Medical-Surgical NursingRespiratory System

Primary functionsa. provides oxygen for metabolism in the tissuesb. removes carbon dioxide, the waste product of metabolism

2 Main Parts

1. Upper Repiratory Tracta. Noseb. Mouthc. Pharynxd. Larynx

2. Lower Respiratory Tracta. Tracheab. Bronchusc. Bronchiolesd. Lungs

NOSE1. Filters, warms and humidifies air 2. First defense against foreign particles 3. Inhalation for deep breathing is to be done via nose 4. Exhalation is done through the mouth 5. Serves as passageway for incoming and outgoing air, filtering, warming, moistening, and chemically examining it.6. Organ of smell (Olfactory receptors located in the nasal mucosa7. Aids in phonation

PHARYNX1. Serves as a passageway and entrance to the respiratory and digestive tracts2. Aids in Phonation3. Tonsils function to destroy incoming bacteria and detoxify certain foreign proteins

LARYNX1. Voice production: during expiration, air passing through the larynx cause the vocal cords to vibrate; short, tense cords2. Serves as a passageway for air and as the entrance to the lower respiratory tract

TRACHEA”windpipe”1. tube about 4 inches long

2. begins just under the larynx (voice box) and runs down behind the breastbone (sternum).3. divides into two smaller tubes called bronchi: one bronchus for each lung.4. composed of about 20 rings of tough cartilage5. widens and lengthens slightly with each breath in, returning to its resting size with each breath out

BRONCHUS1. a passage of airway in the respiratory tract that conducts air into the lungs2. branches into smaller tubes, which in turn become bronchioles3. No gas exchange takes place in this part of the lungs

BRONCHIOLES1. first passageways by which the air passes through the nose or mouth to the air sacs of the lungs in which branches no longer

contain cartilage or glands in their submucosa2. they are branches of the bronchi. The bronchioles terminate by entering the circular sacs called alveoli

LUNGS1. a pair of spongy, air-filled organs located on either side of the chest (thorax). 2. covered by a thin tissue layer called the pleura. The same3. A thin layer of fluid acts as a lubricant allowing the lungs to slip smoothly as they expand and contract with each breath.

Diagnostic Tests1. Spirometry 2. Arterial blood gas determination3. Oximeters 4. Exercise tolerance5. Radiography6. Bronchoscopy 7. Culture, sensitivity tests

General Manifestations of Respiratory Disease1. Sneezing2. Coughing

– Irritation– Controlled by medulla– Constant, dry unproductive vs. productive cough

3. Sputum– Mucus discharge– Yellowish-green– Rusty, dark-colored– Thick, sticky– Hemoptysis

Manifestations1. Breathing patterns and characteristics

– Kussmaul respiration– Labored respiration, prolonged inspiration/expiration times– Wheezing– Stridors

2. Breath sounds– Rales – Rhonchi – Absence

Abnormal patterns of breathing 1.Sleep Apnea cessation of airflow for more than 10 seconds more than 10 times a night during sleep causes: obstructive (e.g. obesity with upper narrowing, enlarged tonsils, pharyngeal soft tissue changes inacromegaly or hypothyroidism) 2. Cheyne-Stokes- periods of apnoea alternating with periods of hyperpnoae causes:

left ventricular failure brain damage (e.g. trauma, cerebral, haemorrhage) high altitude

3. Kussmaul's (air hunger) deep rapid respiration due to stimulation of respiratory centre 4. Hyperventilation

complications: alkalosis and tetany causes: anxiety 5. Ataxic (Biot) irregular in timing and deep causes: brainstem damage 6. Apneustic post-inspiratory pause in breathing causes: brain (pontine) damage 7. Paradoxical - the abdomen sucks with respiration (normally, it pouches uotward due to diaphragmatic descent) causes: diaphragmatic paralysis

Dieases of the Respiratory System

PNEUMONIA– inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.

