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MEDICAL SURGICAL NURSING Professor Gaddie Gonzales | Lesson 1 (Resoiratory System) EXTERNAL NOSE...

MEDICAL SURGICAL NURSING Professor Gaddie Gonzales | Lesson 1 (Resoiratory System) EXTERNAL NOSE - visible structure that forms a prominent Topic Outline: Respiratory System Anatomy and Physiology feature of the face, mostly composed of - Nose hyaline cartilage although the bridge consists - Pharynx of bones they are covered by connective - Larynx tissue and skin - Trachea o Nares (Nostrils) – external openings of the nose - Bronchi o Choanae – openings into the pharynx - Lungs Ventilation and Respiratory Volumes - Changing Thoracic Volume NASAL CAVITY - Pressure Changes and Airflow - extends from the nares to the choanae - Lung Recoil o Nasal Septum – a partition dividing the nasal - Changing Alveolar Volume cavity into right and left parts - Respiratory Volumes - Deviated Nasal Septum – occurs when the - Respiratory Capacities o Gas Exchange septum bulges to one side - Rhythmic Ventilation o Hard Palate – floor of the nasal cavity; separates - Respiratory Membrane Thickness the nasal and oral cavity. Air can flow through the - Surface Area nasal cavity when the oral cavity is closed or full - Partial Pressure of food - Diffusion of Gasses in the Lungs o Conchae – three prominent bony ridges on the - Diffusion of Gasses in the tissues lateral walls on each side of the nasal cavity; o Gas Transport in the Blood - Oxygen Transport increase the surface area of the nasal cavity and o Rhythmic Breathing cause air to churn, so that it can be cleansed, - Respiratory Area in the Brain Stem humidified, and warmed - Generation of the Rhythmic Breathing o Paranasal Sinuses – air-filled spaces within bone, - Nervous Control of Breathing they include the frontal, sphenoidal, ethmoid and - Chemical Control of Breathing maxillary sinuses - Effect of Exercise in Breathing - Respiratory Adaptations in Exercise o Nasolacrimal Ducts – carry tears from the eyes o Sneeze Reflex – dislodges foreign substances from the nasal cavity RESPIRATORY SYSTEM - Photic Sneeze Reflex- stimulated by exposure o The respiratory system supplies oxygen to the to bright light, such as the sun body while eliminating potentially toxic carbon - Pupillary Reflex- causes the pupil to constrict dioxide in response to bright light o The cardiovascular system and Respiratory System share responsibility for supplying the body with PHARYNX (THROAT) oxygen and disposing carbon dioxide - Common passageway for both the respiratory and digestive systems ANATOMY AND PHYSIOLOGY - Can be divided into three regions: o The respiratory system is divided into two: The Nasopharynx, Oropharynx, and upper and the lower respiratory tract Laryngopharynx o The URT includes the external nose, nasal cavity, o Nasopharynx- superior part, located posterior to pharynx and associated structure. the choncae and superior to the soft palate o The LRT includes the larynx, trachea, bronchi, and - Soft Palate- an incomplete muscles and the lungs. connective tissue partition separating the o The URT and LRT are not official anatomical terms nasopharynx from the oropharynx, forms the rather they are arbitrary divisions for the purpose floor of nasopharynx. Elevated during of discussion. swallowing; this movement closes the nasopharynx and prevents food from passing NOSE the oral cavity into the nasopharynx o Consists of the external nose and nasal cavity jc-yellowwww | 1  - Uvula (little grape)– posterior extension of the - Consists of CT and smooth muscle; Reinforced soft palate with 16-20 C-shaped pieces of hyaline - Pharyngeal Tonsil– helps defend the body cartilage against infection - The adult trachea is about 1.4-1.6 cm in o Oropharynx- extends from the uvula to the diameter and about 10-11 cm long epiglottis o C-Shaped Cartilages – form the anterior and - Palatine Tonsils- located in the lateral walls lateral sides of the trachea; protect the trachea near the border of the oral cavity and the and maintain an open passageway for air oropharynx o Cough Reflex– dislodges foreign substances from - Lingual Tonsil- located on the surface of the the trachea posterior part of the tongue - Smoker’s Cough – results from constant o Laryngopharynx- passes posterior to the larynx irritation and inflammation of the respiratory and extends from the