Respiratory System Review

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STRUCTURES OFOF THE CONDUCTING STRUCTURES THE UPPER AIRWAYS: AIRWAYS: NasalCavity Cavity 1.1.Nasal Pharynx II.II.Pharynx Larynx III.III.Larynx IV. Tracheobronchial tree STRUCTURES OF THE STRUCTURES OFLOWER THE AIRWAYS:TISSUES: RESPIRATORY 1.I.Trachea Lungs II.II.Bronchial Alveoli Tree III. Lungs IV. Alveoli

STRUCTURAL FUNCTIONAL DIVISION Respiratory System

NASOPHARYNX

LARYNGOPHARYNX OROPHARYNX

Divisions of the PHARYNX Conducting Airways

LARYNX Conducting Airways

 supported by HORSESHOE C-SHAPED CARTILAGES (C-rings)  protection: MUCOCILIARY BLANKET  point of bifurcation: CARINA TRACHEA Conducting Airways

 inactivates vasoactive substances such as bradykinin  converts angiotensin I to angiotensin II  reservoir for blood storage

 contains abundant heparin producing cells located at the capillaries of the lungs

Functions of the LUNGS Respiratory Tissues

Parts of the Respiratory System: •

Lungs – soft, spongy, elastic structure, airtight chamber with distensible walls; functional structure of the respiratory system; consists of an apex and a base

•

Lobules – functional units of the lungs; consist of respiratory bronchioles, alveoli and pulmonary capillaries.

•

Lung Tissues – made up of elastin and collagen fiber that encircle the airways and small blood vessels.

Parts of the Respiratory System: • Pleura – a thin, smooth, transparent, doublelayered serous membrane that lines the thoracic cavity and encases the lungs; consists of a visceral and parietal fluid layer. • Pleural Space – area of negative pressures to prevent lung from collapsing; contains pleural fluid which separates the pleural layers. • Alveoli – grapelike cluster, around 300 to 400 million in each lung where actual gas exchange occur

CIRCULATION • the lungs are provided with a dual blood supply:

Pulmonary Circulation – arises from the pulmonary artery and provides for the gas exchange functions of the lungs Bronchial Circulation – distributes blood to the conducting airways and supporting structure of the lung. • Heparin-producing cells – particularly abundant in the capillaries of the lungs where small clots are trapped.

Other Related Structures

MECHANICS OF BREATHING 

•

•

Ventilation – movement of air between the atmosphere and the respiratory portion of the lungs. Resistance – determined chiefly by the radius of the airway through which the air is flowing. Lung Compliance – refers to the ease with which the lungs expands and indicates the relationship between the volume and the pressure of the lungs

Compliant Lung

Compliant Lung – distends easily when pressure is applied Noncompliant Lung – requires greater than normal pressure to distend it. SURFACE TENSION – result of air and liquid interface, facilitated by type 2 cells

Noncompliant Lung

MECHANICS OF BREATHING 

Perfusion – blood flow through the lungs

•

Ventilation Perfusion Ratio (V/Q) – necessary to meet adequate oxygenation of the blood.



Diffusion – process by which oxygen and carbon dioxide are exchanged at the air-blood interface

Intact and patent airway

Normal Chest Normal nerve stimuli for Anatomy Contraction and relaxation of Respiratory muscles Adequate Ventilation

Normal Contraction Of RV Normal Pressure and Resistance in The PV

Adequate Perfusion

Intact Pulmonary vessels Adequate pumping action of cardiac muscles

EFFECTIVE OXYGENATION

Adequate Distribution of gases

Intact Blood Vessels

Intact pleural membrane

Adequate amt Of O2 in the air Adequate Diffusion

Adequate amt Of RBC to Carry O2 Adequate bld Flow to the lungs

Adequate Hgb

Cerebral Cortex

Respiratory Control

NEUROLOGIC CONTROL • •

Medulla Oblongata – controls respiration and expiration Pons – controls rate and depth of ventilation Apneustic center – lower pons; stimulates the inspiratory medullary center to promote deep, prolonged inspiration Pneumotaxic center – controls pattern of respiration

•

Cortex – allows voluntary control of breathing

Receptor Sites that Assists in Breathing • Central chemoreceptors – located in the medulla; respond to an increase or decrease in the pH • Peripheral chemoreceptors – located in the aortic arch and carotid arteries; respond to changes in PaCO2 and pH.

