Transcript NUR 244 Assessment of respiratory system

NUR 316
Management of the
Diseases in the Respiratory
System
Learning objectives
At the end of this modules, students will be able:

Describe the structures and functions of the upper and the lower
respiratory tracts.

Discriminate between normal and abnormal assessment findings
identified by inspection, palpation, percussion, and auscultation of
the respiratory system.

Recognize and evaluate the major symptoms of respiratory
dysfunction.

Identify the diagnostic tests to evaluate respiratory function.
Glossary

Apnea: temporary cessation of breathing.

Bronchoscopy: direct examination of the larynx, trachea, and
bronchi using an endoscope.

Dyspnea: difficulty/ shortness of breath.

Hypoxemia: decrease in arterial oxygen tension in the blood.

Hypoxia: decrease in oxygen supply to the tissue and cells.

Hemoptysis: expectoration of blood from the respiratory tract.

Orthopnea: inability to breathe easily except in an upright
position.

Tachypnea: abnormal rapid respiration.
Anatomy and physiologic

Respiratory system is responsible for
ventilation (movement of air in and out of the
airways).

It composes of upper and lower respiratory
tracts.

Upper airway warm and filter the inspired air.
Anatomy and physiologic
(cont.)

Gas exchange: delivering oxygen to the tissue through the
blood steam (inspiration) and expelling waste gases, such as
carbon dioxide, (expiration).
Anatomy and physiologic
(cont.)
Ventilation is effected by three factors:

Airway pressure: the movement of the diagram during
inspiration create a negative pressure which permits
ventilation.

Airway resistance: determined by the size/radius of airways.

Compliance: is the elasticity and expandability of lung and the
thoracic cavity. Requires the presence of the “surfactant”.
Anatomy and physiologic
(cont.)

Pleural:

Covers the lungs.

Has two layers and fluid to lubricate the lungs and thoracic
cavity.

I-Health history

Elicit a description of the present illness and chief complaint, including
onset, course, duration, location, and precipitating and alleviating factors.
Cardinal signs and symptoms of respiratory dysfunction include:-

Dyspnea

Orthopnea

Cough which may be productive or non productive

Increased sputum, which may be purulent (yellow or green),rusty, bloody,
or mucoid sputum

Chest pain

Wheezing and crackles

Clubhing of fingers

Hemoptysis

Cyanosis (e.g. buccal, peripheral)
- b-Explore the client's health history for
risk factors associated with respiratory
disease including :

(1) Personal or family history of lung disease

(2) Smoking (the most significant contributing factor in lung disease)

(3) Occupational or vocational exposure to allergens or environmental
pollutants

( 4) Age-related changes in lung capacity and respiratory function

(5) History of upper respiratory infection

(6) Postoperative changes resulting in diminished respiratory excursion
Physical examination

a- Inspection

(1) observe general appearance, noting body size, age, skin quality and
color, and posture.

(2) Inspect configuration and movement of the thorax during respiration.

(3)Assess characteristics of respiration, including rate, rhythm, depth and
muscles used for breathing.

(4) Note presence of cough and the nature and character of sputum (e.g.
purulent, bloody)

(5) Note clubbing of fingers (i.e. angle of nail bed greater than 160
degrees).

Palpation. Palpate the chest to detect painful areas or masses on
the chest surface and evaluate chest excursion and the presence
or absence of fremitus (i.e. vibration).

Percussion. Assess chest sounds to evaluate underlying tissues.
Resonant sound indicates air-filled lung (normal), whereas dull
or flat sound suggests presence of firm mass (usually abnormal).
Hyperresonant sound in emphysema.

Auscultation. Listen to air movement in lungs to detect normal
or adventitious breath sounds.

(1) Vesicular sounds are low-pitched, rustling sounds heard
over most of lung field, most prominently on inspiration. They
indicate normal, clear lungs.

(2) Bronchial sounds are high-pitched tubular sounds with a
slight pause between inspiration and expiration. They are
normal over large airways.

(3) Bronchovesicular sounds are combination of vesicular and
bronchial sounds, normally heard anterior to the right or left of
the sternum and posterior between the scapulae; inspiration and
expiration are equal. '

(4) Adventitious breath sounds are crackles (i.e. fine to
coarse), wheezes and pleural friction rub.
Laboratory and diagnostic
studies

Radiographic and scanning studies are done to visualize
respiratory system structures. The studies include:

Chest radiography,

chest tomography

Lung scan

Computed tomography (CT) scan

Magnetic Resonance Imaging(MRI).
Bronchoscopy studies are invasive techniques performed
to visualize pulmonary structures and obtain tissue specimens.
Thoracoscopy: used to examine thoracic structure
Thoracentesis involves needle aspiration of pleural fluid for
diagnostic and therapeutic purposes.

