Weber Ch 18 Respiratory

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Weber Ch 18 Respiratory
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2011-10-24 10:31:45
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Weber 18 Respiratory
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Weber Ch 18 Respiratory
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  1. Respiratory System Physiology
    • Primary purpose of respiratory system = gas exchange
    • Transfer of O2 & CO2 between atmosphere & blood
    • Ventilation
    • Diffusion
  2. Tow Parts of Airway
    • UPPER
    • NOSE
    • PHARYNX
    • EPIGLOTTIS
    • LARYNX
    • TRACHEA

    • LOWER
    • BRONCHI
    • BRONCHIOLES
    • AVEOLAR DUCTS ALVEOLI

    RIGHT 3 LOBES/ LEFT 2 LOBES
  3. AIR MOVES FROM OROPHARYNX
    AND LARYNX INTO TRACHEA
    • Tube about 5” long
    • 1” in diameter
    • Bifurcates into right and left mainstem bronchus at carina
    • Right main-stem is shorter, wider, & straighter-aspiration more common
  4. O2 EXCHANGE TAKES PLACE WHEN AIR REACHES THE BRONCHIOLES ALVEOLI (SMALL SACS) FUNCTIONING UNITS OF THE LUNGS
    • 300,000,000 ALVEOLI
    • SITE OF GAS EXGHANGE
    • ALVEOLI COLLAPSE=ATELECTASIS (area of lung that is not working - collapse/ blockage/ etc.)
    • Surfactant produced by lung cells to keep alveoli open
    • Surfactant = lipoprotein produced by type II alveolar
    • cells that decreases surface tension & permits alveolar expansion
  5. CHEST WALL
    • 24 RIBS (12 EACH SIDE/PAIRS)
    • RIBS AND STERNUM PROTECT THE LUNGS AND HEART
    • CHEST WALL PARIETAL PLEURA
    • LUNGS WITH VISCERAL PLEURA
    • SPACE BETWEEN THE PLEURAL LAYERS-filled with thin fluid <10ml
    • -INCREASED AMT.of Fluid = PLEURAL EFFUSION - common in:
    • - - MALIGNANCY, CHF, PNEUMONIA
    • - - EMPYEMA=PURULENT PLEURAL FLUID
    • pyema = purulent
  6. DIAPHRAGM MAJOR MUSCLE OF RESPIRATION
    • ON INSPIRATION, CONTRACTS, PUSHES THE ABDOMEN DOWN
    • INCREASES LATERAL/ANTEROPOSTERIOR DIMENSION OF THE CHEST
    • INCREASES SIZE OF THORACIC CAVITY
    • INTRATHORACIC PRESSURE DECREASES, CAUSES AIR TO ENTER LUNG
    • INNERVATED BY THE RIGHT AND LEFT PHRENIC NERVES, BETWEEN C3-C5
    • INJURY TO THE PHRENIC NERVES-HEMIDIAPHRAGM PARALYSIS
  7. GERONTOLOGICAL CONSIDERATIONS (AGING)
    • DECREASE IN ELASTIC RECOIL OF THE LUNG
    • DECREASE IN CHEST WALL COMPLIANCE
    • INCREASE IN ANTEROPOSTERIOR DIAMETER
    • DECREASE IN FUNCTIONAL AVEOLI
    • LOWER PaO2, HIGHER PaCO2
    • DECREASE IN CELL-MEDIATED IMMUNITY DECREASE IN COUGH
    • MORE SIGNIFICANT IF SMOKER, OBESE, OR CHRONIC DISEASE
  8. General Resp. Health History
    • PROBLEM-BASED HISTORY/COMPLAINT
    • COUGH (PRODUCTIVE OR NONPRODUCTIVE)
    • SHORTNESS OF BREATH/DYSPNEA
    • CHEST PAIN (RESPIRATORY vs.CARDIAC)
    • -ask to take a deep breath and then hold their breath - if pain of inspiration, may be respirator - if pain while holding breath, may be cardiac
    • HOARSENESS OR CHANGE IN VOICE
    • WHEEZES

    “OLD CARTS” MNEMONIC
  9. General Health History
    • PAST HEALTH STATUS:
    • CHRONIC ILLNESSES AFFECT RESP. SYSTEM
    • LUNG PROBLEMS OR INJURY/SURGERY TO CHEST
    • CURRENT MEDICATIONS AFFECT RESP. SYSTEM (Prescription & OTC)
    • ALLERGIES (seasonal or anaphylactic reaction)
    • USE OF INHALER OR HOME OXYGEN
    • TRAVEL OUTSIDE/INSIDE U.S.
    • LAST CXR, TB TEST, FLU & PNEUMONIA VACCINES

