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Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Respiratory

Alterations I

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Anatomy and Physiology of the Respiratory System


Functions of the Respiratory System:
Gas exchange Regulation of pH levels Voice production Olfaction Protection

Topics Discussed Here Are: 1. Anatomy and Physiology of the Respiratory System 2. Assessment of the Respiratory System 3. Diagnostic Tests a. Pulmonary Function Test b. Arterial Blood Gas c. Pulse Oximeter d. Cultures e. Imaging Studies f. Endoscopic Procedure

Parts of the Respiratory System

Upper Respiratory Tract:


Nose Pharynx Associated structures

Nose -

Provides an airway for respiration Moistens and warms the entering air Filters inspired air and cleanses it of foreign matter Serves as a resonating chamber for speech Houses the olfactory receptor

Pharynx - Connects the nasal cavity and mouth to the larynx and esophageal intersection - Common passageway for air, food and drink - Commonly called the throat o Nasopharynx Air passes ONLY o Oropharnx Air and Food o Laryngopharynx Air and Food

Lower Respiratory Tract


Larynx Trachea Main Bronchi Lungs Tracheobronchial Tree Terminal Bronchi Alveoli

Larynx 1. Anterior part of the throat from the base of the tongue to the trachea 2. The 3 Functions of the Larynx are a. To provide an airway b. To act as a switching mechanism to route air and food into the proper chute. Epiglottis Elastic cartilage that covers the larynx c. To function in voice production

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Trachea - Descends from the larynx through the neck to the 4th thoracic vertebrae - Composed of dense regular covering tissue and smooth muscle reinforced with 15 20 Cshaped rings of cartilage to maintain position and keep open - Made up of goblet cells - 2 bronchus (divided) Main Bronchi - The right and left are formed by the division of the trachea - The Right Primary Bronchi is wider, shorter and more vertical than the left - Common site for an inhaled object to become lodged - By the *** Lungs - Principal organ of respiration - Base rest on diaphragm and the apex extends superior to 2.5 cm above the clavicle - Right lung has 3 lobes while the left has 2 lobes o Bronchopulmonary Segments (For postural drainage) Right: 10 Left: 8 Tracheobronchial Tree - Subdivided into Lobar (second) Bronchi - Then Segmental (Tertiary) Bronchi - Finally giving rise to the Bronchioles, which subdivide many times to give rise to the Terminal Bronchioles - Terminal Bronchioles divide into Respiratory Bronchioles which have a few attached Alveoli - Alveoli Small air chambers where gas exchange between air and the blood takes place o Approximately 300 million alveoli o Accounts for most of the lung volume o Provides tremendous surface are for gas exchange
Left Main Bronchus Lobar Bronchi Right Main Bronchus Segmental Bronchi Terminal Bronchioles Respiratory Bronchioles Alveolar Ducts Alveolar Sac

Trachea

Bronchioles

Alveoli

Taken from Anaphy Notes in 1st Year 2nd Sem

As air passageways become smaller, structural changes occur Cartilage support structures decrease Amount of smooth muscle increase Epithelium types changes Terminal bronchioles are mostly smooth muscle with no cartilage which allows the bronchus to alter their diameter when a change***

Alveoli
1. Type 1 Type 2 Type 3 Are a *** of Type 1 pneumocytes Permits GAS EXCHANGE by simple diffusion Round or cube shaped secretory cells that produce surfactant Has Macrophages

2. 3.

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Respiratory Membrane
Where gas exchange between air and blood occurs It is very thin to facilitate the diffusion of gases

Consists of: Thin layers of fluid lining the alveolus Alveolar endothelium Basement membrane of the alveolar epithelium A thin intersecting space Basement membrane of the capillary endothelium Pleura - Thin, double layered serous membrane 1. Parietal Pleura Covers the thoracic wall, diaphragm and mediastinum 2. Visceral Pleura Covers the external lung surface 3. Pleural Cavity Negative resistance space between the parietal and visceral pleura Pressures Intrapleural: Negative (-) Intrathoracic: Negative (-) Intrapulmonary/Intraalveolar: (+/-) o Has a connection with the outside o 764 mmHg (-) = Maximum 764 mmHg (+) Exhaled Pleural Fluid o Fills the pleural cavity o Made by the pleural membrane o Serves as a lubricant o Holds the pleural membrane together

