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Assessment & Disorders
Respiratory System Assessment & Disorders 26/10/2009
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Upper Respiratory System
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Noses and Sinuses Nose Sinuses Begin respiratory system
Filter and warm air Sinuses Openings in facial bones Lighten skull Assist in speech Produce mucus
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Pharynx and Larynx Pharynx Larynx Nasopharynx Oropharynx
Laryngopharynx Larynx Connects laryngopharynx to trachea Routes air and food to proper passageway
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Lower Respiratory system
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Lungs Separated by mediastinum Composed of elastic connective tissue
Divided into lobes which are further divided into segments
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Bronchi and Alveoli Trachea divides into right and left mainstem bronchi Bronchi continue to branch and get smaller (bronchioles) and end as alveoli Air moves through passageways to alveoli where gas exchange occurs
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Bronchioles and Alveoli
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Pulmonary Circulation
Pulmonary arteries Pulmonary veins Pulmonary capillary network
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Pleura Double-layered membrane that covers lungs
Parietal Visceral Hold lungs out to chest wall
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Rib Cage and Intercostal Muscles
Protect lungs 12 pairs ribs Intercostal muscles are between ribs Assist with process of breathing
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Ventilation Divided into inspiration and expiration
Normal is 12–20 breaths per minute
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Inspiration Lasts 1–1.5 seconds Diaphragm contracts and flattens
Intercostal muscles contract Increases size of chest cavity Lungs stretch and volume increases Pressure in lungs slightly less than atmospheric Causes air to rush in
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Expiration Lasts 2 to 3 seconds Passive Muscles relax Diaphragm rises
Ribs descend Lungs recoil Pressure in chest cavity increases (compressing alveoli) Pressure in lungs higher than atmospheric causes gases to flow out of the lungs
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Factors Affecting Respiration
Respiratory center of the brain Chemoreceptors in the brain, aortic arch, and carotid arteries Airway resistance Compliance Elasticity Surface tension of alveoli
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Respiratory Changes Associated with Aging
Cartilage that connects ribs to sternum and spinal cord calcifies Anterior-posterior diameter of chest increases Respiratory muscles weaker Cough and laryngeal reflexes less effective
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Respiratory Changes Associated with Aging
Size of lungs decreases Alveoli less elastic Older client at greater risk for developing respiratory infections
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Assessment Subjective Current complaint or existing condition
Onset or duration of symptoms Ability to maintain ADL Nasal congestion, nosebleeds Sore throat, difficulty swallowing Changes in voice quality Difficulty breathing, orthopnea Pain on breathing
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Assessment (continued)
Subjective Presence of cough frequency, duration, productive or unproductive Sputum amount, color, and consistency Exposure to infections (colds or influenza) History of chronic lung conditions Occupational exposure to chemicals, smoke, asbestos
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Assessment (continued)
Subjective History of previous respiratory problems Allergies to medication or environmental allergens Use of tobacco, chewing tobacco, marijuana, cocaine, injected drugs, and alcohol
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Assessment (continued)
Objective Assess state of health Color Ease of breathing Note respiratory rate and pattern Observe nasal flaring Use of accessory muscles for breathing Listen for hoarseness in client’s speech
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Assessment (continued)
Objective Inspect mucosa of nose, mouth, and oropharynx Inspect neck, position of trachea Inspect anterior/posterior diameter of chest Palpate lips for nodules, chest for tenderness or swelling
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Assessment (continued)
Objective Auscultate breath sounds, note absence or presence and quality Note adventitious breath sounds (wheezing or crackles)
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Pulse Oximetry Monitors oxygen saturation (SpO2) Nursing Care
Amount of arterial hemoglobin that is combined with oxygen Nursing Care Apply to fingertip, forehead, earlobe, or nose Remove nail polish when using fingertip
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Arterial Blood Gases Nursing care
Apply pressure to site 2–5 minutes following arterial puncture
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Serum Alpha1-Antitrypsin
Deficiency in this serum protein contributing factor in emphysema and COPD Normal value in adults 150–350 mg/dL Fasting specimen obtained in client with elevated cholesterol or triglycerides
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Sputum and Tissue Throat or nose swab Sputum specimen
Culture and sensitivity Gram’s stain Acid-fast stain Cytology
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Imaging Techniques X-rays CT scans Ventilation perfusion scans
Nursing care and client teaching If contrast used remember to ask about allergies, especially iodine and seafood
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Pulmonary Function Tests
Measure lung volume and capacity Smoking, caffeine, and bronchodilators interfere with results Nursing care and client teaching Instruct client to stop bronchodilators 4–6 hours prior to test Instruct client not to smoke or drink caffeinated drinks prior to test
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Lung Volumes and Capacities
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Direct Visualization Direct or indirect laryngoscopy
Used to identify and evaluate laryngeal tumors Nursing care and client teaching Make sure consent form has been signed Remove dentures, partial plates, bridges prior to procedure NPO before procedure NPO after procedure until gag reflex returns
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Bronchoscopy Visualize trachea, bronchi and bronchioles
Tumors and structural disorders Obtain tissue biopsy Obtain sputum specimen Removal of foreign body Nursing care and teaching
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Dr Ibrahim Bashayreh, RN, PhD.
