CARE OF CLIENTS WITH

PROBLEMS RELATED TO THE

RESPIRATORY SYSTEM

Earl Francis R. Sumile, RN

Instructor, College of Nursing
University of Santo Tomas
Respiration
Respiration – process by which cells receive oxygen for
cellular metabolism and eliminate carbon dioxide as
metabolic waste.
Processes Involved in Respiration
 1. Ventilation or breathing (inspiration and
expiration) – movement of air in and out of the
lungs as a result of gas flow from an area of
greater pressure to an area of lesser pressure.
 2. Diffusion or gas exchange – movement of
gasses between the air in the alveoli and blood
in the pulmonary capillaries to lower pressure or
concentration
 3. Perfusion or circulation or blood flow –
transport of oxygen and carbon dioxide in the
blood and body fluids to body cells.
Respiratory Control
 1. Medulla oblongata - primary
respiratory center; spontaneous,
rhythmic respiration
 2. Cerebral cortex – voluntary
breathing
 3. Pons varoli – involuntary
breathing
Factors Influencing Respiration
 1. BP changes – decreased BP = increased RR
 2. Change in body temperature – increased temp =
increased RR
 3. Drugs – depressants; decreased RR
 4. Age – decreases with age
 A. Neonate - 35-60/min
 B. Infant – 44/min
 C. Child (5 years) – 20-25/min
 D. Adolescent (10-14 years) – 17-22/min; (15 years) –
20/min
 E. Adult – 16-20/min
 Older adult – 12-16/min
Nursing Assessment
 1. Respiration
 Eupnea – normal respiration; rate and depth are equal
 Tachypnea – fast respiratory rate
 Bradypnea – slow respiratory rate
 Dyspnea – difficult or labored breathing; individualized
perception of breathlessness (awareness of breathing)
 Apnea – periods during which there is no breathing
 Orthopnea – dyspnea that is relieved by upright
position
 Biot’s – respirations of the same depth followed by a
period of apnea
Nursing Assessment
 Cheyne Stokes - gradual increase followed by gradual
decrease in the depth of respirations, and then a period
of apnea
 Kussmaul – deep, rapid and regular breathing
 Paroxysmal Nocturnal Dyspnea – sudden onset of
dyspnea while sleeping in a recumbent position
 2. Cough and secretions
 Cough – sudden, explosive expiratory protective reflex
to remove an irritant from air passages; may be
hacking, croupy, rattling, whooping, barking
 Sputum – substance ejected from the lungs by
coughing or clearing the throat; may be thick, viscous,
tenacious or gelatinous, frothy, mucoid, mucopurulent
Nursing Assessment
 3. Chest pain of pulmonary origin
 A. Chest wall – localized, constant and increases with
movements
 B. Pleura – sharp, abrupt, increased with inspiration or
with cough or sneeze
 C. Lung parenchyma – dull, constant ache, poorly
localized
 4. Cyanosis – dusky bluish color of the mucous
membranes, skin and nailbeds due to excessive
deoxygenation of hemoglobin
 A. Peripheral – extremities and nailbeds are blue due to
peripheral vasoconstriction; secondary to decreased
cardiac output
Nursing Assessment
 B. Central – bluish discolorization of lips, tongue, face
