This document provides information on various diagnostic procedures and exams related to the respiratory system, including: - Chest x-ray to examine the lungs - Sputum specimen collection to identify organisms or abnormal cells - Suctioning procedure for sputum collection - Bronchoscopy for direct visual exam of airways - Pulmonary angiography using catheter and contrast dye - Thoracentesis for fluid or air removal from pleural space - Lung biopsy to obtain tissue for analysis - Ventilation/perfusion lung scan to evaluate blood flow and ventilation - Skin testing using intradermal injection to diagnose infections - Arterial blood gas measurement to assess acid-base state and oxygen carriage - Pulse

1. NURSINGBULLETS: RESPIRATORY SYSTEM – DIAGNOSTIC PROCEDURES

2. RISK FACTORS FOR RESPIRATORY DISORDERS Smoking Use of chewing tobacco Allergies Frequent respiratory illnesses Chest injury Surgery Exposure to chemicals & environmental pollutants Family history of infectious disease Geographic residence & travel to foreign countries

3. DIAGNOSTIC PROCEDURES AND EXAMS Chest x-ray film (radiograph) 1. Description: provides information regarding the anatomical location and appearance of the lungs. 2. Preprocedure a. Remove all jewelry and other metal objects from the chest area. b. Assess the client’s ability to inhale and hold breath. c. Question females regarding pregnancy or the possibility of pregnancy. 3. Postprocedure: Assist the client to dress.

4. Nursingbullets: SPUTUM SPECIMEN 1. Description: a specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells. 2. Preprocedure a. Determine specific purpose of collection and check with institutional policy for appropriate collection of specimen. b. Obtain an early morning sterile specimen from suctioning or expectoration after a respiratory treatment, if a treatment is prescribed.

5. c. Obtain 15 ml of sputum. d. Instruct the client to rinse the mouth with water before collection. e. Instruct the client to take several deep breaths and then cough deeply to obtain sputum. f. Always collect the specimen before client begins antibiotic therapy. 3. Postprocedure a. Transport specimen to laboratory STAT. b. Assist the client with mouth care.

6. Nursingbullets: SUCTIONING PROCEDURE -- SPUTUM SPECIMEN Aseptic technique Hyperoxygenate Lubricate the catheter with sterile water Tracheal suctioning : 4 inches Nasotracheal suctioning : insert to induce cough reflex Don’t apply suction while inserting Suction intermittently for 10-15 seconds Rotate and withdraw Hyperoxygenate & deep breaths

7. Nursingbullets: BRONCHOSCOPY 1. Description: direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope 2. Preprocedure a. Obtain informed consent. b. Maintain NPO status for client from midnight before the procedure. c. Obtain vital signs.

8. d. Assess the result of coagulation studies. e. Remove dentures or eyeglasses. f. Prepare suction equipment. g. Administer medication for sedation as prescribed. h. Have emergency resuscitation equipment readily available. 3. Postprocedure a. Monitor vital signs. b. Maintain client in semi-Fowler position.

9. c. Assess for the return of the gag reflex. d. Maintain NPO status until gag reflex returns. e. Have an emesis basin readily available for client to expectorate sputum. f. Monitor for bloody sputum. g. Monitor respiratory status, particularly if sedation was administered h. Monitor for complications, such as bronchospasm, bronchial perforation indicated by facial or neck crepitus, dysrhythmias, fever, bacteremia, hemorrhage, hypoxemia, and pneumothorax. i. Notify the physician if fever, difficulty in breathing, or other signs of complications occur following the procedure.

10. Nursingbullets: PULMONARY ANGIOGRAPHY 1. Description a. Pulmonary angiography is an invasive fluoroscopic procedure in which a catheter is inserted through the antecubital or femoral vein into the pulmonary artery or one of its branches. b. Pulmonary angiography involves an injection of iodine or radiopaque or contrast material.

11. 2. Preprocedure a. Obtain informed consent b. Assess for allergies to iodine, seafood, or other radiopaque dyes. c. Maintain NPO status of client for 8 hours before procedure. d. Monitor vital signs e. Assess results of coagulation studies f. Establish and intravenous access g. Administer sedation as prescribed h. Instruct the client to lie still during the procedure

12. i. Instruct the client that he or she may feel an urge to cough, flushing, nausea, or salty taste following injection of the dye j. Have emergency resuscitation equipment available 3. Postprocedure a. Monitor vital signs b. Avoid taking blood pressures for 24 hours in the extremity used for injection c. Monitor peripheral neurovascular status of the affected extremity d. Assess insertion site for bleeding e. Monitor for delayed reaction to the dye

13. Nursingbullets: THORACENTESIS 1. Description: removal of fluid or air from the pleural space via a transthoracic aspiration 2. Preprocedure a. Obtain informed consent b. Obtain vital signs c. Prepare the client for ultrasound or chest radiograph, if prescribed, before procedure d. Assess results of coagulation studies

14. e. Note that the client is positioned sitting upright, with the arms and head supported by a table at the bedside during the procedure. f. 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 g. Instruct the client not to cough, breath deeply, or move during the procedure.

