Transcript Respiratory Alterations Fall 2010 Rev 1

Assessment of the
Respiratory System
Irene Owens MSN, FNP-BC
Anatomy and Physiology Review
 Upper
respiratory tract
 Lower respiratory tract
 Lungs
 Accessory muscles of respiration
 Respiratory changes associated with
aging
Assessment Techniques
 Collect
history of client data on family,
personal, smoking, drug use, allergies,
travel, place of residence, dietary
history, occupational history, and
socioeconomic level.
 Assess current health problems such as
cough, sputum production, chest pain,
and dyspnea.
Physical Assessment
 Assessment
of the nose and sinuses
 Assessment of the pharynx, trachea,
and larynx
 Assessment of the lungs and thorax
–Inspection
–Palpation, check fremitus
–Percussion
–Auscultation
Breath Sounds
 Normal
breath sounds include bronchial,
bronchovesicular, and vesicular.
 Adventitious breath sounds include:
–Crackle
–Wheeze
–Rhonchus
–Pleural friction rub
Other Assessments
 Voice
sounds
 Bronchophony
 Whispered pectoriloquy
 Egophony
 Skin and mucous membranes
 General appearance
 Endurance
Psychosocial Assessment
 Some
respiratory problems may be
worsened by stress.
 Chronic respiratory disease may cause
changes in family roles, social isolation,
and financial problems due to
unemployment or disability.
 Discuss coping mechanisms and offer
access to support systems.
Laboratory Tests
 Blood
tests
 Sputum tests
 Radiographic examinations including
standard chest x-rays, digital chest
radiography, CT
 Ventilation and perfusion scanning
 Pulse oximetry
Pulmonary Function Testing
 These
tests evaluate lung volumes and
capacities, flow rates, diffusion capacity,
gas exchange, airway resistance, and
distribution of ventilation.
 Client preparation
 Procedure for performing tests at the
bedside
Other Testing and Follow-Up Care
 Exercise
testing
 Skin testing
Other Invasive Diagnostic Tests
 Endoscopic
examinations
 Thoracentesis: aspiration of pleural fluid
or air from the pleural space
–Client preparation for stinging
sensation and feeling of pressure
–Correct position
–Motionless client
–Follow-up assessment for
complications
Lung Biopsy
 Performed
to obtain tissue for histologic
analysis, culture, or cytologic
examination
 Client preparation
 May be performed in client’s room
(Continued)
Lung Biopsy (Continued)
 Follow-up
care:
–Assess vital signs and breath sounds
at least every 4 hours for 24 hours.
–Assess for respiratory distress.
–Report reduced or absent breath
sounds immediately.
–Monitor for hemoptysis.
Interventions for Clients
Requiring Oxygen
Therapy
Oxygen Therapy
 Hypoxemia:
low levels of oxygen in the
blood
 Hypoxia: decreased tissue oxygenation
 Goal of oxygen therapy: to use the
lowest fraction of inspired oxygen for an
acceptable blood oxygen level without
causing harmful side effects
Hazards and Complications of Oxygen
Therapy
 Combustion
 Oxygen-induced
 Oxygen
hypoventilation
toxicity
 Absorption atelectasis
 Drying of mucous membranes
 Infection
Low-Flow Oxygen Delivery Systems
 Nasal
cannula
 Simple face mask
 Partial rebreather mask
 Non-rebreather mask
High-Flow Oxygen Delivery Systems
 Venturi
mask
 Face tent
 Aerosol mask
 Tracheostomy collar
 T-piece
Noninvasive Positive-Pressure
Ventilation
 BiPAP
cycling machine delivers a set
inspiratory positive airway pressure each
time the client begins to inspire. At
exhalation, it delivers a lower set endexpiratory pressure. Together the two
pressures improve tidal volume.
 Technique uses positive pressure to
keep alveoli open and improve gas
exchange without airway intubation.
Continuous Nasal Positive Airway
Pressure
 Technique
delivers a set positive airway
pressure throughout each cycle of
inhalation and exhalation.
 Effect is to open collapsed alveoli.
 Clients who may benefit include those
with atelectasis after surgery or cardiacinduced pulmonary edema; it may be
used for sleep apnea.
Transtracheal Oxygen Delivery
 Used
for long-term delivery of oxygen
directly into the lungs
 Avoids the irritation that nasal prongs
cause and is more comfortable
 Flow rate prescribed for rest and for
activity
Home Oxygen Therapy
 Criteria
for home oxygen therapy
equipment
 Client education for use
–Compressed gas in a tank or cylinder
–Liquid oxygen in a reservoir
–Oxygen concentrator
Interventions for Clients
with Noninfectious
Problems of the Upper
Respiratory Tract
Fracture of the Nose
 Displacement
of either the bone or
cartilage of the nose can cause airway
obstruction or cosmetic deformity and is
a potential source of infection.
