GAS EXCHANGE AND

RESPIRATORY FUNCTION

Objectives:
Review of basic anatomy and physiology
Respiratory System
Terminology
Medications
Assessment
Diagnostic and Laboratory Procedures/Nursing
Responsibilities
Nursing Diagnosis
Upper Respiratory Tract Disorders
Lower Respiratory Tract Disorders

UPPER RESPIRATORY TRACT DISORDERS

Rhinorrhea
Sinusitis
Rhinitis
Herpes Simplex
Tonsillitis and Adenoiditis
Epistaxis
Laryngitis
Pharyngitis
Laryngeal Carcinoma

LOWER RESPIRATORY TRACT DISORDERS

Restrictive vs. Obstructive

COPD-Asthma, Bronchitis & Emphysema
Pneumonia
PTB
Pleural Effusion & Pneumothorax
Bronchogenic CA
ARDS
Pulmonary Embolism
Histoplasmosis
Pneumoconiosis
Cystic Fibrosis

ANATOMY OF RESPIRATORY SYSTEM

OXYGENATON: the dynamic interaction of
gases in the body for the purpose of delivering
adequate oxygen essential for cellular survival
RESPIRATORY SYSTEM MAIN FUNCTION:
GAS EXCHANGE
Upper Respiratory Tract
A. Functions
1. Filtering
2. Warming and moistening
3. Humidification

Upper Respiratory Tract

Parts
1. Nose - made up of framework of cartilages; divided
into R and L by the nasal septum.
Passageway for incoming and outgoing air, filtering, warming,
and moistening
Organ of smell: olfactory receptors located in the nasal
mucosa
Aids in phonation
2. Paranasal Sinuses includes four
pair of bony
cavities that are lined with
nasal mucosa and ciliated epithelium.
-Paranasal sinuses draining
into the nose:
frontal, maxillary,
sphenoidal, ethmoidal

Upper Respiratory Tract

Parts
3. Tubernate Bones ( Conchae)
4. Pharynx muscular passageway for
both food and air
Nasopharynx -behind the nose; opens
into eustachian tubes; contains
nasopharyngeal tonsils (adenoids)
Oropharynx -forms archway behind the
mouth; contains palatine tonsils
Laryngopharynx opens into esophagus
and larynx
FUNCTIONS:
1. Passageway to the respiratory and
digestive tracts
2. Aids in phonation
3. Tonsils help destroy incoming bacteria

5. LARYNX
LOCATION: at upper end of the trachea, just below the pharynx

- voice production, coughing reflex

Made up of framework of:
Epiglottis valve that covers the opening to
the larynx during swallowing.
Glottis opening between the vocal cords
Hyoid bone u shaped bone in neck
Cricoid cartilage
Thyroid cartilage, forms the Adams apple
Arythenoid cartilage
Speech production and cough reflex
Vocal cords

a. False cords: folds of mucous lining

b. True cords: fibroelastic bands stretched across the hollow
interior of the larynx; the paired cords (folds) and the
posterior arythenoid cartilages make up the glottis

LARYNX
C. FUNCTIONS :
1. Voice production
2. During expiration, air passing
through the larynx causes the vocal
cords to vibrate
3. Short, tense cords produce a high
pitch
4. Long, relaxed cords, a low pitch
5. Serve as part of the passageway for
air and as the entrance to the lower
respiratory tract

6. TRACHEA
consists of cartilaginous
rings
Passageway of air for air
going to and from lungs

Site of tracheostomy
(4th-6th tracheal ring)
A. STRUCTURE
1. Walls: smooth muscle;
contain C-shaped rings of
cartilage that keep the
tube at all times
2. Lining: ciliated mucosa
3. Extend from larynx to
bronchi; 10 to 12 cm long

II. Lower respiratory tract

A. Function: facilitates gas exchange
B. Parts
1. Lungs, are paired elastic structure
enclosed in the thoracic cage, which is an
airtight chamber with distensible walls.
Right 3 lobes, 10 segments
Left 2 lobes, 8 segments
A. STRUCTURE
1. DIVISIONS
a. Root: consists of the primary bronchus and pulmonary artery and
veins bound together by connective tissue
b. Hilum: vertical slit on medial surface of the lung, through which
root structures enter the lung
c. Lobes: three in the right lung, two in the left
d. Apex: pointed upper part of the lung
e. Base: broad, inferior surface of the lung

II. Lower respiratory tract

LUNGS
A. STRUCTURE
2. BRONCHIAL TREE
a. Bronchi: right and left, formed by branching of
the trachea; right bronchus slightly larger and
more vertical than left; each primary bronchus
branches into segmental bronchi all contain Cshaped cartilage
b. Bronchioles: small branches off the secondary
bronchi, distinguished by lack of C-shaped
cartilage and a duct diameter of about 1 mm,
which further branch into terminal bronchioles,
and then alveolar ducts
c. Alveoli: microscopic sacs composed of a single
layer of extremely thin squamous epithilial cells
enveloped by a network of lung capillaries
3. COVERING OF LUNG: visceral layer of pleura

II. Lower respiratory tract

LUNG
B. FUNCTION:
1. Bronchi, bronchioles,
alveolar ducts: passage
to move air into and
out of alveoli
2. Alveoli: provide a
surface area large
enough and thin
enough to allow rapid
gas exchange

II. LOWER RESPIRATORY TRACT

Lungs
Pleural cavity
Parietal
Visceral
Pleural Fluid:
prevents
pleural friction
rub (as seen in
pneumonia and
pleural
effusion)

II. Lower respiratory tract

2. Bronchi
Lobar Bronchi: 3 R and 2 L
Segmental Bronchi: 10 R and
8L
Subsegmental Bronchi
3. Bronchioles
Terminal Bronchioles
Respiratory Bronchioles,
considered to be the
transitional passageways
between the conducting
airways and the gas exchange

II. Lower respiratory tract

4. Alveoli
- functional cellular units or gas-exchange units of the
lungs.
- O2 and CO2 exchange takes place
- Made up of about 300 million
TYPE 1 - provide structure to the alveoli TYPE 2 secrete SURFACTANT, reduces surface tension;
increases alveoli stability & prevents their
collapse TYPE 3 alveolar cell macrophages,
destroys foreign material, such as bacteria
Lecithin
Sphingomyelin
L/S ratio indicates lung maturity
2:1 normal
1:2 immature lungs

PULMONARY CIRCULATION

- Provides for
reoxygenation of blood
and release of CO2
PULMONARY ARTERIES,
carry blood from the
heart to the lungs.
PULMONARY VEINS, is
a large blood vessel of
the circulatory system
that carries blood from
the lungs to the left
atrium of the heart.

