Med surge final (GAS EXCHANGE)

What is Gas Exchange?

process by which O2 is transported to cells & CO2 is transported from cells

What can lead to impaired gas exchange?

issue with perfusion

When does Impaired gas exchange occur?

when the diffusion of gases become impaired because of:

* ineffective ventilation
* reduced capacity for gas transportation (reduced Hgb and/or RBC’s)
* inadequate perfusion

Consequences of Severe & Unresolved Impairment in Gas Exchange

reduced O2 in blood (hypoxemia) OR absence of O2 in blood (anoxia) → O2 deprived tissues (hypoxia) → CELL DEATH

Gas Exchange Risk Factors

* age
* smoking
* chronic medical conditions (that effect blood cells)
* immunosuppression
* reduced stated of cognition
* brain injury
* prolonged immobility (cant mobilize secretions)

Gas Exchange History

* past med HX
* family HX
* current meds (ex: opioids: too much will suppress ventilation)
* lifestyle
* occupation

Primary Prevention

* infection control/hand-washing
* quit smoking
* immunizations
* flu
* pneumococcal
* prevent post-op complications
* insentiver spirometry
* control pain

Gas Exchange: common diagnostic tests

__**Screening Test**__

* Mantoux skin test (Intradermal TB screen test)
* interferon-gamma release assay (IGRA) (blood test that screens for TB)

__**Laboratory Tests**__

* Throat culture
* ABG
* CBC
* D-Dimer
* Sputum
* **Biopsy**

__**Pulse Ox**__

Gas Exchange: Radiologic Studies

* Chest X-ray

uses radiological waves that look @ hard tissue

* can see deformities
* punctured lung
* broken rib

Gas Exchange: Radiologic Studies

* CT scan & Spiral CT scan

uses radiological waves to look for soft tissue (liver, kidney, spleen)

* can use w/ or w/o contrast dye
* check allergies to iodine/shellfish
* check kidney function
* keep PT NPO
* encourage hydration to flush out dye

Gas Exchange: Radiologic Studies

* MRI scan

uses magnetic waves to look @ soft structures (ex: Blood Vessels)

* can use contrast dye
* BE CAUTIOUS OF PT’S WITH METAL IN BODY
* Machine is enclosed, can make PT claustrophobic → give anti-anxiety b$ procedure

Gas Exchange: Radiologic Studies

* ventilation/perfusion (V/Q) Scan

this test checks for respiratory abnormalities

* for PT’s with:
* PE, Asthma, Blood clot
* have Pt inhale med & give injection of med and make sure med is able to perfuse thru lungs with no blockage

Gas Exchange: Radiologic Studies

* Positron Emission Tomography (PET) Scan

test that looks at cells & their function

* can be used for organ malfunction
* uses radioactive glucose substance → that has high affinity for a certian area → place PT under scan → see if cells react to substance
* used if MRI & CT shows nothing

Gas Exchange: Radiologic Studies

* Pulmonary function study/ Peak Flow

fr anyone underlying respiratory condition

* tells avg pulm. function
* get baseline reading → so that when Pt is sick it will help guide treatment
* have PT blow into tube (will give us highest lung capacity)

What is a Bronchoscopy?

Scope that looks down bronchial tube

* for PT’s with
* x-cessive sputum
* dyspnea
* blood in sputum
* REQUIRES MODERATE SEDATION
* pt must be NPO
* have someone to drive them home
* CHECK GAG REFLEX

What is a Transbronchial Needle Biopsy?

If scope sees a mass it can pinch of a piece of mass & look at cells under the microscope

Transbronchial Needle Biopsy Complications

* infection
* can increase damage
* hemorrhage
* can puncture lung if done incorrectly
* bleeding blood vessels (can be cauterized)

What is a Thoracentesis?

the insertion of a needle and pulling fluid/blood/puss

* for PT’s with : dec. pulse ox & RR or SOB

Thoracentesis Nursing Care

* pain meds
* have PT in tripod position
* check drain

Thoracentesis Complications

* infection
* injected & punctured lung
* hemorrhage

Beta-Adrenergic Agents

Short Acting → ex: for acute asthma/prob

Long Acting → ex: for maintenance (control s/s & constant attacks)

