Medical-Surgical Nursing Respiratory System

Primary functions a. provides oxygen for metabolism in the tissues b. removes carbon dioxide, the waste product of metabolism 2 Main Parts 1. Upper Repiratory Tract a. Nose b. Mouth c. Pharynx d. Larynx Lower Respiratory Tract a. Trachea b. Bronchus c. Bronchioles d. Lungs

2.

NOSE 1. 2. 3. 4. 5. 6. 7. PHARYNX 1. 2. 3. LARYNX 1. 2.

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

Serves as a passageway and entrance to the respiratory and digestive tracts Aids in Phonation Tonsils function to destroy incoming bacteria and detoxify certain foreign proteins Voice production: during expiration, air passing through the larynx cause the vocal cords to vibrate; short, tense cords Serves as a passageway for air and as the entrance to the lower respiratory tract

TRACHEAwindpipe 1. tube about 4 inches long

2. 3. 4. 5.

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

BRONCHUS 1. a passage of airway in the respiratory tract that conducts air into the lungs 2. branches into smaller tubes, which in turn become bronchioles 3. No gas exchange takes place in this part of the lungs BRONCHIOLES 1. 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 submucosa 2. they are branches of the bronchi. The bronchioles terminate by entering the circular sacs called alveoli LUNGS 1. 2. 3.

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

Diagnostic Tests 1. Spirometry 2. Arterial blood gas determination 3. Oximeters 4. Exercise tolerance 5. Radiography 6. Bronchoscopy 7. Culture, sensitivity tests General Manifestations of Respiratory Disease 1. Sneezing 2. Coughing Irritation Controlled by medulla Constant, dry unproductive vs. productive cough 3. Sputum Mucus discharge Yellowish-green Rusty, dark-colored Thick, sticky Hemoptysis Manifestations 1. 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 agents 1. Streptococcus pneumoniae (pnemococcal pneumonia) 2. Hemophilus pneumoniae(Bronchopneumonia) 3. Escherichia coli 4. Klebsiella P. 5. Diplococcus P. Predisposing factors 1. Smoking 2. Air pollution 3. Immuno-compromised 4. Prolonged immobility CVA- hypostatic pneumonia 5. Aspiration of food 6. Over fatigue Signs and Symptoms 1. Productive cough Pathognomonic Sign: greenish to rusty sputum 2. Dyspnea with prolonged respiratory grunt 3. Fever, chills, anorexia, gen body malaise 4. Wt loss 5. Pleuritic friction rub 6. Rales/ crackles 7. Cyanosis 8. Abdominal distension leading to paralytic ileus Sputum exam could confirm presence of TB & pneumonia Diagnostic 1. Sputum (GSCS)- gram staining & culture sensitivity - Reveals (+) cultured microorganism. 2. Chest X-ray pulmo consolidation 3. CBC increase WBC 4. Erythrocyte sedimentation rate 5. ABG PO2 decrease Nursing Management 1. Enforce Complete Bed Rest 2. Strict respiratory isolation 3. Meds: a.) Broad spectrum antibiotics Penicillin or tetracycline Macrolides ex azythromycin (zythromax) b.) Anti pyretics c.) Mucolytics or expectorants

4. 5.

Force fluids 2 to 3 L/day Institute pulmonary toileta.) Deep breathing exercise b.) Coughing exercise c.) Chest physiotherapy cupping d.) Turning & reposition - Promote expectoration of secretions 6. Semi-fowler 7. Nebulize & suction 8. Comfortable & humid environment 9. Diet: increase CHO or calories, CHON & Vit. C 10. 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 factors 1. 2. 3. 4. 5. 11.

