RESPIRATORY SYSTEM

Medical Surgical Nursing I 1ST Semester I 2024-2025

The Respiratory Systems Respiration includes the following processes:  Where the auditory or eustachean tube opens
 Pharyngeal tonsil or adenoid.
 functions to supply oxygen for the metabolic needs of the a. Ventilation or Breathing
cells and to remove one of the waste materials of cellular  the movement of air into and out of the lungs Oropharynx
metabolism, the carbon dioxide b. External Respiration
 Extends from the uvula to the epiglottis; located behind the
 exchange of oxygen and carbon dioxide between the
Structural Anatomy of the Respiratory System oral cavity
air in the lungs (alveoli) and the blood
 The oral cavity opens into the oropharynx
c. Transport of respiratory gases
1) Upper Respiratory Tract (Upper Airway)  Both swallowed food and inhales air pass through it
 oxygen and carbon dioxide must be transported to
 primarily refers to the parts of the respiratory system  Features of the oropharynx: Palatine and lingual tonsil
and from the lungs and tissue cells of the body. This
lying outside of the thorax or above the sternal angle
uses blood as the transporting fluid. Laryngopharynx
 is the airway above the glottis or vocal cards
d. Internal respiration
 Includes the Nose, Pharynx and Larynx  Passes posterior to the larynx and extends from the tip of the
 the exchange of oxygen and carbon dioxide between
the blood and the cells. epiglottis to the esophagus
2) Lower Respiratory Tract (Lower Airway)  Common passageway for food and air
 refers to the portions of the respiratory system from Regulation of Body pH
the trachea to the lungs.
Voice production
Olfaction
Innate Immunity
Conducting Zones (Dead Space)
 These are the respiratory passages extending from the nose
to the terminal bronchioles
 For passage or air
 Nose to Terminal Bronchioles
Respiratory Zones
THE LARYNX (VOICE BOX)
 Where absorption of oxygen and removal of carbon dioxide
from the blood takes place  located in the anterior throat (pharynx) and extends from the
 Composed of the respiratory bronchioles, alveolar ducts, and base of the tongue to the trachea
alveoli
Functions
 The respiratory zones begins as the terminal bronchioles
feed into the respiratory bronchioles  passageway for air between the pharynx and the
Functions of the Respiratory System trachea
THE NOSE  specially modified for the production of voice
Gas Exchange or Respiration
Divisions of the Pharynx  also functions for sphincter for lower respiratory tract
 The respiratory system allows oxygen from air to enter the
blood and carbon dioxide to leave the blood and enter the air Nasopharynx
 The cardiovascular system, on the other hand, transports
 Locates posterior to the choanae and superior to the soft
oxygen from the lungs to the body cells and carbon dioxide
palate, an incomplete muscle and connective tissue partition
from the body cells to the lungs
separating the nasopharynx from the oropharynx. Uvula is
the posterior extension of the soft palate.
 Nine Cartilages of the Larynx The Bronchi and Subdivisions: The Bronchial Tree
Unpaired The Trachea (Windpipe)
 Thyroid cartilage  a membranous cylindrical tube attached to the larynx
 Cricoid cartilage – the most inferior  with 16-20 C –shaped pieces of hyaline cartilage
 Epiglottis  extends from the level of the 6th cervical vertebra to the 5th
Paired thoracic vertebra
 Posterior wall has no cartilage and consists of a ligamentous
 Cuneiform cartilages membrane and smooth muscle
 Corniculate cartilages  Flattened posteriorly where it comes into contact with the
 Arytenoid Cartilages esophagus
The most important among the three paired  The trachea projects through the mediastinum and divides
cartilages which anchor the vocal cords to the larynx into right and left main (primary) bronchi.
 Carina- the junction where the trachea and the two primary
bronchi branch is reinforced by a cartilage plate
 Function: passage of air to reach the lungs

The Respiratory Zones

 The respiratory zones begins as the terminal bronchioles

feed into the respiratory bronchioles
 Alveolar ducts
 Alveolar sacs
 Alveoli
 The functional units of the lungs
 Gaseous exchange between blood and air occurs
here where actual gas exchange
 Summary of the Pathway of Air

 The branching of the primary bronchi occurs inside the

LUNGS

The Lungs

 the principal organs of respiration

 free at the pleural cavity, except for attachment to the heart
and trachea at the hilum
Characteristics of the lungs;
o soft, spongy, elastic organs, each weighing 0.5 kg
(together weigh only 1 kg)
o cone-shaped, with its base resting on the diaphragm and
its apex extending superiorly to a point about 1 in above
the clavicle
o pinkish in infants, dark gray and patchily mottled in adults
o Inflated lungs float in water, fetal lung is solid and sink in
water.

Physiology of Respiration

Pulmonary Volumes and Capacities

 Spirometry is the process of measuring volumes of air into
and out of the respiratory system
 Spirometer is the device that measures these respiratory
volumes
Pulmonary Volumes
 The measures of the amount of air movement during
different portions of ventilation
Pulmonary Capacities
 The sums of two or more respiratory volumes
  Pneumotaxic Center
 This fine-tunes the breathing rhythm and prevents
Gas Exchange Transport of Respiratory Gases in the Blood
over inflation of the lungs
 External respiration: Pulmonary gas exchange - Oxygen transport  Continuously sends inhibitory impulses to the
exchange of oxygen and carbon dioxide between the air in inspiratory center of the medulla, and when signals
 After oxygen diffuses through the respiratory membrane into
the lungs (alveoli) and the blood the blood: are particularly strong, the duration of inspiration is
 TRANSPORT OF RESPIRATORY GASES IN THE BLOOD  98.5%- combine reversibly with the iron-containing shortened.
 Internal Respiration: the exchange of oxygen and carbon heme groups of hemoglobin (oxyhemoglobin)
dioxide between the blood and the tissues.  1.5% - remains dissolved in the plasma
Carbon dioxide transport  Apneustic Center
 Provides inspiratory drive by continuously stimulating
 CO2 diffuses from cells, where it is produced, into tissue the medullary inspiratory center
capillaries. After carbon dioxide enters the blood, it is
 Its effect is to prolong inspiration with very short
transported in 3 ways:
 7%- dissolved in plasma expiration to cause breath holding in the inspiratory
 23%- transported in combination with haemoglobin phase, called apneusis.
(carbaminohemoglobin)
 70%- transported in the form of bicarbonate ions

Control of Respiration
Medullary Respiratory Centers
 Dorsal Inspiratory group or inspiratory centers
 pace-setting nucleus which is responsible for the
rhythm of breathing
 When the inspiratory neurons fire, nerve impulses
travel along the phrenic and intercostal nerves to
excite the diaphragm and external intercostals muscle
respectively.
 When the inspiratory center becomes dormant, then
expiration occurs passively, as the inspiratory
muscles are allowed to relax and recoil.
 This cyclic on-off activity is repeated and produces a
respiratory rate between 12 and 20 breaths per
minute.

 Ventral Respiratory group or expiratory center (VRG)

