1. Stacie Pigues, MSN, RN NWCC NUR 1117 Foundations of Nursing RESPIRATORY FUNCTION

2. STRUCTURES OF THE RESPIRATORY SYSTEM

3. Upper Airway: –Mouth –Nose –Pharynx

4. STRUCTURES OF THE RESPIRATORY SYSTEM Lower Airway: –Trachea –Bronchi –Bronchioles –Alveoli –Lungs

5. NORMAL RESPIRATORY FUNCTION –Ventilation –Gas diffusion –Gas transport –Control of ventilation –Defenses of the respiratory system –Normal breathing pattern

6. NORMAL RESPIRATORY FUNCTION Ventilation, or breathing, is the process of moving air into and out of the lungs so that gas exchange can take place. Gas Diffusion refers to the movement of oxygen between the alveoli and the blood.

7. p. 736 GAS DIFFUSION

8. NORMAL RESPIRATORY FUNCTION Gas Transport occurs when oxygen crosses the alveolar-capillary membrane into the blood where blood transports it to the tissues. Control of Ventilation, this process is controlled through neural pathways.

9. DEFENSES OF THE RESPIRATORY SYSTEM Upper Airway functions to: Warm and humidify inspired air while maintaining the fluid character of the lower airway Clean inspired air Protect lower airway from infection and injury due to aspiration

10. DEFENSES OF THE RESPIRATORY SYSTEM Lower Airway functions to: Further clean inspired air “Mucus Blanket” –protects “Mucociliary Elevator”- helps remove bacteria

11. PROTECTIVE REFLEXES Coughing Sneezing

12. FACTORS THAT AFFECT BREATHING Age Activity level Life style

13. NORMAL BREATHING PATTERN Normal Parameters of Respiratory Rates effortless, smooth, even and regular average adult moves ½ L of air per breath

14. NORMAL BREATHING PATTERN Newborns and infants Rapid breathers Breathe 30-60 times per minute Surfactant replacement therapy

15. NORMAL BREATHING PATTERN Toddler and Preschooler Breathing even and smoother By age three, 20-30 breaths per min. Risk for aspiration

16. NORMAL BREATHING PATTERN Child and Adolescent Breathing steadily slows Breathe 12-20 times per minute Adolescence smoking and tobacco use

17. NORMAL BREATHING PATTERN Adults Breathe 12-20 times per minute Structural and functional changes:  Thoracic wall is more rigid  Lungs do not stretch as well  Gas exchange is affected  Protective functions are impaired  Cough is less effective

18. NORMAL BREATHING PATTERN Older Adults Breathe 16-25 times per minute Factors that affect older adults respiratory changes contribute to:  Activity intolerance  Increased respiratory infections

19. HISTORY Do you have a cough? Common causes: Histamines Borderline heart failure Nervous habit “Common” cough-only concerned if it changes

20. HISTORY Are you coughing up sputum? How much? Teaspoon, tablespoon or ½ cup What is the color of the sputum? Clear, yellow, bloody (hemoptysis) Consistency? Thick or thin

21. HISTORY Are you experiencing shortness of breath (dyspnea)? Possible causes: Lung disease CHF Anxiety

22. HISTORY Are you having any chest pain? Possible causes: Infection Inflammation Pneumonia Bronchitis

23. HISTORY What is your normal breathing pattern? When and how often do the breathing problems occur? Identify any exposures putting the patient at risk.

24. FACTORS AFFECTING RESPIRATORY FUNCTION Environment Lifestyle and habits Body position Increased work of breathing

25. ENVIRONMENT Weather Geographical location Air pollution Pollens and allergens

26. LIFESTYLE AND HABITS Smoking: pack(per day/week) or years Drugs and alcohol Nutrition

27. INCREASED WORK OF BREATHING Restricted lung movement Atelectasis May be chronic or acute due to: Smoke inhalation Pulmonary fibrosis Respiratory distress syndrome Pneumonia

28. INCREASED WORK OF BREATHING Restricted lung movement Obesity Chest or abdominal binders Abdominal distension caused by gas/fluid Meds/anesthesia Rib injuries Musculoskeletal chest deformities Severe weakness Neuromuscular disorders

