exam 1 Flashcards
the older adult >65
- death in advanced years not caused by “old age” but disease or infection
- greater risk for illness (normal decline in adaptation)
- changes of aging become apparent when the body is under stress
homeostasis
body’s ability to adapt to or return to a normal state of balance after being subjected to a threat or stress (injury, exposure to pathogens, changes in fluid and nutritional intake, effects of medication, etc.)
homeostenosis
failure of homeostasis, progressive decrease in homeostasis that occurs in every organ system with aging
senescence
normal age related changes in the organ system
older adult concerns
- impaired mobility
- dizziness
- falls
- incontinence
- increased susceptibility to infection
older adults and CVS
- decreased CO
- diminished ability to respond to stress
- HR and SV do not increase with maximum demand
- slower heart recovery rate
- increased BP
- complaints of fatigue w/ increased activity
- increased HR recovery time
- optimal BP <130/80 mmHg
health promotion for older adults with CVS
exercise, pace activites, avoid smoking, low fat low salt diet, stress reduction, BP, weight control
respiratory and older adults
- increase in residual lung volume
- decrease in muscle strength and endurance and vital capacity
- decreased gas exchange and diffusing capacity
- decreased cough efficiency
- pt may experience fatigue and breathlessness after activity, decreased respiratory excursion and chest/lung expansion with less effective exhalation, difficulty coughing secretions
respirtory health promotion
exercise
avoid smoking
adequate fluids
influenza vaccinations
avoid exposure to upper respiratory infections
ingeumentary and older adults
- decreased subq fat, interstitial fluid, muscle tone, glandular activity, and sensory receptors, resulting in atrophy and decreased protection against trauma, sun exposure, and temperature extremes,
- diminished excretions of natural oils and perspiration
- capillary fragility
- pt may show thin wrinkled and dry skin with increased fragility that is easily bruised and sunburned, intolerance of heat and prominent bone structure
integumentary health promotion
limit sun exposure
dress appropriately
stay hydrated
maintain safe indoor temperature
shower rather than hot tub bath
lubricate skin with lotions
reproductive and older adults
female: vaginal narrowing and decreased elasticity, decreased vaginal secretions
male: gradual decline in fertility, less firm
male: gradual decline in fertility, less firm testes and decrease in sperm production
male and female: slower sexual response
female patients may show painful intercourse, vaginal bleeding, vaginal itching and irritation, delayed orgasm
male patients have less firm erection and delayed erection and achievement of orgasm
decrease in phagocytic activity and bactericidal funtion as well as a decrease in T cell function causes
increased susceptibility to and mortality from infections
decreased inflammatory response causes
altered clinical signs of acute infection, absence of fever
decreased antibody response to antigen stimulation of 90% by 75 causes
decreased allergic reactions
diminished antibody production in response to vaccination or infection and reduction in humoral immunity causes
reactivation of infectious diseases
decreased melanocytes cause
increased risk of skin cancer
decreased collagen causes
dry and rough skin
loss of elastic tissue causes
low grade skin infections
decreased elasticity and ineffectiv DNA repair causes
slow wound healing and weak scars
loss of dermal thickness causes
decreased barrier function
smaller adjoining surface between dermis and epidermis casues
paper thin skin and less resistance to shearing force
depression
- most common affective or mood disorder of old age
- risk of suicide increased in older adults
- substance use disorders cause by misuse of alcohol and drugs may be related to depression
- alcohol and drug misuse in older adults often remains hidden because may older adults deny their habit
demntia
course: chronic, gradual onset
progression: slow but even
duration: months to years
awareness: clear
alertness: generally normal
orientation: may be impaired
memory: recent and remote impairment
thinking: impaired judgement; word finding and abstraction are difficult
perception: misperceptions can be absent
psychomotor behavior: normal; may have loss of some previously learned skills
sleep/wake cycle: fragmented, frequent naps
delirium
course: acute, onset often in evening
progression: abrupt
duration: hours to less than 1 mo
awareness: reduced
alertness: fluctuating, lethargic, hypervigilant
orientation: generally impaired, fluctuates by severity
memory: recent and immediate impairment
perception:illusions, delusions, and hallucinations are present; pt difficulty with reality
psychomotor behavior: variable; can be hypo or hyperkinetic
sleep/wake cycle: disturbed, day-night reversal
episodic memory diminishes with age causing
evident in tasks requiring learning and recall of items that are not meaningful like phone numbers
free recall diminishes causing
ability to recall unrelated words decreases
working ability decreases causing
ability to multitask successfully declines with aging along with reduced ability to process complex incoming information
what vision complications are common in older adults
presbyopia: diminished ability to focus on close objects
what hearing complication is common in older adults
presbycusis which is a decreased ability to hear high frequency sounds
taste and smell changes in older adults
decreased ability to taste and smell
pharmacologic impacts on older adults
- polypharmacy
- beers criteria
- altered pharamcokinetics
absorption changes in older adults
- reduced gastric acid; increased pH (less acid) and reduced GI motility; prolonged emptying
- this causes decreased rate of drug absorption and extent of drug absorption
distribution changes in older adults
- there is decreased circulating plasma proteins and total body water, reduced CO, impaired peripheral BF, and increased or decreased % of body fat, and decreased lean body mass
- this causes decreased perfusion, increased ability to store-fat soluble medications causing accumulation of drug, prolonged storage, delayed excretion, and higher peak levels of medication
metabolism changes in older adults
- decreased CO, decreased liver size, diminished intestinal and portal vein flow
- this causes metabolism and delay of breakdown of medication causing prolonged duration of action, accumulation, and drug toxicity
excretion changes in older adults
- decreased renal BF, loss of function nephrons, decreased renal sufficiency
- causing decreased rates of elimination and increased duration of action; danger of accumulation and drug toxicity
alzheimers pathophysiology
- fragments of protein develop in nerve cells that begin to block signals and form amyloid plaques in the brain
- results in decreased numbers of neurotransmitters that provide the connections between the nerve cells in the brain
- blocks communication
risk factors for alzheimers
- women (Black and Hispanic)
