Respiratory Dysfunctions I

Goals of drug therapy

*Relief of bronchospasm *Reduction of airway inflammation and pulmonary congestion *Treatment of pulmonary infection *Reduction of severe pain, anxiety and restlessness

Diagnostic Studies of Respiratory System

*Sputum Studies Spontaneous Induced *Skin Tests Allergies TB

Physiology of Respiration

*Ventilation- the movement of air between the environment and the lungs via inhalation and exhalation. *Compliance- a measure of the ease of expansion of the lungs and thorax, determined by pulmonary volume and elasticity. Diffusion- the exchange between O2 and Co2 from alveolar capillaries to blood stream and vice versa

Effects of Aging on Respiratory System- Structural changes

*calcification of the costal cartilages *chest may appear barrel-shaped, and the elderly may need to use accessory muscles to breathe *Respiratory muscle strength progressively declines after age 50 *decrease in the number of functional alveoli, and they become less elastic

Effects of Aging on Respiratory System- Defense mechanisms

*less effective because of a decline in both cell-mediated and humoral immunity *alveolar macrophages are less effective at phagocytosis *less forceful cough and fewer and less functional cilia *Retained mucus predisposes the older adult to respiratory infections

Effects of Aging on Respiratory System- Respiratory control

*more gradual response to changes in blood oxygen or carbon dioxide level

Group A beta-hemolytic streptococci (GABHS)

*toxic shock syndrome: fever, low BP, malaise, confusion, coma *characteristic rash, often seen early in the course of illness, resembles a sunburn, and can involve any region of the body, including the lips, mouth, eyes, palms and soles *Rheumatic fever-inflammatory disease that can involve the heart,joints, skin, and brain; rash known as erythema marginatum

Bronchodilators

*β2-Adrenergic agonists: cause smooth muscle relaxation *Methylxanthines: Slightly relax the airways in the lungs *Anticholinergics: ipratropium bromide (short-acting), tiotropium (long-acting)-reverse bronchospasm

Lower respiratory tract

-Bronchi-The right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. For this reason, aspiration is more likely to occur in the right lung than in the left lung. -Bronchioles -Alveolar ducts -Alveoli -Lung lobes-The right lung is divided into three lobes (upper, middle, and lower) and the left lung into two lobes (upper and lower).

Control of Respiration

-Chemoreceptors respond to changes in PaCO2 and pH. -Central receptors-located in the medulla and respond to changes in the hydrogen ion (H+) concentration. *An increase in the H+ concentration (acidosis) causes the medulla to increase the respiratory rate and tidal volume. *A decrease in H+ concentration (alkalosis) has the opposite effect. -Peripheral receptors- located in the carotid bodies at the bifurcation of the common carotid arteries and in the aortic bodies above and below the aortic arch. *respond to decreases in PaO2 and pH and to increases in PaCO2. These changes also cause stimulation of the respiratory center.

Diagnostic Tests

-Imaging studies- Chest X-ray, CT, MRI, V/Q scan, pulmonary angiogram, PET scan -Arterial blood gas analysis (ABG's) -Pulmonary function tests -Endoscopic procedures-bronchoscopy, mediastinoscopy, lung biopsy -Thoracentesis

Skin Tests

-May be performed to test for allergic reactions or exposure to TB bacilli or fungi -Be certain that the injection is intradermal and not subcutaneous. After the injection, circle the site(s) and instruct the patient not to remove the marks. When charting administration of the antigen, draw a diagram of the forearm and hand and label the injection sites. The diagram is especially helpful when more than one test is administered

Oximetry

-SpO2 is assessed with each routine vital signs check in many inpatient areas. -Values obtained by pulse oximetry are less accurate if the SpO2 is less than 70%. At this level, the oximeter may display a value that is ±4% of the actual value. -Other factors that can alter the accuracy of pulse oximetry include motion, low perfusion, anemia, cold extremities, bright fluorescent lights, intravascular dyes, thick acrylic nails, and dark skin color.

VATS

-a rigid scope with a lens is passed through a trocar placed into the pleura via one or two small incisions in the intercostal muscles. - The physician views the lesions on a monitor directly via the lens, and biopsy specimens can be taken. -A chest tube is kept in place until the lung expands. Lesions in the pleura or peripheral lung are biopsied via VATS. **VATS is much less invasive than open lung biopsy and is the procedure of choice when appropriate.

Percussion

-assess the density or aeration of the lungs

Mechanical receptors

-juxtacapillary and irritant * located in the lungs, upper airways, chest wall, and diaphragm *stimulated by irritants, muscle stretching, and alveolar wall distortion. *Juxtacapillary (J) receptors are believed to cause the rapid respiration (tachypnea) seen in pulmonary edema. These receptors are stimulated by fluid entering the pulmonary interstitial space.

