The Respiratory System Correlated to the Roy Adaptation Model and Nursing Process

1. The Respiratory SystemCorrelated to the Roy Adaptation Model and Nursing Process Sandy Marks, RN, BSN, MS(HCA) N212 Medical Surgical Nursing 1 Spring 2008

2. Journey through Roy Adaptation Model(RAM) • Roy Adaptation Model → • Patients primarily with alterations in physiological mode → • oxygenation → • respiratory system Course Packet (2007), p 104

3. Objectives - 1 • Review the anatomy and physiology of the respiratory system • Describe the respiratory changes associated with aging

4. Objectives - 2 • Discuss the purpose and interventions (preparation, explanation, procedure, postcare) for the following diagnostic tests: • X-rays: chest, bronchogram, CT, lung scan • Direct visualization: bronchoscopy • Sputum specimen • Thoracentesis • Pulmonary function tests (PFT) • Oximetry • Magnetic resonance imaging (MRI) • Cultures

5. Objectives - 3 • Describe the nursing assessment of the following cardinal signs and symptoms: • cough • sputum • dyspnea • Discuss the pathophysiology, nursing assessment, interventions, and evaluation for Pneumonia

6. The Art of Caring dscherer.com

7. Respiratory Review • Purpose = • provide oxygen for tissue metabolism (O2) • remove carbon dioxide (CO2) • Influences functions of: • acid-base balance • speech • sense of smell • fluid balance • temperature control

8. Review the anatomy and physiology of the respiratory system • upper respiratory tract • lower respiratory tract • divided by trachea (windpipe) • bronchi • bronchioles • alveolar ducts • alveoli trachea bronchi bronchioles alveoli Chabner, 2007

9. Gas Exchange • occurs at alveolar capillary membrane • occurs by diffusion • Pulmonary edema = • excess fluid fills alveoli spaces • impairs exchange of O2 and CO2 capillary Chabner, 2007

10. Normal lung tissue • 300 million alveoli • surface area = tennis court • Right bronchus • slightly wider • shorter • more vertical • increases problems with • intubation • aspiration Chabner, 2007

11. Physiologic changes associated with aging dscherer.com

12. Alveoli • alveolar surface area decreases • diffusion capacity decreases • elastic recoil decreases • bronchioles and alveolar ducts dilate • ability to cough decreases • airways close early

13. Lungs • residual volume increases • vital capacity decreases • efficiency of oxygen and carbon dioxide exchange decreases • elasticity decreases

14. Pharynx and Larynx • muscles atrophy • vocal cords become slack • laryngeal muscles lose elasticity and cartilage

15. Pulmonary Vasculature • increased vascular resistance to blood flow through pulmonary vascular system occurs • pulmonary capillary blood volume decreases • risk of hypoxia increases

16. Exercise Tolerance andMuscle Strength • Exercise Tolerance body’s response to hypoxia and hypercapnea decreases • Muscle Strength respiratory muscle strength, especially the diaphragm and intercostals, decreases

17. Susceptibility to Infection • effectiveness of the cilia increases • immunoglobulin A decreases • alveolar macrophages are altered

18. Chest Wall • anteroposterior (AP) diameter increases • thorax becomes shorter • progressive kyphoscoliosis occurs • chest wall compliance (elasticity) decreases • mobility may decrease • osteoporosis is possible

19. Summary on effects of aging • ↓ recoil and compliance •  AP diameter • ↓ functional alveoli • ↓ in Pa02 • Respiratory defense mechanisms less effective • Altered respiratory controls • More gradual response to changes in O2 and Co2 levels in blood

20. Diagnostic Tests • X-rays: chest, bronchogram, CT, lung scan • Direct visualization: bronchoscopy • Sputum specimen and Cultures • Thoracentesis • Pulmonary function tests (PFT) • Oximetry • Magnetic resonance imaging (MRI)

21. Chest X-Ray Screen, diagnose, evaluate treatment Instructions:

22. X-ray Positions Chabner, 2007

23. Chest X-Ray (Cont.) Posterior Anterior View Left Lateral View

24. Bronchogram • Slightly oblique www.fotosearch.com

25. Computed Tomography: CT Scan Images in cross-section view Uses contrast agents Instructions: Right upper Lobe

26. Lung Scan • most to detect emboli • no food restrictions • breathes radioactive material through a tube for 5 minutes • 6 ventilation images taken • radioactive injection • same 6 images retaken • compare images www.ucl.ac.uk