RESPIRATORY MUSCLES

PRIMARY: diaphragm and

external intercostal
muscles

ACCESORY:
sternocleidomastoid
(elevated sternum), the
scalene muscles (anterior,
middle and posterior
scalene) and the nasal
alae

PHYSIOLOGY OF RESPIRATORY SYSTEM

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.
2.
3.
4.

Contraction of bronchial mucosa

Thickening of bronchial mucosa
Obstruction of the airway
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.

RESPIRATION
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 CENTER prolongs inhalation
NOTE: Chemoreceptors responds to
changes in ph, increased PaCO2 = increase RR

PHYSIOLOGY OF
RESPIRATION
DIFFUSION OF GASES BETWEEN AIR
AND BLOOD
1. Occurs across alveolar-capillary
membranes (i.e., in lungs between
air in alveoli and venous blood in
lung capillaries); adequate diffusion
depends on a balanced ventilationperfusion (V-Q) ratio

PHYSIOLOGY OF
RESPIRATION
DIFFUSION OF GASES BETWEEN AIR
AND BLOOD
2. Direction of diffusion
a. Oxygen: net diffusion toward lower
oxygen pressure gradient (i.e., from
alveolar air to blood)
b. Carbon dioxide: net diffusion toward
lower carbon dioxide pressure gradient
(i.e., from blood to alveolar air)

PHYSIOLOGY OF
RESPIRATION
ADVENTITIOUS BREATH SOUNDS
1. Fine crackles
a. Result of sudden opening of small airways and
alveoli that contain fluid
b. Short, high-pitched bubbling sounds; sounds may be
simulated by rubbing a few strands of hair between
fingers next to the ear
c. Most common during the height of inspiration
d. Associated with conditions such as pneumonia and
pulmonary edema

PHYSIOLOGY OF
RESPIRATION
BLOOD TRANSPORTS CARBON
DIAOXIDE
1. Primarily as a bicarbonate ion
(HCO3-) formed by ionization of
carbonic acid
2. As a solute in plasma
3. In combination with hemoglobin
(carboxyhemoglobin)

RESPIRATORY
EXAMINATION AND
ASSESSMENT
NORMAL BREATH SOUNDS
1. Bronchial sounds (over trachea, larynx): result of
air passing through larger airways; sounds are
loud, harsh, high pitched; expiration longer than
inspiration
2. Bronchovesicular sounds (near main stem
bronchi); result of air moving through smaller air
passages; sounds are moderately pitched,
breezy; inspiratory and expiratory phases equal

RESPIRATORY
EXAMINATION AND
ASSESSMENT

NORMAL BREATH SOUNDS

3. Vesicular sounds (over entire lung
field except large airways): result of
air moving in and out of alveoli; may
reflect sound of air in larger passages
that is transmitted through lung
tissue; sounds are quiet, low pitched;
inspiration longer than expiration

RESPIRATORY
EXAMINATION AND
ASSESSMENT

ADVENTITIOUS BREATH SOUNDS

1. Fine crackles/Rales
2. Course crackles
3. Wheezes
4. Pleural friction rub

RESPIRATORY
EXAMINATION AND
ASSESSMENT

ADVENTITIOUS BREATH SOUNDS

2. Course crackles
a. Rush of air passing through airway
intermittently occluded by mucus
b. Short, low-pitched bubbling sounds
c. Most common on inspiration and at
times expiration
d. Associated with pneumonia and
pulmonary edema

RESPIRATORY
EXAMINATION AND
ASSESSMENT
ADVENTITIOUS BREATH SOUNDS
3. Wheezes
a. Result of air passing through narrowed small airways
b. Sounds are high pitched and musical (sibilant
wheezes), or low pitched and rumbling (sonorous
wheezes or ronchi)
c. Most common on expiration
d. Associated with conditions causing narrowing of
airways, such as asthma, and with conditions that
involve partial obstruction of airway by mucus,
foreign body, or tumor

RESPIRATORY
EXAMINATION AND
ASSESSMENT

ADVENTITIOUS BREATH SOUNDS

4. Pleural friction rub
a. Result of roughened pleural surfaces
rubbing across each other
b. Sounds are crackling, grating
c. Most common during height of
inspiration but can occur throughout
the respiratory cycle
d. Associated with conditions causing
inflammation of the pleura

RESPIRATORY EXAMINATION AND ASSESSMENT

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 of hyperpnoae
pathophysiology: delay in medullary chemoreceptor response to
blood gas changes
causes
left ventricular failure
brain damage (e.g. trauma, cerebral, haemorrhage)
high altitude

RESPIRATORY EXAMINATION AND ASSESSMENT

A.Abnormal patterns of breathing
3. Kussmaul's (air hunger)
- deep rapid respiration due to stimulation of respiratory
centre
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

Abnormal patterns of
breathing
7. Paradoxical
the abdomen sucks with
respiration (normally, it pouches
uotward due to diaphragmatic
descent)
causes: diaphragmatic paralysis

B. Cyanosis
1. Refers to blue discoloration of skin and mucous
membranes , is due to presence of deoxygenated
haemoglobin in superficial blood vessels
2. Central cyanosis = abnromal amout of
deoxygenated haemoglobin in arteries and
that blue discoloration is present in parts of
body with good circulation such as tongue
3. Peripheral cyanosis = occurs when blood
supply to a certain 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

B. Cyanosis
1. 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 obstruction
Position: patient sitting over edge of bed

