RESPIRATORY TREATMENT MODALITIES

DEEP BREATHING AND COUGHING

 Effective coughing can keep the airway clear of
secretions
 Ineffective cough is exhausting and fails to bring up
secretions
Steps:
1. Instruct patient to take two or three deep breaths, using
the diaphragm
 this helps get the air behind the secretions
2. After the third deep inhalation, tell the patient to hold the OXYGEN
breath. THERAPY
3. Cough forcefully  Ordered by the physician to patients whose oxygen
 This is repeated as necessary saturation is less than 90% on room air
 Good hydration can facilitate this process Low-flow Devices:
Nasal Cannula
Huff Coughing  The most common method of
 Ideal for patient with COPD oxygen administration
 have weak cough and airways that collapse easily  Oxygen is delivered through a
1. Exhale deeply to remove as much as trapped air as flexible catheter that has two nasal
possible prongs
2. Take a deep breath in to get air behind the secretions  For the nasal cannula to be
3. Instead of closing the glottis to generate a forceful cough, effective, the patient must
the patient should keep the glottis and mouth open breath through the mouth
 The cannula allows the
use the abdominal muscles to create a series of forced expiration, patient to eat and talk, and its
moving the air and mucus up the bronchial tree (creating "huff" generally more comfortable
sounds) than other methods of
administration
4. Take one more controlled inhalation and final huff to
expel the mucus Simple Face Mask
 Used when higher oxygen
BREATHING EXERCISES concentration is needed
Disadvantages:
Diaphragmatic Breathing  make some patient
 Conscious use diaphragm during breathing can be claustrophobic
relaxing and conserves energy  replaced by cannula when
1. Place one hand on the abdomen and the other on the eating
chest.  A rate of 5-10 L/minute can
2. Concentrate on pushing the abdomen during inspiration deliver oxygen concentration
and relaxing the abdomen on expiration. from 40-60% with a simple
 the chest should move very little face mask

Partial Rebreather Mask

 Uses a reservoir to capture
some exhaled gas for
rebreathing
 Vents on the side of the mask allow room air to mix with
oxygen
 It can deliver 50% or more oxygen concentration

Nonrebreather Mask

Pursed-lip Breathing
 It helps the airway open during exhalation, which
promotes carbon dioxide excretion
 Should be done with diaphragmatic breathing
Nonrebreather
Mask
 Has one or both side vents closed to limit the mixing of
room air with oxygen
 Vents open to allow expiration but remains closed on
inspiration
 The reservoir bag has a valve to store oxygen for
inspiration but does not allow entry of exhaled air
  Can deliver up to 70-100% oxygen
CHEST PHYSIOTHERAPY (CPT)
Includes:
 postural drainage
 percussion and vibration
 It helps move secretions from deep inside the lungs
 Indicated to patient who has a weak or ineffective cough
and is therefore at risk for retaining secretions

Postural Drainage
 Patient is placed in various positions (head down to help
drain secretions) and turned periodically during the
High-flow Devices: treatment so that all lobes of the lungs are drained
Venturi Mask
 Used for patient who
requires precise
percentage of oxygen
 A combination of valves
and specified flow rates
determines oxygen
concentration

Transtracheal Catheter:
 A small tube that is surgically
placed through the base of the
neck directly into trachea to
deliver oxygen
 An alternative method for patients
who are on long-term oxygen
therapy at home
 it does not obstruct the nose or
mouth Percussion
 can easily be covered with a  The therapist uses
loose scarf or collar cupped hands to strike
 Patient is taught to remove and the chest repeatedly,
clean the catheter 2-3 times a day producing sound
to prevent mucus obstruction waves that transmitted
to the chest, loosening
Nursing Interventions: the secretions
 Attached "Oxygen in Use" sign to  May also apply
door of room and instruct client vibration to the patient's
and visitor not to smoke. chest using hands or
 Assess client's color and V/S vibrator to loosen
before and during therapy. secretions
 Ascertain that client does not have  Neubulization should be
chronic lung disease before given before CPT to
administering high concentration humidify secretions
of oxygen  Patient is instructed to cough and deep breathe at
 Attach appropriate apparatus to the oxygen source and intervals during and after treatment
fill the humidification canister prn with water to prevent THORACENTESIS
drying of mucous membranes  Surgical aseptic procedure in which the chest wall is
punctured with a trocar to remove fluid or air for
diagnostic purposes or to alleviate respiratory
NEBULIZED MIST TREATMENTS embarrassment
 NMT use a nebulizer to deliver Fluid withdrawn should be sent to laboratory for:
medication drictly to the lungs  culture and sensitivity
 Bronchodilators mixed with  cytologic exam
saline are most commonly  biochemical test
administered Complications:
 Patient uses hand-held reservoir  pneumothorax from trauma to the lung
with tubing and mouthpiece to  pulmonary edema resulting from sudden fluid shift
breathe in the medication
 Commonly ordered every 4-6 hours and as needed
 Parts of Tracheostomy Tube:
Outer Cannula
 Remains in place at
all times and is
secured by ties to
prevent dislodging
Inner Cannula
 Removed at intervals;
usually every 8 hours
and as needed for
cleaning
 Some newer tracheostomy tubes eliminate the need for
Nursing Interventions: an inner cannula
 Obtain informed consent
 Explain procedure to the client Obturator
 Ensure that chest x-ray is done before and after the
 A guide that is used only
procedure
during insertion of the tube
 Assist and support the client in the sitting position
 After insertion, it is
 Set up a sterile field for the physician
immediately removed and
 Assess pulse and respirations before, during, and after
kept at bedside for
the procedure
emergency use if the
 Inform the patient not to cough during the procedure to
tracheostomy tube is
prevent trauma to the lung
accidentally removed
 After the procedure, label and send specimens for
laboratory tests
 Note and record the amount, color, and clarity of the  Tracheostomy tubes may
fluid withdrawn be metal or plastic
 Place the client on opposite side for approximately 1  Plastic tubes generally
hour to prevent leakage of fluid through the thoracentesis have disposable inner
site cannula
 Observe client for coughing bloody sputum and rapid Plastic tubes have defletable
pulse rate and report their occurrence immediately balloon-like cuff to:
 prevent air escape during
TRACHEOSTOMY mechanical ventilation
 Tracheotomy is a surgical opening through the base of  prevent aspiration of food or secretions
the neck of the trachea
Nursing Interventions:
Nursing Interventions:
 Provide tracheostomy
care at least every 8 hours
 Suction to remove
 Tracheostomy when it is more permanent and has a tube secretions from the lumen
inserted into of the tube
the opening to maintain patency If an inner cannula is present:
 The patient breath through this opening, bypassing the a. remove disposable inner
upper airways cannula
Indicated for patients with: b. care for non-disposable inner cannula
 cancerous larynx removed
 airway obstruction caused by 1. remove and place in peroxide; rinse with NSS using
trauma or tumor surgical aseptic technique
 difficulty clearing secretions 2. remove dried secretions within the cannula using sterile
from the airway pipe cleaner or brush
 the need for prolonged 3. drain excess saline before reinserting the tube which is
mechanical ventilation then lock in place
 Clean around
the stoma
with saline
using aseptic
technique
 apply
antiseptic
ointment if
ordered
  if <7.40 but not < 7.35:
 it is on the acid side of the mean (7.40)
 if it is > 7.40 but not >7.45:
ARTERIAL BLOOD GASES (ABGS)  it is on the alkaline side of the mean
An ABG is one of the most commonly used tests to measure  <7.35: acidemia
oxygenation and blood acid levels, two important measures of a  overall condition: acidosis
patient’s clinical status and correct interpretation can lead to  >7.45: alkalemia
quicker and more accurate changes in the plan of care.  overall condition: alkalosis

 An ABG is a blood test that measures the acidity, or pH, PaCO2

and the levels of oxygen (O2) and carbon dioxide (CO2)  is a measure of the partial pressure of carbon dioxide
from an artery.  indicates whether the patient can ventilate well enough to
 The test is used to check the function of the patient’s rid the body of the carbon dioxide produced as a
lungs and how well they are able to move oxygen into consequence of
the blood and remove carbon dioxide.  metabolism
 This test is commonly performed in the ICU and ER  Normal range: 35-45 mmHg
setting; however, ABGs can be drawn on any patient on  >45mmHg: respiratory acidosis (alveoli hypoventilation)
any floor depending on their diagnosis. results from:
 COPD
 measures the dissolved oxygen and carbon dioxide in the  oversedation
arterial blood  head trauma
 anesthesia/drug overdose
 reveal the acid-base state  neuromuscular impairment
 how well the oxygen is being carried to the body  inadequate ventilation with mechanical ventilator
 <35 mmHg: respiratory alkalosis
 examiner performs an results from:
Allen’s test first to  hypoxia
ensure the hand has  anxiety
adequate collateral  pulmonary embolism
blood flow  pregnancy
 over ventilation with mechanical ventilator
 compensatory mechanism to metabolic acidosis

