Contributed by:
The content was developed to explain the concepts of the respiratory system in nursing practice.
1.
Respiratory System
Johncy Joseph, RN-BSN, MBA
Avenir Solutions, LLC
2.
Respiratory System
Primary Function: Provide Oxygen & Remove CO2
Secondary Functions: Sense of smell, Speech, Acid-base balance, Body-
water, heat balance
Upper Respiratory Tract Lower Respiratory Tract
•Nose: Humidifies, warms, filters air via Cilia Trachea: aka windpipe, in front of
•Sinuses: Air filled cavities within the hollow bones that Esophagus.
surround the nasal passages and provide resonance
during speech Bronchi: Divides at Carina
Passageway for respiratory and GI behind the oral and nasal
Right Bronchus: Wider/Shorter
cavity
Divides into nasopharynx, oropharynx, laryngopharynx Bronchi: Lined with cilia- propels mucus
up or down to expectorant or
Voice Box, just below pharynx swallowed
2 pairs of vocal cords- False and True Cords
Opening between true cords is called glottis Bronchioles: Does not participate in
Glottis: For coughing- Fundamental defense system for lungs gas exchange
Aleveolar ducts and alveoli: Gas
exchange
3.
Upper & Lower Respiratory
4.
• https://www.youtube.com/
watch?v=pNcV6yAfq-g
• https://www.youtube.com/
watch?v=8-4MZ_-Mpv8
5.
• Located in the pleural cavity of the thorax
• Landmark: Starts from Clavicle to the Diaphragm at T12
• Right Lung (3 Lobes)> Left Lung (2 Lobes) (narrower to accommodate heart)
• Respiratory Nerves; Phrenic Nerve, Vagus Nerve, & Thoracic Nerve
6.
Pleural Layers of Lungs
Parietal Layer: Lines inside of the
thoracic cavity, including the the
upper surface of the diagphram
Visceral Pleura: Lines the
pulmonary surface
8.
• Scalene Muscles-
Elevate first two ribs
• Sternocleidomastoid:
Raises the sternum
• Trapezius and
Pectoralis Muscles:
Manage the shoulder
9.
Diagnostic Sputum Collection
Studies Collection by expectoration or suctioning
Chest X-Ray: Anatomical location
and structure of the lungs Pre Procedure
•Check with facility protocol for collection
Pre procedure: •Obtain an early morning sterile specimen by
Remove all jewelry and other metal suctioning or expectoration after a respiratory
objects from the chest area treatment if a treatment is prescribed
Assess client’s ability to inhale and •Instruct the client to rinse the mouth with
hold his or her breath water before collection
Note: Assess for pregnancy status if •Instruct the client to take several deep
client is female breaths and cough deeply to obtain the
sputum
•Always obtain the specimen before the client
Post Procedure begins AB therapy
Help the client to get situated or
Post Procedure: Provide oral care
10.
Direct visualization of Larynx, trachea,
Pre Procedure Post Procedure
•Obtain informed consent •Monitor VS
•NPO at MN •Maintain patient in Semi-Fowler position
•Establish baseline VS •Assess for the return of gag reflex
•Assess the coagulation studies •Maintain NPO status until gag returns
•Remove dentures and eye glasses •Emesis basin readily available for sputum
•Prepare suction equipment •Monitor for bloody sputum
•IV access as needed for possible •Respiratory status- if sedated
sedation needs
•Complications: See below
v=XTC3AKmtrcs •Notify HCP: Fever, SOB, Dyspnea, other
complications
11.
Pulmonary Angiography:
Antecubital/Femoral vein to Pulmonary
Artery to
Pre Procedure
inject dye Post Procedure
•Obtain informed consent •Monitor VS
•Assess for allergies to Iodine, seafood, other radiopaque •Avoid taking BP for 24 hours in the
•NPO Status starting 8 hrs before
extremity used for injection
•Establish baseline VS •Monitor peripheral neurovascular
•Assess for coagulation studies
status of the affected extremity
•Establish IV access, sedation needs •Assess insertion site for bleeding
•Instruct the client to lie still during the procedure •Monitor for delayed reaction to
•Educate the patient that he or she may feel an urge to the dye
cough, flushing, nausea or salty taste following the
injection of dye
•Have EMERGENCY RESUSCITATION equipment available https://www.youtube.com/watch?
v=y1HYVnBY2q0
12.
Thoracentesis: Removal of fluid/air
from lungs
Pre procedure
Post Procedure
•Informed consent
•VS
•VS/Coagulation studies
•Respiratory status
•Prepare the client for US/CXR
•Apply pressure dressing and
•Position: Sitting Upright with the assess the puncture site for
arms and shoulder supported on a bleeding and crepitus
table at the bedside
•Monitor signs for pneumothorax,
•Position: If client cannot sit air embolism, and pulmonary
upright, patient supine toward the edema
unaffected side with the HOB
•Instruct the client to not to https://www.youtube.com/
cough, breathe deeply, or move watch?v=z0dCL4CHGSk
during the procedure
13.
Position During Thoracentesis
14.
Pulmonary Function Tests
Pre Procedure
•Determine if any sort of CNS depressant
•Evaluate lung mechanics administered to the patient before the test
•Gas Exchange •Withhold Bronchodilators
•Acid-base Imbalance through •Void before the test and wear loose clothing
Spiro metric measurements
•Remove Dentures
•Lung volumes
•Instruct the client to refrain from smoking or
•Arterial blood gas levels eating a heavy meal for 4-6hrs before the test
https://www.youtube.com/ Post Procedure
•Resume normal diet, bronchodilators and
respiratory treatments withheld prior to the
procedure
15.
Lung Biopsy: Needle Aspiration of
lung tissue to perform culture or
cytological analysis
Pre Procedure Post Procedure
•Obtain informed consent •Monitor VS
•NPO at MN •Apply dressing the biopsy site and
•Instruct the patient that local monitor for drainage and bleeding
anesthetic will be used for needle •Monitor for signs of respiratory
biopsy and sensation of pressure at distress and notify HCP if they occur
the insertion site during the •Monitor signs for Pneumothorax
procedure and Air Emboli- Notify HCP
•Pain mgx as needed •Prepare the client for CXR
16.