and mucous membrane; secondary to decreased
oxygen of blood; always pathological
 C. Differential – upper part of the body is pink and
lower half is blue or vise versa; usually seen in cardiac
diseases
 5. Breath Sounds
 A. Vesicular – soft, low-pitched sounds heard over the
normal lung fields
 Nursing Assessment
 B. Adventitious - breath sounds not normally
heard in the lungs
• Crackles or Rales – discrete, discontinuous
inspiratory sounds that have dry or wet crackling
quality
• Wheezes – continuous sounds originating from small
air passages that are narrowed by secretions,
swelling or tumors.
• Stridor or Stertorous – noisy respiration
• Friction Rub – grating sound caused by inflammed
pleura rubbing against the chestwall
 Diagnostic Assessment
 1. Radiologic
 A. Chest X-ray – PA, lateral, oblique
 B. Fluoroscopy – direct viewing without film to view
lung expansion and respiratory excursion of diaphragm
 C. Tomography or stratigraphy – computed
tomography permits better visualization of layer or
plane of lugs “slices”; done to check cavities,
neoplasms, lung densities, stereoscopic – 3D
 D. Ultrasound or echogram – harmless, high frequency
sound wave emitted and penetrates the thorax and
bounces back to transducer to picture image
 Diagnostic Assessment
 E. Bronchography – visualizes bronchial tree by x-ray
after iodize radioplaque liquid is introduced via a metal
cannula through the trachea
• Prep – NPO, no dentures, sedative, antispasmodic, done
with topical spray anesthesia
• Post – NPO until gag reflex is back, deep breathing
exercises and coughing to clear airway and postural
drainage to remove dye
 Diagnostic Assessment
 F. Lung scan or scintigram or scintiphotography –
records the pattern of pulmonary radioactivity after
inhalation or IV injection of gamma ray emitting
radionucleotides;
• Perfusion scan – iodine IV (contrast medium)
• Ventilation scan – xenon gas inhaled (contrast medium)
 G. Pulmonary angiography – radiopaque material is
injected via catheter in systemic vein to check emboli,
congenital or acquired lesions of pulmonary vessels
• Prep – dye—radiopaque iodine; check allergy to iodine
and seafoods; give 10 gtts of lugol’s solutionn several
hours before test to block thyroid uptake of radioactive
iodine
 Diagnostic Assessment
 2. Direct Visualization or Endoscopic
 A. Rhinoscopy – direct visualization and examination
of nasal cavity
 B. Laryngoscopy – direct visualization of larynx
• Prep – consent, topical anesthesia, NPO 6-8 hours,
atropine sulfate, sedation
• Post – head of bed elevated, lateral position, ice collar,
check gag reflex and hoarseness, tracheostomy tray at
bedside because of laryngeal edema or spasm
 C. Bronchoscopy – direct examination of trachea,
bronchi and larynx
• Purposes:
b. Inspect parts of respiratory tract
 Diagnostic Assessment
Purposes:
b. Aspirate secretions and exudates n air passage
c. Remove foreign body
d. Do biopsy
Nursing Care – same as in laryngoscopy