HCO3
 is the acid-base components that reflects kidney function
 reduced or increased in the plasma by renal mechanism
 Normal range: 22-26 mEq/L
 <22 mEq/L: metabolic acidosis
results from:
 ketoacidosis
 lactic acidosis
 renal failure
 diarrhea
 >26 mEq/L: metabolic alkalosis
results from:
 fluid loss from UGIT (vomiting or NG suctioning)
 diuretic therapy
 severe hypokalemia
PaO2
 alkali administration
 indicates the amount of oxygen available to bind with
 steroid therapy
hemoglobin. The pH plays a role in the combining power
of oxygen with hemoglobin: a low pH means there is less
oxygen in the hemoglobin. STEPS FOR INTERPRETATION OF ABG VALUES
P: partial pressure Step 1
a: arterial  Look at PaO2:
 Normal range: 80-100 mmHg  does it show hypoxemia?
Example:
 <40 mmHg: life-threatening and requires immediate
 70 mmHg
action
Reading: hypoxemia
 95 mmHg
pH
Reading: normal range
 is a hydrogen ion (H+) concentration of plasma
 calculation is accomplished by using PaCO2 and HCO3
 Normal pH: 7.35-7.45
 with the mean being 7.40
Step 2 Example 3:
 Look at the pH: PaO2 90 mm Hg
 is it acidic or alkaline? pH 7.37
Example: PaCO2 60 mm Hg
 6.2 HCO3 38 mEq/L
Reading: acidic Interpretation:
 7.7 Compensated respiratory acidosis with metabolic alkalosis
Reading: alkalosis
 The acidosis is considered the main disorder, and the
Step 3 alkalosis is the compensatory response because the pH is
 Look at PaCO2: on the acid side of 7.40
 does it show respiratory acidosis, respiratory alkalosis, or
normalcy? Example 4:
Example: PaO2 90 mm Hg
 30 mmHg pH 7.42
Reading: respiratory alkalosis PaCO2 48 mm Hg
 51 mmHg HCO3 35 mEq/L
Reading: respiratory acidosis Interpretation:
Compensated metabolic alkalosis with respiratory acidosis
Step 4
 Look at bicarbonate (HCO3):  The alkalosis is the main main disorder, the acidosis is
 does it show metabolic acidosis, metabolic alkalosis, or the compensatory response because the pH is on the
normalcy? alkaline side of 7.40
Example:
 19 mEq/L Post-procedure:
Reading: metabolic acidosis  Apply constant,
 30 mEq/L firm, directpressure
Reading: metabolic alkalosis to the puncture site
for 5minutes or
Step 5 longer for patients
 Look back at the pH: with blood-clotting
 does it show a compensated or an uncompensated abnormalities
condition?  Place the specimen
If the pH level is abnormal (<7.35 or > 7.45), the PaCO2 value on ice
or HCO3 level, or both, will also be abnormal  Note the client’s
 uncompensated condition temperature on laboratory form
(there has not been enough time for the body to return the pH  Transport the specimen to the laboratory within 15
to its normal range) minutes

If the pH level is within normal limits and BOTH the PaCO2 INTERPRETING ARTERIAL BLOOD GAS
value and HCO3 level are abnormal IMBALANCES
 compensated condition Interpreting arterial blood gases is used to detect respiratory
(there has been enough time for the body to return the pH to acidosis or alkalosis, or metabolic acidosis or alkalosis during an
within its normal range) acute illness. To determine the type of arterial blood gas the key
Example 1:
PaO2 90 mmHg
pH 7.25
PaCO2 50 mmHg
HCO3 22 mEq/L
Interpretation:
Uncompensated respiratory acidosis