Ventilation-Perfusion Lung Scan aka VQ
Measures air and blood flow in your Post Procedure:
lungs •Monitor the client for any
Rule out a pulmonary embolism reaction to the radionuclide dye
Pre Procedure •Educate the patient that the dye
•Obtain Informed Consent will be cleared from the body
after 8 hours
•Assess for client allergies to dye,
iodine, seafood
•Remove jeweler from the chest area
•Review breathing method during
•IV access for sedation if needed
•Have emergency resuscitation
equipment available
18.
Skin Test Procedure: ID Injection for
Infec. Dis.
1. Determine hypersensitivity or previous reactions to skin tests
2. Use a skin site that is free of excessive body hair, dermatitis or blemishes
3. Apply the injection at the upper third of the inner surface of the left arm
4. Circle and mark the injection site
5. Document the date, time, and test site
6. Advise the client to not scratch the site to prevent infection or abscess
formation
7. Instruct the client to avoid washing the site
8. Study the test reaction at the site within 24-72 hours
9. Assess the site for the amount of induration in mm and for the presence of
erythema and vesiculation (small blister like elevations)
19.
Pulse Ox
POX < 91%- Notify HCP
POX < 85% - Body tissues have started to die- produce lactic acid
POX< 70% - Life threatening
20.
Respiratory Treatments
Chest PT Contraindications
•Percussion Unstable VS
•Vibration In ICP
•Postural Drainage Bronchospasm
To loosen the secretions from the Pathological Fractures
affected area to move them into
main airways to expectorate Rib fractures
them. Chest Incisions
21.
CPT Considerations
• CPT in the morning on arising, 1 hour before meals or 2-3 hours after meals
• STOP CPT IF PAIN OCCURS
if patient on enteral/tube feeding.
• First-stop the feed/////Second- Aspirate gastric contents/residual before the CPT
• Administer bronchodilators 15 mins before CPT
• Place a layer of clothing material on patient’s skin before starting the CPT
• Position the client for postural drainage based on CPT
• Percuss the area for 1-2 minutes
• Assess patient’s tolerance of the CPT
• Stop the procedure if patient is cyanotic or exhausted
• Maintain the position for 5-20 minutes after the procedure
• Dispose of Sputum and provide oral care
22.
Postural Drainage Positions
23.
Breathing Retraining: Decreased use of Accessory
muscles to decrease fatigue and increased
elimination of CO2
Pursed Lip Breathing Diaphragmatic Breathing aka
Exhaling through tightly pressed Abdominal/Belly Breathing/Deep
(pursed lips) and inhaling through Breathing
nose with mouth closed. Inhale slowly through nose
Place a hand over abdomen while
https://www.youtube.com/ inhaling, the abdomen should expand
watch?v=RxPRng3FRD4 with inhalation and contract during
exhalation
Note: The client should exhale
three times longer than inhalation https://www.youtube.com/watch?
by blowing through pursed lips v=0Ua9bOsZTYg
24.
Huff Coughing
• Gentle way of coughing
• Speeds air flow while you keep the throat open.
• https://www.youtube.com/watch?v=fqZUt3cAb0g
25.
Incentive • Device used to help you keep your lungs healthy after
surgery or when you have a lung illness, such as
Spirometer pneumonia.
• Teaches you how to take slow deep breaths
• https://www.youtube.com/watch?v=VHN5zPaw96w
Saunders (P 730)
• Sitting/ Upright Position
• Place the mouth tightly around the mouthpiece of the
device
• Instruct the client to inhale slowly to raise and
maintain the flow rate indicator between the 600-900
marks
• Instruct the client to hold the breath for 5 seconds
and then exhale through pursed lips
• Instruct the client to repeat this process 10 times
every hour
26.
Nasal Cannula for low flow: Used for clients with Oxygen
chronic airflow limitation and for long term use
Nasal Cannula for High Flow (NHF): Used for
Delivery
hypoxemic patients with mild to moderate Methods
respiratory distress
1-6 L/min
FiO2: 24% at 1L/min
FiO2: 44% at 6L/min
•Easily Tolerated/ Ease of use
•Assess for nasal mucosa irritation due to dry air
•Assess skin integrity as tubing can cause irritate
the skin: Look for pressure ulcer risk areas
•Add humidification for comfort measures
27.
Simple Face Mask: Used for short term for an
emergency situation
Oxygen Delivery
5-8 L/min at 24-55% FiO2 Methods
Need minimum 5L of O2 to flush CO2 from
the mask
•Inconvenient/ Confining
•Ensure mask fits securely over nose and
•Remove Saliva and mucous from the mask
•Provide skin care to area covered by mask
•Provide emotional support for anxiety due to
claustrophobic feelings
•Monitor for risk of aspiration from inability
to client to clear mouth i.e. if vomiting occurs
28.
Venturi Mask/Ventimask: Acute respiratory Oxygen
failure & Delivers exact desired selected
concentration of O2 Delivery
4-10 L/min at 24-55% FiO2 Methods
•Keep the air entrapment port for the adapter
open and uncovered to ensure adequate O2
•Keep mask snug on the face and ensure tubing
is free of kinks because the FiO2 is altered if
kinking or poor fitting of the mask
•Assess nasal mucosa for irritation, humidify or
aerosol can be added to the system for convert
29.
Partial Rebreather Mask: Used when O2 Oxygen
flow rate and concentration needs to be Delivery
raised. Contraindicated for COPD patients
6-15 L/min at 70-90% FiO2
Methods
•The client rebreathes 1/3rd of the
exhaled Tidal volume which is high in
oxygen thus providing high FiO2
•Adjust flow rate to keep the reservoir
bag 2/3rd full during inspiration
•Make sure the reservoir bag does not
twist or kink
•Deflation of the bag decrease oxygen
delivered but rebreathing of exhaled air
30.
Non Rebreather Mask: ARF with deteriorating Oxygen
respiratory status Delivery
O2 gauge to the max: > 15 L/min at 100% FiO2
Methods
•Adjust flow rate, Anxiety support- Claustrop.
