NURS 372: MedSurg Respiratory I & II and SLC

normal lung sound

Movement of air through the respiratory system when there is no obstruction, inflammation, nor fluid in the airway

-Sounds like a hollow, tubular sound during auscultation

-May sometimes hear it referred to as"bronchial" or "bronchial-vesicular" sounds

abnormal lung sounds

Wheezing

• Rhonchi (low pitched wheeze)

• Crackles (aka "rales")

• Pleural friction rub

• Absent

• Stridor

wheezing

Occurs when there is inflammation and/or narrowing of the airway. Does not clear with coughing.

-Sounds like a loud, high-pitched whistling/squeaky breathing sound.

-Can occur during inspiration, expiration, or both.

-Common causes: Asthma, COPD, emphysema, infection, allergic reaction, obstruction (tumor)

classic sign of asthma

wheezing

asthma

Reversible acute airway obstruction occurs intermittently = reducing airflow

• Characterized by spasms in the bronchi, causing difficulty breathing.

- It is triggered by an allergic reaction or other forms of hypersensitivity.

• Airway become inflamed, narrow and swell, and produce extra mucus =dyspnea

• Inhalers such as bronchodilators and steroids help alleviate asthma s/s

asthma dx

PFT (pulmonary function Test)

dx if PFTs increase by 12%+ after treatment w bronchodilator)

FVC: inhale as deep as possible then exhale as much/as long as possible

FEV1: forced volume in 1 second

PEF: fastest rate of air that a person can blow out of lungs

asthma results in acute airway reduce airflow and leads to

=Airway tissue sensitivity

o Inflammation

asthma triggers

astham cues

Wheezing

o Dyspnea

o Chest tightness

o Coughing

o Increased phlegm (muscus)

o Accessory muscle breathing

hypoxemia

hypoxemia s/s

-Decreased pulse oximetry (< 90%)

-Cyanosis

-Tachycardia

-Decreased LOC (level of conscious)

labs and tests for asthma

Arterial blood gas

o Low pO2, low pCO2

Tests:

• Pulmonary function tests

asthma interventions

Goal is to promote airflow & gas exchange

• Supplemental O2 (via NC or mask)

• Drug therapy

Drug therapy for asthma

control or rescue

control drugs asthma

Reduce airway sensitivity to prevent asthma attacks & maintain gas exchange

o Used every day

o Ex: LABAs, corticosteroids, leukotriene modifiers

rescue drugs asthma

Used to stop an active asthma attack

o Used prior to exercise

o Ex: SABAs

status asthmaticus

Medical emergency

Extreme asthma attack that does not respond to regular treatment/rescue meds

Wheezing

SOB

Hypoxemia

Tachypnea

Cyanosis

Respiratory failure

Tx: usually continuous albuterol, steroid, DuoNeb (albuterol + ipratropium bromide), Magnesium

pt interventions with obstructive respiratory conditions

Avoid environmental triggers (smoke, dust, mold, temp changes of warm to cold)

-Wash bedding w/ hot water to destroy dust mites

-Avoid aspirin, NSAIDS, beta blockers

-Avoid food w/ MSG

-For exercise-induced asthma, use rescue inhaler 30 mins before exercise to prevent or reduce bronchospasm

-Teach pts proper inhaler use techniques

-Teach pts when to seek emergency care (difficulty breathing, walking, or talking; retractions of the neck, chest, or ribs; nasal flaring; grey/blue fingertips or lips; failure of drugs to control worsening symptoms)

-Teach pt to always carry rescue drug inhaler & ensure enough drug remains

rhonchi

Caused by blockages to the main bronchi due to mucous. Air is moving through the tracheal-bronchial passages coated with mucous or secretions.

-Sounds like a low-pitched, coarse breathing sound with a rattle-like quality.

-More common during expiration.

common causes of rhonchi

-Common causes: Pneumonia,bronchitis, cystic fibrosis, thick/tenacious secretions, sputum production

pneumonia

most common respiratory illnesses seen in the hospital setting

• PNA is an infection that inflames your lungs' alveoli (air sacs at the end of a bronchiole). Alveoli fill up with fluid or pus, causing cough, fever, chills and dyspnea (difficulty breathing).

