Respiratory System: Medical and Surgical Nursing (week 2 & 3)

Anatomy and Physiology

A. Primary functions of the respiratory system
• Provides oxygen for metabolism in the tissues
• Maintains heat balance
• Removes carbon dioxide, the waste product of metabolism
B. Secondary functions of the respiratory system
• Facilitates sense of smell
• Produces speech
• Maintains acid-base balance
• Maintains body water levels

Upper Respiratory Airway

1. Nose: Humidifies, warms, and filters inspired air

2. Sinuses: Air-filled cavities within the hollow bones that surround the nasal passages
and provide resonance during speech
3. Pharynx
a. Passageway for the respiratory and digestive tracts located behind the oral
and nasal cavities
b. Divided into the nasopharynx, oropharynx, and laryngopharynx

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4. Larynx
a. Located just below the pharynx at the root of the tongue; commonly called
the voice box
b. Contains 2 pairs of vocal cords, the false and true cords
c. The opening between the true vocal cords is the glottis. The glottis plays an
important role in coughing, which is the most fundamental defense
mechanism of the lungs.
5. Epiglottis
a. Leaf-shaped elastic flap structure at the top of the larynx
b. Prevents food from entering the tracheobronchial tree by closing over the
glottis during swallowing

Lower Respiratory Airway

• Trachea: Located in front of the esophagus; branches into the right and left
mainstem bronchi at the carina
• Mainstem bronchi
o Begin at the carina
o The right bronchus is slightly wider, shorter, and more vertical than the left
bronchus.
o Divide into secondary or lobar bronchi that enter each of the 5 lobes of the
lung
o The bronchi are lined with cilia, which propel mucus up and away from the
lower airway to the trachea, where it can be expectorated or swallowed.

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• Bronchioles
o Branch from the secondary bronchi and subdivide into the small terminal
and respiratory bronchioles
o Contain no cartilage and depend on the elastic recoil of the lung for patency
o The terminal bronchioles contain no cilia and do not participate in gas
exchange.
• Alveolar ducts and alveoli
o Acinus (plural, acini) is a term used to indicate all structures distal to the
terminal bronchiole.
o Branch from the respiratory bronchioles
o Alveolar sacs, which arise from the ducts, contain clusters of alveoli, which
are the basic units of gas exchange.
o Type II alveolar cells in the walls of the alveoli secrete surfactant, a
phospholipid protein that reduces the surface tension in the alveoli; without
surfactant, the alveoli would collapse.
• Lungs
o Located in the pleural cavity in the thorax
o Extend from just above the clavicles to the diaphragm, the major muscle of
inspiration
o The right lung, which is larger than the left, is divided into 3 lobes: the upper,
middle, and lower lobes.
o The left lung, which is narrower than the right lung to accommodate the
heart, is divided into 2 lobes.
o The respiratory structures are innervated by the phrenic nerve, the vagus
nerve, and the thoracic nerves.

• The parietal pleura lines the inside of the

thoracic cavity, including the upper surface
of the diaphragm.
• The visceral pleura covers the pulmonary
surfaces.
• A thin fluid layer, which is produced by the
cells lining the pleura, lubricates the
visceral pleura and the parietal pleura,
allowing them to glide smoothly and
painlessly during respiration.
• Blood flows throughout the lungs via the
pulmonary circulation system.

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Accessory muscles of respiration
➢ include the scalene muscles, which elevate the first 2 ribs;
➢ the sternocleidomastoid muscles, which raise the sternum;
➢ and the trapezius and pectoralis muscles, which fix the shoulders.

The Respiratory Process

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 o The diaphragm descends into the abdominal cavity during inspiration,
causing negative pressure in the lungs.
o The negative pressure draws air from the area of greater pressure, the
atmosphere, into the area of lesser pressure, the lungs.
o In the lungs, air passes through the terminal bronchioles into the alveoli and
diffuses into surrounding capillaries, then travels to the rest of the body to
oxygenate the body tissues.
o At the end of inspiration, the diaphragm and intercostal muscles relax and
the lungs recoil.
o As the lungs recoil, pressure within the lungs becomes higher than
atmospheric pressure, causing the air, which now contains the cellular waste
products carbon dioxide and water, to move from the alveoli in the lungs to
the atmosphere.
o Effective gas exchange depends on distribution of gas (ventilation) and blood
(perfusion) in all portions of the lungs.

