Chapter 11
DSN
Kevin Dobi, MSN, APRN
Lungs and
Respiratory System
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Concept Overview

Oxygenation:
Processes that facilitate and impair oxygenation.
Adequate perfusion is necessary to deliver oxygenated
blood to tissues and remove metabolic waste.
 Intracranial regulation supports oxygenation.
 Adequate oxygenation needed to support intracranial
function.
 Interrelationship necessary.


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Anatomy and Physiology

Respiratory system supplies oxygen to
cells and removes carbon dioxide using
processes of ventilation and diffusion:
Ventilation is the process of moving gases in and out of
lungs by inspiration and expiration.
 Diffusion is the process by which oxygen and carbon
dioxide move from areas of high concentration to areas of
lower concentration.
 After inspiration, concentration of oxygen is higher in
alveoli than in pulmonary capillaries, causing oxygen to
diffuse across alveolar-capillary membrane, then carried
by erythrocytes to cells.

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Anatomy and Physiology
(contd.)



At cellular level, oxygen diffuses into
cells, and carbon dioxide diffuses from
cells into capillaries, where it is carried
by erythrocytes to alveoli.
Carbon dioxide diffuses from pulmonary
capillaries to alveoli and is exhaled.
Cardiovascular system provides
transportation of oxygen and carbon
dioxide between alveoli and cells.
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Structures in the Thorax:
Mediastinum

Three main structures within thorax or
chest:


Mediastinum and right and left pleural cavities.
Mediastinum positioned in middle of
chest. Within it are:





Heart
Arch of aorta
Superior vena cava
Lower esophagus
Lower part of trachea
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Structures in the Thorax:
Pleural Cavities

Pleural cavities contain lungs.



These cavities lined with two types of serous membranes:
 Parietal
 Visceral
pleura
pleura
Chest wall and diaphragm are protected
by parietal pleura, and lungs are
protected by visceral pleura.
Small amount of fluid lubricates space
between pleurae to reduce friction as
lungs move during inspiration and
expiration.
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Structures in the Thorax:
The Lungs


Right lung has three lobes and left has
two.
Each lobe has a major, oblique fissure
dividing upper and lower portions.


However, right lung has a lesser horizontal fissure dividing
upper lung into upper and middle lobes.
Each lung extends anteriorly about 1.5
inches above first rib into base of neck in
adults.

Posteriorly, lungs’ apices rise to level of T1 (first thoracic
vertebrae); lower borders expand down to T12 and, on
expiration, rise to T9.
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External Thorax

Thoracic cage protects most of
respiratory system and consists of:




12 thoracic vertebrae
12 pair of ribs
Sternum
Ribs connect to thoracic vertebrae
posteriorly:
First seven ribs also connected to sternum by costal
cartilages.
 Costal cartilages of eighth to tenth ribs are connected
immediately superior to ribs.
 Eleventh and twelfth ribs are unattached anteriorly, thus
the name “floating ribs.”

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External Thorax (contd.)

Sternum is about 7 inches long and has three
components:



Manubrium
Body
Xiphoid process
Manubrium and body articulate with first
seven ribs; manubrium also supports clavicle.
 Intercostal) is the area between ribs. space
(ICS
 ICS named according to rib immediately
above it; thus, first ICS is located between
first and second ribs.

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Mechanics of Breathing
Diaphragm and intercostal muscles are
primary muscles of inspiration.
 During inspiration, diaphragm contracts and
pushes abdominal contents down, while
intercostal muscles push chest wall outward.
 Combined efforts decrease intrathoracic
pressure, creating negative pressure within
lungs.
 During expiration, muscles relax, expelling air
as intrathoracic pressure rises.

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Mechanics of Breathing
(contd.)
• Accessory muscles contributing to respiratory effort include:

Anterior:
•
•
•
•
•

Sternocleidomastoid
Scalenus
Pectoralis minor
Serratus anterior
Rectus abdominus
Posterior:
Serratus posterior superior
Transverse thoracic
• Serratus posterior inferior
•
•
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Mechanics of Breathing
(contd.)


During inspiration, air is drawn through
mouth or nose and passes through
pharynx and larynx to reach trachea.
Nose, pharynx, larynx, and intrathoracic
trachea make up upper airway.

