Assessment of the Respiratory System Nelia B. Perez RN, MSN Northeastern College March 2009
History * Biographical Data * Current Health * Chief Complaint * Clinical Manifestations
non-cardiac chest pain
Complaints re- nose and sinuses
Non-Cardiac Chest Pain
Pleuritic Chest Pain
Determine the location, duration and intensity of the chest pain to provide early clues to the cause.
Ask the client what instigates the pain and what relieves the pain.
It is a client’s subjective assessment of the degree of work of breathing, exerted for a given task or effort.
May define dyspnea as shortness of breath, suffocation, tightness, being winded, or being breathless.
Note when and how the cough began and how long it has been present.
Determine the frequency of the cough and the time of day when the cough is better or worse.
May be characterized as hacking, dry, hoarse, congested, barking, wheezy or bubbling.
Blood expectorated from the mouth in the form of gross blood, frankly bloody sputum, or blood-tinged sputum.
Attempt to identify the source of the blood – the lungs, a nosebleed, or stomach.
Estimate the amount of blood expectorated .
Produced when air passes through partially obstructed or narrowed airways on inspiration or expiration.
Wheezing may be audible, or it may be heard only with a stethoscope.
Ask the client to identify when the wheezing occurs and whether it resolves spontaneously or medication is required for relief.
Wheezing is not all caused by Asthma.
Stridor Given to high-pitched sounds produced when air passes through a partially obstructed or narrowed upper airway on inspiration. Inquire about changes in voice character, hoarseness, difficulty swallowing, sleep-related disorders, degree of snoring, hypersomnolence in the morning, early morning headaches, weight gain, fluid retention, apnea and restlessness.
Nasal and Sinus Complaints Nosebleeds (epistaxis) Sinus infection Hay fever Postnasal drips Rhinitis Nasal, facial, or referred ear pain
Review of Systems Past Medical History Surgical History Allergies Medications Dietary Habits Social History Family Health History
DIAGNOSTIC TESTING : Noninvasive tests
Pulmonary function testing
Ventilation – perfusion scan
CT and Magnetic Resonance Imaging
Diagnostic Testing: Invasive Tests
Thoracentesis and Pleural Fluid Analysis
Nose and throat culture
Arterial Blood Gases
Management of Clients with Upper Airway Disorders
Methods of Controlling the Airway
A surgical incision into the trachea through overlying skin and muscles for airway management.
Relief of acute or Chronic upper airway obstruction such as obstructive sleep apnea, trauma, bleeding, tumors, tissue swelling, infections, or burns.
Access for continuous mechanical ventilation, with the inability to wean.
Promotion of pulmonary hygiene by accessing airway for secretion removal.
Bilateral vocal cord paralysis
Inability to protect own airway.
Single Cannula Tracheostomy tube
Traditionally, a single lumen tube is passed into the trachea The tube is supplied with an obturator in the lumen which aids insertion and is removed before use. A tracheal cuff allows separation of the lungs from pharyngeal secretions, although it is recognized that some leakage of secretions past the cuff may still occur. Uncuffed tubes are available for patients requiring long-term tracheostomy who have reasonable bulbar function but are unable to clear their secretions.
Double Cannula Tracheostomy Tubes
Double cannula tubes are supplied with an inner tube, which can be removed independently of the outer tube In the event of tube obstruction, this inner tube can be removed and cleaned, thus reducing the incidence of potentially life-threatening complications. This means that this is often the tube of choice especially for ward-based weaning. However, it should be noted that the work of breathing through a double cannula tracheostomy is increased due to the reduction in ID of the tube. In addition, some designs need the inner tube to be in situ to allow connection to the 15 mm ventilator tubing. Double cannula tubes may be fenestrated or unfenestrated
Fenestrated Tracheostomy Tube
Fenestrated tubes have an opening in the posterior part of the outer tube. If the tube is cuffed, the fenestration lies above the cuff. Deflation of the cuff during spontaneous respiration (with the fenestrated inner tube in place) allows air to pass caudally through the tracheostomy lumen and fenestration, as well as around the tracheostomy tube, and up through the larynx. This encourages maximal airflow through the upper airways during speech and also allows assessment of the normal route of air passage during preparation for decannulation. If positive pressure ventilation is required, the unfenestrated inner tube should be inserted, to prevent air leak above the cuff. There are different designs of fenestrations; single and multiple fenestrated tubes are available.
Potential Problems Associated with Tracheostomy Tubes and Cuffs
Changing Tracheostomy Tubes
Tracheal Wall Necrosis
Potential Problems Associated with Tracheostomy Tubes and Cuffs (Cont)
Weaning, Removal and Rescue Breathing : Weaning from a Tracheostomy Tube
Patients can be weaned from mechanical ventilation if they can clear their secretions by mouth with an adequate cough, maintain oxygenation and have a functional upper airways without obstruction.