Blood Supply of the Lungs


Lungs are perfused by 2 circulating pulmonary and bronchial A. Pulmonary Circulation Pulmonary Artery: Supply deoxygenated systemic blood to be oxygenated o Ultimately feeds into the pulmonary capillary network surrounding the alveoli Pulmonary veins: Carry oxygenated blood from the lungs back to the heart B. Bronchial Circulation Bronchial Artery: Provide systemic oxygenated blood to the lung tissues Supply all lung tissues except the alveoli Bronchial veins: Carry the deoxygenated blood back to the heart

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Basic Concepts on The Respiratory System


Ventilation Process o Breathing Process It is the process of moving air into the lungs o Two Phases: Inhalation = Requires ENERGY and Accessory muscles (ACTIVE) Exhalation = PASSIVE Lung Recoil o It is the tendency of an expanded lung to decrease in size due to the following mechanism 1. The elastic fibers in the common tissue of the lungs 2. Surface tension of the film of fluid lining in the alveoli Surfactant: It is the mixture of lipoprotein molecules produced by secretory cells of the alveolar epithelium Pleural Pressure: It is the pressure***

Principles Affecting Ventilation


1. 2. Air flows from areas of HIGHER PRESSURE to LOWER PRESSURE Changes in ventilation result in changes in pressure, As VOLUME in a closed container, the PRESSURE or as VOLUME , PRESSURE o VOL = PRES o VOL = PRES Changes in Tube Diameter result in changes in resistance

3.

Pulmonary Volume
Tidal Volume (TV): It is the volume of air inspired with each breath (500 mL) Inspirational Reserve Volume (IRV): It is the amount of air that can be INSPIRED FORCEFULLY after inspiration of the Tidal Volume (3000 mL @ rest) Expiratory Reserve Volume (ERV): It is the amount of air that can be FORCEFULLY EXPIRED after expiration of the Tidal Volume (1100 mL @ rest) Residual Volume (RV): It is the volume of air still REMAINING in the respiratory passages and lungs after the most forceful expiration (Approximately 1200 mL)

Pulmonary Capacity
Sum of 2 or more pulmonary volume 1. Inspiratory Capacity (IC = TV + IRV) o Amount of air that a person can inspire maximally after a normal expiration (Approximately 3500 mL at rest) 2. Functional Residual Capacity (FRC = ERV + RV) o Volume of air remaining in the lungs after a normal expiration (2300 mL at rest) 3. Vital Capacity (VC = TV + IRV + ERV) o Maximum volume of air exhaled from the point of maximum inspiration (4600 mL at rest) 4. Total Lung Capacity (TLC = TV + IRV + ERV + RV) o Volume of air in the lungs after a maximum inspiration (5800 mL at rest)

Ventilation and Perfusion Balance


A. B. C. D. Normal VQ Ratio 1:1 Low VQ Ratio Shunt ( Ventilation:Q Perfusion High Ventilation Perfusion Ratio: Dead Space ( Ventilation:Q Perfusion) Silent Unit

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Control of Breathing
Respiratory Center Medulla Oblongata Pons Chemoreceptors Central: Located in the medulla Peripheral: Located in the aortic arch and carotid artery Lung Receptor Stretch Receptor: Alveoli Irritant Receptor: Cough Reflex Juxtacapillary Receptor: Detects Congestion Other Modifications: Touch, thermal, pain receptors

Gerontological Considerations
Vital Capacity of the lungs and strength of respiratory muscles starting to peak between 20 25 years With aging 40 years and older, changes in alveoli begin to lose its elasticity There is a decreased ability to rapidly move air in and out of the lungs Older clients may have an absent cough reflex At the age of 50, may have a decrease in alveoli elasticity Decreased vital capacity Amount of respiratory dead space increase with age Decreased defense mechanism

Assessment of the Respiratory System


Health History - Cough - Sputum production/presence of secretions - Chest pain - Wheezing - Difficulty of Breathing - Hemoptysis - Presence of associated symptoms Like fever and its impact to patients ADLs

OLD CARTS
O Onset L Location D Duration C Characteristics A Aggravating Factors R Reliving Factors T Timing S Setting/Symptoms

