MEDICAL SURGERICAL NURSING

LECTURE / NURS 13
PPTS / BOOK

CONCEPT IN OXYGENATION: RESPIRATORY • Gas exchange - the respiratory system organs oversee the gas
DISORDERS exchanges that occur between the blood and the external
environment.
• Passageway - passageways that allow air to reach the lungs
OUTLINE
I Review of Anatomy and Physiology of the Respiratory • Humidifier - purify, humidify, and warm incoming air
Functions I. ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY
II Respiratory Examination Assessment SYSTEM
III Diagnostic Evaluation
IV Respiratory Diseases ANATOMY OF RESPIRATORY SYSTEM
A Pathology and Physiology PARTS OF UPPER RESPIRATORY TRACT
B Causative Factors and Risk Factors
C Chief Complaints
D Relevant Information
E Invasive and Non-Invasive Diagnostic Examination, Its
Result and Implications

TERMINOLOGY MEANING
• Necessary to sustain life
Oxygen • The cardiac and respiratory systems
supply the oxygen demand of the body

• Oxygenated through the mechanisms of

Blood ventilation, perfusion, and transport of
respiratory gases
• Addition of oxygen to any system,
including the human body. It may also
Oxygenation refer to the process of treating a patient
with oxygen, or of combining a medication
or other substance with oxygen
• Process of exchanging oxygen and
carbon dioxide, which is essentially
breathing
Ventilation • Oxygen comes in to the body via the
airway, it’s offloaded onto the red blood
cells while carbon dioxide diffuses across
the membrane into the alveoli and is then
exhaled
• Substances moving across concentration
gradients from areas of higher
Diffusion concentration to areas of lower
concentration
• The process involved with gas exchange
• Body process of supplying oxygenated
blood to the cells and is reliant on
Perfusion
adequate cardiac output in order to be
optimal
1. NOSE
• External nose is made up of a framework of bone and cartilage
• Internally divided into two passages or nares (nasal cavity) by
the septum
→ Air enters the system through the nares
• The septum is covered with mucous membrane, where the
olfactory receptors are located
→ Olfactory receptors are responsible for the sense of
smell
• Respiratory mucus lines most of the nasal cavity that has
lysozymes which destroy bacteria chemically
• Consists of ciliated cells that moves the contaminated mucus
toward the throat
• Turbinate bones (conchae) located internally, assist in warming
and moistening the air
• The major function of the nose are warming, moistening and
filtering air
• Consist of anastomosis of capillaries known as Kiesselbach
Plexus, the site of nose bleeding

• Low oxygen level in the tissues. Note:

Hypoxia • SpO2 <90% as measured by pulse Nasal cavity is surrounded by paranasal sinuses that lighten
oximetry the skull and act as the resonance of speech. It includes four pair
• Low level of oxygen in arterial blood of bony cavities that are lined with nasal mucosa and ciliated
Hypoxemia epithelium. They produce mucus that drains into nasal cavity
• PaO2 below 80 mmHg
• Measures how much oxygen the
hemoglobin in the blood is carrying
Pulse Oximetry • This is called the oxygen saturation and is
a percentage
• Scored out of 100

REESPIRATORY SYSTEM
• Network of organs and tissues that help you breathe
• It includes your airways, lungs and blood vessels
• These parts work together to move oxygen throughout the body
and clean out waste gases like carbon dioxide
WHAT DOES RESPIRATORY SYSTEM DO?
• Oxygen supplier - the job of the respiratory system is to keep
the body constantly supplied with oxygen
• Elimination - elimination of carbon dioxide
2. PHARYNX
• A muscular passageway commonly called the throat
• Air passes through the nose to the pharynx
• About 13 cm (5 inches) long that vaguely resembles a short
length of red garden hose
• Serves as a muscular passageway for both food and air

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→ Nasopharynx - located above the soft palate of the
mouth, contains the opening to the eustachian tubes
which is a narrow passage leading from the pharynx to
the cavity of the middle ear
→ Oropharynx - located directly behind the mouth and
tongue; air and food enter the body through oropharynx
→ Laryngopharynx - extends from the epiglottis to the
sixth cervical level
• Pharyngotympanic tubes drain the middle ears, open into the
nasopharynx
• Clusters of lymphatic tissue called tonsils are also found that
play a role in protecting the body from infection
→ Single pharyngeal tonsil (adenoid) is located high in
the nasopharynx
→ Two palatine tonsils are at the end of oropharynx at the
end of soft palate
→ Two lingual tonsils lie at the base of the tongue
3. LARYNX
• Broad area of lungs resting on diaphragm is called the base and
the narrow superior portion called the apex
• Pleural cavity
→ Parietal pleura - lines the chest walls and secretes small
amounts of lubricating fluid into the intrapleural space or
pleural cavity, this fluid holds the lungs and chest wall
together as a single unit while allowing them to move
separately
→ Visceral pleura - covers the surface of the lungs, blood
vessels, nerves, and bronchi
→ Pleural Fluid - allow optimal expansion and contraction
of the lungs during breathing and prevents pleural
friction rub (as seen in pneumonia and pleural effusion)
• Conducting zone - all other respiratory passages are conducting
zone structures that serve as conduits to and from the respiratory
zone
• Respiratory zone - includes the respiratory bronchioles, alveolar
ducts, alveolar sacs, and alveoli, is the only site of gas exchange

• Also called voice box connects upper and lower airways

• Routes air and food into the proper channels
• Formed by 8 rigid hyaline cartilages
• Made up of framework of:
→ Epiglottis - valve that covers the opening to the larynx
during swallowing
→ Glottis - opening between the vocal cords
→ Hyoid bone - u-shaped bone in neck
→ Thyroid cartilage - forms the Adam’s apple
→ Arytenoid cartilage
→ Cricoid cartilages
→ Vocal cords
→ Speech production and cough reflex
• Larynx opens to allow respiration and closes to prevent
aspiration when food passes through the pharynx Note:
• Vocal cords of larynx permit speech and are involved in the Client post pneumonectomy → affected side to promote
cough reflex expansion Post lobectomy → unaffected side to promote
• For phonation (voice production) drainage
PARTS OF LOWER RESPIRATORY TRACT
RESPIRATORY
DESCRIPTION
MEMBRANE
Walls of the alveoli are composed
Wall Structure largely of a single, thin layer of
squamous epithelial cells

Alveolar pores connecting

neighboring air sacs and provide
alternative routes for air to reach
Alveolar Pores
alveoli whose feeder bronchioles
have been clogged by mucus or
otherwise blocked
The fused basement membranes,
and occasional elastic fibers of the
alveolar and capillary walls construct
Respiratory Membrane the respiratory membrane (air-blood
barrier), which has gas (air) flowing
4. TRACHEA past on one side and blood flowing
• Also known as “windpipe” past on the other
• Air move from the pharynx to larynx to trachea
Sometimes called “dust cells”,
→ Length of 11-13 cm and diameter of 1.5-2.5 cm in adult
wander in and out of the alveoli
• Extend from the larynx to the second costal cartilage, where it Alveolar Macrophages
picking up bacteria, carbon particles,
bifurcates and is supported by 16-20 C-shaped cartilage rings and other debris
• The area where the trachea divides into two branches is called
the carina Scattered amid the epithelial cells
• Consist of cartilaginous rings that form most of the alveolar walls
are chunky cuboidal cells, which
• Serves as passageway of air going to the lungs
Cuboidal Cells produce a lipid (fat) molecule called
• Site of tracheostomy (4th-6th tracheal ring) surfactant, which coats the gas-
• Lined with ciliated mucosa, which are surrounded by goblet cells exposed alveolar surfaces and is
that produce mucus very important in lung function
→ The cilia propel the mucus with dust and particles to the
throat, away from the lungs where it can be swallowed 6. BRONCHI
or spat out
• Right main bronchus
5. LUNGS → Larger, shorter, and straighter than the left
• Paired elastic structure enclosed in the thoracic cage, which is → More common site for an inhaled foreign object to
an airtight chamber with distensible walls become lodged
→ Divided into three lobar branches (upper, middle, and
• Right lung consists of 3 lobes, 10 segments
lower bronchi) to supply the three lobes of right lung
• Left lung consists of 2 lobes, 8 segments
• Left main bronchus
• Main organ of respiration, lie within the thoracic cavity on either → Divides into the upper and lower lobar bronchi to supply
side of the heart the left lobes