 Contains both inspiratory and expiratory neurons
 When forceful breathing becomes necessary, the
expiratory center sends activating impulses to the
muscles of expiration which cause vigorous Hering-Breuer Reflex
depression of the rib cage and more strenuous
expiratory movements.  This supports the rhythmic respiratory movements by limiting
the extent of inspiration
Pons Respiratory Centers
  When the lung is filled with air, the stretch receptors in the
visceral pleura and conducting passages are stimulated, and
transmit inhibitory signals to the medullary inspiratory center
and allow expiration to occur.
 As the lungs recoil, the stretch receptors become quiet, and
inspiration is initiated once again.
Common Indoor and Outdoor Allergen
Chemical Control of Respiration
Indoor Allergens
 Carbon dioxide levels in the blood are the major driving force
for regulating breathing.  Dust mite feces
 A greater than normal amount of CO2 in the blood is called  Dog dander
hypercapnia and less than normal CO2 in the blood is  Cat dander
called hypocapnia.  Cockroach dropper
 Oxygen is not normally as important as carbon dioxide in  Molds
regulating breathing because hemoglobin is very effective at Outdoor Allergens
picking up oxygen in the lungs. As long as carbon dioxide
Peripheral Chemoreceptors  Tress
levels are normal, blood oxygen levels are usually normal as
well.  These are found within the vessels of the neck (the carotid  Weeds
 Changes in blood carbon dioxide levels are not directly bodies and aortic bodies)  Grasses
detected, however. Instead, changes in blood pH are  Sensitive to arterial oxygen levels  Molds
monitored. This can occur because changes in CO2 cause  Between the two, the carotid bodies are the main oxygen
Clinical Manifestations of RHINITIS
changes in pH. sensors
 Sensors responding to changing levels of CO2 , O2 , and H+  When blood oxygen declines to a low level, a condition  Rhinorrhea
ions in the arterial blood are called chemoreceptors. called hypoxia results. Excessive nasal drainage, runny nose
 The chemoreceptors of the carotid bodies and aortic bodies  Nasal Congestion
Central Chemoreceptors  Nasal discharge
are strongly stimulated. They send action potentials to the
 located bilaterally in the medulla respiratory center and produce an increase in rate and depth  Sneezing
 These are sensitive to small changes in blood CO2 and pH of breathing. The increased breathing increases diffusion  Pruritus of the nose, roof of the mouth, throat, ears
o As the blood carbon dioxide levels increase, the from the alveoli in the blood, resulting in more oxygen in the
Pharmacologic Treatment
blood pH decreases (becomes more acidic). blood.
Conversely, as blood carbon dioxide levels Symptom relief
Management of Patients with Upper Respiratory Tract
decrease, the blood pH increases (becomes more  Antihistamine
Disorders
basic)  Corticosteroid nasal spray
 Can detect a decrease in blood pH, typically caused by an Upper Airway Infections  Oral decongestants
increase in blood CO2 (hypercapnia) → the respiratory  Saline nasal spray
center increases breathing and therefore CO2 is removed Rhinitis (Hay Fever)
from the blood. As the blood CO2 levels decrease, blood pH Nursing Management
 Group of disorders characterized by inflammation and
increases; homeostasis is maintained.  AVOID OR REDUCE EXPOSURE TO ALLERGENS AND
irritation of the mucous membranes of the nose.
 Can also detect an increase in blood pH, typically caused by IRRITANTS
 Acute or Chronic
a decrease in carbon dioxide (hypocapnia) → respiratory  Allergic or nonallergic
center decreases breathing and therefore less CO2 is Viral Rhinitis
 Allergic rhinitis: seasonal or perennial
removed from the blood. Because CO2 is continually
 AKA Common Cold
produced, CO2 levels now increase, causing pH to
 Cold refers to an infectious, acute inflammation of the
decrease; thus homeostasis is again maintained.
mucous membranes of the nasal cavity characterized by
  Nasal congestion  Hand hygiene measures  Hypertension
 Rhinorrhea  Anticoagulation therapy
 Sneezing  Liver disease
 Sore throat  Blood dyscrasias
 General Malaise  Neoplasm
 Highly contagious 2 days before the symptoms appear and  Atherosclerosis of nasal vessels
during the first part of the symptomatic phase Epistaxis
Clinical Features
Clinical Manifestations  Nosebleed  Blood may be seen effluxing from both nares or down the
 Low-grade fever Epidemiology posterior oropharynx.
 Nasal Congestion  Visualization of the bleeding usually requires use of a fiber-
 Rhinorrhea  Anterior epistaxis is more common in younger patients. optic laryngoscope.
 Nasal Discharge  Posterior epistaxis is more common in the elderly population.  Bleeding is often more severe than with an anterior bleed.
 Halitosis
Treatment
 Sneezing
 Teary watery eyes
 General malaise
 Headache
 Muscle ache
 Symptoms of viral rhinitis may last from 1 to 2 weeks
 Cold sore (herpes simplex virus)
Medical Management
Anterior Epistaxis
Symptomatic therapy
 Comprise 90% of nose bleeds
 Adequate fluid intake  Most commonly originates from Kiesselbach’s plexus (a
 Rest confluence of arteries on the posterior superior nasal
 Preventions of chilling septum)
 Use of expectorant PRN
 Salt water gargle Etiology
 NSAID  Trauma to the nasal mucosa (usually self-induced)
 Antihistamine  Foreign Body
 Petroleum jelly  Allergic rhinitis
 Alternative medicines  Nasal irritants (such as cocaine, decongestants)
 Steam inhalation  Pregnancy (due to engorgement of blood vessels)
 Direct pressure on the bleeding site.
 Infection (sinusitis, rhinitis)
 Venous pressure is reduced in the sitting position, and
RHINITIS MEDICAMENTOSA leaning forward lessens the swallowing of blood.
 Ice packs
 Rebound rhinitis Posterior Epistaxis
 Cautery with silver nitrate
 Rebound nasal congestion commonly associated with  Comprises approximately 10% of epistaxis  Treatment of other possible underlying causes of bleeding
overuse of the over-the-counter nasal decongestant  More common in older patients and is thought to be
secondary to atherosclerosis of the arteries supplying the
posterior nasopharynx. Acute Pharyngitis
Nursing Management
Etiology
  Sudden painful inflammation of the pharynx, the back portion  Position: Most comfortable is PRONE, with head
of the throat that includes the posterior third of the tongue, turned to side
Tonsilitis and Adenoiditis
soft palate, and tonsils.  Maintain oral airway, until gag reflex returns
 SORE THROAT  Infection and inflammation of the tonsils and adenoids  Apply ICE collar to the neck to reduce edema
 Most common organism- Group A- beta hemolytic  Advise patient to refrain from talking and coughing
streptococcus (GABHS)  Ice chips are given when there is no bleeding and
gag reflex returns
 Notify physician if;
a. Patient swallows frequently
Pathophysiology
Viral Infection (most common cause)
 Adenovirus
 Influenza Virus
 Epstein-Barr Virus
 Herpes simplex virus
Bacterial Infection
Group A Beta-Hemolytic Streptococcus (GABHS)
Group A strep b. Vomiting of large amount of bright red or dark blood
c. PR increased, restless and Temp is increased
Inflammatory response in the pharynx Assessment Findings
Clinical Manifestations  Sore throat and mouth breathing
Rhinosinusitis
 Fiery red pharyngeal membrane and tonsils  Fever
 Lymphoid follicles (swollen and flecked with white-purple  Difficulty swallowing  Formerly known as sinusitis
exudate  Enlarged, reddish tonsils  Inflammation of paranasal sinuses and nasal cavity
 Enlarged and tender cervical lymph nodes  Foul-smelling breath
 Fever  Laboratory Test
 Malaise a) CBC Causes of Rhinosinusitis
 Sore throat b) Throat culture
Vasomotor:
 SCARLATINA-FORM RASH WITH URTICARIA – SCARLET
FEVER  Idiopathic
Medical Management  Abuse of nasal decongestants
 Psychological stimulation
1) Antibiotics – Penicillin
 Irritants
2) Tonsillectomy for chronic cases and abscess formation
Mechanical:
 Tumor
Nursing Intervention
 Deviated septum
1) Pre-operative Care  Crusting
 Consent  Hypertrophied turbinates
 Routine pre-op surgical care  Foreign body
2) POST- operative care  CSF leak
Infections:
  Acute viral infection  Patients with nasotracheal and nasogastric tubes in place Pathophysiology
 Rare nasal infections are at the risk of development of sinus infection.
Acute laryngitis:
 Accurate assessment of patients with the tubes are critical
Hormonal
 results from infection, excessive use of the voice, inhalation
 Pregnancy of smoke or fumes, or aspiration of caustic chemicals.
 Use of oral contraceptives
Chronic laryngitis:
 Hypothyroidism
 results from upper respiratory tract disorders (such as
Clinical Manifestations
Peritonsilar Abscess sinusitis, bronchitis, nasal polyps, or allergy), mouth
 Purulent nasal discharge accompanied by nasal congestion breathing, smoking, gastroesophageal reflux, constant
 Facial pain, pressure, or a sense of fullness  AKA quinsy exposure to dust or other irritants, alcohol abuse, or cancer
 Facial pain-pressure-fullness  Most common suppurative complication of sore throat of the larynx
 Localized or diffused headache  Adult: 20-40 years old  Edema of the vocal cords caused by irritation (from an
 Fever  Collection of purulent exudate between the tonsillar capsule infection, lesion, or overuse of the voice or other cause)
and the surrounding tissues impairs the normal mobility of the vocal cords, causing an
Assessment and Diagnostic Findings
abnormal sound.
 History and physical examination
Clinical Manifestations
 Tenderness to palpation over the inflamed sinus area
 CT SCAN for any sensitive to inflammatory changes and  hoarseness (persistent hoarseness in chronic laryngitis) or
bone destruction aphonia
 Sinus fluid aspiration  changes in the character of the voice
 pain (especially when swallowing or speaking)
Complications
 a dry cough, fever, malaise, dyspnea, throat clearing,
 Osteomyelitis restlessness, or laryngeal edema
 Mucocele- cyst of the paranasal sinuses
Diagnostic exam
Rare:
 indirect laryngoscopy
 Sinus thrombosis Clinical Manifestations  videostroboscopy:
 Meningitis shows the movement of the vocal cords.
 Brain abscess  Severe sore throat
 Ischemic brain infarction  Fever
 Severe orbital cellulitis  Trismus (inability to open the mouth)
 Drooling
 Raspy voice
Medical Management  Odynophagia
 Dysphagia
Bacterial  Otalgia
 Drug of choice: Augmentin
Viral Laryngitis
 Nasal saline lavage  Inflammation of the larynx, often occurs as a result of the
 Decongestants voice abuse or exposure to dust, chemicals, smoke, or other
Keypoints pollutants
 an inflammation of the vocal cords
Treatment
 resting the voice (primary treatment)
 symptomatic care, such as an analgesic and throat lozenges
(for viral infection)
 antibiotic therapy (bacterial infection), usually with
cefuroxime
 identification and elimination of underlying cause (chronic
laryngitis)
 possible hospitalization (in severe acute laryngitis)
 possible tracheotomy if laryngeal edema results in airway
obstruction
 drug therapy, which may include antacids, histamine-2
blockers, antibiotics, and systemic steroids.
Nursing Management
 refrain from talking to avoid straining the vocal cords and
allow vocal cord inflammation to decrease
 place a sign over his bed to remind others of talking
restrictions
 intercom
 Provide a pad and pencil or a slate for communication.
 Provide an ice collar, a throat irrigant, and cold fluids for
comfort.
 chronic obstructive pulmonary disease (COPD) and Normal Range:
asthma can cause a low V/Q ratio.
 Adult: 80-100 mm Hg
Oxyhemoglobin Dissociation Curve  Newborns: 60-70 mmHg
 The oxyhemoglobin dissociation curve is a graphical It is usually measured in arterial blood gases (ABGs) and is
representation that describes the relationship between the expressed in millimeters of mercury (mm Hg).
partial pressure of oxygen (PaO₂) and the percentage
saturation of hemoglobin with oxygen (SaO₂). The curve is
sigmoidal (S-shaped), reflecting hemoglobin’s affinity for
OXYGEN TRANSPORT MECHANISM oxygen under different physiological conditions.
Disorders Associated with PaO2 Imbalances
 The oxygen transport mechanism in the human body is a Key Features of the Curve:
1. Hypoxemia (Low PaO₂) Hypoxemia
complex physiological process that ensures the delivery  is a condition characterized by abnormally low levels of
Left Shift:
of oxygen from the lungs to tissues and the removal of
oxygen in the blood. Definition: PaO₂ < 80 mmHg in
carbon dioxide from tissues to the lungs.  Indicates increased hemoglobin affinity for oxygen, making it
adults
 This process is vital for cellular metabolism and involves more difficult to release oxygen to tissues. Causes include
several key components: ventilation-perfusion (V/Q) alkalosis, hypothermia, and decreased levels of 2,3- Causes:
matching, the oxyhemoglobin dissociation curve, oxygen diphosphoglycerate (2,3-DPG).
a) Chronic Obstructive Pulmonary Disease (COPD):
partial pressure, and clinical assessment and diagnostics
Right Shift: Impaired gas exchange due to obstructed airways and
Ventilation – Perfusion (V/Q) Matching damaged alveoli.
 Indicates decreased hemoglobin affinity for oxygen,
b) Pulmonary Edema: Fluid in the lungs hampers oxygen
 Ventilation-perfusion (V/Q) matching is the relationship facilitating oxygen release to tissues. Causes include
diffusion
between the amount of air reaching the alveoli (ventilation) acidosis, hyperthermia, and increased levels of 2,3- DPG
c) Pulmonary Embolism: A blockage in the pulmonary
and the amount of blood flow reaching the alveoli artery reduces blood flow to the lungs, decreasing
(perfusion). oxygenation.
 For optimal gas exchange, these two processes must be d) High Altitude: Reduced atmospheric oxygen pressure
closely matched. The normal V/Q ratio is approximately 0.8, leads to lower PaO₂.
indicating that perfusion is slightly greater than ventilation e) Acute Respiratory Distress Syndrome (ARDS)
f) Severe inflammation in the lungs causes stiff alveoli,
reducing oxygen transfer
Imbalance Ventilation – Perfusion (V/Q) Ration
High V/Q Ratio: 2. Hyperoxemia (High PaO₂)
 refers to an abnormally high PaO₂, which is generally
 Occurs when ventilation exceeds perfusion, leading to less common and occurs in specific clinical scenarios.
wasted ventilation. Conditions such as pulmonary  PaO2 > 100mmHg
embolism, where blood flow is obstructed, can cause a
high V/Q ratio. Causes:

Low V/Q Ratio: a) Oxygen Therapy: Excessive oxygen administration,

particularly in patients receiving mechanical
 Occurs when perfusion exceeds ventilation, leading to
ventilation, can elevate PaO₂ to dangerous levels.
inadequate oxygenation of blood. Conditions such as Oxygen Partial Pressure (PaO2) and Related Abbreviations
b) Hyperbaric Oxygen Therapy: Treatment involves
chronic obstructive pulmonary disease (COPD) and
Oxygen partial pressure (PaO₂) is the measure of the breathing pure oxygen in a pressurized chamber,
asthma can cause a low V/Q ratio
pressure exerted by oxygen dissolved in the blood and is a crucial significantly increasing PaO₂
 Occurs when perfusion exceeds ventilation, leading to
parameter in assessing oxygenation status.
inadequate oxygenation of blood. Conditions such as
 Related Abbreviations  This helps identify potential risk factors, underlying
conditions, and the nature of the current respiratory issue/.
PaO₂: Partial pressure of oxygen in arterial blood.
Chief Complaint:
Normal Range: 80-100 mm Hg
 What brings the patient in today?
This value reflects the amount of oxygen dissolved in the
 Common complaints include shortness of breath,
arterial blood and is a critical measure of how well oxygen is being
cough, chest pain, and wheezing.
transferred from the lungs to the blood.
Disorders Associated with Abnormal SaO2 and SpO2
SaO₂:

SpO₂:
1. Hypoxemia (Low SaO2/SpO2) History of Present Illness (HPI):
 Chronic Respiratory Diseases: Conditions like COPD,
a. Onset: When did the symptoms start?
asthma, or interstitial lung disease can lead to low
b. Duration: How long have the symptoms been present?
oxygen saturation.
3. SaO₂ (Arterial Oxygen Saturation c. Severity: How severe are the symptoms? Use scales
 Acute Respiratory Conditions: Pneumonia, ARDS,
 SaO₂ represents the percentage of hemoglobin (e.g., 0-10 for pain).
and pulmonary embolism can cause a sudden drop in
molecules in the blood that are saturated with oxygen d. Triggering/Alleviating Factors: What makes the
oxygen levels.
in arterial blood. It is determined through an arterial symptoms better or worse?
 Congenital Heart Disease: Defects that affect
blood gas (ABG) test. oxygenation can result in low SaO₂/SpO₂. Past Medical History:
 Normal Range: 95-100%  Anemia: Reduced hemoglobin levels mean less
a. Respiratory diseases: History of asthma, COPD,
Key Points: oxygen can be carried, even if SaO₂/SpO₂ appears
tuberculosis, pneumonia, etc.
normal.
 SaO₂ is directly measured from arterial blood, b. Surgeries: Any thoracic or respiratory surgeries?
2. Hyperoxemia (High SaO2/SpO2)
providing a precise assessment of oxygenation. c. Allergies: Allergic reactions, particularly those affecting
 SaO₂/SpO₂ > 100% (not typically encountered breathing.
 It is typically used in critical care settings, operating naturally, but can be seen in hyperbaric oxygen
rooms, and for detailed respiratory evaluations. therapy or with excessive supplemental oxygen). Medications:
 SaO₂ is often correlated with PaO₂; as PaO₂  Excessive Oxygen Supplementation: In critically ill
increases, SaO₂ also increases, but this relationship  Current medications: Especially bronchodilators,
patients, over-supplementation can lead to steroids, or antibiotics.
is not linear. The oxygen-hemoglobin dissociation excessively high oxygen levels.
curve illustrates this non-linear relationship  Inhaler or nebulizer use: Frequency and type
Hyperbaric Oxygen Therapy: Family History
4. SpO₂ (Peripheral Oxygen Saturation)  Used to treat conditions like carbon monoxide a. History of respiratory diseases such as asthma or cystic
 SpO₂ is an estimate of the arterial oxygen saturation poisoning, this therapy can cause very high fibrosis
(SaO₂) derived from a non-invasive measurement SaO₂/SpO₂ readings.
using a pulse oximeter, a device typically placed on a Social History
patient's fingertip or earlobe.
a. Smoking: Pack years (number of packs per day × years
 Normal Range: 95-100% Nursing Assessment of the Respiratory System of smoking).
Key Points: b. Occupational exposures: Exposure to dust, chemicals,
1. Patient History
or pollutants.
 SpO2 is widely used in clinical settings for continuous 2. Physical Examination
c. Travel history: Recent travel that might suggest
monitoring of patient’s oxygenation status 3. Diagnostic Tests
exposure to endemic infections
 While SpO2 is generally accurate, it can be affected
Patient History
by various factors such as poor circulation, skin Physical Examination
pigmentation, nail polish, and movement.  Gathering a detailed history is the first step in respiratory
 SpO2 is less accurate at a vary high or very low  The physical examination of the respiratory system involves
assessment.
oxygen saturation levels compared to SaO2 inspection, palpation, percussion, and auscultation.
 trachea), bronchovesicular (medium pitch over major Key Points About NANDA-I:
bronchi).
A. Inspection Nursing Diagnoses:
 General Appearance: Assess the patient’s overall
Adventitious Sounds: NANDA-I provides a comprehensive list of standardized nursing
appearance, including signs of distress, cyanosis, and
 Crackles (Rales): Indicate fluid in the alveoli, as in diagnoses, which are clinical judgments about individual, family, or
use of accessory muscles.
pneumonia, heart failure, or pulmonary fibrosis. community experiences/responses to actual or potential health
 Respiratory Rate and Rhythm: Count the respiratory rate
 Wheezes: High-pitched sounds caused by narrowed problems/life processes.
and observe the pattern (normal: 12-20 breaths per
airways, common in asthma and COPD.
minute in adults).
 Rhonchi: Low-pitched sounds due to secretions in
 Work of Breathing: Note any labored breathing,
large airways. These diagnoses form the basis for selecting nursing interventions
retractions, or nasal flaring.
 Stridor: High-pitched, harsh sound indicative of upper and achieving outcomes.
 Chest Shape and Symmetry: Observe the thorax for any
airway obstruction
deformities like barrel chest, pectus excavatum, or Structure of Nursing Diagnoses:
 Pleural Friction Rub: A grating sound indicating
scoliosis.
pleuritis or pleural effusion. NANDA-I nursing diagnoses typically include three parts:
 Skin and Mucous Membranes: Check for cyanosis (bluish
discoloration) indicating hypoxemia. Problem (P): The name or label of the diagnosis, reflecting the
 Cough: Observe the type of cough (productive or non- patient’s condition or response.
Diagnostic Tests
productive) and sputum characteristics.
Etiology (E): The cause or contributing factors leading to the
Pulse Oximetry (SpO₂): Non-invasive method to measure oxygen nursing diagnosis.
saturation; normal is 95- 100%.
B. Palpation Symptoms (S): The evidence or defining characteristics that
 Tracheal Position: Ensure the trachea is midline; Arterial Blood Gas (ABG) Analysis: Provides information on PaO₂, support the diagnosis.
deviation may indicate tension pneumothorax or mass PaCO₂, pH, and SaO₂.
Purpose of NANDA-I Diagnoses:
effect. Chest X-Ray: Visualizes lung fields, pleural space, and chest wall
 Chest Expansion: Place hands on the patient’s back, abnormalities. 1. To provide a consistent, uniform language for nursing
thumbs together, and ask the patient to take a deep practice.
breath. Check for symmetrical movement Pulmonary Function Tests (PFTs): Measure lung volume, capacity, 2. To enhance communication among nurses and other
 Tactile Fremitus: Palpate the chest wall while the patient flow rates; useful in diagnosing obstructive and restrictive lung healthcare professionals.
says "ninety-nine." Increased fremitus suggests diseases. 3. To promote individualized patient care.
consolidation (as in pneumonia), while decreased Sputum Analysis: Identifies pathogens, cancer cells, or the nature 4. To assist in research and education within the nursing
fremitus suggests pleural effusion or pneumothorax. of the sputum (purulent, bloody, etc.). profession.