- parent or sibling with dementia
- long standing hypertension, brain injury, reduced brain perfusion (blood flow, ischemia), apoptosis
neuro assessment for alzheimer’s
- assess for change in personal hygeine habits and ability to perform ADLs
- assess changes in judgement, abstract thinking, and impulse control
- assess speech and language-difficulty labeling objects, aphasia (inability to talk)
- inquire of family members about personality changes, reports of wandering, changes in cognitive function, orientation, language difficulties, social issues
nutrition assessment for alzheimers
- nutrional and hydration status including ability to swallow and coordinate eating
psychosocial assessment alzheimers
- determine hx of drug or alcohol use
- assess for signs of potential abuse or neglect
MSK assessment alzheimers
- assess ability to move, risk for wandering, or for apraxia (inability to initiate motor function)
- assess pain level
GU and skin assessment alzheimers
assess for incontinence/skin integrity
safety assessment alzheimers
assess potential injury self harm or falls
stage 1 of alzheimers
no apparent symptoms
changes in brain function
stage 2 alzheimers
forgetfullness
loses things or forgets names
stage 3 alzheimers
mild cognitive decline
interference with work, getting los
stage 4 alzheimers
mild to moderate cognitive decline
forgetfullness, depression, withdrawal, confabulation (making up stories)
stage 5 alzheimers
moderate cognitive decline
lose ability to perform ADLs, disoriented
stage 7 alzheimers
moderate to severe decline
disoriented, unable to perform ADLs, sleeping problems, sundowners (agitiation at night), unable to communicate, institutionalized
stage 7 alzheimers
severe cognitive decline
bedfast, aphasia, deteriorated cognitive function
health promotion of alzheimers
- no cure
- focus: slow progression, pt safety, quality of life
- assessment and analysis of subtle changes in clinical presentation to prevent complications
labs and testing for alzheimers
- mini-mental exam
- definitive diagnosis of AD can only be made at autopsy
- rule out other causes of dementia that are reversible, such as deprssion, delirium, substance abuse, inappropriate drug dosage or toxicity
- CT scanning and MRI to assess for atrophy
- PET
medications for alzheimers
- donepezil (aricept)
- rivastigimine (exelon)
- galantamin (razadyne)
- memantine (namenda)
donepezil (aricept)
- inhibits acetylcholinesterase, improving acetylcholinergic function
- treatment of mild-moderate AD
- modest increase in attention, concentration, and mental acuity, does not slow progression of disease
- may cause bradycardia, diarrhea, n/v, or anorexia
rivastigimine (exelon)
- inhibits both acetylcholinesterase and butyrylcholinesterase
- treatment of mild-moderate AD
- modest increase in attention, concentration, and mental acuity
does not slow progression - may cause bradycardia, diarrhea, n/v, or anorexia
- can be administered via transdermal patch
galantamine (razadyne)
- inhibits acetylcholinesterase, improving acetylcholinergic function
- treatment of mild-moderate AD
- modest increase in attention, concentration, and mental acuity, does not slow progression of disease
- may cause bradycardia, diarrhea, n/v, or anorexia
memantine (namenda)
- blocks NMDA glutamate receptors, reducing neuronal excitotoxicity
- noncompetitive antagonist of serotonin (5HT) receptors
- antagonist of different acetylcholine receptors
- generally well tolerated
- can cause dizziness, confusion, headache, insomnia, and agitatio
alzheimers interventions
- nutrition
- increased physical care and feeding
- prevent injury
- reorient client
- keep safe when wandering
- responsive when delusional
nutritional interventions
- encourage favorite foods
- finger foods
- thickened liquids as tolerated
- reminders and assistance as needed
- weight and I&Os
- ascertain clients wishes about feedings
physical care and feeding
- allow pt to remain as independent as possible
- provide a structured schedule recogniing the individual’s routine
- frequently assess client’s self-care needs
- manage incontinence
prevnting injury
- ensure clien’ts environment is arranged for conveinece and safetty
- highly used items close
- bed in lowest position
- supervised with ambulation
- move client where easily observed
- nightlights
- soft restraints
- skin breakdown
complications of AD
- hazards of immobility (pneumonia, falls)
- malnutrition
- dehydration
- polypharmacy
fine crackles (fine rales)
- described as rubbing of hair follicles together
- cause: inflation of previously deflated lung tissue
- present during inspiration (early or late)
- respiratory conditions: fibrosis, bronchitis, pneumonia, COPD
coarse crackles (coarse rales)
- described as popping coarse soudns
- cause: fluid or secretions in lower airways
- early inspiration or early expiration
- conditions: COPD, sputum, pneumonia, PE, HF
rhonchi
- snoring
- causes: obstruction, sputum, secretion in upper airways
- present during inspiration and expiration
- may clear with coughing/suctioning
- conditions: pneumonia, bronchitis, massess (malignant or non), foreign body
wheezing
- described as squakey musical instrument
- cause: bronchoconstriction and inflammation
- present during inspiration, experiation or both
- conditions: astma, COPD
stridor
- high pitched sound during inspiration
- cause: airway obstruction of the throat or upper airway or spasms of the airway
- conditions: allergic reaction, epiglottis, laryngitis
pleural friction rub
- gratting or squeaking
- cause: inflammation of pleural space
- during inspiration and expiration
- conditions: pneumonia, lung malignancy, pleurisy
respiratory safety alert
immediate medical attention required if
- unable to speak
- use of accessory muscles
- retractions
- adventitious lung sounds
- tachypnea
- pulse ox readings below baseline
- abnormal percussion sounds
- cyanosis
- change in LOC
signs of TB
- hemoptysis (bloody sputum)
- low grade fevers
- weight loss
- night sweats
sputum analysis
done to check for microorgansims and abnormal cell growth
if organism is found, sensitivity test is performed to determine effective treatment
nursing implications for sputum collection
patients require suctioning for the collection of sputum may need hyperoxygenation
chest xray
used to ID problems with heart lungs and pleural space
PFT
evaluate lung volumes and capacities to determine the functioning of the lungs
bronchoscopy
direct visualization of respiratory tract down to level of secondary bronchi
throacentesis
used as a diagnostic test or treatment depending on disease process where needle is inserted into pleural space to remove excess fluid or air
lung biospy
small peice of lung tissue removed and analyzed to determine location and size to confirm lung cancer, pulmonary fibrosis, or sarcoidosis
influenza
- types A,B,and C
- highly contagious respiratory infection that is rapidly spread by aerosolized droplets from sneezing, coughing, talking, or direct contact
- incubation 18-72hrs
- virus shedding ends 2-5 days after symptoms first appear (infecctious for up to 7-10 days)
