Medical-Surgical Nursing: An Integrated Approach, 2E

Chapter 18

NURSING CARE OF THE CLIENT: RESPIRATORY SYSTEM

Respiratory System

Its primary function is delivery of oxygen to the lungs and removal of carbon dioxide from the lungs.

Thoracic Cavity

The inside of the chest cage is called the thoracic cavity.

Contained within the thoracic cavity are the lungs, cone-shaped, porous organs encased in the pleura, a thin, transparent double-layered serous membrane lining the thoracic cavity.

The Physiology of the Lungs The right lung is larger than the left and is

divided into three sections or lobes: upper, middle, and lower.

The left lung is divided into two lobes: upper and lower.

The upper portion of the lungs is the apex; the lower portion is the base.

Conducting Airways

The conducting airways are tubelike structures that provide a passageway for air as it travels to the lungs.

The conducting airways include the nasal passages, mouth, pharynx, larynx, trachea, bronchi, and bronchioles.

Pharynx Larynx Trachea

The conducting airways that connect nasal passages and mouth to the lower parts of the respiratory tract.

The passageway for air entering and leaving the trachea and containing the vocal cords.

Commonly known as the windpipe, this tube is composed of connective tissue mucosa and smooth muscle supported by C-shaped rings of cartilage.

Bronchi, Bronchioles

Two tubes, the right and left primary bronchi, that each pass into its respective lung.

Within the lungs, the bronchi branch off into increasingly smaller diameter tubes until they become the terminal bronchioles.

Respiration

A process of gas exchange necessary to supply cells with oxygen for carrying on metabolism, and to remove carbon dioxide produced as a waste by-product.

Two types of respiration: external and internal.

External & Internal Respiration

The exchange of gases between the inhaled air and the blood in the pulmonary capillaries.

The exchange of gases at the cellular level between tissue cells and blood in systemic capillaries.

Signs & Symptoms

1. Dyspnia

2. Cough

3. Sputum Production

4. Chest Pain

5. Wheezing

6. Hemoptesis

Assessment

Auscultation(Listening for Normal and Adventitious Breath Sounds)

Palpation and Percussion

Inspection(client's color, level of consciousness, emotional state)

(Rate, depth, quality, rhythm, effort relating to respiration)

Health History(allergies, occupation, lifestyle, health habits)

Adventitious Breath Sounds

Fine crackles (dry, high-pitched popping…COPD, CHF, pneumonia)

Coarse crackles (moist, low-pitched gurgling…pneumonia, edema, bronchitis)

Sonorous wheezes (low-pitched snoring…asthma, bronchitis, tumor)

Sibilant wheezes (high-pitched, musical … asthma, bronchitis, emphysema, tumor)

Pleural friction rub (creaking, grating… pleurisy, tuberculosis, abscess, pneumonia)

Stridor (crowing…croup, foreign body obstruction, large airway tumor).

Abnormal sounds and some conditions associatedwith them:

Common Diagnostic Tests for Respiratory Disorders

1. Laboratory Tests (Hemoglobin; Arterial blood gases; Pulmonary Function Tests; “Sputum Analysis& culture”).

2. Radiologic Studies (Chest X-ray; Ventilation-perfusion scan; CAT scan; Pulmonary angiography).

3. Other (Pulse oximetry; Bronchoscopy; Thoracentesis; MRI).

Respiratory Care Modilities O TherapyThe administration of O in concentration

greater than that found in environmental atmosphere

Indications -change in respiratory rate - hypoxemia - hypoxia

O Therapy

Cautions

1. O toxicity

2. Suppression of ventelation

3. Source of Cross infection

4. Fire Danger Method of Oxygen Administration

slide(22-1)

Chest Physiotherapy

The Goal of chest physiotherapy is :1. Remove bronchial secretion

2. Improve Ventilation

3. Increase efficiency of respiratory muscles Postural Drainage Chest Percussion &vibration Breathing exercise &retraining

Air Way Management Emergency management of upper airway

obstruction Causes

1. foreign body

2. Secretions

3. Vomiting or food particles

4. Enlarged tissue “edema, Ca, &abscesses” Assessment

Inspection , palpation,& Auscultation

Airway Management

Emergency Measures

1. Opening airway by extend Pt neck back

2. Observe airway

3. Cross finger to clear airway

4. If no passage “Abd thrust”

5. Use resuscitation bag

guide lines p 499

Endotracheal Intubation

Passing endotracheal tube through mouth or nose into the trachea

It is a method of choice in emergency Providing airway for specific patients For mechanical ventilation

