RESPI

MODULE 1: RESPIRATORY SYSTEM ANATOMY/STRUCTURES

UPPER Functions:
ANATOMY AND PHYSIOLOGY STRUCTURES RESPIRATORY ● Conduction of air to
AND FUNCTIONS (NOSE, PHARYNX, lower respiratory
LARYNX) tract
● Filters. It protects
LRT(lower respiratory
tract) from foreign
bodies e.g. dust.
● Warms- regardless of
the temperature
outside of the body.
Air is warmed to
body temperature
before it reaches the
lungs.
● Humidifies- moistens
BODY PORTION FORM FROM
air to about 70-80%
Germ level
humidity.
 Ectoderm- skin hair, nails, sebaceousgland,
LOWER FUNCTIONS:
sense organs, mouth, nose, tooth, enamel RESPIRATORY ● Ciliary body
and mammary glands TRACT ● Production of mucus
 Mesoderm- connective tissue, bones, (TRANCHAE,
● Conduction
cartilages, muscles, ligaments, tendons, MAINSTEM
BRONCHI,
dentin of teeth reproductive system,
SEGMENTAL
heart, BRONCHI,
Circulatory system, lymph SUBSEGMENTAL
 Endoderm-pleurae, peritoneal cavity, lower BRONCHI
bladder and urethra lining, GIT, respiratory tract, RESPIRATORY ● Actual exchange of
parathyroid gases (utilization of
oxygen and
VITAL FUNCTIONS OF RESPIRATORY SYSTEM elimination of carbon
1. Gas exchange (elimination of carbon dioxideand dioxide)
utilization of oxygen ● Macrophage
2. Regulation of acid-base balance ● Production of
surfactant
STRUCTURES AND FUNCTIONS OF
THE RESPIRATORY SYSTEM
- Respiratory System developed from the
fluid environment during the
intrauterine life.
- The first breath took place during
thefirst cry immediately after birth.

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 NOSE
● Olfactory – sense of smell, adjunct to taste
● Gives shape to the face
● 2 nostrils (alae nasae or nares) flaring
may signify difficulty of breathing

PARTS OF THE
NOSE:
A. Columnar epithelial cells- production of
mucus to humidify.
B. Turbinates – rich in blood supply, if injured
nose bleeding will occur(epistaxis).

PHARYNX
 Funnel shape. The pharynx, commonly called
the throat, is a passageway that extends from
the base of the skull to the level of the sixth
cervical vertebra. It serves both the respiratory
and digestive systems by receiving air from the
a. SEPTUM- division between vestibule nasal cavity and air, food, and water from the
(abnormal deviated septum, perforated oral cavity.
septum).
3 PARTS
b. Nasolacrimal glands – ears production
NASOPHARYNX ● Is the upper part of the
SINUSES: throat(pharynx) that
1 FRONTAL SINUS lies behind the nose.
2 ETHMOIDAL
It’s a box-like
2 SPHENOIDAL
2 MAXILLARY chamber about 1 ½
FUNCTIONS: inches on each edge. It
● Help in humidifying the air lies just above the soft
● Lighten the skull part of the roof of the
● Phonation – resonating chamber in mouth (soft palate)
speech and just in back of the
nasal passages.
● It contains adenoid
tissue, which fights

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 infections and the cavity diverges
opening to the anteriorly into the
Eustachian tubes, larynx and
which lead to the ears. posteriorly into the
It provides a major esophagus.
drainage path for
lymphatic fluids and LARYNX (VOICE BOX)
Located at the level of the 4th or 6th cervical spin
generally drains into 3
the throat, nose or CARTILAGES
ears. EPIGLOTTIS ● Closes when you
OROPHARYNX swallow thus aspiration
● The part of the throat
of food and water is
at the back of the
prevented to go to the
mouth behind the oral
lungs during drinking
cavity. It includes the
and eating.
back third of the
● Thyroid – adam’s apple
tongue, the soft palate,
the side and back walls CRICOID ● Where you create
of the throat and the tracheotomy or
tonsils. cricoid stab or
tracheostomy
TONSILS
tube insertion, narrow
(OROPHARYNGEAL)
● Palatine or facial in children
tonsils – sides of the
mouth
● Lingual tonsils – base
of the tongue
● WELDEYER’S RING-
composed of four
tonsils – pharyngeal,
tubal, palatine, lingual

TRACHEA (WIND PIPE)

● Made of 15-20 C- shape cartilages L-11.2 cm,
W- 2 to 2.2 cm.
● Carina – the bifurcation of the trachea
● Landmark for ET insertion
LARYNGOPHARY ● The laryngopharynx:
NX or the position is inferior to
HYPOPHARYNX the epiglottis and is
bordered by the
pharyngoepiglottic
fold superiorly and the
upper esophageal
sphincter inferiorly.
It refers to the
portion of the
pharynx where the

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  Composed the lung tissue, spongy
 24 thousand at birth
 8 years and older, it increases to 3 million
 Surface area- 750 to 860 sq.ft or the size
of tennis court. Above 70 square meters
or some – 40 times the surface area of the
entire body or TBSA.
 10% of oxygen supply consume by the
lungs
 Has NO PAIN RECEPTOR, no sensation
usually pain is referred to other area.
 Left lung – 8 segments, 2 lobes (Upper
and Lower lobe)
 Right lung – 10 segments, 3 lobes
(superior, middle and inferior
MAINSTEM ● Cartilaginous
lobe)
BRONCHI ● 2 mainstem bronchi
 Known as the gas exchanger
1.Left- narrow and
PARIENTAL  Covers the
longer,45-55 degree angle, PLEURA thoraciccavity
more horizontal, not
VISCERAL  Covers the outer
accident prone.
PLEURA surfaces of the lungs
2.Right-wider and
and adheres to them
shorter,20-30 degree angle,
much as the skin of
more vertical, accident
an
prone.
apple.
SEGMENTAL ● Cartilaginous
BRONCHI ● Serve to conduct air, do
not absorb gas
ACCESSORIES: MUSCLES
SUBSEGMENTA ● The smallest DIAPHRAGM Primary or main
L BRONCHI cartilaginous portion of
the conducting muscle of respiration.
structure. Nerve supply – phrenic
nerve.
RESIRATORY ZONES INTERCOSTAL a.Internal
- Forced expiration and
TERMINAL BRONCHOILE and ALVEOLAR
coughing muscles
DUCTS and sacs
- decreases the diameter
- Gas exchange starts here, made of
of the chest wall
muscular tube, can collapse.
b. External
- inspiration
- increases the diameter
of the chest wall
ECTORALIS Both increase the work of
MAJOR breathing.
AND MINOR
RECTUS Forced expiration and
ABDOMINIS coughing

At the end of the smallest bronchioles are

small, hollow sacs called alveoli. As blood
flows through the capillaries, oxygen moves
from the air, and carbon dioxide and water
pass out of the blood. This process is called
GAS EXCHANGE.

SCALENE  Stabilized the upper

ALVEOLI chest wall
 Elevates the 1st and

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 2nd ribs during
inspiration,
increases the size
of the thorax.

STERNOCLEIDO  Stabilizes upper

MASTOID chest wall. Assist in
elevating the rib cage
 Elevates sternum
PARASTERNAL Inspiratory muscle,
increases work of 2.STERNUM
breathing - Manubrium
TRAPEZIUS Inspiratory muscles - Body
- Xiphoid

SUMMARY
Muscles responsible for supraclavicular
retraction
- Sternocleidomastoid
- Scalene
- Trapezius
Inspiratory Muscles
- Parasternal
- Trapezius
- Pectoralis
- IC-external

Expiratory Muscles 3.SCAPULAE – 2

- IC-internal 4.CLAVICLES – 2
- Rectus Abdominis 5.VERTEBRA
- T1-T10 – true and false ribs
ACCESSORIES: BONES - T11-T12- floating rib
1. RIBS
- 12 pairs
- 7 pairs – true libs (attached directly
to sternum)
3 pairs – false ribs 8th,9th, and 10th ribs
(attached to one another by costalcartilages
but not directly to the sternum.)
3 pairs – floating ribs 11th and 12th ribs(not
attached to other ribs and sternum
-Allow full expansion of the chest
-Protect the kidneys

COMMON CONCEPTS

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 3. Cilia -hair like projections – columnar
epithelial cells – propels particles foreign
body(FB) to Oropharynx – coughed or
swallowed
4. Goblet Cells, lysosomes and other
elements to fight invading
bacteria
5. Cough reflex- protective mechanism
rapidly expels air and particles from
airway.
6. Sneeze reflex – cleans nasal passageway
7. Hering-Bruer reflex – prevents over
inflation of the alveoli
8. Alveolar Macrophages – phagocytize and
detoxify.
9. Reflex Bronchoconstriction – sudden
narrowing of the tracheobronchial tree
(TBT) preventing foreign bodies and
noxious substances to enter the system

OXYGENATION
 Respiratory Physiology: most cells in the
body obtain their energy from chemical
reactions involving oxygen and elimination
of carbon dioxide. The exchange of
respiratory gases occurs between
environmental air and the blood. There are
3 steps in the process of oxygenation:
VENTILATION, PERFUSION, and
MUSCLES of respiration must be intact and
the central nervous system able to regulate
the respiratory cycle.

DIFFUSION OR DALTON’S LAW

VENTILATION
 Ventilation is the process of moving gases into
and out of the lungs. Ventilation requires
coordination of the muscular and elastic
properties of the lung and thorax, and intact
innervation. The major inspiratory muscle of
respiration is the diaphragm. It is innervated by
the phrenic nerve – the spinal cord at the fourth
cervical vertebra.
 Diffusion is the movement of molecules from an
area of higher concentration. Diffusion of
respiratory gases occurs at the alveolar capillary
membrane, and the rate of diffusion can be
affected by the thickness of the membrane.
 Increased thickness of the membrane impedes
diffusion because gases take longer transfer
across. Patients with pulmonary edema,
pulmonary infiltrates or a pulmonary effusion
have an increased thickness of the alveolar
capillary membrane resulting in slowed diffusion,
slowed exchange of respiratory gases and impaired
delivery of oxygen to tissues.
 The surface area of the membrane can be altered
as a result of a chronic disease (emphysema), an
acute disease (e.g. Pneumothorax) or a surgical

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 process (e.g. lobectomy). When fewer alveoli are
functioning, the surface area is decreased.

FACTORS DETERMINE LUNG COMPLIANCE:

1. ELASTICITY OF THE LUNG TISSUE
– represents the mechanical properties of
the lungs. to be expanded or distended by
pressure surrounding or inflating the lungs
andto collapse as soon as the latter pressure
disappear.
2. SURFACE TENSION – force exerted by water
molecules on the surface of the lung tissue as
those water molecules pull together. This
occurs at the interface between the alveolar
membrane and the airway. Increase surface
 Breathing- is the effort required to expand and tension increase cohesion within the alveoli
contract the lungs. The work of breathing is closed.
determined by the degree of compliance of the
lunngs, airway resistance, presence of active AIRWAY Is the pressure
expiration and use of accessory muscle of RESISTANCE difference between
respiration the environment
 Compliance – is the ability of the lungs to distend and the alveoli in
or to expand in response to increased intra alveolar relation to the rate
pressure. Compliance is decreased in diseases of flow of inspired
such as pulmonary edema, intertitial and pleural gas. Increased by
fibrosis, congenital or traumatic structural an airway
abnormalities such as Kyphosis or fractured ribs, obstruction small
premature babies. airway disease
 Decreased Compliance – increased airway (such as asthma),
resistance, active expiration or use of accesssory and tracheal edema.
muscles increases the work of breathing, resulting When resistance is
in icnreased energy expenditure. To meet this increased the
expenditure, the body increased its metabolic rate amount of air
and need for oxygen, as well as the elimination of traveling through
carbon dioxide. This sequences is a vicious cycle the anatomical
for the client with impaired ventilation, causing airways is
further deterioration of respiratory status and decreased.
EXPIRATION Is normally a
ability to oxygenate adequately.
passive process
that depends on the
elastic recoil
properties and
requires little or no
muscle work.

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ELASTIC RECOIL Produced by elastic LUNG VOLUMES Normal lung
fibers in the lung volumes are
tissue and by measured through
surface tension in pulmonary
the fluid film lining function testing.
the alveoli. Spirometry
Advanced COPD measures the
lose the elastic volume of air
recoil of the lung entering or leaving
and thorax- work of the lungs.
breathing is Variations in lung
increased. volumes may be
PRESSURES Gases are moved associated with
into and out of the health states such
lungs through as pregnancy,
pressure changes. exercise, obesity or
Intrapleural obstructive and
pressure is negative restrictive
or less than condition of the
atmospheric lung. The amount
pressure. Which is of surfactant,
760 mmHg at sea degree of
level. For air to flow compliance,
into the lungs, strength of
intrapleural respiratory
pressure must muscles can affect
become more pressures and
negative, setting up volumes within
a pressure gradient the lungs.
between the PERFUSION The primary
atmosphere and function of
alveoli. pulmonary
SURFACE TENSION Any factor that circulation is to
reduces the airway move blood to and
caliber (mucosal from the alveolar
edema, capillary
inflammation, membrane so gas
secretion, exchange can
bronchospasm, less occur. Pulmonary
surfactant) will circulation is a
raise the resistance reservoir for blood
to airflow and so the lung can
decrease the increase its blood
ventilation of the volume without
corresponding increasing in
alveoli similarly pulmonary artery
any area in which or venous
the local pressures. The
compliance has pulmonary
decreased (i.e. that circulation also acts
potion of the lung as filter, removing
has become more small thrombi
stiff) will before they can
receive less reach vital organs.
ventilation than the
surrounding more
expandable portion
of the lungs.

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PULMONARY Pulmonary vessels are thinner
CIRCULATION circulation begins than those in the
at the pulmonary systemic circulation
artery, which and contains less
receives poorly smooth muscles,
oxygenated mixed because of the low
venous blood from pressure and
the right ventricle. resistance. The lung
Blood flow through accepts the total
this system cardiac output from
depends on the the right ventricle
pumping ability of and except in cases
the right ventricle, of alveolar hypoxia,
which has an does not direct
output of blood flow from
approximately 4 to one
6 liters/minute. region to another.
The flow EXCHANGE OF Respiratory gases
continuous from RESPIRATORY GASES are exchanges in
the pulmonary the alveoli and the
artery through the capillaries of the
pulmonary body tissues.
arterioles to the Oxygen is
pulmonary transferred from
capillaries where the lungs to the
blood comes in blood, and carbon
contact with the dioxide is
alveola capillary transferred from
membrane and the the blood to the
exchange of alveoli to be
respiratory gases exhaled as a waste
occurs. The oxygen product. At the
rich blood then tissue level, oxygen
circulates through is transferred from
the pulmonary tissues to the blood
venules and to return to the
pulmonary veins alveoli and exhaled.
returning to the left This transfer is
atrium. dependent on the
DISTRIBUTION Pressure within the process of
pulmonary diffusion.
circulatory system
are low in  During inspiration, the upper respiratory
comparison to tract warms and humidifies atmospheric air
those in the increasing PH20 to 47 mmHg > Partial
systemic pressures of other gases decline because total
circulation system. pressure must remain at 760 mmHg.
The normal
pulmonary systolic  Before entering the alveoli, inspired air mixes
arterial pressure is with gas that wasn’t exhaled on the previous
between 20 and 30 expiration. Because this gas contains more
mmHg, the CO2 and less O2 than inspired air, partial
diastolic pressure is pressures change again.
less than 12 mmHg.
And the mean  The air that finally enters the alveoli for
pressure is less diffusion across the respiratory membrane
than 5 than goes to further partial pressures changes.
20mmHg. The
walls of pulmonary However, it remains high in PO2 and low inPCO2.

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 The differential in partial pressures of O2 and Co2
cases the two gases to cross the respiratory
membrane toward the lower side of their respective
pressure gradients. O2 diffuses into the blood, and
CO2 diffuses outward, equalizing gas pressures on
both sides of the respiratory membrane.

OXYGEN CONTENT
 The total amount of O2 in the blood equals to
the amount of O2 bound to Hgb+02
dissolved in plasma.
 SaO2 (Oxygen Saturation) – impt. Index to O2
content
 Hgb. & PaO2 (partial pressure of oxygen in
arterial blood) – affect values of O2 content
 Arterial O2- 20ml/dl of blood
 Mixed O2 – 15ml/dl of blood

OXYGEN DELIVERY (DO2)

 The amount of 02 transported to tissue is
determined by 02 content and cardiac volume.
 In normal adult- 1000 ml. of 02 travels/ min
through arteries to tissue and 775ml.returns to
the right side of the heart and lungs.

CARBON DIOXIDE TRANSPORT

 Carbon dioxide diffuses into red blood cells and
is rapidly hydrated into carbonic acid (H2CO2)
because of the presence of carbonic anhydrase.
 The carbonic acid then dissociates into hydrogen
(H+) and bicarbonate (HCO3) ions. HCO3
diffuses into plasma. In addition, some of the
CO2 in red blood cells react with amino acid
groups forming carbamino compounds. This
reaction can occur rapidly without the presence
of an enzyme. Reduced hemoglobin
(deoxyhemoglobin) can combine with CO2 more
easily the deoxyhemoglobin. Therefore, venous
blood transport the majority of CO2

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 maximum amount of oxygen that could
possibly bind to H. because Hb carries most
of the blood oxygen, a normal SaO2 level is
95% to 100%. Normal Hb level for women is
14 to 18 g/dl for men and 11.5 to 15.5 g/dl. The
oxygen supply may be adequate or
inadequate, depending on tissue demand for
oxygen. Normally tissues use about 250cc of
oxygen/min SvO2 (venous oxygen
saturation) is the amount of oxygen that
returns to the heart from the tissues, normal
SvO2 levels range from 60% to 80%
 Some conditions that raise SvO2 levels and
lower the demand for oxygen include
increased cardiac output, elevated SaO2
levels, vasoconstriction, septic shock,
hypothermia, anesthesia, sedation, and
chemical paralysis.
 Conditions that lower SvO2 demand for
oxygen include decreased cardiac output,
reduced SaO2 levels, vasodilation,
cardiogenic shock, hyperthermia or fever,
shivering, seizures, positive end-expiratory
 pressure and high airway pressure.

SUMMARY OF GAS EXCHANGE AND TRANSPORT

 During diffusion, molecules of oxygen and carbon
dioxide move between the alveoli and the
capillaries. Partial pressure – the pressure exerted
by one gas in mixture of gases – dictates the
direction of movement, which is always from an
area of greater concentration to one of lesser
concentration. In the process, oxygen crosses the
alveolar and capillary membranes into the
circulatory system, where it dissolves in the plasma
and passes through the red blood cell membranes.
Here it attaches to hemoglobin. Which in turn
furnishes body tissues with oxygen. Carbon dioxide
moves in an opposite direction- from the tissues,
across the alveolar capillaries, and out through the
respiratory system.
 The circulatory system transports the oxygenated
blood from the pulmonary veins to the left side of
the heart and then to the rest of the body. The
pulmonoppositeary arteries transport the
deoxygenated blood to the right side of the heart
and then into the arterioles and alveoli for
exchange in the lungs.