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• Lobar Bronchi: 3 right and 2 left
• Segmental Bronchi: 10 right and 8 left
• Subsegmental Bronchi
Bronchioles
Tertiary
bronchi
Primary
bronchi
Alveoli
7. BRONCHIOLES
• The tracheobronchial tree ends at the terminal bronchial
• Terminal Bronchioles
→ Distal to the terminal bronchioles the major function is
no longer air conduction but gas exchange between
blood and alveolar air
• Respiratory Bronchioles
→ Considered to be the transitional passageways between
the conducting airways and the gas exchange
→ Serves as the transition to the alveolar epithelium
• In the bronchioles, airway patency is primarily dependent upon
elastic recoil formed by network of smooth muscles
8. ALVEOLI
• Functional cellular units or gas-exchange units of the lungs
• O2 and CO2 exchange takes place
• Made up of about 300 million
• Produces surfactant
• Types of alveolar cells
→ Type 1 pneumocytes - provide structure to the alveoli
→ Type 2 pneumocytes - secretes surfactant, reduces
surface tension; increases alveoli stability and prevents
their collapse
❖ Composed of lecithin and spingomyelin
❖ Lecitin / Spingomyelin ratio - to determine lung
maturity
❖ Normal Lecitin / Spingomyelin ratio → 2:1
❖ In premature infants, immature lungs → 1:2
❖ Give oxygen of less 40% in premature - to prevent
atelectasis and retrolental fibroplasias
❖ Retinopathy & blindness: in premature
→ Alveolar macrophages - destroys foreign material,
such as bacteria
PULMONARY CIRCULATION
• Provides for reoxygenation of blood and release of CO2
• Gas transfers occurs in the pulmonary capillary bed
• Pulmonary arteries
→ Carry blood from the heart to the lungs
• Pulmonary veins
→ Large blood vessel of the circulatory system that carries
blood from the lungs to the left atrium of the heart
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RESPIRATORY MUSCLES
• Primary: diaphragm and external intercostal muscles
• Accessory: sternocleidomastoid (elevated sternum), the
scalene muscles (anterior, middle and posterior scalene) and the
nasal alae
PHYSIOLOGY OF RESPIRATORY SYSTEM
VENTILATION
• The movement of air in and out of the airways
• The thoracic cavity is an air tight chamber, the floor of this
chamber is the diaphragm.
• Inspiration
→ Air enters through the trachea and moves into the
bronchi, bronchioles, and alveoli, and inflates the lungs
→ Contraction of the diaphragm (movement of this
chamber floor downward)
→ Contraction of the external intercostal muscles increases
the space in this chamber
→ Lowered intrathoracic pressure causes air to enter
through the airways and inflate the lungs
• Expiration
→ With relaxation, the diaphragm moves up and
intrathoracic pressure increases, this increased
pressure pushes air out of the lungs
→ Expiration requires the elastic recoil of the lungs
• Inspiration normally is 1/3 of the respiratory cycle and expiration
is 2/3
• Inspiration is normally requiring energy; expiration is normally
passive requiring very little energy
PROCESS OF OXYGENATION
• When you inhale through your nose or mouth, air travels down
your pharynx (back of your throat), passes through your larynx
(voice box) and into your trachea (windpipe)
• Your trachea is divided into two air passages called bronchial
tubes
→ One bronchial tube leads to your left lung, the other to
your right lung
→ For your lungs to perform their best, your airways need
to be open when you inhale and when you exhale
→ They also need to be free from inflammation (swelling)
and abnormal amounts of mucus.
• Your bronchial tubes lead to smaller air passages called bronchi,
and then into bronchioles. The bronchioles end in tiny air sacs
called alveoli, where oxygen is transferred from the inhaled air to
your blood
→ Alveoli look like clusters of small round fruits.
• After absorbing oxygen, the blood leaves your lungs and is
carried to your heart. From there, it’s pumped through your body
to provide oxygen to the cells of your tissues and organs.
• When cells use oxygen, they produce carbon dioxide and
transfer it to your blood
→ Your bloodstream carries the carbon dioxide back to
your lungs
DRIVING FORCE OF AIRFLOW
• Airflow driven by the pressure difference between atmosphere
(barometric pressure) and inside the lungs (intrapulmonary
pressure)
AIRWAY RESISTANCE
• Resistance is determined chiefly by the radius size of the airway
• Causes of Increased Airway Resistance
✓ Contraction of bronchial mucosa
✓ Thickening of bronchial mucosa
✓ Obstruction of the airway
✓ Loss of lung elasticity
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RESPIRATION • Refers to blue discoloration of skin and mucous membranes, is

• The process of gas exchange between atmospheric air and the due to presence of deoxygenated hemoglobin in superficial
blood at the alveoli, and between the blood cells and the cells of blood vessels
the body • Central cyanosis
• Exchange of gases occurs because of differences in partial → Abnormal amount of deoxygenated hemoglobin in
pressures arteries and that blue discoloration is present in parts of
body with good circulation such as tongue
• Oxygen diffuses from the air into the blood at the alveoli to be
transported to the cells of the body • Peripheral cyanosis
→ Occurs when blood supply to a certain part of body is
• Carbon dioxide diffuses from the blood into the air at the alveoli
reduced, and the tissue extracts more oxygen from
to be removed from the body
normal from the circulating blood, e.g. lips in cold
NEUROCHEMICAL CONTROL weather are often blue, but lips are spared
• Causes of cyanosis
NEDULLA OBLANGATA → Central cyanosis
• Respiratory center initiates each breath by sending messages to ✓ Decreased arterial saturation
primary respiratory muscles over the phrenic nerve - has ❖ Decreased concentration of inspired oxygen:
inspiration and expiration centersIncrease the proportion of high altitude
adolescents who engage in vigorous activity that promotes ❖ Lung disease: COPD with cor pulmoale,
cardiorespiratory fitness for 20 or more minutes per occasion massive pulmonary embolism
❖ Right to left cardiac shunt (cyanotic congenital
PONS heart disease)
✓ Polycythemia
• Has 2 respiration centers that work with the inspiration center to
✓ Hemoglobin abnormalities (rare):
produce normal rate of breathing
methemoglobinaemia, sulfhemoglobinemia
• Pneumotaxic center → Peripheral cyanosis
→ Affects the inspiratory effort by limiting the volume of air ✓ All causes of central cyanosis cause peripheral
inspired cyanosis
• Apneustic center ✓ Exposure to cold
→ Prolongs inhalation ✓ Reduced cardiac output: left ventricular failure or
shock
Note: ✓ Arterial or venous obstruction
Chemoreceptors responds to changes in ph, increased POSITION
PaCO2 = increase RR
• Patient sitting over edge of bed
II. RESPIRATORY EXAMINATION ASSESSMENT GENERAL APPEARANCE
BACKGROUND INFORMATION
DYSPNEA
ABNORMAL PATTERNS OF BREATHING
• Normal respiratory rate < 14 each minute
SLEEP APNEA • Tachypnoea = rapid respiratory rate
• Cessation of airflow for more than 10 seconds more than 10 • Are accessory muscles being used
times a night during sleep → Sternomastoids, platysma, strap muscles of neck
• Causes: obstructive → Characteristically, the accessory muscles cause
→ E.g. obesity with upper narrowing, enlarged tonsils, elevation of shoulders with inspiration and aid respiration
pharyngeal soft tissue changes in acromegaly or by increasing chest expansion
hypothyroidism)
CYANOSIS
CHEYNE-STOKES • Bluish color in the skin, lips, and nail beds caused by a shortage
• Periods of apnea alternating with periods of hyperpnoae of oxygen in the blood
• Pathophysiology: delay in medullary chemoreceptor response to • Cyanosis occurs because blood with low levels of oxygen turns
blood gas changes blue or purple
• Causes • This low-oxygen blood causes a blue-purple tint to the skin
→ Left ventricular failure
CHARACTER OF COUGH
→ Brain damage (e.g. trauma, cerebral, haemorrhage)
→ High altitude • Ask patient to cough several times
• Lack of usual explosive beginning may indicate vocal cord
KUSSMAUL'S (AIR HUNGER) paralysis (bovine cough)
• Deep rapid respiration due to stimulation of respiratory centre • Muffled, wheezy ineffective cough suggests airflow limitation
• Causes: metabolic acidosis (e.g. diabetes mellitus, chronic renal • Very loose productive cough suggests excessive bronchial
failure) secretions due to:
→ Chronic bronchitis
HYPERVENTILATION → Pneumonia
• Complications: alkalosis and tetany → Bronchiectasis
• Causes: anxiety • Dry irritating cough may occur with
→ Chest infection
ATAXIC (BIOT) → Asthma
• Irregular in timing and deep → Carcinoma of bronchus
→ Left ventricular failure
• Causes: brainstem damage
→ Interstitial lung disease
APNEUSTIC → ACE inhibitors

• Post-inspiratory pause in breathing SPUTUM

• Causes: brain (pontine) damage • Volume
PARADOXICAL • Type
→ Purulent - off-white, yellow or green, and opaque;
• The abdomen sucks with respiration (normally, it pouches presence of large numbers of white blood cells
outward due to diaphragmatic descent) → Mucoid - clear, white or grey and occurs in asthma and
• Causes: diaphragmatic paralysis chronic bronchitis and in acute viral respiratory infections
→ Mucopurulent - pale yellow/pale green; commonly
CYANOSIS found in bacterial pneumonia or bronchitis
• Presence or absence of blood?

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FACE
EYES
• Horner's syndrome
→ Constricted pupil, partial ptosis and loss of sweating
which can be due to apical lung tumor compressing
sympathetic nerves in neck)

STRIDOR
• Croaking noise loudest on inspiration
• A sign that requires urgent attention
• Causes: obstruction of larynx, trachea or large bronchus NOSE
• Acute onset (minutes) • Polyps (associated with asthma)
→ Inhaled foreign body → Projecting growth of tissue from a surface in the body,
→ Acute epiglottitis usually a mucous membrane
→ Anaphylaxis
• Engorged turbinate (various allergic conditions)
→ Toxic gas inhalation
• Deviated septum (nasal obstruction)
• Gradual onset (days, weeks)
→ Laryngeal and pharyngeal tumors MOUTH AND TONGUE
→ Cricoarytenoid rheumatoid arthritis
→ Bilateral vocal cord palsy • Look for central cyanosis
→ Tracheal carcinoma • Evidence of upper respiratory tract infection (a reddened
→ Para tracheal compression by lymph nodes pharynx and tonsillar enlargement with or without a coating of
→ Post-tracheostomy or intubation granulomata pus)
• Broken tooth - may predispose to lung abscess or pneumonia
HOARSENESS • Sinusitis is indicated by tenderness over the sinuses on
• Causes palpation
→ Laryngitis • Some patients with obstructive sleep apnea will be obese with a
→ Laryngeal nerve palsy associated with carcinoma of lung receding chin, a small pharynx and a short thick neck
→ Laryngeal carcinoma
TRACHEA
HANDS
• Causes of tracheal displacement:
CLUBBING → Toward the side of the lung lesion
✓ Upper lobe collapse
• Commonly cause by respiratory disease but not emphysema or ✓ Upper lobe fibrosis
chronic bronchitis ✓ Pneumonectomy
• Occasionally, clubbing is associated with hypertrophic ✓ Upper mediastinal masses, such as retrosternal
pulmonary osteoarthropathy (HPO) goiter
→ Characterized by periosteal inflammation at distal ends → Tracheal tug (finger resting on trachea feels it move
of long bones, wrists, ankles, metacarpals and inferiorly with each inspiration) is a sign of gross
metatarsals overexpansion of the chest because of airflow
→ Swelling and tenderness over wrists and other involved obstruction
areas
CHEST: INSPECTION OF SHAPE AND SYMMETRY

BARREL SHAPED
• Anteroposterior (AP) diameter is increased compared with lateral
diameter
• Causes: hyperinflation due to asthma, emphysema