Mediastinoscopy

-scope inserted through small incision in suprasternal notch and advanced into the mediastinum to inspect and biopsy lymph nodes-used to Dx lung CA, non-Hodgkin's lymphoma, granulomatous infections and sarcoidosis

Assessment of Respiratory System

1. accurate health history and a thorough physical examination 2. If respiratory distress is severe, only obtain pertinent information until patient stabilizes 3. Determine hx of: upper/ lower resp probs, allergies, asthma, smoking 4. Take a thorough medication history, including both prescription and over-the-counter medications 5. Determine if the patient has been hospitalized for a respiratory problem/ intubation/ nebulizer

Upper Airway Infections (viral)Collaborative Care

Rest Increase oral fluids Treat symptoms Use antibiotics cautiously Home remedies-what are remedies you or your family use?

A patient's arterial blood gas (ABG) results include the following: pH 7.32, PaO2 84 mm Hg, PaCO2 49 mm Hg, and SaO2 84%. For what should the nurse assess the patient?

Tachypnea: The arterial blood gas analysis indicates respiratory acidosis. Tachypnea is defined as a rapid respiratory rate and indicates respiratory distress. Tetany occurs in metabolic alkalosis. A pleural friction rub is a creaking or grating sound heard during auscultation of the lungs and indicates inflamed pleural surfaces that are rubbing together. Kussmaul respirations are commonly seen in metabolic acidosis and are abnormally deep, very rapid sighing respirations.

Wheezes

continuous high-pitched squeaking or musical sounds caused by rapid vibration of bronchial walls

Rhonchi

continuous rumbling, snoring, or rattling sounds from obstruction of large airways with secretions

CT (computed tomography)

diagnosis of lesions difficult to assess

MRI

diagnosis of lesions difficult to assess by CT scan and for differentiating between vascular and non-vascular structures

Structures and Functions of Respiratory System

*Primary purpose: Gas exchange *Two parts: -Upper respiratory tract -Lower respiratory tract

Arterial blood gases

ABGs are measured to determine oxygenation status and acid-base balance

Antitussive/expectorants

Antitussives: suppress the coughing itself (cough suppressants) Expectorants: make coughing easier while enhancing the production of mucous

Hering-Breuer reflex

As the lungs inflate, pulmonary stretch receptors activate the inspiratory center to inhibit further lung expansion

bronchoscopy

flexible fiberoptic scope used for diagnosis, biopsy, specimen collection or assessment of changes-may also be used to suction mucus plugs, lavage the lungs or remove foreign objects

A dull sound

heard over areas of "mixed' solid and lung tissue, such as over the top area of liver, the heart, particularly consolidated lung tissue (pneumonia), or fluid-filled pleural space.

Nasopharyngitis

inflammation of nares, pharynx, hypopharynx, uvula, and tonsils

Rhinitis

inflammation of nasal cavity

Percutaneous needle aspiration or TTNA

involves inserting a needle through the chest wall, usually under computed tomography (CT) guidance. Because of the risk of a pneumothorax, a chest x-ray is ordered after TTNA

Biot's

irregular breathing with apnea every 4 to 5 cycles

Pleural friction rub

is a creaking or grating sound from roughened, inflamed pleural surfaces rubbing together. Evident during inspiration, expiration, or both and no change with coughing

Lung Biopsy

may be done: (1) transbronchially (2) percutaneously or via transthoracic needle aspiration (TTNA) (3) by video-assisted thoracic surgery (VATS) (4) as an open lung biopsy

Sputum Studies

may be examined for culture and sensitivity to identify an infecting organism (e.g., Mycobacterium, Pneumocystis jiroveci) or to confirm a diagnosis (e.g., malignant cells). Regardless of whether specimen tests are ordered, it is important to observe the sputum for color, blood, volume, and viscosity.

Glucocorticoids (Corticosteroids)

may be used in conjunction with bronchodilating agents when bronchospasm and inflammation are present.

Bronchophony

positive (abnormal) when a person repeats "ninety-nine" and the words are easily understood and are clear and loud.

Whispered pectoriloquy

positive (abnormal) when the patient whispers "one-two-three" and the almost inaudible voice is transmitted quite clearly and distinctly.

Egophony

positive (abnormal) when the person says "E" but it is heard as "A."

Kussmaul breathing

rapid, deep breathing

Sinusitis or Rhinosinusitis

sinus infection- inflammation of sinuses located around nose

Respiratory Therapists

specialized healthcare practitioner who has graduated from a university and passed a national board certifying examination. Respiratory therapists work most often in intensive care and operating rooms, but are also commonly found in outpatient clinics and home-health environments.

Mixed venous blood gases

the percentage of oxygen bound to hemoglobin in blood returning to the right side of the heart.

