New Era University

College of Nursing
MENTORING ACTIVITY: SY 2014-2015
Mentee: Patricia Joy Guinto, Batch 2016
Mentor: Leslie Masaya, Batch 2015
MED-SURG: RESPIRATORY SYSTEM

ANATOMY OF RESPIRATORY SYSTEM

2.

OXYGENATON: the dynamic interaction of gases in the

body for the purpose of delivering adequate oxygen
essential for cellular survival

3.

RESPIRATORY SYSTEM MAIN FUNCTION:

GAS EXCHANGE
I.
Upper Respiratory
Tract
A. Functions
1.
Filtering
2.
Warming and moistening
3.
Humidification
B. Parts

1.
2.
3.
4.

5.
6.

7.

II.

4.

Bronchi

Lobar Bronchi: 3 R and 2 L

Segmental Bronchi: 10 R and 8 L

Subsegmental Bronchi
Bronchioles

Terminal Bronchioles
Respiratory Bronchioles, considered
to be the transitional passageways
between the
conducting airways and the gas exchange
Alveoli
functional cellular units or gas-exchange
units of the
lungs.
O2 and CO2 exchange takes place
Made up of about 300 million
TYPE 1 - provide structure to the alveoli

collapse
TYPE 3 alveolar cell macrophages, destroys
foreign material, such as bacteria

Nose - made up of framework of cartilages; divided

into R and L by the nasal septum.
Paranasal Sinuses includes four pair of bony
cavities that are lined with nasal mucosa and ciliated
epithelium.
Tubernate Bones ( Conchae )
Pharynx muscular passageway for both food and
air

Nasopharynx

Oropharynx

Laryngopharynx

TYPE 2 - secrete SURFACTANT, reduces

surface
tension;

Lecithin

Sphingomyelin
increases
alveoli stability & prevents their
L/S ratio indicates lung maturity
2:1 normal
1:2 immature lungs

PULMONARY CIRCULATION

Tonsils and Adenoids

Larynx voice production, coughing reflex
Made up of framework of:
Epiglottis valve that covers the
opening to the larynx during
swallowing.

Glottis opening between the vocal

cords

Hyoid bone u shaped bone in neck

Cricoid cartilage

Thyroid cartilage, forms the Adams

apple

Arythenoid cartilage

Speech production and cough reflex

Vocal cords
Trachea - consists of cartilaginous
rings

Passageway of air
th th

Site of tracheostomy (4 -6 tracheal

ring)

Client post pneumonectomy affected side to promote

expansion
Post lobectomy unafected side to promote drainage

Lower respiratory tract

A. Function: facilitates gas
exchange
B. Parts
1. Lungs, are paired elastic structure enclosed
in the thoracic cage, which is an airtight
chamber with distensible walls.

Right 3 lobes, 10
segments

Left 2 lobes, 8 segments

Pleural cavity

Parietal

Visceral

Pleural Fluid: prevents pleural friction

rub
(as seen in pneumonia and pleural
effusion)

New Era University

College of Nursing
MENTORING ACTIVITY: SY 2014-2015
Mentee: Patricia Joy Guinto, Batch 2016
Mentor: Leslie Masaya, Batch 2015

Provides for reoxygenation of blood and release of

CO2
PULMONARY ARTERIES, carry blood
from the heart to the lungs.
PULMONARY VEINS, is a large blood
vessel of the circulatory system that
carries blood from the lungs to the left
atrium of the heart.

RESPIRATORY MUSCLES
PRIMARY: diaphragm and external intercostal muscles
ACCESORY:
sternocleidomastoid
(elevated
sternum), the scalene muscles (anterior, middle
and posterior scalene) and the nasal alae


PHYSIOLOGY OF RESPIRATORY SYSTEM

VENTILATION: The movement of air in and out of the

airways.

The thoracic cavity is an air tight chamber. the

floor of this chamber is the diaphragm.
Inspiration:
contraction
of
the
diaphragm
(movement of this chamber floor downward) and
contraction of the external intercostal muscles
increases the space in this chamber.
lowered
intrathoracic
pressure
causes
air
to enter
through the airways and inflate the lungs.
Expiration: with relaxation, the diaphragm moves
up and intrathoracic pressure increases. this
increased pressure pushes air out of the lungs.
expiration requires the elastic recoil of the lungs.
Inspiration normally is 1/3 of the respiratory
cycle and expiration is 2/3.

Exchange of gases occurs because of

diferences in partial pressures.
Oxygen diffuses from the air into the blood at the
alveoli to be transported to the cells of the body.
Carbon dioxide difuses from the blood into the air
at the alveoli to be removed from the body.

NEUROCHEMICAL CONTROL
MEDULLA OBLONGATA respiratory center
initiates each breath by sending messages to
primary respiratory muscles over the phrenic nerve
has inspiration and expiration centers
PONS has 2 respiration centers that work
with the inspiration center to produce normal rate
of breathing
1. PNEUMOTAXIC CENTER
affects the
inspiratory effort by limiting the volume of air
inspired
2. APNEUSTIC CENTER
prolongs
inhalation
NOTE: Chemoreceptors responds to changes in ph,
increased
PaCO2 = increase
RR

DRIVING FORCE FOR AIR FLOW

Airflow driven by the pressure difference between
atmosphere (barometric pressure) and inside the lungs
(intrapulmonary pressure).

RESPIRATORY EXAMINATION AND

ASSESSMENT

Background
information
A. Abnormal patterns of
breathing
1. Sleep Apnea
cessation of airflow for more than 10 seconds
more than 10 times a night during sleep
causes: obstructive (e.g. obesity with upper
narrowing, enlarged tonsils, pharyngeal soft
tissue changes in
acromegaly or hypothyroidism)
2. Cheyne-Stokes
periods of apnoea alternating with
periods of hyperpnoae
pathophysiology: delay in medullary
chemoreceptor response to blood gas changes

AIRWAY RESISTANCE
Resistance is determined chiefly by the radius size
of the airway.
Causes of Increased Airway

1.
2.
3.
4.

Resistance
Contraction of bronchial mucosa
Thickening of bronchial mucosa
Obstruction of the airway
Loss of lung elasticity

RESPIRATION

The
process
of
gas
exchange
between
atmospheric air and the blood at the alveoli, and
between the blood cells and the cells of the body.

3.

4.
5.
6.

causes
left ventricular failure
brain damage (e.g. trauma,
cerebral, haemorrhage)
high altitude
Kussmaul's (air hunger)
deep rapid respiration due to stimulation of
respiratory centre
causes: metabolic acidosis (e.g. diabetes
mellitus, chronic renal failure)
Hyperventilation
complications: alkalosis and tetany
causes: anxiety
Ataxic (Biot)
irregular in timing and deep
causes: brainstem damage
Apneustic
post-inspiratory pause in breathing

causes: brain (pontine) damage

7.

