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  1. 1. Chapter 30 &31 <br /> Acute and Chronic Respiratory Disorders<br />1<br />
  2. 2. Commonly understood to mean movement of air<br />Accomplished by the pulmonary system, consisting of the airways and lungs, the blood vessels perfusing them, the muscles of the thorax and abdomen, and the innervation of these structures<br />VENTILATION<br />2<br />
  3. 3. the movement of atmospheric air into and out of the lungs<br />depends on open airways and contractions of muscles to create pressure gradients for air flow<br />ventilation is the critical first step in the complex process of respiration<br />PULMONARY VENTILATION<br />3<br />
  4. 4. provides oxygen for metabolism in the tissues<br />removes carbon dioxide, the waste product of metabolism<br />Primary functions of the respiratory system<br />4<br />
  5. 5. facilitates sense of smell<br />produces speech<br />maintains acid-base balance<br />maintains body water levels<br />maintains heat balance<br />Secondary functions of the respiratory system<br />5<br />
  8. 8. normally approx 500 ml of air is inhaled and exhaled<br />APNEA-temp interruption in normal breathing, no air movement occurs<br />dyspnea-difficulty breathing<br />orthopnea-difficulty breathing while in a lying position<br />See Table 30-1 for types of breathing patterns<br />BREATHING<br />8<br />
  9. 9. respiratory center of the brain located just above the spinal cord in the brain stem<br />stimulated by changing levels of CO2 & Oxygen<br />Chemoreceptors in the aorta and carotid artery monitor the PH and the amount of carbon dioxide and oxygen in the blood stream.<br />MEDULLA<br />9<br />
  10. 10. NOSE<br />SINUSES<br />PHARYNX<br />LARYNX<br />EPIGLOTTIS<br />UPPER RESPIRATORY TRACT<br />10<br />
  11. 11. Humidifies, warms, and filters inspired air<br />NOSE<br />11<br />
  12. 12. air-filled cavities within the hollow bones that surround the nasal passages<br />provide resonance during speech<br />SINUSES<br />12<br />
  13. 13. located behind the oral and nasal cavities<br />divided into the nasopharynx, oropharynx, laryngopharynx<br />passageway for both the respiratory and digestive tracts<br />PHARYNX (Throat)<br />13<br />
  14. 14. located above the trachea and just below the pharynx at the root of the tongue<br />contains two pairs of vocal cords, the false and true cords<br />opening between true vocal cords is the glottis<br />the glottis plays an important role in coughing<br />coughing is the most fundamental defense mechanism of the lungs<br />LARYNX (Voice Box)<br />14<br />
  15. 15. leaf-shaped elastic structure that is attached alone one end to the top of the larynx<br />it prevents food from entering the tracheobronchial tree by closing over the glottis during swallowing<br />EPIGLOTTIS<br />15<br />
  17. 17. located in front of the esophagus<br />branches into the right and left mainstem bronchi at the carina<br />passageway for air to reach the lungs<br />TRACHEA (Windpipe)<br />17<br />
  18. 18. begins at the carina<br />a ridgelike structure between the openings of the right and left bronchus<br />the right bronchus is slightly wider, shorter, and more vertical than the left bronchus<br />most foreign bodies from the trachea usually enter the right bronchus<br />the mainstem bronchi divides into five secondary or lobar bronchi that enter each of the five lobes of the lung<br />MAINSTEM BRONCHI<br />18<br />
  19. 19. the bronchi are lined with cilia, which propel mucus up and away from the lower airway to the trachea where it can be expectorated or swallowed<br />MAINSTEM BRONCHI<br />19<br />
  20. 20. branch from the secondary bronchi and subdivide into the small terminal and respiratory bronchioles<br />they contain no cartilage and depend on the elastic recoil of the lung for patency<br />the terminal bronchioles contain no cilia and do not participate in gas exchange<br />BRONCHIOLES<br />20<br />
  21. 21. alveolar ducts branch from the respiratory bronchioles<br />alveolar sacs, which arise from the ducts, contain clusters of alveoli, which are the basic units of gas exchange<br />cells in the walls of the alveoli secrete surfactant, a phospholipid protein that reduces the surface tension in the alveoli, without this alveoli collapse<br />ALVEOLAR DUCTS AND ALVEOLI<br />21<br />
  22. 22. innervation of the respiratory structures is accomplished by the phrenic nerve, vagus nerve, and thoracic nerves<br />the parietal pleural lines the inside of the thoracic cavity including the upper surface of the diaphragm<br />the visceral pleura covers the pulmonary surfaces<br />LUNGS<br />22<br />
  23. 23. a thin fluid layer, which is produced by the cells lining the pleura, lubricates the visceral and parietal pleura, allowing them to glide smoothly and painlessly during respiration<br />blood flows through the lungs occurs via the pulmonary system and the bronchial system<br />LUNGS CONT’<br />23<br />
  24. 24. scalene muscles<br />elevate the first two ribs<br />sternocleidomastoid muscles<br />raise the sternum<br />trapezius and pectoralis muscles<br />fix the shoulders<br />accessory muscles of respiration<br />24<br />
  25. 25. the diaphragm descends into the abdominal cavity during inspiration causing negative pressure in the lungs<br />the negative pressure draws air from the area of greater pressure, the atmosphere, into the area of lesser pressure, the lungs<br />in the lungs, air passes through the terminal bronchioles into the alveoli to oxygenate the body tissues<br />THE RESPIRATORY PROCESS<br />25<br />
  26. 26. at the end of inspiration, the diaphragm and intercostal muscles relax and the lungs recoil<br />as the lungs recoil, pressure within the lungs becomes greater than atmospheric pressure causing the air that now contains the cellular waste products of carbon dioxide and water to move from the alveoli in the lungs to the atmosphere<br />THE RESPIRATORY PROCESS<br />26<br />
  28. 28. reduced chest movement<br />decreased ability to inhale and exhale<br />less effective cough<br />increased work of breathing<br />less tolerance for exercise and stress<br />AGE RELATED CONSEQUENCES<br />28<br />
  29. 29. smoking<br />allergies<br />frequent respiratory illnesses<br />chest injury<br />surgery<br />exposure to chemicals and environmental pollutants<br />crowded living conditions<br />family history of infectious disease<br />geographic residence and travel to foreign countries<br />RISK FACTORS FOR RESPIRATORY DISEASE<br />29<br />
  30. 30. HEALTH HISTORY<br />WHAT DO YOU NEED TO KNOW?<br />Chief complaint and hx of present illness<br />past medical hx<br />review of systems<br />functional assessment<br />30<br />
  31. 31. cough<br />pain<br />dyspnea<br />fever<br />sweating<br />nausea/vomiting<br />effort to treat<br />response to treatment<br />PRESENT ILLNESS<br />31<br />
  32. 32. onset-one week ,activity, lying down? <br />duration-each episode, how long<br /> frequency-frequent, occasionally, constantly<br /> type-dry hacking, wet productive, irritating and scratchy<br /> severity-hard enough to throw up?<br />COUGH: <br />32<br />
  33. 33. sputum production & characteristics<br />COLOR-green, yellow, clear, rusty, blood tinged<br />CONSISTENCY-thick, thin,<br />ODOR-there either is or there isn’t<br />AMOUNT-scant, copious, large, small<br /> pain-does it hurt when you cough?<br />have they tried anything to treat it and has it helped<br />COUGH<br />33<br />
  34. 34. onset<br /> duration<br /> severity<br /> precipitating events<br /> associated symptoms<br />Dyspnea:<br />34<br />
  35. 35. location<br /> onset<br /> duration<br /> precipitating events<br /> effects on breathing<br /> relief measures<br />associated symptoms<br />Pain:<br />35<br />
  36. 36. Colds<br />pneumonia<br />tuberculosis/last TB test<br />chronic bronchitis<br />emphysema<br />asthma<br />cancer of resp. tract<br />cystic fibrosis<br />immunizations<br />Sinus infections<br />ear infections <br />diabetes mellitus<br />heart disease<br />allergies / current meds<br />trauma<br />surgeries<br />hospitalizations/ last CXR<br />conditions that suppress the immune system<br />PAST MEDICAL HISTORY<br />36<br />
  37. 37. Family history<br />Major respiratory conditions<br />smoking history<br />37<br />
  38. 38. fatigue<br />weakness<br />fever <br />chills<br />night sweats<br />earaches<br />nasal obstruction<br />sinus pain<br />sore throat<br />hoarseness<br />edema<br />dyspnea<br />orthopnea<br />Review of symptoms<br />38<br />
  39. 39. occupation<br />exposure to pathogens<br />exposure to respiratory irritants<br />typical day<br />usual diet<br />fluid intake<br />smoking history<br /># yrs smokedX pkg/d<br />this equals pack years<br />role in family<br />stressors<br />coping strategies<br />Functional Assessment<br />39<br />
  40. 40. PHYSICAL EXAM<br />be alert to any unusually rapid or slow breathing and to tachycardia, which may be a sign of hypoxia<br />remember normal respiratory rate is 16 - 20 breaths per minute<br />40<br />
  41. 41. Appearance<br />facial expression<br />posture<br />alertness<br />speech pattern<br />obvious distress<br />VS Ht. & Wt.<br />GENERAL SURVEY<br />41<br />
  42. 42. NOSE<br />patency of nares<br />nasal flaring(sign of air hunger)<br />swelling<br />discharge<br />bleeding<br />foreign bodies<br />mucosa should be bright red in color<br />deviation of nasal septum<br />HEAD AND NECK<br />42<br />
  43. 43. SINUSES<br />palpate sinuses for tenderness<br />LIPS <br />pursed-lip breathing, common technique for decreasing dyspnea for pts with chronic respdz<br />inspect lips, tip of nose, top of auricles, gums and under tongue for cyanosis, a bluish color R/t inadequate O2<br />PHARYNX<br />Redness, tonsil exudate or enlargement<br />HEAD AND NECK<br />43<br />
  44. 44. inspect for deviation, can be indicative for a large atelectasis, pleural effusion, aortic aneurysm, enlargement of part of the thyroid gland, and tension pneumothorax<br />TRACHEA<br />44<br />
  45. 45. THORAX<br />look for deformities and lesions<br />observe breathing pattern and effort, should be regular and symmetric<br />palpate for lumps and symmetry<br />palpate for tactile fremitus (What is this?)<br />A tremulous vibration of the chest wall during breathing that is palpable on physical examination. It may indicate inflammation, infection, or congestion.<br />auscultate lungs in systematic manner, usually posterior, sides, anterior<br />45<br />
  46. 46. THORAX<br />listen for normal movement of air and abnormal sounds<br />WHEEZE-high-pitched sound caused by air passing through narrowed passageways, as with asthma or COPD<br />46<br />
  47. 47. THORAX<br />RHONCHUS-dry rattling sound caused by partial bronchial obstruction<br />CRACKLES(RALES)-associated with many cardiac and pulmonary disorders, sounds like rubbing strands of hair between the thumb and forefinger next to the ear<br />47<br />
  48. 48. THORAX<br />COARSE CRACKLES- sounds like a velcro fastener being separated<br />PLEURAL FRICTION RUB-grating, scratchy noise similar to a creaking shoe<br />48<br />
  49. 49. ABDOMEN<br />inspect the abdomen for distention that might interfere with full expansion of the lungs<br />49<br />
  50. 50. EXTREMITIES<br />check color of extremities and edema<br />finger clubbing/chronic resp problems<br />50<br />
  51. 51. HOMAN’S SIGN<br />dorsiflex pts foot<br />suspect thromboplhlebitis if this elicits pain behind the knee or in the calf<br />important to know, the legs and the pelvis are the source of most pulmonary emboli<br />51<br />
  52. 52. NORMAL BREATHING PATTERNS<br />should have regular pattern<br />even depth<br />rate 12-20 breaths/min<br />this is the normal respiratory drive<br />52<br />
  53. 53. TACHYPNEA<br />should have regular pattern<br />even depth<br />rate is faster than 20 breaths/min<br />may be caused by fever, pain, anxiety, respiratory disorders, shock<br />53<br />
  54. 54. BRADYPNEA<br />should have regular pattern<br />even depth<br />rate is slower than 12 breaths/min<br />may be caused by sedatives, narcotics, alcohol; brain, metabolic, and respiratory disorders<br />54<br />
  55. 55. SIGHING RESPIRATIONS<br />should have regular pattern<br />uneven depth; periodic deep breaths (more than 3 sighs/min)<br />rate is 12 to 20 breaths/min<br />may be caused by severe anxiety<br />55<br />
