NCM 112 Care of the Client with Oxygenation Problems - Respiratory Anatomy and Physiology PDF

NCM 112 CARE OF THE CLIENT WITH PROBLEMS IN OXYGENATION, ACUTE AND CHRONIC REVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM ✔ Babies are born with pink lungs but they darken as we breathe polluted air. ✔ You breathe on an average of 14-20 times per minute, 20K (approx.) per day, 7.8...

NCM 112 CARE OF THE CLIENT WITH PROBLEMS IN OXYGENATION, ACUTE AND CHRONIC REVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM ✔ Babies are born with pink lungs but they darken as we breathe polluted air. ✔ You breathe on an average of 14-20 times per minute, 20K (approx.) per day, 7.8M (approx.) per year, and breathed 468M (approx.) in 60 years of lifetime---INVOLUNTARILY. ✔We lose half liter of water a day through breathing. This is the water vapor we see when we breathe into a glass. ✔It is impossible to breathe and swallow simultaneously. ANATOMIC AND PHYSIOLOGIC REVIEW OF THE UPPER AND LOWER RESPIRATORY TRACT ANATOMIC AND PHYSIOLOGIC REVIEW Composed of: (1) upper respiratory tract (2) lower respiratory tract Together, the two tracts are responsible for ventilation *movement of air in and out of the airways ANATOMIC AND PHYSIOLOGIC REVIEW The upper tract (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 UPPER RESPIRATORY TRACT ▪ Upper airway structures consist of the 1. Nose 2. sinuses and nasal passages 3. pharynx, tonsils and adenoids, 4. larynx, and 5. trachea. UPPER RESPIRATORY TRACT ▪ Lower airway structures consist of the 1. Lungs : bronchial and alveolar structures LOWER RESPIRATORY TRACT ▪ The lungs are paired elastic structures enclosed in the thoracic cage, which is an airtight chamber with distensible walls LOWER RESPIRATORY TRACT LUNGS Each lung is divided into lobes Right---3 lobes Left---2 lobes The left lobe is slightly smaller than the right lobe. PLEURA ▪ Serous membrane that lined the lungs and wall of the thorax. ▪ The visceral pleura covers the lungs; the parietal pleura lines the thorax. PLEURA Importance: ✔ You breathe 20,000 times (approx.) per day involuntarily ✔ To avoid friction MEDIASTINUM ▪ The mediastinum is in the middle of the thorax, between the pleural sacs that contain the two lungs. ▪ Heart, thymus, the aorta and vena cava, and esophagus. BRONCHI AND BRONCHIOLES ▪ There are several division of the bronchi within each lobe of the lung 1. Right and left bronchi 2. Lobar bronchi (three in the right and two in the left lung) 3. Segmental bronchi (10 on the right and 8 on the left) 4. Subsegmental bronchi 5. Bronchioles 6. Terminal bronchioles 7. Respiratory bronchioles------ dead space (150mL of air) 8. Alveolar ducts and sacs 9. Alveoli ALVEOLI ✔ Oxygen and carbon dioxide exchange takes place in the alveoli. ✔ arranged in clusters of 15 to 20 ALVEOLI Three types of alveolar cells---(Pneumocyte) 1. Type I are epithelial cells that form the alveolar walls. 2. Type II are metabolically active; secrete surfactant -a phospholipid that lines the inner surface and prevents alveolar collapse. Reduces surface tension, thereby improving overall lung function 3. Type III alveolar cell macrophages are large phagocytic cells that ingest foreign matter (mucus, bacteria) ▪ act as an important defense mechanism PHYSIOLOGY OF THE RESPIRATORY SYSTEM The respiratory system performs this function by facilitating life-sustaining processes such as: 1. oxygen transport 2. respiration and ventilation, and 3. gas exchange. LUNG VOLUMES AND LUNG CAPACITIES LUNG VOLUMES AND LUNG CAPACITIES Lung function which reflects the mechanics of ventilation, is viewed in terms of lung volumes and lung capacities. Lung volumes: ✔ tidal volume, ✔ inspiratory reserve volume, ✔ expiratory reserve volume, and ✔ residual volume. LUNG VOLUMES AND LUNG CAPACITIES Lung function which reflects the mechanics of ventilation, is viewed in terms of lung volumes