Anatomy and Physiology: Respiratory System PDF

Anatomy and Physiology: RESPIRATORY SYSTEM CHRISTIAN DIOR L. AMARANTO, MAN Instructor I ANATOMY OF THE RESPIRATORY SYSTEM ANATOMY OF THE RESPIRATORY SYSTEM NASAL CAVITY PHARYNX (THROAT) LARYNX...

Anatomy and Physiology: RESPIRATORY SYSTEM CHRISTIAN DIOR L. AMARANTO, MAN Instructor I ANATOMY OF THE RESPIRATORY SYSTEM ANATOMY OF THE RESPIRATORY SYSTEM NASAL CAVITY PHARYNX (THROAT) LARYNX TRACHEA BRONCHI LUNGS BEHAVIOR OF GASES AND VENTILATION MUSCLES OF RESPIRATION AIR PRESSURE GRADIENT MUSCLES OF INSPIRATION PRESSURE AND VOLUME PRESSURE GRADIENTS AND MUSCLES OF EXPIRATION AIRFLOW BEHAVIOR OF GASES AND VENTILATION MUSCLES OF RESPIRATION MUSCLES OF INSPIRATION MUSCLES OF EXPIRATION BEHAVIOR OF GASES AND VENTILATION MUSCLES OF RESPIRATION MUSCLES OF INSPIRATION MUSCLES OF EXPIRATION BEHAVIOR OF GASES AND VENTILATION AIR PRESSURE GRADIENT PRESSURE AND VOLUME PRESSURE GRADIENTS AND AIRFLOW  MEASUREMENT OF LUNG FUNCTION PULMONARY VOLUMES AND CAPACITIES PULMONARY VOLUMES PULMONARY CAPACITIES 1. Tidal Volume 1. Inspiratory/Expiratory Capacity 2. Expiratory Reserve Volume 2. Vital Capacity 3. Inspiratory Reserve Volume 3. Functional Residual Capacity 4. Residual Volume 4. Total Lung Capacity  PULMONARY VOLUMES 8000 7000 6000 5000 4000 3000 2000 1000 0  PHYSIOLOGY OF RESPIRATORY SYSTEM DALTON’S LAW BOYLE’S LAW HENRY’S LAW The total pressure exerted by a mixture of If a given amount of gas has a constant To predict how gasses will dissolve in the gases is equal to the sum of the partial temperature, increasing its volume decreases alveoli and bloodstream during gas exchange. pressures of the gases in the mixture. its pressure, and vice-versa.  RISK FACTORS ▪ Environmental allergies ▪ Chest injury ▪ Crowded living conditions ▪ Exposure to chemicals and environmental pollutants ▪ Family history of infectious disease ▪ Frequent respiratory illnesses ▪ Geographical residence and travel to foreign countries ▪ Smoking ▪ Surgery ▪ Use of chewing tobacco ▪ Viral syndromes  DIAGNOSTIC TESTS CHEST X-RAY Provides information regarding the anatomical location and appearance of the lungs. Pre-procedure 1.Remove all jewelry and other metal objects from the chest area. 2.Assess the client's ability to inhale and hold his or her breath. Post-procedure Help the client get dressed.  DIAGNOSTIC TESTS SPUTUM SPECIMEN Specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells. Pre-procedure 1. Determine the specific purpose of collection and check institutional policy for the appropriate method for collection. 2. Obtain an early morning sterile specimen by suctioning or expectoration after a respiratory treatment if a treatment is prescribed. 3. Instruct the client to rinse the mouth with water before collection. 4. Obtain 15 mL of sputum.  DIAGNOSTIC TESTS SPUTUM SPECIMEN Pre-procedure (cont.) 5. Instruct the client to take several deep breaths and then cough deeply to obtain sputum. 6. Collect the specimen before the client begins antibiotic therapy. If already started on antibiotic therapy, ensure the laboratory can utilize an antimicrobial removal device when analyzing the specimen. Post-procedure 1. If a culture of sputum is prescribed, transport the specimen to the laboratory immediately. 2. Assist the client with mouth care. 11 12 13 Compute for the following: 19. TV= 16 20. TLC= 21. IRV= 15 22. ERV= 23. RV= 14 24. VC= 18 25. FRC= 17 11 IRV IC TV Compute for the following: 13 12 19. TV= 500 ml VC 20. TLC= 6 000 ml 15 16 21. IRV= 2 300 ml TLC 22. ERV= 1000 ml 14 23. RV= 1 200 ml 18 ERV 24. VC= 3 800 ml FRC 25. FRC= 2 200 ml 17 RV  DIAGNOSTIC TESTS LARYNGOSCOPY AND BRONCHOSCOPY Direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope. Pre-procedure 1. Maintain NO (nothing by mouth) status as prescribed. 2. Assess the results of coagulation studies. 3. Remove dentures and eyeglasses. 4. Establish an intravenous (IV) access as necessary and administer medication for sedation as prescribed. 5. Have emergency resuscitation supplies readily available.  DIAGNOSTIC TESTS LARYNGOSCOPY AND BRONCHOSCOPY Post-procedure 1. Maintain the client in a semi-Fowler's position. 2. Assess for the return of the gag reflex. 3. Maintain NO status until the gag reflex returns. 4. Monitor for bloody sputum. 5. Monitor respiratory status, particularly if sedation has been administered. 6. Monitor for complications, such as broncho-spasm or bronchial perforation, indicated by facial or neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and pneumothorax. 7. Notify the primary health care provider (PHCP) if signs of complications occur.  