Chapter 18: Respiratory Diagnostic and Therapeutic Procedures

Chapter 18: Respiratory Diagnostic and Therapeutic Procedures

Purpose

• Evaluate respiratory status

• Assess oxygenation of the blood

• Assess lung function

• Assess integrity of the airway

Common Respiratory Diagnostic Procedures

• Pulmonary function tests (evaluate lung volumes, capacities, and airflow)

• Arterial blood gases (assess oxygenation, ventilation, and acid base balance)

• Bronchoscopy (visualize airway, obtain samples, remove obstructions)

• Thoracentesis (remove pleural fluid for analysis or symptom relief)

Nursing Responsibilities

• Ensure informed consent is signed prior to diagnostic procedures

• Verify understanding of the procedure by the client

• Prepare the client according to the specific test requirements

• Monitor for complications during and after procedures (airway compromise, bleeding, respiratory distress)

A nurse is reviewing information with a client who is scheduled for pulmonary function tests. Which of the following statements should the nurse make?​​​​​​​

a

“Do not use inhaler medications for 6 hr following the test.”

b

“Do not smoke tobacco for 6 to 8 hr prior to the test.”

c

“You will be asked to bear down and hold your breath during the test.”

d

“The arterial blood flow to your hand will be evaluated as part of the test.”

b

“Do not smoke tobacco for 6 to 8 hr prior to the test.”

Pulmonary Function Tests (PFTs)

Purpose

• Determine lung function and breathing difficulties

• Identify presence and severity of lung disease

• Assess respiratory risk prior to surgery

Measures

• Lung volumes and capacities

• Diffusion capacity (gas transfer)

• Gas exchange

• Flow rates

• Airway resistance

• Distribution of ventilation

Clinical Indications

• Dyspnea

• Suspected or known lung disease

• Preoperative respiratory risk assessment

Nursing Considerations

• Instruct client not to smoke 6 to 8 hr prior to testing (smoking alters airflow and gas exchange)

• If client uses inhalers, withhold 4 to 6 hr before testing (varies by facility policy)

• Ensure client understands test instructions to ensure accurate results

Arterial Blood Gases (ABGs)

Assess oxygenation and acid base balance of the blood

ABG Components

• pH: amount of free hydrogen ions in arterial blood (acid base status)

• PaO₂: partial pressure of oxygen (oxygenation)

• PaCO₂: partial pressure of carbon dioxide (ventilation)

• HCO₃⁻: bicarbonate concentration (metabolic component of acid base balance)

• SaO₂: percentage of hemoglobin saturated with oxygen

Collection Methods

• Arterial puncture

• Arterial line

Indications and Potential Diagnoses

• Evaluate acid base imbalances

• Monitor respiratory, renal, electrolyte, endocrine, or neurologic conditions

• Assess effectiveness of treatments (e.g., acidosis management)

• Guide oxygen therapy

• Evaluate response to weaning from mechanical ventilation

Arterial Puncture

Preprocedure Nursing Actions

• Obtain a heparinized syringe

• Perform Allen’s test to verify radial and ulnar artery patency

  • Compress radial and ulnar arteries while client makes a fist

  • Release ulnar artery and observe for capillary refill

  • Hand should turn pink within 15 seconds (adequate collateral circulation)

• Explain the procedure and purpose to the client (reduces anxiety and improves cooperation)

Intraprocedure Nursing Actions

• Use surgical aseptic technique

• Collect arterial blood into a heparinized syringe

• Cap the syringe and place specimen in ice and water immediately (preserves pH and oxygen levels)

• Transport specimen to the lab promptly

• Note that radial artery access may be more difficult in older adults due to decreased peripheral circulation

• Arterial punctures are often performed by respiratory therapists in hospital settings

Postprocedure Nursing Actions

• Apply direct pressure to the puncture site for at least 5 minutes

  • Hold pressure for at least 20 minutes if client is on anticoagulant therapy

• Ensure bleeding has stopped before releasing pressure

• Monitor site for:

  • Bleeding

  • Loss of pulse

  • Swelling

  • Changes in temperature or color

• Document procedure, site condition, and client response

• Report ABG results to the provider as soon as available

• Implement prescribed respiratory interventions based on results (e.g., adjust oxygen or ventilator settings)

Allen's Test (Image)

Interpretation of ABG Findings

Blood pH

• pH < 7.35 = Acidosis

• pH > 7.45 = Alkalosis

ABG Measures and Expected Reference Ranges

• pH: 7.35 to 7.45 (overall acid base balance)

• PaO₂: 80 to 100 mm Hg (arterial oxygenation)

• PaCO₂: 35 to 45 mm Hg (ventilation status)

• HCO₃⁻: 22 to 26 mEq/L (metabolic component of acid base balance)

• SaO₂: 95% to 100% (hemoglobin oxygen saturation)

