medical-surgical nursing: an integrated approach, 2e chapter 18 nursing care of the client:...
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Medical-Surgical Nursing: An Integrated Approach, 2E
Chapter 18
NURSING CARE OF THE CLIENT: RESPIRATORY SYSTEM
Respiratory System
Its primary function is delivery of oxygen to the lungs and removal of carbon dioxide from the lungs.
Thoracic Cavity
The inside of the chest cage is called the thoracic cavity.
Contained within the thoracic cavity are the lungs, cone-shaped, porous organs encased in the pleura, a thin, transparent double-layered serous membrane lining the thoracic cavity.
The Physiology of the Lungs The right lung is larger than the left and is
divided into three sections or lobes: upper, middle, and lower.
The left lung is divided into two lobes: upper and lower.
The upper portion of the lungs is the apex; the lower portion is the base.
Conducting Airways
The conducting airways are tubelike structures that provide a passageway for air as it travels to the lungs.
The conducting airways include the nasal passages, mouth, pharynx, larynx, trachea, bronchi, and bronchioles.
Pharynx Larynx Trachea
The conducting airways that connect nasal passages and mouth to the lower parts of the respiratory tract.
The passageway for air entering and leaving the trachea and containing the vocal cords.
Commonly known as the windpipe, this tube is composed of connective tissue mucosa and smooth muscle supported by C-shaped rings of cartilage.
Bronchi, Bronchioles
Two tubes, the right and left primary bronchi, that each pass into its respective lung.
Within the lungs, the bronchi branch off into increasingly smaller diameter tubes until they become the terminal bronchioles.
Respiration
A process of gas exchange necessary to supply cells with oxygen for carrying on metabolism, and to remove carbon dioxide produced as a waste by-product.
Two types of respiration: external and internal.
External & Internal Respiration
The exchange of gases between the inhaled air and the blood in the pulmonary capillaries.
The exchange of gases at the cellular level between tissue cells and blood in systemic capillaries.
Signs & Symptoms
1. Dyspnia
2. Cough
3. Sputum Production
4. Chest Pain
5. Wheezing
6. Hemoptesis
Assessment
Auscultation(Listening for Normal and Adventitious Breath Sounds)
Palpation and Percussion
Inspection(client's color, level of consciousness, emotional state)
(Rate, depth, quality, rhythm, effort relating to respiration)
Health History(allergies, occupation, lifestyle, health habits)
Adventitious Breath Sounds
Fine crackles (dry, high-pitched popping…COPD, CHF, pneumonia)
Coarse crackles (moist, low-pitched gurgling…pneumonia, edema, bronchitis)
Sonorous wheezes (low-pitched snoring…asthma, bronchitis, tumor)
Sibilant wheezes (high-pitched, musical … asthma, bronchitis, emphysema, tumor)
Pleural friction rub (creaking, grating… pleurisy, tuberculosis, abscess, pneumonia)
Stridor (crowing…croup, foreign body obstruction, large airway tumor).
Abnormal sounds and some conditions associatedwith them:
