OXYGENATION

Normal Breath Sounds:

Oxygenation – Ventilation Vesicular: soft, low pitched, over most lung fields,
Nursing Care of Clients with Upper Airway disorders inspiration > expiration

Objectives: Bronchovesicular: med pitched, over main bronchus and

R posterior lung, inspiration>expiration
 To identify all the problems in oxygenation
 To know the medical and nursing responsibilities in Bronchial: loud, high pitched, over manubrium only,
each problem expiration > inspiration extended in asthma
 Nursing Assessment History and Physical
Assessment Tracheal: very loud, high pitched, over trachea only,
 Etiology inspiration > expiration
 Pathophysiology
 Clinical Manifestation Adventitious Sounds: Extra Sounds, Always
 Diagnosis Abnormal
 Treatment Modalities
 Medical and Surgical Crackles or Rales : Discontinuous, fine/medium/coarse,
 Dietetics not cleared by coughing, heard more often on inspiration
 Nursing Management of various respiratory disorders - Dry or wet, due to small airways being forced open in a
 Upper Respiratory Tract Infections disruptive fashion
 Bronchitis - Also heard in atelectasis from disuse of the lung
 Asthma
 Emphysema Rhonchi: Continuous, foghorn, low-pitched, cleared on
 Empyema coughing
 Atelectasis - From air passing through an obstructed airway
 Chronic Obstructive Pulmonary Disease (COPD)
 Bronchiectasis Wheezes: Continuous, tea kettle high pitch, usually
 Pneumonia diffuse and bilateral
 Pulmonary Tuberculocis (TB) - Heard diffusely in asthma
 Lung Abscess - Unilateral = foreign body aspiration
 Pleural Effusion - From air being forced through a constricted airway
 Cysts and Tumors
 Chest Injuries Rub: Pleural sound that is like leather rubbing together
 Respiratory Arrest and Insufficiency - Caused by inflamed pleural surfaces rubbing together
 Pulmonary Embolism - Come and go depending on amount of fluid in pleural
space
Review the Anatomy and Physiology of Respiratory - Documentation: loudness, pitch, quantity, location on
System lung fields, inspiratory/expiratory, effect of coughing, effect
of position change
Common Respiratory Signs and Symptoms
 Dyspnea
 Wheezing
 Chest pain
 Cough
 Hemoptysis
 Sputum production

 Dyspnea
Acute or chronic
Causes
- Respiratory: bronchospasm,bronchitis, pneumonia,
pulmonary embolism, pulmonary edema,pneumothorax,
upper airway obstruction
- Cardiovascular: acute MI, CHFo cardiac tamponade:
water bottle appearance of heart on CXR
- Something else: anemia, DKA, deconditioning,
Nursing Assessment – History and Physical anxiety, etc.
Assessment - If chronic: asthma, COPD, interstitial lung disease,
History Collection: cardiomyopathy
- Personal History Investigation
- Reason for Seeking Care  Good history & PE leads to accurate diagnosis 2/3 of
- Past Health History the time
- Present Illness / Problems  Oximetry or ABG
- Previous Illness  CXR
- Family History  Spirometry
- Occupational History  CBC to r/o dyspnea from anemia
- Medications  ECG
Physical Examination Treatment
-Skin – Cyanosis, Pallor  Treat the cause!
-Nail Clubbing  Oxygen
-Cough and sputum production  Pulmonary rehab: improves exercise capacity,
-Inspect – Palpate – Percussion – ex. Auscultate reduces perceived breathlessness, improves quality
the thorax of life, reduces anxiety and depression, improves
survival
 Treat anxiety

 Cough

 Acute if less than 3 weeks

 Persistent if 3-8 weeks
 Chronic if greater than 8 weeks
 Women more likely to develop loss
Causes:
- URI, pneumonia, aspiration, pulmonary embolism,
pulmonary edema
- In smokers it is usually low-grade chronic bronchitis
- With increased intensity lung cancer
- In nonsmokers is usually postnasal drip, asthma,
GERD, or ACE inhibitors
- ROS may include: fatigue, insomnia, headache, urinary
incontinence, rib fx
- Investigation  Pulse Oximeter
- CXR in smokers, fevers, and weight - Pulse oximetry is a non invasive method of
Treatment: continuously monitoring the oxygen saturation of
 Care for underlying cause hemoglobin (02 Sat)
 elimination of irritants - A sensor or probe is attached to the ear lobe,
forehead, fingertip or the bridge of the nose
 Hemoptysis
 Sputum Analysis
 Expectoration of blood originating below the vocal cords The sputum test analysis involves a sample of
 Usually comes from bronchial arteries (high pressure) sputum to diagnose respiratory disease, identify organism
 Be aware of mimics: upper respiratory tract bleed, upper and identify abnormal cells and also identify pathogenic
GI bleed organisms
Causes:
-Most commonly bronchitis, bronchogenic carcinoma, Sputum Cultures
pneumonia Defining the respiratory tract
Other Causes: Upper = nose, nasal cavity, nasopharynx
-Infection, Good pasture’s syndrome, Wegener’s Lower = larynx, trachea, bronchi, bronchioles, alveoli
granulomatosis, autoimmune, iatrogenic, cocaine, AV
malformation, pulmonary embolism, elevated pulmonary Specimens
capillary pressure, foreign body, airway or parenchymal Sputum specimen: expectorated matter from the trachea,
trauma, fistula formation, idiopathic bronchi, and/or lungs through the mouth
Investigation: Endotracheal specimen: suctioned sputum from an
- CXR, hematocrit, UA, renal labs, coagulation profile, endotracheal or tracheostomy tube (ideal because you are
bronchoscopy bypassing the mouth flora)
-Tumor workup with strong history of smoking and > 1 Bronchoalveolar lavage specimen: wash collected from
week hemoptysis an area of the lung during a bronchoscopy
Treatment:
 Treat cause When to Culture?
 Bronchitis never, almost always viral
Common Diagnostic Evaluation  Pneumonia must ask for different culture medium
 Pulmonary Function Test (PFT) when suspecting anaerobes(aspiration), atypicals,
- Is non invasive diagnostic test pertussis, fungi
- In this test the volume and capacity test aid diagnosis in  Acid fast bacilli
patients with suspected pulmonary dysfunction  Culture: requires serial (3) early morning sputum
- spirometry; Dr. Emad Efat July 2016 cultures because there will:
- Stains
PFT evaluates ventilatory functions - Gram stain be a low yield of bacteria in each
- Determine whether obstructive or irritative disease sample
- Can be utilize as screening test - Long incubation period, up to 6 weeks

 ABG ( Arterial Blood Gas Analysis ) Stains

ABG analysis is a diagnostic procedure that involves Gram stain
measurement of Blood pH and arterial oxygen and carbon - Too many squamous epithelial cells are indicative of
dioxide tensions are both obtained when managing oral mucosal contamination
patients with respiratory problems and adjusting oxygen - Numerous neutrophils are indicative of infection
as needed * Although the absence of neutrophils in a neutropenic
or immunocompromised patient does not rule out infection
ABG Normal Values - Macrophages common in fungal, acid-fast, and
PaO2 – 80 to 100 mmhg other atypical bacterial infections
PaCO2 – 35 to 45 mmhg - Eosinophils indicate allergic reaction or parasitic
pH – 7.35 to 7.45 infection
O2 Saturation – 95 to 99 % - Mucus strands indicate direct attack (antibodies and
lysosomes) of inhaled bacteria

Acid Fast Stain:

- Special stain to look for Mycobacterium and other
acid fast bacteria
 - Low sensitivity, but a positive indicates treatment - Involves inhalation as well as venous injection of a
should begin as long as there is an appropriate clinical radiotracer
picture - Detects areas of the lung that are being perfused and
- Must also report to health department those that are being ventilated for comparison
*Sputum is mucus coughed up from lower airways - Imaging is graded based upon probability of PE
- Use over a CTA if patient has a contrast allergy or is
 Lung Biopsy pregnant (less radiation)
- Guided by bronchoscope or CT
- Fine-needle aspirate or core sample  Thoracentesis
-Core provides more tissue for testing
- Contraindicated for lesions < 1cm or high bleed risk - Ultrasound or CT guided
- Small pneumothorax always occurs as a result - Can be diagnostic and/or therapeutic
- Resolves if tissue is healthy - Short or long-term
- Drain is promptly removed if there is no purulent fluid
 Tuberculin Skin Testing draining (no evidence of infection)
- Mantoux tuberculin skin test (PPD): tuberculin antigen is - Pleural fluid aspiration for obtaining a specimen of
injected beneath the skin, with presence or absence of pleural fluid for analysis, relief of lung compression and
reaction measured in 48-72 hours biopsy specimen collection
- Induration (bump) not erythema measured

