MS SEMI-FINALS - Clearance mechanism

- Immunologic response (cell

CARE OF CLIENTS W/ RESPIRATORY mediated immunity at alveoli)
DISORDERS - Pulmonary protection

MAIN PROCESS Nostril - vestibule

● Respiration - gaseous exchange Vibrissae - hair
between the individual and Sinus - paranasal sinuses
environment - Phonation (sinus)
- Open areas within the skull that are
3 PROCESS OF RESPIRATION lined with mucous membrane
1. Ventilation- movement of gases in Pharynx - funnel shaped tube that extends
and out of the lungs from nose to larynx
- Inspiration (voluntary) - Opening for both respiratory and
- Exhalation (involuntary) digestive systems
2. Diffusion- exchange of gases from Larynx - covered by epiglotis
an area of higher pressure to lower - Close = swallowing
3. Perfusion- availability and - Open = speaking
movement of blood Trachea - 12cm/45inches long
- Divides to left and right bronchi
RESPIRATORY SYSTEM (STRUCTURES)
1. Airway Right bronchi is shorter than left bronchi
● Upper airway Right bronchi is broader
- Nasal cavity Right bronchi is more vertical
- Pharynx
- Larynx (voice box) 2. Pleura - serous membranes that
encloses our lungs
- Upper airway transport gases to ● Visceral pleura - directly
lower airway covers lungs
- Protect lower area from foreign ● Parietal pleura - lines the
bodies cavity of hemithorax
- Humidifies ● Pleural cavity/space -
contains few serous fluids
● Lower Airway that serves as a lubricant
- Trachea (carina-lower
end) (bifurcation) 3. Lungs
- R&L main bronchi ● Right lung - 3 lobes
- Segmental bronchi ● Left lung - 2 lobes
- Sub-segmental ● Mediastinum - separates the
bronchi 2 lungs
- Terminal bronchi - Alveoli - approx. 300 mil in our lungs
(alveoli, capillary - Right lung is broader
beds) - Right lung is shorter
PULMONARY FUNCTION STUDIES Accessory muscles during breathing
● Trapezius
1. Vital Capacity - maximum volume of ● Sternocleidomastoid
the air after the maximum inhalation ● Pectoralis major/minor
2. Tidal Volume - amount of air that ● Intercostal
moves in and out of the lungs with
each breath during normal, restful 5. Respiratory Centers
breathing ● Medulla oblongata - primary
3. Inspiratory Reserve Volume - extra respiratory center
volume that we inhaled ● Pons - contains central
4. Expiratory Reserve Volume - extra chemoreceptors
air that can be exhaled after normal
breathing Central Chemoreceptors - stimulated by
5. Functional residual Capacity - high carbon dioxide
amount of air that remains in the
lungs after normal exhalation Pons
6. Residual Volume - amount of air that ● Pneumotaxic - responsible for
remains in the lungs after a forceful rhythmic quality of breathing
exhalation ● Apneustic - deep, prolonged
breathing
Pneumocytes
● 2 types Peripheral Chemoreceptors - works when
- Pneumocytes I - lines the central chemoreceptors in the medulla are
alveoli / protection to alveoli damaged
- Pneumocytes II - production
of surfactants BIOGRAPHICAL DATA