Corticosteroids

* ↓ inflammation
* COPD, long-term asthma, autoimmune disease, etc…
* RINSE MOUTH OUT AFTER USE OF INHALER

Anticholinergic Agents

for bronchospasm → relaxes smooth muscles

Methylxanthines

stimulates breathing

* use commonly in newborns

Mucolytics

for x-sessive mucus production

* helps top break up mucus

Antibiotics

helps fight respiratory infection

Decongestants

shrink mucosa/open airways

Expectorants

help thin mucous

* ex: dayquil

Antitussives

suppresses cough

What is Cor-Pulmonae

R. SIDED HF

* alveolar hypoxia → pulmonary vasoconstriction → Increase pulm. artery pressure → hypertrophy of R. Ventricle → R. Sided HF

What is the underlying cause of Cor-Pulmonale

an underlying respiratory/pulmonary issue

* scar tissue in lungs
* plum HTN
* COPD

What is Polycythemia?

↑ in RBC

* physiological compensation for hypoxemia
* ↑ RBCs but NOT able to carry ↑ O2 as O2 is NOT available (cyanosis)
* ↑ blood viscosity

What is Anemia?

↓ RBC =↓ hemoglobin = ↓ O2 in blood = hypoxia

* Not a disease but rather a manifestations
* manifestation stems from hypoxia (fatigue, SOB, vital sign change, mental status change)

normal hemoglobin levels

male = 14-17.3

female = 11.7-15.5

normal hematocrit levels

male = 42%-52%

female = 36%-485

Mild anemia s/s

* fatigue
* headache
* dizzy
* weakness

Moderate Anemia S/S

* rapid HR
* SOB

Severe Anemia S/S

* fainting
* chest pain/angina
* heart attack

Anemia Collab Care

* administer O2 as needed
* alternate rest/activity
* monitor H/H (both with be ↓)
* medication teaching
* diet teaching
* eat smaller meals bc they take less energy to metabolize
* increase folic acid/iron/B12
* avoid high carbs

Anemia: Folic Acid Deficiency S/S

* low energy
* dizziness
* weakness
* ulcers in mouth
* numbness/tingling of finger & toes

Anemia: Folic Acid Deficiency

* collab care

* folic acid replacement
* diet high in folate
* leafy greens
* whole grains
* poultry
* liver

Anemia: Cobalamin Deficiency

B12 deficiency/lack of intrinsic factors (IF)

* If ↓ B12 & normal IF = increase diet in B12
* if ↓ IF = give B12 injections (pernicious anemia)

Foods high in B12

* eggs
* meat
* poultry
* shellfish
* milk & milk products

Epistaxis

Nose Bleed

* due to: trauma, foreign body, inhalation meds, drug use, tumors, meds, HTN, anatomic malformation

Anterior Nose bleed

* keep Pt quiet
* have Pt lean forward & sit
* pinch soft portion of nose for 10 min
* apply ice (vasoconstrict vessels)
* partially insert gauze

Posterior Nose Bleed

harder to control/increased risk of aspiration

* if tubes are used to control bleeding:
* observe for resp. distress
* humidified O2
* bedrest
* pain management
* hydration & oral care

Rhinitis

Inflamed nasal passage

Viral Rhinitis

common cold

* viruses invade upper resp. system
* SPREAD BY DROPLET
* increased in winter months
* \

Allergic Rhinitis

triggered by sensitivity reaction to aireborne allergens

* seasonal or chronic

Rhinitis Clinical Mani’s

* nasal itching
* sneezing
* nasal congestion
* rhinorrhea (runny nose)

Rhinitis Treatment

* rest, fluids, diet, analgesics
* antihistamine & decongestant therapy
* recognize s/s & treat them
* avoid crowded area & practice hand hygiene

Sinusitis

Sinus is narrowed or blocked by inflammation of hypertrophy (swelling) of the mucosa

* secretions build up behind the obstruction
* good place for organism growth → leads to infection

Sinusitis Clinical Mani’s

* pain over affected area
* purulent nasal drainage
* nasal obstruction
* headache
* congestion
* fever
* malaise
* dental pain

