Respiratory

COMMON LAB TESTS FOR RESPIRATORY DISORDERS

1. Blood
a. arterial Blood gases
b. blood cultures
c. hemoglobin
d. hematocrit
e. CBC
f. serum electrolytes
g. RAST
h. immunoglobulins
i. cultures Profile II
2. Urine
a. UA
b. culture and sensitiities
c. casts
!. Throat" s#utum culture and sensitiites
$. S%in
&. S#utum s#ecimen
1. standard #recautions are re'uired
2. microbiologic e(amination of secretions from the res#iratory tract
!. may be obtained from #atient e(#ectoration or ia suctioning
$. client should brush teeth and gargle before s#ecimen collection
&. indications" sus#ected #neumonia and malignancy
6. tests include a )ram stain and culture and sensitiity
Pulmonary funtion tests
a. use a s#irometer and record ho* efficiently lungs e(change o(ygen and
carbon dio(ide
b. client sits u#right+ *ears nosecli# and breathes into mouth#iece.
c. uses
i. to diagnose lung disease
ii. to ealuate the e(tent of functional disability
iii. to ealuate lung function #re,o#eratiely
i. to ealuate ho* lungs res#ond to bronchodilators
d. measurements"
-Abnormal .alues" alues less
than /01 of #redicted norm.
Arterial Bloo! "ases
. #2 3.!&,3.$&
. PC42 !&,$& mm 2g
. 2C4!, 22,25 m6'78
. P42 arterial /0,100 mm 2g
. 4(ygen saturation 9&,1001
T#oraentesis
a. insertion of large bore needle into #leural s#ace
b. uses
i. to obtain #leural fluid for analysis
ii. to remoe #leural fluid
iii. to instill medications
c. nursing interentions
i. #osition client either sitting u#right *ith arms and shoulders on
oerbed table+ or in side lying #osition
ii. stress that client must stay ery still during #rocedure
iii. e(#lain that client *ill feel some #ressure
i. strict ase#sis+ standard #recautions
. #ost,#rocedure+ #lace client on unaffected side for at least 1
hour
i. chec% ital signs fre'uently
ii. *atch for signs of #neumothora(+ subcutaneous em#hysema
or shoc%
iii. obtain and label s#ecimens for analysis
Pulse o$imetry
a. measures o(ygen saturation: less accurate than arterial blood gas ;AB)<
b. monitors o(yhemoglobin saturation noninasiely
c. techni'ue
i. #robe cli#s to end of finger or earlobe and #asses a
light through tissue
ii. light is absorbed by #hotodetector
iii. o(imetry calculated from ho* much light RBCs
absorb
i. arterial saturation is dis#layed: normal Sa42 more
than7or e'ual to 9!1
d. #ulse o(imetry unreliable if there is
i. bright light shining on sensor
ii. tremor or sei=ure on e(tremity *here #robe is #laced
iii. #oor #erfusion to location *here #robe is #laced
i. cardiac arrest
. intraascular dye circulating in the blood stream
i. abnormal hemoglobin+ such as carbo(yhemoglobin and
methemoglobin
e. if #ulse o(imetry sho*s significant changes+ erify its results *ith AB)
;arterial blood gas< assay
Piloarpine test %iontop#oresis& or s'eat test
a. measures sodium and chloride e(cretion from s*eat glands
b. often first test #erformed for diagnosing cystic fibrosis
c. usually #erformed on infants
d. #ilocar#ine is administered to stimulate s*eat glands
e. #ers#iration is analy=ed for sodium and chloride content
f. normal findings
i. sodium > 90 m6'78
ii. chloride > 50 m6'78
Artifiial air'ays
A!ult en!otra#eal tu(es
a. #olyinyl tube *ith inflatable cuff
b. inserted through nose or mouth
c. distal end should be a fe* centimeters aboe the carina
d. cuff around tube is filled *ith air
i. creates a seal in trachea
ii. air #ressure in cuff > 2& cm 220 or client ris%s #ressure
necrosis in the tracheal mucosa
e. si=e of tube aries *ith si=e of child or adult
f. #ediatric tubes may not be cuffed
g. *hen tube is inserted+ chec% for #lacement
i. listen for bilateral breath sounds
ii. loo% for bilateral chest moement
iii. chest (,ray
i. measure e(haled carbon dio(ide
. measure #ulse o(imetry
h. nursing interentions
i. e(#lain #rocedure to client
ii. regularly assess tube #lacement and security+ breath sounds+
and bo*el sounds
iii. mar% tube length *ith teeth+ or li#s if edentulous ;toothless<
i. suction to maintain air*ay #atency: obsere secretions for
color+ consistency+ and amount
. assure ins#ired air is *armed and humidified since u##er
air*ay is by#assed
i. #roide oral hygiene and care for area around the tube as
indicated
ii. obsere for s%in brea%do*n around tube site
iii. obsere for #ossible com#lications of as#iration: oral7nasal
#ressure sores: accidental e(tubation: and oral+ nasal and
#haryngeal damage
Tra#eostomy
a. surgical o#ening through the nec% into the trachea
b. indications
i. head and nec% surgery
ii. long term air*ay access: for long,term mechanical entilation
iii. emergency air*ay
c. #ost,o# com#lications
i. tube dislodgement
ii. subcutaneous em#hysema
iii. bleeding
i. infection
d. com#onents of tracheostomy tubes
i. outer cannula
ii. inner cannula
iii. obturator
e. nursing interentions
i. e(#lain #rocedure to client
ii. regularly assess tube #lacement and security
iii. care for tracheostomy as ordered
i. suction to maintain air*ay #atency ;see belo*<
. #roide ade'uate hydration
i. #eriodically clean inner cannula and stoma site
ii. #roide regular oral hygiene
iii. change trach tube as ordered
i(. *atch for s%in irritation7infection at insertion site
(. teach client
1. trach care
2. suctioning #rocedure
!. findings of com#lications
$. ho* to handle accidental dislodgement7e(tubation
*ith obturator
Air'ay sutionin"
a. remoing secretions from the air*ay
b. sites for suction
i. naso#haryn(+ oro#haryn(+ trachea+ or bronchi
ii. through endotracheal tube or tracheostomy
c. e'ui#ment
i. use bulb syringe to suction nose7mouth of neonates+ infants
ii. catheter?s outer diameter should be no larger than one,half
inner diameter of endotrachial lumen
iii. determining length of catheter
1. measure from ti# of nose to base of ear to sternal
notch
2. infant+ young child" Insertion tolerance range" eight
to 1$ cm
!. older child+ adolescent" Insertion tolerance
range"1$ to 20 cm
i. sterile #rocedure in institution: clean #rocedure at home.
