MS unit6 (1)Comprehensive Respiratory System Assessment and Upper Airway Disorders Study Guide

Respiratory System Fundamentals & Terminology

  • Ventilation: The mechanical movement of air into and out of the respiratory tract.
  • Inhalation & Exhalation:
    • Inhalation (Inspiration): Breathing air into the lungs, bringing oxygen (O2O_2) into the body.
    • Exhalation (Expiration): Expelling air out of the lungs, removing carbon dioxide (CO2CO_2) from the body.
  • Diaphragm: The main muscle of respiration that contracts and flattens during inhalation to create negative thoracic pressure.
  • Oxygen Transport & Hemoglobin:
    • Oxygen enters the lungs, crosses into the bloodstream, and is distributed to systemic tissues and organs.
    • Hemoglobin: The red blood cell protein that acts as a transport vehicle (similar to an "Uber") to pick up oxygen molecules and deliver them to target tissues.

Nursing Health History & Patient Assessment

  • WHAT'S UP? Method: A standardized clinical assessment framework (located on page 492) used during patient interviews to gather data regarding respiratory symptoms.
  • Pack-Year Calculation:
    • A mathematical formula used to assign a quantifiable value to a patient's cumulative smoking history.
    • Pack Years=(Packs smoked per day)×(Years spent smoking)\text{Pack Years} = (\text{Packs smoked per day}) \times (\text{Years spent smoking})
  • Inhaled Substance Assessment:
    • Lungs naturally require clean air. Non-natural inhaled substances cause tissue damage and impaired gas exchange.
    • Must assess for use of cigarettes, cigars, vaping, marijuana, and exposure to environmental pollution.
  • Occupational & Environmental Exposures:
    • Assess workplace environments, adequate ventilation, and proper use of Personal Protective Equipment (PPE).
    • Workplace/factory nurses routinely collect exposure data to prevent occupational pulmonary disease.
  • Family & Health History: Inquire about genetic predispositions, familial respiratory conditions, and general clinical baseline data.

Physical Examination: Inspection

  • Mucous Membranes & Upper Airway:
    • Normal color should be pink.
    • Nasal Inspection: Check for bilateral symmetry, mucosal swelling, and exudate/drainage.
    • Posterior Pharynx: Observe color, tissue swelling, and drainage presence.
    • Drainage Documentation: Document color, consistency, clarity, and amount.
    • Mucosal Abnormalities: Check for polyps, growths, or white patches. White throat patches typically indicate streptococcal pharyngitis (strep) or oral candidiasis (thrush).
  • Breathing Observation & Patient Demeanor:
    • Observe body language for signs of dyspnea (shortness of breath).
    • Monitor for nasal flaring or intentional breath-holding secondary to chest pain.
  • Dermatological & Nail Assessment:
    • Skin Color: Documented as normal for ethnicity.
    • Capillary Refill: Normal value is <3 seconds< 3\,\text{seconds}.
    • Cyanosis & Pallor: Assess for general pallor, peripheral cyanosis, or circumoral pallor/cyanosis (pallor or blueness directly surrounding the mouth and lips).
    • Digital Clubbing: Swelling of the distal fingertips indicating long-term, chronic oxygen deficiency. Commonly seen in Chronic Obstructive Pulmonary Disease (COPD), emphysema, and cystic fibrosis.
  • Chest Configuration & Anteroposterior (AP) Diameter:
    • Normal AP Diameter: 2:12:1 ratio (the anteroposterior depth is half the transverse chest width).
    • Barrel Chest: 1:11:1 AP ratio (the anteroposterior depth equals the transverse chest width). Caused by hyperinflation and a flattened diaphragm, preventing complete gas expulsion. Common in lower airway diseases like COPD.
  • Accessory Muscle Use:
    • Observe for sternocleidomastoid/neck muscle retractions, intercostal muscle sinking (retractions between ribs), nasal flaring, and protective positioning (such as tripod positioning) to ease breathing.

