Respiratory assessment

Respiratory Update II Deborah A. Hood DNP RN-BC CM Course Objectives: Describe risk factors, treatments and nursing care of the patient with obstructive sleep apnea. Describe risk factors, treatment and nursing care of the patient with head and neck cancer. Describe risk factors, treatments, and nursing care of the patient with COPD, pneumonia, and influenza. Describe the care and management of the critically ill patient suffering from pulmonary embolus. Disorders of the Oral Pharynx and Tonsils (Non-Infectious) Obstructive Sleep Apnea (OSA) Head and Neck Cancer Obstructive Sleep Apnea (OSA) Cessation of breathing during sleep lasting longer than 10 seconds at a minimum of 5 times per hour. Cause maybe neurogenic, but is usually due to problems with the soft palate or tongue. Contributing factors are obesity, a large uvula, a short neck, smoking, enlarged tonsils/adenoids, and oropharyngeal edema. Men are affected more than women. Obstructive Sleep Apnea History Do you wake up tired? Do you experience day time sleepiness? Are you more irritable? Has anyone complained of personality changes? Does your significant other report snoring or periods where you stop breathing? Obstructive Sleep Apnea (OSA) Pathophysiology: Muscles relax during sleep, displacing the tongue and neck structures causing obstruction of the upper airway though the chest continue to move. Apnea causes a respiratory acidosis. Neural centers of brain are stimulated after 10 seconds or longer of apnea and then corrects the obstruction. Obstructive Sleep Apnea (OSA) Obstructive Sleep Apnea (OSA) Physical Assessment Observe during sleep Decreased pulse ox Cyanosis Cyclical cessation of breathing Snoring Obstructive Sleep Apnea (OSA) Diagnostics: Overnight sleep studies Polysomnography (PSG) –overnight study Electroencephalograph (EEG) Electrocardiograph (ECG) Electromyograph (EMG)-determines depth of sleep, respiratory effect, 02 saturation, muscle movement Pulse oximetry Obstructive Sleep Apnea Obstructive Sleep Apnea (OSA) Non-surgical Management Change in sleeping position Weight loss Position-fixing devices Positive-pressure ventilation (CPAP) Surgical Management Adenoidectomy Uvulectomy Remodeling of posterior oropharynx Obstructive Sleep Apnea Head and Neck Cancers Accounts for about 4% of carcinomas in the U.S Men are affected three times more than women. Occur in people 60 yrs or older, but becoming more prevalent in young adults. Risk factors: Tobacco abuse Alcohol abuse Voice abuse (chronic laryngitis) Chronic exposure to chemicals/pollutants Poor oral hygiene Long-term or severe GERD Head and Neck Cancer Pathophysiology 80% are squamous cell carcinomas—slow growing. Usually first appear as deep ulcerations. Begins with a chronically irritated mucosa that changes into a tougher mucosa (squamous metaplasia). It is then replaced by an increasing tougher, thicker mucosa (hyperplasia). Keratin layer develops (keratosis). Genes controlling cell growth is damaged leading to abnormal, malignant cells. These lesions are often white and patchy or red and velvety. Metastasis often occur to lymph nodes, muscle, bone, or systemically through blood and lymphatic systems. Head and Neck Cancers History Have you had any difficulty in speaking? Do you currently or have you ever abused alcohol or tobacco? Exposure to environmental/occupational pollutants. Have you noticed and sores or lump in your neck? Do you have chronic lung disease? Head and Neck Cancers Physical Assessment: Inspection and palpation of the head and neck to assess for lesions, lumps, and tumors. Laryngeal exam by independent practitioner Common Diagnostics: Labs: CBC, Coagulation Studies, UA, Blood chemistries (liver, renal). CT to evaluate tumor location MRI to differentiate normal from diseased tissue (evaluate soft-tissue invasion). SPECT/PET: to locate additional tumor sites. Laryngoscopy, esophagoscopy, bronchoscopy. Head and Neck Cancers Head and Neck Cancer Head and Neck Cancers Head and Neck Cancers Head and Neck Cancers Head and Neck Cancers Treatment: Non-surgical Radiation Chemotherapy Surgical Small tumors maybe removed with laser/photodynamic therapy. Laryngectomy (partial/total) Tracheostomy Oropharyngeal cancer resections Head and Neck Cancers Post-op Care Monitor airway patency Suctioning Coughing and deep breathing Adequate oxygenation Humidified oxygen Monitor vital signs Hemodynamic status Comfort level Provide a means for communicating Head and Neck Cancers Post-op care: Monitor for hemorrhage Empty drains. Keep clear of clots by “stripping/milking” if there is an MD order. Document in output. Wound care/stoma care Pain management Emotional support Ensure consults: SLP Nutritional services OT/PT Lower Respiratory Problems Chronic Airflow Limitations Asthma-intermittent with obstructive air flow and wheezing - REVERSIBLE COPD – causes irreversible tissue damage and leads to respiratory failure Chronic bronchitis Emphysema Asthma Can occur at any age. Most adults with asthma had it as a child. More common in urban settings than rural. ASA or NSAID’s may trigger asthma. More than 40 million Americans suffer from asthma. 