NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms.

. Maria Fe Juen, RN MN Unit Title: Care of Clients with Disturbances in Gas Exchange and Utilization ***can occur anytime as a complication if admitted, especially if client is bedridden ***nurse needs to be skillful in assessment The Upper Respiratory Tract nose, sinuses, larynx, pharynx A. Nose upper most; organ of smell; first air passage; warms and filters the air mostly cartilage; the only bone is the bridge of the nose, the rest are cartilage opening of nose = nostril / external nares inside the nostril = nostril cavity / vestibule > vestibule anterior part is lined with skin; covered by hair-like structures called cilia (responsible in filtering the air that enters > posterior part of vestibule secretes mucous which traps foreign objects before entering the lungs along the sides of the nose = turbinate (which is rich with nerve supply that warms the air as it enters the lungs) B. Sinuses 4 pairs of bony cavities lined with nasal mucosa  Frontal sinuses  Ethmoid sinuses  Sphenoid sinuses  Maxillary sinuses space inside; bony cavities lined with nasal mucosa connected with a duct that drains out into the nasal cavity from nasal cavity, it is open up to the sinuses; thus, the sinuses are common sites of upper respiratory tract infection because of the patent ducts that drains out from the sinuses to the nasal cavity from mouth ascend to sinuses lightens the head and regulates the voice if congested = punga = headache because of blockage of duct in sinuses C. Pharynx also known as throat has 3 portions:  Nasopharynx just posterior of the nose that houses the tonsils  Oropharynx back of mouth (uvulas, palatine)  Laryngopharynx from hyoid bone to Cricoid cartilage of upper larynx tube-like structure that connects the oral cavity and nasal cavity to the larynx D. Larynx aka voice box / voice organ tube that connects the pharynx to the trachea composed mostly of cartilage o Thyroid cartilage of larynx biggest of all the cartilages (some protrudes at anterior larynx = aka Adam's apple in males) o Cricoid cartilage of larynx anatomic site where an artificial opening is created (for tracheostomy: 49

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN for maintenance of upper airway for the lungs to be more ventilated especially if there is blockage in upper airway/URT or if poor exchange of gases; done in respi failure) o Epiglottis valve flap of cartilage that covers the opening of the larynx during swallowing (if there is trauma or inflammation and valve flap does not close = food enters trachea & aspirate) o Glottis opening between vocal cords in the larynx (if traumatized, infected or inflamed = aphonia) vocal cords not a cartilage! LIGAMENT ligament that is controlled by muscular movements that produce sounds located at the lumen of larynx movement of muscles = vocal cords are stimulated, thus sound is uttered Lower Respiratory Tract / Airway A. Starts with Trachea the windpipe composed of smooth muscles with C-shaped rings of cartilage serves as passage between the larynx and bronchi ***bronchus left and right; bronchi plural; lungs: inverted tree B. Bronchi main stem; 2 main stem bronchus o Left bronchus directed towards the left lung; narrower and longer o Right bronchus directed towards the right lung; shorter, wider, straighter C. Bronchioles last pathway / final pathway connected to the alveoli has no cartilage so it could easily collapse and trap air during exhalation D. Terminal Bronchioles last airway of the conducting system directly connected to the alveoli a portion at the distal of the bronchioles ***nose ----> terminal bronchioles (no exchange of gases; only passageway of the air in and out of the alveoli) (Considered as anatomic dead space) E. Lungs located within the thorax (ribs) separated by a space = mediastinum *** Mediastinum contains the heart, pulmonary vessels, thymus gland, esophagus right lung has 3 lobes: upper, middle, lower left lung has 2 lobes: upper and lower lungs are divided into segments 3 characteristics: porous, spongy and elastic 50

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN thus, it has the capacity to expand called COMPLIANCE and has the capacity to return to less-expanded position during exhalation called LUNG RECOIL *** the heart supplies the lungs with blood through the pulmonary artery which contains unsaturated/less O2 ***only oxygenated when the person inhales pulmonary vein return saturated blood to the heart vital capacity of the lungs = 5800 5900 ml of air F. Alveoli / Alveolus aka lung parenchyma functional unit of the lungs at birth, there are about 24 million of alveoli in adult, approximately 300 million or more; arranged in clusters of 15-20 attaching to terminal bronchioles entire alveoli unit is also known as respiratory zone respiratory zone is made up of alveoli ducts and alveolar sacs alveolar wall of alveolus is very thin and surrounded by solid network of capillaries this connection is called the ALVEOLAR CAPILLARY UNIT where the gas exchange takes place alveoli composed of 3 cells o Pneumocytes type I lines the alveolus (1 only) and is effective in gas exchange; outer portion o Pneumocytes type II metabolically active because these are the cells that produce surfactant (lecithin: sphingomyelin; 2:1) - Surfactant is important for lung repair and prevention of alveolar collapse - Wrong ratio could cause collapse of the lungs o Pneumocytes type III large phagocytic cells (ability to engulf foreign objects like bacteria/viruses) ; mucous acts as defensive mechanism of the lungs

Lung Volume total lung capacity: 5800 5900 ml of air equal to > Tidal volume > Inspiratory reserve volume > Expiratory reserve volume > Residual volume (remaining)

500ml 3000ml 1100ml 1200ml

Tidal volume air that goes in and out during quiet breathing (resting / sleeping) Inspiratory reserve volume extra amount of air inhaled (during deep inhalation) Expiratory reserve volume extra amount of air exhaled during loss expiration Residual volume prevents collapse of lungs; so there should always be residual volume; serves to maintain the less expanded position *** measured by incentive spirometer Thorax provides protection to the lungs, heart and major blood vessels, thymus gland, part of pancreas and liver, lower ribs and diaphragm outer ribs composed of 12 pairs (24 in total) 51

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 1 - 7 pairs = attached to sternum; non-floating 8th - 10th pairs = false ribs attached to each other by intercostal cartilage 11th - 12th pairs = floating ribs; allows full expansion of the lungs
st th

Diaphragm primary muscles for breathing dome-shaped in relaxed position during inhalation, it flattens; it allows full expansion of the lungs nerve supply to diaphragm through phrenic nerve which arises from C3 (3 rd cervical vertebrae) ***phrenic nerve also supplies 2ndary muscles of diaphragm; trauma in C3 could impair ventilation Pleura serous membrane that encloses the lungs has 2 layers  Visceral inner layer directly in contact with lung tissue  Parietal outer layer between these two layers is a potential space containing serous fluid approximately 30ml Pleural space = serves as a lubricant that prevents friction in the lung tissue = presence of fluid could create a pull for lungs to maintain less expanded position during exhalation = meaning no closure because of fluid = impair ventilation = pleural effusion; excessive fluids in space; excessive blood / air Functions of the Respiratory System - performs these functions by facilitating life-sustaining processes such as: 1. Gas Exchange and Transport occurs between the atmospheric air and the blood and between the blood and the cells of the body respiration = exchange of oxygen and carbon dioxide 2 locations in the body: o external occurs in the alveoli capillary level o internal occurs between the cells and tissue level during respiration, body cells and tissues are supplied with oxygen, metabolism takes place, carbon dioxide as waste product is released Composition of Atmospheric Air Nitrogen 78.62% Oxygen 20.84% Carbon Dioxide 0.04% Water Vapor 0.50% Atmospheric pressure at sea level = 760 mmHg Oxygen Transport after diffusion (blood flow that contains oxygen) from capillaries, oxygen is transported then out the body by the circulatory system 52

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 3% oxygen dissolved in the plasma 97% oxygen dissolved in hemoglobin Oxyhemoglobin = forms from the combination of hgb and oxygen. Carbon monoxide and other chemicals may impair the ability of hemoglobin to transport oxygen in the blood

