1 Unit 1 Respiratory A&P ReviewData Collection and Assessment, Diagnostic Tests, Treatments and Nursing Care 1

2 Student Learning GoalsIdentify data to be collected in the nursing assessment of the patient with a respiratory disorder. Identify the nursing implications of age-related changes in the respiratory system. Describe diagnostic tests or procedures for respiratory disorders and nursing interventions. Explain nursing care of patients receiving therapeutic treatments for respiratory disorders.

3 Anatomy of the Respiratory System3

4 Structure of the respiratory system. A, Upper respiratory tractStructure of the respiratory system. A, Upper respiratory tract. B, Lower respiratory tract. 4

5 Nose External nose Nasal cavity The part that is seen on the faceMade of bones and cartilage covered with skin Lining: thick mucous membranes and small hairs Nasal cavity Lies over the roof of the mouth Lined with mucous membranes along with the cilia (small hairlike projections) 5

6 Pharynx A 5-inch tube extending from the back of the mouth to the esophagus Nasopharynx lies behind the nose Oropharynx lies behind the mouth Laryngopharynx lies behind the larynx 6

7 Pharynx cont’d A passage for the respiratory and digestive systemsFunctions in the formation of sounds, especially vowel sounds Tonsils located in the pharynx; may interfere with breathing, particularly nasal breathing, if they become enlarged 7

8 Larynx The air passage between the pharynx and the tracheaContains vocal cords and several types of cartilage, including the thyroid cartilage and the epiglottis During swallowing the epiglottis acts like a lid to help prevent aspiration of food into the trachea Vocal cords: folds of mucous membranes attached to cartilage; extend from the front to the back of the larynx Sounds produced when air from the lungs causes a rapid, repeated opening and closing of the glottis Sounds transformed into speech by lips, jaws, and tongue 8

9 Trachea A 4- to 5-inch tube descending from the larynx into the bronchi Made of cartilage, smooth muscle, and connective tissue lined by a layer of mucous membrane A passageway for air to reach the lungs 9

10 Bronchi Passageway for air to and from the lungsTwo primary bronchi split to the right and left from the trachea Right bronchus is shorter and wider and runs straighter up and down than the left bronchus 10

11 Bronchi cont’d Larger bronchi divide into smaller, or secondary, bronchi; divide again into smaller tertiary bronchi Tertiary bronchi divide into smaller bronchioles, which lead into tiny air sacs called alveoli in the lungs Through the walls of the alveoli, exchange of oxygen and carbon dioxide takes place 11

12 The terminal bronchioles, alveoli, and capillaries.12

13 Lungs Located in right and left sides of the thoracic cavity within the chest wall Thoracic cavity is separated from the abdominal cavity by the diaphragm, a large sheet of muscle Three lobes on the right and two on the left Each lung covered by membrane: the pleura A sac containing a small amount of fluid that acts as a lubricant for the lungs when they expand and contract 13

14 Physiology of the Respiratory SystemMechanism of breathing Inspiration: air entering the lungs Active contraction of the muscles and diaphragm and can be noted by an enlargement of the chest cavity Expiration: air leaving the lungs Muscles relax and the chest returns to normal size Normal breathing: 500 ml of air inhaled and exhaled 14

15 Background AssessmentQuestion: How would you explain the statement “Respiration is monitored and controlled by the brain.” Question: How would you explain the statement “Respiration is monitored and controlled by the brain.” Answer: The respiratory center is located in the medulla, the part of the brainstem just above the spinal cord. Chemoreceptors located in the aorta and carotid artery detect changing blood pH and levels of carbon dioxide and oxygen. Lowered arterial oxygen or raised carbon dioxide stimulates signals down the phrenic nerve. The phrenic nerve sends signals to the respiratory muscles to carry out the major work of breathing. Where is the medulla located? Part of brainstem just above the spinal cord

16 Physiology of the Respiratory System cont’dRespiratory center Located in medulla; controls breathing Stimulated by changing levels of carbon dioxide and oxygen in arterial blood 16

17 Physiology of the Respiratory SystemChemoreceptors in the aorta and carotid artery monitor the pH and amount of carbon dioxide and oxygen in the bloodstream Changes in the pH, increased levels of carbon dioxide, or decreased levels of oxygen cause signals to be sent to the phrenic nerves, which in turn send signals to the respiratory muscles to carry out the major work of breathing

18 Age-Related Changes Muscle atrophy of pharynx and larynx, slackening vocal cords, less elasticity of laryngeal muscles and cartilages May result in a gravelly, softer voice with a rise in pitch Deviation of trachea if scoliosis of upper spinal column 18