Tracheastomy It is a procedure in which an opening is made into

the trachea and indwelling tube is inserted into the trachea

Indication1. To bypass an upper airway obstruction2. To allow removal of tracheobroncheal secretions3. For long term ventilation4. To prevent aspirationComplications “bleeding, pneumonia, air embolism

emphysema pneumothrax

Upper Respiratory Tract Infections/Inflammatory Disorders

Rhinitis (coryza, common cold)

Allergic rhinitis Sinusitis

Pharyngitis Tonsillitis Laryngitis

Upper Respiratory Tract Infections/Inflammatory Disorders

Are the common conditions that affect most people on occasion, some infections are acute and other are chronic

common cold

Often is used when referring to a symptoms of an upper respiratory tract infection ch.ch.by nasal congestion ,sore throat , & cough

Cold referred to a febrile, infectious, acute inflammation,of the mucus membranes of the nasal cavity

common cold

Clinical manifestations

1. Nasal congestion

2. Scratchy or sore throat

3. Sneezing & cough

4. Headache & muscle ache

5. Herpes simplex sore (cold sore )

common cold Medical Management (symptomatic management)

1. Fluid intake ,rest ,prevention of chills.2. Aqueous decongestant,anti histamin, Vit. C.3. Expectorant as needed4. Analgesic for aches ,pain , & fever.5. Antimicrobial to reduce incidence of

complications Nursing Management1. Patient teaching of self care & prevention of

infection & break chain of infection

Rhinitis

Inflammation of nose by viral , obstructive ,allergic reaction.

Clinical manifestations1. Rhinorrhea “ excessive nasal drainage”

2. Nasal congestion, Itching ,& sneezing

3. Headache may occur

Rhinitis

Medical Management

1. Treatment of cause “antibiotics”

2. Decongestant agents

3. Antihistamine

4. In severe cases corticosteroids

Acute Sinusitis

It is inflammation of sinuses , it is resolved promptly if their opening into nasal cavity .

Clinical Manifestations

1. Pressure , pain over the sinus area

2. Tenderness

3. Purulent nasal secretions

Acute Sinusitis Medical Management 1. Antimicrobial agent “Amoxicillin”2. Oral & Topical Decongestant3. Heated mist or Saline irrigation

Nursing management “Teaching patient self care”

Complications1. Meningitis &osteomylitis2. Brain abscess 3. Ischemic infarction

Chronic Sinusitis

It is an inflammation of sinuses that persists for more than 8 weeks in adult & or 2 weeks in children

Clinical Manifestations1. Impaired mucociliary clearness & ventilation

2. Chronic hoarseness & cough

3. Chronic Headache

4. Facial pain

Chronic Sinusitis

Medical Management 1. Strong antibiotics (for 21 days )

2. Surgical intervention to remove obstruction cause that cause block of drainage passage

Nursing Management 1. Increase humidity

2. Increase fluid intake

3. Early signs of sinusitis

Acute Pharyngitis It is a febrile inflammation of throat ,caused by

virus about 70% , uncomplicated viral infection usually subsided promptly within 3-10 days

Clinical Manifestations

1. Fiery red pharyngeal membrane& tonsils

2. Lymphoid follicles that are swollen

3. Enlarge tender cervical lymph node

4. Fever & malaise

5. Sore throat , hoarseness,& cough

Acute Pharyngitis Medical Management1. Supportive measures for viral infection

2. Pharmacologic therapy antibiotics for 10 days “cephalosporin”analgesic for severe sore anti tussive medications

3. Nutritional therapy liquid or soft diet “If liquid can’t tolerated IV fluid administered “

4. Nursing Management (bed rest ,skin assessment, mouth care &normal saline gargle & self care teaching

Chronic Pharyngitis Common in adults who work or live in dusty

surrounding ,use the voice too excess , suffer from chronic cough , & habitually use alcohol & tobacco

