Respiratory

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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

    1. 1. NURSING CARE OF THE CLIENT: RESPIRATORY SYSTEM<br />
    2. 2. Nursing Dx: Respiratory Dysfunction<br />Ineffective Airway Clearance<br />Impaired Gas Exchange<br />Ineffective Breathing Pattern<br />Impaired Verbal Communication<br />Activity Intolerance<br />Anxiety<br />Altered Nutrition: Less than body requirement<br />Risk for Infection<br />
    3. 3.
    4. 4.
    5. 5. Respiratory System<br />Its primary function is delivery of oxygen to the lungs and removal of carbon dioxide from the lungs.<br />
    6. 6. Respiration<br />Process of gas exchange <br />Supply cells with oxygen for carrying on metabolism<br />Remove carbon dioxide produced as a waste by-product.<br />Two types of respiration: external and internal.<br />
    7. 7.
    8. 8. Respiratory Assessment<br />
    9. 9. Assessment Review<br />Vital Signs<br />Respiratory rate & heart rate WNL<br />Oxygen saturation of 95% or higher<br />
    10. 10. Assessment Review<br />Physical Assessment<br />Speak a sentence of 12 words without stopping for breath<br />Walk and talk without stopping for breath<br />No cyanosis, pallor, or jaundice<br />Oral mucus membrane & nail beds pink with rapid capillary refill<br />
    11. 11. Assessment Review<br />Fingertips and nails normal shape, no clubbing<br />Anterior & posterior diameter of chest 2/3 smaller than lateral diameter<br />Space between each rib larger than breath of patient’s finger<br />Breathes in through nose & out through mouth & nose<br />
    12. 12. Assessment Review<br />Breathing quiet<br />Air movement heard in all lobes of both lungs<br />Sputum production minimal, clear or white<br />Muscle development even with no muscle loss on arms & legs<br />Weight proportionate to height; not underweight<br />
    13. 13. Assessment Review<br />Psychological Assessment<br />Oriented, not confused<br />Energy level good, can engage in desired work, recreational & personal activities<br />
    14. 14. Assessment Review<br />Laboratory Assessment<br />RBC<br />Hemoglobin<br />Hematocrit<br />WBC<br /> WNL for age & gender<br />
    15. 15. Assessment: Inadequate Oxygenation<br />Resp rapid & shallow<br />Respirations noisy<br />Cannot speak &gt;4 or 5 words without pausing for breath<br />Change in cognition, acute confusion<br />Decreased oxygen saturation by pulse ox<br />
    16. 16. Assessment: Inadequate Oxygenation<br />Skin cyanosis or pallor (lighter-skinned pts) <br />Cyanosis or pallor of lips or oral mucus membranes (pts of any skin color)<br />Tachycardia<br />Appears to strain to catch breath<br />Fatigue<br />
    17. 17. Physical Assessment: Inadequate O2<br />Take vital signs<br />Auscultate all lung fields<br />Monitor O2 sat<br />Check recent Hgb, Hct, ABGs<br />Assess cognition<br />Assess use of accessory muscles<br />
    18. 18. Physical Assessment: Inadequate O2<br />Assess presence of thick or excessive secretions<br />Assess ability to cough and clear airway<br />
    19. 19. Intervention: Inadequate Oxygenation<br />Apply O2 & assess response<br />Elevate HOB 30 degrees<br />Suction if needed<br />Notify MD<br />Priortize & pace activities to prevent fatique<br />
    20. 20.
    21. 21.