Example 2
PaO2 90 mmHg
pH 7.25 components are checked. The best (and fun) way of interpreting
PaCO2 40 mm Hg arterial blood gas is by using the tic-tac-toe method.
HCO3 17 mEq/L
Interpretation:
Uncompensated metabolic acidosis
For the purpose of this guide, we have set three (3) goals that we
need to accomplish when interpreting arterial blood gases. The
goals are as follows:
1. Based on the given ABG values, determine if values
interpret ACIDOSIS or ALKALOSIS.
2. Second, we need to determine if values define
METABOLIC or RESPIRATORY.
3. Lastly, we need to determine the compensation if it is:
FULLY COMPENSATED, PARTIALLY
COMPENSATED, or UNCOMPENSATED.
We need to keep these goals in mind as they’ll come up later in
the steps for the ABG interpretation technique.
STEPS IN ABG ANALYSIS USING THE TIC-TAC-
TOE METHOD
There are eight (8) steps simple steps you need to know if you
want to interpret arterial blood gases (ABGs) results using the tic-
tac-toe technique.
1. Memorize the normal values.
The first step is you need to familiarize yourself with the normal
and abnormal ABG values when you review the lab results. They
are easy to remember:
 For pH, the normal range is 7.35 to 7.45
 For PaCO2, the normal range is 35 to 45
 For HCO3, the normal range is 22 to 26
2. Create your tic-tac-toe grid.
3. Determine if pH is under NORMAL, ACIDOSIS, or
ALKALOSIS.
The third step of this technique is to determine the acidity or
alkalinity of the blood with the given value of the pH as our
determining factor. Remember in step #1 that the normal pH
range is from 7.35 to 7.45.
 If the blood pH is between 7.35 to 7.39, the interpretation
is NORMAL but SLIGHTLY ACIDOSIS, place it under
the NORMAL column.
 If the blood pH is between 7.41 to 7.45, interpretation is
NORMAL but SLIGHTLY ALKALOSIS, place it under
the NORMAL column.
 Any blood pH below 7.35 (7.34, 7.33, 7.32, and so on…)
is ACIDOSIS, place it under the ACIDOSIS column.
 Any blood pH above 7.45 (7.46, 7.47, 7.48, and so on…)
is ALKALOSIS, place it under the ALKALOSIS
column.
4.
Determine if PaCO2 is under NORMAL, ACIDOSIS, or
ALKALOSIS.
For this step, we need to interpret if the value of PaCO2 is within
the NORMAL range, ACIDIC, or BASIC and plot it on the grid
under the appropriate column. Remember that the normal range
for PaCO2 is from 35 to 45:
 If PaCO2 is below 35, place it under the ALKALOSIS
column.
 If PaCO2 is above 45, place it under the ACIDOSIS
column.
 If PaCO2 is within its normal range, place it under the
NORMAL column.
5.
Determine if HCO3 is under NORMAL, ACIDOSIS, or
ALKALOSIS.
Next, we need to interpret if the value of HCO3 is within the
NORMAL range, ACIDIC, or BASIC and plot it under the
appropriate column in the tic-tac-toe grid. Remember that the
normal range for HCO3 is from 22 to 26:
 If HCO3 is below 22, place it under the ACIDOSIS
column.
 If HCO3 is above 26, place it under the ALKALOSIS
column.
 If HCO3 is within its normal range, place it under the
NORMAL column.
6. Solve for goal #1: ACIDOSIS or ALKALOSIS.
Now, we will start solving for our goals. Looking at the tic-tac-toe
grid, determine whether in what column the pH is placed and
interpret the results:
 If pH is under the ACIDOSIS column, it is ACIDOSIS.
 If pH is under the ALKALOSIS column, it is
ALKALOSIS.
 If pH is under the NORMAL column, determine whether
the value is leaning towards ACIDOSIS or ALKALOSIS
and interpret accordingly.
7. Solve for goal #2: METABOLIC or RESPIRATORY.
Looking back again on the tic-tac-toe grid, determine if pH is
under the same column as PaCO2 or HCO3 so we can accomplish
our goal #2 of determining if the ABG is RESPIRATORY or
METABOLIC. Interpret the results as follows:
 If pH is under the same column as PaCO2, it is
RESPIRATORY.
 If pH is under the same column as HCO3, it is
METABOLIC.
 If pH is under the NORMAL column, determine whether
the value is leaning towards ACIDOSIS or ALKALOSIS
and interpret accordingly.
8. Solve for goal #3: COMPENSATION.
Lastly, we need to determine the compensation to accomplish our
goal #3. Interpret the results as follows:
 It is FULLY COMPENSATED if pH is normal.
 It is PARTIALLY COMPENSATED if all three (3)
values are abnormal.
 It is UNCOMPENSATED if PaCO2 or HCO3 is normal
and the other is abnormal.
HOW TO DRAW ARTERIAL BLOOD GAS?
1. Inform that client about the procedure and that there is no
food or fluid restriction imposed.
2. Note if the client is taking anticoagulant therapy or
aspirin as this may affect results.
3. Note if the client is receiving oxygen therapy (flow rate,
type of administration device), and the client’s current
temperature.
4. Using a heparinized needle and syringe, collect 1 to 5
mL of arterial blood. Common sites for drawing arterial
blood are the radial and brachial artery.
5. Put the syringe with arterial blood in an ice-water bag to
minimize the metabolic activity of the sample.
6. Deliver the blood sample immediately to the laboratory.
7. Apply pressure to the puncture site for 5 minutes or
longer.
ACID-BASE BALANCE AND IMBALANCES
 Acid-base imbalances develop when a person’s normal
homeostatic mechanisms are dysfunctional or
overwhelmed. One type of acid-base imbalance is
acidosis wherein the blood is relatively too acidic (low
pH).
 The body produces two types of acid, therefore, there are
two types of acidosis: respiratory acidosis and metabolic
acidosis.
 On the contrary, alkalosis is a condition wherein the
blood is relatively too basic (high pH), there are also two
types of alkalosis: respiratory alkalosis and metabolic
alkalosis.
 When acid-base imbalances occur, the body activates its
compensatory mechanisms (the lungs and kidneys) to
help normalize the blood pH.
 The kidneys compensate for respiratory acid-base
imbalances while the respiratory system compensates for
metabolic acid base imbalances.
 This does not correct the root cause of the problem, if the
underlying condition is not corrected, these systems will
fail.
RESPIRATORY ACIDOSIS
Respiratory acidosis occurs when breathing is inadequate
(alveolar hypoventilation) and the lungs are unable to excrete
enough CO2 causing PaCO2 or respiratory acid builds up. The
extra CO2 combines with water to form carbonic acid, causing a
state of acidosis — a common occurrence in emphysema. The
kidneys activate its compensatory process by increasing the
excretion of metabolic acids through urination, which increases
blood bicarbonate.
Types of Respiratory Acidosis
 Acute respiratory acidosis. This form of respiratory
acidosis occurs immediately. Left untreated, symptoms
will get progressively worse. It’s a medical emergency
and can become life-threatening.
 Chronic respiratory acidosis. This form of respiratory
acidosis develops through time. It doesn’t cause
symptoms. Instead, the body adapts to the increased
acidity. For example, the kidneys produce more
bicarbonate to help maintain balance. Chronic respiratory
acidosis may not cause symptoms. Developing another
illness may cause chronic respiratory acidosis to worsen
and become acute respiratory acidosis.
Risk Factors
  Hypoventilation. A decrease in ventilation increases the
concentration of carbon dioxide in the blood and
decreases the blood’s pH (brain trauma, coma,
hypothyroidism: myxedema).
 Chronic Obstructive Pulmonary Disease (COPD). In
chronic respiratory acidosis in COPD patients, the body
tries to compensate by retaining more bicarbonate to
overcome acidosis.
 Respiratory Conditions. The lungs are not able to
eliminate enough of the carbon dioxide produced by the
body. Excess carbon dioxide causes the pH of the blood
and other bodily fluids to decrease, making them too
acidic. (pneumothorax, pneumonia, status asthmaticus)
 Drug Intake. Overdose of an opiate or opioid, such as
morphine, tramadol, heroin, fentanyl, or magnesium
sulfate (MgSO4) can cause respiratory acidosis.
Signs and Symptoms
 Altered level of consciousness. Respiratory acidosis
may be the result of an altered level of consciousness
caused by encephalopathy or cerebral edema.
 Confusion. Acute respiratory acidosis may also cause
symptoms involving the brain, including confusion,
stupor, drowsiness, and muscle jerks.
 Disorientation. Respiratory acidosis may result in
disorientation, headache, or even focal neurologic signs.
 Coma. When the lungs can’t remove all of the carbon
dioxide produced by the body through normal
metabolism, the blood becomes acidified, leading to
increasingly serious symptoms, from sleepiness to coma.
 Tremors. Manifest as shaking or jerking muscle
movements.
 Asterixis. An inability to maintain the posture of part of
the body.
Management of Respiratory Acidosis
 Treat underlying conditions.
 Medications. Bronchodilator medicines and
corticosteroids may be used to reverse some types of
airway obstruction, like those linked to asthma and
COPD.
 Weight loss. In the case of obesity hypoventilation
syndrome, significant weight loss may be necessary to
reduce abnormal compression of the lungs.
 Provide mechanical ventilation through oxygen
supplementation. Additional oxygen may be provided
to alleviate the low oxygen level in the blood.
 Manage hyperkalemia through the use of Kayexalate.
Acidosis causes potassium to move from cells to
extracellular fluid (plasma) in exchange for hydrogen
ions, and alkalosis causes the reverse movement of
potassium and hydrogen ions. Kayexalate increases fecal
potassium excretion through the binding of potassium in
the lumen of the gastrointestinal tract.
 Maintain adequate hydration. Provide intravenous
fluids and electrolytes as ordered.
RESPIRATORY ALKALOSIS
 Respiratory alkalosis can result from hyperventilation
since the lungs excrete too much carbonic acid which
increases pH.
 Since respiratory alkalosis occurs quickly, the kidneys do
not have time to compensate.
 Neurological symptoms such as confusion, paresthesias,
and cell membrane excitability occur when the blood pH,
CSF, and ICF increases acutely.
Risk Factors
 Panic. Panic attacks and anxiety are the most common
causes of hyperventilation.
 Hyperthermia. Fever may manifest as hyperventilation.
The exact mechanism is not known but is thought to be
due to carotid body or hypothalamic stimulation by the
increased temperature.
 Brainstem damage. Central neurogenic hyperventilation
(CNH) is the human body’s response to reduced carbon
dioxide levels in the blood. This reduction in carbon
dioxide is caused by the contraction of cranial arteries
from damage caused by lesions in the brain stem.
 Metabolic acidosis. Hyperventilation occurs most often
as a response to hypoxia, metabolic acidosis, increased
metabolic demands, pain, or anxiety.
 Diabetic ketoacidosis (DKA). The only known
compensatory response to metabolic acidosis in DKA is
hyperventilation with consecutive respiratory alkalosis.
 Pregnancy. Progesterone levels are increased during
pregnancy. Progesterone causes stimulation of the
respiratory center, which can lead to respiratory
alkalosis.
 Salicylate toxicity. Salicylate toxicity causes respiratory
alkalosis and, by an independent mechanism, metabolic
acidosis.
Signs and Symptoms
 Numbness. Increased neuromuscular irritability in which
a person loses feeling in a particular part of their body.
 Tingling sensation. Prickling sensation that is usually
felt in the hands, arms, legs, or feet, but can also occur in
other parts of the body.
 Palpitations. Palpitations are the perceived abnormality
of the heartbeat characterized by awareness of cardiac
muscle contractions in the chest.
 Tetany. Tetany or tetanic seizure is a medical sign
consisting of the involuntary contraction of muscles.
 Convulsions. A medical condition where body muscles
contract and relax rapidly and repeatedly, resulting in
uncontrolled actions of the body.
 Signs and symptoms of hypokalemia and
hypocalcemia. Persistent respiratory alkalosis can
induce secondary hypocalcemia and hypokalemia that
may cause cardiac arrhythmias, conduction
abnormalities, and various somatic symptoms such as
paresthesia, hyperreflexia, convulsive disorders, muscle
spasm, muscle twitching, positive Chvostek’s sign, and
tetany.
Management of Respiratory Alkalosis
 Treat underlying condition:
 Medications. Administering an opioid pain reliever or
anti-anxiety medication to reduce hyperventilation.
  Relaxation techniques. Breathing exercises that help
relax and breathe from the diaphragm and abdomen,
rather than chest wall.
 Safety. Stay with the patient.
 Lavage. After massive aspirin ingestions, aggressive gut
decontamination is advisable, including gastric lavage.
 Correction of hypokalemia and hypocalcemia.
 Breathe into a paper bag. Breathing through a paper bag
fills it with carbon dioxide helping in inhaling exhaled air
back into the lungs.
 Oxygenation as indicated. Providing oxygen to help keep a
person from hyperventilating.
METABOLIC ACIDOSIS
Metabolic acidosis is when there is a decrease in bicarbonates and
a buildup of lactic acid occurs. This happens in diarrhea, ketosis,
and kidney disorders. It has three main root causes: increased acid
production, loss of bicarbonate, and a reduced ability of the
kidneys to excrete excess acids.
Risk Factors
 Diabetic Ketoacidosis (DKA). DKA develops when
substances called ketone bodies (which are acidic) build
up during uncontrolled diabetes. DKA occurs mostly in
Type 1 Diabetes Mellitus (DM).
 Chronic Renal Failure (CRF). This is due to reduced
tubular bicarbonate reabsorption and insufficient renal
bicarbonate production in relation to the number of acids
synthesized by the body and ingested with food.
 Chronic Hypoxia. With chronic hypoxia, metabolic and
hypercapnic acidosis develop along with considerable
lactate formation and pH falling to below 6.8.
 Obesity. Obesity, especially in conjunction with insulin
resistance, can increase metabolic acidosis and thus
result in a reduction of urinary citrate excretion.
 Diarrhea. Loss of bicarbonate stores through diarrhea or
renal tubular wasting leads to a metabolic acidosis state
characterized by increased plasma chloride concentration
and decreased plasma bicarbonate concentration.
 Dehydration. Electrolyte disturbances caused by
prolonged vomiting or severe dehydration can cause
metabolic acidosis.
 Aspirin Toxicity. Aspirin overdose causes the body to
not produce ATP, leading to anaerobic metabolism with
consequent raised lactate and ketone bodies. Acute
aspirin or salicylates overdose or poisoning can cause
initial respiratory alkalosis through metabolic acidosis
ensues thereafter.
 Methanol Poisoning. Significant methanol ingestion
leads to metabolic acidosis, which is manifested by a low
serum bicarbonate level. The anion gap is increased
secondary to high lactate and ketone levels. This is
probably due to formic acid accumulation.
Signs and Symptoms
 Altered level of consciousness
 Confusion
 Disorientation
 Lack of appetite
 Coma
 Jaundice
Management of Metabolic Acidosis
 Sodium bicarbonate. Indicated in the treatment of
metabolic acidosis which may occur in severe renal
disease, uncontrolled diabetes, circulatory insufficiency
due to shock or severe dehydration, extracorporeal
circulation of blood, cardiac arrest, and severe primary
lactic acidosis.
 Treat the underlying condition.
 Hydration for diabetic ketoacidosis. The major
treatment of this condition is the initial rehydration.
 Dialysis for chronic renal failure. The control of
metabolic acidosis in hemodialysis is mainly focused on
the supply of bicarbonate during the dialysis sessions.
 Use of diuretics.
 Initiate safety measures.
 Kayexalate. Acidosis causes potassium to move from
cells to extracellular fluid (plasma) in exchange for
hydrogen ions, and alkalosis causes the reverse
movement of potassium and hydrogen ions. Kayexalate
increases fecal potassium excretion through the binding
of potassium in the lumen of the gastrointestinal tract.
METABOLIC ALKALOSIS
Metabolic alkalosis occurs when bicarbonate ion concentration
increases, causing an elevation in blood pH. This can occur in
excessive vomiting, dehydration, or endocrine disorders.
Risk Factors
 Vomiting. Vomiting causes metabolic alkalosis by the
loss of gastric secretions, which are rich in hydrochloric
acid (HCl). Whenever a hydrogen ion is excreted, a
bicarbonate ion is gained in the extracellular space.
 Sodium bicarbonate overdose. Administration of
sodium bicarbonate in amounts that exceed the capacity
of the kidneys to excrete this excess bicarbonate may
cause metabolic alkalosis.
 Hypokalemia. Due to a low extracellular potassium
concentration, potassium shifts out of the cells. In order
to maintain electrical neutrality, hydrogen shifts into the
cells, raising blood pH.
 Nasogastric suction. Just like in vomiting, nasogastric
(NG) suction also generates metabolic alkalosis by the
loss of gastric secretions, which are rich in hydrochloric
acid (HCl).
Signs and Symptoms
 Numbness
 Vomiting
 Diarrhea
 Swelling in the lower legs (peripheral edema)
 Fatigue
 Tingling sensation
 Agitation
 Disorientation
 Seizures
 Coma
Management of Metabolic Alkalosis
 Antiemetic. In the case of vomiting, administer
antiemetics, if possible.
 Ammonium chloride. Ammonium chloride is a
systemic and urinary acidifying agent that is converted to
ammonia and hydrochloric acid through oxidation by the
 liver. Intravenous (IV) ammonium chloride is a treatment
option for severe cases of metabolic alkalosis.
 Acetazolamide (Diamox). Acetazolamide also appears
to be safe and effective in patients with metabolic
alkalosis following treatment of respiratory acidosis from
exacerbations of chronic obstructive pulmonary disease
(COPD).
COMMON COLD (NASOPHARYNGITIS,
RHINOPHARYNGITIS, viral rhinitis )
 Most frequent viral infection in the general population
 It is self limited and caused by virus
 Definition – it is an acute inflammation of the mucous
membranes of the nasal cavity characterized by nasal
congestion, rhinorrhea, sneezing, sore throat and general
malaise
Causes:
 Rhinovirus
 Influenza virus
 Corona virus
 Adenoviruses
 Respiratory syncytial virus
 Entero virus
 Transmission – airborne droplets, direct contact with
infected nasal secretions.
 Weather – prolonged exposure to cold weather
 Upper Respiratory tract infections
 Poor immunity
 Malnutrition
 Often headache and muscle aches
 If illness progress, cough usually appears (influenza flu)
 Symptoms last for 1 to 2 weeks
Medical management
 Self limiting
 Symptomatic therapy
 Adequate fluid intake, rest, prevention of chills and use
of expectorants
 Warm salt water gargles soothe the sore throat
 NSAIDS – aspirin or ibuprofen to relieve aches and
pains
 Antihistamines – to relieve sneezing, rhinorrhea and
nasal congestion.
 Guaifenesin – expectorant, promote removal of
secretions
 Antiviral medications – amantadine, rimatadine –
reduce the severity of the symptoms and reduce the
duration of the common cold
 Topical nasal decongestants (phenyelphrine nasal,
oxymetazoline nasal)
 Herbal medicines – echinacea, zinc nasal spray
 Inhalation of steam – home remedies
Nursing management
Teaching patients self care
 Viruses transmitted through several ways – direct contact
with infected secretions, during coughing and sneezing,
 Hand washing – effective measure
 Importance of being hygiene
 Importance of vaccination
 Awareness programme in day care centers, schools and
community based.

