Medical Surgical Nursing Module 14

OXYGENATION (Respiratory)
RESPIRATORY INTERVENTIONS
Respiratory Therapy
1. Suctioning
RESPIRATORY DISORDERS ❑ Secretions too thick to cough out; inability of pt
❑ O2 prior suction; no more than 15 sec
❑ Position pt w/ extended head & neck
❑ R bronchus [15 to vertical]; L bronchus [25-35]
2. Tracheostomy Care
3. IPPB
❑ O2 & air mixture is forced into pt’s lung during
inspiration
NIO CRUZADA NOVENO, RN ❑  alveolar ventilation; promotes coughing of
secretion; deep adm’n of aerosol meds
RESPIRATORY 2
DISORDERS (NCN)
OXYGENATION (Respiratory) OXYGENATION (Respiratory)
RESPIRATORY INTERVENTIONS RESPIRATORY INTERVENTIONS
Mechanical Ventilation [Respirators] Mechanical Ventilation [Respirators]
➢ Ventilation by mechanical means in those who are ❑ Nursing Care

unable to maintain N levels of O2 & CO2 in blood Assess for:
➢ COPD, neuromuscular dse, ARDS, thoracic ✓ Intermittent mandatory ventilation (IMV)
trauma.. ✓ Positive end expiratory pressure (PEEP)
✓ Continuous positive airway pressure
❑ Modes (CPAP)
✓ Assist/control mode
✓ Intermittent mandatory ventilation (IMV)
✓ Positive end expiratory pressure (PEEP)
✓ Continuous positive airway pressure (CPAP)
RESPIRATORY 3 RESPIRATORY 4
DISORDERS (NCN) DISORDERS (NCN)
Mechanical Ventilation [Respirators] Endotracheal Tube [Artificial Airway]
❑ Nursing Care ➢ cuffed tube inserted by anesthesiologist

✓ Assess for  cardiac output ➢ Suction frequently
✓ Monitor for (+) water balance [I&O, daily ➢ deflate cuff 3-5 min q 1-2hrs
wts, peripheral edema, auscultate BS]
✓ Monitor for barotrauma ❑ Assessment
▪ Assess ventilator setting q 4hrs ✓ ABGs
▪ BS q 2hrs ✓ Hypoventilation & hyperventilation
▪ ABGs [Expiration is longer than insp. cycle – N]
▪ Pulmonary PE q shift ❑ Nursing Care
✓ Monitor GI problems (stress ulcer) ✓ Oral hygiene
✓ Suctioning [frequent]
✓ Humidification
Oxygen Therapy Chest Physiotherapy
➢ most common therapy with respiratory problems ➢ Postural drainage

➢ Percussion
❑ Indications ➢ Vibration
✓ Arterial hypoxemia [COPD,ARDS]
✓ Tissue, cellular & circulatory hypoxia ❑ Nursing Care
❑ Methods ✓ Perform before or 3-4hrs after meal
✓ Masks – 25-35% ✓ Bronchodilators 15-20 min before
✓ Cannula prong 30-40% at 6-8L/min ✓ Remove all tight clothings
✓ Catheter ✓ Percuss on area approx 3min during I& E
❑ O2 toxicity ✓ Vibrate on area during E of 4-5 deep
✓ Eye blindness;lung atelectasis; convulsion ✓ Assist pt in coughing positioning
✓ Provide good oral hygiene
Chest Tubes [Water-Seal Drainage Systems] Chest Tubes [Water-Seal Drainage Systems]
➢ Insertion of catheter into the intrapleural ❑ Nursing Care

space for evacuation of fluid or air ✓ Bottles are always kept below chest level
➢ 2nd or 3rd IC space anterior or mid-axillary line ✓ Check for kinks and leaks
[air]; 8th or 9th IC space [fluid] Water-seal bottle:
Fluid fluctuates up w/ Insp, down w/ Exp;
❑ Types Intermittent bubbling – N w/ exhalation,
coughing or sneezing;
✓ One-Bottle system [collection chamber
No fluctuation/intermittent bubbling –
& water seal]
reexpansion of lung or blockage
✓ Two-Bottle system [ 1 bottle – drainage Continuous bubbling – air leak
collection chamber; 1 bottle – water Suction control bottle:
seal] Air bubbles gently and continuously from
✓ Three-Bottle system [drainage collection, submerged tube
RESPIRATORY water seal and suction control bottle] 9 RESPIRATORY 10
Chest Tubes [Water-Seal Drainage Systems] Thoracic Surgical Procedures
❑ Characteristics of chest drainage 1. Exporatory thoracotomy: incision of the thoracic

✓ Initially very bloody wall, performed to locate bleeding, injuries,
✓ 500-1000ml in 1st 24hrs tumors
✓ When lung is expanded fluid fluctuation
ceases in water seal bottle 2. Thoracoplasty: removal of ribs or portion of ribs to
✓ Closed chest drainage is usually required reduce the size of the thoracic space
for 2-3 days postOP
❑ Removal of chest tube 3. Pneumonectomy: removal of entire lung
✓ Instruct pt to perform Valsalva [Bronchogenic Ca]
maneuver; apply vaseline pressure
dressing to site
✓ Pt is given pain meds prior to removal
RESPIRATORY ✓ Observe air leak after removal 11 RESPIRATORY 12
RESPIRATORY INTERVENTIONS ACID-BASE BALANCE
Thoracic Surgical Procedures Acids

❑ Proton donors
4. Lobectomy: removal of a lobe of the lung ❑ Give H+ in solution
[bronhiectasis, bronchogenic Ca, ❑ Electron acceptors
emphysematous blebs, lung abscess]
5. Segmented resection: removal of one or more Bases
segments of the lung [bronchiectasis] ❑ Proton acceptors
6. Wedge resection: removal of a small, localized ❑ Give OH- in solution
area of disease near the surface of the lung or ❑ Electron donors
lesion that occupies only part of a segment of
lung tissue [excision of nodules for biopsy]
7. Decortication: stripping off the fibrous membrane
that covers the pleura
OXYGENATION (Respiratory) OXYGENATION (ACID-BASE BALANCE)
ACID-BASE BALANCE Metabolic Production of Acids and Bases
Role of Acid-Base Balance Acids

❑ CO2 (H2CO3) [metabolism of fats & CHO]
❑ Acids & bases must be balanced to ❑ Sulfuric acids [S-containing amino acid]
maintain homeostasis in the body’s fluids ❑ Hydrochloric acid [cationic amino acid]
❑ Phosphoric acid [oxidation of phospholipids &
❑ Homeostasis is crucial for all life processes to phosphoproteins]
occur [eg. cellular metabolism, nerve & ❑ Organic acids [lactic acid, acetoacetic acid]
muscle conduction, smooth muscle & ❑ Fecal loss of HCO3-
cardiac muscle contraction]
Bases
❑ Acid-base balances cause changes in the ❑ HCO3- [metabolism of anionic amino a.,
performance of certain body functions citrates]
[eg. respiratory stimulation, changing
electrolyte levels] Production of non-volatile acids is highly dependent on the diet
OXYGENATION (ACID-BASE BALANCE) OXYGENATION (ACID-BASE BALANCE)
Mechanism of pH Regulation Buffer Systems
❑ Neutralization by buffer systems in the blood, ❑ Bicarbonate BS

