AH2 Respiratory Flashcards
1
Q
The nurse assesses a client with a closed chest tube drainage system that is cracked. What should the nurse do?
A
Disconnect chest tube from the system and submerge the chest tube in a bottle of sterile saline in order to maintain the water seal. The system will then need to be replaced. A clamp should be kept at bedside in case the system needs to be changed. A nurse should NEVER clamp a chest tube without a written prescription from the HCP. The drainage system (chest tube and bottle of sterile water) should be kept below the level of the chest if this complication occurs.
2
Q
what are NG tubes used for?
A
to intubate the stomach; removes fluids or gas to decompress stomach and promote comfort. alls surgical anastomoses to heal without distension; decrease risk of aspiration, administer meds to clients who cant swallow. to irrigate the stomach and remove toxic substances such as poison
3
Q
A single lumen tube used to remove gastric contents via intermittent suction or to provide tube feedings
A
Levin tube
4
Q
a double lumen NG tube with an air vent (pig tail) used for decompression with intermittent continuous suction
A
Salem Sump Tube
5
Q
What is important to remember about the air vent in a Salem Sump Tube?
A
it should not be clamped and keep it above the level of the stomach. If leakage occurs through the air vent, instill 30 mL of air into the air vent and irrigate the main lumen with NS
6
Q
When do you check residual volumes in an intubated patient?
A
q4h, before each feeding, and before giving meds
7
Q
What amount of residual indicates you should hold the feeding?
A
more than 100mL due to increased risk for aspiration with levels above 100mL
8
Q
What do you do before instilling anything through an NG tube?
A
aspirate stomach contents and test stomach pH (a pH of 3.5 or lower indicates that the tip of the tube is in a gastric location)
9
Q
How often do you change the sterile dressing of surgically placed gastrostomy or jejunostomy tubes?
A
q8h
10
Q
How often do you irrigate an NG tube?
A
q4h to assess and maintain patency of the tube
gently instill 30-50mL of water or NS with an irrigation syringe
11
Q
What is the purpose of a cyclical feeding?
A
cyclical feeding is administered in the daytime or nighttime for approx 8-16 hours using an infusion pump. Feedings at night allow for more freedom during the day
12
Q
What about bowel sounds and tube feeding?
A
hold feeding and notify HCP if no BS
13
Q
If a client is comatose, how do you position them for a tube feeding?
A
high fowlers on right side
14
Q
What position is a client in for continuous feeding?
A
semi-fowlers at all times
15
Q
How often do you change the feeding container and tubing?
A
q24h
16
Q
Do not hang more solution than required for what time period in order to reduce bacterial growth opportunity?
A
4hours
17
Q
What do you do after administering a tube feeding?
A
flush tube with 30-50mL of water or NS using an irrigation syringe after a feeding
18
Q
Cantor tube
A
single lumen intestinal tube
19
Q
miller-abbott tube
A
double lumen intestinal tube
20
Q
How do you remove an intestinal tube?
A
the tungsten weight is removed from the balloon portion of the tube with a syringe and the tube is gradually (6”qh) as prescribed by HCP
21
Q
a triple lumen gastric tube with an inflatable esophageal balloon (compresses esophageal varices), an inflatable gastric balloon (applies pressure at the cardioesophageal junction), and a gastric aspiration lumen. A NG tube is also inserted in the opposite naris to collect secretions that accumulate above the esophageal balloon
A
Sengstaken-Blakemore tube
22
Q
a four lumen gastric tube for aspirating esophagopharyngeal secretions
A
minnesota tube
23
Q
What special consideration do you need to make with a minnesota gastric tube?
A
keep scissors at the bedside at all times and monitor pt for respiratory distress-if this occurs, cut the tubes to deflate the balloons
24
Q
How do you prevent ulceration or necrosis of the esophaguss
A
release esophageal pressure at intervals as prescribed or by agency policy
25
Signs of esophageal rupture
decreased BP
increase HR
back and upper ab pain
this is an emergency-notify HCP immediately
26
What is the purpose of an endotracheal tube?
to maintain a patent airway and is indicated when a patient needs a mechanical airway
27
when is a tracheostomy performed?
when a client needs are artificial airway for longer than 10-14 days; a tracheostomy will prevent potential damage to the mucosal and vocal cords that can be cause by an endotracheal tube
28
What is proper placement on an xray of a respiratory system tube (orotracheal tube or nasotracheal tube)?
