Assessment of

Respiratory Function
Anatomic and Physiologic Overview
Composed of:
(1) upper respiratory tract
(2) lower respiratory tract

Together, the two tracts are responsible for ventilation

*movement of air in and out of the airways
Anatomic and Physiologic Overview
The upper tract (upper airway) warms and filters
inspired air so that…..
The lower respiratory tract (the lungs) can accomplish
gas exchange.

Gas exchange
involves delivering oxygen to the tissues through the
bloodstream and expelling waste gases, such as carbon
dioxide, during expiration
UPPER RESPIRATORY TRACT
• Upper airway structures consist of the
1. Nose
2. sinuses and nasal passages
3. pharynx, tonsils and adenoids,
4. larynx, and
5. trachea.
LOWER RESPIRATORY TRACT
• The lungs are paired elastic
structures enclosed in the
thoracic cage, which is an
airtight chamber with
distensible walls
LOWER RESPIRATORY TRACT
• Size of a football (approx.)
• The lung fill the area from the collarbone to the
bottom of the ribs.
• Lung is the only organ in the body light enough to
float.
LOWER RESPIRATORY TRACT
LUNGS
Each lung is divided into
lobes
Right---3 lobes
Left---2 lobes
The left lobe is slightly
smaller than the right lobe.
 PLEURA

• Serous membrane that lined

the lungs and wall of the
thorax.
• The visceral pleura covers the
lungs; the parietal pleura lines
the thorax.
 MEDIASTINUM
• The mediastinum is in the
middle of the thorax, between
the pleural sacs that contain
the two lungs.
• Heart, thymus, the aorta and
vena cava, and esophagus.
BRONCHI AND BRONCHIOLES
• There are several division of the bronchi within each lobe of the lung
1. Right and left bronchi
2. Lobar bronchi (three in the right and two in the left lung)
3. Segmental bronchi (10 on the right and 8 on the left)
4. Subsegmental bronchi
5. Bronchioles
6. Terminal bronchioles
7. Respiratory bronchioles------ dead space (150mL of air)
8. Alveolar ducts and sacs
ALVEOLI
Oxygen and carbon dioxide exchange takes place in
the alveoli.
arranged in clusters of 15 to 20
ALVEOLI
Three types of alveolar cells---(Pneumocyte)
• Type I, II, and III
FUNCTION OF THE RESPIRATORY SYSTEM
The respiratory system performs this function by
facilitating life-sustaining processes such as:
1. oxygen transport
2. respiration and ventilation, and
3. gas exchange.
INSPIRATION TO EXPIRATION RATIO IS
1:2
LUNG VOLUMES AND LUNG CAPACITIES
Lung function which reflects the mechanics of
ventilation, is viewed in terms of lung volumes and
lung capacities.
Lung volumes:
tidal volume,
inspiratory reserve volume,
expiratory reserve volume, and
residual volume.
LUNG VOLUMES AND LUNG CAPACITIES
Lung function which reflects the mechanics of
ventilation, is viewed in terms of lung volumes and
lung capacities.
Lung capacity:
• vital capacity,
• inspiratory capacity,
• functional
• residual capacity, and
• total lung capacity
LUNG VOLUMES
Tidal volume (VT or TV)
• The volume of air inhaled and exhaled with each
breath
• 500 mL or 5–10 mL/kg
LUNG VOLUMES
Inspiratory reserve volume (IRV)
• The maximum volume of air that can be inhaled after
a normal inhalation
• 3,000 mL
LUNG VOLUMES
Expiratory reserve volume (ERV)
• The maximum volume of air that can be exhaled
forcibly after a normal exhalation
• 1,100 mL
LUNG VOLUMES
Residual volume (RV)
• The volume of air remaining in the lungs after a
maximum exhalation
• 1,200 mL
LUNG CAPACITIES
Vital capacity (VC)
• The maximum volume of air exhaled from the point of
maximum inspiration
• 4,600 mL
LUNG CAPACITIES
Inspiratory capacity (IC)
• The maximum volume of air inhaled after normal
expiration
• 3,500 mL
LUNG CAPACITIES
Functional residual capacity (FRC)
• The volume of air remaining in the lungs after a
normal expiration
• 2,300 mL
LUNG CAPACITIES
Total lung capacity (TLC)
• The volume of air in the lungs after a maximum
inspiration
• 5,800 mL
PULMONARY DIFFUSION and PERFUSION
PULMONARY DIFFUSION
• process by which oxygen and carbon dioxide are
exchanged from areas of high concentration to areas
of high at the air–blood interface.
PULMONARY PERFUSION
• is the actual blood flow through the pulmonary
circulation.
VENTILATION-PERFUSION RATIO