 Cerebrospinal fluid could indicate skull
fracture.
 Interventions:
–Rhinoplasty
–Nasoseptoplasty
Epistaxis
 Nosebleed
is a common problem.
 Interventions if nosebleed does not
respond to emergency care:
–Affected capillaries are cauterized
with silver nitrate or electrocautery
and the nose is packed.
–Posterior nasal bleeding is an
emergency.
(Continued)
Epistaxis (Continued)
–Assess for respiratory distress and for
tolerance of packing or tubes.
–Administer humidification, oxygen,
bedrest, antibiotics, pain medications.
Nasal Polyps
 Benign,
grapelike clusters of mucous
membranes and connective tissue
 May obstruct nasal breathing, change
character of nasal discharge, and
change speech quality
 Surgery: treatment of choice
Cancer of the Nose and Sinuses
 Cancer
of the nose and sinuses is rare
and can be benign or malignant.
 Onset is slow and manifestations
resemble sinusitis.
 Local lymph enlargement often occurs
on the side with tumor mass.
 Radiation therapy is the main treatment;
surgery is also used.
Facial Trauma
 Le
Fort I nasoethmoid complex fracture
 Le Fort II maxillary and nasoethmoid
complex fracture
 Le Fort III combination of I and II plus
an orbital-zygoma fracture, often called
craniofacial disjunction
 First
assessment: airway
 http://en.wikipedia.org/wiki/Le_Fort_fra
cture_of_skull
Facial Trauma Interventions
 Anticipate
the need for emergency
intubation, tracheotomy, and
cricothyroidotomy.
 Control hemorrhage.
 Assess for extent of injury.
 Treat shock.
 Stabilize the fracture segment.
Obstructive Sleep Apnea
 Breathing
disruption during sleep that
lasts at least 10 seconds and occurs a
minimum of five times in an hour
 Excessive daytime sleepiness, inability to
concentrate, and irritability
 Nonsurgical management and change of
sleep position
 Surgical management:
uvulopalatopharyngoplasty
Disorders of the Larynx
 Vocal
cord paralysis
 Vocal cord nodules and polyps
 Laryngeal trauma
Interventions for Clients
with Noninfectious
Problems of the Lower
Respiratory Tract
Chronic Airflow Limitation
 Chronic
lung diseases of chronic airflow
limitation include:
–Asthma
–Chronic bronchitis
–Pulmonary emphysema
 Chronic obstructive pulmonary disease
includes emphysema and chronic
bronchitis characterized by
bronchospasm and dyspnea.
Asthma
 Intermittent
and reversible airflow
obstruction affects only the airways, not
the alveoli.
 Airway obstruction occurs due to
inflammation and airway
hyperresponsiveness.
Aspirin and Other Nonsteroidal
Anti-Inflammatory Drugs
 Incidence
of asthma symptoms after
taking aspirin and other nonsteroidal
anti-inflammatory drugs (NSAIDs)
 However, response not a true allergy
 Results from increased production of
leukotriene when other inflammatory
pathways are suppressed
Collaborative Management
 Assessment
 History
 Physical
assessment and clinical
manifestations:
–No manifestations between attacks
–Audible wheeze and increased
respiratory rate
–Use of accessory muscles
–“Barrel chest” from air trapping
Laboratory Assessment
 Assess
arterial blood gas level.
 Arterial oxygen level may decrease in
acute asthma attack.
 Arterial carbon dioxide level may
decrease early in the attack and increase
later indicating poor gas exchange.
(Continued)
Laboratory Assessment
 Atopic
(Continued)
asthma with elevated serum
eosinophil count and immunoglobulin E
levels
 Sputum with eosinophils and mucous
plugs with shed epithelial cells
Pulmonary Function Tests
 The
most accurate measures for asthma
are pulmonary function tests using
spirometry including:
–Forced vital capacity (FVC)
–Forced expiratory volume in the first
second (FEV1)
–Peak expiratory rate flow (PERF)
–Chest x-rays to rule out other causes
Interventions
 Client
education: asthma is often an
intermittent disease; with guided selfcare, clients can co-manage this
disease, increasing symptom-free
periods and decreasing the number and
severity of attacks.
 Peak flow meter can be used twice daily
by client.
 Drug therapy plan is specific.
