2. TERMINOLOGIES
VENTILATION – MOVEMENT OF AIR IN & OUT OF
THE LUNGS
RESPIRATION – EXCHANGE OF GASES :
EXTERNAL & INTERNAL
EXTERNAL – BET. ALVEOLI & PULMONARY
CAPILLARIES
INTERNAL – BET. SYSTEMIC CAPILLARIES
PERFUSION – AVAILABILITY & MOVEMENT OF
CAPILLARY BLOOD FOR EXCHANGE OF GASES
MTCAT '09
3. Anatomy of the Upper
Respiratory System
Nose
Sinuses
Pharynx
Larynx
Trachea
MTCAT '09
4. Defenses of the Airways &
Lungs
Nose- particulates larger than 10 mm are
filtered and trapped in the nasal mucosa.
Mucocilliary blanket- 2-10 mm
Mucocilliary escalator system –
composed of mucus secreting goblet
cells in the bronchi, ciliated epithelia &
mucus
Pulmonary alveolar macrophage activity
MTCAT '09
5. Reflexes of the Airways
Sneeze Reflex – characterized by a deep
inspiration, followed by a violent expiratory blast
through the nose
Irritant stimulate the trigeminal nerve
May cause HTP
Cough reflex- start with deep inspiration, glottis
closes. Maximal intrathoracic and intra-airway
pressures are produced to cause the trachea to
narrow.
Triggers the stimulatory impulse from vagus nerve to
medulla
MTCAT '09
6. Reflex bronchoconstriction – protects
upper and lower airways.
Hering breuer reflex – limit lung inflation.
If lung becomes overstretched, HB reflex
is activated.
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9. Lungs
Lungs lie in the thoracic cavity separated by
mediastinum
R lungs – 3 lobes
L lungs – 2 lobes
Lungs are further divided into lobules → terminated
into alveolar sacs
Parietal pleura– covers the lungs and lines the
thoracic wall.
Visceral pleura- covers the surface of each lung
Pleural fluid- slippery serous secretion produced by
the pleural membranes which allows the lungs to
glide easily over the thorax wall
MTCAT '09
12. Substance important in
Alveolar Expansion
Surfactant – lines the alveolus
- Fatty protein provides
surface stability (reduces surface
tension) and prevents collapse of
the alveolar structures (atelectasis)
MTCAT '09
13. Respiratory
Centers
1. Medulla oblangata contains inspiratory
and expiratory centers, the main region
for respiration–
Dorsal respiratory group -the region
responsible for causing the normal,
resting inspiration
Ventral respiratory group is only
active when you need to breathe more
actively. For ex. when you are talking
- provide automatic control of
unconscious breathing
2. Pons- Pneumotaxic area in the pons, important for regulating the
amount of air one takes in with each breath. When we find ourselves
needing to breath faster, the pneumotaxic area tells the dorsal
respiratory group to speed it up. And when we need to take longer
breaths, the pneumotaxic area tells the dorsal respiratory group to
prolong its bursts.
Apneustic center stimulates the inspiratory medullary center to
MTCAT '09
promote deep, prolonged inspiration
14. Major Muscles of
Ventilation
1. Diaphragm –contraction and
relaxation causes changes in the size
and pressure of the chest cavity.
2. External intercostal muscles – further
enlarge thoracic cavity by an upward
and outward motion of the lower ribs.
3. Internal intercostal muscles – used in
forced expiration to stiffen the
intercostal spaces during straining
MTCAT '09
15. 4. Abdominal wall muscles –
aids to forced expiration.
Generate the explosive pressure
that is necessary for coughing.
Contract at the end of forced
inspiration in synchrony with
glottic closure to limit and stop
inspiration abruptly.
MTCAT '09
16. 5. Accessory muscle
a. Scalene- one of the muscles of the
neck responsible for the 1st and 2nd
ribs in inspiration
b. Sternocleidomastoid -= used
during labored breathing to raise
the first 2 ribs and sternum and
increase size of thoracic cavity.
c. Trapezius and pectoralis – fix the
shoulders
MTCAT '09
17. REVIEW OF PHYSIOLOGY
Functions of the Respiratory System
Oxygen transport- o2 is supplied to and CO2 is removed from
the cells by way of the circulating blood.
Respiration- the whole process of gas exchange between the
atmospheric air and the blood and between the blood and cells
of the body.
Ventilation- movement of air in and out of the airways
Diffusion – air crosses the alveolar – capillary membrane
and is carried in the plasma bound chemically to hgb.
Perfusion – blood is delivered through pulmonary
capillary system past the alveoli for the purpose of gas
exchange.
