Alteration in Gas Transport:

Care of the Patient with

Respiratory Tract
Problems
The Nursing Process and Respiration

 Assessment
 Client History
 Why are you here?
 General overall health

 Any ‘colds’ or congestion or allergy

problems?
 Smoking history
 Pack years: number of packs per day times
number of years
 How much time away from work or school
have you missed because of this?
Assessment
 Client History
 Subjective symptoms
 Dyspnea with ADLs?
 Childhood diseases

 Asthma, pneumonia, allergies, croup

 Adult illnesses
 Pneumonia, sinusitis, TB, HIV, emphysema,
DM, HTN, cardiac disease
 Vaccine history
 Flu, pneumonia, BCG
Assessment
 Client History
 Surgeries of upper or lower respiratory
tract
 Injuries to upper or lower respiratory tract
 Hospitalizations
 Date of last
 CXR, PPD, PFT
 Recent weight loss
 Night sweats
Assessment
 Client History
 Sleep disturbances
 How many pillows?
 Family history
 Recent travel
 Occupation
 Leisure activities
Assessment
 Client History
 Drug use
 Recreational (marijuana, cocaine, crack)

 Prescription
 ACE inhibitors
 Antihistamines
 Bronchodilators
 Chemotherapy
 OTC
 Allergy medications
 Home remedies
 Herbals: Elecampane, Hyssop, Mullein, Licorice
Assessment
 Client History
 Allergies
 Foods, drugs, substances
 Allergic response?

 Treatment?

 Diet history
 BMI
 Obese? Malnourished?
 Body weight in pounds times 703 divided by
height in inches squared
 Food intake related to breathing issues?
Assessment
 Client History
 Occupation and Home Life
 Environmental factors and exposure
 Type of heat used in the home

 Animals or pets in home

 Hobbies involving chemicals

 Pest infestation at home or work

 Tie to asthma, wheezing related to roaches

Assessment
 Major signs and symptoms
 Cough
 Type, duration, length
 Sputum production
 Color, consistency, amount
 Dyspnea
 Rate of perception
 ADLs

 Paroxysmal nocturnal dyspnea

 Orthopnea
Assessment
 Major signs and symptoms
 Chest pain
 Wheezing
 Clubbing of fingers / nails
 Hemoptysis
 Cyanosis
Gerontologic Considerations
 Vital capacity and respiratory
muscle strength peak between 20-
25 and then decrease
 Age 40 and older – surface area in
alveoli is reduced
 Age 50 – alveoli loses elasticity
 Loss of chest wall
mobility>decrease in vital capacity
Gerontologic Considerations
 Amount of respiratory dead space
increases with age
 Decreased diffusion capacity with
age – lower oxygen level in arterial
circulation
Risk Factors for Respiratory Disease

 Smoking
 Personal / family history
 Occupation
 Allergens
 Recreational exposure
Physical Assessment
 Nose and Sinuses
 External nose
 Deformities, tumors
 Nostrils: symmetry of size, shape

 Nasal flaring
 Inspect for color, swelling, drainage, bleeding
 Mucous membranes
 Nasal septum
 Bleeding, perforation, deviation
Physical Assessment
 Air movement
 Occlude one nare
 Sinuses
 Via palpation
 Tenderness, swelling
 Tapping
 Penlight
 Frontal, maxillary
Physical Assessment
 Pharnyx, Trachea, and Larynx
 Posterior pharynx
 Tongue depressor
 One side at a time
 Observe rise and fall of palate and uvula (ah)
 Inspect for color, symmetry, discharge,
edema, ulceration, tonsillar enlargement
 Neck
 Inspect for symmetry, alignment, masses,
swelling, bruises, use of accessory neck
muscles in breathing
Physical Assessment
 Neck
 Lymph nodes
 Tender, movable – inflammation
 Hard, fixed – suggest malignancy

