RESPIRATORY C.

Management
I. General Respiratory Anatomy and Physiology a. treatment with antibiotics, decongestants,
A. The respiratory system is comprised of the upper airway antihistamines
and lower airway structures. b. surgery to drain and open sinuses
B. The upper respiratory system filters, moistens and warms c. antral irrigation (sinus irrigation)
air during inspiration. d. Caldwell-Luc procedure
C. The lower respiratory system enables the exchange of D. Upper airway obstruction (choking)
gases to regulate serum PaO2, PaCO2 and Ph. 1. Findings
II. Physiology a. stridor (harsh, vibrating breath)
A. Basic gas-exchange unit of the respiratory system is the b. no sound of air
alveoli. c. both hands of client around the throat
B. Alveolar stretch receptors respond to inspiration by d. management: emergency treatment
sending signals to inhibit inspiratory neurons in the brain i. Heimlich maneuver
stem to prevent lung over distention. ii. cricothyrotomy (cut cricoid
C. During expiration stretch receptors stop sending signals to cartilage)
inspiratory neurons and inspiration is ready to start again. iii. tracheotomy/tracheostomy
D. Oxygen and carbon dioxide are exchanged across the E. Pharyngitis
alveolar capillary membrane by process of diffusion. 1. Inflammation of mucous membranes of pharynx
E. Neural control of respirations is located in the medulla. The 2. Bacterial, viral, environmental causes
respiratory center in the medulla is stimulated by the 3. Treat findings; if culture shows bacteria, use
concentration of carbon dioxide in the blood. antibiotics
F. Chemoreceptors, a secondary feedback system, located in F. Tonsillitis
the carotid arteries and aortic arch respond to hypoxemia. 1. Inflammation and/or infection of tonsils
These chemoreceptors also stimulate the medulla. 2. Acute form is usually bacterial
G. Ph regulation 3. Treat findings; if culture shows bacteria, use
I. Blood Ph (partial pressure of hydrogen in blood): a antibiotics
decrease in blood Ph stimulates respiration G. Peritonsillar abscess
hyperventilation, both through the neurons of the 1. Complication of acute tonsillitis
brain's respiratory center and through the 2. Infection spreads to surrounding tissue
chemoreceptors in carotid arteries and aortic arch. 3. If swelling is massive, can endanger airway
4. Treat findings; if culture shows bacteria, use
II. Blood PaCO2 (partial pressure of carbon dioxide in
antibiotics
arterial blood): an increase in the PaCO2 results in
H. Vocal cord disorders
decreased blood Ph, and stimulates respiration as
1. Laryngitis
described above.
a. inflammation of vocal cords and
III. Blood PaO2 (partial pressure of oxygen in arterial surrounding mucous membranes
blood): a decrease in the PaO2 results in a b. cause: something irritates the larynx
decreased blood Ph, stimulating respiration as c. occurs in viral and bacterial infections
described above. d. in children, called croup (larynx blocked by
IV. When arterial Ph rises or the arterial PaCO2 falls, edema, spasm or both)
hypoventilation occurs. e. treat findings, rest voice, remove irritants,
V. Disorders of the Upper Respiratory System gargle with warm salt water
A. Allergic rhinitis (hay fever) - sensitivity to allergens with 2. Vocal cord paralysis
whitish or clear nasal discharge a. injury, trauma or disease of larynx,
B. Sinusitis laryngeal nerves or vagus nerve
1. Medical condition b. may result as a complication after
2. inflammation of mucus membranes in the sinuses thyroidectomy surgery
a. may be followed by infection with a c. assess how well client can protect airway
yellowish-green discharge
 d. can sometimes be surgically treated with 4. Traps air
Teflon injection 5. As alveolar walls die, there is less surface for vital
I. Cancer of the larynx gas exchange
1. Etiology C. Chronic bronchitis
a. most tumors of the larynx are squamous 1. Definition
cell carcinoma a. inflammatory response in the lung
