Transcript Problems of Gas Exchange, Oxygenation, and Respiratory Function:

Alteration in Gas Transport:
Care of the Patient with Problems of
the Respiratory Tract
Carol Isaac MacKusick, MSN, RN, CNN
Nursing 2903
Fall, 2005
The Nursing Process and Respiration

Assessment

Client History
Why are you here?
 General overall health
 Any ‘colds’ or congestion or allergy
problems?
 Smoking history



Pack years: number of packs per day times
number of years
How much time away from work or school
have you missed because of this?
Assessment

Client History

Subjective symptoms
Dyspnea with ADLs?
 Childhood diseases



Adult illnesses


Asthma, pneumonia, allergies, croup
Pneumonia, sinusitis, TB, HIV, emphysema,
DM, HTN, cardiac disease
Vaccine history

Flu, pneumonia, BCG
Assessment

Client History




Surgeries of upper or lower respiratory
tract
Injuries to upper or lower respiratory
tract
Hospitalizations
Date of last



CXR, PPD, PFT
Recent weight loss
Night sweats
Assessment

Client History

Sleep disturbances





How many pillows?
Family history
Recent travel
Occupation
Leisure activities
Assessment

Client History

Drug use
 Recreational (marijuana, cocaine, crack)
 Prescription





ACE inhibitors
Antihistamines
Bronchodilators
Chemotherapy
OTC



Allergy medications
Home remedies
Herbals: Elecampane, Hyssop, Mullein, Licorice
Assessment

Client History

Allergies
Foods, drugs, substances
 Allergic response?
 Treatment?


Diet history

BMI



Obese? Malnourished?
Body weight in pounds times 703 divided by
height in inches squared
Food intake related to breathing issues?
Assessment

Client History

Occupation and Home Life
Environmental factors and exposure
 Type of heat used in the home
 Animals or pets in home
 Hobbies involving chemicals
 Pest infestation at home or work


Tie to asthma, wheezing related to roaches
Assessment

Major signs and symptoms

Cough
Type, duration, length
 Sputum production



Color, consistency, amount
Dyspnea
Rate of perception
 ADLs
 Paroxysmal nocturnal dyspnea
 Orthopnea

Assessment

Major signs and symptoms





Chest pain
Wheezing
Clubbing of fingers / nails
Hemoptysis
Cyanosis
Gerontologic Considerations




Vital capacity and respiratory
muscle strength peak between 2025 and then decrease
Age 40 and older – surface area in
alveoli is reduced
Age 50 – alveoli loses elasticity
Loss of chest wall
mobility>decrease in vital capacity
Gerontologic Considerations


Amount of respiratory dead space
increases with age
Decreased diffusion capacity with
age – lower oxygen level in arterial
circulation
Risk Factors for Respiratory Disease


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Smoking
Personal / family history
Occupation
Allergens
Recreational exposure
Physical Assessment

Nose and Sinuses

External nose
Deformities, tumors
 Nostrils: symmetry of size, shape





Nasal flaring
Inspect for color, swelling, drainage, bleeding
Mucous membranes
Nasal septum

Bleeding, perforation, deviation
Physical Assessment

Air movement


Occlude one nare
Sinuses

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Via palpation
Tenderness, swelling
Tapping
Penlight
Frontal, maxillary
Physical Assessment

Pharnyx, Trachea, and Larynx

Posterior pharynx

Tongue depressor




One side at a time
Observe rise and fall of palate and uvula (ah)
Inspect for color, symmetry, discharge,
edema, ulceration, tonsillar enlargement
Neck

Inspect for symmetry, alignment, masses,
swelling, bruises, use of accessory neck
muscles in breathing
Physical Assessment

Neck

Lymph nodes
Tender, movable – inflammation
 Hard, fixed – suggest malignancy


Trachea

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Palpate for position, mobility,
tenderness, masses
Larynx

laryngoscope
Physical Assessment

Lungs and Thorax


Inspection
Palpation

Fremitus


99
Crepitus

Bubble wrap
Chest expansion
 Movement

Physical Assessment

Lungs and Thorax

Percussion

Pulmonary resonance



Air, fluid, solid masses
Intercostal spaces only
Diagphragmatic excursion
 Normal 1 -2 inches
 Deep breath / percuss
 No breath / percuss
 Normally higher on the right (liver)
Physical Assessment

Auscultation

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Upright first
Bare chest
Open mouth breathing
Full respiratory cycle
Observe for dizziness
Physical Assessment

Normal breath sounds
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
Bronchial, bronchovesicular, vesicular
Not heard peripherally
Adventitious breath sounds