VENTILATION MATCHES PERFUSION

1:1
Gas Exchange
• Partial pressure of gases
• Pressure exerted by each type of gas in a mixture of
gases.
Partial Pressure Abbreviations
• P = pressure
• PO2 = partial pressure of oxygen
• PCO2 = partial pressure of carbon dioxide
• PAO2 = partial pressure of alveolar oxygen
• PACO2 = partial pressure of alveolar carbon dioxide
• PaO2 = partial pressure of arterial oxygen
• PaCO2 = partial pressure of arterial carbon dioxide
• Pv–O2 = partial pressure of venous oxygen
• Pv–CO2 = partial pressure of venous carbon dioxide
• P50 = partial pressure of oxygen when the hemoglobin is 50% saturated
Neurologic Control of Ventilation
• Resting respiration is the result of cyclical excitation of
the respiratory muscles by the phrenic nerve.
• The rhythm of breathing is controlled by respiratory
centers in the brain.

Medulla oblongata and Pons

Assessment
Assessment
HEALTH HISTORY
• Dyspnea
• Cough
• Sputum production
• Chest pain
• Wheezing
• Hemoptysis
HEALTH HISTORY
Bacterial infection
• Profuse amount of purulent sputum (thick and yellow,
green or rust colored)
Viral bronchitis
• Thin mucoid sputum
Chronic bronchitis/bronchiectasis
• Gradual increase of sputum over time
HEALTH HISTORY
Lung tumor
• Pink-tinged mucoid sputum
Pulmonary edema
• Profuse, frothy, pink material
Lung abscess
• Foul smelling sputum and bad breath
PHYSICAL ASSESSMENT OF THE LOWER
RESPIRATORY STRUCTURES AND BREATHING
PHYSICAL ASSESSMENT OF THE LOWER
RESPIRATORY STRUCTURES AND BREATHING
CHEST CONFIGURATION
• the ratio of the anteroposterior diameter to the lateral
diameter is 1:2.
four main deformities of the chest associated:
• barrel chest,
• funnel chest (pectus excavatum),
• pigeon chest (pectus carinatum), and
• kyphoscoliosis
Chest configuration
Barrel Chest
occurs as a result of overinflation of the lungs.
increase in the AP diameter of the thorax
Emphysema
Hallmark sign of Emphysema
Chest configuration
Funnel Chest (Pectus Excavatum)
occurs when there is a depression in the lower
portion of the sternum.
compress the heart and great vessels, resulting in
murmurs.
May occur with rickets or Marfan’s syndrome.
Funnel Chest (Pectus Excavatum).
Chest configuration

Pigeon Chest (Pectus Carinatum).

• occurs as a result of displacement of the sternum.
• increase in the AP diameter.
• may occur with rickets, Marfan’s syndrome, or severe
kyphoscoliosis
Pigeon Chest (Pectus Carinatum).
Chest configuration

Kyphoscoliosis
• characterized by elevation of the scapula and a
corresponding S-shaped spine.
• limits lung expansion within the thorax.
• may occur with osteoporosis and other skeletal
disorders that affect the thorax
Kyphoscoliosis
BREATHING PATTERN AND RESPIRATORY
RATES
Average: 12-20 breaths per minute or 14-20 breaths per minute
• Eupnea: normal cycle of breathing
• Bradypnea: slow breathing
• Tachypnea: rapid breathing
• Apnea: temporary pauses of breathing
• Obstructive sleep apnea: apneas occur repeatedly during
sleep, secondary to transient upper airway blockage
TACTILE FREMITUS/FREMITUS
• Sound generated by the larynx travels distally along
the bronchial tree to set the chest wall in resonant
motion.
TACTILE FREMITUS: detection of the resulting vibration
on the chest wall by touch
TACTILE FREMITUS/FREMITUS
• “ninety-nine” or “one, two, three,” or “eee, eee, eee”
• The vibrations are detected with the palmar
surfaces of the fingers and hands, or the
ulnar aspect of the extended hands, on the
thorax.
• BONES ARE NOT ASSESSED!
TACTILE FREMITUS/FREMITUS
BREATH SOUNDS
Normal breath sounds are identified as:
vesicular,
bronchovesicular, and
bronchial (tubular) breath sounds
Abnormal (Adventitious) Breath Sounds
• An abnormal condition that affects the bronchial tree
and alveoli may produce adventitious (additional)
sounds.
• Adventitious sounds are divided into two categories:
1. Crackles: discrete, noncontinuous sounds
2. Wheezes: continuous musical sounds
Abnormal (Adventitious) Breath Sounds
CRACKLES (RALES)
•Coarse crackles
• Discontinuous popping sounds heard in early inspiration;
harsh, moist sound originating in the large bronchi
•Fine crackles
• Discontinuous popping sounds heard in late inspiration;
sounds like hair rubbing together; originates in the
alveoli
Abnormal (Adventitious) Breath Sounds
WHEEZES
Sibilant wheezes
• Continuous, musical, high-pitched, whistle like sounds
heard during inspiration and expiration caused by air
passing through narrowed or partially obstructed
airways; may clear with coughing
• Bronchospasm, asthma, and build up of secretions
Abnormal (Adventitious) Breath Sounds
WHEEZES
Sonorous wheezes (rhonchi)
• Deep, low-pitched rumbling sounds heard primarily
during expiration; caused by air moving through
narrowed tracheobronchial passages
• Secretions or tumor
Abnormal (Adventitious) Breath Sounds
FRICTION RUBS (Pleural friction rub)
• Harsh, crackling sound, like two pieces of leather
being rubbed together.
• May subside when patient holds breath. Coughing
will not clear sound.
• Secondary to inflammation and loss of lubricating
pleural fluid
VOICE SOUNDS
Vocal resonance:
• The sound heard through the stethoscope as the
patient speaks
• larynx chest wall bronchi  alveolar tissue
• During the process, the sounds are diminished in
intensity and altered so that syllables are not
distinguishable.
• “ninety-nine” or “eee”
VOICE SOUNDS
• Bronchophony describes vocal resonance that is more
intense and clearer than normal.
• Egophony describes voice sounds that are distorted
(EA)
• Whispered pectoriloquy: heard only in the presence
of rather dense consolidation of the lungs.

