Respiratory Anatomy & Physiology General Respiratory Anatomy and Physiology The respiratory system is comprised of the upper

r airway and lower airway structures The upper respiratory system filters, moistens and warms air during inspiration The lower respiratory system is the site of gas exchange, regulating the body's oxygen (PaO2) and carbon dioxide (PaCO2) levels and acid-base (pH) balance Gas-exchange in the respiratory system occurs in the alveoli and pulmonary capillaries Physiology of Breathing Inspiration: an active process contraction of the intercostal muscles and diaphragm expands the chest intrathoracic pressure decreases, drawing oxygenated air through the upper airway into the lungs Expiration: a passive process relaxation of the intercostal muscles increases intrathoracic pressure carbon dioxide, a waste product of metabolism, is exhaled from the lungs through the upper airway Gas exchange of oxygen and carbon dioxide occurs through diffusion across the alveolar-capillary membrane Neural control of breathing occurs through chemoreceptors in the medulla stimulated by the concentration of hydrogen ions in the blood increased hydrogen levels (acidosis) stimulate increased respiratory rate and volume - "blows off" acid (CO2) Chemical control of breathing occurs through chemoreceptors in the carotid arteries and aortic arch decreased blood pH and oxygen levels and increased carbon dioxide levels stimulate the respiratory center in the medulla Respiratory Anatomy & Physiology General Respiratory Anatomy and Physiology The respiratory system is comprised of the upper airway and lower airway structures The upper respiratory system filters, moistens and warms air during inspiration The lower respiratory system is the site of gas exchange, regulating the body's oxygen (PaO2) and carbon dioxide (PaCO2) levels and acid-base (pH) balance

Gas-exchange in the respiratory system occurs in the alveoli and pulmonary capillaries Physiology of Breathing Inspiration: an active process contraction of the intercostal muscles and diaphragm expands the chest intrathoracic pressure decreases, drawing oxygenated air through the upper airway into the lungs Expiration: a passive process relaxation of the intercostal muscles increases intrathoracic pressure carbon dioxide, a waste product of metabolism, is exhaled from the lungs through the upper airway Gas exchange of oxygen and carbon dioxide occurs through diffusion across the alveolar-capillary membrane Neural control of breathing occurs through chemoreceptors in the medulla stimulated by the concentration of hydrogen ions in the blood increased hydrogen levels (acidosis) stimulate increased respiratory rate and volume - "blows off" acid (CO2) Chemical control of breathing occurs through chemoreceptors in the carotid arteries and aortic arch decreased blood pH and oxygen levels and increased carbon dioxide levels stimulate the respiratory center in the medulla Upper respiratory structures Nose and sinuses

filters, warms and humidifies air first defense against foreign particles inhalation for deep breathing usually occurs through the nose exhalation usually occurs through the mouth Pharynx behind oral and nasal cavities nasopharynx behind nose soft palate, adenoids and eustachian tube oropharynx from soft palate to base of tongue palatine tonsils laryngopharynx base of tongue to esophagus where food and fluids are separated from air bifurcation of larynx and esophagus Larynx between trachea and pharynx commonly called the voice box vocal cords - responsible for voice, airway protection and control of airflow through trachea glottis - opening between vocal cords epiglottis - covers airway during swallowing, protecting against aspiration thyroid cartilage - Adam's apple cricoid cartilage contains vocal cords

the only complete ring in the airway Lower respiratory and other structures Trachea anterior neck in front of esophagus carries air to lungs

Mainstem bronchi right and left older adults - right middle lobe is most likely to receive aspirate in people with swallowing difficulty Conducting airways lobar bronchi surrounded by blood vessels, lymphatics, and nerves lined with ciliated, columnar epithelial cells

cilia move mucus or foreign substances up to larger airways bronchioles no cartilage; collapse more easily no cilia do not participate in gas exchange Alveolar ducts and alveoli

lungs contain approximately 300 million alveoli alveoli surrounded by capillary network

gas exchange happens at alveolar-capillary membrane (blood takes in O2, gives off CO2) alveoli are held open by surfactant which decreases surface tension to minimize alveolar collapse Accessory muscles of respiration - use indicates additional effort needed to breathe scalene muscles - elevate first two ribs sternocleidomastoid - raises sternum trapezius and pectoralis - stabilize shoulders abdominal muscles - puts power into cough and used most often with chronic respiratory problems and acute severe respiratory distress In infants - nasal flaring, sternal or intercostal retractions, grunting Listen older adults - respiratory changes with age include stiffening and reduced function of respiratory structures reduced capacity of respiratory defense mechanisms less effective respiratory control