  56. 56. CHEYNE-STOKES RESPIRATIONS; APNEA<br />breaths are progressively deeper, then becoming more shallow, followed by period of apnea<br />may be caused by severe brain pathology<br />56<br />
  57. 57. KUSSMAUL’S RESPIRATIONS (WITH HYPERVENTILATION)<br />should have a regular pattern<br />deep respirations<br />rate is faster than 20 breaths/min<br />may be caused by metabolic acidosis, diabetic ketoacidosis, renal failure<br />57<br />
  58. 58. BIOT’S RESPIRATIONS; APNEA<br />should have an irregular pattern<br />depth varies, sudden periods of apnea<br />may be caused by neurologic disorders<br />58<br />
  59. 59. obstructive breathing, rising end-expiratory level with forced expirations <br />gradual rise in end-expiratory level during forced rapid breathing<br />may be caused by emphysema<br />59<br />
  61. 61. used to provide information regarding the anatomical location and appearance of the lungs<br />Pre-procedure: remove all jewelry and other metal objects from the chest area, assess ability to inhale and hold breath, question females regarding pregnancy or the possibility of pregnancy<br />Post procedure: assist the client to dress <br />CHEST X-RAY STUDY<br />61<br />
  62. 62. a specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells<br />SPUTUM SPECIMEN<br />62<br />
  63. 63. determine specific purpose of collection and check with institutional policy for appropriate collection of specimen<br />obtain an early morning sterile specimen from suctioning or expectoration after a respiratory treatment, if prescribed<br />obtain 15 mL of sputum<br />SPUTUM-PREPROCEDURE<br />63<br />
  64. 64. instruct client to rinse mouth with water before collection; instruct client to take several deep breaths and then cough deeply to obtain sputum<br />ALWAYS collect specimen before starting antibiotics<br />SPUTUM-PREPROCEDURE<br />64<br />
  65. 65. if culture of sputum is prescribed, transport to laboratory immediately<br />assist the client with mouth care<br />SPUTUM-POSTPROCEDURE<br />65<br />
  66. 66. direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope<br />Used to visualize abnormalities, take biopsy samples or lesions, or remove foreign bodies.<br />BRONCHOSCOPY<br />66<br />
  67. 67. obtain informed consent<br />NPO from midnight before the procedure ( or 6-8 hours)<br />obtain vital signs<br />monitor coagulation studies<br />remove dentures or eyeglasses<br />prepare suction equipment<br />administer medication for sedation as prescribed<br />BRONCHOSCOPY pre-procedure<br />67<br />
  68. 68. have emergency resuscitation equipment readily available<br />BRONCHOSCOPYpre-procedure<br />68<br />
  69. 69. monitor vital signs<br />maintain semi-Fowler’s position<br />assess gag reflex<br />maintain NPO status until gag reflex returns<br />monitor for bloody sputum<br />monitor respiratory status <br />monitor for asymmetric chest movement<br />monitor for swelling of face and neck<br />monitor for dyspnea, diminished lung sounds<br />BRONCHOSCOPY post procedure<br />69<br />
  70. 70. monitor for complications such as brohnchospasm, bacteremia, bronchial perforation indicated by facial or neck crepitus, dysrhythmias, fever, hemorrhage, hypoxemia, and pneumothorax<br />notify physician if fever or difficulty in breathing occurs after the procedure<br />BRONCHOSCOPYpost-procedure<br />70<br />
  71. 71. an invasive fluoroscopic procedure after injection of iodine, radiopaque, or contrast material through a catheter inserted through the antecubital or femoral vein into the pulmonary artery or one of its branches<br />Pulmonary Angiography<br />71<br />
  72. 72. obtain informed consent<br />assess for allergies to iodine, seafood, and other radiopaque dyes<br />maintain NPO status for 8 hours before the procedure<br />monitor vital signs<br />monitor coagulation studies<br />establish an IV access<br />Pulmonary Angiography-preprocedure<br />72<br />
  73. 73. administer sedation as prescribed<br />instruct client to lie still during the procedure<br />instruct client that he or she may feel an urge to cough, or flushing, nausea, or salty taste after injection of the dye<br />have emergency resuscitaiton equipment available<br />Pulmonary Angiography-preprocedure<br />73<br />
  74. 74. monitor VS<br />avoid taking blood pressures in the extremity used for injection for 24 hours<br />monitor peripheral neurovascular status<br />assess insertion site for bleeding<br />monitor for delayed reaction to the dye<br />Pulmonary angiography-postprocedure<br />74<br />
  75. 75. Removal of fluid or air from the pleural space via a transthoracic aspiration<br />Pleural fluid is aspirated and examined for pathogens, other abnormal components. Cells studied for malignance<br />See figure 30-8 page 522<br />Thoracentesis<br />75<br />
  76. 76. obtain informed consent<br />obtain baseline vital signs<br />prepare client for ultrasound or chest x-ray study if prescribed before procedure<br />assess coagulation studies<br />note that client is positioned sitting upright with arms and head supported by a table at the bedside during the procedure<br />Thoracentesis-preprocedure<br />76<br />
  77. 77. if the client cannot sit up, the client is placed lying in bed on the unaffected side with the head of the bed elevated 45 degrees<br />inform client not to cough, breathe deeply, or move during the procedure<br />Thoracentesis-preprocedure<br />77<br />
  78. 78. Thoracentesis-postprocedure<br />monitor VS<br />monitor respiratory status<br />patient is positioned on the unaffected side after the procedure<br />apply a sterile, pressure dressing and assess puncture site<br />monitor for signs of pneumothorax, air embolism, and pulmonary edema<br />observe for uneven chest movements, respiratory distress and hemorrhage<br />Document amount and color of fluid removed<br />78<br />
  79. 79. included a number of different tests used to evaluate lung mechanics, gas exchange and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gases<br />examples: measures of: total lung capacity, forced respiratory volume, functional residual capacity, inspiratory capacity, vital capacity, forced vital capacity (see table 29-4 for definitions)<br />Pulmonary function test (PFT)<br />79<br />
  80. 80. used to diagnose pulmonary disease<br />monitor disease progression<br />evaluate the extent of disability<br />assess the effects of medication<br />PFT<br />80<br />
  81. 81. determine if an analgesic that may depress the respiratory function is being administered<br />consult with physician regarding holding bronchodilators before testing<br />instruct client to void before procedure and to wear loose clothing<br />PFT-preprocedure<br />81<br />
  82. 82. remove dentures<br />instruct client to refrain from smoking or eating a heavy meal for 4 to 6 hours before the test<br />PFT-preprocedure<br />82<br />
  83. 83. resume normal diet and any broncholilators and respiratory treatments that were held before the procedure<br />PFT-post procedure<br />83<br />
  84. 84. an instrument that measures the ventilatory function of the lungs<br />measures volume of air that the lungs can hold<br />the rate of flow of air in and out of the lungs<br />the compliance (elasticity) of lung tissue<br />involves inserting mouthpiece, taking as deep a breath as possible and blowing as hard, as fast, and as long as possible<br />See Table 30-2 for Lung Volumes and Capacities<br />Spirometry<br />84<br />
  85. 85. noninvasive measurement of arterial oxygen saturation<br />A beam of light passes through the tissue , and the amount of light absorbed by oxygen saturated hemoglobin is measured.<br />sensor clipped to earlobe or fingertip<br />factors that interfere with an accurate reading include: hypotension, hypothermia, vasoconstriction, and finger movement, also dark fingernail polish if it is placed on the nail<br />Pulse Oximetry<br />85<br />
  86. 86. visualizes the bronchial tree<br />radiographic procedure<br />pts throat and bronchi are anesthetized<br />Bronchogram<br />86<br />
  87. 87. dye is instilled into the bronchial tree through a catheter or a fiberoptic bronchoscope<br />pt is tilted in different positions for dye to spread in specific directions<br />complications include: pneumonia, delayed hypersensitivity reaction and laryngospasm<br />Bronchogram<br />87<br />
  88. 88. a percutaneous lung biopsy is performed to obtain tissue for analysis by culture or cytological examination<br />a needle biopsy is done to identify pulmonary lesions, changes in lung tissue, and the cause of pleural effusion<br />Lung Biopsy<br />88<br />
  89. 89. obtain informed consent<br />maintain NPO status before the procedure<br />inform the client that a local anesthetic will be used by that a sensation of pressure during needle insertion and aspiration may be felt<br />administer analgesics and sedatives as prescribed<br />Lung Biopsy-preprocedure<br />89<br />
  90. 90. monitor vital signs<br />apply a dressing to the biopsy site and monitor for drainage or bleeding<br />monitor for signs of respiratory distress and notify the physician if they occur<br />monitor for signs of pneumothorax and air emboli and notify physician if they occur<br />prepare client for chest x-ray study if prescribed<br />Lung Biopsy-postprocedure<br />90<br />
  91. 91. Demonstrated lung ventilation and perfusion.<br />the ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation<br />Detects pulmonary embolism and other obstructive conditions<br />a radioactive substance may be inhaled or injected for the procedure<br />Ventilation-perfusion lung scan<br />91<br />
  92. 92. 92<br />
  93. 93. obtain informed consent<br />assess for allergies to dye, iodine, or seafood<br />remove jewelry around the chest area<br />review breathing methods that may be required during testing<br />establish an IV access<br />Ventilation-perfusion lung scan-preprocedure<br />93<br />
  94. 94. Administer sedation if prescribed<br />Usually NPO for 4 hours<br />May take 2 hours<br />Have emergency resuscitation equipment available<br />Ventilation-perfusion lung scan-preprocedure<br />94<br />
  95. 95. monitor client for reaction to the radionuclide for 1 hour for anaphylaxis<br />for 24 hours after the procedure, rubber gloves are worn when urine is being discarded; they should be washed with soap and water before removing, and then the hands should be washed after the gloves are removed( radioactive material is excreted in the urine)<br />Ventilation-perfusion lung scan-postprocedure<br />95<br />
  96. 96. Instruct the client to wash hands carefully with soap and water for 24 hours after the procedure when voiding (lets hope they already do this)<br />Ventilation-perfusion lung scan-postprocedure<br />96<br />
  97. 97. allows visualization of slices or layers of the chest<br />a camera rotates in a circular pattern around the body for a three dimensional assessment of the thorax<br />usually used to look for the presence of lesions or tumors<br />radioactive dye containing iodine may be injected IV<br />COMPUTED TOMOGRAPHY (CT)<br />97<br />
  98. 98. explain the test to the patient<br />they lie on a platform while a special doughnut-shaped radiographic scanner rotates around them<br />stress the importance of remaining still during the scanning<br />assess iodine allergy, if contrast is used, if there is, report it to the radiologist<br />NPO may be required<br />CT preparation<br />98<br />
  99. 99. note side effects of contrast: nausea, vomiting, headache<br />CT postprocedure<br />99<br />
  100. 100. similar to CT but without harmful radiation<br />doughnut-shaped magnet used<br />pt lies on a stretcher that slides into a tubelike device<br />mechanical clanging noises are heard as machine operates<br />MRI<br />100<br />
  101. 101. metal implants such as cardiac pacemakers and orthopedic implants may be affected by MRI, but are not absolute contraindications<br />aneurysm clips, intraocular metal, heart valves made before 1964, and middle ear prostheses generally contraindicate MRI<br />MRI<br />101<br />
  102. 102. explain test to patient<br />get consent form signed<br />assess for claustrophobia<br />anxious pt may require sedation<br />have pt remove metal watch and jewelry<br />MRI preparation<br />102<br />
  103. 103. safety precautions if sedated; otherwise, no special after care is needed<br />MRI postprocedure<br />103<br />