Drug Therapy
 Pharmacologic
management of asthma
can involve the use of:
 Bronchodilators
 Beta2 agonists
 Short-acting beta2 agonists
 Long-acting beta2 agonists
 Cholinergic antagonists
(Continued)
Drug Therapy (Continued)
 Methylxanthines
 Anti-inflammatory
agents
 Corticosteroids
 Inhaled
anti-inflammatory agents
 Mast cell stabilizers
 Monoclonal antibodies
 Leukotriene agonists
Other Treatments for Asthma
 Exercise
and activity is a recommended
therapy that promotes ventilation and
perfusion.
 Oxygen therapy is delivered via mask,
nasal cannula, or endotracheal tube in
acute asthma attack.
Emphysema
 In
pulmonary emphysema, loss of lung
elasticity and hyperinflation of the lung
 Dyspnea and the need for an increased
respiratory rate
 Air trapping, loss of elastic recoil in the
alveolar walls, overstretching and
enlargement of the alveoli into bullae,
and collapse of small airways
(bronchioles)
Classification of Emphysema
 Panlobular:
alveolus
destruction of the entire
 Centrilobular:
openings occurring in the
bronchioles that allow spaces to develop
as tissue walls break down
 Paraseptal: confined to the alveolar
ducts and alveolar sacs
Chronic Bronchitis
 Inflammation
of the bronchi and
bronchioles caused by chronic exposure
to irritants, especially tobacco smoke
 Inflammation, vasodilation, congestion,
mucosal edema, and bronchospasm
 Affects only the airways, not the alveoli
 Production of large amounts of thick
mucus
Complications
 Chronic
bronchitis
 Hypoxemia and acidosis
 Respiratory infections
 Cardiac failure, especially cor pulmonale
 Cardiac dysrhythmias
Physical Assessment and Clinical
Manifestations
 Unplanned
weight loss; loss of muscle
mass in the extremities; enlarged neck
muscles; slow moving, slightly stooped
posture; sits with forward-bend
 Respiratory changes
 Cardiac changes
Laboratory Assessment
 Status
of arterial blood gas values for
abnormal oxygenation, ventilation, and
acid-base status
 Sputum samples
 Hemoglobin and hematocrit blood tests
 Serum alpha1-antitrypsin levels drawn
 Chest x-ray
 Pulmonary function test
Impaired Gas Exchange
 Interventions
for chronic obstructive
pulmonary disease:
–Airway management
–Monitoring client at least every 2
hours
–Oxygen therapy
–Energy management
Drug Therapy
 Beta-adrenergic
agents
 Cholinergic antagonists
 Methylxanthines
 Corticosteroids
 Cromolyn sodium/nedocromil
 Leukotriene modifiers
 Mucolytics
Surgical Management
 Lung
transplantation for end-stage
clients
 Preoperative care and testing
 Operative procedure through a large
midline incision or a transverse anterior
thoracotomy
 Postoperative care and close monitoring
for complications
Ineffective Breathing Pattern
 Interventions
for the chronic
obstructive pulmonary disease client:
–Assessment of client
–Assessment of respiratory infection
–Pulmonary rehabilitation therapy
–Specific breathing techniques
–Positioning to help alleviate dyspnea
–Exercise conditioning
–Energy conservation
Ineffective Airway Clearance
 Assessment
of breath sounds before
and after interventions
 Interventions for compromised
breathing:
–Careful use of drugs
–Controlled coughing
–Suctioning
–Hydration via beverage and humidifier
(Continued)
Ineffective Airway Clearance (Continued)
–Postural drainage in sitting position
when possible
–Tracheostomy
Imbalanced Nutrition
 Interventions
to achieve and maintain
body weight:
–Prevent protein-calorie malnutrition
through dietary consultation.
–Monitor weight, skin condition, and
serum prealbumin levels.
–Address food intolerance, nausea,
early satiety, loss of appetite, and
meal-related dyspnea
Anxiety
 Interventions
for increased anxiety:
–Important to have client understand
that anxiety will worsen symptoms
–Plan ways to deal with anxiety
Health Teaching
 Instruct
the client:
–Pursed-lip and diaphragmatic
breathing
–Support of family and friends
–Relaxation therapy
–Professional counseling access
–Complementary and alternative
therapy
Activity Intolerance
 Interventions
to increase activity level:
–Encourage client to pace activities and
promote self-care.
–Do not rush through morning
activities.
–Gradually increase activity.
–Use supplemental oxygen therapy.
