Download Document

Nursing Assessment:
Respiratory System
Chapter 26 Overview
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
1
Structures and Functions of Respiratory
System
Fig. 26-1. Structures of the respiratory tract. A, Pulmonary functional unit. B, Ciliated mucous membrane.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
2
Structures and Functions of Respiratory
System
Fig. 26-2. Landmarks and structures of the chest wall. A, Anterior view. B, Posterior view.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
3
Structures and Functions of Respiratory
System
Upper Respiratory Tract
Lower Respiratory Tract
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
4
Respiratory System
Purpose : gas exchange, Transfer of
oxygen and co2 between the
atmosphere and the blood
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
5
Upper Rasp Tract
Nose, pharynx, adenoids, tonsils,
epiglottis, larynx and trachea.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
6
Lower Respiratory Tract
Bronchi, bronchioles, alveolar ducts
and alveoli.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
7
Resp tract
• Except for right and left main stem bronchi all
lower airway structures are located inside the
lungs
• Right lung has three lobes ( upper, middle and
lower)
• Left lung has two lobes ( upper and lower)
• Structures of the chest wall : ribs, pleural
muscles of respiration
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Upper respiratory tract
• Nose : inside shaped into three passages
called the turbinate
• Turbinate: increases the surface area of the
nasal mucosa, which moistens and warms the
air that enters through the nose.
• Internal nose opens directly into sinuses
• Nasal cavity connects with pharynx
• Pharynx subdivides : nasopharynx,
oropharynx, and laryngopharynx
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Function of the nose
• Warms, humidifies and filters the air before
entering lungs
• Olfactory nerve : responsible for the sense of
smell
• Lymphatic tissues : adenoids are in the
nasopharynx and the tonsils are in the
oropharynx
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Passage of air
• Air moves from oropharynx to laryngopharynx
• Then from laryngopharynx via epiglottis to
larynx and then to trachea
• Epiglottis is a small flap located behind the
tongue that closes over the larynx during
swallowing . Epiglottis is a mechanical
protection for aspiration.
• Vocal codes are located in the larynx
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Passage of air
• Air passes through the glottis and into trachea
• Trachea : is cylindrical, about 5 inches long , 1
inch in diameter and has U shaped cartilage.
• Trachea bifurcates into right and left stem
bronchi at a point called carina
• Carina: important land mark where the cough
reflex is located, area below carina is
considered the lower respiratory system
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Lower respiratory system
• Right main stem bronchus is shorter, wider
and straighter compared to left main stem
bronchus. Therefore right lung is more
susceptible for aspiration.
• Main stem bronchus subdivides into the lobar,
segmental and sub segmental bronchi. Further
division forms bronchioles. Beyond the
bronchioles are the alveolar ducts and
alveolar sacks
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Lower respiratory system
• Bronchioles: encircled with smooth muscles
that constrict and divides( bronchio
constriction and bronchi dilation). Ex bronchi
dilators act on these smooth muscles . Ex
Albuterol.
• Oxygen and co2 exchange takes place in the
respiratory bronchioles
• Areas before bronchioles serves as conductive
pathways and are called anatomical dead
space.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Lower respiratory system
• Alveoli : small sacs and are the primary site of
gas exchange
• Alveoli are inter connected by pores of khon,
which allow movement of air between
alveolus. Deep breathing promotes movement
of air through these pores and assist in
moving mucus out of the respiratory
bronchioles. Bacteria can also spread through
these pores.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Lower respiratory system
• There are 300 million alveoli in the adult lung
• Alveolar – capillary membrane is a very thin
and is the site of gas exchange. In pulmonary
edema fluid fills in the interstitial space
between alveolar capillary membrane and
decreases gas exchange
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Structures and Functions of Respiratory
System
Fig. 26-3. Structures of lower airways.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
17
Structures and Functions of Respiratory
System
Lower Respiratory Tract, continued
Surfactant
Blood supply
Chest Wall
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
18
surfactant
• Alveoli have a natural tendency to collapse
• Alveolar surface have cells that secrete
surfactant
• Surfactant is a lipoprotein that lowers the
surface tension in the alveoli, reduces the
amount of pressure needed to keep alveoli
inflated and decreases the tendency of the
alveoli to collapse
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Surfactant cont…
• Atelectasis: when not enough surfactant in the
alveoli, the alveoli collapses and gas exchange
is decreased
• ARDS ( acute respiratory distress syndrome) is
wide spread alveoli collapse due to lack of
surfactant. Gas exchange is severely impaired
in ARDS
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Structures and Functions of Respiratory
System
Fig. 26-4. Scanning electron micrograph of lung parenchyma. A, Alveoli (A) and alveolar-capillary membrane
(arrow). B, Effects of atelectasis. Alveoli (A) are partially or totally collapsed.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
21
Blood supply
two types of circulation
• (A) The pulmonary circulation: pulmonary
artery receives deoxygenated blood from the
right ventricle and delivers to the right
ventricle and delivers to the pulmonary
capillaries that are directly connected with
alveoli. Oxygen and co2 exchange occurs here.
