Nursing of adults exam 2 respiratory

ventilation

mechanical process of moving air into and out of the lungs

diffusion

Movement of molecules from an area of higher concentration to an area of lower concentration.

inspiration

breathing in

expiration

breathing out

perfusion

blood flow and supply to the lungs and alveoli through pulmonary circulation

hypoxia

decrease of available oxygen

hypoxemia

A decreased amount of oxygen in the bloodstream

hypercapnia

excessive carbon dioxide in the blood

hypocapnia

deficient carbon dioxide in the blood

respiratory assessment abnormalities- kyphosis

Curvature of spine, hunchback

respiratory assessment abnormalities- scoliosis

lateral curvature of spine

respiratory assessment abnormalities- barrel chest

1:1 ratio, commonly seen in COPD pt's

respiratory assessment abnormalities- funnel chest

sternum grows inward towards spine

respiratory assessment abnormalities- pigeon chest

sternum grows outward

3 sounds that should be heard when auscultating the lungs

bronchial sounds, bronchovesicular sounds, vesicular sounds

Where are bronchial sounds heard?

heard over the trachea, only on anterior part of the chest, longer on expiratory than inspiratory

Where are bronchovesicular sounds heard?

heard over the larger airways in the upper lungs, equal inspiratory and expiratory sounds

Where are vesicular sounds heard?

heard over the peripheral lung fields, longer inspiratory than expiratory

crackles

fine, crackling sounds made as air moves through wet secretions in the lungs, alveoli are popping back open at different times. seen commonly in fluid overload, atelectisis, pneumonia

wheezes

continuous high-pitched whistling sounds produced during breathing

rhonchi

Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways, (sonorous wheezes), over larger airways, sometimes can clear with a cough.

stridor

strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx, medical emergency.

pleural rub

scratchy sound produced by pleural surfaces rubbing against each other

diminished

soft, not a lot of air moving through the peripheral

pulmonary function test (PFT)

how much can pt inhale and exhale, measures how much oxygen in pt's blood, checks for abnormalities or baseline for surgery.

sputum study

culture and sensitivity-looks for infection and bacteria and what antibiotic will work. best to take sample in morning or after nebulizer treatment, have pt do a big cough, sputum may be thick and sticky

types of lung imaging

xray- shape, areas where there is air, fluid collection, masses, infection

CAT scan- cancer, masses, blood clots

CT angiography, MRI, ultrasound, nuclear lung scan, lung perfusion scan, pulmonary artery angiography.

pt education for lung imaging

allergies, pregnant or breastfeeding, medical conditions, artificial joints, do not smoke or exercise 48 hours before testing, results given same day or within a few days, after tests or scans you shouldn't have nuclear testing within 24-48 hours, drink plenty of fluids to wash out tracer 2-3 days after

reasons for testing of lung imaging

fast heart rate, difficulty breathing, chest pain unrelated to heart, emphysema, COPD, tumor or blockage in the airway or lungs, postop for lung surgery

pulmonary angiography

special X-rays of the vessels of the lungs, assesses arterial blood flow to lungs, abnormalities in circulation, pulmonary embolus

rigid bronchoscopy

used for larger airways, can remove blood, secretions, foreign objects, or dead tissue.

fiberoptic bronchoscopy

smaller, more flexible scope. used to suction secretions, used to take tissue samples, puts medication into lungs.

nursing interventions for a bronchoscopy

-ensure pt in 6-8 hours before procedure

-relieve pt anxiety and provide education

-provide oral care

-have emergency resuscitation equipment at bedside

-position conscious pt in semi fowlers

-monitor VS, especially respirations

-assist with specimen collection

risk factors of a bronchoscopy

Pneumothorax, infection, bronchospasm, bleeding

laryngoscopy

visual examination of the larynx, looks for abnormalities, vocal cord problems, lesions.

thorascopy

visual examination of the pleural cavity via small incisions and use of an endoscope.

uses of a thorascopy

-look for problems in lungs that cause symptoms of lung disease

-assess abnormal areas found on lungs following imaging

-take biopsy samples of abnormalities found in lung tissue, chest wall, lymph nodes, pleura, and pleural fluid

