Saint Mary’s University

Bayombong, Nueva Vizcaya

School of Health & Natural Sciences

NURSING DEPARTMENT

Course No. NCM 112

Subject: Care of Clients with Problem in Oxygenation, Fluid & Electrolytes, Infectious,
Inflammatory & Immunologic Response, Cellular Aberrations, Acute & Chronic
Yr. Level: BSN 3
Contact Hours/ Credit Units: 8 hours/week(8 units)

CHAPTER 2
(CARE OF PATIENTS WITH PROBLEMS IN OXYGENATION- RESPIRATORY DISORDERS)

I. Introduction:
Disorders of the respiratory system are common & are encountered by nurses in every
setting, from community to the intensive care unit. Expert assessment skills must be
developed & used to provide the best care for patients with acute & chronic respiratory
problems. Alterations in the respiratory status have been identified as important predictors
in clinical deterioration in hospitalized patients (Helling,Martin et al., 2014). To determine
the normal & abnormal assessment findings & recognize subtle changes that may negatively
impact patients’ outcomes, nurses require understanding of respiratory function & the
significance of diagnostic test results.

II. Learning Objectives:

1. Describe ventilation, diffusion, prefusion & ventilation-perfusion imbalances.
2. Recognize & evaluate major symptoms of the respiratory thru health history & assessment
findings.
3. Describe the nursing management of patients with upper airway disorders.
4. Compare & contrast the upper respiratory tract infections according to cause, incidence,
clinical manifestations, management & significance of preventive healthcare.
5. Use the nursing process
III. Core Content of the Chapter:
o The cells of the body derive the energy they need from oxidation of carbohydrates, fats,
& proteins. This process requires oxygen. Vital tissues, like the brain & the heart, cannot
survive long without continuous supply of oxygen. As a result of oxidation, carbon dioxide
is produced and must be removed from the cells to prevent buildup of acid waste products.
 The respiratory system performs this function by facilitating life sustaining processes such
as oxygen transport, respiration, ventilation & gas exchange.
OXYGEN TRANSPORT
- Movement of oxygen and removal of carbon dioxide from the lungs
RESPIRATION
- Gas exchange between the atmospheric air & the blood & between the blood & cells of
the body
VENTILATION
- It is the process of air flowing into the lungs during inspiration (inhalation) & out of the
lungs during expiration (exhalation). Air flows because of pressure differences between
the atmosphere & the gases of the lungs
PULMONARY DIFFUSION
- Is the process by which oxygen & carbon dioxide is exchanged from areas of high
concentration & to areas of low concentration
PULMONARY PERFUSION
- Is the actual blood flow through the pulmonary vasculature

GAS EXCHANGE

ASSESSMENT

A. HEALTH HISTORY
- Focuses on the physical & functional problems of the pt. & the effects of these problems on
the pt. over all respiratory status
a. Past history or childhood & adult illnesses
b. Family history of respiratory problems
c. Status of immunization
d. History of medication
e. Occupation & occupational environment
f. Habits- smoking, drug use & alcohol intake

B. PHYSICAL EXAMINATION
NOSE & SINUSES
-inspect the external nose for lesions, asymmetry or inflammation
- inspect sinuses for inflammation

PHARYNX & MOUTH

-inspect these structures for colors, symmetry, evidence of exudate, ulceration & enlargement
-open the mouth wide & take deep breath

TRACHEA
 -through direct palpation
-should be in the midline as it enters the thoracic inlet behind the sternum

THORAX
-inspection of the thorax provides information about the musculoskeletal structures, the pt.
nutritional status & respiratory function
- the nurse observes the skin over the thorax for color & turgor & for evidence of loss of
subcutaneous tissue

A. CHEST CONFIGURATION
-Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1:2
➢ Barrel Chest
- Occurs as a result of hyperinflation of the lungs
- There is an increase in the anteroposterior diameter of the thorax- 2:1
- In pt. with emphysema- the ribs are more widely spaced & the intercostal spaces tend to
bulge upon expiration

➢ Funnel Chest (Pectus Excavatum)

- Occurs when there is depression in the lower portion of the sternum
- This may compress the heart & great vessels resulting to murmurs
- May occur with rickets, Marfan’s Syndrome

