LECTURE 1.pptx

On completion of this chapter, the learner will be able to: 1.Describe the structures and functions of the upper and lower respiratory tracts. 2.Describe ventilation, diffusion, perfusion, and ventilation– perfusion imbalances. 3.Explain proper techniques utilized to perform a comprehe...

On completion of this chapter, the learner will be able to: 1.Describe the structures and functions of the upper and lower respiratory tracts. 2.Describe ventilation, diffusion, perfusion, and ventilation– perfusion imbalances. 3.Explain proper techniques utilized to perform a comprehensive respiratory assessment. 4.Discriminate between normal and abnormal assessment findings identified by inspection, palpation, percussion, and auscultation of the respiratory system. 5.Recognize and evaluate the major symptoms of respiratory dysfunction by applying concepts from the patient’s health history and physical assessment findings. 6.Identify the diagnostic tests used to evaluate respiratory function and related nursing implications.  Respiratory System Upper Lower Respiratory Respiratory Tract Tract Ventilation movement of air in and out of the airways A. Nose- passageway for air to pass to and from the lungs. filters, humidifies and warms air that is inhaled.  Portions: EXTERNAL and INTERNAL EXTERNAL portion nasal bones and cartilage nares (external openings of nasal cavities) INTERNAL portion-hollow cavity separated into the right and left nasal cavities by a narrow vertical divider, the septum. B. Paranasal Sinuses 4 pairs of bony cavities Connected by a series of ducts that drain into the nasal cavity. Serve as a resonating chamber in speech. B. Paranasal Sinuses sinuses are named by their location: -frontal -ethmoid -sphenoid -maxillary  C. Pharynx ( ) Tubelike structure that connects the nasal and oral cavities to the larynx. 3 regions: -Nasal (nasopharynx) -Oral (oropharynx) -Laryngeal (laryngopharynx) Function? D. Lymphoid tissues of the throat Guarding the body from invasion by organisms entering the nose and the throat E. Larynx ( )  Cartilaginous epithelium- lined organ that connects the pharynx and the trachea  Major function: - - - E. Larynx (Voice Box) Conists of : - - -Thyroid cartilage -Cricoid cartilage -Arytenoid cartilages -Vocal cords F. Trachea ( )  Composed of smooth muscle with C-shaped rings of cartilage at regular intervals (prevents it from collapsing)  Passage b/w the larynx and the right and left main stem bronchi. A.Lungs  Paired elastic structures enclosed in the thoracic cage. Airtight chamber with distensible walls. Each lung is divided into lobes.  Each lobe is further subdivided into segments separated by fissures, which are extensions of the pleura. B. Pleura  Serous membrane lining the lungs and wall of the thoracic cavity. - pleura covers the lungs - pleura lines the thoracic cavity, lateral mediastinum, walldiaphragm, of the and inner aspects of the ribs. Pleura and small amount of pleural fluid: -Lubricate the thorax and the lungs and permit smooth motion of the lungs within the thoracic cavity during inspiration and expiration. C. Mediastinum  Middle of the thorax, between the pleural sacs that contain the two lungs.  Extends from the sternum to the vertebral column and contains all of the thoracic tissue outside the lungs (heart, thymus, the aorta and vena cava, and esophagus). D. Bronchi and Bronchioles bronchi  ( ) bronchi (3 in the right lung and 2 in the left lung).  ( ) bronchi (10 on the right and 8 on the left) -Facilitate effective postural drainage in the patient. Subsegmental bronchi. -Surrounded by connective tissue that contains arteries, lymphatics, and nerves. D. Bronchi and Bronchioles Bronchioles: have no cartilage in their walls. -Contains :  Submucosal glands- produce mucus that covers the inside lining of the airways.  Bronchi and bronchioles are also lined w/.  Create a constant whipping motion that propels mucus and foreign substances away from the lungs toward the larynx.  Terminal bronchioles- do not have mucous E. Alveoli Lungs is made up of about 300 million alveoli. -Type I cells account for % of the alveolar surface area and serve as a barrier between the air and the alveolar surface; -Type II cells account for only % of this area. Produces type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. - : third type of alveolar cells, are  Respiratio Ventilatio n (Gas n exchange (mechanic al) ) Inhalatio Exhalatio Oxygen n n Transpor t (CHON,CHO,Fat ) CO2 production  In the lung, venous blood and alveolar oxygen are separated by a very thin alveolar membrane. Oxygen diffuses across this membrane to dissolve in the blood. At the same time that oxygen diffuses from the blood into the tissues, carbon dioxide diffuses from tissue cells to blood and is transported to the lungs for excretion. Air flows from a region of higher pressure to a region of lower pressure.  Diaphragm: contract or relax?  Alveoli/Lungs/Chest: expand or recoil?  Lung vs. Atmospheric pressure?  Diaphragm: contract or relax?  Alveoli/Lungs/Chest: expand or recoil?  