 Molecular

exchange of
oxygen and
carbon dioxide
within the
body’s tissues
(Mosby,2006)
 Theprocess by
which gases are
moved into and
out of the lungs
(Mosby,2006)
 The passage of
fluid through a
specific organ
or an area of the
body (Polaski and
Tatro,1996)
 is the process by which oxygen in
the air is brought into the lungs
and into close contact with the
blood, which absorbs it and
carries it to all parts of the body
 Chief complaint
 Signs and Symptoms
 Past Medical History
 Family History
 Psychosocial History and Life-style
 What are the current respiratory symptoms?
 When did each symptom start?
 What is the perceived cause of the
symptom?
 When do the symptoms affect the client?
 What helps to relieve the symptoms?

N.B.: Clients under acute and emergency

situations
 Coughs
› When did it start?
› How long?
› Any pain?
› Sputum?
 Sputum Production
› Color? (clear, yellow green, rust, bloody)
› Odor
› Quality (watery, stringy, frothy, thick)
› Quantity (teaspoon, tablespoon, cup)

FYI: The tracheobroncial tree normally

produces 3 ounces of mucus per day
as part of our normal cleansing
mechanism
 Hemoptysis
› Blood expectorated from the mouth in
the form of gross blood, frankly bloody
sputum, or blood tinged sputum
› Lungs, stomach and epistaxis
› Result of forceful coughing?
› Amount?
 Adventitious Breath sounds
› Wheezing
 Produced when air passes through partially
obstructed/ narrowed airways on expiration
Inspiratory wheezing
Audible /stethoscope
When? Relieves itself? Requires medication
› Stridor
Produced when air passes through partially
obstructed/ narrowed upper airways on
inspiration
Voice changes? (character, hoarseness)
difficulty swallowing
sleep related disorders
head aches
weight gain
fluid retention
Apnea
and restlessness)
 Chest pains
› Retrosternal pains – burning, constant and
aching sensations
 Does the pain/discomfort get better or
worse when changing body position?
 Is the pain/discomfort better or worse with
respirations?
 Is the pain/discomfort intense, dull, or
knifelike?
 Is the pain/discomfort deep or close to the
surface?
 Frequent colds, Sinus infections, Nasal
trauma, Epistaxis (hypertension)
 Childhood and Infectious diseases (TB,
Bronchitis, influenza, asthma, pneumonia,
URI)
 Immunizations – pneumovax
(Pneumococcal Pneumonia)/ flu
 Major illnesses and Hospitalization
 Medications – prescribed/OTC
 Allergies
 Respiratory diseases (Asthma,
emphysema, COPD, lung cancer,
respiratory infections, tuberculosis, and
allergies)
 Occupational/Environmental Exposure
and Geographic Location
› Home, hobbies, work environment
› Exposure to pollutants/ air toxins
› Travel to areas where respiratory
diseases are prevalent
› Living quarters/ Place
 Smoking
› (years of smoking x packs per day = pack
years)
 Alcoholism – ciliary action, decrease
mucus clearance, depress gag reflex
 Drug (Legal/Illegal)Overdose –
respiratory failure
 Exercise
 Inspection,Palpation, Percussion and
Auscultation
 Tachypnea, grasping, grunting, central
cyanosis, open mouth, flared nares,
dyspnea, color of facial skin and lips,
use of accessory muscles
 IE ratio
 Chest wall configuration
 Chest movement
 Fingers and toes – cyanosis, clubbing
<A>
 Trachea – masses, deviation, etc.
 Chest wall - movement, ease and
symmetry using the heel/ulnar aspect
of the hand
 Thoracic Excursion
 Tactile fremitus
 Resonant, Hyper-resonant, dull,
tympanic, or flat
 Apices, Bases, posterior to lateral areas
 Normal breath sounds
 Adventitious breath sounds
 Avoid the bony areas
 Arterial Blood Gas
Analysis (ABG)
› Measures the PaO2,
PaCO2 and pH
› Oxygen saturation,
HCO3

