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Respiratory System part 2 second years student Nursing Collage. Iman Al Shaweesh Sept. 2008 Al Najah Univesity. Health History.

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respiratory system part 2 second years student nursing collage
Respiratory Systempart 2second years studentNursing Collage

Iman Al Shaweesh

Sept. 2008

Al NajahUnivesity

health history
Health History
  • The reason that pt. is seeking health care is, dyspnea (shortness of breath), hemoptysis (blood spit up from respiratory tract), odema, cough, general fatigue, weakness.
  • Nurse must identify chief complain , when started problem ,how long, duration, severity, assess risk factors, identify the impact of s&s on the patient ability to perform daily activitie.
Major s&s are dyspnea, cough, wheezing, sputum production, chest pain, clubbing of fingers, hemoptysis, cyanisis. This S&S are related to duration & severity of disease.
1 dyspnea
  • difficult or labored breathing, shortness of breath. Symptom common to many pulmonary & cardiac disorders, particularly when there is decrease lung compliance or increase airway resistance.
  • Rt. Ventricle will affect by pulmonary disease because it must pump blood through the lung against greater resistance.
Sudden dyspnea in health person indicates.
  • Pneumothorax (air in pleural cavity).
  • Pulmonary embolism
  • RDS.
  • Acute respiratory obstruction.
  • (inability to breath easily except in an upright position). Found in pt. with COPD, heart disease.
  • Dyspnea with an expiratory wheeze occurs with COPD.
  • Noisy breathing result from narrowing of the airway or localized obstruction of major bronchus by tumor or foreign body.
relieve measures
Relieve measures
  • high fowlers position, 02 in sever case.
  • Ask pt. circumstance that produces dyspnea.
  • How much exertion triggers shortness of breath?
  • Cough?
  • Time of day or night? Occur at rest.
  • Shortness sudden or gradual.
2 cough
  • Result from irritation of the mucous membranes any where in the respiratory tract.stimulus many arise from an infectious process or irritant as smoke, dust, gass……….its protect against accumulation of secretion in the bronchi & bronchioles.
clinical manifestation
Clinical manifestation
  • Cough may indicate serious pulmonary disease.
  • Nurse must evaluate character of cough, dry, loose, sever, brassy, hacking.
  • A dry, irritant cough in characteristics of an URTI of viral origin or may be S.E of (ACE) inhibitor therapy.
  • Laryngotracheitis cause an irritative high pitched cough.
Tracheal lesions produce a brassy cough.
  • A sever or changing cough may indicate bronchogenic carcinoma.
  • A cough in the morning with sputum production may indicate bronchitis.
  • A cough that worsen when the pt. is in supine position suggest postnasal drip (sinusitis).
  • Coughing after food intake may indicate aspiration of material into the tracheobronchial trea.
3 sputum production
3-sputum production
  • pt. who coughs long enough produce sputum.
  • Violent coughing cause bronchial spasm obstruction & irritation of bronchi and may result in scope (funting).
  • Uncontrolled cough that is non productive is exhausting & potentially harmful.
clinical manifestation12
Clinical manifestation
  • Thick, yellow, green………………..Indicate bacterial infection.
  • Thin, mucoid sputum……………......Indicate viral.
  • Pink tinged mucoid sputum ……………Indicate lung tumor.
  • Profuse, frothy, pink material ……………...Indicate pulmonary odema.
  • Foul-smelling sputum & bad breath ……….Indicate lung abscess, infection from anaerobic organism.
relieve measure
Relieve measure:
  • Adequate hydration (water).
  • Inhalation of nebulizer.
  • Stop smoking, because it causes inflammation & hyperplasia of mucous, and decrease production of surfactant.
  • If smoking stop sputum will decrease, encourage pt. to drink juices to change sputum taste &select of food that increase the appetite.
4 chest pain
4-chest pain
  • may associated with pulmonary or cardiac disease.
  • Chest pain with pulmonary may be sharp stabbing & intermittent or dull, aching & persistant
  • Pain may refer else where- neck, back, abdomen.
clinical manifestation15
Clinical manifestation
  • Chest pain may occur with pneumonia, pulmonary embolism with lung infarction & pleurisity.
  • It also late symptom of bronchogenic carcinoma.
  • Lung disease not always produce pain because lung & visceral pleura lack sensory nerves & insensitive to pain stimuli & partial pleura has rich supply of sensory nerves.
Pleuritic pain from irritation of partial pleura is sharp, pt. describe it as (like the stabbing of knife). Pt. comfortable when sleep on affected part.
  • Nurse must assess quality, intensity, radiation of pain, relationship of pain to inspiratory & expiratory.
Relieve measures
  • Analgesic medication but not to depress the respiratory center or productive cough.
  • NSAID for pleurituic pain.
  • Regional anesthetic block may be performed to decrease extreme pain.
5 wheesing
  • Is often a major finding in pt. with bronchoconstriction or airway narrowing.
  • Heard with stethoscope & depend on location.
  • Wheezing is a high pitched, musical sound heard mainly on expiration.
  • Relieve measure: Oral or inhaled bronchodilator.
6 clubbing of the fingers
6-clubbing of the fingers
  • is singe of lung disease found in pt. with chronic hypoxic condition, chronic lung infections, CA of lung.
  • Initially manifested as sponginess the nail bed & loss of nail bed angle
7 hemoptysis
  • Expectoration of blood from respiratory tract.
  • Is symptom of both pulmonary & cardiac disorders.
  • Onset is sudden, may be intermittent or continious.
  • Common cause: 1- pulmonary infection.

