Nursing Dx: Respiratory Dysfunction Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Impaired Verbal Communication Activity Intolerance Anxiety Altered Nutrition: Less than body requirement Risk for Infection
Assessment Review Vital Signs Respiratory rate & heart rate WNL Oxygen saturation of 95% or higher
Assessment Review Physical 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 Review Psychological Assessment Oriented, not confused Energy level good, can engage in desired work, recreational & personal activities
Assessment Review Laboratory Assessment RBC Hemoglobin Hematocrit WBC WNL for age & gender
Assessment: Inadequate Oxygenation 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: Inadequate Oxygenation 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: Inadequate Oxygenation Apply O2 & assess response Elevate HOB 30 degrees Suction if needed Notify MD Priortize & pace activities to prevent fatique
Assessment: Upper Airway Problems Voice changes nasal quality if above palate “breathy” or “whispery” if larynx or trachea Snoring Mouth breathing
Assessment: Upper Airway Problems 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 Airway Problems 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 Resp Problems 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 Resp Problems Administer O2 Upright position with arms resting on table or armrests Chest physiotherapy/pulmonary hygiene Pace activities to prevent fatigue
Interventions: Infectious Resp Problems Administer IV, oral, or inhaled drugs Respiratory therapy treatments Reassess resp status after resp therapy Ensure fluid intake 3 liters/day
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 Pneumonia Sputume culture results most frequent strain of found in community-acquired pneumonia Streptococcus pneumoniae
Teresa: Clinical Manifestations Fever stabbing or pleuritic chest pain tachypnea Elderly Weakness Fatigue lethargy Confusion poor appetite without classic s & s
Treatment: Bacterial Pneumonia Started on Penicillin G Response between 1 & 2 days
Complications of Pneumonia Atelectasis Hypotension & shock Pleural effusion Impaired gas exchange
Pneumonia: Impaired Gas Exchange 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?
Tuberculosis: Risk Factors Overcrowded, poor living conditions Poor nutritional status Previous infection Inadequate treatment of primary infection leads to multi-drug resistant organisms Close contact to infected person Immune dysfunction; HIV infection LTC facilities, Prisons Elderly Substance abuse
Tuberculosis Caseation necrosis Inhaled bacteria multiply Tubercle is formed Infected tissue dies Cheeselike center forms
Tuberculosis If patient has adequate immune response: Scar tissue develops around tubercle Walls off bacilli Infected, does not develop TB Inadequate immune response TB can develop rapidly
Reactivation TB Suppressed immune system due to Age Disease Use of immunosuppressive drugs
Tuberculosis: Signs & Symptoms Fatigue Weight loss Anorexia pm fever Dry cough Later productive, purelent/blood tingled Night sweats
Tuberculosis: Interdisciplinary Care Early detection Accurate diagnosis Effective disease treatment Preventing spread to others Tuberculin test Intradermal PPD (Mantoux) test Multiple-puncture (tine) testing
TB: Goals of Medication Treatment Make the disease noncommunicable to others Reduce symptoms of the disease Affect a cure in the shortest possible time
Mr. Howe c/o dyspnea progressive wt loss for several months Productive cough Night sweats “wringing wet” Dx: R/O TB What additional questions should you ask about Mr. Howe’s cough?
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 expected for patient Mantoux test 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 Expectoration tracheal suction Bronchoscopy Used to identify infecting organisms Confirm presence of malignant cells early morning 15 ml required Obtain prior to antibiotics Ask pt to rinse mouth before collecting specimen
Mr. Howe: Bronchoscopy ordered Preparation Informed consent NPO after midnight Explain procedure, obtain baseline vs & ABG Atropine may be ordered to dry secretions
Inform pt of possible expectoration of blood tingled mucus
Tuberculosis: Drug Therapy
Mr. Howe’s Medication Regime Chemotherapy are all Hepatotoxic Ethambutol optic neuritis skin rash Rifampicin n/v Thrombocytopenia turns all bodily secretions a red-orange color (tears, sweat, etc)
Mr. Howe’s Medication Regime INH peripheral neuritis (take Vitamin B 6 in conjunction to prevent) hepatotoxicity GI upset Streptomycin 8th cranial nerve damage routine hearing test caution in renal disease
Mr. Howe’s Medication Regime Pyrazinamid 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
Thoracentesis Pre-Procedure Informed consent-explained & signed Inform about pressure sensations that will be experienced during the procedure Baseline vital signs Make sure that a CXR has been completed
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 puncture site Assess bleeding & crepitus Semi-fowlers or puncture site up Monitor for blood-tingled mucus Assess for hypoxemia, Assess for tachycardia Assess breath sounds
Assessment: Lower Resp Problems 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 Resp Problems 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 Resp Problems Take vital signs Monitor O2 sat Assess cognition Assess sputum Assess ability to cough & clear airway
Interventions: Lower Resp Problems 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 Risk factors Impaired immune defenses Cigarette smoking Acute bronchitis follows a viral URI Chronic bronchitis is a component of COPD
Bronchitis Viral, bacterial or inflammatory Irritants cause increased mucus production and mucosal irritation
Asthma: Signs & Symptoms Chest tightness Cough, dyspnea, sheezing Tachycardia, tachypnea, prolonged expiration Fatigue, anxiety apprenhension Respiratory failure Breath sounds may improve right before failure
Asthma: Treatment Control symptoms Prevent acute attacks Restore airway patency Restore alveolar ventilation Long term control Anti-infammatory agents Long acting bronchodialators Leukotriene modifiers
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 John for You should be alert for the following presenting symptom of COPD? Increased dyspnea Sputum production
Emphysema John is medicated with a bronchodilator to reduce airway obstruction. Assess for Dysrhythmias Central nervous system excitement Tachycardia
Purse Lip Breathing Recommended for John to: Decrease respiratory rate Increase alveolar ventilation Reduce functional residual capacity
Venturi Mask is prescribed for John because: Moderate Oxygen Flow Delivers precise, high-flow rates 24%-50% Humidification available Requires face mask
Bronchiectasis A chronic dilation of the bronchi 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 Pulmonary Emboli 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 Pulmonary Embolus 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 Embolism Mrs. Perkins pulse oximetry has decreased to 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 Embolism With a diagnosis of PE, what intervention is crucial for Mrs. 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. Perkins Mrs. Perkins is receiving a heparin drip. The bag hanging is 20,000 units/500 ml of D5W infusing at 22 ml/hr. How many units of heparin is Mrs Perkins receiving each hour?
Heparin Infusion 880 units 20,000 divided by 500 = 40 units If 22 ml are infused per hour, then 880 units of heparin are infused each hour 40 x 22 = 880
Heparin Therapy What nursing interventions should you implement for Mrs 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 Embolism Mrs Perkins PT is 12.9 and PTT is 98. What are your implications 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 Embolism The doctor has ordered Coumadin for Mrs. Perkins. PT = 22 PTT = 39 INR = 2.8 What 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)