NCM 118 Respiratory System Emergency Nursing PDF

NCM 118: Emergency Nursing (4) PHARYNX (THROAT) Week 3: Respiratory System & Responses to Altered The pharynx is a muscular tube connecting the nasal and Ventilatory Function...

NCM 118: Emergency Nursing (4) PHARYNX (THROAT) Week 3: Respiratory System & Responses to Altered The pharynx is a muscular tube connecting the nasal and Ventilatory Function oral cavities to the larynx and esophagus Lecturer: Mr. Rhandz Rhudie Mongaya, RN It serves as a common passageway for both air and food The nasopharynx, or upper part of the pharynx, helps SUPPLEMENTAL NOTES: direct air from the nasal cavity to the lower respiratory THE ANATOMY AND PHYSIOLOGY OF THE system RESPIRATORY SYSTEM (5) TONSILS AND ADENOIDS Tonsils are collections of lymphoid tissue located in the pharynx Adenoids are similar lymphoid tissue located in the nasopharynx These structures are part of the immune system and help protect against infections (6) LARYNX The larynx, or voice box, is located at the top of the trachea It contains the vocal cords, which vibrate when air passes through, producing sound (speech and singing) (7) EPIGLOTTIS The respiratory system is a complex network of organs and Specialized flap-like structure located in the throat, structures responsible for the process of respiration, which specifically in the region of the larynx (voice box) involves the exchange of gases between the body and the Prevent food and liquids from entering the trachea external environment. The primary goal of the respiratory (windpipe) and the lower respiratory system when system is to supply the body's cells with oxygen (O2) for swallowing. energy production and to remove carbon dioxide (CO2), a waste product of metabolism. LOWER RESPIRATORY SYSTEM Trachea (windpipe) UPPER RESPIRATORY SYSTEM Bronchi and Bronchioles Nose Lungs Nasal Cavity Alveoli Paranasal sinuses Pleura Pharynx (throat) Diaphragm Tonsils and Adenoids Larynx The lower respiratory system's primary function is to facilitate Epiglottis the exchange of gases between the air in the alveoli and the bloodstream. Oxygen is taken up by red blood cells and The upper respiratory system's functions include warming, transported throughout the body, while carbon dioxide is humidifying, and filtering the air as it enters the body. The removed from the bloodstream and exhaled from the lungs. presence of mucous membranes and cilia in these structures This intricate process ensures that the body's cells receive the helps trap and remove particles and microorganisms from the oxygen they need for energy production and that waste carbon inhaled air, preventing them from entering the lower respiratory dioxide is efficiently eliminated. system and potentially causing infections. Additionally, the upper respiratory system contributes to the sense of smell, (1) TRACHEA (WINDPIPE) speech resonance, and immune defense mechanisms. The trachea is a rigid, tubular structure that connects the larynx to the bronchi. (1) NOSE It is lined with ciliated mucous membranes that help trap The nose is the primary external organ of the upper and remove foreign particles, preventing them from respiratory system entering the lungs It serves as the entrance of air into the respiratory system (2) BRONCHI AND BRONCHIOLES The nasal passages are lined with mucous membranes The trachea divides into two main bronchi: the left and and cilia, which filter and moisten incoming air. right bronchi These bronchi further branch into smaller bronchioles, (2) NASAL CAVITY creating a branching network of airways The nasal cavity is the hollow space inside the nose The bronchioles eventually lead to the alveoli, where gas It contains nasal septum (a partition dividing the nose exchange occurs into the left and right sides) and turbinates (scroll-like bones that increase the surface area for air contact) (3) LUNGS The nasal cavity warms, humidifies, and filters the air The lungs are the main organs of the lower respiratory before it enters the lower respiratory system. system They are divided into lobes: the right lung has three lobes (3) PARANASAL SINUSES (upper, middle, and lower), and the left lung has two These are air-filled spaces connected to the nasal cavity lobes (upper and lower) due to the space occupied by The paranasal sinuses include the frontal, ethmoid, the heart sphenoid, and maxillary sinuses They contribute to the resonance of the voice, reduce (4) ALVEOLI the weight of the skull, and may help humidify and warm Alveoli are tiny, thin-walled sacs located at the ends of the air the bronchioles within the lungs Notes by: Gi pangkapoy nga seniors ;) 1  They are the primary sites for gas exchange, where oxygen from inhaled air diffuses into the bloodstream, moist air goes from the nasal cavity into the pharynx and carbon dioxide from the bloodstream diffuses into (the throat). the alveoli to be exhaled. PHARYNX (THROAT): Nasopharynx, Oropharynx, and Laryngopharynx (5) PLEURA Nasopharynx The pleura is a double-layered membrane that surrounds Connects the nasal cavity and pharynx each lung and lines the chest cavity. Oropharynx The visceral pleura covers the lungs surface, and the Connects the oral cavity and the pharynx parietal pleura lines the chest cavity The pleura’s fluid-filled spaces reduces friction during breathing and helps keep the lung surfaces adhered to the chest wall (6) DIAPHRAGM The diaphragm is a dome-shaped muscle located beneath the lungs It plays a crucial role in breathing by contracting and flattening during inhalation and relaxing during exhalation. Soft palate The softer portion of the roof of the mouth is behind RESPONSES TO ALTERED RESPIRATORY FUNCTION - the hard palate which is the part that you can feel with PART 1 your tongue. Together with the Uvula (pendulum like), work Most of the patients who go in the emergency room have together to form a flap or valve that closes the complaints with regards to their breathing airway. nasopharynx when you eat to prevent food going in the nasopharynx. A&P: RESPIRATORY SYSTEM Laryngopharynx The respiratory system is a complex network of organs and Part of the pharynx that structures responsible for the process of respiration, which is continuous with the involves the exchange of gases between the body and the larynx or the voice box. external environment. Up to this point, food Basically the work or the goal of our respiratory system is and air share a to get oxygen and to release carbon dioxide. common path. Primary goal: to supply the body’s cells with oxygen (O2) for Epiglottis energy production and to remove the body’s cells with A spoon shaped flap of carbondioxide (CO2), a waste product of metabolism. cartilage at the top of the larynx Video: Which acts like a lid that seals off the airway when Lungs you're eating. So that food can only go one way, down main job: gas exchange - pulling oxygen into the body the esophagus and towards the