 Will only Catch a developed immune response against

TB
- takes 2-12 weeks to develop a response after an
exposure
- problem if someone does not have a strong enough
immune system to mount a response = potential false
negative
- prevent by using a control that everyone is
exposed to, such as Candida albicans antigen
- Problem when someone has latent TB or old
BCG vaccine with waning immunity against it
*First PPD test will be negative but will stimulate
memory T-cells
*Second PPD will be positive
*This person is a “converter” = why you frequently
have to get “two-step” TB tests to protect against this
being missed

Positive Reading:  Magnetic Resonance Imaging (MRI)

 Patients at high risk for developing active TB: Indications
immunosuppressed, recent contacts, CXR  Multiple sclerosis
demonstrating past infection  Primary tumor assessment and/or Metastatic disease
 Positive if their skin test is ≥ 5 mm  AIDS (taxoplasmosis)
 Other high risk groups: injection drug users,  Infarction (Cerebral Vascular Accident vs Transient
residents/employees of Ischaemic Attack)
hospitals/nursinghomes/prisons/shelters, lab workers,  Hemorrhage
children under 4, comorbid conditions  Hearing loss
 Positive if their skin test is ≥ 10 mm  Visual disturbances
 Infection Trauma
Imaging Studies  Unexplained Neurological symptoms or deficit
 Chest X – ray  Mapping of brain function
 Computed Tomography (CT)
 MRI  Fluoroscopy
 Fluoroscopic Studies - radiologic technique used to examine the body or organ
 Bronchoscopy - Uses x-ray for its purpose
 Ventilation Perfusion Scan (VQ Scan) - While the x-ray machine is able to take one picture at a
time, fluoroscopes are able to take multiple shots per
 Computed Tomography seconds to show it as moving picture
Indications: CXR abnormality, lung tumor, mediastinal
mass, aortic injury, dissection, aneurysm, complicated  Bronchoscopy
infection - Is the using for diagnostic and therapeutic purpose. It’s
When to use contrast: involves a direct inspection of the trachea and bronchi
- Not usually needed for pulmonary imaging as most through a flexible fiber optic or a rigid Bronchoscopy
things will be of differing density than lung tissue - used to determine location of pathologic lesions, to
- Best for vessel enhancement as in PE, aortic aneurysm remove foreign objects, to collect tissues specimen and
or dissection, some tumor protocols remove secretions or any aspirated materials
- See interlobular septal thickening in interstitial lung
disease Common Diagnostic Test for Respiratory Disorders
- Can visualize thrombus in pulmonary artery during PE  Laboratory Tests
- CXR frequently normal  Radiologic Studies
 Others
 Ventilation-Perfusion Scans (VQ Scans)
- Benefits: Less radiation than CT
- Disadvantages: time consuming, doesn’t provide as
much anatomic information as CT
Assessment  Acute Pharyngitis
 Health History ( allergies, occupation, lifestyle, health Is sudden inflammation of the Pharynx
habits) It is a febrile inflammation of throat, caused by virus
 Inspection ( Client’s color, level of consciousness, about 70%, uncomplicated viral infection usually subsided
emotional state ) (rate, depth, quality, rhythm, effort promptly within 3 to 10 days
relating to respiration) Clinical Manifestations
 Palpation and Percussion  Fiery red pharyngeal membrane and tonsils
 Auscultation ( Listening for normal and adventitious  Lymphoid follicles that are swollen
Breath sounds)  Enlarge tender cervical lymph node
 Fever and malaise
Common Upper Respiratory Tract Infections  Sore throat, hoarseness and cough
 Rhinitis or common cold Medical Management
 Allergic Rhinitis  Supportive measure for viral infection
 Sinusitis  Pharmacologic therapy antibiotics for 10 days
 Pharyngitis “cephalosporin” / analgesic for severe sore / anti
 Tonsilitis tussive medications
 Laryngitis  Nutritional therapy: liquid or soft diet “ If liquid is not
tolerated IVF administration is needed”
 Viral Rhinitis or Common Cold  Nursing management ( bed rest, skin assessment,
 Often is used when referring to a symptoms of an mouth care and normal saline gargle and self care
upper respiratory tract infection by nasal congestion, teaching)
sore throat and cough
 Cold referred to a febrile, infectious, acute  Chronic Pharyngitis
inflammation, of the mucus membranes of the nasal  Is a persistent inflammation of the pharynx
cavity  Common in adults who work or live in dusty
surrounding, use the voice too excess, suffer from
 Rhinitis chronic cough and habitually use alcohol and tobacco
 Rhinitis is a group of disorders characterized by Clinical manifestations
inflammation and irritation of the mucous membranes  Constant sense of irritation or fullness in throat
of the nose  Mucus expelled by coughing
 It may be acute or chronic, non allergic or allergic  Difficulty in swallowing
Causes of Rhinitis Medical Management
 Idiopathic  Relieving symptoms ( avoid exposure to irritant,
 Abuse of nasal decongestants correct respiratory and cardiac conditions)
 Irritants ( Smoke, air pollution)  Antihistamine drugs
 Foreign Bodies  Decongestant
Clinical Manifestations  Controlling malaise
 Rhinorrhea “ Excessive nasal drainage Nursing Management
 Nasal Congestion, Itching and sneezing  Patient teaching of self care
 Headache may occur  Avoid alcohol, tobacco, exposure to cold
Medical Management of Rhinitis  Face mask to avoid pollutant
 Treatment of cause “antibiotics”  Warm fluids and warm saline gargle
 Decongestant
 Antihistamine  Tonsillitis
 In severe cases corticosteroids  Are composed of lymphatic tissue and situated on
 teaching patient self care each side of the oropharynx, they frequently are the site
of acute infection
 Acute Sinusitis Clinical Manifestations
 It is an inflammation of sinuses, it is resolved  Tonsils: sore throat, fever, snoring and difficulty of
Clinical Manifestations swallowing
 Pressure, Pain over the sinus area  Adenoids: ear ache, mouth breathing, drainage ear,
 Tenderness frequent cold, bronchitis, noisy respiration, foul smelling
 Purulent nasal secretions breath and voice impairment
Medical Management Medical Management
 Antimicrobial agent “amoxicillin”  For recurrent tonsillitis “Tonsillectomy”
 Oral or Topical Decongestant  Conservative or symptomatic therapy
 Heated mist or Saline Irrigation  Antimicrobial therapy “penicillin” for 7 days
Nursing Management Nursing Management
 Teaching patient self care  Provide post op care: V/S, hemorrhage, position head
Complications turned to side, water or ice chips
 Meningitis and osteomylitis  Teaching patient: S&S of hemorrhage
 Brain abscess  Avoid too much talking or coughing
 Ischemic infarction  Liquid or semi liquid diet for several days
 Alkaline mouth washing with warm saline
 Chronic Sinusitis
 It is an inflammation of sinuses that persists for more  Laryngitis
than 8 weeks in adult and or 2 weeks in children  It is an inflammation of larynx, often occur as a result
Clinical Manifestations of voice abuse or exposure to dust, chemicals,
 Impaired mucociliary clearness and ventilation smoke, and other pollutants
 Chronic hoarseness and cough  Common in winter and easily transmitted
 Chronic headache  The cause of infection is almost virus
 Facial pain Clinical Manifestations
 Hoarseness or aphonia
 Severe cough
Medical Management
 Resting voice and avoid smoking
 Inhale cool stream or an aerosol
 Conservative treatment
 Antibiotics for bacterial organism
Nursing Management
 Rest voice
 Maintain a well humidified environment
 Daily fluid intake

OXYGENATION

Gas Exchange
Occurs after the alveoli are ventilated
Pressure differences (gradient) on each side of the
respiratory membranes affect diffusion
Alveoli:
PO2 100mmHg
PCO2 40mmHg
Venous Blood
PO2 60mmHg
PCO2 45mmHg
 O2 diffusion from alveoli →Pulmonary blood vessels
 CO2 diffusion from pulmonary blood vessels→ Alveoli

