The Respiratory System
Correlated to the Roy Adaptation Model
and Nursing Process
Sandy Marks, RN, BSN, MS(HCA)
N212 Medical Surgical Nursing 1
Spring 2008
Journey through Roy Adaptation Model
(RAM)

Roy Adaptation Model →

Patients primarily with alterations in
physiological mode →

oxygenation →

respiratory system
Course Packet (2007), p 104
Objectives - 1

Review the anatomy and physiology of the
respiratory system

Describe the respiratory changes
associated with aging
Objectives - 2

Discuss the purpose and interventions
(preparation, explanation, procedure,
postcare) for the following diagnostic tests:








X-rays: chest, bronchogram, CT, lung scan
Direct visualization: bronchoscopy
Sputum specimen
Thoracentesis
Pulmonary function tests (PFT)
Oximetry
Magnetic resonance imaging (MRI)
Cultures
Objectives - 3
Describe the nursing assessment of the
following cardinal signs and symptoms:





cough
sputum
dyspnea
Discuss the pathophysiology, nursing
assessment, interventions, and evaluation
for Pneumonia
The Art of Caring
dscherer.com
Respiratory Review

1.
2.

1.
2.
3.
4.
5.
Purpose =
provide oxygen for tissue metabolism (O2)
remove carbon dioxide (CO2)
Influences functions of:
acid-base balance
speech
sense of smell
fluid balance
temperature control
Review the anatomy
and physiology of the
respiratory system
trachea
upper respiratory tract
lower respiratory tract
1.
2.
bronchi
divided by trachea
(windpipe)





bronchioles
bronchi
bronchioles
alveolar ducts
alveoli
alveoli
Chabner, 2007
Gas Exchange

occurs at alveolar
capillary membrane
occurs by diffusion

Pulmonary edema =

1.
2.
excess fluid fills alveoli
spaces
impairs exchange of O2
and CO2
capillary
Chabner, 2007
Normal lung tissue

300 million alveoli
surface area = tennis
court

Right bronchus





1.
2.
slightly wider
shorter
more vertical
increases problems with
intubation
aspiration
Chabner, 2007
Physiologic changes associated with aging
dscherer.com
Alveoli






alveolar surface area decreases
diffusion capacity decreases
elastic recoil decreases
bronchioles and alveolar ducts dilate
ability to cough decreases
airways close early
Lungs




residual volume increases
vital capacity decreases
efficiency of oxygen and carbon dioxide
exchange decreases
elasticity decreases
Pharynx and Larynx



muscles atrophy
vocal cords become slack
laryngeal muscles lose elasticity and cartilage
Pulmonary Vasculature



increased vascular resistance to blood flow
through pulmonary vascular system occurs
pulmonary capillary blood volume decreases
risk of hypoxia increases
Exercise Tolerance and
Muscle Strength

Exercise Tolerance
body’s response to hypoxia and hypercapnea
decreases

Muscle Strength
respiratory muscle strength, especially the
diaphragm and intercostals, decreases
Susceptibility to Infection



effectiveness of the cilia increases
immunoglobulin A decreases
alveolar macrophages are altered
Chest Wall






anteroposterior (AP) diameter increases
thorax becomes shorter
progressive kyphoscoliosis occurs
chest wall compliance (elasticity) decreases
mobility may decrease
osteoporosis is possible
Summary on effects of aging

↓ recoil and compliance

 AP diameter

↓ functional alveoli

↓ in Pa02

Respiratory defense mechanisms less effective

Altered respiratory controls

More gradual response to changes in O2 and Co2
levels in blood
Diagnostic Tests







X-rays: chest, bronchogram, CT, lung scan
Direct visualization: bronchoscopy
Sputum specimen and Cultures
Thoracentesis
Pulmonary function tests (PFT)
Oximetry
Magnetic resonance imaging (MRI)
Chest X-Ray

Screen, diagnose,
evaluate treatment

Instructions:
X-ray
Positions
Chabner, 2007
Chest X-Ray (Cont.)
Posterior Anterior View
Left Lateral View
Bronchogram

Slightly
oblique
www.fotosearch.com
Computed Tomography: CT Scan

Images in crosssection view

Uses contrast
agents
Right upper Lobe

Instructions:
Lung Scan







most to detect emboli
no food restrictions
breathes radioactive
material through a
tube for 5 minutes
6 ventilation images
taken
radioactive injection
same 6 images
retaken
compare images
www.ucl.ac.uk
Ventilation- air distribution in lung
Perfusion- blood supply to & within lung
www.diiradiology.com
www.washingtonhospital.org
Bronchoscopy


Diagnose problems and assess
changes in bronchi / bronchioles
Performed to remove foreign
body, secretions, or to obtain
specimens of tissue or mucus for
further study
Post-Procedure Care / Instructions:
Sputum Specimen