Common Diagnostic Tests for Respiratory Disorders
1. Laboratory Tests (Hemoglobin; Arterial blood gases; Pulmonary Function Tests; “Sputum Analysis& culture”).
2. Radiologic Studies (Chest X-ray; Ventilation-perfusion scan; CAT scan; Pulmonary angiography).
3. Other (Pulse oximetry; Bronchoscopy; Thoracentesis; MRI).
Respiratory Care Modilities O TherapyThe administration of O in concentration
greater than that found in environmental atmosphere
Indications -change in respiratory rate - hypoxemia - hypoxia
O Therapy
Cautions
1. O toxicity
2. Suppression of ventelation
3. Source of Cross infection
4. Fire Danger Method of Oxygen Administration
slide(22-1)
Chest Physiotherapy
The Goal of chest physiotherapy is :1. Remove bronchial secretion
2. Improve Ventilation
3. Increase efficiency of respiratory muscles Postural Drainage Chest Percussion &vibration Breathing exercise &retraining
Air Way Management Emergency management of upper airway
obstruction Causes
1. foreign body
2. Secretions
3. Vomiting or food particles
4. Enlarged tissue “edema, Ca, &abscesses” Assessment
Inspection , palpation,& Auscultation
Airway Management
Emergency Measures
1. Opening airway by extend Pt neck back
2. Observe airway
3. Cross finger to clear airway
4. If no passage “Abd thrust”
5. Use resuscitation bag
guide lines p 499
Endotracheal Intubation
Passing endotracheal tube through mouth or nose into the trachea
It is a method of choice in emergency Providing airway for specific patients For mechanical ventilation
Tracheastomy It is a procedure in which an opening is made into
the trachea and indwelling tube is inserted into the trachea
Indication1. To bypass an upper airway obstruction2. To allow removal of tracheobroncheal secretions3. For long term ventilation4. To prevent aspirationComplications “bleeding, pneumonia, air embolism
emphysema pneumothrax
Upper Respiratory Tract Infections/Inflammatory Disorders
Rhinitis (coryza, common cold)
Allergic rhinitis Sinusitis
Pharyngitis Tonsillitis Laryngitis
Upper Respiratory Tract Infections/Inflammatory Disorders
Are the common conditions that affect most people on occasion, some infections are acute and other are chronic
common cold
Often is used when referring to a symptoms of an upper respiratory tract infection ch.ch.by nasal congestion ,sore throat , & cough
Cold referred to a febrile, infectious, acute inflammation,of the mucus membranes of the nasal cavity
common cold
Clinical manifestations
1. Nasal congestion
2. Scratchy or sore throat
3. Sneezing & cough
4. Headache & muscle ache
5. Herpes simplex sore (cold sore )
common cold Medical Management (symptomatic management)
1. Fluid intake ,rest ,prevention of chills.2. Aqueous decongestant,anti histamin, Vit. C.3. Expectorant as needed4. Analgesic for aches ,pain , & fever.5. Antimicrobial to reduce incidence of
complications Nursing Management1. Patient teaching of self care & prevention of
infection & break chain of infection
Rhinitis
Inflammation of nose by viral , obstructive ,allergic reaction.
Clinical manifestations1. Rhinorrhea “ excessive nasal drainage”
2. Nasal congestion, Itching ,& sneezing
3. Headache may occur
Rhinitis
Medical Management
1. Treatment of cause “antibiotics”
2. Decongestant agents
3. Antihistamine
4. In severe cases corticosteroids
Acute Sinusitis
It is inflammation of sinuses , it is resolved promptly if their opening into nasal cavity .
Clinical Manifestations
1. Pressure , pain over the sinus area
2. Tenderness
3. Purulent nasal secretions
Acute Sinusitis Medical Management 1. Antimicrobial agent “Amoxicillin”2. Oral & Topical Decongestant3. Heated mist or Saline irrigation
Nursing management “Teaching patient self care”
Complications1. Meningitis &osteomylitis2. Brain abscess 3. Ischemic infarction
Chronic Sinusitis
It is an inflammation of sinuses that persists for more than 8 weeks in adult & or 2 weeks in children
Clinical Manifestations1. Impaired mucociliary clearness & ventilation
2. Chronic hoarseness & cough
3. Chronic Headache
4. Facial pain
Chronic Sinusitis
Medical Management 1. Strong antibiotics (for 21 days )
2. Surgical intervention to remove obstruction cause that cause block of drainage passage
Nursing Management 1. Increase humidity
2. Increase fluid intake
3. Early signs of sinusitis
Acute Pharyngitis It is a febrile inflammation of throat ,caused by
virus about 70% , uncomplicated viral infection usually subsided promptly within 3-10 days
Clinical Manifestations
1. Fiery red pharyngeal membrane& tonsils
2. Lymphoid follicles that are swollen
3. Enlarge tender cervical lymph node
4. Fever & malaise
