1. Copyright © 2015. F.A. Davis Company Chapter 29 Respiratory System Function, Assessment, and Therapeutic Measures

2. Copyright © 2015. F.A. Davis Company Learning Outcomes  Describe the normal structures and functions of the respiratory system.  Identify how aging affects the respiratory system.  List data to collect when caring for a patient with a respiratory disorder.  Recognize expected findings when inspecting, palpating, percussing, and auscultating the chest.

3. Copyright © 2015. F.A. Davis Company Learning Outcomes (cont’d)  Identify common diagnostic tests performed to diagnose disorders of the respiratory system.  Plan nursing care for patients undergoing each of the diagnostic tests.  Discuss therapeutic measures used to help patients with respiratory disorders.

4. Copyright © 2015. F.A. Davis Company Normal Respiratory Anatomy  Nose and Nasal Cavities- The nasal mucosa is ciliated epithelium that is highly vascular. The ciliated epithelium also sweeps mucus and pathogens from the nasal cavities and trachea to the pharynx

5. Copyright © 2015. F.A. Davis Company  Pharynx- Consist of 3 sections 1.Nasopharynx- An air passageway behind nose 2.Oropharynx- An air and food passage located in back of throat 3.Laryngopharynx- An air and food passage that opens up either to larynx or esophagus

6. Copyright © 2015. F.A. Davis Company  Larynx- is the voice box and the airway between the pharynx and the trachea  Trachea and Bronchial Tree- the trachea extends from the larynx to the primary bronchi. The bronchial tree is the series of air passages within the lungs  Lungs- occupy the chest cavity on either side of the heart. The functional unit of the lung are the millions of alveoli which are the air sacs that are the site for gas exchange

7. Copyright © 2015. F.A. Davis Company Mechanism of Breathing  Ventilation- movement of air into and out of the alveoli. Air moves from high pressure area to low pressure areas. The respiratory centers are in the medulla oblongata and pons of the brain  Inhalation- occurs when motor impulses from the medulla cause contraction of the respiratory muscles  Exhalation- passive process when diaphragm and intercostal muscles relax

8. Copyright © 2015. F.A. Davis Company Transport of Gases in the Blood  Oxygen is carried by iron in the hemoglobin (Hgb) of red blood cells (RBC’s).  Carbon Dioxide is carried in the blood in the form of bicarbonate ions in the plasma

9. Copyright © 2015. F.A. Davis Company Regulation of Respiration  Respirations are regulated by the nervous system and chemical mechanisms  The medulla oblongata contains an inspiratory center and an expiratory center. The inspiratory center generates impulses that bring about contraction of the respiratory muscles resulting in inhalation. When the impulse stops, exhalation occurs.  Carbon dioxide is the major regulator of respiration because even small changes in C02 blood level change pH.

10. Copyright © 2015. F.A. Davis Company Review of A&P

11. Copyright © 2015. F.A. Davis Company Review of A&P (cont’d)

12. Copyright © 2015. F.A. Davis Company Review of A&P (cont’d)

13. Copyright © 2015. F.A. Davis Company Review of A&P (cont’d)

14. Copyright © 2015. F.A. Davis Company Review of A&P (cont’d)

15. Copyright © 2015. F.A. Davis Company Review of A&P (cont’d)

16. Copyright © 2015. F.A. Davis Company Acid-Base Balance  Respiratory Acidosis- Any decrease in the rate or efficiency of respirations permits excess C02 to accumulate in the blood causing blood pH to decrease. This can occur because of pulmonary disease or any impairment of gas exchange in the lungs.(hypoventilation)

17. Copyright © 2015. F.A. Davis Company Acid-Base Balance  Respiratory Alkalosis- When the rate of respiration increases, eliminating exhaled C02 rapidly, the pH of the blood increases. This can occur during anxiety or hyperventilation.