and lung capacities. Lung capacity: ▪ vital capacity, ▪ inspiratory capacity, ▪ functional ▪ residual capacity, and ▪ total lung capacity LUNG VOLUMES Tidal volume (VT or TV) ▪ The volume of air inhaled and exhaled with each breath ▪ 500 mL or 5–10 mL/kg LUNG VOLUMES Inspiratory reserve volume (IRV) ▪ The maximum volume of air that can be inhaled after a normal inhalation ▪ 3,000 mL LUNG VOLUMES Expiratory reserve volume (ERV) ▪ The maximum volume of air that can be exhaled forcibly after a normal exhalation ▪ 1,100 mL LUNG VOLUMES Residual volume (RV) ▪ The volume of air remaining in the lungs after a maximum exhalation ▪ 1,200 mL LUNG CAPACITIES Functional residual capacity (FRC) ▪ The volume of air remaining in the lungs after a normal exhalation ▪ 2,300 mL LUNG CAPACITIES Vital capacity (VC) ▪ The maximum volume of air exhaled from the point of maximum inspiration ▪ 4,600 mL LUNG CAPACITIES Inspiratory capacity (IC) ▪ The maximum volume of air inhaled after normal expiration ▪ 3,500 mL LUNG CAPACITIES Total lung capacity (TLC) ▪ The volume of air in the lungs after a maximum inspiration ▪ 5,800 mL GAS EXCHANGE GAS EXCHANGE ▪ Partial pressure of gases ▪ Pressure exerted by each type of gas in a mixture of gases. PARTIAL PRESSURE ABBREVIATIONS ▪ P = pressure ▪ PO2 = partial pressure of oxygen ▪ PCO2 = partial pressure of carbon dioxide ▪ PAO2 = partial pressure of alveolar oxygen ▪ PACO2 = partial pressure of alveolar carbon dioxide ▪ PaO2 = partial pressure of arterial oxygen ▪ PaCO2 = partial pressure of arterial carbon dioxide ▪ Pv–O2 = partial pressure of venous oxygen ▪ Pv–CO2 = partial pressure of venous carbon dioxide ▪ P50 = partial pressure of oxygen when the hemoglobin is 50% saturated NEUROLOGIC CONTROL OF VENTILATION NEUROLOGIC CONTROL OF VENTILATION ▪ Resting respiration is the result of cyclical excitation of the respiratory muscles by the phrenic nerve. ▪ The rhythm of breathing is controlled by respiratory centers in the brain: Medulla oblongata and Pons ▪ The apneustic center in the lower pons stimulates the inspiratory medullary center to promote deep, prolonged inspirations. ▪ The pneumotaxic center in the upper pons is thought to control the pattern of respirations. NEUROLOGIC CONTROL OF VENTILATION ▪ The central chemoreceptors: respond to chemical changes in the cerebrospinal fluid, which result from chemical changes in the blood. ▪ The peripheral chemoreceptors: respond first to changes in PaO2, then to PaCO2 and pH. The Hering–Breuer Reflex ▪ Safety mechanism of the respiratory center ▪ Ensures that the lungs never over inflates NEUROLOGIC CONTROL OF VENTILATION ▪ Proprioceptors in the muscles and joints respond to body movements causing increase in ventilation. ROM exercises in an immobile patient stimulate breathing. ASSESSMENT OF PATIENTS WITH LUNG PROBLEM ASSESSMENT OF PATIENTS WITH LUNG PROBLEM HEALTH HISTORY and GENERAL APPEARANCE: ▪ Dyspnea ▪ Cough ▪ Sputum production ▪ Chest pain ▪ Wheezing ▪ Hemoptysis ▪ Clubbing of Fingers ▪ Cyanosis DYSPNEA ▪ Subjective feeling of difficult or labored breathing, shortness of breath ▪ A multidimensional symptom common to many pulmonary and cardiac disorders ▪ Particularly when there is decreased lung compliance or increased airway resistance. DYSPNEA Tachypnea ▪ Abnormally rapid respiration Orthopnea ▪ Shortness of breath when lying flat, relieved by sitting or standing Stridor ▪ High pitch-pitched sound heard (usually on inspiration) when someone is breathing through a partially blocked upper airway Noisy breathing ▪ result from a narrowing of the airway or localized obstruction of a major bronchus by a tumor or foreign body. COUGH ▪ Reflex that protects the lungs from the accumulation of secretions or the inhalation of foreign bodies. ▪ Results from the irritation or inflammation of the mucous membranes anywhere in the respiratory tract ▪ Mucus, pus, blood, or an airborne