Respiratory Notes (RN School)

Respiratory Notes for RN School Chapter 27 Diagnostic studies and related nursing care (endoscopy, thoracentesis) Review assessments of lungs and thorax from health assessment Bronchoscopy: Indicated when? When looking for tumors, pneumonia that won’t go away, bronchial washing. Post-op: Check for a gag reflex these patients are at risk for aspiration, watch for bronchospasm (nurse will be listening for wheezing and stridor -- call respiratory for a bronchodilator) To prepare: NPO, no smoking, have informed consent, Thoracentesis: done to remove fluid from pleural space, or simply for assessment Interventions: Put them on the side of the bed with arms over table Informed consent What needs to be monitored: BP, HR, lung sounds, and respiratory rate Assessment of pneumothorax: unequal chest expansion Post-op pneumothorax interventions: chest x-ray, monitor insertion site, teach patient about signs of pneumothorax, assess lung sounds often, get your specimens labeled and sent to the lab. Arterial blood gas (analysis, interventions to correct underlying problem) You will see ABG’s on test: Will be given a list of ABG’s; you pick which one is most critical, and what pt. needs to be seen first. If patient has hypoxia: give O2 ARDS: Give patient PEEP and put on a ventilator. If patient has pneumonia, administer incentive spirometer If pt. has hypercarbia: Give O2 you may need ABG results to even recognize this Watch for pinpoint pupils, decreased respirations. Pursed-lip, and diaphragmatic breathing. Calculate pack years of smoking: Formula: number of packs per day smoked x years smoked (Assess willingness to quit first) Check occupation for lung disease: Asbestos, paints, gasses, other carcinogens Uncompensated metabolic acidosis causes: Kidney injury: treat underlying problem Uncompensated respiratory acidosis: give O2 when hypoxic Put on mechanical ventilator when CO2 is high. Uncompensated respiratory alkalosis: Give O2 when breathing too quickly. Assessment findings (normal, abnormal) Inspection- look at size of chest for abnormalities (barrel chest) Palpation- chest expansion, tactile fremitus, crepitus (air trapped under the skin- could be from tracheal injury or pneumothorax) Percussion - not used often. Can be used for diaphragmatic excursion(review this) Resonance-normal Auscultation Chapter 28 Oxygen delivery devices (review handout for nursing care) Nasal cannula: often the first to start with. Pros: Easiest and best tolerated. Cons: Pressure injuries on the ears and dries out the nose. 6L/min is the limit Simple face mask: 5-6 L/min at least. If the flow rate is not high enough, patient will rebreath CO2 Venturi mask: Pros: precise amount of oxygen regardless of patient’s respiratory pattern Cons: should not have an aqua pack. Partial rebreather/nonrebreather: Bag must be filled to at least ? with oxygen when applied Tracheostomy collar: Humidification is a must Noninvasive positive pressure ventilation Oxygen administration/safety Patient teaching Don’t smoke No open flames Keep oxygen away from gas range Store flammables somewhere else Hypercarbia: their drive for breathing is a low oxygen level Hypoxia always trumps hypercarbia Normal O2 range for people with COPD hypercarbia -- 88-92 O2 Complications of oxygen therapy O2 induced hypoventilation O2 toxicity: damages lung tissue from high FiO2 delivered over several days. We need to improve oxygenation without this high percentage of oxygen Absorption atelectasis: occurs when someone is given high FiO2, and we have had them on this for 2-3 days. They aren't breathing nitrogen that keeps alveoli open. Not enough nitrogen alveoli collapse. Drying of mucous membranes Infection - associated with delivery equipment Suctioning/ safety issues When to suction: Patient has difficulty breathing, Weak cough (pt with stroke, or neuromuscular disease) Not all trach patients need suctioning. On a mechanical ventilator -- an alarm may go off, when this happens treat the patient; not the alarm (bag the patient) Suction when you hear upper airway noise, if the patient isn’t coughing effectively Technique: Hyperoxygenate before and after suctioning. If they cough, that is how you know you're in the trachea Precautions: Make sure they don’t become hypoxic; they may also have bronchospasms Adverse effects biggest is hypoxia Care of clients with tracheostomy Post op: Look at incision and assess for signs of infection Change dressings using sterile technique. New tracheostomy: if