Distribution – Air is delivered by the smaller peripheral
airways to the alveoli. MTCAT '09
18. MECHANICS OF VENTILATION
Physical factors that govern airflow in
and out of the lungs which include:
- Air pressure variance- air flows from a
region of higher pressure to an area of
lower pressure
- Airway resistance- as determined by the
size of the airway through which the air is
flowing
- Compliance – measure of the elasticity,
expandability and distensibility of the
lungs. MTCAT '09
19. Lung Volumes & Capacities
Lung volumes – amount of air exchanged during
ventilation
Tidal volume (TV) – amount of air that moves in
& out of the lungs during normal breathing
(500mL)
Inspiratory reserve volume (IRV) – maximum
amount of inhaled air in excess of the normal TV
(3000mL)
Expiratory reserve volume (ERV) – maximum
amount of exhaled air in excess of the normal TV
(1100mL)
Residual volume (RV) – amount of air remaining
in the lungs after forced expiration; increases
with age (1200mL) MTCAT '09
20. Lung capacities – 2 or more lung volumes
Vital capacity (VC) = TV+IRV+ERV (amount of
air than can be exhaled from maximal
inspiration) 4600mL
Inspiratory capacity = TV+IRV (maximum
amount of inhaled air at the beginning of
normal expiration & distending the lungs to its
maximum) 3500mL
Functional residual capacity = RV+ERV
(amount of air remaining in lungs after normal
expiration) 2300mL
Total lung capacity = sum of all lung volumes;
total amount of air that the lungs can hold
average pair of human lungs can hold about 8L
of air, but only a small amount of this capacity is
used during normal breathing
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21. Factors Affecting Lung
Volume
Larger volumes Smaller volumes
males Females
taller people shorter people
non-smokers Smokers
athletes non-athletes
people living at high people living at low
altitudes (the body's altitudes (atmosphere
diffusing capacity is less dense at higher
increases in order to altitude, therefore, the
same volume of air
be able to process
contains fewer
more air)
MTCAT '09 molecules of all gases
22. Effects of Aging
Progressive loss of elastic recoil of lungs –
due to elastin & collagen fiber changes
Increased respiratory muscle workload –
due to calcification of soft tissues in chest
wall
Total lung capacity remains constant
Increased residual lung volume – result of
changes in aging MTCAT '09
23. Oxygen is essential for cellular metabolism and
have no capability to store it. Without constant
delivery of oxygen , tissue hypoxia and
anaerobic metabolism result.
Tissue hypoxia – inadequate oxygen supply to
meet the needs of the cell.
Hypoxemic hypoxia- a state of low arterial
PO2, usually due to inadequate pulmonary gas
exchange
Ischemic hypoxia – results from inadequate
circulation of the blood.
Anemic hypoxia – due to anemia and the
resulting inability of the blood to carry
adequate oxygen.
Histotoxic hypoxia – occurs when the tissues
are unable to use the oxygen delivered to
them because of a metabolic poison.
MTCAT '09
24. O2 is carried in the blood in 2 forms:
Physically dissolved oxygen in the plasma
In combination with the hemoglobin of the
RBC
Each 100 mL of arterial blood carries
0.3 ml of O2 physically dissolved in the
plasma and 20 ml of O2 in combination
with Hgb in Ferrous Iron
O2 + Hgb = HgbO2
Hgb combined with oxygen is called
oxyHGB – whereas oxygen – free hgb is
called reduced hgb.
MTCAT '09
25. Erythrocytes
Erythrocytes, or red
blood cells, are the
primary carriers of
oxygen to the cells and
tissues of the body. The
biconcave shape of the
erythrocyte is an
adaptation for
maximizing the surface
area across which oxygen
is exchanged for carbon
dioxide. Its shape and
flexible plasma
membrane allow the
erythrocyte to penetrate
the smallest of
capillaries.
MTCAT '09
26. Red blood cells make up almost 45 percent of
the blood volume.
Their primary function is to carry oxygen from
the lungs to every cell in the body.
Red blood cells are composed predominantly of
a protein and iron compound, called
hemoglobin, that captures oxygen molecules as
the blood moves through the lungs, giving blood
its red color.
As blood passes through body
tissues, hemoglobin then releases the oxygen to
cells throughout the body. Red blood cells are
so packed with hemoglobin that they lack many
components, including a nucleus, found in other
cells. MTCAT '09
27. RBC
33% of an rbc cytoplasm is hemoglobin (Hb) solution
There are 280 million molecules of Hb in each RBC
Consists of 4 protein chains called globins, each chain has
heme group.
MTCAT '09
28. Normal range
Hematocrit- percentage of whole blood volume composed
of RBCs
Male – 42% - 52%
Female – 37% - 48%
Hemoglobin –
Male -13 to 18 g/dL
Female – 12 to 16 g/dL
RBC
Male – 4.6 to 6.2 million/mm3
Female – 4.2 – 5.4 million/mm3
Life span – 120 days (4 mos.)