Pathophysiology
 Direct contact
 Virus can stay in the unhygienic hands for hours
 Enter into naso pharynx
 Binds to ICAM-1 (Intercellular Adhesion Molecule 1)
protein (protein present in leukocytes)
 Through unknown mechanism trigger inflammatory
mediators
 Signs and Symptoms

Clinical manifestations
 Low grade fever
 Nasal congestion
 Rhinorrhea
 Nasal discharge
 Halitosis
 Sneezing
 Tearing watery eyes
 Scratchy or sore throat
 General malaise
 Chills
  Group A beta hemolytic streptococcus (GAS)
 Most common bacterial cause.
 Fever, sore throat and large lymph nodes are the
symptoms
 Contagious - infection spread by close contact

Fungal causes
Candida albicans – oral thrush
Non infectious
 Chemical irritation – smoking
 Thermal irritation
 Head and neck neoplasm
PHARYNGITIS  Allergies, allergic rhinitis
Definition – inflammation of the
 Gastroesophageal reflux disease
pharynx or pharyngeal wall
characterized by pain over
Signs and symptoms
pharynx (sore throat)
 Sore throat, dry or scratchy throat
Classification –
 Acute and  Sneezing
 chronic pharyngitis  Runny nose
 Headache
Acute pharyngitis  Fatigue
 It is of sudden onset  Body aches
 Short duration  Chills
 It may be purulent or ulcerative  Fever

Chronic pharyngitis Strep throat can cause

 Gradual onset  Trouble swallowing
 Long duration of symptoms  Red throat with white
 Due to persistent inflammation of the pharynx patches
 Swollen lymph nodes
Chronic pharyngitis are of 3 types  Fever
 Hypertrophic – characterized by general thickening and  Chills
congestion of the pharyngeal mucous membrane  Loss of appetite and nausea
 Atrophic – the membrane is thin, whitish, glistening  Unusual taste in mouth
 Granular – characterized by numerous swollen lymph  General malaise
follicles on the pharyngeal wall
Diagnostic measures
If tonsillitis involves it is termed as pharyngotonsillitis.  History collections
 Physical examination
Causes:  Throat swab – culture
Majority of cases are due to an infectious organism acquired from  Blood tests – CBC
contact with an infected individual  RSAT – rapid streptococcal
Infectious causes antigen test
 Viral (40-80%)
 Adenovirus – lymph node enlargement will be there and
severe throat pain
 Influenza – rapid onset of high temperature, headache
and sore throat
 Epstein barr virus (mononucleosis) – marked redness and
swelling and exudative tonsillitis Management
 Herpes simplex virus – mouth ulcers  Sympto
 Measles, Rhinovirus, coronavirus, RSV and HIV. matic
treatment
BACTERIAL  Analgesics – acetaminophen and NSAIDS
 GROUP A streptococcus (GAS)  Steroids (dexamethasone)
 Streptococcus pneumoniae  acetaminophen – relieves pain
 Haemophilus influenzae  Antibiotics – for bacterial infection
 Bordetella pertusis  Antiviral – for viral infection
 Cornybacterium diphtheriae  Antifungal – imidazole, triazole, thiazole
 Arcanobacterium haemolyticum
Complications
Streptococcal pharyngitis or strep throat  Ear infection
  Sinusitis
 Abscess near the tonsils
 Rheumatic fever if strep throat is not treated
 Glomerulonephritis
 Scarlet fever

Home care
 Drinking plenty of fluids
 Lemon tea or tea with
honey
 Fluid food rather than
solid
 Gargling with warm salt water
 Using throat lozenges
 Using humidifier
 Proper rest
 Acetaminophen if needed to decrease pain

