Respiratory

Three common nursing diagnosis/Problems and associated outcomes: *Respiratory nursing diagnoses include Ineffective Breathing Pattern, Ineffective Airway Clearance, and Impaired Gas Exchange *The patient will demonstrate knowledge regarding prevention of respiratory dysfunction. *The patient's tissues will have adequate oxygenation. *The patient will mobilize pulmonary secretions. *The patient will effectively cope with changes in self-concept and lifestyle.

*NANDA Diagnosis CHART Health Promotion *prevent respiratory dysfunction has become an increasingly important nursing role. *The nurse and other healthcare professionals can work with organizations such as the American Lung Association (ALA) to provide programs to reduce smoking and pollution and to improve working conditions contributing to lung disease. *More commonly, the nurse works with people in various settings (e.g., ambulatory clinics, schools, industry, and public health) to teach and promote pulmonary health.

*A concentrator is a device that chemically separates oxygen from room air. It is an excellent choice for the patient who requires continuous oxygen in low concentrations. *Make suggestions for modifying ADLs based on thoroughly assessing the extent to which respiratory dysfunction has affected each activity. *For example, consider the following: If meal preparation is a problem, a referral to a Meals on Wheels program may be appropriate. *If mobility is impaired, sponge baths may be a practical alternative to tub bathing. *An elevated toilet seat may help decrease the work needed to rise from the toilet.

*Offer suggestions for activities outside the home. *Social outlets can help the patient to cope with the day-to-day frustrations of lung disease. *The ALA sponsors classes and support groups for people with respiratory disease. Nurses, providers, or therapists often are guest speakers at such gatherings. *Rehabilitation programs offer more structured activities. Their purpose is to increase the patient's ability to function with lung disease. Such programs may provide breathing retraining, exercise, and diet and occupational counseling.

ABG'S *In addition to oxygenation, arterial blood sampling also indicates how effectively the lungs are removing carbon dioxide. *The lungs' regulation of this metabolic waste product is essential for the blood's normal acid-base balance. *The carbon dioxide level affects many functions, including the drive to breathe, affinity of hemoglobin for oxygen, and cardiac function. *The PaCO2 stays nearly constant in the person with healthy lungs. A PaCO2lower then 35 mm Hg indicates hyperventilation, or breathing in excess of metabolic needs. *Healthy people are able to hyperventilate voluntarily. *Hyperventilation is common during an asthma attack and occurs in some patients with head injuries. It may also occur involuntarily during extreme anxiety.

ABG'S *A PaCO2 above 45 mm Hg indicates hypoventilation, in which breathing rate and depth are insufficient to clear carbon dioxide adequately from the blood. *Severe airway obstruction causes hypoventilation, which is a serious problem for patients with advanced COPD. *Respiratory failure is another cause of hypoventilation in patients whose respiratory drive has been diminished by opioids, barbiturates, or trauma.

Sputum Culture *Once the sputum sample is obtained (see Procedure 26-2), the patient may be treated with a broad-spectrum antibiotic until the culture report is back, at which time, the antibiotic may be changed to a drug that is more sensitive to the infectious agent.

ABG's *Arterial blood levels of oxygen (PaO2), carbon dioxide (PaCO2), and pH are the most reliable indicators of gas exchange. *PaO2 is one of the best indicators of how much oxygen is available to tissues. When the PaO2 is lower than normal, tissues may experience hypoxia. *This development is dangerous to all tissues and organs but can be especially damaging to the heart and the brain. *Although PaO2 normally declines with age, an abnormally low PaO2 always indicates gas exchange problems. *PaO2decreases in direct proportion to the severity of lung impairment (Box 26-2).

Chest Physiotherapy *Not all postural drainage positions are well tolerated by all patients. *The Trendelenburg (head-down) position can increase shortness of breath in the patient with COPD because the abdominal organs limit diaphragm movement. *Lying head down can increase intracranial pressure and is contraindicated for patients with acute head injuries. *It can also be very stressful for patients with cardiac problems. The nurse or therapist who administers postural drainage may need to modify the treatment for patients who cannot tolerate the prescribed positions.

Aerosol Therapy *An aerosol is a suspension of microscopic liquid droplets in air or oxygen. *Aerosol therapy may be given for any of the following reasons: To add moisture to oxygen delivery systems To hydrate thick sputum and prevent mucous plugging To administer various drugs to the airways

Aerosol Therapy *A large-volume nebulizer or an ultrasonic nebulizer will deliver a moist fog continuously to the airways. *While absorbing the water, the mucous blanket loosens, which facilitates its removal. *The watery mist also soothes inflamed airways. Heating the water in the nebulizer increases the amount of moisture delivered.

Aerosol Therapy *Check the reservoir frequently to ensure that it is filled with sterile water. *Parts must be screwed together tightly to ensure full delivery of the prescribed level of oxygen. *The large-bore tubing must be drained often to prevent buildup of condensation. Monitor the mist temperature to prevent possible injury. *Finally, because aerosols loosen dried secretions, help the patient remove secretions by instructing the patient to cough or by suctioning.

Assisted Ventilation *To optimize the benefits, experienced personnel should administer positive pressure therapy. *The nurse or respiratory care practitioner (RCP) must assess each patient's breathing needs and individualize treatment accordingly. *Encourage all patients who use CPAP or bilevel positive airway pressure to bring their equipment to the hospital so that potential respiratory complications can be avoided.

Artificial Airways *device inserted through the mouth, nose, or throat to provide direct access to the lungs. *Oropharyngeal airways, nasopharyngeal airways ("nasal trumpets"), endotracheal tubes, and tracheostomy tubes are examples of artificial airways.

Assisted Ventilation *Bilevel positive airway pressure therapy uses a mechanical ventilator to assist inspiration. *The patient's inspiratory effort triggers the ventilator, which pushes air into the lungs. *The positive pressure helps to prevent and treat atelectasis by helping to open underinflated alveoli. *Bilevel positive airway pressure delivers higher pressures during inspiration and lower pressures during expiration to keep airways open. *Continuous positive airway pressure (CPAP) uses oxygen under constant pressure to accomplish this objective. *CPAP is often used at night to decrease periodic hypoxemia associated with sleep apnea.

Assisted Ventilation *CPAP is delivered via specially fitted masks or nasal prongs that are attached to a machine that delivers appropriate pressure. *Many patients do not tolerate CPAP or bilevel positive airway pressure well because the equipment is claustrophobic and noisy. *When these devices are used, the individual controls the respiratory rate and depth. *It is important to note that bilevel positive airway pressure or CPAP does not breathe for the patient and never replaces a ventilator for a patient who requires ventilatory support. *Patients using CPAP or bilevel positive airway pressure devices should always have the physical and cognitive ability to remove the mask in case of vomiting.

Assisting with Incentive Spirometry *The incentive spirometer motivates the patient to breathe deeply by offering the incentive of measuring progress. *Models of incentive spirometers vary greatly, but all provide the patient with some observable indicator of how deep a breath he or she has taken. *Some models use a bellowslike device that deflates as the patient inspires; others use ping-pong balls that float. Regardless of the device, the patient is visually motivated to take increasingly deeper breaths.

Assisting with Incentive spirometry *The patient and nurse set realistic goals for each breathing session, and the patient works independently toward achieving each goal. *Incentive spirometry motivates the patient to take responsibility for the progress of deep-breathing therapy. *A reasonable therapy schedule is 8 to 10 breaths hourly during waking hours. *To avoid hyperventilation, encourage the patient to perform the exercises slowly. Procedure 26-6 explains the details of this technique. Document the results of the exercise in the medical record.

Percussion *Percussion is used to detect fluid-filled or consolidated portions of the lung. *A keen ear and experience with pulmonary assessment are needed to interpret correctly the various alterations in pitch, intensity, duration, and quality of percussion notes.

Ausculation *Listening to breath sounds with a stethoscope provides vital information for evaluating the patient's respiratory status. *The most important reason for listening to the chest is to determine if air is moving through all areas of the lung. *When auscultating with a sensitive stethoscope, you should be able to hear air moving in all lung fields. Breath sounds should be equally loud on both sides of the chest (Fig. 26-7).

Auscultation *Absent or distant-sounding breath sounds in any area of the lung can indicate airway obstruction or can mean that fluid or air has accumulated in the pleural space. *A "silent chest" in a patient with asthma who is experiencing severe shortness of breath is a grave sign of poor ventilation and impending respiratory failure *The quality of breath sounds can also be assessed by auscultation.

Auscultation *Normal breathing should make soft, rustling sounds, like a breeze blowing gently through leaves on trees. *Inspiratory breath sounds are typically louder and longer than expiratory sounds. Nurses must also become familiar with abnormal breath sounds (Table 26-2). *Official nomenclature (as developed by the American Thoracic Society) is presented here, but be aware that alternative terminology is commonly used.