29. INCREASED WORK OF BREATHING Airway Obstruction Any process that reduces the diameter of the airways causing increased airway resistance which requires more effort to breath because air is moving through a narrower passage

30. INCREASED WORK OF BREATHING Airway Obstruction Possible causes of airway obstruction are: Foreign body aspiration Excessive mucus Chronic bronchitis Cystic Fibrosis Asthma Croup Epiglottis Abnormal growths in the airway

31. ASSESSMENT - INSPECTION Body position Assess how your patient is sitting or lying Upright posture (high Fowler’s) allows for better lung expansion Reposition patient

32. ASSESSMENT - INSPECTION What is the rate? How hard are they working to breathe? Describe breathing pattern.  Hypoxemia-low oxygen levels in the blood  Hypercapnia-abnormally high carbon dioxide in the blood  Hyperventilation- excessive elimination of carbon dioxide causing dizziness and respiratory alkalosis

33. ASSESSMENT - INSPECTION Assessing color: Cyanosis- bluish skin discoloration caused by a desaturation of oxygen on the hemoglobin –Central cyanosis-mucus membranes blue around mouth and eyes - indicates SEVERE oxygenation problems

34. ASSESSMENT - INSPECTION Clubbing- round and enlarged fingers and toes Chest deformities- barrel chest Wounds Masses

35. ASSESSMENT - INSPECTION Other signs of respiratory distress: Gasping Panting Wheezing Nasal flaring Retractions

36. ASSESSMENT - PULSE OXIMETRY Pulse Oximetry

37. ASSESSMENT - PULSE OXIMETRY Pulse Oximetry - O2 Saturation Any changes in a patient’s level of consciousness, dizziness, restlessness, agitation, etc.—check pulse oximeter-may be due to hypoxia! If oxygen level normal—check glucose level. Normal Oxygen sat 95-100% with O2 intervention generally required if < 93% Patients with sleep apnea may need to bring their machines to the hospital. These patients are at high risk for hypoxia and respiratory arrest especially post-op. Higher altitudes= less oxygen available for gas diffusion = SOB & activity intolerance (p. 738)

38. ASSESSMENT- AUSCULTATION Anterior Posterior

39. AUSCULTATION-CRACKLES

40. AUSCULTATION-WHEEZES

41. DIAGNOSTIC TESTS AND PROCEDURES Sputum culture- Culture & Sensitivity  Thick and sticky  Yellow or green  Putrid or musty odor  Blood streaked  Frankly red, bloody (hemoptysis)

42. DIAGNOSTIC TESTS AND PROCEDURES Arterial blood gas (ABG) monitoring Arterial blood levels of oxygen, carbon dioxide and PH are the best indicator of gas exchange. Hyperventilation Hypoventilation

43. DIAGNOSTIC TESTS AND PROCEDURES Chest x-ray Pulmonary function tests (PFT) Bronchoscopy Lung scan/CT/MRI

44. DIAGNOSTIC TESTS AND PROCEDURES Throat culture Sputum specimens Cytology Thoracentesis Skin tests –PPD given to test TB exposure –Allergy tests identify airway hypersensitivity in asthmatics

45. NURSING DIAGNOSES Ineffective Breathing Pattern-monitor the patient and encourage slow, deep breathing, turning and coughing Ineffective Airway Clearance-ensure adequate hydration, instruct on how to cough effectively Impaired Gas Exchange- monitor cognitive changes, ABG, O2 Saturation, S & S of respiratory failure

46. OUTCOMES IDENTIFICATION AND PLANNING Knowledge regarding prevention of respiratory dysfunction Adequate oxygenation Mobilize pulmonary secretions Cope with changes in self-concept and lifestyle

47. IMPLEMENTATION Health promotion Preventing respiratory infections Encouraging smoking cessation Reducing allergens Monitoring peak flow

48. IMPLEMENTATION Health promotion Providing adequate hydration Positioning and ambulation Deep breathing and coughing Assisting with incentive spirometry

