6.1 Respiratory Part 1 Flashcards
1
Q
Respiratory ABC’s
A
A - Airway
B - Breathing
C - Circulation
Cannot have B without A, and cannot have C without B
2
Q
Oxygen Therapy
A
- Mainstay of initial treatment
- Advanced airways used as a last resort
- Medications used to reduce infection/inflammation
3
Q
Work of Breathing
A
- The amount of oxygen/energy consumption needed by respiratory muscles to produce enough ventilation/respiration to meet metabolic demands of the body
4
Q
Assessment
A
- Accessory Muscles to Breathe (Retractions)
- Skin color
- Nasal Flaring
- Pursed Lip Breathing
- Symmetrical Chest Expansion
- Ability to communicate in full sentences
VITALS - Pulse oximetry
- Breath sounds
- Full vitals
5
Q
Room Oxygen
A
- Room air is 21% oxygen
6
Q
Oxygen Therapy
A
- Administration of supplemental oxygen greater than 21%
- Decreases work of breathing
- Reduces myocardial stress
7
Q
Hypoxemia
A
- Decrease in arterial oxygen in the blood
8
Q
Hypoxia
A
- Decrease in oxygen supply to the tissue
- Can be caused by problems outside the respiratory system
9
Q
Causes of Hypoxemia
A
- Sepsis
- Fever
- Anemia
10
Q
Low Oxygen Delivery Systems
A
- Nasal Canula
- Simple Mask
- Partial Re-breather
- Non Re-breather
11
Q
High Flow Oxygen
A
- High flow nasal canula
- Venturi Mask
- Noninvasive Positive Pressure Vent (NPPV)
- BIPAP
- CPAP
12
Q
Nasal Canula
A
1 - 6 Liters per Minute
- Max 4 L/min with humidifier
- Maintain oxygen at >92% except for patients with COPD
13
Q
Fio2 (Nasal Canula)
A
- Fraction of Inspired Oxygen and Gas Mixture
Room Air = 21% Fio2 Additional 4% for each liter of oxygen delivered 1 L/min = 24% 2 L/min = 28% 3 L/min = 32% 4 L/min = 36% 5 L/min = 40% 6 L/min = 44%
14
Q
Nursing TIP (Nasal Canula)
A
- Constantly assessing and re-evaluating patient
- Data is gathered for oxygen via ABG’s, Pulse Oximeters, and Capnography (measures amount of exhaled carbon dioxide) - Usually around 35-45 mmHg
15
Q
Simple Mask
A
- Oxygen varies from 40-60%
- Minimum flowrate is 40% = 5 L/min
- 55-60% = 8 L/min
- Delivered temporarily after surgery while recovering or if there is rapid change in patients oxygenation
16
Q
Nursing TIP (Simple Mask)
A
- Assess for signs of respiratory distress
Use of accessory muscles, nasal flaring, prolonged capillary refill >3 seconds, reports of dyspnea or SOB
17
Q
Partial Re-breather
A
- 60-75% Fio2 = 6-11 L/min
- Used for patients with extremely low levels of oxygen
- Mask with reservoir bag
- Make sure bag is always inflated
- Educate patient on making sure to not kink the bag
18
Q
NURSING TIP (Partial Re-breather)
A
- Medical history will tell you what you need to look out for in patients
- A-fib can cause blood clots which may cause hypoxemia
19
Q
Non Re-breather
A
- 10-15 L/min
- Mask with reservoir bag and exhalation ports to prevent room air from entering
- Highest oxygen to be delivered from low oxygen delivery systems
20
Q
NURSING TIP (Non Re-breather)
A
- Oxygen greater than 50% for 24-48 hours can cause injury to the lungs
- Can cause crackles upon auscultation, cough and dyspnea
21
Q
High Flow Nasal Canula
A
- 30-60 L/min with combination of heat and humidity
- Decreases mucous membrane damage and better tolerated
- Used for a lot of COVID patients
22
Q
Nursing TIP (High Flow Nasal Canula)
A
- Humidifiers are a source of infection
- Be sure to change out humidifiers as per hospital policy
23
Q
Venturi Mask
A
- High flow oxygen Fio2 24-50%
- Each color valve can deliver a different flow of oxygen
Blue - 24% Fio2 - 3 L/min
Orange - 50% Fio2 - 15 L/min - Used for patients with “hypoxic drive”
- Includes COPD patients
24
Q
Noninvasive Positive Pressure Vent (NPPV)
A
- Also commonly used for patients with COPD, hypercarbia and acute asthma attack.
