MEDICAL NURSING RESPIRATORY SYSTEM

ASSESSMENT OF RESPIRATION

Learning Objectives

On completion of this chapter, the student will be able to:

 Describe the structures and functions of the upper and lower respiratory tracts.
 Describe ventilation, perfusion, diffusion, shunting and the relationship of
pulmonary circulation to those processes.
 Use assessment parameters appropriate for determining the characteristics and
severity of the major symptoms of respiratory dysfunction.
 Identify the nursing implication of roles/responsibility the various procedures used
for diagnostic evaluation of respiratory dysfunction.

Disorders of respiratory system are common and are encountered by nurses in every
setting from the community to the intensive care unit.

To assess the respiratory system, the nurse must be skilled at differentiating

normal assessment findings from abnormal ones, acute from chronic.

In addition, an understanding of the respiratory function and the significance of

abnormal diagnostic test results is essential.

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 ANATOMY AND PHYSIOLOGIC OVERVIEW

DIAGRAM

The respiratory system is composed of the upper and lower respiratory tracts, the two
tracts are responsible for ventilation and respiration. VENTILATION is movement of air
into and out of lungs. RESPIRATION refers to the exchange of oxygen and carbon
dioxide across cell membrane.

ANATOMY OF THE UPPER RESPIRATORY TRACT

The upper respiratory tract includes the Nose, Para-nasal Sinuses, Turbinate Bones
(Conchae), Pharynx, Tonsils and Adenoids, Larynx and Trachea.

NOSE

The Nose is composed of an external and an internal portion. The external portion
protrudes from the face and is supported by the nasal bones and cartilage. The anterior
nares (nostrils) are the external openings of the nasal cavities.

The internal portion of the nose is a hollow cavity separated into right and left nasal
cavities by the septum. Each nasal cavity is divided in three passageways by the
projection of the turbinates (called conchae) from the lateral walls. The nasal cavities are
lined with highly vascular ciliated mucous membrane called nasal muscasa. Mucus is
secreted by goblet cells that covers the surface of the mucosa and is moved back to the
nasopharynx by the action of the cilia. The nose serves as a passageway for air to pass to
and from the lungs. It filter impurities, humidifies and warms the air as it is inhaled. It is
responsible for olfaction (smell) because the olfactory receptors are located in the nasal
mucosa.

PARANASAL SINUSES

The para-nasal sinuses include four pairs of bony cavities that are ;

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DIAGRAM OF SINUSES

Lined with nasal mucosa and ciliated pseudo-stratified columnar epithelium. The sinuses
are named by their location: frontal, ethmoidal, sphenoid and maxillary. They are
openings in the facial bones.

Function

 Sinuses lighten the skull.

 Assist in speech.
 Produce mucus that drains into the nasal cavities and helps trap debris and
bacteria.

PHARYNX

The pharynx (throat) is a passage way for both air and food. It is divided into three
regions: the NASOPHARYNX, OROPHARYNX and LARYNGOPHARYNX
starts at the nose. Air, mucus and trapped debris move through the nasopharynx,
where the tonsils and adenoids are.

The oropharynx lies behind the oral cavity. It carries both air and food. During
swallowing, the soft palate rises to prevent food from entering the nasopharynx. The
lining of the oropharynx protects it from damage by friction, from chemicals in food
and fluids.

The laryngopharynx, a passage way for both food and air, connects the oropharynx
to the larynx

LARYNX

The larynx (voice box) connects the laryngopharynx with the trachea and route air and
food into the proper passage way. The larynx is protected by cartilages that help keep
it open. The major function of the larynx is vocalization. It consists of the following ;

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  EPIGLOTTIS – a valve flap of cartilage that covers the opening to the larynx
during swallowing
 GLOTTIS – the opening between the vocal cords in the larynx
 THYROID CARTILAGE – the largest of the cartilage structures, part of it
forms the Adam’s apple
 CRICOID CARTILAGE – the only complete cartilaginous ring in the larynx
(located below the thyroid cartilage)
 ARYTENOID CARTILAGES – used in vocal cord movement with the
thyroid cartilage
 VOCAL CORDS - ligaments controlled by muscular movements that produce
sounds, located in Lumen of larynx.

TRACHEA

The trachea or windpipe, is composed of smooth muscle with C – shaped rings of

cartilage at regular intervals. The cartilaginous rings are incomplete on the posterior
surface and give firmness to the trachea, prevention it from collapsing. The trachea serves
as passage between the larynx and the bronchi.

ANATOMY OF THE LOWER RESPIRATORY TRACT

The lower respiratory tract consists of the lungs which contain the bronchial and alveolar
structures.

Functions

 To provide oxygen to the cells of the body.

 To eliminate carbon dioxide, a waste product of metabolism.

The process of respiration include ;

 VENTILATION (BREATHING): Air moves into and out of the lung.

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 EXTERNAL RESPIRATION: Oxygen and carbon dioxide are exchanged between
the alveoli and the blood.
 GAS TRANSPORT: Blood transports oxygen and carbon dioxide to and from the
lungs and cells of the body.
 INTERNAL RESPIRATION: Oxygen and carbon-dioxide are exchanged between
the blood and the cells.

LUNGS

The lungs are conical paired elastic soft and spongy connective tissue structures
enclosed in the thoracic cage, which is an air tight chamber with distensible walls. The
lungs fill both sides of the chest separated by a space called the mediastinum. The heart,
great blood vessels, bronchi, trachea and esophagus sit in the mediastinum. The apex of
each lung is just below the clavicle and the base of each lung rest on the diaphragm.

The lung consists of five lobes. The right has three lobes (upper, middle and lower), the
left has two (upper and lower) and the lobes are further subdivided by fissures (the
oblique fissures). The bronchial tree, another lung structure inflates with air in the alveoli
to fill the lobes. Each lung is enclosed in an adherent serious membrane called the
visceral pleura, which is continuous from the hilum of the lungs with the parietal pleura
that lines the thoracic wall.

BRONCHI

Formed by the division of the trachea into two branches (bronchi)

 RIGHT MAIN-STEM BRONCHUS: larger and straighter than the left, further
divides into three lobar branches (upper, middle and lower lobar bronchi) to
supply the three lobes of right lung.
 LEFT MAIN-STEM BRONCHUS: divides into the upper and lower lobar
bronchi, to supply two lobes of left lung.

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 At the point a bronchus reaches about 1mm in diameter it no longer has
connective tissue sheath and is called a BRONCHIOLE.

BRONCHIOLES

 In the bronchioles, airway patency is primarily dependent upon elastic recoil

formed by network smooth muscles.
 The trachea-bronchial tree ends at the terminal bronchioles. Distal to the terminal
bronchioles, the major function is no longer air conduction, but gas exchange
between blood and alveolar air. The respiratory bronchioles serve as the transition
to alveolar epithelium.