tip of the epiglottis to the passages by cigarette smoke esophagus; lined with stratified squamous epithelium and ciliated columnar epithelium BRONCHI - The trachea divides into the left and right LARYNX main bronchi or primary bronchi, each of o Commonly called Voice box, located in the which connects to a lung anterior throat and extends from the base of the o Left Main Bronchus- more horizontal because it is tongue to the trachea displaced by the heart o Passageway for air between the pharynx and o Right Main Bronchus- where foreign objects that trachea enter the trachea usually lodge because it is o Has 3 unpaired cartilages and 6 paired cartilages shorter, wider and more vertical UNPAIRED CARTILAGE (3) LUNGS o Thyroid Cartilage (shield-shaped) – AKA adam’s - Principal organs of respiration apple; largest cartilage, attached superiorly to - Each lung is cone-shaped the hyoid bone o Right Lung- has 3 lobes (superior, middle, inferior) o Cricoid Cartilage (ring-shaped) - most inferior, o Left Lung- has 2 lobes (superior, inferior) forms the base of the larynx - The lobes of the lungs are separated by o Epiglottis (on the glottis) - 3rd unpaired cartilage; deep, prominent fissures on the lung surface consist of elastic cartilage rather than hyaline, - Each lobe is divided into bronchopulmonary helps prevent swallowed materials from entering segments separated from one another by CT the larynx, as the larynx elevated during septa. swallowing the epiglottis tips posteriorly to cover - The main bronchi branch many times to form the opening of the larynx the tracheobronchial tree PAIRED CARTILAGE (6) TRACHEOBRONCHIAL TREE o Cuneiform (wedge-shaped)- top cartilage o Main Bronchi- divided into two lobar bronchi o Corniculate (horn-shaped)- middle cartilage o Lobar Bronchi- AKA secondary bronchi, two in the o Arytenoid (ladle-shaped)- bottom cartilage left lung and three in the right lung o Vestibular folds- false vocal cords; superior pair, o Segmental Bronchi- AKA tertiary bronchi which when the vestibular folds come together, they extend to the bronchopulmonary segments prevent air from leaving the lungs, when person o Bronchioles- subdivide numerous times to give rise holds his or her breathe. Along with the epiglottis, to terminal bronchioles, which then subdivide into the vestibular folds also prevent food and liquids respiratory bronchioles. from entering the larynx o Respiratory bronchioles- subdivides to form o Vocal folds- true vocal cords; inferior fair, primary alveolar ducts, which are like long, branching source of voice production hallways with many open doorways o Laryngitis- – inflammation of the mucous o Alveoli (hollow sacs)- small air sacs epithelium of the vocal folds Air Passages of Lungs 1. Primary bronchi 2. Lobar (secondary) bronchi TRACHEA 3. Segmental (tertiary) bronchi - Windpipe 4. Bronchioles - Membranous tube attached to the larynx 5. Terminal bronchioles 2  6. Respiratory bronchioles o Coats gas-exposed alveolar surfaces 7. Alveolar ducts o Secreted by cuboidal surfactant-secreting cells 8. Alveoli - Structures become smaller and more numerous from primary bronchi to alveoli PLEURAL CAVITIES - surround the lungs and provide protection RESPIRATORY MEMBRANE against friction - where gas exchange between the air and - PLEURA – serous membrane lining the pleural blood takes place cavity - It is very thin to facilitate the diffusion of gases - Pleurisy- inflammation of the pleural - Consists of 6 LAYERS: membranes o Thin layer of fluid lining the alveolus o PARIETAL PLEURA – lines the walls of the thorax, o Alveolar epithelium – composed of simple diaphragm and mediastinum squamous epithelium o VISCERAL PLEURA – covers the surface of the lung o Basement membrane of the alveolar epithelium - PLEURAL FLUID – acts as a lubricant and helps o Thin interstitial space hold the pleural membranes together o Basement membrane of the capillary endothelium LYMPHATIC SUPPLY o Capillary endothelium – simple squamous - Lungs have two lymphatic supplies epithelium o Superficial Lymphatic Vessels- are deep to the visceral pleura; they drain lymph from the RESPIRATORY ZONE STRUCTURES AND THE RESPIRATORY superficial lung tissue and the visceral pleura MEMBRANE o Deep Lymphatic Vessels- follow the bronchi; they o Terminal Bronchioles lead into respiratory zone drain lymph from the bronchi and associated CTs