STAINING
• Staining of fingers is a sign of cigarette smoking
→ Caused by tar, not nicotine

WASTING AND WEAKNESS

PULSE RATE PIGEON CHEST (PECTUS CARINATUM)

• Localized prominence (outward bowing of sternum and costal
FLAPPING TREMOR (ASTERIXIS) cartilages)
• Unreliable sign • Causes:
• Ask patient to dorsiflex wrists and spread out fingers, with arms → Manifestation of chronic childhood illness due to
outstretched repeated strong contractions of diaphragm while thorax
is still pliable
• Flapping tremor may occur with severe carbon dioxide retention
→ Rickets
(severe chronic airflow limitation)

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PROMINENT VEINS
• Cause: superior vena cava obstruction

ASYMMETRY OF CHEST WALL MOVEMENTS

• Assess this by inspecting from behind patient, looking down the
clavicles during moderate respiration - diminished movement
indicates underlying lung disease
• The affected side will show delayed or decreased movement
• Causes of reduced chest wall movements on one side are
localized:
FUNNEL CHEST (PECTUS EXCAVATUM) → Localized pulmonary fibrosis
• Developmental defect involving a localized depression of lower → Consolidation
end of sternum in severe cases, lung capacity may be restricted → Collapse
→ Pleural effusion
→ Pneumothorax
• Causes of bilateral reduced chest wall movements are
diffuse:
→ Chronic airflow limitation
→ Diffuse pulmonary fibrosis
THE CHEST: PALPATION
CHEST EXPANSION
• Place hands firmly on chest wall with fingers extending around
sides of chest
• As patient takes a big breath in, the thumbs should move
HARRISON'S SULCUS symmetrically apart about 5 cm
• Innar depression of lower ribs just above costal margins at site • Reduced expansion on one side indicates a lesion on that side
of attachment of diaphragm
• Causes: severe asthma in childhood rickets Note:
Note: lower lobe expansion is tested here; upper lobe is tested
KYPHOSIS for on inspection
• Exaggerated forward curvature of spine
APEX BEAT
• Kyphosis is a spinal disorder in which an excessive curve of the
spine results in an abnormal rounding of the upper back • Can be palpated in the precordium left 5th intercostal space, at
• Can occur at any age but is common during adolescence. the intersection with the left clavicular line
• Displacement toward site of lesion - can be caused by:
SCOLIOSIS → Collapse of lower lobe
• Lateral bowing → Localized pulmonary fibrosis
• Scoliosis is a sideways curve of the spine • Displacement away from site of lesion - can be caused by:
→ Pleural effusion
→ Tension pneumothorax
• Apex beat is often impalpable in a chest which is hyperexpanded
secondary to chronic airflow limitation

VOCAL FREMITUS
KYPHOSCOLIOSIS
• Palpate chest wall with palm of hand while patient repeats "99"
• Causes: • Front and back of chest are each palpated in 2 comparable
→ Idiopathic (80%) positions with palms
→ Secondary to poliomyelitis (inflammation involving grey → In this way differences in vibration on chest wall can be
matter of cord) detected
→ Note: severe thoracic kyphoscoliosis may reduce lung
• Causes of change in vocal fremitus are the same as those for
capacity and increase work of breathing)
vocal resonance
LESIONS OF CHEST WALL
• Scars
→ Previous thoracic operations or chest drains for a
previous pneumothorax or pleural effusion
• Thoracoplasty involved removal of large number of ribs on one
side to achieve permanent collapse of affected lung
→ Was once performed to remove TB, but no longer is
because of effective antituberculosis chemotherapy
• Erythema and thickening of skin may occur in radiotherapy
→ There is a sharp demarcation between abnormal and
normal skin

DIFFUSE SWELLING OF CHEST WALL AND NECK RIBS

• Pathophysiology: air tracking from the lungs • Gently compress chest wall anteroposteriorly and laterally
• Causes: pneumothorax, rupture of esophagus • Localized pain suggests a rib fracture

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→ May be secondary to trauma or spontaneous as a result
of tumor deposition or bone disease
CHEST: PERCUSSION
• With left hand on chest wall and fingers slightly separated and
aligned with ribs, the middle finger is pressed firmly against the
chest; pad of right middle finger is used to strike firmly the middle
phalanx of middle finger of left hand
• Percussion of symmetrical areas of:
→ Anterior (chest)
→ Posterior (back)
✓ Ask patient to move elbows forward across the front
of chest to rotate the scapulae anteriorly
→ Axillary region (side)
→ Supraclavicular fossa
• Percussion over a solid structure
→ Example: liver consolidated lung produces a dull note
• Percussion over a fluid filled area
→ Example: pleural effusion produces an extremely dull
(stony dull) note percussion over the normal lung
produces a resonant note
• Percussion over a hollow structure
→ Example: bowel, pneumothorax produces a hyper
resonant note
• Liver dullness:
→ Upper level of liver dullness is determined by percussing
down the anterior chest in mid-clavicular line
→ Normally, upper level of liver dullness is 6th rib in right
mid-clavicular line
→ If chest is resonant below this level, it is a sign of
hyperinflation usually due to emphysema or asthma
• Cardiac dullness:
→ Area of cardiac dullness is usually present on left side of
chest
→ This may decrease in emphysema or asthma
CHEST: AUSCULTATION
BREATH SOUNDS
INTRODUCTION
• Use the diaphragm of stethoscope to listen to breath sound in
each area, comparing each side
• Remember to listen high up into the axillae
• Remember to use bell of stethoscope to listen to lung from above
the clavicles
QUALITY OF BREATH SOUNDS
• Normal breath sounds
→ Are heard with stethoscope over all parts of chest,
produced in airways rather than alveoli (although once
they had been thought to arise from alveoli (vesicles)
and are therefore called vesicular sounds)
→ Normal (vesicular) breath sounds are louder and longer
on inspiration than on expiration
→ There is no gap between the inspiratory and expiratory
sounds
• Bronchial breath sounds
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→ Turbulence in large airways is heard without being
filtered by the alveoli, and therefore produce a different
quality; they are heard over the trachea normally, but not
over the lungs
→ Are audible throughout expiration, and often there is a
gap between inspiration and expiration
• Are heard over areas of consolidation since solid lung conducts
the sound of turbulence in main airways to peripheral areas
without filtering
• Causes include:
→ Lung consolidation (lobar pneumonia) - common
→ Localized pulmonary fibrosis - uncommon
→ Pleural effusion (above the fluid) - uncommon
→ Collapsed lung (Example: adjacent to a pleural effusion)
- uncommon
→ Amphoric sound = when breath sounds over a large
cavity have an exaggerated bronchial quality, low pitch
bronchial breath sound with high pitch overtones
INTENSITY OF BREATH SOUNDS
• Causes of reduced breath sounds include:
→ Chronic airflow limitation (especially emphysema)
→ Pleural effusion
→ Pneumothorax
→ Pneumonia
→ Large neoplasm
→ Pulmonary collapse
ADDED (ADVENTITIOUS) SOUNDS
• Two types of added sounds:
→ Continuous (wheezes) and interrupted (crackles)
• Wheezes
→ May be heard in expiration or inspiration or both
→ Pathophysiology of wheezes - airway narrowing
→ An inspiratory wheeze implies severe airway narrowing
• Causes of wheezes include:
✓ Asthma (often high pitched) - due to muscle spasm,
mucosal oedema, excessive secretions
✓ Chronic airflow diseases - due to mucosal
oedema and excessive secretions
✓ Carcinoma causing bronchial obstruction -
tends to cause a localized wheeze which is
monophonic and does not clear with coughing
• Crackles
→ Some terms not to use include rales (low pitched
crackles) and crepitation’s (high pitched crackles)
→ Crackles are due to collapse of peripheral airways on
expiration and sudden opening on inspiration
→ Early inspiratory crackles
✓ Suggests disease of small airways
✓ Characteristic of chronic airflow limitation
✓ Are only heard in early inspiration
→ Late or pan inspiratory crackles
✓ Suggests disease confined to alveoli
✓ May be fine, medium or coarse
✓ Fine crackles - typically caused by pulmonary
fibrosis
✓ Medium crackles - typically caused by left
ventricular failure (due to presence of alveolar fluid)
✓ Coarse crackles - tend to change with coughing;
occur with any disease that leads to retention of
secretions; commonly occur in bronchiectasis
• Pleural friction rub
→ When thickened, roughened pleural surfaces rub
together, a continuous or intermittent grating sound may
be heard
→ Suggests pleurisy, which may be secondary to
pulmonary infarction or pneumonia
VOCAL RESONNANCE
• Gives information about lungs' ability to transmit sounds
• Consolidated lung tends to transmit high frequencies so that
speech heard through stethoscope takes a bleating quality
(egophony)
→ When a patient with egophony says "bee" it sounds like
"bay"
• Listen over each part of chest as patient says "99"
→ Over consolidated lung, the numbers will become clearly
audible
→ Over normal lung, the sound is muffled
• Whispering pectoriloquy - vocal resonance is increased to such
an extent that whispered speech is distinctly heard
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 TRANS: MEDICAL SURGICAL NURSING 1

HEART RESULT INTERPRETATION

• Lie patient at 45 degrees
• Measure jugular venous pulse for right heart failure ≥ 5 mm • HIV positive
• Examine precordium • Recent contact with an active TB patient
→ Pay close attention to pulmonary component of P2 • Nodular or fibrotic changes on X-ray
(which is best heard at 2nd intercostal space on left) and • Organ transplant
should not be louder than A2
→ If it is louder, suspect pulmonary hypertension
• Cor pulmonale
→ Also called pulmonary hypertensive heart disease • Recent arrivals (<5 years) from high-
≥ 10 mm prevalence countries
→ An alteration in the structure and function of the right
ventricle (RV) of the heart caused by a primary disorder • IV drug users
of the respiratory system • Resident or employee of high-risk
→ May be due to: congregate settings
✓ Chronic airflow limitation (emphysema) • Mycobacteriology lab personnel
✓ Pulmonary fibrosis • Comorbid conditions
✓ Pulmonary thromboembolism • Children <4 years old
✓ Marked obesity
✓ Sleep apnea • Infants, children, and adolescence
✓ Severe kyphoscoliosis exposed to high categories