 D. Transllumination – directing a beam of light

against frontal or maxilliary sinuses
Nursing care – turn overhead lights off
 Diagnostic Assessment
 3. Lung biopsy – pleural needle biopsy

 4. Laboratory studies
 A. Hematological studies – CBC, ESR
 B. Cytologic studies
 C. Sputum – 4 ml specimen
• Methods of taking specimen:
endotracheal – through ET tube
fiberoptic bronchoscopy – by use of bronchoscope
gastric lavage – via NGT
transtracheal – surgical opening of trachea
 Diagnostic Assessment
 D. Bacteriological – smear and culture
 E. Thoracentesis – aspiration of fluid and air from
pleural cavity;
site of insertion: for fluid – 7th to 8th intercostal space mid-
axillary; for air – 2nd or 3rd intercostal space mid-clavicular
prep: consent, no moving, nochoughing, proper positioning,
remoe not more than 1500cc within 30 mins (to prevent
intravascular shift)
post: turned to unaffecte4d side – seal itself; to prevent
seepage
 Diagnostic Assessment
 5. Skin test for TB
 A. PPD – purified protein derivatives
 B. OT – old tuberculin
Techniques:
a. Mantoux test – intracutaneous – for diagnosis
b. Tine test
c. Mono vaccine
d. Heaf screening
*b, c, d – multiple puncture test using jet gun
 Diagnostic Assessment
 6. Pulmonary Function Test – non-invasive
method of assessing the functional capacity of
the lungs; ability of gas to diffuse across the
alveoli capillary membrane and ratio of
ventilated alveoli to perfused capillaries.
 A. Pulse oximetry – non-invasive technique that
measures the oxygen saturation (SaO2) of arterial
blood (uses pulse oximeter)
 B. Spirometry – measures lung capacity, volumes and
flow rates with the use of an intrument called
spirometer.
 Diagnostic Assessment
Pulmonary Volumes:
b. VT (Tidal volume) = 500 ml; volume of air; inspired
with each breath
c. IC (Inspiratory Capacity) = 3500 ml; maximum
amount of air which can be inhaled in
d. IRV (Inspiratory Reserve Volume) = 300 ml;
inspiratory capacity in excess of tidal volume
e. ERV (Expiratory Reserve Volume) = 100-1100 ml;
maximum quantity of air that can be forcibly exhaled
after expiration
f. RV (Residual Volume) = 1200 ml; air remaining after
expiration
g. VC (Vital Capacity) = 4000-5000 ml; maximum
volume of air expired with inspiration
h. TLC (Total Lung Capacity) = 5200-6000 ml; residual
volume + vital capacity
 Diagnostic Assessment
 7. Arterial Blood Gases – examination of arterial
blood to determine the pressure exerted by
oxygen and carbon dioxide in the blood; -
provides objective determination of arterial blood
oxygenation, gas exchange, alveolar ventilation
and acid-base balance; use heparinized syringe.
Sites: radial, brachial, femoral artery
PaO2 – measures O2 dissolved in blood – shows efficiency
of gas exchange ventilation and perfusion
Diagnostic Assessment
PaCO2 – determines the adequacy of ventilation; depends
upon the amount of O2 produced and ability of lungs to
eliminate; shows effectiveness of ventilation
pH – measurement of hydrogen ion concentration
SaO2 – measures oxyhemoglobin saturation
 ACID BASE BALANCE
Regulated by
 1. Chemical Buffer system – substance that
can act as a chemical sponge, either by
soaking up or releasing H2 ions to stabilize pH
• A. Carbonic acid – bicarbonate system – lungs
(CO2); kidneys (bicarbonate)
• B. Phosphate buffer system – kidneys – mop up H2
ions
• C. Protein buffer system – plasma and intracellular
fluid, protein hemoglobin
ACID BASE BALANCE
 2. Respiratory control of pH (medulla)
• 1. Decreased pH (acidic) = increased RR and depth
increased CO2 (lungs) decreased CO2, pH = alkaline
• 2. Increased pH = decreased RR and depth of resp,
increased CO2, pH = acidic
 3. Renal regulation of pH – kidney make
permanent adjustments in pH control of the
retention or excretion of bicarbonate and H2
ions
• 1. In acidosis, excess H2 ions are excreted in kidney
tubules via urine.
• 2. In alkalosis, bicarbonate ions enter tubules and
excreted in urine.
ACID BASE BALANCE
 Compensation
• Kidneys attempt to compensate for
changes in blood bicarbonate
• Lungs attempt to maintain 20:1 ratio
• Shifting of H2 ions from extracellular fluid
to intracellular fluid and vice versa
ACID BASE BALANCE
COMPARISON OF ARTERIAL or VENOUS BLOOD
GASES
ARTERIAL VENOUS
pH 7.35-7.45 7.31-7.41
pO2 80-100 mmHg 35-40 mmHg
pCO2 35-45 41-51

SaO2 96-98% 70-75%

HCO3 22-26 23-25

Base -2+2 -2+2

ex
ACID BASE BALANCE
ABG PROFILE IN RESPIRATORY ACIDOSIS or
ALKALOSIS

ACIDOSIS RESP ALKALOSIS

Decreased pH 7.4 Increased pH

Increased 40 Decreased
pCO2 pCO2

Normal HCO3 24 Normal HCO3

ACID BASE BALANCE
ABG PROFILE IN METABOLIC ACIDOSIS or
ALKALOSIS
ACIDOSIS MET ALKALOSIS
Decreased pH <7.4> Increased pH

