Chap 17 Flashcards
Adequate breathing rates
Adult: 12-20
Child: 15-30
Infant: 25-30
Respiratory observations
- Altered mental status
- Unusual anatomy (Barrel chest)
- patients position
- Tripod
- Sitting with feet dangling, leaning forward
Work of breathing, including
- Retractions
- Use of accessory muscle to breath
- Flared nostrils
- Pursed lips
- One-word dyspnea, two-word dyspnea
- Pale, cyanotic, or flushed skin
- Pedal edema
- Sacral edema
- Noisy breathing
- Wheezing
- Gurgling
- Snoring
- Crowing
- Stridor
- Coughing
- SpO2 less than 95%
- Auscultating
- Lung sounds on both sides during inspiration and expiration
Evaluating vital sign changes
- Increased pulse rate
- Decreased pulse rate (especially in infants and children)
- Changes in the breathing rate
- Changes in breathing rhythm
- Hypertension or hypotension
Wheezes
- High pitched sound
- air moving through narrowed air passages in the lungs
- Commonly on exhale
- Common with asthma, emphysema, and chronic bronchitis
Crackles
- fine crackling or bubbling heard on inspiration
- Fluid in the alveoli or by the opening of closed alveoli
- Also called rales
Rhonchi
- Lowered pitched sounds that resemble snoring or rattling
- Secretions in airway
- Seen with pneumonia or bronchitis
- Also when materials are aspirated into the lungs
- Generally louder than crackles
Stridor
- High pitched sound
- heard on inspiration
- Upper airway sound indicating partial obstruction of the trachea or larynx
- Usually audible without a stethoscope
Patient care for breathing difficulty
- Assessment
- Assess airway on primary assessment and throughout call
- Assist respiration with artificial ventilations and supplemental oxygen when patient has inadequate breathing
- Oxygen
- Oxygen is main treatment for respiratory difficulty
Positioning
-Usually sitting position for supplemental oxygen and supine for artificial ventilation
Prescribed inhaler
- May assist with prescribed inhaler
- After medical direction
Continuous positive airway pressure (CPAP)
CPAP
Continuous Positive Airway Pressure
- NPPV- Noninvasive positive pressure ventilation
- Blows oxygen or air continuously at a low pressure into the airway to prevent the alveoli from collapsing at the end of exhalation, and it can also push fluid out of the alveoli back into the capillaries that surround them
CPAP common uses
Pulmonary edema Drownings Asthma COPD- Bronchitis, Emphysema Respiratory failure in some cases
CPAP contraindications
Anatomic-physiologic
- Mental status so depressed that the patient cannot protect his airway or follow instructions,
- lack of a normal spontaneous respiratory rate (CPAP increases the volume of air the patient breathes but doesn’t increase the patients respiratory rate);
- inability to sit up,
- hypotension generally less than 90mmHg
- inability to get and maintain a good mask seal
Pathologic
- Nausea and vomiting
- penetrating chest trauma
- pneumothorax
- shock
- upper gastrointestinal bleeding
- recent gastric surgery
- any condition that would provide a good mask seal (congenital facial malformations, trauma or burns)
Caution
-Claustrophobia and inability to tolerate the mask and seal; history of inability to use CPAP; secretions so copious that they need to be suctioned; and history of pulmonary fibrosis
CPAP heart considerations
When CPAP is being used the pressure in the lungs causes less blood to return to the heart, so cardiac output decreases, resulting in decreased blood pressure if heart cant compensate.