ABDOMEN
≥ 15 mm
• Palpate liver for enlargement due to secondary deposits of tumor
from lung, or right heart failure • Person with no known risk factors to TB
OTHER

PEMBERTON’S SIGN
PULSE OXIMETER
• Ask patient to lift arms over head • Non-invasive method of continuously monitoring he oxygen
• Look for development of facial plethora, inspiratory stridor, non- saturation of hemoglobin
pulsatile elevation of jugular venous pressure • A probe or sensor is attached to the fingertip, forehead, earlobe
• Occurs in vena cava obstruction or bridge of the nose
• Sensor detects changes in O2 sat levels by monitoring light
signals generated by the oximeter and reflected by the blood
pulsing through the tissue at the probe
• Normal SpO2 = 95% - 100%
• < 85% - tissues are not receiving enough O2
• Results unreliable in:
→ Cardiac arrest
→ Shock
→ Use of dyes or vasoconstrictors
→ Severe anemia
→ High carbon monoxide Level
FEET CHEST X-RAY
• Inspect for edema or cyanosis (clues of cor pulmonale) • This is a non-invasive procedure involving the use of x-rays
• Look for evidence of deep vein thrombosis with minimal radiation
• The nurse instructs the patient to practice the on cue to hold his
RESPIRATORY RATE ON EXERCISE AND POSITIONING breath and to do deep breathing
• Patients complaining of dyspnea should have their respiratory • Instruct the client to remove metals from the chest
rate measured at rest, at maximal tolerated exertion and supine • Rule out pregnancy first
• If dyspnea is not accompanied by tachypnoea when a patient
climbs stairs, one should consider malingering COMPUTED TOMOGRAPHY (CT SCAN) AND MAGNETIC
• Look for paradoxical inward motion of abdomen during RESONANCE IMAGING (MRI)
inspiration when patient is u-spine (indicating diaphragmatic • CT scans
paralysis) → Radiographic procedure that utilizes x-ray machine
→ Better for showing bone and joint issues, blood clots,
TEMPERATURE and some organ injuries
• Fever may accompany any acute or chronic chest infection • MRI
→ Uses magnetic field to record the H+ density of the
III. DIAGNOSTIC EVALUATION tissue
SKIN TEST: MANTOUX TEST OR TUBERCULIN TEST → It does not involve the use of radiation
• This is used to determine if a person has been infected or has → Better for inflammation, torn ligaments, nerve and
been exposed to the TB bacillus spinal problems, and soft tissues
• This utilizes the PPD (Purified Protein Derivatives) → The contraindications for this procedure are the
following:
• The PPD is injected intradermally usually in the inner aspect of
✓ Patients with implanted pacemaker
the lower forearm about 4 inches below the elbow
✓ Patients with metallic hip prosthesis
• The test is read 48 to 72 hours after injection ✓ Other metal implants in the body
• The induration or the bleb will be measured
• (+) Mantoux Test is induration of 10 mm or more
• But for HIV positive clients, induration of about 5 mm is
considered positive
• Signifies exposure to Mycobacterium Tubercle bacilli

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 TRANS: MEDICAL SURGICAL NURSING 1
FLOUROSCOPY
• Studies the lung and chest in motion
• A medical procedure that makes a real-time video of the
movements inside a part of the body by passing x-rays through
the body over a period of time
• Involves the continuous observation of an image reflected on a
screen when exposed to radiation in the manner of television
screen that is activated by an electrode beam
• Structures of different densities that intercept the X-ray beam are
visualized on the screen in silhouette
INDIRECT BRONCHOGRAPHY
• A radiopaque medium is instilled directly into the trachea and
the bronchi and the outline of the entire bronchial tree or selected
areas may be visualized through x-ray
• It reveals anomalies of the bronchial tree and is important in
the diagnosis of bronchiectasis
• Nursing interventions before Bronchogram
→ Secure written consent
→ Check for allergies to sea foods or iodine or anesthesia
→ NPO for 6 to 8 hours
→ Pre-op meds:
✓ Atropine SO4 and valium
✓ Topical anesthesia sprayed
✓ Followed by local anesthetic injected into larynx
✓ The nurse must have oxygen and anti-spasmodic
agents ready
• Nursing interventions after Bronchogram
→ Side-lying position
→ NPO until cough and gag reflexes returned
→ Instruct the client to cough and deep breathe client
BRONCHOSCOPY
• This is the direct inspection and observation of the larynx,
trachea and bronchi through a flexible or rigid bronchoscope
• Passage of a lighted bronchoscope into the bronchial tree for
direct visualization of the trachea and the tracheobronchial tree
• Diagnostic uses:
→ To examine tissues or collect secretions
→ To determine location or pathologic process and collect
specimen for biopsy
→ To evaluate bleeding sites
→ To determine if a tumor can be resected surgically
→ Therapeutic uses
→ To Remove foreign objects from tracheobronchial tree
→ To Excise lesions
→ To remove tenacious secretions obstructing the
tracheobronchial tree
→ To drain abscess
→ To treat post-operative atelectasis
• Nursing interventions before Bronchoscopy
→ Informed consent or permit needed
→ Explain procedure to the patient, tell him what to expect,
to help him cope with the unknown
→ Atropine (to diminish secretions) is administered one
hour before the procedure
→ About 30 minutes before bronchoscopy, Valium is given
to sedate patient and allay anxiety
ASILO, CHESKA LYKA | BSN 2-2
→ Topical anesthesia is sprayed followed by local
anesthesia injected into the larynx
→ Instruct on NPO for 6-8 hours
→ Remove dentures, prostheses and contact lenses
→ The patient is placed supine with hyperextended neck
during the procedure
• Nursing interventions after Bronchoscopy
→ Put the patient on Side lying position
→ Tell patient that the throat may feel sore
→ Check for the return of cough and gag reflex
→ Check vasovagal response
→ Watch for cyanosis, hypotension, tachycardia,
arrythmias, hemoptysis, and dyspnea
✓ These signs and symptoms indicate perforation of
bronchial tree. Refer the patient immediately
LUNG SCAN
• Procedure using inhalation or I.V. injection of a radioisotope
• Scans are taken with a scintillation camera
• Imaging of distribution and blood flow in the lungs
• Measure blood perfusion
• Confirm pulmonary embolism or other blood-flow abnormalities
• Nursing interventions before the procedure:
→ Allay the patient’s anxiety
→ Instruct the patient to Remain still during the procedure
• Nursing interventions after the procedure
→ Check the catheter insertion site for bleeding
→ Assess for allergies to injected radioisotopes
→ Increase fluid intake, unless contraindicated
SPUTUM EXAMINATION
• Laboratory test
• Indicated for microscopic examination of the sputum:
→ Gross appearance
→ Sputum C&S
→ AFB staining
→ Cytologic examination or Papanicolaou examination
• Nursing interventions:
→ Early morning sputum specimen is to be collected
(suctioning or expectoration)
→ Rinse mouth with plain water
→ Use sterile container
→ Sputum specimen for C&S is collected before the first
dose of anti-microbial therapy
→ For AFB staining, collect sputum specimen for three
consecutive mornings
BIOPSY OF THE LUNGS
• Percutaneous removal of a small amount of lung tissue
• For histologic evaluation
→ Transbronchoscopic biopsy - done during bronchoscopy
→ Percutaneous needle biopsy - open lung biopsy
• Nursing interventions before the procedure:
→ Withhold food and fluids
→ Place obtained written informed consent in the patient’s
chart.
• Nursing interventions after the procedure:
→ Observe the patient for signs of Pneumothorax and air
embolism
→ Check the patient for hemoptysis and hemorrhage
→ Monitor and record vital signs
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 TRANS: MEDICAL SURGICAL NURSING 1

→ Check the insertion site for bleeding • The maximum volume of air that can
→ Monitor for signs of respiratory distress be exhaled after a maximum
Vital capacity inhalation
(4,600 mL) • Reduced in COPD
• IRV 3000 mL + TV 500 mL + ERV
1100 mL
• Total of all four volumes
Total Lung Capacity
(5,800 mL) • IRV 3000 mL + TV 500 mL + ERV
1100 mL + RV 1200 mL
ARTERIAL BLOOD GAS
• Laboratory test
LYMPH NODE BIOPSY • Indicate respiratory functions
• Scalene or cervicomediastinal • Assess the degree to which the lungs are able to provide
• To assess metastasis of lung cancer adequate oxygen and remove CO2
• Assess the degree to which the kidneys are able to reabsorb
or excrete bicarbonate
• Assessment of arterial blood for tissue oxygenation,
ventilation, and acid-base status
• Arterial puncture is performed on areas where good pulses are
palpable (radial, brachial, or femoral)
→ Radial artery is the most common site for withdrawal of
blood specimen
• Nursing interventions
→ Utilize a 10-ml of pre-heparinized syringe to prevent
PULMONARY FUNCTION TEST / STUDIES clotting of specimen
→ Soak specimen in a container with ice to prevent
• Non-invasive test
hemolysis
• Measurement of lung volume, ventilation, and diffusing → If ABG monitoring will be done, do Allen’s test to assess
capacity for adequacy of collateral circulation of the hand (ulnar
• Nursing interventions: arteries)
→ Document bronchodilators or narcotics used before
testing
→ Allay the patient’s anxiety during the testing

PULMONARY ANGIOGRAPHY
• This procedure takes x-ray pictures of the pulmonary blood
vessels (those in the lungs)
LUNG VOLUMES • Because arteries and veins are not normally seen in an x-ray, a
contrast material is injected into one or more arteries or veins
LUNG VOLUME MEANING so that they can be seen

