nurs 351: respiratory system

primary function

• provides oxygen for metabolism in the tissues

• removes carbon dioxide (metabolic waste product)

secondary function

• facilitates smell

• produces speech

• maintain acid-base balance

• maintain body water level

• maintain heat balance

upper respiratory tract

• nasal cavity

• sinuses

• pharyngeal tonsils

• nasopharynx

• pharynx

• larynx

• epiglottis

• esophagus

nasal cavity

contains the nose which humidifies, warms, filters inspired air

sinuses

air filled cavities within hollow bones that surround nasal passages

• provide resonance during speech

pharynx

• located behind oral and nasal cavities

• divided into

  • nasopharynx

  • oropharynx

  • laryngopharynx

• passageway for both respiratory and digestive tracts

larynx

• located above trachea and below pharynx

• “voice box”

• two pairs of vocal cords

• contains the glottis

glottis

opening between the true vocal cords in the larynx

• important role in coughing → the most fundamental defense mechanism of the lungs

epiglottis

leaf shaped elastic structure attached to top of larynx

• prevents food from entering the tracheobronchial tree by closing over glottis during swallowing

lower respiratory tract

• trachea

• bronchus/bronchi

• bronchioles

trachea

• located in front of esophagus

• branches into right/left main stem bronchi at carina

bronchus/bronchi

• begin at carina

• right is slightly wider, shorter and more vertical

• main stem divides into 5 secondary or lobar bronchi that enter each lobe of lung

• lined with cilia

bronchi cilia’s function

propel mucus up and away from lower airway to trachea where it can be expectorated or swallowed

bronchioles

• branch from secondary bronchi and subdivide into the small terminal and respiratory branches

• contain NO cartilage and depend on elastic recoil of lung for patency

terminal bronchioles

last branch of bronchioles; contain NO cilia and do NOT participate in gas exchange

alveoli anatomy

• terminal bronchioles

• alveolus

• alveolar capillary network

acinus

indicate all structures distal to terminal bronchiole

alveolar duct

branch from respiratory bronchioles

alveolar sacs

contain clusters of alveoli which are the basic units of gas exchange

surfactant

phospholipid protein that reduces surface tension in alveoli (prevents alveoli collapse)

• secreted by cells in wall of alveoli

right lungs

consists of 3 lobes (upper, middle, lower); much larger than left

left lung

consists of 2 lobes; narrower than right lung to accommodate the heart

parietal pleura

lines inside of thoracic cavity, including upper surface of diaphragm

visceral pleura

covers pulmonary surfaces

pleural fluid

thin fluid that is produced by cells lining the pleura

• lubricates visceral and parietal pleurae → allows them glide smoothly + painlessly

pulmonary and bronchial system

blood flow through lungs occurs via ____

accessory muscles of respiration

• scalene muscles (elevate first 2 ribs)

• sternocleidomastoid muscles

• trapezius and pectoralis muscles

lungs

• located in pleural cavity in thorax

• extend from above clavicles to diaphragm (major muscle of inspiration)

• innervated by phrenic nerve, vagus nerve, thoracic nerve

inspiration

• diaphragm descends into abdominal cavity → causing negative pressure in lungs 

• negative pressure draws air from area of greater pressure (atmosphere) into area of lesser pressure (lungs) 

• in lungs → air passes through terminal bronchioles into alveoli to oxygenate body tissues 

expiration

• diaphragm and intercostal muscles relax and lung recoil 

• as lung recoil → pressure within lungs becomes greater than atmospheric pressure, causing air, (which now contains the cellular waste products of carbon dioxide and water) to move from alveoli in lungs to atmosphere 

• PASSIVE PROCESS

risk factors for respiratory disease

• smoking 

• use of chewing tobacco 

• allergies 

• frequent respiratory illnesses 

• chest injury 

• surgery 

• exposure to chemicals and environmental pollutants 

• crowded living conditions 

• family history of infectious disease 

• geographic residence and travel to foreign countries 

chest x-ray

provides information regarding anatomic location and appearance of lungs

• either AP or lateral

chest x-ray procedure

pre

• remove all jewelry and other metal objects from chest area

• assess ability to inhale and hold breath

• question women regarding (possibility of) pregnancy

post

• assist client to dress

sputum specimen

a specimen obtained by expectoration or tracheal suctioning to assist in identification of organism or abnormal cells

sputum specimen pre-procedure

• determine specific purpose of collection (check institutional policy) 

