RESPIRATORY SYSTEM

Anatomy and physiology

 The upper respiratory tract, known as the upper airway, warms and filters inspired
air so that the lower respiratory tract (the lungs) can accomplish gas exchange.
 Gas exchange involves delivering oxygen to the tissues through the bloodstream
and expelling waste gases, such as carbon dioxide, during expiration.
 The respiratory system works with the cardiovascular system; the respiratory
system is responsible for ventilation and diffusion, and the cardiovascular system
is responsible for perfusion.
 Upper airway structures consist of the nose, sinuses, and nasal passages,
pharynx, tonsils and adenoids, larynx, and trachea
 Lower respiratory tract consists of the lungs which contain the bronchial and
alveolar structure which is needed for gas exchange
Function of the Respiratory System
1. Oxygen Transport
 Oxygen is supplied to, and removed from cell by the way of circulating blood.
 Oxygen diffuses from the capillary wall to the interstitial fluid.
 The movement of the carbon dioxide occurs by diffusion in the opposite direction
–from cell to blood
2. Respiration
 Movement of air in and out of the airway (ventilation) continually replenishes the
oxygen and removes carbon dioxide from the airway and lungs.
3. Ventilation
 During inspiration, air flow from the environment into the trachea, bronchi,
bronchioles and alveoli. During expiration, alveolar gas travels the same route in
reverse.
 Mechanism of ventilation includes:
a. Air pressure variance – air flow from a region of higher pressure to a region
of lower pressure.
b. Airway Resistance – is determined chiefly by the radius or size of the airway
through which air is flowing. With increase resistance, greater than the normal
respiratory effort is required to achieve normal levels of ventilation
c. Compliance- refers to which the lungs expand and indicates the relationship
between the volume and the pressure of the lungs
4. Regulation of Acid-Base Balance
 Insufficient ventilation causes hypercapnia, a respiratory acidemia causes
retention of excessive amount of CO2.
 Hypocapnia, a respiratory alkalemia due to the low amounts of CO2, in the blood
 The effectiveness of ventilation is best measured by the PCO2 in the arterial blood
(PaCO2)

THE RESPIRATORY PROCESS

1. The diaphragm descends into the abdominal cavity during inspiration causing (-)
pressure in the lungs.
2. The (-) pressure draws the air from the area of greater pressure (THE
ATMOSPHERE) into an area of lesser pressure (THE LUNGS)
3. In the lungs, air passes thru the terminal bronchioles into the alveoli to oxygenate
the body tissues
4. At the end of inspiration, the diaphragm & intercostal muscles relax & the lungs
recoil
5. As the lungs recoil, pressure within the lungs becomes greater than atmospheric
pressure, causing the air which now contains the cellular waste products of CO2 &
H2O to move from the alveoli in the lungs to the atmosphere
6. Expiration is a passive process

Control of Respiration
1. Activity of the respiratory muscles is regulated by nerve impulses transmitted by
the brain thru the Phrenic & Intercostal nerves.
2. Neural centers that control breathing is located in the medulla oblongata and the
pons
3. Eupnea – normal breathing

Normal breath sounds

1. Bronchial
  Loud and high-pitched w/ hollow quality.
 Expiration lasts longer than inspiration.
 Best heard over the trachea
 Created by air moving through the trachea close to chest wall.
2. Bronchovesicular
 Blowing sounds that are moderate in pitch and intensity. Inspiration is equal to
expiration.
 Best heard posteriorly between scapula & anteriorly over bronchioles lateral to
sternum at first & second intercostal spaces.
 Created by air moving to large airways.

Abnormal breath sounds

1. Stridor
 A loud, high-pitched crowing sound that is heard, usually w/o a stethoscope,
during inspiration.
 Stridor caused by an obstruction in the upper airway requires immediate
attention.
2. Rhonchi (also called gurgles)
 Low-pitched, snoring sounds that occur when the pt. exhales, although they may
also be heard when the pt. inhales.
 Usually change or disappear w/ coughing
 Sounds occur as a result of air passing through fluid-filled, narrow passages,
diseases where there is increased mucus production such as pneumonia,
bronchitis, or bronchiectasis.
3. Crackles ( Rales )
 Soft, high pitched discontinuous popping sounds that occur during inspiration
 Can be produced by rubbing a lock of hair between the thumb and finger close to
the ear.
 Fluid in the airways
 Obstructive disease in early inspiration, Bronchitis and pneumonia, CHF
4. Wheeze
 deep, low-pitched sounds heard during exhalation
 due to narrowed tracheobronchial passages from secretions
 Continuous, musical, high-pitched, whistle - like sounds heard during inspiration
and exhalation
 narrow bronchioles, associated with bronchospasm, asthma and buildup of
secretions
5. Friction Rub
 Like 2 pieces of rubber rubbed together, inspiration and exhalation
 Inflammation and loss of fluid in the pleural space
 Associated with pleurisy, pneumonia, or pleural infarct.