stomach. If anything and getting rid of carbon dioxide. Normally, during an other than air gets in the larynx, then you have a inhale, the diaphragm contracts to pull downward and cough reflex that coughs it right back out. Now once the chest muscles contract to pull open the chest, air makes it to the larynx, it continues down into the which both helps suck in air like a vacuum, and then trachea during an exhale, the muscles relax, allowing the Trachea or windpipe lungs to spring back to their normal size, which pushes Splits into 2 main bronchi.The point into where they air out. split is called the Carina. It then enters the lungs. The Nasal Cavity right lung has 3 lobes: upper lobe, middle lobe, and When you breathe in, air flows to the nostrils and the lower lobe. The left lung just has 2 lobes: upper enters this cavity. lobe and lower lobe. Lined by cells that release mucus - which is salty, sticky and has lysozymes (enzymes that help kill bacteria) Nose hairs at the entrance of the nasal cavity get coated with that mucus and are able to trap large particles of dust and pollen as well as bacteria, forming tiny clumps of boogers. Paranasal Sinuses The nasal cavity is connected to 4 sinuses, which are air filled spaces inside the bones that surround the nose. Consists of: frontal, ethmoid, sphenoid, and maxillary sinuses. These sinuses help the inspired air to circulate for a bit The right mainstem bronchus is wider and more so it gets warm and moist. vertical than the left. Which is why if you accidentally Act like tiny echo chambers to help amplify your inhale something big that can't be coughed up like a voice. This is why you sound different when you plug peanut, it's more likely to go to the right lung than the your nose or when it gets clogged with mucus when left. The mainstem bronchi then divides into smaller you get a cold. So that relatively clean, warm, and bronchi. The trachea and the first 3 generations of Notes by: Gi pangkapoy nga seniors ;) 2  bronchi are all pretty wide and have cartilage rings for After the first three generations of bronchi, though, the support. Airways get more narrow, called bronchioles, meaning little There's also a layer of smooth muscle which has nerve bronchi, and these can stay open without the need for to the autonomic nervous system in it. cartilage. Air is conducted through smaller and smaller bronchioles for about 15 to 20 generations, and collectively these are known as conducting bronchioles Conducting bronchioles receive oxygenated blood from the bronchial arteries.The walls of those conducting bronchioles are also lined by ciliated columnar cells and mucus secreting goblet cells, as well as a new type of cell called the club cell. Club cells Secrete glycosaminoglycans, which protect the bronchial or epithelium. transform into ciliated columnar cells so they help regenerate and replace damaged cells if needed.Now all these cells receive oxygenated blood from the The Autonomic nervous system is made-up of two basic bronchial arteries of the systemic circulation. types of nerves. Terminal bronchioles Sympathetic nerves which are involved in fight or The last part of the conducting bronchioles flight mode like running from a turkey. Respiratory bronchioles Parasympathetic nerves which are involved in the ​unique because they have tiny outpouchings that butt rest in digest mode like eating ice cream on the beach. off from their walls, which are called alveoli (about 500 million of them in the lungs) Smooth muscle along the trachea in the first few branches Eventually the respiratory bronchioles end when of bronchi have beta 2 adrenergic receptors. Going back there's nothing but alveoli, and at that point the to that turkey, When you're running, the sympathetic nerves airways are called an alveolar duct rather than a stimulate those beta 2 adrenergic receptors and this respiratory bronchiole, and this is the final destination increases the diameter of the Airways, allowing more air of the inhaled air. to get in. Alveolar Wall has a completely different structure than the But those same Airways also have muscarinic receptors, bronchioles which can get stimulated by parasympathetic nerves, no cilia or smooth muscle and instead the walls lined causing a decrease in the diameter of the Airways. by thin epithelial cells called pneumocytes ○ Most are regular pneumocytes called type 1 The large Airways are aligned mostly by ciliated columnar pneumocytes, cells and a handful of goblet cells which get their name from ○ Some, called type 2 pneumocytes have the looking like a wine goblet, and these guys secrete mucus. ability to secrete a substance called surfactant Surfactant helps decrease the surface tension within the alveoli and therefore helps keep them open. Just like the club cells, the type 2 pneumocytes are capable of transforming into type 1 pneumocytes, so they can also help regenerate and replace damaged cells. ○ if a tiny particle ever makes it deep into the lungs, there are alveolar macrophages that can gobble it up and then physically move up to the conducting bronchioles, where they can ride the mucociliary escalator all the way up to the That mucus helps trap particles, and then the ciliated pharynx to be either coughed up or swallowed columnar cells beat rhythmically to move the mucus and any down trapped particles from the air towards the pharynx, where ○ Free from particles, the inhaled air is now in the they can either be spit out or swallowed. This mechanism is alveolus, surrounded by mostly type 1 called the “Mucociliary escalator”. pneumocytes ○ On the other side of the pneumocytes are endothelial cells that line the capillary walls, which is what holds the blood This time though, that blood comes from the pulmonary arteries and is deoxygenated ○ The pneumocytes and the capillaries are glued together with a protein layer called the basement membrane. So the alveolar wall, the basement membrane, and the capillary wall is really all that separates the air from the blood, and this is called the blood gas barrier. ○ At this point, carbon dioxide diffuses out from the deoxygenated blood and into the air of the alveoli, Notes by: Gi pangkapoy nga seniors ;) 3  which then gets breathed out, and with each So the alveolar wall, the basement breath in, oxygen enters the alveoli and freely membrane, and the capillary wall is really all diffuses into the blood. that separates the air from the blood, and this is called the blood gas barrier. ○ At this point, carbon dioxide diffuses out from the deoxygenated blood and into the air of the alveoli, which then gets breathed out, and with each breath in, oxygen enters the alveoli and freely diffuses into the blood. GAS EXCHANGE Ang gas exchange kay ang atong primary action or use This part is where the diffusion happens of the gas of our respiratory system. Air or oxygen inhaled in our exchange, oxygen diffuses through these thin layers into