OVERVIEW OF RESPIRATORY SYSTEM: I. Upper respiratory tract: Fx: 1. Filtering of air 2. Warming & moistening 3. Humidification a. Nose ± cartilage - Parts: Rt nostril separated separat ed by septum Lt nostril
b.
Consists of anastomosis of capillaries ± Kessel ± Bach Plexus ± site of epistaxis Pharynx (throat) ± muscular passageway for air& food Branches: 1. Oropharynx 2. Nasopharynx 3. Layngopharynx
c. Larynx ± voice box Fx: 1. 2.
For phonation Cough reflex
Glottis ± opening Opens to allow passage of air Closes to allow passage of food II. Lower Rt ± Fx for gas exchange a. Trachea ± windpipe - has cartillagenous rings - site for permanent/ artificial a/w ± tracheostomy - Passageway bet. Larynx and bronchi b. Bronchus ± R & L main bronchus c. Lungs ± R ± 3 lobes = 10 segments L ± 2 lobes ± 8 segments Visceral pleura ± covers lungs Parietal pleura ± covers thorax Bronchi ± bronchioles ± teminal bronchioles ± r esp bronchioles - *tracheobronchial tree 150ml of air
Post pneumonectomy pneumonectomy - position affected affected side to promote expansion of lungs lungs Post segmental lobectomy ± position unaffected side to promote drainage Lungs ± covered by pleural cavity, parietal lobe & visceral lobe Alveoli ± acinar ± acinar cells site of gas exchange (O2 & CO2) diffusion: Daltons law of partial pressure of gases 300 million/15 to 20 clusters Type I alveolar cells are epithelial cells that form the alveolar walls. Type II alveolar cells are metabolically active. These cells secrete secre te surfactant, a phospholipid that lines the inner surface and prevents alveolar collapse. Type III alveolar cell macrophages are large phagocytic cells that ingest foreign matter (eg, mucus, bacteria) and act as an important
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defense mechanism.
Ventilation ± movement of air in & out of lungs *movement of the walls of thoracic cage and diaphragm Respiration ± movement of air into cells *gas xchange bet atmospheric air and blood and bet bet blood and cells Type II cells of alveoli ± secretes surfactant Surfactant - decrease surface tension of alveoli Lecithin & spinogometer L/S ratio 2:1 ± indicator of lung maturity If 1:2 ± adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.
I. PNEUMONIA ± inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates. Etiologic agents: 1. Streptococcus pneumoniae (pnemococcal pneumonia) 2. Hemophilus pneumoniae(Bronchopneumonia) pneumoniae(Bronchopneumonia) 3. Escherichia coli 4. Klebsiella P. 5. Diplococcus P. High risk elderly & children below 5 yo
Predisposing factors: 1. Smoking 2. Air pollution 3. Immuno-compromised a. AIDS ± PLP b. Bronchogenic CA - Non-productive Non-productive to productive c ough 4. Prolonged immobility ± CVA- h ypostatic pneumonia 5. Aspiration of food 6. Over fatigue S/Sx: 1. 2. 3. 4. 5. 6. 7. 8.
Productive cough ± pathognomonic: greenish to rus rusty ty spu sputt um Dyspnea with prolonged respiratory grunt Fever, chills, anorexia, gen body malaise Wt loss Pleuritic friction rub Rales/ crackles Cyanosis Abdominal distension leading to paralytic ileus
Sputum exam ± could confirm presence of TB & pneumonia
Dx: 1. Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism. 2. CXR ± pulmo consolidation 3. CBC ± increase WBC Erythrocyte Erythrocyte sedimentation rate 4. ABG ± PO2 decrease Nsg Mgt: 1. 2. 3.