Physical Examination: Palpation, Percussion, & Auscultation

  • Palpation:
    • Definition: Physical assessment through touch.
    • Sinus & Facial Tenderness: Palpate the frontal sinuses (above eyebrows) and maxillary sinuses to evaluate for pressure and sinus tenderness secondary to fluid accumulation/congestion.
    • Lymph Nodes: Palpate cervical, preauricular, and postauricular lymph nodes for edema or enlargement, which signals infection (e.g., strep throat).
    • Crepitus (Subcutaneous Emphysema): Air pockets leaking into the subcutaneous tissue layer beneath the skin. Produces a crackling, popping sensation upon touch (resembling the tactile sensation of crushing Rice Krispies cereal). Frequently occurs as a complication around chest tube insertion sites when air escapes into surrounding tissue.
  • Percussion:
    • Method: Tapping on body surface locations to produce sound waves that indicate underlying tissue density (hollow air-filled, fluid-filled, or solid mass).
    • Clinical Application: Typically performed by advanced practice registered nurses or pulmonologists.
  • Auscultation:
    • Definition: Listening to internal body sounds using a stethoscope or unassisted ears.
    • Lung Sounds: Listen for normal breath sounds and adventitious (abnormal) sounds. Document findings bilaterally. Refer to page 498 and Table 29.4 for sound descriptors/causes, and page 497 for the correct auscultation sequence.
    • Unassisted Auscultation (Cough Assessment):
      • Evaluate cough frequency and productivity (productive vs. nonproductive).
      • Stagnant, retained pulmonary secretions increase pathogen proliferation and worsen respiratory infection.
      • Sputum Documentation: Always record amount and color.
  • Plethysmograph (Pleth) Waveforms & Respiration Monitoring:
    • Table 29.9 (page 495) outlines pleth waveforms displayed on pulse oximeters and bedside monitors.
    • Monitor respiratory rate and depth.
    • Evaluating Oximetry Accuracy: If a pulse oximeter displays a low oxygen saturation (e.g., 88%88\%) in a patient who is non-dyspneic, non-cyanotic, conversant, and in no distress, assess the pleth wave.
    • An unstable or poor pleth wave indicates an inaccurate reading. Potential causes include finger enamel/nail polish, artificial nails, or poor peripheral circulation. Interventions include changing the sensor site or encouraging deep breathing.

Respiratory Patterns & Clinical Terminology

  • Apnea: Absence of respiration.
  • Dyspnea: Subjective difficulty breathing.
    • Assessment: Rated by the patient on a 0 to 100\text{ to }10 scale.
    • Nursing Interventions: Place the patient in High Fowler's position (uses gravity to lower the diaphragm, relieving thoracic stress and promoting maximal lung expansion), administer oxygen as ordered, and provide breathing coaching.
  • Tachypnea: Abnormally rapid respiratory rate.
  • Bradypnea: Abnormally slow respiratory rate.
  • Orthopnea: Dyspnea triggered by position changes, most commonly when lying down flat.
  • Cheyne-Stokes Respiration: A breathing pattern featuring alternating periods of rapid, deep breathing followed by apnea in a regular cycle. Frequently observed at end-of-life.

Laboratory Diagnostics & Arterial Blood Gas (ABG) Analysis

  • Complete Blood Count (CBC): Evaluates Red Blood Cells (RBCs), Hemoglobin (oxygen-carrying protein), and White Blood Cells (WBCs). Elevated WBCs indicate infection; differential counts isolate specific cell elevations.
  • Arterial Blood Gases (ABGs):
    • Blood sample drawn directly from an artery (commonly the radial artery) by a physician or Respiratory Therapist (RT). Nurses do not perform arterial punctures.
    • Nursing Care Post-Procedure: Apply firm direct pressure to the arterial site and monitor continuously for complications like hemorrhage or hematoma.
  • Standard ABG Normal Values (Table 29.5, page 498):
    • pH=7.35 to 7.45\text{pH} = 7.35\text{ to }7.45
    • PaO2=75 to 100 mmHg\text{PaO}_2 = 75\text{ to }100\,\text{mmHg} (Partial pressure of oxygen)
    • PaCO2=35 to 45 mmHg\text{PaCO}_2 = 35\text{ to }45\,\text{mmHg} (Partial pressure of carbon dioxide; regulated by lungs)
    • HCO3−=22 to 26 mEq/L\text{HCO}_3^- = 22\text{ to }26\,\text{mEq/L} (Bicarbonate; regulated by kidneys; basic buffer)
  • Acid-Base Compensation Mechanisms:
    • The lungs adjust CO2\text{CO}_2 levels (acid) to compensate for kidney/metabolic issues.
    • The kidneys adjust HCO3−\text{HCO}_3^- levels (base) to compensate for lung/respiratory issues.
  • Respiratory Acidosis:
    • Criteria: Blood pH<7.35\text{pH} < 7.35 due to elevated CO2\text{CO}_2 retention.
    • Pathophysiology: Results from hypoventilation or shallow breathing where the lungs fail to expel CO2\text{CO}_2.
    • Classic Patient Population: Chronic Obstructive Pulmonary Disease (COPD) patients. Hyperinflated lungs and loss of elasticity cause CO2\text{CO}_2 trapping.
  • Respiratory Alkalosis:
    • Criteria: Blood pH>7.45\text{pH} > 7.45 due to excessive CO2\text{CO}_2 expulsion.
    • Pathophysiology: Results from hyperventilation (unusually rapid breathing) blowing off excessive CO2\text{CO}_2
    • Classic Patient Population: Patients experiencing hyperventilation secondary to panic attacks or severe anxiety.
    • Treatment: Instructing the patient to breathe into a paper bag to re-breathe exhaled CO2\text{CO}_2 and restore normal blood levels.