• early morning sterile specimen from suctioning or expectoration after a respiratory treatment, if a treatment is prescribed 

• obtain 15 mL of sputum 

• instruct 

  • rinse mouth with water prior to collection 

  • take several deep breaths 

  • cough deeply to obtain sputum 

• always collect specimen before starting antibiotics 

sputum specimen post procedure

• if culture of sputum is prescribed → transport specimen to laboratory immediately

• assist with mouth care

bronchoscopy

direct visual examination of larynx, trachea, bronchi with fiberoptic bronchoscope

• through endotracheal tube if already intubated

• twilight sedation and pain killers, if not

bronchoscopy pre-procedure

• informed consent 

• NPO midnight prior 

• obtain vital signs 

• monitor coagulation studies 

• remove dentures or eyeglasses 

• prepare suction equipment 

• administer medication for sedation as prescribed 

• have emergency resuscitation equipment readily available 

bronchoscopy post-procedure

• monitor vital signs 

• semi-fowler's position 

• assess gag reflex 

• NPO until gag reflex returns 

• emesis basin 

• monitor bloody sputum 

• monitor respiratory status, particularly if sedation was administer 

• monitor for complications 

  • bronchospasm, bacteremia, bronchial perforation indicated by facial or neck crepitus, dysrhythmias fever, hemorrhage, hypoxemia, pneumothorax

• notify MD if fever or difficulty breathing

pulmonary angiography

an invasive fluoroscopic procedure following injection of iodine/radiopaque/contrast material (dyes) through catheter inserted through the antecubital or femoral vein into the pulmonary artery or one of its branches

• high pressure

• hundreds of images taken layer upon layer → 3D image

pulmonary angiography purpose

• good for ruling out blood clots (pulmonary embolism)

• is the dye equal on the arterial and venous side? 

  • not equal → blood clot

pulmonary angiography pre-procedure

• informed consent 

• assess for allergies to iodine, seafood, other radiopaque dyes 

• NPO 8 hours prior 

• monitor vital signs 

• monitor coagulation studies 

• establish an IV access 

• administer sedation 

• instruct client 

  • must lie still during procedure 

  • may feel an urge to cough or experience flushing, nausea, salty taste following injection of dye 

• emergency resuscitation equipment available 

pulmonary angiography post-procedure

• monitor vital signs 

• avoid taking blood pressures in extremity use for injection for 24 hours 

• monitor peripheral neurovascular statues 

• assess insertion site for bleeding

• monitor for delayed reaction to dye

thoracentesis

removal of fluid or air from pleural space via transthoracic aspiration

thoracentesis pre-procedure

• informed consent 

• baseline vital signs 

• ultrasound or CXR if prescribed prior to procedure 

• assess coagulation studies 

• positioned sitting upright with arms & head supported by table at bedside during procedure 

• if client cannot sit up, client is placed lying in bed on unaffected side with HOB elevated 45 degrees 

• inform client not to cough, breathe deeply, or move during procedure 

thoracentesis post-procedure

• monitor vital signs

• monitor respiratory status

• apply a pressure dressing and assess puncture site for bleeding and crepitus

• monitor for signs of pneumothorax, air embolism, pulmonary edema

pulmonary function tests

include a number of different tests used to evaluate lung mechanics, gas exchange and acid-base disturbance through spirometric measurements, lung volume and ABGs

pulmonary function tests pre-procedure

• determine if an analgesic that may depress respiratory function is being administered 

• consult with physician regarding holding bronchodilators prior to testing 

• instruct client 

  • void prior to procedure

  • wear loose clothing 

  • remove dentures 

  • refrain from smoking or eating a heavy meal for 4-6 hours prior to the test 

pulmonary function tests post-procedure

• resume normal diet and any bronchodilators and respiratory treatments that were held prior to procedure

percutaneous lung biopsy

performed to obtain tissue for analysis by culture or cytologic examination

needle lung biopsy

done to identify pulmonary lesions, change in lung tissue and the cause of pleural effusion

lung biopsy pre-procedure

• informed consent 

• NPO prior to procedure 

• inform client that local anesthetic will be used but that sensation of pressure during needle insertion & aspiration may be felt 