Oxygen Transport
 Transported from the Lungs to the Tissues
 97% of O2 combines with RBC Hgb
- Oxyhemoglobin carried to tissues
 Remaining O2, is dissolved and transported in
plasma and cells (PO2)

Normal Oxygenation Process

 Cell environment / O2 carrying capacity
 O2 Carrying capacity of blood is expressed by:
Process of Breathing - Red Blood Cells
Inspiration - Air flows into lungs - Hematocrit
Expiration - Air flows out of lungs % of blood that is RBCs
Men 40 – 54%
Inspiration Women 37 – 50%
 Diaphragm and intercostal muscle contract - Hemoglobin
 Thoracic cavity size increases
 Volume of lungs increases Carbon Dioxide Transport
 Intrapulmonary pressure decreases  Must be transported from tissues →Lungs
 Air rushes into the lungs to equalize pressure  Continually produced in the process of cell
Expiration metabolism
 Diaphragm and intercostal muscle relax  65% - carried inside RBCs as bicarbonate (HCO2)
 Lung volume decreases  30% - combines with Hgb →Carbhemoglobin
 Intrapulmonary pressure rises  5% - transported in plasma as carbonic acid (H2CO3)
 Air is expelled
 Inadequate O2 Balance
Behaviors of Negative O2 Balance
 Hypoventilation or Hyperventilation
 Stridor, audible sounds with respiration, wheezing ,
coughing
 Hypoxia
 Change in Mental Status
 Change in Vital Signs
 Cyanosis
 Decrease in GI motility
 Change in Renal Function
 Hypercapnia – From a Greek word hyper – above / too
Factors that Influence Respiratory Function much kapnos – smoke
 Age - also known as hypercarbia / CO2 retention
 Environment - Is a condition of abnormally elevated carbon dioxide
 Lifestyle (CO2) level in the blood
 Health Status
 Medications Nursing Responsibilities
 Stress Nursing Assessment
- HEART
Common Manifestation of Impaired Respiratory - Respiratory Assessment
Function - PMH Past Medical History
 Hypoxia - LIFESTYLE
 Altered breathing patterns HEART
 Obstructed or partially obstructed airway H – Have client describe specific location, onset and
duration of the problem
 Hypoxia E – Explore associated signs and symptoms
 Condition of insufficient oxygen anywhere in the A – Ask activities that worsen or ease the problem
blood R – Rate the severity of discomfort or incapacity
 Rapid pulse T – Talk treatments or interventions used to
 Rapid, shallow respirations and dyspnea alleviate the problem and their effectiveness
 Increased restlessness or lightheadedness
 Flaring of nares Nursing Measure to Promote Respiratory Function
 Substernal or intercostal retractions  Ensure a patent airway
 Cyanosis  Positioning
 Encourage deep breathing, coughing
Abnormal Respiratory Patterns  Ensure adequate hydration
 Tachypnea ( Rapid Rate)
 Bradypnea ( abnormally slow rate ) Physical Assessment
 Apnea ( cessation of breathing ) - Lung auscultation and breathing pattern
 Kussmaul’s breathing ( labored breathing ) - Abdominal Assessment
 Biot’ respiration (abnormal pattern of breathing - Urine output
characterized by groups of quick, shallow inspirations - Skin and Mucous membrane
followed by regular or irregular periods of apnea. - Heart sounds
Characterized by Camille Biot 1876 ) - Circulation
- Edema
Alterations in Ease of Breathing - DVT (Deep Vein Thrombosis)
 Orthopnea – is the sensation of breathlessness in a
recumbent position, relieved by sitting or standing Lung Sounds
 Dyspnea – difficult or labored breathing  Diminished or absent
 Crackles course and fine
- Discontinuous course bubbling
- Fine crackling sound at the middle or end of
inspiration
 Ronchi - A continuous sonorous sound
 Pleural Friction Rub - Grating rubbing sound

Common Test and Nursing Responsibilities

 Measure adequacy of ventilation and gas exchange
- (CBC) Complete Blood Count →Phlebotomy

- (ABG) Arterial Blood Gases →Arterial Puncture

- Pulmonary Function Test →Preparation by teaching

 Test to determine abnormal cell growth or infection in
respiratory system:
Obstructed or Partially Obstructed Airway - Sputum Culture: Growing microorganisms from
Partial Obstruction - Low pitched snoring during sputum
inhalation - Throat Culture: Growth of microorganisms from
Complete Obstruction - Extreme inspiratory effort with throat material
no chest movement  Test to visualize structures of respiratory system:
- Brochoscopy: Is a procedure that lets the specialized
doctor (pulmonologist) look at the lungs and air passages
using a thin tube (bronchoscope). It passes through the
nose or mouth down to throat and into the lungs
- Chest Radiographs: Called a Chest X – Ray (CXR),
using chest film; Is a projection radiograph of the chest
used to diagnose conditions affecting the chest, its
contents and nearby structures.

 Thoracentesis
- Fluid removal from the pleural cavity with a needle

Nursing Responsibilities
 Medications
 Incentive Spirometry
 Chest PT (Physiotherapy)
 Improving Activity Intolerance
 Postural Drainage
- Determine etiology
 Oxygen Therapy
- Assess appropriateness of activity level
 Artificial Airway
- When appropriate gradually increases activity
 Airway Suctioning
- Ensure the client changes position slowly
 Chest Tubes
- Observe for symptoms of intolerance
- Syncope with activity ( refer to MD )
Basic Nursing Interventions
- Perform range of motion (ROM) exercise with
 Airway Maintenance
activity intolerance if immobile
- Facilitate effective coughing
 Mobilization of pulmonary Secretions
- Suctioning Airways
- Auscultate breath sounds, monitor respiratory
- Liquefying and mobilizing sputum
patterns, monitor ABG’s
 Maintenance and promotion of proper lung
- Position client to optimize respiration
expansion:
- Pulmonary toileting
- Re expanding collapsed lungs
- Incentive spirometry
Ex. Closed Chest Tube Drainage
- Suctioning
- Encourage activity and ambulation as tolerated
- Encourage increase fluid intake
- Chest Physiotherapy
- O2
- Medication as ordered