Decreased <24> Increased

HCO3 HCO3

Decreased BE <0> Increased BE

Normal pCO2 40 Normal pCO2
 Signs and Symptoms of Acid-Base
Imbalances:
 Acidosis – increased CO – depression of CNS –
decrease in mental capacity –delirium, coma or
death

 Alkalosis – increased O2 – overexcitability or

irritability of CNS – extreme nervousness, over
excitability, tetany or convulsions
Respiratory Management
 1. Pharmacotherapeutics

 A. bronchodilators – relaxes smooth muscles

of respiratory tract
 B. prednisone – decreases edema of the
respiratory tract
 C. mucolytic – reduces thickness of secretions
 D. antitussive – depresses cough reflex
 E. antihistamines – blocks histamine; anti-
inflammatory
Respiratory Management
 2. Surgery – with chest tube to water sealed
drain post operatively
 A. exploratory thoracotomy – done to confirm
a suspected diagnosis of chest disease; to
determine bleeding in chest trauma
 B. pneumonectomy – removal of an entire
lung to treat bronchogenic cancer,
tuberculosis, bronchiectasis and lung abscess;
postoperatively, positioned to affected side
 C. lobectomy – one lobe is removed;
postoperatively with chest tube and positioned
to affected side
Respiratory Management
 D. segmental resection – segmentectomy;
one or more segment/s is/are removed
following pulmonary tuberculosis or
bronchiectasis
 E. wedge resection – removal of pie-shaped or
a well circumscribed section from the surface
of the lung
 F. decortication – removal of fibrous peel from
visceral pleura; done in empyema, pleural
effusion, prolonged hemothorax
 G. thoracoplasty – removal of ribs;
extrapleural procedure
Respiratory Management
 3. Therapeutic Modalities
 A. O2 therapy
 B. deep breathing and coughing exercises – support
post-op site with pillow
 C. postural drainage – use of specific positions so that
force of gravity can ssist in the removal of bronchial
secretions from the affected bronchioles into bronchi
and trachea by means of expectoration; percussion and
vibration; best done uppon akin in the morining or ½ to
1 hour ac
 D. incentive spiromentry – uses spirometer to
maximize voluntary lung inflation; prevents or treats
atelectasis
Respiratory Management
 4. Mechanical Ventilation

 A. IPPB (intermittent positive pressure breathing) –

supplies air or oxygen under positive pressure (above
atmosphere) during inspiration
 B. PEEP (positive end expiratory pressure) – ventilator
mode that increases and maintains positive pressure at
the end of expiration
 C. CPAP (continuous positive airway pressure) –
technique that maintains positive pressure in the lung
during spontaneous ventilation (T-piece)
Common Respiratory Problems
 Epistaxis (nosebleeding) – usually originates
from the blood vessels in the anterior part of
the septum
Causes:
2. Trauma to nasal mucosa from foreign object
3. Picking o fhte nose
4. Local irritation of the mucous membrane from lack of
humidity in the air
5. Chronic infection
6. Violent sneezing or blowing of the nose
Common Respiratory Problems
Nursing Management:
2. Patient sits up leaning forward with head tipped downward
3. Compress soft tissues of nose against septum with fingers
and maintain pressure for at least five minutes
4. Apply ice or cold copress to nose to constrict blood vessels
5. If bleeding does not stop with direct pressure, place cotton
ball soaked in topical vasoconstrictor (neo-synephrine) into
nose and apply pressure (dependent nursing function)
6. Instrut not to blow nose for several hours after nose bleed
7. Silver nitrate stick or electrocautery (dependent nursing
function)
8. Post nasal pack (dependent nursing function)
Common Respiratory Problems
 Sinusitis – inflammation of air filled cavities
that lines the mucous membranes of the
sinuses