Computed Tomography (CT) Scan: Offers detailed images of the Categories of Nursing Diagnoses:
C. Percussion
Percussion of the Chest: Tap on the chest wall to lungs and mediastinum, useful in diagnosing tumors, infections, or Actual Nursing Diagnoses: These represent problems that are
determine if underlying tissues are filled with air (resonant chronic lung diseases. currently present and supported by signs and symptoms (e.g.,
sound), fluid (dull sound), or solid tissue (flat sound). "Ineffective Airway Clearance").
 Normal: Resonance over the lung fields
Risk Nursing Diagnoses: These indicate potential problems that a
 Abnormal: Dullness (indicating consolidation or NANDA: Nursing Diagnoses
patient may develop, based on risk factors (e.g., "Risk for
effusion), hyperresonance (suggestive of
NANDA International (NANDA-I) is an organization that develops, Infection").
pneumothorax).
refines, and promotes standardized nursing terminology,
Health Promotion Diagnoses: These reflect a patient’s motivation
particularly nursing diagnoses. It was originally known as the North
D. Auscultation and desire to increase well-being and actualize human health
American Nursing Diagnosis Association when it was founded in
potential (e.g., "Readiness for Enhanced Knowledge").
1982, but it became NANDA International in 2002 to reflect its
Breath Sounds:
global reach and influence.
 Normal Breath Sounds: Vesicular (soft and low-
pitched), bronchial (loud and high-pitched over
Syndrome Diagnoses: These are a cluster of predicted actual or a. Encourage deep breathing and coughing exercises to a. Monitor ABGs and SpO₂ to assess gas exchange
high-risk diagnoses related to a certain event or situation (e.g., mobilize secretions. status.
"Post-Trauma Syndrome"). b. Administer prescribed bronchodilators or mucolytics to b. Administer supplemental oxygen as prescribed to
reduce airway resistance. correct hypoxemia.
c. Provide adequate hydration to thin secretions. c. Position the patient to promote lung expansion (e.g.,
Application in Nursing Practice: d. Position the patient to facilitate optimal lung Fowler’s position).
expansion and drainage. d. Encourage controlled breathing techniques, such as
Nurses use NANDA-I diagnoses during the nursing process to
e. Perform suctioning if the patient is unable to clear pursed-lip breathing.
assess patient needs, plan care, implement interventions, and
secretions independently. e. Collaborate with respiratory therapy for interventions
evaluate outcomes.
like mechanical ventilation if necessary.
By using standardized diagnoses, nurses can ensure that care is
evidence-based and consistent.
1. Ineffective Airway Clearance
 Inability to clear secretions or obstructions from the
2. Impaired Gas Exchange
respiratory tract to maintain a clear airway.
 Excess or deficit in oxygenation and/or carbon dioxide 3. Ineffective Breathing Pattern
Related Factors elimination at the alveolar-capillary membrane.
 Inspiration and/or expiration that does not provide
a. Excessive secretions (e.g., in chronic obstructive Related Factors adequate ventilation.
pulmonary disease (COPD), pneumonia)
a. Ventilation-perfusion mismatch (e.g., in pulmonary Related Factors
b. Airway constriction (e.g., asthma)
embolism)
c. Fatigue or decreased energy (e.g., in elderly patients a. Neuromuscular impairment (e.g., in spinal cord
b. Alveolar-capillary membrane changes (e.g., in ARDS,
or those with chronic illness) injuries, Guillain-Barré syndrome)
pneumonia)
d. Pain (e.g., post-surgical, pleuritic pain) b. Pain (e.g., in rib fractures, post-surgery)
c. Hypoventilation (e.g., in COPD, neuromuscular
c. Anxiety
disorders)
Defining Characteristics d. Respiratory muscle fatigue (e.g., in COPD, prolonged
a. Ineffective or absent cough Defining Characteristics mechanical ventilation)
b. Abnormal breath sounds (e.g., crackles, wheezing,
a. Abnormal arterial blood gases (ABGs), such as low Defining Characteristics
rhonchi)
PaO₂, elevated PaCO₂
c. Dyspnea or difficulty breathing a. Altered chest excursion
b. Cyanosis
d. Cyanosis b. Use of accessory muscles for breathing
c. Confusion or altered mental status due to hypoxia
e. Altered respiratory rate and rhythm c. Increased or decreased respiratory rate
d. Dyspnea
d. Shallow or deep breathing
e. Fatigue
e. Dyspnea
f. Tachypnea
Goals/Outcomes
Goals/Outcomes
Goals/Outcomes
a. The patient will maintain a clear airway as evidenced
a. The patient will establish an effective breathing
by the ability to effectively cough up secretions and a. The patient will maintain optimal gas exchange as
pattern as evidenced by regular respiratory rate and
the presence of clear breath sounds. evidenced by ABG values within the normal range or
rhythm appropriate to the patient's condition.
b. The patient will demonstrate improved oxygenation baseline for the patient.
b. The patient will demonstrate decreased use of
with normal or baseline SpO₂ levels. b. The patient will experience relief from dyspnea and
accessory muscles for breathing.
show signs of adequate oxygenation (e.g., normal
skin color, mental alertness). Nursing Interventions
Nursing Interventions
Nursing Interventions a. Monitor respiratory rate, rhythm, and effort regularly.
 b. Position the patient to reduce work of breathing, such b. Plan activities and rest periods to prevent fatigue.
as sitting upright. c. Encourage the use of energy conservation techniques
Lower Respiratory System Disorders
c. Administer analgesics as prescribed to manage pain during ADLs.
and facilitate easier breathing. d. Monitor vital signs and SpO₂ before, during, and after
d. Teach the patient breathing exercises, such as activity to ensure safety.
diaphragmatic breathing. Atelectasis
e. Provide emotional support to reduce anxiety, which 3. Anxiety  Atelectasis is the partial or complete collapse of lung tissue,
can exacerbate breathing difficulties.  Vague, uneasy feeling of discomfort or dread leading to reduced or absent gas exchange. It can involve a
accompanied by an autonomic response. small portion of the lung (segmental atelectasis) or the entire
Related Factors lung (lobar atelectasis).
 The condition can be acute or chronic and is often
a. Hypoxia or dyspnea (e.g., in acute respiratory associated with underlying respiratory conditions,
distress) postoperative states, or prolonged immobility.
b. Unfamiliar environment or procedures (e.g.,  The lungs are composed of lobes—three on the right and
hospitalization, intubation) two on the left. Each lobe is further divided into segments.
c. Fear of suffocation or death The alveoli, small air sacs within the lung tissue, are the
4. Activity Intolerance primary site for gas exchange.
 Insufficient physiological or psychological energy to  Atelectasis involves the collapse of alveoli, leading to a
Defining Characteristics reduction in the area available for oxygen exchange.
endure or complete required or desired daily activities.
a. Restlessness
Related Factors
b. Tachypnea
a. Imbalance between oxygen supply and demand c. Tachycardia
(e.g., in heart failure, COPD) d. Sweating
b. Generalized weakness e. Expressed concern about breathing or health status
c. Deconditioning due to prolonged illness or immobility f. Difficulty concentrating
Defining Characteristics Goal / Outcomes
a. Dyspnea on exertion a. The patient will verbalize reduced anxiety and
b. Fatigue demonstrate relaxation techniques
c. Increased respiratory rate with activity b. The patient will exhibit normal respiratory rate and
d. Decreases oxygen saturation with activity decreased signs of autonomic arousal (e.g., sweating,
e. Verbal reports of weakness or exhaustion tachycardia).
Goals and Outcomes Nursing Interventions
a. The patient will demonstrate improved tolerance to a. Provide clear, consistent information to the patient
activity as evidenced by the ability to perform activities about their condition and treatment plan.
of daily living (ADLs) without significant dyspnea or b. Offer reassurance and remain calm to help reduce the Types of Atelectasis
fatigue. patient’s anxiety.
a. Obstructive (Resorptive) Atelectasis:
b. The patient will show stable vital signs and oxygen c. Encourage the use of relaxation techniques, such as
 Occurs when a blockage obstructs the airway, leading
saturation during and after activity. deep breathing or guided imagery.
to the resorption of the trapped air in the alveoli
d. Ensure a supportive and calming environment,
Nursing Interventions without subsequent replacement. Causes include
reducing unnecessary stimuli.
mucus plugs, tumors, or foreign bodies.
a. Assess the patient’s baseline level of activity and e. Involve the patient in decision-making processes to
gradually increase activity levels as tolerated. enhance their sense of control
  Crowding of ribs on the affected side. Dyspnea (Shortness of Breath): Often the first and most common
 Opacification of the collapsed area. symptom.
CT Scan: Provides a more detailed image of the lungs and helps Cough: Persistent and non-productive, especially in obstructive
identify the underlying cause, such as a mass or obstructive lesion. atelectasis.
Bronchoscopy: Direct visualization of the airways to identify and Tachypnea: Rapid breathing as the body attempts to compensate
possibly remove the cause of obstruction (e.g., mucus plug, foreign for hypoxemia.
body).
Cyanosis: A bluish discoloration of the skin due to low oxygen
Pulse Oximetry/Arterial Blood Gas (ABG): Used to assess the levels, especially in severe cases.
extent of hypoxemia. ABG may show reduced partial pressure of
Diminished Breath Sounds: Reduced or absent breath sounds
b. Non-obstructive Atelectasis oxygen (PaO2) and potentially increased partial pressure of carbon
over the affected area during auscultation.
Compressive Atelectasis: Results from external pressure dioxide (PaCO2) in severe cases.
on the lung, such as from pleural effusion, pneumothorax, or Fever: May occur, particularly postoperatively, due to impaired
Normal SpO2 levels range from 95% to 100%. Values below 90%
tumors. ventilation
are often indicative of significant hypoxemia.
Contraction Atelectasis: Occurs due to fibrosis or scarring,
which causes the lung tissue to contract.
Adhesive Atelectasis: Results from the loss of surfactant, PaO2 measures the amount of oxygen dissolved in arterial blood.
as seen in acute respiratory distress syndrome (ARDS) or Normal PaO2 ranges from 80 to 100 mmHg. Nursing Diagnoses
neonatal respiratory distress syndrome.
In atelectasis, PaO2 is usually decreased due to the reduced 1. Impaired Gas Exchange related to alveolar collapse.
surface area available for gas exchange, leading to hypoxemia. 2. Ineffective Airway Clearance related to obstruction (e.g.,
Depending on the severity of the atelectasis, PaO2 can drop mucus plugs).
significantly, reflecting impaired oxygenation. 3. Ineffective Breathing Pattern related to decreased lung
expansion.
Increased Partial Pressure of Carbon Dioxide (PaCO2): 4. Risk for Infection related to retained secretions and impaired
clearance.
PaCO2 measures the amount of carbon dioxide dissolved in
Pathophysiology 5. Activity Intolerance related to insufficient oxygen supply to
arterial blood. Normal PaCO2 ranges from 35 to 45 mmHg.
tissues.
Airway Obstruction: Obstruction prevents air from reaching the In severe cases of atelectasis, particularly when large areas
alveoli, causing the air present in the alveoli to be absorbed into the of the lung are collapsed or there is significant airway obstruction,
bloodstream, leading to alveolar collapse. PaCO2 may be elevated. Nursing Interventions
External Compression: Factors like pleural effusion or tumors can This occurs because the body's ability to exhale CO2 is Impaired Gas Exchange related to alveolar collapse
exert pressure on the lung, leading to collapse. compromised, leading to hypercapnia (elevated CO2 levels in the
blood). a) Administer Supplemental Oxygen:
Lack of Surfactant: Surfactant reduces the surface tension in the
 Apply oxygen therapy as prescribed (e.g., nasal
alveoli; its absence leads to alveolar collapse. pH: cannula, face mask) to maintain oxygen saturation
above 92%.
The blood pH may also be affected. Normal arterial blood pH
Diagnostic Tests and Results ranges from 7.35 to 7.45.Acidosis (pH < 7.35) can occur if Rationale: Supplemental oxygen improves the
hypercapnia is present due to the accumulation of CO2, which oxygenation of blood, compensating for impaired gas
Chest X-ray: The most common diagnostic tool. forms carbonic acid, lowering the blood pH. exchange due to alveolar collapse.
Findings may include:
b) Monitor Respiratory Status
 Mediastinal shift towards the affected side. Clinical Signs and Symptoms  Regularly assess respiratory rate, depth, effort, and
 Elevation of the diaphragm on the affected side. lung sounds.
 Rationale: Early detection of worsening hypoxemia or Rationale: Effective coughing helps clear secretions from the Rationale: Early identification of infection allows for prompt
respiratory distress allows for prompt intervention. airways, reducing the risk of obstruction. treatment, preventing further complications.

