Med Surg II week 3 (ch 32)

COPD consists of ____, it is a ______ that ______ and is chracterized by ___

chronic bronchitis and pulmonary emphysema

it is a group of lower airway disorders that disrupt airflow and gas exchange

characterized by tissue damage, that is irreversible, increases in severity and eventually leads to respiratory failure

chronic bronchitis problem

airway problem

emphysema problem

alveolar problem

COPD is characterized by

bronchospasms and dyspnea

emphysema two major changes

loss of lung elasticity and hyperinflation of the lung

therefore decreased gas exchange causing an increase in RR

emphysema patho

air trapping caused by loss of elastic recoil in alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles)

breathing in COPD

breathing is more work, the lungs are hyperinflated and become weak and don’t work properly

turn to the use of accessory muscles (neck, chest wall, abdomen) instead, but they are not as efficient

become air hungry, inhalation begins before completing exhalation

Chronic bronchitis patho

inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco

inflammation results in vasodilation, congestion and large amts of thick mucous, mucosal edema, and bronchospasm

impacting only the airways

complication of bronchitis

the large amounts of mucous from inflammation is a breeding ground for bacteria resulting in chronic infections

complications of COPD

hyoxemia, tissue anoxia

acidosis due to poor gas exchange

respiratory infections

cardiac failure, COR PULMONALE

cardiac dysrhythmias

Cor pulmonale

right sided HF caused by chrnoiic pulmonary diseases (COPD)

patho- air trapping increases pressure in lung tissue, narrows lung BV, making BF difficult

increase pressure and narrowed vessels in pul vasculature= heavy work for right side to pump, resulting in R sided HF

COPD history

breathing problems, SOB, can they speak a full sentence without needing a break

wheezing, coughing, history of smoking, dyspnea

COPD assessment

general appearance- wt loss, enlarged neck muscles, tripod position, grooming

respiratory changes- chest size large, respiratory muscle fatigue (short/rapid/shallow RR, abdominal breaths), increased RR, barell chest, ascultate for wheezing

cardiac changes- signs of R sided HF

Barell chest

AP ratio (lateral diameter of chest) is 1:1 rather than 1:5

Dyspnea assessment tool- visual, analog, dyspnea scale

indicate the amount of SOB you have at this time by marking the line

only quantifies one period in time

bronchitis s/s

BLUE BLOATER (r/t cor pulmonale)

cyanotic, clubbing, chronic cough

sputum production

increased rr, increased hgb

cardiac enlargement, right sided heart failure

emphysema charcteristics

pink puffer

increased co2 retention (acid)

pursed lip breathing

orthopnia

Barrel chest, thin appearance

prolonged expiratory time, jerky sentences

no cough

hyperresonance on percussion

Labs for COPD (8)

ABG values- obtain baseline first, assess for oxygenation, ventilation, acid-base status

sputum samples

CBC (wbc confirms infection)

hemoglobin/hct= polycythemia, bone marrow tries to inc RBC to improve hypoxemia

serum electrolytes= acidosis can mean hyperkalemia

serum AAT levels= when unsure of cause of COPD, if its low it can mean COPD

chest xray= see hyperinflation of alveoli, see flat diaphragm

pulmonary function test= assess lung volume and diffusion capacity before/after inhalating a bronchodilatior (re-evaluate as needed)

complication of increased paCo2

pt can go into metbaolic alkalosis via kidney compensation for low o2

COPD longterm impacts

weight loss

anxiety

decreased endurance

potential for pneumonia

airway management of COPD

breathing techniques- use diaphragm, abdominal, pursed lip, to help manage acute dyspneic episodes

positioning= HOB upright, get OOB to chair

suctioning, hydration

*pt should participate

cough enhancement for COPD

effective cough clears mucous membranes

use incentive spirometer first thing in AM and before bed

Pulmonary rehabilitation with COPD

exercise improves indurance and function

teach patient to pace activity with rest, use oxygen

COPD- problems

imbalanced nutrition- tired, fatigued, so need help to get fresh meals and cook

anxiety

activity intolerance- pace activity w rest

potential for pneumonia or other res infections- avoid large crowds, pneumonia vaccination, yearly influenza vaccine

medications for COPD- corticosteroids (exemplars, form, use)

