Nursing of Adults With

Medical & Surgical Conditions

Respiratory Disorders(Diagnostic Tests & Upper Airway

Disorders)

Normal Breath Sounds

Adventitious Breath Sounds

• Crackles (Rales)• Fine, Medium,Coarse

– Sound• Sounds like hair being rolled between the fingers

close to the ear

– Cause• Fluid, mucous, or pus in the small bronchi,

bronchioles, and alveoli

Adventitious Breath Sounds

• Rhonchi– Sound

• Low-pitched, loud, coarse, snoring sounds

– Cause• Narrowing of the tracheobronchial passages due to

secretions, tumors, spasms

• May clear with coughing if due to secretions

Adventitious Breath Sounds

• Wheezes– Sound

• High-pitched, musical, whistlelike sound during inspiration or expiration

– Cause• Narrowed bronchioles due to tumor, bronchospasm,

or foreign matter

Adventitious Breath Sounds

• Pleural Friction Rub– Sound

• Dry, creaking, grating, low-pitched sound

– Cause• Inflammation of pleural surfaces

Diagnostic Tests

• Chest X-ray• Provides visualization of the lungs, ribs, clavicles, humeri,

scapulae, vertebrae, heart, and major thoracic vessels

– Nursing Interventions• Hospital gown• No metal such as pins, bra hooks, jewelry

• Computed Tomography (CT)• Pictures of small layers of pulmonary tissue• Diagonal or cross-sectional

Diagnostic Tests

• Pulmonary Function Testing (PFT)• Assess the presence and severity of disease in the large and small

airways

– Lung Volume• Volume of air that can be completely and slowly exhaled after a

maximum inhalation

– Ventilation • Evaluate the volume of air inhaled or exhaled in each respiratory cycle

– Pulmonary Spirometry• Evaluate the amount of air that can be forcefully exhaled after

maximum inhalation

– Gas Exchange• Determines the degree of function in the pulmonary capillary beds in

contact with functioning alveoli

Diagnostic Tests

• Mediastinoscopy– Surgical endoscopic procedure

– Endoscope is passed into the upper mediatinum to gather lymph nodes for biopsy

• Laryngoscopy– Indirect

• Use of a laryngeal mirror to view the larynx

– Direct• Local or general anesthesia

• Laryngoscope passed over the tongue to view the larynx

Diagnostic Tests

• Bronchoscopy– Performed by passing a bronchoscope into the trachea and bronchi– Rigid or flexible bronchoscope– Local anesthetic and IV general anesthetic– Used to observe for abnormalities, tissue biopsy, and secretions

collected for exam

– Nursing Interventions• NPO for 6-8 hours• NPO until gag reflex returns• Semi-Fowler’s position and turned to side• Assess for signs of laryngeal edema or laryngospasms• Assess for signs of hemorrhage

Bronchoscopy

Diagnostic Tests

• Sputum Specimen• Obtained for microscopic examination

– Nursing Interventions• Must be brought up from the lungs• Collect before meals• Rinse mouth with water before collection• Inhale and exhale deeply three times, cough forcefully, and

expectorate into sterile cup• Early morning samples are ideal

Diagnostic Tests

• Cytology Studies– To detect the presence of abnormal or

malignant cells in sputum, pleural fluid, etc.

Diagnostic Tests

• Thoracentesis• The surgical perforation of the chest wall and pleural space

with a needle for the aspiration of fluid• Diagnostic or therapeutic

– Nursing Interventions• Informed consent• Pt sits on the edge of the bed; arms resting on a pillow on

overbed table• Monitor vital signs, general appearance, and respiratory status

during and after procedure• Place on unaffected side after procedure

Thoracentesis

Diagnostic Tests

• Pulse Oximetry– Monitoring of SaO2– Measures the amount of light being absorbed

by oxygenated and deoxygenated hemoglobin– Clothespin type probe is applied to finger, toe,

earlobe or nose

Pulse Oximetry

Diagnostic Tests

• Arterial Blood Gases– PaO2 Amount of oxygen dissolved in the

plasma (mmHg)– SaO2 Amount of oxygen bound to the

hemoglobin compared to the amount of oxygen the hemoglobin can carry (%)

– PaCO2 Partial pressure of CO2 in the blood– HCO3 Bicarbonate

Diagnostic Tests

• Normal Values• pH 7.35-7.45

• PaCO2 35-45 mm Hg

• PaO2 80-100 mm Hg

• HCO 21-28 mEq/L

• SaO2 95-100%

Diagnostic Tests

• Respiratory vs Metabolic– Respiratory

• PaCO2 Elevated with acidosis; decreased in alkalosis

– Metabolic• HCO3 Elevated with alkalosis; decreased in acidosis

• Acidosis vs alkalosis– Acidosis

• pH of 7.35 and lower

– Alkalosis• pH of 7.45 and higher

Epistaxis

• Etiology/Pathophysiology– Bleeding from the nose– Congestion of the nasal membranes, leading to

capillary rupture– Primary– Seconday

• Hypertension

• Irritation of nasal mucosa– Dryness, chronic infection, trauma

Epistaxis

• Signs & Symptoms– Bright red bleeding from one or both nostrils– Can lose as much as 1 liter per hour

Epistaxis

• Treatment– Sitting postion, leaning forward– Direct pressure by pinching nose– Ice compresses to nose– Nasal packing– Cautery– Balloon tamponade

