Respiratory Nursing Care and Interventions

Nursing Diagnoses and Outcome Identification in Respiratory Care

• Primary Nursing Diagnoses:

  • Ineffective airway clearance.

  • Impaired gas exchange.

• General Outcome Categories:

  • Knowledge regarding prevention of respiratory dysfunction.

  • Adequate tissue oxygenation.

  • Successful mobilization of pulmonary secretions.

  • Effective coping with changes in self-concept and lifestyle.

• Outcome Specification by Prognosis:

  • Acute Problems: Full recovery without residual respiratory complications.

  • Chronic Problems: Managing limitations imposed by the disease and accepting lifestyle/self-concept changes.

  • Terminal Problems: Maintenance of adequate comfort and acceptance of impending death.

Health Promotion and Infection Prevention

• Health Promotion Roles: Nurses work in clinics, schools, industry, and public health settings to provide programs that reduce smoking and pollution, and improve working conditions to prevent lung disease.

• Preventing Respiratory Infections:

  • General Practices: Good nutrition (immune support), avoiding large crowds during peak infection seasons, and rigorous hand hygiene.

  • Hygiene Etiquette: Sneezing/coughing into the sleeve and proper disposal of used tissues.

  • Vaccinations:

    • Influenza: Annual vaccination is required because strains change yearly; high-risk groups include older adults, people with diabetes, asthma, COPD, HIV, cancer chemotherapy patients, transplant recipients, and healthcare workers.

    • Pneumococcal: Recommended for high-risk individuals; revaccination is generally required only for adults older than 65 years or those who are immunocompromised.

    • COVID-19 (SARS-CoV-2): A virus discovered in 2019 that caused a global pandemic with nearly $7 \times 10^6$ deaths in its first three years. High-risk groups include the elderly, immunocompromised, and individuals with obesity.

Smoking Cessation and Allergen Reduction

• Smoking Cessation Stages (States-of-Change Theory):

  1. Precontemplation: Not thinking about quitting.

  2. Contemplation: Thinking about quitting in the next 6 months.

  3. Preparation: Thinking about quitting in the next 30 days.

  4. Action: Actively in the process of quitting.

  5. Maintenance: Abstinent for 6 months or more.

• Relapse: Common; patients often require multiple attempts. Interventions include smartphone apps, professional therapy, and medications.

• Teachable Moments: Diagnosis of lung cancer is often a significant motivator for immediate cessation.

• Reducing Allergens:

  • Workplace Triggers: Over 400 identified, including chemical vapors in paper mills, textile mills, printing plants, and hair salons.

  • Environmental Triggers: Secondhand smoke, seasonal pollens, aspirin sensitivity, cold air, and exercise.

  • Indoor Allergens: Dust mites, pet dander, cockroach eggs/droppings, and molds.

  • Interventions: Skin testing and allergen desensitization (allergy shots).

Monitoring and Hydration

• Peak Flow Monitoring:

  • Measures the highest flow during maximal expiration.

  • Changes in flow reflect airway diameter changes before dyspnea or wheezing occurs.

  • Procedure: Record twice daily (morning and evening) before using bronchodilators. Determine a "personal best" over a 2-week period of well-controlled asthma.

  • Zones:

    • Green: $80\% \text{ to } 100\%$ of personal best (well controlled).

    • Yellow: $50\% \text{ to } 80\%$ of personal best (not well controlled; treatment update may be needed).

    • Red: Below $50\%$ of personal best (requires fast-acting $\beta_2$ agonist and immediate provider contact).

• Hydration:

  • Goal: Keep mucus thin and mobile. Thick, tenacious sputum increases work of breathing and risk of infection.

  • Fluid Intake: $6 \text{ to } 8$ glasses (primarily water) daily.

  • Avoidances: Caffeine and alcohol (diuretic effects); dairy products (may thicken secretions in some patients).

Positioning, Mobility, and Deep Breathing

• Positioning:

  • Frequent movement prevents mucus pooling/bacterial colonization.

  • Unilateral Lung Problems: Position with the "good lung down" to match ventilation and perfusion.

  • Supine Position Risks: Associated with ventilator-associated pneumonia (VAP) and aspiration.

  • Ambulation: Encouraging progressive walking improves exercise tolerance, decreases oxygen consumption, and facilitates effective coughing.

• Deep Breathing and Incentive Spirometry:

  • Benefits: Expands alveoli, moves mucus, and prevents atelectasis.

  • Splinting: Holding a pillow against an abdominal or thoracic incision to minimize pain during breathing/coughing.