- Allows alveoli to open and prevent intubation
25
BiPAP-
- Bilevel Positive Airway Pressure
- 2 pressure settings allowing more air to get in and out
- Used for atelectasis post surgery
26
CPAP
- Goal is to expand collapsed alveoli
- Continuous positive airway pressure
- Specific setting that remains throughout the night. Patients may have difficulty exhaling due to constant positive pressure
- Common for OSA (Sleep Apnea)
- Used for Atelectasis post surgery
27
Oxygen Toxicity
- Lung damage from too much supplemental oxygen
- Occurs when oxygen levels greater than 50% is administered for an extended period of time
MANIFESTATIONS
- Substernal discomfort
- Dyspnea
- Progressive respiratory difficulty
- Fatigue
- Malaise
- Paresthesia
- Restlessness
- Alveolar Atelectasis
28
Oxygen Toxicity Management
- PREVENTION IS THE BEST MANAGEMENT
- Use lowest effective concentrations of oxygen
- Use of CPAP to prevent/reverse atelectasis
29
Upper Airway Obstruction
- Rapid assessment essential (inspection, palpation, auscultation)
- Call code team
- Airway is priority (emergency endotracheal intubation)
30
Endotracheal Intubation
- Passing endotracheal tube (ETT) through mouth or nose into trachea
- Provides patent airway
- Allows for mechanical ventilation and removal of secretions
31
After Intubation of Endotracheal Tube
- Check symmetry of chest expansion
- Auscultate chest sounds both anterior and posterior
- Obtain capnography as indicated
- X-ray to ensure proper tube placement
- Check cuff pressure every 6-8 hours
- Monitor for aspiration
- Ensure high humidity (should be able to see mist in T-piece)
- Administer O2 concentration as prescribed by provider
- Secure tube with tape (cut ends if longer than 3 inches to prevent kinking)
- Insert mouth device to prevent patient from biting the tube
- Use sterile suctioning to prevent infection
- Prevent atelectasis by repositioning patient every 2 hours
- Provide suction and oral hygiene as needed
32
Extubation (removal of ETT)
- Explain procedure
- Have self-inflating bag and mask ready incase ventilatory assistance is needed after extubation
- Suction tracheobronchial tree, remove tape, deflate cuff
- Give 100% oxygen for a few breaths and insert new sterile suction catheter inside
- Have patient inhale, and at peak inspiration, remove the tube and suctioning airway as being pulled out.
33
Post Extubation
- High Fowler position give heated/humidified face mask oxygen
- Monitor RR, chest excursion, stridor, color change, mental status
- Monitor O2 Saturation (pulse ox)
- Patient should be NPO (only ice chips)
- Provide oral hygiene
- Educate patient on deep breathing exercises
34
Endotracheal Tube Complications
D - Displacement of ETT
O - Obstruction of tube/airways
P - Pneumothorax (air in pleural spaces)
E - Equipment Failure
35
Tracheostomy
- Used with complete airway obstructions that cannot be passed by ETT
- May also be used for patients who have had a prolonged ETT
- Opening of airway directly into trachea
- Have extra trach tube and smaller size next to bed at all times
- Always have suctioning equipment ready to maintain patency
- Hyperoxygenation patients before suctioning
- Patient should be in semi-fowler position
36
Non Invasive Positive-Pressure Ventilation (NIPPV)
CPAP/BiPAP
- May eliminate need for ETT or tracheostomy
- Used during respiratory arrest, serious dysrhythmias, cognitive impairment, head/facial trauma
37
Nursing Process CPAP/BiPAP
38
Systemic Assessment of All Body Systems
- Vitals
- Oxygen status
- Secretions
- Neurological Status
- Coping/Emotional Needs
- Comfort Level
- Ability to communicate
39
Equipment Assessment
- Collaborate with Respiratory Therapist (RT)
- Device Settings
- Evaluation of Alarms
- Check tubes, oxygen source, and seal of mask on patient
40
Goals
- Maintain patent airways and gas exchange
- Absence of trauma/infection
- Attain optimal mobility
- Adjustment to non-verbal methods of communication
- Successful coping measures
41
Nursing Diagnosis
- Impaired gas exchange
- Ineffective airway clearance
- Risk for trauma
- Impaired physical mobility
- Impaired verbal communication
- Defensive coping
- Powerlessness
- Anxiety related to CPAP, BiPAP, Hypoxia