• administer analgesics & sedatives as prescribed 

lung biopsy post-procedure

• monitor vital signs 

• apply a dressing to the biopsy site and monitor for drainage or bleeding 

• monitor for signs of respiratory distress and notify physician if they occur 

• monitor for signs of pneumothorax and air emboli, and notify physician if they occur

• prepare client for chest x-ray if prescribed

perfusion scan

blood flow to the lungs is evaluated (radionuclide may be injected)

ventilation scan

determines patency of pulmonary airways and detects abnormalities in ventilation (radionuclide may be injected)

ventilation-perfusion lung scan pre-procedure

• informed consent 

• assess for allergies to dye/iodine/seafood

• remove jewelry from chest area 

• review breathing methods, which may be required during testing 

• establish IV access 

• administer sedation if prescribed

• emergency resuscitation equipment available

ventilation-perfusion lung scan post-procedure

• monitor for reaction to radionuclide

skin test

an intradermal injection used to assist in diagnosing various infectious diseases

skin test procedure

• use test site free of excessive body hair, dermatitis, blemishes 

• apply at upper one third of inner surface of left arm 

• circle & mark injection test site 

• document date, time, test site

skin test pre-procedure

• determine hypersensitivity or previous reactions to skin tests

skin test post-procedure

• instruct client 

  • do NOT scratch test site to prevent infection & abscess formation 

  • avoid scrubbing test site 

• interpret reaction at injection site 24-72 hours after 

• assess test site for 

  • induration (hard swelling) in millimeters 

  • presence of erythema & vesiculation (small blister like elevations) 

arterial blood gases

measures the dissolved oxygen and carbon dioxide in the arterial blood and reveals

• the acid-base state

• how well the oxygen is being carried to the body

• ex: Allen test

normal pH

7.35-7.45

ABG pre-procedure

• perform Allen’s test on both wrists prior to drawing specimens 

• have client rest for 30 minutes prior to specimen collection

• avoid suctioning prior to drawing blood gases 

• do not turn off oxygen unless blood gases are ordered to be drawn at room air 

ABG post-procedure

• place specimen on ice 

• note client's temperature on laboratory form 

• not O2 & type of ventilation client is receiving on form 

• apply pressure to puncture sit for 5-10 minutes

  • longer if client on anticoagulant therapy or has bleeding disorder 

• transport the specimen to laboratory within 15 minutes

pulse oximetry

• noninvasive test that registers client’s hemoglobin oxygen saturation

• normal = 95-100% 

• after a hypoxic client uses up the readily available O2 (PaO2 on ABG testing), reserve O2 attached to the hemoglobin (SaO2) is drawn on to provide oxygen to tissues 

• alerts hypoxemia before clinical signs occur

pulse oximetry procedure

• sensor is placed on the client’s finger, toe, nose, earlobe, or forehead to measure oxygen saturation

• maintain transducer at heart level 

• do not select an extremity with an impediment to blood flow 

• results < 91% necessitate immediate treatment 

• < 85%, the body’s tissues have a difficult time becoming oxygenated

  • < 70% is life threatening

pneumonia

acute inflammation of parenchymal tissues’ functional parts (alveoli and bronchioles)

nasopharyngeal defense

• removes particles from air and destroying invading organisms

• hay fever, common cold, nasal trauma

glottic and cough reflexes

• prevent aspiration into tracheobronchial tree

• stroke, abdominal/chest surgery, sedation/anesthesia, NG tube

mucociliary blanket

• remove secretions, microorganisms, particles

• smoking, inhalation of irritating gases

pulmonary macrophages

• remove microorganisms

• alcohol intoxication, smoking

pneumonia susceptibility

most susceptible

• age (very young and elderly)