influenza a and b
winter months is most common
increased hospitalizations and deaths
risks for influenza
- age (young children or older adults)
- occupation (healthcare workers, daycare providers)
- environmental (dormitories, military quarters, long term care facilities)
- immune system compromise (malignancies, HIV/AIDS)
- chronic illness (renal failure, diabetes, asthma)
- pregnancy
prevention of flu
- annual flu vaccine
- stay away from sick
- cover coughs and sneezes
- dont touch face, mouth, and eyes
- frequent handwashin
- masks
signs and symptoms of influenza
- cough
- headache
- nasal congestion
- runny nose
- sore throat
- fever
- chills
- body aches
- malaise
- fatigue
- vomiting and diarrhea (children)
diagnosis of the flu
- gold standard: viral culture of respiratory secretions
- rapid influenza test (<30 minutes nasal or throat swab)
- presence of antibodies
medical treatment of the flu
- antipyretics
- analgesics
- adequate fluid
- rest
antivirals
- most common L oseltamivir (tamiflu)
- start within 24-48 hrs of onset
- does not cure the flu
- reduces severity and duration of symptoms
complications of the flu
- viral pneumonia
- bacterial pneumonia
- sinus and middle ear secondary bacterial infections
- worsening of chronic medical conditions (congestive HF, asthma, diabetes)
flu nursing assessments
- vitals
- neurofunction (agitation, restlessness, changes in LOC to assess for decreased tissue perfusion from altered gas exchange)
- breath sounds - rhonchi ,crackles, wheezing
- cough, nasal congestion, sneezing, rhinorrhea
- general appearance
- peripheral pulses and skin temp and color
- lab values (ABGs showing respiratory alkalosis to respiratory acidosis), RIDTS
nursing actions flu
- droplet percautions
- humidified O2
- raise HOB
- medications
- increase fluid and nutrition
- obtain cultures
flu education
- hand hygeine
- disinfection of surfaces
- cover coughs or sneezes
- limit contact with others until minimum 10 days from start of symptoms
- report worsening of symtpoms
- fluid and nutritional intake
- medication teaching
- flu vaccine
COVID 19
viral pneumonia cases called coronavirus severe acute respiratory syndrome
transmission of COVID
close contact
respiratory droplets
trasfer via hands
aerosolization during procedures
contaminated surfaces
risk factors for COVID
- age (>65)
- long term care resident
- immunocompromised
- cardiovascular disease
- diabetes
- obesity (BMI >30)
- respiratory disease
- autoimmune disorders
- mental health disorders
- physical or developmental disability
- lifestyle (occupation, education, smoking)
- behavior (handwashing, quarentine)
- ethnic minorities
signs and symptoms of COVID
- no symptoms to life threatening
- 2-14 days after exposure
- fever
- cough
- rhinorrhea
- tachypnea
- dyspnea
- new or increased O2
- headache
- fatigue
- myalgis
- new onset anosmia or ageusia (loss of smell or taste)
- GI symptoms like n/v or diarrhea
diagnosis of covid-19
RT-PCR
in home rapid test
chest imagine
medical treatment of COVID
- no cure
- supportive (prevent severe illness, hospitalization and death)
- vaccination
mild (reducing symptoms, reinforcement of public measures for mtiigating viral speed) - moderate - antivirals
- sever (hospitalization if hypoxic, respiratory distress, or poor perfusion, monitiro for impending ARF, O2 sat, intubation, mechanical vent, prophylactic anticoagulation)
COVID medications
- protease inhibitor
- monoclonal antibody
- nucleotide analog
- corticosteroid
- anticoagulant
complications of COVID
- acute PE
- MI
- DVT
- arterial thrombosis
- ARDS
- Guillain-Barre syndrome
- septic shock
- multiple organ failure
- long COVID
nursing assessment for COVID
- vitals: tachypnea, tachycardia, decreased O2 sat
- neuro: restlessness, agitation, anxiety, lethargy
- respiratory: wheezing, rhonchi, diminished
- perfusion: peripheral pulses, skin temp, skin color, edema
- labs: PCR, cultures, ABGs
nursing actions for COVID
- airborne, contact, and droplet isolation
- admin O2
- antivirals
- pulmonary hygeine (masks, sneezing and coughing, disposal of respiratory equipment)
- position (raise HOB or prone)
- monitor I&Os
- nutrition
- cluster care
- family support
patient education for COVID
- quarantine
- infection control measures
- symptom surveillance- when to call PCP
- self-proning
- disease process and treatment
- post/long covid
pneumonia
- inflammation and infection of the lung parenchyma (functional lung tissue) resulting from bacterial, viral, or fungal infection
- fluid and exudates fill alveoli, impairing the exchange of oxygen and CO2 causing hypoexmia
- localized or diffuse
- bacteria can enter bloodstream causing septic shock
lobar pneumonia
localizes to one area of alveoli
bronchopneumonia
spread throughout lung area
risk factors of pneumonia
- old age
- long term care residence
- smoking
- chronic respriatory disease
- immune system dysfunction (malignancy, HIV/AIDS)
- altered mental status
- prolonged immobility
- aspiration
- prolonged NPO status
- diminished cough, gag, and swallow reflex
- exposure to air pollutantts, gases, or inhalnts
- > 48 hrs of hospital stay
hospital acquired pneumonia
48-72 hrs after administration
recent antibiotic therapy
receving immunosuppressive therapy
diagnosed with chronic disease
treated wihtin healthcare facilities
community acquired pneumonia
not recently hospitalized
not living in health care facility
healthcare associated
develops within 48 hrs of admission to hospital
signs and symptoms of pneumonia
- fever
- tachypnea/dyspnea
- tachycardia
- chills
- rhonchi and wheezing
- use of accessory muscles
- cough, productive or nonproductive
- pleurtitic chest pain
- fatigue
- mentla status changes
- myalgia/arthralgia
- purulent or bloody sputum
- hypotension
- dysrythmias
clinical manifestations and predictors of increased mortality
- altered mental status
- > 30bpm RR
- hypotension
- > 125 bpm HR
- <95 or >104 temperature
- pH <7.35
- serum sodium <130
- hematocrit <30%
- PaO2 <60mmHg
- presence of pleural effusion
diagnosis of pneumonia
- lab studies showing elevated WBCs, C-reactive protein, ABGs showing alkalosis due to tachypnea and then acidosis with hypoexmia, sputum cultures
- imaging
treatment of pneumonia
- dependent on type but if bacterial antibiotics is first round of treatment
- supportive
- hospitalization if indicated
- hypoxia treatment
- bronchodilators
- support CV status and thin secretions
complication of pneumonia
- necrotizing pneumonia
- meningitis
- empyema
- pulmonary fibrosis
- pulmonary HTN
- septic shock
- ARF
- multiple organ failure
nursing assessments for pneumonia
- vitals: tahcypneic, tachycardic, decreased O2 sat, fever
- neuro: agitation, restlessness, anxiety, lethargy, fatigue, alterd LOC
- breath sounds: wheezing, rhonchi, crackles
- perfusion: diminshed peripheral pulses, moist, pale skin, peripheral cyanosis
- respiratory secretions: purulent or bloody secretions
- lab testing (culture, ABGs)
- I&Os
nursing actions pneumonia
- humidified o2 as ordered
- admin medications as ordered (bronchodilators, antibiotics, antipyretics, cough suppressant,etc.)