DIAGNOSTIC TESTS ENDOBRONCHIAL ULTRASOUND 1. Tissue samples are obtained from central lung masses and lymph nodes, using a bronchoscope with the help of ultrasound guidance. 2. Tissue samples are used for diagnosing and staging lung cancer, detecting infections, and identifying inflammatory diseases that affect the lungs, such as sarcoidosis. 3. Post-procedure, the client is monitored for signs of bleeding and respiratory distress.  DIAGNOSTIC TESTS PULMONARY ANGIOGRAPHY ▪ A fluoroscopic procedure in which a catheter is inserted through the antecubital or femoral vein into the pulmonary artery or 1 of its branches. ▪ Involves an injection of iodine or radiopaque contrast material.  DIAGNOSTIC TESTS PULMONARY ANGIOGRAPHY Pre-procedure 1. Assess for allergies to iodine, seafood, or other radiopaque dyes. 2. Maintain NO status as prescribed. 3. Assess results of coagulation studies. 4. Establish an IV access. 5. Administer sedation as prescribed. 6. Instruct the client to lie still during the procedure. 7. Instruct the client that he or she may feel an urge to cough, flushing, nausea, or a salty taste following injection of the dye. 8. Have emergency resuscitation equipment available.  DIAGNOSTIC TESTS PULMONARY ANGIOGRAPHY Post-procedure 1. Avoid taking blood pressure for 24 hours in the extremity used for the injection. 2. Monitor the peripheral neurovascular status of the affected extremity. 3. Assess the insertion site for bleeding. 4. Monitor for reaction to the dye.  DIAGNOSTIC TESTS THORACENTESIS Removal of fluid or air from the pleural space via transthoracic aspiration. Pre-procedure 1. Prepare the client for ultrasound or chest radiograph, if prescribed. before the procedure 2. Assess results of coagulation studies. 3. Note that the client is positioned sitting up right, with the arms and shoulders supported by a table at the bedside during the procedure. 4. If the client cannot sit up, the client is placed lying in bed toward the unaffected side, with the head of the bed elevated. 5. Instruct the client not to cough, breathe deeply, or move during the procedure.  DIAGNOSTIC TESTS THORACENTESIS Post-procedure 1. Monitor respiratory status. 2. Apply a pressure dressing, and assess the puncture site for bleeding and crepitus. 3. Monitor for signs of pneumothorax, air embolism, and pulmonary edema.  DIAGNOSTIC TESTS PULMONARY FUNCTION TEST ▪ Tests used to evaluate lung mechanics, gas exchange, and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gas levels.  DIAGNOSTIC TESTS PULMONARY FUNCTION TEST Pre-procedure 1. Determine whether an analgesic that may depress the respiratory function is being administered. 2. Consult with the PHCP regarding withholding bronchodilators before testing, or alternatively if the testing will be done prior to and after administration of a bronchodilator. 3. Instruct the client to void before the procedure and to wear loose clothing. 4. Remove dentures. 5. Instruct the client to refrain from smoking or eating a heavy meal for 4 to 6 hours before the test.  DIAGNOSTIC TESTS PULMONARY FUNCTION TEST Post-procedure 1. The client may resume a normal diet and any bronchodilators and respiratory treatments that were withheld before the procedure.  DIAGNOSTIC TESTS LUNG BIOPSY ▪ A transbronchial biopsy and a transbronchial needle aspiration may be performed to obtain tissue for analysis by culture or cytological examination. ▪ An open lung biopsy is performed in the operating room.  DIAGNOSTIC TESTS LUNG BIOPSY Pre-procedure 1. Maintain NPO status as prescribed 2. Inform the client that a local anesthetic will be used for needle biopsy, but a sensation of pressure during needle insertion and aspiration may be felt. 3. Administer analgesics and sedatives as prescribed.  DIAGNOSTIC TESTS LUNG BIOPSY Post-procedure 1. Apply a dressing to the biopsy site and monitor for drainage or bleeding. 2. Monitor for signs of respiratory distress, and notify the PHCP if they occur. 3. Monitor for signs of pneumothorax and air emboli, and notify the PHCP if they occur. 4. Prepare the client for chest radiography if prescribed.  DIAGNOSTIC TESTS V/Q LUNG SCAN ▪ The perfusion scan evaluates blood flow to the lungs. ▪ The ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation ▪ A radionuclide may be injected for the procedure.  DIAGNOSTIC TESTS V/Q LUNG SCAN Pre-procedure 1. Assess the client for allergies to dye, iodine, or seafood. 2. Remove jewelry around the chest area. 3. Review breathing methods that may be required during testing. 4. Establish an IV access. 5. Administer sedation if prescribed. 6. Have emergency resuscitation equipment available.  DIAGNOSTIC TESTS V/Q LUNG SCAN Post-procedure 1. Monitor the client for reaction to the radionuclide. 