NCM 112 Care of Clients with Problems in Oxygenation, Fluid and

Electrolytes, Infectious, Inflammatory & Immunologic Reaction

ROBERTO B. AGRAVANTE JR RN
CLASS INSTRUCTOR
 OBJECTIVES
1. Distinguish the structures and functions of the upper respiratory tract, lower
respiratory tract, and chest wall.
2. Describe the process that initiates and controls inspiration and expiration.
3. Describe the process of oxygenation and ventilation.
4. Identify the respiratory defense mechanisms.
5. Describe the significance of arterial blood gas values in relation to respiratory
function.
6. Relate the signs and symptoms of inadequate oxygenation to physical
assessment findings.
7. Link age-related changes of the respiratory system to key differences in
assessment findings.
8. Obtain significant subjective and objective assessment data related to the
respiratory system.
9. Perform a physical assessment of the respiratory system using the appropriate
techniques.
10. Distinguish normal from common abnormal findings in a physical assessment
of a patient’s respiratory system.
11. Describe the purpose, significance of results, and nursing responsibilities
related to diagnostic studies of the respiratory system.
 Conceptual Focus
Functional Ability
Gas Exchange
The primary purpose of the respiratory system is
gas exchange. This involves the transfer of
oxygen (O2) and carbon dioxide (CO2) between
the atmosphere and blood. While adequate
perfusion is needed to distribute O2 to the body
tissues, adequate oxygenationdepends on a
healthy, functioning respiratory system.
Structures and Functions of
Respiratory System

Respiratory System
The respiratory system
is divided into 2 parts:
the upper respiratory
tract and the lower
respiratory tract
 Physiology of Respiration


Oxygenation
Oxygenation refers to the process of obtaining O2 from the atmospheric air and making it available
to the organs and tissues of the body. The lungs’ ability to oxygenate arterial blood adequately is
evaluated by partial pressure of O2 in arterial blood (PaO2), arterial O2 saturation (SaO2), and
patient assessment

 Ventilation
Ventilation involves inspiration, or inhalation (movement of air into the lungs), and expiration, or
exhalation (movement of air out of the lungs). Air moves in and out of the lungs because
intrathoracic pressure changes in relation to pressure at the airway opening. Contraction of the
diaphragm and external intercostal and scalene muscles increases chest dimensions, thus decreasing
intrathoracic pressure. Gas flows from an area of higher pressure (atmospheric) to one of lower
pressure (intrathoracic).
Manifestations of Inadequate
Oxygenation
Gerontologic Considerations:
Effects of aging on Respiratory
System

Age-related changes in the respiratory system can be divided
into
alterations in structure, defense mechanisms, and respiratory
control
 Structural changes include calcification of the costal
cartilages, which can interfere with chest expansion. The
outward
curvature of the spine is marked, especially with osteoporosis,
and the lumbar curve flattens. Therefore the chest may appear
barrel shaped, and the older person may need to use accessory
muscles to breathe.
Respiratory muscle strength progressively declines after age
50.
Overall, the lungs in the older adult are harder to inflate.
Assessment of
Respiratory System

Determining a patient’s needs related to the respiratory
system requires an accurate health history and a thorough
physical examination. A respiratory assessment can be
done as part of a comprehensive physical examination or
as a focused respiratory examination.
 Use judgment in determining whether all or part of
the history and physical examination will be completed,
based on your immediate assessment of the patient’s
degree of respiratory distress. If respiratory distress is
severe, only obtain pertinent information and defer a
thorough assessment until the patient’s condition
stabilizes.
Subjective Data

Important Health Information
Past Health History
It is important to determine the frequency of
upper respiratory problems (e.g., colds, sore
throats, sinus problems, allergies) and whether
seasonal changes influence these problems.
Ask about a
history of lower respiratory problems, such as
asthma, COPD, pneumonia, and tuberculosis
(TB).
 Ask the patient with allergies about possible
precipitating factors or triggers, such as
medications, pollen, smoke, mold, or pet
exposure. Record the characteristics and
severity of the allergic reaction, such as runny
nose, wheezing, scratchy throat, or chest
tightness. Determine the frequency of asthma
exacerbations.
Subjective Data

Because respiratory symptoms are often
manifestations of problems that involve other body
systems, it is important to ask about a history of
other health problems. For example, the patient with
heart problems may have dyspnea (shortness of
breath) because of heart
failure.
 The patient with human immunodeficiency virus
(HIV) infection may have frequent respiratory tract
infections because of compromised immune
function.
 Health History Respiratory System

