medsurg respiratory

respiratory assessment

respiratory assessment

• dyspnea

• cough

• sputum production

• chest pain

• hemoptysis

• adventitious breath sounds

• signs of hypoxia

• signs of respiratory distress

PFT

assess lung function and extent of dysfunction

measures lung volumes and capacities, diffusion capacity, gas exchange, flow rates, airway

• if patient is a smoker, do not smoke 6-8 hrs before test

• if patient uses inhalers, withhold 4-6 hrs before test

ABG

measures pH, PaO2, PaCO2, HCO3

status of oxygenation and acid-base balance of the blood

• can be obtained by arterial puncture or thru arterial line

pH: 7.35-7.45

PaO2: 80-100

PaCO2: 35-45

HCO3: 22-26

acidosis

pH levels less than 7.35

alkalosis

pH levels greater than 7.45

allen’s test

used to assess collateral blood flow to the hands

• usually used in prep for a procedure that has potential to disrupt blood flow in either the radial or ulnar artery

how to perform allen’s test?

• compress the ulnar and radial arteries simultaneously while instructing the client to form a fist

• instruct the client to relax his hand while assessing the palm and fingers for blanching

• release pressure on the ulnar artery while observing the hand for flushing caused by capillary refilling

hand should turn pink within 5-15 seconds, indicating patency of the ulnar artery and an ability to use the radial artery to obtain arterial blood gases.

pulse ox

noninvasive method of continuously monitoring o2 sat

normal: >95%

<90% = tissues are not receiving enough o2

pulse ox considerations

inaccurate readings from:

• anemia

• abnormal hgb

• high carbon monoxide levels

• use of dyes

• dark skin

• nail polish

• sulinght, fluorescent, xenon lights

• patient movement

• bp and o2 on same arm

• cold fingers

• calasis

• swelling

culture and sputum studies

used to deterine bact. inf.

• collect in the morning before anything to eat or drink

• no mouthwash

• deep breathing to stimulate cough

• send specimen 30min-1hr after collecting

  • can alter results if later b/c bact. grows

• results should take w/i 48-72 hrs, preliminary reports w/i 24 hrs

all cultures should be obtained prior to initiation of antibiotic therapy

imaging studies types

• CXR

• computerized tomography (CT)

• magnetic resonance imaging (MRI)

• pulmonary angiography

• lung scan

CXR nursing responsibilities

• usually obtained after full inspiration bc lungs are best visualized when they are well aerated

• patient need to take deep breath and hold

• contraindicated in preg. women

interventions

• does not require fasting, pain

• positioned in a standing, sitting, or recumbent position in order to obtain view of chest

• wear gown, remove metal objects from chest

• may be given a lead shield to minimize radiation exposure to thyroid, ovaries, testicles

CT pre & post procedure nursing responsibilities

• patient lays supine and still for a short time

• typically 30 mins

• typically do not experience claustrophobia but can be given anti-anxiety meds pre-procedure

• if contact dye is used, patient will need to stay NPO for 4hrs before exam

• assess allergies to iodine or shellfish

post

• encourage fluids to flush out dye

MRI pre & post procedure nursing responsibilities

• remove all metal items

  • hearing aids, hair clips, meds with metallic foil components (nicotine patches)

• assess for. implanted metal devices like aneurysm clips, cardiac pacemaker, defibrillator

• patient lie flat and still for 30-90mins

• patient notified they will hear loud humming or thumping noise

  • earplugs offered

• clarify if procedure will use dye or patient needs to be NPO

• typically do not experience claustrophobia but can be given anti-anxiety meds pre-procedure

pulmonary angiography pre & post procedure nursing responsibilities

used to investigate congenital abnormalities of pulmonary vascular tree, high suspicion for PE

pre

• verify consent has been obtained

• assess for allergies to iodine and shellfish

• assess anticoag. status and renal function

• patient not eaten for 6-8 hrs

• administer pre-procedure meds: anti-anxiety, secretion-reducing agents, antihistamines

• may experience warm flushing sensation or chest pain during injection of dye

post

• monitor vital signs, LOC, O2 sat, vascular access site for bleeding or hematoma

• perform freq. assessment of neurovascular status

lung scan pre & post procedure nursing responsibilities

types: V/Q scan, gallium scan, position emission tomography (PET)

pre

• educate patient on procedure

• IV assess needed

• enema is sometimes prescribed prior to gallium scan to dec uptake in the GI tract

• CXR before v/Q

• V/Q and gallium req. small amt od radioisotopes so radiation safety measures not indicated

• may eat or drink before V/Q and gallium

• avoid caffeine, alcohol, tobacco for 24 hrs and NPO 4 hrs before for PET scan

• empty bladder ( foley cath maybe)

post

• encourage fluids to eliminate radioisotopes thru urine

endoscopy procedures

• bronchoscopy (lung cancer)

• laryngoscopy (laryngeal cancer)

• thoracentesis

endoscopy: bronchoscopy

direct inspection and examination of larynx, trachea, and bronchi thru either a flexible fiberoptic or a rigid bronchoscope

bronchoscopy & laryngoscopy pre-procedure nursing responsibilities

• verify consent

• NPO for 4-8 hrs before to reduce risk for asp. when cough reflex is blocked

• RN explains procedure to patient to reduce fear, anxiety

• administer pre-procedure meds: usually atropine or sedative or opioid

• remove dentures and other oral prostheses

• under local anesthesia or mod. sedation

• rigid bronchoscopy general anesthesia may be used

• topical anesthetic like lidocaine sprayed on pharynx or dropped on the epiglottis and vocal cords and into trachea to suppress cough reflex

bronchoscopy & laryngoscopy post-procedure nursing responsibilities

• NPO until cough reflex is back

• once cough reflex back, ice chips and then fluids

• older patient: assess conf and lethargy

• monitor RR

• observe for

  • hypoxia

  • hypotension

  • tachycardia

  • dysrhythmias

  • hemoptysis

  • dyspnea

• small smt of blood tinged sputum and fever expected w/i 24 hrs

• patient not discharged from recovery area until cough reflex and RR back

endoscopy: thoracentesis

surgical perforation of the chest wall and pleural space with a large-bore needle

used for

• obtain specimens for diagnostic evaluation

• instill medication into the pleural space

• remove fluid (effusion) or air from the pleural space for therapeutic relief of pleural pressure

thoracentesis pre-procedure nursing responsibilities

• informed consent form signed by patient

• gather all needed supplies

• obtain pre-procedure x‑ray to locate pleural effusion and to determine needle insertion site

• position sitting upright with arms and shoulders raised and supported on pillows and/or on an overbed table and with feet and legs well-supported

thoracentesis post-procedure nursing responsibilities

• apply a dressing over the puncture site

• assess the dressing for bleeding or drainage

• monitor vital signs and respiratory status hourly for the first several hours after

• auscultate lungs for reduced breath sounds on side of thoracentesis

• encourage the client to deep breathe to assist with lung expansion

• obtain a postprocedure chest x-ray (check resolution)

complication

• mediastinal shift

• bleeding

• infection

biopsy

similar to bronchoscopy

• monitoring for complications

  • SOB

  • bleeding

  • infection

• instruct at report pain, purulent drainage, SOB, bleeding, redness

• mostly for cancers

respiratory care modalities: nursing management

• positioning

• deep breathing exercises

• rest and activity pacing

• incentive spirometry

• hydration

• chest physiotherapy

• oxygen therapy

• suctioning

• artificial airway management

• chest tubes

chest physiotherapy

• chest percussion

  • 3-4x before meals and bedtime

  • bronchodilator 30mins-1hr

  • remain in each position 10-15 mins

• vibration

• postural drainage

  • assess breath sounds before and after

  • assess pain

  • assess sputum

  • oral care

O2 therapy care

• RN can initiate, notify MD

• assess resp status

• pulse ox, ABGs

• semi-fowlers

• promote good oral hygiene

• assess skin integrity

• provide o2 at lowest flow

  • may give higher depending on patient situation

• humidify and titrate o2

• turn, cough, deep breathe

• discontinue O2 gradually

O2 therapy indications

hypoxemia

• inadeq. level of O2 in the blood

hypoxia

• dec in tissue O2

O2 therapy safety considerations

• combustion

  • no vaseline

  • no smoking

• oxygen toxicity

  • high concentrations of O2 for long duration (24-48 hrs)

• oxygen-induced hypoventilation

  • can develop in patients with COPD and chronic hypoxemia

O2 delivery devices

• nasal cannula

• simple mask

• face tent

• non-rebreather mask

nasal cannula

low flow O2 delivery

• FiO2: 24-44%

• 1-6 L/min

• easy, safe

• patient can talk, eat

simple mask

low flow O2 delivery

• FiO2: 40-60%

• 5-6 L/min

• easy to apply

• may be a problem if patient has claustrophobia

face tent

high flow O2 delivery

• FiO2: 24-100%

• 10-15 L/min

• provide humidification

• useful for facial trauma, burns

non-rebreather mask

high flow O2 delivery

• FiO2: 80-95%

• 10-15 L/min

• delivers highest O2 concentration possible

suctioning

• high-fowlers or semi-fowlers

• different catheters

• sterile procedure

• suction pressure: 120-150 mmHg

• apply suction during withdrawal

• apply suction intermittently, not longer than 10-15 secs

• no more than 2 passes; limit to 5 mins

endotracheal intubation

• tube inserted thru nose or mouth into trachea

• allows for emergent airway management

• providing airway for patients who cannot maintain an adeq. airway on their own

• short-term

tracheostomy

• surgical procedure which an opening is made into the trachea

• indwelling tube inserted into trachea : tracheostomy tube

• temp or permanent

laryngeal cancer risk factors

• tobacco (other carcinogens also)

• alcohol

• genetic age

• vitamin deficiency

• weak immune system

laryngeal cancer assessment

• hoarseness

• cough

• sore throat

• pain and burning esp. with hot liquids and citrus juices

• lump in the neck

• dysphagia

• dyspnea

• ulceration

• foul breath

laryngeal cancer diag.

• laryngoscopy

• fine needle asp. biopsy

• CT/MRI

• PET scan

• barium swallow

laryngeal cancer management

• surgery

• radiation

• chemotherapy

indirect v. direct laryngoscopy

indirect: does not need to be NPO before procedure

direct: NPO before and general anesthesia

laryngeal & lung cancer tumor staging and grading

T umor: inc in size

N lymph nodes: inc involvement in regional lymph node

M etastasis: no distant metastasis =M0; distant metastasis = M1

• TNM staging system

  • tumor size (T1, T2, T3)

  • lymph nodes (N1, N2, N3)

  • metastasis (M0, M1, M2)

• grading

  • stage 1: localized

  • stage 2-3: N1, N2

  • stage 4: M1-M3

laryngeal cancer surgical management

• partial laryngectomy

  • used for early stages of cancer

  • portion of larynx is removed with 1 vocal cord and tumor

  • airway intact so no dysphagia

  • voice: hoarse

• total laryngectomy

  • complete removal of larynx

  • more advanced cancer, when tumor extends to vocal cords

• vocal cord stripping

  • removal of mucosa of the edge of vocal cord

• cordectomy

  • excision of vocal cord

• laser surgery

  • treatment and recovery shorter

  • fewer side effects

  • method of choice usually

laryngeal cancer post-laryngectomy care

• airway

  • laryngectomy tube

• speech

  • artifical larynx

• nutrition

  • enteral/parenteral

• body image

• safety

  • asp., inf. hemorrhage

radiation therapy types

• external: teletherapy

• internal: brachytherapy

side effects of teletherapy

• skin reaction

• fatigue

• xerostomia (dry mouth)

• loss of taste

• acute mucositis

• ulceration of mucous membranes

• pain

• dysphagia

radiation nursing care

• oral care

• skin care

• provide rest

chemotherapy systemic effects (manifestations)

• hair loss

• pain

• mouth sores

• trouble breathing

• weakened immune system

• N&V

• constipation, diarrhea

• bruising, bleeding

• rashes

• neuropathy (arms &legs)

chemotherapy management

• promote comfort

• ensure nutrition

• promote rest

• prevent infection

• prevent injury

lung cancer (bronchogenic carcinoma)

leading cancer killer in US

• most common cause is inhaled carcinogens, like cigarette smoke, radon gas, occupational/environmental agents

lung cancer risk factors

• tobacco smoke

• environmental exposure

• genetics

• dietary habits

• previous scars in the lungs (TB, fibrosis)

lung cancer manifestations

• cough or change in chronic cough

• dyspnea

• hemoptysis

• chest or shoulder pain

• recurring fever

• repeated upper respiratory infections

• pleural effusion

lung cancer assessment & diag.

• CXR, CT of chest and brain, US, MRI

• scans: bone, abdominal, PET, liver US

• sputum cytology

• bronchoscopy

• biopsy

if surgery

• PFTs

• ABGs

• V/Q scans

lung cancer medical management

surgery

• pneumonectomy

  • removal of lung

  • lay on affected side

• lobectomy

  • removal of a lobe

• segmentectomy

  • removal of a segment

• wedge resection

  • removal of a small, pie shaped area of the segment (lung tissue)

chemotherapy

radiation

• external RT: teletherapy

• internal RT: brachytherapy

  • principle of DST: distance, shield, time

palliative therapy

chest surgery: chest tube assessment

semi/high fowler’s

• drainage

  • report if >70mL/hr

• fluctuation (tidaling/oscillation)

  • if no tidaling, means lung expanded or obstructed

  • tidaling is expected w/ water seal

• bubbling

  • water seal allows air to leave and prevent from entering

• crepitus

• assess vital signs, breath sounds, SaO2, color, and respiratory effort every 4 hr

• encourage coughing and deep breathing every 2 hr

• document amt, color hourly for 1st 24 hr then q8hr

  • date, time, level

chest surgery: chest tube safety precautions

• keep the drainage system below the client’s chest level, including during ambulation

• monitor chest tube placement and function

  • check the water seal level every 2 hr, and add fluid as needed. The fluid level should fluctuate with respiratory effort.

• tape all connections to ensure system is airtight and prevent chest tube from disconnecting

• expect bubbling in water seal on forced expiration/coughing = chest tube working

• avoid clamping tube unless system needs to be replaced or air leak located

• notify provider if O2 <90, eyelets visible in tube, darainage is above presc. amt or stop w/i 24 hrs

chest surgery: chest tube emergency management

air leaks

• monitor water seal for cont. bubbling

• locate source of leak

  • tighten connection, replace drainage system

• notify provider of air leak

accidental disconnection, system breakage, or removal

• instruct patient to exhale as much as possible and cough to remove as much air from pleural space

• if chest drainage compromised, immerse chest tube in sterile water

• if chest tube accidentally removed, dress with dry, sterile gauze

tension pneumothorax

• causes: sucking chest wounds, prolonged clamping of tube, kinks or obstruction in tubing, mech. vent. w/ high levels of pos. end expiratory pressure (PEEP)

• findings: tracheal deviation, absent breath sounds on one side, distended neck veins, resp. distress, asymmetry of chest, cyanosis

• notify provider or rapid response immediately

chest surgery: chest tube removal

• provide pain meds 30 mins before

• assist provider with sutures and removal

• instruct patient to take a deep breath, exhale, and bear down or take a deep breath and hold it when removing

• apply airtight sterile petroleum jelly gauze dressing. secure with heavyweight stretch tape

• obtain CXR

• monitor excessive would drainage, infection, recurrent pneumothorax

pleural effusion

collection of fluid in the pleural space, usually secondary to other disease process (like cancer)

• usually caused by underlying disease, not usually primary

• fluid, blood, pus

pleural effusion causes

• heart disease

• TB

• pneumonia

• pulmonary infections

• nephrotic syndrome

• connective tissue disease

• PE

• neoplastic tumors

pleural effusion assessment

• s&s of underlying disease

• dyspnea or orthopnea

• cough

• dec. or absent breath sounds

• dec. fremitus: chest vibrates when talking

• dull, flat chest percussion

  • vibration is stronger if there’s a tumor

  • vibration is dec. if it’s fluid

• dec. chest wall expansion

• tracheal deviation to unaffected side

pleural effusion diag.

• physical assessment

• CXR

• chest CT

• thoracentesis

• pleural fluid analysis

• pleural biopsy

pleural effusion management

• treat underlying cause

• chest pain management

• thoracentesis

  • removal of fluid from pleural space

• pleurodesis

  • instillation of meds into pleural space after draining

• surgical pleurectomy

  • removal of pleural layers that have reoccuring pleural effusion

• pleuroperitoneal shunt

  • device that contains a pump chamber that manually transfers fluid from pleural cavity to peritoneal cavity

pulmonary embolus (PE)

obstruction of the pulmonary artery or its branches by a thrombus that originates in the venous system or in the right side of the heart

PE types

• blood clots (most common)

• air

• fat (frac. of long bones)

• amniotic fluid

• septic (infection)

PE risk factors

• DVT

• trauma (frac. of long bones)

• surgery

• pregnancy

• a-fib

• HF

• hyper-coagulability (more dehydrated = risk for)

• prolonged immobility

PE manifestations

• dyspnea, ari hunger: syncope

• chest pain: sudden pleuritic on inspiration, pressure in chest

• anxiety, feelings of impeding doom

• chest wall tenderness

• VS: tachycardia, tachypnea, dec. O2 sat, fever, hypotension

• adventitious breath sounds

• new heart murmurs

• diaphoresis

• pleural effusion

• hemoptysis

PE assessment & diag.

• pulmonary angiography

  • contrast dye and x-ray

• ventilation-perfusion (V/Q) scan

• CXR, ECG, pulse ox, ABGs

• D-dimer assay

  • if elevated = clotting going on somewhere

  • identify early clotting

• spiral chest CT

  • best way to find clot and diag. PE

PE emergency management

emergency management

• O2 (ex. NC)

• IV lines

• dobutamine or dopamine (low bp & hr)

• cardiac glycosides

• morphine (for chest pain but pt at risk for resp. depression)

• sedatives

PE pharmalogic management

pharmalogic management

• anticoagulation therapy

  • heparin

    • prevents clots: subQ, IV (faster anticoag.)

  • warfarin (coumadin)

    • if patient has DVT clot and on subQ, will change to IV b/c works faster for anticoag. but willnot dissolve current DVT , only prevent future DVTs

  • enoxaparin (lovenox)

  • rivaroxaban (xarelto)

• thrombolytic therapy (dissolves clots but risk for bleeding)

  • urokinase, strepokinase, alteplase

  • TPA: tissue plasminogen activator

PE nursing management

prevention

• elevated legs

• move legs (circle toes)

• compression stockings

• SCDs

• ambulate

assessment

manage chest pain

managing O2 therapy

monitor anticoag. and thrombolytic therapy

• heparin: PTT (60-70), aPTT (20-39)

• warfarin: INR (1), PT (9-12.5)

• therapeutic value should be double to show that therapy is effective

  • normal value x 1.5-2.5 (double)

monitor for complications

tuberculosis (TB)

• caused by mycobacterium tuberculosis

• transmitted via airborne route

• may affect organs other than lungs

• risk of transmission dec. after 2-3 wks of anti TB therapy

• early detection and treatment is vital

TB risk factors

• immunocompromised

• contact with an untreated person

• lower socioeconomic status

• crowded environments

• adv. age

• health care occupation

• immigration

TB patho

bacteria transmitted thru the airways to the alveoli

→

phases

• initial exposure: granuloma, ghon tubercle, dormant

• infection: 2-10 wks after exposure

• active disease: compromised immune system

TB manifestations

• persistent cough longer than 3 wks

• night sweats

• low grade fever

• weight loss/anorexia

• purulent, blood tinged sputum

• hemoptysis

TB assessment & diag.

• physical assessment and hx

• skin test: two step PPD/Mantoux test (10mm or >)

• blood test: EBP: quantiferon-TB gold plus

• sputum culture

• CXR

• acid-fast bacilli smear and culture

  • 3 early morning sputum samples

  • wear PPE

  • neg. airflow room

TB: mantoux test

• induration of greater than 10 = pos.

• induration of greater than 5 for an immunocompromised patient = pos.

• patient w/o symp. may recieve preventive therapy

• cross reaction w/ BCG vaccine (bacillus calmette-guerin)

anti-TB meds

R ifampin (rifadin)

I soniazid (INH or nydrazid)

P yrazinamide

E thanbutol hydrochloride (myambutol)

S treptomycen

• 6-12 months

  • initial intensive regimen: 8 wks

    • RIPE meds

  • cont. regimen: 4-7 months

    • RI meds

    • considered noninfectious after 2-3 wks of cont. med treatment

TB nursing management

• prevention infection transmission

• promote airway clearance

• promote activity and nutrition

• improve immunity

• administer O2 as prescribed

• adhere to treatment regimen

  • take full med regimen

• follow up care

• contact social services as necessary

• community clinic as necessary