respiratory nursing #1

8/11/2019 Respiratory Nursing #1

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Medical and Surgical Nursing

Respiratory System Lecture Notes

Prepared by: Mark Fredderick R. Abejo RN,, MAN

MS Abejo1

MEDICAL AND SURGICAL NURSING

Respirator y System

Lecturer:Mark Fredderick R. Abejo RN,MAN


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PHYSIOLOGY OF RESPIRATORY SYSTEM

VENTILATION: The movement of air in and out of the airways.

The thoracic cavity is an air tight chamber. the floor of

this chamber is the diaphragm.

Inspiration: contraction of the diaphragm (movement of

this chamber floor downward) and contraction of the

external intercostal muscles increases the space in this

chamber. lowered intrathoracic pressure causes air to

enter through the airways and inflate the lungs.

Expiration: with relaxation, the diaphragm moves up and

intrathoracic pressure increases. this increased pressure

pushes air out of the lungs. expiration requires the elastic

recoil of the lungs.

Inspiration normally is 1/3 of the respiratory cycle and

expiration is 2/3.

DRIVING FORCE FOR AIR FLOW

Airflow driven by the pressure difference between

atmosphere (barometric pressure) and inside the lungs

(intrapulmonary pressure).

AIRWAY RESISTANCE

Resistance is determined chiefly by the radius size of the

airway.

Causes of Increased Airway Resistance

1. Contraction of bronchial mucosa

2. Thickening of bronchial mucosa

3. Obstruction of the airway

4. Loss of lung elasticity

RESPIRATION

The process of gas exchange between atmospheric air

and the blood at the alveoli, and between the blood cells

and the cells of the body.

Exchange of gases occurs because of differences in

partial pressures.

Oxygen diffuses from the air into the blood at the alveoli

to be transported to the cells of the body.

Carbon dioxide diffuses from the blood into the air at the

alveoli to be removed from the body.

NEUROCHEMICAL CONTROL

MEDULLA OBLONGATA respiratory center

initiates each breath by sending messages to primary

respiratory muscles over the phrenic nerve

- has inspiration and expiration centers

PONS has 2 respiration centers that work with the

inspiration center to produce normal rate of breathing

1. PNEUMOTAXIC CENTER affects the inspiratory

effort by limiting the volume of air inspired

2. APNEUSTIC CENTERprolongs inhalation

NOTE: Chemoreceptors responds to changes in ph, increasedPaCO2 = increase RR

RESPIRATORY EXAMINATION AND

ASSESSMENT

Background information

A. Abnormal patterns of breathing

1. Sleep Apnea

cessation of airflow for more than 10 seconds more

than 10 times a night during sleep

causes:obstructive (e.g. obesity with upper narrowing,enlarged tonsils, pharyngeal soft tissue changes in

acromegaly or hypothyroidism)2.

Cheyne-Stokes

periods of apnoea alternating with periods ofhyperpnoae

pathophysiology:delay in medullary chemoreceptor

response to blood gas changes

causes left ventricular failure brain damage (e.g. trauma, cerebral,

haemorrhage) high altitude

3.

Kussmaul's (air hunger)

deep rapid respiration due to stimulation of respiratorycentre

causes: metabolic acidosis (e.g. diabetes mellitus,

chronic renal failure)

4.

Hyperventilation

complications:alkalosis and tetany

causes:anxiety

5. Ataxic (Biot)

irregular in timing and deep

causes:brainstem damage

6.

Apneustic

post-inspiratory pause in breathing

causes:brain (pontine) damage


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7.

Paradoxical

the abdomen sucks with respiration (normally, itpouches uotward due to diaphragmatic descent)

causes: diaphragmatic paralysis

B.

Cyanosis

1.

Refers to blue discoloration of skin and mucousmembranes , is due to presence of deoxygenatedhaemoglobin in superficial blood vessels

2. Central cyanosis= abnromal amout of deoxygenated

haemoglobin in arteries and that blue discoloration ispresent in parts of body with good circulation such astongue

3. Peripheral cyanosis= occurs when blood supply to acertain part of body is reduced, and the tissue extracts

more oxygen from normal from the circulating blood, e.g.lips in cold weather are often blue, but lips are spared

4. Causes of cyanosis

Central cyanosis decreased arterial saturation decreased concentration of inspired oxygen:

high altitude lung disease: COPD with cor pulmoale,

massive pulmonary embolism right to left cardiac shunt (cyanotic congenital

heart disease) polycythaemia haemoglobin abnromalities (rare):

methaemoglobinaemia, sulphaemoglobinaemia

Peripheral cyanosis all causes of central cyanosis cause peripheral

cyanosis exposure to cold reduced cardiac output: left ventricular failure or

shock

arterial or venous obstructionPosition:patient sitting over edge of bed

General appearance

look for the following

Dyspnea

normal respiratory rate < 14 each minute

tachypnoea = rapid respiratory rate

are accessory muscles being used (sternomastoids,

platysma, strap muscles of neck) - characteristically,the accessory muscles cause elevation of shoulderswith inspiration and aid respiration by increasingchest expansion

Cyanosis

Character of coughask patient to cough several times

lack of usual explosive beginning may indicatevocal cord paralysis (bovine cough)

muffled, wheezy ineffective cough suggests airflowlimitation

very loose productive cough suggests excessive

bronchial secretions due to:- chronic bronchitis

- pneumonia- bronchiectasis

dry irritating cough may occur with:

- chest infection

- asthma

- carcinoma of bronchus- left ventricular failure

- interstitial lung disease

- ACE inhibitors

Sputum

volume

type (purulent, mucoid, mucopurulent)presence or absence of blood?

