RESP full

Atelectasis what is it

Alveolar collapse leading to hypoxemia.

Main concept: impaired gas exchange

Primary Prevention/Interventions:

1. Use of incentive spirometer

• how to use incentive spirometer: inhale  & open lungs as much as possible 

• they do NOT blow into it

• incentive spirometer pt = increase ventilation

  • she thinks sucking on straw = terrible description

  • BREATHE IN DO NOT BLOW INTO IT 

2. Frequent turning

3. Early ambulation

   1. get pt out of bed (into chair)  as early  in the day as possible 

2. get lungs moving so don’t develop secondary problem from immobility  

Asthma: what is it

1. Chronic lung disease

2. Stimuli -> airway inflammation (aka mucosal edema)

3. INFLAMMATION -> Airways permanently narrowed 

4. Airways do not go back to normal even with treatment

trigger Exposure -> initiates inflammatory response

• Vasodilation -> increased fluid and mucus in airways

• Airway constriction -> spasms of bronchial muscles

Examples of triggers:

1. Food

2. Medications

3. inhaled substances

4. Exercise

5. Environmental allergens

6. respiratory infections/irritants

Pt can be asymptomatic but will always have a little bit of inflammation in Lungs (secondary to asthma)

Status Asthmaticus what is it:

1. Rapid onset of severe asthma episode

2. acute ventilatory failure or death - Potential

3. Characterized by hypoxemia (low o2),  hypercarbia (high CO2), and secondary respiratory failure (if don't do something -> lungs give out)

THIS IS AN EMERGENCY 

Potential loss of employment due to inability to function without symptoms

COPD what is it:

Two types of COPD:Emphysema and Chronic Bronchitis: 

pts usually have combo of both

Emphysema Alveolar enlargement and destruction  Leads to impaired gas exchange

Chronic Bronchitis:  Increased mucus production, airway inflammation, thick bronchiole wall

PROF SAID : KEY Physiological changes:

1. Increased CO2, decreased O2

2. COPD patients’ drive to breathe is oxygen levels instead of carbon dioxide levels

COPD patients’ drive to breathe is oxygen levels instead of carbon dioxide levels

• Normally co2 level tells brain to take breath 

• Normally: High co2 lvl -> breathe more to blow off

  • Copd pt retain co2, w/ o2 stat low (fine w. O2 stat of 88-92% on COPD pt as long as asymptomatic and at baseline as long as not struggling

  • Ex: copd pt w/ o2 nasal cannula is at 2 L and  o2 stat is 90 but are symptomatic (sob, rr high , tripod position,) + not at baseline -> turn oxygen up 2-> 3 L slowly titrate it up and slow  o2 raise  

Pneumonia

1. Inflammation of lung tissue and alveoli caused by pathogens

2. Pathogen can be bacterial, viral, or fungal

3. Inflammation leads to increase in fluids and exudate

An impaired gag / swallow reflex would lead to which type of pneumonia? Aspiration PNA

types of pneumonia:

Community acquired pneumonia (CAP) Acquired outside of healthcare facilities Diagnosed less than 48 hours after admission

Hospital Acquired Pneumonia (HAP) Acquired greater than or equal to 48 hours after hospital admission, not present at admission

Ventilator- Associated Pneumonia (VAP) Occurring greater than or equal to 48 hours after endotracheal intubation and mechanical ventilation

Prevention Strategies:

1. Pneumococcal vaccine

   1. Who should get the PNA vaccine?

      1. age > 65, 

      2. anyone age 19+ with certain medical conditions / immunosuppressed

      3. non elderly high risk pneumonia pts @ icu = cyctic fibrosis pt, cerebral pasy pt -> cuz they more immobile -> lungs @ high risk of developing pneumonia 
         
         

Types of pneumonia:

1. Encourage mobility

2. Turn, cough, deep breathe (TCDB)

3. Use of incentive spirometer

Pulmonary edema what is it? 

