1. Timby/Smith: Introductory Medical-Surgical Nursing, 11/e
Chapter 19: Introduction to the Respiratory System

2. Respiratory Anatomy
Upper airway: nose, sinuses, turbinates, pharynx, and larynx
Paranasal sinuses: frontal, ethmoidal, sphenoidal, and maxillary
Lower airway: trachea, bronchi, bronchioles, lungs, and alveoli

3. Accessory Structures
Diaphragm: separates thoracic and abdominal cavities
Mediastinum: wall that divides thoracic cavity into two halves
Pleura: saclike serous membrane
Visceral pleura: covers the lung surface
Parietal pleura: covers the chest wall
Serous fluid: lubricates the visceral and parietal pleurae

4. Respiratory Physiology
Main functions
Respiration: O2 and CO2 exchanged between atmospheric air and the blood and between the blood and cells
Ventilation
Actual movement of air in and out of the respiratory tract

5. Mechanics of Ventilation
Inspiration: movement of O2 into lungs
Expiration: removal of CO2 from lungs
Diffusion: transferring a substance from an area of higher concentration to an area of lower concentration
Perfusion: flow of blood in the pulmonary circulation
Distribution: delivery of atmospheric air to the separate gas exchange units in the lungs

6. Alveolar Respiration
Alveolar respiration determines amount of CO2 in the body
Increased CO2, primarily in body fluids as carbonic acid, causes pH to decrease below 7.4 (normal).
Decreased CO2 causes pH to increase above 7.4.
Kidneys excrete excess hydrogen ions, which keep serum bicarbonate levels near normal.
Lungs eliminate carbonic acid by blowing off more CO2; conserve CO2 by slowing respiratory volume

7. Alveolar Respiration—(cont.)

8. Transport of Gases Oxygen transport
Greater portion combines with hemoglobin in RBCs; oxyhemoglobin
CO2 diffuses from the tissue cells to the blood
Imbalances
Respiratory acidosis; respiratory alkalosis
Metabolic acidosis; metabolic alkalosis

9. Pulmonary Perfusion Perfusion: blood supply to the lungs
Lungs receive nutrients and O2
Bronchial circulation: bronchial arteries supply blood to trachea and bronchi
Pulmonary circulation: pulmonary artery transports venous blood from the right ventricle to the lungs

10. Ventilation/Perfusion Ratio
Cardiopulmonary status
Ventilation/perfusion ratio (V/Q ratio)
Effectiveness of airflow within the alveoli (ventilation)
Adequacy of gas exchange within pulmonary capillaries (perfusion)

11. Question
Movement of air into and out of the lungs sufficient to maintain normal arterial oxygen and carbon dioxide tensions is termed: A) Perfusion B) Ventilation C) Diffusion D) Inspiration

12. Answer
B) Ventilation Rationale: Ventilation is the actual movement of air in and out of the respiratory tract. This process requires a patent airway and intact and functioning respiratory muscles.

13. Problems in Respiratory Physiology
Respiratory insufficiency develops if there is too much interference with ventilation, diffusion, or perfusion.
Abnormalities
Hypoxia: decreased O2 in inspired air
Hypoxemia: decreased O2 in the blood
Hypercapnia: increased CO2 in the blood
Hypocapnia: decreased CO2 in the blood

14. Problems in Respiratory Physiology—(cont.)
Primary factors
Airway resistance
Airway resistance R/T airway diameter, rate of air flow, and speed of gas flow
Examples: asthma, chronic bronchitis, emphysema
Lung compliance
Decrease surfactant, fibrosis, edema

15. Gerontologic Considerations
Cartilage in nasal septum increases in length and can harden; airflow changes
Alveoli walls become thinner and contain fewer capillaries; decreased gas exchange
Lungs lose elasticity; diminished lung expansion
Muscle tone, cough reflex, and cilia decrease
At risk for increased risk for respiratory disease

16. Assessment History General health Family hx of respiratory disease
Frequency of respiratory illness, allergies, and smoking hx
Respiratory treatments or medications, pulmonary tests, occupation
Exercise tolerance, pain, and level of fatigue

17. Assessment—(cont.) Physical Examination
Skin color; LOC; mental status; respiratory rate, depth, effort, and rhythm; use of accessory muscles; and shape of the chest and symmetry of chest movements; finger clubbing
Inspect nose for signs of injury, inflammation; tracheal symmetry
Dyspnea, pain on inspiration, increased or more frequent cough, increased sputum production or change in color/consistency of the mucus, wheezing, hemoptysis

18. Breath Sounds Percussion; tactile or vocal fremitus: say “99”
Auscultation
Normal breath sounds
Vesicular sounds: produced by air movement in bronchioles and alveoli
Bronchial sounds: produced by air movement through the trachea
Bronchovesicular sounds: normal breath sounds heard between trachea and upper lungs

19. Lung Assessment—Auscultation

20. Question
While conducting the physical examination during assessment of the respiratory system, which of the following would describe lung sounds produced by air movement through the trachea and are loud with long expiration? A) Bronchovesicular sounds B) Bronchial sounds C) Sonorous wheezes D) Vesicular sounds

21. Answer
B) Bronchial sounds Rationale: Normal bronchial lung sounds are auscultated over the trachea and are loud with long expiration.

22. Breath Sounds—(cont.) Adventitious Lung Sounds
Crackles (formally called rales): resemble static or the sound made by rubbing hair strands together in one’s ear; sometimes clear with coughing
Wheezes: sibilant (hissing or whistling) or sonorous (full and deep); heard during inspiration and expiration
Sonorous wheezes (formerly called rhonchi): lower pitched and heard in trachea and bronchi
Friction rubs: heard as crackling or grating sounds on inspiration and expiration

23. Diagnostic Tests Arterial Blood Gases (ABGs)
Blood’s pH; O2-carrying capacity; and levels of O2, CO2, and bicarbonate ion
Pulmonary function studies: functional ability of the lungs; spirometer
Sputum studies: pathogenic microorganisms and cancer cells; culture and sensitivity tests

24. Diagnostic Tests—(cont.)
Pulse oximetry
O2 content of hemoglobin
Measures oxygen saturation (SpO2) of arterial blood

25. Diagnostic Tests—(cont.)
Radiography: size, shape, and position of the lungs and other structures of the thorax
Pulmonary angiography: radioisotope study viewing arterial circulation of the lungs: PE
Lung scans: ventilation-perfusion scan (V-Q scan), the gallium scan, positron emission tomography (PET) scan

26. Diagnostic Tests—(cont.)
Bronchoscopy: visualization of the larynx, trachea, and bronchi
Laryngoscopy, mediastinoscopy, and thoracoscopy: examination of pleural cavity
Thoracentesis: removal of excess air or fluid accumulates between visceral and parietal pleurae; must be aspirated by inserting a needle into chest wall

27. Question
The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation on a patient who presents in respiratory distress. What site can ABGs be obtained from? A) A puncture in the radial artery B) The trachea and bronchi C) A swab from the nasopharynx D) An intravenous catheter in the arm vein

28. Answer
A) A puncture in the radial artery Rationale: ABGs determine the blood’s pH; oxygen- carrying capacity; and levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery.

29. Nursing Care Plan: Bronchoscopy
Nursing Diagnosis: Fear, Risk for Aspiration
Interventions
Acknowledge fear, simple explanations; inform that client will receive medications for anxiety
Assess cough/gag reflex
Available suction; semi-Fowler’s position
Report complications of pneumothorax, dysrhythmia, or bronchospasm
Outcomes: Client tolerates procedure without negative effects and maintains patent airway and minimal potential complications.