› PAO2- efficient of gas

exchange
(ventilation/perfusion)
› PaCO2 – efficiency of
ventilation
 Pulmonary Function Test (PFT)
› Evaluation of the lungs (lung volumes, lung
mechanisms, diffusion capabilities of the
lungs)
› Determines: Presence of pulmonary
disease or abnormality of the lung
function, extent of abnormalities, Severity
of impairment, Progression of the disorder,
appropriate treatment
 Pulse Oximetry
› Measures oxygen saturation
› Noninvasive, uses a beam of light
› <B>
 Chest X-ray
› consolidation
 Thoracentesis – air/fluid in the pleural
space
 Biopsy
 Sputum Collection
 Subjective
› Verbalizations
 Objective
› Physical
 Short term – uneasiness, dizzyness, pale skin,
nailbeds, acute hearing, use of accessory
muscles, impaired breathing pattern
Long term – unequal chest expansion,
cyanosis, fainting, comatose, death
• A sensation of difficult
or uncomfortable
breathing or a feeling of
not getting enough air.

• No standard definition
exists for difficulty
breathing
 Inadequate supply of 02
› High altitudes
› Smoke inhalation
› Carbon Monoxide poisoning
› Dilution of inspired air with inert gases
 Interference airway
› Mechanical Obstruction
 Children – aspiration
 Unconscious adults – tongue, aspirated
vomitus, dentures, mucus
 Abnormal functioning bellows motion of
chest wall and diaphragm
› Trauma to chest wall
› Muscle or nerve trauma or impairment
ex. Hiatial hernia
 Adequate number of terminal resp. units
for diffusion
› Emphysema, Pulmonary edema, damage
alveolar-capillary membrane, Physiologic
shunts, Adult respiratory distress syndrome
•Inadequate amount of
hemoglobin
Ex. Severe anemia, Carbon
Monoxide poisoning,
Methemoglobinemia
•Non-functioning/Impaired
respiratory center
Depression of respiratory
center
Increased intracranial
pressure
 Impaired circulatory
system and
ineffective heart
pump
› Heart arrhythmias
› Congestive heart
failure (CHF)
› Heart arrhythmias
› Coronary artery
disease
› Heart attack
› Hemmorage
 Positioning and Posture
› Chest and head are elevated – expansion of
lungs and improves efficiency of resp. muscles
› Semi-Fowler’s – moderate resp. distress
› Sitting upright position leaning on a padded
overbed table with arms resting on the table –
improve secondary inspiratory muscles
› Standing – straight posture while leaning forward
 Environmental Conrol
› Air pollution
› Smoking
› Allergens
 Activity
and Rest
 Oral Hygiene
› Clear secretions
› Breathing through the mouth – dry oral
mucosa – risk of stomatitis (yeast)
› Essential after administration of
mucolytics, steroids, antibiotics, and
enzymes
› Improve appetite and promote well being
› No gas forming foods
 Hydration and Suctioning
› Liquefy bronchopulmonary secretions
› Prevents constipation and fluid imbalances
› 3000-4000 ml of fluid per day
Oral (Yankauer) suction tube. A wall suction unit.
Pneumostat. It uses a one-way valve and
has a small collection chamber.
 Infection
prevention and Control
 Psychosocial Support
› Anxiety = worsen symptoms (dyspnea and
bronchospasm)
 CLASS EXAMPLE USE

Antimicrobials Penicillins, Bactericidals and

Cephalosporins, Bacteristatics
Tetracyclines,
Aminoglycosides,

Cough Preparations Expectorants , Facilitate productive

cough

Decongestants Reduce allergy and

symptoms
 CLASS EXAMPLE USE
Bronchodilators Beta-Allergenics, Symptomatic relief
Theophylline of asthma and
bronchial spasms
Adrenal gluco- Predisone, Symptomatic relief
corticoids Beclomethasone and preventive care
of asthma
Antitussives Narcotics: Codiene To treat dry, non
Non Narcotics: productive cough
dextromethorphan that interfere with
sleep/activites