Needle biopsy is an invasive technique that involves entering
the lung or pleura to obtain tissue for analysis.

Pulmonary function test(PFT): it is done to measure
functional ability of the lung through measuring lung volumes
and capacities.

Sputum culture determines the presence of pathogenic
organisms.

Arterial blood gas (ABG) studies determine O2 and CO2
content and evaluate the body's acid-base balance

Pulse Oximetry: Monitoring oxygen saturation of hemoglobin
(SpO2 or SaO2).

Incentive spirometer: provide visual feedback to encourage
the patient to maximize lung inflation and prevent atelectasis.
Nursing diagnosis

Ineffective breathing pattern

Impaired gas exchange

Altered tissue perfusion (peripheral)

Activity intolerance

Pain

Anxiety

Ineffective individual coping

Knowledge deficit

Risk for infection
Implementation

Assess respiratory status and tissue perfusion, including respiratory rate,
depth and effort; level of consciousness; lung sounds; buccal and
peripheral cyanosis; capillary refill time; color and consistency or sputum;
and pulse oximetry.

Improve breathing patterns.
a. Encourage upright position (semi-Fowler or high-Fowler position)
b. Encourage the client to increase fluid intake to at least 2 to 3 liters of fluid
eachday, unless contraindicated as in congestive heart failure.
c. Use of incentive spirometer
Promote gas exchange

Administering oxygen therapy.

Analyze ABG values and pulse oximetry to determine
need for oxygen therapy.

Assist in administering nebulizer treatment.

Encourage effective coughing. Instruct client to take
three deep breaths in through the nose and out through
the mouth, and on the third breath pull in the abdominal
muscles and cough twice forcefully with mouth open.

Encourage the client to lie on the affected side to splint
the area if there is pain when coughing.

Encourage the client to eliminate or minimize exposure
to all pulmonary irritants, and advise the client to quit
smoking.

Improve activity tolerance. Encourage client to alternate rest
with activity to prevent overexertion that may exacerbate
symptoms and to increase activity gradually.

Provide pain management.

Assess the client for pain, and exclude other potential
complications.

Instruct the client about splinting when the client has chest
pain,

Promote infection control measures.

Instruct the client to avoid crowds or people with known colds,
flu, or respiratory infection.

b. Implement standard precautions and droplet or airborne
precautions as indicated.
Upper respiratory Tract Infection(URTI)
URTI follows invasion of the upper respiratory organs by microbes.

Upper respiratory organs include the:
Nose, sinuses, throat

Common cold is an example of an upper respiratory infection.

Common cold is caused by a virus

Symptoms:- Elevated temperature (fever)

Runny nose

Watery eyes
Treatment of common cold:

Use of antipyretic such as aspirin

Rest

Increased fluid intake

Upper respiratory infections sometimes move down into the chest and
develop into bronchitis or even pneumonia.
Pneumonia

Description. Pneumonia is an inflammatory process
involving the respiratory bronchioles, alveolar space
and walls, and lobes, caused primarily by chemical
irritants or by specific bacterial, viral, fungal,
mycoplasmal, or parasitic organisms.

Pneumonia is the most common cause of death from
infectious disease in North America and the fifth
leading cause of death among the elderly.
Types of pneumonia:

Community Acquire Pneumonia: (CAP) occurs either in the
community setting or within the first 48 hours of
hospitalization. The organisms that most frequently cause CAP
are Streptococcus pneumonia, Haemophilus influenza, and
atypical organisms ( Legionella, Mycoplasma, Chlamydia&
viral)

Hospital Acquire Pneumonia :(HAP) also known as
Nasocomial infection Occurring 48 hours or longer after
admission to the hospital. Bacteria are responsible for the
majority of HAP infection, including Pseudomonas and
Enterobacter, Staphylococcs aureus and Streptococcus
pneumonia.

Pneumonia in Immunocompromized Host:
E.g. pneumocystic carinii , fungal & tuberculosis. It is occur
most commonly in patient with AIDS , nutritional depletion ,
use of broad –spectrum antimicrobial agent, corticosteroids,
chemotherapy, and long term life- support technology
(mechanical ventilation)

Aspiration Pneumonia: refers to entry of endogenous or
exogenous substance into the lower air way such as gastric
content.
Causes of and contributing
1- Smoking and air pollution
3- Altered consciousness: alcohalizm, head injury, seizure,anaesthesia, drug overdose
4- Tracheal intubations (endotracheal intubations, trachestomy)
5- Upper respiratory tract infection
6- Chronic diseases: chronic lung disease, diabetes mellitus, heart disease, uremia,
cancer,
7- Immunosuppressant
8- Malnutrition
9- Inhalation or aspiration of noxious substances
10- Bed rest and prolonged immobility
11- Depress cough reflex
Pathophysiology.