. suction *hen rhonchus is heard
i. ad@ust acuum #ressure to bet*een ,/0 and ,120 mm 2g
ii. insert suction catheter until resistance is met+ then *ithdra*
catheter an inch or t*o
iii. a##ly suction intermittently *hen *ithdra*ing catheter
i(. rotate catheter during *ithdra*al
(. from time of insertion+ s#end no more than fie to ten seconds
(i. re,establish entilation and o(ygenation
(ii. re#eat #rocedure as indicated
(iii. #haryngeal suctioning" less de#th+ less ris% of com#lications
than tracheal suctioning
d. nursing interentions
i. e(#lain #rocedure to client
ii. e(#lain that coughing+ snee=ing or gagging is normal
iii. #lace client in semi,fo*ler?s #osition if condition allo*s
i. maintain standard #recautions
. do not routinely instill saline into air*ay
i. if secretions are thic%+ increase humidity of ins#ired air and
fluid inta%e
ii. #roide #atient *ith e(tra o(ygen and e(tra dee# breaths
before+ during and after #rocedure
1. if #atient is receiing mechanical entilation+ use
entilator
2. if #atient is breathing s#ontaneously+ use manual
resuscitation bag or instruct to dee# breathe
iii. com#are client?s res#iratory status before and after suctioning
i(. do not force catheter
O$y"en !eli)ery !e)ies
Nasal annula
a. used at flo* rates fie to si( liters #er minute ;8PA<
b. higher flo* rates can be ery uncomfortable and cause nasal bleeding
c. deliered o(ygen ;BI42< de#ends on liter flo*+ client?s tidal olume and
res#iratory rate. 6ach liter is a##ro(imately $1 42 added to 211 42 found
in room air.
d. nursing interentions
i. e(#lain #rocedure to client
ii. ensure #rongs are in the nares
iii. #ad tubing around the ears+ as indicated
Simple fae mas*
a. used at flo* rates bet*een & , 12 8PA
b. must hae at least & 8PA to *ash out carbon dio(ide from e(halation:
recommended flo* is / to 10 8PA
c. deliered o(ygen ;BI42< de#ends on liter flo*+ client?s tidal olume and
res#iratory rate
d. not commonly used
+enti,mas* %)enturi mas*&
a. uses air,entrainment #rinci#le to delier #recise BI42
b. due to entrainment+ #roides high rate of total flo*
c. aailable in a range of BI42
d. de#ending on BI42+ flo* rate four to ten 8PA
e. nursing interentions
i. e(#lain #rocedure to client
ii. %ee# nasal cannula on stand,by for meals
iii. assure enturi deice does not become bloc%ed by bedding
i. assess for dry mucous membranes
. oral care
i. s%in care
Non,re(reat#er mas*
a. mas% *ith added reseroir bag
b. used at flo* rates si( to 1& 8PA
c. #roides highest #ercentage of 42 aailable from any mas%+ from 50,
1001
d. used for sic%est clients
e. nursing interentions
i. e(#lain #rocedure to client
ii. client re'uires close monitoring
iii. intubation may be needed
i. assure reseroir bag does not com#letely colla#se during #ea%
ins#iration
1. bag should deflate slightly *hen #atient inhales and
e(#and *hen client e(hales.
2. if bag colla#ses at ins#iration+ increase liter flo* to
bag
. assure #o#,off ales on mas% are not stuc% and *or% #ro#erly
-ome o$y"en t#erapy. t#ree types
a. com#ressed o(ygen comes in tan% or cylinder
b. li'uid o(ygen in reseroir
c. o(ygen concentrator e(tracts and concentrates o(ygen from the air
Positi)e pressure !e)ies
a. CPAP ;continuous #ositie air*ay #ressure<
i. com#ressor #roides air flo* to client
ii. baseline of noninasie #ositie #ressure is
maintained throughout ins#iration and e(halation
iii. used #rimarily to treat slee# a#nea at home for
maintenance of #atient u##er air*ay
b. BiPAPC ;bi,leel #ositie air*ay #ressure<
i. #roides a baseline of noninasie #ositie #ressure
throughout ins#iration and e(halation
ii. #roides #ositie #ressure assist during client?s o*n
s#ontaneous ins#iratory effort
iii. used for clients in res#iratory failure to rest client and im#roe
o(ygenation to aoid intubation
+entilators
1. Aachines? #ur#ose
a. su##ort and maintain client entilation
b. im#roe entilation
c. im#roe o(ygenation
d. decrease *or% of breathing
2. .entilator control modes" assist and synchroni=ed
a. assist,control
i. #reset rate at #reset tidal olume
ii. if client initiates breath+ machine deliers the #reset tidal
olume
b. synchroni=ed intermittent mandatory entilation ;SIA.<
i. machine set to delier a gien rate at a #reset tidal olume
ii. clients can breathe on their o*n bet*een machine breaths but
*ill determine o*n tidal olume
iii. used to gradually decrease machine su##ort of breathing
!. .entilator settings
a. tidal olume" amount of air deliered *ith each machine breath
b. rate" number of breaths deliered by the machine in a minute
c. BI42" fraction of ins#ired o(ygen
d. 142" #ercent of o(ygen ;e.g.+ 501<
$. Sighs" dee# breaths ;higher olume< deliered #eriodically by entilator
&. Positie end e(#iratory #ressure ;P66P<
a. normal #hysiologic P66P is e'ual or less than &cm 224
b. #roides a baseline of #ositie #ressure throughout e(halation
c. used to reduce air*ay colla#se and intra#ulmonary shunting
5. Dursing interentions
a. e(#lain e'ui#ment to client
