Alterations in

Respiratory Function

John Bert N. Macato RN,EMT, RM

 Sinusitis (Acute/ Chronic)
URTI
Cigarette Smoking
 Allergic rhinitis

Inflammatory Process

Edema of the mucous membrane

Hypersecretion of mucous

Infection
Assessment
 Pain
 Maxillary : Cheek, upper teeth
 Frontal : Above the eyebrows
 Ethmoid: in and around the eyes
 Sphenoid: behind the eye, occiput, top of
the head

 General Malaise
 Headache
 Fever
 Stuffy nose
 post nasal drip
 Cough
Nursing Interventions
 Rest
 Increase fluid intake
 Hot wet packs
 Codeine, avoid ASA- increases
the risk of developing nasal
polyps
 Amoxicillin or other anti-
infectives (acute- 7-10 days;
chronic- upto 21 days)
 Nasal decongestants eg
Sudafed, Dimetspp (used for 72
hours)

 Surgical Management
 Functional Endoscopic Sinus
Surgery (FESS)
 Caldwell- Luc Surgery (Radical
Antrum Surgery)
 Do not chew on affected side
 Caution with oral hygiene
 Do not wear dentures for 10 days
 Do not blow nose or sneeze for 2
weeks after removal of packing
 Ethmoidectomy
 Sphenoidotomy/ Ethmoidotomy
 Osteoplastic flap surgery for
frontal sinusitis.
Tonsilitis/ Adenoiditis
 Assessment:
 Sore throat
 Frequent head colds
 Fever
 Snoring
 Dysphagia
 Mouth-breathing
 Earache
 Frequent Head Colds
 Bronchitis
 Foul Breath
 Voice impairment
 Noisy Respiration
 Draining Ears
Nursing Interventions
 Promote Rest
 Increase Fluid Intake
 Warm saline gargle
 Analgesic as ordered
 Antimicrobial as ordered
 Surgery: Tonsillectomy/
adenoidectomy (indicated if
tonsillitis recurs 5-6 times a
year)
 PRE-OP care
 Assess for URTI- coughing and
sneezing post-op may cause
bleeding
 Check PT. Bleeding is a common
post-op complication
 POST-OP care
 Prone, head turned to side, or lateral
position
 When awake, semi-fowler’s position

 Oral airway until swallowing reflex

returns
 Monitor for hemorrhage
 Frequent swallowing
 Bright red vomitus
 Increased PR
 Promote Comfort
 Ice collar, Acetaminophen; Avoid ASA
 Foods and Fluids
 Ice-cold fluids
 Bland foods
 Client Education
 Avoid clearing of throat
 Avoid coughing, sneezing, blowing for 1-
2 weeks
 2-3 L of fluids/ day until ,outh odor
disappears
 Avoid hard, scratchy foods until throat is
healed
 Report s/sx of bleeding

 Throat discomfort between 4th to 8th

postop day is expected
 Stool: Black/ dark for few days due to
swallowed blood
 Plenty of rest for 2 weeks

 Avoid colds, overcrowded public places

Ca of the Larynx

 Predisposing Factors:
 Cigarette Smoking
 Alcohol Abuse

 Voice Abuse

 Environmental pollutants

 Chronic Laryngitis

 (+) Family history

Assessment
 Persistent hoarseness of voice
 Mass on anterior neck
 Dyspnea
 Dysphagia
 Chronic laryngitis
 Burning sensation with hot/acidic
beverages
 Halitosis
 Hemoptysis
 Severe anorexia
 Severe anemia
 Severe weight loss
Management
 Surgery: Subtotal/ total
laryngectomy
 Pre-op care:
 Psychosocial support
 Effects of total laryngectomy
 Loss of voice
 Permanent tracheostomy
 Loss of sesnse of smell
 Establish means of communication to
be used post-op
 Inability to :
 Blow, sip soup and straw, whistle,
gargle, do valsalva maneuver( unable to
lift heavy objects; constipation)
 POST-OP care
 Careof the Client with
tracheostomy
 Establish patient airway
 Suction as necessary
 Use sterile technique

 Semi-fowler’s position

 Use sterile NSS to lubricate suction

catheter tip
 Apply suction during withdrawal of
suction catheter
 Apply suction for 5-10 seconds (Max of
15 sec)
 Insert 3-5 “ of suction catheter