 Trachea
 Palpate for position, mobility,
tenderness, masses
 Larynx
 laryngoscope
Physical Assessment
 Lungs and Thorax
 Inspection
 Palpation
 Fremitus
 99
 Crepitus
 Bubble wrap
 Chest expansion
 Movement
Physical Assessment
 Lungs and Thorax
 Percussion
 Pulmonary resonance
 Air, fluid, solid masses
 Intercostal spaces only
 Diagphragmatic excursion
 Normal 1 -2 inches

 Deep breath / percuss

 No breath / percuss

 Normally higher on the right (liver)

Physical Assessment
 Auscultation
 Upright first
 Bare chest
 Open mouth breathing
 Full respiratory cycle
 Observe for dizziness
Physical Assessment
 Normal breath sounds
 Bronchial, bronchovesicular, vesicular
 Not heard peripherally
 Adventitious breath sounds
 Additional sounds superimposed on
normal sounds
 Indicate pathology
 Crackles, wheezes, rhonchi, pleural
friction rub
Physical Assessment
 Voice sounds
 Assessed when abnormalities noted
 Increased when sound travels through
solid or liquid
 Consolidation of lung, pneumonia,
atelectasis, pleural effusion, tumor,
abscess
 Bronchophony: 99 – loud and clear
 Whispered Pectriloquy: 1, 2, 3 – loud
 Egophony – ‘E’ – heard as an ‘A’
Physical Assessment
 Skin and Mucous Membranes
 Pallor, cyanosis, nail beds
 General Appearance
 Muscle development, general body build
 Muscles of neck, chest
 Endurance
 How does the client move in 10 – 20
steps?
 Speaking exertion
Diagnostic Assessment
 Need to know:
 Normal / abnormal for:
 RBC
 Hgb / Hct
 WBC / leukocytes / neutrophils
 Eosinophils
 Basophils
 Lymphocytes
 Monocytes
 ABGs
 Sputum studies
 Skin (PPD) testing
Diagnostic Testing
 Chest xrays
 Digital Chest Radiography
 CT
 V/Q Scan
 Pulse Oximetry
 PFTs
Diagnostic Testing
 Pulmonary Function Tests (PFTs)
 Used generally in chronic conditions
 Assesses respiratory function
 Determine extent of dysfunction
 Measures lung volumes, ventilatory
function, and mechanics of breathing,
diffusion, and gas exchange
 Assesses response to therapy
 Screening test in hazardous industries
Diagnostic Testing
 Arterial Blood Gases (ABGs)
 Measures blood pH and arterial oxygen
and carbon dioxide levels
 Assesses ability of lungs to provide
adequate oxygen and removal of
carbon dioxide
 Assesses ability of kidneys to maintain
normal pH
Diagnostic Testing
 Pulse Oximetry
 Noninvasive method of monitoring
oxygen saturation of hemoglobin
 Unreliable in cardiac arrest and shock,
dyes or vasoconstictor meds used,
severe anemia, or high carbon
monoxide level
Diagnostic Testing
 Cultures
 Throat or sputum
 Sputum
 Best to obtain early AM
 Rinse mouth, takes deep breaths, coughs,

and expectorates
 Deliver specimen to lab within 2 hours
Diagnostic Examination
 Endoscopy
 Bronchoscopy, laryngoscopy, mediastinoscopy
 Check for patent airway every 15 minutes post
procedure for two hours
 Thoracentesis
 Local anesthetic
 Patient must remain still
 Usually at bedside
 Post procedure: CXR r/o mediastinal shift,
monitor VS, auscultate breath sounds
 Lung biopsy
Diagnosis
 Upper Airway Medical Diagnosis
 Rhinitis
 Viral rhinitis
 Acute sinusitis
 Chronic sinusitis
 Acute pharyngitis
 Chronic pharyngitis
 Tonsillitis and adenoiditis
Diagnosis
 Upper Airway Medical Diagnosis
 Peritonsillar abscess
 Laryngitis
 Upper Airway Nursing Diagnosis
 Ineffective airway clearance
 Acute pain
 Impaired verbal communication
 Fluid volume deficit
 Knowledge deficit
Planning and Implementation
 Upper airway
 Maintain patent airway
 Promote comfort
 Promote communication
 Encourage fluid intake
 Teach self care
 Encourage appropriate hand washing
Planning and Implementation
 Managing potential complications
 Sepsis
 Sepsis
 Meningitis
 Otitis media
Evaluation
 Maintenance of patent airway
 Reports feelings of comfort
 Demonstrates ability to communicate
 Maintains adequate fluid intake
 Identifies strategies to prevent
infections
 Becomes free of s/sx of infection
 Demonstrates adequate knowledge
Upper Airway Obstruction and Trauma