27. Ventilation- air distribution in lungPerfusion- blood supply to & within lung www.diiradiology.com www.washingtonhospital.org

28. Bronchoscopy Diagnose problems and assess changes in bronchi / bronchioles Performed to remove foreign body, secretions, or to obtain specimens of tissue or mucus for further study • Post-Procedure Care / Instructions:

29. Sputum Specimen To diagnose; evaluate treatment Specimen: ID organisms or abnormal cells Culture & Sensitivity (C&S) Cytology Gram stains (e.g. Acid Fast Bacilli)

30. Thoracentesis Specimen from pleural fluid Treat pleural effusion Assess for complications Post-Procedure care: • Positions • Sitting on side of bed over bedside table chest elevated • Lying on affected side • Straddling a chair

31. Pneumothorax Chabner, 2007

32. Pulmonary Function Test (PFTs) Evaluate lung function Observe for increased dyspnea or bronchospasm Instructions:

33. Pulse Oximetry Measures arterial oxygen saturation Pulse oximetry probe on ears, nose, finger, toes, forehead False readings Intermittent or continuous monitoring Ideal values When to Notify MD

34. MRI • Frontal View • White masses = Hodgkin Disease lesions Chabner, 2007

35. MRI – transverse view – same patient Chabner, 2007

36. Nursing Assessment:Cardinal Signs and Symptoms of:1. Cough2. Sputum3. Dyspnea

37. Cough – Main Sign of Lung Disease • how long present • occurs at a specific time (smokers = upon wakening in AM) • related to activity • productive vs nonproductive • congested • dry • tickling • hacking

38. Sputum – normally 3 oz produced/day • important symptom associated with coughing • Check: • duration – long term, short term • color – rust colored • consistency – thick, thin, watery, frothy • odor- foul • amount – describe in tsp, or fractions of cup and if increasing (external or internal cause)

39. Dyspnea – subjective data (perception) • difficulty in breathing or breathlessness • Check: • onset – slow or abrupt • duration - # of hours, time of day • relieving factors – position change, med, stop activity • wheezing, crackles, rales, or stridor occur with breathlessness • Quantify by assessing if interferes with ADL • PND or orthopnea

40. Lung sounds • wheezing • crackles • stridor • auscultation – sequence pg. 534, Iggy • bronchial = trachea & mainstem bronchi • bronchovesicular = branching bronchi • vesicular = small bronchiole periphery

41. Pneumonia: Case Study

42. Nursing Student Tools • Concept Map – Pneumonia • Medical-Surgical Map (Medimap) • Nursing Map Course Packet (2007), pgs 115-117

43. Pathophysiology

44. Toxic sprinkles anyone?

45. Etiology Cause bacteria (75%) viruses fungi Mycoplasma parasites chemicals

46. Classifications Community-acquired pneumonia (CAP) Onset in community or during 1st 2 days of hospitalization (Strep. pneumoniae most common) Hospital-acquired Pneumonia (HAP / nosocomial) Occurring 48 hrs or longer after hospitalization Aspiration pneumonia Pneumonia caused by opportunistic organisms Pneumocystis Carinii

47. Risk Factors CAP Older adult Chronic/coexisting condition Recent history or exposure to viral or influenza infections History of tobacco or alcohol use HAP Older adult Chronic lung disease ALOC Aspiration ET, Trach, NG / GT Immunocompromised Mechanical ventilation

48. Clinical Manifestations - 1 Fevers, chills, anorexia Pleuritic chest pain SOB Crackles / wheezes Cough, sputum production Tachypnea

49. Clinical Manifestations - 2 Mycoplasma (Atypical) feeling tired or weak, headaches, sore throat, or diarrhea. Eventually, most develop a dry cough.  They can, also, develop fever, chills, earaches, chest pain “walking pneumonia”

50. Diagnosis Diagnosis → Physical exam → crackles, rhonchi / wheezes CXR → area of increased density (infiltrates / consolidation) Sputum specimen – Gram stain LUL Infiltrates