 O2 Therapy:
- Low flow
- High flow
- Humidification
- Nasal Cannula
- Simple Mask
- Non rebreathing Mask
- Partial rebreathing
  Doppler Blood Flow Studies – also known as Vascular
 Chest Physiotherapy flow studies. It uses sound waves to measure the flow of
- treatment used with children who have had heart surgery blood through a blood vessel. The results are shown on a
and who may have partial collapse of their lung tissue or computer screen in lines called Waveforms
lung secretions which they are unable to clear themselves
Techniques in Chest physiotherapy  Cardiovascular
1. Percussion/ Clapping/ Cupping Modify Risk Factor
2. Vibration - Diet
3. Postural drainage - Exercise
- Co – morbidities
 Effective Breathing Techniques: Preventing Vasoconstriction
- Position for maximal respiratory function - Positioning
- Pursed lip breathing - Cold Temperature
- Diaphragmatic or abdominal breathing - Nicotine
 Stress and Anxiety Reduction: Prevent Complications
- Remove pertinent cause of anxiety at that moment - Risk DVT
a. Help client gain control over respiration - Position Changes
b. Reassure client not in immediate danger - Early Ambulation
- Chronic Clients - Obstruction Removal
a. Exacerbations and remissions - Bypass Surgery
b. Goal is to reduce general level of anxiety Promoting Rest
c. Learn to control episodes of anxiety to improve - Schedule rest periods
quality of life - Assistance with (ADL’s) Activity of daily living
- desensitization program - Monitor vitals with activity
- guided mastery - Place items ex. Call light
- Quiet environment, decrease stimuli
Administration of Prescribed Medications Positioning to improve (CO) Cardiac Output
 Expectorants -Position semi high fowlers →decrease venous
 Mucolytic return and preload, decrease preload → Decrease risk of
 Bronchodilator heart congestion
 Cough Suppressants Avoiding Valsalva Maneuver
 Corticosteroids - Teach client to avoid valsalva maneuver
 Antihistamines a. Hold breath while turning or moving in bed →Assist
 Antibiotic b. Bearing down during (BM) Bowel movement → Stool
 Vasoconstritors softeners and diet
Avoid Stimulants
Adequate O2 Balance - Avoid appetite suppressants, cold , coffee, tea and
 Behaviors of Negative O2 balance → Cardio chocolate
Vascular Disease Maintaining Fluid Balance
- Arterial - Assess fluid status, monitor I &O, assess breath
- Venous sounds, (JVD) jugular vein distention, pitting edema in
- Impaired Tissue Perfusion dependent areas, fluid and Na+ restriction and electrolyte
 Behaviors of Negative O2 Balance →CV monitoring
- Restlessness, dizziness, syncope, bradycardia, Increase O2 Supply
decrease urine - Administer O2
- Cold and Clammy skin, Cyanosis, Slow Capillary - Educate Client NO SMOKING
refill - Position to facilitate breathing
- Decreased Cardiac Output Dietary Control
- Assess nutritional status
Common Tests and Nursing Responsibilities - Consider a dietician referral to assess nutritional
 (CBC) Complete Blood Count – is a blood test used to needs related to clients
evaluate overall health and detect a wide range of Weight Control
disorders including anemia, infection, and leukemia Evaluate the client’s physiological status in relation
to condition
 Lipid Profile – Usually includes the levels of total - More than body requirements
cholesterol, high density lipoprotein (HDL) cholesterol, - Less than body requirements
Triglycerides and the calculated low density lipoprotein Administration of Prescribed Medications
(LDL) cholesterol Cardiovascular
- Anti Coagulants
 Coagulation Studies - Measure blood’s ability to clot. - Vasodilator Medications
Test can help to asses the risk of excessive bleeding or - Inotropic Medications
developing clots ( thrombosis) somewhere in blood - Anti Dysrhythmics
vessels - Anti Hypertensives
OXYGENATION TRANSPORT HEMATOLOGIC
 EKG / ECG – Is a medical test that detects cardiac DISORDERS
(Heart) abnormalities by measuring the electrical activity Anemia - Is an abnormally low number of circulating red
generated by the heart as it contracts blood cells, or level of hemoglobin, or both, resulting in
diminished oxygen carrying capacity
 Angiography - or arteriography, is a medical imaging Causes of Anemia
technique used to visualize the inside, or lumen of blood  Blood loss – bleeding
vessels and organs of the body with particular interest in  Hemolysis – destruction of RBC’s
the arteries, veins and the heart chambers. This is  Impaired RBC production – lack of nutrients or bone
traditionally done by injecting a radio – opaque contrast marrow failure, etc
agent into the blood vessel and imaging using X-ray
based techniques such as fluoroscopy.
Effects of Anemia Decreased in number of neutrophils, increases
Impaired oxygen transport susceptibility to infection
Reduction in RBC indices and hemoglobin levels Causes
Signs and symptoms associated with the pathogenic - Exposure to high doses of radiation, chemicals and
process that is causing the anemia toxins that suppress hematopoiesis
Compensation may occur if the person is otherwise -Immune mechanisms associated with many
healthy infectious processes including viral hepatitis,
- Increased cardiac output, ventilation rate, mononucleosis, AIDS
plasma volume
Pernicious Anemia ( B12 Anemia)
Anemia / Cytic and Chromic Macrocytic – normochromic (also termed Megaloblastic)
Pernicious anemia is major cause of B12 deficiency
Cytic - refers to cell. Intrinsic factor is a protein made by parietal cells of the
- Microcytic indicates smaller than normal. stomach
- Macrocytic is larger than normal It is required to allow absorption of B12
In pernicious anemia intrinsic factor is deficient
Chromic - Color, as determined by hemoglobin content Autoimmune atopic gastritis: anti parietal antibodies
(Hemoglobin gives the blood cell the red color) interfere with production of intrinsic factor
- Hypochromic indicates less hemoglobin in a RBC Treatment: Life long IM injections of vitamin B12

