Chapter 19 Management of Patients w/ Chest & Lower Respiratory Tract Disorders Flashcards
Atelectasis
Closure/collapse of alveoli
Signs & Symptoms of Atelectasis
Dyspnea
Cough
Sputum prod
Common Causes of Acute Atelectasis
People who are immobilized and have a shallow, monotonous breathing pattern due to thoracic/abdominal surgery
Signs & Symptoms of Acute Atelectasis
Lobar atelectasis (large amount of lung tissue)
Dyspnea
Cough
Sputum prod
Tachycardia
Tachypnea
Pleural
Central cyanosis
How does non-obstructive atelectasis occur?
Occurs as a result of reduced ventilation
How does obstructive atelectasis occur?
Occurs due to a reabsorption of gas (trapped alveolar air is absorbed into the bloodstream)-> no additional air can come in-> collapse
Assessment Findings: Atelectasis
Increased work of breathing & hypoxemia
-Decrease in O2 tension in arterial blood
Auscultation: Decreased breath sounds & crackles over affected area
Nursing Measures to Prevent Atelectasis
Frequent turning
Early mobilization
Strategies to expand the lungs and to manage secretions
Incentive Spirometry
A method of deep breathing that provides visual feedback to encourage the patient to inhale slowly & deeply to max lung inflation & prevent/reduce atelectasis
Purpose of Incentive Spirometry
Ensure that the vol of air inhaled is increased gradually as the patient takes deeper breaths
Steps in Performing Incentive Spirometry
1) Assume a semi-Fowler position/upright position before initiating therapy
2) Use diaphragmatic breathing
3) Place the mouthpiece of the spirometer firmly in the mouth, inspire slowly through the mouth, and hold the breath at the end of inspiration for about 3 secs to maintain the ball/indicator between the lines. Exhale slowly through the mouthpiece
4) Cough during and after each session. Splint the incision when coughing postoperatively
How many times should incentive spirometry be performed?
~10 times in succession, 10 breaths/hr
Goal of Atelectasis Treatment
Improve ventilation & remove secretions
Positive End-Expiratory Pressure (PEEP)
A simple mask and one-way valve system that provides varying amounts of expiratory resistance, usually 10-15 cm H2O
ICOUGH Program for Atelectasis
Incentive Spirometry
Coughing & deep breathing
Oral care: brushing teeth using mouthwash 2x a day
Understanding (patient & staff education)
Getting out of bed at least 3X daily
HOB elevation
Thoracentesis
Removal of the fluid by needle aspiration
Acute Tracheobronchitis
Acute inflammation of mucous membranes of the trachea & bronchial tree
-Often follows upper respiratory tract infection
-> Pts w/ viral infections have decreased resistance & can readily develop a secondary bacterial infections
Acute Tracheobronchitis Clinical Manifestations
Dry, irritating cough
Expectorates a scanty amount of mucoid sputum
Sternal soreness from coughing
Fever/chills
Night sweats
Headache
Gen malaise
What causes bloody sputum in severe tracheobronchitis?
Due to airway mucosa irritation
Nursing Management of Tracheobronchitis
Encourage fluid intake & coughing
Assist px to sit up (prevent accumulation of sputum)
A complete full course of antibiotics as prescribed
Rest to avoid overexertion->relapse
Why are histamines not usually prescribed for tracheobronchitis?
They can cause excessive drying & make secretions more difficult to expectorate
Pneumonia
Inflammation of the lung parenchyma caused by various microorganisms: bacteria, mycobacteria, fungi, & viruses
Pneumonia Risk Factors
Smoking
Neutropenia
Prolonged immobility
Depressed cough reflex
Endotracheal tube
Alcohol intoxication
Sedation (respiratory depression)
Advanced age
Upper respiratory infection
Underlying Disorders that put People at Risk for Developing Pneumonia
HF
Diabetes
ETOH abuse
COPD
Aids
Cancer
Influenza
Cystic Fibrosis
What occurs in the body during pneumonia?