Pneumonia often affects both ventilation and diffusion . An inflammatory
reaction occurs in the alveoli, producing an exudates that interferes with
the diffusion of oxygen and carbon dioxide and fill the alveolar air spaces,
producing lung consolidation

Areas of the lung are not adequately ventilated because of secretions and
mucosal edema that cause partial occulsion of the bronchi or alveoli with a
resultant decrease in alvelor oxygen tension and bronchospasm may occur.

Ventilation – perfusion mismatching or Impaired gas exchange in the
alveoli leads to various degrees of hypoxia, depending on the amount of
lung tissue affected.
Clinical manifestations

A- Typical pneumonia syndrome is characterized by:

Sudden onset fever over 40 C , chills, cough productive with
Purulent sputum and pleurisy chest pain, dullness with
consolidation on percussion of chest ,dyspnea, respiratory
grunting, and nasal flaring ,Flushed cheeks; cyanotic lips and
nail beds ,anxiety and confusion. In the elderly, the only signs
may be mental status change and dehydration.

B- Atypical Pneumonia syndrome: is characterized by
gradual onset, dry cough and extrapulmonary manifestations as
headach, myalagias, fatigue, sore throat, nausea, vomiting and
diarrhea. Crackles are heard.
Laboratory and diagnostic study
findings

Chest radiograph shows density changes, primarily in the
lower lung fields.

Sputum culture and sensitivity are positive for a specific
causative organism.

While blood cell (WBC) count is elevated in pneumonia of
bacterial origin; WBC count is depressed or normal in
pneumonia of mycoplasma or viral origin.
Nursing management

Administer prescribed medications, which may include:

Antibiotics (Penicillne, Erthromycine, Gentamicine)

Mucolytics. expectorants, or antitussive agents& antipyretic

Promote infection control measures, especially droplet precautions as
indicated.

Prevent aspiration pneumonia in a client receiving tube feedings. Keep
the client in an upright position during feedings and for 30 minutes
afterward. Check for residual gastric contents; if more than 100 mL, stop
feeding and reevaluate.

Oxygen administer

Warm, moist inhalation

Increase fluid intake
Complication of pneumonia:

1- Pleurisy: inflammation of pleura

2- Pleural effusion: accumulation of fluid in pleural space

3- Empyema: accumulation of pus in pleural space

4- Atelectasis: collapsed, airless alveoli of one or part of one
lobe may ocurr

5- Pericarditis: inflammation of pericardium

6- Arthritis: inflammation of joint

7- Meningitis: inflammation of brain layer

8- Lung abscess
Chronic obstructive pulmonary
disease

Chronic obstructive pulmonary disease (COPD) is a group
of disorders associated with persistent or recurrent
obstruction of air flow, which include chronic bronchitis,
emphysema, and asthma.

These conditions frequently overlap.

Most commonly, bronchitis and emphysema occur together.

Asthma frequently occurs alone without the triad of bronchitis,
emphysema, and asthma.
Etiology

1-Chronic bronchitis and emphysema. Major causes and
contributing factors to these disorders, which are irreversible,
include

Smoking

Air pollution

Occupational exposure to respiratory irritants

Allergies

Autoimmunity

Infection

Genetic predisposition

Aging

2- Asthma is a reversible diffuse airway obstruction with a
possible genetic component. It may be extrinsic or intrinsic.

Extrinsic factors include external agents or specific allergens
(e.g. dust, foods, mold spores, insecticides).

Intrinsic factors include upper respiratory infection, exercise,
emotional stress, cold, or other nonspecific factors.

Status asthmatics is a severe and persistent asthma that lasts
longer than24hours and does not respond to conventional
therapy.
Pathophysiology.
COPD disrupts airway dynamics, resulting in obstruction of airflow into or out
of the lungs.

Chronic bronchitis. Hypertrophy and hypersecretion in goblet cells and
bronchial mucus glands leading to increased sputum secretion, bronchial
congestion, narrowing of bronchioles, and small bronchi.

Emphysema. Increased size of air spaces (i.e. dead space)
with loss of elastic recoil of lung due to hyperinflation of distal
airways causes airway obstruction. Destruction of alveolar
walls and diffuse airway narrowing causing resistance to
airflow because of loss of supporting structure bronchospasm
further impede airflow.