• All test for consolidation!

Diagnostic Evaluation
• ARTERIAL BLOOD GAS STUDIES
• Allen’s Test/Modified Allen’s Test
Other Diagnostic Examinations
• VENOUS BLOOD SPECIMEN
• PULSE OXIMETRY
Method of continuously monitoring the oxygen
saturation of hemoglobin
• CULTURES
• SPUTUM STUDIES
• PPD
Sputum Exams
• Sputum Analysis – gross appearance
• For Culture and sensitivity – to detect the
actual microorganism causing the infection
• For sputum cytology-to detect cancer cells
• For sputum AFB:
To assist in the diagnosis of TB
For monitoring of the effectiveness of therapy
PPD (Purified Protein Derivatives)
• Mantoux Test
• ID route
• Read result after 48-72 hours after injection
• (+) mantoux test is induration of 15 mm or more
• For HIV positive clients, induration of 5 mm is
considered positive
• (+)Mantoux Test signifies exposure to Mycobacterium
Tubercle Bacilli
ENDOSCOPIC PROCEDURES
BRONCHOSCOPY
• the direct inspection and examination of the larynx,
trachea, and bronchi through either a flexible
fiberoptic bronchoscope or a rigid bronchoscope.
ENDOSCOPIC PROCEDURES
• Informed consent
• Consent
• NPO 4-8 hours (reduce risk for aspiration)
• Fear—sedation
• Sedation given to patients with respiratory
insufficiency may precipitate respiratory arrest.
ENDOSCOPIC PROCEDURES
• Remove dentures and other oral prosthesis
• Local anesthesia
• Topical anesthetic sprayed on the pharynx to suppress
cough reflex and minimize discomfort
ENDOSCOPIC PROCEDURES
After the procedure
• NPO until gag or cough reflex returns
• A small amount of blood-tinged sputum and fever
may be expected within the first 24 hours.
ENDOSCOPIC PROCEDURES
THORACOSCOPY
• diagnostic procedure in which the pleural cavity is
examined with an endoscope
THORACENTESIS
An accumulation of pleural fluid may occur with
some disorders
A sample of this fluid can be obtained by
thoracentesis
A needle biopsy of the pleura may be performed at
the same time.
Biopsy
• excision of a small amount of tissue, may be
performed to permit examination of cells from the
pharynx, larynx, and nasal passages.

