Resp 1 part 2 (exam 3) Flashcards
Positioning
- high fowlers is the best position for air
- Tripod position- COPD patients use this to get optimal airway
activity
its all about supply and demand
- if the supply is low do not increase demand
- supply patient with rest periods
diet
- with severe lung problems, question is it a chore to eat, plan meals around rest periods
- nutritional hake and supplements
- small frequent meals, make meals in advance
what type of diet shhould a patient with COPD have
- high calorie, high protein diet, drink a good amount of fluid (unless heart problems)
turn cough deep breathing
loosens up mucus, moves mucus around helps improve gas exchange
- post op splint incessions, medicate for pin
- contraindications - hernia and intracranial pressure
- do this in the morning after resp. treatment or percussion and vibration treatment
pursed lip breathing
purpose to prolong exhalation to prevent bronchial collapse and air trapping
- helps get out excess CO2
- positive pressure in airways- keep alveoli from collapsing
how to do pursed lip breathing
breath deeply through nose
exhale through pursed lips 3xs as long as exhalation
repeat 8-10 xs 3-4 times daily
Diaphragmatic (abdominal) breathing
focues on using diaphragm to achieve max inhalation and slow resp rate
- used for relaxing accessory muscles doesnt help with gas exchange
incentive spirometer
- suck in on the milkshake
- breath in for at least 5 seconds
- measuring volume of inspired air
- helps control inhulation
- stimulates patient to cough
chest physiotherapy
put patient in a position to facilitate drainage, start percussion or vibration try for 5 mins
- percussion hand in cup and hit on back
- cough and deep breath, suction if needed
- do not do on clear lungs
air way clearing techniques
postral drainage, percussion, vibration
when would it not be a good time to do chest pt
if patient has rib fractures, after they eat
- do 1 hr before meals or 3 hours after
Huff coughing
forced expiratory technique that clears serections with less change in pleural pressure, and less likelihood of bronchial collapse
PEP therapy
airway clearance device- can be used for someone that cant dolerate chesOt PT
- helps to loose mucus and move it up through the airways to the mouth where it can be expectorated
- flutter mucous device has a steel ball , sculations travel to lung to help knocked mucous lose
- accapella device can hook nebulizer treatment to it
oxygen delivery
- considered a medication
- never without O2 from someone who needs it for fear of CO2 retention and respiratory depression” administer and assess
FiO2 of room air
21%
humidification
masks should be humidified
Low flow systems
for patients that are breathing room air just adding to it
- nasal cannula
- simple mask
- partial rebreather
- non rebreather
- reservior bag
nasal cannula
delivers from 1 - 6L of oxygen per min
- humidify above 3 L
- skin integrity - ears and middle of nose
Masks
deliver more O2 at higher concentrations
Simple mask
administer low to moderate concentrations of O2 (6-12L)
- covers nose and mouth
- used only for a short time
- make sure tight seal
- good for mouth breathers
- cant eat or drink while mask is on
- clean frequently q2hr
partial rebreather
allows patient to rebreath some co2
- short term therapy 24hrs
- 10-15 L o2
- bag has to stay inflated
non rebreather
100% FiO2
- reservior bag always needs O2 and to remained filled up
- 1 way valve all CO2 is expelled and can not rebreath any CO2
High flow systems
independent of patients breathing
- venturi mask
- aerosol mask
- trach collar
- t pipes
venturi mask
most reliable and accurate method of delivering precise concentrations of O2
- deliver precise high flow rates of O2
- dial settings on a flow adaptor setting should match wall O2 can be humidified
Aerosol masks
face mask with corified tubing provides a lot of humidification some have condisation bag
Trach collars
not as accurate O2 delivery attaches to neck with strap delivers O2 via tracheastomy
- does not attach snuggly
T- pieces
connects to trach very accurate O2 delvery
allow an inline catheter (Ballard catheter) to be connected for suctioning
- tight fit allows for better O2 and humidity delivery
- empty as necessary
Oral airways
artifical airways
indications for patient that is breathing spontaneously
keep tongue clear of airway
trauma or seziure post up need to be unconcious
- measure from jaw to back angle below ear
- airway should reach from oepning of mouth to the back angle of the jaw
- tip of the nose to the earlobe
insertion
patient on back with neck hyper extended
insert with curved tip pointing up to roof of mouth
rotate 180 degrees as it passes uvula
- do not tape
nasal airway
nasopharynegeal airway (nasal trumpet) inserted through nare and protrudes into back of pharynx - can bypass nasal nucosa great for NG suctioning
BiPAP, CPAP, PEEP
- all involve positive pressure helps move air down to the treachea
- all are aimed at keeping the airways open
- side effects of positive pressure