b. more common among men, age 50 to 65 b. affects few alveoli, mostly airways
c. cigarette smoking and alcohol consumption 2. Findings
are related a. lungs chronically produce fluids
2. Findings b. inflammation and mucus narrow the
a. persistent sore throat airways
b. dyspnea D. Asthma
c. dysphagia 1. Definition/etiology
d. increasing persistent hoarseness a. reversible obstruction of airways
e. weight loss b. inflammation of airways
f. enlarged cervical lymph nodes c. airways hypersensitive to variety of stimuli
3. Management d. bronchospasm is a minor component
a. radiation therapy e. disease waxes and wanes, remissions and
b. chemotherapy exacerbations
c. surgery: removal of all or part of larynx to 2. Findings
treat cancer a. orthopnea, expiratory wheezing
i. total laryngectomy: no voice,
b. barrel chest, cyanosis, clubbing of fingers
permanent stoma in neck with no
c. distention of neck veins
risk of aspiration from oral cavity
d. edema of extremities
ii. radical neck dissection: when
cancer has metastasized to e. increased PCO2 and decreased PO2
surrounding tissues f. polycythemia
4. Nursing interventions 3. Diagnostics
a. arrange for clients with larnygectomies to a. physical examination with history of
meet with members of support groups findings
b. establish a method for communication b. arterial blood gases
before surgery c. chest x-ray
c. maintain airway; have suction equipment 4. Complications
at bedside a. hypoxemia
d. observe for signs of hemorrhage or
infection
b. hypercapnia
c. variety of respiratory infections
e. teach about trach and stoma care
f. assist with period of grieving d. cor pulmonale
e. dysrhythmias
VI. Disorders of Lower Respiratory System (LRS): Obstructive E. Management for obstructive disease
A. General facts: process in chronic obstructive pulmonary 1. Antibiotics and corticosteroids for infection or
diseases chronic inflammation
1. Block airflow out of lungs 2. Bronchodilators
2. Trap air, with impairment of gas exchange 3. Mucolytics
3. Increase the work of breathing 4. Expectorants
B. Emphysema 5. Respiratory program: postural drainage, exercise,
1. Destroys alveoli nebulizer, high protein diet
2. Narrows and collapses small airways F. Nursing interventions common to obstructive diseases
3. Overall lung loses elasticity 1. Assess client's risk of respiratory failure
 2. Assess for degree of respiratory effort for an b. anxiety
increased work of breathing or dyspnea 3. Diagnostics
3. Assess oxygenation with pulse oximeter if a. chest x-ray
hemoglobin level is within normal limits b. biopsy of affected tissue
4. Measure arterial blood gases (ABG) to evaluate gas 4. Management
exchange a. antitussives
5. Administer oxygen as indicated b. oxygen therapy
6. If risk of respiratory failure, anticipate ventilation c. removal of toxic substances
7. Assist with secretion removal as indicated D. Nursing interventions common to all types of pulmonary
8. Pace client activities to reduce oxygen demand fibrosis
9. Teach diaphragmatic breathing and pursed-lip 1. Prevent infection or exposure to infection
breathing 2. Pace clients' activities to reduce oxygen demands
10. Position in a high Fowler's to ease breathing effort and dyspnea
11. Provide for nutritional consults as indicated 3. Reinforce the need for small, frequent meals
12. Reinforce the plan for small, frequent high 4. Encourage daily activities within pulmonary
carbohydrate meals tolerance
13. Provide referrals for: a. provide referrals for:
a. depression associated with disease I. depression associated with disease
b. pulmonary rehabilitation II. stop smoking support groups
c. stop smoking support groups III. occupational rehabilitation
14. For asthma, teach clients that aspirin or peanuts E. Disorders of fluid in pleurae
may stuimulate an asthma attack 1. Pleural fluid disorders - all treated with water seal
VII. LRS Disorders: Restrictive chest drainage systems