-resection/drainage of diseases or masses within pleural cavity

positioning thorascopy

lateral decubitus position: involves side up, round bolster placed under thorax to arch the vertebral column upwards to maximize the intercostal spaces of involved space, arm elevated over head

thorascopy nursing considerations and educations

prior: consent, IV access, stop asprin and blood thinners prior to surgery, NPO at midnight

after: wound care (CT), pain management, monitor VS, encourage deep breathing and coughs, encourage incentive spirometry, ambulate patient, apply SCD's, monitor urine output

thoracentesis

surgical puncture to remove fluid from the pleural space can be done to find the cause and treat symptoms of pleural effusion.

thoracentesis positioning

sitting position with arms and head resting on bedside table, after procedure put in side lying position

rhinitis

inflammation of the nose, common cold (rhinovirus) or allergic rhinitis.

s/s of rhinitis

rhinorrhea, sore throat, cough, watery eyes, low fever, malaise (typically 5-14 days, not with allergic rhinitis)

Pharmaceutical/nonpharmaceutical ways to treat rhinitis

antihistamines, antitussive, decongestant.

stay away from triggers, keep clean house, hand hygiene, cough etiquette

sinusitis

inflammation of the sinuses, maxillary is the most common but there is also acute, subacute, chronic, or recurrent. can be bacterial or viral.

s/s of sinusitis

pressure over sinuses, headache, drainage, stuffiness

meds for sinusitis

Vasoconstrictors, irrigation w sterile water, antibiotic, surgery if chronic to stop blockage

post op sinusitis

no airplane or travel for 2 weeks, watch for frequent swallowing (bleeding), avoid blowing nose, assess temp, no heavy lifting over 10 lbs, ice pack over sinuses, no smoky areas, plenty of fluids, watch for constipation, change drip pad as needed

pharyngitis

inflammation of the throat. can be viral or bacterial. streptococci infection complications.

s/s of pharyngitis

sore throat, dysphagia, fever, chills, headache, malaise, exudate over pharynx and tonsils

medications for pharyngitis

throat swabs/cultures to identify cause, antibiotics if bacterial - penicillin, or cephalosporins, pain management like tylenol if viral

Tonsilitis/Adenoiditis

inflammation of the tonsils and adenoids, more common in children than adults

S/S of Tonsillitis and Adenoiditis

sore throat, dysphagia, fever, malaise, enlarged tonsils, nasal sound to voice, dysphonia, noisy breathing, snoring, patchy white exudate, difficulty swallowing

medications for tonsilitis and adenoiditis

Antibiotics or may require surgery for removal if it's reoccurring

Post op for tonsillectomy and adenoidectomy

lay pt on side, when awake place pt in semi fowlers, monitor VS(RR, O2), lung sounds, gag reflex/ability to swallow, monitor pain, keep suction equipment at bedside, monitor for excessive bleeding, stay on top of pain medications, salt water gargle, avoid blowing nose, avoid milk/milk products, avoid salty/spicy

peritonsillar abscess

can occur after streptococcal or staphylococcal infection

s/s of peritonsillar abscess

sore throat, difficulty/painful swallowing, ear pain, difficulty talking or muffled voice

Treatment of peritonsillar abscess

treated with drainage of abscess and antibiotic therapy.

nursing interventions for peritonsillar abscess

needs aspiration of incision and drainage, cultural collection, pain meds, antibiotics, cool oral fluids, resp status

laryngitis

inflammation of the laryngeal mucous membranes, can affect the vocal cords, if it lasts longer than 2 weeks see dr may be an early sign of laryngeal cancer.

s/s of laryngitis

aphonia (loss of voice), hoarseness, dry cough, throat irritation

causes of laryngitis

bacterial infection, viral infection, overuse/improper use of voice, smoking, allergies

Treatment of laryngitis

rest voice, encourage oral fluids, may require antibiotics, encourage smoking cessation classes if a smoker.

epistaxis

noseblood

causes/risks of epistaxis

trauma, systemic infections, local infection, dry nasal mucosa, hypertension, nasal tumors, inhalation drug use, excessive nose blowing, nose picking, blood dyscrasias, anticoagulant use

Medical Management of epistaxis

direct pressure nares for 5-10 min, ice pack to nose, application of vasoconstrictor, cauterization, silver nitrate sticks, nasal packing, direct pressure via inflated balloon catheter (rhino rocket)

nursing intervention for epistaxis

monitor VS, ice pack, direct pressure to nares, sit up right with head tipped forward and down, no nose blowing.