lymph, interstitial & intracellular fluids ✓ major EC buffer; 1st line defense
✓ Regulated by both kidneys & lungs
❑ Regulation of CO2 excretion by the lungs ✓ N ratio of [HCO3-]/pCO2 = 20:1 → pH 7
❑ Hemoglobin BS
❑ Excretion of acids & bases by the kidneys ✓ 2nd major BS in the plasma
✓ Neutralizes and disposes CO2 in the lungs
❑ Synthesis of ammonia by the kidneys ❑ Phosphate BS
✓ major intracellular BS
❑ Plasma Protein
✓ Minor role in the plasma
Acid-Base Disturbances Acid-Base Disturbances
❑ Three steps to identify the acid-base imbalance: Disturbance pH PaCO2 [HCO3-] Compensation
✓ Determine arterial blood pH [acidosis, (mEq/L) (mmHg)
alkalosis]
✓ Determine CO2 level [respiratory] Respiratory acidosis < 7.35  N  HCO3-
✓ Determine HCO3- level [metabolic]
Respiratory alkalosis > 7.45  N  HCO3-
❑ Normal Values: ABG
✓ Arterial pH [7.35-7.45] Metabolic acidosis < 7.35 N   pCO2
✓ Bicarbonate (HCO3-) [24-28 mEq/L] Hypervent
✓ Carbon dioxide (PCO2) [35-45 mmHg] Metabolic alkalosis > 7.45 N   pCO2
✓ Oxygen (PO2) [95%] Hypovent
✓ O2 saturation [93-98%]
Acid-Base Disturbances Respiratory Acidosis [ pH,  pCO2]
Example: pH = 7.30 ➢ Involve “hypoventilation” leading to retention of

pCO2 = 50 mmHg Paco2
[HCO3- ]= 25 mEq/L
❑ Symptoms:
Disturbance: Respiratory acidosis
✓ Slow, shallow, weak respirations
Compensation:  HCO3- absorption
✓ Declining level of consciousness
[kidneys]
✓ Mental lethargy, confusion, disorientation
Example: pH = 7.31 ✓ Associated signs of impaired oxygenation
pCO2 = 38 mmHg
[HCO3- ] = 20 mEq/L
Disturbance: Metabolic acidosis
Compensation:  pCO2 , hypoventilation
[lungs]
Respiratory Acidosis [ pH,  pCO2] Respiratory Alkalosis [ pH,  pCO2]
❑ Associated disease or conditions: ➢ involve “hyperventilation” leading to excessive

✓ COPD (Emphysema) loss of Paco2
✓ Pneumonia
✓ Head trauma → damage to respiratory ❑ Symptoms:
center ✓ Rapid, deep, “blowing” respirations
✓ Overdose → depression of respiratory ✓ Acute excitation, trembling nervousness
center ✓ Neuromuscular irritability
✓ Barbiturates, anesthetics, narcotics ✓ Numbness & tingling of extremities
✓ Respiratory or cardiac arrest
❑ Nursing Management:
✓ Assess the cause, correct it
✓ Provide O2 & support for ventilation
✓ Administer NaHCO3 as ordered
RESPIRATORY ✓ Monitor pts mental status & serial ABGs 23 RESPIRATORY 24
Respiratory Alkalosis [ pH,  pCO2] Metabolic Acidosis [ pH,  loss of HCO3-]
❑ Associated disease or conditions: ❑ Symptoms:

✓ Asthma (acute bronchial constriction) ✓ CNS depression [cardiac dysrhythmia,
✓ Brain injury (+) resp. center apathy & lethargy, disorientation, coma]
✓ Overdose of ASA, cocaine ✓ Kussmaul breathing
✓ Acute anxiety (“fight” or “flight” response) ✓ Acetone breathe [DM]
✓ High altitude (hyperventilation) ✓ Oliguria or anuria [renal failure]
❑ Nursing Management: ❑ Anion Gap = [Na+ + K+] – [Cl- + HCO3-]

✓ Assess the cause, correct it = 12-16 mEq/L
✓ Coaching pt’s breathing pattern to slow,  Anion gap acidosis – normochloremic
deep respiration, coaching breathing,
breath holding and paper bag breathing  Anion gap acidosis – hypoalbuminemia
✓ Reduce anxiety [anxiolytics/sedatives] [1gm/dl  albumin = 2mEq/L  AG]
N Anion gap - hyperchloremic
Metabolic Acidosis [ pH,  HCO3-] -  loss of HCO3- Metabolic Acidosis [ pH,  HCO3-] -  loss of HCO3-
❑ Associated disease or conditions ❑ Nursing Management:

✓ Severe or prolonged diarrhea ✓ Assess the cause, correct it
✓ Prolonged fasting [anorexia] ✓ Reversal of acidotic state;
✓ Normochloremic acidosis NaHCO3 administration [pH < 7.2]
▪ Diabetid ketoacidosis [ BHBA, AA] ✓ Close watch on VS & level of
▪ Alcoholic acidosis [ BHBA, AA] consciousness
▪ Shock, sepsis, CHF [ Lactic acid] ✓ Cardiac monitoring
▪ Methanol poisoning [ Lactic acid] ✓ Serial ABGs
✓ Hypoalbuminemia, hypercalcemia,
hypermagnesemia, hyperkalemia, lithium
toxicity, IgG myeloma
✓ GI HCO3- losses, defects in renal
acidification [N anion gap]
Metabolic Alkalosis [ pH,  HCO3-] Metabolic Alkalosis [ pH,  loss of HCO3-]
❑ Symptoms: ❑ Nursing Management

✓ CNS excitement [irritability, disorientation, ✓ Assess the cause, correct it
muscular twitching, seizures] ✓ Reversal of alkalotic state;
✓ Dysrhythmia ✓ Volume expansion w/ NaCl
[vomiting/diuretic induced]
❑ Associated disease or conditions: ✓ K+ repletion
✓ Gastric loss of HCl [vomiting, mechanical ✓ Carbonic anhydrase inhibitor
darinage,] ✓ Monitor VS
✓ Use of diuretics ✓ Serial ABGs
✓ Endo/exogenous mineralocorticoid excess
[hypokalemia]
✓ Acetated in parenteral alimentation
✓ Citrate in fresh whole blood [BT]
RESPIRATORY DISORDERS
NIO CRUZADA NOVENO, RN

RESPIRATORY DISORDERS RESPIRATORY DISORDERS
WILFREDO D. QUIJENCIO JR. MD RN RM MAN
PRINCIPLES in OXYGENATION
➢ To maintain oxygenation, the body requires a

constant supply of O2 and CO2.
➢ Oxygenation may be impaired when airways are

affected by airway obstruction.
➢ Oxygenation may be impaired when the

respiratory system is affected by disease,
resulting in damage to lung function.
➢ Oxygen therapy is necessary to restore

oxygenation when oxygenation is impaired.
DISORDERS (WDQ) DISORDERS (WDQ)
RESPIRATION PROCESSES INVOLVED IN RESPIRATION

•process that enables the exchange of O2 and CO2
❑ VENTILATION or BREATHING
Anatomy of the
✓ inspiration and expiration
Respiratoty System
✓ movement of air in and out of the lungs
1. Upper Airway
❑ DIFFUSION or GAS EXCHANGE
nose → oropharynx ✓ movement of gases between air [alveoli]
and blood in the pulmonary capillaries
2. Lower Airway
❑ PERFUSION or CIRCULATION or BLOODFLOW
larynx → alveolus ✓ transport of O2 and CO2 in the blood &
body fluids to the cells
REGULATION OF RESPIRATION REGULATION OF RESPIRATION

Respiratory Centers Humoral Regulation (Chemical)
❑ Medulla ❑ Central chemoreceptors

✓ primary respiratory center ✓ directly (+) by  H+ in the CSF
✓ Spontaneous rhythmic pattern ✓  PCO2 → rapid  H+ in the CSF
✓ affects both rate & depth ✓ located at the medulla oblongata
❑ Cerebral cortex ❑ Peripheral chemoreceptors
✓ voluntary breathing ✓ located at the carotid body & at the
❑ Pons aortic arch
✓ involuntary breathing ✓ aortic arch → brain [via vagus nerve]
❑ Hering Breuer reflexes ✓ carotid body → brain [via
✓ stretch receptors in the lungs glossopharyngel
nerve]
✓ primarily respond quickly to a  PO2 [<50
RESPIRATORY 7 RESPIRATORY mm HG] 8
NURSING ASSESSMENT
FACTORS INFLUENCING RESPIRATION
1. Respiration [breathing patterns]
❑ BP changes:  BP =  RR
❑ Eupnea
❑ Body temperature changes:  temp =  RR
❑ Tachypnea
❑ Drugs: depressants  RR
❑ Bradypnea
❑ Age: decreases with age
❑ Dyspnea
✓ Neonate [35-60/min]
❑ Apnea
✓ Infant [44/min]
❑ Orthopnea
✓ Child 5 yrs [20-25/min]
❑ Biot’s
✓ Adolescent 10-14yrs [17-22/min]
❑ Cheyne Stokes
15yrs [20/min]
❑ Kussmaul
✓ Adult [16-20/min]
❑ Paroxysmal nocturnal dyspnea
✓ older adult [12-16/min]
NURSING ASSESSMENT NURSING ASSESSMENT
2. Cough and secretions 3. Breath/Lung sounds