BLOOD SUPPLY

Supply from two sources enters the lungs

- BRONCHIAL ARTERIES convey blood from the aorta to nourish the bronchi to
the terminal bronchioles.
- PULMONARY ARTERY delivers the blood from the right side of the heart to
the walls of the alveoli to be oxygenated.
- VENOUS RETURN

The four pulmonary veins

- The blood from the bronchial arteries around the area of the hilum, enters the
bronchial veins
- LYMPHATIC DRAINAGE
Two pulmonary lymphatic system

CHEST WALL

 Includes the rib cage, intercostal muscles and diaphragm

 Parietal pleura lines the chest wall and secretes small amounts of lubricating fluid
into the intrapleural space (space between the visceral and parietal pleura). This

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 fluid holds the lung and chest wall together as a single unit while allowing them to
move separately.
 The chest is shaped and supported by 12 pairs of ribs and costal cartilages; the ribs
have several attached muscles
 Contraction of the external intercostal muscles raises the rib cage during
inspiration and helps increase the size of thoracic cavity
 The internal intercostal muscles tend to pull ribs down and in and play a role in
forced expiration
 The diaphragm is the major muscle of ventilation (the exchange of air between the
atmosphere and alveoli). Contraction of muscle fibres causes the dome of the
diaphragm to desend, thereby increasing the volume of the thoracic cavity. As
exertion increases, additional chest muscles or even abdominal muscles may he
employed in moving th thoracic cage.

PULMONARY CIRCULATION

The pulmonary circulation includes the pulmonary arteries and the pulmonary
veins. The pulmonary arteries deliver blood from body tissues via the right heart to the
lungs to be re-oxygenated. The pulmonary veins return oxygenated blood to the left heart,
to be pumped out to the rest of the body. In the lungs, the vessels branch into pulmonary
capillary network that surrounds the alveoli for re-oxygenation of blood and release of
Co2 in the pulmonary capillary beds. Blood vessels enter and exit the lungs at the hilus.

GAS EXCHANGE

Alveolar Ducts and Alveoli

 Alveolar ducts arise from the respiratory bronchioles and lead to the alveoli.
 Alveoli are the functional cellular units of the lungs; about half arise directly from
the alveolar ducts and are responsible for about 35% of alveolar gas exchange.

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  Alveolai products SURFACTANT, a phospholipid substance found in the fluid
lining the alveolar epithelium. Surfactant reduces surface tension and increases the
stability of the alveoli and prevents their collapse.
 Alveolar sacs form the last part of the airway, functionally the same as the alveoli
ducts, they are surrounded by alveoli and are responsible for 65% of the alveolar
gas exchange.

MECHANICS OF RESPIRATION

The mechanism of respiration involves two phases (Ventilation) air movement into and
out of the lungs. The phases are:

 INSPIRATION
 EXPIRATION

Inspiration as air flows into the lungs and expiration when the gases flow out of the
lungs. The two phases make up a breathe and normally occur 12 to 20 times per minute.
Inspiration last about 1 to 1.5 seconds; expiration last about 2 to 3 seconds.

During inspiration, the diaphragm contracts and flattens out and the intercostal
muscles contract to pull the rib cage up and outward. Together, these movements increase
the size of the chest cavity. The lungs stretch and their volume increases. This reduces
pressure within the lungs to slightly less than atmospheric pressure, and as a result air
rushes into the lungs.

Expiration is primary passive. The inspiratory muscles relax, the diaphragm rises,
the ribs descend and the lungs recoil. Pressure in the chest cavity increase, compressing
the alveoli. The pressure within the lungs is higher than atmospheric pressure and gasses
flow out of the lungs.

DIAGRAM

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FACTORS AFFECTING RESPIRATION

Breathing is controlled by

 Respiratory centers in the brain

 Chemo-receptors in the brain, aortic arch and carotid arteries

These centers and receptors respond to changes in the amount of oxygen, carbon dioxide
and hydrogen ions in arterial blood. For example, increase carbon dioxide or a drop in PH
stimulates the respiratory centers and the respiratory rate increases.

 Airway resistance is created by friction as gases move through the airways.

Resistance is increased by airway constriction or Oedema, excess mucus, or by
tumors that narrow the airways. As resistance increases, gas flow decreases.
 Compliance is the distensibility (stretchiness) of the lungs. It depends on both the
lung tissues and the rib cage.
 Elasticity is the tendency of lung tissue to return to its inflamed size and shape.
 Alveoli contain a liquid film that creates.Surface tension, drawing the walls of the
alveolus closer together surfactant reduces this surface tension, prevents the
alveoli from collapsing between breaths and reduces the work of breathing.

ASSESSMENT

HEALTH HISTORY

 Nursing assessment of respiration function is vital in all clients, particularly when

caring for clients with disorders, diseases affecting the respiratory system, as well
as those at risk for respiratory complications of other disorders.
 Collect information from the client (family, if necessary) about current complaint
or reason of seeking care. Ask about the onset and duration of symptoms. Address
about how symptoms have affected the clients ability to maintain activities of
daily living (CADLS).

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PRESENTING PROBLEM/ASYMMETRY

 NOSE/NASAL SINUSES: Symptoms may include colds, discharge epistaxis,

sinus problems (swelling pain), nasal congestion, difficulty breathing
 THROAT: Symptoms may include sore throat, hoarseness, difficulty or painful
swallowing.
 LUNGS: Symptoms may include ;
 Cough: note duration, frequency type (dry, hacking, bubbly, barking, hoarse,
congested), sputum (productive vs non productive), colour, amount,
circumstances related to cough (time of day, positions, talking, anxiety);
treatment.
 Dyspnea: note onset, severity duration efforts to treat, if accompanied by
cough or diaphoresis, time of day when it most likely occurs, interference
with ADL, precipitated by any specific activities, accompanied by cyanosis.
 Wheezing
 Chest pain
 Hemoptysis
 Ask about exposure to infectious conductions such as colds, influenza, chronic
respiratory diseases – asthma, chronic bronchitis, emphysema, chronic
obstructive pulmonary (Lung) disease (COPD), heart failure, previous
pneumonia, tuberculosis

 LIFESTYLE: smoking (note type of tobacco, duration, number per day, number
of years of smoking, inhalation, related cough, desire to quite), marijuana,
cocaine, extent of alcohol consumption.

 OCCUPATION: (work conditions that could irritate respiratory system-

asbestos, chemical irritants, dry cleaning fumes monitoring or protection of
exposure conditions), Geographical location (environmental conditions that could

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 irritate respiratory system – chemical plants/industrial pollutants, coal dust,
animal droppings, type and frequency of exercise/recreation.

 NUTRITION/DIET: fluid intake per 24-hour period, intake of vitamin.

 PAST MEDICAL HISTORY: immunizations (yearly immunization for
cold/flue, frequency and results of tuberculin skin testing), allergies (foods, drugs,
contact or inhalant allergens, precipitating factors, specific treatment,
desensitization).