MTCAT '09
29. Assessment:
Health History
The major signs and symptoms of
respiratory diseases are the ff:
Dyspnea
Cough
Sputum production
Chest pain
Wheezing
Clubbing of the fingers
Hemoptysis
cyanosis MTCAT '09
30. Dyspnea
Dyspnea
• difficult or labored breathing, breathlessness,
SOB
• Symptom common when there is decreased
lung compliance or increased airway
resistance
• Maybe related to a lot of different medical
conditions
MTCAT '09
31. Levels of Dyspnea
Level I Patient can walk 1 mile at own pace
before experiencing shortness of breath
Level II Patient is short of breath after walking
100 yards on level ground or climbing a
flight of stairs.
Level III Patient is short of breath while talking or
performing ADL
Level IV Patient is short of breaths during periods
of inactivity
Orthopnea Shortness of breath when lying down
MTCAT '09
32. Important questions to
ask:
How much exertion triggers SOB?
is there an associated cough?
Is the SOB related to other symptoms?
Was the onset of SOB sudden or gradual?
At what time of the day does SOB occur?
Is the SOB worse when the patient is lying flat
in bed?
Does the SOB occur at rest? With exercise?
Running? Climbing stairs?
MTCAT '09
33. Relief measures (dyspnea)
The mgt of dyspnea is aimed at
identifying and correcting its cause.
Relief is sometimes achieved by:
Placing the patient at rest
Assisting in high fowler’s position
Administration of O2
MTCAT '09
34. Cough
Results from irritation of the mucous
membranes anywhere in the respiratory
tract
Stimulus may arise from an infectious
process or from an airborne irritant
Persistent and frequent cough can be
exhausting and cause pain
Cough may indicate a serious pulmonary
disease
MTCAT '09
35. Cough
Assess for character of cough to know
cause.
Describe as:
Dry –may indicate URTI of viral origin or side
effect of ACE inhibitor therapy
Hacking – colds
Brassy – tracheal lesions
Wheezing- cystic fibrosis
Loose- bronchitis
Severe – bronchogenic carcinoma
MTCAT '09
36. Cough
Note time of onset:
Coughing at night may herald onset of left
sided heart failure or bronchial asthma
Cough in the morning with sputum
production may indicate bronchitis
Cough worsens while in supine position may
indicate sinusitis
Coughing after food intake may be caused
by aspiration
Cough of recent onset is usually from an
acute infection MTCAT '09
37. Relief measures (cough)
Cough suppressants----should be
used with caution
Smoking cessation
Drinking warm beverages
First generation antihistamines with
decongestants
MTCAT '09
38. Sputum production
The reaction of the lungs to any
constantly recurring irritant
May be associated with a nasal
discharge
MTCAT '09
39. Assess character of
sputum
Purulent sputum (thick and yellow, green or
rust-colored)- common sign of bacterial infection
Thin, mucoid sputum- viral bronchitis
Gradual increase of sputum over time- chronic
bronchitis or bronchiectasis
Pink-tinged mucoid sputum- lung cancer
Profuse, frothy, pink material- pulmonary
edema
Foul smelling sputum and bad breath- lung
abscess, bronchiectasis '09
MTCAT
41. Chest pain
Chest pain associated with pulmonary
conditions may be sharp, stabbing, and
intermittent, or it may be dull, aching, and
persistent
MTCAT '09
43. Wheezing
Major finding in a patient with
bronchoconstriction or airway narrowing
High-pitched, musical sound heard
mainly on expiration
Oral or inhalant bronchodilators reverse
wheezing most of the time
MTCAT '09
44. Clubbing of fingers
A sign of lung disease that is found in
patients with chronic hypoxic conditions,
chronic lung infections, or malignancies
of the lung
May be manifested initially as sponginess
of the nail bed and loss of the nail bed
angle
MTCAT '09
45. Hemoptysis
Coughing up of blood arising from a pulmonary
hemorrhage
Blood- alkaline pH (greater than 7.0)
Symptom of both pulmonary and cardiac problems
Onset is usually sudden, intermittent or continuous
Most common causes:
Pulmonary infection
Carcinoma of the lung
Abnormalities of the heart or blood vessels
Pulmonary embolus and infarction
Pulmonary vein or artery abnormalities
MTCAT '09
46. Determine source of
bleeding
Bloody sputum from the nose is usually
preceded by considerable sniffing, with blood
possibly appearing in the nose
Blood from the lung is usually bright red, frothy,
and mixed with sputum. Initial symptoms
include:
Tickling sensation in the throat
A salty taste
A burning or bubbling sensation in the chest
Chest pain
MTCAT '09
47. Cyanosis
Bluish coloring of the skin
Very late indication of hypoxia
Determined by the amount of
unoxygenated hgb in the blood
Appears when there is at least 5g/dl of
unoxygenated hgb
MTCAT '09
48. CYANOSIS
Factors that alter the presence of Cyanosis
1. Pigmentation and thickness
2. Type of light used during assessment –
natural light is desirable
3. Absolute amount of reduced hemoglobin
4. Observer’s perception
1. Activity
2. Duration
3. Distribution
MTCAT '09
49. OBJECTIVE DATA
In addition to the subjective
information obtained through nursing
history, OBJECTIVE, measurable data
must be obtained.