Inspiratory Reserve The maximum volume that can be

Volume inhaled following a normal quiet
(3000 mL) inhalation

Tidal Volume The volume of air inhaled and exhaled

(500 mL) with normal quiet breathing

Expiratory Reserve The maximum volume that can be

Volume exhaled following the normal quiet
(1100 mL) exhalation

Residual Volume The volume of air that remains in the

(1200 mL) lungs after forceful exhalation

LUNG CAPACITIES VENTILATION - PERFUSION SCAN

• Radioactive albumin injection is part of a nuclear scan test that
LUNG CAPACITY MEANING is performed to measure the supply of blood through the
lungs
Functional Residual • The volume of air that remains in the
Capacity lungs after normal, quiet exhalation • After the injection, the lungs are scanned to detect the location
of the radioactive particles as blood flows through the lungs
(2,300 mL) • ERV 1100 mL + RV 1200 mL
• The ventilation scan is used to evaluate the ability of air to
• The amount of air that a person can reach all portions of the lungs
Inspiratory Capacity inspire maximally after a normal • The perfusion scan measures the supply of blood through the
(3,500 mL) expiration lungs
• TV 500 mL + IRV 3000 mL

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 TRANS: MEDICAL SURGICAL NURSING 1
• A ventilation and perfusion scan are most often performed to
detect a pulmonary embolus
→ It is also used to evaluate lung function in people with
advanced pulmonary disease such as COPD and to
detect the presence of shunts (abnormal circulation) in
the pulmonary blood vessels.
THORACENTESIS
• Procedure suing needle aspiration of intrapleural fluid or air
under local anesthesia
• Specimen examination or removal of pleural fluid
• Nursing intervention before Thoracentesis
→ Secure consent
→ Take initial vital signs
→ Instruct to remain still, avoid coughing during insertion of
the needle
→ Inform patient that pressure sensation will be felt on
insertion of needle
• Nursing intervention during the procedure:
→ Reassess the patient
→ Place the patient in the proper position:
✓ Upright or sitting on the edge of the bed
✓ Lying partially on the side, partially on the back
• Nursing interventions after Thoracentesis
→ Assess the patient’s respiratory status
→ Monitor vital signs frequently
→ Position the patient on the affected side, as ordered, for
at least 1 hour to seal the puncture site
→ Turn on the unaffected side to prevent leakage of fluid in
the thoracic cavity
→ Check the puncture site for fluid leakage
→ Auscultate lungs to assess for pneumothorax
→ Monitor oxygen saturation (SaO2) levels
→ Bed rest
→ Check for expectoration of blood
IV. RESPIRATORY CARE MODALITIES
OXYGEN THERAPY
• Oxygen is a colorless, odorless, tasteless, and dry gas that
supports combustion
• Man requires 21% oxygen from the environment in order to
survive
• Signs of Hypoxemia
→ Increased pulse rate
→ Rapid, shallow respiration and dyspnea
→ Increased restlessness or lightheadedness
→ Flaring of nares
→ Substernal or intercostals retractions
→ Cyanosis
LOW FLOW OXYGEN
• Provides partial oxygenation with patient breathing a •
combination of supplemental oxygen and room air
• Low-flow administration devices:
ASILO, CHESKA LYKA | BSN 2-2
→ Nasal Cannula 24-45% 2-6 LPM
→ Simple Face Mask0-60% 5-8 LPM
→ Partial Rebreathing Mask 60-90% 6-10 LPM
→ Non-rebreathing Mask 95-100% 6-15 LPM
→ Croquette
→ Oxygen Tent
HIGH FLOW OXYGEN
• Provides all necessary oxygenation, with patients breathing only
oxygen supplied from the mask and exhaling through a one-way
vent
• High flow administration devices
→ Venturi Mask 24-40% 4-10 LPM
✓ Preferred for clients with COPD because it provides
accurate amount of oxygen
→ Face Mask
→ Oxygen Hood
→ Incubator / isolette
Note:
Note: oxygen hood and Incubator or isolette can be used for
both low and high flow administration
• The nurse should prevent skin breakdown by checking nares,
nose and applying gauze or cotton as necessary
• Ensure that COPD patients receive only low flow oxygen
because these persons respond to hypoxia, not increased CO
levels
TRACHEOBRONCHIAL SUCTIONING
• Suction only when necessary, not routinely
• Use the smallest suction catheter if possible
• Client should be in semi or high Fowler’s position
• Use sterile gloves, sterile suction catheter
• Hyperventilate client with 100% oxygen before and after
suctioning
• Insert catheter with gloved hand
→ 3-5 length of catheter insertion without applying suction
→ Three passes of the catheter are the maximum, with 10
seconds per pass
• Apply suction only during withdrawal of catheter
• The suction pressure should be limited to less than 120 mmHg
• When withdrawing catheter rotate while applying intermittent
suction
• Suctioning should take only 10 seconds (maximum of 15
seconds)
• Evaluate for clear breath sounds on auscultation of the chest
BRONCHIAL HYGIENE MEASURES
• Suctioning: oropharyngeal; nasopharyngeal
STEAM INHALATION
• The purpose of steam inhalation are as follows:
→ To liquefy mucous secretions
→ To warm and humidify air
→ To relieve edema of airways - to soothe irritated airways
→ To administer medication
• It is a dependent nursing function
• Inform the client and explain the purpose of the procedure
• Place the client in Semi-Fowler’s position
• Cover the client’s eyes with washcloth to prevent irritation
• Check the electrical device before use
• Place the steam inhalator in a flat, stable surface
• Place the spout 12-18 inches away from the client’s nose or
adjust distance as necessary
• Caution: avoid burns
→ Cover the chest with towel to prevent burns due to
dripping of condensate from the steam
→ Assess for redness on the side of the face which
indicates first degree burns
• To be effective, render steam inhalation therapy for 15 – 20
minutes
• Instruct the client to perform deep breathing and coughing
exercises after the procedure to facilitate expectoration of
mucous secretions
• Provide good oral hygiene after the procedure
Do after-care of equipment
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 TRANS: MEDICAL SURGICAL NURSING 1
AEROSOL INHALATION
• Done among pediatric clients to administer bronchodilators or
mucolytic-expectorants
MEDI MIST INHALATION
• Done among adult clients to administer bronchodilators or
mucolytic-expectorants
CHEST PHYSIOTHERAPHY (CPT)
• Includes postural drainage, chest percussion and vibration, and
breathing retraining
• Effective coughing is also an important component
• Goals are removal of bronchial secretions, improved ventilation,
and increased efficiency of respiratory muscles
• Postural drainage uses specific positions to use gravity to assist
in the removal of secretions
• Vibration loosens thick secretions by percussion or vibration
• Breathing exercises and breathing retraining improve ventilation
and control of breathing and decrease the work of breathing
• These are procedures for patients with respiratory disorders like
COPD, cystic fibrosis, lung abscess, and pneumonia
• The therapy is based on the fact that mucus can be knocked or
shaken from airways and helped to drain from the lungs
POSTURAL DRAINAGE
• Use of gravity to aid in the drainage of secretions
• Patient is placed in various positions to promote flow of drainage
from different lung segments using gravity
• Areas with secretions are placed higher than lung segments to
promote drainage
• Patient should maintain each position for 5-15 minutes
depending on tolerability
PERCUSSION
• Produces energy wave that is transmitted through the chest wall
to the bronchi
• The chest is struck rhythmically with cupped hands over the
areas where secretions are located
• Avoid percussion over the spine, kidneys, breast or incision and
broken ribs
• Areas should be percussed for 1-2 minutes
VIBRATION
• Works similarly to percussion, where hands are placed on
client’s chest and gently but firmly rapidly vibrate hands against
thoracic wall especially during client’s exhalation
• This may help dislodge secretions and stimulate cough
• This should be done at least 5-7 times during patient exhalation
ASILO, CHESKA LYKA | BSN 2-2
SUCTIONING
• Nursing Interventions in CPT
→ Verify doctor’s order
→ Assess areas of accumulation of mucus secretions
→ Position to allow expectoration of mucus secretions by
gravity
→ Place client in each position for 5-10 to 15 minutes
→ Percussion and vibration done to loosen mucus
secretions
→ Change position gradually to prevent postural
hypotension
→ Client is encouraged to cough up and expectorate
sputum
→ Procedure is best done 60 to 90 minutes before meals
or in the morning upon awakening and at bedtime
→ Provide good oral care after the procedure
INCENTIVE SPIROMETRY
• Types: volume and flow
• Device ensures that a volume of air is inhaled and the patient
takes deep breaths
• Used to prevent or treat atelectasis
• To enhance deep inhalation
• Nursing care
→ Positioning of patient, teach and encourage use, set
realistic goals for the patient, and record the results
CLOSED CHEST DRAINAGE (THORACOSTOMY TUBE)
• Chest tube is used to drain fluid and air out of the mediastinum
or pleural space into a collection chamber to help re-establish
normal negative pressure for lung re-expansion
• Purposes
→ To remove air and/or fluids from the pleural space
→ To reestablish negative pressure and re-expand the
lungs
• Procedure
→ The chest tube is inserted into the affected chest wall at
the level of 2nd to 3rd intercostals space to release air
or in the fourth intercostals space to remove fluid
TYPES OF BOTTLE DRAINAGE
ONE-BOTTLE SYSTEM
• The bottle serves as drainage and water-seal
• Immerse tip of the tube in 2-3 cm of sterile NSS to create water-
seal
• Keep bottle at least 2-3 feet below the level of the chest to allow
drainage from the pleura by gravity
• Never raise the bottle above the level of the heart to prevent
reflux of air or fluid
• Assess for patency of the device
• Observe for fluctuation of fluid along the tube
• The fluctuation synchronizes with the respiration
• Observe for intermittent bubbling of fluid; continues bubbling
means presence of air-leak
• In the absence of fluctuation:
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 TRANS: MEDICAL SURGICAL NURSING 1
→ Suspect obstruction of the device
→ Assess the patient first, then if patient is stable
→ Check for kinks along tubing
→ Milk tubing towards the bottle (If the hospital allows the
nurse to milk the tube)
→ If there is no obstruction, consider lung re-expansion,
(validated by chest x-ray)
→ Air vent should be open to air
TWO-BOTTLE SYSTEM
• If not connected to the suction apparatus
• The first bottle is drainage bottle
• The second bottle is water-seal bottle
• Observe for fluctuation of fluid along the tube (water-seal bottle
or the second bottle) and intermittent bubbling with each
respiration
NOTE: IF CONNECTED TO SUCTION APPARATUS
• The first bottle is the drainage and water-seal bottle
• The second bottle is suction control bottle
• Expect continuous bubbling in the suction control bottle
• Intermittent bubbling and fluctuation in the water-sea
• Immerse tip of the tube in the first bottle in 2 to 3 cm of sterile
NSS
• Immerse the tube of the suction control bottle in 10 to 20 cm of
sterile NSS to stabilize the normal negative pressure in the lungs
• This protects the pleura from trauma if the suction pressure is
inadvertently increased
THREE-BOTTLE SYSTEM
• The first bottle is the drainage bottle
• The second bottle is water seal bottle
• The third bottle is suction control bottle
• Observe for intermittent bubbling and fluctuation with respiration
in the water-seal bottle
• Continuous gentle bubbling in the suction control bottle
→ These are the expected observations
• Suspect a leak if there is continuous bubbling in the water seal
bottle or if there is vigorous bubbling in the suction control bottle
• The nurse should look for the leak and report the observation at
once
→ Never clamp the tubing unnecessarily
IF THERE IS NO FLUCTUATION IN THE WATER SEAL
BOTTLE
• May mean two things
→ Either the lungs have expanded or the system is not
functioning appropriately
• In this situation, the nurse refers the observation to the physician,
who will order for an X-ray to confirm the suspicion
IMPORTANT NURSING CONSIDERATIONS
• Encourage doing the following to promote drainage
• Deep breathing and coughing exercises
• Turn to sides at regular basis
• Ambulate
• ROM exercise of arms
• Mark the amount of drainage at regular intervals
• Avoid frequent milking and clamping of the tube to prevent
tension pneumothorax
WHAT THE NURSE SHOULD DO IF:
• If there is continuous bubbling:
→ The nurse obtains a toothless clamp
→ Close the chest tube at the point where it exits the chest
for a few seconds
→ If bubbling in the water seal bottle stops, the leak is likely
in the lungs
→ But if the bubbling continues, the leak is between the
clamp and the bottle chamber
• Next, the nurse moves the clamp towards the bottle checking the
bubbling in the water seal bottle
→ If bubbling stops, the leak is between the clamp and the
distal part including the bottle
→ But if there is persistent bubbling, it means that the
drainage unit is leaking and the nurse must obtain
another set
→ In the event that the water seal bottle breaks, the nurse
temporarily kinks the tube and must obtain a receptacle
or container with sterile water and immerse the tubing
ASILO, CHESKA LYKA | BSN 2-2
→ She should obtain another set of sterile bottles as
replacement
→ She should never clamp the tube for a longer time to
avoid tension pneumothorax
→ In the event the tube accidentally is pulled out, the nurse
obtains vaselinized gauze and covers the stoma
→ She should immediately contact the physician
REMOVAL OF CHEST TUBE
• Done by physician
• The nurse Prepares:
→ Petrolatum Gauze
→ Suture removal kit
→ Sterile gauze
→ Adhesive tape
• Place client in semi-Fowler’s position
• Instruct client to exhale deeply, then inhale and do Valsalva
Maneuver as the chest tube is removed
• Chest x-ray may be done after the chest tube is removed
• Asses for complications: subcutaneous emphysema and
respiratory distress
ARTIFICIAL AIRWAY
ORAL AIRWAYS
• These are shorter and often have a larger lumen
• They are used to prevent the tongue form falling backward.
NASAL AIRWAYS
• These are longer and have smaller lumen, which causes greater
airway resistance
TRACHEOSTOMY
• This is a temporary or permanent surgical opening in the trachea
• A tube is inserted to allow ventilation and removal of secretions
• It is indicated for emergency airway access for many conditions
• The nurse must maintain tracheostomy care properly to prevent
infection
IV. RESPIRATORY DISEASES AND DISORDERS
• Any of the diseases and disorders of the airways and the lungs
that affect human respiration.
• Diseases of the respiratory system may affect any of the
structures and organs that have to do with breathing, including
the nasal cavities, the pharynx, the larynx, the trachea, the
bronchi and bronchioles, the tissues of the lungs, and the
respiratory muscles of the chest cage
• The respiratory tract is the site of an exceptionally large range of
disorders for three main reasons
→ It is exposed to the environment and therefore may be
affected by inhaled organisms, dusts, or gases
→ It possesses a large network of capillaries through which
the entire output of the heart has to pass, which means
that diseases that affect the small blood vessels are
likely to affect the lung
→ It may be the site of “sensitivity” or allergic phenomena
that may profoundly affect function.
COMMON COLDS
• A viral infection of your nose and throat (upper respiratory tract)
• It is usually harmless, although it might not feel that way
• Many types of viruses can cause a common cold
• Healthy adults can expect to have two or three colds each year
• Infants and young children may have even more frequent colds
• Most people recover from a common cold in a week or 10 days.
Symptoms might last longer in people who smoke
• Generally, you don't need medical attention for a common cold
• However, if symptoms don't improve or if they get worse, see
your doctor
RISK FACTORS
• Age - infants and young children are at greatest risk of colds,
especially if they spend time in child care settings
• Weakened immune system - having a chronic illness or
otherwise weakened immune system increases your risk
• Time of year - both children and adults are more likely to get
colds in fall and winter, but you can get a cold anytime
• Smoking - you're more likely to catch a cold and to have more-
severe colds if you smoke or are around secondhand smoke
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 TRANS: MEDICAL SURGICAL NURSING 1