 Instill 2-5 ml of sterile NSS to liquify

mucous secretions
 Prevent Infection
 Cleanse stoma and tracheostomy
at regular basis
 Change dressings and ties as
necessary
 Establish means of
communication
 Provide psychosocial support
 Assist during speech therapy
 Client teaching:
 Cover tracheostomy with poprous
material
 Avoid swimming

 Avoid use of powder, spray

aerosol near tracheostomy
 Regular follow-up care
Pneumonia
 An infection of pulmonary tissue ,
including the interstitial spaces, the
alveoli and the bronchioles
 The alveoli are filled with
inflammatory products , creating
consolidation
 The edema associated with
inflammation stiffens the lungs ,
decreases lung compliance and vital
capacity and causes hypoxemia
 Features include fever, chills,
breathlessness and often
dehydration
 Can be community acquired or
hospital acquired
 Classified according to
causative agent: bacterial, viral,
fungal or parasitic
 CXR: presents as diffuse
patches throughout the lungs or
consolidation in a lobe
 A sputum culture identifies the
organism
 WBC and ESR are elevated
Classifications of Pneumonia

 Bronchopneumonia
 Patchy and scattered , often
favoring the lower lobes
 Common in the immobile and the
elderly
 Early signs include dullness to
percussion and barely perceptible
fine crackles which persist despite
deep breathing.
Lobar Pneumonia

 Localized pleuritic pain and

bronchial breathing confined to
a lobe
Pneumocystis Carinii
Pneumonia
 Due to HIV infection and
medications given after an
organ transplant
 Clinical features include dry
cough, breathlesness,
hypoxemia and features of stiff
lungs
Nosocomial Pneumonia
 Develops in patients confined in
the hospital for more than 48
hours – hospital acquired
 Leading cause of hospital-
related mortality
 Caused by cross infections
 Klebsiella, Pseudomonas,
E.coli, Enterobacteriacae,
Proteus, Serratia
Legionella Pneumonia

 Occurs in local outbreaks,

especially in relation to cooling
system, or after a trip abroad
Aspiration Pneumonia

 Occurs in people who have

inhaled unfriendly substances
such as vomitus, or gastric acid
 Clinical signs include coughing,
choking, added sounds in
auscultation, gurgly voice or
loss of voice, tachycardia and
sometimes change in color
Chemical Pneumonia

 Seen in ingestion of kerosene or

inhalation of irritating gases
Radiation Pneumonitis

 Mat follow radiation therapy for

breast or lung cancer and
usually occurs 6 weeks or more
after completion or radiation
therapy
Assessment
 Chills
 Elevated temperature
 Pleuritic pain
 Rales, ronchi and wheezes
 Use of accessory muscles for
breathing
 Cyanosis
 Mental status changes
 Sputum production
Diagnostics

 CBC
 Creatinine
 Chest x-ray
 PA-L
 Sputum G/S and C/S
 Sputum AFB 3x (for TB suspect)
Manifestations of Commonly
Encountered Pneumonia
Streptococcal p. (streptococcus
pneumoniae)
 History of previous infections
 Sudden onset, shaking and chills
 Cough, rusty or green (purulent
sputum)
 Pleuritic chest pain, chest dull to
percussion, crackles, bronchial breath
sounds
 Treated with: Pen G, erythromycin,
clinamycin, cephalosphorins,
Cotrimoxazole
 Complications: shock, pleural effusion,
superinfections, pericarditis, otitis
media.
Staphylococcal Pneumonia
(Staphylococcus aureus)
 Prior history of viral infection
 Insidious onset of cough, yellow,
bloode-streaked mucous
 Fever, pleuritic chest pain, varied
pulse rate, may be slow in proportion
to temperature
 Treated with: Nafcillin, methicillin,
clindamycin, vancomycin, cephalotin
 Complications: effusion/
pneumothorax, lung abscess,
empyema, meningitis
Klebsiella pneumonia
(Klebsiella pneumoniae)
 Sudden high fever, chills,
pleuritic pain, hemoptysis
 Dyspnea, cyanosis
 Dark brown, gelatinous sputum
 Treated with: gentamicin,
cefazolin, tobramycin
 Complications: lung abscesses
with cyst formation, empyema,
pericarditis
Mycoplasma pneumonia
(Mycoplasma pneumoniae)
 Gradual onset, severe
headache
 Irritating hacking cough, scanty
mucoid sputum
 Anorexia, malaise, fever,
congestion, sore throat
 Treated with : erythromycin,
tetracycline
Viral pneumonia