42
Collaborative Problems
- Requires working with RT
- Alteration in cardiac function
- Barotrauma from high pressure oxygen delivery (injury from air pressure)
- Pulmonary infection
- Sepsis
- Delirium
43
NURSING INTERVENTIONS
44
Enhancing Gas Exchange
- Good use of analgesics without suppressing respiratory drive
(Especially important for surgical patients)
- Frequent repositioning to diminish effects of immobility
- Monitor fluid balance by assessing peripheral edema, I&O, daily weights
- Administer medication to control primary disease
45
Chest Physiotherapy (CPT)
- Postural drainage (drainage of lung secretions via gravity)
- Chest percussion/vibration
- Breathing retraining
GOALS
- Remove secretions
- Improve ventilation
- Increase efficacy of respiratory muscles
46
Chest Physiotherapy (CPT)
- Uses gravity to remove bronchial secretions and then suctioning
- High-frequency chest wall oscillation with a vest can be used instead of percussion and vibration
47
Effective Airway Clearance
- Assess lung sounds every 2-4 hours
- Clear airways (suctioning)
- CPT
- Position changes
- Promoting mobility
- Provide humidification of airway
- Administer medications
48
Trauma and Infection
- Tube care
- Cuff management
- Scrupulous oral care
- Elevation of HOB
49
Other Interventions
- Range of motion and mobility
- Communication methods
- Stress reduction techniques
- Promote coping for patient
- Include family teachings
- Monitor complications
50
Thoracic Surgery
51
Pre-Op Management
- Verify assessment/diagnosis
- Preform incentive spirometry education
- Relieve anxiety
- Witness/verify informed consent
- Implement NPO
- Administer antibiotics on call to OR
52
Post-Op Management
- Monitor VS/Cardio/Respiratory status
- Utilize oxygen as needed
- Position to protect airway
- Promote mobility
- Maintain fluid volume and nutrition
- Monitor and maintain chest drainage systems
53
Patient Education
- Signs and symptoms to report
- Use of home respiratory treatments
- Importance of progressive activity
- Instructions on shoulder exercises
54
Upper Respiratory Infection (URI)
- Most common reason for seeking healthcare
- Rhinitis/Rhinosinusitis/Pharyngitis/Tonsilitis/Adenoiditis/Laryngitis
- Early detection and interventions help avoid unnecessary complications
- Education based on prevention and health promotion (influenza/pneumonia vaccine)
55
URI in Older Adults
- Serious consequences with concurrent medical problems
- Influenza can exacerbate COPD
- Nose structure with aging may restrict airflow and predispose for geriatric rhinitis (watery drainage)
- Laryngitis is common in older adults
- Antihistamines and decongestants should be used with caution in older adults due to potential interactions with other medications
56
URI Complications
- Airway obstruction
- Hemorrhage
- Sepsis
- Meningitis (inflammation of membranes covering brain/spinal cord due to infection)
- Nuchal Rigidity (neck stiffness)
- Medicamentosa (nasal congestion from extended use of topical decongestants)
- Trismus (inflammation of chewing muscle of jaw)
- Dysphagia
- Aphonia (damage to mouth causing loss of ability to speak)
57
Health History
```
O - Onset
L - Location
D - Duration
C - Characteristics
A - Aggravating Factors
R - Relieving Factors
T - Timing
S - Severity
```
- Also ask about cough/sputum
- Recent travel
- Vaccine status
- Signs and symptoms
- Inspection of nose/neck/throat/lymph nodes
58
Nursing Interventions
- Elevate Head
- Ice collar to reduce inflammation
- Hot pack to reduce congestion
- Analgesics/Antibiotics
- Gargles for sore throat
- Pharyngitis - Needs new toothbrush after 24-48 hours after starting antibiotics
- Alternative communication
- 2-3L of liquid a day
- Soft bland diet
- Rest
59
Patient Education
- Prevention (hand hygiene)
- When to contact healthcare provider
- Need to complete full antibiotic regime
- Annual flu shot
- Pneumococcal vaccine for 65+ and high risk patients (smokers, lung pathologies)
- Discuss smoking cessations
60
Pseudoephedrine (Sudafed)
- Decongestant
- Acts on adrenergic receptors to release norepinephrine. This leads to vasoconstriction which shrinks nasal mucosa membranes causing less congestion.
