Transcript Ch 29 Canvas 16

Chapter 29
Respiratory System
Function, Assessment,
and Therapeutic
Measures
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2015. F.A.
Davis F.A.
Company
Copyright
© 2015.
Davis Company
Learning Outcomes
 Describe the normal structures and functions
of the respiratory system.
 Identify how aging affects the respiratory
system.
 List data to collect when caring for a patient
with a respiratory disorder.
 Recognize expected findings when
inspecting, palpating, percussing, and
auscultating the chest.
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Learning Outcomes (cont’d)
 Identify common diagnostic tests performed
to diagnose disorders of the respiratory
system.
 Plan nursing care for patients undergoing
each of the diagnostic tests.
 Discuss therapeutic measures used to help
patients with respiratory disorders.
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Normal Respiratory Anatomy
 Nose and Nasal Cavities- The nasal mucosa
is ciliated epithelium that is highly vascular.
The ciliated epithelium also sweeps mucus
and pathogens from the nasal cavities and
trachea to the pharynx
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 Pharynx- Consist of 3 sections
1. Nasopharynx- An air passageway behind
nose
2. Oropharynx- An air and food passage
located in back of throat
3. Laryngopharynx- An air and food passage
that opens up either to larynx or esophagus
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 Larynx- is the voice box and the airway
between the pharynx and the trachea
 Trachea and Bronchial Tree- the trachea
extends from the larynx to the primary
bronchi. The bronchial tree is the series of
air passages within the lungs
 Lungs- occupy the chest cavity on either side
of the heart. The functional unit of the lung
are the millions of alveoli which are the air
sacs that are the site for gas exchange
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Mechanism of Breathing
 Ventilation- movement of air into and out of
the alveoli. Air moves from high pressure
area to low pressure areas. The respiratory
centers are in the medulla oblongata and
pons of the brain
 Inhalation- occurs when motor impulses
from the medulla cause contraction of the
respiratory muscles
 Exhalation- passive process when
diaphragm and intercostal muscles relax
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Transport of Gases in the Blood
 Oxygen is carried by iron in the hemoglobin
(Hgb) of red blood cells (RBC’s).
 Carbon Dioxide is carried in the blood in the
form of bicarbonate ions in the plasma
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Regulation of Respiration
 Respirations are regulated by the nervous
system and chemical mechanisms
 The medulla oblongata contains an
inspiratory center and an expiratory center.
The inspiratory center generates impulses
that bring about contraction of the
respiratory muscles resulting in inhalation.
When the impulse stops, exhalation occurs.
 Carbon dioxide is the major regulator of
respiration because even small changes in
C02 blood level change pH.
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Review of A&P
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Review of A&P (cont’d)
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Review of A&P (cont’d)
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Review of A&P (cont’d)
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Review of A&P (cont’d)
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Review of A&P (cont’d)
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Acid-Base Balance
 Respiratory Acidosis-
Any decrease in the rate or efficiency of
respirations permits excess C02 to
accumulate in the blood causing blood pH to
decrease. This can occur because of
pulmonary disease or any impairment of gas
exchange in the lungs.(hypoventilation)
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Acid-Base Balance
 Respiratory Alkalosis-
When the rate of respiration increases,
eliminating exhaled C02 rapidly, the pH of
the blood increases. This can occur during
anxiety or hyperventilation.
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Effects of Aging
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History
 Upper Respiratory Symptoms
 Lower Respiratory Symptoms
 Exposures/Smoking
 Current Treatments
 Family History
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WHAT’S UP?
 Where Is It?
 How Does It Feel?
 Aggravating and Alleviating Factors
 Timing
 Severity
 Useful Other Data
 Patient’s Perception
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Inspection
 Symmetry
 Dyspnea
 Use of Accessory
Muscles
 Color
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Inspection




Symmetry
Resp rate/rhythm
Dyspnea
Use of Accessory
Muscles
 Chest shape
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Palpation
 Sinuses
 Respiratory
Excursion
 Crepitus
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Percussion
 Resonance
 Hyperresonance
 Dull
 Flat
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Auscultation
 Normal Breath Sounds
 Adventitious Sounds
 Compare Bilaterally
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Adventitious Breath Sounds
 Crackles—Coarse or Fine
 Wheezes
 Stridor
 Friction Rub
 Diminished
 Absent
 Chart 29.4 page 603
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Laboratory Tests
 CBC- Dyspnea can be caused by a reduction in
RBC’s or hemoglobin– Elevated WBC’s indicate
infection
 ABGs- Measured to determine the
effectiveness of gas exchange- page 604
 D-Dimer-Helps diagnose the presence of
pulmonary embolism
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Laboratory Test Cont….