1-2 cm above the carina; assess placement by auscultating both sides of the chest while manually ventilating with a resuscitation bag; auscultate the stomach to rule out esophageal intubation-if tube is in the stomach, louder breath sounds will be heard over the stomach than over the chest and abdominal distention will be present
29
What special considerations must be made with an oral tube?
move the tube to the opposite side of the mouth with two HCP present daily to avoid necrosis of the lip and mouth area
30
How often do you monitor cuff pressures of trach tubes
q8h and ensure the pressure does not exceed 20 mm Hg to prevent injury or dip below 15 mm Hg to prevent aspiration
31
In a patient with a tracheostomy, what might bleeding, dyspnea, absence of breath sounds, and crepitus (subcutaneous emphysema) indicate?
hemorrhage or pneumothorax
32
What needs to always be available at bedside for a client with a tracheostomy?
ambu bag, obturator, clamps, and a spare tracheostomy tube, suction
33
Constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage
manifestations:
increased amt of air is required in the cuff to maintain a seal
a larger trach is required to prevent air leak at the stoma
food particles are seen in tracheal secretions
client does not receive the set tideal volume on the ventilaor
tracheomalacia
34
Narrowed tracheal lume is the resutl of scar formation from irritation of tracheal mucosa by the cuff manifested after the cuff is deflated or the trach tube is removed and the client has increased coughing, inability to expectorate secretions, or dyspnea
tracheal stenosis
35
excessive cuff pressure causes erosion of the posterior wall of the trachea. A hole is created between the trachea and the anterior esophagus. The client at highest risk also has a NG tube. manifestations are similar to a tracheomalaciaL food particles are seen in tracheal secretions, increaes air if cuff is needed to achieve a seal, clients coughs and may choke when eating, client does not receive set tidal volume on the ventilator
tracheoesophageal fistula
36
THis is a medical emergency; a malpositioned tube causes its distal tip to push against the lateral wall of the trachea. Continued pressure causes necrosis and erosion of the innominate artery. Manifestations: trach tube pulsates in synchrony with the heartbeat and there is heavy bleeding at the stoma.
trachea-innominate artery fistula
37
What do you do if a patient develops a trachea-innominate artery fistula?
remove trach tube immediately, apply direct pressure to the innominate artery at the stoma site and prepare the client for immediate repair surgery. To prevent, always use correct tube size and length, maintain the tube in midline position, prevent pulling or tugging of the tube, and immediately notify HCP of a pulsating tube
38
What does excessive bubbling in the water seal chamber of a chest tube drainage system indicate?
an air leak in the chest tube drainage system; notify HCP
39
what does gentle bubbling in the suction control chamber of a chest tube drainage system indicate?
that there is suction and does NOT indicate that there is air escaping from the pleural space; vigorous bubbling in the suction control chamber is worrisome
40
When do you notify HCP with regard to chest tube drainage system?
when drainage is more than 100 mL/hr or if drainage becomes bright red or increases suddenly
41
Why might flucuation of the water seal chamber stop?
if tube is obstructed, a dependent loop exists, suction is not working properly, or the lung has reexpanded
42
What must be kept at bedside for a patient with a chest tube drainage system?
clamp and a sterile occlusive dressing
43
What instruction do you give a client when removing a chest tube?
perform valsalva maneuver (deep breath, exhale, bear down); the tube is quickly withdrawn, and an air tight dressing is taped in place. Client may also take a deep breath and hold it while the tube is removed.
44
indicates airway edema and places the client at risk for airway obstruction
stridor-call HCP (high pitched, coarse sound heard with the stethoscope over the trachea)
45
What are three numbers to know regarding pulse ox?
less than 91% call HCP
less than 85% oxygenation of the tissues is compromised
less than 70% is life-threatening
46
client instructions for IS
inhale slowly to raise and maintain the flow rate indicator between the 600 and 900 marks. hold breath for 5 seconds and then exhale through pursed lips
47
causes of high pressure ventilator alarms
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increased secretions are in the airway
wheezing or bronchospasm is causing decreased airway size
the tube is displaced
tube is obstructed by water or a kink
client fights ventilator
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48
causes of low pressure ventilator alarms
disconnection or leak in the ventilator or in the client's aircuff occurs
the client stops spontaneous breathing
49
positive pressure complications
hypotension, pneumothorax, crepitus
50
paradoxical respirations
flail chest
| prepare for intubation with PEEP
51
what is the major complication of pulmonary contusion?
