Ap Biology Test 1 Answer Key

Test 1 Study Guide 1. Respiration * Respiration * Gas exchange * Necessary because cells require oxygen. * Exchanging O2 and CO2 * Carbon Dioxide is a waste product and must be removed from the body. * Internal respiration = gas exchange at the cellular level. * Oxygen diffuses from the blood into the tissue cells. * External respiration = gas exchange at the alveoli level. * Oxygen from the inhaled air diffuses into the blood in the pulmonary capillaries. * Three primary parts of respiration: * Ventilation, profusion, diffusion. * Ventilation = movement of gases into and out of the lung. * Position – dependent areas receive majority of air. * Lung volume
– low volume results in shunting air to lung apices. * Disease – bronchial constriction and airway collapse decrease ventilation. * Ventilator mechanically assists patient to breathe. * Profusion = flow of blood in a specific organ of the body. * Position – dependent areas receive majority of blood. * Hypoxia – results in vasoconstriction and decreased perfusion. * Blockage – results in decreased or absent perfusion to distal areas. * If the heart is not profused enough = heart attack. * If the brain is not profused enough = stroke. * Diffusion = movement of gases across the alveoli. * Oxygen moves from areas of high concentration to areas of low concentration. * Movement of gases occurs at the alveolar capillary membrane. * Alterations occur in thickness and permeability of membrane. 2. Respiratory System * Respiratory Anatomy and Physiology * The respiratory system consists of two main parts: * The upper and the lower tracts. * Its function is to warm, filter, humidify, inspired air. * Nose is the best place to breathe through (helps filter our microorganisms). * Upper Respiratory System * Nose * Mouth * Pharynx = throat, back of nose and mouth (oropharynx and nasopharynx). * Larynx = voice box, connects pharynx to trachea. * Epiglottis = covers larynx during swallowing. * The Nose * First part of respiratory system. * Contains nasal bones and cartilage. * Has numerous superficial blood vessels in the nasal mucosa. * Function is to: filter air, humidify air, aid in phonation (sound), and olfaction (smell). * Warms air better because of blood supply. * The Pharynx * Musculomembranous tube. * Passageway for both air and food. * Protect lower airway. * Nasopharynx and Oropharynx. * The Larynx * AKA voice box. * Made of cartilage and membranes. * Connects the pharynx to the trachea. * Functions: vocalization, keeps the patency of the upper airway, and protects the lower airway. * Sometimes has to be removed in people with throat cancer, and must have an artificial set of vocal cords, voice box. * Lower Respiratory System * Trachea * Main bronchus * Bronchial tree * Lungs = 3 lobes on right, 2 lobes on left. * The right lung is slightly larger than the left. * The left lung contains a hollowed-out notch where the heart nestles. * The Trachea * Made of cartilage. * Tube measures approximately 10-12 cm. Composed of about 20 C-shaped cartilages. * Function: conduct air towards the lungs, mucosa is lined up with mucus and cilia to trap particles and carry them towards the upper airway. * Ultimately the goal is to have the bacteria go out of the body. * The Bronchus * The right and left primary bronchi begin at the carina. * Function: air passage. * Right bronchus is wider, shorter, more vertical. * Significance: easier for infections and obstruction to happen in right bronchus. * Left bronchus is narrower, longer, more horizontal.

* The Bronchioles, Alveoli, and Capillaries * Bronchioles – lined with mucous membranes and cilia which help with ridding the lungs of foreign particles. * Alveoli – each alveolus is one cell thick, which is why the gases, O2, and CO2 can move in and out so easily. * Capillaries – O2 is inhaled and passes from the alveoli into the capillaries. The CO2 in the blood that has already circulated through the body passes from the capillaries to the alveoli. During exhalation, the CO2 passes out of the body. * Capillaries supplies the alveoli with blood. * Must get down to the cellular level for the process of getting the CO2 out and the O2 in. * Function of Respiratory System * Gas exchange through ventilation, external respiration and cellular respiration. * Oxygen and carbon dioxide transport. * Oxygenate venous blood. * Remove carbon dioxide from blood. * Arteries carry oxygenated blood away from the heart; veins bring deoxygenated blood back to the heart. * Diagnostic Tests * ABG (Arterial Blood Gas) analysis * Helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an arterial blood sample. * Normal values: * PaO2 = 80-100 mmHg * Partial pressure of oxygen. * PaCO2 = 35-45 mmHg * Partial pressure of carbon dioxide. * pH = 7.35-7.45 * ↓ 7.35 = alkalosis or ↑ 7.45 = acidosis. * HCO3 = 22-26 mEq/L * Bicarbonate ion. * SaO2 Sat = 95-99% * Arterial oxygen saturation. * Chest X-Ray * Visualization of the chest, lungs, heart, large arteries, ribs, and diaphragm. * First line of diagnostic testing. * Two views: * Antero-posterior = x-rays pass through the chest from the back. * Lateral = x-rays pass through the chest from one side to the other.