b. monitor client?s res#onse to mechanical entilation
c. assure entilator is *or%ing #ro#erly
d. monitor artificial air*ay ;as aboe<
e. assess and #roide for ade'uate nutrition
f. monitor #ulse o(imetry and7or arterial blood gases as ordered
C#est p#ysiot#erapy
1. Consists of coughing+ chest *all #ercussion+ ibration+ and #ostural drainage
2. Eesigned to im#roe air*ay clearance
!. Used for clients *ith retained tracheobronchial secretions
$. Cough" natural clearing mechanism
&. Chest *all #ercussion+ ibration
a. #ercussion inoles cla##ing chest *ith cu##ed hands
b. ibration is do*n*ard ibrating #ressure *ith flat hand: done during
e(halation
5. Postural drainage
a. graitational clearance of air*ay mucous from arious bronchial
segments
b. uses 10 different body #ositions
3. Percussion and ibration done in each #osition: simultaneously client coughs or
nurse suctions to remoe loosened secretions
/. Dursing interentions
a. e(#lain #rocedure to client
b. #lace client in desired #osition according to lobe being drained
c. #ercuss each area for at least three minutes
d. encourage client to cough after each area is #ercussed and ibrated
e. can cause fatigue
Draina"e Systems
1. Chest tube
a. tube #laced in the #leural s#ace to remoe air+ fluid+ or both
b. tube #laced anterior and su#erior to remoe air
c. tube #laced #osterior and inferior to remoe fluid
d. mediastinal tube
i. drains blood or fluid from around heart
ii. no tidaling in mediastinal drainage because tube is not #laced
in lung caity
2. Chest drainage deices
a. collection chamber
i. collects fluid
ii. monitor rate and nature of drainage
b. *ater seal chamber
i. #roides a one,*ay ale" air leaes chest+ cannot reenter it
ii. chec% for bubbling in this chamber" indicates air lea%
iii. if no bubbling+ chec% *ater leel in this chamber
i. chec% for tidaling
c. suction control chamber
i. negatie #ressure transmitted to #leural s#ace is determined
by this chamber+ not by the setting on the *all acuum
ii. *et chamber , suction leel determined by *ater leel
iii. dry chamber , suction leel determined by mechanical setting
d. nursing interentions
i. e(#lain #rocedure to client
ii. do not allo* de#endent loo#s to form in the tubing: #osition the
tubing on the bed so that there is straight graity drainage to
the collection deice
iii. do not routinely stri# or mil% the tubing: allo* for graity
drainage
i. do not routinely clam# the chest tube
. if the tube becomes dislodged and #atient has air lea%+
I. a##ly non-occlusive dressing to allo* air to
leae the chest and #reent tension
#neumothora(
II. reinsert tube immediately
i. tube dislodged+ but #atient has no air lea%
I. a##ly occlusive dressing
II. monitor carefully for res#iratory distress
III. de#ending on client?s condition+ tube may or
may not need to be re#laced
Tu(erulin s*in testin"
a. PPE ;Purified #rotein deriatie< is in@ected intradermally
b. indicates *hether client has been infected *ith Aycobacterium
tuberculosis or has been in contact *ith infected indiidual
c. site chec%ed at $/ to 32 hours after administration
d. contraindicated in clients *ith actie tuberculosis+ or #reious BC)
accine
e. #ositie reaction" induration ;eleated+ red+ and hard< of 10 mm or greater
f. negatie reaction" no change at site or some res#onse+ yet less than 10
mm and only eleated or red
g. if #ositie reaction re'uires a chest (,ray
I/ 0eneral Respiratory Anatomy an! P#ysiolo"y
A. The res#iratory system is com#rised of the u##er air*ay and lo*er air*ay
structures.
B. The u##er res#iratory system filters+ moistens and *arms air during
ins#iration.
C. The lo*er res#iratory system enables the e(change of gases to regulate
serum Pa42+ PaC42 and Ph.
II/ 1pper Respiratory
A. Dose and sinuses
1. Bilters+ *arms and humidifies air
2. Birst defense against foreign #articles
!. Inhalation for dee# breathing is to be done ia nose
$. 6(halation is done through the mouth
B. Pharyn(
1. Behind oral and nasal caities
2. Daso#haryn(
a. behind nose
b. soft #alate+ adenoids and eustachian tube
!. 4ro#haryn(
a. from soft #alate to base of tongue
b. #alatine tonsils
$. 8aryngo#haryn(
a. base of tongue to eso#hagus
b. *here food and fluids are se#arated from air
c. bifurcation of laryn( and eso#hagus
C. 8aryn(
1. Bet*een trachea and #haryn(
2. Commonly called the oice bo(
!. Thyroid cartilage , Adam?s a##le
$. Cricoid cartilage
a. contains ocal cords
b. the only com#lete ring in the air*ay
&. )lottis , o#ening bet*een ocal cords
5. 6#iglottis , coers air*ay during s*allo*ing
III/ Lo'er Respiratory an! Ot#er Strutures
A. Trachea
1. Anterior nec% in front of eso#hagus
2. Carries air to lungs
B. Aainstem bronchi
1. Right and left
2. Right is more ertical+ so right middle lobe is more li%ely to receie
as#irate into it *ith the result of as#iraton #neumonia+ *hich is
more commonly found in elderly #o#ulations
C. Conducting air*ays
1. 8obar bronchi
a. surrounded by blood essels+ lym#hatics+ neres
b. lined *ith ciliated+ columnar e#ithelial cell ;
