This document provides an overview of oxygenation and the respiratory system. It begins with definitions of respiration and acute respiratory disorders. It then covers anatomy and physiology, describing the upper and lower respiratory tract including the nose, sinuses, pharynx, larynx, epiglottis, trachea, lungs, bronchioles, and alveoli. Accessory muscles, lung volumes, ventilation, gas exchange, and the neural control of respiration are discussed. Risk factors, health history questions, and assessments of dyspnea, cough, and sputum production are presented.

1. OXYGENATION BY: LUDY MAE B. NALZARO, RN, MN

2. Respiration Respiratory control is tied closely to: Arterial blood and brain CO2 level Arterial blood oxygen level Acute disorders: Colds and flu Pneumonia Chest trauma COPD Respiratory problems are associated with: Allergies Occupational factors Genetic factors Smoking and tobacco use Infection Neuromuscular disorders Chest abnormalities Trauma Pleural conditions Pulmonary vascular abnormalities LUDY MAE B. NALZARO, RN, MN 2

3. ANATOMY &PHYSIOLOGY

4. RESPIRATORY SYSTEM PRIMARY FUNCTIONS Provides O 2 for metabolism in the tissues Removes CO 2 , the waste product of metabolism SECONDARY FUNCTIONS Facilitates sense of smell Produces speech Maintains acid-base balance Maintains body water levels Maintains heat balance LUDY MAE B. NALZARO, RN, MN 4

6. Produce mucus that drains into the nasal cavityPHARYNX Located behind the oral & nasal cavities Divided: Nasopharynx oropharynx & laryngopharynx Passageway for both the respiratory & digestive tracts LUDY MAE B. NALZARO, RN, MN 5

7. UPPER RESPIRATORY TRACT LARYNX Located above the trachea & just below the pharynx at the root of the tongue Commonly called the “VOICE BOX” Contains 2 pairs of vocal cords, the false & true cords The opening between the true vocal cords is theGLOTTIS EPIGLOTTIS Leaf-shaped elastic structure that is attached along one end to the top of the larynx Prevents the food from entering the tracheo-bronchial tree by closing over the glottis during swallowing LUDY MAE B. NALZARO, RN, MN 6

8. RESPIRATORY SYSTEM LUDY MAE B. NALZARO, RN, MN 7

9. LOWER RESPIRATORY TRACT TRACHEA Located in front of the esophagus Branches into the right & left mainstem bronchi at the carina From larynx to 7th thoracic vertebra LUDY MAE B. NALZARO, RN, MN 8

10. LOWER RESPIRATORY TRACT LUNGS Located in in the pleural cavity in the thorax above the clavicles to the diaphragm - the diaphragm (the major muscle of respiration) The bronchi are lined with cilia which propel mucus up & away from the lower airway to the trachea where it can be expectorated or swallowed RIGHT LUNG larger than the left divided into 3 lobes: the upper, middle & lower lobes LEFT LUNG narrower than the right lung to accommodate the heart ; divided into 2 lobes LUDY MAE B. NALZARO, RN, MN 9

11. Innervation of the respiratory structures is accomplished by the PHRENIC NERVE (C3), VAGUS NERVE & THORACIC NERVES PARIETAL PLEURA - lines the inside of the thoracic cavity including the upper surface of the diaphragm VISCERAL PLEURA - covers the pulmonary surfaces Pleural cavity contains serous fluid A thin fluid (surfactant) layer produced by the cells lining the pleura, lubricates the visceral & parietal pleura, allowing them to glide smoothly and painlessly during respiration LUDY MAE B. NALZARO, RN, MN 10

12. Lung Volumes Ave total capacity of 5900mL (19 y.o. man) A person cannot exhale all the air from the lungs 1200mL of air remains in the lungs even after forceful expiration RESIDUAL VOLUME Prevents collapse of the lung structure during expiration Volume of air that moves in and out with each breath TIDAL VOLUME Usually 500ml The amount of air inhaled during deep breathing (beyond tidal volume) INSPIRATORY RESERVE VOLUME Amount of air exhaled forcibly EXPIRATORY RESERVE VOLUME LUDY MAE B. NALZARO, RN, MN 11

14. Secondary (lobar) bronchi

15. Tertiary bronchi

16. Bronchioles

17. Terminal bronchiolesLUDY MAE B. NALZARO, RN, MN 12

18. BRONCHI LUDY MAE B. NALZARO, RN, MN 13

19. LOWER RESPIRATORY TRACT BRONCHIOLES Contain no cartilage & depend on the elastic recoil of the lung for patency Terminal bronchioles contain no cilia & don’t participate in gas exchange From nose to terminal bronchioles no gas exchange happens and are considered anatomic dead space ALVEOLAR DUCTS & ALVEOLI used to indicate all structures distal to the terminal bronchiole Alveolar ducts branch from the respiratory bronchioles Alveolar sacs which arise from the ducts contain clusters of alveoli which are basic units of gas exchange Cells in the walls of the alveoli secrete surfactant reduces the surface tension in the alveoli without surfactant the alveoli would collapse LUDY MAE B. NALZARO, RN, MN 14

21. Ventilation Movement of air in and out of the lungs 3 forces: Compliance Refers to ease of the lungs to expand and indicates the relationship between the volume and pressure of the lungs Normal: Lungs are elastic so they recoil Diseases the cause fibrosis of the lungs results in “stiff lungs” with long compliance Requires high inspiratory pressure to achieve the set volume of gas Emphysema that damage the elastic structure of the alveolar wall result in ”floppy lungs” with great compliance but poor recoil LUDY MAE B. NALZARO, RN, MN 16

22. Surface tension Surfactant in the alveolar lining lowers surface tension and increases compliance and aids in ventilation and oxygenation Deficiency of surfactant (premature infants) results to stiff lungs = RDS Muscular effort of inspiratory muscles Contraction of the diaphragm and external intercostal muscles enlarges the size of the thorax LUDY MAE B. NALZARO, RN, MN 17

24. reduces tendency for alveoli to collapse LUDY MAE B. NALZARO, RN, MN 18

25. LOWER RESPIRATORY TRACT ACCESSORY MUSCLES OF RESPIRATION SCALENE MUSCLES Elevate the first 2 ribs STERNOCLEIDOMASTOID MUSCLES Raises the sternum TRAPEZIUS & PECTORALIS MUSCLES Fix the shoulders LUDY MAE B. NALZARO, RN, MN 19

26. Movements of the Muscles LUDY MAE B. NALZARO, RN, MN 20

28. Driving Force for Air Flow Airflow driven by: the pressure difference between atmosphere (barometric pressure) & inside the lungs (intrapulmonary pressure).