❑ Cough ❑ Bronchial, Bronchovesicular, vesicular [normal]
✓ Protective mechanism used to keep ❑ Adventitious [abnormal]
tracheobronchial tree free of secretions ✓ Crackles/rales – discrete, discontinuous
✓ Common symptom of respiratory disease inspiratory sounds; vibrations of fluid w/in
✓ Hacking, croupy, rattling, whooping, ✓ Rhonchi – coarse sounds; indicate partial
barking obstruction of the airway
❑ Sputum ✓ Wheezes –continuous musical sounds from
✓ Substance ejected from the lungs by narrowed small air passages
coughing or clearing the throat ✓ Stridor/stertuous – noisy respiration
✓ May be thick, viscous, tenacious or ✓ Friction rub – grating sound
gelatinous, frothy, mucoid, mucopurulent, ✓  breath sounds – poorly ventilated lungs
bloody ✓ Absence of BS – non-expanding
NURSING ASSESSMENT NURSING ASSESSMENT
4. Degree of chest pain and origin 6. Airway patency

❑ Lung parenchyma 7. Bronchospasm
✓ Dull, constant ache, poorly localized 8. Level of consciousness
❑ Pleura 9. Vital signs for temp, RR, pulse & skin color changes
✓ Sharp, abrupt, increased with respiration or 10. Observe for hemoptysis and hypoxia
with cough or sneeze 11. Other systemic complications
❑ Chest wall 12. Oxygen concentration [pulse oximetry]
✓ Localized, constant & increased w/ 13. Conditions associated with respiratory failure
movement
5. Cyanosis
❑ Peripheral – extremities/nailbeds; 2  CO
❑ Central – lips, tongue, face; 2  O2 in blood
❑ Differential – upper or lower half of body;
RESPIRATORY cardiac diseases 13 RESPIRATORY 14
DIAGNOSTIC PROCEDURES DIAGNOSTIC PROCEDURES
Radiologic Studies Bronchoscopy
❑ Chest x-ray ❑ Visualization of the interior of the TB tree w/ a tube-

❑ Lung scintigraphy: measures concentration of - like lighted scope
rays from lung after intake of isotope ❑ Diagnostic: collection of secretion & specimen
❑ Perfusion studies: outline pulmonary vascular ❑ Therapeutic tool to remove foreign materials
structures after intake of radioactive isotopes IV ❑ Procedure and Nursing care:
✓ Pulmonary embolism & blood flow ✓ Place client supine w/ hyperextended neck
abnormalities ✓ PostOP: check pt’s ability to control secretions
❑ Bronchography ✓ Observe for potential complications of
✓ An opaque substance is inserted into trachea, laryngospasm, laryngeal edema, anesthesia
& x-ray of TB tree and lungs is taken complications, subcutaneous emphysema
✓ Client is NPO to prevent dangers of aspiration ✓ Inform pt. to expect hoarseness & sore throat
and regurgitation
Biopsy Thoracentesis
❑ Lung Tissue ❑ A needle puncture through the chest wall

✓ May be done by needle ❑ Aspiration of fluid or air from the pleural sac
✓ During bronchoscopy ❑ Diagnostic and therapeutic
✓ Open lung ❑ Nursing care & intervention:
❑ Lymph node ✓ Secure consent
✓ Scalene or mediastinal ✓ Position: upright leaning on over bed table
✓ To assess metastasis of lung Ca ✓ Remain still, avoid coughing during insertion
✓ Postprocedure: turn on unaffected side
❑ Nursing care: ✓ Bed rest, monitor
✓ Observe for hemothorax and/or pneumothorax
DIAGNOSTIC PROCEDURES
Pulmonary Function Studies
❑ Vital capacity – max volume of air that can be

exhaled after a maximum inhalation
✓ Reduced in COPD
❑ Tidal volume – inhaled + exhaled air [N breathing]
❑ Inspiratory reserve – max inhaled air after N exp
❑ Expiratory reserve – max exhaled air after N insp
❑ Functional residual capacity – remained volume of
air in the lungs after expiration
❑ Residual volume – remained volume of air in the
lungs after forceful expiration
Arterial Blood Gas Studies Sputum Examination
❑ To assess ventilation by measuring : ❑ Gross appearance

✓ Oxygen (PO2) [95%] ❑ C&S
✓ Carbon dioxide (PCO2) [35-45 mmHg] ❑ AFB staining
✓ Arterial pH [7.35-7.45] ❑ Cytologic exam
✓ O2 saturation [93-98%] ✓ Early morning sputum specimen
✓ Bicarbonate (HCO3-) [24-30 mmHg] ✓ Rinse mouth w/ plain water
❑ Determine state of acid-base balance ✓ Use sterile container
❑ Common site for blood ext’n: radial artery ✓ Specimen for C&S is collected before the 1st
❑ 10ml pre-heparinized syringe to prevent clotting dose of antibiotic
❑ Container w/ ice to prevent hemolysis ✓ For AFB staining –3 consecutive mornings
DIAGNOSTIC PROCEDURES RESPIRATORY DISORDERS
Skin Test
CHRONIC CHRONIC
INFECTIOUS TRAUMA
❑ Mantoux test OBSTRUCTIVE RESTRICTIVE
✓ PPD [Purified Protein Derivative]
✓ Intradermal
✓ Read 48-72 hrs after injection
✓ (+) test – induration of 10mm or more • PTB • Asthma • Pleural • Open Wound
✓ For HIV – 5mm (+) test • Pneumonia • Emphysema Effusion • Pneumothorax
✓ Means exposure to Mycobacterium tubercle; • Legionnaire’s • Chronic • Pneumothorax • Hemothorax
but does not signify active disease Bronchitis • Cancer • Rib Fracture
RESPIRATORY DISORDERS (Upper Airway)

Epistaxis
❑ Causes
✓ Trauma/irritation
✓ Infection
✓ Tumors
✓ Systemic dse [HPN, blood dyscrasias]
✓ Systemic treatment [chemotherapy,
anticoagulant]
DISORDERS DISORDERS
RESPIRATORY DISORDERS (Upper Airway) RESPIRATORY DISORDERS (Upper Airway)

Epistaxis Sinusitis
➢ Infection of the paranasal sinuses
❑ Nursing Intervention
✓ Sit up, lean forward, head tipped downward ❑ Causes
✓ Pressure over the soft tissues of the nose for at ✓ Viral
least 5 mins ✓ Bacterial
✓ Cold compress/ice pack ❑ Signs and symptoms
✓ Nasal pack w/ neosenephrine (3-5days) ✓ Pain [Maxillary – cheek, upper teeth; Frontal –
✓ Liquid diet, then soft diet above eyebrows; Ethmoid – in & around the
✓ Avoid oral-temperature taking eyes; Sphenoid – behind eye, occiput, top of
✓ Do not blow nose for 2 days after removal of the head]
nasal pack ✓ Fever and malaise
✓ Notify physician if epistaxis is recurrent ✓ Stuffy nose
✓ Purulent or discolored nasal discharge
RESPIRATORY 27 RESPIRATORY ✓ Headache 28
DISORDERS DISORDERS
Sinusitis Tonsillitis
❑ Nursing Management ❑ Signs and symptoms