Physical Assessment
Inspection: General Appearance Presence of clubbing of the fingers, Normal is 160, Abnormal is 180 Cyanosis Nasal and Sinuses Mouth and Pharynx Trachea Thorax Palpation: Respiratory excursion Tactile fremitus Percussion: Percussion of the Thorax Auscultation: Breath sounds Adventitious

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Laboratory and Diagnostic Evaluation


Pulmonary Function Test (PFT)
It evaluates ventilatory function through spirometric measures on patients with suspected pulmonary dysfunction It is used to assess the respiratory function and to determine the severity or dysfunction of the respiratory status It is performed by the respiratory technicians using a spirometer that has a volume collection device attached to a recorder

Forced Respiratory Vital Capacity


Individual inspires maximally and then exhales maximally as rapidly as possible Volume of air expired at the end of the test is the persons forced expiratory vital capacity Forced Expiratory Volume in 1 second (FEV) Amount of air expired during the 1st 2nd of the test

Purpose: - Determine the cause of dyspnea - Assess the effectives of specific therapeutic regimen - Determine whether a functional abnormality is OBSTRUCTIVE or RESTRCTIVE - Measures pulmonary dysfunction - Evaluate a patient before surgery

General Nursing Intervention In Relation to Diagnostic Process


Provide explanation Correctly identify the patient and identify the procedure to be done Alleviate anxiety Ask the patient to void Wear laboratory gown as necessary Describe the test including who will perform the test Assist in comfortable position after the test

Nursing Consideration in PFT


Explain that this is a painless procedure Inform the laboratory if the patient is taking analgesics Withhold bronchodilators 4 8 hours as ordered Instruct patient to wear his dentures

Arterial Blood Gas Study


Measurement of blood gas pH and of the arterial oxygen and carbon dioxide To determine management of care to patients with respiratory problems and oxygen therapy

Nursing Consideration (Allens Test)


It is usually obtained in through an arterial puncture at the brachial, radial or femoral artery or through an indwelling catheter Use a heparinized blood gas syringe to draw the sample and eliminate air from the sample After blood extraction, put the syringe with blood on a gas of ice After the test, apply pressure for 3 5 minutes or until bleeding has stopped If the patient is receiving anticoagulant, apply pressure longer than 5 minutes if necessary Monitor for VS, WOF signs of circulatory impairment and bleeding tendencies Note on the lab request slip whether the patient was breathing room air / receiving O2 therapy

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If on O2 therapy, note for the flow rate and methods of delivery If on mechanical ventilator, note the setting

Pulse Oximetry
It is used for continuous intermittent monitoring of O2 saturation of hemoglobin It has a sensor that detects changes in O2 saturation levels

Nursing Considerations
Explain the procedure to the patient If pulse oximetery reading are being monitored continuously, set the alarm based on patients condition WOF for O2 saturation Make sure that the hand is on the level of the heart to eliminate venous pulsation Normal O2 are 95% 100% for adults and 93.8% - 100% 1 hour after birth WOF equipment malfunction and poor condition

Cultures
It is used to determine the presence of causative agents responsible for the development of infection Throat Sputum Endotracheal Tube

Nursing Considerations
Assess laboratory test Do not start any antibiotic unless after specimen collection Maintain sterility during and after specimen collection Check for antibiotic therapy

Sputum Studies
1. 2. 3. 4. Teach the patient how to do deep breathing exercises Instruct the patient to rinse the mouth Usually done in the morning Deliver the specimen 2 hours after the collection

For Throat Culture: Nasal swabs may be performed It requires swabbing of the back of the throat streaking a culture plate and allowing the organism to grow for pathogen isolation identification Want the patient that he/she may gag during the swabbing Label correctly the specimen

Imaging Studies
Chest Radiograph - It is used to detect densities produced by fluids, tumors, foreign bodies and other pathologic conditions - Normal chest-X ray radiolucent Purpose: Detect cardiopulmonary disorders To detect mediastinal abnormality Determine the placement of pulmonary catheter, ET Tube and Chest Tube Determine the location of leisure or foreign body Assess pulmonary status Evaluate patients response to intervention