29. atmospheric pressure = 760 mmHg Before inspiration

30. atmospheric pressure = 760 mmHg

31. atmospheric pressure = 760 mmHg

32. Mechanism for the Change in Intrapulmonary pressure Boyle’s Law: Volume x Pressure = Constant Inspiration: Expiration:  Volume  Pressure  Volume  Pressure

33. Respiration The process of gas exchange between atm air and the blood at the alveoli the blood cells and the cells of the body Exchange of gases occurs because of differences in partial pressures. Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body. Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body.

34. Inspiration Contraction of 1) diaphragm 2) external intercostal muscles  The lungs are carried along.   Lung volume   pressure  Air flows in. Forced Expiration Relaxation of diaphragm external intercostal muscles and Contraction of abdominal, internal intercostal and other accessory respiratory muscles.   Lung volume   pressure  Air flows out. Resting Expiration Relaxation of 1) diaphragm 2) external intercostal muscles  The lungs shrink.   Lung volume   pressure  Air flows out.

35. Ventilation-Perfusion Ratios:A- Normal RatioB- Shunts C- Dead SpaceD- Silent Unit

37. Thickening of bronchial mucosa

38. Obstruction of the airway

41. pulmonary circulation Pulmonary Arteries Pulmonary Veins

43. Oxygen Transport LUDY MAE B. NALZARO, RN, MN 35

44. NEURAL CONTROL OF VENTILATION

47. RISK FACTORS FOR RESPIRATORY DISEASE Smoking Use of chewing tobacco Allergies Frequent respiratory illnesses Chest injury Surgery Exposure to chemicals & environmental pollutants Family history of infectious disease Geographic residence & travel to foreign countries LUDY MAE B. NALZARO, RN, MN 40

48. ASSESSMENT

49. HEALTH HISTORY Medical and family history Age Changes in lung capacities and respiratory function Smoking history Assess pack years (# of packs per day multiply # of yrs smoked) Medication use Allergies Travel and area of residence Diet history Hx of previous URI Occupations hx and socioeconomic status Current healthproblems Restlessness Irritability Confusion Hoarseness Dysrhythmias LUDY MAE B. NALZARO, RN, MN 42

50. Dyspnea Also known as: DIFFICULTY OR LABORED BREATHING BREATHLESSNESS SHORTNESS OF BREATH subjective symptom and a reflection of the client’s judgment of the degree of work of breathing he/she exerts for a given task Occur when there is decrease lung compliance or increased airway resistance Sudden dyspnea in healthy person, indicate PNEUMOTHORAX or ACUTE RESPIRATORY OBSTRUCTION LUDY MAE B. NALZARO, RN, MN 43

51. Dyspnea Orthopnea or the inability to breathe easily except in an upright position may be noted in clients with chronic obstructive pulmonary disorder. The following should be assessed further to determine what produces dyspnea: a. Exertion that triggers the shortness of breath b. Presence of cough c. Relation of dyspnea to other symptoms d. Onset of shortness of breath e. Time of day or night dyspnea occurs f. Position of client that worsen/relieves shortness of breath g. Activity of the client when shortness of breath occurs (e.g., at rest, walking, running, climbing the stairs, or exercising) LUDY MAE B. NALZARO, RN, MN 44

52. LUDY MAE B. NALZARO, RN, MN 45 Assessment Flowchart

53. Dyspnea Other assessment in dyspnea that should be noted: a. Client’s rating of the intensity of breathlessness b. Effort required to breath c. Severity of breathlessness or dyspnea LUDY MAE B. NALZARO, RN, MN 46

55. Cough Results from irritation of the mucous membranes anywhere in the respiratory tract. May be triggered by: infectious process from an airborne irritant (e.g., smoke, smog, dust, or gas). May indicate serious pulmonary disease May also be caused by a variety of other problems: Cardiac disease Medications Smoking Gastroesophageal reflux LUDY MAE B. NALZARO, RN, MN 48

56. Cough Conduct a symptom analysis on the characteristics of cough by noting the following: a. How and when the cough began, and how long it has been present b. Frequency of cough c. Time of the day when cough is better or worse d. Describe the cough using client’s own words e. A cough may be described as hacking, dry, hoarse, congested, barking, wheezy, or babbling f. Medications or treatments the client used for the cough g. Precautions used to prevent the spread of infection LUDY MAE B. NALZARO, RN, MN 49

57. Sputum Production This is a reaction of the lungs to any constantly recurring irritant; may be associated with nasal discharge. Sources of sputum may be from: tracheobronchial tree, or secretion from: Oral Nasopharyngeal area Sinuses. LUDY MAE B. NALZARO, RN, MN 50

58. Sputum Production 3. Characteristics of the sputum: Odor Quality/consistency Color Quantity Tsp, tbsp, cup Location Clearing throat – sinuses Deep, full cough – respiratory tree 4. Note any change in color, odor, quality/quantity in the client’s chart LUDY MAE B. NALZARO, RN, MN 51

59. Sputum Production Quality/ Consistency Frothy caused by surfactant in the lung alveoli indicates that the sputum had contact with the lung alveoli or originated from this site. pulmonary edema lung cancer LUDY MAE B. NALZARO, RN, MN 52 Photograph: Frothy secretions of negative pressure pulmonary edema (NPPE).