A. In general: these disorders prevent full lung expansion via
three mechanisms 2. Pneumothorax: air between the pleurae
1. Lung stiffening
2. External compression
3. Muscle weakness
B. Pulmonary fibrosis- lung stiffening
1. Occupational lung diseases
a. coal worker's pneumoconiosis - risk
increases with length of exposure to coal
dust (>15 years), intensity of exposure,
and silica content of dust
b. silicosis: workers who will have inhaled
silica dust
2. Asbestosis
a. inhalation of asbestos fibers
b. disease may develop 15 to 20 years after a. open pneumothorax: hole in the chest wall,
exposure communicates with the lung
C. Pulmonary sarcoidosis - lung stiffening b. closed pneumothorax: hole in lung, chest
1. Etiology wall intact
a. unknown origin c. tension pneumothorax - a nursing and
medical emergency
b. characterized by formation of tubercles,
i. closed pneumothorax
most often in the lungs ii. air is forced into the pleural space
c. may progress to fibrosis with a continued pressure build up
2. Findings
a. dyspnea
 iii. shifts mediastinum away from -Poliomyelitis
affected side with results of a -Amyotrophic Lateral Sclerosis
compressed heart -Muscular dystrophies
iv. treated with chest tube insertion 3. Poliomyelitis
v. cardiac and respiratory arrest if not a. viral infection
treated b. if disease strikes the respiratory muscles
d. examples of the above the result may be respiratory failure
3. Pleural effusion c. may not swallow well
a. fluid (transudate or exudate) in the pleural i. may aspirate
space ii. may lose protective airway reflexes
b. if small, no treatment 4. Amyotrophic lateral sclerosis (ALS; Lou Gehrig's
c. if larger, treated with chest tube insertion Disease)
4. Hemothorax a. affects motor neurons; autonomic, sensory
a. blood in the pleural space and mental function unchanged
b. treated with thoracentesis or chest tube b. manifests as a chronic, progressive
5. Empyema irreversible disorder
a. purulent drainage in the pleural space c. begins usually in distal ends of upper
b. often from a chronic condition such as lung extremities
cancer d. often leads to respiratory failure within two
c. treated with chest tube inserton to five years
6. Chylothorax e. results in ethical issue
a. lymphatic fluid in pleural space i. whether clients want mechanical
b. treated with thoracentesis or chest tube ventilation
6. Musculoskeletal diseases associated with difficulty ii. whether nutritional support is
breathing desired
2. Guillain-Barre syndrome - follows a viral infection iii. if they would rather die when
a. ascending paralysis that may affect disease becomes this severe
muscles of respiration as paralysis ascends f. results in clients' inability to communicate
b. muscles so weak that client cannot breathe or physically move from voluntarily and/or
deeply, a nursing and medical emergency clients lack involuntary reflexes, such as
c. may progress to respiratory failure blinking or gag reflex
i. may require intubation 5. Muscular dystrophies
ii. mechanical ventilation a. progressive symmetrical wasting of
iii. course of illness varies from a few voluntary muscles with no nerve effect
months to years b. as thoracic muscles weaken, breathing
3. Myasthenia gravis becomes more difficult
a. sporadic, progressive weakness of skeletal c. may not swallow well; risk for aspiration
muscle with loss of protective airway reflexes
b. cause: lack of acetylcholine with results of 6. Interventions common to musculoskeletal
a myoneural junction malfunction disorders
c. may not be able to chew and swallow well a. monitor carefully for changes in condition
i. may aspirate b. assess regular swallowing and ability to
ii. may lose protective airway reflexes protect the upper airway
d. repeated muscle movements, especially
towards days end, can exacerbate acute
c. discuss chances of mechanical ventilation
or nutritional support: does client wish
respiratory failure
it?