19 Age-Related Changes Loss of lung elasticity, enlargement of the bronchioles, and a decreased number of functioning alveoli More susceptible to lung infections because of less effective respiratory defense mechanisms Reduced chest movement and ability to inhale and exhale, less effective cough, increased work of breathing, and less tolerance for exercise and stress

20 Age-Related Changes in the Nose, Sinuses, and ThroatNasal obstruction more common because of the softening of the cartilage of the external nose Mucous membrane thinner; produces less mucus Epistaxis (nosebleed) more common in older people Decline in the sense of smell as people age Tissues of larynx are drier and less elastic in older adult Weakened esophageal sphincter allows gastric contents to flow back into the throat when the patient lies down 20

21 Respiratory Terms Apnea Dyspnea Orthopnea Bradypnea TachypneaHemothorax Pneumothorax Crackles – coarse & fine Rhonchi Wheezes Biot’s Resp Cheyne Stokes Resp Kussmaul’s Resp Clubbing (and it is not a night out)

22 Lung Sounds Websites QR CODE LUNG SOUNDS ASSESSMENT

23 Respiratory Terms Atelectasis Empyema Hypercapnia Hypoxemia HypoxiaArterial Blood Gases Bronchoscopy Thoracentesis Thoracotomy Pulse Oximetry Decongestants Antitussives Antihistamines Expectorants Bronchodilators Atelectasis Empyema Hypercapnia Hypoxemia Hypoxia Pleural Effusion Ventilation Tissue Perfusion

24 Nursing Assessment of the Respiratory System24

25 Chief Complaint and History of Present IllnessCough Onset duration frequency type (wet or dry) severity related symptoms (sputum production and pain) 25

26 Chief Complaint and History of Present IllnessDyspnea Onset duration severity precipitating events Pain Location, severity, onset, duration, and precipitating events (trauma, coughing, inspiration)

27 Past Medical History and Family HistoryAllergies, colds, pneumonia, tuberculosis, chronic bronchitis, emphysema, asthma, cancer of the respiratory tract, cystic fibrosis, sinus infections, ear infections, diabetes mellitus, and heart disease Conditions that suppress the immune response 27

28 Past Medical History and Family HistoryAll recent and current medications, including over-the-counter drugs, and dates of the most recent chest radiograph and tuberculin skin test Inquire about pneumonia and influenza immunizations Family history; describe any major respiratory conditions and the smoking history of members of the household

29 Review of Systems Assess for:fatigue, weakness, fever, chills, night sweats, earaches, nasal obstructions, sinus pain, sore throat, hoarseness, edema, dyspnea, and orthopnea 29

30 Functional AssessmentPatient’s occupational history, including exposure to pathogens or substances that might irritate or harm the respiratory tract Ask about the usual diet and fluid intake Smoking history reported in packs per day 30

31 Physical Examination Head and neckInspect the nose for symmetry and for deformity and gently palpate for tenderness Palpate sinus tenderness with thumbs: apply pressure over frontal and maxillary sinuses Inspect lips, tip of nose, top of auricles, the gums, and area under the tongue for cyanosis 31

32 Physical Examination cont’dThorax Inspect chest for deformities and lesions and observe the breathing pattern and effort Palpate thorax for tenderness and lumps Systematically auscultate the lungs bilaterally Inspect the abdomen for distention Inspect extremities for color; palpate for edema 32

33 Sequence for percussion and auscultation of the lungs.33

34 Clubbing is a flattening of the angle between the nail and the skinClubbing is a flattening of the angle between the nail and the skin. A, Normal angle of 160 degrees. B, Early clubbing: the angle is flattened to 180 degrees. C, Advanced clubbing: the angle is greater than 180 degrees. D, The Schamroth technique: the patient puts the nails of the ring fingers of each hand together and holds the other fingers straight up. The examiner looks at the space between the touching nails. If there is no clubbing, the space is diamond shaped. 34

35 Diagnostic Tests and ProceduresRadiologic studies Chest radiography (Chest X-Ray) Fluoroscopy A motion radiograph of the lungs used to screen and diagnose some respiratory disorders. Studies the motion of breathing. Ventilation-Perfusion Scan (Lung Scan) radioactive dye injected. demonstrates lung ventilation/perfusion and detects pulmonary embolism. 35

36 Diagnostic Tests and ProceduresImaging procedures Computed Tomography looks at different sections of the lungs. Identifies lesions and tumors. If contrast dye is used, may be NPO 6-8 hrs. prior to procedure. Magnetic Resonance Imaging non-invasive nuclear procedure which can distinguish between cancerous & non-cancerous cells. May not be able to test with certain metal implants. May need a sedative or open MRI. Positron Emission Tomography

37 Diagnostic Tests and ProceduresPulmonary function tests measurement of amount of air inhaled and exhaled. Spirometry used to measure pulmonary function.