PHYSICAL EXAMINATION

 Inspect for configuration of the chest (Kyphosis, scoliosis, barrel chest) and
cyanosis.
 Determine rate and pattern of breathing (normal rate:12-18/minute, note
tachypnea, hyperventilation or labored breathing pattern.
 Palpate skin, subcutaneous structures, muscles for testure, temperature and degree
of development.
 Palpate for tracheal position, respiratory excurtion (symmetric or asymmetric
movement of the chest), and for fremitus.
 Percuss lung fields – find resonance over normal lung tissue, note hyper-resonance
or dullness, for diaphragmatic excursion (normal distance between levels of
dullness on full expiration and full inspiration is 6-12cm).
 Auscultate for normal (vesicular, bronchial, bronchovesicular) and adventitious
(rales or crackles, rhonchi, Pleura friction rub), breath sound.

Review of diagnostic procedure and nurses role of respiratory system

LABORATORY/DIAGNOSTIC TESTS

Blood studies

 Arterial blood gas (ABGS): Obtained through puncture of radial or femoral artery,
brachial or through arterial catheter.
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 Indication

 Measure acid base balance, base excess/deficit, blood PH, CO 2, O2 saturation

(SaO2), PCO2 (Partial pressure of carbon dioxide), PO 2 (Partial Pressure of
Oxygen).

NURSING CARE/RESPONSIBILITY

 Explain the purpose and procedure to the patient.

 Assist with positioning e.g palm up, wrist, slightly heperanized syringe if radial
artery is used.
 To ensure accurate result, expel air bubbles.
 Gently rotate sample in test tube to mix heparin with the blood.
 Place sample in water container until it can be analyzed.
 Apply pressure to artery for 5 minutes after specimen is obtained to prevent
haematoma at the arterial puncture site.
The normal values, parameter for ABG are ;
ACID-BALANCe as PH ;
 Normal: 7.35 - 7.45
 Alkalaemia increased: 7.45
 Acedemia decreased: 7.35
OXYGENATION PaO2 ;
 Normal: 80-100 mmHg
 Hyperxaemia 100mmHg
 Hypoxaemia 80mmHg
VENTILATION
 SaO2, Normal: 95-98%
 PacO2 Normal: 35-45mmHg
 Hypercapnia 45mmHg
 Hypocapnia 35mmHg

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HAEMOGLOBIN TEST: reflects amount of haemoglobin available for combination
with oxygen

 Normal level of adult man is 135 – 180g/dl (13.5-18g/L)

 Normal level of adult woman is 12-16g/dl (120-160g/L)

Nursing responsibilities during the procedure ;

1. Explain the procedure and it purpose.

2. No special care is required.

HAEMATOCRIT TEST: reflects ratio of red blood cells to plasma increased

haematocrit (polycythaemia) found in chronic hypoxaemia venous blood is used.
 Normal for adult man 40 -54%
 Normal for adult womam is 38 -47%
Nursing responsibility is as in HB test

ANTITRYPSIN ASSAY: is valuable in the identification of individuals with the genetic

abnormality that leads to emphysema. This is a globulin that inhibits certain enzymes.

The normal values of a, – antitrypsin assay ;

MM genotype: 2.1-3.8u/ml

M2 phenotype: 1.05 -2.1u/ml

22 phenotype: 0.5 -0.7 u/ml

The nursing care includes as in haemoglobin ;

1. No food or fluid restrictions are necessary.

COMPLETE BLOOD COUNT

The normal counts of RBCs in ;

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 Male: 4.6 -6.2 million/L
Females: 4.2 – 5.4 million/L
The normal level of WBC: 4.0 - 11 X 101/L
SPUTUM CULTURE AND SENSITIVITY (SPUTUM ANALYSIS)
 Culture: isolation and identification of specific microorganism from specimen
 Sensitivity: determination of antibiotic agent effective against organism (sensitive or
resistant)
 Gram Stain: staining of sputum permits classification of bacteria into Gram-positive
types. Results guide therapy until culture and sensitivity results are obtained. Here
nurse instructs patient to expectorate sputum into the container after coughing deeply.
Obtain sputum in early morning because secretions collect during night.

If unsuccessful, try increasing oral fluids intake unless fluids are restricted collect
sputum in sterile container (Sputum trap) during sanctioning or by aspiration secretions
from the trachea. Send specimen to laboratory promptly.

Nursing care for sputum and sensitivity

 Explain necessity of effective coughing.

 If client unable to cough, heated aerosol will assist with obtaining a specimen.
 Collect specimen in a sterile container that can be capped afterwards.
 Volume need not exceed 1-3ml.
 Deliver specimen to laboratory rapidly.
ACID-FAST SMEAR CULTURE
Test is performed to collect sputum for acid-fast bacilli (AFB). A series of 3 early
morning specimen is used.
Nursing responsibility as in Gram stain
1. cover specimen and send to laboratory for analysis.
CYTOLOGY

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 In this sputum specimen is collected in special container with fixative solution.
Purpose is to determine presence of abnormal cells that may indicate malignant
condition. The nurse should send specimens to laboratory promptly and take measure
in other tests.

OXIMETRY
Test monitors arterial or venous oxygen saturation device attached to the ear lobe
finger or nose for Spo2 or in a pulmonary artery catheter for SVO2 monitoring.

Nursing responsibilities include ;

 Applying probe to finger, forehead, earlobe or bridge of nose.

 When interpreting SPO2 and SVO2 value, first assess patient status.
 Presence of factors that alter accuracy of pulse oximeter (e.g SPO 2 – motion, low
perfusion, bright lights, use of intravenous dyes, acry/mg nails, dark skin colour
for SPO2,
 notify the physician of ±4 percent change baseline or decrease less than 90
percent.
SVO2 – change in O2 delivery or O2 consumptions
 For SVO2 notify physician of ± 10 percent change from baseline or decrease to
less than 60 percent
TUBERCULIN SKIN TEST
 Intradermal test done to detect tuberculosis infection-does not differentiate active
from dormant infections.
 Purified protein derivation (PPD) tuberculin administered to determine any
previous sensitization to tubercle bacillus.
SEVERAL METHODS OF ADMINISTRATION
 Mantouxtest: 0.1ml solution 0.5 tuberculin in injected into the forearm.
 Time test: stainless steel disc with 4 tines impregnated with PPD tuberculin is
pressed into the skin.

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  Results: read within 48 -72 hours: inspect skin and circle zone of induration with
pencil, measure zone diameter in MM
 Negative: zone diameter less than 5 MM
 Doubtful or probable: zone diameter 5-10 MM
 Positive: zone diameter 100 MM or more

PULMONARY FUNCTION TEST/STUDIES

 Evaluation of lung volume and capacities by spirometer, tidal volume (TV), vital
capacity (UC), inspiratpory and expiratory reserve volume (IRV and ERU),
residual functional residual capacity (FRC).
 Involves use of a spirometer to diagram movement of air as client performs
various respiration measures, shows restriction or obstruction to airflow or both.
Nursing care ;
 Explain procedure to help allay anxiety and ensure cooperation.
 Perform test before meals.
 Withhold medication (bronchodilator) 6hrs before procedure, unless otherwise
prescribed.
 After procedure assess pulse and provide rest.

RADIOLOGICAL STUDIES

 Chest X-ray used to screen, diagnose, and evaluate change. Most common views
are postero-anterior and lateral.