• Lung biopsy
• Pleural biopsy
• Lymph node biopsy
RESPIRATORY CARE MODALITIES
Noninvasive Respiratory Therapies
OXYGEN THERAPY
• Oxygen therapy is the administration of oxygen at a
concentration greater than that found in the
environmental atmosphere.
Noninvasive Respiratory Therapies
OXYGEN THERAPY
Indications
• Hypoxemia
• Hypoxia
COMPLICATIONS
• OXYGEN TOXICITY
Oxygen toxicity may occur when too high of oxygen
concentration (greater than 50%) is administered for an
extended period (longer than 24 hours).
• OXYGEN TOXICITY
• It is caused by overproduction of oxygen free radicals,
which are byproducts of cell metabolism.
• If oxygen toxicity is untreated, these radicals can
severely damage or kill cells.
• SUPPRESSION OF VENTILATION
Clients with COPD usually only need low-flow oxygen
because their drive to breathe is primarily based on their
usual state of hypoxia.
The chemoreceptors become insensitive to increased CO2
levels with longterm lung disease.
Increased O2 (administering too much) may stop the
hypoxic respiratory drive and cause CO2 narcosis.
• SUPPRESSION OF VENTILATION
Low oxygen levels are what keeps the client breathing. As
long as the client is hypoxic, he will breathe.
If your client receives more than 2 to 3 L/min of oxygen
with an increase in PaO2, he is no longer hypoxic and could
stop breathing.
 MANAGEMENT OF PATIENTS
WITH CHEST AND LOWER
RESPIRATORY TRACT DISORDERS
ATELECTASIS
• Refers to the closure or collapse or airless condition of
of alveoli
• Often is described in relation to chest x-ray findings
and/or clinical signs and symptoms.
ATELECTASIS
Such pressure may be produced by:
PLEURAL EFFUSION
fluid accumulating within the pleural space
PNEUMOTHORAX
air in the pleural space
HEMOTHORAX
blood in the pleural space
ATELECTASIS
Assessment findings
• dyspnea
• decreased breath sounds on affected side,
• decreased respiratory excursion
• dullness to flatness upon percussion over affected
area
ATELECTASIS
Assessment findings
• Cyanosis
• Tachycardia
• Tachypnea
• elevated temperature
• Weakness
• pain over affected area
ATELECTASIS
Diagnostic tests
a. Bronchoscopy: may or may not reveal an obstruction
b. Chest x-ray shows diminished size of affected lung
and lack of radiance over atelectatic area
c. PaO2 decreased
ATELECTASIS
The goal in treating the patient with atelectasis is to:
improve ventilation
remove secretions
ATELECTASIS
TREATMENT
• incentive spirometry,
• chest percussion,
• postural drainage, and
• coughing and deep-breathing exercises
ATELECTASIS
TREATMENT
If these measures fail:
• bronchoscopy may help remove secretions.
• Humidity and bronchodilators
*Atelectasis secondary to an obstructing neoplasm may
require surgery or radiation therapy.
PNEUMONIA
• Inflammation of the lung parenchyma caused by
various microorganisms, including bacteria,
mycobacteria, fungi and viruses.

• Inflammation of the alveolar spaces of the lung,

resulting in consolidation of lung tissue as the alveoli
fill with exudates
PNEUMONIA
PNEUMONITIS
more general term that described the inflammatory
process in the lung tissue that may predispose or place
the patient at risk for microbial infection
PNEUMONIA
CLASSIFICATIONS:
1. Community-Acquired Pneumonia (CAP)
2. Health-Care Acquired Pneumonia (HCAP)
3. Hospital-Acquired Pneumonia (HAP)
4. Ventilator-Acquired Pneumonia (VAP)
PNEUMONIA
1. Community-Acquired Pneumonia (CAP)
Pneumonia occurring in the community
PNEUMONIA
2. Health-Care Acquired Pneumonia (HCAP)
Pneumonia occurring in the non hospitalized patient
with extensive health care contact with one or more
of the following:
PNEUMONIA
Hospitalization for >2 days in an acute care facility within
90 days of infection
Residence in a nursing home or long-term care facility
Antibiotic therapy, chemotherapy, or wound care within
30 days of current infection
Hemodialysis treatment at a hospital or clinic
Home infusion therapy or home wound care
Family member with infection due to multi-drug resistant
bacteria
PNEUMONIA
3. Hospital-Acquired Pneumonia (HAP)
Pneumonia occurring >48 hours after hospital
admission that did not appear to be incubation at the
time of admission
PNEUMONIA
4. Ventilator-Acquired Pneumonia (VAP)
A type of HAP that develops >48 hours after
endotracheal tube intubation
PNEUMONIA
*Aspiration Pneumonia
Refers to the pulmonary consequences resulting from
entry of endogenous and exogenous substances into
the lower airway.
PNEUMONIA
AT RISK FOR ASPIRATION PNEUMONIA
• Geriatric clients.
• Clients with decreased level of consciousness (LOC).
• Post operative clients.
• Clients with a poor gag reflex.
• Weak clients.
• Clients receiving tube feedings.
PNEUMONIA
SPUTUM RAINBOW
The colors of sputum and their corresponding bacteria
Rust Streptococcus pneumoniae
 Pink Staphylococcus aureus
 Green with odor Pseudomonas aeruginosa
PNEUMONIA
DIAGNOSTIC EXAM
• Fungal/acid-fast bacilli cultures: identify etiologic
agent.
• Sputum culture: positive for infecting organism.
• Bronchoscopy
PNEUMONIA
MANAGEMENT
1. Facilitate adequate ventilation.

a. Administer oxygen as needed and assess its

effectiveness.
b. Place client in Fowler’s position.
c. Turn and reposition frequently clients who are
immobilized/obtunded.
PNEUMONIA
MANAGEMENT
1. Facilitate adequate ventilation.

