Respiratory

Unit Introduction and Learning Objectives

  • Overview: This unit focuses on the fundamentals of respiratory care specifically tailored for Licensed Practical Nurses (LPNs). It covers terminology, physiological adaptation, nursing considerations, and specific interventions to ensure patient safety and improve the quality of care delivery.

  • Primary Objectives:

    • Define terminology regarding Physiological Adaptation.
    • Investigate nursing considerations and appropriate nursing diagnoses for Physiological Adaptation.
    • Provide nursing interventions for clients experiencing Physiological Adaptation issues.
    • Describe the basic principles, systems, and techniques of fundamental nursing practice.
    • Discuss therapeutic nursing care, including safety and precautions for medication administration.
    • Integrate critical thinking and leadership skills to improve client care delivery and safety.

Fundamental Respiratory Terminology

  • Ventilation: The mechanical process involved in moving air into and out of the lung structures.
  • Respiration: The biological exchange of gases between an organism and its surrounding environment.
  • Diffusion: The physical movement of gases moving from an area of higher concentration to an area of lower concentration.
  • Perfusion: The physiological flow of blood through the lungs and the tissues of the body.

Mechanics and Regulation of Breathing

  • Mechanics of Inhalation:

    • The diaphragm contracts and flattens.
    • Intercostal muscles pull the ribs upward and outward.
    • Lung volume increases, creating negative pressure that draws air into the lungs.

  • Elastic Recoil:

    • The diaphragm relaxes.
    • Lung tissue naturally recoils.
    • Pressure within the lungs increases.

  • Mechanics of Exhalation:

    • Intercostal muscles relax.
    • Ribs move downward and inward.
    • Positive pressure is generated, pushing air out of the lungs.

  • Chemical Regulation and the Feed-back System:

    • This system primarily responds to blood CO2CO_2 levels rather than O2O_2 levels.
    • A slight increase in CO2CO_2 can double the respiratory rate.
    • Process:
      1. CO2CO_2 Increase: Blood carbon dioxide levels rise.
      2. Chemoreceptor Detection: Central chemoreceptors respond to changes in pH.
      3. Respiratory Center Stimulation: The Medulla signals for increased breathing.
      4. CO2CO_2 Decrease: Blood carbon dioxide levels normalize.

  • Nervous System Regulation:

    • Higher Brain Centers: Responsible for voluntary control of breathing.
    • Pons: Responsible for fine-tuning the respiratory rhythm.
    • Medulla Oblongata: Contains the respiratory center and automatically generates the breathing rhythm.
    • Peripheral Sensors: Provide feedback to the brain; specifically, the vagus nerve provides feedback through stretch receptors located in the lungs.

Physiological Adaptations and Gas Exchange

  • Normal Respiratory Control vs. Chronic Lung Disease:

    • Normal: CO2CO_2 is the primary driver of respiration; lungs possess normal elasticity and efficient gas exchange.
    • Chronic Lung Disease Adaptation: Oxygen (O2O_2) becomes the primary driver of respiration (hypoxic drive); there is decreased lung elasticity and chronic retention of CO2CO_2.

  • Internal vs. External Respiration:

    • External Respiration: Gas exchange occurring in the lungs at the alveolar-capillary membrane.
    • Blood Transport: Oxygen is carried throughout the body via hemoglobin.
    • Internal Respiration: Gas exchange occurring in the tissues at the capillary-tissue interface.

  • Hypoxemia vs. Hypoxia:

    • Hypoxemia: Low oxygen specifically in the arterial blood. It is measured via PaO2PaO_2 or SaO2SaO_2 and can be detected by pulse oximetry. It often precedes hypoxia.
    • Hypoxia: Inadequate oxygen at the cellular/tissue level. It may occur even if PaO2PaO_2 is normal. It causes cellular dysfunction and can lead to permanent organ damage.