    22. 22. Assessing Lung Sounds<br />
    23. 23. Adventitious Breath Sounds<br /><ul><li>Fine crackles (dry, high-pitched popping…COPD, CHF, pneumonia)
    24. 24. Coarse crackles (moist, low-pitched gurgling…pneumonia, edema, bronchitis)
    25. 25. Sonorous wheezes (low-pitched snoring…asthma, bronchitis, tumor)</li></li></ul><li>Adventitious Breath Sounds<br /><ul><li>Sibilant wheezes (high-pitched, musical … asthma, bronchitis, emphysema, tumor)
    26. 26. Pleural friction rub (creaking, grating… pleurisy, tuberculosis, abscess, pneumonia)
    27. 27. Stridor (crowing…croup, foreign body obstruction, large airway tumor)</li></li></ul><li>Diagnosing Respiratory Disorders<br />Laboratory Tests <br />Hemoglobin<br />Arterial blood gases<br />Pulmonary Function Tests<br />Sputum Analysis<br />Radiologic Studies <br />Chest X-ray<br />Ventilation-perfusion scan <br />CAT scan <br />Pulmonary angiography<br />
    28. 28. Respiratory Disorders<br />Other diagnostic tests<br />Pulse oximetry<br /> Bronchoscopy <br />Thoracentesis<br />MRI<br />
    29. 29. Assessment: Upper Airway Problems<br />Voice changes<br /> nasal quality if above palate<br /> “breathy” or “whispery” if larynx or trachea<br />Snoring<br />Mouth breathing<br />
    30. 30. Assessment: Upper Airway Problems<br />Change in cognition or LOC or acute confusion<br />Decreased O2 sat<br />Skin cyanosis or pallor<br />Cyanosis or pallor of lips or oral mucus membranes<br />Tachycardia & dysrhythmia<br />
    31. 31. Physical Assessment: Upper Airway Problems<br />Take vital signs<br />Monitor O2 sat<br />Assess for presence of thick or excessive secretions<br />Assess ability to cough and clear airway<br />Assess nasal drainage & sputum for color & blood<br />
    32. 32. Physical Assessment: Upper Airway Problems<br />Check WBC & ABG levels<br />Assess cognition<br />Assess hydration status<br />
    33. 33. Intervention: Upper Airway Problems<br />Suction<br />Apply o2 & assess response<br />Keep HOB elevated 30 degrees<br />Notify MD<br />Ensure venous access<br />
    34. 34. Obstructive Sleep Apnea<br />Intermittent absence of airflow through mouth & nose during sleep<br />Occlusion of the oropharyngeal airway<br />Obstruction causes O2 sat, pO2, and pH to rise & pCO2 to rise<br />
    35. 35. Obstructive Sleep Apnea<br />
    36. 36.
    37. 37. Obstructive Sleep Apnea<br />Loud storing during sleep<br />Excessive daytime drowsiness<br />Irritability<br />Restless sleep<br />
    38. 38. Obstructive Sleep Apnea<br />Restore airflow <br />Prevent adverse effects of disorder<br />Weight reduction<br />Alcohol abstinence<br />Improve nasal patency<br />Avoid prone sleeping position<br />
    39. 39. Obstructive Sleep Apnea<br />Treatment of Choice:<br />Continous positive<br />airway pressure (CPAP)<br />
    40. 40. Obstructive Sleep Apnea<br />Tonsillectomy<br />Adenoidectomy<br />
    41. 41. Obstructive Sleep Apnea<br />Uvuloplatopharyngoplasty<br />
    42. 42. Obstructive Sleep Apnea<br />Disturbed Sleep Pattern<br />Fatigue<br />Ineffective Breathing Pattern<br />Impaired Gas Exchange<br />Risk for Injury<br />Risk for Sexual Dysfunction<br />