Paradoxical
the abdomen sucks with respiration
(normally, it pouches uotward due to
diaphragmatic descent)
causes: diaphragmatic paralysis

B. Cyanosis
1.
Refers to blue discoloration of skin and
mucous membranes , is due to presence of
deoxygenated haemoglobin in superficial
blood vessels
2. Central cyanosis = abnromal amout of
deoxygenated
haemoglobin in arteries and that blue
discoloration is present in parts of body with
good circulation such as tongue
3. Peripheral cyanosis = occurs when blood supply
to a
certain part of body is reduced, and the tissue
extracts more oxygen from normal from the
circulating blood, e.g. lips in cold weather are often
blue, but lips are spared
4. Causes of cyanosis
Central cyanosis
decreased arterial saturation
decreased concentration of inspired
oxygen:
high
altitude
lung disease: COPD with cor
pulmoale, massive pulmonary
embolism
right to left cardiac shunt (cyanotic
congenital
heart
disease)
polycythaemia
haemoglobin abnromalities (rare):
methaemoglobinaemia,
sulphaemoglobinaemia
Peripheral cyanosis
all causes of central cyanosis cause
peripheral
cyanosis
exposure to cold
reduced cardiac output: left ventricular
failure or shock
arterial or venous obstruction
Position: patient sitting over edge of bed
General appearance
look for the following
Dyspnea
normal respiratory rate < 14 each
minute tachypnoea = rapid
respiratory rate
are accessory muscles being used
(sternomastoids, platysma, strap muscles of
neck) - characteristically, the accessory
muscles cause elevation of shoulders with
inspiration and aid respiration by increasing
chest expansion
Cyanosis
Character of cough
ask patient to cough several times

lack of usual explosive beginning may

indicate vocal cord paralysis (bovine
cough)
mufled, wheezy inefective cough suggests
airflow limitation
very loose productive cough suggests
excessive bronchial secretions due to:
- chronic bronchitis
- pneumonia
- bronchiectasis
dry irritating cough may occur
-

with:
chest infection

- asthma
- carcinoma of bronchus
- left ventricular failure
- interstitial lung disease
- ACE inhibitors
Sputum
volume
type (purulent, mucoid, mucopurulent)
presence or absence of blood?
Stridor
croaking noise loudest on
inspiration is a sign that requires
urgent attention
causes: (obstruction of larynx, trachea or
large broncus)
- acute onset (minutes)
inhaled foreign body
acute epiglottitis
anaphylaxis
toxic gas inhalation
- gradual onset (days, weeks)
laryngeal and pharyngeal tumours
crico-arytenoid rheumatoid arthritis
bilateral vocal cord palsy
tracheal carcinoma
paratracheal compression by lymph
nodes
post-tracheostomy or
intubation granulomata
Hoarseness
causes
include:
- laryngitis
- laryngeal nerve palsy associated
with carcinoma of lung

laryngeal carcinoma

The Hands
Clubbing
commonly cause by respiratory disease (but
NOT
emphysema or chronic
bronchitis)
occasionally, clubbing is associated with
hypertrophic pulmonary osteoarthropathy (HPO)
characterised by periosteal inflammation at distal
ends
of long bones, wrists, ankles,
metacarpals and metatarsals
sweelling and tenderness over wrists and
other involved areas

Staining
staining of fingers - sign of cigarette smoking
(caused by tar, not nicotine)
Wasting and weakness
Pulse rate
Flapping tremor (asterixis) - unreliable sign
ask patient to dorsiflex wrists and spread out
fingers, with arms outstretched
flapping tremor may occur with severe carbon
dioxide retention (severe chronic airflow
limitation)

The Face
Eyes
Horner's syndrome? (constricted pupil, partial
ptosis and loss of sweating which can be due to
apical lung tumour
compressing sympathetic nerves in neck)
Nose
polpys? (associated with asthma)
engorged turbinates? (various allergic conditions)
deviated septum? (nasal obstruction)
Mouth and tongue
look for central cyanosis
evidence of upper respiratory tract infection (a
reddened pharynx and tonsillar enlargement with
or without a coating of pus)
broken tooth - may predispose to lung
abscess or pneumonia
sinusitis is indicated by tenderness over the
sinuses on palpation
some patients with obstructive sleep apnoea will be
obese
with a receding chin, a small pharynx and a short
thick neck
The Trachea
causes of tracheal displacement:
toward the side of the lung lesion
upper lobe collapse
upper lobe fibrosis
pneumonectomy
upper mediastinal masses, such as retrosternal
goitre
tracheal tug (finger resting on trachea feels it move
inferiorly with each inspiration) is a sign of gross
overexpansion of the
chest because of airflow obstruction
The Chest: inspection
Shape and symmetry of chest
Barrel shaped
anteroposterior (AP) diameter is increased
compared
with lateral
diameter
causes: hyperinflation due to asthma,
emphysema

of lower end of sternum in severe cases, lung

capacity may be restricted

Harrison's sulcus
innar depression of lower ribs just above costal
margins
at site of attachment of diaphragm
causes:
severe asthma in
childhood rickets
Kyphosis , exaggerated forward curvature of spine
Scoliosis , lateral bowing
Kyphoscoliosis: causes:
idiopathic (80%)
secondary to poliomyelitis (inflammation
involving grey matter of cord)
(note: severe thoracic kyphoscoliosis may reduce
lung
capacity and increase work of breathing)
Lesions of chest wall
scars - previous thoracic operations or chest drains
for a
previous pneumothorax or pleural efusion
thoracoplasty (was once performed to remove
TB, but no longer is because of efective
antituberculosis chemotherapy) invovled
removal of large number of
ribs on one side to achieve permanent
collapse of afected lung
erythema and thickening of skin may occur
in radiotherapy; there is a sharp demarcation
between
abnormal and normal skin
Difuse swelling of chest wall and neck

pathophysiology: air tracking from the lungs

causes:
pneumothorax
rupture of oesopahagus
Prominent veins
cause: superior vena caval obstruction
Asymmetry of chest wall movements

Pigeon chest (pectus carinatum)

localised prominence (outward bowing of
sternum and
costal
cartilages)
causes:
manifestation of chronic childhood illness
(due to repeated strong contractions of
diaphragm while thorax is still pliable)
rickets
Funnel chest (pectus excavatum)
developmental defect involving a localised
depression

assess this by inspecting from behind patient,

looking
down the clavicles during moderate respiration diminished movement indicates underlying lung
disease
the affected side will showed delayed or
decreased movement
causes of reduced chest wall movements on one
side are localised:
localised pulmonary
fibrosis consolidation
collapse
pleural
effusion
pneumothroa
x

causes of bilateral reduced chest wall

movements are difuse:

chronic airflow limitation

fibrosis

diffuse pulmonary

The Chest: palpation

chest expansion
place hands firmly on chest wall with fingers
extending around sides of chest (fugyre 4.5)
as patient takes a big breath in, the thumbs
should move symmetrically apart about 5 cm
reduced expansion on one side indicates a lesion
on that side
note: lower lobe expansion is tested here; upper
lobe is tested for on inspection (as above)
apex beat
(discussed in cardiac section)
for respiratory diseases:
displacement toward site of lesion - can be
caused by:
collapse of lower lobe
localised pulmonary
fibrosis
displacement away from site of lesion - can be
caused
by:
pleural effusion
tension
pneumothorax
apex beat is often impalpable in a chest which is
hyperexpanded secondary to chronic airflow
limitation
vocal fremitus
palpate chest wall with palm of hand while patient
repeats
"99"
front and back of chest are each palpated in 2
comparable positions with palms; in this way
differences in vibration on chest wall can be detected
causes of change in vocal fremitus are the same as
those for vocal resonance (see later)
ribs
gently compress chest wall anteroposteriorly and
laterally localised pain suggests a rib fracture (may
be secondary to trauma or spontaneous as a result
of tumour deposition or bone disease)
The Chest: percussion
with left hand on chest wall and fingers slightly
separated and aligned with ribs, the middle finger is
pressed firmly against the chest; pad of right middle
finger is used to strike firmly the middle phalanx of
middle finger of left hand
percussion of symmetrical areas of:
anterior (chest)
posterior (back) (ask patient to move elbows
forward across the front of chest - this rotates
the scapulae anteriorly, i.e. moves it out of the
way)
axillary region (side)
supraclavicular fossa
percussion over a solid structure (e.g. liver,
consolidated lung)
produces a dull note
percusion over a fluid filled area (e.g. pleural effusion)
produces an extremely dull (stony dull) note
percussion over the normal lung produces a resonant
note percussion over a hollow structure (e.g. bowel,
pneumothorax) produces a hyperresonsant note
liver dullness:
upper level of liver dullness is determined by
percussing down the anterior cehst in midclavicular line