•Remove mucus/saliva from the mask
•Ensure valves and flaps are intact and
functional during each breath (Valves should
open during expiration and close during
•Make sure the reservoir bag is patent and
Oxygen source is not disconnected- Pt will
suffocate to death
31.
Modes of
Non-Invasive Positive Pressure
Ventilation aka Bilevel Positive Airway
NO ET Tube or Tracheostomy Tube
Orofacial masks and nasal masks
https://www.youtube.com/watch?
32.
Modes of Ventilation
Continous Positive Airway Pressure
33.
Causes of Ventilator Alarms (BiPAP
or CPAP)
High-Pressure Alarm Low-Pressure Alarm
•Increased secretions are in the airway Disconnection or leak in the
•Wheezing or bronchospasm causing ventilator or in the client’s cuff,
airway to narrow compromised face mask seal
•ET Tube displaced
•Ventilator tubing occluded due to The client stops spontaneous
condensation of water or kinking breathing
•Client coughs, gags, bites on the oral ET
•Client is anxious or fights the ventilator
34.
Respiratory Assessment
35.
Normal Findings Deviations
•Skin Color •Pallor, cyanosis
•Even & Relaxed •Bulging or retracting
•Equal •Horizontal or > 90 degrees
•Rib Slope- Less than 90 degree downward •Uneven Labored, Brady or Tachypnea
•Even, 14-20 mins, unlabored
•Barrrel Chest > 1:2 or other conditions
•Anterior to Posterior to lateral diameter- <1:2
1:2 Ratio
•Depressed or projecting
•Shape & Position of Sternum: Level with
ribs •Deviated to one side
•Position of Trachea: Midline •Less than 3 inches during inspiration
•Chest expansion: 3 inches with deep
36.
Palpation: Perform this in three
Sensation: No pair or tenderness Deviation: Painful, tender, Inflammation
Pain over thorax when Inflamed Fibrous connective tissue
Pain over intercoastal area when pleura inflamed
Vocal/Tactile Fremitus: Client says “99”
Normal: Decreased vibration over periphery of lungs and increased over major
Deviation: Vibration increased over lung when consolidation, Vibration decreased
over major airways if obstruction, pleural effusion, and pneumothorax
37.
Palpation: Thoracic Expansion
• Place hands on posterior thorax at level of 10th vertebrae. Gently press skin
between thumbs and have client take deep breath. Observe thumb
movement.
• Repeat the process anterior aspect
Normal: Symmetrical expansion
Deviation: Asymmetrical Expansion
38.
Percussion: https://www.youtube.com/watch?
https://www.youtube.com/watch?
Normal
Resonance
Deviation
Hyperresonance: Emphysematous
lungs
Dullness over consolidated lungs
Lobar pneumonia, Pleural Effusion,
Tumor
39.
Crackles (Fine): brief,
Vesicular Sounds- Soft and Low discontinuous, popping lung
pitched with a rustling quality sounds that are high pitched.
during inspiration and even softer
•wood burning in a fireplace
during expiration
Early inspiratory or expiratory
crackles are hallmark signs of
https://www.youtube.com/ CHRONIC BRONCHITIS
Late inspiratory crackles may
mean Pneumonia, CHF or
Atelectasis
https://www.youtube.com/
watch?v=VGDdqtIhUdA
41.
Crackles (Coarse) aka Rales Wheeze
popping lung sounds but much Adventitious lung sounds that are
louder than fine crackels continuous with a musical quality.
Bubbling sounds High (Squeaky) or low pitched
(snoring or moaning)
Rolling strands of hair between
your finger Caused by the narrowing of the
airways
https://www.youtube.com/
watch?v=OlOwXqqah4I Asthma, Anaphylatic
https://www.youtube.com/
watch?v=MH4_xJtOPhU
42.
Auscultation
Rhonchi: Bronchial
Continuous, both inspiratory and Low pitched hollow, tubular
expiratory, low pitched adventitious Auscultated over the trachea
lung sounds that are similar to where they are considered
wheezes normal.
Snoring, gurgling or rattle-like quality
https://www.youtube.com/watch? Sounds like Vesicular
43.
Pleural Rubs Bronchovesicular Sounds
Discontinuous or continuous, Normal sounds in the mid-chest
creaking or grating sounds area or in the posterior chest
Walking on Fresh Snow between the scapula.
Leather on Leather type of sound
Localized on specific places of https://www.youtube.com/
chest wall watch?v=-LWha6S1j84
Pericardial Friction Rub
45.
Respiratory Disorders
Johncy Joseph, RN-BSN, MBA
Avenir Solutions, LLC
46.
Chest Injuries:
Rib Facture: Blunt Trauma to Chest
•Pain with movement and Chest splinting
•Impaired Ventilation and inadequate clearance of secretions
Pain and Tenderness at the injury site
Shallow respirations, Client splints chest, Fracture on Chest X-Ray
Ribs usually reunite spontaneously
Fowler position & Pain Management
Assess for respiratory status
Educate the patient about self-splinting with hands
Prepare the client for an intercostal nerve block
48.
Chest Injury: Flail Chest: Blunt
trauma to Chest
• Occurs with hemothorax and rib fractures
• Loose segment of the chest wall becomes paradoxical to the expansion and
contraction of the chest
Paradoxical Respirations:
Inward movement of lungs during inspiration
Outward movement of lungs with expiration
Severe Chest pain/Dyspnea/Cyanosis/Tachycardia/hTN
Tachypnea/Shallow Respirations
Diminished breath sounds
49.
Nursing Interventions for Flail Chest
• Fowler Position
• Humidified Oxygen
• Assess for increased respiratory status
• Encourage coughing and deep breathing
• Pain Mgx
• Maintain bed rest and reduce activity to reduce oxygen
demands
• Prepare for intubation with mechanical ventilation with PEEP
for severity of flail chest
52.
Chest Injury: Pulmonary Contusion
• Caused by interstitial hemorrhage associated with Intraalveolar hemorrhage
causing decreased pulmonary compliance
• Major complication: Acute Respiratory Distress Syndrome
Chest Pain/Dyspnea/Increased bronchial Secretions/Hemoptysis/
Restlessness/Decreased breath sounds/Crackles and wheezes
Maintain patent airway/ Oxygenation Therapy
Fowler position
Monitor for increased respiratory status
Reduce activity to reduce oxygen demand/ Mechanical Ventilation
54.