    43. 43. Tracheostomy<br />Bypass upper airway obstruction<br /> 1. esophagus<br /> 2. trachea<br /> 3. tracheostomy<br /> tube<br />
    44. 44. Tracheostomy<br />Facilitate removal of secretions<br />
    45. 45. Tracheostomy<br />Manage long-term mechanical ventilation<br />
    46. 46. Assessment: Infectious Resp Problems<br />Resp shallow & rapid<br />Decreased O2 sat<br />Skin cyanosis or pallor<br />Cyanosis or pallor of lips & oral mucus membranes<br />Tachycardia<br />Work hard to inhale & exhale<br />Restless anxious or confused<br />
    47. 47. Physical Assessment: Infections<br />Vital signs<br />Auscultate all lung fields<br />Monitor O2 sat<br />Assess cognition<br />Assess sputum<br />Assess ability to cough & clear airway<br />
    48. 48. Lab Values: Infections<br />Elevated WBC<br />ABG:<br /> pH lower than 7.35<br /> HCO3 at or below 24 mmHg<br /> PaCO2 at or below 45 mmHg<br /> PaO2 below 90 mm Hg<br />
    49. 49. Interventions: Infectious Resp Problems<br />Administer O2<br />Upright position with arms resting on table or armrests<br />Chest physiotherapy/pulmonary hygiene<br />Pace activities to prevent fatigue<br />
    50. 50. Interventions: Infectious Resp Problems<br />Administer IV, oral, or inhaled drugs<br />Respiratory therapy treatments<br />Reassess resp status after resp therapy<br />Ensure fluid intake 3 liters/day<br />
    51. 51. Sinusitis<br />
    52. 52. Sinusitis<br />Pain & tenderness<br />Headache, fever, malaise<br />Nasal congestion<br />Purulent nasal discharge<br />Bad breath<br />
    53. 53. Sinusitis: Medication Therapy<br />Antibiotics<br />Oral or topical decongestants<br />Antihistamines<br />Saline nose drops or sprays<br />Systemic mucolytic agents<br />
    54. 54. Sinusitis: Interdisciplinary Care<br />Drain obstructed sinuses<br />Control infection<br />Relieve pain<br />Prevent complications<br />
    55. 55. Sinusitis<br />Endoscopic sinus surgery<br />
    56. 56. Sinus Surgery: Caldwell Luc procedure<br />
    57. 57. Sinus Surgery: Antral irrigation<br />
    58. 58. Sinusitis: Health Promotion<br />Promote nasal drainage<br />Encourage liberal fluid intake<br />Judicious use of nasal decongestants<br />Treat any obstructive process<br />
    59. 59. Pneumonia<br />Inflammation of lung parenchyma<br />Infectious: Bacteria, viruses, fungal protozoa<br />Noninfectious: aspiration of gastric contents, inhalation of toxic or irritating gases<br />Can be classified as community acquired, nosocomial, or opportunistic<br />
    60. 60.
    61. 61. Pneumonia: Signs & Symptoms<br />Primary Atypical PNA<br />Fever<br />Headache<br />Myalgias<br />Arthralgias<br />Dry, hacking, non productive cough<br />Viral PNA<br />Flu-like symptoms<br />Headache<br />Fever<br />Fatigue<br />Malaise<br />Muscle aches<br />
    62. 62. Pneumonia: Signs & Symptoms<br />Pneumocystis PNA<br />Opportunistic infection<br />Abrupt onset<br />Fever<br />Tachypnea<br />SOB<br />Dry, nonproductive cough<br />Respiratory distress <br />Intercostal retractions<br />Cyanosis<br />
    63. 63. Pneumonia<br />Interdisciplinary care<br />Prevention<br />Pneumococcal vaccine<br />Influenza vaccine<br />Medications<br />Antibiotics<br />Bronchodilators<br />Agents to liquefy mucus<br />