  104. 104. Determine past or present exposure to tuberculosis<br />A patient who has ever been vaccinated with BCG will test positive regardless of actual exposure<br />Bacille Calmette-Guérin (BCG) is a vaccine against tuberculosis that is prepared from a strain of the attenuated (weakened) live bovine tuberculosis bacillus, Mycobacterium bovis, that has lost its virulence in humans by being specially cultured in an artificial medium for years. <br />Tuberculin skin tests<br />104<br />
  105. 105. purified protein derivative or old tuberculin is introduced into the skin using a device with four tines<br />the device is firmly pressed on the anterior forearm for 1 sec.<br />This site is marked, recorded, and inspected in 48 to 72 hours for redness and swelling<br />a reaction equal to or greater than 2 mm at one or more puncture sites is positive<br />Multipuncture (tine) test (PPD)<br />105<br />
  106. 106. cleanse puncture site<br />tell pt. The procedure causes pain briefly<br />stress need to return in 48-72 hr to evaluate response<br />pt should not scratch site<br />tell pt skin reaction may persist for a week<br />PPD preparation<br />106<br />
  107. 107. if PPD is positive this test is done<br />old tuberculin is injected intradermally in the lower anterior forearm<br />this site is marked, recorded and inspected after 48-72 hr for swelling and redness<br />a reaction of 5 mm or more is positive for tuberculosis exposure<br />Mantoux test<br />107<br />
  108. 108. tell pt to expect some pain with injection<br />return in 48-72 hours for evaluation of response<br />swelling may persist up to a week<br />Mantoux preparation<br />108<br />
  109. 109. May be performed when respiratory disease is suspected<br />May contain bacterial or malignant cells<br />Also examined for volume, consistency, color, and odor<br />Thick foul smelling, and yellow, green, or rust colored sputum usually indicates a bacterial infection<br />Sputum analysis<br />109<br />
  110. 110. Ordered to determine the presence of bacteria, identify the specific organisms and identify appropriate antimicrobials<br />Collect specimen before antimicrobial therapy is begun<br />Culture and sensitivity<br />110<br />
  111. 111. Performed to determine the presence of acid-fast bacilli<br />Including the bacteria that causes tuberculosis<br />Usually collected on 3 consecutive days<br />Cover and refrigerate or deliver to lab within 1 hour<br />Use sterile container<br />Acid-fast test<br />111<br />
  112. 112. ABG’s<br />measures pH, PaCO2, PaO2, HCO3 and O2 saturation<br />detects alkalosis or acidosis, and alterations in oxygenation status that may occur with many respiratory, cardiac, and metabolic disorders<br />112<br />
  113. 113. ABG’s Normal Values for adults<br />PH: 7.35 - 7.45<br />PaCO2: 35 - 45 mm Hg<br />PaO2: 75 - 100 mm Hg<br />HCO3: 22 - 26 mEq/L<br />O2 saturation: 96 - 100%<br />113<br />
  114. 114. ABG Preparation<br />tell the patient a blood sample will be drawn from an artery (usually radial)<br />an Allen’s test should be done before an arterial puncture to ensure that the arteries to the hand are patent (page 465)<br />The patients hand is formed into a fist while the technician compresses the ulnar artery. Compression of the ulnar artery is continued while the fist is opened. If blood perfusion through the radial artery is adequate, the hand should flush and resume a normal pinkish coloration.<br />114<br />
  115. 115. 115<br />
  116. 116. ABG postprocedure<br />apply pressure to the puncture site for 5-10 minutes<br />note the concentration of any oxygen therapy on lab slip<br />transport the blood gas syringe to the lab in an ice bath within 15 minutes<br />respiratory therapist will usually take sample and analyze it<br />Go to slide 140- (just had ABG’s)<br />116<br />
  117. 117. hydrogen ions (H+) <br />are vital to life<br />expressed as pH<br />body’s pH is normally alkaline between 7.35 and 7.45)<br />117<br />
  118. 118. ACIDS: <br />Produced as end products of metabolism<br />contain hydrogen ions<br />the number of hydrogen ions in body fluid determines its acidity, alkalinity, or if it is neutral<br />118<br />
  119. 119. BASES<br />contain no H+<br />hydrogen ion acceptors<br />accept H+ from acids to neutralize or decrease the strength of a base or to form a weaker acid<br />119<br />
  120. 120. Regulating H+ concentration in the blood<br />BUFFERS: hemoglobin, plasma proteins, carbonic acid/bicarbonate system, phosphate buffer system<br />LUNGS<br />KIDNEYS<br />POTASSIUM<br />120<br />
  121. 121. Lungs regulating system<br />interacts with the buffer system to maintain acid base balance<br />in acidosis: pH goes down and the respiratory rate and depth go up in an attempt to “blow off” acids<br />the carbonic acid created by the neutralizing action of bicarbonate can be carried to the lungs where it is reduced to C)2 and water and exhaled, thus H+ are inactivated and excreted<br />121<br />
  122. 122. Lungs regulating system<br />in alkalosis, the pH goes up and the respiratory rate and depth go down, the CO2 is retained, and the carbonic acid builds to neutralize and decrease the strength of excess bicarbonate<br />the action of the lungs is reversible in controlling an excess or deficit<br />122<br />
  123. 123. Lungs regulating system<br />the lungs can hold H+ until the deficit is corrected or can inactivate H+, changing them to water molecules to be exhaled as CO2, thus correcting the excess<br />the lungs are capable of inactivating only H+ carried by carbonic acid (H2CO3); excess H+ created by other problems must be excreted by the kidneys<br />123<br />
  124. 124. Respiratory Acidosis<br />the total concentration of buffer base is lower than normal, with a relative increasing hydrogen ion (H+) concentration; thus a greater number of H+ are circulating in the blood than can be absorbed by the buffer system<br />124<br />
  125. 125. due to primary defects in the function of the lungs or by changes in normal respiratory patterns from secondary problems<br />remember that any condition that causes an obstruction of the airway or depresses respiratory status can cause respiratory acidosis<br />hypoventilation<br />COPD, CAL, COLD<br />CAUSES OF RESPIRATORY ACIDOSIS<br />125<br />
  126. 126. pulmonary edema<br />pneumonia<br />atelectasis<br />asthma<br />bronchitis or bronchiectasis<br />infection<br />medications such as sedatives, narcotics, or anesthetics<br />CAUSES OF RESPIRATORY ACIDOSIS<br />126<br />
  127. 127. brain trauma<br />CAUSES OF RESPIRATORY ACIDOSIS<br />127<br />
  128. 128. in an attempt to compensate, the respiratory rate and depth increase<br />pH less than 7.35 and PCO2 greater than 45 mm Hg<br />mental status changes such as confusion<br />drowsiness<br />restlessness<br />weakness<br />DATA COLLECTION<br />128<br />
  129. 129. dizziness<br />dyspnea<br />hyperkalemia<br />DATA COLLECTION<br />129<br />
  130. 130. maintain patent airway<br />monitor for signs of respiratory distress<br />administer oxygen as prescribed<br />place client in semi-Fowler’s position unless contraindicated<br />encourage and assist the client to turn, cough, and deep breathe<br />prepare to administer chest physiotherapy and postural drainage as prescribed<br />IMPLEMENTATION<br />130<br />
  131. 131. encourage hydration to thin secretions unless excess fluid intake is contraindicated<br />suction the client as necessary<br />monitor electrolyte values<br />avoid the use of tranquilizers, narcotics, and hypnotics because they further depress respirations<br />administer antibiotics for infection as prescribed<br />IMPLEMENTAION<br />131<br />
  132. 132. a deficit of carbonic acid (H2CO3) or a decrease in H+ concentration<br />results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids<br />Respiratory alkalosis<br />132<br />
  133. 133. due to conditions that cause overstimulation of the respiratory status<br />hyperventilation<br />hypoxemia<br />fever<br />early stages of salicylate poisoning<br />reactions to certain medications<br />pain<br />Causes of respiratory alkalosis<br />133<br />
  134. 134. anxiety<br />hysteria<br />Causes of respiratory alkalosis<br />134<br />
  135. 135. initially, the hyperventilation and respiratory stimulation will cause abnormal rapid and deep respirations (tachypnea)<br />in an attempt to compensate, respiratory rate and depth then go down<br />pH is greater than 7.45 and PCO2 is less than 35 mm Hg<br />altered mental status<br />pallor around the mouth<br />DATA COLLECTION<br />135<br />
  136. 136. tingling of the fingers<br />dizziness<br />spasms of the muscles of the hands<br />hypokalemia<br />DATA COLLECTION<br />136<br />
  137. 137. maintain a patent airway<br />provide emotional support and reassurance to the client<br />encourage appropriate breathing patterns<br />IMPLEMENTATION<br />137<br />
  138. 138. provide cautious care with ventilator clients so that the client is not forced to take breaths too deeply or rapidly<br />monitor electrolyte values<br />administer sedatives as prescribed<br />IMPLEMENTATION<br />138<br />
  139. 139. Thoracentesis<br />breathing exercises<br />chest physiotherapy<br />suctioning<br />humidification & aerosol<br />oxygen<br />IPPB<br />artificial airways<br />mechanical ventilation<br />chest tubes<br />thoracic surgery<br />video thoracoscopy<br />drug therapy<br />THERAPUTIC MEASURES<br />139<br />
  140. 140. performed to aid in lung expansion and expectoration of respiratory secretions<br />indicated when pts are immobilized or after general anesthesia<br />Breathing Exercises<br />140<br />
  141. 141. sit in a semi-Fowler’s position for maximal lung expansion<br />place on hand on the abdomen to feel it rise and fall with breathing<br />inhale deeply through the nose, pause 1 to 3 seconds, and exhale slowly through the mouth<br />Deep Breathing and Coughing<br />141<br />
  142. 142. after 4 to 6 deep breaths, cough deeply from the lungs to aid in the expectoration of sputum<br />after thoracic or abdominal surgery, splint the incision with a pillow to minimize discomfort and support the incision<br />Deep Breathing and Coughing<br />142<br />
  143. 143. used to inhibit airway collapse and to decrease dyspnea in pts with chronic lung disease<br />instruct pt to pucker lips as if to whistle, blow out a candle, or blow through a straw<br />then they should inhale through the nose and slowly exhale through pursed lips<br />exhalation should last twice as long as inhalation<br />Pursed-Lip Breathing<br />143<br />
  144. 144. chest percussion and vibration<br />postural drainage<br />Chest physiotherapy<br />144<br />
  145. 145. goal is to improve oxygen and carbon dioxide exchange in the lungs by removing excessive mucous secretions with a suction catheter<br />Suctioning<br />145<br />
  146. 146. use strict aseptic technique<br />administer oxygen before inserting the suction catheter because the procedure temporarily interferes with the patient’s air flow<br />moisten the catheter in sterile water and insert the catheter through the nose or mouth before applying suction<br />Suctioning Key Points<br />146<br />
  147. 147. apply suction intermittently as the catheter is rotated and withdrawn from the airway<br />maintain the pressure gauge between 80 and 100 mm Hg<br />limit each suction pass to 10 seconds (try holding your breath while you do this)<br />allow the patient to rest briefly, encourage deep breathing, and rinse the catheter with sterile solution between suction attempts<br />Suctioning Key Points<br />147<br />
  148. 148. monitor the patients response to suctioning<br />if tachycardia or increased respiratory distress develops, stop the procedure and give the patient oxygen as ordered<br />document the amount, color, odor, and consistency of the patient’s secretions as well as the patient’s status before and after the procedure<br />Suctioning Key Points<br />148<br />
  149. 149. creates water vapor to raise the relative humidity of inspired gas to 100%<br />there are room humidifiers and medical oxygen is humidified as it bubbles through a container of water<br />sterile water should be used to prevent the spread of bacteria<br />Humidifiers<br />149<br />
  150. 150. suspended liquid particles of bronchodilators or inactive fluids such as water or saline<br />delivered by devices called nebulizers (pts call them puffers sometimes)<br />can be hand held<br />may be connected to an oxygen mask<br />pt should sit upright and slowly inhale, hold the breath briefly and exhale slowly<br />Aerosol therapy<br />150<br />