2. Instruct the client that the radionuclide clears from the body in about 8 hours. 3. Encourage increased fluid intake to clear the dye from the body if there is no fluid restriction.  DIAGNOSTIC TESTS COMPUTED TOMOGRAPHY PULMONARY ANGIOGRAPHY ▪ The scan visualizes the pulmonary arteries and blood flow. ▪ Its main use is to diagnose pulmonary embolism and is the preferred method. ▪ A contrast dye is injected.  DIAGNOSTIC TESTS COMPUTED TOMOGRAPHY PULMONARY ANGIOGRAPHY Pre-procedure ▪ Similar to the V/Q lung scan; in addition, renal function should be adequate and dosing of the contrast should be done by a pharmacist. Post-procedure ▪ Similar to the V/Q lung scan  DIAGNOSTIC TESTS SKIN TESTS ▪ A skin test uses an intradermal injection to help diagnose various infectious diseases. ✓ Determine hypersensitivity or previous reactions to skin tests. ✓ Use a skin site that is free of excessive body hair, derma-titis, and blemishes. ✓ Apply the injection at the upper third of the inner surface of the left arm. ✓ Circle and mark the injection test site. ✓ Document the date, time, and test site. ✓ Advise the client not to scratch the test site to prevent infection and possible abscess formation. ✓ Instruct the client to avoid washing the test site. ✓ Assess the reaction at the injection site 24 to 72 hours after administration of the test antigen. ✓ Assess the test site for the amount of induration (hard swelling) in millimeters and for the presence of erythema and vesiculation (small blister-like elevations).  DIAGNOSTIC TESTS ARTERIAL BLOOD GAS ▪ Measurement of the dissolved oxygen and carbon dioxide in the arterial blood helps indicate the acid-base state and how well oxygen is being carried to the body.  CHEST INJURIES 1. RIB FRACTURE ▪ Results from direct blunt chest trauma and causes a potential for intrathoracic injury, such as pneumothorax, hemothorax, or pulmonary contusion. ▪ Pain with movement, deep breathing, and coughing results in impaired ventilation and inadequate clearance of secretions.  CHEST INJURIES 1. RIB FRACTURE (cont.) Assessment Pain and tenderness at the injury site that increases with inspiration. Shallow respirations Client splints chest Fractures noted on chest x-ray  CHEST INJURIES 1. RIB FRACTURE (cont.) Interventions 1. Note that the ribs usually reunite spontaneously. 2. Open reduction and internal fixation of the ribs (rib plating) may be done. 3. Place the client in a Fowler's position. 4. Administer pain medication as prescribed to maintain adequate ventilatory status. 5. Monitor for increased respiratory distress. 6. Instruct the client to self-splint with the hands, arms, or a pillow. 7. If the pain is severe, prepare the client for an intercostal nerve block as prescribed.  CHEST INJURIES 2. FLAIL CHEST ▪ It occurs from blunt chest trauma associated with accidents, which may result in hemothorax and rib fractures. ▪ The loose segment of the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall.  CHEST INJURIES 2. FLAIL CHEST (cont.) Assessment ▪ Paradoxical respirations (inward movement of a segment of the thorax during inspiration with outward movement during expiration) ▪ Severe pain in the chest ▪ Dyspnea ▪ Cyanosis ▪ Tachycardia ▪ Hypotension ▪ Tachypnea, shallow respirations ▪ Diminished breath  CHEST INJURIES 2. FLAIL CHEST (cont.) Interventions 1. Maintain the client in Fowler's position. 2. Administer oxygen as prescribed. 3. Monitor for increased respiratory distress. 4. Encourage coughing and deep breathing 5. Administer pain medication as prescribed. 6. Maintain bed rest and limit activity to reduce oxygen demands. 7. Open reduction and internal fixation of the ribs (rib plating) may be done. 8. Prepare for intubation with mechanical ventilation, with positive end- expiratory pressure (PEEP) for severe flail chest associated with respiratory failure and shock.  CHEST INJURIES 2. PULMONARY CONTUSION ▪ Characterized by interstitial hemorrhage associated with intra-alveolar hemorrhage, resulting in decreased pulmonary compliance. ▪ The major complication is acute respiratory distress syndrome.  CHEST INJURIES 2. PULMONARY CONTUSION (cont.) Assessment ▪ Dyspnea ▪ Restlessness ▪ Increased bronchial secretions ▪ Hypoxemia ▪ Hemoptysis ▪ Decreased breath sounds ▪ Crackles and wheezes  CHEST INJURIES 2. PULMONARY CONTUSION (cont.) Interventions 1. Maintain a patent airway and adequate ventilation. 2. Place the client in a Fowler's position. 3. Administer oxygen as prescribed. 4. Monitor for increased respiratory distress. 5. Maintain bed rest and limit activity to reduce oxygen demands. 6. Prepare for mechanical ventilation with PEEP if required.  