 Influenza, parainfluenza, RSV,

adenovirus, varicella, rubella,
rubeola, HSV, cytomegalovirus,
Epstein Barr virus
 Cough
 Pronounced constitutional
symptoms (severe headache,
anorexia, fever and myalgia)
Nursing Diagnoses
 Ineffective airway clearance related
to copious tracheobronchial
secretions
 Risk for deficient fluid volume related
to fever and dyspnea
 Activity intolerance related to
impaired respiratory function
 Imbalanced nutrition less than body
requirements
 Deficient knowledge and about
treatment regimen and preventive
health measures.
Planning and Goals

 The major goals of the patient

may include improved airway
patency, rest to conserve
energy, proper fluid volume,
adequate nutrition, an
understanding of the treatment
protocol and preventive
measures, and absence of
complications
Therapeutics
 Antibiotic regimen for a max of 7-8
days only to minimize the
emergence of resistance
 Switch therapy: Intravenous
antibiotic treatment may be shifted to
oral anti8biotics after 48-72 hours if
the following parameters are fulfilled:
 A.) ther is less cough and resolution of
respiratory distress
 B.) the temperature is normalizing
 C.) the etiology is not a high risk
(virulent or resistant) pathogen
 D.) there is no unstable co-morbid
conditions or life threatening conditions
 E.) oral medications are tolerated
 For abundant secretions, may
give acetylcysteine (Fluimucil)
100mg or 200mg sachet
dissolved in ½ glass water TID.
Discontinue if patient has
wheezing.
Nursing Implementation for
Pneumonia
 Administer oxygen as prescribed
 Monitor respiratory status
 Monitor for labored respirations,
cyanosis ,cold clammy skin
 Encourage coughing and deep
breathing and use of incentive
spirometer
 Position in semi-fowler’s to facilitate
breathing and lung expansion
 Change position frequently and
ambulate as tolerated to mobilize
secretions
 Provide chest physiotherapy
 Perform nasotracheal suctioning if
the client is unable to clear
secretions
 Monitor pulse oximitry
 Monitor and record color,
consistency, and amount of sputum
 Provide a high calorie, high protein
diet with small frequent feedings
 Encourage fluids upto 3 liters per
day to thin secretions unless
contraindicated
 Provide a balance of rest and
activity, increasing activity grasdually
 Administer antibiotics as prescribed
 Administer asntipyretics,
bronchodilators, cough
suppressants, mucolytic agents and
expectorant as prescribed
 Prevent the spread of infection by
hand washing and proper disposal of
secretions.
Client Education for
Pneumonia
 The importance of rest, proper
nutrition and adequate fluid intake
 Avoid chilling and exposure to
individual with respiratory infections
or viruses
 Instruct client regarding medications
and the use of inhalants as
prescribed
 Instruct the client to notify physician
if chills, fever, dyspnea, hemoptysis
or increased fatigue occurs
 Instruct the client in the importance
of receiving immunizations as
recommended
Prevention and risk factors for
Pneumonia
 Any condition producing mucus or
bronchial obstruction and interfering
with normal drainage (COPD, CA)
 Immunosuppressed patients
 People who smoke, because
cigarette smoke disrupts mucociliary
and macrophage activity
 Immobile patients breathing
shallowly
 Patients with depressed cough reflex
owing to drugs or weakness, has
aspirated foreign material during
unconsciousness or those with
abnormal swallowing mechanism
 NPO patients receiving antibiotics,
has increased pharyngeal
colonization of bacteria
 Frequently intoxicated people.
Alcohol suppresses body reflexes,
WBC mobilization, trachiobronchial
ciliary mobilization
 Patients receiving sedatives
 prevention through frequent
suctioning of unconscious patients,
with poor gag and cough reflexes
 Elderly people are at risk
 Patients receiving respiratory
therapy using not properly cleaned
equipment.
Lung abscess
 A localized lesion in the lung
containing pus and necrotic tissue
that collapses and forms cavities, or
pockets in the lungs
 May occur from aspiration of vomitus
or infected material from the upper
respiratory tract; or secondary to
bronchial obstruction due to a tumor.
 May also be a sequela of necrotizing
pneumonia ,tuberculosis. Pulmonary
embolism, trauma, bronchial
neoplasms.
Nursing Assessment