Asthma and COPD Dr Ibrahim Bashayreh, RN, PhD. 25/10/2010
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Asthma Asthma is a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways 26/10/2009
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Asthma Asthma is a chronic (long-term) disease that makes it hard to breathe. Asthma can't be cured, but it can be managed. With proper treatment, people with asthma can lead normal, active lives. 26/10/2009
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Etiology Cause of asthma is unknown but many factors play a part:
Genetic factors: Asthma tends to run in the family Environmental factors: pollen, dust, mold, tobacco smoke Occupational exposure: chemicals and gases 26/10/2009
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Normal bronchiole/ Asthmatic bronchiole
26/10/2009
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How asthma works If you have asthma, your airways (breathing passages) are extra sensitive. When you are around certain things, your extra-sensitive airways can: Become red and swollen - your airways get inflamed inside. They fill up with mucus. The swelling and mucus make your airways narrower, so it's harder for the air to pass through. 26/10/2009
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Cont. Become "twitchy" and go into spasm - the muscles around your airways squeeze together and tighten. This makes your airways narrower, leaving less room for the air to pass through. The more red and swollen your airways are, the more twitchy they become. 26/10/2009
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Symptoms Hard breathing caused by irritants
Asthma inducers: If you breathe in something you're allergic to- for example, dust or pollen- or if you have a viral infection- for example, a cold or the flu- your airways can become inflamed (red and swollen). 26/10/2009
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Cont. Asthma triggers: If you breathe in an asthma trigger like cold air or smoke, or if you exercise, the muscles around your airways can go into spasm and squeeze together tightly. This leaves less room for air to pass through. It's important for every person with asthma to know what they triggers and inducers are. 26/10/2009
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What are the Triggering Factors?
Domestic dust mites Air pollution Tobacco smoke Occupational irritants Animal with fur Pollen 26/10/2009
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Triggering Factors ( cont.)
Respiratory (viral) infections Chemical irritants Strong emotional expressions Drugs ( aspirin, beta blockers) 26/10/2009
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Asthma: Early Clinical Manifestations
Expiratory & inspiratory wheezing Dry or moist non-productive cough Chest tightness Dyspnea Anxious &Agitated Prolonged expiratory phase Increased respiratory & heart rate 26/10/2009
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Asthma: Early Clinical Manifestations
Wheezing Chest tightness Dyspnea Cough Prolonged expiratory phase [1:3 or 1:4] 26/10/2009
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Asthma: Severe Clinical Manifestations
Hypoxia Confusion Increased heart rate & blood pressure Respiratory rate up to 40/minute & pursed lip breathing Use of accessory muscles Diaphoresis & pallor Cyanotic nail beds Flaring nostrils 26/10/2009
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Classification At risk- breathing test normal, mild symptoms
Mild- breathing test shows mild limitation, increasing symptoms Moderate- person will typically seek care for symptoms, shortness of breath with significant exertion, lung tests abnormal Severe- shortness of breath with limited activity, lung tests abnormal Review. Ask them to describe someone they’ve worked with who had COPD and determine at what level that person might have been. 26/10/2009 48
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Asthma: Diagnostic Tests
Pulmonary Function Tests FEV1 decreased Increase of 12% - 15% after bronchodilator indicative of asthma PEFR decreased Symptomatic patient eosinophils > 5% of total WBC Increased serum IgE Chest x-ray shows hyperinflation ABGs Early: respiratory alkalosis, PaO2 normal or near-normal severe: respiratory acidosis, increased PaCO2, 26/10/2009
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Asthma: Nursing Diagnoses
Ineffective airway clearance r/t bronchospasm, ineffective cough, excessive mucus Anxiety r/t difficulty breathing, fear of suffocation Ineffective therapeutic regimen management r/t lack of information about asthma Knowledge deficit 26/10/2009
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Medical Management of Asthmatic Patient
Limit exposure triggering agents Medications such as: inhaled corticosteroids, inhaled beta2 adrenergic agonist, and cromolyn sodium 26/10/2009
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Asthma Medications: Anti-inflammatory
Leukotriene modifiers Interfere with synthesis or block action of leukotrienes Have both bronchodilation and anti-inflammatory properties Not recommended for acute asthma attacks Should not be used as only therapy for persistent asthma Accolate, Singulair, Zyflo Corticosteroids Not useful for acute attack Beclomethasone: vanceril, beclovent, qvar Cromolyn & nedocromil Inhibits immediate response from exercise and allergens Prevents late-phase response Useful for premedication for exercise, seasonal asthma Intal, Tilade 26/10/2009
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Asthma Medications: Bronchodilators