Pulmonary Function Test *Specialized breathing tests measure lung size and airway patency. *Spirometry produces graphic representations of lung volumes and flows. These graphs are essential in determining the severity of a patient's restrictive or obstructive lung disease. *Common measurements include tidal volume, vital capacity, and forced expiratory volume in 1 second (FEV1). *More highly specialized pulmonary function tests can provide additional information on lung function, characteristics, and capacities.

Bronchoscopy *allows the physician to visualize the airways directly. *A flexible fiberoptic tube connected to a viewing screen is inserted through the patient's nose. *A handheld control directs the scope into the trachea and bronchi. *The bronchoscope can be used to collect sterile sputum specimens or tissue samples for laboratory examination or to withdraw large sputum plugs or aspirated objects obstructing the airways.

Dyspnea *Shortness of breath is a subjective symptom of lung problems. *Some patients with severe lung disease appear to breathe with great difficulty, yet at such times, they may report that their breathing is fine. *Others may complain of severe dyspnea even when objective data (e.g., blood gas values or pulmonary function tests) indicate no apparent problem. Family members and people close to the patient are helpful in providing supportive information.

Chest Pain *Ask the patient if he or she has any chest pain and to describe the characteristics of the pain. *Chest pain can be associated with various conditions, some of which are respiratory disorders. *Diseases characterized by inflammation or infection often cause pain. *Inflammatory mediators such as histamine may directly stimulate nerve endings made hypersensitive by the disease process. *This occurs in the airways of the patient with bronchitis who complains of a burning sensation with each cough.

Chest Pain *Acute bronchitis can make the simple act of breathing painful because the flow of cooler air across sensitized nerves can cause them to react. *Mediators may also be responsible for edema formation, which can further contribute to pain as swollen tissues exert pressure on nerves. *Patients with pneumonia often experience pain with deep breathing because each breath increases pressure on pain receptors that are already compressed and irritated by swollen, inflamed lung tissue.

Chest Pain *Various emotions accompany breathing problems. Acute episodes of dyspnea bring anxiety and fear (Fig. 26-3). *Panic often accompanies severe dyspnea. *Patients with chronic respiratory problems may experience self-consciousness and embarrassment. *Because breathlessness may interfere with communication ability, the patient with chronic respiratory problems may feel isolated. *This can contribute to frustration, irritability, and eventual depression caused by continued illness and loss of independence.

Chest Physiotherapy *commonly is prescribed to help clear excessive bronchial secretions from airways. *It is based on the premise that mucus can be shaken from the walls of the airways and helped to drain from the lungs. *Chest physiotherapy can be useful for many patients with cystic fibrosis, COPD, lobar collapse, bronchiectasis, and mucous plugging. Contraindications are pneumonia (Yang et al., 2013), hemoptysis, and pneumothorax.

Chest Physiotherapy *The primary techniques of this method of secretion mobilization are percussion, vibration, and postural drainage. *Any of these physiotherapy techniques can be used alone, but they are most effective when used together. *The patient's ability to tolerate these procedures may limit the vigor with which they are applied, so positioning and clapping techniques may need to be modified. *Often, the respiratory therapist or physical therapist provides chest physiotherapy in the acute care setting.

Chest Tubes *An injury may result in blood in the pleural space (hemothorax). *Surgery involving the chest wall almost always results in the collapse of a lung (pneumothorax); a chest tube is used to re-expand the collapsed lung and remove fluid. *When a lung collapses spontaneously (spontaneous pneumothorax), a chest tube is used to remove air from the pleural space and re-expand the lung.

Chest Tubes *The physician inserts the chest tube into the intrapleural space. *It is sutured in place and covered with an occlusive sterile dressing. *The chest tube is connected to the collection/water seal system by a rubber tube that can be 2 to 4 feet long. *Suction can be ordered if additional pressure is required to re-expand the lung. *The water seal prevents air from entering the pleural space as the patient inspires. It is important to keep the extra tubing looped at the level of the patient; otherwise, fluid can accumulate in dependent loops.

Suctioning *In addition to causing hypoxia, suctioning can cause cardiac ysrhythmias, hypotension, and atelectasis. Because suctioning can stimulate a gag reflex, vomiting (with the potential for aspiration) is possible. *Suctioning can greatly relieve the dyspnea that accompanies excessive secretions, but the process is frightening and unpleasant for nearly all patients. *Be prepared to offer a great deal of reassurance.

Chest Tubes *drainage device the physician places in the pleural space to drain fluid, air, or blood. *Although the tube is placed and removed by a physician, the nurse is responsible for assisting with tube insertion and continually monitoring and assessing the status of a patient with a chest tube. *Normally, the pressure within the thoracic cavity is negative compared to atmospheric pressure. *This negative pressure moves air into a person's lungs on inhalation. *Any interruption in this negative pressure gradient may necessitate the need for a chest tube. *The fluid buildup from a disease process may inhibit the lung's ability to expand normally; the fluid must be drained from the pleural space.

Diagnostic Procedures *The most commonly used tests for assessing respiratory status are chest x-ray and pulmonary function tests. *More specialized tests include lung scans and pulmonary angiography, bronchoscopy, skin testing for allergies in asthma, and skin tests for tuberculosis.

Chest X-rays *The chest x-ray is widely used to identify pathologic changes in the lung and chest that may explain the patient's breathing problems. *From a chest x-ray, the radiologist can detect abnormal fluid or air in the pleural space or a collapsed lung (pneumothorax). *The x-ray can also show if portions of the lungs are consolidated (as in pneumonia) or underinflated (as in atelectasis). *Sometimes, routine x-rays initially detect tumors. *The chest x-ray is also used to determine the position of catheters and tubes and to monitor a patient's response to therapy. *Lung scans and angiography are specialized radiographic techniques used to study blood flow and ventilation in the lung.

Common Manifestations of altered respiratory function: Cough, Sputum Production, Dyspnea, Chest Pain *Smoke is an irritant, and coughing is the natural response to smoke. *A cough's primary function is to help clear substances from the airways. *A cough also serves as a warning signal: It should alert the person that possibly harmful stimuli are damaging the airways and that he or she should take measures to prevent further irritation. *A cough that accompanies a disease may come from mediators released from inflamed tissues. These mediators, such as histamine, irritate the airways and can trigger a cough.

Common Manifestations of altered respiratory function: Cough, Sputum Production, Dyspnea, Chest Pain *Not all coughs originate from lung problems. •The patient with borderline heart failure, for example, often has a chronic cough. *Some people may cough for no apparent reason as a nervous habit. *Because coughs are so common, their value as a diagnostic sign is limited. *Many people live with a cough, expressing concern only when it changes in severity or frequency. *By contrast, some people may have a serious lung disease but a minimal cough.

Control of Ventilation *The process of ventilation is regulated through neural pathways. *Specialized neurons in the brain stem, known collectively as the respiratory centers, generate regular impulses. These impulses are transmitted to the respiratory muscles, causing them to contract and relax rhythmically. *Peripheral and central chemoreceptors in the aortic arch and carotid arteries (peripheral receptors) and the medulla (central receptors) are sensitive to circulating blood levels of carbon dioxide and hydrogen ions.

Control of Ventilation *Carbon dioxide plays the primary role in determining the frequency and depth of ventilation. *If PaCO2 levels in the blood increase, chemoreceptors (peripheral and central) are stimulated, causing more deep and rapid breathing. *The opposite is also true: Breathing slows when PaCO2decreases. Normal breathing is usually regular and smooth because carbon dioxide levels remain fairly constant.

Coughing *Retained secretions increase the work of breathing and may contribute to atelectasis and hypoxemia. *No single measure controls respiratory secretions more effectively than a strong cough that pushes secretions upward. *To cough effectively, the patient must be able to take a deep breath and generate rapid airflow (see Procedure 26-5).

Coughing *For many patients, producing a strong cough is difficult or impossible. The patient experiencing postoperative or trauma-related pain may be unable or unwilling to take the deep breath needed to cough. *Patients with COPD are often unable to exhale quickly enough to generate an effective cough. Some patients are simply too weak to cough, and others do not understand how to produce an effective cough. *Finally, a patient with a tracheostomy or endotracheal tube cannot cough with optimal efficiency because the glottis cannot close.

Deep Cough *Encourage the postoperative patient who does not have lung disease to cough deeply. *Deep coughing will help to mobilize secretions and to open collapsed alveoli. *The patient should inspire as deeply as possible and then hold the breath a second or so while closing the glottis. He or she should then release the air while suddenly opening the glottis.

Deep Cough *The deep cough can cause pain around the incisional area in patients who have had abdominal or thoracic surgery. *To help control the pain, the patient can support the incisional area with a pillow, using it as a splint to immobilize the wound. This is referred to as splinting the incision. *For patients with severe incisional discomfort, scheduling coughing sessions after the patient has received pain medications may prove helpful.