  151. 151. Air in the atmosphere contains approximately 21% oxygen, which is usually sufficient<br />Individuals with pulmonary disease or injury may need supplemental oxygen<br />Oxygen is considered a drug and should be treated as such, you need an order and there may be serious side effects as well as benefits<br />Oxygen therapy<br />151<br />
  152. 152. If you observe a patient becoming lethargic or bradypneic, immediately notify a supervisor or physician, these are symptoms of adverse effects of oxygen therapy<br />Oxygen is delivered from a bulk system, mounded on the wall of a patient’s room or it can be delivered from a cylinder unit on wheels<br />Oxygen therapy<br />152<br />
  153. 153. A tube is needed to connect the flowmeter to the specific oxygen delivery device<br />This tube is then attached to the patient via nasal cannula or mask<br />Oxygen therapy is ordered in liters per minute or FIO2<br />FIO2 mean fraction of inspired oxygen<br />It is written as 0.30, which means 30% oxygen concentration<br />Oxygen therapy<br />153<br />
  154. 154. The most common used delivery device is the nasal cannula<br />It fits around the face and directly into the nares by way of two prongs<br />It is designed to deliver a flow of oxygen from 1 to 6 L/min with approximate FIO2 of 0.24 to 0.44 or 24 to 44% oxygen concentration delivered<br />Oxygen therapy<br />154<br />
  155. 155. 24% @ 1 L/min<br />28% @ 2 L/min<br />32%@ 3 L/min<br />36% @ 4 L/min<br />40% @ 5 L/min<br />44% @ 6 L/min<br />Anything over 6 L/min will not increase the % of O2 delivered, using nasal cannulas<br />Nasal Cannula (nasal prongs)<br />155<br />
  156. 156. If you notice, anytime you add a liter, you have a 4% increase in the O2 delivered, you can remember 1L will give you 24% then add 4% every time you go up a liter<br />Nasal Cannula (nasal prongs)<br />156<br />
  157. 157. Used for client with chronic airflow limitation (CAL, COPD) and for long-term oxygen use<br />The CAL or COPD pt who retains CO2 should never receive O2 at a rate higher than 2 to 3 liters/min<br />The potential for apnea or respiratory distress occurs<br />Nasal Cannula (nasal prongs)<br />157<br />
  158. 158. Place the nasal prongs in the nostrils with the openings facing the patient<br />Add humidification as prescribed when a flow rate higher than 2 liters /min is prescribed<br />Check the water level and change the humidifier as needed<br />Monitor the client for changes in respiratory rate or depth<br />Implementation<br />158<br />
  159. 159. Assess mucosa as high flow rates have a drying effect and increase mucosal irritation<br />Monitor skin integrity as the oxygen tubing can irritate the skin<br />Provide water-soluble jelly to the nares PRN<br />Do not use any petroleum based lubricant<br />Implementation<br />159<br />
  160. 160. There are 4 types of available<br />Simple oxygen mask<br />Partial rebreathing mask<br />Nonrebreathing mask<br />Air entrainment (Venturi) mask<br />Masks<br />160<br />
  161. 161. Designed to deliver an FIO2 ranging from 0.35 to 0.55 <br />Which is 35% to 55% <br />It must be 6 L/min at least<br />If not 6L/min, CO2 may build up in the mask, which would be very dangerous for your patient<br />Seen on page 525<br />Simple mask<br />161<br />
  162. 162. Flow rate must be set to at least 6 L/min<br />45%-50% @ 6 L/min<br />55%-60% at 8 L/min<br />Simple mask<br />162<br />
  163. 163. Includes a reservoir bag to elevate the potential FIO2<br />Pt rebreathes part of their own exhaled gas<br />Design of the mask allows almost no rebreathed gas to contain CO2 from pts lungs, only enriched oxygen<br />Expected FIO2 range 0.35-0.60 (35 to 60%)<br />Flow setting must be at least 6<br />Partial rebreathing mask<br />163<br />
  164. 164. None of the pts exhaled gas is rebreathed<br />Includes a reservoir bag<br />Series of valves to direct fresh supply of gas with each breath<br />Expected FIO2 should be 1.0(100%)<br />Controversy stating only 0.7 (70%)(because experimentally the highest F1O2 is approximately 0.7%)<br />Also must be 6-10 on flow meter<br />Used most often in client who may need to be placed on a ventilator<br />Nonrebreathing mask<br />164<br />
  165. 165. Provides a specific FIO2<br />Usually must place an attachment to the mask<br />% of oxygen delivered is determined by the color of the attachment, must read the manufacture’s instructions<br />Example: Pink=50%, Blue=60% etc.<br />This mask delivers the highest concentration of O2 when compared with the other masks<br />Air entrainment mask (Venturi)<br />165<br />
  166. 166. Be sure mask fits securely over nose and mouth, as a poorly fitting mask reduces the FIO2 delivered<br />Monitor the skin and provide skin care to the area covered by the mask because pressure and moisture under the bag may cause skin breakdown<br />Monitor the client closely for risk of aspiration because the mask limits the client’s ability to clear the mouth, especially if vomiting occurs<br />Implementation<br />166<br />
  167. 167. Provide emotional support to decrease anxiety to the client who feels claustrophobic<br />Consult with physician regarding switching the client from a mask to a nasal cannula during eating<br />With a reservoir bag, make sure it does not twist or kink, which results in a deflated bag<br />Implementation<br />167<br />
  168. 168. Fits over the client’s chin, with the top extending halfway across the face<br />O2 content varies<br />Useful instead of a tight-fitting mask for the client who has facial trauma and burns<br />Face tent<br />168<br />
  169. 169. Can be used to deliver high humidity and the desired oxygen to the client with a tracheostomy<br />Special adapter called the T piece can be used to deliver any desired FIO2 to the client with a tracheostomy, laryngecotmy, or endotracheal tube<br />Oxygen delivered 24% to 100% with flow rates at least 10L/min<br />Tracheostomy collar and T piece<br />169<br />
  170. 170. Change delivery system to a nasal cannula during mealtimes<br />Ensure that aerosol mist escapes from the vents of the delivery system during inspiration and expiration<br />Empty condensation from the tubing to prevent the client from being lavaged with water and to promote an adequate flow rate<br />Ensure that there is sufficient water in canister and change the aerosol water container as needed<br />Keep the exhalation port on T-piece open and uncovered(if occluded, the client can suffocate)<br />Implementation<br />170<br />
  171. 171. Monitor the liter flow to be sure it is as prescribed<br />Assess the patient’s response to therapy; monitor reports of blood gas analyses<br />Inspect the tubing for kinks, obstructions, loose connections, listen for hissing sound in O2 mask: feel for adequate O2 flow<br />Maintain sterile water in the humidifier reservoir<br />Key points with oxygen therapy<br />171<br />
  172. 172. Clean and replace oxygen therapy equipment according to agency policy<br />Post a no smoking sign and advise the patient and visitors that smoking is not allowed because oxygen supports combustion<br />Key points with oxygen therapy<br />172<br />
  173. 173. Assess color and vital signs before and during treatment<br />Place an “oxygen in use” sign at client’s bedside<br />Assess for presence of chronic lung problems<br />Humidify the oxygen<br />Implementation<br />173<br />
  174. 174. Intermittent Positive Pressure Breathing Treatments<br />Used to achieve maximal lung expansion<br />The IPPB equipment delivers humidified gas with positive pressure, which forces air into the lungs with inhalation and allows passive exhalation.<br />Facilitates maximal exchange of oxygen and carbon dioxide gases in the alveoli and promotes a productive cough.<br />Mucolytics and bronchodilators common<br />IPPB<br />174<br />
  175. 175. Oral airway<br />Nasal airway<br />Endotracheal tube<br />Tracheostomy<br />Artificial Airways<br />175<br />
  176. 176. Orotracheal<br />Nasotracheal<br />Endotracheal tubes<br />176<br />
  177. 177. Used to maintain a patent airway<br />Indicated when the client needs mechanical ventilation<br />If client requires artificial airway for longer than 10 to 14 days, a tracheostomy may be created to avoid mucosal and vocal cord damage than can be caused by the endotracheal tube<br />The cuff located at the distal end of the tube, when inflated, produces a seal between the trachea and the cuff to prevent aspiration and ensure delivery of a set tidal volume when mechanical ventilation is used, an inflated cuff also prevents air from passing to the vocal cords, nose or mouth<br />Endotracheal tubes<br />177<br />
  178. 178. Allows use of a larger diameter tube and reduces the work of breathing<br />Indicated when the client has a nasal obstruction or a predisposition to epistaxis<br />Uncomfortable and can be manipulated by the tongue causing airway obstruction; an oral airway may be needed to keep the client from biting on the tube<br />Orotracheal<br />178<br />
  179. 179. Smaller-sized tube increased resistance and increases client’s work of breathing<br />Discouraged in clients with bleeding disorders<br />More comfortable for the client, and the client is unable to manipulate with tongue<br />Nasotracheal<br />179<br />
  180. 180. Placement is confirmed by chest x-ray study (correct placement is 1 to 2 cm above carina)<br />Placement is assessed by auscultating both sides of chest while manually ventilating with resuscitation bag<br />If breath sounds and chest wall movement are absent on the left side, the tube may be in the right mainstem bronchus<br />Implementaion<br />180<br />
  181. 181. Auscultation over the stomach is performed to rule out esophageal intubation<br />If the tube is in the stomach, louder breath sounds will be heard over the stomach than over the chest, and abdominal distention will be present<br />Secure the tube immediately after intubation with adhesive tape<br />Implementaion<br />181<br />
  182. 182. Monitor position of tube at lip or nose<br />Monitor skin and mucous membranes<br />Suction only when needed (Why)<br />Implementaion<br />182<br />
  183. 183. The oral tube needs to be moved to the opposite side of the mouth daily to prevent pressure and necrosis of the lip and mouth area, prevent nerve damage, and facilitate inspection and cleaning of the mouth; moving the tube to the opposite side of the mouth should be done by two health care providers<br />Implementaion<br />183<br />
  184. 184. Prevent pulling or tugging on the tube to prevent dislodgement; suction, coughing and speaking attempts by the client place extra stress on the tube and can cause dislodgement<br />Keep a resuscitation (Ambu) bag at bedside at all times<br />Assess pilot balloon to ensure cuff is inflated<br />Implementaion<br />184<br />
  185. 185. Hyperoxygenate the client and suction the endotracheal tube and the oral cavity<br />Place client in semi-Flower’s position<br />The cuff is deflated and the tube is removed at peak inspiration<br />Instruct the client to cough and deep breathe to assist in removing accumulated secretions in the throat<br />Extubation<br />185<br />
  186. 186. apply oxygen therapy as prescribed<br />Monitor respiratory status for signs of obstruction and notify physician if they occur<br />Inform client that hoarseness or a sore throat is normal and to limit talking if it occurs<br />Extubation<br />186<br />
  187. 187. A tracheotomy is a surgical incision made into the trachea to establish an airway<br />A tracheostomy is the stoma or opening that results from the tracheotomy<br />The tracheostomy can be temporary or permanent<br />Tracheostomy<br />187<br />
  188. 188. Monitor respirations<br />Monitor ABGs and pulse oximetry<br />Encourage coughing and deep breathing<br />Maintain a semi-to high-Fowler’s postion<br />Implementation<br />188<br />
  189. 189. Monitor for bleeding, difficulty breathing, absence of breath sounds, and crepitus, which are indications of hemorrhage, pneumothorax, and subcutaneous emphsema<br />Implementation<br />189<br />
  190. 190. provide respiratory treatments as prescribed<br />Suction as needed: hyperoxygenate the client before suctioning<br />If client is allowed to eat, sit the client up for meals and ensure that the cuff is inflated(if the tube is not capped) for meals, and for 1 hour after meals<br />Implementation<br />190<br />
  191. 191. Assess the stoma and secretions for blood or purulent drainage<br />Follow physician’s orders and agency policy for cleaning the tracheostomy site and inner cannula; usually half-strength hydrogen peroxide is used<br />Administer humidified oxygen as prescribed as the normal humidificaiton process is bypassed in a client with a tracheostomy<br />Implementation<br />191<br />