***creates own parietal pressure (dissolved fluids in alveoli) 104 mmHg Carbon Dioxide Transport Carbon Dioxide is the waste product of tissue metabolism and is carried by the blood in the following ways: a). combined with water as carbonic acid (70%) b). with hemoglobin (23%) c). dissolved in plasma (7%) - carbonic anhydrase is an enzyme in the RBC that breaks down the CO2 into Hydrogen ions and Bicarbonate ions - when venous blood enters the lungs for gas exchange, this reaction reverses forming CO2 which then exhaled 2. Ventilation Movement of air in and out of the airways which continually replenish the oxygen and removes the carbon dioxide from the airways in the lungs. During inspiration, air flows from the environment into the trachea, bronchi, bronchioles and alveoli. During expiration, alveolar gas travels the same route in reverse. Factors that Govern Airflow in and out of the Lungs o adequate atmospheric oxygen o clear air passage o adequate pulmonary compliance and recoil o regulation of respiration It is accomplished by: (a) Compliance properties of lungs and thorax - ease with which the lungs expands effectively - if stiff lungs = lungs cant have effective recoil and low compliance - Floppy lungs = result with greater compliance but lesser recoil (b) Resistance to airflow / surface tension - less surfactant = less surface tension = atelectasis / collapse of lungs - surfactant produced by type II pneumocytes - enough surfactant to increase compliance and aid in lung ventilation 53

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN Relationship between Ventilation and Perfusion (contains O2 blood) > the ventilation is the airflow > perfusion is the blood flow that determines the efficiency of gas exchange > normal is a normally functioning alveolus and normal pulmonary capillary flow > ventilation and perfusion match Normal Ventilation Perfusion

Dead Space Unit exists when there is ventilation without perfusion eg. Pulmonary embolus at capillary level preventing blood flow through the pulmonary artery

Shunt Unit when there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists and unoxygenated blood continues to circulate (eg. Atelectasis, pneumonia where the alveoli collapse)

Silent Unit when there is neither ventilation nor perfusion eg. Pulmonary embolus combined with ARDS (Adult Respiratory Distress Syndrome). The alveoli collapse 3. Muscular effort - important muscles that supports respiratory effort: scalene (elevates the 1st and 2nd ribs) and schleidomastoid muscle - during inspiration, upper chest enlarges and stabilized in the chest wall - during exhalation, these muscles relax - in inspiration, abdominal muscles also contract and pushes the diaphragm and flattens - in expiration, abdominal muscles relaxes and diaphragm in relaxed position 4. Respiratory Control - URT / LRT have no intensity control (they only facilitate respiration) - medulla oblongata and pons of the brain stem are responsible for respi control - medulla oblongata has levels of respiratory centers > dorsal respiratory provides normal inhalation > ventral respiratory provides increased ventilation during deep inhalation - during inspiration and expiration, output pass through ventral and lateral portions of the spinal cord phrenic nerve from C3 54

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN stimulate nerve neurons in the diaphragm stimulate intercostal neurons result to rhythmic movement of the accessory muscles - pons = contain apneustic center which contain expiratory and inspiratory neurons that fine tunes the breathing - normal breathing = no sound on breathing - if impaired medulla = abnormal movement of intercostal muscles - thrombosis, increased ICP = impaired medulla and pons 5. Reflex Control - located in the carina (stimulated by the neural nerve) - result to cough = high velocity expiratory gas flow - this reflex control can expel 6. Peripheral Control - sensing of partial pressure of oxygen and PCO2 at tissue, cells and circulatory system - increased PCO2 in circulation, tissue and cell level = client inhales and exhales - decreased PO2 in circulation = send message to brain = increased respiration - greatest ventilatory drive that causes simultaneous increase in respiratory rate and pattern = decreased PO2 (<70mmHg) and increased PCO2 - normal PCO2: 35 45 mmHg; normal PO2 = 90 100 mmHg *** pulmonary function test or ABG analysis; pulse oximetry = to measure PO2/PCO2 7. Respiratory Defense Mechanism - filtration of air starts from the nose. Larger particles (>10mm) are generally filtered; smaller particles (<1mm) may enter the lower airways - clearance mechanism of the lower airways and alveoli *** cough reflex an automatic protective reflex used to clear the trachea - occurs most rapidly in cleaning process > mucociliary system (to terminal bronchioles) dead and phagocytic cells are excreted > alveolar macrophages are active phagocytes that remove dead cells and protein and secrete substances that regulate the immune system. > lymphatics aids in the excretion of dead phagocytic cells from the alveolar macrophages 8. Immunologic Defense Mechanism - responds by mobilizing the blood neutrophils and blood monocytes wherein the thymus dependent (T) and thymus independent (B) lymphocytes produce specific antibodies within the alveoli that contributes to the increased resistance of alveoli from microorganisms specifically mycobacterium tuberculosis and pneumocystis carinii (cause pneumonia) these are opportunistic microorganisms because they will invade the body 55

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN when there is suppression of immune system 9. Regulation of Acid Base Balance - though gas exchange, lungs play important role in regulation of acid-base balance Normal PaCO2 = 35-45mmHg Normal PaO2 = 90-104 / 97-100 mmHg inc PaCO2 more than 7.5 pH = respiratory alkalosis or hypocapnea or alkalemia 35 PaCO2 = hypercapnea = respiratory acidosis or respiratory acidemia Factors Interfering with Oxygenation and Normal O2 CO2 Exchange o Development congenital atresia of trachea, premature (not enough surfactant) = dec surface tension o Environment altitude (N: sea level atmospheric pressure), heat, cold, and air pollution ***high altitudes = dec O2 atmospheric pressure o Lifestyle physical exercise / activity increases the rate and depth of respiratory and heart rate o health status diseases of cardiovascular system and respiratory system affects oxygenation (anemia = dec Hgb) o Narcotics such as morphine and meperidine hydrochloride (Demerol) decreases the rate and depth of respirations ( may lead to shallow breathing) Assessment Age related changes of the respiratory system - at birth, major respiratory changes occurs the lungs that is filled with fluid becomes filled with air - infants have small chest and short airways predisposes to aspiration of foreign objects that can block the airways - respiratory rate is more rapid than any other times in life chest rounded - children, diameter from front to back decreases in proportion to the transverse diameter - adults experience normal changing processes > change in thorax and breathing pattern > movements of cilia in the upper airway slows and becomes less effective which predisposes old clients to respiratory ________ > the lungs becomes rounded as a result of increased anteroposterior diameter, circumference, area, and height of the lungs as a result of changes in thoracic curvature in cases of kyphosis, osteoporosis, and scoliosis > deterioration of lung function due to loss of alveolar wall tissue and elastic tissue fibers > chronic exposure to environmental pollutants may also influence the decline of lung function Kyphosis increase convexity in the curvature of the thoracic spine Scoliosis lateral deviation of the spine Past Health History - Childhood and infectious diseases: childhood diseases related to respiratory systems, congenital problems, premature birth history or other systemic and organ diseases - Immunizations: inquire about vaccination about pneumonia (Pneumovax and influenza vaccine). Pneumovax provides a lifelong immunity against pneumococcal pneumonia, while flu shots must be received annually 56