d. Administer analgesics as ordered to relieve pain

associated with breathing
e. Auscultate breath sounds every 2—4 hours.
f. Monitor ABGs.
PULMONARY TUBERCULOSIS
• Infectious disease that primarily affects the lung
parenchyma.
• Also may be transmitted to other parts of the body—
meninges, kidneys, bones and lymph nodes
• Mycobacterium tuberculosis
• An acid-fast aerobic rod that grows slowly and is
insensitive to heat and ultraviolet light.
PULMONARY TUBERCULOSIS
Transmission and risk factors:
• TB spreads from person to person by AIRBORNE
transmission.
• An infected person releases droplet nuclei (usually
particles 1 to 5 mcm in diameter) through talking,
coughing, sneezing, laughing or singing.
PULMONARY TUBERCULOSIS
Transmission and risk factors:
• Larger droplets settle
• Smaller droplets remain suspended in the air and are
inhaled by a susceptible person.
PULMONARY TUBERCULOSIS
Transmission and risk factors:
• Transmitted thru droplet nuclei --- 3 ft or 1 meter
away
• Transmitted airborne--- beyond 3 feet or 1 meter.
PULMONARY TUBERCULOSIS
RISK FACTORS
Close contact with someone who has active TB.
Immunocompromised status
Substance abuse
Pre-existing medical conditions or special treatment
Immigration from countries with a high prevalence of
TB
PULMONARY TUBERCULOSIS
RISK FACTORS
Institutionalization (long-term care facilities,
psychiatric institutions, prisons)
Living in overcrowded, substandard housing
Being a health care worker performing high-risk
activities
PULMONARY TUBERCULOSIS
Areas with high resistance rates:
• National Capital Region, including Laguna
• Cebu
• Davao
• Zamboanga
• Cavite
• Pampanga
Areas with low resistance rates:
• Palawan
• Mountain Province and Benguet
PULMONARY TUBERCULOSIS
Clinical manifestations
Low grade fever
Cough
Night sweats
Fatigue
Weight loss
Hemoptysis
PULMONARY TUBERCULOSIS
Diagnostic Tools
Direct Sputum Smear Microscopy
Sputum AFB
Chest X-ray
Cavitation
PPD
PULMONARY TUBERCULOSIS
Common medication given
Rifampicin
Isoniazid (INH)
Pyrazinamide
Ethambutol
Streptomycin
PULMONARY TUBERCULOSIS
• Rifampicin—red to red orange urine/secretions
• INH-increased tingling sensation/numbness-peripheral
neuritis
• Pyranizinamide- purine accumulation/ increased uric acid
• Ethambutol-eyes or ocular neuritis (visual alteration) not
given for less than 12 years old
• Streptomycin-ototoxicity

ALL CAN CAUSE HEPATOTOXICITY!

PULMONARY TUBERCULOSIS
• Rifampicin- increased fluid intake
• INH- Vit B6 (Pyridoxine)
• Pyranizinamide- increased fluid intake/allupurinol
• Ethambutol- eye examination/ refer to MD
• Streptomycin- refer to MD
ALL CAN CAUSE HEPATOTOXICITY! Check AST and ALT
Jaundice- STOP drugs!
PULMONARY TUBERCULOSIS
TREATMENT
• A private room with negative airflow ventilated
to the outside is necessary.
• Drug therapy must be continued for 6-12 months
• Client is generally considered noninfectious after
1-2 weeks of continuous drug therapy.
PULMONARY TUBERCULOSIS
TREATMENT
• Drugs taken for 6-12 months--Rifampicin, INH,
Streptomycin and Ethambutol
• Non-compliance can lead to drug-resistant PTB.
PULMONARY TUBERCULOSIS
PREVENTIVE THERAPY
• Isoniazid preventive therapy for 6 to 12 months
(prophylaxis)
• Vaccine:
• BCG administration
PULMONARY TUBERCULOSIS
NURSING MANAGEMENT
Teach the isolated patient to cough and sneeze into
tissues and to dispose of secretions properly.
Instruct the patient to wear a mask when he leaves
his room. Visitors and personnel should wear high-
efficiency particulate air respirator masks when in his
room. (N95 MASK)
rest
PULMONARY TUBERCULOSIS
NURSING MANAGEMENT
eat balanced meals. Record weight weekly.
Teach him the signs of adverse medication effects;
warn him to report them immediately.
Emphasize the importance of regular follow-up
examinations to watch for recurring tuberculosis.
PRACTICE QUESTION
PULMONARY HEART DISEASE
• COR PULMONALE
• Condition that results from PH, which causes the right
side of the heart to enlarged because of he increased
work required to pump blood against high resistance
through the pulmonary vascular system.
• Causes right sided heart failure
PULMONARY EMBOLISM
This refers to the obstruction of the pulmonary artery
or one of its branches by a blood clot (thrombus)
that originates somewhere in the venous system or
in the right side of the heart.
Most commonly, pulmonary embolism is due to a clot
or thrombus from the deep veins of the lower legs.
PULMONARY EMBOLISM
• Thrombus dislodges from moves into the lungs the
legs or pelvis
• Thrombus dislodges from clot forms on heart valve
and breaks loose; heart valve smaller growths break
off and form embolus
• Atrial fibrillation--Atrial quiver causing turbulent blood
flow; could cause clot that travels to lungs
PULMONARY EMBOLISM
• Central venous catheters
• Fractures
• Immobility
• Dehydration
• polycythemia vera
PULMONARY EMBOLISM
• Pregnancy
• Vein disorders: varicose veins
• Sickle cell disease
• Thrombophlebitis
• Birth control pills/hormone
• Smoking
• Cancer
• Amniotic fluid Ruptured
PULMONARY EMBOLISM
Signs and symptoms
• Shortness of breath/restless—first sign
• Chest pain: sharp, substernal
• Cough (hemoptysis)
• Restlessness
• Tachycardia
PULMONARY EMBOLISM
Signs and symptoms
• Low-grade fever Inflammation
• Cyanosis
• Crackles; pleural rub-heard at embolism site due to
inflammation
• Pulmonary hypertension
PULMONARY EMBOLISM
DIAGNOSTIC EXAM
• ABGs: hypoxemia.
• D-dimer test positive: increases with PE; increases if
clot is present in the body.
• Chest x-ray: small infiltrate or effusion.
• Lung perfusion scan: ventilation–perfusion mismatch.
PULMONARY EMBOLISM
Patient Teaching for prevention of Pulmonary Embolism
Active leg exercises to avoid venous stasis
Early ambulation
Use of elastic compression stockings
Avoidance of leg-crossing and sitting for prolonged
periods
Drink fluids
CHEST TRAUMA
• Blunt thoracic injuries