OXYGEN SATURATION
Cardiac output refers to the volume of blood
pumped from the heat each minute a normal
cardiac output of 4 to 8 liters per minute is
maintained by a normal heart rate and
stroke volume. SaO2, expressed as a
percentage, represents the actual amount of
oxygen bound to Hb. Divided by the

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 - Such as anemias,
increases in the
body’s
metabolic
demands such as
pregnancy or fever
and infection and
alteration that
affect that
patient’s chest
wall movement or
the
central nervous
system.
 DECREASED
INSPIRED OXYGEN
CONCENTRATION
LUNG RESISTANCE -When the
Force that must be overcome for effective concentration of
ventilation inspired oxygen
3 KINDS: declines, the
1. ELASTIC- chest wall rigidity oxygen carrying
2. NON-ELASTIC – factors that capacity of blood
interferes with ventilation as obesity, decreased.
pregnancy, diseases Decreases in the
3. AIRWAY – problem with airflow as mucus, fraction of
edema inspired oxygen
concentration
(FiO2) can be
cause by an upper
or lower airway
FACTORS AFFECTING OXYGENATION
obstruction
PHYSIOLOGIC  ANY CONDITION limiting delivery of
FACTORS THAT AFFECTS inspired oxygen to
CARDIOPULMONA alveoli, decreased
R environmental
Y FUNCTION oxygen (occurs at
- These general high altitudes) or
classifications of decreased
the cardiac inspiration as the
disorder include result of an
disturbances in incorrect oxygen
conduction, concentration
impaired valvular setting or
function, respiratory
myocardial therapy
hypoxia, equipment.
cardiomyopathic  HYPOVOLEMIA
conditions and -Hypovolemia is a
peripheral tissue reduced
hypoxia, circulatory blood
respiratory volume resulting
disorders include from extra cellular
hyperventilation, fluid loss that
hypoventilation occurs in
and hypoxia. condition such as
 ALTERATION THAT shock and severe
AFFECT THE dehydration. If the
OXYGEN fluid loss is
CARRYING significant, the
CAPABITY OF BLOOD body tries to adopt
by increasing the

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 heart rate and DEVELOPMEN These are the
peripheral TAL FACTORS developmental stages of
vasoconstriction to the patient/clients, and
increase volume of the normal aging process
blood returned to can affect tissue
the heart of oxygenation.
increase the  PREMATUR
cardiac output EINFANTS
 INCREASE - Are at risk for
D hyaline membrane
METABOLI diseases or IRDS (
C infant respiratory
- Pregnancy, wound distress
healing, and syndrome) which
exercises and is thought to be
fever caused by a
 CONDITIONS surfactant
AFFECTING CHEST
deficiency. The
WALL MOVEMENT
surfactant
- Any condition that synthesizing
reduces chest wall ability of the lungs
movement can
develops late in
result in decreased
pregnancy about
ventilation. If the
the 7th month and
diaphragm cannot
may therefore, be
fully descend with
lacking in preterm
breathing, the infants.
volume of inspired  INFANTS
air decreases and AND
less oxygen is TODDLERS
delivered to the - Are at risk for
alveoli and upper respiratory
subsequently to tract infection as
tissues. aresult of frequent
1.pregnancy exposure to other
2.obesity children and
3.musculoskeletal exposure to
abnormalities second hand
smoke. In
addition, during
teething process,
some infants
develop nasal
congestion which
encourages
bacterial growth
and increases the
potential for
respiratory tract
infection.
 SCHOOL AGE
CHILDREN AND
ADOLESCENTS
- School age
children and
adolescent are
exposed to
respiratory
infections and

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 respiratory risk distensible. The
factors such as trachea and large
second-hand bronchi become
smoke and enlarges from
cigarette smoking. calcification of the
A healthy child airways, and
usually does not alveoli enlarge,
have adverse decreasing the
pulmonary effects surface area
from respiratory available for gas
infections. A exchange.
person who starts
smoking in
adolescence and
continuous to
smoke into middle
age, however, has
an increased risk
for
cardiopulmonary
disease and lung
cancer.

 YOUNG AND
MIDDLE
AGE ADULTS
- Young and middle
age adults are at BEHAVIORAL Behavior or lifestyle may
risk to multiple FACTORS: directly or indirectly affect
cardiopulmonary (BEHAVIOR OR the body’s ability to meet
risk factors: an LIFESTYLE) oxygen requirements.
unhealthy diet, Lifestyle factors that
lack of exercises, influence respiratory
stress, drugs and functioning includes
smoking. nutrition, exercise,
 OLDER ADULTS – the cigarette smoking,
cardiac and substance abuse and
respiratory system stress.
undergo changes
throughout the aging  NUTRITION
process. In the arterial - Nutrition affects
system, atherosclerotic cardiopulmonary
plaques develop and functions in
the systematic blood several ways.
pressure may rise. Severe obesity
- Chest wall decreases oxygen
compliance is demands to meet
decreased in the metabolic needs.
older patient due The malnourished
to osteoporosis patient may
and calcification experience
of the costal respiratory muscle
cartilages. The wasting, resulting
respiratory in decreased
muscles weaken muscle strength
and the pulmonary and respiratory
vascular excursion.
circulation Coughing
becomes less efficiency is
reduced secondary

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 to respiratory greater oxygen
muscle weakness, extraction by
putting the patient working muscles.
at risk for Fully conditioned
retention of people can
pulmonary increase oxygen
secretions. Diet consumption by
high in fat 10% because of
increase increased cardiac
cholesterol and output and
thermogenesis in increased
the coronary efficiency of the
arteries. Patient myocardial
who are obese and muscles.
or malnourished  CIGARETT
are at risk for E
anemia. Diets SMOKING
high in Cigarette smoking
carbohydrates is associated wit a
may play a role in number of
increasing the diseases including
carbon dioxide heart disease,
load for patients chronic
with carbon obstructive lung
dioxide retention. disease and lung
As carbohydrates cancer. Cigarette
are metabolized, smoking can
an increased load worsen peripheral
of carbon dioxide vascular and
is created and coronary artery
excreted via disease. Inhaled
lungs. nicotine cause
vasoconstriction of
 EXERCISE peripheral and
- Exercise increases coronary blood
the body’s vessels, increasing
metabolic activity blood pressure
an oxygen and decreasing
demands. The rate blood flow to
and depth of peripheral vessels.
respiration The risk of lung
increase. Enabling cancer is 10 times
the person to greater for a
inhale more person who smoke
oxygen and expire than for a
excess carbon nonsmoker.
dioxide. Exposure to side
- Physical exercise stream smoke
program has many increases the risk
benefits. People of lung cancer in
who exercise 3 to the nonsmoker.
4 times a week for  SUBSTANCE ABUSE
20 to 40 minutes -excessive use of alcohol
increased blood and other drugs can
flow, lower pulse impair tissue oxygenation
rate, blood in two ways. First the
pressure, person who chronically
decreased abuses substances often
cholesterol, and has a poor nutritional

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intake. ENVIRONMEN 
The environment can
With the resultant TAL FACTORS also influence
decrease in intake of iron oxygenation. The
rich foods, hemoglobin incidence of
production declines. pulmonary diseases is
Second excessive use of higher is smoggy,
alcohol and certain other urban areas that in
drugs can depress the rural areas. In
respiratory center, addition, the patient’s
reducing the rate and work place may
depth of respiration and increase the risk for
the amount of inhaled pulmonary disease.
oxygen. Substances abuse Occupational
by either smoking or pollutants include
inhaling, such s crack asbestos, talcum
cocaine or inhaling fumes powder, dust and
from paint or glue cans airborne fibers.
cause direct injury to SUMMARY
lungtissue that can lead to FACTORS AFFECTING OXYGENATION:
permanent lung damage 1. PHYSIOLOGICAL
an impaired oxygenation. 2. DEVELOPMENTAL
 ANXIETY/STRESS 3. BEHAVIORAL
- A 4. ENVIRONMENTAL
continuous state of
severe anxiety
increases the
PHYSICAL ASSESSMENT
body’s metabolic
ASSESSMENT GOAL:
rate and the
oxygen demand.
1. Detect early changes in patient’s
The body responds
pulmonary function
to anxiety and
2. Ensure prompt care and treatment
other stresses by
an increased rate
WHEN TO ASSESS:
and depth of
- Hospital admissions
respiratory. Most
- at regular intervals during illness
people can adapt,
- routine health evaluation or screening
but some,
- done daily for ambulatory patients
particularly those
- more frequently for patients who are acutely
with chronic
ill/more susceptible to disease(pediatric and
illnesses or acute
geriatric clients, those who activities are
life-threatening
limited by medications, surgery or debilitating
illnesses such as
condition)
myocardial - assessment can be deliberate or
infarction cannot organized – e.g. newly admitted patients
tolerate the or informal e.g. during patient’s bath
oxygen demands meals
associated with
anxiety. INSPECTION
1. Evaluating the thorax & lungs
Begin your assessment by gathering the
necessary equipment. You’ll need a
stethoscope, a marker pen and a tape
measureor ruler. You’ll also need an area
that’s well lightened (preferably with natural
light).
Typically, your assessment will proceed in
this order: inspection, palpation, percussion,
and auscultation. You’ll finish by assessing
respiratory excursion separately.

Regina Mae Tamano

 2.Inspecting the thorax
help the patient to a sitting position,
then observe his respirations and general
appearance. Note his respiratory rate and
any unusual breathing pattern.
Remember that men and children use
thediaphragm to breathe, whereas
women use the thoracic muscles. In
both male and female patients, be alert
for any accessory muscle use.
Watch for use of the
sternocleidomastoid,scalene, or
trapezius muscles to breathe, or for
supraclavicular retractions, if they’re
present, the impeded. Similarly, watch for
prolonged exhalation
Standing directly in front of the patient,
check his skin for discoloration,
scars, lumps, dimples, lesions, and
ulceration. Then asses his chest for
symmetry of thoracic and
respiratory muscles.
Mentally position the ribs, trachea, and
lungs within the patient’s anterior
thorax. Next, inspect the posterior
thorax, noting
any skin or other abnormalities. Mentally
position the scapulae, ribs and vertebrae
within the posterior thorax.
Inspection/Observation
To properly inspect a patient with a
respiratory disorder, look at everything
including his behavior. Examine your
patient from head to toe and
document
your initial findings.
Mental State
Delirium, confusions or hallucinations: may
mean hypercapnia or severe hypoxemia
(with elderly patient, don’t attribute
disorientation to age)
Fearfulness: seen in patients with acute
respiratory distress, usually restless, with an
anxious expression.
COLOR
Flushing: the patient is retaining carbon
dioxide
Cyanosis of the buccal mucosa and lips:
indicates hypoxemia, although anemia if
present, may affect with recognition.
Peripheral cyanosis indicates vascular
changes, (if patient has dark ski, check
soles of his feet and palms of his hands
for
duskiness)
Pink skin: seen in patients with pure
emphysema – patient usually thin, with
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cardiac enlargement and sparse sputum
production
Ruddy skin with blue overtones: seen in
patients with pure chronic bronchitis.
Patients usually heavyset, with ankle
edema and distended neck veins.
EYES
Engorged veins, swollen optic disc or
papilloedema: means that patient is
retaining carbon dioxide.
LIPS
Pursed lips: seen in patients with COPD.
Breathing out through pursed lips helps
the patient get rid of more CO2.
Circumoral cyanosis (a bluish or dusky
ring circling the mouth): means
presence of hypoxemia.
NOSE
Nose flaring: means respiratory distress,
especially in infants. May be
accompanied by respiratory grunt.
Nasal polyps may interfere with
respirations
Red, swollen nose: means allergies
INSPECTING THE NOSE, MOUTH
AND THROAT
NOSE: equipment: penlight, nasoscope
with light, ophthalmoscope or otoscope
with light or nasal speculum
 Procedure: observe the size, shape,
placement, and general condition of the
patient’s nose
 Abnormal findings: Flaring
nostrils, which suggest
respiratory difficulty.
 Procedure: test for nasal obstruction by
holding a small mirror under the patient’s
nostril. Observe the condensation circles
that appear as the patient breathes.
 Abnormal Findings:
Condensation circles of varying
sizes, indicating a partial nasal
obstruction or an absent
condensation circle, indicating
total nasal obstruction
 Procedure: ask the patient to tilt his head
back; gently push up the tip of his nose.
Using a penlight, observe the mucous
membranes, septum, and inferior
turbinate.
 Abnormal findings: gray, pale, red
or swollen mucous membranes
 Discharge or purulent drainage
 Foreign objects
 Deviated septum (septum that
inclines toward one side or the
 other, giving it an S shape)
 Perforated septum (indicated if
light shines through the
perforation into opposite
nostril)
 Nasal Polyps (pale, shiny balls
with stalks) attached to
turbinate.
 Procedure: using a nasal speculum,
carefully expand the nostril and observe
the inferior and middle turbinate.
Note: Don’t use a nasal speculum when
examining a young or uncooperative
child; you may injure him.
 Abnormal findings: nasal polyps
 Purulent drainage
 Pallor and engorgement (may
indicate allergic rhinitis)
MOUTH & THROAT: equipment:
penlight, tongue depressor
 Procedure: observe color and condition
of lips
 Abnormal Findings: Lesions,
cyanosis, pallor. NOTE: Lips
normally are slightly darker
than surrounding skin.
 Procedure: ask the patient to open
hismouth and say “Ahh”. Observe his
mucous membranes. If the patient’s
Caucasian or Oriental, they should be
smooth and pink; of he’s black, they
should be a patchy pink.
 Lesions, bleeding, odor,
ortenderness
 Procedure: Observe gums and teeth.
Nursing tips: if your patient age 2 or
younger? Estimate the number of teeth he
should have by subtracting six from the
number of months in his age.
 Abnormal Findings: puffy, tender
or bleeding gums
 Discolored, broken, maloccluded
teeth; delayed eruption of teeth
 Note: Teach the patient good
dental hygiene and refer him to a
dentist, if necessary. Also, keep
inmind that poor gum condition
may indicate malnutrition.
 Procedure: Ask patient to stick out his
tongue; observe for velvety-pink
appearance
 Abnormal Findings: smoothness,
cracks, coating glossitis (tongue
inflammation), lesions, lack of
mobility.
 Procedure: observe palate, uvula tonsils,
and pharynx. Important: to avoid
stimulating the patient’s gag reflex,
depress only one side of his tongue at a
Regina Mae Tamano
time.
 Abnormal findings: cleft palate
and/or ovula
 Enlarge, inflamed tonsils.
Note:during childhood, tonsils
normally is larger, with a
glandular (not smooth)
appearance.
 Pus, exudates, or follicles on
pharynx
NECK
 Retractions of muscles: indicates
respiratory distress, esp.in
COPD.
 Trachea position: should be centrally
located. With tension pneumothorax or
large pleural effusion, trachea shift
away from involved side. With
atelectasis, trachea may shift toward
affected side.
 Lack of turgor: indicates dehydration
 Vein engorgement: suggests high venous
pressure.
SIGNS AND ASSOCIATED
CONDITION:
 Postural disorder as forward
displacement of neck and
shoulders;rickets-softening of the
ribs causes depression of the lower
sternum
SIGNS: upper thoracic kyphosis, protuberant
abdomen and functional heart murmur. May
compress internal/vital organs along area of
depression
SCARS: indicate patient had previous chest
surgery or injury
 Anterior- posterior diameter of
chest:should be smaller than the
lateral diameter. Remember chest
tends to become barrel – shaped
with chronic lung disease.
 Sternum – should be located
midlineanterior, giving rise to a
visible projection known as the angle
of Louis.
CHEST DEFORMITIES
 FUNNEL CHEST –
PECTUS
EXCAVATUM
 PHYSICAL CHARACTERISTICS:
- Sinking or funnel-shaped
depression of lower sternum
diminished anteroposterior chest
diameter.
 SIGNS AND
ASSOCIATED
CONDITIONS:
- Postural disorders, such as forward
displacement of neck and
shoulders.
PIGEON CHEST – PECTUS
CARINATUM
 PHYSICAL CHARACTERISTICS:
- Projection of sternum beyond
abdomen’s frontal plane. Evident in
two variations: projection greatest at
xiphoid process; projection greatest
at or near center of sternum
BARREL CHEST
 PHYSICAL CHARACTERISTICS:
 Enlarged antero-posterior and
transverse chest dimensions,
chest appears barrel-shaped
 Prominent accessory muscles; the
ribs tend to be more horizontal
than sloped. No bulges. No
depression
 SIGNS &
ASSOCIATED
CONDITIONS:
 Chronic respiratory disorders
 Increase shortness of breath
 Chronic cough
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 Wheezing
MANIFESTED IN CHRONIC
RESPIRATORY DISORDERS AS
EMPHYSEMA AND ASTHMA.
NOTE: The general over inflation, including
the upper chest. The upper chest now
moves in the so-called “pump handle” up
and down movement, due to action of the
accessory “strap” muscles of respiration.
This is a” trick movement” rescue attempt to
increase ventilation.
The lower chest is over inflated and less
mobile as to the normal so-called “bucket
handle” lateral and upward motion of the
rib cage. This region of the chest normally
is the major area of rib movement to assists
breathing, and is the stabilizing region of
diaphragm attachment necessary for that
muscle to work properly. The diaphragm
is
 the dominant chest wall organ of
respiration.
BIFID STERNUM
 PHYSICAL CHRACTERISTICS:
 Complete or incomplete sternal
separation
 SIGNS &
ASSOCIATED
CONDITIONS:
 Missing or supernumerary ribs;
ectopia cordis (development of
heart outside the thoracic
cavity).
 CHEST MOVEMENT
 Inspiratory intercostal
retractions: occur in patients with
COPD, asthma or pulmonary
fibrosis, Note: sudden violent
intercostal and neck retractions
can be caused by airway
obstruction. E.g. aspiration of
foreign body.
- Inspiratory intercostal bulges: mean
aneurysm, tumor or cardiac
enlargement.
- Use of accessory muscles during
respiration; suggests respiratory
distress. Seen in patients with COPD
and asthma.
 Localized expiratory bulging; 9 MAJOR RESPIRATORY PATTERNS
associated with flail chest. EUPNEA
 How to recognize it:
Normal respiration rate and rhythm. For
adult 5-17 breaths per minute;
teenagers 12 to 20 breaths per minute;
children aged 2 to 12:20 to 30 breaths
per minute;newborn:30- 50 breaths per
minute.
Occasional deep breaths at a rate of two to
three per minute.
 Normal respiratory rate and
rhythm. Adults & teenagers, 12-
20 breaths per minute; for
neonates, 30-50 breaths per
minute. Occasionally, deep
breaths at a rate of 2 to 3 per
minute.

TACHYPNEA
 How to recognize it:
Increased respiratory, as seen in
RESPIRATORY PATTERNS fever, pneumonia, compensatory
 Except for an occasional deep breath, respiratory alkalosis, respiratory
breathing pattern should be rhythmical. insuffiency, lesions in the
If the breathing isn’t rhythmical. Note brain’s
for the depth, rate and pattern for several respiratory control center, and aspirin
minutes. Then document your findings. poisoning.
 Increased respiratory rate, as
seen with fever. Respiratory rate
increases about 4
breaths/minutefor every degree
Fahrenheit above
normal.

BRADYPNEA
 How to recognize it
Slower but regular respirations. Can
occur when the brain’s respiratory
control center is affected by an
opiate,a tumor, alcohol, a metabolic
disorder, or respiratory
decompensation. This pattern is
normal during sleep.

APNEA
 How to recognize it: absence of
breathing; may occur.
Periodically, respiratory
failure

HYPERPNEA
 How to recognize it: deeper
respiration; rate normal

Regina Mae Tamano

CHEYNE-STROKES
 How to recognize it: respiration
gradually become faster and
deeper than normal, then slower,
over a 30 to 170 second period.
Alternating with periods of
apneafor 20 to 60 seconds.
Cause: increased intracranial
pressure, severe congestive heart
failure, renal failure, meningitis,
drug over dose.

BIOT’S
 How to recognize it: faster and
deeper respirations than normal,
with abrupt pauses between
them. Each breath has same
depth. May occur with spinal
meningitis or other CNS
conditions.