USES
- Nasal decongestion for cold, allergies, sinuses
CAUTION
- Kidney/Liver abnormalities
- Coronary Artery Disease (CAD)
- HTN
SIDE EFFECTS
- HTN
- Nervousness
- CNS Stimulation
- Insomnia
- Tremors
- Urine Retention
- Increased HR
MONITOR
- BP and HR
EDUCATION
- Monitor BP for HTN and only use as directed
61
Dextromethorphan (Delsym)
- Antitussives (non-opioid)
- Depresses cough center in medulla oblongata (goes through first pass metabolism)
USES
- Dry, nonproductive cough
CAUTION
- Atopic syndrome caused by histamine releases
- Hallucinations if taken too much
SIDE EFFECTS
- Drowsiness/Nausea
- Rash
- Difficulty Breathing
Monitor
- Drug interactions, mental status, St. John Wort interactions
Education
- 30 minutes before meals
62
Codeine
- Antitussives (opioid)
- Suppresses cough and often mixed with antihistamines and expectorants
CAUTION
- History of drug dependance
- Respiratory pathologies
- Seizure disorders
- Hepatic Impairment
- GI disorders
- Increased intracranial pressure
SIDE EFFECTS
- Respiratory depression
- Constipation
- Pruritis
- Drug Dependance
MONITOR
- Respiratory Status
63
Guaifenesin (Robitussin/Mucinex)
- Reduces viscosity of secretions. (Increased volume decreased viscosity)
- Helps expel more secretions when coughing
SIDE EFFECTS
- Rash
MONITOR
- Discontinue if it does not help patient
EDUCATION
- Increase PO fluids to help further loosen mucus
64
Obstructive Sleep Apnea
- Disorder where upper airway gets partially or completely blocked in sleep
- Seen more in obese patients and older patients
- Results in apnea, hypoxia, and sleep disturbances
- Hypoxic periods affect BP and HR
MANIFESTATIONS
- Insomnia, Snoring, Awake At Night, Intellectual deterioration, pulmonary hypertension, cor pulmonale (heart failure), enuresis (involuntary urination), polycythemia (blood cancer)
DIAGNOSIS
- Monitor sleep
Treatment
- CPAP, BiPAP, oxygen therapy, potential surgery
65
Epitaxis
- Hemorrhage from the nose in the anterior septum. May result in airway compromise and significant blood loss
RISK FACTORS
- Infection, drying mucosa, trauma, HTN, arteriosclerosis, aspirin use, nose-picking, tumor, thrombocytopenia, liver disease
NURSING MANAGEMENT
- ABC's, Vitals, Cardiac monitoring and pulse ox, reduce anxiety, pinch soft portion of nose for 5-10 minutes
INTERVENTIONS
- Phenylephrine spray for vasoconstriction, cauterizing with silver nitrate, gauze packing, balloon-inflated catheter inserted into nasal cavity for 3-4 days, antibiotics
TEACHING
- Avoid nasal trauma, nose picking, forceful blowing, spicy foods, tobacco, exercise
- humidify to prevent dryness, pinch nose to stop bleeding, if bleeding does not stop in 15 minutes seek medical attention
66
Cancer of the Larynx
- Most common in men, and patients over age 65
RISKS
- Gender, Age, Tobacco, Alcohol, African Americans, poor nutrition, Human Papillomavirus, Genetic syndromes, workplace exposures to wood dust, paint fumes, chemicals
MANIFESTATIONS
- Early signs include hoarseness, persistent cough, sore throat, raspy voice, lump in neck
- Late signs include dysphagia, dyspnea, nasal obstruction, ulcerations, foul breath,
DIAGNOSTIC
- Biopsy, barium swallow test, endoscopy, CT, MRI, PET scan, tumor grade and stage
MANAGEMENT
Stage 1&2 - Radiation therapy, cordectomy, endoscopic laser excision, partial laryngectomy
STAGE 3&4 - Radiation therapy, chemotherapy, chemoradiation, total laryngectomy
67
Cancer of Larynx Nursing Process
Assessment - nutrition, bmi, albumin, glucose, electrolytes,
POST OP CARE
- reduce anxiety, maintain patent airways, control secretions, alternate communication, adequate nutrition, self esteem and self care
COMPLICATIONS
- Respiratory distress, hemorrhage, infection, wound breakdown, aspiration, tracheostomas stenosis
68
Atelectasis
- Collapse of alveoli.
- Most often occurs in post-op setting
- Increased work of breathing and hypoxemia
69
Atelectasis manifestations
```
- Dyspnea, cough, sputum production
ACUTE
- Tachycardia
- Tachypnea
- Pleural Pain
- Central cyanosis
```
70
DIAGNOSIS ATELECTASIS
- Crackles in lungs (resolved with deep breathing)
- Chest X-ray
- Pulse ox less than 90%
71
Prevention of Atelectasis
- Frequent turning
- Mobilization
- Incentive spirometry
- Deep breathing
- Secretion management
- Metered dose inhaler and nebulizer
72
Interventions Atelectasis
- Improve ventilation
- Remove secretions through first line defenses including
- Incentive spirometry
- Frequent turning
- Early ambulation
- Lung volume expansion maneuvars
73
I-COUGH (Prevention of post-op pulmonary complications)
I - Incentive Spirometry (10 times an hour)
C - Cough/Deep Breathe
O - Oral Care (prevent germs)
U - Understanding Education
G - Get out of Bed (helps lungs/circulation)
H - Head of Bed Elevated (30-45 degrees)