Stridor

croaking noise loudest on inspiration

is a sign that requires urgent attention

causes: (obstruction of larynx, trachea or largebroncus)

- acute onset (minutes) inhaled foreign body acute epiglottitis anaphylaxis toxic gas inhalation

- gradual onset (days, weeks) laryngeal and pharyngeal tumours crico-arytenoid rheumatoid arthritis bilateral vocal cord palsy tracheal carcinoma paratracheal compression by lymph nodes post-tracheostomy or intubation

granulomata

Hoarseness

causes include:- laryngitis- laryngeal nerve palsy associated with

carcinoma of lung- laryngeal carcinoma

The Hands

Clubbing

commonly cause by respiratory disease (but NOTemphysema or chronic bronchitis)

occasionally, clubbing is associated with hypertrophicpulmonary osteoarthropathy (HPO) characterised by periosteal inflammation at distal ends

of long bones, wrists, ankles, metacarpals andmetatarsals

sweelling and tenderness over wrists and otherinvolved areas

Staining

staining of fingers - sign of cigarette smoking (caused by

tar, not nicotine)

Wasting and weakness

Pulse rate Flapping tremor (asterixis)- unreliable sign

ask patient to dorsiflex wrists and spread out fingers, with

arms outstretched

flapping tremor may occur with severe carbon dioxide

retention (severe chronic airflow limitation)


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The Chest:palpation

chest expansion

place hands firmly on chest wall with fingers extendingaround sides of chest (fugyre 4.5)

as patient takes a big breath in, the thumbs should move

symmetrically apart about 5 cm

reduced expansion on one side indicates a lesion on thatside

note: lower lobe expansion is tested here; upper lobe is

tested for on inspection (as above)

apex beat

(discussed in cardiac section)

for respiratory diseases: displacement toward site of lesion - can be caused by:

collapse of lower lobe

localised pulmonary fibrosis displacement away from site of lesion - can be caused

by:

pleural effusion

tension pneumothorax apex beat is often impalpable in a chest which is

hyperexpanded secondary to chronic airflow limitation

vocal fremitus

palpate chest wall with palm of hand while patient repeats"99"

front and back of chest are each palpated in 2 comparablepositions with palms; in this way differences in vibration onchest wall can be detected

causes of change in vocal fremitus are the same as those forvocal resonance (see later)

ribs

gently compress chest wall anteroposteriorly and laterally

localised pain suggests a rib fracture (may be secondary to

trauma or spontaneous as a result of tumour deposition orbone disease)

The Chest:percussion

with left hand on chest wall and fingers slightly separated andaligned with ribs, the middle finger is pressed firmly against

the chest; pad of right middle finger is used to strike firmly themiddle phalanx of middle finger of left hand

percussion of symmetrical areas of: anterior (chest) posterior (back) (ask patient to move elbows forward

across the front of chest - this rotates the scapulaeanteriorly, i.e. moves it out of the way)

axillary region (side) supraclavicular fossa

percussion over a solid structure (e.g. liver, consolidated lung)

produces a dull note

percusion over a fluid filled area (e.g. pleural effusion)

produces an extremely dull (stony dull) note

percussion over the normal lung produces a resonant note

percussion over a hollow structure (e.g. bowel, pneumothorax)produces a hyperresonsant note

liver dullness:

upper level of liver dullness is determined by percussingdown the anterior cehst in mid-clavicular line

normally, upper level of liver dullness is 6th rib in right

mid-clavicular line if chest is resonant below this level, it is a sign of

hyperinflation usually due to emphysema, asthma

cardiac dullness: area of cardiac dullness is uaully present on left side of

chest this may decrease in emphysema or asthma

The Chest:auscultation

breath sounds

introductionone should use the diaphragm of stethoscope to listento breath sound in each area, comparing each side

remember to listen high up into the axillae

remember to use bell of stethoscope to listen to lung

from above the clavicles

quality of breath sounds

normal breat sounds are heard with stethoscope over all parts of

chest, produced in airways rather than alveoli(although once they had been thought to arisefrom alveoli (vesicles) and are therefore calledvesicular sounds)

normal (vesicular) breath sounds are louder and

longer on inspiration than on expiration; andthere is no gap between the inspiratory andexpiratory sounds

bronchial breath sounds turbulence in large airways is heard without

being filtered by the alveoli, and therefore

produce a different quality; they are heard overthe trachea normally, but not over the lungs

are audible throughout expiration, and oftenthere is a gap between inspiration and expiration

are heard over areas of consolidation since solidlung conducts the sound of turbulence in mainairways to peripheral areas without filtering

causes include:

- lung consolidation (lobar pneumonia) -

common- localised pulmonary fibrosis - uncommon

- pleural effusion (above the fluid) -

uncommon- collapsed lung (e.g. adjacent to a pleural

effusion) - uncommon amphoric sound = when breath sounds over a

large cavity have an exaggerated bronchialquality)

intensity of breath sounds

causes of reduced breath sounds include: chronic airflow limitation (especially

emphysema) pleural effusion pneumothorax

pneumonia

large neoplasm pulmonary collapse

added (adventitious) sounds

two types of added sounds: continuous (wheezes) andinterrupted (crackles)

wheezes

may be heard in expiration or inspiration or both

pathophysiology of wheezes - airway narrowing an inspiratory wheeze implies severe airway

narrowing


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causes of wheezes include:- asthma (often high pitched) - due to muscle

spasm, mucosal oedema, excessivesecretions

- chronic airflow diseases - due to mucosaloedema and excessive secretions

- carcinoma causing bronchial obstruction -

tends to cause a localised wheeze which ismonophonic and does not clear with

coughing

crackles some terms not to use include rales (low pitched

crackles) and creptitations (high pitchedcrackles)

crackles are due to collapse of peripheralairways on expiration and sudden opening oninspiration

early inspiratory crackles- suggests disease of small airways

- characteristic of chronic airflow limitation- are only heard in early inspiration

late or paninspiratory crackles

-suggests disease confined to alveoli

- may be fine, medium or coarse

- fine crackles - typically caused by

pulmonary fibrosis- medium crackles - typically caused by left

ventricular failure (due to presence of

alveolar fluid)- coarse crackes - tend to change with

coughing; occur with any disease that leadsto retention of secretions; commonly occurin bronchiectasis

pleural friction rub

when thickened, roughened pleural surfaces rubtogether, a continuous or intermittent gratingsound may be heard

suggests pleurisy, which may be secondary topulmonary infarction or pnuemonia

vocal resonanance

gives information about lungs' ability to transmit sounds

consolidated lung tends to transmit high frequencies so

that speech heard through stethoscope takes a bleetingquality (aegophony); when a patient with aegophony says"bee" it sounds like "bay"

listen over each part of chest as patient says "99"; overconsolidated lung, the numbers will become clearlyaudible; over normal lung, the sound is muffled

whispering pectoriloquy - vocal resonance is increased tosuch an extent that whispered speech is distinctly heard

