pulmonary system

8/9/2019 Pulmonary System

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Respiratory System



TERMINOLOGIES



ACUTE BRONCHITIS- is an inflammation of the bronchi accompanied

by mucus production and subsequent obstruction of airflow. Infectious agents, such as influenza virus,streptococci, pneumococci, staphylococci andhaemophilus, can cause acute bronchitis.

ACUTE RESPIRATORY FAILURE- is caused by the cardiac and pulmonary system

Inadequately exchanging O2 and CO2 in the lungs.

ATELECTASIS- is the collapse of the lung tissue or incompleteexpansion of a lung caused by the absence of air in aportion of the lung or the entire lung.



ATELECTASIS

ACUTE BRONCHITIS EMPHYSEMA



BRONCHIECTASIS- is a condition marked by chronic abnormal

dilation of bronchi and destruction of bronchial wall.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE- refers to a group of long term pulmonary

disorders marked by resistance to airflow.

TYPES

• ASTHMA- episodic airway obstruction caused by

bronchospasm, increased mucus secretions, andmucosal edema.

- maybe intrinsic or extrinsic (atopic)



• INTRINSIC- a reaction to internal, non-allergic factors.

• EXTRINSIC- a reaction to a specific external allergens.

CHRONIC BRONCHITIS- characterized by excessive mucus production with

productive cough lasting at least 3 months per year for 2consecutive years. Usually caused by prolonged exposureTo bronchial irritants such as smoking,second hand smokeair pollution, dust, and toxic fumes.

EMPHYSEMA- abnormal, permanent enlargement of the acini

that’s accompanied by destruction of the alveolar walls.it occurs when alveolar gas is trapped and gas exchange

is compromised.



COR PULMONALE- is a heart condition in which hypertension of pul-

monary circulation leads to enlargement of the rightventricle.

CROUP

- is a severe inflammation and obstruction of theupper airway that usually follows an upper respiratorytract infection. It’s a childhood disease characterized bya sharp bark like cough.

CYSTIC FIBROSIS- is a multisystem genetic disorder, a defect of the

Exocrine glands, causing tenacious mucus in the lungs.



EMPYEMA- is a form of pleural effusion in which the fluid

in the pleural space contain pus.

EPIGLOTTIDITIS- is an acute inflammation of the epiglottis that

tends to cause airway obstruction.

HEMOTHORAX- is a collection of blood in the pleural cavity.

HYPOXEMIA- is a deficiency of O2 in the arterial blood but

isn’t as severe as anoxia.

HYPOXIA

- is a deficiency of O2 at a cellular level.



LEGIONNAIRES’ DISEASE-is an acute noncommunicable bronchopneumoniacaused by an airborne bacillus.

LUNG ABCESS- is a lung infection accompanied by pus

accumulation and tissue destruction.

PLEURAL EFFUSION- is accumulation of fluid in the interstitial space

of the lung.

PLEURISY- is an inflammation of the pleurae characterized

by dyspnea and stabbing pain, leading to restriction of breathing.



PNEUMONIA- is an acute infection of lung parenchyma

commonly impairing gas exchange.

PNEUMOTHORAX- is a collection of air in the pleural cavity that

Leads to partial or complete lung collapse.

CLOSED PNEUMOTHORAX- condition in which air enters the pleural space

From within the lungs.

OPEN PNEUMOTHORAX-condition in which atmospheric air flows directly into

the pleural cavity.



TENSION PNEUMOTHORAX- condition in which air in the pleural space

compresses the thoracic organ and blood vessels, thus

reducing blood flow to and from the heart.

PULMONARY EDEMA- is a common complications of cardiac disorder

in which extravascular fluid accumulates in the tissueand alveoli.

PULMONARY EMBOLISM- occurs when a clot or foreign substance lodges

in a pulmonary artery.

PULMONARY HYPERTENSION- any condition that increases resistance to blood

flow in the pulmonary vessels. (COPD).



PULMONARY FIBROSIS- is scar tissue formation in the connective tissue

of the lungs.

PULMONARY INFARCTION- occurs when lung tissue is denied blood flow and

dies.

RESPIRATORY DISTRESS SYNDROME (hyaline membrane disease)

- is the most common cause of neonatal mortality.in respiratory distress syndrome, the premature infantdevelops a widespread alveolar collapse.

SARCOIDOSIS- is a multisystem, granulomatous disorder that

characteristically produces enlarge lymph nodes,



pulmonary infiltration, and skeletal, liver, eye orskin lesions.

SILICOSIS- is a progressive disease characterized by

nodular lesion that commonly progress to fibrosis.