* Nursing interventions: * Instruct patient to hold their breath while x-ray is taken. * Inform patient x-ray is done by radiology department and the film plate may feel cold. * Instruct patient to wear a hospital gown and remove all jewelry. * Contraindicated in pregnancy. * Sputum Analysis * Analyzes the sample of sputum to diagnosis respiratory diseases, identify organism, and identify abnormal cells. * Pre-test: * Encourage to increase fluid intake because everything needs to be moist to cough; hard to cough if mouth is dry. * Intra-test: * Rinse mouth with H2O only, instruct patient to take 3 deep breaths and force a deep cough, collect early morning sputum. * If unable to cough, may need to use a steam nebulizer. * Post-test: * Provide oral hygiene, label specimen correctly (name, time). * Pulse Oximetry * Non-invasive method of continuously monitoring the oxygen saturation of hemoglobin. * A sensor or probe is attached to the ear lobe, forehead, fingertip, or the bridge of the nose. * A pulse oximeter responds to pulsations (i.e. pulsing capillaries). * Works by passing a beam of red and infrared light through a pulsating capillary bed. Ratio of red to infrared blood light transmitted gives a measure of the oxygen saturation in the blood. * Principle – oxygenated blood is bright red while the deoxygenated blood is blue-purple. * Bronchoscopy * Direct inspection of the trachea and bronchi through a flexible fiber optic or a rigid bronchoscope. * Done to determine location of pathologic lesions, to remove foreign objects, to collect tissue specimen, and remove secretions or aspirate materials. * Pre-test: * Consent, NPO for 6 hours (so not to aspirate), teaching. * Intra-test: * Position supine or sitting upright in a chair, administer sedative, gag reflex will be abolished (numbed), remove dentures (so they do not come loose during procedure). * Post-test: * NPO until gag reflex returns (usually within 2hrs), position semi-fowler’s with head turned to side, hoarseness (temporary), CXR after procedure, keep trach set and suction for 24 hours. * Have trouble breathing the first thing you do is sit them up.

* Pulmonary Function Tests (how well patient is breathing in and out) * Volume and capacity tests aid diagnosis in patient with suspected pulmonary dysfunction. * Evaluates ventilatory function . * Determines whether obstructive or restrictive disease. * Can be utilized as screening test. * Measures lung volumes = amount of air exchanged during ventilation. * Measures lung capacities. * Pre-test: * Teaching, no smoking for 3 days, only light meal 4 hours before test. * Intra-test: * Position sitting, bronchodilator, nose-clip and mouth piece, fatigue and dyspnea during the test. * No anesthesia involved. * Post-test: * Adequate rest periods, loosen tight clothes (prevent restriction). * Spirometry * Measures airflow = how much and how fast air one breaths out. * Patient will breathe through a tight fitting mouthpiece and may wear a nose clip. * Promotes deep breathing. * Nursing interventions: * Breath out into the mouthpiece which is connected to a spirometer. * Eat a light meal before the test. * Do not smoke for 4–6 hours before the test (smoke constricts airway, provide instructions on how to stop smoking). * Stop using bronchodilators or inhalers 6–8 hours before the test. * Patient may feel SOB or lightheadedness during test. * Use q2hr while awake to prevent pneumonia. * Peak Expiratory Flow Rate * Measures how fast a person can exhale. * How well the airways work. * Uses a Peak Expiratory Flow Meter = small handheld device with a mouthpiece on one end and a scale with a moveable arrow. * Commonly used to diagnose and monitor lung diseases. * Asthma, chronic bronchitis, COPD, emphysema. * Home monitoring: * Helps to determine whether treatments are working or detect if condition is getting worse. This allows anticipation on when breathing will become worse and to take medications or call HCP before symptoms get too severe. * A decreased in peak flow indicates blocked or narrowed airways. * A significant fall in peak flow can signal the onset of lung disease. * Especially when accompanied with persistent coughing, SOB, or wheezing. * Nursing interventions: * Inform patient that repeated efforts may cause lightheadedness. * Loosen tight clothes that may restrict breathing. * Sit up straight or stand during the test. * PEFR are not as accurate as spirometry. * Inform of proper procedure. * Breath in as deeply as possible. * Blow into the instrument’s mouthpiece as hard and fast as possible. * Do this 3 times, and record the highest flow rate. * Respiratory Deficiency * Signs and Symptoms: * Dyspnea = breathing difficulty; associated with many conditions. * Conditions = CHF, obstruction, pulmonary