normally, upper level of liver dullness is 6th rib in

right
mid-clavicular line
if chest is resonant below this level, it is a
sign of hyperinflation usually due to
emphysema, asthma
cardiac dullness:

area of cardiac dullness is uaully present on left

side of chest
this may decrease in emphysema or asthma
The Chest: auscultation
breath sounds
introduction
one should use the diaphragm of stethoscope
to listen to breath sound in each area,
comparing each side remember to listen high
up into the axillae
remember to use bell of stethoscope to listen
to lung from above the clavicles
quality of breath sounds
normal breat sounds

are heard with stethoscope over all parts of

chest, produced in airways rather than
alveoli (although once they had been
thought to arise from alveoli (vesicles)
and are therefore called vesicular
sounds)
normal (vesicular) breath sounds are
louder and longer on inspiration than on
expiration; and there is no gap between
the inspiratory and expiratory sounds
bronchial breath
sounds
turbulence in large airways is heard
without being filtered by the alveoli, and
therefore produce a different quality; they
are heard over the trachea normally, but
not over the lungs
are audible throughout expiration, and
often there is a gap between inspiration
and expiration
are heard over areas of consolidation
since solid lung conducts the sound of
turbulence in main airways to peripheral
areas without filtering
causes include:
- lung consolidation (lobar
pneumonia) - common
- localised pulmonary fibrosis uncommon
- pleural effusion (above the
fluid) - uncommon
- collapsed lung (e.g. adjacent to a
pleural efusion) - uncommon
amphoric sound = when breath sounds
over a large cavity have an exaggerated
bronchial quality)
intensity of breath sounds
causes of reduced breath sounds include:

chronic airflow limitation

(especially emphysema)
pleural effusion
pneumothorax
pneumonia
large neoplasm
pulmonary collapse

added (adventitious) sounds

two types of added sounds: continuous
(wheezes) and interrupted (crackles)
wheezes

may be heard in expiration or inspiration or

both
pathophysiology of wheezes - airway
narrowing
an inspiratory wheeze implies severe
airway narrowing

causes of wheezes include:

- asthma (often high pitched) - due to
muscle spasm, mucosal oedema,
excessive
secretion
s
- chronic airflow diseases - due to
mucosal oedema and excessive
secretions
- carcinoma causing bronchial
obstruction tends to cause a localised wheeze
which is monophonic and does not
clear with coughing
crackles
some terms not to use include rales (low
pitched
crackles) and creptitations (high
pitched crackles)
crackles are due to collapse of
peripheral airways on expiration and
sudden opening on inspiration
early inspiratory crackles
- suggests disease of small airways
- characteristic of chronic airflow
limitation
- are only heard in early inspiration
late or paninspiratory crackles
- suggests disease confined to alveoli
- may be fine, medium or coarse
- fine crackles - typically caused
by pulmonary fibrosis
- medium crackles - typically caused
by left ventricular failure (due to
presence of
alveolar
fluid)
- coarse crackes - tend to change with
coughing; occur with any disease that
leads
to retention of secretions; commonly
occur
in
bronchiectasis
pleural friction rub
when thickened, roughened pleural
surfaces rub
together, a continuous or intermittent
grating sound may be heard
suggests pleurisy, which may be
secondary to pulmonary infarction or
pnuemonia
vocal resonanance
gives information about lungs' ability to transmit
sounds consolidated lung tends to transmit high
frequencies so that speech heard through
stethoscope takes a bleeting quality (aegophony);
when a patient with aegophony says "bee" it
sounds like "bay"
listen over each part of chest as patient says
"99"; over consolidated lung, the numbers will
become clearly audible; over normal lung, the
sound is muffled
whispering pectoriloquy - vocal resonance is
increased to such an extent that whispered speech
is distinctly heard
The Heart
lie patient at 45 degrees

The Abdomen

pulmonary
thromboembolism marked
obesity
sleep apnoea
severe kyphoscoliosis

palpate liver for enlargement due to secondary

deposits of tumour from lung, or right heart failure
Other
measure jugular venous plse for right heart failure
examine preacordium; pay close attention to
pulmonary component of P2 (which is best heard
at 2nd intercostal space on left) and should not
be louder than A2; if it is louder, suspect
pulmonary hypertension
cor pulmonale (also called pulmonary hypertensive
heart disease) may be due to:
chronic airflow limitation (emphysema)
pulmonary fibrosis

Permberton's sign
ask patient to lift arms over head
look for development of facial plethora,
inspiratory stridor, non-pulsatile elevation of
jugular venous pressure
occurs in vena caval obstruction
Feet

inspect for oedema or cyanosis (clues

of cor pulmonale)
look for evidence of deep vein thrombosisd
Respiratory rate on exercise and positioning
patients complaining of dyspnoea should have
their respiratory rate measured at rest, at
maximal tolerated exertion and supine
if dyspnoea is not accompanied by
tachypnoea when a patient climbs stairs, one
should consider malingering
look for paradoxical inward motion of abdomen
during inspiration when patient is uspine
(indicating diaphragmatic paralysis)
Temperature: fever may accompany any acute or
chronic chest infection

DIAGNOSTIC EVALUATION

1. Skin Test: Mantoux Test or Tuberculin

Skin Test

This is used to determine if a person has been

infected or has been exposed to the TB bacillus.

This utilizes the PPD (Purified Protein

Derivatives).
The PPD is injected intradermally usually in the
inner aspect of the lower forearm about 4 inches
below the
elbow.

The test is read 48 to 72 hours after injection.

(+) Mantoux Test is induration of 10 mm or

more.
But for HIV positive clients, induration of about 5
mm is considered positive

Signifies exposure to Mycobacterium Tubercle

bacilli

2. Pulse Oximeter
Non-invasive method of continuously
monitoring he oxygen saturation of
hemoglobin
A probe or sensor is attached to the fingertip,
forehead, earlobe or bridge of the nose
Sensor detects changes in O2 sat levels by
monitoring light signals generated by the
oximeter and reflected by the blood pulsing
through the tissue at the probe

Normal SpO2 = 95% - 100%

< 85% - tissues are not receiving enough O2

Results unreliable in:

Cardiac arrest

Shock
Use of dyes or
vasoconstricto
rs

Severe anemia
High carbon
monoxide
Level

3. Chest X-ray

This is a NON-invasive procedure involving the use

of x- rays with minimal radiation.

The nurse instructs the patient to practice the on

cue to
hold his breath and to do deep breathing

Instruct the client to remove metals from the

chest.

Rule out pregnancy first.