5000 deaths from acute asthma occur in the U.S annually. Asthma Pathophysiology: Intermittent and reversible airflow obstruction affecting only the airways, due to: Inflammation obstructs the lumen of the airways. Allergens bind to antibodies (IgE). The inflammatory response begins in which histamine, mast and WBC cells congest the area. Blood vessels dilate, capillaries leak leading to more swelling and congestion due to mucus production. Bronchospasm: airway hyper-responsiveness (allergens/pollutants) causes narrowing due to constriction. Severe bronchospasm can limit airflow to alveoli. Asthma Asthma History: How often do you have attacks? What are your triggers? Recent URI? Experienced other allergic symptoms (skin, rhinitis) History of smoking? Asthma Physical Assessment: Audible wheeze (louder on exhalation) Increased respiratory rate Coughing Accessory muscle use “barrel chest” Unable to speak in complete sentences Hypoxemia Changes in LOC Asthma Common Diagnostics: Labs: ABG’s, CBC, drug levels (Theophylline) Pulmonary Function Tests Chest X-ray Asthma Asthma Treatment: Drug therapy Preventative Medications: decrease airway responsiveness. Bronchodilators (long acting: Serevent) Cholinergic antagonist (Atrovent) Corticosteroids (Flovent, Prednisone) NSAID (Tilade) Methylxanthines (Theo-dur) Leukotriene Antagonist (Singulair, Xolair) Rescue Drugs: stop attack once it starts Bronchodilators (short-acting: Albuterol, Xopenex) Cholinergic antagonist Asthma Patient/Family Teaching Goals to improve airflow by decreasing the frequency of attacks. Education Assess respiratory status with peak flow at lease twice per week. How to self-treat When to consult practitioner Drug therapy Compliance Use spacer Lifestyle management Exercise (aerobic)—may require pre-medication Cessation of smoking Oxygen therapy Minimize exposure to allergens Asthma COPD Chronic Bronchitis Emphysema COPD Prevalence of chronic bronchitis and emphysema is about 13.5 million (chronic bronchitis) and 2 million (emphysema). Fourth leading cause of morbidity and mortality in the U.S. Chronic Bronchitis Pathophysiology: Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants. Chronic inflammation increases the number and size of mucus glands thus more mucus is produced. Bronchial walls thicken and impair airflow. Mucus plugs and infection narrow airways causing decreased gas exchange. Emphysema Pathophysiology: Two major changes occur: Loss of lung elasticity Hyperinflation of the lung COPD History: Occupational history Smoking history What are the patients triggers? Assess cough pattern Has sputum production changed? When do you experience the most sputum? Problems with ADL’s, sexual activity, or sleeping? Experienced unplanned weight loss? COPD Physical Assessment: General appearance Rapid, shallow breathing Barrel chest Fremitus Hyperresonant sounds on percussion Wheezes on inspiration and expiration Delayed capillary refill Pallor/Cyanosis Clubbing to the digits Lower extremity edema (right sided heart failure) COPD Common Diagnostics: Labs: ABG’s, CBC, sputum for gram stain and C&S, Chest X-ray PFT’s COPD COPD Treatment: Non-surgical management: Airway maintenance (liquefy secretions) Cough enhancement Oxygen therapy Drug therapy Pulmonary rehabilitation Exercise conditioning Breathing exercises Surgical management: Lung reduction Lung transplantation COPD COPD Patient/family teaching: Disease teaching Avoidance of infectious agents Medication instruction Nutrition regimen Exercise regimen Oxygen precautions Smoking cessation Infectious Respiratory Problems Influenza Pneumonia Influenza Highly contagious acute viral respiratory infection. Patients are contagious 24 hrs prior to becoming symptomatic. Can lead to complications (pneumonia, respiratory failure, death). Annual vaccinations are recommended for all, especially for the elderly as well as those who are immunocompromised, or debilitated. Teach patients to wash hands often and observe the new “etiquette” surrounding coughing and sneezing. They should isolate themselves until completely recovered. Influenza Physical Assessment: Severe headache Muscles aches Fever Chills Fatigue Weakness Anorexia Sore throat Rhinorrhea Pneumonia 2-5 million cases annually. Seventh leading cause of death. Highest incidence among institutionalized older adults. Maybe community