lungs goes into our alveoli wherein it diffuses to the the capillaries together with the byproduct, the carbon capillary or to the bloodstream. So, padung sa heart dioxide from the gas exchange, also diffuses into the then i-pump dayon sa systemic circulation to our alveoli para ma exhale. tissues that needs the oxyhemoglobin that means the oxygen part of it to be converted into energy. The unoxygenated blood goes back to the systemic veins BRONCHI AND BRONCHIOLES with the by-product of carbon dioxide, i-pump nasad Bronchioles siya balik towards the lungs to be exhaled. receive oxygenated blood from the bronchial arteries A fundamental physiological process that occurs within of the systemic circulation the respiratory system, specifically in the alveoli of the Terminal bronchioles lungs. It involves the movement of gases, primarily ○ The last part of the conducting bronchioles oxygen (O2) and carbon dioxide (CO2), between the air Respiratory bronchioles in the lungs and the bloodstream. This process ensures ○ ​unique because they have tiny out pouchings that that the oxygen is taken into the body for cellular butt off from their walls, which are called alveoli respiration, while carbon dioxide, a waste product of (about 500 million of them in the lungs) metabolism, is removed from the body. ○ Eventually the respiratory bronchioles end when there's nothing but alveoli, and at that point the STEP-BY-STEP (Gas Exchange) airways called an alveolar duct rather than a Breathing, or ventilation, is the process by respiratory bronchiole, and this is the final which air containing oxygen is brought into the destination of the inhaled air. lungs during inhalation (inspiration) and air Alveolar Wall containing carbon dioxide is expelled from the ○ has a completely different structure than the 1. Ventilation lungs during exhalation (expiration). This bronchioles movement of air is facilitated by the contraction ○ no cilia or smooth muscle and instead the walls and relaxation of the diaphragm and other lined by thin epithelial cells called pneumocytes respiratory muscles. Most are regular pneumocytes called type 1 The alveoli are tiny, thin-walled sacs located at pneumocytes, the ends of the bronchioles in the lungs. They Some, called type 2 pneumocytes have the 2. Alveoli are surrounded by a network of capillaries, ability to secrete a substance called which are small blood vessels surfactant Oxygen and carbon dioxide move across the Surfactant helps decrease the surface thin walls of the alveoli and capillaries through tension within the alveoli and therefore a process called diffusion. Diffusion is driven helps keep them open. by the principle of gasses from an area of Just like the club cells, the type 2 higher concentration to an area of lower pneumocytes are capable of concentration. transforming into type 1 pneumocytes, so Oxygen Diffusion: Oxygen in the they can also help regenerate and inhaled air has a higher concentration in replace damaged cells. the alveoli than in the capillaries. As a result, oxygen molecules diffuse from the ○ if a tiny particle ever makes it deep into the lungs, alveoli into the capillaries, binding to the there are alveolar macrophages that can gobble it hemoglobin in red blood cells for up and then physically move up to the conducting transport to body tissues. bronchioles, where they can ride the mucociliary 3. Diffusion Carbon Dioxide Diffusion: Carbon escalator all the way up to the pharynx to be dioxide, produced as a waste product of either coughed up or swallowed down metabolism, has a higher concentration ○ Free from particles, the inhaled air is now in the in the capillaries than in the alveoli. This alveolus, surrounded by mostly type 1 concentration gradient causes carbon pneumocytes dioxide molecules to diffuse from the ○ On the other side of the pneumocytes are capillaries into the alveoli, from where it is endothelial cells that line the capillary walls, which expelled during exhalation. is what holds the blood So again, diffusion is when oxygen diffuses This time though, that blood comes from the into the capillaries through that thin layer at the pulmonary arteries and is deoxygenated end of the alveoli. The carbon dioxide also ○ The pneumocytes and the capillaries are glued diffuses from the capillaries into the alveoli to together with a protein layer called the basement be exhaled. So, it’s the concept of a higher membrane. concentration to a lower concentration. Notes by: Gi pangkapoy nga seniors ;) 4  When carbon dioxide dissolves in the blood, it reacts with water to form carbonic acid (H2CO3). Carbonic acid can then dissociate into bicarbonate ions (HCO3-) and hydrogen ions (H+) An increase in carbon dioxide levels leads to an increase in carbonic acid formation, resulting in higher levels of hydrogen ions. This makes the blood more acidic (lower pH). More CO2 = Acidic due to carbonic acid. This is important because maintaining acid base balance is crucial in order to have an efficient gas exchange in the lungs. So Oxygen (O2) and Carbon Dioxide (CO2) exchange between the blood and in the alveoli is influenced by the acid-base balance. So a body or a system that has low pH or is on acidosis can impair the activity of hemoglobin to bind with Oxygen (O2) leading to reduced oxygen delivery to the tissues. The respiratory system helps regulate this by adjusting the rate and depth of breathing. If the blood becomes too acidic, the respiratory rate increases to exhale more carbon dioxide and reduce the levels of hydrogen ions. Conversely, if the blood becomes too alkaline, the respiratory rate decreases to retain carbon dioxide and increase the levels of hydrogen ions. 2. Chemoreceptors and Respiratory Rate: Photo: Gas Exchange Specialized chemoreceptors in the brain stem monitor OXYGEN TRANSPORT the levels of carbon dioxide and hydrogen ions in the Oxygen is transported in the bloodstream from the lungs to the blood. These chemoreceptors respond to changes in body’s tissues primarily by binding to a molecule called pH and carbon dioxide concentration by sending hemoglobin, which is found in red blood cells. Hemoglobin is signals to the respiratory centers in the brain, which a protein that has a high affinity for oxygen, allowing it to adjust the respiratory rate and depth to restore normal efficiently pick up oxygen in the lungs and release it where it’s pH levels. needed. Oxygen Diffusion into Red Blood Cells RESPIRATORY ASSESSMENT ↓ HISTORY Formation of Oxyhemoglobin (oxygenated Hgb) Build the patient’s health history by asking short, open ↓ ended questions Blood Circulation Conduct the interview in several short sessions if you ↓ have to, depending on the severity of the patient’s Oxygen Release in Tissues condition ↓ ○ Ngano man? Kay respiratory problems biya atong Oxygen Utilization gicater so probably the patient has diffuculty in ↓ breathing Carbon Dioxide Transport Ask their family to provide