Upper Respiratory System Disorders

Rhinitis Definition: inflammation of the mucous membrane of the nose marked especially by rhinorrhea, nasal congestion and itching, and sneezing Etiology allergic (often called "hay fever") - caused by a exposure to various factors including environmental allergens, i.e. dust, mold, dander, pollen infectious - caused by cold viruses, bacterial infections Findings excessive nasal drainage and congestion, postnasal drip with sore throat allergic causes: nasal itchiness and sneezing, watery eyes viral causes (common cold): sore throat, general malaise, fever, chills, headache bacterial causes: purulent nasal discharge, fever. Diagnostics: history of findings, type and color of drainage Management identify the cause

relieve findings using antihistamines, decongestants, NSAIDs if headache bacterial causes: anti-infectives allergic causes: reduction of exposure to allergic causes and desensitization immunizations or treatments viral or bacterial causes: encourage more fluids rest

salt water gargles, vitamin C, zinc Nursing interventions administer prescribed medications for relief

teach client environmental reduction of allergens specific medication information hand washing to avoid the spread of the common cold

Sinusitis Definition: inflammation of one or more of the paranasal sinuses

Etiology viral or bacterial upper respiratory infection tooth infection allergic rhinitis sniffing aerosols/powders structural defects of the nose underwater swimming Findings frontal headache tenderness over the affected sinus(es), especially when palpated or percussed purulent nasal drainage and congestion nasal obstruction malaise tooth pain fever Diagnostics: x-ray or CT shows fluid in sinuses and mucous membrane swelling Management

pharmacologic nasal saline decongestants nasal corticosteroids mucolytics antihistamines

antibiotics analgesics antipyretics surgery to drain and open sinuses antral irrigation (sinus irrigation) functional endoscopic sinus surgery Nursing interventions administer (and teach) about taking prescribed medications encourage fluid intake (non-carbonated, non-alcoholic) of at least 6 to 8 (8 ounces) glasses daily nasal cleaning techniques: hot showers, steam inhalation or nasal irrigation with saline spray followed by nose blowing nasal irrigation as needed client teaching importance of promoting sinus drainage proper use of antibiotics with follow-up if no symptom resolution reduction of environmental factors if allergies contribute Upper airway obstruction - partial or complete This is a MEDICAL EMERGENCY! Etiology aspiration of food or foreign body laryngeal edema secondary to anaphylactic allergic response trauma Findings stridor (harsh, vibrating sound during inspiration)

Listen inability to talk with complete obstruction restlessness accessory muscle use both hands of client around the throat tachycardia skin color changes, i.e. pallor, cyanosis in children, prolonged hypoxemia results in cardiac arrest secondary to inadequate ventilation, oxygen or circulation

Diagnostics: observations at time of occurrence Management: emergency treatment airway clearance techniques conscious victim

infants (less than 1 year): back blows and chest thrusts

younger children: modified Heimlich maneuver ("astride") older children & adults: Heimlich maneuver unconscious victim - begin CPR endotracheal intubation cricothyrotomy (cut cricoid cartilage) tracheotomy/tracheostomy Nursing interventions: basic life support guidelines for obstructed airway Pharyngitis Definition: inflammation of mucous membranes of pharynx Etiology: viral, bacterial or fungal infections beta-hemolytic strep accounts for 5-15% of cases and untreated may result in rheumatic heart disease or glomerulonephritis Findings scratchy throat throat pain, often severe, worsened by swallowing pharynx can appear red and edematous with or without patchy white or yellow exudates

Diagnostics: throat cultures and/or rapid strep antigen test Management pharmacologic antimicrobial therapy - penicillins for strep throat (erythromycin if allergic to penicillin) antifungal therapy such as nystatin for fungal causes analgesics such as ibuprofen or topical anesthetic sprays or lozenges symptomatic relief prevent secondary complications Nursing interventions administer prescribed medications encourage increased fluid intake of cool, bland liquids and gelatin; avoid citrus juices and carbonated beverages teach importance of taking all of prescribed antimicrobials to avoid complications of strep infection Tonsillitis and adenoiditis Definition: inflammation and infection of the tonsils and especially the palatine tonsils Etiology: acute form is usually bacterial; typically viral in association with pharyngitis Findings sore throat - may be recurrent fever difficulty swallowing enlarged tonsils and adenoids - may be "kissing tonsils" (where they are touching) foul smelling breath (halitosis) noisy respirations - snoring loudly during sleep if enlarged adenoids recurrent ear infections

Diagnostics: positive throat cultures for causative microbes Management

anti-infectives, antipyretics, analgesics fluids, rest tonsillectomy and/or adenoidectomy if indicated (recurrent infections) Nursing interventions administer medication as prescribed provide postoperative care after tonsillectomy/adenoidectomy observe for postoperative complications (hemorrhage, airway obstruction) provide positioning that allows for comfort and drainage of mouth and pharynx (prone, head turned to the side) maintain ice collar for comfort client and family teaching findings of hemorrhage - frequent swallowing use of prescribed mouthwashes and pain medications

semi-liquid diet 48 to 72 hours postoperative

6. Peritonsillar abscess o Definition: complication of acute tonsillitis or pharyngitis with spread of tonsillar infection into the surrounding tissue o Etiology: untreated bacterial tonsillar infection o Findings inability to swallow saliva with drooling marked tonsillar enlargement, possibly threatening airway "hot potato" or muffled voice high fever and chills increased white blood cell count facial swelling o Management intravenous antibiotics drainage of abscess possible emergency tonsillectomy Nursing interventions monitor airway patency and resolution of infection administer prescribed medications

