Respiratory 1 Flashcards
Pneumonia (Aspiration) Risks
Aspiration happens frequently, even in healthy people.
Alcohol abusers
Depressed resps from meds
Sleep apnea
GERD
Aspiration of bacteria from dental plaques a big cause for concern
Pneumonia (Aspiration) Assessment
Hypoxemia, dyspnea, new onset respiratory symptoms, fever, and chills
Dullness with percussion, decreased breath sounds, crackles or bronchial breath sounds
Myalgia, GI symptoms, confusion in elderly patients
Pneumonia (Aspiration) Management
Antibiotic therapy
Cornerstone of treatment
First dose within 8 hours of arrival to hospital
Supportive therapy
Oxygen, mechanical ventilation, pulmonary toilet, nutritional support
Prevention
Influenza and pneumococcal vaccine
Pulmonary Embolism
Venous thromboembolism: Virchow’s triad (venous stasis, hypercoagulability, vein wall damage)
Immobility, heart failure, dehydration, and varicose veins contribute to decreased venous return, increased retrograde pressure in the venous system, and stasis of blood with resultant thrombus formation.
Atrial fibrillation another big culprit
Assessment—Pulmonary Embolism
New worsening dyspnea or sustained hypotension without other explanation
Sustained sinus tach without explanation
Pleuritic chest pain, cough, apprehension, leg swelling (if DVT), and pain.
Can be hypoxic (decreased PO2/SaO2)
Can be a sudden death event if the embolus is large.
Diagnostics
CT angio—CT of chest with IV contrast shows up vasculature (gold standard). If dialysis patient, it’s okay/not a contraindication
Transthoracic echocardiogram (TTE)
Management—Pulmonary Embolism
O2 & or ventilator support as needed
Heparin and thrombolytics, not at the same time (contraindications?)
Treat at least 5 days IV Heparin; overlap with oral anticoagulants.
Continue oral anticoagulants for 3 to 6 months.
Prevention
- early ambulation after surgery
- LMWH
- SCDs
Asthma
Hallmarks:
Airway inflammation
Non specific hyper-irritability or hyper-responsiveness of the tracheal-bronchial tree
These cause:
BRONCHOCONSTRICTION
Clinical Manifestations of Asthma
Asymptomatic Wheezing Cough: productive or unproductive Dyspnea Chest tightness Hypoxemia
Severe Asthma: Treatment
B-adrenergic agonists: nebulizers q 20mins to 4h prn
Corticosteroids
IV aminophylline
Humidified oxygen
Pulse ox and ABGS (respiratory alkalosis in the beginning)
Status Asthmaticus
Life threatening emergency: respiratory alkalosis to respiratory alkalosis
Refractory to usual treatment
At risk for respiratory failure
Symptoms are more severe More prolonged Extreme anxiety Increased work of breathing Diaphoretic Muscle retractions c/o chest tightness
- ***HTN, tachycardic, ventricular arrhythmias
- ***pCO2 decreased in beginning then increases when patient fatigues
Status Asthmaticus: Interventions
Increase frequency/dose of bronchodilators—can give back-to-back nebulizers IV corticosteroids q4-6 hours IV Magnesium: acts as a bronchodilator Epinephrine subcutaneously (carefully) Oxygen to keep pO2>60 and O2 sats >90% IVF for hydration Chest PT May need mechanical ventilation
Benefits of Noninvasive Ventilation
CPAP / BiPAP
Both deliver positive pressure
Benefits: No EndoTrachealTube utilized Some studies indicate decreased mortality with acute respiratory failure Enhances alveolar ventilation Decrease work of breathing Improve gas exchange
Disadvantages of Noninvasive Ventilation
Gastric distention
Barotrauma
Hemodynamic changes
CPAP
Air delivered to lungs through a tight fitting mask
Constant positive pressure through mask
Keeps alveoli open
Decrease work of breathing
Patient must be able to breathe spontaneously
Very uncomfortable
Put Duoderm on bridge of nose to prevent breakdown.
BiPAP
Considered a refinement of CPAP
Positive airway pressure at end of exhalation; higher positive airway pressure during inhalation
Enhances oxygenation and ventilation
2 different pressures
Individualized based upon patient status / needs
BiPAP Nursing Management
Mask must be adequately sealed
Monitor oxygenation status via pulse ox
Monitor level of comfort, respiratory status, level of consciousness, hemodynamic status
Monitor for complications: skin integrity, gastric distention, eye irritation, sinus pain / congestion
Noncandidates for Noninvasive Ventilation
Large secretions, unable to clear secretions
Uncooperative
Impaired mental status
Hemodynamically unstable
Need airway protection
Need continuous ventilatory support (pH dropping with increasing hypercapnia)
Requires nursing vigilance !
Airway Obstruction
Symptoms
- stridor, anxiety, cyanosis
- SOB, restlessness, tachycardia
Treatment (treat the cause)
Edema or swollen airways= steroids, ice, NSAID
Food or foreign object=Heimlich Maneuver
Sleep apnea= use of CPAP or BiPAP apparatus, oral airways, weight loss
Chronically engorged tonsils and infections= surgery
Give oxygen for hypoxemia
Endotracheal intubation
Tracheostomy
Oropharyngeal Airways
Used to maintain an airway in a patient who is unconscious
Removed when patient regains consciousness as it may stimulate gag reflex
Nasopharyngeal Airways
AKA nasal trumpet
Better tolerated by conscious patients
Lubricate prior to insertion
Size is important
Invasive Ventilation
Tube inserted by MD, NP, Paramedic. Passes through vocal cords, approx. 2cm above carina. Cuff seals off lower airway from upper airway
Used for short term airway, ventilatory access, & secretion removal
May cause trauma to teeth, oral or tracheal mucosa
Intubation
Immediately after insertion of an ET tube, placement must be verified to make sure it’s in the trachea and not the stomach, and that it’s not in the right main stem.
1) CO2 detector briefly placed on end of ETT to check
2) Listen for bilateral breath sounds
3) Get a CXR. Most definitive way
ET Tube
Nursing Care
- Assessment- breath sounds, ABG’s , VS, skin color, reposition in mouth every 12/24 hours, note cm at lip line.
- Prevent dislodgement- sedation (propofol, midazolam), ?restraints, use bite guard, tape securely or use ETT immobilizer
Suctioning Q4h as needed, noting quality of secretions and performing oral care
Prevent infection (no lavage), monitor temp and WBCs Use Ballard suction catheter