they cough out the tube, use sutures strings to keep the airway open or use a bag valve mask on the face and have somebody occlude the opening. Tracheostomy care: Usually have disposable inner cannula. Patient is most at risk for coughing out tube when changing ties. Teaching: speaking with tracheostomy is possible, but a person with a laryngectomy doesn’t have vocal cords, so they will need other methods to speak. Complications of accidental decannulation After 72 hours a nurse may put the tube back in Chapter 29 Post-op care for nasal surgery Nasal packing: Can become dislodged and become an airway obstruction. Assessment: look for excessive swallowing. May indicate bleeding. Mouth breathing; They need to be taught to drink a lot of fluid. Don't strain Don’t use aspirin or NSAIDS (at risk for bleeding) Upper airway obstruction How do you know if they have one: stridor or inability to speak Interventions: Heimlich. Chest thrusts, CPR. Children explore with their mouths Toilet tube rule: if an object can be dropped through the holder it is too small for the child to be playing with Don’t let them eat foods like grapes or anything small that could occlude the airway Up to age 1, we give them back blows (when choking) Facial trauma Protect airway Test CSF for glucose What bone is most likely to be broken: mandible (it protrudes) Eye exam: We want to know that the eye moves and that they can see. Intermaxillary fixation: They need to carry wire cutters, because if they vomit they need to cut them off to avoid aspiration Care of the client with laryngeal cancer Radiation of the head, neck, and chest: Biggest concern is radiation esophagitis: can’t eat, Usually need a peg tube before radiation starts to ensure adequate nutrition. Skin damage Laryngectomy: Total laryngectomy: they will not aspirate. Partial laryngectomy: they are at a huge risk for aspiration Subtotal laryngectomy feeding precaution: (read in book subglottic method of feeding) Patient needs to sit up right. Small bites Patient teaching: Methods of communication: discuss this before they have their surgery Should avoid swimming May need vocational rehab Back to shower stream Need to carry a card that says, “I'm a total neck breather” (this is for a CPR situation where they would be bagged.) Shave carefully OSA: Lose weight Sleep with head of bed elevated, Smoking cessation CPAP and Bi-pap If CPAP or Bi-pap doesn’t work surgery is an option Chapter 30 Care of the client with asthma Patho: inflamed airways: reactive airway disease Inflammation triggered by an allergen starts in childhood and moves to adulthood Clinical manifestation: wheezing, increased work of breathing, tachypnea Usually occurs in childhood. New onset in adults is not seen often Carbon dioxide will rise when air gets trapped -- resp alk ? resp acidosis Exercise induced asthma: need short acting beta 2 (albuterol) take when they have symptoms: take before they exercise or know there is a trigger coming. What meds will a patient with asthma that occurs every 2 weeks need?: Will need a rescue inhaler Inhaled steroid: maintenance drug Long acting beta 2 agonists Black box is because people will use a long acting inhaler during an asthmatic crisis -- long acting takes too long to kick in. Wash out the mouth when using a steroid -- at risk for oral candidiasis. Dilantin & methylxanthine (aminophylline) therapeutic range 10-20 mcg/mL (small range means there is not much difference between therapeutic and toxic levels) Atrovent: anticholinergic Peak expiratory flow meter Teaching: find personal best reading, everything else compares to that personal best. We want to see how quickly can they get air out. Green-yellow-red zones 50-75% of best means they are in the red zone When a patient is in the yellow zone: Use a short-acting bronchodilator If it doesn’t get better: use it again, call the doctor, or go to the ER When in the red zone: Use short-acting inhaler and go to the ER Drugs used for seasonal allergy asthma: Cromolyn sodium (bronchodilator that is used for kids with asthma) Cromolyn is a mucolytic agent: take 1-2 puffs QID with seasonal allergies, start 2-3 weeks before allergy season. Care of the client with COPD Most important contributing factor: smoking Occupations that contribute to acquiring COPD: Coal mining, sewing factory contributes to getting COPD Difference between emphysema and chronic bronchitis Emphysema: problems with alveoli Chronic Bronchitis: name points to airway issue Defining characteristic is a productive