Causes of Impaired Oxygenation

  • Airway Obstruction: A physical blockage (partial or complete) preventing air from reaching the lungs.
  • Ventilation-Perfusion (V/Q) Mismatch: Improper matching of air (ventilation) and blood flow (perfusion) in the lungs; commonly seen in COPD and pneumonia.
  • Alveolar Hypoventilation: Inadequate air exchange at the alveolar level, often resulting from respiratory depression.
  • Diffusion Impairment: Barriers to gas exchange between the alveoli and capillaries, such as in pulmonary fibrosis.

Clinical Assessment: Inspection and Palpation

  • Inspection:

    • Rate and Pattern: Normal adult rate is 12−20 breaths/minute12-20\,\text{breaths/minute}. Observe depth and rhythm.
    • Accessory Muscle Use: Use of neck and intercostal muscles indicates respiratory distress.
    • Chest Wall Movement: Observe for symmetry during inspiration and expiration.
    • Skin/Extremities: Observe for cyanosis (blue discoloration) and finger clubbing (a sign of chronic hypoxia).

  • Palpation:

    • Chest Wall Expansion: Assess symmetry by placing hands on the posterior chest during breathing.
    • Tactile Fremitus: Vibration felt during speech. It is increased with lung consolidation and decreased in cases of air trapping (emphysema) or pleural effusion.
    • Tracheal Position: Should be midline; deviation suggests a tension pneumothorax or lung collapse.
    • Abnormalities: Palpate for tenderness, masses, or Crepitus (a crackling sensation indicating subcutaneous emphysema, which requires immediate medical attention).

Clinical Assessment: Auscultation and Diagnostics

  • Normal Breath Sounds:

    • Vesicular: Heard in peripheral lung fields.
    • Bronchial: Heard over the trachea.
    • Bronchovesicular: Heard between the scapulae.

  • Adventitious (Abnormal) Sounds:

    • Wheezes: High-pitched, musical sounds indicating narrowed or obstructed airways (common in asthma/COPD).
    • Crackles: Fine or coarse discontinuous popping sounds suggesting fluid in the alveoli or small airways (common in pneumonia/CHF).
    • Rhonchi: Low-pitched snoring or gurgling sounds indicating secretions in larger airways; may clear with coughing.
    • Decreased Sounds: Suggest poor air movement, pleural effusion, or pneumothorax.

  • Diagnostic Tests and Normal Values:

    • Pulse Oximetry (SpO2SpO_2): Normal is 95−100%95-100\%. Levels below 90%90\% indicate significant hypoxemia.
    • Arterial Blood Gas (ABG):
      • PaO2PaO_2: 80−100 mmHg80-100\,mmHg (Direct measure of arterial oxygenation). Values below 60 mmHg60\,mmHg require immediate intervention.
      • pHpH: 7.35−7.457.35-7.45 (Identifies respiratory acidosis or alkalosis).
      • PaCO2PaCO_2: 35−45 mmHg35-45\,mmHg (Evaluates adequacy of ventilation; elevated in hypoventilation).
    • Chest X-ray: Identifies infiltrates, effusions, pneumothorax, and structural abnormalities.
    • Pulmonary Function Tests (PFTs): FEV1/FVC>70%FEV_1/FVC >70\% is normal; used to distinguish between obstructive and restrictive diseases.

Nursing Interventions for Impaired Oxygenation

  • Positioning: Use Semi-Fowler's or High-Fowler's position (30−90∘30-90^{\circ}) to maximize lung expansion and avoid lung compression from slumping.
  • Oxygen Therapy: Titrate to maintain SpO2>90%SpO_2 >90\%. (Standard target is often noted as >92%>92\% in clinical goals).
    • Nasal Cannula: 1−6 L/min1-6\,L/min.
    • Simple Mask: 5−10 L/min5-10\,L/min.
    • Non-rebreather Mask: 10−15 L/min10-15\,L/min.
  • Breathing Exercises:
    • Incentive Spirometry: Inhale slowly and deeply, hold for 3−5 seconds3-5\,\text{seconds}. Perform 10 repetitions hourly10\,\text{repetitions hourly}.
    • Pursed-lip Breathing: Helps maintain open airways during exertion and reduces anxiety.
  • Airway Clearance:
    • Suctioning to remove secretions.
    • Chest physiotherapy to mobilize secretions.
    • Hydration (maintaining fluid balance) to thin secretions.
  • Medication: Administer bronchodilators to open airways and corticosteroids to reduce inflammation.
  • Energy Conservation:
    • Prioritize activities and cluster care to minimize exertion.
    • Use assistive devices (shower chairs, reachers, electric can openers).
    • Teach patients to sit during tasks and schedule rest periods.