TERMINOLOGY

REVIEW OF
MICROORGANISMS
A. Bacterial pathogens
3. Haemophilus influenzae: small,
gram-negative, highly pleomorphic
bacillus; causes acute meningitis
and URTI
4. Klebsiella pneumoniae
(Friedlanders bacillus): gramnegative, encapsulated, nonsporeforming bacillus; causes pneumonia
and UTI

REVIEW OF
MICROORGANISMS
A. Bacterial pathogens
5. Mycobacterium tuberculosis (tubercle
bacillus): acid-fast actinomycete
causes tuberculosis
6. Pseudomonas aerucginosa: gramnegative, non-spore-forming bacillus;
important cause of hospital-acquired
infections; respiratory equipment can
be source; causes pneumonis, UTIs,
and the sepsis that complicates severe
burns

REVIEW OF
MICROORGANISMS
A. Bacterial pathogens
1. Bordetella pertussis small, gramnegative coccobacillus; causes
pertussis or whooping cough
2. Streptococcus pneumoniae: grampositive, encapsulated diplococcus;
causes pneumococcal pneumonia
(most commonly lobar) and often
responsible for sinusitis, otitis media,
and meningitis

REVIEW OF
MICROORGANISMS
B. Rickettsial pathogen: Cosiella burnetii: only
rickettsiae species not associated with a vector;
causes Q fever, an infection clinically similar to
primary atypical pneumonia
C. Fungal pathogens:
1. Histoplasma capsulatum: dimorphic fungus
producing chlamydospores in infected tissue; causes
histoplasmosis
2. Pneumocystis carinii: a unicellular organism thought
to be transmitted by air-borne droplets

REVIEW OF
MICROORGANISMS
D. Viral pathogens:
1. DNA viruses: adenoviruses cause acute respiratory
tract disease, adenitis, pharyngitis, and other
respiratory tract infections, as well as conjunctivitis
2. RNA viruses
a. Coronaviruses: frequently associated with a mild
URTI
b. Picarnoviruses: cause poliomyelitis, coxsackie
disease, common colds
c. Retroviruses: invade T lymphocytes and are
associated with malignancies, HIV, and AIDS

General appearance
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 shoulders with inspiration and aid respiration by
increasing chest expansion
Cyanosis
Character of cough
ask patient to cough several times
lack of usual explosive beginning may indicate vocal cord paralysis
(bovine cough)
muffled, wheezy ineffective cough suggests airflow limitation
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 large broncus)
- acute onset (minutes)
inhaled foreign body
acute epiglottitis
anaphylaxis
toxic gas inhalation
- gradual onset (days, weeks)
laryngeal and pharyngeal tumours

 Sputum
volume
type (purulent, mucoid, mucopurulent)
presence or absence of blood?
Stridor
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 NOT emphysema or
chronic bronchitis)
- occasionally, clubbing is associated with hypertrophic pulmonary
osteoarthropathy (HPO)
characterised by periosteal inflammation at distal ends of long
bones, wrists, ankles, metacarpals and metatarsals
sweelling and tenderness over wrists and other involved 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

RELATED PHARMACOLOGY
1.
2.
3.
4.
5.
6.

Bronchodilators
Mucolytic agents and expectorants
Antitussives
Narcotic antagonist
Antihistamines
Antituberculars

RELATED PHARMACOLOGY
BRONCHODILATORS
A. Description
1. Reverse bronchoconstriction, thus
opening air passages in the lungs
2. Act by stimulating beta-adrenergic
sympathetic nervous system receptors,
relaxing bronchial smooth muscle
3. Available in oral, parenteral (IM,SC,IV),
rectal, and inhalation preparations

RELATED PHARMACOLOGY
BRONCHODILATORS
B. Examples
1. Adrenergics: act at beta-adrenergic receptors in
bronchus to relax smooth muscle and increase
respiratory volume: albuterol, epinephrine HCl,
metaproterenol sulfate, salmeterol
2. Xanthines: act directly on bronchial smooth muscle,
decreasing spasm and relaxing smooth muscle of
the vasculature: aminophylline, theophylline

RELATED PHARMACOLOGY
BRONCHODILATORS
B. Examples
3. Anticholinergics: inhibit action of
acetylcholine at receptor sites on the
bronchial smooth muscle: ipratropium
(Atrovent)
4. Steroids: exert antiinflammatory effect
on nasal passages: fluticasone,
beclomethasone

RELATED PHARMACOLOGY
BRONCHODILATORS
B. Examples
5. Leukotriene receptor antagonists: block action of
leukotriene to reduce bronchoconstriction and
inflammation associated with asthma; montelukast
sodium, zafirlukast, zileuton

C. Major side effects: dizziness (decrease in BP);

CNS stimulation (sympathetic stimulation);
gastric irritation (local effect)

RELATED PHARMACOLOGY
BRONCHODILATORS
D. Nursing care
1. Avoid administration to clients with hypertension,
hyperthyroidism, and cardiovascular dysfunction
2. Avoid concurrent administration of CNS stimulants
(adrenergics) and bronchoconstricting agents (beta
blockers)
3. Administer during waking hours
4. Assess vital signs, especially respirations
5. Assess intake and output
6. Administer with food

RELATED PHARMACOLOGY
MUCOLYTIC AGENTS AND EXPECTORANTS
A. Description
1. Liquify secretions in the respiratory tract, promoting
a productive cough
2. Mucolytics act directly to break up mucous plugs in
tracheobronchial passages
3. Expectorants act indirectly to liquify mucus by
increasing respiratory tract secretions via oral
absorption
4. Mucolytic agents are available in inhalation
preparations; expectorants are available in oral
preparations

RELATED PHARMACOLOGY
MUCOLYTIC AGENTS AND EXPECTORANTS
B. Examples:
1. Mucolytic: acetylcysteine (Mucomyst), SCMC,
ambroxol, bromhexime, H2O
2. Expectorant: guaifenesin, potassium iodide

C. Major side effects:

1. GI irritation (local effect)
2. Skin rash (hypersensitivity)
3. Oropharyngeal irritation and bronchospasm with
mucolytics

RELATED PHARMACOLOGY
MUCOLYTIC AGENTS AND
EXPECTORANTS
D. Nursing Care
1. Promote adequate fluid intake
2. Encourage coughing and deep
breathing
3. Avoid administering fluids immediately
after liquid expectorants
4. Assess respiratory status
5. Have suction apparatus available