Three functions of upper airway:
 Conducts air to lower airway.
 Protects lower airway from foreign
matter.
 Warms, filters, and humidifies
inspired air.
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Mechanics of Breathing
(contd.)

Lower airway consists of:






Trachea
Right and left main stem bronchi
Segmental and subsegmental bronchi
Terminal bronchioles
Bronchi are further subdivided into
increasingly smaller bronchioles.
Bronchioles open into alveolar ducts and
terminate in multiple alveoli, where gas
exchanges occur.
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Anatomy and Physiology:
Topographic Markers

Topographic markers are surface
landmarks helpful in locating underlying
structures and in describing exact
location of physical finding.
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Topographic Markers:
Anterior Chest Wall


Nipples
Suprasternal notch:


Manubriosternal junction (angle of Louis):


Depression at ventral aspect of neck, just above
manubrium.
Junction between manubrium and sternum; useful for rib
identification.
Midsternal line:

Imaginary vertical line through middle of sternum.
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Topographic Markers:
Anterior Chest Wall (contd.)

Costal angle:


Clavicles:


Intersection of costal margins, usually no more than 90
degrees.
Bones extending out both sides of manubrium to shoulder;
they cover first ribs.
Midclavicular lines: MCL

Imaginary vertical lines on right and left sides of chest
that are “drawn” through clavicle midpoints, parallel to
midsternal line.
 Know
These!
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Topographic Markers:
Lateral Chest Wall

Anterior axillary lines:


Imaginary vertical lines on right and left sides of chest
“drawn” from anterior axillary folds through anterolateral
chest, parallel to midsternal line.
Posterior axillary lines:

Imaginary vertical lines on right and left sides of chest
“drawn” from posterior axillary folds along posterolateral
thoracic wall with abducted lateral arm.
 Know
These!
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Topographic Markers:
Lateral Chest Wall (contd.)

Midaxillary lines:

Imaginary vertical lines on right and left sides of chest
“drawn” from axillary apices; midway between and
parallel to anterior and posterior axillary lines.
 Know
These!
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Topographic Markers:
Posterior Chest Wall

Vertebra prominens:


Vertebral line:


Spinous process of C7; visible and palpable with head bent
forward.
Imaginary vertical line “drawn” along posterior vertebral
spinous processes.
Scapular lines:

Imaginary vertical lines on right and left sides of chest
“drawn” parallel to midspinal line; pass through inferior
angles of scapulae in upright patient with arms at sides.
 Know
These!
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Assessment
Questions
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General Health History:
Present Health Status




Do you have any chronic illnesses?
Do you have allergies?
Do you have difficulty breathing during
daily activities?
Do you have difficulty breathing when you
sleep?


In what position do you sleep?
Are you currently taking any oral
medications for a respiratory disorder?

If so, what are you taking, and how effective have they
been?
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General Health History:
Present Health Status (contd.)

Do you use an inhaler?




What medication is in inhaler?
What is the purpose?
How often?
Do you use oxygen at home?

Does oxygen relieve symptoms?
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General Health History:
Past Medical History


Have you ever had problems with your lungs?
Have you been diagnosed with respiratory diseases
such as the following:








Asthma
Bronchitis
Bronchiectasis
Emphysema
Lung cancer
Tuberculosis
Pneumonia
Have you ever had an injury to your chest?
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General Health History:
Personal and Psychosocial History

Do you smoke?



Have you smoked in the past?
How often do (did) you smoke?
Have you ever tried to quit?
 Why
do you think you were
unsuccessful?
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General Health History:
Family History

Is there a family history of lung disease?





Tuberculosis
Cancer
Cystic fibrosis
Emphysema
Asthma
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General Health History:
Home Environment

Are there environmental conditions that
may affect your breathing at home?
Air pollution
Possible allergens in home, such as pets.
Type of heating or air conditioning, including air filtering
system.
 Hobbies: woodworking, plants, metal work.
 Exposure to smoking of others in home.



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General Health History:
Occupational Environment

Where do you work?





Factory
Outdoors
In heavy traffic
Are you frequently exposed to any allergens?
If you are exposed to irritants, do you
wear a mask or respirator mask?
Does work area have special ventilation to clear
pollutants?
 Do you wear monitor to evaluate exposure?
 Do you have periodic health examinations, pulmonary
tests, or radiographic examinations?