• Exposure - if you're around crowds, such as at school or on an STAGES OF COMMON COLDS

airplane, you're likely to be exposed to viruses that cause colds
STAGE 1: EARLY (DAYS 1-3)
SIGNS AND SYMPTOMS
• Sneezing
• Runny or stuffy nose
• Runny nose
• Sore throat
• Stuffy nose
• Cough
• Cough
• Congestion
• Hoarseness
• Slight body aches or a mild headache
• Sneezing STAGE 2: ACTIVE (DAYS 4-7)
• Low-grade fever • Body aches
• Generally feeling unwell • Headache
HOW TO SHARE COMMOM COLDS • Runny eyes and nose
• Crowded spaces • Fatigue
• Shared surfaces • Fever
• Poor hygiene STAGE 3: LATE (DAYS 8-10)
CAUSES OF COMMON COLDS • Colds usually begin to wind down, but some symptoms may
• Although many types of viruses can cause a common cold, persist
rhinoviruses are the most common cause • Some people develop a nagging cough that can last up to two
• A cold virus enters your body through your mouth, eyes or nose months after a respiratory infection
• The virus can spread through droplets in the air when someone • If a secondary infection occurs, it’s time to see your healthcare
who is sick coughs, sneezes or talks provider
• It also spreads by hand-to-hand contact with someone who has
a cold or by sharing contaminated objects, such as eating NURSING ASSESSMENT
utensils, towels, toys or telephones • History of exposure
→ If you touch your eyes, nose or mouth after such contact, → A history of exposure to known carriers
you're likely to catch a cold • History of intake
→ Because supportive care is a primary goal in all cases,
historical information regarding oral intake and hydration
• Acute ear infection (otitis media) status is important
→ This occurs when bacteria or viruses enter the space
NURSING DIAGNOSES
behind the eardrum. Typical signs and symptoms
include earaches or the return of a fever following a Based on the assessment data, the major nursing diagnoses are:
common cold • Ineffective breathing pattern related to the inflammatory process
• Asthma in the respiratory tract
→ A cold can trigger wheezing, even if you don't have • Ineffective airway clearance related to mechanical obstruction of
asthma. If you have asthma, a cold can make it worse the airway secretions and increased production of secretions
• Acute sinusitis • Anxiety related to the disease experienced by the child
→ In adults or children, a common cold that doesn't resolve
NURSING CARE PLANNING AND GOALS
can lead to swelling and pain (inflammation) and
infection of the sinuses The major nursing care planning goals for a child with acute
nasopharyngitis are:
• Other infections
→ A common cold can lead to other infections, including • The patient will report increased energy
strep throat, pneumonia, and croup or bronchiolitis in • The patient will remain afebrile
children • The patient will expectorate sputum effectively
→ These infections need to be treated by a doctor • The patient will express feelings of comfort in maintaining air
exchange
PREVENTION
• The patient will experience no further signs or symptoms of
• Wash hands infection
• Disinfect stuff
• Cover your mouth NURSING INTERVENTIONS
• Do not share • Positioning - place the patient in a semi-Fowlers position using
• Stay away from people with colds pillows to facilitate lung expansion
• Take care of your self • Increase fluid intake - encourage increased fluid intake to
decrease the viscosity of secretions
WHEN TO SEE A DOCTOR • Increase room humidity - increase the humidity by using cool
mist vaporizers to relieve stuffiness of the nose
ADULTS • Administer medications - administer antibiotics as prescribed
• Ever greater than 101.3 F (38.5 C) lasting more than three days after a positive culture result
• Fever returning after a fever-free period EVALUATION
• Shortness of breath
• The patient reported increased energy
• Wheezing
• The patient is afebrile
• Severe sore throat, headache or sinus pain
• The patient was able to expectorate sputum effectively
CHILDREN • The patient expressed feelings of comfort in maintaining air
exchange
• Fever of 100.4 F (38 C) in newborns up to 12 weeks
• Rising fever or fever lasting more than two days in a child of any
• The patient experienced no further signs or symptoms of
infection
age
• Severe symptoms, such as headache, throat pain or cough DOCUMENTATION
• Difficulty breathing or wheezing • Breath sounds, presence and character of secretions, use of
• Ear pain accessory muscles for breathing
• Extreme fussiness • Plan of care
• Unusual drowsiness • Teaching plan
• Lack of appetite • Responses to interventions and actions performed
• Attainment or progress towards desired outcomes
• Modifications to the plan of care

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TREATMENT CLASSIFICATION OF PNEUMONIA