-Systolic blood pressure needs of at least 90mmHg
CPAP considerations/ dangers
- Positive pressure can cause a weak area to rupture in lungs
- BiPAP (bilateral positive airway pressure) is commonly used in hospitals for patients with COPD or Asthma, who are at risk of ruptures in lungs
- Patients at risk of vomiting are positive pressure aspirating into the lungs
- Drying of corneas of the eyes due to bad mask seal`
Two different CPAP machines
Battery powered
- Blows oxygen or air at an adjustable pressure
- Advantage is using only as much oxygen as the patient needs
- Disadvantage- Battery needs to be charged
Venturi principle
- Shaped channels that produce different flow rates
- Advantage is lighter weight and no battery
- Disadvantage is that it used oxygen quickly
CPAP application
- Apply mask or allow patient to hold it on face initially
- Start low level at 2-5 cm H2O
- Assess mental status, vital signs and level of dyspnea frequently
- Raise level if no relief within a few minutes
- Remove if mental status or respiratory conditions deteriorates and use BVM
Types of COPD (Chronic Obstructive Pulmonary Disease)
- Emphysema
- Chronic bronchitis
- Black lung
COPD causes
- Middle-aged or older patients due to disorders take time to develop as tissue react to irritants
- Cigarette smokers
- Chemical, air pollutants, or repeated infections
Chronic Bronchitis
The bronchiole lining is inflamed and excess mucus is formed. The cells in the bronchioles that normally clear away accumulations of mucus are not able to do so. the sweeping apparatus on these cells, the cilia, has been damaged or destroyed
Emphysema
The walls of the alveoli break down, greatly reducing the surface are for respiratory exchange. The lungs lose elasticity. These factors combine to allow stale air laden with carbon dioxide to be trapped in the lungs, reducing the effectiveness of normal breathing efforts
Hypoxic drive
Body is a hypercapnia drive. Smokers move to hypoxia drive since body runs on low oxygen levels. The higher levels of oxygen from oxygen administration will signal body to stop breathing
-Oxygen needs will out weight any risk
Asthma
- Seen in young and old patients
- Chronic disease that has episodic exacerbations or flares (irregular intervals)
- Does not produce a hypoxic drive
- Steroid inhalers used with Albuterol
- Attacks can be precipitated by insect stings, air pollutants, infections, strenuous exercise, or emotional stress
- Occurs when the small bronchioles that lead to the air sacs of the lungs become narrowed because of contractions of the muscles that make up the airway. Also produces thick mucus the when combined causes the small passages to close down restricting airflow
- Lets air in because lungs exert outward pull on inhalation but stale air becomes trapped and requires forcefulness to exhale
- Wheezing noise
Pulmonary edema
People with CHF (congestive heart failure) may experience fluid that accumulates in the lungs, preventing them from breathing adequately
- Typically occurs on left heart damage, often myocardial infarction (heart attack) or chronic hypertension. Back up of blood going into the left atrium causing fluid going back into the lungs
- Can also happen at extreme elevation (low atmospheric pressure)
- Patients with left sided heart failure also have right sided failure that leads to pedal edema and JVD. In bedridden patients fluid accumulates in the sacral area of the lower back and abdominal cavity.
- Fluid in the lungs while sleeping lead to mild dyspnea that can be relieved by sleeping propped up on one pillow, then two, or even three pillows till overload and awakens to feeling of drowning
Signs-Feeling worse every night, weight gain of several pounds in a few days, anxiety, pale and sweaty skin, tachycardia, hypertension, respirations that are rapid and labored, and low oxygen saturation. Severe case you’ll hear gurgling, and crackles or sometimes wheezes with auscultations. Cough up frothy sputum usually white but sometimes pink tinged
- Pulmonary edema treatments
- High-concentration oxygen
- Keep legs hanging down (legs up may push more fluid into the already overloaded circulatory system
- CPAP
Pneumonia
An infection of one or both lings caused by bacteria, viruses, or fungi. It results from the inhalation of certain microbes that grow in the lungs and cause inflammation
-People with COPD or chronic health problems are at high risk
Signs and symptoms
- Coughing (mucus can be greenish, yellow or bloody
- Fever, sever chills
- Shortness of breath
- Chest pains that are sharp and pleuritic(worsens on inhalation)
- headache, pale, sweaty skin, fatigue and confusion
- May hear crackles in one region while auscultating
-Pneumonia is thought to be bacterial and antibiotics are usually prescribed
Spontaneous Pneumothorax
Lungs collapsing without injury or any other obvious cause
Usually the result of a rupture of a bleb, a small section of the lung that is weak. Once bleb ruptures, the lung collapses and air leaks into the thorax
- People prone to bleb
- Tall people
- Smokers
Patients with collapsed lung typically have sharp, pleuritic chest pains and shortness of breath
Signs will be auscultation of breath sounds that are decreased or absent on the side with the injured lung
Treatment
- Administer oxygen an treat patient like anyone else who is short of breath
- CPAP is contraindicated
- Catheter to remove air from cavity
Pulmonary embolism
Blood clot, air, or fat blocks an artery to the lung
- Most common example is a blood clot that starts in a vein, often a vein in the leg or in the pelvis. This dangerous type of clot is called a deep vein thrombosis(DVT). DVT is common in cancer patients which makes the blood more prone to clotting. Lying down or sitting in one position for an extended period can also make blood more prone to clot
- Air can cause damage and fat (example marrow of a fractured bone gets fat into circulation)
signs and symptoms
-sharp, pleuritic chest pain, shortness of breath, anxiety, a cough (sometimes bloody sputum), Sweaty skin that is pale or cyanotic, tachycardia, and tachypnea, dizziness, pain or swelling in both legs, and sometime wheezing during auscultation. If clot is large patient might be hypotensive or go into cardiac arrest
- Treatments
- Administer oxygen like someone with shortness of breath
Epiglottitis
Infection that inflames the area around and above the epiglottis, the tissue swells.