- pulmonary hygeine (incentive spirometry, TCDB, postural drainage, percussion, early mobility)
- patient positioning (HOB 30 degrees)
- I&O (3L/day)
- nutrition
-activity
education for pneumonia
- hand hygeine
- respiratory ettiqute
- adequate rest
- antibitocs
- proper nutritoin and fluid intake
- s/s of worsening respiratory condition
- pnuemonia vaccine
tuberculosis
highly communicable respiratory infection caused by mycobacterium tuberculosis that is transmitted by droplets inhaled from coughing or sneezing
classifications of TB
- latent TB
- primary TB
- primary progressive TB
- drug resistant TB
risk factors for TB
- homeless
- incarcerated
- crowded areas or facilities
- older adults and children <5
- malnutrition
- alcohol or IV drug use
- populations outside of US
- low socioeconomic groups
- racial and ethnic minorities
- close contact
signs and symptoms of TB
- fatigue
- weightloss
- night sweats
- cough w. rusty colored sputum
- dyspnea
- orthopnea
- rales
diagnosis of TB
- sputum culture and staining
- quanitferon TB gold
- manatoux test
- chest xray (suspicious cavitating lesiosn) showing gas filled space within llungs
goals of TB treatment
cure disease and minimize transmisison
four drug combo (RIPE) for 9-12 months
RIPE medications
rifampin
isoniazid
pyrazinamide
ethamutol
modifications for special populations like HIV+, pregnancy, drug resistance, and children
induration of 5 mm + is positive in
- HIV infected persons
- persons with fibrotic changes on chest xray
- persons who are immunosuppressed
10 mm + induration is postive in
- recent immigrants
- IV drug abusers
- residents and employees of high risk settings
- mycobacteriology lab personel
- pesrons with clinical conditions that place them at high risk
- child younger than 4
- infants, children, and adoescents exposed to adults in high-risk categories
15 mm+ is positive in
any person with no known risk factors
complications of TB
- respiratory failure
- bronchopleural fistula
- pleural effusions
- extra pulmonary TB (meningitis, lymphadenopathy, bone disease, liver and kidney failure)
assessments for TB
- oxygenation for decreased O2 sat
- temperature check for fever and use of antipyretics
- sputum for blood-tinged or rusty colored
- breath sounds for wheezing, rales, and rhonchi
TB nursing actions
- humidified O2
- airborne isolation
- antibiotics (RIPE)
- ensure adequate nutrition
pt education for TB
- skin and blood testing for infected individuals and close contacts
- medications to ensure no spread
- assess pt support systems
obstructive sleep apnea
- partial or complete obstruction of the airway during sleep
- with the onset of sleep, the body muscle tone relaxes, which includes muscles of upper airway causing airway collapse and period of apnea
- during episodes of apnea there is no movement of air in or out (no gas exchange O2/CO2 causing hypoexmia, hypercapnia, and acidosis
risk factors for obstructive sleep apnea
- a-fib
- nocturnal dysrhythmias
- type 2 diabetes
- heart failure
- pulmonary hypertension
- males
- obesity
- cigarette smoking
- alcohol use
- age 40-65
- craniofacial or upper airway soft tissue abnormalities
- menopause
signs and symptomsof OSA
- loud snoring
- snorting
- witness apnea
- gasping during sleep
- recurrent waking
- nocturnal restlessness
- choking
- excessive dayitme sleepiness
- falling asleep often
- short and repetitive attention lapses
- mood swings
- taking intentional naps
diangosis of sleep apnea
- sleep hx - patterns, snoring, daytime sleepiness
- polysomnography (in sleep lab or at home, apnea-hypopnea index (# of apneic events each hr), used to characterize severity)
OSA treatment
- CPAP (continuous positive airway pressure)
- weight management
- sleep in nonsupine position
- quit smoking
- no alcohol or sedatives ac bed
- oral appliance - holds mandible forward to keep airway open
- tongue retaining devices
- surgery (removal of excess tissues)
- inspire
- weight reduction
CPAP vs BIPAP
CPAP has same air pressure on inhale and exhale whole BIPAP has different pressure levels for inhale and exhale
uvulopalatopharyngoplasty
- performed if conservative therapy doesn’t work where the tonsil, adenoids, uvula, some of soft palate or tissue at side of throat are removed
- post-op patient will be sore, have stiches in thraot, need O2 mask, need HOB raised, avoidance of difficult activity, clear liquids to advance to soft foods, avoid spicy, acidic, hard or crunchy foods, cold or room temp foods, and rinsing of mouth after meals
inspire implant
- only FDA approvid OSA therapy inside body
- implant delivers gentle pulses to the airway muscle to keep airway open
- implant placed near collarbone
OSA complications
- heart disease: cardiovascular disease (HTN), MI, a-fib, sudden cardiac death
- pulmonary HTN -> heart failure
- stroke
- diabetes
- depression
- weight gain
- chronic fatigue
nursing assesstions for OSA
- vitals: HTN and dysrythmias
- height and weight: obesity
- sleep, rest, and activity hx - symptoms of OSA
- post op - assess for edema, bleeding, and respiratory distress
nursing actions for OSA
- assist with CPAP application and teaching
- admin medications (HTN, dysrythmias, post-op pain meds, mouth wash)
- diagnostic testing, sleep study, ECG, and echocardiogram
pt education for OSA
- disease process: patho, risk factors, management
- medications
- CPAP: setup, cleaning, changing supplies, contact information
- weight reduction
laryngeal cancer
malignant tumor of larynx and or hypopharynx
usually from heavy alcohol drinking and smoking, results in squamous cells becoming precancerous
risk factors for laryngeal cancer
- tobacco and alcohol use
- poor diet
- comprosied immune system
- HPV
- family hx
- occupational hazards (coal dust, asbestos)
- sex: male
- age
- race (white and black)
- GERD
signs and symptoms of laryngeal cancer
- change in voice
- persistent sore throat
- constant cough
- pain with swallowing
- difficulty swallowing
- ear pain
- trouble breathing
- lump or mass in neck
- unintentional weightloss
- hemoptysis
- foul breath odor
diagnosis of laryngeal cancer
- health hx: general info, other medical conditions, onset of symptoms, risk factors, family hx
- physical: neck ,thyroid, lymph nodes, muscles
- laryngoscopy
- biopsy
- chest xray
- MRI
- PET
- lab testing
treatment of laryngeal cancer
- radiation therapy
- chemo
- surgery: laser surgery, cordectomy, partial laryngectomy (changes voice, preserves breathing and swallowing ability), total laryngectomy (complete loss of voice w/ permanent tracheostomy, retains swallowing ability, but high risk for aspriation)
nursing assessments for laryngeal cancer
- review of risk facors
- review symptoms and complaints
- skin/vocal/swallowing assessments
- labs: electrolytes, wbc, platelet count (risk for bleeding)
nursing actions for laryngeal cancer
- encourage deep breathing, suction pt prn, admin o2 prin, HOB raised
- chemo as ordered
- institute bleeding precautions
- speech therapy
- oral hygeine
- assess and treat for pain
nursing assessment post op laryngeal cancer
- vitals: hypotension, tachycardia
- oxygen status
- patency of trach
- weight, nutritional intake, calorie count
nursing actions post-op laryngeal cancer
- trach care (humidified o2 via trach collar, pulmonary hygeine, suction equipment, replacement trach tube, obturator at bedside, management of oral secretions with Yankauer)
- aspiration precautions
- provides means for communication
- nutritional consultation (swallowing impairments)
education on laryngeal cancer
- diagnostic testing and interventions
- disease managements
- trach management
- chemo management (antiemetics, avoiding crowds, report infections, report increasing bruising, blood in urine or stool, or increased fatigue, n/v)
- communication management, writing or speech
patient education; radiation
- skin care: avoid heat or ice, lotions or powders, sun exposure, extreme temps, shaving, do not rub, scratch, wear loos fitting soft clothing, cleanse wiht mild soap
- oral care: soft toothbrush, hard candy or chewing gum, examine cavity for infection, ulcers, or bleeding
- throat care: limit vocal use, soft foods, lots of water, sucking on ice chips or saline, throat spray or mouth wash
causes of laryngeal trauma
- blunt or penetrating objects
- ingestion or inhalation of caustic agents
- pressure from prolonged intubation
patient outcomes for laryngeal trauma are related to
early recognition and maintenance of airway
signs and symptoms of laryngeal trauma
- hoarse
- pain
- stridor
- dyspnea
- dysphagia
- hemoptysis
airway obstruction can occur from
airway edema, laryngeal fracture, or hematoma development
diagnosis of laryngeal trauma
- exam of neck for swelling, bruising, subq emphysema, tracheal deviation, and open wounds
- cervical CT
- fiberoptic laryngoscope
- flexible bronchoscopy
medical treatment for laryngeal trauma
- maintain a patent airway (endotracheal intubation or tracheostomy)
- stabilize cervical spine if needed
- diagnostics wait until ariway protected and cervical spine stabilized
surgical treatment for laryngeal trauma
- hematoma evacuation
- laceration repair
- trach
- stabilization/repair of fractures
nursing assessments laryngeal trauma
- vitals: tachypneic, tachycardic, hypoexmic, resppiratory distress
- assess neck and airway for discoloration, change in voice, stridor, use of accessory muscles for breathing, restlessness, indicating hypoexia is present
nursing actions for laryngeal trauma
- keep trach tray and emergency equipment at bedside
- provide humidified air: decreased edema
- keep HOB at 45+ degrees
- aspiration precations
pt education for laryngeal trauma
- symptoms to report
- when to seek emergency care
- voice rest (prevent increased trauma and edema)
hemoglobin
low hemoglobin results in lack of binding oxygen and CO2
oxygen saturation
the percentage of hemoglobin bound with oxygen, this is measured non-invasively and estimates oxygenation status
red blood cells
transport oxygena dn carbon dioxide, an inadequate amount of RBCs result in not enough binding material
low RBCs = low Hgb = decreased transportation of oxygen and carbon dioxide
anemia
lack of RBCs or hemoglobin that causes insufficient oxygenation to the body
hyperventilation
too much air movement, breathing too quickly or deeply or both
hypoventilation
too little airmovement can be due to pt breathing too slowly or too shallow
hypoexmia
lack of oxygen in the blood
hypoxia
lack of oxygen in the cells
peak flow
vollume of air a patient can move in and out of lungs
respiration
movement of oxygen and CO2 across capillary and cellular membranes
ventilation
movement of air in and out of the lungs
lower airway disorders negatively impact
oxygenation, ventilation, and gas exchange which impact tissue perfusion
gas exchange
oxygen transport to all cells in the body and waste products of metabolism (CO2) is transported away from cells
gas exchaneg is acheived via
ventilation by lungs, o2 transport in blood, and perfusion via heart and vascular system
three mechanisms must be function for adequate gas exchange to occur
- adequate ventilation (breathing)
- adequate transport of o2 and co2 via RBCs w/ Hgb
- adequate perfusion (circulation)
complications impacting gas exchange
- problems with lung structure that causes difficulty in moving air in and out of alveoli (ventilation problem)
- inability to bind and release o2 and co2 due to low RBC count or low Hgb (transport problem)
- inability to pump oxygenated blood to cells (perfusion problem)
asthma
- chronic lung disease
- intermittenet, reversible, airway obstruction
- affects bronchial airways
- inflammation of the lung’s airways and tightening of the muscles that surround the airways
- triggered by exposure to irritants, exercise, cold weather, or risk factors
risk factors for asthma
- genetics: race/ethnicity show elevated levels in black, mixed race, native american and alaskans, family hx
- environmental: mold, dampness, allergies, air pollution, urbanization, viral infections, eczema
- occupational: exposure to irritants - wood, dust, chemicals
- obesity
- stress
asthma triggers
- allergies
- tobacco
- certain drugs
- exercise
- stress
- viral and bacterial infections
- weather changes
- acid reflux
- pollution
asthma s/s
- wheezing
- dyspnea
- coughing
- increased sputum
- increased RR
- retractions, use of accessory muscles
- cyanosis
- chest tightness
- tahcycardia
- elevated BP
- restlessness, change in LOC
- inability to lie flat
- anxiety
- decreased peak flow
- INABILITY TO SPEAK IN FULL SENTENCES
- QUIET LUNGS = NO AIR MOVEMENT
diagnosis of asthma
- detailed hx
- focused physical
- PFTs
- chest xray
- pulse ox
- ABGs
- peak expiratory flow
asthma action plan
used for assessment and monitoring frequency of symptoms and triggers and response to therapy
acute attack
peak flow readings, pulse ox, ABGs
meds for asthma
- anti-inflammatories/corticosteroids (fluticasone) to reduce mucous production and swelling
- bronchodilators including beta2-adrenergic agonists (albuterol, salmeterol) to relax bronchial smooth muscle; opening the airway (decreasing obstruction) and anticholinergics (ipratropium) to decrease airway wall area and thickness
- leukotriene modifiers to inhibit leukotriene mediated inflammatory process
eduction w/ asthma
control of triggers and environmental factors
long term preventers of asthma
- used daily regardless of symptoms
- inhaled anti-inflammatories
- oral theophylline
rescue relievers
- used during asthma attack
- short acting bronchodilators (ALBUTEROL)
- oral anti-inflammatories
asthma complications
status asthmaticus is life threatening
status asthmaticus
if pt is wheezing decreases and has little to no breath sounds this indicates pt cannot move air throughout system and indicates respiratory failure
asthma assessments
- vitals w/ o2 sat
- peak flow reading
- abgs
- breath soudns
- LOC
- ability to speak
- cough
- use of accessory muscles
- tripod or semi fowlers
- dyspnea
- hx of previous intubation
nursing actions for asthma
IV access
provide O2
admin meds as ordered
pt education on asthma
- asthma action plan
- avoidance of triggers and risks
- pursed lip breathing
- meds
- proper inhaler technique
- peak flow meter
- smoking cessation
- cleaning respiratory equipment
COPD
- chronic airflow limitation (obstruction) caused by small airway disease and destruction of lung tissue
- progressive disease with exacerbations
- composed of emphysema and chronic bronchitis
emphysema
injury to alveoli over time by irritants causing decreased lung elasticity and hyperinflattion of alveoli leading to collapse of small airways prematurely leading to air trapping and ineffective o2/co2 exchange causing unoxygenated blood to be circualted
chronic bronchitis