  192. 192. Obtain assistance in changing tracheostomy ties: cut and remove old ties holding the tracheostomy in place<br />Keep a resuscitation (Ambu) bag, obturator, and a tracheotomy set at the bedside<br />Implementation<br />192<br />
  193. 193. Tube obstruction<br />Tube dislodgement<br />Pneumothorax<br />Subcutaneous emphysema<br />Bleeding<br />Infection<br />Tracheal stenosis<br />Tracheoesophageal fistula<br />Trachea-innominate artery fistula<br />Complications of a Tracheostomy<br />193<br />
  194. 194. Used to overcome the client’s inability to ventilate or oxygenate adequately<br />It may be intermittent or continuous, short or long term<br />Mechanical Ventilation<br />194<br />
  195. 195. Depending on the patients needs, ventilators may be programmed to control or assist the rate of ventilation.<br />Ventilators deliver oxygen ranging in concentration from 21% oxygen to 100% oxygen. (Oxygen concentration = FI02)<br />Tidal volume is the present amount of oxygenated air delivered during each ventilator breath (usually 10 – 15ml/kg)<br />Respiratory rate setting is the total number of breaths delivered per minute.<br />Positive end expiratory pressure may be prescribed to keep the pressure in the lungs above the atmospheric pressure at he end of expiration.<br />This reduces collapse of small airways and alveoli, increasing the functional residual capacity and improving ventilation.<br />Mechanical Ventilation<br />195<br />
  196. 196. Assess the client first and the ventilator second<br />Assess vital signs, respiratory status, and breathing patterns<br />Monitor color, particularly in the lips and nail beds<br />Monitor the chest for bilateral expansion<br />Obtain a pulse oximetry reading<br />Implementation<br />196<br />
  197. 197. Assess the need for suctioning and observe type, color, and amount of secretions<br />Ensure that the alarms are set<br />If a cause of an alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is corrected<br />Implementation<br />197<br />
  198. 198. Empty ventilator tubings when moisture collects<br />Turn client at least every 2 hours or get client out of bed as prescribed to prevent complications of immobility<br />Have resuscitation equipment available at the bedside<br />Establish an alternate method of communication because the patient cannot speak while intubated<br />Implementation<br />198<br />
  199. 199. Increased secretions in the airway<br />Wheezing or bronchospasm causing decreased airway size<br />Displacement of the endotracheal tube<br />Obstructed endotracheal tube because of water or a kink in the tubing<br />Client coughs, gags, or bites on the tube<br />Client is anxious or fights the ventilator<br />Causes of high pressure alarms<br />199<br />
  200. 200. Disconnection or leak in the ventilator or in the client’s airway cuff<br />The client stops spontaneous breathing<br />Causes of low pressure alarms<br />200<br />
  201. 201. Hypotension caused by the application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart<br />Respiratory complications such as pneumothorax or subcutaneous emphysema as a result of positive pressure<br />Complications of ventilation therapy<br />201<br />
  202. 202. Gastrointestinal alterations as stress ulcers<br />Malnutrition<br />Infections<br />Muscular deconditioning<br />Ventilator dependence or inability to wean<br />Complications of ventilation therapy<br />202<br />
  203. 203. The process of going from ventilator dependence to spontaneous breathing<br />Weaning<br />203<br />
  204. 204. Continuous positive airway pressure<br />Maintains positive pressure in the airway during sleep<br />Avoids apnea<br />Small and have a nose mask that is worn during sleeping<br />CPAP<br />204<br />
  205. 205. Inserted to drain air or fluid from the “PLEURAL SPACE” of the lungs<br />Permits re-expansion of a collapsed lung<br />Used in pts with hemothorax, pneumothorax or pleural effusion<br />Inserted under sterile conditions by physician<br />Page 523<br />Chest Tubes ( watched video)<br />205<br />
  206. 206. Performed in OR or at bedside/ED<br />Small incision made to insert tube<br />Fourth intercostal space to remove air (pneumothorax)<br />Eigth or ninth intercostal space to remove fluids (hemothorax)<br />Tubes are sutured in place at insertion and an air tight, sterile dressing is applied<br />Chest Tubes<br />206<br />
  207. 207. The other end of the plastic chest tube (distal end) is connected to a rubber tubing that leads to a pleural drainage device<br />This device has three chambers:<br />The collection chamber<br />The water seal chamber<br />The suction chamber<br />Chest Tubes<br />207<br />
  208. 208. Chest fluid and air drain into the collection chamber<br />Air is diverted to the water seal chamber<br />When the drainage chamber is full, it can be changed without changing out the whole device<br />The collection chamber just twists out and a new one is twisted in<br />Collection chamber<br />208<br />
  209. 209. Air is diverted here<br />It can be seen bubbling up through the water<br />It should not be a constant bubbling, more like an intermittent bubbling<br />If it is constant there may be an air leak<br />Waterseal chamber<br />209<br />
  210. 210. Agency policy may permit the chest tubing to be clamped for 10 seconds while the leak is found<br />Check your connections and your dressing at the site of insertion<br />You should have hemostats in the room for just this purpose<br />Waterseal chamber<br />210<br />
  211. 211. Suction pressure is controlled here<br />Gentle bubbling is expected in the suction chamber<br />Inside the chamber is a tube that is partially submerged in water<br />The depth of the tube in the water regulates the amount of suction<br />Suction Control Chamber<br />211<br />
  212. 212. This tube is hollow and will have a water in it<br />There will be a rise and fall of water in this tube during inspiration and expiration (tidaling)<br />During chest tube insertion, the water is added to the control chamber and how much is instilled is determined by the physician depending on the amount of suctioning required<br />Suction Control Chamber<br />212<br />
  213. 213. A chest radiograph is obtained to confirm placement of the tube<br />Chest Tubes<br />213<br />
  214. 214. Monitor VS and breath sounds frequently<br />Assess dressing to be sure a tight seal is maintained<br />Tape tubing connections and inspect frequently to detect air leaks<br />Coil extra tubing on the bed to avoid kinks<br />Implementation<br />214<br />
  215. 215. Keep drainage system on the floor<br />Monitor drainage for blood clots or lung tissue which could clog the tube<br />Implementation<br />215<br />
  216. 216. Observe the water seal chamber for bubbling, it is usually seen unless the lung has reexpanded or the tubing is occluded <br />After checking for kinks or occlusion of the tubing, notify the charge nurse or physician of reexpansion<br />Always chart the bubbling and if there is no bubbling, checking for occlusion and finding none and then notifying the physician or CN<br />Implementation<br />216<br />
  217. 217. Drainage is monitored by marking the drainage level on the drainage receptacle, do this on your first assessment of the patient and chart it!<br />You will then have the correct amount of drainage that occurred by the end of your shift, which you will chart as output<br />Implementation<br />217<br />
  218. 218. An alternate to the large chest drainage system<br />The valve is a disposable unit that is attached to the chest tube and to a sterile drainage receptacle<br />air and fluid can flow in but cannot flow backward into the chest<br />This is good for the client who can ambulate<br />Heimlich Flutter Valve<br />218<br />
  219. 219. Thoracotomy<br />The surgical opening of the chest wall<br />Reasons for thoracic surgery<br />To evaluate chest trauma<br />Removal of tumors and cysts<br />Thoracic Surgery<br />219<br />
  220. 220. Pneumonectomy<br />Lobectomy<br />Segmental resection<br />Wedge resection<br />Surgical procedures on the Lungs<br />220<br />
  221. 221. The removal of an entire lung<br />Pneumonectomy<br />221<br />
  222. 222. The removal of one lobe of a lung<br />Lobectomy<br />222<br />
  223. 223. The extensive dissection and removal of a section of the lung<br />Segmental resection<br />223<br />
  224. 224. The removal of a small, triangular section of lung tissue<br />Wedge resection<br />224<br />
  225. 225. Stripping of the membrane that covers the visceral pleura<br />Decortication<br />225<br />
  226. 226. The removal of ribs<br />Thoracoplasty<br />226<br />
  227. 227. Everything that goes along with any type of surgery<br />What you want to stress are breathing exercises and explanation of a chest tube if one may be required<br />Preoperative nursing care<br />227<br />
  228. 228. Everything that goes with any type of surgery <br />What you want to stress<br />Vital signs<br />Lung sounds<br />Mental state<br />Dressings<br />Chest tube function and drainage<br />Postoperative nursing care<br />228<br />
  229. 229. Drug Therapy <br />View table on page 532 - 533<br />
  230. 230. Decongestants<br />Decongestants are adrenergic agents<br />
  231. 231. Mimic the action of epinephrine and norephinephrine<br />Cause constriction of nasal blood vessels and reduce the swelling of mucous membranes<br />Sudafed (common over the counter)<br />With systemic vasoconstriction they may elevate the blood pressure<br />Systemic effects are less severe with topical drops and sprays<br />People with hypertension, heart disease, and hyperthyroidism should not take over the counter cold remedies without talking to the Dr or pharmacist. <br />231<br />Decongestants<br />
  232. 232. Antitusives<br />Antitussives suppress the cough reflex<br />
  233. 233. Antitussives<br />When a cough is nonproductive, creates pain and interferers with sleep or wound healing cough suppression may be indicated<br />Codeine is effective (but is an opioid with many side effect)<br />Dextromethorphan is commonly used<br />Be careful suppressing the cough because it is a protective mechanism.<br />233<br />
  234. 234. Antihistamines<br />Antihistamines are also called histamine 1 blockers <br />
  235. 235. They block the effects of histamine(one of the chemicals that causes allergic symptoms)<br />Prescription and over the counter<br />Dry nasal secretions<br />Benadryl - common first generation antihistamine<br />May cause dizziness, dry mouth, constipation, blurred vision, urinary retention, tachycardia, drowsiness and impaired judgment<br />235<br />Antihistamines<br />
  236. 236. Second generation <br />Claritin – less likely to cause drowsiness<br />236<br />Antihistamines<br />
  237. 237. Expectorants<br />Thin respiratory secretions<br />
  238. 238. Thin respiratory secretions so they are more readily mobilized and cleared from the airways<br />238<br />Expectorants<br />
  239. 239. Antimicrobials<br />Kill or inhibit the growth of bacteria, viruses, or fungi<br />
  240. 240. Usually treat only bacterial infections because they are not effective against viruses or fungi<br />Specific antimicrobials are best selected after culture and sensitivity tests are performed on a specimen of respiratory secretions<br />Instruct on proper self medications<br />240<br />Antimicrobials<br />
  241. 241. Bronchodilators<br />Relax smooth muscle in the bronchial airways and blood vessels<br />
  242. 242. Asthma and COPD<br />Primary drawback is their tendency to cause cardiac and CNS stimulation<br />Some bronchodilators act primarily to prevent bronchial constriction where as other relieve it.<br />242<br />Bronchodilators<br />
  243. 243. Corticosteroids<br />Anti-inflammatory drugs<br />
  244. 244. Parenterally, orally, inhalation<br />Reduce inflammation and edema in the respiratory tract<br />Less commonly used to treat COPD<br />Do no discontinue steroid therapy abruptly<br />244<br />Corticosteroids<br />
  245. 245. Mast Cell Stabilizers<br />Used to prevent acute asthma attacks<br />
  246. 246. Intal<br />Tilade<br />Not useful in stopping an attack after it starts<br />246<br />Mast Cell Stabilizers<br />
  247. 247. Leukotriene Inhibitors<br />Leukotriens Mediate allergic responses<br />
