KEY NOTES

Adapted from Smeltzer Medical Surgical Nursing 11th edition

CHAPTER 21 ASSESSMENT OF RESPIRATORY FUNCTION

The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in
the chain of lymph nodes guarding the body from invasion of organisms entering the nose and throat. The
tonsils do not aid digestion, do not contain nerves that provoke sneezing, nor do they regulate airflow to the
bronchi.

Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the patient is
recumbent, it is essential to turn the patient to assess all lung fields so that dependent areas can be assessed
for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine
the dependent areas of the lungs can result in missing significant findings.

Laryngotracheitis is associated with an irritated, high-pitched cough.

A cough in the morning with sputum production is indicative of bronchitis.

A sputum specimen should be delivered to the laboratory within 2 hours of collection. Allowing the specimen to
stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it
difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen is not an appropriate action.

The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and
yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection.

Stridor is a harsh, high-pitched sound heard on inspiration, usually without need of stethoscope, secondary to
upper airway obstruction.

A cough of recent onset is usually from an acute infection and may be associated with pneumonia.

Wheezing is a high-pitched, musical sound heard mainly on expiration (asthma) or inspiration (bronchitis). It is
often the major finding in a patient with bronchoconstriction or airway narrowing.

Dyspnea (shortness of breath) and wheezing are generally associated with marked bronchospasm. Wheezing
is not indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.

Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia,
bronchitis, and congestive heart failure.

Coarse crackles: discontinuous popping sounds heard in early inspiration; harsh, moist sound originating in the
large bronchi associated with chronic obstructive pulmonary disease.

Soft, high-pitched, popping sounds that occur during inspiration would be heard in a patient with heart failure or
pulmonary fibrosis.

The arterial oxygen tension (partial pressure or PaO 2) indicates the degree of oxygenation of the blood, and the
arterial carbon dioxide tension (partial pressure or PaCO 2) indicates the adequacy of alveolar ventilation.

ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide
and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH.

Most of the carbon dioxide (90%) is carried by red blood cells; the small portion (5%) that remains dissolved in
the plasma (PCO2) is the critical factor that determines carbon dioxide movement into or out of the blood. The
PO2 and PaO2 have to do with oxygen in the blood, not carbon dioxide. PaCO 2 is an arterial measurement, not a
 KEY NOTES
Adapted from Smeltzer Medical Surgical Nursing 11th edition
venous measurement. Capillary blood samples are venous blood, not arterial blood, so it is not as accurate as
an ABG.

Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed.
It can be used during transport and causes the patient no discomfort. Pulse oximetry does not replace ABG
measurement as it is not as accurate. Assessment of the patient's nailbeds does not give an accurate
measurement of the concentration of oxygen in the blood.

An incentive spirometer is used to assist the patient with deep breathing after surgery. Some patients with
asthma use peak flow meters to measure levels of expired air.

After a Bronchoscopy it is important that the patient takes nothing by mouth until the cough reflex returns
because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing
for several hours.

Tidal volume refers to the volume of air inspired and expired with a normal breath.

Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced
inspiration.

Forced vital capacity is vital capacity performed with a maximally forced expiration.

Residual volume is the maximal amount of air left in the lung after a maximal expiration.

Vital capacity is measured by having the patient take in a maximal breath and exhale fully through a
spirometer.

Vital lung capacity is the maximum volume of air exhaled from the point of maximum inspiration, and
neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity.

Inspiratory capacity is the maximum volume of air inhaled after normal expiration.

A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to
compression of the heart and great vessels, resulting in murmurs.

A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of
overinflation of the lungs.

A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the
anteroposterior diameter.

Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine and limits
lung expansion within the thorax.

Biot's respiration is characterized by periods of normal breathing (three to four breaths) followed by varying
periods of apnea (usually 10 seconds to 1 minute).

Cheyne-Stokes is a similar respiratory pattern but involves a regular cycle where the rate and depth of
breathing increase and then decrease until apnea occurs.

Eupnea is a normal breathing pattern of 12 to 18 breaths per minute.

Bradypnea is a slower-than-normal rate (less than 10 breaths per minute), with normal depth and regular
rhythm, and no apnea.
 KEY NOTES
Adapted from Smeltzer Medical Surgical Nursing 11th edition
Tachypnea is a faster-than-normal respiratory rate (over 20 per minute)

Pulmonary function tests (PFTs) are routinely used in patients with chronic respiratory disorders. They are
performed to assess respiratory function and to determine the extent of dysfunction. Such tests include
measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas
exchange.

Pulmonary perfusion is the actual blood flow through the pulmonary circulation.

Postprocedure care focuses on providing adequate oxygenation, monitoring for bleeding, and providing pain
relief (great multiple answers)

MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma (assessment of chest
wall invasion); and to evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and
chronic thrombolytic pulmonary hypertension. In this patient, the MRI is not being done to assess the patency
of the bronchial tree or to evaluate inflammatory activity in the lung. An MRI would not assess the ability to
expand the lung.