Gas Exchange in the Tissues

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Gas Exchange in the Lungs

Risk Factors for Respiratory Disorders

▪ Allergies
▪ Chest injury
▪ Crowded living conditions
▪ Exposure to chemicals and environmental pollutants
▪ Family history of infectious disease
▪ Frequent respiratory illnesses
▪ Geographical residence and travel to foreign countries
▪ Smoking
▪ Surgery
▪ Use of chewing tobacco
▪ Viral syndromes

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 ❖ Diagnostic Tests
▪ Chest x-ray film
- Provides information regarding the anatomical location and
appearance of the lungs
- Pre procedure
- Remove all jewelry and other metal objects from the chest area.
- Assess the client’s ability to inhale and hold his or her breath.
- Post procedure: Help the client to get dressed.

Sputum specimen
- Specimen obtained by expectoration or tracheal suctioning to assist
in the identification of organisms or abnormal cells
• Pre procedure
✓ Determine the specific purpose of collection and check institutional
policy for the appropriate method for collection.
✓ Obtain an early morning sterile specimen by suctioning or
expectoration after a respiratory treatment if a treatment is
prescribed.
✓ Instruct the client to rinse the mouth with water before collection.
✓ Obtain 15 mL of sputum.
✓ Instruct the client to take several deep breaths and then cough deeply
to obtain sputum.
✓ Always collect the specimen before the client begins antibiotic
therapy.
• Post procedure
✓ If a culture of sputum is prescribed, transport the specimen to the
laboratory immediately.
✓ Assist the client with mouth care.

Laryngoscopy and bronchoscopy

- Direct visual examination of the larynx, trachea, and bronchi with a
fiberoptic bronchoscope
• Pre procedure
✓ Maintain NPO (nothing by mouth) status as prescribed.
✓ Assess the results of coagulation studies.
✓ Remove dentures and eyeglasses.
✓ Establish an intravenous (IV) access as necessary and administer
medication for sedation as prescribed.
✓ Have emergency resuscitation equipment readily available.

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 • Post procedure
✓ Maintain the client in a semi-Fowler’s position.
✓ Assess for the return of the gag reflex.
✓ Maintain NPO status until the gag reflex returns.
✓ Monitor for bloody sputum.
✓ Monitor respiratory status, particularly if sedation has been administered.
✓ Monitor for complications, such as bronchospasm or bronchial
perforation, indicated by facial or neck crepitus, dysrhythmias,
hemorrhage, hypoxemia, and pneumothorax.
✓ Notify the health care provider (HCP) if signs of complications occur

Pulmonary function tests

- Tests used to evaluate lung mechanics, gas exchange, and acid-
base disturbance through spirometric measurements, lung
volumes, and arterial blood gas levels.

• Pre- procedure
✓ Determine whether an analgesic that may depress the respiratory
function is being administered.
✓ Consult with the HCP regarding withholding bronchodilators before
testing.
✓ Instruct the client to void before the procedure and to wear loose
clothing.
✓ Remove dentures.
✓ Instruct the client to refrain from smoking or eating a heavy meal for 4 to 6
hours before the test.

• Post procedure:
✓ Client may resume a normal diet and any bronchodilators and respiratory
treatments that were withheld before the procedure.

LUNG BIOPSY
• Description
a. A transbronchial biopsy and a transbronchial needle aspiration may be
performed to obtain tissue for analysis by culture or cytological
examination.
b. An open lung biopsy is performed in the operating room.
• Pre procedure
✓ Maintain NPO status as prescribed.

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 ✓ Inform the client that a local anesthetic will be used for a needle biopsy
but a sensation of pressure during needle insertion and aspiration may be
felt.
✓ Administer analgesics and sedatives as prescribed.