18. Copyright © 2015. F.A. Davis Company Effects of Aging

19. Copyright © 2015. F.A. Davis Company History  Upper Respiratory Symptoms  Lower Respiratory Symptoms  Exposures/Smoking  Current Treatments  Family History

20. Copyright © 2015. F.A. Davis Company WHAT’S UP?  Where Is It?  How Does It Feel?  Aggravating and Alleviating Factors  Timing  Severity  Useful Other Data  Patient’s Perception

21. Copyright © 2015. F.A. Davis Company Inspection  Symmetry  Dyspnea  Use of Accessory Muscles  Color

22. Copyright © 2015. F.A. Davis Company Inspection  Symmetry  Resp rate/rhythm  Dyspnea  Use of Accessory Muscles  Chest shape

23. Copyright © 2015. F.A. Davis Company Palpation  Sinuses  Respiratory Excursion  Crepitus

24. Copyright © 2015. F.A. Davis Company Percussion  Resonance  Hyperresonance  Dull  Flat

25. Copyright © 2015. F.A. Davis Company Auscultation  Normal Breath Sounds  Adventitious Sounds  Compare Bilaterally

26. Copyright © 2015. F.A. Davis Company Adventitious Breath Sounds  Crackles—Coarse or Fine  Wheezes  Stridor  Friction Rub  Diminished  Absent  Chart 29.4 page 603

27. Copyright © 2015. F.A. Davis Company Laboratory Tests  CBC- Dyspnea can be caused by a reduction in RBC’s or hemoglobin– Elevated WBC’s indicate infection  ABGs- Measured to determine the effectiveness of gas exchange- page 604  D-Dimer-Helps diagnose the presence of pulmonary embolism

28. Copyright © 2015. F.A. Davis Company Laboratory Test Cont….  Sputum Cultures- Have pt take several deep breaths and cough sputum into sterile container  Throat Culture- Use swab to reach pharynx without touching pt mouth  Nasal Samples- Use of nasal swab or wash to identify flu or respiratory virus  SpO 2- Sensor that measures the percentage of hemoglobin that is saturated with oxygen  Capnography- Measures a person’s exhaled CO2 level

29. Copyright © 2015. F.A. Davis Company Diagnostic Tests  Chest X-Ray- diagnose pulmonary disorder  CT Scan- NPO 4 hrs, Check allergies if contrast used, void for comfort  VQ Scan (Ventilation Perfusion Scan- lung scan  PFTs- determines lung volume, capacity & flow rate- Study table 29.7/page 606  Pulmonary Angiography- Administration of contrast dye to examine pulmonary vessels- **Femoral artery is used as injection site so pt will need to lie flat for 8 hours so injection site does not bleed.

30. Copyright © 2015. F.A. Davis Company Diagnostic Test Cont…- Bronchoscopy  Use of flexible endoscope to examine larynx, trachea, and bronchial tree.  NPO 6-8 hours  Anesthetic spray to numb throat, sedative  Atropine to dry up excess secretions.  Pt NPO till gag reflex returns, touch back of throat with a cotton swab

31. Copyright © 2015. F.A. Davis Company  Smoking Cessation- Behavior modification, Counseling, Setting a quit date, Nicotine replacement therapy, Drug therapy, Acupuncture, Hypnosis  Deep Breathing and Coughing  Huff Coughing- Coughing with mouth open- **a short huff helps clear larger airways while a long huff helps open and clear smaller airways Therapeutic Measures

32. Copyright © 2015. F.A. Davis Company Breathing Exercises  Diaphragmatic Breathing- place one hand on the chest and the other on the abdomen as you try to push out the abdomen during inspiration and relaxing the abdomen during expiration  Pursed lip breathing

33. Copyright © 2015. F.A. Davis Company  Use Fowler’s or semi-Fowler’s position to keep abdominal contents from crowding the lungs  Good lung down- Patients with unilateral lung disease can benefit from the “good lung down.” Gravity will cause greater blood flow to the good lung thereby increasing O2 saturation Positioning