Malnutrition Overcrowding Alcoholism Ingestion of infected cattle (mycobacterium BOVIS) Virulence Over fatigue

Signs and Symptoms 1. Productive cough yellowish 2. Low grade fever 3. Night sweats 4. Dyspnea 5. Anorexia, general body malaise, wt loss 6. Chest/ back pain 7. Hempotysis Diagnosis 1. 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 Management 1. Complete Bed Rest 2. Strict respiratory isolation 3. O2 inhalation 4. Semi fowlers position 5. Force fluid to liquefy secretions 6. Nebulize & suction 7. Comfortable & humid environment 8. Diet increase CHO & calories, CHON, Vits., minerals 9. Short course chemotherapy a. Isoniazid (INH) b. Rifampin (RIF) c. Ethambutol d. Pyrazinamide e. 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. Dyspnea 3. Chest & joint pains 4. Cyanosis 5. Anorexia, gen body malaise, wt loss 6. Hemoptysis Diagnostic 1. Histoplasmin skin test = (+) 2. ABG pO2 decrease

Nursing Management 1. Complete Bed Rest 2. Meds: a.) Anti fungal agents b.) Corticosteroids c.) Mucolytic/ or expectorants 3. O2 force fluids 4. Nebulize, suction 5. Complications: a.) Atelectasis b.) Bronchiectasis COPD 6. Prevent spread of histoplasmosis: a.) Spray breeding places or kill the bird

COPD Chronic Obstructive Pulmonary Disease TYPES

1. 2. 3. 4. Chronic bronchitis Bronchial asthma Bronchiectasis 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 factors 1. Smoking all COPD types 2. Air pollution Signs and Symptoms 1. Productive cough 2. Dyspnea on exertion 3. Prolonged expiratory grunt 4. Scattered rales/ rhonchi 5. Cyanosis 6. Pulmonary HPN a.)Leading to peripheral edema b.) Cor pulmonary respiratory in origin 7. Anorexia, generalized body malaise Diagnostic 1. ABG Nursing Management (Same as emphysema)

1. 2.

3. 4. 5. 6. 7.

8.

Complete Bed Rest Administer medications as ordered a.) Bronchodilators b.) Corticosteroids c.) Antimicrobial agents d.) Mucolytics/ expectorants O2 Low inflow Force fluids High fowlers Nebulizer & suction Institute a. P posture b. E end c. E expiratory d. P pressure Health Teaching: a.) Avoid smoking b.) Prevent complications 1.) Cor pulmonary R ventricular hypertrophy 2.) CO2 narcosis lead to coma 3.) Atelectasis 4.) 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 Types 1.

2.

Extrinsic asthma a. Acute episodes triggered by type I hypersensitivities b. Onset in childhood Intrinsic asthma a. Onset during adulthood b. Stimuli target hyperresponsive tissue = acute attack

Predisposing factor 1. Extrinsic Asthma called Atropic/ allergic asthma a.) Pallor b.) Dust c.) Gases d.) Smoke e.) Dander f.) Lints 2. Intrinsic Asthma Cause: a.) Herediatary b.) c.) d.) e.) f.) 3. Drugs aspirin, penicillin, blockers Food additives nitrites Foods seafood, chicken, eggs, chocolates, milk Physical/ emotional stress Sudden change of temp, humidity &air pressure

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

Signs and Symptoms 1. Cough, dyspnea, tight feeling in chest 2. Wheezing 3. Rapid, labored breathing 4. Thick, sticky mucus coughed up 5. Tachycardia and pulse paradoxus

6. 7. 8. 9. Diagnostic

a. Pulse differs on inspiration and expiration Hypoxia Respiratory acidosis Severe respiratory distress Respiratory failure

Pulmonary function test decrease lung capacity 1. ABG PO2 decrease Nursing Management 1. Complete Bed Rest for all types of COPD 2. Medsa.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids b.) Corticosteroids due inflammatory. Given 10 min after administration of bronchodilator c.) Mucolytic/ expectorant d.) Mucomist at bedside put suction machine. e.) Antihistamine 3. Force fluid 4. O2 all COPD low inflow to prevent respiratory distress 5. Nebulize & suction 6. Semifowler all COPD except emphysema due late stage 7. Health teachings a.) Avoid predisposing factors b.) Complications: a.) Status astmaticus- give epinephrine & bronchodilators b.) Emphysema c.) Adherence to medications