Pneumothorax: Air in the pleural cavity
Absent breath sound on the affected
Decreased chest expansion on the
affected side
Subcutaneous Emphysema evidenced
by Crepitus on palpation
Sucking sound with open chest wound
Tracheal deviation to the unaffected
side with Tension Penumothorax
55.
Pneumothorax: Nursing Intervention
• Apply a non-porus dressing over an open chest wound
area
• Administer Oxygen
• Place the client in Fowler’s Position
• Prepare the client for chest tube placement which will
remain in place until the lung has fully expanded
• Monitor Chest Tube Placement and drainage system
• Monitor for subcutaneous emphysema
56.
Air under the skin.
Subcutaneous: Tissue beneath
the skin
Emphysema: Trapped air
Usually benign- Does not
Catheters under the Subq to
release the air
Chest Tube in case of
Pneumothorax related
Subq Emphysema
57.
Acute Respiratory Failure
• Insuficient oxygen is transported to the blood or inadequate expulsion of CO2
from the lungs.
• Client’s compensatory mechanism fails
• Inability of the patient to breath/ventilate on their own need increased oxygen
and or mechanical ventilation
• ARDS is a very specific type of respiratory failure
Causes include:
Dysfunction in nerves and muscles that control breathing
Damage to the tissues and ribs around the lungs
Problems with the spine, such as scoliosis
Drug or alcohol overdose/Trauma
58.
Nursing Interventions for ARF
• Identify and treat the underlying cause of the
respiratory failure
• O2 administration to maintain PaO2, >70-60 mm of Hg
• Fowler’s Position/Deep breathing
• Administer Bronchodilators
• Prepare the client for mechanical ventilation, if patient
continues to deteriorate
61.
• Airways become inflamed, narrow
and swell, produce extra mucus,
which makes it difficult to
breathe.
• Chronic Inflammatory Disorder
• Hyper-responsiveness to triggers
• S/S
Wheezing, breathlessness, chest
tightness
Cough associated with airflow
Status Astamaticus: Life
Threatening
Asthma Can cause pneumothorax, Acute
https://www.youtube.com/ Cor Pulmonale Or Respiratory
Arrest
62.
Asthma
Environmental Medication Triggers
•Pet dander/Cockroaches/Dust •Aspirin (Acetylsalicylic Acid)
•Exhaust fumes/Fireplaces/Mold •B-blockers
•Perfume/Cologne/ POLLEN •NSAID
•Sudden weather changes Occupational Hazards
•Metal Salts
Physiological Factors •Wood and vegetable dust
•GERD •Industrial or chemical waste
•Hormonal Changes
•Sinusitis Food
•Stress •Sulfites
•Viral Upper Respiratory Infection •Beer, wine, dried fruit, shrimp, processed
potato
•Monosodium Glutamate
63.
Asthma Severity Classification
Mild Intermittent Moderate Persistent
•Symptoms may occur twice weekly or less •Daily Symptoms may occur
•Asymptomatic between exacerbations •Daily use of inhaled Anti Beta-blocker (Beta-
•Exacerbations are brief (hours to agonist)
days)/intensity can vary •Exacerbations occur at least twice weekly and
•Nocturnal Symptoms twice a month or less may last for days
•Nocturnal symptoms occur more frequently
than once weekly
Mild Persistent
•More than twice a week
Severe Persistent
•Exacerbations can impact activity
•Continuous symptoms
•Nocturnal more than twice monthly
•Physical activity require limitations
•Frequent exacerbations occur
•Nocturnal exacerbations occur frequently
64.
Asthma Treatment: Medication- Inhalers
Bronchodilators: Open the airways
• Ipratropium (Atrovent): Asthma and COPD
• Albuterol (Proventil): Treat or prevent bronchospasm
• Fluticasone/Salmeterol: Symptom management of Asthma and
COPD
• Salameterol (Serevent): Prevent asthma attack, exercised induced
bronchospasm, COPD
• Budesonide/Fomoterol (Symbicort): Asthma and COPD
• Ipratropium Bromide/Albuterol (Combivent): COPD
• Tiotropium (Spirivia): Treat or Prevent bronchospasm caused by
COPD, reduce flare ups of serious symptoms
• Levalbuterol (xopenex): Treat or prevent bronchospasm
65.
Bronchodilators: Relax smooth muscles of the
bronchi and dilate airways
Indication: Asthma, COPD and other restrictive airway diseases
Contraindicated: Hypersensitivity, PUD, Severe Cardiac Disease, Cardiac
Arrhythmias, HYPERTHYROIDISM and Uncontrolled Seizures
Caution: HTN, DM, or Narrow-angle Glaucoma
Examples: Albuterol (Proventil/Ventolin), Theophylline (Theolair), Salmeterol
(Serevent), Clenbuterol (Spiropent)
Theophylline interacts with Digoxin causing Digoxin toxicity, decrease lithium and
dilantin effectiveness
Theophylline interact with Beta blockers, Cimetidine (Tagament), erythromycin-
increasing the effect of Theophylline
Barbituates and Carbamezepine (Tegetrol)- Decreases the effect of Theophylline
66.
Side effects of Bronchodilators
• Palpitations and tachycardia
• Dysrhythmias
• Restelessness, Nervousness, tremors
• Anorexia, N-V
• HA and Dizziness
• Hyperglycemia
• Dry Mouth and Throat Irritation with inhalers
• Increased tolerance and paradoxical bronchoconstriction
with inhaler
67.
Nursing Interventions for
• Assess for VS and Breath Sounds and Cardiac Dysrhythmias
• Monitor for cough, wheezing, decreased breath sounds, and sputum production
• Monitor for restless and confusion and provide adequate hydration
• Administer the medication at regular intervals around the clock to maintain a
sustained therapeutic leve
• Administer oral medications with or after meal to reduce GI irritation
• Monitor serum Theophylline level = 10-20 mcg/ml
• Early signs of Theophylline Toxicity:
Restlessness/Nervousness/Tremors/Palpitations/Tachycardia
• IV Theophylline should be administered slowly with an IV pump
68.