Enforce CBR Strict respiratory isolation Meds: a.) Broad spectrum antibiotics Penicillin or tetracycline Macrolides ± ex azythromycin (zythromax) b.) Anti pyretics c.) Mucolytics or expectorants 4. Force fluids ± 2 to 3 L/day 5. Institute pulmonary toileta.) Deep breathing exercise b.) Coughing exercise c.) Chest physiotherapy ± cupping d.) Turning & reposition reposition - Promote expectoration expectoration of secretions secretions 6. Semi-fowler 7. Nebulize & suction 8. Comfy & humid environment 9. Diet: increase CHO or calories, CHON & vit C 10. Postural drainage - To drain secretions using gravity Mgt for postural postural drainage: drainage : a.) Best done before meals or 2 ± 4 hrs after meals to prevent Gastroesophageal Reflux b.) Monitor VS & breath sounds Normal breath sound ± bronchovesicular bronchovesicular c.) Deep breathing exercises d.) Adm bron chodilators chodilators 15 ± 30 min before procedure e.) Stop if pt can¶t tolerate procedure f.) Provide oral care ± it may alter taste sensation g.) C/I ± pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma) Normal IOP ± 12 ± 21 mmHg 11. HT: a.) Avoidance of pr ecipitating ecipitating factors b.) Complication: Atelectacies & meningitis c.) Compliance to meds
PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB or tubercle bacilli or acid fast bacilli ± gram (+) aerobic, motile & easily destroyed by heat or sunlight. Predisposing factors: 1. Malnutrition 2. Overcrowding 3. Alcoholism 4. Ingestion of infected cattle (mycobacteri um BOVIS) 5. Virulence 6. Over fatigue S/Sx: 1.
Productive cough ± yellowish
2. Low fever 3. Night sweats 4. Dyspnea 5. Anorexia, general body malaise, wt loss 6. Chest/ back pain 7. Hempotysis Diagnosis: 1. Skin test ± mantoux test ± infection of Purified CHON Derivative PPD DOH ± 8-10 mm induration WHO ± 10-14 mm induration Result within 48 ± 72h (+) Mantoux test ± previous exposure to tubercle bacilli Mode of transmission ± droplet infection 2. Sputum AFB ± (+) to cultured microorganism 3. CXR ± pulmonary infiltrate caseosis necrosis 4. CBC ± increase WBC Nursing Mgt: 1. CBR 2. Strict resp isolation 3. O2 inhalation 4. Semi fowler 5. Force fluid to liquefy secretions 6. DBCE 7. Nebulize & suction 8. Comfy & humid environment 9. Diet ± increase CHO & calories, CHON, Vit, minerals 10. Short course chemotherapy
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Intensive phase INH ± isoniazide Rifampicin resistance
- give before meals for absorption - given within 4 months, given simultaneously simultaneously to prevent -S/E: peripheral neutitis ± vit B6 Rifampicin -All body secretions turn to red orange color urin e, stool, saliva,
sweat & tears. PZA ± Pyrazinamide ± given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity Stand Standa ard regimen 1. Injection of streptomycin ± aminoglycoside Ex. Kanamycin, gentamycin, neomycin S/E: a.) Ototoxicity ± damage CN # 8 ± tinnitus ± hearing loss b.) Nephrotoxicicity ± monitor BUN & Crea
HT: a.) Avoid pred factors b.) Complications: 1.) Atelectasis 2.) Miliary TB ± spread of Tb to other system c.) Compliance to meds
- Religiously take meds
HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted to birds manure. S/Sx: Same as pneumonia & PTB ± like 1. Productive cough 2. Dyspnea 3. Chest & joint pains 4. Cyanosis 5. Anorexia, gen body malaise, wt loss 6. Hemoptysis Dx: 1. 2.
Histoplasmin skin test = (+) ABG ± pO2 decrease
Nsg Mgt: 1. CBR 2. Meds: a.) Anti fungal agents Amphotericin B (Fungizone) S/E : a.) Nephrotoxcicity check BUN b.) Hypokalemia b.)Corticosteroids c.) Mucolytic/ or expectorants 3. O2 ± force fluids 4. Nebulize, suction 5. Complications: a.) Atelectasis b.) Bronchiectasis COPD 6. Prevent spread of histoplasmosis: a.) Spray breading places or kill the bird.