fluticasone= inhaler, must rinse mouth out after to prevent thrush

prednisone= pilll

not longterm, for exacterbations

Advair= combination of fluticaosne and salmeterol, use IV in hospital

medications for COPD- Mucolytics

acetylcysteine (mucomyst)= nebulizer, has rotten odor

guaifenesin

medications for COPD- Short Acting Beta Agonists

albuterol= ventolin

bronchodilator, s/e is tachycardia, tremors, palpitations

medications for COPD- Long acting beta agonists

Salmeterol= severent

given alone or with fluticaone/adavair

medications for COPD- Cholinergic Antagonists

ipratropium= atrovent

tiotropium= spiriva (s/e= dry mouth, urinary retention)

come as pills that are crushed with an inhaler, inhaled powder

COPD evaluation

achieve effective breathing patterns that decrease work of breathing (diaphragmatic, abdominal, pured lip)

maintain body weight within 10% of idea weight

decreased anxiety

increase activity to tolerable level

avoid serious respiratory infections

Pulmonary embolism- definition

a collection of solids/liquid/or air enters venous circulation and lodges in pulmonary vessels

abrupt or slow onset

pulmonary embolism types

fat embolism from fracture of femur

bolus of air from central line

risk factors of pulmonary embolism

prolonged immobilization

Central venous catheters

surgery

pregnancy, oral BCP

obestiy

age

genetic conditions that inc blood clotting

hx of thromboembolism

PT NEED TO BE ANTICOAGULATED TO PREVENT

PE diagnosis

angiogram with dye

MRI with dye

PE highway

from VTE up leg to right atrium, right ventricle, thru pul artery and to the lungs, where it loged

PE respiratory s/s

dyspnea, tachypnea, tachycardia

pleuritic chest pain (sharp/stabbing pain on inspiration)

dry cough, hemopotysis

PE cardiac s/s

distended neck veins

syncope

cyanosis

systemic hypotension

abnormal heart sounds, abnormal ecg

general s/s of PE

low grade fever due to inflammatory response

petichiae

flu like symtoms

PE labs

ABG= hypoxia, resp alkalosis to resp acidosis

paO2-fiO2 (ratio falls= start hyperventilating causing resp alk, lactic acidosis, met acid)

pulse oximetry- hypoxemia

signs to monitor of PE

hyoxemia, hypotension, potenial for excessive bleeding, anxiety

PE interventions

call rapid response

nonsurgical= monitor ABG, o2 sat, give heparin IV, warfarin (coumadin) PO

surgical= embolectomy, vena cava filter

heparin apTT time

1.5-2.5 times control

Vena cava filter

place in pt who tend to develop clots, blood passes thru filter in VC and captures clots

warfarin antedote

heparin antedote

vitamin K- phytonadione

protamine sulfate

What excludes a pt from receiving thrombolytics

recent surgery

PE prevention

stop smoking, decrease wt

increase physical activity

if traveling/sitting for long periods, get up frequently

drink water

refrain from massage/compressing leg muscles

s/e from anticoagulation

bleeding

ph levels, co2 levels, o2 levels

ph levels= 7.35-7.45

co2 levels= 35-45

o2 levels= 80-100

Acute respiratory failure- types

ventilatory/hypercapnic failure (Co2 is >50, pH <7.35)

oxygenation/hypoxemic failure (O2 is <60)

combined ventilatory/oxygenation failure (o2 <60, co2 >50 with pH <7.35)

Acute respiratory failure- Ventilatory failure (patho, what is the problem, specific examples?)

problem is with the actual movement of the air, the chest pressure does not change enough to allow air/o2 to flow in/out of lungs, co2 is retained

problems- physical issue with lungs/chest wall, defect in respiratory control center in brain, poor function of respiratory muscles (ESP DIAPHRAGM)

Acute respiratory failure- Ventilatory failure (extrapulmonary causes and intrapulmonary causes)

extrapulmonary causes= polio, SCI, opioids

intrapulmonary causes= COPD, PE, pneumothorac

Acute respiratory failure- Oxygenation failure (patho, what is the problem, specific examples?)

thoracic pressure changes are normal, air can be moved in/out) but does not oxygenate the pulmonary blood sufficiently

ventilation is normal, problem is decreased lung perfusion

impaired diffusion of oxygen at the alveolar level

ex= high altitudes, breahting air with low o2 levels, abnormal Hgb

Acute respiratory failure- Combined failure (patho, specific examples?)