Tracheostomy tube is usually plugged by inserting a tracheostomy plug (decannulation stopper) into the opening of the outer cannula if the tube has a “tight to shaft” cuff, fenestration, or no cuff. This closes off the tracheostomy , allowing air flow and respiration to occur normally through the nose and mouth.
Air-cuffed tubes without fenestration may not be safety capped.
Explain the process to the patient and to the family.
Use diagnostic tests such as ABG analysis and measurement of spontaneous respiratory mechanics.
… Inability to clear mucus
Remove the tracheostomy plug immediately if any manifestation of respiratory distress or ventilation impairment appear.
Also assess the client’s quality of phonation and ability to deep breathe and cough effectively.
If oxygen has been administered via the tracheostomy, administer it at a prescribed rate flow using nasal prongs.
Prepare for possible return to mechanical ventilation and have a manual resuscitation bag available at the bedside.
Removing a Tracheostomy Tube
A tracheostomy tube is removed after resumption of normal respiration as indicated by the clients ability to breathe comfortably with the tracheostomy plugged, to plugged, to cough and expectorate secretions and to maintain normally ABG values or oxygen saturation.
Gradually increase the length of the plugging session until the client is comfortable and confident with the tube plugged continuously for at least 24 hours.
Place a petroleum gauze pad covered by sterile dressing over the stoma after it is removed.
Every 8 hours, clean the skin around the stoma
Remove mucus with hydrogen peroxide
Rinse area with normal saline and apply a fresh, dry dressing over the healing stoma.
Continue monitoring .
Performing Rescue Breathing
Nursing Management of the Client with Tracheostomy
Explain procedure to patient.
If tracheostomy tube has been suctioned, remove soiled dressing from around tube and discard with gloves on removal.
Perform hand hygiene and open necessary supplies
Cleaning A Nondisposable Inner Cannula
Prepare supplies before cleaning inner cannula.
Open tracheostomy care kit and separate basins, touching only the edges. If kit is not available, open two sterile basins.
Fill one basin fraction ½-inch (1.25 cm) deep with hydrogen peroxide .
Fill other basin fraction ½-inch (1.25 cm) deep with saline.
Open sterile brush or pipe cleaners if they are not already in cleaning kit. Open additional sterile gauze pad
Don disposable gloves.
Remove oxygen source if one is present. Rotate lock on inner cannula in a counterclockwise motion to release it.
Gently remove inner cannula and carefully drop it in basin with hydrogen peroxide. Remove gloves and discard.
Clean inner cannula.
Don sterile gloves.
Remove inner cannula from soaking solution. Moisten brush or pipe cleaners in saline and insert into tube, using back-and-forth motion.
Agitate cannula in saline solution. Remove and tap against inner surface of basin.
Place on sterile gauze pad.
Suction outer cannula using sterile technique.
Replace inner cannula into outer cannula. Turn lock clockwise and make sure that inner cannula is secure. Reapply oxygen source if needed.
Replacing Disposable Inner Cannula
Release lock. Gently remove inner cannula and place in disposable bag. Discard gloves and don sterile ones to insert new cannula. Replace with appropriately sized new cannula. Engage lock on inner cannula.
Applying Clean Dressing and Tape
Dip cotton-tipped applicator in saline and clean stoma under faceplate. Use each applicator only once, moving from stoma site outward.
Apply hydrogen peroxide to area around stoma, faceplate, and outer cannula if secretions prove difficult to remove. Rinse area with saline.
Pat skin gently with dry 4 x 4 gauze.
Slide commercially prepared tracheostomy dressing or prefolded non-cotton-filled 4 x 4 dressing under faceplate.
Change tracheostomy tape.
Leave soiled tape in place until new one is applied.
Cut piece of tape that is twice the neck circumference plus 4 inches (10 cm). Trim ends on the diagonal.
Insert one end of tape through faceplate opening alongside old tape. Pull through until both ends are even.
Slide both tapes under patient’s neck and insert one end through remaining opening on other side of faceplate. Pull snugly and tie ends in double square knot. Check that patient can flex neck comfortably.
Carefully remove old tape. Reapply oxygen source if necessary.
Remove gloves and discard. Perform hand hygiene. Assess patient’s respirations. Document assessments and completion of procedure.