2- CA of lung.

3- Abnormalities of heart &

blood vesserls.

4- Pulmonary artery or vein abnormalities.

5- Pulmonary emboli & infarction.

DX. Evaluation:

  • Chest x-ray.
  • Chest angiography.
  • Bronchoscopy
  • Full history & physical examination
Inspection of blood, small amount or massive hemorrhage. Source of bleeding gums( blood appearing in noise).
  • Lung (bright red, frothy salty taste haemoptesis.
  • Stomach(haemoptesis dark blood).
8 cyanosis
  • Is a bluish coloring of skin, very late indicator of hypoxia.
  • Presence or absence of cyanosis is determined by amount of unoxygenated hemoglobin in blood. When there is 5g/dl of unoxygenated HG. A pt. with 15g/dl HG will not demonstrate cyanosis until 5g/dl of HG become unoxygenated.
  • Cyanosis is not reliable singe of hypoxia. Because anemic pt. rarely manifest cyanosis.
In the present of pulmonary condition cyanosis assess by tongue & lips.
  • Peripheral cyanosis results from decrease blood flow to certain area & not indicate central problem.
physical assessment of upper respiratory tract
Physical assessment of upper respiratory tract

Noise & sinuses

  • Inspect external nose for lesion, asymmetry or inflammation .ask pt. to tilt head background, gently pushing tip of nose& inspect mucosa for color, swelling, & bleeding.nasal Deviation, Perforation.
  • Nurse inspect inferior & middle turbinates then nurse palpate frontal & maxillary sinuses for tenderness using thumb & gently pressure. Frontal & maxillary sinuses can be inspected by (transilliumination). If light fails to generate, the cavitycantain fluid.
Pharynx & mouth
  • Ask pt to open mouth & take breath inspect for color, symmetry, ulceration or enlargement.
  • Trachea.(position, mobility of trachea).
assessment of lower respiratory structures breathing
Assessment of lower respiratory structures & breathing
  • ThoraxInspection of thorax provide information about musculoskeletal structure, nutritional status & respiratory system. Note symmetry.
  • Chest configuration. Normal ratio of anterioposterior diameter to lateral diameter is 1:2. Four deformities of chest associated with respiratory disaease.
A-Barrel chest.
  • Result of overinflation of the lungs
  • Increase in anterioposterior diameter of thorax
  • Pt. with emphysema, ribs are more wildely spaced & intercostals spaces tend to blug on expiration.
B-Funnel chest (pectus excavatum)
  • Occur where is depression in lower portion of sterum this may compress heart & great vessels resulting in murmers.
  • May occur with rickets or marfans syndrom
C-Pigeon chest (pectus carinatum).
  • Occur as result of displacement of sternum.
  • Increase anterioposterior diameter.
  • Rickets , marfans syndrome, sever hyposkoliosis.
  • Is characterized by elevated of scapula & corresponding S- shape spine.
  • This limit lung expantion.
  • Occure with osteoporosis.
breathing pattern respiratory rates
Breathing pattern & respiratory rates
  • Normal breath 12-18 b/m, regular in depth & rythem. This descripe as eupnea.
  • Bradycardia – slow breathing associated with increase ICP , brain injury, drug overdose.
  • Tachypnea- rapid breathing. Pt with pneumonia, metabolic acidosis, pulmonary odema, septicemia.
  • Hyperventilation – shallow, irregular breathing. hyperventilation associated with sever acidosis is called ( kussmauls respiration