The Heart

lie patient at 45 degrees

measure jugular venous plse for right heart failure

examine preacordium; pay close attention to pulmonary

component of P2 (which is best heard at 2nd intercostalspace on left) and should not be louder than A2; if it islouder, suspect pulmonary hypertension

cor pulmonale (also called pulmonary hypertensive heart

disease) may be due to:

chronic airflow limitation (emphysema)

pulmonary fibrosis

pulmonary thromboembolism

marked obesity

sleep apnoea

severe kyphoscoliosis

The Abdomen

palpate liver for enlargement due to secondary deposits of

tumour from lung, or right heart failure

Other

Permberton's sign ask patient to lift arms over head look for development of facial plethora, inspiratory

stridor, non-pulsatile elevation of jugular venouspressure

occurs in vena caval obstruction

Feet

inspect for oedema or cyanosis (clues of corpulmonale)

look for evidence of deep vein thrombosisd

Respiratory rate on exercise and positioning

patients complaining of dyspnoea should have theirrespiratory rate measured at rest, at maximal toleratedexertion and supine

if dyspnoea is not accompanied by tachypnoea whena patient climbs stairs, one should considermalingering

look for paradoxical inward motion of abdomen

during inspiration when patient is uspine (indicatingdiaphragmatic paralysis)

Temperature: fever may accompany any acute or chronic

chest infection

DIAGNOSTIC EVALUATION

1. Skin Test: Mantoux Test or Tuberculin Skin Test

This is used to determine if a person has been infected orhas been exposed to the TB bacillus.

This utilizes the PPD (Purified Protein Derivatives). The PPD is injected intradermally usually in the inner

aspect of the lower forearm about 4 inches below theelbow.

The test is read 48 to 72 hours after injection. (+) Mantoux Test is induration of 10 mm or more. But for HIV positive clients, induration of about 5 mm is

considered positive

Signifies exposure to Mycobacterium Tubercle bacilli


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2. Pulse Oximeter

Non-invasive method of continuously monitoring heoxygen saturation of hemoglobin

A probe or sensor is attached to the fingertip, forehead,earlobe or bridge of the nose

Sensor detects changes in O2sat levels by monitoring

light signals generated by the oximeter and reflected bythe blood pulsing through the tissue at the probe

Normal SpO2 = 95% - 100% < 85% - tissues are not receiving enough O2 Results unreliable in:

Cardiac arrest Shock Use of dyes or

vasoconstrictors Severe anemia High carbon

monoxide Level

3. Chest X-ray

This is a NON-invasive procedure involving the use of x-rays with minimal radiation.

The nurse instructs the patient to practice the on cue tohold his breath and to do deep breathing

Instruct the client to remove metals from the chest. Rule out pregnancy first.

5. Computed Tomography (CT Scan) and Magnetic Resonance

Imaging ( MRI )

The CT scanis a radiographic procedure that utilizesx-ray machine.

The MRIuses magnetic field to record the H+density ofthe tissue.

It does NOT involve the use of radiation.

The contraindications for this procedure are thefollowing: patients with implanted pacemaker,

patients with metallic hip prosthesis or other metalimplants in the body.

This chest CT scan shows a cross-section of a personwith bronchial cancer. The two dark areas are the lungs. The lightareas within the lungs represent the cancer.

Clear MRI images of lung airways during breathing.

6. Flouroscopy

Studies the lung and chest in motion Involves the continuous observation of an image

reflected on a screen when exposed to radiation in themanner of television screen that is activated by anelectrode beam.

Structures of different densities that intercept the X-raybeam are visualized on the screen in silhouette

7. Indirect Bronchography

A radiopaque medium is instilled directly into thetrachea and the bronchi and the outline of the entire

bronchial tree or selected areas may be visualizedthrough x-ray.

It reveals anomalies of the bronchial treeand isimportant in the diagnosis of bronchiectasis.

Nursing interventions BEFORE Bronchogram

Secure written consent

Check for allergies to sea foods or iodine or

anesthesia NPO for 6 to 8 hours Pre-op meds: atropine SO4and valium,

topical anesthesiasprayed; followed by local

anestheticinjected into larynx. The nurse musthave oxygen and anti spasmodic agents ready.

Nursing interventions AFTER Bronchogram Side-lying position NPO until cough and gag reflexes returned Instruct the client to cough and deep breathe

client

8. Bronchoscopy

This is the direct inspection and observationof thelarynx, trachea and bronchi through a flexible or rigid

bronchoscope. Passage of a lighted bronchoscopeinto the bronchial

tree for direct visualization of the trachea and thetracheobronchial tree.

Diagnostic uses: To examine tissues or collect secretions To determine location or pathologic process

and collect specimen for biopsy


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To evaluate bleeding sites To determine if a tumor can be resected

surgically

Therapeutic uses To Remove foreign objects from

tracheobronchial tree

To Excise lesions To remove tenacious secretions obstructing the

tracheobronchial tree To drain abscess To treat post-operative atelectasis

Nursing interventions BEFORE Bronchoscopy Informed consent/ permit needed Explain procedure to the patient, tell him what

to expect, to help him cope with the unkown Atropine (to diminish secretions) is

administered one hour before the procedure About 30 minutes before bronchoscopy,

Valium is given to sedate patient and allayanxiety.

Topical anesthesia is sprayed followed bylocal anesthesia injected into the larynx

Instruct on NPO for 6-8 hours Remove dentures, prostheses and contact lenses The patient is placed supine with

hyperextended neckduring the procedure

Nursing interventions AFTER Bronchoscopy

Put the patient on Side lying position

Tell patient that the throat may feel sore with . Check for the return of cough and gag reflex. Check vasovagal response. Watch for cyanosis, hypotension, tachycardia,

arrythmias, hemoptysis, and dyspnea. Thesesigns and symptoms indicate perforation ofbronchial tree. Refer the patient immediately!

9. Lung Scan

Procedure using inhalation or I.V. injection of a

radioisotope, scans are taken with a scintillation camera. Imaging of distribution and blood flow in the lungs.

(Measure blood perfusion) Confirm pulmonary embolism or other blood- flow

abnormalities

Nursing interventions BEFORE the procedure: Allay the patients anxiety Instruct the patient to Remain still during the

procedure

Nursing interventions AFTER the procedure Check the catheter insertion site for bleeding Assess for allergies to injected radioisotopes Increase fluid intake, unless contraindicated.