Types of pharyngitis

1. Hypertrophic :ch.ch.by general thickening& congestion of pharyngeal mucus membrane

2. Atrophic : probably late stage of first type

3. Chronic Granular : ch.ch.by numerous swollen lymph follicles on the pharyngeal wall

Chronic Pharyngitis

Clinical Manifestations 1. Constant sense of irritation or fullness in throat

2. Mucus expelled by coughing

3. Difficulty in swallowing

Medical Management 1. Relieving symptoms

Avoiding exposure to irritant

Correct respiratory & cardiac conditions

Chronic Pharyngitis

2. Antihistamine drugs

3. Decongestant

4. Controlling malaise Nursing Management1. Patient teaching of self care

2. Avoid alcohol , tobacco , exposure to cold

3. Face mask to avoid pollutant

4. Warm fluids,&warm saline gargle

Tonsillitis The tonsils are composed of lymphatic tissue &

situated on each side of the oropharynx ,they frequently are the site of acute infection (tonsillitis)

Clinical Manifestations Tonsils : sore throat, fever , snoring & difficulty of

swallowing Adenoids : ear ache , mouth breathing , drainage

ear ,frequent cold , bronchitis, noisy respiration, foul smelling breath &voice impairment

Tonsillitis Medical Management1. For recurrent tonsillitis “tonsillectomy”

2. Conservative or symptomatic therapy

3. Antimicrobial therapy “penicillin” for 7 days

Nursing Management1. Provide post op. care :V/S ,hemorrhage , position head

turned to side,water or ice chips

2. Teaching patient :S&S of hemorrhage

3. Avoid too much talking or coughing

4. Liquid or semi liquid diet for several days

5. Alkaline mouth washing with warm saline

Laryngitis It is an inflammation of larynx ,often occur as

a result of voice abuse or exposure to dust , chemicals , smoke , & other pollutants

Common in winter & easily transmitted The cause of infection is almost virus

Clinical Manifestations

1. Hoarseness or aphonia

2. Severe cough

Laryngitis Medical Management1. Resting voice & avoid smoking 2. Inhale cool steam or an aerosol3. Conservative treatment 4. Antibiotics for bacterial organisms Nursing Management1. Rest voice 2. Maintain a well humidified environment 3. Daily fluid intake

Pleurisy/Pleural Effusion

Pleurisy is a painful condition that arises from inflammation of the pleura, or sac that encases the lung.

Pleural effusion occurs when the inflamed pleura secretes increased amounts of pleural fluid into the pleural cavity.

Atelectasis Collapse or airless condition of the alveoli

caused byhypoventilation,obstruction of airway or compression

Clinical Manifestations1. Cough & sputum production2. Dyspnea ,tachypnea ,tachycardia3. Sings of pulmonary infection may present4. Fever 5. Central cyanosis

Atelectasis Management

1. First line measures :(turning , early ambulation , lung volume expansion , coughing, spirometry ,breathing exercises

2. If there is no response : (PEEP , IPPB)

3. Bronchoscopy

4. Postural Drainage & percussion

5. If cause is compression remove the cause

Acute Tracheobronchitis An inflammation of the mucus membrane of

the trachea & the bronchial tree , often follow upper respiratory tract infection

Clinical Manifestations1. Dry irritating cough “expectorate sputum”2. Sternal soreness from coughing3. Fever ,stress , night sweating 4. Headache & general malaise5. As the infection progress the patient develop

(shortness of breath, noisy breath ,&purulent sputum

Acute Tracheobronchitis Medical Management1. Antibiotics depend on symptoms & culture2. Expectorant may be prescribed3. Increase fluid intake4. Rest & cool therapy 5. Suctioning & Bronchoscopy Nursing Management1. Patient teaching 2. Encourage fluid intake3. Coughing exercises to remove secretions4. Complete antibiotics course,5. Prevent over exertion

Pneumonia An inflammation of the lung tissue that is caused

by microbial agent

Community Acquired Pneumonia (CAP)1. Occurs either in community setting or within the

first 48 hrs of hospitalization2. Most common in people younger than 60 yrs3. Most prevalent during winter & spring 4. Caused by pneumococcus & H influenza5. Virus the cause in infants & children

Pneumonia Hospital Acquired Pneumonia (HAP) the

onset of pneumonia symptoms more than 48 hrs after admission to hospital. Also called nosocomial infection

Common organism E.colli ,Klebsiella ,S.aurious It occurs when host defense impaired in certain

conditions Pneumonia in the Immuno compressed host Caused by organisms also observed in