Pulmonary vein then return returns
oxygenated blood to the left atrium, which
then delivers to the left ventricle
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Structures and Functions of Respiratory
System
Fig. 26-5. A small portion of the respiratory membrane greatly magnified. An extremely thin interstitial layer of
tissue separates the endothelial cell and basement membrane on the capillary side from the epithelial cell and
surfactant layer on the alveolar side of the respiratory membrane. The total thickness of the respiratory
membrane is less than 1⁄5000 of an inch.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
23
Blood supply cont.….
This oxygenated blood then is pumped by
ventricles to the aorta, which supplies the
oxygenated blood to the systemic circulation
• Venous blood : collected from the capillary
network of the body is returned to the right
atrium by venae cava
• ( B) Bronchial circulation : starts with the
bronchial artery , which arises from the
thoracic aorta and provides oxygenated blood
to lungs
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Blood supply
Deoxygenated blood returns to from the
bronchial circulation via azygos vein into
superior vena cava.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Chest wall
• Shaped , supported and protected by 24 ribs(
12 on each sides)
• Thoracic cage : ribs and sternum , protects the
heart and lungs
• Parietal pleura : membrane that lines the
chest cavity and has sensory pain fibers – feel
pain.
• Visceral pleura : membrane that lines the
lungs – pain sensory fibers not found
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Chest wall cont.…
• Intra pleural space : space between the
pleural layers, normally contains 20 to 25 ml
of fluid, this fluid provides lubrication and
cohesiveness between layers
• Fluid drains from the pleural space by
lymphatic circulation
• Pleural effusion : accumalation of fluid in the
intra pleural space
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Diaphragm
• The diaphragm is the major muscle of
respiration
• During inspiration: diaphragm contracts
increasing intra thoracic volume which pushes
the abdominal contents downwards, at the
same time external intercostal muscles and
the scale muscles contracts, increasing the
lateral and the anterior posterior dimension of
the chest. This causes the size of the thoracic
cavity to increase and intra thoracic pressure
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
diaphragm
• Decrease in intra thoracic pressure allows the
air movement to the lungs( air moves from
high to low), expiration or air movement out
of lungs is vise versa
• Diaphragm is made of two hemidiaphrams
• Diaphragm is innervated by right and left
phrenic nerve
• Phrenic nerve arises from spinal cord between
C3 AND C5.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Diaphragm
• If spinal cord injury above C 3 results in total
diaphramatic paralysis and patients therefore
be put on a ventilator for breathing.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Structures and Functions of Respiratory
System
Physiology of Respiration
Ventilation
Compliance
Diffusion
Oxygen-hemoglobin dissociation curve
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
31
Physiology of Respiration
• Ventilation : movement of air into the lungs (
inspiration) and movement of air out of the
lungs ( expiration).
• Dyspnea ( shortness of breath) – neck and
shoulder muscles can assist the effort ( use of
accessory muscles can be a sign of respiratory
distress
• Compliance : elasticity of the lungs and the
elastic recoil of the chest wall
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Physiology of respiration cont..
When compliance is decreased lungs are more
difficult to inflate. Ex pulmonary edema,
pneumonia, and ARDS.
conditions that make lung tissue less elastic or
distensible ex pulmonary fibrosis and
sarcoidosis.