Prevention
 Avoid sharing food, drinks and eating utensils
 Hand washing after coughing or sneezing
 Use alcohol based hand sanitizers
 Avoid smoking
  Dyspnea (difficulty in breathing), predominantly in
children
 Dry, burning throat
 Dry irritating paroxysmal cough.
 Cold or flu-like symptoms
 Swollen lymph nodes in the throat, chest, or face
LARYNGITIS  Hemoptysis (coughing out blood)
It is the inflammation of larynx leading  Increased production of saliva.
to oedema of laryngeal mucosa and  Signs of acute URTI.
underlying structures.
 Dry thick sticky secretions.
 Dusky red and swollen vocal cords.
ETIOLOGY
INFECTIOUS:  congestion of laryngeal mucosa.
 Viral laryngitis can be caused
TREATMENT
by rhinovirus, influenza
SUPPORTIVE
virus, parainfluenza
 Voice rest.
virus, adenovirus, coronavirus,
 Steam inhalation.
and RSV.
 Cough suppressants.
 Bacterial laryngitis can be caused by group A
 Avoid smoking and cold climet.
streptococcus, streptococcus pneumoniae, C.
 Fluid intake.
diphtheriae, M. catarrhalis,haemophilus
influenzae, bordetella pertussis, and M. tuberculosis. DEFINITIVE
 Fungal laryngitis can be caused by Histoplasma,  If laryngitis due to gastroesophageal reflux, an H2-
Candida (especially in immunocompromised persons) inhibitor (ranitidine) or proton-pump inhibitor
(omeprazole) is used to reduce gastric acid secretions.
NON INFECTIOUS  If laryngitis is caused by thermal or chemical burns,
 Inhaled fumes steroids are used.
 Acid reflux disease  In viral laryngitis, drinking sufficient fluids will be
 Allergies helpful.
 Excessive coughing, smoking, or alcohol consumption.  If laryngitis is due to a bacterial or fungal infection,
 Inflammation due to overuse of the vocal cords appropriate antibiotic or antifungal therapy is given.
 Prolonged use of inhaled corticosteroids for asthma
treatment To improve vocal hygiene
 Thermal or chemical burns  Drinking lot of fluids - Drink 7-9 glasses of water per
 Laryngeal trauma, including iatrogenic one caused by day; herbal tea and chicken soup also provides soothing
endotracheal intubation effect.
 Maintaining good general health - Exercise regularly.
Predisposing factors  Avoiding smoking - They are bad for the heart, lungs
 Smoking and vocal tract.
 Psychological strain  Eating a balanced diet - Include vegetables, fruits and
 Physical stress whole grain foods.
 Acid reflux  Avoid dry, artificial interior climates.
 Frequent sinus infectionsr  Do not eat late at night - may have problems when
stomach acid backs up on the vocal cords.
 Types – acute (less then 3 weeks)and chronic (more than  Use a humidifier to assist with hydration.
3 weeks )

Pathophysiology
 Due to etiological factors
 The mucosa of the larynx becomes congested and may
become oedematous.
 A fibrinous exudate may occur on the surface.
 Signs and symptoms
 Sometimes infection involves the perichondrium of
laryngeal cartilages producing perichondritiis.

CLINICAL FEATURES
 Husky, high pitched voice.
 Body aches, Fever, Malaise.
 Dysphonia (hoarseness) or aphonia (inability to speak)
 Dysphagia (difficulty in swallowing)
 Follicular tonsillitis
 It is an inflammation of the
tonsils and their crypts. The
onset is sudden and the tonsils
will appear red, white pus
spots over the swollen tonsils

TONSILS Catarrhal tonsillitis

 When tonsils are inflamed as
 Tonsils are large part of the generalised
lymphoid tissue infection of the oropharyngeal
situated in the mucosa it is called catarrhal
lateral wall of the tonsillitis.
oropharynx.
 4 types of tonsil – Membranous tonsillitis
tubal, palatine,  Some times exudation
pharyngeal and from crypts may coalesce
lingual tonsils. to form a membrane over
 Tonsils have small the surface of tonsil,
pockets over the giving rise to membranous
surface is called as tonsillitis.
CRYPTS.
Parenchymatous tonsillitis
Tonsillitis – inflammation of  When the whole tonsil is
the tonsils most commonly uniformly congested and
caused by viral or bacterial swollen it is called acute
infection parenchymatous
tonsillitis
Causes
Viral infection – most COMPLICATIONS
common cause  Peri tonsillar Abscess or
 Adenovirus quincy
 Rhinovirus  Para Pharyngeal Abscess
 Influenza  SOM
 Coronavirus  Acute nephritis
 Respiratory syncytial virus  RHEUMATIC Fever
 Epstein barr virus, HSV, HIV  Laryngeal edema
 Septicemia
Bacterial infection  Bacterial endocarditis
 Streptococcus
 Stap. Aureus Signs and symptoms
 Strep pneumoniae  Discomfort in throat
 Sore throat
Pathophysiology  Difficulty in swallowing
 Due to etiological factors  Generalized body ache
 The process of inflammation originate within the tonsil  Fever
 hyperemia and oedema with conversion of lymphoid  Earache and Thick speech
follicles in to small abscesses which discharge into  Swollen congested tonsils with white pus filled spots
crypts.  Halitosis
 Clinical features  Chills
 When inflammatory exudate collects in tonsillar  Sometimes yellowish exudate from crypts
crypts these present as multiple white spots on inflamed
tonsillar surface giving rise of follicular tonsillitis. Diagnosis
 History collection
Classification / types  Physical examination
 Acute  Throat swabs
 Chronic  RSAT – rapid streptococcal antigen test
 Bacterial  Monospot test – a blood test can detect certain
 Viral – resolve within one week. antibodies, which can help confirm that a person
 Follicular symptoms are due to mononucleosis.
 Catarrhal  CBC
 Membraneous
 Parenchymatous tonsillitis Management
  Analgesics – to reduce pain  Avoid hard, scratchy foods
 Sore throat relief measures  Report signs of bleeding
 Antibiotics – penicillin or amoxicillin  Expect stool to be black or dark for a few days due to
 If viral origin – complete recovery is made within one swallowed blood
week. In chronic cases surgery will do.  Résumé normal activity immediately
 Home mgt

TONSILLECTOMY
 Removal of the inflamed tonsil
Methods
1. Dissection and snare method – removal
of the tonsil by use of a forceps and snare
scissors. The tonsils are completely
removed and the remaining tissue is
cauterized. There will be minimal post
operative bleeding

 Electrocautery – it uses electrical

energy to separate the tonsillar
tissue and assists in
reducing blood loss
through cauterization.
 But thermal injury to
surrounding tissue is
common
 Radiofrequency
ablation –
radiofrequency energy
is used to the tonsil
tissue through probes to remove the tonsil
 Coblation tonsillectomy – it combines radiofrequency
energy with the use of ionized sodium molecules to
ablate tissues
 Harmonic scalpel – it uses ultrasonic energy to vibrate
the blade.
 Laser assisted serial tonsillectomy (LAST)
 Microdebrider – powered rotary shaving device with
continuous suction

Care of a patient after tonsillectomy

 Position patient on side until fully awake after general
anesthesia or in mid – fowlers position when awake
 Monitor for signs of hemorrhage: frequent swallowing
(inspect throat), bright red vomitus, rapid pulse,
restlessness
 Promote comfort: apply ice collar to neck (reduce the
bleeding by vasoconstriction), use acetaminophen

Give appropriate food and fluids

 Give ice –cold fluids and bland foods during initial
period (ex- ice chips, frozen juice bars)
 Milk is usually not given because it may increase mucus
and cause patient to clear throat.
 Never give dark colored or red colored juices or fluids –
because if vomitus contain blood it will be difficult to
identify.

Instruct patient to:

 Avoid attempting to clear throat immediately after
surgery (may initiate bleeding)
 Avoid coughing, sneezing, vigorous nose blowing, and
vigorous exercise for 1-2 weeks
 Drink lots of fluids (2-3L/day).
  Cough with or without sputum production
 Intercostal retractions
 pulling in of the skin between the ribs when breathing
 Shortness of breath that gets worse with exercise
or activity
 Wheezing
 Comes in episodes
 May be worse at night or in early morning
ASTHMA  May go away on its own
An inflammatory  Gets better when using bronchodilators
disorder of the  Gets worse when breathing in cold air
airways, which  Gets worse with exercise
causes attacks of  Gets worse with heartburn (reflux)
wheezing,  Usually begins suddenly
shortness of breath,
chest tightness, and Emergency symptoms:
coughing.  Cyanosis to the lips and face (central)
 Decreased level of alertness such as severe drowsiness or
Causes: confusion, during an asthma attack
The  Extreme difficulty of breathing
Allergic Response  Rapid pulse
(Allergens)  Severe anxiety due to shortness of breath
 dust mites
 Sweating
 animal dander
 molds
Additional symptoms that may be associated with this disease:
 cockroaches
1. Abnormal breathing pattern
 pollens
 breathing out takes more than twice as long as breathing
in
Environmental Factors
2. Breathing temporarily stops
(irritants)
3. Chest pain
 Cigarrete
4. Nasal flaring
smoke/air pollution
5. Tightness in the chest
 Indoor chemicals
 Infections
ASTHMA CLASSIFICATION ACCORDING TO THE
 Intrinsic factors
FREQUENCY OF SYMPTOMS
 emotional upset
 stress