ARDS
52
accumulation of atmospheric air in the pleural space, which results in a rise in intrathoracic pressure and reduced vital capacity; leads to collapsed lung; breath sounds are absent on affected side; decreased chest expansion unilaterally; crepitus; sucking sound with an open chest wound
pneumothorax
53
tracheal deviation to the unaffected side
tension pneumothorax
54
interventions for pneumothorax
apply a nonporous dressing over an open chest wound
administer oxygen
Fowlers
prepare for chest tube placement
55
causes include sepsis, fluid overload, shock, trauma, neurological injuries, burns, DIC, drug ingestion, aspiration, and inhalation of toxic substances
ARDS
56
hypoxemia despite high concentrations of delivered oxygen; pulmonary infiltrates
ARDS
57
How do you diagnose pneumonia?
sputum culture
| WBC and ESR are elevated too
58
the collection of fluid in the pleural space
pleural effusion; prepare client for thoracentesis
59
surgically stripping the parietal pleura away from the visceral pleura to produce an intense inflammatory reaction that promotes adhesion formation between the two layers during healing
Pleurectomy: treatment for recurrent pleural effusion
60
instillation of a sclerosing substance into the pleural space via a thoracotomy tube to create an inflammatory response that scleroses tissue together
pleurodesis: treatment for recurrent pleural effusion
61
collection of pus within the pleural cavity; most commonly caused by pulmonary infection and lung abscess caused by thoracic surgery or chest trauma, in which bacteria are introduced directly into the pleural space
empyema
62
inflammation of the visceral and parietal membranes so that they rub together during respiration and cause pain; may be caused by pulmonary infarction or pneumonia
pleurisy
63
less than 200 mm Hg indicates ARDS; normal is greater than 300 mm Hg
PaO2/FiO2
64
What instruction do you give a patient with pleurisy?
lie on AFFECTED side to splint the chest
65
occurs when a thrombus forms (most commonly in a deep vein), detaches, travels to the right side of the heart, and then lodges in a branch of the pulmonary artery
pulmonary embolism
66
risk factors for pulmonary embolism
those at risk for DVT: prolonged immobilization, surgery, obesity, pregnancy, heart failure, advanced age, or a history of thromoboembolism
67
apprehension and restlessness, blood-tinged sputum, chest pain, cough, crackles and wheezes on auscultation, cyanosis, distended neck veins, dyspnea with anginal and pleuritic pain that is exacerbated by inspiration; feeling of impending doom, hypotension, petechiae over the chest and axilla, shallow respirations, tachypnea and tachycardia
assessment findings: pulmonary embolism
68
how long must someone be on meds before risk of transmitting TB is reduced greatly?
2-3 weeks of TB meds; but overall therapy lasts 6-12 months; when three sputum cultures are negative, patient is no longer infectious (cultures are taken every 2-4 weeks once meds have been started)
69
What's the relationship between the bacille Calmette-Guerin vaccine and TB?
patients who have had a bacille Calmette-Guerin vaccine will have a positive TB skin test result and should be evaluation for TB with a chest x-ray
70
What does a chest x-ray show if a patient has TB?
a chest x-ray is not a conclusive diagnosis of TB, but it will show multinodular infiltrates with calcification in the upper lobes
71
mechanical ventilation strategies for ARDS patient
PEEP
low tidal volume (bc lungs are noncompliant and too much volume might pop the lungs)
lower levels of oxygen (maintain respiratory drive)
PaO2 > 60 mm Hg and oxygen saturation > 90%
72
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vasoconstrictors
inotropic agents
antibiotics
corticosteriods
mucolytics
diuretics
colloids
opioids
neuromuscular blockers (never given by itself-always given with sedatives-never want to be paralyzed and awake)
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meds for ARDS
73
SOB and chest pain
closed pneumothorax
74
Limit suctioning to how long?