PHYSICAL ASSESSMENT
primary techniques - IPPA
MTCAT '09
51. Physical Assessment
INSPECTION
observe for the rate and pattern of breathing
To accurately assess the resting pt’s RR
1. count the number of times the chest rise and fall in 1 full
minute.
2. Observe the breathing pattern and effort
3. Actual volume can be measured by a spirometer.
4. Note relative length of inspiration and exhalation.
Prolonged inspiration indicates obstruction of the upper
airways (Croup, epiglotitis)
Long exhalation indicates air trapping
(asthma,emphysema)
5. Note use of accessory muscles
6. Observe for color (cyanosis)
MTCAT '09
7. Check for deformities
52. Inspection
Normal chest
Slight retraction of
intercostal spaces
2x as wide as deep
Anterior/posterior
diameter
1:2
MTCAT '09
53. Inspection
Barrel chest
Occurs as a result of
over inflation of the
lungs
Increase in anterior-
posterior diameter of
the thorax
2:2
MTCAT '09
54. Inspection
Funnel chest
(Pectus Excavatum)
Depression of the
lower portion of the
sternum
Complications
Heart damage
i Cardiac output
MTCAT '09
55. Inspection
Pigeon chest
(Pectus Carinatum)
Displacement of the
sternum
Sternum protrudes
outward
h anterior-posterior
diameter
MTCAT '09
62. Inspection: Breathing
patterns
Depth
Kussmaul's
h rate & depth
Assoc. with severe acidosis
Apneustic
Prolonged gasping followed by a short
breath
MTCAT '09
63. Inspection: Breathing
patterns
Rhythm
Apnea
Cessation breathing
Cheyne-stokes
Regular cycle with increasing rate and
depth, then decrease until apnea (usually
about 20 secs) occur
MTCAT '09
64. Inspection: Breathing
patterns
Rhythm
Biot’s
Periods of normal breathing (3-4 breaths)
followed by a varying period of apnea
(usually 10-60 secs)
Assoc w/ h ICP
MTCAT '09
65. Inspection:
Trachea
Deviation
Pleural effusion
Tension pneumothorax
Atelectasis
Color
LOC
Emotional state
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66. PALPATION
Uses hands to assess:
Trachea – slightly
movable & quickly
returns to midline after
displacement
Tactile fremitus –
transmission of vibration
of air movement through
chest wall during
phonation (99 method)
Thoracic excursion
MTCAT '09
68. Percussion
Rational
To determine if
underlying tissue is
filled with air or solid
material
Procedure
Pt sitting
Tap starting at shoulder
compare rt to lf
MTCAT '09
70. Auscultation
Purpose
Asses air flow
through bronchial
tree
Procedure
Diaphragm of
stethoscope
Superior inferior
Compare rt to lf
MTCAT '09
71. Auscultation: Results
Normal
Vesicular
Lung field
Soft and low
Bronchial
Trachea & bronchi
Hollow
Bronchovesicular
Mixed
Between scapulae
Side of sternum
1st & 2nd intercostal space
MTCAT '09
72. Auscultation: Results
Adventitious
Crackles
Soft, high pitched, discontinuing popping sounds that
occur during inspiration
air bronchi with secretions
Fine crackles
Discontinuous popping sounds heard in late inspiration
Sounds like hair rubbing together
Originates in the alveoli
Etiology: pneumonia, bronchitis
Course Crackles
Discontinuous popping sounds heard in early inspiration
Harsh, Moist sound originating in the large bronchi
MTCAT '09
COPD
73. Auscultation: Results
Sibilant Wheezes
Wheezes Continuous, musical,
Sonorous wheezes High pitched
(rhonchi) Whistle-like
I&E
Deep low pitched
Caused by air
Snoring
narrowed passages,
>E partially obstructed
Caused by air May clear with
narrowed coughing
tracheobronchial
Etiology:
passages
Asthma
Etiology: h secretions
bronchospasm
MTCAT '09
Build-up of
secretions
74. Auscultation: Results
Pleural friction rub
D/t inflammation of
pleural space
Grating, creaking
I&E
Best heard
Anterior, Lower,
lateral area
MTCAT '09
76. A child with difficulty breathing and a
“barking” cough id displaying signs
associated with which condition?
A. Asthma
B. Croup
C. Cystic fibrosis
D. Epiglottitis
MTCAT '09
77. When assessing the lung sounds of a
child with asthma, which sound are you
most likely to hear?
A. Murmurs
B. Sonorous Wheezing
C. Sibilant Wheezing
D. Crackles
E. Pleural friction rub
MTCAT '09
78. Diagnostics: Imaging Studies
A. Chest X-ray (Chest radiography; Serial chest x-
ray)
Visualization of the chest, lungs, heart, large
arteries, ribs, and diaphragm while standing
in front of the machine
Two views are usually taken:
1. Antero-posterior view - x-rays pass
through the chest from the back
2. Lateral view - x-rays pass through
the chest from one side to the other
MTCAT '09
79. B. Computed tomography
• CT scan is an imaging
method in which the lungs
are scanned in successive
layers by a narrow-beam x-
ray.