RISK FACTORS FOR RESPIRATORY DISEASE

1. Smoking
2. Tobacco
3. Allergies
4. Frequent respiratory illnesses
5. Chest injury
6. Surgery
7. Chemicals & environmental
pollutants
8. Family history of infectious disease
9. Geographic residence
10. Travel to foreign countries

DIAGNOSTIC TESTS
1. CHEST X-RAY (CXR) FILM (RADIOGRAPH)
- Information on the anatomic location & appearance
PRE-PROCEDURE NURSING CARE
1. remove jewelry band other metal object
2. inhale and hold breath
3. assess for pregnancy

2. SPUTUM SPECIMEN
- Expectoration
- identify organisms or abnormal cells
PRE-PROCEDURE NURSING CARE
1. Determine purpose
2. Early morning specimen
3. 15 ml
4. Rinse the mouth with water prior to collection
5. Collect specimen before antibiotics
6. Deep breaths then cough

SUCTIONING PROCEDURE IN OBTAINING SPUTUM SPECIMEN

1. Aseptic technique
2. Hyper-oxygenate before and after
3. Lubricate catheter with sterile water
4. Tracheal suctioning: 4 inches
5. Nasotracheal suctioning: insert to induce cough
6. Suction intermittently for 10 to 15 sec
7. Rotate and withdraw

4. BRONCHOSCOPY
PRE-PROCEDURE NURSING CARE
1. Informed consent
2. NPO prior
3. Coagulation studies
4. Remove dentures or eyeglasses
5. Prepare suction
6. Sedatives
7. Resuscitation equipment available
POST-PROCEDURE NURSING CARE
1. V/S
2. Ý Fowler’s
3. CHECK GAG REFLEX
4. NPO
5. Monitor for bloody sputum
6. Monitor respiration
7. Monitor for complications
8. Notify the MD if complications
occur
5. PULMONARY ANGIOGRAPHY
 insertion of a fluoroscopy via the antecubital or femoral vein into the pulmonary
artery
 it involves iodine or radiopaque or contrast material
PRE-PROCEDURE NURSING CARE
1. Secure consent
2. Assess for allergy to seafood
3. Remain still during procedure
POST-PROCEDURE NURSING CARE
1. No BP for 24 hours in the
affected extremity
2. Monitor neurovascular status
3. Assess bleeding
4. Monitor dye reaction

6. THORACENTESIS
PRE-PROCEDURE NURSING CARE
1. CXR or U/S prior to the procedure
2. Upright
3. Do not cough, breathe deeply, or move during the procedure
POST-PROCEDURE NURSING CARE
1. Monitor respiratory status
2. Pressure dressing
3. Assess site for bleeding and crepitus

7. LUNG BIOPSY
PRE-PROCEDURE NURSING CARE
1. Local anesthetic
2. Pressure during insertion and aspiration
3. Administer analgesics & sedatives as prescribed
POST-PROCEDURE NURSING CARE
1. Pressure dressing
2. Monitor for bleeding
3. Monitor for respiratory distress
4. Monitor for complications
5. Prepare for CXR

8. VENTILATION PERFUSION LUNG SCAN - determines the patency of the

pulmonary airways
PRE-PROCEDURE NURSING CARE •
• Assess for allergy to seafood
• Remove jewelry
• IV access
• Administer sedation
• Emergency resuscitation
equipment
POST-PROCEDURE NURSING CARE
Handle secretions carefully for 24 hours
9. SKIN TESTS
PRE-PROCEDURE NURSING CARE
• Determine hypersensitivity or previous reactions to skin tests
PROCEDURE
1. Should be off excessive body hair & dermatitis
2. Circle, document the date, time and test site
POST-PROCEDURE NURSING CARE
1. Do not scratch
2. Do not wash
3. Assess for induration (hard swelling), erythema and vesiculation (small blister-
like elevations)

10. PULSE OXIMETRY

- NORMAL VALUE: 95% - 100%
PROCEDURE
1. A sensor is placed: finger, toe, nose, earlobe or forehead
2. Don’t select an extremity with an impediment to blood flow
3. Lower than 91% - immediate treatment
4. Lower than 85% - hypo oxygenation
5. Lower than 70% - life-threatening situation

11. CHEST PHYSIOTHERAPY (CPT)

NURSING CARE
1. Morning upon arising
2. 1 hr. before meals or 2-3 hrs.
after meals
3. Stop if pain occurs
4. Mouth care
CONTRAINDICATIONS OF
CHESTPHYSIOTHERAPY (CPT)
1. Ý respiratory distress
2. Hx of fractures
3. Chest incisions

12. POSTURAL DRAINAGE - use of the gravity

1. A.M. upon arising

 2. 1 hour before meals, 2-3 hours
after meals
3. Stop if cyanosis or exhaustion
occurs
4. Maintain position 5-20 minutes
after
5. Mouth care
6. Unstable V/S
7. Increased ICP