    • FAMILY HISTORY: (lung cancer, asthma,
    • bronchitis, emphysema, TB or cystic fibrosis)
  10. General Health History:
    LIFESTYLE PRACTICES:
    • SMOKING (pack year history)
    • ENVIRONMENTAL EXPOSURE (pollutants, allergens, 2nd hand smoke)
    • OCCUPATIONAL EXPOSURE (coal, insecticides, paint, pollution, asbestos)
    • STRESS
    • ADL Difficulties
  11. Inspection of Client:
    • GENERAL APPEARANCE (apprehensive, restless, nasal flaring, use of accessory muscles)
    • CHEST SYMMETRY & SHAPE
    • POSTURE/TRIPOD POSITION
    • BREATHING EFFORT/ RESP. RATE (12-20 adult, 16-25 elderly)
    • SPINE
    • Scoliosis - curvature of spine
    • Kyphosis - hunch back
    • Lordosis - sway back
    • Pectus carinatum - pigeon chest/outward or forward protrusion of sternum
    • Pectus excavatum - funnel chest/indented or sunken sternum/chest
  12. Difficulty Breathing
    • Pursed lips -(Pursed lips to slow expiration & keep alveoli open longer esp. asthma, emphysema & CHF)
    • Orthopnea (tripod position)
    • Accessory muscle use
    • Splinting
    • Increased AP diameter
    • Tachypnea > 20 b/min.
    • Cyanosis (late sign)
    • Clubbing (after long period)
    • COPD - Never put on more than 2L of O2 - oxygen level will be met and they will stop breathing
  13. Inspect for Oxygenation & Breathing Patterns:
    • NAIL, SKIN & LIP COLOR
    • O2 SATURATION > 90 %
    • ABNORMAL BREATHING PATTERNS
    • Bradypnea/tachypnea - Bradypnea < 12 b/min & Tachypnea > 20 b/min
    • Hyperventilation - increased rate & depth
    • Kussmaul - deep & laborious hyperventilation with ketoacidosis (DKA to blow off CO2 in metabolic acidosis)
    • Cheyne-Stokes -gradual increase in deep & rapid breathing with intervals of apnea (increased ICP, CHF & renal failure, infants)
    • Air trapping - = rapid inspiration with prolonged expiration (pursed lips with emphysema); inspiration usually > expiration
    • Biot - totally disorganized/irregular pattern (meningitis or severe brain damage)
    • Stridor -harsh musical sound due to broncholaryngospasm (croup, epiglotitis, foreign body obstruction), vocal cord edema)
  14. RESPIRATORY PALPATION:
    • Tracheal position - thumbs
    • Anterior & posterior chest for tenderness/pain or warmth
    • Crepitus - fingertips
    • Vocal tactile fremitus (“99”) – palms -feel with palms or ulnar surface while pt. Says 99 or 123 should feel equal bilat. & slight decrease in bases normally
    • decreased/absent fremitus when vibrations blocked from emphysema, pleural effusion, PE
    • increased fremitus when vibrations enhanced such as pneumonia & tumor (consolidated)

    • Normal v. increased v. decreased
    • Thoracic expansion for symmetry
    • Anterior
    • – below xiphoid process
    • Posterior
    • – T9-10
    • Normal
  15. PERCUSSION OF THORAX
    nFOR TONE

    nResonance

    nHyperresonance


    nDull

    nFlat

    nTympany


    nDIAPHRAGMATIC EXCURSION

    nNormal

    nAbnormal
  16. Auscultation
    • Memorize this:
    • BRONCHIAL (LOUDER, HIGHER PITCH)
    • EXPIRATION>INSPIRATION
    • BRONCHIAL VESICULAR (MEDIUM PITCH)
    • EXPIRATION=INSPIRATION
    • VESICULAR (SOFT, LOW PITCH, RUSTLING)
    • INSPIRATION>EXPIRATION
  17. Auscultation Patterns:
  18. Adventitious Sounds
    • Crackles/Rales = popping or bubbling sound at end of inspiration & don’t go away with coughing
    • further define as fine, medium, or coarse (hear on expiration) due to air passing thru fluid
    • Ex. - Pneumonia, CHF, asthma, bronchitis, emphysema

    • Rhonchi - harsh, low pitch snoring/moaning sounds esp. expiration that may clear with coughing due to air
    • passing thru airways narrowed by secretions
    • Ex. - bronchitis, sleep apnea, stridor with broncholaryngospasm, or croup

    • Wheezes - high pitch musical sound/squeak esp. on expiration not cleared by coughing due to air
    • passing thru constricted bronchus (Ex. - asthma)

    • Friction rub - low pitch grating or creaking sound like leather rubbing together on both inspiration & expiration not cleared by coughing due to
    • inflammation of pleural surfaces (visceral & parietal surfaces)
    • Ex. – pleuritis/pleurisy
  19. Auscultate Vocal Sounds If Tactile Fremitus
    Present
    Bronchophony (muffled 99, 123 v. clear)