10 seconds
75
chest pain that is sudden in onset, dyspnea, increased RR
pulmonary embolism
76
Positive TB skin test indurations for HIV and non HIV patients
HIV TB skin test is positive if induration is >5mm; TB skin test is otherwise positive if induration is >10mm
It is possible for HIV positive patients to have a false negative due to immunosuppressive meds
77
When the patient in respiratory distress has inspiratory wheezing, and then it ceases, it is an indication
of airway obstruction. This finding requires emergency action to restore the airway.
78
NIPPV is most effective in treating patients with respiratory failure resulting from
chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions.
79
A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure(s) would most likely be implemented to maintain cardiac output?
Administer crystalloid fluids or colloid solutions.
80
It is appropriate to suction a patient with
pneumonia using a mini-trach if blind suctioning is ineffective or difficult. An absent or compromised gag reflex, long-term mechanical ventilation, and a history of aspiration contraindicates the use of a mini-trach.
81
occurs when the amount of air does not match the amount of blood that the lung receives (e.g., COPD, pulmonary embolus).
Ventilation-perfusion mismatch
82
The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication does the nurse know is being used to decrease this patient's pulmonary congestion and agitation?
For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.
83
A typical physical examination finding for a patient with pneumonia is
increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.
84
If the dressing at the Chest Tube insertion site is loose,
an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.
85
always do what around a chest tube site?
palpate for subcutaneous emphysema
86
PaO2 60%
PaO2>50mm Hg with a pH 35 breaths/min
less than adequate RR
criteria for mechanical ventilation
87
ventilation with a set rate and tidal volume, but patient can breathe between mandatory breaths; machine will recognize spontaneous breath and will deliver set amount of tidal volume
assist-control (A/C)
88
during spontaneous breaths patient will breathe the volume they want to breathe
Synchronized Intermittent Mandatory Ventilation (SIMV) (for patients less sick than assist -control)
89
two modes of mechanical ventilation that deliver mandatory breaths
Assist-Control
| Synchronized Intermittent Mandatory Ventilation
90
client breathes completely on own, but with some mechanical assistance at the beginning of the breath so patient can finish on his/her own
Pressure Support (PSV)
91
keeps positive pressure in the airway all the time to make it easier for a patient to complete a respiratory cycle
Continuous Positive Airway Pressure (CPAP)
92
mechanical vent tidal volume setting
6-12 mL/kg based on ideal body weight
93
Inspiratory pressure limit setting on mechanical ventilation
15-20cm/H2O
94
Positive End Expiratory Pressure (PEEP) setting on a mechanical ventilator
5-10cm/H2O; ensures enough air in lungs at end of respiration to keep lungs inflated and helps with oxygenation (pursed lips breathing will naturally increase PEEP)
95
nosocomial lung infection following the initiation of mechanical ventilation
ventilator-associated pneumonia (VAP); pneumonia is considered ventilator associated if intubation and mechanical ventilation occurred within 48 hours of onset
96
* elevate HOB 30-45 degrees
* daily sedation interruption and readiness to extubate assessed
* Daily oral care with clorahexidine-based solution
* peptic ulcer disease prophylaxis (mechanical ventilation makes more gastric acid that ends up in airway)
* DVT prophylaxis
Care of patients on mechanical ventilation
97
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overall tolerance of ventilation
RR, pattern, synchronicity with vent, potential hypoxia, adventitious breath sounds
vent settings
neuro status
nutritional status
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assessment of a pt on mechanical ventilator
98
three stages to wean a patient from ventilator
gradually removed from ventilator
Endotracheal tube removed
Removal from oxygen
**If clinically stable, weaning can take 2-3 hours
99
criteria for Weaning from the Ventilator
* patient is stable physiologically
* signs of improvement
* reversal of disease or condition
* stable VS and ABG's
100
Weaning from the Endotracheal Tube
* spontaneous breathing
* maintain adequate airway
* effectively cough
* swallow
* move the jaw
* lift head off the bed
101
O2 is gradually decreased to maintain normal PaO2
Nutritional Status: higher fat diet for less carb burn, adequate protein intake, dietary support, monitor closely throughout the entire process. Have suction, ambu bag, nasal cannulla bedside
Weaning from Oxygen
102
indicates laryngeal spasms (A medical emergency) after ET tube removal
stridor
103
Pulmonary contusion patients will typically have what restricted?