60. Sputum Production 2. Mucoid/ sticky COPD Bronchitis asthma LUDY MAE B. NALZARO, RN, MN 53

61. Sputum Production 3. Thick, purulent, with foul odor greater mucus production coupled with pus in the purulent types. Lung abscess Bronchiectasis Mucopurulent - sign of respiratory tract infection - acute bronchitis and pneumonia LUDY MAE B. NALZARO, RN, MN 54

63. Sputum Production 5. Watery Common colds allergy LUDY MAE B. NALZARO, RN, MN 56

64. Sputum Production Color: 1. Rust pneumococcal infection implies the breakdown of RBCs and their phagocytosis by alveolar macrophages e.g., chronic pulmonary edema LUDY MAE B. NALZARO, RN, MN 57 Rusty Hemoptysis

65. Sputum Production 2. Yellow-green colored sputum bacterial infection LUDY MAE B. NALZARO, RN, MN 58

66. Sputum Production 3. Pink colored pulmonary edema 4. White colored asthma 5. Gray colored bronchitis LUDY MAE B. NALZARO, RN, MN 59

67. Sputum Production 6. Brick red colored sputum Klebsiella infection LUDY MAE B. NALZARO, RN, MN 60

68. Sputum Production 7. Salmon colored sputum staphylococcal infection LUDY MAE B. NALZARO, RN, MN 61

69. Sputum Production 8. Brown aspergillosis 9. Anchovy-chocolate amebic abscess 10. Red sputum and saliva rifampin use LUDY MAE B. NALZARO, RN, MN 62

70. Hemoptysis Refers to the blood expectorated from the mouth in the form of gross blood, frankly blood sputum, or blood-tinged sputum. Identify whether the source of blood are the lungs, a nosebleed, or the stomach. Obtain an estimate of the amount of blood expectorated using specifications (i.e., teaspoon, tablespoon, or cup). Pulmonary causes of hemoptysis include: Chronic bronchitis Bronchiectasis Pulmonary tuberculosis Cystic fibrosis Pulmonary embolism Pneumonia Lung cancer Lung abscess. LUDY MAE B. NALZARO, RN, MN 63

71. Wheezing A high-pitched, musical sound produced when air passes through partially obstructed or narrowed airways on inspiration or expiration. Could be heard with or without the use of a stethoscope. A client may not complain of wheezing but take note when the client reports chest tightness or chest discomfort. Ask the client when the wheezing occurs and whether it resolves spontaneously or is relieved by medication. LUDY MAE B. NALZARO, RN, MN 64

72. Wheezing This manifestation is not always caused by asthma but may also be caused by : mucosal edema airway secretions collapsed airways foreign objects tumors partially obstructing air flow. LUDY MAE B. NALZARO, RN, MN 65

73. Stridor High-pitched sound produced when air passes through a partially obstructed or narrowed upper airway upon inspiration. Associated with respiratory distress and can be life threatening due to compromised airway. Commonly seen in: Epiglottitis Sleep apnea Heart failure Aspiration Ask client about: Changes in voice character, Hoarseness Difficulty swallowing Sleep-related disorders Early morning headaches Weight gain Fluid retention Apne Restlessness. LUDY MAE B. NALZARO, RN, MN 66

74. Chest Pain occur with: Pneumonia pulmonary embolism with lung infarction Pleurisy bronchogenic carcinoma. Assess the quality, intensity, and radiation of pain. Identify and explore precipitating factors . Note the relationship of pain to the inspiratory and expiratory phases of respiration. Ask client whether activity, coughing, or movement brings pain and what relieves pain. LUDY MAE B. NALZARO, RN, MN 67

75. CHEST PAIN: The most common causes of chest pain are: – ischaemic heart disease: severe constricting, central chest pain – pleuritic pain: sharp, localized pain, usually lateral; worse on inspiration or cough – anxiety or panic attacks: a very common cause of chest pain Inquire about circumstances that bring on an attack. SOB: The degree of exercise that brings on the symptoms must be noted (e.g. climbing one flight of stairs, after 0.5 km (1/4 mile) walk). LUDY MAE B. NALZARO, RN, MN 68

76. Symptom Analysis Things to assessed when client describes a specific respiratory manifestation: Onset = when it begin Location = where Duration = how long Characteristics Ask in common language, note about amnt, size, # and extent of chief complaint Aggravating and relieving factors Factors that precipitate/worsen/alleviate a manifestation Associated manifestation s/sx that occur in conjunction with chief complaint LUDY MAE B. NALZARO, RN, MN 69

77. Timing Both onset & period during which problem has occurred Setting Time, place or particular situation in which the client experiences the complaint Severity Scale of 1-10 (1 as the least and 10 as the most) LUDY MAE B. NALZARO, RN, MN 70

78. Gather information based on Gordon’s, giving emphasis on the following: Current Respiratory Problems: Ask regarding recent changes in the breathing pattern. Perception on activities that might cause the changes/symptoms Number of pillows used when sleeping at night LUDY MAE B. NALZARO, RN, MN 71

79. Hx of Respiratory Disease Colds, allergies, asthma, TB, bronchitis, pneumonia or emphysema Frequency of the disease occurrence, duration, and tx/mgt of the disease Exposure to any pollutants LUDY MAE B. NALZARO, RN, MN 72

80. Assessment Collecting Objective Data: PE Client preparation Equipment and supplies: exam gown and drape Gloves Stethoscope light source Mask Skin marker Metric ruler

81. Key assessment points: Provide privacy for the client Keep your hands warm to promote client’s comfort during exam Remain nonjudgmental about client’s habits and lifestyle, particularly smoking

82. Cyanosis Central Cyanosis Peripheral Cyanosis

83. Assessment of the Hands Clubbing of the fingernails

84. Assessment of the Hands Staining Wasting and weakness Pulse rate Flapping Tremor

85. Assessment of the Face Eyes Horner's syndrome? (constricted pupil, partial ptosis and loss of sweating which can be due to apical lung tumour compressing sympathetic nerves in neck) Nose polpys? (associated with asthma) engorged turbinates? (various allergic conditions) deviated septum? (nasal obstruction) Mouth and tongue look for central cyanosis evidence of upper respiratory tract infection (a reddened pharynx and tonsillar enlargement with or without a coating of pus) broken tooth - may predispose to lung abscess or pneumonia

86. Inspect: For nasal flaring and pursed lip breathing Color and shape of nails Observe color of face, lips, and chest

87. Shape and symmetry of chest Barrel Shaped

88. Shape and symmetry of chest Pigeon Chest ( Pectus Carinatum )

89. Shape and symmetry of chest Funnel Chest

90. Shape and symmetry of chest Kyphosis Scoliosis Kyphoscoliosis

91. Posterior Thorax Inspect configuration and client’s positioning Observe for use of accessory muscles and assess chest expansion

92. Posterior Thorax Palpate for: Tenderness Sensation Crepitus Surface characteristics Fremitus

93. Posterior Thorax Auscultate for breath sounds, adventitious sounds Auscultate voice sounds: bronchophony, egophony, whispered pectoriloquy