16. 3. Postprocedure a. Monitor vital signs b. Monitor respiratory status c. Apply a pressure dressing, and assess the puncture site for bleeding and crepitus. d. Monitor for signs of pneumothorax, air embolism, and pulmonary edema

17. Nursingbullets: LUNG BIOPSY 1. Description a. A percutaneous lung biopsy is performed to obtain tissue for analysis by culture or cytological examination b. A needle biopsy is done to identify pulmonary lesions, changes in lung tissue, and the cause

18. 2. Preprocedure a. Obtain informed consent b. Maintain NPO status. c. Inform the client that a local anesthetic will be used but that sensation of pressure during needle insertion and aspiration may be felt. d. Administer analgesics and sedatives as prescribed 3. Postprocedure a. Monitor vital signs b. Apply dressing to the biopsy site and monitor for drainage or bleeding c. Monitor for signs of respiratory distress, and notify physician if they occur d. Monitor for signs of pneumothorax and air emboli, and notify physician if they occur e. Prepare the client for chest radiography if prescribed

19. Nursingbullets: VENTILATION PERFUSION LUNG SCAN 1. Description a. The perfusion scan evaluates blood flow to the lungs. b. The ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation. c. A radionucleotide may be injected for the procedure 2. Preprocedure a. Obtain informed consent b. Assess client for allergies to dye, iodine, or seafood c. Remove jewelry around the chest area d. Review breathing methods that may be required during testing.

20. e. Establish an intravenous access f. Administer sedation if prescribed g. Have emergency resuscitation equipment available. 3. Postprocedure a. Monitor client for reaction to nucleotide b. Instruct client to wash hands carefully with soap and water for 24 hours following the procedure.

21. Nursingbullets: SKIN TEST 1. Description: A skin test is an intradermal injection used to assist in diagnosing various infectious diseases 2. Preprocedure: Determine hypersensitivity or previous reactions to skin tests

22. 3. Procedure a. Use test injection test that is free of excessive body hair, dermatitis, and blemishes. b. Apply the injection at the upper one third of inner surface of the left arm c. Circle and mark the test site d. Document the date, time, and test site

23. 4. Postprocedure a. Advise the client not to scratch the test site so as to prevent infection and abscess formation b. Instruct the client to avoid washing the test site. c. Interpret the reaction at the injection site 48 to72 hours after administration of the test antigen d. Assess the test site for the amount of induration (hard swelling) in millimeters and for the presence of erythema and vesiculation (small blisterlike elevations)

24. Nursingbullets: ARTERIAL BLOOD GASES 1. Description: measurement of the dissolved oxygen and carbon dioxide in the arterial blood to reveal the acid-base state and how well the oxygen is being carried to the body 2. Preprocedure a. Perform Allen’s test before drawing radial artery specimens. b. Have the client rest for 30 minutes before specimen collection. c. Avoid suctioning before drawing ABG sample. d. Do not turn off oxygen unless the ABG sample is ordered to be drawn with client breathing room air.

25. 3. Postprocedure a. Place the specimen on ice. b. Note the client’s temperature on laboratory form. c. Note the oxygen and type of ventilation that the client is receiving on the laboratory form. d. Apply pressure to the puncture site for 5 to 10 minutes and longer if the client is taking anticoagulant therapy or has a bleeding disorder. e. Transport the specimen to the laboratory within 15 minutes.

26. Nursingbullets: PULSE OXIMETRY 1. Description a. Pulse oximetry is a noninvasive test that registers the oxygen saturation of the client’s hemoglobin. b. This arterial oxygen saturation (SaO 2 ) is recorded as a percentage. c. The normal value is 95% to 100%.

27. d. After a hypoxic client uses up the readily available oxygen (measured as the arterial oxygen pressure, PaO 2 , on ABG testing), the reserve oxygen, that oxygen attached to the hemoglobin (SaO 2 ), is drawn on to provide oxygen to the tissues. e. A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur.

28. 2. Procedure a. A sensor is placed on the client’s finger, toe, nose, ear lobe, or forehead to measure oxygen saturation, which then is displayed on a monitor. b. Maintain the transducer at heart level. c. Do not select an extremity with an impediment to blood flow. d. Results lower than 91% necessitate immediate treatment. e. If the SaO 2 is less than 85%, the tissues of the body have a difficult time becoming oxygenated; an SaO 2 of less than 70% is life threatening.

29. Nursingbullets: CHEST PHYSIOTHERAPY Best time - morning upon arising, 1 hr before meals or 2-3 hrs after meals Stop if pain occurs Provide mouth care CONTRAINDICATIONS OF CHEST PHYSIOTHERAPY (CPT) Increased respiratory distress History of fractures Chest incisions

30. POSTURAL DRAINAGE: use of the gravity NURSING CARE Position the client Best time – A.M. upon arising, 1 hr before meals, 2-3 hrs after meals Stop if cyanosis or exhaustion occurs Maintain position 5-20 mins after Provide mouth care after the procedure

31. CONTRAINDICATIONS OF POSTURAL DRAINAGE Unstable V/S Increased ICP CLIENT INSTRUCTIONS FOR INCENTIVE SPIROMETRY Use the lips to form seal around the mouth piece Inspire deeply Hold inspiration for a few seconds Forcefully exhale Avoid the use of spirometry at mealtime - it may cause nausea

32. Nursingbullets: Chest Tube Thoracotomy Chest Tubes/Water seal drainage Insertion of a catheter into the intrapleural space to maintain constant negative pressure when air/fluid have accumulated Chest tube is inserted to underwater drainage to allow for the space of air/fluid and prevent reflux of air into the chest For evacuation of air, chest tube is placed in the second or third intercostal space, anterior or midaxillary line (air rises to upper chest)

33. For drainage of fluid, chest tube is place in the eight or ninth intercostal space, midaxillary line. Chest tube is connected to tubing for the collection system; the distal end of the collection tubing must be placed below the water level in order to prevent atmospheric air from entering the pleural space. Drainage system: water-seal drainage system can be set up using one, two, or three bottles; or a commercial, disposable device (e.g., Pleur-evac) may be used.

34. One-Bottle System

35. 2. Two-bottle system a. One bottle serves as a drainage collection chamber, the other as a water seal. b. The first bottle is the drainage collection and has two short tubes in the rubber stopper. One of these tubes is attached to the drainage tubing coming from the client; the other is attached to the underwater tube of the second bottle (the water-seal bottle). The air vent of the water-seal bottle must be left open to the atmospheric air. If suction is used, the first bottle serves as drainage collection and water-seal chamber, and the second bottle serves as the suction chamber

36. Two-way Bottle System

37. Nursing care: without suction 1. Examine the entire system to ensure air tightness and absence of obstruction from kinks or dependent loops of tubing 2. Note oscillation of the fluid level within the water-seal tube. It will rise on inspiration and fall on expiration due to changes in the intrapleural pressure. If oscillation stops and system is intact, notify physician. 3. Check the amount, color, and characteristics of the drainage. If drainage ceases and system is not blocked, assess for signs of respiratory distress from fluid/ air accumulation

38. Three-Bottle System a. This system has a drainage collection, a water seal, and a suction-control bottle. b. The third bottle controls the amount of pressure in the system. The suction control bottle has three tubes inserted in the stopper, two short and one long. One short tube is joined with the tubing to former air vent of the water-seal; the second short tube is connected to suction. The third (long) tube (or suction-control tube) is located between the short tubes and has one end open to the atmosphere and other below the water level.

39. Nursing care: with suction 1. Attach suction tubing to suction apparatus, and chest catheter to drainage system 2. Open suction slowly until a stream of bubbles is seen in the suction chamber. There should be continuous bubbling in this chamber and intermittent bubbling in the waters seal. Check for an air leak in the system if bubbling in water seal is constant; notify physician if air leak 3. Check drainage, keep drainage system below level of client’s chest, keep Vaseline gauze at bedside, encourage coughing and deep breathing, and provide ROM

40. 4. Always keep drainage system lower than the level of the client’s chest 5. Keep Vaseline gauze at bedside at all times in case chest tube falls out 6. Encourage coughing and deep breathing to facilitate removal of air and drainage from pleural cavity 7. Never clamp chest tubes. 8. Removal of the chest tube: instruct the client to perform Valsalva maneuver; apply Vaseline pressure dressing to the site 9. If the water-seal bottle should break, immediately obtain some type of fluid-filled container to create an emergency water seal until a new unit can be obtained

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