RESPIRATORY

MODALITIES
Kate Carpio

imal patient care

fterOBJECTIVE
the test or
arterial blood gas
ain the principles of
thenursing
After

the lecture, the learner will be able to:

Have

enhanced knowledge on selected respiratory diagnostic test and

procedures (ie.Pulse Oximeter, ABG Analysis and Chest Tubes

)Understand
Identify

the nursing implications of the various

procedures
Provide

used for diagnostic evaluation of respiratory function.

optimal patient care before, during and after the test or procedure.

Interpret
Explain

the implications of the test results

arterial blood gas measurements.

the principles of chest drainage and the nursing responsibilities

related to the care of the patient with a chest drainage system.

ANATOMY &PHYSIOLOGY

PURPOSE OF THE
RESPIRATORYSYSTEM
The

lungs, in conjunction with the

circulatory system, deliver oxygen to
and expel carbon dioxide from the cells
of the body. The upper respiratory
system warms and filters air. The lungs
accomplish gas exchange.

STRUCTURES OF THE
UPPERRESPIRATORY TRACT
Nose
Sinuses

and nasal passages

Pharynx
Tonsils

and adenoidsLarynx: epiglottis,

glottis,vocal cords, and cartilages
Trachea

PARANASAL SINUSES

CROSS-SECTION OF NASAL CAVITY

UPPER RESPIRATORY SYSTEM

STRUCTURES OF THE LOWER

RESPIRATORYSYSTEM
Lungs
Pleura
Mediastinum
Lobes

of the lungs
Left: upper and lower Right: upper, middle,
and
lower Bronchi and bronchioles
Alveoli

LOWER RESPIRATORY SYSTEM

THE LOBES OF THE LUNGS AND BRONCHIOLE TREE

VENTILATION: THE MOVEMENT OF AIR IN AND OUT OF

THE AIRWAYS.
Thoracic
airtight

cavity

chamber.

Diaphragm
Floor
Inspiration
contraction

of the diaphragm(movement of this

chamber floor downward)contraction of the external
intercostal muscles increases the space in this
chamber

Lowered

intra thoracic pressure

Expiration:

with relaxation
Diaphragm moves up and intra
thoracic pressure increases
Increased pressure
pushes air out of the lungs.
Expiration requires the elastic recoil
of the lungs. Inspiration normally is
1/3 of the respiratory cycle and
expiration is2/3.

GAS EXCHANGE AND RESPIRATORY FUNCTION

VENTILATION-PERFUSION RATIOS:
A- NORMAL RATIO
B- SHUNTS C- DEAD SPACE

D- SILENT UNIT

LIGHTER SIDE

HOW

good is your
is your clinical
clinical eye?

READ OUT LOUD THE TEXT INSIDE THE TRIANGLE

BELOW.THE TRIANGLE BELOW.

MORE THAN LIKELY YOU SAID,"A BIRD IN THE BUSH.

If this IS what YOUsaid, then youfailed to see

thatthe wordTHEis repeated twice! Sorry, look
again.

NEXT, LET'S PLAY WITH SOME WORDS.WORDS.WHAT

DO YOU SEE?WHAT DO YOU SEE?

WHAT DO YOU SEE?

PULSE OXIMETRY
A

noninvasive method to monitor the oxygen

saturation of the blood (SaO2)
Does not replace ABGs Normal level is 95-100%.
May be unreliable
> cardiac arrest
> shock
> when dyes (ie, methylene blue) or
> vasoconstrictor medications
> severe anemia
> high carbon monoxide level.