High risk -elderly & children below 5 y/o

Etiologic agents1. Streptococcus pneumoniae (pnemococcal pneumonia) 2. Hemophilus pneumoniae(Bronchopneumonia)3. Escherichia coli4. Klebsiella P.5. Diplococcus P.

Predisposing factors1. Smoking 2. Air pollution3. Immuno-compromised4. Prolonged immobility – CVA- hypostatic pneumonia5. Aspiration of food6. Over fatigue

Signs and Symptoms1. Productive cough –Pathognomonic Sign: greenish to rusty sputum2. Dyspnea with prolonged respiratory grunt3. Fever, chills, anorexia, gen body malaise4. Wt loss5. Pleuritic friction rub6. Rales/ crackles7. Cyanosis8. Abdominal distension leading to paralytic ileus

Sputum exam – could confirm presence of TB & pneumonia

Diagnostic1. Sputum (GSCS)- gram staining & culture sensitivity - Reveals (+) cultured microorganism.2. Chest X-ray – pulmo consolidation3. CBC – increase WBC4. Erythrocyte sedimentation rate5. ABG – PO2 decrease

Nursing Management1. Enforce Complete Bed Rest2. Strict respiratory isolation3. Meds:

a.) Broad spectrum antibioticsPenicillin or tetracyclineMacrolides – ex azythromycin (zythromax)

b.) Anti pyretics c.) Mucolytics or expectorants

4. Force fluids – 2 to 3 L/day5. Institute pulmonary toilet-

a.) Deep breathing exerciseb.) Coughing exercisec.) Chest physiotherapy – cuppingd.) Turning & reposition - Promote expectoration of secretions

6. Semi-fowler7. Nebulize & suction8. Comfortable & humid environment9. Diet: increase CHO or calories, CHON & Vit. C10. Postural drainage - To drain secretions using gravity

PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB or tubercle bacilli or acid fast bacilli – gram (+) aerobic, motile & easily destroyed by heat or sunlight.

Predisposing factors1. Malnutrition2. Overcrowding3. Alcoholism4. Ingestion of infected cattle (mycobacterium BOVIS) 5. Virulence11. Over fatigue

Signs and Symptoms1. Productive cough – yellowish2. Low grade fever3. Night sweats4. Dyspnea5. Anorexia, general body malaise, wt loss6. Chest/ back pain7. Hempotysis

Diagnosis1. Skin test – Mantoux test – infection of Purified CHON Derivative PPD

DOH – 8-10 mm induration WHO – 10-14 mm induration Result within 48 – 72h (+) Mantoux test – previous exposure to tubercle bacilli

Mode of transmission – droplet infection

Nursing Management1. Complete Bed Rest2. Strict respiratory isolation3. O2 inhalation4. Semi fowler’s position5. Force fluid to liquefy secretions6. Nebulize & suction7. Comfortable & humid environment8. Diet – increase CHO & calories, CHON, Vits., minerals9. Short course chemotherapy

a. Isoniazid (INH)b. Rifampin (RIF)c. Ethambutold. Pyrazinamidee. Streptomycin

HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted to birds manure.

Signs and Symptoms Same as pneumonia & PTB – like

1. Productive cough 2. Dyspnea3. Chest & joint pains4. Cyanosis5. Anorexia, gen body malaise, wt loss6. Hemoptysis

Diagnostic1. Histoplasmin skin test = (+) 2. ABG – pO2 decrease

Nursing Management1. Complete Bed Rest2. Meds:

a.) Anti fungal agentsb.) Corticosteroidsc.) Mucolytic/ or expectorants

3. O2 – force fluids4. Nebulize, suction5. Complications:

a.) Atelectasisb.) Bronchiectasis COPD

6. Prevent spread of histoplasmosis:a.) Spray breeding places or kill the bird

COPD – Chronic Obstructive Pulmonary DiseaseTYPES

1. Chronic bronchitis2. Bronchial asthma3. Bronchiectasis4. Pulmonary emphysema – terminal stage

For all types of COPD: #1 cause is smoking Expect doctor to prescribe bronchodilators LOW-FLOW OXYGEN only so as not so suppress the respiratory

drive

CHRONIC BRONCHITIS- called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet mucus producing cells leading to narrowing of smaller airways.