• Can be prevented with vaccine

• Treated with antibiotics, steroids, diuretics, breathing treatments

PNA types

CAP (community acquired→ on admission or within 48 hrs of admission)

HAP (hospital acquired → develops >48 hrs after admission)

HCAP

VAP

HCAP PNA

(healthcare associated → develops <48 hrs from admission in pt w risk factors

In hospital for >48 hours in past 90 days, Nursing home or assisted living, IV therapy, wound care, abx/chemo in past 30 days, seen at hospital or dialysis clinic in past 30 days

VAP PNA

(ventilator associated pneumonia → dx within 48-72 hours after endotracheal intubation, often leads to sepsis)

prevention ("ventilator bundles" of interventions): hand hygiene, oral care, HOB elevation

risk for PNA in hospital

stay laying flat for long time

weak immunity

nurses coming in and out of other sick pt rooms

risk factors for PNA

Is an older adult

• Has a chronic lung disease•

Has never received the PNA vaccine or received it more than 5 years ago

• Did not receive the flu vaccine in the previous year

• Has an altered level of consciousness

• Has had a recent aspiration event

• Has presence of endotracheal,tracheostomy, or nasogastric tube

• Has poor nutritional status

• Has reduced immunity

• Uses drugs that increase gastric pH (histamine [H2] blockers, antacids)

• Is currently receiving mechanical ventilation

• Has recently been exposed to respiratory viral or flu infection

• Uses tobacco or ETOH or is exposed to high amounts of second hand smoke

s/s of PNA

Fever=may be blunted in elderly... confusion may be 1st sign

productive cough w purulent sputum

pleuritic pain

differs from cardiac chest pain because it worsens with deep breath

Chills

Myalgia

Headache

Tachycardia

hemoptysis

Resp symptoms: difficulty breathing, use of accessory muscles, hypoxemia, tachypnea, dyspnea, crackles, wheezing, dulled percussion, increased fremitus

concerns for PNA

Decreased gas exchange

• Potential for airway obstruction due to inflammation, pulmonary secretions, fatigue, muscle weakness

• Potential for sepsis due to presence of infectious microorganisms

• Potential for empyema due to spread of infectious organisms from the lung into the pleural space=Empyema:

most common complication of PNA

pleural effusion (fluid gets inside lining btw chest cavity and lungs)

treat w diuretics

other PNA complications

decreased gas exchange

potential for airway obstruction/pulmonary emphyema (alveoli fill with pus)

Sepsis (monitor VS for fever/tachycardia/hypotension)

empyema

collection of pus in the pleural space = impairs gas exchange

= reduces effective ventilation

cues for PNA

o Dyspnea

o Tachypnea

o Cougho SpO2 desaturation

o Cyanosiso Purulent, blood-tinged, or rust colored sputum

o Fever

o Elevated WBC

o Pleuritic chest discomfort

o Diminished breath sounds or crackles

o Altered cognition (older adults)

tests for PNA

o Sputum culture

o Blood culture

o CBC (WBC elevated, except older adults)

o Blood gases

o CXR=(definitive diagnosis...looks white, increased density)

ABGs

Procalcitonin

Inflammatory markers (eg: CRP)

SpO2

bronchoscopy (scope view airways to check for abnormalities and can take biopsy... must check for return of gag reflex before resume PO)

treatment for PNA

o Administer anti-infectives and bronchodilators as prescribed

o Supplemental oxygen

o Incentive spirometry

o Encourage coughing/deep breathing

treatment goals PNA

Maintain adequate gas exchange with SaO2 of at least 95% or pt's baseline level

o Maintain patent airways AEB absence of crackles and wheezes on auscultation

o Patient is free from infection AEB absence of fever and a WBC count within normal limits

o Avoid empyema

nursing considerations for PNA

• PNA can be prevented with vaccine. PNA often follows influenza.Encourage annual flu vaccine too.

• Monitor for complications: sepsis and empyema

• Encourage pulmonary hygiene and progressive ambulation

• Provide adequate hydration

• Assess risk for aspiration

• Monitor for early signs of sepsis

• Provide vigorous oral care

crackles

AKA: rales.

Occurs when there is fluid, pus or mucous in the small airways

. There are 2 types:Coarse and Fine.

Both commonly heard during inspiration.

Common causes: Fluid overload, pulmonary edema, heartfailure, lung infection (PNA).

coarse crackles

Loud, popping, bubbling noise. Sounds like ripping apart Velcro.

Coarse crackles = heard gen'l anterior/posterior area.

fine crackles

Brief popping sounds that are high-pitched. Sounds like wood burning in a fireplace.

heard in lower basesof lungs

pleural rub

Occurs when 2 inflamed pleural linings rub against each other during respirations.

-Sound like creaking or grating sounds. Similar to walking on fresh snow or a rough grating sound.