Ineffective Airway Clearance
1. change position frequently
2. provide humidification and hydration
3. perform frequent hyperinflation and suctioning
4. controlled coughing
5. Perform Suctioning
Provide adequate hydration
Prevent tube movement
Risk for impaired gas exchange
Continuous monitoring trhough pulse oximetry
Do not allow smoking, aeresol spray
Do not shake beddings or create dust clouds
Be careful when tending to patients hair or shaving
Risk for infection
Use aseptic technique
Always inspect the site
Perform dressings, care of tracheostomy aseptically.
Risk for Aspiration
Give intravenous fluids for the 1 st 24 hours post tracheostomy
Oral intake may be attempted once patient is conscious.
Consult with the speech therapist.
Assess for the presence of tracheosophageal fistula before permitting oral feedings.
Position in upright position when feeding.
If oral intake is limited, continue IV fluids or enteral feedings.
Risk for constipation
Assess for recent BM
Use prescribed stool softener, laxatives and even enemas or suppositories as a necessary.
Anxiety and Fear
Allow patient enough time to communicate
Assist family in reassuring the patient
Risk for Ineffective Therapeutic Regimen Management and Risk for ineffective Family Therapeutic Management
Teach self care
Involve the SO
Educate the patient and family regarding care.
Managing for Stability
Managing for Change
Discussion Questions #2 What are the most significant changes affecting your unit ? Has the unit been able to effectively respond to these changes ?
The Strategic Plan – A Tool for Managing Change Part Three: Review
Profile of Existing Services
Historical Changes in Services
“ Where Are We Now?”
Trends and Best Practices
Local Factors Affecting Changes
How Did We Get in This Situation?” “ What Will Likely Happen if We Continue As We Are?”
The Components of the Strategic Plan Strategic Plan Operational Plans Monitoring and Evaluation Action Plan Action Plan Action Plan Action Plan Action Plan Action Plan Vision and Values for Library Services Goals for Unit Service Strategic Directions The Mission
The Vision describes a preferred future that is realistic and attainable but also optimistic. The Vision retains all that is positive about the library today but also enhances and improves the library to create a better future.
Values describe core beliefs that are the foundation of the organization and affect day to day operations.
Mission describes the reason for being by answering three questions: (1) What is the unit’s function? (2) Who does the unit serve? (3) How does the unit fulfill its function?
Goals are broad statements that define attainable accomplishments that will allow the library to realize its Vision. Goals bridge the gap between the present and the preferred future of the library.
Strategic Directions describe the broad initiatives necessary to achieve each goal.
Action Plans are the tasks necessary to pursue each Strategic Direction. Action Plans are specific, measurable, tied to a schedule and often assigned to departments for implementation.
Vision Goals Position the College of Nursing as an institution that is continually relevant and vital to the success of Santiago’s future, providing essential services for vibrant, healthy, sustainable and diverse communities. The Northeastern College – Nursing Department, rooted in Santiago’s vibrant and healthy community, are meeting places and destinations that enliven their neighborhoods, enhance understanding of cultural diversities, and link people to one another, to a sense of Santiago’s past, and to their shared future. Strategic Directions Community & Civic Role Information Gateway: Develop Community Facilities Marketing & Communication
Discussion Questions #3 How current are your UNIT’s Vision, Mission and Goals? Do you have an effective plan for dealing with your UNIT’s future?
Why Plans Fail Part Four:
Why We Fail # 1 Ineffective Vision
An Effective Vision for Strategic Planning
Embraces Change As Opportunity
Reasonable and Rewarding
Relevant to the Community and the Specific Challenges to be Addressed
Directly Tied to Goals / Strategic Directions and Ultimately Recommendations
Why We Fail # 2 No Follow-Through – Poor Implementation
Effective Implementation and Evaluation Local Strategic Plan Unit Strategic Plan Action Plans Performance Measures Capital / Operating Budget Implementation Strategies
Why We Fail # 3 Poor Leadership
Willingness to Embrace Change
Desire to Reposition the College of Nursing in the Community
An Effective Communicator
Why We Fail # 4 Poor Communication
A Statement of Purpose
An Opportunity to Speak to the Community Leaders, Parents, Students and Staff
A Means to Reposition the College of Nursing as a Key Player in the Community’s Development
Your Strategic Plan
Discussion Questions #4 If your group has done a strategic plan, was it successful? Why / why not? If your group has not done a strategic plan, what are the barriers to doing the plan?
Part Five Doing A Plan – What’s Involved
Creating a Plan: Who is Involved
The Authors of the Plan
Advisors and Observers
Review and Comment
Senior Management Staff
Faculty and Staff
The General Public
Creating a Plan : Roles & Responsibilities
Design the process and facilitate Board/senior staff discussions
Document discussion and prepare report
Prepare the Environmental Scan
Creating a Plan : Other Considerations
Monitoring and Updating
Discussion Question #5 What are the options for your unit to prepare a strategic plan?