Causes:
2. Viral – influenza, adenovirus, staphyloccocus aureus
3. Bacterial – streptococcus pneumoniae, haemophilus
influenzae
4. Allergic – seasonal
Common Respiratory Problems
Signs and Symptoms:
2. Fever and malaise
3. Stuffy nose
4. Slowly developing pressure over the
involved sinus
5. Persistent cough
6. Post nasal drip
7. Headache
Common Respiratory Problems
Nursing Management:
2. Positioning – to drain secretions
a. Proetz – supine position with 3 head pillows, head
on neutral position; for ethmoidal and sphenoidal
sinusitis
b. Parkinsons – supine position with 3 head pillows,
head turned to sides; for frontal and maxillary
sinusitis
3. Analgesics and antipyretics
4. Decongestants
5. Antibiotics
Common Respiratory Problems
5. Cald-wel-luc surgery (radical antrum
operation) – incision made under the upper
lip to treat chronic maxillary sinusitis
Priority Nursing Care:
b. Proper oral hygiene done with caution to avoid
injury to the incision
c. Don’t chew on affected side
d. No dentures for ten days
e. No blowing of nose for two weeks
f. No sneezing (if you must sneeze, keep mouth
open)
Common Respiratory Problems
 Tonsilitis – inflammation of the tonsils
and their crypts

Signs and Symptoms:

2. Sore throat
3. Pain on swallowing
4. Fever and chills
5. General muscle aching and malaise
Common Respiratory Problems
Nursing Management:

3. Rest and increase fluid intake

4. Warm saline throat irrigation
5. Ice collar to relieve discomfort
6. Analgesic and antipyretics
7. Antibiotics
8. Surgery – tonsillectomy
Tonsillectomy
Pre-op Care:
b. Check for loose tooth
Post-op Care:
 Position on side until fully awake than to
mid-fowler’s
 Monitor for hemorrhage – frequent
swallowing, bright red vomitus, rapid pulse,
and restlessness
 Comfort – apply ice collar to neck; use
acetaminophen in place of aspirin
 Food and fluids – give cold fluids and bland
foods; no milk
Tonsillectomy
e. Patient teaching