Lung vs. Atmospheric pressure? Reflects the mechanics (process) of ventilation. Lung volumes are categorized as: Tidal volume Inspiratory reserve volume Expiratory reserve volume Residual volume Lung capacity is evaluated in terms of: Vital capacity Inspiratory capacity Functional residual capacity Total lung capacity  TERM SYMBOL DESCRIPTION N. VALUE SIGNIFICANCE VT The volume of air 500 mL The tidal volume Tidal or inhaled and exhaled may not vary, Volume TV with each breath even with severe disease.  TERM SYMBOL DESCRIPTION N. VALUE SIGNIFICANCE IRV The Maximum volume of Inspiratory 3000 air inhaled with each Reserve mL Volume breath  TERM SYMBOL DESCRIPTION N. VALUE SIGNIFICANCE ERV The maximum 1100 Expiratory Expiratory volume of air that mL reserve volume Reserve can be exhaled is decreased Volume forcibly after a with restrictive normal exhalation. conditions, such as obesity, ascites, pregnancy.  TERM SYMBOL DESCRIPTION N. VALUE SIGNIFICANCE RV The volume of air 1200 May be Residual remaining in the mL increased with Volume lungs after a obstructive maximum disease. exhalation.  TERM SYMBOL DESCRIPTION N. VALUE SIGNIFICANCE VC The maximum 4600 A decrease in volume of air exhaled mL vital capacity Vital from the point of may be found in Capacity maximum inspiration: neuromuscular VC=TV+IRV+ERV disease, generalized fatigue, atelectasis, pulmonary edema, COPD, and obesity.  TERM SYMBOL DESCRIPTION N. VALUE SIGNIFICANCE IC The maximum 3500 A decrease in Inspiratory volume of air inhaled mL inspiratory Capacity after normal capacity expiration: may may IC=TV+IR indicate V restrictive disease. It may also be decreased  TERM SYMBOL DESCRIPTION N. VALUE SIGNIFICANCE FRC The volume of air 2300 FRC may be Functional remaining in the mL increaded with Residual lungs after a normal COPD and Capacity expiration: decreased in ARDS and FRC=ERV+RV obesity.  TERM SYMBOL DESCRIPTION N. VALUE SIGNIFICANCE TLC The volume of air in 5800 TLC may be Total Lung the lungs after a mL decreased with Capacity maximum restrictive inspiration disease such as atelectasis and TLC=TV+IRV+ERV+R pneumonia and V increased in COPD.  Resting respiration (12-20cpm) is the result of cyclic excitation of the respiratory muscles by the phrenic nerve. The inspiratory and expiratory centers in the medulla oblongata and pons (respiratory centers) control the rate and depth of ventilation to meet the body’s metabolic demands. – The apneustic center in the lower pons stimulates the inspiratory medullary center to promote deep, prolonged inspirations.  Receptor sites that assists in the brain’s control of respiratory function. –Peripheral chemoreceptors are located in the aortic arch and the carotid arteries and respond first to changes in PaO2, then to partial pressure of carbon dioxide (PaCO2) and pH. –Central chemoreceptors: located in the medulla, respond to chemical changes in the cerebrospinal fluid, which result from chemical changes in the blood. These receptors respond to an increase or decrease in the pH and convey a message to the lungs to change  The vital capacity:peaks b/w 20 and 25 years of age and decrease thereafter. With aging (40 years and older), changes occur in the alveoli that reduce the surface area available for the exchange of oxygen and carbon dioxide. At approximately 50 years of age, the alveoli begin to lose elasticity. – decrease in vital capacity occurs with the loss of chest wall mobility. These changes result in a lower oxygen levels in the arterial circulation. Despite these changes, older adults are able to carry out activities of daily living, but they may have decreased tolerance for, and require additional rest after, prolonged or vigorous I. Health History – Initially focuses on the patient’s presenting problem and associated symptoms. In conducting the history, explore the ff: – haracter, nset, ocation, uration, everity, attern ggravating and alleviating factors – radiation (if relevant), and timing of the presenting problem and associated signs and symptoms. Explore: How these factors impact the patient’s A. Dyspnea- subjective feeling of difficult or labored breathing, breathlessness, shortness of breath. B. Cough- a reflex that protects the lungs from the accumulation of secretions or the inhalation of foreign bodies.Mucus, pus, blood, or an airborne irritant, such as smoke or a gas, may stimulate the cough reflex. C.Sputum Production-the reaction of the lungs to any constantly recurring irritant and often results from persistent coughing. D.Chest pain or discomfort-may be associated with  E.Wheezing- is a high-pitched, musical sound heard on either expiration (asthma) or inspiration (bronchitis). F.Hemoptysis- expectoration of blood from the respiratory tract. G. Cyanosis- May be a sign of Hypoxia/Hypoxemia H. Tachypnea and Bradypnea II. Past Health, Social, and Family History Specific questions are asked about childhood illnesses, immunizations (including the most recent influenza and pneumonia vaccinations), medical conditions, injuries, hospitalizations, surgeries, allergies, and current medications (including over-the-counter medications and herbal remedies). Personal and social history diet, exercise, sleep, recreational habits, and religion. The nurse assesses for risk factors and genetic factors that may contribute to the patient’s lung condition.  