Deep breathing *Shallow breathing or an ineffective cough can lead to mucous plugging, atelectasis, hypoxemia, and pneumonia. *Taking deep breaths helps to expand alveoli and promote an effective cough, which decreases the risk of atelectasis. *Deep breathing is essential for the prevention of pulmonary complications in the at-risk patient. *Pain, lung disease, muscle weakness, or neurologic impairment can hinder a patient's ability to breathe deeply. *A major nursing task is to coach and encourage the patient in deep-breathing techniques. Procedure 26-5 explains this technique.

Deep breathing *Deep breathing is useful for all patients, especially after surgery. *There are no contraindications to deep breathing: Anyone can do it at any time. Deep breathing may cause discomfort for the patient with an abdominal incision or broken ribs; this can be minimized by splinting the incision with a pillow. *Deep breathing decreases the risk of atelectasis by opening collapsed alveoli. A deep breath also strengthens the cough and aids in moving mucus in the airways.

Oxygen Therapy *used primarily to reverse hypoxemia. It can help to accomplish three fundamental goals: Improved tissue oxygenation Decreased work of breathing in patients with dyspnea Decreased work of the heart in patients with cardiac disease

General Principles of oxygen Administration *Oxygen is prescribed either in terms of flow or concentration, depending on the patient's needs and the delivery device's capabilities. *Oxygen flow is expressed in liters per minute. *Concentration is expressed as a percentage or as a fraction of inspired oxygen (FiO2). *A general rule for safe oxygen therapy is to use the lowest oxygen concentration or flow possible to achieve an acceptable blood oxygen level.

Defenses of the Respiratory system *The lower respiratory tract's conducting tubes further filter and clean incoming air. *An epithelial layer containing millions of ciliated cells and mucus-producing glands lines these airways. *The mucous membrane produces a "mucus blanket" that efficiently traps bacteria and microscopic foreign particles. *The ciliated cells provide motion to the mucus blanket, allowing it to carry trapped matter upward and out of the respiratory tract. This "mucociliary escalator" protects the airways by constantly sweeping potentially harmful material out of the lungs. *At the alveolar level, specialized scavenger white blood cells called macrophages help decrease the risk of infection by engulfing bacteria and other particles that may have bypassed the mucous blanket.

Defenses of the Respiratory System *The sneeze and cough reflexes also protect the lungs and airways. *Irritants trapped in the nose stimulate sneezing; that reaction helps to expel trapped material from the nasal passages, thereby decreasing irritation and helping to prevent infection. *Coughing clears the lower airways much like sneezing helps to cleanse the nose. *A forceful expulsion of air from the lungs can remove large amounts of germ-laden mucus. This action is vital for keeping the lungs free from infection. * Coughing also helps to prevent mucous plugs from forming and to remove plugs already formed. In this way, airways remain open so that all areas are available for gas exchange.

Control Of Ventilation *Chemoreceptors are also stimulated by decreases in PaO2 and pH in the arterial blood. When this is sensed, ventilation will increase. *In general, alteration in the PaCO2 in arterial blood is the primary driver for ventilation responses, whereas the PaO2 and pH have less of an influence

Defenses of the respiratory system *A major function of the upper respiratory tract is to warm and humidify inspired air. This moisture and warmth are necessary to maintain the fluid character of the mucus in the lower respiratory tract. *The upper respiratory tract also cleans inspired air. The nose is a highly effective filter for foreign particles. It traps dust and irritants in hairs lining the nostrils or in the mucous layer of the nasal passages. *The upper respiratory tract protects the lower respiratory tract from infection and from injury due to aspiration. The epiglottis acts as a trapdoor by preventing large particles of food or foreign matter from being accidentally aspirated.

Diagnostic test and procedures TABLE 26-3 NORMAL ARTERIAL BLOOD GAS VALUES PaO2 80-100 mm Hg PaCO2 35-45 mm Hg pH 7.35-7.45 HCO3- 22-26 mEq/L Base excess ±2

Diagnostics and procedures Levels of Hypoxemia Mild: PaO2 of 60-80 mm Hg SpO2 of 91-95 mm Hg Moderate: PaO2 of 40-60 mm Hg SpO2 of 74-91 mm Hg Severe: PaO2 of less than 40 mm Hg SpO2 of less than 74 mm Hg

Sputum Production: *Especially frightening can be the coughing up of blood, or hemoptysis. *Blood-filled secretions that originate in the lungs may indicate a serious condition such as lung cancer or tuberculosis. *Often, however, bloody secretions originate in the nose. Drainage from the nose or mouth can drip backward into the throat, mixing with the mucus of the lower airways.

Dyspnea *A person who is unable to breathe sufficiently to meet the body's oxygen and metabolic demands experiences the discomfort of breathlessness. *This subjective feeling of labored breathing and breathlessness is known as dyspnea. *The patient may deny usually being short of breath unless you can specify degrees of dyspnea to which he or she can relate. *Ask how far the patient can walk before needing to rest (a mile, a city block, a flight of stairs, 20 feet).

Dyspnea *The most common cause of dyspnea is the increased work of breathing that occurs with lung disease. Along with increased work of breathing, other causes of dyspnea may need to be assessed. *Reduced lung capacity, alterations in oxygen and carbon dioxide levels, or stimulation of receptors on the intercostals or diaphragm can contribute to dyspnea. *People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low blood oxygen levels. *People who become dyspneic during anxiety attacks often have no heart or lung disease.

Dyspnea Level I The patient can walk 1 mile at own pace before experiencing shortness of breath. Level II The patient becomes short of breath after walking 100 yards on level ground or climbing a flight of stairs. Level III The patient becomes short of breath while talking or performing ADLs. Level IV The patient is short of breath during periods of no activity. Orthopnea The patient is short of breath lying down.

Handheld Nebulizer *Small-volume nebulizers (Fig. 26-10) offer an alternative to patients who are unable to operate MDIs. *Instead of providing a full dose of medication in one or two breaths, the handheld nebulizer delivers a steady stream of aerosolized medicine that the patient breathes over the course of several minutes. *The use of nebulizers eliminates the problem of trying to coordinate inspiration with cartridge activation. These devices are operated by means of a compressor or by oxygen at 4 to 5 L/min. *The patient inhales deeply and holds each breath for a moment, which allows for more effective aerosol deposition into distant portions of the airways. *The patient continues breathing slowly in this manner until the nebulizer is empty.

Dyspnea Management *Effective treatment for dyspnea addresses both its physical and psychological components. *Common interventions used to manage dyspnea include anxiety control, activity modification, and comfort measures that modify the patient's breathing pattern. *Regardless of its specific cause, dyspnea can be extremely frightening, both for the patient who is experiencing it and for the nurse who must treat it. *To help the patient, remain calm while offering reassurance. *Speak calmly and slowly, offering one simple direction at a time to minimize the patient's anxiety. *Listening empathically and helping the patient relax are sometimes all that he or she needs to relieve dyspnea. *When uncontrolled anxiety is the primary cause of a patient's dyspnea, the provider may prescribe mild antianxiety medication.

Dyspnea Management *Comfort measures include the use of positioning. The patient usually is most comfortable sitting upright, which allows the diaphragm to move freely. *If oxygen is ordered, see that it is operating as prescribed. Focus the patient's efforts on slowing the breathing rate. *The patient should breathe through the nose if possible, using the diaphragm for inspiration. *Assist by gently pushing down on the patient's shoulders; this discourages the inefficient use of accessory muscles.

Dyspnea Management *Usually, with gentle encouragement and reassurance, the patient's breathing rate will gradually decrease and the dyspnea will pass. *Whenever dyspnea occurs, try to establish its immediate cause and its severity. *Comfort measures are always appropriate, as is oxygen when a standing order is available. *Most institutions have policies allowing nurses to begin oxygen therapy for the dyspneic patient while they are seeking a provider's order. *When oxygen and comfort measures do not decrease dyspnea within a short period or when dyspnea appears suddenly and without warning, notify the provider.

Encouraging Smoking Cessation *Smoking cessation is a positive step toward health, regardless of the length of time a person has been a smoker. *State-of-change theory provides a basis for understanding the process underlying changing an addictive habit. The five stages outlined in the process are as follows: *Precontemplation (not thinking about quitting) *Contemplation (thinking about quitting in the next 6 months) Preparation (thinking about quitting in the next 30 days) *Action (in the process of quitting) *Maintenance (abstaining from tobacco use for 6 months or more)

Encouraging Smoking Cessation *Relapse is common during smoking cessation attempts (Agency for Healthcare Research and Quality, 2008). P *Provide positive encouragement, and explain that it often takes more than one attempt to successfully stop smoking. *Ultimately, it is up to the smoker to be responsible for choosing and carrying out personal change. *Often, the diagnosis of lung cancer provides a teachable moment when patients are motivated to stop smoking

End Tidal Monitoring *The sampling device is connected to a monitor that may display the EtCO2 in graphic (capnography) or numeric (capnometry) form. *Normal EtCO2 is 35 to 45 mm Hg. EtCO2 may be measured in several circumstances. *When an endotracheal tube is inserted into a patient, a one-time EtCO2 device may be attached to the end of the tube to assure placement of the tube into the trachea rather than the esophagus. *Placement in the trachea would result in a reading of at least 5 mm Hg.