    64. 64. Pneumonia<br />Treatment<br />Oxygen therapy<br />Chest physiotherapy<br />Nursing Diagnosis<br />Ineffective airway clearance<br />Ineffective breathing pattern<br />Activity intolerance<br />
    65. 65. Theresa<br />A 20 year old college student <br />Lives in a small dormitory with 30 other students.<br />Four weeks into the Spring semester, she was diagnosed with bacterial pneumonia<br />Admitted to the hospital<br />
    66. 66. Teresa: High Priority Intervention<br />Specimens for culture are taken prior to beginning the antibiotic<br />Administering prior to cultures may make it impossible to determine the actual agent causing the pneumonia.<br />
    67. 67. Theresa: Bacterial Pneumonia<br />Sputume culture results <br />most frequent strain of found in community-acquired pneumonia<br />Streptococcus pneumoniae<br />
    68. 68. Teresa: Clinical Manifestations <br />Fever<br />stabbing or pleuritic chest pain<br />tachypnea<br />Elderly<br />Weakness<br />Fatigue<br />lethargy <br />Confusion<br />poor appetite without classic s & s<br />
    69. 69. Treatment: Bacterial Pneumonia<br />Started on Penicillin G<br />Response between 1 & 2 days<br />
    70. 70. Complications of Pneumonia<br />Atelectasis<br />Hypotension & shock<br />Pleural effusion<br />Impaired gas exchange<br />
    71. 71. Pneumonia: Impaired Gas Exchange<br />Results in hypoxia<br />Earliest sign and symptom of which is a change in the level of consciousness.<br />
    72. 72. Interventions<br />Oxygen by nasal cannula<br />Plan for periods of rest during activities of daily living.<br />Monitor pulse oximetry readings every 4 hours.<br />What oxygen delivery system would be most effective for Theresa?<br />
    73. 73. Nasal Cannula<br /><ul><li>Low flow delivery device
    74. 74. 2 l/min = ~28%
    75. 75. Higher flow rates (>5 l/min) dry nasal membranes</li></li></ul><li>Simple Face Mask<br />Flow rates 6-12 l/min<br />Delivers 35-50% O2<br />Pt comfort issues (Maybe used for Mr. Howe if SOB)<br />
    76. 76. Non-Rebreathing Mask<br />Delivers accurate, high concentrations of oxygen<br />Achieves 60-90% O2 delivery<br />
    77. 77. Oxygen Conserving Cannula<br />Built in oxygen reservoir<br />30-50% O2 delivery<br />Increased comfort<br />
    78. 78. Nebulizers/Humidifiers<br />02 is drying to mucous membranes<br />Nebulizers<br />Bubble-through humidifier<br />&gt;4 l/min<br />Humidifiers<br />Heated water<br />
    79. 79. Tuberculosis<br />Infection of the lung tissue <br />Mycobacterium tuberculosis<br />
    80. 80. Tuberculosis<br />Spread through droplet<br />nuclei:<br />Coughing<br />Sneezing<br />Speaking<br />Singing<br />
    81. 81.
    82. 82. Tuberculosis: Risk Factors<br />Overcrowded, poor living conditions<br />Poor nutritional status<br />Previous infection<br />Inadequate treatment of primary infection leads to multi-drug resistant organisms<br />Close contact to infected person<br />Immune dysfunction; HIV infection<br />LTC facilities, Prisons<br />Elderly<br />Substance abuse<br />
    83. 83. Tuberculosis<br />Caseation necrosis<br />Inhaled bacteria multiply<br />Tubercle is formed<br />Infected tissue dies<br />Cheeselike center forms<br />
    84. 84.