Receptor Sites that Assists in Breathing • Stretch Receptors – located in the alveoli • Hering-Breuer reflex - stimulated when the lungs are distended and inhibits respiration so that the lungs do not become over distended • Proprioceptors – located in the muscles and joints; respond to body movements • Baroreceptors – located in the aortic arch and carotid bodies; respond to an increase or decrease in arterial blood pressure causing a reflex hypoventilation or hyperventilation

NURSING ASSESSMENT Nursing History: Risk factor Analysis Cancer: ♥ cigarette smoking – 3 or 4 clients who develop laryngeal cancer have smoked or currently smoke ♥ alcohol – act synergistically with tobacco ♥ occupational exposure – asbestos, wood dust, mustard gas, petroleum products,other noxious fumes ♥ Age ♥ Genetic Predisposition

Nursing History: Risk factor Analysis

Dust Mite House Dust

Pollen Grains

Asthma ♥ heredity ♥ environmental factors ♥ excitatory states, exercise, changes in temperature, strong odors Chronic Obstructive Pulmonary Disease (COPD) ♥ cigarette smoke- leading risk factor ♥ aging process ♥ hereditary and genetic predisposition

Nursing History: Risk factor Analysis Pulmonary embolism ♥ thrombi – most of which originated in the deep calf, femoral, popliteal or lilac veins ♥ major operations ♥ tumors, air, fat, bone marrow, amniotic fluid

Pulmonary Tuberculosis ♥ repeated close contact with an infected person ♥ low income population, poor nutrition ♥ residents of long term care facilities or institutional settings ♥ homeless people ♥ health care workers exposed to active TB

a. Biographical and Demographic Data • Name, sex, and living situation • Age – lung cancer and chronic lung disorders make the client appear older b. Current Health: Chief Complaint Dyspnea – difficult, uncomfortable or unpleasant breathing indicative of the discrepancy between the need for ventilation and the ability to meet the need; one of the most common manifestations of clients with pulmonary and cardiac disorders

Lung Cancer

Cough – a reflex that facilitates the removal of secretions and foreign materials from the tracheobronchial tree and the lungs - Dry, hoarse, congested, barking, wheezing, bubbling - weakness/paralysis of resp muscles, prolongrd inactivity, depression of medullary fxn - may cause stress incontinence -SPUTUM Characterististics: • Dry irritative cough • Severe changing cough • Cough at night • Cough at AM

• Hemoptysis – refers to the blood expectorated from the mouth in the form of gross blood, frankly bloody sputum, or bloodtinged sputum – Blood from nose – due to sniffing/irritation – Blood from lungs – bright red, frothy, salty taste, alkalinic with tickling sensation on throat, burning/bubbling sensation on chest – Blood from stomach – dark in color, acidic

Current Health: Chief Complaint Wheezing – produced when air passes through partially obstructed or narrowed airways on inspiration and expiration; may be audible or maybe heard only with stethoscope Stridor – harsh, high-pitched sound produced when air passes through a partially obstructed or narrowed upper airway on inspiration; associated with respiratory distress

Current Health: Chief Complaint Chest Pain – caused by coughing and pleuritic infections – Onset, location and radiation – Duration and character or quality – Frequency – Factors that predispose or relieve the pain – RETROSTERNAL PAIN – PLEURITIC CHEST PAIN Cyanosis – bluish discoloration of the skin and mucus membrane which occur when the level of the hemoglobin present in the blood is reduced

Symptoms Analysis

• Setting – time and place or particular situation – physical setting and psychological environment in which the client experiences the complaint • Timing – onset and period during which the problem has occurred; specific time of day • Client’s perception – unique properties of the complaint • Quantity and quality – amount, size, number, and extent of the chief complaint • Location – to determine whether the problem is cardiac or respiratory in origin • Aggravating and relieving factors – what precipitates worsens or alleviates a symptom? • Associated manifestations – chills, fever, night sweats, anorexia, weight loss, excessive fatigue, anxiety, hoarseness

Past Health History

• Childhood and Infectious Diseases – occurrence of TB, bronchitis, influenza, asthma and pneumonia ;existence of congenital problems; premature birth history. • Immunization – vaccination against pneumonia and influenza; date of vaccination • Major Illnesses and Hospitalization – previous hospitalization for respiratory problems; medical treatment; and the present status of the problem • Medications – prescribed and OTC medications; herbal remedies many products affect the respiratory system • Allergies – foods, medications, pollens, smoke, fumes, dust and animal dander, molds allergic manifestations (chest tightness, wheezing, cough, rhinitis, watery eyes, scratchy throat)

Family Health History • Identify blood relatives and family members who have had respiratory disorders, age and cause of death of deceased family member; household members who smoke