epistaxis education

no picking, humidification in home, if nose bleeds do not stop seek medical attention

nasal obstruction: deviated septum

-obstruction/partial obstruction of nostril, impedes sinus drainage

-congenital or due to trauma

nasal obstruction: nasal polyps

-round swellings in the nasal mucosa

-impaired nasal breathing and sinus drainage

-usually benign

nasal obstruction: hypertrophied turbinates

-caused by chronic rhinitis

-impairs airflow and sinus drainage > sinusitis

fractured nose s/s

edema, pain, external bleeding, epistaxis, nasal deformity, nasal obstruction

pt may require surgery and needs radiology studies to rule out other facial fractures

nursing interventions of a fractured nose

severe= drainage of CSF fluid, if nose is running collect drainage on tissue and if there's a 'halo' this is a positive sign, the nurse can also test with dextrostix which will appear positive if there is glucose in the drainage

laryngeal trauma/obstruction: causes of trauma

MVC, intubation, thyroid cartilage fracture, strangling

laryngeal trauma/obstruction: s/s of trauma

neck swelling, bruising, tenderness obstruction

laryngeal trauma/obstruction: allergic reaction

head/neck injury, severe inflammation of throat, foreign body.

top priority: airway

medications for allergic treatment

Diphenhydramine, H2 blocker, epinephrine, steroid

s/s of laryngeal trauma/obstruction allergic reaction

stridor, dysphagia, hoarseness, cyanosis, hemopytsis,, difficulty breathing, inability to breathe, respiratory arrest, drooling, bloody foamy sputum

obstructive sleep apnea

upper airway obstruction (short period of apnea) and reduced ventilation during sleep.

obstructive sleep apnea risk factors

male gender, african americans, hispanics, pacific islanders, overweight, hereditary, smaller than average airways, increased age, smoking, frequent heavy consumption, use of sedatives

s/s of sleep apnea

loud snoring, periods of apnea (10 seconds or more), drops in oxygen saturation, fatigue, headache, inability to concentrate, sore throat, inuresis (bed wetting), erectile dysfunction

what can lead to sleep apnea lead to?

cardiovascular complications, hypertension, arrhythmias, stroke, heart failure, myocardial infarction

laryngeal cancer

most common type of head/neck cancer

laryngeal cancer risk factors

male, over 65, smoking, chewing tobacco, alcohol, industrial pollutant exposure, acid reflux, chronic laryngitis, HPV infection

laryngeal infection s/s

prolonged hoarseness (often earliest sign), halitosis, feeling of a lump in the throat, dysphagia, pain, burning in throat, dyspnea, weight loss, weakness, increased metabolism, anemia, anorexia

tracheostomy

surgical opening is created in the throat and a tube is inserted. used to maintain airway. can be permanent or temporary.

nursing interventions for pt's with a tracheostomy

-monitor VS for airway obstruction

-when pt is awake put in semi fowlers

-tracheal dilator and additional trach tube at bedside

-never force dislodged trach back into place

-make sure linens/gown do not cover trach

-use trach shield/collar for extra oxygen

endotracheal intubation

tube inserted through the mouth (or nose) into the trachea to maintain airway. tube is connected the ventilator and requires humidification.

reasons a pt would be endotracheal intubation

unresponsive pt's (overdose/head injury/stroke), severe airway swelling (protective measures), respiratory distress/patients requiring general anesthesia

complications with endotracheal intubation

VAP, lung damage (hyperinflation injuries), decreased lung expansion, accidental dislodging/removal of the tube

what do should the nurse do if the endotracheal tube gets dislodged?

bag pt and call her help/physician

nursing care of ventilated pt

Auscultate breathe sounds, monitor LOC, humidification, Q2 turns, oral care, suction secretions, alternation of communication, sit up head of bed

nursing care for extubation

fowlers/semi fowlers, no talking for awhile, watch VS closely

acute bronchitis

inflammation of the mucous membranes

causes of acute bronchitis

Haemophilus, influezae, streptococcus pneumoniae, mycoplasma pneumoniae, fungal infections, Aspergillus

assessment findings of acute bronchitis

fever, chills, malaise, headache, dry irritating and nonproductive cough, mucopurulant sputum

Medical Management of acute bronchitis

bed rest, antipyretics, expectorants, antitussives, increased fluids, antibiotics, listen to lung Q4 hours, cough and deep breathe, humidification

pnuemonia

inflammatory process affecting the bronchioles and alveoli.

medical management of pneumonia

antibiotic therapy, hydration, O2, bed rest, chest PT, postural drainage, bronchodilators, analgesics, antipyretics, cough expectorants or suppressant.