The Respiratory System Correlated to the Roy Adaptation Model and Nursing Process

1
The Respiratory SystemCorrelated to the Roy
Adaptation Model and Nursing Process

• Sandy Marks, RN, BSN, MS(HCA)
• N212 Medical Surgical Nursing 1
• Spring 2008

2
Journey through Roy Adaptation Model(RAM)

• Roy Adaptation Model ?
• Patients primarily with alterations in
• physiological mode ?
• oxygenation ?
• respiratory system

3
Objectives - 1

• Review the anatomy and physiology of the
  respiratory system
• Describe the respiratory changes associated with
  aging

4
Objectives - 2

• Discuss the purpose and interventions
  (preparation, explanation, procedure, postcare)
  for the following diagnostic tests
• X-rays chest, bronchogram, CT, lung scan
• Direct visualization bronchoscopy
• Sputum specimen
• Thoracentesis
• Pulmonary function tests (PFT)
• Oximetry
• Magnetic resonance imaging (MRI)
• Cultures

5
Objectives - 3

• Describe the nursing assessment of the following
  cardinal signs and symptoms
• cough
• sputum
• dyspnea
• Discuss the pathophysiology, nursing assessment,
  interventions, and evaluation for Pneumonia

6
The Art of Caring
7
Respiratory Review

• Purpose
• provide oxygen for tissue metabolism (O2)
• remove carbon dioxide (CO2)
• Influences functions of
• acid-base balance
• speech
• sense of smell
• fluid balance
• temperature control

8
Review the anatomy and physiology of the
respiratory system
trachea

• upper respiratory tract
• lower respiratory tract
• divided by trachea (windpipe)
• bronchi
• bronchioles
• alveolar ducts
• alveoli

bronchi
bronchioles
alveoli
9
Gas Exchange

• occurs at alveolar capillary membrane
• occurs by diffusion
• Pulmonary edema
• excess fluid fills alveoli spaces
• impairs exchange of O2 and CO2

capillary
10
Normal lung tissue

• 300 million alveoli
• surface area tennis court
• Right bronchus
• slightly wider
• shorter
• more vertical
• increases problems with
• intubation
• aspiration

11
Physiologic changes associated with aging
12
Alveoli

• alveolar surface area decreases
• diffusion capacity decreases
• elastic recoil decreases
• bronchioles and alveolar ducts dilate
• ability to cough decreases
• airways close early

13
Lungs

• residual volume increases
• vital capacity decreases
• efficiency of oxygen and carbon dioxide exchange
  decreases
• elasticity decreases

14
Pharynx and Larynx

• muscles atrophy
• vocal cords become slack
• laryngeal muscles lose elasticity and cartilage

15
Pulmonary Vasculature

• increased vascular resistance to blood flow
  through pulmonary vascular system occurs
• pulmonary capillary blood volume decreases
• risk of hypoxia increases

16
Exercise Tolerance andMuscle Strength

• Exercise Tolerance
• bodys response to hypoxia and hypercapnea
  decreases
• Muscle Strength
• respiratory muscle strength, especially the
  diaphragm and intercostals, decreases

17
Susceptibility to Infection

• effectiveness of the cilia increases
• immunoglobulin A decreases
• alveolar macrophages are altered

18
Chest Wall

• anteroposterior (AP) diameter increases
• thorax becomes shorter
• progressive kyphoscoliosis occurs
• chest wall compliance (elasticity) decreases
• mobility may decrease
• osteoporosis is possible

19
Summary on effects of aging

• ? recoil and compliance
• ? AP diameter
• ? functional alveoli
• ? in Pa02
• Respiratory defense mechanisms less effective
• Altered respiratory controls
• More gradual response to changes in O2 and Co2
  levels in blood

20
Diagnostic Tests

• X-rays chest, bronchogram, CT, lung scan
• Direct visualization bronchoscopy
• Sputum specimen and Cultures
• Thoracentesis
• Pulmonary function tests (PFT)
• Oximetry
• Magnetic resonance imaging (MRI)

21
Chest X-Ray

• Screen, diagnose, evaluate treatment
• Instructions

22
X-ray Positions
23
Chest X-Ray (Cont.)
Posterior Anterior View
Left Lateral View
24
Bronchogram

• Slightly oblique

25
Computed Tomography CT Scan

• Images in cross-section view
• Uses contrast agents
• Instructions

Right upper Lobe
26
Lung Scan

• most to detect emboli
• no food restrictions
• breathes radioactive material through a tube for
  5 minutes
• 6 ventilation images taken
• radioactive injection
• same 6 images retaken
• compare images

27
Ventilation- air distribution in lungPerfusion-
blood supply to within lung
28
Bronchoscopy

• Diagnose problems and assess changes in bronchi /
  bronchioles
• Performed to remove foreign body, secretions, or
  to obtain specimens of tissue or mucus for
  further study

• Post-Procedure Care / Instructions

29
Sputum Specimen

• To diagnose evaluate treatment
• Specimen ID organisms or abnormal cells
• Culture Sensitivity (CS)
• Cytology
• Gram stains
• (e.g. Acid Fast Bacilli)