5. Computed Tomography (CT Scan) and Magnetic
Resonance
Imaging ( MRI )

The CT scan is a radiographic procedure that

utilizes x-ray machine.
+
The MRI uses magnetic field to record the H
density of the tissue.
It does NOT involve the use of radiation.
The contraindications for this procedure are
the following: patients with implanted
pacemaker, patients with metallic hip
prosthesis or other metal implants in the
body.

Clear MRI images of lung airways during breathing.

6. Flouroscopy

Studies the lung and chest in motion

Involves the continuous observation of an
image reflected on a screen when exposed to
radiation in the
manner of television screen that is activated
by an electrode beam.
Structures of different densities that intercept
the X-ray beam are visualized on the screen in
silhouette
7. Indirect Bronchography

A radiopaque medium is instilled directly into the

trachea and the bronchi and the outline of
the entire bronchial tree or selected areas
may be visualized
through x-ray.
It reveals anomalies of the bronchial
tree and is important in the diagnosis of
bronchiectasis.

Nursing interventions BEFORE Bronchogram

Secure written consent

Check for allergies to sea foods or
iodine or anesthesia

NPO for 6 to 8 hours

Pre-op meds: atropine SO4 and valium,
topical anesthesia sprayed; followed by
local anesthetic injected into larynx. The
nurse must have oxygen and anti
spasmodic agents ready.

Nursing

interventions AFTER Bronchogram

Side-lying position
NPO until cough and gag reflexes returned
Instruct the client to cough and deep
breathe client

8. Bronchoscopy
This is the direct inspection and observation of the

This chest CT scan shows a cross-section of a person

with bronchial cancer. The two dark areas are the lungs. The light
areas within the lungs represent the cancer.

larynx, trachea and bronchi through a flexible or rigid

bronchoscope.
Passage of a lighted bronchoscope into the bronchial
tree for direct visualization of the trachea and the
tracheobronchial tree.
Diagnostic uses:
To examine tissues or collect secretions
To determine location or pathologic
process
and collect specimen for biopsy

To evaluate bleeding sites

To determine if a tumor can be
resected surgically

Therapeutic uses

To Remove foreign objects from

9. Lung Scan

Procedure using inhalation or I.V. injection of a

radioisotope, scans are taken with a scintillation
camera.
Imaging of distribution and blood fow in
the lungs. (Measure blood perfusion)

Confrm pulmonary embolism or other bloodflow

the

tracheobronchial tree
To Excise lesions
To remove tenacious secretions obstructing

abnormalities

Nursing interventions BEFORE the procedure:

Allay the patients anxiety

Instruct the patient to Remain still

during
the
procedure

Nursing interventions AFTER the procedure

Check the catheter insertion site for

bleeding

Assess for allergies to injected

radioisotopes

Increase fluid intake, unless

contraindicated.

tracheobronchial
To drain abscess tree
To treat post-operative atelectasis

Nursing interventions BEFORE

Bronchoscopy

Informed consent/ permit needed

Explain procedure to the patient, tell him
what to expect, to help him cope with the
unkown

Atropine (to diminish secretions) is

administered one hour before the
procedure
About 30 minutes before
bronchoscopy, Valium is given to
sedate patient and allay anxiety.

Topical anesthesia is sprayed followed

by
local anesthesia injected into the
larynx

Instruct on NPO for 6-8 hours

Remove dentures, prostheses and contact

lenses
The patient is placed supine with
hyperextended neck during the
procedure
Nursing interventions AFTER
Bronchoscopy

Put the patient on Side lying position

Tell patient that the throat may feel sore

with .

Check for the return of cough and gag

refex.

Check vasovagal response.

Watch for cyanosis, hypotension,
tachycardia, arrythmias, hemoptysis,
and dyspnea. These
signs and symptoms indicate perforation
of
bronchial tree. Refer the patient
immediately!

10. Sputum Examination

Laboratory test

Indicated for microscopic examination of the

sputum:
Gross appearance, Sputum C&S, AFB
staining, and for Cytologic examination/
Papanicolaou examination

Nursing interventions:
Early morning sputum specimen
is to be collected (suctioning or
expectoration)

Rinse mouth with plain water

Use sterile container.

Sputum specimen for C&S is collected
before the frst dose of anti-microbial
therapy.

For AFB staining, collect sputum specimen

for
three consecutive
mornings.

11. Biopsy of the Lungs

Percutaneous removal of a small amount of lung

tissue

For histologic evaluation

Transbronchoscopic biopsydone during
bronchoscopy,
Percutaneous needle biopsy
Open lung biopsy

Nursing interventions BEFORE the procedure:

Withhold food and fluids

Place obtained written informed consent in

the
patients chart.
Nursing interventions AFTER the procedure:

Observe the patient for signs of

Pneumothorax
and air embolism

Check the patient for hemoptysis and

hemorrhage

Monitor and record vital signs

Check the insertion site for bleeding

Monitor for signs of respiratory distress

12. Lymph Node Biopsy

Scalene or cervicomediastinal

To assess metastasis of lung cancer

13. Pulmonary Function Test / Studies

Non-invasive test
Measurement of lung volume, ventilation, and
difusing capacity

Nursing interventions:
Document bronchodilators or narcotics
used before testing

Allay the patients anxiety during the testing

LUNG CAPACITIES:
Functional Residual Capacity (ERV 1100 mL + RV 1200
mL =
2300 mL )
The volume of air that remains in the lungs after
normal, quiet exhalation
Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500
mL )
The amount of air that a person can inspire
maximally after a normal expiration
Vital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL =
4600 mL )
The maximum volume of air that can be exhaled
after a maximum inhalation

Reduced in COPD
Total Lung Capacity (IRV 3000 mL + TV 500 mL + ERV
1100 mL + RV 1200 mL = 5800 mL )

Total of all four volumes

14. Arterial Blood Gas

Laboratory test

Indicate respiratory functions

Assess the degree to which the lungs are able to
provide adequate oxygen and remove CO 2
Assess the degree to which the kidneys are
able to reabsorb or excrete bicarbonate.
Assessment of arterial blood for tissue
oxygenation, ventilation, and acid-base status
Arterial puncture is performed on areas where
good pulses are palpable (radial, brachial,
or femoral).
Radial artery is the most common site for
withdrawal of blood specimen

Nursing interventions:
Utilize a 10-ml. Pre-heparinized
syringe to prevent clotting of
specimen

Soak specimen in a container with ice to

prevent hemolysis

If ABG monitoring will be done, do Allens

test to assess for adequacy of
collateral circulation of the hand (the
ulnar arteries)

LUNG VOLUMES: (ITER)

Inspiratory reserve volume
(3000 mL)
The maximum volume that can be inhaled
following a normal quiet inhalation.
Tidal volume (500 mL)
The volume of air inhaled and exhaled with
normal quiet breathing
Expiratory reserve volume (1100 mL)
The maximum volume that can be exhaled
following the normal quiet exhalation
Residual volume (1200 mL)
The volume of air that remains in the lungs after
forceful exhalation

15. Pulmonary Angiography

This procedure takes X-ray pictures of the
pulmonary blood vessels (those in the lungs).
Because arteries and veins are not normally seen
in an X- ray, a contrast material is injected into one
or more
arteries or veins so that they can be seen.
16. Ventilation - Perfusion Scan

Radioactive albumin injection is part of a

nuclear scan
test that is performed to measure the supply
of blood through the lungs.
After the injection, the lungs are scanned to
detect the location of the radioactive particles
as blood flows
through the lungs.
The ventilation scan is used to evaluate the
ability of air to reach all portions of the lungs.
The perfusion scan measures the supply of blood
through the lungs.
A ventilation and perfusion scan is most often
performed to detect a pulmonary embolus. It is
also used to evaluate lung function in people with
advanced pulmonary disease such as COPD and to
detect the presence of shunts
(abnormal circulation) in the pulmonary blood
vessels.

