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Nursing 201 Advanced Respiratory

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Title: Nursing 201 Advanced Respiratory


1
  • Nursing 201Advanced Respiratory
  • 3.0 Nursing Assessment of the Respiratory System
    and Management of the Patient Undergoing
    Diagnostic Procedures
  • 3.1 Nursing Management of Patients with Upper
    Respiratory Disorders, Patients with Oxygen
    therapy and Patients with Tracheostomies

Laurie Brown RN, MSN, MPA-HA, CCRN
2
Functions of the Respiratory System
  • Provide Oxygen
  • Remove Carbon Dioxide
  • Maintain Acid-Base Balance
  • Facilitation of sense of smell
  • Production of speech
  • Maintenance body water and heat balance

3
The Pulmonary System
  • Consists of the lungs, airways, chest wall, and
    pulmonary circulation.
  • The upper respiratory system acts to conduct air
    exchange... both into and out of the gas-exchange
    structures of the lungs.

4
The Pulmonary System
  • The three steps in this process are
  • Ventilation
  • Diffusion
  • Perfusion

5
The Pulmonary System
  • Ventilation is... The movement of air in and out
    of the lungs.
  • The conducting airways allow air into and out of
    the gas-exchange structures of the lung.

6
The Pulmonary System
  • Diffusion is...
  • The movement of gases between air spaces in the
    lungs and the bloodstream.
  • The conducting airways terminate where the gas
    exchange airways begin.

7
The Pulmonary System
  • Perfusion
  • Perfusion is the movement of blood into and out
    of the capillary beds of the lungs to body organs
    and tissues.

8
Application
  • Think about your clinical experiences. Can you
    give some examples of how the heart and lungs are
    dependent upon one another?

9
Anatomy and Physiology (Structure and Function)
of the Respiratory System
  • Upper Airway
  • Nose and Sinuses
  • External Nares
  • Septum
  • Turbinates

10
Anatomy and Physiology (cont.)
  • Filtration of large particles of dust and other
    matter is accomplished by trapping of the
    particulates by the nasal hairs.

11
Anatomy and Physiology (cont.)
  • Pharynx Any obstruction (i.e., tissue swelling,
    presence of a foreign body, or tongue falling
    back into the pharynx) can lead to cessation of
    ventilation.
  • Larynx aka the voice box, connects the
    pharynx to the trachea.

12
Anatomy and Physiology (cont.)
  • The internal laryngeal muscles control vocal
    cord length and tension, and the external
    laryngeal muscles move the larynx as a whole.
  • The larynx is innervated by the laryngeal nerve,
    which initiates the cough reflex in response to
    stimulation by foreign particles (objects).

13
Anatomy and Physiology (cont.)
  • Lower Airway
  • Trachea- aka the windpipe, connects the larynx
    to the right and left mainstem bronchi. The point
    at which the trachea bifurcates into the right
    and left bronchi is called the carina.

14
Anatomy and Physiology (cont.)
  • The bronchi are considered the conducting airways
    of the lungs. The right and left main bronchi
    enter the lungs at the hili, or roots of the
    lungs, along with the pulmonary blood and
    lymphatic vessels.

15
Factors Affecting Ventilation
  • Airway resistance
  • The size of the airway affects the amount of
    airflow!

16
Anatomy and Physiology (cont.)
  • Bronchial walls have three layers an epithelial
    lining, a smooth muscle layer, and a connective
    tissue layer.
  • The epithelial lining of the bronchi contains
    single-celled exocrine glands, the
    mucus-secreting goblet cells and ciliated cells.
  • With branching, the layers of epithelium that
    line the bronchi become thinner.

17
Anatomy and Physiology (cont.)
  • The conducting airways terminate where the gas
    exchange airways begin.
  • The gas-exchange airways made up of the
    respiratory bronchioles, alveolar ducts, alveolar
    sacs and alveoli. This group of structures is
    sometimes referred to as the acini.