information if the patient ↓ cannot Oxygen Exchange in the Lungs Respiratory disorders may be caused or exacerbated by Process: Once it is oxygenated, it becomes oxyhemoglobin obesity, smoking, and workplace conditions, so be sure then goes through your blood circulation and then when it to ask about these passes certain body tissues or systems that needs oxygenated Previous Health Status blood to create energy or that has cells that needs energy, ○ Look at the patient’s health history, especially: i-utilize niya ang oxygen from that oxyhemoglobin and then A smoking habit mubalik ra gihapon ang blood sa bloodstream, balik padung sa Exposure to secondhand smoke heart then pumped back to the lungs para mugawas ang Allergies by-product nga carbon dioxide and ang hemoglobin makuha Previous Surgeries nasad balik ug oxygen. Respiratory diseases, such as Pneumonia and Tuberculosis ACID-BASE BALANCE Ask about current immunizations, such as Flu shot or The respiratory system plays a crucial role in maintaining the Pneumococcal Vaccine body's acid-base balance, also known as pH balance. This Determine if the patient uses any respiratory equipment, balance is essential for proper cellular function and overall such as O2 or nebulizers, at home physiological stability. The Lungs (Respiratory System) works Compute for “Pack Years” in conjunction with the kidneys to regulate the levels of carbon ○ Pack Years - term used in the context of assessing dioxide (CO2) and bicarbonate ions (HCO3-) In the blood, an individual’s history of smoking. It is the measure which in turn helps regulate the body's pH. that quantifies the cumulative exposure to cigarette smoke over time, taking into account both the The acid-base balance is maintained through the control of two number of cigarettes smoked per day and duration primary components: of smoking. 1. Carbon Dioxide (CO2) and Bicarbonate (HCO3-) ○ One pack-year is defined as 20 cigarettes (which is Levels: typically the number of cigarettes in a standard pack) per day for one year. Therefore, if someone smoked Notes by: Gi pangkapoy nga seniors ;) 5  20 cigarettes a day for a year they would have a “1 2. Orthopnea pack year” smoking history. 3. Cough ○ Take consideration or take into account the smoking 4. Sputum Production history of a patient 5. Wheezing 6. Chest Pain Formula to calculate pack-years: 7. Sleep Disturbances Pack-years = (number of cigarettes smoked per DYSPNEA day X number of years smoked / 20) One of the most common symptoms that we can Where: assess to patients with respiratory problems ○ Number of cigarettes smoked per day: the Commonly seen in patients with pulmonary or cardiac average number of cigarettes you smoked each compromise day Information about the onset of symptoms gives clues as ○ Number of years smoked: the total number of to the source and duration of the problem years you smoked. Assess the patient's SOB by asking them to rate usual ○ The division by 20 accounts for the fact that there level of dyspnea on a scale of 0-10 are typically 20 cigarettes in a standard pack. ○ 0 = no dyspnea, 10 = worst they have experienced ○ Example: a px smokes 8 sticks per day and he Ask the patient to rate their current level of dyspnea; has been smoking for 10 years: So, 8 x 10 = 80. grade dyspnea as it relates to activity, such as climbing a 80/20 = 4. 4 pack years. set of stairs or walking a city block Grading Dyspnea Family History: ○ To assess dyspnea as objectively as possible, ask ○ Ask the patient if they have a family history of your patient to briefly describe how various activities cancer, predisposing factors to cancer, sickle cell affect his breathing. Then, document his response anemia, heart disease, or chronic illness, such as using this grading system: asthma or emphysema, and all other heredofamilial Grade 0: not troubled by breathlessness diseases. except with strenuous exercise ○ Determine whether the patient lives with anyone Grade 1: troubled by shortness of breath when who has had or who has an infectious disease, such hurrying on a level path or walking up a slight as tuberculosis or influenza. hill Lifestyle Patterns: Grade 2: walks more slowly on a level path ○ Include the workplace because some workplace (because of breathless-ness) than people of may be detrimental to the health of the lungs. the same age or has to stop to breathe when ○ Ask about the patient’s workplace because some walking on a level path at his own pace jobs, such as coal mining, construction work, Grade 3: stops to breathe after walking about gasoline stations, and laboratories with a lot of 100 yards (91 m) on a level path fumes expose workers to substances that can Grade 4: too breathless to leave the house or cause lung disease. breathless when dressing or undressing. ○ Ask about the patient's home, community, and other What does the nurse ask? environmental factors (i.e., secondhand smoking, 1. Does the dyspnea occur when the patient is lying smoke belching, air pollution) that may influence flat? how the patient deals with their respiratory 2. Does the dyspnea awaken the patient at night? problems. 3. Does the dyspnea occur only with exertion? ○ Example: You may ask questions about interpersonal relationships, stress management, ORTHOPNEA and coping methods. Is a specific type of breathing difficulty in which they ○ Ask about the patient’s sex habits and drug use, experience SOB when lying down. which may be connected with acquired Patient tends to sleep with his upper body elevated immunodeficiency syndrome-related pulmonary Ask the patient how many pillows they use (answer disorders. (Ex. A lot of AIDS patients have reflects the severity of orthopnea) pneumonia or tuberculosis) For instance, a patient who uses three pillows when ○ We also ask about the patient’s stress management sleeping can be said to have “three pillow orthopnea”. and coping methods because as we know, stress COUGH can induce a lot of kinds of diseases. A frequent respiratory symptom with verifying Current Health Status: significance ○ Begin by asking why the patient is seeking care External agents, inflammation of the respiratory mucosa, cause many respiratory disorders are chronic. pressure on an airway caused by a tumor may stimulate Asking “Ma’am/Sir, ngano niari ka karon?” But a cough such as: we just have to know why the px is needing ○ Smoke immediate care because most of the ○ Allergies respiratory disorders are chronic so gidala2 ra ○ Heartburn nila or naanad na or kahibalo na silo unsay ○ Asthma buhaton. So unsa ang nakalahi ngano karon ○ Certain medications (ACE inhibitors, Beta pagpa tan-aw jud sila/ magpa emergency man Blockers) sila? What does the nurse ask? ○ Ask how the patient’s latest acute episode 1. At what time of the day do you cough most often? compares with previous episodes and what relief 2. Is the cough productive? Has it changed recently (if measures are helpful and unhelpful. chronic)? If so, how? 3. What makes the cough better? What makes it Check for Chronic Complaints: worse? 