 Medical Diagnosis
 Sleep apnea
 Obstructive
 Central

 Mixed

 Epistaxis
 Nasal Obstruction
 Fractures of the nose
 Laryngeal Obstruction
 Laryngeal Carcinoma
Upper Airway Obstruction and Trauma
 Nursing Diagnosis
 Knowledge deficit
 Anxiety
 Ineffective airway clearance
 Impaired verbal communication
 Nutritional imbalance
 Alteration in body image
 Self care deficit
 Sleep deprivation
 Risk for injury
 Fatigue
Planning and Implementation
 Sleep apnea
 Avoid ETOH
 Decrease body mass
 CPAP
 Uvulopalatopharyngoplasty
 Tracheostomy
 Pharmacologic Management
 Low flow O2

 Triptil

 Education
Planning and Implementation
 Epistaxis
 Dependent on location of site
 Generally anterior
 Pinch outer portion / sit upright
 Silver nitrate / gelfoam / electrocautery
 Topical vasoconstrictors
 Monitor VS
 Estimate amount of blood loss
 Don’t forget standard precautions
Planning and Implementation
 Nasal Obstruction
 Deviation of nasal septum
 Submucous resection
 Generally outpatient
 Promote drainage
 Alleviate discomfort
 Frequent oral hygiene
Planning and Implementation
 Fractures of the nose
 Bleeding from site
 Bruising
 Clear fluid
 CSF

 Glucose positive

 Surgical reduction ~ one week post injury

 Ice therapy
 Control anxiety
 Oral hygiene
Planning and Implementation
 Laryngeal Obstruction
 Often fatal
 Acute laryngitis, urticaria, scarlet fever,
anaphylaxis, foreign bodies
 Edema: SQ Epi 1:1,000 /
corticosteroid
 Abdominal thrust (Heimlich)
 Emergent tracheotomy
Planning and Implementation
 Laryngeal Cancer
 Risk factors: chart 22-5
 Dependent upon tumor staging (chart
22-6)
 Laryngectomy
 Radiation
 Speech therapy
 Potential complications: respiratory
distress, hemorrhage, infection, wound
breakdown
Laryngeal Cancer
 Educate preoperatively
 Reduce anxiety
 Maintain patent airway
 Encourage speech therapy
 Maintain adequate nutrition
 Promote positive body image
 Teach self care
Evaluation
 Adequate level of knowledge
 Lessened anxiety
 Clear airway
 Acquires effective communication
 Appropriate intake
 Positive self and body image
 Complication free
 Adheres to home therapy
Chest and Lower Respiratory Tract
 Medical Diagnosis
 Atelectasis
 Patho: figure 23-1

 Acute tracheobronchitis
 Pneumonia
 MUST know table 23-1 and charts 23-2, 23-3

 Review older adult considerations / risk

factors
 Assess any older adult with AMS for pneumonia
 May not have cough or fever
Nursing Diagnosis
 Ineffective airway clearance
 Activity intolerance
 Fluid volume deficit
 Altered nutrition
 Knowledge deficit
 Impaired gas exchange
 Pain
 Fatigue
Planning and Implementation
 Avoid potential complications:
 Continuing symptoms
 Shock
 Respiratory failure
 Atelectasis
 Pleural effusion
 Confusion
 Superinfection
Planning and Implementation
 Improve airway patency
 Hydration
 Humidification
 Oxygen therapy
 CPT
 Promote rest
 Long recovery periods
 Conserve energy
 Promote fluid intake
Planning and Implementation
 Maintain adequate nutrition
 Determine caloric needs with RD help
 Educate client
 Teach self care
Evaluation
 Adequate airway patency
 Optimal rest patterns
 Maintains appropriate nutrition and
hydration status
 Knowledgeable of disease and
treatment
 Adheres to treatment strategies
 Complication free
Inhalation Injury – Smoke and Carbon
Monoxide