SUDDEN INFANT SYNDROME- kills apparently healthy infants, usually between

ages 4 weeks and 7 months, for reason that remainunexplained even after an autopsy.

TUBERCULOSIS- is an infectious disease in which pulmonary

infiltrates accumulates in the lungs, cavities develop,and masses of granulated tissue form.



Symptom Analysis

• Dyspneamost common manifestations by clientwith pulmonary disorder.a subjective symptom.

• Coughnote when and how thecough began. (sudden/gradually).how long it has been present.use the clients own words to describe thecough.determine which medications or treatments

the client has used for the cough.



• Sputum production normal 3 ounces per day as part of normal

cleansing mechanism.color, odor, quality, and quantity.increase in several disorders.

• Hemoptysisidentify the source of the blood

lungs ---- bright redgit ---- dark red

forceful coughing

e.g.; chronic bronchitis, bronchiectasis, PTB• Wheezing

produce when air passes to a partiallyobstructed / narrowed airways



• Stridorhigh pitched sounds produces when airpasses a partially obstructed airway.associated with respiratory distresse.g; apnea, heartfailure, aspirationinquire about voice changes.e.g; hoarness of voice

• Chest paincan be present both in pulmonary andcardiac problem.

conduct a symptom analysis.- onset - location- duration - characteristics- aggravating factor

- relieving factor



• Associated manifestations- chills -weight loss- fever - excessive fatigue- night sweats - anxiety- hoarseness

• Childhood and infectious disease

- occurrence of tuberculosis, bronchitis,influenza, asthma, pneumonia, andfrequency of lower and upper respiratoryinfection.

• Immunization- pneumonia --- pneumovax



• Family health history- genetically transmitted disease

e.g; asthma- infectious conditions

e.g; PTB, COPD

• Psychosocial history

- occupation- geographic location- environment- habits



PHYSICALEXAMINATION



Chest wall configuration1. Barrel chest

- AP diameter is increased and equals thetransverse diameter.

e.g; emphysema



• Pigeon chest- the sternum just forward and increased

AP diameter.

e.g; congenital septal defectmarfans syndrome



• Funnel chest- deformity in which sternum is depressed

and the organs that lie below it are com-pressed.



• Thoracic kyphoscoliosis- hunched back appearance- accentuation of the normal thoracic curve

e.g; spinal tuberculosis, aging

poor posture



• Chest movementsmen – abdominal breathingwomen -- thoracic breathing- use of accessory muscle- retractions, symmetry

• Adventitious breath sounds- abnormal breath sounds superimposed

on normal breath sounds.

• Normal breath sounds

• vesicular breath sounds- heard throughout the chest andheard best in the base of the lungs.

- they are low pitched,soft,swishing

sounds, best heard during inspiration



Adventitious breath sounds• Crackles (formerly called rales)

- audible when there is a sudden openingof small airways that contain fluids.- heard during inspiration and do not

clear with a cough.

e.g; pulmonary edema, pulmonaryfibrosis, and pneumonia• Rhonchi (also known as gurgles)

- occur as a result of air passing through

fluid filled, narrowed passages.- disease with excess mucus production.- usually heard during expiration and may

clear with cough.

e.g; pneumonia, bronchitis, bronchiectasis



• Wheezes- a continuous musical or hissing noise that

result from the passage of air through a

narrowed airway.• Pleural friction rub

- a creaking, grating sound.- a result of pleural inflammation often

associated with pleurisy pneumonia orpleural infarct.

INSERT:BREATH SOUNDSSITES OF RESPIRATORY RETRACTIONS



2. Lung volume determination- lung volume is measured by a gas dilution

technique or body plethysmography( an instrument for measuring and

recording changes in the size andvolume of extent and organs byblood volume).

3. Diffusion capacity- studies of the lung diffusing capacity or

carbon monoxide capacity.



Nursing Responsibilities1. Education about the purpose, procedure and

implication of the test.2. Give explicit instructions.3. Client should not smoke or use bronchodilators

for 6 hours before undergoing a PFT.4. Normal to feel shortness of breath.

• Pulse oximetry- simple and safest method of assessing

oxygenation.- gives a percentage of hemoglobin that

is saturated with oxygen.- any condition that can cause decrease

arterial blood flow can give inaccurateor no reading.



• Capnography- noninvasive procedure use to measure

exhaled CO2 concentration of clientsreceiving mechanical ventilation.

• Arterial Blood Gas- use of arterial blood to measure PaO2

PaCO2 and Ph directly.- measures the efficiency of gas exchange.