Deviated Septum and Nasal Polyps

• Etiology/Pathophysiology– Congenital abnormality– Injury– Nasal septum deviates from the midline and can

cause a partial obstruction– Nasal polyps are tissue growths usually due to

prolonged inflammation

Deviated Septum and Nasal Polyps

• Signs & Symptoms– Stertorous respirations (snoring)– Dyspnea– Postnasal drip

Deviated Septum and Nasal Polyps

• Treatment– Medications

• Corticosteroids

• Antihistamines

• Antibiotics

• Analgesics

– Nasoseptoplasty– Nasal polypectomy

Allergic Rhinitis and Allergic Conjunctivitis (Hay Fever)

• Etiology/Pathophysiology– Antigen/antibody reactions in the nasal

membranes, nasopharynx, and conjunctiva due to allergens

Allergic Rhinitis and Allergic Conjunctivitis (Hay Fever)

• Signs & Symptoms– Edema– Photophobia– Excessive tearing– Blurring of vision– Pruritus– Excessive nasal secretions and/or congestion– Sneezing– Cough– Headache

Allergic Rhinitis and Allergic Conjunctivitis (Hay Fever)

• Treatment– Avoid allergen– Antihistamines– Decongestants– Topical or nasal corticosteroids

• Vancenase, Beconase

– Analgesics– Hot packs over facial sinuses

Upper Airway Obstruction

• Etiology/Pathophysiology– Inflammation of tissue– Dentures– Aspiration– Tongue– Laryngeal spasm

Upper Airway Obstruction

• Signs & Symptoms– Stertorous respirations– Altered resp. rate and character– Apneic periods– Hypoxia– Cyanosis– Wheezing– Stridor

Upper Airway Obstruction

• Treatment– Open the airway– Remove obstruction– Artificial airway

• Pharyngeal, endotracheal, and tracheal

– Tracheostomy

Tracheostomy

Tracheotomy Tubes

Cancer of the Larynx

• Etiology/Pathophysiology– Squamous cell carcinoma– Heavy smoking and alcohol use– Chronic laryngitis– Vocal abuse– Family history

Squamous Cell Carcinoma of the Larynx

Cancer of the Larynx

• Signs & Symptoms– Progressive or persistent hoarseness– Pain radiating to the ear– Difficulty swallowing– Hemoptysis

Cancer of the Larynx

• Treatment– Radiation– Surgery

• Partial laryngectomy– temporary tracheostomy

• Total laryngectomy– Permanent tracheostomy

– No voice

• Radical neck dissection

Acute Rhinitis(Common Cold, Acute Coryza)

• Etiology/Pathophysiology– Inflammation of the mucous membranes of the

nose and accessory sinuses– Virus(es)

Acute Rhinitis(Common Cold, Acute Coryza)

• Signs & Symptoms– Thin, serous nasal exudate– Productive cough– Sore throat– Fever

Acute Rhinitis(Common Cold, Acute Coryza)

• Treatment– No specific treatment– Analgesic

• NO Aspirin for infants, children and adolescents (Reye’s Syndrome)

– Antipyretic – Cough suppressent– Expectorant– Antibiotic, if infection present– Encourage fluids

Acute Follicular Tonsillitis

• Etiology/Pathophysiology– Inflammation of the tonsils– Bacterial infection (streptococcus)– Viral

Acute Follicular Tonsillitis

• Signs & Symptoms– Enlarged, tender, cervical lymph nodes– Sore throat– Fever– Chills– Enlarged, purulent tonsils– Elevated WBC

Acute Follicular Tonsillitis

Acute Follicular Tonsillitis

• Treatment– Antibiotics– Analgesics– Antipyretics– Warm saline gargles– Tonsillectomy and adenoidectomy

• 4-6 weeks after infection has subsided

Acute Follicular Tonsillitis

– Post-op• Assess for excessive bleeding

– Frequent swallowing

• Ice cold liquids – ice cream– Avoid acidic juices

• Ice collar

• Avoid coughing, sneezing, or vigorous nose blowing

Laryngitis

• Etiology/Pathophysiology– Inflammation of the larynx– Acute or chronic– Viral or bacterial– May cause severe respiratory distress in

children under 5 yrs

Laryngitis

• Signs & Symptoms– Hoarseness– Voice loss– Scratchy and irritated throat– Persistent cough

Laryngitis

• Treatment– Viral; no specific treatment– Bacterial; antibiotics– Analgesics– Antipyretics– Antitussives– Warm or cool mist vaporizer– Limit use of voice

Pharyngitis

• Etiology/Pathophysiology– Inflammation of the pharynx– Chronic or acute– Frequently accompanies the common cold– Viral, most common– Bacterial

• Gonococcal

• Streptococcus (strep throat)

Pharyngitis

• Signs & Symptoms– Dry cough– Tender tonsils– Enlarged cervical lymph glands– Red, sore throat– Fever

Pharyngitis

• Treatment– Antibiotics

• Penicillin, erythromycin

– Analgesics– Antipyretics– Warm or cool vaporizor

Sinusitis

• Etiology/Pathophysiology– Inflammation of the sinuses– Usually begins with an upper respiratory

infection– Chronic or acute– Viral or bacterial

Sinusitis

• Signs & Symptoms– Constant, severe headache– Pain and tenderness in involved sinus region– Purulent exudate– Malaise– Fever

Sinusitis

• Treatment– Antibiotics– Analgesics– Antihistamines– Vasoconstrictor nasal spray (Afrin)– Warm mist vaporizor– Warm, moist packs– Nasal windows