c. cilia moe mucus or foreign substances u# to larger
air*ays
2. Bronchioles
a. no cartilage: colla#se more easily
b. no cilia
c. do not #artici#ate in gas e(change
E. Aleolar ducts and aleoli
1. 8ungs contain a##ro(imately !00 million aleoli
2. Aleoli surrounded by ca#illary net*or%
!. )as e(change area ;blood ta%es 42+ gies off C42<
$. )as e(change ha##ens at aleolar,ca#illary membrane ;al,ca#
memb<
&. 2eld o#en by surfactant *hich decreases surface tension to
minimi=e aleolar colla#se
6. Accessory muscles of res#iration , use indicates additional effort needed
to breathe
1. Scalene muscles , eleate first t*o ribs
2. Sternocleidomastoid , raise sternum
!. Tra#e=ius and #ectoralis , stabili=e shoulders
$. Abdominal muscles , #uts #o*er into cough and used most often
*ith chronic res#iratory #roblems and acute seere res#iratory
distress
I+/ P#ysiolo"y
A. Basic gas,e(change unit of the res#iratory system is the aeoli.
B. Aleolar stretch rece#tors res#ond to ins#iration by sending signals to
inhibit ins#iratory neurons in the brain stem to #reent lung oer
distention.
C. Euring e(#iration stretch rece#tors sto# sending signals to ins#iratory
neurons and ins#iration is ready to start again.
E. 4(ygen and carbon dio(ide are e(changed across the aleolar ca#illary
membrane by #rocess of diffusion.
6. Deural control of res#irations is located in the medulla. The res#iratory
center in the medulla is stimulated by the concentration of carbon dio(ide
in the blood.
B. Chemorece#tors+ a secondary feedbac% system+ located in the carotid
arteries and aortic arch res#ond to hy#o(emia. These chemorece#tors
also stimulate the medulla
). Ph regulation
I. Blood Ph ;#artial #ressure of hydrogen in blood<" a decrease in
blood Ph stimulates res#iration hy#erentilation+ both through the
neurons of the brain?s res#iratory center and through the
chemorece#tors in carotid arteries and aortic arch.
II. Blood PaC42 ;#artial #ressure of carbon dio(ide in arterial blood<"
an increase in the PaC42 results in decreased blood Ph+ and
stimulates res#iration as described aboe.
III. Blood Pa42 ;#artial #ressure of o(ygen in arterial blood<" a
decrease in the Pa42 results in a decreased blood Ph+ stimulating
res#iration as described aboe.
I.. Fhen arterial Ph rises or the arterial PaC42 falls+ hy#oentilation
occurs.
+/ Disor!ers of t#e 1pper Respiratory System
A. Allergic rhinitis ;hay feer< , sensitiity to allergens *ith *hitish or clear
nasal discharge
I. Aanagement , antihistamines+ nasal steroid s#rays
B. Sinusitis
I. Aedical condition
I. inflammation of mucus membranes in the sinuses
II. may be follo*ed by infection *ith a yello*ish,green
discharge
II. Aanagement
I. treatment *ith antibiotics+ decongestants+ antihistamines
II. surgery to drain and o#en sinuses
III. antral irrigation ;sinus irrigation<
I.. Cald*ell,8uc #rocedure
C. U##er air*ay obstruction ;cho%ing<
I. Bindings
I. stridor ;harsh+ ibrating breath<
II. no sound of air
III. both hands of client around the throat
I.. management" emergency treatment
I. 2eimlich maneuer
II. cricothyrotomy ;cut cricoid cartilage<
III. tracheotomy7tracheostomy
E. Pharyngitis
1. Inflammation of mucous membranes of #haryn(
2. Bacterial+ iral+ enironmental causes
!. Treat findings: if culture sho*s bacteria+ use antibiotics
6. Tonsillitis
1. Inflammation and7or infection of tonsils
2. Acute form is usually bacterial
!. Treat findings: if culture sho*s bacteria+ use antibiotics
B. Peritonsillar abscess
1. Com#lication of acute tonsillitis
2. Infection s#reads to surrounding tissue
!. If s*elling is massie+ can endanger air*ay
$. Treat findings: if culture sho*s bacteria+ use antibiotics
). .ocal cord disorders
1. 8aryngitis
a. inflammation of ocal cords and surrounding mucous
membranes
b. cause" something irritates the laryn(
c. occurs in iral and bacterial infections
d. in children+ called crou# ;laryn( bloc%ed by edema+ s#asm
or both<
e. treat findings+ rest oice+ remoe irritants+ gargle *ith *arm
salt *ater
2. .ocal cord #aralysis
a. in@ury+ trauma or disease of laryn(+ laryngeal neres or
agus nere
b. may result as a com#lication after thyroidectomy surgery
c. assess ho* *ell client can #rotect air*ay
d. can sometimes be surgically treated *ith Teflon in@ection
2. Cancer of the laryn(
1. 6tiology
a. most tumors of the laryn( are s'uamous cell carcinoma
b. more common among men+ age &0 to 5&
c. cigarette smo%ing and alcohol consum#tion are related ,
es#ecially in combination
2. Bindings
a. #ersistent sore throat
b. dys#nea
c. dys#hagia
d. increasing #ersistent hoarseness
e. *eight loss
f. enlarged cerical lym#h nodes
g. nec% #ain7lum# in nec% ;late<
!. Aanagement
a. radiation thera#y
b. chemothera#y
c. surgery" remoal of all or #art of laryn( to treat cancer
I. total laryngectomy" no oice+ #ermanent stoma in
nec% *ith no ris% of as#iration from oral caity
II. radical nec% dissection" *hen cancer has
metastasi=ed to surrounding tissues , total
laryngectomy and radical nec% dissection to
remoe ad@acent cancerous tissue
$. Dursing interentions
a. arrange for clients *ith larnygectomies to meet *ith
members of su##ort grou#s
b. establish a method for communication before surgery
c. maintain air*ay: hae suction e'ui#ment at bedside
d. obsere for signs of hemorrhage or infection
e. teach about trach and stoma care
f. assist *ith #eriod of grieing
+I/ Disor!ers of Lo'er Respiratory System %LRS&. O(struti)e
A. )eneral facts" #rocess in chronic obstructie #ulmonary diseases
1. Bloc% airflo* out of lungs
2. Tra# air+ *ith im#airment of gas e(change