10. Sputum Examination Laboratory test Indicated for microscopic examination of the sputum:

Gross appearance, Sputum C&S, AFB staining, and

for Cytologic examination/ Papanicolaou examination

Nursing interventions: Early morning sputum specimenis to be

collected (suctioning or expectoration) Rinse mouth with plain water Use sterile container. Sputum specimen for C&S is collected before

the first dose of anti-microbial therapy. For AFB staining, collect sputum specimen for

three consecutive mornings.

11. Biopsy of the Lungs

Percutaneous removal of a small amount of lung tissue For histologic evaluation

-Transbronchoscopic biopsydone during bronchoscopy,

- Percutaneous needle biopsy- Open lung biopsy


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Nursing interventions BEFORE the procedure:

Withhold food and fluids Place obtained written informed consent in the

patients chart.

Nursing interventions AFTER the procedure:

Observe the patient for signs of Pneumothoraxand air embolism

Check the patient for hemoptysis and

hemorrhage

Monitor and record vital signs Check the insertion site for bleeding Monitor for signs of respiratory distress

12. Lymph Node Biopsy Scalene or cervicomediastinal To assess metastasis of lung cancer

13. Pulmonary Function Test / Studies Non-invasive test Measurement of lung volume, ventilation, and diffusing

capacity Nursing interventions:

Document bronchodilators or narcotics usedbefore testing

Allay the patients anxiety during the testing

LUNG VOLUMES: (ITER)

Inspiratory reserve volume (3000 mL) The maximum volume that can be inhaled following a

normal quiet inhalation.Tidal volume (500 mL)

The volume of air inhaled and exhaled with normal quiet

breathingExpiratory reserve volume (1100 mL)

The maximum volume that can be exhaled following thenormal quiet exhalation

Residual volume (1200 mL) The volume of air that remains in the lungs after forceful

exhalation

LUNG CAPACITIES:

Functional Residual Capacity (ERV 1100 mL + RV 1200 mL =2300 mL)

The volume of air that remains in the lungs after normal,

quiet exhalation

Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500 mL) The amount of air that a person can inspire maximally

after a normal expirationVital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL =4600 mL )

The maximum volume of air that can be exhaled after amaximum inhalation

Reduced in COPDTotal Lung Capacity (IRV 3000 mL + TV 500 mL + ERV 1100mL + RV 1200 mL = 5800 mL)

Total of all four volumes

14. Arterial Blood Gas Laboratory test Indicate respiratory functions

Assess the degree to which the lungs are able to provideadequate oxygen and remove CO2

Assess the degree to which the kidneys are able toreabsorb or excrete bicarbonate.

Assessment of arterial blood for tissue oxygenation,ventilation, and acid-base status

Arterial puncture is performed on areas where goodpulses are palpable (radial, brachial, or femoral).Radial artery is the most common site for withdrawal of

blood specimen

Nursing interventions: Utilize a 10-ml. Pre-heparinized syringe to

prevent clotting of specimen Soak specimen in a container with ice to

prevent hemolysis If ABG monitoring will be done, do Allens

test to assess for adequacy of collateralcirculation of the hand (the ulnar arteries)

15. Pulmonary Angiography

This procedure takes X-ray pictures of the pulmonaryblood vessels (those in the lungs).

Because arteries and veins are not normally seen in an X-ray, a contrast material is injected into one or more

arteries or veins so that they can be seen.


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16. Ventilation - Perfusion Scan

Radioactive albumin injection is part of a nuclear scan

test that is performed to measure the supply of bloodthrough the lungs.

After the injection, the lungs are scanned to detect thelocation of the radioactive particles as blood flows

through the lungs.

The ventilation scan is used to evaluate the ability of airto reach all portions of the lungs. The perfusion scanmeasures the supply of blood through the lungs.

A ventilation and perfusion scan is most often performedto detect a pulmonary embolus. It is also used to evaluatelung function in people with advanced pulmonary diseasesuch as COPD and to detect the presence of shunts

(abnormal circulation) in the pulmonary blood vessels.

17. Thoracentesis

Procedure suing needle aspiration of intrapleural fluid or

air under local anesthesia Specimen examination or removal of pleural fluid

Nursing intervention BEFORE Thoracentesis

Secure consent Take initial vital signs Instruct to remain still, avoid coughing during

insertion of the needle Inform patient that pressure sensation will be

felt on insertion of needle

Nursing intervention DURING the procedure: Reassess the patient Place the patient in the proper position:

Upright or sitting on the edge of

the bed

Lying partially on the side,

partially on the back

Nursing interventions after Thoracentesis Assess the patients respiratory status Monitor vital signs frequently Position the patient on the affected side, as

ordered, for at least 1 hour to seal the puncture

site Turn on the unaffected side to prevent leakage

of fluid in the thoracic cavity Check the puncture site for fluid leakage

Auscultate lungs to assess for pneumothorax Monitor oxygen saturation (SaO2) levels Bed rest Check for expectoration of blood

RESPIRATORY CARE MODALITIES

1. Oxygen Therapy

Oxygen is a colorless, odorless, tasteless, and dry gas that

supports combustion Man requires 21% oxygenfrom the environment in order

to survive Indication: Hypoxemia Signs of Hypoxemiao Increased pulse rate

o Rapid, shallow respiration and dyspneao Increased restlessness or lightheadednesso Flaring of nareso Substernal or intercostals retractions

o Cyanosis

Low flow oxygenprovides partial oxygenation with patientbreathing a combination of supplemental oxygen and room air.

Low-flow administration devices:o Nasal Cannula 24-45% 2-6 LPMo Simple Face Mask 0-60% 5-8 LPMo Partial Rebreathing Mask 60-90% 6-10 LPM

o Non-rebreathing Mask 95-100% 6-15 LPMo Croupetteo Oxygen Tent

High flow oxygenprovides all necessary oxygenation, withpatients breathing only oxygen supplied from the mask andexhaling through a one-way vent.

High flow administration devices

o Venturi Mask 24-40% 4-10 LPM Preferred for clients with COPD because it

provides accurate amount of oxygen.

o

Face Masko Oxygen Hood*o Incubator / isolette*

Note: * can be used for both low and high flow administration

The nurse should prevent skin breakdown by checkingnares, nose and applying gauze or cotton as necessary

Ensure that COPDpatients receive only LOW flowoxygenbecause these persons respond to hypoxia, not

increased CO levels.