Diagnostic Examinations:
 Chest X- ray
 White cell counts:
 eosinophil
 IgE
 Lung function test
 Peak flow
measurement
 ABGs Medical Management
Goal:
Peak Flow Monitoring  Avoid the substances that trigger symptoms
 Peak flow meters. Peak flow meters measure the highest  Control airway inflammation
airflow during a forced expiration.
 Daily peak flow monitoring. This is recommended for Medications:
patients who meet one or more of the following criteria:  Long-term control medications:
have moderate or severe persistent asthma, have poor  used on a regular basis to prevent attacks, not to
perception of changes in airflow or worsening symptoms, treat them
have unexplained response to environmental  Inhaled corticosteroids (such as Azmacort,
or occupational exposures, or at the discretion of the Vanceril, AeroBid, Flovent)
clinician or patient.  Leukotriene inhibitors (such as Singulair and Accolate)
 Function. If peak flow monitoring is used, it helps  Long-acting bronchodilators (such as Serevent)
measure asthma severity and, when added to symptom help open airways
monitoring, indicates the current  Omilizumab (Xolair)
degree of asthma control.  which blocks a pathway that the immune system uses to
trigger asthma symptoms
Clinical Manifestations:  Cromolyn sodium (Intal) or nedocromil sodium (Tilade)
  Aminophylline or theophylline (not used as frequently as 3. Monitoring the client for side effects of
in the past) administered medications
 Sometimes a single medication that combines steroids 4. Monitoring the client's arterial blood gases as
and bronchodilators are used (Advair, Symbicort) an indication of improvement or deterioration
 Quick relief, or rescue medications:
 are used to relieve symptoms during an attack
 Short-acting bronchodilators (inhalers) such as Proventil,
Ventolin, Xopenex, and others Discharge Instructions:
 Corticosteroids, such as methylprednisolone, may 1. The need to identify and eliminate any actual or
be given intravenously, during a severe attack, potential allergen, substance or condition that could
along with other inhaled medications precipitate an asthma attack.
2. The need to permit no smoking around the client.
Possible Complications 3. The need to report frequent use of rapid
 Death acting bronchodilators.
 Decreased ability to exercise and take part in other 4. The need to take long term medication as prescribed
activities even when there are no asthma attacks.
 Lack of sleep due to nighttime symptoms 5. How to use an inhaler
 Permanent changes in the function of the lungs and a spacer.
 Persistent cough 6. How to use a peak flow
meter and the
 Trouble breathing that requires breathing assistance
significance of the
(ventilator)
readings.
7. Assisting the family to
Nursing Management
create an asthma
Nursing Assessment
management
Assessment of a patient with asthma includes the following:
and emergency plan.
 Assess the patient’s respiratory status by monitoring
8. When to contact a
the severity of the symptoms.
healthcare provider or
 Assess for breath sounds. seek emergency services.
 Assess the patient’s peak flow.
 Assess the level of oxygen saturation through the
pulse oximeter.
 Monitor the patient’s vital signs.

Nursing Diagnosis
 Based on the data gathered, the nursing diagnoses
appropriate for the patient with asthma include:
 Ineffective airway clearance related to increased
production of mucus and bronchospasm.
 Impaired gas exchange related to altered delivery of
inspired O2.
 Anxiety related to perceived threat of death.

Nursing Care Planning & Goals

 To achieve success in the treatment of a patient with
asthma, the following goals should be applied:
 Maintenance of airway patency.
 Expectoration of secretions.
 Demonstration of absence/reduction of congestion with
breath sounds clear, respirations noiseless, improved
oxygen exchange.
 Verbalization of understanding of causes and
therapeutic management regimen.
 Demonstration of behaviors to improve or maintain clear
airway.
 Identification of potential complications and how to
initiate appropriate preventive or corrective actions.

Nursing Interventions include:

1. Removing any potential allergen or trigger from
the child's environment like flowers or perfumes
2. Maintaining a quite calm environment to reduce
anxiety and promote normal respiratory rate
 PNEUMONIA  inhalation of toxic chemicals causing inflammation and
An acute infection of the lungs tissue damage
that occurs when infectious agent  Example
enters and multiplies in the lungs  Pneumonoultramicroscopicsilicovolcanoconiosis
of a susceptible person  Inhalation of silica dusts from volcanic ashes

Etiology: Complications:
Bacterial Pneumonia  Most common:
 common cause of CAP is  Pleurisy
Streptococcus  Pleural effusion
 pneumoniae  generally, resolve within 1-2
 also called pneumococcal pneumonia weeks
 accounts for 90% of all bacterial pneumonia  Atelectasis
 other causes:
 Staphylococcus aureus Diagnostic Tests
 Mycoplasma pneumoniae  CXR examination
 Hospital-acquired pneumoniae (HAP) are more often  Sputum and blood culture
more often serious
 causes: Management:
 Escherichia coli  Broad-spectrum antibiotics
 Haemophilus influenzae before culture results are
 Pseudomonas aeruginosa completed
 For viral: rest and fluids
Viral Pneumonia  Expectorants
 most common cause are  Bronchodilators
influenza viruses patients  Analgesics
will viral pneumonia are
less ill than with bacterial Nursing Management
but they are ill for a 1. Assess respiratory symptoms. Symptoms of fever,
longer period of time chills, or night sweats in a patient should be reported
because antibiotic is ineffective to virus immediately to the nurse as these can be signs of
bacterial pneumonia.
Fungal Pneumonia 2. Assess clinical manifestations. Respiratory assessment
 causes: should further identify clinical manifestations such as
 Candida pleuritic pain, bradycardia, tachypnea, and fatigue, use of
 Aspergillus accessory muscles for breathing, coughing, and purulent
 Pneumocystis carinii sputum.
 a fungus that typically causes pneumonia in patients with 3. Physical assessment. Assess the changes in temperature
AIDS and pulse; amount, odor, and color of secretions;
frequency and severity of cough; degree of tachypnea or
Aspiration Pneumonia shortness of breath; and changes in the chest x-ray
 most often occurs in patients with decreased levels of findings.
consciousness or an impaired cough or gag reflex 4. Assessment in elderly patients. Assess elderly patients
 can occur with: for altered mental status, dehydration, unusual behavior,
 alcohol ingestion excessive fatigue, and concomitant heart failure.
 stroke
Diagnosis
 general anesthesia
1. Ineffective airway clearance related to copious
 seizures/other serious illnesses tracheobronchial secretions.
2. Activity intolerance related to impaired respiratory
Ventilator-Associated Pneumonia (VAP) function.
 develops in the patients who are intubated and 3. Risk for deficient fluid volume related to fever and a
mechanically ventilated rapid respiratory rate.
 Endotracheal tube keeps the glottis open allowing
secretions to be aspirated into the lungs Nursing Care Planning & Goals
1. Improve airway patency.
Hypostatic Pneumonia 2. Rest to conserve energy.
 occurs to patient who hypoventilate because of bedrest, 3. Maintenance of proper fluid volume.
immobility, or shallow respiration 4. Maintenance of adequate nutrition.
 secretion pools in dependent areas of the lungs 5. Understanding of treatment protocol and preventive
 inflammation of lung parynchema and infection measures.
6. Absence of complications.

Chemical Pneumonia
Nursing Priorities 2. Breathing exercises. Teach the patient breathing
1. Maintain/improve respiratory function. exercises to promote secretion clearance and volume
2. Prevent complications. expansion.
3. Support recuperative process. 3. Follow-up check up. Strict compliance to follow-up
4. Provide information about disease process, prognosis, checkups is important to check the latest chest x-ray
and treatment. result or physical examination findings.
4. Smoking cessation. Smoking should be stopped because
Nursing Interventions it inhibits tracheobronchial ciliary action and irritates the
To improve airway patency: mucous cells of the bronchi.
1. Removal of secretions. Secretions should be removed
because retained secretions interfere with gas exchange
and may slow recovery.
2. Adequate hydration of 2 to 3 liters per day thins and
loosens pulmonary secretions.
3. Humidification may loosen secretions and improve
ventilation.
4. Coughing exercises. An effective, directed cough can
also improve airway patency.
5. Chest physiotherapy. Chest physiotherapy is important
because it loosens and mobilizes secretions.

To promote rest and conserve energy:

1. Encourage avoidance of overexertion and possible
exacerbation of symptoms.
2. Semi-Fowler’s position. The patient should assume a
comfortable position to promote rest and breathing and
should change positions frequently to enhance secretion
clearance and pulmonary ventilation and perfusion.

To promote fluid intake:

 Fluid intake. Increase in fluid intake to at least 2L per
day to replace insensible fluid losses.

To maintain nutrition:
 Fluids with electrolytes. This may help provide fluid,
calories, and electrolytes.
 Nutrition-enriched beverages. Nutritionally enhanced
drinks and shakes can also help restore proper nutrition.

To promote patient’s knowledge:

1. Instruct patient and family about the cause of pneumonia,
management of symptoms, signs, and symptoms, and the
need for follow-up.
2. Instruct patient about the factors that may have
contributed to the development of the disease.

Evaluation
1. Expected patient outcomes include the following:
2. Demonstrates improved airway patency.
3. Rests and conserves energy by limiting activities and
remaining in bed while symptomatic and then slowly
increasing activities.
4. Maintains adequate hydration.
5. Consumes adequate dietary intake.
6. States explanation for management strategies.
7. Complies with management strategies.
8. Exhibits no complications.
9. Complies with treatment protocol and prevention
strategies.