All of these musculoskeletal disorders EXCEPT Guillain-Barre feature the letter
M: d. assist with coughing and secretion
-Myasthenia gravis clearance as indicated
 e. prevent infection f. IV fluids to treat dehydration
7. Nursing interventions
f. assess for with appropriate referrals for
a. monitor finger oximeter if hemoglobin
depression that is often associated with
levels within normal limits
these diseases
b. promote hydration to liquify secretions
g. administer medications specific to the c. teach effective coughing techniques to
disease condition minimize energy expenditure
h. assist/provide occupational or/and d. suction if necessary
physical rehibilitation as indicated e. teach the need to continue entire course of
i. maintain adequate nutrition antimicrobial therapy which is usually
j. with terminal disorders, provide for seven to ten days
referrals for family f. teach that findings are expected to be less
2. LRS Disorders: Infectious within 48 to 72 hours of initial therapy
1. Pneumonia 8. Pulmonary tuberculosis (PTB)
3. Definition/etiology a. Etiology
i. mycobacterium tuberculosis
a. acute infection of lung parenchyma ii. bacilli lodge in alveoli
b. cause: bacterium, virus, protozoan,
iii. pulmonary infiltrates
mycobacterium, mycoplasma, or rickettsia
iv. can spread throughout body via
c. pneumonia is the leading cause of death
blood
from infectious causes
v. multi-drug resistant PTB is
d. may affect only a region of lung: lobar
becoming more prevalent
pneumonia, bronchopneumonia
vi. PTB incidence is rising with
e. may be the result of:
increasing homelessness and AIDS
i. primary infection
b. Findings
ii. secondary to other lung damage
i. weakness with fatigue
iii. aspiration
ii. anorexia with weight loss
4. Risk factors for pneumonia
iii. night sweats
a. pre-existing pulmonary disease
iv. chest pain
b. abdominal and thoracic surgery
v. productive cough
c. mechanical ventilation
c. Diagnostics
d. advanced age
i. sputum and gastric contents,
e. decreased ability to protect airway or
analysis for the presence of acid-
cough effectively
fast bacilli
f. artificial airway
ii. chest x-ray for presence of active
g. chronic illness and debilitation
or calcified lesions, "coin" lesions
h. depressed immune function
iii. tuberculin testing
i. cancer
1. tine, mantoux tests
5. Diagnostics
1. checked 48 to 72
a. chest radiograph
hours for
b. sputum culture, sensitivity and microscopic
induration
analysis, Gram stain, cytology
2. positive if >10 mm
c. ABG as indicated by clinical condition
induration in
6. Management
healthy persons
a. antimicrobials, depending on pathogen
iv. establishes if there is an antibody
b. antipyretic
response to the tubercle bacillus
c. expectorants
v. if positive, indicates prior exposure
d. antitussives
to bacillus, not an active disease
e. supplemental oxygen, as indicated
d. Management
 i. long-term, six to 24 months,
antimicrobial therapy with isoniazid
(INH) (Hyzyd) or rifampin
(Rifadin), with ethambutol HCL
(Etibi) in some cases
ii. bed rest or chair rest until findings
abate
iii. surgical resection of involved lung
if medication is not effective
iv. high carbohydrate, high protein
diet with frequent small meals
e. Nursing interventions
i. with active infection, client must be
isolated with airborne precautions
when in the hospital
ii. teach client
1. proper techniques to
prevent spread of A. Pulmonary embolism
infection: hand washing, 1. Definition/etiology
etc. a. clot blocks blood from the "bed" of arteries
2. to report bloody sputum that feed the lung
3. not to use over the counter b. client is breathing but gases are not
(OTC) medications without exchanged - ventilation without perfusion
health care provider's c. hypoxemia results
approval d. can be mild or immediately fatal, based on
4. importance of taking the size and location of clot(s)
medications as prescribed e. usually clot has traveled from deep veins in
1. adherence to the leg or pelvis
treatment regimen 2. Diagnostics
2. return at scheduled a. ventilation/perfusion (V/P) scan, also called
times for lab V/Q scan
testing of liver b. ABG
enzymes c. EKG
3. Management
3. an increase in B6 to a. oxygen via mask
minimize peripheral b. anticoagulation - heparin in acute and
neuropathies, a coumadin for chronic risk
common side effect c. thrombolytics
of drug therapy d. filter surgically placed in vena cava for long
2. Lung abscess term care
3. Localized area of lung infection B. Acute respiratory distress syndrome (ARDS)