Nursing care ;

In this, the nurse instructs patient to undress to waist, put on gown and remove any
metal between neck and waist.

COMPUTED TOMOGRAPHY (CT)

Test is performed for diagnostic of lesions difficult to assess by conventional X –
ray studies, such as those in the hilum, mediastinum.
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MAGNETIC RESONANCE IMAGING (MRI)
Test is used for diagnosis of lesions difficult to assess by CT scan (e.g) lung apex
near the spine).
Here, the nurse explains purpose, takes, measures as in chest x-ray and instructs
the patient to remove all metal (e.g jewellery watch) before test. It takes an hour
VENTILATION/PERFUSION (V/P) LUNG SCAN:
Test is used to identify areas of the lung not receiving air flow (Ventilator) or blood
flow (Perfusion). It involves injection of radioisotope and inhalation of small amount of
radioactive gas (Xenon). As gamma detecting device is used to record
radioactivity.Ventilation without perfusion suggests pulmonary embolus.
Nursing care
 Check dor Z –ray
 Check for dye allergy
 Obtain an accurate weight so that the dosage of radioactive agent can be calculated
NB: No special care or precaution is needed afterwards (post test) because the
gas and isotope transmit radioactivity for only brief interval

PULMONARY ANGIOGRAM

Study is used to visualize pulmonary vasculature and locate obstructions such as

pulmonary embolus. A radio-opaque dye is injected, usually throught a catheter into
the pulmonary artery or right side of the heart,

Nursing measures same as chest x-ray ;

 Know that dye injection may cause flushing, warm sensation and coughing. Check
pressure dressing site after procedure.

 Monitor blood pressure, pulse rate, and circulation distal to injection site. Report
and record significant changes.

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POSITRON EMISSION TOMOGRAPHY (PET)

Test is used to distinguish benign and malignant lung nodules. It involves IV injection
of a radioisotope with short half life.

Nursing measures same as V/P (Ventilatfion/perfusion)

ENDOSCOPIC EXAMINATION BRONCHOSCOPY

This study is performed in outpatient, procedure room, ward, or theatre. It is the

direct inspection and examination of the larynx trachea and bronchi through either
flexible fibroptic bronchoscope or a rigid bronchoscope that can be directed into the
segmental bronchi.

Diagram

Indication

 To remove foreign bodies from the tracheobronchial tree.

 To remove secretions obstructing the tracheobronchial tree when patient can not
clear them.
 To destroy and excise lesions.

Nursing Responsibilities Before the Procedure

 Prior to the procedure confirm that a signed or consent form has been obtain.
 Explain procedure, remove dentures and partial plate or oral prosthesis.
 Provide mouth care.
 Keep client NPO 6-12 hours to reduce aspiration.
 Give prescribed drug e.g atropine, opiod and diazepam as prescribed.
 Monitor vital signs.
 Have emergency resuscitation equipment readily available.

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During Procedure ;

 Position client in semi-Fowler's.

 Procedure takes 30-45 minutes.

After procedure ;

 Keep resuscitation and suction equipment at the bed side.

 NPO by client until cough and gag reflex returns.
 Maintain client in semi-Fowler's position.
 Closely monitor vital signs and respiratory status.
 Give ice sips when reflexes is established, then fluids.
 Provide emesis basin and tissues for expectorating sputum and saliva.
 Monitor colour, character of respiratory secretions, hemorrhage sore throat and
hoarse voice after procedure, then notify physician.
 A fever may develop during the first 24 hours after procedure.
 Observe for hypoxia, hypo-tension, tachycardia, dysrhythmias and hemoptysis.
 Report any shortness of breathy purulent sputum, wheezing, difficulty in
breathing or chest pain immediately.

MEDIASTINOSCOPY

Test is used for inspection and biopsy of lymph nodes in mediastinal area.

The nurse prepared patient for surgical intervention. Obtains signed permit.
Afterwards, monitor as for bronchoscopy.

BIOPSY

In the lung, biopsy specimen may be obtained by transbrochial or open lung biopsy.
This test is used.;

Indication

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 To obtain specimen for laboratory analysis

Nursing Responsibilities

Same as bronchoscopy

THORACENTESIS

This is the insertion of a needle through the chest wall into the pleura space.

Indication

 To obtains specimen of pleura fluid for diagnosis.

 To remove pleura fluid and air from pleura cavity.
 Pleura biopsy.
 Instillation of medication into the pleura space.

Nursing Responsibilities

 Consent form signed and go with X-ray to procedure room.

 Position patient upright or sitting at edge of the bed with the feet supported and
arms and head on a padded bed table.
 Instruct client not to talk, cough.
 Obtain vital signs.

During Procedure

 Assist and reassure patient.

 If large volume of fluid is removed, monitor for decrease breath.
 Send specimen to the laboratory.
 Encourage not to cough.

After Procedure

 Obtain vital signs.

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  Monitor patient for bleeding.
 Apply pressure over the punctured site.
 Advise patient to be on bed rest.
 Record total amount of fluid withdrawn.
 Document the nature of fluid, colour.
 Prepare sample for laboratory evaluation.
 Monitor the patient at intervals for increasing respiratory rate, faintness tightness
of chest, rapid pulse and signs of hypoxemia.

THORACOSCOPY

Thoracoscopy is a diagnostic procedure in which the pleura cavity is examined with

an endoscope. Small incisions are made into the pleura cavity in an intercostal space,
location of the incision depends on the clinical and diagnostic findings.

After any fluid present in the pleura cavity is aspirated, the fiberoptic
mediastinoscope is inserted into the pleura cavity and its surface inspected through the
instrument.

After the procedure

A chest tube may be inserted and the pleura cavity is drained by negative pressure
water seal drainage.

Indication

 For diagnostic evaluation of pleura effusions,

 Pleura disease
 Tumor stage
 Biopsy

NSG Intervention or Respiration

 Monitor shortness of breath in the care facility and at home.

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  Minor activity restriction.
 If chest tube is inserted, monitor the chest drainage system and chest tube insertion
site.

TRACHEOSTOMY

A tracheostomy is a surgical incision into the trachea for the purpose of establishing
and airway. It is the stoma (an opening) that results from the tracheostomy. The
tracheostomy can be temporary or permanent.

Indications are to ;

 Bypass an upper airway obstruction.

 Facilitate removal of secretions.
 Permit long-term mechanical ventilation.
 Permit oral intake and speech in the patient who requires long term mechanical
ventilation.