✓ Positioning ✓ Sore throat
✓ Analgesics, antipyretics ✓ Dysphagia
✓ Antimicrobials ✓ Otalgia (ear pain)
✓ Nasal decongestants [Sudafed, Dimetapp] ✓ Generalized malaise
✓ Irrigation of maxillary sinuses w/ warm NSS ✓ Cervical lymphadenopathy
✓ Caldwell-Luc Surgery [Radical Antrum Surgery] ✓ Fever
▪ Do not chew on affected side ✓ Foul breath
▪ Caution w/ oral care to prevent trauma,
infxn
▪ Do not wear dentures for 10 days
▪ No blowing of nose for 2 wks
RESPIRATORY ▪ Avoid sneezing for 2 wks after surgery 29 RESPIRATORY 30
DISORDERS DISORDERS

Tonsillitis Tonsillitis
❑ Nursing Management ❑ Nursing Management

✓ Rest and  fluid intake ✓ Surgery – Tonsillectomy
✓ Warm saline throat irrigation ▪ PostOP Care:
✓ Ice collar to relieve discomfort • Position on side until fully awaken, then
✓ Analgesics and antipyretics mid-fowlers
✓ Antibiotics • Oral airway until swallowing reflex (+)
✓ Surgery – Tonsillectomy • Monitor for hemorrhage [frequent
▪ PreOP Care: swallowing, bright red vomitus,  PR]
• Check for loose tooth • Comfort [ice collar, Acetaminophen]
• Assess for URTI [postOP bleeding] • Foods & fluids [cold fluids, bland
• Check PT foods]
• Patient teaching
DISORDERS DISORDERS

Laryngeal Cancer
Laryngeal Cancer
❑ Management
❑ Predisposing Factors ✓ Subtotal laryngectomy – retains voice
✓ Over use of voice [teachers, singers] ✓ Total – absolute loss of voice
✓ Family predisposition to cancer ✓ Tracheostomy – temporary or permanent
❑ Signs and symptoms ▪ PostOP Care:
✓ Persistent hoarseness associated with otalgia • Establish patent airway
& dysphagia • Head of bead elevated 45
✓ Lump on throat • Assist patient on communicating –
✓ Pain in the adam’s apple that radiates to the provide writing materials, etc
ear • Practice swallowing
✓ Dyspnea, enlarged cervical nodes and • Cover tracheostomy w/ porous
cough material
• Avoid powder, spray, aerosol near
RESPIRATORY 33 RESPIRATORY trachea 34
DISORDERS DISORDERS

COPD – DO that obstruct the pathway of normal alveolar
CHRONIC CHRONIC ventilation either by spasm of the airways, mucus
INFECTIOUS TRAUMA
OBSTRUCTIVE RESTRICTIVE secretions, or changes in the airway &/or alveoli
Emphysema vs Chronic Bronchitis
• PTB • Asthma • Pleural • Open Wound permanent overdistention of long-term inflammation of

• Pneumonia • Emphysema Effusion • Pneumothorax alveoli w/ resulting destruction mucus memb. of bronchial tubes w/
• Legionnaire’s • Chronic • Pneumothorax • Hemothorax of the alveolar walls recurrent cough & sputum prod’n for
Bronchitis • Cancer • Rib Fracture 3 mos or more in 2 consecutive yrs
“PINK PUFFER” “BLUE BLOATER”
DISORDERS DISORDERS
RESPIRATORY DISORDERS (COPD)
Emphysema Chronic Bronchitis
Cigarette smoking, Heredity, Cig. smoking, RTI, Pollutants

Aging process
Inflammation
Disequilibrium between
Bradykinin, Histamine, PGs
ELASTASE & ANTIELASTASE
 Capillary permeability
Destruction of ELASTIC RECOIL
Fluid/Cellular Exudation
Overdistention of ALVEOLI
Edema of mucus membrane
Retention of CO2 Hypersecretion of mucus
Hypoxia, Respiratory Acidosis Persistent Cough

RESPIRATORY 37 38
DISORDERS
39
RESPIRATORY DISORDERS (COPD)
Emphysema Chronic Bronchitis
No cyanosis (Pink) Cyanosis (Blue)

Thin appearance Edematous
Exertional dyspnea Exertional dyspnea
Ineffective cough Recurrent cough w/
Barrel chest Sputum production
Purse lip breathing Digital clubbing
Prolonged expiration Respiratory rate
Use of accessory muscles Use of accessory muscles
R-sided Heart Failure R-sided Heart Failure

Pulmonary HPN Cor pulmonale
Spontaneous Pneumothorax
RESPIRATORY 42
DISORDERS
THE DIFFERENCE….
RESPIRATORY DISORDERS (COPD) RESPIRATORY DISORDERS (BRONCHIECTASIS)

Collaborative Management ❑ An irreversible condition of bronchi with
❑ Rest:  O2 demand of tissues destruction of muscular and elastic structure
❑  fluid intake
❑ Good oral care. To remove sputum & prevent infxn
of the bronchial wall
❑ Diet:  calorie,  CHON,  CHO ❑ A condition in which damage to the airways
❑ O2 therapy 1-3LPM [2lpm safest] causes them to widen and become flabby
❑ Breathing exercises [pursed-lip breathing] and scarred
❑ Avoid cigarette smoking, alcohol, pollutants
❑ CPT- percussion, vibration, postural drainage
❑ Bronchial hygiene measures [steam, aerosol,
medimist inhalation]
❑ Pharmacotherapy [Antitussives, Bronchodilators,
antihistamine, steroids, antimicrobials]
DISORDERS DISORDERS
RESPIRATORY DISORDERS (BRONCHIECTASIS) RESPIRATORY DISORDERS (BRONCHIECTASIS)

❑ SIGNS AND SYMPTOMS ❑ DIAGNOSTICS
✓ Chronic cough with purulent sputum
✓ Hemoptysis ✓ Bronchoscopy
✓ Exertional dyspnea ✓ CBC – possible increase in WBC
✓ CT scan – detects presence or absence of
bronchial dilation
DISORDERS DISORDERS
DISORDERS DISORDERS
RESPIRATORY DISORDERS (ASTHMA) RESPIRATORY DISORDERS (ASTHMA)

❑ TYPES OF ASTHMA
❑Chronic inflammatory disease of the airways
characterized by hyper-responsiveness, mucosal ✓Immunologic asthma- occurs in childhood
edema and mucous production ✓Non-immunologic asthma- occurs in
adulthood and associated with recurrent
❑Disorder of the bronchial airways characterized respiratory infections.
by periods of reversible bronchospasm ✓Mixed, combined immunologic and non-
immunologic
❑Also known as the “reactive airway disease”
DISORDERS DISORDERS
RESPIRATORY DISORDERS (ASTHMA)

❑ CAUSE AND RISK FACTORS
✓Family history of asthma

✓Allergens: dust, pollens
✓Secondary smoke inhalation
✓Air pollution
✓Stress
DISORDERS DISORDERS
❑ Signs & Symptoms: ❑ Signs & Symptoms:

✓ Tends to sit up ✓ Cyanosis
✓ Restlessness/anxiety ✓ Chronic barrel chest
✓ Dyspnea, tachypnea, tachycardia ✓ Elevated shoulders
✓ Flaring of alae nasi, retractions ✓ Distended neck veins
✓ Cough, tightness or pressure on chest ✓ Orthopnea
✓ Cold clammy skin ✓ Tenacious mucoid sputum
✓ Diaphoresis
✓ Wheezing
✓ Pallor, Cyanosis
DISORDERS DISORDERS

ASTHMA ALLERGY (Extrinsic)
INFLAMMATION (Intrinsic) ❑COMPLICATION
✓STATUS ASTHMATICUS- a life-threatening
Histamine, A. Bronchospasm asthmatic attack in w/c symptoms of asthma
Bradykinin, B. Edema of the mucus membrane continues and do not respond to treatment.
PG, Serotonin, C. Hypersecretion of mucus
Leukotrienes…
Exhaustion Respiratory Narrowing of AWs,

effort  work of breathing
Hypoventilation
Air trapping Hypoxia, Respiratory Acidosis
DISORDERS DISORDERS
RESPIRATORY DISORDERS (ASTHMA)