95. Normal Breath Sounds

96. ASSESSING BREATH SOUNDS LUDY MAE B. NALZARO, RN, MN 89

97. Abnormal Breath Sounds

98. Anterior Thorax Inspect for: shape and configuration position of sternum slope of ribs intercostal spaces, Observe for: quality and pattern of respiration use of accessory muscles

99. Anterior Thorax Palpate for: Tenderness Sensation Surface masses Fremitus Anterior chest expansion

101. Anterior Thorax Percuss for tone

103. Anterior Thorax Auscultate for anterior breath sounds, adventitious sounds, and voice sounds

105. EFFECTS OF AGING Aging Affects the mechanical aspects of ventilation by decreasing chest wall compliance and elastic recoil of the lungs Changes in these properties reduce ventilatory reserve Aging causes the oxygen to decrease but no effect on carbon dioxide. LUDY MAE B. NALZARO, RN, MN 98

106. DIAGNOSTIC TESTS

107. IMAGING STUDIES X - ray CT Scan MRI Fluoroscopy Pulmonary Angiography Ventilation - Perfusion Scan Gallium Scan PET

109. Instruct on the purpose of the procedure and the location

110. Procedures takes approx 15 minutes

111. No restriction on food, fluid, or medication prior to the procedure

112. No sedation or anesthetic

113. Remove all jewelry & other metal objects

114. Lead apron for men and women of childbearing age

115. Assess ability to inhale & hold the breath

116. Question regarding pregnancy of possibility of pregnancy CHEST X-RAY (CXR) FILM (RADIOGRAPH)

117. Chest X-Ray

118. Front View Side View

119. Computed Tomography Scan

121. The two dark areas are the lungs. The light areas within the lungs represent the cancer. Computed Tomography Scan

124. A continuous x-ray beam is passed through the body part being examined, and is transmitted to a TV-like monitor so that the body part and its motion can be seen in detail.

125. Used to assist with invasive procedures (chest needle biopsy) performed to identify lesions.

127. PULMONARY ANGIOGRAPHY PRE-PROCEDURE NURSING CARE Informed consent Assess for allergies to iodine, seafood & dyes NPO prior to procedure V/S Assess coagulation studies Establish an IV Administer sedation Client must lie still during the procedure LUDY MAE B. NALZARO, RN, MN 109

128. PULMONARY ANGIOGRAPHY PRE-PROCEDURE NURSING CARE Urge to cough Emergency equipment available POST-PROCEDURE NURSING CARE V/S No BP for 24 hrs in the affected extremity Monitor peripheral neurovascular status Assess for bleeding Monitor dye reaction LUDY MAE B. NALZARO, RN, MN 110

129. PULMONARY ANGIOGRAPHY Contraindication: Pregnancy Dye allergies Unstable client Uncooperative client Complications: Cardiac dysrthymias Anaphylatic reactions to dye Risk for death LUDY MAE B. NALZARO, RN, MN 111

130. Radioisotope Diagnostic Procedure (Lung Scan) Types: Ventilation-perfusion scan Gallium scan Positron emission tomography Used to detect normal lung functioning, pulmonary vascular supply and gas exchange LUDY MAE B. NALZARO, RN, MN 112

132. performed to measure the supply of blood through the lungs.

134. Imaging 20-40 minutes

135. Indication:

136. to detect a pulmonary embolus (ventilation without perfusion)

137. to evaluate lung function in COPD

138. to detect the presence of shunts (abnormal circulation) in the pulmonary blood vessels.

140. determine whether a patient has inflammation in the lungs, abscess, adhesions, presence of tumor (sarcoidosis).

141. Used to stage bronchogenic cancer and record tumor regression after chemotherapy

143. the outline of the entire bronchial tree or selected areas may be visualized through x-ray.

145. Secure written consent

146. Check for allergies to sea foods or iodine or anesthesia

147. NPO for 6 to 8 hours

148. Pre-op meds:

149. Atropine SO4

150. Valium

151. Topical anesthesiasprayed

152. followed by local anesthetic injected into larynx.

153. Oxygen and antispasmodic agents must be ready.

154. Nursing interventions AFTER Bronchogram

155. Side-lying position

156. NPO until cough and gag reflexes returned

158. Positron Emission Tomography Used to evaluate lung nodules for malignancy Can detect and siplay metabolic changes in tissue, distinguish normal from abnormal, viable from dead cells LUDY MAE B. NALZARO, RN, MN 119

159. Positron Emission Tomography

161. Imaging of distribution and blood flow in the lungs. (Measure blood perfusion)

164. Assess for allergies to injected radioisotopes

166. BRONCHOSCOPY Purposes of diagnostic bronchoscopy are: (1) to examine tissues or collect secretions, (2) to determine the location and extent of the pathologic process and to obtain a tissue sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy), (3) to determine if a tumor can be resected surgically, and (4) to diagnose bleeding sites (source of hemoptysis). Therapeutic bronchoscopy is used to: (1) remove foreign bodies from the tracheobronchial tree, (2) remove secretions obstructing the tracheobronchial tree when the patient cannot clear them, (3) treat postoperative atelectasis, and (4) destroy and exciselesions. LUDY MAE B. NALZARO, RN, MN 124

167. BRONCHOSCOPY visual examination of the larynx, trachea & bronchi with a fiber-optic bronchoscope PRE-PROCEDURE NURSING CARE Informed consent NPO 6-8hrs prior Explain procedure to reduce fear and decrease anxiety Assess coagulation studies Remove dentures or eyeglasses Prepare suction Have resuscitation equipment available LUDY MAE B. NALZARO, RN, MN 125

169. About 30 minutes before bronchoscopy.

170. Valium is given to sedate patient and allay anxiety.

171. To inhibit vagal stimulation (prevent bradycardia, dysrhthmias and hypotension)

172. Topical anesthesia is sprayed followed by local anesthesia injected into the larynx

173. The patient is placed supine with hyperextended neck during the procedureNursing interventions BEFORE Bronchoscopy

174. DIAGNOSTIC TESTS POST-PROCEDURE NURSING CARE V/S  Fowler’s position Assess gag reflex (+, may offer ice chips) NPO until gag reflex returns Monitor for bloody sputum Monitor respiratory status Monitor for complications: bronchospasm, bronchial perforation, crepitus, dysrhythmia, fever, hemorrhage, hypoxemia, and pneumothorax Notify the MD if complications occur LUDY MAE B. NALZARO, RN, MN 127

