WEST COAST UNIVERSITY NUR 121

1. WEST COAST UNIVERSITYNUR 121 Respiratory System Disorders

2. The Respiratory System is crucial to every human being. Without it, we would cease to live outside of the womb. • The organs of the respiratory system make sure that oxygen enters our bodies and carbon dioxide leaves our bodies. • It is divided into two sections: Upper Respiratory Tract and the Lower Respiratory Tract. • Included in the upper respiratory tract are the Nostrils, Nasal Cavities, Pharynx, Epiglottis, and the Larynx. • The lower respiratory tract consists of the Trachea, Bronchi, Bronchioles, and the Lungs. • As air moves along the respiratory tract it is warmed, moistened and filtered. The Respiratory System

3. Functions - BREATHING or ventilation - EXTERNAL RESPIRATION, which is the exchange of gases (oxygen and carbon dioxide) between inhaled air and the blood. - INTERNAL RESPIRATION, which is the exchange of gases between the blood and tissue fluids. - CELLULAR RESPIRATION • In addition to these main processes, the respiratory system serves for: - REGULATION OF BLOOD pH, which occurs in coordination with the kidneys, and as a - DEFENSE AGAINST MICROBES - Control of body temperature due to loss of evaporate during expiration The Respiratory System

4. Breathing and Lung Mechanics • Ventilation is the exchange of air between the external environment and the alveoli. • The body changes the pressure in the alveoli by changing the volume of the lungs. As volume increases pressure decreases and as volume decreases pressure increases. • There are two phases of ventilation; inspiration and expiration. • Each lung is completely enclosed in a sac called the pleural sac. • The intrapleural fluid completely surrounds the lungs and lubricates the two surfaces so that they can slide across each other. • The rhythm of ventilation is also controlled by the "Respiratory Center" which is located largely in the medulla oblongata of the brain stem. T • This is part of the autonomic system and as such is not controlled voluntarily (one can increase or decrease breathing rate voluntarily, but that involves a different part of the brain). • While resting, the respiratory center sends out action potentials that travel along the phrenic nerves into the diaphragm and the external intercostal muscles of the rib cage, causing inhalation. • Relaxed exhalation occurs between impulses when the muscles relax. Normal adults have a breathing rate of 12-20 respirations per minute. Respiratory System Anatomy and Physiology

5. When one breathes air in at sea level, the inhalation is composed of different gases. These gases and their quantities are Oxygen which makes up 21%, Nitrogen which is 78%, Carbon Dioxide with 0.04% and others with significantly smaller portions. • Air enters into the nasal cavity through the nostrils and is filtered by coarse hairs (vibrissae). • Dust, pollen, smoke, and fine particles are trapped in the mucous that lines the nasal cavities The Pathway of Air

6. Air then travels past the nasopharynx, oropharynx, and laryngopharynx, which are the three portions that make up the pharynx. • The pharynx is a funnel-shaped tube that connects our nasal and oral cavities to the larynx. • The tonsils which are part of the lymphatic system, form a ring at the connection of the oral cavity and the pharynx. Here, they protect against foreign invasion of antigens. Therefore the respiratory tract aids the immune system through this protection. • Then the air travels through the larynx. • The larynx closes at the epiglottis to prevent the passage of food or drink as a protection to our trachea and lungs. • The larynx is also our voicebox; it contains vocal cords, in which it produces sound. Sound is produced from the vibration of the vocal cords when air passes through them. The Pathway of Air

7. Inspiration is initiated by contraction of the diaphragm and in some cases the intercostals muscles when they receive nervous impulses. During normal quiet breathing, the phrenic nerves stimulate the diaphragm to contract and move downward into the abdomen. This downward movement of the diaphragm enlarges the thorax. When necessary, the intercostal muscles also increase the thorax by contacting and drawing the ribs upward and outward. Inspiration