Discharge and Home Care Guidelines

1. Oral antibiotics. Teach the patient about the proper
administration, potential side effects, and symptoms to
report.
  S/S, Dx, medical management, and nursing intervention
PLEURAL EFFUSION are the same as the care of patient with pleural effusion
 Collection of fluid in
pleural space Pathophysiology
 Almost secondary to Stage 1: Simple (the
other diseases exudative phase)
The first stage of empyema is
 Increase pleural fluid called simple empyema. It
production or occurs when extra fluid
inadequate fluid
reabsorption
 Collection of fluid in the
pleural cavity begins to build up in the pleural
 Prevents maximum cavity. This fluid can become
expansion of the lung infected and may contain pus.
Stage 2: Complicated (the
Etiology: fibrinopurulent phase)
Complication of: In complicated empyema, the fluid in the pleural cavity begins to
 Disseminated cancer (lung, thicken and form “pockets.”
breast), lymphoma
 Pleuropulmonary infection (pneumonia) Stage 3: Frank (the organizing phase)
 CHF, liver cirrhosis, nephrosis Finally, the infected fluid causes scarring to the inner layers that
 Others: line the pleural cavity in the lungs. This causes difficulty
 sarcoidosis breathing as it stops the lungs from inflating properly.
 SLE
Risk Factors
 peritoneal dialysis
 pneumonia
Clinical Manifestations:  bronchiectasis
 May or may not have pleuritic pain  chronic obstructive pulmonary disease (COPD)
 Increasing SOB (🡻 lung expansion)  rheumatoid arthritis
 Cough and tachypnea  alcoholism
 Dullness over the affected area upon percussion  diabetes
 Decrease or absent of breath sounds over the effusion  a weakened immune system
 Pleural friction rub may be auscultated  surgery or recent trauma
 lung abscess
Diagnostic Evaluations:
 Chest examination Symptoms
 dullness (percussion) Simple empyema
Simple empyema occurs in the early stages of the illness. A
 (-) breath sounds
person has this type if the pus is free-flowing. The symptoms of
 CXR
simple empyema include:
 Thoracentesis (diagnostic)  shortness of breath
 biochemical  dry cough
 bacteriologic  fever
 cytologic exam  sweating
 chest pain when breathing that may be described as
Management: stabbing
 Bed rest is recommended to  headache
enhance spontaneous  confusion
resolution of the effusion  loss of appetite
 Therapeutic thoracentesis if
effusion is severe Complex empyema
 Chest tube insertion  Complex empyema occurs in the later stage of the
(thoracostomy) illness. In complex empyema, the inflammation is more
 Treatment of the primary severe. Scar tissue may form and divide the chest cavity
underlying disease into smaller cavities. This is called loculation, and it’s
more difficult to treat.
Empyema  If the infection continues to get worse, it can lead to the
 The collection of pus in the formation of a thick peel over the pleura, called a pleural
pleural space peel. This peel prevents the lung from expanding.
 It is a pleural effusion that is Surgery is required to fix it.
infected
 Usually a complication of Other symptoms in complex empyema include:
pneumonia, PTB, lung abscess  difficulty breathing
  decreased breath sounds  There are no specific criteria to decide when surgery is
 weight loss necessary for empyema. One study found that those with
 chest pain symptoms lasting less than 4 weeks had better surgery
results than people who had symptoms lasting more than
Complications 4 weeks.
In rare instances, a case of complex empyema can lead to more
severe complications. These include sepsis and a collapsed lung, Fibrinolytic therapy
also called a pneumothorax. The symptoms of sepsis include:  A doctor may also recommend fibrinolytic therapy,
 high fever which uses drugs known as fibrinolytic agents. The
 chills therapy helps to drain pleural fluid, and doctors may use
 rapid breathing it in combination with a tube thoracostomy.
 fast heart rate  A 2018 study assessing the effectiveness of VATS
 low blood pressure surgery in comparison to fibrinolytic therapy after tube
A collapsed lung can cause sudden, sharp chest pain and shortness thoracostomy found that both methods are highly
of breath that gets worse when coughing or breathing. effective.

Diagnosing Empyema Nursing Diagnosis

 Complete medical history and physical examination
 Chest X-rays and CT scans will show whether or not
there’s fluid in the pleural space.
 An ultrasound of the chest will show the amount of
fluid and its exact location.
 Blood tests can help check your white blood cell count,
look for the C-reactive protein, and identify the bacteria
causing the infection. White cell count can be elevated
when you have an infection.
 During a thoracentesis, a needle is inserted through the
back of your ribcage into the pleural space to take a
sample of fluid. The fluid is then analyzed under a
microscope to look for bacteria, protein, and other cells.
 Ineffective airway clearance related to bronchospasm,
increased production of secretions, weakness
 Impaired Gas Exchange related to airway obstruction
secondary to the buildup of secretions, Bronchospasme
 Imbalanced Nutrition : Less Than Body
Requirements related to Shortness of breath, anorexia,
nausea, vomiting, drug effects, weakness.
 Pain related to the process of infection in the lung

Treatment
Antibiotics
 Doctors usually prescribe antibiotics as the first
treatment for simple cases of empyema. Because
different strains of bacteria cause empyema, finding the
right antibiotic is crucial.
 Antibiotic treatment typically takes 2 to 6 weeks to work.

Drainage
 Draining the fluid is essential to prevent simple
empyema progressing to complicated or frank empyema.
It also helps keep the condition under control.
 To drain the fluid, a doctor performs a tube
thoracostomy, which involves inserting an ultrasound or
computer-guided tube into the chest cavity and removing
the liquid from the pleural space.

Surgery
 For advanced cases of empyema, surgery may be the best
treatment option. One study found that a surgery called
decortication yielded better results than tube drainage in
people with advanced empyema.
 Decortication involves removing the pus “pockets” and
fibrous tissue from the pleural space, which helps the
lungs expand properly.
 There are two types of surgeries available. In most cases
a surgeon will perform a video-assisted thoracotomy CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(VATS). This procedure is less invasive, less painful, (COPD)/ CHRONIC AIRWAY LIMITATION (CAL)
and has a shorter recovery time than an open-  A group of pulmonary disorders characterized by
thoracotomy, which requires a surgeon to open the chest. difficulty exhaling because of airways that are narrowed
 In some cases, however, a surgeon will perform an open- or blocked by inflammation and mucus
thoracotomy.
Classification
  There are two classifications of COPD: chronic
bronchitis and emphysema. These two types of COPD Management:
can be sometimes confusing because there are patients Goal:
who have overlapping signs and symptoms of these two  Reverse the airflow obstruction
distinct disease processes.  Bronchodilators: ipratropium bromide
 Metered-dose inhalation of beta-adrenergic agonist or
atropine-like agent
 Pulmonary rehabilitation to reduce symptoms that limit
activity

Health Maintenance and Prevention

 Smoking must be stopped, as this is the most frequent
cause
 Avoid all respiratory irritants
 Acute respiratory infections should be treated

PULMONARY EMPHYSEMA
Causes of COPD/CAL (Emphysema-Bronchitis Complex) A complex lung disease
 Cigarette smoking characterized by:
 Air pollution  destruction of alveoli
 Occupational exposure  enlargement of distal air
 Allergy spaces
 Autoimmunity  breakdown of alveolar wall
 Infection  There is a slowly
 Genetic predisposition progressive deterioration of
 Aging lung function for many
years before the development of illness
Chronic Bronchitis
 A chronic infection of the Classifcation:
lower respiratory tract Panacinar (or panlobular)
characterized by excessive  Emphysema is related to
mucus secretion, cough, the destruction of alveoli,
and dyspnea associated because of an
with recurring infection of inflammation or
the lower respiratory tract deficiency of alpha 1-
antitrypsin
 Infection/irritation/
 It is found more in young
hypersensitivity
adults who do not have
 local hyperemia
 hypertrophy of the mucus chronic bronchitis.
glands
 increase in size and Centroacinar (or centrilobular)
number of mucus-  Emphysema is due to destruction of terminal bronchiole
producing elements in muchosis, due to chronic bronchitis.
bronchi (mucous glands &  This is found mostly in elderly people with a long history
goblet cells) of smoking or extreme cases of passive smoking.
 Inflammation and edema
 narrowing and obstruction of Causes:
airflow  Cigarette smoking
 Alpha-1-antitrypsin deficiency
 a substance that fights a destructive enzyme in the lungs
called trypsin
Clinical Manifestations:  Air pollution
Usually insidious, developing over a period of years:  Genetic predisposition
 Presence of a productive cough lasting at least 3 months  Abnormal airway reactivity (asthma)
a year for 2 successive years  Gender (men > women)
 Production of thick, gelatinous sputum:  Old age
 greater amounts produced during superimposed
infections
 Wheezing and dyspnea as disease progresses