A wide range of diagnostic studies may be performed in patients with respiratory conditions. NOTE!!! The nurse should educate the patient on the purpose of the studies, what to expect, and any possible side effects related to these examinations prior to testing. The nurse should note trends in results because they provide information about disease progression as well as the patient’s 1. Chest x-ray (CXR) film (radiograph) Provides information regarding the anatomic location and appearance of the lungs Normal pulmonary tissue is radiolucent; therefore, densities produced by fluid, tumors, foreign bodies, and other pathologic conditions can be detected by x- ray examination Preprocedure  Remove all jewelry and other metal objects from the chest area Assess client’s ability to inhale and hold breath Post procedure Assist client to dress  : lungs are scanned in successive layers by a narrow- beam x-ray  : provide a cross-sectional view of the chest  : can distinguish fine tissue density  : may be used to define: pulmonary nodules and small tumors, mediastinal abnormalities  adenopathy, which are difficult to visualize with other techniques.  : MRIs are similar to CT scans except that magnetic fields and radiofrequency signals are used instead of a narrow-beam x-ray.  : more detailed diagnostic image than CT scans  : used to characterize: pulmonary nodules, stage bronchogenic carcinoma (assessment of chest wall invasion), and evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension Procedu re The patient is placed in a supine position on a narrow, padded, nonmetallic bed that slides to the desired position inside the scanner. The patient is asked to remain still. The patient is advised to keep his eyes closed to promote relaxation and prevent a closed-in- feeling. If the test is prolonged with the patient lying flat, monitor him for orthostatic hypotension. Contraindication of MRI Patients with claustrophobia Patients who are confused or agitated Patients with implantable metal objects such as pacemakers, infusion pumps, aneurysm clips, inner ear implants, and metal fragments in one or both eyes, because the magnet may move the object within the body and injure the patient. The fluoroscopy procedure is an imaging technique that gathers real-time moving images using a fluoroscope of internal structures of patients. The fluoroscopy procedure is an imaging technique that gathers real-time moving images using a fluoroscope of internal used to investigate thromboembolic disease of the lungs An invasive fluoroscopic procedure in which a catheter is inserted through the antecubital or femoral vein into the pulmonary artery or one of its branches Involves an injection of iodine or radiopaque or contrast material Preprocedure a. Obtain informed consent b.Assess for allergies to iodine, seafood, or other radiopaque dyes c. Maintain NPO status for 8 hours prior to the procedure d. Monitor vital signs e. Assess results of coagulation studies Preprocedure f. Establish an IV access g. Administer sedation as prescribed h.instruct the client he or she must lie still during the procedure i.instruct the client that he or she may feel an urge to cough, flushing, nausea, or a salty taste following injection of the dye j. Have emergency resuscitation equipment available  Post procedure a. Monitor vital signs b.Avoid taking of blood pressure for 24hrs in the extremity used for injection c. Monitor peripheral neurovascular status d. Assess insertion site for bleeding In the perfusion scan, blood flow to the lungs is evaluated - A radionuclide may be injected for the procedure The ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation -For a ventilation scan, you will breathe in a gas with the tracer in it through a face mask or a tracer may be injected. You will then be asked to hold your breath for a short time.  Preprocedure a. Obtain informed consent b. Assess for allergies to dye, iodine, or seafood c. remove jewelries around the chest d.Review breathing methods that may be required during testing e. Establish an IV access f. Administer sedation if prescribed g. Have emergency resuscitation equipment available Post procedure a. Monitor client for reaction to radionuclide b.For 24 hrs following the procedure, rubber gloves being worn when urine is being discarded should be washed with soap and water before removing; then the hands should be washed after the gloves are removed. c.Instruct the client to wash hands carefully with soap and water for 24 hrs following the procedure Endoscopy is the insertion of a long, thin tube directly into the body to observe an internal organ or tissue in detail. direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope Purpose : (1)to examine tissues or collect secretions, (2)to determine the location and extent of the pathologic process and to obtain a tissue sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy), (3)to determine if a tumor can be resected surgically, and (4)to diagnose bleeding sites (source of hemoptysis). :therapeutic bronchoscopy is used to: (1) remove foreign bodies from the tracheobronchial tree, Pre procedure a. Obtain informed consent b. NPO from midnight prior to the procedure c. Obtain