Complementary and Alternative Medicine Herbal remedies for upper respiratory infections Echinacea (dried root or tea) Garlic cloves Horseradish Slippery elm tea Alternate systems of care for upper respiratory infections Ayurveda Acupuncture Cupping

Complementary and Alternative Medicine Traditional Chinese medicine

7. Vocal cord disorders o Laryngitis definition: inflammation of vocal cords and surrounding mucous membranes etiology irritation of the larynx due to chemical, mechanical, infectious or allergic causes common with upper respiratory infections croup and epiglottitis are types of laryngeal inflammation that can lead to airway obstruction requiring emergency treatment findings hoarse voice swollen lymph nodes in neck (cervical lymphadenopathy) fever
larynx blocked by edema, spasm or both management rest voice treat findings gargle with warm salt water remove irritants

cool or moist air may bring relief, steamy bathroom, outside in the cool night air, cool air vaporizer Vocal cord paralysis etiology injury, trauma or disease of larynx, laryngeal nerves or vagus nerve may result as a complication after thyroidectomy surgery or endotracheal intubation damage to both laryngeal nerves may lead to airway obstruction emergency treatment needed! findings: hoarse voice, difficulty swallowing diagnostics: laryngoscopy shows abnormal vocal cord movement. management swallowing evaluation to assess for aspiration voice therapy surgical treatment - to improve the voice by changing the position of the paralyzed vocal cord

8. Disorders of Lower Respiratory System - Obstructive

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Chronic obstructive pulmonary disease (COPD) Definition: chronic irreversible airway obstruction with slowed exhalation

emphysema - walls of alveoli enlarge and lose elasticity, trapping air and decreasing capacity for vital gas exchange

chronic bronchitis - chronic inflammatory response in the bronchioles of the lung cor pulmonale, with right heart failure, is a late complication of COPDrelated pulmonary hypertension Etiology primary cause of COPD - environmental, due to smoking tobacco 3% of emphysema cases - genetic (due to alpha-1 antitrypsin deficiency), occur without tobacco exposure Findings cough sputum production, purulent with acute infection dyspnea on exertion - may occur with minimal activity or at rest in advanced stages and with acute exacerbation use of accessory muscles of breathing, particularly with severe COPD or respiratory distress restlessness with respiratory difficulty or distress anxiety barrel chest (increased anterior-posterior diameter) weight loss if breathing difficulty interferes with eating Diagnostics spirometry and other pulmonary function tests chest x-ray sputum examination

arterial blood gases: increased PaCO2, decreased PaO2 low oxygen saturation levels with higher hematocrit

9. Management

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reduction of risks - tobacco smoking cessation or reduction of exposure to tobacco smoke and other inhaled environmental irritants

pharmacologic treatments inhaled bronchodilators - albuterol (beta-adrenergic), ipratropium (anticholinergic) inhaled or oral corticosteroids - prednisone (IV during exacerbations), methylprednisolone (Medrol) expectorants - guaifenesin o supplemental oxygen therapy - oxygen is titrated to lowest dose needed to maintain oxygen saturation around 90% with rest, exercise, and sleep o pulmonary rehabilitation exercise program o airway clearance techniques - effective coughing, chest physiotherapy, postural drainage, vibration o surgery - lung volume reduction surgery for emphysema 10. Nursing interventions o client and family teaching diaphragmatic breathing pursed-lip breathing inspiratory muscle training controlled coughing pacing of daily activities physical conditioning small frequent meals with nutritional supplements avoid temperature and humidity extremes, air pollution, and high altitudes o check oxygen saturation at rest and with activity - administer oxygen at the lowest dose needed to maintain oxygen saturation at least 90% with rest, exercise and sleep o monitor for complications of COPD respiratory insufficiency respiratory failure dysrhythmias pulmonary infections cor pulmonale 11. Asthma o Definition: a chronic lung disorder marked by recurrent episodes of bronchospasmrelated airway obstruction triggered by hyperreactivity to various stimuli, producing airway narrowing and tenacious, thick, excess, mucous

characterized by remissions and exacerbations exacerbations - more prevalent during particular seasons, especially with extrinsic and infectious etiologies, i.e., ragweed season, cold or flu season

one of the most common chronic pediatric health problems Etiology extrinsic: asthma associated with inflammation and reactivity in response to a specific environmental exposure cold air humidity allergens such as pollens, molds, dust mites, animal dander drugs: aspirin & NSAIDs intrinsic: asthmatic inflammation and reactivity in response to physical stimuli respiratory infection exercise gastroesophageal reflux-related aspiration stress 12. Findings o with asthma exacerbation (expiratory) wheezing, often audible - wheezing may decease or stop with o

worsening bronchoconstriction as airflow becomes severely limited Listen shortness of breath cough with sputum production normal or low oxygen saturation chest tightness tachycardia use of accessory respiratory muscles with respiratory distress high normal PaCO2 and low normal PaO2 findings with exposure to trigger shortness of breath

