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Biological molecules (2.3-2.4)

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The Mole and Equations

Care for Client with Oxygenation Problem

Review of Lung Anatomy and Functions

Respiratory System
- Two main parts:
  - Upper Respiratory System
    - Nose/Sinuses/Nasal Passages
    - Pharynx/Tonsils and Adenoids
    - Larynx
    - Trachea
  - Lower Respiratory System
    - Bronchus
    - Bronchioles
    - Respiratory Units

The Upper Airways

The Nasal Cavity
- Serves as a passageway for air.
- Lined with mucous membrane to produce mucus and filter.
- Highly vascular to warm air.
- Receives draining mucus from sinuses.
- Lined with olfactory nerves.
- Functions:
  1. Filter air
  2. Humidify/Warms air
  3. Aid in phonation
  4. Olfaction

The Sinuses

Four paired bony cavities, lined with mucous membrane and ciliated pseudostratified columnar epithelium.
- Named after their location:
  - Frontal
  - Ethmoidal
  - Sphenoidal
  - Maxillary
- Function:
  1. Lightens the skull
  2. Resonate speech
  3. Trap/Drain debris

The Pharynx

A funnel-shaped musculo-membranous tube that is composed of:
- Nasopharynx
- Oropharynx
- Laryngopharynx
Lymphoid Tissues
1. Adenoids
2. Tonsils
Functions:
1. Passageway for food/air
2. Protects lower airways

The Larynx

Composed of cartilage and membranes, connecting pharynx to the trachea.
Contains vocal cord
Functions:
1. Protects lower airway
2. Vocalization
3. Facilitates coughing

The Trachea

A cartilaginous tube of 12-15cm.
Composed of 16-20 C-shaped rings of cartilages.
Lined with mucus and cilia.
Located anteriorly to the esophagus
Functions: Passageway between the larynx and bronchi

The Bronchial Tree

Bronchus Function: Air Passage
- Primary Bronchus
  - Right Bronchus
    - Shorter
    - Wider
    - More vertical
  - Left Bronchus
    - Narrower
    - Longer
    - More horizontal

The Bronchioles

Main bronchi subdivide into secondary (lobar) bronchi.
Right middle lobe bronchus are smaller in diameter and length.
Bronchi further subdivide in tertiary (segmental)bronchi then to smaller and smaller terminal bronchioles (last part of the conducting airway).
Smallest parts are at risk of collapsing due to absence of cartilage

The Respiratory Acinus

The functional unit of the lungs.
It consists of:
- Respiratory bronchioles
- Alveolar ducts
- Alveolar sac
Functions: Gas Exchange through respiratory membrane

Respiratory Membrane

Respiratory membrane is composed of two epithelial cells:
1. Type 1 pneumocyte –most of abundant, thin and flat, where gas exchange occur
2. Type 2 pneumocyte –secretes lung surfactant
3. Type 3 pneumocyte -macrophages

Accessory Structures

Thoracic Cavity/Cage and Respiratory Muscles
- Composed of sternum, the rib cage, intercostal muscles.
- The cavity is separated by the diaphragm.
- Inspiratory muscles (diaphragm and intercostal muscles)

Pleura

Double layered serous membrane that covers the lungs and the inside of the thoracic cage
- Visceral and parietal pleurae
- Has slightly negative pressure in the pleural space
- Pleural space contains serous fluid that lubricates

Ventilation and Respiration

Pulmonary Ventilation –the act of breathing, the exchange of air between lungs and the environment
- Inspiration
- Expiration

Airway Resistance, Lung Compliance and Elasticity

Respiratory Passageway Resistance –affected by friction created by constriction of the airway, presence of mucus or infections material, and by tumor
Lung Compliance –depends on the elasticity of the lung tissue and flexibility of the rib cage
Lung Elasticity –the ability of the lung tissue to distend and recoil

Alveolar Surface Tension

A liquid film of mostly water covers the alveolar walls.
The liquid film creates a state of tension due to the strong affinity of liquid molecule to each other.
This tension aids in alveolar recoil.
Surfactant is a lipoprotein that reduces surface tension