CAP,HAP. Has subtle onset with progressive dyspnea ,

fever , &productive cough

Pneumonia Clinical Manifestations1. Sudden onset of shaking chills2. Rapidly increase in body temperature 38-40 C3. Chest pluratic pain increased by deep

breathing 4. Patient looks severely ill with marked

tachypnea5. Shortness of breath6. Orthopnea 7. Poor appetite 8. Diaphoresis &tires easily 9. Purulent sputum

Pneumonia Medical Management1. Appropriate antibiotics depend on culture

result2. Hydration (increase fluid intake )3. Antipyretic for fever & Headache4. Warm moist inhalation to relieve irritation5. Antihistamine to relieve sneezing & rhinorrhea6. Oxygen & respiratory supportive measures Complications : Shock & respiratory failure , Atelectasis & plural effusion Super infection

Chronic Obstructive pulmonary Disease (COPD)

Disease state in which air flow is obstructed by emphysema or bronchitis or both

The airway obstruction is usually progressive & irreversible

Clinical Manifestations1. Cough2. Increase work of breathing3. Severe dyspnea that interfere with patient

activity

Chronic Obstructive pulmonary Disease (COPD)

Medical Management1. Inhaled bronchodilators to improve airway

2. Oxygen therapy as prescribed

3. Pulmonary rehabilitation emotional & physiologic needs ,breathing exercises ,&methods of symptoms elevation

Chronic Obstructive pulmonary Disease (COPD) Nursing Management Patient Education About COPD1. Breathing exercise2. Inspiratory muscles training3. Self care activity4. Coping measures Complications1. Pneumonia2. Atelectasis3. Pneumothrax4. Respiratory insufficiency & failure

Chronic Bronchitis

It is a productive cough that lasts in each of 2 consecutive years in a patient whom other causes of cough is excluded

Clinical Manifestations

1. Chronic productive cough in winter

2. Increase frequency of respiratory infection

Chronic Bronchitis Medical Management the objective of

treatment are to keep the bronchioles opened & functioning

1. Antibiotics therapy for recurrent infection2. Bronchodilators to remove secretion3. Postural Drainage & chest percussion4. Hydration & fluid intake 5. Corticosteroid may be used6. Smoker patient should stop smoking

Emphysema A complex and destructive lung disease

wherein air accumulates in the tissues of the lungs.

Smoking is the major cause of Emphysema Classification 1. Panlobular : destruction of the respiratory

bronchiole,alevular duct &alveoli2. Centrilobular : pathogenic changes take

place mainly in the center of secondary lobule

Emphysema

Clinical Manifestations

1. Increase dyspnea on exertion

2. Anoroxia & Weight loss

3. Weakness & Inactivity

4. Pursed –lip- breathing

5. Increase cough wheezing purulent sputum & occasionally fever

Emphysema

Medical Management

1. Bronchodilators

2. Antimicrobial Agents

3. Oxygen therapy

4. Pulmonary rehabilitation

5. Smoking cessation

6. corticosteroids

Asthma

A condition characterized by intermittent airway obstruction in response to a variety of stimuli. “inflammatory”

Asthma differ from COPD in that it is reversible process either spontaneously or with treatment

Allergy is the strongest predisposing factor for the development of asthma

Asthma

Clinical Manifestations

1. The most three common symptoms are: a- coug b- dyspnea c- wheezing

2. Hypoxemia may occur along with a- cyanosis b- diaphoresis c- tachycardia d- widened pulse pressure

Asthma Prevention : allergic test to identify the

substances cause the symptoms and avoid it as possible

Complications1. Asthmaticus2. Rib fracture 3. Pneumonia4. Atelectases

Asthma Medical Management Pharmacologic Therapy (long term)1. Corticosteroid :most effective ant

inflammatory medication (inhaled form)2. Long-acting beta2adrenergic agonist mild to

moderate bronchodilator (theophilline3. Quick relive medications (short acting beta2

adrenergic agonists4. Peak flow monitoring

Asthma Nursing Management1. Immediate care based on severity of

symptoms2. Assessment & Allergic History3. Administer medication & observe patient

response4. Antibiotics as prescribed for infection5. Assist in intubations procedure if needed6. Psychological support for patient & his family

Acute Respiratory Failure

Conditions wherein there is a failure of the respiratory system as a whole.

