res care

CHAPTER 28: Respiratory Care

KEY TERMS

  • Crepitus (KREP-ih-tuss): A crackling or popping sensation felt under the skin due to air trapped in subcutaneous tissue.

  • Cyanosis (SYE-uh-NOH-siss): A bluish discoloration of the skin due to inadequate oxygenation.

  • Endotracheal tube (EN-doh-TRAY-kee-uhl TOOB): A tube inserted into the patient's trachea to maintain an open airway.

  • Exhalation (EKS-ha-LAY-shun): The process of expelling air from the lungs.

  • Hemothorax (HEE-moh-THAW-raks): The presence of blood in the pleural cavity.

  • Hypoxemia (HYE-pok-SEE-mee-ah): A deficiency of oxygen in the blood.

  • Hypoxia (HYE-pok-see-ah): A deficiency of oxygen in the tissues of the body.

  • Incentive spirometer (in-SEN-tiv spye-ROM-uh-tur): A device used to encourage deep breathing in patients.

  • Inhalation (IN-hah-LAY-shun): The process of taking air into the lungs.

  • Nebulizer (NEB-yoo-LYE-zer): A device that delivers medication in the form of a mist to be inhaled.

  • Parietal pleura (pah-RYE-et-uhl PLOO-rah): The outer layer of pleura that lines the thoracic cavity.

  • Pleural effusion (PLOOR-uhl ef-YOO-zhun): Accumulation of fluid in the pleural space.

  • Pneumothorax (NEW-moh-THAW-raks): Air in the pleural cavity which can cause lung collapse.

  • Sputum (SPYOO-tum): Mucus or fluid coughed up from the respiratory tract.

  • Tension pneumothorax (TEN-shun NEW-moh-THAW-raks): A life-threatening condition where air becomes trapped in the pleural space and increases pressure on the lungs.

  • Tracheostomy (TRAY-kee-AWS-tuh-mee): A surgical procedure to create an opening in the trachea to allow airflow.

  • Visceral pleura (VISS-uh-ruhl PLOO-rah): The inner layer of pleura that covers the lungs.

CHAPTER CONCEPTS

  • Acid–Base Balance

  • Caring for Patients

  • Clinical Judgment

  • Oxygenation

  • Perfusion

  • Safety

  • Stress and Coping

  • Teaching and Learning

LEARNING OUTCOMES

  • Define terms associated with respiratory care.

  • Explain the mechanics of inhalation and exhalation.

  • Describe regulation of respirations (chemical and nervous control).

  • Explain physiological changes in respiration of chronic lung disease patients.

  • Differentiate between internal and external respiration.

  • Contrast hypoxia and hypoxemia.

  • Identify causes of impaired oxygenation.

  • List assessment points for impaired oxygenation patients.

  • Describe various assessment findings indicating impaired oxygenation, including palpation and auscultation.

  • Discuss significance of diagnostic tests in caring for oxygenation-impaired patients.

  • Explain nursing interventions for impaired oxygenation.

  • Discuss safety measures for patients receiving supplemental oxygen.

  • Identify types of oxygen sources and delivery devices.

  • List energy conservation tips for chronic lung disease patients.

  • Describe various artificial airways and suctioning techniques.

  • Discuss tracheostomy tube care.

  • Illustrate chest tube placement and working of drainage systems.

  • Discuss care for patients with chest tubes.

  • Plan care for patients with respiratory disorders.

  • Discuss safety issues in respiratory care.

  • Answer skills questions mentioned in the chapter.

SKILLS

  • 28.1 Obtaining a Sputum Specimen

  • 28.2 Obtaining a Throat Culture Specimen

  • 28.3 Assisting With Incentive Spirometry

  • 28.4 Administering a Nebulizer Treatment

  • 28.5 Administering Supplemental Oxygen

  • 28.6 Performing Nasopharyngeal and Oropharyngeal Suctioning

  • 28.7 Performing Endotracheal and Tracheostomy Suctioning

  • 28.8 Performing Tracheostomy Care

  • 28.9 Maintaining Chest Tubes

NORMAL OXYGENATION

  • The airway is the pathway for air to enter and exit the lungs:

    • Entry: Nostrils → Pharynx → Trachea → Bronchi → Bronchioles → Alveoli

    • A patent airway refers to being unobstructed.

Mechanics of Breathing

  • During inhalation, the diaphragm contracts downwards, leading to chest cavity expansion. This causes lower lung pressure (negative pressure), pulling air in

  • Inhalation (Inspiratory phase): Process of air flowing into the lungs, also known as inspiration.

  • Upon expiration, muscles relax, reducing chest cavity size, increasing lung pressure and forcing air out. This process is termed exhalation (Expiration).

REGULATION OF RESPIRATION

  • Involves nervous control (medulla) and chemical regulation (chemoreceptors) in carotid and aortic bodies.

  • Chemoreceptors signal medulla with changes in O2 levels and blood pH, modulating rate and depth of breathing.