Hyperpnea – increase depth of respiration.
  • Hyperventilation – increase in rate & depth . inspiration & expiration are equal in duration.
  • 1-Thoracic palpation:
  • The nurse palpates the thorax for tenderness, masses, lesion, vocal fremitus, and respiratory excursion. Nurse performs direct palpation with finger tips or ball of the hand (for deeper masses).
A-Respiratory excursion:
    • Is an estimation of thoracic expansion & may dissolve significant information about thoracic movement during breathimg.
    • Pt. instructed to inhale deeply while the movement of nurse thumbs. This movement is normally symmetry. Asymmetric excursion due to fracture rib, trauma, & unilateral bronchial obstruction.
    • Decrease chest excursion due to chronic fibrotic disease.
B-Tactile fremitus
      • Sound generated by the larynx travels distally a lone the bronchial tree to test the chest wall in resonant motion. Pt asks to repeat 99.
      • Pt. with emphesema- rupture of aloveoli & trapping of air, exhibit no tactile fremitus.
      • Tactile fremitus increase over lob affected with pneumonia.
C-Thoracic percussion
  • Nurse use percussion to determine a whether underlying tissues are filled with air, fluid or solid material.also used to estimate size, location certain structure with thorax. (heart. Diaphragm).
D-diaghragmatic excusion

Normal resonance of the lung stops at the diaphragm, the position of diaphragm is different in inspection & expiration.

Assess position & motion of diaphragm by ask pt. to take breath & hold it, nurse

marked with pen. Distance between the two markings indicates range of motion.

8-10cm in healthy, 5-7 most people. The diaphragm is about 2cm. higher in Rt.

Because position of heart.

dx evaluation
  • Pulmonary function test. Routinely used in pt. with chronic respiratory disorders, test should measurements of lung volume, ventilatory function & mechanism of breathing diffusion & gas exchange.
  • Arterial blood gas study. Aid in assessing the ability of the lungs to provide adequate o2 & remove co2. the ability of kidney to reabsorb & excrete bicarbonate ions to maintain body normal PH. ABGs are obtained through an arterial puncture at radial, brachial, femoral, or indwelling arterial catheter.
Pulse oximetry. Non invasive method of continuously monitoring o2 sat. of hemoglin. Aprobe or sensor is attached to the fingertip forehead, earlobe, bridge of nose. Normal 95-100%, decrease 85 indicate that tissue are not receiving enough o2.
  • Culture. Throat culture to identify pathogenic organism, drug sensitivity testing. Specimen to lab must be within 2 hr.s (overgrowth of organisim). Specimen taken at morning.
Imagining studies. Include X- ray, CT, MRI (magnetic resonance imagimg, radioscopic diagnostic scans.

1-Chest x-ray: normal pulmonary tissue is radiolucent, there for densties produced by fluid, tumors, foreign bodies & pathogenic condition can be detected by x-ray.

2-CT : used to identify pulmonary nodules & small tumors that are not visible on routine chest x-ray.

3-MRI:are more diagnostic image than CT… characterized pulmonary bodules.

4-Fluoroscopic studies: used to assess with invasive procedures as chest needle biopsy. To study movement of chest wall, heartr, diaphragm.To detect , diaphragm paralysis & lung masses.