  248. 248. Useful in the treatment of asthma – they inhibit the allergic response helping to prevent but not interrupt acute asthmatic attacks<br />Accolate<br />Zyflo<br />Singulair<br />248<br />Leukotriene Inhibitors<br />
  249. 249. mucolytics<br />Reduce the viscosity and elasticity of mucus<br />
  250. 250. Mucomyst is used as an inhalant to thin the secretions <br />Important for the patient to remain well hydrated<br />250<br />mucolytics<br />
  251. 251. Thrombolytics<br />Dissolve blood clots <br />
  252. 252. Streptase<br />Abbokinase<br />Alteplase<br />Activase<br />252<br />Thrombolytics<br />
  253. 253. Lung Herbs<br />9 Lung Herbs For Colds and Respiratory Help<br />
  254. 254. Mullein is a soothing expectorant that makes the mucous more fluid and less sticky, hence it can be coughed up more easily. It also helps relax the muscles in the bronchial passage. It is used for bronchitis, colds, persistent coughs, tuberculosis, pleurisy, and whooping cough<br />254<br />Mullein<br />
  255. 255. Angelica is a warming remedy that is good for the digestive system as well as the respiratory system. It is an expectorant, which means it will encourage coughing and the elimination of excess mucous. It helps strengthen the lungs when they are weakened, and was traditionally used for many types of infections. <br />255<br />Angelica <br />
  256. 256. Ginger is great in cases of excess phlegm, and bronchitis, and can also be used at the beginning of a cold. Like many of these lung herbs, its great for the digestive system also. Ginger is often used for nausea, and helps circulation. <br />256<br />Ginger<br />
  257. 257. Garlic has been studied a lot for its immune benefits. Its great both in the digestive system, and the lungs. It helps 'sterilize' the bronchial passage in the lungs, and has been used in bronchial infections like tuberculosis. It's great for the 'common cold', and garlic capsules can be bought. Kyolic garlic is excellent. even though its an aged garlic. Fresh garlic, consumed within 15 minutes of being cut open, in a tea with honey and lemon juice, is also an excellent remedy, with very strong antibacterial and antimicrobial benefits. It's great for tonsillitis, throat infections, and similar. As well as its cleansing effect on the lungs, garlic helps encourage mucous to coughed up.<br />257<br />Garlic <br />
  258. 258. Cinnamon should not be used in pregnancy. As a lung herb it's more warming than angelica, and can be used at the beginning of chesty colds. Mills suggests making a tea of powdered cinnamon and fresh ginger. It is also used in chest infections. Cinnamon is also great for the digestive system, and was also traditionally used in convalescence. <br />258<br />Cinnamon <br />
  259. 259. This is a great lung herb for getting rid of excess mucous through coughing. It is very soothing, however, and the types of coughs it encourages are not dry hacking coughs that just produce more irritation. Its great for chronic bronchitis in the elderly, or for those who are weakened physically in some way. It can also be used for nervous coughing, and is a digestive tonic similar to angelica<br />259<br />Elecampane <br />
  260. 260. Coltsfoot is also an expectorant. It's great for dry coughs, and because of its mucilage content, is very soothing when the bronchial passages are irritated. <br />260<br />Coltsfoot <br />
  261. 261. More than a seasoning for cooking, this lung herb has antiseptic properties as well as being an expectorant and digestive tonic. It helps 'disinfect' the air passages, and also has a calming effect on the bronchial tube. It is generally used for more asthmatic conditions and dry coughs, but not really for bronchitis. Large amounts of thyme should not be taken during pregnancy. <br />261<br />Thyme<br />
  262. 262. This lung herb is used as a cough suppressant, which as indicated above, should only be used under some circumstances. But it is used in helping treat strong and incessant coughing to the point of exhaustion. <br />262<br />Wild Cherry Bark <br />
  263. 263. DISORDERS OF THE RESPIRATORY SYSTEM<br />263<br />
  264. 264. ACUTE VIRAL RHINITISTHE COLD<br />264<br />
  265. 265. Last 2 - 14 days, <br />first 3 days most contagious<br />headache <br />sneezing<br />stuffiness<br />sore throat <br />runny nose<br />Fatigue<br />lethargic<br />Fever and chills in severe cases<br />SIGNS AND SYMPTOMS<br />265<br />
  266. 266. DIAGNOSIS<br />HISTORY AND EXAM<br />
  267. 267. Rest<br />fluids<br />diet<br />antipyretics<br />analgesics<br />Antivirals (not commonly used)<br />Vitamin C<br />antihistamines<br />decongestants<br />TREATMENT<br />267<br />
  268. 268. Acute Bronchitis<br />268<br />
  269. 269. Follows a cold or the flu<br />usually viral<br />Bacterial: Streptococcus pneumoniae, haemophilus influenzae<br />Irritation and inflammation : increase mucous <br />ETIOLOGY AND RISK FACTORS<br />269<br />
  273. 273. INFLUENZA<br />273<br />
  274. 274. Acute viral respiratory infection<br />Several types then subtypes (A,B,C)<br />Most susceptible:<br />very young<br />elderly<br />institutionalized<br />chronic disease <br />you<br />Etiology and Risk Factors<br />274<br />
  275. 275. Bronchitis<br />Viral or Bacterial Pneumonia<br />myocarditis<br />pericarditis<br />Rye Syndrome<br />confusion<br />Guillain-Barre’<br />toxic shock<br />Myositis (swelling of the muscles)<br />renal failure<br />COMPLICATIONS<br />275<br />
  276. 276. Chills <br />fever<br />muscle pain<br />headache<br />dry hacking cough<br />SIGNS AND SYMPTOMS<br />276<br />
  278. 278. Rest<br />fluids<br />diet<br />analgesics<br />antipyretics<br />Antivirals (Symmetrel, Flumadine, Tamiflu, Relenza for type A & B)<br />prevention; flu shot<br />TREATMENT<br />278<br />
  279. 279. PNEUMONIA<br />279<br />
  280. 280. Inflammation of the alveoli & bronchioles <br />infectious<br />Psuedomonas<br />Candidia<br /> noninfectious<br />fumes<br />dust<br />chemicals<br />Nosocomial<br />poor hand washing<br />poor sterile technique<br />contaminated equipment<br />contact<br />Etiology and Risk Factors<br />280<br />
  282. 282. Lobar Pneumonia<br />one or more lobes<br />Bronchopneumonia<br />bronchioles & alveoli<br />Interstitial pneumonia<br />lung tissue surrounding the alveoli<br />Gram + bacteria<br />pneumococcal<br />staphylococcal<br />streptococcal<br />Gram - bacteria<br />pseudomonas<br />influenza<br />legionnaires’ disease<br />Viral<br />PATHOPHYSIOLOGY<br />282<br />
  283. 283. PLEURISY<br />PLEURAL EFFUSION<br />ATELECTASIS<br />LUNG ABCESS<br />DELAYED RESOLUTION<br />EMPYEMA<br />SYSTEMIC COMPLICATIONS<br />pericarditis<br />arthritis<br />meningitis<br />endocarditis<br />COMPLICATIONS<br />283<br />
  284. 284. Fever<br />chills<br />sweats<br />chest pain<br />cough<br />sputum production<br />hemoptysis<br />dyspnea<br />headache<br />SIGNS & SYMPTOMS<br />284<br />
  285. 285. BACTERIAL<br />abrupt onset<br />severe shaking chills<br />sharp stabbing lateral chest pain<br />intermittent cough productive of rusty sputum <br />VIRAL<br />burning or searing chest pain in sternal area<br />continuous barking hacking cough with small amount of sputum production<br />headache<br />SIGNS & SYMPTOMS<br />285<br />
  286. 286. History<br />exam<br />CXR<br />sputum gm. Stain<br />sputum C&S<br />CBC<br />Blood culture<br />DIAGNOSIS<br />286<br />
  287. 287. 3L of fluid/24 hours<br />bedrest<br />analgesics <br />antipyretics<br />oxygen<br />IPPB<br />antibiotics<br />Vaccine<br />not recommended for children under age 2<br />only given once in a lifetime/There have been some questions regarding the once in a lifetime<br />TREATMENT<br />287<br />
  288. 288. Ineffective airway clearance R/T<br />Increased sputum production<br />Thick secretions<br />Ineffective cough<br />Nursing diagnoses<br />288<br />
  289. 289. What can a nurse do?<br />Decrease production of sputum and promote expectoration by administering antimicrobials, decongestants and expectorants as ordered<br />Teach and encourage deep breathing and coughing<br />Change positions at least every 2 hours to help mobilize secretions<br />Chest physiotherapy and aerosol therapy<br />Suctioning if needed<br />Provide tissues and receptacle<br />Chart amount, color, consistency of secretions<br />Ausculate lung sounds frequently to assess the effects of interventions<br />Ineffective airway clearance<br />289<br />
  290. 290. Edema and secretions with pneumonia may interfere with gas exchange<br />Pt may have hypoxemia-low O2 in blood or hypercapnia-accumulation of CO2 in blood<br />Need to improve gas exchange<br />Impaired gas exchange<br />290<br />
  291. 291. What’s a nurse to do?<br />Monitor vital signs, lung sounds and skin color to assess gas exchange<br />Be alert for signs of hypoxemia: restlessness, tachycardia and tachypnea<br />Report abnormal ABGs<br />Check hemoglobin values, signals less O2 carrying ability<br />Mobilize secretions as mentioned before<br />Elevate HOB<br />Administer O2 as ordered<br />Impaired gas exchange<br />291<br />
  292. 292. Activity usually restricted but may range from bed rest to BRP<br />Schedule nursing care to prevent over tiring<br />Allow periods of uninterrupted rest<br />Provide assistance until pt is able to do self-care<br />Encourage visitors not to tire pt with long visits<br />Evaluate ability to tolerate ADLs<br />Activity intolerance<br />292<br />
  293. 293. What’s a nurse to do?<br />Assess pts usual dietary habits<br />Monitor weight by weighing pt before breakfast using same scale<br />Monitor albumin and lymphocyte blood counts to detect low levels that are common with inadequate protein<br />Typical diet: high protein, soft<br />Assist pt with meal if needed<br />Document intake<br />Provide oral care before meals<br />Elevate HOB arrange tray in attractive and convenient manner<br />Nasal cannula recommended during meals<br />If pt tires, more frequent smaller meals would be better<br />Altered nutrition: less than body requirments<br />293<br />
  294. 294. Fever, mouth breathing and inadequate intake may increase the risk for this diagnosis<br />Dehydration causes secretions to be thicker and more difficult to expectorate<br />Risk for fluid volume deficit<br />294<br />
  295. 295. Decreased skin turgor<br />Concentrated urine<br />Dry mucous membranes<br />Elevated hemoglobin and hematocrit<br />Signs and symptoms of fluid volume deficit<br />295<br />
  296. 296. What’s a nurse to do?<br />Encourage 3L of fluid daily unless contraindicated<br />Administer IV fluids as ordered<br />If permitted give hard candy which stimulates thirst and fluid intake<br />Record intake and output<br />Fluid volume deficit<br />296<br />
  297. 297. Monitor temp q2-4h<br />Administer antipyretics as ordered<br />Keep pt dry and lightly covered<br />Keep room comfortable temp, avoid chilling<br />Tepid sponge baths for fevers as ordered<br />Hypothermia blanket as ordered to reduce temp<br />Fluid volume deficit<br />297<br />
  298. 298. Administer analgesics as ordered<br />Position pt for comfort<br />Encourage splinting painful areas during deep breathing and coughing<br />Massage to promote comfort<br />Notify the physician if pain is unrelieved or worsens<br />Pain<br />298<br />
  299. 299. Gradually increase activities as you recover, fatigue may persist for several weeks<br />Avoid people with colds or other infections<br />Get plenty of rest, good nutrition and 3 L of fluids each day unless contraindicated<br />Complete any prescribed drugs after discharge<br />Nursing Care Plan page 539<br />Teaching Plan for Pneumonia 540 <br />Nutrition Concepts page 540 <br />What to teach regarding pneumonia<br />299<br />
  301. 301. PREVENTING ASPIRATION<br />301<br />
  302. 302. Keep suction equipment on hand<br />Position upright with neck in neutral position<br />Thinken liquids<br />302<br />Prevention measures: <br />
  303. 303. Elevate the head of bed if enteral feeding <br />Measure residual before each bolus feeding<br />If greater than 100ml with hold the feeding and notify the physician<br />Stop continuous feeding for 20-30 min before lowering the patients head<br />If they must be kept flat then place on right side<br />Check the residual every 4 hours and if more than 20% of hourly rate consult the physician <br />303<br />Prevention of Aspiration Pneumonia<br />
  304. 304. PLEURISY<br />Inflammation of the pleura<br />
  305. 305. Pneumonia<br />tuberculosis<br />chest wall injury<br />pulmonary infarction<br />Tumors<br />Common Causes<br />305<br />