❑ Diagnostic tests:
✓ Pulmonary functional tests [VC, FVC]
❑ Management:
✓ Pharmacotherapy
▪ Beta agonists [Epinephrine, Terbutaline..]
▪ Methylxanthines [Aminophylline]
▪ Corticosteroids
▪ Anticholinergics [Atropine]
▪ Mast cell inhibitors [Cromolyn Na]
✓ Oxygen via nasal cannula
✓ Fluids to 3L/day
✓ Breathing exercises
✓ Metered dose inhaler
DISORDERS DISORDERS

❑ Diagnostic tests: ❑ Nursing management
✓ Pulmonary functional tests [VC, FVC] ✓Promote pulmonary ventilation
❑ Management:
✓ Pharmacotherapy
✓Facilitate expectorant
▪ Beta agonists [Epinephrine, Terbutaline..] ✓Health teaching
▪ Methylxanthines [Aminophylline] ▪ Breathing techniques
▪ Corticosteroids ▪ Stress management
▪ Anticholinergics [Atropine] ▪ Avoid allergens
▪ Mast cell inhibitors [Cromolyn Na]
✓ Oxygen via nasal cannula
✓ Fluids to 3L/day
✓ Breathing exercises
✓ Metered dose inhaler
DISORDERS DISORDERS
RESPIRATORY DISORDERS (ASTHMA) RESPIRATORY DISORDERS (ATELECTASIS)

❑ Nursing management ❑ Collapse of part or the entire lung due to
✓Promote pulmonary ventilation bronchial obstruction
✓Facilitate expectorant ❑ Closure or collapse of alveoli
✓Health teaching ❑ Acute or chronic in nature
▪ Breathing techniques ❑ Maybe due to:
▪ Stress management ✓ Intrabronchial obstruction (secretions,
▪ Avoid allergens tumors, bronchospasm, foreign bodies)
✓ Extrabronchail compression ( tumors,
enlarged lymph nodes)
✓ Intrabronchail disease (carcinoma,
inflamed structures)
DISORDERS DISORDERS
RESPIRATORY DISORDERS (ATELECTASIS)

❑ SIGNS AND SYMPTOMS
✓ Cough
✓ Sputum production
✓ Low grade fever
✓ Dyspnea
✓ Tachycardia
✓ Pleural pain
✓ Central cyanosis
✓ Crackles upon auscultation
✓ Decreased breath sounds on the affected side
DISORDERS DISORDERS

❑ DIAGNOSTICS
✓ CXR reveals patch infiltrates
✓ ABG reveals decreased PO2
✓ Bronchoscopy
DISORDERS DISORDERS
DISORDERS DISORDERS

❑ NURSING MANAGEMENT
✓ Prevention of atelectasis in hospitalized patient is
an important nursing responsibility
✓ Turn and reposition patient every 1 – 2 hours while
bedridden or obtunded
✓ Encourage early mobility if permitted
✓ Promote liquification and removal of secretions
✓ Avoid administration of large does of sedatives
and opiates that depresses respiratory and cough
reflexes
✓ Prevent abdominal distention
✓ Administer prophylactic antibiotics to prevent
respiratory infection
DISORDERS DISORDERS
CHRONIC CHRONIC
INFECTIOUS TRAUMA
OBSTRUCTIVE RESTRICTIVE
• PTB • Asthma • Pleural • Open Wound
• Pneumonia • Emphysema Effusion • Pneumothorax
• Legionnaire’s • Chronic • Pneumothorax • Hemothorax
Bronchitis • Cancer • Rib Fracture
RESPIRATORY 2
DISORDERS (WDQ)
RESPIRATORY DISORDERS (INFECTIOUS)
Pneumonia
➢ acute inflammatory process of the alveolar spaces
→ lung consolidation → exudate [alveoli]
❑ Types:
✓ Bacterial pneumonias
▪ Lobar [Strep] – constant dry, hacking
cough, pleuritic pain, watery to rust-
colored sputum
▪ Bronchopneumonia [Strep/Staph] – due to
aspiration, productive cough w/ yellow or
green sputum
✓ Alveolar pneumonia [viral] – scanty sputum
✓ Atypical pneumonia [rickettsial] – “walking”,
RESPIRATORY non-productive cough 3 RESPIRATORY 4
RESPIRATORY DISORDERS (INFECTIOUS) RESPIRATORY DISORDERS (INFECTIOUS)
Pneumonia Pneumonia
➢ acute inflammatory process of the alveolar spaces
➢ETIOLOGY
→ lung consolidation → exudate [alveoli]
1. BACTERIAL/ VIRAL
➢ An inflammatory process of lung parenchyma ▪ Streptococcus pneumoniae,
associated with marked increase in alveolar and ▪ Pseudomonas aeruginosa,
interstitial fluids ▪ Influenza
2. Secondary to respiratory tract infection
3. Incidence decreases with age
o The higher the age, the higher or
stronger the resistance
Pneumonia Pneumonia
RISK FACTORS CLINICAL MANIFESTATIONS:
➢ Age: too young and elderly are most prone 1. Chest pain, irritability, apprehensiveness,
to develop restlessness, nausea, anorexia
➢Smoking, air pollution 2. Cough- productive, rusty/ yellowish/
➢URTI greenish sputum, splinting of affected
➢Altered consciousness side, chest retraction
➢Tracheal intubation 3. High fever
➢Prolonged immobility: post-operative, bed- 4. Fine rales and wheezing upon
ridden patients auscultation
Pneumonia Pneumonia
DIAGNOSTIC EXAMS:
1. Chest X-ray Drug therapy:
2. Sputum culture 1. Antibiotics
3. Blood culture • Penicillin,
4. Increased WBC • Cephalosphorin,
5. Elevated sedimentation rate • Tetracycline,
• Erythromycin
2. Cough suppressants
3. Expectorants
Pneumonia
NURSING MANAGEMENT
1. Promote adequate ventilation- positioning,
Chest physiotherapy
2. Provide rest and comfort
3. Prevent potential complications
4. Health teaching; skin care, hygiene
5. Drug therapy
6. Rest and adequate activity
7. Proper nutrition
Tuberculosis (TB) Tuberculosis (TB)

➢ Airborne, infectious, communicable dse due to ❑ RISK FACTORS
Mycobacterium tuberculosis; acute or chronic ✓Poor living conditions, overcrowded
❑ Symptoms:
✓Poor nutritional intake
✓ fatigue, malaise, anorexia, wt. Loss, night ✓Previous infection
sweats ✓Close contact with infected person
✓ Productive chronic cough, hemoptysis ✓Inadequate treatment of primary infection
(advanced)
✓ Late afternoon low grade fever
❑ Diagnostics:
✓ TB skin test
✓ Chest x-ray
✓ Bacteriologic sputum studies
PULMONARY TUBERCULOSIS OXYGENATION (Respiratory)

• Primary infection
inhalation of M.T RESPIRATORY DISORDERS (INFECTIOUS)
• Bronchopneumonia Tuberculosis (TB)
• Phagocytosis ❑ CLINICAL MANIFESTATIONS
✓Productive cough
• Necrotic degeneration
✓Hemoptysis
• Scar formation and calcification of lesions ✓Dyspnea
• Dev’t of allergic reaction to tubercle bacilli ✓Rales
• Living bacilli is dormant in the body ✓Malaise
✓Night sweats
✓Weight loss
• Secondary infection ✓Anorexia
– Activation of the dormant bacteria among infected ✓Vomiting
individuals ✓Indigestion
DISORDERS (WDQ) ✓Pallor
DISORDERS (WDQ)
Tuberculosis (TB)
❑ DIAGNOSTIC TESTS:
➢Chest X-ray
➢Sputum acid- fast
➢Mantoux Test
✓ 1 ml of PPD (Purified Protein
Derivative)
✓ Read after 48- 72 hours
✓ Induration: 10 mm= positive
exposure to TB bacillus
5-9 mm= doubtful, may
repeat the procedure
< 4 mm = Negative