 Sputum Cultures- Have pt take several deep
breaths and cough sputum into sterile
container
 Throat Culture- Use swab to reach pharynx
without touching pt mouth
 Nasal Samples- Use of nasal swab or wash to
identify flu or respiratory virus
 SpO2- Sensor that measures the percentage
of hemoglobin that is saturated with oxygen
 Capnography- Measures a person’s exhaled
CO2 level
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Diagnostic Tests
 Chest X-Ray- diagnose pulmonary disorder
 CT Scan- NPO 4 hrs, Check allergies if
contrast used, void for comfort
 VQ Scan (Ventilation Perfusion Scan- lung
scan
 PFTs- determines lung volume, capacity &
flow rate- Study table 29.7/page 606
 Pulmonary Angiography- Administration of
contrast dye to examine pulmonary vessels**Femoral artery is used as injection site so
pt will need to lie flat for 8 hours so injection
site does not bleed.
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Diagnostic Test Cont…Bronchoscopy
 Use of flexible endoscope to examine larynx,
trachea, and bronchial tree.
 NPO 6-8 hours
 Anesthetic spray to numb throat, sedative
 Atropine to dry up excess secretions.
 Pt NPO till gag reflex returns, touch back of
throat with a cotton swab
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Therapeutic Measures
 Smoking Cessation- Behavior modification,
Counseling, Setting a quit date, Nicotine
replacement therapy, Drug therapy,
Acupuncture, Hypnosis
 Deep Breathing and Coughing
 Huff Coughing- Coughing with mouth open**a short huff helps clear larger airways while
a long huff helps open and clear smaller
airways
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Breathing Exercises
 Diaphragmatic Breathing- place one hand on
the chest and the other on the abdomen as
you try to push out the abdomen during
inspiration and relaxing the abdomen during
expiration
 Pursed lip breathing
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Positioning
 Use Fowler’s or semi-Fowler’s position to
keep abdominal contents from crowding the
lungs
 Good lung down- Patients with unilateral
lung disease can benefit from the “good
lung down.” Gravity will cause greater blood
flow to the good lung thereby increasing O2
saturation
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Oxygen Therapy
 Nasal canula- low flow device
 Masks (low flow device)- may make pt feel
clausterphobic. Used when higher 02
concentration is needed.
- partial rebreather- used to capture some
exhaled gas for rebreathing
- non rebreather- has one or both side vents
closed to limit the mixing of room air with oxygen
 Venuturi Mask- high flow device with a
combination of valves for specified flow rates
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Risk of Oxygen Therapy
 Pts with COPD usually have chronically high
PCO2 levels so they depend on low PO2 levels
to stimulate breathing, and high
supplemental flow rates can depress
respirations. These patients should be
maintained on no more than 1-2 liters of
oxygen per minute
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Oxygen Masks
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Transtracheal Oxygen
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NMT- Nebulizer mist treatment
 Use of a nebulizer to deliver med directly
into lung
 Given by RT
 Most commonly ordered every 4-6 hours or
as needed
 Some pts give themselves breathing
treatments at home
 Bronchodialators such as albuteral are most
commonly administered
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MDI- Metered Dose Inhalers
 Administers topical medication directly into
lungs
 Using a spacer can increase the amount of
med that gets to lungs
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Spacer
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Incentive Spirometer
 Used to encourage deep breathing in pts at
risk for collapse of lung tissue (atelectasis).
 Most commonly ordered for post op patients
 Pts should use the spirometer 10 times each
hour while awake
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Incentive Spirometer
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Chest Physiotherapy
 Involves postural drainage, percussion, and
vibration to help move secretions from deep
inside the lungs
 Usually indicated for pts who have a weak or
ineffective cough and is at risk for retaining
secretions
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Chest Physiotherapy
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High Frequency Chest Wall
Oscillation Vest
 Sometimes called vest therapy
 Alternative to Chest Physiotherapy because it
does not require the presence of a therapist
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Vibratory Positive Expiratory
Pressure Device
 Small hand held device
 When pt blows into the mouthpiece, it makes
a heavy steel ball bounce around which
sends vibrations back into airways to help
loosen mucus
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Vibratory Positive Expiratory
Pressure Device
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Thoracentesis
 Involves the insertion of a needle into the
pleural space.