c) Encourage Deep Breathing Exercises Ineffective Breathing Pattern related to decreased lung c) Educate on Proper Hand Hygiene
 Instruct the patient to perform deep breathing expansion  Teach the patient and family members about the
exercises every hour while awake. importance of handwashing before and after touching
a) Positioning
the patient.
Rationale: Deep breathing promotes alveolar expansion  Place the patient in a semi-Fowler’s or high-Fowler’s
and enhances gas exchange. position. Rationale: Proper hand hygiene helps reduce the
transmission of infectious agents
d) Use Incentive Spirometry Rationale: Upright positioning facilitates lung expansion and
 Encourage the use of an incentive spirometer every 1- decreases the work of breathing. d) Promote Effective Coughing and Hydration
2 hours.  Encourage adequate fluid intake and effective
b) Encourage Regular Position Changes:
coughing techniques to clear secretions.
Rationale: Incentive spirometry promotes deep lung  Turn the patient every 2 hours if bedridden or
expansion, helping to re-inflate collapsed alveoli and encourage ambulation as tolerated. Rationale: Clearing secretions helps prevent the
improve oxygenation. development of infections, such as pneumonia.
Rationale: Regular position changes and ambulation
promote lung expansion and reduce the risk of further e) Gradually Increase Activity
atelectasis.  Encourage the patient to gradually increase activity as
Ineffective Airway Clearance related to obstruction (e.g.,
tolerated, starting with passive range-of-motion
mucus plugs) c) Provide Rest Periods
exercises, progressing to sitting, and eventually
 Schedule activities to allow for periods of rest
a) Encourage Hydration ambulation.
between interventions.
 Provide fluids as tolerated, encouraging the patient to
Rationale: Gradual activity helps build endurance while
drink at least 2-3 liters per day, unless Rationale: Conserving energy helps the patient maintain a
preventing fatigue and conserving energy.
contraindicated. more effective breathing pattern by reducing fatigue.
Activity Intolerance related to insufficient oxygen supply to
Rationale: Adequate hydration helps thin respiratory d) Administer Analgesics if Pain is a Factor
tissues
secretions, making them easier to clear.  Provide pain relief as needed, especially if the patient
is post-surgical. a) Monitor Response to Activity
b) Administer Bronchodilators and Mucolytics:
 Assess the patient’s response to activity, including
 Administer medications such as albuterol (a Rationale: Pain control can reduce splinting (shallow
vital signs (e.g., heart rate, respiratory rate, SpO2)
bronchodilator) or acetylcysteine (a mucolytic) as breathing due to pain), thereby improving lung expansion
and signs of distress (e.g., shortness of breath,
prescribed. and breathing patterns.
fatigue).
Rationale: Bronchodilators open airways, while mucolytics Risk for Infection related to retained secretions and impaired
Rationale: Monitoring ensures that activity levels are safe
break down thick mucus, facilitating airway clearance. clearance
and that the patient is not overexerting, which could
c) Perform Chest Physiotherapy a) Maintain Aseptic Technique exacerbate their condition.
 Include percussion, vibration, and postural drainage in  Use aseptic technique during suctioning and other
b) Provide Oxygen During Activity if Needed
the care plan. respiratory interventions.
 Administer supplemental oxygen during activities if
Rationale: These techniques help mobilize secretions in the Rationale: Preventing the introduction of pathogens during the patient experiences significant desaturation or
lungs, making them easier to expectorate. respiratory care reduces the risk of infection. dyspnea.

d) Assist with Coughing Techniques b) Monitor for Signs of Infection Rationale: Supplemental oxygen during exertion helps
 Teach and assist the patient in effective coughing  Observe for increased temperature, changes in maintain adequate tissue oxygenation, preventing activity
techniques, such as huff coughing. sputum color, and elevated white blood cell count. intolerance.

c) Schedule Rest Periods:

  Allow the patient to rest between activities.  Allows direct access to the lung for treatment of persistent Non-infectious Tracheobronchitis: Triggered by exposure to irritants
atelectasis. like smoke, dust, chemicals, or allergens.
Rationale: Rest periods prevent fatigue and help the patient
 Pain, risk of infection, and prolonged recovery time.
recover between activities. Risk Factors
3. Lung Volume Reduction Surgery:
Age: Young children and the elderly are more susceptible due to
 Removal of a portion of the lung to improve lung function and weaker immune systems.
Pharmacological Approach breathing in specific cases like chronic obstructive
Immunocompromised Status: Individuals with weakened immune
1. Mucolytics: pulmonary disease (COPD) leading to atelectasis.
systems, such as those with HIV/AIDS or undergoing
 Reduces lung volume to improve overall function.
Name: N-acetylcysteine (NAC) chemotherapy, are at higher risk.
 Similar to thoracotomy, including pain and risk of infection
Effect: Breaks down mucus to make it easier to expel, which Pre-existing Respiratory Conditions: People with asthma, chronic
Complications
helps clear the airways. obstructive pulmonary disease (COPD), or allergic rhinitis are more
1. Respiratory Failure: Reduced lung function can lead to prone to developing acute tracheobronchitis.
Side Effects: Nausea, vomiting, abdominal pain, and in rare inadequate oxygenation and carbon dioxide removal.
cases, allergic reactions Allergic rhinitis are more prone to developing acute
2. Infection: Stagnant mucus in collapsed areas can lead to tracheobronchitis.
bacterial growth and pneumonia.
Exposure to Irritants: Smoking, air pollution, and occupational
2. Bronchodilators 3. Pleural Effusion: Accumulation of fluid in the pleural space can exposure to dust and chemicals increase the likelihood of the
Albuterol (a beta-2 agonist) occur secondary to atelectasis. condition.