To diagnose; evaluate treatment
Specimen: ID organisms or abnormal
cells



Culture & Sensitivity (C&S)
Cytology
Gram stains

(e.g. Acid Fast Bacilli)
Thoracentesis

Specimen from
pleural fluid

Treat pleural effusion

Assess for
complications

Post-Procedure care:
Positions
•Sitting on side of bed over bedside table
chest elevated
•Lying on affected side
•Straddling a chair
Pneumothorax
Chabner, 2007
Pulmonary Function Test (PFTs)

Evaluate lung function

Observe for increased
dyspnea or
bronchospasm

Instructions:
Pulse Oximetry






Measures arterial
oxygen saturation
Pulse oximetry probe
on ears, nose, finger,
toes, forehead
False readings
Intermittent or
continuous monitoring
Ideal values
When to Notify MD
MRI


Frontal View
White masses =
Hodgkin
Disease lesions
Chabner, 2007
MRI – transverse view – same patient
Chabner, 2007
Nursing Assessment:
Cardinal Signs and Symptoms of:
1. Cough
2. Sputum
3. Dyspnea
Cough – Main Sign of Lung Disease








how long present
occurs at a specific time (smokers = upon
wakening in AM)
related to activity
productive vs nonproductive
congested
dry
tickling
hacking
Sputum – normally 3 oz produced/day

important symptom associated with coughing

Check:
duration – long term, short term
color – rust colored
consistency – thick, thin, watery, frothy
odor- foul
amount – describe in tsp, or fractions of cup
and if increasing (external or internal cause)
1.
2.
3.
4.
5.
Dyspnea – subjective data (perception)


1.
2.
3.
4.


difficulty in breathing or breathlessness
Check:
onset – slow or abrupt
duration - # of hours, time of day
relieving factors – position change, med,
stop activity
wheezing, crackles, rales, or stridor occur
with breathlessness
Quantify by assessing if interferes with ADL
PND or orthopnea
Lung sounds

wheezing
crackles
stridor

auscultation – sequence pg. 534, Iggy

bronchial = trachea & mainstem bronchi
bronchovesicular = branching bronchi
vesicular = small bronchiole periphery




Pneumonia: Case Study
Nursing Student Tools



Concept Map – Pneumonia
Medical-Surgical Map (Medimap)
Nursing Map
Course Packet (2007), pgs 115-117
Pathophysiology
Toxic sprinkles anyone?
Etiology

Cause






bacteria (75%)
viruses
fungi
Mycoplasma
parasites
chemicals
Classifications

Community-acquired pneumonia (CAP)


Onset in community or during 1st 2 days of hospitalization
(Strep. pneumoniae most common)
Hospital-acquired Pneumonia (HAP / nosocomial)

Occurring 48 hrs or longer after hospitalization

Aspiration pneumonia

Pneumonia caused by opportunistic organisms

Pneumocystis Carinii
Risk Factors




CAP
Older adult
Chronic/coexisting
condition
Recent history or
exposure to viral or
influenza infections
History of tobacco or
alcohol use







HAP
Older adult
Chronic lung disease
ALOC
Aspiration
ET, Trach, NG / GT
Immunocompromised
Mechanical ventilation
Clinical Manifestations - 1






Fevers, chills, anorexia
Pleuritic chest pain
SOB
Crackles / wheezes
Cough, sputum production
Tachypnea
Clinical Manifestations - 2
Mycoplasma (Atypical)
 feeling tired or weak,
headaches, sore throat, or
diarrhea.

Eventually, most develop a
dry cough. They can, also,
develop fever, chills,
earaches, chest pain

“walking pneumonia”
Diagnosis

Diagnosis →
 Physical exam → crackles,
rhonchi / wheezes


CXR → area of increased
density
(infiltrates / consolidation)
Sputum specimen –

Gram stain
LUL Infiltrates
CXRLUL Pneumonia
www.med.wayne.edu
Interventions and Treatment

Treatment
 Antibiotics → choose based on age, suspected
cause & immune status


Supportive care → IV fluids, supplemental oxygen
therapy, respiratory monitoring, cough
enhancement
*may take 6-8 weeks for CXR to normalize
Nursing Diagnoses…

Impaired gas exchange R/T
Pneumonia

Pain R/T infection in lung
Pneumonia
Complications
Hypoxemia
Pleural effusion
Atelectasis
Pleurisy
Atelectasis
Pleurisy
Pleural Effusion
Atelectasis

A = obstruction

B = accumulation of
fluid of air
Chabner, 2007
Additional learning resources


NANDA approved nursing diagnoses specific
to respiratory system: p125 of study packet
Skills Lab:



Heart and Lung Sounds Trainer
Learning Lung Sounds, Cardionics CD
Audio-visual material
Resources




Beers, M. & Berkow, R. (Ed.). (2000). The Merck
Manual of Geriatrics (3rd ed.). Whitehouse
Station: Merck & Co., Inc.
Chabner (2007). The Language of Medicine (8th
ed.). St. Louis: Saunders.
Ignatavicius, D. & Workman, L. (2006). MedicalSurgical Nursing Critical Thinking for
Collaborative Care (5th ed.). St. Louis: Elsevier
Saunders.
Scherer, D. (2008). Pictures retrieved March 31
and available at dscherer.com
dscherer.com