Types of Tracheostomy Tubes

 Double – lumen tube

 Single – lumen tube
 Cuffed tube
 Cuff-less tube
 Fenestrated tube
 Cuffed fenestrated tube
 Metal Tracheostomy
 Talking Tracheostomy

Complications of a Tracheostomy

 Tube obstruction
 Tube dislodgment

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 Tracheomalacia
 Tracheal stenosis
 Tracheoesophageal fistula
 Trachea in-nominate artery fistula

Procedure for Suctioning Tracheostomy

 Gather all supplies

 Provide privacy.
 Explain the procedure and provide for communication (e.g. eye blinking or raising
a finger to indicate distress).
 Place in semi-Fowler's or Fowler's position
 Use standard precautions and sterile technique as indicated
 Assess lung sounds suction as needed using sterile technique
 Wearing clean gloves remove the tracheostomy dressing
 Wearing sterile gloves, use sterile applicator or gauze 4 x 4s moistened with
normal saline to clean the incision.
 If the tracheostomy tube has an inner cannula that can be removed for cleaning,
remove the tube and soak it is sterile saline
 Cleanse the tracheostomy tube flange (collar) in the same manner as the incision
 Clean the inner cannula using a small brush or cotton Tipped applicators.
 Rinse thoroughly in normal saline and tap it gently to remove excess liquid
 Suction the outer cannula using sterile technique
 Replace the inner cannula into the tracheostomy tube
 Replace the dressing.
 Do not cut the dressing or use a cotton filled dressing because fibers may be
aspirated into the respiratory tract
 Apply clean tracheostomy ties or a clean tracheostomy holder
 Once the tracheostomy is secured, remove the old ties
 Assess breathing and tolerance of the procedure

23
  Dispose of supplies and used solutions.
 Wash hands
 Repeat care three time daily.

Documentation

 Date: Suction for moderate amount time of thin, yellow sputum. Lung sounds
clear after suncting. Incision clean, no evidence of inflammation. Healing well,
tolerated procedure well

 Signature …..J Peters RN

 Organize questions so that patient can use a simple “yes” or “No” response
(nodding head, using hand signals or squeezing the nurse’s hand), equally an
erasable board or note pad to communicate.
 Keep call light or tap bell with the patient reach.
 Reinforce that the ability to speak will return when the tube is removed.
 Observe special precautions during the immediate extuation period
 Monitor for signs such as increased respiratory distress increased restlessness,
hoarseness and laryngeal stridor.
 Assess for adequacy of cough and gag reflex.

Nursing Care/Management ;

Before the procedure, the nurse should explain to the patient and family the purpose
of the procedure. Inform them that the patient will not be able o speak if an inflated cuff
is used and when cuff is removed, normal speech will be possible.

It is essential that the following preventive nursing intervention be consistently

implemented.

 Minimize infection

24
  Provide constant cool airway humidification to avoid thicken and crusting of
bronchial secretion
 All respiratory therapy equipment should be changed every 6 hours
 Provide frequent mouth care
 Maintain adequate nutrition through par-enteral or gastrointestinal feedings with
supplements.
 Assess for bowel sounds, tube placement
 Elevate head of the bed at 45 degrees and inflate the tracheostomy tube, then
administer feeding 20-30 minutes
 Keep head of bed elevated for 45-600
 Assess at regular intervals
 Ensure adequate ventilation and oxygenation
 Assess lung sounds regularly
 Turn and reposition the patient every 2 hours for maximum ventilation and lung
perfusion
 Assess respiratory frequency, tidal volume and vital capacity
 Perform postural drainage, percussion and vibration
 Provide safety and comfort
 Assess for aspiration in unconscious person, tube placement in regular intervals
 Change taps or ties whenever soiled to decrease skin irritation.
 Always keep spare tube at bed side

ASTHMA

Definition :

Asthma is an inflammatory disease characterized by hyper responsiveness of the

airways and periods of bronchospasm, resulting in intermittent airway obstruction .

The onset of asthma is sudden or may be gradual

25
AETIOLOGY

Asthma is caused by increased responsiveness of the trachea and bronchi to various

stimuli that cause narrowing of the airways and difficulty in breathing. The common
factors triggering an asthma attack include:

ENVIRONMENT FACTORS

 Change in temperature (cold air)

 Change in humidity (dry air)
 Atmospheric pollutants
 Cigarette and industrial smoke, Ozone sulphur dioxide, formaldehyde.
 Exhaust fumes, oxidants, aerosol sprays
 Strong odors, perfumes
 Allergen inhalation
 Feathers, animal dander's, dust mites, molds allergens
 Foods treated with sulfates, beer, wine, fruit juices, snack foods salads potatoes,
shellfish and dried fruits etc
 Stress and emotional upset
 InfeQction: Vital upper respiratory infection sinusitis
 Medications: Aspirin and NSA-IDs, B-blockers (including eye drops of glaucoma)
 Enzymes: including those in laundry detergents
 Occupational exposure: Metal salts, wood, dust, industrial chemicals and plastics.

PATHOPHYSIOLOGY

There are two types of asthma Extrinsic asthma results from inflammatory response
caused by mast cell activation (by dust, pollen, animal dander, foods and molds),
neutrophils, eosinophil and lymphocytes. These activated mast cells release several
chemicals called mediators. These chemicals include histamine, bradykinin,
prostaglandins, and leukotrienes, perpetuate the inflammatory response, causing

26
increased blood flow, vasoconstriction, fluid leak from the vasculature, attraction of
white blood cells to the area and bronchoconstriction.

Further, alpha- and beta2 – adrenergic receptors of the sympathetic nervous system
are located in the bronchi. When the alpha- adrenergic receptors are stimulated,
bronchoconstriction occurs, and when the beta2 – adrenergic receptors are stimulated
bronchodilation results. The balance between alpha and beta 2 receptors is controlled
primarily by cyclic adenosine mono-phosphate (CAMP). Alpha – adrenergic receptor
stimulation results in a decrease in CAMP, which leads to an increase of chemical
mediators released by the mast cells and bronchoconstriction, Beta2 – receptor stimulation
results in increased level of CAMP, which inhibits the release of chemical mediators and
causes bronchodilation.

Intrinsic asthma occurs in adults 35 yeas of age, the asthma attack is often severe.

Clinical Manifestations

 Recurrent episodes of wheezing

 Breathlessness or dyspnea
 Chest tightness
 Cough at night and in the early morning
 Diaphoresis
 Tachycardia
 Widened pulse pressure may occur along with hypoxemia
 Central cyanosis

Assessment and Diagnostic Findings

 A complete family environmental and occupational history is essential

 Client history of eczema
 Respiratory distress: shortness of breath
 Expiratory wheeze

27
  Prolonged expiratory phase, air trapping (barrel chest if chronic)
 Use of accessory muscles respiration
 Irritability (from hypoxia), diaphoresis

Medical Management

 Drug theraphy: Bronchodilators

 Beta – adrenergic agonists
 Metered does inhaler (MDI)
 Nebulizer – infants and toddlers
 Rescue drugs for acute attack corticosteroids
 Inhaled by MDI or nebulizers
 Oral for persistent wheezing
 IV in hospital
 Nonsteroidal antinflamatory agents
 Cromolyn sodium
 Nedocromil
 Leukotriene inhibitors and receptor antagonists
 Used for maintenance, not rescue
 Xanthine – derivatives
 Theophylline (oral)
 Aminophylline (IV)
 Used for staus asthmaticus
 Procedure for the use of oral inhaler
 Physical therapy
 Hyposensitization
 Exercise

Diagnostic Tests

 ABGs indicate respiratory acidosis

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  Sputum and blood test may disclose eosinophil (elevated levels of eosimophils
 Serum levels of immunoglobulin E may be elevated if allergen is present
 Use of oximetry reveal hypoxemia during acute attack

Complications

 Status asthmaticus
 Respiratory failure
 Pneumonia
 Atelectasis
 Airway abstraction during acute episode
 Dehydration from diaphoresis and insensible fluid loss with hyperventilation.