1. Abnormal fluid accumulation in the alveoli and interstitial spaces

2. pulmonary edema results in decreased gas exchange

Pulmonary edema  = abnormal fluid accumulation in lung & alveoli we’re never supposed to have fluid inside lungs

Causes:

1. Heart Disease (Cardiogenic)

pulmonary edema due to heart disease = cardiogenic 

1. Heart failure fluid overload causes leakage of pulmonary capillaries

2. Acute Myocardial Infarction can lead to acute failure of left ventricular function

IF LEFT SIDE OF HEART NOT WORKING -> it BACKS UP TO LUNGS -> FLUID VOLUME BACKED UP -> can NOT breathe through that 

2. Physical injury to lungs (Noncardiogenic)

physical injury to lungs = considered non cardiogenic (has nothing to do with heart)

1. Damage to alveolar lining = increased permeability

   1. increased permeability -> fluid can get through

   2. If have inflammation to an area -> increase fluid and exudate 

3. Sepsis, aspiration (Noncardiogenic)

sepsis, aspiration is also non cardiogenic

1. Inflammatory response increased fluid and exudate

prof said she wants us to remember that you can not breathe through fluid, exudate 

Pneumothorax Definition:

1. Collapsed lung due to air in pleural space.

2. Can involve a partial or complete lung collapse.

Pleural Effusion Definition:

1. Abnormal accumulation of fluid between pleural layers of the lungs.

Pleural cavity is filled with fluid 

****fluid built up outside the lung

How does this diagnosis affect his ability to oxygenate?

1. decreased lung expansion

2.  impaired chest wall movement

3.  decreased lung surface area for functioning alveoli

impaired gas exchange cuz lost alveoli surface area 

Outline an initial treatment plan.

1. Diagnostic imaging: Xray, CT scan

2.  Apply oxygen as needed

3.  Meds: diuretics if applicable

if diuretic doesnt work 

4.  Intervention: thoracentesis, VATS, thoracotomy

   1. 1. thoracentesis = bedside option 

   2. 2. VATS - least invasive surgery 

   3. 3. Thoracotomy - most invasive surgery

What would you assess?

1. vital signs

2.  oxygen therapy

What position would maximize lung expansion, increasing the patient’s ability to breathe?  high-fowlers, upright

Obstructive Sleep Apnea what is it?

1. Nasopharyngeal tissue narrowing airway obstruction

2. Collapse of airway leads to decreased oxygen saturation and increased carbon dioxide levels

3. Reduced high-quality, deep sleep

Risk factors:

1. Diabetes mellitus

2. Post menopausal

3. Obesity

4. Heart disease

5. Males

6. Elderly 

Lung Cancer what is it:

risk factors

Types:

Non-small cell

o Most common

o Good prognosis if diagnosed at early-stage

Small cell

o Aggressive, metastasizes

o Poor prognosis regardless of when diagnosed

Risk Factors:

Primary cause: smoking

o 10x more likely than non-smokers

Secondhand smoke

Radon, occupational pollutants, asbestos

Influenza

 Viral infection caused by Influenza type A, B, or C

o Type A and Type B are the most common and cause epidemics

o Type C is typically asymptomatic

COVID 19:

 Viral infection caused by SARS-CoV-2

Symptoms range from asymptomatic severe

Pathophysiology of COVID-19

o pulmonary inflammation and procoagulant state

o Inflammatory response causes an increase in fluid and

exudate in the alveoli impaired gas exchange

o Procoagulant state = clotting

High risk for DVT, pulmonary embolism

What lab increases in a procoagulant state? d-dimer

o Severe cases: cytokine storm can lead to respiratory failure, multi-organ failure

Prevention: vaccination, appropriate droplet/airborne precautions

Atelectasis what does it look like

1. Shortness of breath (SOB)

2. Decreased breath sounds

3. Signs of hypoxia

   1. Early: Restlessness, anxiety, tachycardia, confusion

      1. Ex: pt tells u abt grandkids & y @ hospital THEN early confusion from early hypoxia = communicates, remembers you, BUT ASKS SAME QUESTION

   2. Late: Bradycardia, extreme restlessness, dyspnea, cyanosis, pallor

Asthma: what does it look like:

1. Wheezing

• Inspiratory and/or expiratory

  • Inspiratory = more concerning!

• Intercostal retractions

  • Indicate blocked airways

  • Very concerning!