• form of injury to the chest including the ribs, heart

and lungs, great vessels, trachea and esophagus
BLUNT INJURY
CAUSES
• Motor vehicle accident
• Pedestrian accident
• Fall
• Sports injury
• Crush injury
• Explosion
PENETRATING INJURY CAUSES:
• Knife
• Gunshot
• Stick
• Arrow
• Occupational injury
BLUNT TRAUMA
Rib Fracture:
• Most common chest injury.
• May interfere with ventilation and may lacerate
underlying lung.
BLUNT TRAUMA
Clinical manifestations
• Anterior chest pain
• Overlying tenderness
• Ecchymosis
• Crepitus
• Swelling
BLUNT TRAUMA
• To reduced pain, the patient splints the chest by
breathing in a shallow manner and avoids sighs, deep
breaths, coughing and movement
BLUNT TRAUMA
Rib Fracture:
• Give analgesics to assist in effective coughing and
deep breathing.
• Encourage deep breathing with strong inspiration;
give local support to injured area by splinting with
hands.
PNEUMOTHORAX
• occurs when the parietal or visceral pleura is breached
and the pleural space is exposed to positive
atmospheric pressure.
• Pneumothorax is when the lung collapses due to air
accumulating in the pleural space
PNEUMOTHORAX
PNEUMOTHORAX
Assessment findings
1. Sudden sharp pain in the chest, dyspnea, diminished
or absent breath sounds on affected side, tracheal shift
to the opposite side (tension pneumothorax
accompanied by mediastinal shift)
2. Weak, rapid pulse; anxiety; diaphoresis
PNEUMOTHORAX
Nursing interventions
1. Provide nursing care for the client with an
endotracheal tube: suction secretions, vomitus, blood
from nose, mouth, throat, or via endotracheal tube;
monitor mechanical ventilation.
PNEUMOTHORAX
Nursing interventions
2. Restore/promote adequate respiratory function.
a. Assist with thoracentesis and provide appropriate
nursing care.
b. Assist with insertion of a chest tube to water- seal
drainage and provide appropriate nursing care.
c. Continuously evaluate respiratory patterns and
report any changes.
PNEUMOTHORAX
Nursing interventions
3. Provide relief/control of pain.
a. Administer narcotics/analgesics/sedatives as ordered
and monitor effects.
HEMOTHORAX
• Blood in pleural space as a result of penetrating or
blunt chest trauma.
• Accompanies a high percentage of chest injuries.
• Can result in hidden blood loss.
HEMOTHORAX
• Assist with thoracentesis to aspirate blood from pleural
space, if being done before a chest tube insertion.
• Assist with chest tube insertion and set up drainage system
for complete and continuous removal of blood and air.
• Auscultate lungs and monitor for relief of dyspnea.
• Monitor amount of blood loss in drainage.
• Replace volume with I.V. fluids or blood products.
FLAIL CHEST
• Loss of stability of chest wall as a result of multiple
rib fractures, or combined rib and sternum fractures.
• When this occurs, one portion of the chest has lost its
bony connection to the rest of the rib cage.
FLAIL CHEST
• During respiration, the detached part of the chest will
be pulled in on inspiration and blown out on
expiration (PARADOXICAL MOVEMENT)
• Normal mechanics of breathing are impaired to a
degree that seriously jeopardizes ventilation, causing
dyspnea and cyanosis.
FLAIL CHEST
FLAIL CHEST
• Stabilize the flail portion of the chest with hands;
apply a pressure dressing and turn the patient on
injured side
• Thoracic epidural analgesia may be used for some
patients to relieve pain and improve ventilation
FLAIL CHEST
Medical management
• Supportive
• Ventilatory support
• Clearing secretion from the lungs
• Controlling pain
CARDIAC TAMPONADE
• Compression of the heart as a result of accumulation
of fluid within the pericardial space.
• Caused by penetrating injuries, metastasis, and other
disorders.
CARDIAC TAMPONADE
• pericardiocentesis
MANAGEMENT OF PATIENTS
WITH CHRONIC PULMONARY
DISEASE
Chronic Obstructive Pulmonary Disease