5-Pulmonary angiography: used to investigate thromboembolic disease of the lung as congenital abnormalities of pulmonary vascular tree.( it involve rapid injection of radiopaque agent ( from femoral vein, arm vein) into the vascular of the lungs for radiographic study of pulmonary vessels
6-Radioisotope DX. Procedures (lung scan).Ventilation- perfusion lung scan is first performed by injecting a radioactive agent into a peripheral vein & then obtaining a scan of the chest into detects radiation.Used clinically to measure the integrity pf pulmonary vessels relative to blood flow to evaluate blood flow abnormalities as seen in pulmonary emboli. It takes 20-40 minute.
vi endoscopic procedure
VI.Endoscopic procedure
  • Bronchoscopy is direct inspection & examination of the larynx, trachea, & bronchi through either a flexible fiberoptic scope or rigidf bronchoscope.
  • Purpose of DX. Bronchoscopy.
      • To examine tissue or collect secreations.
      • To determine location & obtain tissue.
      • To determine if tumor can be resected surgically.
      • To DX. Bleeding site.
Thepaputic bronchoscopy is used to:
  • Remove foreign bodies.
  • Remove recreation obstruction the tracheobronchial tree.
  • Treat post operative atelactasis.
  • Destroy & excise lesion.
    • Reaction to local anesthesia.
    • Infection
    • Aspiration
    • Bronchoscopy
    • Hypoxemia
NSG intervention:
  • consent form, NPO, explain procedure, preoperative medication ( atropine, sedation)… prescribed to inhibit vagal; stimulation, suppress cough. Also pt. must remove dentures.
  • Post op. pt. must be NPO until the cough reflex returns. Ice-chips & fluid given.
  • Observe v/s, hypoxia, bleeding, hypotention, tachycardia, dysarythmia.

(DX. Treat & biobsy).

  • Is DX procedure in which the pleural cavity is examined with an endoscope. Small incisions are made into the pleural cavity.
  • Chest tube may be inserted & pleural cavity is drained by negative- pressure water seal drainage.
NSG intervention:
    • Monitor shortness of breath (which may indicate pneumothorax).
    • Monitor chest drainage if chest tube is in place.
    • Monitor activity restriction.
  • A thin layer of pleural fluid normally remains in the pleural space. An accumulation.
  • may occur in some disorders. Sample can obtain by (aspiration of pleural fluid for DX. To therapeutic purposes).
  • Needle biobsy can be performed at same time. Study includes grams stain culture & sensitivity, acid- fast staining, PH…..
  • The excision of small amount of tissue, may be performed to permit examination of cells from the pharynx, larynx.
  • Pleural biopsy: is accomplished by needle biopsy of the pleura or by pleuroscipy. Visual exploration through a fiberoptic bronchoscopy.
  • Lung biobsy procedures: is performed to obtain lung tissue for examination to identify the nature of lesion.
There are several non-surgical technique as:
    • transcantheter bronchial brushing
    • trans brachial lung biopsy
    • percutanous.
  • NSG intervention: same as bronchoscopy, monitor shortness of breath, bleeding, infection, report pain, redness of biopsy, site, pus……..
  • Lymph node biopsy : scalene node biopsy may performed to detect lymph spread of pulmonary disease as hodgkins carcinoma.
management of pt s with upper respiratory tract disorder
Management of pt.s with upper respiratory tract disorder

1-Rhinitis: is a group of disorder characterizes by inflammation & irritation of the mucous membranes of the nose. It may be classified as non allergic & allergic.


  • Non allergic rhinitis may be caused by a variety of factors including.
  • Environmental factors such as change temp. Humidity odors, foods, infection, age, systemic disease, drugs (cocaine). Or prescribed medication, foreign body.

Rinorrhea (excessive nasal drainage, runny nose), nasal congestion, discharge itching, sneezing, and headach.