Asthma. Basic pathologic changes include:

Narrowing of the bronchial airways

Bronchospasms

Increased mucosa

Mucosal edema secondary to inflammation.
Clinical manifestations

Chronic bronchitis
(1) History of productive cough that lasts 3 months per year for 2
consecutive years
(2) Persistent cough, known as smoker's cough, usually in the
winter months
(3) Persistent sputum production
(4) Recurrent acute respiratory infections
(5) "Pink puffer appearance

Emphysema
(1) History of chronic bronchitis
(2) Slow onset of symptoms (typically over several years), which
can lead to right sided heart failure (i.e. cor pulmonale)
(3) Progressive dyspnea, initially only on exertion and later also
at rest
(4) Progressive cough and increased sputum production, use of
accessory muscles
(5) Anorexia with weight loss and profound weakness
(6) Dusky color leading to cyanosis
(7) Clubbing of fingers

Asthma
(1) Chest tightness and dyspnea
(2) Cough
(3) Wheezing
(4) Expiration more strenuous and prolonged than inspiration
(5) Use of accessory muscles of respiration & nasal flaring
(6) Hypoxia with restlessness, anxiety, cyanosis, weak pulse, and
diaphoresis
Laboratory and diagnostic study
findings

Chronic bronchitis
(1) Pulmonary function studies identify decreased forced
expiratory volume (FEV), decreased forced vital capacity
(FVC), increased residual volume (RV), and total lung capacity
(TLC) that is normal to slightly increased.
(2) Chest radiograph shows an enlarged heart with a normal or
flattened diaphragm.
(3) ABG studies during the acute phase show significantly
increased Paco2 and decreased Pa02.
(4) Sputum culture reveals secondary bacterial infection with
gram-negative or gram-positive organisms, such as
Diplococcus pneumoniae and H.influenzae.

b. Emphysema
(1) Pulmonary function studies identify decreased FEV,
decreased FVC, increased RV, and increased TLC.
(2) Chest radiograph shows a Flattened diaphragm, decreased
vascular markings with hyperradiolucence, and increased
anteroposterior (AP) diameter (i.e. "barrel chest").
(3) ABG studies detect increased PaC02 and decreased Pa02
(4) Blood analysis reveals polycythemia (i.e. increased numbers
of red blood cells in response to hypoxemia).

C.Asthma.
(1)-Pulmonary function studies during acute episode identify
markedly decreased FEV, increased RV, and increased TLC in
response to air trapping. These study values improve after
treatment.
Nursing management

Provide nursing care for the client with chronic bronchitis or
emphysema.

a. Administer prescribed medications, which may include
antibiotics, bronchodilator, mucolytic agents, and
corticosteroids.

Antibiotics should be administered at the first sign of
infection, such as a change in the sputum.

Narcotics, sedatives, and tranquilizers, which can further
depress respirations, should be avoided.

Clear airways with postural drainage, percussion (i.e.
clapping) or vibrating, and suctioning as appropriate

Promote infection control. Encourage the
client to obtain influenza and pneumonia
vaccines at prescribed times.

Improve breathing patterns. Demonstrate
and encourage diaphragmatic and purse-lip
breathing. Have the client take a deep breath
and blow out against closed lips.
Provide nursing care for the client
with asthma

Administer prescribed medications, which may include:

Adrenergics( Adrenaline),

Bronchodilators(aminophlline)

Corticosteroids( Dexamethasone, Solu –cortef) for acute attack
.

Nebulized aerosol(Ventoline) relive bronchospasme.

Oxygen therapy
Provide treatment during an acute
asthmatic attack.

(1) Stay with the client and keep him calm and in an upright
position.

(2) Do purse-lip breathing with the client; encourage
relaxation techniques.

Implement measures to prevent asthmatic attacks. Teach
the client the following skills:
(1) Identify and eliminate or minimize exposure to pulmonary
irritants.
(2) Remove rugs and curtains from the home; change air filters
frequently; keep the home as dust free as possible; and keep
windows closed during windy and high pollen days.
(3) Use an inhaler and take medications as prescribed, and notify
the physician when not gaining complete relief.
(4) Notify the physician when a respiratory infection occurs.
(5) Obtain influenza and pneumonia vaccines at prescribed times.
(6) Monitor peak expiratory flow rate.
Pleural effusion

Description. Pleural effusion is a collection of fluid in the pleural space,
which is located between the visceral and parietal surfaces

Etiology. Pleural effusion usually results from diseases such as neoplastic
tumors (of which bronchogenic cancer is the most common malignancy),
congestive heart failure, tuberculosis, pneumonia, pulmonary infection, and
connective tissue disease.