8. Expiration • It is normally a passive process and does not require muscles to work (rather it is the result of the muscles relaxing). • When the lungs are stretched and expanded, stretch receptors within the alveoli send inhibitory nerve impulses to the medulla oblongata, causing it to stop sending signals to the rib cage and diaphragm to contract. • The muscles of respiration and the lungs themselves are elastic, so when the diaphragm and intercostal muscles relax there is an elastic recoil, which creates a positive pressure (pressure in the lungs becomes greater than atmospheric pressure), and air moves out of the lungs by flowing down its pressure gradient. Expiration

9. Respiratory System Disorders Upper respiratory Problems Structural and Traumatic Disorders of the Nose Deviated Septum Definition: Deflection of the normally straight nasal septum. Etiology: Trauma to the nose Congenital disproportion, a condition where size of the septum is not proportional to the size of the nose.

10. Inspection – the septum is vent to one side, altering the air passage. Symptoms: Pt. may experience obstruction of nasal breathing, edema, or dryness of the nasal mucosa with crusting and bleeding (epistaxis). Medical management: • Nasal allergy control. • Severe symptoms – nasal septoplasty to reconstruct and properly align the deviated septum. Assessment

11. Identifying and avoiding triggers of allergic reaction. - avoid house dust - avoid dust mites - avoid mold spores - avoid pollens - avoid pet allergens - avoid smoke Nasal Allergy Control

12. Incidence: Occurs approx. 46% of bone injuries incases of facial traumas. Etiology: Trauma Complications: airway obstruction, epistaxis, menigeal tear, septal hematoma, and cosmetic deformity. Classification: unilateral bilateral – flattened look. Epistaxis – most common sign. Complex Nasal Fracture

13. Assessment: Inspection – assess pt.’s ability to breathe through each side of the nose and note for sign of edema, bleeding or hematoma. Ecchymosis under one or both eyes (raccoon eyes). • Inspect internally for presence of septal deviation, hemorrhage, or leakage of clear fluid indicating leakage of CSF. • Quick test – done to test for CSF leak if noted leakage is clear. Nasal Fracture

14. Keeping the pt. on upright position to promote maintenance of airway. • Application of ice pack on the face to reduce edema and bleeding • Medical management is to realign the fracture using close or open reduction ( septoplasty or rhinoplasty • Rhinoplasty – reestablish cosmetic appearance anmd proper function of the nose and adequate airway. . Nursing Management

15. Performed as an outpatient procedure using regional anesthesia. • Plastic implants are sometimes use dto re-shape the nose. • Nasal packing maybe reinserted to prevent bleeding or septal hematoma formation. • Nasal septal splints maybeinserted to help prevent scar tissue betwee surgical site and lateral nasal wall. Rhinoplasty

16. No aspirin or NSAIDS for 2 weeks prior to surgery to reduce risk of bleeding. • Immediate post-op - - maintenance of airway - assessment of respiratory status - pain management - observation surgical site for bleeding, infection and edema. Nasal Surgery Nsg. Management

17. Definition – reaction of the nasal mucosa to a specific allergen. Types: Intermittent – s/s less than 4 days a week or less than 4 weeks a year Persistent – s/s occurs more than 4 days a week or more than 4 weeks a year. Etiology: pet saliva, dust mites, molds, or cockroaches. Occurrence: s/s can occur whenever a patient is exposed to a specific allergen. Sensitization to an allergen occurs with initial allergen exposure, which results in production of antigen-specific immunoglobulin E (IgE). Allergic Rhinitis

18. Pathophysiology: After exposure, mast cells and basophils release histamine, prostaglandins and leukotrienes, which causes early symptoms of sneezing, itching, rhinorrhea, and moderate congestion. 2 -4 hours after exposure, there is infiltration of inflammatory cells into the nasal tissues causing and maintaining inflammatory response. Resembles common colds. Allergic Rhinitis