  • Incentive Spirometer: A device providing visual feedback (bellows or floating balls) to motivate deep inspiration.

  • Schedule: $8 \text{ to } 10$ breaths hourly during waking hours.

Coughing Techniques and Pursed-Lip Breathing

• Coughing Varieties:

  • Deep Cough: Glottis closure followed by sudden release; best for mobilizing secretions and opening alveoli.

  • Stacked Cough: Releasing several short blasts of air; less painful for post-op patients and prevents airway collapse.

  • Low-Flow (Huff) Cough: Saying "huff" during exhalation; ideal for COPD patients to prevent airway collapse during high-pressure exhalation.

  • Quad Cough: Manual assistance for neuromuscular or quadriplegic patients; the nurse pushes in and upward below the rib cage during exhalation (similar to the Heimlich maneuver).

• Pursed-Lip Breathing:

  • Creates back pressure in the airways to prevent collapse during exhalation.

  • Prevents air trapping in patients with obstructive lung diseases (COPD, asthma).

Chest Physiotherapy (CPT)

• Purpose: Shake mucus from airway walls and encourage drainage.

• Contraindications: Pneumonia, hemoptysis, and pneumothorax.

• Techniques:

  • Percussion: Rhythmic striking with cupped hands over secretory areas (avoiding spine, kidneys, or incisions).

  • Vibration: Rapid, vigorous vibration of hands on the chest during exhalation.

  • Oscillatory Positive Expiratory Pressure (PEP): Combines vibration with resistive exhalation to open peripheral alveoli.

  • Postural Drainage: Using gravity and specific positions. Trendelenburg (head-down) is contraindicated in patients with head injuries (increased ICP), cardiac problems, or severe COPD (diaphragm restriction).

Aerosol and Medication Therapy

• Drug Types:

  • Bronchodilators: Relax smooth muscle; monitor for increased heart rate, agitation, and restlessness.

  • Corticosteroids: Used for inflammation; fewer systemic effects than oral version. Patients must rinse their mouth to avoid oral fungal infection (thrush).

  • Cromolyn: Prevents asthma attacks.

  • Antibiotics: Used for stubborn infections (e.g., in Cystic Fibrosis).

• Delivery Systems:

  • Metered-Dose Inhalers (MDIs): Premeasured gas-powered puffs. Spacers can improve efficiency. If taking both, use the bronchodilator before the steroid to open airways.

  • Dry Powder Inhalers (DPIs): Breath-activated; require a minimum inhalation flow rate.

  • Handheld Nebulizers: Delivers steady stream of aerosol over several minutes; useful if inspiration/activation coordination is difficult.

  • Large-Volume/Ultrasonic Nebulizers: Provide continuous moist fog; requires frequent reservoir checks (sterile water) and drainage of condensation in tubing.

Oxygen Therapy Principles and Systems

• Goals: Reverse hypoxemia, improve tissue oxygenation, and decrease the workload of the heart and lungs.

• Oxygen Parameters: Prescribed by flow ($L/min$) or concentration (FiO2). Aim for PaO_2 > 60\,mm\,Hg or SpO_2 > 93\%. It is rarely necessary to exceed $PaO_2$ of $90\,mm\,Hg$.

• Delivery Devices:

  • Nasal Cannula/Simple Mask: For low oxygen needs.

  • Nonrebreather Mask: Reservoir-type mask set at $12 \text{ to } 15\,L/min$ to prevent CO2 rebreathing.

  • High-Flow Nasal Cannula (HFNC): Delivers up to $60\,L/min$ at increased pressure.

  • Transtracheal Catheter: Surgical insertion through the neck into the trachea; less waste, used for long-term home care.

• Safety and Precautions:

  • Oxygen is a drug and requires a prescription (except in emergencies).

  • Combustion risk: Post "No Smoking" signs.

  • Toxicity: High concentrations can damage newborn retinas (blindness) and adult lung tissue.

  • COPD Concerns: Hypercapnia is the normal drive to breathe, but chronic retainers may rely on hypoxia. Target $SpO_2$ for COPD patients is typically $88\% \text{ to } 92\%$.

Management of Dyspnea and Hyperventilation

• Dyspnea Management:

  • Speak calmly and slowly; remain with the patient.

  • Positioning: Sit the patient upright to allow the diaphragm to move freely.

  • Coach to slow the breathing rate; push down on shoulders to discourage the use of accessory muscles.

• Hyperventilation Management:

  • Defined by PaCO_2 < 35\,mm\,Hg. Symptoms include dizziness and tingling.