Oxygen Safety and Equipment Management

  • Safety Measures:
    • Strictly enforce a "No Smoking" policy.
    • Keep oxygen at least 5 feet5\,\text{feet} away from heat sources or open flames.
    • Secure oxygen tanks upright.
    • Monitor for Oxygen Toxicity: Signs include cough, chest pain, and decreased respiratory drive, especially with FiO2>50%FiO_2 >50\%.
  • Oxygen Sources:
    • Compressed Gas Cylinders: Portable, high-pressure tanks requiring regulators.
    • Liquid Oxygen Systems: Stores oxygen in liquid form; converts to gas upon use. Preferred for home use.
    • Oxygen Concentrators: Extracts oxygen from room air; suitable for long-term therapy without refills.

Artificial Airways and Suctioning

  • Types of Airways:
    • Oropharyngeal Airway: Curved plastic; prevents the tongue from blocking the airway in unconscious patients.
    • Nasopharyngeal Airway: Soft rubber tube for the nostril; preferred for semi-conscious patients.
    • Endotracheal Tube (ET): Inserted into the trachea for mechanical ventilation.
  • Suctioning Procedure:
    • Use sterile technique.
    • Pre-oxygenate the patient before the procedure.
    • Insert the catheter without suction; apply suction only during withdrawal.
    • Limit suctioning to 10−15 seconds10-15\,\text{seconds}.
    • Monitor oxygen levels and heart rate throughout.

Tracheostomy Care

  • Anatomy: Includes the Outer Cannula, Inner Cannula (removable), Obturator (guide for insertion), Flange (neck rest), and Cuff (balloon seal).
  • Care Essentials:
    • Inner Cannula: Clean or replace every 8 hours8\,\text{hours} using saline (and hydrogen peroxide for reusable ones).
    • Humidification: Essential to prevent mucus plugs; use humidified oxygen or heat moisture exchangers.
    • Cuff Management: Maintain pressure at 20−25 cmH2O20-25\,cmH_2O to prevent tracheal damage.
    • Stoma Care: Clean with saline and gauze; assess for infection.

Chest Tube Management

  • Indications: Used for pneumothorax, hemothorax, pleural effusion, or empyema.
  • Chest Drainage System Components:
    • Collection Chamber: Collects drainage; monitor volume, color, and consistency.
    • Water Seal Chamber: Prevents air from entering the chest. Look for "tidaling" (movement with breathing). Continuous bubbling indicates an air leak.
    • Suction Control Chamber: Regulates negative pressure; must maintain sterile water at the prescribed level.
  • Nursing Care:
    • Keep the drainage unit below the level of the patient's chest.
    • Ensure tubing is free of kinks.
    • Monitor for complications like tube dislodgement or subcutaneous emphysema.

Care Planning and Safety Protocols

  • Common Nursing Diagnoses:
    • Ineffective breathing pattern.
    • Impaired gas exchange.
    • Activity intolerance.
    • Risk for infection.
    • Anxiety.
  • SMART Goals Example: Patient will maintain oxygen saturation above 92%92\%.
  • Safety Alarms: Respond to ventilator alarms immediately; verify settings at the start of every shift; never silence an alarm without investigation.
  • Fall Prevention: Secure oxygen tubing to prevent tripping; keep the call button in reach.