Psychosocial History • Occupation - work environment and hobbies; exposure to dust, asbestos, beryllium, silica and other toxins or pollutants • Geographical Location – recent travel to areas where respiratory disorders are prevalent • Environment – living conditions; how many are in the household • Habits – history of smoking; use of smokeless tobacco; alcohol use; use of recreational drugs • Exercise – typical activities • Nutrition – amount of caloric intake

Concept of Oxygenation •ASSESSMENT

Physical Assessment • establish the baseline information and provide framework for the detection of any changes that might occur in a client’s condition

Inspection

• Head and Neck – inspect for gross abnormalities that would interfere with respiration; odor of breath ● Note nasal flaring, breathing with pursed lips, or cyanosis

• Chest – observe chest wall configuration; size, contour, and anteroposterior diameter

• INSPECTION

 HEAD and NECK   Chest Wall CHEST Configuration * SHAPE OF THE CHEST: elliptical CHEST WALL DEFORMITIES

TYPE OF DEFORMITY

DESCRIPTION

ETIOLOGY

BARREL CHEST

APD = TD

Chronic Airflow Disorder

FUNNEL CHEST (Pectus excavatum)

Sternum is DEPRESSED, narrowing of the APD

Congenital in nature

PIGEON CHEST (Pectus carinatum)

Sternum projects forward, increased APD, wider TD

Congenital in nature

Thoracic Kyphoscoliosis

Appearance: hunchover, hunch back

Congenital in nature, spinal TB, osteoporosis, RA, poor posture

Chest movement  Retractions – most prominent in the lateral chest; indicative of labored breathing  Respirations  Biot’s Respiration – irregular periods of apnea that are followed by several breaths that are even in rate and depth  Cheyne – Stokes respiration – characterized by periods of hyperventilation alternating with periods of apnea  Kussmauls respiration – increased depth in breathing C. Pattern  Rate  Volume

IRREGULAR BREATHING PATTERNS TYPES OF IRRGULAR BREATHING PATTERN

DESCRITPTION

KUSSMAUL’S RESPIRATION

Blows more carbon dioxide through DEEP and RAPID BREATHING.

CHEYNE-STOKES RESPIRATION (also classified under APNEIC BREATHING PATTERNS)

Marked rhythmic, WAXING and WANING, from, VERY DEEP and VERY SHALLOW breathing and TEMPORARY APNEA. Common with CHF, ICP and drug overdose.

BIOT’S (Cluster) RESPIRATION (also classified under APNEIC BREATHING PATTERNS)

SHALLOW BREATHS interrupted by APNEA. Common with CNS disorders.

• INSPECTION  HEAD and NECK   Chest Wall CHEST Configuration Chest Movement  FINGERS * normal respiratory rate (accdg. and TOES to KOZIER) = 12 – 22 cpm.  observe for clubbing * men: abdominal breathers  perform the Schamroth’s Test * women: thoracic breathers  perform the Blanch Test  SKIN

Palpation • Trachea – palpate for masses, crepitus (air in the subcutaneous tissues), or deviation from the midline • Tacrile Fremitus/Vocal Fremitus • Thoracic excursion

• PALPATION

TRACHEA

> Place the thumb of the palpating hand on one side of the trachea and the remaining of the fingers on the other side. > Move the trachea gently from side-to-side along its length while palpating for masses, crepitus or deviations from the midline. NORMAL FINDINGS: trachea is movable and quickly returns to midline after CHEST WALL displacement. > Holding the HEEL or ULNAR ASPECT OF THE HAND against the client’s chest. > Palpate for the ribs and intercostal spaces. > Locate the angle of Louis (manubriosternal junction) by first palpating the clavicle and following its course of attachment at the

• PALPATIONCHEST WALL: POSTERIOR THORACIC

> Place the palms of both hands overEXCURSION the lower thorax with the thumbs adjacent to the spine and fingers stretched laterally. > Ask the client to take a deep breath while observing the movement of the hands an any lag in movement. NORMAL FINDINGS: full and symmetric chest expansion (thumbs should move apart with an equal distance at the same time. Approximately 3 to 5 cmWALL: (1.5 to 2 in). CHEST ANTERIOR THORACIC EXCURSION > Place the palms of both hands on the lower thorax with fingers laterally along the lower rib cage and thumbs along the costal margin. > Ask the client to take a deep breath while observing the movement of the hands and any

Percussion Sounds • •

• • •

Resonant sounds – low pitch hollow sounds heard over normal tissue Hyperresonant sounds – louder and lower pitch than resonant which indicate increases amount of air in the lungs or pleural space (EMPHYSEMA, PNEUMOTHORAX) Dull sounds – thudlike and medium pitch and normally heard over the liver and heart, occur over dense lung tissue such as tumor or consolidation Flat notes – soft high pitch heard during percussion of airless tissue (bony structure) Tympanic notes – high, drumlike sounds heard with percussion over the stomach, a large tension on pneumothorax or a large air-filled chamber

• NORMAL BREATH SOUNDS UPON AUSCULTATION AUSCULTATIO BREATH SOUNDS N DESCRIPTION LOCATION CHARACTERISTIC VESICULAR

BRONCHOVESICULAR

Soft-intensity, lowpitched, “gentlesighing” sounds created by air moving through smaller airways (bronchioles & alveoli). Moderate intensity and moderate pitched blowing sounds created by air moving through larger airways (bronchi).