• Post procedure
✓ Apply a dressing to the biopsy site and monitor for drainage or bleeding.
✓ Monitor for signs of respiratory distress and notify the HCP if they occur.
✓ Monitor for signs of pneumothorax and air emboli and notify the HCP if
they occur.
✓ Prepare the client for chest radiography if prescribed.

Thoracentesis

- Removal of fluid or air from the pleural space via transthoracic

aspiration
• Pre procedure
✓ Prepare the client for ultrasound or chest radiograph, if prescribed,
before procedure.
✓ Assess results of coagulation studies.
✓ Note that the client is positioned sitting upright, with the arms and
shoulders supported by a table at the bedside during the procedure
✓ If the client cannot sit up, the client is placed lying in bed toward the
unaffected side, with the head of the bed elevated.
✓ Instruct the client not to cough, breathe deeply, or move during the
procedure.
• Post procedure
✓ Monitor respiratory status.
✓ Apply a pressure dressing and assess the puncture site for bleeding
and crepitus.
✓ Monitor for signs of pneumothorax, air embolism, and pulmonary
edema.

Arterial blood gas

▪ Measurement of the dissolved oxygen and carbon dioxide in the arterial
blood helps to indicate the acid-base state and how well oxygen is being
carried to the body.

▪ Measures the acidity (pH) and the levels of oxygen and carbon dioxide in
the blood from an artery. This test is used to find out how well your lungs
are able to move oxygen into the blood and remove carbon dioxide from
the blood.

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❖ Collection of an ABG specimen
✓ Obtain vital signs.
✓ Determine whether the client has an arterial line in place (allows for
arterial blood sampling without further puncture to the client).
✓ Perform the Allen’s test to determine the presence of collateral
circulation
✓ Assess factors that may affect the accuracy of the results, such as
changes in the O2 settings, suctioning within the past 20 minutes, and
client’s activities.
✓ Provide emotional support to the client.
✓ Assist with the specimen draw; prepare a heparinized syringe (if not
already prepackaged).
✓ Apply pressure immediately to the puncture site following the blood
draw; maintain pressure for 5 minutes or for 10 minutes if the client is
taking an anticoagulant.
✓ Appropriately label the specimen and transport it on ice to the
laboratory.

❖ Acidosis and Alkalosis

▪ Acidosis occurs when the pH of blood falls below 7.35
▪ There are two types of acidosis based upon the cause:
respiratory and metabolic
▪ Alkalosis occurs when the pH of blood increases above 7.45
▪ There are two types of alkalosis based upon the cause:
respiratory and metabolic
❖ Normal values for ABGS
pH = 7.35 – 7.45
PaCO2 = 35 – 45 (Acid) if CO2 increases body becomes acidic
HCO3= 22 – 26 (Basic) if HCO3 increases alkalosis
PaO2 80 -100
pH = 7.26 PaCO2= 50 HCO3= 24 N
Uncompensated respiratory acidosis
pH = 7.56 PaCO2= 23 HCO3= 22 N
Uncompensated Respiratory alkalosis
Respiratory Opposite Metabolic Equal

❖ ABG Arterial Blood Gas

pH= 7. 50 CO2 = 38N HCO3= 30

uncompensated metabolic alkalosis
pH= 7.32 Co2= 48 HCO3= 30
Partially compensated Respiratory acidosis
pH 7.50 CO2= 48 HCO3= 29
partially compensated metabolic alkalosis

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 Respiratory Opposite Metabolic Equal

pH 7.35N CO2 28 HCO3 16

Fully compensated metabolic acidosis

pH 7.45 N CO2 48 HCO3 =29

Fully compensated metabolic Alkalosis

Respiratory Treatments

Breathing retraining

- This includes exercises to decrease use of the accessory muscles of

breathing, to decrease fatigue, and to promote carbon dioxide (CO2)
elimination.

- The main types of exercises include pursed-lip breathing and diaphragmatic

breathing.