Nursing Responsibility1. Perform Allen's test

- quick test for collateral circulation2. Apply continuous pressure to the site for

5 min --- radial/brachial site10 min – femoral site



Insert video clip:

-Performing Allen's test.-Withdrawing arterial blood

samples.-Pulse oximetry.



• Ventilation – Perfusion Studies- assessment of the distribution of

ventilation ( ventilation scan).- assessment of the pulmonary vasculature

( perfusion scan).

1. Ventilation scan- radioactive gas is inhaled and produce

an image of the areas where ventilationoccurs.

e.g: pulmonary embolus

2. Perfusion scan (non-iodine base)- radiologic material is injected intra-venously and carried to the pulmonaryvasculature.



2. Test to Evaluate Anatomic Structure

• Radiographic Imaging• Radionuclide studies• Endoscopy• Alveolar lavage

1. Radiography- able to illustrate graphically the cause of respiratory dysfunction.1.1 Chest X-ray

Indications:• part of routine screening procedure• when pulmonary disease is suspected



• to monitor the status of respiratorydisorder and abnormalities.

e.g: pleural effusionatelectasistubercular lesion

• to confirm endotracheal or tracheostomytube placement.• after traumatic chest injury• in any other situation in which radiographic

information helps in the management of arespiratory problem.



Positions:1. Posteroanterior view

- x – ray beam penetrates from the back- shoulder are rotated forward to pull the

scapula away from the lung field.2. Anteroposterior view

- x – ray beam penetrates from the front of the chest.

- heart appears larger than it really is andlarger than PA view.

3. Lateral view- accompanies a standard PA view- view is taken from the right or left side of

the chest.- allows better visualization of the heart

the heart and dome of diaphragm.



4. Lateral Decubitus view (lying down)- client lies on the right or left side depending

on which side of the chest is being assessed.- to determine whether opaque areas on the

pleura are due to solid or liquid media.

5. Oblique view- used to visualized behind and around under

lying structure.

6. Lordotic view- use for clearer view of the upper lung fields.- beam is directed @ an upward angle.- results in removal of the clavicle and 1 st and

2 nd ribs from the field of vision.



• Fluoroscopy- use to visualize the chest and intra -

thoracic structure whether they functiondynamically.

e.g; observing transbrochial passageof biopsy forceps during bronchoscopy.

Indications :observing the diaphragm during inspiration andexpiration.determine mediastinal shift movement during

deep breathing.assessing the heart, blood vessels and relatedstructures.identifying esophageal abnormalities

detecting mediastinal masses.



Images are not as clear and definitive asObtained on a standard chest film.

• computed tomography- helpful in identifying peripheral or

mediastinal lung disease.• magnetic resonance imaging

- more detailed images of anatomicstructure.

• ultrasonography- use in conjunction with other pulmonary

diagnostic procedure.e.g: thoracentesis and pleural biopsy(to asses fluid or fibrotic abnormalities)

- accurate in detecting the amount of

pleural fluid.



• gallium scan- used to distinguished embolism from

pneumonitis.

- many organs take up radioactive galliumas do some tumors and areas of inflammation.

- done 24 to 48 hours after injection

- not iodine base and produces no sideeffects.

• bronchoscopy- fiberoptic instruments

- involves passage of lighted bronchoscopeinto the bronchial tree

- maybe performed for diagnostic ortherapeutic purpose.



diagnostic:- examination of tissue.- evaluation of tumor for potential surgical

resection.- collection of tissue,specimens for diagnostic

therapeutic:- remove foreign body

- remove thick, viscous secretions.- treat post-operative atelectasis.- destroy and remove lesion.

Nursing Responsibility:

- informed consent- NPO for 6 hours (until swallowing reflex

returned).- throat may be sore after the procedure.

- remove any dentures.



ti t iti i i d h d i h



-patient position is supine and head is hyper-extend.

-observe for respiratory distress.

dyspneachange in respiratory rateuse of accessory musclechange in or absent lung sounds

-observe for Hemoptysis-pneumothoraxsudden sharp pain.difficult rapid breathing.

cessation of normal chest movements onaffected side. -diaphoresis.tachycardia. -increased temperatureweak pulse. -pallor

hypotension. -dizziness. -anxiety.



Insert video clip: - assisting with insertion and

management of closed chestdrainage.

-changing a disposable chest tubedrainage.

M t f PNEUMOTHORAX



Management of PNEUMOTHORAX• place patient in fowlers position• administer oxygen therapy via nasal cannula

• pain medications ( avoid respiratory depression)• insertion of chest tube and attached to a chestdrainage system.