CHEST INJURIES 3. PNEUMOTHORAX ▪ Accumulating atmospheric air in the pleural space results in increased intrathoracic pressure and reduced vital capacity, or the greatest amount of air expires from the o lungs after taking a deep breath. ▪ The loss of negative intrapleural pressure results in the collapse of the lung. ▪ A spontaneous pneumothorax occurs when a pulmonary bleb, or small air- containing spaces deep in the lung, ruptures. ▪ An open pneumothorax occurs when an opening through the chest wall allows positive atmospheric air pressure into the pleural space. ▪ A tension pneumothorax occurs when a positive pressure buildup occurs in the pleural space, either from a blunt chest injury or mechanical ventilation with PEEP.  CHEST INJURIES 3. PNEUMOTHORAX Assessment ▪ Absent or markedly decreased breath sounds on the affected side ▪ Cyanosis ▪ Decreased chest expansion unilaterally ▪ Dyspnea ▪ Hypotension ▪ Sharp chest pain Subcutaneous emphysema as evidenced by crepitus on palpation ▪ Sucking sound with an open chest wound ▪ Tachycardia ▪ Tachypnea ▪ Tracheal deviation to the unaffected side with tension pneumothorax  CHEST INJURIES 3. PNEUMOTHORAX Interventions 1. Diagnosis of pneumothorax is made by chest x-ray. 2. Apply a nonporous dressing over an open chest wound. 3. Administer oxygen as prescribed. 4. Place the client in a Fowler's position. 5. Prepare for chest tube placement, remaining in place until the lung has expanded fully. 6. Monitor the chest tube drainage system. 7. Monitor for subcutaneous emphysema.  ACUTE RESPIRATORY FAILURE ▪ Occurs when insufficient oxygen is transported to the blood or inadequate carbon dioxide is removed from the lungs, and the client's compensatory mechanisms fail ▪ Causes include a mechanical abnormality of the lungs or chest wall, a defect in the respiratory control center in the brain, or an impairment in the function of the respiratory muscles. ▪ In oxygenation failure or hypoxemic respiratory failure, oxygen may reach the alveoli but cannot be absorbed or used properly, resulting in a PaO2 lower than 60 mm Hg, arterial oxygen saturation (SaO2) lower than 90%, or partial pressure of arterial carbon dioxide (PaCO2) greater than 50mm Hg occurring with acidemia.  ACUTE RESPIRATORY FAILURE ▪ Respiratory failure can be hypoxemic, hypercapnia, or both. The mechanism behind failure is inadequate gas exchange. Arterial oxygen, carbon dioxide, or both are not kept at normal levels, resulting in failure. ▪ Many clients experience both hypoxemic and hypercapnic respiratory failure and retained carbon dioxide in the alveoli displaces oxygen, contributing to the hypoxemia. ▪ Manifestations of respiratory failure are related to the extent and rapidity of change in PaO2 and PaCO2.  ACUTE RESPIRATORY FAILURE Assessment ▪ Dyspnea ▪ Restlessness ▪ Confusion ▪ Tachycardia ▪ Hypertension ▪ Dysrhythmias ▪ Decreased level of consciousness ▪ Alterations in respirations and breath sounds ▪ Headache (less common)  ACUTE RESPIRATORY FAILURE Intervention 1. Identify and treat the cause of the respiratory failure. 2. Administer oxygen to maintain the PaO2 level above 60 to 70mm Hg. 3. Place the client in a Fowler's position. 4. Encourage deep breathing. 5. Administer bronchodilators as prescribed. 6. Prepare the client for mechanical ventilation if supplemental oxygen cannot maintain acceptable PaO2 and PaCO2 levels.  ACUTE RESPIRATORY DISTRESS SYNDROME ▪ A form of acute respiratory failure that occurs as a complication caused by a diffuse lung injury or critical illness and leads to extravascular lung fluid. ▪ The major site of injury is the alveolar-capillary membrane. ▪ The interstitial edema causes compression and obliteration of the terminal airways, leading to reduced lung volume and compliance. ▪ The ABG levels identify respiratory acidosis and hypoxemia that do not respond to an increased percentage of oxygen. ▪ The chest X-ray shows bilateral interstitial and alveolar infiltrates; interstitial edema may not be noted until the fluid content increases by 30%. ▪ Causes include sepsis, fluid overload, shock, trauma, neurological injuries, burns, DIC, drug ingestion, aspiration, and inhalation of toxic substances.  ACUTE RESPIRATORY DISTRESS SYNDROME Assessment ▪ Tachypnea ▪ Dyspnea ▪ Decreased breath sounds ▪ Deteriorating ABG levels ▪ Hypoxemia despite high concentrations of delivered oxygen ▪ Decreased pulmonary compliance ▪ Pulmonary infiltrates  ACUTE RESPIRATORY DISTRESS SYNDROME Interventions 1. Identify and treat the cause of the acute respiratory distress syndrome. 2. Administer oxygen as prescribed. 3. Place the client in a Fowler's position. 4. Restrict fluid intake as prescribed. 5. Provide respiratory treatments as prescribed. 