13. INCENTIVE SPIROMETRY

1. Lips should seal the mouth piece
2. Inspire deeply
3. Hold inspiration
4. Forcefully exhale
5. Avoid the use at mealtimes

OXYGEN (O2) ADMINSITRATION

1. NASAL CANNULA (NASAL PRONGS)

- 1-6L/min
- 24% to 44%
FI02 DELIVERED VIA NASAL CANNULA
 24% at 1 L/min
 28% at 2 L/min
 32% at 3 L/min
 36% at 4 L/min
 40% at 4 L/min
 44% at 5 L/min
NURSING CARE
1. Humidification
2. Monitor humidifier
3. Assess RR
4. Assess mucosa
 5. Assess skin integrity
6. Water-soluble jelly

Advantages
1. Most commonly used oxygen delivery device
2. Safe and simple; comfortable and easily tolerated
3. Effective for low oxygen concentration
4. Does not impede eating or speaking.
5. Low flow 24% - 44%
Disadvantages
1. it can be easily be dislodge and can cause dryness of the nasal mucosa and
headache if flow rate exceeds 6 L/min
2. Can’t deliver concentration higher than 44%
3. Can’t be used in complete nasal obstruction

2. SIMPLE FACE MASK

- 40% - 60%
- short term O2 therapy
- minimal flow rate of 5 L/min
NURSING CARE
1. Fitting mask
2. Skin care
3. Monitor for aspiration
4. Emotional support
5. Claustrophobic

Advantages
1. Simple mask is used when an increased delivery of oxygen is needed for short
period (less than 12 hours)
2. The mask should fit closely to the face to deliver this higher concentration of
oxygen effectively.
Disadvantages
1. Hot and confining; may irritate patient’s skin
2. Tight seal which may cause discomfort
3. Interfere with talking and eating
4. Impractical for long-term therapy because of imprecision

3. PARTIAL REBREATHER MASK

- 70% - 90%
- 6 – 15 L/min
- rebreathes 1/3 of the exhaled TV
NURSING CARE
• Reservoir should not twist or kink
• Reservoir inflated 2/3 full on
inspiration

Advantages
1. Opening in the mask allow patient to inhale room air if oxygen source fails
2. The patient rebreathes about 1/3 of the expired air from the reservior bag.
Disadvantages
1. Eating and talking is difficult
2. Tight seal is required
3. Potential for skin breakdown

4. NON-REBREATHER MASK
- Ý 90%
- Use in deteriorating respiratory status
NURSING CARE
1. Remove mucus or saliva
2. Assess client
3. Valve & flaps functional
4. Valves open during expiration
5. Close during inspiration
6. Monitor kinks & twisting

5. VENTURI MASK
 1. accurate O2 inhalation
2. Adapter contains holes
3. Adapter allows selection of the amount of O2 desired
4. 24% to 55%
5. 4-10L/min

NURSING CARE
1. Monitor closely
2. Mask fits snugly
3. Tubing is free of kinks
4. Monitor mucous membranes

Disadvantage
 Hot and confining; may irritate patient’s skin
 Tight seal which may cause discomfort
 Interfere with talking and eating
 O2 concentration may be altered if mask is loosely fit, tubing kinks, o2 intake
ports become blocked, flow is insufficient, or patient is hyperneic
6. FACE TENT - useful for client with facial trauma or burn

7. AEROSOL MASK - used for the client who has thick secretions

8. TRACHEOSTOMY COLLAR OR T-PIECE

- For high humidity & the desired O2 to the client with a endotracheal or
tracheostomy

FACE TENT, AEROSOL MASK, TRACHEOSTOMY COLLAR & T- PIECE

NURSING CARE
 1. Nasal cannula during meals
2. Empty condensation
3. Monitor water in the canister
4. Exhalation port in the T-piece always open

9. OXYGEN TENT
1. Is a bendable piece of clear plastic held over your child's bed or crib by a frame.
2. The plastic is then tucked under the mattress. It may also be called a croup,
mist, or Ohio tent.
3. Oxygen or regular air is blown into the tent.
4. Oxygen tent allows for delivery for between 30%-50% humidified oxygen
5. Maintain temperature at 17.8°C-21.2°C
6. Secure the canopy by tucking in all sides and maintain closure whenever
possible to prevent oxygen leak at the bottom of tent.
7. Avoid use of friction-type toys or battery-operated device when oxygen is in use
8. Check dampness of clothes to prevent chilling.

ARTIFICIAL AIRWAY
A. Endotracheal Tube
Purpose:
1. Tracheal Suctioning
2. Positive Pressure Breathing
 Nursing. Care:
1. Humidify air
2. Suction PRN
3. NGT
4. Promote Communication
5. Confirm placement
6. Monitor the cuff

B. TRACHEOSTOMY TUBE
Purpose: Same as Et
Types:
1. Plastic
2. Metal
Parts:
1. Outer Cannula
2. Inner Canula
3. Obsturator
Nursing. Care:
1. Asepsis
2. No sedative
3. Suction PRN
4. Hemostats
5. NGT, TPN & Oral nutrition
6. Wash the stoma
7. Tub bath
8. Avoid swimming
9. Weaning
UPPER RESPIRATORY TRACT INFECTIONS
 most common cause of illness and affect most people on occasion.
 Some infections are acute, with symptoms that last several days others are
chronic, with symptoms that last a long time
 occur when micro-organisms such as viruses and bacteria are inhaled
 URIs affect the nasal cavity, ethmoidal air cells, and frontal, maxillary, and
sphenoid sinuses; as well as the pharynx, larynx, and trachea.