- Use to be a disease common in children but not anymore
- Childhood vaccination Haemophilus influenzae type B (the bacterium that used to cause most cases in children)
- Typical in adults male in forties who may have had a recent cold
- Symptoms
- Sore throat and painful or difficult swallowing
- Typically tripod position
- sick appearance, muffled voice, fever and drooling
- Alarming sound of Stridor indicates the airway has significant degree of obstruction
Onset is faster in children than adults
Treatment
- Keep patient calm and comfortable which means don’t inspect the throat
- Administer high concentration oxygen
- Transport immediately
If untreated, up to 10% of children die. Adults can tolerate the swell but might bear risk of losing airway
Cystic Fibrosis
Genetic disease that typically appears in childhood, cystic fibrosis (CF) causes thick, sticky mucus that accumulates in the lungs and digestive system. The mucus can cause life threatening lung infections and serious problems with digestion
Signs and symptoms
- Coughing with larges amounts of mucus
- Fatigue
- Frequent occurrences of pneumonia characterized by fever, more coughing than usual, worse shortness of breath than usual, more septum than usual, and loss of appetite
- Abdominal pain and distension
- Coughing up blood
- Nausea
- Weight loss
Viral respiratory infections
Most common afflictions a person might get
Sore or scratchy throat with sneezing, a runny nose and a feeling of fatigue. May be a fever and chills.
The infection can spread into the lings, causing shortness of breath, especially in those who have chronic health conditions.
The cough can be persistent and produce sputum that is yellow or greenish. Symptoms usually persist for 1-2 weeks
Because the infection is viral, antibiotics do not help and may worsen things by promoting antibiotic resistances
Bronchoconstriction
Constriction, or blockage, of the bronchi that lead from the trachea to the lungs
Metered-dose inhaler
Inhaler or Puffer
Activation of the inhaler provides a metered dose of medication
Dilates the air passages, making breathing easier. These drugs are in the form of a fine powder. The timing of the activation of the inhaler in relation to a deep breath is very important to prevent the fine powder from coming to rest on the moist inner surface of the mouth
Steps
- 5 R’s, Make sure inhaler is at room temp and shaken vigorously
- Make sure patient is alert enough to use
- Make sure patient first exhales deeply
- Have patient put his lips around the opening and press the inhaler to activate spray as he inhales deeply
- Hold breath as long as possible
Spacer devices
makes the exact timing necessary to use an inhaler less critical. The inhaler is activated into the spacer device (sometime called a Aerochamber). The medication stays inside the chamber and can then be inhaled directly into lungs
Inhaler drugs
Drugs Albuterol (Ventolin, Proventil, Volmax) Metaproterenol (Alupent, metaprel Levalbuterol (Xopenex) Albuterol/ Levalbuterol (Combivent)
Contraindications
- Not alert
- Not prescribe to patient
- No permission from medical direction
- Patient already has taken maximum doses
Side effects
- Increased pulse rate
- Tremors
- Nervousness
SVN (Small Volume Nebulizer)
Nebulizing a medication involves running oxygen or air through a liquid medication. The patient breaths the vapors.
Used in hospitals, ambulance, and prescribed to patients
For patients usually with chronic respiratory conditions such as asthma, emphysema, or chronic bronchitis
Some ambulance would carry albuterol
Same side effects and precautions as inhalers