4. Usually follows pneumonia, TB or aspiration 1. Definition/etiology
5. Treatment consists of draining and culturing a. alveolar capillary membrane becomes
abscess and antimicrobial therapy more permeable to fluids
b. increased extravascular lung fluid
IX. LRS Disorders: Miscellaneous c. pulmonary compliance decreases
d. intrapulmonary shunt increases
e. refractory hypoxemia
 f. usually seen after lung injury or massive b. cytological sputum analysis
multi-system organ disease c. bronchoscopy
2. Findings d. biopsy
a. restlessness, anxiety SQUAMOUS CELL CARCINOMA
b. dyspnea
c. tachycardia A. Risk factors
d. cyanosis 1. Is most often associated with cigarette smoking
e. intercostal retractions 2. Exposure to environmental carcinogens e.g. uranium,
3. Diagnostics asbestos
a. clinical presentation and history of findings
B. Characteristics
b. hypoxemia on ABG despite increasing 1. Accounts for 30-35% of lung cancer cases
inspired oxygen level 2. Is more common among men
c. chest x-ray shows diffuse infiltrates 3. Findings occur earlier because of bronchial obstructive
4. Management characteristics (arises from bronchial epithelium)
a. optimize oxygenation 4. Causes cavitating pulmonary lesions
I. mechanical ventilation 5. Usually metastasizes locally
II. sedation may be required
C. Therapy
III. paralytic agents may be necessary
1. Life expectancy is better than small cell carcinoma
b. antibiotics, as indicated
2. Surgical resection is often attempted
c. corticosteroids
SMALL CELL CARCINOMA
5. Nursing interventions
a. plan for frequent rest periods A. Risk Factors
b. monitor trends in oxygenation status, 1. Cigarette smoking
ABGs, respiratory effort 2. Environmental carcinogens
c. observe for behavioral changes and vital B. Characteristics
signs; confusion and hypertension may 1. Accounts for 15% to 25% of lung cancers
indicate cerebral hypoxia 2. Spreads early
C. Lung cancer 3. Very malignant form
1. Definition/etiology 4. Is often associated with endocrine disturbances
a. types of lung cancer C. Therapy
I. squamous cell carcinoma 1. Poorest prognosis
2. Average survival is less than one year
II. small-cell (oat cell) carcinoma
ADENOCARCINOMA
III. adenocarcinoma
A. Risk Factors
IV. large cell carcinoma 1. Not related to cigarette smoking
b. prognosis is generally poor 2. Lung scarring
c. largely preventable if smokers stop and 3. Chronic interstitial fibrosis
nonsmokers avoid second hand smoke
2. Findings
B. Characteristics
1. More common among women
a. hoarse voice
2. Accounts for about half of all lung cancers
b. changes in breathing
3. Usually located in peripheral section of lungs
c. persistent cough or change in cough
4. Often no clinical signs or findings until well advanced
d. blood-streaked or bloody sputum
e. chest pain or tightness in chest wall C. Treatment
f. recurring pneumonia, pleural effusion 1. Does not respond well to chemotherapy
g. weight loss 2. Most often, surgical resection is attempted
3. Diagnostics LARGE CELL CARCINOMA
a. medical imaging examinations
A. Risk Factors F. optimize nutritional status
1. Cigarette smoking 3. Cor pulmonale
2. Environmental carcinogens A. Definition/etiology
B. Characteristics A. right ventricular hypertrophy and
1. Occurs in 15-25% of all lung cancers subsequent chronic heart failure
2. Frequently metastases via blood B. cause: heart must pump against great
3. Usually peripheral rather than centrally located in the lung resistance from lung's blood vessels: called
lobes increased pulmonary vascular resistance
(PVR)
C. Therapy
C. increased PVR results from chronic lung
1. Usually client is not a candidate for surgery due to the high
disease
frequency of metastasis
D. may be due to primary pulmonary
2. Tumors often responds to radiation therapy but frequently
hypertension as well
recurs
B. Diagnostics
A. Management
A. pulmonary artery pressure readings via a
A. nonsurgical
catheter
A. chemotherapy
B. echocardiogram
B. radiation therapy
C. chest radiograph
C. laser therapy to de-bulk tumor
D. ABG
D. thoracentesis and pleurodesis E. EKG
B. surgical C. Management
A. thoracotomy A. administer oxygen as ordered
A. wedge resection - part of a B. if hemoglobin within normal limits (WNL),
lobe monitor oxygenation with finger or pulse
B. segmental resection- part oximeter
of a lobe C. bed rest, as needed
C. lobectomy - one or more D. monitor effects of medications
lobes A. cardiac glycosides
D. pneumonectomy - entire B. pulmonary artery vasodilator
right or left lung C. diuretics
B. Nursing interventions D. restricted fluid intake as indicated
A. post-operative care E. nursing interventions
A. chest drainage A. monitor for changes in oxygenation
B. routine post operative care status
A. monitor respiratory status B. pace activities in clients who tire
frequently easily
B. teach effective deep 4. Respiratory failure
breathing and cough A. Definition: lungs cannot maintain arterial oxygen
techniques levels or eliminate carbon dioxide
C. refer to physical therapy A. PaCO2 > 50 mm Hg
for exercises for shoulder
on affected side B. PaO2 < 50 mm Hg
D. relieve pain C. clients with chronic lung disease
C. optimize oxygenation precautions
D. provide opportunities for the client A. look for drop from baseline
to talk about cancer; as needed, function
refer to support groups B. this is a nursing and medical
E. teach information as based on emergency
treatment plan and prognosis C. clients are always hypoxemic
 B. Etiology • When caring for a client on a ventilator, if an alarm sounds, first,
A. lung diseases that harden the alveolar- assess the client. See if the alarm resets or if the cause is obvious.
capillary membrane to trap O2 If the alarm continues to sound and the client develops distress,
B. neuro-muscular or musculoskeletal disconnect the client from the ventilator, use a manual
disorders resuscitation bag to ventilate with 100% oxygen and page or call
A. respiratory drive dulled or blunted the respiratory therapist immediately.
B. muscles too weak to breathe • If the ventilator tube disconnects, the low pressure alarm will
C. Diagnostics: ABG sound.
D. Management • If the high pressure alarm sounds on the ventilator, the nurse
A. oxygen per mask should check for some type of obstruction or occlusion of the
B. mechanical ventilation airway: mucous plugs, biting of the tube by the client, tube slips
C. monitor for improvement in the underlying into right main stem bronchus, or increased secretions.
cause for the respiratory failure • To maximize therapeutic effect of inhalers, the key is technique.
D. Oxygen is essential for life. So, before all else, keep airways It is critical to teach clients the right technique and observe how
open and ease breathing effort. well they use the inhaler.
E. Clients with chronic lung disease use more oxygen and energy to • Smoking cessation is critical to reduce the risk and severity of
breathe. This can create a vicious cycle in which the client works lung disease. Second-hand smoke enhances the risk of children to
harder, and continually requires more oxygen and more energy. develop asthma or other chronic lung diseases.
F. Nursing interventions for clients with chronic lung disease should • Best approach to pulmonary embolus is prevention. The use of
include pacing of activities, because these clients have little intermittent compression stockings prevents clots in the deep
reserve for exertion. veins.
G. Quality of life for clients can be significantly improved if clients Clients with pulmonary TB need intensive community follow up to
routinely use diaphragmatic breathing and pursed-lip breathing. ensure that they continue with pharmacological treatment once discharged
H. Clients with asthma must understand the different types of from the hospital. Clients who stop therapy too soon are the source for the
inhalers and when to use each type. Some rescue inhalers are for more deadly multi-drug resistant forms of pulmonary TB.
acute dyspnea. Other inhalers are for maintenance or preventative
types of drugs.
I. A finger or pulse oximeter reading is simply one element of an
assessment. It is not the whole picture.
J. Cyanosis, a late finding, is determined by oxygenation and
hemoglobin content.
K. Clients with anemia may be severely hypoxemic and never turn
blue, but rather "ashen".
L. Clients with polycythemia may be cyanotic with adequate tissue
oxygenation.
M. The serious public health issue of pulmonary TB requires control
and reporting of any incidence and recent contacts that the client
had so prophalactic therapy for two to three months can be
initiated.
N. When caring for a client after a chest tube insertion, an occlusive
dressing is placed around the chest tube insertion site and the
connections of the chest tube system are taped to prevent air
leaks at connections. An occlusive dressing is one that is totally
covered, as well as the edges with non-porous tape. This dressing
is typically not changed and not expected to have any drainage on
it.