irritant, such as smoke or a gas, may stimulate cough reflex. COUGH SPUTUM PRODUCTION ▪ Reaction of the lungs to any constantly recurring irritant and often results from persistent coughing ▪ The nature of the sputum is indicative of its cause. COUGH Bacterial infection ▪ Profuse amount of purulent sputum (thick and yellow, green or rust colored) Viral bronchitis ▪ Thin mucoid sputum Chronic bronchitis/bronchiectasis ▪ Gradual increase of sputum over time Lung tumor ▪ Pink-tinged mucoid sputum Pulmonary edema ▪ Profuse, frothy, pink material Lung abscess ▪ Foul smelling sputum and bad breath CHEST PAIN ▪ Chest pain associated with pulmonary conditions may be sharp, stabbing, and intermittent, or it may be dull, aching, and persistent. ▪ The pain usually is felt on the side where the pathologic process is located ▪ Pleuritic pain from irritation of the parietal pleura is sharp and seems to “catch” on inspiration “like the stabbing of a knife” WHEEZING ▪ A high-pitched, musical sound heard mainly on expiration (asthma) or inspiration (bronchitis). ▪ Major finding in a patient with bronchoconstriction or airway narrowing. ▪ It is heard with or without a stethoscope, depending on its location. ▪ Rhonchi are low-pitched continuous sounds heard over the lungs in a partial airway obstruction. ▪ It is heard with or without a stethoscope, depending on its location. HEMOPTYSIS Expectoration of blood from the respiratory tract The most common causes are: ▪ Pulmonary infection ▪ Carcinoma of the lung ▪ Abnormalities of the heart or blood vessels ▪ Pulmonary artery or vein abnormalities ▪ Pulmonary emboli and infarction HEMOPTYSIS ▪ Determine the source of bleeding *hemoptysis is reserved for blood coming from the respiratory tract ▪ Bloody sputum from the nose or the nasopharynx—sniffing Note: ▪ Blood from the lung is usually bright red, frothy, and mixed with sputum. alkaline pH ▪ If the hemorrhage is in the stomach—hematemesis “coffee grounds” acid pH CLUBBING OF FINGERS ▪ Sign of lung disease found in patients with chronic hypoxic conditions, chronic lung infections, and malignancies of the lung. CYANOSIS ▪ bluish coloring of the skin ▪ very late indicator of hypoxia ▪ Cyanosis appears when the hemoglobin becomes unoxygenated, reducing the effective circulating hemoglobin to two thirds of the normal level. PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM CYANOSIS ▪ Affected by room lighting ▪ Patient’s skin color ✔ Central cyanosis ✔ Peripheral cyanosis  PHYSICAL ASSESSMENT OF THE LOWER RESPIRATORY STRUCTURES AND BREATHING THORACIC INSPECTION ✔ Color ✔ Turgor ✔ Asymmetry THORACIC INSPECTION PHYSICAL ASSESSMENT OF THE LOWER RESPIRATORY STRUCTURES AND BREATHING When you perform lung physical assessment, what technique will you use? a. inspection, auscultation, percussion and palpation b. Auscultation, inspection, percussion and palpation c. Inspection, palpation, percussion and auscultation d. Palpation, percussion, auscultation and inspection CHEST CONFIGURATION ▪ the ratio of the anteroposterior diameter to the lateral diameter is 1:2. four main deformities of the chest associated: ▪ barrel chest, ▪ funnel chest (pectus excavatum), ▪ pigeon chest ▪ (pectus carinatum), and ▪ kyphoscoliosis CHEST CONFIGURATION Barrel Chest ✔ occurs as a result of overinflation of the lungs. ✔ increase in the AP diameter of the thorax ✔ Emphysema HALLMARK SIGN OF EMPHYSEMA CHEST CONFIGURATION Funnel Chest (Pectus Excavatum) ✔ occurs when there is a depression in the lower portion of the sternum. ✔ compress the heart and great vessels, resulting in murmurs. ✔ May occur with rickets or Marfan’s syndrome. FUNNEL CHEST (PECTUS EXCAVATUM) CHEST CONFIGURATION Pigeon Chest (Pectus Carinatum). ▪ occurs as a result of displacement of the sternum. ▪ increase in the AP diameter. ▪ may occur with rickets, Marfan’s syndrome, or severe kyphoscoliosis PIGEON CHEST (PECTUS