A. RHINITIS
 group of disorders characterized by inflammation and irritation of the mucus
membranes of the nose
 may be acute or chronic, nonallergic or allergic

Classifications:
a. Acute Rhinitis
 associated with environmental allergies or respiratory viral infections
b. Chronic Rhinitis
 set of symptoms that persists for months or even years
c. Nonallergic Rhinitis
 Involves chronic sneezing, drippy nose with no apparent cause.
d. Allergic Rhinitis
 Caused by an allergen such as pollen, dust, dander or flakes of skin from
certain animals, and molds.
 Clinical Manifestations:
a. Rhinorrhea – excessive nasal drainage
b. Nasal congestion
c. Purulent nasal discharge
d. Sneezing
e. Pruritus of the nose, roof of the mouth, throat, eyes, and ears
f. Headache

Medical Management:
a. Pharmacologic Therapy – antihistamine and corticosteroid nasal spray

Nursing Management:
a. Instructs the patient to avoid or reduce exposure to allergens and irritants.
b. Instructs the patient about the importance of controlling the environment at
home and at work.
c. Instructs the patient in correct administration of nasal medication.
d. Instructs hand hygiene technique with the patient as a measure to prevent
transmission of organisms.

B. COMMON COLD
 acute inflammation of the mucous membranes of the nasal cavity characterized
by nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise
 contagious because virus is shed for about 2 days before the symptoms appear
and during the first part of the symptomatic phase

Clinical Manifestations
a. low-grade fever
b. nasal congestion
c. rhinorrhea and nasal discharge
d. sneezing
e. tearing watery eyes
f. “scratchy” or sore throat
g. general malaise
h. chills
i. headache
j. muscle aches
 Medical Management
a. Pharmacologic Therapy
 Expectorants
 NSAID’s
 Antihistamines
 Antiviral medications

Nursing Management
a. Instruct adequate fluid intake.
b. Instruct to have adequate rest.
c. Instruct proper handwashing.
d. Instruct to cover mouth when sneezing or coughing.

C. PHARYNGITIS
 infection or irritation of the pharynx
 80% is due to viral infection and 20% bacterial infection

Classifications
1. Acute Pharyngitis
 a sudden painful inflammation of the pharynx
 most cases are caused by viral infection which spreads easily in the droplets
of coughs and sneezes and unclean hands that have been exposed to the
contaminated fluids.

Clinical Manifestations
a. fiery-red pharyngeal membrane and tonsils
b. lymphoid follicles that are swollen and flecked with white-purple exudate
c. enlarged and tender cervical lymph nodes
d. fever
e. malaise
f. sore throat
g. headache
h. myalgia
i. vomiting
j. nausea
k. anorexia
l. scarlet fever
 Pharyngitis—inflammation without exudate
A. Redness and vascularity of the pillars and uvula are mild to moderate.
B. Redness is diffuse and intense

Medical Management
a. Pharmacologic Therapy – antivirals, antibiotics, analgesics
b. Nutritional Therapy – liquid or soft diet, cool beverages, warm liquids,
flavored frozen desserts

Nursing Management
a. Instruct the patient to stay in bed during the febrile stage of illness
b. instruct to have adequate rest.
c. Instruct patient that used tissues should be disposed of properly.
d. Instruct warm saline gargles or throat irrigations.
e. Encourage proper mouth care.
f. Instruct the patient about preventive measures that include not sharing
eating utensils, glasses, napkins, food, or towels
g. Using a tissue to cough or sneeze and to dispose it properly after use.
h. Avoiding exposure to tobacco and secondhand smoke.

2. Chronic Pharyngitis
 persistent inflammation of the pharynx or persistent sore throat
 common in adults who work in dusty surroundings, use their voice to
excess, suffer from chronic cough, or habitually use of alcohol and
tobacco.

Clinical Manifestations
a. Constant sense of irritation or fullness in the throat
b. Mucus that collects in the throat and can be expelled by coughing
c. Difficulty swallowing
d. Headache
e. Fever
f. Tired voice

Medical Management
a. Nasal sprays
b. Antihistamines
c. Analgesics

Nursing Management
a. Instruct patient to avoid contact with others until the fever subsides.
b. Recommend avoidance of alcohol, tobacco, secondhand smoke, and
exposure to environmental or occupational pollutants.
c. Encourage patient to drink plenty of fluids.
d. Encourage gargling with warm saline solution.

D. TONSILITIS
 Inflammation of the tonsils
Clinical Manifestations
a. sore throat
b. fever
c. snoring
d. difficulty swallowing
e. mouth-breathing
f. earache
g. foul-smelling breath
h. voice impairment
i. noisy respiration

Medical Management
a. Antibiotic therapy
b. Tonsillectomy

Nursing Management
a. Instruct increase fluid intake
b. Encouraged gargling with warm salt-water
c. Instruct adequate rest
d. Post-operative care:
 Position patient to a prone position with head turned to side
 Apply an ice collar to the neck
 Basin and tissues are provided for the expectoration of blood and mucus.
 Administer analgesics as ordered.
 If there is no bleeding, water and ice chips may be given to the patient as
soon as desired.
 Instruct to refrain from too much talking and coughing
 Administer antibiotics as ordered to prevent complications
e. Teaching patient self-care:
 eat an adequate diet with soft foods
 avoid spicy, hot, acidic, or rough foods, milk and milk products
 instructs the patient about the need to maintain good hydration
 avoid vigorous tooth brushing or gargling
 encourages the use of a cool-mist vaporizer or humidifier in the home
postoperatively.
 avoid smoking and heavy lifting or exertion for 10 days
 E. LARYNGITIS
 inflammation of the larynx, often occurs as a result of voice abuse or exposure
to dust, chemicals, smoke, and other pollutants
 often caused by the pathogens that cause the common cold and pharyngitis

Clinical Manifestations
a. hoarseness
b. aphonia
c. severe cough
d. sore throat
e. inflamed uvula

Medical Management
a. Antibiotic therapy
b. Corticosteroids
c. Expectorant agents

Nursing Management
a. Instruct patient to rest the voice and to maintain a well-humidified
environment.
b. Instruct to have adequate daily fluid intake.
c. Instruct patient about the importance of taking prescribed medications.

OTHER RESPIRATORY DISORDERS

1. CHEST INJURIES
A. RIB FRACTURE - results from blunt chest trauma
NURSING CARE
1. Note that ribs unite spontaneously
2. ÝFowler’s
3. Pain medications
4. Monitor for respiratory distress
5. Instruct the client to self-splinting
6. Prepare for possible intercostal nerve block

B. FLAIL CHEST
ASSESSMENT
1. Paradoxical respirations
2. Severe chest pain
3. dyspnea
4. Cyanosis
5. Tachycardia
6. Hypotension
7. Tachypnea
8. Diminished breath sounds

NURSING CARE
1. ÝFowler’s
2. Humidified O2
3. Monitor respiratory distress
4. Coughing & deep breathing
5. Pain meds
6. Bed rest
7. Positive end-expiratory pressure (PEEP) for severe

C. PULMONARY CONTUSION - intra-alveolar hemorrhage resulting to ACUTE

RESPIRATORY DISTRESS SYNDROME (ARDS)
ASSESSMENT
1. Dyspnea
2. Hypoxemia
3. Ý bronchial secretions
4. Hemoptysis
5. Restlessness
6. Decreased breath sounds
7. Rales and wheezes

NURSING CARE
 Maintain airway
 ÝFowler’s
 O2 as Rx
 Monitor respiratory distress
 Maintain bed rest
 PEEP

D. PNEUMOTHORAX
 accumulation of atmospheric air in the pleural space
 may lead to lung collapse
KINDS
1. SPONTANEOUS PNEUMOTHORAX
2. OPEN PNEUMOTHORAX
3. TENSION PNEUMOTHORAX
 Dyspnea
 Tachycardia
 Tachypnea
 Sharp chest pain
 Absent breath sounds
 ß chest expansion unilaterally

 Cyanosis
 Hypotension
 Sucking sound
 Tracheal deviation
NURSING CARE
1. Apply dressing over an open chest wound
2. O2 as Rx
3. Ý Fowler’s
4. Chest tube

CHEST TUBE DRAINAGE SYSTEM

1. returns (-) pressure to the intra-pleural space
2. remove abnormal accumulation of air & fluids
3. serves as lungs while healing is going on
 A. COLLECTION CHAMBER
B. WATER SEAL CHAMBER
C. SUCTION CONTROL CHAMBER

Principles:
a. Gravity
b. Suction
c. Waterseal

NURSING CARE
1. Occlusive dressing
2. A CXR assesses the position of the tube & determines re-expansion
3. Assess respiratory status
4. Drainage system below the chest
5. Ensure secure connections
6. Coughing &DBE
7. Change position q 2
8. Do not strip

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

 a group of diseases that includes - -EMPHYSEMA, ASTHMA, BRONCHIECTASIS
CHRONIC BRONCHITIS

CHRONIC BRONCHITIS
Bronchial Inflammation Þ Ý mucus Þ ß cilia Þ respiratory acidosis
Causes:
 Smoking
 Pollution
 Allergens
Assessment:
1. Chronic Cough
2. Blue Bloater:
3. Cyanotic
4. Edema
5. Chronic cough
6. Exertional dyspnea
7. ÝRR
8. Hypoxia
9. Polycythemia- ÝRBC
10. Hypercapnia
11. Cor pulmonale-RVH & dilatation
12. Resp. acidosis
13. Incidence in heavy cigarette smokers

EMPHYSEMA
Destruction and Overdistension of the Alveoli
ß
Air Trapping
ß
Respi. Acidosis
CAUSES:
 1. Smoking, Pollution and Allergens
2. ß alpha-antitrypsin – causes expansion of the alveolI - strengthens the walls of
the alveoli (blebs)
Assessment:
pink puffer:
1. Mucus secretions
2. Speaks in short & jerky sentence
3. Coughing
4. Anxiety
5. Orthopneic position
6. Frequently develop URTI
7. Barrelled chest
8. Prolonged expiratory time
9. SOB
10. Digital clubbing
11. Wheezing

BRONCHIECSTASIS
 Permanent dilation & distension of the bronchi; may lead to Ý mucus production
Þ respiratory Acidosis
 The most common symptoms of bronchiectasis include: a persistent cough
that usually brings up phlegm (sputum)

CAUSES:
1. Infection
 2. Atelectasis
3. Aspiration

ASSESSMENT:
1. Mucupurelent mucus
2. Dyspnea
3. Fever
4. Orthopneic position
5. Anxiety
ASTHMA
- Characterized by recurring episodes of paroxysmal dyspnea, wheezing
on inspiration/expiration caused by constriction of the bronchi and
viscous mucus secretions.
TYPES:
1. Extrinsic
2. Intrinsic – asthma w/ physiological cause
3. STATUS ASTMATICUS– severe form of constriction & inflammation
despite treatment; may lead to respiratory or cardiac failure.
ASSESSMENT:
1. Exertional Dyspnea
2. Barrelled chest
3. Hyperesonance
4. Spontaneous pneumothorax

Pharmacologic Therapy for COPD and Asthma

1. Bronchodilators:
Xanthines, aminophyline, theophyline
2. Adrenergics:
a. Isoproterenol(Isuprel),
b. Terbutaline,(Brethine),
c. Metaproterenol(Aluputent)
3. Expectorants: Guaifenessin(Robitusin)
4. Mucolytics: Acetylcysteine(Mucomyst)
5. Steroids: Prednisone
6. Propylaxis (anti-allergy): Cromolyn Na(Intal)
NURSING CARE:
 V/S
 ß O2 conc. ( 2L)as Rx
 Monitor pulse oximetry
 Respiratory & chest
physiotherapy
 Pursed-lip breathing
 Record the color, amount &
consistency of sputum
 Suction
 Daily wt.
 Small, frequent feedings
 Ý calorie & CHON diet with supplements
 Encourage fluids
 Ý Fowler’s
 Stop Smoking
 Activity as tolerated
 Avoid powerful odors
PNEUMONIA- is an inflammation of the lung parenchyma caused by various
organisms including bacteria, mycobacteria, clamydia, mycoplasma, fungi,
parasites, and viruses.
ASSESSMENT
1. Grade fever
2. Chills
3. Chest pain
4. Grating sound
5. Rusty Sputum
6. Rales or crackles on auscultation
7. Dullness or hyperesonance
8. Dx test:
 x-ray
 gram-staining
 sputum culture & sensitivity

NURSING CARE for PNEUMONIA

1.  Fluids
2. Chest Physiotherapy
3. Chest splinting
4. Incentive Spirometer
5.  calorie & CHON diet
6. Small frequent meals
7. Rest & activity as tolerated
8. Antibiotics as Rx
a. Azthromycin
b. Clarythromycin
c. Doxycycline
d. Fluoroquinolone
e. Ceftrioxone
f. inezolid (Zyvox)
g. Nafcelline
h. clyndamycin

LUNG CANCER
- Tumor in the Bronchial Epithelium; men 40 & Ý
TYPES:
1. Epidermoid/Squamous:
2. Adenocarcinoma
3. Small cell(Oat cell)
4. Large cell
CAUSES:
1. Genetics
2. Carcinogens
3. Infection
4. Smoking
ASSESSMENT:
1. Respiratory Pattern Changes
2. Hemoptysis
3. Dyspnea
4. Chest Pain
5. Fatigue
6. Anorexia
7. Persistent Dry Cough

Dx Test:
Sputum cytology
Lung biopsy
Bronchoscopy
NSG. RESPONSIBILITIES:
1. Early detection
2. Radiation – Cobalt
3. Chemotheraphy – does not distinguish normal from abnormal
4. Surgery – tx of choice
a. Pneumonectomy
b. Lobectomy
* Segment resection
* Wedge resection

PULMONARY TUBERCULOSIS
 Highly communicable disease caused by a gram + acid-fast bacili
(mycobacterium tuberculosis)
  Causes/ Ý Risk groups:
1. Imunosuppression
2. Overcrowding
3. 3rd world country
4. Children ß5 yrs.old
5. Alcoholics
6. Smoking