➢ Pigeon Chest (Pectus Carinatum)

- Occurs as a result of displacement of the sternum
- There is an increase in the anteroposterior diameter
- May occur with rickets, Marfan’s Syndrome & severe kyphoscoliosis

➢ Kyphoscoliosis
- Elevation of the scapula & S-shaped spine
- This deformity limit lung expansion within the thorax
- It may occur with osteoporosis & other skeletal disorder that affect the thorax

B. BREATHING PATTERN & RESPIRATORY RATES

Eupnea 12-18 cpm Normal
Bradypnea Less than 12 cpm- Slow Increase ICP, Brain Injury & Drug Overdose
breathing
Tachypnea More than 20 cpm- Fast Pneumonia, Pulmonary Edema, metabolic acidosis,
breathing severe pain, rib fracture
Hypoventilation Slow, irregular breathing
Hyperventilation Increase in both rate & depth of
respiration that results to
increase arterial PaCO2
Hyperapnea Increase in the depth of
respiration
Kussmaul’s Respiration Severe acidosis of diabetic origin
Apnea Cessation of breathing
Cheyne Stokes Respiration Alternating episodes of apnea Heart failure & damage to the respiratory center
& periods of deep breathing (drug induced, tumor & trauma)

C. RESPIRATORY EXCURSION
- Is an estimation of thoracic expansion & may disclose significant information about thoracic
movement during breathing
- The nurse assesses the pt. for range & symmetry of excursion
- Place both hands posteriorly at the level of T9-T10 then ask the pt. take a deep breath
- Decreased Chest Excursion- chronic fibrotic disease
- Asymmetric Excursion- Pleurisy, Fractured Ribs, Trauma or Unilateral bronchial
obstruction
D. THORACIC PERCUSSION
- Percussion sets the chest wall & underlying structures producing audible & tactile
vibrations
- The nurse uses percussion to determine whether underlying tissues are filled with air, fluid
or solid material
- Also use to estimate the size & location of certain structures with in the thorax (diaphragm,
heart & liver)
TACTILE FREMITUS

CHARACTERISTICS
a. Flatness- soft
b. Dullness- medium
c. Resonance
d. Hyperresonance
e. Tympany

E. THORACIC AUSCULTATION
- Useful in assessing the flow of air through the bronchial tree & in evaluating the presence of
fluid & solid obstruction in the lungs

BREATH SOUNDS
-Normal breath sounds are distinguished by their location over a specific area of the lungs & are
identified as vesicular, bronchovesicular & bronchial (tubular) breath sounds

Adventitious Breath Sounds

-Maybe produced with abnormal condition that affects the bronchial tree & alveoli

a. Crackles (Rales)
-discrete non continuous sounds that result from delayed reopening of deflated airways
-high pitched, soft, crackling/popping sound heard during inspiration
-pneumonia, bronchitis, heart failure, bronchiectasis & pulmonary fibrosis

b. Wheezes
-are associated with bronchial wall oscillation & changes in airway diameter
-heard during expiration
 -asthma, chronic bronchitis, bronchiectasis

c. Pleural Friction Rub

-result from inflammation of the pleural surfaces that induces crackling, grating sound
usually heard in inspiration & expiration

C. CHIEF COMPLAINT
a. Dyspnea
- Difficult or labored breathing, breathlessness, shortness of breath
- Symptom of many cardio & respi d/o particularly when there is decreased lung compliance
or increased airway resistance
- The right ventricle of the heart is affected ultimately by lung disease because it must pump
blood through the lungs
- May be associated with neurologic & neuromuscular d/o (MG & GBS)
- Sudden dyspnea- pneumothorax, acute respiratory obstruction, ARDS
- ORTHOPNEA- inability to breath easily except in an upright position – heart disease &
COPD