Prevention

 Patients with recurrent asthma should undergo tests to identify the substances that
precipitate the symptoms
 Possible causes are dust-mites, dust certain types of cloth, pets, horses detergents,
soaps, certain foods molds and pollen's. If the attacks are seasonal, pollen's can
strongly be suspected then patient is instructed to the avoid causative agent if
possible.
 Educate patient on knowledge about his ailment. (Teaching patient on self care)
 Use of outpatient follow – up care for patients
 Health care providers should encourage the use of peak flow meters that measures
the highest volume of air flow during a forced expiration. Volume is measured in
colour – coded zone:
 Green zone signifies 80% to 100% of personal best
 Yellow 60% to 80%
 Red, less than 60%
 If peak-flow falls below the red zone, the patient should take the appropriate
action prescribed by his or her health care provide.

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Nursing Interventions

 Place patient in high-Fowler's position.

 Administer oxygen as prescribed
 Administer medications as prescribed
 Provide humidification/hydration to loosen secretions
 Provide chest percussion's and postural drainage when bronchodilation improves
 Monitor for respiratory distress
 Provide client teaching and discharge planning concerning
 Modification of environment
 Ensure that room is well ventilated
 Stay indoors during grass cutting or when pollen count is high
 Use damp dusting
 Avoid rugs, draperies or curtains, stuffed animals
 Avoid natural fibers (wool and feathers)
 Importance of moderate exercises

Procedure for use of oral inhaler

 Remove the cap from the mouth piece and shake the inhaler well.
 Hold the inhaler so the metal canister containing the medication is upside down
 Breath out as full as possible
 Open your mouth and tilt your head back slightly. Hold the inhaler at 2 inches
from your mouth.
 Firmly press the metal canister down into the mouthpiece. This releases the
medication. At the sometime begin to inhale slowly through your mouth.
 Hold your breath for about 10 seconds
 Slowly breathe out through your nose and pursed lips
 Wait about 5 minutes, shake the inhaler, and repeat if necessary. Cap and store the
inhaler.

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  Rinse your mouth with water or gargle after the last inhalation
 Periodically clean the mouth piece by removing the canister and rinsing the mouth
piece in warn water. Dry it and replace the canister

The nurse should reinforce the procedure that has been taught.

STATUS ASTHMATICUS

Status Asthmaticus is severe and persistent asthma that does not response to
conventional therapy. The attack can last longer than 24 hrs. infection, anxiety, nebulizer
abuse, dehydration, increased adrenergic blockage and non specific irritants may
contribute to these episodes Anacute episode may be precipitated by hypersensitivity to
aspirin.

PATHOPHYSIOLOGY TO ASTHNSA

The basic characteristics of Asthma (constriction of the broncholar smooth muscle,

swelling of the bronchial mucosa and thickened secretions) decrease the diameter of the
bronchi and are apparent in status asthmaticus. Ventilation perfusion abnormality results
in hypoxia and respiratory alkalosis initially followed by respiratory acidosis. There is a
reduced PaO2 (saturated O2) and an initial respiratory alkalosis with a decreased PacO 2
and an increased PH. As status asthmaticus worsens, the Paco 2 increases and the PH falls
reflecting respiratory acidosis

Clinical Manifestation

 Labored breathing
 Prolong exhalation
 Engorged neck veins
 Wheezing

The extent of the wheezing does not indicate the severity of the attack

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 As the obstruction worsens, the wheezing may disappear and this is a sign of
impending respiratory failure.

ASSESSMENT/DIAGNOSTIC FINDINGS

 Pulmonary function studies are the most accurate

 Arterial blood gas
 Respiratory alkalosis (low Paco2) most common findings in patients with asthma
 A rising Paco2 (to normal levels or levels indication respiratory acidosis)
frequently is a danger sign of impending respiratory failure.

Medical Management

 In the emergency setting, the patient is treated initially with a short-acting beta-
adrenergic agonist and corticosteroids.
 Patient requires supplemental oxygen and intravenous fluids for hydration
 Oxygen therapy is initiated to treat dyspnea, central cyanosis and hyposmia
 Humidified O2 by either venture mask or nasal catheter is administer
 The flow is based on the arterial blood gas value and pulse oximetry
 Need for hospitalization include poor pulmonary function test results and
deteriorating blood gas levels (respiratory acidosis) which may indicate that the
patient is tiring and will require mechanical ventilation.

Death from asthma is associated with several risk factors include the following ;

 Past history of sudden and severe exacerbation

 Two or more hospitalizations for asthma within the past year
 Three or more emergency care visits for asthma in the past year
 Excessive use of short acting beta canisters per month)
 Recent withdrawal from systemic corticosteroids
 Comorbidity of cardiovascular disease or copd
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  Psychiatric disease
 Low socioeconomic status
 Urban residence

Nursing Management

 The nurse constantly monitor the patient for the first 12-24 hrs until status
asthmaticus is under control
 The nurse assesses the patient’s skin turgor to identify signs of dehydration
 Fluid intake is essential to combat dehydration, loosen secretions and facilitate
expectoration.
 The nurse administers intravenous fluids as prescribed, up to 3 to 4L/day
 The patient’s energy needs to be preserved room should be quiet, free of respiratory
puritans including flowers, tobacco smoke, perfumes or odors of cleaning agents.
 A non-allergenic pillow should be used.

Surgical Management of Largngectomy

There are four different types of laryngectomy ;

 Partial laryngectomy
 Supraglottic laryngectomy
 Hemilaryngectomy
 Total largngectomy
 Maintain a patent airway as demonstrated by normal respiratory rate and rhythm
 Maintain optimal fluid intake

LARYNGECTOMY: removal of the larynx may be necessary for some clients.

33
 PARTIAL LARYNGECTOMY: (removal of one half or more of the larynx), client
is able to resume normal speaking, breathing and swallowing.

TRACHEOSYTOMY: (surgical opening into the trachea) tube may be inserted to

maintain the airway the early post operative period, but it is usually removed within a
week and the stoma is allowed to heal.

In TOTAL LARYNGECTOMY, the entire larynx is removed, along with the

surrounding tissues. Normal speech is lost and a PERMANENT TRACHEOSTOMY is
created. The tracheostomy tube inserted during surgery may be left in place for several
weeks and then removed, leaving a natura stoma, or left in place permanently. Because
the trachea and the esophagus are permanently separated by this surgery, there is no risk
of aspiration during swallowing.

NSG care plan client with upper respiratory infection :

Monica Underman is a 27 years old woman who was recently treated for tonsillitis
causedby group A streptococcus. She presents to the emergency department (ED) 10 days
later appeariny acutely ill. She states that her throat is, so sore that she has difficulty
swallow and even liquids. Babara Ironhorse, the ED nurse, completes an assessment of
Ms Wunderman.