  306. 306. Abrupt and severe pain<br />one side of the chest<br />breathing and coughing aggravate the pain<br />Symptoms<br />306<br />
  307. 307. UNDERLYING DISORDER<br />PAIN RELIEF<br />Analgesics<br />anti-inflammatory<br />antitussives<br />antimicrobials<br />local heat<br />TREATMENT<br />307<br />
  308. 308. Pain R/T inflammation<br />Ineffective breathing pattern R/T splinting, pleural effusion<br />Nursing diagnoses for pleurisy<br />308<br />
  309. 309. When reported, obtain complete description<br />Location<br />Severity<br />Precipitating factors<br />Alleviating factors<br />Use pain scale<br />Interventions for pain<br />309<br />
  310. 310. Administer ordered analgesics<br />Splinting for the affected side<br />Splint rib cage when coughing<br />Apply heat if ordered<br />Give antitussives if ordered to decrease painful coughing<br />If on bed rest, assist pt with regular position changes<br />Administer NSAIDs as ordered to reduce pain and inflammation<br />Interventions for pain<br />310<br />
  311. 311. Monitor breathing pattern, pay attention to chest symmetry during breathing<br />Encourage pt to turn, take deep breaths and couth<br />Encourage to ambulate if permitted<br />Elevate HOB<br />Ineffective breathing pattern<br />311<br />
  312. 312. If pleural effusion develops, progressive dyspnea, decreased or absent breath sounds in the affected area and decreased chest wall movement on the affected side, a thoracentesis may be done to remove accumulated fluid<br />If done at bedside you, the nurse will assist<br />So be ready!!!<br />Complications<br />312<br />
  313. 313. CHEST TRAUMA<br />313<br />
  314. 314. PENETRATING<br />Gunshot, stab wounds<br />pneumothorax<br />tears of aorta, vena cava, other major vessels <br />NONPENETRATING<br />MVA, Falls, Blast<br />rib fx<br />pneumothorax<br />pulmonary contusions<br />cardiac contusions<br />CATEGORIES OF CHEST TRAUMA<br />314<br />
  315. 315. Obvious trauma<br />chest pain<br />dyspnea<br />asymmetrical chest wall movement<br />cyanosis<br />weak rapid pulse<br />decreased blood pressure<br />tracheal deviation<br />distended neck veins<br />bloodshot or bulging eyes<br />SIGNS & SYMPTOMS<br />315<br />
  316. 316. Stabilization<br />prevention<br />dressing tape three sides(called a vented dressing)<br />An airtight dressing could cause a tension pneumothorax<br />do not remove impaled objects<br />VS<br />LOC<br />O2<br />semi-fowlers<br />MEDICAL TREATMENT<br />316<br />
  317. 317. PNEUMOTHORAX<br />An accumulation of air in the pleural cavity that results in complete or partial collapse of a lung.<br />Air enters the space between the chest wall and the lung either through a hole in the chest wall or through a tear in the bronchus, bronchioles, or alveoli.<br />317<br />
  318. 318. Tension<br />air is repeatedly entering the pleural space<br />lung on affected side collapses<br />mediastinal shift<br />Open<br />chest wound<br />air moves in and out freely<br />lung on affected side collapses<br />medistinal flutter<br />TENSION / OPEN PNEUMO<br />318<br />
  319. 319. Dyspnea<br />tachypnea<br />tachycardia<br />restlessness<br />pain anxiety <br />decreased movement of the involved chest wall<br />Asymmetric chest movement<br />diminished breath sounds<br />progressive cyanosis<br />chest wound<br />sucking chest wound (air can be heard or felt from wound)<br />SIGNS & SYMPTOMS<br />319<br />
  320. 320. Needle aspiration of fluid/air from pleural space<br />chest tube insertion<br />surgical repair of a tear<br />If persistent air leak( variety being studied) <br />intrapleural tetracycline<br />blood patches<br />fibrin glue<br />TREATMENT<br />320<br />
  321. 321. If chest tube: monitor insertion site<br />Document amount and characteristics of drainage<br />Add to I&O<br />Give chest tube care<br />Monitor for increasing respiratory distress:<br />Tachycardia<br />Dyspnea<br />Cyanosis<br />Restlessness<br />Anxiety<br />Nursing care<br />321<br />
  322. 322. Inspect trachea for deviation which may be caused by mediastinal shift<br />occurs when a lung collapses and the heart, trachea, esophagus, and great blood vessels shift toward the unaffected side<br />Mediastinal flutter<br />Occurs with an open pneumothorax, everything may shift back and forth toward the unaffected side with inspiration then toward the affected side with expiration<br />Nursing care<br />322<br />
  323. 323. Check ABGs for hypoxemia and hypercapnia<br />Immediately report deteriorating respiratory status<br />Protect chest tube and monitor its function<br />Nursing care/ineffective breathing pattern<br />323<br />
  324. 324. Position pt for comfort in a Fowler’s or semi-Fowler’s position, avoid side-lying until affected lung has re-expanded, could cause mediastinal shift<br />Support and encourage pt to deep breath and cough q2h while awake<br />Administer O2 as ordered<br />Nursing care/ineffective breathing pattern<br />324<br />
  325. 325. Speak calmly to pt, explain every procedure<br />Tell pt about chest tube<br />Give pt opportunity to ask questions and express fear<br />Nursing care/fear<br />325<br />
  326. 326. Monitor pulse and blood pressure<br />If blood pressure falls and pulse rate increases, you should suspect mediastinal shift, notify physician immediately, this could be fatal<br />Nursing care/risk for decreased cardiac output<br />326<br />
  327. 327. Monitor for signs of pain<br />Document characteristics of pain<br />Administer analgesics as ordered<br />Document the effects of drug therapy<br />Rate pain on 0-10 scale<br />Use positioning, massage, distraction etc.<br />Notify physician if measures fail and pain is not relieved<br />Nursing care/pain<br />327<br />
  328. 328. Monitor for signs and symptoms of infection<br />Fever<br />Increased pulse and respirations<br />Foul drainage from tube insertion site<br />Elevated WBC<br />Nursing care/risk for infection<br />328<br />
  329. 329. Use sterile technique for invasive procedures and dressing changes<br />Administer prescribed antimicrobials<br />Monitor hydration status and promote fluid intake of 2 to 3 L/d unless contraindicated<br />Before discharge instruct pt on chest tube care and to notify physician of S/S of infection<br />Fever or increasing redness, swelling, or drainage from insertion site<br />Nursing care/risk for infection<br />329<br />
  330. 330. Accumulation of blood between the chest wall and the lung<br />Pressure around the lung increases, causing partial or complete collapse of the lung<br />Results from lacerated or torn blood vessel, lung malignancy, pulmonary embolus<br />May also be caused by anticoagulation therapy<br />HEMOTHORAX<br />330<br />
  331. 331. Essentially like a pneumothorax, nursing care is similar<br />Surgical intervention may be necessary to control bleeding<br />Pt is at risk for decreased cardiac output due to hemorrhage<br />Hemothorax treatment<br />331<br />
  332. 332. RIB FRACTURES<br />Most common chest injuries<br />blunt injury/MVA-hit steering wheel<br />Ribs 4 to 9 most commonly affected<br />Takes approx 6 wks to heal <br />
  333. 333. Pain at injury site (especially during inspiration)<br />bruising<br />Swelling<br />Visible bone fragments at site of injury<br />shallow breathing<br />protective holding of the chest<br />SIGNS & SYMPTOMS<br />333<br />
  334. 334. Pain relief to allow adequate chest expansion<br />intercostal nerve blocks<br />no binders or rib belts restricts expansion of chest<br />encourage deep breathing every four hours<br />Complication: pneumonia or atelectasis due to inadequate chest expansion<br />TREATMENT<br />334<br />
  335. 335. Goal: effective breathing pattern<br />Breathing exercises to prevent pulmonary complications<br />Instruct splinting while deep breathing and coughing<br />Adequate pain control is essential, monitor q2h, rate pain on scale 0-10<br />Administer prescribed analgesics<br />Provide a calm environment<br />Encourage pt to rest<br />Evaluate effects of pain measures<br />Inform physician if pain isn’t controlled<br />Nursing care<br />335<br />
  336. 336. FLAIL CHEST<br />Two adjacent ribs on the same side of the chest are broken in two or more places. Results in paradoxical movement<br />
  337. 337. Severe dyspnea<br />cyanosis<br />tachypnea<br />tachycardia<br />paradoxical movement-affected part will move in with inspiration and moves out with expiration-opposite of how it should be<br />SIGNS & SYMPTOMS<br />337<br />
  338. 338. History<br />Exam CXR<br />ABG<br />DIAGNOSIS<br />338<br />
  339. 339. Adequate oxygenation <br />Cough & deep breathing<br />IPPB<br />pain management<br />Respiratory Distress<br />intubation<br />ventilator<br />TREATMENT<br />339<br />
  340. 340. PULMONARY EMBOLUS<br />Foreign substance carried through the blood<br />Usually blood clots but may be fat, air, tumors, bone marrow, amniotic fluid or clumps of bacteria<br />Ventilation-perfusion mismatch.<br />Alveoli are ventilated + no blood flow= no gas exchange<br />340<br />
  341. 341. If a large pulmonary vessel is obstructed, alveoli collapse, cardiac output falls, there is constriction of the bronchi and the pulmonary artery, and sudden death may ensue.<br />341<br />
  342. 342. Surgery of the pelvis or lower legs<br />Immobility<br />Obesity<br />Estrogen therapy<br />Clotting abnormalities<br />If a large pulmonary vessel is obstructed, alveoli collapse, cardiac output falls, there is constriction of the bronchi and the pulmonary artery, and sudden death may occur<br />Etiology and risk factors<br />342<br />
  343. 343. Sudden chest pain worsens with breathing<br />tachypena<br />dyspnea<br />apprehensive<br />diaphoretic<br />cough <br />hemoptysis<br />Crackles may be heard on auscultation <br />fever<br />tachycardia<br />SIGNS & SYMPTOMS<br />343<br />
  344. 344. History and physical<br />ABG<br />EKG<br />lung scan<br />Pulmonary angiogram<br />DIAGNOSIS<br />344<br />
  345. 345. MEDICAL<br />Heparin to establish and maintain (PTT 2 -2.5 times the normal rate)<br />Coumadin 6 months<br />Fibrinolytics<br />oxygen<br />intubation<br />ventilation<br />SURGICAL<br />embolectomy<br />vena cava interruption <br />venous thrombectomy<br />See pg 546 for pictures of filters<br />TREATMENT<br />345<br />
  346. 346. Must monitor risk factors that led to the embolism<br />Homans’ sign assessed in each leg<br />Nursing care<br />346<br />
  347. 347. Monitor respiratory rate and effort<br />Breath sounds<br />Skin color<br />Pulse<br />Blood pressure<br />Nursing care/altered cardiopulmonary tissue perfusion<br />347<br />
  348. 348. ABGs report abnormalities to physician<br />Elevate HOB <br />Administer O2 as prescribed<br />Administer prescribed IV fluids<br />Document I&O<br />Active/passive ROM<br />Early ambulation after surgery<br />Antiembolism and pneumatic compression stockings<br />Nursing care/altered cardiopulmonary tissue perfusion<br />348<br />
  349. 349. Remain calm<br />Tell pt what is being done<br />Explain equipment and procedures in terms pt can understand<br />Encourage pt to express concerns and ask questions<br />Permit family member to remain with the patient<br />Nursing care/anxiety<br />349<br />
  350. 350. See patient teaching plan page 547 for pulmonary embolism<br />350<br />
  351. 351. ARDS<br />Acute Respiratory Distress Syndrome<br />351<br />
  352. 352. Progressive pulmonary disorder that follows lung trauma. <br />Infiltrate development <br />fluid shift<br />pulmonary edema<br />atelectasis<br />Cardiac dysrhythmias<br />renal failure<br />stress ulcers<br />thrombocytopenia<br />DIC (disseminated intravascular coagulation)<br />oxygen toxicity<br />sepsis<br />ETIOLOGY & RISK FACTORS<br />352<br />
  353. 353. Increased respiratory rate<br />fine crackles<br />restless<br />agitated<br />confused<br />increased pulse rate<br />cough<br />Dyspnea with retractions<br />cyanosis<br />diaphoresis<br />diffuse crackles and rhonchi<br />SIGNS & SYMPTOMS<br />353<br />
  354. 354. History<br />exam<br />CXR<br />ABG<br />pH increases Co2 falls<br />O2 falls despite O2<br />pH decreases respiratory acidosis<br />DIAGNOSIS<br />354<br />
  355. 355. Intubation with ventilator<br />treat underlying cause<br />corticosteroids debatable issue<br />TREATMENT<br />355<br />
  356. 356. Characterized by interstitial hemorrhage associated with intraalveolar hemorrhage resulting in decreased pulmonary compliance<br />The major complication is acute respiratory distress syndrome (ARDS)<br />Pulmonary Contusion<br />356<br />