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General Health History:
Travel

Have you recently traveled to foreign
countries or areas of the United States
where you may have been exposed to
uncommon respiratory diseases?
Examples:


Histoplasmosis in Southeast and Midwest?
Schistosomiasis or severe acute respiratory syndrome
[SARS] in Southwest Asia, Caribbean, and Asia?
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Problem-Based History


Commonly reported problems related to
lungs are cough, shortness of breath, and
chest pain with breathing.
A symptom analysis is completed, which
includes:








Onset
Location
Duration
Characterization
Aggravation factors
Related Symptoms
Treatments
Severity
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Problem-Based History:
Cough

When did you first notice cough?



Describe your cough.





Is cough constant, or does it come and go?
Has cough changed since you first noticed it?
Is it dry?
Productive?
Hacking?
Hoarse?
How often are you coughing up sputum
(all of the time or just periodically)?


What is color of sputum?
Consistency of sputum (thick, thin, frothy)?
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Problem-Based History:
Cough (contd.)

Have you noticed if sputum has an odor?

Have you noticed other symptoms:

Shortness of breath?

Chest pain or tightness with breathing?

Hoarseness?

Gagging?

Does coughing tire you out?

Keep you awake at night?

Have you done anything to treat cough such
as medications, fluids, or vaporizer?
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Problem-Based History:
Shortness of Breath

How long have you had shortness of breath?



Short of breath all the time, or does it come and go?
Describe your shortness of breath:

Harder to inhale or exhale or difficulty with both?

Do symptoms interfere with your activities?
Does anything seem to trigger episodes or make shortness of
breath worse?

If it occurs at night, in what position do you sleep?

How many pillows do you use?

Does changing your position affect problem?
Have you noticed any other problems when you are short of
breath?
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
Problem-Based History:
Chest Pain with Breathing

How long have you had pain in chest with
breathing?


When did this start?
Does pain radiate to other areas such as neck or arms?
What does pain feel like (viselike, tight,
sharp, burning)?
 When it started, was pain associated with
injury to ribs or respiratory infection?




Pain worse with deep inspiration?
Does pain interfere with getting enough air?
Pain Scale: 0-10
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Problem-Based History:
Chest Pain with Breathing
(contd.)


Is there anything that makes pain worse,
such as movement or coughing?
Have you done anything to treat pain,
such as heat, splinting, or pain
medication?

Have any measures been effective?
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Physical
Examination PE
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Examination:
Routine Techniques



Inspect patient for general appearance, posture, and
breathing effort.
Observe respirations for rate and quality, breathing
pattern, and chest expansion.
Inspect nails, skin, and lips for color.
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Examination: Routine
Techniques–Posterior Thorax


Inspect posterior thorax for shape and
symmetry, and muscle development.
Auscultate posterior and lateral thorax
for breath sounds.
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Examination: Routine
Techniques – Anterior Thorax


Inspect anterior thorax for shape and
symmetry, muscle development,
anteroposterior diameter to lateral
diameter, and costal angle.
Auscultate anterior thorax for breath
sounds.

K.Dobi, 1988 UTEP
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Gymnastics
44
Examination: Advanced Practice
and Special Circumstances

Posterior thorax:






Palpate posterior thoracic muscles for
tenderness, bulges, and symmetry.
Palpate posterior chest wall for thoracic
expansion.
Palpate posterior thorax wall for vocal (tactile)
fremitus.
Percuss posterior and lateral thorax for tone.
Percuss thorax for diaphragmatic (respiratory)
excursion.
Auscultate thorax for vocal sounds (vocal
resonance).
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Examination: Advanced Practice
and Special Circumstances
(contd.)

Anterior thorax:





Palpate trachea for position.
Palpate anterior thoracic muscles for
tenderness, bulges, and symmetry.
Palpate anterior chest wall for thoracic
expansion.
Palpate the anterior thorax wall for vocal
(tactile) fremitus.
Percuss anterior thorax for tone.
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Age-Related Variations:
Infants, Children, and
Adolescents

Assessing respiratory status of infants,
children, or adolescents follows sequence
as for adult—there are differences worth
noting:
Infants must be undressed to diaper for exam.
Keep infant covered when not examining to prevent
exposure and cooling.
 Conduct exam while infant is calm; exam of a crying infant
is difficult.
 By ages of 2 or 3 years, child is usually cooperative.
 Prior to that age, you need to develop a relationship with
child to improve cooperation.


