The Respiratory System Correlated to the Roy Adaptation Model and Nursing Process
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Transcript of The Respiratory System Correlated to the Roy Adaptation Model and Nursing Process
The Respiratory SystemCorrelated to the Roy Adaptation Model and Nursing ProcessSandy Marks, RN, BSN, MS(HCA)
N212 Medical Surgical Nursing 1Spring 2008
Course Packet (2007), p 104
Journey through Roy Adaptation Model(RAM) Roy Adaptation Model →
Patients primarily with alterations inphysiological mode →
oxygenation →
respiratory system
Objectives - 1
Review the anatomy and physiology of the respiratory system
Describe the respiratory changes associated with aging
Objectives - 2 Discuss the purpose and interventions
(preparation, explanation, procedure, postcare) for the following diagnostic tests: X-rays: chest, bronchogram, CT, lung scan Direct visualization: bronchoscopy Sputum specimen Thoracentesis Pulmonary function tests (PFT) Oximetry Magnetic resonance imaging (MRI) Cultures
Objectives - 3
Describe the nursing assessment of the following cardinal signs and symptoms:
cough sputum dyspnea
Discuss the pathophysiology, nursing assessment, interventions, and evaluation for Pneumonia
dscherer.com
The Art of Caring
Respiratory Review Purpose =1. provide oxygen for tissue metabolism (O2)2. remove carbon dioxide (CO2)
Influences functions of:1. acid-base balance2. speech3. sense of smell4. fluid balance5. temperature control
Chabner, 2007
Review the anatomy and physiology of
the respiratory system1. upper respiratory tract
2. lower respiratory tract
divided by trachea (windpipe)
bronchi bronchioles alveolar ducts alveoli
trachea
bronchi
alveoli
bronchioles
Chabner, 2007
Gas Exchange
occurs at alveolar capillary membrane
occurs by diffusion
Pulmonary edema =1. excess fluid fills alveoli
spaces2. impairs exchange of O2
and CO2 capillary
Chabner, 2007
Normal lung tissue 300 million alveoli surface area = tennis
court
Right bronchus slightly wider shorter more vertical increases problems with1. intubation2. aspiration
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Physiologic changes associated with aging
Alveoli
alveolar surface area decreases diffusion capacity decreases elastic recoil decreases bronchioles and alveolar ducts dilate ability to cough decreases airways close early
Lungs
residual volume increases vital capacity decreases efficiency of oxygen and carbon dioxide
exchange decreases elasticity decreases
Pharynx and Larynx
muscles atrophy vocal cords become slack laryngeal muscles lose elasticity and
cartilage
Pulmonary Vasculature
increased vascular resistance to blood flow through pulmonary vascular system occurs
pulmonary capillary blood volume decreases risk of hypoxia increases
Exercise Tolerance andMuscle Strength Exercise Tolerance
body’s response to hypoxia and hypercapnea decreases
Muscle Strengthrespiratory muscle strength, especially the diaphragm and intercostals, decreases
Susceptibility to Infection
effectiveness of the cilia increases immunoglobulin A decreases alveolar macrophages are altered
Chest Wall
anteroposterior (AP) diameter increases thorax becomes shorter progressive kyphoscoliosis occurs chest wall compliance (elasticity) decreases mobility may decrease osteoporosis is possible
Summary on effects of aging ↓ ↓ recoil and compliancerecoil and compliance
AP diameter AP diameter
↓ ↓ functional alveolifunctional alveoli
↓ ↓ in Pa02in Pa02
Respiratory defense mechanisms less effective Respiratory defense mechanisms less effective
Altered respiratory controlsAltered respiratory controls More gradual response to changes in O2 and Co2 More gradual response to changes in O2 and Co2
levels in bloodlevels in blood
Diagnostic Tests
X-rays: chest, bronchogram, CT, lung scan Direct visualization: bronchoscopy Sputum specimen and Cultures Thoracentesis Pulmonary function tests (PFT) Oximetry Magnetic resonance imaging (MRI)
Chest X-RayChest X-Ray Screen, diagnose, Screen, diagnose,
evaluate treatmentevaluate treatment
Instructions:Instructions:
Chabner, 2007
X-ray Positions
Chest X-Ray Chest X-Ray (Cont.)(Cont.)
