Collaborative

Management of the
client experiencing
Alterations in
Respiratory Function

Acute Health Challenges- NURS-3072

Facilitator: Keith Opoku, RN, MN
Monday, July 10th, 2023
Note:

At Humber College, there is a commitment to

respect, diversity and inclusiveness, valuing the
positions, opinions, and perspectives of diverse
individuals in addition to protecting everyone’s
human rights to enhance our community

https://hrs.humber.ca/hr-resources/human-
rights-equity-and-inclusion/human-rights-equity-
and-inclusion/humbers-public-commitment-to-
equity-diversity-and-inclusion-edi/humbers-
public-commitment-to-equity-diversity-and-
inclusion.html#:~:text=Advancing%20equity
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%20leadership%20at%20all%20levels.
Classroom Guidelines
and Rules

Does anyone have any suggestions?

• Ensure you are respecting on another
• Kindly place your hand up to participate and
I as the facilitator will select you to speak
• It is most effective if we take turns and
allow one individual to speak
• Engage in active listening
• Self-reflect and provide insightful
contributions
• Attendance
Learning
Objectives
 Structures and
Functions of
the Respiratory
System

What is the Respiratory System?

What are the major tasks?

Structures and
Functions of the
Respiratory System
Structures and Functions
of the Respiratory
System
Physiology of Respiration

• Ventilation: inspiration (movement

of air into the lungs) and
expiration (movement of air out of
the lungs)
• Elastic recoil: Tendency for the
lungs to recoil after being
stretched
• Compliance (distensibility)
elasticity of the lungs
Age-Related
Considerations: • Structure • Defense mechanisms
Effects of Aging •  Elastic recoil
  Cell-mediated immunity

on the •  Chest wall

  Specific antibodies

Respiratory compliance   Cilia function

System •  Anteroposterior   Cough force

diameter   Alveolar macrophage

•  Functioning alveoli function

• Respiratory control
 Response to
hypoxemia
 Response to
hypercapnia
Assessme
nt of the
Respirato
ry System
Assessment of the Respiratory
System
Diagnostic Studies
of the Respiratory
System
Pulse Oximetry

• Arterial oxygen
saturation can
be monitored
with a probe on
the finger, toe,
ear, forehead or
nose bridge
 Sputum Studies
~Culture and Sensitivity
~Gram Stain
~Acid-fast bacilli (AFB)
smear and culture
Blood Studies
Hemoglobin Hematocrit

• Amount of • Ratio of RBCs to

hemoglobin plasma cells
available for • Polycythemia
combination (increased
with oxygen hematocrit) is
associated with
chronic hypoxia
Arterial Blood Gas:

Determines oxygenation status and acid-base

balance

Obtained by arterial puncture or from an arterial

catheter in the radial or femoral artery
Arterial Blood Gas
Radiology
Chest
Radiograph
(Chest X-ray)

Test is used to screen,

diagnose, and evaluate
change.
Computed Tomography
(CT scan)
• Test is performed for
diagnosis of lesions difficult to
assess by conventional
radiographic studies, such as
those in the hilum, the
mediastinum, and the pleura.
Images show
Magnetic
Resonance
Imaging (MRI)

Test is used for diagnosis of

lesions difficult to assess by CT
(e.g., lung apex near the spine).
Pulmonary
Angiography
(Arteriogram)
• Study is used to visualize
pulmonary vasculature and
locate obstruction or
pathological conditions such as
pulmonary embolus. Contrast
medium is injected through a
catheter into the pulmonary
artery or right side of the heart.
Bronchoscopy

• Flexible fibre-optic endoscope

is used for diagnosis, biopsy,
specimen collection, or
assessment of changes. It may
also be used to suction mucous
plugs or to remove foreign
objects.
Mediastinoscop
y

Test is used for inspection

and biopsy of lymph nodes
in mediastinal area.
Lung biopsy

• Specimens may be obtained by

transbronchial or open lung
biopsy. This test is used to
obtain specimens for
laboratory analysis.
Thoracentesis

• Test is used to obtain specimen of

pleural fluid for diagnosis, to remove
pleural fluid, or to instill medication.
The physician inserts a large-bore
needle through the chest wall into
pleural space. A chest radiograph is
always obtained after procedure to
check for pneumothorax.
Pneumonia
(PNA)
Pneumonia (PNA)

The discovery of
Acute
Common with sulpha drugs and
inflammation of
significant penicillin was
lung parenchyma
morbidity and pivotal in the
caused by
mortality treatment of
microbial organism
pneumonia
Etiology
Likely to result when defense
mechanisms become
incompetent or overwhelmed

Decreased cough and

epiglottal reflexes may allow
for aspiration
Etiology

• Mucociliary mechanism impaired

• Pollution
• Cigarette smoking
• Viral upper respiratory
infections
• Tracheal intubation
• Normal changes of aging
Etiology

Three ways organisms reach

lungs:
• Aspiration from nasopharynx
or oropharynx
• Inhalation of microbes such
as Mycoplasma pneumoniae
• Hematogenous spread from
primary infection elsewhere in
body
Community-acquired
pneumonia

Lower respiratory infection of lung • Organisms implicated

• Streptococcus pneumoniae
Onset in community or during first
2 days of hospitalization • Legionella
• Mycoplasma
Highest incidence in midwinter
• Chlamydia

Smoking important risk factor

Hospital AKA Nosocomial pneumonia
Acquired
Pneumonia
(HAP) Ventilator-associated pneumonia (VAP)
is a sub-set of HAP in the ICU

Multidrug-resistant organisms are

major problem in treating HCAP.