Assessment - T :1020F (38.80c)

On inspectfion of her mouth an acutely swollen and reddened area of the soft palate
is noted. Yellow exudate is present. CBC reveals on elevated WBC of 16,000m3. A
diagnosis of peritonsillar abscess is made. Needle aspiration of the abscess is performed.

Nursing diagnosis

The following Nursing Diagnosis are identified for MS Wounderman

 Acute pain related to swelling

 Risk for ineffective airway clearance related to pain and swelling

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  Deficient fluid volume related to fever and difficulty in swallowing fluids

Expected outcomes for the plan of care for Ms W

Ms Wunderman will experience minimal pain or no pain

NURSING PROCESS: THE PATIENT UNDERGOING LARYNGECTOMY

Nursing Diagnoses

 Deficient knowledge about the surgical procedure and post operative care
 Anxiety and depression related to diagnosis of cancer and impending surgery
 Ineffective airway clearance related to excess mucus production 2 0 to surgical
alteration in the airway
 Impaired verbal communication related to anatomic deficit 20 to removal of the
larynx and to oedema
 Imbalance related to inability to ingest food 20 to swallowing difficulties
 Disturbed body image and low self esteem 2 0 to major neck surgery, change in
structure and function of the larynx
 Self care deficit related to pain, weakness, fatigue.

If cervical lymph nodes contain cancer cell, a modified or radical neck dissection
may be done along with total laryngectomy. In a radical neck dissection cervical lymph
nodes, the sternocleidomastoid muscle internal jugular vein, cranial nerve XI (spinal
accessory), and sub-maxillary salivary gland are removed on the tumor side of the neck.
After surgery, the client may have difficulty lifting and turning the head because of
muscle loss. The shoulder on the affected side drops. Postoperative neck exercises can
help reduce shoulder drop and increase range of motion on the affected side

SPEECH REHABILITATION

35
Various techniques may be used to restore – A surgical procedure: the
TRACHESOPHAGEAL PUNCTURE (TEP) is method used to restore speech

TEP creates a small fistula (passage between the posterior tracheal wall and anterior
oesophagus. A small, one way value in the fistula allows the client to force air from the
lungs into the mouth by covering the tracheostomy stoma with a finger. The air creates
vibration and sound, the client uses the lounge lips, teeth and palate to articulate words.
The one way value prevents food from entering the trachea.

 Several speech generators are available for the laryngectomy client one type is
held against the neck, it transmits vibrations to the neck and into the mouth.
Muscles of the mouth and tongue form vibrations into the words.
 Another device delivers a tone into the mouth through a plastic tube. The lips,
tongue and mouth muscles form the sound into words.

Esophageal speech uses swallowed air and controlled belching to create sound and form
words.

Prioritizing Nursing care for Client

 The immediate priority of care for the client who has undergone a total
laryngectomy with radical neck dissection is maintaining a patent airway,
facilitating communication, promoting nutrition become priority for nursing.

Nursing Diagnosis

 RISK FOR IMPAIRED AIRWAY CLEARANCE : Expected outcome - Airway

will remain clear evidence by clear breath sounds and absence of stridor,
respiratory distress
1. Apply cold packs to the neck as prescribed: “Applying cold pack constricts
blood vessels and reduces oedema development”
2. Withhold food and fluids until cough and gag reflexes have returned. “Local
anaesthesia used during removal of benign tumor, nodules and small
36
 malignancies impairs the cough, gag reflexes, increasing the risk for
aspiration.”

 IMPAIRED VERBAL COMMUNICATION : Expected outcome - will

effectively communicate needs using alternative ways of communicating (both short
long term
1. Before surgery, assess for additional obstacles to communication. “Hearing
loss, illiteracy, previous stroke/weakness may affect the ability to use
alternate communication strategies”
2. Provide alternate ways to communicate (pencil and paper, magic state, an
alphabet board) and encourage practice. “Having the client choose what to
practice helps reduce anxiety and increase the sense of control.”
3. Encourage the client to consult a speech therapist before surgery if possible
“The client may be a candidate for esophageal speech, TEP or a speech
generator.”
4. Assess frequently, place the call bell at hand when leaving. “The pressure and
availability of a caring nurse decrease anxiety and promote
communication.”
 IMBALANCE NUTRITION: LESS THAN BODY REQUIREMENTS :
Expected outcome - will consume 100% of the recommended diet once oral intake
is allowed. Weight will remain stable. After surgery enteral or parenteral feedings
often are prescribed unto client is able to eat. After a total laryngectomy, the client
initially loses the senses of taste and smell patient may partially recover the sense of
taste but may complain that eating no longer hold pleasure.
1. Assess nutritional status using height and weight charts, reported weight loss
and body mass indicators as skin folds. “A complete assessment aids in
planning to meet current and anticipated calorie.”

37
 2. Evaluate current diet, preferred foods and understanding of nutrition.
“Providing a diet that takes the client’s preferences into account will
encourage adequate intake”
3. Monitor intake and output and food consumption. “Monitoring food and fluid
intake is necessary to determine whether the client is consuming adequate
calories and fluids for heating”
4. Weight daily. “This daily weight provides a measure of both nutritional
status and fluid balance”
5. Contact the dietitian for further evaluation, planning and education. “A
professional can identify nutritional needs and help plan a diet to meet
them”
6. Encourage experimentation with foods of different textures and temperature
“cold foods or foods with a soft texture are easier to swallow”
7. Encourage frequent, small meals rather than three large meals per day. “The
client who has difficulty swallow is likely to consume more food this way”
8. Recommended liquid supplements such as needed to increase calorie intake.
Provide information about where to obtain supplements “liquid dietary
supplements provide balanced nutrition and added calories. They are
available in major supermarkets.”
9. Provide mouth care before meals and supplemental feedings. For the client
with stomatitits esophagitis related to radiation or chemotherapy, provide a
topical anaesthetic such as viscous lidocaine before eating. “Bad breath or
foul taste in the mouth suppresses appetite. Inflamed mucosa may make
eating uncomfortable. A topical anaesthetic can relieve discomfort and
promote food intake.”
10. Provide an anti-emetic 30 minutes before eating if nausea is a problem. “An
anti-emetic can relieve nausea and make eating possible.”
 GRIEVING : Expected outcome - will express feelings about the diagnosis and
effects of treatment on ability to speak.

38
 The client with laryngeal cancer faces the diagnosis of cancer, the prospect of
mutilating surgery, loss of both a body part and important function, speech. Loss of
speech affects social interactions, one’s career, and ability to get help when
necessary. A radical neck dissection changes the appearance and function
of the neck, altering body image and self concept.
1. Provide opportunities for the client and family members to express feelings
of grief, anger, fear about the diagnosis of cancer, impending surgery and the
anticipated loss of speech. “The client needs the opportunity/permission to
grieve anticipated losses in order to move toward coping and acceptance of
the loss.”
2. Be calm and supportive. Provide privacy and emotional support for the
client and family to work through the grieving process. “It is important for
the client and family to know that their feelings of loss are real and
accepted by care givers.”
3. Help the client and family discuss the potential impact of the loss in family
structure and function. “Discussion helps family members to understand
and support one another.”
4. Refer the client and family for counseling as appropriate. “Counselling may
be necessary to prevent a sense of defeat and hopelessness.”
5. Help the client and family identify additional resources for coping such as
strategies they have used in the past to deal with crises. “This identify
strengths they can use to deal with the present situation.”