Health Perception–Health Management

• Describe your daily activities. Have breathing
problems prevented you from doing activities that you used
to be able to do? Are your breathing problems better, worse,
or about the same compared with 6 months ago?
• How do your breathing problems affect your self-care
abilities?
• Have you ever smoked? Do you smoke now? If so, what have
you smoked? Cigarettes? Cigars? Pipes? Electronic cigarettes?
• If yes, how many cigarettes each day and for how long? Are
you interested in stopping smoking? Are there aids we can tell
you about that would assist your quitting? Would you be
willing to come back for a visit so that we can explore your
quitting? If you stopped smoking, did you do so because of
your health?
 How did you stop?
• Have you ever used chewing tobacco?
• Have you ever smoked street drugs?∗
• Do you get the flu shot yearly? When was your last flu shot?
Have you had a Pneumovax vaccination?
• What equipment helps you manage your respiratory
problems?
 Health History
Respiratory System

Nutritional-Metabolic
• Have you recently lost weight because of trouble eating
related to your respiratory problem? How much weight have
you lost?
Have you lost this weight voluntarily?
• Do any foods affect your breathing?∗ Sputum production?
Elimination
• Does your breathing problem make it hard for you to get to
the toilet?
• Are you inactive because of shortness of breath to the point
that you have incontinence? Constipation?
Health History Respiratory System


Activity-Exercise
• Are you ever short of breath during exercise?∗ At rest?∗
• Do you get too short of breath to do the things you want to do?∗
• Is your home 1 story? 2 stories? How many steps from the street
to your door?
• Can you walk up a flight of steps without stopping?
• Are you able to maintain your typical activities of daily living? If
not, what are you able to do independently? What do you need
help with? What have you had to give up?
• What do you do when you get short of breath? Does this help?
How long does it take you to recover after you have been short of
breath?
Health History Respiratory System


Sleep-Rest
• Do breathing problems cause you to wake up during the night?∗
• Can you lie flat at night? If not, how many pillows do you use?
• Do you need to sleep upright in a chair?∗
• Are you or your partner aware of any snoring?
• Do you awaken in the morning feeling rested?
• Do you ever wake up in the morning with a headache?∗
• Do you fall asleep easily during the day?
Health History
Respiratory System

Cognitive-Perceptual
• Do you have any pain associated with breathing?∗
On a scale from 0 to 10, with 0 being “no pain” and
10 being “the worst pain you can imagine,” where
would you rate your pain? Does it hurt more on
inspiration?∗ Expiration?∗ Or both?∗
• If you are having pain with breathing, describe the
pain.
• Has the pain gotten better, worse, or stayed about
the same over the past 6 months?
• Do you ever feel restless, irritable, or confused
without a reason?∗
• Do you have difficulty remembering things?∗
 Health History
Respiratory System

Self-Perception–Self-Concept
• Describe how your respiratory
problems have changed your life.
• If you use O2, do you ever go out
without bringing it with you?
How often does this occur? Why?
Role-Relationship
 • Has your respiratory problem
caused any problems in your
work, family, or social relationships?
Health History Respiratory
System

 Sexuality-Reproductive
• Has your respiratory problem caused a change in your
sexual activity?∗
• Have you and your partner talked about ways to minimize
your breathing problems during sexual activity?
 Coping–Stress Tolerance
• On a daily/weekly basis, how often do you leave your home?
• Do you feel under any stress right now?
• Does stress influence your breathing?∗
• Do you notice if your emotions have any effect on your
respiratory problems?
• Are you aware of any respiratory support groups in your area?
Health History
Respiratory System
 Value-Belief
• What do you think causes/has caused your respiratory
problem(s)?
• How are you feeling right now?
• Do you think the things you have been told to do for your
respiratory problems help? If not, why?
• What are you looking for/expecting from the HCP today,
in terms of your breathing problem(s)?