- The client should inhale slowly through the nose.

- The client should place a hand over the abdomen while inhaling; the
abdomen should expand with inhalation and contract during exhalation.

- The client should exhale 3 times longer than inhalation by blowing through
pursed lips.

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Chest physiotherapy (CPT)
• Percussion, vibration, and postural drainage techniques are performed over
the thorax to loosen secretions in the affected area of the lungs and move
them into more central airways.
• Contraindications
a. Unstable vital signs
b. Increased intracranial pressure
c. Bronchospasm
d. History of pathological fractures
e. Rib fractures
f. Chest incisions
• Perform chest physiotherapy (CPT) in the morning on arising, 1 hour before
meals, or 2 to 3 hours after meals.
• Stop CPT if pain occurs.
• If the client is receiving a tube feeding, stop the feeding and aspirate for
residual before beginning CPT.
• Administer the bronchodilator (if prescribed) 15 minutes before the
procedure.
• Place a layer of material (gown or pajamas) between the hands or percussion
device and the client’s skin.
• Position the client for postural drainage based on assessment.
• Percuss the area for 1 to 2 minutes.
• Vibrate the same area while the client exhales 4 or 5 deep breaths.
• Monitor for respiratory tolerance to the procedure Stop the procedure if
cyanosis or exhaustion occurs.
• Maintain the position for 5 to 20 minutes after the procedure.
• Repeat in all necessary positions until the client no longer expectorates
mucus.
• Dispose of sputum properly.
• Provide mouth care after the procedure.

Incentive Spirometry
• The purpose of incentive spirometry is to facilitate a sustained slow deep
breath.
• Incentive spirometry is designed to mimic natural sighing by encouraging
patients to take slow, deep breaths.
• Incentive spirometry is performed using devices which provide visual cues to
the patients that the desired flow or volume has been achieved.
• The basis of incentive spirometry involves having the patient take a
sustained, maximal inspiration (SMI).
• An SMI is a slow, deep inspiration from the Functional Residual Capacity up
to the total lung capacity, followed by ≥5 seconds breath hold.

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 Oxygen Therapy

➢ Administration of oxygen at greater than 21% to provide adequate

transport of oxygen in the blood while:
o Decreasing the work of breathing and reducing stress on
the myocardium
➢ Hypoxemia: a decrease in the arterial oxygen tension in the blood
➢ Hypoxia: a decrease in oxygen supply to the tissues and cells that can
also be caused by problems outside the respiratory system
➢ Severe hypoxia can be life threatening

Oxygen Toxicity
➢ May occur when too high a concentration of oxygen (greater than 50%) is
administered for an extended period
➢ Symptoms include substernal discomfort, paresthesias, dyspnea,
restlessness, fatigue, malaise, progressive respiratory difficulty, refractory
hypoxemia, alveolar atelectasis, and alveolar infiltrates on x-ray
➢ Prevention:
o Use lowest effective concentrations of oxygen
o PEEP or CPAP prevent or reverse atelectasis and allow lower
oxygen percentages to be used

Supplemental Oxygen Delivery Systems

Device Oxygen Delivered Nursing Considerations

• Easily tolerated
Nasal cannula 1-6 L/min for oxygen • Can dislodge easily.
concentration (FiO2) of • Doesn’t get in the way of eating or
(nasal prongs) 24% (at 1 L/min) to 44% talking
(at 6 L/min) • Effective oxygen concentration can be
delivered.
• Allows the client to breath through the
nose or mouth
• Ensure that prongs are in the nares
with openings facing the client
• Assess nasal mucosa for irritation from
drying effect of higher flow rates
• Assess skin integrity, as tubing can
irritate skin
• Add humidification as prescribed and
check water levels