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN - Major illnesses and hospitalization: inquire for previous hospitalization, treatment and surgery - Laboratory and diagnostic exams like chest x-rays and results - Medications (previous) hypersensitivity reactions to medicines - History of allergies allergens (dander, pollen, dust) - Symptoms that occurs in allergic reactions - Family history: ask any respiratory diseases like tuberculosis, asthma - Psychosocial history: elderly (occupation = factory?), exposed to smoke, habits, lifestyle, exercise, nutrition (last 24hr meal) - Geographic location if client is exposed to epidemic of respiratory diseases like SARS, TB - Environment substandard housing (overcrowded) Present Health History - Present complaints, chief complaints, to establish priorities for interventions o Dyspnea difficult and labored breathing during which the individual has persistent, unsatisfied need for air and feels distress o Cough sudden audible expulsion of air from the lungs; essential protective response that serves to clear the lungs, bronchi and trachea of irritants and secretion and prevent aspiration of foreign materials into the lungs. May be: > Productive accompanied by expectorated secretions > Non-productive dry, harsh cough with secretions o Chest pain needs further evaluation! Suggests insufficient oxygen to heart muscles because of poor gas exchange o Wheezing heard during expiration; denotes narrowed / partially obstructed airway o Hemoptysis presence of blood in sputum; ulcerations / cavity formation in lung tissues o Clubbing of fingers prolonged / chronic insufficient oxygen in the body cells and tissues of the client; occurs in elderly *** ask duration! When it started! Intensity, sputum production = ask color Review of Systems (Systems Approach Assessment) Ask the client to describe other manifestation associated with respiratory system , in addition to signs and symptoms prevented (from head to toe assessment) to focus on the complaints of the client.

Physical Assessment of the Respiratory Tract (IPPA) Inspection upper parts of the Respiratory System A. Head and Neck o Nose Deviation in the nose, shape, size, color, flaring of nostrils/discharges Palpate to determine areas of tenderness, masses and displacement of bone and cartilage o Determine patency of both nasal cavities o Red mucosa, edematous B. Facial Sinuses - Facial Sinuses Inspect the maxillary and frontal sinuses for swelling and tenderness 57

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN C. Lip and Buccal Mucosa o Inspect for pallor and cyanosis, blisters, swelling, (crust, scales, white patches-leukoplakia), excessive dryness, ulceration D. Teeth and Gums o Missing teeth, presence of caries, brown/black discoloration of the enamel, redness of gums, spongy texture, bleeding/tenderness, atrophied gums, swelling E. Tongue o Inspect the surface, position, color, texture, smooth, red (may indicate Iron and Vit. B12 deficiencies; dry furry tongue, nodes, ulceration, discolorations and tenderness F. Oropharynx o Reddened, edematous, presence of lesions, plaque or exudates G. Trachea o Inspect for lateral deviation, neck tumor Chest Configuration 1. Barrel Chest - Increased in anterior and posterior diameter of thorax; chronic inflation of lungs due to emphysema 2. Funnel Chest - Pectus Excavatum - Depression the lower portion of the sternum - May compress heart and Great Blood Vessels may cause murmurs may occur in Rickets and Marfans Syndrome 3. Pigeons Chest o Pectus carinatum o Protrusion of the sternum may occurs with rickets/severe kyphoscoliosis 4. Kyphoscoliosis o Elevation of scapula and S shaped spinal column o Lateral deviation or S shaped spine Chest Movement - Obstruction of chest movement during respiration. Normal respiration is 12-22 cpm. Note the amplitude or depth of expansion an rhythm - Abdominal breathing is more apparent in men, while women use thoracic muscles - Note the use of accessory muscles, retractions, symmetry and paradoxical movements Fingers and Toes o Inspect for clubbing of fingers and toes which may be present in clients with pulmonary fibrosis, lung cancer and bronchoectasis o Clubbing of fingers occurs as a compensatory mechanism in chronic hypoxia o With clubbing, the nail bed loses its normal angle degrees between the toenail plates and the finger and the angle increases to 180 on advance clubbing, finger takes a spoon like appearance. (assess early clubbing by using Schamroth technique)

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NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN o Note the color of the nail beds to assess the status of peripheral tissue oxygenation by quickly and gently press the finger and release (capillary refill) o Normal capillary refill occurs within 3 seconds. Nail beds should be pink without cyanosis or dusky blue color Palpation o The use of the hands of to feel various structures on and below the surface of the body Trachea o Gently place the thumb on one side of the trachea and remaining fingers on the other side. Move the trachea from side to side. Take note for the presence of masses, deviation from midline and crepitus (air in the subcutaneous tissue). The trachea is usually slightly movable. A chest mass/goiter or an acute chest injury that may displace the trachea. Chest Wall o Palpate the chest wall by holding the heel or ulnar aspect of the hand against the clients chest. Assess for crepitus , defects or tenderness, muscle tone, edema, and tactile fremitus (the vibration of air movement through the chest wall while the client is speaking) Thoracic Excursion o On thoracic excursion, the client sits upright, place hands on the clients posterior chest wall. The thumbs oppose each other on either side of the spine, and fingers face upward and out like butterfly wing. As the client inhales your hands should move up and out symmetrically. Any asymmetry suggests a disease process in that area. Tactile Fremitus o Palpate the posterior chest wall while the client say words that produces intense vibrations (91). The vibrations are transmitted from larynx via pathways and can be perceived on the chest wall. Compare the intensity of vibrations on both sides for symmetry o Stronger vibrations are felt when there is consolidation in underlying lung as in pneumonia o Decreased tactile fremitus is usually associated with pleural effusion and pneumothorax

Percussion o o Assessment techniques of producing sounds by tapping on the chest wall with the hand tapping on the chest wall produces sounds that are described in relation to their acoustic properties. Resonant Sounds - Are low pitch, hollow sounds heard over Normal lung tissue Hyperresonant - Sounds indicate and increase amount of air in the lungs or pleural space. The sounds are louder and lower and lower pitch than resonant sounds usually produced in cases of pneumothorax and emphysema. However, normally heard in children and in very thin adults. Dull - Sound over dense lung tissues such as tumor or consolidation. These sounds are thud-like and medium pitch, normally heard overt the liver and heart Flat Notes - Prolapse 59

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN - Are soft and high pitch; they result from percussion over airless tissue, the sounds can be replicated with the percussion of the thigh or bony structures Tympanic Notes - Are high hollow drum like sounds heard with percussion over the stomach, a large tension pneumothorax, or a large air filled chamber such as (empty stomach). Begin percussion at the apices and proceed to the bases moving from the posterior to the lateral and to the anterior areas. Best done when the client is in an upright position with arms crossed to separate the scapula of the posterior chest

Auscultation Involves listening to chest sounds with a stethoscope. By listening to the lungs when the client breaths through an open mouth, you can assess the following: o Character of the breath sounds o Presence of adventitious breath sounds o The character of the spoken and whispered voice

Breath Sounds Normal 1. Vesicular (Normal) - Soft intensity, low pitch, gentle sighing, sounds created by air moving through smaller airways. Could be heard over most of both lungs. Inspiratory sounds but lasts longer than expiratory 2. Bronchovesicular o Moderate intensity and moderate pitch, blowing pitch. Created by air through larger airways. Can be heard in the first and second interspace anteriorly and between the scapula; inspiratory and expiratory sounds are about equal 3. Bronchial o High pitch loud sounds, created by air moving over the manubrium. Expiratory sounds lasts longer than inspiratory 4. Tracheal o Very loud, high pitched sounds can be heard over the trachea. Inspiratory and expiratory sounds are equal Adventitious Breath Sounds (Abnormal) 1. Crackles (Rales) - Fine, short, interrupted crackling sounds, alveolar rales are high pitched, while bronchial rales are low pitched an air passing through fluid or moves in air passages (in the lower lung lobes) 2. Gurgles (Ronchi) o Continues low pitched course, gurgling, harsh louder sounds with a moaning or snoring quality. Created by air passages as a result of secretions (bronchi, bronchioles), swelling or tumors. 3. Friction Rub o Superficial grating or creaking sounds heard during inspiration or expiration which is the result of the rubbing together of inflamed pleural surfaces, lower anterior and lateral chest. 60