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2. Tracheobronchial suctioning

Suction only when necessary not routinely

Use the smallest suction catheter if possible Client should be in semi or high Fowlersposition Use sterile gloves, sterile suction catheter Hyperventilate client with 100% oxygen before and

after suctioning

Insert catheter with gloved hand (3-5 length of catheterinsertion) without applying suction. Three passes of thecatheter is the maximum, with 10 seconds per pass.

Apply suction only during withdrawal of catheter The suction pressure should be limited to less than 120

mmHg When withdrawing catheter rotate while applying

intermittent suction Suctioning should take only 10 seconds (maximum of 15

seconds) Evaluate: clear breath sounds on auscultation of the chest.

3. Bronchial Hygiene Measures Suctioning: oropharyngeal; nasopharyngeal

a. Steam inhalation The purpose of steam inhalation are as follows:

- to liquefy mucous secretions

- to warm and humidify air- to relieve edema of airways- to soothe irritated airways- to administer medication

It is a dependent nursing function Inform the client and explain the purpose of the procedure Place the client in Semi-Fowlers position Cover the clients eyes with washcloth to prevent irritation Check the electrical device before use Place the steam inhalator in a flat, stable surface. Place the spout 1218 inchesaway from the clients nose or

adjust distance as necessary CAUTION: avoid burns. Cover the chest with towel to

prevent burns due to dripping of condensate from the steam.Assess for redness on the side of the face which indicatesfirst degree burns.

To be effective, render steam inhalation therapy for 1520

minutes Instruct the client to perform deep breathing and coughing

exercises after the procedure to facilitate expectoration ofmucous secretions.

Provide good oral hygiene after the procedure. Do after-care of equipment.

b. Aerosol inhalation

done among pediatric clients to administer brochodilators ormucolytic-expectorants.

.

c. Medimist inhalation

done among adult clients to administer bronchodilators ormucolytic-expectorants.

4. Chest Physiotheraphy ( CPT )

Includes postural drainage, chest percussion and vibration,and breathing retraining. Effective coughing is also animportant component.

Goals are removal of bronchial secretions, improvedventilation, and increased efficiency of respiratory

muscles. Postural drainage uses specific positions to use gravity to

assist in the removal of secretions. Vibration loosens thick secretions by percussion or

vibration.

Breathing exercises and breathing retraining improveventilation and control of breathing and decrease thework of breathing.

These are procedures for patients with respiratorydisorders like COPD, cystic fibrosis, lung abscess, and

pneumonia. The therapy is based on the fact that mucuscan be knocked or shaken from airways and helped to

drain from the lungs.

Postural drainage Use of gravity to aid in the drainage of secretions. Patient is placed in various positions to promote flow of

drainage from different lung segments using gravity. Areas with secretions are placed higher than lung

segments to promote drainage.

Patient should maintain each position for 5-15 minutesdepending on tolerability.

Percussion Produces energy wave that is transmitted through the

chest wall to the bronchi. The chest is struck rhythmically with cupped hands over

the areas were secretions are located.

Avoid percussion over the spine, kidneys, breast orincision and broken ribs. Areas should be percussed for1-2 minutes

Vibration Works similarly to percussion, where hands are placed on

clients chest and gently but firmly rapidly vibrate handsagainst thoracic wall especially during clients exhalation.

This may help dislodge secretions and stimulate cough. This should be done at least 5-7 times during patient

exhalation.


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Suctioning

Nursing Interventions in CPT Verify doctors order Assess areas of accumulation of mucus secretions. Position to allow expectoration of mucus secretions

by gravity Place client in each position for 5-10 to 15 minutes

Percussion and vibration done to loosen mucussecretions

Change position gradually to prevent posturalhypotension

Client is encouraged to cough up and expectorate

sputum Procedure is best done 60 to 90 minutes before

meals or in the morning upon awakening and atbedtime.

Provide good oral care after the procedure

5. Incentive Spirometry

Types: volume and flow

Device ensures that a volume of air is inhaled and thepatient takes deep breaths.

Used to prevent or treat atelectasis To enhance deep inhalation

Nursing care Positioning of patient, teach and encourage use,

set realistic goals for the patient, and record theresults.

6. Closed Chest Drainage ( Thoracostomy Tube ) Chest tube is used to drain fluid and air out of the

mediastinum or pleural space into a collection chamberto help re-establish normal negative pressure for lung re-

expansion.Purposes To remove air and/or fluids from the pleural space To reestablish negative pressure and re-expand the

lungs

Procedure

The chest tube is inserted into the affected chestwall at the level of 2ndto 3rdintercostals space torelease air or in the fourth intercostals space toremove fluid.

Types of Bottle Drainage

One-bottle system

The bottle serves as drainage and water-seal Immerse tip of the tube in 2-3 cm of sterile NSS to

create water-seal. Keep bottle at least 2-3 feet below the level of the

chest to allow drainage from the pleura by gravity. Never raise the bottle above the level of the heart

to prevent reflux of air or fluid. Assess for patency of the device Observe for fluctuation of fluid along the tube. The

fluctuation synchronizes with the respiration. Observe for intermittent bubbling of fluid;

continues bubbling means presence of air-leak

In the absence of fluctuation:

Suspect obstruction of the deviceAssess the patient first, then if patient is stableCheck for kinks along tubing;Milk tubing towards the bottle (If the hospital allows the

nurse to milk the tube)

If there is no obstruction, consider lung re-expansion;

(validated by chest x-ray)Air vent should be open to air.

Two-bottle system

If not connected to the suction apparatus The first bottle is drainage bottle; The second bottle is water-seal bottle Observe for fluctuation of fluid along the tube

(water-seal bottle or the second bottle) andintermittent bubbling with each respiration.

NOTE! IF connected to suction apparatus

1. The first bottle is the drainage and water-seal bottle;2. The second bottle is suction control bottle.

3.

Expect continuous bubbling in the suction control bottle;4. Intermittent bubbling and fluctuation in the water-seal

5. Immerse tip of the tube in the first bottle in 2 to 3 cm ofsterile NSS

6. Immerse the tube of the suction control bottle in 10 to 20cm of sterile NSS to stabilize the normal negative

pressure in the lungs.7. This protects the pleura from trauma if the suction

pressure is inadvertently increased


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MS Abejo14

Three-bottle system

The first bottle is the drainage bottle; The second bottle is water seal bottle The third bottle is suction control bottle.