Hemolytic Anemia B12 DEFICIENCY

 Premature destruction of RBC’s B12 is essential for:
Characterized By:  Synthesis of DNA
-Retention of iron and other products of hemoglobin  Prevention of abnormal fatty acids from being
destruction – destroyed blood cells release their contents deposited into neuronal lipids (like myelin)
which then circulate in the blood D- Neurologic and anemia ( unlike folic acid)
- Compensatory increase in erythropoiesis Deficiencies are related to its function:
* Increase in reticulocytes due to hyperactive bone  Impaired cellular maturation and division (difficult
marrow increasing production of RBCs making RBCs)
Most are:  Predisposes myelin to breakdown and results in
- Normocytic ( normal blood cells) neurologic symptoms associated with vitamin B12
- Normochromic (normal color indicating deficiency:
hemoglobin content is normal) - Symmetric paresthesia of the feet and fingers (tingling)
Signs and Symptoms - Loss of vibratory and position sense
- Fatigue, dyspnea, tachycardia, others - Spastic ataxia
depending on cause Could result from diet – B12 can’t be synthesized and is
- May see increase in unconjugated found in animal products ( technically, the bacteria
bilirubin resulting in mild jaundice associated with them)
Causes
- Intrinsic to RBCs: Defects in RBC membrane, Anemias from Deficient RBC Production Folic Acid
hemoglobin, enzyme systems ( usually Deficiency Anemia
inherited)  Macrocytic – nomochromic
- Extrinsic: Drugs, toxins, bacteria, trauma,  Folic acid is required for DNA synthesis and
immune therefore, RBC maturation
Extravascular - destruction takes place in the spleen  May present similarly to B12 deficiency, but without
Intravascular neurological changes or gastric atrophy
Often associated with faulty heart valves:  Etiologies may include:
- Hemoglobin binds to plasma proteins - Inadequate intake ( alcohol, elderly, indigent)
- If too much hemoglobin in blood: - Increased demand ( pregnancy, infancy, cancer)
* Free hemoglobin in the blood =Hemoglobinemia - Folate antagonist chemotherapy (methotrexate)
- Makes plasma turn red - Malabsorption syndromes
* Excreted in urine = Hemoglobinuria
- Makes urine darker in color Anemias from Deficient RBC Production Hypochromic
Iron Deficiency Anemia
Types of Hemolytic Anemias  Decreased RBCs, hemoglobin and hematocrit level:
1. Membrane Disorders Microcytic
- hereditary spherocytosis ( affects RBC membrane,  Causes:
making it a sphere) - Dietary deficiency
- Acquired hemolytic anemias and hemolytic diseases of - Chronic blood loss (most common)
the new born (immune associated) - Increased demands during growth periods
2. Hemoglobinopathies – Affect hemoglobin  Manifestations are related to lack of hemoglobin and
- Sickle cell disease impaired oxygen transport
- Thalassemia - Fatigability
* Alpha - Palpitations
* Beta - Dyspnea
3. G6PD Deficiency - Enzyme involved in RBC - Angina
membrane production - hereditary - Tachycardia
- Brittle, thin, coarsely ridged and spoon shaped nails
Aplastic Anemia (koilonychia)
Primary condition of bone marrow stem cells that results - A red, sore and painful tongue
in a reduction of all three hematopoietic cell lines: - dry, sore corners of the mouth (angular stomatitis)
RBCs, WBCs and Platelets (Pancytopenia)
Onset may be insidious or very acute and severe
Initial presenting symptoms: weakness, fatigability,
pallor, petechiae, bruises, bleeding Sickle Cell Disease
 Chronic hemolytic anemia Signs and Symptoms
 Inherited disorder (a point mutation changes one )  Dyspnea = sudden shortness of breath, or breathing
 Blood cells form an elongated shape and may adhere difficulty
to vessel walls ( often resulting in ischemia causing  Cough
pain, organ failure)  Large amounts of sputum
 Caused by a mutation in the beta chain of  Anorexia
hemoglobin (HbS)  Recurrent infection
 When hemoglobin is deoxygenated, beta chain link  Clubbing
together forming the ”sickle” shape  Crackles and wheezes
Diagnosis
Sickle Cell Mechanism  X ray
Autosomal Recessive Trait:  CT scan
A person with only one mutated gene ( heterozygous =  Sputum culture
from mom or dad) only 40% of the beta chains are Hbs  Test to find underlying cause
proteins. The rest are normal. Considered a carrier Therapeutic intervention
If both genes are sickle cell (homozygous = from mom  Antibiotics
and dad), then 80 – 95% are HbS - much more severe  Mucolytics, Expectorants
 Chest Physiotherapy
HbS is sensitive to changes in the oxygen content of  Oxygen
RBCs. Low O2 causes sickling  Surgical Resection
 “Sickle” shape = clumping = obstruction of
microcirculation = tissue hypoxia Pneumonia
 Sickling is initially reversible with oxygenation
 Repeated episodes = permanent sickling Pathophysiology
 Cells are fragile and easily destroyed  Acute Lung Infection
 Precipitating factors: Cold, Stress, Physical exertion,  Inflammation and alveolar damage
Hypoxia, Dehydration, Infection, Acidosis  Alveoli filled with exudate
 Reduced surface area for gas exchange
Remember: Fetal Hemoglobin Has No Beta Chains Etiology
 It has alpha chains and gamma chains in place of  Bacteria, usually streptococcus pneumoniae
beta  Virus
 This means it cannot sickle  Fungus
 Persons with some fetal hemoglobin are partly  Aspiration
protected from sickle cell disease  Artificial ventilation (VAP)
 Hypostasis
Thalassemias  Chemical
 Mutation in the gene that directs synthesis of the Prevention
chains  Pneumococcal Vaccine
 Deficiency in hemoglobin (hypochromic, microcytic)  Flu vaccine
 Excess production of unaffected chains( excess  Coughing and deep breathing
alpha chain causes insoluble “Heinz bodies”  Hand washing
Alpha  Frequent mouth care, continuous suction for ventilator
 Defective gene for alpha chain synthesis associated pneumonia
 1-4 defective genes Signs and Symptoms
 Affects both fetal and adult Hb  Chest pain
 In fetus, gamma4 Hb may form; in adult, beta4 Hb may  Fever, chills
form  Cough, dyspnea
Beta  Yellow, rusty or Blood – tinged sputum
 Defective gene for beta chain synthesis  Crackles, wheezes
 >100 different mutations  Malaise
 Affects only adult Hb Signs and Symptoms in Elderly
 Alpha4 Hb may form New Onset
Nursing Care of Clients with Gas Exchange Disorders  Confusion
 Lethargy
PLEURA  Fever
Parietal Pleura – lines the thoracic wall and superior  Dyspnea
aspect of the diaphragm Complications
Visceral Pleura – Covers the lung  Pleurisy = is an inflammation of the lining of the lungs
Pleural cavity – Or the space between the two layers and chest (the pleura) that leads to chest pain when you
contains a thin layer of serous fluid take a breath or cough
 Pleural effusion = excess fluid accumulates in the
Bronchiectasis pleural cavity, the fluid filled space that surrounds the
Permanent enlargement of parts of the airways of the lungs. This excess can impair breathing by limiting the
lungs. Symptoms typically include a chronic cough expansion of the lungs
productive mucus  Atelectasis = the collapse or closure of a lung resulting
in reduced or absent gas exchange. It may affect part or
Pathophysiology all of a lung. It is usually unilateral
 Chronic infection  Spread of infection
 Dilation of One or more Diagnosis
 Large bronchi  Chest x ray
 Airway obstruction  Sputum culture
Etiology  Blood culture
 Secondary to CHF, Asthma, TB
 Therapeutic Interventions  A posterior – anterior chest radiograph is used to detect
 antibiotic – PO or IV chest abnormalities. However, a chest radiograph may
 Antiviral medication (zovirax) be used to rule out the possibility of pulmonary TB in a
 Bronchodilators = open up (dilate) the breathing person who has had a positive reaction to a TST or TB
passages by relaxing the bronchial smooth muscle blood and no symptoms of disease
 Expectorants = increase bronchial secretions and  The presence of acid – fast - bacilli (AFB) on a sputum
make it easier to cough up mucus from the airways smear or other specimen often indicates TB disease,
and lungs but it does not confirm a diagnosis of TB because some
 Oxygen acid- fast- bacilli are not M. Tuberculosis. A positive
 Fluids – Fluids help minimize mucosal drying and culture for M. Tuberculosis confirms the diagnosis of TB
maximize ciliary action to move secretions. disease.
Encourage increased fluid intake of up to 3000 ml / Therapeutic Interventions
day For all patients, the initial M. Tuberculosis isolate should
( Some clients cannot tolerate increased fluids because be tested for drug resistance
of underlying disease)  Combination of Drugs for 6 to 24 months
 INH
Tuberculosis  Rifampicin
 Streptomycin
Pathophysiology  Ethambutol
 AFB Implant or Bronchioles or Alveoli = AFB stands for  Occasional Surgical Removal – surgery is rarely used
Acid Fast Bacilli. It is a test used to diagnosed to treat TB; it may be used to treat extensively drug-
Tuberculosis. A sputum specimen is obtained and resistant TB (XDR – TB) or to treat complications of an
tested for AFB. If the specimen is negative, it helps rule infection in the lungs or another part of the body. When
out TB. There are other tests that are also used in used: it can help repair lung damage like serious
combination with this test to diagnose Tuberculosis bleeding that can’t be stopped other ways, or for
including a chest X ray repeated lung infections other than TB or to remove a
 Tubercle Formed = the bacillus spreads slowly and pocket of bacteria that cannot be killed with long-term
widely in the lungs, causing the formation of hard medicine treatment.
nodules (tubercles) or large cheese like masses that  Isolation
break down the respiratory tissues and form cavities in
the lungs. Nursing Diagnosis:
 Immune System Keeps in Check = Typically, M. Lower Respiratory Disorders
Tuberculosis remains dormant – immune system keeps 1. Impaired Gas Exchange
it in check (latent tuberculosis). If the immune system 2. Ineffective Airway Clearance
compromised, reactivation occur. Active disease 3. Ineffective Breathing Pattern
classically presents with fever, weight loss, night sweats 4. Activity Intolerance
and productive cough ( with or without hemoptysis) that
does not respond to conventional antibiotic therapy 1. Impaired Gas Exchange
 5% to 10% Infected become ill Monitor
 May activate with impaired immunity  Lung Sounds, Respiratory Rate and effort
At Risk  Dyspnea
 Elderly  Mental Status
 Alcoholics  SpO2, ABGs
 Those living in crowded conditions Position
 Mew immigrants  Fowler’s
 Those with HIV  Good Lung Down
Signs and Symptoms Administer Oxygen
 Cough Teach Breathing Exercises
 Blood tinged sputum Discourage Smoking
 Night sweats
 Anorexia and weight loss 2. Ineffective Airway Clearance
 Low grade fever Monitor
 Dyspnea, chest pain (late)  Lung sounds
Diagnostic Tests  Sputum
 PPD skin test Encourage
 Chest X ray  Fluids
 Sputum cultures  Deep Breathing
 QuatifFERON – TB Gold – simple blood test, aids in  Coughing
detection of Mycobacterium tuberculosis, QTF is an Administer Expectorants
interferon – gamma (IFN-Y) release assay and used as Turn every 2 hours Daily or ambulate