Clinical Nursing Focus

• pH reflects overall status, but PaCO₂ and HCO₃⁻ identify respiratory vs metabolic cause

• PaO₂ and SaO₂ assess adequacy of oxygenation

• Trends over time are more important than single values (treatment response monitoring)

Arterial Blood Gases (ABGs) Complications

Hematoma and Arterial Occlusion

• Blood accumulates under the skin at the puncture site

• Can impair distal circulation

Nursing Actions

• Observe for:

  • Swelling

  • Color changes

  • Temperature changes

  • Pain

  • Loss of pulse (arterial compromise)

• Apply firm pressure to the site

• Notify the provider immediately if manifestations persist

Air Embolism

• Air enters the arterial system during catheter insertion

Nursing Actions

• Place the client in a flat or Trendelenburg position (prevents air migration)

• Instruct the client to bear down and hold their breath (Valsalva maneuver)

• Monitor for:

  • Sudden shortness of breath

  • Decreased SaO₂

  • Chest pain

  • Anxiety

  • Air hunger

• Notify the provider immediately

• Administer oxygen as prescribed

• Obtain ABGs

• Continuously assess respiratory status for deterioration

Bronchoscopy

Allows visualization of the larynx, trachea, and bronchi

Performed using a flexible fiber-optic or rigid bronchoscope

Can be done:

• Outpatient

• In a surgical suite under general anesthesia

• At bedside with local anesthesia and moderate (conscious) sedation

Can be performed on mechanically ventilated clients via the endotracheal tube

Indications and Potential Diagnoses

• Visualization of abnormalities:

  • Tumors

  • Inflammation

  • Strictures

• Biopsy of suspicious tissue (lung cancer)

  • Increased risk for bleeding and perforation

• Aspiration of deep sputum or lung abscesses:

  • Culture and sensitivity

  • Cytology (e.g., pneumonia)

Therapeutic Uses

• Removal of foreign bodies

• Removal of secretions from the tracheobronchial tree

• Treatment of postoperative atelectasis

• Destruction or excision of lesions

Bronchoscopy Considerations

Preprocedure Nursing Actions

• Assess for:

  • Allergies to anesthetic agents

  • Use of anticoagulants

• Ensure informed consent is signed

• Remove dentures prior to procedure

• Maintain NPO status 4 to 8 hr (prevents aspiration when cough reflex is suppressed)

• Administer prescribed preprocedure medications:

  • Anxiolytic

  • Atropine (reduces secretions)

  • Viscous lidocaine

  • Local anesthetic throat spray

Intraprocedure Nursing Actions

• Position client sitting or supine

• Assist with specimen collection and labeling

• Ensure prompt transport of specimens to the lab

• Continuously monitor:

  • Vital signs

  • Respiratory pattern

  • Oxygenation status

• Use caution with older adult clients:

  • Sedation can precipitate respiratory arrest in those with respiratory insufficiency

Postprocedure Nursing Actions

• Monitor:

  • Respirations

  • Blood pressure

  • Heart rate

  • Pulse oximetry

  • Level of consciousness

• Assess for confusion or lethargy, especially in older adults

• Assess for return of gag and cough reflex before oral intake

  • Withhold oral intake until reflexes return

  • Gag reflex may be delayed in older adults

• Once gag reflex returns:

  • Offer ice chips

  • Progress to fluids

• Monitor for complications:

  • Fever lasting more than 24 hr (infection)

  • Productive cough

  • Significant hemoptysis (small blood-tinged sputum is expected)

  • Hypoxemia

• Be prepared to manage:

  • Aspiration

  • Laryngospasm

• Provide oral hygiene

• Encourage coughing and deep breathing every 2 hr

  • Older adults have increased risk of pneumonia due to reduced cough effectiveness and secretion clearance

• Do not discharge until adequate cough reflex and respiratory effort are present

Client Education

• Gargling with salt water or using throat lozenges may reduce throat soreness

Bronchoscopy Complications

Laryngospasm

• Uncontrolled contraction of vocal cords causing airway obstruction

Nursing Actions

• Continuously monitor for respiratory distress

• Keep resuscitation equipment readily available

Pneumothorax

• Can occur after rigid bronchoscopy

Nursing Actions

• Assess breath sounds and oxygen saturation

• Obtain follow-up chest x-ray

Aspiration

• Occurs when oral or gastric contents enter the airway

Nursing Actions

• Keep client NPO until gag reflex returns (usually about 2 hr)

• Suction airway as needed

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider?

a

Blood-tinged sputum

b

Dry, nonproductive cough

c

Sore throat

d

Bronchospasms

d

Bronchospasms

---

The nurse should notify the provider immediately. Blood-tinged sputum, a dry, nonproductive cough, and a sore throat