Observe for intermittent bubbling andfluctuation with respiration in the water- seal

bottle Continuous GENTLE bubbling in the suction

control bottle. These are the expected observations. Suspect a leak if there is continuous bubbli ng in

the WATER seal bottle or if there is VIGOROUS

bubbling i n the suction control bottle. The nurse should look for the leak and report the

observation at once. Never clamp the tubingunnecessarily.

If there is NO fluctuation in the water seal bottle, it may meanTWO things

Either the lungs have expanded or the system is NOTfunctioning appropriately.

In this situation, the nurse refers the observation to the

physician, who will order for an X-ray to confirm thesuspicion.

Important Nursing considerations

Encourage doing the following to promote drainage: Deep breathing and coughing exercises Turn to sides at regular basis Ambulate ROM exercise of arms Mark the amount of drainage at regular intervals Avoid frequent milking and clamping of the tube to

prevent tension pneumothorax

What the nurse should do if: If there is continuous bubbling:

The nurse obtains a toothless clamp

Close the chest tube at the point where it exits the chestfor a few seconds.

If bubbling in the water seal bottle stops, the leak is

likely in the lungs, But if the bubbling continues, the leak is between the

clamp and the bottle chamber.

Next, the nurse moves the clamp towards the bottle checking thebubbling in the water seal bottle.

If bubbling stops, the leak is between the clampand the distal part including the bottle.

But if there is persistent bubbling, it means that thedrainage unit is leaking and the nurse must obtain

another set. In the event that the water seal bottle breaks, thenurse temporarily kinks the tube and must obtain a

receptacle or container with sterile water andimmerse the tubing.

She should obtain another set of sterile bottle asreplacement. She should NEVER CLAMP the tube

for a longer time to avoid tension pneumothorax. In the event the tube accidentally is pulled out, the

nurse obtains vaselinized gauze and covers thestoma.

She should immediately contact the physician.

Removal of chest tubedone by physician

The nurse Prepares:

Petrolatum GauzeSuture removal kit

Sterile gauzeAdhesive tape

Place client in semi-Fowlers position

Instruct client to exhale deeply, then inhale and dovalsalva maneuver as the chest tube is removed.

Chest x-ray may be done after the chest tube is

removed Asses for complications: subcutaneous emphysema;

respiratory distress

7. Artificial Airway

a. Oral airways- these are shorter and often have a larger lumen.They are used to prevent the tongue form falling backward.

b. Nasal airways- these are longer and have smaller lumen Whichcauses greater airway resistance

c. Tracheostomy- this is a temporary or permanent surgicalopening in the trachea. A tube is inserted to allow ventilation andremoval of secretions. It is indicated for emergency airway accessfor many conditions. The nurse must maintain tracheostomy care

properly to prevent infection.

RESPIRATORY DISEASES AND

DISORDERS

I. PNEUMONIA inflammation of the lung parenchyma

leading to pulmonary consolidation because alveoli is filledwith exudates

A. ETIOLOGIC AGENTS

1. Streptococcus pneumoniae (pneumococcalpneumonia)

2. Hemophilus influenzae (bronchopneumonia)3. Klebsiella pneumoniae4. Diplococcus pneumoniae5. Escherichia coli

6. Pseudomonas aeruginosa


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MS Abejo15

B.

HIGH RISK GROUPS

1. Children less than 5 yo

2. Elderly

C.

PREDISPOSING FACTORS

1. Smoking

2. Air pollution

3.

Immunocompromised (+) AIDS

Kaposis Sarcoma

Pneumocystis Carinii Pneumonia

DOC: Zidovudine (Retrovir) Bronchogenic Ca

4. Prolonged immobility (hypostatic pneumonia)5. Aspiration of food (aspiration pneumonia)6. Over fatigue

D. SIGNS AND SYMPTOMS

1. Productive cough, greenish to rusty2. Dyspnea with prolong expiratory grunt3. Fever, chills, anorexia, general body malaise

4. Cyanosis

5.

Pleuritic friction rub6. Rales/crackles on auscultation7. Abdominal distentionparalytic ileus

E. DIAGNOSTICS

1. Sputum GS/CSconfirmatory; type and sensitivity;(+) to cultured microorganism

2. CXR(+) pulmonary consolidation3. CBC

Elevated ESR (rate of erythropoeisis) N = 0.5-1.5% (compensatory mech to decreased O2)

Elevated WBC4. ABGPO2 decreased (hypoxemia)

F.

NURSING MANAGEMENT

1. Enforce CBR (consistent to all respi disorders)

2. Strict respiratory isolation3. Administer medications as ordered

Broad spectrum antibioticsPenicillinpneumococcal infections

TetracyclineMacrolides

Azithromycin (OD x 3/days)

1. Too costly2. Only se: ototoxicity transient

hearing loss Anti-pyretics

Mucolytics/expectorants

4. Administer O2 inhalation as ordered

5.

Force fluids to liquefy secretions6. Institute pulmonary toilet measures to promote

expectoration of secretions DBE, Coughing exercises, CPT

(clapping/vibration), Turning and repositioning7. Nebulize and suction PRN

8. Place client of semi-fowlers to high fowlers9. Provide a comfortable and humid environment10. Provide a dietary intake high in CHO, CHON,

Calories and Vit C

11. Assist in postural drainage Patient is placed in various position to drain

secretions via force of gravity

Usually, it is the upper lung areas which aredrained

Nursing management:Monitor VS and BS

Best performed before meals/breakfast or2-3 hours p.c. to prevent gastroesophageal

reflux or vomiting (pagkagising maraming

secretions diba? Nakukuha?)Encourage DBEAdminister bronchodilators 15-30 minutes

before procedureStop if pt. cant tolerate the procedureProvide oral care after procedure as it mayaffect taste sensitivity

Contraindications:

Unstable VS

Hemoptysis

Increased ICP

Increased IOP (glaucoma)

12. Provide pt health teaching and d/c planning Avoidance of precipitating factors

Prevention of complicationsAtelectasisMeningitis

Regular compliance to medications Importance of ffup care

II. PULMONARY TUBERCULOSIS (KOCHS DISEASE)

infection of the lung parenchyma caused by invasion ofmycobacterium tuberculosis or tubercle bacilli (gram negative,acid fast, motile, aerobic, easily destroyed by heat/sunlight)

A.