• Drink plenty of fluids, humidify air, use saline nasal rinses, and
adequate rest BASED ON THE PLACE ACQUIRED
• Antibiotics are of no use against cold viruses and shouldn’t be
used unless there’s a bacterial infection COMMUNITY ACQUIRED PNEUMONIA
• Chest X-ray or other test to rule out other causes of your • Pneumonia that occurs in the community
symptoms • CAP occurs either in the community setting or within the first 48
• Some remedies include: hours of hospitalization
→ Pain relievers • Usually begins as common respiratory infections
→ Decongestant nasal sprays • Streptococcus pneumonia is the most common cause
→ Cough syrup • Common agents are:
→ Antihistamines → S. pneumoniae
→ Expectorants → H. influenzae
• Alternative medicine → Legionella
→ Vitamin C → Pseudomonas Aeruginosa
→ Zinc → Other gram-negative rods
PNEUMONIA • H. Influenzae is another cause of CAP
• Inflammation of the lung parenchyma leading to pulmonary • Mycoplasma Pneumonia, occurs most often in older children and
consolidation because alveoli is filled with exudates young adults
• Inflammation of the alveolar spaces of the lungs, resulting in • Viruses are the most common cause of pneumonia in infants and
• consolidation of lung tissue as the alveoli fills with exudates children but are relatively uncommon causes of CAP in adults

HOSPITAL ACQUIRED PNEUMONIA

• HAP, also known as nosocomial pneumonia, is defined as the
onset of pneumonia symptoms more than 48 hours after
admission to the hospital
• Results from exposure to potentially infectious agents, such as
P. Aeruginosa, S. Aurous in the hospital setting
• These bacilli colonize in the Oropharyngeal region and are
aspirated to the lungs
• Common organisms:
→ Enterobacter species
→ Escherichia coli
→ Klebsiella species
→ Proteus
→ Serratia marcescens
→ P. aeruginosa
ETIOLOGIC AGENTS → Methicillin sensitive or methicillin resistant
• Streptococcus pneumoniae (pneumococcal pneumonia) Staphylococcus aureus
• Hemophilus influenzae (bronchopneumonia)
• Klebsiella pneumoniae PREDISPOSING FACTORS
• Diplococcus pneumoniae • Smoking
• Escherichia coli • Air pollution
• Pseudomonas aeruginosa • Immunocompromised
→ (+) AIDS
HIGH RISK GROUPS ✓ Kaposi’s Sarcoma
• Children less than 5-year-old ✓ Pneumocystis Carinii Pneumonia
• Elderly ❖ DOC: Zidovudine (Retrovir)
→ Bronchogenic Ca
MODE OF TRANSMISSION • Prolonged immobility (hypostatic pneumonia)
• Pathogens can be introduced into the lungs by 3 primary routes • Aspiration of food (aspiration pneumonia)
• Aspiration - transmitted micro-organisms from the oropharynx • Over fatigue
and GIT to the lungs by direct contact
✓ Causes: SIGNS AND SYMPTOMS
✓ Glottis disorder
✓ Pts with NGT
• Productive cough, greenish to rusty
✓ Unconscious patients • Dyspnea with prolong expiratory grunt
• Inhalation - important MOT for organisms suspended in water • Fever, chills, anorexia, general body malaise
droplets and spread into the air with coughing, sneezing and • Cyanosis
talking • Pleuritic friction rub
• Circulatory spread - spread of infection occurs when pathogens • Rales or crackles on auscultation
are transmitted through the circulatory system to lung from pre- • Abdominal distention Paralytic ileus
existing infection in other parts of the body.
PATHOPHYSIOLOGY DIAGNOSTICS
• Invasion of microorganisms • Sputum GS/CS
→ Confirmatory
• Inflammatory reaction occurs in the alveoli
→ Type and sensitivity
• Exudates production that interferes with the diffusion of oxygen → (+) to cultured microorganism
and carbon dioxide
• Chest X-Ray
• Migration of WBC, mostly neutrophils and filling of the normal air → (+) pulmonary consolidation
containing space
• Complete Blood Count
• Reduced ventilation of the lung because of secretions and → Elevated ESR (rate of erythropoiesis)
mucosal edema ✓ N = 0.5- 1.5% (compensatory mech to decreased
• Partial occlusion of the bronchi or alveoli O2)
• Decreases alveolar oxygen tension → Elevated WBC
• Hypoxia • Arterial Blood Gas (ABG)
→ PO2 decreased (hypoxemia)

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NURSING MANAGEMENT ✓ 10-14 mm (WHO)

• Enforce CBR (consistent to all respiratory disorders) ✓ 5 mm in AIDS patients is +
→ Indicates previous exposure to tubercle bacilli
• Strict respiratory isolation
• Sputum AFB (+) tubercle bacilli
• Administer medications as ordered
→ Broad spectrum antibiotics • CXR – (+) pulmonary infiltrated due to caseous necrosis
✓ Penicillin – pneumococcal infections • CBC – elevated WBC
✓ Tetracycline
✓ Macrolides NURSING MANAGEMENT
❖ Azithromycin (OD x 3/days) • Enforce CBR
→ Anti-pyretic
• Institute strict respiratory isolation
→ Mucolytics/expectorants
• Administer O2 inhalation
• Administer O2 inhalation as ordered
• Forced fluids
• Force fluids to liquefy secretions 6. Institute pulmonary toilet
• Encourage DBE and coughing
• Measures to promote expectoration of secretions
→ No clapping in chronic PTB → d/t hemoptysis → may
→ DBE
lead to hemorrhage
→ Coughing exercises
→ CPT (clapping/vibration) • Nebulize and suction PRN
→ Turning and repositioning • Provide comfortable and humid environment
• Nebulize and suction PRN • Institute short course chemotherapy
• Place client of semi-fowlers to high fowlers → Intensive phase
• Provide a comfortable and humid environment
✓ INH
❖ SE: peripheral neuritis (increase vitamin B6 or
• Provide a dietary intake high in CHO, CHON, Calories and Vit C pyridoxine
• Assist in postural drainage ✓ Rifampicin
→ Patient is placed in various position to drain secretions ❖ SE: red orange color of bodily secretions
via force of gravity ✓ PZA
→ Usually, it is the upper lung areas which are drained ❖ May be replaced with Ethambutol (SE: optic
→ Nursing management: neuritis) if (+) hypersensitivity to drug
✓ Monitor VS and BS ❖ Side Effects: allergic reactions; hepatotoxicity
✓ Best performed before meals/breakfast or 2-3 hours and nephrotoxicity
p.c. to prevent gastroesophageal reflux or vomiting ➢ Monitor liver enzymes
✓ Encourage DBE ➢ Monitor BUN and CREA
✓ Administer bronchodilators 15-30 minutes before ✓ INH given for 4 months, PZA and Rifampicin is
procedure given for 2 months, and A.C. to facilitate absorption
✓ Stop if patient can’t tolerate the procedure ❖ These 3 drugs are given simultaneously to
✓ Provide oral care after procedure as it may affect prevent development of resistance
taste sensitivity → Standard Regimen
✓ Contraindications: ✓ Streptomycin injection (aminoglycosides)
✓ Unstable VS ❖ Neomycin, Amikacin, Gentamycin
✓ Hemoptysis ❖ Common SE: 8th CN damage
✓ Increased ICP ➢ Tinnitus
✓ Increased IOP (glaucoma) ➢ Hearing loss
• Provide patient health teaching and d/c planning ➢ Ototoxicity
→ Avoidance of precipitating factors ❖ Nephrotoxicity
→ Prevention of complications ➢ BUN (N = 10-20)
✓ Atelectasis ➢ CREA (N = 8-10)
✓ Meningitis • Health teaching and discharge planning
→ Regular compliance to medications → Avoidance of precipitating factors: alcoholism,
→ Importance of FFUP care overcrowding
PULMONARY TUBERCULOSIS (KOCH’S DISEASE) → Prevention of complications
✓ Atelectasis
• Infection of the lung parenchyma caused by invasion of ✓ Military TB
mycobacterium tuberculosis or tubercle bacilli ❖ Extrapulmonary TB: meningeal, Pott’s, adrenal
→ Gram negative, acid fast, motile, aerobic, easily glands, skin, cornea
destroyed by heat/sunlight → Strict compliance to medications
PRECIPITATING FACTORS ✓ Never double the dose
✓ Continue taking the medications if missed a day
• Malnutrition → Diet modifications: increased CHON, CHO, Calories,
• Overcrowding Vitamin C
• Alcoholism: Depletes VIT B1 (thiamin) → Importance of FFUP care
• Alcoholic beriberi
HISTOPLASMOSIS
• Malnutrition
• Acute fungal infection caused by inhalation of contaminated dust
• Physical and emotional stress with Histoplasma capsulatum from birds’ manure
• Ingestion of infected cattle with M. bovis
• Virulence (degree of pathogenicity)
MODE OF TRANSMISSION
• Airborne → Droplet infection
SIGNS AND SYMPTOMS
• Productive cough (yellowish)
• Low grade afternoon fever, night sweats
• Dyspnea, anorexia, malaise, weight loss
• Chest/back pain
• Hemoptysis
DIAGNOSTICS
• Skin testing
→ Mantoux test – PPD
✓ Induration width (within 48-72 h)
✓ 8-10 mm (DOH)

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PREDISPOSING FACTORS → Antimicrobials