Sputum Cultures & Specialized Pulmonary Testing

  • D-Dimer: A blood test measuring fibrin degradation products. An elevated D-dimer indicates blood clot breakdown and is used to evaluate for Pulmonary Embolism (PE).
  • Culture and Sensitivity (C&S): Laboratory collection of microorganisms grown on a culture dish to identify specific pathogens and determine effective anti-infective therapies.
    • Throat Swab: Used to diagnose conditions like streptococcal pharyngitis (strep) and distinguish viral from bacterial infections.
    • Nasal Swab: Used to detect viral infections including COVID-19, Influenza A & B, Respiratory Syncytial Virus (RSV) (often processed together on a 4-plex swab), and routine screening for Methicillin-Resistant Staphylococcus aureus (MRSA).
    • Sputum Culture: Evaluates lower respiratory tract secretions for pathogens (e.g., differentiating bacterial vs. fungal pneumonia to guide appropriate drug therapy).
    • Collection Timing: Optimal collection is first thing in the morning because secretions collect in the lungs overnight.
    • Acid-Fast Bacilli (AFB): A specialized sputum collection test used specifically to diagnose Tuberculosis (TB).
  • Expectorants (e.g., Guaifenesin / Mucinex): Pharmacology agent that pulls fluid into the respiratory tract to thin mucus secretions, making coughs productive and clearing stagnant fluid before pathogens proliferate.
  • Capnography (page 499): Continuous real-time measurement of exhaled carbon dioxide levels. Primarily used in critical care settings for intubated and mechanically ventilated patients.

Imaging Studies, Spirometry, & Diagnostic Scopes

  • Chest X-Ray: Radiographic image of thoracic structures.
    • Bones and dense structures absorb radiation and appear bright white.
    • Air-filled spaces appear dark.
    • Fluid or infiltrates (pneumonia, effusions) appear as hazy white regions, especially at lung bases.
  • Computed Tomography (CT) Scan: Advanced cross-sectional imaging assessing structural abnormalities and pulmonary blood supply.
  • Ventilation-Perfusion (V/Q or VP) Scan:
    • Diagnostic test evaluating both ventilation (VV) and perfusion (QQ).
    • Perfusion Phase: Intravenous injection of radioactive dye to visualize blood flow through pulmonary vessels.
    • Ventilation Phase: Inhalation of radioactive gas to evaluate airflow throughout lung tissue.
    • Clinical Purpose: A mismatch between ventilation and perfusion indicates a Pulmonary Embolism (PE) or compression by a mass.
  • Pulmonary Function Tests (PFTs) (Table 29.10, page 500):
    • Uses a spirometer to measure lung volumes and capacities.
    • Tidal Volume (VTV_T): The volume of air inhaled and exhaled during a single normal breath.
    • Functional Residual Capacity (FRCFRC): The volume of air remaining in the lungs at the end of a normal passive exhalation. Critical metric for evaluating gas trapping in COPD.
  • Pulmonary Angiography: X-ray imaging of pulmonary blood vessels following direct injection of radiopaque contrast dye.
  • Endoscopic Examinations:
    • Laryngoscopy: Direct visualization of the larynx (voice box).
    • Bronchoscopy: Insertion of a flexible scope past the larynx into the bronchial tree.
    • Functions: Direct mucosal visualization, tissue biopsy, removal of foreign bodies (e.g., swallowed button batteries or small plastic toys), and bronchial washing.
    • Pre- and Post-Procedure Nursing Care: Local anesthesia is sprayed to numb the pharynx, which suppresses the gag reflex. Patients must remain NPO prior to the procedure and remain NPO post-procedure until the gag reflex completely returns.
    • Assessing Gag Reflex: Touch a cotton-tipped applicator or fingertip to the posterior pharynx to confirm a gag response.
    • Post-Procedure Sputum Expectation: A small amount of pink-tinged or blood-streaked sputum is a normal finding due to mucosal irritation. Coughing up frank red blood is abnormal.