cough that goes on for over 2 years. Coarse crackles and wheezing because of narrowed airways. Pursed lip breathing Complications: Hypoxia Acidosis Fatigue Right sided heart failure Interventions: Make them stop smoking. Can’t be cured but slow down progression Same drugs that treat asthma treat chronic bronchitis Mucinex is common Inhaled corticosteroids: short and long acting. Inhaled beta 2 agonists adverse effect: tachycardia They come to the hospital with acute exacerbation: usually a respiratory illness I.e. flu & pneumonia Get vaccine for both, avoid large crowds, wear a mask Lung reduction surgery for emphysema may be an option Bronchial hygiene: cough and deep breath. COPD teaching Alternate rest and activity Make sure you do activities below level of the heart Change your environment by lowering your work surfaces. Energy conservation techniques They get full really fast. Need smaller more frequent meals to maintain adequate nutrition Flutter valves can also be used for COPD Check blood sugars for all patients on systemic steroids. Xolair: used for asthma that does not respond to other treatments Monitor at doctors office for 1 hour after treatment because you don’t want them to go into anaphylaxis Care of the child with cystic fibrosis Patho: thick sticky mucus that affects lungs and pancreas. Patients need pancreatic enzyme replacements...often times become diabetic because of the damage from pancreas. Usually don’t live past 40. Lung transplants Need postural drainage: using gravity to remove mucus Percuss for 30 mins (Now there are vests for percussion) Need drugs that think secretions Bacterial infections (Burkholderia cepacia pseudomonas) with long lifespan, slow growing, and hard to get rid of. Medications for Cystic fibrosis: Antibiotics, pancreatic enzyme replacement, bronchodilators, mucolytic agents, inhaled steroids Care of the client with lung cancer including chest tube management Largest risk factor: smoking 5-year survival rate is less than 10% because it is usually very progressed by the time it is discovered. All chronic smokers need a screening spiral CT scan (insurance will not pay for this) Treatment options Small cell lung cancer: Fast growing surgery will not even be considered Radiation and chemo is used Non small cell lung cancer: Can be removed with surgery. If everything is removed there may be a good outcome Open chest surgery: Risks: infection Pain management: Very important. Patient can die from complications, because pain was not effectively treated. Come back with a chest tube: pneumothorax, chest trauma End of life care/hospice may be an option\ Post-op thoracotomy care Impaired gas exchange Ineffective airway clearance Acute pain Impaired mobility upper extremities Risk for imbalanced fluid volume Chest tube management: Know 3 chambers: 1st chamber: Collects fluid from client - mark - assure all connections intacct - air leak can cause pneumothorax. 2nd chamber: Water seal - may see bubbles with respirations until lung seals off - continual means leaking. Fluid in tubing will fluctuate when breathing. 3rd chamber: Suction amount determined by depth of water in this chamber -- will bubble continually if there is a water column. Water seal- keeps are from getting into pleural space. Might see bubbles if there is a tear in the lung. Expect to see tidaling Chest tube just for drainage and we start seeing bubbles: be concerned with a developing leak. Tape all connection Worst case scenario: tubing gets pulled apart, stick the end of the tubing in sterile water to keep the seal. If the whole tube is pulled out. Cover with an occlusive sterile dressing and tape on 3 sides to let some of the air leak out. Know the purpose of each of the three chambers Patient with chest tube needs to go to the bathroom. We can take it with them. Need approval from provider to disconnect suction. Keep below the level of the chest when transporting suction. Pulmonary HTN: probably won’t live 5 years unless you get a transplant Medications: IV Vasodilators at home Teach patient how to take care of their pumps: check for occlusions etc. Others – occupational lung disease (general); pulmonary fibrosis, pulmonary hypertension Chapter 31 Care of the client with respiratory infection – Colds: Need to get throat culture: only way to know. Group A hemolytic strep: can cause rheumatic fever and glomerulonephritis pharyngitis/tonsillitis: laryngitis, sinusitis: post op care sinusitis: Peds – tonsillectomy: done after several diagnoses