Transcript Bowel Diversion: Ostomies

Respiratory System:
Assessment
NRS 108
Spring 108
Majuvy L. Sulse MSN, RN, CCRN, CNE
Anatomy, Physiology and Functions of
the Respiratory System
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Respiratory System
provides the cells of the
body with oxygen and
eliminates carbon dioxide
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Pulmonary ventilation-air
moving in and out of lungs
External respirationexchange of oxygen and
carbon dioxide between
the alveoli and blood
Internal respiration –
exchange of gases is
made between the blood
and cells
Gas transport-oxygen and
carbon dioxide transported
to and from the lungs and
cells by the blood
Mechanics of Ventilation
Breathing (Ventilation):
 Inspiration
 Expiration
Upper Respiratory Tract
Upper Respiratory System
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Nose
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Sinuses
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contains hair follicles, mucus membranes that traps
bacteria
Turbinates increase surface area for filtering, heating
and humidifying air
Lightens the skull, assists in speech and produce mucus
that drains into nasal cavities to help trap debris
Pharynx
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Funnel shaped 13 cm long & has 3 regions:
nasopharynx, oropharynx, laryngopharynx
Serves as passageway for air/food
Upper Respiratory System cont’d
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Larynx
 Composed of cartilages
 Thyroid cartilage-Adam’s apple
 Cricoid cartilage-vocal chords
 Glottis-opening between the true vocal chords
 Epiglottis-prevents aspiration
 Provides routes for air and food into proper passageway
Trachea (windpipe)
 About 12-15 cm long
 Also has mucosal linings that traps debris
 Branches into the right & left bronchi
Lower Respiratory Tract
Lower Respiratory System
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Bronchi
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Bronchioles
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Mainstem branches into 5 secondary bronchi that enters the 5
lobes of the lungs
Composed of connective issues, blood vessels and cartilage is
ringlike and resist collapse
Lined with ciliated, mucus secreting epithelium to propel
mucus away from lower airways
Have no cartilage and depend on the elastic recoil of the lung
to remain open
Alveolar ducts and Alveoli
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Alveolar sacs arise ducts which contain the basic units of gas
exchange
Normal lung contains-300 million alveoli
Secrets surfactant-protein reducing the surface tension of
alveoli
LUNGS
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Cone shaped organs, sponge-like and elastic lies
in the pleural cavity in the thorax
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Apex-top- extends above the clavicle
Base-bottom-above the diaphragm
Right lung-3 lobes
Left lung-2 lobes
Innervations-phrenic nerve (pleura) and intercostal
nerves (diaphragm)
Pleura-smooth membranes covering the lungs
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Visceral-outside lining
Parietal-inner covering
Pulmonary Circulation
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Pulmonary circulation-highly vascular
network
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Deoxygenated blood from R ventricle of heartpulmonary artery-arterioles and capillariesenmeshed around alveoli where gas exchange
takes place
Freshly oxygenated blood is carried by the
capillaries-venules-pulmonary veins-left
atrium-left ventricle-aorta and throughout
systemic circulation
Pulmonary Circulation
Assessment of Respiratory System
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History taking (personal & family hx)
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Demograhics
Occupation
Medical history-hx of smoking, medications, allergies,
diet
current health problems (cough, chest pain, dyspnea,
sputum production)
Psycho-social Assessment
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Lifestyle
Stress
Coping mechanisms
Support systems
Assessment of Respiratory System
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Physical Assessment
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Inspection-includes skin
assessment & color
Palpation-assess respiratory
movement symmetry (tactile
or vocal fremitus, crepitus)
Percussion-assess pulmonary
resonance (flat, dull, tympany,
hyperresonance)
Auscultation-listening to
normal & adventitious lung
sounds (wheezing, rhochi,
pleural rub, crackles)
Normal Lung Sounds
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Bronchial-high pitched heard over trachea &
larynx
Bronchovesicular- moderate sound over major
bronchi
Vesicular-soft rustling sound over bronchioles &
alveoli
Normal
Decreased
Increased
Adventitious Lung Sounds
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Crackles/ Rales
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FineCoarse
High or Low pitched
Wheeze
 Rhonchus
 Friction Rub
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Other Assessments
Voice sounds
 Bronchophony
 Whispered pectoriloquy
 Egophony
 Skin and mucous membranes
 General appearance
 Endurance
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Diagnostic Assessment
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MRI
Endoscopic examinations
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Thoracenstesis- aspiration of pleural fluid or air from the pleural
space
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Bronchoscopy
Laryngoscopy
Mediastinoscopy
Client preparation for stinging sensation and feeling of pressure
Correct position
Motionless client
Follow-up assessment for complications
Lung Biopsy- Assess vital signs and breath sounds at least every 4
hours for 24 hours.
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Assess for respiratory distress.