1. Dyspnea SPUTUM Notes by: Gi pangkapoy nga seniors ;) 6  A pulmonary illness often results in the production of and warm sputum Introduce yourself to the patient and explain why you are If a patient produced sputum ask them to estimate the there amount produced in teaspoons or some other common measurement INSPECTION What does the nurse ask? Cyanosis - bluish discoloration 1. What is the color and consistency of the sputum? Labored breathing 2. Has it changed recently (if chronic)? If so, how? Anterior-posterior diameter of the chest 3. Do you cough up blood? If so, how much and how Chest deformities often? Patient’s posture The nurse should ask the patient about the amount and Position of the trachea color of the sputum produced in 24 hours. Respiratory rate ○ Color of the sputum provides information about the Respiratory effort infection Duration of inspiration versus the duration of expiration Thoracic expansion Color of Sputum and its Implications: Patient’s extremities Yellow, Green - bacterial infection Occurs as a result of overinflation of Yellow - may occur if there are many eosinophils in the lungs, which increases the the sputum, thereby signifying allergy rather than anteroposterior diameter of the thorax infection Occurs with aging and is a hallmark Rust-colored (Yellow sputum mixed with blood) - sign of emphysema and COPD may signify Tuberculosis Mucoid, Viscid, or blood-streaked - often a sign of viral infection. BARREL CHEST Persistent slightly blood-streaked - present in patients with carcinoma Large amount of clotted blood - present in patients with pulmonary infarct WHEEZING What should the nurse ask? ○ When does wheezing occur? Aka Pectus Carinatum ○ What makes you wheeze? Occurs when there is a depression in ○ Do you wheeze loudly enough for others to hear it? the lower portion of the sternum ○ What helps stop your wheezing? May compress the heart and great vessels, resulting in murmurs CHEST PAIN May occur with rickets of Marfan Chest pain due to a respiratory problem is usually the Syndrome result of ○ Pleural inflammation ○ Inflammation of the Costochondral Junctions PIGEON CHEST ○ Soreness of Chest Muscles because of Coughing May also be a result of indigestion Less common causes of pain include rib or vertebral fractures caused by coughing for osteoporosis What should the nurse ask? ○ Where is the pain? ○ What does it feel like? ○ Is it sharp, stabbing, burning, or aching? Occurs as a result of the anterior ○ Does it move to another area? displacement of the sternum, which ○ How long does it last? also increases the anteroposterior ○ What causes it? diameter ○ What makes it better? May occur with rickets, Marfan SLEEP DISTURBANCES syndrome, or severe kyphoscoliosis May be related to obstructive sleep apnea or other sleep disorder requiring additional evaluation FUNNEL CHEST If the patient complains of being drowsy or irritable in the daytime, ask these questions: ○ How many hours of continuous sleep do you get at night? ○ Do you wake up often during the night? ○ Does your family complain about your snoring or restlessness? PHYSICAL ASSESSMENT The patient’s spine curves to one side Examine the back first using IPPA (Inspection, THORACIC and the vertebrae are rotated Palpation, Percussion, Auscultation) KYPHOSCOLIOS Because the rotation distorts the lung Always compare one side with the other; then examine IS tissue, it may be more difficult to the front of the chest using the same sequence assess respiratory status The patient can lie back down when you examine the Absence of breathing front of their chest if that is more comfortable for them APNEA Periods of apnea may be short and Before you begin the PE, make sure the room is well-lit occur sporadically, such as Cheyne Notes by: Gi pangkapoy nga seniors ;) 7  Stokes respirations or other abnormal Sore muscles may result from protracted coughing respiratory patterns A collapsed lung can cause pain This condition may be life-threatening if periods of apnea last long enough PALPATION Should be addressed immediately PALPATING THE CHEST Increased rate and depth Usually occurs with extreme stress, fear, or anxiety HYPER-APNEA Causes of hyperventilation orders of CNS, overdose of drug salicylate, or severe anxiety Rapid, deep, and labored breathing Occurs in patients with metabolic acidosis, especially with associated KUSSMAUL diabetic ketoacidosis Respiratory system tries to lower the CO2 level in the blood and restore it to normal pH Regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea May result from severe CHF, drug 1. To palpate the chest, place the palm of your hand lightly CHEYNE-STOKE over the thorax, as shown on the left picture. overdose, increased ICP, or renal S 2. Palpate for tenderness, alignment, bulging, and failure May be noted in elderly persons during retractions of the chest and intercostal spaces. sleep (not related to any disease 3. Assess patient for crepitus, especially around drainage process) sites. Irregular pattern characterized by 4. Repeat this procedure on the patient’s back varying depth and rate of respirations 5. Next, use the pads of your fingers, as shown on the BIOT’S picture on the right, to palpate the front and back of the followed by periods of apnea RESPIRATION thorax. May be seen with meningitis or severe brain damage 6. Pass your fingers over the ribs and any scars, lumps, lesions, or ulcerations. 7. Note the skin temperature, turgor, and moisture. PALPATION 8. Also note tenderness and bony subcutaneous crepitus. The muscles should feel firm and smooth. PALPATE FOR TACTILE FREMITUS Palpable vibrations caused by the transmission of air through the bronchopulmonary system Fremitus is decreased: ○ Over areas where pleural fluid collects ○ When the patient speaks softly ○ With pneumothorax, atelectasis, and emphysema Fremitus is increased: ○ Normally over the large bronchial tubes and abnormally over areas in which alveoli are filled with fluids or exudates (pneumonia) CHECKING FOR TACTILE FREMITUS Chest wall should feel smooth, warm, and dry CREPITUS ○ Feels like puffed rice cereal crackling under the skin ○ Indicated that the air is leaking from the airways or lungs If the patient has a chest tube, you may find a small amount of subcutaneous air around the insertion site If the patient has NO chest tube, or the area of crepitus When you check the back of the thorax for tactile is getting larger, ALERT THE PRACTITIONERS RIGHT fremitus, ask the patient to fold his arms across his AWAY! chest, as shown here. The movement shifts the scapulae Gentle palpation should not cause the patient pain out of the way. If the patient complains of chest pain, try to find a painful What to do? area on the chest wall. Check for tactile fremitus by lightly placing your open palms on both sides of the patient’s back without GUIDE IN ASSESSING SOME