KUSSMAUL’S RESPIRATION
 How to recognize it: Faster and
deeper respirations without
pauses; in adults, over 20
breaths/mins. Breathing usually
sounds labored, with deep
breaths resembles sighs. May
accompany or result from renal
failure or metabolic acidosis.

APNEUSTIC BREATHING
 How to recognize it: prolonged
gasping inspiration, followed by
extremely short, inefficient
expiration. May accompany or
result from lesions in the brain’s
respiratory center.
SPINAL ABNORMALTIES
 If any of the following abnormalities are severe,
they can inhibit the patient’s respirations and
decrease ventilations to the lungs. Some cases
are obvious while others may need x-ray to
determine the diagnosis.
1) KYPHOSIS – Abnormality in the
convexity of the spine.

2) SCOLIOSIS – lateral deviation of the spine,

which results in an S-shaped curve.On concave
side of the chest, the patient’s ribs are close
together. On convex side of the chest, his ribs are

Regina Mae Tamano

 further apart.
3) LORDOSIS – is the abnormal increase in the
forward curvature normal spin. Protuberant
abdomen & functional heart murmur
4) SPONDYLISTHESIS – is an abnormal spinal
condition in which one -vertebra slips or is
displaced over another vertebra. The drawing
shows spondylolisthesis as a result of a lumber
vertebra (L5) slipping over the sacrum (S1).
5) KYPHOSCOLIOSIS – a combination of
kyphosis & scoliosis. The patient’s spine convex
as seen in kyphosis and also S- shaped as seen in
scoliosis.
6) SPONDYLOLISTHESIS – is an abnormal
spinal condition in which one - vertebra slips or is
displaced over another vertebra.
spondylolisthesis as a result of a lumbar vertebra
(L5) slipping over the sacrum (S1). Not
affecting respiratory function.
EXTREMITIES
 SKIN
 Warm / elevated temp. ;
Suggestsinfection
 Diaphoresis or clamminess;
means hypoxemia or decreased
blood pressure or decreased
perfusion.
Regina Mae Tamano
ASSESSING THE FINGERS
FORCLUBBING
To quickly assess the fingers for clubbing,
have the patient place the first phalanges of
the forefingers together. Normally, the base of
the nails are concave and create a small,
diamond-shaped space when the first
phalanges are opposed (as shown in the top
illustration next slide). When clubbed
fingers
are opposed, the now convex bases of the
nailscan touch without leaving a space.
FINGERS AND TOES
 Clubbing: associated with COPD,
tuberculosis or chronic
hypoxemia
 Remember: clubbing is divided into early
clubbing – the angle between the nail and
the nail bed is flattened to 180 degrees.
In late clubbing, the angle where the nail
meets the finger is inverted to 120
degree.
 Asterixis: to check, pull patient’s hand
back toward his elbow. Flapping of the
middle finger will occur in patients with
CO2 narcosis or hepatic failure.
 Nail bed cyanosis: suggests
hypoxemia, particularly if it
accompanie s central cyanosis
 LEGS - Thrombophlebitis: leads to
pulmonary embolism. Check patient’s
calves for redness, swelling, warmth and
Homan’s sign.
 HOMAN’S SIGN: may mean presence of
deep vein thrombosis. To check, seat the
patient on a chair and forcefully dorsiflex
his foot, presence of pain in his calf
muscle means positive Homan’s sign.
 ANKLE EDEMA: indicates fluid
overloadin the patient’s tissues. Seen in
COPD or right –sided ventricular failure
(cor pulmonale). To check for ankle
edema; press your fingers into ankle
edema, holdand release. Note the
impression your
fingers leave on the skin.
PEDIA ASSESSMENT
 Multiple (more than 5) “café de au-lait”spots
 may be associated with neurofibromatosis PALPATION (TACTILE FREMITUS, RESPIRATORY
EXCURSION
PEDIATRIC ANATOMY
While you’re examining a child, note any structural
abnormalities of his chest. Chest abnormalities in
children and their significance include the
following:
 An unusually wide space between the nipples may
indicate Turner’s syndrome. (The distance
between the outside areolaredges should not be
more than 1 quarter or ¼ of the patient’s chest
circumference).
 Rachitic beads (bumps at the coctochondrial
junction of the ribs) may indicate rickets.
 Pigeon chest maybe a sign of Marfan’s of
Morquio’s syndrome or any chronic upper
respiratory tract obstruction; funnel chest may
indicate rickets or Marfan’s syndrome; barrel
chest may indicate chronic respiratory disease,
such as cystic fibrosis or asthma.
 Localized bulges may suggest underlying
pressures, such as cardiac enlargement or
aneurysm.

 Certain normal anatomical differences that

distinguish a child’s respiratory tract make
especially prone to respiratory prob lems such as
airway obstruction. Example: A child’s mucous
membranes are loosely attached to his airway. As
a result, they’re easily irritated, which may cause
edema and coughing.
 His airway is smaller in diameter than an adult’s
and contains a greater proportion of soft tissue,
including the soft palate and tongue. All of these
factors make airway obstruction more likely if
excessive mucus formation or edema occurs for
any reason,
 An infant’s larynx is located two or three cervical
vertebrae higher than an adult’s,increasing the
risk of obstruction by aspiration.

Keep in mind that even an apparently minor

respiratory system problem may become life
threatening. When your pediatric patient has such
problem, treat him with special care.

Regina Mae Tamano

 PHYSICAL ASSESSMENT (PERCUSSION)
How to Percuss Your Patient’s Chest The
sound you hear when you percuss your patient’s chest
can help to identify and locate any abnormalities in his
lungs. Use guidelines to aids you in mastering this
assessment skill.

Percussing the Thorax and lung fields

1. Place your nondominant hand on the patient’s
anterior thorax. Use the tip of the middle finger of
your dominant hand to tap on the middle finger of
your other hand just below the distal joint. Percuss
the patient’s anterior thorax at the left clavicle, then
the right.
2. Assess diaphragmatic excursion, or how effectively
the diaphragm extends vertically. Begin, by asking the
patient to exhale. Then percuss to locate the upper edge
of the diaphragm (where the normal lung resonance
changes to dullness, indicating the position of the
diaphragm at full expiration). Mark this spot with a
pen.
3. Ask the patient to inhale as deeply as possible.
Percuss until you locate the diaphragm at the point of
full inspiration. Use the pen to mark this spot as well.
Repeat both steps of this procedure on the opposite
side of the back.
4. Use a ruler or tape measure to determine the
distance between the marks. The distance,which is
normally 1 ½” to 2” (3 to 5 cm) long, should be equal
on the right and left sides.

PERCUSSION SITES

Regina Mae Tamano

 PERCUSSION NOTES
Note & pitc intensi Quality
location h ty AUSCULTATION
Resonance: Low Moderat Hollow
normal lung e to loud
Hyperresona Low Loud Booming 1
n ce;
Emphysemato
us lung or
pneumothorax
Tympanic ; High loud Musical
abdomen ,
distended drumli ke
with air
Dullness; high Soft thudlik e
liver. Pleural
effusion
Flatness; high soft Extrem e
sternum, dullnes
atelectatic s
lung

NURSING TIP
 Remember that when you use the lateral position
to examine your patient’s posterior chest, the
bed mattress and the organ displacement
involved distort sounds and lung expansion. To
offset these effects, examine the uppermost side
of your patient’s chest first; then roll on his
other side and repeat the examination, for
comparison.

 When you assess the patient’s thorax, keep in

mind the three thoracic portion to be examined-
posterior, anterior and lateral. You can examine
any of these areas first and perform the lateral
examination during the posterior or anterior
assessment. The most important point is to
proceed systematically, always comparing one
side of the patient’s thoraxwith the other side. (In
this way, the patient serves as his own control.)
Remember to examine the apices during the
posterior and the anterior examinations
Guide to Respiratory Sounds
Important:
 After inspection, lung auscultation is your best
assessment tool for most respiratory emergencies.
It can detect a bronchial obstruction or fluid in
the pleural space.
 To auscultate, listen with a stethoscope over all
lung fields anteriorly, posteriorly and laterally. If
time allows.
 Press the stethoscope diaphragm firmly against
the patient’s skin, wetting his chest hairs if
possible to reduce rubbingsounds. Have the
patient inhale and exhale slowly and deeply
through his mouth.
 Compare the sound on each side of hischest
to distinguish normal from adventitious
sounds.
 Note: if your patient is lying on his side, his
uppermost lung will be better ventilated. Keep

Regina Mae Tamano

 this in mind when comparing breath sounds. bronchovesicular breath sounds have a soft, low
ADVENTITIOUS BREATH SOUNDS pitched, breezy sounds. They’re lower pitch than
DIAPHRAGMATIC EXCURSION bronchial sounds but higher pitched than
VOICE RESONANCE vesicular sounds.

1) BRONCHIAL OR TRACHEAL GUIDE TO ADVENTITIOUS BREATH SOUND

 Pitch - High
 Intensity - Loud, predominantly on
expiration
 Normal Findings - When listening over
the trachea or mainstem bronchus,you’ll
hear a sound like a blown through a
hollow tube.
 Abnormal Findings - When you hear bronchial
sounds over peripheral lung, it may indicate.
overinflation or emphysema
2) VESICULAR
 Pitch - High on inspiration; low on
expiration.
 Intensity - Loud on inspiration; soft on
expiration.
 Normal findings - When listening over
peripheral lung, you’ll hear sounds that have
a soft, breezy quality.
 Abnormal findings - Decrease sounds in
affected peripheral lung may indicate early
pneumonia or emphysema. Sounds are
decreased because patient’s barrel chest
causes lungs to be further from chest wall.
3) BRONCHOVESICULAR
Pitch: Moderate
 Intensity: Moderate
 Normal findings - When listening over large
airways, over either side of sternum, Angle of
Louis, and between the scapulae, you’ll hear a
blowing sound.
 Abnormal findings - When you hear
bronchovesicular. Sound over peripheral
lung, it may indicate consolidation.
Abnormal breath sounds include absent or decreased
breath sounds and bronchial breath sounds heard
over lung areas than the mainstem bronchi.
Adventitious sounds are also abnormal and maybe
heard incidental to normal breath sounds. They
include crakles, rhonchi, wheezes, and pleural fiction
rubs.
The following information and illustrations will help
you recognize the characteristics and location of
adventitious sounds.
1. CRACKLES - Of the two kinds of crackles, fine
crackles can be heard anywhere in the lungs.
Typically, you’ll first hear them over the lung bases.
Their high-pitched, short crackling sounds are heard
best on inspiration. Coarse crackles, on the other
hand, are loud, low-pitched bubbling and gurgling
sounds that start in early inspiration and may last
through expiration.
2. RHONCHI - These abnormal breath sounds are
heard over the central airways. Two type; sonorous
-generally they’re loud, coarse, low-pitched bubbling
sounds. Sibilant
– high pitched, may resemble a wheezing sound. Both
may be heard equally well during inspiration and
expiration.
3. WHEEZES - Coming from large bronchi, wheezes
are high-pitched, musical whistling sounds, which may
occur during both inspiration and expiration but
predominant during expiration. Usually an end-
expiratory.

GUIDE TO NORMAL BREATH SOUNDS 4. STRIDOR - Air passing through narrowed airways
on inhalation.
The sound of a patient’s breathing indicates the
condition of his respiratory and other body
systems. To help you assess your patient’s
5.PLEURAL FICTION RUBS - These
breathing you’ll need to recognize normal breath coarse, low-pitched abnormal sounds are heard at the
sounds.
anterolateral wall during the end of inspiration and
Air moving through the tracheobronchial tree beginning of expiration.
normally produces tracheal, bronchial,
bronchovesicular, and vesicular breath sounds.
Tracheal and mainstem bronchial breath sounds
are heard over the trachea. Loud,high pitched,
and hollow, they’re longer on expiration than
inspiration.
Vesicular breath sounds are heard over the
anterior thorax and the posterior andlateral
thorax. They’re longer and louder during
inspiration than expiration.
Heard over the mainstem bronchi at the first and
second intercostals spaces between the scapulae,

Regina Mae Tamano

 ASSESSING FOR RESONANCE
If you detect any respiratory abnormalities during
palpation, percussion, auscultation, assess the
patient’s voice sounds for vocal resonance. The
significance of vocal resonance is based on the
principles that sound carries best through a solid,
less wellthrough fluid, and poorly through air.
Normally, you should hear vocal resonance as muffled,
unclear sounds, loudest medially and less intense at
the lung periphery. Voice sounds that become louder
and more distinct at the lung periphery signal
bronchophony, an abnormal finding except over the
trachea and posteriorly over the upper right lobe. To
elicit bronchopony, ask your patient “99” or one, two,
three”, while you auscultate the thorax systematically.
Bronchopony usually accompanies enhanced fremitus
abnormal bronchial breath sounds, and dullness on
percussion.
Nursing Care:
 Explain procedure
 Undress up to waistline-put on dept.gown
 Det. LMP not done in 1st trimester, 2nd and 3rd,
use lead apron
 Remove metal objects and jewelries that may
block structures and seen in film.
COMMON RADIOGRAPHIC FILM
Frontal
-Performed with the X-ray beam positioned posteriorly
and anteriorly and with the patient in an upright position.
- Posteroanterior (PA) view is the most common frontal
view and is preferred over anteroposterior (AP) view
because the heart is anteriorly situated in the thorax and
magnified less in a PA view than in an AP view
-The frontal views show greater lung area than other
views because of the lower diaphragm position.

DIAGNOSTIC TESTS LATERAL

- Performed with the X-ray beam directed toward
I. Radiological exams the patient’s side.
II. Bronchoscopic exams - The most common lateral view and is preferred
III. Sputum exams over the right lateral (RL) view because the heart
IV. Biopsy is left of midline and magnified less in an LL
V. Thoracentesis view than in RL view.
VI. Pleural fluid exams - Lateral views visualize lesions not apparent on a
VII. Pulmonary function tests: PA view.
1. Spirometry
2. ABG-invasive/non-invasive
OBLIQUE
- Performed with the X-ray beam angled between
RADIOLOGIC EXAMS the frontal and lateral views. This view helps
 Chest x-ray evaluate intrathoracic disorders (such as pleural
effusion), esophageal abnormalities, and
DIAGNOSTIC EXAMS mediastinal masses (rarely, it is also used to
localize lesions within the chest).
1. Radiographic/Roentgenography/x-ray
-1st discovered by Dr. Wilhelm Roentgen
A. Chest x-ray- complete evaluation of pulmonary and LORDOTIC
cardiac systems. When focused on the chest, it can help
- Performed with the X-RAY beam directed
spot abnormalities or disease of the airway, blood vessels,
bones, heart, and lungs. through the axis of the middle thoracic lobe and
Structure seen: with the patient learning back against the film
 Bony structures- sternum, scapula, clavicle, ribs, plate
upper portion of humerus, vertebrae - This view evaluates the collapse of the area or
 Diaphragm the presence of pleural fluid
 Heart shadow DECUBITUS
 Trachea/Bronchi -performed with the X-ray beam parallel to the
 Lung Tissue floor and with patient in one of several horizontal
positions (supine, prone, or side).
USES: - This view demonstrates the extent of pulmonary
 Routine screening abscesses or cavity, the presence of free pleural
 Suspected pulmonary pathology fluid or pneumothorax and the mobility of
e.g tumor, inflammation, fluid, blood or air, mediastinal mass when the patient changes
fractures, diaphragmatic, hernia. positions.
 Confirm tube placement- ET, TT, CT, NGT
Contraindication: Pregnancy-teratogenic

Regina Mae Tamano

 1. client will be instructed to breathe and hold his
breath while the film is taken (ensure maximum
expansion of the lungs)
2. Client must keep still while film is taken-pre
menopausal, pregnant, men and women of
reproductive age should wear protective lead to:
a. Prevent congenital anomalies of future
children
b. Destruction of developing fetus
c. Prevent cancer growth
RECUMBENT
-performed with the x-ray beam overhead and with the
patient supine
This view helps distinguish free fluid from encapsulated
fluid and from an elevated diaphragm
B. FLUOROSCOPY- a medical imaging test that uses an
x-ray beam that passes continuously through the body to
create an image
- obtain a better view of organs, blood vessels, tissues and
bones.
Why need fluoroscopy?
1. Barium X-rays- to see the movement as the
intestines move the barium through them
2. Electrophysiologic procedures- to treat patients
with irregular heartbeats
3. Arthrography- to view one or more joints
4. Placement of IV catheters- to guide the catheter
inside your body into a specific location
5. Percutaneous kyphoplasty/vertebroplasty- to
treat spinal vertebrae fractures.
6. Cardiac catheterization- to see the blood flow
through the coronary arteries, checking for
arterial blockages
7. Hysterosalpingogram- an x-ray of the fallopian
tubes and uterus
8. Needle or transbronchial biopsies- to obtain a
biopsy of tissue from a lung.
Preparation:
1. Prepare and ask questions
2. Sign consent
3. Let doctor know if age. Is breast feeding
4. Ensure full list of medication
5. Review pre-procedure instructions
6. Inform aeg is allergy to iodine or aeg is pregnant
C. Chest Tomography- it uses x-ray and computer
technology to make detailed pictures of the organs and
structures inside your chest
- In a CT scan, an X-ray beam moves in a circle
around your body. It takes many images, called
slices, of the lungs and inside the chest
Regina Mae Tamano
- During the test, you may receive a contrast dye.
This will make parts of your body show up better
in the image.
- CT scans can also be done to help remove a
sample of a sample of fluid from the chest. They
are useful in keeping an eye on tumors and other
conditions of the chest before and after
treatment.
- A CT scan may be done when another type of
exam, such as an X-ray or physical exam, is not
conclusive
CHEST TOMOGRAPHY
D. Lung scan- detect alterations in lung perfusion and
ventilation
Perfusion scan- using radionucleotide tagged albumin
with technetium (Tc-99m) injected into the vein.
I
Albumin lodges temporarily at small diameter of the
pulmonary capillaries
Gamma ray detecting devise is passed over the client’s
chest and records the distribution of albumin in the lungs.
Detect pulmonary embolus
Ventilation scan (V-scan)- inhalation of Xenon, which is
then radioactively scanned. Detect pulmonary cancer.
E. Pulmonary Angiography- x ray after injection of the
radiopaque medium into the pulmonary vasculature,
visualizes pulmonary vessels, pattern, size and patency.
F. Thoracic Sonogram- uses sound waves; not very useful
in pulmonary assessment, do not penetrate air.
II. ENDOSCOPIC EXAMS
Bronchoscopy- a procedure to look directly at the airways
in the lungs using a thin, lighted tube (bronchoscope). The
bronchoscope is put in the nose or mouth. It is moved
down the throat and windpipe (trachea), and into the
airways.
2 types:
1. Diagnostic
2. Therapeutic
2 kinds of bronchoscope
1. Flexible fiberoptic bronchoscope
2. Rigid bronchoscope
Diagnostic uses:
1. Direct visualization of the TBT abnormalities,
tumors, inflammations
2. Removal of biopsy specimen
3. Aspiration of deep sputum for C/S and cytology.
Therapeutic Uses:
1. Aspiration of retained secretions
2. Control of bleeding
3. Removal of aspirated FB
 4. Placement of radiation beads in unresectable
lung tumor

Nursing care:
1. Explain procedure - Place the unconscious patient on the side, with
2. Give oral hygiene the evening and morning prior the head of the bed slightly elevated to prevent
to test aspiration
3. Advise NPO x 6-12 hrs. - Provide an emesis basin and instruct the patient
4. Do postural drainage the morning before the test to spit out saliva rather than swallow it. Sputum
5. Remove dentures/ note loose teeth/oral may be blood tinged. Notify the doctor if
inflammation excessive bleeding
6. Adm. Sedative if needed - Collect sputum for 24 hours immediately
following a bronchoscopy for cytological studies
and culture
Intra: - Instruct the patient to refrain from clearing his
7. Intubation is performed- assist reassure client throat and coughing, which may dislodge the clot
that breathing will not be obstructed- ask to at a biopsy site and cause hemorrhage. Advise the
breathe through the mouth (spray anesthesia is patient to avoid smoking for the rest of the day of
used, advised client to spit it out-given to increase the procedure because it irritates the tissues
comfort and prevent gagging) - -Restrict food and fluids until after the gag reflex
returns (usually in 11/2 to 2 hours, although it
Post: may take longer in some patients)
8. Keep client NPO until gag reflex has returned 2- - To test for gag reflex, touch the back of the tongue
6hrs blade. If patient had general anesthesia, check for
9. Observe client for side effects of anesthesia: bowel sounds. Only after bowel sounds and gag
palpitations, rapid breathing pulse, increase B/P, reflex have returned, the patient can begin to take
rapid deep breathing oral nourishment as ordered. You can offer ice
10. Observe for S/S of laryngospasm or laryngeal chips, then water, and within a few hours his
edema or bleeding. usual diet.