Additional sounds superimposed on
normal sounds
Indicate pathology
Crackles, wheezes, rhonchi, pleural
friction rub
Physical Assessment

Voice sounds


Assessed when abnormalities noted
Increased when sound travels through
solid or liquid




Consolidation of lung, pneumonia,
atelectasis, pleural effusion, tumor,
abscess
Bronchophony: 99 – loud and clear
Whispered Pectriloquy: 1, 2, 3 – loud
Egophony – ‘E’ – heard as an ‘A’
Physical Assessment

Skin and Mucous Membranes


General Appearance



Pallor, cyanosis, nail beds
Muscle development, general body
build
Muscles of neck, chest
Endurance


How does the client move in 10 – 20
steps?
Speaking exertion
Diagnostic Assessment

Need to know:

Normal / abnormal for:
 RBC
 Hgb / Hct
 WBC / leukocytes / neutrophils
 Eosinophils
 Basophils
 Lymphocytes
 Monocytes
 ABGs
 Sputum studies
 Skin (PPD) testing
Diagnostic Testing
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Chest xrays
Digital Chest Radiography
CT
V/Q Scan
Pulse Oximetry
PFTs
Diagnostic Testing

Pulmonary Function Tests (PFTs)
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Used generally in chronic conditions
Assesses respiratory function
Determine extent of dysfunction
Measures lung volumes, ventilatory
function, and mechanics of breathing,
diffusion, and gas exchange
Assesses response to therapy
Screening test in hazardous industries
Diagnostic Testing

Arterial Blood Gases (ABGs)



Measures blood pH and arterial oxygen
and carbon dioxide levels
Assesses ability of lungs to provide
adequate oxygen and removal of
carbon dioxide
Assesses ability of kidneys to maintain
normal pH
Diagnostic Testing

Pulse Oximetry


Noninvasive method of monitoring
oxygen saturation of hemoglobin
Unreliable in cardiac arrest and shock,
dyes or vasoconstictor meds used,
severe anemia, or high carbon
monoxide level
Diagnostic Testing

Cultures


Throat or sputum
Sputum
Best to obtain early AM
 Rinse mouth, takes deep breaths, coughs,
and expectorates
 Deliver specimen to lab within 2 hours
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Diagnostic Examination

Endoscopy
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Thoracentesis

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Bronchoscopy, laryngoscopy, mediastinoscopy
Check for patent airway every 15 minutes post
procedure for two hours
Local anesthetic
Patient must remain still
Usually at bedside
Post procedure: CXR r/o mediastinal shift,
monitor VS, auscultate breath sounds
Lung biopsy
Diagnosis

Upper Airway Medical Diagnosis


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Rhinitis
Viral rhinitis
Acute sinusitis
Chronic sinusitis
Acute pharyngitis
Chronic pharyngitis
Tonsillitis and adenoiditis
Diagnosis

Upper Airway Medical Diagnosis


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Peritonsillar abscess
Laryngitis
Upper Airway Nursing Diagnosis


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Ineffective airway clearance
Acute pain
Impaired verbal communication
Fluid volume deficit
Knowledge deficit
Planning and Implementation

Upper airway



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Maintain patent airway
Promote comfort
Promote communication
Encourage fluid intake
Teach self care

Encourage appropriate hand washing
Planning and Implementation

Managing potential complications
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Sepsis
Sepsis
Meningitis
Otitis media
Evaluation


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Maintenance of patent airway
Reports feelings of comfort
Demonstrates ability to
communicate
Maintains adequate fluid intake
Identifies strategies to prevent
infections
Becomes free of s/sx of infection
Demonstrates adequate knowledge
Upper Airway Obstruction and Trauma

Medical Diagnosis

Sleep apnea
Obstructive
 Central
 Mixed

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
Epistaxis
Nasal Obstruction
Fractures of the nose
Laryngeal Obstruction
Laryngeal Carcinoma
Upper Airway Obstruction and Trauma
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Nursing Diagnosis
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Knowledge deficit
Anxiety
Ineffective airway clearance
Impaired verbal communication
Nutritional imbalance
Alteration in body image
Self care deficit
Sleep deprivation
Risk for injury
Fatigue
Planning and Implementation

Sleep apnea



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
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Avoid ETOH
Decrease body mass
CPAP
Uvulopalatopharyngoplasty
Tracheostomy
Pharmacologic Management
 Low flow O2
 Triptil
Education
Planning and Implementation