5. Sore throat , hoarseness,& cough
Acute Pharyngitis Medical Management1. Supportive measures for viral infection
2. Pharmacologic therapy antibiotics for 10 days “cephalosporin”analgesic for severe sore anti tussive medications
3. Nutritional therapy liquid or soft diet “If liquid can’t tolerated IV fluid administered “
4. Nursing Management (bed rest ,skin assessment, mouth care &normal saline gargle & self care teaching
Chronic Pharyngitis Common in adults who work or live in dusty
surrounding ,use the voice too excess , suffer from chronic cough , & habitually use alcohol & tobacco
Types of pharyngitis
1. Hypertrophic :ch.ch.by general thickening& congestion of pharyngeal mucus membrane
2. Atrophic : probably late stage of first type
3. Chronic Granular : ch.ch.by numerous swollen lymph follicles on the pharyngeal wall
Chronic Pharyngitis
Clinical Manifestations 1. Constant sense of irritation or fullness in throat
2. Mucus expelled by coughing
3. Difficulty in swallowing
Medical Management 1. Relieving symptoms
Avoiding exposure to irritant
Correct respiratory & cardiac conditions
Chronic Pharyngitis
2. Antihistamine drugs
3. Decongestant
4. Controlling malaise Nursing Management1. Patient teaching of self care
2. Avoid alcohol , tobacco , exposure to cold
3. Face mask to avoid pollutant
4. Warm fluids,&warm saline gargle
Tonsillitis The tonsils are composed of lymphatic tissue &
situated on each side of the oropharynx ,they frequently are the site of acute infection (tonsillitis)
Clinical Manifestations Tonsils : sore throat, fever , snoring & difficulty of
swallowing Adenoids : ear ache , mouth breathing , drainage
ear ,frequent cold , bronchitis, noisy respiration, foul smelling breath &voice impairment
Tonsillitis Medical Management1. For recurrent tonsillitis “tonsillectomy”
2. Conservative or symptomatic therapy
3. Antimicrobial therapy “penicillin” for 7 days
Nursing Management1. Provide post op. care :V/S ,hemorrhage , position head
turned to side,water or ice chips
2. Teaching patient :S&S of hemorrhage
3. Avoid too much talking or coughing
4. Liquid or semi liquid diet for several days
5. Alkaline mouth washing with warm saline
Laryngitis It is an inflammation of larynx ,often occur as
a result of voice abuse or exposure to dust , chemicals , smoke , & other pollutants
Common in winter & easily transmitted The cause of infection is almost virus
Clinical Manifestations
1. Hoarseness or aphonia
2. Severe cough
Laryngitis Medical Management1. Resting voice & avoid smoking 2. Inhale cool steam or an aerosol3. Conservative treatment 4. Antibiotics for bacterial organisms Nursing Management1. Rest voice 2. Maintain a well humidified environment 3. Daily fluid intake
Pleurisy/Pleural Effusion
Pleurisy is a painful condition that arises from inflammation of the pleura, or sac that encases the lung.
Pleural effusion occurs when the inflamed pleura secretes increased amounts of pleural fluid into the pleural cavity.
Atelectasis Collapse or airless condition of the alveoli
caused byhypoventilation,obstruction of airway or compression
Clinical Manifestations1. Cough & sputum production2. Dyspnea ,tachypnea ,tachycardia3. Sings of pulmonary infection may present4. Fever 5. Central cyanosis
Atelectasis Management
1. First line measures :(turning , early ambulation , lung volume expansion , coughing, spirometry ,breathing exercises
2. If there is no response : (PEEP , IPPB)
3. Bronchoscopy
4. Postural Drainage & percussion
5. If cause is compression remove the cause
Acute Tracheobronchitis An inflammation of the mucus membrane of
the trachea & the bronchial tree , often follow upper respiratory tract infection
Clinical Manifestations1. Dry irritating cough “expectorate sputum”2. Sternal soreness from coughing3. Fever ,stress , night sweating 4. Headache & general malaise5. As the infection progress the patient develop
(shortness of breath, noisy breath ,&purulent sputum
Acute Tracheobronchitis Medical Management1. Antibiotics depend on symptoms & culture2. Expectorant may be prescribed3. Increase fluid intake4. Rest & cool therapy 5. Suctioning & Bronchoscopy Nursing Management1. Patient teaching 2. Encourage fluid intake3. Coughing exercises to remove secretions4. Complete antibiotics course,5. Prevent over exertion
Pneumonia An inflammation of the lung tissue that is caused
by microbial agent
Community Acquired Pneumonia (CAP)1. Occurs either in community setting or within the
first 48 hrs of hospitalization2. Most common in people younger than 60 yrs3. Most prevalent during winter & spring 4. Caused by pneumococcus & H influenza5. Virus the cause in infants & children