Immuno-suppressive therapy
Risk factors for HAP General debility
Endotracheal intubation
 Aspiration pneumonia: usually
follows aspiration of material
from the mouth or the stomach
into the trachea and
Aspiration subsequently the lungs
Pneumonia

Usually with history of loss of

consciousness
Gag and cough reflexes
suppressed
 Clients at risk
• Severe protein-calorie malnutrition
• Immune deficiencies
• Transplant clients who have received
Opportunistic immuno-suppressive drugs.
Pneumonia • Chemotherapy/radiation recipients
• Radiation, chemotherapeutic, and
corticosteroid therapy
Causes of opportunistic
pneumonia
• Bacterial and viral causative agents
• Pneumocystis jiroveci (PCP)
• Cytomegalovirus
CAP, HAP, Aspiration pneumonia: usually follows aspiration of
fungal, material from the mouth or the stomach into the
trachea and subsequently the lungs
aspiration,
Opportunistic pneumonia: clients with altered immune
opportunistic response are highly susceptible to respiratory
infections.

CAP: Onset in community or during first 2 days of

hospitalization

HAP: Occurring 48 hours or longer after admission and

not incubating at time of hospitalization
Pathophysiology
Stage 1: Stage 2: Red Grey
Resolution
Congestion hepatization hepatization
• Outpouring of • Massive dilation • ↓ Blood flow • Resolution and
fluid to alveoli of capillaries • Leukocyte and healing if no
• Organisms • Alveoli fill with fibrin complications
multiply organisms, consolidate in • Exudate lysed
• Infection neutrophils, affected part of and processed
spreads RBCs, and fibrin. lung. by
• Interferes with • Causes lungs macrophages
lung function to appear red • Tissue restored
and granular,
similar to liver
FYI EXUDATE VS TRANSUDATE
Pathophysiologi
cal Course of
Pneumonia
Clinical Sudden onset of fever Chills
CAP symptoms
Cough productive of
Pleuritic chest pain

Manifestations
purulent sputum

Physical examination findings

Dullness to percussion ↑ Fremitus Bronchial breath sounds Crackles

Atypical manifestations
Extrapulmonary
Gradual onset Dry cough Crackles
manifestations

Initial manifestations are highly variable in viral pneumonia.

Found in association with systemic viral diseases

Measles, varicella-zoster, herpes simplex, influenza virus infection
WHAT ARE
SOME
COMPLICATIONS
ASSOCIATED
WITH
PNEUMONIA?
Nursing Dyspnea, cough
(productive or Chest pain, sore

Assessment nonproductive),
nasal congestion,
pain with
throat, headache,
abdominal pain,
muscle aches
Fatigue, weakness,
malaise
Anorexia, nausea,
vomiting

breathing

Splinting affected Asymmetric chest

Fever, chills Tachypnea
area movements

Pink, rusty,
Use of accessory Crackles, friction purulent, green,
Tachycardia
muscles rub yellow, or white
sputum

Changes in mental Altered

Tube feedings Prolonged bed rest
status consciousness

Exposure to
Pain with
Dyspnea Nasal congestion chemical toxins,
breathing
dust, or allergens
Nursing Assessment
History History
• Use of antibiotics, • Lung cancer
corticosteroids, • COPD
chemotherapy, or • Diabetes mellitus
immunosuppressants • Debilitating disease
• Recent abdominal or thoracic • Malnutrition
surgery •
• Smoking AIDS
• Alcohol use disorder
• Respiratory infections
Diagnostic Tests
Physical
History Chest x-ray
examination

Sputum Pulse
Gram stain of
culture and oximetry or
sputum
sensitivity ABGs

CBC, Blood
differential cultures
Diagnostic Findings
• Leukocytosis
• Abnormal ABGs
• Pleural effusion
• Pneumothorax on x-ray
Pneumonia on X-Ray
Collaborative Care
Oxygen for Analgesics for Fluid intake at least
Antibiotic therapy Antipyretics
hypoxemia chest pain 3 L per day

Teach nutrition, Encourage those at

hygiene, rest, risk to obtain
Caloric intake at Prompt treatment
regular exercise to Strict asepsis influenza and
least 1 500 per day of URIs
maintain natural pneumococcal
resistance vaccinations.