30
Thoracentesis

• Specimen from pleural fluid
• Treat pleural effusion
• Assess for complications
• Post-Procedure care

• Positions
• Sitting on side of bed over bedside table
  chest elevated
• Lying on affected side
• Straddling a chair

31
Pneumothorax
32
Pulmonary Function Test (PFTs)

• Evaluate lung function
• Observe for increased dyspnea or bronchospasm
• Instructions

33
Pulse Oximetry

• Measures arterial oxygen saturation
• Pulse oximetry probe on ears, nose, finger, toes,
  forehead
• False readings
• Intermittent or continuous monitoring
• Ideal values
• When to Notify MD

34
MRI

• Frontal View
• White masses Hodgkin Disease lesions

35
MRI transverse view same patient
36
Nursing AssessmentCardinal Signs and Symptoms
of1. Cough2. Sputum3. Dyspnea
37
Cough Main Sign of Lung Disease

• how long present
• occurs at a specific time (smokers upon
  wakening in AM)
• related to activity
• productive vs nonproductive
• congested
• dry
• tickling
• hacking

38
Sputum normally 3 oz produced/day

• important symptom associated with coughing
• Check
• duration long term, short term
• color rust colored
• consistency thick, thin, watery, frothy
• odor- foul
• amount describe in tsp, or fractions of cup and
  if increasing (external or internal cause)

39
Dyspnea subjective data (perception)

• difficulty in breathing or breathlessness
• Check
• onset slow or abrupt
• duration - of hours, time of day
• relieving factors position change, med, stop
  activity
• wheezing, crackles, rales, or stridor occur with
  breathlessness
• Quantify by assessing if interferes with ADL
• PND or orthopnea

40
Lung sounds

• wheezing
• crackles
• stridor
• auscultation sequence pg. 534, Iggy
• bronchial trachea mainstem bronchi
• bronchovesicular branching bronchi
• vesicular small bronchiole periphery

41
Pneumonia Case Study
42
Nursing Student Tools

• Concept Map Pneumonia
• Medical-Surgical Map (Medimap)
• Nursing Map

43
Pathophysiology
44
Toxic sprinkles anyone?
45
Etiology

• Cause
• bacteria (75)
• viruses
• fungi
• Mycoplasma
• parasites
• chemicals

46
Classifications

• Community-acquired pneumonia (CAP)
• Onset in community or during 1st 2 days of
  hospitalization (Strep. pneumoniae most common)
• Hospital-acquired Pneumonia (HAP / nosocomial)
• Occurring 48 hrs or longer after hospitalization
• Aspiration pneumonia
• Pneumonia caused by opportunistic organisms
• Pneumocystis Carinii

47
Risk Factors

• HAP
• Older adult
• Chronic lung disease
• ALOC
• Aspiration
• ET, Trach, NG / GT
• Immunocompromised
• Mechanical ventilation

• CAP
• Older adult
• Chronic/coexisting condition
• Recent history or exposure to viral or influenza
  infections
• History of tobacco or alcohol use

48
Clinical Manifestations - 1

• Fevers, chills, anorexia
• Pleuritic chest pain
• SOB
• Crackles / wheezes
• Cough, sputum production
• Tachypnea

49
Clinical Manifestations - 2

• Mycoplasma (Atypical)
• feeling tired or weak, headaches, sore throat, or
  diarrhea.
• Eventually, most develop a dry cough.  They can,
  also, develop fever, chills, earaches, chest pain
• walking pneumonia

50
Diagnosis

• Diagnosis ?
• Physical exam ? crackles, rhonchi / wheezes
• CXR ? area of increased density
• (infiltrates / consolidation)
• Sputum specimen
• Gram stain

LUL Infiltrates
51
CXR- LUL Pneumonia
52
Interventions and Treatment

• Treatment
• Antibiotics ? choose based on age, suspected
  cause immune status
• Supportive care ? IV fluids, supplemental oxygen
  therapy, respiratory monitoring, cough
  enhancement
• may take 6-8 weeks for CXR to normalize

53
Nursing Diagnoses

• Impaired gas exchange R/T Pneumonia
• Pain R/T infection in lung Pneumonia

54
Complications

• Hypoxemia
• Pleural effusion
• Atelectasis
• Pleurisy

Atelectasis
Pleurisy
Pleural Effusion
55
Atelectasis

• A obstruction
• B accumulation of fluid of air

56
Additional learning resources

• NANDA approved nursing diagnoses specific to
  respiratory system p125 of study packet
• Skills Lab
• Heart and Lung Sounds Trainer
• Learning Lung Sounds, Cardionics CD
• Audio-visual material

57
Resources

• Beers, M. Berkow, R. (Ed.). (2000). The Merck
  Manual of Geriatrics (3rd ed.). Whitehouse
  Station Merck Co., Inc.
• Chabner (2007). The Language of Medicine (8th
  ed.). St. Louis Saunders.
• Ignatavicius, D. Workman, L. (2006).
  Medical- Surgical Nursing Critical Thinking for
  Collaborative Care (5th ed.). St. Louis
  Elsevier Saunders.
• Scherer, D. (2008). Pictures retrieved March 31
  and available at dscherer.com

58
(No Transcript)