175. Endoscopic Thoracoscopy

176. Endoscopic Thoracoscopy Pleural cavity is examined with endoscope Small incision into pleural cavity in an intercostal space Indicated: Pleural effusion Pleural diseases Tumor staging LUDY MAE B. NALZARO, RN, MN 129

177. LUNG BIOPSY a percutaneous lung biopsy - culture or cytologicexamination Invasive technique involving entering the lung or pleura to obtain tissue for analysis Used to make a definite dx regarding the type of malignancy, infection, inflammation, or other type of lung disease PRE-PROCEDURE NURSING CARE Informed consent NPO prior Local anesthetic Pressure during insertion and aspiration Administer analgesics & sedatives as Rx LUDY MAE B. NALZARO, RN, MN 130

178. DIAGNOSTIC TESTS LUNG BIOPSY POST-PROCEDURE NURSING CARE V/S Pressure dressing Monitor for hemoptysis/bleeding Monitor for respiratory distress Monitor for complications: pneumothorax and air emboli Prepare for CXR Chest tube management for open lung biopsy LUDY MAE B. NALZARO, RN, MN 131

181. Check the patient for hemoptysis and hemorrhage

182. Monitor and record vital signs

183. Check the insertion site for bleeding

185. Thoracenthesis

186. COMPLICATIONS pneumothorax (3-30%), hemopneumothorax, hemorrhage, hypotension (low blood pressure due to a vasovagal response) reexpansion pulmonary edema. LUDY MAE B. NALZARO, RN, MN 135

187. DIAGNOSTIC TESTS PRE-PROCEDURE NURSING CARE Informed consent V/S CXR or U/A prior to the procedure Assess coagulation studies Upright ( sitting on the side of the bed with the feet on a stool, leaning over the bedside table) Do not cough, breath deeply, or move during the procedure LUDY MAE B. NALZARO, RN, MN 136

188. DIAGNOSTIC TESTS POST-PROCEDURE NURSING CARE Apply pressure on the puncture site Use semi-fowlers or puncture site up Monitor V/S, respiratory status Assess site for bleeding and crepitus Monitor for signs of PNEUMOTHORAX, AIR EMBOLISM & PULMONARY EDEMA Determine if MD wants a follow up CXR LUDY MAE B. NALZARO, RN, MN 137

189. DIAGNOSTIC TESTS SPUTUM SPECIMEN obtained by expectoration or tracheal suctioning identify organisms or abnormal cells PRE-PROCEDURE NURSING CARE Determine specific purpose Early morning sterile specimen 5-15 ml of sputum Rinse the mouth with water prior to collection Take several deep breaths and then cough forcefully Collect the specimen before antibiotic therapy LUDY MAE B. NALZARO, RN, MN 138

190. LUDY MAE B. NALZARO, RN, MN 139

191. DIAGNOSTIC TESTS SUCTIONING PROCEDURE IN OBTAINING SPUTUM SPECIMEN Aseptic technique Hyperoxygenate Lubricate the catheter with sterile water Tracheal suctioning : 4 inches Nasotracheal suctioning : insert to induce cough reflex Don’t apply suction while inserting Suction intermittently for 10-15 seconds Rotate and withdraw Hyperoxygenate & deep breaths LUDY MAE B. NALZARO, RN, MN 140

192. DIAGNOSTIC TESTS SPUTUM SPECIMEN POST-PROCEDURE NURSING CARE Label the container Transport specimen to lab stat Mouth care LUDY MAE B. NALZARO, RN, MN 141

193. Skin Test: Mantoux Test or Tuberculin Skin Test This is used to determine if a person has been infected or has been exposed to the TB bacillus. This utilizes the PPD (Purified Protein Derivatives). The PPD is injected intradermallyusually in the inner aspect of the lower forearm about 4 inches below the elbow. The test is read 48 to 72 hours after injection. (+) Mantoux Test is induration of 10 mm or more. But for HIV positive clients, induration of about 5 mm is considered positive Signifies exposure to Mycobacterium Tubercle bacilli

196. DIAGNOSTIC TESTS PULSE OXIMETRY a non-invasive test that registers arterial O 2 saturation (SaO 2 ) NORMAL VALUE: 95%-100% alert hypoxemia before clinical signs occurs PROCEDURE A sensor is placed: finger, toe, nose, earlobe or forehead Don’t select an extremity with an impediment to blood flow >91% - immediate treatment SaO2 >85% - hypo-oxygenation SaO2is  70% - life-threatening LUDY MAE B. NALZARO, RN, MN 145

198. Cardiac arrest

199. Shock

200. Use of dyes or vasoconstrictors

201. Severe anemia

203. POST-PROCEDURE NURSING CARE Resume normal diet and any bronchodilators & respiratory treatments that were held prior to the procedure Observe for increased dyspnea or bronchospasm after the testing LUDY MAE B. NALZARO, RN, MN 148 PULMONARY FUNCTION TEST (PFTs)

204. Determine pH, oxygen and carbon dioxide concentrations the ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation aid in assessing: the ability of the lungs to provide adequate oxygen and remove carbon dioxide the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. LUDY MAE B. NALZARO, RN, MN 149 ARTERIAL BLOOD GASES (ABGs)

205. PRE-PROCEDURE NURSING CARE Inform client on the procedure Perform Allen’s test prior to drawing radial artery specimens Have the client rest for 30 mins prior to specimen collection Avoid suctioning prior to drawing ABGs Don’t turn off O 2 unless the ABGs are ordered to be drawn at room air LUDY MAE B. NALZARO, RN, MN 150

206. POST-PROCEDURE NURSING CARE Apply pressure on the puncture site for 5-10 mins & longer if the client is on anticoagulant therapy or has bleeding disorder Be sure that no air bubbles in the specimen Place the specimen on ice Note the client’s temperature on the laboratory form Note the O 2 & type of ventilation that the client is receiving on the laboratory form Transport the specimen to the laboratory within 15 mins LUDY MAE B. NALZARO, RN, MN 151 ARTERIAL BLOOD GASES (ABGs)