SPO2
Oxygen

saturation ratio of
oxyhemoglobin(HbO2) to the
total concentration of
hemoglobin
(HbO2+deoxyhemoglobin)

PULSE OXIMETER

RECOMMENDED CONTINUOUSLY
FOR
critical or unstable airway
post-operative
conscious

clients

sedation for diagnostic procedure

history

with risk for significant desaturation

known

lung dysfunction

morbidly
with

obese/obstructive apneas

acute pain who received analgesics

cardiopulmonary
transfers
during

disorder

of critically ill clients

hemodialysis

INTERMITTENTLY
On

supplemental oxygen
Tracheostomy
long term mechanical
ventilator for stable, chronic
respiratory failure

NOT RECOMMENDED
during

cardiopulmonary resuscitation
Hypovolemia
assess of adequacy of ventilatory
support
detecting worsening lung function in
patients on high concentration of
oxygen

NURSING CONSIDERATIONS
Be familiar with the
manufacturer's
recommendations for the device.
Use the correct size to avoid skin
complications and ensure
accurate readings

NURSING CONSIDERATIONS
Reevaluating the sensor
oWhen using disposable

site periodically.
sensors, assess the
site every two to four hours and replace the
sensor every 24 hours.
oWhen using a reusable sensor, the site
should be checked every two hours and
changed every four hours.
oManufacturer's recommendations regarding
cleaning agents should also be followed.

NURSING CONSIDERATIONS
Check

that the right type of sensor is

being used.
To exclude motion artifact caused by
shivering, patients should be kept warm.
To avoid potential interference from
ambient light, the sensor can be covered
with the patient's linens. Nail polish or
artificial nails should be removed

NURSING CONSIDERATIONS
Nurses

should explain why

pulse oximetry is being used,
how it works, and what the
readings indicate in language
the patient and family can
comprehend.

HOW GOOD IS YOUR

CLINICALEYE?

ARTERIAL BLOOD GASES

Measurement

of arterial
oxygenation and carbon dioxide
levels.
Used to assess the adequacy of
alveolar ventilation and the ability
of the lungs to provide oxygen and
remove carbon dioxide.
Also assesses acid-base

ABG ANALYSIS
Pre-test:

Secure equipments-heparinized
syringe, needle, container with ice
Choose site carefully, perform the
Allens test
Intra-test: Obtain a 5 mL specimen from
the artery(brachial, femoral and
radial),no air on the syringe

Post-test:
Apply

firm pressure for 5 minutes or

15minutes with patients on
anticuagulants,
Label specimen correctly not
ingoxygenation and amount or room air
if applicable,
Place in the container with ice
Assess for swelling, bruising,
numbness,tingling, and pain

pH/PaCO2/PaO2/HCO3

O2 saturation on a specified FiO2

pH=arterialbloodpHPaCO2
(or PCO2)=arterialpressureofCO2,in mm HgPaO2
(or PO2)=arterialpressureofO2, in mm Hg
HCO3=serumbicarb.conc.,inmEq/literO 2
saturation=%hemoglobinsaturated with O2

7.49/42/88/3297%O2

saturation n100%

O2
7.41/39/88/3295%O2saturationon100%
O27.21/75/41/20onroomair7.32/50/98/22
99%
O2saturationon room air

ABG ANALYSIS
ABG normal valuespH 7.357.45PaCO2
35-45 mmHgHCO3
22- 26 mEq/LPaO2
80-100 mmHgO2
Sat95-99%

THE 6 EASY STEPS TOABG

ANALYSIS:
1.

Is the pH normal?
2. Is the CO2. normal?
3. Is the HCO3normal?
4. Match the CO2 or the HCO3 with thepH5.
5. Does the CO2 or the HCO3 go the opposite
direction of the pH?
6. Are the PaO2 and the SaO2 saturation
normal?

METABOLIC ACIDOSIS
Due

to renal failure
Manifestations: headache, confusion,
drowsiness, increased respiratory rate
and depth, decreased blood pressure,
decreased cardiac output, dysrhythmias,
shock; if decrease is slow, patient maybe
asymptomatic until bicarbonate is
15mEq/L or less
Correct the underlying problem and
correct the imbalance; bicarbonate
maybe administered

With

acidosis, hyperkalemia mayoccur

as potassium shifts out of the cell
As acidosis is corrected, potassium shifts
back into the cell and potassium levels
decrease
Monitor potassium levels
Serum calcium levels may be low with
chronic metabolic acidosis

