This video is an overview of the respiratory system that can be used for Nursing Medsurg or NCLEX exams.
As a nurses it is important to understand about respiratory assessment and disorders. A thorough assessment of breath sounds is vital to detect any pathology or disorder. Abnormal breath sounds include friction rub, rales, basilar rales, rhonchi, stridor, and wheezes. Nursing students should be aware of the risk factors for respiratory disorders, including allergies, exposure to chemicals and pollutants, and smoking.
Chest injuries can lead to severe respiratory distress and nursing interventions such as maintaining the client in Fowler's position, administering oxygen and pain medication as prescribed, monitoring for increased respiratory distress, and encouraging coughing and deep breathing are crucial.
Pulmonary embolism, a life-threatening condition, requires immediate intervention from the Rapid Response Team and the healthcare provider. Nursing interventions for pulmonary embolism include reassurance of the client and elevating the head of the bed, administering oxygen, obtaining vital signs and checking lung sounds, preparing for the administration of heparin therapy, and documenting the event and interventions taken.
Tuberculosis, an infectious respiratory process caused by tubercle bacilli, requires diagnostic tests such as PPD and sputum culture. Nurses should be aware of the different types of tuberculosis, including latent and active, and provide airborne precautions, 6 air exchanges per hour, and ask the patient to wear a mask when leaving the room.
Asthma is caused by airway inflammation and can be triggered by allergens, exercise, and irritants. Nursing interventions for asthma include keeping the airway patent and administering systemic corticosteroids. It is important for nursing students to be knowledgeable about respiratory assessment and disorders to provide optimal care for patients.
Assessment is a critical component of caring for patients with respiratory disorders. Nursing assessments include gathering information about the patient's medical history, current symptoms, and risk factors for respiratory disorders. In addition, nurses must perform a thorough physical assessment, paying close attention to breath sounds and other signs of respiratory distress.
Breath Sounds
Breath sounds are an essential component of the physical assessment of the respiratory system. The different types of breath sounds can provide valuable information about the underlying cause of respiratory distress. Nurses must be familiar with the different types of breath sounds and their associated pathologies.
Friction rub is caused by the rubbing of pleural surfaces against one another and is usually the result of inflammation processes.
Rales or crackles are adventitious breath sounds associated with pathology. Rales could be the result of air bubbles in secretions or movement of fibrotic tissue during breathing. Rales are often accompanied with left ventricular congestive heart failure, atelectasis, fibrosis, and pulmonary edema. They are related to the opening of previously closed small airways and alveoli.
Rhonchi are continuous low-pitched, sonorous breath sounds that are most prominent during expiration and could be a result of air passing through airways narrowed by inflammation, bronchospasm, or secretions.
Stridor is a continuous adventitious sound of inspiration associated with upper airway obstruction. Wheezes are continuous breath sounds that are high-pitched and musical, often associated with asthma, COPD, and foreign body aspiration.
Risk Factors for Respiratory Disorders
Several risk factors can contribute to the development of respiratory disorders. Nurses must be aware of these risk factors and be able to identify them during patient assessments. Some of the common risk factors for respiratory disorders include:
Allergies and crowded living conditions
Chest injury
Exposure to chemicals and environmental pollutants
Family history of infectious disease
Frequent respiratory illnesses
Geographical residence and travel to foreign countries
Smoking or use of chewing tobacco
Viral syndrome
Chest Injuries
Chest injuries, such as flail chest and pneumothorax, can cause severe respiratory distress and require immediate nursing interventions.
Flail Chest
Flail chest is characterized by paradoxical respirations, severe pain in the chest, dyspnea, cyanosis, tachycardia, tachypnea, hypotension, shallow respirations, and diminished breath sounds. Nursing interventions for flail chest include maintaining the client in a Fowler's position and limiting activity, administering oxygen and pain medication as prescribed, monitoring for increased respiratory distress, and encouraging coughing and deep breathing.
Pneumothorax
Pneumothorax is characterized by absent breath sounds on the affected side, cyanosis, decreased chest expansion unilaterally, dyspnea, hypotension, sharp chest pain, subcutaneous emphysema as evidenced by crepitus on palpation, sucking sound with open chest wound, tachycardia, and tachypnea. Nursing interventions for pneumothorax include applying a nonporous dressing over an open chest wound, administering oxygen as prescribed, placing the client in Fowler's position, preparing for chest tube placement, monitoring the chest tube drainage system, and monitoring for subcutaneous emphysema.
Medical Diagnosis with Nursing Interventions
Nurses must be familiar with the nursing interventions for various respiratory disorders. Here are some examples:
Pulmonary Embolism
Pulmonary embolism is characterized by apprehension and restlessness, blood-tinged sputum, chest pain, cough, crackles and wheezes on auscultation, cyanosis, distended neck veins, dyspnea accompanied by anginal pain.