!. Increase the *or% of breathing
B. 6m#hysema
1. Eestroys aleoli
2. Darro*s and colla#ses small air*ays
!. 4erall lung loses elasticity
$. Tra#s air
&. As aleolar *alls die+ there is less surface for ital gas e(change
C. Chronic bronchitis
1. Eefinition
a. inflammatory res#onse in the lung
b. affects fe* aleoli+ mostly air*ays
2. Bindings
a. lungs chronically #roduce fluids
b. inflammation and mucus narro* the air*ays
E. Asthma
1. Eefinition7etiology
a. reersible obstruction of air*ays
b. inflammation of air*ays
c. air*ays hy#ersensitie to ariety of stimuli
d. bronchos#asm is a minor com#onent
e. disease *a(es and *anes+ remissions and e(acerbations
2. Bindings
a. ortho#nea+ e(#iratory *hee=ing
b. barrel chest+ cyanosis+ clubbing of fingers
c. distention of nec% eins
d. edema of e(tremities
e. increased PC42 and decreased P42
f. #olycythemia
g. use of accessory muscles to breathe
!. Eiagnostics
a. #hysical e(amination *ith history of findings
b. arterial blood gases
c. chest (,ray
$. Com#lications
a. hy#o(emia
b. hy#erca#nia
c. ariety of res#iratory infections
d. cor #ulmonale
e. dysrhythmias
6. Aanagement for obstructie disease
1. Antibiotics and corticosteroids for infection or chronic inflammation
or actue e(acerbation
2. Bronchodilators , long acting for control+ short acting for
emergency relief
!. Aucolytics
$. 6(#ectorants
5. Res#iratory #rogram" #ostural drainage+ e(ercise+ nebuli=er+ high
#rotein diet. See Postural Drainage
2y#er ;oer as in
hy#eractie<
Ca ;sounds li%e carbon
dio(ide<
2y#erca#nia G Too much
carbon dio(ide
in arterial blood
2y#o ;under as in
hy#odermic+ under s%in<
4( ;sounds li%e o(ygen< 2y#o(emia G Dot enough
o(ygen in arterial blood
B. Dursing interentions common to obstructie diseases
1. Assess client?s ris% of res#iratory failure
2. Assess for degree of res#iratory effort , an increase in *or% to
breathe+ dys#nea+ or use of accessory muscles
!. Assess o(ygenation *ith #ulse o(imeter if hemoglobin leel is
*ithin normal limits
$. Aeasure arterial blood gases ;AB)< to ealuate gas e(change
&. Administer o(ygen as indicated
5. If ris% of res#iratory failure+ antici#ate entilation
3. Assist *ith secretion remoal as indicated
/. Pace client actiities to reduce o(ygen demand
9. Teach dia#hragmatic breathing+ #ursed,li# breathing and energy
conseration methods
10. Position in a high Bo*ler?s to ease breathing effort
11. Proide for nutritional consults as indicated
12. Reinforce the #lan for small+ fre'uent high carbohydrate meals
1!. Proide referrals for"
a. de#ression associated *ith disease
b. #ulmonary rehabilitation
c. smo%ing cessation su##ort grou#s
1$. Bor asthma+ teach clients that as#irin or e(#osure to un%no*n
allergens may stimulate an asthma attac%
+II/ LRS Disor!ers. Restriti)e
A. In general" these disorders #reent full lung e(#ansion ia three
mechanisms
1. 8ung stiffening
2. 6(ternal com#ression
!. Auscle *ea%ness
B. Pulmonary fibrosis, lung stiffening
1. 4ccu#ational lung diseases
a. coal *or%er?s #neumoconiosis , ris% increases *ith length
of e(#osure to coal dust ;H1& years<+ intensity of e(#osure+
and silica content of dust
b. silicosis" *or%ers *ho *ill hae inhaled silica dust
2. Asbestosis
a. inhalation of asbestos fibers
b. disease may deelo# 1& to 20 years after e(#osure
c. high ris% for mesothelioma , lung cancer s#ecific to
asbestos
C. Pulmonary sarcoidosis , lung stiffening
1. 6tiology
a. un%no*n origin
b. characteri=ed by formation of tubercles+ most often in the
lungs
c. may #rogress to fibrosis
2. Bindings
a. dys#nea
b. an(iety
!. Eiagnostics
a. chest (,ray
b. bio#sy of affected tissue
$. Aanagement
a. antitussies
b. o(ygen thera#y
c. remoal of to(ic substances
d. #ro#er use of #ersonal #rotectie e'ui#ment to decrease
lung damage
E. Dursing interentions common to all ty#es of #ulmonary fibrosis
1. Preent infection or e(#osure to infection
2. Pace clients? actiities to reduce o(ygen demands and dys#nea
!. Reinforce the need for small+ fre'uent meals
$. 6ncourage daily actiities *ithin #ulmonary tolerance
a. #roide referrals for"
I. de#ression associated *ith disease
II. smo%ing cessation su##ort grou#s
III. occu#ational rehabilitation
E/ Disor!ers of flui! in pleurae
1. Pleural fluid disorders , all treated *ith *ater seal chest drainage
systems
2. Pneumothora(" air bet*een the #leurae
a. o#en #neumothora(" hole in the chest *all+ communicates
*ith the lung
b. closed #neumothora(" hole in lung+ chest *all intact
c. tension #neumothora( , a nursing and medical emergency
i. closed #neumothora(
ii. air is forced into the #leural s#ace *ith a continued
#ressure build u#
iii. shifts mediastinum a*ay from affected side *ith
results of a com#ressed heart
i. treated *ith chest tube insertion
. cardiac and res#iratory arrest if not treated
d. e(am#les of the aboe
!. Pleural effusion
a. fluid ;transudate or e(udate< in the #leural s#ace
b. if small+ no treatment
c. if larger+ treated *ith chest tube insertion
d. re#eated #leural effusion may be treated *ith #leurodesis
to scar tissue and decreased fluid secretions
$. 2emothora(
a. blood in the #leural s#ace
b. treated *ith thoracentesis or chest tube
&. 6m#yema
a. #urulent drainage in the #leural s#ace
b. often from a chronic condition such as lung cancer
c. treated *ith chest tube inserton
5. Chylothora(
a. lym#hatic fluid in #leural s#ace
b. treated *ith thoracentesis or chest tube
F/ Musulos*eletal !iseases assoiate! 'it# !iffiulty (reat#in"
1. )uillain,Barre syndrome , follo*s a iral infection
a. asen!in" paralysis that may affect muscles of