    85. 85. Tuberculosis<br />If patient has adequate<br />immune response:<br />Scar tissue develops around tubercle<br />Walls off bacilli<br />Infected, does not develop TB<br />Inadequate immune<br />response<br />TB can develop rapidly<br />
    86. 86. Reactivation TB<br />Suppressed immune system due to<br />Age<br />Disease<br />Use of immunosuppressive drugs<br />
    87. 87. Tuberculosis: Signs & Symptoms<br />Fatigue<br />Weight loss<br />Anorexia<br />pm fever<br />Dry cough<br />Later productive, purelent/blood tingled<br />Night sweats<br />
    88. 88. Tuberculosis: Interdisciplinary Care<br />Early detection<br />Accurate diagnosis<br />Effective disease treatment<br />Preventing spread to others<br />Tuberculin test<br />Intradermal PPD (Mantoux) test<br />Multiple-puncture (tine) testing<br />
    89. 89. TB: Goals of Medication Treatment<br />Make the disease noncommunicable to others<br />Reduce symptoms of the disease<br />Affect a cure in the shortest possible time <br />
    90. 90. Tuberculosis: Nursing Diagnosis<br />Deficient Knowledge<br />Ineffective Therapeutic Regimem Management<br />Risk for Infection<br />
    91. 91. Mr. Howe<br />c/o dyspnea <br />progressive wt loss for several months<br />Productive cough<br />Night sweats “wringing wet”<br />Dx: R/O TB<br />What additional questions should you ask about Mr. Howe’s cough?<br />
    92. 92. Assessing Cough<br />How it feels<br />How bad it is<br />What makes it better or worse<br />When it started<br />Amount, color, odor, and consistency of sputum<br />
    93. 93. Mr. Howe<br />Diagnostic test expected for patient<br />Mantoux test<br />Sputum for acid-fast bacillus<br />Chest X-ray<br />History and Physical Examination<br />
    94. 94. Mantoux Test<br />Positive result only indicate exposure or has received BCG immunization <br />BCG immunization: Eastern Europe and countries where TB is endemic<br />Is not diagnostic for active TB<br />
    95. 95. Mantoux Test<br />Give upper 1/3 surface of the forearm<br />Needle is inserted with bevel up<br />0.1 ml of purified derivative (PPD) inserted intradermally)<br />Read 48-78 hrs<br />Induration 1.5 mm or greater is + (HIV or immunosuppressed pts 5 mm or greater +<br />
    96. 96. Sputum Studies<br />Sputum Samples<br />Expectoration tracheal suction<br />Bronchoscopy<br />Used to <br />identify infecting organisms<br />Confirm presence of malignant cells<br />early morning<br />15 ml required<br />Obtain prior to antibiotics<br />Ask pt to rinse mouth before collecting specimen<br />
    97. 97. Mr. Howe: Bronchoscopy ordered<br />Preparation<br />Informed consent<br />NPO after midnight<br />Explain procedure, obtain baseline vs & ABG<br />Atropine may be ordered to dry secretions<br />
    98. 98. Bronchoscopy<br />
    99. 99. Mr. Howe: Post Bronchoscopy <br />Complications<br /><ul><li>Aspiration
    100. 100. Infection
    101. 101. Pneumothorax</li></li></ul><li>Mr. Howe: Post Bronchoscopy Care<br />NPO until gag reflex<br /><ul><li>Monitor vital signs
    102. 102. Assess for dyspnea, hemoptysis, & tachycardia
    103. 103. Notify MD if fever, difficulty breathing
    104. 104. Semi-Fowler’s position
    105. 105. Give H2O as first fluid
    106. 106. Inform pt of possible expectoration of blood tingled mucus</li></li></ul><li>Tuberculosis: Drug Therapy<br />
    107. 107. Mr. Howe’s Medication Regime<br />Chemotherapy are all Hepatotoxic<br />Ethambutol<br />optic neuritis<br />skin rash<br />Rifampicin<br />n/v<br />Thrombocytopenia<br />turns all bodily secretions a red-orange color (tears, sweat, etc)<br />
    108. 108. Mr. Howe’s Medication Regime<br />INH<br />peripheral neuritis (take Vitamin B 6 in conjunction to prevent)<br /> hepatotoxicity<br />GI upset<br />Streptomycin<br />8th cranial nerve damage <br />routine hearing test<br />caution in renal disease<br />
    109. 109. Mr. Howe’s Medication Regime<br />Pyrazinamid<br />Heptoxicity<br />hyperuricemia <br />monitor uric acid & hepatic function<br />
    110. 110. Mr. Howe’s Hospital Care<br />Teach handwashing, cover nose and mouth when coughing, sneezing<br />Droplet Isolation-negative pressure room<br />Special particulate respirator mask<br />Psychosocial support-reinforce need to take medication<br />