(COPD)
• Preventable and treatable slowly progressive
respiratory disease of airflow obstruction involving the
airways, pulmonary parenchyma, or both
Lung parenchyma
Includes any form of lung tissue, including:
bronchioles,
bronchi,
blood vessels,
interstitium and
alveoli.
Chronic Obstructive Pulmonary Disease
(COPD)
• Preventable and treatable slowly progressive
respiratory disease of airflow obstruction involving the
airways, pulmonary parenchyma, or both
• obstruction to airflow impedes breathing.
• “chronic airflow limitation”
• not fully reversible
Chronic Obstructive Pulmonary Disease
(COPD)
•name given to a condition in which two
pulmonary diseases exist at the same time,
primarily chronic bronchitis and
emphysema.
•Also, chronic asthma with either emphysema or
chronic bronchitis may cause COPD.
Chronic bronchitis
•occurs when the
bronchi stay
inflamed due to
infection or irritation
causing obstruction
of the small and large
airways.
Bronchitis signs and symptoms
• Excessive mucous production--early sign
• Chronic cough 3 months every year for two years
• Airflow obstruction
• Dyspnea with increased intolerance to exercise;
labored breathing at rest—early sign
Bronchitis signs and symptoms
• Accessory muscle use
• Wheezes/rhonchi/crackles of expiration
• Prolonged expiration
•Polycythemia
• Pulmonary hypertension resulting in right sided heart
failure
• Edema; ascites
Emphysema
•condition in which the lungs have lost their
elasticity, thus impeding gas exchange.
• Hyperinflation of alveoli
• Destruction of alveolar walls
• Destruction of alveolar capillary walls
• Narrowed tortuous, small airways
• Loss of lung elasticity.
Emphysema
1. Panlobular Emphysema
2. Centrolobular (Centroacinar)
Emphysema
Emphysema signs and symptoms
• Dyspnea; tachypnea; air hunger
• Barrel-shaped chest
Emphysema signs and symptoms
• Dyspnea; tachypnea; air hunger
• Barrel-shaped chest
• Accessory muscle use
• Prolonged expiration
• Clubbing of fingers and toes
• Inspiratory crackles, wheezes
• Decreased chest expansion
Emphysema signs and symptoms
•Pursed lip breathing; puffer breathing
• Client prefers “seated” position
• Weight loss
• Respiratory acidosis
• Productive morning cough
Risk Factors of COPD
Chronic bronchitis and emphysema are both primarily
caused by:

cigarette smoking
Risk Factors of COPD
Others:
• Prolonged and intense exposure to occupational dusts
and chemicals
• Indoor and outdoor air pollution as to the total
burden of inhaled particles on the lung
•Deficiency of Alpha1-antitrypsin
Clinical Manifestations-COPD
• Cough
• Sputum production
• Dyspnea of exertion
• Patient’s inability to participate even in mild exercises
• Occurs even at rest
• Barrel chest thorax configuration
• Chronic hyperinflation
Assessment and Diagnostic Findings
• Pulmonary Function Test
• Bronchodilator Reversibility testing
• Arterial blood gas measurement
• X-ray
• Alpha1 antitrypsin deficiency screening
Factors that determine the clinical course and
survival of patients with COPD
• History of cigarette smoking
• Passive smoking exposure
• Age
• Hypoxemia
• PAP
• Resting HR
Factors that determine the clinical course and
survival of patients with COPD
• Weight loss
• Reversibility of airflow obstruction
• Stressors that leads to exacerbations
• Psychosocial factors
Complications of COPD
• Respiratory insufficiency and failure
• Respiratory infections
• Pulmonary edema
• Cor-pulmonale
• Spontaneous pneumothorax from ruptured of
emphysematous bleb
Spontaneous pneumothorax from ruptured of
emphysematous bleb
Complications
• Respiratory insufficiency and failure
• Respiratory infections
• Pulmonary edema
• Cor-pulmonale
• Spontaneous pneumothorax from ruptured of
emphysematous bleb
• Sleep-onset dyspnea and frequent or early morning
awakenings
Medical Management