34. Copyright © 2015. F.A. Davis Company Oxygen Therapy  Nasal canula- low flow device  Masks (low flow device)- may make pt feel clausterphobic. Used when higher 02 concentration is needed. - partial rebreather- used to capture some exhaled gas for rebreathing - non rebreather- has one or both side vents closed to limit the mixing of room air with oxygen  Venuturi Mask- high flow device with a combination of valves for specified flow rates

35. Copyright © 2015. F.A. Davis Company Risk of Oxygen Therapy  Pts with COPD usually have chronically high PCO2 levels so they depend on low PO2 levels to stimulate breathing, and high supplemental flow rates can depress respirations. These patients should be maintained on no more than 1-2 liters of oxygen per minute

36. Copyright © 2015. F.A. Davis Company Oxygen Masks

37. Copyright © 2015. F.A. Davis Company Transtracheal Oxygen

38. Copyright © 2015. F.A. Davis Company NMT- Nebulizer mist treatment  Use of a nebulizer to deliver med directly into lung  Given by RT  Most commonly ordered every 4-6 hours or as needed  Some pts give themselves breathing treatments at home  Bronchodialators such as albuteral are most commonly administered

39. Copyright © 2015. F.A. Davis Company MDI- Metered Dose Inhalers  Administers topical medication directly into lungs  Using a spacer can increase the amount of med that gets to lungs

40. Copyright © 2015. F.A. Davis Company Spacer

41. Incentive Spirometer  Used to encourage deep breathing in pts at risk for collapse of lung tissue (atelectasis).  Most commonly ordered for post op patients  Pts should use the spirometer 10 times each hour while awake

42. Copyright © 2015. F.A. Davis Company Incentive Spirometer

43. Copyright © 2015. F.A. Davis Company Chest Physiotherapy  Involves postural drainage, percussion, and vibration to help move secretions from deep inside the lungs  Usually indicated for pts who have a weak or ineffective cough and is at risk for retaining secretions

44. Copyright © 2015. F.A. Davis Company Chest Physiotherapy

45. Copyright © 2015. F.A. Davis Company High Frequency Chest Wall Oscillation Vest  Sometimes called vest therapy  Alternative to Chest Physiotherapy because it does not require the presence of a therapist

46. Copyright © 2015. F.A. Davis Company Vibratory Positive Expiratory Pressure Device  Small hand held device  When pt blows into the mouthpiece, it makes a heavy steel ball bounce around which sends vibrations back into airways to help loosen mucus

47. Copyright © 2015. F.A. Davis Company Vibratory Positive Expiratory Pressure Device

48. Copyright © 2015. F.A. Davis Company Thoracentesis  Involves the insertion of a needle into the pleural space.  Commonly done to aspirate fluid in patients with pleural effusion (fluid trapped in pleural space)

49. Copyright © 2015. F.A. Davis Company Chest Drainage  Indications-When fluid or air has collected in the pleural space  Chest Tube Insertion- drainage tubes through the chest wall into the pleural space  Drainage System- has a water seal chamber, a suction chamber, and a drainage chamber  Keep 2 padded clamps at the bedside in the event the chest tube is disconnected from the drainage system  Nursing Care- Box 29.1 page 614

50. Copyright © 2015. F.A. Davis Company Chest Drainage System

51. Copyright © 2015. F.A. Davis Company Tracheostomy  Definition- Surgical opening through base of neck into trachea  Indications- Due to pts having cancerous larynx removed, airway obstuction due to trauma or a tumor, pts who cannot clear secretions from airway, or pts who need prolonged mechanical ventilation  Nursing Care ‒ Suctioning ‒ Cleaning ‒ Communication ‒ Teaching