17. Thoracentesis

Procedure suing needle aspiration of intrapleural

fluid or
air under local anesthesia

Specimen examination or removal of

pleural fluid

Nursing intervention BEFORE Thoracentesis

Secure consent

Take initial vital signs

Instruct to remain still, avoid coughing
during insertion of the needle

Inform patient that pressure sensation

will be
felt on insertion of
needle

site

Nursing intervention DURING the procedure:

Reassess the patient

Place the patient in the proper position:

Upright or sitting on the
edge of the bed
Lying partially on the
side, partially on the
back

Nursing interventions after Thoracentesis

Assess the patients respiratory status

Monitor vital signs frequently

Position the patient on the afected
side, as ordered, for at least 1 hour to
seal the
puncture
on the
unaffected side to prevent leakage
Turn

of fluid in the thoracic cavity

Check the puncture site for fluid leakage
Auscultate lungs to assess for pneumothorax
Monitor oxygen saturation (SaO2) levels
Bed rest
Check for expectoration of blood

RESPIRATORY CARE MODALITIES

1. Oxygen Therapy

Oxygen is a colorless, odorless, tasteless, and dry

gas that
supports
combustion
Man requires 21% oxygen from the environment
in order to survive

Indication: Hypoxemia

Signs of Hypoxemia
o Increased pulse rate
o Rapid, shallow respiration and dyspnea
o Increased restlessness or lightheadedness
o Flaring of nares
o Substernal or intercostals retractions
o Cyanosis
Low fow oxygen provides partial oxygenation with
patient breathing a combination of supplemental
oxygen and room air. Low-flow administration devices:
o Nasal Cannula 24-45% 2-6 LPM
o Simple Face Mask 0-60%
5-8 LPM
o Partial Rebreathing Mask 60-90%
6-10 LPM
o Non-rebreathing Mask
95-100% 6-15 LPM
o Croupette
o Oxygen Tent
High fow oxygen provides all necessary
oxygenation, with patients breathing only oxygen
supplied from the mask and exhaling through a oneway vent.
High flow administration devices
o Venturi Mask
24-40% 4-10 LPM

Preferred for clients with COPD

because it
provides accurate amount of
oxygen.
o Face Mask
o Oxygen Hood*
o Incubator / isolette*
Note: * can be used for both low and high flow administration

The nurse should prevent skin breakdown by checking

nares, nose and applying gauze or cotton as necessary
Ensure that COPD patients receive only LOW flow
oxygen because these persons respond to hypoxia, not
increased CO levels.

2. Tracheobronchial suctioning

Suction only when necessary not routinely

Use the smallest suction catheter if possible

Client should be in semi or high Fowlers

position

Use sterile gloves, sterile suction catheter

Hyperventilate client with 100% oxygen
before and after suctioning

Insert catheter with gloved hand (3-5 length of

catheter
insertion) without applying suction. Three passes
of the catheter is the maximum, with 10 seconds
per pass.

Apply suction only during withdrawal of catheter

The suction pressure should be limited to less
than 120 mmHg

When withdrawing catheter rotate while applying

intermittent suction
Suctioning should take only 10 seconds
(maximum of 15 seconds)

Evaluate: clear breath sounds on auscultation of

the chest.

3. Bronchial Hygiene Measures

Suctioning: oropharyngeal; nasopharyngeal

Goals are removal of bronchial secretions,

improved ventilation, and increased efficiency of
respiratory muscles.
Postural drainage uses specific positions to use
gravity to assist in the removal of secretions.
Vibration loosens thick secretions by percussion or
vibration.

Breathing exercises and breathing retraining

improve ventilation and control of breathing
and decrease the work of breathing.
These are procedures for patients with
respiratory disorders like COPD, cystic fibrosis,
lung abscess, and pneumonia. The therapy is
based on the fact that mucus can be knocked or
shaken from airways and helped to
drain from the lungs.

Postural drainage

Use of gravity to aid in the drainage of secretions.

Patient is placed in various positions to promote
flow of drainage from different lung segments
using gravity.
Areas with secretions are placed higher
than lung segments to promote drainage.
Patient should maintain each position for 5-15
minutes depending on tolerability.

a. Steam inhalation

The purpose of steam inhalation are as follows:

- to liquefy mucous secretions
- to warm and humidify air
- to relieve edema of airways
- to soothe irritated airways
- to administer medication
It is a dependent nursing function
Inform the client and explain the purpose of the procedure
Place the client in Semi-Fowlers position
Cover the clients eyes with washcloth to prevent irritation
Check the electrical device before use
Place the steam inhalator in a flat, stable surface.
Place the spout 12 18 inches away from the clients nose or
adjust distance as necessary
CAUTION: avoid burns. Cover the chest with towel to
prevent burns due to dripping of condensate from the steam.
Assess for redness on the side of the face which indicates
first degree burns.
To be effective, render steam inhalation therapy for 15 20
minutes
Instruct the client to perform deep breathing and coughing
exercises after the procedure to facilitate expectoration of
mucous secretions.
Provide good oral hygiene after the procedure.
Do after-care of equipment.

b. Aerosol inhalation

done among pediatric clients to administer

brochodilators or mucolytic-expectorants.
.
c. Medimist inhalation

done among adult clients to administer

bronchodilators or mucolytic-expectorants.
4. Chest Physiotheraphy ( CPT )
Includes postural drainage, chest percussion and
vibration, and breathing retraining. Efective
coughing is also an important component.

Percussion
Produces energy wave that is transmitted through the
chest wall to the bronchi.
The chest is struck rhythmically with cupped hands over
the areas were secretions are located.
Avoid percussion over the spine, kidneys, breast or
incision and broken ribs. Areas should be percussed for
1-2 minutes
Vibration
Works similarly to percussion, where hands are placed on
clients chest and gently but firmly rapidly vibrate hands
against thoracic wall especially during clients exhalation.
This may help dislodge secretions and stimulate cough.
This should be done at least 5-7 times during patient
exhalation.

Suctioning
Nursing Interventions in CPT

Verify doctors order

Assess areas of accumulation of mucus

secretions.
Position to allow expectoration of mucus
secretions by gravity

Place client in each position for 5-10 to 15

minutes
Percussion and vibration done to loosen
mucus secretions

Change position gradually to prevent

postural
hypotensio
n
Client is encouraged to cough up and
expectorate sputum

Procedure is best done 60 to 90 minutes

before
meals or in the morning upon awakening
and at bedtime.

Provide good oral care after the procedure

5. Incentive
Spirometry

Types: volume and flow

Device ensures that a volume of air is inhaled

and the patient takes deep breaths.

Used to prevent or treat atelectasis

To enhance deep inhalation

Nursing care

Positioning
of
patient,
teach
and
encourage use, set realistic goals for the
patient, and record the results.

Types of Bottle Drainage

One-bottle system

The bottle serves as drainage and water-seal

Immerse tip of the tube in 2-3 cm of sterile
NSS to create water-seal.