❑ TREATMENT
➢Ethambutol ❑ Intervention:
✓ TB medications [6-12 mos] – “DOT”
➢Rifampicin ▪ INH, RIF, PZA (2mos); INH,RIF (4mos)
➢Isoniazid ▪ Pt not infectious 2-3wks of tx
➢Pyrazinamide ✓ Sputum smears q 2-4wks until (-)
➢Streptomycin ✓ Bed rest until w/o symptoms
✓ Resp isolation until (-) sputum
✓ Teachings on how to prevent spread
✓ Diet: high CHO, high protein, high vit. B6
✓ Frequent oral hygiene

❑ CLIENT EDUCATION: ❑ CLIENT EDUCATION:
✓TB is infectious but can be cured ✓Regimen is usually 6 months.
✓Transmitted by droplet infection and not ✓Regular check-up to monitor progress
carried on articles like clothing or eating should be done.
utensils ✓Sputum samples are obtained first before
✓Individual is generally considered not drug therapy is started.
infectious after 1-2 weeks of medication ✓Advise proper handwashing and use of
✓Medication regimen should be continuous mask for people in contact with infected
and uninterrupted. persons who are not yet under treatment.
Tuberculosis (TB)
❑ CLIENT EDUCATION:
✓Regimen is usually 6 months.
✓Regular check-up to monitor progress
should be done.
✓Sputum samples are obtained first before
drug therapy is started.
✓Advise proper handwashing and use of
mask for people in contact with infected
persons who are not yet under treatment.
RESPIRATORY DISORDERS (Restrictive) RESPIRATORY DISORDERS (Restrictive)
Pleural Effusion and Pneumothorax Pleural Effusion and Pneumothorax
➢ Pleural effusion – accumulation of fluids ❑ Assessment

➢ Pneumothorax – accumulation of air → pleural ✓ Sudden sharp chest pain
space [open, close, spontaneous, tension] ✓ Shortness of breath (SOB)
✓ Restlessness/anxiety
❑ Causes ✓ Tachycardia, tachypnea
✓ Trauma ✓ Diminished/absent BS
✓ Thoracic surgery ✓ Chest asymmetry
✓ Positive pressure ventilation ✓ Deviation of larynx/trachea towards
✓ Thoracentesis unaffected side
✓ CVP line insertion ✓ Cyanosis
✓ Emphysema ✓ Tympanitic sound on chest percussion
Pleural Effusion and Pneumothorax Bronchogenic Carcinoma
❑ Nursing Interventions ➢ primary pulmonary tumors arising from bronchial

✓ Remain w/ pt., stay calm epithelium; metastasis primarily by direct extension,
✓ High-Fowler’s via circulatory or lymphatic system
✓ Pain management
✓ O2 therapy ❑ Incidence
✓ Chest tube/Thoracentesis ✓ Men > 40y/o mostly affected
✓ Chest x-ray ✓ 1 out of 10 heavy smokers
✓ ABGs ✓ Right lung > left lung
✓ Monitor for shock ❑ Etiology
✓ Inhaled carcinogens [cigarette smoke,
asbestos, nickel, iron oxides,…
✓ Preexisting pulmonary DO [COPD, TB]
Bronchogenic Carcinoma Bronchogenic Carcinoma
❑ Assessment ❑ Diagnostic Tests

✓ Persistent cough [productive, blood-tinged] ✓ Chest x-ray
✓ Chest pain, dyspnea ▪ presence of tumor; metastasis
✓ Unilateral wheezing, friction rub ✓ Sputum for cytology reveals malignant cells
✓ Fatigue, anorexia ✓ Bronchoscopy
✓ Nausea & vomiting ▪ biopsy reveals malignancy
✓ Pallor ✓ Thoracentesis
▪ pleural fluid w/ malignant cells
✓ Biopsy of scalene lymph nodes - metastasis
Bronchogenic Carcinoma Neuromuscular Disorders
❑ Management – depends on cell type, stage of ❑ Myasthenia Gravis - dev’t of generalized

disease and condition of pt. muscular weakness causing difficulty in
✓ Radiation therapy swallowing;
✓ Chemotherapy ✓ unable to manage oral secretions
✓ Surgery – when entire tumor can be ✓ Tracheostomy & mechanical ventilator
removed necessary as disease progresses
❑ Nursing Care
✓ Provide support & guidance to client ❑ Guillain-Barre Syndrome – acute infectious
✓ Relief/control of pain polyneuritis
✓ Meds as ordered, monitor effects ✓ Numbness and tingling in the fingers & toes
✓ Control nausea ✓ Muscular weakness & ascending type of
✓ Client teaching & discharge paralysis
RESPIRATORY DISORDERS (Restrictive) RESPIRATORY DISORDERS (TRAUMA)
Thoracic Deformity Types of Traumatic Injury
❑ Kyphoscoliosis ❑ Open wounds of the chest

✓ Abnormal convex curvature of the spine ❑ Hemothorax or Pneumothorax
❑ Fractured Ribs
❑ Pectus Excavatum ❑ Flail Chest
✓ “funnel chest” ❑ Cardiac Tamponade
✓ Concave deformity resulting from the ✓ Acute accumulation of blood or fluid in the
depression of the sternum pericardial sac [interferes diastolic filling];
✓ Occurs from blunt or penetrating trauma
RESPIRATORY DISORDERS (TRAUMA) RESPIRATORY DISORDERS (TRAUMA)
Fractured Ribs Fractured Ribs

➢ most common chest injury from blunt trauma
➢ ribs 4-8 most commonly fractured, least protected ❑ Management
➢ splintered or displaced fx’d ribs may penetrate the ✓ Narcotics
pleura and lungs ✓ Intercostal nerve block
❑ Nursing Care
❑ Assessment ✓ Provide pain relief
✓ Pain on inspiration ▪ Analgesics as ordered & monitor effects
✓ Point tenderness & bruising at injury sites ▪ Semi or high Fowler’s position
✓ Splinting w/ shallow respirations ✓ Monitor closely for complications
❑ Diagnostic Tests ▪ Assess for bloody sputum [lung
✓ CXR reveals area & degree of fx penetration]
✓  PCO2 ;  PO2 (later) ▪ Observe for s/s of pneumo/hemothorax
RESPIRATORY DISORDERS (TRAUMA) RESPIRATORY DISORDERS (TRAUMA)
Flail Chest Flail Chest

➢ fracture of several ribs → instability of affected
chest wall ❑ Assessment findings
➢ the flail portion and underlying tissues move ✓ Severe dyspnea: rapid shallow, grunty
paradoxically to the rest of the chest cage & lungs breathing
➢ flail portion is sucked in on inspiration and bulges ✓ Paradoxical chest motion
out on expiration ✓ Cyanosis, possible neck vein distention
✓ Tachycardia, hypotension
❑ Etiology ❑ Diagnostic Tests
✓ Trauma [sternal rib fx w/ possible ✓ PO2 decreased
costochondral separations] ✓ PCO2 elevated
✓ pH decreased
RESPIRATORY DISORDERS (TRAUMA) RESPIRATORY INTERVENTIONS
Flail Chest Respiratory Therapy
❑ Management 1. Suctioning
✓ Maintain an open airway ❑ Secretions too thick to cough out; inability of pt
✓ Suction secretions/blood from nose, throat, ❑ O2 prior suction; no more than 15 sec
mouth via ET ❑ Position pt w/ extended head & neck
✓ Note changes in amount, color and ❑ R bronchus [15 to vertical]; L bronchus [25-35]
characteristics 2. Tracheostomy Care
✓ Monitor mechanical ventilation 3. IPPB
✓ Encourage turning, coughing and deep ❑ O2 & air mixture is forced into pt’s lung during
breathing inspiration
✓ Monitor for signs of shock ❑  alveolar ventilation; promotes coughing of
secretion; deep adm’n of aerosol meds
Mechanical Ventilation [Respirators] Mechanical Ventilation [Respirators]
➢ Ventilation by mechanical means in those who are ❑ Nursing Care

unable to maintain N levels of O2 & CO2 in blood Assess for:
➢ COPD, neuromuscular dse, ARDS, thoracic ✓ Intermittent mandatory ventilation (IMV)
trauma.. ✓ Positive end expiratory pressure (PEEP)
✓ Continuous positive airway pressure
❑ Modes (CPAP)
✓ Assist/control mode
✓ Intermittent mandatory ventilation (IMV)
✓ Positive end expiratory pressure (PEEP)
✓ Continuous positive airway pressure (CPAP)
Mechanical Ventilation [Respirators] Endotracheal Tube [Artificial Airway]
❑ Nursing Care ➢ cuffed tube inserted by anesthesiologist