Sinusitis Collab Care

* control underlying cause (ex: allergies)
* antibiotics
* decongestants
* nasal corticosteroids
* increase fluids
* nasal clearing/cleaning
* avoid smoking
* increase HOB

What is Obstructive Sleep Apnea?

partial of complete airway obstruction during sleep

* __*apnea*__ = cessation of airflow >10 secs
* NARROWING OF PASSAGES → Reduction of muscle tone during sleep
* tongue falling back to obstruct airway
* DECREASED O2 & INCREASED CO2

Obstructive Sleep Apnea Long Term Effects

* HTN
* dysrhythmias
* HF
* CAD

What happens bc of Chronic Obstructive Sleep Apnea

* impaired memory inability to concentration
* failure to accomplish task
* interpersonal difficulties

Obstructive Sleep Apnea Risk Factors

* obesity
* smoking
* cranial abnormalities
* type 2 diabetes
* HF
* acromegaly

Chronic Obstructive Sleep Apnea Clinical Mani’s

* insomnia
* daytime sleeping
* partner may notice snoring
* restless behaviors
* periods of apnea

Obstructive Sleep Apnea Treatment

* __**MILD:**__ change positioning (lie on side or sit PT up)
* avoid sedatives and alcohol
* weight loss
* CPAP

Influenza

Highly contagious (may cause morbidity & mortality)

* Flu season: September-April
* need annual flu vax every year due to different flu virus mutating over time

Influenza Diagnosis

* HX & Physical
* Viral Cultures (takes 3-10 days)
* Rapid Flu Test (nasal secretions)
* best done within 48 hrs on onset of symptoms
* results in 30 mins

Influenza Collab Care

* __**Prevent:**__ Good hand washing and getting vaccinated
* antiviral- inhaler, oral or IV ( best if given within 48hrs os s/s onset)
* supportive therapy**/treat s/s:** (rest, analgesics, antipyretics, hydration)

Acute Bronchitis

inflammation of bronchi

* viral or bacterial

Acute Bronchitis Clinical Mani’s

* cough
* sputum production
* headache
* SOB on exertion
* rhonchi/wheezing

Acute Bronchitis Collab Care

* supportive (rest, fluids, etc…)
* antitussives
* anti-inflammatory
* bronchodilators
* mucolytic

Tuberculosis

Infectious disease caused by mycobacterium tuberculosis

* lungs MOST COMMONLY infected
* AIRBORNE SPREAD (Transmission requires close, frequent/prolonged exposure)
* leading cause of death in PT’s with HIV/AIDS
* CAN LAY DORMANT IN BODY
* has affinity for lungs but can spread and grow in other organs

Latent Tuberculosis Infection (LTBI)

Dormant TB/Asymptomatic/Not Infectious

* + skin test
* - sputum & chest x-ray
* can become active if immune system becomes compromised
* granuloma forms leading to fibrosis & calcification

Primary Tuberculosis Infection (PTBI)

Not infectious/Asymptomatic

* weakened immune system (prevents calcification)
* + skin test

Primary Progressive TB Infection (PPTBI)

PT exposed/Symptomatic/Infectious

* ACTIVE FORM
* + result on any test
* immunocompromised (HIV, Chemo, etc…)

Tuberculosis Risk Factors

* the homeless
* inner-city residents
* foreign-born ppl
* living or working in institutions
* IV drug users
* Poverty, Poor access to health care
* immunosuppression
* shelters/prision

TB Testing

* skin test (Mantoux)
* 5: + if immunosuppressed
* 10: + if high risk PT
* 15: + for any type of PT
* Interferon gamma release assay (IGRA)
* usually done if PT has gotten TB vax (usually ppl born outside of the USA)
* Chest X-ray
* + if TB is active
* - if Tb is latent
* LOOKING FOR FIBROSIS/SCAR TISSUE
* Sputum Testing- MOST DEFINITIVE

TB Clinical Mani’s

* pulmonary TB

* initial dry cough that becomes productive
* fatigue
* malaise
* anorexia
* weight loss
* low-grade fever
* night sweats
* LATE S/S: dyspnea & hemoptysis

TB Acute care

Airborne Isolation

* private room
* wear HEPA masks
* appropriate drug therapy
* have PT wear mask outside room