Thoracentesis

Surgical perforation of the chest wall and pleural space using a large-bore needle

Used to:

• Obtain pleural fluid for diagnostic evaluation

• Instill medication into the pleural space

• Remove fluid (effusion) or air for therapeutic relief of pleural pressure

Performed under local anesthesia at the bedside, procedure room, or provider’s office

Ultrasound guidance decreases risk of complications

Indications and Potential Diagnoses

• Determine cause of pleural effusion:

  • Transudates (heart failure, cirrhosis, nephrotic syndrome, hypoproteinemia)

  • Exudates (inflammatory, infectious, neoplastic conditions)

• Empyema

• Pneumonia

• Blunt, crushing, or penetrating chest trauma

• Postoperative complications from lung or cardiac surgery

Client Presentation

• Large pleural effusions compress lung tissue causing:

  • Chest pain

  • Shortness of breath

  • Cough

  • Other signs of pleural pressure

• Assessment findings:

  • Abnormal or diminished breath sounds

  • Dullness to percussion

  • Decreased chest wall expansion

  • Pain related to inflammation

Interpretation of Findings

• Aspirated fluid analyzed for:

  • Appearance

  • Cell count

  • Protein and glucose levels

  • Enzymes (LDH, amylase)

  • Abnormal cells

  • Culture

transudates vs exudates

Thoracentesis Considerations

Preprocedure Considerations

• Percussion, auscultation, x-ray, or ultrasound used to locate effusion and insertion site

• Older adults may require assistance maintaining position due to arthritis, tremors, or weakness

Preprocedure Nursing Actions

• Verify informed consent

• Gather all required supplies

• Obtain preprocedure chest x-ray

• Position client:

  • Sitting upright

  • Arms and shoulders supported on pillows or overbed table

  • Feet and legs well supported

• Client education:

  • Remain absolutely still

  • Do not cough or talk unless instructed (prevents needle injury)

Intraprocedure Nursing Actions

• Assist provider using strict surgical aseptic technique

• Prepare client for pressure sensation during needle insertion and fluid removal

• Monitor:

  • Vital signs

  • Skin color

  • Oxygen saturation

• Measure and document amount of fluid removed

• Label specimens at bedside and send promptly to laboratory

• Fluid removal limited to 1 L at a time (prevents re-expansion pulmonary edema)

Postprocedure Nursing Actions

• Apply dressing to puncture site and assess for bleeding or drainage

• Monitor vital signs and respiratory status hourly for first several hours:

  • Respiratory rate and rhythm

  • Breath sounds

  • Oxygenation status

• Auscultate lungs for decreased breath sounds on affected side

• Encourage deep breathing to promote lung expansion

• Obtain postprocedure chest x-ray:

  • Confirm resolution of effusion

  • Rule out pneumothorax

effusion

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client’s room?

Select all that apply.

a

Oxygen equipment

b

Incentive spirometer

c

Pulse oximeter

d

Sterile dressing

e

Suture removal kit

a

Oxygen equipment

c

Pulse oximeter

d

Sterile dressing

Thoracentesis Complications

Mediastinal Shift

• Shift of thoracic structures to one side

Nursing Actions

• Monitor vital signs

• Auscultate lungs for decreased or absent breath sounds

Pneumothorax

• Collapsed lung due to lung injury during procedure

Nursing Actions

• Monitor for:

  • Diminished breath sounds

  • Distended neck veins

  • Chest wall asymmetry

  • Respiratory distress

  • Cyanosis

• Review postprocedure chest x-ray results

Client Education

• Can occur within first 24 hr

• Report:

  • Deviated trachea

  • Sharp chest pain

  • Affected side not moving with breathing

  • Increased heart rate

  • Rapid, shallow respirations

  • Nagging cough

  • Air hunger

Bleeding

• Risk increased with movement or bleeding disorders

Nursing Actions

• Monitor for coughing and hemoptysis

• Assess vital signs and labs:

  • Hypotension

  • Decreased hemoglobin

• Inspect thoracentesis site for bleeding

Infection

• Bacterial introduction at needle site

Nursing Actions

• Maintain sterile technique

• Monitor temperature after procedure

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?

a

Position the client upright, leaning over the bedside table.

b

Explain the procedure to the client. ​​​​​​​

c

Perform an Allen’s test on the client​​​​​​​.

d

Administer benzocaine spray to the client.

a

Position the client upright, leaning over the bedside table.

When taking actions, the nurse should identify that positioning the client in an upright position, bent over the bedside table, widens the intercostal space for the provider to access the pleural fluid.

A nurse is assessing a client following a thoracentesis. Which of the following findings should the nurse report?

Select all that apply.

a

Dyspnea

b

Localized bloody drainage on the dressing

c

Fever

d

Hypotension

e

Report of pain at the puncture site

a

Dyspnea

c

Fever

d

Hypotension