When performing bronchoscopy

- The bronchoscopy tube, inserted through the
nostril into the bronchi, has four channels. Two
light channels (a) provide a light source; one
visualizing channel (b) to see through and open
channel (c) that accommodates biopsy forceps,
cytology brush, suctioning, lavage, anesthetic or
oxygen.

Patient care after bronchoscopy

After:
- Monitor vital signs every 15 mins or as ordered,
until they are stable. Notify the doctor
immediately of any complications or
deterioration in the patient’s condition
- Keep resuscitative equipment and tracheostomy
tray available for 24 hours after the test.
- Place conscious patient in the semi fowlers
position

Regina Mae Tamano

30
DIAGNOSTIC PROCEDURES (CONT.)
UNIT TITLE
SPUTUM EXAM
 Cytologic (exfoliative) Testing- is performed to
WHEN TO COLLECT:
● Before starting an antibiotic (unless it is to evaluate
effectiveness of drug therapy)
● Early morning (AFB and cytology)
● Before meals
● Before a routine oral hygiene procedure such as
brushing with toothpaste or gargle with antiseptic
solution.
COLLECTING A SPUTUM
 Use these guidelines to help you collect a sputum
specimen that can be accurately analyzed by the
laboratory.
o Collect the specimen first thing in the
morning, if possible, have the patient
brush his teeth and rinse his mouth
before coughing into sputum cup
o Make sure the patient coughs deeply
enough. If you’re using a suction
catheter, make sure it extends all the way
to the bronchus
o Collect at least 5cc
o If the patient has a contagious disease,
collect the sputum specimen in a
nonporous container and label it
“contaminated”
o Take the specimen to the lab immediately
ANALYZING A SPUTUM SPECIMEN
Four types of tests may be performed on a sputum
specimen to identify the infecting organism or abnormal
cells.
 Gram stain- a gram stain is colored purple. When
the stain combines with bacteria in a sample, the
bacteria will either stay purple or turn pink or red.
If the bacteria turn pink or red, they are gram
negative
 The test permits rapid visualization of
bacteria from smear and indicates if the
specimen is representing (many white blood
cells, few epithelial cells) or if oral
contamination has occurred (few WBC’s any
epithelial cells). Gram staining often provides
early presumptive diagnosis of lower
respiratory infection, such as bacterial
pneumonia.
 Acid fast staining- helps rapidly identify
organisms of genus mycobacterium since they
retain carbolfuchsin stain after treatment with an
acid-alcohol solution. This test provides early
presumptive diagnosis of tuberculosis.
 Culture and sensitivity- testing allows growth and
isolation of microbes for positive identification
and determination of their vulnerability to
specific antibiotics. The tests helps diagnose
lower respiratory tract infection or confirm
earlier presumptive diagnosis from a stained
smear.
identify cancer cells and other abnormal cells to
help diagnose and type malignant pulmonary
lesions and identify granulomas, inflammation,
and other benign conditions.
BIOPSY
 Tracheobronchial tissues are taken for
cytologic assessment
 Pleural biopsy- small thoracotomy
incision using a COPE needle
 Lung biopsy- maybe done by surgical
exposure- open lung biopsy.
COMPLICATIONS
 Fever, pain from intercostal nerve injury
(rare)
 Pneumothorax (S/S: dyspnea, pallor or
cyanosis, diaphoresis, excessive pain
 Hemothorax
THORACENTESIS
Definition: Aspirating pleural fluid by puncturing the
chest wall to remove excess fluid of air from pleural cavity.
Purposes: It is done for diagnostic purposes or to relieve
breathing difficulties in clients with:
 TB
 Cancer
 Pleural effusion
 Pulmonary edema
 Chest injuries/trauma
 Also performed to introduced chemotherapeutic
drug intrapleurally
POSITIONING A PATIENT FOR
THORACENTESIS
 To prepare the patient for thoracentesis, place
him in one of the three positions:
o Sitting on the edge of the bed with arms
over bed table
o Sitting up in bed with arms on over bed
table
o Lying partially on the side, partially on
the back with arms over the head. These
positions serve to widen the intercostal
spaces and permit easy access to the
pleural cavity.

PREPARATORY PHASE
1. Assemble equipments needed: use aseptic
technique
2. Disinfect according to hospital protocol
(betadine, alcohol)
3. Sterile gauze, sterile cotton balls
4. Sterile kidney basin
5. Clean receptacle where to put gauze/cotton balls
after use
6. Trocar large needle attached to a syringe or stop
cork
7. Sterile container to collect specimen/s to send to
laboratory
ACTUAL PROCEDURE
 Explained procedure to patient and so will be
done by physician who will do the procedure.
 Secure written consent
 Assists the client to assume a position that allows
easy access to intercostal space.
 Two positions commonly used.
o Sitting position with arms above the
head, which spreads the ribs and
enlarges the intercostal space
o Sitting on one side with arm held to the
fron and up.
 Using the sterile technique, the physician inserts
a trocar or the physician attaches a syringe or stop
cork to the aspirating needle.
 Prior to insertion the physician will percuss the
chest and select the exact site for insertion of
needle.
o A site on the lower posterior chest is often
used to remove fluid and a site on the
lower anterior chest used to remove air.
 A chest x-ray prior to the procedure will help
pinpoint the best insertion site. Remember, if
stop cork is used it should be closed position so
that air will not enter the pleural space.
 The physician will insert the trocar/needle into
the pleural cavity/space. The obturator will be
removed and the fluid is withdrawn. If with
syringe the physician will aspirate the fluid to
flow freely.
 Collect specimen to be sent to the laboratory and
label. Fluid considered infected, caution should
be observed
 If large container is used to received fluid, the
tubing is attached from stop cork to the adaptor
on the receiving bottle.
 Assist patient throughout the procedure
 Record time the procedure started; time ended
and the physician who performed
 Measure collected fluid and document amount,
color, or fluid collected.
 Send specimen to lab
 Observe proper disposal technique according to
hospital protocol.
RECOGNIZING COMPLICATIONS OF
THORACENTESIS
Identify the following possible complications of
thoracentesis by watching for their characteristic signs
and symptoms:
 Pneumothorax: apprehension, increased
restlessness, cyanosis, tachycardia, absent or
diminished breath sounds on the affected side
 Tension pneumothorax: dyspnea, chest pain,
tachycardia, deviated trachea.
 Fluid re-accumulation: increasing and persistent
cough, respiratory distress, hemoptysis,
subcutaneous emphysema
 Mediastinal shift: labored breathing, cardiac
dysrhythmias, cardiac distress, pulmonary
edema (pink frothy sputum, paradoxical pulse)
INTERPRETING RESULTS OF THORACENTESIS
 Effusion- accumulation of fluid or the fluid itself
in the pleural cavity
 Pleural effusion- sometimes referred to as “water
on the lungs”. Is the build up excess fluid between
the layers of the pleura outside the lungs
-Certain characteristics classify pleural fluid as either a
transudate (a lower protein fluid that has leaked normal
blood vessels with increased permeability)
 Transudative effusion- fluid leaks into the pleural
space. Generally, results from diminished
colloidal pressure within the pleural cavity,
ascites, systemic and pulmonary venous
hypertension, congestive heart failure, hepatic
cirrhosis, and nephritis.
 EXAMINING PLEURAL FLUID Interpretation: if count is above 1,000/mm3 or
Characteristic Possible Cause 50% neutrophils, may indicate septic or non-
Light, straw colored Normal septic inflammation.
Purulent Empyema  Lymphocyte count
Blood tinged  Hemothorax Interpretation: of count is over 50%, may indicate
 TB TB, lymphoma or other form of cancer
 Pulmonary  Blood clots
infarction Interpretation: May indicate neoplasm, TB or
 Neoplastic infection
disease  Specific gravity
 Accidental tissue Interpretation: If measure exceeds 1.016, may
damage from indicate neoplasm, TB, or infection, if less than
thoracentesis 1.104 may indicate CHF.
Milky  Chylothorax  Total protein
Interpretation: Levels below 3g/dl suggest
 Invasion of
neoplasm, TB or infection
thoracic duct by a
tumor or an  Lactic dehydrogenase
inflammatory Interpretation: Levels rise in cancer and other
process with transudates
 Traumatic  Glucose
rupture of Interpretation: Conditions associated with
thoracic duct exudates; decrease heart failure and other
conditions associated. If less than serum glucose
 Cellular debris or
cholesterol level, may suggest cancer, bacterial infection, or
nonseptic inflammation.
crystals
Low protein fluid  Sediment Interpretation: may represent
 Cirrhosis
cancerous cells, cellular debris, or cholesterol
 CHF crystals.
Protein rich fluid  Infectious disease
 Asbestosis Special considerations:
 Pulmonary  To prevent hypovolemic shock, fluid is removed
infarction slowly and no more than 1,200 ml of fluid is
 Lymphatic removed at one time.
drainage disorder  Pleuritic or shoulder pain may indicate pleural
irritation by needle point.
 At chest x-ray is usually ordered after the
NURSING TIP procedure to detect pneumothorax and evaluate
 On the patient’s chart, document the color and the results of the procedure.
amount of pleural fluid obtained, indicate which
studies the doctor ordered, also note how well the
patient tolerated the procedure.

SIGNIFICANCE OF PLEURAL FLUID ANALYSIS

 Gram stain culture and sensitivity
Interpretation- Positive results may mean the
early stage of bacterial infection. In the later
stages of bacterial infection, the fluid may look
grossly purulent with a positive gram stain, yet
cultures may be negative from antibiotic therapy.
 Acid fast stain culture
Interpretation: Positive results may indicate TB
 RBC count
Interpretation: If count is about 10,000mm3 and
the specimen is pink or light red, it may indicate
tissue damage. If count is above 100,000/mm3
and the specimen is grossly bloody suggest
intrapleural malignancy, pulmonary infarction,
TB, or closed chest trauma. If a hemothorax is
present, the hematocrit of the pleural fluid will be
similar to that of capillary blood.
 Leukocyte count
 PULMONARY FUNCTION TESTS
I. SPIROMETRY (SPIROMETER)
 Measure peak flow rate
Peak flow rate- the highest flow point during
maximal expiration helps determine the extent of
obstructive disease or bronchospasm.
Measurement of peak flow rate may precipitate or
worsen bronchospasm. This measurement can
also be made before and after bronchodilator
administration or respiratory therapy to gauge
the effectiveness of treatment.
 The patient can also be instructed how to perform
this procedure at home, to monitor airway
obstruction. A fall in the peak flow rate may
indicate that the patient’s condition is
deteriorating.
 To measure peak flow rate, first obtain a flow
meter, disposable mouthpiece, and a predicted
values table. Then, wash your hands, next attach MEASUREMENT OF PULMONARY FUNCTION
a mouthpiece to the flow meter, and press the
 Vital capacity (VC)- Total volume of air that can
release button behind the mouthpiece to set the
be exhaled after maximum inspiration) 4,800ml
pointer on the flow meter at zero.
 Inspiratory capacity (IC)- amount of air that can
 Explain the procedure to the patient to ensure his
be inhaled after normal expiration) 3,600 Ml
cooperation, (essential to accurate results). Have
the patient sit upright in a bed or chair. Then, ask  Tidal volume (TV)- amount of air inhaled or
him to inhale as deeply as possible, Tell him to exhaled during normal breathing) 500 ml
insert the mouthpiece and to seal his lips tightly  Minute volume (MV)- inspiratory reserve volume
around it. (IRV)- (amount of air inspired above normal
 Instruct him to exhale forcefully in one short, inspiration) 3,100 ml
sharp blast. Complete emptying of the lungs isn’t  Expiratory reserve volume (ERV)- (amount of air
necessary because peak flow is achieved within that can be exhaled after normal respiration)
the first half second of expiration. 1,200 ml.
 Remove the mouthpiece, and tell the patient to  Residual volume (RV)- (amount of air remaining
relax. Then, note the reading on the dial (each in the lungs after forced expiration) 1,200 ml
mark equals 5 liters). Record peak flow as the  Functional residual capacity (FRC)- (amt of air
observed number or the percentage of predicted remaining in the lungs after normal expiration)
peak flow. 2,400 ml
 Repeat the test twice, after resetting the pointer  Total Lung capacity (TLC)- (total volume of the
 Record adverse effects during the test such as lungs when maximally inflated) 6,000 ml
wheezing or coughing.  Forced vital capacity (FVC)- (dynamic
measurement of the amount of air exhaled after
NURSING TIP: maximum inspiration).
 Instruct the patient scheduled for pulmonary  Forced expiratory volume (FEV)- (volume of air
function test (spirometry) expired in the 1st, 2nd, or 3rd second of FVC
 Not to eat a heavy meal before the test maneuver).
 Not to smoke for 4 to 6 hours before the test
IMPLICATIONS
 Explain the nature and operation of a spirometer
 Normal or increased VC with decreased flow rates
 Assure the patient that the procedure is painless
may indicate any condition that causes a
and that he can rest between tests.
reduction in functional pulmonary tissue, such as
 Don’t sedate the patient before the tests inform pulmonary lesions, pulmonary edema,
the pulmonary function is taking an analgesic atelectasis, excision of pulmonary tissue,
that depresses respiration. pulmonary congestion, or obstruction of
 As ordered, withhold bronchodilator medication bronchus.
for 4-6 hours before the tests.  Decreased VC- with normal or increased flow
 Check with the doctor and therapist concerning rates may indicate decreased respiratory effort
withholding intermitting positive-pressure resulting from neuromuscular disease, drug
breathing therapy. overdose, or head injury; upper abdominal
incisions, tight dressings, or kyphoscoliosis; or
limited movement of diaphragm resulting from
 gastric distension, pregnancy, ascites, or
abdominal tumor.
 Decreased IC indicates restrictive disease
 Decreased TV indicate restrictive disease and
requires pulmonary function study or chest
radiography.
 ERV can be normal in emphysema; decreased
ERV may indicate other diseases such as
pulmonary edema.
 Abnormal IRV alone doesn’t indicate respiratory
dysfunction; IRV decreases during normal
exercise.
 ERV varies, even in healthy persons.
 RV greater than 35% of total lung capacity (TLC)
after maximal expiratory effort. Obstructive
disease such as emphysema
 Increased FRC indicates over distension of lungs,
which may result from obstructive pulmonary
disease
 Low TLC indicates restrictive disease; high TLC
indicates over distended lungs associated with
obstructive disease.
 Decreased FVC indicates flow resistance in
respiratory system from obstructive disease
 Decreased FEV1, and increased FEV2 and FEV3
may indicate obstructive disease; decreased or
normal FEV1 may indicate restrictive disease.
ARTERIAL BLOOD GAS ANALYSIS
 Allen’s test
SITES FOR ARTERIAL BLOOD GAS
EXTRACTION
 Radial- common
 Brachial
 Femoral- least
PROCEDURE: ABG
 Consent not needed/may depend on SOP of
institution
 Explain procedure to the client: takes 5-10 min
duration, usual sites, 5cc of blood to be extracted,
little bit painful than venous extraction, client to
keep still- gain access to artery.
 Done by personnel with knowledge and trained
on anatomy and extraction.
 No contraindication
 Gather materials:
o ice in bowl- delayed diffusion process
o heparinized syringe 5ml- prevent clotting
o needle- G 20-21-22
o betadine swabs
 Advised client to breathe normally
^RR- dec. PaCO2- resp alkalosis
Dec RR- ^PaCO2- resp acidosis
 Take temp- result to adjust to body temo
o dec. T- ^PaCO2 dec. Ph
o ^T- Dec. PaCO2 ^Ph
 Anesthesia- if used do skin test- NOT usually
used due to:
o Takes puncture to the skin more twice
o Risk to local and gen. reactions
o Vasoconstriction effect impair success of
puncture
 Allen’s test- quick assessment of collateral
circulation of hand.
o Ensure circulation of hand in case of
thrombosis after puncture.
Analysis:
Positive- flushing after release of ulnar artery
(pink)
Negative- remains pale/ do not use hand for
extraction test other hand
o Bubbles must be expelled immediately-
affects O2 contents in specimen
o Place in ice before transport after
bending needle; specimen should not be
transferred because:
 Prevent hemolysis
 Prevent atm. Air to mix with
blood gas
 Air tight specimen remain stable
within one hour
 Maintain pressure at extraction
site
ABG PROCEDURE
 Apply pressure dressing 3-5 minutes
 Prevent hematoma formation
 Inform physician about result after analyzing
result
Acidosis- a condition in which there us too much acid
in the body fluids
Causes:
 Overproduction of acid that builds up in the
blood
 Common causes: cardiogenic shock,
hypovolemuc shock and severe heart failure
Alkalosis- occurs when your blood and body fluids
contain an excess of bases or alkali

Cause:
 Overabundance of bicarbonate in the blood.
Respiratory acidosis- a condition that occurs when the
lungs cannot remove all the CO2 the body produces.
Lowers ph in the blood.
S/S:
 Shortness of breath
 Fatigue
 Confusion
 Sleepiness and headache
Treatment:
 Bronchodilator and corticosteroids
 CPAP/BIPAP- low O2
Respiratory Alkalosis- primary decrease in CO2 partial
pressure with or without compensatory decrease in
bicarbonate.
 Ph maybe high or near normal
 Cause hyperventilation e.g. pulmonary
embolism and asthma
Treatment:
 Breath into paper bag. Fill the paper bag with
CO2 by exhaling into it
 Restrict oxygen intake into the lungs. Breathe
using pursed lips or breathing through one
nostril.
Metabolic acidosis- develops when too much acid is
produced in the body. It can also occur when the
kidneys cannot remove enough acid in the kidney.
S/S:
 Confusion
 Fast heartbeat
 Headache
 Vomiting
Treatment:
 Oral or IV sodium bicarbonate to raise ph
 Bronchodilator
 CPAP
 Sodium citrate to treat kidney failure
 Insulin and IV to treat Ketoacidosis.
Metabolic alkalosis- a condition that occurs when your
blood becomes overly alkaline
2 kinds:
1. Chloride responsive- results from loss of
hydrogen ions usually by vomiting or
dehydration
2. Chloride resistant- results when body retains
many bicarbonate or when there is a shift of
hydrogen ions from your blood to your cells
Treatment:
Chloride responsive:
 Increase intake of sodium chloride- keep your
blood more acidic and reduce alkalosis
 IV drip contain sodium chloride
Chloride resistant: (Body depleted of potassium)
 Take pills containing potassium chloride- 2-
4/day
 IV potassium chloride
ABG INTERPRETATION
Normal ABG Levels
 pH hydrogen – 7.35- 7.45
 PaCO2 Carbon dioxide - 35-45 mmHg
 HCO3- Bicarbonate – 22-26 mmol/L
 If the ABG results reveal pH numbers are not
within normal range, the patient’s pH level is
either acidotic or alkalotic
 The lower the number, the more acidotic the
patient is. For instance, a pH of 3 is severely
acidotic and requires emergency intervention.
 Alkalosis is the opposite. The higher the pH, the
more base is in the blood sample, which can
disrupt the normal functioning of the body.
 Once you’ve determined whether there is too
much acid or too much base, you can move on to
determine the cause of it.
HCO3 : RESPIRATORY OR METABOLIC?
 After you’ve determined whether the
sample is acidic or alkaline, you need to
work out if it’s due to respiratory or
metabolic causes
 If the cause is respiratory in nature, the
PaCO2 will be out of normal range,
whereas for metabolic problems the
HCO3 will be abnormal.
 Low PaCO2 points to respiratory
alkalosis, and high HCO3 can indicate
metabolic alkalosis
PACO2: COMPENSATED OR
UNCOMPENSATED?
 Compensation can be thought of as body’s
attempt at correcting an imbalance: Is one system
in the body trying to compensate for an
abnormality in another system? We can
investigate this by looking at the opposing
component of the problem.
 For example, in acidosis, we’d look at the level of
HCO3 whereas in alkalosis, to determine if the
body is compensating, we’d look at what the
PaCO2 is doing.
 If the other level (or component) is within normal
ranges, then the problem is non-compensated or
uncompensated
 However, if the other component has gone
outside its normal reference ranges, we can think
of it as compensation occurring (the body is
trying to fix the problem). To assess how well it
has been able to do this, we need to refer back to
the pH. If the pH is not within or close to the
 normal ranges, then a partial compensation
exists. If the pH is back within normal ranges,
then a full-compensation has occurred. PULSE OXIMETRY