6. Administer diuretics, anticoagulants, or corticosteroids as prescribed 7. Prepare the client for intubation and mechanical ventilation using PEEP.  ASTHMA 1. Chronic inflammatory disorder of the airways that causes varying degrees of obstruction in the airways 2. Marked by airway inflammation and hyper-responsiveness to a variety of stimuli or triggers. 3. It causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing associated with airflow obstruction that may resolve spontaneously; it is often reversible with treatment. 4. Severity is classified based on the clinical features before treatment. 5. Status asthmaticus is a severe life-threatening asthma episode that is refractory to treatment and may result in pneumothorax, acute cor- pulmonale, or respiratory arrest.  ASTHMA Assessment ▪ Restlessness ▪ Wheezing or crackles ▪ Absent or diminished lung sounds ▪ Hyperresonance ▪ Use of accessory muscles for breathing ▪ Tachypnea with hyperventilation ▪ Prolonged exhalation ▪ Tachycardia ▪ Pulsus paradoxus ▪ Diaphoresis ▪ Cyanosis ▪ Decreased oxygen saturation ▪ Pulmonary function test results that demonstrate decreased airflow rates  ASTHMA Interventions 1. Monitor vital signs. 2. Monitor pulse oximetry. 3. Monitor peak flow. 4. During an acute asthma episode, provide interventions to assist with breathing. 5. To identify possible triggers and measures to prevent episodes 6. About the management of medication and proper administration 7. About the correct use of a peak flowmeter 8. About developing an asthma action plan with the physician and what to do if an asthma episode occurs.  CHRONIC OBSTRUCTIVE PULMONARY DISEASE 1. Also known as chronic obstructive lung disease and chronic airflow limitation 2. Chronic obstructive pulmonary disease is a disease state characterized by airflow obstruction. 3. Chronic bronchitis and emphysema are progressive lung diseases that fall under the general category of chronic obstructive pulmonary disease. 4. Chronic bronchitis is when the bronchial tubes become inflamed, and excessive mucus production occurs due to irritants or injury. 5. Emphysema is when the air sacs in the lungs are damaged and enlarged, resulting in hyperinflation and breathlessness. 6. Progressive airflow limitation occurs, which is associated with an abnormal inflammatory response of the lungs that is not completely reversible. 7. Chronic obstructive pulmonary disease (COPD) leads to pulmonary insufficiency, pulmonary hypertension, and cor pulmonale.  CHRONIC OBSTRUCTIVE PULMONARY DISEASE Interventions 1. Monitor vital signs. 2. Administer a concentration of oxygen based on ABG values and oxygen saturation by pulse oximetry as prescribed 3. Monitor pulse oximetry. 4. Provide respiratory treatments and CPT. 5. Instruct the client in diaphragmatic or abdominal breathing techniques, tripod positioning, and pursed-lip breathing techniques, which increase airway pressure and keep air passages open, promoting maximal carbon dioxide expiration.  CHRONIC OBSTRUCTIVE PULMONARY DISEASE Interventions (cont.) 6. Record the color, amount, and consistency of sputum. 7. Suction the client's lungs, if necessary, to clear the airway and prevent infection. 8. Monitor weight. 9. Encourage small, frequent meals to maintain nutrition and prevent dyspnea. 10. Provide a high-calorie, high-protein diet with supplements. 11. Encourage fluid intake up to 3000 ml/day to keep secretions thin unless contraindicated.  CHRONIC OBSTRUCTIVE PULMONARY DISEASE Interventions (cont.) 12. Place the client in a Fowler's position and lean forward to aid breathing. 13. Allow activity as tolerated. 14. Administer bronchodilators as prescribed, and instruct the client to use oral and inhalant medications. 15. Administer corticosteroids as prescribed for exacerbations. 16. Administer mucolytics as prescribed to thin secretions. 17. Administer antibiotics for infection if prescribed.  PNEUMONIA ▪ Infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles ▪ The inflammation-related edema stiffens the lung, decreases lung compliance and vital capacity, and causes hypoxemia. ▪ Pneumonia can be community-acquired or hospital-acquired. The chest x-ray film shows lobar or segmental consolidation, pulmonary infiltrates, or pleural effusions. ▪ A sputum culture identifies the organism. ▪ The white blood cell count and the erythrocyte sedimentation rate are elevated.  PNEUMONIA Assessment ▪ Chills ▪ Elevated temperature ▪ Pleuritic pain ▪ Tachypnea ▪ Rhonchi and wheezes ▪ Use of accessory muscles for breathing ▪ Mental status changes ▪ Sputum production  PNEUMONIA Interventions 1. Administer oxygen as prescribed. 2. Monitor respiratory status. 