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 4. Wheeze o Continues high pitched, squirky, musical sounds (all over lung fields); Created by air passing through constricted bronchi as a result of secretions or swelling of tumors. Voice Sounds Sounds to test the patency of the canal or cavity Bronchophony Increase in clarity and intensity of vocal resonance that may result from an increase in lung tissue density such as in consolidation of pneumonia Egophony Change in the voice sound of patient with pleural effusion. Like the sound of letter E to that of letter A Whispered Pectoriloquy Voice sounds or whispers are transmitted already through the pulmonary structure and an already audible through a stethoscope sign of lung consolidation

Breathing Patterns and Respiratory Rates Normal Rate/min o New Born 30-80cpm o 1 y/o 20-40cpm o 2 y/o 20-30cpm o 8 y/o 15-25cpm o 16 y/o 15-20cpm o Adults 12-20cpm Eupnea Normal respiration that is quiet, rhythmic and effortless

Abnormal Breathing Patterns Bradypnea - An abnormally slow respiration rate which may be seen in clients who have taken drugs such as Morphine SO4 (respi depression), those who have metabolic acidosis or increased ICP Tachypnea o Rapid rate is seen in patients with fever, pneumonia, pulmonary edema, severe pain, metabolic acidosis, septicemia, rib fracture. Hyperventilation o Kussmauls Respirations; an excessive amount of air in the lungs o Kussmauls Breathing: one particular type of hyperventilation accompanies metabolic acidosis (deficient HCO3, excess in acid)

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NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN Hypoventilation o Inadequate alveolar ventilation CO2 is retained in the blood stream Cheyne-Stokes Respiration o Characterized by alternating episodes of apnea and periods of deep breathing. Usually associated with heart failure and damage to the respiratory center Apnea o Partial absence of breathing

Use of Accessory Chest Muscles a. Intercostal Retractions - Indrawing between the ribs b. Substernal Retractions o Indrawing in between the breastbone c. Suprasternal Retractions o Indrawing above the clavicles d. Tracheal Tug o Indrawing and downward pull of trachea during inspiration e. Flail Chest o The ballooning out of the chest wall through injured rib spaces.

Upper Airway Disorders 1. Epistaxis - Occurs in all ages especially in children and elderly - Causes Trauma, foreign bodies, nasal spray abuse, street drug use, anatomic malformation, allergic rhinitis Systemic disease (atherosclerosis, HPN, blood dyscrasias) Systemic treatment (Chemotherapy or anticoagulants) - Nursing Interventions 1. Sit up and lean forward, head tipped to prevent pressure over the soft tissues of the nose for at least 5-10 minutes. ***pinch anterior portion of the nose (Kiesselbachs Plexus area which is prone to injury) 2. Cold compress or ice pack (for vasoconstriction) 3. Nasal pack with Neosenephrine with bacterial ointment (48-72 hours) 4. Monitor BP (elderly to detect HPN) 5. Humidification 6. Do not blow nose for 2 days after removal of nasal pack 7. Application of water soluble ointment around the nares 62

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 8. Monitor for airway obstruction of bleeding 9. Inspect the oral cavity and visible posterior plug 10. Liquid diet and gradually to soft diet 11. Avoid oral temperature checking (inaccurate reading) o Surgical Management If it is due to arterial artery trauma/injury artery ligation must be performed 2. Rhinitis o Aka Rhinosinusitis o May be classified into: 1. Acute Aka common cold or Coryza It can be viral (Rhinovirus under Picornavirus group and Herpes Simplex Virus 1) or Bacterial May last for 5-7 days Spread by airborne droplet and direct hand contact 2. Allergic Due to allergic reaction from the environment 3. Vasomotor Dx when acute /allergic (-) skin test Rhinitis medicamentosa Dx when drug abuse, overuse of nasal sprays, intranasal cocaine - S/Sx Tickling, irritation, sneezing, dryness of the nose or nasopharynx, nasal secretions, nasal obstruction, watery eyes, general malaise, headache - Dx Test Culture of nasal discharges (if acute rhinitis is suspected) - Nursing Management Focuses on Health Education and Prevention of Infection 1. Identify strategies to prevent the spread of infection by: a. Washing of hands often b. Using disposable tissues c. Avoid crowds during the flu season d. Avoid individuals with known colds or respiratory infections e. Obtaining an influenza vaccination if recommended (esp. if elderly diagnosed with a chronic illness) 2. Practice good health to prevent illness by: a. Eating a nutritious diet b. Getting plenty of rest and sleep c. Avoiding and reducing stress when possible d. Exercising appropriately e. Avoiding smoking and excessive intake of alcohol f. Increasing humidity in house especially during winter g. Practicing adequate oral hygiene 3. Avoid allergens if allergens are associated with URTI 63

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 4. Identify strategies to control the environment by: a. Adequate humidifying of quarters b. Reducing irritants dust, chemicals, tobacco smoke when possible c. Limiting the exposure to household pets particularly in the bathroom/bedroom 5. Describe strategies to relieve symptoms of URTI, including: a. Gurgling with saltwater b. Increasing fluid intake, particularly hot liquids c. Providing warm moist air shower or humidifier to relieve swollen mucous membranes d. Avoiding irritants(dust, chemicals, tobacco smoke) when possible 6. Recognize signs and symptoms of infection a. Upper res respiratory symptoms persisting longer than 7-10 days b. Extreme red throat or white patches on the back of the throat c. Discolored drainage or foul smelling nasal discharge d. Prolonged fever 100.5F (>38C) > 2 days e. SOB, wheezing f. Swollen glands g. Severe pain or tenderness around the eyes or persistent pain in the sinus areas h. Severe headache o Medical Management There is no cure for the common cold Management consists of symptomatic therapy which includes: 1. Adequate fluid intake 2. Rest 3. Prevention of chilling 4. Aqueous nasal decongestant 5. Antihistamines 6. Vitamin C and expectorants as needed 7. Warm salt water gargles (soothes the sore throat) 8. Aspirin, Ibuprofen, acetaminophen relieves pain, aches and fever 9. Antimicrobial agents do not affect the viruses but may be used as prophylaxis for high risk respiratory patients 3. Sinusitis - Chronic inflammation of the sinuses that persists for more than 8 weeks in adult and 2 weeks in a child - Acute inflammation of the sinuses for fewer than 8 weeks in an adult and 2 weeks in a child - Obstruction or inflammation of Ostia Discharge will accumulate behind the obstructed portion Medium for microbes Infiltration to the mucous membrane of the sinuses Infection of the sinuses - S/Sx Pain over the affected sinus Purulent nasal discharge Nasal obstruction 64

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN Congestion Fever Malaise Person looks and feels sick - Sinus Radiograph 1. Opacification of mucous membranes 2. Thickened mucous membranes o Nursing Interventions: Teaching Patients Self-Care A. Promote sinus drainage by increasing environmental humidity by (steam bath, hot shower, facial sauna) B. Increasing fluid intake C. Applying local heat (hot wet packs) D. Avoid sinus infection, and learn how t recognize the early signs and symptoms E. Stress the importance of following the recommended medical regimen F. Explain to the patient that fever, severe headache, and Nuchal rigidity are sign of potential complications that need further care o Medical Management A. Medical Decongestant (like Sudafed, Dimetapp) B. Antibiotic as prescribed C. Irrigation of maxillary sinuses with warm normal saline or sinus lavage D. Vaporizer or humidifier Softens secretions Prevent nasal crusting E. Topical or systemic vasoconstrictors F. Intranasal steroids and mucolytic agents o Surgical Management A. Endoscopic Sinus Surgery (Direct Visualization of Sinuses) B. Caldwell-Luc (Radical Antrum Surgery) on and of maxillary sinusitis to remove diseased tissue C. Ethmoidectomy D. Sphenoidectomy E. Osteoplastic Flap for recurrent frontal sinusitis Post-Op Care: A. B. C. D. E. F. G. H. Observer for profuse bleeding 24h post-operatively Instruct the client not to chew on affected site Take precaution with oral hygiene to prevent trauma of incision Instruct client not to wear dentures Do not blow nose and avoid sneezing for 7-10 days after surgery Ice compress to nose and cheek Elevate the head 45 angle 24-48 hours post-op Nasal pack is removed next morning after the surgery Antral packing is good for 36-72h 65

