Medsurge respiratory 2

Common respiratory conditions

• Obstructive Sleep Apnea

  • Chronic

• Pneumonia

  • Acute

• Chronic Obstructive Pulmonary disease

  • Chronic

• Asthma

  • Acute and Chronic

• Pulmonary Embolism

  • Acute

• Pulmonary Tuberculosis

  • Acute and Chronic (can last 3-6 months)

Obstructive sleep apnea

• Normally, during both sleep and wakefulness, muscles in the pharynx keep the airway open to allow airflow into the lungs. However, in OSA, the muscles in the back of the throat including the togue relax and significantly narrow or block the airway.

• These brief periods of partial (hypopnea) or full (apnea) airway obstruction cause 10-20 second breathing interruptions that occur throughout the entire night.

• During an apneic event, oxygen saturation can decrease to 60% or less.

• Eventually, hypoxia and hypercapnia trigger the resumption of ventilation efforts.

• This pattern can repeat five or more times each hour, disrupting the restful phases of sleep.

Risk factos of Obstructive sleep apnea

• Physical features such as:

• fatty tissue in the neck

  • Males 17”

  • Females 15”

• large tongue or tonsils

• recessed chin

• deviated nasal septum

• Obesity

  • incr fat around neck

• Medical conditions that cause upper

  airway congestion, such as allergies

• Advanced age/ Male gender

• Family history of OSA

• Lifestyle factors, such as smoking and the use of alcohol, sedatives, or tranquilizers

Complications of Obstructive sleep apnea

• Daytime sleepiness

• Increased cardiovascular disease including hypertension and Myocardial infarction

• Increased risk of stroke

• Increased risk of complications during surgery

• Increased risk of work-related or driving accidents

Clinical cues of Obstructive sleep apnea

• Snoring

• Sleepiness

• Significant other reports

  • Headaches (particularly in the morning)

  • Cognitive changes/irritability

  • Impotence

  • Arrhythmias

  • Hypertension

Treatments of Obstructive sleep apnea

• Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPap) to increase air pressure in the throat so that the airway does not collapse during breathing

• Mandibular advancement devices (MAD)

• Sleep position changes such as side-lying and raising the head of the bed (avoidance of supine position)

• Smoking cessation

Nursing interventions of Obstructive sleep apnea

• Obtain and document information about the patient's sleep pattern and the amount of sleep achieved nightly and weekly.

• Assess the patient for OSA risk factors, including hypertension, obesity, diabetes mellitus, and cardiovascular disease.

• Ask the patient about episodes of daytime sleepiness, motor vehicle accidents that may have been caused by fatigue or sleepiness, and insomnia.

• Review the settings on CPAP or BiPaP, as well as any discomfort issues, such as nasal dryness, sleep positions, irritated facial skin, or air leaks around the mask, which might indicate a wrong sized mask.

• Measure oxyhemoglobin saturation.

Obstructive sleep apnea Nursing Diagnosis

Ineffective breathing pattern

Sleep deprivation

The lobes of the lungs

Gas exchange

SpO2 is obtained in noninvasive manner, norm values are 95-100%

PaO2 is obtained from blood in artery and is mire accurate, norm values are 80-100%

Upper Airway

Lower Airway

Pneumonia

Types:

• Bacteria

• Virus

• Fungi

• Opportunistic

• Aspiration (noninfectious)

Classification:

• Community Acquired (CAP)

  • onset in community or in 1st 2 days of hospitalization

• Hospital Acquired (HAP)

  • Onset 2 days after hospitalization

• Healthcare Associated (HCAP)

• Ventilator Acquired (VAP)

  • Raise HOB 30-45

  • Suctioning

  • Appears when not cared for properly

Pneumonia Pathophysiology

• excessive fluid in the lungs, caused by a inflammatory process. Inflammation is triggered by an infectious organism or by inhalation of irritating agents

• Infection process begins with pathogens in the alveoli

• Pathogens multiply, fluids form, WBC migrate into alveoli causing local capillary leak, edema, and exudate

• Fluids thickens the alveoli wall

• Fluid, blood cells, bacteria fills the alveoli

• The fibrin & edema of inflammation stiffen lungs

• Vital capacity, compliance, and surfactant decrease

• Atelectasis reduces ability of lungs to oxygenate blood, resulting in hypoxemia, reduced oxygenation and reduced perfusion

Pneumonia Risk Factors

• History of COPD, influenza, aspiration, heart

  failure, AIDS, Immunocompromised

• Altered level of consciousness……WHY???

  • increased risk for aspiration

• History of tobacco use or alcohol

• Mechanical ventilation

• Tracheostomy or NG tubes……Why???

  • feed them if nG tube is in lungs they die

  • Tracheostomy bacteria can crawl into

• Unvaccinated (Pneumococcal or influenza)

• Geriatric patient (symptoms may include change in behavior)

• Poor nutritional status

Cyanosis

Poor perfussion, deficient oxygenation of blood

Clubbing

Chronic Hypoxia (LONG TERM CONDIITON)

No intervention to fix

• COPD

• OSA

Mottling

Acute hypoxic status

Assessment findings in Pneumonia

• Pleuritic chest pain, or abdominal pain

• Headache, fever, chills

• Difficulty breathing

• Tachypnea, respiratory distress

• Productive cough with mucus

• Purulent sputum production

• Crackles, wheezing, or Rhonchi

  • For crackles give diuretic

  • Wheezing give bronchodilator

  • Rhonchi give hydration

• Hypotension, rapid pulse (secondary to dehydration, or advanced stage)

DIagnostic Tests for Pneumonia

• CBC

• Sputum Sample

• Blood culture (As soon as possible usually before1st dose of antibiotics)

• ABGs and pulse oximetry

• Serum electrolytes

• CXR

• Thoracentesis-Diagnostic and therapeutic

• Chest tube placement-Diagnostic and therapeutic

Nursing diagnosis for pneumonia

• Ineffective airway clearance r/t increased secretions

• Impaired gas exchange r/t altered functioning of alveoli

• Acute pain r/t coughing

• Infection r/t increased wbc and presents of 5 signs of infection

Treatments for pneumonia

Anti-infectives: Ceftriaxone (Rocephin) IV or Amoxicillin Clavulanic (Augmentin) PO. (used

except if viral)

• Oxygen therapy

• Bronchodilators: Albuterol

• Antitussives: Codeine Sulfate

• Hydration IV and/or PO

• High calorie diet

• Hygiene (oral) and rest

• Prevention: Pneumococcal vaccine Q5yrs & Influenza vaccine Q1 yr.

• NSAID

Nursing Interventions for pneumonia

• O2 therapy: Collaborative

• Chest physiotherapy

  • No need for doctors orders

  • Can’t do on self

  • Break up mucus on wall

  • Rhonchi

  • Contraindicated on Pregnant person, spinal chord injury,

• Cough, deep breathe, and incentive spirometry: Collaborative

• Adequate hydration- 2-3L/day unless otherwise contraindicated

• Bronchodilators: independent

• Patient teaching

Emphysema

LOSS OF ELASTIC RECOIL IN LUNGS

• Alveolar sacs lose elasticity, small airways

narrow

• Alveoli become enlarged and flabby with a

decreased area for effective gas exchange

• Air trapping occurs because lungs do not recoil

which causes increase work of breathing.

• Diaphragm becomes flat and weak which causes

use of accessory muscles & air hunger.

• CO2 is produced faster than it can be removed

which results in respiratory acidosis. pH < 7.35 &

CO2 >45.

• Low arterial oxygen (PaO2) secondary to decreased ability for gas diffusion.

Clinical Manifestations:

• Barrel Chest 2/1

• Sit in tripod position to breath

• use of clavicle and accessory muscles to breath

Chronic Bronchitis

• An inflammation of the bronchioles and bronchi caused by chronic exposure to irritants (What is

  the most common irritant?)

  • Smoke from cigarettes

• Irritant triggers inflammation, vasodilation, congestion, mucosal edema, and bronchospasms

• Hypersecretion of mucus for at least 3 months

• Ciliary function is reduced, bronchial walls thicken, airway becomes narrow

• Alveoli become damaged and fibrosed

• Chronic inflammation causes increase in number and size of mucous glands which produce increased amounts of thick mucous.

• Thick bronchial walls plus increased mucous block smaller airways and narrow large airways

• Clinical manifestations

  • Productive cough

  • Dyspnea

  • Cyanosis

  • use of accessory muscles

  • Cor pulmonale

COPD compplications

• COPD affects the oxygenation & perfusion to all tissues.