No clearing of throat
No coughing, sneezing, vigorous nose bleeding
and vigorous exercise for one to two weeks
Drink fluids two to three liters a day
Avoid hard and scratchy foods such as popcorn
and pretzels
Expect stools to be black or dark for a few days
Common Respiratory Problems
 Laryngeal Cancer
 Predisposing factors:
• Overuse of voice
• Teachers
• Singers
• Family predisposition to cancer
 Signs and Symptoms:
• Persistent hoarseness associated with otalgia and
dysphagia
• Lump on the throat
• Pain in the adam’s apple that radiates to the ear
• Dyspnea, enlarged cervical nodes and cough
Common Respiratory Problems
 Surgical Management:
• Partial laryngectomy
• Total laryngectomy
• Tracheostomy – temporary or permanent
 Post-operative Care:
• Head of bed elevated 45o
• Assist patient in communicating – provide writing
materials, etc
• Post partial laryngectomy – patient will be able to talk
• Post total laryngectomy – no voice; artificial larynx
now available
• Practice swallowing
• Loss of sense of smell
Common Respiratory Problems
 Tracheostomy Care:
• Immediate postop; wound or stoma care – aseptic
technique
• In case of accidental removal of the tracheostomy tube,
the following should be at bedside
• Sterile forceps – to open the stoma
• Sterile set of tracheostomy tube – to be inserted by
the physician
• Provide adequate humidity – cool moist humidifier
• Cover the stoma during the day and remoisten it when it
dries. Use scarf, bib or turtleneck
• Wash stoma with washcloth and warm water and soap
daily
• Aspirate secretions if cough mechanism is not effective
Common Respiratory Problems
• Instill 3-5 ml of normal saline to loosen mucous plugs
before suctioning
• Hyperoxygenate before and after suctioning
• Take bath with caution making sure water or soap does
not enter the stoma. No swimming is allowed.
Common Respiratory Problems
 COPD – Chronic obstructive pulmonary
disease
 OAD – Obstructive airway disease
 CAL – Chronic airway limitation
Chronic bronchitis
 Excessive mucous production and
recurrent productive cough for two years
or longer
 Causes:
 Inhalation of physical or chemical irritants
 Viral or bacterial infections
Chronic bronchitis
 Signs and Symptoms:
 Chronic productive cough “cigarette cough”
 Grayish white sputum
 Dyspnea
 Cyanosis, tachycardia
 Respiratory acidosis
 Ankle edema, distended neck vein
 “Blue bloaters”
Chronic bronchitis
 Nursing management:
 Pharmacotherapeutics – mucolytic,
expectorants, antitussives, antihistamines
 Supportive measures – avoid smoking,
inhaled irritants, control of environmental
temperature, proper nutrition, adequate
hydration
Emphysema
 Destructive changes in alveolar walls and
enlargement of air spaces distal to
bronchioles; loss of recoil and air trapping
 Causes – unknown
 Predisposing factors:
 Smoking
 Alpha antitrypsin deficiency
 Familial tendency
Emphysema
 Signs and symptoms:
 Uses accessory muscles to breathe
 Ruddy collor
 No cyanosis
 Thin with “barrel-chest”
 Nursing management:
 Pursed-lip breathing
 Forward – leaning position
 Low O2 concentration
Asthma
 Bronchial spasms and constrictions
characterized by expiratory wheezing
 Causes:
 Genetic
 Immunologic
 Allergic
 Environmental
Asthma
 Common Factors that Triggers an Attack:
 Environmental factors – change in temperature or
humidity
 Atmospheric pollutants – cigarettes, industrial smoke
 Strong odors – perfume, insecticides
 Allergens – feathers, dust, food, pollens, laundry
detergents
 Exercise
 Stress or emotional upset
 Medications – aspirin, NSAIDs
Asthma
 Signs and symptoms:
 Episodic dyspnea
 Accessory muscle breathing
 Inspiratory or expiratory wheezing
 Respiratory alkalosis
 Status asthmaticus – respiratory acidosis
 Nursing management:
 Bronchodilators – epinephrine, theophylline,
aminophylline, proventil, terbutaline
 Corticosteroids – solumedrol, dexamethanol
Common Respiratory Problems
 Pneumohemohydrothorax – presence of
air, blood or water in the thoracic cavity
 Flail Chest – multiple rib fracture
characterized by paradoxical breathing
Flail Chest
 Nursing Management:
 CTT – Chest tube or closed thoracotomy tube;
surgical introduction of tube into the 7th and
8th intercostal space midaxillary to remove
water or blood (hydrothorax or hemothorax)
and 2nd or 3rd intercostal space mid-clavicular
to get rid of air (pneumothorax)
 Water sealed drainage
Flail Chest
 Nursing Care of Clients with CTT to H2O
sealed drain:
 Maintain patency of tube by milking or
stripping away from the patient towards the
drainage bottle
 Fasten tubing to bed to prevent dependent
loops
Flail Chest
 If fluid is not fluctuating in the water seal
chamber:
• Be sure patient is not lying on tubes
• Check connections to be sure chest tube
system is intact
• Ask patient to cough or change position to
see if fluctuation is restored
• Fluctuation will stop when lung has
reexpanded
Flail Chest
 Keep 2 hemostats with rubber prongs at the
bedside so that the chest tube can be clamped
if the system becomes disconnected or broken
Flail Chest
 An alternative method with no clamping of
tubes is to keep a liter bottle of sterile water
at bedside at all times. If the patient’s chest
drainage unit breaks or cracks:
• Insert the end of the pt’s chest tube into
the bottle of sterile water
• Remove any of the cracked or broken
system
• Obtain new system as soon as possible
Flail Chest
 Never lift the closed drainage system above
the pt’s chest because this will allow fluid to
be pulled into the pleural space
 When transporting a patient, chest tubes
should not be clamped unless it is necessary
for few minutes; bottles placed below the
chest level
Flail Chest
 If chest tube is accidentally pulled out of
chest:
• Apply gloves, pinch skin opening together
with fingers
• Apply petrolatum jelly gauze and sterile 4x4
dressing
• Cover dressing with adhesive tape and call
surgeon immediately