INTER-MS quiz 5 (ch. 20: asthma, bronchiectasis, cystic fibrosis + respiratory modalities)

what are chest tubes used for?

To remove fluid, blood, and/or air from the pleural cavity

-helps lungs re-expand

-reestablishes negative pressure

-there are various sizes

flutter valve

A one-way valve that allows air to leave the chest cavity but not return; formed by taping three sides of an occlusive dressing to the chest wall, leaving the fourth side open as a valve

-opens when the intrathoracic pressure is greater than the atmospheric pressure

-used during emergency transport or small/moderate pneumothorax

-increases patient mobility

-must always vent any attached drainage bag

What does bubbling in the water seal chamber indicate?

indicates an air leak

what does tidaling in the chest tube mean?

tidaling is normal and reflects the normal pressure changes; indicates that the chest tube is patent

-during inhalation, water levels rise

-during exhalation, water levels decline

water suction control

-the amount of water in the chamber controls suctioning to the lungs

-usually filled with about 20cm of water

-adjust the suction until gentle bubbling occurs in the third chamber

dry suction control

-no water is used

-dial in desired negative pressure

-must vent when decreasing pressure is noted

nursing management for chest tube patients:

-add water to water seal chamber and suction control chamber as indicated

-maintain patency of drainage system: keep tubing loosely coiled and tape connections

-observe for tidaling

-observe for any air leaks (bubbling in water seal chamber)

-observe fluid levels in water-seal chamber

-assess patient's vitals/lung sounds, drainage amount/color, and any signs of infection

-encourage deep breathing/incentive spirometry and ROM

-monitor for complications (vasovagal response, subQ emphysema, or re-expansion pulmonary edema)

-sterile dressing care

-change chest tube when full (report over 100mL/hr)

why should you never milk or strip a chest tube?

it can increase intrapleural pressure and damage the lungs

-instead, position tubing so that drainage flows freely

what are 3 things you would notify the HCP for within the first hour of chest tube drainage?

1) drainage that is greater than 200 mL in the first hour

2) subcutaneous emphysema (air trapped under the skin)

3) respiratory distress

the nurse should elevate the chest tube drainage system above the chest for optimal drainage. True or false?

false

(always have chest tube BELOW patient's chest level)

what should the nurse do if the chest tube drainage has been overturned?

tell the patient to exhale and cough

-do NOT clamp the drainage tube

what should the nurse do if there is a break in the chest tube drainage system?

place the distal end of the drainage tube in sterile water to maintain the water seal

removal of chest tubes:

-removal occurs when lungs have successfully re-expanded and the chest drainage is minimal

-must pre-medicate the patient prior to removal (opioids, NSAIDs, or local anesthetics)

-have patient do the valsalva maneuver (bare down) during removal

-apply an occlusive dressing

-chest x-ray is performed

-monitor for any respiratory distress

complications of chest tube placement:

-vasovagal response: sudden drop in HR/BP triggered by pain/discomfort during chest tube placement (can lead to lightheadedness and fainting)

-subcutaneous emphysema (air gets trapped under the skin)

-re-expansion pulmonary edema (fluid build up in lung tissue which happens very quickly and can lead to respiratory distress)

Asthma:

WHAT: chronic inflammation of the airways causing hyperresponsiveness, mucosal edema, and mucus production

S/S: recurrent episodes of wheezing, dyspnea, cough, and chest tightness; use of accessory muscles, acidosis, and tachypnea

INTERVENTIONS: prevention through avoidance of triggers (pollen etc.), short-acting and quick relief medications for acute exacerbations such as albuterol or ipratropium; inhaled corticosteroids such as beclomethasone for long-term control; peak flow monitoring

what cells play a significant role in asthma?

mast cells, macrophages, T lymphocytes, neutrophils, and eosinophils

what is airway remodeling?

structural changes in the airways such as thickening of airway walls, increased smooth muscle mass, and changes to the epithelial lining of the airways

-leads to narrowed airways and impaired lung function

an asthmatic cough always presents with mucus. True or false?

false

(can be a cough with or without mucus)

complications of asthma:

-Status asthmaticus

-Respiratory failure (hypercapnic= high CO2, leading to acidosis)

-Pneumonia

-Atelectasis

-airway obstruction leading to hypoxemia (give oxygen)

(fluids given due to dehydration from fluid loss from sweating or hyperventilation)

nursing management for patients with asthma

-obtain a history of allergies

-identify triggers

-administer prescribed medications

-administer fluids for dehydration

-educate about chronic management and not just acute episodic care/meds

what does a peak flow monitor measure?

the highest volume of airflow during a forced expiration

-patient takes deep breath, then exhales hard and fast

-have patient stand/sit in upright position

-tested 3 times (highest score is recorded)tr

-green zone= 80-100% under control

-yellow zone= 60-80% under control (need albuterol)

-red zone= less than 60% (emergency treatment needed)

status asthmaticus:

WHAT: rapid onset, severe, and persistent asthma that does not respond to conventional asthma therapy

-can occur with little to no warning

S/S: same as severe asthma; dyspnea, wheezing, prolonged exhalation, and JVD

INTERVENTIONS: initially treated with short-acting beta blocker, systemic corticosteroids given; supplemental oxygen (high-flow using partial or complete non-rebreathing mask) and fluids given; magnesium sulfate may be given to relax smooth muscle; endotracheal intubation may be needed if too severe

what can contribute to status asthmaticus episodes?

infections, anxiety, abuse of inhalers, dehydration, and increased adrenergic blockage

nursing management for status asthmaticus:

-assess airway and patient's response to treatment

-monitor all vitals often for 12-24 hours

-administer fluids

-monitor BP and cardiac rhythm

-identify factors that led to attack

cystic fibrosis:

WHAT: thick, viscous secretions in the lungs, pancreas, liver, intestines, and reproductive tract

*serious mucus= clogged respiratory tract= low oxygen

*genetic disorder (defective chloride transportation)

S/S: low oxygen saturation, chronic/productive cough, fatigue, recurrent upper respiratory infections, blood-tinged sputum, clubbing of fingers, barrel chest, wheezing, thick mucus, respiratory failure, abdominal distention, weight loss/loss of appetite (due to clogging of pancreas), and fatty stools (steatorrhea)

INTERVENTIONS: antibiotic therapy, bronchodilators, nutritional support (encourage high caloric meals), mucolytics, increase fluids, postural drainage, and exercise; administration of influenza vaccinations to prevent infections; promotion of airway clearance through breathing techniques

nursing management of cystic fibrosis:

-monitor for signs of respiratory failure (watch for low pulse oximetry readings)

-encourages adequate fluids and nutrition (high calories and enzymes WITH meals)

-postural drainage/chest percussion

-promote breathing exercises

-educate about reducing exposure to crowds/preventing infections etc.

-for chronic disease, palliative care discussed

bronchiectasis

WHAT: a chronic, irreversible dilation of the bronchi and bronchioles which causes permanent enlargement of the cartilaginous airways in the lungs

CAUSES: airway obstruction, genetics, pulmonary infections, idiopathic causes

S/S: chronic cough, purulent/copious sputum, recurrent infections, blood-tinged sputum, and clubbing of the fingers

INTERVENTIONS: postural drainage, chest physiotherapy, smoking cessation, antibiotics, bronchodilators/mucolytics

diagnostics for cystic fibrosis:

-Sweat chloride test

-chest x-ray

-pulmonary function tests

-fecal fat tests

-enzyme analysis

lung or pancreatic transplants for patients with cystic fibrosis does not cure the patient, but extends life to 10-20 years. True or false?

true

(patients will always be at risk for pulmonary infections)

complications for cystic fibrosis:

-bronchiectasis

-chronic infections

-respiratory failure

-pneumothorax

-hemoptysis

-diabetes

-osteoporosis

-electrolyte imbalances/nutritional deficiencies

nursing management for bronchiectasis:

-focus is on clearing pulmonary secretions

-educate about smoking cessation

-postural drainage

-monitor for early S/S of respiratory infection

-educate about conserving energy

asthma attacks may lead to respiratory ________

acidosis

what is the main diagnostic test for asthma?

pulmonary function tests

common triggers for asthma:

-allergens (elevated eosinophils)

-smoking

-stress

-sickness (influenza or upper respiratory tract infections)

-severe weather (cold)

-strenuous activity (take meds 20-30 minutes before activity)

asthma patients should avoid _________ and ____________ medications.

NSAIDs and Beta Blockers

what medications are used for the short-term relief of an acute asthma attack?

albuterol (bronchodilator) and ipratorium (anticholinergic that dries out secretions)

1st- albuterol

2nd- ipratropium

3rd- methylprednisolone

___________________ are used for preventative/chronic asthma

inhaled corticosteroids (such as beclamethasone)

side effects of inhaled steroids:

-sores in mouth (oral thrush)

-sepsis/sickness

-blood sugar levels increased

side effects of albuterol

tachycardia/palpitations, insomnia, and tremors

diagnostics for bronchiectasis:

-chest X-ray

-high-resolution CT

-sputum culture

-pulmonary function tests

-bronchoscopy

bronchoscopy

visual examination of the bronchi

-must be NPO for 4-6 hours prior

-nurse must check gag reflex has returned before giving food after

key points for patients on chest tubes:

-assessment of breath sounds, symmetric lung expansion, and oxygen saturation

-monitor for signs of respiratory distress (tachypnea, shallow breathing, use of accessory muscles)

-assess pain level (patient's pain can interfere with deep breathing; give analgesics to relieve)

-encourage deep breathes, coughing, and ambulation

-monitor color, consistency, and amount of drainage

patients should be encouraged to stay still and to not change positions with a chest tube. True or false?

false

(movement/positioning can help facilitate more drainage)

