NRSG 250: Exam 2 - Respiratory

What is obstructive sleep apnea (OSA)?

occurs when the upper airway repeatedly collapses during sleep, causing pauses in breathing

What are the risk factors for OSA?

1. Obesity

2. Large neck circumference or short neck

3. Large tonsils, adenoids, uvula, or tongue

4. Smoking

5. Oropharyngeal edema (more likely after surgery)

6. Alcohol or sedative use before sleep

What are the nighttime manifestations of OSA?

1. loud snoring

2. Pauses in breathing for 10 seconds or longer

3. Restless sleep

4. Frequent awakening or gasping

What are the daytime manifesations for OSA?

1. Excessive daytime sleepiness

2. Morning headache

3. Irritability

4. Difficulty concentrating

5. Fatigue

What can untreated OSA manifestations lead to?

1. HTN

2. dysrhythmias

3. HF

4. stroke

5. depression

6. motor vehicle accidents → daytime drowsiness

What management is used for OSA?

Nonsurgical:

• weight loss

• avoid ETOH and sedatives before sleep

• sleep position changes

• CPAP or BiPAP therapy (take off when taking oral meds)

• Oral or position-fixing devices

Surgical:

• removal/reduction of obstructing tissue (adenoidectomy, uvulectomy)

• if nonsurgical is ineffective

What pt teaching is needed for OSA?

1. use positive-pressure device every night

2. BP and therapy adherence

3. report mask discomfort, skin breakdown, or dryness

4. clean equipment as instructed

What is a total laryngectomy?

removal of the larynx, or voice box; possible d/t head or neck cancer

• airway is permanently separated from mouth & nose

• trachea brought to neck surface → creates permanent stoma

• Pt breathes through stoma via artificial airway & loses natural voice production

What are potential post-op laryngectomy complications?

1. stoma/airway obstruction

1. thick secretions/mucus plugging

2. tube dislodgement

3. pneumothorax

4. subcutaneous emphysema

5. bleeding

6. infection

7. aspiration risk before swallow clearance

8. wound breakdown or fistula formation

What are nursing considerations for post-op laryngectomy?

Priority = ABCs!

• assess stoma patency

• maintain humidified O2 as ordered & suction only as needed

• Monitor O2, resp effort, and secretions

• Keep emergency airway equipment at bedside

• ventilate through stoma if CPR is needed

Nutrition and swallowing

• NG or enteral feeding → while tissues heal

• oral intake → only after provider clearnace or swallow eval

• extra nutrition → wound healing

What is the daily care for post-op laryngectomy?

1. stoma care & skin protection

2. humidification

3. suctioning as needed

4. good oral hygiene

5. HOB elevated

6. communication support

What pt teaching is needed for a laryngectomy?

1. protect stoma from water

   • avoid swimming

   • use shower shield

   • body faces away from shower head

2. use humidification or heat-moisture exchanger

3. know when to seek help from difficulty breathing or bleeding

What is the proper way to suction a tracheostomy or laryngectomy tube?

1. connect catheter to suction machine. do not touch end of catheter that will go inside tube

2. insert catheter inside (usually length of tube + ¼ in.)

3. apply suction by putting thumb over hold while you gently pull catheter out. Gently roll catheter btwn thumb & forefinger as you pull catheter out

What are some communication options for speech after a laryngectomy?

1. Writing or communication board

2. Mouthing words or gestures

3. Electrolarynx/artificial larynx

4. Esophageal speech (using belching to create speech)

5. Tracheoesophageal voice prosthesis

What are nursing support methods for speech after an laryngectomy?

1. provide communication tools early

2. allow extra time for responses

3. use normal tone of voice

4. consult speech-language pathology

5. address anxiety, frustration, or changes in body image

6. obtain referral to speech-language pathologist (ST)

What is pneumonia (PNA)?

an infection or inflammatory process in the lungs that causes the alveoli to fill with fluid, mucus, or pus → impaired gas exhange

Types:

1. Community-acquired pneumonia

2. Hospital-acquired pneumonia

3. Ventilator-associated pneumonia

4. Aspiration pneumonia

What causes PNA?

1. Bacteria, viruses, & fungi

2. Aspiration of oral or gastric contents

3. Inhalation of irritants

What are the manifestations of PNA?

Respiratory:

1. productive sough

2. dyspnea

3. increased RR

4. crackles / diminished breath sounds

5. pleuritic chest pain

6. hypoxemia

Systemic:

7. fever / chills

8. fatigue / weakness

9. poor appetite

10. tachycardia

11. confused / ALOC (esp. in older adults)

What diagnostics are used for PNA?