modern alternative to TB skin test (TST, PPD on Suction PRN
Mantoux). QTF is highly specific and sensitive: a Consider CPT or Mucus Clearance Device
positive result is strongly predictive of true infection with
M. Tuberculosis. It cannot distinguish between active 3. Ineffective Breathing Pattern
tuberculosis disease and latent Monitor
 A definite diagnosis of tuberculosis can only be made by  Respiratory Rate, Depth, Effort
culturing Mycobacterium Tuberculosis organism from a  ABGs, SpO2
specimen taken from the patient (most often sputum, Determine / Treat Cause
but may also include pus, CSF, biopsied tissue). A Position
diagnosis made other than by culture may only be Teach Diaphragmatic Breathing
classified as “ probable” or “presumed”
 The Mantoux tuberculin skin test (TST) or TB blood test 4. Activity Intolerance
can be used to test for M. Tuberculosis infection. Monitor Response to Activity
Additional test are required to confirm TB disease.  Vital signs
 SpO2
Use Portable O2 for Ambulation common causes of transudative pleural effusions in the
Allow Rest between activities United States are heart failure and cirrhosis. Systemic
Obtain Bedside commode issue
Increase Activity slowly Heart failure
Refer to Pulmonary Rehabilitation Liver or Kidney Disease
 Exudative – a buildup of protein-rich fluid in the cavity
Additional Diagnosis for TB around the lungs, caused by local injuries to the tissue
Risk for ineffective self health management in and around the lungs; impairs breathing by limiting
 Teach patient and family the expansion of the lungs. Common causes are
 Consider visiting nurse / DOT Cancer, trauma, infections
Risk for infection transmission Pneumonia
 Teach patient and family TB
 Maintain isolation precautions CA
Signs and Symptoms
Prevention of TB Spread  Dyspnea
 Clean, well ventilated living areas  Pain
 Isolation of patients who have active TB  Cough
 High efficiency filtration masks  Tachypnea
 Gowns, gloves, goggles if contact with sputum likely  Diminished Lung Sounds
Diagnostic Tests
Restrictive Disorders  Analgesics
 Diseases that restrict lung expansion, resulting in a  Chest x ray
decreased lung volume, an increased work of breathing  Thoracentesis – invasive procedure to remove fluid or
and inadequate ventilation and / or oxygenation air from the pleural space
 Examples of restrictive lung diseases: Asbestosis,  Chest tube
Sarcoidosis and Pulmonary Fibrosis  Test to determine cause
 Reduced Compliance – the lung’s ability to stretch and
expand Pulmonary Fibrosis
 Limited Chest wall expansion Lungs become scarred, thickened, stiff tissue, they are
damaged. The accumulation of excess fibrous connective
Pleurisy tissue, leads to thicken of the the walls and causes
reduced oxygen supply in the blood
Pathophysiology
 Inflammation of Visceral and Parietal Pleurae Pathophysiology
 Friction Between Pleurae on Inspiration  Injury to alveoli
Etiology  Scarring, Fibrosis
 Secondary to Pneumonia, TB, CA, PE  Impaired Gas Exchange
Signs and Symptoms Signs and Symptoms
 Sharp pain on inspiration  Progressive Dyspnea
 Shallow breathing  Crackles
 Fever, elevated WBC  Chronic Cough
 Friction Rub  Clubbing
Therapeutic Interventions Etiology
 Pain management  Heredity
 Treat underlying causes  Virus
Diagnostic Tests  Environmental / Occupational Exposure
 Chest X ray  Immune Dysfunction
 CBC  Idiopathic
 FVC, FEV1= The FEV1 ratio, also called Tiffeneau- Diagnosis
Pinelli index, is a calculated ratio used to diagnose  Chest X ray
obstructive and restrictive lung disease.  CT Scan
 It represents the proportion of a person’s vital capacity  Bronchoscopy – examines the lower airways, including
that they are able to expire in the first second of forced the larynx, trachea, bronchi and bronchioles; used to
expiration to the full vital capacity examine the mucosal surface of the airways for
 Test to determine Cause abnormalities that might be associated with a variety of
lung diseases
Pleural Effusion - fluid in the pleural cavity  Lung Biopsy
Hydrothorax – Serous fluid  ANA Titer – A positive ANA Titer blood test indicates
Empyema – Pus the presence of an autoimmune disease
Chylothorax – Lymph Therapeutic Interventions
Hemothorax - Blood  Glucocorticoids - to stop the inflammation resulting in
tissue damage, prednisone
Pathophysiology  Immune Suppressants – azathioprine or
 Excess fluid between visceral and parietal pleurae cyclophosphamide to slow progression of lung scarring
( Parietal pleura is the pleura which lines the inside of  Smoking Cessation
the chest wall. Visceral pleura is the pleura which  Oxygen
covers the surface of the lung)  Flu / Pneumonia Vaccines
 Pleural fluid not reabsorbed  Pulmonary Rehabilitation
 May collapse lung  Lung transplant
Etiology
 Transudative – In transudative effusions, fluid pressure Atelectasis
in the blood vessels increases; and pressure exerted by Collapse or airless condition of alveoli caused by
blood proteins, such as albumin, may also be hypoventilation, obstruction to airways, or compression.
decreased. These circumstances may cause fluid from Causes: bronchial obstruction by secretions due to
the blood vessels to move into the pleural space; most impaired cough mechanism or conditions that restrict
normal lung expansion on inspiration. Postoperative Intrinsic (Nonatopic) Asthma
patients at high risk Respiratory Infections
- Epithelial damage, IgE production
Pathophysiology Exercise, hyperventilation, cold air
 Collapse of Alveoli – Atelectasis is a collapse of lung - Loss of heat and water may cause bronchospasm
tissue affecting part or all of one lung. Tiny sacs in your Inhaled irritants
lungs, called alveoli, don’t inflate - Inflammation, Vagal reflex
Etiology Aspirin and other NSAIDs
 Hypoventilation - Abnormal arachnoid acid metabolism
Sings and Symptoms
 Insidious Asthma
 include cough
 sputum production Pathophysiology
 low grade fever  Inflames and narrows the airways
 Respiratory distress - Inflammation of Bronchial Mucosa
 Anxiety - Spasm of Bronchial Smooth Muscles
 symptoms of hypoxia occur if large areas of lung are - Air Trapping
affected - Usually Reversible
 Fine crackles  Airway remodeling – Asthma is a chronic disease that
 Diminished Breath Sounds can lead to permanent lung damage. Permanent
 Dyspnea changes in the airways appear to result from repeated
Therapeutic Interventions asthmatic events causing recurrent bouts of
 Prevention inflammation of the bronchi, which in turn can ultimately
 Cough and Deep Breathe led to airway fibrosis (scarring) and permanent
 Incentive Spirometer narrowing of the airways ( remodeling)
 Turn Etiology
 Ambulate  Heredity
 Airborne Allergies
Nursing Diagnosis:  Pollution
Restrictive Disorders  Smoking
1. Impaired Gas Exchange Triggers
2. Ineffective Breathing Pattern  Smoking
3. Acute Pain  Allergens
Obstructive Disorders  Infection
1. Airway Obstruction  Sinusitis
2. Difficult Exhalation  Stress
 GERD
AIRWAY OBSTRUCTION IN ASTHMA Signs and Symptoms
Inflammatory Mediators  Dyspnea
Airway Inflammation  Wheezing
- Increased mucociliary function  Cough
- Edema  Sputum
- Epithelial Injury  Use of accessory muscle
Increased Airway Responsiveness  May be worse at night
- Bronchospasm Complication
- Airflow limitation  Status Asthmaticus
Extrinsic (Atopic) Asthma  Severe, Sustained Asthma
Type I Hypersensitivity  Worsening Hypoxemia
Allergen  Respiratory Alkalosis Progresses to Respiratory
- Mast cells release inflammatory mediators Acidosis
Cause acute response within 10 to 29 minutes  May be life threatening
- WBCs enter region and release more Diagnostic Tests
inflammatory mediators  History and physical examination
Airway inflammation causes late phase response in 4 to 8  Spirometry – measuring of breath
hours  ABGs
 Allergy skin testing
Therapeutic Interventions
 Monitor with Peak Flow Meter
 Avoid Triggers
 Avoid Smoking
 Bronchodilators
1. Adrenergic (Albuterol) beta2 – dilates bronchi by a
direct action on the beta2- receptors on the bronchial
smooth muscle to relax the muscles
2. Leukotriene Inhibitors ( Accolate, Singular) not
used for acute asthma attacks; helps reduce
inflammation in airways, inhibits leukotriene production.
Leukotriene, causes nasal passages to swell and make
excess mucus. It is also responsible for tightening
airways in an asthma attack, making it harder to
breathe.
3. Theophylline ( Rare) bronchodilator – relaxes
muscles in lungs and chest, making the lungs less
sensitive to allergens and other causes of
bronchospasm; used to treat symptoms such as
 wheezing or shortness of breath caused by asthma, shortness of breath, wheezing or an increase risk of
bronchitis, emphysema and other breathing problems lung infections. Complications may include COPD
4. Beta 1 heart Beta 2 Lungs ( 1 heart, 2 lungs) Signs and Symptoms
Therapeutic Interventions  Cough
 Corticosteroids - decrease inflammation  Sputum production
 Inhaled, IV, PO  Dyspnea
 Mast Cell Inhibitors (Exercise Induced) – stops release  Prolonged expiration
of histamine and related mediators; used to prevent or  Barrel Chest –trapped air
control certain allergic disorders. Blocks mast cell  Activity Intolerance
degranulation, stabilizing the cell Complications
 Antihistamine  Cor Pulmonale – a condition that causes the right side
 Oxygen PRN of the heart to fail. Long term high blood pressure in the
arteries of the lung and right ventricle of the heart can
CHRONIC OBSTRUCTIVE PULMONARY DISORDERS lead to cor pulmonale. High blood pressure in the
Emphysema arteries of the lungs is called pulmonary hypertension
- Enlargement of air spaces and destruction of  Weight Loss
lung tissue  Pneumothorax – an abnormal collection of air in the
Chronic bronchitis pleural space between the lung and the chest wall
- Obstruction of small airways  Respiratory Failure – inadequate gas exchange by
Bronchiectasis the respiratory system, with the result that levels of
- Infection and inflammation destroy smooth arterial oxygen, carbon dioxide or both cannot be
muscle in airways →permanent dilation maintained within their normal ranges. A drop in blood
oxygenation is known as hypoxemia; a rise in arterial
Pathophysiology carbon dioxide levels is called hypercapnia
Chronic Bronchitis
 Chronic inflammation Hypoxemia
 Low grade infection  PO2 greater than 60 mmHg
 Hypertrophied Mucus Glands in Bronchi - Cyanosis
 Impaired Ciliary Function  Impaired function of vital centers
 Ineffective Airway Clearance - Agitated or combative behavior, euphoria, impaired
 Diagnosed after ILL 3 months of year for 2 consecutive judgement, convulsions, delirium, stupor, coma
years - Retinal hemorrhage
Emphysema - Hypotension and bradycardia
 Destruction of Alveolar Walls  Activation of compensatory mechanisms
 Loss of Elastic Recoil - Sympathetic system activation
 Damage to Pulmonary Capillaries
 Air trapping Hypercapnia
 Impaired gas Exchange  PCO2 greater than 50 mmHg
 Respiratory acidosis
- Increased respiration
- Decreased nerve activity
* Carbon dioxide narcosis
* Disorientation, somnolence, coma
- Decreased muscle contraction
* Vasodilation
- Headache; warm flushed skin