    • Lift gown to assess for INTERCOSTAL RETRACTIONS

2. Tripod positioning

   1. Increase ventilation 

   2. Opens airways 

   3. Indicates breathing difficulty 

3. Dyspnea, tachypnea - chat said yes i think no

4. Chest tightness

5. Anxiety - i think yes chat says no

6. Coughing (productive or dry

Status asthmaticus what does it look like

1. Respiratory alkalosis initially – hyperventilation

2. Progresses to respiratory acidosis— air trapping because narrowing on exhalation

3. Inability to speak in full sentences

4. Peak flow rate is reduced by 50% or more of their personal best score

5.  Confusion decreased LOC- chat said i dont think 

6. Cyanosis - chat said i dont think 

7. Respiratory failure

COPD what does it look like

1. Tripod positioning and pursed lip breathing

2. Barrel chest— late-stage manifestation

   1. Chest wall hyperinflated 

   2. Takes years 

3. Weight gain from lack of activity due to exertional dyspnea

4. Weight loss due to frequent dyspnea— late-stage manifestation

   1. Ex: pt w/ 20 yr COPD

   2. SOB all time -> burn more cal & is more work

5. Chronic cough

6. Sputum production

 Assessment findings:

1. Chronically low O2 saturation

2. Clubbed fingernails

What does their arterial blood gas (ABGs) look like?

1. PaO2 < 80 GOAL > 60

2. PaCO2 > 45 

3. SaO2 88-92% GOAL > 90%

Pulmonary edema what does it look like?

1. Profuse, pink frothy sputum

   1. Fluid in lungs

2. “Feeling of drowning” when lying down

3. Shortness of breath, often worse when lying down

4. Crackles (fluid)

5. Hypoxemia

6. diaphoresis, clamminess and cold skin - i think chat said no

7. Tachycardia - cuz compensating for low oxygenation, pumps more to get more oxygenated blood to body - chat said no i also said no 

A hallmark sign of pulmonary edema is pink, frothy sputum.

Pneumonia what does it look like:

1. Pleuritic chest pain

2. Fever, malaise

3. Crackles, rhonchi

4. yellow/green sputum

5. Increased WBC

6. Hypoxemia

Pneumothorax what does it look like:

1. Diminished lung sounds

   1. diminished lung sounds = if lost half of lung volume -> expect diminished heart sounds

   2. Asymmetric chest wall movement

      1. if one lung is inflating normally and other lung inflating at half are they going to have symmetric chest wall movement - no

      2. cuz one is inflating more than the other is inflating  

      3. asymmetric chest wall movement -> assess them w/o gown to look at chest wall movement 

   3. Deviated trachea (tension pneumothorax) The trachea deviates AWAY from the collapsed lung 

   2. SQ emphysema: air is trapped in the tissue beneath the skin—often seen after lung injuries

      1. emphysema = air where it does not belong

      2. are u supposed to have air in sq tissue? no

Pleural effusion:

1. Dry cough

   1. Fluid sits outside lung tissue
      
      

2. Pleuritic chest pain

3. Respiratory distress

4. Dyspnea

Influenza

s/s

prevention

complications

Symptoms peak around 1-3 days and last up to 10 days

Prevention

How do we prevent the flu? Annual vaccination

o This is a  INACTIVE virus

o FALSE: The flu vaccine can give you the flu.

Complications:

o Secondary infections such as pneumonia, sinus infections, ear infections

Lung Cancer s/s

1. Hemoptysis

2. Significant weight loss, fatigue

SOB - i think no chat says yes

Wheezing, hoarseness - i think no but chat says yes 

Pleuritic chest pain - i think no but chat says yes 

Atelectesis how to treat it

if  prevention strategies don’t work and pt still gets atelectasis despite inceptive spirometer use  and correct edu 

sometimes they use C pap or bipap 

Further Interventions:

1. CPAP/BiPap: to open alveoli more invasively with positive pressure inside the lungs

2. Bronchoscopy to clear out the lungs

• bronchoscopy = if its really bad/real nasty lungs 

True/False: Frequent ambulation is essential to prevent atelectasis.