coughing chest tightness wheezing with bronchospasm

13. Diagnostics o acute phase physical examination and history serum studies - arterial blood gases chest x-ray: hyperinflation, flattening of diaphragm pulmonary function tests: decreased FEV1, prolonged expiratory phase, reduced peak expiratory flow rate o chronic phase peak expiratory flow rate monitoring to guide therapy and identify when to seek care. allergy testing: skin prick or serum RAST testing, IgE to identify allergic triggers pulmonary function tests: bronchial reactivity challenge testing with methacholine or specific antigen to identify severity of airway reactivity bronchoscopy o complications in acute or remission phases hypoxemia - low PaO2 hypercapnia - high PaCO2 recurrence of other respiratory infections respiratory failure absence of wheezing may be an indication of absence of airflow - emergency respiratory care is needed with possible intubation 14. Management
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pharmacologic therapy long-acting control medications inhaled corticosteroids (ICS) - fluticasone, beclomethasone long-acting beta agonists (LABA) - salmeterol leukotriene antagonist - montelukast anticholinergic inhaler - tiotropium mast cell stabilizers - cromolyn sodium inhaler short-acting "rescue" medications short-acting beta agonists (SABA) as needed - albuterol inhaler or nebulizer exacerbation: oral (prednisone) or intravenous corticosteroids (methylprednisolone) with tapering dose as exacerbation resolves peak flow monitoring

oxygen for acute management anti-allergy therapy (immunotherapy) 15. Nursing interventions o client and family teaching diaphragmatic breathing pursed-lip breathing inspiratory muscle training controlled coughing pacing of daily activities physical conditioning avoid temperature and humidity extremes, air pollution, and high altitudes small frequent meals with nutritional supplements o evaluate need for home oxygen therapy at rest and with activity
o o

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asthma action plans and medication administration plans - include the school monitor for complications of COPD respiratory insufficiency respiratory failure dysrhythmias pulmonary infections cor pulmonale

16.
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Restrictive Respiratory Disorders

Overview Definition: irritants, e.g., toxic drugs, radiation, and industrial substances, cause damaging inflammation of the alveoli and interstitial tissue of the lungs; as a result, the lungs become scarred, stiff, and non-compliant Intrapulmonary restrictive conditions - abnormality of lungs, pleura or pleural cavity lung expansion restricted through stiffening of the lung tissue (pulmonary fibrosis, pulmonary sarcoidosis) air or fluid occupying the pleural cavity causes lung tissue to collapse (pneumothorax, hemothorax, pleural effusion, empyema)

Extrapulmonary restrictive conditions - lungs are normal; restriction occurs through respiratory muscle weakness or external compression of the chest wall neuromuscular conditions that cause respiratory muscle weakness (spinal cord injury, muscular dystrophy, GuillainBarr, Myasthenia Gravis, poliomyelitis, amyotrophic lateral sclerosis) central nervous system conditions that impair the respiratory center (head injury, CNS lesions, opioids) 17. Intrapulmonary restrictive conditions o Pulmonary fibrosis: intrapulmonary disorder of lung stiffening, with various etiologies idiopathic pulmonary fibrosis: chronic, progressive disorder of lung with inflammation and scarring occupational lung diseases coal worker's pneumoconiosis - risk increases with length of exposure to coal dust (>15 years), intensity of exposure, and silica content of dust silicosis: workers who have inhaled silica dust asbestosis 1. inhalation of asbestos fibers 2. disease may develop 15 to 20 years after exposure 3. high risk for mesothelioma (lung cancer specific to asbestos) findings of pulmonary fibrosis exertional dyspnea nonproductive chronic cough chronic inspiratory crackles nail clubbing possible o Sarcoidosis: intrapulmonary disorder of lung characterized by formation of granulomas in the lungs, as well as heart, lymph nodes, bones and skin; may progress to fibrosis of lungs etiology: unknown; 3 to 4 times more prevalent in African Americans findings of sarcoidosis may be asymptomatic dyspnea cough chest pain o Diagnostics for intrapulmonary restrictive conditions chest x-ray, chest CT - pulmonary lymph node enlargement and pulmonary infiltrates pulmonary function tests - used for disease staging and to guide treatment decisions bronchoscopy or closed lung biopsy - pulmonary granulomas o Management of intrapulmonary restrictive conditions corticosteroid therapy to suppress the inflammatory response avoid environmental exposure to inhaled irritants proper use of personal protective respiratory equipment with high-risk occupations and hobbies Nursing interventions for intrapulmonary restrictive conditions prevent infection or exposure to infection including immunization to prevent influenza and pneumonia instruct client to pace activities to reduce oxygen demands and dyspnea administer oxygen as needed for hypoxemia and dyspnea, particularly in advanced stages of disease

reinforce the need for small, frequent meals in advanced stages encourage daily activities and exercise within pulmonary tolerance provide referrals depression associated with disease smoking cessation support groups pulmonary rehabilitation occupational rehabilitation 18. Disorders in which lung tissue collapses o Definition: any number of disorders in which the pleural space is abnormally occupied by air or fluid, resulting in reduced lung capacity

