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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