disease. * Nursing interventions: * Fowler’s position to promote maximum lung expansion and promote comfort. * Alternative is the orthopneic position = being propped up in bed with pillows. * Start O2 usually via nasal cannula at 2L. * Provide comfort and distractions. * Notes: * Eupnea = Regular breathing. * Dyspnea = difficulty breathing. * Orthopnea = sit forward, allows best exchange. Tripod position (orthopneic). * Tachypnea = increased breathing (rapid), above 20. * Bradypnea = decreased breathing (slow), below 10. * Apnea = absence or cessation of breathing (count how long each period of apnea lasts). * Hypoxia = lack of O2. * Nasal cannula = 2L or under (best). * Chemoreceptors measure the CO2 in the body. * Turn oxygen up too high = death. * Cough and Sputum Production * Cough is a protective reflex (if food goes into larynx, coughing will get it to come back up). * Sputum production has many stimuli. * Thick, yellow, green or rust-colored. * Profuse, pink, frothy. * Scant pink-tinged, mucoid. * Hemoptysis = blood in sputum. * Nurse interventions: * Provide adequate hydration (loosens secretions). * Administer aerosolized solutions. * Advise smoking cessation. * Oral hygiene. * Cyanosis * Bluish discoloration of the skin. * Dark skin individuals – observe the soles of feet and palms of hands. * A late indicator of hypoxia = low amount of oxygen. * Appears when the unoxygenated hemoglobin is more than 5g/dL. * Central cyanosis = observe color on the undersurface of tongue and lips. * Peripheral cyanosis = observe the nail beds, earlobes. * Cyanosis of the lips, mucous membranes = late indicators. * Restlessness, disoriented = early indicators. * Nursing interventions: * Check for airway patency (always first intervention). * Oxygen therapy. * Positioning. * Suctioning (measure output). * Chest physiotherapy. * Check for gas poisoning (carbon dioxide binds to hemoglobin much quicker). * Measures to increase hemoglobin (CBC measures hemoglobin and hematocrit). * Hemoglobin (amount of oxygen bound to RBC) = 14–17 (normal) * Hematocrit (amount of RBC in a certain sample) = percent of RBC in cell. * Hemoptysis * Expectoration of blood from the respiratory tract (coughing up blood). * Common causes – pulmonary infection (lung infection), lung Cancer, bronchiectasis (whitening of the bronchi), pulmonary emboli (blood clot; patients may have feeling of impending doom, to get rid of clot give anticoagulant, have patient sit up take deep breath). * Bleeding from stomach = acidic pH, coffee ground material. * Nursing interventions: * Keep patent airway. * Determine the cause. * Suction and oxygen therapy. * Epistaxis = nose bleed * Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane. * Most common site = anterior septum . * Causes: trauma, infection, hypertension, blood dyscrasias, nasal tumor, cardiac diseases. * Nursing interventions: * Position patient – upright, leaning forward, tilted (prevents swallowing and aspiration). * Do not tilt head back, blood can go into stomach and cause nausea/vomiting. * Apply direct pressure. * Pinch nose against the middle septum for 5-10 minutes. * If unrelieved, administer topical vasoconstrictor, silver nitrate, gel foams. * Assist in electrocautery and nasal packing for posterior bleeding. * Optimal Ventilation * Tripod breathing position. * Orthopneic position. 3. Oxygen Therapy * Oxygen Therapy Devices * Low Flow * Deliver oxygen less than the patient’s inspiratory needs, therefore additional room air is also breathed in. * Nasal Cannula * Medium Concentration Mask * Partial Rebreather * Non-Rebreather Mask * High Flow * Deliver oxygen to meet the patient’s total inspiratory requirements. * Venturi Mask * Nasal Cannula * O2 delivers at 6 L or less. * O2 at 4 L or less do not need to be humidified. * Needs upper airway free from obstruction. Flow Rate L/min | 1–2 | 2–4 | 4–6 | O2 Concentration % | 24–28 | 28–34 | 36–44 | * Nasal cannula have two soft prongs which are inserted into the patient’s nostrils, O2 flows from the nasal cannula into the nasopharynx, oxygen can be delivered at 6 liters or less, flow rates of 4 L or less do not need to be humidified, can be used at very low flow rates for children, lightweight and generally comfortable, patients are able to eat, drink and speak, mouth breathers can benefit from this device, needs upper airway to be free from obstruction, are available with different prong shapes. * Nasal cannula are contraindicated in patients with nasal obstruction (i.e. nasal polyps). * Use sterile water because tap water can cause bacteria to grow in the lungs. * Medium Concentration Mask * Used when nostrils are unavailable or O2 needs are greater than used with nasal cannula. * Caution – flow rate must be minimum 5 L/min.