Etiology of disorders in which lung tissue collapses pneumothorax: air in the pleural space, causing lung collapse open pneumothorax: air enters the pleural space through a hole in the chest wall, e.g., gunshot wound closed pneumothorax: air enters the pleural space through a hole in the lung tissue, i.e., after lung resection tension pneumothorax: closed pneumothorax with rapid accumulation of air in pleural space, increasing pressure 1. high pressure causes mediastinal and tracheal shift away from the affected side, compressing the heart and preventing adequate cardiac output 2. results in cardiac tamponade (and possibly pulseless electrical activity) - emergency situation!
all types of pneumothorax - treated with chest tube insertion pleural effusion: fluid (transudate or exudate) in the pleural space; treated with thoracentesis or chest tube hemothorax: blood in pleural space; treated with thoracentesis or chest tube empyema: purulent drainage in pleural space; usually a complication of pneumonia, treated with chest tube and antibiotics

chylothorax: milky white lymphatic fluid in pleural space, treated with thoracentesis or chest tube, pleurodesis or surgery 19. Findings: worsening respiratory distress o asymmetrical chest movement o progressive dyspnea o diminished or absent lung sounds on affected side o low oxygen saturation levels o fatigue and activity intolerance o tachycardia o restlessness, anxiousness o chest pain o progressive cyanosis 20. Diagnostics o chest x-ray that supports diagnosis
o

white blood cell count - high in empyema

o HCT/HGB - below baseline in hemothorax 21. Management o treatment of cause o placement of chest drainage device o thoracentesis with or without chest drainage device in pleural effusion or hemothorax 22. Nursing interventions o position client for comfort and to promote ease of breathing o monitor respiratory status and effort o administer pain medications as ordered

maintain/monitor chest tube and closed chest drainage system ensure that the chest tube drainage system is closed, has no leaks, all connections are taped or secured, and there are no kinks or dependent loops in the tubing monitor volume and characteristics of drainage - notify care provider if drainage exceeds 70-100 mL/hour keep the collection device below chest level or insertion site at all times fluctuations of the water level with client's respirations (tidaling) is an expected finding do not routinely strip tubing occlusive dressing - prevents air from entering pleural space through insertion site (reinforce as necessary) ensure that client has appropriate chest x-rays - daily, following changes to chest tube status and when tube is removed 23. Neuromuscular diseases that affect breathing o GuillainBarr syndrome (see also Lesson 8 C: Neurological - Degenerative Disorders) definition: a group of autoimmune peripheral neuropathies resulting in symmetric and ascending motor paralysis; an acute condition; potentially fatal if respiratory muscles are affected etiology: unknown; often follows stimulation of immune system such as after an infection, surgery, trauma, viral immunization or HIV progressive phase of the syndrome lasts from a few days to four weeks plateau phase resolution of findings varies findings

typically begins with weakness accompanied by tingling sensation in the extremities ascending paralysis begins in the lower extremities and may affect the entire body autonomic nervous system involvement may include fluctuations in blood pressure and dysrhythmias, usually with severe disease pain - hyperesthesias, paresthesias, muscle aches and cramps when the weakness/paralysis reaches the respiratory muscles the client is unable to maintain an adequate respiratory effort diagnostics: EMG shows abnormal nerve conduction management supportive care including mechanical ventilation if indicated during acute phase plasmapheresis or intravenous immunoglobulin 24. Myasthenia gravis (see also Lesson 8 C: Neurological - Degenerative Disorders) o definition: autoimmune disorder with fluctuating weakness of skeletal muscle o etiology: antibodies attack acetylcholine receptors in the neuromuscular junction o findings skeletal muscle weakness with a pattern of fluctuation, and improved strength after rest muscles most commonly involved are facial muscles including those responsible for chewing and swallowing and speech - risk for aspiration proximal muscle weakness in neck, shoulders and hips exacerbations can be caused by stress, temperature extremes, pregnancy, certain drugs myasthenic crisis can cause respiratory failure and need for emergent care o diagnostics EMG anticholinesterase (Tensilon) test - improved muscle contractility following administration (note: atropine should be available for emergency use during this test) o management

pharmacologic: anticholinesterases and cholinesterase inhibitors pyridostigmine (Mestinon) neostigmine (Prostigmin) ambenonium (Mytelase)

corticosteroids and other immunosuppressive agents plasmapheresis thymectomy (if thymus dysplasia exist) o nursing interventions monitor neurologic and respiratory status for disease progression aspiration precautions if swallowing is affected schedule periods of rest between activities discuss potential triggers and reduction or avoidance techniques educate about importance of adherence to medications to promote muscle strength and avoid complications 25. Poliomyelitis o definition: viral infection that can affect nerves and can lead to partial or full paralysis o etiology - virus spread by person-to-person contact, contact with infected mucus or phlegm from the nose or mouth, contact with infected feces o findings