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IT IS CONTRAINDICATED DURING THE 1st TRIMESTER OF PREGNANCY! Lead apron may be used if necessary If X-ray is done at bedside, place cardiac monitor or lead wires and other safety pins as far as possible

Provide Health Teaching


It is non-invasive Remove jewelries Instruct the patient to take a deep breath to visualize the lungs Computed Tomography Scan (CT-Scan) - It is an imaging method in which the lungs are scanned in succeeding layers by a narrow beam Xray - It visualizes fine densities of the lungs and other parts of the respiratory system - It provides more detailed information by sending multiple beams from different angles and using a computer to interpret them - It can be used in conjunction with contrast media radio opaque materials such as barium and iodine which will show up on a CT Scan

Nursing Considerations
Assess for iodine allergy, and reveal function test for those patients with contrast media Assess for claustrophobia Consent for patient with contrast media Remove all jewelries Instruct patient that they will hear sounds during the procedure and remain still throughout the procedure Breastfeeding women must wait 24 hours after the administration of contrast before resuming feeding Magnetic Resonance Imaging (MRI) - It is the same as the CT-Scan, except magnetic fields and radiofrequency signals are used instead of a narrow beam X-ray - It is used to characterize pulmonary nodules to help stage bronchogeneric cancer and to evaluate inflammatory activities of certain disease processes - It has the ability***

Nursing Consideration
Same with CT-Scan Assess for any metal implant and clips, patients with pacemakers are contraindicated for MRI Patient should be warned that the machine is very very noisy, may be given headphones Patient must remain still Pulmonary Angiogram - It is the most commonly used diagnostic procedure for patients with thromboembolic disease of the lungs

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Continuation Pulmonary Angiogram It is the most commonly used diagnostic procedure for patients with thromboembolic disease of the lungs It involves rapid injection of a radiopaque agent into the vasculature of the lungs Same as Pulmonary Angiogram Radiographic examination of the pulmonary circulation following injection of radiopaque iodine contrast agent*** Assess for allergic reaction to Iodine The catheter can be inserted in the main pulmonary artery of*** Nursing Considerations: Contraindicated during pregnancy Monitor patient for ventricular arrhythmias caused by irritation from passage of the catheter through the heart chamber Instruct patient to fast for 8 hours before the test Instruct the patient that: o He may feel flushed, o Experience an urge to cough or; o Have salty taste for approximately 3.5 minutes after injection of contrast media Check for renal function test IV Hydration may be needed AFTER THE TEST - Maintain the patient on bed rest for 6 hours - Observe site for bleeding - Monitor Vital Signs - Be alert for acute renal failure Radioisotope Diagnostic Procedure PET, V/Q Scan, Gallium Scan It is used to assess normal lung ventilation function, pulmonary vascular supply and gas exchange For PET Scan The Entire procedure will take 1 3 hours Should NOT be done to pregnant women Child bearing women MUST be screened well before administering the procedure The client needs to be still after the procedure Instruct to move slowly after the procedure Encourage the client to increase OFI (Oral Fluid Intake)

Endoscopic Procedure
Bronchoscopy - Direct visualization and examination of the larynx, trachea and bronchi - TIVA (Total Intravenous Anesthesia) Purposes of Bronchoscopy To examine the tissue To collect specimens To determine whether the tumor can be resected To diagnose bleeding sites Therapeutic use

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Nursing Considerations Before the procedure Consent must be obtained Explain the procedure to the patient NPO 6 8 hours after the procedure Administer pre-operative medications Thoracentesis Aspiration of fluid for diagnosis / therapeutic purposes Removal of FLUID and AIR Aspiration of pleural fluid for analysis Pleural biopsy Instillation of medication into the pleural space NURSING RESPONSIBILITY Before the procedure Obtain consent Review Chest X-Ray Administer sedation as prescribed Position the patient in upright position Expose the entire chest

After the procedure NPO Assess for respiratory status Health teaching on what to report immediately to the physician

After the procedure Apply pressure over the insertion site Record the amount of fluid removed Assess for respiratory rate, respiratory movement

Biopsy Excision of a small amount of tissue, it is performed to permit examination of cells from the pharynx, larynx and nasal passages Nursing considerations will be based on the concept of perioperative nursing care

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