• Cor pulmonale (right sided heart failure)

• Hypoxemia and acidosis

• Respiratory insufficiency

• atelectasis

• pneumothorax

• Increase in respiratory infections secondary to increased mucous and poor oxygenation

• (Ensure patients are aware of early s/s of respiratory infection)

• Cardiac dysrhythmias secondary to hypoxemia

• Malnutrition (secondary to dyspnea & early satiety)

COPD Assessment

• Presents of cyanosis

• Shallow, rapid, ineffective respirations

• Color/consistency of sputum

• Breath sounds and breathing pattern

• Ability to have a conversation

• Cognitive ability

• Ability to perform ADLs

• Nutritional status

• Clubbing of fingernails/Barrel chest

COPD Diagnostic Testing

• ABGs

• Sputum

• CBC

• CXR

• Pulmonary function test (lung volumes, flow volumes, and diffusion capacity)

• Peak expiratory flow rates

COPD nursing diagnoses

• Imbalanced nutrition less than body requirements r/t ????

  • Give soft foods

• Impaired gas exchange r/t ????

• Activity intolerance r/t ????

• Ineffective airway clearance r/t ????

• Anxiety r/t ????

  • give antianxiety meds

• Ineffective breathing pattern r/t ????

COPD Interventions

• Airway patency is the most important intervention

• Frequent focused assessment

• Cough enhancement

• O2 therapy to relieve hypoxemia & hypoxia

• Beta-2 adrenergic agents (e.g., Albuterol)

• Anticholinergic agents (e.g., Ipratropium bromide)

• Methylxanthines (e.g., Theophylline)

• Corticosteroids (e.g., Prednisone, IV solumedrol)

• NSAIDS

• Encourage high calorie, high protein diet.

• Mucolytic agents (e.g., Guaifenesin)

• Pulmonary rehabilitation

• Lung transplant/reduction for endstage COPD

• Promote smoking cessation

• Pulmonary rehabilitation

• Pneumococcal vaccine

• Influenza vaccine

• Yearly flu vacine

• pneumococcal conjugate vaccine

• WASHING HANDS

• Staying hydrated

• Exercise

• VACUMMING AND FILTRATION TO REDUCE IRITTANTS

Pursed Lip Breathing

Helps manage dyspnea, COPD

Breath in through nose 1-2 sec

Purse lips and breath out, use abdominal muscles to squeez out, don’t puff cheeks, 4 secs

• Deep breath through nose for 2 seconds and slowly and gently Exhale through pursed lips while counting to 4

• Reduces Dyspnea and panic

• Encourage patients with COPD with ADL

• encourages relaxation

• GOAL: Prolonged expiration keeps smaller airways open for longer which increases oxygenation

COPD

diseases with permanent or temporary narrowing of small bronchi, in which forced expiratory flow is slowed

bronchitis, Emphysema, dyspnea

Risk factors: cigarette smoking and pollutants, genetic factors AATD predisposes people to develop COPD

Asthma

• Chronic airflow Limitation that presents as an acute attack

• Chronic but reversible airflow obstruction (Unlike COPD which is non-reversible)

• Inflammation in the airway causes hyperresponsiveness that causes bronchoconstriction,

• mucosal edema, and mucus production

• Inflammation occurs due to irritants such as cold or dry air, small particles in the air, allergy,

• aspirin or NSAIDS.

• Eosinophils increase (why?)

  • Produce proteins that are toxic and can increase harm

• Inflammation leads to cough, chest tightness, wheezing, and dyspnea

• When not controlled attacks are more frequent and damage occurs.

• Patients should be well educated regarding the avoidance of triggers and medications for control vs medications used for acute attacks.

Asthma Assessment factors

• Cough (productive or not)

• Wheezing

• Chest tightness

• Dyspnea

• Diaphoresis

• Tachycardia

• Hypoxemia and central cyanosis

Mild

• cough, sneezing, chest tightness, breathing <2 a week

Moderate

• same as mild but more frequent

Severe

• respiratory distress, marked wheezing, or absent breath sounds, pulsus paradoses >10mm HG, chest wall contractions

Asthma medication therapy

• Quick relief (rescue medications)

  • Beta2-agonists

  • Anticholinergics

• Long-acting medications

  • Corticosteroids

  • Long-acting beta2–agonists

Asthma Client Teaching

• How to identify and avoid triggers

• How to perform peak flow monitoring

• How to implement an action plan

• When and how to seek assistance

Pulmonary embolism

• A collection of particulate matter (solids, liquids, air) that enters venous circulation & lodges in pulmonary vessels.

• Large emboli obstruct pulmonary blood flow, reduce oxygenation of all tissues, including pulmonary tissue.

• Deoxygenated blood moves to arterial circulation causing hypoxemia

• Blood clots formed in deep veins are most common cause.

• PE is a common condition which can lead to death within 1 hour of onset of symptoms.