Pneumothorax
 Air enters the pleural cavity
 Air takes up space, restricting lung expansion
 Partial or complete collapse of the affected lung:
- Spontaneous : Air filled blister on the lung ruptures
- Traumatic: Air enters through chest injuries
* Tension: Air enters pleural cavity through wound on
inhalation, cannot leave on exhalation
Mechanism Of COPD * Open: Air enters pleural cavity through the wound
 Inflammation and fibrosis of the bronchial wall on inhalation and leaves on exhalation
 Hypertrophied mucous glands →excess mucus Pathophysiology
- Obstructed airflow  Air in the Intrapleural Space
 Loss of alveolar tissue  Complete or partial collapse of the lung
- Decreased surface area for gas exchange  Intrapleural space = the pressure within the pleural
 Loss of elastic lung fibers cavity. Normally, the pressure within the pleural cavity is
- Airway collapse, obstructed exhalation, air slightly less than the atmospheric pressure, in what is
trapping known as negative pressure.
Etiology  When pleural cavity is damaged / ruptured and the
 Smoking intrapleural pressure becomes equal to or exceeds the
 Passive Smoke Exposure atmospheric pressure, pneumothorax may ensure
 Pollutants
 Familial Predisposition Types of Pneumothorax
 A1AT Deficiency ( Emphysema) – Alpha 1 antitrypsin 1. A spontaneous pneumothorax is when part of your
deficiency6 is a genetic disorder that may result in lung lung collapses. It happen if air collects in the pleural
diseases or liver disease. Onset of lung problems is space ( the space between your lungs and chest wall).
typically between 20 to 50 years old. This may result in The trapped air in the pleural space prevents your lung
from filling with air, and the lung collapses.
2. A traumatic pneumothorax is caused by an injury Monitor ABGs
that tears your lung and allows air to enter the pleural Mechanical Ventilation
space. This is the area between your lungs and your Nursing Diagnoses: Chest Trauma
chest wall. The air trapped in your pleural space Impaired Gas Exchange
prevents your lung from filling with air, which causes it Ineffective Breathing Pattern
to collapse. Acute Pain
Tension Pneumothorax. A pneumothorax is a condition in ACUTE RESPIRATORY FAILURE
which air becomes trapped in the pleural space. This is Pathophysiology
usually caused by trauma to the lung, or a “punctured” Hypoventilation
lung. The patient continues to breathe, pulling air into the Unable to maintain ABGs
injured lungs, but the air escapes into the chest cavity. Any impairment in oxygenation or ventilation in which the
arterial oxygen tension falls below 60mmHg and/ or the
PNEUMOTHORAX carbon dioxide tension rises above 50mmHg and the pH
drops below 7.35.
Signs and Symptoms Etiology
COPD
Shallow, Rapid Respirations Aspiration
Asymmetrical Chest Expansion Neurological Disease
Dyspnea
Chest Pain Signs and Symptoms
Absent Breath Sounds over Affected Area Worsening ABGs
Tension Pneumothorax Increasing Dyspnea
Signs and Symptoms Restlessness, Confusion
Lethargy
Tracheal Deviation Coma and Death
Bradycardia Diagnostic Test
Cyanosis ABGs
Shock and Death if untreated PaO2 <60 mmHg
PaO2 > 50mmHg
Test to determine cause
PNEUMOTHORAX
Therapeutic Interventions
Oxygen
Diagnostic Tests Bronchodilators
Correct Underlying cause
History and Physical Examination Intubation and Ventilation
Bedside Ultrasound Check advance directives
Chest Xray ACUTE RESPIRATORY
ABGs, ApO2 DISTRESS SYNDROME
Therapeutic Interventions Exudate enters the alveoli
Monitor ABGs and Respiratory Status - Blocks gas exchange
Chest Tube to water seal drainage - Makes inhalation more difficult
Pleurodesis (Sclerosis) for recurrent collapse
Pleurodesis – performed to prevent recurrence of Neutrophils enter the alveoli
pneumothorax or recurrent pleural effusion. Uses - release inflammatory mediators,
medicine to adhere lung to chest wall, seals up space proteolytic enzymes, reactive oxygen species
between the outer lining of lung and chest wall (pleural ACUTE RESPIRATORY
cavity) to prevent fluid or air from continually building up DISTRESS SYNDROME (ARDS)
around lungs Pathophysiology
Can be done chemically or surgically Alveolocapillary Membrane Damage (A thin layer tissue
Involves the adhesion of the two pleurae that mediates the exchange of gases between the alveoli
Nursing Care and the blood in the pulmonary capillaries) PULMONARY
Monitor Respiratory Status GAS EXCHANGE occurs across this membrane. All
Monitor Chest Drainage System disorders causing ARDS cause massive pulmonary
Report Changes Promptly inflammation that injures the alveolocapillary membrane
and produces severe pulmonaryedema, shunting and
RIB FRACTURES hypoxemia
Etiology Pulmonary Edema
Trauma Alveolar Collapse
Cough Lungs Stiff and noncompliant
CPR Lungs may hemorrhage
Care
Control Pain ACUTE RESPIRATORY
Encourage Coughing and Deep Breathing DISTRESS SYNDROME (ARDS)
Promote Adequate ventilation
FAIL CHEST Etiology
Life threatening condition that occurs when a segment of Acute lung injury
the rib cage breaks due to trauma and becomes detached Sepsis
from the rest of the chest wall Shock
Causes multiple rib fractures Aspiration
Ribcage not able to maintain bellows action Not usually in patients with chronic respiratory disease
Part of the chest wall moves independently, the chest Signs and Symptoms
cannot expand properly and cannot properly draw air into Dyspnea
the lungs Elevated RR
Care Fine crackles
Respiratory Acidosis Spirometry
Restlessness, Confusion Sputum Analysis
Death Rate 45% to 50 %
COPD