End Tidal Monitoring *Placement of the ET tube in the esophagus would result in a reading less than 5 mm Hg. *During CPR, EtCO2 provides an indication of the effectiveness of chest compressions. *A reading of 10 to 20 mm Hg indicates good quality compressions. Readings lower than 10 mm Hg suggest inadequate circulation and therefore inadequate compressions.

End Tidal Monitoring *Continuous EtCO2 readings may be obtained in patients receiving patient-controlled analgesia (PCA). *Because medications used in PCA have the potential to suppress respirations, monitoring of respiratory function is essential. *Although pulse oximetry may provide information, the readings displayed on the pulse oximeter may lag behind actual oxygenation status by five minutes or more.

End Tidal Monitoring *On the other hand, EtCO2 will drop rapidly when respirations are reduced. This provides an early alert to a potentially dangerous decrease in the patients breathing.

ABG'S *Arterial blood sampling also indicates the blood's acidity or alkalinity. *The pH is a measure of the blood's acid-base balance. *Biochemical processes essential to all cellular life require a close balance of acids and bases. *Normally, arterial blood pH ranges from 7.35 to 7.45. Arterial pH below 7.35 is described as acidosis, whereas pH above 7.45 indicates alkalosis (Table 26-3).

End Tidal co2 Monitoring *Exhaled CO2, measured at the end of exhalation (end tidal), is a sensitive indicator of adequacy of ventilation. *Although pulse oximetry may take several minutes to display changes in oxygen saturation of the hemoglobin in the blood, end-tidal CO2 (EtCO2) changes rapidly in response to changes in the patient's breathing. *To monitor EtCO2, the patient wears a nasal sampling device similar in appearance to an oxygen nasal cannula

Oral or Nasal Pharyngeal Airways *These airways are used to bypass upper airway obstructions or to facilitate secretion removal (Fig. 26-12). *Oropharyngeal airways (Fig. 26-12A) are simple to insert but are poorly tolerated by all but the comatose patient. *The noncomatose patient is likely to gag on an oropharyngeal airway, so a nasal trumpet (Fig. 26-12B) is preferable. *These airways should be well lubricated with water-soluble gel before they are inserted into the nose.

Endotracheal Tubes *plastic tube inserted through the nose or mouth into the trachea (Fig. 26-13). *These airways are used to ventilate a patient during surgery or when mechanical ventilation is necessary. *They are also used to protect the airway in a comatose person.

Life span considerations for older adults *Structural and functional changes occur in the respiratory system in the later decades of life. *The thoracic wall becomes more rigid, and the lungs become less able to stretch. There is no significant decrease in total lung capacity, but ventilation of nongas exchange areas of the lungs increases. *The lung's protective functions are impaired: 1.)There is decreased ciliary activity and stiffening of the chest wall with declining chest muscle strength, and the cough is less propulsive and effective in airway clearance. *Finally, gas exchange is affected: Normal PaO2 decreases, and there is a decreased response to hypercapnia (Tabloski, 2013). *These respiratory changes contribute to the activity intolerance and increased incidence of respiratory infections in older adults.

Factors interfering with oxygenation (Environment) *The percentage of oxygen humans breathe, referred to as the fraction of inspired oxygen concentration (FiO2), remains stable at around 21% when breathing "room air" (no supplemental oxygen). *The atmosphere contains about 21% oxygen. *oxygen concentration does not change appreciably, its partial pressure decreases steadily as altitude increases. *Lower oxygen pressure at higher elevations means that less oxygen is available to the lungs for gas diffusion. *Thus, even healthy people are likely to experience shortness of breath and activity intolerance at higher elevations.

Gas Transport *As oxygen crosses the alveolar-capillary membrane into the blood, the blood transports it to the tissues in two forms. *Small amounts of oxygen are physically dissolved in plasma (3% of O2), but most oxygen that the blood carries to the tissues is attached to hemoglobin molecules on red blood cells (97% of O2). *Hemoglobin has the unique ability to carry oxygen in its molecular form rather than as an ion. This difference is significant because tissues require molecular oxygen for metabolism.

Gas transport *The blood carries carbon dioxide in several forms. *Blood transports carbon dioxide in a dissolved state (PaCO2), but carbon dioxide also can combine with some amino acids. *The most important transport mechanism for carbon dioxide is in its dissolved form. When combined with water, carbon dioxide dissociates into bicarbonate ions. *These ions form the primary component of the bicarbonate buffer system (HCO3−), which plays a major role in maintaining the body's acid-base balance.

Chest tubes *The water seal chamber allows drainage and air to drain into the collection chamber without air entering the chest tube. *The water seal chamber is filled with sterile water up to the mark identified by the manufacturer. *Mild fluctuation in the water seal chamber is normal as the patient breathes. *Bubbles in the water seal chamber when a patient coughs may indicate an intermittent air leak. *Continuous bubbling in the water seal chamber indicates an ongoing air leak and should be reported to the physician.

Heimlich Manuever *The American Heart Association (AHA) recommends the use of abdominal thrusts (formerly known as the "Heimlich maneuver") as treatment for foreign body obstruction in adults and children. *In this procedure, abdominal thrusts are used to generate high pressures that can dislodge an aspirated obstruction. *After establishing that the choking person cannot cough or speak, the nurse must act quickly. *Stand behind the person, and wrap your arms around the patient's waist. *With one fist against the abdomen and the other grasping the opposite wrist, squeeze rapidly and tightly with an upward thrusting motion. Repeat this movement until you have successfully dislodged the obstruction or until the person loses consciousness.

Medications *Home use of respiratory medications can be simplified by prepackaged unit-dose medications, but these are more expensive than stock bottles of medications. *If the patient can learn to measure dosages, stock bottles may be more cost-effective. *Teach the patient to recognize side effects of medications and to understand why they are dangerous. *Stress the dangers of taking medications more frequently than ordered. If the medications provide no relief, the patient should call the provider.

Home Oxygen Systems *The respiratory equipment that patients use at home also differs from hospital equipment. *At home, the patient can receive oxygen from high-pressure cylinders, liquid gas systems, or electrically powered concentrators. *Compressed oxygen from high-pressure tanks is best for the patient who only occasionally requires supplemental oxygen. *Liquid oxygen systems allow the patient to leave home. *Portable "walkers" can be filled from a stationary unit at home. *The walkers are small enough to be carried or wheeled in a small cart, yet they hold an hour of oxygen (Fig. 26-19).

Hyperventilation management *The patient who hyperventilates exhibits rapid breathing and symptoms such as dizziness and tingling sensations; ABG indicates a PaCO2 below 35 mm Hg. *The patient may experience subjective feelings of dyspnea. *Direct nursing efforts at decreasing patient anxiety and getting the patient to breathe at a slower rate. *If simple encouragement cannot accomplish this, the patient may use a paper bag as a rebreathing device. *The patient breathes in and out of the bag for several breaths. In the process of rebreathing the exhaled carbon dioxide from the bag, the patient's PaCO2 can gradually slow the rate of breathing until it returns to normal. *The dizziness and tingling sensations should disappear. As with dyspnea, a complete assessment of hyperventilation is needed, and referral to the provider may be required.

Hyperventilation Management *Patients hyperventilating for medical conditions other than anxiety may delay needed treatment while breathing into a bag. *Breathing into a bag should be performed only under the direct supervision of the nurse and under protocols or a provider's order; excessive breathing of CO2 may increase the patient's panic.

Inspection *Such problems are relatively harmless and indicate only local vasoconstriction, whereas central cyanosis is a late sign of oxygen deprivation and could be life threatening. *In people with dark skin tones, cyanosis may be best assessed in the oral cavity and eyelids. See Figure 26-5 for a photo of cyanosis. *Inspect the fingertips and toes. Clubbing is an unusual phenomenon seen in many patients with respiratory or cardiac disease. For reasons that are unclear, the tips of the fingers and toes become rounded and enlarged (see Chapter 17). *Long-term tissue hypoxia causes the release of platelet-derived growth factor and other mediators that cause dilation of the vessels of the fingertips. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD.

Inspection *Finally, inspect the chest to detect obvious chest deformities, wounds, or masses. *The chest's overall shape is important but less obvious. *In COPD, the patient's chest becomes overinflated over time because of an inability to exhale fully. *This increases the anterior-posterior chest diameter, resulting in a barrel-shaped appearance (see Figure 26-6).

Inspection *The patient with COPD often sits in a forward-leaning position, which uses the accessory muscles to help enlarge the chest cavity for more air. *This indicates shortness of breath and may be seen as well in patients without COPD who are having other respiratory or cardiac problems. *Note other obvious signs of dyspnea, such as gasping, audible wheezing, or panting respirations. In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.