Peripheral lungs, bases of the lungs

INSPIRATION. About 2.5 times longer than the expiratory phase (2:1).

Between the Equal inspiratory and scapulae and expiratory phases lateral to the (1:1). sternum at the 1st and 2nd ICS.

• AUSCULTATIO NORMAL BREATH SOUNDS UPON AUSCULTATION N BREATH SOUNDS DESCRIPTION LOCATION CHARACTERISTIC BRONCHIAL

High-pitched, loud, “harsh-sounds”.

Trachea.

Louder than vesicular sounds. Have short inspiratory and long expiratoryphases (1:2).

• ABNORMAL BREATH SOUNDS UPON AUSCULTATION AUSCULTATIO BREATH DESCRIPTION COURSE LOCATION N SOUNDS CRACKLES/ RALES

High-pitched. Fine, short, interrupted crackling sounds. Sounds like rubbing locks of hair between thumbs and fingers

Air passing through fluid or mucus in any air passage.

Bases of the lower lung lobes.

CONDITION: Pulmonary Edema, fibrosis, pneumonia

Heard during INSPIRATION and do not clear with cough GURGLES/ RONCHI

Continuous, lowpitched, coarse, gurgling, harsh, louder sounds, with moaning and snoring quality. EXPIRATION (can be heard on both)

Air passing through narrowed air passages as a result of secretions, swelling and tumors. CONDITION: PNEUMONIA, BRONCHITIS, BRONCHIECTASIS

Most lung areas but are louder on the trachea and bronchi.

• AUSCULTATIO ABNORMAL BREATH SOUNDS UPON AUSCULTATION N BREATH DESCRIPTION COURSE LOCATION SOUNDS FRICTION RUB

Superficial grating or creaking sound . “2 pcs of leather rubbing together” INSPIRATION and EXPIRATION

WHEEZE

Continuous, highpitched, squeaky, musical sounds. EXPIRATION.

Rubbing together of inflamed pleural surfaces. CONDITION: Pleurisy, Pneumonia, Pleural infarct Air passing through constricted bronchus as a result of secretions, swelling or tumors. CONDITION: Asthma

Heard most often in areas of greater thoracic expansion (lower anterior and lateral chest).

On all lung fields.

INSPECTION OF AN OBSTRUCTED AIRWAY UPON INSPECTION

INTERPRETATION

Low-pitched snoring sound during inhalation, labored breathing

Partial obstruction of the upper airway

Absence of sounds and rise and fall, accompanied (at times seen with deep retractions)

Complete/total airway obstruction

Stridor (a harsh high-pitched sound heard during inspiration)

Lower airway obstruction

Other adventitious breath sounds

DIAGNOSTIC PROCEDURES

PULMONARY FUNCTION TESTS Nursing Responsibilities: – Determine whether an analgesic that may depress the respiratory >function Provide information about is being administered. function by – respiratory Advise the client not to SMOKE OR measuring lung volume, lung EAT A HEAVY MEAL = 4 to 6 hrs before the test. and mehanics diffusion – capabilities Withhold BRONCHODILATOR of the lungs medications for 6 hrs before the test.

PULMONARY FUNCTION TESTS – Instruct the client to void before the procedure and wear loose clothing. – Remove dentures. – The client is asked to breathe through the mouth only. A nose clip is used to prevent air from escaping. The client is asked to perform different breathing maneuvers while measurements are obtained

PULSE OXIMETRY • Pulse oximeter measures the • REMINDERS: percentage of Hemoglobin saturated – Sensor NOT placed distally in BP with OXYGEN. cuffs, pressure dressings etc. – Sensor should NOT be taped into the •finger. Pulse oximeter passes a beam of light through the tissue and the – No dark nail polish. sensor measures the AMOUNT of – Normal O2 Sat. by 90-100% light absorbed O2- saturated HgB.