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 • Interferes with eating and talking
Simple face mask 5-8 L/ min oxygen flow for • Can be warm and confining
FiO2 of 40%-60% • Ensure that mask fits securely over nose
Minimum flow of 5 L/ min and mouth
needed to flush CO2 from • Remove saliva and mucus from the mask
mask
• Provide skin care to area covered by mask
• Provide emotional support to decrease
anxiety in the client who feels
claustrophobic
• Monitor for risk of aspiration from inability
of client to clear mouth (i.e., if vomiting
occurs)
• Keep the air entrapment port for the
Venturi mask 4-10 L/ min oxygen flow adapter open and uncovered to ensure
(Ventimask) for FiO2 of 24%-55% adequate oxygen delivery
Delivers exact desired • Keep mask snug on the face and ensure
selected concentrations tubing is free of kinks because the FiO2 is
of O2 altered if kinking occurs or if the mask fits
poorly
• Assess nasal mucosa for irritation;
humidity or aerosol can be added to the
system as needed
• The client rebreathes one-third of the
Partial rebreather 6-15 L/ min oxygen flow exhaled tidal volume, which is high in
mask for FiO2 of 70%-90% oxygen, thus providing a high FiO2
• Adjust flow rate to keep the reservoir bag
two-thirds full during inspiration
• Keep mask snug on face Make sure the
reservoir bag does not twist or kink
• Deflation of the bag results in decreased
oxygen delivered and rebreathing of
exhaled air

Nonrebreather FiO2 of 60%-100% at a • Adjust flow rate to keep the reservoir bag
mask rate of flow that inflated.
maintains the bag two- • Keep mask snug on the face
thirds full • Remove mucus and saliva from the mask
• Provide emotional support to decrease
anxiety in the client who feels
claustrophobic
• Ensure that the valves and flaps are intact
and functional during each breath (valves

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 should open during expiration and close
during inhalation)
• Make sure the reservoir bag does not twist
or kink or that the oxygen source does not
disconnect; otherwise, the client will
suffocate

Tracheostomy The tracheostomy collar • Ensure that aerosol mist escapes from the
collar and T-bar or can be used to deliver the vents of the delivery system during
T-piece (face tent; desired amount of oxygen inspiration and expiration
face shield to a client with a • Empty condensation from the tubing to
tracheostomy prevent the client from being lavage with
water and to promote an adequate oxygen
A special adaptor (T-bar flow rate (remove and clean the tubing at
or T-piece) can be used to least every 4 hr)
deliver any desired FiO2 • Keep the exhalation port in the T-piece
to client with open and uncovered (if the port is
tracheostomy, occluded, the client can suffocate)
laryngectomy, or • Position the T-piece so that it does not pull
endotracheal tube The on the tracheostomy or endotracheal tube
face tent provides 8-12 L/ and cause erosion of the skin at the
min and the FiO2 varies tracheostomy insertion site
due to environmental
loss

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Nursing Diagnoses

❖ Impaired Gas Exchange

❖ Ineffective Airway Clearance
❖ Decrease Tissue Perfusion
❖ Ineffective Breathing Pattern
❖ Imbalanced Nutrition: Less Than Body Requirements
❖ Risk for Infection
❖ Deficient Knowledge
❖ Activity Intolerance

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Management of Patients With Upper Respiratory Tract Disorders (URIS)

Treated in community
May be minor, acute, settings: doctor offices,
Most common reason for
chronic, severe, or life urgent care clinics, long-
seeking healthcare
threatening term care facilities, or
self-care at home

Early detection of signs

and symptoms and Patient teaching focus on Special considerations for
appropriate interventions prevention and health older adults: Refer to
can avoid unnecessary promotion Chart 22-1
complications

Upper Respiratory Tract Infection

❖ Rhinitis and rhinosinusitis: acute, chronic
❖ Pharyngitis: acute, chronic
❖ Tonsillitis, adenoiditis
❖ Peritonsillar abscess
❖ Laryngitis

Rhinitis and Rhinosinusitis

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Pharyngitis

Question #1

Is the following statement true or false?