Epistaxis

Dependent on location of site

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Generally anterior
Pinch outer portion / sit upright
Silver nitrate / gelfoam / electrocautery
Topical vasoconstrictors
Monitor VS
Estimate amount of blood loss
Don’t forget standard precautions
Planning and Implementation

Nasal Obstruction


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Deviation of nasal septum
Submucous resection
Generally outpatient
Promote drainage
Alleviate discomfort
Frequent oral hygiene
Planning and Implementation
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Fractures of the nose
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Bleeding from site
Bruising
Clear fluid
 CSF
 Glucose positive
Surgical reduction ~ one week post injury
Ice therapy
Control anxiety
Oral hygiene
Planning and Implementation
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Laryngeal Obstruction



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
Often fatal
Acute laryngitis, urticaria, scarlet fever,
anaphylaxis, foreign bodies
Edema: SQ Epi 1:1,000 /
corticosteroid
Abdominal thrust (Heimlich)
Emergent tracheotomy
Planning and Implementation

Laryngeal Cancer




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
Risk factors: chart 22-5
Dependent upon tumor staging (chart
22-6)
Laryngectomy
Radiation
Speech therapy
Potential complications: respiratory
distress, hemorrhage, infection, wound
breakdown
Laryngeal Cancer
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Educate preoperatively
Reduce anxiety
Maintain patent airway
Encourage speech therapy
Maintain adequate nutrition
Promote positive body image
Teach self care
Evaluation
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Adequate level of knowledge
Lessened anxiety
Clear airway
Acquires effective communication
Appropriate intake
Positive self and body image
Complication free
Adheres to home therapy
Chest and Lower Respiratory Tract

Medical Diagnosis



Atelectasis
 Patho: figure 23-1
Acute tracheobronchitis
Pneumonia
 MUST know table 23-1 and charts 23-2, 23-3
 Review older adult considerations / risk
factors


Assess any older adult with AMS for pneumonia
May not have cough or fever
Nursing Diagnosis




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Ineffective airway clearance
Activity intolerance
Fluid volume deficit
Altered nutrition
Knowledge deficit
Impaired gas exchange
Pain
Fatigue
Planning and Implementation
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Avoid potential complications:
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Continuing symptoms
Shock
Respiratory failure
Atelectasis
Pleural effusion
Confusion
Superinfection
Planning and Implementation
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Improve airway patency
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Promote rest
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Hydration
Humidification
Oxygen therapy
CPT
Long recovery periods
Conserve energy
Promote fluid intake
Planning and Implementation
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Maintain adequate nutrition


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Determine caloric needs with RD help
Educate client
Teach self care
Evaluation

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Adequate airway patency
Optimal rest patterns
Maintains appropriate nutrition and
hydration status
Knowledgeable of disease and
treatment
Adheres to treatment strategies
Complication free
Inhalation Injury – Smoke and Carbon
Monoxide



Produce local injuries by
inflammation, irritation, and
damage to pulmonary tissues
Systemic injuries
S &S of CO poisoning


Mild – headache, visual disturbances,
irritability, nausea
Severe – confusion, hallucinations,
ataxia, coma
Therapeutic Management
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100% oxygen
Artificial ventilation
Hyberbaric chamber – more rapid
Tx of CO poisoning
Possible intubation
Steroids, antibiotics,
bronchodilators
Monitor rate and depth of
respirations at least every hour
Planning and Intervention
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VS assessment / monitoring
Respiratory assessment
Pulmonary physiotherapy
Mechanical ventilation
Psychological care of child and
parents
Pulmonary Tuberculosis


Risk factors (chart 23-4)
CDC recommendations (chart 23-5)

Classification of disease


0-5; class 3 – clinically active
Older adult
AMS, fever, anorexia
 Delayed reactivity or recall phenomenon
with PPD


Airborne precautions!!

Close the door!
Nursing Diagnosis




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Ineffective airway clearance
Knowledge deficit
Activity intolerance
Potential for treatment non adherence
Impaired gas exchange
Fatigue
Alteration in nutrition
Social isolation
Planning and Implementation

Medical Management



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
Drug resistance is major problem
Table 23-2 lists current recommended
first line drug therapy
Therapy lasts up to 12 months
HIV infection has increased prevalence
Drug therapy should be dispensed in
two week intervals
Planning and Implementation

Potential Complications



Malnutrition
Medication side effects
Drug resistance



Determine which clients should participate
in directly observed therapy (DOT)
Miliary TB
Decreased effectiveness with oral
contraceptives
Planning and Implementation





Promote airway clearance
Encourage patient adherence
Promote adequate nutrition
Encourage rest
Educate patient regarding routes of
transmission and disease manifestations