Conditions that restrict lung movement. ex
pleural effusion
In COPD compliance is increased and air is
retained
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Physiology of respiration cont..
• Diffusion : oxygen and carbon dioxide move
back and forth across the alveolar – capillary
membrane
• Oxygen moves from alveolar gas ( atmospheric
air ) into arterial blood and carbon dioxide
from the arterial blood into alveolar gas.
Diffusion continues until equilibrium is
reached.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Transportation of oxygen
• Oxygen is carried in the blood in two forms:
dissolved oxygen in blood ( Pao2) and oxygen
bound to hemoglobin ( Svo2).
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Structures and Functions of Respiratory
System
Fig. 26-6. Oxygen-hemoglobin dissociation curve. The effects of acidity and temperature changes are shown.
2,3-DPG, 2,3-Diphosphoglycerate; PaO2, partial pressure of oxygen in arterial blood; PCO2, pressure of carbon
dioxide.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
36
Oxygen-hemoglobin dissociation
curve
• Describes the affinity ( ability to attach) for
hemoglobin for oxygen.
• Oxygen delivery to tissues: depends on the
amount of oxygen that can be picked up in the
lungs and the ease at which hemoglobin gives
up oxygen once it reaches the tissues.
• Shift to the left : alkalosis, hypothermia, and
decreased Co2 causes the shift to the left.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Shift to the left
• Arterial blood picks up oxygen easily at the
level of lungs but delivers oxygen less readily
at the level of tissues. Ex during open heart
surgery patients body temperature is kept low
and after the surgery , higher concentration of
oxygen is given until temperature is back to
normal to promote tissue perfusion .
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Shift to the right
• Acidosis , hyperthermia, increased carbon
dioxide and increased 2,3 DPG causes shift to
the right.
• Blood picks up oxygen less readily at the level
lungs but delivers more readily to the tissues.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Structures and Functions of Respiratory
System
Physiology of Respiration, continued
Arterial blood gases
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
40
Arterial blood gases
• Measures oxygenation status and acid base
balance
• ABG analysis : measurement of Pao2, Paco2,
PH, and bicarbonate in arterial blood.
• Normal Pao2 decreases with advancing age
and varies with elevation( higher elevation
results in lower Pao2)
• Metabolic acidosis causes kussmaul
respiration ( irregular breathing with pause.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Structures and Functions of Respiratory
System
Table 26-1. Normal Arterial and Venous Blood Gas Values *.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
42
Structures and Functions of Respiratory
System
Table 26-3. Critical Values for Pao2 and Spo2 *.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
43
oximetry
• SPO2 : oxygen saturation level obtained using
pulse oxy- meter . Normal value > 95 %
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Structures and Functions of Respiratory
System
Control of Respiration
Chemoreceptors
Mechanical receptors
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
45
Control of respiration
• Respiratory centers in medulla ( brain stem )
responds to changes in chemical and
mechanical signals from the body
• Chemoreceptors: receptor that respond to
chemical changes( PH), acidosis causes
medulla to increase the rate of respiration and
tidal volume. Alkalosis causes the respiratory
rate and tidal volume to decrease.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
COPD
• Patients with COPD lives with elevated Paco2
levels
• These patients maintain ventilation due to
hypoxic drive
• Be mindful when administering of high
concentration of oxygen to COPD patients as
oxygen can depresses the respiratory drive.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Mechanical receptor
• Hering Breuer reflex
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Structures and Functions of Respiratory
System
Respiratory Defense Mechanisms
Filtration of air
Mucociliary clearance system
Cough reflex
Reflex bronchoconstriction
Alveolar macrophages
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
49
Respiratory defense mechanism
•
•
•
•
•
Filtration of air
Mucociliary clearance system
Cough reflex
Reflex bronchoconstriction
Alveolar macrophage
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Gerontologic Considerations: Effects of
Aging on Respiratory System
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
51
Effect of age on respiratory system
structure
•
•
•
•
Chest wall stiffening
Decreased elastic recoil of lungs
Decreased chest wall compliance
Increased anterior posterior diameterincreases functional residual capacity
• Decreased functional capacity – diminished
breath sounds
• Decreased expiratory muscle strength