18
  • Lower Airway
  • Trachea
  • Bronchi
  • (Right and Left Mainstem Bronchi)
  • Subsegmental Bronchi (Bronchioles)
  • Nonrespiratory
  • Respiratory
  • Alveolar Ducts, Alveolar Sacs
  • Alveoli

19
Anatomy and Physiology (cont.)
  • Adult lungs contains approximately 300 million
    alveoli. Lungs contain approx. 25 million
    alveoli at birth. Alveoli are connected by tiny
    openings called pores of Kohn, which are present
    in the alveolar epithelium. These pores allow
    movement between alveoli that promotes even
    distribution of air and collateral ventilation if
    a small airway becomes obstructed however, they
    also allow bacteria to move from alveolus to
    alveolus.

20
Anatomy and Physiology (cont.)
  • Lung Circulation
  • The lungs receive blood from both the pulmonary
    and bronchial circulation.

21
Anatomy and Physiology (cont.)
  • Bronchial arteries originate from the thoracic
    aorta. Blood is returned from the bronchial
    system to the left atrium by the azygos vein.
  • Bronchial Circulation
  • Provides nutrients to the tissues of the
    tracheobronchial tree.
  • Warms and moistens inspired air.

22
Anatomy and Physiology (cont.)
  • Pulmonary circulation
  • Facilitates gas exchange
  • Delivers nutrients to lung tissues
  • Acts as a reservoir for the left ventricle
  • Serves as a filtering system that removes clots,
    air and other debris from the circulation.

23
Anatomy and Physiology (cont.)
  • Lungs and Thoracic Cage
  • The thoracic cage is composed of the ribs,
    sternum, scapulae and vertebral column.
  • The thoracic cage houses the lungs, heart, great
    vessels, lymph nodes, thymus gland, and
    esophagus. Intercostal muscles lie between the
    ribs, and the diaphragm forms the floor of the
    thoracic cage.

24
Anatomy and Physiology (cont.)
  • The chest wall (skin, ribs, intercostal muscles)
    protect the lungs from injury, and its muscles,
    along with the diaphragm, perform the muscular
    work of breathing.
  • The lungs are spongy, paired, conical-shaped
    structures that extend from just above the
    clavicles to the eleventh or twelfth rib.
  • The primary function of the lungs is gas
    exchange!

25
Anatomy and Physiology (cont.)
  • Lung pleurae
  • Parietal pleurae
  • Visceral pleurae
  • Pleural effusion is an abnormal accumulation
    of fluid in this potential space.

26
Anatomy and Physiology (cont.)
  • Ventilation
  • Ventilation is the mechanical movement of gas or
    air into and out of the lungs.
  • Ventilation vs. Respiration

27
Anatomy and Physiology (cont.)
  • Breathing and Lung Function
  • Passive in the process of breathing
  • Pleural cavities are closed
  • Inspiration
  • Inspiratory muscles

28
Anatomy and Physiology (cont.)
  • Contraction of the external intercostals and
    scalene muscles cause the anterior part of the
    thoracic cage to rise during inspiration.
  • During exercise, or in diseased states, the
    sternocleidomastoid muscles raise the sternum,
    resulting in an increased diameter of the
    thoracic cage.

29
Anatomy and Physiology (cont.)
  • Expiration
  • Is normally a passive process produced by elastic
    recoil of the chest wall. Active exhalation that
    results from disease, exercise or coughing causes
    the internal intercostal and abdominal muscles to
    contract.

30
Anatomy and Physiology (cont.)
  • Compliance and Elasticity
  • Two properties that permit the lungs to expand
    and return to their resting state are compliance
    and elasticity.

31
Anatomy and Physiology (cont.)
  • Compliance is the quality of yielding to pressure
    and represents the ease with which the lungs can
    be stretched while consuming a volume of air.
    Determinants of compliance include
  • Elastic recoil of the lung and chest wall
  • Alveolar surface tension
  • An increase in compliance means that the lungs
    are abnormally easy to inflate.
  • A decrease in compliance indicates stiffness or
    difficulty in inflating the lungs.

32
Anatomy and Physiology (cont.)
  • Elasticity of the chest wall
  • Elastic recoil of the lungs is the tendency of
    the lungs to return to the resting state.
    Elasticity of the lungs is determined by the
    elastic and collagen fibers of the lungs.
  • Conditions in which lung tissue stiffens, such
    as pulmonary fibrosis or interstitial lung
    disease, results in a decrease in lung
    compliance.

