Respiratory 100131162132-phpapp01 (1)
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  • Primary function of respiratory system is transport of O2 and CO2. This requires the four processes collectively known as respiration: 1.      Pulmonary ventilation is the movement of air into and out of the lungs (breathing). This involves gas pressures and muscle contractions.2.      External respiration is the exchange of O2 (loading) and CO2 (unloading) between blood and alveoli (air sacs). 3.      Transport of respiratory gases between lungs and tissues. 4.      Internal respiration is gas exchange between blood and tissue cells.  Cellular respiration - the includes the metabolic pathways which utilize O2 and produce CO2, which will not be included in this unit.
  • What should you expect to Notice in a patient with adequate oxygenation and tissue perfusion related to respiratory function?
  • Loss of normal pharyngeal muscle tonePharynx collapse during inspirationTongue falls against posterior pharyngeal wallAsphyxia causes brief arousal from sleepRestores airway patency & airflowMay occur 100s of times a night
  • Inflammation of the mucus membranes of sinusesFollows a upper respiratory infectionRisks high in patients with impaired immunity
  • Obstruction of sinusImpaired drainage
  • Nursing diagnosisPainImbalanced Nutrition: Less than Body Requirements
  • External sphenoethmoidectomy

Respiratory 100131162132-phpapp01 (1) Respiratory 100131162132-phpapp01 (1) Presentation Transcript

  • NURSING CARE OF THE CLIENT:RESPIRATORY SYSTEM
  • 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
  • Assessing Lung Sounds
  • Adventitious Breath Sounds Fine crackles (dry, high-pitched popping…COPD, CHF, pneumonia) Coarse crackles (moist, low-pitched gurgling…pneumonia, edema, bronchitis) Sonorous wheezes (low-pitched snoring…asthma, bronchitis, tumor)
  • Adventitious Breath Sounds Sibilant wheezes (high-pitched, musical … asthma, bronchitis, emphysema, tumor) Pleural friction rub (creaking, grating… pleurisy, tuberculosis, abscess, pneumonia) Stridor (crowing…croup, foreign body obstruction, large airway tumor)
  • Diagnosing RespiratoryDisordersLaboratory Tests Radiologic Studies Hemoglobin  Chest X-ray  Ventilation-perfusion Arterial blood gases scan Pulmonary Function  CAT scan Tests  Pulmonary Sputum Analysis angiography
  • Respiratory DisordersOther diagnostic tests Pulse oximetry Bronchoscopy Thoracentesis MRI
  • 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
  • Physical Assessment: Upper AirwayProblems Check WBC & ABG levels Assess cognition Assess hydration status
  • Intervention: Upper AirwayProblems Suction Apply o2 & assess response Keep HOB elevated 30 degrees Notify MD Ensure venous access
  • Obstructive Sleep Apnea Intermittent absence of airflow through mouth & nose during sleep Occlusion of the oropharyngeal airway Obstruction causes O2 sat, pO2, and pH to rise & pCO2 to rise
  • Obstructive Sleep Apnea
  • Obstructive Sleep Apnea Loud storing during sleep Excessive daytime drowsiness Irritability Restless sleep
  • Obstructive Sleep Apnea Restore airflow  Weight reduction Prevent adverse  Alcohol abstinence effects of disorder  Improve nasal patency  Avoid prone sleeping position
  • Obstructive Sleep Apnea  Treatment of Choice: Continous positive airway pressure (CPAP)
  • Obstructive Sleep Apnea Tonsillectomy  Adenoidectomy
  • Obstructive Sleep Apnea Uvuloplatopharyngopla sty
  • Obstructive Sleep Apnea Disturbed Sleep Pattern Fatigue Ineffective Breathing Pattern Impaired Gas Exchange Risk for Injury Risk for Sexual Dysfunction
  • Tracheostomy Bypass upper airway obstruction 1. esophagus 2. trachea 3. tracheostomy tube
  • Tracheostomy Facilitate removal of secretions
  • Tracheostomy Manage long-term mechanical ventilation
  • 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
  • Physical Assessment: Infections Vital signs Auscultate all lung fields Monitor O2 sat Assess cognition Assess sputum Assess ability to cough & clear airway
  • Lab Values: Infections Elevated WBC ABG: pH lower than 7.35 HCO3 at or below 24 mmHg PaCO2 at or below 45 mmHg PaO2 below 90 mm Hg
  • Interventions: Infectious RespProblems Administer O2 Upright position with arms resting on table or armrests Chest physiotherapy/pulmonary hygiene Pace activities to prevent fatigue
  • Interventions: Infectious RespProblems Administer IV, oral, or inhaled drugs Respiratory therapy treatments Reassess resp status after resp therapy Ensure fluid intake 3 liters/day
  • Sinusitis
  • Sinusitis  Pain & tenderness  Headache, fever, mal aise  Nasal congestion  Purulent nasal discharge  Bad breath
  • Sinusitis: Medication Therapy Antibiotics  Saline nose drops or sprays Oral or topical decongestants  Systemic mucolytic agents Antihistamines
  • Sinusitis: Interdisciplinary Care Drain obstructed sinuses Control infection Relieve pain Prevent complications
  • Sinusitis Endoscopic sinus surgery
  • Sinus Surgery: Caldwell Lucprocedure
  • Sinus Surgery: Antral irrigation
  • 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
  • Pneumonia: Signs & SymptomsPrimary Atypical PNA Viral PNA Fever  Flu-like symptoms Headache  Headache  Fever Myalgias  Fatigue Arthralgias  Malaise Dry, hacking, non productive cough  Muscle aches
  • Pneumonia: Signs & SymptomsPneumocystis PNA  Dry, nonproductive Opportunistic cough infection Respiratory distress Abrupt onset  Intercostal Fever retractions Tachypnea  Cyanosis SOB
  • PneumoniaInterdisciplinary care Medications Prevention  Antibiotics Pneumococcal  Bronchodilators vaccine  Agents to liquefy Influenza vaccine mucus
  • PneumoniaTreatment Nursing Diagnosis Oxygen therapy  Ineffective airway Chest physiotherapy clearance  Ineffective breathing pattern  Activity intolerance
  • 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?
  • Nasal Cannula  Low flow delivery device  2 l/min = ~28%  Higher flow rates (>5 l/min) dry nasal membranes
  • Simple Face Mask  Flow rates 6-12 l/min  Delivers 35-50% O2  Pt comfort issues (Maybe used for Mr. Howe if SOB)
  • Non-Rebreathing Mask  Delivers accurate, high concentrations of oxygen  Achieves 60-90% O2 delivery
  • Oxygen Conserving Cannula  Built in oxygen reservoir  30-50% O2 delivery  Increased comfort
  • Nebulizers/Humidifiers 02 is drying to mucous membranes Nebulizers  Bubble-through humidifier  >4 l/min Humidifiers  Heated water
  • Tuberculosis Infection of the lung tissue Mycobacterium tuberculosis
  • TuberculosisSpread through dropletnuclei: Coughing Sneezing Speaking Singing
  • Tuberculosis: Risk Factors Overcrowded, poor living  Close contact to conditions infected person Poor nutritional status  Immune dysfunction; Previous infection HIV infection Inadequate treatment of primary infection leads  LTC facilities, to multi-drug resistant Prisons organisms  Elderly  Substance abuse
  • TuberculosisCaseation necrosis Inhaled bacteria multiply Tubercle is formed Infected tissue dies Cheeselike center forms
  • TuberculosisIf patient has adequate Inadequate immuneimmune response: response Scar tissue develops  TB can develop around tubercle rapidly Walls off bacilli Infected, does not develop TB
  • Reactivation TBSuppressed immune system due to Age Disease Use of immunosuppressive drugs
  • Tuberculosis: Signs & Symptoms Fatigue  Dry cough Weight loss  Later productive, Anorexia purelent/blood tingled pm fever  Night sweats
  • Tuberculosis: InterdisciplinaryCare Early detection Tuberculin test Accurate diagnosis  Intradermal PPD Effective disease (Mantoux) test treatment  Multiple-puncture Preventing spread to (tine) testing others
  • TB: Goals of MedicationTreatment Make the disease noncommunicable to others Reduce symptoms of the disease Affect a cure in the shortest possible time
  • Tuberculosis: Nursing Diagnosis Deficient Knowledge Ineffective Therapeutic Regimem Management Risk for Infection
  • 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
  • Bronchoscopy
  • 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
  • Physical Assessment: Lower RespProblems Take vital signs Monitor O2 sat Assess cognition Assess sputum Assess ability to cough & clear airway
  • Lab Values: Lower RespProblems Elevated RBC, HCT, HGB Elevated WBC ABGs ph <7.35 HCO3 > 24mm Hg PCO2 > 45 mm HG PaO2 < 80 mm Hg
  • 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
  • Acute Bronchitis
  • Bronchitis: Signs & Symptoms Non-productive cough  Chest pain Later becomes  Moderate fever productive Paroxysmal cough  General malaise
  • BronchitisTreatment Medications Symptomatic  ASA or tylenol Rest  Broad spectrum Increased fluid intake antibioticNursing Intervention  Cough expectorant teaching
  • Asthma Chronic inflammatory disorder of the airways Brief (acute asthma fatal) Persistent irritation of the airways
  • Asthma: Risk Factors Allergies Family history occupational exposure Respiratory viruses Exercise in cold air Emotional stress
  • Asthma: Triggers Allergens Resp tract infection Exercise Inhaled irritants Secondhand smoke Medications
  • Asthma: Acute/early response Vasoconstriction Edema Mucus production
  • Asthma: Patho Inflammatory  Impaired mucus mediators released clearing Activation of  SOB inflammatory cells  trapping of air Bronchoconstriction impairs gas Airway edema exchange
  • Asthma: Signs & Symptoms Chest tightness  Fatigue, anxiety Cough, dyspnea, apprenhension sheezing Tachycardia, Respiratory failure  Breath sounds may tachypnea, prolonged expiration improve right before failure
  • Asthma: Treatment Control symptoms Long term control Prevent acute  Anti-infammatory attacks agents Restore airway  Long acting patency bronchodialators Restore alveolar  Leukotriene ventilation modifiers
  • Asthma: TreatmentQuick relief Administration Short acting methods adrenergic  Metered-dose inhaler stimulants (MDI) Anticholinergic drugs  Dry powder inhaler Methylxanthines (DPI)  Nebulizer
  • 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
  • Pulmonary Embolism
  • 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)
  • IVC Filters  Greenfield  Bird’s Nest Filter Filter