• provide intermittent positive pressure breathing

-teach patient how to cough, breath deeply andperform passive exercise.• may give ice chips and small sips of water

laryngoscopy- visual examination of the larynx

e.g: nodules laryngeal papillomaspolypscancer



INSERT VIDEO CLIP

1 I di l



1. Indirect laryngoscopy- indirect visualization allows inspection of

nasopharynx and posterior soft pallate

using a small or an instrument resemblinga telescope.

note:- drainage - bleeding

- ulcerations - masses2. Direct laryngoscopy- direct visualization of the larynx with the

use of lighted endoscope.

avoid touching the tongue to avoidstimulating the gag reflex.

• alveolar lavage



alveolar lavage- sterile saline is injected using a bronchoscope

to wash tissue, (or during bronchoscopy) thesaline is then aspirated and examined fortypical cell.

e.g: interstitial lung diseasepneumocystic carilli

• endoscopic thoracotomy- a diagnostic procedure that is an alternative

open lung biopsy• pulmonary angiography

- assessment of the vascular structure of thethorax.

- congenital abnormalities of the pulmonaryvascular tree.

- abnormalities of the pulmonary venouscirculation.



Pls. Insert video:Nurse’s role in a pulmonarycatheter insertion.

d i ff f h



-destructive effects of emphysema.

contrast medium is injected into the vascularsystem through an indwelling catheter(pulmonary artery).

3. Specimen Recovery Analysis

• sputum collection- normally the goblet cells produce 100ml

of mucus a day.- note for bacteria, fungus, cellular elements- inspect for:

color quantityquality presence of bloodfood particles

- should be done before the start of any anti-microbial treatment.

Direct method



. Direct method- the client coughs into a sputum container.

. Indirect method- sterile suction catheter with an attachedsputum trap.

- transtracheal aspirationsert video clip:

a puncture is made with a needleollect specimen for culture through a cricothyroid membraneputum/throat into the trachea and sputum is

aspirated.



Incision site

• gastric lavage



• gastric lavage- use to uncooperative patient or severely

ill patients.

- sputum is swallowed during sleep and aftercoughing.

gram stain culture and sensitivity studyGram stain --- to classify bacteriaGram positiveGram negative(cultures)

provide guidelines forappropriate antimicrobialtherapy.

• nose and throat culture pls. insert video:

- sterile cotton swabs collect a specimen for

• thoracenthesis culture / nasal

- procedure used to drain fluid or air found inthe pleural space.



THORACENTESIS- is a procedure in which fluid between the

chest cavity and lungs is collected through a needle

Indications:

• help determine the cause of fluid in the lung cavity• relieve shortness of breath and pain caused by anaccumulation of excess pleural fluid



• to determine the cause of an infection or empyema



to determine the cause of an infection or empyema.

specific gravityglucoseproteinpHcytology evaluation

Post procedure/ nursing responsibility• amount color and consistency of the fluid.• turn the patient on the unaffected side to

facilitate lung expansion (1 hour).

PLEURODESIS- cytotoxic medications is injected into thepleural space after thoracentesis.

- patient must roll about to coat the entire

pleural space.

• biopsy



biopsy- removal of a small piece of living tissue

from an organ.

plerual biopsy- can be performed surgically through a small

thoracotomy incision or during thora-

centesis.

thoracotomy- surgical opening in the thoracic cavity

needle biopsy- the needle removes a small fragments of

parietal pleura.

- required microscopic examination

Nursing Responsibility:



Nursing Responsibility:• informed consent• position same as thoracentesis

• patient must hold still (procedure is painful)• prepare chest tube and chest drainage(pneumothorax may develop)

• Lung Biopsy ( open lung biopsy )- to identify pulmonary tumors or parenchymalchanges.

UPPER AIRWAY DISORDER LOWER AIRWAY AND



PULMONARY VESSELDISORDER

HEMORRHAGIC, INFECTIOUSAND INFLAMATORY

DISORDERS .- epitaxis - sinusitis- pharyngitis - tonsilitis

- rhinitis - diphtheria- peritonsilar abscessAIRWAY OBSTRUCTION- laryngeal edema- laryngospasm- laryngeal paralysis- laryngeal injury- nasal polyps- deviated nasal septum and

nasal fracture

ASTHMA- intrinsic - extrinsic

CHRONIC OBSTRUCTIVEPULMONARY DISEASE- asthma

- emphysema- chronic obstructive

bronchitis TRACHEOBRONCHITISBRONCHIECTASIS

PULMONARY EMBOLISMPULMONARY HYPERTENSION

PARENCHYMAL AND PLEURAL



PARENCHYMAL AND PLEURALDISORDER

ATELECTASISNEOPLASTIC LUNG DISORDER- malignant lung tumor- benign lung tumorsRESTRICTIVE LUNG DISORDER- cystic fibrosis- sarcoidosis