• Distinguishes fine tissue
density
• Used to define pulmonary
nodules and small tumors
adjacent to pleural surfaces
which are not visible on
routine CXRs
MTCAT '09
80. C. Magnetic Resonance
imaging (MRI)
Similar to CT scan except that magnetic
fields and radiofrequency are used instead
of narrow beam x-rays
Used to characterize pulmonary nodules,
to help stage bronchogenic carcinoma, and
to evaluate inflammatory activity in
interstitial lung disease
MTCAT '09
82. D. Flouroscopic studies
Used to assist with
invasive procedures
such as chest needle
biopsy or
transbronchial biopsy.
It may be used to
study the movement of
the chest wall,
mediastinum, heart,
and diaphragm. MTCAT '09
83. E. Pulmonary Angiography
Most commonly used to
investigate
thromboembolic disease
of the lungs
It involves the rapid
injection of a radiopaque
agent into the vasculature
of the lungs.
MTCAT '09
84. F. Radioisotope Diagnostic
Procedures
V/Q scan (ventilation/perfusion scan)- used
clinically to measure the integrity of the
pulmonary vessels relative to blood flow and to
evaluate blood flow abnormalities
Gallium scan- used to detect inflammatory
conditions, abscesses, adhesions, and the
presence, location, and size of tumors. Used to
stage bronchogenic Ca.
Positron Emission Tomography (PET) scan-
used to evaluate lung nodules for malignancy.
MTCAT '09
85. Pulmonary Function Tests (PFT)
• a group of tests measuring lung function
• Measure of diffusion capacity
• client breathes in a harmless gas for a
very short time (one breath)
• the concentration of the gas in the air
exhaled is measured
• the difference in the amount of gas
inhaled and exhaled can help estimate
how quickly gas can travel from the
lungs into the blood
MTCAT '09
86. Body plethysmograph -
most accurate
• Client sits in a
sealed, clear box
that looks like a
telephone booth
while breathing in
and out into a
mouthpiece
• Changes in pressure
inside the box help
determine the lung
volume
MTCAT '09
87. Cont…(PFT)
Spirometry test – measures airflow;
client will breathe through a tight
fitting mouthpiece and will have
nose clips
Nursing Interventions: Instruct client
to:
a. breathe into a mouthpiece that
is connected to an instrument
(spirometer)
b. eat a light meal before the test
c. not to smoke for 4 - 6 hours
before the test
d. stop using bronchodilators or
inhaler medications 6-8hrs
prior
e. Inform client that temporary
shortness of breath or light-
headedness may be felt
MTCAT '09
88. Peak Expiratory Flow Rate
(PEFR)
• measures how fast a person can exhale
• it is one of many tests that measure how well the
airways work
• requires a peak expiratory flow (PEF) monitor, a
small handheld device with a mouthpiece at one
end and a scale with a moveable indicator
(usually a small plastic arrow)
• commonly used to diagnose and monitor lung
diseases such as asthma, chronic
bronchitis, chronic obstructive pulmonary
disease (COPD), & emphysema
MTCAT '09
89. • A decrease in peak flow indicates blocked or narrowed
airways
• A significant fall in peak flow can signal the onset of a lung
disease esp. when accompanied by persistent coughing,
SOB, or wheezing
• PEFR measurements are not as accurate as the
spirometry
• Nursing Interventions:
• Inform client that repeated efforts may cause
lightheadedness
• Loosen any tight clothing that might restrict breathing
• Sit up straight or stand while performing the tests
• Instruct client on proper procedure to do this test:
• Breathe in as deeply as possible.
• Blow into the instrument's mouthpiece as hard and fast
as possible.
• Do this 3 times, and record the highest flow rate
MTCAT '09
90. Throat Culture
Also known as throat swab culture
a laboratory test to isolate and identify
organisms that may cause infection in the
throat; when throat infection is suspected,
particularly strep throat
back of the throat is swabbed with a sterile
cotton swab near the tonsils
Nursing Interventions:
Instruct client not to use antiseptic mouthwashes
before the test
Inform client that he may experience a gagging
sensation when the back of the throat is swabbed
Instruct to resist gagging and closing the mouth
during procedure (test only takes a few seconds)
MTCAT '09
91. Bronchoscopy (Fiber Optic
Bronchoscopy)
views the airways and diagnose
lung disease
may also be used during
the treatment of some lung
conditions
flexible bronchoscope is usually
used (less than ½in wide and
about 2ft long)
scope is passed through the mouth
or nose, and then into the lungs
rigid bronchoscope requires
general anesthesia
flexible bronchoscope uses local
anesthesia (spray if via mouth and
throat; numbing jelly if via nose)
IV meds may be given to help
relax the client
MTCAT '09
92. Cont…(Bronchoscopy)
Nursing Interventions:
Inform client that spraying of local anesthesia will
cause coughing at first, which will stop as the
anesthetic begins to work
Inform client that as the anesthesia wears off, the
throat may be scratchy for several days
Instruct client on NPO 6-12hrs prior (withhold ASA or
Ibuprofen if client takes it on a regular basis or as
ordered)
Place client on NPO 1-2hrs after the procedure or
until (+) for gag reflex MTCAT '09
93. Sputum Culture
Sputum is obtained for analysis to identify
pathogenic organisms and to determine
whether malignant cells are present.