Diagnostic Evaluations:
 Pulmonary function test
 Arterial blood gases (ABGs)
Emphysema Symptoms:  Impaired gas exchange related to chronic inhalation of
1. Shortness of breath is the most common symptom of toxins.
emphysema.  Ineffective airway clearance related to
2. Cough, sometimes caused by the production of mucus bronchoconstriction, increased mucus production,
3. wheezing ineffective cough, and other complications.
4. tolerance for exercise decreases over time  Ineffective breathing pattern related to shortness of
5. One of the hallmark signs of breath, mucus, bronchoconstriction, and airway irritants.
emphysema is "purse-lipped  Self-care deficit related to fatigue.
breathing.“  Activity intolerance related to hypoxemia and ineffective
6. Barrel chest breathing patterns.
Diagnostic Examinations Planning & Goals
 Chest x-ray  Improvement in gas exchange.
 Lung Function Test  Achievement of airway clearance.
 If with family history:  Improvement in breathing pattern.
 alpha-1-antitrypsin blood test  Independence in self-care activities.
 White cell count  Improvement in activity intolerance.
 ABG exam  Ventilation/oxygenation adequate to meet self-care
needs.
Management:  Nutritional intake meeting caloric needs.
 Smoking cessation  Infection treated/prevented.
 Ipratropium bromide  Disease process/prognosis and therapeutic regimen
(Atrovent) understood.
 long-acting bronchodilator  Plan in place to meet needs after discharge.
 Methylxanthines
(Theophylline) and other Nursing Interventions
 Bronchodilating To achieve airway clearance:
medications  The nurse must appropriately administer bronchodilators
 Steroid medications and corticosteroids and become alert for potential side
 Antibiotics effects.
 Oxygen therapy (low-flow)  Direct or controlled coughing. The nurse instructs the
 Chest physiotherapy patient in direct or controlled coughing, which is more
effective and reduces fatigue associated with undirected
Complications: forceful coughing.
 Respiratory failure
 Pneumonia; overwhelming To improve breathing pattern:
respiratory infection  Inspiratory muscle training. This may help improve the
 Right heart failure breathing pattern.
 Diaphragmatic breathing. Diaphragmatic breathing
Surgical Management reduces respiratory rate, increases alveolar ventilation,
 Bullectomy. Bullectomy is a surgical option for select and sometimes helps expel as much air as possible
patients with bullous emphysema and can help reduce during expiration.
dyspnea and improve lung function.  Pursed lip breathing. Pursed lip breathing helps slow
 Lung Volume Reduction Surgery. Lung volume expiration, prevents collapse of small airways, and
reduction surgery is a palliative surgery in patients with control the rate and depth of respiration.
homogenous disease or disease that is focused in one
area and not widespread throughout the lungs. To improve activity intolerance:
 Lung Transplantation. Lung transplantation is a viable  Manage daily activities. Daily activities must be paced
option for definitive surgical treatment of end-stage throughout the day and support devices can be also used
emphysema. to decrease energy expenditure.
 Exercise training. Exercise training can help strengthen
muscles of the upper and lower extremities and improve
Nursing Management exercise tolerance and endurance.
Nursing Assessment  Walking aids. Use of walking aids may be recommended
 Assess patient’s exposure to risk factors. to improve activity levels and ambulation.
 Assess the patient’s past and present medical history.
 Assess the signs and symptoms of COPD and their To monitor and manage potential complications:
severity.  Monitor cognitive changes. The nurse should monitor for
 Assess the patient’s knowledge of the disease. cognitive changes such as personality and behavior
 Assess the patient’s vital signs. changes and memory impairment.
 Assess breath sounds and pattern.  Monitor pulse oximetry values. Pulse oximetry values
are used to assess the patient’s need for oxygen and
Diagnosis administer supplemental oxygen as prescribed.
  Prevent infection. The nurse should encourage the patient
to be immunized against influenza and S. pneumonia
because the patient is prone to respiratory infection.

Discharge and Home Care Guidelines

 Setting goals. If the COPD is mild, the objectives of the
treatment are to increase exercise tolerance and prevent
further loss of pulmonary function, while if COPD is
severe, these objectives are to preserve current
pulmonary function and relieve symptoms as much as
possible.
 Temperature control. The nurse should instruct the
patient to avoid extremes of heat and cold because heat
increases the temperature and thereby raising oxygen
requirements and high altitudes increase hypoxemia.
 Activity moderation. The patient should adapt a
lifestyle of moderate activity and should avoid emotional
disturbances and stressful situations that might trigger a
coughing episode.
 Breathing retraining. The home care nurse must
provide the education and breathing retraining necessary
to optimize the patient’s functional status.

CHEST TRAUMA
PNEUMOTHORAX
Collection of free air in the chest
outside the lung that causes the
lung to collapse.

Causes:
Spontaneous pneumothorax:
 is caused by a rupture of
a cyst or a small sac
(bleb) on the surface of
the lung
 Symptoms:
Can also develop as a result of underlying lung diseases:  Chest pain
 cystic fibrosis  usually has a sudden onset, the pain is sharp and may
 COPD/CAL lead to feelings of tightness in the chest
 lung cancer  Shortness of breath
 asthma  Tachycardia
 infections of the lungs.  Tachypnea
 Cough
Traumatic Pneumothorax  Fatigue
 Occur as a result of knife  Cyanosis
or gun shot wound or
from protruding broken Diagnostic Examinations:
ribs
 Chest auscultation (absence of breath sounds)
 It allows air to enter the
 Chest percussion (hyperresonance)
pleural space
 Positive "coin test"
Open Pneumothorax  two coins when tapped on the affected side, produce a
tinkling resonant sound upon auscultation
 Occurs when air can
enter and escape through  Chest X-ray
the opening in the pleural
space Management:
 Small pneumothorax may be
Closed Pneumothorax with no treatment other than rest
 If air collects in the space and is unable to escape  Aspiration of air via needle
thoracentesis
Tension pneumothorax  Chest tube attached to a water
 the lung continues to seal drainage system are used to
leak air into the chest remove larger amount of air or
cavity and results in blood in the pleural space
compression of the chest  Small devices that have
structures, including special one-way valves to air
vessels that return blood to escape but not reenter may
to the heart be used patient treated at
home
 Pleurodesis (sclerosis) for
recurrent pneumothorax
 injecting sterile talc or
antibiotic (tetracycline) into
the pleural space to irritate
pleural membrane, making
them stick together

FLAIL CHEST
 When multiple ribs are
fractured, the structural
support of the chest is
impaired

 One portion of the chest has

lost its bony connection to
the rest of the rib cage
Hemothorax  During respiration, the
 Presence of blood in the pleural space detached part of the chest
 It can occur without or will be pulled in on
with accompanying inspiration and blown out
pneumothorax on expiration (paradoxical
(hemopneumothorax) movement)
 Often results from  Normal mechanics of
traumatic injury breathing impaired to a
 Other causes: degree that seriously
jeopardizes ventilation
 lung cancer
 pulmonary embolism
 anticoagulant use
  Generally associated with other serious chest injuries,  Combines the features of the other system and may or
lung contusion, lung laceration, diffuse alveolar damage may not be attached to suction
Ex:
Clinical Manifestations:  PleurEvac
 Pain
 Dyspnea Nursing Interventions:
 Cyanosis  Ensure that the tubing is not kinked; tape all connections
 Paradoxical movements of involved chest wall to prevent separation
 Gently milk the tube if specifically ordered in the
Management: direction of the drainage system to maintain patency;
 Stabilize the flail portion: milking can cause pneumothorax
 with hands  Maintain the drainage system below the level of the chest
 apply pressure dressing  Turn the client frequently, make sure that the chest tube
 turn patient on his injured side is not compressed
 place 10-pound sandbag at site  Report drainage on dressing immediately because it is
of flail not a normal occurrence
 Thoracic epidural analgesia  Observe fluctuation of the of fluid in tube
 Supplemental oxygen  level will rise upon inhalation; fall on exhalation
 Intubation and mechanical ventilation may be necessary  if there are no fluctuation: either the lung has fully
 Operative stabilization of chest wall in selected patient expanded or the chest tube is clogged
 Palpate the area around the chest tube insertion for
CHEST TUBES subcutaneous emphysema or crepitus
 Use of tubes and suction to  it indicates air is leaking into the subcutaneous tissue
return negative pressure to  Situate drainage bottle or PleurEvac to avoid breakage
intrapleural space  Place two clamps at bedside for use if the water-seal
 To drain air from bottle is broken
intrapleural space:  clamp the chest tube immediately to prevent air from
 chest tube is inserted in the entering the intrapleural space
2nd or 3rd ICS  Encourage coughing and deep breathing every 2 hours,
 To drain blood or fluid: splinting the area as needed
 catheter would be placed at  Instruct the client to exhale or strain as the tube is
lower site, usually the 8th or 9th withdrawn by the physician
ICS  apply a gauze dressing immediately and firmly secure
with tape to make airtight dressing
One-bottle Underwater (water seal)  Encourage movement of the arm on the affected area
System: ----- LORD TABANG
 Allows air or fluid to drain from
the pleural cavity by gravity via
glass rod which extends
approximately 2 cm below the
surface of the water within the
collection bottle

Two-bottle Drainage System:

 Involves one bottle that acts as
a collection chamber and
provides the water seal
 While a 2nd bottle to be
connected to a suction
apparatus
 The bubbling of the second
bottle indicates that the desired suction is maintained

Three-bottle System:
 Bottle 1 serves to collect
drainage
 Bottle 2 acts as the
water seal chamber
 Bottle 3 controls suction

Commercially prepared plastic unit

designed for close chest suction: