medsurg respiratory

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

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

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* 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

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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

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normal: >95%

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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

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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

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* **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

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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 h%%r
* 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

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

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* 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