Compensat Respirato Acidic pH Pa HCO

ed or ry or or Co2 3
uncompens metabolic alkalot
ated ic
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Metabolic Acidos Low Low
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Metabolic Alkalo High High
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Compensat Respirato Acidos Norm Hig
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Compensat Respirato Alkalo Norm Lo  Pulse oximetry is a test used to measure the
oxygen level (oxygen saturation) of the blood. It
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is an easy, painless measure of how well oxygen is
Compensat Metabolic Acidos Norm Low
being sent to parts of your body furthest from
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your heart, such as the arms and legs.
Compensat Metabolic Alkalo Norm High
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FACTORS AFFECTING PULSE OXIMETRY
READING
Conclusion:
 Poor skin contact
 This ABG is an example of a partially
 Movement
compensated metabolic alkalosis
 Low perfusion
 Case study 2  Venous pulsation
 Outside light
Consider the following:  Anemia
o pH = 7.30
o PaCO2= 50 PULSE OXIMETRY
o HCO3= 30  Continuous non-invasive electronic monitoring
 Q1.Is it an acidosis or an alkalosis? of client’s arterial oxygen saturation
-Acidosis  Best combined with ABG
 Q2. Is the problem of a respiratory or metabolic  SPO2 (oxygen saturation- as measured by pulse
nature? CO2 high? oximeter- non invasive
-respiratory acidosis  SaO2- Oxygen saturation as measured by blood
 Q3. Is there any compensation occuring? Has the analysis- invasive
body tried to fix the problem? HCO3 high, pH
high?
- Partial compensated respiratory
acidosis
  Equipment:
Note false reading in: Nasal and Tracheal suctioning
1. Dyes- cardiac output studies 1. Negative pressure-source
2. Increase carboxyhemoglobin- smoking clients 2. Suction canister
3. Connective tubing
Inaccurate reading in clients 4. Suction catheter
1. Taking vasoconstrictor drugs
2. Constrictive clothing, BP cuff Endotracheal suctioning:
3. Conditions as shock hypothermia dec. cardiac Articles containing: A clean Tray
output arterial vascular disease (Raynaud’s 1. Sterile suction
disease), carbon monoxide poisoning, edema of
2. Normal saline or sterile water in a
monitoring site.
container
3. Sterile gloves, mask and face shield
NURSING CARE:
4. Alcohol swab
 Check strength of pulse 5. Stethoscope
 Check capillary refill
 Remove nail polish- blocks transmission A sterile tray containing:
 Protect sensor from light- cover with towel 1. Sterile bowl
 Avoid placing sensor to extremity with cuff, 2. Bowl
pressure dressing or arterial line. 3. Gauze
TWO KINDS OF SENSOR
Closed Suctioning
1. Transmission- light transmitted by led- light
The incorporation of a suction system into a
emitting diodes through vascular tissues (finger)
mechanical ventilator that permits airway
2. Reflectance- light transmitted by the vascular
beds (forehead) suctioning without disconnecting patients from the
ventilator.
IV SPECIAL PULMONARY TREATMENTS
 Bronchial hygiene Open Suction
 Suctioning The endotracheal suctioning technique is classically
 Nebulization performed by means of the opentracheal suction
 Humidification system (OTSS), which involves disconnecting the
 Postural drainage patient from the ventilator and introducing a
 Oxygen therapy single-use suction catheter into the patient's
 Breathing and Coughing exercises endotracheal tube.

SUCTIONING
 The act or process of exerting a force upon a solid,
liquid or gaseous body by reason of reduced air SUCTIONING PROBLEMS: HOW TO SOLVE AND
pressure over part of its surface. To remove from AVOID THEM TO AVOID PROBLEM NEXT TIME
body cavity or passage by suction. In case of Suction patient only when necessary. If
respiratory problems many people require possible, get him to cough up secretions.
suctioning to remove excess secretions and Suction gently. if patient is having
mucous from the airway. difficulty, remove catheter before he has
bronchospasm and give oxygen. With
SUCTION (negative pressure)- close system bronchospasms do not withdraw catheter,
I. Sterile technique give 02through it.
o Use sterile gloves
o Medical asepsis #1 PROBLEM:
o Suction tip to individual orifice Your patient sounds congested, but you'reunable to
II. Suction catheters suction any secretions from his endotracheal tube or
o Y-tube connector trach tube. Or, the secretions you do suctions are
o Button type extremely dry or viscous.
o Open-ended
o Whistle-tip WHAT TO DO
III. Suction source  Using a syringe (with the needleremoved),
o Wall-mounted outlet suction instill 2 to 3 saline solution into the
o Portable suction machine endotracheal tube or trach tube.
IV. Routes- oral, nasal, buccal cavity, tracheal via  Hyperinflate the patient's lungswith a hand-
airways held ventilator.
 Proceed with suctioning Repeat procedure
 again later, ifnecessary, but only after you've
given patient a chance to rest.
TO AVOID PROBLEM NEXT TIME
1. Keep patient well ventilated
2. Administer humidification therapy and aerosol
treatments, as ordered. Or requestan order from the
doctor.
3. Don't give milk or milk product to thepatient,
because they can thicken and increase sputum.
#2 PROBLEM:
You're suctioning the mouth of an aphasicstroke
patient and find that he won't cooperate with you.
WHAT TO DO
 Try to calm him by speaking calmlyand
soothingly.
 Ask another nurse to keep patient'smouth open
with a padded tongue blade. This will keep him
from biting down the catheter.
TO AVOID PROBLEM NEXT TIME
1. Regularly turn the patient from side to side so
secretions will drain from his mouthnaturally.
2. Encourage him to cough up secretions by
demonstrating what you want him to do
#3 PROBLEM
You're suctioning a patient through his nose
and suddenly observe that his heart ratesdropped to 40.
WHAT TO DO
1. Stop suctioning immediately.
2. Remove catheter and give oxygen.
3. Monitor and document vital signs.
4. Notify doctor, if necessary.
TO AVOID PROBLEM NEXT TIME
1. Avoid nasal suctioning unless other
methods of removing secretions fail.
2. Closely observe patient's heart rate
throughout entire procedure.
#4PROBLEM
You begin suctioning your patient and notice
pink-tinged mucus.
WHAT TO DO
 Check for pulmonary edema.
 Find out if he's been taking Isuprel, which can
cause pink-tinged mucus.Ask if he's just eaten red
gelatin.
TO AVOID PROBLEM NEXT TIME
1. Keep your patient well hydrated so his mucosa
won't get dry and be prone to injury.
2. Make sure catheter is in correct size. Trya smaller
size to minimize trauma. Review the technique you're
using tomake sure it's correct
Nursing Responsibilities for NG Tube to
Suction
1. Assess tube every 2 to 4 hrs for patency
2. Irrigate clogged tube according to
physician's instructions
3. Monitor vacuum source setting
4. Assess tubing connections & color,
amount, & consistency of gastric drainage
5. Assess positioning of tubing
6. Auscultate bowel sounds every 4 hours
OXYGEN THERAPY
✓ Is colorless, odorless and tasteless
✓ It is administered to treat the harmful and possibly
lethal effects of hypoxemia
HYPOXEMIA - it is the decrease of oxygen supply in
the blood stream
HYPOXIA - it is the decrease of oxygen supply in
the tissue
Forms:
1. Liquid Portable System (Cylinder)
2. Wall outlet (which leads via pipes to thelarge
stores of oxygen)
3. It can be administered by mask, nasal cannula, face
tent, ventilator or nebulizer. The needs for oxygen are
assessed by the following:
✓ Arterial blood gas (ABG)
✓ Oxygen saturation measuring device (Oximeters)
4. Monitoring for the indication for
Hypoxemia
The level of oxygen (PaO2) and carbon dioxide
(PaCO2) in the patient’s arterial blood (PaO2 is
normally 80-100 mmHg, PaCO2 is normally 35 to 45
mmHg
 OXYGEN DELIVERY SYSTEM toxicity include progressive atelectasis,
Low-flow and high-flow refers to the rates of oxygen consolidation, and fibrosis of the lung. ABG
delivered by the equipment used. analysis is monitored

LOW-FLOW SYSTEM OXYGEN CONCENTRATION IN VARIOUS DELIVERY

✓ Deliver oxygen at flow rates that SYSTEMS
supplement the oxygen contained in 1. Nasal Cannula
ambient (room) air a) low flow
✓ Deliver a wide range of oxygen concentration from 21- b) 1 to 6 L/Min
90 percent c) 24 - 44%
2. Simple face mask
HIGH FLOW 02 DELIVERY SYSTEM a) Low flow
02 from source minus room air O2 cont. 80- 100% b) 5 to 8 L/min
c) 40 - 60%
COMPLICATIONS 3. Partial rebreather mask
1. Oxygen-induced hypoventilation a) Low flow
A normal respiratory drive occurs when blood b) 6 to 10 L/min
carbon dioxide rises slightly and stimulates the c) 60 – 80%
primary respiratory centers in the carotid bodies and 4. Non-rebreather mask
the arch of the aorta are activatedby decreases in a) Low flow
blood oxygen tension (e.g., lower 60mmHg) b) 6 to 15 L/min
2. Oxygen Toxicity c) 95 – 100%
is a medically induced, potentially fatal, 5. Venturi mask
progressive condition in which ventilatory failure a) High flow
occurs in clients who inspire a high concentration b) 4 to 15 L/min
of oxygen for a prolonged period of time. c) 24 – 40/50%
 Early indications of oxygen toxicity may include 6. Face tent
a mild tracheobronchitis that begins as a substernal a) Low flow
soreness, nasal congestion, pain on inspiration, and b) 4 to 8 L/min
I increased coughing. c) 30 – 50
 Clients at risk for oxygen toxicity are those of
bleomycin or steroids and
those with hyperthermia, hyperthyroidism,
protein deficiency, vitamin E deficiency, and
adrenergic stimulation. PULMONARY TREATMENTS TO UPPER RESPI
 Assessment findings at the end stage of oxygen CONT.
of the patient’s room, as well as inside his
REDUCING OXYGEN HAZARDS room. Doing so will alert visitors not to
COMBUSTION: smoke.
High oxygen concentration will make a fire burn 5. Don’t give the patient smoking materials or
hotter and more rapidly. And, it can make smoldering matches
objects, such as cigarettes, burst into flame. Also, 6. Avoid cheating static electricity during
oxygen under pressuremay explode when subjected to oxygen use by having the patient wear all
heat. To help protect patient and his family from these cotton (or at least 85% cotton and 15%
hazards, give them the following safety instructions. synthetic fabric) and use all cotton sheets and
1. Notify the local fire department that oxygen blankets
is in the house 7. Keep electrical devices at least 5’ (1.5m) away
2. Keep the oxygen source (usually a tank or from the oxygen. Use a straight razor instead
concentrator) at least 5’ (1.5m) from heat of an electrical razor when saving during
source. oxygen use.
3. If the patient is confined to bed and the heat 8. Avoid electric heating pads and electric
source is stationary (for example, a radiator or blankets.
baseboard heater) turn it off, if possible and 9. Remove all candles from the patient’s room.
place an alternate heat source at a safe Give him a flashing light to keep in case of
distance from the oxygen. Neverse a fireplace power failure, or if a light bulb burns out.
for heat. 10. Keep all aerosol cans out of the
4. Take stringent measures to prevent smoking. patient’s room. Prohibit use of lotions, creams
Post large, clearly printed no smoking signs or other products with oil or alcohol during
on the front door of the house and on the door oxygen use and for 3 to 6 hrs after use is
 stopped. Alcohol and oil are both flammable.
And oxygen remains in linens and clothing for a
long as 3 to 6 hrs after use.
12. Substitute glycerin when giving body rubs.
Instead of a temp-reducing alcohol bath, use
ice bags or towel moistened with cool water.
13. Keep the patient’s hand oil and grease-free.
Don’t use petroleum jelly or other Oil-Based
moisturizers to relieve facial dryness. Use
water- soluble lubricating jelly instead.
14. Never lubricate any oxygen delivery
equipment.
Keep a fire extinguisher on hand. Make sure the
patient and his family know how to use it. Apply these
rules when using portable oxygen equipment as well
as stationary equipment.
NEBULIZATION
 A nebulizer is a piece of medical equipment that
a person with asthma or another respiratory
condition can use to administer medication
directly and quickly to the lungs
 A nebulizer turns liquid medicine into a very
fine mist that a person can inhale through a face
mask or mouthpiece.
 Types of Nebulizers:
1. Jet- this uses compressed gas to make an
aerosol (tiny particles of medication in the
air)
2. Ultrasonic- This makes an aerosol
through high-frequency vibrations. The
particles are larger than with a et
nebulizer
3. Mesh – liquid passes through a very fine
mesh to form the aerosol. This kind od
nebulizer puts out the smallest particles.
It’s also the most expensive.
PURPOSE: Nebulized therapy is often called a breathing
treatment. You can use nebulizers with a variety of
medications, both for controlling asthma symptoms and
for relief right away. These include: Corticosteroids to
fight inflammation (such as budesonide, flunisolide,
fluticasone, and triamcinolone)
 You may use a nebulizer to inhale medication to
clear your airways or to treat infections
 To add moisture to oxygen delivery system
 To hydrate thick sputum and prevent
mucus plugging.
 To administer various drugs to the airways.
Nursing Care
 Put the client in upright position Instruct the
client to breathe slowly and deeply
 Take time to coach the weak orelderly client
 Assist by holding the apparatus when
necessary
 Instruct the client to keep the medicine cup up
right during the treatment
 Proper care of device after use
HUMIDIFICATION
-process of increasing the water vapor content of a gas.
 HUMIDIFIER – adds moisture to air to prevent
dryness that can cause irritation in many parts of
the bod
 Types of Humidifiers:
ACTIVE HUMIDIFIERS -Act
by allowing air passage inside a heated
water reservoir. These devices are placed
in the inspiratory limb of the ventilator
circuit, proximal to the ventilator.
PASSIVE HUMIDIFIERS- there are
independent from any external energy
source or external water supply. They
function as heat and moisture exchangers
(HMEs) and are placed like an artificial
nose between a tube and Y piece.
 Nursing Care
Check thermometer readings regularly
Insufficient water in the humidifier can
cause the heating device to overheat
Temperature of 32.2-37.8 degrees.
Centigrade is acceptable. Properly clean
humidifier according to manufacturer’s
advice (per brochure) to avoid bacterial or
viral proliferation.
POSTURAL
 drainage uses gravity to help move mucus
from the lungs up to the throat. The
person lies or sits in various positions so
the part of the lung to be drained is a high
as possible. That part of the lung is then
drained using percussion, vibration and
gravity.
 Position – your chest should be lower
than your hips, which you can achieve by
lying on a slanted surface or propping
your hips up about 18 to 20 inches with
pillows or another item. This position is
best for draining the bottom front parts of
 your lungs.
 PHYSIOTHERAPY

POSTURAL DRAINAGE
Purpose- drains pulmonary secretion by gravity into
major
bronchi or trachea. Then coughed out or swallowed.
Procedure- place lung segment to be drained
uppermost,
Position- head down by elevating foot of bed 35-45 PHYSIOTHERAPY
degrees  Have position for CHEST PERCUSSION

NURSING CARE
Don’t perform immediately after meals
Decrease angle if client can’t tolerate
Monitor cardiac and respiratory status.
Position the client
Best time- AM upon arising. 1 hr before meals. 2-3 hrs
after meals
Stop if cyanosis or exhaustion occurs
Maintain position 5-20 mins after
Check VS
Assess lung sounds
Assess skin color and temp
Administer medicine as per doctor’s order
Provide mouth care after the Procedure

DON’T PERFORM WHEN CLIENT IS: CHEST VIBRATION

 Have brittle bones or broken ribs  PHYSIOTHERAPY: VIBRATION
 Have acute asthma or tuberculosis PURPOSE
 Have injuries to spine  Increases velocity and turbulence of
 Have recent surgery exhaled air
 Are experiencing intense pain  loosens and helps propel them
 Have increased pressure in the skull  into larger bronchi
 Recently experienced heart attack  to be expectorated or spitted out or
 Have pulmonary embolism or lung abscess suctioned
 Have an active hemorrhage
PROCEDURE:
SEQUENTIAL POSITION FOR
 Places hands flat (side by side w/ your
COMPLETE POSTURAL DRAINAGE:
fingers extended) on the chest segment
-Upper lobes, anterior segments you’re draining
-Upper lobes, posterior segment, right posterior bronchus  Instruct client to inhale deeply, then as he
-Upper lobe, posterior segment, left posterior bronchus
exhales, vibrate his chest by contracting
-Right middle lobe
and relaxing the muscles of your arms &
- Left lingual
- Lower lobes, apical segment shoulders. Stop vibrating when he inhales
-Lower lobes, anterior basal segment repeat procedure several times.
- Lower lobe, lateral basal segment
- Lower lobe, posterior basal bronchus NURSING CARE:
 Use vibrations instead of percussion if the
client has extreme pain in chest area, is frail,
POSTURAL DRAINAGE just had thoracic surgery
Adjustable beds to facilitate various position for postural  Vibrate chest in each postural drainage
drainage. position may alternate w/ percussion.
 Don’t vibrate over spine sternum or
below thoracic cage
 Avoid pressing hard on ribs- painful
 Try to synchronize w/ exhalation.
May use specially- design electric
 vibrator to produce the same effect.
 PHYSIOTHERAPY: PERCUSSION
 Purpose – mechanically dislodges thick,
tenacious secretions from the bronchial walls so
can be expectorated, swallowed or coughed out
or suctioned
 Procedure – hold your hand in a cupped shape.
Keep your fingers flexed & your thumb tight
against your index finger.
Percuss the chest segment you’re draining by
alternating your hands n a rhythmic manner,
trap air between hands & client’s chest to be
effective- a hollow sound can be heard instead
of a loud slap
Nursing Care:
 Line client’s skin w/ towel, sheet or
gown
 Percuss 3-5 ins in each postural
drainage position
 Don’t percuss over client’s spine or below
thoracic care- danger of tissue damage
Avoid percussion if client has rib or spine
fractures, flail chest or other traumatic chest
injuries, pulmonary hemorrhage, embolus,
mastectomy w/ silicone implant,
metastatic lesionsof ribs, pneumothorax or
hemothorax
BREATHING EXERCISES
- ABNORMAL BREATHING EXERCISE
 Bronchodilators are a type of medication that
make breathing easier by relaxing themuscles in
the lungs & widening the airways(bronchi). They’re
often used to treat long-term conditions where the
airways may become narrow and inflamed, such
as asthma, a common lung condition caused by
inflammation of the airways.
 Bronchodilator or broncholytic (although the
latter occasionally includes secretory inhibition as
well) is a substance that dilates the bronchi &
bronchioles, decreasing resistance in the
respiratory airway & increasing airflow to the
lungs.
RESPIRATORY DRUGS: ANTIHISTAMINES
Antihistamines are medication that help w/
allergies, & also w/stomach problems, cold,
anxiety & more.
Antihistamines are a class of drugs commonly
used to treat symptoms of allergies. These
drugs help treat condition caused by too much
histamine, a chemical created by your body’s
immune system
Common allergens that cause allergy:
1. Food
2. Dust
3. Pollen
4. Latex
5. Insect bite
6. Certain medications/drugs Too
much histamine, caused by your body being
oversensitive & overreacting to an allergen,
causes a variety of symptoms include:
1. Congestion, coughing
2. Wheezing, shortness of breath
3. Tiredness (fatigue)
4. Itchy skin, hives & other skinrashes
5. Itchy, red , watering eyes
6. Running or blocked nose or
sneezing
7. Insomnia
8. Nausea & vomiting