fluid restrictions
104
* s/s of chest wall injury
* Breath sounds initially clear, later crackles
* pulse ox indicates hypoxia
* ABGs reveal respiratory acidosis and hypoxemia
* CXR initially clear but pulmonary infiltrates appear later
Pulmonary Contusion Diagnosis
105
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Provide adequate oxygenation
Insure ventilation and secretions removal
Management fluids carefully (CVP monitoring)
Pain control
Antimicrobial agents
Diuretics (decrease pulmonary edema)
GI prophylaxis
IS is HUGE!
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Pulmonary contusion Management
106
flail chest often leads to
pneumothorax (due to sharp free floating ribs that can puncture the lungs)
107
air between chest wall and the pleural space. Normal pleural space is negative pressure and the shift in the pressure causes the lung to collapse
pneumothorax
108
three types of pneumothorax
simple
traumatic
tension
109
* spontaneous
* caused by a bronchopleural fistula
* ruptured bleb or blister on lung surface
* can be associated with diffuse lung disease
simple pneumothorax (closed)
110
* caused by laceration of the lung itself
* ribfractures, puncture wounds, gun shots, surgical procedures
* often accompanied by hemothorax
* may be caused by an open injury or sucking chest wound
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Traumatic Pneumothorax (open)
place an occlusive dressing over opening and secure on three sides-that way hole is occluded during inspiration, but air can escape on expiration through the fourth, nonsecured side
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111
* Air is drawn in the pleural space from a lacerated lung or opening in chest wall
* One way valve effect
* Each breath draws air in but does not allow it to escape
* Medical Emergency
* Tracheal and Mediastinal shift away from affected side
* Causes circulatory collapse
Tension Pneumothorax
112
dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention, and cyanosis
symptoms of tension pneumothorax
113
patient instructions if lung collapsed
ask patient to inhale and strain against a closed glottis to re-expand the lung and eject air from the thorax
114
* Air into the tissues and travels underneath the skin
* Crackling sensation when palpated
* Sometimes found in entire body
* Not usually serious
* Spontaneously resorbed
* Underlying cause addressed
subcutaneous emphysema
115
In a high velocity impact, the shearing force may result in
laceration or transection of the aorta
116
Compression of the chest may result in
contusion, crush injury, and organ rupture
117
Difference in clinical manifestation between pneumothorax vs hemothorax
pneumothorax has hyperresonance to percussion while hemothorax has dullness to percussion
(both have dyspnea, diminished or absent breath sounds)
118
muffled, distant heart sounds, hypotension, neck vein distention, increased CVP
cardiac tamponade: Medical Emergency: pericardiocentesis with surgical repair ASAP
119
Treatment for flail chest
O2 as needed to maintain O2 saturation, analgesia, stabilize flail segment with positive pressure ventilation (CPAP, BiPAP), or intubation and mechanical ventilation; treat associated injuries
120
Treatment for tension pneumothorax ( medical emergency)
needle decompression followed by chest tube insertion with chest drainage system
121
What does it mean if there is an absence of bubbling in a chest tube drainage water seal chamber
either there is a block in the drainage system, or the lungs are reexpanded, or the system is attached to suction
122
What do you do if the drainage system is overturned and the water seal is disrupted?
Return it to an upright position and encourage the patient to take a few deep breaths, followed by forced exhalations and cough maneuvers
123
What is the wall setting typically for suction of a wet suction system?
80-120 mm Hg
no bubbling in the suction chamber would indicate that suction is not connected properly or dialed high enough, or that there is a pleural air leak so large that suction is not high enough to evacuate it
124
What about chest tube dressings? Do you change them?
Dressings are not routinely changed. If there is visible drainage, notify HCP physicina for instructions.