Surfactants Cigarette Smoking - most common cause

● Lipoprotein that lowers the surface
tension of the alveoli ● History - past medical HX (childhood
● Reduces the amount of pressure diseases)
needed to inflate the alveoli - Past medical hx
● Decreases the tendency of alveoli - Primary complex (common in
to collapse kids)
- Pneumonia
4. Thorax and Diaphragm - Immunization
- Diaphragm is the main muscle of - Medications
respiration esp. during inspiration - allergies
- Diaphragm is being innervated to
Phrenic Nerves ● Family hx
- Thorax provides protection to lungs ● Psychosocial hx & lifestyle
● Geographical location
● Occupation
DIAGNOSTIC PROCEDURES - Local anesthesia - to
suppress gag reflex
Skin Test: Mantoux test
● Intradermal After Procedure
● Purified protein Derivatives (PPD) ● Pos. the pt. side-lying to prevent
● 48-72 hrs reading aspiration
● Instruct pt. not to wet the area ● NPO until gag reflex return
● (+) mantoux test: 10mm o more ● Teach pt. to do deep breathing and
● (+) mantoux test: exposure to coughing exercises
myobacterium tubercule bacilli
● Used to czech HIV + (5mm-9mm) Complication
● Low grade fever - most common
Quantiferon TB Test for PTB (QFT)
● Intradermal Bronchoscopy
● Blood test to detect infection with ● Direct inspection and observation of
tuberculosis the larynx, trachea, and bronchi
through a flexible and rigid
Chest X-ray bronchoscope.
● Remove metals ● Can be used as:
● Instruct pt. how to do deep breathing - Diagnostic - collect
exercises specimen, secretions,
determining the location of
Fluoroscopy - used to study the lung and the pathologic area
chest in motion - Therapeutic - remove
aspirated foreign objects,
Bronchography/Bronchogram excise of small lesions
● A radiopaque medium is installed
directly into the trachea, bronchi and Nursing Interventions (before procedure)
the bronchial tree or selected areas ● Consent
may be visualized ● NPO
● Pre-op meds
Nursing Intervention (before procedure) ● Remove dentures
● Check for allergies (seafoods,
iodine) After procedure
● NPO for 3-6 hrs ● Side lying pos.
● Informed consent ● NPO until gag reflex return
● Prepare oxygen and antispasmodic ● Watch out for possible perforation of
agent ready at bedside bronchial tree
● Give pre-op meds
- Atropine sulfate - decreases S/Sx:
body fluids ● Hemoptysis
- Diazepam - reduces anxiety, ● Sianosis
makes pt. relaxed and calm ● Dyspnea
● Hypotension
Lung Scan - following radioscope or ● For sputum C&S, it should be done
injection, scans are taken 2/ scintillation first before the first dose of
camera antimicrobial
- It measures blood perfusion through
the lungs Lung Biopsy

Possible findings: 3 ways to get specimen for biopsy

● Pulmonary Embolism ● Transbronchoscopic
● Other blood flow abnormalities ● Percutaneous Needle
● Open Lung
Interventions:
● Instruct pt. to remain still during the Lymph node biopsy - to assess/test
procedure metastasis (cervicomediastinal)
● Consent
Arterial Blood Gas Studies (ABG) - used
Sputum Examination to assess ventilation and acid-base balance
Look for: ● Withdraw blood from radial artery
● Gross appearance (color) ● Perform Allen’s test
- Rusty - pneumococcal - Assess for adequate
pneumonia collateral circulation of the
- Greenish - pseudomonas hand (ulnar artery)
infection - Apply pressure on both
- Blood-tinged - Pulmonary arteries
Tuberculosis (PTB) - Assess the time when the
hand returns to pinkish color
Sputum Culture and Sensitivity - to be (normal within 6 secs)
able to detect actual microorganism causing
the respiratory infection Things to prepare:
● 10mL pre-heparinized syringe to
Acid Fast Bacillus Staining (AFB) - used prevent clotting
for Pulmonary Tuberculosis ● Put specimen in the container w/ ice
to prevent hemolysis
Cytologic Examination: assess for the ● Take O2Sat
presence of cancer cells