RESPIRATORY DRUGS:
 Epinephrine hydrochloride
 Nasadrine
 Dimetapp
Nursing care:
 Watch for rebound congestions, Dob
caution in administration esp.in
children
 Antitussive drug- act on the cough center in the
brain & decrease the sensitivity of cough receptors
- When the cough receptors in the respiratory
passages & lungs are stimulated, they send
signal to the cough center located in the
brain. The impulse generated travels down &
stimulate the respiratory muscles to produce a
cough.
- Antitussive relieve cough by:
 Acting on the cough center inthe brain
 Decreasing the sensitivity of
cough receptors
 Interrupting cough impulse
transmission
 Numbing the cough receptors in the
respiratory passages & lungs.
- Side effect of antitussive:
 Chest numbness
 Constipation
 Confusion
 Dizziness
 Gastrointestinal upset
 Hallucination
 Headache
 Nasal congestion
- Brand name of antitussive:
 Balminil DM
 Benylin DM
 Benzonatate
 Bronchopan
 Robitussin DM
 Difference of antitussive & expectorant:
 Antitussive- are cough suppressants.
They relieve cough by blocking cough
reflex. This will reduce coughing.
 Expectorants- thin mucus, this may
help cough clear the mucus from
airway. Helps to expel mucus
 Mucolytic- used to manage mucus
hypersecretion and its sequelae like
recurrent infections in patient of
COPD, cystic fibrosis & bronchiectasis.
Used to help break up & thin mucus,
making it easier to clear from the
airways.
 Gualifenesin, by contrast, increases the
water content of the mucus, thinning it
out so that it can be coughed up.
Precautions:
 Most mucolytics are very safe, but
should not be used in children under 6.
Do not take mucolytics if you have a
stomach ulcer.
Drink plenty of fluids while taking this
medication. Fluids will help to break up
mucus and clear congestion
THORACIC SURGERY
 Exploratory thoracotomy
o A diagnostic procedure
Thoracotomy is surgery to open your
chest. During this procedure, a surgeon
makes an incision in the best wall between
your ribs, usually to operate on your lungs.
Through this incision, the surgeon can
remove part or all of a lug. Thoracotomy is
often done by treat lung cancer.
o Thoracostomy is a procedure that
places a tube in the space between
your lungs & chest wall (pleural
space). It’s done
o Thoracostomy is used to treat the
following:
 Pneumonia
 Injury to chest wall that causes
bleeding around your lungs
 Infections in the pleural space
 Collapse lung (pneumothorax)
 Cancer that has caused fluid build up
around your lungs
 Fluid that has collected around your
lungs during chest surgery.
 Thoracostomy is often done w/ another
procedure. To treat lung cancer, surgeons can
perform a few different types of procedures.
Which surgery you have depends on the stage
of your cancer.
1. Wedge resection – removes a wedge-shaped
piece from the area of your lungs that
contains cancer & some healthy tissue
around it.
 2. Posterolateral

2. Segmentectomy removes one

segment of a lung
3. Pneumonectomy remove an entire lung
4. Extrapleural pneumonectormy
removes a lung, the lining of your lungs &
heart (pleura
 After the procedure is done, the surgeon
reinflates your lung. Temporary tubes in
your chest drain fluid, blood & air that may
have collected around your lungs during
thesurgery. These tubes will stay in place
for a few days.

3. Sternal incision

 Tracheobronchial sleeve resection or a sleeve

lobectomy is a surgical procedure to remove a
love of the lungs & part of the bronchi (airway)
usually to eliminate a cancerous or aggressive
tumor. In this procedure, the ends of the bronchus
are rejoined, & any remaining loves are reattached  Thoracotomy is performed on the right or left side
to the bronchus. of the chest. An incision on the front of the chest
 Surgical chest incisions thoracotomy through the breast bone can also be used, but is
1. Anterolateral rare
 Nursing management: Preop:
1. Consent
2. Pre-op meds- given to feel relax & sleepy
3. ET
4. Foley catheter
5. Monitor Arterial Line, CVP line, ECG,
Pulse Oximeter
During surgery:
1. Position – flat on your back or on theside
a. Anterolateral incision
b. Median sternotomy
c. Posterolateral incision
2. Checked ET,CT, & bleeding Post-op:
1. Check drains & chest tube – tube is used to
remove air, blood or fluid from around your
lungs or heart. The chest tube is attached to
a container to collect the draining blood or
fluid.
2. Take ABG- measure the amount of oxygen
& CO2
3. Post op meds- antibiotic, analgesic
4. Deep breathing & coughing exercise
5. Early mobilization-may sit on bed,shoulder
exercise
6. Observe post op reaction
 PTPS(Post Thoracotomy Pain
Syndrome) – pain @ incision site for
2 months orlonger,
 Dizziness
 Blood clots – arms/legs –
causes heart attack/stroke
 Lung problems
 Decreased BP
 Atelectasis
WATER SEAL DRAINAGE SYSTEM (WSDS)
 Removal of air from thoracic cavity- one bottle
system
 Chest drains also known as under water sealed
drains (UWSD) are inserted to allow draining of
the pleural spaces of air,blood or fluid, allowing
expansion of the lungs & restoration of negative
pressure in the thoracic cavity. The underwater
seal also prevents backflow of air or fluid into the
pleural cavity
PURPOSE
- to allow air to exit from the pleural space on
exhalation & prevent air from entering the
pleural cavity or mediastinum on inhalation.
When thewater seal chamber is filled w/ sterile
fluid up to the 2cm line, a 2cm water seal is
established.
- Air bubbling through the water seal chamber
intermittently is normal when the patient
coughs or exhales, but if there is continuous air
bubbling in the chamber, it can indicate a lead
that should be evaluated.
COMPLICATION
 Prolonged air leak
 Multifactorial lung edema
 Atrial fibrillation
 Empyema of chest cavity
 WHAT SHOULD BE DONE IF
BUBBLING IN THE SUCTION
CONTROL CHAMBER STOPS?
 In wet suction control, gently bubbling is
normal. If there is no bubbling, ensure the
connections are tight & turn the suction
higher.
 If suction is not ordered, ensure the
suction port is left open to air.
HOW TO FIX AIR IN THE LUNGS:
 A tube inserted through the skin & rib cage.
That removes the air between the lungs &
ribs cage. The air leak will then open &
close
 WSDS – close chest drainage system
 Thoracostomy
  SIGNS & SYMPTOMS
 Bruising, discoloration or swelling in the
area of the broken bones
 Marks from being thrown against a seat
belt (after a car accident)
 Sharp, severe chest pain
 Difficulty inhaling or getting a full breath.

 MANAGEMENT
 Get enough oxygen- maintain
adequate ventilation
 Check bleeding – internal
 Fluid management
 Manage pain
 DISPOSABLE CHEST DRAINAGE  Manage unstable chest wall- use pillow to
put pressure on the flail segment
 Practice universal precaution – wear PPE

2.PNEUMOTHORAX
 DIFFERENCE OF NORMAL
PNEUMOTHORAX & TENSION
PNEUMOTHORAX
1. Normal pneumothorax
- Occurs when air leaks into the space
between your lung & chest wall
- Classified as open (external wound) or
closed. The pleural pressure equilibrates w/
atmospheric pressure, resulting in lung
collapse
2. Tension pneumothorax
- Severe condition that results when air is
trapped in the pleural space under positive
pressure, displacing mediastinal structures, &
compromising cardiopulmonary function.
- Develops when air continuously enters the
chest w/out evacuation.

CHEST TRAUMA  PNEUMOTHORAX

1. FLAIL CHEST - Abnormal collection of air in the space
between the thin layer of tissuethat covers
the lungs & the chest cavity
- Collapsed lung
- Caused by a blunt or penetrating chest
injury, certain medical procedures, or
damage from underlying lung disease

 DIFFERENT TYPES OF COLLAPSED LUNG:

1. PRIMARY SPONTANEOUS
PNEUMOTHORAX: collapsed lung
sometimes happen in people who don’t have
other lung problems. It can occur due to
abnormal air sacs in the lungs that break
apart & release air.
2. SECONDARY SPONTANEOUS
- is a chest in which sections of broken ribs are PNEUMOTHORAX – several lung diseases
isolated from, & interfering w/, normal chest may cause a collapsed lung. These include
movement chronic obstructive pulmonary disease
- The chest cannot expand properly &
(COPD), cystic fibrosis & emphysema.
cannot properly draw air into the lungs.
3. INJURY – RELATED PNEUMOTHORAX –
 injury to the chest can cause collapsed lung.
Some people experience a collapse lung due to
a fractured rib, a hard hit to the chest or a
knife or gunshot wound.
4. LATROGENIC PNEUMOTHORAX - after
certain medical procedures such as lung
biopsy or central venous line insertion, some
people can have complications that include a
pneumothorax.
5. CATAMENIAL PNEUMOTHORAX- rare
condition affects women who have
endometriosis. Endometrial tissue lines the
uterus. W/ endometriosis, it grows outside
the uterus & attaches to an area inside the
chest. The endometrial tissue forms cyts that
blled into the pleural pace, causing the lung
to collapse.
 SYMPTOMS
 Chest pain on one side especially when
taking breaths.
 Cough
 Fast breathing, fast heart rate
 Fatigue
 SOB
MANAGEMENT:
 Check VS
 Administer Oxygen
 Needle aspiration
 Chest tube drainage
 Chemical pleurodesis – use
Doxycycline or talc
 Surgery – video -Assisted
Thoracoscopic Surgery (VATS)
- Minimally invasive procedure that
uses a small camera to help the surgeon
remove lung tissue.
LUNG RE-INFLATION
 Lung inflation exercises
3. LUNG CONTUSSION
 CHEST TRAUMA – injuries can range from
thoracic wall contusion or laceration, to
pneumothorax, flail chest & cardiac tamponade.
RISK FACTORS:
 TWO TYPES OF CHEST TRAUMA:
1. PENETRATION OR BLUNT – stabbing,gunshot
wound
2. BLUNT CHEST TRAUMA -sharp object tearing
deep into skin & muscle isn’t the main cause of
tissue damage. E.g. car accident, falls
4. HEMATHORAX
is when blood collects between your chest wall &
your lungs. This area where blood can pool is
known as the pleural cavity. The buildup of the
volume of blood in this space can pool is known
as the pleural cavity. The buildup of the volume
of blood in this space can eventually cause your
lung to collapse as the blood pushes on the
outside of the lung.
 SYMPTOMS
 Pain or feeling of heaviness in yourchest
 Dyspnea
 Fast heartbeat
 High fever – 38C
 Anxious, cold sweats
 CAUSES OF HEMOTHORAX
 Blunt force trauma injury
 Fluid & cancer around the lungs, called
malignant pleural effusion
 Large vein torn open when a catheter is
inserted while you’re in the hospital
 Tissue around your lungs dying, called
pulmonary infarction
 Blood not clotting properly & leaking into
the chest cavity
 Tuberculosis
 TREATMENT
 Thoracentesis/ thoracostomy
 Thoracotomy
 Observe for possible complications:
1. hypovolemic shock
2. empyema
3. sepsis
 Maintain adequate ventilation
5.ATELECTASIS
 Is a complete or partial collapse of the entire lung
or area(lobe) of the lung. It occurs when the tiny air
sacs(alveoli) w/in the lung become deflated or
possibly filled w/ alveolar fluid.
 CAUSES:
 Surgery – is the most common reasonpeople
develop atelectasis
 Chest pressure- pressure from outside the
lungs can make deep breathing difficult.
 Blocked Airway – a blocked airway can
also cause atelectasis.
 Smoking
 COPD
 Using oxygen for a long time
 Long term bed rest
 TREATMENT:
 Performing deep-breathing exercises
(incentive spirometry) and using a device to
assist w/ deep coughing may help remove
secretions & increase lung volume.
 Positioning the body so that the headis lower
than the chest (postural drainage
  Tapping on your chest over the collapsed area (+)
to loosen mucus - The test site is first cleaned and disinfected.
The forarm is then marked using a water-
CONDITIONS AFFECTING THE UPPER soluble skin marker. A drop of each allergen
RESPIRATORY SYSTEM is then placed corresponding to a number of
 Nose
the grid. When a sterile needle (lancet) is used
 Pharynx
to prick in the middle of each drop of allergen
 Larynx
using light pressure.
- (+) red bump appear within 15 mins
RHINITIS
3. Radioallergosorbent test (RAST)-
- Is an inflammation and swelling of the
measures amount of lgE antibodies
mucous membrane of the nose.
- Colds & allergies are the most
 TREATMENT:
common causes of rhinitis
 Antihistamines w/ decongestants
 Nasal spray
 TYPES:
 Corticosteroid
1. Allergic Rhinitis
 Immunotherapy- allergy shot, SLIT 0
2. Chronic Rhinitis
sublingual immunotherapy
3. Atrophic Rhinitis
 NURSING ALERT:
 CAUSES:
 Do not blow the nose too hard or
 Chronic sinus infection
frequently (spread inf. Sinuses- infected-
 Autoimmunity
eardrum- perforated)
 Hormonal imbalance
 Blow both nostrils at the same time (to
 Poor nutritional status
equalize pressure)
 Heredity
 Iron deficiency anemia
 TIPS TO PREVENT ALLERGIES:
 Bacterial infection
1. Stay indoors when pollen counts are high
2. Avoid exercising outdoors early in
 SYMPTOMS OF ALLERGIC RHITIS the morning
 Sneezing, runny nose, stuffy nose 3. Take showers immediately after being
 Coughing outside.
 Sore throat 4. Keeps windows and doors shut as
 Watery eyes frequently as possible during allergy
 Frequent headache
season
 Excessive fatigued
5. Keep mouth & nose covered while
 Ozena- abundant foul-smelling
performing yard work
exudates.
6. Try not to rake leaves or mow the loan

 TYPES OF ALLERGIC RHINITIS

1. Seasonal – spring/fall season – 7. Bathe your dog at least twice perwk to
outdoor allergen minimize dander.
2. Perennial – year around – indoor 8. Remove carpeting from your
substances bedroom
9. Start taking antihistamine before an
 RISK FACTORS: allergic reaction has the chance to occur
 Family history 10. Wet mop hard floors, rather than
 Asthma sweeping
 Atopic eczema
11. Wash your hands immediately after
 Cigarette smoke
touching pets, and make sure your furry
 Chemicals
friends stay off your bed. You’ll also want
 Humidity to wash your cloths after visiting homes
 Air pollution that have pets.
 Hairspray
 Perfumes, cologne  HOME REMEDIES:
 Wood smoke 1. For seasonal or pollen allergies try using
 Fumes air conditioner instead of opening
windows.
 DIAGNOSTIC TEST: 2. Using a dehumidifier or a high- efficiency
1. Skin prick test- small red bumpappears particulate air (HEPA) filter can help you
 control your allergies while indoors.
3. If you’re allergic to dust mites, wash
your sheets & blankets in hot water
that’s above 130°F (54.4°C)
4. Adding a HEPA filter to your vacuum &
vacuuming weekly may also help. Limiting
carpet in your home can also be useful.
OTHER TREATMENTS HELPFUL INMANAGING
SEASONAL ALLERGY:
 Acupuncture
 Nasal saline irrigation
 Butterbur supplements
 Honey
 Probiotics
EPISTAXIS (NOSE BLEEDING)
 TYPES
1. Anterior – bleeds come from the front of
the nose, & are more frequent
2. Posterior- bleeds come from the back of the
nose. Heavier & difficult to control
WHO GETS NOSEBLEED?
1. Children between ages 2 to 19
2. Adults between ages 45 to 65
3. Atherosclerosis (hardening of the walls of
arteries)
4. Nose picking – dry & crusty
5. Trauma/irritation
 HOW TO STOP NOSEBLEED?
1. Relax
2. Sit upright & lean your body & your head
slightly forward. This will keep the blood from
running down your throat, which can cause
nausea, vomiting & diarrhea. (Do not lay flat
orput your head between your legs)
3. Breathe through your mouth.
4. Use a tissue or damp washcloths to catch
the blood
5. Use your thumb & index finger to pinch
together the soft part of the nose against the
hard bony ridge that forms the bridge of the
nose. Squeezing at or above the body part of
the nose will not put pressure where it can
help stopthe bleeding
6. Keeping pinching your nose continuously for at
least 5 mins (timedby clock) before checking if
the
bleeding has stopped. If your nose is still
bleeding, continue squeezing the nose for
another 10 mins.
7. If you’d like, apply an icepack to the bridge of
your nose to further help constrict blood vessels
(which will slowthe bleeding) & provide comfort.
8. You can spray an OTC decongestant spray, such
as oxymetazoline (Afrin, Dristan, Neo-
Synephrine, Vicks Sinex) into the bleeding side
of the nose & then apply pressure to the nose.
9. Warning. These topical decongestant sprays
should be used over a long period of time.
Doing so can cause anincrease in the chance
of nosebleed.
10. After the bleeding stop, Do not bend over,
strain and/or lift anything heavy. Do not blow
or rub your nose for several days.
PHARYNGITIS
- Inflammation of the Pharynx
- Sore throat
 CAUSES:
Viral Infections- common cold, influenza
or mononucleosis
Bacterial Infection – Strep throat- cause by
a Group A streptococcus.
 INCUBATION Pd.
2-5 days
 CAUSES OF PHARNGITIS:
1. Measles
2. Chicken pox
3. Adenovirus which is one of the causes
of common cold
4. Croup- childhood illness distinguishes by
barking cough
5. Whooping cough
6. Group A Streptococcus
7. Second hand smoke
 SIGNS & SYMPTOMS
1. Fever a low-grade fever w/ a cold & higher-
grade fever w/ the flu)
2. Sore throat/ scratchy throat
3. Swollen lymph nodes
4. Difficulty of swallowing
5. Loss of appetite
6. Red throat w/ white or gray patches
7. Increase WBC
 DIAGNOSTIC TEST
1. Physical Exam – white/gray patches
2. Throat culture or rapid strep test
3. Blood test & CBC
  HEALTH TEACHINGS
1. Drink plenty of fluids ➤Weaken voice
2. Eating warm broth
3. Gargling w/ warm salt water (1 teaspoon ➤Loss of voice
of salt per 8 ounces of water)
4. Use humidifier ➤Hoarse dry throat
5. Bed rest

 MEDICAL TREATMENTS ➤ Constant tickling or minor throat irritation

1. Amoxycillin & Penicillin – 7-10 days
2. Acetaminophen or Ibuprofen ➤Dry cough
3. Throat lozenges

 PREVENTION Diagnostic Test:

1. Avoid sharing food, drinks & eatingutensils
2. Avoid individuals who are sick
3. Wash your hands often, especially before
eating & after coughing or sneezing
4. Use alcohol based hand sanitizers
when soap & water aren’t available
5. Avoid smoking & inhaling secondhand smoke
LARYNGITIS
• inflammation of your voice box (larynx) from overuse,
irritation or infection.
• Acute Laryngitis - A temporary condition caused by
overusing the vocal cords.
Causes:
1. Laryngoscopy
Laryngoscopy - is an exam at the back of the throat
including voice box (larynx). Done in different ways:
• Indirect laryngoscopy uses a small mirror held at the
back of your throat. The health care provider shines a light
on the mirror to view the throat area.
• Fiberoptic laryngoscopy (nasolaryngoscopy)
uses a small flexible telescope. The scope is passed
through your nose and into your throat.
You sent
• Laryngoscopy using strobe light can also be done. Use of
strobe light can give the provider more information about
problems with your voice box.