ASSESSMENT:
1. Asymptomatic
2. Anorexia
3. Wt. Loss
4. Fatigue
5. Low grade P.M. fever
6. Night sweats
7. Sputum – yellow green
8. Hemoptysis
9. Chest pain
10. Ý tactile fremitus
Classifications of TB
Class 0: no exposure; no infection
Class 1: exposure; no evidence of infection
Class 2: latent infection; no disease (eg, positive PPD reaction but no clinical
evidence of active TB)
Class 3: disease; clinically active
Class 4: disease; not clinically active
Class 5: suspected disease; diagnosis pending
Diagnostic Test:
1. Sputum test
2. Sputum Culture – TOC
3. Tuberculin test – Check for the presence of antibodies due to exposure
a. Mantoux test
b. Multiple puncture test (Tine or Monovac)
Nursing Care
1. Chemoprophylaxis – only indicated in primary infection
2. Multi-drug therapy:

R-ifampicin
I-NH
P-yrazinamid
E-tambutol
S-treptomycin
PLEURAL EFFUSION
 collection of fluid in the pleural space
ASSESSMENT
a. Sharp pleuritic pain
b. Dyspnea
c. Dry non-productive cough
d. Tachycardia
e. Ý temperature
f. ß breath sounds
g. CXR shows pleural effusion & a mediastinal shift away from the fluid

NURSING CARE
a. Identify & treat underlying cause
b. Monitor breath sounds
c. Monitor pulse oximetry
d. ÝFowler’s
e. Coughing & DBE
f. Thoracentesis
g. If pleural effusion is recurrent, prepare the client for pleurectomy or
pleurodesis
PLEURECTOMY- surgically stripping the parietal pleura
PLEURODESIS - involves instillation of a sclerosing substance into the
pleural space via a thoracotomy tube

EMPYEMA- pus within the pleural cavity; fluid is thick, opaque & foul
smelling
ASSESSMENT
 Fever & chills
 Chest pain
 Cough
 Dyspnea
 Anorexia & wt. loss
 Malaise
 Night sweats
 Diminished chest wall movement on the
affected side
 Pleural exudate on chest CXR

NURSING CARE
 Monitor breath sounds
 ÝFowler’s
 Coughing & DBE
  Antibiotics as Rx
 Chest splinting

PLEURISY- inflammation of the visceral & parietal membranes, may be

caused by pulmonary infarction or pneumonia
ASSESSMENT
 Sharp pleuritic pain
 Dyspnea
 Dry non-productive cough
 Tachycardia

NURSING CARE
 Identify & treat cause
 Monitor lung sounds
 Analgesics as Rx
 Apply hot & cold applications as Rx
 Coughing & DBE
 Instruct the client to lie on affected side to splint
chest

PULMONARY EMBOLISM
1. Dislodgement of thrombus to the pulmonary artery
2. Caused by thrombus & pulmonary emboli
3. Other risk factors: deep vein thrombosis, immobilization, surgery,
obesity, pregnancy, CHF, advanced age, prior history of
thromboembolism

ASSESSMENT
 Dyspnea
 Chest pain
 Tachypnea & tachycardia
 Hypotension
 Shallow respirations
 Rales on auscultation
 Cough
 Blood-tinged sputum
 Distended neck veins
 Cyanosis

NURSING CARE
 O2 as Rx
 Ý Fowler’s
 Maintain bed rest
 Incentive spirometry as Rx
 Pulse oximetry
 Prepare for intubation & mechanical ventilation
  IV heparin (bolus)
 Warfarin (Coumadin)
 Monitor PT & PTT closely
 Prepare the client for embolectomy, vein ligation, or insertion of an
umbrella filter as Rx

CARBON MONOXIDE POISONING

LEVELS OF CARBON MONOXIDE
LEVEL ASSESSMENT FINDING
5% to 10% Impaired visual acuity
11% to 20% Flushing
21% to 30% Nausea & impaired dexterity
31% to 40% Vomiting, dizziness, & syncope
41% to 50% Tachypnea & tachycardia
Ý 50% Coma & death

NURSING CARE
 Remove victim from exposure
 Administer O2
 Assess for basic life support
 V/S
 Monitor carbon monoxide levels

HISTOPLASMOSIS
 Caused by spores of Histoplasma capsulatum
 Transmitted by inhalation of spores, which are commonly located in
contaminated soil
 Found in bird droppings
ASSESSMENT
 Dyspnea
 Chills
 Fever
 Chest pain
 Pulmonary infiltrates on CXR
 Elevated WBC
 Splenomegaly & hepatomegaly

NURSING CARE
 O2 as prescribed
 Monitor breath sounds
 Antiemetics, antihistamines, antipyretics & corticosteroids as Rx
 Fungicidal medication
 Coughing & DBE
 Ý Fowler’s
  V/S
 Monitor for nephrotoxicity