Pathophysiology. The pleural space contains a small amount of lubricating
fluid that allows the pleural surfaces to move without friction. Excess fluid
accumulates in the space until it becomes clinically evident. The effusion can
be composed of a clear fluid, or it can be bloody or purulent.
Clinical manifestations

Large pleural effusion
(1) Shortness of breath
(2) Minimal or no breath sounds
(3) Dull, flat sound when percussed
(4) Tracheal deviation away from the affected side may occur when
significant accumulation of fluid occurs.

Small to moderate pleural effusion
(1) Respiratory difficulty or comprised lung expansion may not be evident.
(2) Dyspnea may not be present.
Laboratory and diagnostic study findings

Chest radiograph shows fluid in the pleural space.

Pleural f1uid obtained by thoracentesis and treated with an acidfast bacillus stain may reveal tuberculosis or red and white blood
cells.

Nursing management.

Prepare the client for thoracentesis, which is performed to remove
f1uid, obtain a specimen for analysis, and relieve dyspnea.

Assist the physician with administering chemically irritating
agents, which may be instilled to obliterate the pleural space and
prevent further accumulation of f1uid.

Provide pain relief. Position client to decrease pain and administer
pain medication, as needed .
Pulmonary Tuberculosis
Definition:

Pulmonary tuberculosis (T.B) is an infectious disease that
primarily affects the lung parenchyma. It also may be
transmitted to the other parts of the body including the
meninges, kidney, bones and lymph nodes.

The primary infectious agent mycobacterium tuberculosis or
tubercle bacillus is an acid –fast, aerobic rod that grows
slowly and is sensitive to heat and ultraviolet light

Transmission
TB spreads from person to person by airborne transmission. An infected person
release droplet through talking, coughing, sneezing, laughing, or singing

Risk factors for TB
1- Close contact with an infected person.
2- Recent positive tuberculosis test i.e. recently converted from negative to positive
skin test.
3- Large tuberculin reaction (12 mm or more in diameter).
4- Preexisting medical condition e.g. diabetics, malignancy or chronic renal failure,
hemodialysis, malnourish
5- People living in overcrowded homes substandard living, with low, income i.e.
low socioeconomic class.
6- Immunocompromised status (e.g. HIV, cancer, transplanted organ, high dose of
corticosteroids
7- Immigration from countries with high prevalent TB
Pathophysiology

A susceptible person inhales mycobacterium bacilli and
become infected. The bacteria are transmitted through the
airways to the alveoli, where they are deposited and begin to
multiply.

The bacilli also transported via the lymph system and blood
stream to other areas of lung & other area of body (kidney,
bone, and cortex).

The body’s immune system responds initiating an
inflammatory reaction .Phagocytes engulf many of the bacteria
and TB specific lymphocytes destroy the bacilli and tissue.
Granulomas are transformed to a fibrous tissue mass, the
central portion of which is a called Ghon tubercle.

The material (bacteria and macrophages) becomes necrotic,
forming a cheesy mass.

This mass may become calcified and form a collagenous scar.

Clinical manifestation:
1-Low grade fever
2-Cough may be nonproductive or mucopurulent sputum
3-Night sweat
4-Fatigue
5-weight loss
6-Hemoptysis
Assessment and diagnostic
studies

Tuberculin skin test ( Mantoux test).Injection of 0.1mLtuberculin or purified
protein derivative(PPD) intradermal layer of the inner aspect of the forearm. The
test read after 72 hrs. A reaction occurs when both induration(hardening or
thickness of tissue) & erythema (redness) are noted. A wheel measuring 5mm or
more is considered significant.

Sputum testing: Positive Acid fast bacilli, Positive
Mycobacterium tuberculosis

Chest X-ray: Active or calcified lesion

Blood tests: WBCS,ESR are increased
Medical Intervention:
TB is treated primarily with chemotherapeutic agent for 6 to 12
months. More than one drug of the following are used:

Streptomycine

Isoniazid(INH)

Para amino salicylic acid

Rifampin

Ethambutol

Pyrazinamide
Nursing Intervention

Maintain patient diet high-carbohydrates, protein, vitamin B6&C,
caloric and fluid intake.

Provide small frequent meal

Maintain bed rest

Instruct the patient to cover nose and mouth when sneezing or
coughing& use of disposable tissue papaer to prevent spread of
infection

Provide oral hygiene and hygiene

Maintain infection control precautions

Provide adequate air ventilation in room

The nurse instruct medication, schedule and side effect to patient
Question?