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN I. Increase fluid intake J. Avoid strenuous activities for 2 weeks K. Mild analgesics as prescribed 4. Pharyngitis (Acute/Chronic) o Acute A febrile inflammation of pharyngeal walls, may include the tonsils, palate and the uvula, caused by bacteria, virus or fungus o Chronic Chronic exposure to dusty environments, excess use of voice, suffer from chronic cough and habitual use of alcohol/tobacco o S/Sx Scratchy throat, pain, dysphagia, sensation of lump in the throat, mild fever, headache, muscle and joint pain, Coryza and rhinorrhea o Dx Test Throat culture o Nursing Management Instruct the client to stay on bed during febrile conditions and to rest frequently once out of bed Avoid contact with other persons until fever subsides Dispose tissues properly Warm saline gargle or irrigation/lozenges Apply ice collar for severe sore throat Proper mouth care Instruct the client to resume activities gradually Encourage to drink plenty of fluids Avoid environmental or occupational pollutants, alcohol, smoke Instruct the client and family the importance of taking the full course of therapy Early recognition if symptoms that indicate possible complications o Medical Management Mucolytic expectorant Antihistamine decongestant Aspirin/Acetaminophen Antimicrobial Antitussive 5. Laryngitis o Acute or chronic inflammation of the vocal cords/larynx o Causes Bacterial or viral URTI, excessive use of voice, inhalation of smoke or fumes, aspiration of caustic chemicals, Chronic URTI, exposure to irritants, alcohol abuse GERD caused by the relaxation of the cardiac sphincter o S/Sx Hoarseness of voice from mild to complete loss of voice (aphonia), pain, dry cough, fever, laryngeal edema, malaise, it may be a complication of chronic sinusitis and chronic bronchitis 66

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN o Dx Test Laryngoscopy may reveal, red, inflamed, and occasionally hemorrhagic vocal cords, sharp edges and exudates o Nursing Management A. Rest the voice B. Maintain a well humidified environment C. Increase fluid intake D. Avoid or eliminate any primary tract infection E. Avoid smoke or inhaling cool steam or aerosol If the case is due to GERD A. Elevate HOB 6-10inches B. Avoid eating or drinking 3 hours before sleeping C. Avoid caffeine, alcohol, tobacco o Medical Management 1. Antibiotic 2. Corticosteroid to decrease inflammation 3. Mucolytics to thin and mobilize secretions 4. Humidification of Environment moisten and liquefy secretions 5. H2 Blocker (Antacid) Neutralize and decrease acid secretions o Nursing Diagnosis 1. Ineffective airway clearance related to excessive secretions 2. Impaired verbal communication related to upper airway irritation 3. Pain related to airway irritation 4. Fluid volume deficit related to lack of fluid intake 5. Risk for altered nutrition less than body requirements 6. Risk for superinfection 7. Knowledge deficit related to lack of preventive measures 6. Cancer of the Larynx (Laryngeal CA) - Squamous cell carcinoma is the most common form of laryngeal cancer - Predisposing factors Cigarette, alcohol occupational exposure to asbestos and wood dust, petroleum products, inhalation and noxious fumes, chronic laryngitis and voice abuse *** Cancer In situ pre-invasive cancer S/Sx

Hoarseness lasts longer than 2 weeks, voice change, dysphagia and aspiration during swallowing, sensation of foreign body in the throat, halitosis, Hemoptysis, anorexia, pain or burning in the throat while drinking citrus juice hot liquids, weight loss Clinical effects of metastasis includes; dysphagia, dyspnea, cough, enlarge lymph node, pain radiating to the ear Medical Management Radiation (may be combined with chemotherapy or surgery) 67

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN Chemotherapy (Pharmacologic treatment) Surgery a. Partial Laryngectomy Recommended only in the early stage of CA growth in the larynx in the glottic area b. Supraglottic Laryngectomy Indicated in the early Supraglottic tumor Hyoid, glottis, and vocal cords are removed c. Hemilaryngectomy Extends beyond vocal cords May result to hoarseness in voice d. Total Laryngectomy CA extends beyond the vocal cords and recurrent growth Results to a change in the airways Permanent tracheostomy tube and NGT Nursing Diagnosis Knowledge deficit r/t the surgical procedure and post op care Anxiety r/t the Dx of CA and impending surgery Ineffective airway clearance related to surgical alteration in the airway Impaired verbal communication related to removal of the larynx and to edema Altered nutrition: less than body requirements , related to swallowing difficulties Disturbance in body image, self-concept, and self esteem related to major neck surgery Self-care deficit related to post-operative care Potential for noncompliance with rehabilitation program and home maintenance management

NCM of Clients With Cheat and Lower Respiratory Tract Disorders: The Nursing Process Approach A. Atelectasis - Refers to the closure, partial or complete lung collapse 1. Absorption atelectasis bronchial occlusion d/t retained secretions 2. Compression atelectasis external compression; may be caused by diaphragmatic hernia or a surgical incision that may cause swelling or edema post-op E.g. Rib fracture, obesity (thickened adipose tissue that may compress the alveolar walls) In NB, it may be caused by lecithin and sphingomyelin May be classified into: o Acute occurs frequently in the post-op setting or in people who are immobilized and has a shallow breathing pattern (General Anesthesia narcotics, bedridden patients) o Chronic occurs in chronic airway obstruction that impede or block the airflow to an area of the lung (i.e. alveoli) E.g. in asthmatic clients, bronchitis, COPD) ***Client will die of complications

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NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN Clinical Manifestations/S/Sx Cough, sputum production, and low grade fever In acute atelectasis, there is marked respiratory distress: dyspnea, tachycardia, tachypnea, pleural pain, and central cyanosis (a bluish skin hue that is a late sign of hypoxemia), anxiety Diagnostic Test o Chest X-Ray consolidation of some parts of the lungs, whole lobes or the right or left lung o Auscultation decrease breathing sounds; presence of crackles/rales heard over the affected area o Pulse Oximetry decrease O2 saturation; N is 97%-104% or 95%-100% < 90% O2 saturation, dec PaCO2 hypoxemia will result, (Dec O2 supply to the body cells in tissues); poor ventilation and perfusion Medical Management goal of management to patient with atelectasis is: to improve ventilation and remove secretions o Mucolytics o Bronchoscopy o Humidity o Bronchodilators (Salbutamol, Bricanyl) o Surgery for obstructing neoplasm Nursing Management Prevention: Nursing measures to prevent Atelectasis: o Encourage post-op clients to cough and deep breath every 1-2 hours (Health teaching regarding this will be started pre-op) o Frequent turning and early mobilization (Health teaching regarding this will be started pre-op) Prevents accumulation of secretions in the bronchial tree o Frequent turning and early mobilization o Spirometry and Voluntary deep breathing (Normal Inspiratory Reserve volume) o Suctioning and aerosol nebulization to follow by chest physical therapy (Postural drainage and chest percussion) if indicated to remove tracheobronchial secretions Percussion and Vibration measure to mobilize secretions for easy expectoration (can be augmented by postural drainage) B. Respiratory Infections 1. Pneumonia - An acute inflammation of the lung parenchyma (alveoli); that impairs gas exchange Classification According to Location 1. Bronchopneumonia Involves the distal airways and alveoli, bronchioles, terminal bronchioles and alveoli 2. Lobular Pneumonia Only a part or a portion of a lob is involved 3. Lobar Pneumonia Involves of an entire lobe 69 o o