207. ACID-BASE BALANCE Respiratory System: CO2 (acid) Metabolic acidosis – (Lungs) excrete CO2 Metabolic alkalosis – (Lungs) retain CO2 Renal or Metabolic System: H ion(acid) ; HCO3(base) Respi. acidosis – (Kidney) excrete H+ ; retain HCO3 Respi. alkalosis – (Kidney) retain H+ ; excrete HCO3 Normal ABG Values : Ph : 7.35 – 7.45 PCO2 : 35 – 45 mgHG HCO3 : 22-26 meq/L PO2 : 80-100 mgHg Base excess : (+2 or –2) LUDY MAE B. NALZARO, RN, MN 152 ARTERIAL BLOOD GASES (ABGs)

208. ARTERIAL BLOOD GAS SITE: Radial Artery TEST: Allens Test Ph  acidosis alkalosis PCO2  alkalosis acidosis HCO3 acidosis alkalosis LUDY MAE B. NALZARO, RN, MN 153 ARTERIAL BLOOD GASES (ABGs)

209. ARTERIAL BLOOD GAS 1. Assess ph, PCO2 & HCO3 2. Identify imbalance. If ph is normal use 7.4 7.4 – acidosis 7.4 – alkalosis 3. Identify if compensated or uncompensated uncompensated- if one component is normal & the other is abnormal compensated – if both PCO2 & HCO3 are abnormal in opposite directions 4. If compensated, identify if partially or fully partially – if ph is abnormal fully - if ph is normal LUDY MAE B. NALZARO, RN, MN 154 ARTERIAL BLOOD GASES (ABGs)

210. RESPIRATORY TREATMENTS LUDY MAE B. NALZARO, RN, MN 155

211. CHEST PHYSIOTHERAPY (CPT) Percussion and vibration over the thorax to loosen secretions in the affected areas of the lungs NURSING CARE Best time - morning upon arising, 1 hr before meals or 2-3hrs after meals Stop if pain occurs Provide mouth care CONTRAINDICATIONS  respiratory distress Hx of fractures Chest incisions If procedure increases bronchospasm Obese LUDY MAE B. NALZARO, RN, MN 156 RESPIRATORY TREATMENTS

212. CHEST PHYSIOTHERAPY (CPT) PROCEDURE Use cupped hands or percussion device Stop if painful Effective 1st thing in the morning or 1 hr before or 2-3hrs after meals Instruct to take a deep breaths and cough during the procedure Administer the bronchodilator (if prescribed) 15 minutes before the procedure. POST PROCEDURE Asses oxygenation status Offer oral hygiene LUDY MAE B. NALZARO, RN, MN 157

213. POSTURAL DRAINAGE use of the gravity to drain the secretions from segments of the lungs May combined with CPT NURSING CARE Consent Position the client Best time – A.M. upon arising, 1 hr before meals, 2-3 hrs after meals Stop if cyanosis or exhaustion occurs Maintain position 5-20 mins after Provide mouth care after the procedure LUDY MAE B. NALZARO, RN, MN 158

214. nionoveno@yc respi disorders 159 Chest PhysiotherapyPostural Drainage

215. Chest PhysiotherapyPostural Drainage CONTRAINDICATIONS OF POSTURAL DRAINAGE Unstable V/S Increased ICP LUDY MAE B. NALZARO, RN, MN 160

216. Incentive Spirometer Type: Flow and Volume Device ensures that a volume of air is inhaled and the patient takes deep breaths. Used to prevent or treat atelectasis

217. Volume Oriented Flow Oriented

218. CLIENT INSTRUCTIONS Use the lips to form seal around the mouth piece Inspire deeply Hold inspiration for a few seconds Forcefully exhale Avoid the use of spirometry at mealtimes it may cause nausea LUDY MAE B. NALZARO, RN, MN 163

219. Nebulizer Therapy A hand-held apparatus disperses a moisturizing agent or medication such as a bronchodilator into the lungs. device must make a visible mist. Nursing care: instruct patient in use. breathe with slow, deep breaths through mouth and hold a few seconds at the end of inspiration. Coughing exercises may be encouraged to mobilize secretions after a treatment. Assess patient before treatment and evaluate patient response after treatment.

220. OXYGEN THERAPY LUDY MAE B. NALZARO, RN, MN 165

221. Delivery Devices Nasal cannula Simple face mask Partial rebreather mask Non-rebreather mask Venturi mask Small volume nebulizer

222. OXYGEN (O 2 ) ADMINSITRATION NURSING CARE V/S OXYGEN IN USE sign Humidify the O 2 LUDY MAE B. NALZARO, RN, MN 167

223. NASAL CANNULA (NASAL PRONGS) flow rates of 1-6L/min; 24% (at 1L/min) to 44% (at 6L/min) flow rates higher than 6L/min don’t significantly increase oxygenation NOTE: Client who retains CO2 should never receive O2 at rates higher than 2-3 L/min unless on a mechanical ventilator effective O2 concentration can be delivered to both nose breathers & mouth breathers with the use of a nasal cannula LUDY MAE B. NALZARO, RN, MN 168

224. Nasal Cannula It delivers a relatively low concentration of oxygen (24% - 45% ) at flow rate of 2 – 6 L/min.

225. Nasal Cannula Indication Low FiO2 Long term therapy Contraindications Apnea Mouth breathing Need for High FiO2

226. NASAL CANNULA (NASAL PRONGS) Fraction of Inspired Oxygen (FiO2) DELIVERED VIA NASAL CANNULA 24% at 1L/min 28% at 2L/min 32% at 3L/min 36% at 4L/min 40% at 5L/min 44% at 6L/min LUDY MAE B. NALZARO, RN, MN 171

227. NASAL CANNULA (NASAL PRONGS) NURSING CARE Add humidification Monitor humidifier Assess RR Assess the mucosa high flow rates have a drying effect & increase mucosal irritation Assess the skin integrity O2 tubing can irritate the skin Provide water-soluble jelly LUDY MAE B. NALZARO, RN, MN 172

228. SIMPLE FACE MASK 40%-60% for short term O 2 therapy or to deliver O 2 in an emergency minimal flow rate of 5L/min - to prevent the rebreathing of exhaled air NURSING CARE Be sure the mask fits Provide skin care pressure & moisture under the mask may cause skin breakdown Monitor for aspiration the mask limits the client’s ability to clear the mouth esp if vomiting occurs Provide emotional support to decrease anxiety in the client who feels claustrophobic LUDY MAE B. NALZARO, RN, MN 173