Nursing Interventions:
Drinking a lot of water and other fluids
the night before collection may help
Perform back tapping or chest clapping
on client to aid in loosening the sputum
Instruct client on proper specimen
collection
Collect morning specimen
Gargle with water only before
specimen collection cough deeply
and spit sputum in a sterile cup
Send specimen to lab ASAP
MTCAT '09
94. Oximetry
measures oxygen concentration (%) in the blood
pulse oximeter- most commonly used; because they respond
only to pulsations, such as those in pulsating capillaries of the
area tested
pulse oximeter works by passing a beam of red and infrared light
through a pulsating capillary bed
ratio of red to infrared blood light transmitted gives a measure of
the oxygen saturation in the blood
Normal o2 saturation: 95%-100%, <85% indicates that the
tissues are not receiving enough oxygen
Principle: oxygenated blood is bright red while the deoxygenated
blood is blue-purple
Other types:
intracardiac oximetry - blood that is within the heart or on
whole blood that has been removed from the body
More recently, using a similar technology to oxymetry,
MTCAT '09
carbon dioxide levels can be measured at the skin as well
95. THORACENTESIS- aspiration of pleural fluid for
diagnostic purposes
Site :
Air : 2nd /3rd ICS, MCL
Fluid : 7th/8th ICS, PAL
Position :
over a bed table
straddling in a chair
seated in bed with affected hand raised over the
head
MTCAT '09
96. ARTERIAL BLOOD GASES
ARTERIAL PUNCTURE ALLEN’S TEST
ABG studies aid in assessing the ability of the lungs to
provide oxygen and remove carbon dioxide and the
ability of the kidneys to reabsorb or excrete bicarbonate
ions to maintain normal body '09
MTCAT pH.
97. Levels of Hypoxemia
MILD PaO2 of 60-80mmHg
MODERATE PaO2 of 40-60mmHg
SEVERE PaO2 of less than 40mmHg
MTCAT '09
98. NORMAL ACID-BASE BALANCE
Parameter Normal Value Definition and Implications
Partial pressure of oxygen in arterial blood
(decreases with age)
In adults < 60 years:
PaO2 80-100 Hg
60-80 mmHg = mild hypoxemia
40-60 mmHg = moderate hypoxemia
< 40 mmHg = severe hypoxemia
Identifies whether there is acidemia or
pH 7.35-7.45 alkalemia:
pH<7.35 = acidosis; pH>7.45 = alkalosis
Partial pressure of CO2 in the arterial blood:
PaCO2 35-45 mmHg PCO2<35 mmHg = respiratory alkalosis
PCO2>45 mmHg = respiratory acidosis
Estimated HCO3 concentration after fully
Standard HCO3 22-26 mEq/L oxygenated arterial blood has been
equilibrated with CO2 at a PCO2 of 40
mmHg at 38C; eliminates the influence of
respiration on the plasma HCO3
concentration
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99. Nursing Diagnosis
INEFFECTIVE BREATHING PATTERN
The state in which an individual’s
inhalation and/or exhalation pattern does
not enable adequate pulmonary inflation
or emptying.
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100. Defining characteristics:
dyspnea
tachypnea
abnormal ABG values
cough
respiratory depth changes
assumption of three- point position
pursed lip breathing
used of accessory muscles
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101. INEEFECTIVE AIRWAY CLEARANCE
The state in which an individual is unable to
clear secretions or obstructions from the
respiratory tract to maintain airway patency.
Defining characteristics:
Abnormal breath sounds
changes in rate and depth of respiration
tachypnea
effective or ineffective cough
cyanosis
dyspnea
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102. IMPAIRED GAS EXCHANGE
The state in which an individual experiences
a decreased passage of oxygen and/or CO2
between the alveoli of the lungs and the
vascular system.
Defining Characteristics:
restless
irritability
inability to move secretions
hypercapnia
hypoxia
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103. GOALS/ OBJECTIVES/ PLANNING
1. Patient will demonstrate knowledge
regarding prevention of respiratory
dysfunction.
2. Patient’s tissues will have adequate
oxygenation.
3. Patient will mobilize secretions.
4. Patient will effectively cope with changes
in self-concept and lifestyle.