Nursing Education for
• DO NOT CRUSH ENTRIC-COATED or SUSTAINED RELEASE TABLETS
• Avoid tea or caffeine/OTC medication that can cause palpitations or tachycardia
• Educate patient about smoking cesations
• To monitor the level of blood glucose if patient diabetic
• Wear a medic bracelet
• Educate patient how to use inhaler/spacer/nebulizer
• Educate patient about s/s of bronchodilators
69.
Asthma Treatment: Medication-
Steroids: Reduce inflammation or for tissue growth and
•Prednisone (Deltasone): Reduce inflammation
•Beclomethosone (Beconase): Prevent asthma attacks
•Fluticasone (Flonase): It can treat pain, itching, and swelling caused
by many skin diseases when applied topically. It can also prevent
asthma attacks when inhaled.
•Budesonide (Entocort, Pulmicort, Rhinocort): Used to treat Crohn’s
disease and Ulcerative Colitis, but can be used for asthma attacks
•Methylprednisolone (Solumedrol): Used as a anti-rejection med
70.
Asthma Treatment: Medication- Anti-
Anti-Inflammatory: Prevents or counteracts swelling (inflammation) in joints and
Zafirlukast (Accolate): Treat asthma and prevent attacks
Zileuton (Zyflo): Prevent and control asthma attacks
71.
Chronic Obstructive Pulmonary
Disease (COPD)
72.
S/S of COPD/ Nursing Assessment
• Cough/Sputum Production
• DOE
• Wheezing and Crackles
• Weight Loss
• Barrel Chest (Emphysema)
• Use of accessory muscle use
• Orthopnea
• Cardiac Dysrhythmias
• Congestion or hyperinflation lungs
• ABG Levels- What kind of Acid-Base Imbalance?
73.
Nursing Intervention for Acute COPD
Episode (P 739)
• Position the client in High-fowler position or sitting to
aid in breathing
• O2 as prescribed
• Stay with the patient decrease anxiety
• Bronchodilators
• Record the color, amount and consistency of sputum
• Corticosteroids
• Auscultate lung sounds before and after treatments
74.
Nursing Interventions of COPD
• Monitor VS/ POX/Weight
• Administer low O2, driving force of breathing in COPD patient low PO2
• Respiratory Treatments and CPT
• Educate the patient about diaphragmatic or abdominal breathing techniques and pursed
lip breathing techniques
• Record the color, amount and consistency of sputum
• Suction the client lungs if needed be
• Encourage small, frequent meals to maintain nutrition and prevent dyspnea
• High Calorie diet, high protein diet with vitamin supplements
• Keep fluid intake of 3L/day to loosen up secretions
• Bronchodilators
• Steroids for maintenance therapy
• Administer antibiotics for infections
75.
Discharge Education for COPD
• Activity as tolerated, plan rest periods with activity
• Avoid eating gas producing foods, spicy, and extremely hot or cold foods
• Avoid infections and crowds
• Avoid extreme temperatures
• Avoid environmental allergens- pet dander, feather, dust
• Avoid powerful odors
• Meet nutritional requirements
• Recognize the signs and symptoms of respiratory infections and hypoxia
• Use pursed-lip breathing or abdominal breathing
• When dusting, use a wet cloth
76.
• Inflammation of the bronchial tubes
• Excessive secretions of mucus into the Chronic Bronchitis
tube
• Tissue swelling that may narrow or
close off bronchial tubes
• Cough that occurs every day with
sputum production that lasts for at
least 3 months, 2 years in a row.
• Causes
Cigarette/Smoking
Occupational hazards
Environmental irritants- Pollution
• Treatments include bronchodilators,
steroids, and oxygen therapy.
77.
• Exhalation is slowed or stopped because Emphyse
over-inflated alveoli do not exchange gases ma
when a person breaths due to little or no
movement of gases out of the alveoli
• Emphysema changes the anatomy of the
lung- Loss of elasticity
• Barrel Chest- Hallmark
• Causes
Cigarette Smoking
Air Pollution
79.
Medication Inhalation Devices
• Metered Dose Inhaler (MDI): Uses a chemical propellant to push the
medication out of inhaler
• Dry Powder Inhaler (DPI): No chemical propellant but it requires strong and
fast inhalation
• Nebulizer: Delivers fine liquid mist through a medication tube or a mask that
fits over the nose and mouth, using air or oxygen under pressure
Note: If two different medications are to be inhaled. Administer
BRONCHODILATOR FIRST and then GLUCOCORTICOID
Note: If two different inhaled medications, then wait 5 minutes after the first
dose to inhale second med. If the two medications are same, wait 1-2 minutes
before taking the second dose.
80.
Metered Dose Inhalers: How to Use It
81.
Why use a Spacer?
Spacers can make it easier for medication
MDI with
to reach the lungs, and also mean less Spacer
medication gets deposited in the mouth
and throat, where it can lead to irritation
and mild infections.
Spacers should always be used with MDIs
that deliver inhaled corticosteroids.
82.
• Shake the inhaler well before use (3-4 shakes)
• Remove the cap from your inhaler, and from your spacer, if it has one
• Put the inhaler into the spacer
• Breathe out, away from the spacer
• Bring the spacer to your mouth, put the mouthpiece between your teeth and close your lips
around it
• Press the top of your inhaler once
• Breathe in very slowly until you have taken a full breath. If you hear a whistle sound, you are
breathing in too fast. Slowly breath in.
• Hold your breath for about ten seconds, then breath out.
83.
Some asthma medications can be taken in the form of a
dry powder using a small, hand-held device called a dry Dry Power
powder inhaler (DPI). Inhaler
Dry powder inhalers deliver medication to the lungs as
you inhale through the device.
84.
Severe Acute Respiratory Syndrome
• Respiratory illness caused by CORONAVIRUS – aka SARS associated coronavirus
• An outbreak of SARS in southern China/HongKong
Syndrome begins with Fever- bodyache and mild respiratory symptoms
Flu-like and may include fever, myalgia, lethargy symptoms, cough, sore
throat, and other nonspecific symptoms.