- decreased venous return and blood pressure due to increased pressure
- edema so such pressure pushes fluid out of cells
- subcutaneous emphysema
- barotraumas-when you blow out a lung
BiPAP
Bilevel positive airway pressure
- pressure set for inspiration and expiration
- higher during inspiration and lower with expiration
- nasal or mask
- keep air tight seal
- CO2 retentation these work great
CPAP (continuous positive airway pressure)
- continuous pressure
- pressure delivered continusouly during spontaneous breathing
nasal or mask or via mechanical ventilation
keep air tight seal - sleep apnea
PEEP (positive end expiratory pressure)
end expiratory pressure
usually via mechanical ventiation
especially useful in treatment of patients with ARDs
Oxygen toxicity
never without O2 from someone who needs it: administer and assess
O2 toxicity
may occur with high PO2 levels usually for extended periods of time. The key is to administer oxygen as needed, maintain PO2 levels within normal limits
- assessment is key ecause of physiologic changes in the alveoli, the patient may experience cough and sore throat
what physiologic changes occur as a result of O2 toxicity
decreased surfactant production, alveoli colapse, fibrosis
- causes severe inflammatory response because of oxygen radicals and damages alveolar capillary membrane
- lead to acute respiratory distress syndrome
what are the other signs and symptoms related to O2 toxicity
pulmonary edema
hypoxemia
shunting of blood
symptoms of o2 toxicity
cough sore throat substernal chest pain nausea vomiting paresthesia- numbness malaise- fatigue - if allowed to continue O2 toxicity may eventually lead to endstage fibrosis. this decreases lung complicance and creates major respiratory problems
prevention of 02 toxicity
use lowest effective concentration of oxygen
PEEP or CPAP prevent or reverse atelectasis and allow lower oxygen precetages to be used
CO2 Narcosis
- occurs in pt with extremely high CO2 levels
- what patients whould be at risk for CO2 narcosis- copd, drug over, dose, mederate sedation
What is the main S/S associated with CO2 narcosis
decreased level of conciousness, lungs cant fix a problem in lung
Decrease CO2 , increase H, and Decrease pH (decrease O2)
increased RR and TV
over time COPD patients
develop a tolerance to high CO2 levels
Tracheostomies assessment and suctioning
suction when needed, listen to lungs and assessment
Thracheostomies oxygenation
hyperoxygenate before and after suctioning
Tracheostomies patient safety
- no residue on cannula including excess liquid
- hold onto faceplate when ties are removed (do not remove old ties until new ties are in place, dislodgement)
- make sure the trach cannula is locked into place
- get help if needed
- do not cut the trach dressing- use precut dressing
- cuff pressure- just enough (use minimum amount of air required to obtain airway seal think blood supply)
- suction before deflating cuff- even nasosuction
- during which part of respiration should the nurse deflate the cuff - expiration air and particles go out into mouth
Tracheostomies emergency care
have another trach tube and obturator at bedside
do not manipulate immediately after surgery (usually 24 hrs)
comes out oxyenate and replace it
suctioning
importance of assessment
- based on need not routine
- suctioning and trach are
patient safety principles
delegation issues
- stable predictable, patients LPNs can suction
- asepsis
- do not suction on way down
LPN
Stable patients only
- assess the need for suctioning
- suctioning
- evaluate wheather status is improved after suctioning
- trach care
- not the first suction
NAP
provide oral care
suction oropharynx (after being trained)
report need for suctioining to RN
types of suctioning
oropharyngeal- mouth - clean
nasotracheal- nose - sterile
endotracheal- if patient is vented- sterile
chest surgeries
some patients may require a chest tube
position side laying or head down
head down is not to be used on patients with chest trauma or head injury
Thorocotomies
incision into thoracic cavity may or may not involve lungs
- major surgery cuts into bone muscle cartilage mediam sternotomy and lateral thoractomies
median sternotomy open heart surgery
anterolateral thoracotomy front side
posterolateral thoractomy back side
- pain meds assess incision, splinting cough, chest tube care
Lobectomies and resections
taking out portion of lung
- 2 different chest tube 1 for air and 1 for fluid
- lung expands some to facilitate
Pneumonectomies
removal of entire lung
- only time you will see a clamped tube
- positioning is very important turned from back to operative side to prevent fluid from filling good lung
- risk assessment and postoperative pulmonary toilet what time of history would predispose patients have more complications post op chest surgery smoking COPD asthema
mediastinal
space that lies between the right and left thoracic cavities and contains large blood vessels heart mainstem bronchus and thymus gland. If fluid accumulates here the heart can become compressed and stop beating , causing death