33
Anatomy and Physiology (cont.)
  • Review lung volumes and capacities related to
    normal pulmonary function.

34
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35
Anatomy and Physiology (cont.)
  • Diffusion
  • Two-way gas diffusion occurs through the thin
    alveolar (alveolocapillary) walls. Alveoli
    consist of Type I and Type II epithelial cells.
    (Alveoli also contain alveolar macrophages).
  • Thin, flat, squamous Type I cells, the most
    abundant, form the alveolar walls through which
    gas exchange occurs.

36
Anatomy and Physiology (cont.)
  • Type II epithelial cells aid gas exchange by
    producing surfactant a lipid like substance
    that coats the alveolus, preventing total
    alveolar collapse, and facilitates gas exchange
    by decreasing surface tension.

37
Anatomy and Physiology (cont.)
  • Diffusion (cont.)
  • Once inspired oxygen reaches the alveoli, oxygen
    diffusion occurs into the pulmonary capillary due
    to the greater partial pressure of oxygen of
    alveolar air in contrast to the partial pressure
    of oxygen in venous blood.
  • Carbon dioxide diffuses in the opposite
    direction because the partial pressure of the
    carbon dioxide in the venous blood is greater
    than that of the alveolar air.

38
Anatomy and Physiology (cont.)
  • Diffusion of oxygen is decreased by the
    following four factors
  • A decrease in atmospheric oxygen
  • A decrease in alveolar ventilation
  • A decrease in alveolar-capillary surface area
  • An increase in the thickness of the alveolar
    capillary membrane.

39
Anatomy and Physiology (cont.)
  • Ventilation-Perfusion
  • Efficient gas exchange is dependent on a balance
    between ventilation or air flow (V) and perfusion
    or blood flow (Q).
  • In the normal lung, alveolar ventilation is
    about 4 L/min and pulmonary blood flow is about 5
    L/min. The overall V/Q ratio of normal lungs is
    0.8.

40
Anatomy and Physiology (cont.)
  • Ventilation-Perfusion (cont.)
  • When ineffective gas exchange results from a
    physiologic abnormality, the result may be
    reduced ventilation to a lung unit (shunt),
    reduced perfusion to a unit (dead-space
    ventilation), or both (silent unit).

41
Anatomy and Physiology (cont.)
  • Ventilation-Perfusion (cont.)
  • Impaired blood flow, secondary to a pulmonary
    embolus is likely to result in a high V/Q ratio,
    resulting in dead-space or wasted ventilation.
  • In this case, the air does not participate in
    gas exchange, but does contribute to the work of
    breathing.

42
Anatomy and Physiology (cont.)
  • Ventilation-Perfusion (cont.)
  • Low V/Q ratios indicate that the lungs are
    poorly ventilated in relation to the amount of
    blood flow. For example, blood flow to the
    alveolus may be normal but fluid in the alveolus,
    bronchospasm, or mucus plugs increase airway
    resistance and may prevent adequate ventilation.

43
Shunting
  • Normal
  • Congenital conditions
  • Patent ductus arteriosus
  • Tetralogy of Fallot

44
Shunting
  • Normal
  • Normal Ventilation - No perfusion
  • V/Q Mismatch
  • No ventilation Normal Perfusion
  • Alveolar Hypoventilation
  • No ventilation No perfusion
  • Intrapulmonary shunting

45
2
Normal Ventilation Normal Perfusion
Shunting
Normal Ventilation NO Perfusion
NO Ventilation Normal Perfusion
NO Ventilation NO perfusion
46
Anatomy and Physiology (cont.)
  • Control of Respiration
  • Breathing can be viewed as an automatic loop
    process in which sensors (chemoreceptors)
    continually feed data to a central processor
    (medulla oblongota and pons). The respiratory
    center in the brain stem (pons and medulla)
    control respiration by transmitting impulses to
    the respiratory muscles, causing them to contract
    and relax.

47
Anatomy and Physiology (cont.)
  • Control of Respiration (cont.)
  • Composed of several groups of neurons.
  • The Dorsal Respiratory group (DRG)
  • The Ventral Respiratory Group (VRG)

48
Anatomy and Physiology (cont.)
  • Control of Respiration (cont.)
  • Breathing is usually involuntary, because
    homeostatic changes in ventilatory rate and
    volume are adjusted automatically by the nervous
    system to maintain normal gas exchange.
    Voluntary breathing is necessary for talking,
    singing, laughing, and deliberately holding ones
    breath. The mechanisms that control respiration
    are very complex.