After 2-7 days client may develop dry cough and dyspnea
SARS may eventually lead to shortness of breath and/or pneumonia;
Person to person (direct exposure to infected material- contaminated droplets)
Travel to areas prominent with SARS virus (South East Asian Countries)
85.
Prevention of SARS: No Vaccine
• Handwashing
• Disinfection of surfaces for fomites
• Wearing a surgical mask
• Avoiding contact with bodily fluids
• Washing the personal items of someone with SARS in
hot, soapy water (eating utensils, dishes, bedding, etc.)
• Keeping children with symptoms home from school
86.
Infection of the pulmonary tissue, Pneumoni
including interstitial space- alveoli and
a
Edema associated with inflammation
causes stiffening of lung tissue resulting
lung compromise
Community Acquired
Hospital Acquired
CXR Finding: Lung Consolidation,
Pleural effusions, Pulmonary infiltrates
Lab Finding: Elevated WBC and ESR
87.
Assessment of PNA or S/S
• Chills
• Elevated temperature
• Pleuritic Pain: Pain that gets worse when you breathe, cough,
sneeze
• Tachypnea
• Rhonchi/Wheeze/Crackles
• Use of Accessory muscle use
• Mental Status Change
• Sputum production
88.
Nursing Interventions of PNA
• Administer O2 and monitor respiratory status
• Monitor for labored breathing, cyanosis, cold and clammy skin
• Encourage coughing and deep breathing/ use of IS/Semi-fowler position
• Turn and reposition patient as tolerated- Ambulate if you can to mobilize
the secretions
• CPT
• High calorie/High-Protein diet/ Fluids upto 3L/day
• Antibiotics as prescribed
• Antipyretics, Bronchodilators, Cough Suppressants, Mucolytic Agents,
Expectorants
• Hand Hygiene
89.
Patient Education about
• Patient must rest,
proper nutrition, and
adequate fluid intake
• Avoid individuals with
chilling and flu like
symptoms
• Received
Pneumococcal
vaccinations
90.
Influenza: Flu/ Highly CONTAGIOUS
• Yearly vaccination S/S
• Vaccination Acute onset of fever and bodyache
Contraindicated: HA/Fatigue/Weakness/Anorexia
People with Egg Sorethroat/Cough/Rhinorrhea
Allergy
• Hand Hygiene
Interventions
• Avian Flu: Bird flu
(H5N1) Encourage rest
• Swine Flu (H1N1) Encourage fluids to prevent pulmonary
complications
Monitor lung sounds
Antipyretics/Antitussives
Antiviral
91.
Person to person
is rare
cooling water
92.
A buildup of fluid between the tissues that line Pleural
the lungs and the chest. Effusion
Assessment or S/S
Pleuritic Pain
Progressive DOE
Dry non-productive cough caused by bronchial
irritation or mediastinal shift
Diminished breath sounds in the affected area
93.
Nursing Intervention of Pleural
• Identify and treat the underlying cause/Monitor the
breath sounds
• Fowler Position
• Encourage DB and Coughing
• Prepare the client for Thoracentesis
• Chronic Pleural Effusion- Pleurectomy or Pleurodesis
94.
• Fluid is thick/Opaque/Foul-smelling
• Pulmonary Infection/Lung Abscess Empyema: Collection
of pus pleural cavity
Focus on the infection
Emptying the empyema cavity
Re-expanding the lung
Recent fever or trauma
Chest pain/Cough/Dyspnea
Anorexia/Weight Loss
Malaise
Febrile and Chills
Night sweats
Pleural exudate on CXR
95.
Nursing Interventions
• Breath Sounds
• Semi to Fowler Position
• Encourage DB and Coughing/use of IS/Splint the chest
• ABs
• Thoracentesis or CT placement- Chest Expansion
Note : Pleural Thickening- Prepare the client for decortication
Decortication= Surgical procedure to remove restrictive mass of fibrin and
inflammatory cells
96.
• Inflammation of the visceral and parietal
membranes caused by Pulmonary infarction or
Pneumonia Pleurisy
• Pleuritic Pain
• Usually occurs on one side of the chest in th
lower lateral aspect
Knifelike pain aggravated on DB and Coughing
Pleural friction rub heard on Auscultation
Interventions: Same as Pleural
Effusion/Empyema
Instruct the client to lie on the affected side to
splint chest
97.
Risk factors
Pulmonary
•Prolonged Immobilization
Embolism
•Advanced age
•Hx of Thromboembolism
98.
• Apprehension and Restlessness/Sudden onset of Dyspnea
• Blood Tinged Sputum
• Chest Pain
• Cough
• Crackles and wheezes on auscultation/Cyanosis
• JVD
• Dyspnea with Anginal pain and pleuritic pain, exacerbated by inspiration
• Feeling of impending doom
• hTN
• Petechiae over the chest area and axila
• Shallow respiration
• Tachypnea and Tachycardia
• https://www.youtube.com/watch?v=0PEhvACEROI
99.
Nursing Interventions for PE: Medical
1. Notify the Rapid Response Team
2. Stay with the patient
3. Reassure the client and elevate the head of the bed
4. Prepare to administer oxygen
5. VS and check lung sounds
6. Prepare to obtain ABGs
7. Heparin Therapy
8. Document the event, interventions taken and the client’s response to
treatment
• Nursing Diagnosis- Impaired Gas Exchange related to decreased pulmonary
perfusion.
100.
Pulmonary fungal infection caused by Histoplasmo
spores of Histoplasma Capsulatam
sis
Transmission occurs by inhalation of
Spores are commonly found in
contaminated soil and bird droppings
Similar to PNA
Positive Skin Test for Histoplasmosis
Positive Agglutination test
Splenomegaly and Hepatomegaly
101.
Skin Test for Histoplasmosis
To check if you have been exposed to a fungus called Histoplasma Capsulatam
The fungus causes an infection called Histoplasmosis
The health care provider cleans an area of your skin, usually the forearm.
An allergen is injected just below the cleaned skin surface
The injection site is checked at 24 hours and at 48 hours for signs of a reaction
Occasionally, the reaction may not appear until the fourth day
Normal Results: No reaction
Abnormal Results: Induration
102.