    111. 111. Mr. Howe’s Teaching Plan<br />Preventive measures to avoid catching viral infections<br />Taken drugs in combination to avoid bacterial resistance<br />Take meds at the same time of day on an empty stomach<br />Follow med regimen 6-12 months as prescribed<br />
    112. 112. Mr. Howe’s Teaching Plan<br />Adequate nutritional status<br />Annual check-up<br />Annual Check-up: liver function tests<br />Notify MD if signs of hepatitis, hepatoxicity, neurotoxicity, & visual changes occur<br />
    113. 113. Thoracentesis<br />Used to obtain pleural fluid for analysis<br />Needle inserted between ribs second and third intercostal spaces<br />Fluid withdrawn with syringe or tubing connected to sterile vacuum bottle<br />
    114. 114. Thoracentesis<br />Pre-Procedure<br />Informed consent-explained & signed<br />Inform about pressure sensations that will be experienced during the procedure<br />Baseline vital signs<br />Make sure that a CXR has been completed<br />
    115. 115. Thoracentesis: Positioning<br />Lying on the unaffected side with the bed elevated 30 – 40 degrees<br />Sitting on the edge of the bed with her feet supported and her arms and head on a padded overbed table.<br />Straddling a chair with her arms and head resting on the back of the chair.<br />
    116. 116. Post Thoracentesis<br />Apply pressure to puncture site<br />Assess bleeding & crepitus<br />Semi-fowlers or puncture site up<br />Monitor for blood-tingled mucus<br />Assess for hypoxemia,<br />Assess for tachycardia<br />Assess breath sounds<br />
    117. 117. Why is a chest x-ray ordered post procedure? <br />
    118. 118. Assessment: Lower Resp Problems<br />Resp shallow and rapid<br />Decreased oxygen saturation<br />Skin cyanosis or pallor<br />Cyanosis or pallor of lips & mucus membranes<br />Tachycardia<br />Work hard to inhale & exhale<br />
    119. 119. Assessment: Lower Resp Problems<br />Restless & anxious<br />Thin compared to height<br />Muscles of neck appear thick<br />Arm & leg muscles appear thin<br />Clubbed fingers<br />Chest is barrel shaped<br />Rib space more than a finger breath apart<br />
    120. 120. Physical Assessment: Lower Resp Problems<br />Take vital signs<br />Monitor O2 sat<br />Assess cognition<br />Assess sputum<br />Assess ability to cough & clear airway<br />
    121. 121. Lab Values: Lower Resp Problems<br />Elevated RBC, HCT, HGB<br />Elevated WBC<br />ABGs<br /> ph &lt;7.35<br /> HCO3 &gt; 24mm Hg<br /> PCO2 &gt; 45 mm HG<br /> PaO2 &lt; 80 mm Hg<br />
    122. 122. Interventions: Lower Resp Problems<br />Upright position<br />Chest Physiotherapy<br />O2 low to maintain resp of 16 breaths minute<br />Pace activities<br />Administer inhaled drugs<br />Respiratory therapy<br />Fluid intake at least 3L daily<br />
    123. 123. Bronchitis<br />Common in adults<br />Risk factors<br />Impaired immune defenses<br />Cigarette smoking<br />Acute bronchitis follows a viral URI<br />Chronic bronchitis is a component of COPD<br />
    124. 124. Bronchitis<br />Viral, bacterial or inflammatory<br />Irritants cause increased mucus production and mucosal irritation<br />
    125. 125. Acute Bronchitis<br />
    126. 126. Bronchitis: Signs & Symptoms<br />Non-productive cough<br />Later becomes productive<br />Paroxysmal cough<br />Chest pain<br />Moderate fever<br />General malaise<br />
    127. 127. Bronchitis<br />Treatment<br />Symptomatic<br />Rest<br />Increased fluid intake<br />Nursing Intervention<br />teaching<br />Medications<br />ASA or tylenol<br />Broad spectrum antibiotic<br />Cough expectorant<br />
    128. 128. Asthma<br />Chronic inflammatory disorder of the airways<br />Brief (acute asthma fatal)<br />Persistent irritation of the airways<br />
    129. 129. Asthma: Risk Factors<br />Allergies<br />Family history occupational exposure <br />Respiratory viruses<br />Exercise in cold air<br />Emotional stress<br />
    130. 130. Asthma: Triggers<br />Allergens<br />Resp tract infection<br />Exercise<br />Inhaled irritants<br />Secondhand smoke<br />Medications<br />
    131. 131. Asthma: Acute/early response<br />Vasoconstriction<br />Edema<br />Mucus production<br />
    132. 132. Asthma: Patho<br />Inflammatory mediators released<br />Activation of inflammatory cells<br />Bronchoconstriction<br />Airway edema<br />Impaired mucus clearing<br />SOB<br />trapping of air impairs gas exchange<br />
    133. 133.