Respiratory Volume and Capacity

Lung Volume
1. Tidal Volume (TV)
2. Inspiratory Reserve Volume (IRV) –amount of air that can be inhaled forcibly (3,000 ml)
3. Expiratory Reserve Volume (ERV) –amount of air that can be forced out (1,100 ml)
4. Residual Volume (RV) –volume of air that remains in the lungs after a forced expiration (1,200 ml)
Lung Capacity
1. Vital Capacity (VC) –sum of TV+IRV+ERV
2. Inspiratory Capacity (IC) –sum of TV+IRV
3. Functional Residual Capacity (FRC) –sum ERV+RV
4. Total Lung Capacity (TLC) –sum TV+IRV+ERV+RV

Respiration

External Respiration
Internal Respiration

Neurologic Control of the Respiratory System

Respiratory Centers in the Medulla Oblongata and Pons
Chemoreceptors in medulla, carotid and aortic bodies
Example Increased CO_2 Concentration Chemoreceptors Increased Respiratory Rate Control center

Respiratory Assessment History Taking

Consider the Following:
1. Reason for Seeking Care
  - Chief complaints
    - Cough
    - Sputum production
    - Hemoptysis
    - Wheezing
    - Stridor
    - Chest pain
2. Present illness (History of Present Illness)
3. Previous illness (Past Medical History)
  - Childhood/infectious diseases
  - Respiratory immunizations
  - Major illnesses/hospitalization
  - Medication
  - Allergies
4. Family History
5. Social History
  - Occupational or environmental exposure
  - Geographic location
  - Personal habits (Years of Smoking x packs/day = pack years)

Physical Examination

Skin/Lip/Mucous Membrane Color
Nail Clubbing
Cough and Sputum Production
Inspection-Palpation-Percussion-Auscultation of the Thorax

Common Diagnostic Test and Procedure

Sputum Examination:
- To assess for gross appearance of the sputum
- Sputum C/S
- AFB
- Cytologic Examination
- Nursing Responsibilities:
  - Best done in the morning just after awakening.
  - Teaching coughing exercises.
  - Increase fluid intake the night prior to procedure.
  - Provide mouth care after the procedure
Arterial Blood Gas:
- To assess ventilation and acid-base balance
- Normal Values:
  - pH:
  - PaO_2:
  - PaCO_2:
  - HCO_3:
- Nursing Responsibilities:
  - Specimen should be collected in heparinized needle and syringe.
  - Place sample in ice and should be taken immediately to the lab.
  - Indicate in client is receiving oxygen supplementation.
  - Apply pressure to puncture site for 2-5 minutes.
  - Do not collect specimen on the same arm for IV infusion,
Pulse Oximetry:
- To assess oxygen saturation in blood
- Normal Values:
- Nursing Responsibilities:
  - Assess for factors that may alter findings.
Chest X-ray:
- To identify abnormalities in chest structure and lung tissue
- Nursing Responsibilities:
  - No special procedure in needed.
  - Clothes and metallic objects on person must be remove so as not to alter result.
Computed Tomography (CT Scan):
- Use when x-ray do not show some areas well
- Helps to differentiate pathologic conditions
- Nursing Responsibilities:
  - No special preparation
Positron Emission Tomography (PET Scan):
- Use to identify lung nodules
- Has 25% lower radiation as compared to CT
- Nursing Responsibilities:
  - No alcohol, coffee, or tobacco is allowed for 24 hours prior to test. Encouraged increase fluid intake post-test to eliminate the radioactive material.
Magnetic Resonance Imaging:
- Use when CT do not show tissue alterations well
- Nursing Responsibilities:
  - Assess for any metallic implants.
  - Test will not be performed in the presence of such,
Pulmonary Angiography:
- Done to identify tumors, pulmonary emboli, aneurysm and vascular changes and pulmonary circulation
- A catheter is inserted in the brachial and or femoral artery into the pulmonary artery, dye is injected
- ECG leads are applied to the chest for cardiac monitoring. Images of the lungs are taken
- Nursing Responsibilities:
  - Monitor injection site and pulses distal to the side after the test.
Pulmonary Ventilation/Perfusion Scan (V/Q Scan):
- Done through two nuclear scans (ventilation and perfusion)
- Perfusion –done by injecting radioactive albumin into a vein and scanning the lungs.
- Ventilation –done by inhaling radioactive gas
- Nursing Responsibilities:
  - No special preparation is needed.
  - Encouraged client to increase fluids after the procedure,
Bronchoscopy:
- Direct visualization of the larynx, trachea, and bronchi with bronchoscope.
- Nursing Responsibilities:
  - Routine preoperative care
  - Provide mouth care
  - Have resuscitation and suction equipment at bedside
  - Monitor V/S during procedure
  - NPO for 2 hours or until fully awake
  - Provide emesis basin for secretion and saliva (note color and characteristics)
  - Collect post bronchoscopy sputum for cytology
Lung Biopsy:
- Done to obtain tissue to differentiate tumors of the lungs
- Nursing Responsibilities:
  - Same as Bronchoscopy
Thoracentesis:
- Aspiration of fluid or air in the pleural space
- Nursing Responsibilities:
  - Before and During:
    - Administer cough suppressant.
    - Position client upright, leaning forward with arms and head supported on an anchored overbed table.
    - A sensation of pressure may be felt even if anesthesia use.
  - After:
    - Monitor pulse, color, O_2 sat and other signs.
    - Apply a dressing on puncture site and position on the unaffected site for 1 hour.