19. Corticosteroids Nasal Spray ex. Flonase, Nasonex. Inhibits inflammatory response. begins 2 weeks pollen season. Use on regular basis and not prn. D/C if nasal infection develops. • Mast Cell Stabilizer – Cromolyn Spray inhibits degranulation of sensitized mast cells. If isolated exposure such as cat, use prophyllactically (10-15 min before exp.). • Leukotriene Receptor Antagonist and Inhibitor antagonist – Singulair. Monitor LFT periodically. Administer on empty stomach. Allergic Rhinitis Drug Therapy

20. Anticholinergic Nasal spray – Atrovent. Blocks hypersecretory effects by competing for binding sites on the cell. Dryness of mouth and nose may occur. Prevents symptoms with onset of action after 1 hour of use. • Antihistamines ( 1st generation agents)- Tavist, Benadryl. Bind with H1 receptors on target cells blocking histamine binding. Cross blood brain barrier casuing sedation. Allergic Rhinitis Drug Therapy

21. Cause of significant morbidity and mortality each year. Death ave. 36,000 per year in the U.S. Occurs most in persons over 60 year of age. Two main groups of Influenza Virus A and B Clinical Manifestations: • Cough • Fever • Myalgia accompanied by headache and sore throat. Influenza (Flu)

22. Pathophysiology – uncomplicated s/s will rsubside in 7 days. In older person may experience weakness that persist for weeks. • Convalescent phase may markby hyperactive airways and chronic cough. • Most common complication of influenza is Pneumonia. Influenza

23. Vaccines administration – two types inactivated and live attenuated. • Vaccines should be given in the fall ( mid Oct to End of Winter late March). • High priority is given to groups like elderly > 50 year old and to group that can transmit influeza – healthcare workers. • S/E – soreness at the injection site. • C/I – history of Guillain-Barre syndrome and sensitivity to eggs because the vaccine is produced in eggs. Nursing and Collaborative Management.

24. Inactivated Vaccine Groups at High Risk Anyone >50 years old. Adult at any age with chronic cardiac or pulmonary disease. Adults who had regular medical follow-up or were hospitalized during the preceding year. Residents of long term care facilities. Immunocompromised adults Women who will be in second or third trimester of pregnancy during influenza season. Groups who can transmit Influenza to high risk person Healthcare workers Providers of home care to high risk persons Household members of high risk persons. Live Attenuated Influenza vaccine All persons 5-49 years of age Given intranasally Target Groups for Influenza Immunization

25. Obstruction of the Nose and Paranasal Sinuses

26. Polyps – benign mucous membrane masses that form slowly in response to repeated inflammation of sinus or nasal mucosa. • S/S • nasal obstruction • Nasal discharges (clear mucus) • Speech distortion Tx. Removal via endoscopic or laser surgery Topical or systemic cortecosteroids may slsow polyp growth. Polyps

27. Tracheostomy Surgical incision into the trachea for the purpose of establishing an airway. Stoma opening resulting from the tracheotomy. Indications: • Bypass an upper airway obstruction • Facilitate removal of secretions • Permits long term mechanical ventilation • Permits oral intake and speech in the pt. who requires long-term mechanical ventilation Problem Related to trachea and Larynx

28. Can be performed as an emergency procedure or as a scheduled surgical procedure. It can be permanent or temporary. • A double lumen trach has 3 major parts. - Outer cannula - Inner cannula - Obturator • Air flow in and out of tracheostomy without air leakage Tracheostomy

29. Uncuffed tubes and fenestrated tubes that are in place or capped allow the client to speak. • Swallowing is possible with a tracheostomy tube in place however laryngeal elevation is affected and it is important to assess the client’s risk for aspiration prior to intake. • ADVANTAGES • Less risk of long term damage to the airway. • Increased client comfort(no tube in the mouth). • Decreased incidence of pressure ulcer in the oral cavity and upper airway. • Client can eat. • Allows client to talk. Tracheostomy