  • Elevated carbon dioxide levels cause acidosis; medulla responds increasing the respiratory rate to eliminate CO2.

Specifics about Chronic Lung Disease

  • In chronic lung disease, CO2 levels trap in the alveoli, impeding normal diffusion:

    • The body adapts, shifting the stimulus for respirations to hypoxia, as higher CO2 levels become ineffective.

  • Caution is needed with supplemental oxygen, as excessive levels can lead to respiratory depression by diminishing the body's natural drive to breathe.

INTERNAL AND EXTERNAL RESPIRATION

  • External Respiration: Gas exchange between alveoli and capillaries; Oxygen diffuses from alveoli (high concentration) to capillaries (low concentration).

  • Internal Respiration: Gas exchange between bloodstream and body cells. Oxygen transported through blood to tissues where it diffuses into cells, while CO2 diffuses into blood for exhalation.

ANATOMY AND PHYSIOLOGY CONNECTION: THE PLEURA

  • The pleura is a double-layered membrane lining the thoracic cavity and covering the lungs:

    • Parietal pleura: Lines the chest cavity;

    • Visceral pleura: Covering the lungs.

    • Pleural space: Contains a small amount of fluid maintaining negative pressure; loss leads to lung collapse (atelectasis).

IMPAIRED OXYGENATION

  • Blocked airway/poor alveolar gas exchange leads to hypoxemia (low blood O2) and hypoxia (low tissue O2).

Signs and Symptoms of Hypoxia

  • Early Signs:

    • Agitation

    • Anxiety

    • Level of consciousness changes

    • Irritability

    • Tachypnea

  • Late Signs:

    • Bradycardia

    • Cyanosis

    • Bradycardia

    • Cardiac arrhythmias

    • Decreased respiratory rate (Bradypnea)

    • Retractions

Causes of Impaired Oxygenation

  • Obstructed airway (e.g., tumors, choking), chronic lung disease, and factors impairing lung expansion (e.g., fluid from the heart, infection) can induce hypoxemia. Blocked airways can be resolved via suctioning or interventions like the Heimlich maneuver.

Real-World Example of Hypoxia Impacting Behavior

  • A patient mistakenly discharged a firearm at his reflection during a hypoxic episode.

CARING FOR PATIENTS WITH IMPAIRED OXYGENATION

  • Remain calm, encourage deep slow breaths, offer reassurance, and monitor vitals often.

Assessing Respiratory Status

  • Color of skin and membranes for cyanosis, respiratory effort (noting dyspnea), effective cough (producing sputum), and lung sounds with stethoscope.

    • Sputum Observations: appearance and color indicative of infections; treatment adjustments required based on sputum characteristics.

Chest Assessment

  • Inspection: Look for retractions and accessory muscle use.

  • Palpation: Monitor chest excursion.

  • Auscultation: Assess for crackles indicating fluid presence.

OXYGENATION STATUS

  • Begin with assessing orientation and subtle changes in behavior that can indicate hypoxia.

OXYGEN SATURATION MEASUREMENT

  • Use a pulse oximeter with a healthy range of 95% to 100% SaO2. Be cautioned for inaccuracies in dark skin tones or fingernail polish that might lead to misreadings.

DIAGNOSTIC TESTS

  • Key Tests: Arterial blood gases (ABGs), sputum specimens, and cultures significantly aid diagnosis of respiratory issues.

SPUTUM OBTAINMENT

  • Best collected in the morning; Techniques:

    1. Coughing and expectorating into a sterile container.

    2. Suctioning via tubes to gather specimen directly.

THROAT CULTURE

  • Guard against contamination; cultivate techniques to acquire streptococcal or other infections to avoid sequelae like rheumatic fever.

RECOMMENDATIONS FOR RESPIRATORY CARE

  • Patients post-surgery or on bedrest require turning and deep breathing exercises every 2 hours to avert pneumonia and other complications. Encourage smoking cessation to minimize lung issues.

INCENTIVE SPIROMETRY

  • Encourage deep breaths using an incentive spirometer, aiming for set goals to avoid pulmonary complications.

NEBULIZER ADMINISTRATION

  • A nebulizer combines liquid medication with air to convert it into a fine mist. Proper usage yields effective delivery to lung pathways.

CHEST DRAINAGE SYSTEMS

  • Chest tubes restore negative pressure; types are single/multi-chamber systems. Proper monitoring of output and drainage is essential.

MAINTAINING CHEST TUBES

  • Monitor for kinks, suction changes, drainage characteristics, and alert for leaks.

CASE STUDY: CARE FOR COPD & PNEUMONIA

  • Assessment focuses on lung sounds, cough productivity, oxygen saturation, and performance of daily activities. Employ effective treatments to improve lung function and oxygen saturation.

FINAL KEY POINTS

  • Physiology of respiration, importance of oxygenation, surgical implementations, oxygen implications, and thorough assessments are necessary to ensure comprehensive respiratory care.