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Respiratory Notes (RN School)
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These are notes for a nursing school exam that covers all things respiratory.
Transcript
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.
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