Inspection *In addition to describing the breathing pattern, observe the patient's color. *Cyanosis around the lips and under the tongue indicates serious hypoxemia. Cyanosis is a bluish skin discoloration caused by a desaturation of oxygen on the hemoglobin in the blood. *Hemoglobin, the major carrier of oxygen in the blood, is bright red when saturated with oxygen. *When not carrying oxygen, it becomes deep blue. This bluish state should be distinguished from peripheral cyanosis (e.g., blue fingertips on a cold day).

Pulse Oximetry *Most importantly, interpretation of SpO2 depends on the operator's understanding of hemoglobin and its unique properties. Because of the manner in which hemoglobin combines with oxygen, relatively slight changes in SpO2 may actually reflect large changes in blood oxygenation. *Experience and clinical judgment help the skilled practitioner relate oximetry readings to patient condition. Refer to Procedure 26-1 for guidance using pulse oximetry.

Laboratory Studies *Any sputum the patient coughs up should be inspected. *Normal respiratory secretions are clear or white. Normal sputum has no odor and medium consistency. *Thick and sticky sputum is usually difficult to expectorate and may indicate that the patient is poorly hydrated. *Sputum produced by patients with asthma is stringy, like thickened egg white. Life-threatening pulmonary edema produces frothy, pink secretions.

Factors interfering with oxygenation (Environment) *People's reactions to weather conditions are highly personalized. *Some tolerate heat and humidity well; others may complain of difficulty breathing under these conditions. *People who move to different climates may experience slight changes in breathing patterns until they adjust to their new surroundings. *People with chronic respiratory diseases often find breathing more difficult when the weather is hot and humid because humidity makes the air thicker. *Some people with asthma breathe more easily in warm, dry climates; others find a damp climate more soothing.

Lifestyle choices (Smoking, drug and alcohol use, nutrition) *Smoking is the most important lifestyle choice affecting respiration. *Smokers are far more likely than nonsmokers to experience emphysema, chronic bronchitis, lung cancer, oral cancer, and cardiovascular diseases. *By producing more mucus and by slowing the mucociliary escalator, smoking inhibits mucus removal and can cause airway blockage, promoting bacterial colonization and infection. *Regardless of whether or not a clinically identifiable lung disease is present, smokers usually breathe more rapidly than do nonsmokers.

Lifestyle choices (Smoking, drug and alcohol use, nutrition) *Barbiturates, opioids, and some sedatives (legal or illegal) can depress the central nervous system with a resulting decrease in respiration. *Alcohol in large doses can achieve the same effect. *The intoxicated person is in danger of vomiting and aspirating stomach contents into the lungs. *Alcohol depresses the reflexes that protect the airways, so if vomiting occurs, stomach contents can easily slip into the trachea, causing choking and aspiration. If the victim is revived, aspiration is likely to cause pneumonia.

Lifestyle choices (Smoking, drug and alcohol use, nutrition) *Without proper diet, the body cannot effectively produce plasma proteins and hemoglobin. *In addition, sufficient caloric and protein intake is required for respiratory muscle strength. *People with diminished muscle strength work harder at breathing. *Adequate nutrition is also essential for maintaining a competent immune system. *Malnourished patients (e.g., from poverty or eating disorders) are at greater risk than well-nourished people for contracting pneumonia and other respiratory infections.

Stacked Cough *Some patients find coughing painful even after having received pain medication. *For them, a stacked cough may cause less pain and be almost as effective. *Stacked coughing is the release of several short blasts of air instead of one deep cough. This type of cough prevents excessive stretching of the incisional area and also minimizes the airway collapse that may accompany deep coughing.

Low Flow huff cough *A third type of cough is called low-flow or "huff" coughing. *The low-flow cough is most effective for patients with COPD, whose airways tend to collapse with rapid exhalation. *Slowing the airflow actually is more helpful in expelling secretions. *Instruct the patient to inhale deeply. *Instead of closing the glottis and generating high pressure, the patient says "huff" three or four times while exhaling.

Main factors that increase the work of breathing:Restricted Lung Movement *Some diseases cause lung tissue to swell and thicken. *Oxygen has greater difficulty passing through thickened alveolar walls. Because stiff lungs require more work to expand, the respiratory muscles consume an increased amount of oxygen. *In any of these situations, less oxygen is available to the blood for the tissues. *Actual stiffening of the lung tissues can result from acute or chronic lung injuries. Smoke inhalation, pulmonary fibrosis, respiratory distress syndrome (in the adult or infant), and infections such as pneumonia are examples of disorders that make lung tissues swell and stiffen. These types of problems are classified as restrictive lung disorders.

Main factors that increase the work of breathing: Restricted Lung Movement *Not all restrictive problems are caused by lung injuries or lung diseases. *A patient can have perfectly healthy lungs, but other factors may prevent the lungs from expanding completely. *Although the reasons for restriction may vary, the same problems with oxygenation can result. *Pain from a surgical incision is a common example of this. *For the patient with a high abdominal incision, the discomfort of breathing deeply often forces shallow breathing; this is why atelectasis is common in patients after surgery. *Other factors that can restrict breathing include severe obesity, chest or abdominal binders, abdominal distention by gas or fluid, medications or anesthesia, rib injuries, musculoskeletal chest deformities, and severe weakness or neuromuscular disorders.

Lifestyle choices (Smoking, drug and alcohol use, nutrition) *In the obese person, chest movement is restricted, especially in the supine position; this restriction causes shallow respirations and increased respiratory rate. *The extra work required to carry extra body weight increases oxygen demands. *For airways to remain patent, adequate fluid intake is necessary to keep secretions thin and easy to cough up (expectorate).

Main factors that increase the work of breathing:Restricted Lung Movement *Certain conditions and diseases may cause the lungs to stiffen or may restrict expansion of the chest. *Stiffer lungs (or lungs not allowed to expand fully) tend to collapse, and their alveoli also collapse. This condition is called atelectasis and reduces the amount of space available for gas exchange.

Heimlich maneuver *If unconsciousness occurs, lay the victim in a supine position. Sweep the victim's mouth with the fingers in an attempt to pull out any obstruction. *If no obstruction is evident, try to ventilate the victim with a manual resuscitator or with mouth-to-mouth breathing. *Follow with abdominal thrusts, and repeat the sequence until it is successful.

Manual Resuscitation Bag and Mask *When the patient is unable to sustain adequate ventilation, use a manual resuscitation bag and mask until recovery occurs or an airway can be inserted and mechanical ventilation begun or death is pronounced. *A manual resuscitation bag is a basic emergency equipment. This bag can also be used to hyperinflate the lungs just before suctioning and can be adapted to attach to a tracheostomy or endotracheal tube if the face mask is removed. (A resuscitation bag is pictured in Fig. 3 of Procedure 26-7.)

Aerosol Medications *Various drugs are administered by aerosol. *Bronchodilators reverse bronchospasm most quickly when administered directly to the lungs. *Although commonly used and highly effective, these agents are powerful medications that may have serious side effects. *Closely monitor all patients receiving bronchodilators for signs of increased heart rate, nervous agitation, and restlessness. *Inhaled corticosteroids are used to fight lung inflammation. *For patients with asthma and chronic lung disease, aerosol steroids offer a safe alternative to oral steroids with fewer long-term negative systemic effects. *Other types of medications delivered by aerosol include cromolyn (Intal), which is used to prevent asthma attacks. Patients with cystic fibrosis can receive antibiotics delivered by aerosol to counter stubborn lung infections.

Metered Dole Inhalers *Gas-powered, cartridge-type nebulizers called metered-dose inhalers (MDIs) provide the patient with a premeasured dose of aerosolized medication. *Squeezing the gas cartridge discharges a single puff of medication that the patient inhales deeply into the lungs. MDIs are ordinarily self-administered by the patient, but nurses are usually responsible for providing instruction in their use. *These devices are portable, compact, and highly convenient to use. *For many people, the MDI is simple to operate, but others find it difficult to activate the inhaler and inhale simultaneously. *A chamber (or "spacer") that attaches to the MDI helps to minimize this problem and improves the MDI's efficiency.

Monitoring Peak Flow *A peak flow meter is a handheld device that measures the highest flow during maximal expiration; the meter indicates how rapidly the patient can breathe out air. *Changes in peak flow measurements reflect changes in airway diameter; they occur before symptoms of respiratory distress, such as dyspnea, wheezing, or increased coughing, appear. *Peak flow measurement can be used to individualize therapy and prevent the onset of an acute asthma attack. Peak flow measurement may also be useful in patients with chronic bronchitis or emphysema.

Monitoring Peak Flow *instruct patients to perform and record peak flow measurement twice a day, once in the morning and once in the evening. *Patients should take measurements before using any bronchodilators. *Initially, the patient will determine his or her "personal best" (the highest peak flow measure that he or she obtains over a 2-week period during which the asthma was well controlled). *Once this value is obtained, the following zones can be determined:

Normal Breathing Pattern *Although respiratory rate varies depending on a person's age, normal breathing generally is smooth, even, and regular. *The rate does not vary significantly from one minute to the next unless the person's activity level changes. *Exhaling normally takes twice as long as inhaling. *Usually, a person breathes slightly faster when awake than when asleep. *Normally, each breath is about the same size. Despite an occasional sigh or yawn, the chest of a person who is breathing quietly will be seen to rise and fall the same amount from breath to breath. *People who use their diaphragms effectively to breathe make their abdomens rise and fall. *The average adult moves about a half a liter (500 mL) of air per breath.