Nursing Interventions for
• Oxygen/BS/DB and Coughing/Semi-fowler
• Antiemetics/Antihistamines/Antipyretics/
Corticosteroids
• FUNGICIDAL Medications
• Monitor for NEPHROTOXICITY from Fungicidal
Meds
• Instruct the client to spray the floor with water
before sweeping barn and chicken coops
103.
• The growth of tiny collections of Sarcoidosis: Can't be
inflammatory cells in different parts of the cured, but treatment
body
• Epitheloid Cell Tubercules in the lung
may help
• Cause is unknown but high titer of EBV
• Highest incidence in African-Americans
Assessment- S/S
Night sweats
Fever/Weight loss/Cough & Dyspnea
Skin Nodules
Kveim Test: Sarcoid Node Antigen (Allergen)
injected intradermal and causes a local
nodular lesion in about 1 month
104.
Occupational Lung Diseases: Exposure to
environmental pollutants/fumes
Occupational Asthma Pneumoconioisis- Silcosis aka
Coal Miner’s Disease (Black Lung)
Diffuse Interstitial Fibrosis – Asbestosis, Talcosis,
Berylliosis
Extrinsic Allergic Alveolitis- Farmer’s lung, Bird Fancier’s
Lung, Machine Operator Lung
Assessment and Treatment Based on Disease Process
105.
Tuberculosis: Highly Communicable- Mycobacterium
106.
Mycobacterium Tuberculosis
• Aerobic, non-motile, nonsporulating acid fast Rod bacterium that secretes Niacin
• Primarily affects upper lobes of the lungs- because of the high Oxygen content
• When bacillus reaches a susceptible site, it multiplies freely
• Bacteria can travel to brain, intestine, peritoneum, kidney, joints and liver
• Patients reports of s/s only when the disease is in its advance stages
• If not treated properly, bacteria can mutate into MDRO strain of TB (MDR-TB)
• Treatment Goal: Prevent transmission, control symptoms, prevent progression
Risk Factors
Children under 5 years of age/ Older Adults/Individuals with Drug/EtOH Abuse
Drinking unpasteurized milk from a cow infected with bovine Tuberculosis
Homeless individuals/ Crowded areas with minority group
Individuals who live in malnutrition, infection, immunocompromised
107.
•Airborne or Droplet
•Infected person coughs, laughs, sneezes or sings
•Exposed individuals are tested through PPD
•Two-three weeks after receiving TB medication, the risk of transmission is greatly
•Droplets enter in lungs, defense system of body encapsulate the bacteria creating scar
•Failure to encapsulate the bacteria, may cause the entry of bacteria in lymph nodes
causing inflammatory response known as GRANULOMATOUS INFLAMMATION
•Primary Lesions Form: Dormant but can get reactivated if exposed again
•Active TB can cause necrosis and cavitation in the lesions- rupture, spread of necrotic
tissue and damage to various parts of body
108.
What to ask a client if suspected of
• History of Tuberculosis?
• Client’s country of origin and travel to countries in which the TB
incidence is high?
• Recent history of influenza, pneumonia, febrile-illness, cough or
foul-smelling sputum
• Previous tests for TB- Results of the testing?
• Recent BCG administration
Note: Individuals with BCG will have positive Tuberculin Test, should be evaluated
further for TB with CXR
109.
S/S- Assessment- Clinical
• May be asymptomatic in primary infection
• Fatigue/Lethargy
• Anorexia/Weight loss
• Low Grade Fever/Chills
• Night Sweats
• Persistent cough and the production of mucoid and mucopurluent sputum,
possibly streaked with blood
• Chest tightness and dull aching chest pain accompanied with cough
• CXR- Not definitive, but multinodular infiltrates with calcification in the upper
lobes
• Auscultation (Advanced Disease): Bronchial breath sounds, Rhonchi, Crackles
• Wheezes- Partial obstruction of bronchus due to compression from lymph nodes
110.
TB Testing
Quantiferon TB- Gold Test: Blood test, sensitive and rapid test (24 hrs)- Diagnosis
Sputum Cultures: Acid fast smear.
Note: Sputum culture negative after three months of treatment
Mantoux SkinTest/PPD: Intradermal injection of Purified Protein Derivative
Induration > or = 5 (Positive test for Immunocompromised patients)
Indutation > or = 10 (Positive test for immigrants, residents, employees, children<4
Indutation > or = 15 (Positive test for anyone else)
Positive skin test requires a CXR to rule out active TB
111.
Hospitalized Client with TB
• Airborne and Droplet Isolation- N95 Mask (Particulate Respirator- Fitted)
• Negative pressure room- Door of the room must be tightly shut
• The room should have at least 6 exchanges of fresh air and ventilation to outside
environment
• Hand Hygiene
• Client must wear a surgical mask if the TB patient needs to leave the room for a
procedure
• Respiratory isolation discontinued once he or she is no longer considered
infectious
• 2-3 weeks post TB medication, transmission is greatly reduced
112.
Client Education: TB
• Educate the client to follow the medication regimen exactly as prescribed
• Always have medication supply on hand/Through Hand Hygiene –family included
• Medication regimen is continued over 6-12 months
• Educate the client of TB medication side effects
• Reassure the client, post 2-3 weeks treatment, he or she is unlikely to infect anyone
• Educate patient about adequate nutrition, well balanced diet to promote healing and
prevent recurrence of the infection
• Increase intake of food rich in iron, vitamin C and protein
• Instruct the client to cover mouth while coughing, sneezing and put tissues in plastic bags
• Sputum culture is needed every 2-4 weeks after the initiation of treatment
• When three sputum culture is negative, patient is no longer considered infectious
• Avoid excessive exposure to Silicone or dust because they can further cause lung damage
• Treatment compliance is essential, follow-up care and sputum cultures as prescribed
113.
TB Medications
• Treatment is difficult because the bacterium has a waxy substance on the capsule
that makes penetration and destruction difficult
• Multidrug regimen is used to destroy the organism asap
• Individuals with active TB for 6-9 months (Immunocompromised patients take
longer)
• Post 2-3 weeks of treatment patient becomes low risk of transmission
• Sputum culture becomes negative after three months of treatment
• Individuals who have been exposed to active TB are treated with PREVENTIVE
ISONIAIZID for 9-12 months
• TB is treated with two lines of drugs: First Line and Second Line of Drugs
114.