 If answer is “yes” to any of the above questions, ask the

patient to describe
Health History Respiratory
System
 Medications
Take a thorough medication history, including the names of
prescription and over-the-counter (OTC) medications and
non-prescription (illicit) substances.
 Ask about the dose (if known),
frequency, length of time taken, any side effects, and the reason
for taking the medication.
 Assess for overuse of short-term
bronchodilators as a key indicator of symptom control. Cough is
a common side effect of angiotensin-converting enzyme
(ACE) inhibitors. Encourage the patient to bring all medication bottles
and any inhalers to each visit with an HCP.
 If the patient is using O2 for a breathing problem, record the
fraction of inspired O2 concentration (FIO2), flow rate (liters per
minute), method of administration, number of hours used per day,
and effectiveness of the therapy. Assess safety practices, including
the patient’s cognitive and physical ability related to using O2 and
any metered-dose inhalers.
Health History Respiratory
System
 Surgery or Other Treatments
Find out if the patient has been hospitalized for a
respiratory problem. Note the dates, therapy
(including surgery), and status of the problem.
 Determine if the patient has ever been intubated
because of a respiratory problem. Ask about the
use of and response to respiratory treatments,
such as a nebulizer, humidifier, airway
clearance modalities, high-frequency chest wall
oscillation, postural drainage, and percussion.
Health History
Respiratory
System
 Genetic Risk Alert
• Respiratory problems that have a strong genetic
link include cystic fibrosis, COPD from α1-
antitrypsin deficiency, and asthma.
• If people have a family history of these
respiratory problems, they have a greater risk for
developing them.
• Although cigarette smoking is a major risk factor
for COPD, only a minority of cigarette smokers
develop symptomatic disease.
 The risk for COPD related to cigarette smoking is
genetically related.
 Determine if there is a family history of any
respiratory problems
that may have genetic or familial tendencies.
Respiratory Assessment

Objective Data

 Physical Examination
Vital signs are important data to collect before
examining the respiratory system.

 Nose
Inspect the nose for patency, inflammation,
deformities, symmetry,
and discharge. Check each nare for air patency
with respiration while
briefly occluding the other nare. Tilt the
patient’s head backward and
push the tip of the nose upward gently.
 Physical
Examination

Objective Data

 With a nasal speculum and a good light, inspect the

interior of the nose. The mucous membrane should
be pink and moist, with no evidence of edema
(bogginess), exudate, or bleeding. Inspect the nasal
septum for deviation, perforations, and bleeding.
Some septal deviation is normal in an adult. Inspect
the turbinates for polyps, which are abnormal,
fingerlike projections of swollen nasal mucosa.
 Polyps may result from long-term irritation of the
mucosa (e.g., from allergies). Assess any discharge
for color and consistency. Purulent
and malodorous discharge could occur with a
foreign body. Watery discharge could be related to
allergies or from cerebrospinal fluid.
Bloody discharge could be from trauma or dryness.
Thick mucosal discharge could mean an infection
Physical Examination

Objective Data

 Mouth and Pharynx

Using a good light source, inspect the interior of the
mouth for color, lesions, masses, gum retraction,
bleeding, and poor dentition. Inspect
the tongue for symmetry and lesions.
 Observe the pharynx by pressing a tongue blade
gently against the middle of the back of the tongue.
If the oropharynx is tight, have the patient yawn,
since this usually allows more structures to be
visible.
 Techniques in Physical
Examination
 Inspection
First, observe the patient’s appearance and note any evidence
of respiratory distress, such as tachypnea or use of accessory
muscles. Next, determine the shape and symmetry of the chest.
Chest movement should be equal on both sides, and the anterior-
posterior (AP) diameter should be less than the side-to-side or
transverse diameter. Normal AP ratio is 1:2. An increase in AP diameter
(e.g., barrel chest) may be due to normal aging or result from
lung hyperinflation.
 Look for abnormalities in the sternum (e.g., pectus carinatum [a
prominent protrusion of the sternum]) and pectus excavatum (an
indentation of the lower sternum above the xiphoid process). Note any
spinal curvature. Spinal curvatures that affect breathing include
kyphosis, scoliosis, and kyphoscoliosis.
Techniques in Physical
Examination