TYPES OF CHEST PAIN * touching his back with your fingers, as shown. Ask the Painful costochondral joints are typically located at patient to repeat “ninety-nine” loud enough to produce the midclavicular line or next to the sternum palpable vibrations. Then palpate the front of the chest A rib or vertebral fracture is quite painful over the using the same hand positions. fracture Notes by: Gi pangkapoy nga seniors ;) 8  What do the results mean? Vibrations that feel more intense on one side than the other indicate tissue consolidation on that side. Less intense vibrations may indicate emphysema, pneumothorax, or pleural effusion. Faint or no vibrations in the upper posterior thorax may indicate bronchial obstruction or a fluid-filled pleural space. PALPATION EVALUATE SYMMETRY To evaluate the patient’s chest wall symmetry and expansion: ○ Place your hands on the front of the chest wall with your thumbs touching each other at the 2nd intercostal space ○ As the patient inhales deeply, watch your thumbs They should separate simultaneously and equally to a distance several centimeters away WARNING SIGNS from the sternum When you hear hyperresonance ○ Repeat the measurement at the 5th intercostal during percussion, it means you space have found an area of increased You may take the same measurement on the air in the lung or pleural space. back of the chest near the 10th rib HYPERRESONANCE Expect to hear hyperresonance WARNING SIGNS in your patients with: Chest expansion may be ○ Pneumothorax The patient’s chest may decreased at the level of the ○ Acute Asthma expand asymmetrically if they diaphragm if the patient has: ○ Bullous Emphysema have: Emphysema When you hear abnormal Pleural effusion Respiratory depression dullness, it means you have found Atelectasis Diaphragm paralysis areas of decreased air in the Pneumonia Atelectasis lungs. Pneumothorax Obesity ABNORMAL Expect abnormal dullness in the Ascites DULLNESS presence of: ○ Pleural fluid PERCUSSION ○ Consolidation Atelectasis ○ Tumor AUSCULTATION KEY POINTS: In Auscultation, we use a stethoscope As air moves through the bronchi, it creates sound waves that travel to the chest wall The sound produced by breathing changes as air moves larger to smaller airways Sounds also change if they pass through fluid, mucus, or narrowed airways Auscultation sites are the same as percussion sites Percussion is used to: Listen to a full cycle of inspiration and expiration at Find: find the boundaries of lungs each site, using the diaphragm of the stethoscope Determine: determine whether the lungs are filled with Ask the patient to breath through his mouth if it does not air, fluid, or solid material cause discomfort; nosebreathing breathing alters the Evaluate: evaluate the distance the diaphragm travels pitch of breath sounds between the patient’s inhalation and exhalation PERCUSSING THE CHEST NORMAL BREATH SOUNDS You used your non-dominant hand’s middle finger, you Heard over the trachea hyperextended it, and you used your dominant hand’s middle Harsh and discontinuous (1) Tracheal finger to tap on your non-dominant hand’s middle finger just Occur when the patient inhales or slightly below the joint of your middle finger. exhales Usually heard next to the trachea just GUIDE FOR THE SITES FOR PERCUSSION above or below the clavicle (2) Bronchial Loud, high-pitched, and discontinuous Loudest when the patient exhales Notes by: Gi pangkapoy nga seniors ;) 9  Medium-pitched and continuous by rubbing thumb and finger together near the (3) Broncho Best heard over the upper third of the ear) vesicular sternum and between the scapulae Secondary to inflammation and loss of when the patient inhales or exhales lubricating pleural fluid Heard over the rest of the lungs Soft and low-pitched DIAGNOSTIC ASSESSMENTS (4) Vesicular Non-Invasive Prolonged during inhalation and shortened during exhalation ○ Oximetry Invasive VOCAL FREMITUS ○ Arterial Blood Gases (ABG) Is the type of sound produced by chest vibrations as ○ Pulmonary Capillary Wedge Pressure the patient speaks. ○ Pulmonary Angiography Abnormal transmission of voice sounds can occur over ○ Ventilation-Perfusion (V/Q) Scan consolidated areas because sound travels well through ○ Capnography fluid ○ Bronchophony: NON-INVASIVE PROCEDURES Ask the patient to say “ninety-nine” or “blue OXIMETRY moon” A non-invasive technique that measures Over normal tissue, the words sound muffled the arterial oxyhemoglobin (SpO2) of Over consolidated areas, the words sound arterial blood unusually loud Uses pulse oximeter ○ Egophony: A sensor or proble, uses a beam of red Ask the patient to say “e” and infrared light that travels through Over normal lung tissue, the sound is muffled tissue and blood vessels Over consolidated areas, it sounds like the Oxygen saturation is determined by the letter A amount of each light absorbed; ○ Whispered Pectoriloquy: nonoxygenated hemoglobin absorbed Ask the patient to whisper “1, 2, 3” DEFINITION more red light, and oxygenated Over normal lung tissue, the numbers are hemoglobin absorbs more infrared light almost indistinguishable Sensors are available for use on a finger, a Over consolidated tissue, the numbers sound toe, a foot (on infants), an earlobe, loud and clear forehead, and the bridge of the nose A range of 95%-100% is considered normal ADVENTITIOUS SOUNDS For patients with chronic lung disease, a Abnormal no matter which part of the lungs you can level of 88% to 92% may be considered hear them within normal limits CRACKLES Unreliable when vasoconstriction ○ Coarse Crackles medications of IV dyes are used Discontinuous popping sounds heard in early Assess for the presence of health inspiration problems that may impact oxygenation. Harsh, moist sound originating in the large Assess the patient’s respiratory rate and bronchi depth and mental status, skin Obstructive pulmonary disease temperature and color, and CRT. ○ Fine Crackles ○ Hard time detecting patients with cold Discontinuous popping sounds heard in late clammy skin, so we have to warm the inspiration patient for the pulse ox to detect Sounds like hair rubbing together Assess the quality of the pulse proximal Originates in the alveoli to the sensor application site. Pneumonia, fibrosis, bronchitis, pleural fluid Assess for edema of the sensor site. ○ If extremities are edematous, earlobes WHEEZES (usually heard on expiration, but may be are used heard on inspiration; associated with changes in airway NSG If absent or weak signal: check vital signs, diameter) CONSIDER patient condition, connections, and ○ Sonorous Wheezes (ronchi) ATIONS circulation to site. Deep, low-pitched rumbling sounds heard If extremely cold: cover with a warm primarily during expiration blanket and/or use another site. Caused by air moving through narrowed If a bright light (sunlight or fluorescent tracheobronchial passages light) is suspected of causing equipment Associated with secretions or tumor