52. Copyright © 2015. F.A. Davis Company Passy-Muir Speaking Valve

53. Copyright © 2015. F.A. Davis Company Intubation  Placing an ET (endotrachial tube) through the nose or mouth into the trachea to maintain adequate oxygenation because of airway obstuction or respiratory failure  Pts in Cardiac arrest or pts undergoing general anes for surgery are intubated and mechanically ventilated  Some pts have advance directives and do not wish to be intubated  Intubation is usually used short term because it can damage vocal cords and surrounding tissue

54. Copyright © 2015. F.A. Davis Company Intubation

55. Nursing Care of Intubated Pt.  Regular assessments of lung sounds and respiratory status  Oral tubes are repositioned and resecured to oposite side of mouth every 24 hours  If pt is awake they should be instructed not to pull on tube- an order for soft restraints may be necessary for confused pts  ET tubes have a cuff to help maintain proper placement  Pts are often anxious so reassure and talk to patient

56. Copyright © 2015. F.A. Davis Company  Pts may need suctioning if they are unable to cough effectively (sterile process)  Require frequent mouth care  Monitor ABG’s and O2 saturation

57. Copyright © 2015. F.A. Davis Company Mechanical Ventilation  Invasive ‒ Indications ‒ Nursing Care ‒ Trouble-Shooting Alarms

58. Copyright © 2015. F.A. Davis Company Mechanical Ventilation Indications- provide ventilation for patients who are unable to breath effectively on their own. Ventilators use positive pressure to push oxygenated air into the lungs at preset intervals. Mechanical ventilation is needed after some surgeries, Cardiac or pulmonary arrest, declining ABG’s, or injuries that affects muscles of respiration. ‒ Ventilator Modes- Ventilators can control ventilation or assist pts own function

59. Copyright © 2015. F.A. Davis Company Ventilator Alarms  Low pressure- can be caused by disconnecting tubing, leaks in tubing or around ET tube, or an underinflated cuff  High pressure- might occur if pt needs to be suctioned, biting on tube, coughing, trying to talk, kinked or obstucted tubing

60. Copyright © 2015. F.A. Davis Company Nursing Responsibility for mechanical ventilation  Check advanced directive before intubating pt and putting them on mechanical ventilation  Keep HOB elevated 45 degree angle to reduce risk of aspiration  Oral care  Regular suctioning  Communicate with pt (pt may become anxious

61. Copyright © 2015. F.A. Davis Company Noninvasive Positive Pressure Ventilation  Indications- alternative to intubation and mech ventilation for pts who are able to breath on their own but unable to maintain normal ABG’s  Advantages- noninvasive  Cpap (continuous positive airway pressure)- the same amount of oxygen pressure is maintained throughout inspiration and expiration  Bipap (bilevel positive airway pressure)- a lower positive pressure is used on expiration  Nursing Care- Apply adhesive barrier to areas that come in contact with mask. Place pt in semifowlers position to prevent gastric distention

62. Copyright © 2015. F.A. Davis Company 1.Pneumothorax 2.Dyspnea 3.Inhalation 4.Exhalation What occurs in response to negative pressure in the thoracic cavity? Review Question

63. Copyright © 2015. F.A. Davis Company 1.Respiratory alkalosis 2.Respiratory acidosis 3.Metabolic alkalosis 4.Metabolic acidosis Which acid-base imbalance results from impaired respiratory function? Review Question

64. Copyright © 2015. F.A. Davis Company 1.Stridor 2.Friction rub 3.Crackles 4.Wheezes Which adventitious breath sound is generated by narrowed inflamed airways? Review Question

65. Copyright © 2015. F.A. Davis Company 1.Nicotine replacement 2.Drug therapy 3.Behavior modification 4.Hypnosis 5.Setting a quit date What is the best method to recommend for smoking cessation ? Select all that apply. Review Question

66. Copyright © 2015. F.A. Davis Company 1.Antihistamines 2.Vibratory Positive Expiratory Pressure Device 3.Oxygen 4.Room humidifier 5.Huff coughing Which interventions can help patients expectorate sputum ? Select all that apply. Review Question