PRECIPITATING FACTORS

1. Malnutrition

2.

Overcrowding3. Alcoholism: Depletes VIT B1 (thiamin)alcoholic

beriberimalnutrition4. Physical and emotional stress5. Ingestion of infected cattle with M. bovis6. Virulence (degree of pathogenecity)

B. MODE OF TRANSMISSION: Airborne dropletinfection

Tracheostomy usually done at bedside, 10-20 minutes

Stress test: 30 minutes

Mammography: 10-20 minutes

LARYNGOSPASMtracheostomy STAT

OR Tracheostomy: laryngeal, thyroid, neck CA

DIAPHRAGMprimary muscle for respiration

INTERCOSTAL MUSCLESsecondary muscle for respiration

ALVEOLI (Acinar cells) functional unit of the lungs; site for gas

exchange (via diffusion)

VENTILATIONmovement of air in and out of the lungs RESPIRATIONlungs to cells

Internal

External

RETROLENTAL FIBROPLASIA retinopathy/blindness in

immaturity d/t high O2 flow in pedia patients


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MS Abejo16

C.

SIGNS AND SYMPTOMS

1. Productive cough (yellowish)

2. Low grade afternoon fever, night sweats3. Dyspnea, anorexia, malaise, weight loss

4. Chest/back pain5. Hemoptysis

D.

DIAGNOSTICS1. Skin testing

Mantoux testPPD

Induration width (within 48-72 h)

8-10 mm (DOH)

10-14 mm (WHO)

5 mm in AIDS patients is +indicates previous exposure to tubercle

bacilli2. Sputum AFB (+) tubercle bacilli3. CXR(+) pulmo infiltrated due to caseous necrosis4. CBCelevated WBC

E.

NURSING MANAGEMENT1. Enforce CBR

2. Institute strict respiratory isolation3. Administer O2 inhalation4. Forced fluids5. Encourage DBE and coughing

NO CLAPPING in chronic PTB d/t

hemoptysis may lead to hemorrhage

6. Nebulize and suction PRN7. Provide comfortable and humid environment

8. Institute short course chemotherapy

Intensive phase

INH

SE: peripheral neuritis (increase vit

B6 or pyridoxine

Rifampicin SE: red orange color of bodily

secretionsPZA

May be replaced with Ethambutol

(SE: optic neuritis) if (+)hypersensitivity to drug

SE: allergic reactions; hepatotoxicity

and nephrotoxicity1. Monitor liver enzymes2. Monitor BUN and CREA

INH given for 4 months, PZA andRifampicin is given for 2 months, A.C. tofacilitate absorptionThese 3 drugs are given simultaneously to

prevent development of resistance

Standard Regimen

Streptomycin injection (aminoglycosides)

Neomycin, Amikacin, Gentamycin

1. common SE: 8thCN damage tinnitus hearing loss ototoxicity

2. nephrotoxicitya. BUN (N = 10-20)

b. CREA (N = 8-10)9. Health teaching and d/c planning

Avoidance of precipitating factors : alcoholism,overcrowding

Prevention of complicationsAtelectasis

Military TB (extrapulmonary TB:meningeal, Potts, adrenal glands, skin,

cornea)

Strict compliance to medicationsNever double the dose! Continue takingthe meds if missed a day)

Diet modifications: increased CHON, CHO,Calories, Vit C

Importance of ffup care

III. HISTOPLASMOSIS acute fungal infection caused byinhalation of contaminated dust with Histoplasma capsulatumfrom birds manure

A.

PREDISPOSING FACTORS Inhalation of contaminated dust

2.

SIGNS AND SYMPTOMS

PTB like symptoms Productive cough Fever, chills, anorexia, generalized body

malaise Cyanosis Chest and joint pains Dyspnea Hemoptysis

3.

DIAGNOSTICS

Histoplasmin skin test is (+) ABG analysis reveals pO2 low

4.

NURSING MANAGEMENT

Enforce CBG

Administer meds as orderedAntifungal agents

Amphotericin B (Fungizone) SE:nephrotoxicity and hypokalemia

Monitor transaminases, BUN and

CREACorticosteroidsAnti-pyretics

Mucolytics/expectorants Administer oxygen inhalation as ordered Forced fluids Nebulize and suction as necessary

Prevent complications

Bronchiectasis, atelectasis

Prevention of spreadSpraying of breeding places

Kill bird and owner! Hehe!

CHRONIC OBSTRUCTIVE PULMONARY DISEASES

1. Chronic Bronchitis

2. Bronchial Asthma

3.

Bronchiectasis

4.

Pulmonary Emphysema


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MS Abejo17

I. CHRONIC BRONCHITIS (Blue Bloaters) Inflammationof the bronchi due to hypertrophy or hyperplasia of goblet

mucous producing cells leading to narrowing of smallerairways

A. PREDISPOSING FACTORS

1.

Smoking2. Air pollution

B.

SIGNS AND SYMPTOMS

1. Consistent productive cough2. Dyspnea on exertion with prolonged expiratory

grunt3. Anorexia and generalized body malaise4. Cyanosis5. Scattered rales/rhonchi

6. Pulmonary hypertension Peripheral edema Cor pulmonale

C.

DIAGNOSTICS

1.

ABG analysis: decreased PO2, increased PCO2,respiratory acidosis; hypoxemia cyanosis

D.

NURSING MANAGEMENT

1. Enforce CBR2. Administer medications as ordered

Bronchodilators Antimicrobials Corticosteroids Mucolytics/expectorants

3. Low inflow O2 admin; high inflow will causerespiratory arrest

4. Force fluids5. Nebulize and suction client as needed6. Provide comfortable and humid environment

7.

Health teaching and d/c planning avoidance of smoking prevent complications

CO2 narcosiscomaCor pulmonale

Pleural effusionPneumothorax

Regular adherence to meds Importance of ffup care

II. BRONCHIAL ASTHMA reversible inflammatory lungcondition caused by hypersensitivity to allergens leading to

narrowing of smaller airways

A. PREDISPOSING FACTORS

1. Extrinsic(Atopic/Allergic Asthma)

Pollens, dust, fumes, smoke, fur, dander, lints2. Intrinsic(Non-Atopic/Non-Allergic)

Drugs (aspirin, penicillin, B-blockers) Foods (seafoods, eggs, chicken, chocolate) Food additives (nitrates, nitrites) Sudden change in temperature, humidity and

air pressure Genetics Physical and emotional stress

3. Mixed typecombination of both

B.