Posterior Anterior View Left Lateral View
www.fotosearch.com
Bronchogram Slightly
oblique
Computed Tomography: CT Computed Tomography: CT ScanScan Images in Images in cross-cross-
sectionsection view view
Uses contrast Uses contrast agentsagents
Instructions:Instructions:
Right upper Lobe
www.ucl.ac.uk
Lung Scan most to detect emboli
no food restrictions breathes radioactive
material through a tube for 5 minutes
6 ventilation images taken
radioactive injection same 6 images
retaken compare images
www.diiradiology.com www.washingtonhospital.org
Ventilation- air distribution in lungPerfusion- blood supply to & within lung
BronchoscBronchoscopyopy
Diagnose problems and assess Diagnose problems and assess changes in bronchi / bronchioleschanges in bronchi / bronchioles
Performed to remove foreign Performed to remove foreign body, secretions, or to obtain body, secretions, or to obtain specimens of tissue or mucus for specimens of tissue or mucus for further studyfurther study
Post-Procedure Care / Instructions:Post-Procedure Care / Instructions:
Sputum SpecimenSputum Specimen
To diagnose; evaluate treatmentTo diagnose; evaluate treatment Specimen: ID organisms or abnormal Specimen: ID organisms or abnormal
cellscells Culture & Sensitivity (C&S)Culture & Sensitivity (C&S) CytologyCytology Gram stains Gram stains
(e.g. Acid Fast Bacilli)(e.g. Acid Fast Bacilli)
ThoracentThoracentesisesis
Specimen from Specimen from pleural fluidpleural fluid
Treat pleural effusionTreat pleural effusion
Assess for Assess for complicationscomplications
Post-Procedure care:Post-Procedure care:PositionsPositions
•Sitting on side of bed over bedside table Sitting on side of bed over bedside table chest elevated chest elevated•Lying on affected sideLying on affected side•Straddling a chairStraddling a chair
Chabner, 2007
Pneumothorax
Pulmonary Function Test Pulmonary Function Test (PFTs)(PFTs)
Evaluate lung functionEvaluate lung function
Observe for increased Observe for increased dyspnea or dyspnea or bronchospasmbronchospasm
Instructions:Instructions:
Pulse Pulse OximetryOximetry Measures arterial Measures arterial
oxygen saturationoxygen saturation Pulse oximetry probe Pulse oximetry probe
on ears, nose, finger, on ears, nose, finger, toes, foreheadtoes, forehead
False readingsFalse readings Intermittent or Intermittent or
continuous monitoring continuous monitoring Ideal valuesIdeal values When to Notify MDWhen to Notify MD
Chabner, 2007
MRI Frontal View White masses =
Hodgkin Disease lesions
Chabner, 2007
MRI – transverse view – same patient
Nursing Assessment:Cardinal Signs and Symptoms of:
1. Cough2. Sputum3. Dyspnea
Cough – Main Sign of Lung Disease how long present occurs at a specific time (smokers = upon
wakening in AM) related to activity productive vs nonproductive congested dry tickling hacking
Sputum – normally 3 oz produced/day important symptom associated with coughing
Check: 1. duration – long term, short term2. color – rust colored3. consistency – thick, thin, watery, frothy4. odor- foul 5. amount – describe in tsp, or fractions of cup
and if increasing (external or internal cause)
Dyspnea – subjective data (perception) difficulty in breathing or breathlessness Check:1. onset – slow or abrupt2. duration - # of hours, time of day3. relieving factors – position change, med,
stop activity4. wheezing, crackles, rales, or stridor occur
with breathlessness Quantify by assessing if interferes with ADL PND or orthopnea
Lung sounds wheezing crackles stridor
auscultation – sequence pg. 534, Iggy
bronchial = trachea & mainstem bronchi bronchovesicular = branching bronchi vesicular = small bronchiole periphery
Pneumonia: Case StudyPneumonia: Case Study
Course Packet (2007), pgs 115-117
Nursing Student Tools
Concept Map – Pneumonia Medical-Surgical Map (Medimap) Nursing Map
PathophysiologyPathophysiology
Toxic sprinkles anyone?Toxic sprinkles anyone?