malfunction: turn off light or cover the probe ○ Sibilant Wheezes with a dry washcloth (bright light can Continuous , musical, high-pitched, interfere with operation of light sensors and whistle-like sounds heard during inspiration cause an unreliable report) and expiration caused by air passing through Excessive motion of the sensor probe site, narrowed or partially obstructed airways such as with extremity tremors or shivering, Bronchospasm, asthma, build-up of secretions can also interfere with obtaining an accurate reading FRICTION RUBS ○ Pleural Friction Rub INVASIVE PROCEDURES Harsh, crackling sound, like two pieces of leather being rubbed together (sound imitated ARTERIAL BLOOD GAS Assess the ability of the lungs to DEFINITION provide adequate oxygen and remove Notes by: Gi pangkapoy nga seniors ;) 10  carbon dioxide and the ability of the ○ Air bubbles - Make sure you remove kidneys to reabsorb or excrete all air bubbles in the sample syringe bicarbonate ions to maintain normal body because air bubbles alter the results. pH Measurements of blood pH and of arterial oxygen and carbon dioxide tensions are ABG syringe looks different from 3cc syringe obtained when managing patients with due to their specific design and purpose. respiratory problems and adjusting oxygen They are used for collecting samples of therapy as needed arterial blood directly from an artery. Obtained through an arterial puncture at ➔ Look for an artery with pulse to get the radial, brachial, or femoral artery, or blood sample. through an indwelling arterial catheter ➔ If dili kaayo ma kaayo mu get ug ABG, sometimes masagul siya with venous In most critical care units, a doctor, blood from the sample. respiratory therapist, or specially trained ➔ Usual indicator that arterial blood was critical care nurse draws ABG samples, acquired: backflow of bright red usually from an arterial line if the patient blood when needle is injected into the has one. artery. (slow backflow if venous blood The most common site is the radial artery which is darker in color) but the brachial or femoral arteries can also be used. ○ Femoral arteries are typically used in Difference of the ABG Syringe from the patients who are edematous/ have low Normal Syringe consciousness. Designed to minimize the introduction Before drawing blood from a radial artery, of air bubbles into the blood samples an Allen’s Test is performed in order to Often has a lower lock or lower slip make sure that the ulnar artery can provide tip to securely attach it to the arterial good circulation catheter or needle to prevent leaks ○ Let the patient make a fist, occlude the during sample collection radial and ulnar artery, and then Has a thin Heparin coating (white instruct the patient to open the fist. component), an anti-coagulant within Since the ulnar and radial arteries are the walls of the syringe to prevent occluded, you expect the palms to be blood from clotting within the syringe. a little pale. Once you release the occlusion, color slowly returns to the Make sure the sample of arterial blood is palm. kept cold, and delivered as soon as ○ This means that the ulnar artery is possible to the laboratory for analysis. patent and can provide adequate Some chemical reactions that alter findings blood circulation. Therefore, blood continue to take place after the blood is can be drawn from the arterial site. drawn; rapid cooling and analysis of the ABG is a painful procedure. Always inform sample minimizes this. patient ahead of pain that is experienced ○ Special handling of ABG syringe are NSG MGMT during procedure. highly sensitive to time and temp. Apply pressure to the puncture site for 5 ○ Deliver the sample ASAP to the lab as minutes and tape a gauze pad firmly. O2 and CO2 levels can change if the ○ This reduces the risk of bleeding. The sample is exposed to the air for too pressure is greater in the artery than long that of the veins so there is a high risk You just have to memorize these normal values. for bleeding. A (acid), B (basic) ○ After the shift, reassess patient for arm discoloration (may present as NV hematoma). To be safe, press pH A 7.35- 7.45 B puncture site with cotton for about 5 mins, then put tape with pressure. PaCO2 B 35-45 A Observe if the patient is breathing in (Respiratory) room air, attached to oxygen mask or HCO3 A 22-26 B mechanical ventilator. (Metabolic) ○ We have to take note of the fraction of inspired oxygen (FIO2) because it is ABG The lesser your pH, the more acidic. The computed in the machine. For oxygen, INTERPRET more your pH, it is basic. When I say basic, naa nana equivalent na number like for ATION it is alkaline. So alkalosis. your face mask, for your mechanical The more CO2 in your body= more ventilator etc carbonic acid. So more than 45, it is Examples of conditions that can interfere acidic, less than 35, it is basic or alkaline. with test results For your HCO3, less HCO3 means acidic ○ Failure to properly heparinize the and then more HCO3 is basic. syringe before drawing a blood sample or exposing the sample to air. 1st step in ABG Interpretation: know ○ Venous blood in the sample may whether it is acidic or alkaline. The lower PaO2 levels and elevate PaCO2 only way to do this is to look at the pH, levels. just check the values of your pH. ○ If pH < 7.35 = acidic Notes by: Gi pangkapoy nga seniors ;) 11  ○ If pH > 7.45 = alkalosis PaCO3 that is basic, so it’s metabolic Next step: know whether it is acidosis. respiratory or metabolic. So for the compensation, you will check if your body is doing something to balance Example: pH is acidic (7.29), PaCO2 (50), out everything. Since it is already acidic, HCO3 (27). pH is acidic, PaCO2 is acidic and your respiratory system (PaCO3) is trying HCO3 is basic. The pair is the pH and PaCO2. In to compensate for that acid by lowering the the case present the symptom is respiratory PaCO3 level (30 = basic). However, since symptom, so it is Respiratory Acidosis (since your pH level is not yet normalized, this is both pairs are acidic) considered partially compensated. ○ PaCO2 = Respiratory All you have to remember is that your body ○ HCO3 = Metabolic is trying to compensate. If acidic, there will be a system who would like to compensate by being alkaline or basic. Uncompensated Example: pH is acidic (7.26), PaCO2 is acidic (49), and HCO3 is normal (24). First step: See if it's acidic or alkaline. Since pH is 7.26, it is acidic. Second step: See if it's respiratory or metabolic. Since it is acidic, find which of either PaCO2 or HCO3 is acidic as well. In Example: pH is (7.47), PaCO2 is (47), then the example, PaCO2 is acidic, unlike HCO3 is (28). So your pH is basic, PaCO2 is HCO3 that is normal, so it’s respiratory acidic, HCO3 is basic. acidosis. Since HCO3 is within normal limits, the body is not doing anything to normalize the acidosis. This is considered uncompensated because the kidneys are not compensating with the