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN Causes o Primary Inhalation/aspiration of pathogen including pneumococcal, viral, mycoplasmal pneumonia Further classified into Bacterial or Viral Bacterial Pneumonia Triggers alveolar inflammation Cause area of decrease ventilation Engorgement of capillaries That surrounds the alveoli Pulmonary stasis of alveolar air or gas Breakdown of alveoli-capillaries Formation of Pus/Secretions = exudates Productive cough (objective and subjective) Viral Pneumonia Infiltrate alveolar cells Inflammation Spread of inflammation and infection to terminal bronchioles, pleura and capillaries Accumulation of secretions o Secondary Lung damage due to noxious chemicals or can result from hematogenous spread of bacteria Aspiration Pneumonia anything aspirated and causes lung damage

S/Sx Coughing, sputum production, pleuritic chest pain, shaking, chills, fever, wide range of physical sign from diffuse to fine crackles to signs of localized or extensive consolidation and pleural effusion

Dx Test o Sputum analysis (to determine if viral or bacterial) o Transtracheal aspirate (like, thoracentesis, fluid from lungs is aspirated) o WBC Count increased o Pleurocentesis (Thoracentesis) o Bronchoscopy visualization of lower airways Goal of Management - To improve airway patency, conserve energy, maintenance of proper nutrition and fluid volume, preventive measures and absence of complications

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NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN Medical Management Antimicrobial therapy varies with causative agent Humidified O2 therapy Mechanical ventilation - ET Tube, ambubag, respirator, suction to remove discharges from airways, steam inhalation Nursing Dx Includes 1. Ineffective airway clearance r/t copious bronchial secretions 2. Activity intolerance r/t altered respiratory function 3. Risk for fluid volume deficit r/t fever and dyspnea 4. Altered nutrition less than body requirements 5. Knowledge deficit r/t treatment regimen and prevention measures Nursing Intervention Improving airway (removing secretions, hydration, humidification, coughing, and deep breathing, with incentive spirometer, chest physiotherapy, O2 as desired) o Promoting rest and conserving energy: Avoid overexertion, only moderate activity Comfortable position (semi-fowlers position) Promoting fluid intake (inc fluid intake) Maintaining nutrition (fluids with electrolytes, nutrients by parenteral) Monitoring and managing potential complications (shock and respiratory failure, atelectasis, and pleural effusion, superinfection) Promoting home and community based care teaching patient of self care 2. Pulmonary Tuberculosis Acute or chronic infection caused by M. tuberculosis, characterized by pulmonary infiltrates, formation of granuloma, fibrosis and cavitation - Spread from person to person Risk Factors 1. 2. 3. 4. 5. 6. 7. 8. Close contact with someone who has active TB Immunocompromized status A person without adequate healthcare Preexisting medical condition or special treatment Emigration to countries with high prevalence of TB Institutionalization jails, home for the aged, orphanages Living in overcrowded and substandard housing Being a healthcare worker performing in high risk environments o o o o

Pathophysiology o Factors exposure of susceptible person to infection compromised/inadequate immune system response the body initiates inflammatory reaction this tissue reaction results in the accumulation of exudates in the alveoli the tubercle ulcerates, releasing cheesy material into the 71

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN bronchi then becomes airborne resulting in the further spread of the disease the ulcerations heal and become a scar tissue this causes infected lung to become more inflamed resulting in further development of tubercle formation S/Sx 1. Over fatigue; lack of O2 2. Weakness 3. Anorexia (weigh loss) 4. Night sweats 5. Low grade fever 6. Cough that produces purulent sputum, occasional Hemoptysis and chest pain Dx Test o o CXR to detect lesions or cavitations in affected lobe Tuberculin Skin Test tubercle bacillus extracts with purified protein derivative; given ID in the lateral aspect of the forearm; results are drawn after 48-72 hours (+) if it has redness/Erythema in affected site o Stains and cultures of sputum, CSF, Urine, drainage from abscess/pleural field (pleural effusion) Medical Management o Antitubercular therapy (Isoniazid or INH isonicotinylhydrazine, Rifampicin, Streptomycin, Pyrazenamide, Ethambutol or combination of INH and Rifampin o Deafness may be a side effect of antitubercular meds o ***Treatment lasts 3mos 6mos-1yr Nursing Diagnosis includes o Ineffective airway clearance r/t copius tracheobronchial secretions o Knowledge deficit about treatment regimen and preventive measures o Activity intolerance r/t fatigue, altered nutrition status and fever Nursing Interventions Promoting airway clearance (inc fluid intake postural drainage) Advocating adherence to treatment regimen Promoting activity and adequate nutrition Monitoring and managing potential complications, malnutrition, side effects of medication, multidrug resistance and spread of TB infections) o Promoting home and community based care by teaching self care 3. Lung Abscess - Is a lung infection accompanied by pus accumulation and tissue destruction, abscess may be putrid due to anaerobic bacteria - May be a complication of upper airway infections Causes: o o o Necrotizing pneumonia often the result of aspiration of oropharyngeal contents Poor oral hygiene with dental or gingival dse. Septic pulmonary emboli 72 o o o o

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN Pathophysiology Infection in the lungs or obstruction in the bronchi abscess becomes surrounded, or encapsulated, by a wall of fibrous tissue the necrotic process may extend to the lumen of the bronchus or pleural space establishes communication with the respi tract or pleural cavity or both the purulent contents are expectorated continuously in the form of sputum if the pleura is involved, collection of pus in the pleural cavity results S/Sx - Cough that may produce blood, purulent, purulent or foul smelling sputum, pleuritic chest pain, dyspnea, excessive sweating, chills, fever, headache, malaise, weight loss Complications 1. Empyema accumulation of pus in a body cavity such as the chest 2. Hemorrhage 3. New growth or tumor Dx Test o o o o o o o Auscultation: Crackles/Rales, (wheezing), friction rub, decrease or absence of breath sounds may result Percussion: dullness (may be due to tumor) Palpation strong vibrations CXR reveals infiltration of fluid/secretions in the pleural cavity or bronchioles Percutaneous aspiration of an abscess or bronchoscopy Blood cultures, gram stain, culture of sputum WBC count may rise if infection is present

Medical Management Antibiotic specific for the causative microorganisms Postural drainage (slight trendelenburg) and chest physiotherapy Resection of the lesions or removal of the diseased section of the lung (lobectomy) when there is active Hemoptysis or there is no response to medical management Nursing Management o Provide chest physiotherapy including coughing and deep breathing exercises o Inc fluid intake o Provide quiet and restful environment o Unconscious patient with seizures, prevent aspiration of secretions, suctioning and positioning to promote drainage o Provide good mouth care/hygiene to eliminate unpleasant odor or taste of discharges C. Pleural Conditions disorders that occur in pleural cavity 1. Pleurisy or Pleuritis inflammation of visceral and parietal pleura that line the inside of the thoracic cage and envelop the lungs Causes o o o

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NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN o Develop as a complication of: pneumonia , TB, Viruses, SLE (Systemic Lupus Erythematosus), rheumatoid arthritis, uremia, Dresslers Syndrome (aka late pericarditis d/t MI, 6 weeks to 2 months after acute MI) S/Sx o Pleuritic pain (sharp stabbing pain that inc in respiration), dyspnea, fever, suppressed cough, pallor