b. Cough
- Although cough is a reflex that protects the lungs from the accumulation of secretion or
inhalation of foreign bodies- it can be a symptom of a number of d/o of the pulmonary
system
- It results from the irritation of mucous membranes anywhere in the respiratory tract
- May arise from infectious process or from airborne irritant such as smoke, smog, dust or gas
- A persistent & frequent cough can be exhausting & cause pain & may indicate serious
pulmonary disease
- Describe the cough: Dry, Hacking, Brassy, Wheezing, Loose or Severe
- A dry irritative cough—upper respiratory tract infection
- The time of coughing is also noted
- Coughing at night—left sided heart failure or bronchial asthma
- Coughing at morning—bronchitis
- Coughing after food intake—aspiration of material at tracheobronchial tree
- Cough of recent onset—acute infection
- Assessment of cough
Acute Cough Last for less than 3 weeks
Sub-Acute Cough Last for 3-8 weeks
Chronic Cough More than 8 weeks

c. Sputum Production
- Is the reaction of the lings to any constantly recurring irritant
- May also be associated with nasal discharge
- The nature of the sputum is indicative of the causal indication
Purulent Sputum (thick & yellow, green, rust colored) Bacterial Infection
Thin Mucoid Sputum Viral Bronchitis
Pink Tinged Mucoid Lung Tumor
Profuse, Frothy, Pink Sputum Pulmonary Edema
 Foul Smelling Sputum & Bad Breath Lung Abscess, Bronchiectasis

d. Chest Pain
- Maybe associated with pulmonary or cardiac disease
- Maybe sharp, stabbing & intermittent or maybe dull, aching & persistent
- May occur with pneumonia, pulmonary embolism with lung infarction & pleurisy
- Bronchogenic Carcinoma- pain is dull & persistent
- Pleuritic Pain- like a stab of a knife---irritation of the parietal pleura
- The nurse assesses the quality, intensity, & radiation of pain & identifies & explores
precipitating factors & pts. position

e. Wheezing
- Major finding in a pt. with bronchoconstriction or airway narrowing
- High pitched, musical sound heard upon expiration

f. Hemoptysis
- Expectoration of blood from the respiratory tract
- Symptom of both pulmonary & cardiac d/o
- Usually sudden, intermittent or continuous
- May vary from blood-tinged sputum to large sudden hemorrhage

g. Cyanosis
- Bluish discoloration of the skin
- Late indication of hypoxia
- May appear when there is at least 5g/dl of unoxygenated hemoglobin
- In the presence of pulmonary condition, central cyanosis is assessed by observing the color
of tongue & lips
- Indicates a decrease in O2 tension in the blood
- PERIPHERAL CYANOSIS- result from the decreased blood flow to a certain body area

h. Clubbing of the Fingers

- Is a sign of lung disease that is found in pt. with chronic hypoxic conditions, chronic lung
infection or malignancies of the lungs
- Initially manifested by sponginess of the nail bed & loss of nail bed angle

D. DIAGNOSTIC EVALUATION
a. Pulmonary Function Test
- Are routinely used in chronic respiratory d/o
- They are performed to assess respiratory function to determine the extent of dysfunction
- Includes measurements of lung volumes, ventilatory function & the mechanics of breathing,
diffusion & gas exchange
- Useful in monitoring the course of a pt. with an established respiratory disease & assessing
the response to therapy
- It may also be used as a screening tests in potentially hazardous industries such as coal
mining, exposure to asbestos & noxious fumes, dusts & gases
- Used to screen pts. who are scheduled for thoracic & upper abdominal surgery
 - Generally, are performed by a technician using SPIROMETER that has volume collecting
device attached to a recorder that demonstrates volume & time simultaneously

Vital Capacity Volume of air that can be exhaled after maximum exhalation 4600 ml
Tidal Volume Volume of air inhaled & exhaled with normal quiet breathing 500 ml or
5-10ml/kg
Inspiratory Reserve Maximum volume of air that can be inhaled following a 3000 ml
Volume normal quiet inhalation
Expiratory Reserve Maximum volume that can be exhaled following a normal 1100 ml
Volume quiet exhalation
Functional Residual Volume of air that remains in the lungs after a quiet normal 2300 ml
Capacity exhalation
Residual Volume Volume of air that remains in the lungs after a forceful 1200 ml
exhalation

b. Arterial Blood Gas

- Measurement of the blood pH & of arterial O2 & CO2 tensions
- PaO2- indicates degree of oxygenation; PaCO2- adequacy of alveolar ventilation
- Aid in assessing the ability of the lungs to provide adequate O2 & remove CO2
- Serial ABG analysis is also a sensitive indicator of whether the lung has been damaged after
chest trauma
- RADIAL ARTERY- is a common site for withdrawal of blood specimen
- ALLEN’S TEST- is done to assess for adequacy of collateral circulation of the hand
- HEPARIZED SYRINGE is use to draw 10 ml of blood specimen- prevent clotting