  • Depend on cause if viral, medication given to reduce symptoms.
  • In allergic rhinitis tests may perform, corticosteroid desensitizing immunization may require.
If bacterial infection- antimicrobial agent.
  • Antihistamine for allergy for sneezing, itching, rhinrrhea.
  • Oral decongestant agent.
NSG Manegement.
    • Avoid or decrease exposure to allergens & irritants.
    • Controlling environment.
    • Technique of administer nasal medication.
    • Hygiene, blow the nose before medication.
    • Treat symptom.
    • In elderly, nurse discusses value of vaccine in the fall to achieve immunity prior the beginning of flu season.
2 viral rhinitis common cold
2-Viral rhinitis (common cold).
  • Is used when referring to an URTI & is self- limited & caused by a virus (viral rhinituis).
  • nasal congestion, rhinorrhea, sneezing, sore throat & general malaise characterize it.
  • Cold are highly contagious because virus is shed for about two days befot the symptoms appear.
The 6 viruses known to produce S&S of viral rhinitis are rhiniuvirus, parainfluenza virus, corona virus, resp. syncytial virus influenza, adenovirus. Each one have multiple strain.(e.g 100 strains of rhinivirus, which account of 50% of al colds.
      • Nasal congestion, runny nose, sneezing, nasal discharge, nasal itching, tearing watery eyes, scratchy or sore throat, general malaise.
      • Low grade fever, chills, headache, muscle aches.
      • In some people it exacerbates to herpes simplex.
      • Symptom last 1-2 wk.s.
  • Consist of symptomatic therapy, no specific treatment.
  • Adequate fluid intake.
  • Rest, increase intake of vitamin C, use expectorant.
  • Warm salt water gargles
  • NSAID as aspirin, ibuprofen relieves the aches, pain, & fever.
Some research suggests Zink lozenges, may decrease duration of cold symptoms if taken within 1st 24 hr.s of onset.
  • Antibiotic should not be used.
  • NSG Manegement
    • Teach pt. how to break the chain of infection, hand washing (most effective).
    • Teach method to treat symptom & prevent measure.
3 acute sinusitis
3-Acute sinusitis
  • The sinuses, mucus lined cavities filled with air that drain normally into the nose, are involved in a high proportion of URTI.
  • If opening to nasal are clear, the infection resolve promptly.
  • Some individual are more prone to sinusitis because of their occupation as paint.
  • Acute sinusitis is an infection of the Para nasal sinuses.
  • It frequently developa as aresult of an URTI.
  • Nasal congestion caused by inflammation, odema, transudation of fluid, lead to obstraction of the sinus cavity.
  • This provide an excellent modium for bacterial growth.


Bacterial organism account for 60% of acute sinusitis as streptococcus pneumonia, hemophilus influenza, moraxella catarrbalis.
  • Dental infection associated with acute sinusitis

Facial pain, nasal obstruction, fatigue, purulent nasal discharge, fever, headache, facial ear pain & fullness, dental pain, cough, decrease sense pf smell, sore throat, eyelid edema.

assessment dx finding
Assessment & DX finding
  • History & physical examination.
  • Tenderness over the infected sinus area.transilluminated (decrease transmission of air).
  • Sinus x-ray. (Fluid level, mucisal thikining).
  • Computed tomograghy scanning is most effective DX tool.
  • If not treated lead to meningitis brain abscess, ischemic infarction, osteomyelitis, sever orbital cellulites.


  • Goal to treat infection, shrink the nasal mucosa & relieve pain.
  • Antimicrobial, first line…amoxicillin, erythromycin, bactrim….
Mucolytic agent, decease nasal congestion.
  • Antihistamine
  • If pt. continues to have symptom 7-10 days, the sinuses may need to be irrigated & hospital may be required.

NSG Management

    • Teach method to promot drasinage as inhaling system, increase fluid intake, local heat.
Inform pt. about S.E of nasal spray body receptors depened on spray to keep nasal passage open. (rebond congestion).
  • Teach early signe of a sinus infection & recommended preventive measures as following health practices, avoid contact with people have URTI.
  • Explain the fever nuchal rigidity, sever headach as signe of potential complication.
chronic sinusitis
Chronic Sinusitis
  • Is an inflammation of sinuses that persists for more than 3 wk.s in adult & 2 wk.s in children. Estimated that 32 millions develop/year.
  • Is an inflammation of sinuses that persists for more than 3 wk.s in adult & 2 wk.s in children. Estimated that 32 millions develop/year.
  • Blockage that persist for greater 3 wk. may occur because of infection, allergy, or structural abnormalities.
This result in stagnant recreation, an ideal medium for infection.
  • Organism as acute & immunocompremized at risk of fungal.
clinical manifestation73
Clinical Manifestation
  • Impaired mucocilliary clearance & ventilation, cough, chronic hoarseness, chronic headach in periorbital area, facial pain.
  • Fatigue, nasal stuffness, decrease smell & taste, fullness in the ears.
  • Symptoms are generally pronounced on awakening.
dx finding assessment
DX finding & assessment
  • History, computed tomography scan or MRI if fungal suspected.
  • Rule out other systemic disorders as tumor.
  • Nasal endoscopy.