res#iration as #aralysis ascends
b. muscles so *ea% that client cannot breathe dee#ly+ a
nursing and medical emergency
c. may #rogress to res#iratory failure
i. may re'uire intubation
ii. mechanical entilation
iii. course of illness aries from a fe* months to years
2. Ayasthenia grais
a. s#oradic+ #rogressie *ea%ness of s%eletal muscle
b. cause" lac% of acetylcholine *ith results of a myoneural
@unction malfunction
c. may not be able to che* and s*allo* *ell
i. may as#irate
ii. may lose #rotectie air*ay refle(es
d. re#eated muscle moements+ es#ecially to*ards days
end+ can e(acerbate acute res#iratory failure
!. Poliomyelitis
a. iral infection
b. if disease stri%es the res#iratory muscles the result may be
res#iratory failure
c. may not s*allo* *ell
i. may as#irate
ii. may lose #rotectie air*ay refle(es
$. Amyotro#hic lateral sclerosis ;A8S: 8ou )ehrig?s Eisease<
All of these musculos%eletal disorders 6IC6PT )uillain,Barre feature
the letter A"
,Ayasthenia grais
,Poliomyelitis
,Amyotro#hic 8ateral Sclerosis
,Auscular dystro#hies
a. affects motor neurons: autonomic+ sensory and mental
function unchanged
b. manifests as a chronic+ #rogressie irreersible disorder
c. begins usually in distal ends of u##er e(tremities
d. often leads to res#iratory failure *ithin t*o to fie years
e. results in ethical issue
i. *hether clients *ant mechanical entilation
ii. *hether nutritional su##ort is desired
iii. if they *ould rather die *hen disease becomes this
seere
f. results in clients? inability to communicate or #hysically
moe from oluntarily and7or clients lac% inoluntary
refle(es+ such as blin%ing or gag refle(
&. Auscular dystro#hies
a. #rogressie symmetrical *asting of oluntary muscles *ith
no nere effect
b. as thoracic muscles *ea%en+ breathing becomes more
difficult
c. may not s*allo* *ell: ris% for as#iration *ith loss of
#rotectie air*ay refle(es
5. Interentions common to musculos%eletal disorders
a. monitor carefully for #an"es in condition
b. assess regular s'allo'in" and ability to #rotect the u##er
air*ay
c. discuss client #reference for mechanical )entilation or
nutritional support" does client *ish itJ
d. assist *ith ou"#in" and secretion clearance as indicated
e. #reent infetion
f. assess for *ith a##ro#riate referrals for !epression that is
often associated *ith these diseases
g. administer me!iations s#ecific to the disease condition
h. assist7#roide oupational or2an! p#ysial
re#i(ilitation as indicated
i. maintain ade'uate nutrition
@. *ith terminal disorders+ #roide for referrals for family
+III/ LRS Disor!ers. Infetious
A/ Pneumonia
1. Eefinition7etiology
a. acute infection of lung #arenchyma
b. cause" bacterium+ irus+ #roto=oan+ mycobacterium+
myco#lasma+ or ric%ettsia
c. #neumonia is the leading cause of death from infectious
causes
d. may affect only a region of lung" lobar #neumonia+
broncho#neumonia
e. may be the result of"
i. #rimary infection
ii. secondary to other lung damage
iii. as#iration
2. Ris% factors for #neumonia
a. #re,e(isting #ulmonary disease
b. abdominal and thoracic surgery
c. mechanical entilation
d. adanced age
e. decreased ability to #rotect air*ay or cough effectiely
f. artificial air*ay
g. chronic illness and debilitation
h. de#ressed immune function
i. cancer
!. Eiagnostics
a. chest radiogra#h
b. s#utum culture+ sensitiity and microsco#ic analysis+ )ram
stain+ cytology
c. AB) as indicated by clinical condition
$. Aanagement
a. antimicrobials+ de#ending on #athogen
b. anti#yretic
c. e(#ectorants
d. antitussies
e. su##lemental o(ygen+ as indicated
f. I. fluids to treat dehydration
&. Dursing interentions
a. monitor finger o(imeter if hemoglobin leels *ithin normal
limits
b. #romote hydration to li'uify secretions
c. teach effectie coughing techni'ues to minimi=e energy
e(#enditure
d. suction if necessary
e. teach the need to continue entire course of antimicrobial
thera#y *hich is usually seen to ten days
f. teach that findings are e(#ected to be less *ithin $/ to 32
hours of initial thera#y
g. encourage #neumonia accine for high,ris% grou#s
B/ Pulmonary tu(erulosis %PTB&
1. 6tiology
a. mycobacterium tuberculosis
b. bacilli lodge in aleoli
c. #ulmonary infiltrates
d. can s#read throughout body ia blood
e. multi,drug resistant PTB is becoming more
#realent
f. PTB incidence is rising *ith increasing
homelessness and AIES
2. Bindings
a. *ea%ness *ith fatigue
b. anore(ia *ith *eight loss
c. night s*eats
d. chest #ain
e. #roductie cough
!. Eiagnostics
a. s#utum and gastric contents+ analysis for the
#resence of acid,fast bacilli
b. chest (,ray for #resence of actie or calcified
lesions+ KcoinK lesions
c. tuberculin testing
i. tine+ mantou( tests
chec%ed $/ to 32 hours for
induration
#ositie if H10 mm induration in
healthy #ersons: #ositie if H& mm
induration in clients *ho are
immunosu##ressed
d. establishes if there is an antibody res#onse to the
tubercle bacillus
e. if #ositie+ indicates #rior e(#osure to bacillus+ not
an actie disease
$. Aanagement
a. long,term+ si( to 2$ months+ antimicrobial thera#y
*ith isonia=id ;ID2< ;2y=yd< or rifam#in ;Rifadin<+
*ith ethambutol 2C8 ;6tibi< in some cases
b. bed rest or chair rest until findings abate
c. surgical resection of inoled lung if medication is
not effectie
d. high carbohydrate+ high #rotein diet *ith fre'uent
small meals
&. Dursing interentions
a. *ith actie infection+ client must be isolated *ith
airborne #recautions *hen in the hos#ital
b. teach client
i. #ro#er techni'ues to #reent s#read of
infection" hand *ashing+ etc.