229. Simple Face Mask Volumes greater that 10 LPM does not increase O2 delivery Indications Moderate FiO2 Contraindications Apnea Need for High FiO2

230. Simple Face Mask It delivers oxygen concentrations from 40% - 60% at liter flows of 5 - 8 L/min

231. F I 0 2 DELIVERED VIA SIMPLE FACE MASK 40% at 5L/min 45% to 50% at 6L/min 55% to 60% at 8L/min NOTE: PYRAMID POINT : Flow rate must be set to at least 5L/min to flush the mask of CO2 LUDY MAE B. NALZARO, RN, MN 176

232. PARTIAL REBREATHER MASK 70%-90% with flow rates of 6-15L/min the client rebreathes 1/3 of the exhaled tidal volume NURSING CARE Make sure that the reservoir does not twist or kink Keep the reservoir bag inflated 2/3 full during inspiration deflation results in decreased O 2 delivered & rebreathingof exhaled air LUDY MAE B. NALZARO, RN, MN 177

233. Partial Rebreather Indications Moderate FiO2 Contraindications Apnea Need for High FiO2

234. Non-Rebreather Mask  90% most frequently use in deteriorating respiratory status requiring intubation has a one-way valve between the mask & reservoir and two flaps over the exhalation ports entire quantity of O 2 from the reservoir bag the flaps prevent room air from entering thru the exhalation ports LUDY MAE B. NALZARO, RN, MN 179

235. Non-Rebreather Mask Range 80-95% at 15 LPM Indications Delivery of high FiO2 Contraindications Apnea Poor respiratory effort

236. Non-Rebreather Mask F IO2 DELIVERED: 60% to 100% F IO2 at a liter flow that maintains the bag 2/3 full NURSING CARE Remove the mucus or saliva from the mask Assess the client Ensure the valve & flaps are functional Valves should open during expiration & close during inspiration Monitor for kinks & twisting LUDY MAE B. NALZARO, RN, MN 181

237. HIGH-FLOW OXYGEN DELIVERY SYSTEM 24% to 100% at 8-15L/min high-flow systems include: Venturi mask aerosol mask face tent tracheostomy collar, and T-piece deliver a consistent and accurate O 2 concentration LUDY MAE B. NALZARO, RN, MN 182

238. VENTURI MASK give accurate O 2 concentration an adapter is located between the bottom of the mask & the O 2 source the adapter contains holes of different sizes that allow only specific amounts of air to mix with the O 2 the adapter allows selection of the amount of O 2 desired LUDY MAE B. NALZARO, RN, MN 183

239. VENTURI MASK F IO 2 DELIVERED: 24% to 55% F IO 2 with flow rates of 4-10L/min NURSING CARE Monitor closely to ensure an accurate flow rate Keep the orifice for the Venturi adapter open uncovered to ensure adequate oxygen delivery Ensure the mask fits snugly & that tubing is free of kinks Monitor mucous membranes LUDY MAE B. NALZARO, RN, MN 184

240. FACE TENT fits over the client’s chin, with top extending halfway across the face the O 2 concentration varies useful for the client who has facial trauma or burns because it is not tight AEROSOL MASK used for the client who has thick secretions TRACHEOSTOMY COLLAR OR T-PIECE the tracheostomy collar can be used to deliver high humidity & the desired O 2 to the client with a tracheostomy a special adapter, called T-piece can be used to deliver any desired FIO 2 to the client with a tracheostomy, laryngectomy or endotracheal tube LUDY MAE B. NALZARO, RN, MN 185

241. Venturi Mask, Nonrebreathing Mask, Partial Rebreathing Mask

242. FACE TENT, AEROSOL MASK, TRACHEOSTOMY COLLAR & T-PIECE F IO 2 DELIVERED: 24% to 100% F IO 2 with flow rates of at least 10L/min NURSING CARE Change to nasal cannula during meals Empty condensation Monitor water in the canister & change the aerosol water container as needed Keep the exhalation port in the T-piece open Position the T-piece so that it does not pull on the tracheostomy or endotracheal tube it may cause erosion of the skin at the tracheostomy insertion site LUDY MAE B. NALZARO, RN, MN 187

243. T-Piece and Tracheostomy Collar

245. at the foot or head of the bed

246. on the oxygen equipmentNote: Oxygen is colorless, odorless, tasteless and a dry gas that support combustion, therefore leakage cannot be detected.

247. Oxygen Therapy Safety Precautions ﾘInstruct the client and visitors about the hazard of smoking with oxygen in use. ﾘMake sure that electric device are in good condition in order to prevent the occurrence of short-circuit sparks. ﾘAvoid materials that generate static electricity, such as woolen blankets and synthetic fibers. Cotton blankets should be used. ﾘAvoid the use of volatile, flammable materials such as oils, greases, alcohol and acetone near clients receiving oxygen. ﾘMake known the location of fire extinguishers LUDY MAE B. NALZARO, RN, MN 190

248. Complications of Oxygen Therapy Oxygen toxicity Reduction of respiratory drive in patients with chronic low oxygen tension Fire

249. Oxygen Toxicity Oxygen concentrations>50% for extended periods of time (longer than 48 hours) cause an overproduction of free radicals, which can severely damage cells. Symptoms include: substernal discomfort Paresthesias Dyspnea Restlessness Fatigue Malaise Progressive respiratory difficulty Refractory hypoxemia Alveolar atelectasis, and alveolar infiltrates on x-ray. Prevention: Use lowest effective concentrations of oxygen.

250. ARTIFICIAL AIRWAY Endotracheal Tube Purpose: Tracheal Suctioning Positive Pressure Breathing Nsg. Care: Humidify air Suction PRN NGT Promote Communication Confirm placement Monitor the cuff LUDY MAE B. NALZARO, RN, MN 193

251. TRACHEOSTOMY TUBE PURPOSE : SAME AS ET TYPES : Plastic Metal PARTS: Outer Cannula Inner Canula Obsturator LUDY MAE B. NALZARO, RN, MN 194

252. TRACHEOSTOMY TUBE NSG. CARE: Asepsis No sedative Suction PRN Hemostats NGT, TPN & Oral nutrition Wash the stoma Tub bath Avoid swimming Weaning LUDY MAE B. NALZARO, RN, MN 195

253. Tracheostomy

254. Tracheostomy Bypasses the upper airway to bypass an obstruction, allow removal of secretions, permit long-term mechanical ventilation, prevent aspirations of secretions, or replace an endotracheal tube Complications include: Bleeding Pneumothorax Aspiration Subcutaneous or mediastinal emphysema Laryngeal nerve damage Posterior tracheal wall penetration. Long-term complications include: airway obstruction, infection, rupture of the in nominate artery, dysphagia, fistula formation, tracheal dilatation, and tracheal ischemia and necrosis.