Evaluation

 Airway remains patent, experiences no difficulty breathing

 Communicates care needs effectively by use of assistive devices such as a call
bells.
 Anxiety remains within a manageable level-expresses a sense of hope
 Maintains weight

39
  Demonstrates willingness to participate in speech therapy and support groups
 Acquires an adequate knowledge, verbalizing and understanding of the surgical
procedure and performing self-care adequately.
 Maintains balance nutrition and adequate fluid intake
 Exhibits improved body image, self esteem and self—concept
 Expresses feelings and concerns making
 Accepts information about support group

OCCUPATIONAL LUNG DISEASES

Occupational or environmental lung diseases result from inhaled dust or chemicals.

The duration of exposure and the amount of inhalants have a major influence on whether
the exposed individual will have lung damage

Another factor is the susceptibility of the host.

AETIOLOGY

Caused by substances inhaled in work place. Occupational lung diseases are more
common in:

 Industrial areas than in rural areas

 Small and medium sized business than in larger industrial plans.

Types

Occupational lung diseases can be divided into several categories. The major one are

 The pneumoconiosis (black lung disease)

 Asbestos – related lung diseases
 Hypersensitivity diseases including occupational asthma allergic alverolitis and
 Byssinosis (brown lung disease)

PATHOPHYSIOLOGY

40
 Pneumoconiosis (“dust in the lungs”) is caused by inhalation and retention of dust
particles. Examples of this condition are:

 Silicosis
 Asbestosis
 Byssinosis

SILICOSIS: caused if inhaled silica dust, most common form seen in miners, foundry
workers and others who inhale relatively low concentration of dust for 10-20 years.

In this dust accumulation is tissue or tissue reaction with shaped nodules throughout
the lungs.

In complicated silicosis there is progressive massive fibrosis throughout the

decreased lung function and corpulmonale. In acute silicosis, there is inflammatory
reaction within alveoli, diffuse fibrosis and rapid progression to respiratory failure.

Clinical Manifestation

 Breathlessness
 Weakness
 Chest pain
 Productive cough with sputum
 dies of corpulmonale and respiratory failure

Preventive measures include

 dust control and improved ventilation to reduce dust levels

 sand blasters in enclosed spaces can use special suits and breathing apparatus

ASBESTOSIS – RELATED LUNG DISEASE

Asbestosis caused lung cancer, malignant mesothelioma of pleura and periosteum,

cancer of the larynx and certain gastrointestinal cancer, asbestosis of fibrotic lung

41
disease. Fibrosis caused by asbestos called asbestosis, asbestos fibres accumulated around
terminal bronchioles, surrounds fibres with iron rich tissue, forming asbestos body with
characteristic picture on X-ray inhaled after 20-30 years of exposure. pleura plaques
which are calcified lesion develop on pleura

Early manifestation

 dysponea
 basal crackles
 decreased vital capacity

Treatment

 radical pleurectomy
 pneumonectomy

Preventive measures

 enforcement for regulations governing mining, milling and use of asbestos

 protective masks must be used when working with asbestos

HYPERSENSITIVITY DISEASES

This fall into occupational category which can occur in bronchi, bronchioles or
alveoli, coarse dust causes bronchial reactions, fine dust previous small airway and
alveoli reactions

 In occupational asthma, hypersensitivity reaction mediated by histamine

bronchoconstriction and increase mucus production repeated attacks if cause
unrecognized and asthma is untreated may lead to permanent destructive lung
diseases, asthmatic responses that is well established can be provoked by other
factors (I.e house dust, cigarette smoke), fatigue, breathing cold air, and coughing
where wheezing is major symptoms.

42
 Prevention

Total elimination of antigen

In farmer’s lung (hypersensitivity pnewmothitis or allergic alveolitis), alveoli are

inflamed increase WBCS, sometimes filled with fluid, if exposure infrequent or level
of dust low, symptoms are mild and treatment not sought, chronic form develops over
a period of time, fibrosis occurs

Symptoms

 fatigue
 shortness of breath
 dry cough
 fever and chills
 symptom may be severe enough to require emergency treatment and
hospitalization

Preventive measures include

 properly dried and stored farm products (hay, straw, sugar cane) – do not cause
allergic alveolitis presumably fungi only grow on moist condition.

BYSSINOSIS (BROWN LUNG DISEASE): is occupational diseases occurs in textile

workers, mainly in cotton workers but also afflict workers in flax and hemp industries
cause is fund in bales of raw cotton

In this, chronic bronchitis and emphysema develop in time. Constriction of

bronchioles in response to something in crude cotton. Symptoms of asthma and allergy
persists and there is exposure to cotton antigen.

Clinical manifestation

43
  Tightness in chest on returning to work after a weekend away (Monday fever)
 Persistent of symptom increases tightness of chest with chronic bronchitis and
emphysema as the person leaves industry as respiratory cripples.

Preventive measures include

 Dust control measures

 Protecting bales of cotton by washing with steam and other agents to inactivate
causative agent.
 Try to detect persons who are likely to become sensitized to cotton dust and keep
them out of high risk areas

Management

Medical therapy of these patients signs and symptoms and complications

The major role of the nurses is to be knowledgeable about the cause and prevention
of occupational lung diseases so that appropriate information and teaching can be
presented to the community

 Prevent or decrease environmental occupational risk

 Well designed effective ventilation can reduce exposure to irritants
 Wearing mask is appropriate in some occupations
 Cigarette smoking must be avoided
 Early diagnosis is essential if disease process is to be halted.

Treatment

 To decrease or stop exposure to harmful agents

 Periodic chest x – rays and pulmonary function studies for exposed employees
with known risk of lung disease

44
 Symptomatic relief if there is coexisted problem such as pneumonia, chronic
bronchitis, emphysema or asthma by providing nursing care accordingly

CHEST TRAUMA AND THORACIC INJURIES

Chest trauma is a major problem often seen in the casualty. Injury to the chest may
affect the bony chest cage, pleura and lungs, diaphragm or mediastinum contents.

AETIOLOGY

Injury to the chest are broadly classified into two groups, blunt and penetrating

 Blunt trauma or non penetrating injuries damage the structures within the chest
cavity without disrupting chest wall integrity. Blunt injury occurs when the body
is struck by a blunt object such as steering wheel. The external injury may appear
minor but the impact may cause severe, life – threatening internal injuries such as
ruptured spleen
 Blunt steering wheel injury to chest may lead to rib fracture, flail chest,
pneumothorax, haemopneumothorax, cardiac contusion, pulmonary contusion,
cardiac tamponade, great vessels tears.

45