Pneumonia Hospital Acquired Pneumonia (HAP) the
onset of pneumonia symptoms more than 48 hrs after admission to hospital. Also called nosocomial infection
Common organism E.colli ,Klebsiella ,S.aurious It occurs when host defense impaired in certain
conditions Pneumonia in the Immuno compressed host Caused by organisms also observed in
CAP,HAP. Has subtle onset with progressive dyspnea ,
fever , &productive cough
Pneumonia Clinical Manifestations1. Sudden onset of shaking chills2. Rapidly increase in body temperature 38-40 C3. Chest pluratic pain increased by deep
breathing 4. Patient looks severely ill with marked
tachypnea5. Shortness of breath6. Orthopnea 7. Poor appetite 8. Diaphoresis &tires easily 9. Purulent sputum
Pneumonia Medical Management1. Appropriate antibiotics depend on culture
result2. Hydration (increase fluid intake )3. Antipyretic for fever & Headache4. Warm moist inhalation to relieve irritation5. Antihistamine to relieve sneezing & rhinorrhea6. Oxygen & respiratory supportive measures Complications : Shock & respiratory failure , Atelectasis & plural effusion Super infection
Chronic Obstructive pulmonary Disease (COPD)
Disease state in which air flow is obstructed by emphysema or bronchitis or both
The airway obstruction is usually progressive & irreversible
Clinical Manifestations1. Cough2. Increase work of breathing3. Severe dyspnea that interfere with patient
activity
Chronic Obstructive pulmonary Disease (COPD)
Medical Management1. Inhaled bronchodilators to improve airway
2. Oxygen therapy as prescribed
3. Pulmonary rehabilitation emotional & physiologic needs ,breathing exercises ,&methods of symptoms elevation
Chronic Obstructive pulmonary Disease (COPD) Nursing Management Patient Education About COPD1. Breathing exercise2. Inspiratory muscles training3. Self care activity4. Coping measures Complications1. Pneumonia2. Atelectasis3. Pneumothrax4. Respiratory insufficiency & failure
Chronic Bronchitis
It is a productive cough that lasts in each of 2 consecutive years in a patient whom other causes of cough is excluded
Clinical Manifestations
1. Chronic productive cough in winter
2. Increase frequency of respiratory infection
Chronic Bronchitis Medical Management the objective of
treatment are to keep the bronchioles opened & functioning
1. Antibiotics therapy for recurrent infection2. Bronchodilators to remove secretion3. Postural Drainage & chest percussion4. Hydration & fluid intake 5. Corticosteroid may be used6. Smoker patient should stop smoking
Emphysema A complex and destructive lung disease
wherein air accumulates in the tissues of the lungs.
Smoking is the major cause of Emphysema Classification 1. Panlobular : destruction of the respiratory
bronchiole,alevular duct &alveoli2. Centrilobular : pathogenic changes take
place mainly in the center of secondary lobule
Emphysema
Clinical Manifestations
1. Increase dyspnea on exertion
2. Anoroxia & Weight loss
3. Weakness & Inactivity
4. Pursed –lip- breathing
5. Increase cough wheezing purulent sputum & occasionally fever
Emphysema
Medical Management
1. Bronchodilators
2. Antimicrobial Agents
3. Oxygen therapy
4. Pulmonary rehabilitation
5. Smoking cessation
6. corticosteroids
Asthma
A condition characterized by intermittent airway obstruction in response to a variety of stimuli. “inflammatory”
Asthma differ from COPD in that it is reversible process either spontaneously or with treatment
Allergy is the strongest predisposing factor for the development of asthma
Asthma
Clinical Manifestations
1. The most three common symptoms are: a- coug b- dyspnea c- wheezing
2. Hypoxemia may occur along with a- cyanosis b- diaphoresis c- tachycardia d- widened pulse pressure
Asthma Prevention : allergic test to identify the
substances cause the symptoms and avoid it as possible
Complications1. Asthmaticus2. Rib fracture 3. Pneumonia4. Atelectases
Asthma Medical Management Pharmacologic Therapy (long term)1. Corticosteroid :most effective ant
inflammatory medication (inhaled form)2. Long-acting beta2adrenergic agonist mild to
moderate bronchodilator (theophilline3. Quick relive medications (short acting beta2
adrenergic agonists4. Peak flow monitoring
Asthma Nursing Management1. Immediate care based on severity of
symptoms2. Assessment & Allergic History3. Administer medication & observe patient
response4. Antibiotics as prescribed for infection5. Assist in intubations procedure if needed6. Psychological support for patient & his family
Acute Respiratory Failure
Conditions wherein there is a failure of the respiratory system as a whole.