Therapeutic Management and Procedure

Coughing Exercises
- After using a bronchodilator treatment (if prescribed), inhale deeply and hold your breath for a few seconds
- Cough twice. The first cough loosens the mucus; the second expels secretion
- For huff coughing, lean forward and exhale sharply with a “huff” sound. This technique helps keep your airways open while moving secretions up and out of the lungs
- Inhale by taking rapid short breaths in succession (sniffing to prevent mucus from moving back into smaller airways
- Rest
Deep Breathing Exercises
- Place client in comfortable position
- Ask the client to flex knees to relax abdominal muscles
- Ask the client to place one hand or both hands on abdomen
- Instruct the client to breathe in deeply through the nose keeping mouth closed
- Ask the client to purse lips and breathe out slowly, making a “whooshing” sound without puffing cheeks
Peak Flow Meter
* A simple method of measuring the degree of airway obstruction and helps to detect and monitor moderate to severe respiratory disease
* Wash and dry hands
* Assemble equipment
* Explain the procedure
* Set the pointer to zero
* Ask the client to obtain a comfortable position
* Ask the patient to take a deep breath
* Holding PEF meter horizontally, ask the client to place their lips and teeth around the mouthpiece, ensuring a good seal
* Ask the patient to breath out hard and fast
* Note the reading and then return pointer to zero
* Ask the client to repeat procedure twice
Chest Physiotherapy
- Percussion
- Vibration
- Postural Drainage
- Nursing Care
  - Check doctor’s order
  - Consider positioning through initial auscultation
  - Do CPT of upper lobes before the lower lobes
  - 10-15min in each position for a total of 30min per session
  - Change position gradually to prevent postural hypotension
  - Best done 60 to 90min before meal or upon waking up or before bed time
  - Provide good oral hygiene
Incentive Spirometer
- Done to enhance deep inhalation. As the client inhales indicators (balls/light) goes up which signifies good lung expansion.
- Wash and dry hands
- Assemble equipment
- Explain the procedure
- Set the pointer to zero
- Ask the client to obtain a comfortable position
- Instruct the client to place his lip around the mouth piece and inhale deeply
- Encourage the client to go higher than the set point
- Encourage to repeat procedure few times in a day
- Health teach about proper care of device
Oxygen Administration
- Assess for signs and symptoms of hypoxemia
- Verify doctor’s order
- Ensure room safety
- Position client
- Open source of O_2 and check for device functionality
- Humidify air by filling up the humidifier
- Place administration device properly
- Coach normal breathing
- Oronasal hygiene/lubrication of nares
- Asses effectiveness
- Make relevant documentation
Suctioning
- Client should be in semi- or high-Fowler’s position
- Observe sterile technique by using sterile gloves and suction tip
- Hyperventilate with 100% oxygen before and after suctioning
- Insert catheter with gloved hand
- Apply suction during withdrawal of catheter
- Rotate catheter during withdrawal while applying intermittent suction
- Suctioning should be done within 5-10sec (maximum of 15)
- Evaluate