 Initially cough, with small

amount of sputum, a low-grade
fever and malaise
 In time, sputum becomes
copious and often foul- smelling,
sometimes containing blood
 Pleuritic chest pain
 Onset is sudden, with chills,
high fever cough and malaise
Measures to reduce risk of
suppurative lung disease
 Antibiotic therapy before dental
manipulation.
 Adequate dental and oral
hygiene since anaerobic
bacteria play a role in the
pathogenesis of lung abscess
 Give appropriate antimicrobial
therapy to those with
pneumonia
Management

 Postural drainage, effective

coughing and deep breathing
exercises
 Bronchoscopy may be needed
to drain abscess
 High CHON, high CHO diet
 Surgery if medical intervention
is inadequate
 Emotional support
 Surgical intervention is rare:
 Pulmonary resection (lobectomy)
when there is massive hemoptysis
or no response to medical
management.

 Pharmacologic Therapy
 IV: Clindamycin (Cloecin)
 meropenem (Merrem)
 piperacillin/tazobaqctam (Zosyn)

 May last for 4-8 weeks.

COPD
 Also known as Chronic
Obstructive Lung Disease
(COLD) and Chronic Airflow
Limitation (CAL)
 Characterized by airflow
limitation that is not fully
reversible
 There is progressive airflow
limitation into and out of the
lungs, elevated airway
resistance, irreversible lung
distention and ABG imbalance
 Caused by Emphysema and
Chronic Bronchitis or a
combination of both.
 Leads to pulmonary
insufficiency, pulmonary
hypertension and cor pulmonale
Risk factors of COPD:

 Exposure to tobacco smoke (80-

90 % of COPD cases)
 Passive smoking
 Occupational exposure
 Ambient air pollution
 Genetic abnormalities, including
a deficiency of alpha 1-
antitrypsin.
COPD- chronic bronchitis
 A disease of the airways, defined as
the presence of irritating cough
(smoker’s cough) and sputum
production for at least 3 months is
each of 2 consecutive years
 Develops in heavy smokers
 In many cases , smoke or other
environmental pollutants irritate the
airways resulting in hypersecretion of
mucous and inflammation
 This constant irritation causes the
mucus-secreting glands and goblet
cells to increase in number, ciliary
function is reduced, and more mucus
is produced.
 Bronchial walls become thickened
resulting in narrowing of lumen, and
mucus may plug the airway.
 Adjacent alveoli may become
damaged and fibrosed, resulting in
altered function of alveolar
macrophages. As a result the client
becomes more susceptible to
respiratory infection
 Clients abandons the fight for
normal blood gases and feels
less breathless, but pays for
symptomatic relief with edema,
cyanosis and inadequate gas
exchange (Blue bloaters)
COPD- emphysema

 An abnormal distention of the air

spaces beyond the terminal
bronchioles with destruction of
the walls of the alveoli
 Commonly caused by smoking
 Protein breakdown is the villain
which causes erosion of the
alveolar system, dilation of distal
air spaces and destruction of
elastic fibers
 Alveoli lose their elastic recoil,
then weaken and rupture.
 Air remains trapped in the lungs,
(formation of air pockets or
bullae); carbon dioxide
accumulates (hypercapnia) with
resulting respiratory acidosis
 Cor pulmonale is one of the
complications of emphysema
 Client with emphysema tries to
maintain near normal blood
gases at the expense of
brathlesness and weight loss,
no cyanosis occurs (pink
puffers)
 The flat diaphragm works
paradoxically and becomes
expiratory in action, thus,
drawing the lower ribs in
inspiration ( Hoover’s sign)
Types of Emphysema
 Centrolobar Emphysema
 Affects the respiratory bronchioles
 Most common type of emphysema