2-adrenergic agonists Rapid onset: quick relief of bronchoconstriction Treatment of choice for acute attacks If used too much causes tremors, anxiety, tachycardia, palpitations, nausea Too-frequent use indicates poor control of asthma Short-acting Albuterol[proventil]; metaproterenol [alupent]; bitolterol [tornalate]; pirbuterol [maxair] Long-acting Useful for nocturnal asthma Not useful for quick relief during an acute attack Salmeterol [serevent] 26/10/2009
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Asthma Medications: Bronchodilators con’t
Methylxanthines Less effective than beta- adrenergics Useful to alleviate bronchoconstriction of early and late phase, nocturnal asthma Does not relieve hyperresponsiveness Side effects: nausea, headache, insomnia, tachycardia, arrhythmias, seizures Theophylline, aminophylline Anticholinergics Inhibit parasympathetic effects on respiratory system Increased mucus Smooth muscle contraction Useful for pts w/adverse reactions to beta- adrenergics or in combination w/beta- adrenergics Ipratropium [atrovent] Ipratropium + albuterol [Combivent] 26/10/2009
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Management of Asthmatic Patient
Identify and assess status Avoid precipitating factors Bring inhaler for each appointment Drug considerations: Avoid ASA, NSAIDs, barbiturates, and narcotics Drug interactions with asthmatic medications (ex. Theophylline vs. Antibiotics, Cimetidine) Chronic corticosteroid users may require steroid supplementation For sedation, nitrous oxide/oxygen and/or small doses of oral diazepam is recommended 26/10/2009
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Asthma: Client Teaching
Correct use of medications Signs & symptoms of an attack Dyspnea, anxiety, tight chest, wheezing, cough Relaxation techniques When to call for help, seek treatment Environmental control Cough & postural drainage techniques 26/10/2009
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COPD Chronic obstructive pulmonary disease is a slowly progressive disease that is characterized by a gradual loss of lung function COPD includes chronic bronchitis, chronic obstructive bronchitis, or emphysema, or combinations of these conditions 26/10/2009
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Epidemiology 20.3 million Americans report having asthma
5,000 deaths annually from asthma 12.1 million Americans reported being diagnosed with COPD 119,000 deaths annually from COPD COPD is the 4th leading cause of death in the U.S. 26/10/2009
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Chronic Bronchitis Inflammation of the main airway passages (bronchi) to the lungs, which results in the production of excess mucous, a reduction in the amount of airflow in and out of the lungs, and shortness of breath 26/10/2009
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Emphysema A respiratory disease characterized by breathlessness brought on by the enlargement, or over-inflation of, the air sacs (alveoli) in the lungs 26/10/2009
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Signs and symptoms Wheezing Coughing Sputum production
Shortness of breath Chest tightness ASK the learners. Go back to the breath through the closed hand exercise to discuss s/s. 26/10/2009 61
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Diagnosis Clinical symptoms Chest x-ray Lung function tests ABGs
Discuss briefly 26/10/2009 62
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COPD Nursing diagnosis Ineffective airway clearance r/t secretions
Impaired gas exchange r/t altered supply O2 Altered health maintenance r/t ineffective individual coping Risk for infection r/t inadequate defense system Knowledge deficit of COPD Altered role performance r/t changes in role 26/10/2009
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Nursing DX Ineffective breathing pattern r/t musculoskeletal impairment , decreased energy Inability to sustain spontaneous ventilation r/t muscle fatigue Activity intolerance r/t imbalance of O2 supply 26/10/2009
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Clinical Features of COPD Patients
Mild COPD: no abnormal signs, smokers cough, little or no breathlessness Moderate COPD: breathlessness with/without wheezing, cough with/without sputum Severe COPD: breathlessness on any exertion/at rest, wheeze and cough prominent, lung inflation usual, cyanosis, peripheral edema, and polycythemia in advanced disease 26/10/2009
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Diagnosis Spirometry Bronchodilator Reversibility Testing
Breathing test which measures the amount and rate at which air can pass through the airways Bronchodilator Reversibility Testing Relaxing tightened muscles around the airways and opening up airways quickly to ease breathing Other pulmonary function testing Diffusion capacity Chest X-ray Arterial Blood Gas Shows oxygen level in blood 26/10/2009
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Medical Management of COPD Patient
Smoking cessation and elimination of environmental pollutants Palliative measure such as regular exercise, good nutrition, flu and pneumonia vaccines Bronchodilators, corticosteroids, anticholinergics, and NSAIDs 26/10/2009
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Management of COPD Patient
Review history for concurrent heart disease Avoid treatment if upper respiratory tract infection is present Treat in upright position Avoid rubber dam in severe cases Use pulse oximetry (if pulse ox <91%, use low flow 2-3L/min) Avoid Nitrous oxide/oxygen in severe cases Avoid barbiturates, narcotics, antihistamines, and anticholinergics If patient is on steroid regimen, supplement as needed Drug interactions with COPD medication 26/10/2009
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26/10/2009
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