    134. 134. Asthma: Signs & Symptoms<br />Chest tightness<br />Cough, dyspnea, sheezing<br />Tachycardia, tachypnea, prolonged expiration<br />Fatigue, anxiety apprenhension<br />Respiratory failure<br />Breath sounds may improve right before failure<br />
    135. 135. Asthma: Treatment<br />Control symptoms<br />Prevent acute attacks<br />Restore airway patency<br />Restore alveolar ventilation<br />Long term control<br />Anti-infammatory agents<br />Long acting bronchodialators<br />Leukotriene modifiers<br />
    136. 136. Asthma: Treatment<br />Quick relief<br />Short acting adrenergic stimulants<br />Anticholinergic drugs<br />Methylxanthines<br />Administration methods<br />Metered-dose inhaler (MDI)<br />Dry powder inhaler (DPI)<br />Nebulizer<br />
    137. 137. Chronic Obstructive Pulmonary Disease<br />A collective term used to refer to chronic lung disorders<br />Air flow into or out of the lungs is limited<br />
    138. 138.
    139. 139.
    140. 140. John<br />Emphysema for 25 years<br />H/O smoking<br />Diagnosis: Bronchitis<br />
    141. 141. John: Cigarette Smoking<br />Major causative factor in the development of respiratory disorders<br />lung cancer<br />cancer of the larynx<br />Emphysema<br />chronic bronchitis<br />
    142. 142. During assessment you note the presence of a “barrel chest”.<br />“air trapping” in the lungs<br />
    143. 143. Barrel Chest<br />Slow progressive obstruction of airways<br />Airways narrow<br />Resistance to airflow increase<br />Expiration slow and difficult<br />Result: mismatch between alveolar ventilation and perfusion, leading to impaired gas exchange<br />
    144. 144. Major symptoms to assess John for<br />You should be alert for the following<br />presenting symptom of COPD?<br />Increased dyspnea<br />Sputum production<br />
    145. 145. Emphysema<br />John is medicated with a bronchodilator to reduce<br />airway obstruction. Assess for<br /> Dysrhythmias<br />Central nervous system excitement<br />Tachycardia<br />
    146. 146. Purse Lip Breathing<br />Recommended for John to:<br />Decrease respiratory rate<br />Increase alveolar ventilation<br />Reduce functional residual capacity<br />
    147. 147. Venturi Mask is prescribed for John because:<br />Moderate Oxygen Flow<br />Delivers precise, high-flow rates<br />24%-50%<br />Humidification available<br />Requires face mask<br />
    148. 148. Bronchiectasis<br />A chronic dilation of the<br />bronchi caused by:<br />pulmonary TB infection<br />chronic upper respiratory tract infections<br />complications of other respiratory disorders <br />
    149. 149. Obstruction of a pulmonary artery by a bloodborne substance<br />
    150. 150. Pulmonary Embolism: <br />Common Cause:<br />Deep vein thrombosis<br />
    151. 151. Pulmonary Embolism<br />
    152. 152. Other sources of Pulmonary Emboli<br />Fat Emboli<br />From fractured long bones<br />Air Emboli<br />From IVs<br />Amniotic fluid<br />Tumors<br />
    153. 153. Mrs. Perkins<br />Mrs Perkins is suspected of having a pulmonary embolus. <br />What diagnostic test confirms this diagnosis?<br />