structures and terminate in alveoli o Respiratory zone includes the: VENTILLATION AND RESPIRATORY VOLUMES → Respiratory bronchioles - Ventilation (breathing) – the process of → Alveolar ducts moving air into and out of the lungs. → Alveolar sacs - Uses diaphragm: skeletal muscle that → Alveoli (air sacs)—the only site of gas separates thoracic and abdominal cavities exchange - 2 PHASES: o Conducting zone structures include all other o Inspiration – inhalation; movement of air into the Passageways lungs; diaphragm descends and rib cage expands; thoracic cavity volume increases, ALVEOLI pressure decreases; air moves into alveoli (lungs) o Simple squamous epithelial cells largely compose o Expiration– exhalation; movement of air out of the the walls lungs; diaphragm relaxes and rib cage recoils; o Alveolar pores connect neighboring air sacs thoracic cavity volume decreases, pressure o Pulmonary capillaries cover external surfaces of increases; air moves out of lungs. alveoli. CHANGING THORACIC VOLUME PLEURA MEMBRANE AND CAVITIES - The muscles associated with the ribs are o Pleura: double-layered membrane around lungs responsible for ventilation o Parietal pleura: membrane that lines thoracic o Muscles of Inspiration- include the diaphragm cavity and the muscles that elevate the ribs and sternum, o Visceral pleura: membrane that covers lung’s such as the external intercostals surface - Diaphragm (partition) a large dome of o Pleural cavity: space around each pleura skeletal muscle that separates the thoracic cavity from abdominal cavity Gas crosses the respiratory membrane by diffusion o Muscles of Expiration- internal intercostals; o Oxygen enters the blood depress the ribs and sternum. o Carbon dioxide enters the alveoli PRESSURE CHANGES AND AIRFLOW Alveolar macrophages (dust cells) - Two physical principles that govern the o Add protection by picking up bacteria, carbon airflow: particles, and other debris o Changes in volume result in changes in pressure. Surfactant (a lipid molecule) 3  o Air flows from an area of higher pressure to an o Expiratory Reserve Volume- air that can be area of lower pressure expired forcefully (1100 mL) - During INSPIRATION, air flows into the alveoli o Residual Volume- air still remaining in the because atmospheric pressure is greater than respiratory passages and lungs after maximum the alveolar pressure. expiration (1200mL) - During EXPIRATION, air flows out of the alveoli because alveolar pressure is greater than RESPIRATORY CAPACITIES: atmospheric pressure. o Functional Residual Capacity – ERV+RV: Amount of air remaining in the lungs at the end of a normal LUNG RECOIL expiration (2300mL) - The tendency for an expanded lung to o Inspiratory Capacity- TV+IRV: Amount of air a decrease in size. person can inspire maximally after a normal - When thoracic volume and lung volume expiration (3500mL) decrease during quiet expiration. o Vital Capacity- IRV+TV+ERV: maximum volume of - Two factors keep the lungs from collapsing: air that a person can expel from the respiratory Surfactant and Pleural Pressure tract after maximum inspiration (4600mL) o Surfactant (surface acting agent)- reduces the o Total Lung Capacity- IRV+ERV+TV+RV: Also equal surface tension of the fluid lining the alveoli to the VC + RV (5800mL) (surface acting agent). o Pleural Pressure- – lower than alveolar pressure, GAS EXCHANGE which causes the alveoli to expand. o Gas exchange between air and blood occurs in Factors that Influence Pulmonary Ventilation the respiratory membrane o Lung elasticity: lungs need to recoil between o Blood flow from lungs through left side of heart to ventilations - decreased by emphysema tissue capillaries o Lung compliance: expansion of thoracic cavity - o Oxygen diffuses from capillaries into interstitial fluid affected if rib cage is damaged because Po2 in interstitial fluid is lower than o Respiratory passageway resistance: occurs during capillary an asthma attack, infection, tumor o Oxygen diffuses from interstitial fluid into cells (Po2) is less CHANGING ALVEOLAR VOLUME o Dead Space- the parts of the respiratory o Increasing thoracic volume results in decreased passageways where gas exchange between air pleural pressure, increased alveolar volume, and blood do not occur decreased alveolar pressure, and air movement into the lungs (inspiration). RHYTMIC VENTILATION o Decreasing thoracic