Mucolytics Water Thin mucus

acetylcycteine

Antiallergenics Cromolyn sodium Chronic pulmonary

conditions that lead
to dry sputum
Antihistamines Diphenyhydramine Relieve symptoms
HCl, terfenadine of allergies
 Oxygen Administration
 Facilitating Effective coughing
 Artificial Airways
 Mechanical Ventilators
 Administering Oxygen
› Require when hypoxemia occurs of
expected to occur
› Does not cure
› Indications: Reduced arterial blood oxygen,
increased work of breathing, and
decreased myocardial workload
 Oxygen Induced Hypoventilation
› Primary resp. centers(medulla and pons) –
inc. CO2
› Secondary resp. centers (carotid bodies, arch
of aorta) – dec. in O2
› Administration of oxygen would decrease
ventilation
 Oxygen Toxicity
› Prolonged exposure to high conc. of
oxygen
› Pathologic: 24-48 hours
› Symptoms: mild tracheobronchitis,
substernal soreness, nasal congestion,
pain on inspiration, and inc. coughing
› May cause structural damage to lung
tissue; impair transport of 02
› ABG monitoring
 Ocular Damage
› Exposure of cornea and lens to 100 %
oxygen
› tearing, of retina, edema and visual
impairment
 Familiar with various methods of 02
admin.
 Knowledgeable of 02 therapy –
administer and detect equipment
malfunction
 Masks, nasal
cannulas, face
tent, ventilator, or
nebulizer
A nasal cannula.
A simple face mask.
A partial rebreather mask. A nonrebreather mask.
A Venturi mask. – inspired air + fixed oxygen conc.
oxygen face tent.
Pediatric oxygen tent. oxygen tank on a wheeled stand
 Low flow - supplement
 High flow – meet/ exceeds the clients
inspiratory flow rate – accurate delivery
of inspired oxygen

 Oxygen and compressed gases are dry

 Humidity – water vapor in air
 Aerosol – suspension of solid/liquid
particles in a flow of gas
 Addition of water vapor to inspired gas
› Prevents drying and irritation
› Prevents drying and thickening of
secretions
› Loosens secretions
Insert flow meter into the wall unit.
This flow meter is set to deliver 2 L/minute.
 Used to hydrate the airways
 Administer of aerosolized medication
 Therapy for mobilization of secretions
 Water, isotonic saline and 0.25 to 0.45% saline
 May be done before Intermittent Positive
pressure breathing treatments and postural
drainage (Mist Therapy)
 After tracheostomy

*May have bronchospasm – bronchodilator

therapy
A tracheostomy mist collar.
 Effective Coughing
› Augments the ciliary clearance
mechanisms, thus maintaining patent
airways
› Uses the diaphragm, proper posture, slow
and deep stacked breaths, and short
expulsive blasts of air to , mobilize and
expectorate secretions
 Ineffective coughing
› Collapse of airways
› Rupture of thin walled alveoli
› Pneumothorax
› Dangerous for unstable cardiac and
cerebral function
 Assume a position that will facilitate
effective use of abdominal muscles –
sitting position with knees slightly flexed
 Take slow, deep inspirations,
diaphragmatic breathing
 Do a Valsalva type maneuver
 Exhale through pursed lips – movement of
secretions tracheobroncal cough reflex
centers
 Learn cough technique before it is
intended
 Encourages maximal breathing
 Involves visualization of amount of
volume of inspired air on the
spirometer
 Goal or volume is set by practitioner
 Exhale to a point of comfort
 Place the mouthpeice
 Inhale through the mouth only until goal
is attained
 Hold for 3 to 5 seconds
 Exhale normally
 Rest
 Repeat
 Diaphragm is used, not accessory
muscles
 Increased tidal volume, decreased RR,
inc. exercise tolerance and inc. in
alveolar ventilation
 Abdomen rises when inhalation
 Contracts upon exhalation
 Position the patient (Semi-Fowlers with
knees bent)
 Place thumbs in the epigastric notch,
spread fingers around lower ribs
 Inhale; press the thumbs against abdominal
wall with slight pressure
 Pause naturally (smooth ventilation pattern,
even distribution of air)
 Exhale; press inward and upward (Contract
abdominal muscle, pursed lip)
 Ideally, the length of IE ratio is 1:2
 Additional work on inspiratory muscles
during diaphragmatic breathing
 Inspiratory muscle strength and
endurance is improved
 Flow resistor with a one way valve
 Inhale; closes with resistance
 Exhale; opens with minimal resistance
 Prevents airway collapse
 Helps empty the lungs more
completely
 Inhale through the nose
 Exhale through pursed lips
 Combination of percussion over the chest
wall, vibration, coughing, deep breathing
 Usually done by physiotherapists
 Done to mobilize secretions, inc. exercise
tolerance, improve ventilation and restore
effective breathing patterns
 Should be done 2 hours before meal to
avoid vomiting and aspiration
 Percussion – indirect clapping on chest wall
with cupped hands
Vibration- energy waves from the hand are
used to move secretions from affected lung
areas during expiration