CHAPTER 23 MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY TRACT

DISORDERS

The drug that is commonly used to control pain for patients with pleurisy is indomethacin

Smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount
of mucus production, reduces the oxygen-carrying capacity of hemoglobin, and distends the alveoli in the
lungs.

In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds
on the affected side.

Paradoxical chest wall movements occur in flail chest conditions.

Tracheal deviation occurs in a tension pneumothorax.

Muffled or distant heart sounds occur in pericardial tamponade.

As with rib fracture, treatment of flail chest is usually supportive. Management includes ventilatory support,
clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is
important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is
required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the fail
segment.

The signs and symptoms of a large pneumothorax include dyspnea, air hunger, increased use of accessory
muscles, and cyanosis.

Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide
(BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in
distinguishing ARDS from hemodynamic pulmonary edema.

Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion
maneuvers (deep breathing exercises, incentive spirometry), and coughing serve as the first-line measures to
minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or
who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure
(PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.
 KEY NOTES
Adapted from Smeltzer Medical Surgical Nursing 11th edition
For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis.
Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stocking are
general preventive measures.

Early signs of acute respiratory failure are those associated with impaired oxygenation and may include
restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the
hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia,
tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest.

Injuries to the chest are often life-threatening and result in one or more of the following pathologic states:
hypoxemia from disruption of the airway; injury to the lung parenchyma, rib cage, and respiratory musculature;
massive hemorrhage; collapsed lung; pneumothorax; hypovolemia from massive fluid loss from the great
vessels, cardiac rupture, or hemothorax; cardiac failure from cardiac tamponade, cardiac contusion, or
increased intrathoracic pressure.

Most empyemas occur as complications of bacterial pneumonia or lung abscess. They also result from
penetrating chest trauma, hematogenous infection of the pleural space, nonbacterial infections, and iatrogenic
causes (after thoracic surgery or thoracentesis)

CHAPTER 24 CHRONIC PULMONARY DISEASE

The most important risk factor for COPD is cigarette smoking.

Complications of COPD include pneumothorax, atelectasis, pneumonia, and pulmonary hypertension (cor
pulmonale).

Bronchodilators, which may be prescribed for patients who also have reactive airway disease, may also assist
with secretion management.

Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the new definition of
COPD, it is considered a disease process separate from COPD. Bronchiectasis may be caused by a variety of
conditions, including airway obstruction, diffuse airway injury, pulmonary infections and obstruction of the
bronchus or complications of long-term pulmonary infections, or genetic disorders such as cystic fibrosis.
Bronchiectasis is not caused by pulmonary hypertension or atelectasis. Clinical manifestations of
bronchiectasis include hemoptysis, chronic cough, copious purulent sputum, and clubbing of the fingers

Nursing management focuses on alleviating symptoms and helping patients clear pulmonary secretions.
Nursing management does not focus on clearing atelectasis, preventing pulmonary secretions, or decreasing
pulmonary hypotension.

Medical management of bronchiectasis may include Antimicrobial therapy based on the results of sensitivity
studies on organisms cultured from sputum is used to control infection. A year-round regimen of antibiotic
agents may be prescribed with different types of antibiotics at intervals. Chest physiotherapy, including
percussion and postural drainage, is important in the management of secretions. Smoking cessation is
important because smoking impairs bronchial drainage by paralyzing ciliary action, increasing bronchial
secretions, and causing inflammation of the mucous membranes, resulting in hyperplasia of the mucous
glands.

CHAPTER 25 RESPIRATORY CARE MODALITIES

 KEY NOTES
Adapted from Smeltzer Medical Surgical Nursing 11th edition
Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period.
Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive
respiratory difficulty.

Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive end-expiratory
pressure (PEEP) or continuous positive airway pressure (CPAP) is used with oxygen therapy to reverse or
prevent microatelectasis, thus allowing a lower percentage of oxygen to be used. Oxygen is moistened by
passing through a humidification system. Changing the tubing on the oxygen therapy equipment is the best
technique for controlling bacterial growth.

A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric
secretions in the unconscious or paralyzed patient.

Preoperative teaching for a patient who will undergo a thoracotomy includes the use of incentive spirometry,
turning, coughing, deep breathing, and splinting the incision.

Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air,
fluid, and blood.

Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During
the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Stable
vital signs and arterial blood gases are important predictors of successful weaning.

Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The
patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. Patients without a
pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should
notice that the fluid has stopped fluctuating in the water-seal chamber.

The Venturi mask provides the most accurate method of oxygen delivery. A Venturi mask is the most reliable
and accurate method for delivering precise concentrations of oxygen through noninvasive means. The Venturi
mask is used primarily for patients with COPD because it can accurately provide an appropriate level of
supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. This type of mask is constructed
in a way that allows a constant flow of room air blended with a fixed flow of oxygen. . Other methods of
oxygen delivery include the aerosol mask, tracheostomy collar, and face tents.

The ultimate goal of home ventilator therapy is to enhance the patient's quality of life, not simply to support or
prolong life. The ultimate goal of home ventilator therapy is not to let the patient die at home.

Endotracheal intubation may be used for no longer than 3 weeks, by which time a tracheostomy must be
considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord
paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing.