Nursing Dx: Respiratory Dysfunction Ineffective Airway Activity Intolerance Clearance Anxiety Impaired Gas Exchange Altered Nutrition: Less than body Ineffective Breathing Pattern requirement Impaired Verbal Risk for Infection Communication
Respiratory System Its primary function is delivery of oxygen to the lungs and removal of carbon dioxide from the lungs.
Respiration Process of gas exchange Supply cells with oxygen for carrying on metabolism Remove carbon dioxide produced as a waste by-product. Two types of respiration: external and internal.
Respiratory Assessment Health History (allergies, occupation, lifestyle, health habits) Inspection (clients color, level of consciousness, emotional state)(Rate, depth, quality, rhythm, effort relating to respiration) Palpation and Percussion Auscultation (Listening for Normal and Adventitious Breath Sounds)
Assessment ReviewVital Signs Respiratory rate & heart rate WNL Oxygen saturation of 95% or higher
Assessment ReviewPhysical Assessment Speak a sentence of 12 words without stopping for breath Walk and talk without stopping for breath No cyanosis, pallor, or jaundice Oral mucus membrane & nail beds pink with rapid capillary refill
Assessment Review Fingertips and nails normal shape, no clubbing Anterior & posterior diameter of chest 2/3 smaller than lateral diameter Space between each rib larger than breath of patient’s finger Breathes in through nose & out through mouth & nose
Assessment Review Breathing quiet Air movement heard in all lobes of both lungs Sputum production minimal, clear or white Muscle development even with no muscle loss on arms & legs Weight proportionate to height; not underweight
Assessment ReviewPsychological Assessment Oriented, not confused Energy level good, can engage in desired work, recreational & personal activities
Assessment ReviewLaboratory Assessment RBC Hemoglobin Hematocrit WBC WNL for age & gender
Assessment: InadequateOxygenation Resp rapid & shallow Respirations noisy Cannot speak >4 or 5 words without pausing for breath Change in cognition, acute confusion Decreased oxygen saturation by pulse ox
Assessment: InadequateOxygenation Skin cyanosis or pallor (lighter-skinned pts) Cyanosis or pallor of lips or oral mucus membranes (pts of any skin color) Tachycardia Appears to strain to catch breath Fatigue
Physical Assessment:Inadequate O2 Take vital signs Auscultate all lung fields Monitor O2 sat Check recent Hgb, Hct, ABGs Assess cognition Assess use of accessory muscles
Physical Assessment:Inadequate O2 Assess presence of thick or excessive secretions Assess ability to cough and clear airway
Intervention: InadequateOxygenation Apply O2 & assess response Elevate HOB 30 degrees Suction if needed Notify MD Priortize & pace activities to prevent fatique
Assessment: Upper AirwayProblems Voice changes nasal quality if above palate “breathy” or “whispery” if larynx or trachea Snoring Mouth breathing
Assessment: Upper AirwayProblems Change in cognition or LOC or acute confusion Decreased O2 sat Skin cyanosis or pallor Cyanosis or pallor of lips or oral mucus membranes Tachycardia & dysrhythmia
Physical Assessment: Upper AirwayProblems Take vital signs Monitor O2 sat Assess for presence of thick or excessive secretions Assess ability to cough and clear airway Assess nasal drainage & sputum for color & blood
Assessment: Infectious RespProblems Resp shallow & rapid Decreased O2 sat Skin cyanosis or pallor Cyanosis or pallor of lips & oral mucus membranes Tachycardia Work hard to inhale & exhale Restless anxious or confused
Sinusitis: Health Promotion Promote nasal drainage Encourage liberal fluid intake Judicious use of nasal decongestants Treat any obstructive process
Pneumonia Inflammation of lung parenchyma Infectious: Bacteria, viruses, fungal protozoa Noninfectious: aspiration of gastric contents, inhalation of toxic or irritating gases Can be classified as community acquired, nosocomial, or opportunistic
Theresa A 20 year old college student Lives in a small dormitory with 30 other students. Four weeks into the Spring semester, she was diagnosed with bacterial pneumonia Admitted to the hospital
Teresa: High Priority Intervention Specimens for culture are taken prior to beginning the antibiotic Administering prior to cultures may make it impossible to determine the actual agent causing the pneumonia.
Theresa: Bacterial PneumoniaSputume culture results most frequent strain of found in community- acquired pneumonia Streptococcus pneumoniae
Teresa: Clinical Manifestations Fever Elderly Weakness stabbing or pleuritic Fatigue chest pain lethargy Confusion tachypnea poor appetite without classic s & s
Treatment: Bacterial Pneumonia Started on Penicillin G Response between 1 & 2 days
Complications of Pneumonia Atelectasis Impaired gas exchange Hypotension & shock Pleural effusion
Pneumonia: Impaired GasExchange Results in hypoxia Earliest sign and symptom of which is a change in the level of consciousness.
Interventions Oxygen by nasal cannula Plan for periods of rest during activities of daily living. Monitor pulse oximetry readings every 4 hours. What oxygen delivery system would be most effective for Theresa?
Mr. Howe c/o dyspnea Dx: R/O TB progressive wt loss What additional for several months questions should you Productive cough ask about Mr. Howe’s cough? Night sweats “wringing wet”
Assessing Cough How it feels How bad it is What makes it better or worse When it started Amount, color, odor, and consistency of sputum
Mr. Howe Diagnostic test Mantoux test expected for patient Sputum for acid-fast bacillus Chest X-ray History and Physical Examination
Mantoux Test Positive result only indicate exposure or has received BCG immunization BCG immunization: Eastern Europe and countries where TB is endemic Is not diagnostic for active TB
Mantoux Test Give upper 1/3 surface of the forearm Needle is inserted with bevel up 0.1 ml of purified derivative (PPD) inserted intradermally) Read 48-78 hrs Induration 1.5 mm or greater is + (HIV or immunosuppressed pts 5 mm or greater +
Sputum Studies Sputum Samples early morning Expectoration tracheal 15 ml required suction Obtain prior to Bronchoscopy antibiotics Used to Ask pt to rinse mouth identify infecting before collecting organisms specimen Confirm presence of malignant cells
Mr. Howe: BronchoscopyorderedPreparation Informed consent NPO after midnight Explain procedure, obtain baseline vs & ABG Atropine may be ordered to dry secretions
Mr. Howe: Post BronchoscopyComplications Aspiration Infection Pneumothorax
Mr. Howe: Post BronchoscopyCare NPO until gag reflex Monitor vital signs Assess for dyspnea, hemoptysis, & tachycardia Notify MD if fever, difficulty breathing Semi-Fowler’s position Give H2O as first fluid Inform pt of possible expectoration of blood tingled mucus
Tuberculosis: Drug Therapy
Mr. Howe’s Medication Regime Chemotherapy are Rifampicin all Hepatotoxic n/vEthambutol Thrombocytopenia optic neuritis turns all bodily skin rash secretions a red- orange color (tears, sweat, etc)
Mr. Howe’s Medication RegimeINH Streptomycin peripheral neuritis 8th cranial nerve (take Vitamin B 6 in damage conjunction to routine hearing test prevent) caution in renal hepatotoxicity disease GI upset
Mr. Howe’s Medication RegimePyrazinamid Heptoxicity hyperuricemia monitor uric acid & hepatic function
Mr. Howe’s Hospital Care Teach handwashing, cover nose and mouth when coughing, sneezing Droplet Isolation-negative pressure room Special particulate respirator mask Psychosocial support-reinforce need to take medication
Mr. Howe’s Teaching Plan Preventive measures to avoid catching viral infections Taken drugs in combination to avoid bacterial resistance Take meds at the same time of day on an empty stomach Follow med regimen 6-12 months as prescribed
Mr. Howe’s Teaching Plan Adequate nutritional status Annual check-up Annual Check-up: liver function tests Notify MD if signs of hepatitis, hepatoxicity, neurotoxicity, & visual changes occur
Thoracentesis Used to obtain pleural fluid for analysis Needle inserted between ribs second and third intercostal spaces Fluid withdrawn with syringe or tubing connected to sterile vacuum bottle
ThoracentesisPre-Procedure Baseline vital signs Informed consent- Make sure that a explained & signed CXR has been Inform about completed pressure sensations that will be experienced during the procedure
Thoracentesis: Positioning Lying on the unaffected side with the bed elevated 30 – 40 degrees Sitting on the edge of the bed with her feet supported and her arms and head on a padded overbed table. Straddling a chair with her arms and head resting on the back of the chair.
Post Thoracentesis Apply pressure to Monitor for blood- puncture site tingled mucus Assess bleeding & Assess for crepitus hypoxemia, Semi-fowlers or Assess for puncture site up tachycardia Assess breath sounds
Why is a chest x-ray ordered postprocedure?