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Age-Related Variations:
Older Adults

Assessing respiratory status of older
adults usually follows same procedures as
other adults, although there are may be
structural and functional differences
noted:

Posterior thoracic stooping or bending or kyphosis
may alter thorax wall configuration and make
thoracic expansion more difficult.
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Pathophysiology
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Common Problems and Conditions: Infections
and Inflammatory Conditions – Acute
Bronchitis


Acute bronchitis is inflammation of mucous membranes
of bronchial tree caused by viruses or bacteria.
Clinical findings:




Cough initially nonproductive but may become productive after few days.
Patients may complain of substernal chest pain aggravated by coughing.
Other clinical manifestations include fever, malaise, and tachypnea.
Rhonchi and crackles frequently heard on auscultation, with wheezing heard
after coughing.
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Common Problems and Conditions: Infections
and Inflammatory Conditions – Pneumonia
Pneumonia is inflammation of terminal bronchioles and
alveoli; may be caused by bacteria, fungi, viruses,
mycoplasma, or aspiration of gastric secretions.
 Clinical findings:
 Viral pneumonia tends to produce a nonproductive cough
or clear sputum.
 Bacterial pneumonia, however, causes productive cough
that may produce white, yellow, or green sputum.
 Other clinical findings associated with pneumonia include
fever, tachypnea, and dyspnea.
 Crackles and wheezes may be heard on auscultation of the
lungs.

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Common Problems and Conditions: Infections
and Inflammatory Conditions –
Tuberculosis

Tuberculosis is a contagious, bacterial infection caused
by Mycobacterium tuberculosis.


Primarily in lungs, but kidney, bone, lymph node, and meninges can also be
involved.
Clinical findings:
Patient usually asymptomatic in early stages of disease; initial clinical
manifestations consist of fatigue, anorexia, weight loss, fever.
 Characteristic finding later in disease is cough that becomes increasingly
frequent, producing a mucopurulent sputum.

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Common Problems and Conditions:
Infections and Inflammatory Conditions
– Pleural Effusion

Pleural effusion is accumulation of serous fluid in
pleural space between visceral and parietal pleurae.

Clinical findings:

Degree of manifestation depends on amount of fluid accumulation and position
of patient.

If effusion occurs rapidly and if it is large, there may be dyspnea, intercostal
bulging, or decreased chest wall movement.
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Common Problems and Conditions: Chronic
Pulmonary Disease – COPD
Asthma


Asthma is hyperreactive airway disease characterized by:

Bronchoconstriction

Airway obstruction

Inflammation.
Asthma occurs in response to:

Allergens or pollutants

Infection

Cold air

Vigorous exercise

Emotional stress
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Common Problems and Conditions: Chronic
Pulmonary Disease –
Asthma (contd.)


Clinical findings signs include:

Increased respiratory rate with prolonged expiration

Audible wheeze

Dyspnea

Tachycardia

Anxious appearance

Possible use of accessory muscles

Cough
Prolonged expiration, expiratory and occasionally inspiratory
wheeze, and diminished breath sounds are common findings
with auscultation.
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Common Problems and Conditions: Chronic
Pulmonary Disease – COPD
Emphysema


Emphysema is destruction of alveolar walls that causes
permanent abnormal enlargement of air spaces.
Clinical findings:
Classic appearance of a patient with advanced emphysema is underweight with
barrel chest and short of breath with minimal exertion.
 Other findings reveal diminished breath and voice sounds, possible wheezing or
crackles on auscultation, and decreased diaphragmatic excursion on percussion.

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Common Problems and Conditions: Chronic
Pulmonary Disease – COPD
Chronic Bronchitis


Chronic bronchitis characterized by hypersecretion of
mucus by goblet cells of trachea and bronchi resulting in
productive cough for 3 months in each of 2 successive
years.
Caused by irritants such as cigarette smoke and air
pollution or by infection.
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Common Problems and Conditions:
Chronic Pulmonary Disease –
Chronic Bronchitis (contd.)