It is a sudden & life threatening deterioration of gas exchange function of the lung

Acute : a fall in arterial PaO2 to less than 50mmHg &a rise in arterial PaCo2to greater than 50mmHg

Acute Respiratory Failure

Causes

1. Decrease respiratory derive “brain”

2. Dysfunction of chest wall “nerves & muscles”

3. Dysfunction of lung parenchyma “expansion”

4. Postoperative & inadequate ventilation

Acute Respiratory Failure Clinical Manifestations1. Impaired oxygenation & may be include

restlessness2. Fatigue & headache3. Dyspnea & air hunger4. Tachycardia &hypertension5. Confusion & lethargy6. Diaphoresis …… Respiratory Arrest7. Uses of accessory muscles

Acute Respiratory Failure

Medical management:

Intubations and mechanical ventilation may be required to maintain adequate ventilation and oxygenation while the case corrected

Acute Respiratory Failure Nursing management:1. Monitoring patient responses and

arterial blood gases 2. Monitoring vital sign3. turning ,mouth car , skin care , and rang

of motion .4. Teaching about the underlying disorders 5. Assists in intubations procedure

Pulmonary Embolism Obstruction of a pulmonary artery by a

bloodborne substance. Deep vein thrombosis is a common cause of

pulmonary embolism. Other types (Air , Fat , Septic ) Clinical Manifestations1. Dyspnea & Tachypnea2. Sudden & pluretic chest pain3. Fever & cough & hemoptesis4. Apprehension Diaphoresis & syncope

Pulmonary Embolism Medical Management

1. Emergency Management

i. Nasal O2

ii. IV infusion for Medication

iii. Perfusion Scan

iv. ABGs &ECG

v. Small dose of Morphine

vi. Intubation & mechanical Ventilation

Pulmonary Embolism

Pharmacologic Management

i. Anticoagulant therapy heparin 5000-10000 bolus then 18u/kg/hrs warfarin for three months

ii. Thrombolytic therapy (STK , Actylase (TPA))

iii. Surgical Management (Surgical Embolectomy)

Pulmonary Embolism

Nursing Management

1. Preventing thrombus formation

2. Monitoring thrombolytic therapy

3. Providing post operative nursing care

4. Managing O2 therapy

5. Preventing anxiety

6. Monitor for complications+

Pneumothorax/Hemothorax Traumatic disorders of the respiratory

tract wherein the underlying lung tissue is compressed and eventually collapses.

Types

1. Simple Pnuemothrax

2. Traumatic Pnuemothorax

3. Tension

Pneumothorax/Hemothorax Clinical Manifestations

1. Sudden pluretic pain

2. Anxious patient , dyspnea & air hunger

3. Increase use of accessory muscles

4. Central cyanosis

5. Tympanic sound in percussion

6. Absent of breath sound & tactile fremetus

7. Agitation Diaphoresis & hypotension

Pneumothorax/Hemothorax Medical Management1. High concentration supplemental O22. Chest tube for drainage3. In emergency anything may be use to fill the

chest wound 4. Heavy dressing 5. Needle aspiration thoracenthesis6. Connecting chest tube to water seal drainage7. An emergency thoractomy may also

performed

Pulmonary Edema

A life-threatening condition characterized by a rapid shift of fluid from plasma into the pulmonary interstitial tissue and the aveoli, resulting in markedly impaired gas exchange.

Can result from severe left ventrical failure, rapid administration of I.v. fluids, inhalation of noxious gases, or opiate or barbiturate overdose.

Adult Respiratory Distress Syndrome

A life-threatening condition characterized by severe dyspnea, hypoxemia, and diffuse pulmonary edema.

Usually follows major assault on multiple body systems or severe lung trauma.

Bronchiectasis

A chronic dilation of the bronchi. Main causes of this disorder are

pulmonary TB infection, chronic upper respiratory tract infections, and complications of other respiratory disorders of childhood, particularly cystic fibrosis.

Neoplasms of the Respiratory Tract

Benign neoplasms. Lung cancer. Cancer of the larynx.

Epistaxis

A hemorrhage of the nares or nostrils. May be unilateral (most common) or

bilateral. Blood loss can be minimal to severe.

Smoking

Cigarette smoking is indicated as a major causative factor in the development of respiratory disorders, such as lung cancer, cancer of the larynx, emphysema, and chronic bronchitis.