• Direct laryngoscopy uses a tube called a

➤Viral infection
laryngoscope. The instrument is placed in the back of your
throat. The tube may be flexible or stiff.
➤Straining vocal cords by talking/yelling
Complications:
➤Bacterial infection
• Epiglottitis
➤Drinking too much alcohol
• Trouble breathing and swallowing
➤Chronic Laryngitis - results from long term exposure to
irritants. • Pneumonia

Causes: •Throat cancer

➤Frequent exposure to harmful chemicals or allergens Nursing Management:

• Voice rest
➤Frequent sinus infection
• Warm gargles
➤Smoking or being around smokers
• Bed rest
➤Overusing your voice
• Avoid alcohol and caffeine intake
➤ Low grade yeast infection cause by frequent use of an
asthma inhaler • Avoid smoking

➤Hoarse voice • Throat lozenges but not cough drops that contain
menthol
S/S:
• Use humidifier - alleviate dryness

• Increase fluid
• Corticosteroid
• Get vocal therapy to analyze and correct the way you use
your voice and any abnormal speech patterns that place
stress on your vocal cords and voice box.
• Gargle with 1/2 tsp. of salt and 1/2 tsp. of baking soda in
8 oz. of warm water.
• Avoid screaming or talking loudly for long periods of
time.
Obstructive sleep apnea (OSA)-This happens when
the airways swell and prevent a person from sleeping well,
which can lead to other medical issues without treatment.
Tonsillar cellulitis. It's also possible the infection will
worsen and spread to other areas of the body. This is
known as tonsillar cellulitis.
Peritonsillar abscess. The infection can also cause a
person to develop a buildup of pus behind the tonsils,
called a peritonsillar abscess. This can require drainage
and surgery.
Treatment

• Avoid decongestants, which can dry your throat. • Mild case - don't necessary treatment

• Refrain from whispering, which can strain the voice. • Severe - Antibiotic - penicillin

• Wash your hands regularly to avoid catching colds and • Tonsillectomy

upper respiratory infections.
Diagnosis:
• Avoid toxic chemicals in the workplace.
• Throat culture
• avoid foods that cause indigestion and heartburn.
• Complete blood count
TONSILLITIS
• Acute tonsillitis - symptoms will last 10 days or more.
• inflammation of the tonsils
• Chronic tonsillitis - symptoms continue longer than
• Your tonsils are the two lymph nodes located on each the acute presentation.
side of the back of your throat. They work as a defense
mechanism and help prevent your body from getting an Symptoms:
infection.
• Sore throat
• Tonsillitis can occur at any age and is a common
childhood illness. • Halitosis

• tender lymph nodes in the neck

Causes:
• Tonsil stone
Virus - common cold
Is tonsillitis contagious?
Bacterial infection - Strep throat
No - but the infectious organisms that cause it can pass to
Symptoms: other people for 24 to 48 hours before you develop any
symptoms.
• Sore throat
Viral tonsillitis
• Difficulty or pain while swallowing
Viruses are the most common cause of tonsillitis. The
• Scratchy sounding voice viruses that cause the common cold are often the source
of tonsillitis, but other viruses can also cause it, including:
• Bad breath • Rhinovirus
• Epstein barr virus
• Fever and chills • Hepatitis A
• HIV
• jaw and neck tenderness from swollen lymph nodes
Bacterial tonsillitis
Complications:
Bacterial tonsillitis is most common in children between
the ages of 5 to 15 years.
Around 15 to 30 percent of tonsillitis cases in this age
group result from bacteria. Most often, it's strep bacteria
which causes strep throat.
Management:
• Drink plenty of fluids
• Get lots of rest
• Gargle with warm salt water
Management:
• Use throat lozenges
• Eat popsicle or other frozen foods
• Use humidifier
• Avoid smoke
• Take acetaminophen or Ibuprofen
• Use throat sprays rather than lozenges for young
children.
Tonsillitis is most common in children, because they
come into close contact with others every day at school
and play.
Adenoiditis
Adenoiditis is the inflammation of the adenoid tissue,
which is caused by bacterial or viral infection & is usually
found in children
Symptoms:
 The swelling or enlargement of the adenoid tissue
generally restricts passage of air through the
upper respiratory tract, leading to difficulty in
breathing through the nose. This problem leads
to:
 Predominant breathing through the mouth,
which eventually causes sore/dry throat
 Stuffy nose/nasal congestion
 Snoring and trouble sleeping due to difficulty in
breathing
 Obstructive sleep apnea
 Earache
 Sounding nasal when talking or conversing
 Nasal discharge with greenish yellow mucus,
which may be a sign of infection.
Complications:
Middle ear infection: Since the adenoids are situated
next to the Eustachian tubes of the middle ear,
inflammation of adenoids may block the opening of the
tubes leading to middle ear infection.
Glue ear: In adenoiditis, blockage of the Eustachian
tubes causes build-up of mucus in the middle ear, which
interferes with the movements of the tiny bones and
consequently affects hearing.
Sinus infection: The sinuses are hollow regions located
within the facial bones which contain pockets of air and
communicate with the nasal passage. Enlarged adenoids
may both the opening of the sinuses into the nose, thereby
resulting in accumulation of secretion in the sinuses,
which can get infected.
Vomiting: This happens when the child inadvertently
swallows a great deal of pus, mainly while sleeping at
night.
Chest infections: If the adenoids become severely
infected with a virus or bacteria, child may experience
chest infections like pneumonia or bronchitis due to
spread of the infection to the lungs, bronchi.
Diagnosis:
 History of child's ear, nose and throat problem
 Physical exam - head and neck
 Flexible tube place through the nose - swab for
bacteriological culture
 Blood test
 X-ray of the throat or neck
 Check for any obstructive sleep apnea
 Optic fiber endoscopy
Treatment:
Middle ear infection - reduce pain and antibiotic
Adenoidectomy - observe for complications e.g. bleeding
and anesthetic reactions.
Observe nasal sound while talking - require speech
therapy
SINUSITIS
An inflammation or infection or infection of one of the
paranasal sinuses. PANSINUSITIS - more than one sinus
You sent
sinusitis
• Pathology-two protective mechanisms of the sinuses
fail to function leads impaired mucociliary action
• obstructed ostial opening
Mucus can accumulate in the sinus and becomes infected.
Classification:
1. Acute sinusitis - 3-5 days
2. Sub acute sinusitis - 1-3 mos. a. polymorphonuclear cells - infectious

3. Chronic sinusitis - greater than 3 mos. 4. Recurrent sinusitis

sinusitis - attacks every year
b. eosinophils - allergic sinusitis
Causes:
➤ Endoscopy
➤ Infection
➤ Allergies ➤ Culture/staining
➤ Chemical or particulate irritation of sinuses

S/S: CONDITIONS AFFECTING THE LOWER

RESPIRATORY SYSTEM
➤ Headache
ASTHMA
➤ Facial tenderness and/or swelling when Long term lung disease than inflames and
narrows the airways, the airways react strongly to
➤ facial areas over sinus areas are touched. inhaled substances, the muscles along the airways
constrict and excess mucus plugs up the narrowed
➤ Pressure or pain due to mucus pressing on sinus tissue airways (bronchi)
or inflammation of sinuses.
Causes
➤ Fever  Hereditary
 Other allergic conditions eczema and rhinitis
➤ A cloudy, discolored nasal drainage is often seen in  Urbanization with increase asthma prevalence,
bacterial sinus infections. smoking, drinking
 Events in early life affect the developing lungs,
➤ Congestion and increases the chances such as low birth rate,
tobacco smoke and pollution
➤ Post nasal drip  Exposure to a range of allergens and irritants are
also thought to increase asthma, like air
pollution and house dust mites, molds
➤ Sore throat occupational exposure to chemical and fumes or
dust.
➤ Cough  Children and adults who are overweight

➤ Tooth pain, Ear pain, Eye pain Common attack triggers

o Pets
➤ Fatigue o Smoke
o Air pollution
➤ Bad breath o Exercise excessive
o Pest
➤ Nasal drainage usually is clear or whitish colored in o Pets
people with noninfectious sinusitis. o Strong chemicals
o Certain occupation exposure
➤ Ulceration can occur with rare fulminant fungal
Signs and Symptoms
infections with sharply defined edges and a black, necrotic
 Chest tightness
center in the nasal area.
 Shortness of breath
Diagnostic test:  Wheezing sound
 Coughing
➤ X-ray
Diagnostic test
 Rev medical history
➤ CT scan
 Allergy
 Spirometry
➤ MRI scan
 Chest X-ray
 Blood test/Skin test
➤ Examination of nasal secretion
Treatment
 Bronchodilators
  Anti-Inflammatory Medicines
 Biological therapies for asthma, inhaler Xolair
(Omalizumab (Subcutaneous), Nucala
(Mepolizumab special eosinophil only if
present)
You can take asthma medicines in several different
ways you may breathe medicines or metered inhalers
Why is asthma worst at night?
 The way you sleep, sleeping on your back can
result in mucus dripping into your throat or acid
reflux coming back up from your stomach, also
sleeping on you back puts pressure on your chest
and lungs, which makes breathing more difficult.
However, lying face down or on your side can
put pressure on your lungs.
 Triggers in your bedroom and triggers that
happen in the evening, if you’ve been outside in
the early evening you may have brought pollen
in with you.
-Montelukast (medications for asthma) but you cannot
sleep properly for allergic rhinitis
-Air that’s too hot or too cold: Hot air can cause airways
to narrow when you breathe in, Col air is an asthma
trigger for some people
-Lung function changes: lung functions lessen at night as
a natural process
Types of Asthma
1. Adult onset asthma,
a. asthma can start at any age, but its more
common in people younger than 40.
2. Status Astmathicus,
a. these long lasting asthma attacks don’t
go away when you use bronchodilators,
they’re a medical emergency that needs
treatment right away
3. Asthma in children,
a. Coughing especially during play, at night
or while laughing
b. Less energy or pausing to catch their
breath while they play
c. Fast or shallow breathing
d. Wheezing
e. Shortness of breath
f. Weakness or fatigue
4. Exercise induced bronchoconstriction
a. Due to exercise
5. Allergic asthma
a. Due to allergies
6. Non allergic asthma,
a. this types of flares in extreme weathers
heat of summer or cold of winter
7. Occupational asthma
a. More on your line of work
8. Eosinophilic asthma
a. Marked by high levels of white blood
cells called eosinophils, it usually affects
adults between 35- 05 years old
9. Nocturnal asthma
a. Worst at night
10. Aspirin Asthma
a. Side effects of aspirin maintenance
11. Cough variant Asthma
a. Long term cough non treatment,
continuous
Management
1. Assess the vital signs as needed while in distress,
increase respiratory rate and rhythm indicate
early sign of impending respi distress
2. Assess breath sounds and adventitious sound
such as wheezes and stridor
3. Assess the relationship of inspiration to
expiration
4. Assess the presence of paradoxical pulse of 12
mmHg or greater indications sever airflow
obstruction
5. Monitory Oxygen Saturation
6. Plan for periods of rest between Activities
7. Maintian head of bed elvated
8. Encourage client to use poursed lip breathing for
exhalation
9. Administer Short acting beta 2 adrenergic
agonist
a. Albuterol (Proventil, Ventollin)
b. Levabuterol (Xopenex)
c. Terbutaline (Brethine)
10. Inhaled corticosteroids
a. Budesonide (Pulmicort)
b. Fluticasone( Flovent)
c. Beclomethasone (Vancenase)
d. Mometasone (Asmanex Twishaler)
CHRONIC BRONCHITIS (BLUE BLOATER)
Bronchitis is characterizing by inflammation of
the bronchial tubes(bronchi) the air passages that extend
form the terachea into the small airways and alveolie
Chronic bronchitis occurs when the lining of the
bronchial tubes repeatedly becomes irritated and
inflamed. The continuous irritation and swelling can
damage the airways and cause a buildup of sticky mucus,
making it difficult for air to move through the lungs
CHRONIC BRONCHITIS
A type of OCPD many people who have chronic
bronchitis eventually develop emphysema which also a
type of OCPD
ACUTE BRONCHITIS,
 Acute bronchitis develops from a cold or other 3. Encourage rest, avoidance of bronchial irritants
respiratory infection, Symptoms last less than 4 weeks, along with healthy and light diet to ease healing
often improving within a few days without lasting effects. 4. Advise the patient to finish the entire course of
antibiotics and explain the use of healthy foods
on medicine absorption
SYMPTOMS 5. Caution the individual on utilizing the over-the-
 Persistent cough (often referred to as smoker’s counter cough suppressants antihistamines and
cough) decongestants which might cause retention of
 Coughing up mucus that may be yellow or green and drying secretions. Cough preparations
 Wheezing containing mucolytic guaifenesin are suitable
 Chest discomfort 6. Advise the individual that a dry cough may
 Fatigue persist following aggravation of airways. Suggest
avoiding surroundings that are dry and suggest
 Fever
the use of a humidifier. Encourage the patient to
 Frequent and severe respite infcetions
completely stop smoking
 Swelling in the legs and akles (Peripheral 7. Educate the individual to recognize and instantly
edema) report early symptoms of acute bronchitis
8. Gargle with salt water
TREATMENTS 9. Steam inhalation
 Bronchodilator 10. Use humidifier in bedroom
 Theophylline 11. Use honey
 Steroids
 Pulmonary Rehabilitation
EPHYSEMA
Destroys alveoli that are air sacs in the lungs the air sacs
weaken eventually break, which reduces surface are of the
Lifestyle remedies to alleviate chronic bronchitis lungs and the amount of oxygen that can reach
 Breathing in warm moist air from humidifier can bloodstream this makes it hard to breathe (class photos)
help ease coughs and loosen mucus in your
airways TYPES
 Taking steps to limit irritants you inhale may
also help reduce inflammation 1. Centrilobular
 physical activity can help strengthen muscles a. Most common type associated with
that help you breathe smoking and coal workers, its starts in
 Pursed lip breathing respiratory bronchioles and spreads in
upper half of the lungs
CAUSES 2. Panacinar
 Smoking a. Associated with Alpha 1 antitrypsin
 Air pollution deficiency found in the lower half of the
 Infection ullgns cuaseing damage to the air sacs
3. Paraseptal (distal acinar)
DIAGNOSTISC a. Can occur alone or with the other kinds;
 X-ray when it occurs alone, its’s often with a
 ABG collapsed lung in a young adult. Affects
around the septa or pleura associated
 Blood test
with inflammation
 Spirometry
 Pulse oximetry Symptoms
 Ct scan  Exhaustion
There’s no cure for chronic bronchitis but there  Weight loss
are several treatments and therapies available to help
 Depression
manage your symptom. Certain lifestyle changes may
also help make you more comfortable  Bluish gray lips and finger nails

NURSING RESPONSIBILITES CAUSES

1. Boost secretion via ambulation coughing and
deep breathing
2. Increase fluid intake to liquiefy secretions and
protect against dehydration brought by fever
and tachypnea.
 Cigarette smoking
 Exposure to high pollution chemical fumes or
lung irritants
 A genetic condition called alpha-1 deficiency can
lead to a rare form of emphysema called alpha-1
deficiency related emphysema
  History of childhood respiratory infections
 A compromised immune system especially as a
result of HIV and rare disorders such as marfan
syndrome
DIAGNOSTIC TEST
1. Imaging, CT scan x-ray too look at your lungs
2. Blood test to determine how well your lungs
are transferring oxygen
3. Pulse oximetry to measure the oxygen content
of your blood
4. Lung function test, which measure how much
air your lungs can breathe in and out and how
well your lung delivers oxygen into your
bloodstream
5. Arterial blood gas tests to measure the
amount of blood and carbon dioxide in your
blood
6. Electrocardiogram (ECG) to check heart
function and rule out disease
COMPLICATIONS
 Pneumonia, viral or bacterial
 Many respiratory tract infections
 Cor pulmonale, a failure of the right side of
your heart
 Pneumothorax it is when air collects between
the lungs and the chest cavity that can lead to
lung collapse
 Respiratory acidosis which is when the lungs
can’t obtain enough oxygen leading to coma
 Hypoxemia which is when the lungs cannot
adequately oxygenate the blood
TREATMENT
 Bronchodilator
 Steroid
 Antibiotic
THERAPIES
 Pulmonary Rehabilitation – walking yoga and
breathing exercises
 Oxygen therapy (LOW FLOW)
 Surgery – lung volume reduction may be used to
remove small parts of the damaged lung and
lung transplant replace the entire lung
 Vaccination
NURSING MANAGEMENT
1. Asses the pt v/s characteristics of respiration
every 4 hours’ breath sounds
2. Suction secretions
3. Administer supplemental oxygen
4. Administer prescribed medications
5. Elevate head of bed – semi-fowlers position
6. Nebulization
7. Chest physiotherapy
8. Pulmonary rehabilitation program
9. Educate lifestyle changes
10. Demonstrate pursed lip and deep breathing
exercise
11. Ensure maintain quiet environment conductive
for resting and limit activity
BRONCHIECTASIS (PINK PUFFERS)
 Bronchiectasis is a condition where the
bronchial tubes of the lungs are permanently
damaged widened and thickened. These
damaged air passages allow bacteria and mucus
to build up and pool in the lungs. This results in
frequent infections and blockages of the airways
 No cure but its manageable with treatment
SYMPTOMS
 Barrel chest
 Coughing up blood wheezing sound
 Shortness of breath chest pain
 Weight loss
 Coughing up large amount of mucus everyday
 Mucus production
CAUSES
Cystic fibrosis (CF) bronchiectasis. This
type is related to having CF and is genetic condition that
causes a typical production of the mucus. CF affects your
lungs and other organs, like your pancreas and liver.
This results in repeated infections in your lungs and may
cause bronchiectasis.
Non-CF bronchiectasis
Previous respiratory infection pneumonia or
tuberculosis, primary ciliary dyskinesia, primary or
secondary immunodeficiency and COPD and asthma
DIAGNOSTIC TEST
 Ct scan
 Physical exam findings
 Cbc
 Immunoglobin levels
 Sputum culture
 Bronchoscopy
 Sweat chloride testing -used to screen for cystic
fibrosis in young adults with no identifiable
predisposing cause for bronchiectasis
TREATMENT
 Chest physiotheraphy
 Surgery
 Draining (ngt tube, suction)
 Lifestyle changes
 Bronchodilator
 Cortosteoriouid
 Antimicrobial therapy
TIPS FOR LIVING WITH BRONCHIECTASIS
 Take medications as prescribed
 Eat a healthy balanced diet
 Drink lots of water and not alcohol
 Get annual flu shot
 Wash hands
 Perform breathing exercises techniques
  Maintain good posture  Pulmonary edema
 Save your energy
 Relax and incorporate rest period throughout Nursing Management:
the day  Assess patient using a 1-10 pain rating scale for
intensity, characteristic and location of pain
PLEURISY  Deep breathing exercise and relaxation
 Inflammation of the pleura techniques
 When pleurisy is accompanied by pleural effusion, the  Vital signs and characteristics of respiration
fluid buildup will put pressure on the lungs and cause  Elevate head of bed
them to stop working properly.  Change position- reduce pain perception
 Shortness of breath- increase fluid buildup  Ensure calm non-threatening tone when
speaking to the client and maintain eye to eye
contact
Symptoms:  Use therapeutic touch
 Pain on one side of your chest  Use brief and simple touch
 Pain in your shoulders and back  Limit external sources of unnecessary stimuli
 Shallow breathing to avoid feeling pain particularly on times of planned rest and sleep
periods.
Causes:  Assist in developing schedule for rest and
 Tuberculosis and other bacterial infection activities of daily living.
 Cancerous tumor such as mesothelioma, pleural  Recognize the needs of the patient regarding self-
lymphoma and angiosarcoma care and accomplishment of activities
 Trauma to the chest
 Pneumothorax
 Thoracic endometriosis LUNG CANCER
 Viruses- influenza, mumps, adenovirus,  Lung cancer begins in the lungs and may spread
cytomegalovirus to lymph nodes or other organs in the body such
 Rheumatoid arthritis as the brain
 Pneumonia  When the cancer cells spread from one organ to
 SLE (Systemic lupus erythematosus) another, they are called metastases