exposure to inhaled irritants causing inflammation of bronchi and bronchioles leading to bronchial wall thcikness, inflammation, and causes obstruction, as well ass increased production of mucus causing obstruction
biggest cause of COPD
smoking
COPD s/s
- increased work of breathing
- SOB
- use of accessory muscles
- tripod position with emphysema
- skin color changes (blue = bronchitis, p= emphysema)
- increased AP diameter (barrel chest)
- o2 sat <90%
- cough
- increased sputum
- crackles or wheezes
- pursed lip breathing
- clubbing
- anxiety
- wieght loss = emphysema
- weight gain = bronchitis
pink puffer
linked with emphysema showin
- increased CO2 retention (pink skin)
- minimal cyanosis
- purse lip braething
- dyspnea
- hyperresonance on chest percusion
- orthopneic
- barrel chest
- exertional dyspnea
- prolonged expiratory time
- speaks in sort jerky sentences
- anxious
- use of accessory muscles to breathe
- thin apperance
blue bloater
linked with chronic bronchitis
- airway flow problem
- color: dusky to cyanotic
- recurrent cough and increased sputum production
- hypoxia
- hypercapnia (increased pCO2)
- respiratory acidosis
- high Hgb
- increased respiratory rate
- exertional dyspnea
- increase incidence in smokers
- digital clubbing
serious issues with chronic bronchitis
- cardiac enlargement
- use of accessory muscles to breathe
- leads to right sided heart failure (bilateral pedal edema, increased JVD
medical management of COPD exarcerbations
- management of symptoms
- delivery supplemental o2 and avoid intubation (BIPAP or CPAP)
- evaluation of effectives of treatment and determine a course of therapy is to administer a broncho dilator treatment after inital spirometry test and then repeat and how pulmonary obstruction is reveresed
complications of COPD
- thrush
- hypoexmia
- respiratory acidosis
- infection
- pneumothorax
- acute respiratory failure
- dysrhythmia
- depression
- pulmonary HTN which cases right sided heart failure
with emphysema, blebs/air pockets occur from trapped gas in alveoli which can lead to
collapsed lung if the bleb ruptures
copd diagnosis
- pt hx
- physical
-PFTs - o2 sat
- chest xray/CT
- abgs
- cbc
- sputum culture
treatment goals of COPD
- assess and monitor disease
- reduce modifibale risk factors: smoking
- manage stable COPD
- education
- manage exacerbations
COPD medications
- bronchodilators (beta2adrenergic agonists, and anticholinergics)
- corticosteroids
- mucolytics
- antibiotics
respiratory support
- o2 admin
- BIPAP
- intubation and mechanical ventilation
surgery for COPD
- lung volume reduction
- bullectomy (remove blebs)
- lung transplant
COPD nursing assessments
- o2 sat
- RR
- breath sounds
- pursed lip breathing
- presence of cough
- temperature
- dyspnea
- change in mental status
- weight
- number of pillows at night
dyspnea
SOB on exertion
not always indicative of disease
may not be relieved by sitting or standing
orthopnea
involves difficulty in breathing when lying flat
usually indicates underlying disease
relived by sitting or standing
nursing actions COPD
- admin medications
- provided o2
- raise HOB or tripod position
- small, frequent meals with dietary supplements
- suction as needed
- conserve energy
patient education COPD
- COPD action plan
- pursed-lip breathing
- huff coughing
- pacing of activites
- smoking cessation
- nutritional needs
- medication regiment
- proper inhaler use
- cleaning of equipment
- vaccines
- avoid crowds and ill people
- recognition of symptoms of exacerbation
- coping strategies
COPD nutrition
- maintain healthy weight and well balanced diet
- drink 6-8 glasses of water/day
- 4-6 small meals to allow better movement of diaphragam
- eat complex carbs, good sources of protein, and unsaturated fats
- eat fruits and veggies
- limits simple carbs and sodium
asthma/copd inhaler use
- review proper inhaler technique videos, brochure, and posters
- most effective way to ensure proper inhaler technique is to physically show the pt
- ask pt how they use device and teach accordingly
- if pt is unable to use one device properly it may be time to try another
- many different inhalers and nebulizers
cystic fibrosis
- inherited genetic chronic disease that affects the lungs and digestive system
- increased thick mucous builds up in respiratory, GI, and reproductive systems
- increased survival rate
- other organs are affect (85% of mortalities from respiratory failure)
respiratory CF symptoms
- persistent productive cough
- thick, stucky mucous
- wheezing
- s/s of distress: tachypnea, irregular breathing pattern, retractions, nasal flaring, pursed lip breathing, diaphoresis
- cyanosis
- clubbing of fingers and toes
- repeated lung infections
- decreased exercise capacity
GI s/s of CF
- intestinal blockage (meconium ileus in newborns EARLIEST SIGN)
- poor weight gain and growth
- failure to thrive
- decreased absorption of protein
- vitamin A, D, E, and K deficiency
- steatorrhea: fatty greasy foul smelling poop
- severe constipation
diagnosis of CF
- sweat chloride test (normal <30mEq/l, CF >60 mEq/L)
- mandatory screening in newborns
- chest xray
- PFTs
- stool analysis
medications for CF
- bronchodilators
- mucolytics (mucomyst, mannitol, etc)
- inhaled hypertonic saline
- anti-inflammatories
- fat soluble vitamins (ADEK)
- pancreatic enzyme replacement
- antibiotics
- CFTR (elexacaftor, texacaftor)
surgery for CF
- lung transplant
- pancreas transplant
*neither will reverse condition just prolong life)
assessments for CF
- vtials with o2 sat
- breath sounds
- weight loss
- stool patterns
- sputum culture
CF actions
- airway clearance techniques postural drainage and percussion, flutter device, huffing technique, 2-4x/day
- admin meds
- provide o2
- administer nutritional supplements
- add salt to meals
- emotional support
CF education
- airway clearance techniques
- supplements to meet nutritional needs
- taking medications as prescribed
- avoiding risk factors of an exacerbation (infection control, distance 6ft from other with CF)
- monitoring schedule
- vaccines
- genetic screening/counseling
lung cancer
- malignant tumor of the bronchi or lung tissue
- most common site of metastasis from other cancer
types of lung cancer
- non-small cell (85%) of cases including squamous cell carcinoma, adenocarcinoma, large cell carcinoma
- small cell
risk factors of lung cancer
- smoking (90%) of cases
- risk of lung cancer increases as # of cigarettes smoked and the length of time spent
- second hand smoke
- environmental and occupation pollutants
lung cancer s/s
- become more apparent as disease progresses
- new cough that doesn’t go away
- hemoptysis
- SOB
- wheezing, diminisshed or absent breath sounds
- hoarseness
- chest pain
- weight loss
- weakness
- headache (brain metastasis)
- bone pain (bone metastasis)
diagnosis of lung cancer
- xray or CT scan to ID mass
- PET scan to determine stage of cancer
- sputum for cytology (IDs certain tumor cells)
- bronchoscopy to examine tissues
- mediastinoscopy for collection of biopsy
- bone and abdominal scan to show metastatic lesions
nonsurgical treatment of lung cancer
- chemo
- radiation
- immunotherapy
- targeted therapy
- pain management
- complementary therapies
- palliative care
- hospice
surgical lung cancer mangement
- thoarcentesis
- lobectomy (entire lobe removed)
- pnuemonectomy (entire lung removed)
- wedge resection (small lobe removed)
- open thoracotomy