EtiologyEtiology
CauseCause bacteria (75%)bacteria (75%) virusesviruses fungifungi MycoplasmaMycoplasma parasitesparasites chemicalschemicals
ClassificatiClassificationsons
Community-acquired pneumonia (CAP)Community-acquired pneumonia (CAP) Onset in community or during 1Onset in community or during 1stst 2 days of hospitalization 2 days of hospitalization
(Strep. pneumoniae most common)(Strep. pneumoniae most common)
Hospital-acquired Pneumonia (HAP / nosocomial)Hospital-acquired Pneumonia (HAP / nosocomial) Occurring 48 hrs or longer after hospitalizationOccurring 48 hrs or longer after hospitalization
Aspiration pneumoniaAspiration pneumonia
Pneumonia caused by opportunistic organismsPneumonia caused by opportunistic organisms Pneumocystis CariniiPneumocystis Carinii
Risk FactorsRisk Factors
CAPCAP Older adultOlder adult Chronic/coexisting Chronic/coexisting
conditioncondition Recent history or Recent history or
exposure to viral or exposure to viral or influenza infectionsinfluenza infections
History of tobacco or History of tobacco or alcohol usealcohol use
HAPHAP Older adultOlder adult Chronic lung diseaseChronic lung disease ALOCALOC AspirationAspiration ET, Trach, NG / GT ET, Trach, NG / GT ImmunocompromisedImmunocompromised Mechanical ventilationMechanical ventilation
Clinical Manifestations - 1Clinical Manifestations - 1 Fevers, chills, anorexiaFevers, chills, anorexia Pleuritic chest painPleuritic chest pain SOBSOB Crackles / wheezesCrackles / wheezes Cough, sputum productionCough, sputum production TachypneaTachypnea
Clinical Manifestations - 2Clinical Manifestations - 2
Mycoplasma (Atypical)Mycoplasma (Atypical) feeling tired or weak, feeling tired or weak,
headaches, sore throat, or headaches, sore throat, or diarrhea. diarrhea.
Eventually, most develop a Eventually, most develop a dry cough. They can, also, dry cough. They can, also, develop fever, chills, develop fever, chills, earaches, chest painearaches, chest pain
““walking pneumonia”walking pneumonia”
DiagnoDiagnosissis
Diagnosis Diagnosis →→ Physical exam → crackles, Physical exam → crackles,
rhonchi / wheezesrhonchi / wheezes
CXR → area of increased CXR → area of increased density density
(infiltrates / consolidation)(infiltrates / consolidation)
Sputum specimen – Sputum specimen – Gram stainGram stain
LUL Infiltrates
www.med.wayne.edu
CXR- LUL Pneumonia
Interventions and TreatmentInterventions and Treatment TreatmentTreatment
Antibiotics → choose based on age, suspected Antibiotics → choose based on age, suspected cause & immune statuscause & immune status
Supportive care → IV fluids, supplemental oxygen Supportive care → IV fluids, supplemental oxygen therapy, respiratory monitoring, cough therapy, respiratory monitoring, cough enhancementenhancement
*may take 6-8 weeks for CXR to normalize*may take 6-8 weeks for CXR to normalize
Nursing Diagnoses…Nursing Diagnoses… Impaired gas exchange R/T Impaired gas exchange R/T
PneumoniaPneumonia
Pain R/T infection in lung Pain R/T infection in lung PneumoniaPneumonia
ComplicatiComplicationsons
HypoxemiaHypoxemia
Pleural effusionPleural effusion
AtelectasisAtelectasis
PleurisyPleurisy
Atelectasis Pleurisy
Pleural Effusion
Chabner, 2007
Atelectasis
A = obstruction
B = accumulation of fluid of air
Additional learning resources NANDA approved nursing diagnoses specific
to respiratory system: p125 of study packet Skills Lab:
Heart and Lung Sounds Trainer Learning Lung Sounds, Cardionics CD Audio-visual material
Resources Beers, M. & Berkow, R. (Ed.). (2000). The Merck
Manual of Geriatrics (3rd ed.). Whitehouse Station: Merck & Co., Inc.
Chabner (2007). The Language of Medicine (8th ed.). St. Louis: Saunders.
Ignatavicius, D. & Workman, L. (2006). Medical-Surgical Nursing Critical Thinking for
Collaborative Care (5th ed.). St. Louis: Elsevier Saunders.
Scherer, D. (2008). Pictures retrieved March 31 and available at dscherer.com
dscherer.com