3. Monitor for labored respirations, cyanosis, and cold and clammy skin. 4. Encourage coughing and deep breathing and use of the incentive spirometer. 5. Place the client in a semi-Fowler's position to facilitate breathing and lung expansion. 6. Change the client's position frequently and ambulate as tolerated to mobilize secretions.  PNEUMONIA Interventions (cont.) 7. Provide CPT. 8. Perform nasotracheal suctioning if the client is unable to clear secretions. 9. Monitor pulse oximetry. 10. Monitor and record color, consistency, and amount of sputum. 11. Provide a high-calorie, high-protein diet with small, frequent meals. 12. Encourage fluids, up to 3 L/day, to thin secretions unless contraindicated.  PNEUMONIA Interventions (cont.) 13. Provide a balance of rest and activity, increasing activity gradually. 14. Administer antibiotics as prescribed. 15. Administer antipyretics, bronchodilators, cough suppressants, mucolytic agents, and expectorants as prescribed. 16. Prevent the spread of infection by hand washing and the proper disposal of secretions.  INFLUENZA ▪ Also known as the flu; highly contagious acute viral respiratory infection. ▪ It may be caused by several viruses, usually known as types A, B, and C. ▪ Yearly vaccination is recommended to prevent the disease, especially for those older than 50 years of age, individuals with chronic illness or who are immunocompromised, those living in institutions, and healthcare personnel providing direct care to clients.  INFLUENZA Assessment Acute onset of fever and muscle aches Headache Fatigue, weakness, anorexia Sore throat, cough, and rhinorrhea  INFLUENZA Interventions 1. Encourage rest. 2. Encourage fluids to prevent pulmonary complications (unless contraindicated). 3. Monitor lung sounds. 4. Provide supportive therapy such as antipyretics or antitussives as indicated. 5. Administer antiviral medications as prescribed for the current strain of influenza.  PLEURAL EFFUSION ▪ Pleural effusion is the collection of fluid in the pleural space. ▪ Any condition that interferes with the secretion or drainage of this fluid will lead to pleural effusion.  PLEURAL EFFUSION Assessment ▪ Pleuritic pain that is sharp and increases with inspiration ▪ Progressive dyspnea with decreased movement of the chest wall on the affected side ▪ Dry, nonproductive cough caused by bronchial irritation or mediastinal shift ▪ Tachycardia ▪ Elevated temperature ▪ Decreased breath sounds over the affected area ▪ Chest x-ray film shows pleural effusion and a mediastinal shift away from the fluid if the effusion is more than 250 ml.  PLEURAL EFFUSION Interventions 1. Identify and treat the underlying cause. 2. Monitor breath sounds. 3. Place the client in a Fowler's position. 4. Encourage coughing and deep breathing. 5. Prepare the client for thoracentesis. 6. If pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as prescribed.  PLEURAL EFFUSION Interventions Pleurectomy 1. It consists of surgically stripping the parietal pleura away from the visceral pleura. 2. This produces an intense inflammatory reaction that promotes adhesion formation between the two layers during healing.  PLEURAL EFFUSION Interventions Pleurodesis 1. Involves the instillation of a sclerosing substance into the pleural space via a thoracotomy tube. 2. The substance creates an inflammatory response that scleroses tissue together.  EMPYEMA ▪ Collection of pus within the pleural cavity. ▪ The fluid is thick, opaque, and foul-smelling. ▪ The most common cause is pulmonary infection and lung abscess caused by thoracic surgery or chest trauma, in which bacteria are introduced directly into the pleural space. ▪ Treatment focuses on treating the infection, emptying the empyema cavity, re-expanding the lung, and controlling the infection.  EMPYEMA Assessment ▪ Recent febrile illness or trauma ▪ Chest pain ▪ Cough ▪ Dyspnea ▪ Anorexia and weight loss ▪ Malaise ▪ Elevated temperature and chills ▪ Night sweats ▪ Pleural exudate on chest  EMPYEMA Interventions 1. Monitor breath sounds. 2. Place the client in a semi-Fowler's or high-Fowler's position. 3. Encourage coughing and deep breathing. 4. Administer antibiotics as prescribed. 5. Instruct the client to splint the chest as necessary. 6. Assist with thoracentesis or chest tube insertion to promote drainage and lung expansion. 7. If marked pleural thickening occurs, prepare the client for decortication if prescribed; this surgical procedure involves the removal of the restrictive mass of fibrin and inflammatory cells.  PLEURISY ▪ Inflammation of the visceral and parietal membranes may be caused by pulmonary infarction or pneumonia. ▪ The visceral and parietal membranes rub together during respiration and cause pain. ▪ Pleurisy usually occurs on one side of the chest, usually in the lower lateral portions of the chest wall.  