Predisposing factors1. Smoking – all COPD types2. Air pollution

Signs and Symptoms1. Productive cough 2. Dyspnea on exertion

3. Prolonged expiratory grunt 4. Scattered rales/ rhonchi5. Cyanosis 6. Pulmonary HPN

a.)Leading to peripheral edema b.) Cor pulmonary – respiratory in origin

7. Anorexia, generalized body malaise

Diagnostic1. ABG

Nursing Management(Same as emphysema)

1. Complete Bed Rest 2. Administer medications as ordered

a.) Bronchodilatorsb.) Corticosteroidsc.) Antimicrobial agentsd.) Mucolytics/ expectorants

3. O2 – Low inflow4. Force fluids5. High fowlers6. Nebulizer & suction7. Institute

a. P – postureb. E – endc. E – expiratoryd. P – pressure

8. Health Teaching: a.) Avoid smokingb.) Prevent complications

1.) Cor pulmonary – R ventricular hypertrophy2.) CO2 narcosis – lead to coma3.) Atelectasis4.) Pneumothorax – air in pleural space

c.) Adhere with the medications

BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller airway

2 Types1. Extrinsic asthma

a. Acute episodes triggered by type I hypersensitivitiesb. Onset in childhood

2. Intrinsic asthmaa. Onset during adulthoodb. Stimuli target hyperresponsive tissue = acute attack

Predisposing factor1. Extrinsic Asthma – called Atropic/ allergic asthma

a.) Pallorb.) Dust c.) Gasesd.) Smokee.) Danderf.) Lints

2. Intrinsic Asthma -Cause:

a.) Herediataryb.) Drugs – aspirin, penicillin, b blockersc.) Food additives – nitritesd.) Foods – seafood, chicken, eggs, chocolates, milke.) Physical/ emotional stressf.) Sudden change of temp, humidity &air pressure

3. Mixed type: combination of both extrinsic & intristic Asthma 90% cause of asthma

Signs and Symptoms1. Cough, dyspnea, tight feeling in chest2. Wheezing3. Rapid, labored breathing4. Thick, sticky mucus coughed up5. Tachycardia and pulse paradoxus

a. Pulse differs on inspiration and expiration6. Hypoxia7. Respiratory acidosis8. Severe respiratory distress9. Respiratory failure

Diagnostic

Pulmonary function test – decrease lung capacity1. ABG – PO2 decrease

Nursing Management1. Complete Bed Rest for all types of COPD2. Meds-

a.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroidsb.) Corticosteroids – due inflammatory. Given 10 min after administration of bronchodilatorc.) Mucolytic/ expectorantd.) Mucomist – at bedside put suction machine.e.) Antihistamine

3. Force fluid4. O2 – all COPD low inflow to prevent respiratory distress5. Nebulize & suction6. Semifowler – all COPD except emphysema due late stage7. Health teachings

a.) Avoid predisposing factorsb.) Complications:

a.) Status astmaticus- give epinephrine & bronchodilatorsb.) Emphysema

c.) Adherence to medications

BRONCHIECTASIS – abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.