38 Lung Volumes and CapacitiesTLC – Total Lung Capacity FEV – Forced Expiratory Volume FRC – Functional Residual Capacity IC – Inspiratory Capacity VC – Vital Capacity FVC – Forced Vital Capacity

39 Diagnostic Tests and ProceduresArterial Blood Gas (ABG) analysis Gasses in the blood pH, PaCO2, PaO2, HCO3 detects acidosis or alkalosis alterations in oxygenation status

40 Normal ABG Ranges pH: PaCO2: 35 – 45 mm Hg PaO2: 80 – 100 mm Hg HCO3: 22 – 26 mEq/L

41 pH: Normal Blood pH: Below = acidosis (< 7.35) Above = alkalosis (> 7.45)

42 PaCO2 Normal : 35-45 mmHg. Increase = respiratory acidosisDecrease = respiratory alkalosis

43 PaCO2 PaCO2 reacts w/ H2O to become acidic. If PaCO2 accumulates such as when respiration is impaired, CO2 levels increase (Asthma, Bronchitis, Emphysema, CHF). Increased levels of PaCO2 denote respiratory acidosis. If PaCO2 levels drop, the pt. is in respiratory alkalosis (hyperventilation, pain).

44 HCO3 (Bicarbonate) Metabolic influences on pHNormal: mEq/L Decrease = metabolic acidosis Increase = metabolic alkalosis

45 How to assess ABG’s: Start with pH: acidotic or alkalotic?Then move on to PaCO2 & HCO3, which will reveal whether the imbalance, if any, is respiratory or metabolic in origin.

46 Examples: pH 7.3-acidotic PaCO2 35-normal HCO3 20-low, Acidotic Metabolic Acidosis (diabetic ketoacidosis)

47 pH 7.48-alkalotic PaCO2 38-normal HCO3 30-high, alkalotic Answer: Metabolic alkalosis (vomiting).

48 pH 7.3-low, acidic PaCO2 50-high, acidic HCO3 24-normal Answer: Respiratory acidosis (COPD, pneumonia).

49 pH 7.49-high, alkalotic PaCO2 30-low, alkalotic HCO3 24-normal Answer: Respiratory alkalosis (hyperventilation, acute asthma).

50 Diagnostic Tests and ProceduresPulse oximetry Sputum analysis Culture and sensitivity acid-fast test cytologic specimens Throat Culture

51 Diagnostic Tests and ProceduresFiberoptic Bronchoscopy direct visualization of lung tissue via a bronchoscope through the nose or mouth. Purpose: observe lung tissue obtain biopsy bronchial washing for C&S determine location, extent of tumor removal of foreign objects removal of mucous plug

52 Fiberoptic BronchoscopyPre-op: NPO, consent, remove dentures, sedation of throat. Sprayed with local anesthesia (Cetacaine). Post-op: NPO, check gag reflex, lying on side decreases aspiration Observe for SOB, dysphagia, bleeding, edema of throat Educate patient and family

53 Common Therapeutic MeasuresThoracentesis puncture of chest wall to remove excess fluid/air from pleural cavity. Can also instill medications Uses large bore needle to insert & withdraw fluid off pleural space. 53

54 Thoracentesis Specimens measured & sent to lab for biopsy, C&SInvasive procedure; obtain signed consent Assisting with Thoracentesis: position pt. to sitting position on side of bed w/torso leaning on bedside table. Use a pillow for comfort.

55 Thoracentesis A chest x-ray may be ordered after the procedure to detect any pulmonary complications (air embolism, hemothorax, pneumothorax, pulmonary edema). Acute SOB, asymmetrical chest, absent or diminished lung sounds may indicate a pneumothorax.

56 Common Therapeutic MeasuresBreathing exercises Deep breathing and coughing exercises Pursed-lip breathing Sustained maximal inspiration

57 Common Therapeutic MeasuresChest physiotherapy involves: Chest percussion Chest vibration Postural drainage Suctioning Sterile for tracheal; clean for oral Preoxygenate; limit suction to 10 seconds as you withdraw from airway Humidification and aerosol therapy

58 A, The patient is positioned for a thoracentesisA, The patient is positioned for a thoracentesis. B, The needle is inserted into the pleural space, avoiding lung tissue and the diaphragm. The exact location of the puncture varies. 58

59 Incentive spirometry encourages deep breathing by providing a visual cue to the patient about the efficiency of deep breathing. 59

60 Percussion. 60

61 Vibration. 61

62 Common Therapeutic MeasuresOxygen therapy Intermittent positive-pressure breathing (IPPB) treatments Artificial airways Mechanical ventilation Chest tubes Thoracic surgery 62

63 Oxygen Therapy Room air (atmospheric air) is 21% oxygen.Oxygen therapy requires a medical order that should be treated like any drug order.