BRONCHIECTASIS abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.
Predisposing factors 1. Recurrent upper & lower RI 2. Congenital anomalies 3. Tumors 4. Trauma Signs and Symptoms 1. Productive cough 2. Dyspnea 3. Anorexia, gen body malaise- all energy are used to increase respiration. 4. Cyanosis 5. Hemoptisis Diagnostic 1. ABG PO2 decrease 2. Bronchoscopy direct visualization of bronchus using fiberscope Nsg Mgt: before bronchoscopy 1. Consent, explain procedure MD/ lab explain RN 2. NPO 3. Monitor VS Nsg Mgt after bronchoscopy 1. Feeding after return of gag reflex 2. Instruct client to avoid talking, smoking or coughing 3. Monitor signs of frank or gross bleeding 4. 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 factor 1. Smoking 2. Allergy 3. Air pollution 4. High risk elderly 5. Hereditary Signs and Symptoms 1. Productive cough 2. Dyspnea at rest 3. Anorexia & generalized body malaise 4. Rales/ rhonchi 5. Bronchial wheezing 6. Decrease tactile fremitus 7. Resonance to hyperresonance percussion 8. Decreased or diminished breath sounds 9. Pathognomonic: Barrel chest increase post/ anterior diameter of chest 10. Purse lip breathing to eliminated PCO2 11. Flaring of alai nares Diagnosis 1. Pulmonary function test decrease vital lung capacity 2. ABG Nursing Management 1. Complete Bed Rest 2. Administer medications as ordered a. Bronchodilators b. Corticosteroids c. Antimicrobial agents d. Mucolytics/ expectorants 3. O2 Low inflow 4. Force fluids 5. High fowlers 6. Nebulize & suction 7. Institute P posture E end E expiratory P pressure 8. Health teachings a.) Avoid predisposing factors b.) Complications: c.) Status astmaticus- give epinephrine & bronchodilators d.) 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 conditions Eg. open pneumothorax air enters pleural space through an opening in chest wall

2.

-Stab/ gun shot wound Tension Pneumothorax air enters plural space with at inspiration & cant escape leading to over distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side. Eg. flail chest paradoxical breathing

Predisposing factors 1.Chest trauma 2.Inflammatory lung conditions 3.Tumor Signs and Symptoms 1. Sudden sharp chest pain 2. Dyspnea 3. Cyanosis 4. Diminished breath sound of affected lung 5. Cool moist skin 6. Mild restlessness/ apprehension 7. Resonance to hyper resonance Diagnosis 1. ABG pO2 decrease 2. Chest X-ray confirms pneumothorax Nursing Management 1. Endotracheal intubation 2. Thoracenthesis 3. Meds Morphine SO4 Anti microbial agents 4. Assist in test tube thoracotomy Nursing Mgt if pt is on Chest Physiotherapy attached to H2O drainage 1. Maintain strict aseptic technique 2. Prepare at bedside a.) Petroleum gauze pad if dislodged Hemostan b.) If with air leakage clamp c.) Extra bottle 3. Meds Morphine SO4 Antimicrobial 4. Monitor & assess for oscillation fluctuations or bubbling a.) If (+) to intermittent bubbling means normal or intact - H2O rises upon inspiration - H2o goes down upon expiration b.) If (+) to continuous, remittent bubbling 1. Check for air leakage 2. Clamp towards chest tube 3. Notify MD c.) If (-) to bubbling 1. Check for loop, clots, and kink 2. Milk towards H2O seal 3. Indicates re-expansion of lungs When will MD remove chest tube: 1. If (-) fluctuations 2. (+) Breath sounds 3. CXR full expansion of lungs Nursing Mgt of removal of chest tube 1. 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