Exudate os produced interfering w/diff of O2 & CO2
WBCs fill the airspace
Areas of the lung are not properly ventilating
Hypoxemia occurs
Clinical Manifestations of Pneumonia
Fever
Chills
Pleuritic chest pain
Tachypnea
Shortness of breath
Use of accessory muscles with respirations
Headache
Myalgia
Mucopurulent sputum
Cough
Fatigue
Orthopnea
**Older Adult: Change in mentation: Developing sepsis, Desaturation
Community-Acquired Pneumonia (CAP)
Type of pneumonia that occurs w/in a comm or w/in first 48hrs post hospitalization
- Viral origin in infants & children
- Rate of infection increases w/age
Healthcare-Associated Pneumonia (HCAP)
Often caused by multidrug-resistant organisms
Early diagnosis and treatment are critical
Non-hospitalized patient with extensive health
care contact with one or more of the following:
* Hospitalized for 2 or more days within past 90
days of infection
* Resident of a long-term care facility
* Hemodialysis patient
* Home infusion therapy
* Wound care
Common Causes of HCAP
Hospitalized for 2+ days w/in past 90 days of infection
Resident of a long-term care facility
Hemodialysis patient
Home infusion therapy
Wound care
Hospital-Acquired Pneumonia
Develops 48hrs or more after hospitalization
Subtype of health care–associated pneumonia
Potential for infection from many sources
* Infections are usually:
* Virulent organism such as MRSA
* MDR- multi drug resistant organisms
* Occur with underlying medical disorders
* Associated with high mortality rate
Ventilator-Associated Pneumonia
Develops 48hrs or more after endotracheal tube intubation
Nursing Interventions for VAP Prevention
Elevate HOB 30-45 degrees
Oral care w/chlorhexidine daily
Daily sedation vacations & assess readiness to extubate
Peptic ulcer disease prophylaxis
DVT prophylaxis
Medical Management of Pneumonia
Supportive treatment includes rest, fluids, antipyretics, antitussives, decongestants, antihistamines, and oxygen for hypoxia
Antibiotics not indicated for viral infections but are used for secondary bacterial infection
Administration of appropriate antibiotic with bacterial pneumonia
IV antibiotic if hemodynamically unstable, unable to take PO meds, and GI tract is functioning normally
Hemodynamically Unstable Vital Signs Criteria
Temp > 100
HR > 100
RR > 24
Systolic BP 90
O2 Sat
Nursing Interventions for Pneumonia
Oxygen therapy as needed
Administration of ordered antibiotics (for bacterial infections)
* Make sure if blood cultures are ordered that they are obtained before starting antibiotics
Removal of secretions
* Hydration: thins and loosens secretions, ↑RR → ↑ fluid loss
* Humidification: loosens secretions- retained secretions impair gas exchange
Turning & positioning
* Encourage deep breathing and coughing
* Rest & avoidance of over exertion
* Maintain nutrition
Monitoring for complications- vital signs are VITAL
* Sepsis/Septic shock
* Respiratory failure
Should start responding within 24 – 48 hours after treatment starts
Incentive spirometer: prevent atelectasis
Sepsis
Systemic response to infection
Manifested by two of the following:
* Temp > 38 Celsius or 100.4
* HR > 90
* RR > 20
* WBC > 12,000
Septic Shock
Circulatory imbalances occur and are profound
* Hemodynamically unstable
* Perfusion that is not adequate to promote organ function
Hypotension
Increased mortality
Planning and Goals of Care for Patients with Pneumonia
Improved airway patency
Increased activity
Maintenance of proper fluid volume
Maintenance of adequate nutrition
Understanding of the treatment protocol and preventive measures
Absence of complications
Based on patient outcomes plan for home, community, and transitional care
Expected Outcomes for Pneumonia
Demonstrates improved airway patency
Rests and conserves energy and then slowly increasing activities
Maintains adequate hydration; adequate dietary intake
Verbalizes increased knowledge about management strategies
Complies with management strategies
Exhibits no complications
Aspiration Pneumonia
Inhalation of foreign substance into the lung
Result is:
* Tachycardia
* Dyspnea
* Central cyanosis
* Hypotension
* Can be fatal
Risk Factors for Aspiration Pneumonia
Seizure
Brain injury
Decreased LOC
Lying flat
Stroke
Swallowing disorders
Cardiac arrest
Preventing Aspiration
Maintain HOB up at a 30-45-degree angle
Use sedatives sparingly
Before starting tube feedings - confirm placement
Swallow evaluation by speech therapy
Chronic Obstructive Pulmonary Disease (COPD)
Chronic lung inflammation that narrows the airways
What occurs in the body with COPD?