* To prevent CO2 from building up inside the mask and prevent rebreathing. * Aspiration of vomit is more likely with a mask. Flow Rate L/min | 5 | 6 | 8 | O2 Concentration % | 35 | 40 | 50 | * Partial Rebreathing Mask * Used when high concentrations of O2 are needed. * High concentrations are used with the critically ill and unstable patients. * Patient does not breath room air (one-way valve allows CO2 to escape). * Caution that reservoir bag does not empty completely. * Set flow rate so that mask remains two thirds full during inspiration and keep reservoir bag free of twists or kinks. * Minimum flow rate 10 L/min. * Aspiration of vomitus is more likely when a mask is in place. * Interdependent nursing collaboration with respiratory therapist. Flow Rate L/min | 6–15 | O2 Concentration % | 60–100 | * Non-Rebreathing Mask * Used when high concentrations of O2 are needed. * High concentrations are used with the critically ill and unstable patients. * Patient does not breath room air (one-way valve allows CO2 to escape). * Caution that reservoir bag does not empty
completely. * Ensure that reservoir bag does not deflate complete at the end of inspiration. * Minimum flow rate 10 L/min. * Aspiration of vomitus is more likely when a mask is in place. Flow Rate L/min | 10–15 | O2 Concentration % | Up to 80 | * Venturi Mask * High flow method of delivering high concentrations of O2. * Uses a venturi valve to deliver a precise amount of O2. * Caution at higher than 40% the total flow might not meet the total inspiratory demands. * Increasing the flow rate does not increase the concentration. * Adjust valve setting on mask not flow rate. * Humidification * Humidifier is attached to the flow meter. * Caution - fluid should be changed daily. * Use sterile water only! * Change fluid daily, les chance for contamination. * Pulse Oximetry * Non-invasive method of continuously monitoring the oxygen saturation of hemoglobin. * A sensor or probe is attached to the ear lobe, pinna of ear, fingertip, or the bridge of the nose. * Arterial oxygen saturation (SaO2) – normal: >95%. * A pulse oximeter responds to pulsations (i.e. pulsing capillaries). * Works by passing a beam of red and infrared light through a pulsating capillary bed. Ratio of red to infrared blood light transmitted gives a measure of the oxygen saturation in the blood. * Principle – oxygenated blood is bright red while the deoxygenated blood is blue-purple.

* Incentive Spirometer * Used to help keep lungs clear and active. * Helps to keep lungs expanded especially after surgery. * Procedure: * Sit up in bed or on side of bed. * Place the mouthpiece in your mouth and seal your lips tightly around it. * Breath in slowly and as deeply as possible, raising the yellow piston toward the top of the column. The yellow coach indicator should be in the blue outlined area. * Hold your breath as long as possible (at least 5 seconds). Allow the piston to fall to the bottom of the column. * Rest for a few seconds and repeat the above steps. Position the yellow indicator on the left side of the spirometer to show your best effort. Use the indicator as a goal to work toward during each repetition. * Patients should do several sets of breathing using the IS. After each set, practice coughing to be sure the lungs are clear. Use a pillow to splint the abdomen if there is pain. * Important Points * All critically ill patients require oxygen. * Central cyanosis is caused by both cardiac and pulmonary disease. * Central cyanosis – observe color on the undersurface of tongue and lips. * Peripheral cyanosis results from a sluggish peripheral circulation. * Peripheral cyanosis happens in hypovolemia, cardiogenic shock, a cold environment and arterial or venous obstruction. Observe color of the nail beds, earlobes. In dark skin individuals observe the soles of feet and palms of hands. * Hypoventilation and disorders affecting ventilation perfusion matching are the most frequent causes of cyanosis seen in acute emergencies * Cyanosis is a bluish discoloration of the skin. It is a late indicator of hypoxia. * High concentrations of inspired oxygen do not depress ventilation patients in acute respiratory failure. * Oxygen therapy must be prescribed and monitored. * Monitoring – clinical, subjective report from the patient. Objective (i.e. dyspnea, cyanosis, mental status changes [restlessness, agitation, confusion]). * Patients do not die from a high CO2 level alone, they die from hypoxemia. * Pulse oximeters measure oxygenation, not ventilation. * Pulse oximeter – potential sources of error for pulse ox readings include: abnormal Hgb, hypoperfusion, hypothermia, anemia, venous congestion, skin pigmentation, nail polish, vital dyes (methylene blue) used in radiographic procedures. * ABG – provides information on ventilation, oxygenation and acid-based balance.

* Indications for O2 Therapy * Documented hypoxemia. * Severe trauma. * MI – heart not getting enough oxygen and the tissue dies. * Short term therapy. * Surgical intervention. * Post anesthesia recovery is an example of surgical intervention. * Defined as PaO2 less than normal range. * PaO2 less than 60 or SaO2 less than 90 on room air. * PaO2 and/or SaO2 less than desired for a specific clinical situation. * Everyone admitted through ED gets put on supplemental oxygen. * Precautions and Possible Complications * PaO2 < 60 + elevated PaCO2 may lead do ventilatory depression. * Administration of O2 to patients with chronic CO2 retention may limit their drive to breath. * Fire hazard. * Bacterial contamination in humidifier or nebulizers. * Ventilatory depression may occur in spontaneously breathing patients. * Limitations of Therapy * Oxygen therapy has limited benefit for the treatment of hypoxia due to anemia. * Should not be used in lieu of but in addition to mechanical ventilation. 4. Respiratory Illnesses * Pneumonia * Inflammation of the lungs. * Inflammation of the alveoli and respiratory bronchioles. * Consolidation and solidification of exudate. * Consolidation alveoli full of exudate. * Etiology: * Infection (i.e. bacteria, virus, fungi, other microbes could be protozoa or parasites). * Most common bacteria is streptococcus pneumonia. * Non-infectious such as aspirated or inhaled substances. * Contributing factors: * Aspiration often occurs with tube feedings, post-op or post-procedure pneumonia can occur due to over-sedation, inadequate ventilation occurs due to immobility (lying in bed), depressed cough reflex (anesthesia, CVA), alterations in respiratory function (COPD, advanced age), immunosuppressed (patients on immunosuppressant medications, HIV (Pneumocystis carinii). * Over-sedation. * Inadequate ventilation.