More people are infected than have active TB
Teach self care
Evaluation


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Maintain patent airway
Adequate level of knowledge
Adheres to treatment regimen
Participates in self care
Maintains optimal rest patterns
Complication free
Lung Abscess

Causative factors



Bacterial pneumonia
Oral aspiration / obstruction
Nursing Diagnosis



Airway clearance
Knowledge deficit
Alteration in nutrition
Planning and Implementation
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Administer AB therapy
Monitor for adverse effects
CPT
TCDB
Appropriate nutritional intake
Emotional support
Educate regarding self care
Pleural Condition Diagnoses

Medical Diagnosis


Pleural Conditions
 Pleurisy
 Pleural effusion
 Empyema
Nursing Diagnosis


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
Anxiety
Pain
Knowledge Deficit
Self Care Deficit
Alteration in Nutrition
Airway Clearance
Planning and Implementation

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
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
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Pleural friction rub, decreased
fremitus, absent breath sounds
Pain relief, comfort measures
TCDB
Thoracentesis
Implement medical regimen
Monitor chest tube drainage
Empyema – long healing process
Diagnosis

Pulmonary Edema





Life threatening
Generally, abnormal cardiac function
‘flash’ pulmonary edema post surgery
Crackles in bases, increasing throughout
Nursing Diagnosis


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Airway clearance
Cardiac function
anxiety
Planning and Implementation





Administer O2
Assist with ventilation as
appropriate
Medication administration
Monitor patient response
Educate and prepare patient and
family
Diagnosis

Acute Respiratory Failure




Difference between acute and chronic
Chronic: COPD / neuromuscular dx
Acute: VP mismatch, alveolar
hypoventilation, PaO2 < 50
Nursing Diagnosis

Similar to other airway constrictive
disease states
Planning and Implementation





Assist with intubation / mechanical
ventilation
Monitor response
Prevent complication
Enable communication
Educate family and patient
Diagnosis

Acute Respiratory Distress
Syndrome


Inflammatory trigger
Nursing Diagnosis


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
Airway clearance
Anxiety
Pain
Nutritional alterations
Planning and Implementation
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
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Close monitoring
Ventilator support
CPT
Frequent assessment
Education
Rest and comfort measures
Pulmonary Hypertension


Causes: Chart 23-7
Nursing Management



Identify high risk patients
Educate regarding s/sx
Oxygen therapy
Cor Pulmonale




Right ventricle enlargement
Generally, from COPD
S/ Sx generally r/t underlying
disease state
Treatment related to addressing
underlying disorder
Pulmonary Embolism




Risk factors: Chart 23-8
Home care: Chart 23-9
Diagnosis: CXR, ECG, V/P scan, ABGs
Nursing diagnosis



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Knowledge deficit
Anxiety
Airway clearance
Pain
Decreased cardiac output
Risk for injury (bleeding)
Planning and Intervention




Improve respiratory and vascular status
Anticoagulation therapy
Thrombolytic therapy
Surgical intervention




Rare
Minimizing risk most important step
Monitor therapy
Manage pain
Sarcoidosis




Hypersensitivity response
Biopsy required for diagnosis
Corticosteroid therapy
May involve other body systems
Occupational Lung Diseases

Medical Diagnosis






Silicosis
Coal workers’ pneumoconiosis
Asbestosis
Prevention is key
Educate clients to wear a mask
Consider also hobbies
Diagnosis



Lung and Chest Carcinoma: to be
covered in oncology section
Chest Trauma: to be covered
during trauma seminar
Aspiration: similar to pneumonia
and obstructive disorders


High risk in patients with altered LOC
Do not force feed clients!
Chronic Obstructive Pulmonary
Disease





Airflow limitation
Irreversible
Chronic bronchitis, emphysema
Risk factors: Chart 24-1
Three primary symptoms:



Cough
Sputum production
Dyspnea
Assessment

Spirometry – evaluation of airflow
obstruction






Ratio of FEV: FVC
Less than 70%
Health history overview: chart 24-2
Assessment: chart 24-3
Stages of COPD: table 24-1
Crackles
Nursing Diagnosis









Impaired gas exchange
Ineffective airway clearance
Ineffective breathing pattern
Activity intolerance
Knowledge deficit
Ineffective coping
Anxiety
Alteration in nutrition
Fatigue
Planning and Implementation

Potential complications:








Respiratory insufficiency
Chronic respiratory failure
Acute respiratory failure
Atelectasis
Pulmonary infection
Pneumonia
Pneumothorax
Pulmonary hypertension
Planning and Implementation