 Observe the respiratory rate, depth, and rhythm. The

normal adult respiratory rate is 12 to 20 breaths/min.
Inspiration (I) should take half as long as expiration (E) (I/E
ratio = 1:2). Observe for abnormal breathing patterns, such
as Kussmaul (rapid, deep breathing), CheyneStokes
(abnormal respirations characterized by alternating periods
of apnea and deep, rapid breathing), or Biot’s (irregular
breathing with apnea every 4 to 5 cycles) respirations.
 Skin color provides clues to respiratory status. Cyanosis, a
late sign of hypoxemia, is best seen in light-skinned
patients as a bluish tinge to the mucous membranes, lips,
and palms of the hands.
 Techniques in Physical
Examination
 Palpation
Determine tracheal position by gently placing the index fingers
on either side of the trachea just above the suprasternal notch and
gently pressing backward. Normal tracheal position is midline; deviation
to the left or right is abnormal. Tracheal deviation occurs away from
the side of a tension pneumothorax or a neck mass, but toward the side
of a pneumonectomy or lobar atelectasis.
 Symmetry of chest expansion and extent of movement aredetermined
at the level of the diaphragm. Place your hands over the lower anterior
chest wall along the costal margin and move them inward until the
thumbs meet at midline. Ask the patient to breathe deeply. Observe the
movement of the thumbs away from each other.
Normal expansion is 1 in (2.5 cm). Hand placement on the
posterior side of the chest is at the level of the tenth rib. Move the
thumbs until they meet over the spine (Fig. 25.5). You can check
expansion
 Techniques in Physical
Examination
 Fremitus is the vibration of the chest wall made by
vocalization. You can feel tactile fremitus by placing the palmar
surface of your hands against the patient’s chest with the
fingers hyperextended. Ask the patient to repeat a phrase, such
as “boy-oh-boy,” “toy boat,” or “blue balloons,” in a deeper,
louder-than-normal voice. At the same time, move your hands
from top to bottom on the patient’s chest (Fig. 25.6). As you
palpate, simultaneously compare vibrations (right side vs. left
side, from top to bottom).
 https://youtu.be/ITQWS_jdPXs
 Techniques in Physical Examination

 Percussion
Percussion is used to assess
the density or aeration of the
lungs. Percussion sounds are
described in Table 25.5
Techniques in
Physical
Examination

 The anterior chest is percussed

with the patient in a semi-
sitting or supine position.
Starting above the clavicles,
percuss downward, intercostal
space by intercostal space (Fig.
25.7).
Techniques in
Physical
Examination

 The area over lung

tissue should be resonant,
except for the area of cardiac
dullness (Fig.
25.8). To percuss the
posterior chest, have the patient
sit leaning
forward with arms folded.
Techniques in
Physical
Examination

THE AREA OVER LUNG

TISSUE SHOULD BE RESONANT,
EXCEPT FOR THE AREA OF
CARDIAC DULLNESS (FIG.
25.8). TO PERCUSS THE
POSTERIOR CHEST, HAVE THE
PATIENT SIT LEANING
FORWARD WITH ARMS FOLDED.
THE POSTERIOR CHEST SHOULD
BE RESONANT
OVER LUNG TISSUE TO THE
LEVEL OF THE DIAPHRAGM (FIG.
25.9).
 Techniques in Physical
Examination
Auscultation
During chest auscultation, have the patient
breathe slowly and a little
more deeply than normal through the mouth.
Auscultation should
proceed from the lung apices to the bases,
comparing opposite areas
of the chest. If the patient is in mild
respiratory distress or you think
the patient will tire easily, start at the bases.
Place the stethoscope over
lung tissue, not over bony prominences. At
each placement of the
stethoscope, listen to at least 1 cycle of
inspiration and expiration.
Visualize the location of normal breath
sounds by using a lung model
(Fig. 25.10).
Diagnostic Studies of the Respiratory System
Diagnostic Studies of the Respiratory System
Diagnostic Studies of
the Respiratory System

Two methods are used to assess the efficiency of

gas transfer in the lung and tissue oxygenation:
(1) pulse oximetry and (2) analysis of arterial
blood gases (ABGs)
These are primarily used to assess for hypoxia.
For the patient with normal or near-normal
cardiac function, assessing PaO2 or SaO2 is
usually enough to determine the
level of oxygenation. With either one, we can also
use CO2 monitoring to assess for hypercapnia to
determine patient’s oxygenation and
ventilatory status.
OXIMETRY

Oximetry
Arterial O2 saturation can be monitored
noninvasively and continuously using a pulse
oximetry probe on the finger, toe, ear,
forehead, or bridge of the nose. The abbreviation
SpO2 is used to indicate the O2 saturation of
hemoglobin as measured by pulse oximetry. SpO2
and heart rate are displayed on the monitor as
digital readings. Normal SpO2 values are 94% to
99%
ARTERIAL BLOOD GAS