* Pathophysiology: * Inflammatory process. * Antigen-antibody response. * Anti-antibody response occurs and endotoxins are released. * Air spaces in alveoli become clogged with exudate. * Alveoli become irritated so the body produces exudate (accumulation of fluid) to try and rid itself of the invading organism. The exudate interferes with perfusion and ventilation. * Signs and Symptoms: Viral | Bacterial | Fever: low grade | Fever: high | Cough: nonproductive | Cough: productive | WBC count: normal to low elevation | WBC count: high elevation | CXR: minimal changes evident | CXR: obvious infiltrates | Clinical course: less severe than bacterial | Clinical course: more severe than viral | * Cough, fatigue, loss of appetite, pleuritic pain (worsens when coughing or during inspiration, hurts to breathe), dyspnea, chills, fever, alt in WBC, sputum production (purulent, rust color), crackles or rales, pleural rub, tachypnea, confusion (especially in older people), headache, excessive sweating, clammy skin. * Tests and labs: * CXR = inhale and hold breath. * ABG * Pulse Oximetry * Sputum collection * CBC = WBC, RBC, Platelet. * Bronchoscopy * Interventions: * Maintaining patent airway. * Monitor respiratory rate, depth and use of accessory muscles, cough and deep breath, incentive spirometer, suctioning, hydration (iv, oral). * Clearing airway of exudate. * Postural drainage and percussion. * Adequate oxygenation. * Oxygen therapy. * Assess level of oxygenation. * ABG, pulse oximetry. * Pain management * Splint chest wall with pillow when coughing. * Nutritional support/hydration. * Small, frequent, balanced meals. * IV, oral fluids (increased hydration). * Physical rest with frequent repositioning (posturing). * Bedrest, limited activity. * Medications: * Antipyretics – acetaminophen to reduce fever. * Antibiotics – many times start with a broad spectrum antibiotics (PCN, erythromycin, cephalosporin) until culture and sensitivity results available. * Bronchodilators – albuterol, theophylline/aminophylline. * Mucolytic agent – guaifenesin (Mucinex), acetylcysteine (Mucomyst). * Tuberculosis * Lung infection caused by Mycobacterium tuberculosis, an acid-fast bacillus (AFB). * Basically little tubercles sit in lungs, form pockets, and bleed. * Etiology and Pathophysiology: * Organisms are contracted by airborne droplets from another person with an active form of the disease. * Infection occurs depends on the host’s susceptibility, virulence of the tubercle bacilli, number of bacilli inhaled. * Not highly contagious. * Prolonged exposure required to produce infection. * Granuloma or tubercle forms. * A mass or nodule of chronically inflamed tissue with granulations that is usually associated with an infective process or tubercle forms as the body attempts to surround the bacilli to contain the disease. * Ghon’s tubercle. * Calcification or scarring of the lung tissue – seen on CXR. * Risk factors: * Elderly, infants, weakened immune systems, in frequent contact with an infected person, poor nutrition, crowded or unsanitary conditions. * Used to sequester people with tuberculosis in sanitariums and TB wards. * Signs and Symptoms: * Cough (productive in active stage, dry in inactive stage), fever (usually low grade during afternoon and night, infection gets so overwhelming temperature rises too much), night sweats, anorexia, weight loss, chest pain, hemoptysis, dyspnea, wheezing, crackles, enlarged painful lymph nodes, hoarseness. * Tests and Labs: * Purified protein derivative (PPD) – a protein from the killed tubercle bacilli injected intradermally. Evaluated by measuring the area of induration. Read at 48 and 72 hours later. An induration of 5 mm or more is considered positive in that the person has been exposed to tuberculosis. * CXR – may reveal granulomas or tubercles, calcified lesions, cavitation in the lung. * Sputum collection for AFB – typically done on three consecutive days. * Chest CT Scan * Bronchoscopy * Interventions: * Hospitalization for active disease then continued at home. * Airborne precautions with strict infection control. * Airborne precautions – isolation room with negative air pressure, caregivers wear N95 particulate respiratory masks. * Infection control – patient should cover mouth and nose when coughing or sneezing, double bag secretions, use disposable items, disinfect nondisposable items . * For caregivers – plan care to limit prolonged exposure to patient. * Oxygenation * Nutrition/hydration * Disease must be reported to local health department. * Medications: * Prophylactic treatment – usually isoniazid (INH) for 6–12 months. * INH – alcohol interferes with metabolism and may cause hepatitis. Monitor hepatic enzymes, report signs of neuropathy and hepatitis. Given with pyridoxine (vitamin