ARTERIAL BLOOD GAS ANALYSIS

• Use of ARTERIAL BLOOD to measure: • Nurse’s – PaO2, Responsibilities: PaCo2, pH – Educate the client regarding the need for the test. – Explain to the client the need to hold still. – Perform the Allen’s Test. – Keep the client calm. – 5 – 10 mL of arterial blood is

ARTERIAL BLOOD GAS Arterial Blood Gas Analysis ANALYSIS

• A needle connected to a heparinized syringe is utilized. • Most common site for blood withdrawal is the RADIAL ARTERY. • Apply continuous pressure to the site for 5 minutes and 10 minutes for femoral sites. • Place specimen on a container with ice & transport immediately to the lab.

ABG INTERPRETATION • Oxygenation Status – O2 Therapy • Acid – Base – pH: – PaCO2: – HCO3:

Interpretation 7.35 – 7.45 35- 45 mmHg 22- 26mEq/L

• Presence of and degree of compensation

CHEST X – RAY • Visualization of lungs, heart and surrounding structures. – Routine screening procedure – Suspicion of pulmonary disease – Monitor status of respiratory disorders – Evaluate extent of traumatic chest injury – Provide radiographic information

CT SCAN • Cross – sectional view of anatomic structures.

MRI SCAN • Use of magnetic field to provide a more detailed imagery than a CT scan. • May permit visualization of structures as they function.

ULTRASONOGRAPHY • Helpful and accurate in detecting the amount and location of 50mL or less of pleural fluid. • Permits visualization for obtaining an adequate amount of pleural fluid for laboratory analysis without unnecessary puncturing and probing. • 15 – 30 minutes in duration.

BRONCHOSCOPY • Pre - procedure

– Explain. Obtain informed consent. The test • Post procedure • Diagnostic/ Therapeutic lasts 30 – 45 minutes in duration. – Monitor patient’s vital signs. – NPO 6 hours prior to the test. of the • Permits visualization – Take note of dentures, the patient’s – Client must remove contact lenses bronchial tree via a lighted andrespiratory other prosthesis. status. bronchoscope – IV sedatives are administered to suppress

– Observe expectorated secretions. cough and anxiety. – Topical – NPO anesthetic will be returns. applied at the back until reflex of the mouth to decrease the gag reflex. – Feeding begins with ice chips. – Patient is positioned supine with head hyperextended. – Monitor lung sounds. – Inform the client that it is normal for the client to feel sore in the throat and difficulty

LARYNGOSCOPY • Permits visualization of the larynx – INDIRECT •Use of a mirror to visualize nasopharynx for drainage, bleeding and ulceration.

– DIRECT •Use of an endoscope to visualize the movement and

ALVEOLAR LAVAGE • Sterile saline injected to wet the tissue, then aspirated to examine atypical cells.

PULMONARY ANGIOGRAPHY • Assessment of pulmonary vascular structuressedation throughas anprescribed injection of a -Administer contrast medium through an - Avoid takingcatheter. BP for 24 hrs in the indwelling involved extremity • NURSING RESPONSIBILITIES: -Monitor peripheral neurovascular – Obtain informed consent status of extremities – Assess of allergies to iodine, seafood & other rediopaque dyes – NPO for 8 hrs before the test

THORACENTESIS • NURSING RESPONSIBILITIES: Pre-procedure: – Obtain informed consent – Ask pt. to sit upright while leaning on the tray table. – Instruct the client to hold still. Post-procedure: - Position pt. on the UNAFFECTED SIDE. - Apply pressure dressing & assess puncture site for bleeding & crepitus - Monitor for signs of pneumothorax, air embolism & pulmonary edema.

SPUTUM COLLECTION • Acid – fast bacillus staining/ sputum culture – Indirect method: • Direct method:

• Sterile suction catheter with an – Obtain early morning specimen (15 attached sputum trap or transtracheal ml) aspiration.

– Instruct client to rinse mouth with water • Gastric lavage – Deep breathing – Cough outconsistency, sputum in container Note color, odor and

amount

NOSE AND THROAT CULTURE • Swab nose and throat with the use of sterile cotton swab.

LUNG BIOPSY • Open Lung Biopsy • Aspiration Biopsy – After identification of the lesion via CXR and fluoroscopy, a needle will be inserted through the chest wall into the lung tissue and the lesion. – Definitive diagnosis of malignant neoplasms and granulomas – CX: hemoptysis,

SKIN TEST/MANTOUX TEST

• PPD (Purified Protein Derivative) • Intradermal • Read within 48-72 hrs after injection • (+) = induration of 10 mm or more • HIV (+) clients = 5 mm induration is (+) • (+) result = exposure to Mycobacterium tubercle bacilli