METABOLIC ALKALOSIS
Most

commonly due to vomiting orgastric

suction; may also be caused , especially
long-term diuretic use

Hypokalemia

will produce alkalosis

Manifestations:

symptoms related calcium,

respiratory depression, tachycardia, and
symptoms of hypokalemia

Correct

underlying disorder, supply chloride

to allow excretion of excess bicarbonate, and
restore fluid volume with sodium chloride
solutions

RESPIRATORY ACIDOSIS
Always

due to a respiratory problem within

adequate excretion of CO2

With

chronic respiratory acidosis, the body

may compensate and may be asymptomatic;
symptoms may include a suddenly increased
pulse, respiratory rate, and BP; mental
changes; feeling of fullness in the head

Potential

increased intracranial pressure

Treatment

is aimed at improving ventilation

RESPIRATORY ALKALOSIS
Always due to hyperventilation
Manifestations: light
headedness, inability to
concentrate, numbness and
tingling, and sometimes loss of
consciousness

O2 SATURATION VS.ABG

GAS EXCHANGE AND RESPIRATORY

FUNCTION

LETS EXERCISE!
pH

PaCO2

HCO3

PaO2

mEq/L

mmHg

SaO2

7.27

53

24

50

79

7.52

29

23

100

98

7.18

44

16

92

95

7.60

37

35

92

98

7.30

30

14

68

92

Remarks

Lighter Side

CAN YOU READ THIS?

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and I awlyas tghuhot slpelingwas imorantt!was ipmorantt!

CHEST DRAINAGE
Used

to treat spontaneous and

traumatic pneumothorax
Used postop to re-expand the lung &
remove excess air, fluid, blood
by restoring negative intrapleural
pressure.
To assess and measure drainage
from the intrapleural space.

CHEST TUBES

long, semi-stiff, clear plastic tubes that are inserted into the chest, so that they can drain
collections of fluids or air from the space between the pleura

INDICATION
Pneumothorax

: a collection of air in
thepleural space.

a. Closed b. Open c. Tension

Hemothorax : a collection of blood in
the pleural space, maybe from
surgery, maybefrom a traumatic
injury.
Empyema: Pus can collect in the
pleural space

CLOSED-CHEST DRAINAGESYSTEM

CHEST TUBE DRAINAGE SYSTEM

DO

Keep

the system closed and below chest

level.
Make sure all connections are taped and
the chest tube is secured to the chest
wall.
Ensure that the suction control chamber
is filled with sterile water to the20-cm
level or as prescribed.
If using suction, make sure the suction
units pressure level causes slow but

DO
Make

sure the water-seal chamber is filled

with sterile water to the level specified by the
manufacturer. You should see fluctuation
(tidaling) of the fluid level in the water-seal
chamber; if you dont, the system may not be
patent or working properly, or the patients
lung may have re-expanded.

Look

for constant bubbling in the water-seal

chamber, which indicates leaks in the
drainage system. Identify and correct external
leaks. Notify the healthcare provider
immediately if you cant manage it.

DO

Assess
the

amount, color, andconsistency of

drainage in thedrainage tubing and in
thecollection chamber.

Mark
the

drainage level on theoutside of the

collection chamber(with date, time, and
initials) every8 hours or more frequently
ifindicated.

Report
drainage

thats excessive

DO
Encourage

the patient to perform deep

breathing, coughing, and incentive
spirometry. Assist with repositioning or
ambulation as ordered. Provide adequate
analgesia.

Assess

vital signs, breath sounds,SpO2, and

insertion site for subcutaneous emphysema
as ordered. When the chest tube is removed,
immediately

Apply

a sterile occlusive petroleum gauze

dressing over the site to prevent air from
entering the pleural space.

DONT

Dont let
the

drainage tubing kink,loop, or interfere with the

patientsmovement.

Dont

clamp

chest tube, exceptmomentarily when replacing

theCDU, assessing for an air leak, orassessing the
patients tolerance ofchest tube removal, and
duringchest tube removal.

Dont
the

aggressively manipulate

chesttube; dont stripor milk it.

Knowing

is not
enough; we must apply.
Willing is not enough;
we must do.