Acute pharyngitis of a bacterial nature is most commonly caused by group A beta-
hemolytic streptococci
Answer to Question #1
True.
Rationale: Acute pharyngitis of a bacterial nature is most commonly caused by
group A beta-hemolytic streptococci

❖ URI Potential Complications

▪ Airway obstruction
▪ Hemorrhage
▪ Sepsis
▪ Meningitis or brain abscess
▪ Nuchal rigidity
▪ Medicamentosa
▪ Acute otitis media
▪ Trismus
▪ Dysphagia
▪ Aphonia
▪ Cellulitis

❖ URI Nursing Process: Assessment

▪ Health history
▪ Signs and symptoms: headache, cough, hoarseness, fever, stuffiness,
generalized discomfort, and fatigue
▪ Allergies
▪ Inspection of nose, neck, throat, and palpation of lymph nodes

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 Question #2

What should the nurse palpate when assessing for an upper respiratory tract
infection?
A. Neck lymph nodes
B. Nasal mucosa
C. Tracheal mucosa
D. All of the above

Answer to Question #2

A.Neck lymph nodes

Rationale: The nurse should palpate the neck lymph nodes along with the trachea
and the frontal and maxillary sinuses when assessing for an upper respiratory tract
infection
The nurse should inspect the nasal and tracheal mucosa when assessing for an upper
respiratory tract infection

❖ URI Nursing Process: Diagnoses

▪ Ineffective Airway Clearance

▪ Acute Pain
▪ Impaired Verbal Communication
▪ Fluid Volume Deficit
▪ Knowledge Deficit related to prevention, treatment, surgical procedure,
postoperative care

❖ URI Nursing Process: Planning

▪ Airway management, reduce risk of aspiration
▪ Pain management
▪ Effective communication strategy
▪ Increase hydration
▪ Patient teaching: self-care, prevention, and health promotion
▪ Home care, if indicated
❖ URI Nursing Process: Interventions
▪ Elevate head
▪ Ice collar to reduce inflammation and bleeding
▪ Hot packs to reduce congestion
▪ Analgesics for pain
▪ Gargles for sore throat
▪ Use alternative communication

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 ▪ Encourage liquids; at least 2 to 3 L/day
▪ Soft bland diet
▪ Rest

❖ URI Nursing Process: Evaluation

▪ Maintenance of patent airway
▪ Expresses relief of pain
▪ Able to communicate needs
▪ Evidence of positive hydration
▪ Absence of complications
❖ Patient Education
▪ Prevention of upper airway infections
▪ Emphasize frequent hand washing
▪ When to contact health care provider
▪ Need to complete antibiotic treatment regimen
▪ Annual influenza vaccine for those at risk

❖ Obstruction and Trauma of the Upper Respiratory Airway

➢ Obstructive sleep apnea—; Tx: CPAP, BiPAP, oxygen therapy, surgery
➢ Epistaxis
➢ Nasal obstruction—S/S: deviated septum, turbinate hypertrophy, polyps
➢ Fractures of the nose—S/S: traumatic obstruction; Tx: reduction of
fracture, control epistaxis and edema
➢ Laryngeal obstruction—S/S: edema,; Tx: subcutaneous epinephrine,
tracheotomy

❖ Obstruction and Trauma of the Upper Respiratory Airway—Epistaxis

➢ Hemorrhage from the nose

➢ Anterior septum, most common site
➢ Serious problem, may result in airway compromise or significant blood
loss

Medical Management

o Pinch soft portion of nose for 5 to 10 minutes

o Phenylephrine spray, vasoconstriction
o Cauterize with silver nitrate or electrocautery
o Gauze packing or balloon-inflated catheter inserted into nasal cavity
for 3 to 4 days
o Antibiotic therapy

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❖ Control of Epistaxis—Packing of Nasal Cavity or Balloon Catheter

Nursing Management
❖ Airway, breathing, circulation
❖ Vital signs, possible cardiac monitoring and pulse oximetry
❖ Reduce anxiety
❖ Patient teaching:
o Avoid nasal trauma, nose picking, forceful blowing, spicy
foods, tobacco, exercise
o Adequate humidification to prevent dryness
o Pinch nose to stop bleeding; if bleeding does not stop in 15
minutes, seek medical attention

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