<C>
 Positioning a client so that gravity is
used to drain specific lung segments or
retained secretions
 Pillows and towels used to support
joints
 5 to 10 mins.
 Discontinue if cyanosis, dyspnea,
change in VS, no more secretions, non
productive cough occurs
 Maintain airway patency

 Oral (Oropharyngeal)
 Nasal (Nasolpharyngeal, Nasal
Trumpets)
 Endotracheal
 Tracheostomy
› Length: distance between lips
and the angle of the jaw
› Too long; gagging
› Too short; increase airway
obstruction (tongue)
› Contraindication:
Consciousness, facial
fractures, or foreign body in
the oral cavity
› Short term

<D>
 Hollow, soft rubber tube
 Nares to the base of the tongue
 Length: Nose to the Earlobe
 Diameter: smaller than the nostril
 Patients who cannot tolerate oral airways,
frequent nasotracheal suctioning(avoid
trauma to mucus membranes)
 Should be rotated every 8 hours
 If longer than a week, use endotracheal
tracheostomy tubes instead
 Long, slender, and hollow tube
 Inserted to the trachea (carina) via
mouth or nose
 Passes to the vocal cords
 Oral – short term
 Nasal – long term, more secure, more
comfortable, risk for sinusitis
 Surgical opening made into the trachea
› Avoid complication in the upper airways, stable, easy
suctioning and ready attachment of equip.
› Can eat and talk
 Indications:
› Need long term artificial airway
› Upper airway obstruction
› Upper airway bleeding
› Altered level of consciousness
› Inability to clear lower airway secretions
› Continuous mechanical ventilations
› Sleep apnea
› Airway burns
Block
 Ventilates the lungs
 Indications: Inadequate ventilation and
hypoxemia
› Intermittent Positive-Pressure Breathing
› Positive End-Expiratory Pressure and
Continuous Airway Pressure
› Pressure support Ventilation
› High Frequency Ventilation
› Unilateral Lung Ventilation
 Assisted (Person Cycled)
 Controlled (Machine Cycled)
 Pressure cycled ventilator to deliver
pressurized breaths to a spontaneously
breathing client
 10 to 20 mins
 Adjusts and controls the inspiratory flow
pressure and flow rates to match the
particular degree of an individual patient's
condition
 maintenance of positive pressure at
the end of expiration, increasing the
opportunity for gas exchange
 Disadvantage: increase in intrathoracic
pressure
 Augments spontaneous resp. effort
with a preset level of positive airway
pressure
 Forpatients with severe noncompliant
lungs
 Required tracheal intubation that
permits separate ventilation for each
lung; different volume per lung
 Mosby A., (1991) Medical-Surgical Nursing: Concepts
and Clinical Practice, 4th ed. Mosby Year Book,Inc. ;USA
 Mosby E.,(2006) Mosby’s Pocket Dictionaryof Medicine,
Nursing and Health Professions.5th ed. Elseviier Pte.Lte.
; Singapore
 Polaski A. and Tatro S., Luckman’s Core Principles and
Practice of Medical-Surgical Nursing, W.B. Saunders Co.;
USA
 www.scribd.com/doc/14097540/NCP-of-Difficulty-of-Breathing
Retrieved on Sept. 7,2009
 www.accrn.org/dob Retrieved on Sept. 7,2009