Effect: Relaxes the muscles around the airways, making it Prevention Seasonal Variations: Higher incidence during cold seasons due to
easier to breathe. increased viral activity and indoor crowding.
1. Early Mobilization: Encouraging patients to move and breathe
Side Effects: Tremors, increased heart rate, nervousness, deeply soon after surgery or during prolonged bed rest helps Pathophysiology
and headache prevent atelectasis.
Infection or Irritation: The respiratory tract is exposed to pathogens
3. Anti-Inflammatory Drugs: 2. Incentive Spirometry: Use of an incentive spirometer to or irritants, leading to the activation of the immune response.
encourage deep breathing and lung.
Corticosteroids (e.g., prednisone) Inflammatory Response: The body's immune system responds by
Acute Tracheobronchitis releasing inflammatory mediators such as histamines, cytokines,
Effect: Reduce inflammation in the airways and lungs. and prostaglandins, leading to swelling of the tracheal and
Acute tracheobronchitis is an inflammation of the trachea bronchial mucosa.
Side Effects: Weight gain, osteoporosis, diabetes, and
and bronchi, primarily characterized by a sudden onset of
increased susceptibility to infections Mucus Production: The inflammation stimulates the goblet cells to
symptoms such as cough, mucus production, and airway irritation.
produce excessive mucus, leading to congestion and airway
This condition is typically triggered by viral or bacterial obstruction.
Medical / Surgical Management infections, though non-infectious causes such as environmental
pollutants can also contribute. Cough Reflex: The irritation of the airways triggers the cough reflex,
1. Bronchoscopy which is the body’s attempt to expel the mucus and clear the
Etiology airways.
 A procedure where a flexible tube is inserted through the
mouth or nose to directly visualize and remove obstructions Viral Tracheobronchitis: The most common type, often caused by Resolution or Progression: In most cases, the inflammation
in the airways. viruses such as influenza, respiratory syncytial virus (RSV), resolves as the immune system clears the infection or the irritant is
 Clears blockages that cause atelectasis. rhinoviruses, adenoviruses, or coronaviruses removed. However, in some cases, the condition may progress to
 Minor bleeding, infection, or temporary discomfort more severe respiratory infections like pneumonia.
Bacterial Tracheobronchitis: Less common, this type can be caused
2. Thoracotomy: by bacteria like Mycoplasma pneumoniae, Bordetella pertussis, or Diagnostic Tests
Streptococcus pneumoniae.
 A surgical procedure to open the chest cavity to address
more severe cases or underlying conditions.
History and Physical Examination: A thorough history of the Interventions
patient’s symptoms, recent viral infections, or exposure to irritants is
 Administer analgesics as prescribed.
crucial. Physical examination often reveals rhonchi, wheezing, or a
 Encourage the use of a pillow to splint the chest while
productive cough.
coughing.
Chest X-ray: Usually performed to rule out pneumonia, the X-ray  Educate the patient on relaxation techniques to reduce pain
may show normal results or reveal mild bronchial wall thickening. perception.
Sputum Culture: If Activity Intolerance related to Fatigue and Dyspnea
Dyspnea: Shortness of breath, particularly on exertion.
bacterial
Interventions
Chest Discomfort: Resulting from prolonged coughing.
 Plan for periods of rest between activities.
Wheezing and Rhonchi: Audible on auscultation, indicating airway
 Assist with activities of daily living as needed.
narrowing and mucus in the bronchi.
 Monitor the patient’s response to activity and adjust the plan
Fever: Low-grade fever may be present, more common in viral or of care accordingly.
bacterial infections.
NCLEX Priority Nursing Interventions
Fatigue: General malaise and tiredness due to the infection.
Airway Management: Ensuring a patent airway through
positioning, suctioning if necessary, and administering
tracheobronchitis is suspected, a sputum sample may be cultured bronchodilators.
to identify the causative organism. The result will guide antibiotic Nursing Diagnoses and Interventions Based on NANDA – I
therapy. Oxygenation: Administering oxygen and monitoring oxygen
Ineffective Airway Clearance related to increased mucus
saturation to prevent hypoxia.
Pulmonary Function Tests (PFTs): Rarely needed in acute cases, production.
but may be used if chronic obstructive pulmonary disease (COPD) Infection Control: Implementing standard precautions,
Interventions
is suspected or if symptoms persist. encouraging proper hand hygiene, and educating the patient on
 Encourage fluid intake to thin mucus secretions. preventing the spread of infection.
Viral Panel Testing: In cases of viral etiology, a viral panel test may  Teach and assist with effective coughing techniques.
be done to identify the specific virus involved. Medication Administration: Administering prescribed
 Administer prescribed bronchodilators to open airways.
medications, including antibiotics or antivirals, and monitoring for
 Position the patient in semi-Fowler’s or high Fowler’s
adverse effects
position to ease breathing.
 Monitor respiratory rate, rhythm, and breath sounds
regularly.

Clinical Signs and Symptoms

Cough: Often persistent and may be productive or non-productive. Impaired Gas Exchange related to airway obstruction and
Pharmacological Approach
inflammation.
Mucus Production: Thick, yellow or green sputum is common, Antibiotics (if bacterial)
especially in bacterial infections. Interventions
a) Amoxicillin/Clavulanate:
Sore Throat: Due to irritation of the upper airways  Administer oxygen therapy as prescribed.
 Effective against common respiratory pathogens.
 Monitor oxygen saturation levels using pulse oximetry.
 Side effects: Diarrhea, nausea, rash, allergic
 incentive spirometer.
reactions.
 Educate the patient on the importance of smoking cessation
b) Azithromycin:
if applicable.
 Often used for atypical pathogens like Mycoplasma
Acute Pain related to Chest Discomfort from Coughing pneumoniae
  Side effects: Gastrointestinal upset, prolonged QT  Vaccination: Annual influenza vaccination and  Prolonged hospital stay
interval, potential for hepatotoxicity. pneumococcal vaccines can reduce the risk of respiratory  Mechanical ventilation
infections.  Immunocompromised status
Antiviral Agents (if viral)
 Good Hygiene Practices: Regular handwashing and avoiding  Prior antibiotic therapy
a) Oseltamivir (Tamiflu): close contact with infected individuals can minimize the  Underlying chronic diseases
 May be used in influenza-related tracheobronchitis. spread of pathogens.
Pathophysiology
 Side effects: Nausea, vomiting, headache, potential  Smoking Cessation
neuropsychiatric effects.  Avoidance of triggers The infectious agent reaches the alveoli, triggering an
inflammatory response.
Bronchodilators
Alveolar sacs fill with inflammatory cells, exudate, and fibrin,
a) Albuterol: Pneumonia
leading to consolidation and impaired gas exchange.
 A short-acting beta-agonist used to relieve
bronchospasm. Pneumonia is an inflammatory condition of the lung, primarily The severity of symptoms depends on the extent of the lung
 Side effects: Tremors, tachycardia, palpitations, affecting the alveoli, caused by bacterial, viral, fungal, or parasitic involvement and the virulence of the pathogen.
nervousness infections.
Diagnostic Tests and Results
b) Ipratropium: It can be classified into community-acquired pneumonia
 An anticholinergic agent used for bronchodilation (CAP) or hospital-acquired pneumonia (HAP), depending on the  Chest X-ray:
 Side effects: Dry mouth, cough, blurred vision. setting in which it is contracted.  Shows consolidation or infiltrates in the affected lung
area
Corticosteroids (for severe inflammation) Community-Acquires Pneumonia (CAP)  Sputum Culture
a) Prednisone:  Occurs outside of healthcare settings  Identifies the causative organism.
 Used to reduce airway inflammation.  Common pathogens include Streptococcus pneumoniae,  Blood Culture
 Side effects: Weight gain, hyperglycemia, increased Mycoplasma pneumoniae, and respiratory viruses.  May show bacteremia, particularly in severe cases.
risk of infection, mood changes.  CBC (Complete Blood Count):
Hospital Acquired Pneumonia (HAP)  Often reveals leukocytosis (elevated white blood cell
Expectorants and Mucolytics
 Occurs 48 hours or more after hospital admission and was count) in bacterial infections.
a) Guaifenesin: not incubating at the time of admission.  Pulse Oximetry/Arterial Blood Gas (ABG):
 Helps thin and loosen mucus.  Often caused by more resistant bacteria, such as  Evaluates oxygenation and may reveal hypoxemia
 Side effects: Nausea, dizziness, rash. Pseudomonas aeruginosa, Staphylococcus aureus  Procalcitonin Levels:
(including MRSA), and Gram-negative bacilli  Elevated in bacterial pneumonia, aiding in
distinguishing bacterial from viral infections.

Complication
Clinical Signs and Symptoms
Pneumonia: Secondary bacterial infection can lead to pneumonia, Risk Factors / Predisposing Factor
 Fever, chills, and malaise
especially in vulnerable populations. Community Acquires Pneumonia  Cough with or without sputum production
Chronic Bronchitis: Recurrent episodes may lead to chronic  Age (very young or elderly)  Pleuritic chest pain
bronchitis or chronic obstructive pulmonary disease (COPD).  Chronic respiratory diseases (e.g., COPD, asthma)  Dyspnea and tachypnea
 Smoking and alcohol use  Crackles or rales on auscultation
Airway Obstruction: Excessive mucus production can lead to
 Immunosuppression (e.g., HIV, chemotherapy)  Cyanosis in severe cases
airway blockage, necessitating emergency interventions.
 Comorbid conditions (e.g., diabetes mellitus, heart failure)  Altered mental status, particularly in elderly patients
Prevention
Hospital Acquired Pneumonia Nursing Diagnosed and Interventions – NANDA – I
 Ineffective Airway Clearance related to excessive secretions  Side Effects: Nausea, vomiting, and neuropsychiatric Cancer Therapy: Chemotherapy and radiation therapy can impair
and inflammation: effects immune function, increasing susceptibility to infections
 Encourage deep breathing and coughing exercises. Bronchodilators Organ Transplantation: Immunosuppressive medications used to
 Administer bronchodilators as prescribed. prevent graft rejection increase the risk of infections.
a) Albuterol for bronchodilation and relief of bronchospasm.
 Position the patient in a semi-Fowler’s position to facilitate
 Side Effects: Tachycardia, tremors, and anxiety Chronic Steroid Use: Long-term use of corticosteroids can suppress
lung expansion.
the immune system, making patients more susceptible to infections.
 Perform chest physiotherapy to aid in the mobilization of Corticosteroids
secretions. Autoimmune Diseases: Conditions such as rheumatoid arthritis and
a) Prednisone for severe inflammatory response.
systemic lupus erythematosus, particularly when treated with
Impaired Gas Exchange related to alveolar-capillary membrane  Side Effects: Hyperglycemia, immunosuppression,
immunosuppressive agents, can increase the risk of pneumonia.
changes: osteoporosis.
Diabetes Mellitus: Poorly controlled diabetes can impair immune
 Monitor oxygen saturation and ABG results. Complications
function and increase susceptibility to infections.
 Administer supplemental oxygen as needed.
Sepsis: A severe systemic infection that can lead to multi-organ
 Position the patient to maximize lung expansion (e.g., high Pathophysiology
failure.
Fowler’s position)
Inflammatory Response: The immune system's inability to mount an
Respiratory Failure: Due to overwhelming infection and
Risk for Deficient Fluid Volume related to fever and increased effective response results in insufficient containment of the
compromised lung function
respiratory rate: infection, leading to inflammation and consolidation in the alveoli.
Pleural Effusion: Accumulation of fluid in the pleural space, leading
 Monitor fluid intake and output. Impaired Gas Exchange: The inflammatory exudate in the alveoli
to impaired breathing.
 Encourage oral fluids or administer IV fluids as prescribed. impairs gas exchange, leading to hypoxemia and potential
Abscess Formation: Localized collection of pus within the lung respiratory failure.
Acute Pain related to inflammation of lung tissue
tissue.
Diagnostic Tests
 Administer analgesics as prescribed.
Prevention
 Encourage the use of a pillow to splint the chest during Chest X-ray: May reveal infiltrates, consolidation, or atypical
coughing. Vaccination: Pneumococcal and influenza vaccines are patterns, depending on the pathogen.
recommended for at-risk populations.
Pharmacological Approach CT Scan of the Chest: Provides detailed images and can identify
Hand Hygiene: Essential to prevent the spread of infectious agents. patterns specific to certain pathogens (e.g., ground-glass opacities
Community Acquired – Pneumonia
in PCP)
Smoking Cessation: Reduces the risk of lung infections.
a) Amoxicillin-Clavulanate or Ceftriaxone
Sputum Culture: Identifies the causative organism but may be less
 Inhibits cell wall synthesis leading to cell lysis and Infection Control in Hospitals: Adherence to infection prevention
reliable in certain patients.
death. protocols, including the use of sterile techniques and timely removal
 Clavulanate prevents the breakdown of amoxicillin. of invasive devices. Bronchoscopy with Bronchoalveolar Lavage (BAL): Useful for
 Side Effects: Gastrointestinal disturbances, allergic diagnosing pathogens not easily identified in sputum cultures,
In Immunocompromised Patient
reactions especially in cases of PCP or fungal infections.
Pneumonia is a significant concern for immunocompromised
Hospital Acquired Pneumonia Blood Cultures: May be positive for bacteria or fungi, depending on
individuals due to their reduced ability to fight infections.
the pathogen.
a) Piperacillin-tazobactam or Meropenem
These individuals are at increased risk of developing various
 for broad-spectrum coverage Serology and PCR: Used for detecting specific viral, fungal, or
types of pneumonia, often with atypical presentations and more
 Side Effects: Nephrotoxicity, superinfections (e.g., C. atypical bacterial infections.
severe outcomes.
difficile).
Complete Blood Count (CBC): Can reveal leukocytosis or
Predisposing Factors
Antivirals: leukopenia, depending on the type of infection.
HIV/AIDS: Advanced immunosuppression can lead to opportunistic
a) Oseltamivir for viral pneumonia caused by influenza. inhibits Clinical Signs and Symptoms
infections like Pneumocystis jirovecii pneumonia (PCP).
neuraminidase, limiting the spread of the virus.
Fever and Chills: Often present but may be subtle or absent due to  Side Effects: Rash, gastrointestinal symptoms, bone Alcohol or Drug Use: Impaired consciousness and motor control
altered immune responses. marrow suppression. due to substance use can increase the risk of aspiration.
Cough: May be productive or non-productive. Complications Dysphagia: Difficulty swallowing, often seen in elderly or post-
stroke patients, increases the risk of aspiration.
Dyspnea: Shortness of breath, which can be acute or gradual. Respiratory Failure: Due to severe lung involvement or ineffective
treatment. Pathophysiology
Pleuritic Chest Pain: Pain associated with breathing or coughing.
Sepsis: A systemic response to infection leading to multiorgan Aspiration pneumonia occurs when aspirated material—such
Fatigue and Weakness: Often more pronounced than in
failure. as food particles, gastric contents, or saliva—enters the lungs.
immunocompetent individuals.
Pleural Effusion or Empyema: Accumulation of fluid or pus in the This material can contain bacteria or irritants that cause an
Altered Mental Status: Especially in severe cases or in patients with
pleural space. inflammatory response in the lung tissue. The inflammatory process
significant comorbidities
can lead to:
Prevention
Nursing Diagnosis and Interventions – NANDA – I
Local Infection: Bacteria such as Streptococcus pneumoniae,
Vaccination: Ensure immunocompromised patients receive
Same as HAP/CAP Staphylococcus aureus, and Anaerobes can infect the lung tissue.
appropriate vaccinations (e.g., pneumococcal, influenza).
Pharmacological Treatment Increased Inflammation: This results in alveolar damage, impaired
Infection Control: Adhere to strict hygiene and infection control
gas exchange, and consolidation of lung tissue.
Antibiotics: practices.
Abscess Formation: In severe cases, abscesses or necrotizing
a) Ceftriaxone (Rocephin): Regular Monitoring: Routine follow-ups to detect and manage early
pneumonia may develop.
 Broad-spectrum cephalosporin with action against signs of infection.
many Grampositive and Gram-negative bacteria. Diagnostic Tests
Aspiration Pneumonia
 Side Effects: Gastrointestinal issues, hypersensitivity
Chest X-ray:
reactions. Aspiration pneumonia is an infection that occurs when food,
b) Piperacillin-Tazobactam (Zosyn): liquid, or other substances are inhaled into the lungs, causing  Shows infiltrates or consolidation in the lungs. Common
 Broad-spectrum beta-lactam antibiotic with beta- inflammation and infection. findings include a right lower lobe infiltrate or consolidation
lactamase inhibitor. due to the right main bronchus being more vertically
 Side Effects: Allergic reactions, electrolyte imbalances It typically affects the right lung due to anatomical differences oriented.
in the bronchial tree, but can affect either lung.
Antifungals (for fungal pneumonia): CT Scan:

a) Fluconazole (Diflucan):  Provides a more detailed view, showing the extent and
 Effective against Candida and Cryptococcus location of the infection.
 Side Effects: Hepatotoxicity, gastrointestinal Risk Factors Sputum Culture:
disturbances.
b) Voriconazole (Vfend): Neurological Disorders: Conditions such as stroke, Parkinson’s  Identifies causative bacteria and determines antibiotic
 Used for Aspergillus and other fungal infections. disease, or Alzheimer’s disease impair swallowing and cough sensitivity.
 Side Effects: Visual disturbances, hepatotoxicity. reflexes.
Blood Tests:
Antivirals (for viral pneumonia): Impaired Consciousness: Sedation, anesthesia, or altered mental
status can decrease the protective mechanisms of the airway.  May show elevated white blood cell count (leukocytosis) and
a) Oseltamivir (Tamiflu): other markers of infection (e.g., Creactive protein).
 Inhibits neuraminidase enzyme in influenza. Gastroesophageal Reflux Disease (GERD): Reflux increases the
risk of aspiration of gastric contents. Bronchoscopy:
 Side Effects: Nausea, vomiting.
Poor Oral Hygiene: High bacterial loads in the oral cavity can lead  In some cases, this may be used to visualize the airways
Antibiotics for PCP:
to aspiration of pathogenic organisms. and obtain cultures.
a) Trimethoprim-Sulfamethoxazole (Bactrim):
Clinical Signs and Symptoms
 Effective for Pneumocystis jirovecii pneumonia.
Fever: Often present with a high temperature. Sepsis: A severe systemic infection that can lead to multi-organ enzyme 2 (ACE2) receptors on the surface of respiratory epithelial
failure. cells.
Cough: Usually productive, with sputum that may be purulent or
greenish. Chronic Lung Disease: Prolonged or severe infections may result in The virus then replicates within these cells, leading to:
chronic lung damage.
Dyspnea: Difficulty breathing or shortness of breath Viral Replication: Causes direct damage to the respiratory
Preventions epithelium.
Chest Pain: Often pleuritic, or sharp and worsened by breathing.
Good Oral Hygiene: Regular brushing and dental check-ups to Inflammatory Response: The immune system responds by
Wheezing or Crackles: On auscultation of the lungs.
reduce the risk of oral bacteria. releasing cytokines, leading to inflammation in the lungs.
Hypoxemia: Low oxygen levels in the blood, which may be evident
Proper Positioning: Especially in patients with impaired swallowing Alveolar Damage: The inflammation can cause damage to the
through oxygen saturation levels
or consciousness. alveoli, impairing gas exchange and leading to hypoxia. Diffuse
Nursing Diagnosis
Swallowing Therapy: For patients with dysphagia, working with a Alveolar Damage (DAD): This severe form of lung injury is
Impaired Gas Exchange related to inflammation and infection speech therapist to improve swallowing. characteristic of ARDS and can result in respiratory failure.
in the lungs.
Regular Assessment: For high-risk patients to monitor and manage Diagnostic Tests
Monitor Vital Signs: Regularly assess respiratory rate, oxygen aspiration risk factors.
Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR):
saturation, and lung sounds to detect changes.
Severe Acute Respiratory Syndrome
Detects SARS-CoV RNA in respiratory specimens such as
Administer Oxygen Therapy: To maintain adequate oxygen levels
Severe Acute Respiratory Syndrome (SARS) is a viral nasopharyngeal swabs, sputum, or bronchial lavage fluid. Positive
and alleviate hypoxemia.
respiratory illness caused by the SARS-associated coronavirus results confirm infection.
Positioning: Encourage semi-Fowler’s or Fowler’s position to (SARS-CoV), which emerged in 2002-2003.
Serology Tests: Detect antibodies against SARS-CoV. These are
improve lung expansion and reduce the risk of further aspiration.
It is characterized by fever, dry cough, and difficulty more useful in the later stages of the disease or in retrospective
Risk for Aspiration related to impaired swallowing or breathing, and it can progress to pneumonia and acute respiratory diagnosis.
decreased level of consciousness. distress syndrome (ARDS).
Chest X-ray: Shows atypical pneumonia with patchy infiltrates or
Monitor Swallowing: Assess swallowing ability and modify diet as SARS is highly contagious, with transmission occurring ground-glass opacities, commonly affecting the lower lobes.
needed (e.g., thickened liquids, pureed foods). primarily through respiratory droplets
CT Scan: Provides a more detailed image, showing areas of
Oral Hygiene: Ensure regular oral care to reduce bacterial load and Risk Factors consolidation or ground-glass opacities indicative of viral
the risk of aspiration. pneumonia.
Close Contact with Infected Individuals: Especially in healthcare
Patient Education: Educate patients and caregivers on proper settings or household environments.
eating techniques and positioning to reduce aspiration risk.
Travel to Endemic Areas: Particularly during the initial outbreak,
Pharmacological Approach areas like Hong Kong, China, and other parts of Asia were
Same as previously discussed: antibiotics and bronchodilators hotspots.
Clinical Signs and Symptoms
Medical / Surgical Approach Compromised Immune System: Individuals with weakened immune
systems, such as the elderly or those with chronic illnesses, are at SARS presents with a range of symptoms that typically appear 2-10
Drainage of Abscesses: To remove pus and reduce infection. higher risk. days after exposure:
Bronchoscopic Removal of Foreign Bodies: If the aspiration Healthcare Workers: Due to frequent exposure to infected patients. Fever: Often high (above 38°C or 100.4°F) and one of the earliest
involved a solid object. signs.
Crowded Living Conditions: Increases the likelihood of transmission
Complications Dry Cough: Persistent and unproductive.
Pathophysiology
Lung Abscess: A localized collection of pus within the lung tissue. Dyspnea: Shortness of breath, which may progress to severe
SARS-CoV enters the human body primarily through the
Pleural Effusion: Accumulation of fluid in the pleural space. respiratory distress.
respiratory tract, where it binds to the angiotensin-converting
Malaise: General feeling of unwellness or fatigue. a) Corticosteroids
 Can reduce inflammation but may cause side effects
Myalgia: Muscle pain or body aches.
like immunosuppression, hyperglycemia, and
Headache: Common in the early stages of the disease. osteoporosis with prolonged use
Diarrhea: Occurs in some cases, especially in later stages. Complications
Nursing Diagnoses and Interventions Acute Respiratory Distress Syndrome (ARDS): A life-threatening
condition requiring mechanical ventilation.
Impaired Gas Exchange related to alveolar damage and
inflammation. Respiratory Failure: May necessitate prolonged ventilatory support
Monitor Oxygenation: Regularly check oxygen saturation and Sepsis: Severe systemic infection that can lead to multi-organ
Pathophysiology
arterial blood gases (ABGs) to assess the severity of hypoxia. failure.
Administer Oxygen Therapy: Use nasal cannula, face mask, or Long-Term Lung Damage: Scarring or fibrosis in the lungs, leading The pathophysiology of pleurisy involves inflammation of the pleural
mechanical ventilation as required to maintain adequate oxygen to chronic respiratory issues. layers.
levels. This inflammation leads to increased production of pleural fluid or,
Prevention
Positioning: Encourage semi-Fowler’s or Fowler’s position to in some cases, fibrous exudates.
Quarantine and Isolation: Infected individuals should be isolated to
optimize lung expansion and ease breathing. The friction between the inflamed pleural layers results in sharp,
prevent transmission.
Risk for Infection related to impaired immune response and pleuritic chest pain.
Travel Restrictions: Limiting travel to and from areas with active
exposure to SARS-CoV The inflammation can also lead to a restrictive pattern in lung
outbreaks.
Implement Isolation Precautions: Use airborne, droplet, and contact function due to pain and decreased lung expansion.
Personal Protective Equipment (PPE): Healthcare workers should
precautions to prevent the spread of the virus. Diagnostic Tests
use appropriate PPE, including N95 masks, gowns, gloves, and eye
Promote Hand Hygiene: Ensure proper handwashing practices are protection.
followed by the patient, healthcare workers, and visitors.
Vaccination: While no vaccine was available during the initial
Administer Antiviral Medications: If available and prescribed, to outbreak, ongoing research aims to develop vaccines against
reduce viral load and prevent disease progression. SARS and related coronaviruses.

PLEURISY

Pleurisy, also known as pleuritis, is an inflammatory condition of the

pleura, which are the two thin layers of tissue surrounding the
lungs.
The inflammation of the pleura causes the layers to rub against
Pharmacological Approach each other, leading to sharp, stabbing chest pain that often worsens
Antiviral Agents: with breathing or coughing.

a) Ribavirin Risk Factors

 During the SARS outbreak, there were no specific
antiviral drugs proven effective against SARS-CoV.
 Side Effects: Hemolytic anemia, teratogenic effects,
and elevated bilirubin levels
Anti Inflammatory
 Clinical Signs and Symptoms
Surgical Approach

Complications

Pharmacological Approach
Nursing Diagnoses and Intervention NANDA – I

Preventive Measures

PLEURAL EFFUSION
j

Risk Factors

Pathophysiology
Clinical Signs and Symptoms

Types of Pleural Effusion

Diagnostic Tests Nursing Diagnoses and Interventions – NANDA – I

 Complications

Preventive Measures

Pharmacological Approach

Surgical Approach

EMPYEMA
 TYPES OF EMPYEMA

Risk Factors

Clinical Signs and Symptoms

Pathophysiology
Diagnostic Tests

Nursing Diagnoses and Interventions – NANDA – I

 Complications

Preventive Measures

Surgical Approach

Pharmacological Approach

PULMONARY EDEMA
Types of Pulmonary Edema

Pathophysiology

Clinical Signs and Symptoms

Risk Factors Diagnostic and Laboratory Tests Nursing Diagnoses and Intervention – NANDA - I
 ARDS
Pharmacological Approach Surgical Approach

Complications

Category of ARDS
Prevention
 Phases of ARDS

Nursing Diagnoses and Intervention – NANDA – I

Diagnostic and Laboratory Tests Clinical Signs and Symptoms

Pharmacological Approach

Prevention

Pulmonary Hypertension

Complications Risk Factors

Types based on Underlying Cause
 Clinical Signs and Symptoms
Diagnostic and Laboratory Tests Pharmacological Approach

Nursing Diagnoses and Intervention – NANDA – I

 Risk Factors

Diagnostic and Laboratory Tests

Complications

Pulmonary Embolism

Types of Pulmonary Embolism Pathophysiology Clinical Signs and Symptoms

 Prevention

Nursing Diagnoses and Intervention – NANDA - I

Surgical Approach

Complications

FB

Pharmacological Approach