Narrowing occurs in the airways via inflammatory response to noxious air particles
Hypersecretion of mucus
Over time scar tissue is formed-> further narrowing of the lumen
True or False (T or F): COPD is a reversible condition
False
Chronic Bronchitis
Inflammation of bronchi persisting over a long time; type of chronic obstructive pulmonary disease (COPD)
What occurs in bronchitis?
Presence of cough and sputum production for at least 3 months in each of 2 consecutive years
Hypersecretion of mucus occurs
Bronchial lumen decreases
Increased susceptibility to respiratory infections
Emphysema
Impaired O2 & Co2 exchange resulting from destruction of walls of over distended alveoli
What occurs w/emphysema?
Alveolar surface in direct contact with pulmonary capillaries continuously decreases
Leading to an increase in dead space, ↓O2 diffusion → Hypoxemia
Co2 elimination is impaired → Co2 retention →Respiratory acidosis
End stage progresses slowly over years
COPD Risk Factors
Tobacco
Second hand smoke
Increased age
Occupational exposure
Air pollution
Clinical Manifestations of COPD
Chronic cough
Sputum prod
Dyspnea
Barrel chest
Shoulders may go up on inspiration
As COPD worsens → Dyspnea at rest may develop
Weight loss
Dyspnea interferes with eating
↑ work of breathing takes more energy
Accessory muscle use
↑ risk for respiratory infections
Tend to lean forward
COPD Physical Assessment Findings
↓ breath sounds
Expiratory wheeze
Use of accessory muscles
Barrel chest
Clubbing of the fingers
Unable to finish a sentence w/out becoming SOB
COPD Medical Management
Smoking cessation (zyban/ aventyl & chantix)
Supplemental O2 as needed
Prescribe meds
Surgical interventions
Palliative Care
Advantages of Bronchodilators
Relieve bronchospasm
Reduce airway obstruction
Allow increased O2 distribution
Improves alveolar ventilation
At what level of SpO2 do you want a COPD patient to be?
At 90% or higher
Advantages of Diaphragmatic Breathing
Reduces RR
Increases alveolar ventilation
Helps expel as much air as possible during expiration
Advantages of Pursed Lip Breathing
Prolongs exhalation
Prev collapse of small bronchioles
Helps px to control rate & depth of expiration
Reduces the amnt of air trapped
Enables the px to gain control of dyspnea
Help reduces feeling of panic
Tripod Position
Sit w/arms propped on the overbed table or sit w/ams propped on knees
Causes of Pneumothorax
Changes can develop in large bullae-> may rupture-> pneumothorax
Severe coughing
Signs of Pneumothorax
Rapid onset of SOB
Chest pain
Asymmetry of chest movement
Absence of breath sounds on the affected side
Asthma
A chronic inflammatory diseases of the airways characterized by episodes of severe breathing difficulty, coughing, and wheezing.
Causes of Asthma
Airway hyper responsiveness
Mucosal edema
Mucus prod
Common Asthma Triggers
Air pollutants, cold, heat, wether changes, perfumes, smoke
Foods: shellfish, nuts
Exercise
Stress
Viral resp infections
Clinical Manifestations of Asthma Exacerbations
Cough (prod or not)
Chest tightness
Wheezing
Dyspnea
Diaphoresis
Tachycardia
Hypoxemia & central cyanosis
Quick-Relief Asthma Meds
Beta-2 adrenergic meds
Anticholinergics
Complications of Asthma
Status asthmaticus
Respiratory failure
Pneumonia
Hypoxia
Long-Acting Asthma Meds
Corticosteroids
Long-acting beta-2 adrenergic agonists
Leukotriene modifiers
Quick-Relief for Acute Asthma Episodes
Short-acting, beta2-adrenergic agonists:
-Side effects: ↑ Bp & HR, ↑ risk dysrhythmias, shakiness
-Use cautiously in patients with cardiac disorders
Most common meds: Albuterol Proventil Ventolin Xopenex
Anticholinergics (if beta2-adrenergic agonists are not tolerated):Atrovent
Long-Acting Asthma Meds Control
Corticosteroids (Most potent anti-inflammatory)
Reduce bronchial hyper-responsiveness