ACUTE RESPIRATORY Stop Smoking!!!

DISTRESS SYNDROME (ARDS) Oxygen 1 to 2 L/m
Supportive Care
Pulmonary rehab
Diagnostic Tests Surgery
ABGs Endobronchial Valve – is an implantable medical device –
Chest Xray a small, one-way valve, which is implanted in an airway in
Tests to determine cause the pulmonary system to treat one of several lung
conditions
Therapeutic Interventions Mechanical ventilation
Oxygen End of life planning
Intubation
Mechanical ventilation Medications
Treat underlying cause Bronchodilators
Supportive Care Corticosteroids
Expectorants
EMPHYSEMA
Neutrophils in the alveoli secrete trypsin
ACUTE RESPIRATORY - Increased neutrophil numbers due to inhaled
DISTRESS SYNDROME (ARDS) irritants can damage alveoli
a1- antitrypsin inactivates the trypsin before it
can damage the alveoli
- A genetic defect in a1 – antitrypsin synthesis
Nursing Diagnosis: Respiratory Failure leads to alveolar damage
Impaired Gas Exchange
Ineffective Airway Clearance EMPHYSEMA
Ineffective Breathing Pattern
Activity Intolerance Sign and Symptoms
Anxiety
Disturbed Thought Processes Diminished Breath Sounds
Self care Deficit Dyspnea
Progressive Activity Intolerance

CAUSES OF RESPIRATORY FAILURE

Hypoventilation — hypercapnia, hypoxia
- Depression of the respiratory center
- Diseases of respiratory nerves or muscles

Ventilation / perfusion mismatching

Impaired diffusion – hypoxemia but not hypercapnia
- Interstitial lung disease
- ALI / ARDS
- Pulmonary Edema
- Pneumonia
COPD
Diagnostic Test
Chest X ray
CT Scan
ABGs CHRONIC BRONCHITIS
CBC Chronic irritation of airways
 - Increased number of mucous cells
- Mucus hyper secretion
Productive cough

Signs and Symptoms

Wheezing, crackles
Chronic Cough
Dyspnea
Thick, Tenacious Sputum
Increased susceptibility to infection
Mucous Plugs
PINK PUFFERS VERSUS
BLUE BLOATERS
Pink puffers ( usually emphysema)
- Increase respiration to maintain oxygen levels
- Dyspnea; increased ventilatory effort
- Use accessory muscles; pursed – lip breathing

Blue bloaters ( usually bronchitis)

- Cannot increase respiration enough to maintain
oxygen levels
- Cyanosis and polycythemia
- Cor pulmonale
CYSTIC FIBROSIS
Recessive disorder in chloride transport proteins
- High concentrations of NaCL in the sweat
- Less Na+ and water in respiratory mucus and in
pancreatic secretions
Mucus is thicker
* Obstructs airways
* Obstructs the pancreatic and biliary ducts
Cystic Fibrosis
Pathophysiology
Exocrine Gland Disorder
Thick Tenacious Secretions
Blocked Pancreatic Enzymes

Etiology
Heredity PULMONARY EMBOLISM
Signs and Symptoms Pathophysiology
Thick, Tenacious Sputum Blood clot in pulmonary artery
Frequent Respiratory Infections Ventilation – perfusion mismatch – a condition in which
Finger Clubbing one or more areas of the lung receive oxygen but no blood
Malabsorption flow, or they receive blood flow but no oxygen due to
Fatty, Foul smelling Stools some diseases and disorders
Death from antibiotic resistant infection Impaired Gas Exchange
Diagnostic Tests Lung infarction – Death of one or more sections of lung
“Kiss Your Baby” Campaign – the sponsors of the tissue due to deprivation of an adequate blood supply
campaign said if your baby tasted salty when kissed have PULMONARY EMBOLISM
the child checked for CF Etiology
Sweat Chloride Test – a common and simple test used to DVT Most common cause of PE
evaluate a patient who is suspected of having cystic Fat emboli from compound fracture
fibrosis… Patients with cystic fibrosis produced larger Amniotic fluid emboli during labor and delivery
quantities of sweat chloride than normal individuals Prevention
Therapeutic Interventions Regular ambulation
Hydration Prompt treatment of DVT
Inhaled Mucolytic Medication In high risk patients:
Bronchodilators, Corticosteroids Warfarin (Coumadin)
Expectorants Enoxaparin
Chest Physiotherapy Heparin
Antibiotics PULMONARY EMBOLISM
Prevent Infection Signs and Symptoms
Pancreatic Enzyme Replacement ( Pancrease, Viokase) Sudden Onset Dyspnea
Therapeutic Interventions Tachycardia
Ibuprofen May Slow Lung Deterioration - High dose Tachypnea
Ibuprofen May Slow Cystic Fibrosis Lung Disease; Cough
Inflammation increases damage done to the lungs; the Crackles
use of high doses has also raised concerns about the Hemoptysis
potential for unwanted effects, which has limited the use of
these drugs in cystic fibrosis PULMONARY EMBOLISM
Lung Transplant
Diagnosis
Spiral CT scan
Lung Scan
Angiogram – used to visualize the inside, or lumen of
blood vessels and organs of the body Monitor Respiratory Status
D – Dimer – a blood test that measures a substance Bedrest
released when a blood clot breaks up. Ordered without lab Positioning
tests and imaging scans, to help check for blood clotting Comfort Measures
problems COR PULMONALE
Right sided heart failure secondary to lung diseases or
pulmonary hypertension
PULMONARY EMBOLISM - Decreased lung ventilation
- Pulmonary vasoconstriction
- Increased workload on the right heart
Therapeutic Interventions - Decreased oxygenation
Thrombolytics - Kidney releases erythropoietin more RBCs
Heparin made Polycythemia makes blood more
Warfarin (Coumadin) viscous
Oxygen - Increased workload on the heart
Embolectomy (Rare) – the emergency surgical removal of LUNG CANCER
emboli which are blocking blood circulation; an emergency Small Cell Lung Cancer
procedure often as the last resort Large Cell Carcinoma
Jugular or femoral filter for recurrent PE Adenocarcinoma
Squamous Cell Carcinoma

LUNG CANCER
PULMONARY EMBOLISM
Etiology
Smoking - smokers 13 times more likely to develop
cancer as nonsmokers
Nursing Diagnosis Environmental Tobacco Smoke
Other Carcinogens
Impaired Gas Exchange Asbestos
Risk for Injury Related to Anticoagulant use Arsenic
PULMONARY VENOUS Pollution
HYPERTENSION Signs and Symptoms
Secondary None until late
- Elevation of pulmonary venous pressure Productive cough
- Increased pulmonary blood flow Recurrent infection
- Pulmonary vascular obstruction Dyspnea
- Hypoxemia Hemoptysis
Anorexia and weight loss
Primary Pain
- Blood vessel walls thicken and constrict Wheezing / Stridor
PULMONARY ARTERIAL
HYPERTENSION
Pathophysiology LUNG CANCER
Elevated pressure in pulmonary arteries
Right ventricular failure
Complications
Etiology Pleural effusion
Unknown Superior vena cava syndrome
Secondary; CAD, Valve disease Ectopic hormone secretion
Signs and Symptoms ADH
Dyspnea ACTH ( cushing’s syndrome)
Fatigue PTH ( hypercalcemia)
Crackles Actelectasis
Cyanosis Metastasis
Tachypnea Diagnostic Tests
PULMONARY ARTERIAL Chest X ray
HYPERTENSION CT Scan
Diagnostic Test Sputum analysis
ABG’s Biopsy
Cardiac Catheterization Additional test to find metastasis
ECG
Additional Tests to find cause
Therapeutic Interventions
Low sodium diet LUNG CANCER
Diuretics
Vasodilators
Oxygen
Warfari Therapeutic Interventions
Stage (TNM System)
PULMONARY ARTERIAL Chemotherapy ( usually palliative)
HYPERTENSION Radiation ( usually palliative)
Nursing Diagnoses: Lung Cancer
Nursing Care Impaired Gas Exchange
 Ineffective Airway Clearance
Imbalanced Nutrition
Pain
Constipation
Anticipatory Grieving
Activity Intolerance
THORACIC SURGERY
Pneumonectomy – or pneumectomy is a surgical
procedure to remove a lung
Lobectomy – Removal of just one lobe of the lung is
specifically referred to as a lobectomy
Resection – a segment of the lung as a wedge resection
( or segmentectomy)
VATS – video assisted thoracic surgery – minimally
invasive surgical procedure used to access the chest
cavity to operate on the lung, mediastinum and pleura; to
treat conditions such as cancer, pneumothorax, infection,
cysyts and other thoracic disorders
Transplant

THORACIC SURGERY

Preoperative Care
Monitor respiratory status
Teach
Routine pre op teaching
What to expect
Visit SICU
Include Family
Postoperative Care
Invasive care setting
Monitor
Vital signs
SpO2, ABGs
Hemodynamic Parameters
Lung sounds
Ventilator
Chest tubes

THORACIC SURGERY

Nursing Diagnoses
Ineffective Airway Clearance
Impaired Gas Exchange
Acute Pain
Impaired Physical Mobility
Risk for Infection