Report reduced or absent breath sounds immediately.
Monitor for hemoptysis
Diagnostic Assessment
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Blood tests
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Sputum tests
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CBC
ABGs-Arterial blood gas
Culture/sensitivity
cytology
Radiographic examinations
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Chest X ray
Tomography
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CT scan
PET –Positron emission tomography
VQ scan
Diagnostic Assessment
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Non-invasive tests
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Pulse oximetry
Skin tests
Pulmonary Function tests-evaluate lung volumes and capacities,
flow rates, diffusion capacity, gas exchange, airway resistance, and
distribution of ventilation.
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Forced Vital Capacity (FVC)
Forced expiratory volume (FEV1)
FEV1/FVC
FEF 25-75%
Functional residual capacity (FRC)
Total Lung Capacity (TLC)
Residual volume (RV)
DLCO
Common Measurements in Pulmonary Function Testing
UPPER RESPIRATORY
DISORDERS/INFECTIONS
Epistaxis
Rhinitis
Sinusitis
Pharyngitis (Viral,
Bacterial/Streptococcal)
Influenza
Epistaxis (Nosebleed)
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Most common in children, men and elderly.
 Most likely anterior bleeding in children – may resolve
spontaneously.
 Posterior bleeding in elderly - may require treatment
Causes:
 Trauma
 Foreign bodies
 Nasal spray
 Drugs: street drugs, aspirin/anticoagulants/NSAIDS,
 Deformities
 Allergic rhinitis
 Tumors.
 Any condition that may prolong bleeding time or alter platelet count.
Epistaxis (Nosebleed) cont’d
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Interventions:
 keep quiet
 assume position - sitting, leaning forward or reclining
 apply pressure
 Apply ice
 nasal packing
 do not blow nose
 obtain medical help if bleeding continues
Vasoconstrictive agent: phenylephrine (Neo-Synephrine)
Cauterization: silver nitrate stick or electrocautery
Packing by health care provider (48-72hrs). Posterior packing may alter
breathing, predispose to infection, painful.
May require surgery
Allergic Rhinitis
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Two types of allergic rhinitis:
 seasonal - occurs particularly during pollen seasons
 perennial - occurs throughout the year
Most-common causes of allergic rhinitis:
 pollen
 dust mites
 mold
 animal dander
Reactions from allergic rhinitis include:
 sneezing
 congestion
 runny nose
 itchy nose, throat, eyes, and ears
Allergic Rhinitis cont’d.
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Preventive measures:
 environmental controls, such as air conditioning, during pollen
season
 avoiding areas where there is heavy dust, mites, molds
 avoiding pets
Treatments for allergic rhinitis (as determined by physician and based
on client’s condition) include:
 oral medications (antihistamine, decongestant)
 inhaled medications (cromolyn sodium, Flonase)
 immunotherapy
 allergy injections
Nonallergic Rhinitis
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Types of nonallergic rhinitis:
 vasomotor rhinitis (irritant
rhinitis)
 eosinophilic
 rhinitis medicamentosa
 neutrophilic rhinosinusitis
 structural rhinitis
 nasal polyps
 primary vasomotor instability
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Causes:
 fumes
 odors
 temperature
 atmospheric changes
 smoke
 other irritants
Reactions from nonallergic rhinitis
include:
 sneezing
 congestion
 runny nose
 itchy nose, throat, eyes, and
ears
Nonallergic Rhinitis cont’d.
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Preventive measure – avoiding the primary cause.
Treatments:
 oral medications (antihistamine, decongestant)
 inhaled medications (saline nasal spray, corticosteroid
spray)
 immunotherapy
 allergy injections
 surgery for some conditions
Rhinitis (Summary)
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Inflammation of the mucous membrane of the nose.
May be acute ( coryza/common cold), chronic or allergic in nature.
Clinical manifestations vary with each type: nasal discharge, headache,
sneezing, altered sense of smell, post nasal drip, fever.
No specific treatment for common cold. Rest, liquids, proper diet,
antipyretics, and analgesics. Complications or secondary bacterial
infections may require antibiotics.
Antihistamines, nose sprays, decongestants.
Teaching: Hand washing, proper nose blowing, avoid crowds, specific
allergens, yearly flu shot (vulnerable populations), seek medical help for
high fever, earache, symptoms lasting> 2 weeks, or recurrent colds.
Sinusitis
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Acute or Chronic
Bacterial or Viral
Inflammation of the sinuses
Clinical manifestations:
 Acute: pain over affected sinuses, purulent drainage, pressure, congestion, fever,
malaise, headaches.
 Chronic:
 May be difficult to diagnose because of non-specific symptoms.
 Rarely febrile.
 Severe pain and purulent drainage is absent.
 May resemble allergies.
 May need X-ray or CT scan to confirm diagnosis.