64 O2 Devices Nasal Cannula: 1-6 L Delivers 24-40% O2 Allows for freedom, level of O2 varies with the rate and depth of respirations. When do we humidify?

65 Simple Mask: 6-10L need minimum of 6 L to prevent CO2 buildup.delivers 35-55% O2 fits over mouth and nose, less leaking humidifies air as O2 is dry and irritating. good for mouth breathers 65

66 Partial Rebreathing Mask:Flow rates 6 – 10 L Delivers % O2 Reservoir bag Bag should deflate with inspiration (not less than 1/3). Allows some room air to enter, eliminates CO2 so pt doesn’t rebreathe his CO2.

67 Non-Rebreathing Mask:Delivers % O2 Also has resevoir bag Highest concentration Little or no room air enters. None of pts. exhaled gas is rebreathed Used for acutely ill patients. O2 toxicity can occur including lung fibrosis, atelectasis, retinal injury and vision impairment.

68 Venturi Mask or Ventimask:Delivers specific O2 by adjusting flowrate and adjusting device windows Delivers 24-50% O2 Room air enters mask via side windows and mixes with O2.

69 Oxygen delivery systems. A, Nasal cannula. B, Standard oxygen maskOxygen delivery systems. A, Nasal cannula. B, Standard oxygen mask. C, Partial rebreathing oxygen mask. D, Venturi oxygen mask. E, Transtracheal oxygen delivery. 69

70 Mechanical Ventilators:Delivers O2 ranging from 21% to 100%. Range from assistance with ventilation to complete control. Patient needs emotional support.

71 Artificial Airways Oral Airway Nasal Airway Endotracheal TubeTracheostomy

72 Chest Tubes Used to drain air or fluid from the pleural spaces of the lungs. Permits re-expansion of a collapsed lung in a patient. Chest fluid and air drain into the drainage collection chamber of the chest tube device.

73 A, A commonly used disposable chest drainage systemA, A commonly used disposable chest drainage system. B, Diagram of chambers of water-seal chest drainage. 73

74 Chest Tubes 3 Compartments: The collection chamberChest fluid and air drain into here The water seal chamber Air is diverted to the water-seal The suction chamber Depth of tube in water controls suction

75 Nursing Care of Chest TubesMonitor VS Monitor Breath Sounds & O2 status Assess dssg for tight seal Tape and inspect connections Coil extra tubing on bed to avoid kinks Monitor drainage – mark on container Strip and milk tubes only if ordered

76 Two techniques for removing blood clots from chest tubes. A, StrippingTwo techniques for removing blood clots from chest tubes. A, Stripping. B, Milking. Both can create excessive negative pressure in the pleural space, but milking is safer than stripping. Follow agency policies and physician orders in relation to these procedures. 76

77 Nursing Care of Chest TubesObserve chambers for bubbling Initially see bubbles in water seal chamber until lung is re-expanded If suction attached, suction chamber will bubble (some have dry suction chambers) Look for tidaling Rise and fall (water fluctuation) with breathing in water seal chamber

78 Nursing Care of Chest TubesIf tubing disconnects from drainage system, double clamp close to insertion site (chest). Obtain help stat. Dssg change – sterile, vaseline gauze After tube d/c’d, would we change the dressing?

79 Preoperative Nursing Care of the Patient with a Thoracotomy79

80 Routine Preoperative Nursing CareEmphasize postoperative breathing exercises If insertion of a chest tube is anticipated, explain the procedure to the patient 80

81 Assessment Monitor vital signs Monitor lung soundsMonitor mental status Monitor dressings Monitor chest tube function and drainage 81

82 Interventions Impaired Gas Exchange Ineffective Breathing PatternIneffective Airway Clearance 82

83 Video Thoracoscopy Inserting an endoscope through small thoracic incision Procedures that can be done with this instrument include resection of pulmonary and mediastinal lesions, biopsy, drainage of effusions, sympathectomy, vagotomy, and thymectomy 83

84 Drug Therapy Decongestants Corticosteroids AntitussivesAntihistamines Expectorants Antimicrobials Bronchodilators Corticosteroids Mast cell stabilizers Leukotriene inhibitors Mucolytics Thrombolytics 84