  • Interventions: Reassurance, benzodiazepines (if prescribed), or rebreathing into a paper bag under direct supervision.

Assisted Ventilation and Artificial Airways

• Noninvasive Positive Pressure Ventilation (NIPPV):

  • CPAP: Continuous pressure to keep airways open (common for sleep apnea).

  • Bilevel (BiPAP): Higher pressure on inspiration, lower on expiration.

  • Note: These do not breathe for the patient; patient must be able to remove the mask if vomiting to avoid aspiration.

• Artificial Airways:

  • Oropharyngeal: Keeps airway open; used in PACU; poorly tolerated if patient is conscious (gagging).

  • Nasopharyngeal (Nasal Trumpet): For frequent suctioning; must be lubricated with water-soluble gel.

  • Endotracheal (ET) Tube: Inserted for surgery or mechanical ventilation.

  • Tracheostomy: Surgically implanted below the larynx. Types include cuffed (decreases aspiration, prevents air leak during ventilation) and fenestrated (allows speaking when plugged because of holes in the outer cannula).

Tracheostomy Care and Complications

• Components: Outer cannula, flange, obturator (insertion guide), and inner cannula.

• Risks: Bleeding (post-op), stoma infection, pneumonia, and tube occlusion (from dried secretions).

• Nursing Care:

  • Maintain hydration and humidification.

  • Use sterile technique for cleaning and suctioning post-operatively.

  • Provide writing implements for communication.

  • Do not cut gauze dressings (loose threads cause inflammation).

  • Security: Always stabilize the tube when changing ties; two-person care is recommended to prevent accidental extubation.

Suctioning Techniques

• Indications: Coarse crackles, diminished breath sounds, increased heart/respiratory rate, or decreased oxygen saturation.

• Equipment: Yankauer (oral/tonsil-tip) or deep bronchial catheters.

• Safety Limits:

  • Hyperoxygenate before attempts.

  • Apply suction intermittently.

  • Limit to 3 passes, maximum 10 seconds per pass.

  • Pressure Settings:

    • Adults/Children: $-80 \text{ to } -120\,mm\,Hg$.

    • Infants: $-60 \text{ to } -80\,mm\,Hg$.

  • Risks: Hypoxia, dysrhythmias, hypotension, and atelectasis.

Chest Tubes

• Indications: Hemothorax (blood), pneumothorax (air/collapse), or pleural effusion (fluid).

• System Components:

  1. Collection Chamber: Keep upright; mark drainage every shift.

  2. Water Seal Chamber: Filled with sterile water to manufacturer mark. Fluctuations are normal; continuous bubbling indicates a leak.

  3. Suction Chamber: Set typically at $-20\,cm\,H_2O$; requires gentle bubbling.

• Wall Suction Setting: Typically $-80 \text{ to } -120\,mm\,Hg$ to maintain the system's negative pressure.

Emergency Airway Measures and Resuscitation

• Obstruction Levels:

  • Partial: Loud snoring or gasping; loud coughing. Allow them to cough; do not slap the back.

  • Near-Total: High-pitched inspiratory stridor.

  • Total: No sound, no cough.

• Abdominal Thrusts: Standing behind the patient, fist against abdomen, upward thrusting motion.

• Unconscious Choking: Supine position, chest compressions, search for obstruction (no blind sweeps).

• Manual Resuscitation Bag: Deliver $16 \text{ to } 20$ breaths per minute for an adult. Tilt chin back and pull jaw forward to ensure a seal.

Home and Community Care

• Infection Control at Home: Transition from sterile to clean technique. Patients must watch for yellow/green sputum, fever, and difficulty raising sputum.

• Home Oxygen Systems:

  • Compressed Gas: For occasional use.

  • Liquid Oxygen: Portable "walkers" for mobility outside the home.

  • Concentrator: Chemically separates oxygen from room air; best for continuous low-concentration needs.

• Energy Conservation:

  • Sponge baths instead of tubs; elevated toilet seats.

  • Pacing activities and rest periods; sit while performing tasks.

  • Limit activity for 1 hour post-meals.

• Psychosocial Needs: Sexual function (use bronchodilators before activity; passive positions); FMLA for job security; support groups for coping.

Outcome Evaluation Criteria

• Knowledge: Patient demonstrates deep breathing/coughing or discusses physiological effects of smoking.

• Management: Patient lists infection signs, verbalizes medication side effects, and demonstrates safe home oxygen use.

• Physical: Successful mobilization of secretions and demonstration of pursed-lip breathing.

• Lifestyle: Identification of support people and use of oxygen-conserving measures like sitting while dressing.