 Associated with chronic bronchitis

and bronchial inflammation
 Originates at the center of the
lobule and is distinct from the
periphery of the acinus with its
septae and vessels
 Variable and patchy and has a
predilection for upper lung zones
 Panlobar or panacinar
emphysema
 Associated with severe alpha 1-
antitrypsin defeciency and affects
the alveoli themselves, causing
more destruction.
 Little association with chronic
bronchitis
Clinical syndrome of COPD

 Patients with empysematous,

dyspneic or Type A COPD are
referred as PINK PUFFERS
 Those with bronchitic, tussive or
Type B COPD are referred as
BLUE BLOATERS
Pink puffers
 Have predominant emphysema
 Symptoms of relatively
advanced age ( >60 yrs)
 Progressive exertional dyspnea,
weight loss, little or no cough
and expectoration.
 Mild hypoxia, hypocapnia and
little improvement in airflow after
treatment with bronchodilators.
They usually undergo a slowly
progressive downhill course
Blue Bloaters
 Predominant chronic bronchitis
 At relatively young age
 Chronic cough and expectoration,
episodic dyspnea and weight gain
 Wheezing and ronchi, cor
pulmonale, accompanied by edema
and cyanosis
 Severe hypoxia, hypercapnia,
polycythemia
 Improvede airflow after treatment
with bronchodilators and relatively
preserved lung volumes.
Nursing implementation for
COPD
 Monitor vital signs
 Administer a low concentration
of oxygen (2-3 L/min) as
prescribed ; in emphysema, the
stimulus to breathe is a low PO2
instead of an increased in PCO2
 Monitor pulse oximetry
 Provide respiratory treatments
and chest physiotherapy
 Instruct the client in
diaphragmatic or abdominal and
pursed-lip breathing techniques
 Record the color, amount and
consistency of sputum
 Suction the client, if necessary ,
to clear airway and prevent
infection
 Monitor weight
 Encourage small frequent meals
to prevent dyspnea
 Provide high CHO and high
CHON diet with supplements
 Encourage fluids up to 3000
ml/day to keep secretions thin
unless contraindicated
 Position in high fowler’s or
orthopneic position
 Allow activity as tolerated
 Administer bronchodilators as
prescribed and instruct the client
in the use of both oral and
inhalant medications
 Administer corticosteroids as
prescribed to reduce
inflammation
 Administer mucolytics as
prescribed to thin secretions
 Administer antibiotics for
infection as prescribed
 Coping measures:
 Patients experience anxiety,
apprehension, frustration of
having to work to breathe
 Adapt a hopeful and encouraging
attitude
 Emphasis should be in controlling
his symptoms and increasing self
esteem and sense of mastery and
well-being
 Patient education and home
health care:
 Stop smoking
 Tell him what to expect. He and
family caring for him will need
patience
 Help patient accept set realistic
short term and long term goals
 The objective is to increase
exercise tolerance and prevent
further loss of pulmonary function
 Educate the patient about the
disease process
 Recognize the signs and
symptoms of respiratory
infection and hypoxia
 Adhere to activity limitations,
altering rest periods with activity
 Avoid exposure to individuals
with infections and avoid crowds
 Instruct to avoid extremes of
heat and cold
 Demonstrate pursed-lip and
diaphragmatic or abdominal
breathing
 Instruct the client in the use of
medications and inhalers
 Instruct the client in the use of
oxygen therapy
 Instruct the client in nutritional
requirements
 Avoid eating gas-producing
foods, spicy foods, and
extremely hot and cold foods
 Instruct in the importance of
receiving immunizations as
recommended
 When dusting , use a wet cloth
 Avoid powerful odors
 Avoid extremes in temperature
 Avoid fireplaces, pets, and
feather pillows
Asthma
 An intermittent reversible airway
obstruction characterized by
hyperresponsiveness or
heperirritability and
inflammation of the airways
 Substances that have no effect
when inhaled by normal
individuals can cause
bronchoconstrictions in patients
with asthma
 A principal feature of asthma is
its extreme variability, both from
patient to patient and from time
to time in the same patient.
 Allergy is the strongest
predisposing factor for asthma
Incidence and etiology:

 Asthma occurs in 3-8 % of the

population
 It is traditionally divided into 3
forms
 An allergic form – extrinsic form
 An intrinsic form

 Mixed asthma
 Extrinsic Intrinsic
(allergic) (infectious /
miscellaneous)

Age of Onset 3- 35 y.o Under 3, over 35-40

Symptoms Season of perennial, Worse in winter, cold

frequently pollen and seasons,
mold related exacerbated by cold
air, air pollution, and
primarily by infection

Mucus Clear and foamy Thick and white or

discolored

Family History positive No greater than in

general population

Skin Tests Positive and Negative or positive

correlating non-correlating

Serum Ig E High or normal normal

Response to Good response to Poor response to

therapy immunotherapy and bronchodilators, no
bronchodilator response to
immunotherapy
 The following may trigger an
asthma attack:
 Allergenicfoods (eggs, nuts,
wheat, dairy products)
 Chest infection

 Drugs e.g. NSAIDS, ASA

 Exercise

 Car exhaust

 Exercise

 Frustrated expression of emotion

 Premenstruation

 Pollen
 Smoking
 Warm blooded pets
 Weather

 Education about these risk

factors and prevention is vital in
care of patients in asthma
Biochemical mediators

 Ig E cell mediated, histamine

from mast cells
 Serotonin, prostaglandins,
thromboxanes,
endoperoxidases, also cause
tissue inflammation and maybe
particularly important in the
pathogenesis of nonallergic
asthma
Pathophysiologic basis:

 Get a whole sheet of paper

 Make a tracing of the
pathophysiology of asthma
using your book.
Other classification of asthma
and their clinical features
 Mild chronic asthma
 -manifestsan intermittent dry
cough often at night or morning
and wheezes once or twice a
week
Severe Chronic Asthma
-frequent exacerbations and
symptoms that significantly affect
quality of life
 Unstable- most severe form; also
known as brittle asthma which shows
greatly fluctuating peak flows,
persistent symptoms despite multiple
drug treatment and unpredictable
severe falls in lung functioning, often
without known precipitating factors.
 Acute asthma- large airways are
obstructed by bronchospasm and the
small airways by edema and mucus
plugging.
 Associated with breathlessness,
rapid breathing and abdominal
paradox
 Severe acute asthma
 Most commonly develops slowly,
often after several weeks of
wheezing
 Alternately, attack is sudden,
especially if there has been poor
drug control
 Can be fatal within minutes
Status asthmaticus

 Severe asthma attacked

prolonged over 24 hours.
 Clinical manifestations include
fatigue, PR > 100bpm and
cyanosis
 Use of accessory muscles
 Pulsus paradoxus
 Exercise – induced asthma
 -hyperventilation during exercise,
especially in cold weather causes
bronchospasm
 Nocturnal asthma- 80% in
asthmatics
 -interferes
with sexual intercourse
and sleeping
 Occupational asthma
 -may take weeks or years to
develop
Diagnosis:

 Sputum analysis
 -may appear purulent
 -reveal Curschmann’s spirals

 - reveals Charcot’s Layden

crystals
 Hematologic studies- modest
leukocytosis and eosinophilia
 Pulmonary function testing
 Chest x-ray
 ABG studies- PCO2 is low less
that 36 mmHg. An increased
PCO2 or normal PCO2
indicates severe obstruction
Nursing Assessment:
 Cough
 Dyspnea
 Wheezing
 Diaphoresis
 Tachycardia
 General chest tightness
 Hypoxemia
 Central cyanosis
 History- + family hx- periodic
reversible airflow obstruction
Nursing Implementation:
 Assess airway patency
 Elevate head
 Administer humidified O2
 Continuously monitor resp
status:
 Give Medications as prescribed
(Bronchodilators)
 Sympathomimetics ( B2 agonists)
 Methlyxanthines (Theophylline)

 Anti cholinergic agents (Ipratropium)

DO NOT GIVE BETA
BLOCKERS!!!!!
Anti-inflammatory agents:
 Corticosteroids and cromolyn
sodium

 Preventexacerbations
 Teaching:
 Positioning
 Pursed-lip exercises

 Nutrition: Avoid over feeding!