Asthma how do you treat it:

1. Symptom control

2. Minimize triggers

   1. Ex: pet allergy -> no pets

   2. s/s never go away  -> goal: min s/s as much as possible 

3. Medications: goals are to both prevent and control symptoms

Client education

1. Behavior modification (lifestyle changes, avoidance of triggers)

2. Medication adherence

3. Use and purpose of peak flow meters

Peak flow meter = only for pts w/ severe uncontrolled asthma, not every asthma pt

1. Monitors lung function by measuring max speed of exhalation (breathe out/breathe into monitor as hard & fast as can) 

2. Tracks daily lung function by detecting subtle changes in airflow, indicating a possible impending asthma attack 

   1. Decrease speed & force = bronchoconstriction sign 

Status asthmaticus how do you treat:

1. Short acting beta 2 agonist  (ex: albuterol) + short acting anticholinergics (atrovant)

   1. Need short acting medication 

1. Systemic IV corticosteroids

   1. Extreme airway inflammation -> Inhaled steroids not gonna cut it  

Client is considered responding to treatment when:

1. Visible improvement in s/s that are maintained for 30 minutes post- bronchodilator dose (ex: albuterol) 

   1. Potential loss of employment due to inability to function without symptoms

2. Peak flow rate is greater than 70% of personal best score

COPD: how do you treat it:

This diagnosis is IRREVERSIBLE

Goals

1. Reach acceptable oxygen level without excessive CO2 retention

2. Symptom control

3. Maintain quality of life

   1. goal: can stay at home + keep pt out of hospital as much as possible) 

4. Prevent exacerbations

5. Slow disease progression

6. Reduce modifiable risk factors

7. For inpatient: positive-pressure ventilation (BiPap) to improve ventilation and oxygenation

8. Medications: First-line maintenance includes anticholinergics + Beta2 agonist

Pneumonia treatment

1. Antibiotics

2. Bronchodilators

3.  Anti-inflammatories

4.  hydration and humidifier

5.  antipyretics

What should I assess?

1. vital signs, 

2. lung sounds, 

3. presence of cough/sputum, 

4. skin color, 

5. lab values—abg, sputum culture, wbc—chest xray

appropriate nursing actions

1. Sputum culture and sensitivity = Identify pathogens before starting antibiotics

2. Antibiotic administration = Treat bacterial infection

3. Bronchodilators = Open airways

4. Supplemental oxygen = Improve oxygenation

5. Semi/high Fowler’s position = Promote lung expansion

6. Mobility = Enhance airway clearance

7.  PRN medications (fever, pain) = Symptom management

8.  Fluid intake = Thin secretions

9. Hand hygiene = Prevent infection spread

Pulmonary Edema: Treatment

1. Diuretics: address root cause of fluid volume overload

   1. The problem in pulmonary edema is you have fluid we have to fix that how do we get rid of fluid? diuretics 

   2. diuretics make you pee it off

2. Oxygen: compensates for impaired gas exchange

   1. Oxygen is a band aid to bigger problem when it comes to fluid volume overload 

   2. We have to fix the problem and the only way to fix the problem is to give diuretics  

3. Positioning to optimize ventilation: maximizes lung function by redistributing fluid

   1. positioning to optimize ventilation  would be high fowlers 

4.  If cardiogenic, medications for heart failure: vasodilators, calcium channel blockers, positive inotropes

UNDERSTAND WE HAVE TO TREAT THE ROOT CAUSE

she will  not ask if we give dieutics first or oxygen first - cuz both are correct  

Pneumothorax Treatment:

1. Needle decompression

   1. needle decompression that pleural cavity is filling 

   2. ex: have balloon blowing up  - needle decompression means we put a little needle in there  and let all the air out 

   3. decompressing the pleural cavity that has filled with air and your releasing all of that with the decompression 

2. Chest tube

   1. permanently put in for a little while to continuously get rid of air that is building up in pleural cavity 

3. Nursing management before, during, and after treatment procedures

   1. ex: how are they oxygenating before, how are they oxygenating during the procedure, how are they oxygenating after the procedure, if they have a chest tube how do we manage that chest tube

   2. apply oxygen and then prepare for needle decompression 

leural Effusion Treatment:

1. Diuretics

1. Helpful in fluid volume overload causes, such as heart failure, renal failure

• diuretics help get rid of fluid 

2. These help by getting rid of excess fluid

2. Thoracentesis

1. Works by draining off the fluid using a catheter inserted into the pleural cavity

2. Least invasive procedure, local anesthesia

• pt sits like this on the side of the bed

  • if can’t sit up like this, sometimes pt can lay on side and physician can access it like that