COPD ± Chr Chro onic Ob Obsstruc ructtive Pulmo ulmonary Dise Disea ase 1. 2. 3. 4.
Chronic bronchitis Bronchial asthma Bronchiectasis Pulmonary emphysema ± terminal stage
CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet mucus producing cells leading to n arrowing arrowing of smaller airways. airways. Predisposing factors: 1. Smoking ± all COPD types 2. Air pollution S/Sx: 1. Prod cough 2. Dyspnea on exertion 3. Prolonged expiratory grunt
4. 5. 6.
Scattered rales/ rhonchi Cyanosis Pulmo HPN ± a.)Leading to peripheral edema b.) Cor pulmonary ± respiratory in origin 7. Anorexia, gen body malaise Dx: 1.
ABG PO2
PCO2
Resp acidosis
Hypoxemia ± causing cyanosis Nsg Mgt: (Same as emphysema) 2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller airway. Predisposing factor: 1. Extrinsic Asthma ± called Atropic/ allergic asthma a.) Pallor b.) Dust c.) Gases d.) Smoke e.) Dander f.) Lints 2. Intrinsic AsthmaCause: Herediatary Drugs ± aspirin, penicillin, F blockers Food additives ± nitrites Foods ± seafood, chicken, eggs, ch ocolates, milk Physical/ emotional stress Sudden change of temp, h umidity &air pressure 3. mixed type: type: combi of both ext & intr. Asthma 90% cause of asthma S/Sx: 1. 2. 3. 4. 5. 6. 7. Dx: 1. 2.
C ± cough ± n on productive to productive D ± dyspnea W ± wheezing ± wheezing on expiration Cyanosis Mild apprehension & restlessness Tachycardia & palpitation palpitation Diaphoresis Pulmo function test ± decrease lung capacity ABG ± PO2 decrease
Nsg Mgt: 1. CBR ± all COPD 2. Medsa.) Bronchodilator through inhalation inhalation or metered m etered dose inhaled / pump. Give 1 st before corticosteroids b.) Corticosteroids ± due inflammatory. Given 10 min after adm bronch odilator c.) Mucolytic/ expectorant d.) Mucomist ± at bedside put suction machine. e.) Antihistamine
3. Force fluid 4. O2 ± all COPD low inflow to prevent resp distress 5. Nebulize & suction 6. Semifowler ± all COPD except emphysema due late stage 7. HT a.) Avoid pred factors b.) Complications: Status astmaticus- give epinephrine & bronchodilators Emphysema c.) Adherence to med
BRONCHIECTASIS ± abnormal permanent dilation of bronchus r esulting to destruction of muscular & elastic tissues of alveoli. Predisposing factors: 1. Recurrent upper & lower RI 2. Congenital anomalies 3. Tumors 4. Trauma S/Sx: 1. Productive cough 2. Dyspnea 3. Anorexia, gen body malaise- all energy are used to increase respiration. 4. Cyanosis 5. Hemoptisis
Dx: 1. 2.
ABG ± PO2 decrease Bronchoscopy ± direct visualization visualization of bronchus using fiberscope. Nsg Mgt: before bronchoscopy 1. Consent, explain procedure ± MD/ lab explain RN 2. NPO 3. Monitor VS
Nsg Mgt after after bronch ncho osco scopy 1. 2. 3. 4. -
Feeding after return of gag r eflex Instruct client to avoid talking, smoking or coughing Monitor signs of frank or gross bleeding Monitor of laryngeal spasm DOB Prepare at bedside tracheostomy set
Mgt: same as emphysema emphysema except Surgery Pneumonectomy ± removal of affected lung Segmental lobectomy ± position of pt ± unaffected side
PULMONARY EMPHYSEMA ± irreversible terminal stage of COPD Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases. Body will compensate over distension of thoracic cavity Barrel chest Predisposing factor: 1. Smoking
2. 3. 4. 5. S/Sx: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Allergy Air pollution High risk ± elderly Hereditary - E 1 anti trypsin to release elastase for recoil o f alveoli.