Decreased bronchioles and alveoli cause oxygenation failure; work of breathing increases; respiratory muscles are unable to function effectively

occurs in patients with abnormal lungs…chronic bronchitis, emphysema, asthma attack

Acute resp failure interventions

oxygen

position of comfort- semi to high fowlers

relacation, diversion, guided imagery

energy conserving measures= relieve anxiety, relax, pursed lip breathing

Acute resp failure meds

analgesics

steriods

bronchodilators

Acute Respiratory Distress syndrome definition

hypoxia that persists even when oxygen is delivered at 100%

ARDS clinical manifestations

decreased pulmonary compliance

dyspnea

noncardiac associated bilateral pulmonary edema

dense pulmonary infiltrates seen on xray= see inflammation, cytokine storm

ARDS diagnostic assessment

lower paO2 value on ABG

refractory hypoxemia- not treatable with o2

whited out (ground glass) appearance to cxr (cytokine storm)

no cardiac involvement on ECG

low-to-normal PCWP

ARDS o2 interventions

endotracheal tube and mechanical ventilation with posititve end expiratory pressure (PEEP) or continous positive airway pressure (CPAP)

ARDS pharm interventions

inf= abx

bronchodilators

fluid therapy (BUT BECAREFUL! easy to overhydrate, monistor s/s of rtn)

ARDS nutrition therapy

risk for malnutrition

tube feeds

no bowel sounds use TPN

stabilizing ETT nursing interventions

assess tube placement- end tidal co2, breath sounds, portal cxr, see chest rise/fall, assess for stomach dstn (in stomach)

oral hygiene= chlorhexidine oral care, movement HOB

restraints

pain assessment

communication= look at pt first, not ventilator

mechanical sedation for ETT

diprivan (propofol)

use in assist control settings so pt does not wake up and yank it out

side effects of sedation= hypotensoin, dec rr,

types of positive pressure ventilators

pressure cycled ventilators

time cycled ventilators

volume cycled ventilators

(set by amount of pressure, time, and volume)

what are the ways patients recieves breath from ventilators

assist control ventilation= set RR, machine delivers whether the pt has control of breaths or not, full control

synchronized intermittent mandatory ventilation= machine set to a lower RR, if pt does not initiate enough of own breaths, machine kicks in, allows pt to do some breathing

pressure support=can initiate own breath

CPAP= continuous positive pressure

BiPAP= higher w inspiration and lower w exhalation, more comfortable

ventilator controls/setting- tidal volume

500 mL

volume of air with each breath, based on weight

ventilator controls/setting- rate

10-14 bpm

ventilator controls/setting- fraction of inspired oxygen

FiO2, notmal 21%

20-100%

100= really sick, want lower numbers

ventilator controls/setting- Peak airway (inspiratory) pressure (PIP)

highest pressure exerted in inspiration

ventilator controls/setting- Continuous positive airway pressure (CPAP)

mode of support,

patient breathes spontaneously, but pressure stays positive to keep alveoli open

ventilator setting- Positive end expiratory pressure (PEEP)

for pt who are really sick

increase oxygen and gas ecchange by maintaining a baseline pressure at the end of exhalation

consideration about delivering oxygen

it can dry mucous membranes causing breakdwon

want to humibidy and warm to body temp

complications of mechanical ventilation

cardiac problems

GI problems (always place NGT)

nutritional problems- want TPN/Tube feeds

musculoskeletal trauma

VAP

ventilator dependence

DOPE achrosyn to troublehsoot ventilator alarms

displaced

obstruction

pneumothroax

equipment failure

respiratory complications from mechanical ventilation

barotruama= damage to lungs from too much + pressure

volutrauma= damage to lungs from too much volume given only to one lung

extubation

hyperoxygenate pt

thoroughly suction ET and oral cavity to prevent sputum from dislodging

rapidly deflate cuff of ET
tell pt to inspire deeply, and remove during expiration

tell pt to cough

MONITOR AFTER, monitor o2, breath pattern, position i high fowersl and give face mask