 Produce local injuries by

inflammation, irritation, and
damage to pulmonary tissues
 Systemic injuries
 S &S of CO poisoning
 Mild – headache, visual disturbances,
irritability, nausea
 Severe – confusion, hallucinations,
ataxia, coma
Therapeutic Management
 100% oxygen
 Artificial ventilation
 Hyberbaric chamber – more rapid Tx
of CO poisoning
 Possible intubation
 Steroids, antibiotics, bronchodilators
 Monitor rate and depth of
respirations at least every hour
Planning and Intervention
 VS assessment / monitoring
 Respiratory assessment
 Pulmonary physiotherapy
 Mechanical ventilation
 Psychological care of child and
parents
Pulmonary Tuberculosis
 Risk factors (chart 23-4)
 CDC recommendations (chart 23-5)
 Classification of disease
 0-5; class 3 – clinically active
 Older adult
 AMS, fever, anorexia
 Delayed reactivity or recall phenomenon
with PPD
 Airborne precautions!!
 Close the door!
Nursing Diagnosis
 Ineffective airway clearance
 Knowledge deficit
 Activity intolerance
 Potential for treatment non adherence
 Impaired gas exchange
 Fatigue
 Alteration in nutrition
 Social isolation
Planning and Implementation
 Medical Management
 Drug resistance is major problem
 Table 23-2 lists current recommended
first line drug therapy
 Therapy lasts up to 12 months
 HIV infection has increased prevalence
 Drug therapy should be dispensed in
two week intervals
Planning and Implementation
 Potential Complications
 Malnutrition
 Medication side effects
 Drug resistance
 Determine which clients should participate
in directly observed therapy (DOT)
 Miliary TB
 Decreased effectiveness with oral
contraceptives
Planning and Implementation
 Promote airway clearance
 Encourage patient adherence
 Promote adequate nutrition
 Encourage rest
 Educate patient regarding routes of
transmission and disease manifestations
 More people are infected than have active TB
 Teach self care
Evaluation
 Maintain patent airway
 Adequate level of knowledge
 Adheres to treatment regimen
 Participates in self care
 Maintains optimal rest patterns
 Complication free
Lung Abscess
 Causative factors
 Bacterial pneumonia
 Oral aspiration / obstruction
 Nursing Diagnosis
 Airway clearance
 Knowledge deficit
 Alteration in nutrition
Planning and Implementation
 Administer AB therapy
 Monitor for adverse effects
 CPT
 TCDB
 Appropriate nutritional intake
 Emotional support
 Educate regarding self care
Pleural Condition Diagnoses
 Medical Diagnosis
 Pleural Conditions
 Pleurisy
 Pleural effusion
 Empyema