Productive cough Dyspnea at rest ± due terminal Anorexia & gen body malaise Rales/ rhonchi Bronchial wheezing Decrease tactile fremitus (should have vibration)± palpation ± ³99´. Decreased - with air or fluid Resonance to hyperresonance ± percussion Decreased or diminished breath sounds Pathognomonic: barrel Pathognomonic: barrel chest ± increase post/ anterior diameter of chest Purse lip breathing ± to eliminated PCO2 Flaring of alai nares
Diagnosis: 1. Pulmonary function test ± decrease vital lung capacity 2. ABG ± a.) Panlobular / centrolobular centrolobular emphysema pCO2 increase pO2 decrease ± hypoxema resp acidosis Blue bloaters b.) Panacinar/ Centracinar pCO2 decrease pO2 increase ± hyperaxemia resp alkalosis Pink puffers Nursing Mgt: 1. CBR 2. Meds ± a.) Bronchodilators b.) Corticosteroids c.) Antimicrobial Antimicrobial agents d.) Mucolytics/ Mucolytics/ expectorants 3. O2 ± Low inflow 4. Force fluids 5. High fowlers 6. Neb & suction 7. Institute P ± posture E ± end E ± expiratory to prevent collapse of alveoli P ± pressure 8. HT a.) Avoid smoking b.) Prevent complications 1.) Cor pulmonary ± R ventricular hypertrophy 2.) CO2 narcosis ± lead to coma 3.) Atelectasis 4.) Pneumothorax ± air in pleural space 9. Adherence to meds
RESTRICTIVE LUNG DISORDER
PNEUMOTHORAX ± partial / or complete collapse of lungs due to entry or air in pleural space. Types: 1. Spontaneous pneumothorax ± entry of air in pleural space without obvious cause. Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions Eg. open pneumothorax ± air enters pleural space through an opening in chest wall -Stab/ gun shot wound 2. Tension Pneumothorax ± air enters plural space with @ inspiration inspiration & can¶t escape leading to over distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side. Eg. flail chest ± ³paradoxical breathing´ Predisposing factors: 1.Chest trauma 2.Inflammatory 2.Inflammatory lung conditions 3.Tumor S/Sx: 1. Sudden sharp chest pain 2. Dyspnea 3. Cyanosis 4. Diminished breath sound of affected lung 5. Cool moist skin 6. Mild restlessness/ apprehension 7. Resonance to hyper resonance Diagnosis: 1. ABG ± pO2 decrease ± 2. CXR ± confirms pneumothorax Nursing Mgt: 1. Endotracheal intubation 2. Thoracenthesis 3. Meds ± Morphine SO4 Anti microbial agents 4. Assist in test tube thoracotomy Nursing Mgt if pt is on CPT attached to H2O drainage 1. Maintain strict aseptic technique 2. DBE 3. At bedside a.) Petroleum gauze pad if dislodged Hemostan b.) If with air leakage ± clamp c.) Extra bottle 4. Meds ± Morphine SO4 Antimicrobial 5. Monitor & assess for oscillation fluctuations or bubbling a.) If (+) to int ermittent ermittent bubbling means n ormal or intact - H2O rises upon inspiration - H2o goes down upon expiration b.) If (+) to continuous, remittent bubbling bubbling 1. Check for air leakage 2. Clamp towards chest tube 3. Notify MD c.) If (-) to bubbling 1. Check for loop, clots, and kink 2. Milk towards H2O seal 3. Indicates re-expansion of lungs When will MD remove chest tube: 1. If (-) fluctuations 2. (+) Breath sounds 3. CXR ± full expansion of lungs
Nursing Mgt of removal of chest tube 1. DBE 2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space. 3. Apply vaselinated air occlusive dressing Maintain dressing dry & intact