Closed Chest Drainage (Thoracotomy Tube)

To remove air and/or fluids from the pleural space
To reestablish negative pressure and re-expand the lungs
Type of Closed Chest Drainage
- One Bottle System
- Two Bottle System
- Three Bottle System

One Bottle System

The bottle serves as drainage and water seal
Immerse tip of drainage tube in 2-3 cm of sterile water to create water seal
Bottle should be kept lower that the body about 2-3 feet
Never raise the bottler higher than the chest
Assess for patency of device
Observe for fluctuation of fluid along the tube
Observe for intermittent bubbling of fluid
In the absence of fluctuation
Suspect obstruction of the device
If without obstruction consider lung re-expansion to be validated by x ray
Air vent should be open for air

Two Bottle System

Without suction apparatus
- First bottle is drainage; the second is water seal
- Observe for fluctuation of fluid along the tube (water seal bottle) and intermittent bubbling with each respiration
With suction apparatus
- First bottle is drainage and water seal bottle; the second bottle is suction control bottle
- Immerse tip of the tube in the first bottle in 2-3cm of sterile NSS; immerse the the tube of the suction control bottler in 10-20cm of sterile NSS to stabilize the normal negative pressure in the lungs. This protects the pleura from trauma if the suction pressure is inadvertently increased.
- Expect continuous bubbling in the suction control bottler; intermittent bubbling and fluctuation in water seal

Three Bottle System

First bottle is drainage bottle; second bottle is water seal; third bottle is suction control bottler
Observe for intermittent bubbling and fluctuation with respiration in water seal bottle; continuous bubbling in the suction control bottle
Nursing Care:
- Encourage to do following to promote drainage
  1. Deep breathing and coughing exercises
  2. Turn to sides at regular basis
  3. Ambulate
- ROM exercises of arms
- Mark the amount of drainage at regular intervals
- Avoid milking and clamping of tube to prevent tension pneumothorax
- Removal of test tube –done by doctors
  - Prepare:
    1. Petroleum gauze
    2. Suture removal kit
    3. Sterile gauze
    4. Adhesive tape
- Place client in semi-Fowler’s position
- Instruct client to exhale deeply and to strain (Valsalva maneuver) as the chest tube is removed
- Chest x-ray may be done after the tube removal
- Observe for complications

Arterial Blood Gas

To assess ventilation and acid-base balance
Radial artery is the common site for withdrawal of blood specimen.
Perform Allen’s test before procedure
Use 10ml pre-heparinized syringe
Place the specimen in a container with ice
Interpretation
- Determine if the disorder is acidosis or alkalosis in nature
- Determine if the disorder is respiratory or metabolic in origin
- Identify if there is compensation
- Determine if compensation is full or partial

Imbalance

| | pH | PCO2 | HCO3 | PO2 | Compensaton | | :-------------- | :- | :-------- | :-------- | :------- | :------------------------------------------------------------------------- | | Respiratory Acidosis | | | | | Kidneys conserve HCO3 Eliminate H+ to épH |
| Uncompensated | ê | é | N | N | |
| Compensated | N | é | é | é | |
| Respiratory Alkalosis | | | | | Kidneys eliminate HCO3 Conserve H+ to êpH | | Uncompensated | é | ê | N | N | | | Compensated | N | ê | ê | ê | | | Metabolic Acidosis | | | | | Hyperventilation to ê CO2 And conserve HCO3 | | Uncompensated | ê | N | ê | ê | | | Compensated | N | ê | ê | ê | | | Metabolic Alkalosis | | | | | Hypoventilation to é CO2 Kidneys keep H+ and excrete HCO_3 |
| Uncompensated | é | N | é | é | |
| Copensated | N | é | é | é | |