RELATED PHARMACOLOGY
ANTITUSSIVES
A. Description
1. Suppress the cough reflex
2. Inhibit the cough reflex either by direct
action on the medullary cough center
or by indirect action peripherally on
sensory nerve endings
3. Available in oral preparations

RELATED PHARMACOLOGY
ANTITUSSIVES
B. Examples:
1. Narcotic codeine, hydrocodone bitartrate
2. Nonnarcotic dextrometorphan hydrobromide (Vicks
44), diphenhydramine HCl (Benadry)

C. Major side effects:

1. Drowsiness (CNS depression)
2. Nausea (GI irritation)
3. Dry mouth (anticholinergic effect of antihistamine in
combination products

RELATED PHARMACOLOGY
ANTITUSSIVES
D. Nursing care
1. Provide adequate fluid intake
2. Avoid administering fluids immediately after liquid
preparations
3. Encourage high Fowlers position
4. Avoid use postoperatively and for clients with head
injury
5. Administer narcotics cautiously: avoid giving with
CNS depressants; caution client to avoid hazardous
activity; assess for signs of dependence

RELATED PHARMACOLOGY
NARCOTIC ANTAGONIST
A. Description
1. Displaces narcotics at respiratory
receptor sites via competitive
antagonism
2. Reverses respiratory depression caused
by narcotic overdose
3. Available in parenteral (IV,SC, IM)
preparations

RELATED PHARMACOLOGY
NARCOTIC ANTAGONIST
B. Example: Naloxone HCl (Narcan)
C. Major side effects:
1. CNS depression acts on opioid receptors in CNS
2. Nausea
3. vomiting

D. Nursing care
1. Assess vital signs, especially respirations
2. Have O2 and emergency resuscitative equipment
available

RELATED PHARMACOLOGY
ANTIHISTAMINES
A. Description
1. Block the action of histamine at receptor sites via
competitive inhibition; also exert antiemetic,
anticholinergic, and CNS depressant effects
2. Relieve symptoms of the common cold and allergies
that are mediated by the chemical histamine
3. Available in oral and parenteral (IM, IV) preparations

RELATED PHARMACOLOGY
ANTIHISTAMINES
B. Examples:
1.
2.
3.
4.
5.
6.

Brompheniramine maleate
Diphenhydramine HCl
Promethazine HCl
Combination products
Drixoral
Triaminic

RELATED PHARMACOLOGY
ANTIHISTAMINES
C. Major side effects:
1. Drowsiness and dizziness CNS
depression
2. GI irritation local effect
3. Dry mouth anticholinergic effect of
decreased salivation
4. Excitement paradoxic effect

RELATED PHARMACOLOGY
ANTIHISTAMINES
D. Nursing care
1. Avoid administration with CNS
depressants
2. Caution client to avoid engaging in
hazardous activities
3. Administer with food or milk to avoid GI
irritation
4. Offer gum or hard candy to promote
salivation

RELATED PHARMACOLOGY
ANTITUBERCULARS
A. Description
1. Used to treat tuberculosis;
administered in combination (first-line
and second-line drugs) over a
prolonged time period to reduce the
possibility of mycobacterial drug
resistance
2. Available in oral and parenteral (IM)
preparations

RELATED PHARMACOLOGY
ANTITUBERCULARS
B. Examples
1.

First-line drugs
a. Ethambutol: interferes with mycobacerial RNA synthesis
b. Isoniazid: interferes with mycobacterial cell wall synthesis
c. Paraaminosalicylic acid (PAS): interfere with
mycobacterial folic acid synthesis
d. Rifampicin: interferes with mycobacterial RNA synthesis
e. Streptomysin sulfate: inhibits mycobacterial protein
synthesis

RELATED PHARMACOLOGY
ANTITUBERCULARS
B. Examples
1. Second-line drugs: inhibit
mycobacterial cell metabolism
a. Capreomycin
b. Cycloserine

RELATED PHARMACOLOGY
ANTITUBERCULARS
C. Major side effects
1. GI irritation direct tissue irritation
2. Suppressed absorption of fat and B complex
vitamins, especially folic acid and B12; depletion of
vitamin B6 by INH
3. Dizziness CNS effect
4. CNS disturbances direct CNS toxic effect
5. Liver disturbances direct liver toxic effect

RELATED PHARMACOLOGY
ANTITUBERCULARS
C. Major side effects
6. Blood dyscrasias decreased RBCs,
WBCs, platelet synthesis
7. Streptomycin: ototoxicity direct
auditory (CN 8) nerve toxic effect
8. Ethambutol: visual disturbances
direct optic (CN 2) nerve toxic effect
9. Rifampicin: red discoloration of all body
fluids

RELATED PHARMACOLOGY
ANTITUBERCULARS
D. Nursing care
1. Support natural defense mechanism of client;
encourage intake of food rich in immunesstimulating nutrients such as A, C, and E, and the
minerals selenium and zinc
2. Obtain sputum specimens for acid-fast bacillus
3. Monitor blood work during therapy
4. Instruct the client to take the drugs regularly as
prescribed; reinforce need for medical supervision

RELATED PHARMACOLOGY
ANTITUBERCULARS
D. Nursing care
5. Offer client emotional support during therapy
6. Use safety precautions (supervise ambulation) if
CNS effects are manifested
7. Instruct client regarding nutritional side effects and
encourage foods rich in B complex vitamins
8. Encourage client to avoid use of alcohol during
therapy

RELATED PHARMACOLOGY
ANTITUBERCULARS
D. Nursing care
9. Ethambutol: encourage frequent visual
examinations
10.Rifampicin: instruct client that body
fluids may appear orange-red
11.Streptomycin: encourage frequent
auditory examinations
12.Evaluate clients response to
mechanism

RELATED PROCEDURES
1.
2.
3.
4.
5.
6.
7.
8.
9.