Dx Test o o Auscultation reveals a characteristic pleural friction rub (directly over the area of pleural inflammation; Palpation over affected area may reveal coarse vibration) Palpation strong vibrations

Medical Management o o o Anti-inflammatory agents Analgesics Thoracentesis to remove fluid from lung cavity

Nursing Management o Stress the importance of bed rest o Administer anti-tussive (for dry cough) and pain medication as prescribed o Severe pain requires a narcotic analgesic as prescribed (overuse may cause respi depression) o Encourage to cough 2. Pleural Effusion/Empyema o Pleural Effusion excess fluid in the pleural space o Empyema accumulation of pus and necrotic tissue in the pleural space, usually associated with an infection in the pleural space, may be idiopathic or may be related to pneumonitis, carcinoma, perforation or esophageal rupture S/Sx o Dyspnea, pleuritic chest pain, fever and malaise

Dx Test o o o o CXR shows radiopaque fluid in dependent regions Auscultation reveals decreased breath sounds; rales friction rub Percussion presence of dullness over effused areas which doesnt change with respiration Pleural biopsy

Medical Management o o o o Thoracentesis Chest tube (Empyema) to allow drainage of discharges Decortication surgical removal of thick coating over the lungs Parenteral Antibiotics IV, IVTT 74

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN o O2 administration for associated hypoxia Nursing Management o Explain the procedure its purpose and effects o Instruct the client to verbalizing any discomfort and breathing during the procedure o Instruct the client to breath normally and avoid sudden movement such as coughing or sighing o Monitor vital signs during the procedure o Watch for respiratory depression or pneumothorax (sudden onset of dyspnea and cyanosis after thoracentesis o Encourage deep breathing to promote lung expansion (Semi-fowlers) o Meticulous chest tube care use aseptic technique for changing dressings around the insertion site o Ensure chest tube patency by watching bubbles in the underwater seal chamber o Record the amount color and consistency of drainage (to be recorded in the IO Sheet) take note that if fluid is removed abruptly, the client may suffer bradycardia, hypotension, severe pain, and even cardiac arrest (alveolar collapse)

1. Acute Bronchitis/Bronchitis - Inflammation of the bronchi on the lower respiratory tract usually due to infection it is common, usually a sequelae to URI Causes o Virus in most cases, rhinovirus/influenza o Bacteria S. pneumoniae, Hemophilus pneumoniae S/Sx o Persistent cough and expectorate, a small amount of mucoid sputum, fever, chills, night sweats, headache and general malaise o As the infection progresses, may have shortness of breath, inspiratory stridor and expiratory wheeze Dx Test: Sputum Culture and CXR Medical Management 1. 2. 3. 4. 5. Antibiotic for specific causative microorganism Expectorants Mild analgesics or antipyretics Endotracheal intubation for acute cases leading to acute respiratory failure Cool vapor therapy or steam inhalation

Nursing Management 1. 2. 3. 4. Increase bronchial hygiene (inc fluid intake, and coughing to remove secretions) Emphasize the need to complete the full course of antibiotic Avoid overexertion Moist heat on the chest may relieve soreness and pain 75

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 2. Chronic Obstructive Pulmonary Disease (COPD) - Refers to long term pulmonary disorders characterized by air flow resistance - Results from emphysema, chronic bronchitis, asthma or combination of these disorders - Isnt always symptomatic and may cause only minimal disability, however worsen with time Causes 1. 2. 3. 4. 5. Cigarette smoking Recurrent or chronic RTC Air pollution Allergies Familial and hereditary factors such as alpha-antitrypsin deficiency

Pathophysiology o Risk factors inflammation of the airways inc mucus production, destruction of alveolar septa and peribronchiolar fibrosis mucus plugs and narrowed airways airways enlarged upon inspiration allowing air to pass beyond obstruction hyperinflation of alveoli on expiration airways narrow and gas flow is prevented air trapping

S/Sx 1. Pain (Frontal, Ethmoid, Sphenoid, Maxillary and Occiput) 2. General malaise 3. Headache, fever 4. Post nasal drip nasal discharges 5. Persistent cough and dyspnea Medical Management Goals 1. Goal is removal of bronchial secretions 2. Improve ventilation 3. Reduce complications, promote exercise and promote/improve general health Medical Management 1. Inhaled bronchodilators by nebulization 2. Long term O2 therapy 3. Pulmonary rehabilitation the goal: a. To restore the patients level of independent function b. To improve patients quality of life Consists of educational, psychosocial, behavioral, and physical components Breathing exercise program (such as purse lip breathing| to improve functional status and methods to alleviate symptoms

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NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN Nursing Management 1. 2. 3. 4. 5. 6. 7. 8. 9. Teaching patient and SO about COPD Breathing exercises Activity pacing Inspiratory muscle training Self care activities Physical activities Physical conditioning perform activities that can be tolerated Precautions for O2 therapy (steps and preparation) Coping measures be active in group activities, prayer meeting, group therapy measures

Nursing Dx o o o o o o o Impaired gas exchange r/t ventilation perfusion inequality Ineffective airway clearance r/t bronchoconstriction, increased mucus production, ineffective cough and bronchopulmonary infection Ineffective breathing pattern r/t SOB, mucus, bronchoconstriction and airway irritants Self care deficit r/t fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation Activity intolerance d/t fatigue, hypoxemia, and ineffective breathing patterns Ineffective individual coping r/t reduced socialization, anxiety, depression, lower activity level, and inability to work Knowledge deficit of self care to be performed at home

*** droplet infection 1-5 micrometer A. Asthma - Chronic inflammatory disease of the airways in which inflammation causes varying degrees of obstruction in the airways - It is intermittent acute attack can occur in minutes or hours, it is unpredictable - There are symptom-free periods - The attack usually occurs at night and early morning - Can begin at any age, it may develop in childhood at before the age of 40 - It affects ones lifestyle Classification of Asthma 1. Extrinsic environmental allergens (dust, smoke, change of humidity in the environment) 2. Intrinsic reaction of the body from non-allergic causes; internal/biological cause: stress, over fatigue, emotions-crying, anger S/Sx 1. Dyspnea/SOB 2. Cough 3. Wheezing 77

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 4. Prolonged expiration (to expel retained air in the lungs CO2) - D/t excessive retention of CO2 o Late symptoms: cyanosis, sweating, tachycardia o Complications: Status asthmaticus the client is not anymore responding to medications and may result to respiratory failure - Workload of the respiratory system is increased; breathing rate is 5-10 times more than the eupneic breathing, tachypnea to hyperventilation may lead to right sided heart failure acute cor pulmonale heart is already involved in respi failure decreased blood flow to the heart decreased BP and Pulse decreased venous return may lead to hypoxemia may lead to respiratory failure and cardiac failure - Last recourse is tracheostomy attached to ventilator Pathophysiology Predisposing Factors (Extrinsic and Intrinsic Factors) inc IgE stimulation hypersensitivity reaction of body from predisposing factors degranulation of mast cells Histamines Bradykinins Leukotrienes Prostaglandins Airway Hypersensitiveness/Hyper-responsiveness Mucus Secretions Non-Productive Coughing Inflammation Bronchospasms Dyspnea, SOB, DOB, Tachypnea, Chest Tightness, Wheezing During Expiration