Diuretics

used to decrease the pulmonary congestion

Positron emission tomography (PET) scan

used to distinguish benign and malignant pulmonary nodules-since malignant lung cells have increased uptake of glucose, this uses IV radioactive glucose prep which can demonstrate increased uptake of glucose in malignant lung cells

Pulmonary function tests (PFT)

used to evaluate lung function, involves use of spirometer to assess air movement as patient performs prescribed resp maneuvers

Thoracentesis

used to obtain specimen of pleural fluid for diagnosis, to remove pleural fluid or instill medication-check x-ray for pneumothorax

Chest X-ray

used to screen, diagnose, and evaluate changes in resp system-most common views are AP and Lateral

pulmonary angiography

used to visualize pulmonary vasculature and locate obstructions or pathological conditions (pulmonary embolus)

Open lung biopsy

used when pulmonary disease cannot be diagnosed by other procedures. The patient is anesthetized, the chest is opened with a thoracotomy incision, and a biopsy specimen is obtained. Nursing care for the procedure is the same as after thoracotomy.

Lifestyle modifications

*Avoid tobacco exposure *Reduce fatty food intake and keep balanced diet *Limit exposure to common allergens *Maintain standards of hygiene *Follow an exercise routine *Protect yourself against pollution *Take advantage of natural supplements *Stay hydrated *Reduce alcohol intake

Respiratory blood supply and air exchange

*Blood Supply **Pulmonary-provides the lungs with blood that participates in gas exchange **Bronchial-provides oxygen to the bronchi and other pulmonary tissues *Chest Wall-lined with a membrane called the parietal pleura, and the lungs are lined with a membrane called the visceral pleura. The parietal and visceral pleurae join to form a closed, double-walled sac Ribs Pleura Diaphragm

Influenza

*Caused by influenza virus- causes 36,000 deaths and 200,000 hospitalizations annually *Three types -Influenzavirus A -Influenzavirus B -Influenzavirus C *All strains can mutate over time *Spread by direct contact *Vaccine-children, elderly, health care workers, chronic illness

Respiratory Defense Mechanisms

*Filtration of air *Mucociliary clearance system-the mucociliary escalator. This term is used to indicate the interrelationship between the secretion of mucus and the ciliary activity. *Cough reflex-protective reflex action that clears the airway by a high-pressure, high-velocity flow of air *Alveolar macrophages-rapidly phagocytize inhaled foreign particles such as bacteria *Reflex bronchoconstriction-in response to irritants, the bronchi constrict in an effort to prevent entry of the irritants

Upper Airway Infections -bacterial

*Group A beta-hemolytic streptococci (GABHS) *Corynebacterium diphtheria (diphtheria) *Neisseria gonorrhea (gonorrhea) *Chlamydia pneumoniae (chlamydia) *Group C beta-hemolytic streptococci

Risk Factors linked to Respiratory Dysfunction

*Medical: asthma, allergies, overweight *Genetic:Cystis fibrosis, COPD resulting from a1-atrypsis deficiency and asthma *Social: work related- dust, nano particles, "green" building materials *Environmental: temperature extremes, the increased geographic span of allergens, and air quality

Upper Respiratory Tract

*Nose-protect the lower airway by warming and humidifying air and filtering small particles before air enters the lungs *Mouth- *Pharynx *Epiglottis *Larynx *Trachea-bifurcates into the right and left mainstem bronchi at a point called the carina. The carina is located at the level of the manubriosternal junction, also called the angle of Louis. The carina is highly sensitive, and touching it during suctioning causes vigorous coughing.

Registered Dietician

A dietitian is like an investigator seeking to learn about your current and desired state of health

The nurse would interpret an induration of 5 mm resulting from tuberculin skin testing as a positive finding in which patient?

A patient who is human immunodeficiency virus- infected: Induration of 5 mm in an HIV-infected person is considered a positive reaction.

Case Management

Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.

Voice sounds

Conditions that increase lung density or when the lung is consolidated (e.g., pneumonia) will have positive (abnormal) voice sounds.

Stridor

a continuous musical or crowing sound of constant pitch. Result of partial obstruction of larynx or trachea

Tympany

a drumlike, loud, empty quality sound heard over a gas-filled stomach or intestine, or pneumothorax

Hyperresonance

a loud, lower-pitched sound than normal heard over hyperinflated lungs, such as in COPD and acute asthma

Resonance

a low-pitched sound heard over normal lungs

Pulmonologist

a medical specialty that deals with diseases involving the respiratory tract.Pulmonologists are specially trained in diseases and conditions of the chest, particularly pneumonia, asthma, tuberculosis, emphysema, and complicated chest infections.

Coarse crackles

a series of long-duration, discontinuous, low-pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa. Evident on inspiration and, at times, expiration

Fine crackles

a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration

A flat sound

a soft, high-pitched sound of short duration heard over very dense tissue where air is not present, such as over heavy muscles and bones.

Cheyne-Stokes

abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing

Ventilation-perfusion scan (V/Q)

assess ventilation and perfusion of lungs, uses IV radioisotope to assess perfusion