Abdominal thrust (Heimlich Maneuver)

Bronchoscopy
Chest physiotherapy
Chest tubes
Mechanical ventilation
Oxygen therapy
Suctioning of airway
Thoracentesis
Tracheostomy care

RELATED PROCEDURES
ABDOMINAL THRUST (HEIMLICH
MANEUVER)
A. Definition: short, abrupt pressure
against the abdomen, two
fingerbreadths above the umbilicus,
to raise intrathoracic pressure, which
will dislodge an obstruction such as a
bolus of food or a foreign body

RELATED PROCEDURES
ABDOMINAL THRUST (HEIMLICH
MANEUVER)
A. Definition: short, abrupt pressure
against the abdomen, two
fingerbreadths above the umbilicus,
to raise intrathoracic pressure, which
will dislodge an obstruction such as a
bolus of food or a foreign body

RELATED PROCEDURES
ABDOMINAL THRUST (HEIMLICH MANEUVER)
Symptoms of obstruction
1. Partial: noisy respiration, dyspnea,
lightheadedness, dizziness, flushing of face,
bulging of eyes, repeated coughing
2. Total: cessation of breathing, inability to speak
or cough, extension of head, facial cyanosis,
bulging of eyes, panic, unconsciousness

RELATED PROCEDURES
ABDOMINAL THRUST (HEIMLICH MANEUVER)
Nursing care
1. Assess client no longer than 3 to 5 seconds
a. Ask if client is choking
b. Determine if victim can speak or cough
c. Observe for universal choking sign (thumb and
forefinger encircling throat under chin)
d. Assess respirations: observe for rise and fall of
chest; listen for escape of air from nose and mouth
on expiration; feel for flow of air from nose and
mouth on expiration

RELATED PROCEDURES
ABDOMINAL THRUST (HEIMLICH MANEUVER)
Nursing care
2. Initiate intervention in the presence of a partial
obstruction
a. Allow the individuals expulsion cough to dislodge
the obstruction
b. Assess for signs of total obstruction
c. Remove foreign bodies coughed up into the mouth

RELATED PROCEDURES
ABDOMINAL THRUST (HEIMLICH MANEUVER)
Nursing care
3. Initiate intervention in the presence of a total
obstruction
a. Open the individuals mouth and remove the
obstruction
b. Standing behind the conscious victim, encircle the
waist and thrust upward and inward against the
diaphragm with intertwined clenched fists

RELATED PROCEDURES
ABDOMINAL THRUST (HEIMLICH MANEUVER)
Nursing care
c. If victim becomes unconscious, active EMS
system; straddling the hips of the unconscious
supine victim, place the heel of one hand on the
other and thrust upward and inward against the
diaphragm
d. Repeat abdominal thrust several times (may
require 6 to 10 thrusts) until foreign body is
dislodged or until help arrives

RELATED PROCEDURES
ABDOMINAL THRUST (HEIMLICH MANEUVER)
Nursing care
e. Determine patency of airway; remove foreign
objects from mouth; attempt rescue breathing
f. Continue pattern of abdominal thrusts if
breathing is not reestablished
g. If an airway cannot be established, an
emergency cricothyrotomy may be necessary
h. Assess for signs of injury to liver or spleen; there
is a higher risk when abdominal thrusts are
performed with the victim in recumbent position

RELATED PROCEDURES
BRONCHOSCOPY
A. DEFINITION
1. Visualization of the tracheobronchial
tree via a scope advanced through the
mouth or nose into the bronchi
2. Performed to remove foreign body, to
remove secretions, or to obtain
specimens of tissue or mucus for
further study

RELATED PROCEDURES
BRONCHOSCOPY
B. Nursing Care

1. Obtain an informed consent

2. Keep NPO for 6 to 8 hours before procedure
3. Administer ordered preprocedure medications to
produce sedation and decrease anxiety
4. Inform client to expect some soreness, dysphagia,
and hemoptysis after the procedure
5. Advise client to avoid coughing or clearing throat
6. Observe for signs of hemorrhage and/or respiratory
distress; keep head of bed elevated
7. Monitor VS until stable
8. Do not allow fluids until gag reflex returns

RELATED PROCEDURES
CHEST PHYSIOTHERAPY
A. Definition: Activities that assist the client to
mobilize respiratory secretions that could lead to
atelectasis and/or pneumonia
B. Types of interventions
1.
2.
3.
4.

Incentive spirometer
Percussion (Clapping)
Vibration
Postural drainage

RELATED PROCEDURES
CHEST PHYSIOTHERAPY
B. Types of interventions
1. Incentive spirometer: mechanical device used to
promote maximum inspiration and loosening of
secretions; measures air inspired, providing visual
feedback to client
2. Percussion (Clapping): use of cupped hands to
repeatedly strike chest wall over congested areas;
action causes loosening of secretions

RELATED PROCEDURES
CHEST PHYSIOTHERAPY
B. Types of interventions
3. Vibration: palmar surface of hands are
placed on chest over congested area
and vibrated as client exhales; used
with percussion to loosen secretions
4. Postural drainage: positioning client to
permit gravity drainage of congested
lung segments

RELATED PROCEDURES
CHEST PHYSIOTHERAPY
C. Nursing care
1. Assess baseline breath sounds and ability of client to
tolerate procedure
2. Administer prescribed bronchodilators, mucolytic,
analgesics
3. Position client
a. Fowlers position for incentive spirometry and to
drain upper lung segments
b. Sidelying and prone position with head lower than
affected segment

RELATED PROCEDURES
CHEST PHYSIOTHERAPY
C. Nursing care
4. Teach use of incentive spirometer
a. After exhaling, form seal around
mouthpiece with lips
b. Take slow deep breath and hold inspiration
for a few seconds before exhaling
c. Repeat 10x per hour or as ordered

RELATED PROCEDURES
CHEST PHYSIOTHERAPY
C. Nursing care

5. Perform percussion and vibration for several minutes

over affected areas being managed with postural
drainage
6. Encourage coughing and expectoration of
secretions; provide tissues and appropriate
receptacle
7. Allow rest periods as needed
8. Evaluate color, amount of secretion, quality of
breath sounds after procedure
9. Encourage a 2 3-liter fluid intake daily to liquify
secretions

