NU437: Respiratory Disorders
                                Required Reading: Luckman-Core
                                Principles of Medical/Surgical Nursing
                                 Instructor:  M. Ledford
 
 

Chapters: 21-22
 

 The following material is to augment your study of the above required reading material, not replace it or any of the other hand-outs.  Use the hand-out of review tests for each chapter to evaluate your retention of the material.  If you were unsuccessful with some of the questions, return to the text and review further and attempt the evaluations tests again.  If you need further assistance, please contact me by phone or e-mail.
 

 The first two chapters of Unit Six covers anatomy/physiology, assessment and nursing management of respiratory disorders.  This is material you have covered previously, however, if you feel unsure of any of this material, you should review those areas in which you feel weak.

 Respiration is a physiological function that is synonymous with life.  When we experience difficulty in breathing it is perceived as a threat to life.  Patients with respiratory disorders are very anxious and fearful of impending death.  The level of fear is not directly related to the real possibility of death.
 Respiratory problems are one of the major health cost issues due to the frequency of acute and chronic disorders.  Chronic respiratory disorder is an especially recognized cost outlier for all health care facilities.  The major cost outlier is chronic obstructive pulmonary disease (COPD), which is more recently called chronic airflow limitation (CAL).
 

 The study begins with incidence of tumors and cancer of the larynx.  Ninety percent of tumors affecting the head and neck are squamous cell in origin and are fast seeding.  Tobacco and alcohol abuse are the primary risk factors for tumor development in the United States.  There are over 12,500 new cases and 3700 deaths per year from laryngeal cancer.  Prevention is aimed toward minimizing risk factors and recognizing early warning signs of cancer.  Box 21-1 list the clinical warning signs of laryngeal cancer.
      Managed care of the client with head and neck cancer begins with a thorough history and physical examination, and laboratory findings provide clues to the presence of a malignancy.  Clinical manifestations are outlined in the box on page 549.  Therapy ranges from nonsurgical management of maximizing air exchange through radiations, chemotherapy, and surgical intervention.  Dietary management is important with clients with advance laryngeal cancer.  Box 21-2 gives criteria for staging of head and neck cancer.  Education pre/post-op are important aspects of nursing intervention as discussed in the text.  A client education guide is offered in the boxes on page 555 and 558.
       The remainder of the chapter discusses obstructive upper airway disorders.  An upper airway obstruction is a life-threatening emergency defined as a significant interruption in airflow through the nose, mouth, pharynx, or larynx.  Causes include edema, occlusion by the tongue, cancer, abscess, thick secretions, anaphylaxis, trauma, or foreign body aspiration, to name a few.  Emergency interventions and preventions are outlined.  Chronic airway obstruction, hemorrhagic, infectious, and inflammatory conditions are also discussed.  Study questions and critical thinking exercises are offered at the end of the chapter as well as in the handouts to augment you learning.
 

       Chronic respiratory problems, such as chronic obstructive pulmonary disease (COPD), now called chronic airflow limitation (CAL) and certain restrictive lung diseases, can cause significant disability.  These diseases can lead to disability for the client and significant health care costs for the patient and national economy.
      CAL is characterized by increased airway resistance, irreversible lung distention, and arterial blood gas imbalance.  The triad of diseases that are classified as Cal are asthma, pulmonary emphysema and chronic bronchitis.
     The chapter begins discussion of Asthma.  Although asthma is considered a CAL disease, it is discussed separately due to the difference in its clinical presentation.  Asthma is intermittent in nature, and characterized by intermittent narrowing of the bronchial airways in relation to bronchial smooth muscle constriction. excess mucus production and mucosal edema.  These reactions by the airways can be of intrinsic origin (e.g., stress or exercise) or extrinsic origin (e.g., allergies to pollen or dust).  The incidence & etiology, risk factors & prevention, pathophysiology, complication, clinical manifestations (box page 571), medical management and nursing management are discussed.
      The two other major disorders involved in COPD/CAL are chronic bronchitis and emphysema.  Chronic bronchitis, is a disease of the bronchioles, caused by irritation/ inflammation of the bronchial walls, such as swelling and increased mucus production.  The narrowing of the airways created the need for increased effort in expiration as also seen with emphysema.  Chronic bronchitis and asthma often precedes emphysema.
        In pulmonary emphysema, the alveolar walls are destroyed by enzymes call proteases.  The destruction of the terminal bronchiole makes it harder to push air out during expiration.  Air becomes trapped, causing further alveolar destruction and bleb and bullae formation.  The result is decreased alveolar surface area for diffusion of gases across the capillary-alveolar surface.  This leads to "dead space" or areas not used in O2 exchange.  Classifications of pulmonary emphysema are panlobular, centrilobular, and paraseptal.
     The incidence, etiology, risk factors, and pathophysiology of CAL are discussed.  Clinical manifestations are outlined in the box on page 576, as well as a comparison of bronchitis and emphysema manifestations on page 577.  Complications, medical management and nursing management are discussed.
     The next section of the chapter discusses parenchyma disorders, disorders of the lung tissue.  This is in contrast to the previous discussion of the airway disorders.  The discussion of parenchymal disorders follows the same format  of incidence & etiology, risk factors, pathophysiology, clinical manifestations, medical management and nursing management.  The critical to remember highlight are designed to be helpful in the study of respiratory disorders.
     Noncardiogenic pulmonary edema  and acute respiratory failure are discussed briefly.  Acute respiratory failure can be classified an ventilatory failure (hypoventilation), oxygenation failure Leading to hypoxemia, or a combination of both.  Ventilatory failure results from disorder that impair the ventilatory drive,  chest wall or respiratory muscles, or other factors.
     Adult respiratory distress syndrome (ARDS). most common for of noncarcigenic pulmonary edema.  ARDS is characterized by dyspnea, hypoxemia, decreased pulmonary compliance, pulmonary infiltrate and increases in extravascular lung fluid.  The mortality rate exceeds 50%.  The major site of injury is the alveolar-capillary membrane.  Massive central system sympathetic discharge leads to systemic vasoconstriction with redistribution of large volumes of blood into the pulmonary circuit, producing severe elevation of hydrostatic pressure and lung injury.  DIC may also occur.  This test is disappointing in the brevity of coverage of this acute life threatening disorder and its high incidence of over 15,00 cases annually in the U.S.  The key to successful management is early detection and initiation of treatment.
     The remainder of the chapter discusses restrictive lung diseases.  These are divided into two classifications: Intrapulmonary and Extrapulmonary.  These disorder account for a major number of pulmonary disorders.  Causes of these disorders are in box 22-6.  Occupation lung diseases are the most common occupational health problems.  Characteristics of these disorders are reviewed in table 22-6.  The restrictive lung disorder of lung cancer is a rapidly raising health problem with the most common cause related to cigarette smoke, both passive and active participation.
    Disorders of the pulmonary vasculature include pulmonary embolism and pulmonary hypertension.  These two entities are discussed briefly.  Disorders of the pleura and pleural space complete the discussion of pulmonary disorders.
     Again study questions and critical exercise are offered at the end of the chapter to evaluate and augment you study of this chapter.
     Complete the study material in the handouts.  If you have question, you may contact me through e-mail or phone.
 
 

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