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Defense mechanism
•
•
•
•
•
•
Decreased cell mediated immunity
Decreased specific antibodies
Decreased cilary function
Decreased cough reflex
Decreased alveolar macrophage function
Decreased sensation in pharynx
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Respiratory control
• Decreased response to hypoxemia
• Decreased response to hypercapnia
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Diagnosis studies
• Ventilation/ perfusion or V/Q scan- dx
pulmonary embolism, uses radioactive dye
• Pulmonary angiogram- locate obstruction and
pathogenic conditions, uses dye
• Bronchoscopy – for diagnosis, biopsy,
specimen collection, suction and lavage
• Pulmonary function test – used to evaluate
lung function using spirometer
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
Assessment of Respiratory System
Subjective Data
Important health information
Past health history
Medications
Surgery or other treatments
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
56
Assessment of Respiratory System
Subjective Data, continued
Functional health patterns
Health perception–health management pattern
Nutritional-metabolic pattern
Elimination pattern
Activity-exercise pattern
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
57
Assessment of Respiratory System
Subjective Data
Functional health patterns, continued
Sleep-rest pattern
Cognitive-perceptual pattern
Self-perception–self-concept pattern
Role-relationship pattern
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
58
Assessment of Respiratory System
Subjective Data
Functional health patterns, continued
Sexuality-reproductive pattern
Coping–stress tolerance pattern
Values-belief pattern
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
59
Assessment of Respiratory System
Objective Data
Physical examination
Nose
Mouth and pharynx
Neck
Thorax and lungs
Inspection
Palpation
Percussion
Auscultation
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
60
Assessment of Respiratory System
Fig. 26-7. Estimation of thoracic expansion. A, Exhalation. B, Maximal inhalation.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
61
Assessment of Respiratory System
Table 26-6. Percussion Sounds.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
62
Assessment of Respiratory System
Fig. 26-8. Sequence for examination of the chest. A, Anterior sequence. B, Lateral sequence. C, Posterior
sequence. For palpation, place the palms of the hands in the position designated as “1” on the right and left
sides of the chest. Compare the intensity of vibrations. Continue for all positions in each sequence. For
percussion, tap the chest at each designated position, moving downward from side to side. Compare percussion
sounds at all positions. For auscultation, place the stethoscope at each position and listen to at least one
complete inspiratory and expiratory cycle. Keep in mind that, with a female patient, the breast tissue will
modify the completeness of the anterior examination.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
63
Assessment of Respiratory System
Fig. 26-9. Diagram of percussion areas and sounds in the anterior side of the chest.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
64
Assessment of Respiratory System
Fig. 26-10. Diagram of percussion areas and sounds in the posterior side of the chest. Percussion proceeds
from the lung apices to the lung bases, comparing sounds in opposite areas of the chest.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
65
Assessment of Respiratory System
Fig. 26-11. Normal auscultatory sounds.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
66
Assessment of Respiratory System
Table 26-8. Normal Physical Assessment of the Respiratory System.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
67
Diagnostic Studies of Respiratory
System
Sputum Studies
Skin Tests
Endoscopic Examinations
Bronchoscopy
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
68
Diagnostic Studies of Respiratory
System
Fig. 26-12. Fiberoptic bronchoscope. A, The transbronchoscopic balloon-tipped catheter and the flexible
fiberoptic bronchoscope. B, The catheter is introduced into a small airway and the balloon inflated with
1.5 to 2 mL of air to occlude the airway. Bronchoalveolar lavage is performed by injecting and withdrawing
30-mL aliquots of sterile saline solution, gently aspirating after each instillation. Specimens are sent to the
laboratory for analysis.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
69
Diagnostic Studies of Respiratory
System
Fig. 26-13. Transbronchial needle biopsy. The diagram shows a transbronchial biopsy needle penetrating the
bronchial wall and entering a mass of subcarinal lymph nodes or tumor.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
70
Diagnostic Studies of Respiratory
System
Fig. 26-14. Thoracentesis. A catheter is positioned in the pleural space to remove accumulated fluid.
Copyright © 2011, 2007 by Mosby, Inc.,
an affiliate of Elsevier Inc.
71