- stop when the patient holds a breath.

common causes of pleural rub

Pleurisy (infected pleural lining), pleural effusion (fluid buildup bxn 2 pleural layers-AKA pleural space), pulmonary infarct, TB, PNA

absent breathe sounds

Occurs when there is complete obstruction of airway by excessive fluid in lungs, tumor or collapsed lung=(Pneumothorax)

-You will not hear any lung sounds because the lung has collapsed or lung is filled with a lot of fluid; thus, no air movement/gas exchange.

common causes of absent breathe sound

Com Collapsed lung from a lung puncture wound or excessive mechanical/artificial ventilation. Fluid overload from HF, pulmonary edema, severe ARDS, tumor

FiO2 with nasal canula

O2 up to 6L (gen care units)

oRoom air = 21% FiO2

o1L NC = 24% FiO2

goes up about 4 per liter of FiO2

max is at 6 L nc =FiO2=44%

nursing considerations for nasal canula and FiO2

nasal canula safety consideration with oxygen

Oxygen enhances combustion

o No cigarettes, flammable materials (nail polish/alcohol or oil), candles, gas burners/fireplaces/open flames are not to be used in same room as O2

-Inspect electrical cords for fraying

-ambulation/fall risk education

o Educate pt if going home on oxygen

No smoking in the house

No open flames & flammable liquids present

nasal canula skin protection

Check skin underneath NC tubing for skin breakdown(especially behind ears) q 4-8 hours

• Position the tubing so it does not pull on the patient's face and nose (tubing also fall risk)

• During any periods of transport, connect NC to portable oxygen tank and make sure tank is full

• If your patient is requiring an increase in O2 requirement=please notify the RT & MD

-mouth care q 8 hours =check nasal/oral membranes for cracks (lubricate)

-clean tubing

use humidification with NC when

if NC is delivering 4L O2 or higher

how to clean NC

clean cannula or mask & skin beneath tubing with warm water

-Change tubing per policy bc can harbor microorganisms (usually q7days or q24hrs if humidified)

Noninvasive PositivePressure Ventilation (NPPV)

CPAP

BiPAP

CPAP

continuous positive airway pressure

pressure delivery of O2 steady

BiPAP

bilevel positive airway pressure

=inspire=higher pressure

=exhale=lower pressure

-usually more sick pt, insurance doesnt really cover

non rebreather mask

Used in emergencies = for short-term increases in oxygenation

• Delivers up to 95% of O2

• Usually found on crash cart, sometimes in pt rooms near wall oxygen, or RT supplies them

INFLATE BAG FIRST! plug hole w finger

invasive ventilation

Mechanical ventilator

• Delivers 100% oxygen

• Seen in ER or ICU

• Patient will be intubated (aka:breathing tube placed), which will then be hooked up to mechanical ventilation

ambu bag

Can deliver up to 100% oxygen

• Emergency situations

hold chin up, mask over face

tracheostomy

a tracheal stoma (opening) in the neckmade by a surgical incision.

A small plastic tube is then inserted through this opening.

• Surgical incision is made in trachea to create an artificial airway for gas exchange

• Can be temporary or permanent

tracheostomy indications

• acute airway obstruction

• airway protection

• laryngeal or facial trauma or burns

• airway involvement during head/neck surgery

• for prolonged unconsciousness

-paralysis

-inability to be weaned from mechanical ventilation

nursing considerations tracheostomy

Have an extra tracheostomy kit of the same size and one size smaller

• Make sure there is an obturator taped to wall at head of the bed

• Have inner cannulas and suction catheters in the room

• Check if tracheostomy is midline

-have suction available

suction safety

Preoxygenate w 100% O2 for 30s-3 mins

Insert suction catheter until you meet resistance (do NOT apply suction during insertion)

Apply suction as you withdraw but never for more than 10-15 sec at a time

Can repeat up to 3 passes

tracheostomy complications

Tube obstruction (r/t secretions of cuff displacement), tube dislodgement/decannulation (emergency if occurs within 72h post surgery), pneumothorax, subcutaneous emphysema, bleeding, infection

SABA

Bronchodilators

o Induce rapid bronchodilation through relaxing bronchiolar smooth muscle by binding to beta 2 receptors in lungs

o Administered to improve bronchospasm (wheezing, shortness of breath, chest tightness, or cough) within 5 -15 mins and can control symptoms for up to 6 hrs

examples of SABAs

Xopenex, Albuterol inhaler

LABAs

Bronchodilators

o Given for bronchospasm, but onset slow with long duration (within 15-30mins; helps control symptoms for approx. 12 hrs)

o Primary use is prevention of an asthma attack

LABA exmaples

Salmeterol (Serevent)

what are labas given with

Given with an inhaled corticosteroid to reduce risk of rebound bronchoconstriction