Keep bottle at least 2-3 feet below the level of

the
chest to allow drainage from the pleura by
gravity.
Never raise the bottle above the level of the
heart to prevent reflux of air or fluid.

Assess for patency of the device

Observe for fluctuation of fluid along the
tube. The fluctuation synchronizes with the
respiration.

Observe for intermittent bubbling of fluid;

continues bubbling means presence of air-leak
In the absence of fluctuation:
Suspect obstruction of the device
Assess the patient first, then if patient is stable
Check for kinks along tubing;
Milk tubing towards the bottle (If the hospital
allows the nurse to milk the tube)
If there is no obstruction, consider lung reexpansion; (validated by chest x-ray)
Air vent should be open to air.
Two-bottle system

6. Closed Chest Drainage ( Thoracostomy Tube )

Chest tube is used to drain fluid and air out of the
mediastinum or pleural space into a collection
chamber
to help re-establish normal negative pressure for
lung re- expansion.
Purposes

To remove air and/or fluids from the pleural

space
To reestablish negative pressure and reexpand the lungs
Procedure
The chest tube is inserted into the affected
nd
rd
chest wall at the level of 2
to 3
intercostals space to release air or in the
fourth intercostals space to remove fluid.

If not connected to the suction apparatus

The first bottle is drainage bottle;
The second bottle is water-seal bottle
Observe for fluctuation of fluid along the tube
(water-seal bottle or the second
bottle) and intermittent bubbling with
each respiration.

NOTE! IF connected to suction apparatus

1.
The first bottle is the drainage and water-seal
bottle;
2.
The second bottle is suction control bottle.
3.
Expect continuous bubbling in the suction control
bottle;
4.
Intermittent bubbling and fluctuation in the waterseal
5. Immerse tip of the tube in the first bottle in 2 to 3
cm of sterile NSS
6. Immerse the tube of the suction control bottle in
10 to 20 cm of sterile NSS to stabilize the normal
negative
pressure in the lungs.
7. This protects the pleura from trauma if the
suction pressure is inadvertently increased

Three-bottle system

Removal of chest tube

done by physician

The nurse Prepares:

The first bottle is the drainage
Petrolatum
bottle; The second bottle is
Gauze
Suture
water seal bottle
removal
kit
The third bottle is suction control bottle.
Sterile
gauze
Adhesive
Observe for intermittent bubbling and
tape
fuctuation with respiration in the

Place client in semi-Fowlers position

water- seal bottle
valsalva
Instruct client
to exhale
then is
inhale
Continuous GENTLE bubbling in the suction
maneuver
as thedeeply,
chest tube
removed.
control bottle. These are the expected observations.
removed
Chest x-ray may be done after the chest tube
Suspect a leak if there is continuous bubbling in
the WATER seal bottle or if there is VIGOROUS

Asses for complications: subcutaneous

emphysema;
bubbling in the suction control bottle.
respiratory distress
The nurse should look for the leak and report the
observation at once. Never clamp the tubing
Artificial Airway
7. ecessarily.
unn

She should immediately contact the physician.

fluctuation in the water seal bottle, it may

If there is NO
mean
TWO things

Either the lungs have expanded or the system

is NOT
functioning appropriately.
In this situation, the nurse refers the observation
to the physician, who will order for an X-ray to
confirm the suspicion.
Important Nursing considerations

Encourage doing the following to promote

drainage:

Deep breathing and coughing exercises

Turn to sides at regular basis

Ambulate

ROM exercise of arms

Mark the amount of drainage at regular intervals

Avoid frequent milking and clamping of the
tube to prevent tension pneumothorax

What the nurse should do if:

If there is continuous bubbling:

The nurse obtains a toothless clamp

Close the chest tube at the point where it exits
the chest for a few seconds.

If bubbling in the water seal bottle stops, the

leak is
likely in the lungs,
But if the bubbling continues, the leak is
between the clamp and the bottle chamber.
Next, the nurse moves the clamp towards the bottle
checking the bubbling in the water seal bottle.
If bubbling stops, the leak is between the
clamp and the distal part including the
bottle.

But if there is persistent bubbling, it means

that the
drainage unit is leaking and the nurse must
obtain another set.
In the event that the water seal bottle
breaks, the nurse temporarily kinks the tube
and must obtain a
receptacle or container with sterile
water and immerse the tubing.
She should obtain another set of sterile bottle
as replacement. She should NEVER CLAMP
the tube
for a longer time to avoid tension
pneumothorax.
In the event the tube accidentally is pulled
out, the nurse obtains vaselinized gauze and
covers the stoma.

a. Oral airways- these are shorter and often have a larger

lumen.
They are used to prevent the tongue form falling backward.
b. Nasal airways- these are longer and have smaller
lumen Which causes greater airway resistance
c. Tracheostomy- this is a temporary or permanent
surgical opening in the trachea. A tube is inserted to
allow ventilation and removal of secretions. It is
indicated for emergency airway access for many
conditions. The nurse must maintain tracheostomy care
properly to prevent infection.

RESPIRATORY DISEASES AND

DISORDERS

I.

PNEUMONIA

inflammation
of
the
lung
parenchyma leading to pulmonary consolidation
because alveoli is filled with exudates

A.

ETIOLOGIC AGENTS
1.
Streptococcus
pneumoniae
(pneumococcal
pneumonia
)
2.
Hemophilus influenzae (bronchopneumonia)
3.
Klebsiella pneumoniae
4.
Diplococcus pneumoniae
5.
Escherichia coli
6.
Pseudomonas aeruginosa

B.

C.

PREDISPOSING FACTORS
1.
Smoking
2.
Air pollution
3.
Immunocompromised

(+) AIDS

Kaposis Sarcoma

Pneumocystis Carinii Pneumonia

DOC: Zidovudine (Retrovir)

Bronchogenic Ca
4. Prolonged immobility (hypostatic pneumonia)
5. Aspiration of food (aspiration pneumonia)
6. Over fatigue

D.

SIGNS AND SYMPTOMS

1.
Productive cough, greenish to rusty
2.
Dyspnea with prolong expiratory grunt
3.
Fever, chills, anorexia, general body malaise
4.
Cyanosis
5.
Pleuritic friction rub
6.
Rales/crackles on auscultation
7.
Abdominal distention paralytic ileus

E.

DIAGNOSTICS
1.
Sputum GS/CS confirmatory; type and
sensitivity;

2.
3.

4.
F.

HIGH RISK GROUPS

1.
Children less than 5 yo
2.
Elderly

(+) to cultured microorganism

CXR (+) pulmonary consolidation
CBC

Elevated ESR (rate of erythropoeisis) N =

0.51.5% WBC
(compensatory mech to

Elevated
ABG PO2 decreased (hypoxemia)

NURSING MANAGEMENT
1.
Enforce CBR (consistent to all respi disorders)
2.
Strict respiratory isolation
3.
Administer medications as ordered

Broad spectrum
antibiotics

Penicillin pneumococcal infections

Tetracycline

Macrolides

Azithromycin (OD x
3/days)
1.
Too costly
2. Only se: ototoxicity
transient hearing loss

4.
5.
6.

7.
8.
9.