of strep throat, or sleep apnea and snoring Sleep apnea stunts growth in children because growth hormone is released during sleep and they aren’t getting quality sleep. No red liquids Teach parents to start with a liquid diet and to watch for excessive swallowing The more active they are the more likely they are to bleed Day 7-10 the child is at risk for hemorrhage because the scab sloughs off Epiglottitis: Swollen epiglottis. (viral condition) When epiglottis is swollen, it covers the trachea, and causes an upper airway obstruction. Patient will present drooling, tongue protruding, and chin thrust out. Treat with Racemic Epinephrine Get the Dr. ASAP they need to be intubated Croup (LTB) Airway swelling; defining characteristic :croupy cough Teach parents to watch for: stridor, retractions of the soft tissue, nasal flaring Keep pediatric crash cart close by Medications: steroids to decrease inflammation RSV Clogs up small airways; very dangerous in children especially under the age of 2 Contact precautions with a mask added Care of the client with pneumonia Types of Pneumonia Community acquired/Hospital acquired: Clinical manifestations: Cough, fatigue, tachypnea, fever. Most common Sx amoong elderly is confusion D?T hypoxia; cough and fever In older adults they may not have a fever and there WBCs may not go up. Watch for confusion Nursing interventions: Positioning Coughing Deep breathing Encourage oral fluids Collaborative interventions O2 IV fluids Teaching: Avoid crowds, S/s of getting worse, Recommend getting vaccine Care of the client with tuberculosis Clinical manifestation: Night sweats Coughing up blood Fatigue Ask if they have been out of the country They will be on airborne precautions Fit-tested mask When might the disease become active: Immunocompromised patients (chemo/H.I.V/etc.) Drugs used to treat: INH, Rifampin, Pyrazinamide. Ethambutol Take meds 6 months - 1 year Bacteria grows in the sputum Populations that get TB: Homeless (Someone has to watch patient take their meds -- direct observed treatment.) Health promotion – flu, pneumonia immunization Influenza vaccine once a year. (Live virus no longer used. Pneumonia vaccine: Can start at age 2 re-evaluate every 5 years Chapter 32 Care of the client with pulmonary embolism Most common cause is a blood embolism; post-op pts are at risk, Patients taking hormone replacements, women taking BCP, Patients in A-Fib Long periods of immobility puts you at risk for DVT (Smoking compounds this risk) Signs/symptoms Crackles SOB Chest pain Poor oxygenation Interventions: Assess the patient Stay with the patient Call for help Dose for lovenox:1 mg/kg once a day Prophylaxis use; 30-40 mg once a day Heparin will be given I.V. 20 units/kg/hr aPTT -- Heparin INR -- Coumadin Care of the client with ARDS Brought by acute injury to the lung, burns, sepsis Feed them early and position them accordingly Treated with steroids and NSAIDS Alveoli fill with sticky mucus and collapse Will become hypoxic Care of the client with tracheal/chest trauma (review handout) Broken ribs can puncture a lung and cause a pneumothorax Hurts to breath; they may not breath deep enough Tension pneumothorax: Air in the pleural space Air continues to escape; pressure builds up, heart moves, and causes opposite lung to collapse. Emergency treatment: Needle on affected side to get the air out an Needle decompression and a chest tube Care of the mechanically ventilated client (review handout) Indications: ARDS Trauma to the trachea or chest Respiratory failure Prolonged surgery with long anesthesia time Monitoring: VS Secretions BP will drop because of change of the pressure in the chest Know the settings on the machine and Alarms must always be set at all times If you don’t know what's going on with the patient and the alarm keeps going off, take them off the vent and manually bag them Feed patient early. If they don’t have nutrition it is harder to wean them off the ventilator Oral care every 2 hours Hand hygiene Keeping HOB elevated Weaning off the ventilator: Turn their control rate down gradually 10 - 8 - 6 etc ... Gradually decrease and monitor response Whatever the patient was on with the vent, add 10% more oxygen Watch for bronchospasms after they come off the ventilator Take care of the patient first Above may not be inclusive. Any “care of the client” category may include clinical manifestations, diagnostic studies, collaborative care/ interventions, medications. Test will include delegation questions, medication questions.