255. Tracheostomy Tubes

256. Nursing Diagnoses: Patients with Endotracheal Intubation or Tracheostomy Communication Anxiety Knowledge deficit Ineffective airway clearance Potential for infection

258. Cuff pressure can cause mucosal ischemia.

259. Use minimal leak technique and occlusive technique.

260. Check cuff pressure often.

261. Prevent tube friction and movement.

263. Secure tracheostomy tubes in place

264. Prevent accidental decannulation

265. Suction

266. Remove old Dressing

267. Sterile procedure: H2O, H2O2, brush, q-tip, 2X2s

268. Turn and remove inner cannula; clean, rinse, replace; turn and click into place

270. Tracheostomy care is delivered at least q 8 hrs; or more often as needed

272. Air must be humidified.

273. Maintain proper temperature.

275. Assess need for suctioning from the client who cannot cough adequately.

276. Suctioning is done through the nose or the mouth.

277. Suctioning can cause:

278. Hypoxia (see causes to follow)

279. Tissue (mucosal) trauma

280. Infection

281. Vagal stimulation and bronchospasm

283. Less is better

284. Hyperoxygenate before suctioning

285. Instill NS only if secretions are dry or to induce cough

286. Insert tube until resistance, then withdraw 1-2 cm

287. Must be past end of artificial airway

288. Less than 10 seconds

289. Twist catheter as it is withdrawn

291. Use of a catheter that is too large for the artificial airway

292. Prolonged suctioning time

293. Excessive suction pressure

295. Cuff is deflated as soon as the client can manage secretions and does not need assisted ventilation.

296. Change from a cuffed to an uncuffed tube.

297. Size of tube is decreased by capping; use a smaller fenestrated tube.

299. Ventilators

300. Suctioning using negative pressure to remove excessive mucous secretion to maintain patent airway to collect specimen for diagnostic testing Procedure: Use appropriate catheter size: F 5-8 for infants, F 8-10 for children and F12-18 for adult. Position client in fowlers( for those with intact gag reflex), side lying (for unconscious) to prevent aspiration Adult pressure: 50-75 mmhg in infants, 100-120 mmhg in adults Preoxygenate client Lubricate catheter tip by immersing in cup of saline solution Insert catheter through during inspiration (when epiglottis is open) without exerting the suction yet (OPEN PORT) until you feel resistance. Retract catheter by 1 cm before exerting suction Exert suction by CLOSE PORT, withdrawing catheter in rotating motion within 5-10 seconds only!!!! Hyper oxygenate for a full minute between subsequent suctioning. Encourage deep breathing! LUDY MAE B. NALZARO, RN, MN 210

301. NURSING PRIORITIES LUDY MAE B. NALZARO, RN, MN 211

302. NURSING PRIORITY GOAL: To promote adequate respiratory function Adequate O2 supply from the environment. Man requires 21% of O2 from the environment in order to survive. Deep breathing and coughing exercises. To promote maximum lung expansion and to loosen mucous secretions. Positioning. The semi-fowler’s or high fowlers position promotes maximum lung expansion. LUDY MAE B. NALZARO, RN, MN 212

303. NURSING PRIORITY Patent airway. To promote gaseous exchange from the person and the environment. Causes of airway obstruction: mucus secretions edema of airways spasms of airways foreign bodies. Airway obstruction is characterized by noisy breathing. Adequate hydration. To maintain moisture of the mucus membrane lining the respiratory tract. This is necessary to prevent irritation and infection. LUDY MAE B. NALZARO, RN, MN 213

304. NURSING PRIORITY Avoid environmental pollutants, alcohol and smoking. These factors inhibit mucociliary function. Chest physiotherapy (CPT)- percussion, vibration, and postural drainage (PVD). These procedures are dependent nursing function. LUDY MAE B. NALZARO, RN, MN 214

305. NURSING PRIORITY Postural drainage is expulsion of secretions various segments by gravity. involves placing the client in different positions so that the area of the lung congestion will be in vertical position with the bronchus. This facilitates drainage by gravity. LUDY MAE B. NALZARO, RN, MN 215

306. NURSING PRIORITY Steam inhalation Purposes: To liquefy mucous secretions To warm and humidify air To relieve edema of airways To soothe irritated airways To administer medications LUDY MAE B. NALZARO, RN, MN 216

307. NURSING PRIORITY Coughing single most effective measure to control respiratory secretions upward. Deep breathing expands the alveoli and mobilizes secretions. Pursed lip breathing Allows a gradual decline of pressure hence preventing lung collapse LUDY MAE B. NALZARO, RN, MN 217

308. ALTERED BREATHING PATTERNS Tachypnea rapid respiratory rate Bradypnea slow respiratory rate Apnea cessation of breathing LUDY MAE B. NALZARO, RN, MN 218

309. Hyperventilation excessive amount of air in the lungs. It results from deep, rapid respirations. Cheyne-stokes marked rhythmic waxing and waning of respirations from very deep or very shallow breathing and temporary apnea. Biot’s shallow breathes interrupted by apnea LUDY MAE B. NALZARO, RN, MN 219

310. LUDY MAE B. NALZARO, RN, MN 220

311. LUDY MAE B. NALZARO, RN, MN 221

312. LUDY MAE B. NALZARO, RN, MN 222

313. ALTERED BREATHING PATTERNS Kussmauls increased rate and depth, seen in metabolic acidosis and renal failure. Apneustic prolonged gasping inspiration followed by a very short, usually inefficient expiration. Dypsnea difficult or labored breathing. Orthopnea inability to breathe except in an upright or sitting position. LUDY MAE B. NALZARO, RN, MN 223

314. CLASSIFICATION OF PULMONARY DISORDERS Restrictive disorders Pneumonia PTB Laryngeal Carcinoma Lung Cancer Chronic obstructive pulmonary disease Emphysema Chronic Bronchitis Bronchial Asthma Pulmonary vascular disorders Pulmonary Embolism ARD