PLEURISY Assessment ▪ Knife-like pain aggravated by deep breathing and coughing ▪ Dyspnea ▪ Pleural friction rub heard on auscultation  PLEURISY Interventions 1. Identify and treat the cause. 2. Monitor lung sounds. 3. Administer analgesics as prescribed. 4. Apply hot or cold applications as prescribed. 5. Encourage coughing and deep breathing. 6. Instruct the client to lie on the affected side to splint the chest.  PULMONARY EMBOLISM ▪ It occurs when a thrombus forms (most commonly in a deep vein), detaches, travels to the right side of the heart, and then lodges in a branch of the pulmonary artery. ▪ Clients prone to pulmonary embolism are those at risk for deep vein thrombosis, including those with prolonged immobilization, surgery, obesity, pregnancy, heart failure, advanced age, or a history of thromboembolism. ▪ Fat emboli can occur as a complication following a fracture of a long bone and can cause pulmonary emboli. ▪ Treatment is aimed at prevention through risk factor recognition and elimination.  PULMONARY EMBOLISM Assessment ▪ Apprehension and restlessness ▪ Blood-tinged sputum ▪ Chest pain ▪ Cough ▪ Crackles and wheezes on auscultation ▪ Cyanosis ▪ Distended neck veins ▪ Dyspnea accompanied by anginal and pleuritic pain, exacerbated by inspiration ▪ The feeling of impending doom ▪ Hypotension ▪ Petechiae over the chest and axilla ▪ Shallow respirations ▪ Tachypnea and tachycardia  PULMONARY EMBOLISM Interventions 1. Notify the Rapid Response Team and primary health care provider (PHCP). 2. Reassure the client and elevate the head of the bed. 3. Prepare to administer the oxygen. 4. Obtain vital signs and check lung sounds. 5. Prepare to obtain an arterial blood gas. 6. Prepare for the administration of heparin therapy or other therapies. 7. Document the event, interventions, and the client's response to treatment.  HISTOPLASMOSIS ▪ Pulmonary fungal infection caused by sports of Histoplasma capsulatum. ▪ Transmission occurs by the inhalation of spores which commonly are found in contaminated soil. ▪ Spores also are usually found in bird droppings.  HISTOPLASMOSIS Assessment ▪ Similar to pneumonia ▪ Positive skin test for histoplasmosis ▪ Positive agglutination test ▪ Splenomegaly, hepatomegaly  HISTOPLASMOSIS Interventions 1. Administer oxygen as prescribed. 2. Monitor breath sounds. 3. Administer antiemetics, antihistamines, anti-pyretics, and corticosteroids as prescribed. 4. Administer fungicidal medications as prescribed. 5. Encourage coughing and deep breathing. 6. Place the client in a semi-Fowler's position. 7. Monitor vital signs. 8. Monitor for nephrotoxicity from fungicidal medications. 9. Instruct the client to wear a mask and spray the floor with water before sweeping the barn and chicken coops.  SARCOIDOSIS ▪ Presence of epithelioid cell tubercles in the lung. ▪ The cause is unknown, but a high titer of Epstein-Barr virus may be noted. ▪ Viral incidence is highest in African Americans and young adults.  SARCOIDOSIS Assessment ▪ Night sweats ▪ Fever ▪ Weight loss ▪ Cough and dyspnea ▪ Skin nodules ▪ Polyarthritis ▪ Kveim test: Sarcoid node antigen is injected intradermally and causes a local nodular lesion in about one month.  SARCOIDOSIS Interventions 1. Administer corticosteroids to control symptoms. 2. Monitor temperature. 3. Increase fluid intake. 4. Provide frequent periods of rest. 5. Encourage small, frequent, nutritious  TUBERCULOSIS ▪ Highly communicable disease caused by Mycobacterium tuberculosis. ▪ M. tuberculosis is a nonmotile, nonsporulating, acid-fast rod that secretes niacin; it multiplies freely when the bacillus reaches a susceptible site. ▪ Because M. tuberculosis is an aerobic bacterium, it primarily affects the pulmonary system, especially the upper lobes with the highest oxygen content. Still, it also can affect other body areas, such as the brain, intestines, peritoneum, kidney, joints, and liver.  TUBERCULOSIS ▪ An exudative response causes nonspecific pneumonitis and the development of granulomas in the lung tissue. ▪ Tuberculosis has an insidious onset, and many clients are not aware of symptoms until the disease is well advanced. ▪ Improper or noncompliant use of treatment programs may cause the development of mutations in the tubercle bacilli, resulting in a multidrug-resistant strain of tuberculosis (MDR-TB). ▪ Treatment aims to prevent transmission, control symptoms, and prevent disease progression.  