nursing assessments for lung cancer
- vitals
- breath sounds
- cough
- pain
- appetite/weight
postop lung cancer asssessment
- vitals
- breath sounds
- suture line
- chest tube
chest tube information
- know suction setting
- dress
- skin: s/s of infection or subq emphysema
- position of collection container and tubing
- monitor water seal chamber showing enough water and tidaling NOT bubbling
- suction chamber: enough water and gentle constant bubbling (wet) OR set to correction suction setting (dry)
- supplies present at bedside (sterile 4x4 gauze pads, petroleum gauze tape, small container of sterile water
lung cancer nursing actions
- provide humified o2
- admin medication (pain, anxiolytics, bronchodilators)
- small, frequent meals, semi-fowlers
postop nursing action for lung cancers
- maintain closed chest tube system
- position: upright, below level of chest
- tubing: no dependent loops, no kinks
- prevent any inadvertent air leaks: tape connections
- NEVER CLAMP CHEST TUBE: may result in increased air or flui in pleural space, worsening the pneumothorax and lead to a tension pneumothroax
- do not milk or strip tubing
lung cancer pt education
- breathing techniques
- pace activites
- smoking cessation program
- nutritonal needs (small, frequent meals)
- med regimen
- pain medications
- follow up appointments
- advance directives
- hospice/palliative care
pulmonary embolism
- obstruction of one or more branches of the pulmonary artery (PA) by particulate matter from somewhere else in the body
- blood clot or other matter travels to the lungs, lodges in PA and causes decreased or blocked BF or perfusion to functioning alveoli causing HYPOEXMIA
increase in pulmonary vascular resistance (PVR) as result of PE due to
difficulty passing blood flow and cannot move past venous obstruction causing decreased oxygenation, CO , and hypotension causing hypoxia
most common cause of PE
previous DVT dislodging
what can a PE be caused by
- DVT/blood clot
- piece of tumor
- amniotic fluid, air, or fat (nonthrombotic)
risk factors for PE
- immobility
- DVT
- obesity
- smoking
- chronic heart or vascular disease
- fracture
- hip or knee replacement
- major surgery or tauma
- varicose veins
- hx of previous venous thromboemolism
- malignancy
- age >50 years
- estrogen use (oral contraceptives)
- pregnancy
- hypercoagubaility, endothelial injury, and stasis of blood flow when clot forms
massive or high risk PE
- prolonged hypotension requiring pharmacological support
- right and left ventricular dysfunction
- shock and/or cardiac events
submassive or intermediate risk
- normal BP
- right ventricular dysfunction (ECG)
- myocardial necrosis shown by high levels of troponin and elevated BNP
low risk PE
- normal BP
- no right ventricular
- no elevated biomarkers
s/s of PE
- sudden onset
- chest pain, dyspnea, and tachycardia are most comon
- accessory muscle use
- tachycardia
- anxiety
- impending doom
- change in mental status
- dizziness, lightheaded
- crackles
- cough
- hemoptysis
- fever
- diaphoresis
- s/s of DVT
signs of dvt
- unilateral LE
- pain
- redness
- warmth
cardiac involvement in PE
- JVD (when PE is mimicking right side heart failure)
- decreased CO when blockage of blood into the heart causing hypotension, decreased pulse strength, increased HR, decreased perfusion/cyanosis, mental status changes, long term heart failure, cool and clammy skin, fatigue
- hypotension
- PEA
diagnosis of PE
- ECG to eliminate MI
- CXR to rule out infectious processes
- D-dimer showing elevated levels of fibrin to confirm clot is present
- ABGs
- spiral CT w/ IV contrast
- ventilation/perfusion scan (V/Q scan)
- pulmonary agniogram
- LE ultrasound
definitive diagnosis of PE can only be performed with what tests
CT scan
angiogram
and V/Q scan
treatment of PE
- improved oxygenation to removal of PE
- care based on patients presentation (stable vs unstable), risk factors, and comorbidities
- medications, IV fluids, thrombolytic therapy, embolectomy, IVC filter, IV heparin
anticoagulation for PE treatment
- factror xa inhibitors: apixibam (Eliquis), rivaroxaban (Xarelto), Fondaparinux (arixtra)
- IV Heparin
- Subq low molecular weight heparin: dalteparin (fragmin), enoxaprin (lovenox)
- needed for at least 3 months post discharge
thrombolytic therapy
alteplase (t-PA)
catheter directed thrombolysis
embolectomy
catheter
surgical
IVC filter
placed in inferior vena cava so clot will get caught in filter and not travel in lungs, used to be long term but now contraindicated
thrombolytics indicated for
massive PEs
given IV or direct therapy
high risk for bleeding
IV heparin drips are used for
moderate clots
PTT levels to show proper clotting factors
must perform bridging meaning to get them off drip to an oral med
cather managment of PE
- less complaints
- can be either a thread into clot using pressurized saline to break it up or corkscrew device
- can dislodge causing another embolism
open surgery for PE
- open procedure
- cut open the vessel and suck out the clot
- MAJOR SURGERY
nursing assessment for PE
- airway
- oxygenation
- frequent VS
- s/s of bleeding
- mental status
- s/s of decreased CO
- cardiac rhythm
- urine output
- s/s of DVT
labs for PE
ABGs
aPTT or anti-Xa assay (heparin)
if there is decreased perfusion to the body the first organ to fail is the
kidneys so monitor BUN/creatinine and should be at least 30mg/hr
nursing actions for PE
- elevate HOB
- administer IVF
- admin anticoags or thrombolytic anticoagulants or thrombolytics
- initiate bleeding precautions
- prepare for procedures
- post-op care
- be prepared for intubation and resuscitation
health promotion for PE
- smoking cessation
- weight loss
- hydration
- activity/exercise
- compression stocking
- elevate legs at night
- stop estrogen use
- take anticoagulants as ordered
- s/s of DVT
- s/s of PE
- hospitalization
discharge/ disease mangement of PE
- lifestyle modification
- medical alert bracelet
- meds requiring lab monitoring like heaprin or warfarin
- bleeding precaustions
- limit of vit K in diet if on warfarin
- s/s of recurrent DVT or PE
- follow up appointments
- when to call 911
warfarin
- dose with INR
- vitamin K = antidote
heparin drip
- dose with Xa or PTT
- protamine sulfate = antidote
high PTT, INR, Xa =
high risk for bleeding
decreased INR, PTT, or Xa =
increased clotting
bleeding precuations
- no straight razor only electric
- soft toothbrushes
- avoid injuries
- no NSAIDs or ASA
- no IM injections
Fresh frozen plasma can be used to
decrease bleeding time
acute respiratory failure
- not a disease but a condition caused by another disease or disorder
- occurs when insufficient oxygen is transported to the blood (hypoexmic) or inadequate carbon dioxide is removed from the lungs (hypercapnic) and the client’s compensatory mechanisms fail
hypoxemic RF
- type I
- PaO2 <60 mmHg despite increased inspired o2 with normal or low PaCO2 (V/Q mismatch or impaired oxygen diffusion)
hypercapnic RF
- type II
- respiratory acidosis : PaCO2 >50mmHg and ph <7.35
- hypoexmia may or may not be present (impair ventilation or causes hypoventilation
impaired ventilation (hypoventilation)
- airway obstruction
- respiratory muscle weakness/paralysis (ex. myasthenia gravis)
- chest wall injury
- anesthesia
- opioid admin
V/Q mismatch
- COPD
- restrictive lung diseases (sarcoidosis, pulmonary fibrosis)
- atelectasis
- pulmonary embolus
- pneumothorax
- ARDs