30. Cuffed – protect the lower airway by producing a seal between upper and lower airway. Use to client receiving mechanical ventilation. • Uncuffed – cuffless, when the client can protect the airway from aspiration and children under 8 y/o. • Single lumen tube – client with long or extra thick neck. • Tracheostomy tube with cuff and pilot balloon – low pressure, high volume cuff distributes cuff pressure over large area, minimizing pressure on tracheal wall. • Uncuffed fenestrated – used when client weaning client from trach tube. • Cuffed fenestrated – facilitates ventilation and speech. For client who does not require ventilation at all times. • Metal tracheostomy – cuffless double lumen tube. used for permanent tracheostomy. Can be cleaned and reused. • Talking/speaking trach- • Foam filled cuff Types of tracheostomy Tube

31. Assess /monitor • oxygenation and ventilation and V/S hourly. • Thickness, quantity, odor, and color of mucous secretions. • Stoma and skin surrounding stoma for s/s of infection (redness, swelling, or drainage). • Provide adequate humidification and hydration to reduce mucus plugging. • Maintain surgical aseptic technique when suctioning to prevent infection. Tracheostomy Nursing Management

32. Provide the client with emergency call system. • Provide the client with methods to communicate. • Provide emotional support. • If cuffless tube keep pressure below 20 mmHg to reduce the risk of tracheal necrosis due to prolonged compression of tracheal capillaries. • Provide trach care every 8 hours. • Change non-disposable trach tube q 6-8 weeks or per protocol. • Reposition client q 2 hour to prevent atelectasis or pneumonia. • Provide oral hygiene q 2 hour to maintain mucosal integrity. • Minimize dust in client’s room • If client is able to eat, position in an upright position and tip the client’s chin to chest to enable swallowing. • Administer prescribed medications. Tracheostomy Nursing Management

33. Accidental decannulation - keep the trachobturator and spare trach tube at the bedside at all times. - call for assistance. - first 72 hours after surgery is am emergency because trach has not matured and replacement maybe difficult. - mature tracheostomy- nurseshould insert obturator immediately into the tracheostomytrach and insert a new trach tube around the obturator. Complications and Nursing Implications

34. Ineffective Airway Clearance • Ineffective therapeutic regimen management. • Impaired verbal communication • Risk for infection • Impaired swallowing Nursing Diagnosis

35. Nursing Management Lower Respiratory

36. Definition: Pneumonia is an inflammatory process in the lungs that produces excess fluid. Triggered by infectious organism or by the aspiration of an irritant. • Lung parenchyma inflammation process results in edema and exudate that fills the alveoli. • Pneumonia can be a primary or complication of another disease or condition. • It affects all ages but the young, older adults clients, and clients who are immunocompromised are more susceptible. Pneumonia

37. Advanced age • Recent exposure to viral or influenza infections • Tobacco use. • Chronic lung disease (asthma) • Aspiration • Mechanical ventilation (ventilator acquired pneumonia). • Impaired ability to mobilize secretions (decreased level of consciousness, immobility, recent abdominal or thoracic surgery. • Immunosuppressive drugs • Malnutrition • Upper respiratory infections. Common Risk Factors

38. Chest X –Ray – shows consolidation of lung tissue. • Pulse Oximetry – Decreased O2 saturation levels. • CBC – elevated WBC count ( may not be present in older adult clients). • Sputum culture – obtain from suctioning if client unable to cough. Direct identification of responsible organism. • Arterial Blood Gases (ABGs) Decreased PaO2 and increased PaCo2 due to impaired gas exchange in the aveoli. Diagnostic Procedures

39. Monitor for s/s • Fever • Dyspnea/tachypnea • Pleuritic chest pain • Sputum production • Crackles and wheezes • Coughing • Dull chest percussion over areas of consolidation • Poor oxygen saturation ( low SaO2) Assessments