49. NURSING INTERVENTIONS Coughing Deep cough Stacked cough Low-flow (huff) cough Quad cough

50. NURSING INTERVENTIONS Pursed-lip breathing Chest physiotherapy –Percussion –Vibration –Postural drainage

51. NURSING INTERVENTIONS Aerosol Therapy –Aerosol medications-a suspension of liquid droplets in air or oxygen –Aerosols can be uses for several reasons: Adds moisture to oxygen Hydrates mucus to prevent mucus plugs Used to administer drugs, such as: Bronchodilator Corticosteroids Antibiotics

52. METERED-DOSE INHALERS (MDI’S)

53. HANDHELD NEBULIZERS

54. OXYGEN THERAPY ADMINISTRATION Oxygen therapy can be used to accomplish three fundamental goals in patient care: Improves tissue oxygenation allowing for better healing to occur- when in the healing process, the body’s metabolic demand for oxygen is increased. Helps decrease work of breathing in patients with shortness of breath or dyspnea Decreases the work of the heart in patients with cardiac diseases

55. OXYGEN THERAPY ADMINISTRATION Oxygen flow is ordered in liters per minute. General rule in the use of O2 therapy is to use the lowest amount possible to achieve an acceptable blood oxygen level. You will find that most patients’ will have an order for Oxygen if the SaO2 is below 93%. Oxygen is used to help stabilize the patient and then they will be slowly weaned off O2 therapy. You will monitor for color, alertness, heart rate, O2 Sat, and breathing effort. *ENSURE THAT THE APPROPRIATE AMOUNT OF OXYGEN PRESCRIBED IS BEING DELIVERED!

56. SELECTION OF OXYGEN SYSTEMS Various devices are available for providing oxygen at different flow rates and concentrations Device used depends on patients oxygenation status Best oxygen device is provided with consideration of comfort for the patient

57. OXYGEN THERAPY Nasal Cannula By Nasal Cannula (BNC) Flow Rate- 1L to 6L per minute Oxygen concentration range 22%-44% Oxygen concentration varies with breathing patterns

58. OXYGEN THERAPY Venturi mask Flow rate- 3L to 8L per minute Oxygen concentration range- 24% to 50%

59. OXYGEN THERAPY Simple mask Flow rate- 6 to 10L per minute Oxygen concentration range 40%-60% Oxygen concentration varies with breathing patterns

60. OXYGEN THERAPY Reservoir (Non-rebreather) mask Flow rate- 10 to 15L per minute Oxygen concentration range 90%+ Used for critically ill patients

61. OXYGEN SAFETY Oxygen is a drug; an order is required Monitor flow rate to ensure accurate amount is being administered Normal range for oxygen saturation is 95- 100%; O2 for <93% Teach the importance of wearing oxygen device Smoking is prohibited

62. OXYGEN SAFETY Review the Safety Alerts in Craven regarding COPD & oxygen The normal drive to breath is high carbon dioxide level (hypercapnia); however, the patient with COPD has become accustomed to this, therefore their drive to breath is hypoxemia (low oxygen level). Patients with COPD must be maintained with low concentrations of oxygen. Oxygen therapy requires physician order-may see oxygen initiated, changed and discontinued without a written order on the chart if respiratory therapy utilizes oxygen protocol. This protocol has medical staff approval.

63. NURSING INTERVENTIONS Dyspnea management Hyperventilation management Assisted ventilation –BiPAP (Bilevel Positive Airway Pressure) –CPAP (Continuous Positive Airway Pressure)

64. NURSING INTERVENTIONS Artificial Airways Oral or Nasal Pharyngeal Airways Endotracheal Tubes Trachesotomy

65. PHARYNGEAL AIRWAYS Oral Airways Nasal Trumpets

66. ENDOTRACHEAL TUBE

67. TRACHEOSTOMY Cuffed Uncuffed

68. SUCTIONING Suction catheter kit Yankauer

69. CHEST TUBES Pneumothorax- air in the pleural space Hemothorax-blood in the pleural space

70. VENTILATORS

71. DISCHARGE NEEDS Infection control Medications Home oxygen systems Energy conservation Fostering self-esteem

72. REFERENCES Craven, R, Hirnle, C. & Jensen, S.(2013). Fundamentals of Nursing (7 th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Chapter 25.