 Nursing Diagnosis
 Anxiety
 Pain
 Knowledge Deficit
 Self Care Deficit
 Alteration in Nutrition
 Airway Clearance
Planning and Implementation
 Pleural friction rub, decreased
fremitus, absent breath sounds
 Pain relief, comfort measures
 TCDB
 Thoracentesis
 Implement medical regimen
 Monitor chest tube drainage
 Empyema – long healing process
Diagnosis
 Pulmonary Edema
 Life threatening
 Generally, abnormal cardiac function
 ‘flash’ pulmonary edema post surgery
 Crackles in bases, increasing throughout
 Nursing Diagnosis
 Airway clearance
 Cardiac function
 anxiety
Planning and Implementation
 Administer O2
 Assist with ventilation as
appropriate
 Medication administration
 Monitor patient response
 Educate and prepare patient and
family
Diagnosis
 Acute Respiratory Failure
 Difference between acute and chronic
 Chronic: COPD / neuromuscular dx
 Acute: VP mismatch, alveolar
hypoventilation, PaO2 < 50
 Nursing Diagnosis
 Similar to other airway constrictive
disease states
Planning and Implementation
 Assist with intubation / mechanical
ventilation
 Monitor response
 Prevent complication
 Enable communication
 Educate family and patient
Diagnosis
 Acute Respiratory Distress
Syndrome
 Inflammatory trigger
 Nursing Diagnosis
 Airway clearance
 Anxiety
 Pain
 Nutritional alterations
Planning and Implementation
 Close monitoring
 Ventilator support
 CPT
 Frequent assessment
 Education
 Rest and comfort measures
Pulmonary Hypertension
 Causes: Chart 23-7
 Nursing Management
 Identify high risk patients
 Educate regarding s/sx
 Oxygen therapy
Cor Pulmonale
 Right ventricle enlargement
 Generally, from COPD
 S/ Sx generally r/t underlying
disease state
 Treatment related to addressing
underlying disorder
Pulmonary Embolism
 Risk factors: Chart 23-8
 Home care: Chart 23-9
 Diagnosis: CXR, ECG, V/P scan, ABGs
 Nursing diagnosis
 Knowledge deficit
 Anxiety
 Airway clearance
 Pain
 Decreased cardiac output
 Risk for injury (bleeding)
Planning and Intervention
 Improve respiratory and vascular status
 Anticoagulation therapy
 Thrombolytic therapy
 Surgical intervention
 Rare
 Minimizing risk most important step
 Monitor therapy
 Manage pain
Sarcoidosis
 Hypersensitivity response
 Biopsy required for diagnosis
 Corticosteroid therapy
 May involve other body systems
Occupational Lung Diseases
 Medical Diagnosis
 Silicosis
 Coal workers’ pneumoconiosis
 Asbestosis
 Prevention is key
 Educate clients to wear a mask
 Consider also hobbies
Diagnosis
 Lung and Chest Carcinoma: to be
covered in oncology section
 Chest Trauma: to be covered
during trauma seminar
 Aspiration: similar to pneumonia
and obstructive disorders
 High risk in patients with altered LOC
 Do not force feed clients!
Chronic Obstructive Pulmonary
Disease

 Airflow limitation
 Irreversible
 Chronic bronchitis, emphysema
 Risk factors: Chart 24-1
 Three primary symptoms:
 Cough
 Sputum production
 Dyspnea
Assessment
 Spirometry – evaluation of airflow
obstruction
 Ratio of FEV: FVC
 Less than 70%
 Health history overview: chart 24-2
 Assessment: chart 24-3
 Stages of COPD: table 24-1
 Crackles
Nursing Diagnosis
 Impaired gas exchange
 Ineffective airway clearance
 Ineffective breathing pattern
 Activity intolerance
 Knowledge deficit
 Ineffective coping
 Anxiety
 Alteration in nutrition
 Fatigue
Planning and Implementation
 Potential complications:
 Respiratory insufficiency
 Chronic respiratory failure
 Acute respiratory failure
 Atelectasis
 Pulmonary infection
 Pneumonia
 Pneumothorax
 Pulmonary hypertension
Planning and Implementation
 Promote smoking cessation
 Improve gas exchange
 Medication administration
 Measure improve in flow rates
 Airway clearance
 CPT
 Controlled coughing
 Huff coughing
 Increased fluids
Planning and Implementation
 Improving breathing patterns
 Inspiratory muscle training
 Diaphragmatic breathing
 Pursed lip breathing
 Standing against wall
 Over bedside table with pillows
 Improving activity tolerance
 Determine limitations
 Determine client preferences
 Pacing activities
 Exercise training
Planning and Implementation
 Self care strategies
 Realistic goal setting
 Heat / cold extremes
 Heat increases oxygen demands
 Cold promotes bronchospasms