  • Uncommon.
  • sever orbital cellulites
  • meningitis, encephalitis
  • cavenous sinus thrombosis
treatment of chronic sinusitis
Treatment of chronic sinusitis
  • As acute course 3-4 wk.s)
  • Surgical management when medical failed incision & drainage sinus, removing tumor, correct structural deformities (excise fungal ball & necrotic tissue & drain sinus).
  • Topical corticosteroid, antimicrobial agents are administer before & after surgery.
NSG Management
  • Nurse teaches pt. how to promote sinus drainage at home by increase envoromental humidity.
  • Increase fluid, follow medication regime.
  • Instrucr signe of sinus infection.
4 acute pharyngitis
4-Acute Pharyngitis
  • Is an inflammation or infection in the throat usually causing symptoms of a sore throat.


  • Most cases of acute pharyngitis are caused by viral infection.
  • When group.A beta-hemolytic streptococcus- most common cause acute pharyngitis the condition know as strep throat.
Body response by triggering an inflammatory response in the pharynx, this results in pain, fever, vasodilation, edema, tissue damage, manifested by redness & swelling in the tonsillar pillars, uvula & soft palate, creamy exudates may be presented in tonsillar pairs.
  • If a beta- hemolytic streptococci is a more sever illness.
Complication include, sinasitus, OM, peritonsillar abscess, mastoiditis & cervical adenitis.
  • In rare case meningitis, pneumonia.


  • Afiery red pharyngitis membrane & tonsils lymphoid follicles those are swollen & flacked with white purple exudates. Enlarge tender cervical lumph nodes.
  • Fever, malaise, sore throat may present.
assessment dx
Assessment & DX.
  • Latex agglutination (LA) / strep antigen
  • Throat culture
  • Nasal swab & blood culture


  • Viral………supportive measures
  • Bacterial…….. penicillin, erythromycin, cephalosporin (10 day).
  • analgesia, aspirin, acamol.
  • Antitussive med. Codian
  • Nutritional therapy, liquid, soft, in sever case IV
nsg management
NSG Management
  • Stay in bed during febril stage.
  • Disposed of tissue to decrease spread infection.
  • Examin skin for rash, because pharungitis may precede some communicable disease as rubella.
  • Warm saline gargles or irrigation.
  • Ice collar can relieve sever throats.
Mouth care.
  • Full course of antibiotics, A beta-hemolytic strep. Infection possible develop complication as nephritis, RF, which may have onset 2-3 wk.s of pharyngitis.
  • Nurse must instruct the important of take full course of med.)
chronic pharyngitis
Chronic Pharyngitis
  • Is a persistent inflammation of the pharynx, its common in adults who work or live in dusty surrounding, use their voice to excess, suffer from chronic cough, use alcohol.

Three type of chronic pharyngitis

  • Hypertrophic: general thickening & congestion of the pharyngeal mucusemembrane.

B. Atrophic : late stage of type one membrane is thin, whitish, glistening.

C. Chronic granular(clergymanas sore throat), characterized by numerous swollen lymph follicles on the pharynx.


  • Pt. sense, constant sense of irritation or fullness on throat.
  • Mucous that collects in the throat can be expelled by coughing & difficulty swallowing.
  • Rx based on relieving symptoms avoid exposure to irritants.
  • Nasal congestion- nasal spray contain ephedrine sulfate
  • Aspirin or acetaminiphil.
  • Analgesic, antihistamin q 4-6 hr.
nsg management86
NSG Management
  • Avoid contact with other.
  • Alcohol, tobacco, smoke, exposure to cold are avoided.
  • Drink plenty of fluids
  • Gargelling with worm saline may relieve throat discomfort.
  • Lozenges will keep throat moistened.