It is a sudden & life threatening deterioration of gas exchange function of the lung
Acute : a fall in arterial PaO2 to less than 50mmHg &a rise in arterial PaCo2to greater than 50mmHg
Acute Respiratory Failure
Causes
1. Decrease respiratory derive “brain”
2. Dysfunction of chest wall “nerves & muscles”
3. Dysfunction of lung parenchyma “expansion”
4. Postoperative & inadequate ventilation
Acute Respiratory Failure Clinical Manifestations1. Impaired oxygenation & may be include
restlessness2. Fatigue & headache3. Dyspnea & air hunger4. Tachycardia &hypertension5. Confusion & lethargy6. Diaphoresis …… Respiratory Arrest7. Uses of accessory muscles
Acute Respiratory Failure
Medical management:
Intubations and mechanical ventilation may be required to maintain adequate ventilation and oxygenation while the case corrected
Acute Respiratory Failure Nursing management:1. Monitoring patient responses and
arterial blood gases 2. Monitoring vital sign3. turning ,mouth car , skin care , and rang
of motion .4. Teaching about the underlying disorders 5. Assists in intubations procedure
Pulmonary Embolism Obstruction of a pulmonary artery by a
bloodborne substance. Deep vein thrombosis is a common cause of
pulmonary embolism. Other types (Air , Fat , Septic ) Clinical Manifestations1. Dyspnea & Tachypnea2. Sudden & pluretic chest pain3. Fever & cough & hemoptesis4. Apprehension Diaphoresis & syncope
Pulmonary Embolism Medical Management
1. Emergency Management
i. Nasal O2
ii. IV infusion for Medication
iii. Perfusion Scan
iv. ABGs &ECG
v. Small dose of Morphine
vi. Intubation & mechanical Ventilation
Pulmonary Embolism
Pharmacologic Management
i. Anticoagulant therapy heparin 5000-10000 bolus then 18u/kg/hrs warfarin for three months
ii. Thrombolytic therapy (STK , Actylase (TPA))
iii. Surgical Management (Surgical Embolectomy)
Pulmonary Embolism
Nursing Management
1. Preventing thrombus formation
2. Monitoring thrombolytic therapy
3. Providing post operative nursing care
4. Managing O2 therapy
5. Preventing anxiety
6. Monitor for complications+
Pneumothorax/Hemothorax Traumatic disorders of the respiratory
tract wherein the underlying lung tissue is compressed and eventually collapses.
Types
1. Simple Pnuemothrax
2. Traumatic Pnuemothorax
3. Tension
Pneumothorax/Hemothorax Clinical Manifestations
1. Sudden pluretic pain
2. Anxious patient , dyspnea & air hunger
3. Increase use of accessory muscles
4. Central cyanosis
5. Tympanic sound in percussion
6. Absent of breath sound & tactile fremetus
7. Agitation Diaphoresis & hypotension
Pneumothorax/Hemothorax Medical Management1. High concentration supplemental O22. Chest tube for drainage3. In emergency anything may be use to fill the
chest wound 4. Heavy dressing 5. Needle aspiration thoracenthesis6. Connecting chest tube to water seal drainage7. An emergency thoractomy may also
performed
Pulmonary Edema
A life-threatening condition characterized by a rapid shift of fluid from plasma into the pulmonary interstitial tissue and the aveoli, resulting in markedly impaired gas exchange.
Can result from severe left ventrical failure, rapid administration of I.v. fluids, inhalation of noxious gases, or opiate or barbiturate overdose.
Adult Respiratory Distress Syndrome
A life-threatening condition characterized by severe dyspnea, hypoxemia, and diffuse pulmonary edema.
Usually follows major assault on multiple body systems or severe lung trauma.
Bronchiectasis
A chronic dilation of the bronchi. Main causes of this disorder are
pulmonary TB infection, chronic upper respiratory tract infections, and complications of other respiratory disorders of childhood, particularly cystic fibrosis.
Neoplasms of the Respiratory Tract
Benign neoplasms. Lung cancer. Cancer of the larynx.
Epistaxis
A hemorrhage of the nares or nostrils. May be unilateral (most common) or
bilateral. Blood loss can be minimal to severe.
Smoking
Cigarette smoking is indicated as a major causative factor in the development of respiratory disorders, such as lung cancer, cancer of the larynx, emphysema, and chronic bronchitis.