Pulmonary embolism findings

• Sudden and abrupt onset of dyspnea

• Pleuritic chest pain & increased heart rate

• Crackles, cough, hemoptysis

• Distended neck veins, syncope, cyanosis, and hypotension

• Abnormal EKG and heart sounds

• Sense of impending doom, anxiety, and fearfulness.

Diagnostic Testing for PE

• ABG

• CXR & CT Angiogram

• Transesophageal echocardiogram (TEE)

Nursing dainosis for PE

• Impaired gas exchange r/t disruption of pulmonary perfusion

• Decreased cardiac output r/t altered pulmonary circulation.

• Anxiety r/t hypoxia

PE interventions

• Activate Rapid Response Team (per hospital policy)

• O2 therapy (including mechanical ventilation if needed)

• Frequent ABGs & continuous pulse ox

• IV fluids

• Frequent VS & focused assessment

• Anticoagulant therapy (What precautions should be taken?)

  • Bleeding risk

• Fibrinolytic therapy (Clot busters)

  • Bleeding risk

• Antianxiety medications

Surgical interventions PE

Embolectomy: Surgical removal of embolus from pulmonary blood vessels

Tuberculosis

• A highly infectious disease caused by Mycobacterium tuberculosis

• Bacilli make it past the upper airway defense systems and enter the lungs.

• The organism implants in alveoli or respiratory bronchiole

• An inflammatory response is initiated as the bacteria multiply.

• The organism continues to slowly grow and enters into the lymphatic system

• A tubercle lesion is formed

Tuberculosis Risk Factors

• Compromised immune system (ex. HIV, elderly)

• People in overpopulated areas (ex. Homeless shelters, Prisons)

• IV drug abusers

• Work in high risk environment

Signs and Symptoms for TB

• Fatigue/ Lethargy

• Weight loss/ Anorexia

• Low grade fever

• Night sweats

• Persistent Cough

• Hemoptysis

Diagnostic testing TB

• Mantoux test: Intradermal injection of 0.1mL of PPD into the forearm

• Sputum smear: Acid-fast smear provides an indication of tubercle bacillus

• Sputum culture: Confirms presents of M. Tuberculosis

• Chest x-ray: Reveals lesions

TB Interventions

• Newly diagnosed or suspected TB: Placed in respiratory isolation (Negative pressure rooms, N95 mask)

• Long term combination drug therapy:

• Typically, no less than 6 months and can be as long as 1 years.

• Encouragement: Assure patients that fatigue will gradually decrease. EDUCATION: Teach patients the importance of medication compliance.

• Patients need to always have medication on hand

• Patients may benefit from a personal medication administration record.

TB medications

Common Medications:

• Isoniazid (INH)

• Rifampin (RIF)

• Pyrazinamide (PZA)

• Ethambutol (EMB)

Chest tube

● Monitor vital signs during insertion and throughout therapy.

● Monitor for Tracheal deviation.

● Monitor patency (tube not dislodged, no kinks, wall suction at prescribed settings).

● Ensure that the chest tube is NEVER placed higher than the chest.

● Monitor drainage for amount per shift, color, and consistency.

● Palpate area around chest tube insertion site for crepitus, if felt mark the area and assess

for “Spreading.”

● Continue to encourage patient to deep breathe and cough.

● Keep a petrolatum gauze dressing and a sterile dry dressing.

Thoracentesis

● Prepare patient for procedure providing reassurance regarding pain (Because patients are

awake for the procedure, they often have a great sense of fear about pain)

● Ensure proper positioning.

● Monitor vital signs before, during, and after procedure.

● Ensure MD has appropriate space for maintaining aseptic technique.

● Assess breath sounds after procedure.

● Send specimens to lab as ordered and per hospital policy, discard per hospital policy if no

orders for lab.

Introduction to respiratory therapist

● Perform focused respiratory assessments

● Administer respiratory medications (inhalants, nebulizers)

● Change and manage oxygen therapy devices (nasal cannula, venti mask)

● Set up and manage ventilators

● Perform artificial airway suction and care in collaboration with RN.

● Provide oral care in collaboration with RN.

Surgical Management of Patients with COPD

Bullectomy

• for patients with bullous emphysema

Lung Volume Reduction Surgery

• reduces hyperinflation of lungs and allows the functional tissue to expand, improving elastic recoil of lung

• does not curer or improve life expectancy

• decreases dyspnea and improves lung function and improves quality of life

Lung Transplant

• for end-stage emphysema

• improves quality of life and functional capacity in patient