125
how do you obtain a sample from the chest tube?
form a loop in the tubing in an area to get the most recently drained fluid, the swab the sampling site with antiseptic and allow to dry. They aspirate from the sampling site with syringe, cap syringe, and label with patient name, date, time, and source of specimen. Send to lab
126
medial sternotomy
surgery involving heart
127
lateral thoracotomy
most surgeries involving the lung
Two Types:
posterolateral-lung
anterolateral-used for surgery or trauma victims, mediastinal operations, and wedge resections of upper and middle lobes of lung
128
removal of entire lung
pneumonectomy
129
Nursing care of a patient after thoracotomy
frequent position changes to promote drainage of pockets of fluid
encourage slow deep breathing, turning, and coughing to control respiratory pattern
ambulate 3-4 times a day to promote deep breathing and lung reexpansion
elevate HOB to maximize respiratory efforts
130
Describe risk factors for pulmonary embolism (long answer)
most pulmonary emboli result from DVT; lethal pulmonary emboli typically originate in the femoral or iliac veins. Highest rate of DVT is seen in spinal cord injury patients,. Other frequent sites of origin would include the right atrium due to AFib and upper extremities and the pelvic veins (after childbirth). Upper extremity DVT occassionally occurs in the presence of central venous catheters or cardiac pacing wires. These cases may resolve with removal of the catheter. Thrombi can dislodge with sudden standing, changes in the rate of blood flow (Valsalva maneuver). Fat emboli can occur from fractured long bones or air emboli from improperly administered IV therapy. Tumor emboli may occur from primary or metastatic malignancies
131
measures appropriate for prevention and management of pulmonary embolism.
pulmonary embolectomy with placement of vena cava filter
tPA, Activase to dissolve the embolus
Heparin or Lovenox to prevent future clots
Basic DVT prophylaxis (mobilization, change position in bed q2h, flex and extend hips, knees, feet q2-4h while awake, chair for meals, ambulate 4-6xday, TED hose, SCDs)
132
Manifestations of pulmonary embolism
classic triad is dyspnea, chest pain, and hemoptysis
133
Describe risk factors for pulmonary embolism (short answer)
immobility, surgery within the last three months, stroke, paresis, paralysis, history of DVT, malignancy, obesity in women, heavy cigarette smoking, and HTN
134
cor pulmonale
enlargement of the right ventricle secondary to diseases of the lung, thorax, or pulmonary circulation. Pulmonary HTN is typically a preexisting condition in the individual with cor pulmonale. May be present with or without overt heart failure. Most common cause of cor pulmonale is COPD. (dyspnea on exertion, lethargy, fatigue)
135
an acute inflammation of the lung parenchyma that is most frequently caused by a microorganism
pneumonia (prevalent in ages 1-4 and >65)
136
results when the defense mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents. Decreased consciousness depresses the cough and epiglottal reflexes, which may allow aspiration of oropharyngeal contents into the lungs. Tracheal intubation interferes with the normal cough reflex and the mucociliary escalator mechanism. It also bypasses the upper airways, in which filtration and humidification of air normally take place. Air pollution, cigarette smoking, URI's, and normal changes that occur with aging can impair the mucociliary mechanism. Diseases such as leukemia, alcoholism, and DM are associated with an increased frequency of gram neg bacilli
Etiology of Pneumonia
137
Organisms that cause pneumonia reach the lung by three methods:
Aspiration of normal flora from the nasopharynx or oropharynx. Many of the organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults.
Inhalation of microbes present in the air
Hematogenous spread from a primary infection elsewhere in the body
138
a lower respiratory tract infection with onset in the community or during the first 2 days of hospitalization
Community acquired pneumonia
139
pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization
Hospital-Acquired, Ventilator Associated, and Health Care Associated Pneumonia (HAP)
140
onset of symptoms is often sudden: fever, shaking chills, SOB, cough productive of purulent sputum, and sometimes pleuritic chest pain. If elderly, confusion or stupor may occur. Physical exam shows pulmonary consolidation (bronchial breath sounds, crackles, dullness to percussion, and increased fremitus)
manifestations of pneumonia
141
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appropriate antibiotic therapy
increase fluid intake to >3L/day
Limit activity
Antipyretics
Analgesics
Oxygen therapy
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treatment of pneumonia
142
Most common cause is sepsis. Direct and indirect lung injuries (aspiration of gastric contents, pneumonia, severe massive trauma, embolism, inhalation of toxic substances, near-drowning, DIC, shock, etc). The pathophysiologic changes are thought to be due to stimuation of the inflammatory and immune systems, which causes an attraction of neutrophils to the pulmonary interstitium. The neutrophils cause a release of biochemical, humoral, and cellualur mediators that increase pulmonary capillary permeability, destruction of elastin and collagen, formation of pulmonary microemboli, and pulmonary artery vasoconstriction.
