Respiratory

1. Respiratory Metropolitan Community College Fall 2013 Jane Miller, RN MSN

3. Objectives • Identify patients at risk for pulmonary embolism (PE) • Identify clinical manifestations of pulmonary embolism • Identify diagnostic tools for determination of pulmonary embolism • Identify treatment of pulmonary embolism to include oxygenation, nonsurgical management, surgical management, and nursing interventions • Identify intervention for prevention of pulmonary embolism • Identify patient education necessary for management of pulmonary embolism • Identify pathophysiology and causes of acute respiratory failure. • Define pathophysiology and causes of acute respiratory distress syndrome (ARDS)

4. Identify clinical manifestations, diagnostic assessment, and interventions for patients with ARDS • Identify the patient who requires intubation and mechanical ventilation • Identify procedure for endotracheal intubation including indications for, verifying tube placement, and nursing care • Define goals of mechanical ventilation, including types of, controls and settings, and care of the patient to prevent complications • Define the weaning process from the ventilator to extubation • Identify pathophysiology, clinical manifestations, diagnostic tests, and interventions for pneumonia, tuberculosis, lung abcess, emphysema, cystic fibrosis, pulmonary hypertension, pulmonary edema

5. Pulmonary System

8. Risk Factors • Smoking • Pack year = twenty cigarettes smoked every day for one year • Inactivity • DVT & PE • Cardiovascular disease • Obesity • Sleep apnea • Substance abuse • Pneumonia, CNS depression, PE • Trauma • Burns, spinal cord injury, brain injury, blunt and penetrating chest injuries • Occupation • Construction, farmers, firemen, janitors • Culture • Testing & treatment • Environment • Work & home • Hand and oral hygiene • Nutrition • Travel and area of residence • SARS, TB

11. Adventitious Breath Sounds • Crackles (Rales) • Caused by fluid, inflammation, infection, or secretions • Pneumonia, bronchitis, CHF, pulmonary edema, fibrosis • Fine or course “popping” sound, nonmusical, discontinuous • Lounder during inspiration • Wheezes (Rhonchi) • Caused by narrowing of the airway • Bronchospasm, secretions, airway inflammation • High-pitched musical sound, continuous • Heard during inspiration and expiration equally

12. Stridor • Caused by an obstruction • High-pitched crowing • Heard only during inspiration • Requires immediate intervention • Pleural Friction Rub • Caused by pleural inflammation • Rubbing or grating sound, walking on fresh snow • Heard during inspiration only http://www.easyauscultation.com/adventitious-breath-sounds.aspx

14. Assessment • Patient interview • Complaint, symptoms, previous illness & hospitalizations, medications, allergies • Physical exam • General appearance • Mentation • Rate, depth, and rhythm of respirations • Kussmaul’s: increased rate and depth • Cheyne-Stokes: rapid breathing then apnea • Thoracic size, shape, & expansion • Skill color, temperature, moisture

15. Gerontological Considerations • Respiratory function decreases • Skeletal changes from osteoporosis • Rib cage becomes more rigid • Anterior posterior diameter increases • Alveolar surface decreases • Lung tissue becomes less elastic • Comorbidities

16. Upper Airway Disorders • Disorders of the head & neck • Nasal and facial fractures • Result of trauma • Deformity, tenderness, edema, bleeding, crepitation, pain, difficulty talking or chewing, diplopia, CSF leak • Diagnosed by clinical exam, x-ray, CT scan, CSF halo test • Treatment includes rest, ice, head elevation, pain management, closed reduction, spliniting, ORIF, jaw wired shut

17. Nursing Management • Elevate HOB • Apply ice • Provide pain control • Liquid diet high in protein and calories • Treat N&V, especially if jaw wired shut • Oral care • Monitor patency of airway • Watch for bleeding • Educate on risks for nose bleeds • Educate about no straining with CSF leak

18. Inflammation & Infection of Nose & Paranasal Sinuses • Rhinitis: inflammation of the nasal mucous membrane • Sinusitis: inflammation of the paranasal and frontal sinuses • Nasal obstruction • Polyps • Foreign bodies

19. Nursing Management • Administer allergy medications • Educate regarding avoiding allergens or triggers, signs of allergic reaction, when to seek medical care • Assist in foreign body removal • Close other nostril, and gently blow through affected nostril • Post operative monitoring is required

20. Airway Obstruction • Potentially a life threatening emergency • Causes • Inhalation burns • Infection • Allergic response • Laryngeal trauma • Tumor • Aspiration • Assess for stridor

21. Nursing Management • Type of obstruction determines nursing needs • Assess their ability to talk • Quick visual assessment • Patient history if applicable • Assess O2 sat & apply oxygen • Heimlich maneuver • IV • Administer IV steroids, antibiotics • Oral suctioning • Intubation and tracheostomy equipment at the bedside • Crash cart

22. Tracheostomy • Surgical placement of an artificial airway below the thyroid cartilage (Adam’s apple) • Usually temporary but not always • Used for • Acute airway obstruction • Intubation longer than 7-10 days • Vigorous pulmonary hygiene • Obstructive sleep apnea

24. After Placement • Sutured into place to prevent decannulation • Also secured with ties • The tube remains in place until the tracheal stoma is well established and won’t close back up • A post tracheotomy kit is kept at bedside or on the nursing unit if accidental decannulation occurs • An obturatoris kept at bedside to assist in reinserting the tube if it comes out.