✓ Assess for  cardiac output ➢ Suction frequently
✓ Monitor for (+) water balance [I&O, daily ➢ deflate cuff 3-5 min q 1-2hrs
wts, peripheral edema, auscultate BS]
✓ Monitor for barotrauma ❑ Assessment
▪ Assess ventilator setting q 4hrs ✓ ABGs
▪ BS q 2hrs ✓ Hypoventilation & hyperventilation
▪ ABGs [Expiration is longer than insp. cycle – N]
▪ Pulmonary PE q shift ❑ Nursing Care
✓ Monitor GI problems (stress ulcer) ✓ Oral hygiene
✓ Suctioning [frequent]
✓ Humidification
Oxygen Therapy Chest Physiotherapy
➢ most common therapy with respiratory problems ➢ Postural drainage

➢ Percussion
❑ Indications ➢ Vibration
✓ Arterial hypoxemia [COPD,ARDS]
✓ Tissue, cellular & circulatory hypoxia ❑ Nursing Care
❑ Methods ✓ Perform before or 3-4hrs after meal
✓ Masks – 25-35% ✓ Bronchodilators 15-20 min before
✓ Cannula prong 30-40% at 6-8L/min ✓ Remove all tight clothings
✓ Catheter ✓ Percuss on area approx 3min during I& E
❑ O2 toxicity ✓ Vibrate on area during E of 4-5 deep
✓ Eye blindness;lung atelectasis; convulsion ✓ Assist pt in coughing positioning
✓ Provide good oral hygiene
Chest Tubes [Water-Seal Drainage Systems] Chest Tubes [Water-Seal Drainage Systems]
➢ Insertion of catheter into the intrapleural ❑ Nursing Care

space for evacuation of fluid or air ✓ Bottles are always kept below chest level
➢ 2nd or 3rd IC space anterior or mid-axillary line ✓ Check for kinks and leaks
[air]; 8th or 9th IC space [fluid] Water-seal bottle:
Fluid fluctuates up w/ Insp, down w/ Exp;
❑ Types Intermittent bubbling – N w/ exhalation,
coughing or sneezing;
✓ One-Bottle system [collection chamber
No fluctuation/intermittent bubbling –
& water seal]
reexpansion of lung or blockage
✓ Two-Bottle system [ 1 bottle – drainage Continuous bubbling – air leak
collection chamber; 1 bottle – water Suction control bottle:
seal] Air bubbles gently and continuously from
✓ Three-Bottle system [drainage collection, submerged tube
RESPIRATORY water seal and suction control bottle] 47 RESPIRATORY 48
Chest Tubes [Water-Seal Drainage Systems] Thoracic Surgical Procedures
❑ Characteristics of chest drainage 1. Exporatory thoracotomy: incision of the thoracic

✓ Initially very bloody wall, performed to locate bleeding, injuries,
✓ 500-1000ml in 1st 24hrs tumors
✓ When lung is expanded fluid fluctuation
ceases in water seal bottle 2. Thoracoplasty: removal of ribs or portion of ribs to
✓ Closed chest drainage is usually required reduce the size of the thoracic space
for 2-3 days postOP
❑ Removal of chest tube 3. Pneumonectomy: removal of entire lung
✓ Instruct pt to perform Valsalva [Bronchogenic Ca]
maneuver; apply vaseline pressure
dressing to site
✓ Pt is given pain meds prior to removal
RESPIRATORY ✓ Observe air leak after removal 49 RESPIRATORY 50
RESPIRATORY INTERVENTIONS ACID-BASE BALANCE
Thoracic Surgical Procedures Acids

❑ Proton donors
4. Lobectomy: removal of a lobe of the lung ❑ Give H+ in solution
[bronhiectasis, bronchogenic Ca, ❑ Electron acceptors
emphysematous blebs, lung abscess]
5. Segmented resection: removal of one or more Bases
segments of the lung [bronchiectasis] ❑ Proton acceptors
6. Wedge resection: removal of a small, localized ❑ Give OH- in solution
area of disease near the surface of the lung or ❑ Electron donors
lesion that occupies only part of a segment of
lung tissue [excision of nodules for biopsy]
7. Decortication: stripping off the fibrous membrane
that covers the pleura
OXYGENATION (Respiratory) OXYGENATION (ACID-BASE BALANCE)
ACID-BASE BALANCE Metabolic Production of Acids and Bases
Role of Acid-Base Balance Acids

❑ CO2 (H2CO3) [metabolism of fats & CHO]
❑ Acids & bases must be balanced to ❑ Sulfuric acids [S-containing amino acid]
maintain homeostasis in the body’s fluids ❑ Hydrochloric acid [cationic amino acid]
❑ Phosphoric acid [oxidation of phospholipids &
❑ Homeostasis is crucial for all life processes to phosphoproteins]
occur [eg. cellular metabolism, nerve & ❑ Organic acids [lactic acid, acetoacetic acid]
muscle conduction, smooth muscle & ❑ Fecal loss of HCO3-
cardiac muscle contraction]
Bases
❑ Acid-base balances cause changes in the ❑ HCO3- [metabolism of anionic amino a.,
performance of certain body functions citrates]
[eg. respiratory stimulation, changing
electrolyte levels] Production of non-volatile acids is highly dependent on the diet
Mechanism of pH Regulation Buffer Systems
❑ Neutralization by buffer systems in the blood, ❑ Bicarbonate BS

lymph, interstitial & intracellular fluids ✓ major EC buffer; 1st line defense
✓ Regulated by both kidneys & lungs
❑ Regulation of CO2 excretion by the lungs ✓ N ratio of [HCO3-]/pCO2 = 20:1 → pH 7
❑ Hemoglobin BS
❑ Excretion of acids & bases by the kidneys ✓ 2nd major BS in the plasma
✓ Neutralizes and disposes CO2 in the lungs
❑ Synthesis of ammonia by the kidneys ❑ Phosphate BS
✓ major intracellular BS
❑ Plasma Protein
✓ Minor role in the plasma
Acid-Base Disturbances Acid-Base Disturbances
❑ Three steps to identify the acid-base imbalance: Disturbance pH PaCO2 [HCO3-] Compensation
✓ Determine arterial blood pH [acidosis, (mEq/L) (mmHg)
alkalosis]
✓ Determine CO2 level [respiratory] Respiratory acidosis < 7.35  N  HCO3-
✓ Determine HCO3- level [metabolic]
Respiratory alkalosis > 7.45  N  HCO3-
❑ Normal Values: ABG
✓ Arterial pH [7.35-7.45] Metabolic acidosis < 7.35 N   pCO2
✓ Bicarbonate (HCO3-) [24-28 mEq/L] Hypervent
✓ Carbon dioxide (PCO2) [35-45 mmHg] Metabolic alkalosis > 7.45 N   pCO2
✓ Oxygen (PO2) [95%] Hypovent
✓ O2 saturation [93-98%]
Acid-Base Disturbances Respiratory Acidosis [ pH,  pCO2]
Example: pH = 7.30 ➢ Involve “hypoventilation” leading to retention of

pCO2 = 50 mmHg Paco2
[HCO3- ]= 25 mEq/L
❑ Symptoms:
Disturbance: Respiratory acidosis
✓ Slow, shallow, weak respirations
Compensation:  HCO3- absorption
✓ Declining level of consciousness
[kidneys]
✓ Mental lethargy, confusion, disorientation
Example: pH = 7.31 ✓ Associated signs of impaired oxygenation
pCO2 = 38 mmHg
[HCO3- ] = 20 mEq/L
Disturbance: Metabolic acidosis
Compensation:  pCO2 , hypoventilation
[lungs]
Respiratory Acidosis [ pH,  pCO2] Respiratory Alkalosis [ pH,  pCO2]
❑ Associated disease or conditions: ➢ involve “hyperventilation” leading to excessive