ARDS
143
a sudden and progressive form of acute respiratory failure in which the alveolar capillary membrane becomes damaged and more permeable to intravascular fluid. PaO2/FiO2 ratio is less than 200
ARDS
144
oxygen administration, positive pressure ventilation, positioning (supine to prone positioning), hemodynamic monitoring using a central venous or pulmonary artery catheter, administer crystalloid fluids in CO falls, use inotropic drugs (dopamine, dobutamine), packed RBCs if necessary to increase hemoglobin (and oxygen carrying capacity of blood)-target is 9-10g/dL with SpO2 of 90%.
ARDS treatment
145
When blood passes through the lungs without participating in gas exhange as a result of ARDS, pneumonia, or pulmonary edema
intrapulmonary shunt (conditions in which the alveoli are filled with fluid)-treat with mechanical ventilation and a high fraction of inspired O2 (FiO2) to improve gas exchange, as oxygen alone will not suffice
146
occurs when gas exchange across the alveolar membrane is compromised by a process that thickens, damages, or destroys the membrane
diffusion limitation that results in hypoxemic respiratory failure
147
insufficient O2 is transferred to the blood, or inadequate CO2 is removed from the lungs leading to eith hypoxemia or hypercapnia
respiratory failure
148
Hypoxemic respiratory failure: V/Q mismatch, shunt (when blood exits the heart without participating in gas exchange), diffusion limitation, or hypoventilation. Most common causes are V/Q mismatch and shunt. Common causes: ARDS, pneumonia, toxic inhalation, hepatopulmonary syndrome, massive pulmonary embolism, pulmonary artery laceration and hemorrhage, anatomic shunt in heart, cardiogenic pulmonary edema, shock (decreases blood flow thorough pulmonary vasculature), high cardiac output states (diffusion limitations)
Hypercapnic respiratory Failure: Caused by Asthma, COPD, Cystic Fibrosis, brainstem injury/infarction, sedative and opioid OD, spinal cord injury, severe head injury, thoracic trauam like flail chest, kyphoscoliosis, pain, morbid obesity, myasthenia gravis, polyneuropathy, ALS, phrenic nerve injury, Guillain-Barre syndrome, muscular dystrophy, multiple sclerosis
etiology of respiratory failure
149
related to the extent of the change in PaO2 or PaCO2, the rapidity of the change, and the patient’s ability to compensate for this change. When compensatory mechanisms fail, respiratory failure occurs. Dyspnea, tachypnea, prolonged expiration, nasal flaring, use of accessory muscles, cyanosis
manifestations of respiratory failure
150
respiratory therapy to mobilize secretions and deliver oxygen, drug therapy: bronchospasm with albuterol, reduce airway inflammation with corticosteriods, reduce pulmonary congestion with Lasix or morphine, treat pulmonary infections with antibiotics, reduce anxiety pain, and agitation with Ativan, Sublimaze, morphine
treatment of respiratory failure
151
Surgical Resection is treatment of choice (may need radiation or chemo too)
pneumonectomy: removal of a lung
Lobectomy: removal of one or more lobes
Segmented or wedge resection
Assesss cardiopulmonary function studies and ABGs to see if patient can withstand surgery.
Radiation Therapy: primary therapy if cant undergo surgery
sometimes used preoperatively to reduce tumor mass
Cheno
Biologic and Targeted Therapy: drugs that block the growth of molecules involved in specific aspects of tumor growth (erlotinib)
Prophylactic Cranial Radiation: for pts with small cell carcinoma of the lung with early metastases esp to CNS
Bronchoscopic Laser Therapy: remove obstructing bronchial lesions
Photodynamic therapy: bronchoscopic laser therapy for lung cancer. Profimer is injected IV and selectively concentrates in tumor cells, after 48 hours, the tumor is exposed to laser, producing a toxic form of oxygen that destroys the tumor cells. Necrotic tissue is removed with a bronchoscope
Airway Stenting: used alone or in combo with other techniques for relief of dyspnea, cough, or respiratory insufficiency. Can delay extension of tumor into the airway lumen
Cryotherapy: tissue is destroyed by freezing
Discuss the modes of therapy and related nursing management for patients undergoing surgery for lung or laryngeal cancer.