Anti-pyretics

Mucolytics/expectorants
Administer O2 inhalation as ordered
Force fluids to liquefy secretions
Institute pulmonary toilet measures to
promote expectoration of secretions

DBE,
Coughing
exercises,
CPT
(clapping/vibration), Turning and
repositioning
Nebulize and suction PRN
Place client of semi-fowlers to high fowlers
Provide a comfortable and humid environment

Usually, it is the upper lung areas which

are drained
Nursing management:

Monitor VS and BS

Best performed before

meals/breakfast
or to prevent
2-3 hours p.c.
gastroesophageal
reflux
or vomiting (pagkagising
maraming
secretions diba? Nakukuha?)

Encourage DBE

Administer bronchodilators 15-30

minutes
before procedure
Stop if pt. cant tolerate the procedure
Provide oral care after procedure as it
may
taste sensitivity
afect
Contraindications:

Unstable VS

Hemoptysis

Increased
ICP

Increased IOP (glaucoma)

12. Provide pt health teaching and d/c
planning

Avoidance of precipitating
factors

Prevention of complications

Atelectasis

Meningitis

Regular compliance to medications

Importance of ffup care

Tracheostomy usually done at bedside, 10-20 minutes

Stress test: 30 minutes
Mammography: 10-20 minutes
LARYNGOSPASM tracheostomy STAT
OR Tracheostomy: laryngeal, thyroid, neck CA
DIAPHRAGM primary muscle for respiration
INTERCOSTAL MUSCLES secondary muscle for
respiration
ALVEOLI (Acinar cells) functional unit of the lungs;
site for gas
exchange (via diffusion)

VENTILATION movement of air in and out of the

lungs

RESPIRATION lungs to cells

Internal

External
RETROLENTAL
FIBROPLASIA

retinopathy/blindness in immaturity d/t high O2 fow in

pedia patients

II.

PULMONARY TUBERCULOSIS (KOCHS DISEASE)

infection of the lung parenchyma caused by invasion of
mycobacterium tuberculosis or tubercle bacilli (gram
negative,acid fast, motile, aerobic, easily destroyed by
heat/sunlight)
10. Provide a dietary intake high in CHO,
CHON, Calories and Vit C
11. Assist in postural drainage
Patient is placed in various position
to drain secretions via force of gravity

A.

PRECIPITATING FACTORS
1.
Malnutrition
2.
Overcrowding
3. Alcoholism: Depletes VIT B1 (thiamin) alcoholic
beriberi malnutrition
4.
Physical and emotional stress

5.
6.
B.

Ingestion of infected cattle with M. bovis

Virulence (degree of pathogenecity)

MODE OF TRANSMISSION: Airborne

droplet infection

C.

D.

E.

SIGNS AND SYMPTOMS

1.
Productive cough (yellowish)
2.
Low grade afternoon fever, night sweats
3.
Dyspnea, anorexia, malaise, weight loss
4.
Chest/back pain
5.
Hemoptysis
DIAGNOSTICS
1.
Skin testing

Mantoux test
PPD

Induration width (within 48-72 h)

8-10 mm (DOH)

10-14 mm (WHO)

5 mm in AIDS patients is +
indicates
previous
exposure
tubercle bacilli
2.
Sputum AFB (+) tubercle bacilli
3.
CXR (+) pulmo infiltrated due to caseous
necrosis
4.
CBC elevated WBC

9.

to

NURSING MANAGEMENT
1.
Enforce CBR
2.
Institute strict respiratory isolation
3.
Administer O2 inhalation
4.
Forced fluids
5.
Encourage DBE and coughing
NO CLAPPING in chronic PTB
d/t hemoptysis may lead to
hemorrhage
6.
Nebulize and suction PRN
7.
Provide comfortable and humid environment
8.
Institute short course chemotherapy

Intensive
phase

INH

SE: peripheral neuritis (increase

vit
B6 or pyridoxine

Rifampicin
SE:
red
orange
color
of
bodily secretions

PZA
May
be
replaced
with
Ethambutol (SE: optic neuritis) if
(+) hypersensitivity to drug
SE:
allergic
reactions;
hepatotoxicity and nephrotoxicity
1.
Monitor liver enzymes
2.
Monitor BUN and CREA
INH given for 4 months, PZA
and Rifampicin is given for 2 months,
A.C. to facilitate absorption
These
3
drugs
are
given
simultaneously
to
prevent
development of resistance

Standard
Regimen

Streptomycin injection
(aminoglycosides)

Neomycin, Amikacin,
Gentamycin
th
1. common
SE:
8
CN
damage

tinnitus

hearing loss ototoxicity

2.
nephrotoxicity
a.
BUN (N = 1020)

b.
CREA (N = 8-10)
Health teaching and d/c planning

Avoidance of precipitating factors :

alcoholism, overcrowding
Prevention of complications

Atelectasis

Military
TB
(extrapulmonary
TB:
meningeal, Potts, adrenal glands,
skin,
cornea
)
Strict compliance to medications
Never double the dose! Continue
taking the meds if missed a day)
Diet modifications: increased CHON,
CHO, Calories, Vit C
Importance of ffup care

3.

4.

SIGNS AND
SYMPTOMS
PTB like symptoms
Productive cough
Fever, chills, anorexia,
body malaise
Cyanosis
Chest and joint pains
Dyspnea

NURSING MANAGEMENT

Enforce CBG

Administer meds as ordered

Antifungal agents

Amphotericin B (Fungizone)
SE:
nephrotoxicity and hypokalemia

PREDISPOSING FACTORS

Inhalation of contaminated dust

2.

DIAGNOSTICS

Histoplasmin skin test is (+)

ABG analysis reveals pO2 low

III. HISTOPLASMOSIS acute fungal infection caused by

inhalation of contaminated dust with Histoplasma
capsulatum from birds manure
A.

Hemoptysis

Monitor transaminases, BUN and

CREA
Corticosteroids
Anti-pyretics
Mucolytics/expectorants
Administer oxygen inhalation as ordered
Forced fluids
Nebulize and suction as necessary
Prevent complications

Bronchiectasis, atelectasis
Prevention of spread

Spraying of breeding places

Kill bird and owner! Hehe!

CHRONIC OBSTRUCTIVE PULMONARY DISEASES

generalized
1.
2.
3.
4.

Chronic Bronchitis
Bronchial Asthma
Bronchiectasis
Pulmonary Emphysema

I.

CHRONIC
BRONCHITIS
(Blue
Bloaters)

Inflammation of the bronchi due to hypertrophy or

hyperplasia of goblet mucous producing cells leading to
narrowing of smaller airways

II.

BRONCHIAL ASTHMA reversible inflammatory lung

condition caused by hypersensitivity to allergens
leading to narrowing of smaller airways

A.

PREDISPOSING FACTORS

A.

PREDISPOSING FACTORS
1.
Smoking
2.
Air pollution

B.

SIGNS AND SYMPTOMS

1.
Consistent productive cough
2. Dyspnea on exertion with prolonged
expiratory grunt
3.
Anorexia and generalized body malaise
4.
Cyanosis
5.
Scattered rales/rhonchi
6.
Pulmonary hypertension

Peripheral edema

Cor pulmonale

C.