Indication
fluid or air remval to re-expand lung
may be from trauma, pneumothorax, hemothorax, surgery
insertion
patient prep
adequate exposure
Local anesthetic
Maintenance and nursing care
lung sounds- crackles, deminished lung sounds
drainage- amount color consistancy, decrease in amount in a few days
pain - so htey can cough and deep breath
deep breathing and resp status
CXR- reports , do daily
Subcutaneous emphysema- air under skin, should dissolve on their own
Basic intervention
pulmonary toilet help chest to expand to help with removal
- no milking or stripping increases pressure
- check connection
- 3 compartments
- collection fluid drainage from pleural space collects - fluid drainage from pleural space collects here - amount color consistancy
- water seal - acts as 1 way valve and creates a seal so that evaluated air connect re enter pleural space
- check for continous bubbling (bad)
- tidaling ball makes up and down (good)
- suction
- continous bubbling (good)
- monitor suction control chamber it evaporates (keep at 20)
specimen collection
small gage needle into tubing self healing tubing
facilitate drainage
no dependent loops
below chest level
fluid levels and suction
no clamping kinks in tubing
Suction verses water seal
water seal no suction gravity
ambulation and transfer
place to water seal
maintain integrity of system
positioning
Dressing care
occlusive airtight vaseline based if not occlusive air leaks can occur
- reinforced as needed
- asepsis
- suture care
equipment troubleshooting
bubbling in the H2O seal compartment continous bubbling leak
no tidaling
tube may be blocked
sudden decrease in drainage
king or clog
Emergency care
unit spills over- change divice
disconnected- from patient put in saline and create water seal
removed from patient occulsiive dressing (vaseline) on 3 sides
MDI
small hand held pressurized device deliver measured dose of drug with activation
- dosing usually 1-2 puffs
Shake inhaler
breath out all the way
- hold inhaler or spacer chamber in mouth, slowly breathe in through mouth and press inhaler one time, breathe slowly and deeply in
DPI
dry powedered medication that is breath activated aerosol created during inhalation no propellent is used less manual dexterity than MDI no needed to to coordiante puffs with inhalation quick deep breath for 10 seconds no spacer counter avoid humidity may club
Nebulizer
delivers a suspension of pine particles of liquid in gas
take medication in an aerosle form by O2 or compressed air
sit upright
breath slowly and deep diapgramtic breathing
clean
mucolytics
break down mucus change characteristics of mucus , increase or liquefy respiratory secretions and aid in clearing of airways (mucomist should be given with a bronchodialter)
expectorants
increase cough reflex
increase productive cough to clear airways
enhances the output of respiratory tract fluids by reducing the adhesiveness and surfance tension of these fluids allowing easier movement of the less vicous secretions
- humabid
Bronchodilators
let air in
- b2 adrenergic agonists, anticholinergic agents methylaxtines
- stimulate sympathetic nervous system to cause bronchodilation
- short and long acting
short acting
used to relieve acute bronchospams “rescue” medication onset with mins and last for 4-8 hrs
cause bronchodilation and increase mucociliary clearance
- albuterol
- short term more than 4 x a week build up tolerance
long acting
usinig with inhaledcorticcosteriods for long term control of asthma
used only once ever 12 hrs , they are affective for 12 hrs not to be used for quick relief of bronchospasm
ex- salmeterold, formoterol
combination therapy
inhaled corticosteriod and a long acting b2 adregneric agent
ex advair and symbicort
anticholinergic
work on parasympathetic system to block bronchoconstriction
- cause broncodilation
- slower onset peak 30 min duration 4-6 hrs
theohyllines (methlxanthines)
PO or IV
bronchodilator with mild anti inflammatory effects
montior serum blood levels for toxicity narrow margin of saftey
therapeutic levles 10-20 (drs usually give 5-10)
antihistamines
allergic reactions -hyperactivity of airway
block the release or action of histamine that increases secretions and narrows airways
allergra claritin zyrtec benadryl
corticosteroids
PO IV and MDI/DPI forms anti inflammatory med reduce bronchial hyperresponsiveness
- example prednisone, pulmocort, flovent
increase blood sugar increase risk of infection
may take 2 weeks
taper dose
leukotrine modifers
block action of leuktrines (potent bronchoconstrictors can cause airway edema and inflammation)
singulair
maitience not very good alone mointor liver fuction
- can affect comodin warfirin
tb therapy
compliance huge issue
6-9 month therapy
- isoniazid- can cause peripheral neourpathy, can react ith teptiromy, GI upset
- rifampin- red discoloration of body fluids an drecrease effectiveness of birth control
- metabolized in liver no drinking monitor liver enzymes
pH
acid 7.35-7.45 alkaline
CO2
alkalotic 32-48 acidic
HCO3
acidic 22-28 alkalotic