49
Anatomy and Physiology (cont.)
  • Control of Respiration (cont.)
  • The lungs are innervated by the autonomic
    nervous system (ANS). Fibers of the sympathetic
    division in the lung branch from the upper
    thoracic and cervical ganglia of the spinal cord.
  • Fibers in the parasympathetic division of the
    ANS travel in the Vagus nerve to the lung.
  • The parasympathetic and sympathetic divisions
    control airway caliber (interior diameter of the
    lumen) by stimulation bronchial smooth muscle to
    contract or relax.

50
Anatomy and Physiology (cont.)
  • Control of Respiration (cont.)
  • Chemoreceptors
  • Chemoreceptors monitor the pH, PaCO2, and PaO2
    of arterial blood.
  • Central chemoreceptors monitor arterial blood by
    indirectly sensing changes in the pH of CSF.
  • Peripheral chemoreceptors are somewhat sensitive
    to changes in PaO2 and pH, but are sensitive
    primarily to oxygen levels in arterial blood
    (PaO2)

51
Anatomy and Physiology (cont.)
  • Physiologic Changes With Aging
  • Thoracic cage become rigid
  • Kyphosis is common
  • Increase in the A-P diameter of the chest
  • Decreased chest wall compliance
  • Increased work of breathing
  • Diminished cough reflex
  • Delayed warning

52
Anatomy and Physiology (cont.)
  • Clinical Implications
  • Older adults are especially susceptible to
  • Respiratory fatigue
  • Aspiration pneumonia
  • Diminished responsiveness to hypoxia and
    hypercapnia

53
Respiratory volume
54
Dead Space
  • Up to 1/3rd of each breath
  • What must a patient do when tidal volume is NOT
    significantly greater than dead space?

55
Medulla
C3-C5
56
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57
Factors That Affect Tissue Oxygenation
  • Oxygen tension arterial blood
  • Hemoglobin content
  • Hemoglobin saturation
  • Blood-flow to tissues
  • Diffusion of oxygen to tissues
  • Diffusion of Carbon dioxide
  • Arterial Ph
  • Body Temperature

58
Oxygen-Hemoglobin Dissociation Curve
  • Relationship between PaO2 and saturation of
    hemoglobin
  • This saturation reflects the amount of oxygen
    available to the tissues
  • Allows for lower O2 sats (75) to provide
    adequate O2 to tissues,
  • But no reserves
  • Allows man to live at higher altitudes

59
Changes in PaO2 result in small changes in
saturation
Oxygen Tension (mm Hg)
60
pH 7.3 SaO2 92 PaO2 68
Oxygen Tension (mm Hg)
61
pH 7.5 SAO2 92 PaO2 57
Oxygen Tension (mm Hg)
62
Oxygen-Hemoglobin Dissociation Curve
  • Shift to right (temp pH )
  • O2 Harder to bind in lungs BUT easier release O2
    to tissue
  • Shift to Left (temp pH )
  • O2 easier to bind in lungs BUT not easy to
    release to tissues

63
Normal Oxygenation
  • O2 in 100 ml of blood
  • Arterial - 20.1
  • Venous - 15.5
  • Oxygen transport
  • Arterial - 1005 ml O2/min
  • Venous - 775 ml O2/min

64
Normal Ph and temp
Hb
Hb
Hb
Hb
Hb
Hb
Hb
Hb
Hb
Tissue Demand
Hb
Hb
Hb
65
Tests
  • Thoracentesis
  • Ventilation/Perfusion scan
  • Pulmonary Function Test

Bronchoscopy
66
Thoracentesis
67
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68
Flail Chest
Normal
Normal
Inspiration
Expiration
69
Flail Chest
Inspiration
Expiration
Paradoxical chest wall movement
70
Pneumothorax
71
Consolidation
72
Chest Tubes
73
Chest Tubes
  • Collection chamber
  • Water seal
  • Suction chamber
  • Tubing

74
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75
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76
Respiratory Assessment
  • 1. Stop and LOOK at patient
  • What is the abnormality?
  • What is the pattern of breathing?
  • Are they scared or somnolent?
  • Breathing through mouth or nose?
  • Body position?
  • How bad do they look?