CARINATUM) CHEST CONFIGURATION Kyphoscoliosis ▪ characterized by elevation of the scapula and a corresponding S-shaped spine. ▪ limits lung expansion within the thorax. ▪ may occur with osteoporosis and other skeletal disorders that affect the thorax KYPHOSCOLIOSIS THORACIC PALPATION ▪ palpates the thorax for tenderness, masses, lesions, respiratory excursion, and vocal fremitus Respiratory excursion ▪ thoracic expansion ▪ may disclose significant information about thoracic movement during breathing ▪ Place both hands posteriorly at the level of T9 or T10. ▪ Observe for symmetry. THORACIC PALPATION TACTILE FREMITUS/FREMITUS ▪ Sound generated by the larynx travels distally along the bronchial tree to set the chest wall in resonant motion. TACTILE FREMITUS: detection of the resulting vibration on the chest wall by touch THORACIC PALPATION TACTILE FREMITUS/FREMITUS ▪ “ninety-nine” or “one, two, three,” or “eee, eee, eee” ▪ The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. ▪ BONES ARE NOT ASSESSED! TACTILE FREMITUS/FREMITUS  The nurse is assessing tactile fremitus in a client with pneumonia. For this examination, the nurse should use the: a. fingertips. b. ulnar surface of the hand. c. dorsal surface of the hand. d. finger pads. THORACIC PERCUSSION ▪ Percussion sets the chest wall and underlying structures in motion, producing audible and tactile vibrations. ▪ determine whether underlying tissues are filled with air, fluid, or solid material. THORACIC AUSCULTATION ▪ Useful in assessing the flow of air through the bronchial tree and in evaluating the presence of fluid or solid obstruction in the lung structures. ▪ Auscultates for normal breath sounds, adventitious sounds, and voice sounds. ▪ Examination includes auscultation of the anterior, posterior, and lateral thorax THORACIC AUSCULTATION BREATH SOUNDS Normal breath sounds are identified as: ✔ vesicular, ✔ bronchovesicular, and ✔ bronchial (tubular) breath sounds THORACIC AUSCULTATION Abnormal (Adventitious) Breath Sounds ▪ An abnormal condition that affects the bronchial tree and alveoli may produce adventitious (additional) sounds. ▪ Adventitious sounds are divided into two categories: 1. Crackles: discrete, noncontinuous sounds 2. Wheezes: continuous musical sounds THORACIC AUSCULTATION CRACKLES (RALES) 1. Coarse crackles ▪ Discontinuous popping sounds heard in early inspiration; harsh, moist sound originating in the large bronchi 2. Fine crackles ▪ Discontinuous popping sounds heard in late inspiration; sounds like hair rubbing together; originates in the alveoli THORACIC AUSCULTATION WHEEZES 1. Sibilant wheezes ▪ Continuous, musical, high-pitched, whistle like sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways; may clear with coughing ▪ Bronchospasm, asthma, and build up of secretions THORACIC AUSCULTATION WHEEZES 2. Sonorous wheezes (rhonchi) ▪ Deep, low-pitched rumbling sounds heard primarily during expiration; caused by air moving through narrowed tracheobronchial passages ▪ Secretions or tumor THORACIC AUSCULTATION FRICTION RUBS (Pleural friction rub) ▪ Harsh, crackling sound, like two pieces of leather being rubbed together. ▪ May subside when patient holds breath. Coughing will not clear sound. ▪ Secondary to inflammation and loss of lubricating pleural fluid THORACIC AUSCULTATION VOICE SOUNDS Vocal resonance: ▪ The sound heard through the stethoscope as the patient speaks ▪ larynx 🡪chest wall 🡪bronchi 🡪 alveolar tissue ▪ During the process, the sounds are diminished in intensity and altered so that syllables are not distinguishable. ▪ “ninety-nine” or “eee” THORACIC AUSCULTATION VOICE SOUNDS ▪ Bronchophony describes vocal resonance that is more intense and clearer than normal. ▪ Egophony describes voice sounds that are distorted (E🡪A) ▪ Whispered pectoriloquy: heard only in the presence of rather dense consolidation of the lungs. ▪ All test for consolidation! END