Transcript Respiratory - Faculty Sites - Metropolitan Community College

Metropolitan Community College
Fall 2013
Jane Miller, RN MSN
Objectives
 Identify patients at risk for pulmonary embolism (PE)
 Identify clinical manifestations of pulmonary embolism
 Identify diagnostic tools for determination of pulmonary
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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)
 Identify clinical manifestations, diagnostic assessment, and
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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
Pulmonary System
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
Adventitious Breath Sounds
 Crackles (Rales)
 Caused by fluid, inflammation, infection, or secretions
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Pneumonia, bronchitis, CHF, pulmonary edema, fibrosis
 Fine or course “popping” sound, nonmusical,
discontinuous
 Lounder during inspiration
 Wheezes (Rhonchi)
 Caused by narrowing of the airway
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Bronchospasm, secretions, airway inflammation
 High-pitched musical sound, continuous
 Heard during inspiration and expiration equally
 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
Assessment
 Patient interview
 Complaint, symptoms, previous illness &
hospitalizations, medications, allergies
 Physical exam
 General appearance
 Mentation
 Rate, depth, and rhythm of respirations
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Kussmaul’s: increased rate and depth
Cheyne-Stokes: rapid breathing then apnea
 Thoracic size, shape, & expansion
 Skill color, temperature, moisture
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
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
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
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
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
Airway Obstruction
 Potentially a life threatening emergency
 Causes
 Inhalation burns
 Infection
 Allergic response
 Laryngeal trauma
 Tumor
 Aspiration
 Assess for stridor
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
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
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 obturator is kept at bedside to assist in reinserting
the tube if it comes out.
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
Assessing a New Trach Tube
 Auscultate the lungs
 Monitoring O2 sats
 Amount of blood in the sputum and around
site
 Crepitis around the neck
 Respiratory distress
 Patency of tracheal tube
 Postoperative pulmonary edema (POPE)
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
 Trach cares 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
Lower Airway Disorders
 Pneumonia
 Tuberculosis
 Lung abcess
 Emphysema
 Pulmonary embolism
 Acute respiratory failure
 Pulmonary edema
 Acute respiratory distress syndrome
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
Pneumonia
 Causes
 Bacteria
 Viruses
 Fungi
 Protozoa
 Parasites
 Radiation therapy
 Aspiration
 Inhalation of toxic gases or chemicals
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
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
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
Nursing Management
 Administer antibiotics
 Fluoroquinolones - recommended
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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
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
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
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
Diagnosis
 Mantoux tuberculin skin test
 Chest x-ray
 Acid-fast bacillus smear
 Sputum culture
Nursing Management
 Administer drug therapy as ordered by health care
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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
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
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
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Diagnosis
 Sputum culture
 Bronchoscopy
 Pleural or blood cultures
 CT scan
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
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
Diagnosis
 ABGs
 CBC
 X-ray
 CT scan
 Pulmonary function test
Nursing Management
 Administer supplemental oxygen
 Monitor ABGs
 Support and anxiety reduction
 Provide time for rest
 Education
 Smoking cessation
 Safe use of oxygen
 Infection prevention
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
Risk Factors
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Most common – prior history of DVT or PE
Recent surgery
Pregnancy
Prolonged immbolization
Long trips in airplanes, trains and cars
Oral contraceptives
Pelvic, Hip or femur fractures
Trauma
Burns
Central venous catheters
Genetic conditions causing increased clotting
Four Types
1. Massive occlusion of the pulmonary
circulation
2. Infarction of a portion of lung tissue
3. Embolus without infarction
4. Multiple pulmonary emboli that are
chronic or recurrent
Clinical Manifestations
 Depend on the size, location, and amount of
obstruction
 Classic triad: hemoptysis, dyspnea, chest pain
 Occurs in < 20% of patients
 May be asymptomatic
 Massive PE
 Typically presents with sudden crushing substernal
chest pain, shock, loss of consciousness
 Usually fatal
 May also present with tachypnea, crackles, tachycardia,
diaphoresis, cyanosis
Diagnosis
 Difficult because many diagnostic test used to evaluate
lung function may come back normal
 ABG, Pulse oximetry, CBC
 only abnormal is some cases
 Chest x-ray
 Normal initially, 24-72 hours may show infiltrates
 D-Dimer test
 >500 mg/L shows the body is trying to break down clots
 Pulmonary angiogram
 Provides 100% certainty that an obstruction exists
 Spiral CT
Nursing Management
 Prevention
 Evaluate risk factors on admission and during
hospitalization
 Range of motion, ambulation, leg compression devices
 Administer anticoagulant medication - heparin
drip until coumadin started and PT/INR is
therapeutic
 Administer oxygen
 Monitor labs for anticoagulant effectiveness