subclinical infection (95% of cases): ranging from no findings to malaise, headache, red throat, slight fever, vomiting nonparalytic: back pain, diarrhea, fatigue, headache, irritability, leg pain, moderate fever, muscle stiffness, neck pain and stiffness, rash paralytic: fever; abnormal sensations; bloated feeling in abdomen; difficulty breathing, constipation; muscle pain, contraction or spasms; sensitivity to touch; stiff neck and back post-polio syndrome: a complication that develops in some people, usually 30 or more years after initial infection complications may include aspiration pneumonia, cor pulmonale, kidney stones, urinary tract infections, shock o management prevention - vaccination based on form of disease and findings 26. Amyotrophic lateral sclerosis (ALS; also called Lou Gehrig's Disease) (see also Lesson 8 C: Neurological - Degenerative Disorders) o definition: a disease of the nerve cells in the brain and spinal cord that control voluntary muscle movement o etiology: loss of motor neurons responsible for supplying electrical stimulation to the muscles genetic defect in 10% of cases; otherwise cause is unknown occurs in mid-life affecting men more often than women chronic, progressive, and irreversible o findings usually begins in upper extremities progressive neuromuscular weakness, spasticity, inability to communicate or move voluntarily, loss of involuntary reflexes such as blinking and gag reflex autonomic, sensory and mental function unchanged leads to respiratory failure and death within 2 to 6 years o ethical issues whether clients want mechanical ventilation or nutritional support they may want to die before the disease becomes severe importance of advanced care planning and hospice referral 27. Muscular dystrophies o progressive symmetrical wasting of voluntary muscles with no nerve effect o as thoracic muscles weaken, breathing becomes more difficult o may not swallow well; risk for aspiration with loss of protective airway reflexes 28. Nursing interventions common to neuromuscular disorders affecting breathing o monitor frequently for changes in respiratory status such as respiratory failure and infection o regularly assess swallowing and ability to protect the upper airway o discuss client preferences for mechanical ventilation or nutritional support; communicate and advocate for client wishes o assist with coughing and secretion clearance as indicated o prevent respiratory infection through reduction of risk and immunization (influenza & pneumococcal vaccines) o assess for depression and anxiety, common with these diseases, and provide appropriate referrals o administer medications specific to the disease condition o assist/provide occupational or/and physical rehabilitation as indicated o maintain adequate nutrition utilizing appropriate methods to reduce risk of aspiration if swallowing affected

with terminal disorders, provide for referrals for family such as palliative care and hospice

29.
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Disorders of the Lower Respiratory System - Infectious

Pneumonia Definition: disease of the lungs, primarily caused by infection, characterized by inflammation and consolidation of lung tissue followed by resolution; accompanied by fever, chills, cough, and difficulty breathing

Etiology community-acquired: exposure to infectious organisms outside of hospital hospital-acquired: secondary to infectious organism exposure, i.e., pseudomonas, or risk factors associated with a health care setting and occurring 48 hours or more after admission aspiration: chemical irritation and inflammation associated with aspiration of food or stomach contents or normal oral flora opportunistic: caused by microorganisms that are usually harmless but that can be pathogenic in individuals with depressed immune function, such as Pneumocystis carinii, Cytomegalovirus, and Legionnaires' disease pneumonia is the leading cause of death from infectious causes risk factors 1. preexisting pulmonary disease 2. depressed immune function such as HIV, chemotherapy and other immunosuppressant drugs 3. atelectasis secondary to surgery or immobility 4. mechanical ventilation or artificial airway 5. advanced age, particularly with chronic illness, frailty 6. decreased ability to protect airway, swallow safely or cough effectively

30. Findings o fever, chills, malaise

o o o o o

shortness of breath with decreased oxygen saturation productive cough with purulent sputum pleuritic chest pain crackles in affected lobe(s), egophony, whispered pectoriloquy (indicating consolidation) age-related findings older adults - atypical presentation is common with acute confusion while other findings may be less evident

in infants and young children, lethargy, crankiness and poor appetite may indicate an acute infection such as pneumonia.

31. Diagnostics o chest x-ray - reveals consolidation or infiltrates in affected lobes labs complete blood count - increased white blood cells arterial blood gases - respiratory acidosis (low pH, high PaCO2), hypoxemia (low PaO2) sputum culture, sensitivity and microscopic analysis, Gram stain, cytology identify causative organism and appropriate treatment o bronchoscopy - to obtain sputum specimen when organism is difficult to identify 32. Management
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pharmacologic antimicrobials (depends on pathogen) - monitor for signs of resolving infection antipyretic, analgesic - acetaminophen or NSAIDs expectorants - guaifenesin antitussives - dextromethorphan, codeine o respiratory support as needed, may include mechanical ventilation in severe cases 33. Nursing interventions o monitor pulse oximetry, titrate oxygen as indicated o promote hydration to liquify secretions o monitor respiratory status including rate, effort, signs of failure or distress, auscultate