volume results in increased o Normal respiration rate is 12-20 respiratory per pleural pressure, decreased alveolar volume, minute (adults) increased alveolar pressure, and air movement o Controlled by neurons in medulla oblongata out of the lungs (expiration). o Rate is determined by number of times respiratory muscles are stimulated RESPIRATORY VOLUMES AND CAPACITIES o Spirometry- is the process of measuring volumes of RESPIRATORY MEMBRANE THICKNESS air that move into and out of the respiratory o Increases in the thickness of the respiratory system membrane result in decreased gas exchange o Spirometer- device that measures the respiratory volumes SURFACE AREA o Respiratory Volumes- are measures of the amount o Small decreases in surface area adversely affect of air movement during different portions of gas exchange during strenuous exercise. When ventilation the surface area is decreased to 1/3 or 1/4 of o Respiratory Capacities- are sums of two or more normal, gas exchange is restricted under resting respiratory volumes conditions RESPIRATORY VOLUMES: PARTIAL PRESSURE o Tidal Volume- Air inspired or expired with each o is the pressure exerted by a specific gas in a breath (at rest, quiet breathing = 500mL) mixture of gases, such as air o Inspiratory Reserve Volume- air that can be inspired forcefully beyond the resting TV (3000 mL) DIFFUSION OF GASES IN THE LUNGS 4  o O2 diffuses from a higher partial pressure in the o Higher Brain Centers – allow voluntary control of alveoli to a lower pp in the pulmonary capillaries. breathing. o CO2 diffuses from a higher partial pressure in the o Hearing-Breuer Reflex – supports rhythmic pulmonary capillaries to a lower pp in the alveoli respiratory movements by limiting the extent of inspiration DIFFUSION OF GASES IN THE TISSUES o Touch, Thermal, Pain Receptors – can stimulate o O2 diffuses from a higher pp in the tissue capillaries breathing to a lower pp in the tissue spaces. o CO2 diffuses from a higher pp in the tissues to a CHEMICAL CONTROL OF BREATHING lower pp in the tissue capillaries o Hypercapnia – a greater than normal amount of CO2 in the blood GAS TRANSPORT IN THE BLOOD o Carbon Dioxide – major chemical regulator of OXYGEN TRANSPORT breathing o Oxyhemoglobin- hemoglobin with oxygen bound o Chemoreceptors (in medulla oblongata) – to its heme groups respond to changes in blood pH o Chemoreceptors (In Carotid and Aortic Bodies) – More oxygen is released from hemoglobin if (four factors) respond to changes in blood O2. o Partial pressure for O2 is low o Hypoxia – a condition when blood O2 declines to o Partial pressure for CO2 is high a low level o pH is low o Temperature is high EFFECT OF EXERCISE IN BREATHING o Breathing increases abruptly CO2 Transport and Blood pH o Breathing increases gradually o Carbonic Anhydrase- enzyme that promotes the - Anaerobic Threshold – the highest level of uptake of CO2 by RBCs exercise that can be performed without - As CO2 levels increase, blood pH decreases causing a significant change in blood Ph (becomes more acidic) - As CO2 levels decrease, blood pH increases RESPIRATORY ADAPTATIONS TO EXERCISE (becomes more basic) o Training results in increased minute volume at maximal exercise because of increased TV and RHYTMIC BREATHING respiratory rate. RESPIRATORY AREA IN THE BRAINSTEM - Medullary Respiratory Center – establishes Topic Outline: Respiratory System Quiz 1 rhythmic breathing Respiratory Process Dorsal Respiratory Groups (2) – primarily Lung Assessment responsible for stimulating contraction of the - Volume of Oxygen and Carbon Dioxide diaphragm. - Adventitious Sounds Ventral Respiratory Groups (2) – primarily Blood Oxygenation Process Diagnostic Test/Procedure responsible for stimulating the external and - Chest X-Ray internal intercostal, and abdominal muscles - Bronchoscopy - Pre-Botzinger Complex – establish the basic - Sputum Culture rhythm of breathing - Arterial Blood Gas o Pontine Respiratory Group- is a collection of - Pulmonary Angiography neurons in the pons. - Pulmonary Angiogram - Thoracentesis - It plays a role in switching between inspiration - Pulmonary Function Test and expiration - Lung Biopsy - D-Dimer GENEERATION OF RHYTMIC BREATHING - involves the integration of stimuli that start and LESSON 1 stop inspiration o Perfusion- exchange of oxygen and carbon o Starting inspiration dioxide between RBC and the