Sinusitis cont’d.
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Treatment:
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Antibiotics for 10-14 days
Analgesics
Decongestant
Nasal corticosteroids
Mucolytics
Avoid 1st generation Antihistamines (Benadryl, Tavist,
Chlor-Trimeton) cause increased viscosity of mucus.
Chronic: may require broad-spectrum for 4-6 weeks.
Steam humidification
Hot and wet packs over the sinus area
Nasal saline irrigations
Surgical Management
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Antral irrigation
Caldwell-Luc procedure
Nasal antral window procedure
Endoscopic sinus surgery
Pharyngitis
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Inflammation of the pharynx.
Frequently results in a sore throat.
Acute pharyngitis – an acute inflammation of the pharyngeal walls. Includes
tonsils, palate and uvula.
 Viral (70% of cases): including the the common cold virus, flu
(influenza) virus, adenovirus, mononucleosis, HIV, and various others.
 Bacterial: B-hemolytic streptococcus (20% of cases); Group A
streptococcus (causes " strep throat" in about 15% of cases; other less
common bacteria found in sore throats include Corynebacterium,
Arcanobacterium, Neisseria gonorrhoeae, Chlamydia pneumoniae,
and others. In up to 30% of cases, no organism is identified
Peak: late fall, winter, spring
Pharyngitis cont’d.
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Symptoms:
 Sore throat or scratchy throat, red and edematous pharynx with or
without patchy exudate
 Strep throat may be accompanied by fever, headache, and swollen
lymph nodes in the neck
 Viral pharyngitis may be associated with runny nose and postnasal
drip
 Severe cases may be accompanied by difficulty swallowing and,
rarely, difficulty breathing
 Additional symptoms are dependent on the microorganisms causing
the infection
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Strep throat is a serious cause of pharyngitis. The complications of strep
throat: acute rheumatic fever, kidney dysfunction, and severe diseases
such as bacteremia and streptococcal toxic shock syndrome.
Pharyngitis cont’d.
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Diagnosis:
 Throat culture (Rapid strep test)
 CBC with diff
 Mono test (R/O mononucleosis)
Medical Treatment:
 Antibiotics if Bacterial : Penicillin unless allergy, then Biaxin or
Erythromycin
 Zithromycin also useful
Nursing Care:
 Supportive: Increase fluid intake, saline gargles, throat lozenges, avoid
citrus.
Tonsillitis
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Inflammation and infection of the tonsils and
lymphatic tissues located on each side of the
throat
Contagious airborne infection, usually bacterial
Antibiotics
Surgical intervention
Peritonsillar Abscess
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Complication of acute tonsillitis
Pus behind the tonsil, causing one-sided swelling
with deviation of the uvula
Trismus and difficulty breathing
Percutaneous needle aspiration of the abscess
Completion of antibiotic regimen
Laryngitis
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Inflammation of the mucous membranes lining
the larynx, possibly including edema of the vocal
cords
Acute hoarseness, dry cough, difficulty
swallowing, temporary voice loss (aphonia)
Voice rest, steam inhalation, increased fluid
intake, throat lozenges
Therapy: relief and prevention
Influenza
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Upper respiratory infection caused by viruses A, B, C
Influenza-related deaths average 20,000 per year.
 Mostly in persons > 60 yrs of age with underlying heart or
lung disease.
Clinical Manifestations: abrupt onset, fever, cough, myalgia
(muscle pain), headache, sore throat, malaise, dyspnea and
diffuse crackles (pulmonary complications).
Uncomplicated : last for 7 days; may take longer for older
adults
Complication: Pneumonia. If bacterial pneumonia, flu gets
better, but worsening cough and purulent sputum.
Influenza
Prevention: Flu vaccine: given Mid-October before
exposure.
 Soreness at injection site.
 Contraindication: allergy to eggs
 Drug therapy: Flumadine or Symmetrel to decrease or
prevent symptoms of A influenza.
 High risk, usually not vaccinated persons.
 Relenza and Tamiflu for type A & B. Must be given
within 2 days of onset of symptoms
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NURSING DIAGNOSIS:
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Impaired Gas Exchange
Interventions include:
 Cough enhancement
 Oxygen therapy
 Respiratory monitoring
Ineffective Airway Clearance
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Interventions include:
 Help client to cough and deep breathe at least
every 2 hours.
 Administer incentive spirometer—chest
physiotherapy if complicated.
 Prevent dehydration.
 Monitor intake and output of fluids.
 Use bronchodilators, especially beta2 agonists.
 Inhaled steroids are rarely used.
Potential for Sepsis
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Primary intervention is prescription of antiinfectives for eradication of organism causing
the infection.
Drug resistance is a problem, especially
among older people.
Interventions for aspiration pneumonia aimed
at preventing lung damage and treating
infection.