  • put needle in -> pull fluid out -> removing fluid-> lung reexpands (lung naturally fills up space where its supposed to be) 

  • if pt has recurrent pleural effusion pt may need more invasive surgical options

    
    
    
    

    Surgical options:

    1. VATS: Video-assisted thoracoscopic surgery

       1. Minimally invasive chest surgery

       2. Used for recurrent pleural effusions, or complicated

       3. effusions for other reasons

       4. Post procedure: chest tube in place

          1. lil insertion  

          2. scope put in -> then pulled out 

          3. min. surgical option)

       
       
       

       2. Thoracotomy

          1. Open chest surgery

          2. Used for effusions with trapped fluid, lungs with thick scar tissue, or advanced empyemas (infected pleural effusion)

          3. Post procedure: chest tube in place

1. empyemas = infected pleural effusion

2. infected pleural effusion -> fluid outside lung has pus in it (harder to remove) -> often needs open surgical procedure 

   1. (thoracotomy = extensive/invasive surgical option)

OSA How do you treat it:

Zepbound (Tirzepatide): GLP-1 medication approved for moderate-to-severe OSA in

adults with obesity, in conjunction with other lifestyle changes

1. Increases weight loss

2.  Decreases apneic episodes

3.  Improves sleep quality

Provigil (Modafinil): CNS stimulant

1.  Reduces daytime sleepiness

Lung Cancer Treatment:

1. Radiation, chemotherapy

2. Pain management

3. Surgery (non-small cell)

4. Palliative care

   1.  Typically stage 4

Surgical Management: Procedures:

Pneumonectomy: Entire lung removal

Lobectomy: Removal of a lobe

Wedge resection: Partial lobe removal

Post-op Care:

Chest tube management

Monitoring for bleeding

Case Study: A patient is post-op following a lobectomy. What are some key nursing

assessments in post-op care?

lung sounds, vital sounds, chest tube management

impaired gas exchange, decreased ventilation

Influenza Treatment:

Supportive with rest, fluids, antipyretics, analgesics

o Antivirals within 48 hours of symptom onset

Nursing Care:

1. Droplet precautions 

2. Monitor for complications and worsening of symptoms

COPD diagnosis:

1. Gather patient history

2. Pulmonary function tests: determine severity of airflow limitation

3. Chest X-ray

Asthma diagnosis:

Diagnosis:

1. Patient history 

   1. Onset of symptoms 

   2. known triggers,

   3. frequency of symptoms

      1. Effects treatment intensity, meds

   4. Alleviating factors

   5. genetic history

2. Pulmonary function tests

1. MAIN DIAGNOSIS 

2. PROF SAID SHE WANTS US TO KNOW = pts w/ asthma & COPD are diagnosed w/ pulmonary function test 

3. PFT tells u = how healthy lungs are 

4. Get dose amount THEN DO AGAIN (goal = evaluate if numbers improve pre->post treatment)

3. Chest X-ray

Pneumonia Diagnostic Tool:

FOR SURE be an indicator that PNA is present?

a. Chest x-ray

c. Sputum culture and sensitivity

NOT:

wbc = dont tell you why the wbc count is abnormal 

abg tell you something is going on but not explicitly that it is pneumonia 

Pulmonary edema diagnosis

1. CXR

2. Echocardiogram to assess cardiac function

   1. echocardiogram to asses cardiac func - is this cardiogenic?  the only way to know is to assess the heart

   2. it looks at heart functioning 

   3. if heart functioning poorly -> & left side of heart ejection fraction is not 55% (instead  its 20%) -> fluid backing up into lungs 

Lung Cancer Medical Management:

1. Identifies pulmonary tumors

• Chest Xray

• CT scan

• Bronchoscopy

2. Identifies specific tumor cells 

   1. Sputum test

   2. Lung biopsy

3. Detects areas of increased metabolic activity that occurs with rapidly dividing cancer cells

   1. PET scans

4. Internally assesses lung structures

   1. Bronchoscopy

Pneumothorax Diagnosis

1. CXR

2. Ultrasound or CT scan 

Pleural Effusion Diagnosis:

1. Chest X-ray

2. CT scan of chest

Both show fluid