Normal Breathing pattern •Normal breathing is nearly effortless. Little muscular work is required to move air through the lungs. *That is why quiet breathing is almost unnoticeable and ordinarily has no associated sounds. *The rate and depth of ventilation increase during exercise to provide more oxygen to the tissues and to remove excess carbon dioxide. *An athlete normally breathes more slowly and deeply while at rest than someone who is less fit. *This is likely due to increased efficiency of respiratory muscles in the athlete.

General assessment of Patients normal pattern of breathing Be sensitive to the patient's ability to answer questions; *if necessary, wait on less important questions until a better time. *Unlike eating, sleeping, or elimination patterns, the patient is likely to have taken no notice of the normal breathing pattern. *Few people can provide specific information about how often or how deeply they breathe. *The normal breathing pattern of the person with chronic respiratory problems may differ greatly from that of the healthy person. For example, the patient with chronic asthma ordinarily may breathe with a slight wheeze. *Similarly, the patient with chronic obstructive pulmonary disease (COPD) may grow to accept shortness of breath after walking two city blocks as normal.

Normal breathing pattern *The patient begins to consider that something is wrong only if exercise tolerance decreases below this standard. These examples show that the nurse must take care in eliciting information about normal breathing patterns. *Patients who indicate that their breathing is ordinarily fine or unremarkable may have adjusted to a baseline breathing pattern that is abnormal for most people.

Airway Obstruction; Finally, altered bronchial smooth muscle tone also causes airway obstruction. *Normal smooth muscle tone maintains the patency of the smallest airways—the bronchioles. *Allergy or injury may cause the smooth muscle to become hyperreactive to stimuli. This greatly increases smooth muscle tone, which narrows airway lumens and makes breathing difficult. *Airway hyperreactivity, or bronchospasm, is a common problem for patients with asthma. *By contrast, patients with emphysema experience breathing problems because of abnormally low bronchial smooth muscle tone. *Years of damage to the bronchiole walls make them floppy and unable to remain open during exhalation. *Air becomes trapped in the alveoli, leaving little space for newly inspired air and making full inspiration difficult.

Older adult (60 y and older)16-25 Common Manifestations of altered respiratory function: Cough, Sputum Production, Dyspnea, Chest Pain Cough: *Establish if a cough is ordinarily present and at what times of the day it usually occurs. *A cough is usually a reflexive response to irritation in the airways. There is not a "normal" cough. *Any cough, regardless of how obvious its origin, is most often an indication that the lungs or airways are being subjected to some form of irritation. *Coughs can be triggered by many chemical and physical substances or by physical conditions, such as hot, dry air.

General Principles of oxygen Administration *When administering oxygen, assess the patient's response regularly to determine the need for continuation or adjustment of therapy. *The patient's color, alertness, heart rate, and breathing effort are general indicators of the effectiveness of oxygen therapy. *Arterial blood gas (ABG) monitoring and pulse oximetry provide more specific information concerning patient response to oxygen therapy. *For most patients, the aim of oxygen therapy should be to maintain the PaO2 above 60 mm Hg or the SpO2 above 93%. It is rarely necessary to exceed a PaO2 of 90 mm Hg or an SpO2 greater than 97%. *Most often, patients use oxygen continuously for as short a time as possible until they can maintain satisfactory blood oxygenation without it. *Most patients require relatively low concentrations of oxygen to correct hypoxemia. See Procedure 26-7 for a general guide to administering oxygen.

Oxygen Delivery Methods *If a patient needs only a small amount of additional oxygen to maintain adequate oxygenation, he or she can use a cannula or low concentration Venturi-type mask. *If the patient requires a moderate amount of oxygen, a simple mask is suitable. *When a patient needs a high concentration of oxygen, a reservoir-type mask, often called a nonrebreather mask, can be used. *Although the reservoir bag does not need to be fully inflated, the oxygen flow rate should be set at 12-15 LPM. *This valve and reservoir system reduces rebreathing of CO2. Table 26-6 compares and contrasts various commonly used oxygen delivery systems. *Patients who require more precise delivery of oxygen, along with assistance with ventilation, need a mechanical ventilator to regulate oxygen and breathing.

Manual resuscitation bag and mask *To deliver effective ventilation, tilt the patient's chin back and pull the jaw forward to open the airway. *Hold the mask tightly over the patient's mouth and nose, maintaining a good seal with one hand as you use the other hand to compress the bag and deliver air into the lungs. *The bag is self-inflating, and a one-way valve allows exhaled air to escape. *A normal rate of inflations for an adult is 16 to 20 breaths per minute. *The tidal volume delivered, as well as the amount of oxygen, can vary depending on the rate and technique used to compress the bag.

Oxygen Therapy *Some patients need oxygen therapy to maintain adequate arterial blood oxygen levels. *Lung disease, cardiovascular problems, blood disorders such as anemia, and high metabolic demands of healing tissues can limit the body's oxygen supply.

Palpitation *The nurse's hands are used to assess abnormalities such as swelling or tenderness. Palpation is also used to determine the extent and pattern of thoracic expansion and to note the position of the trachea. *Palpation may detect abnormal chest wall vibrations transmitted through inflamed or fluid-filled lung tissues. *Fremitus (the vibration of air movement through the chest wall) is best felt by placing the balls of the palms of the nurse's hand on the patient's back as he or she says "99."

Palpitation *The intrascapular spaceis a good area to feel tactile fremitus because it diminishes as you move out in the lung fields. *Increased tactile fremitus can be present in consolidation in the lung, whereas decreased fremitus may occur with pleural effusion, pulmonary edema, emphysema, or bronchial obstruction.

Dysfunction Identification *When gathering information about the onset and duration of a recent breathing problem, determine if the problem is continuous or intermittent. *If the problem seems to be continuous, perhaps, some new exposure, such as new carpeting or a new pet, has triggered an allergic reaction. *The patient may have contracted an infection that has progressed or has remained subacute. If the problem is intermittent, ask if the patient can identify the circumstances that bring on the difficulty. *Perhaps, the patient's breathing worsens at certain times of the day or when the patient engages in certain activities. Assess cough, sputum production, shortness of breath, and discomfort or pain.

Physical Assessment *The primary techniques used in physical assessment are inspection, palpation, percussion, and auscultation. *Sputum is visually examined. Auscultation- *Observe the patient's breathing effort by noting obvious use of shoulder or neck muscles. *Healthy people use the muscles of the neck and upper chest to help them breathe deeply during vigorous exercise. *The patient with breathing problems may consistently use accessory muscles to ease dyspnea and improve breathing.

Provide Adequate Hydration *The nurse can help maintain the mobility of mucus by encouraging fluids in all patients who are at risk for dried secretions. *Fluid intake ideally should be 6 to 8 glasses of fluid, preferably water, every day. *Caffeinated beverages (e.g., coffee, tea, cola) and alcohol can have a diuretic effect, thus dehydrating the patient. *In some patients, milk products tend to thicken secretions, so these patients should avoid dairy products. *Patients whose oral intake is restricted may require additional aerosol therapy to ensure secretion mobility.

Positioning and Ambulation *Changing positions and movement in general help to shift respiratory mucus into portions of the airways where it may generate a cough, making expectoration easier. *Positioning and movement prevent mucus from pooling, which decreases the risk of bacterial colonization and infection. *Mucus tends to pool in the airways of people with limited mobility. *Immobile patients, patients experiencing pain, and patients with limited exercise tolerance (because of heart or lung disease) often retain secretions.

Positioning and ambulation *Encourage changing positions frequently. *Whenever possible, position the patient with unilateral lung problems with the good lung down to promote optimal matching of ventilation and perfusion. *Moving the patient from one side to another or assisting with ambulation when possible aids the lung's natural clearance mechanisms. *Supine position has been associated with an increase in VAP and increased risk for aspiration, especially in patients receiving tube feedings.

Positioning and ambulation *Ambulation is difficult for some respiratory patients because of dyspnea with exertion. *Whenever possible, help promote exercise tolerance by encouraging progressive ambulation. *Additional benefits of increased exercise tolerance include decreased oxygen consumption and extra strength for effective coughing. *Some patients may need portable oxygen during periods of ambulation.

Metered-dose inhaler (MDI) *Because MDIs can deliver different types of respiratory medication, patients may use several MDIs in their medication regimen. *A complete understanding of each medication's actions and dosing schedule is essential for optimal management of respiratory symptoms. *Instruct the patient to rinse the mouth with water after administration of an MDI; many drugs administered by this route may cause oral fungal infection (thrush).