vital signs d. Asses the results of coagulation studies e. Remove dentures or eyeglasses f. Prepare suction equipment g. Administer medication for sedation as prescribed h.Have emergency resuscitation equipment readily available Post procedure a. Monitor vital signs b. Maintain semi-fowler’s position c. Asses for the return of gag reflex d. Maintain NPO status until gag reflex returns e.Have an emesis basin readily available for client to expectorate sputum f. Monitor for bloody sputum g.Monitor respiratory status, particularly if sedation was administered h.Monitor for complications, such as bronchospasm, bronchial perforation indicated by facial and neck crepitus i.Notify the physician if fever, difficulty in breathing, or other signs of complication occur following the procedure.  pleural cavity is examined with an endoscope primarily indicated in the diagnostic evaluation of pleural effusions, pleural disease, and tumor staging  Nursing Interventions: Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might indicate a pneumothorax), and minor activity restrictions, which vary depending on the intensity of the procedure. If a chest tube is in place, monitoring the chest drainage system and chest tube insertion site is essential. Removal of fluid or air from the pleural space via a transthoracic aspiration  Preprocedure a. Obtain consent b. Obtain vital signs c.prepare the client for ultrasound or chest radiograph, if prescribed, prior to procedure d. Assess result of coagulation studies e.Note that the client is positioned sitting upright, with the arms and legs supported by a table at the bedside  Preprocedure f. If the client cannot sit up, the client is placed lying in bed on the unaffected side with the head of the bed elevated 45 degrees g. Instruct the client not to cough, breath deeply, or move during the procedure Post procedure a. Monitor vital signs b. Monitor respiratory status c.Apply a pressure dressing, and assess the puncture site for bleeding and crepitus d.Monitor for signs of pneumothorax, air embolism, and pulmonary edema  A percutaneous lung biopsy is performed to obtain tissue for analysis by culture or cytologic examination. A needle biopsy is done to identify pulmonary lesions, changes in the lung tissue, and the cause of pleural effusion. Preprocedure a. Obtain informed consent b. Maintain NPO status prior to procedure c.Inform the client that a local anesthetic will be used but that a sensation of pressure during needle insertion and aspiration may be felt. d. Administer analgesic and sedatives as prescribed. Post procedure a. Monitor vital signs b.Apply a dressing to the biopsy site and monitor for drainage and bleeding c.Monitor for signs of respiratory distress, and notify the physician if they occur d.Monitor for signs of pneumothorax and air emboli, and notify the physician if they occur e. Prepare the client for chest x-ray film if prescribed A specimen obtained by expectoration or tracheal suctioning to assist in the identification of organism or abnormal cells.  Preprocedure a.Determine specific purpose of the collection and check with the institutional policy for appropriate collection of the specimen b.Obtain an early morning sterile specimen from suctioning or expectoration after a respiratory treatment,if a treatment is prescribed c. Obtain 15ml of sputum  Preprocedure d.Instruct the client to rinse the mouth with water prior to collection e.Instruct the client to take several deep breaths and then cough deeply to obtain sputum f. Always collect the specimen before starting antibiotics  Post procedure a.If a culture sputum is prescribed, transport specimen to a laboratory immediately. b. Assist the client with mouth care  a.A noninvasive test that registers the oxygen saturation of the client’s hemoglobin. b.This arterial oxygen saturation (SaO2) is recorded as a percentage. c. The normal value is 95% to 100%. d.A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur.  Procedure a.A sensor is placed on the client’s finger, toe, nose, earlobe, or forehead to measure oxygen saturation, which is then displayed on a monitor. b.Do not select an extremity with an impediment to blood flow. c. Results lower than 91% necessitate immediate treatment. d.If the saO2 is below 85%, the body’s tissues have a difficult time becoming  Measure the dissolved oxygen and carbon dioxide in the arterial blood and reveal the acid-base state and how well the oxygen is being carried to the body. Normal ABG values pH: 7.35 to 7.45 PcO2: 35 to45 mm Hg HcO3: 22 to 27  Preprocedure a.Perform Allen’s test prior to drawing radial artery specimens b. Have the client rest for 30 min. prior to specimen colletion c. Avoid suctioning prior to drawing ABG’s d.Do not turn off oxygen unless the ABG’s are ordered to be drawn at room air  Post procedure a. place the specimen on ice b. Note the client’s temperature on laboratory form c.Note the oxygen and the type of ventilation that the client is receiving on the laboratory form d.Apply pressure to the puncture site for 5 to 10 minutes and longer if the client is on anticoagulant Therapy or has a bleeding disorder. e. Transport the specimen to the laboratory within 1 minute