ii. to re#ort bloody s#utum
iii. not to use oer the counter ;4TC<
medications *ithout health care #roider?s
a##roal
i. im#ortance of ta%ing medications as
#rescribed
adherence to treatment regimen
return at scheduled times for lab
testing of lier en=ymes
an increase in B5 to minimi=e
#eri#heral neuro#athies+ a common
side effect of drug thera#y
. family and close contacts must be tested for
disease
C/ Lun" a(sess
1. 8ocali=ed area of lung infection
2. Usually follo*s #neumonia+ TB or as#iration
!. Treatment consists of draining and culturing abscess and
antimicrobial thera#y
I3/ LRS Disor!ers. Misellaneous
A/ Pulmonary em(olism
1. Eefinition7etiology
a. clot bloc%s blood from the KbedK of arteries that feed the
lung
b. client is breathing but gases are not e(changed ,
entilation *ithout #erfusion
c. hy#o(emia results
d. can be mild or immediately fatal+ based on the si=e and
location of clot;s<
e. usually clot has traeled from dee# eins in the leg or
#elis
2. Eiagnostics
a. entilation7#erfusion ;.7P< scan+ also called .7L scan
b. AB)
c. 6M)
!. Aanagement
a. o(ygen ia mas%
b. anticoagulation , he#arin in acute and coumadin for
chronic ris%
c. thrombolytics
d. filter surgically #laced in ena caa for long term care
B/ Aute respiratory !istress syn!rome %ARDS&
1. Eefinition7etiology
a. aleolar ca#illary membrane becomes more #ermeable to
fluids
b. increased e(traascular lung fluid
c. #ulmonary com#liance decreases
d. intra#ulmonary shunt increases
e. refractory hy#o(emia , does not res#ond to o(ygen thera#y
f. usually seen after lung in@ury or massie multi,system
organ disease
2. Bindings
a. restlessness+ an(iety
b. dys#nea
c. tachycardia
d. cyanosis
e. intercostal retractions
!. Eiagnostics
a. clinical #resentation and history of findings
b. hy#o(emia on AB) des#ite increasing ins#ired o(ygen
leel
c. chest (,ray sho*s diffuse infiltrates
$. Aanagement
a. o#timi=e o(ygenation
I. mechanical entilation
II. sedation may be re'uired
III. #aralytic agents may be necessary
b. antibiotics+ as indicated
c. corticosteroids
&. Dursing interentions
a. #lan for fre'uent rest #eriods
b. monitor trends in o(ygenation status+ AB)s+ res#iratory
effort
c. obsere for behaioral changes and ital signs: confusion
and hy#ertension may indicate cerebral hy#o(ia
C/ Lun" aner
1. Eefinition7etiology
a. ty#es of lung cancer
I. s'uamous cell carcinoma
S41AMO1S CELL CARCINOMA
A/ Ris* fators
1. Is most often associated *ith cigarette smo%ing
2. 6(#osure to enironmental carcinogens e.g. uranium+ asbestos
B/ C#arateristis
1. Accounts for !0,!&1 of lung cancer cases
2. Is more common among men
!. Bindings occur earlier because of bronchial obstructie characteristics ;arises
from bronchial e#ithelium<
$. Causes caitating #ulmonary lesions
&. Usually metastasi=es locally
C/ T#erapy
1. 8ife e(#ectancy is better than small cell carcinoma
2. Surgical resection is often attem#ted
II. small,cell ;oat cell< carcinoma
III. adenocarcinoma
IV. large cell carcinoma
SMALL CELL CARCINOMA
A/ Ris* Fators
1. Cigarette smo%ing
2. 6nironmental carcinogens
B/ C#arateristis
1. Accounts for 1&1 to 2&1 of lung cancers
2. S#reads early
!. .ery malignant form
$. Is often associated *ith endocrine disturbances
C/ T#erapy
1. Poorest #rognosis
2. Aerage surial is less than one year
ADENOCARCINOMA
A. Ris* Fators
1. Dot related to cigarette smo%ing
2. 8ung scarring
!. Chronic interstitial fibrosis
B. C#arateristis
1. Aore common among *omen
2. Accounts for about half of all lung cancers
!. Usually located in #eri#heral section of lungs
$. 4ften no clinical signs or findings until *ell adanced
C. Treatment
1. Eoes not res#ond *ell to chemothera#y
2. Aost often+ surgical resection is attem#ted
LAR0E CELL CARCINOMA
A. Ris* Fators
1. Cigarette smo%ing
2. 6nironmental carcinogens
B. C#arateristis
1. 4ccurs in 1&,2&1 of all lung cancers
2. Bre'uently metastases ia blood
!. Usually #eri#heral rather than centrally located in the lung lobes
C. T#erapy
1. Usually client is not a candidate for surgery due to the high fre'uency of
metastasis
2. Tumors often res#onds to radiation thera#y but fre'uently recurs
b. #rognosis is generally #oor
c. largely #reentable if smo%ers sto# and nonsmo%ers aoid
second hand smo%e
2. Bindings
a. hoarse oice
b. changes in breathing
c. #ersistent cough or change in cough
d. blood,strea%ed or bloody s#utum
e. chest #ain or tightness in chest *all
f. recurring #neumonia+ #leural effusion
g. *eight loss
!. Eiagnostics
a. medical imaging e(aminations
b. cytological s#utum analysis
c. bronchosco#y
d. bio#sy , most definitie diagnostic tool for lung cancer
$. Aanagement
a. nonsurgical
i. chemothera#y
ii. radiation thera#y
iii. laser thera#y to de,bul% tumor
i. thoracentesis and #leurodesis
b. surgical
i. thoracotomy
*edge resection , #art of a lobe
segmental resection, #art of a lobe
lobectomy , one or more lobes
#neumonectomy , entire right or left lung
&. Dursing interentions
a. #ost,o#eratie care
i. chest drainage
ii. routine #ost o#eratie care
monitor res#iratory status fre'uently