• antibiotic therapy

• chronic diseases

  • diabetes, cardiac, respiratory, ETOHism

• smoking

• post-operative patients

• immunosuppressed (AIDS, organ transplant, chemo)

pneumonia complications

• bacteremia/septicemia

  • may spread to brain, heart, peritoneum

• empyema

• lung abscess (may need I & D)

empyema

pus in pleural cavity

pneumonia etiology

• infectious agents by droplet inhalation

• smoke inhalation

• aspiration: food or gastric contents

pneumonia: bacterial etiology

• most common: streptococcus pneumonia G(+), diplococcus pneumoniae G(+)

• gram (+): Staphylococcus aureus, Streptococcus pyogenes

• gram(-): Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, Haemophilus influenzae, Legionella pneumophila

pneumonia: viral etiology

influenza viruses, parainfluenza, RSV, CMV (=90% mortality for organ transplant individuals)

pneumonia: fungal etiology

candida, mucor, aspergillus, histoplasmosis, coccidomycosis, blastomycosis

pneumonia: other etiology

• other: mycoplasma pneumoniae

• protozoal = pneumocystis carinii

pneumonia categories

1. persons < 60 without co-morbidity who can be treated outpatient

2. persons at least 60 with co-morbidity who can be treated outpatient

3. persons with community-acquired pneumonia who require hospitalization but not ICU

4. persons with community-acquired pneumonia who require ICU

pneumonia subjective manifestations

• lassitude (general illness) and severe malaise

• chest pain that increases with inspiration and dyspnea

pneumonia objective manifestations

• high T (106) and shaking chills

• high RR, use of accessory muscles, orthopnea

• cough and sputum

• gray complexion → toxic

• rales

• rhonchi

• decreased breath sounds at site of consolidation

• friction rub (pleuritic pain)

• dull to percussion

• E → A changes due to consolidate

• high HR

consolidation

mass of infection → impedes ability to exchange gases in the lungs

rales

fine inspiratory crackles (fluid in alveoli)

rhonchi

coarse inspiratory/expiratory crackles (mucus in bronchi)

pneumococcal pneumonia sputum

purulent, rusty

staphylococcal pneumonia sputum

yellow, blood streaked

Klebsiella pneumonia sputum

red, gelatinous

mycoplasma pneumonia sputum

non-productive that advances to mucoid

pneumonia diagnostics

• high WBC and ESR

• CXR — patchy or lobar pulmonary infiltrates

• sputum/blood cultures

• ABGs: hypoxemia, respiratory alkalosis

pneumonia in elderly

• sudden onset of confusion

• weakness and lethargy

• falling

pathologic changes in pneumonia

1. congestion

2. red hepatization

3. gray hepatization

4. resolution

1. congestion

4-24 hours; serous exudate from initial inflammatory response pours into alveoli

2. red hepatization

48 hours; extravasation of RBCs, fibrin, PMNs into alveoli → tissue firm and red

3. gray hepatization

72 hours - 1 week; fibrin accumulates and granulates → RBCs and PMNs start disintegrating

4. resolution

1 week - 12 days; can start in 48 hours with antibiotics

• enzymes lyse consolidation

• macrophages phagocytize inflammatory cells

• exudate expectorated

pneumonia treatment

culture and sensitivity tests (blood, sputum)

• to determine organism and appropriate antibiotic therapy

• no culture results for 48 hours — treat empirically often with Rocephin (ceftriaxone)

• pneumococcal: penicillin and cephalosporins

• gram (-): gentamycin or tobramycin

nursing care of pneumonias

• monitor vitals

• medications (antipyretics, antibiotics, bronchodilators)

• observe for signs of respiratory distress

• encourage cough & deep breathing

  • splint as needed

  • incentive spirometry

• observe sputum

  • color, consistency, amount

• chest PT, postural drainage, suction

• oxygen therapy

• pulse oximetry

• position: semi-Fowler’s

• activity: plan rest periods

• diet: high calorie, high protein

• fluids: PO 3-4 l/day & IV fluids

• anxiety: encourage expression of feelings

• cover nose & mouth when coughing

• oral care

• monitor lab studies

• evaluate client responses to treatment

pneumonia prevention

pneumococcal vaccine and stop smoking