PLEURA AND PLEURAL SPACE- pleural effusion

- bronchopleural fistula

INFECTIOUS DISORDER- influenza- pneumonia- lung abcess

- pulmonary tuberculosis- extrapulmonarytuberculosis

NURSING DIAGNOSIS FOR CLIENTS WITH



NURSING DIAGNOSIS FOR CLIENTS WITHUPPER AIRWAY DISORDER

• anxiety and fear• impaired nutrition: less than body requirements• impaired verbal communication

• ineffective airway clearance• risk for aspiration• risk for constipation• risk for impaired gas exchange• risk for ineffective family/individual therapeutic

regimen management• risk for infection

NURSING DIAGNOSIS FOR CLIENTS WITH LOWER



NURSING DIAGNOSIS FOR CLIENTS WITH LOWERAIRWAY AND PULMONARY VESSEL DISORDER

• activity intolerance• anxiety• deficient knowledge• decisional conflict• disturbed sleep pattern

• imbalance nutrition: less than body requirements• impaired gas exchange• ineffective airway clearance• ineffective breathing pattern• ineffective coping• interrupted family process• risk for infection• sexual dysfunction



ASTHMA



ASTHMA- a disorder of the bronchial airways charac-

terized by serious bronchospasm.

INTRINSICNON-ALLERGIC

EXTRINSICALLERGIC

TRIGGERED BY INTERNAL

DISORDER SUCH AS:- common colds- upper respiratory

infection

- exercise

DUST

LINTPOLLENINSECTSMOLD

SPORESSMOKEMEDICATIONSFOODS



Facts:• asthma is believed to be an inherited dis-

order that interacts with environment fxto cause the disease.

• asthmatic symptoms usually worsen @ night

• a severe, life threatening complications of asthma is status asthmaticus. It is an acuteepisode of bronchospasm that can increasethe workload of breathing 5 to 10 times.

• risk factors include air pollution andcigarette smoking.

CLINICAL MANIFESTATIONS :



CLINICAL MANIFESTATIONS :• marked respiratory effort• feeling of chest constrictions

• inspiratory and expiratory wheezing• non-productive coughing• tachycardia/tachypnea• prolonged expiration

EMERGENCY MANAGEMENT STATUS ASTHMATICUS

inhaled beta-adrenergic

intravenous theophyllineintravenous steroidsoxygen if needed

intravenous corticosteroids

inhaled beta-adrenergicsoxygen if neededintubation and mechanicalventilation, if needed

N i M



Nursing Management:

• assess respiratory effort• monitor arterial blood gas• monitor results of pulmonary function test• monitor color, consistency, and amount of sputum• place client’s in fowler’s position• encourage fluids to thin secretions• reposition frequently• administer oral care every 2 to 4 hours• assess effectiveness of therapy• monitor for side effects of bronchodilator therapy

Chronic Obstructive Bronchitis



- inflammation of the bronchi which cause

cause increased mucous production and chroniccough. Thicker, more tenacious mucus and impairedciliary function is present. The airway collapse, andair is trapped in the distal part of the lung.

Emphysema

- a disorder in which the alveolar walls aredestroyed, which leads to permanent over distentionof the air space. Air passages are obstructed due tothese changes, rather than from mucous production

CHRONIC BRONCHITIS EMPHYSEMA



productive coughdecreased exercise

tolerancewheezingshortness of breathprolonged expirationelevated hematocrit

polycythemiacyanosis and peripheraledema (blue bloater)signs and symptoms of cor-

pulmonale / right sides heartfailure

dyspnea on exertion whichprogress eventually to

dyspneaat resttachypnea with prolongedexpirationsuse of accessory muscle

barrel chestthinnesspink color and dyspnea(pink puffer)

characteristic sitting positionof leaning forward with armsbraced on knees to supportthe shoulder and chest forbreathing

NURSING MANAGEMENT



• assess respiratory status and report changes tophysician

• maintain high fowlers position• administer low flow oxygen• monitor effectiveness of bronchodilators and

assess for side effects

encourage 8 to 10 glasses of fluid daily, if notcontraindicated• use cautions in administering narcotics• instruct on:

- proper coughing technique- pursed lip breathing- diaphragmatic breathing

• assess for any changes in vital signs during activityand instruct client to stop if these occurs



• remain with the client during acute episodes• use/encourage relaxation technique

• provide emotional support• facilitate discussion of changes in sexualfunction

pulmonary system

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