    154. 154. Pulmonary Embolism<br />The plasma D-dimer test is highly specific for the presence of a thrombus.<br />An elevated d-dimer indicates a thrombus formation and lysis.<br /> What assessment data would support that Mrs. Perkins has experienced a pulmonary embolus?<br />
    155. 155. Clinical Manifestations of Pulmonary Embolus<br />Sudden, unexplained dyspnea, tachypnea or tachycardia<br />Cough<br />Chest pain<br />Hemoptysis<br />Sudden changes in mental status (hypoxia)<br />
    156. 156. Diagnosing Pulmonary Embolism<br />Ventilation-Perfusion Scan<br />Nuclear imaging test<br />Determines percentage of each lung that is functioning normally<br />Pulmonary Angiography<br />
    157. 157. Pulmonary Embolism<br />Mrs. Perkins pulse oximetry has decreased<br />to 90%. What does this indicate?<br />The normal pulse oximeter reading is 93% - 100%. <br />A reading of 90% indicates Mrs Perkins has an<br /> arterial oxygen level of about 60<br />
    158. 158. Pulmonary Embolism<br />With a diagnosis of PE, what intervention is crucial for<br />Mrs. Perkins?<br />Institute and maintain bedrest<br />Bedrest reduces metabolic demands and tissue needs for oxygen.<br />
    159. 159. Management: Pulmonary Emboli<br />Anticoagulation therapy<br />Heparin<br />Coumadin for ~6 months<br />Thrombolytic therapy<br />Use very cautiously only for acute, massive PE<br />Urokinase, Streptokinase & tPA<br />Inferior Vena Cava filter<br />
    160. 160. Mrs. Perkins<br />Mrs. Perkins is receiving a heparin drip.<br />The bag hanging is 20,000 units/500 ml of <br />D5W infusing at 22 ml/hr. How many units of<br />heparin is Mrs Perkins receiving each hour?<br />
    161. 161. Heparin Infusion<br />880 units<br />20,000 divided by 500 = 40 units<br />If 22 ml are infused per hour, then 880 units<br />of heparin are infused each hour<br />40 x 22 = 880<br />
    162. 162. Heparin Therapy<br />What nursing interventions should you implement for<br />Mrs Perkins receiving Heparin? <br />Keep protamine sulfate readily available<br />Assess for overt & covert signs of bleeding<br />Avoid invasive procedures and injections<br />Administer stool softeners as ordered<br />
    163. 163. Pulmonary Embolism<br />Mrs Perkins PT is 12.9 and PTT is 98. What are your <br />implications for administering heparin to Mrs Perkins?<br />A normal PTT is 39 seconds<br />58-78 is 1.5 to 2 times the normal value and is within the normal therapeutic range<br />A PTT of 98 means Mrs Perkins is not clotting; medication should be held.<br />
    164. 164.
    165. 165. Pulmonary Embolism<br />The doctor has ordered Coumadin for Mrs.<br />Perkins. PT = 22 PTT = 39 INR = 2.8<br />What action should you implement<br />Give the Coumadin because the theurapeutic INR level is 2-3.<br />What is the antidote for Coumadin?<br />
    166. 166. Pulmonary Embolism: Teaching<br />Use a soft bristle toothbrush to reduce the risk of bleeding<br />Avoid aspirin<br />Aspirin is an antiplatlet which may increase bleeding tendencies.<br />
    167. 167. Pulmonary Embolism: Teaching<br />Wear a medic alert band<br />Increase fluid intake to 2-3L day (increases fluid volume which prevents DVT the common cause of PE)<br />
    168. 168. IVC Filters<br />Greenfield Filter<br />Bird’s Nest Filter<br />

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