Dx Test 1. Pulmonary Function Test reveal signs of airway obstruction, low/decreased vital capacity, inc residual volume and inc functional residual volume because of air trapping 2. Serum IgE inc 3. CXR may reveal hyperinflation of the alveoli because of air trapping; some parts of the lungs may have atelectasis due to poor ventilation 4. ABG inc PaCO2; hypoxemia, dec O2 saturation 5. Skin Testing test for specific allergens the client is hypersensitive to 6. Bronchial Challenge test with the use of non-specific agent is applied to bronchi and assessed for bronchoconstriction reaction histamine or metacholine 7. Pulse Oximetry may show a reduced saturated O2 level Medical Management 1. Bronchodilators reduce airway edema and increases pulmonary ventilation; reduces vasoconstriction 2. Corticosteroids anti-inflammatory 3. Mast cells stabilizers Cromolyn Na (is an example of a mast cells stabilizer) prophylactic; Nidocromil effective in allergic asthma - Mast cells constituent of connective tissue containing large basophilic granules that contain heparin, serotonin, bradykinin, histamine 78

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 4. O2 Low Humidified needed to treat dyspnea, cyanosis, and hypoxemia; recover from asthma attack 5. Anti-IgE Therapy - still under investigation because of its association to the cause of asthma 6. Sedation to blunt the client response effort to prevent further air trapping that may lead to further inc in BP 7. O2 Therapy/Inhalation if result in pulse oximeter is low; continuous O2 inhalation is recommended 8. ET Intubation and Mechanical Ventilation Nursing Management o o o o o o Asses the patients respiratory status by monitoring severity of symptoms RR Rhythm and Pattern Obtain a history of allergic reactions especially to medications Obtain a history of allergic reactions especially to medications Monitor patients response to medication Assist in intubation if needed Keep the patient and family informed about the condition and any procedures to be performed

Nursing Diagnosis 1. Ineffective breathing pattern r/t impaired respiratory pattern 2. Ineffective airway clearance r/t increased production of secretions 3. Impaired gas exchange d/t air trapping 4. Risk for decreased tissue perfusion 5. Activity intolerance r/t exacerbations or acute attack of disease 6. Imbalance nutrition less than body requirements 7. Disturbed sleeping pattern related to acute attack of the disease 8. Knowledge deficit r/t lack of information 9. Self care deficit d/t acute attack of disease 10. Altered sexual pattern 11. Sexual dysfunction 12. Risk for decisional conflict r/t changes in lifestyle and environment B. Emphysema - Abnormal permanent enlargement of acini accompanied by destruction of terminal bronchioles and alveolar walls - Caused by recurrent inflammation or absent of enzyme antitrypsin or both - Presence of over distended, non functional alveoli which may rupture resulting to loss of aerating surface - -Antitrypsin enzyme is normal defense mechanism against protease and elastase Classification based on the changes taking place in the lungs 1. Paraseptal (Panacinar) - There is a de3struction of the alveoli in the lower lobes of the lungs - Patient with this type of emphysema has hyperinflated chest (barrel chest) 2. Centrilobular (Centriacina) - The pathologic changes take place in the bronchioles usually in the upper lung regions, but usually the alveolar sac remains intact 79

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 3. Panlobular - Affects both the bronchioles and the alveoli commonly involved in the lower lungs. This occurs most often in smokers S/Sx 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Cough Dyspnea Cheat pain Sputum production Adventitious breath sounds Pursed lip breathing Tend to assume upright, leaning forward position Alteration in LOC Cyanosis Skin cool to touch Decreased metabolism Weakness, fatigue Anorexia, weight loss

Dx Test 1. 2. 3. 4. 5. CXR hyperinflation, low flat diaphragm Pulmonary Function Test increase vital capacity ABG analysis hypoxemia, dec O2, inc PaCO2; no effective gas exchange; hypercapnea Inc Hgb/Hct compensatory mechanism from hypoxemia Chest CT Scans presence of obstruction in air flow

Therapeutic Management Improve ventilation Bronchodilators, corticosteroids, O2 Remove bronchial secretions nebulization, postural drainage, chest physiotherapy Promote exercise aerobic exercise to respiratory muscles, breathing exercises Control Complications edema and cor pulmonale are treated with diuretics and digitalis. Phlebotomy may reduce the blood volume and reduces cardiac workload o Improve general health promote healthy life style, avoid allergens, avoid high altitude, adequate nutrition C. Pulmonary Edema - Abnormal accumulation of fluid in the lung tissue and/or alveolar space; a severe life threatening situation - This occurs as a result of: Increase microvascular pressure from abnormal cardiac function Hypervolemia or sudden inc in intravascular pressure on the lungs, in cases of pneumonectomy or lobectomy o o o o

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NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN S/Sx o Inc respiratory distress, characterized by: Dyspnea, air hunger, and cyanosis of the lips and nails, anxious, foamy/frothy blood tinged secretion, confused and stuporous in severe cases

Dx Test 1. Auscultation reveals crackles in the lung bases that rapidly progresses towards the apices of the lungs d/t the movement of air through the alveolar fluid 2. CXR reveals increasing interstitial markings 3. Pulse oximetry values begin to fall 4. ABG analysis inc hypoxemia Medical Management o o o o o Vasodilators Diuretics d/t fluid overload (client is on fluid restriction; IV drip count is done per minute) O2 inhalation to correct hypoxemia Intubation and mechanical ventilation is given if necessary Morphine in severely anxious clients and those in pain

Nursing Management Assisting with administration of O2; intubation and mechanical ventilation if respiratory failure occurs o Administer medications prescribed and monitor response to medication o Measure intake and output and record o Monitor vital signs and respiratory status D. Chest Tumors - Maybe benign or malignant arising within the lung, chest wall or mediastinum - It can be a metastasis from a primary tumor site elsewhere in the body - It is frequently occurs because the bloodstream transport cancer cell elsewhere in the lungs Lung Cancer (Bronchogenic CA) Arise from a single transformed epithelia cell in the tracheobronchial airways due to environmental carcinogenic factors binds to cells DNA and damages it this damage results to cellular changes growth and eventually malignant cells Cancer o

Risk Factors 1. Genetic predisposition and underlying disease (COPD) 2. Tobacco smoke (Tar content) 3. Second hand smoke people who are involuntarily exposed to tobacco smoke in a close environment (home, car or building) 4. Environmental and occupational exposure (motor vehicle emissions and pollutants in the environment) 81

NCM202B_A NCM of Clients with Disturbances in Gas Exchange and Utilization Ms. Maria Fe Juen, RN MN 5. Dietary smokers who eat a diet low in fruits and vegetables which are rich in Vit A b/c of eating less -carotene or other compounds found in fruits and vegetables S/Sx o o o o o o o o o Dx Test 1. 2. 3. 4. CXR CT Scans Sputum cytology ABG, pulmonary function test Cough or change in a chronic cough that is dry, persistent, without sputum production Cough may become productive when theres presence of infection Wheezing (when bronchus becomes partially close with tumor) Dyspnea Hemoptysis/blood tinged sputum Chest/shoulder pain may indicate chest wall or pleural involvement and bone metastasis Chest pain and tightness, hoarseness, dysphagia, head and neck edema Symptoms of pleural or pericardial effusion Non specific symptoms of weakness, anorexia, weight loss

Medical Management Radiation therapy and chemotherapy Gene therapy with define tumor antigens, more specific therapies to modulate the immune system (still under the study that show promise in treating lung CA) o Immunotherapy still investigational o Surgery (In many patients with Bronchogenic CA, the lesions is inoperable at the time of diagnosis) However, if surgery has to be done, these are the following: Surgical resection for localized tumors , no evidence of metastatic spread and adequate cardiopulmonary function Lobectomy removal of a lobe of a lung] Pneumonectomy a entire lung is removed Nursing Management 1. Managing symptoms 2. Relieving breathing problems 3. Reducing fatigue 4. Referral to pulmonary rehabilitation 5. Psychological Support o o

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