First Line of Medications for TB
(Most Effective)
Saunders Page 759- 765
•Rifampin (Rifadin)
•Ethambutol (Myambutol)
•Rifabutin (Mycobutin)
•Rifapentine (Priftin)
115.
Isoniazid: Bactericidal: Inhibits Mycolic Acids
Contraindications: Side effects:
Hypersensitivity & Acute Liver Disease •Hypersensitivity Reactions
•Peripheral Neuritis/Neuropathy
Caution: •Neurotoxicity
Hepatic Disease/Alcoholism/ Renal •Hepatotoxicity- Check Liver Functions
Impairment •Pyridoxine (Vitamin B6) Deficiency
•Irritation at the injection site
•N-V/ Dry Mouth
•Dizzines/ Hyperglycemia
•Vision Changes
116.
• Assess for hypersensitivity/Mental Status/Visual Changes
• Assess for hepatic dysfunction
• Assess for sensitivity of Nicotinic Acid
• Assess for liver function test
• Monitor for signs of Hepatotoxicity: Anorexia, N-V, Jaundice, Dark Urine, Yellow
S
• Monitor for tingling, numbness or burning of the extremities
• Assess for dizziness and initiate safety precautions
• CBC and BG levels
• Administer 1 hr before or 2 hrs after the meal to increase absorption.
• Administer 1 hr before antacids
• Administer Pyridoxine to reduce Neurotoxicity
117.
Client Education Regarding Isoniazid
• Medication compliance utmost importance
• Not to take any other medication without consulting with the
provider
• Avoid Alcohol
• Take medication on an empty stomach with 8oz of water 1 hour
before or 2 hours after meal and any antacids
• Avoid Tyramine-containing food because it can cause red and
itching skin, pounding heartbeat, light headedness, hot/clammy
skin
• Recognize signs of neurotoxicity, hepatitis, hepatotoxicity (Notify
Provider)
118.
Rifampin (Rifadin): Inhibits bacterial RNA
Contraindicated: Side Effects
Clients with Hypersensitivity to Rifampin Hypersensitivity Reaction
Acid reflux, N V D
Caution: RED ORANGE COLORED BODY
Hepatic Disease SECRETIONS (Urine/Sweat)
Alcoholism Vision Changes
Hepatotoxicity and hepatitis
Rifampin decreases the effect of many Increased uric acid levels
medications Colitis
Oral Anticoagulants, Oral Hypoglycemics Blood Dyscrasias
Digoxin (Lanoxin), Flucanazole (Diflucan)
Dilantin, Verapamil Hydrochloride
119.
Ethambutol (Myambutol):
Interferes with cell metabolism and multiplication by inhibiting one or more
Inhibits RNA Synthesis and is only active during cell division
Slow acting, and must be with other bactericidal agents
Contraindication: Children< 13 years, Hypersensitivity, Optic Neuritis
Caution: Renal Failure, Gout, Ocular Disease, Diabetic Retinopathy, cataracts, or
ocular inflammatory conditions. Patient taking neurotoxic medications because
neurotoxicity increases
Side effects: Same as Rifampin, In addition- Joint pain, Thrombocytopenia,
anaphylactoid reaction (same as anaphylactic reaction)
121.
Chest Tube
Johncy Joseph, RN-BSN, MBA
Avenir Solutions, LLC
122.
Chest
Tube
• Hollow, flexible tube placed
into the chest
• Indication: Drain blood, fluid,
or air from around your
lungs, heart, or esophagus
• Placed between ribs and
pleural cavity
• Creates a vacuum to suck out
air and blood
• https://www.youtube.com/
watch?v=qR3VcueqBgc
• https://www.youtube.com/
watch?v=mBI1XE14fDE
123.
Chest Tube Mechanism: 3-Chamber
• Normal Breathing works
on Negative Pressure
• Every chest tube will
have 3 chambers
1. Collection
2. Water Seal
3. Suction Control
124.
• Assess the drainage
amount q 4 hours or q shift,
using a piece of white Tape
• Drainage should be
serosanguinous
• Notify MD if drainage is
BRIGHT RED (Hemothorax)
• Notify MD if drainage is >
100 ml/hr
125.
It has about 2 cm of Water in it
Water Seal
Serves as a one way valve
Allows air to exit from the Chamber
Water prevents the escaped air
to go back to the patient
Continuous BUBBLING- Bad Sign
Indicates- Air leak- Notify Provider
Gentle TIDALING: Good (inhaling
and exhaling)
126.
Applying suction to the patient
as prescribed by the provider Suction Control
Chamber
Water in the Suction Chamber
as well
Depending on the height of
the water, provider can
increase or decrease the
suction power
BUBBLING = GOOD
(Suction is working)
No bubbling= No suction
127.
Suction Types
Wet Suction Dry Suction
• Water in the suction chamber • No water in the suction chamber
for suction • Suction is controlled by suction
• Gentle Bubling- Suction Workin from the wall
• No Bubling- No Suction
128.
Chest Tube Consideration
• Chest tube always below chest level on the ground to promote drainage (Do not hang or suspend it
from anywhere)
• Encourage client to cough and deep breath/Reposition them q hour to facilitate drainage
• CXR to confirm the position of the tube and expansion of lung
• Monitor the lung sounds and respiratory status
• Monitor for signs of extended pneumothorax or Hemothorax
• Do not strip/milk the CT unless specified/Clamp the CT without HCP approval
• Keep a clamp and a sterile occlusive dressing at the bedside at all times
• If air is leaking- Clamp of the Chest tube for one minute while RN assess for leaks
• If CT dislodge from the apparatus- insert the chest tube into a bottle of sterile water, replace it with a
new system
• If the CT is accidentally pulled out- Pinch the skin together, apply an occlusive sterile dressing, cover the
dressing with overlapping pieces of 2inch tape and call the HCP immediately. Tape from three sides.
• When removing CT - Ask the client to take a deep breath and hold it. After removing the tube, a dry
sterile dressing, petroleum gauze (Tefla) to seal the wound (sometime patients are asked to bear
down)
+1-315-636-4485
+91 98151-74050 