Normal Values:
Blood pH 7.35 to 7.45
PaCO2 35 to 45 mmHg
PaO2 80 to 100 mmHg
HCO3 22 to 26 meq/L
O2 Sat 96-100%

HOW TO ANALYZE ABG

1. Check the pH
pH < 7.35 ( acidosis)
pH = 7.40 (normal)
pH > 7.45 (alkalosis)

2. Determine primary cause of disturbance

Acidosis

If PCO2 > 40 respiratory

If HCO3 < 24 metabolic

Alkalosis

If PCO2 < 40 respiratory

If HCO3 .> 24 metabolic

pH
R pH

O ph

M ph

E ph

HCO3
PCO2

respiratory alkalosis

PCO2

respiratory acidosis

HCO3

metabolic alkalosis

HCO3

metabolic acidosis

3. Determine the degree of compensation

Fully compensated pH is normal
Partially compensated PCO2 & HCO3
are abnormal, pH abnormal
Uncompensated pH is abnormal, either
of PCO2 or HCO3 is normal

NURSING DIAGNOSIS
NURSING DIAGNOSIS
Ineffective Airway Clearance
Impaired Gas Exchange
Decrease Cardiac Output
Ineffective Tissue Perfusion
OTHER NURSING DIAGNOSIS
Deficient knowledge
Activity intolerance
Disturbed Sleep Pattern
Imbalanced Nutrition
Acute pain
Anxiety

Nursing Management:
Assess and monitor

Fluid and electrolyte status

Respiratory status

Nursing activities

Administer oxygen as prescribed

Maintain direct pressure over arterial
puncture site for 5 to 10 minutes after
drawing the sample
Avoid O2 contamination of arterial specimen
Report result as soon as possible

PLANNING
1. Health Promotion
Adequate ventilation
Prevent inhalation of dust and fumes
discourage over use of inhalers, sprays
and nose drops

2. Restoration and Maintenance

Coughing techniques 5x q1-2 hours

Suctioning
Reducing metabolic demands
Rest
Decreasing effort of breathing
Maintaining nutrition and hydration
Maintaining elimination

3. Preventing and controlling infection

Medical asepsis
Prophylaxis (e.g. vaccines)
Medications

Oxygen therapy
Purposes:
Improved tissue oxygenation
Decrease work of breathing in
dyspneic clients
Decrease work of the heart in
clients with cardiac disease

 Hypoxemia
Hypoxia
Types
Hypoxic hypoxia results from decrease
in the diffusion of O2 from the lungs
into the arterial blood (e.g. decrease O2
in inspired air (high altitude): lung
problems Atelectasis, pneumonia and
pulmonary edema

Anemic hypoxia occurs in conditions where

there is insufficient hgb as in anemic
problems and CO poisoning

Ischemic hypoxia results from decrease

tissue perfusion (e.g. MI, CHF, hypovolemic
shock, vascular diseases and thrombosis

Assessment for the Need for Oxygen

Increase HR
Dyspnea, rapid, shallow breathing
cardiac dysrhythmias
Drowsiness
Headache
disorientation, excitement,
apprehension

 flaring nostrils
yawning
restlessness
cyanosis
ICS and sternal retractions

GOALS OF O2 THERAPY
Psychological ad physical comfort

Information regarding purposes

Comfort measures such as hygiene (skin.
Oral, nasal at least q 2 hours
Proper positioning and repositioning

Promoting safety
Knowledge dissemination regarding O2
properties such as odorless, colorless,
tasteless and heavier than air
O2 supports combustion (no smoking rule,
electrical equipment should be far from O2
proximity
Drying effect of O2

 Maintaining adequate oxygen

Mode of Supply
Low-flow System system that delivers
O2 at a rate less than the inspiratory
rate requirement

Types
Nasal Cannula (Nasal Prong) O2 flow 16 lpm which delivers 21-24%. Mouth
breathing is discouraged
Face mask O2 flow rates from 35-60 %
between 5-10 lpm. Inspired air should be
equal or higher than minute ventilation of
the client. The following may be used:

 Partial re breathing mask (50 to 70%)

Face tents or hoods
Incubators (22 40%)
Humidifying tent provide mists to
transport O2 to terminal alveoli
O2 tent suitable for administration of
moderately high concentration of O2.
(croup disease 21 to 30%)

CANNULA

VENTURI MASK

SIMPLE O2 MASK

RESERVOIR MASK

High-flow provides the total volume

of inspired gas for the client; that is
the client only breathes the gas that
is being supplied

TYPES:
Non-rebreathing mask
concentration is high as 95%. Useful
therapy for MI

 Venturi Mask deliver a precise,

fixed concentration of O2 ranging
from 24-50%

Humidifier is not required to 30%

below
Used in COPD because increase
concentration of O2 might depress
ventilation. It prevents abrupt changes
on PaO2 and PCO2 and is thereby an
effective method to control the
amount of inspired air.

Other ways
Tracheostomy
Portable O2
Hyperbaric oxygenation delivering a 100%
O2 in an environment of increase
atmospheric pressure. Used to treat carbon
monoxide poisoning, air embolism, acute
cyanide poisoning

Incentive Spirometry - The client will

blow air out of the lungs and then to
inhale deeply through a mouth piece
attached to a device that measures
the clients maximum inspiration.