B6) to decrease side effects. * Active disease – multiple drugs used – isoniazid (Laniazid), rifampin (Rifadin) (makes sweat and urine orange), pyrazinamind (Pyrazinamide) * Usually patient started with three drugs for several months then reduced to two. Drugs can be added and subtracted depending on patient’s tolerance of the medication regimen. * Not taking meds as ordered can lead to multidrug-resistant TB. * Taking multiple drugs at multiple times throughout the day is confusing and can lead to noncompliance (i.e. homeless, illiterate, etc). * Pleurisy * Inflammation of pleura (sac that encases the lung). * Often accompanied by abrupt onset of pain during inspiration and coughing. * Etiology and Pathophysiology: * Occurs as a result of another respiratory illness. * Other illness may be pneumonia, viral infections, pleural effusion, lung cancer, TB, CHF, pulmonary embolism or trauma to lung. * Pleura becomes rough. * Rub together with each breath. * Friction rub – rough, grating sound heard with a stethoscope. * Signs and Symptoms: * Acute pain – sharp, stabbing, may radiate to the shoulder. * Usually unilateral (right bronchi more vertical). * Localized to specific area of lung. * Worsens with coughing, deep breathing, chest movement.

* Tests and Labs: * Auscultate for friction rub * CBC * Thoracentesis (pleural effusion) * Chest tube (pleural effusion) * CXR * Ultrasound of chest * Pleural effusion results from an inflamed pleura which secretes increased amounts of pleural fluid into the pleural cavity. * Interventions: * Bedrest. * Vital Signs – particularly temperature and respiratory rate. * Assess respiratory status, percussion and auscultation of lung sounds (friction rub – rough, grating sound heard with a stethoscope) . * Deep breathing, coughing and splinting chest wall with pillow when coughing. * Medications: * Analgesics or NSAIDS – pain and fever. * Antibiotics – underlying illness. * Cough suppressant for non-productive cough – at night to promote rest. * Adult Respiratory Distress Syndrome * Life threatening lung condition that prevents enough oxygen from getting into the blood. * Etiology and Pathophysiology: * Respiratory failure caused by shock, trauma, burns, bacterial or viral pathogens, aspiration, toxic injury. * Fluid accumulates in the alveoli. * Damaged pulmonary capillary membrane. * Impaired gas exchange. * Pulmonary edema develops. * Increased permeability of alveolar blood vessels, allows fluid to accumulate in the alveolar spaces (air sacs) and pulmonary edema develops. * Signs and Symptoms: * Labored, rapid breathing; hypotension; multiple organ system failure; dyspnea; cyanosis; crackles; wheezing; blood-tinged sputum; critically ill patient; hypoxemia resistant to oxygen therapy. * Tests and Labs: * ABG * CBC * CXR – large, diffuse infiltrates or “white-outs” with normal heart size. * Sputum C&S * Bronchoscopy

* Interventions: * Oxygen therapy * Mechanical ventilation * Treat underlying cause * Hydration * ABG * Pulse oximetry * Suctioning * Medications: * Steroids – methylprednisolone (Solu-Medrol). * Steroids to reduce inflammation and decrease fluid shift. * Diuretics – furosemide (Lasix). * Bronchodilator – aminophylline (Aminophylline). * Neuromuscular blocking agent - pancuronium bromide (Pavulon). * Pavulon given to suppress patient’s own respiratory effort. * Vasopressor – dopamine (Intropin). * Dopamine given to raise blood pressure. * Bronchitis * Inflammation of the bronchial tree w/ increased mucus production. * May be acute or chronic. * Type of COPD. * Etiology: * Acute – recent respiratory illness or infection. * Those at risk are infants, children, elderly, people with heart or lung disease, smokers, allergies. * Chronic – caused by cigarette smoking, air pollution, asbestos, coal miners, frequent lung infections. * Pathophysiology: * Hypertrophy of mucus secreting glands. * Bronchial fill with exudate. * Narrowing of large and small airways. * Patient has a history of recurrent respiratory infections. * Signs and Symptoms: * Acute – chest discomfort, productive cough, fatigue, fever, dyspnea, wheezing. * Chronic – chest discomfort, non-productive cough, productive cough, fatigue, fever, dyspnea, wheezing, swelling of lower extremities, “blue bloater”, frequent respiratory infections. * If mucus is yellow or green there may be infection. * Dry, nagging cough lasts for weeks in chronic phase. * Fever – low grade. * “Blue bloater” – cyanosis around lips. * Been deep breathing for so long patient gets barrel chested. * Tests and Labs: * CXR – reveals lung hyperinflation or “barrel chest”. * PFT = pulmonary function tests (how well can patient forcefully exhale or inhale). * Pulse Oximetry * ABG reveals a low PaO2 and a high PaCO2. * CBC reveals polycythemia (increased RBC’s). * Sputum – check for infection. * Interventions: * No exposure to smoke * Hydration/nutrition. * Rest. * Antipyretic. * Breath humidified air or steam from bathroom helps to liquefy secretions. * Oxygen therapy depending on ABG or pulse oximetry results. * Pursed lip breathing (breathe in through nose and slowing out through pursed lips). * Increase activity as tolerated. * Medications: * Bronchodilators – theophylline (Theo-Dur). * Steroids – corticosteroid (Prednisone). * Oral steroids for short-term therapy of acute exacerbations. Long-term given by inhalation to reduce systemic side effects. * Patient must be gradually taken off of steroids. * Mucolytic agent – acetylcysteine (Mucomyst). * Treat underlying illness (i.e. respiratory infection, concurrent heart disease). * Emphysema * Progressive destruction of alveoli related to chronic inflammation. * Type of COPD. * Etiology and Physiology: * Airways lose elasticity and the walls thicken. * Airflow impeded during expiration. * Alveoli become over-distended with trapped air and rupture. * Because airflow is impeded during expiration, the alveoli are like balloons, they will hyper-inflate and break or pop like a balloon. * Cilia disappear. * Smoking is most common cause. * Deficiency in alpha-1-antitrypsin. * Genetic component – deficiency in alpha-1-antitrypsin, which is an enzyme that inhibits the activity of the enzyme elactase, which breaks down lung tissue.

* Signs and Symptoms: * Early symptoms include daily morning cough with clear sputum. * “Pink puffer”. * Barrel chest. * Pursed-lip breathing (caused by forced exhalation). * Use of accessory muscles. * Underweight. * Clubbing of fingers. * Tests and Labs: * CXR – reveals lung hyperinflation or “barrel chest”. * PFT = pulmonary function tests. * Pulse Oximetry * ABG reveals a low PaO2 and a high PaCO2. * CBC reveals polycythemia (increased RBC’s). * Sputum – check for infection. * Interventions: * No exposure to smoke. * Hydration/nutrition. * Diet – high in carbohydrates to supply needed energy for the extra work of breathing. * Supplements as needed to provide additional calories (body is undergoing stress and needs energy to help fight infection). * Rest. * Antipyretic. * Breath humidified air or steam from bathroom helps to liquefy secretions. * Oxygen therapy depending on ABG or pulse oximetry results. * Pursed lip breathing. * Increase activity as tolerated. * Medications: * Bronchodilators – theophylline (Theo-Dur). * Steroids – corticosteroid (Prednisone). * Mucolytic agent – acetylcysteine (Mucomyst). * Treat underlying illness i.e. respiratory infection, concurrent heart disease. * Bronchiectasis * Destruction and widening of the large airways. * Permanent. * Etiology and Pathophysiology: * Permanent enlargement of large bronchi, associated with respiratory infections or illnesses. * Causes – TB, chronic URI, cystic fibrosis, tumors, exposure to lung irritants. * Bronchi lose elastic recoil property.

* Secretions thicken and accumulate in bronchi. * Secretions in bronchi become a medium for infection. * Signs and Symptoms: * Cyanosis, halitosis, chronic cough with foul smelling sputum, clubbing, hemoptysis, fatigue, paleness, dyspnea, weight loss, wheezing, crackles more prominent during morning. * Tests and Labs: * ABG – decreased PaO2, increased PaCO2, respiratory acidosis. * CBC – polycythemia, increased hematocrit and hemoglobin. * CXR – hyperinflation of lungs. * PFT – respiratory flow rate decreases and lung volume increases. * Sputum and C&S – identify bacterial organisms. * PPD – prior exposure of tuberculosis. * Sweat test – diagnosis: cystic fibrosis. * Interventions: * Suction to remove secretions. * Prevent or eliminate infection. * Maintain oxygenation. * Oxygenation therapy. * Nebulizer treatment. * Percussion and drainage. * ABG and pulse oximetry. * Diet high in carbohydrates and calories. * Medications: * Mucolytic agents. * Antibiotics. * Flu and pneumonia vaccines. * Bronchodilators. * Steroids. * Pneumothorax * AKA Collapsed lung. * Air accumulation in the pleural space. * Occurs when air leaks from inside of the lung to the space between the lung and the chest wall. The lung then collapses. The dark side of the chest is filled with air that is outside of the lung tissue. * Etiology and Pathophysiology: * Closed – internal only (i.e. blunt trauma, broken rib). * Open – external trauma (i.e. gunshot wound, stabbing). * Spontaneous – sudden collapse of lung, usually does not have an obvious cause. * Tension – life threatening, air accumulates in the pleural space and cannot escape. * Worst kind you can have. * Associated with mechanical ventilators, air entering the space cannot escape resulting in collapsed lung, mediastinal shift to the unaffected side