  357. 357. Dyspnea<br />Hypoxemia<br />Increased bronchial secretions<br />Hemoptysis<br />Restlessness<br />Decreased breath sounds<br />Rales and wheezes<br />Signs and Symptoms<br />357<br />
  358. 358. Maintain airway and ventilation<br />Place client in high Fowler’s position<br />Administer oxygen as prescribed<br />Monitor for increased respiratory distress<br />Maintain bed rest and limit activity to reduce oxygen demands<br />Prepare for mechanical ventilation as prescribed<br />Implementation<br />358<br />
  359. 359. Occurs when the client cannot eliminate carbon dioxide from the alveoli<br />The carbon dioxide retention results in hypoxemia<br />Oxygen reaches the alveoli but cannot be absorbed or used properly<br />The lungs can move air sufficiently but cannot oxygenate the pulmonary blood properly<br />Respiratory failure<br />359<br />
  360. 360. Respiratory failure occurs as a result of mechanical abnormality of the lungs or chest wall, a defect in the respiratory control center in the brain, or an impairment in the function of the respiratory muscles<br />Respiratory failure<br />360<br />
  361. 361. Dyspnea<br />Headache<br />Confusion<br />Restlessness<br />Tachycardia<br />Cyanosis<br />Dysrhythmias<br />Decreased level of consciousness<br />Alterations in respirations and breath sounds<br />Respiratory failure/Signs and Symptoms<br />361<br />
  362. 362. Identify and treat the cause<br />Administer O2 as prescribed to maintain the PaO2 level above 60 mm Hg<br />Place the client in high Fowler’s position<br />Encourage deep breathing<br />Administer bronchodilators as prescribed<br />Prepare the client for mechanical ventilation if supplemental O2 cannot maintain acceptable PaO2 levels<br />Respiratory failure/what to do?<br />362<br />
  363. 363. The collection of fluid in the pleural space<br />Any condition that interferes with either secretion or drainage of this fluid will lead to pleural effusion<br />Pleural effusion<br />363<br />
  364. 364. Pleuritic pain that is sharp and increases with inspiration<br />Dyspnea on exertion<br />Dry nonproductive cough caused by bronchial irritation or mediastinal shift<br />Malaise<br />Pleural effusion/signs and symptoms<br />364<br />
  365. 365. Tachycardia<br />Elevated temperature<br />Decreased breath sounds<br />CXR shows pleural effusion and a mediastinal shift away from the fluid<br />Pleural effusion/signs and symptoms<br />365<br />
  366. 366. Identify and treat underlying cause<br />Monitor vital signs<br />Monitor breath sounds<br />Place client in high Fowler’s position<br />Encourage coughing and deep breathing<br />Prepare client for thoracentesis<br />Implementation<br />366<br />
  367. 367. Chronic Obstructive Pulmonary Disease (COPD)<br />5th leading cause of death in US<br />
  368. 368. A combination of asthma, chronic bronchitis, & emphysema.<br />May see only one or two, but usually all three.<br />COLD- Chronic Obstructive Lung Disease<br />CAL – Chronic Airflow Limitation<br />CHRONIC OBSTUCTIVE PULMONARY DISEASE<br />368<br />
  369. 369. Pulmonary function test common diagnostic procedure<br />Provides info about airway dynamics, lung volumes, and diffusing capacity<br />Airway dynamics – patients ability to inhale or exhale by force<br />Diffusing capacity – ability of gases to diffuse across the alveolar capillary membrane<br />Test are effort dependent – patient must be mentally alert, cooperative and able to follow directions. <br />369<br />CHRONIC OBSTUCTIVE PULMONARY DISEASE<br />
  370. 370. Reactive Airway Disease<br />ASTHMA<br />370<br />
  371. 371. Early /acute episode:<br />Begins when triggers ( allergens, irritants, infections, exercise) activate the inflammatory process<br />Airway constrict & becomes edematous<br />Mucus secretions increases, forming plugs in the ariways<br />Tenacious sputum is produced<br />Usually occur within 30-60 minutes after exposure to the trigger and resolve some 30-60 minutes later<br />Fig 31-1 page 551<br />Asthma Attacks<br />371<br />
  372. 372. Late Phase<br />Begins 5-6 hours after the early phase<br />Red & white blood cells infiltrate the swollen tissues of the airways<br />Lasts several hours or days<br />Risk for another acute episode until the phase subsides<br />Asthma<br />372<br />
  373. 373. Constriction of the bronchi & broncioles.<br />Results in a ventilation perfusion mismatch<br />Severe, persistent bronchospasm is called status asthmaticus<br />Bronchospasm<br />373<br />
  376. 376. HISTORY<br />PHYSICAL EXAM<br />PFT : DECREASED EXPIRATORY AIR VOLUME<br />ABG’s if moderate to severe symptoms<br />DIAGNOSIS<br />376<br />
  378. 378. RELIEVERS – RELIEVE ACUTE SYMPTOMS<br />CONTROLLERS – PROVIDE LONG TERM CONTROL<br />Beta 2 receptor agonists are the most often used relievers<br />Controllers: inhaled glucocorticoids, leukotriene inhibitors, long acting beta 2 receptor agonists, mast cell stabilizers and xanthines.<br />MEDICATIONS<br />378<br />
  380. 380. Inflammation caused by inhaled irritants, including cigarette smoke<br />At first, only large airways are affected, but smaller airways are eventually involved.<br />Mucus obstructs the airway, causing air to be trapped in distal portions of the lungs<br />Alveolar ventilation is impaired and hypoxemia may develop<br />See Teaching Plan page 561 for Chronic Bronchitis and Emphysema<br />Chronic Bronchitis<br />380<br />
  381. 381. Right sided heart failure secondary to pulmonary disease.<br />Cor-Pulmonale<br />381<br />
  382. 382. Centrilobar<br />cigarette smoking<br />Affects mainly the respiratory bronchioles<br />Panlobular<br />hereditary deficiency of alpha 1 -antitrypsin<br />Affects the respiratory bronchioles and the alveoli.<br />May have both at the same time<br />Figure 31-4 Page 554<br />Emphysema ( Pink Puffer)<br />382<br />
  383. 383. Alveolar walls breakdown cause permanent distention of air spaces & decrease in elastic recoil. Partially collapsed airways. Bullae & blebs develop<br />Emphysema<br />383<br />
  384. 384. Heart failure<br />Respiratory failure<br />Increased PaCO2<br />Decreased PaO2<br />Complications<br />384<br />
  385. 385. Infection<br />air pollution<br />smoking<br />adverse drug reaction<br />Left ventricular failure<br />MI<br />PE<br />Spontaneous Pneumothorax<br />Factors Leading to Complications<br />385<br />
  386. 386. Bronchitis<br />Productive Cough<br />External Dyspnea<br />Wheezing<br />Elevated RBC<br />Cor Pulmonale- dyspnea, cyanosis, peripheral edema, “blue bloater”<br />Signs & Symptoms<br />386<br />
  387. 387. Dyspnea on exertion, then on rest<br />thin patients<br />use accessory muscles<br />increase in chest diameter “barrel chest”<br />“Pink Puffers”<br />Emphysema<br />387<br />
  388. 388. Diagnosis: History & exam, PFT<br />decrease in forced expiratory volume and forced vital capacity<br />increase in residual capacity and volume and total lung capacity<br />Emphysema without Chronic Bronchitis<br />388<br />
  389. 389. Drug therapy<br />oxygen therapy<br />Chest physiotherapy<br />Exercise <br />Nutrition<br />Surgical Treatment (lung volume reduction surgery) LVRS <br />Treatment<br />389<br />
  390. 390. Lung Volume Reduction Surgery<br />Up to 30% of the hyperinflated lung tissue is excised to improve the mechanics of breathing, enabling the patient to breath more deeply<br /><ul><li>Effectiveness still being evaluated
  391. 391. Recovery period is long
  392. 392. Mortality rate 5%-10%</li></li></ul><li>Abnormal dilation and distortion of bronchi & bronchioles, usually confined to one lung lobe or segment.<br />Typically follows recurrent inflammatory conditions infections or obstruction.<br />Some times congenital.<br />Bronchiectasis<br />391<br />
  393. 393. Coughing.<br />Production of purulent sputum in large quantities.<br />Fever<br />hemoptysis<br />nasal stuffiness<br />sinus drainage<br />Fatigue <br />weakness<br />Signs and Symptoms<br />392<br />
  394. 394. Control symptoms<br />prevent spread.<br />Antibiotics<br />oxygen therapy<br />chest physiotherapy<br />Treatment<br />393<br />
  395. 395. Cystic Fibrosis<br />Hereditary disorder<br />
  396. 396. Cystic Fibrosis<br />
  397. 397. Hereditary disorder<br />Dysfunction of the exocrine gland<br />Production of thick tenacious mucous<br />Obstruction of the pancreatic ducts so that pancreatic enzymes cannot be delivered to the GI tract<br />Stools bulky and foul smelling<br />Women have reduced fertility<br />Males often have vas deferens absent<br />Cystic Fibrosis<br />396<br />
  398. 398. Infection.<br />Emphysema.<br />Atelectasis.<br />Complications<br />397<br />
  399. 399. Pancreatic enzyme replacement<br />Chest physiotherpay<br />Aerosol & nebulizer treatments<br />Bronchodilators<br />Anti-inflammatory agents<br />Inhaled deoxyribonuclease<br />Lung transplantation<br />Treatment of Cystic Fibrosis<br />398<br />
  400. 400. GOAL:<br />Effective airway clearance<br />Prevention/treatment of infection<br />Adequate nutrition<br />Effective therapeutic regimen management<br />Nursing Care<br />399<br />
  401. 401. TB<br />Sarcoidosis<br />pneumoconiosis <br />Interstitial fibrosis<br />Lung cancer<br />Restrictive pulmonary disordersReduce lung volumes<br />400<br />
  402. 402. A highly communicable disease caused by Mycobacterium tuberculosis<br />A nonmotile, nonsporulating, acid-fast rod that secrets niacin; and when the bacillus reaches a susceptible site, it multiplies freely<br />Tuberculosis (TB)<br />401<br />
  403. 403. Because it is an aerobic bacterium, it primarily affects the pulmonary system, especially the upper lobes where oxygen content is greatest, but can also affect other areas of the body such as the brain, intestines, peritoneum, kidney, joints, and liver<br />Tuberculosis (TB)<br />402<br />
  404. 404. An exudative-type response causes a nonspecific pneumonitis and development of granulomas in the lung tissue<br />Has an insidious onset, and many clients are not aware of symptoms until the disease is well advanced<br />Tuberculosis (TB)<br />403<br />
  405. 405. A multidrug-resistant strain (MDR-TB) of TB can exist as a result of improper or noncompliant use of treatment programs and the development of mutations in the tubercle bacilli<br />The goal of treatment is to prevent transmission, control symptoms and prevent progression of the disease<br />Tuberculosis (TB)<br />404<br />
  406. 406. Alcoholism<br />Intravenous drug use<br />Malnutrition<br />Infection<br />The elderly<br />The homeless<br />Tuberculosis (TB)/risk factors<br />405<br />
  407. 407. Refugees<br />Minority groups<br />Individuals from a lower socioeconomic group<br />Children younger than 5 years old<br />Individuals living in crowded areas such as long-term care facilities, prisons, and mental health facilities<br />Tuberculosis (TB)/risk factors<br />406<br />
  408. 408. Individuals in constant, frequent contact with an untreated or undiagnosed individual<br />Individuals with immune dysfunction, human immunodeficiency virus (HIV), or who are immunosuppressed from medication therapy<br />Drinking unpasteurized milk if the cows are infected with bovine TB<br />Tuberculosis (TB)/risk factors<br />407<br />
  409. 409. Via aerosolization or airborne route by droplet infection<br />When an infected individual coughs, laughs, sneezes, or sings, droplet nuclei containing TB bacteria enter the air and may be inhaled by others<br />TB-Transmission<br />408<br />
  410. 410. Identification of those individuals in close contact with the infected individual is important so that they can be tested and treated as necessary<br />When contacts have been identified, these people are assessed with a tuberculin test and chest x-ray study to determine infection with TB<br />After the infected individual has received TB medication for 2 to 3 weeks, the risk of transmission is greatly reduced<br />Tuberculosis (TB) transmission<br />409<br />
  411. 411. Droplets enter the lungs and the bacteria form a tubercle lesion<br />The body’s defense systems encapsulate the tubercle, leaving a scar<br />If encapsulation does not occur, bacteria may enter the lymph system, travel to the lymph nodes, and cause an inflammatory response called granulomatous inflammation<br />TB-Disease progression<br />410<br />
  412. 412. Primary lesions form; the primary lesions may become dormant, but can be reactivated