respiratory acidosis. Example: pH is acidic (7.26), PaCO2 is acidic (49), and HCO3 is acidic (20). Since everything is acidic and we don't ○ So, both pH and HCO3 are in partner know if it's respiratory or metabolic, we will so it is Metabolic Alkalosis (since both do the math. All you have to do is subtract are basic/alkaline) the example values from the closest range Partial Compensation of values. PaCO2 has the range of 35-45 and the example is 49, you will subtract 49 and 45 leading to an answer of 4. Similar to HCO3 with a range of 22-26 and an example of 20, you will subtract 22 and 20 leading to an answer of 2. Next, with 4 from PaCO2 and 2 from HCO3, consider which value is farther. Since 4 is farther and has the bigger For compensation, it is either fully difference, this is considered having a more compensated, partially compensated, problem. Hence, it is a respiratory uncompensated. acidosis. ★ It is fully compensated when your pH is Because it is already respiratory acidosis at normal level. and your kidneys are acidic as well, this is ★ Partially compensated is tricky, so here is considered as uncompensated. an example: Let’s say ph is 7.35 so it's normal and fully compensated. PaCO2 is 46 and your Example: pH is acidic (7.26), PaCO2 is basic HCO3 is 27. So your pH is normal, PaCO (30), and HCO3 is acidic (19) is acidic and HCO3 is basic. The dilemma First step: See if it's acidic or alkaline. here is that your respiratory is acidic while Since pH is 7.26, it is acidic. your metabolic system is basic Second step: See if it's respiratory or Check kung asa mas duol ang pH. So it is metabolic. Since it is acidic, find which of at the boundary of acidity (7.35). The pH is either PaCO2 or HCO3 is acidic as well. In partnered with respiratory hence, it is a the example, HCO3 is acidic, unlike fully compensated respiratory acidosis Notes by: Gi pangkapoy nga seniors ;) 12  since it is normal and mas duol sa acidity anesthesia to numb the insertion site, if required. so it means siya ang nipartner sa respi Ensure the patient’s comfort by addressing any concerns, providing distractions, and Always first check whether it is acidosis or communicating effectively throughout the alkalosis. Second, check whether it is procedure. We also observe the patient for any respiratory or metabolic. Lastly, check for signs of discomfort, pain, or distress during the compensation. procedure. And after which, we document the details including the amount and the characteristics of the fluid drained, take note of PULMONARY CAPILLARY WEDGE PRESSURE the patient’s response and v/s, and assist in the A hemodynamic collection of the specimen and label it. measurement used POST-PROCEDURE to assess the For post-procedure care, we assist the patient in pressure within the a comfortable position and monitor still for any left sides of the heart signs of complications (e.g. bleeding, infection, and the function of difficulty in breathing). Also included in the the left ventricle. It post-procedure instructions for the patient are is typically measured any restrictions in movement, activity, or wound DEFINITION care. during a pulmonary artery catheterization, a procedure in which a We just need to inform the patient about the catheter is inserted into a pulmonary artery to potential post procedure sensations such as monitor various pressures within the heart and residual soreness or mild discomfort pulmonary circulation. which are normal. PATIENT We continue to provide emotional support to EDUCATION The normal PCWP is 8-12 mmHg. If above that, the patient addressing any concerns. After it might indicate a left-sided heart failure. that, then documentation and make sure to send the specimen for pleural fluid analysis PLEURAL FLUID ANALYSIS as soon as possible to the laboratory. A diagnostic procedure that involves analyzing the fluid that accumulates in the pleural PULMONARY ANGIOGRAPHY space, the space between the layers of the Pulmonary angiography is a medical imaging pleura (the membranes that line the lungs and procedure that involves the visualization of the chest cavity) blood vessels in the lungs, specifically the Pleural fluid pulmonary arteries. It is primarily used to analysis involves diagnose pulmonary embolism (PE), a obtaining a sample potentially life-threatening condition in which a of the pleural fluid blood clot travels to and blocks one of the DEFINITION pulmonary arteries, affecting blood flow to the through a procedure called lungs. thoracentesis. ○ While it is highly accurate in diagnosing During PE, it is an invasive procedure and still thoracentesis, a carries the risk for bleeding, infection and thin needle or catheter is inserted through the potential damage to blood vessels. chest wall and into the pleural space to DEFINITION ○ In some institutions, if available, they try to withdraw fluid. Once the fluid sample is collected, do less invasive imaging tests first like it is sent to a laboratory for analysis. computed tomography pulmonary During thoracentesis, the role of the nurses is angiography (CTPA) and the ventilation ensuring safety and comfort of the patient. Their perfusion scan because they offer a responsibilities encompass various aspects of balance of accuracy and reduced pre-procedure preparation, procedural invasiveness. assistance and patient monitoring, and Pulmonary angiography provides detailed post-procedure care of the patient. information about the location, size, and extent PRE-PROCEDURE of blood clots in the pulmonary arteries. It For pre-procedure, an informed consent is allows healthcare professionals to make needed and the patient is informed and well accurate diagnoses and determine the explained regarding the procedure. During the appropriate treatment plan for patients suspected procedure, we assist patient into the appropriate of having pulmonary embolism. NSG position for the procedure which is often sitting BEFORE RESPONSIB upright and leaning slightly forward. We could Stop taking certain medicines before the ILITIES provide pillows for cushion to help the patient procedure if instructed by the doctor (HCP) maintain a comfortable and steady position. And NPO status then during that, we also have to do v/s Have someone drive you from home to the monitoring and report any changes or hospital abnormalities to the doctor. DURING NSG MGMT DURING PROCEDURE Remove jewelry or other objects During the procedure, if you are an OR nurse or Empty the bladder before the procedure an outpatient scrub nurse, you help set up the Position px supine on the X-ray table sterile field because this procedure is sterile and you have to maintain aseptic technique. We STEP BY STEP PROCEDURE: could assist the doctor in administering local 1. Intravenous (IV) line will be put/inserted into px’s arm or hand Notes by: Gi pangkapoy nga seniors ;) 13  Probably a large bore needle because A gamma camera, which detects radiation a contra