-LABAs should never be prescribed as the only drug therapy for asthma

corticosteroid inhalers

Anti-inflammatory

• Help improve bronchiolar airflow by decreasing the inflammatory response of the mucous membranes in the airways

• Primary use is to prevent asthma attacks caused by inflammation or allergies

use daily even if no symptoms present

• Rinse with water or mouthwash after each use, check mouth daily for lesions/drainage to prevent infection

corticosteroid inhaler examples

Flovent (fluticasone), Pulmicort (budesonide)

oral corticosteroids

Anti-inflammatory agents for moderate-to-severe flare ups of obstructive lung diseases that are poorly responsive to bronchodilators

• May be used long-term for difficult to control chronic obstructive lung diseases

• Take on a scheduled basis, even when no symptoms are present, cant stop before surgery

oral corticosteroids examples

Prednisone, Solumedrol

leukotriene modifiers

Preventing the inflammatory mediator Leukotriene from stimulating inflammation

• Purpose is to prevent asthma attacks triggered by inflammation or allergens

• Take daily

• Max efficacy requires continued use for 48-72 hrs

• Ex: Singulair (montelukast)

COPD

a collection of lower airway disorders that interfere with airflow and gas exchange

•Includes: emphysema & chronic bronchitis

COPD risk factros

-Cigarette smoking, environmental factors, genetics, and asthma

Genetics (AAT deficiency)=Alpha 1 antitrypsin protects lungs/liver

COPD dx

based on FEV1

FEV1= pulmonary function test that measure how much air a person can exhale in 1 second

Other tests: ABGs, sputum samples, CBC (WBC), Hgb/Hct (compensation for hypoxemia), electrolytes (changes r/t acidosis), CXR (hyperinflation and flat diaphragm), nutritional status (total protein, albumin levels)

at what point in pack year history is COPD present

20-pack-year history or longer often have early-stage COPD

how to find pack years

# of packs/day X # of years

complications of COPD

hypoxemia

o acidosis

o respiratory infection

o cardiac failure (cor pulmonale)

o dysrhythmias

o respiratory failure

cardiac failure (cor pulmonale)

R side of heart must work harder to pump blood through narrowed lung blood vessels⇒increased workload⇒systemic backup

cues for COPD

Coughing

• Exertional dyspnea

• Wheezing

• Crackles

• Increased sputum

• SpO2 desat

• Weight loss

• Barrel chest (emphysema)

• Accessory muscle use;

• Prolonged expiration

• Tachypnea w/ activity

• Orthopnea

• Cyanosis

• Delayed cap refill

• Clubbed fingers=late s/s

• Heart dysrhythmias

• Respiratory Acidosis

hypoxemia

priority to notice for COPD

Resp rate

COPD nursing interventions

• Monitor spO2, resp rate/depth, blood gases (resp.acidosis)

• Administer O2 based on blood gases and spO2

• Provide chest physiotherapy (percussion)

• Teach pt about diaphragmatic or abdominal breathing, tripod positioning, pursed-lip breathing techniques

• Activity limitations, alternating rest periods with activity

• Avoid exposure to individuals with infections

• Avoid extremes in temperature, smoke, perfume, other allergens

Trend weight

• Encourage small, frequent meals

• Provide high-calorie, high-protein diet with supplements

• Place pt in a Fowler's position and leaning forward

• Administer bronchodilators, corticosteroids, mucolytics

• Instruct pt on the use of inhaler & oral respiratory meds

• Educate about smoking cessation and immunizations

• Administer antibiotics for infection if prescribed

o2 interventions for COPD

titrate btw 88-92%, usually 2-4 L NC or up to 40% via venturi)

activity with COPD

(2-3x/week)

Walk until symptoms limit walking, rest, then continue until reaching 20 mins of walking (add 5 more minutes of walking as rest time decreases)

diet with COPD

High cal, high protein diet/hydration (at least 2 L/day)

Eat smaller, more frequent meals (4-6) that are easy to chew/non gas forming foods

Avoid caffeine or foods that induce coughing

sx with COPD

bullectomy, lung volume reduction surgery→removal of hyperinflated lung tissue, lung transplant

Chronic bronchitis

airway problem

Inflammation of bronchi/bronchioles due to irritants **esp. smoking!!