and downward displacement of diaphragm can be observed. * Signs and Symptoms: * Sharp chest pain, dyspnea, chest tightness, fatigue, tachycardia, cyanosis, nasal flaring, hypotension, decreased or absent breath sounds on affected side. * Pneumothorax can be small with minor symptoms or large with severe symptoms. * Tests and Labs: * CXR * ABG * Interventions: * Small – possible to use needle to remove air. * Large – chest tube to remove air. * Oxygen therapy. * Surgery for recurrent spontaneous pneumothorax requires pleural cortication to form scar tissue and thus seal hole in lung. * Diet high in protein to promote healing. * Medications: * Analgesics to control pleuritic pain (i.e. morphine or meperidine (Demerol)). * Local anesthetic injected locally for chest tube insertion. * Throat Cancer * Cancer of the vocal cords, larynx (voice box) or other areas of the throat. * Etiology and Pathophysiology: * Causes are smoking, chronic alcohol abuse, chronic laryngitis, overuse of the voice. * Also occupational exposure to chemicals and toxins. * Human papilloma virus (usually in genitals, but in throat because of oral sex). * Signs and Symptoms: * Hoarseness, difficulty speaking, change in voice; difficulty swallowing with or without pain; laryngeal pain; lump in the throat, swelling of neck; abnormal (high pitched) breathing sounds; hemoptysis; unintentional weight loss. * Tests and Labs: * Laryngoscopy * X-rays of head, neck, chest (might show shadow that need to be investigated further). * CT scans * MRI (no metal) * Biopsy (can be combined with laryngoscopy). * Barium swallow (drink barium and take x-ray to see any abnormalities in throat). * Interventions: * Treatment depending on extent of disease and condition of patient. * Radiation. * Chemotherapy. * Laryngectomy with tracheostomy. * Radical neck dissection. * Remove jugular and try to save blood flow to the brain as much as possible, but may not be able to swallow for rest of life. May have to have tracheostomy or voice amplifier to talk. * Lung Cancer * Malignant tumors in lungs. * Etiology and Pathophysiology: * Cigarette smoking. * Second hand smoke. * Arsenic in drinking water. * Radon gas. * Asbestos. * Chemicals, gasoline, diesel exhaust. * Signs and Symptoms: * Early stages – asymptomatic [for many years]. * Chronic cough; hemoptysis; dyspnea; wheezing; chest pain; loss of appetite; unintentional weight loss; weakness; difficulty swallowing; hoarseness, change in voice; nail problems; joint pain; facial swelling, paralysis; eyelid drooping; bone pain. * Tests and Labs: * CXR – many tumors cannot be seen on CXR. * CT scans, MRI, PET scan (glucose is injected into the body, shows up more white or red where there are high amounts of glucose in the body; less amounts show up blue or green). * Bronchoscopy * Sputum for cytology * Biopsy * Interventions: * Treatment depending on extent of disease and condition of patient. * Radiation. * Chemotherapy. * Surgery – pneumonectomy, lobectomy, segmental resection. * Pneumonectomy – removal of an entire lung. * Lobectomy – removal of a lobe of a lung. * Segmental resection – removal of a segment of a lung. * Sinusitis * Inflammation with resulting infection of mucous membranes of one or more of the paranasal sinuses. * Etiology and Pathophysiology: * Healthy sinuses contain no bacteria or germs, mucous is able to drain and air to circulate. * When sinuses are blocked or mucous builds up bacteria and germs can grow and sinusitis occurs. * Risk factors – allergic rhinitis, large adenoids, abuse of decongestants, swimming, exposure to smoke, allergies. * Sinusitis can occur from one of these conditions: * Small hairs (cilia) in the sinuses, which help move mucous out, do not work properly due to some medical conditions. * Cold and allergies may cause too much mucous to be made and block the sinuses. * Deviated septum, nasal bone spur, nasal polyps may block opening. * Signs and Symptoms: * Halitosis or loss of smell; cough, often worse at night; fatigue and malaise; fever; headache – pressure behind the eyes, facial tenderness, tooth ache; nasal congestion and discharge; sore throat and postnasal drip. * Tests and Labs: * Physical exam including inspection of the nose for polyps and throat. * Culture of nasal discharge. * Transillumination of sinuses. * X-rays and CT scans. * Nasal endoscopy to visualize anterior nasal cavity and sinus openings. * Interventions: * Warm, moist washcloth. * Hydration to liquefy mucous. * Inhale steam (hot bath). * Nasal saline. * Humidifier. * Avoiding allergy triggers. * Medications: * Nasal corticosteroid spray. * Antihistamine. * To decrease swelling of nasal polyps, allergies. * OTC nasal decongestant – should not be used for more than 3-5 days, rebound nasal congestion can occur.