Anticholinergic Apnea Auscultation Bronchodilator Cheyne-Stokes COPD Cor Corticosteroid Crackles Cromolyn Croup Hypercapnia Hyperpnea Hyperventilation hypocapnia Hypoventilation Hypoxemia Hypoxia Influenza Kussmaul's Kyphosis Mucolytic Nosocomial

Pulmonale sodium

breathing pneumonia

Pleurodesis Pneumoconiosis Scoliosis Tachypnea Thoracentesis Wheezes

• • • • • • • • • • • • • • • • • • •

Action of Cilia Alveolocapillary membrane Alveolus of lungs Central venous catheter Drainage of lower lobes Epiglottis Glottis and vocal chords Heimlich manuever Larynx Lungs Paranasal Sinuses Pneumocystis Carinii Pneumonia Pneumothorax Postural drainage of lungs Respiratory System Sternum Trachea Tubercolosis Two views of the nasal cavity