Powdered Dose Inhalers *An alternative to MDIs, a dry powder inhaler (DPI), delivers medication to the lungs in the form of a dry powder. *DPIs come in different shapes and sizes. The device needs to be loaded or actuated and is breath activated. *Once the dose is loaded, the patient places the mouthpiece of the device into the mouth and takes a deep breath. *If the patient has an insufficient inhalation flow rate, the dose delivered may be incomplete. *A minimum respiratory effort is needed for proper delivery; therefore, its use is reserved for older children and adults.

Preventing Respiratory infections *Health teaching can limit both exposure to and occurrence of acute respiratory infections such as influenza and pneumonia. *Promote optimal immune function by encouraging good nutrition. Remind the patient to avoid exposure to known infected people or large crowds during peak flu season. *Good hygiene practices, especially hand hygiene, sneezing or coughing into the sleeve rather than hands, and proper used tissue disposal, prevent the spread of communicable respiratory infections.

Preventing Respiratory Infections *High-risk patients (e.g., older adults; people with diagnosed diabetes or respiratory disorders such as asthma or COPD; people with immune system dysfunction, such as patients with AIDS, patients undergoing cancer chemotherapy, and transplant recipients; and healthcare workers) should receive annual influenza vaccinations. *Influenza vaccines are changed annually based on anticipated new strains; *revaccination every fall before flu season is required to produce effective immunity. Pneumococcal vaccination is also recommended for high-risk people. *Revaccination is required only for adults older than 65 years or people who are immunocompromised

Monitoring Peak Flow *Green zone—80% to 100% of personal best (asthma is well controlled; proceed on routine treatment plan) *Yellow zone—50% to 80% of personal best (asthma is not well controlled, and treatment plan may need to be increased) *Red zone—below 50% of personal best (take a fast-acting beta2 agonist, and contact a healthcare provider immediately)

Providing Adequate Hydration *Inadequate moisture in the airways makes respiratory mucus thick and difficult to cough up. *Sticky, tenacious sputum that coats the respiratory tract increases work of breathing for any patient and makes breathing especially difficult for those with chronic lung disease. *Mucus that is hard to expectorate promotes infection because the bacteria it traps have time to multiply. *Dried, sticky mucus also causes excessive coughing, which worsens pain in postoperative or trauma patients. *Finally, mucous plugs in the airways can lead to atelectasis and decreased oxygenation.

Oxygen delivery method *Transtracheal catheters, implanted surgically, are becoming more common. *These catheters (12 French or smaller) are inserted through the patient's neck into the trachea. *They are attached to a portable oxygen system. With this oxygen delivery device, less oxygen is wasted because the catheter enters the lung directly. *The patient needs less oxygen to manage the condition well. Safety Considerations

Pt teaching points *Most respiratory patients are managed in the community, except for those experiencing periods of acute respiratory dysfunction or who have exacerbation of a chronic respiratory condition. *Home respiratory therapy can include peak flow monitoring, handheld aerosol treatments, chest physiotherapy, oxygen, or ventilator care. *How much and what kind of home therapy the patient receives depends on many factors, including the patient's age, ability to learn procedures, family support, degree of impairment, and motivation. *The nurse is often the one to assess these characteristics for the purpose of making recommendations to the provider. *Often, the nurse is responsible for making home care arrangements and for much of the teaching involved.

Pt teaching points *Patients are likely to use pieces of equipment normally considered disposable after 2 or 3 days in the hospital, such as cannulas or small-volume nebulizers, for much longer periods in the home. *Hospital procedures performed under sterile conditions, such as tracheostomy care and suctioning, may be done using clean technique at home. *Although cost considerations and limited facilities make sterilization difficult, infection control at home can be practically as effective as it is in the hospital. *Ensure that the patient clearly understands the importance of infection control because potentially lethal pneumonia may result from respiratory infection. *Stress the importance of hand hygiene. Teach the patient effective cleaning of all equipment.

Pt teaching points *The patient must learn the signs of impending respiratory infection. Increased sputum production, change of sputum color to yellow or green, fever, and increasing difficulty in raising sputum often signal the onset of infection. *If the patient has a standing order for antibiotics, it is appropriate to begin taking the medication when these signs appear. *If there is no relief within a day or two, the patient should contact the provider. *The patient should complete the full prescription of antibiotics to avoid fostering the development of drug-resistant organisms. *He or she should immediately report appreciable amounts of blood in the sputum, a severe increase in shortness of breath, or any other severe symptoms to the provider.

Pulse Oximetry *The pulse oximeter uses infrared light to determine the percentage of hemoglobin that combines with oxygen. *An SpO2 greater than 95% is considered normal, whereas values lower than 93% usually indicate the need for oxygen therapy and further assessment. *Several factors affect the accuracy and proper interpretation of oximetry. *The patient must have adequate peripheral blood flow for the oximeter to detect a pulse. Conditions such as room lighting, patient motion, cigarette smoking, or dark polish on the patient's fingernails can affect sensor accuracy.

Pulse Oximetry *Forehead reflectance oximetry is less susceptible to poor tissue perfusion and able to more accurately record oxygen saturation in patients with poor perfusion. *Carbon monoxide poisoning results in false high readings; edema at the sensor site produces false low readings. *Patients with anemia may have a high SpO2 reading, because most of the hemoglobin has oxygen attached to it. However, because of the anemia, there are fewer hemoglobin molecules in the blood, and therefore, the patient may be hypoxic.

Diagnostics and procedures Pulse OxIMETRY *Pulse oximetry offers a noninvasive and indirect means for approximating oxygenation, whereas arterial blood sampling (an intravenous needle inserted into an artery) provides a precise, direct measure of oxygenation through blood gases. *To measure oxygenation through pulse oximetry, a sensor is attached to the patient's finger or earlobe. This allows assessment of heart rate and oxygen saturation, either intermittently or continuously.

Pulse oximetry *Oximetry is a convenient and painless alternative to needlesticks, is simple to use, and provides immediate data. *These advantages make oximetry an invaluable tool for determining the patient's need for oxygen therapy and assessing the therapy's effectiveness. *The oximeter registers arterial oxygen saturation (SpO2).

Quad coughing *Patients with neuromuscular disease and quadriplegic patients often need direct assistance to generate an effective cough. *The patient takes a deep breath, or the nurse provides a deep breath with a manual resuscitation bag. *The patient then holds the deep breath for a moment. *With your hands placed just below the patient's rib cage, assist the patient by quickly pushing in and upward, much like performing the Heimlich maneuver. *The resultant rush of air acts as a cough by helping to dislodge mucus from the airways.

Pursed Lip Breathing *helps patients with obstructive lung diseases such as COPD or asthma by causing a back pressure in the airways, which eases exhalation and prevents air trapping. *To perform pursed-lip breathing, the patient takes a deep breath and holds it for a moment, then exhales slowly through lips held almost closed. *By pushing the air against the small orifice made by the pursed lips, the patient builds pressure backward through the airways. *This back pressure pushes the airways open throughout exhalation and prevents airway collapse. *Thus, more air escapes during exhalation and helps prevent air trapping.

Reducing Allergens *Reducing exposure to allergens that can trigger bronchoconstriction and inflammation is an important preventive measure. *Although the mortality rate from asthma has declined in the last 20 years, the prevalence of asthma continues to increase (ALA, 2012). * More than 400 occupational asthma triggers have been identified; the most common triggers are chemical vapors found in workplaces, such as paper and textile mills, chemical plants, printing plants, and hair salons. *Most businesses and workplaces ban smoking, which has significantly reduced exposure to secondhand smoke.

Reducing Allergens *Aspirin sensitivity, cold air, or exercise can induce an allergic attack. *Seasonal pollens from trees, grasses, and flowering plants frequently exacerbate asthma symptoms in the spring or late summer. *Indoor allergens include dust mites, pet dander, cockroach eggs and droppings, and molds. *Nurses can be instrumental in working with the patient and family to identify individual asthma triggers and motivate the family to restructure the environment to limit allergen exposure. *Allergens can be identified through skin testing, and a program of allergen desensitization (allergy shots) can be instituted.

risk Identification and dysfunction identification *Causes of the patient's breathing problem may be rooted in long-term habits, occupational exposure, or past illnesses. *Assess whether the patient's immunization status is current. *Influenza immunization is recommended annually (CDC, 2010), and pneumococcal vaccination is recommended for all adults older than 65 years or anyone with chronic respiratory conditions (CDC, 2014d). *Information about smoking habits is most important for providing insight into the patient's condition

Risk Identification *The duration and extent of cigarette smoking are sometimes expressed in terms of pack-years: *1 pack-year is equal to smoking one pack of cigarettes (20 cigarettes) a day for 1 year. *Pack-years are calculated to quickly quantify the risk of chronic disease. *A person who has smoked two packs a day for 40 years would be said to have an 80 pack-year smoking history. *A person who has smoked 10 cigarettes a day for 6 years would have a pack history of 3 years. *To calculate pack-years, multiply the number of cigarettes smoked per day by the number of years smoked and divide by 20 (most packs contain 20 cigarettes).