NURSING MANAGEMENT
1.
Enforce CBR
2.
Administer medications as ordered

Bronchodilators

Antimicrobials

Corticosteroids

Mucolytics/expectorants
3. Low inflow O2 admin; high inflow will
cause respiratory arrest
4.
Force fluids
5.
Nebulize and suction client as needed
6.
Provide comfortable and humid environment
7.
Health teaching and d/c planning

avoidance of smoking
prevent complications

CO2 narcosis coma

Cor pulmonale
Pleural effusion
Pneumothorax
Regular adherence to meds
Importance of ffup care

Extrinsic (Atopic/Allergic Asthma)

Pollens, dust, fumes, smoke, fur,

2. dander, lints
Intrinsic
(Non-Atopic/Non-Allergic)

Drugs
(aspirin, penicillin, B-blockers)

Foods (seafoods, eggs, chicken,

chocolate)
Food
additives (nitrates, nitrites)
Sudden change in temperature,
humidity and air pressure

Genetics

Physical and emotional stress

3.
Mixed type combination of both
B.
1.
2.
3.
4.
5.
6.

DIAGNOSTICS
1. ABG analysis: decreased PO2, increased
PCO2, respiratory acidosis; hypoxemia
cyanosis

D.

1.

SIGNS AND
SYMPTOMS
Cough that is productive
Dyspnea
Wheezing on expiration
Tachycardia, palpitations and diaphoresis
Mild apprehension, restlessness
Cyanosis

C.

DIAGNOSTICS
1.
PFT decreased vital lung capacity
2.
ABG analysis PO2 decreased

D.

NURSING MANAGEMENT
1.
Enforce CBR
2.
Administer medications as ordered
Bronchodilators administer first to
facilitate absorption of corticosteroids

Inhalation

MDI

Corticosteroids

Mucolytics/expectorants

Mucomyst

Antihistamine

3.
4.
5.
6.
7.
8.

Administer oxygen inhalation as ordered

Forced fluids
Nebulize and suction patient as necessary
Encourage DBE and coughing
Provide a comfortable and humid environment
Health teaching and d/c planning

Avoidance of precipitating factors

Prevention of complications

III.

Status asthmaticus

DOC:
Epinephrine

Aminophylline
drip

Emphysema
Regular adherence to medications
Importance of ffup care

D.

BRONCHIECTASIS permanent dilation of the

bronchus due to destruction of muscular and elastic
tissue of the alveolar walls (subject to surgery)

E.

A.

PREDISPOSING FACTORS
1.
Recurrent lower respiratory tract infection

Histoplasmosis
2.
Congenital disease
3.
Presence of tumor
4.
Chest trauma
B.
1.
2.
3.
4.
5.
6.

C.

SIGNS AND
SYMPTOMS
Consistent productive cough
Dyspnea
Presence of cyanosis
Rales and crackles
Hemoptysis
Anorexia and generalized body malaise

DIAGNOSTICS
1.
ABG analysis reveals low PO2
2. Bronchoscopy direct visualization of
bronchi lining using a fibroscope

Pre-op

Secure consent

Explain procedure

NPO 4-6 hours

Monitor VS and breath sounds

Post-operative

Feeding initiated upon return of gag

reflex
Instruct client to avoid talking,
coughing and smoking as it may
irritate respiratory tract

Monitor for s/sx of frank or gross

bleeding

Monitor for signs of laryngeal spasm

DOB and SOB prepare trache

set
SURGERY
1.
Segmental lobectomy
2.
Pneumonectomy

Most feared complications

Atelectasis
Cardiac tamponade: muffled heart
sounds, pulsus paradoxus, HPN

NURSING MANAGEMENT
1.
Enforce CBR
2. Low inflow O2 admin; high inflow will
cause respiratory arrest
3.
Administer medications as ordered

Bronchodilators

Antimicrobials
Corticosteroids
(5-10
minutes
after bronchodilators)

Mucolytics/expectorants
4.
Force fluids
5.
Nebulize and suction client as needed
6.
Provide comfortable and humid environment
7.
Health teaching and d/c planning

Avoidance of
smoking

Prevent
complications

Atelectasis

CO2 narcosis coma

Cor
pulmonale

Pleural
efusion

Pneumothorax

Regular adherence to meds

Importance of ffup
care

IV. PULMONARY EMPHYSEMA terminal and

irreversible stage of COPD characterized by :

Inelasticity of alveoli

Air trapping

Maldistribution of gasses (d/t increased air

trapping)

Overdistention of thoracic cavity (Barrel

chest)
compensatory mechanism increased AP
diameter

A.

PREDISPOSING FACTORS
1.
Smoking
2.
Air pollution
3. Hereditary: involves alpha-1 antitrypsin
for elastase production for recoil of the
alveoli
4.
Allergy
5. High risk group elderly degenerative
decreased
vital
lung
capacity
and
thinning of alveolar lobes
SIGNS AND
SYMPTOMS
1.
Productive cough
2.
Dyspnea at rest
3.
Prolonged expiratory grunt
4.
Resonance to hyperresonance
5.
Decreased tactile fremitus
6.
Decreased breath sounds ( if (-) BS lung
collapse)
7.
Barrel chest
8.
Anorexia and generalized body malaise
9.
Rales or crackles
10. Alar flaring
11. Pursed-lip breathing (to eliminate excess CO2)

RESTRICTIVE LUNG DISEASE

V.

PNEUMOTHORAX partial or complete collapse of

the lungs due to accumulation of air in pleural space
A.

TYPES
1. Spontaneous air enters pleural space
without an obvious cause

Ruptured blebs (alveolar filled

sacs)
inflammatory lung
conditions
2. Open air enters pleural space through an
opening in pleural wall (most common)

Gun shot wounds

Multiple stab wounds

3. Tension air enters pleural space during
inspiration and cannot escape leading to
overdistention of the thoracic cavity
mediastinal shift to the affected side (ie. Flail
chest) paradoxical breathing

B.

PREDISPOSING FACTORS
1.
Chest trauma
2.
Inflammatory lung condition
3.
tumors
SIGNS AND SYMPTOMS
1.
Sudden sharp chest pain, dyspnea, cyanosis
2.
Diminished breath sounds
3.
Cool, moist skin
4.
Mild restlessness and apprehension
5.
Resonance to hyperresonance

B.

C.

D.

DIAGNOSTICS
1.
ABG analysis reveal
Panlobular, centrilobular PO2 elevation
and PCO2 depression respiratory
acidosis (blue bloaters)

Panacinar/centriacinar PCO2
depression and
PO2 elevation (pink pufers hyperaxemia)
2.
Pulmo function test decreased vital lung
capacity
NURSING MANAGEMENT
1.
Enforce CBR
2.
Administer medications as ordered

Bronchodilators

Antimicrobials

Corticosteroids

Mucolytics/expectorants
3. Low inflow O2
admin; high inflow will
cause respiratory arrest and oxygen toxicity
4.
Force fluids
5.
Pulmonary toilet
6.
Nebulize and suction client as needed
7.
Institute PEEP in mechanical ventilation

PEEP positive end expiratory pressure

allows for maximum alveolar diffusion

prevent lung collapse

8.
Provide comfortable and humid environment
9. Diet modifications: high calorie, CHON,
CHO, vitamins and minerals
10. Health teaching and d/c planning

Avoidance of smoking

Prevent complications

Atelectasis

CO2 narcosis coma

Cor
pulmonale

Pleural
efusion

Pneumothorax

Regular adherence to meds

Importance of ffup care

C.

D.

DIAGNOSTICS
1.
ABG analysis: PO2 decreased
2.
CXR confirms collapse of lungs

E.

NURSING MANAGEMENT
1.
Assist in endotracheal intubation
2.
Assist in thoracentesis
3.
Administer meds as ordered

Narcotic analgesics Morphine sulfate

Antibiotics
4.
Assist in CTT to H20 sealed drainage