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Pulmonary System -nursing process


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Assessment: Subjective Data
Shortness of Breath:
- When: day, night, with or without activity
-orthopnea (difficulty breathing when lying down)

dry, productive, hacking
-treatment an success of treatment

-color, consistency, odor, blood
Chest pain:
-location, description, treatment and success of treatment

Past medical history

Family History


Allergy and environment
Assessment: Objective Data
Four techniques:

Configuration of the thorax:
-AP diameter approximately one hald the width of lateral diameter
-pigeon chest, barrel chest, funnel chest, kypho-scoliosis

Physician signs of pre-existing pulmonary disease
-clubbing of digits, scars, pursed lip breathing

Breathing Pattern:
-normal: rate 12-20, smooth, effortless, regular and symmetrical
-ABNORMAL: tachypnea, bradypnea, hyperventialtion, hypoventilation, cheyne-stokes, apnea

Signs of labored breathing:
-gasping, difficuylty speaking, nasal flaring, pursed lip breathing, accessory muscle use
-fatigue and breathlesness upon exertion

skin and nail beds:
-pale flushed, mottling (blotchy), cyanosis, clubbing

Presence of cough

Level of Consciousness
Memory Board (when doing assessment)

*Chest -wall symetry
*Respiratory rate and pattern
*Accessory muscle use
*Masses or scars
*Paradoxical movement
Food for thougt
men, children, infrants and singers usually use abdominal or diaphramatic breathing.

most women usually use chest or intercostal breathing
*Symmetric chest expansion
*measure chest excursion
*Tactile fremitus (palpable vibration)
*Detects crepitus or any abnormal shapes
Resonance is the noranl sound heard over the lungs

Flat: thigh: consolidation, atelectasis

Dull: thudlike: solid areas like pneumonia

Hyperresonant: stomach: hyperinflation of the lungs

Typanic: drumlike: pneumothorax
Have the patient breathe through the mouth

Nose breathers alter breath sounds

Should be systematic
Voice Sound
Bronchophoney "99"

Egophony "E"

Whispered pectroiloquy "123"
Respiratory Rate

Pulse Rate


Oxygen Saturation
Diagnostic Tests
Sputum Exam
Chest X-Ray, CT scans, MRI
Pulmunary function test -measure lung size, airway patency, vital capacity and tidal volume

Peak expiratory flow rate (peak flow)
Aterial blood gases
Complete Blood count
Pulse oximetry
Nursing Diagnosis

(Ineffective Breathing Pattern)
-state in which a person's inhalation and/or exhalation pattern does not enable adequate pulmonary inflation or emptying

-RELATED FACTORS: pain, neuromuscular impairment, anxiety, fatigue, musculoskeletal impairment

DEFINING FACTORS: Dyspnea, shorness of breath, tachypnea, cyanosis, abnormal ABG
Nursing Diagnosis

(Ineffective airway clearance)
-state in which a person is unable to clear secreation or obstructions fro the respiratory tract to maintain airway patency.

RELATED FACTORS: fatigue, decreased energy, increased secretions, cognitive impairment, trauma, incision pain

DEFINING FACTORS: abnormal breath sounds, tachypnea, ineffective cough, cyanosis
Nursing Diagnosis

(Impaired gas exchange)
-state in which a person experiences a decreased passage of O2 and/or CO2 between the alveoli of the lungs and the vascular system

RELATED FACTORS: hyper and hypoventilation

DEFINING FACTORS: confusion, irritability, restlessness, increased or decreased respiratory rate
Goals and outcome are directed at:
-maintaining a ptent airway
-maintaining adequate gas exchange
-promoting good lung expansion
-mobilizing pulmonary secretions
-maintaining tissue perfusion
-increasing endurance
-performance of activities of daily living
Energy Conservation
-organize activity
-small, frequent meals
-teach strategies for independient ADL's

Self Concept:
Implementation: Airway Maintenance

-semi-fowlers or high fowlers positions make breathing easier
-Repositioning clients frequently prevents pooling of secretions
-Ambulation: may require O2 supplementation
Implementation: Airway Maintenance

Secretion Mobilization
-Hydration: encourage fluids to liquefy secretions. Avoid milk and dairy, as it tends to thicken secretions
-Aerosol therapy and humidification
-Incentive Spirometry
-Coughing and deep breathing
Implementation: Airway Maintenance

Types of Cough
Deep cough: take a deep breath and hold for 1-2 seconds, release air and cough

-Cascade or stacked cough: release of several short blast of air

-Low flow (Huff) cough: inhale deeply, don't hold and exhales saying "huff" 2-3 times

-Quad cough: administer a deep breath, hold for a few seconds and nurse holds below the rib cage and pushes in and up. Rushing air acts to push mucous out of the airway
Implementation: Airway Maintenance
-Pursed lip breathing -helps release trapped air from hyperinflated lungs
-Chest physical therapy and postural drainage (percussion and vibration)
Implementation: Airway Maintenance

(Artificial airways)
-oral airways
-nasal airways
-endotracheal tubes
-tracheotomy tubes

When using artificail airways, air bypasses the body's natural defenses and mechanisms for warming and humidifying

(Oxygen Therapy)
-decreases the work of breathing, of the heart and improves tissue perfusion
Methods of Delivery for Oxygen Therapy
Nasal Cannula: low flow delivery, do not use when more than 4L/min of O2 is needed

Mask: simple: used for short term and can deliver 30-60% O2
-reservoir: delivers higher concentrations

-venturi: delivers 24-50% with low flow O2

Safety: no smoking or flammable substance

-working of system and flow delivery
-HR, RR, level of consciousness, color, O2 saturation
Did the client's behaviors match the behavior stated in the goals and outcomes
Pharmacology: Antihistamines
-common drugs: Benadryl (diphenhydramine)

-Actions: (H-1 antagonist). Inhibits action of histamine and causes vasocontriction and decrease respiratory secretions. Relaxes the smooth muscle in the bronchial tree

-side effects: drowsiness, dry mouth and nose, hypotension, syncope
Pharmacology: Decongestants
-may be oral or nasal
-common drugs: Afrin (oxymetozoline) and sudafed (pseudoephredrine)
-actions: shrink enlarged nsal mucosa and relieve stuffiness by stimulating alpha adenergic receptors causing vasoconstrition

-side effects: insomnia, nervousness, tremors

-sustained use (greater than 3 days) of nasal decongestants can cause rebound congestion and worsening of symptoms
Pharmacology: Antitussives
use with caution

-common drugs: vicsk formula (dextromethorphan)

-actions: suppresses cough through direct action on the couhg reflex center in the medulla

-side effects: dizziness, drowsiness, nausea
Pharmacology: Expectorants
Aide in the removal of mucous

-common drugs: Roitussin (guaifissen)

-actions: works by reflex stimulation to loosen thick secretions which in turn lessens the tendency to cough

-side effects: nausea and vomiting

-drug interactions: anti thyroid drugs, lithium, potassium sparing diuretics
Respiratory Infection
Affects airway clearnance and breathing patterns by changing the amount and characteristics of secretions
Restrictive diseases
-limit lung expansion
-decrease lung volume
-decrease pulmonary compliance
-increase work on breathing
Obstructive disease
-impedes air flow to lung
-can be cause by edema of the airway or tongue
Complications of Oxygen
-O2 induced hypoventilation
-O2 toxicity
-Ocular damage

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