77
  • 2. Count respiratory rate
  • 3. Evaluate their air movement
  • In and out equally?
  • How much air is he moving?
  • Having difficulty with inhalation or expiration?
  • Using accessory muscles?
  • Do you hear
  • stridor, rattle or congestion, wheezing

78
  • 4. Assess vital signs
  • 5. Assess breath sounds
  • 6. Did the patient get worse suddenly or slowly?
  • 7. How do they tolerate exercise

79
Sputum
  • Quality
  • Quantity
  • Associated Systems
  • Aggravating factors
  • Alleviating factors
  • Timing

80
Documentation of Breath Sounds
  • Location - anatomic landmarks (anterior/posterior/
    lateral, level rib)
  • Bilateral or Unilateral
  • Intense-loud/soft/absent/diminished/muffled/distan
    ce
  • Duration inspiratory or expiratory
  • Pitch High or low

81
Nursing Diagnosis
82
Nursing Interventions
83
Oral Pharyngeal
84
Oral Intubation
85
Nasal Intubation
86
Tracheostomy
87
Problems with Tubes Balloons
88
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89
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90
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91
Suction
92
Complications of Suctioning
  • Hypoxemia
  • Dysrhythmia
  • PVCs, tachycardia, bradycardia, asystole
  • Bronchospasm
  • Airway trauma
  • Infection
  • Atelectasis/lobar collapse

93
Hb
Hb
Hb
SvO2 60-80
Hb
Hb
Hb
Hb
Hb
Hb
Tissue Demand
Hb
Hb
Hb
94
Suctioning
60-80
95
Oxygen Delivery Devices
Nasal Prongs
2L 23-28 3L 28-30 4L 32-36
Oxygen Mask
Nasal Catheter
6-8L/min 35-60
96
Partial Rebreathing Mask
Nonrebreathing Mask
6-10 L/min 65-75
8-12 L/min 85-95
97
Venturi Mask 24-50
98
Canopy or Oxygen Tent
99
Oxygen Toxicity
  • Concentration
  • Duration
  • Lung Disease
  • gt50 from 24-48 hours

100
Oxygen Toxicity S/S
  • Unproductive cough
  • Chest pain
  • GI upset
  • dyspnea

101
Oxygen Toxicity
  • S/S become more severe
  • ? in vital capacity
  • ? Compliance
  • Crackles
  • Hypoxia
  • ? Damage to lungs

102
Throat Culture
103
Common Causes for Nosebleeds --- local
Epistaxis
  • Allergies
  • Cocaine
  • irritants
  • Foreign Bodies
  • Nasal Sprays
  • Neoplasms
  • Nose picking
  • Septal deviation
  • Sinusitis
  • Sneezing
  • Trauma
  • URI

104
Common Causes for Nosebleed(Systemic)
  • Anemia
  • Anticoagulants
  • Arteriosclerosis
  • Blood dyscrasia (leukemia, thrombocytopenia)
  • Chronic Obstructive Pulmonary Disease
  • Diabetes Mellitus
  • End-stage hepatic cirrhosis
  • End-stage renal
  • Hypertension

105
Epistaxis
  • First Aid
  • Packing the Nose

106
Upper Airway Obstruction with Croup
  • Inflammation and Edema
  • Upper Airway obstruction
  • Increased Resistance to Air Flow

107
Upper Airway Obstruction with Croup
  • Increased intrathoracic negative pressure
  • Collapse of Upper airway
  • Respiratory Failure

108
Croup Syndromes
  • Croup Sound worse than they look
  • Epiglottitis Look worse than they sound

109
TonsillectomyPost-op
  • Prone or side
  • avoid coughing
  • ice to neck
  • clear liquid - soft diet
  • Tylenol - No ASA
  • observe for frequent swallowing
  • Concerns???

110
Laryngectomy
  • Lack of Humidity
  • Cold Air
  • Diminished smell and taste
  • Fear of drowning or suffocation
  • Dried secretions
  • Irritation of skin
  • Self-conscious

111
Blom-Singer Prosthesis
112
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