•Pharmacologic therapy
•Bronchodilators
•Metered dose inhalers
Classes of bronchodilators:
•Beta-adrenergic Agonists
•Anticholinergic Agents
•Methylxanthines
Medical Management

•Pharmacologic therapy
•Cortecosteroids
• Beclomethasone
• Budesonide
• Flunisolide
• Fluticasone
• Triamcinolone
Medical Management
•Oxygen Therapy
• Long term continuous therapy
• <55 mmHg or less PaO2
• Night time oxygen therapy
• Intermittent oxygen therapy
BRONCHIECTASIS
•An irreversible condition marked by chronic
abnormal dilation of bronchi and destruction of
bronchial walls
•Occurs throughout the tracheobronchial tree or
can be confined to one segment or lobe

•Separate disease from COPD

BRONCHIECTASIS
Causes:
• Airway obstruction
• Diffuse airway injury
• Pulmonary infections and obstruction of bronchus or
complications of long term pulmonary infections
• Genetic disorder (CF)
BRONCHIECTASIS
Inflammatory process with pulmonary infections
 damage to the bronchial wall loss of
supporting structure  production of thick
sputum obstruction of bronchi permanently
distended and distorted walls impaired
mucociliary clearance inflammation and
infection extended to the peribronchial tissues
BRONCHIECTASIS
Symptoms
•Chronic cough
•Production of purulent sputum in copius amount
•Hemoptysis
•Clubbing of fingers
•Repeated episodes of pulmonary infection
BRONCHIECTASIS
Assessment and Diagnostic Findings
•A definitive sign is sputum consistently negative
for tubercle bacilli
*CT scan—presence of bronchial dilatation
BRONCHIECTASIS
Medical management
•Chest physiotherapy
•Smoking cessation
•Anti-microbial therapy
•Vaccination (Flu Vaccine and Pneumococcal Vaccine)
•Bronchodilators
BRONCHIECTASIS
Surgical interventions
•Pneumonectomy
•Lobectomy
•Segmental resection
BRONCHIECTASIS
Nursing management
•Avoid exposure to others with upper respiratory
infections
•Early detection of signs and symptoms
•Nutritional status and adequate diet
ASTHMA
•Chronic inflammatory disease of the airways that
causes airway hyperresponsiveness, mucosal
edema and mucus production
•Largely irreversible
ASTHMA
Symptoms:
•Cough
•Chest tightness
•Wheezing
•Dyspnea
ASTHMA
Causes:
•Allergens • Sinusitis with post nasal drip
•Airway irritants •Medications
•Exercise • Viral respiratory tract
infections
•Stress and emotional
upsets •GERD
ASTHMA
Pathophysiology:
Causes and contributing factors of asthma
diffused airway inflammation
hyperresponsiveness of airways limited
airflow symptoms of asthma
ASTHMA
Assessment and diagnostic findings
•Positive family, environmental and occupational
history
•Sputum and blood test
•Elevated serum level of immune globulin E if allergy
is present
•Presence of hypocapnia and respiratory alkalosis
•Patient becomes more fatigued.
ASTHMA
Prevention:
•Avoid causative agent
•Knowledge in the care of self
ASTHMA
Complications:
•Status asthmaticus
•Respiratory failure
•Pneumonia
•Atelectasis
•Hypoxemia
•Insensible fluid loss from hyperventilation
ASTHMA
Medical management
• Long-acting control medications
• Corticosteroids
• Long-acting beta 2-adrenergic agonists

• Quick relief medications

• Short acting beta-adrenergic agonists
• Anti cholinergics
ASTHMA
Nursing management:
•Implement basic asthma management principles
•Establish programs for asthma education
•Give the patient knowledge about inhalers, anti-
allergy therapy and avoidance measure
•Give the patient a brief background about
asthma.
STATUS ASTHMATICUS
•Severe and persistent asthma that does not
respond to conventional therapy.
•The attacks can last longer than 24 hours.
STATUS ASTHMATICUS
Causes:
•Infection
•Anxiety
•Nebulizer abuse
•Dehydration
•Increased adrenergic blockage
•Non-specific irritants
STATUS ASTHMATICUS
Clinical manifestations:
•Labored breathing
•Prolonges exhalation
•Engorged neck veins
•Wheezing
STATUS ASTHMATICUS
Assessment and diagnostic findings:
•PFT: most accurate
•ABG: positive respiratory alkalosis
STATUS ASTHMATICUS
Medical management
•Short-acting beta-adrenergic agonist and
corticosteroids
•Oxygen therapy
•Mechanical ventilation PRN