Tracheotomy

surgical incision into trachea to create an airway to maintain gas exchange

Tracheostomy

stoma (opening) that results from tracheotomy

can be temporary or permanent

trach care

suctioning (do this before removing inner cannula)

cleaning and replacing- neck ties changed PRN, dressing and inner cannula replaced once a shift (Q12 hrs), clean around stoma w chlorhexidine

NEVER cut gauze pad and place around stoma, only use precut

ensure warmth and humidification

prevent accidental decannulation- have obturator at bedside

trach complications

tube obstruction

tube dislodgement and accidental decannulation

pneumothroac

subcutaneous emphysema

bleeding and infection

chest trauma- examples

50% of deaths of patients who experience unintentional traumatic injuries

pulmonary contusion= bruised lung

rib fracture

flail chest

pneumothorax, hemothroax, tension pneumothroax

flail chest- definition, cause, treat

paradoxical chest movement, sucking inward of the loose chest area during inspiration and puffing out during expiration

cause= 3 or more ribs broken in 2 or more places

prob will need mech ventilation w PEEP

what is a pneumothorax? what causes it?

air in the pleural space causes a loss of negative pressure, a rise in chest pressure, and a reduction in vital capacity, which can lead to lung collapse

Caused by blunt chest trauma

common s/s of a pneumothorax

assymetric lung expansion

tracheal deviation (tension pneumo)

sob, unequal rise and fall, absent breath sounds

hypoxia, hyperresonance on percussion on side

hemothorax

bleeding in chest cavity

closed pneumothorax

air enters the space between the lung and chest wall from inside the lung

ex= COPD

open pneumothorac

hole in the chest wall allows air to pass freely between the outside environment and the space around the lung

ex=stab wound

tension pneumothorax- ER!

air from ruptured lung enters pleural cavity without means of escape, air pressure builds up and effected lung is compressed

all mediastinal tissues are displaced to the opposite side of the chest

HALLMARK SIGN= tracheal deviatoin

chest tube

placed in the intrapleural space, apply suction

restore negative pressure to re-expand lungs

insertion is via a puncture wound, guided by finer

chest tube drainage system

chamber 1- collects from fluid draining from pt

chamber 2= water seal prevents air from entering pt pleural space

chamber 3= suction control of system

has portable options, some have dry suction, some have sterile water

nursing management of chest tube

assess cardiopulmonary and VS every 1-4 hours PRN

assess, treat, and reassess for pain

montior output every 1-4 hours and record amount/color

evalaute chest tube drainage system for rise/fall (tidaling) and check connections

maintain semifowlers 30-45 degree angle to assist in drainage/lung expansion/comfort

encourage deep breathing/cough/incentive spirometry to help lungs reexpand

chest tube reportable conditions

blood drainage of 70ml/hr or greater

sudden stopping of drainage

change in character of drainage

absence of tidaling in water-seal chamber or persistent bubbling

bubbling in chest tube

water levels will normally rise/fall w rsepiration until the lung is expanded

bubbling immediatelay after insertion signifies that air is being removed from the pleural space

bubbling with exhalation and coughing is ok

HOWEVER persistent bubbling indicates air leak in pt lung or ddrainage system

how should CDU be position to a pt

one foot below chest tube insertion site and free of dependent loops/kinks

supplies for chest tube

betadine swabs, clamps, 4×4 ABD, gauze, tape, sertile gloves and water

How do you handle tubes

do not strip tube, can lead to tension pneumothorax

milk with hand over hand method

disconnection of chest tube from CDU- management after

insert chest tbue end into sterile water (creates water seal, negative pressure to prevent air from entering)

call provider STAT

once connected, a full chest assessment is needed, CXR

dislodgment of chest tube

if tube is pulled out, promptly pressure dressing using several 4×4

stay with patient to observe for respiratory distress

call provider stat

prepare for new tube insertion

s/s of tension pneumothorax

acute respiratory distress

tachypnea, shallow respirations, decreased breath sounds

cyanosis, asymmetrical breathing

decreased BP, tachycardia

marked deviation of trachea

ER management of tension pneumothorax w chest tube

start o2 at 4 liters, call provider stat, monitor vs, prepare for new insertion

pt may need cxray and abg