lungs teach effective coughing techniques to minimize energy expenditure teach the need to continue entire course of antimicrobial therapy which is usually 7 to 10 days o teach that improvement of findings should occur within 48 to 72 hours of initial therapy - contact provider if not improving o encourage influenza and pneumococcal vaccine for high-risk groups 34. Pulmonary tuberculosis (PTB) o Definition: a chronic infection caused by an acid-fast bacillus, generally transmitted by inhalation or ingestion of infected droplets
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Etiology: mycobacterium tuberculosis, which is often dormant, later reactivating typically bacilli lodge in alveoli but can affect almost any organ pulmonary infiltrates increased prevalence of multi-drug resistant PTB, especially among the homeless and AIDS victims Findings weakness with fatigue anorexia with weight loss night sweats chest pain cough - begins dry and progresses to a productive cough with purulent and/or blood tinged sputum

35. Diagnostics laboratory culture for sputum and gastric contents - analysis for the presence of acidfast bacilli interferon-gama release assay (IGRA) - blood test to measure immune system response o chest x-ray - for presence of active or calcified lesions ("coin" lesions) o Mantoux skin test positive if > 10 mm induration in healthy persons (or positive if > 5 mm induration in clients who are immunosuppressed) - additional tests are needed false-negative responses - common in people who are immunosuppressed; two-step Mantoux is used for this population (and health care providers) false positives - may occur for those who have received the BCG vaccine (commonly administered outside the U.S.) o diagnosis of TB requires all of the following: medical history, physical exam, TB skin test or blood test, chest x-ray and sputum or other culture 36. Management
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o o o o o

long-term (6 to 24 months) - antimicrobial therapy with isoniazid (INH) (Hyzyd) or rifampin (Rifadin); ethambutol HCL (Etibi) in some cases activity as tolerated surgical resection of involved lung if medication is not effective

high carbohydrate, high protein diet with frequent small meals TB is a reportable disease - report to appropriate agencies; family and close contacts must be tested for disease 37. Nursing interventions o with active infection airborne precautions and client placed in negative airflow room in the hospital use NIOSH-approved N95 particulate filtering facepiece respirator when providing care; visitors can wear surgical masks provide client with surgical mask if transport needed o obtain sputum specimen early in morning - best for definitive diagnosis o teach client proper techniques to prevent spread of infection, including hand washing report bloody sputum not to use over-the-counter medications without health care provider's approval due to possible drug-drug interactions not to wear soft contact lenses if taking rifampin (can cause reddish-orange discoloration of saliva, sweat, tears, urine, skin) importance of taking medications as prescribed adherence to treatment regimen return at scheduled times for lab testing of liver enzymes an increase in B6 (or B complex) vitamin minimize peripheral neuropathies (a common side effect of antituberculars) 38. Lung abscess o Definition: localized collection of purulent fluid in the lung with cavity formation o Etiology: usually a complication of pneumonia, TB or aspiration o Management broad-spectrum antimicrobial treatment after culture of fluid percutaneous imaging or surgical resection - to drain abscess if the infection does not resolve with pharmacologic treatment 39. Severe acute respiratory syndrome (SARS) o Definition: respiratory illness caused by the coronavirus (called SARS-associated coronavirus) o Etiology: infection is spread by close person-to-person contact by direct contact with infectious material (respiratory secretions or contact with persons or objects infected with infectious droplets) o Findings syndrome begins with a fever, overall feeling of discomfort, body aches, and mild respiratory symptoms; dry cough and dyspnea may develop later last pandemic occurred in 2003 o Diagnosis: laboratory confirmation of SARS-CoV infection o Management hospitalization if radiographically confirmed pneumonia (or acute respiratory distress syndrome) of unknown etiology droplet precautions report to Centers for Disease Control and Prevention (CDC) supportive care; no specific treatment has been shown to consistently improve the outcome of the ill persons o Nursing interventions

assess temperature and monitor for signs of pneumonia instruct clients to avoid contact with those suspected of having SARS and to avoid travel to countries where an outbreak of SARS exists frequent hand hygiene; persons with suspected disease should wear mask to prevent transmission

40.
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Disorders of Lower Respiratory System - Miscellaneous

Pulmonary embolism Definition: blood clot prevents blood from perfusing the "bed" of arteries that feed the lung, resulting in pulmonary infarction and decreased cardiac output; emboli can also be composed of air or fat

Etiology matter blocks blood from the "bed" of arteries that feed the lung so client is breathing but gases are not exchanged hypoxemia occurs can be mild or immediately fatal, based on the size and location of matter symptoms develop over a period of minutes and require emergency treatment! types of embolus 1. blood clot - has usually traveled from deep veins in the leg or pelvis 2. fat - from fractured femur, hip 3. amniotic fluid - postdelivery 4. air- from injection of large air bolus through IV or arterial line primary cause is prolonged immobility poor hydration and conditions that impair circulation (atrial fibrillation, heart failure) contribute to clot development with fat embolism, findings occur about 24 hours after the initial fracture Findings small embolus - client may be asymptomatic

large embolus 1. sudden onset of dyspnea and cough with low oxygen saturation 2. pleuritic chest pain 3. anxiety, apprehension - feeling of "impending doom" 4. cough - productive or nonproductive 5. tachycardia and tachypnea