Predisposing factors1. Recurrent upper & lower RI2. Congenital anomalies3. Tumors4. Trauma

Signs and Symptoms1. Productive cough2. Dyspnea3. Anorexia, gen body malaise- all energy are used to

increase respiration.4. Cyanosis5. Hemoptisis

Diagnostic1. ABG – PO2 decrease2. Bronchoscopy – direct visualization of bronchus using

fiberscopeNsg Mgt: before bronchoscopy

1. Consent, explain procedure – MD/ lab explain RN

2. NPO3. Monitor VS

Nsg Mgt after bronchoscopy1. Feeding after return of gag reflex2. Instruct client to avoid talking, smoking or coughing3. Monitor signs of frank or gross bleeding4. Monitor of laryngeal spasm

DOB Prepare at bedside tracheostomy set

Management: same as emphysema except Surgery Pneumonectomy – removal of affected lung

Segmental lobectomy – position of pt – unaffected side

PULMONARY EMPHYSEMA – irreversible terminal stage of COPD– Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases.– Body will compensate over distension of thoracic cavity – Barrel chest

Predisposing factor1. Smoking2. Allergy3. Air pollution4. High risk – elderly5. Hereditary

Signs and Symptoms 1. Productive cough2. Dyspnea at rest 3. Anorexia & generalized body malaise4. Rales/ rhonchi5. Bronchial wheezing6. Decrease tactile fremitus 7. Resonance to hyperresonance – percussion 8. Decreased or diminished breath sounds 9. Pathognomonic: Barrel chest – increase post/ anterior diameter of chest10. Purse lip breathing – to eliminated PCO211. Flaring of alai nares

Diagnosis1. Pulmonary function test – decrease vital lung capacity2. ABG

Nursing Management1. Complete Bed Rest2. Administer medications as ordered

a. Bronchodilatorsb. Corticosteroidsc. Antimicrobial agentsd. Mucolytics/ expectorants

3. O2 – Low inflow4. Force fluids5. High fowlers6. Nebulize & suction7. Institute

P – posture E – end E – expiratory P – pressure

8. Health teachingsa.) Avoid predisposing factorsb.) Complications:

c.) Status astmaticus- give epinephrine & bronchodilatorsd.) Emphysema

c.) Adherence to medications

RESTRICTIVE LUNG DISORDER

PNEUMOTHORAX – partial / or complete collapse of lungs due to entry or air in pleural space.

Types:1. Spontaneous Pneumothorax – entry of air in pleural space without obvious cause

Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditionsEg. open pneumothorax – air enters pleural space through an opening in chest wall

-Stab/ gun shot wound2. Tension Pneumothorax – air enters plural space with at inspiration & can’t escape leading to over distension of thoracic cavity

resulting to shifting of mediastinum content to unaffected side.Eg. flail chest – “paradoxical breathing”

Predisposing factors1.Chest trauma2.Inflammatory lung conditions3.Tumor

Signs and Symptoms1. Sudden sharp chest pain 2. Dyspnea3. Cyanosis4. Diminished breath sound of affected lung5. Cool moist skin6. Mild restlessness/ apprehension7. Resonance to hyper resonance

Diagnosis1. ABG – pO2 decrease –2. Chest X-ray – confirms pneumothorax

Nursing Management1. Endotracheal intubation2. Thoracenthesis3. Meds – Morphine SO4- Anti microbial agents4. Assist in test tube thoracotomy

Nursing Mgt if pt is on Chest Physiotherapy attached to H2O drainage

1. Maintain strict aseptic technique2. Prepare at bedside

a.) Petroleum gauze pad if dislodged Hemostanb.) If with air leakage – clamp c.) Extra bottle

3. Meds – Morphine SO4Antimicrobial

4. Monitor & assess for oscillation fluctuations or bubblinga.) If (+) to intermittent bubbling means normal or intact

- H2O rises upon inspiration - H2o goes down upon expiration

b.) If (+) to continuous, remittent bubbling1. Check for air leakage2. Clamp towards chest tube3. Notify MD

c.) If (-) to bubbling 1. Check for loop, clots, and kink2. Milk towards H2O seal3. Indicates re-expansion of lungs

When will MD remove chest tube:1. If (-) fluctuations2. (+) Breath sounds3. CXR – full expansion of lungs

Nursing Mgt of removal of chest tube1. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space. 2. Apply vaselinated air occlusive dressing - Maintain dressing dry & intact