teach effectie dee# breathing and cough
techni'ues
refer to #hysical thera#y for e(ercises for
shoulder on affected side
reliee #ain
iii. o#timi=e o(ygenation
i. #roide o##ortunities for the client to tal% about
cancer: as needed+ refer to su##ort grou#s
. teach information as based on treatment #lan and
#rognosis
i. o#timi=e nutritional status
D/ Cor pulmonale
1. Eefinition7etiology
a. right entricular hy#ertro#hy and subse'uent chronic heart
failure
b. cause" heart must #um# against great resistance from
lung?s blood essels" called increased #ulmonary ascular
resistance ;P.R<
c. increased P.R results from chronic lung disease
d. may be due to #rimary #ulmonary hy#ertension as *ell
2. Eiagnostics
a. #ulmonary artery #ressure readings ia a catheter
b. echocardiogram
c. chest radiogra#h
d. AB)
e. 6M)
!. Aanagement
a. administer o(ygen as ordered
b. if hemoglobin *ithin normal limits ;FD8<+ monitor
o(ygenation *ith finger or #ulse o(imeter
c. bed rest+ as needed
d. monitor effects of medications
I. cardiac glycosides
II. #ulmonary artery asodilator
III. diuretics
I.. restricted fluid inta%e as indicated
e. nursing interentions
I. monitor for changes in o(ygenation status
II. #ace actiities in clients *ho tire easily
E/ Respiratory failure
1. Eefinition" lungs cannot maintain arterial o(ygen leels or
eliminate carbon dio(ide
a. PaC42 H &0 mm 2g
b. Pa42 > &0 mm 2g
c. clients *ith chronic lung disease #recautions
i. loo% for dro# from baseline function
ii. this is a nursing and medical emergency
iii. clients are al*ays hy#o(emic
2. 6tiology
a. lung diseases that harden the aleolar,ca#illary membrane
to tra# 42
b. neuro,muscular or musculos%eletal disorders
i. res#iratory drie dulled or blunted
ii. muscles too *ea% to breathe
!. Eiagnostics" AB)
$. Aanagement
a. o(ygen #er mas%
b. mechanical entilation
c. monitor for im#roement in the underlying cause for the
res#iratory failure
Points to Remem(er
4(ygen is essential for life. So+ (efore all else+ %ee# air*ays o#en and ease
breathing effort.
Clients *ith chronic lung disease use more o(ygen and energy to breathe. This
can create a icious cycle in *hich the client *or%s harder+ and continually
re'uires more o(ygen and more energy.
Dursing interentions for clients *ith chronic lung disease should include #acing
of actiities+ because these clients hae little resere for e(ertion.
Luality of life for clients can be significantly im#roed if clients routinely use
dia#hragmatic breathing and #ursed,li# breathing.
Clients *ith asthma must understand the different ty#es of inhalers and *hen to
use each ty#e. Some rescue inhalers are for acute dys#nea. 4ther inhalers are
for maintenance or #reentatie ty#es of drugs.
A finger or #ulse o(imeter reading is sim#ly one element of an assessment. It is
not the *hole #icture.
Cyanosis+ a late finding+ is determined by o(ygenation and hemoglobin content.
Clients *ith anemia may be seerely hy#o(emic and neer turn blue+ but rather
KashenK.
Clients *ith #olycythemia may be cyanotic *ith ade'uate tissue o(ygenation.
The serious #ublic health issue of #ulmonary TB re'uires control and re#orting of
any incidence and recent contacts that the client had so #ro#halactic thera#y for
t*o to three months can be initiated.
Fhen caring for a client after a chest tube insertion+ an occlusie dressing is
#laced around the chest tube insertion site and the connections of the chest tube
system are ta#ed to #reent air lea%s at connections. An occlusie dressing is
one that is totally coered+ as *ell as the edges *ith non,#orous ta#e. This
dressing is ty#ically not changed and not e(#ected to hae any drainage on it.
Fhen caring for a client on a entilator+ if an alarm sounds+ first+ assess the
client. See if the alarm resets or if the cause is obious. If the alarm continues to
sound and the client deelo#s distress+ disconnect the client from the entilator+
use a manual resuscitation bag to entilate *ith 1001 o(ygen and #age or call
the res#iratory thera#ist immediately.
If the entilator tube disconnects+ the lo* #ressure alarm *ill sound.
If the high #ressure alarm sounds on the entilator+ the nurse should chec% for
some ty#e of obstruction or occlusion of the air*ay" mucous #lugs+ biting of the
tube by the client+ tube sli#s into right main stem bronchus+ or increased
secretions.
To ma(imi=e thera#eutic effect of in#alers+ the %ey is techni'ue. It is critical to
teach clients the right techni'ue and obsere ho* *ell they use the inhaler.
Smo*in" essation is critical to reduce the ris% and seerity of lung disease.
Second,hand smo%e enhances the ris% of children to deelo# asthma or other
chronic lung diseases.
Best a##roach to pulmonary em(olus is #reention. The use of intermittent
com#ression stoc%ings #reents clots in the dee# eins.
Clients *ith #ulmonary TB need intensie ommunity follo' u# to ensure that
they continue *ith #harmacological treatment once discharged from the hos#ital.
Clients *ho sto# thera#y too soon are the source for the more deadly multi,drug
resistant forms of #ulmonary TB.