✓ COPD (Emphysema) loss of Paco2
✓ Pneumonia
✓ Head trauma → damage to respiratory ❑ Symptoms:
center ✓ Rapid, deep, “blowing” respirations
✓ Overdose → depression of respiratory ✓ Acute excitation, trembling nervousness
center ✓ Neuromuscular irritability
✓ Barbiturates, anesthetics, narcotics ✓ Numbness & tingling of extremities
✓ Respiratory or cardiac arrest
❑ Nursing Management:
✓ Assess the cause, correct it
✓ Provide O2 & support for ventilation
✓ Administer NaHCO3 as ordered
RESPIRATORY ✓ Monitor pts mental status & serial ABGs 61 RESPIRATORY 62
Respiratory Alkalosis [ pH,  pCO2] Metabolic Acidosis [ pH,  loss of HCO3-]
❑ Associated disease or conditions: ❑ Symptoms:

✓ Asthma (acute bronchial constriction) ✓ CNS depression [cardiac dysrhythmia,
✓ Brain injury (+) resp. center apathy & lethargy, disorientation, coma]
✓ Overdose of ASA, cocaine ✓ Kussmaul breathing
✓ Acute anxiety (“fight” or “flight” response) ✓ Acetone breathe [DM]
✓ High altitude (hyperventilation) ✓ Oliguria or anuria [renal failure]
❑ Nursing Management: ❑ Anion Gap = [Na+ + K+] – [Cl- + HCO3-]

✓ Assess the cause, correct it = 12-16 mEq/L
✓ Coaching pt’s breathing pattern to slow,  Anion gap acidosis – normochloremic
deep respiration, coaching breathing,
breath holding and paper bag breathing  Anion gap acidosis – hypoalbuminemia
✓ Reduce anxiety [anxiolytics/sedatives] [1gm/dl  albumin = 2mEq/L  AG]
N Anion gap - hyperchloremic
Metabolic Acidosis [ pH,  HCO3-] -  loss of HCO3- Metabolic Acidosis [ pH,  HCO3-] -  loss of HCO3-
❑ Associated disease or conditions ❑ Nursing Management:

✓ Severe or prolonged diarrhea ✓ Assess the cause, correct it
✓ Prolonged fasting [anorexia] ✓ Reversal of acidotic state;
✓ Normochloremic acidosis NaHCO3 administration [pH < 7.2]
▪ Diabetid ketoacidosis [ BHBA, AA] ✓ Close watch on VS & level of
▪ Alcoholic acidosis [ BHBA, AA] consciousness
▪ Shock, sepsis, CHF [ Lactic acid] ✓ Cardiac monitoring
▪ Methanol poisoning [ Lactic acid] ✓ Serial ABGs
✓ Hypoalbuminemia, hypercalcemia,
hypermagnesemia, hyperkalemia, lithium
toxicity, IgG myeloma
✓ GI HCO3- losses, defects in renal
acidification [N anion gap]
Metabolic Alkalosis [ pH,  HCO3-] Metabolic Alkalosis [ pH,  loss of HCO3-]
❑ Symptoms: ❑ Nursing Management

✓ CNS excitement [irritability, disorientation, ✓ Assess the cause, correct it
muscular twitching, seizures] ✓ Reversal of alkalotic state;
✓ Dysrhythmia ✓ Volume expansion w/ NaCl
[vomiting/diuretic induced]
❑ Associated disease or conditions: ✓ K+ repletion
✓ Gastric loss of HCl [vomiting, mechanical ✓ Carbonic anhydrase inhibitor
darinage,] ✓ Monitor VS
✓ Use of diuretics ✓ Serial ABGs
✓ Endo/exogenous mineralocorticoid excess
[hypokalemia]
✓ Acetated in parenteral alimentation
✓ Citrate in fresh whole blood [BT]

Medical Surgical Nursing Module 14

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OXYGENATION (Respiratory)

OXYGENATION (Respiratory) OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS RESPIRATORY INTERVENTIONS

Mechanical Ventilation [Respirators] Mechanical Ventilation [Respirators]

➢ Ventilation by mechanical means in those who are ❑ Nursing Care

OXYGENATION (Respiratory) OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS RESPIRATORY INTERVENTIONS

Mechanical Ventilation [Respirators] Endotracheal Tube [Artificial Airway]

❑ Nursing Care ➢ cuffed tube inserted by anesthesiologist

RESPIRATORY INTERVENTIONS RESPIRATORY INTERVENTIONS

Oxygen Therapy Chest Physiotherapy

➢ most common therapy with respiratory problems ➢ Postural drainage

OXYGENATION (Respiratory) OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS RESPIRATORY INTERVENTIONS

➢ Insertion of catheter into the intrapleural ❑ Nursing Care

OXYGENATION (Respiratory) OXYGENATION (Respiratory)

RESPIRATORY INTERVENTIONS RESPIRATORY INTERVENTIONS

Chest Tubes [Water-Seal Drainage Systems] Thoracic Surgical Procedures

❑ Characteristics of chest drainage 1. Exporatory thoracotomy: incision of the thoracic

RESPIRATORY INTERVENTIONS ACID-BASE BALANCE

Thoracic Surgical Procedures Acids

OXYGENATION (Respiratory) OXYGENATION (ACID-BASE BALANCE)

ACID-BASE BALANCE Metabolic Production of Acids and Bases

Role of Acid-Base Balance Acids

OXYGENATION (ACID-BASE BALANCE) OXYGENATION (ACID-BASE BALANCE)

Mechanism of pH Regulation Buffer Systems

❑ Neutralization by buffer systems in the blood, ❑ Bicarbonate BS

Acid-Base Disturbances Acid-Base Disturbances

OXYGENATION (ACID-BASE BALANCE) OXYGENATION (ACID-BASE BALANCE)

Acid-Base Disturbances Respiratory Acidosis [ pH,  pCO2]

Example: pH = 7.30 ➢ Involve “hypoventilation” leading to retention of

OXYGENATION (ACID-BASE BALANCE) OXYGENATION (ACID-BASE BALANCE)

Respiratory Acidosis [ pH,  pCO2] Respiratory Alkalosis [ pH,  pCO2]

❑ Associated disease or conditions: ➢ involve “hyperventilation” leading to excessive

Respiratory Alkalosis [ pH,  pCO2] Metabolic Acidosis [ pH,  loss of HCO3-]

❑ Associated disease or conditions: ❑ Symptoms:

❑ Nursing Management: ❑ Anion Gap = [Na+ + K+] – [Cl- + HCO3-]

OXYGENATION (ACID-BASE BALANCE) OXYGENATION (ACID-BASE BALANCE)

❑ Associated disease or conditions ❑ Nursing Management:

OXYGENATION (ACID-BASE BALANCE) OXYGENATION (ACID-BASE BALANCE)

Metabolic Alkalosis [ pH,  HCO3-] Metabolic Alkalosis [ pH,  loss of HCO3-]

❑ Symptoms: ❑ Nursing Management

NIO CRUZADA NOVENO, RN

WILFREDO D. QUIJENCIO JR. MD RN RM MAN

➢ To maintain oxygenation, the body requires a

➢ Oxygenation may be impaired when airways are

➢ Oxygenation may be impaired when the

➢ Oxygen therapy is necessary to restore

OXYGENATION (Respiratory) OXYGENATION (Respiratory)

RESPIRATION PROCESSES INVOLVED IN RESPIRATION

REGULATION OF RESPIRATION REGULATION OF RESPIRATION

❑ Medulla ❑ Central chemoreceptors

OXYGENATION (Respiratory) OXYGENATION (Respiratory)

OXYGENATION (Respiratory) OXYGENATION (Respiratory)

NURSING ASSESSMENT NURSING ASSESSMENT

2. Cough and secretions 3. Breath/Lung sounds

NURSING ASSESSMENT NURSING ASSESSMENT

4. Degree of chest pain and origin 6. Airway patency