→ Corticosteroids
• Inhalation of contaminated dust
→ Mucolytics or expectorants
SIGNS AND SYMPTOMS Low inflow O2 admin; high inflow will cause respiratory arrest
• PTB like symptoms • Force fluids
• Productive cough • Nebulize and suction client as needed
• Fever, chills, anorexia, generalized body malaise • Provide comfortable and humid environment
• Cyanosis • Health teaching and d/c planning
• Chest and joint pains → Avoidance of smoking
→ Prevent complications
• Dyspnea
→ CO2 narcosis → coma
• Hemoptysis → Cor pulmonale
DIAGNOSTICS → Pleural effusion
→ Pneumothorax
• Histoplasmin skin test is (+)
• Regular adherence to meds
• ABG analysis reveals pO2 low
• Importance of FFUP care
NURSING MANAGEMENT
2. BRONCHIAL ASTHMA
• Enforce CBG
• Administer meds as ordered • Reversible inflammatory lung condition caused by
→ Antifungal agents hypersensitivity to allergens leading to narrowing of smaller
✓ Amphotericin B (Fungizone) airways
✓ Side Effects: nephrotoxicity and hypokalemia
✓ Monitor transaminases, BUN and CREA
→ Corticosteroids
→ Anti-pyretics
→ Mucolytics/expectorants
• Administer oxygen inhalation as ordered
• Forced fluids
• Nebulize and suction as necessary
• Prevent complications
→ Bronchiectasis, atelectasis
• Prevention of spread
→ Spraying of breeding places
→ Kill bird
PATHOPHYSIOLOGY
CHRONIC OBSTRUCTIVE PULMONARY DISEASES • Exposure to allergens
• IG-E attach with mast cells
1. CHRONIC BRONCHITIS (BLUE BLOATERS) • Release several chemical mediators
• Inflammation of the bronchi due to hypertrophy or hyperplasia of • Inflammation
goblet mucous producing cells leading to narrowing of smaller • Increased blood flow, vasoconstrictions, fluid leak from
airways vasculature
• Mucosal edema, bronchospasm and increased mucus
production
• Bronchoconstriction
• The underlying pathology in asthma is reversible diffuse airway
inflammation that leads to long term airway narrowing
→ Macrophages, Mast cells, T lymphocytes, neutrophils,
and eosinophils all play a key role in the inflammation of
asthma
→ Mast cells release mediators when activated which
include histamine, bradykinin, prostanoids, cytokines,
leukotrienes, etc.
• During exacerbations of asthma, bronchoconstriction is IgE-
dependent release of mediators from mast cells

PREDISPOSING FACTORS PREDISPOSING FACTORS

• Smoking • Extrinsic (Atopic/Allergic Asthma)
• Air pollution → Pollens, dust, fumes, smoke, fur, dander, lint
• Intrinsic (Non-Atopic/Non-Allergic)
SIGNS AND SYMPTOMS → Drugs (aspirin, penicillin, B-blockers)
• Consistent productive cough → Foods (seafoods, eggs, chicken, chocolate)
• Dyspnea on exertion with prolonged expiratory grunt → Food additives (nitrates, nitrites)
→ Sudden change in temperature, humidity and air
• Anorexia and generalized body malaise
pressure
• Cyanosis → Genetics
• Scattered rales/rhonchi → Physical and emotional stress
• Pulmonary hypertension • Mixed type → combination of both
→ Peripheral edema
→ Cor pulmonale SIGNS AND SYMPTOMS
• Cough that is productive
DIAGNOSTICS • Dyspnea
• ABG analysis • Wheezing on expiration
→ Decreased PO2, increased PCO2, respiratory acidosis; • Tachycardia, palpitations and diaphoresis
hypoxemia → cyanosis • Mild apprehension, restlessness
• Cyanosis
NURSING MANAGEMENT
DIAGNOSTICS
• Enforce CBR
• Administer medications as ordered • PFT → decreased vital lung capacity
→ Bronchodilators • ABG analysis → PO2 decreased

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NURSING MANAGEMENT SURGERY

• Enforce CBR • Segmental lobectomy
• Administer medications as ordered • Pneumonectomy
→ Bronchodilators - administer first to facilitate absorption → Most feared complications
of corticosteroids ✓ Atelectasis
✓ Inhalation ✓ Cardiac tamponade: muffled heart sounds, pulsus
✓ MDI paradoxus, HPN
→ Corticosteroids
→ Mucolytics/expectorants NURSING MANAGEMENT
→ Mucomyst • Enforce CBR
→ Antihistamine • Low inflow O2 admin; high inflow will cause respiratory arrest
• Administer oxygen inhalation as ordered • Administer medications as ordered
• Forced fluids → Bronchodilators
• Nebulize and suction patient as necessary → Antimicrobials
• Encourage DBE and coughing → Corticosteroids (5-10 minutes after bronchodilators)
→ Mucolytics/expectorants
• Provide a comfortable and humid environment
• Force fluids
• Health teaching and d/c planning
→ Avoidance of precipitating factors • Nebulize and suction client as needed
→ Prevention of complications • Provide comfortable and humid environment
✓ Status asthmaticus • Health teaching and d/c planning
❖ DOC: Epinephrine → Avoidance of smoking
❖ Aminophylline drip → Prevent complications
✓ Emphysema ✓ Atelectasis
• Regular adherence to medications ✓ CO2 narcosis → coma
• Importance of FFUP care ✓ Cor pulmonale
✓ Pleural effusion
3. BRONCHIECTASIS ✓ Pneumothorax
• Permanent dilation of the bronchus due to destruction of • Regular adherence to meds
muscular and elastic tissue of the alveolar walls (subject to • Importance of FFUP care
surgery)
4. PULMONARY EMPHYSEMA
• Terminal and irreversible stage of COPD characterized by:
→ Inelasticity of alveoli
→ Air trapping
→ Maldistribution of gasses (d/t increased air trapping)
→ Overdistention of thoracic cavity (Barrel chest) →
compensatory mechanism → increased AP diameter

PREDISPOSING FACTORS
• Recurrent lower respiratory tract infection
→ Histoplasmosis
• Congenital disease PATHOPHYSIOLOGY
• Presence of tumor
• Prolonged exposure to smoke/pollutant irritates
• Chest trauma
• the airways
SIGNS AND SYMPTOMS • The walls of the alveoli are destroyed
• Consistent productive cough • The alveolar surface area continually decreases
• Dyspnea • Increase in dead space and impaired oxygen diffusion
• Presence of cyanosis • Pulmonary capillary bed is reduced
• Rales and crackles • Pulmonary blood flow is increased
• Hemoptysis • Right ventricle maintains a higher blood pressure in the
• Anorexia and generalized body malaise pulmonary artery
• CO2 elimination is impaired
DIAGNOSTICS
• Hypercapnia
• ABG analysis reveals low PO2 • Hypoxemia
• Bronchoscopy – direct visualization of bronchi lining using a fibro • Increased pulmonary artery pressure
scope
→ Pre-operative
• Congestion, Dependent edema, Distended neck veins
✓ Secure consent TYPES OF EMPHYSEMA
✓ Explain procedure
✓ NPO 4-6 hours PANLOBULAR EMPHYSEMA
✓ Monitor VS and breath sounds
→ Post-operative • Destruction of respiratory bronchiole, alveolar duct, and alveoli.
✓ Feeding initiated upon return of gag reflex • All the air spaces within the lobule are enlarged
✓ Instruct client to avoid talking, coughing and • Patient has a barrel chest, marked dyspnea on exertion and
smoking as it may irritate respiratory tract weight loss
✓ Monitor for s/sx of frank or gross bleeding
✓ Monitor for signs of laryngeal spasm CENTRILOBULAR EMPHYSEMA
❖ DOB and SOB → prepare trach set • The pathologic changes take place mainly in the center of
secondary lobule, while the peripheral portions of the acinus are
preserved.

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• Derangement of ventilation- perfusion ratios, producing chronic

hypoxemia, hypercapnia, polycythemia and episodes of RHF
• Leads to central cyanosis, peripheral edema and respiratory
failure
PREDISPOSING FACTORS
• Smoking
• Air pollution
• Hereditary: involves alpha-1 antitrypsin
→ For elastase production
→ For recoil of the alveoli
• Allergy
• High risk group OPEN
→ Elderly
→ Degenerative • Air enters pleural space through an opening in pleural wall (most
→ Decreased vital lung capacity and thinning of alveolar common)
lobes → Gun shot wounds
→ Multiple stab wounds
SIGNS AND SYMPTOMS
• Productive cough
• Dyspnea at rest
• Prolonged expiratory grunt
• Resonance to hyperresonance
• Decreased tactile fremitus
• Decreased breath sounds
• If (-) BS → lung collapse
• Barrel chest
• Anorexia and generalized body malaise
• Rales or crackles TENSION
• Alar flaring
• Air enters pleural space during inspiration and cannot escape
• Pursed-lip breathing (to eliminate excess CO2) leading to overdistention of the thoracic cavity
DIAGNOSTICS → Mediastinal shift to the affected side (ie. Flail chest) →
paradoxical breathing
• ABG analysis reveal
→ Panlobular, centrilobular PO2 elevation and PCO2
depression → respiratory acidosis (blue bloaters)
→ Panacinar/centriacinar PCO2 depression and PO2
elevation (pink puffers – hyperoxemia)
• Pulmonary function test – decreased vital lung capacity
NURSING MANAGEMENT
• Enforce CBR
• Administer medications as ordered
→ Bronchodilators
→ Antimicrobials
→ Corticosteroids
→ Mucolytics or expectorants PREDISPOSING FACTORS
• Low inflow O2 admin; high inflow will cause respiratory arrest • Chest trauma
and oxygen toxicity • Inflammatory lung condition
• Force fluids • Tumors
• Pulmonary toilet
SIGNS AND SYMPTOMS
• Nebulize and suction client as needed
• Sudden sharp chest pain, dyspnea, cyanosis
• Institute PEEP in mechanical ventilation
→ PEEP – positive end expiratory pressure • Diminished breath sounds
→ Allows for maximum alveolar diffusion • Cool, moist skin
→ Prevent lung collapse • Mild restlessness and apprehension
• Provide comfortable and humid environment • Resonance to hyperresonance
• Diet modifications: high calorie, CHON, CHO, vitamins and DIAGNOSTICS
minerals
• Health teaching and d/c planning • ABG analysis: PO2 decreased
→ Avoidance of smoking • CXR – confirms collapse of lungs
→ Prevent complications NURSING MANAGEMENT
✓ Atelectasis
✓ CO2 narcosis → coma • Assist in endotracheal intubation
✓ Cor pulmonale • Assist in thoracentesis
✓ Pleural effusion • Administer meds as ordered
✓ Pneumothorax → Narcotic analgesics – Morphine sulfate
• Regular adherence to meds → Antibiotics
• Importance of FFUP care • Assist in CTT to H20 sealed drainage
RESTRICTIVE LUNG DISEASE (PNEUMOTHORAX)
Partial or complete collapse of the lungs due to accumulation
of air in pleural space
TYPES OF PNEUMOTHORAX
SPONTANEOUS
• Air enters pleural space without an obvious cause
→ Ruptured blebs (alveolar – filled sacs) → inflammatory
lung conditions

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