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104. NURSING PATIENTS WITH THREATS
TO VENTILATION
1. Planning for Health Promotion
2. Planning for Health Restoration and
Maintenance
a. Maintaining Patent Airway
1. Coughing techniques
2. Nebulization
3. Steam inhalation
4. Suctioning
5. Chest physiotherapy(CPT)/ Chest mucus
mobilization MTCAT '09
105. NURSING PATIENTS WITH THREATS
TO VENTILATION
b. Breathing Exercises
c. Preventing and Controlling Infection
d. Oxygen Therapy
e. Incentive Spirometry
f. Appropriate pharmacologic agents
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107. Breathing exercises
Pursed-lip breathing
Involves deep inspiration and prolonged
expiration through pursed lips to prevent
alveolar collapse.
While sitting up, the client is instructed to
take a deep breath and to exhale slowly
through pursed lips, as if blowing through a
straw.
Clients need to control exhalation phase so
that it is longer than inhalation.
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108. Pursed lip breathing
Instruct client to breathe in slowly through
the nose for 1 count
Purse lips as if going to whistle
Breathe out gently through pursed lips for 2
slow counts (breathe out twice as slowly as
when breathing in). Let the air escape
naturally
Keep doing pursed lip breathing until no
longer short of breath
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109. Breathing exercises
Diaphragmatic breathing
Requires the client to relax intercostal
and accessory respiratory muscles
while taking deep inspirations.
The client concentrates on expanding
the diaphragm during controlled
inspiration.
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110. Diaphragmatic breathing
The client is taught to
place one hand flat
below the breast bone
above the waist and
the other hand 2-3 cm
below the first hand.
The client is asked to
inhale while the lower
hand moves outward
during inspiration
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111. Preventing and Controlling
Infections
HEATH TEACHING can limit both
exposure to and occurrence of ARTI
such as influenza and pneumonia.
Promote optimal immune function by
encouraging good nutrition
Remind client to avoid exposure to known
infected people or large crowds during peak
flu seasons
Good hygiene practices
Advising high-risk people to receive annual
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flu vaccination
112. Coughing
No single measure controls respiratory
secretions more effectively than a strong
cough that pushes secretions upward.
To cough effectively, the client must be
able to take deep breath and generate
rapid airflow.
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113. Controlled
Coughing exercise
Assist client in a comfortable sitting position
Instruct client to lean head forward slightly while placing both feet
firmly on the ground.
Breathe in deeply using diaphragmatic breathing
Instruct to hold breath for three seconds.
While keeping the mouth slightly open, instruct to cough out twice.
The client should feel his diaphragm pushed upward while doing
this. The first cough should bring up the phlegm, and the second
cough should move it towards the throat.
Instruct to spit the phlegm out into a tissue. Remember to check
the colour; if the phlegm is yellow, green or brown, or has blood in
it.
Allow client to rest and repeat these steps once or twice if
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necessary.
114. Nebulization
Nebulization – a process of adding moisture or
medications to inspired air by mixing particles of varying
sizes with air. A nebulizer uses the aerosol principle to
suspend a maximum number of water drops or particles
of the desired size in inspired air. Moisture added to the
RS through nebulization improves clearance of
pulmonary secretions.
Often used for administration of bronchodilators and
mucolytic agents.
The client inhales deeply and holds each breath for a
moment, which allows for more effective aerosol
deposition into distant portions of the airways.
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115. Steam Inhalation
Purpose:
To liquefy mucus secretions
To warm and humidify inspired air
To relieve edema of airways
To soothe irritated airways
To administer medications
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116. Steam Inhalation
Place client in semi fowler’s position.
Cover client’s eyes with wash cloth.
Check electrical device before use
Place steam inhalator in a flat, stable surface
Place the spout 12-18 inches away from the
client’s nose or adjust the distance as necessary.
Cover chest with a towel
Render steam inhalation for 15-20 minutes for
effectivity
Instruct client to perform DBE and coughing
exercises after the procedure
Provide good oral hygiene after the procedure.
Document MTCAT '09
117. Suctioning
Purpose:
Remove excess mucus secretions to
maintain patent airway
Collect sputum or secretions for
diagnostic testing
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118. Suctioning (Oropharyngeal
and Nasopharyngeal)
Assess indications for suctioning:
• audible secretions during respiration
• adventitious breath sounds
Position:
• conscious: Semi-Fowler’s position
• unconscious: lateral position facing the
nurse
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120. Appropriate size of sterile suction
catheter, to prevent trauma to mucus
membranes of airways
• Adult Fr. 12-18
• Child Fr. 8-10
• Infant Fr. 5-8
Don sterile gloves.
Length of catheter:
• Measure from the tip of the client’s nose to
the earlobe or about 13 cm(5 in) for an adult)
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121. Lubricate catheter, to reduce friction
o Nasopharyngeal suction tip- water soluble lubricant
o Oropharyngeal suction tip- sterile water or NSS
Apply suction during withdrawal of the suction
catheter (never during insertion). Withdraw
catheter in a rotating manner.