body’s tissues. o Increasing inspiration o Diffusion- exchange of oxygen and carbon o Stopping inspiration dioxide between the alveoli and the RBC in the bloodstream NERVOUS CONTROL OF BREATHING 5  QUIZ 1 diaphragm- which is the major muscle of Primary Function: respiration o Provides oxygen for the metabolism of the tissue. o Right Lungs: longer than the other side that is Removes Carbon Dioxide, the waste product of divided into 3 lobes (Upper, Middle, Lower) oxygen. o Left Lungs: which is narrower than the other lung Secondary Function: to accommodate heart that is divided into two o Facilitate sense of smell, produce sounds/speech lobes. (Upper and Lower) it maintains acid-base and heat balance. o Three nerves in the cavity- these innovated by Upper Respiratory Airway Phrenic, Vagal, Thoracic Nerve o Humidifies, warms and filters inspire air: Nose Accessory Muscles o Air-filled cavities within the hollow bones that o Scalene Muscle- elevated the first two ribs surround nasal passages and provides during o Sternocleidomastoid muscle raises the sternum speech: Nasal Sinuses (through inhalation) o Trapezius and Pectoralis Muscle for the shoulder o Passageway for the respiratory and digestive tracts located behind the oral and nasal cavity, RESPIRATORY PROCESS divided into nasopharynx, oropharynx, o Diaphragm descends into the abdominal cavity laryngopharynx: Pharynx during inspiration during negative pressure in the o Commonly called as the voice box, located just lungs below the pharynx at the root of the tongue: o Diffusion (Inhalation): From higher to Lower Larynx concentration o Glottis opening between the true vocal cords that o In the lungs, air passes through the terminal also plays an important role in coughing which is bronchioles into the alveoli and diffuses into the most fundamental defense mechanism of the surrounding capillaries then travels to the rest of lungs. the body to oxygenate the body tissues. o Leaf-shaped elastic flap structure at the top of the - Oxygenated blood is brighter red larynx. It also prevents food from entering the - Unoxygenated blood is dark red tracheobronchial tree by closing over the glottis o At the end of the of inspiration, the diaphragm during swallowing epiglottis and intercostal muscles relax and the lungs Lower Respiratory Airway recoils. o Located in front of the esophagus branches into o Osmosis (Exhale)- From lower to higher the right and left mainstem bronchi at the carina: concentration Trachea o Effective gas exchange depends on the o Mainstem bronchi at the carina. The right is wider, distribution of gas (ventilation) and blood shorter, and more vertical than the left. It is divided (perfusion) in all portion of the lungs. into secondary or lobes of the lungs. This is also Additional Notes: lined with cilia, which propel mucus up and away o Pneumonectomy is defined as the surgical from the lower airway to the trachea, where it can removal of the entire lungs. be expectorated or swallowed o Lobectomy is the surgical removal of some parts o Bronchioles is the branch from the secondary of lungs bronchi and subdivide into the small terminal and - Post OP bed position will be in the unaffected respiratory bronchioles. It contains no cartilage position and depend on the elastic recoil of the lungs for o Phospholipids is in the protein family patency the terminal bronchioles contain no cilia o Surfactant is the mixture of lipids and proteins and do not participate in gas exchange - Age of viability: 21-36 weeks, as early as 20 o Alveoli: are the structural distal to the terminal weeks ducts that branches from the bronchioles it o Functional Unit of Organs: contains cluster of acinus which are the basic unit - Kidney- Nephrons of gas exchange - Heart/Muscle- Cardiomyocytes-sacromere o Surfactant: A phospholipid protein that reduces - Lungs- Alveoli the surface tension without these alveoli would - Brain- Neurons collapse. - Thyroid- Follicle - Bone- Osteons Lungs - Liver- Lobule o Located at the pleural cavity in the thorax that - Pancreas- acinus, islet of langerhans extend from just above the clavicles to the - Stomach- 4 main secretions, cardia, fundus, body, pyloric part 6  - Rhonci: Low-pitch snoring sounds LUNG ASSESSMENT o Secretions/ Fluids o Rate - Crackles: crackling and bubbling sounds- fine Normal 12-20 cpm Eupnea coarse - Rales: rattling sounds Higher