c. Pulse Oximetry
- Non-invasive method of continuously monitoring the O2 saturation (SaO2) & referred to as
SpO2 when using a pulse oximeter
- Effective to monitor subtle/sudden changes in O2 sat
- A probe or a sensor is attached to the fingertips (forehead, earlobe or bridge of the nose)
- The sensor detects changes in O2 sat levels by monitoring light signal generated by the
oximeter & reflected through the tissue at the probe
- Normal- SpO2= 95-100%
- Less than 85%= indicates that the tissues are not receiving enough O2

d. Cultures
- Maybe performed to identify organisms responsible for respiratory infections
*Sputum Cultures- are used in diagnosis, drug sensitivity & guide treatment

e. Sputum Studies
- Obtained for analysis to identify pathogenic organisms & to determine whether malignant
cells are present
- EXPECTORATION- method of collecting a sputum specimen with in 2h—to lab

f. Chest X-ray
- Normal pulmonary tissue—RADIOLUCENT
 - Densities produced by fluids, tumors, foreign bodies & other pathologic conditions can be
detected through x-ray
- Routine x-ray consists of 2 views: posteroanterior & lateral projections
- Usually taken after full inspiration (deep breath) because the lungs are best visualized when
they are aerated & the diaphragm is at its lowest point so the largest expanse of lung is
visible

g. CT Scan
- Imaging method in which the lungs are scanned in successive layers by a neuron beam x-
ray
- Used to define pulmonary nodules & small tumors adjacent to the pleural surfaces

h. MRI
- Similar to CT scan except that magnetic fields & radiofrequency signals are used instead of
a narrow beam x-ray
- Yields a more detailed diagnostic than CT
- Used to characterize pulmonary nodules, help stage bronchogenic carcinoma & to evaluate
inflammatory activity, interstitial lung disease, acute pulmonary embolism & chronic
thrombolytic pulmonary hypertension

i. Fluoroscopic Studies
- It is used to assist with invasive procedures such as chest needle biopsy or transbronchial
biopsy used to identify lesions
- Use to study the movement of the chest wall, mediastinum & diaphragm
- Detect diaphragm & locate lung masses

j. Pulmonary Angiography
- Use to detect thromboembolic disease of the lungs such as pulmonary emboli & congenital
abnormalities of the pulmonary vascular tree
- It involves the rapid injection of a radiopaque dye to study the pulmonary vessel
- Performed by injecting the radiopaque dye into the vein or both arms (simultaneously) or
femoral vein with a needle or catheter

k. Lung Scan (Radioisotope Diagnostic Procedure)

- V/Q Scan, gallium Scan & PET
- Used to assess normal lung functioning, pulmonary vascular supply & gas exchange
- Measures blood perfusion to the lungs
- Confirms pulmonary embolism & other blood flow abnormalities

l. Bronchoscopy
- Direct inspection & observation of the larynx, trachea & bronchi through a bronchoscope
Diagnostic Use:
1. Collect secretions
2. Determine location of pathologic process & collect specimen for biopsy
Therapeutic Use:
1. To remove aspirated foreign objects
 2. To excise small lesions

Nursing Care:
Before
1. Informed consent
2. NPO 6-8 h
3. Remove dentures
After
1. Side lying position
2. Check return of gag reflex before giving fluids
3. Watch for cyanosis, hypotension, tachycardia, arrythmias, hemoptysis & dyspnea—obstruction

m. Thoracentesis
- Aspiration of fluid or air from the pleural space
Nursing Care:
Before
1. Consent
2. Take v/s
3. Position: Upright leaning on overbed table
4. Instruct the pt. to remain still, avoid coughing during insertion of needle to prevent trauma to
the lungs
5. Pressure may be felt upon insertion of the needle—topical anesthesia

After
1. Turn on unaffected side to prevent leakage of fluid in the thoracic cavity
2. Bedrest
3. Check expectoration of blood
4. Monitor v/s