40. Respiratory status (airway patency, breath sounds, respiratory rate, use of accessory muscles, oxygenation status) before and following interventions. • Sputum (amount and color) • History of smoking and chronic lung conditions. • Recent exposure to influenza • Factor that increase the risk for aspirations ( swallowing problem – stroke). • Difficulty mobilizing secretions (generalized weakness). • General appearance (temp. skin color), lab findings. Assess/monitor

41. Impaired gas exchange • Ineffective airway clearance • Activity intolerance • Imbalance nutrition: less than body requirements. • Acute pain NANDA Nursing Diagnosis

42. Administer heated and humidified Oxygen therapy as prescribed. • Position the client in high-Fowler’s position to facilitate air exchange. • Encourage coughing, or suction to remove secretions. • Encourage deep breathing with incentive spirometer to prevent alveolar collapse. • Administer medications as prescribed: • Antibiotics penicillins and cephalosporins. • Initially given as IV then switched to an oral form as client’s improves. • Obtain any Cx specimens prior to giving the first dose of ATB. ATB can be given while waiting for the results of the ordered culture. Nursing Intervention

43. Bronchodilators • Short acting beta agonist – albuterol (proventil, ventolin)quickly bronchodilation. • Methylxanthines- theophyline (Theo-Dur), requires close monitoring of serum medications level due to narrow therapeutic range. • Corticosteroids – prednisones, decrease airway inflammation. Monitor for s/e immunosuppression, fluid retention, hyperglycemia, poor wound healing. Nursing Interventions

44. Immunization can decrease a client’s risk of development of community acquired pneumonia. • Influenza vaccine • Pneumococcal vaccine – administered one time and helps prevent pneumococcal infections including pneumonia. Recommended for older adults and those with chronic illnesses. • Determine the client’s physical limitations and structure activity to include periods of rest. • Promote adequate nutrition. • Provide support to client and family. • Encourage verbalization of feelings. Nursing Interventions

45. Atelectasis – Airway inflammation and edema leads to alveolar collapse and increase the risk for hypoxemia. - Diminish or absent breath sounds over affected area. - Chest X- ray shows area of density. • Acute respiratory failure – Persistent hypoxemia. • Monitor oxygenation levels and acid-base balance. • Prepare for intubation and mechanical ventilation as indicated. • Bacteremia – (sepsis) can occur if pathogens enter the bloodstream from the infection in the lungs. Complications and Nursing Implications

46. Obstructive Pulmonary Diseases

47. COPD encompasses two diseases • Emphysema • Chronic bronchitis Emphysema – loss of lung elasticity and hyperinflation of lung tissue. Emphysema cases destruction of the alveoli leading to decrease surface area for gas exchange, carbon dioxide retention and respiratory acidosis. Chronic Bronchitis – is an inflammation to the bronchi and bronchioles due to chronic exposure to irritants. Chronic Obstructive Pulmonary Diseases.

48. COPD usually affects middle age to older adults. • Risk Factors: • Cigarette smoking – primary risk factor for the development of COPD. • Alpha-antitrypsin deficiency • Exposure to air pollution. Risk Factors

49. Pulmonary Function tests – comparison of forced expiratory volume (FEV) to forced vital capacity (FVC) are used to classify COPD as mild to severe. As COPD advance the FEV and FVC decreases. • Chest X-ray – reveals hyperinflation and flattened diaphragm in late stages of emphysema. • Arterial Blood Gases – ABGs are monitored to evaluate respiratory status. Increase PaCo2 and decrease PaO2/. • Respiratory acidosis, metabolic alkalosis (compensation). • Pulse oximetry Monitor Os saturation levels • Less than normal (normal = 94-98%) O2 saturation levels. Diagnostic tests

50. Peak Expiratory Flow Meters - Used to monitor treatment effectiveness. - decrease with obstruction, increase with relief of obstructions. • AAT levels are used to assess for AAT deficiency. • Monitor hemoglobin and hematocrit to recognize polycythemia (compensation to chronic hypoxia). • Evaluate sputum and WBC counts for diagnosis of acute respiratory infections. Diagnostic tests