 Assess for symptoms of bleeding
Acute Respiratory Failure
 Lungs cannot meet the physiological needs of the
body due to failure of heart, lungs or both
 Hallmark of ARF is respiratory difficulty with
abnormal ABG’s
 3 categories
 Hypoxemic (failure of oxygenation)
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Low O2 in blood
 Hypercapneic (failure of ventilation)
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high CO2 in blood
 Failure of the respiratory centers in the CNS
Chart 36-2
Pg. 1007
Clinical Manifestations
 Dyspnea
 Hypoxemia
 Tachypnea
 Adventitious lung sounds
 Productive cough
 Agitated
 Tachycardia
Chart 36-3
Pg. 1007
Causes
 Acute lung injury
 Pneumothorax
 Oversedation
 Obesity
 Diaphragmatic fatigue
 Cervical spinal cord injury
 Guillain-Barre syndrome
Diagnosis
 ABGs
 Won’t see any compensation because the
kidneys have not had time to compensate for the
altered pH
 Chest x-ray
 Assists in identifying the primary disorder
 Treatment is aimed at fixing the hypoxemia
and treating the underlying cause
Acute Pulmonary Edema
 Abnormal accumulation of fluid in the lungs
 Caused by dysfunction of the heart, lungs, or both
 Lungs have no time to compensate
 Cardiogenic
 Increased hydrostatic pressure in the capillary bed
secondary to increased pulmonary venous pressure due
to heart failure
 MI, hypertension, pericarditis, cardiac tamponade
 Noncardiogenic
 Injury of the alveolar-capillary membrane
 Pneumonia, drowning, acute lung injury, ARDS
Clinical Manifestations
 Dyspnea
 Crackles
 Wheezes
 Central cyanosis
 Cough with pink frothy sputum
 Cardiogenic
 Tachycardia, hypotension, and cool diaphoretic skin
 Noncardiogenic
 Tachycardia, hypertension, bounding pulses, and dry
skin
Nursing Management
 Administer oxygen
 Prepare for intubation
 Administer diuretic such as lasix
 Emotional support
 Cardiogenic
 Morphine to decrease venous return
 Nitroglycerin to decrease preload
ARDS
 Acute Respiratory Distress Syndrome
 Progressive form of respiratory failure where there is
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alveolar capillary inflammation and damage
Buildup of fluid in the alveoli which prevents oxygen
from passing into the bloodstream.
Makes the lungs heavy and stiff
Hypoxia despite mechanical ventilation
Often occurs along with the failure of other organ
systems, such as the liver or kidneys = MODS
Mortality = 40%
Risk Factors
 Almost any disease process that generates large-scale
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inflammation and injury can cause ARDS
Sepsis
Organ transplantation
HIV infection
Active malignancy
More on Pg. 1015
Mechanical ventilation
Alcoholism
Lung injury
Clinical Manifestations
 Early sign is hyperventilation with respiratory
alkalosis
 As hypoxemia increases
 Dyspnea, tachypnea, use of accessory muscles, cyanosis,
crackles, wheezes, may have pink frothy sputum
 Eventually the patient will require intubation and
ventilation
 Late findings
 Hypotension and decreased cardiac output
 Diagnosis: ABGs, sputum culture, chest x-ray
Nursing Management
 Treatment is aimed at the underlying cause
 Administration of oxygen
 Preparation for intubation
 Careful fluid restriction
 Limit lung edema while preventing hypotension and
renal failure
 Administer vasopressors ex: dopamine
 Nutrition
 Preoxygenate before activity
 Care for intubated patients
Endotracheal Intubation
 Indications
 Inadequate oxygenation or ventilation
 Airway protection
 Surgery
 Oral endotracheal intubation
 Tube placed through mouth
 Passes through the vocal cords into the trachea
 Cuff helps to prevent secretions from being aspirated
and prevents air from escaping before ventilating the
lungs
Mechanical Ventilation
 Most ventilators are positive pressure ventilators
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because they provide increased pressure on inspiration
Monitors rates, pressures, and volumes and delivers set
volumes and/or pressures during the inspiratory cycle
Goal is to decrease the work of breathing for the
patient
If the ventilator does all the work it is a mandatory
breath
If the ventilator provides support during inspiration or
expiration it’s an assisted breath
Modes
 Assist control (CMV)
 The patient can trigger a breath or the breath can be
time triggered
 Preset volume or pressure is delivered each time
 Synchronized intermittent mandatory ventilation
(SIMV)
 Set rate where a set volume or pressure is delivered
 The patient can breath between the set rate and receive
the volume from their effort
 Most common mode
 Pressure support
 Patient must have a reliable respiratory effort
 No set rate or tidal volume delivered
 When patient inspires it delivers a set pressure
to assist the inspiration
 Often used in combination with SIMV
 Pressure-controlled
 Full control mode with set rate and pressure
 Tidal volume varies from breath to breath
 Used for patients who have restrictive disease
such as ARDS
 Positive end-expiratory pressure (PEEP)
 Not a mode but rather a ventilator setting
 Prevents the pressure of the circuit from
returning to zero at the end of expiration
 Prevents alveoli from collapsing and not
opening again
 Usually set at 5 cm of H2O
Nursing Management
 Assessment
 How they are breathing
 Assess the tube for size and depth
 Position of head
 How is the tube secured
 Leak around the cuff
 Oral assessment
 Amount and color or secretions
 LOC & agitation
 Head to toe assessment
 Listen to their lungs
 Have an ambu bag at the bedside
 Provide nutrition
 Enteral preferred but may need parental
 Provide for communication
 Oral care
 Turning q 2hrs, especially the head
 Ensure adequate rest
 Provide emotional support
Weaning
 As soon as the patient is put on mechanical
ventilation the nurse should start planning
for weaning
 No “best practice” identified
 Many tools available for evaluation
 One method is to put the client on a t-piece
with oxygen or 1 hour. If tolerating after 1
hour extubate
References
 Osborn, Wraa, & Watson chapters 33, 34, 35, & 36
 Pack years calculator
http://smokingpackyears.com/calculate
 Lung sounds
http://www.easyauscultation.com/lung-sounds.aspx