impaired diffusion (alveolar)
- pulmonary edema
- ARDs
signs and symptoms of hypercapnic RF
- headache
- confusion
- decreased LOC (somnolence)
- tachycardia
- tachypnea
- dizzy
- flushed: pink/red skin (high CO2)
hypoexmic RF
- tachypnea
- tachycardia
- hypertension
- agitation, restlessness, confusion
- anxiety
- cyanotic - blue/grey skin (low O2)
- coma
early signs of ARF
- dyspnea
- restlessness
- anxiety
- fatigue
- hypertension
- tachycardia
intermediate signs of ARF
- confusion
- lethargy due to increased CO2
- pink skin color
late signs of ARF
cyanosis and coma
labs for ARF
- ABGs
- venous oxygen saturation
- Hgb/Hematocrit
- sputum culture
treatment of ARF
- underlying cause
- supplemental O2 (nonrebreather mask with 100% FIO2 high flow nasal cannula
- BIPAP/CPAP
- invasive (mechanical) ventilation via endotracheal tube or tracheostomy
medications used for ARF
- inhaled bronchodilators
- inhaled steroids
- diuretics (for pulmonary congestion/edema)
- sedation (control of anxiety and decrease work of breathing)
- antibiotics (pneumonia)
complications of ARF
- cardiac failure
- multiple organ dysfunction
- death
nursing assessments for ARF
- airway/breathing
- vitals
- skin color (hypoxic or hypercapnia)
- cardiac monitoring
- neuro: anxiety, impending doom, decreased LOC, hypoexmia = agitation, hypercapnia = somnolence
nursing actions/interventions for ARF
- administer o2 and meds as ordered
- elevate HOB or sit up in chair
- good lung down to improve gas exchange of bad lung
- chest PT
- IV fluids/hydration
- nutritional support
- BIPAP or CPAP
- potential mechanical ventilation
patient education for ARF
- disease process
- medication
- infection prevention (handwashing, vaccines)
- smoking cessation
- diet and hydration
- pulmonary rehab including breathing techniques (pursed lip breathing), energy conservation, and exercise
acute respiratory distress syndrome
acute inflammation in lungs cause by injury that leads to pulmonary edema and hypoexmia
increasing pulmonary edema and alveolar collapse creates “dead space” where no gas exchange can occur
most common cause of death with ARDs
multiorgan failure
modeling
sign that pt is near death, severly cyanotic with large white spots
direct injury includes
- pneumonia
- lung trauma
- lung surgery
- near drowning
indirect injury
- sepsis
- burns
- multiple blood transfusions
causes of ARDs
- sepsis
- severe trauma
- aspiration
- smoking
- mass transfusion
- cardiopulmonary bypass
- pneumonectomy
- pulmonary embolism
- drug or alc overdose
s/s of ARDs
- restless, confusion
- tachypnea
- tachycardia
- crackles
- diaphoresis
- use of accessory muscles
- cyanosis or mottling
diagnosis of ARDs
- serial chest xrays (bilateral lung infiltrates is hallmark sign with ground glass appearance)
- labs (ABGs, CBC, cultures, coag studies, electrolytes, LFTs and BUN/Creatinine)
treatment of ARDs
- mechnical ventilation
- high flow nasal canula
- extracorporeal membrane oxygenation (ECMO)
- prone positioning
ECMO
a pump that circulates blood through an artificial lung outside of the body, where oxygenation and CO2 is removed, blood is then returned into the blood stream
medications for ARDs
- antibiotics
- corticosteroids
- neuromuscular blocking agents or paralytics
- hydration - IV fluids
- nutrition (enteral or parenteral feeding started within 48-72 hrs of mechnical ventilation
ARDs complications
- ventilator associated pneumonia (VAP): regular mouth care and suctioning
- barotrauma
- renal failure
- multisystem organ dysfunction syndrome (MODS)
barotrauma
at risk fr alveolar or lung rupture resulting in pneumomediastinum (air in mediastinal space) or pneumothorax causing further hypoexmia
assessment of ARDs
- hemodynamic monitoring (vitals, central venous or pulmonary artery pressure)
- neuro: LOC w/ pupil checks
- sedation monitoring
- lung sounds crackles –> diminished
- secretions
- output
- monitor ventilator
- cardiac monitoring
- skin
- daily chest xray
ARDs interventions/actions
- airway suctioning
- administer meds prn
- positioning (prone, fowlers, frequent changes)
- infection prevention
teaching of ARDs
refers to underlying disease process
chest trauma
blunt or penetrating trauma
blunt trauma
blunt object hitting chest or chest striking blunt surface
penetrating trauma
sharp objects entering the chest and causing damage to internal structures or organs
common injuries occurring from chest trauma include
- flail chest
- pneumothorax
- hemothorax
- cardiac constitution
- cardiac tamponade
flail chest
- 3+ adjacent ribs fractured in 2+ places resulting in a free segment of ribs
- result of blunt or crush chest trauma
- paradoxical chest wall movement (HALLMARK SIGN) with each inhalation, the damaged area moves inward; on exhalation the chest moves outward
pneumothorax
reduction in negative thoracic pressure because of air in pleural space making inspiration difficult because lung cannot fully expand
resulting from blunt or penetrating trauma
hemothorax
blood fills the pleural space, negative pressure is lost, limiting th elungs ability to expand loss of blood may result in hemodynamic compromise
result of lacerated vessel from trauma
symptoms of chest trauma
- tachypnea
- asymmetrical chest rise and fall
- tracheal deviation
- agitation, anxiety, decreased LOC
- SOB
- subq emphysema
- pain (guarding of area or splinting)
diagnosis of chest trauma
- chest xray
- ultrasound
- chest CT
- abgs
- serum lactate
- H/H
- CBC, CMP, coag, and type and cross match for routine
treatment of chest trauma
- airway breathing circulation
- chest tube (for pneumo and hemothorax)
- medications including analgesics and antibiotics
- thoracotomy
- flail chest surgical rib fixation
complications of chest trauma
- tension pneumothorax
- cardiac tamponade
tension pneumothorax
- may occur if air or blood collects in pleural space and is not removed, the postive pressure in pleural caavity increases and the affected lung collapses
- can result in compression of heart, vena cava, aorta, and contralateral affected lung
- tracheal deviation toward unaffected side
cardiac tamponade
- excessive air, fluid, or blood collecting in pericardial sac
- heart cannot adequately fill or contract because of compression of ventricles
- treated with a pericardiocentesis the insertion of large bore needle into pericardial space to drain the fluid
assessments of chest trauma
- respiratory effort
- visualization of chest
- breath sounds
- VS
- pain
- LOC
- chest tube
- subq emphysema
chest tubes
- assess amount and color of drainage
- red free flowing drainage in excess of 100 mL/hr or amount indicated by provider indicates hemorrhage; cloudiness may indicate infeciton, notify HCP drainage amount
- water seal chamber may tidal but shouldn’t show continuous bubbling or indicative of air leak
subq emphysema
- air from chest injury espacing into subq space indicating potential chest trauma or chest tube not positioned appropriately
- subq emphysema of head and neck could be life threatening because airway could be compromised
nursing interventions for chest trauma
- o2
- anticipate and prep for intubation
- elevate HOB
- encourage cough and deep breathing, incentive spirometer
- encourage early ambulation
- amdin pain meds
- chest tube management
education for chest trauma
- use of pain meds
- cough and deep breathing
- incentive spirometer
- splinting while coughing
- MTV safety