* negative pressure room


* make sure PT takes meds

TB Ambulatory Care

Pt able to go home (even if +)

* monthly sputum cultures
* teach PT how to minimize exposure to others
* ensure PT adheres to treatment
* stop smoking
* notify health depratment

Active TB Disease

* 4-Drug regimen
* teach PT side effects & when to seek medical care
* monitor liver function (med is hard on liver)
* avoid alcohol
* may have to direct observed therapy (watch PT take med)

Latent TB Infection

* + TB test
* drug therapy to prevent TB INFECTION FROM BECOMING ACTIVE

What is Pneumonia?

acute infection of lung parenchyma

* chronic disease that decreases immune system
* decrease ability to cough & swallow
* can happen if pt is recently sick (pneumonia follow-up)

3 ways organisms reach lungs

* aspiration from nasopharynx or oropharynx
* inhalation of microbes in air
* infection in body. that can spread to lungs through bloodstream

What impaires mucociliary

* pollution
* smoking
* upper resp. infections
* tracheal intubation
* aging

Ventilator Acquired Pneumonia (VAP)

develops 48-2 hrs after endotracheal intubation

Community Acquired Pneumonia (CAP)

develops in a community NOT a hospital

Healthcare Associated Pneumonia (HCAP)

48-72 hrs after admission or following a stay in a healthcare setting

Pneumonia Collab Care

* O2
* Positioning (dec. risk of aspiration)
* Hydration (helps thin mucous)
* Rest & Activity
* PT Teaching

Pneumonia S/S

* high fever
* cough w/ sputum
* pleuritic chest pain
* tachycardia
* low BP
* headache
* loss of appetite

Pneumonia Medications

* antibiotics
* analgesics/antipyretics
* cough suppressants
* corticosteroids
* bronchodilators (due to inflammation of airway)

What is a Pulmonary Embolism?

occurs when a blood clot becomes lodged in a lung artery → blocking blood flow to lung tissue

* clots often comes from legs

Pulmonary Embolism Risk Factors

* thrombi in legs
* immobilization
* surgery within the last 3 mo.
* stroke
* malignancy
* obesity
* smoking
* HTN/ Coronary heart disease

Pulmonary Embolism Clinical Mani’s

* dyspnea!
* anxiety
* tachycardia
* cough/hemoptysis
* chest pain
* syncope
* sudden change in mental status
* massive emboli (produce hypotension & shock)

Pulmonary Embolism Collab Care

* O2 therapy
* Bedrest- semi fowlers
* **DRUG THERAPY:** anticoagulant & thrombolytic agent
* **SURGERY**: embolectomy/vena cava filter

Pulmonary EmbolismDiagnostic Tests

* D-DIMER
* V/Q scans
* CT scan
* MRI

What is Asthma?

Disease of inflammation along bronchial hyper-responsiveness

* reversible expiratory airflow limitation
* mucosal inflammation
* bronchial smooth muscle contraction
* x-cess mucous production

Asthma Clinical Mani’s

* WHEEZING!
* coughing
* dyspnea
* chest tightness
* use of accessory muscle to breath
* anxiety
* tachycardia
* diminished breath sounds (could mean airway is completely closed off)

Intermittent asthma

Pt is exposed to trigger & sees S/S maybe 2x a month

Mild Persistent Asthma

3-4x a month

* albuterol as needed
* may use inhaled corticosteroids

Moderate Persistent Asthma

around 5x a mo.

Sever Persistent Asthma

Pt sees S/S everyday

Asthma Collab Care

* medications
* O2
* Nebulizer treatments
* avoid triggers/causative factors
* daily monitoring of peak flow expiratory flow rate)

How to use Metered Dose Inhalers (MDI)

1. hold inhaler 2-3 cm from mouth → shake → spray one puff & inhale → hold for 10 sec
2. give 1-2 minutes in between each puff OF THE SAME TYPE OF INHALER
3. give 5 minutes BETWEEN DIFFERENT MEDS
4. RINSE MOUTH AFTER STEROID INHALERS

What is COPD

disease state characterized by the presence of airflow obstruction

* decreased lung capacity