Diagnostics chest CT with contrast (spiral CT) D-dimer - elevated ventilation/perfusion (V/P) scan (also called V/Q scan) arterial blood gases - low PaO2, high PaCO2 EKG Management prevention is best treatment - preventive anticoagulants with orthopedic surgeries and when bed-bound oxygen titrated to correct hypoxemia - may need mask or high-flow oxygen

pharmacologic 1. anticoagulation - heparin IV or low molecular weight heparin for acute PE; warfarin (Coumadin) chronically to reduce risk of recurrence 2. thrombolytics (for large emboli) 3. pain and anxiety filter surgically placed in vena cava for long term prevention Nursing interventions monitor for changes in respiratory and cardiovascular status early ambulation and compression stocking use during hospitalization to prevent deep vein thrombosis 41. Acute respiratory distress syndrome (ARDS); called acute lung injury (ALI) in early stages o Definition: unregulated inflammatory response to a significant acute injury or inflammatory process anywhere in the body results in damage to the alveolar capillary membrane resulting in a non-cardiac pulmonary edema o Etiology alveolar capillary membrane becomes more permeable to fluids increased extravascular lung fluid pulmonary compliance decreases intrapulmonary shunt increases refractory hypoxemia usually seen after lung injury or massive multi-system organ disease o Findings restlessness, anxiety - ill appearance low oxygen saturation that does not respond to oxygen therapy - requiring emergency care dyspnea, tachypnea, respiratory failure requiring emergency care tachycardia cyanosis (late) intercostal retractions, accessory muscle use frothy sputum (uncommon)

lung sounds early are clear; crackles throughout in later stages

Listen interstitial fibrosis develops in some patients who survive ARDS Diagnostics clinical presentation and history of findings arterial blood gases - hypoxemia and respiratory acidosis despite increasing inspired oxygen level chest x-ray - diffuse infiltrates Management: treat precipitating condition, e.g., antibiotics for sepsis optimize oxygenation to maintain saturation > 88% and to correct respiratory acidosis mechanical ventilation with PEEP, possible extracorporeal membrane oxygenation (ECMO) sedation may be required

paralytic agents may be necessary

corticosteroids to reduce inflammation antibiotics for infectious causes fluid restriction may be used to reduce pulmonary microvascular pressure with central venous pressure monitoring to guide therapy

nutritional management via tube feeding or other method when mechanically ventilated Nursing interventions plan for frequent rest periods monitor trends in oxygenation status, arterial blood gases observe for behavioral changes and signs of confusion monitor vital signs, respiratory effort; hypertension may indicate cerebral hypoxia

care of client receiving corticosteroids prevent and treat complications, e.g., malnutrition, deep vein thrombosis, nosocomial infections, DIC 42. Cor pulmonale o Definition: right heart failure that develops due to sustained lung resistance in chronic lung disease, i.e., COPD

Etiology: heart must pump against great resistance to move blood from the right heart to the left heart through the lung's blood vessels; increased pulmonary vascular resistance (PVR) right ventricular hypertrophy and subsequent chronic heart failure increased PVR results from chronic lung disease, pulmonary hypertension, pulmonary fibrosis Findings fatigue, tachypnea, exertional dyspnea, and cough anginal chest pain - due to right ventricular ischemia or pulmonary artery stretching hemoptysis Diagnostics pulmonary artery pressure readings via PA catheter echocardiogram chest radiograph arterial blood gases EKG Management manage underlying lung disease administer oxygen as ordered to prevent hypoxemia monitor oxygenation with pulse oximeter frequent rest periods

medications: cardiac glycosides, pulmonary artery vasodilator, diuretics restricted fluid intake as indicated o Nursing interventions monitor for changes in oxygenation status monitor effects of medications pace activities for clients who tire easily 43. Respiratory failure o Definition: lungs cannot maintain arterial oxygen levels or eliminate carbon dioxide

Etiology lung diseases that harden the alveolar-capillary membrane, trap O2 a multitude of conditions can cause respiratory failure neuromuscular or musculoskeletal disorders respiratory drive dulled or blunted respiratory muscles weak Findings PaCO2 > 50 mm Hg PaO2 < 60 mm Hg clients with chronic lung disease precautions look for drop from baseline function clients are always hypoxemic and hypercarbic classic presentation: the three "H's" or hypoventilation, hypoxemia, hypercapnia Diagnostics: arterial blood gases Management emergency care! oxygen per mask, CPAP, or intubation and mechanical ventilation control anxiety (not being able to breath is scary, thus anxiety increases which increases oxygen needs) monitor for improvement in the underlying cause for the respiratory failure Nursing interventions observe for signs of hypoxia and respond to prevent occurrence of respiratory failure administer medications and oxygen as prescribed supportive care for emotions, skin integrity, gastrointestinal function, renal function

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