Clinical findings: Chronic bronchitis
 Symptoms are productive cough, increased mucus
production, and dyspnea.
 Findings on auscultation are rhonchi, sometimes
cleared by coughing.
 When sufficient mucus occludes alveoli, crackles
may be heard.
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Common Problems and Conditions:
Acute or Traumatic Conditions –
Pneumothorax


Pneumothorax results from air in pleural spaces.
Three types of pneumothorax:
 Closed: May be spontaneous, traumatic, or
iatrogenic.
 Open: Occurs following penetration of chest by
either injury or surgical procedure.
 Tension: Develops when air leaks into pleura and
cannot escape.
 Know
these three types!
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Common Problems and Conditions:
Acute or Traumatic Conditions –
Pneumothorax (contd.)

Clinical findings: Pneumothorax
 Signs vary, depending on amount of lung collapse.
 With minor collapse, patient may be slightly short of
breath, anxious, and have chest pain.
 With large amount of lung collapse, patient may be in
severe respiratory distress, including dyspnea,
tachypnea, and cyanosis.
 Decreased chest wall movement on affected side; may
also have paradoxic chest wall movement.
 If severe, may be tracheal displacement toward
unaffected side with a mediastinal shift.
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Common Problems and Conditions:
Acute or Traumatic Conditions –
Hemothorax


Hemothorax results from blood in pleural space caused
by injury to the chest but also may be complication of
thoracic surgery.
Clinical findings:

Signs are similar to those described for pneumothorax, although it is common
to note distant muffled breath sounds and dullness with percussion
over affected area.
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Common Problems and Conditions:
Other Pulmonary Conditions –
Atelectasis


Atelectasis refers to collapsed alveoli caused by
external pressure from tumor, fluid, or air in pleural
space (compression atelectasis) or by removal of air
from hypoventilation or obstruction by secretions
(absorption atelectasis).
Clinical findings:
 Affected lobe has diminished or absent breath
sounds.
 Oxygen saturation may decrease to less than 90%.
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Common Problems and Conditions:
Other Pulmonary Conditions –
Lung Cancer


Lung cancer is uncontrolled growth of anaplastic cells in
lung.
Agents such as tobacco smoke, asbestos, ionizing
radiation, and other noxious inhalants can be causative
agents.
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Common Problems and Conditions:
Other Pulmonary Conditions –
Lung Cancer (contd.)

Clinical findings:

Most common initial symptom reported is a persistent cough.

Weight loss, congestion, wheezing, hemoptysis, labored
breathing, or dyspnea are other manifestations that occur with
advanced disease.
Lung sounds may be normal or diminished over affected area; if
there is a partial obstruction of airways from tumor, wheezes
may be heard.
Percussion tones may be normal or may be dull over tumor,
particularly if cancer is large or patient has associated
atelectasis.


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Question 1
Before caring for the patient, the nurse
reviews the test results. A chest
radiographic report shows that there is
atelectasis in the right base. During lung
auscultation, what would the nurse expect
to find?
A.
B.
C.
D.
Increased fremitus in the right base.
Diminished breath sounds.
Wheezing throughout.
Symmetrical chest expansion.
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Question 2
The nurse is caring for a patient who is suffering
from chronic obstructive pulmonary disease. He
coughs frequently and produces a thick white
sputum. During auscultation, the stethoscope
should be placed:
Over the scapula to enhance adventitious lung
sounds.
B. So that it is barely touching the skin to avoid
auditory artifact.
C. Over the left lung fields first.
D. In one position long enough to hear an entire
inhalation-exhalation set.
A.
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Case Study
Sean is a 10-year-old male child who attends
a local middle school. He has two siblings in
his home. All of his immunizations are up to
date. He has a history of eczema and
chickenpox. His favorite activities are
baseball and basketball. He loves to go to
the movies with his best friend, Josh. His
father smokes inside the home. Sean has
recently had a hospitalization for asthma.
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80
Case Study (contd.)
Subjective data:
 Complains of increased shortness of breath,
especially with exercise.
 Mother says he seems to be using the inhaler
more.
 Mother admits to not having a lot of
knowledge regarding inhaler usage.
 Objective data:
 Vital signs: T 98.0; P 61; R 17. Height: 4 ft
5 in. Weight 85 lb.
 Lungs: Clear on auscultation, no wheezing
present.
 Heart: RRR, no murmurs present.

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81
Case Study (contd.)
Questions:
1.
What risk factors does Sean have for asthma?
2.
What measures might help to prevent asthma
exacerbation?
3.
What should the nurse do in this clinical situation?
Prioritize actions.
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The End
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