or hospital acquired. Community is the most common. Pneumonia Pneumonia Pathophysiology: Excess of fluid in the lungs due to the inflammatory process that is triggered by inhalation of infectious organisms or irritating agents. Inflammation occurs in the interstitial spaces, the alveoli, and often the bronchioles due to the invasion of the bacteria causing edema and formation of exudate. Alveoli walls thicken impeding oxygenation and perfusion. Fibrin and edema stiffen the lung reducing compliance and vital capacity. Pneumonia may start in a segment then progress to a lobe. May lead to septicemia if organisms move into the bloodstream. Pneumonia History: Assess risk factors: Older adult Did not receive a recent immunization for pneumonia. Chronic health problems/chronic lung disease Tobacco/alcohol abuse/illicit drugs Living/working conditions Diet Exercise Sleep patterns Pneumonia Physical Assessment: General appearance Chest/pleuritic pain Myalgia Headache Chills Fever Cough (sputum production) Respiratory distress Tachycardia (rapid, weak) Hypotensive (dehydration and vasodilation) Crackles, wheezing, bronchial sounds to affected lung field Pneumonia Common Diagnostics: Labs: sputum for gram stain and C&S, CBC (increased or decreased WBC count), BC, UA/UC, HIV testing. CXR may not become diagnostic for 2 days after onset of symptoms. Pulse oximetry Bronchoscopy Pneumonia Pneumonia Treatment Oxygenation Airway clearance Fluid resuscitation Medications: Antibiotic therapy Bronchodilators Steroids Respiratory Problems of the Critically Ill Pulmonary Embolism Pulmonary Embolism Can occur at any age. Most common pulmonary disease among hospitalized patients. Major risk factors for DVT leading to PE: Prolonged immobility Central venous catheters Surgery Obesity Advancing age Conditions that increase blood clotting History of thromboembolism Pulmonary Embolism Patient History: Assess sudden onset of distress Determine risk factors Does the patient have a history of DVT, recent surgery, or prolonged immobility? Pulmonary Embolism Pathophysiology: Collection of particulate matter (solid, liquid, air) that enters venous circulation (vena cava to right atrium) and lodges in a pulmonary artery. Platelets collect on the embolus causing vasoconstriction which leads to pulmonary hypertension. Blood flow is obstructed leading to reduced oxygenation of the body. Pulmonary Embolism Sources of emboli: Fat Oil Tumor cells Amniotic fluid Foreign objects (broken IV catheters) Injected particles Septic emboli Pulmonary Embolism Physical Assessment: Symptoms: Sudden onset of dyspnea Pleuritic chest pain Described as sharp, stabbing on inspiration Severe apprehension, restlessness Feeling of impending doom Cough Hemoptysis secondary to pulmonary infarction Dry Pulmonary Embolism Physical Assessment: Tachycardia Breath sounds maybe normal or they may have crackles Pleural friction rub Tachypnea Diaphoresis Low-grade temp Petechiae over chest and axilla Decreased oxygen saturation and PaO2 S3 and S4 heart sound Severe hypotension Pulmonary Embolism Common Diagnostics: ABG’s Spiral CT Chest X-ray (infiltrates) Venous doppler Transesophageal echocardiogram (TEE) VQ Lung Scan Pulmonary Embolism Pulmonary Embolism Pulmonary Embolism Treatment: Medical Oxygen Drug Therapy Anticoagulants Lovenox Heparin drip Coumadin therapy Fibrinolytics Retavase TPA Pulmonary Embolism Treatment: Surgical Embolectomy: surgical removal of the embolus from the pulmonary blood vessel. Inferior vena cava interruption/filter Pulmonary Embolism Inferior Vena Cava Filter Pulmonary Embolism Pulmonary Embolism Nursing management/teaching: Anxiety Support family/patient Monitor for bleeding Advise patient/family on bleeding precautions Decreased Cardiac Output Inotropic support IV fluid therapy Manage hypoxemia Pulmonary Embolism Prevention: Avoid prolongation of bed rest Assess risk factors and intervene DVT prophylaxis Teach patient to adhere to Coumadin therapy SCD’s/venodynes SQ heparin/low-molecular weight heparin (Lovenox) References Ahrens, T., Prentice, D., & Kleinpell, R. (2007). Pulmonary Anatomy and Physiology. In Quincy McDonald (Ed.), Critical Care Nursing Certification (5 ed., pp. 171-227). New York: McGraw-Hill. Ignatavicius, D. D., & Workman, L. M. (2010). Medical-Surgical Nursing Patient-Centered Collaborative Care (6 ed.). St. Louis: Saunders Elsevier. References (Images) www.anaesthetist.com www.clivir.com www.diagnosingsleepapnea.com www.dkimages.com www.examiner.com www.fn.bmj.com www.images.timnhanh.com www.metrohealth.org References (Images) www.powershowz.medicalillustration.com www.thesleepapneaonline.com www.aboutneckcancer.com www.riversideonline.com www.surgery.med.umich.edu www.uth.tmc.edu www.news.wustl.edu/news