Apply suction for 5-10 seconds (max 15 seconds)
Pre oxygenate client with 100% oxygen.
Hyperventilate with manual resuscitaiton bag
before and after suctioning
Allow 20-30 second interval between each suction
Provide oral and nasal care
Dispose contaminated equipment safely.
Assess effectiveness of suctioning
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Document.
122. Chest Physiotherapy (CPT)
Chest physiotherapy- a group of therapies in combination to
mobilize pulmonary secretions.
Is based on the premise that mucus can be shaken from
the walls of the airways and helped drain form the lungs.
CPT should be followed by productive coughing and
suctioning of the client who has decreased ability to cough.
CPT is recommended for clients who produce greater than
30 ml of sputum per day or have evidence of atelectasis by
CXR exam.
Includes:
Postural drainage
Chest percussion
Vibration
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123. Guidelines for CPT
Know the clients normal range of VS
Know the client’s medications
Know the client’s medical history
Know the client’s level of cognitive
function
Be aware of the client’s exercise
tolerance
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124. Chest percussion
Involves striking the chest wall over the area
being drained.
The hand is positioned so that the fingers and
thumb touch and the hands are cupped.
Percussion of the chest wall sends waves of
varying amplitude and frequency through the
chest, changing the consistency and location of
the sputum.
Take care to avoid striking over the spine or
kidneys, on female breasts, or on incisions or
broken ribs. MTCAT '09
125. Vibration
In this technique, use hands like a gentle
jack hammer: place hands on the client’s
chest and rapidly and vigorously vibrate
them while the client exhales.
This technique may help dislodge
secretions and stimulate a cough.
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126. Postural Drainage
Postural drainage uses gravity to assist
in the movement of secretions.
The client is assisted in various positions
to facilitate mucus flow from different
segments of the lungs.
Note that not all postural drainage
positions are well tolerated by all clients.
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128. OXYGEN THERAPY
Administration of Supplemental Oxygen
Indication: hypoxemia
Signs of hypoxemia:
Restlessness (initial sign)
Increased PR
Rapid, shallow respiration and dyspnea
Light headedness
Flaring of nares
Substernal or intercostals retractions
Cyanosis (late sign)
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129. Oxygen systems
1. Low flow administration devices
Nasal cannula (24-45% at 2-6 LPM)
May be used in clients with COPD at 2-3 LPM if
venturi mask is not available
Simple face mask (40-60% at 5-8 LPM)
Partial Rebreathing Mask (60-90 % at 6-10
LPM)
Non-Rebreathing Mask (95-100% at 6-15
LPM)
Croupette
Oxygen Tent
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130. 2. High flow administration devices
• Venturi mask (24%-50%). Low-
concentration venture- type mask is
preferred for clients with COPD because it
provides accurate amount of oxygen. They
require 2-3 LPM or 28% oxygen
• Face mask.
• Oxygen hood. Can be used for low and
high flow concentration
• Incubator/Isolette. Can be used for low
and high flow concentration.
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131. Oxygen Therapy
Assess signs and symptoms of hypoxemia
Check doctor’s orders
Position patient, preferably in semi-Fowler’s.
Open source of oxygen before insertion of oxygen
device.
Regulate oxygen flow accurately. Excessive
administration of oxygen can cause oxygen
narcosis (respiratory alkalosis)
Place a “NO SMOKING” sign at bedside
Strictly enforce this warning
Oxygen greatly accelerates combustion
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132. Avoid use of oil, greases, alcohol, and ether
near the client receiving oxygen.
Humidify oxygen. Place sterile water into the
oxygen humidifier.
Provide food oronasal hygiene.
Lubricate nares with water-soluble lubricant to
soothe the mucus membrane. Do not use oil.
Assess effectiveness of oxygen therapy. Check
VS, especially RR; note quality of respiration.
Make relevant documentation.
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133. Incentive Spirometry
The incentive spirometry motivates the
client to breathe deeply by offering the
incentive of measuring progress.
The client is visually motivated to take
increasingly deeper breaths.
A reasonable therapy schedule is 8-10
breaths hourly during waking hours
To avoid hyperventilation, encourage client
to perform the exercises slowly.
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134. Incentive Spirometry
Purpose
Improve pulmonary ventilation and
oxygenation
Loosen respiratory secretions.
Prevent or treat atelectasis by expanding
collapsed.
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135. Common Medications for clients
with Respiratory Conditions
Agent How Provided Clinical Notes
Bronchodilators Unit dose packs; solution •Used to treat wheezing
Terbutaline (Bricanyl) for administration via from asthma, COPD
Albuterol (Ventolin) hand held nebulizer; •May cause nervousness
Ipratropium (Atrovent) some solutions for and tremors
injection •May cause tachycardia
Theophylline, Oral via tabs and liquids; •SE include nausea.
aminophylline injectable intravenous Headache, agitation
solution •Toxic levels may include
cardiac dysrhythmias and
seizures
•Wide variety of available
preparation; use extra
caution in administration
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