VOLUMETRIC INCENTIVE SPIROMETER

Aerosol Therapy

To add moisture to oxygen delivery systems

To hydrate thick sputum and prevent mucus
plugging
To administer various drugs in the airway
NSS
Detergents e.g. propyl glycol or glycerine
to decrease viscosity of secretions by
reducing surface tension

AEROSOL MASK

 Mucolytics e.g. acetylcysteine change

the physical characteristics of bronchial
secretions and increase mobilization
Others antibiotics, steroids,
vasoconstricrtors, bronchodilators

Devices
Nebulizers
Humidifiers

MANUAL RESUSCITATOR-BIG VALVE MASK

IPPB refers to pressure greater than the

atmospheric pressure at the airway opening during
the inspiration. The clients inspiratory effrot
triggers the ventilator which pushes air to the lungs
Pressure assisted
Client controlled
Prescribed QID
adults 10 to 15 minutes
children 10 to 15 minutes

 Observe for signs of

Hyperventilation:
Headache, chest pain, tingling of the fingers
and toes, numbness, vertigo, syncope
Gastric distention
Dangers of worsening pneumothorax
Possible air trapping in clients with obstructive
diseases

Artificial airway
Functions:
Ensure open airway
Facilitate administration of high
concentration of oxygen and
humidification
Facilitate mechanical ventilation

TYPES:
Oropharyngeal airway prevents the tongue
from falling back and blocking the airway
Endotracheal intubation inserted through
the mouth (orotracheal) or nostril
(nasotracheal)

ENDOTRACHEAL TUBES

ORAL AIRWAYS

NASAL TRUMPHETS

 Tracheostomy inflated with at least 1-3 cc

of air to seal off. A slight air leak should
always be left to decrease pressure in the
trachea and prevent ischemic necrosis thus
preventing the development of tracheoesophageal fistulas.

Signs to Determine Adequate Amount of Air

Aphonia because air flow in the vocal
cords
Absence of an audible escape of air from
the nose, mouth and tracheostomy tube
when occluded

TRACHEOSTOMY CARE
3 MAIN PRINCIPLES
1. maintain patent airway suction
10-15 minutes during the first 24
hours
Sign of mental occlusion
changes in vital signs
changes in mental attitude

2. Prevent infection

Remove inner cannula and cleanse it as

often as necessary
Dressing should be change and sites
must be inspected for inflammation

3. Prevent drying and crusting of the

mucosa

Provide adequate hydration

Installation of at least 2-3 cc of
NSS

Ventilation Therapy (Mechanical Ventilation)

use of mechanical device
Purposes:
To maintain adequate alveolar
ventilation
To provide pulmonary system the
mechanical power to maintain
physiologic ventilation

 To manipulate ventilatory patterns and

airway pressures to improve efficiency
of ventilation
To decrease myocardial workload by
diminishing the work of breathing

Indications:
1. Impaired ventilation
Chronic airway obstruction
Restrictive defects
Neuromuscular defects
Respiratory center damage or
depression

2. Impaired gas exchange and diffusion

ARDS
Atelectasis
Pneumonia
Tumor

RELATED PROCEDURES
CHEST TUBES
A. Definition
1. Use of tubes and suction to return negative pressure
to the intrapleural space, expanding lungs
2. To drain air from the intrapleural space, the chest
tube is placed in the second ot third intercostal
space; to drain blood or fluid, the catheter would be
placed at a lower site, usually the eight or ninth
intercostal space

RELATED PROCEDURES
CHEST TUBES
B. Commercial drainage systems (PleurEvac)

1. Calibrated collection chamber for drainage

2. Water seal chamber: prevents atmospheric air from
entering pleural space; fluid level will normally
fluctuate with respirations until lung is fully
expanded; continuous bubbling may indicate air leak
3. Suction control chamber: controls amount of suction,
usually 10 to 20 cm H2O, if gravity drainage is
insufficient; bubbling indicates that suction level is
maintained; some systems use dry suction

RELATED PROCEDURES
CHEST TUBES
C. Nursing care
1. Ensure that the tubing is not kinked; tape all
connections to prevent separation
2. Milking and stripping chest tubes is not safe
practice because it increases negative intrapleural
pressure and does not significantly affect tube
patency
3. Maintain the drainage system below the level of the
chest
4. Turn the client frequently, making sure the chest
tubes are not compressed

RELATED PROCEDURES
CHEST TUBES
C. Nursing care
5. Report drainage on dressing immediately; this is not
normal occurrence
6. Observe for fluctuation of fluid in water-seal
chamber (tidaling); the level will rise on inhalation
and fall on exhalation; if there are no fluctuations,
either the lung has expanded fully or the chest tube
is clogged; length of time for lung expansion
depends on etiology

RELATED PROCEDURES
CHEST TUBES
C. Nursing care
7. Palpate the area around the chest tube insertion site
for subcutaneous emphysema or crepitus, which
indicates that air is leaking into the subcutaneous
tissue
8. Situate the drainage system to avoid breakage
9. Place two clamps at the bedside for use when
changing systems or if a leak is suspected; clamps
are used judiciously and only in emergency
situations because they can cause tension
pneumothorx

RELATED PROCEDURES
CHEST TUBES
C. Nursing care

10. Encourage movement, coughing, and deep breathing

every 2 hours, splinting the area as needed; assess breath
sounds
11. Assess for tracheal deviation, a sign of tension
pneumothorax
12. Verify that chest x-rays have been done before chest
tubes are removed
13. Instruct the client to exhale or strain (Valsalvas
maneuver) as the tube is withdrawn by the physician;
apply a gauze dressing immediately and firmly secure
with tape to make an airtight dressing

RELATED PROCEDURES
MECHANICAL VENTILATION
A. Definition: use of a mechanical
device to instill a mixture of air and
oxygen into the lungs using positive
pressure; a device such an AmbuBag
can be used temporarily during a
respiratory arrest

RELATED PROCEDURES
MECHANICAL VENTILATION
B. Types of ventilators
1. Pressure cycled: delivers a volume of
gas with positive press during
inspiration
2. Volume cycled: delivers a preset tidal
volume of inspired gas regardless of
pressure
3. Time cycled: deliver volume of gas for
a predetermined inspiratory time

RELATED PROCEDURES
MECHANICAL VENTILATION
C. Modes of ventilation
1.
2.
3.
4.