Diagnosis: Types of lung cancer:

 Chest X-ray  Small cell- adenocarcinoma and squamous cell
 Blood test carcinoma
 CT and MRI scan o A disease in which malignant (cancer)
cells form in the tissues of the lung
 Ultrasound
 Non-small cell lung carcinoma
 ABG
Symptoms:
Treatment:
 Chest pain
 Antibiotics for bacterial infection
 Chronic cough
 Anti-inflammatory or biologic drugs for diseases  Hemoptysis
like SLE and anti-rheumatoid arthritis  Difficulty of breathing
 Anticoagulants as part of the Trusted Source  Facial swelling
treatment when the cause is a pulmonary  Loss of appetite
embolism
 Swollen neck veins
 Surgery for pus (empyema) individuals with large  Wheezing
amounts of fluid in their lungs (pleural effusion)
might have to stay in the hospital with a drain Diagnosis:
tube in the chest until fluids drain adequately.
 CT and PET
 Oxygen therapy for a pneumothorax  Sputum cytology
 Antiparasitic medications for pneumonia that is  Biopsy
caused by a parasite, though this cause is rare  Bronchoscopy

Stages of small cell lung cancer:

1. Limited- cancer is confined to one lung and
nearby lymph nodes. (Lymph nodes are part
Complications after treatment: of the lymphatic system that help filter out
 Bleeding in the lungs diseased cells.)
 Pneumothorax
 Hemothorax
 2. Extensive- cancer has spread to the other
lung and lymph nodes. It also may have
spread to bones, the brain and other organs.
Complications:
 Pleural effusion
 Pain
 SOB
Treatment:
 Radiation therapy
 Chemotherapy
 Immunotherapy
 Surgery
Types of non-small cell lung cancer:
1. Squamous cell carcinoma- cancer that forms in
the thin, flat cell lining the inside of the lungs.
This is also called epidermoid carcinoma.
Smoking is the single biggest risk factor of
squamous cell lung carcinomas
2. Large cell carcinoma- cancer that may begin in
several types of large cell. Sometimes called
undifferentiated carcinoma/ It grows and
spreads quickly. It can form in any portion of the
lungs.
3. Adenocarcinoma- cancer that begins in the cells
that line in the alveoli and make substances such
as mucus. It typically develops in the outer
portions of the lungs. Typically, slow growing.
Diagnosis:
 Blood work- blood tests can look for elevated
levels of proteins and blood cells that can show
cancer
 Urine test- a urinalysis can look for substances in
your urine that are a sign of cancer
 CT scan- takes detailed pictures of the inside of
the lungs to look for tumors
 PET scan- can look for places where cancer may
have spread. PET scans can also help doctors
determine whether nodules found on CT scans
might be cancerous.
 X-rays- takes images that can help look for
tumors
 Sputum cytology- you cough up a sample of
mucus. The mucus will be analyzed in a lab to
look for NSCLC.
 Bronchoscopy- a bronchoscopy- uses a tiny
camera on the end of the long thin tube to look
closely at the airways. This can help doctors see
tumor type and placement
 Endobronchial ultrasound- a type of
bronchoscopy that uses an attached ultrasound
probe. Doctors use it to look for and take a sample
of the lymph nodes between the lungs/
 Biopsy- a doctor will remove a tiny piece of lung
tissue or a small sample of lung fluid
 Thoracentesis
 Thoracoscopy- uses a tiny camera to collect
images of the lining of the chest and look for
tumors. It’s a surgical procedure that doctors will
do as the same time as biopsy.
Treatment:
 Surgery- the first treatment option in the early
stages of all types of lung cancer. Surgery can
remove the tumor and surrounding areas of the
tissue. A surgeon might remove all or part of the
affected lung.
 Ablation- uses heat to kill cancer cells. It’s an
alternative when surgery is not an option
 Radiation therapy- uses energy to kill cancer
cells. It can shrink tumors and help treat areas
that surgery cannot treat;
 Chemotherapy- uses strong medication to kill
cancer cells. Doctors recommend chemo when
cancer has spread or isn’t responding to
radiation. The type of NSCLC will determine the
exact chemo medications you’ll take.
 Targeted therapy- uses specialized anticancer
medications that attack cancer cells but not
healthy cells
 Immunotherapy- teaches your immune system
how to fight cancer cells. It can be especially
effective when combined with chemotherapy.
 A 2020 study trusted source involving more than
500 participants found that people with
adenocarcinoma had the longest life expectancy:
about 1 month longer than people with squamous
cell carcinoma, and 4 months longer than people
with large cells carcinoma and other types of
NSCLC.
Stages of Lung Cancer:
Non small lung cancer is divided into 4 stages:
 Stage 1- cancer has not metastasized
 Stage 2- cancer is detected in the lung and
surrounding lymph node
 Stage 3A- cancer has metastasized in the lymph
nodes and lungs (only on the side where cancer
cells proliferate)
 Stage 3B- cancer has progressed to other lymph
nodes
 Stage 4- cancer has metastasized to other distant
organs
RISK FACTOR TO LUNG CANCERS:
 Fam history
 Smoking or exposure to secondhand smoke
 Previous radiation treatment
 Exposure to carcinogens (occupational or
environmental)
Symptoms:
 Chronic cough
 Hemoptysis
 Anorexia
 Changes in mentation
 Changes in the body temperature
 Presence of small mass or lumps in the collarbone
or neck.
Prevention of lung cancer:
 Smoking cessation
 Vitamin A, E, and C intake
 Precaution with environmental exposure to
carcinogens
Nursing Management
 Provide information to the patient about the
diagnosis, planned treatments, length of therapy,
possible complications and expected outcomes
 Equip the patient with the necessary knowledge
regarding proper deep breathing, ROM exercises
and coughing techniques.
 Recommend tension free workouts and avoid
hard exercises, heavy lifting and isometric
exercise.
 Instruct to consume a high protein diet and to
consume high calorie snacks- stimulates tissue
regeneration and there is sufficient circulation
volume to aid in tissue perfusion
 Monitor patient’s behavior, expression and
remarks to accept his/her condition.
 Reassure patient with positive reinforcement and
acknowledge his/her worries, concerns and
anxieties. Encourage to communicate negative
emotions.
 Ascertain the patency of the chest tube drainage
system in patients who have undergone lung
segmentectomy, lobectomy, segmental resection
or wedge resection.
 Maintain accurate ABG, hemoglobin levels and
pulse oximetry readings on the patient.
 Monitor air movement or abnormal breath
sound.
 Encourage patient to adopt supine to side
position and upright sitting position.
 Observe patients level of consciousness (LOC)
and assess for signs of restlessness or changes in
mention.
 Assess and rate patient’s intensity of pain.
Analyze features of pain (stabbing, persistent,
burning)
 Implement suctioning to clear excess secretion
and instruct patient on proper coughing and
breathing technique.
 Examine patient’s sputum and aspirated
secretions for volume, color and consistency.
 Provide ultrasonic nebulizer or oxygen therapy to
the patient.
 Administer IVF
 Recommend to consume fluid at least 2.5 L daily
within the limits of his/her cardiac tolerance.
PNEUMONIA
• Pneumonia is an acute inflammatory response deep in
the lungs, in the alveoli.
• When a tissue is infected or injured, there is an
inflammatory response that is, in the simplest
sense, an accumulation of pus.
• When the deep lungs are injured or infected, pus
accumulates there. Pus in the alveoli is pneumonia.
Etiology:
 pneumococcus- rusty
 virus - white
 fungi - clear white
 protozoa - mucoid
 bacteria -yellow or green
Symptoms:
 Chest pain when you breathe or cough
 Confusion or changes in mental awareness (in
adults age 65 and older)
 Cough, which may produce phlegm
 Fatigue
 Fever, sweating and shaking chills
 Lower than normal body temperature (in adults
older than age 65 and people with weak immune
systems)
 Nausea, vomiting or diarrhea
 Shortness of breath
Types of Pneumonia:
1. Community acquired pneumonia -occurs outside
hospital or other health care facilities. It may be caused
by:
• Bacteria - Streptococcus pneumonia
• Bacteria like organism - Mycoplasma pneumonia
• Fungi
• Viruses including Covid 19
2. Hospital acquired pneumonia - Some people catch
pneumonia during a hospital stay for another illness.
People who are on breathing machines (ventilators), often
used in intensive care units, are at higher risk of this type
of pneumonia.
3. Health care-acquired pneumonia -is a bacterial
infection that occurs in people who live in long-term care
facilities or who receive care in outpatient clinics,
including kidney dialysis centers. Like hospital-acquired
pneumonia, health care-acquired pneumonia can be
caused by bacteria that are more resistant to antibiotics
4. Aspiration pneumonia occurs when you inhale food,
drink, vomit or saliva into your lungs. Aspiration is more
likely if something disturbs your normal gag reflex, such
as a brain injury or swallowing problem, or excessive use
of alcohol or drugs.
Risk factors of Pneumonia:
• Children who are 2 years old or younger
• People who are age 65 or older
• Being hospitalized. You're at greater risk of
pneumonia if you're in a hospital intensive care unit,
especially if you're on a machine that helps you breathe (a
ventilator).
• Chronic disease. You're more likely to get pneumonia if
you have asthma, chronic obstructive pulmonary disease
(COPD) or heart disease.
• Smoking. Smoking damages your body's natural
defenses against the bacteria and viruses that cause
pneumonia.
 Weakened or suppressed immune system. People
who have HIV/AIDS, who've had an organ
 transplant, or who receive chemotherapy or long-
term steroids are at risk.
Complications:
 Bacteria in the bloodstream (bacteremia).
Bacteria that enter the bloodstream from your
lungs can spread the infection to other organs,
potentially causing organ failure.
 Difficulty of breathing
 Fluid accumulation around the lungs (pleural
effusion). Pneumonia may cause fluid to build up
in the thin space between layers of tissue that line
the lungs and chest cavity (pleura). If the fluid
becomes infected, you may need to have it
drained through a chest tube or removed with
surgery.
 Lung abscess. An abscess occurs if pus forms in a
cavity in the lung. An abscess is usually treated
with antibiotics. Sometimes, surgery or drainage
with a long needle or tube placed into the abscess
is needed to remove the pus.
Prevention:
 Get vaccinated
 Make sure children get vaccinated
 Practice good hygiene
 Don't smoke
 Keep your immune system strong. Get enough
sleep,
exercise regularly and eat a healthy diet.
Diagnosis:
 Blood test
 Chest X-ray
 Pulse oximetry
 Sputum test
 CT Scan
 Pleural fluid culture
Nursing management:
Ineffective airway clearance:
• Assess the rate, rhythm, and depth of respiration,
chest movement, and use of accessory muscles.
• Assess cough effectiveness and productivity
• Auscultate lung fields, noting areas of decreased or
absent airflow and adventitious breath sounds: crackles,
wheezes.
• Observe the sputum color, viscosity, and odor.
Report changes.
• Assess the patient's hydration status.
• Elevate the head of the bed and change position
frequently.
• Teach and assist the patient with proper deep-
breathing exercises. Demonstrate proper splinting of the
chest and effective coughing while in an upright position.
 Encourage the patient to do so often.
 Suction as indicated: frequent coughing,
adventitious breath sounds, desaturation related
to airway secretions.
 Maintain adequate hydration by forcing fluids to
at least 3000 mL/day unless contraindicated
(e.g., heart failure).
 Offer warm, rather than cold, fluids.
 Assist and monitor effects of nebulizer treatment
and
 other respiratory physiotherapy: incentive
spirometer, IPPB, percussion, postural drainage.
Perform treatments between meals and limit
fluids when appropriate.
 Encourage ambulation. Helps mobilize
secretions and reduces atelectasis.
 Administer medications, as indicated:
o Mucolytics increase or liquefy
respiratory secretions.
o Expectorants increase productive cough
to clear the airways by liquefying lower
respiratory tract secretions and reducing
their viscosity.
o Bronchodilators are medications used to
facilitate respiration by dilating the
airways
o Analgesics are given to improve cough
effort by reducing discomfort but should
be used cautiously because they can
decrease cough effort and depress
respirations.
 Use humidified oxygen or humidifier at the
bedside.
 Monitor serial chest ×-rays, ABGs, and pulse
oximetry readings.
 Assist with bronchoscopy and thoracentesis, if
indicated.
 Anticipate the need for supplemental oxygen or
intubation if the patient's condition deteriorates.
o These measures are needed to correct the
hypoxemia. Intubation is needed for deep
suctioning efforts and provides a source for
augmenting oxygenation.
 Urge all bedridden and postoperative patients to
frequently perform deep breathing and coughing
exercises.
PULMONARY TUBERCULOSIS
 A contagious, airborne infection that destroys
body tissue.
 Pulmonary TB occurs when M. tuberculosis
primarily attacks the lungs. However, it can
spread from there to other organs.
 TB is one of the world's deadliest diseases, with
approximately 1.3 million related deaths
occurring worldwide in 2017.
 Pulmonary TB is curable with an early diagnosis
and antibiotic treatment.
Symptoms
 cough up phlegm
 cough up blood
 have a consistent fever, including
low-grade fevers
  have night sweats • Cardiac tamponade
 have chest pains
 have unexplained weight loss
Diagnosis:
How pulmonary TB spreads 1. Mantoux (tuberculin) TEST
 shaking hands PPD - purified protein derivatives
 sharing food or drink Tuberculin antigen
 sleeping in the same bed < 5mm =negative
 Kissing 5-9 mm =doubtful(?)

Risk factors for pulmonary TB 10>mm=positive

 correctional facilities
2.Chest X-ray: TB lesions
 group homes
 nursing homes
3.SPUTUM FOR AFB - early morning deep cough - 2 ml
 hospitals specimen collected - THREE CONSECUTIVE (+)
 shelter RESULTS
S/S: • CT scan
 Systemic - afternoon rise of temperature (low • Bronchoscopy
grade fever) • Thoracentesis
 Night sweats, weight loss, fatigue or malaise, • Lung biopsy
anorexia, Cachexia, chest pain
 Pulmonic - coughing for 3 weeks or more, Treatment:
hemoptysis, Influenza- like symptom  TB drugs
 Ghon's complex- lesions remains in the LUNGS  Isoniazid
even after the INFECTION has been long  Pyrazinamide
resolved.
 Ethambutol
Latent TB - You have TB infection but the  Rifampicin
- Your doctor might recommend an approach called
bacteria in your body are inactive.
directly observed therapy (DOT) to ensure that you
Active TB - This condition makes you sick
complete your treatment. Stopping treatment or skipping
and in most cases can spread to others. It
doses can make pulmonary TB resistant to medicines,
can occur weeks or years after infection
with TB bacteria. leading to MDR-TB.

MDR-TB (Multidrug therapy)

 is TB that is resistant to the typical antibiotics
Risks factors: used to treat the condition, which are isoniazid
• weakened immune system - conditions that and rifampicin.
can weaken immune system:
Some of the factors that contribute to MDR-TB
 HIV/AIDS
include:
 Diabetes
• healthcare providers prescribing an incorrect
 Severe kidney disease drug to treat 1B
 Certain cancers • people stopping treatment early
 Drugs to prevent rejection of transplanted organs • people taking poor-quality medications
 Some drugs used to treat rheumatoid arthritis
•Traveling or living in certain areas with high Tips to minimize risk for pulmonary TB
tuberculosis rate • Provide education on preventing TB like cough
• IV drugs or excessive alcohol use etiquette.
• Cigarette smoke • Avoid extended close contact with someone who has TB.
• Regular contact of people who are ill • Air out rooms regularly.
• People who work in prisons, homeless shelters, • Cover your face with a mask that is approved for
psychiatric hospitals or nursing homes due to protection against TB.
overcrowding and poor ventilation
• Close contact with someone who has TB I. PREVENTIVE
• BCG (Bacillus Calmette Guerin)
Complications: • Chemoprophylaxis - IPT (Isoniazid
• Spinal pain Preventive Therapy)
• Joint damage
• Meningitis
•Liver/kidney problem
Il. CURATIVE
 CHEMOTHERAPY - after 2-3 weeks’ strict
compliance the client is no longer a PUBLIC
HAZARD
-USE of 1,2,3 or more drugs at a time.

Effects of ANTI TB drugs

 ETHAMBUTOL - Blurred vision, eye pain (optic
neuritis)
-RED-GREEN Color BLINDNESS
 RIFAMPICIN - red urine & Body discharges
 STREPTOMYCIN -ringing in the ear, damage to
the eight cranial nerve, feeling of drunkenness
 Pyrazinamide
- increase uric acid in the blood- hyperuricemia,
arthralgias and
 Gl distress
 Isoniazid - peripheral neuritis, hepatic enzyme
elevation, hepatitis, and hypersensitivity.

HOSPITALIZATION - in ACUTE symptom

Eg. FRANK hemoptysis, severe dyspnea, emaciation
SURGERY - chest tube insertion to WSDS (complication)

XPTB - XTB
 Occurring anywhere outside the lungs but in
areas with good oxygen (aerobic) like:
1. renal
- bone plate
- meninges
- GUT
-Pericardium
-Endocrine glands
-Lymph nodes

MOTT
• Mycobacterium Other Than Tuberculosis
• Other strains but may show symptoms that of
tuberculosis
 Kansasil
 Avium - intracellulare
 Scrofulaceum
 BOViS
 Fortuitum

NURSING MANAGEMENT:
• Identify others at risk like household members, close
associates and friends.
• Instruct patient to cough or sneeze and expectorate into
tissue and to refrain from spitting.
• Review proper disposal of tissue and good hand washing
techniques.
• Monitor temperature as indicated.
• Stress importance of uninterrupted drug therapy.
Evaluate patient's potential for cooperation.
- Provide frequent small "snacks" ' in place of large meals
as appropriate.