Promote smoking cessation
Improve gas exchange



Medication administration
Measure improve in flow rates
Airway clearance




CPT
Controlled coughing
Huff coughing
Increased fluids
Planning and Implementation

Improving breathing patterns






Inspiratory muscle training
Diaphragmatic breathing
Pursed lip breathing
Standing against wall
Over bedside table with pillows
Improving activity tolerance




Determine limitations
Determine client preferences
Pacing activities
Exercise training
Planning and Implementation

Self care strategies


Realistic goal setting
Heat / cold extremes
Heat increases oxygen demands
 Cold promotes bronchospasms




Lifestyle modification
Coping strategies
Self care teaching
Evaluation







Knowledgeable of smoking dangers
Improved gas exchange
Achieves maximal airway clearance
Improves breathing pattern
Demonstrates strategies for activity
tolerance and self care
Effective coping
Avoids complications
Bronchiectasis





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Separate from COPD now
Management similar to COPD
CPT
Smoking cessation
Postural drainage
Energy conservation measures
Asthma
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Chronic inflammatory disease
Sxs: cough, chest tightness, wheezing, dyspnea
Is reversible
Most common chronic disease of childhood
Predisposing factors:
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Allergens
Airway irritants
Exercise
Stress
Sinusitis
Medications
Viral respiratory tract infections
GERD
Asthma
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Nursing Diagnosis
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Anxiety
Airway clearance
Breathing patterns
Fluid volume deficit
Knowledge deficit
Assessment
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Health history
Comorbid conditions
Sputum cultures / serum samples
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Elevated levels of eosinophils
ABG / pulse ox
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Hypoxemia during attacks
Hypocapnia and respiratory alkalosis
PaCO2
 May rise initially
 Return to baseline indicative of impending
respiratory failure
Planning and Intervention
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Prevention is key
Pharmacology
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Long acting: corticosteroids, antiinflammatory agents
Quick relief: relief of acute symptoms,
bronchodilators
Table 24-4 details medications
Oxygen therapy is often indicated during acute
attacks
 Can be mixed with helium (Heliox) to improve
delivery to the alveoli
Planning and Intervention
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Peak flow monitoring
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Monitor respiratory status
Thorough history of allergens
Medication administration
Fluid administration
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Daily is recommended
Intake and output recording
Preparation for mechanical ventilation
Planning and Intervention
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Prevention of complications
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Status asthmaticus
Respiratory failure
Pneumonia
Atelectasis
Airway obstruction
Dehydration
Status Asthmaticus
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Attack that does not respond to
conventional therapy
Close monitoring first 12-24 hours
Volume status closely monitored
Energy conservation
No respiratory irritants
Nonallergenic pillow
Cystic Fibrosis
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<40% reach adulthood
Airflow obstructive disease with genetic
component
Elevated sweat chloride

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>60 mEq/L
Steatorrhea
Control of infections key
Nursing interventions similar to other
obstructive diseases
Lung transplantation – small number
End of life care important
Respiratory Procedures
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Inhalation therapy
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Oxygen therapy
Humidification
Aerosol therapy
Artificial ventilation
Continuous positive airway pressure
(C-PAP)
Oxygen Therapy
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Nasal cannula / mask / tent
Apply to anyone who is hypoxic or with
stridor
Considerations
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Avoid open flames and electrical appliances
Monitor response
Adverse effects to premature infant’s retina
Caution with COPD
Oxygen toxicity
Use humidification
Check skin integrity
Aerosol Therapy
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Used to deposit medications directly
into airways
Types
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Hand-held nebulizers
Metered-dose inhaler (MDI)
Spacer device
Close the door when administering
Chest Physiotherapy (CPT)

Postural drainage in conjunction
with adjunctive techniques

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Manual percussion, vibration,
squeezing the chest, cough, forceful
expiration, and breathing exercises
Considerations
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Percuss over rib cage
Used in increased sputum production
CPT
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Contraindications
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Pulmonary hemorrhage
Pulmonary embolus
ESRD
Increased intracranial pressure
Minimal cardiac reserves
Artificial Ventilation
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Nasotracheal
Orotracheal
Tracheostomy
Considerations

In children, tubes have more acute
angle and are softer to mold to
contours of trachea
Smoking Cessation
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Anyone who smokes is an increased
risk for pulmonary problems
Assist clients interested in smoking
cessation programs
Teach all clients who smoke the
warning signs of lung cancer
That’s All, Folks!
Any questions or comments?