•ABGs are obtained to determine oxygenation

status and acid-base balance. ABG analysis
includes measurement of the PaO2, PaCO2
(the partial pressure of CO2 in arterial blood),
acidity (pH), bicarbonate
(HCO3-), and SaO2. . Blood for ABG analysis
can be obtained by arterial puncture or
from an arterial catheter, which is usually
inserted into the radial or femoral artery. Both
techniques allow only intermittent analysis, but
an arterial catheter permits ABG sampling
without repeated arterial punctures.
ARTERIAL BLOOD GAS
ARTERIAL BLOOD GAS
 SPUTUM STUDIES
Observe the patient’s sputum for color,
volume, viscosity, and presence or absence of
blood. We can obtain a sputum sample
by expectoration, tracheal suction, or
bronchoscopy. When the patient is
unable to expectorate spontaneously, sputum
may be collected by inhaling an irritating
aerosol, usually hypertonic saline. This is
called sputum induction.
SPUTUM STUDIES
SKIN TEST
•Skin tests may be done to test for allergic reactions or exposure to TB bacilli or fungi. Skin tests
involve the intradermal injection of an antigen. For example, a positive result on a TB skin test
means that the patient has been exposed to the antigen. It does not mean that the patient has TB.
A negative result means either no exposure or a depression of cell-mediated immunity, which
occurs in HIV infection.
•Our responsibilities are similar for all skin tests. First, to prevent a false-negative reaction, be sure
that the injection is intradermal and not subcutaneous. After the injection, circle the site(s) and tell
the patient not to remove the marks. When charting administration of the antigen, draw a diagram
of the forearm and hand, and label the injection site. The diagram is especially helpful whene the
patient receives more than 1 test.
•When reading test results, use a good light. If an induration is present, use a marking pen to
indicate the periphery on all 4 sides of the induration. As the pen touches the raised area, make a
mark. Then
determine the diameter of the induration in millimeters. Do not measure reddened, flat areas.
SKIN TEST
SKIN TEST
 BRONCHOSCOPY
Bronchoscopy is a procedure in which the bronchi are visualized through a
fiberoptic tube.
Bronchoscopy may be used for diagnostic purposes (obtain biopsy
specimens) and for treatment (e.g., to remove mucous plugs, foreign bodies).
Laser therapy, electrocautery, cryotherapy, and stents may be placed through
a bronchoscope to achieve patency of an airway that has been partially or
nearly fully obstructed by tumors
Bronchoscopy can be done in an outpatient procedure room, in a surgical
suite, or at the bedside in the critical care unit or on a medical-surgical unit.
The patient may be positioned supine, in lowFowler’s, or even be seated. The
HCP inserts the bronchoscope
through the nose or mouth. Depending on the approach, the nasopharynx or
oropharynx is anesthetized with local anesthetic spray. The bronchoscope is
coated with water-soluble lubricant and inserted down into the airways. Small
amounts (30 mL) of sterile saline may be injected through the scope and
withdrawn and examined for cells, a technique termed bronchoalveolar
lavage (BAL). Bronchoscopy can be done through the endotracheal tube of
a mechanically ventilated patient.
 Thoracentesis
 Thoracentesis is the insertion of a large-bore
needle through the chest wall into the pleural
space to obtain specimens for diagnostic
 evaluation, remove pleural fluid, or instill
medication . The patient is positioned sitting
upright, leaning on an overbed table with feet
supported. The skin is cleansed and a local
anesthetic (lidocaine) is injected subcutaneously. A
percutaneous catheter may be left in to allow
further drainage of fluid.
 Pulmonary Function Test

 Pulmonary function tests (PFTs) measure lung volumes

and airflow. The results of PFTs can diagnose pulmonary
disease, monitor disease progression, assess response
to bronchodilators, and evaluate disability. Airflow
measurement is obtained by trained personnel using a
spirometer.
 The patient inserts a mouthpiece, takes as deep a breath
as possible, and exhales as hard, as fast, and for as long
as possible. Verbal coaching is given to
ensure that the patient continues blowing out until
exhalation is complete. Computer software calculates the
patient’s percent of predicted values, that is, how well the
performance compares with an average based on age,
gender, race, and height.14 Normal values are 80% to
120% of the predicted value.
Pulmonary Function Test
Pulmonary Function Test
 Chest X Ray

 An X-ray is an imaging test that uses small amounts of

radiation to produce pictures of the organs, tissues, and
bones of the body. When focused on the chest, it can
help spot abnormalities or diseases of the airways, blood
vessels, bones, heart, and lungs. Chest X-rays can also
determine if you have fluid in your lungs, or fluid or air
surrounding your lungs.
 Chest X-rays require very little preparation on the part of
the person getting it.
 You will need to remove any jewelry, eyeglasses, body
piercings, or other metal on your person. Tell your doctor
if you have a surgically implanted device, such as a heart
valve or pacemaker. Your doctor may opt for a chest X-
ray if you have metal implants. Other scans, such
as MRIs, can be risky for people who have metal in their
bodies.