Inhaled SystemicInhaled CorticosteroidsFluticasoneBudesonideSpacer should be used*Rinse mouth out with water after use to prevent thrush
Asthma Life-Threatening Exacerbations (S/S)
Vital signs: RR > 30, HR > 120, ↓O2 saturation
Dyspneic at rest
Audible wheezing
Speaks in words not sentences
Patient usually sitting forward
Accessory muscles in the neck are used
Patient often is agitated
Neck vein distention
Maybe drowsy or confused
Deteriorating blood gases (Resp. acidosis)
If the patient has been wheezing & then there is an absence of a wheeze…
…the chest is silent & the patient is in respiratory arrest
Nursing Interventions for Asthma
Admin meds as ordered
Works w/resp therapy
Px may become dehydrated & may need IV fluids if very diaphoretic
ABGs
Monitor responses to meds
Assess for impending respiratory failure
Goal of Oxygen Therapy
Provide adequate transport of oxygen in the blood
Decreasing the work of breathing
Reducing stress of myocardium
Key Indications for Oxygen Therapy
Change in respiration rate or pattern early indicator of need for O2
Hypoxemia
Avoid oxygen toxicity in COPD
patients - nurse should administer
Nasal Cannula
Suggested Flow Rate:1-2 L/min
-O2 percentage setting: 24-28
Suggested Flow Rate: 3-5 L/min
-O2 percentage setting: 32-40
Suggested Flow Rate: 6 L/min
-O2 percentage setting: 44
Simple Mask
Suggested Flow Rate: 5-8 L/min
-O2 percentage setting: 40-60
Partial Rebreathing Mask
Suggested Flow Rate: 8-11 L/min
-O2 percentage setting: 50-75
Moderate oxygen concentration
Non-rebreathing Mask
Suggested Flow Rate: 10-15 L/min
-O2 percentage setting: 80-95
High oxygen concentration
Face Tent
Suggested Flow Rate: 8-10 L/min
-O2 percentage setting: 28-100
Venturi Mask
Suggested Flow Rate: 4-6 L/min
-O2 percentage setting: 24, 26, 28 (Provides low level of supplemental O2)
Suggested Flow Rate: 6-8 L/min
-O2 percentage setting: 30, 35, 40
Aerosol Mask
Suggested Flow Rate: 8-10 L/min
-O2 percentage setting: 28-100
Trach-Collar
Suggested Flow Rate: 8-10 L/min
-O2 percentage setting: 28-100
A 63-year old client w/ a 35-year history of smoking two packs of cigarettes per day has a chronic cough that produces thick sputum, peripheral edema, and cyanotic nail beds. Based on these assessment findings, the nurse suspects that the client may be experiencing which of the following?
A) Acute respiratory disease syndrome (ARDS) B) Asthma C) Chronic obstructive bronchitis D) Emphysema
C) Chronic obstructive bronchitis
A client w/ acute asthma is experiencing inspiratory & expiratory wheezing & decreased force expiratory volume. What is the nurse’s priority intervention?
A) Beta-adrenergic blockers
B) Bronchodilator
C) Inhaled steroids
D) Oral steroids
B) Bronchodilator
The nurse is auscultating the lungs of a patient with asthma. The nurse describes the high-pitched, sibilant, musical sounds heard as?
A) Rales
B) Crackles
C) Wheezes
D) Rhonchi
C) Wheezes
A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following statements should the nurse include?
A) “Take quick breaths upon inhalation”
B) “Place your hand over your stomach”
C) “Take a deep breath through your nose”
D) “Puff your cheeks upon exhalation”
C) “Take a deep breath through your nose”
The nurse is caring for a client w/ COPD experiencing hypoxemia and hypercapnia. Which outcome will the nurse evaluate?
A) The client will demonstrate adequate oxygenation.
B) The client will avoid use of supplemental oxygen to decrease hypoxic drive.
C) Monitor pulse oximetry every 8 hours while awake.
D) Educate the client about the use of diaphragmatic breathing techniques.
A) The client will demonstrate adequate oxygenation
A client is seen with chronic bronchitis. Which clinical symptoms does the nurse assess in this client?
A) Chest pain during respiration
B) Sputum & productive cough
C) Fever, chills, and diaphoresis
D) Tachypnea and tachycardia
B) Sputum & productive cough