-semi fowlers, high fowlers, or side-to-side positioning should be encouraged

patients with chest tubes should have a daily chest x-ray performed. True or false?

true

(to make sure it is still in the right place)

during inspiration with a chest tube, the pressure is _______ and causes a ________ in the water level in the water seal chamber

negative; increase

during expiration with a chest tube, the pressure is _____ and causes a ______ in the water level in the water seal chamber

positive; decrease

what does stopped tidaling in the chest drainage system indicate?

kinked tube, air leak, obstruction, or lungs are fully expanded

an ________ will show up as bubbling in the water seal chamber.

air leak

what does gentle, steady, and continuous bubbling in the suction chamber mean?

there is a good amount of suction being applied

(vigorous or violent bubbling could indicate that the suction is ordered too high)

there should be a steady rise and fall of water levels in the _____________

water seal chamber

(called tidaling)

-continuous bubbling in water chamber= air leak

what does tidaling in the water seal chamber tell us?

the lungs have not yet re-expanded

(when tidaling stops, could indicate that the lungs have re-expanded)

monitor the collection chamber of the chest drainage system every hour for the first 8 hours from insertion. True or false?

true

when do you notify HCP when monitoring the collection chamber output?

-BRIGHT red blood (over 100 mL/hr) --> indicates active hemorrhage

(DARK blood= older blood= normal after a few days of surgery)

when there is a decrease or blockage in drainage, what do you assess first?

assess patient first (auscultate lung sounds, tell patient to cough, and reposition patient), then check chest tube drainage system

diminished breath sounds in patients with chest tubes = _______________

the chest tube is not working, and the lungs may be filling up with blood or fluid

assess lung sounds/dressing/signs of infection in patient's with chest tubes every _________

2 hours

2 major complications of chest tubes:

D-disconnection

-cough/exhale

-apply occlusive dressing on 3 sides

D- damage

-place distal end of tube into sterile water

during chest tube removal, tell patient to:

take a deep breath, hold it, and bare down

What is chest physiotherapy?

using postural drainage, percussion, and vibration to promote drainage of secretions from the lungs

-nurse should use a cupped-shaped hand for vibration/percussion

-patient should be in side lying position for percussion

-check vital signs, and assess bilateral lung sounds before starting

trach suctioning should be less than ________ in depth and less than _______ seconds in length

12 cm; 10 sec

a patient should be encouraged to use an incentive spirometer approximately 10 breaths per hour between treatments while awake. True or false?

true

indications for nebulizer treatments:

-difficulty clearing secretions

-reduced vital capacity

-unsuccessful at simpler methods

how can you prevent oxygen toxicity?

-use the lowest effective concentration of oxygen

-PEEP or CPAP

what is the primary oxygen administration method for a patient with COPD?

venturi mask

nursing management of tracheostomy

-Continuous monitoring and assessment

-Maintain patency by proper suctioning

-Semi-Fowler's positioning

-Administer analgesia and sedatives

-Provide an effective means of communication

Indications for mechanical ventilation

apnea, respiratory distress with confusion, circulatory shock, controlled hyperventilation

labs: PaO2 <55, PaCO2 >50, or pH <7.32

Non-invasive positive pressure ventilation

BiPAP and CPAP

indications: respiratory arrest, serious dysrhythmias, cognitive impairment, head/facial trauma

nursing assessment/interventions for patients on mechanical ventilation:

-assess comfort level, neurological status, and communicate needs

-enhance gas exchange

-promote effective airway clearance

-prevent trauma and infection

-promote optimal level of mobility

how can a nurse enhance gas exchange?

-provide analgesics to relieve pain (without suppressing respiratory drive)

-frequent repositioning

-monitor for adequate fluid balance

-assess peripheral edema

nursing interventions for effective airway clearance:

-assess lung sounds at least every 2-4 hours

-suction, CPT, position changes, and promote mobility

-humidification of airway

3 stages of weaning from ventilator

1) patient is gradually removed from the ventilator

2) then from either the endotracheal or tracheostomy tube

3) then finally removed from oxygen

what can failure to wean a patient off the vent result in?

-BP deviation of greater than 20 mmHg

-alteration in HR greater than 20 bpm

-ALOC

-cardiac dysrhythmias

-tachypnea

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client

has wheezes in the right lung lobes

A client with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed?

with meals

Nearly 90% of clients with cystic fibrosis have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals.

what does pursed-lip breathing help with?

It helps slow expiration, prevents collapse of the airways, releases air trapped in the lungs, and helps the client control the rate and depth of respirations.

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

An inhaled beta2-adrenergic agonist

The nurse is instructing the client with asthma in the use of a newly prescribed leukotriene receptor antagonist. What should the nurse be sure to include in the education?

The client should take the medication an hour before meals or 2 hours after a meal.

signs of oxygen toxicity:

-substernal discomfort

-paresthesia

-dyspnea

-restlessness

-fatigue

-refractory hypoxemia

chloride levels in sweat above 60 indicates what?

CF

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