25. TYPES OF TRACHEAL TUBES • Made of silicone, plastic, stainless steel, or silver • With or without a cuff • Mechanical ventilation requires cuffed tubes to seal the airway to maintain pressures for ventilation • Cuffed tubes decrease aspiration risk but do not eliminate it • Inner cannulas prevent tube obstructions from thick crusted secretions • Average adult size are 7 to 8 • Shiley or Bivona are most common

27. Assessing a New Trach Tube • Auscultate the lungs • Monitoring O2 sats • Amount of blood in the sputum and around site • Crepitisaround the neck • Respiratory distress • Patency of tracheal tube • Postoperative pulmonary edema (POPE)

28. Tracheostomy Care • Encourage cough and deep breathing • Suction as necessary, but keep to a minimum • Limit to 5-10 seconds with each pass • Pre-oxygenate with 100% Oxygen when suctioning • Insert catheter till patient starts to cough or meet slight resistance – do not use force • Trachcares should be done every 8 to 12 hours with cleaning or changing the inner cannula • Clean under and around the face plate • Assess for skin breakdown

29. Lower Airway Disorders • Pneumonia • Tuberculosis • Lung abcess • Emphysema • Pulmonary embolism • Acute respiratory failure • Pulmonary edema • Acute respiratory distress syndrome

30. Pneumonia • Inflammatory process that results in edema of the alveoli and bronchioles • Risk factors • Advanced age • Compromised immune system • Lung disease • Alcoholism • Altered LOC • Smoking • Intubation • Malnutrition • Immobility

32. Pneumonia • Causes • Bacteria • Viruses • Fungi • Protozoa • Parasites • Radiation therapy • Aspiration • Inhalation of toxic gases or chemicals

33. Community Acquired Pneumonia • Begins outside hospital or is diagnosed w/in 48 hours after admission • Patient did not reside in a long-term facility prior to admission • Bacterial or viral • Incidence of CAP is highest in winter months • Smoking an important risk factor • Usually treated on an outpatient basis

34. Hospital Acquired Pneumonia • Occurs > 48 hours after hospital admission • Mortality rate of 20% to 50% • 90% of HAP infections are bacterial • Compromised immune systems, chronic lung disease, intubation, and mechanical ventilation increase risk

35. Clinical Manifestations • Fever • Chills • Increased respiratory rate, >20 • Increased heart rate, >100 • Rusty bloody sputum • Crackles • X-ray abnormalities • Chest discomfort • Cough • Fatigue, muscle aches, headache, nausea

36. Nursing Management • Administer antibiotics • Fluoroquinolones - recommended • Ex: Ciprofloxacin, Levofloxacin • Start while still identifying the specific pathogen • Maintain airway and O2 saturation above 93% • Promote nutrition and hydration • Provide small, frequent, high-carb, high-protein meals • Elevate the head of bed • Pain relief for chest discomfort • Provide time for rest

37. Discharge Priorities/Prevention • Continue deep breathing and coughing exercises 4x/day, 6-8 weeks • Signs and symptoms to report to health care provider • Chills, fever, dyspnea, hemoptysis, fatigue • Continue and complete antibiotic therapy as directed • Continued rest with gradual increase in activity • Proper nutrition and fluid intake • Avoid others that are ill

38. Pulmonary Tuberculosis • Contagious bacterial infection • Mycobacterium tuberculosis • Transmitted via aerosolization • Affects people with repeated close contact with an infected but undiagnosed person • Opportunistic infections common with HIV/AIDS • The newest form of TB is multidrug-resistant tuberculosis (MDRTB) • Resistant TB is difficult and costly to treat and can be fatal

39. Clinical Manifestations • Dyspnea • Weight loss • Cough • Sputum production, may be streaked with blood • Sleep disturbances • Lethargy, exhaustive fatigue, activity intolerance • Nausea • Low-grade fever may have occurred for weeks or months • Night sweats

40. Diagnosis • Mantoux tuberculin skin test • Chest x-ray • Acid-fast bacillus smear • Sputum culture

41. Nursing Management • Administer drug therapy as ordered by health care provider • Keep patient in negative pressure room • Wear N-95 mask • Maintain isolation until three consecutive sputum cultures have tested negative • Focus on preventing the spread of the infection • Drug therapy can take as long as 9 months • Signs & symptoms to report • Discuss pain management, handling fatigue, importance of good nutrition

42. Lung Abcess • Localized area of lung destruction caused by liquefaction necrosis • Secondary to anaerobic and aerobic organisms that colonize the upper respiratory tract • Periodontal disease • History of pneumonia • Bronchial carcinoma or obstruction • TB • Fungal infections

43. Clinical Manifestations • Spiking temperature • Night sweats • Chills • Cough with foul sputum, may be blood tinged • Pleural chest pain • Tachycardia • Short of breath • Diminished lung sounds • Dullness on percussion over the abcessed area • Oxygen saturation may decrease with larger abcesses

44. Diagnosis • Sputum culture • Bronchoscopy • Pleural or blood cultures • CT scan

45. Nursing Management • Administer antibiotics • Penicillin G or clindamycin • Maintain airway and O2 saturation above 93% • Elevate the head of bed • Pain relief for chest discomfort • Diet high in protein • Provide time for rest • Educate about medication use after discharge

46. Emphysema • Identified by alteration of the lung architecture and destruction of alveolar walls • Lungs lose their elasticity, air spaces are enlarged which causes limited airflow out of the lungs • Form of COPD • Primary cause is smoking

48. Diagnosis • ABGs • CBC • X-ray • CT scan • Pulmonary function test

49. Nursing Management • Administer supplemental oxygen • Monitor ABGs • Support and anxiety reduction • Provide time for rest • Education • Smoking cessation • Safe use of oxygen • Infection prevention

50. Pulmonary Embolism • Complication of a DVT • Thrombus breaks loose and blocks a branch of the pulmonary artery • Produces widespread pulmonary vasoconstriction • Impairs ventilation and perfusion • Results in life-threatening hypoxemia, pulmonary ischemia and pulmonary infarction