SARCOIDOSIS
 Epitheloid cell tubercles in lung
 Cause is unknown
ASSESSMENT
 Night sweats
 Fever
 Weight loss
 Cough
 Skin nodules
 Polyarthritis
NURSING CARE
 Corticosteroids
 Monitor temperature
 Increase fluid intake
 Provide frequent periods of rest
 Encourage small, frequent meals

OCCUPATIONAL LUNG DISEASE: SILICOSIS

Known as ASBESTOSIS and COAL WORKER’S PNEUMONIA
- caused by the inhalation of inorganic dusts
- common in miners & sandblasters
- Tuberculosis (PTB) is a frequent complication
ASSESSMENT
 Frequent respiratory infections
 Bloody sputum
 Cough
 CXR: Nodular lesions of the
lungs
NURSING CARE
 Administer antitussive
 Administer medication for TB
as Rx
 Eliminate the toxic substances
 Administer O2 as Rx
 Encourage coughing & DBE

ACID-BASE BALANCE
Ph – 7.35 – 7.45
ßph – acidosis ( Ý H ion conc.)
Ýph – alkalosis( ßH ion conc.)

BUFFER SYSTEM:
Bicarbonate Carbonic
HCO3 acid
Strong base CO3
Weak acid
20 : 1

Normal ABG Values:

Ph : 7.35 – 7.45
PCO2 : 35 – 45 mm HG
HCO3 : 22-26 meq/L
PO2 : 85 – 100 mmHg
Base excess : (+2 or –2)
Respiratory Acidosis
1. Carbonic acid excess:
2. Increase retention of carbon
dioxide
3. Pco2 is greater than 45 mm Hg
4. pH is below 7.45
Common causes:
1. Inadequate ventilation
(dyspnea)
2. Respiratory obstruction
(mechanical- tumor) (Functional
 – asthma)
3. Impaired gas exchange –
(emphysema)
4. Neuromascular impairment –
(spinal cord injury)
Signs of Resp. Acidosis
1. Dyspnea
2. Irritability
3. Disorientation
4. Tachycardia
5. Cyanosis
6. Coma
Compensatory mechanisms
1. The urinary system excretes
increased hydrogen ions to
compensate for the respiratory
system’s to blow off CO2
2. The urinary system retains
sodium to facilitate the body’s
attempt to increase sodium
bicarbonate
3. The rate and depth of
respirations increase
4. With chronic hypoxia, decrease
oxygen levels become the
stimulant to breathe: normally,
elevated CO2 level stimulate
breathing
Respiratory Alkalosis
1. Carbonic acid deficit
2. hyperventilation blows off
excessive CO2
3. PCo2 is less than 35 mm Hg
4. pH is above 7.45
Common Causes
1. Hyperventilation related to
anxiety/panic
2. Excessive mechanical
ventilation
Signs and symptoms
1. Deep,rapid breathing
2. Lightheadedness
3. Tingling and numbness
4. Tinnitus
5. Loss of concentration
6. unconsciousness
Compensatory mechanism
• The urinary system may
decrease the excretion of
hydrogen ions to maintain the
pH in the normal range.
Metabolic Acidosis
1. Base bicarbonate deficit
2. Excess acid other than carbonic
acid (a respiratory acid)
accumulates beyond the body’s
ability to neutralize it;
3. Bicarbonate is below 22 mEq/L
4. ph is below 7.35
Common Causes
1. Cellular breakdown with
 increase ketones (Starvation,
terminal CA, ketoacidosis,
dieting)
2. Renal insufficiency (acute and
chronic renal failure)
3. Lactic acid accumulation from
anaerobic metabolism
Signs of Metabolic Acidosis
1. Weakness
2. Headache
3. Disorientation
4. Deep rapid breathing (kausmaul
Respiration)
5. Fruity odor breath
6. Nausea and vomiting
7. coma
Compensatory mechanism
1. The respiratory system
compensates by
hyperventilation in an attempt
to blow off CO2 and raise pH
2. The urinary system excretes
hydrogen ions to remove
excess hydrogen ions and
sodium is retained to help
increase sodium bicarbonate
Metabolic Alkalosis
1. Base bicarbonate excess
2. Bicarbonate is above 26 mEq/L
3. pH is above 7.45
Common causes:
1. Loss of gastric juice (vomiting,
nasogastric decompression,
lavage)
2. Excessive ingestion of alkaline
drugs sodiium bicarbonate
(baking soda)
3. Potent diuretics may precipitate
hypokalemia; in the presence of
hypokalemia, the kidney
conserve potassium and
excreate hydrogen ion
Sign of Metabolic Alkalosis
1. Muscle hypertonicity (tetany)
2. Tingling
3. Tremors
4. Shallow and slow respirations
5. Dizziness
6. Confusion
7. coma
Compensatory mechanisms of
Metabolic alkalosis
1. The respiratory system
compensate by decreasing the
rate and depth of breathing to
retain Co2 and decrease the pH
2. The urinary system excretes
sodium bicarbonate