Risk Identification *Family and personal history are also essential to a thorough evaluation. *Cystic fibrosis is genetically transmitted, as is α1-antitrypsin deficiency, which causes emphysema not related to cigarette smoking that develops in early adulthood. *The patient with asthma often recalls a childhood with allergies and eczema. A history of dental problems may explain a patient's bronchiectasis or lung abscess.

Risk Identification *Investigate a sleep history by including information about excessive daytime sleepiness, morning headache or sore throat, personality changes, or loud snoring or frequent periods of apnea during sleep reported by the spouse. *These symptoms commonly occur in sleep apnea, which is common in obese, middle-aged adults. *Sleep apnea causes a significant decrease in oxygenation because of multiple apneic periods during sleep.

Risk identification *Chronic bronchitis, emphysema, and lung cancer are directly related to smoking and are more likely to occur in patients with a long history of heavy smoking. *The patient who has lived in poverty and is malnourished, for example, is more at risk for infections such as tuberculosis. *Tuberculosis and other respiratory infections also are more common in people who abuse alcohol. *People with substance abuse are likely to have problems fighting infection because of self-neglect and the lowered effectiveness of their immune systems.

Risk identiifcation *Work history often provides relevant information. *Many occupations involve exposure to fumes or dust, such as silicon and asbestos, which are toxic to lung tissue. *Agricultural workers are exposed to organic dusts such as molds that can cause infections and asthma-like symptoms.

Bronchoscopy *Nursing interventions for a bronchoscopy include ensuring informed consent, teaching before the procedure, and maintaining NPO (nothing by mouth) status until the gag reflex returns after the procedure. *Monitoring after the procedure includes frequent assessment for dyspnea, hemoptysis, or cardiac arrhythmias.

Skin Test *Skin tests can be performed to identify a patient's allergies to specific substances. *By determining possible sources of airway hypersensitivity in asthmatic patients, allergists can help them avoid the offending substances. *These tests also help the allergist devise serums for desensitizing the patient. *Another type of skin test is used to establish whether or not a patient has been exposed to tuberculosis. *In the tuberculin skin test (TST), purified protein derivative (PPD) is injected under the skin. *A positive reaction helps identify people who may have been exposed to tuberculosis.

Laboratory studies (Sputum culture, ABG's, End Tidal C02 monitoring) *Sputum that is yellow or green or has a putrid or musty odor may indicate infection. *When infection is suspected, collect a sputum sample in a sterile container and send the sample to the laboratory for examination. *Blood-streaked mucus indicates airway inflammation. It commonly occurs during harsh coughing episodes in patients with bronchitis, tuberculosis, or lung cancer. *Frankly red, bloody mucus (hemoptysis) is a sign of continual bleeding somewhere in the airways that requires immediate response and thorough investigation.

Sputum Culture *The patient who has a productive cough, is febrile, and shows other signs of infection should have a sputum sample evaluated by the laboratory. *A Gram stain can be performed quickly to determine if infection is present and to classify the organism as Gram positive or Gram negative. *Sputum is cultured to identify the specific agent causing the infection (this takes 2 to 3 days). *A sensitivity test done at the same time will indicate the best antibiotic to use against the causative agent

Sputum Production *Ask the patient how much sputum he or she usually coughs up (a teaspoon, a tablespoon, a half cup?) and about its color. *As with a cough, sputum production may be a natural consequence of irritation, but it is never really normal. *Respiratory mucus, or sputum, is another protective feature of the airways. *Mucus is normally produced in such small amounts that a cough from a healthy person is dry and nonproductive. *Raising mucus with a deep cough indicates that the lungs are attempting to clear away irritants.

Sputum Production *Although the lungs may seem to be the obvious source of expectorated sputum, sometimes coughed-up secretions originate in the nose, mouth, or throat. *It is necessary to determine if the patient raises the secretions with a genuine deep cough or if he or she "snorts" and clears them from the nasal passage. *It is also necessary to determine if the secretions are cleared from the mouth (appear as frothy oral secretions). *When a cough is productive, it is important to establish the source of the sputum and to assess its color, volume, consistency, and other noteworthy characteristics.

Suctioning *Some patients produce excessive amounts of oral secretions. *These patients can use a "tonsil-tip" (Yankauer) suction tube (Fig. 26-16) to evacuate excess saliva and thick mucus from the back of the throat. This suction catheter is also attached to wall or portable suction. *Patients with deep bronchial secretions may require deep suctioning. *Properly performed, suctioning can greatly improve airflow in the lungs, which promotes oxygenation. *However, the procedure carries several risks. Because oxygen, as well as mucus, is withdrawn from the airways, suctioning can cause temporary hypoxia.

Suctioning *Apply suction intermittently to help minimize catheter damage to the trachea's delicate mucosal lining. *Limit suctioning passes to three for each suctioning procedure, with 10 seconds as the recommended time limit for each suction attempt (Lewis et al., 2014). *Usually, the suction regulator is set between 80 and 120 mm Hg for larger children and adults and between 60 and 80 mm Hg for infants.

See procedure 26-8 Suctioning *Atelectasis and pneumonia may develop in patients who cannot cough effectively to expectorate mucus. *Excessive mucus can even cause the airway to occlude. To prevent this, the nurse may have to suction the airways. *Suctioning is appropriate only when secretions are present in the upper airways, as indicated by coarse crackles, diminished breath sounds, increased inspiratory pressure, increased respiratory rate, or decreased oxygen saturation.

Suctioning *To suction the airways, insert a catheter through the nose, mouth, or tracheal tube. *Attach the catheter to a portable or wall unit suction device, which provides the suction pressure for secretion removal. *Effective suctioning can clear the oral cavity and nasopharyngeal areas of secretions. *Secretions deep in the trachea are more difficult to remove, but the suctioning procedure is similar, regardless of where the secretions are found. Procedure 26-9 gives complete instructions on secretion removal by suctioning.

tracheostomy *various types. *All tubes contain an outer cannula that fits into the trachea and a flange that rests against the neck and allows the tube to be fastened in place. *An obturator is a guide that is inserted into the tracheostomy tube to ease insertion and is then removed. *Some tracheostomy tubes contain an inner cannula that locks into place and can be removed for cleaning (Fig. 26-14). *Cuffed tracheostomy tubes contain an inflatable cuff (or balloon) that is inflated to stabilize the tube in the trachea (Fig. 26-15). *Advantages of a cuffed tracheostomy tube include decreased risk of aspiration, prevention of air leakage, and access to mechanical ventilation.

Tracheostomy *Low-pressure cuffs are preferred to decrease the incidence of tracheal mucosal damage. *Fenestrated tracheostomy tubes are tubes with holes in the outer cannula. *When the patient is being ventilated, the inner cannula remains in place. *When weaning is attempted, the inner cannula can be removed and the cuff deflated; this allows the patient to breathe around the tube and through the fenestration. *Another advantage of the fenestrated tube is that speaking is possible when the tracheostomy is plugged because the hole permits exhaled air to flow over the vocal cords.

Tracheostomy *artificial airway consisting of a plastic tube surgically implanted just below the larynx into the trachea; the tube bypasses the mouth and upper airway. *The surgical procedure that establishes the artificial airway is called a tracheotomy; the resultant airway is a tracheostomy. *This procedure is most often done as a temporary measure. *Unlike a permanent laryngectomy, in which the entire larynx is removed, a tracheotomy leaves the structure of the airway intact. *A patient may require this procedure to bypass a severe or recurrent upper airway obstruction.

Tracheostomy *The patient who regularly aspirates food or stomach contents may need a tracheostomy to protect the airway. *A few patients may need this type of airway to help with secretion control because a tracheostomy provides ready access for suctioning. *Finally, the patient who requires long-term mechanical ventilation may need a tracheostomy to provide the safest and most stable artificial airway available. *Many tracheotomized patients on the general nursing unit are former patients of the ICU or have had head and neck surgery.

`Main factors that increase the work of breathing: Airway Obstruction *Any process that reduces the diameter of the conducting airways causes increased airway resistance. Breathing then requires more effort because air must move through a narrower passage. *Airways become obstructed in several ways. *They can become plugged by foreign material, mucus, or abnormal growths. *Children who aspirate small objects experience airway obstruction. *The patient who has chronic bronchitis, cystic fibrosis, or asthma may experience airway obstruction from excessive mucus production. *Patients with lung cancer may experience difficulty breathing as tumors obstruct large bronchi.

`Main factors that increase the work of breathing: Airway Obstruction *Inflammation caused by chemical or physical irritants also can increase airway resistance. *Inflammation makes airways swollen and edematous. *As the walls of the airways thicken, lumen size decreases. *Asthma, bronchitis, and bronchiolitis are examples of conditions in which small airways become inflamed and narrowed. *Croup and epiglottitis, most common in young children, obstruct upper airways by swelling the throat tissues.