 Commonly done to aspirate fluid in patients
with pleural effusion (fluid trapped in pleural
space)
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Chest Drainage
 Indications-When fluid or air has collected in
the pleural space
 Chest Tube Insertion- drainage tubes
through the chest wall into the pleural space
 Drainage System- has a water seal chamber,
a suction chamber, and a drainage chamber
 Keep 2 padded clamps at the bedside in the
event the chest tube is disconnected from
the drainage system
 Nursing Care- Box 29.1 page 614
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Chest Drainage System
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Tracheostomy
 Definition- Surgical opening through base of
neck into trachea
 Indications- Due to pts having cancerous
larynx removed, airway obstuction due to
trauma or a tumor, pts who cannot clear
secretions from airway, or pts who need
prolonged mechanical ventilation
 Nursing Care
‒ Suctioning
‒ Cleaning
‒ Communication
‒ Teaching
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Passy-Muir Speaking Valve
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Intubation
 Placing an ET (endotrachial tube) through the
nose or mouth into the trachea to maintain
adequate oxygenation because of airway
obstuction or respiratory failure
 Pts in Cardiac arrest or pts undergoing
general anes for surgery are intubated and
mechanically ventilated
 Some pts have advance directives and do not
wish to be intubated
 Intubation is usually used short term
because it can damage vocal cords and
surrounding tissue
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Intubation
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Nursing Care of Intubated Pt.
 Regular assessments of lung sounds and
respiratory status
 Oral tubes are repositioned and resecured to
oposite side of mouth every 24 hours
 If pt is awake they should be instructed not
to pull on tube- an order for soft restraints
may be necessary for confused pts
 ET tubes have a cuff to help maintain proper
placement
 Pts are often anxious so reassure and talk to
patient
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 Pts may need suctioning if they are unable to
cough effectively (sterile process)
 Require frequent mouth care
 Monitor ABG’s and O2 saturation
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Mechanical Ventilation
 Invasive
‒ Indications
‒ Nursing Care
‒ Trouble-Shooting
Alarms
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Mechanical Ventilation
Indications- provide ventilation for
patients who are unable to breath
effectively on their own. Ventilators use
positive pressure to push oxygenated air
into the lungs at preset intervals.
Mechanical ventilation is needed after
some surgeries, Cardiac or pulmonary
arrest, declining ABG’s, or injuries that
affects muscles of respiration.
‒ Ventilator Modes- Ventilators can control
ventilation or assist pts own function
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Ventilator Alarms
 Low pressure- can be caused by
disconnecting tubing, leaks in tubing or
around ET tube, or an underinflated cuff
 High pressure- might occur if pt needs to be
suctioned, biting on tube, coughing, trying
to talk, kinked or obstucted tubing
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Nursing Responsibility for
mechanical ventilation
 Check advanced directive before intubating
pt and putting them on mechanical
ventilation
 Keep HOB elevated 45 degree angle to
reduce risk of aspiration
 Oral care
 Regular suctioning
 Communicate with pt (pt may become
anxious
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Noninvasive Positive Pressure
Ventilation
 Indications- alternative to intubation and mech
ventilation for pts who are able to breath on their
own but unable to maintain normal ABG’s
 Advantages- noninvasive
 Cpap (continuous positive airway pressure)- the
same amount of oxygen pressure is maintained
throughout inspiration and expiration
 Bipap (bilevel positive airway pressure)- a lower
positive pressure is used on expiration
 Nursing Care- Apply adhesive barrier to areas
that come in contact with mask. Place pt in
semifowlers position to prevent gastric distention
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Review Question
What occurs in response to negative
pressure in the thoracic cavity?
1. Pneumothorax
2. Dyspnea
3. Inhalation
4. Exhalation
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Review Question
Which acid-base imbalance results from
impaired respiratory function?
1. Respiratory alkalosis
2. Respiratory acidosis
3. Metabolic alkalosis
4. Metabolic acidosis
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Review Question
Which adventitious breath sound is
generated by narrowed inflamed airways?
1. Stridor
2. Friction rub
3. Crackles
4. Wheezes
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Review Question
What is the best method to recommend for
smoking cessation?
Select all that apply.
1. Nicotine replacement
2. Drug therapy
3. Behavior modification
4. Hypnosis
5. Setting a quit date
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Review Question
Which interventions can help patients
expectorate sputum?
Select all that apply.
1. Antihistamines
2. Vibratory Positive Expiratory Pressure
Device
3. Oxygen
4. Room humidifier
5. Huff coughing
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