SIGNS AND SYMPTOMS

1. Cough that is productive2. Dyspnea3. Wheezing on expiration

4.

Tachycardia, palpitations and diaphoresis5. Mild apprehension, restlessness6. Cyanosis

C.

DIAGNOSTICS

1. PFTdecreased vital lung capacity2. ABG analysisPO2 decreased

D.

NURSING MANAGEMENT

1. Enforce CBR

2. Administer medications as ordered Bronchodilators administer first to facilitate

absorption of corticosteroids

InhalationMDI

Corticosteroids Mucolytics/expectorants Mucomyst Antihistamine

3. Administer oxygen inhalation as ordered4. Forced fluids5. Nebulize and suction patient as necessary

6. Encourage DBE and coughing7. Provide a comfortable and humid environment8. Health teaching and d/c planning

Avoidance of precipitating factors Prevention of complications


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MS Abejo18

Status asthmaticus

DOC: Epinephrine

Aminophylline drip

Emphysema Regular adherence to medications Importance of ffup care

III.

BRONCHIECTASIS permanent dilation of the bronchusdue to destruction of muscular and elastic tissue of thealveolar walls (subject to surgery)

A.


1. Recurrent lower respiratory tract infection

Histoplasmosis2. Congenital disease

3. Presence of tumor4. Chest trauma

B. SIGNS AND SYMPTOMS

1. Consistent productive cough2. Dyspnea3. Presence of cyanosis4. Rales and crackles

5. Hemoptysis6. Anorexia and generalized body malaise

C.

DIAGNOSTICS

1.

ABG analysis reveals low PO22. Bronchoscopy direct visualization of bronchilining using a fibroscope Pre-op

Secure consentExplain procedure

NPO 4-6 hoursMonitor VS and breath sounds

Post-operativeFeeding initiated upon return of gag reflexInstruct client to avoid talking, coughingand smoking as it may irritate respiratorytract

Monitor for s/sx of frank or gross bleedingMonitor for signs of laryngeal spasm

DOB and SOB prepare trache set

D.

SURGERY

1. Segmental lobectomy

2. Pneumonectomy Most feared complications

AtelectasisCardiac tamponade: muffled heart sounds,

pulsus paradoxus, HPN

E.

NURSING MANAGEMENT

1. Enforce CBR2. Low inflow O2 admin; high inflow will cause

respiratory arrest

3. Administer medications as ordered Bronchodilators Antimicrobials Corticosteroids (5-10 minutes after

bronchodilators) Mucolytics/expectorants

4.

Force fluids5. Nebulize and suction client as needed6. Provide comfortable and humid environment

7. Health teaching and d/c planning Avoidance of smoking Prevent complications

Atelectasis

CO2 narcosiscomaCor pulmonalePleural effusionPneumothorax

Regular adherence to meds Importance of ffup care

IV. PULMONARY EMPHYSEMA terminal and irreversible

stage of COPD characterized by : Inelasticity of alveoli Air trapping Maldistribution of gasses (d/t increased air trapping)

Overdistention of thoracic cavity (Barrel chest) compensatory mechanismincreased AP diameter


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A.


1. Smoking2. Air pollution

3. Hereditary: involves alpha-1 antitrypsin forelastase productionfor recoil of the alveoli

4. Allergy

5.

High risk group elderly degenerative decreased vital lung capacity and thinning ofalveolar lobes

B. SIGNS AND SYMPTOMS

1. Productive cough2. Dyspnea at rest

3. Prolonged expiratory grunt4. Resonance to hyperresonance5. Decreased tactile fremitus6. Decreased breath sounds ( if (-) BS lung collapse)

7. Barrel chest8. Anorexia and generalized body malaise9. Rales or crackles10. Alar flaring

11.

Pursed-lip breathing (to eliminate excess CO2)

C.

DIAGNOSTICS

1. ABG analysis reveal Panlobular, centrilobular PO2 elevation and

PCO2 depression respiratory acidosis (bluebloaters)

Panacinar/centriacinar PCO2 depression and

PO2 elevation (pink puffershyperaxemia)2. Pulmo function testdecreased vital lung capacity

D.

NURSING MANAGEMENT

1. Enforce CBR

2. Administer medications as ordered Bronchodilators

Antimicrobials Corticosteroids Mucolytics/expectorants

3. Low inflow O2 admin; high inflow will causerespiratory arrest and oxygen toxicity

4. Force fluids

5. Pulmonary toilet6. Nebulize and suction client as needed7. Institute PEEP in mechanical ventilation

PEEPpositive end expiratory pressure allows for maximum alveolar diffusion prevent lung collapse

8. Provide comfortable and humid environment9. Diet modifications: high calorie, CHON, CHO,

vitamins and minerals10. Health teaching and d/c planning Avoidance of smoking Prevent complications

AtelectasisCO2narcosiscomaCor pulmonalePleural effusion

Pneumothorax Regular adherence to meds Importance of ffup care

RESTRICTIVE LUNG DISEASE

V. PNEUMOTHORAX partial or complete collapse of thelungs due to accumulation of air in pleural space

A. TYPES

1. Spontaneous air enters pleural space without an

obvious cause Ruptured blebs (alveolar filled sacs)

inflammatory lung conditions

2. Openair enters pleural space through an openingin pleural wall (most common) Gun shot wounds Multiple stab wounds

3. Tensionair enters pleural space during inspirationand cannot escape leading to overdistention of thethoracic cavity mediastinal shift to the affectedside (ie. Flail chest) paradoxical breathing

B.


1. Chest trauma2. Inflammatory lung condition

3.

tumors

C.

SIGNS AND SYMPTOMS

1. Sudden sharp chest pain, dyspnea, cyanosis2. Diminished breath sounds

3. Cool, moist skin4. Mild restlessness and apprehension5. Resonance to hyperresonance

D.

DIAGNOSTICS

1. ABG analysis: PO2 decreased2. CXRconfirms collapse of lungs

E. NURSING MANAGEMENT

1. Assist in endotracheal intubation

2.

Assist in thoracentesis3. Administer meds as ordered Narcotic analgesicsMorphine sulfate Antibiotics

4. Assist in CTT to H20 sealed drainage

respiratory nursing #1

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