Assist clients at risk

Elevate head of Assist immobile
for aspiration with Emphasize need to
Reposition client bed 30–45 degrees clients with turning
eating, drinking, take course of
every 2 hours. for clients with and deep
and taking medication(s).
feeding tube. breathing.
medications.
 Dyspnea not present
SpO2 ≥ 95
Free of adventitious breath sounds
Clear sputum from airway

Evaluation Normal breathing patterns

No signs of hypoxia
Normal chest x-ray
No complications related to pneumonia
Reports pain control
Verbalizes causal factors
Adequate fluid and caloric intake
Performs activities of daily living
 Most preventable cancer; leading cause of
cancer-related death in Canada (both men and
women)

• Cigarette smoking most important risk factor

Etiology • followed by exposure to inhaled carcinogens

Lung cancer
Pathophysiology • Paraneoplastic syndrome

• Usually nonspecific and appear late in the

disease process
Clinical • Most significant and first-reported symptom:
manifestations persistent cough that may be productive of
sputum
What are some
carcinogens?
Paraneoplastic
Syndromes
 Diagnostic studies
• Chest radiography, CT scan, PET scan, MRI
• Staging
• Screening for lung cancer

Interprofessional care
• Surgical therapy
• Radiation therapy
Lung Cancer • Stereotactic radiotherapy
• Chemotherapy
• Biological therapy
• Other therapies
• Prophylactic cranial radiation
• Bronchoscopic laser therapy
• Phototherapy
• Airway stenting
• Cryotherapy
Other Types of Lung Tumours
Primary lung tumours include sarcomas, lymphomas, and
bronchial adenomas.

The lungs are a common site for secondary metastases and

are more often affected by metastatic growth than by primary
lung tumours.
Pulmonary capillaries are ideal sites for tumour emboli; the
lungs have an extensive lymphatic network.
 Presence of air in the
pleural space

Pneumothora Types of pneumothorax

x
• Closed pneumothorax
• Open pneumothorax
• Tension pneumothorax
• Hemothorax
• Chylothorax
Pneumothorax

Clinical manifestations
Small: mild tachycardia and dyspnea
Large: respiratory distress, including
shallow, rapid respirations; dyspnea; air
hunger; decreased oxygen saturation
Interprofessional care
May resolve spontaneously
Aspiration of pleural space
Insertion of chest tube (water-seal
drainage)

30A-58
Pneumothorax (Cont.)

30A-59
Pneumothorax

30A-60
Pneumothorax, hemothorax,
hemopneumothorax
Chest Tubes and
Pleural Drainage Chest
tube
insertion Heimlich
Pleural valves
drainage Small
chest
tubes

30A-62
Chest Tubes and
Pleural
Drainage (Cont.)

30A-63
Chest Tubes and
Pleural
Drainage (Cont.)

30A-64
Air Leak
(bubbling)
Nursing Management: Chest Drainage
• Complications
• Routine milking or stripping of chest tubes to maintain patency
is no longer recommended because it can cause dangerously
high intrapleural pressure and damage to pleural tissue.
• Clamping of chest tubes during transport or when the tube is
accidentally disconnected is no longer advocated; there is a
danger of rapid accumulation of air in the pleural space,
causing tension pneumothorax.
30A-66
 Chest tube malposition

Re-expansion pulmonary edema

Vasovagal response with symptomatic

Chest Tube hypotension
Complication
s Infection at the skin site

Pneumonia

Shoulder disuse (“frozen shoulder”)

30A-67
Chest Tube Removal
• Removed when lungs are re-expanded and fluid drainage
has ceased
• Suction is discontinued gradually.
• Gravity drainage

30A-68
 Preoperative care

Surgical therapy

• Thoracotomy
• Video-assisted thoracic
surgery (VATS)
Chest
Surgery
Postoperative care

30A-69
Pleural Effusion

Types
Transudative Exudative

Can be determined from a sample of pleural fluid obtained via thoracentesis

Empyema: pleural effusion that contains pus

30A-70
Pleural Effusion (Cont.)
• Clinical manifestations
• Progressive dyspnea; decreased movement of the chest wall on
the affected side; pleuritic pain from the underlying disease;
dullness to percussion and absent or decreased breath sounds
over the affected area during physical examination
• Manifestations of empyema include those of pleural effusion as
well as fever, night sweats, cough, and weight loss.

30A-71
Thoracentesis Diagnostic
Types
Therapeutic

The patient sits on the edge of a bed

and leans forward over a bedside
table.

1 000–1 200 mL of pleural fluid is

removed at one time

Rapid removal can result in

hypotension, hypoxemia, or pulmonary
edema.

30A-72
Pleural Effusion (Cont.)
• Interprofessional care
• Treat the underlying cause.
• Treatment of pleural effusions secondary to malignant disease
is a more difficult concern.

30A-73