Potential for Pneumonia or Other
Respiratory Infections
 Risk

is greater for older clients
Interventions include:
–Avoidance of large crowds
–Pneumonia vaccination
–Yearly influenza vaccine
Sarcoidosis
 Granulomatous
disorder of unknown
cause that can affect any organ, but the
lung is involved most often
 Autoimmune responses in which the
normally protective T-lymphocytes
increase and damage lung tissue
 Interventions (corticosteroids): lessen
symptoms and prevent fibrosis
Occupational Pulmonary Disease
 Can
be caused by exposure to
occupational or environmental fumes,
dust, vapors, gases, bacterial or fungal
antigens, or allergens
 Worsened by cigarette smoke
 Interventions: special respirators that
ensure adequate ventilation
 See page 640 Iggy
BOOP
 Patho:
inflammatory process that
allows connective tissue plugs to form in
the lower airways and in the tissue
between the alveoli. Inflammation
triggers WBC’s with connective cell
growth that occludes and obliterates
these airways and leads to restricted
lung volume with decreased VC. Not a
true pneumonia. No known cause
BOOP cont
 Triggers
Infectious organisims, drugs
antiseizure medications cocaine, RA, SLE,
also related to chest radiation therapy for
cancer. Solid organ transplant patients
 Usually S?S present for months and do not
improve with standard ABX.
 CT will suggest BOOP not confirm it
 Biopsy needed to confirm BOOP
 Treatment Corticosteroids
Interventions for Clients
with Infectious Problems
of the Respiratory Tract
Rhinitis
 Inflammation
of the nasal mucosa
 Often called “hay fever” or “allergies”
 Interventions include:
–Drug therapy: antihistamines and
decongestants, antipyretics, antibiotics
–Complementary and alternative
therapy
–Supportive therapy
Sinusitis
 Inflammation
of the mucous
membranes of the sinuses
(Continued)
Sinusitis
 Nonsurgical
(Continued)
management
–Broad-spectrum antibiotics
–Analgesics
–Decongestants
–Steam humidification
–Hot and wet packs over the sinus area
–Nasal saline irrigations
Surgical Management
 Antral
irrigation
 Caldwell-Luc procedure
 Nasal antral window procedure
 Endoscopic sinus surgery
Pharyngitis
 Sore
throat is common inflammation of
the mucous membranes of the pharynx.
 Assess for odynophagia, dysphagia,
fever, and hyperemia.
 Strep throat can lead to serious medical
complications.
 Epiglottitis is a rare complication of
pharyngitis.
Tonsillitis
 Inflammation
and infection of the tonsils
and lymphatic tissues located on each
side of the throat
 Contagious airborne infection, usually
bacterial
 Antibiotics
 Surgical intervention
Peritonsillar Abscess
 Complication
of acute tonsillitis
 Pus behind the tonsil, causing one-sided
swelling with deviation of the uvula
 Trismus and difficulty breathing
 Percutaneous needle aspiration of the
abscess
 Completion of antibiotic regimen
Laryngitis
 Inflammation
of the mucous
membranes lining the larynx, possibly
including edema of the vocal cords
 Acute hoarseness, dry cough, difficulty
swallowing, temporary voice loss
(aphonia)
 Voice rest, steam inhalation, increased
fluid intake, throat lozenges
 Therapy: relief and prevention
Influenza
 “Flu”
is a highly contagious acute viral
respiratory infection.
 Manifestations include severe headache,
muscle ache, fever, chills, fatigue,
weakness, and anorexia.
 Vaccination is advisable.
 Antiviral agents may be effective.
Pneumonia
 Excess
of fluid in the lungs resulting
from an inflammatory process
 Inflammation triggered by infectious
organisms and inhalation of irritants
 Community-acquired infectious
pneumonia
 Nosocomial or hospital-acquired
 Atelectasis
 Hypoxemia
Laboratory Assessment
 Gram
stain, culture, and sensitivity
testing of sputum
 Complete blood count
 Arterial blood gas level
 Serum blood, urea nitrogen level
 Electrolytes
 Creatinine
Impaired Gas Exchange
 Interventions
include:
–Cough enhancement
–Oxygen therapy
–Respiratory monitoring
Ineffective Airway Clearance
 Interventions
include:
–Help client to cough and deep breathe
at least every 2 hours.
–Administer incentive spirometer—
chest physiotherapy if complicated.
–Prevent dehydration.
(Continued)
Ineffective Airway Clearance (Continued)
–Monitor intake and output of fluids.
–Use bronchodilators, especially beta2
agonists.
–Inhaled steroids are rarely used.
Potential for Sepsis
 Primary
intervention is prescription of
anti-infectives for eradication of
organism causing the infection.
 Drug resistance is a problem,
especially among older people.
 Interventions for aspiration
pneumonia aimed at preventing lung
damage and treating infection.