TUBERCULOSIS Risk Factors ▪ Children younger than 5 years of age ▪ Drinking unpasteurized milk if the cow is infected with bovine tuberculosis ▪ Homeless individuals or those from a lower socioeconomic group, minority group, or refugee group ▪ Individuals in constant, frequent contact with an untreated or undiagnosed individual ▪ Individuals living in crowded areas, such as long-term care facilities, prisons, and mental health facilities ▪ Older client ▪ Individuals with malnutrition, infection, immune dysfunction, or human immunodeficiency virus infection; or immuno-suppressed as a result of medication therapy ▪ Individuals who abuse alcohol or are intravenous drug users  TUBERCULOSIS Transmission ▪ Via the airborne route by droplet infection ▪ When infected individual coughs, laughs, sneezes, or sings, droplet nuclei containing tuberculosis bacteria enter the air and maybe inhaled by others. ▪ Identifying those in close contact with the infected individual is important so they can be tested and treated as necessary. ▪ When contacts have been identified, these persons are assessed with a tuberculin skin test and chest x-rays to determine infection with tuberculosis. ▪ After the infected individual has received tuberculosis medication for 2 to 3 weeks, the risk of transmission is reduced greatly.  TUBERCULOSIS Disease Progression ▪ Droplets enter the lungs, and the bacteria form a tubercle lesion. ▪ The defense systems of the body encapsulate the tubercle, leaving a scar. ▪ If encapsulation does not occur, bacteria may enter the lymph system, travel to the lymph nodes, and cause an inflammatory response termed granulomatous inflammation. ▪ Primary lesions form; the primary lesions may become dormant but can be reactivated and become a secondary infection when re-exposed to the bacterium. ▪ In an active phase, tuberculosis can cause necrosis and cavitation in the lesions, leading to rupture, the spread of necrotic tissue, and damage to various parts of the body.  TUBERCULOSIS Client History ▪ Past exposure to tuberculosis ▪ Client's country of origin and travel to foreign countries in which the incidence of tuberculosis is high ▪ Recent history of influenza, pneumonia, febrile illness, cough, or foul-smelling sputum production ▪ Previous tests for tuberculosis; results of the testing ▪ Recent bacillus Calmette-Guérin (BCG) vaccine (a vaccine containing attenuated tubercle bacilli that may be given to persons in foreign countries or to persons traveling to foreign countries to produce increased resistance to tuberculosis).  TUBERCULOSIS Client History ▪ May be asymptomatic in primary infection ▪ Fatigue ▪ Lethargy ▪ Anorexia ▪ Weight loss ▪ Low-grade fever ▪ Chills ▪ Night sweats ▪ Persistent cough and the production of mucoid and mucopurulent sputum, which is occasionally streaked with blood ▪ Chest tightness and a dull, aching chest pain may accompany the cough.  TUBERCULOSIS Chest Assessment ▪ A physical examination of the chest does not provide conclusive evidence of tuberculosis. ▪ A chest x-ray is not definitive, but multinodular infiltrates with calcification in the upper lobes suggest tuberculosis. ▪ If the disease is active, caseation and inflammation may be seen on the chest x-ray.  TUBERCULOSIS Chest Assessment Advanced disease ▪ Dullness with percussion over-involved parenchymal areas, bronchial breath sounds, rhonchi, and crackles indicate advanced disease. ▪ Partial bronchus obstruction caused by endobronchial disease or compression by lymph nodes may produce localized wheezing and dyspnea.  TUBERCULOSIS QuantiFERON-TB Gold Test A blood analysis test by an enzyme-linked immunosorbent assay. A sensitive and rapid test (results can be available in 24 hours that assists in diagnosing the client.  TUBERCULOSIS Sputum Cultures ▪ Sputum specimens are obtained for an acid-fast smear. ▪ A sputum culture identifying M. tuberculosis confirms the diagnosis. ▪ After medications are started, sputum samples are obtained again to determine the effectiveness of therapy. ▪ Most clients have negative cultures after 3 months of treatment.  TUBERCULOSIS The Hospitalized Client 1. The client with active tuberculosis is placed under airborne isolation precautions in a negative pressure room; to maintain negative pressure, the door of the room must be tightly closed. 2. The room should have at least 6 fresh air exchanges per hour and be ventilated to the outside environment, if possible. 3. When caring for the client, the nurse wears a particulate respirator (a special individually fitted mask) and a gown when clothing contamination exists. 4. Thorough hand washing is required before and after caring for the client. 5. If the client needs to leave the room for a test or procedure, the client is required to wear a surgical mask.