Chronic inflammation thickens bronchial walls and increases number/size of mucus secreting glands → obstructs smaller airways and narrows larger ones

Hypoxemia=major concern

Body might compensate by producing more RBCs (polycythemia)

Resp. acidosis may also occur but it is more common in emphysema

Exacerbations cause increased purulent sputum & worsening SOB (often leads to pneumonia)

“Blue bloater” (productive cough, edema, cyanosis, wheezing, dyspnea, clubbing of fingers)

emphysema

alveolar problem

destruction of elastic lung tissue/alveolar walls due to chronic inflammation from irritants (such as cigarette smoke… smoke increases protease release which breaks down elastin in lungs)

air trapping occurs due to loss of elastic recoil in alveoli

Causes overstretching/hyperinflation + collapse of small airways + flattening of diaphragm

Increases effort to breathe (“air hunger” sensation)

CO2 retention (hypercapnia)

Chronic respiratory acidosis→ metabolic alkalosis may develop as compensatory mechanism via kidney retention of HCO3

“Pink puffer” (CO2 retention, pursed lip breathing, barrel chest/hyperinflation of lungs/diaphragm flattened, thin/cachectic, orthopneic, wheezes/crackles, neck vein distention, peripheral edema, mental status changes)

diaphragmatic breathing

lie on back with knees bent, place hands on abdomen, breathe from abdomen while keeping chest still

=stregthens diaphram

tripod positioning

=lean forward and then sit up with arms elevated on a table

=gets more air in the lungs when you are feeling short of breath and may make it feel easier to breathe.

pursed lip breathing

breathe in through nose, purse lips, breathe out slowly without puffing cheeks (exhale twice as long as inhale), use abdominal muscles to squeeze out every bit of air that you can

-in two, out 4 seconds

=keep airways open longer so that you can remove the air that is trapped in your lungs by slowing down your breathing rate and relieving shortness of breath

proper coughing technique

cough when waking up and before meals

Sit upright w feet on floor, turn shoulders inward and place head slightly downward, take 3-5 quick breaths, then a deeper breath → lean forward → 2-3 mini coughs, then a comfortable deep breath (repeat entire procedure at least 2 times)

COPD meds

Beta2 agonists (SABA/LABA... usually LABA)

anticholinergics: aclidinium bromide, ipratropium bromide

Corticosteroids

Mucolytics= Guaifenesin, acetylcysteine

Leukotriene Modifiers (Montelukast)=For inflammation

abx PRN (active infection)

SABA/LABA considerations with COPD

Eg: SABA (albuterol), LABA (salmeterol)

SABAs can cause nervousness/anxiety /tachycardia/palpitations/shaking

corticosteroids with COPD

Eg: Fluticasone combo drugs, prednisone

Risk of thrush, hyperglycemia, Gi ulcers, weight gain, do not stop abruptly

goals of tx with COPD

Improve oxygenation and reduce CO2 retention

Prevent weight loss

Minimize anxiety

Improve activity tolerance

Prevent resp infections w vaccines

lung cancer

-result of repeated exposure to inhaled substances that cause chronic tissue irritation/inflammation interfering with regulation of cell growth in lungs

• Lung tumors can grow and obstruct the bronchus=impairs gas exchange

• Tumors in other areas of lung tissue can compress and obstruct the airway

• Lung cancer can spread to lymph nodes, bone, liver, brain, and adrenal glands

lung cancer cues

Hoarseness

o Wheezing

o Persistent cough

o Blood-streaked, rust-colored or purulent sputum

o Hemoptysis

o Chest pain or chest tightness

o Shoulder, arm, or chest wall pain

o Recurrent pleural effusion, PNA, or bronchitis

o Dyspnea

o Fever

o Weight loss

o Clubbing of the fingers

other dx ways of lung cancer

CXR (find lesion), CT scan (identify lesion/guide biopsy), biopsy, MRI/PET scans locate metastases

definitive dx of lung cancer

biopsy (definitive diagnosis, identify cancerous cells)

lung cancer treatement

chemo

radiation

Lobectomy• removal of a lobe

Pneumonectomy• removal of the entire lung

thoracentesis

photodynamic therapy

chemotherapy for lung cancer side effects

N/V, alopecia, open sores on mucous membranes, immunosuppression with neutropenia, anemia, thrombocytopenia, peripheral neuropathy

thoracentesis

removing fluid from pleural space around lungs

Positioning: sitting up and leaning forward on arms/pillows (kinda like tripod), lying supine with arm of affected side raised above head

Major complication is shock (if fluid is taken off too quickly)

BP drops, tachycardia

Post procedure care: monitor for pneumothorax!! (collapsed lung... happens if needle goes too deep into pleural space)

s/s: decreased LS on affected side, tachycardia, trouble breathing, chest pain