 Lifestyle modification
 Coping strategies
 Self care teaching
Evaluation
 Knowledgeable of smoking dangers
 Improved gas exchange
 Achieves maximal airway clearance
 Improves breathing pattern
 Demonstrates strategies for activity
tolerance and self care
 Effective coping
 Avoids complications
Bronchiectasis
 Separate from COPD now
 Management similar to COPD
 CPT
 Smoking cessation
 Postural drainage
 Energy conservation measures
Asthma
 Chronic inflammatory disease
 Sxs: cough, chest tightness, wheezing, dyspnea
 Is reversible
 Most common chronic disease of childhood
 Predisposing factors:
 Allergens
 Airway irritants
 Exercise
 Stress
 Sinusitis
 Medications
 Viral respiratory tract infections
 GERD
Asthma
 Nursing Diagnosis
 Anxiety
 Airway clearance
 Breathing patterns
 Fluid volume deficit
 Knowledge deficit
Assessment
 Health history
 Comorbid conditions
 Sputum cultures / serum samples
 Elevated levels of eosinophils
 ABG / pulse ox
 Hypoxemia during attacks
 Hypocapnia and respiratory alkalosis
 PaCO2
 May rise initially

 Return to baseline indicative of impending

respiratory failure
Planning and Intervention
 Prevention is key
 Pharmacology
 Long acting: corticosteroids, anti-
inflammatory agents
 Quick relief: relief of acute symptoms,
bronchodilators
 Table 24-4 details medications
 Oxygen therapy is often indicated during acute
attacks
 Can be mixed with helium (Heliox) to improve

delivery to the alveoli

Planning and Intervention
 Peak flow monitoring
 Daily is recommended
 Monitor respiratory status
 Thorough history of allergens
 Medication administration
 Fluid administration
 Intake and output recording
 Preparation for mechanical ventilation
Planning and Intervention
 Prevention of complications
 Status asthmaticus
 Respiratory failure
 Pneumonia
 Atelectasis
 Airway obstruction
 Dehydration
Status Asthmaticus
 Attack that does not respond to
conventional therapy
 Close monitoring first 12-24 hours
 Volume status closely monitored
 Energy conservation
 No respiratory irritants
 Nonallergenic pillow
Cystic Fibrosis
 <40% reach adulthood
 Airflow obstructive disease with genetic
component
 Elevated sweat chloride
 >60 mEq/L
 Steatorrhea
 Control of infections key
 Nursing interventions similar to other
obstructive diseases
 Lung transplantation – small number
 End of life care important
Respiratory Procedures
 Inhalation therapy
 Oxygen therapy
 Humidification
 Aerosol therapy
 Artificial ventilation
 Continuous positive airway pressure
(C-PAP)
Oxygen Therapy
 Nasal cannula / mask / tent
 Apply to anyone who is hypoxic or with
stridor
 Considerations
 Avoid open flames and electrical appliances
 Monitor response
 Adverse effects to premature infant’s retina
 Caution with COPD
 Oxygen toxicity
 Use humidification
 Check skin integrity
Aerosol Therapy
 Used to deposit medications directly
into airways
 Types
 Hand-held nebulizers
 Metered-dose inhaler (MDI)
 Spacer device
 Close the door when administering
Chest Physiotherapy (CPT)
 Postural drainage in conjunction
with adjunctive techniques
 Manual percussion, vibration,
squeezing the chest, cough, forceful
expiration, and breathing exercises
 Considerations
 Percuss over rib cage
 Used in increased sputum production
CPT
 Contraindications
 Pulmonary hemorrhage
 Pulmonary embolus
 ESRD
 Increased intracranial pressure
 Minimal cardiac reserves
Artificial Ventilation
 Nasotracheal
 Orotracheal
 Tracheostomy
 Considerations
 In children, tubes have more acute
angle and are softer to mold to
contours of trachea
Smoking Cessation
 Anyone who smokes is an increased
risk for pulmonary problems
 Assist clients interested in smoking
cessation programs
 Teach all clients who smoke the
warning signs of lung cancer
That’s All, Folks!

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