Controlled mandatory ventilation (CMV)

Assist control ventilation (ACV)
Intermittent mandatory ventilation (IMV)
Synchronized intermittent mandatory ventilation
(SIMV)
5. Pressure support ventilation (PVS)
6. Positive end expiratory pressure (PEEP)
7. Continuous positive airway pressure (CPAP)

RELATED PROCEDURES
MECHANICAL VENTILATION
C. Modes of ventilation
6. PEEP: maintains positive pressure at the end of
expiration to keep alveoli open, increasing the
functional residual capacity (FRC)
7. CPAP: similar to PEEP but exerts positive pressure
throughout the respiratory cycle; the client must be
breathing spontaneously; may be used without
intubation or mechanical ventilation

RELATED PROCEDURES
MECHANICAL VENTILATION
D. Nursing care
1. Maintain ventilator settings and notify the
respiratory department and the physician id
distress occurs
2. Maintain a sealed system between the
ventilator and the client so that volume to be
delivered is dept constant and air is not lost
around the tubing; this is accomplished by
inflating the cuff of the endotracheal tube or
tracheostomy tube to the minimum occlusive
volume

RELATED PROCEDURES
MECHANICAL VENTILATION
D. Nursing care
3. Perform suction as necessary; humidified oxygen
helps to liquify secretions that must be removed
4. Assess for signs of respiratory insufficiency, such as
breath sounds, tachypnea, cyanosis, and changes in
sensorium
5. Check pulse oximetry and blood gases as ordered to
determine effectiveness of ventilation
6. Establish a means of communication because client
will be unable to speak while on a ventilator

OXYGEN THERAPY
A. Definition: administration of supplemental
oxygen to prevent or treat tissue hypoxia
B. Methods: depend on clients condition
1. Nasal cannula: 1 to 6 liters per minute (24% to
43%), least restrictive
2. Simple mask: 5 to 8 LPM (40% to 60%)
3. Partial rebreathing mask: 8 to 11 LPM (50% to 90%)
4. Nonrebreather mask: 12 to 15 LPM (90% to 100%)
5. Venturi mask: delivers precise percentage of
oxygen inspired

OXYGEN THERAPY
C. Nursing care
1. Monitor for signs of hypoxia: agitation, confusion,
lethargy, pallor, diaphoresis, tachycardia, cyanosis
(late)
2. Monitor arterial oxygen saturation as ordered with
pulse oximeter
a. Attach sensor, usually to finger or ear lobe; avoid
extremity with impediment to blood flow
b. Check preset alarm for 02 saturation (SaO2); if less
than 85%, adjustment is needed

OXYGEN THERAPY
C. Nursing care
3. Maintain safety precaution (oxygen
supports combustion): place oxygen in
use sign on door; remind client and
visitors not to smoke or use faulty
electric devices; be aware of fire
extinguishers and oxygen turn-off valve
4. Verify client does not have COPD before
administering high concentration of O2
to prevent CO2 narcosis

OXYGEN THERAPY
C. Nursing care
5. Provide for humidification of oxygen flow rates
greater than 4LPM to prevent drying of secretions
6. Specific care related to method
a. Cannula nares care with water soluble lubricant
b. Rebreather masks ensure that bag does not
deflate completely
c. Venturi mask set LPM to deliver specified FIO2;
use appropriate adapter to mix room air with
oxygen; ensure ports are not obstructed

SUCTIONING OF AIRWAY
A. Definition
1. Mechanical aspiration of mucous
secretions from the tracheobronchial
tree by application of negative pressure
2. Used to maintain a patent airway,
obtain a sputum specimen, or stimulate
coughing
3. May be nasotracheal, oropharyngeal, or
through an endotracheal or
tracheostomy tube

SUCTIONING OF AIRWAY
B. Nursing care
1. Place client in semi-Fowlers position
2. Assess proper functioning of equipment
before and after using
3. Hyperoxygenate by increasing flow
rate; encourage deep breathing
4. Lubricate the suction catheter with
sterile saline or water or water-soluble
gel
5. Apply no suction while the catheter is
being inserted

SUCTIONING OF AIRWAY
B. Nursing care
6. Insert the catheter: if tracheal suction is being used,
insert to the end of the tube (approximately 4
inches); if nasotracheal suction is being used, insert
until the cough reflex is induced or resistance is
met; when resistance is met withdraw catheter 2 cm
before initiating suction
7. Rotate and withdraw the catheter while suction is
applied; do not exceed 10 to 15 seconds
8. Clear the catheter with sterile solution and
encourage the client to breathe deeply

THORACENTESIS
A. Definition
1. Removal of fluid or air from pleural space; this is
done for diagnostic purposes or to alleviate
respiratory distress
2. No more than 1000 ml of fluid should be removed at
a time; fluid withdrawn should be sent to the
laboratory for culture and sensitivity, analysis of
glucose, protein, and pH
3. Complications include pneumothorax from trauma to
the lung and pulmonary edema resulting from
sudden fluid shifts

THORACENTESIS
B. Nursing care
1. Obtain an informed consent
2. Ensure that chest x-ray examination is
done before and after the procedure
3. Assist and support the client in the
sitting position
4. Inform the client not to cough during
the procedure to prevent trauma to
lungs
5. Assess pulse and respirations before,
during, and after the procedure

THORACENTESIS
B. Nursing care
6. Note and record the amount, color, and
clarity of the fluid withdrawn
7. Place client on opposite side for 1 hour
to promote lung expansion
8. Observe the client for coughing, bloody
sputum, and rapid pulse rate and
report their occurrence immediately
9. Monitor for subcutaneous emphysema
(crepitus)

TRACHEOSTOMY CARE
A. Definition: removal of dried secretions from the
cannula to maintain a patent airway, prevent
infection, and prevent irritation
B. Nursing care
1. Provide tracheostomy care at least every 8 hours
2. Suction to remove secretions from the lumen of the
tube
3. Clean around the stoma with saline, using sterile
technique; apply antiseptic ointment if ordered

TRACHEOSTOMY CARE
B. Nursing care
4. If an inner cannula is present
a. Remove disposable inner cannula and
replace with new one
b. Care for nondisposable inner cannula using
surgical aseptic technique; remove and
place in peroxide; remove secretions within
the cannula with a sterile brush; rinse with
normal saline; drain excess saline before
reinserting the tube, which is then locked in
place

TRACHEOSTOMY CARE
A. Nursing care
5. Change the tracheostomy tape, being careful not to
dislodge the cannula; tie with a double knot
6. Place a tracheostomy dressing or fenestrated 4 x 4
inch (unfilled) dressing below the stoma to absorb
expelled secretions
7. Humidify inhaled air if ordered because air is
bypassing normal humidification process in the
nasopharynx