Labs:

• CBC

• sputum gram stain, C&S

• blood cultures if indicated

• ABGs if resp. distress or worsening O2 → pH imbalance

• Electrolytes, BUN, creatinine

• Lactate if sepsis suspected → increased lactate = sepsis

Imaging:

• CXR → fluid build-up

• Pulse ox

• CT chest or thoracentesis

What is important to consider before administering antibiotics?

Ensure a culture has been collected, but do not delay urgent treatment for an unstable pt

What is the tx for PNA?

Medication:

• antibiotics, antivirals, antifungals

Management:

• give O2 as ordered & monitor response

• coughing, deep breathing

• Incentive spirometry

• promote hydration

• cluster care → allow rest

• monitor lung sounds, SpO2, resp. effort, & temp

Nutrition:

• small, frequent, high-protein meals

• adequate fluids

What pt teaching is used for PNA?

1. Take medications exactly as prescribed

2. Complete the full antibiotic course if ordered

3. Increase activity gradually & rest when fatigued

4. Maintain hydration and nutrition

5. Perform coughing, deep breathing, or incentive spirometry as instructed

6. Avoid smoking and respiratory irritants

7. Reduce exposure to people with respiratory infections

8. Stay current with recommended vaccines

9. report increased SOB, recurring fever, chest pain, confusion, blue lips, severe weakness, and worsening cough / blood sputum

What is tuberculosis (TB)?

an airborne infectious disease caused by Mycobacterium tuberculosis

• most often affects lungs

What are the key characteristics of TB?

1. spread through airborne from person w/ infectious TB

2. Secondary TB: can remain latent and reactivate later

3. granulomas may form in infected tissue

4. increased exposure = increased risk

5. Resistant TB: difficult to treat → can be fatal

What are the risk factors for TB?

1. close contact to someone w/ active TB

2. immunocompromised pts

3. HIV

4. living or working in congregate settings

What are the manifestations of TB?

1. Persistent cough

2. Sputum production

3. Hemoptysis or blood-streaked sputum

4. Low-grade fever

5. Night sweats

6. Fatigue or weakness

7. Anorexia and weight loss

8. Chest pain

9. Dyspnea

10. pallor

Assessment findings:

1. activity intolerance

2. diminished or bronchial breath sounds

3. dullness to percussion over involved areas

4. increased transmission of spoken or whispered sounds

5. symptoms may develop gradually → may delay seeking of care

What are the diagnostics to screen for a general TB infection?

1. screening for TB infection

2. TST or PPD

3. interferon-gamma release assay (IGRA)

4. positive results need to be confirmed → does not indicate ACTIVE disease; possible for it to be latent)

   • false negative = immune system not working

What are the diagnostic to evaluate for an active TB disease?

1. CXR

2. sputum acid-fast bacillus smear

3. sputum culture

4. nucleic acid amplification test (NAAT)

What nursing interventions are used for TB?

Infection Control

1. place pt in airborne infection isolation

2. use neg-pressure room

3. fit-tested N85 or higher

4. limit transport outside of room

5. teach pt to cover cough and wear surgical mask during transport

Other

6. administer TB meds & monitor for side effects

7. reinforce strict adherence

8. coordinate w/ public health → public safety

What pt teaching is used for TB?

1. take medications exactly as prescribed & complete the full treatment course

2. Report medication side effects promptly

3. Keep follow-up appointments and lab monitoring

4. Maintain nutrition and hydration

5. Balance activity with rest

6. Use cough etiquette

7. Avoid exposing others until cleared by the healthcare team

8. report increased SOB, chest pain, coughing blood, jaundice, N/V, abd pain, numbness/tingling

What is chronic obstructive pulmonary disease (COPD)?

a chronic, progressive lung disease that causes airflow limitation and difficulty breathing

Types:

• chronic bronchitis

• emphysema

What are the key characteristics of COPD?

1. dyspnea & wheezing

2. chronic cough & sputum production

3. use of accessory muscles

4. decreased acitivity tolerance

5. ventilation-perfusion mismatch

6. COPD is not fully reversible, but symptoms and exacerbations can be managed

What is emphysema?

type of COPD characterized by the destruction of alveoli → decreased elasticity of the lungs and difficulty in exhalation

What is the patho of emphysema?

1. Alveolar wall destruction

2. Loss of elastic recoil & air trapping

3. Hyperinflation of the lungs

4. Bullae formation

5. Decreased surface area for gas exchange

What are the manifestations of emphysema?

1. barrel chest

2. pursed-lip breathing

3. thin appearance or weight loss

4. diminished breath sounds