Proper Examination:
● It should be done early in the
morning
● Hey may not rinse or rinse their
mouth (tap water)
● Use sterile container
● For AFB, it is done for consecutive
mornings
Thoracentesis - aspiration of fluid or air Lung Chest Physiotherapy - an airway
from the pleural space clearance technique to drain the lungs
● Excess in fluid - pleural effusion
● Excess in air - pneumothorax 3 ways steps of Chest Physiotherapy
● Excess in blood - hemothorax ● Postural drainage
● Percussion
Nursing responsibilities: ● Vibration
● Consent
● Monitor V/S Nursing Interventions (before procedure)
● Instruct pt. to remain still ● Verify doctor’s order
● Instruct pt. to avoid coughing ● Assess the accumulation of mucous
● Tell the pt. that pressure sensation secretions
might be felt during the insertion ● 10-15 mins each positions
● Upright pos. (leaning forward) ● Gradual changes in pos.
- Orthopneic pos. (tripod pos.) ● 60-90 mins (whole chest
physiotherapy)
After Procedure: ● Done before meal time
● Pos. the pt. in side-lying pos.
● Instruct the pt. to have bed rest until After procedure
v/s in normal ● Provide proper oral hygiene
● Instruct the pt. to report
expectoration of blood Closed-Chest Drainage / Thoracostomy
● Asses v/s Tube - used to remove air or fluids from
pleural cavity
Common Respiratory Interventions - To reestablish lung expansion
● Oxygen therapy - adult (2-3L / min) - To reestablish negative pressure
● Tracheobronchial Suctioning - (adult
- supine) (babies - semi/high fowler) ● Water = Hydrothorax
● Bronchial Hygiene Measures - insert ● Air = Pneumothorax
3-5 inches of suction catheter / ● Blood = Hemithorax
apply intermittent suctioning ● Pus = Pyothorax / Empyema
● Chest Physiotherapy
● Incentive Spirometry 3 principle of CCD
● CCD 1. Drainage by Gravity - bottle should
be 2-3 ft below the chest level
2. Displacement principle - an air
vent will expel the air from the bottle
as drainage occupies the space in
the bottle
3. The Suction / Negative Pressure -
it aids in removing the air/fluid from
the pleural space
Different types of CCD Things to prep for the removal of tube
● 1 bottle system ● Petrolatum gauze
● 2 bottle system ● Sterile suturing kit
● 3 bottle system ● Sterile gauze
● Adhesive tape
1 bottle system
● drainage/collection bottle Patient preparation
● Water-seal bottle ● Pos. the client in semi-fowler pos.
● The tube is 2-3 cm immersed on the ● Instruct to do deep exhalation
sterile NSS exercises
● Valvalsa maneuver
2 bottle system (w/o suction app.)
● Bottle 1 - drainage bottle (check the After
amount of level every shift) ● Assess for possible complication
● Bottle 2 - serves as water-seal - Respiratory distress
(observe any fluctuation and - Subcutaneous emphysema
intermittent bubbling in each
respiration) Deviated Septum - deflection or bending
on the normally straight nasal septum
With a suction app.
● Bottle 1 - drainage and water-seal Possible Etiology:
bottle ● Secondary to trauma
● Bottle 2 - suction control bottle ● Secondary to congenital
disproportion
3 bottle system
● Bottle 1 - drainage bottle S / Sx:
● Bottle 2 - water-seal bottle ● Obvious facial changes
● Bottle 3 - suction control bottle ● DOB because of obstruction
● Epistaxis
*Check if there is intermittent bubbling ● Nasal edema
for patency*
Management:
Nursing Interventions ● Nasal Septoplasty
● Encourage to perform DBE & CE ● Cold compress after trauma to
● Turn the pt. side-side frequent (q2) minimize edema/trauma
● Encourage to perform ADL ● Nasal allergy control
● Encourage ambulation
● Dont forget to mark the amount Nasal Fracture - usually caused by
drainage in regular basis substantial blow on the middle
● Avoid clamping & milking frequently
it may lead to Tension Unilateral - 1 side fracture
Pneumothorax Bilateral - both side fracture
Complex - involve subsequent damage of
adjacent facial structures
Possible Complications: Sinusitis - inflammation on the sinus lining
● Airway obstruction
● Epistaxis Etiology:
● Septal hematoma ● Secondary to URTI
● Cigarette smokers
S / Sx: ● Secondary to allergic rhinitis -
● Facial deformity inflammation - edema of sinus -
● Epistaxis hypersecretion of mucus
● Hematoma
● Edema S / Sx:
● Ecchymosis (racoon’s eye) ● Fever
● Clogged nose
Nursing Responsibilities: ● Headaches
● Check for drainage ● Facial pain
● Clear drainage might be CSF so it ● Nasal drip
need glucose test (+ - glucose)
Management:
Management: ● Provide rest and sleep
● Keep the pt. In upright pos. ● Increase OFI
(maintain airway) ● hot/warm wet packs
● Cod compress ● Warm NSS
● Prevent complication ● Pain reliever (codeine)
● Surgery (rhinoplasty) ● Antibiotics (amoxicillin)
● Dimetapp (3 days)
Epistaxis - nosebleed ● Functional Endoscopic Sinus
Surgery
Etiology: - Dont chew on the affected
● Trauma side
● Environmental trauma - Oral hygiene and be cautious
● Hypertension to prevent trauma on the
● Secondary to other diseases incision site
● Leukopemia - Not o use dentures for 10
days
Management: - Not to blow the nose for 2
● Lean head forward and apply weeks
pressure on the nose soft issue - Avoid sneezing for 2 weeks
(5-10mins)
● Cold compress to prevent Tonsillitis / Adenoiditis - avoid tonsillitis on
vasoconstriction kids prone for rheumatic heart disease
● Apply nasal pack w/ neosynephrine
(2-5days) S/Sx:
● Liquid to soft diet to facilitate ● Sore throat
swallowing ● Fever
● Dont blow nose for 2 days ● Dysphagia
 ● Mouth breathing Atelectasis - lung collapse
● Hoarseness of voice
● Noisy respiration Etiology:
● Draining ears ● Trauma
● Compressed lungs
Management: ● Secondary to bronchospasm -
● Provide rest and sleep airway destruction - decrease
● Increase OFI production of surfactant -
● Warm gargle hyperventilation (progressive
● Analgesics regional)
● Antimicrobial
● Surgery S/Sx:
● Restlessness
Pre-op Care: ● Pain from area of atelectasis
● Assess for URTI ● Tachypnea (shallow breathing)
● Check Partial Prothrombin TIme ● Tachycardia
● Dullness on percussion
Interventions: ● Absent bronchial breath sounds
● Consent ● Crackles at the base of alveoli
● Monitor v/s
● Maintain sterility of area Interventions: Hypoxia
● Frequent respiratory assessment
Post-op care: ● Respiratory hygiene measures (q1
● Lateral pos. alt. Prone pos. spirometer)
● Semi-fowler’s pos. (conscious and ● Maintain oxygen inhalation
awake) ● Pos. in not affected site
● NGT should be intact until gag reflex
returns Interventions: Complications
● Monitor v/s ● Antibiotics
● Administer pain reliever as ● Promote and encourage ambulation
prescribed (promotes lung expansion
● Encourage DBE ● Increase OFI
● Ice collars
● w/ gag reflex, offer cold foods and Health teachings:
fluids ● Report any s/sx
● Avoid red/dark beverages for few ● DBE and CE
weeks
● Assess for any s/sx of hemorrhage Pulmonary Edema
- Frequent swallowing ● Over hydration accumulation of fluid
- Frequent clearing of throat ● Pink frothy sputum
- Report vomiting ● Sudden transudation of fluid from
- Monitor v/s pulmonary capillaries into alveoli
 Pulmonary capillary permeability Pulmonary Embolism - undissolved mass
that travels in blood stream
Hydrostatic pressure
Obstructed blood flow to lungs
Blood colloidal osmotic pressure (thrombophlebitis/obesity)

Fluid accumulation in alveoli Pressure on pulmonary artery and reflex

constriction of blood vessels
Diffusion of gas
Pulmonary circulation
Hypoxia
Pulmonary infection

S/Sx: S/Sx:
● Restlessness ● Chest pain
● Dyspnea, orthopnea, fatigue ● Sudden onset of dyspnea
● Increased heart rate ● Restlessness
● Increased respiratory rate ● Irritable
● Pale skin ● Anxious
● Pink frothy sputum ● Rapid shallow breathing
● Friction rub
Nursing Interventions: ● crackles

Relieve Anxiety
● Morphine SO4
● DBE
● Frequent rest

Improve Cardiac Functions

● O2 inhalation
● Aminophylline
● D5W
● High fowlers pos.
● Digitalis
● Diuretics
● Nitroglycerin
● Reduce Na diet, reduce OFI

Health teachings:
● Medications
● Rest
● Diet
● Complications: edema, wt gain,
dyspnea