Assessment: Lower RespProblems Resp shallow and rapid Decreased oxygen saturation Skin cyanosis or pallor Cyanosis or pallor of lips & mucus membranes Tachycardia Work hard to inhale & exhale
Assessment: Lower RespProblems Restless & anxious Thin compared to height Muscles of neck appear thick Arm & leg muscles appear thin Clubbed fingers Chest is barrel shaped Rib space more than a finger breath apart
Interventions: Lower RespProblems Upright position Chest Physiotherapy O2 low to maintain resp of 16 breaths minute Pace activities Administer inhaled drugs Respiratory therapy Fluid intake at least 3L daily
Bronchitis Common in adults Acute bronchitis follows a viral URIRisk factors Chronic bronchitis is a component of Impaired immune COPD defenses Cigarette smoking
Bronchitis Viral, bacterial or inflammatory Irritants cause increased mucus production and mucosal irritation
Bronchitis: Signs & Symptoms Non-productive cough Chest pain Later becomes Moderate fever productive Paroxysmal cough General malaise
Chronic Obstructive PulmonaryDisease A collective term used to refer to chronic lung disorders Air flow into or out of the lungs is limited
John Emphysema for 25 years H/O smoking Diagnosis: Bronchitis
John: Cigarette Smoking Major causative factor in the development of respiratory disorders lung cancer cancer of the larynx Emphysema chronic bronchitis
During assessment you note the presence of a“barrel chest”. “air trapping” in the lungs
Barrel Chest Slow progressive obstruction of airways Airways narrow Resistance to airflow increase Expiration slow and difficult Result: mismatch between alveolar ventilation and perfusion, leading to impaired gas exchange
Major symptoms to assess JohnforYou should be alert for the followingpresenting symptom of COPD? Increased dyspnea Sputum production
EmphysemaJohn is medicated with a bronchodilator to reduceairway obstruction. Assess for Dysrhythmias Central nervous system excitement Tachycardia
Purse Lip BreathingRecommended for John to: Decrease respiratory rate Increase alveolar ventilation Reduce functional residual capacity
Venturi Mask is prescribed for Johnbecause: Moderate Oxygen Flow Delivers precise, high-flow rates 24%-50% Humidification available Requires face mask
BronchiectasisA chronic dilation of thebronchi caused by: pulmonary TB infection chronic upper respiratory tract infections complications of other respiratory disorders
Obstruction of a pulmonary artery by a bloodborne substance
Pulmonary Embolism:Common Cause: Deep vein thrombosis
Other sources of PulmonaryEmboli Fat Emboli From fractured long bones Air Emboli From IVs Amniotic fluid Tumors
Mrs. Perkins Mrs Perkins is suspected of having a pulmonary embolus. What diagnostic test confirms this diagnosis?
Pulmonary Embolism The plasma D-dimer test is highly specific for the presence of a thrombus. An elevated d-dimer indicates a thrombus formation and lysis.What assessment data would support that Mrs. Perkins has experienced a pulmonary embolus?
Clinical Manifestations of PulmonaryEmbolus Sudden, unexplained dyspnea, tachypnea or tachycardia Cough Chest pain Hemoptysis Sudden changes in mental status (hypoxia)
Diagnosing Pulmonary Embolism Ventilation-Perfusion Scan Nuclear imaging test Determines percentage of each lung that is functioning normally Pulmonary Angiography
Pulmonary EmbolismMrs. Perkins pulse oximetry has decreasedto 90%. What does this indicate? The normal pulse oximeter reading is 93% - 100%. A reading of 90% indicates Mrs Perkins has an arterial oxygen level of about 60
Pulmonary EmbolismWith a diagnosis of PE, what intervention is crucial forMrs. Perkins? Institute and maintain bedrest Bedrest reduces metabolic demands and tissue needs for oxygen.
Management: Pulmonary Emboli Anticoagulation therapy Heparin Coumadin for ~6 months Thrombolytic therapy Use very cautiously only for acute, massive PE Urokinase, Streptokinase & tPA Inferior Vena Cava filter
Mrs. PerkinsMrs. Perkins is receiving a heparin drip.The bag hanging is 20,000 units/500 ml ofD5W infusing at 22 ml/hr. How many units ofheparin is Mrs Perkins receiving each hour?
Heparin Infusion 880 units20,000 divided by 500 = 40 unitsIf 22 ml are infused per hour, then 880 unitsof heparin are infused each hour40 x 22 = 880
Heparin TherapyWhat nursing interventions should you implement forMrs Perkins receiving Heparin? Keep protamine sulfate readily available Assess for overt & covert signs of bleeding Avoid invasive procedures and injections Administer stool softeners as ordered
Pulmonary EmbolismMrs Perkins PT is 12.9 and PTT is 98. What are yourimplications for administering heparin to Mrs Perkins? A normal PTT is 39 seconds 58-78 is 1.5 to 2 times the normal value and is within the normal therapeutic range A PTT of 98 means Mrs Perkins is not clotting; medication should be held.
Pulmonary EmbolismThe doctor has ordered Coumadin for Mrs.Perkins. PT = 22 PTT = 39 INR = 2.8What action should you implement Give the Coumadin because the theurapeutic INR level is 2-3. What is the antidote for Coumadin?
Pulmonary Embolism: Teaching Use a soft bristle toothbrush to reduce the risk of bleeding Avoid aspirin Aspirin is an antiplatlet which may increase bleeding tendencies.
Pulmonary Embolism: Teaching Wear a medic alert band Increase fluid intake to 2-3L day (increases fluid volume which prevents DVT the common cause of PE)