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wash area around stoma daily with a moist cloth. remove tube daily and clean it in the same manner. The inner cannula may been to be removed and cleaned more frequently. A scarf or loose shirt may be used to shield the stoma. Cover stoma when coughing and during any activity such as shaving or applying makeup so that foreign substances are not inhaled. Wear a platic collar in the shower and swimming is contraindicated. Bedside humidifier can be used, and patient should maintain a high oral intake of fluids. Patient should wear a medic alert bracely about the use of neck breathing. The ability to smell smoke and food is lost as patient no longer breathes through nose. Patient should install smoke and carbon monoxide monitors in home.
Laryngeal Stoma Care:
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Chronic interstitial fibrosis is associated with the development of
adenocarcinoma of the lung
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associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium.
Non–small cell carcinoma
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patient positioning with lung disease
Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion.
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The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?
Deflate the cuff on the tube.
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The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement?
Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.
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The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed?
he nurse should assess the tracheostomy ties to ensure that they are not too tight. The nurse ensures that there is room for two fingers to slide comfortably under the ties
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The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider in this procedure, which is the initial nursing action?
Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. Additionally, resuscitative equipment should already be available at the client's bedside.
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A health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by which mechanism?
Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance
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Assist Control Mode:
Allows for mandatory and spontaneous breaths at a set tidal volume. Mandatory breaths per minute are set (as an example: 12 bpm, 500ml tidal volume). The patient can also initiate breaths between the mandatory breaths. The machine will sense the spontaneous breath and insure that the patient gets 500 ml tidal on the spontaneous breath as well as the mandatory.
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SIMV:
Same as assist control, but the machine does not assist on the spontaneous breaths. It simply allows the patient to muster whatever tidal volume they can during a spontaneous breath.
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Pressure Support:
Completely spontaneous breathing mode. The machine is only providing positive pressure that the beginning of the breath cycle to assist the patient. The pressure (amount of assistance) is set on the machine by RT. This mode is done before the patient is weaned off of the ventilator.
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Continuous Positive Airway Pressure (CPAP):
Completely spontaneous mode with positive pressure throughout the respiratory cycle. Again, the pressure is ordered a healthcare provider.
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BiPAP:
Same as CPAP, but different pressure can be set on inspiration and exhalation.
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A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies?
Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure
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A nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, which nursing action is appropriate?
The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of each shift or least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) should be treated with prescribed antacids. If there is no prescription for the antacid, the health care provider should be notified. Documentation of the findings should be done after the administration of an antacid.
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A nurse and an unlicensed assistive personnel (UAP) are assisting the respiratory therapist to position a client for postural drainage. The UAP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas?
Postural drainage uses specific client positions that vary depending on the affected lobe or lobes. The positions usually place the head lower than the affected lung segments to facilitate drainage of secretions. Postural drainage often is done in conjunction with chest percussion for maximum effectiveness.
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A nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse determines that the tube is positioned above which area of the respiratory system?
The carina is a cartilaginous ridge that separates the openings of the two main (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected because only the right lung will have breath sounds and rise and fall with ventilation.
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A nurse is caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse should assess for which characteristic of wound drainage expected in the immediate postoperative period?
Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction, which drains serosanguineous fluid. In the first 24 hours after surgery, the drainage may total 80 to 120 mL
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A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively the nurse should place the client in which position?
After any procedure involving lung surgery, the nurse should position the client in semi-Fowler's position. This position allows for maximal lung expansion and promotes drainage through chest tubes that may be placed during surgery.
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The nurse is providing care for a client recently admitted with new onset pleurisy. Upon auscultation of the client's lungs, the nurse notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds?
Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, friction between the visceral and parietal lung surfaces decreases, and the pleural friction rub disappears
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describe bronchial breath sounds
Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and a distinct pause can be heard between the inspiration and expiration phases. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue, as in a lung mass, atelectasis, or pneumonia.