Therapeutic Measures & Invasive Procedures

  • General Nursing Therapies: Smoking cessation education, coughing and deep breathing coaching, oxygen therapy delivery, nebulizer treatments, metered-dose inhalers (MDIs), and incentive spirometry.
  • Thoracentesis (page 505):
    • Definition: Surgical perforation of the chest wall and pleural space with a large-bore needle to aspirate fluid.
    • Indications: Removal of excess pleural fluid (pleural effusion), fluid analysis/culture, tissue biopsy, or lung re-expansion.
    • Nursing Interventions & Positioning: Assess dyspnea on a 0 to 100\text{ to }10 scale pre- and post-procedure (dyspnea rating should decrease after fluid removal). Position patient sitting upright in High Fowler's position leaning forward over an overbed table, allowing gravity to pull fluid to the lung base.
    • Monitoring: Observe respiratory effort and bilateral chest expansion. Major complication risk: Pneumothorax (lung collapse from accidental lung puncture).
    • Clinical Note: Large volume aspirations (e.g., up to 3 L3\,\text{L} of fluid in heart failure patients) require close hemodynamic and respiratory monitoring.
  • Chest Tube Drainage Systems:
    • A sealed closed-suction drainage apparatus (e.g., Thoravac, Thoracil, Pneumosil) designed to restore negative intrapleural pressure.
    • Indications:
      • Pneumothorax: Air in the pleural space (chest tube placed high in the anterior chest).
      • Hemothorax: Blood in the pleural space (chest tube placed lower in the thoracic cavity).
    • Nursing Management: Maintain a closed seal. Never knock over or empty the drainage chamber. Mark output levels on the outside of the chamber at shift change to track total drainage.

Upper Respiratory Tract Disorders

  • Epistaxis (Nosebleed) (page 518):
    • Etiology: Low humidity, dry indoor air, seasonal allergies, nasal trauma (e.g., physical impact, nose picking), acute hypertension (sudden blood pressure spike), blood dyscrasias, or anticoagulant therapy (e.g., Warfarin).
    • First-Line Treatment: Have the patient sit upright and lean forward (leaning backward causes blood swallowing, severe nausea/emesis, and unmeasurable blood loss). Apply direct pressure by pinching the soft tissue of the nose for several minutes and apply ice packs.
    • Advanced Interventions: Nasal packing with gauze, chemical cauterization, or placement of a Rapid Rhino balloon catheter to exert internal pressure on bleeding vessels.
  • Nasal Polyps:
    • Grape-like clusters of swollen mucosa projecting into the nasal passages, strongly linked to chronic allergic rhinitis and nasal inflammation.
    • Treatment: Controlling allergies, nonsteroidal anti-inflammatory drugs (NSAIDs), nasal corticosteroid sprays, antihistamines, or surgical excision.
  • Deviated Septum:
    • Deflection of the nasal septum that partially occludes one nasal passage, impairing airflow and impeding nasogastric (NG) tube insertion.
    • Treatment: Surgical repair via rhinoplasty.
  • Sinusitis:
    • Inflammation of the mucosal lining of the paranasal sinuses.
    • Etiology: Upper Respiratory Infections (URIs), nasal polyps, environmental allergies, or fungal/bacterial infections.
    • Clinical Manifestations: General malaise, facial/sinus tenderness upon palpation, headache, fever, mild leukocytosis, and purulent (yellow/green) nasal drainage.
    • Management: Rest, humidified air, analgesics, nasal saline irrigation, decongestants (reduce swelling), expectorants (thin secretions), and systemic antibiotics for persistent bacterial cases.
    • Complications of Untreated Sinusitis: Sepsis (septicemia), brain abscess, and meningitis.
  • Sleep Apnea (page 521):
    • Central Sleep Apnea: Neurological condition where the central nervous system fails to send neural signals to the diaphragm and respiratory muscles.
    • Obstructive Sleep Apnea (OSA): Mechanical obstruction where pharyngeal muscles and the tongue relax during supine sleep, falling backward to block the upper airway. Risk factors include obesity, large neck circumference, and genetic predisposition.
    • Clinical Manifestations: Severe snoring, hypoxemia, sudden loud gasping for air, morning headaches, excessive daytime fatigue/somnolence, systemic hypertension, and increased stroke risk.
    • Diagnosis: Polysomnography (sleep study), often initiated following observations reported by a bed partner.
    • Lifestyle Modifications: Weight reduction, avoidance of alcohol or sedatives prior to sleep, and smoking cessation.
    • Airway Pressure Devices:
      • CPAP (Continuous Positive Airway Pressure): Delivers continuous positive air pressure throughout inhalation and exhalation to keep the airway open.
      • BiPAP (Bilevel Positive Airway Pressure): Delivers two distinct pressure settings—a higher pressure during inhalation and a lower pressure during exhalation.
    • Nursing Responsibilities: Verify that device pressure settings match the physician's order. Maintain proper hygiene protocols, including weekly changes of filters and tubing to prevent health care-associated pneumonia.