    Whispered Pectoriloquy (123 muffled v. clear)

    Egophony (eee sounds like eee v. aaa)

    • If palpate fremitus with “99” then listen with stethoscope posteriorly for these
    • All the above vocal sounds indicate consolidation if
    • clearly heard (should be muffled normally except eee,
    • abnormal if aaa sound)
    • Increased fremitus with consolidation v. decreased fremitus with air trapping (COPD)
    • Listen with stethoscope to posterior
  20. Acute Bronchitis
    • Inflammation of mucous membranes of bronchial tree due to viral/bacterial infection
    • Nonproductive cough becomes productive in few days
    • Fever, malaise, tachypnea, & chest pain
    • Rhonchi, crackles, or wheezing

    • Acute bronchitis = nasal cold goes to chest
    • Viral bronchitis with clear sputum or nonproductive
    • cough
    • Bacterial bronchitis with white, yellow, or green sputum with odor & productive cough
  21. Acute Bronchitis
    • Typical Pneumonia Syndrome
    • Sudden onset
    • Chills
    • Fever, tachycardia, tachypnea
    • Productive cough (purulent)
    • Pleuritic chest pain (worse with coughing or deep resp.)
    • Pulmonary consolidation
    • - Dullness of percussion
    • - fremitus
    • - Bronchial breath sounds
    • - Crackles
    • Rhonchi
    • Nasal Flaring
    • Confusion/stupor in elderly

    • Pneumonia = acute inflammation of lung parenchyma due to bacteria, virus, fungi, parasites, or chemicals (aspirate gastric acid)
    • Elderly may not show typical s/s of fever & tachycardia but rather confusion/stupor
  22. Clinical Manifestations of TB
    • Fatigue
    • Malaise
    • Anorexia
    • Weight loss
    • Low grade fever
    • Night sweats
    • Cough - non productive then later productive with reddish/brown sputum

    • Mycobacterium Tuberculosis (airborne droplets /isolation)
    • Multi drug resistant strains esp. in Africa & AIDS
    • pts.
    • Very prevalent in HIV
    • Tubercles = areas of TB with outer granular mass /
    • calcified
    • Caseation = inner necrotic center like cheeselike with TB
  23. Pleural Effusion (accumulation of fluid in pleura space)
    • Degree of symptoms depends on amount of fluid
    • Dyspnea
    • Intercostal bulging
    • Decreased chest wall movement
    • Diminished fremitus over effusion
    • Percuss dull to flat
    • Diminished breath sounds

    • Normally < 10 ml of fluid in pleural space between
    • visceral & parietal pleura.
    • Fluid accumulates due to inflammation, infection, CA or injury
  24. Traumatic Resp. Conditions:
    Pneumothorax/Hemothorax
    • 3 Types PNEUMOTHORAX
    • Closed spontaneous
    • Open due to penetrating injury
    • Tension with trapped air
    • (trachea shifts to OPPOSITE SIDE)
    • SOB, Anxious, Chest pain
    • Tachypnea & Dyspnea
    • Cyanosis
    • Hyperresonance
    • Decreased chest wall movement on affected side or paradoxical movement
    • Booming percussion
    • Tracheal displacement toward unaffected/ opposite side
  25. HEMOTHORAX:
    • Due to blood in pleural space usually from chest injury or thoracic surgery
    • Symptoms similar to Pneumothorax
    • Distant muffled breath sounds
    • Percusses dull over affected area
  26. Asthma Manifestations
    • Tachypnea with prolonged expiration
    • Wheezing, cough, dyspnea,
    • Decreased tactile fremitus
    • Hyperresonance in children & adults
    • Severe diminished breath sounds
  27. COPD (Emphysema)
    • Signs & Symptoms:
    • SOB/dyspnea
    • Barrel chest
    • Use of accessory muscles
    • Pursed lip breathing
    • Retractions
    • - PCO2 Resp. Acidosis
    • - secretions
    • Orthopnea/Tripod position
    • Hyperresonance
  28. ATELECTASIS:
    • Collapsed alveoli due to accumulation of secretions or hypoventilation
    • Diminished breath sounds
    • Decreased fremitus
    • Dull percussion
    • O2 saturation < 90 %
    • Area above with egophony & whispered pectoriloquy
  29. RESP. NURSING DIAGNOSES
    • INEFECTIVE BREATHING PATTERN
    • INEFFECTIVE AIRWAY CLEARANCE
    • IMPAIRED GAS EXCHANGE
    • IMPAIRED VENTILATION
    • ACTIVITY INTOLERANCE/FATIGUE RT DYSPNEA
    • RISK FOR RESP. INFECTION
    • ANXIETY RT FEAR OF SUFFOCATION
    • KNOWLEDGE DEFICIT RT ASTHMA MEDS
    • DISTURBED SLEEP RT COUGH OR DYSPNEA

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